The Pharmacist Who Says No to Drugs

It’s important on at least two counts that Neel — or someone like him — review the medications these people are receiving.

First is safety. The risks of adverse effects expand exponentially with the number of medications "onboard," partly because they indicate the presence of numerous diseases or other medical problems and provide an opportunity for both drug-disease and drug-drug interactions.

Second is cost. "The rule of thumb," Neel says, "is $100 a drug."

That’s per patient, per month. Thus the cost of having someone on, say, 15 different medications — many of which may be unnecessary or even harmful — is $1,500 a month, or $18,000 a year.

[Editor’s note: Neel today points out that the figure has doubled in the seven years between 2004 and 2011 — to $200 a day and $36,000 a year.]

Getting Up Close and Personal

First up today is the chart for a 68-year-old man who is on many drugs, including Nitrofurantoin, an antibacterial that’s prescribed for urinary tract infections. Neel enters the man’s age, weight, height and information from his blood work into a calculator programmed with certain formulas he uses over and over. Neel explains that toxic levels of the drug will build up in the man’s system because his kidneys aren’t as efficient as they used to be.

Why would a doctor prescribe it? "Because," Neel says, "it works in young people."

The next chart is for an 89-year-old woman who’s on 13 different prescription medications, including Zantac, which raises an immediate flag for Neel. There are no blood chemistry tests in her charts, but Neel quickly computes her probable renal clearance at 32.5 cubic centimeters a minute. "This tells me right off the bat she shouldn’t be taking it," he says.

He then types his suggestion to the doctor: "Zantac dose too high/could lead to hepatic shutdown ... resulting in serious patient adverse events."

Neel opens the next chart, that of an 82-year-old woman who’s on 17 different medications, including, for type 2 diabetes, a prescription drug called metformin.

He’s dumbfounded at first, then angry. He reads the suggestion slip he typed out six weeks earlier: "Patients with serum creatinine clearance less than 60cc-m use of metformin is contraindicated and places the patient at high risk for lactic acidosis, which is fatal in most cases."

In a little while, Neel joins the staff for lunch in the cafeteria and spends much of the time soaking up details about residents that may prove useful in his work. On the way back from lunch Neel stops to visit with them in their rooms or in the hallway.

Next: “I gave him his life back." >>