It seems obvious: the medicine your doctor prescribes can't help you if you don't take it, or don't take it the way you're supposed to. So it may surprise you that according to the Centers for Disease Control, prescription medications are not taken as prescribed an astounding 50% of the time -- and up to 30% of new prescriptions are never filled at the pharmacy at all.
Host, Jonathan Fialkow, M.D. and his guest, Baptist Health clinical pharmacist Sara Eltaki, PharmD, talk about why sticking to the correct medication routine, or 'medication adherence', is so important to get the maximum benefit and avoid potential problems.
Ever wonder what happens when you miss a dose of your medication? Or if you accidentally take too much? What should you ask your doctor or pharmacist when you get a new prescription? Why is it important to inform your doctor about other medications and supplements you're taking?
Get answers to these questions and more in this episode of Baptist HealthTalk.
It seems obvious: the medicine your doctor prescribes can't help you if you don't take it, or don't take it the way you're supposed to. So it may surprise you that according to the Centers for Disease Control, prescription medications are not taken as prescribed an astounding 50% of the time -- and up to 30% of new prescriptions are never filled at the pharmacy at all.
Host, Jonathan Fialkow, M.D. and his guest, Baptist Health clinical pharmacist Sara Eltaki, PharmD, talk about why sticking to the correct medication routine, or 'medication adherence', is so important to get the maximum benefit and avoid potential problems.
Ever wonder what happens when you miss a dose of your medication? Or if you accidentally take too much? What should you ask your doctor or pharmacist when you get a new prescription? Why is it important to inform your doctor about other medications and supplements you're taking?
Get answers to these questions and more in this episode of Baptist HealthTalk.
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At Baptist Health, South Florida, it's our mission to care for you when you're injured or sick; and help you stay healthy and fit. Welcome to the Baptist Health Talk podcast, where our respected experts bring you timely practical health and wellness information, to improve your family's quality of life.
Dr. Jonathan Fialkow:
Hello, Baptist Health Talk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and certified lipid specialist at Miami Cardiac and Vascular Institute, and chief population health officer at Baptist Health, South Florida. In today's podcast, we're talking about taking your medications. Whether you have diabetes, high blood pressure or strep throat, the medicine your doctor prescribes can't help you if you don't take it, or if you take it incorrectly. Sounds pretty obvious, right? Well, apparently it's not. According to the Centers for Disease Control, between 20 to 30% of new prescriptions are never filled at the pharmacy, and they estimate that medication's not taken as prescribed an astounding 50% of the time. What's going on here? Why are these numbers causing alarm among doctors and pharmacists, and what can we do to help people stick to their correct medication routines? We're going to shine some light on this phenomenon with the help of my guest, Sara Eltaki, PharmD, the clinical pharmacist with Baptist Health. Welcome to the podcast, Sara.
Sara Eltaki:
Thank you, Jonathan. Happy to be here.
Dr. Jonathan Fialkow:
So I think before we get into the educational components regarding the medications, let's educate people about the role of a clinical pharmacist. Tell us what your education was and what the role of the clinical pharmacist is in our healthcare delivery system.
Sara Eltaki:
Sure. So as a pharmacist in general, as of early 2000's, all of us receive a doctorate in pharmacy. So we go to school right after, you know, your undergrad education for four years, most of us. Some of us go through accelerated programs, but mostly four years, get our doctorate degree. There's the option to go through residency training, so postgraduate training to be specific for, you know, clinical practice, meaning I see a patient, I hear a disease state, I learn about all their medications, and help basically stand by your prescribers or physicians, nurse practitioners, to come up with the best regimens for the patient. So that really kind of lends itself into being a clinical pharmacist. We're much more than that lick, stick, and pour a lot of people think pharmacists are. We stand by the prescribers. We go through the patient's regimens and we say what is best given their labs, given their history. We really are the medication experts and we help out with that component of patient care.
Dr. Jonathan Fialkow:
Again, the clinical component is the unique component. As you mentioned, you're part of the care team of the patient, direct patient contact, reviewing what's prescribed, what their other needs are, and making sure that we get the best outcome for that patient, which is why [crosstalk 00:02:39].
Sara Eltaki:
Absolutely. Yeah, we're right there by bedside, pre COVID, but right there by bedside. Yes.
