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5 - Adverse Drug Events, Polypharmacy, and Medication Management |
107
Inappropriate Medications
The second form of suboptimal drug use is
inappropriate medication.
3,8-10
In 1991, a set
of explicit criteria were developed via Delphi
survey of U.S. geriatric experts that is commonly
referred to as the Beers criteria.
11
These explicit
criteria have subsequently been updated three
times; the most recent is an evidence-based
approach supported by the American Geriat-
rics Society for drugs to avoid (also commonly
referred to as high-risk drugs) and drug–disease
interactions.
12
Various U.S. and non-U.S. groups
have adopted some specific criteria for use as
quality indicator measures in various popula-
tions of elders. Table 5-1 shows a list of high-
risk drugs planned to be used as quality indi-
cators by the National Committee for Quality
Assurance (NCQA) based in part on the Beers
criteria.
13
Notable additions to the high-risk
drug list include glyburide and megestrol, two
medications not previously included in earlier
iterations of these criteria. Glyburide has been
shown to have an increased risk of severe and
prolonged hypoglycemia, whereas megestrol
has been shown to have an increased risk of
thrombotic events.
12
Previous studies evaluating
prescribing patterns of potentially inappropriate
medications (not including these new additions)
showed that between 12.3% and 21.5% of older
outpatients received one or more high-risk medi-
cations.
14,15
Drugs that can potentially exacer-
bate three common diseases in older adults
(i.e., dementia, history of falls or fractures, and
chronic kidney disease) were also selected by
NCQA as quality measures. Table 5-2 shows the
drug–disease interactions proposed for 2014,
with the only notable addition being anticonvul-
sants in those with a history of falls or fractures.
16
Previous studies using these criteria (excluding
the anticonvulsant/falls or fracture interaction)
reported that the prevalence of drug–disease
interactions was 15.2% to 19.4% in older outpa-
tients; the most common problem was the use of
highly anticholinergic medications in those with
dementia.
17
Table 5-1. High-Risk Medications in the
Elderly per NCQA HEDIS Criteria
Therapeutic Class
High-Risk
Medication(s)
Anticholinergics, 1st
generation
antihistamines
Brompheniramine
Carbinoxamine
Chlorpheniramine
Clemastine
Cyproheptadine
Dexbrompheniramine
Dexchlorpheniramine
Diphenhydramine (oral)
Doxylamine
Hydroxyzine
Promethazine
Triprolidine
Anticholinergics, for
Parkinson disease
Benztropine (oral)
Trihexyphenidyl
Anti-infectives, other Nitrofurantoin
Nitrofurantoin macro
-
crystals
Nitrofurantoin mono-
hydrate/macrocrystals
Antiplatelets
Dipyridamole, oral
short-acting
Ticlopidine
Cardiovascular, alpha
agonists, central
Guanabenz
Guanfacine
Methyldopa
Reserpine >0.1 mg/day
Cardiovascular, other Disopyramide
Digoxin >0.125 mg/day
Nifedipine, immediate
release
Central nervous
system, tertiary tricy
-
clic antidepressants
Amitriptyline
Clomipramine
Imipramine
Trimipramine
Central nervous
system, barbiturates
Amobarbital
Butabarbital
Butalbital
Mephobarbital
Pentobarbital
Phenobarbital
Secobarbital
Central nervous
system, vasodilators
Ergot mesylates
Isoxsuprine
Central nervous
system, other
Chloral hydrate
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| Fundamentals of Geriatric Pharmacotherapy
Therapeutic Class
High-Risk
Medication(s)
Central nervous
system, other
Thioridazine
Meprobamate
Central nervous
system, nonbenzo-
diazepine hypnotics
Eszopic
lone
Zaleplon
Zolpidem
Endocrine system,
estrogens with or
without progestins
Conjugated estrogen
Esterified estrogen
Estradiol
Estropipate
Endocrine system,
sulfonylureas, long
duration
Chlorpropamide
Glyburide
Endocrine system,
other
Megestrol
Desiccated thyroid
Gastrointestinal
system, other
Trimethobenzamide
Pain medications,
skeletal muscle
relaxants
Carisoprodol
Chlorzoxazone
Cyclobenzaprine
Metaxalone
Methocarbamol
Orphenadrine
Pain medications,
specific nonsteroidal
anti-inflammatory
drugs
Indomethacin
Ketorolac, oral and
parenteral
Pain medications,
specific opioids
Meperidine
Pentazocine
HEDIS, Healthcare Effectiveness Data and Informa
-
tion Set
See reference 13 for more information.
