Download Medication Use Resource Module

Medication Use
Resource Module
CASE 1
RC is a 78 year old white female brought to your clinic by her two daughters with the chief concern that
“she is on too many medications”. She has been seeing a number of different providers in recent months
with a variety of complaints. A large number of new medications have been added to her regimen by
different doctors, but she has no primary physician to look at the whole picture. Her daughters are
worried that she is overmedicated. They admit that that RC has a lot of physical complaints and ailments
for which she frequently seeks medical care.
RC complains that she has been feeling bad lately. Her balance is impaired and she has had 2 falls in the
past month, resulting in minor bruises and cuts but no fractures. Her daughters have noted a decline in
her cognitive function lately, with increased confusion and forgetfulness. She complains of insomnia and
has been sleepy during the day. She admits to feeling depressed. She reports dizziness but cannot
characterize it further. There also has been a recent decline in her eating and she complains of nausea,
anorexia, and constipation. She has just completed a 10 day course of Erythromycin for a respiratory
infection.
Her medical problems are: HTN, DM, hypercholesterolemia, CHF with EF of 40%, back pain from
degenerative disk disease, depression, anxiety, GERD, rhinitis, urinary incontinence, mild dementia with
MMSE of 24.
Her medication list: Aspirin 81 mg qd, HCTZ 25 mg qd, Lisinopril 20 mg qd, Coreg 12.5 mg bid, Digoxin
.125 mg qd, Lasix 40 mg qd, KCL 20 mEq qd, Zocor 40 mg qd, Glipizide 10 mg po qd, Zoloft 50 mg qd,
Valium 5 mg bid, Darvocet N100 tid, Ditropan XL 10 mg qd, Prevacid 30 mg qd, Aricept 10 mg qhs,
Flonase 2 sprays each nostril qd, Allegra 60 mg bid, Vit C 500 mg qd, Vit E 400 iu qd, Vit B complex qd,
Ginkgo biloba tid, Benadryl 25 mg hs for sleep.
On exam she is a thin older woman who appears mildly lethargic. Wt=124, Pulse=72, Resp=20, BP lying
= 126/70, BP standing = 100/64. Lungs are clear to ausculatation, no JVD. Heart is regular without
gallop or murmur. Abdomen is nontender, no masses. Extremities are without edema.
Repeat MMSE today is 18/30.
QUESTIONS
1)
2)
3)
4)
5)
6)
7)
8)
9)
What factors contribute to her ending up on so many medications?
What medication is the most likely cause for her nausea and anorexia?
Which medications increase her risk for falls?
Which medications may adversely affect her cognitive function?
Which medications could cause her orthostatic blood pressure drop?
Which medications are most likely aggravating her constipation?
Which medications would you discontinue due to adverse effects, inappropriate choice of
medication, or duplication of therapy?
Which medications are noncritical and might be reasonable to discontinue to simplify the drug
list?
Which medications are most essential to continue?
ANSWERS TO QUESTIONS
1) Her risk factors for polypharmacy are multiple medical problems, multiple doctors, and multiple
somatic complaints.
2) Her nausea and anorexia are worrisome for Digoxin toxicity. The recent course of Erythromycin
probably increased her Digoxin level.
3) Medications with psychotropic or sedative effects may increase fall risk: Valium, Darvocet N100,
Benadryl, and Zoloft. The medications contributing to orthostasis may also increase fall risk –
see below.
4) RC has had a significant decline in her MMSE score from 24 to 18, suggesting some acute cause.
She is on several medications that may adversely affect cognition, including Valium, Darvocet
N100, Ditropan, and Benadryl.
5) Medications with antihypertensive effects or diuretics may cause an orthostatic drop in blood
pressure. She is on Lisinopril, Coreg, Lasix, and HCTZ.
6) Ditropan and Benadryl cause constipation from their anticholinergic effects. Narcotics such as
Darvocet N100 cause constipation. The diuretics, Lasix and HCTZ, may cause volume depletion
and contribute to constipation.
