We in medicine have diseases that have some treatment, but the treatment is effective when started 'early'. Again some of the diseases .this is very clear. If one does not treat TB or infection quickly , one could have bad outcome. The infection can spread or one can get in to sepsis and die. The TB can damage the lungs more and cause chronic symptoms and and then can have shortness of breath etc. But in certain diseases, one is on the fence. The treatment of high blood pressure is clear - everyone with high blood pressure must be on medicines to bring it down. But disease like PULMONARY FIBROSIS is different. Not all those patients who show FIBROSIS on CT scan get worse. In my personal estimate may be 20-25 % get worse . In this situation the treatment becomes tricky. The reason is it SOES NOT CURE OR EVEN HAULT the worsening of the fibrosis . In addition to that it is costly and also the drugs have side effects. When yo look at the days and talk to drug company representative, they show data that if the treatment is delayed , then the response is not as good.SO how do you decide?
That brings me to the story for today.
I had seen this 80 plus years old patient. She had some cough and also some shortness of breath . But the her activity level was so low that shortness of breath was not that major problem. She was seen by me and we did the work up and she had high resolution CT scan of chest and breathing tests and walk test . She had Fibrosis . The CT scan confirmed it and the breathing tests also showed that she had reduced pulmonary reserve and the diffusion of oxygen was markedly reduced . The walk test showed that her oxygen was reduced when she walked for 6 minutes. So we talked about the disease and diagnosis and use of oxygen and other medicines that CAN help . The medicines that we us for the fibrosis. are considered special pharmacy medicines , which means they are not available in regular pharmacy . We have to do special forms and attach reports etc and then drug company will approve and check with insurance on coverage etc . The cost is high - may be $20000 plus a year . So they also have FOUNDATION that offers help for copay. The patient has to give information on their income and consent to check on all of this . We gave her the forms and bring them back when completed . She did come for the follow up , but did not want the new medicines. So she continued to have some cough. Then she went to California and stayed there for 6 months or so . When she came back , we went over the same options. In all more than 1 year had passed since original diagnosis and we continued the same path . She would take the forms home and then would not bring them back and would come for the follow up. She was getting old and was on oxygen and also continued to have cough. She had hiatal hernia on the CT scan and the primary care and family wanted that fixed and so she had surgery for that and nothing changed . The new scan continued to show hiatal hernia - which means the surgery failed.
Her shortness of breath and need for oxygen was getting worse. We did do the tests like walk test and breathing tests and CT scan and that showed that she was worse. So now after 3 years since the original diagnosis was made , she agreed for the medicines. We did the form and she was approved and started the medicines. The medicines cause gastrointestinal side effects - nausea and diarrhea and also causes weight loss. She had them and so now instead of increasing the dose , she was taking half the lowest dose and still has same problem - cough oxygen drop and shortness of breath.
I am not sure if she would have been better if she had started medicines early. The studies do show that when started early, the RATE OF DECLINE IS reduced . IT does not reverse the process nor does it hault the process , but the worsening is slowed. So may be she would not have reached the point where she is now ,if she had started medicines 3 years ago . I do not have answer.
No comments:
Post a Comment