In Europe, the development and use of
complementary explicit criteria, called STOPP
(Screening Tool of Older Person’s Prescrip-
tions), not only considers drugs to avoid and
drug–disease interactions but other important
aspects of optimal prescribing, including thera-
peutic duplication, duration of use, dosage, and
drug–drug interactions.
9
In addition, there are
explicit criteria for excessive drug dosage, such
as for drugs that are primarily cleared renally.
18
Any of these criteria can be helpful in the review
of an individual patient’s drug regimen, but they
can also be employed to evaluate prescribing
patterns among populations of patients. For
this, criteria can be applied to data sets such as
pharmacy claims data or managed care data.
Although these explicit criteria are easily applied
to computerized pharmacy claims data, this
evaluation is controversial, because the criteria
are out of date as soon as they are published.
Moreover, it is difficult to consider patient-
specific characteristics that may make a poten-
tially inappropriate medication appropriate for a
specific patient.
Table 5-2. Potentially Harmful
Drug–Disease Interactions in the
Elderly per NCQA HEDIS Criteria
Disease Potentially Harmful Drug(s)
Falls Anticonvulsants
Benzodiazepines
Nonbenzodiazepine hypnotics
(i.e., barbiturates, chloral
hydrate, “Z” drugs [eszopi
-
clone, zaleplon, zolpidem])
Tricyclic antidepressants (both
tertiary and secondary)
SSRIs
Antipsychotics
Dementia Tricyclic antidepressants (both
tertiary and secondary)
Antipsychotics
H
2
blockers
Anticholinergics
Benzodiazepines
Nonbenzodiazepine hypnotics
(i.e., barbiturates, chloral
hydrate, “Z” drugs [eszopi-
clone, zaleplon, zolpidem])
Chronic kidney
disease/
chronic renal
failure (eGFR
<30 mL/min)
All NSAIDs
NSAIDs, nonsteroidal anti-inflammatory drugs;
SSRIs, selective serotonin reuptake inhibitors. See
reference 16 for more information.
Table 5-1. (cont’d)
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Another approach to determining inappro-
priate drug use is the use of implicit criteria such
as the Medication Appropriateness Index (MAI)
(T ab le 5-3).
10,19
The MAI consists of 10 questions
and has extensive instructions for use and good-
to-excellent reliability and predictive validity.
10
When the MAI is applied to the drug regimens
of older adults being discharged home from the
hospital, up to 92% had some potential inappro-
priate prescribing problems, commonly in the
domains of dosage, directions, and medication
cost.
20
Some potential advantages to using the
MAI is that it allows for consideration of patient-
specific characteristics found in a medical
record, is very sensitive in detecting potential
problems, and is never out of date. Disadvan-
tages of the MAI are the time required (up to
10 minutes per drug) and the high level of drug
therapy expertise required of evaluators.
Table 5-3. Medication Appropriateness
Index
Questions to ask about each individual medication:
1.
Is there an indication for the medication?
2.
Is the medication effective for the condition?
3.
Is the dosage correct?
4.
Are the directions correct?
5.
Are the directions practical?
6.
Are there clinically significant drug–drug
interactions?
7.
Are there clinically significant drug–disease/
condition interactions?
8.