7) The following medications should be discontinued:
1. Digoxin – patient having signs of toxicity. There is a small risk of CHF exacerbation with
discontinuation of Digoxin (Packer, M et al. Withdrawal of Digoxin from Patients with
Chronic Heart Failure Treated with Angiotensin-Converting-Enzyme Inhibitors. NEJM
1993; 329: 1-7)
2. Valium – has a very long half-life in the elderly, causes sedation and increased risk of
falls and fractures.
3. Darvocet N100 – weak analgesic but with narcotic side effects of sedation, constipation,
and may be affecting cognition.
4. Ditropan – anticholinergic effects may contribute to constipation and cognitive
deterioration. Disadvantages outweigh benefits for urinary incontinence in this case.
5. Benadryl – sedating and has anticholinergic effects. Generally should avoid as a sleep aid
in the elderly.
6. HCTZ – duplication of therapy, patient is on two diuretics and may be causing volume
depletion, orthostasis, effects on mental status. May also consider stopping the Lasix and
Potassium temporarily until volume status and orthostasis are improved, but need to
monitor CHF status carefully for exacerbation.
7. Ginkgo Biloba – minimal effectiveness
8. Could simplify vitamin regimen – stop Vit C, continue Vit E for dementia. Many seniors
taking a variety of different vitamins and number of pills can be reduced by taking a
single good multivitamin.
8) The following medications are noncritical and could try patient off them if the conditions for
which they were prescribed are not that active or symptomatic at present:
1. Prevacid for GERD
2. Allegra and Flonase for rhititis
9) These medications are important to continue:
1. Lisinopril and Coreg for CHF – improve survival in patients with heart failure and LV
systolic dysfunction.
2. Zocor – reduces risk of vascular events
3. Glipizide – needed for management of diabetes
4. Aricept – delays deterioration of Alzheimer’s disease
5. Zoloft – patient needs to be evaluated for depression after
mental status improved from adverse effects of other meds. May benefit from an
increase in Zoloft dose.
CASE 2
AH is an 86 year old woman with hypertension, osteoarthritis, and urinary incontinence who presents to
your clinic as a new patient for medical evaluation. She reports no history of heart problems and has had
no complaints of chest pain, palpitations, or shortness of breath. She does report a fall one month ago
when she lost her balance when she went outside to retrieve her mail. She has had some mild
forgetfulness and occasionally may miss her medications.
Her current medications are HCTZ 25 mg qd, Norvasc 5 mg qd, Celebrex 200 mg qd, and Detrol LA 4 mg
qd.
She lives in her own one-story home. Her daughter and son live nearby and check on her regularly. The
patient does not drive.
On examination, her Wt=156, Pulse=80 and is irregular, Resp=16, BP=126/70. Lungs are clear. Heart is
irregularly irregular without murmur. Abdomen is soft and nontender. No edema in legs. Gait shows
some mild imbalance and increased path deviation, no gross ataxia and Romberg’s is negative. MMSE
score is 25/30.
EKG confirms that rhythm is atrial fibrillation.
QUESTIONS
1)
2)
What are the pros and cons of starting coumadin in this patient?
Do the benefits outweigh risks and would you start coumadin?
The benefit of starting coumadin is reduced risk of stroke from the atrial fibrillation. Potential concerns
are gait imbalance/fall risk and mild forgetfulness. However, these problems do not seem severe enough
to necessitate withholding anticoagulation. The patient is started on coumadin and her family agrees to
assist with monitoring medication compliance and provides transportation to visits for PT/INR checks.
She has been on a stable dose of coumadin for 4 months when she returns to your office with symptoms
of urinary frequency and dysuria for 2 days. Urinalysis shows positive nitrite and leukocyte esterase and
microscopic exam has 50+ WBCs. Urine culture is pending. You decide to empirically treat for a UTI
pending culture results.
QUESTION
1)
What antibiotics could you prescribe to treat the UTI that would not affect the PT/INR?
Trimethoprim/Sulfa would not be a good choice because it can significantly alter the PT/INR. Quinolones
like Ciprofloxacin may occasional affect the protime, and if it is used the patient needs close monitoring.
Nitrofurantoin does not interact with coumadin and is a reasonable choice. Penicillins do not alter the
protime but often may not provide adequate antimicrobial coverage.