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Pharmacology small group facilitator notes - 1
Johnston
Facilitator Notes
Pharmacology in Older Adults
Small Group Session
Created by Bree Johnston, Anna Chang, and Helen Chen
UCSF Division of Geriatrics
LEARNING OBJECTIVES
Case #1:
1. Recognize medication nonadherence as a possible explanation of lack of therapeutic benefit
2. List common sources of non-adherence
3. Discuss effective methods for exploring nonadherence with a patient
4. Discuss the importance of drug prices as a potential cause of non-adherence, and list strategies for dealing
with this issue
5. (Optional: discuss policy issues surrounding drug marketing and pricing, the physicians’ role, and Medicare
Part D)
Case #2:
1. List physiologic changes in elders that impact pharmacokinetics of commonly used drugs
2. Use the MDRD to calculate the decline in renal function with aging, and describe its advantages over the
Cockroft-Gault equation
3. Use the “Cockroft-Gault” equation to estimate the decline in renal function with aging and describe
advantages and limitations of this tool
4. Recognize symptoms of digoxin toxicity
5. Gain an awareness of the range of costs of medications, appreciating how much cheaper “older” and generic
drugs can be than newer brand name drugs
Case #3:
1. Define polypharmacy in the context of appropriate drug prescribing
2. Describe adverse consequences of polypharmacy, including drug-drug interactions, side effects, and a
“prescribing cascade”
3. Discuss the importance of exploring medications as a potential cause of new or unexplained symptoms
Online Drug Pricing
www.drugstore.com
www.familymeds.com
www.walgreens.com
www.costco.com
www.pillbot.com
Online Drug Interaction Facts
www.efactsweb.com
Online GFR Calculator
http://medcalc3000.com/GRFEstimate.htm
Medicare D
www.medicare.gov
http://www.medicareadvocacy.org
Pharmacology small group facilitator notes - 2
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Rough Time Outline for 2 hour session:
15 minutes
Introduction to session
30 minutes
Case 1
30 minutes
Case 2
30 minutes
Case 3
15 minutes
Wrap up and review of learning objectives
NOTE TO FACILITATOR:
FACILIATOR INSTRUCTIONS
There are a few different ways to do this exercise:
1. Have students look up drug prices and compare Medicare Part D plans prior to class, and come in
prepared to discuss them. You can break up the group and give assignments to different groups of
students, such as:
▪ A-H: Look up regimen prices on PDA or another source
▪ I-Q: Assign one –two Medicare Part D plans in your area
▪ R-Z: Assign another Medicare Part D plan in your area
2. Or have an internet connection in the room and do the exercises together, or if you have multiple
computer connections, you can do the assignments in small groups and come back together.
Students should be instructed to bring a calculator, a pharmacology textbook or a PDA based pharm program
such as Epocrates.
Case #1 Learning objectives:
1. Recognize medication nonadherence as a possible explanation of lack of therapeutic benefit
2. List common sources of non-adherence
3. Discuss effective methods for exploring nonadherence with a patient
4. Discuss the importance of drug prices as a potential cause of non-adherence, and list strategies for dealing
with this issue
5. (Optional: discuss policy issues surrounding drug marketing and pricing, Medicare part D, and related
issues).
Case #1:
Mrs. BJ is an 80 year old woman with CAD, status post non - ST segment elevation myocardial infarction 6
months ago. She also has Type 2 diabetes, hypertension, COPD, osteoarthritis, and hypercholesterolemia.
Following her MI, a persantine thallium test showed a fixed perfusion defect inferiorly but no other
abnormalities, and she continued on medical management. Two months ago she was found to have severe
osteoporosis, and treatment was begun for that.
You see her in you continuity clinic, and she says she is doing well. You note that her blood pressure is 160/88,
Pulse 80 R 18 and glycosylated hemoglobin level is 9.0%.
She is retired, widowed, and lives alone. Her children live far away. She is still at home, but is having more
difficulty getting around and paying bills. Somebody comes in to clean her house once a week.
