geriatric prescribing and medication reduction in the elderly · understand the cause of adverse...
TRANSCRIPT
Geriatric Prescribingand
Medication Reductionin the Elderly
G EO R G E W. B R E T T M D
C H I E F M E D I C A L O F F I C E R
C A P STO N E P E R FO R M A N C E SYST E M S
Dr. Brett is Chief Medical Officer for Capstone Performance Systems providing expert Medicare Risk Adjustment Services to PACE and similar organizations.
Dr. Brett serves as Vice-Chair of the Clinical Advisory Committee for CareKinesis – a PACE-centric medication management and distribution pharmacy.
Capstone Performance Systems and Carekinesis are members of Tabula Rasa HealthCare.
Disclosures
Understand the Seriousness of Polypharmacy in Frail Elderly
Understand the cause of Adverse Drug Events (ADE’s)
Learn about strategies to minimize number of medications being taken by the elderly.
Purpose of this Session
5
Joyce Hesselberth New York TImes
“All substances are poisons; there is none which is not a
poison. The right dose differentiates a
poison from a remedy.”
Paracelsus
(1493-1541)
Occupation: alchemist, physician,
astrologer, and general occultist
6
“The administration of more medicines than are clinically indicated, representing unnecessary drug use”
(Montamat 2004)
Often Defined as using > 5 Medications.
Polypharmacy: A Serious Threat to the Elderly
Prevalence of PolypharmacyDefined as > 5 prescription Medications
2000: 8.2%
2006 Medicare Part D
2012: 15%
Biggest Increase: Antihyperlipidemics, Antidepressants, PPI’s, and Muscle Relaxants.
JAMA. 2015;314(17):1818-1830
9
Polypharmacy doesn’t start and end with your Prescriptions
42% of Patients don’t tell the Provider about the Complementary and
Alternative Medicines they were using (CAM)
JAMA Intern Med. 2016;176(4):545-546
10
My Pet Peeve….
Where was it written
That when a person turns 65 years old
11
My Pet Peeve….
Where was it written
That when a person turns 65 years old
That what arrives in the mail
Is their Medicare Card
12
My Pet Peeve….
Where was it written
That when a person turns 65 years old
That what arrives in the mail
Is their Medicare Card
And
Their First Prescription for Omeprazole?
13
Chronic Use of PPI’s isassociated with
1. Osteoporosis
2. Hip Fractures
3. Clostridia Dificile Colitis
4. Community Acquired Pneumonia
5. Dementia1. Based on mouse studies, reason felt to be an increase
in Beta Amyloid in the Brain
14
JAMA Neurol. 2016;73(4):410-416
PRACTICAL: More Drugs = higher costs = Risk of outspending the Part D Bid
QUALITY: Maintaining compliance with CMS Prescription Drug Benefit Manual:
Chapter 9 – Part D Program to Control Fraud Waste and Abuse
PATIENT CARE: More Drugs = Adverse Drug Events
Polypharmacy…. What’s the big deal?
Scope of Polypharmacy
40% of Community Dwelling elders take 4-9 medications per day
20% of Community Dwelling elders take 10 or more medications per day.
