Management of medications is sometimes handled sub-optimally, at least in the United States. At the extreme, physicians who prescribe multiple medications prescribe some medications that treat the side effects of other medications. This could be considered physician negligence in extreme cases.

An example was given in a class I took at UCSF (the University of California at San Francisco). UCSF physicians jointly provided remote advice for a physician treating a developmentally disabled patient living in a rural area of Northern California. The patient could no longer stand. The UCSF physicians recommended changing medications because some of the medications might have been prescribed to treat the side effects of other medications. Afterward, the patient was not only able to walk but run.

This situation of prescribing a medication to treat the side effect of another medication is sometimes done knowingly rather than mistakenly. For example, a necessary medication may have a significant side effect — for example, a medication could cause a patient to gain weight — but the medication is so important that this side effect is tolerated. In one case I know, the patient was given another medication to suppress her appetite in this situation.

A logical solution to the problem is to try to find a medication that is equally effective that does not cause weight gain. A knowledgeable pharmacist is a more logical person to find such a replacement drug than the physician.

I propose that there be consultant pharmacists that should devote their time to resolve such situations. The consultant pharmacist would work with the physician to identify effective medications without the side effects or without drug interactions. To avoid any conflicts of interest, a consultant pharmacist should not profit from the sale of medications.

A consultant pharmacist could also meet directly with patients in the following situations:

1. When a patient receives a new medication to inform the patient on how to take the medication
2. When the patient’s physician identifies a possible drug side effect or interaction
3. Periodically for patients taking a large number of medications. The consultant pharmacist could suggest medication changes to the patient’s physician, or provide a simplified schedule for taking medications.

A consultant pharmacist could also ensure a patient’s safe transition from a hospital stay to back home.

When a patient is admitted to a hospital, the patient’s current medications are recorded, and any medications the patient brings are usually taken away for the duration of the stay. Medications for the hospital stay are prescribed or re-prescribed; a physician can do this with consultation from the consultant pharmacist.

At discharge, a physician and a consultant pharmacist could meet with the patient to restore the individual’s at-home medication regimen, possibly adding or changing medications. A consultant pharmacist would ensure there are no medication errors and ensure efficacy.

There are a number of up-and-coming drug-connected areas that require further research:

1. The effects of genes on the metabolism of drugs
2. The effect of bacteria in a patient’s gut—referred to as the patient’s “microbiome”—on the actions of drugs. In the future, this information could be used to provide dosing advice to physicians prescribing medications.

Genes and drugs

There are two categories of drugs that may require different doses dependent upon the genetics of the patient:

1. Active drugs that work before they are metabolized
2. Prodrugs that work after they are metabolized. A physician prescribing one of these categories of drugs, to ensure the drugs work and do not have side effects, will adjust the dosage as necessary for slow metabolizers and ultra-fast metabolizers (as identified by a patient having certain CYP gene variants, genes that produce enzymes that control the synthesis and breakdown of chemicals in cells).

Given normal dosing, a slow metabolizer may get too large a dose of an active drug, while an ultra-fast metabolizer may get too large a dose of a prodrug. For example, the milder narcotic codeine, a prodrug, metabolizes to the narcotic morphine; with normal dosage, an ultra-fast metabolizer could get a toxic dose of morphine.

The microbiome and drugs

It is known that different people have different bacteria within their gut; this bacteria is called their “microbiome.” Some types of bacteria store a drug without chemically modifying it, whereas others modify drugs to make them more or less effective; in either case, this can change the effects of the drug. Conversely, a drug could change the makeup of bacteria in a microbiome, which could affect health.

Another research area may be the effect of drugs on paraplegics, quadriplegics or other persons confined to a wheelchair. Drug doses are often given based upon weight. In my experience with a paraplegic patient, she was given too high a dose of pain medication once and too high a dose of an anesthetic during an operation another time, failing to wake up quickly.

Some possible problems with drug doses for such patients are the following:

• Difficulty weighing the patient: It is difficult to weigh a quadriplegic, paraplegic or other person confined to a wheelchair. The person must be weighed in the wheelchair, then the wheelchair is weighed, and the weight of the chair is subtracted. Some medical personnel may be too lazy to do this, or this may be too difficult to do.
• Patient looks heavier: Another possibility is that non-use of muscle results in greater flabbiness, making the patient look heavier than she is.
• Different effects of drugs: The extra fat in place of muscle may have an effect upon how the medication works.

In any case, when a physician suspects that a patient has received too high or too low a dose of a medication, the physician could send a referral to the consulting pharmacist. The consultant pharmacist could then try to identify factors that resulted in the over or under-dose, e.g., incorrect measurement of weight, prodrug or active drug, patient genetics or microbiome. The consultant pharmacist could then provide advice for future physicians who would prescribe medications for the patient. The use of consultant pharmacists could significantly improve medical care.

What would be useful for a consultant pharmacist is to have a verifiably correct list of a patient’s medications. This could be done with a universal patient medical record.

A universal patient medical record with a complete list of a patient’s medications could also enable an ordering physician to be informed of duplicate medication orders and enable a personal physician for the patient to identify when the patient is not refilling a vital medication. Further, a universal patient medical record could enable automated clinical checking upon ordering, including checking for drug interactions and dosage appropriateness for the patient.

Michael R. McGuire is the author of A Blueprint for Medicine.

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