Medscape Editor's Key Points:
Although a patient may do well on a given medication, monitor short- and longer-term side effects.
Referring physicians should always review past patient medications to see the duration and dosage taken previously.
Doctors should always discuss the manufacturer's treatment limitations with the patient.
Making Sure Meds Do More Good Than Harm
When a medication prescribed for a specific condition seems to be keeping the condition in check, the physician and patient can be lulled into a sense of complacency. With some medications, the physician risks being lulled into liability.
A 66-year-old woman with a history of depression, stroke, thyroid event, emphysema, and congestive heart failure was being maintained on a number of medications by her HMO physician for bipolar disorder. In June, this physician referred the patient to a gastroenterologist, Dr. G, who prescribed metoclopramide for reflux disease.
The patient continued taking metoclopramide while treating with Dr. G, who noted some improvement the next March. In April, Dr. G noted no side effects and gave the patient a 3-month metoclopramide prescription. In June, the HMO physician also noted no side effects.
The next month, the patient began treating with Dr. IM, an internist, because her original internist had quit the HMO. On her first visit, the patient sought a medication refill and also complained of dizziness over 3 years and trembling. On a return visit to go over laboratory results, Dr. IM noted some elevated thyroid levels. He adjusted the patient's thyroid medications and referred her for pulmonary rehabilitation.
On the patient's return in February the next year to request a change in medication for her mental state, Dr. IM changed her medication from paroxetine to fluoxetine and wrote a 6-month prescription for metoclopramide. Two visits later, in July, the patient complained of ringing in both ears, episodes of passing out, and motion disorders followed by confusion and incontinence. After his own negative neurological examination, Dr. IM referred the patient to a neurologist.
Dr. IM's next information on the patient was news of her hospitalization the next March for a fall. On the patient's final visit to him 3 weeks later, Dr. IM noted that the patient had not followed through on the neurology consult.
When the patient did finally see the neurologist in May, that specialist diagnosed Parkinson's disease, "probably aggravated by metoclopramide." On a visit to a subsequent motion disorder expert, that physician diagnosed probable "tardive dyskinesia related to metoclopramide use and mild Parkinson's probably related to metoclopramide use."
In a lawsuit against Dr. IM, the patient alleged that she was negligently maintained on metoclopramide for over 2 years, resulting in tardive dyskinesia and related symptoms.
In her theory against Dr. IM (and against Dr. G as well), plaintiff noted that the manufacturer states that metoclopramide is indicated as a short-term (4-12 weeks) therapy for adults with symptomatic reflux disease.
As the case progressed, the patient's expert witnesses testified that metoclopramide is not intended for long-term use because of its neurological side effects. Other physicians testified that the patient's breathing difficulties and fainting episodes were related to the long-term metoclopramide use. The lawsuit was resolved informally prior to trial.
In assuming the patient's care, Dr. IM followed his custom and practice of conducting a discussion with her on all the medications she was taking. Bringing up in those discussions the treatment limitations suggested by the manufacturer of metoclopramide, however, could well have avoided a lawsuit down the road.
This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories. The article was originally titled "Putting an Expiration Date on Prescriptions." Brand-name drugs were changed to their generic names for this reprint.
© 2019 Cooperative of American Physicians, Inc.
This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.
Cite this: Gordon T. Ownby. Malpractice Case: When Useful Prescriptions Can Become Dangerous - Medscape - Mar 01, 2019.