Scare me into compliance ...

March 12, 2006 9:52 PM

DoctorFilter: Please scare me into being more conscientious, but not to a point where my anxieties go ape.

I am a 325-pound man. I am currently on a prescription of 360 mg verapamil SR and 20 mg lisinopril, daily. I am normally extremely good about taking these, along with a multivitamin and three Metamucils. However, on the weekends, I seem to regularly forget about them, most likely because I don't follow any routine on the mornings I get up.

I'm wondering what I'm doing to my body and my blood pressure. By forgetting to take these medications on the weekends, and then beginning them again on the workweek, am I increasing my danger of a heart attack or a stroke? Am I reducing their effectiveness during the week?

I am currently between doctors; although I'm looking for a new one at the moment, I imagine once I select one there will be some slight delay with the transfer of paperwork and so on. I don't fully trust nor like the doctor I currently have, and I know some people have obtained medical advice on AskMeFi before, thus this anonymous question.

I'll take everything with a grain of salt, but at the same time, I would ask that only people with some very solid medical knowledge respond — either extremely knowledgeable laymen, or, preferably, professionals.

If I were reading this question as a respondent, I'm sure I'd urge the anonymous questioner to be compliant, and tell them they're not doing themselves any good forgetting on the weekend. Trust me, I plan to be compliant. But what I'm essentially seeking is mental ammunition that will encourage me to be conscientious on the weekend. (Please, however, keep in mind that I also unfortunately sometimes let my anxieties get the better of me. Thus, putting it in the context of telling me I'm going to have a heart attack tomorrow is not the best route to go in this answer, please.)

Thank you.

Postscript: please note I'm perfectly aware that my morbid obesity is an extremely dangerous situation in and of itself. I'm trying. I've been trying for a long time, but I'm trying. Weight loss advice would in other circumstances be appreciated, but need not be given in this thread.

posted by anonymous to health & fitness (23 comments total)

If there is something that you do every morning, regardless of it being a weekend or not, I would add taking your medicine to that routine. Or try a note on your bedroom door, or the door to your apt/house. The point being that you either do it along with something that you currently have no problem doing, or put up reminders where you will have to take notice before getting out of the bedroom or house.

Can't speak to the risks of going on and off your medicine, but I used the above strategy when I was taking a daily med that I kept forgetting - especially on business trips. Decided to make it part of my "brushing teeth" routine and that pretty much fixed it.
posted by qwip at 10:07 PM on March 12, 2006

As someone in a similar situtation (40 mg lisinopril and 12.5 hctz) I found that taking them as I go to bed is the best option. I forget morning medications too but I always remember taking stuff before I go to bed, it's part of my evening ritual. Putting all the pills into a weekly reminder dispenser helped as well.

As for the motivation, I looked into what uncontrolled hypertension would do to me in the long run. Amputation, stroke, etc. really put into focus what I can expect if I am not conscientious about taking the pills. Also, I had an ultrasound of my heart that showed a thickening of the heart walls. I could literally see the damage I had already done, while never noticing it otherwise. These two things helped me really see the consequence of not taking the pills regularly.

Good luck.
posted by karmaville at 10:09 PM on March 12, 2006

A practical solution could be just as usual as a psychological one. You could put a pill jar on top of your toothbrush, for instance.
posted by abcde at 10:28 PM on March 12, 2006

As useful, that is.
posted by abcde at 10:28 PM on March 12, 2006

I work mine into my 'brushing teeth' routine. In fact, the company that makes my asthma med Advair used exactly that as an 'advertising campaign' of sorts. One day, out of the blue, they sent me a toothbrush, reminding me to take my Advair twice a day when brushing your teeth as a mode of compliance. Maybe that will work for you?

I didn't need the reminder, however, having trouble breathing if I forget to take a dose is enough of a reminder for me!
posted by spinifex23 at 10:30 PM on March 12, 2006

I treat hypertensive patients very, very often. It's often difficult to achieve compliancy for many reasons, and I think you're doing a pretty good job not just for taking it 5/7 days of the week, but also being aware that this pattern isn't optimal.

Also, I believe you when you say that you're aware of your obesity. It's very difficult to deal with, very easy to get discouraged, and is one of those things that just takes a long time to notice any results. So keep trying!


The reason why you should take your medicines over the weekend is that they're active for 24 hrs. Your blood pressure will suffer as a result. Couple this with typical weekend activites of going bananas and watching TV or movies, and you could raise it even more from emotional/psychological stressors. As karmaville wrote, taking them both at night could be an easy bedtime task to remember.

Most likely, you are not reducing the effectiveness of the drugs over the week. If you're taking the medicines for any reason other than straight-up primary hypertension, you might be putting yourself at increased risk for other things. For example, lisinopril is often used in diabetics and patients with left ventricular heart dysfunction.

Missing doses of both medicines will bump your pressure up over the weekend. This could result in an increased chance of stroke, TIA, hypertensive urgencies/emergency. Depending on your medical background, it could also significantly increase your risk of suffering a heart attack. I'm not trying to scare you into take your meds, but just trying to relay the risks.

