What’s Best – Guideline-Directed Medical Therapy OR

Patient-Directed Medical Therapy

This picture has too many pointers all directed at the heart.

My cardiology group supervises cardiology fellows and University of Connecticut residents to provide cardiology consultation service to uninsured and underinsured patients admitted to Hartford Hospital.

The hospital pharmacy can provide these patients with a month of their medications on discharge, but some are homeless and cannot use even those medications, given their social situations. Many of these cardiology patients have heart failure with reduced ejection fraction (HFrEF). Guideline-directed medical therapy (GDMT) improves survival in patients with HFrEF. Consequently, patients with HFrEF should be discharged on a diuretic, a beta blocker, a renin-angiotensin system antagonist, a sodium glucose transport 2 inhibitor (SGLT2) and an aldosterone blocker. Unfortunately, underinsured and homeless patients are almost never able to follow these complex regimens so they often take nothing after discharge and especially after using up their free supply. I know this sounds like medical heresy, but I advocate for putting these patients on the drug that keeps them asymptomatic and out of the hospital: “Vitamin F” or “Vitamin L” for furosemide or Lasix, respectively. I discuss this decision with the patient and explain the consequences either way, and follow their wishes, but strongly advocate for only diuretic.

I encourage these patients to buy their drugs at a pharmacy that offers inexpensive generic drugs. Walmart offers many generic drugs at the price of $4 for a month or $10 for a 3-month supply. I have occasionally bought the 3-month supply for some of our frequent HFrEF rebounders in an effort to increase the time between when they develop intolerable heart failure. Other pharmacies may have similar plans, but I could not find them. I googled Walmart, Walgreens and CVS with the question, “Does X pharmacy sell generic drugs for 90 days for $10 or less” and the only hit was Walmart. Google did say that Walgreens had such a plan, but no longer.

By the way, to check if the patient is actually taking the diuretic, check the value of using the chloride as discussed in my post "Pissing Away the Chloride." - https://pauldthompsonmd.substack.com/p/pissing-away-the-chloride

Since we’re on the topic of generic drugs, always try to use the generic names of medications when they are released. That way you learn the generic name and are more likely to get the generic at lower cost after the drug becomes available.

I always feel a little defensive when not recommending GDMT for every patient, but my goal with using only vitamin F is to keep patients feeling well as long as possible.

Here are the Rules:

- Practice patient-directed medical care and not just guideline-directed medical therapy.

- Using only “Vitamin F” or “Vitamin L” is often the best drug for keeping underinsured patients with HFrEF asymptomatic.

- The “best medicines” are not the best if they are too expensive to be used.

- Check the chloride as a marker of diuretic adherence.

#medicalcare #prescriptiondrugs #heartfailure #diuretics #medicationcompliance #cardiology