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Tutorial - The Drugs Don't Work

We had a discussion about the reasons why a patient might think that their medicines aren't working while I was with you in 2018. I thought it would be a good idea to put a summary of our discussion for you to refer to in the future.

When a patient says this you must try to find out more information from the patient. Don't just accept that the drug is not any good as there may be other reasons that the drug isn't helping. Here are the reasons that you came up with:

1. They have been given the wrong medicine

2. The diagnosis is wrong and so the treatment is wrong too

3. The medicine is right but the dose is wrong

4. The diagnosis is right and the medicine is right but the patient isn't taking it properly

5. The diagnosis is right and the drug is right but the patient is taking it by the wrong route

6. The diagnosis is right and the treatment is right but the patient doesn't follow your instructions properly

7. The diagnosis is right and the drug is right but the clinician doesn't prepare the patient properly

8. The patient's expectations aren't realistic

Of course, a lot of these overlap with one another. This a shorter list of reasons:

1. The medicine is the wrong one for the disease. This is self-explanatory. E.g. An antibiotic won't work for a nasal allergy. An antihistamine won't work for a bacterial throat infection. Your history taking and examination will confirm the disease present and you should prescribe the right drug.

2. The diagnosis is wrong. If acute bacterial rhinosinusitis is diagnosed an antibiotic may be useful for the patient. That antibiotic won't work if the real diagnosis is acute viral rhinosinusitis. Getting the right diagnosis is important.

3. The wrong dose or duration. It is important that the correct dose and duration are prescribed. If they are not then the drug may not work. For example, if a patient has allergic rhinitis you may want to prescribe an antihistamine. This is a good choice for the disease. If it is prescribed once a week, however, it is unlikely to be of benefit. Always check that the patient has the right medicine, the right dose and the right frequency and duration.

4. Compliance problems. Patients don't always do what we advise. Sometimes they forget to take the medicine or they apply the medication incorrectly. E.g. nasal steroid sprays must be used every day in a head down posture. If the patient only uses it a few times a week or looks upwards when they spray the nose the drug is unlikely to work.

5. Patient expectations. Sometimes the patient believes that the drug will cure them when, in fact, it is a drug that will relieve symptoms only. A good example of this is salbutamol inhalers in asthma. The drug will never cure the asthma but it will make the symptoms of the disease better while it is being used. In ENT it is common for patients with chronic rhinosinusitis to think that a single bottle of steroid spray is going to cure them forever. They are disappointed when, a few days after stopping their sprays, the symptoms return. They then say that the drug didn't work. We must always educate patients about the intention of treatment and the prognosis of their disease.

6. Inadequate patient preparation. Always give a discharging ear a good clean before prescribing topical medication. This will help the drug work and is especially important wen treating fungal infections.

Summary

If the patient complains that the drugs don't work you should check the following:

a. The diagnosis

b. That the right drug has been given for the right duration by the right route

c. That the patient is using it properly

d. That the patient's expectations are correct