Evolution of thought processes

Phone rings. “Hello, may I help you?”
“Hi, I was wondering if I can take an Aleve for my shoulder ache? I also take lisinopril.”

7 years ago:
WTF is lisinopril?
Time: instantaneous

6 years ago:
I know how to spell lisinopril!
Time: ~0.5 seconds

5 years ago:
Lisinopril is for blood pressure!
Time: ~1-2 seconds

4 years ago:
Have I seen this before? Yes… I have because Aleve is naproxen sodium, and I’ve seen people take Naprosyn with lisinopril.
Time: ~2-3 seconds

3 years ago:
Lisinopril is an ACE inhibitor, and I see this combination every day.
“Sure, that’s fine.”
Time: ~0.75 seconds

2 years ago:
*Visual, mental review of systems, picturing the RAAS pathway and envisioning how naproxen is metabolized to see where and how the two intersect.*
“Sure, that’s fine.”
Time: ~0.5 seconds or so

Most recently:
How old is she? What’s her creatinine clearance? Might she be better off with diclofenac or celecoxib? Eh, it’s probably okay on a short-term basis, and it’s not a terrible choice, but it’s probably not the best choice, either.
“Sure, that’s fine.”
Time: ~1-2 seconds

What’s the next step, I wonder? Quicker processing? Maybe. Deeper comprehension? Hopefully.

This development of thought processes is the difference between these two residents. The ability to take in a situation in its entirety, process it efficiently, while remaining calm and friendly takes time and exposure, and has very little to do with intelligence or any other innate quality.

* Naproxen is considered an unacceptable agent in geriatric patients even though it is used in the elderly pretty regularly. (My grandmother, for instance.) Probably because most internists, orthopods, and others are often not terribly familiar with geropharmacology, which is why geriatrics is its own specialty both in Medicine and Pharmacy.

2 thoughts on “Evolution of thought processes

  1. As a rheumatologist I’m not quite sure what your beef is with naproxen. No NSAIDS are really safe in the elderly, but if they are needed, naproxen is as good as any, maybe the best. Celecoxib is easier on the stomach but if there is any angina, naproxen at low dose with a proton pump inhibitor would probably be my next choice. Hope your grandmother is doing well. Maybe I’m the one treating her.

  2. I’ve got no personal beef with naproxen. I think it’s a fine drug for most of the world. I take it myself, from time to time. :) It is, however, considered unacceptable in the geriatric population due mostly to its long half-life. Unacceptable being defined as primary literature indicating greater prevalence or severity of adverse reactions with a particular agent and when there are equally effective agents within the same class.

    Personally, I like diclofenac quite a lot. Way cheaper than celecoxib, and while its renal and CV effects aren’t as nice, I don’t know that celecoxib is ~$150 a month better. Naproxen probably won’t cause GI bleeds, hypertension, renal and heart failure in an average geriatric patient, but if n is large enough, the probability of an adverse reaction occurring approaches 1 — diclofenac, ibuprofen, Relafen, and Lodine are all safer choices.

    And then there are the DMARDs, many of which are also considered off-limits.

    Citations available for all of the above if you are really interested.

    Edit: Forgot to mention that I added your blog to my feed reader. :)

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