Is there unnecessary duplication with other
medication(s)?
9. Is the duration of therapy acceptable?
10. Is this medication the least expensive
alternative compared to others of equal utility?
See reference 10 for more information.
Underuse of Medications
A third form of suboptimal drug use is underuse
of medications.
3
This may i
nvolve an
undiagnosed and untreated condition (e.g.,
depression), a diagnosed condition but omitted
treatment (e.g., beta blocker post-myocardial
infarction [MI]), or the underuse of preventive
treatment (e.g., calcium and vitamin D).
21
Suggested causes for underprescribing in the
elderly population may include clinicians’ fear
of polypharmacy and risk of adverse drug reac-
tions, age discrimination, and financial barriers
for patients. Underprescribing in the elderly
population may lead to increased morbidity,
disability, and healthcare utilization and costs.
21
Underuse detected by either implicit or
explicit criteria has been shown to affect older
adults in all clinical settings. An implicit measure
known as the Assessment of Underutilization
(AOU) has demonstrated good reliability and
sensitivity to change in randomized controlled
trials.
22,23
One study of 196 older veteran
outpatients taking over five medications found
that 64% had evidence of medication underuse
as determined by the AOU.
5
The three most
common drug classes that were underused were
antihypertensives, anticoagulants, and lipid-
lowering agents.
5
The two most common explicit criteria for
medication underuse in older adults are the
Assessing Care of Vulnerable Elders (ACOVE)
(Table 5-4) criteria
24,25
and the Screening Tool
to Alert Doctors to Right Treatment (START)
criteria.
9,23,26
The ACOVE criteria were developed
by the RAND corporation as part of a large effort
to educate clinicians and provide an evidence-
based tool to assess the quality of healthcare of
frail older adults. One study applying the START
criteria to 600 hospitalized older patients found
evidence of underuse in 57.9%.
26
The most
common types of underuse detected by the
START criteria were statins in atherosclerotic
disease, warfarin in chronic atrial fibrillation, and
anti-platelet therapy in arterial disease.
KEY POINT:
Suboptimal drug
use is prevalent in older adults and is
manifested as unnecessary, underused,
or inappropriate medications.
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| Fundamentals of Geriatric Pharmacotherapy
A D E
The term adverse drug reaction (ADR) implies a
specific reaction usually related to the pharma-
cology of a drug, whereas an ADE is defined as
any noxious, unintended, and undesired effect
of a drug. In some studies, an ADE has been
identified as any injury due to drug therapy.
Therefore, ADEs are more encompassing and
may include not only ADRs but also harmful
adverse drug withdrawal events and therapeutic
failures. Not all ADEs or ADRs are preventable,
but if serious injury or death is the outcome of an
ADE, an evaluation should be made to identify
whether a change could reduce future likelihood
of a similar outcome.
27
Earlier literature tends
to focus just on ADRs, whereas some recent
studies evaluated ADEs that incorporated ADRs,
adverse drug withdrawal events and therapeutic
failures combined. When critiquing a publica-
tion or study, the specific definition being used
should be clear, especially when comparing
Table 5-4. ACOVE-3 Quality Indicators for Underuse of Medications
If This Is Present: Consider Adding This:
Steroid therapy Calcium + vitamin D + bisphosphonate
DM and proteinuria ACEI and aspirin
Vaccination not contraindicated Influenza, pneumococcal, tetanus toxoid, reduced diph-
theria toxoid, and acellular pertussis (Tdap) vaccines
Opioid therapy Laxatives
Peptic ulcer disease, high risk (75+; NSAIDs,
steroid, warfarin use; or history of PUD/GI bleed)
Proton pump inhibitor or misoprostol
Atrial fibrillation Anticoagulant
HF ACEI, selective beta blocker
Chronic obstructive pulmonary disease Inhaled long-acting bronchodilator/steroid
Stroke Antithrombotic
HTN, HF, and IHD Beta-blocker
HTN and either DM, HF, or chronic kidney disease ACEI
IHD with myocardial infarction Antiplatelet, beta-blocker, statin
Osteoarthritis Acetaminophen
Osteoporosis Bisphosphonate
ACEI, angiotensin-converting enzyme inhibitor; DM, diabetes mellitus; NSAIDs, nonsteroidal anti-inflammatory
drugs; PUD, peptic ulcer disease; GI, gastrointestinal; HF, heart failure; HTN, hypertension; IHD, ischemic heart
disease. See reference 25 for more information.
