Compliance Follow-Up

Today I learned something new.  In the discussion of my most recent cross-post on KevinMD, Dr. Steven Reznick says:

In most patient – physician visits I have seen in my 30 plus years of practice  the physician identifies a problem and tries to explain it to the patient in lay terms. The physician then outlines the choices and options for treatment and will say which one he/she prefers. The risks and benefits of the choice are discussed. In most cases the physician and or staff access the patients drug plan to make sure what is being prescribed is covered by the patients insurance. Most practitioners ask the patient if they have any questions or concerns before the visit is complete.  Once the patient leaves without raising a question or concern , as the physician you assume the patient is going to follow the mutually agreed upon care plan. You also assume that if there is a problem with the plan after the patient leaves, they will call you, stop back in the office or set up another visit to address their concerns. You do not expect the patient to not fill the prescription or not take it and then show up at a follow-up appointment to check on the efficacy of the treatment only to find out they have not taken the medication at all. It clearly is a two way street communication between physician and patient. If a patient believes a medication is causing an adverse effect or if they want to stop the medication for other reasons it is reasonable to assume that the patient will contact the prescribing physician to discuss the options and choices including how to safely eliminate the medicine .  These options are explained at most visits, they are written in practice instruction books and welcome to the office manuals, they are placed on practice web sites… 

I honestly have never heard this.  In fact, I think I’ve heard the opposite.  Don’t call!  Two different times I have called about a prescription that wasn’t working for me:

Growing up, it was hammered into me that you always finish a prescription.  Always.  That lesson stuck with me.  In college once when I got sick enough that I thought I should see a doctor, I went to the student health clinic.  A prescription was written.  Always finish the prescription became a problem because when I took the first dose, my neck turned red and my throat swelled up, making it difficult to breathe.  Benadryl and time helped.  Thinking perhaps the problem was something other than the medicine, I took a second dose later.  Oops.  Obviously, this was a prescription I wouldn’t be able to finish.  I phoned the clinic and the doctor said, as if I was an idiot, “Well, quit taking it then!”  My follow-up question was whether I needed a different prescription to replace it, or if she needed to see me again. The doctor told me that wouldn’t be necessary.  I was stunned.  Why had she written a prescription if I didn’t need one?  It really sounded like I should have just quit taking it on my own and not bothered her.

The other time I had a severe reaction to a medication, I called the doctor’s office.  The receptionist didn’t want to hear about it and gave me the nurse’s voice-mail.  She didn’t call back.  I called again just before the office closed and left another message, miffed that I was being ignored but resigned to not getting a call until the next day.  Still no call.  The third day I called again.  The receptionist said that my call should have been returned (ya’ think?!), and she put me through to the nurse’s voice-mail once again.  Finally, much later, the nurse phoned and said that if I wouldn’t take the medicine that caused vertigo & vomiting, then they’d write a prescription for the medicine that makes my throat swell; those were my choices.  I chose to go without.  Six weeks later, at my follow-up appointment, I specifically asked, “My understanding from the medication insert is that I’m supposed to call you if I experience an adverse reaction to the medicine, but you wouldn’t take my call.  Under what circumstances should I phone you between appointments?”  The response was, “Never!  There would never be any reason for you to call between appointments.”

Twice I’ve called about prescriptions.  Twice I’ve been blown off.  Given this history, it is not reasonable to assume that I’ll be making any attempt to phone a doctor about a prescription.  Unless specifically instructed otherwise, my inclination would be to figure things out on my own and take it up with the doctor at my next appointment.

Dr. Reznick’s comment makes me think that perhaps I should phone my podiatrist about those ridiculous Flector patches he prescribed.  That prescription was Plan B; after a trip to the pharmacy, I made the choice to go with Plan A instead.  I really thought it would be okay to just mention that at my next follow-up appointment.  Now I wonder.

Remembering to Take Pills

It can be a challenge to remember to always take prescribed medicines.  When I first was given one prescription, it was no problem.  Adding a second was still okay, but adding a third made it a little hard to remember which pills I’d taken.

My solution was two-fold.  For my prescriptions, I’d take all three bottles down from the cupboard and set the bottles in front of me.  I’d open one bottle, take that medicine, then move the bottle off to the left.  Next I’d open the second bottle, take that medicine, and move the second bottle off to the left.  Finally, I’d open the third bottle, take the final medicine, and put everything back in the cupboard.  It worked great for the prescriptions, but I was so tired of opening bottles and swallowing pills that the other part of my solution was to stop all supplements (vitamin C, calcium…)

When these three medicines were to be taken only with morning and evening meals, the dancing-bottles system worked reasonably well.  When a mid-day dose was added, things got a bit more complicated.  I very quickly realized that I needed a way to confirm that I’d taken every dose.  With a family history of osteoporosis, I also suspected that I needed a way to get calcium back into the mix of pills I was swallowing.

