Saturday, September 15, 2007

a satisfying moment

I told off a doctor yesterday, at one point telling him he was wrong and the latest scientific research said something different from what he was telling me. I was very pleased with myself when I got off the phone.

The doctor I have seen for many years retired from general practice about a year ago. Because I see a gynecologist for my annual checkup and I haven't been sick I haven't had any reason to deal with replacing him. But I've got a cough lingering from a cold a month ago, and it wasn't going away using my usual system. So I figured I would start by making an appointment with my doctor's replacement, and see if I like him ok.

During the appointment I tried very hard to communicate that I don't like to take a lot of medication, in part because I tend to be very sensitive to side effects. However, I have learned by bitter experience that I need to take medication to nip these lingering coughs in the bud. My previous doctor had given me asthma medication to help quiet the irritation, and I like inhalers because not much medication gets into my system. Partly because I was out of town when the cold started, my usual system didn't work this time. So I was really to try something more than the short-acting inhaler I have used before (along with Mucinex and a Nasacort inhaler earlier in the cold cycle).

The doctor gave me a new medication, saying that the inhaler I was using was too short acting to be doing me any good. I don't know a lot about asthma medications, so what he told me he was prescribing Advair it didn't mean anything to me. I should have worried when he said "We are going to hit it hard." We talked a little about diabetes and he told me I didn't need to keep my blood glucose as low as I do, so I was already concluding he wasn't the doctor for me.

When I got the medication home from the pharmacy I read the Advair package insert. The top of the insert has a black boxed warning saying:
physicians should only prescribe ADVAIR DISKUS for patients not adequately controlled on other asthma-controller medications (e.g., low- to medium-dose inhaled corticosteroids) or whose disease severity clearly warrants initiation of treatment with 2 maintenance therapies.
I haven't tried a plain inhaled steriod--the inhaler I have been using is Albuterol, a brochodilator, not a steriod. I got on the web to read more about Advair and found people complaining about many serious problems other than worsening asthma symptoms. I decided no way was I going to take this medication without trying a low-dose inhaled corticosteriod first.

Knowing the problem of communicating clearly via a message left for the nurse, I faxed the doctor a letter telling him I didn't want to take Advair and requested instead that he write me a prescription for a low-dose inhaled corticosteroid.

He called me around 1 pm. He thought he could simply reassure me that the most serious danger of Advert didn't apply to me, as I don't have serious asthma (at most mild-cough variant asthma, and it may not even be that but just a post-infection irritation syndrome). I said there were other side effects listed that worried me. He told me that if I read those lists for something like Tylenol or Ibuprofin I would also find scary side effects. I said that is why I take those medications with care (I don't take Ibuprofin before or during exercise because there is some evidence that dehydration can contribute to side effects involving kidney damage). I said that some of the listed side effects, such as jitteriness and sleeplessness, are ones that I often have trouble with, and there was also a warning for people with diabetes. He said I am only diagnosed with prediabetes (that is what my previous doctor had written on my chart, but I think the distinction being made is that I don't take medication for diabetes). I said I keep my blood glucose tightly controlled after meals and even a small amount of steriods in my system could make that harder. He told me I didn't need to worry about blood glucose after meals, only the average (measured by the A1c test) mattered. That is when I told him he was wrong, that the latest scientific research showed otherwise. He said that research is paid for by companies that have medications that lower blood glucose after meals. (My main source of knowledge of the scientific research is this very persistent layperson.)

But by that point he was finally ready to give up arguing with me and agree to call in a prescription for a milder medication. I suspect his revenge was to not get it done--it hadn't been received when I went by the pharmacy around 4:30 pm but they were able to call and get it. He also prescribed a dose so low that my pharmacy didn't have that dose in stock, but the low dose is what I wanted. I'm using QVAR 40 mg.x2 twice a day. It hasn't worked magic, but I think it is helping and he said about both it and the stronger Advert that I should use it for two weeks before stopping so I won't give up on it quickly.

I already have a recommendation from a friend for another doctor.

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