the incidence and prevalence of a drug-related
outcome. The following epidemiology review
includes studies focused on ADRs, studies
focused on ADEs, and studies that have used
overlapping terminology for ADRs and ADEs.
Adverse Drug Reactions
Epidemiologic studies of ADRs have gener-
ally focused on specific venues of care (e.g.,
nursing home, primary care, hospital) and
show that ADRs are common in older adults. In
a 4-year study of nursing homes, 67% of resi-
dents were found to have at least one probable
ADR over the study time period.
28
Another study
of 335 nursing home residents found 207 ADRs
via a retrospective chart review over a 1-year
period.
29
In a year-long, cohort study of commu-
nity nursing homes in Massachusetts, 1.89 ADEs
per 100 nursing home resident months were
reported.
30
A study of older adult primary care
patients found that 14% had experienced an
ADE within a 3-month period.
31
This compares
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Adverse Drug Withdrawal Events
Clinicians and investigators have reported
numerous cases of adverse drug withdrawal
events (ADWEs) and a few retrospective studies
of this phenomenon in elderly patients. In a
single nursing home in Texas, over an 18-month
period, 62 patients experienced a total of 94
ADWEs (mean 0.54 per patient), corresponding to
an incidence of 0.32 reactions per patient-month.
41
Cardiovascular (37%) and central nervous system
(22%) drug classes were most frequently associ-
ated with an ADWE. Over 27% of ADWEs were
rated as severe. Another study conducted a
retrospective review of 627 elderly nursing
home patients, focusing on the occurrence
of ADWEs during a 3-month period of newly
admitted patients to a long-term care facility who
had medications reduced due to inappropriate
prescribing. Out of 105 documented ADEs, only
2% were considered an ADWE. ADWEs that did
occur were confusion due to discontinuation
of antipsychotic medications, reoccurrence of
depression due to discontinuation of an antide-
pressant, and hyperglycemia due to discontinu-
ation of a hyperglycemia oral agent.
42
A study of ambulatory elderly patients inves-
tigated ADWEs in 124 patients and discovered
that out of 238 drugs stopped, 62 (26%) resulted
in 72 ADWEs in 38 patients.
43
Cardiovascular
(42%) and central nervous system (18%) drug
classes were the most frequently associated with
an ADWE. In 26 of the ADWEs (36%), patients
required hospitalization, emergency department,
or urgent care clinic visits. Most of the ADWEs
were exacerbations of an underlying disease,
and some withdrawal events occurred up to 4
months after the medication was discontinued.
In another study, ADWEs were investigated in
the postoperative period in a single hospital.
44
Of
1,025 patients, 50% were over the age of 60 years.
Thirty-four patients suffered postsurgical compli-
cations due to drug therapy withdrawal. Specific
drug classes involved in ADWEs included anti-
hypertensives (especially angiotensin-converting
enzyme inhibitors [ACEIs]), antiparkinson medi-
to a study of community-dwelling older adults in
Iowa that found 10% of subjects self-reported an
ADR, of which 50% received consequent labora-
tory work and 7% were hospitalized.
32
Further-
more, a study of community-based older adults
with mobility limitations found 21% reported an
ADE in the previous 12 months that resulted in
83% contacting their prescriber and 56% having
their medication discontinued.
