Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Playing Pollyanna in a PolyPill WorldApr 3, 2009 09:56 EDT
I'm trying hard to figure out how I feel about the entire pollypill concept. I've been staunch in my belief that we should not start combination therapies until we have figured out which components do the best job for our patients. Displaying often my backward and archaic attitude as some would lable it, I loathe starting Lotrel until I've figured if I need more ace or more amlodipine. Is my patient's enemy leg swelling or cough? Do they need more afterload reduction for their MR provided by the ace or do they require more amlodipine for angina or pulmonary hypertension? The only place where I would ever be enthusiastic about using a polypill would be in the virgin anterior MI patient parked in ER #1 who could swallow clopedigrel, aspirin and 50 mg of lopressor right down the hatch. Now that's a polypill!
When prescribing a medication or performing a procedure, I always project from my subconcious the absolute worst thing that could happen to a patient, then prepare for a way out, an explanation, or a "plan B". I imagine with mass polypill prescribing , a patient coming back into the office with a rash, fatigue or GI upset. Do I indict the aspirin, the statin or the ace inhibitor for the crime? How do I untangle each potentially guilty party from my patient's medical regimen? How many weeks will it take to figure it out? Will they need a medrol dose pack and then just punt and start all over with separate components? If so, which one?
Don't tell me that side effects of medications are rare. 8% of aspirin utilizers get an ulcer. About 30% of patients in our practice have intolerances to statins. I've even seen a rash on two occasions with beta blockers. What about angioedema, though rare, who wants to flip a coin to decide whether to re-start the ace or the aspirin?
The other bothersome issue with the polypill is that embracing this concept indicates that we will have given up on primary prevention in its truest sense. I make a distinction between true primary prevention and pharmacologic primary prevention. Healthy eating, exercise, proper sleep hygiene, stress avoidance, first and second hand smoke avoidance, maintainance of a normal body weight, a healthy happy relationship with those around you, a productive work environment, spiritual well being............these are the (wal) nuts and bolts of longevity. In the pill popping society of today, I fear that many will embrace this misunderstood "golden ticket to health" and still continue to eat, smoke and be sedentary. Maybe our enthusiasm for a polypill in America needs to be preceded by a massive push for the primary prevention nonagram described above.
I think Steve Nissen had an excellent point in his discussion with Dr. Yusuf. Is the polypill concept "for the developing world or the developed?"
In a world where resources are limited and only IF the polypill concept does improve compliance and can be purchased at a less expensive price, perhaps in places where foods are not fortified with things like folic acid or where citizens can't afford 5 pills, then maybe it's best. In America where we have encyclopedias, radio, television, internet, ipods, cell phones and mass transit to help us attend lectures, health sessions, and screenings, etc. maybe we just need to focus on implementation of the basics first. We need to push for true primary prevention, then after a while, the polypill concept might find it's right place in American medicine.
It takes the same level of compliance to swallow one pill once per day as it does 5 pills once per day. In most cases, we can get to at least q. day or b.i.d. dosing with most regimens, so with that reasoning, I'm just not convinced that I even want to tackle this concept in my practice. I've tried to play Pollyanna by trying hard to look at the bright side, but I know that even Pollyanna had to learn to walk again. So will I when it comes to figuring out how to best incoporate this concept into my practice for the good of my patients. After this round of discussions, it seems that this combination pill will be "coming to a pharmacy near" ME at some point in my lifetime ,............... no matter if I'm a Pollyanna or not.