Her Current medications are:
Pharmacology small group facilitator notes - 3
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Fluticasone Inhaled twice daily
Albuterol/iprratropium (Combivent) Inhaler four times a day
Alendronate 70mg weekly
Metformin 500mg PO twice daily
Amlodipine 5mg daily
Glynase prestabs 6mg PO every morning
Celecoxib 200mg po daily
Simvastatin 20mg po daily
ASA 325mg po daily
Metoprolol 100mg twice daily
Fosinopril 10 mg po daily
Calcium carbonate 500mg po twice daily and Multivitamins one daily
You decide to increase her metformin from 500mg PO twice daily BID to 500mg PO three times daily and her
amlodipine from 5mg to 10mg QD. Her other medications are continued.
Three months later her blood pressure is 166/92, Pulse 78 and glycosylated hemoglobin is 9.2%.
She denies any acute health problems but says she is having a harder time walking and getting around, and has
given up driving after a scary episode where she ran a red light. She is having more financial troubles because
of all the help she is hiring to manage at home. She now has to take taxis to get around, hires a woman to help
her 3 times a week, and is having her groceries delivered.
Case #1 Questions:
1. What are possible explanations for her lack of response to blood pressure and anti-hypertensive therapies?
2. How would you explore this further?
3. How much would this medication regimen cost? What resources would help you determine the cost of
medications?
4. What steps could you take to try to improve her blood pressure and glucose control?
CASE #1 ANSWERS AND DISCUSSION
1. What are possible explanations for her lack of response to blood pressure and anti-hypertensive
therapies?
Students should be able to list:
Worsening disease (DM and hypertension)
She might have gained weight
Dietary indiscretion could increase blood pressure and increase glucose levels
She could have secondary hypertension (renal artery stenosis, sleep apnea, pheochromocytoma try to emphasize that common things are common)
Drug nonadherence
NSAIDs, including COX-2 inhibitors, can sometimes raise blood pressure
How do NSAIDs cause hypertension?
Both diastolic and systolic BP are increased by 6-8 mmHg, most often noted in patients who are already
hypertensive.
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NSAIDs inhibit cyclooxygenease, the enzyme which converts arachidonic acid to prostaglandins (PGE).
 PGE2 inhibits sodium chloride reabsorption in the thick ascending loop of Henle and collecting
tubule. As a result, inhibiting prostaglandin synthesis would increase salt and water retention.
 Prostaglandins also cause vasodilation. Inhibiting prostaglandin synthesis can increase peripheral
vasoconstriction.
*The above mechanisms probably augment hypertension. However, the exact cause of the increase in BP
is not known.
2. Explore barriers to adherence, including:
memory problems
conscious nonadherence (due to side effects, nonbelief in drugs, other assumptions)
costs/lack of prescription coverage
inability to get drugs (might be a factor for this woman who has to take the taxi everywhere)
poor health literacy or numeracy - not understanding how to take drugs
has osteoarthritis and lives alone, could she have difficulty opening the bottle or picking up the
pills?
It is worthwhile spending some time talking about ways to explore adherence, including taking a
nonjudgmental history. “Many people have a hard time remembering to take all of their drugs, is this
ever a problem for you?” “Are there things you do to help yourself remember to take your drugs (e.g.
putting them next to the toothbrush, in a pill box, etc)?” “Do you ever have trouble getting or paying for
your drugs?” Other ways to explore adherence would include having the patient bring in drugs and
describe how they take them, looking at refill patterns, setting up a mediset with pharmacy or visiting
nurse, doing a home visit.
3. How much would this medication regimen cost?
Medication Costs (for one month of medication)
Fluticasone Inhaled BID
Albuterol/ipratropium (Combivent) Inhaler QID
Alendronate 70mg weekly
Metformin 500mg PO BID
Amlodipine 5mg QD
Glynase prestabs 6mg PO QAM
Celecoxib 200mg po QD
Simvastatin 20mg po QD
ASA 325mg po QD
Metoprolol 100mg BID
Fosinopril 10 mg po QD
Calcium carbonate 500mg po BID and Multivitamins QD
TOTAL
$94/inhaler
$74/inhaler
$67
$63
$44.