The half-life time for lisinopril is 12 hours. For verapamil, it's anywhere between 5-12 hours (I just called the pharmacy to confirm). If you were to skip two days' worth of doses, the concentration of lisinopril would be around 1/16th what it would be if you had just taken it. For verapamil, it'd likely be less. Medicines usually require 5-6 doses to reach steady state (amount drug in = amount drug out), so what's going on is this:
- take meds M-F, reach steady state by the end
- skip the weekend, eliminate most of the meds from your body
- start taking meds again, reach steady state by the end.

Since you already have a low level at the end of the weekend, you may only need 3-5 doses. I don't specifics about this. But I think this info suggests that, optimally, you should take the meds every day.


So let's cut this down to the basics:
- You know you need to take your meds every day
- I think you should take them every day, too
- Let's come up with a way to help you take them every day!

Try taking all of them at night, since bedtime is pretty much unavoidable. If you've got a mirror, you can dry-erase marker some memos. Tie something to your toothbrush, or have the medicine bottles lined in a row. You could also get one of those 7-day pill containers marked with the days of the week, to help you remember. And keep at it with the weight control! Everything that goes into may help you keep your pressures down without one, or both medicines.
posted by herrdoktor at 10:45 PM on March 12, 2006

I'm not familiar with studies that have looked at weekend "non-adherence" (when patient's don't take their meds), but I wouldn't be surprised if it's out there. Usually the poorly controlled BP risks are over years, but your weekends without meds probably aren't helping, since your blood vessels are used to lower pressures during the week, and then get hit with higher ones during the weekends. I don't know your BPs on and off medications, either. Let's also not forget about another major result of high blood pressure, often in the shadows of heart disease and stroke: kidney failure.

I won't harp on the weight thing, but maybe as a motivation factor: if you were able to lose some weight steadily, you might be able to get your BP under better control and not have to take multiple BP pills in the first place.

I don't know all your risk factors, so I can't say anything for sure, but you're right, the odds of having a heart attack tomorrow if blood pressure and obesity are your only problems is hopefully, probably, not super high. But take that low risk over a long time, and there's your stroke and heart attack. (Major heart disease risk factors, very roughly: smoking, male > 55, female > 65, diabetes, high blood pressure, cholesterol (high LDL, low HDL), family history of early heart attacks.)

The way you describe it, you're probably more compliant than most of my patients I've seen complications with, but in my time so far, I've seen everything from heart attack to stroke to kidney failure all related to hypertension. And that's heart attack as in sudden death, or heart attack as in "heart failure with difficulty breathing walking 5 steps to the bathroom." I've seen stroke when patients can't think of the words they want to say (an aphasia), and turn into grumpy, frustrated, angry men who are put into nursing homes because they can't take care of themselves and their families can't (or won't) take care of them. I've seen people spend years of their lives on hemodialysis, which involves going to a dialysis center three times a week for hours each day, getting their blood cleaned, and feeling like crap the rest of the week. They go from "fully functional" to "can't keep their jobs with such a schedule", and they get depressed and feel worthless.

Scary enough for you?
posted by gramcracker at 10:54 PM on March 12, 2006

Here, maybe this will scare you. This is my post-open heart surgery xray. It hurt like a motherfucker. The pain was so enormous that I wasn’t sure if I could survive it. After the third day I was praying to die. I had one sixteen inch incision, and five smaller ones. My sternum was sawed in half and wired back together. And this was after surviving the stroke.

Don't you think, if there was some magic pill I could have taken to spare myself from that hell, I would have taken it? I was 27 years old. Take your medicine.
posted by astruc at 11:57 PM on March 12, 2006 [1 favorite]

I process digitally-delivered information better than stuff I just make a mental note of, that's why I email myself reminders or - in the case of things i need to do in meat-space - program them into the datebook of my cell phone. My phone makes an annoying noise, and I do that task! Works well for a pill. Many phones will do a weekend-only schedule-beep for ya, too.
posted by By The Grace of God at 1:01 AM on March 13, 2006

I just flagged herrdoktors answer as fantastic. Keep his "voice" in mind when looking for your new doc. To answer your question, my best advice to you is to get one of those plastic 7 day pill containers. You can find them at a drug store, or Target. Put it somewhere that you can't avoid seeing it and it will be a good reminder to check to see if you've taken your pills for the day.

Also, work on the weight, but be good to yourself. At the very least, set reasonable goals, give yourself a pat on the back for small victories, and you'll do fine. I don't know where you live, but spring is breaking out all over the northern hemisphere. Get out and walk!
posted by SteveInMaine at 7:34 AM on March 13, 2006

I also have daily medicines which I tend to forget, particularly when I'm travelling.

