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BACK TO POLYPHARMACY

OP Kapoor

Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.

When I was a student and a young doctor, I used to see senior specialists of Bombay writing in their firm, illegible hand writing a long list of medicines covering almost two pages of their letterheads. This specially applied to prescriptions of physicians and paediatricians. These usually included 2-3 types of injections.

I have worked hard and given lectures all over the country advising doctors to stop using injections in routine (non-emergency) cases because of the risk of transmitting hepatitis virus and now the AIDS virus. I have also been successful in coaxing doctors to reduce the number of drugs in their prescriptions and thus discourage polypharmacy.

A practitioner always faces difficulty in treating an average patient of ischaemic heart disease (IHD), who also has other risk factors like diabetes, hypertension, hyperlipidaemia and other incidental illnesses like arthritis and spondylosis due to old age.

It has already been shown that a patient of IHD must get a prescription for aspirin, statins and betablockers life time in addition to other drugs. Thus my ambition of coaxing doctors to cut the size of the prescription does not seem to be working well.

Like multi-drug resistant (MDR) tuberculosis, blood pressure is also becoming MDR type. More than 50% of the patients need two drugs and nearly 20% of the patients need three drugs to control BP.

Diabetic patients are being advised to take a combination of insulin, oral sulphonylurea and biguanides. All moderately severe diabetics have now been advised to take Ramipril 10 mg life time (according to HOPE study) to reduce all future complications of stroke and renal failure.

The shock I received recently was a prescription for CCF. In olden days it was digoxin and a diuretic. Later on, it was realised that if the patient is in sinus rhythm, digoxin is not effective. Instead ACE inhibitors were found to be the best line of treatment for every patient of CCF. As time has gone by, a patient of CCF is being advised :

1. Carvedilol - a selective betablocker (in the past betablockers were contra-indicated).

2. Angiotensin receptor blocker like losartan.

3. Digoxin even in a patient of sinus rhythm.

4. Spironolactone - it has a special effect in patients of CCF.

Thus, it pains me to say that even in a patient of CCF, we are reverting to polypharmacy based on different theories put forward by cardiology Pandits and not to forget that most of the patients of CCF will have hypertension, diabetes, hyperlipidaemia and many other co-incidental illnesses of that age, for which they will require additional drugs.

Finally, the nuisance of side effects of all these drugs (e.g. constipation requiring laxatives) and interactions (unknown to us) which may be interfering with the action of some of the drugs prescribed by us in good faith have to be kept in mind.


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