Older adults are seven times more likely to have a hospitalization for a adverse drug event than younger persons
NEJM; 365:2002-12
Scope of Polypharmacy
• Sheer number of medications being taken“Shock and Awe”
• Drug – Drug Interactions
• Medication Adherence
• Cost to Participant.Co-PaysCoverage Gap: Refills fall off at the end of the year.(Not an issue for PACE Participants)
Coumadin 9mg dailySynthroid 88 mcg dailyMiralax 17 gms dailyBeano 5 tabl po TIDKCL 20 meq TIDMag Oxide 400 BIDFloranex 1 tab QIDFlomax 0.4 BIDProscar 5 mg dailyArmodafinil 300 dailySenna 2 tablet dailyMiacalcin I spray dailyNorco 5/300 q 4 hr prnVoltaren Gel 1% QID
Protonix 40 mg dailyReglan 10 dailLactase 3 tab TIDAndrogel 1 pakt topically dailyZetia 10mg dailyCardizem 300mg dailyAtenolol 25 mg dailyOscal w D 1000 dailyAlphagan 0,1% 1 gtt BIDAtorvastatin 40mg dailySingulair 10mg HSDuoNebs inhaled QIDColace 200 mg BIDHumalog SQ TIDLevemir SQ BIDZofran 4 mg q4 hr prn
“Shock and Awe”78 yr old man admitted to our local Nursing Home 4/18/2014
Adverse Drug Events (ADE’s)
Any new symptom or sign
in the elderly,
should be considered to be a Adverse Drug Reaction
until proven otherwise
BMJ 1997; 315: 1096-99
Adverse Drug Events
RISK OF ADVERSE DRUG EVENTS:
◦2 Medications: 13%
◦5 Medications: 58%
◦7 or more Medications 82%
Interventions to Improve the Appropriate Use of Polypharmacy for Older People
The Cochrane Library 2012 Issue 5
In-Patient Care Setting:◦ Affects 2,000,000 hospitalizations a year
◦ Increases Length of Stay by 1.7 – 4.6 days
◦ Quality of life during that hospital stay?
Out-Patient Care Setting:◦ Causes over 3,500,000 Office Visits
◦ Causes 1,000,000 Emergency Room Visits (Underestimate)
◦ Causes 125,000 Hospital Admissionshttp://health.gov/hai/ade.asp
Impact of Adverse Drug Events
During the 45 Day Post Discharge Window◦ Adverse Drug events (ADEs) occurred frequently
◦ More than half occurred within 14 days
◦ ADE’s occurred in ONE IN FIVE Discharges
◦ One Third of the ADE’s were preventable
◦ The more severe events were the most preventable
◦ Only a “small portion” of the identified ADE’s were the result of medications on the Beer’s List
JAGS 61: 1894-99, Nov 2013
Post-Hospitalization and ADE’s
“Start Low, Go Slow”
“My Clinical Experience”
Drug - Drug Interaction Tables
Beers Criteria, (and presumably STOPP)
“ADEs are common and often preventable in older adults…Beers criteria medications play a small role in these events, suggesting that efforts to improve quality and safety of medication use…must extend beyond a singular focus on Beers criteria medications.”
Kanaan et. al: J Am Geriatric Society 61:1894 – 1899, Nov 2013
Current Tools to Avert ADE’sDon’t Work
Problems with PHARMACOKINETICS:
What your body does to the drug
Problems with PHARMACODYNAMICS:
What the drug does to your body
Problems with ALLERGIES
Cause of Adverse Drug Events
Problems Arising from Problems with Pharmacokinetics
Nearly half of hospitalizations for ADE’s involved adults ≥80 years of age, which was 3.5 times as high as adults 65-69 years of age…“Two Thirds of these hospitalizations were due to Unintentional Overdoses.”
Budnitz DS et al. Emergency Hospitalizations for ADE’s in
Older Americans. NEJM 2011; 365: 2002-12
Adverse Drug Reactions
Participant Adherence? Perhaps to some degree
Pharmacokinetics“What your body does to a drug.”
Whole purpose of “drug metabolism” is to water-solubilize the drug so it can be excreted
Why Unintentional Overdoses?
Medication Changes and Adverse Drug Events: Patient Errors
•Patient Related Errors leading to ADE’s
•Cohort study of over 30,000 Medicare enrollees.
•Reasons for Adverse Drug Reactions•Modifying the Medication Regimen: 41.9%• Administering the medication (31.8%)
• Failure to follow clinical advice re: medication use: 21.7%
J. Am Geriatric Soc 2007:55:271-276
Participant Adherence?
Perhaps to some degree
Pharmacokinetics“What your body does to a drug.”
Whole purpose of “drug metabolism” is to water-solubilize the drug so it can be excreted
Why Unintentional Overdoses?