A physical solution works for me. Every night after I brush my teeth, the pill bottles go into the sink. First thing in the morning I have no choice but to remember them.
posted by tkolar at 11:16 AM on March 13, 2006

Give yourself credit for the pills you are taking.
posted by Ironmouth at 11:25 AM on March 13, 2006

My husband would also forget his (4, 2xdaily) meds from time to time. I got him one of these ($6.99 at Target) and it helps a lot. He pretty much always remembers his morning meds but I try to remind him about his night meds, as those are the ones he seems to forget.
posted by Lynsey at 11:50 AM on March 13, 2006

I'm pretty good with my twice-daily medication routine because I have to take it with food. Two pills with breakfast, and two with dinner. In truth, not only do I rarely (if ever) miss a dose now, but I've gotten a lot better about eating -- no skipping meals or getting to the end of the day and realizing that I'd forgotten to eat, and conversely, I don't do much snacking anymore. I think it's made a difference with my metabolism, which was pretty sluggish before.
posted by penchant at 1:33 PM on March 13, 2006

Verapamil SR does not have a 5 hour half life.
posted by ikkyu2 at 7:30 PM on March 13, 2006

I second the suggestions to get a pillbox, but I'd go one further and get a pillbox with an alarm on it. Here's one kind, but there are lots of kinds available, both much simpler and less expensive, and way fancier and more expensive. In fact, I like the idea so much I might get one for myself.
posted by redheadeb at 7:54 PM on March 13, 2006

Ikkyu2: it doesn't? From my PDR: "The mean elimination half-life in single-dose studies ranged from 2.8 to 7.4 hours. In these same studies, after repetitive dosing, the half-life increased to a range from 4.5 to 12.0 hours." This is for the immediate-release form.

Would it be incorrect to assume that the half-life for verapamil is the same in the SR and non-SR versions as they're the same chemical, even though bioavailability is extended in the SR form? This is what I understand to be true for another drug I'm familiar with, Toprol. While things like peak plasma concentration, time to peak, peak-trough variability are increased, increased, and typically decreased, in extended-release forms of medications, the actual half-life remains the same.
posted by herrdoktor at 8:46 PM on March 13, 2006

I think you're victim to misunderstanding the term 'half-life' and how it's used, herrdoktor. Why would you ever bring up elimination half-life with regard to a sustained-release drug? It's not a parameter you care about; you care about serum levels, as evidenced by your post, where you (wrongly) used the verapamil half life to make a calculation about the serum levels.

Point is that when the time to peak is non-negligible compared to what you're calling the elimination 'half-life', you can't actually count on levels to drop by half over that time; your half-life becomes an artifactual number related to elimination kinetics, not something you can use to make predictions about drug levels. People use elimination half-life as synonymous with 'half-time', i.e., time to make plasma level drop by half; sustained-release preps invalidate that.

Kids these days.
posted by ikkyu2 at 1:05 AM on March 14, 2006

I've used half-life correctly, and I am correct in the half-life of verapamil. The half-life of verapamil SR is the same. You're right, though: typically, I wouldn't care about half-life of a sustained-release drug in making approximations of serum concentration.

In my first response, I mistakenly thought that the poster was using verapamil in its immediate-release form. That's my fault, and is inexcusable.

I responded to your comment re: verapamil SR's half-life with what I knew, and asked (without meaning to offend, I might add) if half-life wouldn't be the same for the SR and immediate-release forms. I correctly presumed that the half-life is the same, despite differences in bioavailability. This response wasn't an attempt to append my first response or address my incorrect substition of plain verapamil for verapamil SR, though it should've been. This, too, is my fault, and I apologize.

But "kids these days?" Eeesh. What crawled up your butt to warrant such a response? I'm all for being corrected and called out when I'm wrong, but there's no need to be disrespectful in doing so.
posted by herrdoktor at 6:59 AM on March 14, 2006

Frivolity, my dear sir, nothing more.
posted by ikkyu2 at 8:30 AM on March 14, 2006

Boy, then don't I feel silly for overreacting. Again, my humblest apologies. Woke up on the wrongest side of the bed this AM, and still feeling agitated.
posted by herrdoktor at 8:47 AM on March 14, 2006

Okay, so for the layman (and somebody who's takes Verapamil SR), I'm curious: what is the bioavailability of Verapamil in SR form? I'm assuming here that "bioavailability" refers to the length of time the drug is effective.
posted by SteveInMaine at 11:13 AM on March 14, 2006

I don't know for certain. There exists bioavailability curves for drugs that plot serum concentration over time. I don't have this handy to me now.

I think it'd be safe to assume that the duration of effectiveness is 24 hrs, for most purposes. This is predicated on a desire to control blood pressure, not on clearance of the drug, and also on the assumption that the drug is released over a period of time to allow for 24 hrs worth of coverage if you took the med regularly (this, purely based on the once-a-day dosing regimen). In other words, if you take your verapamil SR at intervals > 24 hrs, the serum concentration may fall below effective levels.

It's important to note that many once-a-day drugs are processed by the body and converted into active metabolites that persist and have effects well past 24 hrs. Again, I don't have the concentration curves handy. Nor do I have a dose-response curve. Verapamil may indeed work over 36 hrs, but is dosed daily for compliance reasons.

Basically, it's a daily med which, taken regularly, should work over 24 hrs.
posted by herrdoktor at 3:41 PM on March 14, 2006