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    Michael L. Aaronson, MD
    Kidney Doctor and High Blood Pressure Specialist
    7401 O Street Lincoln, NE 68510
    Phone: 402-484-5600

    Saturday, March 2, 2019

    How Do I Remember to Take My Pills Correctly?

    Kidney Question from patient to Dr. M. Aaronson: 

    I am having trouble remembering to take my water pills, especially the ones I'm supposed to take in the afternoon. Do you have any advice for me?

    Michael Aaronson, MD, Kidney Doctor and Medical Health Blogger:

    One of the jobs of the kidneys is to retain water. If a patient is taking water pills (also called diuretics) to help rid the body of excess fluid, and that person forgets to take the diuretics at the prescribed time, there can be consequences. Forgetting to take your water pills may lead to a significant gain in water weight.

    Today's health blog will describe a method to help you remember to take your diuretics and other medications on time. Improved adherence to your prescribed medical regimen can lead to better health and prevent hospitalizations. The goal is to provide a method that is easy to set up and simple to follow.

    I see a referral population. Sometimes the patients I serve require a complicated water pill regimen, given their kidney problems. If we are trying to keep the body at a "dry weight" or weight were there is no extra fluid on board, water pills may need to be taken at different times of the day and on different days of the week. When this type of complex regimen is ordered by your doctor, it can be hard for a person to remember to take the right pills that are prescribed at the right time.

    What is the secret to success? First, understand the regimen. Make sure you know the pills you need to take and when you are supposed to take them. Misinterpreting the plan could lead to worsening outcomes, including kidney failure.

    Next, understand the scope of the "possible" problem. Many patients who are on water pills might avoid nephrology assistance by taking their pills correctly. There are so many different ways to take these pills, and there are so many people on them. Using 2016 data from the Medical Expenditure Panel Survey, we learn that many patients are on diuretics both alone and in combination with other medications (so called combination pills). Let's briefly review some of the top written diuretics:

    Most written  Name of med  Number of scripts written

    12th most written  Hydrochlorothiazide 43,472,270 prescriptions
    Comment: Usually written once a day but can be ordered twice a day. I have seen twice a day usage in the setting of kidney stone (nephrolithiasis) prevention.

    15th Furosemide     32,692,726
    Comment: Can be written twice a day or once a day. If furosemide (also known as Lasix) doesn't work, we may order another "loop" diuretic called torsemide or bumetanide.

    33rd  Potassium            22,380,348
    Comment: Potassium is not a diuretic. However, potassium is commonly prescribed when a patient is on diuretics because one of the side effects of water pill medicine use is low potassium that needs to be replaced. Potassium can be written once, twice, or more times a day.

    Not on the most written list: metolazone. This one is usually reserved for the nephrologists after a referral is made. Metolazone is a powerful diuretic. It can be written daily or to be taken on Monday, Wednesday, and Friday. There are several regimens that can be used.

    Primary care providers, kidney doctors, cardiologists, and other doctors order these medications for several reasons. Indications for water pill use include high blood pressure (hypertension), edema, chronic kidney disease, and heart failure.

    Some of these diuretic medications are written once a day. Some water pills are taken twice a day. Metolazone can be ordered three times a week on Monday, Wednesday, and Friday. As we stated previously, remembering the multiple combination regimens can be complex. Forgetting can be dangerous. If a person forgets their diuretic, has kidney disease, but does remember to take their daily potassium, there is a risk of hyperkalemia (elevated potassium in the body). The patient could also become fluid overloaded and need to be admitted to the hospital.

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    Let me present to you a system to remember some of these complex regimens. This system will work not only for your diuretic medications but also help you remember all your medications -- even the once daily prescriptions!

    We start with the pill box. This works for many, but there are caveats. Problems arise when a person is away from the box or regimens change, such as the medication dose of a particular diuretic. If your physician increases your furosemide dose from 40 mg to 80 mg, you have to fish out the pills and adjust the amounts in the box accordingly. It can be tough given generic pills all look the same (see the figure below). If you limit your filling to a week at a time, or a day at a time, this approach to dosing and times to take the medicine are usually spot on. See the figure for an example of my preferred type of pill box:

    Figure: Michael Aaronson, MD's preferred type of pill box: a daily, mobile box that allows for morning, noon, and night administration of medication.

    Notice that the pill box is mobile. It contains medication for one day. You can take the medication with you if you go somewhere. I prefer this type of pill box over the weekly kind because of the benefit of portability. If you are not home at lunchtime, for example, you can take your lunchtime medication on time because it is with you. No worries about catching up or getting behind. If the pill box is home, you may even miss a dose.

    The problem with this strategy is a person has to constantly remember to think about pills and they have to remember to take them at the right time. Even if the pills are in your pocket or in your purse, if you don't remember to take them, the medication gets missed.

    Wouldn't it be better to be reminded to take the medication? I think so. Most people today have smartphones. My suggestion is to use that technology to remember to take your prescription medication. The secret is to use the phone's alarm app to remember to take your prescription meds. The process is easy once it is set up! The beauty of this system is that there are alarm clock apps for android phones, iPhones, tablets, and more. So if you don't have a smartphone, you can use an inexpensive tablet to do the very same thing.

    The first figure in this medical blog shows a picture of an alarm clock app that is set to go off Monday, Wednesday, and Friday at 7:30 AM. The purpose of this alarm is to remind the patient to take metolazone at that time. Not shown is the ability to set different alarm types to remind you to take certain medications. You can label the alarms to remind you what needs to be taken and when.

    Here is another example: the following figure shows an alarm that is set to remind the patient to take the second dose of furosemide (lasix) at 5:30 PM daily. In this case the person will be reminded daily. The name of the alarm will be furosemide. The ringtone will be Oxygen.


    If the patient is taken off furosemide and placed on once daily torsemide, the afternoon alarm can be deleted. Note the added benefit to the evening reminder: if you have additional medication to take, let's say metformin if you are a diabetic, you can take it at this time as well. No remembering required.

    There are many methods people have tried to improve medication adherence. This includes a systems approach where pharmacies or health insurance companies track whether or not patients are filling prescriptions. All of that is in good faith and helps. But in my opinion, the best way to make sure you are taking your pills correctly at the time you need too is to develop a system that is non-intrusive that doesn't take over your life. Living with a chronic medical problem, or trying to prevent worsening of a disease, such as chronic lower extremity swelling that transitions to acute heart failure doesn't have to consume your existence. There are tips and tricks that you can use to get things done without having to think about your condition all of the time. Try the pill box - alarm clock reminder method to remember to take your water pills as well as your other medicines correctly. If it works really well for my kidney patients, it will likely work well for you!