Medication Coordination

I have just been started on three new medications, two of which replace other medications I had been taking, and the third one is for a new issue.  I have also recently started on a new dosage of another medication. That makes nine prescribed medications, along with fish oil, and a variety of vitamins and minerals.  I have several recommendations to share regarding the coordination of medications for others like me who are helping to keep so many people employed in the pharmacy industry.
First of all, when a doctor suggests a new medication, ask these questions:  what is it for; what is the dosage and when should I take it, and with or without food; how long until the med starts working; possible side effects, and what to do if they occur. Also find out if the medication is for a specific period of time, such as an antibiotic, or something you may need to take long term, such as blood pressure medication.  Have your doctor check to make sure there are no contraindications for any malady you may have, and that there will be no adverse interactions with your other meds.
Don't start more than one new medication at a time.  If you do, it will be difficult to keep track of which med is having what effect, and if there are side effects, you won't know which one is causing them.  When I started these four medications, I did them about 1 week apart. For most meds, that is enough time to tell how it affects you.  Ask your doctor if you should wait longer between starting new medications.
These medications were given to me by three different doctors- my primary care physician (PCP), my gynecologist, and my urologist.  I had each one check that there were no adverse interactions with the other meds I take.  Once I am established on a new medication, I always reorder it through my PCP.  That way, there is one central place that I go to for all my meds, I don't have to try to remember who I need to call, which pharmacy, etc.
Speaking of pharmacies, I have some thoughts there, as well.  Our medical insurance requires that we get our meds from their mail order pharmacy, 90 days supply at a time.  Many pharmacies and chain stores have their own list of inexpensive meds, such as Walmart, which sells many generic meds for $4 for a 30 day supply, or $10 for a 90 day supply.  This is less expensive than our mail order pharmacy, so two of my meds I get at Walmart, and skip the insurance.
Always keep a list of your medications, including dosages and times per day in your purse or wallet.  That way, you will always have it handy when going to a doctor, or if you need to go to the emergency room.  Include on the list a section of any meds you are allergic to, and what reaction it causes.
When you start a new med, remember that some meds need to build up in your system before you will get any effect, so be patient.  Other kinds of meds will kick in right away, with sharper effects and side effects, which will calm down after a few days or a week.   One of my new meds caused terrible dry mouth and nose initially, which has calmed down over the week I have been taking it.  If you don't think a medication is working, or if it continues to have side effects you can't live with, talk to your doctor.  Don't try to adjust it or stop taking it on your own.  If you do, you may get yourself in trouble by ending up with an unintentional overdose, or ineffective underdose.  

Patience Serves Better than Anger

I have been going through a very frustrating time trying to get a medication through my insurance company. Here is a synopsis: I called the doctor to fax a script in to the new mail order pharmacy at least a month ago. It is a compounded medication, I have been on it for about 8 years, with no problems in coverage. I checked on it a week later: The pharmacy claims they never got the fax, the doctor's office claims they got a receipt that the fax went through.

Next: They got the script, but they need to check on the ingredients. Meanwhile, I can see that I will be running out of the medication, so I start to taper the dosage. I continue to check every few days. Next issue: The insurance company decided they needed prior authorization since it is not on their formulary. I call my doctor's office, they claim they were never contacted about the need for prior authorization. Meanwhile, I have totally run out of the medication.

Fast forward to this weekend: I call the pharmacy, who tell me they are waiting for prior authorization (as if this were a new development). I call the insurance company, and am told that they denied the prior authorization yesterday, and I need to contact my doctor about switching to a different medication. I am having symptoms now of being without this medication, so I double up on a different medication who's function is related to this medication. (I always tell my patient's not to adjust the dosages of their meds on their own- to always consult their doctor- do as I say, not as I do.) Of course, it was Saturday afternoon, and my doctor's office was closed until today (Monday).

The topic of this blog could be the frustration of dealing with inept systems, the confusion of trying to figure out when to call each of the various parties involved in a situation (in this case, the insurance company, the pharmacy and the doctor's office), the anger of being at the mercy of organizations whose primary objectives are counter to my own (in this case, I need my medication, they are concerned with controlling costs and getting paid). My focus is not any of those topics, though I did get some satisfaction telling my story. Instead, I want to focus on keeping your cool in phone calls like these.

Each phone call I made during this process (there were at least 15) got me more and more frustrated. I needed my medication, and despite my best efforts, I was not able to get it. My biggest pet peeve is other people wasting my time or other resources for me.

