(1994; 115 pages) [French] [Spanish]
Chapter 11. STEP 6: Monitor (and stop?) the treatment
You have now learned how to choose a rational drug treatment, how to write the prescription and what to tell your patient. Yet even a well chosen treatment may not always help the patient. Monitoring the treatment enables you to determine whether it has been successful or whether additional action is needed. To do this you need to keep in touch with your patient, and this can be done in two ways.
Passive monitoring means that you explain to the patient what to do if the treatment is not effective, is inconvenient or if too many side effects occur. In this case monitoring is done by the patient.
Active monitoring means that you make an appointment to determine yourself whether the treatment has been effective. You will need to determine a monitoring interval, which depends on the type of illness, the duration of treatment, and the maximum quantity of drugs to prescribe. At the start of treatment the interval is usually short; it may gradually become longer, if needed. Three months should be the maximum for any patient on long-term drug therapy. Even with active monitoring the patient will still need the information discussed in Chapter 10.
The purpose of monitoring is to check whether the treatment has solved the patient's problem. You chose the treatment on the basis of efficacy, safety, suitability and cost. You should use the same criteria for monitoring the effect, but in practice they can be condensed into two questions: is the treatment effective? Are there any side effects?
History taking, physical examination and laboratory tests will usually provide the information you need to determine the effectiveness of treatment. In some cases more investigations may be needed.
Treatment is effective
If the disease is cured, the treatment can be stopped.4 If the disease is not yet cured or chronic, and the treatment is effective and without side effects, it can be continued. If serious side effects have occurred you should reconsider your selected drug and dosage schedule, and check whether the patient was correctly instructed. Many side effects are dose dependent, so you may try to lower the dose before changing to another drug.
4 Except in cases in which a standard duration of treatment is crucial, such as with most antibiotics
Treatment is not effective
If the treatment is not effective, with or without side effects, you should reconsider the diagnosis, the treatment which was prescribed, whether the dose was too low, whether the patient was correctly instructed, whether the patient actually took the drug, and whether your monitoring is correct. When you have determined the reason for the treatment failure you should look for solutions. So the best advice is to go again through the process of diagnosis, definition of therapeutic objective, verification of the suitability of the P-drug for this patient, instructions and warnings, and monitor-ing. Sometimes you will find that there is no real alternative to a treatment that has not been effective or has serious side effects. You should discuss this with the patient. When you cannot determine why the treatment was not effective you should seriously consider stopping it.
Table 8: Some examples of drugs in which a slow reduction in dose should be considered
If you decide to stop drug treatment you should remember that not all drugs can be stopped at once. Some drugs (Table 8) have to be tailed off, with a decreasing dosage schedule.
Exercise: patients 39-42
In the following cases, try to decide whether the treatment can be stopped or not. Cases are discussed below.
Man, 40 years. Review visit after pneumonia, treated with oral ampicillin (2 grams daily) for one week. No symptoms remain, only slight unproductive cough. Examination normal.Patient 40:
Man, 55 years. Severe myalgia and undefined arthritis for many years. Has been on prednisolone (50 mg daily) and indometacin (10 mg daily) for a long time. Epigastric pain and pyrosis over several months, for which he takes aluminum hydroxide tablets from time to time. During the consultation he complains that the epigastric pain and pyrosis have not disappeared; in fact they have become worse.Patient 41:
Woman, 52 years. Mild hypertension for the past two years. Responded well to a thiazide diuretic (25 mg daily). The maintenance dose has already been decreased twice because her blood pressure had dropped to around normal. She regularly forgets to take the drug.Patient 42:
Man, 75 years. Had been prescribed temazepam for one week, (10 mg daily) because of sleeplessness after his wife died six months ago. He asks for more, because he is afraid he will still not be able to sleep.
Patient 39 (pneumonia)
The course of treatment was defined in advance. It was effective and without side effects. The ampicillin can be stopped.
Patient 40 (epigastric pain)
In this case the treatment has not been effective because the epigastric pain is a side effect of the drugs used for myalgia. The treatment that really needs monitoring is the anti-inflammatory drugs, not the aluminium hydroxide. The problem can be solved by finding out whether the pain occurs at certain times, rather than being continuous. In this case the dosage schedule could be adjusted to reach peak plasma concentrations at those times, and the total daily dose could be lowered. The lesson to be learned from this patient is that it is better to reconsider the original therapy rather than to ‘treat’ its side effects with another drug.
Patient 41 (mild hypertension)
This treatment seems effective and without side effects. The patient is no longer hypertensive and may not need continued therapy, especially since she regularly forgets to take the drug. You can stop the treatment for assessment but you must continue to monitor the patient.
Patient 42 (insomnia)
As the patient wants to continue the treatment it was obviously effective. However, benzodiazepines can produce psychological and physical dependence when taken regularly for more than a few weeks. In addition, tolerance develops quickly and this can lead patients to take more than the recommended dose. You should explain this to the patient and also tell him that the nature of the sleep induced by such drugs is not the same as normal sleep, but the result of suppressed brain activity. Encourage him to try to return to natural sleep patterns; possibly a warm bath or a hot milk drink will help to promote relaxation before bedtime. It may also help to encourage him to express his feelings about his loss; acting as a sympathetic listener is probably your major therapeutic role in this case, rather than prescribing more drugs. In this case the drug can be stopped at once because it was only used for one week. This cannot be done when patients have taken benzodiazepines for longer periods of time.
STEP 6: Monitor (and stop?) the treatment
Was the treatment effective?
a. Yes, and disease cured:
Stop the treatment
b. Yes, but not yet completed:
Any serious side effects?
• No: treatment can be continued
• Yes: reconsider dosage or drug choice
c. No, disease not cured:
Verify all steps:
• Diagnosis correct?
• Therapeutic objective correct?
• P-drug suitable for this patient?
• Drug prescribed correctly?
• Patient instructed correctly?
• Effect monitored correctly?