Sunday, 6 September 2009


I work full time. If patients problems through the working week, I am keen to sort them out with them. Sometimes, problems can be around the use of medication. Maybe it isn't working. Last week I had a patient 'phone because they'd been prescribed something else and wanted to know if she could take both tablets together. Maybe it's side effects (a patient last week had his rivastigmine patches stopped and a yellow card filled out after they caused ghastly rashes beneath each patch). Often it's because something destabilised the otherwise manageable situation (such as a patient last week with a chest infection who's otherwise manageable confusion/dementia became unmanageable and another lady who's daughter was going on holiday so couldn't give mum her tablets for that week).

My secretary receives messages from patients and carers that need attending to. Partly because it's important to them, partly because I don't like delays, partly because I've to do the work anyway so may as well do it straight away and largely because I get stressed if there's work to do that I leave for another time, I sort out such queries straight away. Well, my secretary gets their file out and attaches the message to the front, but such queries are invariably dealt the same morning or afternoon.

Some GPs write to me for advice about medication, which I very much welcome. Whether it's about a specific patient or whether it's about a concern they have/have read I usually get a touch too enthusiastic in replying. Because I know GPs need the information to be clinically relevant and because in Primary Care those who work with the GPs and need to understand and give the same message/work in the same sort of way, my letters back to Primary Care are not too abstract/theoretical and instead focus on the broad clinical headlines. Sure, I'll mention authors' names if relevant, so the GP can look it up if they have an interest, and so it's clear what the sources of my opinions are (and it's not just me making stuff up!) but by and large shared information is me waffling a bit about a topic. This is in my thoughts because the last letter was on why I wanted an ECG done before I planned to see a patient with dementia (who'd been seen by my nursing colleagues) in her care home. The typed letter was a touch over 2 A4 pages long. This is typical. What can I say, as is evident here, and as nurses chide me, I all too readily can waffle.

Getting medication right and sharing information about it matters. Patients, rightly, are keen to remind us of this.

Clinicians changing medication that another clinician initiated can cause difficulties. A GP changed a gentleman's lorazepam to haloperidol last week. The gentleman was under my care and had been for a couple months, with progression of his severe dementia, with nursing colleages and me seeing him at least once every week.

The gentleman was in respite care, where I'd seen him and nurses spoke with staff about his management.

He was wandersome, the home called his GP saying he was restless and distressed and hard to manage, the GP stopped lorazepam and started haloperidol.

The gentleman's Lewy Body dementia did not respond well to haloperidol, oh no. Poor bloke was rigid the next day. And drooling, come to that. By rigid, I mean he was so rigid he couldn't stand up, couldn't walk and couldn't eat. He was on 5mg of haloperidol twice a day which in older adults is a very significant/high dose, typically x10 what could be started.

The marketing authorisation for haloperidol says, "Baseline ECG is recommended prior to treatment in all patients, especially in the elderly . . ." and when the dose goes up an ECG is desirable, "During therapy, the need for ECG monitoring (e.g. at dose escalation) should be assessed . . ."

No ECG was done for this gentleman before starting haloperidol or during it's use.

Drugs in dementia cause risk as well as benefit. My GP colleagues can't be reasonably expected to keep up to date with this since it's a specialist area of prescribing and consideration to risk/benefits, often with incapacitated adults. Can a GP reasonably be expected to have read about the DART trial published this year and the effects of an antipsychotic doubling your risk of death in dementia (with 3 year survival of 30% on placebo vs 59% on an antipsychotic)? The trial was published in the Lancet Neurology. If a GP reads that, they can't read about, say, dermatology. GPs have so much to keep up to date with I can't expect GPs to know that this Summer a trial showed that dementia drugs increase your risk of syncope (collapse from an abnormal heart rhythm) by 12.9 per 1000 patient years) because reading such trials within the Archives of Internal Medicine and digesting and considering clinical implications. These are meaningful to Consultants who prescribe a lot (e.g. 1 in 77 patients every year will have a syncopal event, which is serious, since I've far more than 77 patients on these drugs) but less meaningful to individual patients (e.g. a patient would need to be on the drug for 77 years to be likely to have one episode of syncope).

Because of this, I have offered to take all decisions on prescribing of all antipsyhotics off my GPs. I offer to visit all GP surgeries a couple times a year for an hour on a lunchtime to talk through what heads up they may need about new stuff, what they want our service to do well/differently. Most GPs bit my hand off in their enthusiasm to do pass it over prescribing decisions to me. I visit every single care home in my patch, they all know to call our service if they've problems (since we've a specialist team to support them who're in the care homes every week).

The GP who stopped the lorazepam and started haloperidol was a locum GP covering for a GP who was on holiday. There were reams of letters from me/my team about the gentleman but still the systems didn't work optimally.


Time for more thought on how to solve that one.


Jobbing Doctor said...

Dear Shrink,

Thoughtful post as ever. I personally would never dream of starting Haloperidol at 5mg bd. This is, in my view, not good medicine, and maybe the GP who employed the locum could do with a chat, so that he can alert the PCT to poor medical practice.

This is every bit as bad as the prescribing of Diamorphine at too high a dose.

A couple of other points - I hate the way you guys are so keen on Lorazepam - I don't like it at all.

I am also actually quite good at Dermatology!


Milk and Two Sugars said...

The hospital I'll be working in next year touts haloperidol as first-line treatement for "behavioural disturbance" (assuming one has done the responsible thing and sought serious organic disease / medication effects). It perturbs me that we're expected to prescribe a medication with so many recognised problems, most of which are honestly beyond my ability to predict for wont of any experience. Is there anything you would want to pass on to someone in my situation, if you had the opportunity?

Milk and Two Sugars said...

Besides checking the national prescribing guide prior to prescribing, that is?

Dr. Shock said...

The GP should inform the locum GP, take care and keep up the good work,
Dr Shock

The Shrink said...

JD, I wouldn't presume to comment on your dermatological expertise - my point was that you've such a diverse range of disciplines to keep abreast of that to expect all GP colleagues to know about a specific bit of a specific topic (like pharmacological adjuncts in the management of behavioural and psychological symptoms of dementia) isn't terribly fair!

M&2S, yes . . . drugs aren't that useful. We don't have a "lower the volume to stop them screaming so loudly" tablet, we're fresh out of the "stop them pulling their drip out" pills and we don't have a "stop them scratching the staff" tonics. Almost all behaviours aren't evidencing behaviours directluy related to pathology that lends itself to medication, or lends itself to rpesentations where there's a drug with a product license for that indication. There's a risk that drugs are prescribed for spurious presentations because as a doctor prescribing is a big part of what we're seen to be about. That's the easy thing to do. It's not the right thing to do.

Dr Shock, I met with the GP now he's back from his holidays and hopefully good practice can be shared.

Anonymous said...

very interesting post.this is my first time visit here.i found so many interesting stuff in your blog especially its discussion..thanks for the post! roxicodone online