Pharmacogenomics:
Are the Drug Metabolizing genes from Parents functional? Nonfunctional?
Competitive Inhibition:
Genes are functional, but multiple drugs are vying for it simultaneously
Up/Down Regulation:
Gene is functional, but another drug is inducing more gene to be produced or inhibiting its use
Impaired Renal Function
Pharmacokinetics and Unintentional Overdoses leading to ADR’s
Pharmacogenomics
Currently, there are 58 known Cytochrome P-450 enzymes (CYP’s) that are known to metabolize drugs.
Only a handful are clinically significant
60-70% of Drugs are metabolized by◦ CYP2C9, CYP2C19, CYP2D6, and CYP3A4
That is fine if the CYP’s are functioning….but what if there are mutations to these enzymes that are responsible for eliminating drugs from the body?
As with all proteins (enzymes) DNA codes for the production of all the CYP’s.
Most frequent error events are Single Nucleotide Polymorphisms (“SNP’s”).
These SNP’s can lead 3 Metabolic Phenotypes◦ Poor Metabolizers◦ Extensive (Normal) Metabolizers◦ Ultra-Rapid Metabolizers
Inheriting two SNPs that code for fast metabolism of CYP3A4 can lead to devastating consequences when taking codeine which would then be highly converted to morphine
Pharmacogenomics
30% of the population have mutations of the genes that code for CYP2C19 making them poor/slow metabolizers
Clopidogrel needs CYP2C19 to be converted to its active form
Therefore 30% of your participants receiving Clopidogrelare not benefiting from its effects?
If you don’t test, how are you to know?
Pharmacogenomics:
Each Drug needs one CYP to be metabolized.
What if Multiple Drugs taken at the same time are metabolized by the same CYP? Which one gets metabolized? Which one “wins?”
The drug with the highest Affinity Coefficient for the CYP.
Other Meds are left behind Toxic Levels ADE’s
Competitive Inhibition
Isoenzyme conceptCYP Substrates Inhibitors Inducers
1A2 Theophylline, caffeine, imipramine, mexiletine
Quinolones Cigarette smoking
2A6 Coumarin, nicotine Diethyldithiocar-bamate
2C9 NSAID, losartan, irbesartan, S-warfarin, celecoxib
Sulfaphenazole Rifampin
2C19 Omeprazole, R-warfarin
2D6 Codein, antiarrhythmics, b-blockers, anti-H1, SSRI
Quinidine
2E1 Alcohol, chlorzoxazone Alcohol
3A4 CCB, anti-H1 2nd, BZD, cyclosporin, HMG CoA
Macrolides, imidazoles
Rifampin, phenytoin
Affinity conceptCYP3A4
Inhibitors Substrates Inducers
DRUG – DRUG INTERACTIONS
Greater than 80% of Drug - Drug Interactions involve the Cytochrome P-450 System (CYP)
Analysis based on multiple 2x2 Comparisons is obsolete and often inappropriate
There are now software/tools developed to predict the correct dose to start at in a Poly-Medicated Participant
How Prescribing is EvolvingPreference Precision
Preference Based Era Evidenced-Based Era Precision Based Era
The Clinician’s Best Insight
The Clinician’s Best Insight
Population-basedAlgorithms.