Dr. Jonathan Fialkow:
In the offices as well. It's, you know, not just the hospital. Again, we have clinical pharmacists as part of our teams in our ambulatory space.
Sara Eltaki:
Correct, yeah.
Dr. Jonathan Fialkow:
So one of the benefits of a clinical pharmacist, there are many, has to do with medication adherence, the patient's likelihood to take medications. Let's talk about this medication adherence concept. It's part of quality measures from insurance companies. It's something doctors may not think about. They think, I prescribed the medication, patient walks out the door, everything's done. Everything's great, and then we get the outcome we want. What are the components of ... First, what is medication adherence? Then what are the components that meet mainly to decrease adherence via patient?
Sara Eltaki:
Absolutely. So medication adherence is how do you take your medications? Now, I want to take a step back because there is a different word that a lot of people use, which is medication compliance. I personally do not like that word because it's a very one sided word. What I mean by that is a lot of people say, well, my doctor told me to take it like this. So I have to take it like this. Well, there's a two sided component to adherence. It's not only that the prescriber's telling you to take it, but how are you, as the patient, able to take a medication? So that being said, what adherence is-
Dr. Jonathan Fialkow:
It is a softer term. We're not mandating. It's a patient-doctor decision, but I agree with you. Adherence is a better term.
Sara Eltaki:
It's a definitely, it's a softer term because it's taking into consideration you as the patient, and how you're able to take a med as well as what the prescriber needs you to take to get better. So medication adherence is just that. It's, are you taking the medication as prescribed to help you get better? Sounds very simple, as you said in your instructions, but it isn't. Patients tend to kind of, life gets in the way, you know, you go out for a walk and then you go see family members, and then you say, oops, I forgot my medication at home. I'll take it later. Then you forget to take it later because you're taking care of a baby or your family member or whatever it might be. So medication adherence is really tricky and it actually lends itself to additional issues in your health if you don't take your medications as prescribed.
Dr. Jonathan Fialkow:
You know, medication adherence, again, doctor-patient decide the patient will take the medication, desired outcome. Sometimes they don't even refill the medications, right? Isn't that something we see as well? Can we speak to?
Sara Eltaki:
Yeah. So that's a very common issue. There's actually a terminology for that. That's called prescription abandonment. The reason that happens is multifactorial, meaning there's several issues that lend itself. How many times have you heard a patient say, I just don't want to take a medication? There usually is something behind that. So a lot of it, probably the biggest one, is financial barriers. Either that the medication is too expensive and that they can't afford it or to the patient, you know, they're on 15 of them, and three of them are the same reason. Let's say heart failure. They say, oh, well, why do I need to take three of these meds? Well, they all work differently. So it's an education of why to take the medication.
Sara Eltaki:
That leads into, when I said the 15, the amount of medications a patient is taking. So sometimes when you take more, it may make you feel funny or you don't feel like you should be taking that many. Then I've had several patients who actually split up their medications multiple times a day because they feel like I shouldn't be taking 15 at a time. So there's a lot of educational opportunities to help patients kind of start taking medications appropriately to help them.
Dr. Jonathan Fialkow:
Those are again, great points and things we see in practice. Now let's walk through kind of a patient experience, okay? Patient arguably to be given a prescription, whether it's for a long period of time or a certain time period, it's to make something better or to prevent something, right? As a preventive cardiologist, we ask people to take medications. They're feeling fine, they can say, why am I taking this pill? I feel okay. The goal is so you don't feel poorly in the future with something that we can avoid, like a stroke or heart attack. So now patient's meeting a doctor and, through an evaluation, the doctor feels the patient may benefit from medication. What are the questions that we would recommend the patient ask of the doctor when the prescription is being given to better understand the reason for the medication to be more adherent? What would we recommend that the patients ask doctors when they're being given a prescription?
Sara Eltaki:
So I think one of the biggest assumptions that's made when picking a prescription is that a lot of prescriptions are once a day. There are several medications that are actually twice a day. I think one of the first questions the patient should ask, if they're concerned about how many times a day they have to take a medication is, how many times a day do I have to take this? What are the side effects is probably the next biggest question that you need to ask, because if you're prepared for it or if it's something that you're willing to experience to help with the disease state that you have, then that's the conversation that you need.
