Diagnosis: Polypharmacy – Case study

I can’t help but smile when providers dictate that a patient has a diagnosis of polypharmacy.  Let’s cure that condition! These case studies are kind of challenging because you could go a few different directions, but they do certainly provide some educational opportunities! Here’s the med list:

Cardizem CD 120 mg daily

Aspirin 81 mg daily

Lipitor 40 mg daily

Lisinopril 10 mg daily

Novolog 4 units TID with meals

Lantus 25 units at bedtime

Metformin XR 2000 mg daily

Celexa 20 mg daily

Ativan 0.5 mg as needed

Trazodone 100 mg at bedtime

Paxil 40 mg daily

Prilosec 20 mg daily

Zofran 4 mg three times daily as needed

Tums as needed

Macrobid 100 mg daily

Ibuprofen 400 mg four times daily as needed

Neurontin 400 mg three times daily

Mobic 15 mg daily

Pulmicort 0.5 mg nebs twice daily

Albuterol nebs four times daily as needed

 

-The big questions I would want to know first from the medication list –

1. Would like to know GI status with potential duplicate NSAIDs contributing to any symptoms – i.e. how often using Zofran, Tums etc.  Also metformin/antibiotic could certainly contribute to any GI complaints

2.  Obvious duplicate SSRI’s (Celexa, Paxil) – there better be a really good reason for that, although from my experience its almost always a mistake. This patient most likely does have some significant behavioral/psych concerns given the number of psych meds. Potentially neuropathy with gabapentin and maybe an SNRI would be something to consider. – PS students: I can remember the question, “Do we need to know brand names or generic names for an exam?” – Life will be easier for you if you know both or in some cases all names 🙂

3.  Kidney Function is going to be very important as many drugs can affect or be affected by renal function (Macrobid, Metformin, NSAIDs, Lisinopril…)

4.  Diabetes, HTN, Respiratory and Pain assessment are of course necessary based on this med list, but I’m trying to help you learn how to prioritize! – Sound off if you’ve got something to contribute!

 

10 Comments

  1. Thomas. Kaye

    Quite a list. Other considerations that I would comment on. In practical applications the validation of these meds being current is needing to be established .
    Patient age.
    Patient gender
    Why?
    If aged, the prescribers need to be communicated with. Likly the patient is being seen by multiple prescribers. Cardiologist. Endocrinologist , psycharity . Gender. Female. Likely as makes are much less compliant.
    Does the patient live alone?
    Is there care givers available ?
    Payer source. Commercial or public funded?
    There may also be multiple family members invoked with the med list who don’t have Rx coverage.
    Clinically the authors comments are spot on, however actionable results often are within the psychosocial . The benzo ( Ativan) is considered as worthless and too often serves as a placebo by prescribers who are tiring to please the patient .
    These patients are generally small
    In number and trigger as high cost/utilizers. They require high touch points.
    And lastly where is the pharmacist in this as the likly point of one pharmacy filling is also present. Tom

    Reply
    • chri1599

      Appreciate your effort Tom, thanks for your input!

      Reply
  2. Lori Olson

    My first thought was WOW. My second thought was great learning tool for new nurses. Would love to sit beside one with this list to see if there is a reaction. Third thought was is this a case of two many spoons in the soup or EPIC? We often see discharge med lists that were not looked at carefully and old previously discontinued orders mixed in with new changes. What would really work in this new system is that a pharmacist is on staff and looking at the list prior to discharge from the hospital then the doctor then the nursing home.

    Reply
    • chri1599

      Pharmacists are seeking increased roles in clinical care…there are too many medication problems! – thanks for the kind words 🙂

      Reply
  3. Pharm Osazone

    Quite agree Lori. What is obtainable is that these patients see different Dr.s on subsequent visits, with the doctors copying the previous medications from their files while adding new ones based on the present complain. Funny enough, most of the new complaints are side effects of their previous medications!

    Reply
  4. ma.PharmD

    there is a lots of drug -drug interaction in this list !! why 4 medications for anixity!!!

    another things ” tums contain Ca and I learned Ca containing Antacid may increase relase of HCl ” may be not a big problem in this pt.

    however, my brain was exploded from brands names looool

    Reply
    • chri1599

      Brand names get used all the time in practice, which probably leads to more confusion than anything, and I’m guilty of doing it as well!

      Reply
  5. Fraizer J-C

    In UK we don’t have access to medical records of the ‘prescribee’ – Is Canada any different ? – brand names in UK totally different – and disparaged use of .
    Are you allowed to conduct a one to one interview with the patient and submit a medicines use report ? 9 to the presribee and the prescriber ?

    Reply
  6. Nathan

    I agree, anytime we look at a patients meds, all factors should be considered. Is this patient experiencing significant somnolence due to side effects of meds, are there meds added to decrease side effects of other meds, and can we combine meds to “kill two birds with one stone”? Not meant to be an all inclusive case but something for people to consider when identifying and then critically thinking about alternative options. Its one thing to mention to a prescriber things that have been identified, another to be prepared with a full alternative recommendation with reasoning and evidence.

    Reply

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Written By Eric Christianson

April 6, 2014

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