It was simple enough to make a little chart and print a list of everything I needed to take.  I’d tape the list to my kitchen cupboard where my meds were stored, and use a highlighter to mark off every dose as I took it.  Problem solved.

After a while, though, opening all those bottles every day got tedious.  About that time, our superhero, RA Guy, did a post about a pill sorter he was using, and I got one to try.  It was easy to see why he liked his – I sure liked mine.  Instead of opening all those bottles daily, I only needed to open them once a week.  When I filled it the fourth week, I knew it was time to visit my friendly pharmacist again.

Nothing lasts forever, though.  Unfortunately, some of the pill compartments have started to pop open, spilling my pills all over the counter (or onto the floor, and a few times even down the sink).  If I had fewer or smaller pills, I’d buy another box like what’s wearing out.  I suspect, thought, that I need something with larger compartments.

Looking at replacement options,  I found a fairly elaborate one (pictured at right) and contacted the company selling it.  This has the features I like about my current pill-boxes (four separate compartments per day, every day is individually removable), but holds an entire month’s worth of medicine and has slightly larger compartments than what I currently have.  It also includes an alarm; if (like me) you’re sometimes tempted to skip lunch, that alarm calls you to come eat so you can take your prescriptions.  The down-side is that it takes a whole lot more space than the flat little boxes I use now.  I’ve found a local supplier, so even got to see the thing 3D.  Price is what’s holding me back right now (well, price and trying to figure out where I’d have space to put the thing – it’s not exactly inconspicuous).

Whether it’s a single-compartment box at the corner drug-store, a more elaborate box like I’m using now, or the mammoth one I’m considering next, I highly recommend a pill-box to help keep track of multiple medications.

Disclosure:  I have not receive any compensation for expressing this opinion – however, I’d be willing to accept a gift of one of these awesome looking pill boxes and giving it a workout so that I could write a thorough review after putting it through its paces.

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*Sorry, don’t recall who sent me a link to the fancy pill organizer. I’d give credit if I knew.  Feel free to speak up in the comments.

Diclofenac

My newest NSAID is worthless.  Just thought I’d be up front about that so there’s no confusion where I stand on this subject.

The podiatrist prescribed Flector Patches and provided a sample.  I am not impressed.

Flector is diclofenac on an adhesive patch.  The backing peels off so that the patch can be applied directly to the skin.  Simple enough theory, and maybe it stays in place on other body parts, but I’m here to tell you that it doesn’t work on the soles of the foot.  Patches on feet will slide all over the place until they scrunch up in an uncomfortable wad.  Although the sticky stuff that’s supposed to hold the patches in place doesn’t stick to skin, after the patch has slid around all cattywampus, it does an awesome job of sticking to socks.

I suppose it’s possible to try taping the things in place, but what’s the point of an adhesive patch that doesn’t adhere?

Then there’s the task of getting at the patch in the first place.  Although some might think it a good idea, my readers with RA will immediately understand the drawback.  What marketing genius decided to make this stuff impossible to access by putting it in a ziplock package?!

One can’t help but be impressed at the persistence of putting diclofenac out there so many different ways.  As Arthrotec, the pill has a stomach-protectant added (for those who can’t manage to take prilosec to prevent the stomach upset that can accompany NSAIDs). As Cambia, it’s added to water and drunk in solution.  As Voltaren, diclofenac comes in tablets taken similar to ibuprofen, mobic, or the hundred other NSAID pills.  Voltaren pills also come in an extended-release formulation (so that the drug company can charge extra money for the same drug, even though they’re manufacturing fewer pills). Voltaren Ophthalmic is available for the eyes, and there’s even Voltaren Gel for topical application.   Pennsaid is another topical form of diclofenac, as is Solaraze Gel.  This medicine really gets around.

Although the diclofenac pills are reasonably priced, that can’t be said of the topical forms of this drug.  Of the different types of diclofenac I’ve been prescribed (voltaren gel, solaraze gel, and flector patches), none are on my insurance formulary.  Yep – tier three.  These things are expensive.  Flector comes with thirty patches in a box, and I’m supposed to use four patches a day.  That 30-patch box doesn’t last a month; it lasts a week.  That comes to $280 a month for annoying things that slide around on my feet, ruin my socks, and don’t do anything to relieve the pain.

Not happening.  I’ll go back to the Solaraze Gel.  It does help, and the $70 tube lasts three months (more or less, depending on how many joints I use it on).

This is my personal opinion.  If you have questions about your own medications, talk to your doctor or pharmacist.

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Thank you for all the nice notes.
First computer virus I’ve gotten since 1991.  Hopefully it’s the last.