What are Relative Contraindications in Medications?

Relative contraindications in medications occur when a specific drug may pose risks to a patient but could still be used if the potential benefits outweigh those risks. These are different from absolute contraindications, where the medication should never be used under any circumstance.

In relative contraindications, the decision to give the medication depends on careful assessment by healthcare professionals. They weigh the likelihood of harm against the potential therapeutic benefit for the individual.

Understanding the concept of relative contraindications is important because there are circumstances where withholding a medication might lead to worse outcomes for a patient than the risks of prescribing it.

Examples of Relative Contraindications

There are several instances where relative contraindications are commonly encountered in healthcare. The risks depend on the patient’s condition, overall health, and other factors.

Here are some examples:

• High Blood Pressure and Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): NSAIDs, such as ibuprofen, can elevate blood pressure and lead to kidney problems in people with hypertension. However, they might still be prescribed for temporary pain relief if no safer alternative is available and the patient’s blood pressure is well managed.
• Pregnancy: Many medications are relatively contraindicated during pregnancy because of potential risks to the foetus. For example, loratadine (an antihistamine) may be used after careful consideration during pregnancy if the potential benefit for controlling severe allergic reactions outweighs the possible risks.
• Asthma and Beta Blockers: Beta blockers are typically avoided in people with asthma because they can cause bronchoconstriction (narrowing of the airways). However, they may still be prescribed in certain heart conditions if the need to manage the heart problem is greater than the risk of worsening asthma.
• Kidney Disease and Contrast Media: Certain contrast agents used in imaging tests are relatively contraindicated in people with kidney problems. These agents can put additional strain on the kidneys. However, they might still be used in critical diagnostic procedures, provided the healthcare team takes measures to reduce the risk, such as proper hydration.
• Diabetes and Corticosteroids: Corticosteroids can raise blood sugar levels and are relatively contraindicated in people with diabetes. Yet, they might be used short-term for life-threatening conditions like severe inflammation if no equally effective alternative is available.

Why Relative Contraindications Are Important

Relative contraindications highlight the need for informed decision-making in healthcare. Unlike absolute contraindications, they allow some flexibility, meaning a drug could be used safely if appropriate precautions are taken.

They are important for the following reasons:

1. Balancing Risks and Benefits: In cases where untreated conditions could worsen the patient’s health, relative contraindications give healthcare teams the option to find safe, customised solutions.
2. Allowing Essential Treatments: If no alternative treatment exists, prescribing medications under relative contraindications ensures the patient doesn’t miss out on potentially life-saving care.
3. Encouraging Monitoring: Drugs prescribed under these circumstances come with special instructions to monitor the patient closely, improving safety.

Factors Considered Before Prescribing

When deciding whether to prescribe a medication with a relative contraindication, healthcare providers consider several factors specific to the patient.

These include:

• Severity of the Condition Being Treated: What level of treatment is required? If a condition is mild, alternative therapies might be explored instead of using the relatively contraindicated drug.
• Presence of Safer Alternatives: If an equally effective medication with fewer risks is available, that option might be chosen first.
• Risk of Worsening Underlying Conditions: If the medication could significantly exacerbate an existing condition, it is less likely to be prescribed.
• Patient Age: Older adults may be more vulnerable to side effects and need extra caution.
• Health of Vital Organs: The function of organs like the liver, kidneys, and heart determines whether the body can process certain drugs without harm.
• Dose and Duration of Treatment: Sometimes, a lower dose of a relatively contraindicated drug for a short period might reduce the potential risks.
• Patient Preferences: Patients often play an active role in deciding whether to take certain medications, especially if the risks need balancing.

Examples from Practice

Relative contraindications arise frequently in clinical practice where balancing risks and benefits allows patients to receive necessary treatment.

Example 1:
A patient with mild kidney impairment requires an imaging test with contrast dye to detect a suspected life-threatening blockage. While contrast dye is relatively contraindicated in kidney impairment, the imaging test is critical. The medical team decides to proceed with the contrast agent but takes extra measures, such as pre-hydrating the patient and monitoring kidney function afterward.

Example 2:
A diabetic patient with severe asthma has a sudden cardiac event. The cardiologist considers prescribing a low-dose beta blocker to protect the patient’s heart. Although both diabetes and asthma are relative contraindications for beta blockers, the heart condition presents a higher immediate risk. The cardiologist chooses a cardioselective beta blocker with less impact on the lungs and adjusts the patient’s diabetes management plan.

These examples show how healthcare professionals assess risks and adapt treatment plans to accommodate individual patient needs while mitigating dangers.

Precautions When Prescribing with Relative Contraindications

When a medication with a relative contraindication is prescribed, doctors and other healthcare professionals take additional precautions to balance safety and effectiveness.

These precautions often include:

• Adjusting Dosage: Prescribing the lowest effective dose can help reduce the risk of side effects.
• Monitoring Side Effects: Regular check-ups and communication with the patient allow the medical team to quickly detect and manage any adverse reactions.
• Using Supplemental Medication: For example, diuretics might be prescribed alongside certain heart medications to reduce potential harm.
• Providing Instructions for Safe Use: Patients might be instructed to take the medication with or without food, avoid alcohol, or follow specific schedules.
• Regular Testing: Blood tests or imaging may be performed to track liver, kidney, or heart function while the patient takes the medication.

Difference Between Absolute and Relative Contraindications

Absolute and relative contraindications differ in their level of risk and level of flexibility.

Feature	Absolute Contraindications	Relative Contraindications
Risk Level	Severe and life-threatening	Potential but not always severe
Flexibility	Medication should NEVER be given	Medication MAY be given if benefits outweigh risks
Possible Actions	Alternative treatments must always be chosen	Medication might be prescribed with precautions
Examples	Penicillin for penicillin allergy	NSAIDs in controlled hypertension

Patient Role in Managing Risks

Patients can actively engage in their healthcare when a relative contraindication is identified.

Steps patients can take include:

• Understanding the Risks and Benefits: Ask the healthcare provider why the medication is being prescribed and what precautions to follow.
• Sharing Relevant Health Information: Be honest about medical history, current conditions, and any other medications being used.
• Reporting Side Effects Promptly: Notify a doctor or pharmacist if worrying symptoms develop.
• Attending Regular Follow-Ups: These visits help assess whether the medication is working and whether the risks are being properly managed.

Training and Guidelines for Healthcare Professionals

Healthcare professionals follow evidence-based guidelines and training to manage relative contraindications effectively. In the UK, resources like the British National Formulary (BNF) and the National Institute for Health and Care Excellence (NICE) provide detailed guidance on prescribing medicines with relative contraindications.

Training includes:

• Case-Based Learning: Practical examples teach doctors how to manage relative contraindications.
• Specialty Updates: Staying informed about the latest research ensures better decision-making.
• Simulation Exercises: Simulated situations help new healthcare professionals prepare for real-life scenarios.

Final Thoughts

Relative contraindications provide flexibility and allow healthcare teams to make thoughtful, patient-centred decisions. By carefully weighing risks against potential benefits and putting safeguards in place, patients can still receive the treatment they need, even when certain conditions pose a risk.

Both healthcare professionals and patients have roles to play in ensuring safe use of relatively contraindicated medications, with ongoing communication and monitoring being key to positive outcomes.