I tend to be a very rational person. There were several times I wanted to snap at people I was dealing with, to ask them what kind of idiots work for their company, to demand that they send me my medication immediately, OR ELSE!!!! But what good would it do me? It would not get me my medication any faster. Most often, the person I was talking to was not the person who was responsible for the actions of their company, it would not be fair to them for me to let loose on them. In fact, in most cases, they did their best to track down answers for me. I did at times ask to talk to someone else in the company, as seemed beneficial, but in most cases, once I got all my questions answered, I thanked the person and hung up.

I think I handled this situation the best way I could. Blaming does not solve any problems, it just muddies the waters and makes it more difficult to get anything resolved. I have little control of this situation, but I can control my responses. I chose to stay calm, to accept that I can no longer get this medication. I could appeal the denial, but I have decided not to. I am still frustrated by this, but this is just one of those things life throws at us from time to time. My plan now is to take this as an opportunity to meet with my doctor, to review all my medications and see what changes might benefit me. This will delay my getting this situation resolved by a few more days, but in the end, I hope to come out better than before.   

Should You Play With Your Meds?

Before I get into the topic of playing with meds (stopping, starting or changing the dosage of medication without the guidance of a doctor), I have to post a disclaimer.  I am not a doctor or pharmacist, and can not and will not presume to tell you how to take your medication.  I am not advocating the practice of playing with your meds, I am writing this post because I acknowledge that people do play with their meds, and often they do it without understanding what they are doing, which can be dangerous.

The two most common reasons for admission to the psychiatric crisis unit where I work are stopping medications and taking too much.  People stop taking their meds for several reasons.  They don't like the side effects, the med costs too much or they think they don't need it anymore.  Some medications cure the problem, and these medications are prescribed for a short term.  Other medications don't cure the problem, but they control the symptoms.  These medications are prescribed long term, and if you feel like the problem is gone, it is because the medication is working.  If you stop taking this kind of medication, the symptoms will likely return.

So what should you do if you think you no longer need a medication you are taking, if you don't like how it affects you, or you think you need to adjust the dosage up or down?  Call your doctor, tell them what you are thinking.  (S)he will guide you with any changes in your medication, or explain to you why changing would not be a good idea.  Your doctor doesn't know that there is a problem unless you tell them, you should work together as a team to optimize your medications.  We sometimes have patients admitted to our hospital units so their doctor can closely monitor a medication change.  Most meds don't need this level of monitoring, but do need some guidance from your doctor.

Sometimes, despite knowing that it is not the best route, people change their meds on their own.  As I said before, I can not tell you how to take your meds, but I can give some suggestions that can help you manage your meds safely.  The most important thing is to know about each of your meds: the name, what you take it for, the strength, dosage, when it should be taken, with/without food, etc.  Among the things to find out are any interactions to avoid.  Some medications affect other medications, and should be taken at different times.  Sometimes there are foods that interact, such as grapefruit juice, which interacts with several types of meds.

There are some meds which can give you rebound or withdrawal symptoms if you stop them cold turkey.  These medications need to be tapered off of slowly, some over a shorter, others over a longer period of time.  If you think a medication is helpful, but does not do as much as you want, you might be tempted to increase the dosage.  Either taking it more often than prescribed, or taking more each time you take it may increase the effect you want, but it might not, and it might be dangerous.  Your liver and kidneys are responsible for filtering out foreign substances from your body.  Increasing a medication might be toxic to your liver or kidneys.  This is one of the many reasons why having a doctor's guidance for med changes is important.    

Medications are usually delivered with a sheet of information.  Sometimes these are very helpful, but often they are too generic, and don't give all the info you should have about your meds. Pharmacists are very knowledgeable (its their job), and can answer any questions you might have.  There are websites and books that have information about meds.  I f you just take one or two meds, you can go to the website for that med, or for the manufacturer to get full info- more than you ever cared to have.  If you take several meds, it might be worth investing in a book about
medications.  Here are some popular ones.
Some good med info can be found at these websites (among others): Web MD, Rx List, Drugs.com.  Useful info includes dosage, side effects, maximum to take at a time and maximum in a 24 hr period, interactions to avoid, contraindications, whether the med needs tapering, the mechanism by which the med works and how it is metabolized and removed from your system.  Some meds are fast acting, and are effective each time you take them.  Others need to build up in your system, and adjusting the dosage up one day and down the next can throw off the balance.

When a patient comes in to our hospital after taking too much medication, we ask them why.  Sometimes it was deliberate, either a suicide attempt or a call for help.  Often, though, they say something like "I just wanted the pain to go away for awhile", or  "I just wanted to sleep". I can understand this urge.  There have been times that I felt this way.  Taking an overdose of medication can be too costly for the brief 'relief' it might bring.   Keep open communication with your doctor.  If you show understanding and responsibility, your doctor may give you some flexibility in how you take your meds. Whether (s)he does or not, you are the one taking care of your body.  Take your medications responsibly.