Teachable moments: Take your best shot

“Yes, Doctor. I know this heavily marketed medication lowers blood pressure very well, but there are more things to consider,” I said. “Is the cost prohibitive for her?” he asked. “It’s very expensive, but that is not the only issue,” I said. “What else is there to consider?” he asked defensively.

“Did you know that postmarketing studies on this drug have shown significantly more CV deaths vs. placebo?”

“How could you possibly know that, and how could that possibly be the case?”

“I’m a pharmacist. It’s my job to know such things.” I deliberately brought the trials to his attention so that he could evaluate them.

“Well, the rep was just in yesterday and didn’t say a word about that,” he argued.

 “The same rep knew nothing of the trials when I asked whether he had further information on them,” I replied. 

“Reps visit pharmacies?” he said incredulously.

“This one used to,” I answered. “Incidentally, I never saw him again after the last visit, when I asked him about the post-marketing trials."

“The medication clearly has the ability to lower pressure to evidence-based blood pressure goals,” said the doctor. “I have literature on its safety and effectiveness, and have observed its effectiveness in my practice. It seems extraordinary to me that a medication that lowers blood pressure so well could result in CV deaths. Please educate me,” he added, with obvious sarcasm.

Let's start right now

I told him that a frequently unmentioned side effect of some blood pressure medications is interference with one or more cardioprotective mechanisms, which offsets any CV protection that would otherwise be afforded by lower BP. 

I gave him examples of such mechanisms, including endothelial fibrinolytic activity and a decreased ApoA/ApoB ratio.

His demeanor started to change. Maybe the big words gave me some credibility in his eyes. I don’t know, but in the interest of patient care I was willing to do whatever it took to get through to him.

“Well, that does seem to make sense,” he said. I could tell that he wanted to throw in some of the Latinate jargon that typifies the medical profession, but he didn’t seem to have any handy.

Finally he said, “So what do you suggest?”

Opportunity knocks

My mind raced. I was tempted to seize the opportunity to educate him on the virtues of proper drug selection.

If I could influence him, maybe I could influence other prescribers. Maybe other pharmacists could do the same thing. Perhaps then the use of junk drugs that waste billions of healthcare dollars would start to go down. I could describe how there is little or no evidence that many of the top 200 prescribed medications improve outcomes. How nice it would be to put an end to most of the CR formulations and most of the SNRIs, not to mention the gabamimetics. We could see better outcomes with initial hypertension therapy if chlorthalidone were preferred over HCTZ. Atenolol will quickly fall out of favor when a beta-blocker is indicated. Undoubtedly, we will see fewer CV events with NSAIDs when prescribers are more aware of oral diclofenac. Maybe the ongoing disappointments from so-called innovations in drug development will end if "me too" drugs are subject to more critical review before they're prescribed. Drug selection could finally be based on outcomes evidence. Let’s start right now.

Since the patient was diabetic and had CAD, I suggested either ramipril or perindopril, based on the HOPE and EUROPA trials. Silence ensued.

“I am not familiar enough with either of those medications. Let’s do lisinopril," he said.

“That is a far better choice than the first,” I said, “but I’m unclear on your rationale.”

“Don’t worry about it. Just be glad we're not sticking with my first choice - which I might not have changed, if it weren’t for the problem with cost,” he said. I was shocked.

“I’ll do the prescribing and you do the dispensing,” he said. “Like it or not, that’s the reality, and I don’t see it changing anytime soon. Your profession is not exactly known for progressiveness.” 

Whether I liked it or not, at least we ended the conversation agreeing on something.

Larry LaBenne is staff pharmacist with Martin’s Pharmacy in DuBois, Penn. Contact him at larrylabenne.rx@gmail.com.