Clinical Trials in Selected Cohorts
The Clinician’s Best Insight
Population-based Algorithms
AndIndividualized
Genomic information
andPatient - Specific
Criteria
Drugs’ Anticholinergic Burden
is
A Huge Risk to the Elderly
And these drugs are EVERYWHERE including OTC’S
Pharmacodynamics and ADE’s
Falls
Delirium
Drowsiness, Dizziness
Cognitive Impairment
Impulsive behavior
Constipation
Urinary Retention
Tachycardia, arrhythmias, increased angina
Decreased sweating – Hyperthermia
Mydriasis – Vision blurs leading to falls
Dry Eyes
Dry Mouth – Dental issues, teeth extraction
Tremors
Anticholinergic Effects of Medications
There is less Acetylcholine in the brain with aging
Poorer Drug Metabolism
Increased Permeability of the Blood Brain Barrier
Older Participants More Sensitive to Anticholinergic Effects
AGE (years) PREVALENCE
60 – 75 27%
≥ 75 90%
Drugs Aging 2013; 30: 321-330
Anticholinergic drugs are given to those who are most sensitive
to their adverse effect
Developed by Dr. Malaz Boustani, Indiana University for Aging Research ◦ 0 = No Anticholinergic Burden◦ 1 = Mild Anticholinergic Burden (e.g. Atenolol, Furosemide)◦ 2 = Moderate Anticholinergic Burden (e.g. Carbamazepine)◦ 3 = Severe Anticholinergic Burden (e.g. Amitriptyline, Quetiapine)
Score of 2: “Clinical Anticholinergic Effect” (e.g. Delirium)
Score of ≥3: “Clinically Impactful” (e.g. falls)
The effect of each drug’s ACB is CUMULATIVE
The higher the ACB score, the higher the adverse events.
Aging Health. 2008;4(3):311-20
Anticholinergic Cognitive Burden Scale (ACB)
Anticholinergics andCommunity Acquired Pneumonia
Population Based Study.
Age: 65 – 94
1,039 Cases of Pneumonia◦ 59% Occurred with Acute Use (Rx within 90 days of event)◦ 35% Controls
◦ 53% Occurred with Chronic Use (3 or more Rx within year)◦ 36% Controls
J Am Geriatr Soc. 2015 Mar;63(3):476-85.
Retrospective Cohort Study (Australian VA)
Admissions for Confusion◦ Drugs included if ACB ≥2◦ Excluded those with known dementia
If on two Anticholinergic Medications ◦ Adjusted Incident Rate Ratios(IRRs) 2.58
If on three or more Anticholinergics◦ Adjusted Incident Rate Ratios (IRRs): 3.98
Anticholinergics and Hospital Admissions for Confusion or Dementia
JAGS 62:1916 – 22, 2014
“Cumulative Use of Strong Anticholinergics and Incident Dementia”
Participants >65 years of age on anticholinergics
Mean follow-up was 7.3 years
23.2% developed dementia (79.9% was Alzheimer’s)
The higher the anticholinergic exposure the higher the risk◦ (Total Standardized Daily Dose “TSDD”)
JAMA Intern Med. 2015;175(3):401-407.
Anticholinergics NowAssociated With Dementia
Scope of Polypharmacy
• Potentially Inappropriate Medications
Beer’s Criteria Potentially Inappropriate Medications in Elderly
• Potentially Inappropriate medications because of• Drug-Disease interaction
• Drug –Syndrome interaction
• Leads to exacerbation of Disease or Syndrome
• Potentially Inappropriate Medications to be used with caution in the elderly
Scope of Polypharmacy
“Under-prescribing”◦ Participant who has polypharmacy is less likely to be prescribed a
much needed medication than participant taking 4 or less medications
Drugs Inhibiting other Drug’s Activation.◦ Different form of “Drug-Drug Interaction◦ Omeprazole and Clopidogrel
◦ Inhibition of CYP2C19 prevents Clopidogrel from being converted to its active form
◦ Paroxetine/Fluoxetine and Tamoxifen◦ Inhibition of CYP2D6 prevents Tamoxifen from being converted to its active
form, Endoxifen
Polypharmacy and Underprescribing
The more drugs a participant takes, the more likely an indicated prescription will not be prescribed
Br J Clin Pharmacol. 2008 Jan; 65(1): 130–133
Polypharmacy and Risk of30 Day Hospital Readmission
JAMDA 2013, Vol14. No 10; p761-67
What I’m saying is
We prescribe with precious little information about what is going to happen to that medication (pharmacogenomics, competitive
inhibition, pharmacodynamics issues)
andits effect after mixing with, on average, 10 other medications that
the PACE participant takes….
When we write prescriptions, do we really know what we are
doing?
