Ulcers Then and Now

Patient complaints about the high cost of prescription drugs are a leitmotif of many office visits, and sometimes they are the main theme. Patients are crying out for our help on this issue, even if the medication is not related to our specialty. One of my elderly rheumatoid arthritis patients recently told me that the cost of his pioglitazone had gone up an additional $50 to reach a staggering monthly cost of $148. Not all that glitters is gold, but it might as well be judging from the price tag. He and his wife gave up their cable television so they could pay for the drug. He didn’t come across as one of those well-heeled retirees who are not eligible for drug company assistance. I went online and printed out the manufacturer’s patient assistance form. I wasn’t sure he’d be able to fill out the form, but I hold on to the hope that getting his cable service restored will be enough of an incentive for him to get this done.

It feels like the only bargains in medicine are the old generic drugs. I know I’m really dating myself with this confession, but I remember when Tagamet (cimetidine) was brand name only. It was the blockbuster drug of the day. When I was new in practice, the Tagamet sales rep pleaded: "I really want you to prescribe a lot of Tagamet, because my holiday bonus is on the line!" This story stands out in my mind as a moment of refreshing candor by a drug representative.

Expensive stomach medications to mend or prevent the onslaught of gastric mucosal damage caused by our nonsteroidal anti-inflammatory drugs (NSAIDs) have always been a part of the background of my rheumatology practice. Although the names of the medications have changed, the high price tags associated with these drugs have remained a consistent feature. But back in omeprazole’s heyday, the first proton pump inhibitor was dubbed "the purple pill." Now that it is available inexpensively over the counter, it has been stripped of its regal purple color. It is now a mousey brown, and its expensive cousin Nexium is adorned with the royal color. Considering the drug’s price tag, they probably should have made it green, like the color of newly printed cash, but I suspect the marketing people didn’t think that "the green pill" had the same sales appeal as the purple pill.

For many patients on chronic NSAID therapy, a second drug to help prevent ulcers and GI bleeding is appropriate, but this raises the patient’s drug costs, and it is very hard to convince asymptomatic patients that they need to take the purple pill, or anything else for that matter, when they don’t perceive it as necessary.

Although GI symptoms and endoscopic findings of ulceration correlate poorly, I invariably continue to ask patients about upset stomach symptoms, and I always ask whether they have a history of ulcer disease. Once a patient gives a history of ulcers, I try to get an idea of the severity of the problem, and I ask follow-up questions regarding hospitalization, blood transfusion, or surgery. Nowadays, only the sickest patients with active GI bleeding require hospitalization, but things were different in the distant days before our high-priced drugs. One man told me that he had an ulcer in 1965. Treatment options were very limited. Ulcer patients from that era frequently tell me their treatment included dietary remedies such as eating baby food for 6 weeks.

My patient was hospitalized in the era before proton pump inhibitors. He told me he had been having a lot of upper abdominal pain, and the doctor ordered an injection of pain medication. The evening nurse administered this but forgot to chart it. The old saying goes, "if you didn’t chart it, you didn’t do it." That was exactly the conclusion of the night nurse. Seeing that the injection had not been charted, she also gave my patient a shot.

Perhaps my patient was exaggerating, or perhaps the passage of about 46 years altered his memory of the event, but he told me that after receiving two injections fairly close together, he slept for 3 days. He probably benefited from the sleep, and when he finally woke up from his iatrogenic hibernation, his hospital roommate told him that he had become a semi-celebrity. Lots of important people from the hospital administration had been holding candlelight vigils at his bedside and were hoping that he would recover and not sue the hospital.

Hospital administrators were only too happy to make amends, and they reassured my patient that the nurse who had failed to document his first dose of pain medication had been summarily fired. Although some people might have been appeased by this bit of obsequious viciousness, for my patient it had the opposite than intended effect. He told them they had to rehire the nurse immediately, or he would sue the hospital. He had the hospital over a barrel, the hospital knew it, and they promptly rehired the nurse.

Anyone could make a mistake, he told me, and besides that, the nurse was a widow with two children to raise. I was overwhelmed by this man’s magnanimous spirit, but I was bothered by a nagging question. He had been sick and heavily sedated for 3 days, so how did he know that the nurse was a widow with two children? I asked him this question, since digressions like this are the best part of my job. When I spoke with him, he was a tremulous old man with many chronic problems, but at the time of his hospitalization he had been a police officer. He had investigated the accidental death of the nurse’s husband! I was awed by this amazing coincidence, and I couldn’t help but think that perhaps the greatest form of quality improvement is forgiving an occasional mistake, something that has become increasingly rare in health care. It seems as if everyone is touting the greatness of evidence-based medicine, but there’s a lot of homespun wisdom in this anecdote. Perhaps a little more wisdom, plus some low-cost generics, might be just the thing health care reform is lacking.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.

