The Art of Prescribing (Or Not)

By HANS DUVEFELT

I have learned a few things about prescribing medications during my 42 years as a physician. Some are old lessons, and some are more recent. I thought I’d share some random examples.

First: I don’t like to have to use medications, but when they seem necessary, I choose, present and prescribe them with great care.

CHOOSING MEDICATIONS

Medications are like people. They have personalities. With so many choices for any given diagnosis or symptom, I consider their mechanism of action, possible beneficial additional effects and their risk of unwanted side effects when selecting which one to prescribe. To some degree that goes against today’s dogma.

Blood pressure medications, for example, have what I call an A-list and a B-list. The A-list contains drugs with a proven track record of not only reducing blood pressure, but also actual heart attack and stroke risk. Why we choose from the B-list, the drugs that don’t decrease cardiovascular risk or actually increase it, is a little beyond this simple country doctor’s ability to understand.

ACE inhibitors like lisinopril and diuretics like hydrochlorothiazide are the two recommended first choices in this country. But the A-list also contains amlodipine, a calcium channel blocker and, further down, metoprolol, a beta blocker. I make those less favored A-listers my initial choice in two scenarios:

Amlodipine is my choice when I see a hypertensive patient who prefers a set-it-and-forget-it treatment plan. No bloodwork is required after starting it to monitor for kidney or electrolyte problems, so even if the patient doesn’t come back for a year or more, there is no real risk involved.

Metoprolol, which blocks the effect of the stress hormone adrenaline on the cardiovascular system, is what I talked my own doctor into prescribing for me. That was back in the day, when I was a hard working, somewhat Type A personality with high blood pressure. With the passage of time, life experience, weight loss and my transformative relationship with my Arabian horses, my blood pressure normalized and I didn’t need medication anymore.

Years ago, we all selected blood pressure medications according to the “phenotype” (appearance or general impression) of the patient: metoprolol if intense, hydrochlorothiazide if swollen, nifedipine if cold-handed, lisinopril If naturally hypokalemic (low potassium).

Antidepressants definitely have their personalities, even within a given class, like serotonergic drugs. Fluoxetine is a bit energizing. Sertraline is a bit calming but, in my experience, can bring out an unwanted sensitivity in some “thin-skinned” men. Escitalopram is relatively side effect free and therapeutic in even low doses. Paroxetine is a potent bubble wrap that stops suffering for people stuck in difficult situations but it also dampens positive emotions. It is the hardest one of its class to get off, even with very slow tapering.

The now too popular “atypical antipsychotics” also have differences within the class. Aripiprazole is the least sedating while quetiapine is the most. It is even used primarily for sleep in some situations. But it has greater risk for QT-prolongation and sometimes provokes frightening demonic nightmares in people without psychosis in the first place. Olanzapine is also very sedating and puts on more weight than most drugs in the class, but I haven’t seen it cause psychosis.

SWITCHING STRATEGIES

I often scratch my head when colleagues taper a patient off one drug and start another member of the same class from scratch. I don’t do that. If I need to switch someone from fluoxetine because its energizing effect bothers them to, say, escitalopram, I move directly from one day to the next to a roughly equipotent dose of the other drug. (I hardly ever use escitalopram’s predecessor, citalopram, because it has too many side effects and was fraudulently marketed as relatively side effect free.)

Even switching from a serotonergic drug to a serotonin-norepinephrine drug like duloxetine, I just ballpark it and slide right over to a similar dose (Low, medium or high) and haven’t seen any ill effects of this time saving strategy.

PRESENTING A PRESCRIPTION

I love to tell stories, so I usually talk a bout the history of the medication I am suggesting for my patient. I think it helps the patient understand that I know the medication I am recommending very intimately. There’s probably nothing more frightening than being prescribed a treatment the doctor doesn’t seem to know much about. And only a minority of patients are impressed with descriptions of molecular structure, unless it is when I say things like “the muscle relaxant cyclobenzaprine is related to the antidepressant amitriptyline that is FDA approved for nerve pain, so it can do more than relax your muscles”.

