Why doctors hesitate to prescribe these common drugs

Doctors have a tendency to overprescribe drugs (better safe than sorry!) rather than underprescribe drugs. Nevertheless, many common drugs are underprescribed due to complications with therapy or fear of possible adverse effects. In some cases, these fears are well founded. But, when patients go without effective therapy that they could otherwise have, it can lead to poor outcomes and worse quality of life. It might be worth considering (or reconsidering) how you prescribe the following medications: 

Topical steroids

The fear of using corticosteroids is so common that it has its own name: corticophobia. For topical steroids, this fear stems from well-known and severe adverse effects like Cushing syndrome and permanent skin atrophy. However, these effects are rare when topical corticosteroids are used properly. Nevertheless, corticophobia is one of the main reasons why patients don’t stick to using topical steroid treatment. As a result, undertreatment of chronic diseases, like atopic dermatitis, may require patients to resort to more drastic therapies—which can have even higher risks of side effects. 

Patients aren’t the only ones with corticophobia, though. In one study, investigators used a Topical Corticosteroid Phobia (TOPICOP) questionnaire to investigate the rates of corticophobia among four types of healthcare professionals. While pharmacists had the highest rate of corticophobia (with a TOPICOP score of 48.5%), general practitioners weren’t far behind (46.0%), followed by pediatricians (39.7%), and dermatologists (32.3%).

“In conclusion, prominent corticophobia exists among healthcare professionals, especially among pharmacists and general practitioners, probably based on insufficient knowledge of [topical corticosteroids]. This may lead to mistrust among patients, as they frequently discuss their treatment with these professionals,” the investigators wrote. “Therefore, it is important to continue to provide education about topical treatments to all concerned professionals in order to improve patients’ confidence in using these products.”

Warfarin

Warfarin is the most commonly prescribed oral anticoagulant, and it’s been the gold-standard oral anticoagulation therapy for some 65 years. (Before that, it was sold as a rat poison.) 

However, getting patients started on warfarin is very tricky. In fact, during the initiation phase, warfarin has one of the highest adverse event rates of any single drug. As a blood thinner, warfarin’s most common side effect is bleeding, while less common side effects include tissue damage and purple toes syndrome.

The tricky parts to getting patients started on warfarin are due to its narrow therapeutic window and its wide variation in individual patients’ responses—what’s appropriate dosing for one patient could result in hemorrhage in another. It also has a lot of drug-drug interactions, some of which can be harmful. So, it’s particularly important to carefully monitor patients on warfarin.

Because of its tricky nature and its high rates of adverse events, warfarin remains underprescribed. Perhaps that’s as it should be, as newer and more reliable direct oral anticoagulants (DOACs)—such as apixaban, dabigatran, edoxaban, and rivaroxaban—are just as effective as warfarin, have far fewer side effects, and don’t require close monitoring. 

The one advantage warfarin still has over DOACs is price. It usually costs less than $25 per month, which is well below the cost of all DOACs. For indigent patients, warfarin may still be the most practical therapy. 

Metformin

Metformin is a first-line therapy for type 2 diabetes. It was the fourth most prescribed drug in the United States in 2017, with a cost as low as $5. Even so, only about half of people with type 2 diabetes take it and continue to use it long term. Why only half? “Given metformin’s low cost, excellent safety profile, and effectiveness, such high rates of non-use warrant explanation,” wrote researchers in an article published in Patient Preference and Adherence who were intent on finding out that explanation. 

Through patient focus groups, chart review, and one-on-one interviews with patients and providers, the researchers determined that both patients and providers felt that gastrointestinal side effects were the main barrier to using metformin. 

The researchers noted that even though doctors can try to help minimize side effects through counseling, dose titration, and use of extended-release formulations, these efforts haven’t been thoroughly studied nor clinically proven to be effective. 

“Pragmatic clinical trial research on optimal dose, formulation, and counseling for new metformin users should be considered,” the researchers suggested. “One example would be a study to assess whether adherence and outcomes are superior among when patients are routinely started on extended-release as opposed to immediate-release metformin.”

Benzodiazepines

Benzodiazepines—including diazepam, clonazepam, lorazepam, chlordiazepoxide, and alprazolam—are anxiolytics often used to treat anxiety disorders, such as phobias, panic disorder, and generalized anxiety disorder. They’re typically prescribed for short-term use as part of an overall treatment plan. 

Various benzodiazepines—or “benzos”—have similar sedative effects, but they differ in potency, onset of action, and half-life, noted Arash Javanbakht, MD, assistant professor of psychiatry, Wayne State University, in an article for The Conversation. 

“For example, while diazepam has a half-life of up to 48 hours, the half-life of alprazolam can be as short as six hours. This is important, as a shorter half-life is linked with higher potential for addiction and dependence,” Dr. Javanbakht wrote. “That is one reason physicians typically are not excited about prescribing [alprazolam] for long periods of time.” 

There are safer treatments than benzodiazepines, such as cognitive behavioral therapy, but this requires more time and attention to be as effective, he explained. Other medications for the treatment of anxiety disorders are selective serotonin reuptake inhibitors like fluoxetine, sertraline, and citalopram. 

“Especially when combined with psychotherapy, these medications are effective and are safer options than the benzos, and without a risk of addiction,” Dr. Javanbakht advised. 

Medications for obesity

A study that analyzed health data on millions of US patients found that only 1.3% of those eligible for weight‐loss medication received a prescription. (Patients deemed eligible for medication included those with a BMI ≥ 30 kg/m2 as well as those with a BMI = 27-29.9 kg/m2 who also had at least one weight-related comorbidity.) Of the few scripts that were written, three in four were for phentermine. 

In a related editorial, William Dietz, MD, PhD, director and chair, Sumner M. Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health at The George Washington University, asked: “[W]hy, despite five effective FDA‐approved drugs for weight loss, is the highly prevalent problem of obesity undertreated?”

He speculated on some of the factors that contribute to this conundrum: 

• Physicians don’t recognize or record that a patient is obese

• Patients may not expect help or ask their physician for help with weight loss

• Physicians aren’t knowledgeable about the use and duration of pharmacotherapy for weight loss

• Physicians may demonstrate weight bias against people with obesity

• Health insurance may not cover pharmacotherapy for weight loss

“Although treatment alone will not end the obesity pandemic, resolving the treatment conundrum will be essential to improve the lives and reduce the costs of those people already affected,” Dr. Dietz wrote.