$40
$80
$136
$5 (not covered by MC-D)
$14
$60
$10 (not covered by MC-D)
$687/month
$8244/year
Pharmacology small group facilitator notes - 5
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What resources would help you determine the cost of medications? Epocrates for handheld devices,
www.drugstore.com, multiple other web sites (see cover sheet)
4. How could you help this woman with a less expensive regimen?
Are there cheaper alternatives (yes, many):
 HCTZ or atenolol rather than amlodipine?
 With mild osteoarthritis, it is quite possible that acetaminophen and/or glucosamine
might be cheaper, safer, and equally effective
 Glynase prestabs TM are a very expensive alternative to glyburide….generic
glipizide or glyburide would be much cheaper (~$10) with no evidence of different
outcomes
Does she qualify for Medi-Cal or other insurance?
Can she get drug samples? (there are some politics here that you may or may not want to explore)
Can you get higher dose pills (sometimes the same price) and split them in half?
Can she shop at cheaper pharmacies?
Other?
What about Medicare D?
Medicare D: The Basics
1. Total the patient’s annual costs. In 2006, the break even point for potential Medicare D enrollees is
about $775. Patients whose annual costs are less are unlikely to benefit from Medicare D, although they
may wish to sign up for a low premium plan to avoid the non-enrollment penalty (1%/month for life, i.e.
a delay in enrollment of 24 months would mean that the patient will pay a penalty of 24% over the
monthly premium.
2. Calculate the out of pocket costs: On the basic plan, the patient is liable for the first $250 of actual drug
costs and then 25% of the next $2000 in actual drug costs for a total out of pocket cost of $750.
3. Coverage gap or “donut hole”: the patient is liable for the next $2850 in actual (not the co-pays) drug
costs or a ‘True Out Of Pocket’ (TROOP) expense of $3600. TROOP is calculated based on the retail
cost of the medications, so patients may benefit from shopping around at discount pharmacies or using
plan-based mail order services. Some more expensive Prescription Drug Plans (PDPs) may provide
coverage in the donut hole. While co-pays and the 25% coinsurance count towards TROOP, costs that
do NOT count towards TROOP include:
 Premiums. Patients must continue to pay premiums even if they are paying full price for
medications.
 Medications purchased from overseas/Canada
 Medications purchased outside the plan (therefore, paying for cheaper medications out of pocket
while in the gap may not be wise)
 Costs incurred for non-formulary medications
 Medications obtained through drug company sponsored prescription assistance plans.
 Most over the counter meds, benzodiazepines, and barbiturates
4. Catastrophic coverage. Once the patient has reached $3600 in TROOP, Medicare will resume coverage
and will pay for 95% of drug costs. On most PDPs, what this translates to is that the patient will resume
paying the usual co-payment.
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In practice, each plan is a little different and it can be very challenging to select a plan. Medicare.gov has a PDP
comparison tool which can be helpful to patients/families who are computer literate. In fact, plans that are
cheaper up front may result in patients spending a longer time in the “donut hole” (see comparison chart)
Reprinted with permission
Mrs. J’s monthly actual drug cost is $672 (not including her OTC meds). Her annual cost for OTC meds
is $180. Her current annual drug cost is $8244.
Basic Medicare D plan:
 $250 deductible
 $32/month average premium
 No coverage for OTCs
 No coverage in donut hole: pt is liable for all of drug costs up to maximum of $3600 in TROOP
Blue Cross Medicare RX Gold plan:
 Monthly Premium
$34
 No Deductible
 No coverage for OTCs ($15/month)
 No coverage in donut hole
 Tiered monthly co-payments for Mrs. BJ’s meds:
o 6 tier 1 drugs
$10 co-pay x 6
o 3 tier 2 drugs
$3 co-pay x 3
o 1 tier 3 drugs
$60 co-pay x1
$60
$9
$60
$129/ mo, not including premiums
Pharmacology small group facilitator notes - 7
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AARP Medicare RX plan:
 Monthly premium:
 Deductible: $250
 No coverage for OTCs
 No coverage in donut hole
 Tiered monthly co-payments for Mrs. BJ’s meds:
o 6 tier 1 drugs
$5 co-pay x 6
o 3 tier 2 drugs
$28 co-pay x 2
o 1 tier 3 drug
$55 co-pay x 1
Plan
A:
Deductible?
