There are often many ways to do things, even taking your meds. But there is always a best way and a little knowledge about your medicines can be of considerable benefit in discovering the best way. I have always believed, as Gertrude Stein quipped “to be a difference, it has to make a difference.” So, what follows either is proven to make a difference or common sense from available facts make a difference very likely.
“Unfortunately, there’s a disconnect between what’s taught to doctors and what we know from chronotherapy research [when to take meds],” says circadian biologist Georgios Paschos of the University of Pennsylvania School of Medicine.1 “Except for a few conditions, clinical medicine hasn’t yet caught up with our findings.” Nevertheless, he predicts, this will change in the next decade or two. I propose to catch you up right now in this chapter concerning the best way to reorganize your medical treatments.
What Dr. Paschos laments is that research investigating how to provide better medical results by timing medications is known but has not found its way into clinical medical practice. Delayed clinical application is not a new drawback; medicine divides into two camps: physicians (MDs) who concentrate on providing and researching patient care and “basic scientists” (mainly PhDs) who concentrate on researching how our bodies work, how disease disrupts, and how medicine works to correct disease. Having both degrees (MD, Ph.D.) and experience in both disciplines, I appreciate how both work and that their professional communications are primarily group-based. A while back, an attempt to bridge the information gap foraged for a season; it promoted basic science more rapidly being put into practice and was termed translational medicine. Nevertheless, we see medical communication still has gaps. This paper will inform the reader what is of importance that failed to make the break concerning medication usage.
Medicines can be taken by mouth (swallowed or held under the tongue), inhaled, injected with a hypodermic needle, or, gasp, (mostly in children) by rectal suppository. Obviously, injections are the fastest to work followed closely by inhaled or under the tongue methods.
One-third of adults experience difficulty when swallowing solid meds.2 Obviously, moving the meds to the very back of the tongue and dispatching them with a large gulp of liquid helps. A study on the best way to swallow meds showed there is relief in extending the neck forward during swallowing or sucking bottled water from its bottle when swallowing solid meds.3
Swallowed meds, however, depend on the particular medication’s absorption curve. Since most medicine’s beneficial actions depend on having a proper amount in the bloodstream (therapeutic range), knowing about the time it takes to reach beneficial levels and how long beneficial levels last is important and we will spend time on that aspect. In general, meds that need to be taken infrequently are absorbed more slowly but are eliminated more slowly.
Avoiding Adverse Drug Reactions:
Meds always have drawbacks termed side effects or if severe enough, adverse drug reactions. Adverse drug reactions are by definition severe enough to require a trip to receive medical care. Side effects are results that are different than the medicine is designed to produce. They usually are mild with one exception—allergic reactions. Allergic reactions range from itchy rashes to having the face swell to difficulty breathing. Having difficulty breathing is the most dangerous; swelling of the face or difficulty-breathing rates an immediate 911 call.
Adverse drug reactions are more common in elderly patients. In medical lingo, elderly means the transition between middle age and old (i.e. over 65 years). Adverse reactions serious enough to be reported in Italy were 1.2% annually in persons over 65 years.4 Unreported reactions are likely many times higher. In one large study, almost 7% of elderly hospital admissions were to treat adverse drug reactions.5
Drugs have many side effects; look at the warning sheets included with your prescription. Wow. Those materials are not too helpful because they include many possibilities that are unlikely but included because of legal implications. Get information from your doctor. When a new medicine is prescribed ask, “What should I look out for that would indicate side effects?” The best information, however, is from the pharmacist for what reactions new meds might have.
A few drugs are inherently dangerous, such as blood thinners, chemotherapy meds, and antiarrhythmics (meds to keep the heartbeat regular). Patients on dangerous drugs should follow instructions carefully and learn all they can about the medicine from their doctor and reliable sites on the internet. Reliable sources are the Agency for Healthcare Research and Quality (www.ahrq.gov/…/btpills.htm), WebMD, and websites of academic institutions, such as Mayo Clinic and Johns Hopkins.
The most common serious adverse reactions are from drug interactions. The elderly often take a number of medicines because of multiple co-morbidities. One study had the average number of meds for seventy-year-olds at eight.6 The greater the number of meds, the greater the chance of interactions. Having a too large number of meds is termed polypharmacy and a movement is underway to reduce the number of meds in the elderly with polypharmacy.5 At least on your yearly checkup visit, you should review your meds with the doctor to make sure you need each one. On a cautionary note, discontinuing meds needs to be done gradually.
