For Clinicians | Which Medications Can’t Be Missed

Aug 27, 2026 | HCP, Preparedness

couple looking at computer asking questions

For Clinicians | Which Medications Can’t Be Missed

How to Help Patients Rank their Medication List Before a Disruption

By Dr. Jamie Wilkey, PharmD — Director of Clinical Strategy, Jase
Medically reviewed and edited by Kristen Carpenter, PA-C

September is National Preparedness Month and that’s a big deal for us over here at Jase. When it comes to medications, your patients get the same advice they get every year: keep some extra medication on hand. But between all the prescription medications they take and the OTC products and supplements, that one line of advice quickly grows confusing and unmanageable. Nobody has ever published a ranking of which medications matter most, so patients sort it themselves.

Why there isn’t a ranking

One team went through 186 academic articles and 252 web pages of preparedness guidance for chronically ill patients, spanning cancer, cardiovascular disease, diabetes, chronic respiratory disease, and kidney disease. Recommended amounts on hand for the medications that treat these conditions ran anywhere from having a cushion of 3 days to a full month depending on which source you opened. Most of the recommendations traced back to expert opinion rather than evidence. None of it answers which medications actually tolerate an interruption. The review catalogues how much to have and never asks which one matters most.¹

To make matters more opaque, the literature it covered ends in 2014. The gap is still open today. So when a patient asks us how much to keep on hand, we don’t have anything more than generalities to give them.

How to rank a list

Here’s the 4 questions we use:

How sick does this patient get without this drug?
How fast does that happen?
How likely is this one to be short when everyone needs it?
Can this particular patient actually get to a pharmacy in a bad week?

Run a list through those and the order falls out. It’s not always what the patient expects. The table below answers the first two for the most common classes. Those are drug properties. The last two are yours, because only you know this patient.

Class	Clock	What goes wrong	What to tell them
Levothyroxine	Weeks	Seven-day half-life, so the pool drains slowly and most patients feel nothing for days.²	Put it at the bottom. Don’t spend the worry here.
Antihypertensives, the forgiving ones (ACE inhibitors, ARBs, amlodipine)	Days	Pressure drifts back toward baseline over roughly a week. Nothing rebounds.³	Resume when they can. Never double up to catch up.
Antihypertensives, the rebound ones (clonidine, beta-blockers)	Fast, and stopping is what starts it	Stopping is the event. Clonidine cessation can drive pressure past where it started, and concurrent beta-blockade makes it worse.4	Call before the last dose. This is never the one they stretch.
Inhaled controller and rescue (asthma, COPD)	Splits by disease	In asthma, losing the controller invites an exacerbation. In COPD, withdrawal didn’t change exacerbation risk in a large trial, though lung function fell.⁵	The rescue inhaler travels with them either way.
Oral diabetes medications	Days, with one inversion	Sulfonylureas push insulin whether or not the patient ate. Skipped meals show up in most severe hypoglycemia admissions, though comorbidity drives it more than fasting alone.⁶	If food is short, the sulfonylurea is the conversation.
Proton pump inhibitors	About two weeks	Rebound acid hypersecretion after a long course. Symptoms arrive well after the last dose, then fade.⁷	Warn them that a rebound is coming and that it passes.
Insulin	Hours, and the shortest clock here	Pump therapy uses no long-acting insulin, so there’s no depot underneath it. When delivery stops, nothing is holding the floor.8	Every pump patient needs a written pen-and-syringe fallback. Check ketones if delivery stops more than an hour.
Anticoagulants (DOACs, warfarin)	Hours for DOACs, days for warfarin	DOAC half-lives run about 5 to 17 hours, so protection falls off fast. Warfarin drifts down slowly. Patients assume the reverse.9	Never double a warfarin dose after a miss.
Antiseizure medications	Days to weeks	Sustained nonadherence tracks with worse seizure control and higher mortality.¹⁰ Occasional missed doses did not acutely raise seizure risk in drug-resistant epilepsy. 11	Mid-list, not top. Consistency matters more than any single dose.
Chronic corticosteroids	Speeds up under stress	Anyone on steroids long enough to be suppressed needs more under physiologic stress, not less. A disaster is physiologic stress.¹²	Never the one to skip. Sick days need more, not less.
Psychiatric medications (antidepressants, antipsychotics, lithium, benzodiazepines)	Varies, and the clock isn’t the point	Stopping is one hazard. Restarting at the previous dose is a separate one. Part 2 of this series is all about mental health medications in a disaster	Both stopping and restarting need a plan, and both plans come from the prescriber.