Dr. Jonathan Fialkow:
That's important too.
Sara Eltaki:
Yes, absolutely.
Dr. Jonathan Fialkow:
So arguably, and I think you're right with those questions, if there's a feeling that a person would benefit from being on a medication, that the doctor should explain that to the patient, you have this, we're looking to achieve this or looking to prevent this, and this medication has been shown to be helpful. So then the patient will say, yeah, but what are the side effects? What are the negatives? That should be the conversation. Does the benefit of the medication outweigh the negative? Even just paying for it is a negative, remembering to take it is a negative. So we have to make sure that the benefit outweighs those negatives.
Dr. Jonathan Fialkow:
Again, when people are aware of the side effects, I think that's a great point, so they can be prepared. Arguably as a prescriber of medication, sometimes we tell people, will I get that? It's, we don't know. Try it. Let's see what happens. Come back. We'll review because not everyone gets every side effect. So that's great. What about, should all medicines be taken on an empty stomach? Should they all be taken in the morning? How about, you know, what are things we want to look at with those terms?
Sara Eltaki:
With medications, it's really interesting. There's so much study and research behind medications. They don't all work the same. So some medications you take on an empty stomach for it to work better. Some medications you take with food for it to work better. Some medications in the morning work better, some medications at night work better. So it really depends on the medication. So that's a conversation a patient, or you as a patient, should have with your prescriber to figure out what is the best timing of that medication equally. You can talk to your pharmacist about that information as well.
Dr. Jonathan Fialkow:
So I do think that's a great role for the clinical pharmacist. Because again, as a prescriber, I'll just add another medication. I won't get into, what are you already taking? When are you taking them? Arguably, our prescription regimen can be every three hours they're popping a pill. I think part of the clinical pharmacist role, part of it because there's obviously much component, is let's go through your medications. Maybe you take these together in the morning and these at night, maybe you take these before breakfast so it's not confusing to the patient. The more medications, the more times they take it, the less likely there'll be adherence. So I think that's really important. I don't really get patients ask me that all that much. I'm proactive, but when do I take it? Is it with food or without food? Should I take this at night? I think those are really important considerations when a medication is being prescribed, right?
Sara Eltaki:
Yeah, absolutely. Yeah. I think, you know, the bottles that you get from the pharmacy usually come with labels, but those labels are, you know, some of the times there were three or four of them at once and you can't really distinguish what's what. So if you're ever confused, call up your local pharmacy, talk to the pharmacist and ask them, can you give me a little bit more information about this medication? They're fully equipped to give you that information.
Dr. Jonathan Fialkow:
That's a great recommendation as well, it's a nice resource is to call the pharmacist. So let's talk about the consequences again, a physician and the patient decide that a medication is indicated. It should be determined what's the purpose of it. How about what are the more common reasons people will ... Let me rephrase that. What are the more common ways we can determine if a medication has a bad effect? We know you'll feel something when you're on a medication, because we're feeling something all the time. Was it the medication that caused it? So how you work with people who have a medication, if their pinky itches or they feel nauseated three days later or they find that they get up in the middle of the night, how can we assess whether it's the medication or coincidental and not the medication? Kind of a loaded question, I know.
Sara Eltaki:
A little bit, but I'll try to answer as best as I can. So I think a lot of that has to do with just monitoring. First of all, actually education. So when a patient gets the medication, education is really the biggest tool you can give to a patient. Whether, you know, if you're really good with listening to someone tell you something, ask them. Say, hey, can you just tell me what this medication is about? I have all this written paperwork and I'm not going to read it. That's kind of the biggest assumption is, oh, you have all these papers, read it. But anyway, so education is the biggest thing that we could do for the patients first, is that we educate, we talk to them. We say, hey, these are your common side effects. These are common. These are going to very likely happen.
Sara Eltaki:
But remember, it's not detrimental in a way. But then there's rare and serious complications. If you do experience these, don't pass go, call your prescriber. I think that that is the biggest thing that we can start with with the patients. So arming them with that information upfront kind of makes them more vigilant of their own health and say, wait a minute. I remember someone telling me that when I take this medication, it's going to cause me to cough. Now, all of a sudden I have a cough. Okay, but now it bothers me. So it's bothering me. Let me talk to my prescriber and see if there's an alternative medication that I can take.
