Prescribe vs De-prescibe? Who is doing what? February 7, 2019

Welcome to a new series on Medscape. Most of us spent years learning how to safely and correctly prescribe pharmacologic agents. However, little of our training has been devoted to the opposite—stopping these medications wisely and safely. And there are relatively few guidelines to assist us in discontinuing chronic medications.
Cases in Deprescribing: When to Get Rid of the Statin by Charles P. Vega, MD
https://www.medscape.com/viewarticle/908235?nlid=127730_1521&src=WNL_mdplsfeat_190205_mscpedit_wir&uac=164666HZ&spon=17&impID=1877241&faf=1

      Very interesting, is not it?  If I got it right, our medical team has no one idea how to care for patients, how to treat any medical condition, and all what they are able to do just PRESCRIBE. But after one Rx medicine, and patient went to another clinic, what another doctor suppose to do? How MD suppose to show to patient that he is better then another one? There is only one way, to re-prescribe medicine. This is what we all do have. When we come to any other doctor, this doctor will take one medicine and replaced it with Rx to the another medicine, same family, same side effects, same harm.
     This trick also very well known to patient. We are no longer buy this trick. So, what is the next step? To start to check up treatment effect? Not at all. No one teached modern MD how to treat any medical condition. All what they do know what to Rx for any one disease. For chronic patient such as diabetics medication is already was Rx-ed. It is all set up in first patient visits after diagnose was made. So, what left for other doctors? Only one choice, to de-Prescribe what one Rx-ed and then after a while to Rx the same medicine but under another name of provider.
      Now, there is full panel of discussion, what to do, when Rx statins and how to de-Rx statins. I would be happy to participate in this discussion, but there is no spot for patient's voice.  So, I use my blog instead.

A 79-year-old man presents to your clinic for his initial primary care visit after moving into the area to be closer to his children. You note that his past medical history includes hypertension, type 2 diabetes, osteoarthritis of the knee and hip, and mild cognitive impairment. His daughter, who accompanies him to the visit, says that she wanted him closer to her due to his cognitive dysfunction.

Interesting case to study how medical providers provide medical care. In case of diabetes type 2 there are must be other medical conditions such as Asthma or COPD, Sleep Aphenea, high cholesterol, and more. It is diabetes type 2. Patient has long history of medical problems, newer was healthy.

His medications include lisinopril, amlodipine, acetaminophen, naproxen, atorvastatin, and aspirin. You ask if he takes any medications for diabetes, and the patient reports that his previous provider stopped that some time ago because he was losing weight gradually.

         Let us take a look at the medication. But before what is patient's blood sugar level? For my big surprise, there is no one question by anyone MD who discussed this case. The level of sugar must be first on the panel of discussion. It is not. It is taken for granted that diabetic type 2 without obesity does not need medicine to reduce level of sugar. And also why previous provider stopped medication for diabetes? Just because of weight loss? Say no more. Weight loos is resulted by high blood sugar numbers. But because of no one take care for this numbers they are not recorded. It was very simple, medicine was stopped. Diabetes stayed.
     There is even no glucose strips in medical box of this diabetic type 2. There were no question what is glucose level at home. Diabetes type 2 left aside of any discussions.
     acetaminophen and naproxen, two types of pain killers. There is no discussion between MD and patient what kind of pain patient has. What for pain killers taken? As it is clear from panel of discussion, it is also out of concern of any MD. They simple ignore this info, like it has no any value. Does it? 

He has no history of cardiovascular events. His daughter is concerned because of two mechanical falls in the past month, a result of tripping on throw rugs.

If there is no history of CVD then why patient takes Asprin?
two times just last month patient fall. It is presented as it is simple tripping on throw rugs. So, before that these rugs did not lead to fall? If I was MD I would sent patient to MRI to check up for silent stroke.  People do not fall without reason. No one will take pain killer if there is no pain. More obvious patient has severe headaches result of not properly controlled blood pressure.

 The patient's blood pressure today is 156/90 mm Hg and his pulse is 75 beats per minute.

This BP is already elevated, but there is not too much attention from MD. It is looks like it is OK for 79 years old man with history of diabetes type 2, which looks like he reversed, right? If there is history of diabetes type 2, weight loss, and not follow up blood sugar reading it means that diabetes type 2 was reversed.  Most important do not take blood glucose level, and stay as you are.

Statins may not be effective in improving rates of cardiovascular disease and mortality among older adults. In a trial that included nearly 1500 adults over 65 years of age with no history of cardiovascular events, pravastatin 40 mg failed to improve risk for cardiovascular disease or overall mortality over 6 years of follow-up when compared with placebo. Analyses from other trials of statins and retrospective studies also find modest or no improvement in the risk for cardiovascular disease, and no effect on mortality.

      Let take short look at the trial. Why there are only provastatin and placebo? What about Lipitor? If train was right then it is better to do study in another way.  There is no need for 6 years follow up. If medicine is right then medical condition will start to improve. Of cause, when it is only prevention of mortality then it is best way to wait as long as it takes to see if medicine works or not.
      All diabetics type 2 do have elevated cholesterol. Why? Because of eating and wrong diet? No. It is abnormalities in our food utilization, which is resulted diabetes type 2. Someone born in this condition. Other developed it as a result of malnutrition in early childhood. All types of statins such as simvastatin, provastatin, atrovastatin, anyone else, does not improve abnormalities of food utilization. Lipitor do the job. But Lipitor is brand medicine, very expensive. So, MD usually present that Lipitor is the same as all other statins, but with lower price. Still, if take studies just one years and result would be dramatically different. No one statin decreas high cholesterol. Lipitor do the job. When cholesterol is high, then mortality of CVD is increased. And vice versa.
     Does anyone need prove of this statement? Ask your doctor, and ask your doctor to sent special Rx to Lipitor in stead of any other statins. Then check up your cholesterol. See the result of by your own eyes, if Lipitor is right for you.

However, patients under the age of 85 years with diabetes may still experience not only an improvement in the risk for cardiovascular disease with statins, but a reduction in risk for all-cause mortality as well. Moreover, I am missing a major part of this patient's cardiovascular profile because I have no lipid profile on record.     

Probably MD did not get paid for test?
      As I started with, MD has no one idea what to do with patient in his clinic. Statins can lead to pain, to myopathy.  But this is just case study, and there is no real 79 years old man. What I try to find out, what is this disclose about? What author try to say? And what all other providers discuss? They discuss, if this patient needs statins or not. Looks like there is nothing what they can see in this case.
     Pity of us. We are just cases study for every one MD every one of us.

via Ravenvoron