Does Simpler mean Failure?

April 27, 2009

We often wish for the highest level of sophistication for our patients, the Mercedes Benz of regimens. We do this even when studies pop up saying that old medications are just as good as new ones, but cost half as much.

The Chronicles of Clinic continues…

The past few weeks have seen several “downgrading” of regimens in my clinic. A gentleman whom I have seen in clinic a few times serves as the classic example. He has multiple comorbid conditions including suffering a stroke in the past. It doesn’t seem to have stopped him from having some unadulterated fun including driving around fast food pick-up windows with his friends and taking a hit of cocaine now and then, but that is another story. He was placed on a regimen of Lantus and Humalog when he was admitted to another hospital earlier this year. I had previously placed him on 70/30, on which he was finally beginning to have some decent results. The Lantus/Humalog regimen is one I would not have considered for him because of his history of poor compliance, but there it was when he saw me in clinic after hospital discharge. I discussed with him then if he would be able to keep up with a 4-shots a day regimen, and he swore he would.

Over the ensuing weeks I received two phone calls from his home nurse about persistent hyperglycemia into the 400’s. During the second conversation I recommended that he stop the Lantus/Humalog and instead return to his 70/30, but on his return to clinic he said he stayed with the intense regimen anyway. Was his compliance any better? Nope.

Last week I saw him again in clinic, after a prior admission for chest pain (which turned out to be vasospasm secondary to cocaine use). I almost BEGGED him to return to the 70/30. He has agreed this time that if he cannot maintain good compliance during the next 4 weeks, I will not refill his Lantus/Humalog but instead he will return to 70/30 insulin.

On leaving the room I felt an odd mixture of relief and disappointment, almost that something had failed here. I know it wasn’t really my failure that he could not stay on the Lantus/Humalog regimen, but it felt like it for a few minutes. Was simplifying his regimen admitting to failure?

I struggle with this from time to time even though I very well know that the most challenging regimens, while they can achieve great results, may not be the best for some patients. There are a variety of reasons: cost, educational level, visual acuity, manual dexterity, age, comorbidities, compliance etc. The “best regimen,” like the “best diet” is often simply the one the patient will stick to and achieve some result, if even not the optimal result. We all know this deep down, but we often wish for the highest level of sophistication for our patients, the Mercedes Benz of regimens. We do this even when studies pop up saying that old medications are just as good as new ones, but cost half as much.

This feeling of “settling” for a “lesser” regimen isn’t helpful at all. I need to remind myself that as long as the patient gets to the destination, the vehicle doesn’t mater that much so long as it is safe and reliable. Not everyone can handle a ride in a formula one race car to get from point A to B. Sometimes a ride in a good old Toyota is just fine.