Selecting medications

April 30th, 2018

I find it amusing when I’m watching the evening news on TV and a dozen ads appear for medications with smiling happy people and at the end an announcer rattles off the side effects, ranging from rashes to gastrointestinal issues and sometimes death.  Obviously everyone who takes these medication will hopefully not get all of these side effects.  This brings to mind a situation that I’m finding more common in my practice:  there needs to be shared decision making between doctor and patient when selecting therapeutic medications.

Here are some helpful points to help you and your medical provider to customize your medication regimen.

• There are often MANY medications in each drug class.  If one medication does not work or you experience unpleasant side effects, don’t be afraid to tell your provider you want to try another.  I call this the “Goldie Locks and the Three Bears” process.  As I mentioned earlier, not everyone will have the same side effects from the same medication.
• Find out what has worked for others in your family.  At a recent conference, a psychiatrist mentioned that she treats families where they “swear” by certain anti-depressants and shun others because they don’t work or have unpleasant side effects.  It may not be too far from the truth that people who share some of the same genes would respond better to some medications than others.  I frequently ask my patients with high blood pressure if they have a close relative who also has high blood pressure and what they are taking and whether their regimen is effective.  Over the years, we are learning that high blood pressure has many different causes with a root in genetics.  It makes perfect sense to consider treatments that have worked for blood relatives.
• Do you process medications quickly or slowly?  People who process medications quickly through their bodies usually have to take higher doses, and vice versa.  In general, people who have smaller body sizes and women would be more likely to be slow metabolizers.  To get a better understanding, I like to propose the analogy of people who drink alcohol.  Some people can have one glass of wine and get very tipsy (slow metabolizer), whereas others can have a bottle and remain sharp (fast metabolizer).  Ask yourself, when you take Tylenol or Motrin for pain, do you usually need to take a lot for the pain to go away or can you get by with just one pill?  If you are the latter, you are a slow metabolizer which means you may want to tell your medical provider that you should start on a low dose and increase slowly.
• Find out what the main side effects are and discuss them in the office with your healthcare provider.  Are these compatible with your life and your other health issues?  For example, one type of weight loss medication called Orlistat has a major side effect of diarrhea.  This may not be the best choice if you have hemorrhoids which get worse and can be quite painful with frequent bowel movements!  In the treatment of hypertension, one of the first line drugs is a diuretic (makes you urinate) called hydrochlorthiazide (HCTZ).  For many people who have a long commute in the morning, having to find a bathroom on a subway or bus can be yet another hassle in your day.  Fortunately, there are over 200 other medications to treat blood pressure now!  If the diuretic doesn’t fit into your life, why not try another medication which fits better into your lifestyle.
• Maybe there are side effects which you actually want!  No, I didn’t mistype that last sentence!  Interestingly enough, some side effects can be positive.  A few examples: Metformin taken by diabetics for lowering blood sugar has the side effect of weight loss, Finasteride taken for enlarged prostate can regrow men’s balding areas on their head, Topamax is an antiseizure medication that can also reduce migraines and causes weight loss, Spironolactone is a diuretic (water pill) used for treating high blood pressure that can also reduce body hair (requiring less shaving of the body) and induce breast growth.  Talk with your doctor and ask if there may be a medication which can “kill two birds with one stone”.
• Find a dosing regimen that works for you.  Some medications have “extended release” versions so instead of having to take a medications twice or three times a day, you only have to take it once.  This can also give you a cost savings since you would only need half the number of pills.
• Is there a similar drug with a generic version.  In general, generic versions are cheaper than their brand name counterparts and can be just as effective.  If you healthcare provider prescribes a medication and you realize at the pharmacy that the co-pay is way too expensive, don’t leave the pharmacy with the medication.  Once you do, you will not be able to bring it back for a refund!  I advised that you inform the pharmacist and your provider that the cost is too expensive.  The pharmacist can work with your provider to prescribe a less expensive and likely generic version.
• Healthcare providers often do not know what the cost of the medication will be for your particular insurance.  In the US, each insurance creates a formulary of preferred drugs.  If you are prescribed a non-formulary medication, it will likely cost you more.  I recommend that patients obtain this formulary from their insurance each year (since it can change yearly), and bring it to each provider visit and encourage him/her to prescribe medications on that list.  Some EMR (electronic medical records) can identify the formulary medications, but may not always update with your particular insurance.  As a rough guide, if you have seen a commercial on TV for the medication, it is not likely to be on the formulary as it is a newer medication.