Tuesday, February 23, 2016

BS Medicine's top 20 medications

I'm addicted to podcasts. One of my favorite medical podcasts is BS Medicine. The hosts have deep medical knowledge and an enviable commitment to evidence based medicine. In addition, they approach the podcast from a clinicians perspective and don't get so lost in the science that they forget we are here to help patients.

For their 300th podcast they did a special episode surrounding the dorm room question: If you could have only 20 medications, what would they be?

They had an interesting list and they spoke extensively justifying their list. The explanation and the list stretched over two episodes. Afterwards they did a third podcast to go over the next 10 medications that barely missed the cut.

I loved the thought exercise but I thought James, Mike, Tina and Mike really missed the boat on a few. Here is their list and mine:

The list is the same through the first three, but then I added normal saline. How can you include epinephrine and not include normal saline? And don't start with me that salt water is not a drug. Saline will cure everything from a hangover to cholera. Essential medication.

They included oral contraceptives. My feeling is that 99% of the function of OCPs could be replaced by IUDs so women could continue to have control over their bodies and I get an additional medication. I will give up treating dysfunctional urterine bleeding, PCO and other maladies that benefit from OCPs.

I also skipped diphenhydramine. If the allergic reaction is bad enough, then we'll give epineprine, otherwise tough tootles.

I used pentoprazole rather than omeprazole because I wanted an IV formulation. I skipped the losartan and added apixiban instead. I just couldn't leave all those people with pulmonary embolism, atrial fibrillation and DVTs to fend for themselves with aspirin alone. The losartan omission is a bit tough to stomache as a nephrologist but truly most of the advantage of ARBs can be duplicated with good blood pressure and glycemic control (at least in diabetics). And the other renal diseases tend to be rare. Additionally I'm not as convinced as the podcasters that ARBs are just ACEi without the cough. I can't remember seeing ARB heart failure data as impressive as:

Consensus Trial Grade 4 CHF, 1988
I don't know enough ID to vet their antibiotics so I accepted their argument and brought in all three of their antibiotics.

That left me with three more medications after I gave the heave-ho to fluconazole and PEG. To fill this I hadded drugs to treat three of the great infectious diseases that plague this earth: HIV, TB and malaria. Seems morally wrong to ignore them. HAART is one of the greatest medical advances in our lifetime. They have an NNT that approaches one. In 1995, 55,000 Americans died of HIV and they died at young, productive ages causing incalculable losses to the nation. Blood pressure and heart failure medications are hugely important therapeutic target but treatment primarily benefits people in the tail end of their lives. Treating infectious diseases needs to be prioritized because of the age of the people affected.

What's your list?

-- Update --

I received this tweet:

I think he is exactly right. I can use heparin IV or subcutaneous. In this 20 medicine restricted world, thrombophilia will be treated like diabetes, all subcutaneous injection, all the time.

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