As the number of prescribing physicians increased so does adverse drug reactions.7 Each additional prescriber increased the chance of adverse effects by almost a third. The problem is a lack of effective communication between prescribers. You, the patient, need to monitor medication changes.
The first line of defense is to inform your primary care doctor’s office, probably through the doctor’s assistant, that a new medicine is being added. Next, you need to check for drug interactions. Yes, your doctor should have examined your drug list and the pharmacy is supposed to do that but you should always play it safe. Several websites have interaction checkers, which work well: WebMD and Walgreens are two.
Years ago, I was boarding a plane to lecture at a medical conference when my cell phone rang. It was Mom who wanted me to know she loved me because she was about to die. This was highly irregular because Mom was one of the most stoic people I knew. I immediately drove 200 miles to Tulsa and found Mom was correct; she had a pulse rate in the thirties and was about to die from heart failure. She was overmedicated inappropriately with two similar heart meds, which had slowed her pulse rate to disastrous levels. I stopped her meds and by late afternoon, she was feeling much better. I took her to the best restaurant in Tulsa for dinner. I called her doctor, informed him of the overmedication, and requested that I be informed of future medication changes. Mom kept seeing him because he was so nice.
Judge your doctor by professionalism and results. The doctor should be aware of what you are taking just as you should. I fired a financial advisor because he did not know what my portfolio contained during our conversations. How can advisors advise without knowing particulars? Review your meds in detail with your doctor when new meds are added or otherwise at least yearly.
Make no mistake: You are responsible for monitoring your meds. Bring all of your medicines to each doctor visit. Include any supplements you are taking, so the doctor will be accurately aware of your therapeutic routine. Acts showing you take your therapy seriously will make your doctor more attentive. I almost failed auto shop class in high school but whenever I was told I need auto repairs before wealthy enough to buy a new car, I would ask for explanations of why this needed to be fixed and more often than not, a cheaper alternative was offered.
During emergencies, knowledge of medications taken is important. Keeping a list of medicines for you and spouse in your wallet or on your smartphone is a safeguard to solve the problem if needed and have your wife do the same.
Medication errors are more common than patients realize. A few years ago, when I was prescribed a rare drug, a middle practitioner, wrote for a dose that would have soon become an overdose problem. When I pointed it out, she was very embarrassed. The pharmacist would have almost certainly caught the glaring mistake but the point is we must remain on guard. Had I not been a physician, I would not have known the dose was wrong. To guard against errors, patients should know the major side effects of new medications, which is the second layer of protection because overdosing would be likely to have side effects.
Patients have responsibilities at the pharmacy as well. Make sure that the name on the medicine vial is yours. Most of the time the pharmacist will meet with you before you get new meds; if not ask to meet with the pharmacist. They should be good at telling you what the medicine is for, what it does, and what side effects it has. Pharmacists are trained specifically about medicines and their nuances.
When to take meds is rarely included with prescriptions. The drug labels tell you how many times a day to swallow them and occasionally advise you to take some with meals. However, our bodies have clocks that synchronize with sleep/wakefulness cycles. For instance, statins that lower our cholesterol work by inhibiting the liver from making it. Our livers make the most cholesterol as we sleep, therefore statins are most effective when taken at bedtime.
Next, especially with once a day meds, there is a drug concept that is important—drug absorption curve. Aspirin is coated with a retardant to keep it from dissolving in the stomach and causing erosions. Such are labeled enteric-coated or safety-coated. Enteric-coated low-dose tablets are the recommended aspirins to take for wellbeing. Their major function is to prevent heart attacks, among other benefits, by partly disrupting the clotting mechanism. The optimal time to achieve the highest level of aspirin in the morning is to take aspirin at night.7 Taking coated aspirin at night makes sense because the greatest numbers of heart attacks and the most serious ones occur in the morning hours.8
People having arthritis pain should note when they have the worst episodes and time their NSAIDS pain meds four to six hours before. Usually, this means the arthritis meds should be started in the mornings.
Medicines that are taken once a day are termed extended-release (ER). Many meds are available in ER form. Usually, that is the more desirable form because their absorption and reduction is slower that meds that must be taken more often. As a group, they should be taken at night because metabolism and a lot of risks slow as we sleep.
Non-compliance is common in the elderly. One can forget to take meds or forget they have taken meds. A Pill Organizer will help prevent this. Develop a routine to ensure compliance. Just before going to turning off the lights and going to bed, I need to do three things: set up coffee, get nightly water poured, and take meds. Establish a routine to take meds and stick to it. Pair it with other repetitive tasks so each reinforces the other.
