Wednesday, October 24, 2012

Popping Pills

Mondays are always crazy busy days in a govt hospital. It’s as if a rash of people get sick over the weekend and can’t wait to get to the doctor early on Monday morning. That leads to a lot of chaos and confusion and fights over who came first and who has the more serious disease and should be seen on a priority basis. All this leads to not only heartburn for the patients’ waiting in the long queues but also poses quite a challenge to the doctors (who are just recovering after a weekend well spent) every Monday morning. And amidst all this serious and very sick patients there comes one who inadvertently lightens up the whole day with an accidental joke. But believe me; the patient is usually ignorant that what he/she says is absurdly humorous. But it’s enjoyable all the same. A complete stress-buster in the midst of all that tension.

Like today, when I was in the midst of a roller-coaster ride of patients (too many sick people/too few doctors, as usual) there walked in a patient, a middle aged lady who told me something bizarre and comical at the same time. When I had prescribed to her a drug which needed to be taken along with food and was explaining the necessity to not to take it on an empty stomach, she exclaimed enthusiastically that she had a method of her own to take drugs. And even before I asked she volunteered the information that she usually took all her medicines between the first and second course of her meal. Flabbergasted I asked her to elaborate, as I had personally never heard of such a thing before and she went on to say that she first took Sambar Rice and then stopping her meal there, she proceeded to take her medicines and then she again went back to eating Rasam rice. She said proudly that this ensured that the pills were not acting on an empty stomach and that there was food in her stomach before and food in her stomach after the medicines thus protecting her from the medicines effects. I had difficulty keeping my face straight and breaking into laughter as I nodded my head sagely at her, praised her intelligence at discovering such a fantastic system to take medicines and sent her away well pleased with her own cleverness. There was absolutely nothing objectionable about her technique in taking medicines. But neither was it necessary.

And that made me think that most often our patients do things blindly, trusting to us doctors without really reasoning out why they do the things they are asked to do by the doctors. And we doctors with our superior attitudes of I know best and also due to a lack of time fail to explain properly to our patients why we tell them to do certain things. Now I cannot go around explaining to each and every patient the intricacies of drug absorption and why certain medicines have to be taken on an empty stomach and why certain medicines should never be taken on an empty stomach. But I can actually do it in detail on a blog post and hopefully those who read it will understand a bit more about medicine and pharmacology and the do’s and don’ts of popping pills. So here goes.

The first and foremost thing to say is that the method the lady I mentioned above follows is completely unnecessary. When we say take a medicine with food, we don’t mean it literally. A medicine can be taken half an hour before or after food. As long as the stomach is not empty for a long time with just the medicine in it. This is done for two reasons. A starving stomach has usually a high acid content already inside it and some medicines can increase the acids produced by the stomach leading to the formation of an ulcer or at least stomach ache in the immediate aftermath of taking the medicine. This can be prevented by taking food along with the medicine as the food absorbs the acid, dampens the medicines effects and protects the stomachs lining from being eaten up by our own stomach acids. If you already have acidity or ulcers you can ask your doctor for a safe drug; for there are many alternative forms of the same medicine with the active -disease fighting ingredient being the same, but the salt with which it is made (like sodium replaced by potassium) can be changed, a small change which has the big effect of changing where the medicine is absorbed from- either the stomach or the intestine.

For example everyone knows the painkiller Diclofenac, also known as Voveran. Diclo Sodium is absorbed from the stomach, while Diclo Potassium is absorbed from the intestines. You can see how this would be useful for patients with acidity. Diclo Potassium is labeled Enteric Coated – which means the drug is covered by an insoluble layer which does not get digested by the stomachs acids. But wait till it passes through the stomach and gets into your intestine. The thick protecting layer dissolves immediately, the medicine comes into touch with the intestine cells is rapidly absorbed from there, gets into the blood and acts on your pain. Result – pain relief and no acidity at the same time.

The other reason we ask medicines to be taken with food is to decrease the absorption speed of the medicine from the stomach (to the blood) to a more manageable level. While fast absorption of a medicine is very necessary for some diseases- think heart attack- where you cannot have a single minute’s delay between taking the medicine and its effect to take place, it is not always beneficial. On an empty stomach the medicine is rapidly absorbed and acts very fast while its effect also disappears very fast- leading to an increased number of pills to be taken again and again. This causes difficulty when it comes to certain diseases where we need the medicine to be in the blood for a long time instead of disappearing immediately. Like back pain for instance. 

Taking the same example of the painkiller Diclo again, we can either take the regular drug which can act for a time period of 6 hrs for moderate pain or we can go for a RR-form of the medicine- the rapid release form which acts immediately but only for half the time as regular (to be taken every 3hrs) or we can take the SR form- the sustained release form which is absorbed slowly in low doses and acts slowly for a long time- almost double the time (to be taken every 12hrs). so for the same pain we can take a painkiller either every 3hrs, every 6hrs or every 12hrs. That’s 2 tablets or 4 tablets or 8 tablets a day- depending on your doctors choice of the medicine he prescribes for you. So be specific about the severity of the pain when talking to your doctor to help him decide.

And now we come to the medicines which should only be taken on an empty stomach and never with food. The reason is very simple- food interferes with the absorption of the medicine. There are certain antibiotics which cannot be absorbed when food is present inside the stomach and hence should always be taken at least an hour before food. One example is taking Iron tablets. An iron tablet should never be taken along with dairy products like Milk, cheese butter etc. because the cells which should absorb the iron from the medicine is busy absorbing the calcium from the stomach and the entire iron tablet is lost unabsorbed and of no use to the body. So iron and calcium - never mix please.

These are just a few examples of what makes a doctor instruct you to take a medicine at a specific time. I cannot be more exhaustive here as that would mean I end up writing a pharmacology textbook. So please ask your doctor for more detailed explanations. Or read the instructions printed on the label more carefully. Take care.


  1. Aww doc, this takes me to all my education ka times :'( what has IT done to me now??? I have forgotten the ADME of drug absorption, computational chemistry AND Pharmacology (what I ideally specialized in!) :'( SOOOOOOOOOO BAD DiS LIFE thing is!!

    Do stop by my blog! I'd love your comments & visits!!

  2. Laughing at the woman's ingenious way of taking medicines! :D
    That was a wonderful and simplified explanation of the Do's and Dont's of taking medicines the right way! Look forward to more such informative posts from a doctor's perspective! :)

  3. I very recently happened to visit a doctor and I asked him the reason and he told me the same thing.

    And as for that lady, Well Doc, you should be thankful to her, she not only ended up brightening the first day of your week, but also makes all of us share a hearty laugh :-)

    1. true that Ash..she absolutely relaxed me off in the middle of a tense day..humor can be found in soo many unexpected places...