Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. Hi, my name's Dr Warrick Bishop and welcome to my podcast and videocast station. Today, I'm absolutely delighted to have as a guest for discussion around all things cardiological, Dr Alistair Begg, a senior cardiologist with an interest in rehabilitation who's based in Adelaide. Hi Alistair, how are you? Good, thanks Warrick. Thanks for having me along and how are you? Yeah, I'm good, thank you. And I'm really enthusiastic about discussing today's topic, which is really the sort of to-do lists that we'd like our patients to contemplate or think about when they come to see us and when they are thinking about their medication and visiting different doctors. So I know you often think of it in terms of a to-do list. So maybe share with me what you would... be expecting or hoping from your patients in terms of being organised and prepared for their consultations and understanding their medications? Sure. Well, look, I like it when people bring an up-to-date list of their medications because things might have changed since last review. They may have been to another health professional or they may have been in a hospital. And if they've got sort of a checklist, that would be really good. And also if they can bring in a list of questions, because when they go to the cardiologist, they often have things that they want to ask, but they sometimes don't remember. And like all of us, we're under pressure. If you've got a little list of things, when you go into the consultation, you maximise your visit, take a list of questions. Yeah, look, that's true. And I see that myself, Alistair. One of the things, particularly with that medication list, is, as you say, Patients can see their local doctor. They may have been in hospital. They may have seen another specialist. And interestingly, even though we've got an Australia-wide healthcare card, we don't have everyone onto that. So medications can be changed and there's no single point where all those medications are brought together. And I have patients sort of aghast, sort of looking at me saying, don't you know what I'm on? Isn't it on the computer? And, of course, all our computers are in our offices and they don't connect globally with every area that person's gone. So I say to patients, you've got to be responsible for the tablets you are on and then bring them along so that we can deal with them. So generally, when we're thinking about medications and the like, we'll give people a script and send them on their way. Do you give patients any advice when you've provided them with a script in general terms? I mean, sometimes they just need basic information, you know, what it is, what are the likely things to watch out for with side effects, how many prescriptions there are, so if they've got, you know, repeats. Some of the common names, sometimes they get a bit confused because of generics. So they're the sort of things I generally tell people in the first visit and subsequent visits. And so it's important to get a complete understanding of why you're on it, what the likely things to watch out for are. And also sometimes ask the pharmacist for an information sheet too because when they're starting on a new drug. It's quite good to have an information sheet about all the do's and don'ts when they're on a particular medication. And also, yeah, making sure that they continue to take it, which is obviously one of our jobs is to make sure that the compliance is good, to make sure people are getting the benefits. As they say, drugs only work when you take them. That's true. So in my own practice, I tend to try and make sure I let... the patient know how long they need to take medication for. So, for example, for someone who's had a stent, we use a second blood thinning agent, and that's generally for a year. So I let the patient know that, but I let them know that they can't miss that tablet because they run a high risk of that artery that's been stented blocking. So I try and let them know, just as you do, how long they need to take their tablets for. So aspirin or cholesterol, I'll say you'll take this to life and make a joke out of it because of the double meaning. I'm very cautious about telling people too many side effects and generally say most of these medications are well tolerated by most people. And I try not to plant a seed of a potential side effect because my experience over the years is if I said to someone, this could give you slight dizziness and a little bit of blurred vision. that some people will have slight dizziness and blurred vision before they even leave my consulting room and get this group filled. And that's called a nocebo effect or an effect or side effect that someone believes they're going to get, which is the reverse of a placebo effect, which reflects someone believing that something will help them. So it is an interesting space and I'm sure you like me have had patients come back. with the drug information sheets from the pharmacist with every side effect highlighted and the patient's suffering those and you just don't know what the next step is. So it is a complicated one. What do you advise your patients in terms of the time to take their tablets, Alistair? Well, I try and get them to take it at the same time every day. That way they'll get into a routine so that they will increase the chance to actually take the medication. It's important for some medications that it's taken with food and other medications you have to take on an empty stomach with no milk, for example. So there are some specific cardiac drugs that do need to be taken at a particular time or in a particular way, and it's good to get people into the routine. I try and give people once a day medications as possible, and that makes it easier from a compliance point of view, obviously. And also check when they're taking it because there's some recent evidence that taking blood pressure tablets at night improves the tolerability and also reduces the risk of heart attack and stroke. So sometimes you may just need to check in with the patients when they're actually taking the medication. That's true. And what about if someone thinks that they've missed a medication, Alistair? What do you tend to do then? What's your advice? Well, if they think that they may be doubling up, it's generally better to wait to the next dose rather than doubling up because doubling up is more likely to do harm than good. And of the tablets that often people ask about the timing, the statins are often an agent or a group of class of drug where patients will regularly ask us. Do these need to be taken at a specific time? Do you have any answer for the statins in particular, Alistair? Well, I mean, the statins generally can be taken at any time. They're probably one of the ones that you can take morning, noon or night, as long as you remember to take them. If you miss the occasional dose of statin, it's not going to make a huge difference versus, say, a blood pressure tablet or a blood thinner where it's more critical. Just while we're on cholesterol tablets, the azetamide, needs to be taken at night to get the best effects. So that's probably one difference. And if you're on a