“Doc, I cannot sleep well at night since I started taking the blood thinner (apixaban/Eliquis).”

“Hmm, that is not a typical side effect of the blood thinner. Have you considered any other changes to your routine that could be affecting how you sleep at night?”

“Doc, I also have joint pains and diarrhea since I started the blood thinner. Can I stop it?”

(The patient has had joint pains and diarrhea pre-dating the start of the blood thinner.)

I explain what Eliquis does and why is it necessary for the patient’s new diagnosis of atrial fibrillation.

I can see they are not convinced.

At the next visit, I note that the patient has started cutting the pills in half so that they are taking 2.5 mg twice a day instead of the recommended dose of 5 mg twice a day.

At the following visit, they have stopped taking the blood thinner altogether. They have not had any bleeding. We briefly discuss other options and finally the elephant in the room is addressed, the medication is too expensive.

The hidden barrier of cost

As a cardiologist, I see this with several expensive medications, another example being sodium-glucose cotransporter-2 inhibitors empagliflozin (Jardiance) and dapagliflozin (Farxiga). Patients often say that they have noticed no benefit from the medication and have elected to stop it, and only much later is it revealed that cost is the driving force behind noncompliance.

Although many patients talk about affordability of drugs and procedures upfront, I practice in the southern region of the United States, where many older patients would be embarrassed to admit financial hardship. When patients talk about almost impossible side effects, my first instinct is to explain to them again why the medication is important, to allay their fears regarding the side effects, and to try to find other reasons for the side effects that they have mentioned. At this point, I am usually not trying to offer them samples or explore patient assistance programs, because they have not mentioned cost issues. However, I am now realizing that maybe I should offer them assistance without asking them directly if the drug is too expensive, because trying to address imaginary side effects is futile and time-consuming.

Navigating financial embarrassment

There are times when we are going in circles regarding the side effects of the medication, when the patient’s family member suddenly interrupts, asking if there is a cheaper alternative.

Not only is it unfortunate that health care is so expensive, it is also disheartening to see that people have to make excuses for not being able to afford needed health care despite having good insurance. Although a lot of conversations with my patients these days are focused on affordability, it is uncomfortable for many people, myself included, to talk about finances. Many patients fear being judged by their health care teams if they admit that they cannot pay for their medications.

I sincerely hope the prices for these ubiquitous drugs are slashed soon. Until then, I shall reflect on the best way to bring up cost of medications without offending patients when they start reciting a laundry list of side effects; it is gratifying to be able to find creative ways to ensure that our patients get the medications that they need.

Shuchita Gupta is a cardiologist.