The challenge of the right pill for the right ill!

Mr. Kanniyappan (name changed) whom I saw yesterday in the clinic, is a known patient of hypertension and diabetes taking regular treatment with us in our clinic. 

"Doctor, I am having severe swelling in both my feet. My feet feel so heavy that I am not able to lift them and walk anywhere." 

This was Mr. Kanniyappan's main complaint. This is not the first time that he has come to the clinic with this complaint. I knew immediately what to do. I usually ask him to bring his tablets, which he gets from the public health system. He laid out the tablets on my table and I sorted them out. 

This is how his tablets look. Mr. Kanniyappan has poor vision due to cataracts in both his eyes. The ophthalmologist we referred him to keeps deferring the surgery because when his sugars are under control, his BP is sky high and when the BP is under fair control, the sugars are off the charts and when both are under fair control, there is nobody to accompany him to the hospital for the surgery! He also has another major limitation, he cannot read or write. Most importantly, Mr. Kanniyappan lives alone and has nobody at home to support him in his treatment. 

Just take a look at the spread of tablets he is taking. He is getting Tab. Amlodipine once daily for the BP, Tab. Enalapril twice daily for the BP, Tab. Glimepiride 1 mg once daily for the diabetes, Tab. Atorvastatin once daily for the cholesterol and Tab. Clopidogrel for his heart condition. He also has anaemia and so he is also getting iron tablets. These are the tablets that are arranged on my table in the picture above. How do you think, a person like Mr. Kanniyappan, who cannot read, has poor vision, lives alone, can manage to take these almost identical looking tablets correctly. 

In fact Mr. Kanniyappan was taking the Tab. Amlodipine twice daily and Tab. Enalapril once daily, the exact opposite of how frequently he should be taking each one. When Tab. Amlodipine is taken twice daily, the drug which has a very long duration of action in the body, tends to cause adverse effects like severe swelling of the feet. This was not happening for the first time for Mr. Kanniyappan, and so we reorganised the tablets for him in separate packets, labelled the packets with numbers and pictures which he can see if they are drawn out in big size, and sent him home. 

This is as much a challenge in the physician-patient communication, as is talking to them and giving them instructions about healthy behaviours. This is where it is so useful to have colour coded pills. At least it would help explain the tablets with the colours to the patients who cannot read. Please listen to a podcast I had made about colour coded pills a few months ago in this link. Patients who have the means, and who are supported by others in the family have pill caddies or even digital pill dispensers into which the pharmacist or the family member sorts the daily pills as per time of the day they should be taken. 

That is the next order of business at our clinic. We have to figure out cost-effective and sustainable solutions to pill sorting and dispensing for elderly patients living in our project villages, often alone. This would make a significant change to their medications, many of whom are taking multiple pills for many chronic conditions.