My Other Clinical Rule on Drug Therapy
I wrote recently about what I call Clinical Rule #1: a patient who is doing well is likely doing well. I often invoke this rule when someone is looking to worry a simple patient situation into a serious one. But that is not my only rule. Here is one related to drug therapy.
I’ve taught medical students and pharmacy students for many years. Of course, entrance into these professional programs require that students successfully complete a course in calculus, even though calculus is not used extensively during the curriculum. Calculus looks at first derivatives, the slopes of curves which are either increasing, decreasing or zero.
So, I sometimes explain to students that we require calculus so that students can use their knowledge of first derivatives to understand patient care: patients are either getting better, getting worse, or staying about the same. And looking at patients and symptoms in this way can help us decide if treatment is appropriate.
Some years ago, our boy scouts were fooling around and one of them fell off a wall. Insofar as we were preparing to leave on a camping adventure, John said he hurt his arm, but was OK. I suggested that we wait a little while to see how he did – better, worse or the same. Within five minutes he had an ashen appearance and clearly was doing worse. He had to have his broken arm set before he could rejoin the troop.
For most acute injuries and illnesses, we will be looking to get better or at least not get worse. Recovery of function always involves getting better; staying the same or getting worse is not success.
Drug therapy goals should be obvious when you think about it in this way.
You get a prescription for an antibiotic. It may take a short time to kick in, but you should be getting better. Staying about the same or getting worse are clear signs that treatment is not appropriate.
Getting better is not expected for all drug treatments.
- Patients with Alzheimer’s disease may take one of several drugs for cognitive function: galantamine (Razadyne™), rivastigmine (Exelon™), donepezil (Aricept™), memantine (Namenda™).
- These drugs are not going to cure Alzheimer’s disease; drug treatment that maintains function and slows decline is appropriate therapy.
Stephen Hawking, the great theoretical English physicist from Cambridge University in England, has amyotrophic lateral sclerosis. Successful treatment for ALS will at best minimize a slow functional decline as the disease progresses.
My mom has been trying fish oil for her age-related macular degeneration. (There is no established evidence for fish oil helping macular degeneration). While she has good and bad days, the best she can hope for with macular degeneration is to have more good days and fewer bad ones. A great result would be to just maintain her current vision without further decline. An improvement in vision might qualify as a miracle.
There are many variables to the human condition, disease states and drug therapy.
Human life is a story of the slow and steady decline in physiological function from teenage years to old age – brain, heart, lungs, liver, kidneys and sexual function all slowly decline.
Medicines can often produce short-term improvements and help many patients maintain health as they age. Blood pressure, blood sugar and cholesterol can all be well controlled in most patients; so can many other health problems.
As you take your medicines, think about the goal of improving, maintaining, or slowing various disease states. Talk to your prescriber or pharmacist if you have any concerns or questions about your medicines. Focus on taking care of yourself.