Wednesday, March 16, 2016

Why a tendency to use a sledgehammer instead of logic?

The government has banned 344 fixed dose combinations of drugs available in India. Most of them are combinations of antibiotics, painkillers or cough medicines. Some of the combinations do not make sense while others are positively dangerous. Trouble is that the list itself is incomplete and seems illogical. For example, combinations of Cefixime, a third generation cephalosporin used in typhoid, with linezolid and levofloxacin have been banned, but not its combination with cloxacillin. Linezolid and cloxacillin are both indicated only for gram positive bacteria, as for an abscess, whereas levofloxacin would make more sense. The list does not include fixed dose combinations of anti-tuberculosis drugs which have been supported by the World Health Organization because they ensure that the patient takes all 4 drugs. This stops patients from taking partial treatment and emergence of resistant strains of the bacteria. The problem is that all these combinations are for patients who weigh less than 50kg and inadequate for heavier people. Also a patient with tuberculosis gains weight once the disease comes under control, so the dose needs to be increased. The biggest problem is that there is no law on who can call himself a doctor. While rules are very strict about trained doctors, who have to undergo Continuing Medical Education, to keep up to date, there are no rules for the millions of quacks who practice with complete impunity. Homeopaths, vaids, physiotherapists, dietitians, foot massagers and even snake oil salesmen are allowed to call themselves doctors and prescribe allopathic drugs. Companies make combinations for these illiterates who find it convenient to prescribe a concoction of stuff in the hope that something will work. Poor patients go to these charlatans because their fees are less than trained physicians. However, India is not the only country with drug combinations. Every country has over the counter, or OTC, preparations for simple illnesses, such as flu or loose motions, which are combinations of commonly used drugs. Cough, especially dry, can cause great inconvenience, especially because it tends to get worse at night when the patient lies down, keeping her awake. Most syrups for dry coughs will contain codeine, pholcodine or dextromethorphan, mostly in combination with an antihistamine. These make people drowsy so should be taken only before going to bed. Unfortunately, some people have become addicted to such combinations. But taking a sledgehammer approach takes away treatment options from trained doctors. Morphine is invaluable for treatment of heart attacks and terminal cancer but is not available on prescription. That has not stopped an addiction epidemic in Punjab. But, as is normal in India, drug companies have obtained injunction orders from courts so patients can relax for the next 25 years. You cannot do good unless it is logical.

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