The Consultation Room

Prof. Dr. CMK. Reddy

General & Vascular Surgeon, Halsted Surgical Clinic, Chennai, Tamilnadu, India

Chapter 41: Selection of drugs

Some drugs, which may have duel effect, may beconveniently used, if the patient has both the symptoms. We can give several examples: for a young girl with persistent vomiting of functional nature (such as anorexia nervosa), you may choose chlorpromazine, a powerful antiemetic as well as psychotropic agent.

For a woman who needs to be treated for amebiasis, urinary tract infection (UTI) and pelvic infection (PID), a combination of a quinolone/imidazole, may be considered. For a man with mild BP and features of prostatism, prazocin or tamsulosin may be useful and for someone with bronchiectasis and small aortic aneurysm under observation, long term use of doxycycline may be appropriate.

If you had chosen to start an antibiotic for any infection and the patient is improving, don’t change it, just because the bacteriological report is not supporting your selection. If you wish, you may add another antibiotic based on the report and don’t allow the lab report override your clinical judgment.

If a patient calls few days after taking your prescription, says the medicines didn’t agree with him, developed ‘allergic’ symptoms and wants to know what to do. You might have given 4 or 5 drugs in the prescription and it may be difficult to identify the ‘culprit’. Best course of action in such situations is to advise to stop all the medicines and take some antihistaminic or antacid, as the case may be. Then, after a few days, ask him to restart the medicines, one by one, with a gap of 1-2 days for each. By this method, most of the times, we would be able to identify the culprit, for which we can prescribe of a suitable (hopefully, less troublesome) substitute.

Chapter 42: Generic vs brand names

There are positive and negative points in both, butthe Govt always focuses on the economy to the patient, even taking chances about their quality and difficulties of the profession. Unfortunately, except the cost (which is not always true), all other factors are not in favor of prescribing by generic names.

Firstly, for generations, the medical fraternity is more acquainted and familiar with the brand names, than their generic formulae.

Secondly, writing generic names of all the ingredients in multidrug combinations becomes very tedious and time consuming.

Thirdly, even it’s a single drug, when it’s prescribed in generic, the pharmacist chooses the manufacturer, naturally who ever offers him maximum margin of profit, even if it’s substandard.

Finally, some patients prefer branded medicines, made by timehonored standard companies, familiar to them. Best solution is the strict drug pricing policy of the Govt, especially over the multinational companies and bring down the maximum retail price (MRP) of the branded products, to a level, almost on par with those of generics. This gives the Doctor to choose the ‘best’ brand for the molecule, without much financial burdon on the patient.

Chapter 43: Dosage of drugs

Our Indian patients may not require or tolerate thedosage schedule, prescribed in western literature. Meticulous care has to be exercised while calculating the dose of medicines to patients in extremes of age and those with compromised renal, hepatic or cardiac functions, especially those drugs with a narrow therapeutic index (maximum tolerable dose/minimum effective dose).

The website mentioned toselect drugs (medplusmart.com), can be very useful to find the dosage of some rare drugs, if you have internet in your office. Of course, as indicated CIMS or PDR may be referred.

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“I specialize in referrals to specialists!”

Chapter 44: Prohibited drug combinations

In 2016, Govt of India prohibited manufacture and marketing of more than 340 fixed-dose drug combinations. To give some examples:

Antihistaminic with anti-diarrheals.

Penicillin with Sulphonamides.

Vitamins with Analgesics.

Tetracycline with Vitamin C.

Hydroxyquinoline group of drugs with any other drug except for external use.

Corticosteroids with any other drug for internal use

Aceclofenac + Paracetamol + Rabeprazole

Nimesulide + Diclofenac

Nimesulide + Cetirizine + Caffein

Nimesulide + Tizanidine

Paracetamol + Cetirizine + Caffeine

Diclofenac + Tramadol + Chlorzoxazone

Dicyclomine + Paracetamol + Domperidone

Nimesulide + Paracetamol dispersible tablets

Paracetamol + Phenylephrine + Caffeine

Diclofenac + Tramadol + Paracetamol

Diclofenac + Paracetamol + Chlorzoxazone

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“We can’t find anything wrong with you, so we’re going to treat you for Symptom Deficit Disorder.”

Chapter 45: Advice on lifestyle modification

‘ospitals and graveyards are filled withthose who ignored and insulted nature’.

World health Organization (WHO) says health is not mere absence of diseases, but some thing more and calls as ‘comprehensive positivehealth, which includes physical, mental,

social, environmental and spiritual wellbeing’. ‘Just because you are notsick, doesn’t mean you are healthy’.

You all agree that many ofthe problems we see in day-to-day practice are directly or indirectly related to the inappropriate lifestyle of the patients, such as over eating, obesity, lack of physical exercise, consumption of tobacco, alcohol or drugs, high stake gambling or horse races, extramarietal affairs, undiplomatic communicative habits, lack of self-confidence & positive thinking, getting tensed up for insignificant issues and so on.

Besides prescribing medicines, the Doctor has to spare extra time to counsel them against these unhealthy habits and how they make the drugs ineffective in providing permanent relief.

We have to go into full details of what they eat from morning to night and suggest practical modifications and assure them that the body will get adopted to the new diet regime very soon, without getting (or feeling) weak.

But it is very important, to have the moral right to advise the patients, we should set good examples for them to emulate. We should maintain optimal body weight and refrain from smoking or alcohol consumption during consulting hours (preferably quit the habit).

Remember that tremendous moral boost to a smoker is a smoking Doctor. ‘We should eat to live and not live to eat’.

There is a saying that ‘if a man eats one meal a day, he is a yogi. If he eats two meals, he is a bhogi and if he eats three meals a day, he is a rogi’.

‘A health-conscious society impoverishes the local Doctor’.

He who takes medicine and neglects the style of life, wastes the skill of his Doctors.

Don’t take health for granted. You will realize this only when you get sick.

Risk calculation of smoking

If one smokes 10 cigarettes/day for one year, on an average life expectancy is reduced by a month. It means, 20 cigaretes/day for 12 years, life is reduced by 2 years.

Remember the popular statement we make to a smoker coming with chronic limb ischemia – ‘you can have either your cigarette or the leg, but not both’.

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