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The Decision to Start Medication - A Doctor's Perspective · Doctor Turned Health Coach

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  Welcome to the Doctor Turned Health Coach Podcast. My name is Dr. Ashwari.
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  I'm a family medicine physician, board certified and licensed in California.
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  And on this channel we talk about everything related to health,
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  achieving your ideal health goals, and a few tips and tricks to make it a little
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  bit easier with the expertise of a physician and the guidance of a health coach. So, let's dive in.
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  When should you take a prescription medication?
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  Prescription medications are a hot topic, especially these days,
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  as we are developing newer and newer medications very rapidly,
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  thanks to technology, and as they come on the market a little bit quicker,
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  it's understandable that people are going to have some doubts,
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  like, hey, what's this chemical that I'm putting into my body?
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  I want to approach this from maybe three different diseases, let's just say.
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  One might be a very serious autoimmune disease, and one would be weight loss,
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  and another one would be high blood pressure.
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  These are pretty common ones now, so I think it's very befitting for this podcast episode.
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  I always think of medications as a
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  another tool nothing else it's not
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  a magical technology it's not something that
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  is right for everyone it's just another tool and for
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  the right person this tool can be very effective and whoever ends up using this
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  tool both the physician and the patient you must know how this tool functions
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  best when we talk about a very serious medical condition i'm going to use a giant cell arteritis.
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  So GCA, it's a very serious condition of, it's a vessel disease,
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  a blood vessel disease near the eye that can cause blindness,
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  that can cause other things.
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  The good news is we have fantastic medications to treat it.
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  Usually pretty serious medications like steroids, but these are very effective
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  and we can get rid of it, done, treat it, it goes away.
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  So there's no real debate here
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  the risk is so high that without the
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  medication unfortunately vision loss and other problems
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  are too high of a risk so medications in this sense make a lot of sense and
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  it's still really important for me to have that discussion with my patient hey
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  i'm going to put you on this super high dose you know 80 milligram 100 milligrams
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  of prednisone which is a steroid.
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  These are the side effects. This is what we're going to look for.
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  If any of these things develop, we can intervene right away,
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  like blood sugar problems, mood changes, sleep problems.
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  You're going to be on this for a while. We're going to monitor things.
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  The decision matrix there is rather simple.
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  Now we go to blood pressure. Blood pressure is oftentimes a lifestyle-related issue.
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  So when your weight is high, your blood pressure goes high. When your stress
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  is high, your blood pressure goes high. When you don't sleep good,
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  your blood pressure goes high.
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  And when we can manipulate those factors a little bit, we can usually see blood pressure go down.
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  Now one of my patients might say, look doc, I've tried all those things.
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  It's really not working. And so then now we come to the option of medications.
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  Now, we have a lot of tools in this regard. While for giant cell arteritis, we only had prednisone.
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  For blood pressure, we got beta blockers, angiotensin receptor blockers,
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  ACE inhibitors, calcium channel blockers, diuretics, all sorts of medications,
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  that can help us lower somebody's blood pressure.
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  But here we have to think a little bit deeper.
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  Because if this is a lifestyle-related issue and I just lower your blood pressure,
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  it is not the same as you making the lifestyle changes that would lower that blood pressure.
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  Even though the end result is the same, the lower blood pressure reading on
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  a blood pressure cuff, the overall effect is a little bit better with blood
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  pressure medications, but it would be much better with lifestyle changes.
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  But I have to look at this patient in front of me. Is he or she really able
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  to make those necessary changes? Sometimes it's a lot of changes.
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  And for many, many reasons, it may not be possible.
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  So we weigh all of those options and the patient says, look,
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  doc, I've tried everything. You don't understand. I just can't do it. I can't do it.
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  Now we know, we got to try this medicine on you. And just like the prednisone,
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  with this medicine, let's say I start them on lisinopril, an ACE inhibitor.
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  I want to make sure their kidney function is good, their potassium is good,
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  that they don't have any other side effects. They don't get any random swellings.
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  They don't get any other issues with this medicine. I want to monitor them.
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  Doesn't mean we're not going to work on the lifestyle stuff.
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  We're continually going to work on the lifestyle stuff. But now we have an option.
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  Now we have a medication.
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  And when i choose a medication i try
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  to think about out of 100 people how many
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  would have a serious side effect with this medication if it's
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  only one i think that's a safe risk
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  to take as long as the actual risk of high blood pressure is really high and
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  yes it is high blood pressure over your lifetime is going to be additive and
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  cause so much damage from dementia to heart attack to stroke to heart failure to kidney failure.
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  These are the deep discussions that I have to have with my patient and by no
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  means is this a 15-minute discussion like in the traditional health insurance model.
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  This is about a 25-hour discussion over many many weeks and months and a lot
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  of monitoring and a lot of tracking.
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  Now we're going to get to weight loss. There are a lot of great medications
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  out there for weight loss but it's important to say that we've also had a lot
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  of great medications in the past for weight loss that have fallen out of favor,
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  though maybe not rightfully so because they were quite safe.
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  I look at my patient. Are they dealing with the kind of weight issue, right?
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  They have some obesity. It's causing a lot of other problems.
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  Is it a good idea to start some medications to lower their overall risk?
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  Now, for some, it might be just an aesthetic thing.
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  And in that case, if it's purely aesthetic, it may not make a lot of sense,
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  because the side effects might be too much.
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  But sometimes it's not just aesthetics, it's aesthetics tied to their mental
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  health, to their well-being, to how they're perceived.
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  In that case, we have to have a deeper discussion.
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  Somebody may have tried a lot of lifestyle interventions and simply not been
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  able to lower their overall weight.
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  In that case, trying a medication might be a great option. And that's when I
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  again have to look, what are the risks of this medication?
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  If the risk overall, only one out of a hundred has a serious side effect and
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  my patient is willing to take that risk,
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  generally that's a good risk profile to accept because, again,
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  we're treating something that has a lot of inherent risk itself,
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  which is this high body mass index.
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  So I hope I give you an idea of how to think about these things.
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  Now, when we didn't discuss all the different aspects of social media,
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  social media says statins are bad, steroids are bad, all these new GLP-1 medications are bad.
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  Well, social media, again, that's a whole different aspect.
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  That's a whole different discussion, and I would love for my patients to bring
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  in those articles to me so that we can discuss them one by one,
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  break them down, what's real, what's not.
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  But if you're getting your information kind of generally from social media,
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  it can be risky because you might either get a treatment that's bad for you,
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  or you might get a treatment that doesn't do anything,
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  or you might get a treatment, or you might miss out on a treatment that could
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  really change your life.
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  This is the heuristic. This is the model that I follow. Number one,
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  what is the disease itself?
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  Like, how serious is it? Two, how much can my patient themselves affect the
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  overall outcome of this disease?
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  Three, how effective is this medicine even? Like if we just lower the blood
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  pressure, does that make a difference?
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  If we just lower somebody's weight, does that make an overall health difference?
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  And finally, what are the risks of using this medication?
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  If you want more information, please go to my website, droshori.com.
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  I have lots of great articles there in my newsletter that comes out every week.
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  You can subscribe there, and thank you for listening.