Three exceptions

The table above is great for a quick scan. Steroids, clonidine and seizure meds need more context than the table can hold.

Ask every patient on long-term steroids what they do when they get sick. If they don’t have an answer, that’s your time to shine in educating them. Physiologic stress raises the requirement, so the sick-day rule is to double the oral dose at a fever above 100.4F and triple it above 102.2F.12 Omission during stress is what precipitates adrenal crisis. A patient rationing their bottle is under stress and cutting the dose at the same time. Something to watch for sure.

Check whether your clonidine patients are also on a beta-blocker. Stopping clonidine suddenly can push blood pressure higher than it was before treatment, and being on a beta-blocker too makes that worse.4 That’s why an elective taper stops the beta-blocker several days first. Patients on both would need top priority attention if access to those medications were disrupted.

And now for epilepsy. Sustained nonadherence tracks with worse seizure control and higher mortality.¹⁰ But a prospective study published this year in drug-resistant epilepsy found that occasional missed doses did not acutely raise seizure risk.11 So they sit in the middle of the ranking, not at the top. A missed dose is not the emergency. Multiple missed doses are.

You intuitively know which of these goes first. The patient doesn’t, not off the top of their head. So the next time their list is in front of you, help them sort it into what’s critical and what has some flexibility.

Where we sit, and what to take away

This is where Jase specializes: the undefined middle of appropriate medical preparation. We help patients get ahead of a disruption before it throws off a critical regimen, with a licensed provider reviewing every request. Disasters hit chronic conditions unevenly, and we help sort out what comes first. A complement to primary care, never a replacement for it.

The ranking is the thing to walk away with, and it’s an order rather than an amount. Every list has one drug that is most critical, and most patients aren’t clear exactly what that one is.

And now before you go you should know we still have one class that is so important that it needs its own article: psychiatric medications. Stopping them is one hazard and restarting them is another. So our next article will be a deep dive on mental health medications in a disaster.

