The importance of reviewing patients’ medicines

The importance of reviewing patients’ medicines

Vijay Gopichandran


Over the past few weeks, I have seen several patients all whose problems could be fixed easily with just a tweaking of their prescription list. I am writing this blog to share these experiences to highlight the importance of a review of the patients’ medication lists. Nowadays many patients, especially senior patients, are on multiple medicines. It is not uncommon to find a senior who is on five to ten tablets per day, for their diabetes, hypertension, cholesterol and other conditions. Such a condition where patients are on multiple medicines is referred to as polypharmacy. The World Health Organization in its recent report on Polypharmacy has highlighted the growing incidence of polypharmacy in many countries due to an aging population and increasing prevalence of non-communicable diseases. The report also highlights that the important steps to be undertaken to avoid adverse reactions due to polypharmacy are appropriate prescription, medication review, proper dispensing, communication, and patient. In this blog, I will share a few experiences of patients who had multiple drugs on their prescriptions. A careful review of these drugs helped some of the important problems of these patients.


Mrs. T is a regular visitor at my clinic. She has diabetes and is on regular tablets for it and is under good control. A few months ago, she came to the clinic with a sudden onset of palpitations and breathlessness since the previous night. On careful examination, she had an irregularly irregular heart rate. Her ECG showed that she had a condition called Atrial Fibrillation. Atrial Fibrillation is an irregular beating of the heart which results from some structural abnormality of the chambers of the heart. Rarely it can happen without any identifiable structural abnormality, in which case it is referred to as idiopathic lone atrial fibrillation. Mrs. T was seen in a tertiary care center and was diagnosed as having this condition. She was started on some medicines to control the heart rate, and medicine to prevent blood clotting called acenocoumarin. In patients who have atrial fibrillation, the atria do not contract well. So there is stagnation of blood in the atria. This predisposes the blood to clot. If these clots get dislodged into circulation, they can cause serious problems. So acenocoumarin is given to prevent these clots in patients with atrial fibrillation. Mrs. T started the medicines and her heart rate was controlled and she started feeling better. Last week Mrs. T came to see me with acute and painful swelling of her left knee. On examination the knee was warm, it was painful to touch and there seemed to be some fluid collection in the knee. I carefully reviewed her prescription and all medicines that she was taking and noticed that Mrs. T had been started on a drug called Ibuprofen in combination with paracetamol for her knee joint arthritis by another local physician. Ibuprofen is a drug which has anti-platelet action. Platelets are essential for preventing bleeding. So, when the physician added Ibuprofen to the medication list without noticing the presence of acenocoumarin, he precipitated a state of heightened bleeding tendency, which led to the bleeding inside the knee joint. Mrs. T needed an emergency referral to a tertiary care centre for the care of her knee. But a careful review of her prescription could have prevented this serious complication.


The above example was serious and resulted in a major complication. Failure to review prescriptions can also lead to milder issues which can be dramatically fixed just by adjusting the prescription. These experiences are rewarding. There was a 40-year-old lady who came to the clinic with extreme weakness and fatigue. On examination, she was very pale. Her haemoglobin level was only 7 g/dl, which is extremely low. I started her on iron supplement tablets. She started feeling better but continued to have a low haemoglobin even after two months of treatment. Then I carefully reviewed the prescription to note that she had started self-medicating herself with over the counter antacids. Antacids usually contain aluminium and magnesium hydroxide, both of which can reduce the absorption of the iron by more than 70%. This can hamper the improvement of the iron levels in the body that is expected with treatment. I just advised her to space her antacids and iron tables two hours apart and it substantially helped her haemoglobin levels go up.


Last week I saw an elderly man in the clinic who complained of severe constipation. He has been seen elsewhere and had a lengthy prescription. The prescription contained Amlodipine, used for control of blood pressure, metformin used for control of blood sugar, atorvastatin used for control of cholesterol levels, aspirin to prevent heart attacks, a liquid antacid to help the aspirin induced gastritis. The other physician had also started him to laxative tablets to ease his bowel movements. A careful review of the prescription shows two drugs, both of which can cause constipation, namely amlodipine, and antacids. When given together these two drugs can worsen the experience of constipation. I removed the liquid antacid from the prescription, switched over from Amlodipine to another anti-hypertensive medicine and gave him dietary advice and recommended increased fluid intake to help the constipation. He came to the clinic yesterday with a look of absolute relief and satisfaction that his constipation had resolved.


There is an increasing belief among us clinicians that there is “a pill for every ill”. This is not true. I remember my teacher Dr. Misra used to sit with the previous prescription of every patient and carefully go over each drug in it and weed out the unnecessary ones. I do the same with all my patients. Many of my patients do not have properly maintained medical records or prescriptions. Often, they just bring a bag full of tablets. Some of the more organized patients bring a small plastic box which serves as their pill container. I empty the bag / box on my table and spend time sorting out the tablets and reviewing them carefully. It is a time-consuming exercise but worth every second of the time it consumes. There have been many instances where I have picked up irrational drug combinations and removed them. Sometimes, patients go to several doctors in a desperate search for a cure for their problems. They sometimes take pills prescribed by different doctors. I have noticed some patients taking the same tablet in two different brand names prescribed by different doctors, thus taking double the required dose. I have also seen patients who see different doctors for different illnesses and not informing the doctors about seeing other physicians. One patient was prescribed aspirin to prevent heart attacks by both the diabetes doctor as well as the heart doctor and the patient was taking a double dose of aspirin. It is extremely important to carefully review the medications and actively engage with the patients to explain to them the role of each of the tablets that have been prescribed to them. Many times, adjusting the prescription list in itself can be a great treatment exercise.