Modern medicine is a field that involves following guidelines. As pharmacists, we see a lot of repetition. Eighty per cent of our day seems to involve the same classes of drugs as the previous day. With added pressures of extra duties over the last few years, it can become a busy environment where you struggle to remind yourself of the clinical nature of your job. This includes the possibility of discussing with patients whether the medication they’re picking up is still appropriate for them. Here are common examples of medication groups that are worth reviewing with your patients.

Acid lowering medications (PPIs, H2 antagonists) I put this first because at least half of your patients have probably been taking one for more than the recommended six weeks. The human body was not designed for chronic gastric acid suppression. If you look back you will probably see that this patient has been on this medication for years. Nutrient depletions with this class include beta-carotene, boron, calcium, chromium, copper, folic acid, iron, phosphorus, selenium, thiamin, vitamins B12, C, D, E, K and zinc. It makes it hard to maintain bones, digest food, absorb nutrients, activate digestive enzymes and maintain normal flora in the gut. A new study shows an increased incidence of interstitial cystitis in patients on this long term. You might better solve the patient’s heartburn by removing the offending food agent or, perhaps, decreasing gastric pH in order to increase lower esophageal spincter tone. They may feel awful if they come off it too quick, so I suggest slow tapering. In a televised interview, I explained how to use the acid increasing theory to treat heartburn:

OTC codeine products Here is a product line I wish would go away or be moved to prescription status. I can’t recall any of the many customers that get this product that are new to it. The volume of acetaminophen alone is probably harming their liver, but the addiction to codeine leaves the pharmacist as a police officer and judge as to when they got it last and why they are on it in the first place. In an email I recently sent to Health Minister Rona Ambrose, I urged her to rethink the status of this medication and shared a discussion I had with NIHB on how they were concerned about the addiction from this class on the native population. Unfortunately, I received an impersonal form-type letter back that attempted to educate me on the various drug classes in the country and how they felt all was well with this type of medication as far as a risk/benefit ratio goes. For now, we keep patients to 100 tablets every two weeks, maximum, and this is a population that does not want to talk about their use of this medication. I often find it helpful to discuss their pain or use of this drug.

Daily ASA therapy Twenty years ago, this therapy was certainly in vogue. In fact, even today it is a valuable tool for those at risk of a heart attack. It is one of my favorite medications that became famous without any real studies to back it up and is probably the most off label use medication in use today and is recommended by position statements from various groups. There are, however, many out there that just put themselves on this medication without first seeking the advice of their physician. If your patient has had a heart attack or is at risk of having one, has had a stent put in or bypass surgery, has coronary artery disease, is over 50 or 60, respectively, with high blood pressure or is a diabetic who smokes, then they should be on this therapy. Otherwise, the risk of bleeding versus the benefit of reducing a heart attack is not generally worth it, not to mention the risk of kidney damage from chronic ASA administration. If you fill this prescription or see your patient buying it, you may easily uncover the good from bad reasons they are taking it and steer them to their physician for a re-evaluation. They may have just been put on it years ago for no good reason.

Sedatives (sleeping pills, anti-anxiety medications) Whether it is for sleep or anxiety, these medications are ubiquitous. We may not know why the patient was put on the daytime sedative originally, but quite often they have been taking it for a while. Patients often rely on sleep medications when they work. You owe it to them to question their use without causing further anxiety or uncomfortable vibes. In one patient who approached me with the goal of coming off of her lifelong benzodiazepine, I went back to the root causes of anxiety in some of these people. The body senses when an abnormal process happens internally and responds to it with adrenalin. It turns out Susanna (who proudly asks us to use her name with this story whenever I can) was having glucose regulation issues. Her glucose would drop and her cortisol would spike, causing a corresponding increase in anxiety. When we changed her diet using a low glycemic index and more frequent, smaller meals and added chromium for hypoglycemia, her anxiety dropped off to a level where she could manage tapering off of diazepam. Oh, and she also went gluten free, (sorry, all you anti-gluteners, but when she added this to her lifestyle she claimed it helped). In the end, she stopped 40 years of needless sedative use. She does use Relora periodically now for the odd bout of anxiety. In regards to sleeping pills, the change in sleep architecture over long-term use is not what the brain or body was designed to live with and may be what causes increased depression in sedative users, especially in the elderly. A discussion of proper sleep hygiene can help these patients come off of these medications.

Other opportunities While these are the most common chances to have an impact by revisiting commonly refilled medications, other potential opportunities to investigate your patient’s health exist with statins and the cholesterol/inflammation discussion, bisphosphonates and duration of use and side effects, ADHD meds and their over use in North America, progestin/CEE use, unmonitored iron therapy, overuse of antibiotics, use of antidepressants without a real diagnosis and a refresher on the Beers Criteria for your elderly patients. As a pharmacist we need to remind ourselves that refilled medications mark a path that we are taking our patients down (good or bad) and deserve a thought process that can have a beneficial effect on the patient’s wellbeing, even if it results in that patient coming off of the prescription.

Graham MacKenzie PhC Stone’s Pharmasave