33
The highest
rate was found in another study of community-
dwelling older adults who were just discharged
from a hospital. In this study, 18.7% had at least
one ADE within 45 days of discharge.
34
In a study of hospitalized elderly inpatients,
26% experienced an ADE, and 66% of the ADEs
likely contributed to the admission.
35
An observa-
tional study of hospitalized patients age 80 and
above reported an incidence of 13%, of which
63% were considered preventable.
36
A meta-analysis of studies that evaluated
ADRs and hospital admissions reported that
older adults have four times the risk of an ADR-
related hospital admission compared to younger
patients. A majority of those ADR-related hospital
admissions were considered preventable.
37
A
more recent retrospective cohort study in older
veterans found that ADRs were associated with
10% of hospital admissions with 37% considered
preventable.
38
Risk factors for ADRs in older adults include
polypharmacy, multiple comorbidities, previous
ADR, dementia, and the use of specific medi-
cations such as opioids, anticoagulants, anti-
cholinergics, and benzodiazepines.
39
In a study
of nursing home residents, those taking nine or
more medications were 2.33 times more likely to
experience an ADR compared to those taking
less than nine. In a community-dwelling study
of older patients with mobility limitations, the
number of drugs dispensed in the previous year
was an independent risk factor for an ADR.
33
In
hospitalized older adults, comorbidity was asso-
ciated with the risk of ADR in that there was a
direct relationship between the Charlson Comor-
bidity Index and the risk of ADR.
40
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112
| Fundamentals of Geriatric Pharmacotherapy
cations (especially levodopa/carbidopa), benzo-
diazepines, and antidepressants.
Many of these previous examples were drug
withdrawals resulting from a prescriber abruptly
discontinuing an agent because it was deemed
inappropriate or unnecessary or was suspected
of causing an adverse event. Another area of
concern is in transitions of care, in which discon-
tinuation of medication could occur unintention-
ally for an elderly patient. One study of patients
transferred from a nursing home to hospital and a
hospital to a nursing home showed ADEs attrib-
uted to medication changes in 20% of patients;
50% of those ADEs were caused by discontinu-
ation of a medication. The medications asso-
ciated with an ADWE due to discontinuation
were metoprolol, colchicine, metoclopramide,
insulin, carbamazepine, and codeine.
45
The
study suggests that medication reconciliation is
important in the prevention of ADWE in elderly
patients.
Little is known about the risk factors for
ADWEs. In the Texas nursing home study,
ADWEs were associated with multiple diagnoses,
multiple medications, longer nursing home
stays, and being hospitalized.
41
In primary care
patients, the number of medications stopped
was a significant predictor of ADWEs.
44
Analyses
reveal that the risk of an ADWE increased as
the length of time off medication increased.
45
It
is important to note, however, that ADWEs rarely
occur when medications are discontinued by
tapering.
KEY POINT:
Gradual dosage reduction
should be attempted one drug at a time with
a tapering dose, carefully observing the eect
of each change. Documentation of the plan
and results of previous drug withdrawals
is important for any medical history.
erapeutic Failure
Few data exist about the prevalence of thera-
peutic failure in older adults. Two studies used
a reliable and valid 10-question causality algo-
rithm, called the Therapeutic Failure Question-
naire, and reported that between 5% and 11.2%
of hospital admissions in older U.S. veterans are
due to an ADE.
46,47
Among the most common
conditions with therapeutic failure in both studies
were heart failure and chronic obstructive pulmo-
nary disease.
46,47
Another study from Belgium
showed that 8.2% of hospital admissions to
a geriatric ward were due to drug therapy
failure as measured by an implicit Likert scale
measure.
48
It is important to note that most cases
of therapeutic failure reported by these studies
were preventable and mostly due to medication
nonadherence.
46-48
Other reasons for therapeutic
failure reported included lack of prescribing or
too low a dose of an evidence-based drug.
