Can I Change That Medication? — A Question a Convalescent Care Pharmacist Has Carried for 20 Years
The cases discussed in this article are composites of multiple cases, and care has been taken to ensure that individuals cannot be identified.
In a convalescent ward,
finding a place for a patient to go after discharge is also part of the job.
We couldn't find a destination for a patient.
They were turned down by the geriatric health services facility they had hoped for.
The reason was the medication.It was a patient taking Keppra.
This was back before generic versions were available.
They said they were afraid of seizures.
They said it was difficult to manage.
The medical social worker (MSW) asked me, "Is there anything we can do?" but
I didn't know if it was okay to change it.
I didn't know if it was okay to change it.
If I don't change it, there's nowhere for them to go.
But,
if I do change it, a seizure might occur.
In the first place,
what kind of seizure caused them to start taking Keppra in the first place?
It wasn't written in the referral letter provided upon admission.
The type of seizure, either.
When the last seizure occurred, either.
Why this medication was chosen, either.
Nothing had reached us.
When DOACs first came out
The first time I hesitated about whether it was okay to change a medication was
when DOACs first started appearing.
A patient who came to convalescent rehabilitation from an acute care hospital.
A DOAC had been prescribed to prevent the recurrence of a cerebral infarction.
Unlike warfarin, which has been around for a long time,
it required less frequent blood tests,
there were almost no dietary restrictions,
and the risk was lower for certain bleeding events, such as cerebral hemorrhage.
These were touted as major benefits.
But compared to warfarin, the drug price was more than 10 times higher.
At the stage of looking for a discharge destination, a "wait" was called.
Warfarin
required blood tests,
had dietary restrictions,
and required dose adjustments while monitoring PT-INR to prepare for bleeding risks.
Even so,
there was more accumulated evidence for warfarin. The price was also overwhelmingly cheaper.
Expectations for new drugs, a sense of caution, and drug prices.
I didn't know which was correct.
Should I change it?
Is it okay not to change it?
In the first place, do I even have enough information
here to make a change?
I think it was the first question
where I felt there was 'no right answer'.
About the patient who had nowhere to go
Let's return to the story about Keppra at the beginning.
I think this was the event in my 20 years as a pharmacist
that made me the most emotional.
The patient was making good progress with rehabilitation.
There were no falls, and their level of independence had increased.
It was at the point where
we just needed to decide where they would be discharged to.
One day, when things seemed to be going smoothly,
we received an inquiry from a geriatric health services facility.
'Can you change the antiepileptic drug?'
Can it be changed...?
I asked the attending physician.
The attending physician was also troubled.
We hadn't received information on what type of seizures they had.
The information sheet from the acute care phase only said 'Epilepsy (history), currently taking Keppra'.
Was it focal onset seizures or generalized seizures?
When was the last seizure?
What was the background behind why Keppra was chosen...
Perhaps it wasn't something that was started in the acute phase. There are many cases where the prescription details from home are simply continued.
Without knowing anything,
I was only being asked 'if it was okay to change it'.
There are cheaper options.
Phenytoin, valproate.
But if a seizure occurred after changing the medication—
who would take responsibility for that?
I couldn't change it.
The admission to the geriatric health services facility fell through.
Where did the results of the rehabilitation
that the patient had built up go...?
I still remember
the sense of helplessness I felt at that moment.
The story of SGLT2 inhibitors
This is a recent story.
A patient hospitalized for heart failure came to the convalescent ward.
An SGLT2 inhibitor had been started in the acute care phase.
I like this medication.
It is one of the four drugs known as the
so-called“Fantastic Four” for heart failure treatment. The evidence for its protective effects on the heart and for reducing readmissions is mounting. I truly believe it is a well-crafted medication.
When discharge planning began in earnest,
a voice was raised from the facility side.
“Can’t you do something with diuretics instead?”
The drug price is high.
At the facility, medication costs are included in the comprehensive payment.
Excessively high medication costs are a burden for the facility.
The patient was in their 90s.
Although they had lived alone, they could no longer live by themselves. Admission to a facility was the goal.
I know it’s a good drug. But this person might not be able to get into the facility.
Those two things clashed in my mind.
In the end, the medication was changed.
I consulted with the attending physician,
recorded the circumstances,
and also wrote it in the information referral form for the facility.
I didn’t feel satisfied.
It was precisely because I knew it was a good drug that it was painful.
This person’s “place of living” and “best treatment”
were not pointing in the same direction.
There are moments like that in convalescent care.
There are definitely moments when the place of living becomes more important.
Even after 20 years, the same question arises.
Evidence-based drugs, good drugs, safe drugs.
Patients who have been prescribed such things come to the convalescent ward.
And we think, in order to create a place for them to go.
Should we change it?
Is there a way to avoid changing it?
By changing it, what do we lose? What do we gain?
The doctors in the acute care phase choose and select and carefully pick the best medication for the patient in order to save their life.
As a result, the patient is able to reach the place that connects to their “convalescent” life.
Even so,
the best during hospitalization and the best after discharge can sometimes diverge.
That is not anyone’s fault.
It is likely because the structure of medical care and welfare
is set up that way.
Therefore, please, at least send the information.
Why was that medication chosen?
What was the seizure type?
When did it last occur?
To what extent was it stabilized?
If we have information, we have room to think.
Without information, we cannot act.
A prescription is not just for the duration of a person's hospitalization.
It is also a choice for that person's future.
Even after 20 years, the same question remains.
Perhaps I will continue to be asked this.
And I want to keep thinking about it.
Column: The True Nature of the Wall—Why Expensive Medications Are Difficult to Use
In convalescent rehabilitation wards, medication costs are included in the basic hospitalization fee.
In principle, the hospital's revenue does not increase based on the amount of medication used. Geriatric health services facilities (roken) have a similar structure, where the facility's medication costs are included in the nursing care benefits.
The guideline for medication costs that prevents a geriatric health services facility from operating at a loss is approximately 233 yen per day (2021 estimate). Many SGLT2 inhibitors and new antiepileptic drugs far exceed this level.
In the 2026 medical fee revision, the scope of medications excluded from the bundled payment in convalescent rehabilitation wards (so-called "excluded drugs") was expanded, but antiepileptic drugs and diuretics remain outside this scope. When a facility or ward requests to "change the medication," this structure is often the reason behind it.
Related Articles
いいなと思ったら応援しよう！
よろしければ応援お願いします！いただいたチップはオロナミンCの購入費としてモチベーションと活力アップに使わせていただきます✨