Dr. Jonathan Fialkow:
So I think those points are well taken. It doesn't mean the side effects are dangerous or life threatening. Of course, if your tongue's swelling and you can't breathe, you know, you don't mess around. I think I want to get the allergies in the second, but because a side effect may happen doesn't mean you're going to get it. It's probabilities. It's always remarkable to me in the clinical trials where they give a group of people a medicine and give a similar group of people a placebo or a sugar pill, the amount of side effects of the placebo, right? You know, 20% complained I couldn't sleep, and 10% complained of diarrhea. They're getting a sugar pill, which means things happened, but we attribute it to the medication that might have nothing to do with the medication. So that's where we have to look at the probabilities in the more common side effects.
Dr. Jonathan Fialkow:
Again, that's the conversation you have with, again, your doctor, your nurse practitioner, or your clinical pharmacist, who's on your care team. So I've had a lot of patients come in and we may want to prescribe a medication. They say, well, I'm allergic to that medication. Well, what happened? Well, five years ago, they gave me a similar medication and you know, I had an upset stomach. Can you talk a little bit about an allergy to a medication or a family, in which case we will not use that family of medication, versus, you know, an intolerance or some other type of side effects?
Sara Eltaki:
Right? So, I mean, I always encourage patients to tell me what happened when they take a medication. So whenever you're with a prescriber and if they do ask you or clinical pharmacist, anybody in healthcare, if they ask you what are your allergies, by all means, tell them, you know, this is what happened. But in turn, if they don't ask, what was the reaction, you should always offer that up, because to you and might have been an allergy, like you mentioned upset stomach, but in reality, that's just a side effect of the medication. What I'm trying to get at is potentially we could harm ... Sorry, let me start over. Potentially what we can ... Okay. Sorry. Let's do that part over. Okay. So with allergies, what ...
Dr. Jonathan Fialkow:
You got it. Don't worry about it. You got time.
Sara Eltaki:
This is where the brain is moving faster than my lips. Okay.
Dr. Jonathan Fialkow:
[inaudible 00:15:41].
Sara Eltaki:
Yeah. All right. Let me regroup and try to say this again.
Sara Eltaki:
So whenever a patient thinks that they have an allergy, what we always encourage is tell us about it. Tell us what you had experienced with the medication. The reason being is that it gives us good insight to what might have happened. Something that might not seem like a big deal to the patient might actually be a big deal in terms of an allergy. I'll give a really good example. Statins, which is a medication for cholesterol, if someone said, oh, I had muscle aches with that, that to someone might not seem like a big deal, but that is actually a really big deal, and we would not want to use that medication. So we always encourage, tell us about that. Tell us about your reactions. But on the flip side, we don't want to exclude a medication from using it, like an antibiotic let's say, because we end up losing an entire class of medication that we could potentially use to treat a disease state by falsely or over-reporting an allergy to a medication.
Dr. Jonathan Fialkow:
That's great. The allergy symptoms, swollen tongue, you know, difficulty breathing, wheezing, rashes, those are things that arguably would be reproducible if you gave the medication again or the family. But if you have an intolerance, something happened to you, that doesn't mean you couldn't use another medication in the family with a better outcome. So again, I think that's a great way to explain it. What about the difference between taking a medication and ... What is the difference between a prescribed medication and let's say a dietary supplement? Something, you know, you have an issue, you go into one of the dietary supplement stores and you buy something to treat a medical condition, which of course they're not indicated for. Talk a little bit about what the safety and what the data behind the prescribed medication is.
Sara Eltaki:
Oh, this is one of my favorite things to tackle-
Dr. Jonathan Fialkow:
Oh, go with it, man, go with it.
Sara Eltaki:
Especially when talking with patients. One of the first things that come out is oh, I want to take a dietary supplement because it's-
Dr. Jonathan Fialkow:
Something natural.
Sara Eltaki:
... More natural. Exactly. It's more natural. That might be the case, but natural doesn't mean safe. Especially with natural products, there's no regulation behind safety and efficacy. So they will market a product and actually, if you notice in their marketing, they can never say what it's for. They can say it's for bone health, but they won't say it can treat.