46-48
R A
D E G
P
Although many studies of clinical pharmacist
interventions to improve drug therapy have been
published, most are limited to specific drugs or
disease states or are poorly controlled. There
are few randomized controlled trials (RCTs)
designed to reduce suboptimal drug use in older
adults that have demonstrated ADE reductions.
This discussion focuses on RCTs and systematic
reviews.
One RCT of a clinical pharmacist interven-
tion with 208 elderly outpatient veterans with
polypharmacy showed that the rate of ADEs was
lower in the intervention compared to the control
group; 32.2% versus 40% (P = 0.19).
49
Another
RCT in 808 older veterans that compared outpa-
tient care by a geriatric evaluation and manage-
ment team to the usual care showed a 35%
reduction in the risk of serious ADRs.
22
Three separate RCTs involving 1,184 elderly
hospitalized patients showed that three different
types of interventions (i.e., pharmacist drug
regimen review, group patient education, and
multidisciplinary education) all reduced ADE
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readmissions.
50-52
However, a systematic review
of 21 descriptive studies and 10 controlled
trials of clinical pharmacists providing medica-
tion reviews for patients of all ages at hospitals
concluded that, despite variable study design
and outcome measures, medication use, health
services use, and costs were improved.
53
One RCT in nursing homes focused on
warfarin demonstrated that a nurse intervention
using Situation, Background, Assessment, and
Recommendation (SBAR) to communicate with
physicians led to an increase of international
normalized ratio (INR) tests within the therapeutic
range and a reduction in ADEs (although not
statistically significant).
54
However, a systematic
review including both randomized and nonran-
domized controlled studies in nursing home
populations outside of the United States identi-
fied improved MAI scores, improved prescrip-
tion of psychoactive medications, decrease in
hospital usage, and fewer falls as evidence of
the effect of pharmacist intervention on ADEs.
55
KEY POINT:
A variety of interventions
involving clinical pharmacy services
and interprofessional education have
been shown to reduce ADEs.
O R
I D-R
P E
Medication Reconciliation
Medication reconciliation, which is defined
by The Joint Comission as “the process of
comparing a patient’s medication orders to all
of the medications that the patient has been
taking,”
56
is another opportunity for pharmacists
to reduce the risk for drug-related problems,
particularly for patients moving from one venue
of care to another. A medication reconciliation
should be done whenever a patient is transferred
between levels of care such as hospital admis-
sion and discharge, nursing home admission,
or transfer to independent living. This is espe-
cially useful on discharge of a patient back to an
independent living situation, because the institu-
tion’s medication formulary may be different from
that of their Medicare Part D plan. Drugs from a
similar class, or the same agent with a different
dosage form, may have been started and need
to be changed back to those previously taken
at home.
In its most basic form, medication recon-
ciliation is a comparison of one medication list
to another, which is vital for identifying tran-
scription errors and omissions. However, medi-
cation reconciliation provides an excellent
opportunity for improving a patient’s pharma-
cotherapy. To perform a full review, additional
data obtained from a medication history, medical
records review, and/or the patient is necessary
to match medications with their indications,
clarify intended duration of therapy, or provide
the rationale behind any intentional medication
changes. Therefore, some healthcare settings
employ enhanced medication review practices
that incorporate these extra data.
medication reconciliation he or she should also
assess potential adverse effects and medica-
tion adherence or knowledge problems. This
process is enhanced in the outpatient setting
when patients bring in all prescription and
non-prescription medications, including herbal
and alternative therapies, to each healthcare
visit. Additional probing may be needed to fully
ascertain the extent of nonprescription product
use (e.g., multivitamins, vitamin E, gingko biloba,
ibuprofen, calcium carbonate) because patients,
not believing them to be medications, may not
voluntarily disclose these products to healthcare
professionals.
KEY POINT:
Optimal medication
reconciliation should include more
than just a comparison of drug lists.