Prescribing in the ElderlyUnique Challenges:
◦Pre-marketing drug trials exclude elderly participants
◦Approved doses may not be appropriate for the elderly.◦ Special Pharmacokinetics:◦ Absorption, Distribution, Metabolism, Excretion
◦ Special Pharmacodynamics:◦ Physiologic Effects of the Drug
◦ Fraility:◦ What percent of participants have normal albumin?
“People in Clinical Trials don’t look like people
who take drugs”
Quote: Jerry Avorn, MD
Cerreta F et al. N Engl J Med 2012;367:1972-1974.
Polypharmacy: Who cares?
Medicare Part D: Fraud Waste and Abuse
Cost: PACE is a Medicare Part D Plan◦ Capitated payment through a “bid” process◦ PACE is therefore at risk for drug expenditures
Participant Adherence: Drug Misadventures◦ The more medications…◦ The more Different Schedules…◦ Equals the more mistakes in dosing◦ If a lower dose of med isn’t working, is it because a higher
dose is needed, OR because the participant was not taking it?
Etiology of Polypharmacy
Fear of Discontinuing Medications
Medications added to treat acute illness during hospitalization Continued upon discharge Not needed, or not needed in as high a dose Hospital Formulary Switches over home meds.
Care Delivery by Multiple Physicians Participant bounces from specialist to specialist each adding their specific Rx to the mix Each Specialist adding meds per their Clinical Practice Guidelines
Transitional Care: Poor Medication Reconciliation Major reason for 30 Day Readmission Rates
Etiology of Polypharmacy
Medication Prescribing CascadeNew drug prescribed to treat old drug’s side effects
Sharing of Medications and DiversionNo “short fills” for Narcotics
Use of Over the Counter Medications
Adherence to multiple Clinical Practice Guidelines
Prescribing Cascade
UpToDate
Etiology of Polypharmacy
Fear of discontinuing Medications◦ Physicians love to prescribe medications, hate to
discontinue medications◦ Wasn’t a good “Doctor Visit” if they left without a new Script!
◦ Lack of information as to why it was prescribed◦ “There must have been a good reason to Rx it.”
◦ Belief that the condition for which it was prescribed still exists today.◦ PPI’s for GERD or PUD
◦ Atypical Antipsychotics for dementia related behaviors
Etiology of Polypharmacy
Fear of discontinuing Medications ◦ Belief that discontinuing a medications will lead to
catastrophic events◦ Stopping isosorbide will cause an acute MI
◦ Stopping furosemide will lead to flash pulmonary edema.
◦ Participant who has donepazil restarted will not return to the functional level achieved before discontinuation.
◦ It was prescribed by a “specialist” who is “THE EXPERT” in the treatment of given disease entity.
Useful Tools to Potentially Identify Inappropriate Medications:
1. Beers Criteria
2. NCQA/HEDIS High Risk Medications
3. START/STOPP Criteria
Beers Criteria
Initially published in Archives Int. Medicine in 1991 by Mark Beers MD et al.
List of inappropriate medications in the Nursing Home Population (initially)
◦ Use for Quality Assurance Review
◦ Health Services Research
◦ Clinical Practice Guideline development
In 2011, AGS assumed responsibility for updating and revising Beers Criteria
Revised in 1997, 2003, 2012, and November 2015
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Beer’s Criteria 2015
1. Drugs that are Potentially Inappropriate
2. Drugs that are Potentially Inappropriate 1. Drug/Disease Interaction
2. Drug/Syndrome Interaction
3. Drug/Drug Interaction (new in 2015)
3. Drugs that should be used with Caution
4. Drugs whose dosage should be modified in the presence of renal impairment (new 2015)
JAGS 63:2227-2246
New to Beers 2015: Drug-Drug Interactions
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New to Beers:Dosage Adjustment in Renal Impairment
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Sample: Beers Criteria 2015
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START STOPPAge and Ageing 2007; 36:632-638
Int.J Clin Pharmacol Ther 2008;46 (2):72-83
START:◦Screening Tool to Alert doctors to the Right
Treatment
STOPP:◦ Screening Tool of Older Persons Potentially
Inappropriate Prescriptions
START/STOPPMore recent than the Beer’s Criteria
Organized by physiologic systems
References the following:◦ Drug – Class Duplication◦ Drug-Drug Interactions◦ Drug-Disease Interactions
Addresses Under-treatment of the elderly
START (n = 22)
STOPP (n = 65)
Stopping Medications “Comission versus Omission?”