Sources

Tomio J, Sato H. Emergency and disaster preparedness for chronically ill patients: a review of recommendations. Open Access Emergency Medicine, 2014. 186 academic articles and 252 web pages screened; recommended supply ranged from 3 days to 1 month; the authors state that most of the recommendations have not been validated scientifically and that a large number rest on anecdotal evidence or expert opinion. https://pmc.ncbi.nlm.nih.gov/articles/PMC4753992/
Administration and Pharmacokinetics of Levothyroxine, in 70 Years of Levothyroxine. NCBI Bookshelf. Elimination half-life averages roughly 6 to 7 days in euthyroid adults and about 7.5 days in treated hypothyroid patients, which is what supports once-daily dosing. https://www.ncbi.nlm.nih.gov/books/NBK585644/
Amlodipine besylate (NORVASC). FDA prescribing information via DailyMed. Terminal elimination half-life of about 30 to 50 hours, from which a return toward baseline over several days follows. The label separately notes that amlodipine gives no protection against the dangers of abrupt beta-blocker withdrawal, which is the distinction this row turns on. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b00570ff-4081-4514-b45b-eb6f753450f5
Clonidine. StatPearls, NCBI Bookshelf: abrupt discontinuation may result in rebound hypertension, the risk is higher with concurrent beta-blockade through unopposed alpha-adrenergic activity, and beta-blockers are withdrawn several days before tapering clonidine. https://www.ncbi.nlm.nih.gov/books/NBK459124/ Catapres (clonidine hydrochloride) FDA label: sudden cessation has produced nervousness, agitation, headache and tremor with a rapid rise in blood pressure and elevated plasma catecholamines, and rare instances of hypertensive encephalopathy, cerebrovascular accident and death have been reported after withdrawal. https://www.accessdata.fda.gov/drugsatfda_docs/label/2012/017407s037lbl.pdf
Asthma: Rank MA, et al. The risk of asthma exacerbation after stopping low-dose inhaled corticosteroids: a systematic review and meta-analysis of randomized controlled trials. Journal of Allergy and Clinical Immunology, 2013. Patients with well-controlled asthma who stop regular low-dose inhaled corticosteroids have increased exacerbation risk compared with those who continue. https://pubmed.ncbi.nlm.nih.gov/23321206/ COPD: Magnussen H, et al. Withdrawal of inhaled glucocorticoids and exacerbations of COPD. New England Journal of Medicine, 2014;371(14):1285-1294. 2,485 patients with a history of COPD exacerbation on triple therapy; stepwise fluticasone withdrawal over 12 weeks was noninferior for moderate or severe exacerbations, with a greater decline in lung function during the final withdrawal step. https://pubmed.ncbi.nlm.nih.gov/25196117/
Burge MR, Schmitz-Fiorentino K, Fischette C, Qualls CR, Schade DS. A prospective trial of risk factors for sulfonylurea-induced hypoglycemia in type 2 diabetes mellitus. JAMA, 1998. No hypoglycemia occurred across 156 fasting studies in elderly patients receiving maximum sulfonylurea doses. The retrospective literature reaches the opposite conclusion, with omission of one or more meals implicated in 80% of severe drug-induced hypoglycemia admissions; risk concentrates in renal or hepatic impairment, alcohol use, and polypharmacy rather than in fasting alone. https://jamanetwork.com/journals/jama/fullarticle/1150338
Reimer C, Sondergaard B, Hilsted L, Bytzer P. Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology, 2009;137(1):80-87. Randomized double-blind placebo-controlled trial in 120 healthy volunteers given 8 weeks of esomeprazole 40 mg followed by 4 weeks of placebo; clinically relevant heartburn, acid regurgitation, and dyspepsia appeared after withdrawal and persisted at least 2 weeks. Conducted in healthy volunteers, not chronic PPI patients. https://pubmed.ncbi.nlm.nih.gov/19362552/
Ketones and Insulin Pumps. UCSF Diabetes Teaching Center. Pump therapy carries higher ketone risk because long-acting insulins are not used and rapid-acting insulin is delivered in very small amounts; check glucose and ketones if basal delivery is interrupted for more than an hour. https://diabetesteachingcenter.ucsf.edu/content/ketones-and-insulin-pumps
Ferri N, Colombo E, Tenconi M, Baldessin L, Corsini A. Drug-Drug Interactions of Direct Oral Anticoagulants (DOACs): From Pharmacological to Clinical Practice. Pharmaceutics, 2022;14(6):1120. Elimination half-lives: rivaroxaban 5 to 9 hours in healthy adults, edoxaban 8 to 11 hours, apixaban 8 to 15 hours, dabigatran 12 to 17 hours. https://pmc.ncbi.nlm.nih.gov/articles/PMC9229376/
Faught E, et al. Nonadherence to antiepileptic drugs and increased mortality: findings from the RANSOM Study. Neurology, 2008. Medicaid claims analysis of 33,658 adults with epilepsy across 388,564 treated quarters, 26% of them nonadherent; nonadherence was associated with more than a threefold increase in mortality, hazard ratio 3.32 (95% CI 3.11 to 3.54). https://pubmed.ncbi.nlm.nih.gov/18565827/
Goldenholz DM, et al. Does Missing Medication Acutely Change Seizure Risk? A Prospective Study. Annals of Neurology, 2026. Prospective community-based cohort of 27 adults with drug-resistant epilepsy, defined as three or more seizures per month, followed 10 months each across 7,853 person-days with 93% average adherence; occasional missed doses did not measurably raise immediate seizure risk, while prior seizure history did predict future seizures. https://pmc.ncbi.nlm.nih.gov/articles/PMC12782288/
Adrenal Crisis. StatPearls, NCBI Bookshelf. Sick day rules: doubling the oral corticosteroid dose for fever exceeding 100.4°F (38°C) and tripling it for fever exceeding 102.2°F (39°C). https://www.ncbi.nlm.nih.gov/books/NBK499968/