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Reducing Medication Burden and Risks in COVID-19

There are some scary things happening across the country with regards to COVID-19 infections. One of the biggest risks is to our geriatric population. I’ve heard reports all over the place on this topic and concerns are likely heavily dependent upon the region you are in. One of the questions I’m asking myself is, how can I make the lives of our essential healthcare staff easier? One of those answers is reducing medication burden. The other question I am asking, is there a way to reduce the risk of transmitting the virus?

I’ve encountered staff shortages plenty of times in my long term care and assisted living communities. Reducing the medication burden can greatly reduce the workload of caregivers who administer those medications. As a consultant pharmacist, this is what I’m good at and have years of practice doing.

Here are some targets to reduce staff workload, reduce polypharmacy and hopefully reduce the risk of COVID-19 transmission.

Supplements

Now is not the time for using supplements that have no to minimal efficacy. If there isn’t a good reason for the patient to be on a supplement or they have not experienced any beneficial effects, stop the supplement. Common targets for me to review include glucosamine/chondroitin, vitamin C, vitamin E, garlic, iron, multivitamins, and many others. Be sure that the patient is actually taking these supplements for a reason. If they aren’t taking them for a purpose and obvious benefit, stop them.

Multiple daily dosages

Many times with blood pressure medications, we may be able to consolidate dosing. Metoprolol, amlodipine, ACE Inhibitors, and ARBs are a few examples of medications that are sometimes split. They may have been split up for a reason (i.e. elevated nighttime blood pressure), but make sure that there is a good rationale for it otherwise we may be able to reduce pill burden.

Nebulizers

There has a lot of talk about nebulizers increasing the risk of transmission of COVID-19. This presents an opportunity to reassess nebulizer use. Do they actually need administration 4 times per day? Can that COPD patient get by with 2 per day? Are they capable of using an inhaler?

If a nebulizer is necessary (in many cases, it probably will be), I’d do everything you can to try to get the patient into an area that does not have air recirculating with the rest of the facility.

Accuchecks

An 88-year-old with dementia likely does not need their blood sugar checked four times per day. This puts extra strain on our staff, creates another encounter where viral transmission could happen, and not to mention is an inconvenience to the patient. Be sure to assess those patients who are receiving frequent accuchecks to see if we could reduce them.

Nasal/Eye/Ear: Reducing Medication Burden

Nasal/Eye/Ear administration will likely be a higher risk situation for transmission (particularly nasal). Take a look at the patient’s chronic regimen and if they do utilize nasal administration for a medication, take a look and see if it is still necessary and indicated. The most common nasal agents I see used are normal saline and steroids. It is allergy season, but it doesn’t hurt to take a look and see why they are on the medication and if it is still necessary.

Prescribing Cascade

Be on the lookout for the prescribing cascade in an effort of reducing medication burden. I provide some examples here:

Unused PRN’s

Staff should also be encouraged to take a look at unused PRN’s. Let’s reduce the number of medications being handled and carried around. If the patient hasn’t used a specific medication for several months, let’s take the time to discontinue it and give our staff one less thing to look at.

Hydroxychloroquine and Azithromycin

I would strongly encourage you to stay on top of the evidence for the use of these medications. You are likely going to see them. If you notice a trend in the orders for these medications, do not be afraid to ask difficult questions of the providers who are writing for these medications. This is especially true in low-risk situations. There are shortages that have been reported on account of COVID-19 use.

In addition, geriatric patients who have electrolyte imbalances or are on other QTc prolonging medications are at higher risk for QTc prolongation. Hydroxychloroquine and azithromycin have been reported to exacerbate this issue. QTc prolongation risk may be another reason to try to minimize and reduce the use of antipsychotics. I discuss QTC prolongation drugs at length in my latest book on drug interactions.

What else would you add to this list to ease the burden of our front-line staff??

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Written By Eric Christianson

April 15, 2020

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