Prescribing for different kinds of patients
Older patients
Elderly patients may be on a number of different medications for various conditions, which increases the number of potential drug interactions. The Department of Health’s Medicines and Older People (2001) states that four in five people over 75 take at least one prescribed medicine, with 36% taking four or more medicines.
Older people often have more problems with the practical aspects of drug taking. They may need help with reminder charts, compliance aids (eg, a medication organiser) and specially written instructions.
Try to keep their drug schedule as simple as possible. When starting a new drug, keep the dosage low at first. Be careful not to write off side-effects of medication as the effects of ageing.
Most prescriptions for older people are repeat prescriptions, so regular review is essential. (More information on Repeat Prescribing is available here.)
The most important effect of age on medication is a reduction in renal clearance. Many older patients therefore excrete drugs slowly and are highly susceptible to nephrotoxic drugs. This effect may be exacerbated by an acute illness, particularly one that causes dehydration.
Visit the Department of Health website for more information.
Children
Children have a very different response to drugs, and doses should always be calculated with care. Often, licensed indications do not cover the clinical needs of children and are not tested extensively on children. This is particularly true for drugs that are started in secondary care.
The BNF for Children provides practical information on the use of medicines in children of all ages from birth to adolescence and, in 0 –18 Years: Guidance for all Doctors, the GMC states you should be familiar with this.
See the British National Formulary for Children website for more details.
Substance misusers
There are 210,815 adults in contact with NHS treatment services, according to the National Treatment Agency for Substance Misuse. Many practices will register substance misusers for their primary healthcare needs, but leave treatment of their addiction to the local drug dependency unit. Others may get more involved, offering prescribing services, for example. Find out what the arrangement is in your practice.
It is unlikely that you will be involved in prescribing to substance misusers but, if you are seeing them for other reasons, that will not stop them asking. They will be familiar with the system, can have a highly plausible reason why a prescription is needed, and be very persistent.
There should be firm boundaries for these patients – they will probably be under an agreed contract for their treatment – so understanding the procedure in the practice will help you to deal with them.
Prescribing diamorphine, dipipanone and cocaine for addicts can only be done with a special licence. These and other Schedule 2 drugs must be prescribed on a particular form (which one depends on which country you are in – check the BNF for details).
For more information see the National Treatment Agency for Substance Misuse website.
Patients with chronic conditions
Patients with chronic conditions are likely to be on long-term medication, and this is a common cause of problems.
Ensuring that these patients are adequately monitored and their prescriptions regularly reviewed is important. It is not uncommon for patients to decide to give themselves a “drug holiday” or start an alternative therapy without telling their GP.
A study has shown that patients with a chronic condition who are just starting on a medication have poor compliance. After ten days, 30% of patients were not taking their medication correctly. After four weeks this figure had fallen slightly to 25%. Of these, most were not complying intentionally. The study suggests that patients starting on long-term treatment need more support to encourage them to take their drugs.
Source: Quality and Safety in Health Care 13; 172–5 (2004)
Treating yourself, family and friends
The GMC’s guidance on doctors treating themselves or those close to them is clear: “Wherever possible, you should avoid providing medical care to anyone with whom you have a close personal relationship.” This includes prescribing drugs to family members. You should not treat yourself.