If a Provider can prescribe a medication to treat a condition not fearing a possible adverse drug event, (e.g. a rash), knowing they will discontinue the medication should it occur…..
Why then….does a prescriber fear stopping medications (e.g. digoxin) when a frail elderly participant is having anorexia and weight loss over concerns of precipitating CHF or rapid Atrial Fibrillation knowing to restart if symptoms develop?
Risk of Discontinuing Medications.
Broad based studies on the subject are limited
26% of drug discontinuation resulted in worsening of the underlying disease state◦ Recurrence of angina◦ Re-elevation of blood pressure
4% were associated with withdrawal reaction◦ Beta-Blockers◦ Benzodiazepams
Arch. Int. Med 1997: 157:2205-2210
Discontinuing Medications
Tapering of medication preferable
Exceptions include◦ Dangerous signs or symptoms attributable to drug
◦ Clinical Inertia in the participant
◦ Future opportunities for drug modification limited
Rule of thumb:◦ Drugs can be tapered at the same rate at which they were
titrated up upon initiation.
Discontinuing Medications
Common Drugs Requiring Tapering◦ Opioids
◦ Beta-Blockers
◦ Clonidine
◦ Gabapentin
◦ Serotonin Uptake Inhibitors
◦ Serotonin-Norepinephrine Uptake Inhibitors
◦ Tricyclic Antidepressants
Strategies for Medication Reduction
Take time at Reassessment for critical review of all medications
Ask the participant if he/she would like their medication burden decreased.◦ Ask the participants if they feel they are taking too much medication.◦ You may be surprised!! Not everyone is in love with their medications
Be positive: Let the participant know that medication reduction will likely make them feel better
Reassure that you are looking out for exacerbation of symptoms and that the medication will be restarted in necessary
Strategies for Medication Reduction
What is the participant’s prognosis?
Is the medication really in keeping with the participant’s Goals of Care?◦ Is Medication burden an issue for someone in the functional or
palliative pathway.
◦ Is the medication appropriate given the participant’s overall prognosis?
Is the medication’s “time to benefit” such that it is unlikely to help a participant with perhaps limited life expectancy?
Strategies for Medication ReductionCheck for evidence of adherence. If not being used, why prescribe the medication?
◦ Are there several Salmeterol/Fluticasone (“Advair”) inhalers unused in the house?
◦ Are the number of pills remaining in the vials matching the refill date?
◦ Does the participant admit to not taking certain meds?
◦ For those participants on narcotics, has a random urine drug screen been done to rule out diversion?
78 y.o. Caucasian female admitted to the ACME PACE Program. She lives alone in a low income senior housing. She smoked 1 PPD for 40 years. She gets Meals on Wheels, and needs assistance with bathing and cueing for dressing. She walks with a walker and has occasional falls. Daughter comes by to check on her and pay her bills and take her shopping.
PMH: T.I.A. 2005, COPD, Diabetes Mellitus with neuropathy and occasional falls, Peripheral Arterial Disease, Venous Insufficiency, Hypertension, Major Depression with anxiety neurosis, and remote history of an M.I. She has mild dementia. She has incontinence and wears briefs.
She is in the Functional Pathway
Case Study
Vitals: BP=115/72: Pulse 52: RR=18:Temp 98.4: Wt. 108 lbs.
BMI: 18.9
General: Thin, frail and slightly disheveled in appearance.
HEENT negative. Carotids with soft bruits.