B:
Premiums
Basic
$250
$384
(32 x 12)
Blue
Cross
Medicare
Rx Gold
None
$408
AARP
Medicare
Rx
$250
$117.60
C. Pre-coverage
gap co-pays or
coinsurance
(25% on basic
plan)
$500
Time pre-donut
hole:
3.34 months
Time pre-donut
hole: 3.34
months
129 x 3.34:
$430.86
$136 x 3.34:
420.84
$9.80 mo
$30
$56
$55
$136/mo, not including premiums
TROOP
pre-donut
hole:
A+C
D: Cost in
donut hole
Time in donut hole
(until
TROOP = $3600, ie
A + C + D)
Time in
catastrophic
coverage
E: Postdonut hole
costs
Total costs#:
A+B+C+D+E
Potential
annual
savings
$750
$2850
4.24 months
(2850/672)
4.42 months
$148.51
$4132.51
$3931.49
$430.86
$3169.14
4.71 months
(3169.14/672)
3.95
months
$509.55
(monthly copay x 3.95)
$4517.55
$3546.45
$670.84
$2929.16
4.35 months
(2929.16/672)
4.31 months
$586.16
$4303.76
$3760.24
*Costs are only estimates as plans handle months with partial coverage differently—some plans may elect to finish out the month of coverage even if the beneficiary
technically would be in or out of the coverage gap.
#Does not include the out of pocket costs for her OTC meds, which are the same under each plan.
BOTTOM LINE: WITH ANY MEDICARE D PLAN SHE SPENDS ABOUT $4000-4500/YEAR ON
PRESCRIPTION DRUGS, SO SHE SAVES $3500-3900. THE CHEAPEST PLANS MAY NOT BE
THOSE WITH THE LOWEST PREMIUMS OR NO DEDUCTIBLES.
How much you want to get into Medicare Part D is up to you.
Review the learning objectives of Case #1 with students
Case #1 Learning objectives:
1. Recognize medication nonadherence as a possible explanation of lack of therapeutic benefit
2. List common sources of non-adherence
3. Discuss effective methods for exploring nonadherence with a patient
4. Discuss the importance of drug prices as a potential cause of non-adherence, and list strategies for dealing
with this issue
5. (Optional: discuss the larger policy issues surrounding pharmaceutical industry drug pricing, extending
patents, marketing, and Medicare D).
CASE #2
Learning objectives
1. List physiologic changes in elders that impact pharmacokinetics of commonly used drugs
2. Use the MDRD to calculate the decline in renal function with aging, and describe its advantages over the
Cockroft-Gault equation
Pharmacology small group facilitator notes - 8
Johnston
3. Use the “Cockroft-Gault” equation to estimate the decline in renal function with aging and describe
advantages and limitations of this tool
3. Recognize symptoms of digoxin toxicity
Case #2
A70-year-old (white) man with coronary artery disease and congestive heart failure comes in for a regular
appointment. He has been having gradually increasing nausea, anorexia, fatigue, and inactivity over a few
months. He reports no shortness of breath or chest pain. He has been on the same medical regimen for ten years:
Digoxin .125 mg PO QD
Furosemide 40 mg PO QD
Lisinopril 40 mg PO QD
Atenolol 50 mg PO QD
ASA 325 mg PO QD
His weight has declined over the past year from 70kg to 60kg. His creatinine level had been stable over the past
ten years at 1.4, but is 1.8 today. His last digoxin level two years ago was normal at 1.0.
10 years ago
Wt.
70 kg
Cr
1.4
BUN 20
Alb
4.0
Today
60 kg
1.8
32
3.8
Today he appears somewhat thin. BP 140/80, HR 60 and regular, remainder of examination is normal.
Case 2 Questions
A. What changes in pharmacokinetics can you expect to see with aging?
B.