I also talk about how the medication works, what it does and doesn’t do and what the common side effects are. And this is something I started doing recently: Instead of saying “up to 10% of people get a cough from lisinopril, I’ve started saying “one possible side effect is a tickle in the throat kind of cough, but 90% of people have no such problems from it”.

The placebo effect, or the power of suggestion, has often been ignored, but we know very well that treatments prescribed with confidence by an empathic physician produce better results than prescriptions presented as “well, we might try this”.

DOSING MEDICATIONS

“Start low, go slow” is a sound principle. It helps to know how long a medication generally takes to work. It also helps to know what the most commonly used dose is and what the dose-response curve looks like. For example, the blood pressure medication hydrochlorothiazide at 50 mg per day is marginally more powerful than 25 mg, but with much greater risk of causing low potassium. Many people don’t seem to know that the typical step in dosing medications is a doubling: Lisinopril comes in 2.5, 5, 10, 20 and 40 mg – so does anybody really believe we also need a 30 mg dose? I only have one patient on that strength pill.

MEDICATIONS THAT DIDN’T WORK

I sigh internally when I hear that a patient has tried many medications that “didn’t work”. I then have to probe just how much they took, for how long and whether there was any effect at all.

A typical example is when a patient takes the necessarily low starting dose of a medication and stops it before they reach the target dose needed to expect any result. The details can be hard to nail down, but it is sometimes well worth finding out when faced with a patient who claims to have failed everything.

Another common scenario is when a 10 day course of an antibiotic only partly relieves the symptoms of an infection. That’s not a treatment failure – the patient just needed another round of it.

Sometimes we get important information hearing about medications that didn’t work. If an antidepressant makes a person feel agitated, it could possibly mean their depression is bipolar rather than unipolar.

In some cases, the sheer number of medications that didn’t work can make us question our diagnosis. With hypertension, that raises the possibility of what we call secondary hypertension. In those cases, we have to start looking for the single cause of the treatment resistance, such as renal artery stenosis, pheochromocytoma, aldosteronism, alcoholism, thyroid disease, sleep apnea and many others. With psychiatric symptoms, such as anxiety, I have seen how life circumstances such as a bad marriage or overbearing in-laws can make medications completely ineffective.

WHEN NOT TO PRESCRIBE, OR AT LEAST LIMIT PRESCRIBING

Sometimes we are quick to prescribe pharmaceuticals because that seems like the most practical thing we can do to help our patient. Getting an anxious or depressed patient an appointment with a therapist takes time, for example.

One of the more profound lessons of my generation of doctors is how the fluoxetine cohort of antidepressants changed the natural history of depression by sometimes or perhaps even often causing permanent brain changes in patients who take them.

As I mentioned, paroxetine can be particularly hard or even impossible to stop. But the entire class has been associated with this SSRI discontinuation syndrome.

There is a growing anti-SSRI movement and increasing controversy about the use of this class of drugs. There are scientific papersblogsbest selling books, medical practices and clinics offering patients help in quitting antidepressants.

In my own practice, I have become much more conservative when treating depressed patients. The other day, for example, I saw a woman already taking duloxetine for chronic pain and long-standing depression. She was feeling more depressed because of the isolation the pandemic has brought her, separated from her family across the border. She had poor sleep, poor appetite and cried out of the blue, she told me.

I lowered my voice, leaned forward and said, “There is no medication that can take away the pain we feel when life itself changes the way it has. We need to find new ways to carry on, and a good therapist can be like a coach to help us see what we can do, so we don’t get stuck but start moving forward. Our counselor has an opening on Monday and I can prescribe you medication to help you sleep better. Then, next week we can touch base and see how you’re doing. Are you okay with that?”

She wiped her tears and nodded. I was not about to escalate her antidepressant the way I might have considered 10 years ago.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

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