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| Fundamentals of Geriatric Pharmacotherapy
Medication erapy Management
Pharmacists can play a major role in resolving
and preventing drug-related problems, espe-
cially suboptimal drug use with medication
therapy management (MTM). MTM was adopted
by the Center for Medicare & Medicaid Services
as a recognized reimbursable service for bene-
ficiaries of Medicare Part D.
57
Regardless of
the care setting, this process consists of the
following steps: (1) taking a thorough medica-
tion history, (2) matching a patient’s problem
list with his or her medication history to detect
potential over- and underuse, (3) assessing the
appropriateness of the remaining drugs, and
(4) making drug therapy recommendations to
prescribers, other healthcare professionals, and
patients to resolve any drug-related problems
detected. Pharmacists conducting MTM may
benefit from using a structured tool to improve
efficiency and consistency. A recent review
describes the various tools for assessment of
inappropriate prescribing in the elderly patient,
comparing those that may be helpful in daily
practice, professional training, and research.
58
Using explicit criteria, the Tool to Improve Medi-
cations in the Elderly via Review (TIMER
®
) may
help in the assessment of
•
unnecessary use,
• underuse,
• inappropriate use (high-risk drugs),
• drug–drug and drug–disease interactions,
• medication nonadherence,
• attainment of therapeutic goals,
• medication cost and coverage, and
• ADRs, including those due to allergies.
59
KEY POINT:
MTM is a valuable
service that is increasingly provided by
pharmacists in many healthcare systems.
Another helpful tool using implicit criteria is
the MAI, which considers 10 domains (see Table
5-3) to evaluate each medication in a patient’s
regimen (described earlier in this chapter).
10
Step 1 for MTM is to identify the medications
a patient is supposed to be taking. The medica-
tion history is usually obtained from the patient or
caregiver and medical or pharmacy records. A
medication reconciliation can provide the neces-
sary medication list but may not be comprehen-
sive (see Medication Reconciliation, above).
After the pharmacist has an accurate and
complete medication list for a patient, Steps 2,
3, and 4 are undertaken. Step 2 evaluates each
medication to determine whether it is necessary
for the patient. Each medication should corre-
spond with one or more medical problems in the
patient’s past medical history or current problem
list. Drugs that lack an indication may be unnec-
essary for the patient and should be evaluated
to see whether they can be discontinued. Some-
times an indication exists but is not documented,
and steps should be taken to clarify the intended
indication. Drugs such as anticonvulsants, anti-
depressants, and corticosteroids should be
tapered gradually to minimize a resurgence of
an undocumented underlying condition, or with-
drawal symptoms.
60
In addition, it is important to
evaluate whether drug therapy was prescribed
to treat any adverse effects of another medica-
tion. An example of this prescribing cascade
would be the use of levodopa to treat parkinson-
like symptoms caused by metoclopramide.
61
Another example of unnecessary drug use can
occur in patients near the end of life.
62
Chapter 6
provides a more detailed discussion of factors to
consider at this stage.
Step 3 considers whether untreated medical
conditions might benefit from evidence-based
pharmacotherapy. For Step 4, the pharmacist
must then evaluate whether the remaining drug
therapy is appropriate. For example, a medica-
tion cannot be considered effective when the
risks associated with drug therapy outweigh
potential benefits. Another example of unneces-
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5 - Adverse Drug Events, Polypharmacy, and Medication Management |
115
sary medication is therapeutic duplication (i.e.,
two drugs from the same class). To assess proper
dosing, the pharmacist should evaluate a drug’s
pharmacokinetics and side effect profile and
the patient’s renal and hepatic function. Patient
preference and copay costs associated with
the prescription drug plan’s formulary must also
be considered. Other comorbid conditions and
concomitant medications also need to be taken
into account to avoid drug–disease or drug–
drug interactions. Limiting the use of as-needed
drugs and considering medications that can be
dosed as few times per day as possible will help
to enhance medication adherence.
