Substitution

The pharmacists at Central Medical Stores in Mbabane must have been surprised last month when they looked at the expiry date on their stocks of the anti-HIV drug, nevirapine (NVP). It was May 2015. They put in an emergency order, but the supplier had “production problems”. Swaziland was in danger of running out, so existing stocks had to be rationed.

Our solution was to restrict repeat prescriptions to a week’s treatment until the stock rupture was corrected. When patients came to pick up their medication, we offered to substitute another drug, efavirenz (EFV) for the NVP. Good plan, eh? Well, it isn’t easy to convince someone, whose HIV has been effectively suppressed, to change their treatment, the same treatment which we have promoted as being essential to their health.

I had to explain the situation to the patients, what measures we had taken to conserve stocks, the advantages and disadvantages of changing their treatment regimen. If they agreed, I had to alter their chronic care file, their treatment record, their clinic book and to write out a new prescription. This could take between 15-30 minutes. Last week, we substituted EFV for NVP for 42 patients. That’s a lot of extra work.

This photograph bears no relation to the subject of this blog. It is quite cold in the mornings in July. So Santa Claus socks are appropriate.
This photograph bears no relation to the subject of this blog. It is quite cold in the mornings in July. So Santa Claus socks are appropriate.

Most people agreed to the substitution, “if that’s what you think is best, doctor.” With some patients, the process was less straightforward. One man was a night guard. He was unhappy about the substitution because he had taken EFV when he first started treatment. The standard advice is to take this drug at night because it causes drowsiness. He got caught sleeping on the job and was nearly sacked. His regime was changed from EFV to NVP some years ago; now I was proposing to change it back.

I suggested taking the drug before he would normally go to sleep, in his case, 9am. “So what do I do when I have days off work?” he asked. I told him that it was best to take the drug at the same time each day.

“But then I will be drowsy during daytime on my days off,” he said. I asked a colleague for some advice on this issue, and she said, “Too difficult. Leave him on his current regime.” However, when I told him that we thought it best not to change his medication, he was upset. “This new drug sounds better than my old one. And my job’s rubbish. I’m fed up working nights. When I find a new job working in the daytime, will you switch me over then?” The best possible solution, I thought.

This man has nothing to do with this post, but he has a lovely face
This man has nothing to do with this post, but he has a lovely face

Another patient was deaf but could use sign language. I had just read a magazine article on signing in Swaziland, so I thought I could try my hand (sorry). I managed N-V-P and E-F-V, but little else. I struggled to get him to understand that the new drug, EFV, should be taken once daily, not twice daily like NVP. He confused this with the once daily drug co-trimoxazole. After a fraught 15 minutes getting nowhere, I decided to leave him on his current regime and wrote on his chronic care file, his treatment card and patient held record the reasons why he was not suitable for substitution. At this point, he opened his bag and showed me the past three months’ worth of NVP combination treatment which he had not taken.

One of our pharmacy assistants is proficient in sign language. She quizzed him about why he had not taken the drugs as prescribed. He explained, “Co-trimoxazole suits me best as I only have to take one pill a day.”

“But that tablet is not suppressing your HIV! It’s an antibiotic.”

Realising that once daily dosing was the most important thing for him about taking medication, I went through my spiel again, this time with the pharmacy assistant, promoting once daily EFV.

Later in the week, I saw a young lady who was very interested in what I had to say about the side effects of EFV. I told her about sleepiness, dizziness, mood changes, strange dreams and hallucinations. “Oh, I already have special dreams. I get messages from God in my dreams,” she explained. “Will I be able to communicate better with God on the new pill, doctor?” I told her that dreams were not reality and hopefully, she would not be bothered by the side effects of EFV.

“But I am training to be a pastor. I want to prophesize and see visions. It will help me in my future work.” I told her that I thought that she should not switch drugs because her mental state might deteriorate. She insisted on my making the substitution.

“What you refer to as hallucinations, I call being in closer touch with God. If you give me this medication, you are doing God’s work.” I prescribed a month’s treatment and will review her, personally.

One patient whose medication was switched from NVP to EFV developed mania within a couple of weeks. He wanted his care to be transferred to a remote rural clinic, where he grew up. He said he needed to look after his thriving business raising chickens. Reasonable enough, I thought. “How many chickens do you have?” I asked. “Four,” he replied. “And some are not laying.” I persuaded him to stay under our care while we sorted out his medication.

This whole process reminds me of my work as a GP in Leicester, switching people from one form of a drug to another to save a few pence, then switching them back again as the manufacturers changed their prices. It was one of the things which drove me crazy about working in the NHS. And now I am doing it here in Swaziland. Only another 200 patients to go.

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2 Replies to “Substitution”

  1. This posting is on of my favourites. I was intrigued by the decision tree (almost triage-like steps?) in determining the medication regime. And of course, relatively knowing little about the NHS, had to do some internet research to contextualise.

  2. Judy, the only bit about the NHS is at the end. I get annoyed when the bean counters tell me to alter medication to save the NHS money, without factoring in my time, the patient’s time, potential side effects… And then to do it all over again, when the prices change. Disappointing.

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