One of the most common medication-related problems I see is not necessarily starting the wrong medication. Sometimes the medication is completely appropriate when it is initially prescribed, but the problem is that it never gets stopped. A medication is started for a specific condition, the patient improves, and the original reason for treatment slowly becomes forgotten. Months or even years later, the medication remains on the medication list. Here are a few unique situations I’ve seen in my career as a clinical pharmacist.
Ophthalmic corticosteroids can be very useful for treating inflammation and may be prescribed after an eye procedure or for a specific inflammatory eye condition. However, these medications are not generally intended to continue indefinitely without appropriate follow-up. Prolonged corticosteroid eye exposure can increase the risk of complications such as increased intraocular pressure, glaucoma, cataracts, and infection.
Steroid creams are another medication that can quietly become chronic therapy. Topical corticosteroids are often very effective for treating inflammatory skin conditions, but the risks associated with prolonged use depend on the potency of the corticosteroid, the location of application, the amount being used, and the duration of therapy. A prescription that simply says to apply the medication twice daily may not provide enough guidance about when treatment should end. Patients may continue applying the cream whenever they notice itching or a rash, even when the original indication has changed or resolved. Prolonged use of potent topical corticosteroids can contribute to skin thinning and other local adverse effects. When reviewing these medications, it is important to determine whether the patient still has an active indication and whether continued daily treatment is actually necessary.
Nystatin is another medication that can sometimes remain on the medication list longer than necessary. A patient may develop oral or cutaneous candidiasis and appropriately receive nystatin treatment. The infection improves, but the medication continues to appear on the medication administration record or medication list because nobody formally discontinued it. Nystatin is generally being used to treat a specific fungal infection rather than as a medication that should automatically continue indefinitely.
Antibiotics are perhaps one of the most obvious examples of medications that should have a defined treatment duration. A patient may receive an antibiotic for pneumonia, a urinary tract infection, cellulitis, or another infection, improve clinically, and then somehow remain on the medication well beyond the original treatment period. I remember a case several years ago where Augmentin was continued for months without someone recognizing it was for an acute infection that had resolved.
Anticoagulation is a little different because many patients legitimately require long-term or even lifelong therapy. The concern is not that anticoagulants should automatically be stopped after a certain period of time. Instead, the original indication can sometimes become unclear over time. A patient may have started anticoagulation for a postoperative or otherwise provoked venous thromboembolism (excellent board exam nugget), while another patient may have atrial fibrillation that continues to justify long-term therapy. Be sure to recognize the indication for anticoagulation. In the case of DVT/PE, a lifelong duration may not be appropriate or necessary in some instances.
Seizure prophylaxis medications can create a similar problem. Some patients are started on an antiseizure medication following a neurologic event, traumatic brain injury, surgery, or another situation where temporary seizure prophylaxis is considered appropriate. The medication may initially be prescribed with the expectation that it will be used for a limited period of time. However, if there is no clear follow-up or stop date, the medication can remain on the patient’s regimen for months or years.
Some of the best medication interventions involve deprescribing rather than prescribing something new. Look for medications that were started for a specific problem that has resolved, medications without a clearly documented indication, medications that were intended for a limited duration, and medications that were supposed to be tapered or discontinued but never were.
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