Putting an Expiration Date on Prescriptions

When a medication prescribed for a specific condition seems to be keeping the condition in check, the physician and patient can be lulled into a sense of complacency. With some medications, the physician risks being lulled into liability.

A 66-year-old woman with a history of depression, stroke, thyroid event, emphysema, and congestive heart failure was being maintained on a number of medications by her HMO physician for bipolar disorder. In June 1996, this physician referred the patient to a gastroenterologist, Dr. G, who prescribed Reglan for reflux disease.

The patient continued taking Reglan while treating with Dr. G, who noted some improvement in March 1997. Dr. G noted no side effects and gave the patient a three-month Reglan prescription in April of 1997. In June, the HMO physician also noted no side effects.

The next month, the patient began treating with Dr. IM, an internist, because her original internist had quit the HMO. On her first visit, the patient sought a medication refill and also complained of dizziness over three years and trembling. On a return visit to go over laboratory results, Dr. IM noted some elevated thyroid levels. He adjusted the patient’s thyroid medications and referred her for pulmonary rehabilitation.

On the patient’s return in February 1998 to request a change in medication for her mental state, Dr. IM changed her medication from Paxil to Prozac and wrote a six-month prescription for Reglan. Two visits later, in July 1998, the patient complained of ringing in both ears, episodes of passing out, and motion disorders followed by confusion and incontinence. After his own negative neurological examination, Dr. IM referred the patient to a neurologist.

Dr. IM’s next information on the patient was news of her hospitalization in March 1999 for a fall. On the patient’s last visit to him three weeks later, Dr. IM noted that the patient had not followed through on the neurology consult.

When the patient did finally see the neurologist in May 1999, that specialist diagnosed Parkinson’s Disease “probably aggravated by Reglan.” On a visit to a subsequent motion disorder expert, that physician diagnosed probable “tardive diskinesia related to Reglan use and mild Parkinson’s probably related to Reglan use.”

In a lawsuit against Dr. IM, the patient alleged that she was negligently maintained on Reglan for over two years, resulting in tardive diskinesia and related symptoms.

In her theory against Dr. IM (and against Dr. G as well), plaintiff noted that the manufacturer states that Reglan is indicated as a short-term (4 to 12 weeks) therapy for adults with symptomatic reflux disease. As the case progressed, the patient’s expert physicians testified that Reglan is not intended for long-term use because of its neurological side-effects. Other physicians testified that the patient’s breathing difficulties and fainting episodes were related to the long-term Reglan use. The lawsuit was resolved informally prior to trial.

In assuming the patient’s care, Dr. IM followed his custom and practice of conducting a discussion with her on all the medications she was taking. Factoring in the treatment limitations suggested by the manufacturer of Reglan could well have avoided a lawsuit down the road.

Gordon Ownby is CAP-MPT’s general counsel. Comments on Case of the Month may be directed to gownby@cap-mpt.com.