Based on the MDRD equation, what was his estimated glomerular filtration rate 10 years ago and what
today?
C.
Based on the Cockroft-Gault equation, what was his estimated creatinine clearance 10 years ago and what
is it today?
D. Are there any important drug interactions in his regimen?
E.
What are possible explanations for his symptoms?
F.
How would you adjust his medications?
G. (optional) About how much does he pay for his medications every month?
CASE 2 ANSWERS AND DISCUSSION
Question A: What changes in pharmacokinetics can you expect to see with aging?
Elderly people often experience changes in physiology and body composition over time that result in
changes in the pharmacokinetics of specific drugs. Sometimes those changes can result in new problems,
even when a patient has been on the same medications for years.
Students should be able to list some of the changes with aging that might alter pharmacokinetics. First,
they should be able to state that muscle and lean body mass tend to decrease with aging, which results in
a smaller volume of distribution (and higher serum levels) of water soluble drugs such as digoxin.
Pharmacology small group facilitator notes - 9
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Conversely, fat soluble drugs such as diazepam have a larger volume of distribution due to increased
relative body fat. The most important consequence of this is that fat soluble drugs have a longer half life
in older persons.
In addition, renal function tends to decline with aging. This is not universal. On average, about a third
of elders have no significant decline in renal function with aging. Equations such as the Cockroft and
Gault equation can help “guestimate” creatinine clearance based on age, weight, and serum creatinine,
but are not reliable in individual cases.
Changes in hepatic metabolism of drugs are variable. Cytochrome P450 enzyme activity tends to decline
with age, although this is extremely complex, and depends on gender, genetics, the specific enzyme
involved, etc. Conjugation/glucoronidation tends to be less impacted by aging. Hepatic blood flow is
extremely variable and depends in large part of comorbidities.
Question B. The MDRD is a pretty complicated equation, though more accurate than Cockroft-Gault
(though it is only valid only for adults between ages 18 and 70 and includes a modifier for white vs black
race). So it is the best equation to use if you have access to it or a calculator; in the absence of a
calculator, the Cockroft-Gault equation is much easier to perform, though less accurate. I use an online
version of it (there is a brief and extended version of it online).
REF: AS Levey et al. Annals of Internal Medicine 1999; 130: 461-70.
http://www.nephron.com/mdrd/default.html
MDRD
10 years ago
(simple version)
(extended version)
55.6/ml/min/1.73m2
54.9/ml/min/1.73m2
TODAY
32.4/ml/min/1.73m2
39.8/ml/min/1.73m2
Question C: Based on the Cockroft-Gault equation, what was his estimated creatinine clearance 10
years ago and what is it today?
10 years ago: (140 – 60) x 70
72 x 1.4
= 55.5
(140 – 70) x 60
72 x 1.8
= 32.4
Today
So Cockroft-Gault, easier but probably a little less accurate, MDRD probably more accurate, but only
practical with computer/PDA support.
LIMITATIONS: Neither equation is accurate in very advanced age, and both are likely to be inaccurate
in patients with very low or very high muscle mass. It should be emphasized that if a very
accurate Cr Cl is needed, a 24 hour urine sample should be collected.
Question D. Are there any important drug interactions in his regimen?
Pharmacology small group facilitator notes - 10
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Although many patients are able to tolerate this drug regimen, some interactions can occur. First,
digoxin and atenolol can interact to produce bradycardia or AV block. Heart rate and/or EKG should be
closely following when this combination is used. Lisinopril can raise K+, and lasix can waste K+, so
sometimes this combination can be useful in “balancing” K.
Furosemide can cause hypokalemia, which can exacerbate digoxin toxicity. In any patient on furosemide,
particularly in the presence of digoxin, electrolytes should be monitored, and consideration should be
given to replacement of potassium if serum levels are low or borderline.
Furosemide can also induce renal insufficiency if diuresis is overly aggressive. ACE inhibitors can
further contribute to renal insufficiency, particularly when the patient is intravascularly depleted or has
renal artery stenosis.
