A foolish consistency is the hobgoblin of little minds. — Ralph Waldo Emerson
Mrs. K was recently hospitalized for hypertensive urgency, with severely elevated blood pressure and atypical chest pain. She was ruled out for an MI, and was started on hydralazine. When I saw her for a follow-up visit the following week, her blood pressure was great and the chest pain had not recurred, but she said she was so tired, she could barely keep her eyes open. It turned out the hydralazine had been prescribed to be taken “every eight hours” so she had been setting an alarm to take the third dose at midnight.
As clinicians, we often grumble about our nonadherent patients who won’t take their medicines consistently (or at all), or don’t stick to their recommended diet. Lately, however, I have been thinking about the problems and risks of overadherence. We all know them: the people who are so rigid with medication or diet that they end up with a negative impact on their health. I have had patients continue their medicine despite significant side effects, when they could have called and been switched to a more tolerable drug. I have elderly patients who have spent most of their adult lives on restrictive low sugar, low fat diets. Now they have COPD, cancer, or another condition where they have lost significant weight and have become malnourished. I encourage them to liberalize their diet, but they are “scared” to eat the things that they were formerly told to avoid. I currently have a patient with chronic hyponatremia that I am managing with sodium tablets, but she still tells me that she is purchasing low sodium products “so my blood pressure does not get too high.” Another patient was prescribed levetiracetam in the setting of a hyperglycemic seizure, and continued it for two years after the neurology consultant recommended to taper off.
I have found that overadherence can have a number of root causes:
Lack of Knowledge and Counseling
This is a common one, and usually our fault as clinicians. We have instructed the patient to take a medication, but did not clearly explain the situations where the product should be stopped or temporarily held. An example is a patient who continues their diuretic despite an acute illness with nausea and vomiting, and they end up with dehydration or even an acute renal injury.
Overadherence often goes hand-in-hand with anxiety. I often see this with patients who check their blood pressure multiple times per day. I suspect they are driving their pressure higher by worrying about it all the time. Another example is patients who go beyond a second opinion to get a third and fourth. Instead of sticking with one plan, they are constantly looking for a better one. They think they are being a “great patient” but never develop a productive relationship with any one clinician.
This one is driven by a misguided belief that “more is better.” A common scenario is a hospitalized patient who is prescribed a protein pump inhibitor for short term gastrointestinal protection while completing a prednisone taper. Six months later, the clinician realizes they are still taking the antireflux medication. The patient has requested refills and hesitates to stop the medicine because it was started in the hospital. Or maybe the clinician is not sure how long the patient was meant to continue the medicine, and continues the drug “just in case,” despite the risks of long term use.
Blind Adherence to Algorithms
A familiar situation for overadherence is a patient who continues health screenings beyond the age of benefit, such as the 80-plus year old woman with severe heart failure who is still receiving yearly mammograms. She may be harmed by a biopsy that will not prolong her life or improve her health.
What to do? The answer is always to talk to your patients. Ask: What medications are you taking? How are you taking them? How do they make you feel? Review what each medicine is for and situations where the meds should be stopped or held temporarily. Encourage the patient to contact you if there is a problem or concern. Ask at length about diet, vitamins, and supplements. Get to know your patients well, and make sure they are comfortable enough to tell you the whole story.
My patient, Mrs. K, trusts me. Though she was anxious about her blood pressure spiking and causing a heart attack, we talked it over and she agreed to shift her hydralazine dosing so she could take the last dose of the day right before bedtime. She started sleeping better and got her energy back. Since then, I have been more persistent in asking patients to explain how and when they take their medications, especially those who are on more complicated schedules.
Nuance and individualization make for the best care. That is the advantage we have over “Dr. Google” or, in the not-too-distant future, “Dr. AI.”
What cases of overadherence have you seen in your own practice? Share in the comments.
Melissa Schiffman, MD is a community-based primary care physician who practices in Suburban Philadelphia. She enjoys books, birds, gardens, and word nerdery. Her favorite medical term is "borborygmi." Find her on Twitter at: @MSchiffmanMD. Dr. Schiffman is a 2022–2023 Doximity Op-Med Fellow.
All names and identifying information have been modified to protect patient privacy.
Animation by Jennifer Bogartz