NSAIDs and CHF – The Prescribing Cascade

88 year old male has a history of osteoarthritis.  He has tried self treatment with acetaminophen 325 mg twice daily with no benefit.  Upon a recent evaluation with his primary provider, he was prescribed Naproxen 500 mg two times daily.

His current medication list includes:

  • Lasix 20 mg daily
  • Enalapril 10 mg daily
  • Amlodipine 2.5 mg daily
  • Metoprolol 12.5 mg twice daily
  • Aspirin 325 mg daily
  • Sulcralfate 1 gm four times daily
  • Senna S 2 tablets daily

Within a few weeks following the Rx of Naproxen 500 mg twice daily, our patient begins to experience worsening shortness of breath, an increase in swelling in his ankles, and his weight has increased 6 pounds.  He is diagnosed with a CHF exacerbation.  Lasix was increased from 20 to 40 mg daily to help manage the situation.  The NSAID likely contributed to the exacerbation.

Leg_Edema NSAIDs

Playing hindsight, this is a case where you would strongly try to avoid NSAIDs.  It is always critical to assess if patients have had an adequate trial of a medication.  Acetaminophen 325 mg twice daily for osteoarthritis is not an adequate trial in my opinion before declaring treatment failure.  Not only can the NSAID exacerbate CHF, but this gentleman is also on sulcralfate which is usually used to treat GI symptoms like GERD or dyspepsia, both of which could be exacerbated by NSAIDs.

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Digoxin Toxicity – The Highest Level I’ve Ever Seen

A 78 year old male was found driving around in his car making abnormal turns and proceeded to drive to a parking lot where he was driving in circles.  He presents to the ER with primary symptoms of confusion and cognitive decline.  Vital signs were fairly normal with a significantly lower pulse noted.

Upon review of his medication list, it was noted that he was on Digoxin 375 mcg daily.  This is a high dose for a middle aged individual.  Remember that this patient is 78!

photo courtesy: Burroughs Wellcome and Company
photo courtesy: Burroughs Wellcome and Company

Upon checking a digoxin level, it was quickly confirmed that he had digoxin toxicity.  His level was 7.58!  Usual upper limit of normal is considered to be about 2.  This is the highest digoxin level I’ve ever seen.  The part that amazed me was that he really wasn’t displaying many classic digoxin toxicity symptoms.  If you ever see an elderly individual on 250 mcg daily or above, this should be an immediate alert in your head to monitor closely for digoxin toxicity.  The dosing of 375 mcg daily in this case would be of high concern to (at a minimum) monitor.  This gentleman did have some renal insufficiency as well.  Always remember that digoxin is cleared by the kidney!

I would also add that with this gentleman’s confusion, it would be nice to try to dig into the patient history to identify if he has had cognitive trouble before digoxin toxicity as well.  This is a very high digoxin level and I will never know, but suspect that this patient may have inadvertently been taking more than one tablet per day.  What’s the highest digoxin level you’ve seen?

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Iron Supplements for Anemia – Med List Review

77 year old female has a past medical history including but not limited to: GERD, PMR, Hypertension, Iron Deficiency Anemia, Osteoporosis.  Her current medication list includes:

  • Ferrous Sulfate 325 daily
  • Aspirin 81 mg daily
  • Ranitidine 150 mg twice daily
  • Prednisone 10 mg daily
  • Alendronate 70 mg weekly
  • Ferrous Gluconate 324 mg daily
  • Enalapril 10mg daily
  • Acetaminophen 500 mg as needed

There is an obvious question to ask here.  This patient is using two different iron supplements for anemia.   Our patient is on both Ferrous Gluconate and Ferrous Sulfate.  I would suspect this is an oversight, or the patient did this on their own.  It would be appropriate to get rid of one of the supplements.  With that stated, it will also be important to assess anemia and iron stores in the future to make sure that long term iron supplementation doesn’t get continued indefinitely without follow up.

Image courtesy of Ed Uthman
Image courtesy of Ed Uthman

This patient has a history of PMR and is likely taking the prednisone for that reason.  I would likely suspect the prednisone is long term, but the length of prednisone therapy always needs to be assessed for appropriateness.  Because of the prednisone, this patient is at higher GI risk (on Aspirin as well).  The prednisone increases the risk of osteoporosis and this patient is likely on alendronate for treatment of that.  I’m usually not an advocate for adding medications in the elderly if we can help it, but assessing if calcium and vitamin D supplementation is necessary would be appropriate here.

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Case Study: GI Side Effects and Polypharmacy

A patient was on 30+ medications.  I always kind of wonder what it would be like to be on that many medications, but hope I never find out.  I simply think of the sheer volume of that many pills and depending upon the size each pill, it is probably close to the size of your fist.

The chief complaint was nausea, go figure.  The nausea had been a complaint for quite some time.  This patient had been on multiple medications to treat the nausea:  Carafate, multiple different PPI’s, Zofran, H2 blockers, Compazine etc.

Polypharmacy was extremely problematic in this case because it’s hard to even know where to start.  Virtually any medication can cause GI problems right?

Nausea can be awful for patients - identifying what meds we should rule out first can be tricky! Photo courtesy of NASA
Nausea can be awful for patients – identifying what meds we should rule out first can be tricky! Photo courtesy of NASA

When assessing GI side effects and polypharmacy, its important to start with those medications that are common causes of GI side effects.  In this case, the patient was on multiple notorious medications that could cause nausea/upset stomach.  Byetta (exenatide), pilocarpine, metformin, and an NSAID were all a part of this extensive medication list.  These medications have significantly high rates of GI side effects, and you could potentially imagine how much distress they could cause working together.

Two other important things to remember when assessing something like this is to look at the timing as well as the dose.  It is common sense that in nearly every case more drug may mean more benefit, but it also can come at a price of more side effects.

The last point:  You want to anticipate what problems (and how severe these problems will be) we will encounter when we try to rule out medications by reducing or discontinuing them.  For example if we discontinued Byetta, we would likely have to be prepared to have an alternative to treat blood sugars.

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Managing Short Term Constipation and Avoiding Polypharmacy

59 year old female who is rehabbing from a knee replacement.  On day 3 following the procedure, the patient is still experiencing a significant amount of pain.  She has been discharged from the hospital and is taking Percocet 2 tablets four times daily for pain management.

Other medications include:

  • Lisinopril
  • Aspirin
  • Omeprazole
  • Metoprolol
  • Senna 1 tablet daily
  • Miralax (as needed)

On days 5-7 post-op, the patient is still requiring some of the Percocet for pain management.  This patient due to the Percocet was beginning to experience some constipation.  She has had a history of constipation in the past even prior to the use of the opioid.

On day 7, she is placed on Senna S 1 tablet twice daily to help relieve the constipation with minimal results.  A day or two later, she was also recommended to try Miralax 17 grams daily on a scheduled basis.  She does begin to have regular bowel movements and the Percocet use is also now on the decline with pain greatly improving.

In cases like this, with the eventual discontinuation of the Percocet, most patients will stop taking the laxatives on their own, but it is important to reassess where, why and when laxatives were initiated as they can linger if patients don’t ask questions.  If you identify patients on chronic laxatives, help make sure that they haven’t been started and continued due to a short term course of a constipating medication.

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Interprofessional Medication Education