By Stephanie Levin-Gervasi
December 9, 1999
Photo: Photodisc

“Small is beautiful” and “start low, go slow” could turn out to be the new maxims for determining drug dosages in the future. Or at least that’s the implication of a report in the September issue of the journal Postgraduate Medicine.

The study could have significant implications since side effects prompt many people to abandon treatment. An estimated 75 to 80 percent of adverse reactions are dose-related, meaning that the dose deemed appropriate by the physician is not appropriate for the patient, the study says.

Already the rule for seniors

Customized doses, or the “start low, go slow” approach, have long been the rule of thumb for the elderly—and with good reason. The elderly are particularly vulnerable to medication misuse, according to Dolores Alford, PhD, RN, FAAN, an independent gerontonic-nursing consultant in Dallas. “The age discrepancy between seniors is enormous. A prescribed dosage for a 60-year-old might be too high a dosage for an 80-year-old. Older individuals cannot metabolize drugs the same way younger people can.”

Twenty-three percent of nursing home admissions result from inappropriate use of prescribed medication, said Carlo Michelotti, MPH, RPh, chief executive of the California Pharmacists Association in Sacramento.

If a new drug is involved, the elderly should be given samples, not full prescriptions, Alford said. “No elderly person should ever be sent home with a long-term prescription,” she said.

Don’t try this at home

Concerns about overdosing should not be construed as an invitation for patients to begin experimenting with dosages. Already, some seniors slice pills in half in an effort to economize on the high cost of drugs, a practice pharmacists and healthcare workers find alarming, Michelotti said.

Much of the confusion surrounding drug dosages and interactions can be nipped in the bud at the pharmacist’s counter, Michelotti maintains. “Statistics show that a pharmacist’s intervention or patient education cuts drug misadventures by two-thirds,” he said.

“If consumers would only use the same pharmacy to fill prescriptions, life would be easier and safer,” said Kim Roberson, RPh, senior director of professional affairs for the Texas Pharmacy Association. “Pharmacists maintain a drug profile on all patients that we readily check.”

Dosing errors frequently crop up in the pediatric population, as well. Indeed, pediatric problems can begin with a teaspoonful of medicine, said Dolores Jones, EdD, PNP, RN, of the National Association of Pediatric Nurse Associates & Practitioners in Cherry Hill, N.J. “The one-teaspoon-fits-all is not a good rule of thumb in pediatrics,” she said.

A plastic syringe teaspoon is 5 ml, while a home teaspoon can range from 4 ml to 7 ml. “When prescriptions don’t come with a plastic syringe or parents don’t have one on hand, they use a household teaspoon, and, in good faith, overdose their child,” Jones said.

It is also common for parents to buy cough syrup for one child’s cough, then give it to another child for a sore throat, not realizing that the medication may be inappropriate or too potent, she said. “For infants, the common culprits for overdoses are Tylenol or aspirin products and cough or cold syrups,” Jones said. “Parent education is the best antidote for overdosing. It’s incumbent upon nurses to make sure that parents clearly understand the instructions for medications.”

Observation the best guide

As for doses recommended in the PDR, if they need amending, that is not something that Medical Economics Co. Inc., the publisher of the PDR, can do, said Mukesh Mehta, RPh, director of the new business department and professional services at PDR publishing headquarters in Montvale, N.J.

“We represent what the FDA approves, not the findings. If the FDA finds that something is not viable, it is up to them to change it. Most doctors realize that the PDR’s role is to communicate approved information,” he said.

If there is any principle for determining how much is too much or how much is just right, it is listening to and observing the patient, according to Alford. “Every health professional has an obligation to observe for side effects, from the individual drug to the combination of drugs. And it is not in the hands of one health professional, but in everyone’s.”