Prescribing steroids and cytotoxic agents

SP Sirur

 8/16 Talmakiwadi, Tardeo Road, Mumbai - 400007, India

Correspondence Address:
S P Sirur
8/16 Talmakiwadi, Tardeo Road, Mumbai - 400007
India

Every physician has a duty of care in the administration of treatment, a breach of which may amount to medical negligence. Before administering or prescribing any treatment, one should consider the attendant complications and side effects. This duty to take care is particularly important when cytotoxic or immunosuppressive drugs are prescribed.

We are all aware that various tests, including liver function tests, complete blood count, and renal function tests, are mandatory before starting methotrexate therapy. Sometimes a patient may not be able to afford these investigations and a dermatologist may be tempted to start treatment without them. Also, once treatment is started the dermatologist may not insist on investigations for monitoring the onset of side effects. However, one should not buckle under such pressure.

The following case that came up before the Calcutta State Consumer Disputes Redressal Commission will illustrate the importance of ordering all essential investigations.

A mechanic with a complicated mature cataract was operated for removal of the cataract. During the surgery, it was noticed that the patient had total retinal detachment with retinopathy. Post-operatively there was loss of vision. The ophthalmologist insisted that apart from the other routine and essential tests, he had also advised a ′B′ scan (to determine the status of the posterior segment), but the operation was performed without doing it since the patient could not afford it.

The doctor was held negligent for not advising the ′B′ scan (resulting in loss of vision post-operatively) before performing the operation and a compensation of Rs. 1,00,000 was awarded to the patient. The Court refused to believe the doctor′s contention because there was no noting to that effect in the case paper.

Thus, it follows that pre-treatment investigations must be done if mandatory. Failure to do so can result in a claim for compensation for loss or injury resulting from such negligence. In case the patient cannot afford or refuses to get investigations done, it is therefore prudent to record that fact in the OPD/indoor papers.

It is pertinent to note the observations of the Supreme Court in the case of Poonam Verma vs. Dr. AP, where the patient was suspected to be suffering from typhoid fever, but the doctor had not advised a Widal test. The patient subsequently died of typhoid encephalopathy. The Court, hearing an appeal of alleged medical negligence, said: "We cannot ignore the usual practice of almost all the doctors that when they want pathological tests to be done, they advise in writing on a prescription setting out the tests which are required to be done. Admittedly, Respondent no.1 had not done it in writing. He says that he had advised it orally. This cannot be believed, as this statement is contrary to the usual code of conduct of medical practitioners."

Whenever investigations are asked for, proper documentation in the medical records must be made. This will avoid future litigation alleging that essential tests were not advised nor performed by the attending doctor.

The pharmaceutical market is flooded with innumerable drugs and some drugs are phonetically similar to another drug. In addition, illegible writing can result in the chemist dispensing one drug for another. It is always better to be conversant with a few trade names to avoid confusion and medical mishaps.

According to the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, "Every physician should, as far as possible, prescribe drugs with generic names and he/she shall ensure that there is rational prescription and use of drugs."

Since the two major factors for the dissatisfaction of patients or their relatives are morbidity and mortality, steroids, immunosuppressive and cytotoxic drugs should be used sparingly and only when necessary, with a constant watch for side effects. Appropriate precautions should be taken before starting the therapy and during its course.

The Indian Medical Council Regulations, 2002, also incorporates a provision with respect to prescription of steroids: "A registered medical practitioner shall not contravene the provisions of Drugs and Cosmetics Act and regulations made there under. Accordingly, prescribing steroids/psychotropic drugs when there is no absolute medical indication, and selling schedule H and L drugs and poison to the public, except to his patients in contravention of the above provision, shall constitute gross professional misconduct on the part of the physician."