Dr. Jonathan Fialkow:
They can't treat a medical condition. Right.
Sara Eltaki:
Yeah. It doesn't treat a medical condition, but they can tell you, this will be for some health, this health, bone health, eye health, you know, and the reason being is that it hasn't gone through the stringent regulations and testing that prescription medications has gone through. That doesn't necessarily mean that they're all bad. This is where I always come. This is where I stop and pause and say, if it's something that is of importance to my patient who wants to take it, I just request that you tell me about it because there are a lot of drug interactions between your prescribed medications in those.
Dr. Jonathan Fialkow:
You know, I tell people again, you know, arsenic is natural. Cyanide is natural. I mean, this feeling that because it's natural, it's safer. Pretty much every medication was derived from some natural substance, which had a physiological effect. Then it's been purified and tested and regulated. So you're getting the benefits of the natural substance, but in a regulated, safe way, which is, you know, sometimes lost with people. So I again, appreciate that. Couple of final moments. Again, so much we can go on regarding medications and how they're used and how they should be used and sometimes how they're not used. We do want to recognize that sometimes the medication is prescribed inappropriately. So it is okay for the patient to challenge the doctor and say, why are you giving this to me? What are we looking for? But a couple of families of medications I just want to emphasize, and I want to start with the anticoagulants, for example, because obviously if someone has a need for an anticoagulation medicine to prevent a stroke, you know, they may bleed a little bit, but obviously the stroke risk without the medicine's higher than the bleeding risk.
Dr. Jonathan Fialkow:
So sometimes people will take half the dose. Is half the dose, half as dangerous? Is twice the dose, twice as effective if you have a benefit? Can you talk a little bit about dosing and maybe speak at an anticoagulants in particular if that's relevant?
Sara Eltaki:
Yeah, sure. So with anticoagulants, they're blood thinners. That's really what that class of medication is. So I know when I was going through pharmacy school, I was like, blood thinners? What does that actually mean? How can you thin out your blood? But all that means is that your blood won't clot as much or as well as it used to, which helps prevent things like strokes or clots in your veins. There's a lot of new medications that are out that are twice a day, like you mentioned. There's obviously a lot of risk factors with blood thinners. So if you cut yourself, you find that you might bleed a little bit longer.
Dr. Jonathan Fialkow:
But you do stop bleeding, you just bleed longer.
Sara Eltaki:
You do eventually stop bleeding.
Dr. Jonathan Fialkow:
Right. Exactly. You can pull a tooth on blood thinners. They will stop bleeding.
Sara Eltaki:
You will stop bleeding eventually, but it just takes a little bit longer. That's one of the pieces of education that we give, but some of them come as twice a day. Taking it once a day actually is detrimental because it's not working the way it should work. We need your blood to be a certain level of thin, is the best way I can describe this, in order for us to prevent those clots. So taking it once a day is not going to be safer for you, so the potential side effects of the medication. If anything, your blood might not be as thin as it should be.
Dr. Jonathan Fialkow:
It may not work at all, quite frankly.
Sara Eltaki:
Really, yeah.
Dr. Jonathan Fialkow:
As you were saying, between you absorbing it, getting it the level in your blood, if you take less than the established dose, you may get no function.
Sara Eltaki:
Yeah, exactly. Without getting really too technical there, there's something called a therapeutic window. Basically, there's a bottom of it, which is where the minimally effective dose or dosing of the medication works. Then there's the top of the window, which is it's still effective and safe. So that's a therapeutic window. When we dose medications multiple times a day, it's in order for us to keep that level within that window. So when someone takes something once a day, we're basically going up into the therapeutic window and then coming back down out of the therapeutic window, so now it's not being effective at all. Then what ends up happening is that you take it again, you kind of maybe spike back up into therapeutic window, but come back out. So taking it two at a time, what ends up, let's say in the opposite you forgot to take it at night and now you wake up the next morning. You say, oh, shoot. I forgot to take it. You're going to actually spike a [crosstalk 00:23:19].
Dr. Jonathan Fialkow:
Don't do that. Don't double your dose.
Sara Eltaki:
Don't ever do that.
Dr. Jonathan Fialkow:
Right. Right. Go with you forgot.