After these steps of the MTM process are
completed, a plan of care is developed, which
must be communicated to be effective. It is
imperative to communicate drug therapy recom-
mendations to prescribers and other health-
care professionals to resolve any drug-related
problems detected. In addition, patients in the
ambulatory care setting and their caregivers
should receive both written and verbal medica-
tion education to help to increase adherence.
Considering generic options, utilizing compli-
ance aids (e.g., pill boxes, medication calen-
dars), and encouraging family support can help
to improve medication adherence.
63-65
MTM has evolved with the enactment of
the Medicare Prescription Drug Benefit (Part D).
In addition, MTM may further expand into new
healthcare models, such as the medical home
model and accountable care organizations.
Provision of MTM by pharmacists has great
potential to reduce drug-related problems in
older patients.
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116
| Fundamentals of Geriatric Pharmacotherapy
C: S D U A
D E
Setting:
Inpatient ward.
Subjective:
WF is a 74-year-old man who saw his primary care provider because he noticed when he
woke up that his “heart wasn’t beating right; it feels like it is going too slow.” WF denied chest
pain, shortness of breath, nausea, or vomiting. He did note feeling dizzy earlier in the week. Six
weeks earlier, WF was started on diltiazem CD 180 mg daily by his primary care physician to
further lower his blood pressure to goal. His physician also at that time decreased the dose of
his metoprolol tartrate from 75 to 50 mg bid. WF was sent to the hospital for admission.
Past Medical History:
HTN, T2DM, CAD s/p angioplasty 2 years ago, previous MI, EF = 60%, PVD s/p left femoral to
posterior bypass, and history of one episode of atrial fibrillation (4 years ago).
Medications on Admission:
Digoxin 0.25 mg daily, diltiazem CD 180 mg daily, metoprolol tartrate 50 mg bid, lisinopril
20 mg daily, isosorbide mononitrate 30 mg daily, hydrochlorothiazide 12.5 mg daily, KCl
40 mEq every a.m., EC ASA 325 mg daily, warfarin 5 mg daily, famotidine 20 mg at bedtime,
vitamin C 500 mg daily
, insulin glargine 26 units subcutaneously at bedtime, insulin lispro
8 units subcutaneously with meals, vitamin E 400 international units daily, ibuprofen 200 mg
two tablets as needed for pain (takes at least one dose per day), multivitamin daily, calcium/
vitamin D 500 mg/200 international units twice daily.
Physical Examination:
BP 110/50 mmHg, P 38 BPM, RR 24. The rest of the physical examination is unremarkable.
Labs:
Potassium 6.9 mEq/L, serum creatinine 1.9 mg/dL (baseline 1.2 mg/mL), BUN 35 mg/dL,
fasting glucose 102 mg/dL, WBC 5800/mm
3
, hematocrit 35%, digoxin level 2.78 ng/mL,
INR 2.3.
Electrocardiogram: bradycardia with normal sinus rhythm.
Hospital course: WF was admitted to the coronary care unit and received sodium polystyrene
sulfonate for increased potassium; digoxin, diltiazem, and metoprolol were held, but all other
home medications were continued. Over the next few days, his heart rate and blood pressure
increased to 82 BPM and 145/85 mmHg, respectively. WF was transferred to the geriatrics
evaluation and management team and restarted on metoprolol for hypertension and coronary
artery disease. The pharmacist on the geriatrics team was asked to review the patient’s home
medications for appropriateness. After interviewing the patient and reviewing the records, the
pharmacist provided the following medication assessment and plan.
Assessment:
1.
Hospital admission secondary to medication-related adverse events: Use of multiple
agents to treat hypertension without titration to maximum dose, use of digoxin and
warfarin without current indication, use of NSAID despite current diagnosis and treat
-
ment of HTN, and use of potassium chloride supplementation in the presence of an
ACEI.
2.
Home medications without a current indication for use in this patient: famotidine,
warfarin, digoxin, vitamin C, and vitamin E.
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