Chest with diminished breath sounds, but no wheezing or rhonchi. FVC normal. Cor: RRR without murmurs. Abdomen without masses. Ext +2 Edema. Absent peripheral pulses.
Neuro: diminished monofilament testing and positive Rhomberg.
She was oriented to person but not place nor time and exhibited recent memory impairment.
Case StudyExam
Hgb/Hct: 11.5/34%, WBC = 8,800, Plts = 230k
BUN/Creat = 36/1.3: Na+ = 130
GFR(Cockcroft-Gault) = 31ml/min
Hemoglobin A-1c = 7.1
LDL Cholesterol = 68
ALT = 65
AST = 38
Alk. Phos. = 101
Case StudyLaboratory Studies
1. Lisinopril 10 mg po daily
2. Amlodipine 5 mg po daily
3. Glyburide 5 mg po BID
4. Metoprolol 25 mg po BID
5. Metformin 500 mg po BID
6. Pregabalin 50 mg po BID
7. Aspirin 81 mg po daily
8. Lasix 20 mg po daily
9. Gabapentin 300 mg po QID
10. Timoptic ophth. drops
11. Fluticasone/Salmeterol 100/50: one puff BID
12. Clopidogrel 75 mg po daily
13. Donepezil 10mg po daily
14. Oxybutinin 5mg BID
15. Lorazepam 0.5 mg po TID
16. Spiriva DPI 18 mcg daily
17. Albuterol MDI Rescue inhaler
18. Nortriptyline 75 mg po daily
19. Lantus 10 units daily
20. Citalopram 10mg po daily
Case Study: Medications
•Does she need Lantus? Only 10 units a day?
•Should she be on Metformin? Has Stage IIIb CKD
•Does she need to be on Amlodipine? 1. Maximize one or the other antihypertensive meds2. Here, with DM and CKD, would maximize the ACEI
3. What is the target BP? Her BP is low and she is falling.
•Does she need both Gabapentin and Pregabalin?• How do you really know either is working?
•What is the Nortriptyline prescribed for? 1. Anticholinergic and has dementia2. Anticholinergic and incontinent despite the Rx3. If for neuropathy, already on 2 other meds for same.
Case Study Comments
•She is already incontinent but using Depends. • Is the Oxybutinin effective? Could dose be decreased?• Is her incontinence that much worse off the medication?• She is already demented!• What’s it doing to olfaction and importantly gustation? (Malnutrition?!?)
•Reason for Furosemide?• No history of CHF.• Not indicated for treating venous insufficiency
•Is Fluticasone needed with Salmeterol?• Already on Tiotropium. • Can she use the DPI correctly? Did anyone observe?
•What is the rationale for both ASA & Clopidogrel?• Even if “indicated.” She is falling. Risk for hemorrhage?
Case Study Comments
•Is there a need for Donepezil?• Did the family note improvement in cognition when it was started?
• She is possibly malnourished. Is it contributing to nausea/anorexia?
•Why on Glyburide?• GHB is 7.1. NPA Model Practice for DM would suggest maintaining
between 8-9.
• It is contraindicated in CKD
• Glipizide dose adjusted is more appropriate if needed.
•Does she need Lorazepam 0.5mg TID?• Can it be made prn? Can the dose be gradually reduced.
• She has history of falls.
Case Study Comments
Can the Metoprolol be weaned or dose reduced?◦ Resting pulse is 52.
◦ If for angina, has she been symptomatic? Is she active enough to get angina?
◦ If for BP, then, again, what is the target BP in this case?
◦ Also receiving Timoptic Ophthalmic drops = Beta Blocker as well
History of Depression on Citalopram.◦ Has she ever stopped taking her medication?
◦ Has a previous provider ever attempted to wean her off?
Case Study Comments
Participant Adherence:
Do we have any idea if she is taking her medications,
If so, is she taking them correctly?
Is she missing any doses?
Is she taking extra doses forgetting she already took her dose for the day?
Case Study Comments
96