Dogs are picky. Sometimes, they do just what you ask them to. Other times, they may not. They’re friendly with one person, and they growl at the next. Sometimes, different breeds get along; sometimes, they don’t. Now that I’m thinking about it, dogs and medication have more similarities than I realized.
Think about it: some drugs work exactly as intended for our patients. Some drugs don’t. Two different drugs may not pose any risk to a patient. But there are times when two different drugs don’t mix well.
The point is that physiology plays a huge role in which type of drugs (and how much) we prescribe. Although this may seem like common knowledge, Nancy Myers, a clinical pharmacist at Unity Health, says that certain physiological conditions, particularly in obesity, can drastically affect the way drugs behave in a patient’s body.
As common of a condition as childhood and adult obesity are in the United States today, it’s time to reconsider how we prescribe drugs to individuals with obesity and other physiological conditions. Doing so will ensure that we keep patients safe from adverse drug reactions and other potential complications that might occur from an improper dosage.
Physiological changes without dosage changes create problems.
Some medications tend to hang around in the body of an individual with obesity longer than they would for an individual of healthy weight. This delayed response causes some providers to think medication changes need to be made, so they prescribe a different dosage or a new drug altogether. “Prescribing without giving the patient’s body time to respond to the first dose can lead to some dangerous outcomes,” Nancy says.
Overdose/Underdose. Without considering that a drug may take longer to metabolize in the body of a patient with obesity, a doctor may prescribe a higher dosage of that same drug, causing the effects of the drug to stack on top of one another and cause an overdose. “You need to be sure you give an adequate amount of time for the drug to metabolize in the patient’s body. If you don’t, the patient may be overmedicated due to slowed metabolism. Conversely, patients may also be under-medicated if physiological conditions are not considered,” Nancy says.
Adverse Reactions. Prescribing a new drug may cause a negative reaction between the patient’s body, and the combination of the two drugs. “Because a medication may be hanging around longer, a patient may have an adverse reaction to the combination of the two medications,” Nancy explains. “But, when you assume the old drug that you prescribed has been eliminated from the body, you discount the fact that the new drug may be interacting and causing some negative side effects for the patient.”
Inaccurate Trials/Results. Assuming drugs are ineffective for individuals with obesity may mean that drug trials and information collected at the clinical level may have skewed data. Being mindful of the way drugs are absorbed, metabolized, and eliminated in individuals with obesity will allow the medical community to have data that more accurately shows the results of certain doses and side effects of various drugs in different body types.
The wait for clinical trials begins.
“We don’t have a lot of information from clinical trials and research on the significance of obesity in the clinical impact of drugs,” Nancy says. Historically, clinical trials did not always recruit participants who represent individuals most affected by a particular disease or condition. In other words, the patients who would benefit the most from these trials are the ones not being recruited to participate.
This created gaps in our understanding of the effectiveness of diseases and treatments across populations. A limited number of clinical trials for patients with obesity means that we must carefully consider the way in which we prescribe medications to these patients.
Obesity is also closely linked to several social determinants of health (SDOH), such as food insecurity, poverty, and access to care, and co-morbidities, such as diabetes and cardiovascular disease. Limited clinical trials prevent health care professionals from knowing the full effects of certain medications on individuals with obesity.
What can providers do?
It will take time for clinical drug trials to adequately address this patient population. For now, it’s important that we pause and think about what factors may be at play because of the physiological changes in a patient’s body.
“At this point, while we wait for data to be collected and made available, it’s critical that the prescriber, patient, and care coordinators work together to determine what changes are needed with the medication,” Nancy says.
In a team-based approach, multiple parties are at play. The provider prescribes the medicine to the patient. The care coordinator then follows up with the patient a few weeks out to ensure the patient is handling the medication well and taking it properly. Then, the pharmacist will perform an assessment with the patient to gather critical data about the outcomes and record any changes in the effectiveness of the drug. A team-based approach also ensures that any needed changes are referred up the chain to the provider, who can then change the dosage or prescribe other drugs as appropriate.
Patients know their bodies. As health care professionals, that can sometimes be our greatest asset. “Because of the limited trials and research, most of our feedback has to come from the patients. That’s why it’s critical that we stay in tune with our patients and consider the possibility that the drug is metabolizing differently in our patients with obesity,” Nancy says.
How can our patients trust that they're getting the right dose or type of medicine?
The best thing a patient can do in any situation is to ask questions if they feel uncomfortable or want more information about a medication. The key to a patient taking control of their own health is through good communication. In this case, Nancy says, it’s about asking the right questions.
“It’s important to always consider the patient perspective,” she says. Patients should ask three main questions with regard to the medication they are prescribed:
- What should I expect the results of this medication to be?
- What should I expect the side effects of this medication to be?
- Whom should I contact if I have questions or concerns after I have started taking this medication?
These three questions will allow patients to know what to look out for while taking their medication, but it will also provide doctors and pharmacists with key information about how the patient’s body is reacting to the medication. “When you have open communication with your care coordinators or care teams and let them know how you’re feeling after you’ve started your medication, you provide them with valuable information they can use to evaluate whether your responses are normal or whether changes need to be made,” Nancy says.
Don't wait to communicate.
In health care, it is vital that patients maintain an open and honest conversation with their providers in order for them to receive the best care possible. Unfortunately, that is not always the case. “I have some patients that come to me saying that they didn’t want to call their doctor when they had problems with their medication because the doctor was busy,” Nancy says.
When those patients come in for their next doctor’s visit, they may not have been taking the medication for the entire duration it was prescribed. “They may have quit the medicine one week after it was prescribed because of how it made them feel. They only took the medication for a week instead of three months like they were supposed to. So, then you’re starting from square one and have lost valuable time for improving patient outcomes,” Nancy says.
Honest and judgment-free communication will go a long way in properly caring for our patients. Instead of waiting for their doctor’s visit, a patient may feel more comfortable calling the clinic and speaking with someone about their concerns with the medication. “When they voice their issues, we can try to correct their problems and get them on a medication that agrees with their body,” Nancy says.
Ultimately, good practice comes from value-based strategies and team collaboration. Caring for our patients is not a one-person job. There are countless unforeseen changes that may occur and several new variables to consider. The important thing is that we remain focused on recording any changes we notice and keeping a constant line of communication with our patients and our care team.
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