There are meds that should be taken with meals and others that should be taken on an empty stomach. It does not always hold true but a rule often applies that if the medication should be taken with meals, the pharmacist will place a label advising so on the prescription. If no label is present, take the medicine on an empty stomach; unless it upsets your stomach. Pain meds are rarely labeled because they usually are taken as needed, but some, especially narcotics, should be taken with food to avoid an upset stomach.
There are some foods that should be avoided when taking certain medicines. When taking blood thinners, one should memorize that considerable list of potentially harmful foods and supplements. Grapefruit interacts with a number of meds.9 Particularly, grapefruit affects the absorption of cholesterol-lowering meds and some heart meds and may raise their levels in the blood dangerously high. If you are taking those meds, it would be wise to substitute other citrus and avoid grapefruit altogether.
The liver and kidneys eliminate medications; medications don’t just disappear. People with diseases of these organs likely will need to have doses reduced. When getting new prescriptions, patients with decreased function of these organs should remind the prescriber by saying, “Does this dosage take my kidney problems into account?
Cost savings:
Pharmacy companies have been brilliant in the last century in giving doctors great tools to treat age-related diseases. The average male lifespan in a century has gained 24 years (52 years to 76 years) and it has been in no small part from advances in medications. The advances are not cheap; every decade the cost of medical technology has doubled. Patent protections provide the economic impetus to invest huge amounts of money in research. Patent protection lasts 17 years, and then companies other than the developer can apply to produce competitive products, termed generic medications. Generic means without a trade name; generic is the chemical name.
The pharmaceutical and medical device companies have a great system of direct marketing to physicians. They send out drug reps in large numbers who go directly to the medical offices and clinics to convince the doctors that their company’s product is better. Pharmaceutical companies are business companies; they promote more expensive medicines. They often come bearing gifts. The unwary prescribers (physicians, nurse practitioners, and physicians assistants) can be misled into costing their patients more with no added benefit. The medical profession is generally very professional but there are a number of bumps in the road.
Another pharmaceutical marketing ploy is direct to patient advertising. TV ads are replete with smiling happy people because of buying expensive meds. Remember the past cigarette ads? If you get interested in asking your doctor for the medicine—do it in the manner of asking for an opinion as to whether the medicine will be worth a premium. There are studies showing that patients asking for a specific medicine or test often get it. Remember Garth Brook’s song “Unanswered Prayers”. That’s what most of the advertised drugs are about.
Generic drugs cost 20% or even less than brand named ones because they don’t share the cost of development. Are generic users settling for less quality? No, not at all. The FDA has stringent criteria for approval of generic medications. The chemical composition of active ingredients must be identical and the absorption must be the same. This means the drug works the same way and is in the same amount. Over 2,000 generic’s absorptions were compared to the brand’s and the generics averaged 96.5%, which provides the same clinical results as the brand name.10 Further, in dozens of medical studies, outcomes were compared and in every case study were identical.11
The FDA monitors both classes of medications for adverse events the same to ensure continued quality. Most non-generic drugs have alternatives in the same class, which will suffice. There are diabetes meds that have no generics to do what they do. A possible difference is that generics may have different additives, other than the active ingredients, then the brand names, which can upset a few patients. Overall, there are few if any reasons for paying premiums for the same drug.
Another area of possible savings is in getting a prescription for an over the counter medicine if you take it on a regular basis. A person taking Prilosec at 40mg daily pays more than a $5 prescription of the same active ingredient.
This is a yearly savings of $345. If you are requiring higher doses of non-narcotics pain relievers such as Aleve or Advil, there are modest savings with prescriptions. Get informed and be involved.
Tablet splitting can cut your cost of medications in half but several steps are necessary to ensure safety. Some time-release medicines and capsules are not eligible for splitting. Tablets that are FDA approved for splitting will say so in the package insert and will be scored. Some tablets may be spilt that are not FDA approved, ask your health-care professional. Use a and do not split the entire bottle because split tablets can deteriorate over time. Do not split tablets that disintegrate, you can’t be sure of the dosage.
Generally, larger quantities of the same medicines are cheaper. The standard amount is monthly but medicines taken long-term can be purchased for 90 days—cheaper. And it saves the extra trouble of remembering refills and extra trips. Simplify, simplify, and simplify for a better life.