NSAIDs and ACE inhibitors can interact to affect GFR.
 NSAIDs act on the AFFERENT arteriole. By inhibiting prostaglandins, which dilate the afferent
arteriole, NSAIDs can cause constriction and decreased blood flow through the afferent arteriole and
into the glomeruli.
 ACE inhibitors act on the EFFERENT arteriole. By inhibiting angiotensin 2, which constricts the
efferent arteriole, ACE inhibitors can cause dilation and increased blood flow out of the glomeruli
through the efferent arteriole.
 Possible end result of using NSAIDs and ACE inhibitors: afferent arteriole constriction + efferent
arteriole dilation → ↓glomerular capillary pressure and ↓GFR. It is a similar mechanism as
precipitating acute renal failure when starting ACE inhibitors in patients with reduced renal
perfusion (bilateral renal artery stenosis, volume depletion, etc).
In summary, although this regimen can be safe, heart rate, rhythm, electrolytes, and renal function
should be closely monitored.
(If students have epocrates, they can run drug-drug interactions).
Question E. What are possible explanations for his symptoms?
Hopefully the students will get to digoxin somewhat quickly. Digoxin can have a number of toxicities
associated with it, including many GI complaints (anorexia, diarrhea, nausea/vomiting, weakness), CNS
complaints (dizziness, headache, visual disturbances, confusion), cardiac problems (palpitations,
bradycardia, ventricular ectopy) and miscellaneous (gynecomastia). At higher serum levels, serious
adverse effects can occur and include complete AV block, bradycardia, ventricular dysrhythmias,
delirium, and hallucinations.
Digoxin lowers the heart rate by a combination of direct, indirect, and parasympathetic (vagal nerve)
effects:
In the AV node, digoxin. . .
 decreases automaticity
 increases maximal diastolic resting membrane potential
 longer effective refractory period
Pharmacology small group facilitator notes - 11
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
slower conduction velocity (increased PR interval).
In instances of serious toxicity, Digibind (digoxin immune FAB) can be used (See page 1021 in Katzung).
Try not to focus on the pathology of serious dig cardiac toxicity.
Question F: How would you adjust his medications?
This patient does not necessarily need to be on his digoxin. It could be discontinued or the dose could be
halved. Digoxin can often be discontinued safely, depending on the indication. Recent data suggests that
digoxin might actually be harmful for women with congestive heart failure, and men do not appear to
experience a mortality benefit from digoxin (Rathore S. S., Wang Y., Krumholz H. M.N Engl J Med
2002; 347:1403 2002). For patients with atrial fibrillation who need rate control, clinical considerations
will determine whether digoxin, a beta blocker, or another agent is preferred.
F.
How much does he pay for his medications every month?
Digoxin .125QD
Furosemide 40 mg QD
Lisinopril 40 mg QD
Atenolol 50 mg QD
ASA 325 mg QD
TOTAL
$8.00/month (epocrates)
$3.00/month (epocrates)
$25.00/month (epocrates)
$3.00/month (epocrates)
$1.00/month (epocrates)
$40/month = ~ $500/year
This is a fairly inexpensive regimen, since many of these medications are “old” off patent drugs.
However, even an inexpensive regimen like this one adds up to about $500/year, which can be significant
for an elderly person on a fixed income.
Please review Case 2 learning objectives!
1. List physiologic changes in elders that impact pharmacokinetics of commonly used drugs
2. Use the MDRD to calculate the decline in renal function with aging, and describe its advantages over the
Cockroft-Gault equation
3. Use the “Cockroft-Gault” equation to estimate the decline in renal function with aging and describe
advantages and limitations of this tool
3. Recognize symptoms of digoxin toxicity
CASE #3
Learning objectives
1. Define polypharmacy in the context of appropriate drug prescribing
2. Describe adverse consequences of polypharmacy, including drug-drug interactions, side effects, and a
“prescribing cascade”
3. Discuss the importance of exploring medications as a potential cause of new or unexplained symptoms
Case #3
You are a new intern. Mr. P is an 80 year old who you are just picking up from the finishing resident. He is
here for an acute appointment because his wife says that he became confused and started experiencing visual
Pharmacology small group facilitator notes - 12
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hallucinations two days ago. She denies that he has fever, chest pain, cough, pain, diarrhea, nausea, vomiting,
or any other new or obvious symptoms. His vital signs are BP 150/88, P 64, RR 16. His general examination
is normal. Neurologic examination is significant for cogwheel rigidity and fluctuating mental status. He is
unable to complete a mini-mental state exam because he keeps losing attention.