Sara Eltaki:
Yeah. So you actually have the potential of going into a risk area outside of that therapeutic window.
Dr. Jonathan Fialkow:
So the reality is ... I'm sorry, go ahead.
Sara Eltaki:
No, no, go ahead. Go ahead.
Dr. Jonathan Fialkow:
So the reality is take it as prescribed. If you find it's difficult for you to take it as prescribed because you're forgetting or you're feeling issue, speak to the doctor, speak to your pharmacist, don't make the decisions on your own to change the timing or the frequency or the dosing, because that could have negative consequences.
Sara Eltaki:
Correct.
Dr. Jonathan Fialkow:
To that point again, I want to get into other points. Speak a little bit about what happens if someone does miss a dose of a medication. I mean, you know, these things are meant to help people over time periods. You know, it's not going to the ... Well, I'll leave it to you. What if someone misses a dose of medication?
Sara Eltaki:
So my rule of thumb, actually, I think not my rule of thumb, but really the rule of thumb, is that if wherever you are closest to in windows. So what I mean by that is if you take a medication once a day, you basically have a 12 hour window because you cut that 24 hours in half. Right? So if your next dose is ... If you forgot to dose and you're within a 12 hour frame from when you were supposed to take it, you go ahead and you can take it and just continue taking it as you were. However, if you are outside of that window, don't take it. Just skip that dose, go to the next dose. What you don't want to do is to have that double up effect. So that's kind of the rule of thumb. If you're close enough to when you were supposed to take it, go ahead and take it. If you're too far out, don't take it.
Dr. Jonathan Fialkow:
You're not going to arguably drop dead if you don't take a medication.
Sara Eltaki:
No, no.
Dr. Jonathan Fialkow:
So my last question, and I'm challenging my producer, Carol Higgins, I think this should be a fall podcast, has to with antibiotics. We're not going to talk about the over prescription of antibiotics. That would be a different discussion, but what is the danger if someone has a course of antibiotics because they don't feel well, and within a few days, they feel better and stop the antibiotics before they complete the course. What's the importance of that three, seven, 10 day course to continue it even after your symptoms might have abated?
Sara Eltaki:
So with antibiotics or with any sort of infection, a lot of those times we do feel better, but the infection is still brewing within us. If we stopped taking an antibiotic before it's supposed to be over just because we feel better, that bug that's still sitting inside of you is smart. That's a very smart bug. It says, oh, I see that thing that just killed all my friends. I'm going to now arm myself to not get killed by that. That's what causes resistance to an antibiotic. So when we, as healthcare professionals, are constantly pushing, make sure you finish your course of antibiotics, that's the reason why. We're trying to prevent antibiotic resistance. With antibiotic resistance, we then truly eliminate entire class of antibiotics that we can't use to now treat what used to be as simple infection.
Dr. Jonathan Fialkow:
So similarly, complete the course or discuss with your doctor if it's something that you're having trouble with. Well, this is great stuff, Sarah. Again, thanks for lending your time, and more importantly I guess, your expertise. There's a lot of other things, a lot of other roads we can go down. I think maybe discussing down the road, how people who have to take care of elderly or family members, how they can kind of work with the medications and various other components, but for right now, anything you want to add before we wrap up or anything you want to reiterate that we did discuss?
Sara Eltaki:
Just, you know, for the healthcare consumers out there, really trust in your pharmacist. They are your most accessible healthcare professionals. There's a lot of training that goes into our knowledge base. Really, if they have any questions, you can always start there, and if it's something that they're not able to answer, they will definitely tell you to go talk to your prescriber. So that would be my last piece.
Dr. Jonathan Fialkow:
Again, as we incorporate clinical pharmacists into our care teams more and more, this will be a great education service to patients when they get put on antibiotics past just the doctor or the nurse practitioner prescribing it. So great stuff. Listeners, again, ask questions, nothing wrong with that, of your care provider or even the pharmacist. Education is critical. You know, try not to make decisions on your own in terms of when to take medications and how much to take. Don't go looking for side effects, but if you do feel something that you think is related to the medication, feel free to follow up with your provider and discuss it. Thanks for listening. As usual, if you have any thoughts, ideas for future topics or any other concerns, please email us at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. Thanks for listening. Stay safe.
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