Transcript Medication Review

Response to symptoms by
Community Pharmacists
Andrew McLachlan
Faculty of Pharmacy
University of Sydney
Centre for Education and Research in
Ageing, Concord Hospital
This session..
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Sentinel symptoms of concern
Frailty as a symptom
Multiple medications
Risk assessment to inform management
Importance of a comprehensive history
“ 90% of the diagnosis is in the history”
• Look and Listen
• Careful review of precipitating factors
Mr NL
– 78 year old man
– Lives alone, supportive
nephew nearby
– Mobilises with wheelchair
– eGFR 60 ml/min/1.73 m2
– Assistance with shopping,
cleaning and cooking
Mr NL
Presents with
– decreased mobility (ataxia) and confusion
Symptoms not to ignore
Unexplained weight loss
• common feature of many chronic underlying
illnesses (cancers, chronic infections, depression).
Persistent fever (> 37.5 oC)
• chronic underlying infection, cancer or some other
illness
Unexplained changes in bowel habits
• bowel disease like inflammatory bowel disease or
cancer.
• gastrointestinal disorders like ulcers, cancers and
infections.
Symptoms not to ignore
Confusion
• behaviour change, disorientation, hallucinations
• low blood sugar, side effects of drugs, possible
head injury or a psychiatric condition.
Shortness of breath
• lung or heart disease.
Flashing lights
• retinal detachment
Hot, red or swollen joints
• arthritis or joint infection.
Symptoms not to ignore
Chest pain
• crushing and radiating, suspect heart disease.
• Sweating and difficulty breathing.
Sudden unexplained headaches
• fever, stiff neck, rash, mental confusion, seizure,
vision changes, weakness, numbness, or speaking
difficulties.
Sudden loss of function
• weakness or numbness of the face, arm, or leg
• loss of speech, blurring or loss of vision.
• stroke or a transient ischaemic attack – urgent
treatment is needed.
Mr NL
– 78 year old man
– Lives alone, supportive
nephew nearby
– Mobilises with wheelchair
– Assistance with shopping,
cleaning and cooking
Mr NL
Admitted to Hospital with
– decreased mobility (ataxia) and confusion
On examination
– UTI
– hyperkalaemia
– hyponatremia
Mr NL
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Medical history from
carer and GP
Parkinson’s disease
ischemic heart disease
hypertension
schizophrenia
previous fall
previous episode of
delirium
previous suspected TIA
• Gout
• Vision impairment
• MMSE: 25/30
• eGFR 60 ml/min/1.73 m2
Product on Admission
Dose (mg)
Frequency
Medicines
Drug generic name
Mirtazapine
Olanzapine
Oxazepam
Benztropine
Levodopa + carbidopa
Allopurinol
Isosorbide mononitrate
Indapamide
Perindopril
Amoxycillin
Trimethoprim
Aspirin
Potassium chloride
Lactulose
Docusate + senna
Avanza
Zyprexa
Alepam
Cogentin
Sinemet
Zyloprim
Imdur
Natrilix SR
Coversyl
Amoxil
Triprim
Cardiprin
Slow-K
Actilax
Coloxyl + senna
45mg
10mg
7.5mg
1 mg
100 mg / 25 mg
300mg
120mg
1.5 mg
4 mg
250 mg
300 mg
100 mg
600 mg
30mL
bd
n
bd
bd
tds
d
m
m
bd
tds
d
d
1d
prn n
2 bd prn
First rule of geriatric medicine
Old + sick = adverse drug reaction
Prof David Le Couteur, Concord Hospital
Jerry Avorn
Adverse drug reactions
Oldest old
ADRs increase
Repeat admission increasing
Zang et al, Repeat adverse drug reactions causing hospitalization in older Australians: a population-based
longitudinal study 1980–2003. Brit J Clin Pharmacol 2007
Adverse effects in older patients
Reduction in organ function
Altered
pharmacokinetics
Altered
pharmacodynamic
Reduced
homeostatic function
Adverse effects
Multiple
diseases
Multiple
medications
Poor
adherence
Medications which may worsen
cognition or cause confusion
• anticholinergic agents
• anticonvulsants (phenytoin,
carbamazepine)
• antiparkinsonian agents
