It’s the drugs, man

It bothers me more than I thought it would when patients in the hospital demand brand name drugs.  I had an elderly encephalopathic patient a few weeks ago with spikes of hypertensive emergencies.  His systolic would hover around the 180s, with occasional spikes to the 220s.  And the wife flatly refused to allow us to give him anything other than his home meds.  Toprol XL and Micardis, or nothing.  (She also insisted that the Toprol be given at night, not morning — so my patient’s heart rate would drop to the 30s during sleep and the night staff would, understandably, flip out.  It took us a few days to realize this was happening.) The son, who worked for some pharmaceutical, was actually a lot more reasonable, but of course he couldn’t be around as much.

(P.S. They had hired a private nurse for I don’t know what.   Our own staff nurses would take the vitals every two hours, in additional to hourly rounding, and administer all meds. He seemed like a nice guy, but all he did was sit in an armchair by the window. Not a bad job.)

It doesn’t take Freud to realize that I had some countertransference issues with this patient’s wife.

In any case, I called in my resident to help me handle the situation.  She showed me how to explain the fact that although Toprol XL and Micardis might be great when he is otherwise well, this guy has had a major neurological event, and the body’s response to that is driving up his blood pressure.  Compromise reached was that the wife could keep giving the Toprol and Micardis if she wanted, but she had to agree to us giving the generic anti-hypertensives labetolol (in the same class as Toprol, but faster-acting and stronger) and hydralazine (with a different mechanism of action).  Eventually we got his pressures to goal range.

What irritated me, though, was that this took several days.  Several days when the patient was getting more encephalopathic from his hypertension, and getting more just-in-case MRIs ($$$$).  I’d never met someone before who thinks generics are junk. (Or at least, no one who comes right out and says it.)  It’s a very different mindset from me, who buys her shoes at Payless and her clothes at Dress Barn.  I know that branded drugs may be more effacacious, but to my mind, the cost-benefit ratio isn’t worth it.

I think what really annoyed me was this woman’s worthless spending obstructing her husband’s health.  Medicare was footing the bill here, certainly for the hospital stay and possibly for the private nurse.  I don’t know that the situation would necessarily have been different if they were paying for it all themselves; probably not.  I’m glad we finally did reach a compromise and get this man’s pressure down, but it should not have taken a week.

3 thoughts on “It’s the drugs, man

    1. I have a pharmacist friend who refuses to substitute warfarin for Coumadin. (He says the 80-125% FDA requirement is too broad for something like warfarin, where small changes in dose can dramatically alter the clotting cascade.) Quick PubMed search on the topic turned up mostly consumer-awareness and ethics/policy articles. There was one Canadian study on an increased seizure frequency after switching to generic — but the confidence interval included the null hypothesis.

      I don’t think there’s good evidence that generics are worse, and I’d prefer prescribing generics, but some patients hold very fixed beliefs on the subject.

  1. I bet late, but eh. I’ve had a similar problem before with patients, it’s the mentality that you get what you pay for. If you’re not using the latest and most expensive anything, you’re not giving the best standard of care. I’m glad that you were able to find common ground in the end

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