,Medicine
Just keep taking the tablets
John Linklater
One of the surprising discoveries that each doctor makes for himself after a few years in general practice, is the high proportion of tablets and capsules that the patients leave unconsumed. This is especially true when several different kinds of tablet have to be prescribed at the same time. The problem is not easy to solve. Doctors certainly do not wish to give patients unnecessary treatment but they are, in a sense, hoist with their own petard in the form of the explosion of medical, chemical and pharmacological knowledge, as the major drug firms compete to produce more specific, potently effective substances.
Most diseases involve several organs and functions, and the patient will thus often recover more quickly if several different substances are prescribed concurrently.
In an acute infection arising in an elderly chronic bronchitic, for example, an antibiotic is given to deal with the infecting organism. but a mucus thinning agent such as bromhexine hydrochloride as well as some bronchodilator is useful to clear the lungs of pus. The patient may, meanwhile, be in mild heart failure due to the difficulty of forcing blood through congested lungs, so that a cardiac stimulant, and a diuretic to remove surplus body fluids, should also usually be added. The increased flow of urine which results will tend to deplete the patient's store of potassium and a supplement is given, quite apart from any cough linctus that he may ask for, or something to help him sleep.
In the days when most treatments came in a corked bottle, meticulously wrapped and topped with red sealing wax, the doctor could exercise his skill in making up the required mixture ad hoc to suit each case. The patient would then only have one medicine to swallow, and would probably finish it all, particularly if he had paid for it.
Nowadays, however, the doctor can very easily find himself in the position of prescribing six or seven different kinds of tablet at the same time, with the ever-present possibility that the patient will discover that some "suit him"
better than others, or that some are more difficult to swallow, or that he simply gets into a muddle and takes only those tablets that he recognises as old friends.
Most doctors, nurses, health visitors, receptionists and, even vicars, will have spent varying lengths of time un-muddling the tablets, usually of the elderly patient, and getting them back into the right bottles.
The same problem does not often arise in hospitals providing that the staff have an adequate knowledge of English. There is nothing to prevent the hospital doctor from ordering as complex and appropriate a therapeutic regime as he wishes. Hospital specialists thus often fail to understand the general practice desirability of using tablets containing several different drugs and tend to refer to this scathingly as polypharmacy. Students are taught to avoid such fixed combinations and manufacturers follow suit.
If polypharmacy refers to a combination of several necessary drugs which would anyway have been prescribed separately, then it is the modern, solid state, version of one aspect of elegant dispensing. It is not undesirable. It is to be distinguished from the medically reprehensible blunderbuss mixture of different drugs, given in the hope that one or other of them may be effective, and that the rest will do no harm. Blunderbuss therapy is usually the backstop of the doctor who has not made a precise or complete diagnosis.
Most experienced general practitioners will have discovered several well-known brands of tablets containing drug combinations that are of great value in conditions such as asthma, and many of us have wished that the prejudice against polypharmacy could have been overcome in many other common conditions. Drugs for high blood pressure, for example, often cause side effects. The skilful combinations of substances to calm the central nervous system, slow the heart rate, relax the peripheral arterioles and remove excess fluid, while keeping the salt balance correct, in one tablet, would be of great benefit to a patient who may be instructed to take six to ten assorted tablets daily. The ideal solution would be for drug firms to manufacture minute slow-release pellets of appropriate products, containing very little inert vehicle, and which would thus be unsuitable for direct sale across the counter. The pharmacist, however, could load these pellets in standard size capsules in the precise proportion laid down in each prescription. Such meticulous prescribing would by no means be generally necessary, but would certainly satisfy the traditional criteria of elegance, as well as the realistic, commonsense requirements of general practice. Patients are unlikely to waste medication given in the form of a single capsule to be taken once or twice a day.
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