(levodopa, pergolide)
• antipsychotics
• opiods (esp pethidine)
• benzodiazepines
• corticosteroids
• some CV medicines
(digoxin, metoprolol,
propranolol)
• NSAIDs (incl COX-2
selective agents)
• H2 blockers
• some anti-infectives
(ciprofloxacin, aciclovir,
cotrimoxazole)
Product on Admission
Dose (mg)
Frequency
Medicines
Drug generic name
Mirtazapine
Olanzapine
Oxazepam
Benztropine
Levodopa + carbidopa
Allopurinol
Isosorbide mononitrate
Indapamide
Perindopril
Amoxycillin
Trimethoprim
Aspirin
Potassium chloride
Lactulose
Docusate + senna
Avanza
Zyprexa
Alepam
Cogentin
Sinemet
Zyloprim
Imdur
Natrilix SR
Coversyl
Amoxil
Triprim
Cardiprin
Slow-K
Actilax
Coloxyl + senna
45mg
10mg
7.5mg
1 mg
100 mg / 25 mg
300mg
120mg
1.5 mg
4 mg
250 mg
300 mg
100 mg
600 mg
30mL
bd
n
bd
bd
tds
d
m
m
bd
tds
d
d
1d
prn n
2 bd prn
First rule of geriatric medicine
Old + sick = adverse drug reaction
Second rule of geriatric medicine
Everything is complicated: multifactorial and multiple
comorbities
Prof David Le Couteur, Concord Hospital
Frailty
Renal disease
Drug interactions
pregnancy
Environmental factors
Obesity
Age
Hepatic disease
Others diseases
Pharmacokinetics
Adherence
Therapeutic
drug monitoring
Genetic differences
Pharmacodynamics
Variability in Drug Response
Dose individualisation
Pharmacodynamic
monitoring
TDM
• integral role in pharmacotherapy
• (in age care) valuable tool in
– optimising dose selection
– medication safety
– ADR identification and management
How old is old…..
• Chronological “age”
• Functional “age”
• Old
• Oldest old
• Frail old
Frailty
Complex or phenotype………consisting of
• Decreased mobility (walk time)
• Reduced strength (eg grip strength)
• poor nutritional status (weight loss)
• Exhaustion
• Declining physical activity
……………..increased number of medicines
Fried et al . Frailty in older adults: evidence for a phenotype.
J Gerontol A Biol Sci Med Sci 2001; 56, M146-56
"It is not age that is at fault but
rather our attitudes toward it"
Cicero, Essay on Old Age, 73 B.C.
Clinically Significant Drug
Interactions
Three basic ingredients are needed
o 2 drugs
o 1 patient
…..all of these can impact on the significance
Who is at risk from serious drug
interactions?
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Older and very young people
multiple medications
multiple prescribers
multiple disease states
chronic and serious illness
changes in organ function
Medications on CRGH admission
Number of regular medications on admission
Number of patients
12
10
8
6
4
2
0
1 2
3 4 5
6 7 8
9 10 11 12 13 14 15 16 17 18 19 20
Number of regular medications
n = 42
Clinical Significance of drug
Interactions
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Patient characteristics
Nature of pharmacodynamic response
Mechanism of drug interaction
Safety margin of the interacting drugs
Size of the dose
Duration of therapy
Time course of drug interaction
Order and timing of administration
……my “current” working list
The short answer….
o The interactions that are likely to lead to
significant misadventure in your patients
o This will differ from practice to practice
o We can focus on the drugs…..
o But it’s the people we give them to that
determines the significance of a drug-drug
interaction
Summary
o Know and recognise sentinel symptoms of
concern
o Frailty is an important predictor of risk
o Multiple medications need to be managed
o Risk assessment informs management
o Taking a comprehensive history is essential
Mr NL
On discharge (1 month)
Ceased
– Levodopa- no clear beneficial response
– Benzotropine- contributing to confusion
– Aspirin - risk without clear benefit
– Indapamide - ceased and restarted
Dose reduction
– oxazepam, olanzapine and mirtazipine
UTI and electrolyte disturbance resolved