Lastly, everything unfortunately, expires, including drugs both prescription drugs and OTC meds (over the counter meds). A 1979 law required all pharmaceutical and OTC producers to label their products with a date they would guarantee potency. Guess what? Their incentive is to sell you medicine, so? The military stockpiles a large amount of medicine in case it becomes needed rapidly and they became concerned about the cost of expiration dates. They commissioned a study by the FDA to determine how long meds actually lasted. The study showed almost all meds were just as good as when manufactured after 15 years!12 Another report examined potencies of over 3,000 lots of 122 medications to see if a different time of manufacture made a difference. They found that the average time beyond the expiration dates before any drop in potency could be detected was over 5 and 1/2 years.13 Much more impressive, a researcher found 14 meds that were expired 28 to 40 years in a retail pharmacy in original, unopened containers. When these meds were tested for potency, strength was maintained to at least 90% levels of the original prescription.14 There is a general consensus among experts that storing meds in the refrigerator further extends usefulness. There are a few exceptions: nitroglycerin, insulin, and liquid meds. Tetracycline, the antibiotic, questionably becomes toxic. However, the tetracycline toxicity was from a discontinued preparation and no other reports of harm from taking outdated drugs are available.15 Have we all been throwing away perfectly good meds because we are being fed lies?—no, because we are not informed, which is what we need to make correct choices.
An additional consideration that I have is taking medicine newly on the market on a long-term basis. In Canada, about one-fourth of newly released medications are recalled because of side effects.9 If a medicine has been on the market for years, I am reassured that long-term use is safe, which is another benefit of generics. They have been available for at least 17 years, which is the length of a patent’s protection.
I have always believed that when others embraced the premise that working harder or longer would bring success was true but the real secret to success was working smarter. The same applies to your health choices. Absolutely.
1. Simon M. Timing When to Take Your Daily Medications. In: AARP Bulletin http://www.aarp.org/health/drugs-supplements/info-12-2013/timing-of-daily-medications-key.html; 2013.
2. Schiele JT, Schneider H, Quinzler R, Reich G, Haefeli WE. Two techniques to make swallowing pills easier. Annals of family medicine 2014;12:550-2
3. Marengoni A, Pasina L, Concoreggi C, et al. Understanding adverse drug reactions in older adults through drug-drug interactions. European journal of internal medicine 2014.
4. Franceschi M, Scarcelli C, Niro V, et al. Prevalence, clinical features and avoidability of adverse drug reactions as cause of admission to a geriatric unit: a prospective study of 1756 patients. Drug safety : an international journal of medical toxicology and drug experience 2008;31:545-56.
5. Scott IA, Anderson K, Freeman CR, Stowasser DA. First do no harm: a real need to deprescribe in older patients. The Medical journal of Australia 2014;201:390-2.
6. Green JL, Hawley JN, Rask KJ. Is the number of prescribing physicians an independent risk factor for adverse drug events in an elderly outpatient population? The American journal of geriatric pharmacotherapy 2007;5:31-9.
7. Bonten TN, Saris A, van Oostrom MJ, et al. Effect of aspirin intake at bedtime versus on awakening on circadian rhythm of platelet reactivity. A randomised cross-over trial. Thrombosis and haemostasis 2014;112.
8. Suarez-Barrientos A, Lopez-Romero P, Vivas D, et al. Circadian variations of infarct size in acute myocardial infarction. Heart 2011;97:970-6.
9. Bailey DG. Grapefruit-medication interactions. CMAJ : Canadian Medical Association journal = journal de l’Association medicale canadienne 2013;185:507-8.
10. Davit BM, Nwakama PE, Buehler GJ, et al. Comparing generic and innovator drugs: a review of 12 years of bioequivalence data from the United States Food and Drug Administration. The Annals of pharmacotherapy 2009;43:1583-97.
11. Kesselheim AS, Misono AS, Lee JL, et al. Clinical equivalence of generic and brand-name drugs used in cardiovascular disease: a systematic review and meta-analysis. JAMA 2008;300:2514-26.
12. Drug Expiration Dates – Do They Mean Anything? In. http://www.health.harvard.edu/fhg/updates/update1103a.shtml: Harvard Health Publications 2003.
13. Lyon RC, Taylor JS, Porter DA, Prasanna HR, Hussain AS. Stability profiles of drug products extended beyond labeled expiration dates. Journal of pharmaceutical sciences 2006;95:1549- 60.
14. Cantrell L, Suchard JR, Wu A, Gerona RR. Stability of active ingredients in long-expired prescription medications. Arch Intern Med 2012;172:1685-7.
15. Pierson JC. Let’s put an expiration date on the current approach to drug expiration dates. Journal of the American Academy of Dermatology 2014;71:193-4.