combination drug where you're taking the statin plus azetamide, it's important that you take that at night to get the maximum benefit from the cholesterol lowering of the azetamide. So that's certainly worth noting and being aware of. My understanding was that some of the earlier statins that had shorter half-lives, like simvastatin, and pravastatin and fluvastatin were probably better taken at night, a bit like ezetimibe. But the more recent statins, which you're obviously talking about, atorvastatin and rosuvastatin, it doesn't really matter because their half-life is really quite long. But that's certainly worth remembering and probably just as long as nighttime works for you, thinking about taking your cholesterol-lowering medication at night makes a bit of sense. I think that's when the liver's most synthetic and most... likely to be producing cholesterol. So that's the best time to be trying to dampen down that activity. Some people get the chance to go on holidays, even though they're taking medications. What do you sort of advise people when they're going on holidays? Have you got any hints or tips for them? Yeah, well, look, now that we're sort of hopefully coming out of the COVID era, there'll be a few more people travelling overseas. and on long trips and there is a in australia there's a regulation you can write a special prescription called a regulation 24 prescription that enables you to get more than one month supply so if you're going out back for six months and you know when you're a chemist rather than missing your tablets you can actually get the chemist to give you more than one month supply which is quite a useful thing particularly in the sort of age group of patients i see there's a lot of travelers A lot of people are either retired or semi-retired, so they're doing lots of travel. And being able to sort of make the medication visits easier just makes a whole lot of sense. So that's a good one to remember, isn't it? We write regulation 24 on the prescription and that allows the pharmacist to provide six months' worth of medication for that patient should they be travelling and it could be difficult for them to get those medications otherwise. Is that correct? That's it, right? That's exactly right. Beautiful. Look, for those travellers, one of the things that I often let them know as well is that it's probably worth carrying some medications in your hand luggage and some medications in your packed luggage because it just happens you can lose one or the other. So sometimes carrying your medications in two spots is not a bad idea, particularly if you just can't miss those medications. I'm going to wrap up because we've come pretty close to the end now, but what I want to talk about is generic medicines. You touched on them briefly, but tell me what is a generic, Alistair? What does it mean? Okay, well, a generic medicine really just means that it's a medicine that's produced with the basic name of the medication. That's not the brand name, but the basic name of the drug. So, I mean, a classic would be, you know, paracetamol. Everyone knows paracetamol is a drug, but there's a whole lot of different brands. There's Panadol. There's all different types of brands that are sort of more the names of the companies that produce those drugs. So a generic medicine can be produced by a number of different companies, and they're generally a bit cheaper because you don't pay for the branding of the drug. And they're usually able to be produced after a certain period of time that the developers have had to benefit from the profit from their research and development. A drug goes off patent and then it's able to be produced by many different companies. And then those medicines are called generic medicines and they're generally a bit cheaper. And often they're as good, but some people feel that they like to stick to the brand. So it often depends on the drug, but there are some drugs where generics are fine. Other drugs, I try and recommend the brand. So it depends a bit on the drug, but they're generally cheaper and they're produced by many companies around the world. From my own experience, it seems like the propensity for us to use generics means that the new agents have new names and it can cause confusion. And there are many, if you like, medications that I'd be very familiar with. Paracetamol is a good example, but they've now got a new trade name, branded name. And so the name changes. And I think for patients as well as me, I often find this confusing and it's a really hard thing to get around. I think, I guess you see the same. I do. I mean, some drugs have got about 10 different names. So if people are on five or six different drugs, it can be extremely confusing. So just for sort of ease of use, I try and stick to the same name of the drug. But it even gets challenging as a doctor too because it's often drugs that come along that you may sound similar, but you have to check it and make sure it actually is the same drug. It might be a slightly different brand name. So it can be very confusing. Yeah, it certainly is. Look, the other thing is that these generics are often made in a different factory by a different company, and they are put together using the same scientific chemical, the active ingredient, but they can be compounded with other fillers or other colorings that the original branded product didn't have. I've got a patient who absolutely swears blind to me he can't take Crestor, which is the original branded Reservistatin cholesterol-lowering tablet, but he can take the generic of the same agent. And the only thing I can put that down to is the difference in the fillers or the colours, which I think is a really interesting situation and one that I don't know, have you seen that? Or it's one to certainly be aware of, I think. Yeah, I haven't seen it with the statins, but I have seen it with many other drugs. Some people can tolerate, for instance, a branded drug, and then when it goes on to a generic, they either find that they can't tolerate it. And sometimes they find that it's not as effective because there's quite a wide margin of effective sort of ratio for a generic drug to be approved. It could be anywhere between 80% and 120% effective, and it can still be approved for use. So I think that's the other thing to keep in mind is that the effectiveness of the different generic drugs may vary a little bit compared to the branded drugs. Yeah, well, an interesting space. Look, we've chatted about these medications and our to-do lists for about 15 minutes. I think it's been really valuable. I hope those people listening have been able to take away some gems, particularly a list of your questions, a list of your medications and some tips about travel and some stuff on generics. Alistair, thank you so much for sharing today. I hope that's been useful for your listeners, Warrick, and sharing some practical tips. Yeah, thank you. Look, I'm going to wrap up. For those listening, if you have any queries or questions, drop us a line at info at drwarrickbishop.online. Wish you the very best. Take care. Bye for now. And please don't die from a heart attack. Goodbye. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
