Polypharmacy - A Question of Ethics or Pure Ignorance

I have come across quite a number of patients coming to my clinic seeking for treatment for the same condition after having attended other private clinics. I have chosen a couple of paediatric cases. Both children, one is a three year-old toddler and another is one and half-year old. They both suffered from intractable diarrhoea and vomiting. The older one had been suffering for more than ten days and the latter for more than a week. They both looked listless and irritable. They had not been feeding well and appeared dry and thin. The little one's bottom was raw due to prolonged purging.

According to both mothers they had been to clinics and were prescribed medications which they kept giving to their children and yet the diarrhoea never seemed to ease let alone cease.

The mother (AR) of the older child was desperate and without being prompted had proceeded to take out from her bag all the medications prescribed by the clinic and altogether with consultation, she said she forked out RM75.00. I noticed that the woman was not really educated and yet had the sense of bringing all the medications which had failed to "cure" her child, to show them to me. I was impressed as not many would bring along their "failed" or ineffective medications and yet expect the next doctor to "cure" them.

The second mother (CP) did not bring the prescribed drugs but I made her go home to get them for me to see. I always tell this kind of patients that since I don't know what drugs have been given to them earlier, I might prescribe the same ineffective drugs and they would still not get better.

What I found was interesting. For simple diarrhoea, an array of drugs: an anti-diarrhoeal preparation, anti-vomiting, anti-fever,vitamin and anti-colic were prescribed between the two kids.

Five different types of drugs prescribed
for childhood diarrhoea (Mother AR)

Three different types of drugs to treat
diarrhoea in a child  (Mother CP)

All the kids needed was an oral rehydration therapy using a pre-packed oral rehydration salts. These should be given to them as directed till the diarrhoea stops  and other soft diet like porridge and milk can be continued.

In this case, the purging should not be prevented by giving an anti-diarrhoeal preparation as the body is throwing out "something" which is not safe for absorption by the body. Use of many drugs for this simple diarrhoea which 85% of the time is due to virus, would only prolong the diarrhoea and discomfort as happened in these two cases.

For most childhood diarrhoea only
oral rehydration salt (ORS) solution is needed

Why are these drugs prescribed? It seems to me either the practitioner is treating the symptoms such as vomiting rather than the root cause of the condition or for pure monetary considerations: the more drugs are prescribed, the more profit is generated (and likely the more side-effects). Either way, the patients suffer. It is an undesirable outcome.

For both children, I just advised their mothers to stop those drugs and offer them oral rehydration salt (ORS) and told them to return in 48 hours if the diarrhoea had not subsided. True enough they both recovered on that treatment alone and at the cost of RM7 (without consultation fee)

I have seen adults also being prescribed an anti-diarrhoeal preparation when all they need is only a replacement fluid therapy till their diarrhoea usually due to gastritis or food poisoning stops. Most diarrhoea except for bloody ones are supposed to be treated this way. Over treatment with several drugs will only worsen or prolong the gastrointestinal condition.

Polypharmacy is unethical and ignorance is unacceptable.

Fruit and Drug Interactions

A recent study by a Canadian group has shown that taking certain prescription drugs with grapefruit juice can lead to adverse reactions due to high levels of the drug in the body as a result their metabolising enzyme in our body being deactivated by chemicals found in the fruit known as furanocoumarins. 

Without the enzyme, more of the ingested drugs will be available to our body making it toxic. It is said that taking one tablet of such a drug with grape juice is equivqlent to taking 10 tablets with plain water. An anti-hypertensive drug, felodipine, was reported to have increased its level to three times after patients had a glass of grapejuice compared with a glass of water.

Grapefruit juice can alter action of certain drugs in the body

So it is important to ask your doctors or pharmacists to help check for you which foods you are taking that might interact with your present medications. From my patients' experiences I came to know of some herbs which also interfere with antihypertensive medications causing dangerously low blood pressure (due to resultant drug overdose) with accompanying dizziness and possible collapse.

The Stuff of Primary Care and A Duty of Care

Nearly 90% of patients who visit Primary Care clinics or General Practitioners suffer from respiratory conditions. While many of these are due to viral infections and therefore do not warrant an antibiotic therapy, a small proportion of others are due to allergic reactions giving rise to an asthma.

It is therefore important for a doctor especially at this point of contact to examine the respiratory system especially listening to breath sounds to determine a diagnosis which ensures a proper treatment for the patient.  Sadly many doctors, possibly due to the heavy attendances or simply negligent, have not conducted this step satisfactorily.

I have recently attended to a 10 year old boy who has been coming to the clinic since August 2012 for recurrent coughs. The first time he came he was given the usual anti-cough mixture, the second time it was the same, the third time the doctor ordered a sputum for AFB ( Acid-Fast Bacilli) for suspected TB (tuberculosis) and given a double antibiotic regime as he thought the child could have pneumonia despite not having any fever. The recurrent coughs had never stopped and the father kept bringing the child and another two sputum AFB were ordered and I noted only one test came back without any report as the samples were said to be not satisfactory. I also could not find the chest x-ray ordered by the third doctor and so reluctantly have to order a new one which I was not happy about.

There is no continuity of care for this child who is rather quiet. He was seen by four different doctors before coming to me. It didn't help that the child kept denying that he had breathing difficulties especially after physical exercise. I took his blood sample to see whether his hemoglobin level is normal as though he has no pallor, his father insisted that he has not been eating well. The boy's Hb level was good at 13.4g/dL.

I did a full examination of his respiratory system and listen intently for his lung sounds and detected the mild wheezes. I made a diagnosis of asthma and treated the child accordingly and the coughs have since been reduced and the father is very happy to at last be told of the diagnosis and how to deal with the condition.

It is very important to make a firm diagnosis in this case and relieve the family of the anxiety about their son's intractable condition. Listening to the chest properly and defining the sound relating to which part of the respiratory tree that is causing the sound is therefore critical in this case.

Needless to say, the best confirmatory test for the diagnosis of asthma is to perform the respiratory function test namely spirometry on this 10-year old child for which the father has to take him to the hospital as unfortunately the facility is yet to be made available at our clinic level. This test will also determine the severity of his asthma.