Patient complaints about the high cost of prescription drugs are a leitmotif of many office visits, and sometimes they are the main theme. Patients are crying out for our help on this issue, even if the medication is not related to our specialty. One of my elderly rheumatoid arthritis patients recently told me that the cost of his pioglitazone had gone up an additional $50 to reach a staggering monthly cost of $148. Not all that glitters is gold, but it might as well be judging from the price tag. He and his wife gave up their cable television so they could pay for the drug. He didn’t come across as one of those well-heeled retirees who are not eligible for drug company assistance. I went online and printed out the manufacturer’s patient assistance form. I wasn’t sure he’d be able to fill out the form, but I hold on to the hope that getting his cable service restored will be enough of an incentive for him to get this done.

It feels like the only bargains in medicine are the old generic drugs. I know I’m really dating myself with this confession, but I remember when Tagamet (cimetidine) was brand name only. It was the blockbuster drug of the day. When I was new in practice, the Tagamet sales rep pleaded: "I really want you to prescribe a lot of Tagamet, because my holiday bonus is on the line!" This story stands out in my mind as a moment of refreshing candor by a drug representative.

Expensive stomach medications to mend or prevent the onslaught of gastric mucosal damage caused by our nonsteroidal anti-inflammatory drugs (NSAIDs) have always been a part of the background of my rheumatology practice. Although the names of the medications have changed, the high price tags associated with these drugs have remained a consistent feature. But back in omeprazole’s heyday, the first proton pump inhibitor was dubbed "the purple pill." Now that it is available inexpensively over the counter, it has been stripped of its regal purple color. It is now a mousey brown, and its expensive cousin Nexium is adorned with the royal color. Considering the drug’s price tag, they probably should have made it green, like the color of newly printed cash, but I suspect the marketing people didn’t think that "the green pill" had the same sales appeal as the purple pill.

For many patients on chronic NSAID therapy, a second drug to help prevent ulcers and GI bleeding is appropriate, but this raises the patient’s drug costs, and it is very hard to convince asymptomatic patients that they need to take the purple pill, or anything else for that matter, when they don’t perceive it as necessary.

Although GI symptoms and endoscopic findings of ulceration correlate poorly, I invariably continue to ask patients about upset stomach symptoms, and I always ask whether they have a history of ulcer disease. Once a patient gives a history of ulcers, I try to get an idea of the severity of the problem, and I ask follow-up questions regarding hospitalization, blood transfusion, or surgery. Nowadays, only the sickest patients with active GI bleeding require hospitalization, but things were different in the distant days before our high-priced drugs. One man told me that he had an ulcer in 1965. Treatment options were very limited. Ulcer patients from that era frequently tell me their treatment included dietary remedies such as eating baby food for 6 weeks.

My patient was hospitalized in the era before proton pump inhibitors. He told me he had been having a lot of upper abdominal pain, and the doctor ordered an injection of pain medication. The evening nurse administered this but forgot to chart it. The old saying goes, "if you didn’t chart it, you didn’t do it." That was exactly the conclusion of the night nurse. Seeing that the injection had not been charted, she also gave my patient a shot.

Perhaps my patient was exaggerating, or perhaps the passage of about 46 years altered his memory of the event, but he told me that after receiving two injections fairly close together, he slept for 3 days. He probably benefited from the sleep, and when he finally woke up from his iatrogenic hibernation, his hospital roommate told him that he had become a semi-celebrity. Lots of important people from the hospital administration had been holding candlelight vigils at his bedside and were hoping that he would recover and not sue the hospital.

Hospital administrators were only too happy to make amends, and they reassured my patient that the nurse who had failed to document his first dose of pain medication had been summarily fired. Although some people might have been appeased by this bit of obsequious viciousness, for my patient it had the opposite than intended effect. He told them they had to rehire the nurse immediately, or he would sue the hospital. He had the hospital over a barrel, the hospital knew it, and they promptly rehired the nurse.

Anyone could make a mistake, he told me, and besides that, the nurse was a widow with two children to raise. I was overwhelmed by this man’s magnanimous spirit, but I was bothered by a nagging question. He had been sick and heavily sedated for 3 days, so how did he know that the nurse was a widow with two children? I asked him this question, since digressions like this are the best part of my job. When I spoke with him, he was a tremulous old man with many chronic problems, but at the time of his hospitalization he had been a police officer. He had investigated the accidental death of the nurse’s husband! I was awed by this amazing coincidence, and I couldn’t help but think that perhaps the greatest form of quality improvement is forgiving an occasional mistake, something that has become increasingly rare in health care. It seems as if everyone is touting the greatness of evidence-based medicine, but there’s a lot of homespun wisdom in this anecdote. Perhaps a little more wisdom, plus some low-cost generics, might be just the thing health care reform is lacking.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.