You review his medical record and find the following:
4 months ago
2 months ago
6 weeks ago
4 weeks ago
2 weeks ago
He is noted to have complaints of GERD and BP of 160/90.
Started on HCTZ 25 mg PO QD and omeprazole 20mg PO QD.
Comes in with gout attack on Right MTP
BP 140/85
No further heartburn symptoms
Piroxicam 20mg QD added
Gout flare is improved
Complaining of more GI distress again
BP again up at 160/90
Metoprolol 25mg BID added.
Omeprazole increased to 40mg PO QD
Referred to GI
GI endoscopy reveals esophagitis and gastritis
Metoclopromide 10mg PO TID added to his regimen.
GI symptoms better.
Exam reveals Parkinsonism
Sinemet 25/300 TID added.
Medication list today:
Piroxicam 20mg po QD
Ompeprazole 40mg PO QD
Metoclopromide 10mg PO TID
HCTZ 25mg PO QD
Metoprolol 25mg PO BID
Sinemet 25/100 TID
Questions
1. Were any medication errors made in this case?
2. Could medications be causing any of his symptoms? Which ones?
3. How could you clean up this mess?
CASE 3 ANSWERS AND DISCUSSION
The students may have to struggle with this one for awhile. You can do this as a group, or to stimulate
discussion, you can ask the students to break up into groups and assign each group to discuss one of the
medications and whether it might be contributing to symptoms in this case. Let them work on this for a
few minutes, then bring them back together, and have them share if any of this patient’s symptoms could
possibly be caused by any of his medications. After they flounder, you may have to walk them through
the case.
Pharmacology small group facilitator notes - 13
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DRUG
HCTZ 25mg PO QD
Omeprazole 40mg PO QD
Piroxicam 20mg po QD
Metoclopromide 10mg PO TID
Metoprolol 25mg PO BID
Sinemet 25/100 TID
POTENTIAL SIDE EFFECTS
Gout, hypokalemia, rash
Headache, diarrhea
GI upset, peptic ulcer, GI bleed, renal insufficiency, allergic
reactions, bronchospasm, can raise BP
Parkinsonism, other CNS effects, mental status changes, seizures
Bradycardia
Confusion, mental status changes
This is an unfortunate, but not all that uncommon scenario, where one drug leads to another, until
there is a “cascade” of medications and medication side effects. When a patient develops new symptoms,
medications should always be suspected. It is possible that most of his problems are due to his
medications. HCTZ could have exacerbated gout. Rather than continuing HCTZ and starting
piroxicam, HCTZ could have been replaced by a beta blocker or another blood pressure agent.
Piroxicam may have contributed to more his dyspepsia and gastritis. Rather than adding
metoclopromide for his esophagitis, omeprazole could have been increased or he could have been tried off
piroxicam. Rather than beginning sinemet, metoclopromide could have been stopped. His confusion is
likely the result of his sinemet.
With all the above changes, it is possible that this patient could be weaned down to only
metoprolol and omeprazole.
Polypharmacy could be defined as:
1. The concomitant use of multiple medications (>5?, >9?)
2. A medical regimen that includes at least one inappropriate or unnecessary medication
3. The use of medications to treat adverse effects of another medication
4. The likelihood of adverse effects from the number of type of medications exceeds the likelihood of
benefit
Review Case 3 Learning Objectives:
1. Define polypharmacy in the context of appropriate drug prescribing
2. Describe adverse consequences of polypharmacy, including drug-drug interactions, side effects, and a
“prescribing cascade”
3. Discuss the importance of exploring medications as a potential cause of new or unexplained symptoms
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