What considerations should be taken when prescribing medication to a patient with a chronic condition?

Prescribing Medication to Patients with Chronic Conditions

When prescribing medication to patients with chronic conditions, prioritize patient education about treatment goals, safety concerns, and side effects; conduct regular follow-up assessments; use the lowest effective dose; and actively screen for drug interactions and polypharmacy risks. 1

Core Prescribing Principles

Patient Education and Shared Decision-Making

• Provide comprehensive counseling before initiating any medication, covering treatment goals, expected outcomes, potential side effects, drug interactions, and alternative treatment options 1, 2
• Discuss the specific time horizon to benefit versus time to harm for each medication, as chronic conditions often require balancing immediate symptom relief against long-term preventive benefits 1, 2
• Document the patient's understanding and reasoning for accepting or declining treatment to ensure informed consent 2
• Address patient expectations explicitly, particularly when medication effects relate to population-level mortality/morbidity benefits rather than immediate symptom relief 3

Common pitfall: Over 13% of patients do not understand why they are taking their cardiovascular medications, with knowledge gaps most prevalent among older adults, those with less education, and Black patients 4. This lack of understanding directly undermines adherence and outcomes.

Dosing and Medication Selection

• Start with the lowest effective dose and use immediate-release formulations initially rather than extended-release products 1
• Simplify regimens by selecting medications that can treat multiple conditions simultaneously (e.g., beta-blockers for hypertension, angina, heart failure, and atrial fibrillation) 1
• Match each of the patient's conditions with their medications to identify potentially inappropriate medications (PIMs) 1

Monitoring and Follow-Up

• Schedule follow-up visits every few weeks during the initial treatment period to assess effectiveness, monitor for side effects, and evaluate the need for ongoing medication 1
• Reassess the risk-benefit balance regularly, as 53.8% of adults aged 18-34 years and higher percentages of older adults have multiple chronic conditions that complicate treatment decisions 5
• Continue medication only if there is clinically meaningful improvement in symptoms and function that outweighs safety risks 1

Risk Assessment and Mitigation

Drug Interaction Screening

• Review all current medications using state prescription drug monitoring program (PDMP) data before prescribing to identify dangerous combinations 1
• Avoid specific high-risk combinations: lovastatin or simvastatin with protease inhibitors in HIV patients (causes harm), opioids with benzodiazepines (increases overdose risk), and nicorandil with nitrates (excessive hypotension) 1, 6
• Consider antiretroviral therapy regimens with more favorable lipid and cardiovascular risk profiles when treating patients with both chronic coronary disease and HIV 1

Polypharmacy Management

• Use validated tools such as STOPP/START criteria, Beers criteria, or EURO-FORTA to identify potentially inappropriate medications in older adults 1
• Recognize that 30-75% of older adults do not take medications as prescribed, with non-adherence increasing with polypharmacy and leading to worse outcomes 1
• Consider deprescribing as an integral component of good prescribing practice, particularly when medication burden outweighs benefits 1

Special Population Considerations

Immunocompromised and High-Risk Patients

• Patients with chronic lung disease, chronic heart disease, or diabetes require closer monitoring due to 1.4-5.9 times increased risk for complications 7
• Immunocompromised patients (HIV, transplant recipients, chronic renal failure) require modified treatment approaches, such as intravenous rather than oral formulations for certain infections 7
• Ensure pneumococcal vaccination (PCV20 alone or PCV15 followed by PPSV23) in patients with chronic lung disease, heart disease, or immunocompromising conditions 7

Patients with Mental Health Comorbidities

• Optimize treatment for depression and other mental health conditions, as these patients have increased risk for medication non-adherence and adverse outcomes 1
• Strongly consider tricyclic or SNRI antidepressants for analgesic and antidepressant effects in chronic pain patients with depression 1
• Avoid benzodiazepines in patients receiving opioids due to exacerbated respiratory depression risk 1

Patients with Substance Use Disorders

• Screen for drug and alcohol use with validated tools (DAST, AUDIT) or single screening questions before prescribing controlled substances 1
• Incorporate risk mitigation strategies including more frequent monitoring, urine drug testing, and PDMP review when prescribing to patients with substance use history 1
• Offer or arrange medication-assisted treatment (buprenorphine or methadone with behavioral therapies) for patients with opioid use disorder 1

Chronic Coronary Disease-Specific Guidance

Antiplatelet Therapy

• In patients with prior myocardial infarction or remote PCI, prescribe aspirin 75-100 mg daily lifelong after initial dual antiplatelet therapy (DAPT) period 1
• Clopidogrel 75 mg daily is a safe and effective alternative to aspirin monotherapy 1
• In patients without prior MI or revascularization but with evidence of significant obstructive CAD, aspirin 75-100 mg daily is recommended lifelong 1

Renal Considerations

• Delay CABG beyond 24 hours after angiography when clinically feasible to reduce acute kidney injury risk 1
• Use normal saline for contrast-induced AKI prevention; bicarbonate and N-acetyl-L-cysteine offer no additional benefit 1
• Recognize that patients with chronic kidney disease have higher atherosclerosis burden and worse outcomes, requiring similar medical therapy as patients without CKD despite limited trial data 1

Adherence Optimization

Practical Strategies

• Simplify complex treatments using long-acting formulations and medications that treat multiple conditions simultaneously 1
• Address the multifactorial barriers to adherence including multimorbidity, physical/cognitive impairment, poor patient education, and treatment cost/complexity 1
• Recognize that approximately 50% of prescriptions are incorrectly taken by patients, and 33-69% of drug-related hospital admissions result from non-adherence 1

Critical caveat: Patients often cannot assess the accuracy of health information from media, internet, or direct-to-consumer advertising, leading to decision paralysis and questioning of physician recommendations 8. Proactively address these information sources during consultations.