Patient complaints about the high cost of prescription drugs are a leitmotif of many office visits, and sometimes they are the main theme. Patients are crying out for our help on this issue, even if the medication is not related to our specialty. One of my elderly rheumatoid arthritis patients recently told me that the cost of his pioglitazone had gone up an additional $50 to reach a staggering monthly cost of $148. Not all that glitters is gold, but it might as well be judging from the price tag. He and his wife gave up their cable television so they could pay for the drug. He didn’t come across as one of those well-heeled retirees who are not eligible for drug company assistance. I went online and printed out the manufacturer’s patient assistance form. I wasn’t sure he’d be able to fill out the form, but I hold on to the hope that getting his cable service restored will be enough of an incentive for him to get this done.

It feels like the only bargains in medicine are the old generic drugs. I know I’m really dating myself with this confession, but I remember when Tagamet (cimetidine) was brand name only. It was the blockbuster drug of the day. When I was new in practice, the Tagamet sales rep pleaded: "I really want you to prescribe a lot of Tagamet, because my holiday bonus is on the line!" This story stands out in my mind as a moment of refreshing candor by a drug representative.

Expensive stomach medications to mend or prevent the onslaught of gastric mucosal damage caused by our nonsteroidal anti-inflammatory drugs (NSAIDs) have always been a part of the background of my rheumatology practice. Although the names of the medications have changed, the high price tags associated with these drugs have remained a consistent feature. But back in omeprazole’s heyday, the first proton pump inhibitor was dubbed "the purple pill." Now that it is available inexpensively over the counter, it has been stripped of its regal purple color. It is now a mousey brown, and its expensive cousin Nexium is adorned with the royal color. Considering the drug’s price tag, they probably should have made it green, like the color of newly printed cash, but I suspect the marketing people didn’t think that "the green pill" had the same sales appeal as the purple pill.

For many patients on chronic NSAID therapy, a second drug to help prevent ulcers and GI bleeding is appropriate, but this raises the patient’s drug costs, and it is very hard to convince asymptomatic patients that they need to take the purple pill, or anything else for that matter, when they don’t perceive it as necessary.

Although GI symptoms and endoscopic findings of ulceration correlate poorly, I invariably continue to ask patients about upset stomach symptoms, and I always ask whether they have a history of ulcer disease. Once a patient gives a history of ulcers, I try to get an idea of the severity of the problem, and I ask follow-up questions regarding hospitalization, blood transfusion, or surgery. Nowadays, only the sickest patients with active GI bleeding require hospitalization, but things were different in the distant days before our high-priced drugs. One man told me that he had an ulcer in 1965. Treatment options were very limited. Ulcer patients from that era frequently tell me their treatment included dietary remedies such as eating baby food for 6 weeks.

My patient was hospitalized in the era before proton pump inhibitors. He told me he had been having a lot of upper abdominal pain, and the doctor ordered an injection of pain medication. The evening nurse administered this but forgot to chart it. The old saying goes, "if you didn’t chart it, you didn’t do it." That was exactly the conclusion of the night nurse. Seeing that the injection had not been charted, she also gave my patient a shot.

Perhaps my patient was exaggerating, or perhaps the passage of about 46 years altered his memory of the event, but he told me that after receiving two injections fairly close together, he slept for 3 days. He probably benefited from the sleep, and when he finally woke up from his iatrogenic hibernation, his hospital roommate told him that he had become a semi-celebrity. Lots of important people from the hospital administration had been holding candlelight vigils at his bedside and were hoping that he would recover and not sue the hospital.

Hospital administrators were only too happy to make amends, and they reassured my patient that the nurse who had failed to document his first dose of pain medication had been summarily fired. Although some people might have been appeased by this bit of obsequious viciousness, for my patient it had the opposite than intended effect. He told them they had to rehire the nurse immediately, or he would sue the hospital. He had the hospital over a barrel, the hospital knew it, and they promptly rehired the nurse.

Anyone could make a mistake, he told me, and besides that, the nurse was a widow with two children to raise. I was overwhelmed by this man’s magnanimous spirit, but I was bothered by a nagging question. He had been sick and heavily sedated for 3 days, so how did he know that the nurse was a widow with two children? I asked him this question, since digressions like this are the best part of my job. When I spoke with him, he was a tremulous old man with many chronic problems, but at the time of his hospitalization he had been a police officer. He had investigated the accidental death of the nurse’s husband! I was awed by this amazing coincidence, and I couldn’t help but think that perhaps the greatest form of quality improvement is forgiving an occasional mistake, something that has become increasingly rare in health care. It seems as if everyone is touting the greatness of evidence-based medicine, but there’s a lot of homespun wisdom in this anecdote. Perhaps a little more wisdom, plus some low-cost generics, might be just the thing health care reform is lacking.

Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind. E-mail him at rhnews@elsevier.com.