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Carroll2017 PDF
Carroll2017 PDF
Teachable Moment
Story From the Front Lines Transitions of care are also associated with medication errors,
An 83-year-old woman with a history of atrial fibrillation and conges- whichmakehospitaldischargeanopportunetimetoaddresspolyphar-
tive heart failure was admitted to the hospital after presenting with macy.AstudyconductedinelderlypatientsintheVAsystemfoundthat
lightheadedness and palpitations secondary to atrial fibrillation with 44% had at least 1 unnecessary medication at discharge.1
rapid ventricular response. This was her third admission for atrial The medication list for this patient was simplified at discharge,
fibrillationwithuncontrolledheartrateinthepast6months.Pharmacy but could more have been done to optimize the safety of her regi-
records indicated she had not refilled either of her prescribed nodal men? With the use of established prescribing tools such as Beers
blocking agents for several months. She was restarted on her reported Criteria and STOPP,3 physicians can eliminate redundant or inap-
home dose of metoprolol succinate at 50 mg daily and diltiazem propriate medications in geriatric patients. In a study of nursing home
180 mg daily with prompt normalization of heart rate. She was dis- patients presenting to the emergency department, both sets of cri-
charged the following day. teria identified the same number of patients at risk of potentially
Twodaysafterreturninghome,thepatientpresentedtotheemer- inappropriate medications.3 In addition, there was no difference in
gency department with a presyncopal episode caused by bradycardia the length of hospital stay and 12-month mortality when compar-
and hypotension after an unintentional metoprolol overdose. She was ing patients prescribed potentially inappropriate medications
admitted to the intensive care unit and initiated on a glucagon drip. Her according to Beers vs STOPP criteria.
symptomsresolvedafter24hours,andshewastransferredtothefloor. Another strategy to optimize safe prescribing is to carefully match
At discharge, the patient expressed frustration with her home medica- eachmedicationtoanassociatedmedicalcondition.4 Medicationswith-
tionregimen,statingthatitwasconfusing,burdensome,andexpensive. out a clear indication can generally be discontinued. This patient was
Herpillregimenathomeincluded11medications:metoprolol,diltiazem, on a daily antihistamine as well as a histamine 2 blocker but had no his-
digoxin, apixaban, atorvastatin, lisinopril, furosemide, ibandronate, tory of seasonal allergies, gastritis, or gastroesophageal reflux disease.
loratadine,ranitidine,andamultivitamin.Thepatientandherfamilyde- Thus, loratadine and ranitidine could be discontinued with monitor-
sired to simplify her medication regimen, preferring to continue only ing for recurrent symptoms. She was also on a multivitamin, despite
thosethatwouldhelppreservefunctionandkeepthepatientoutofthe consuming a normal diet, which could be stopped as it was financially
hospital. At discharge digoxin and atorvastatin were discontinued. burdensome and unnecessary.
Teachable Moment Optimizinganindividual’smedicationtakesintoaccountmorethan
The majority of this patient’s medications were prescribed in accor- just practice guidelines but also patient preferences. Correctly assess-
dance with practice guidelines. However, harm was caused by not con- ing the unique preferences of the patient allows for tailoring medica-
sideringtheentirecontextandindividualcircumstancesforthispatient, tion regimens to each patient’s individual circumstances, including af-
resulting in polypharmacy and multiple hospitalizations. fordability, tolerability, and goals of care. In this case, the patient’s pri-
Polypharmacyiscommon,withnearly20%ofcommunity-dwelling orities were to minimize pill burden, improve affordability, and avoid
adultsolderthan65yearsprescribed10ormoremedications.1 Changes hospitalization if at all possible.
inpharmacokineticsandpharmacodynamicsassociatedwithagingput Polypharmacy is a well-established problem for elderly patients.
olderpatientsatgreaterriskforadversedrugevents.Onestudy2 found The discharge process provides an opportune time to address patient
that compared with patients taking fewer than 5 medications, patients preferences and eliminate unnecessary medications. With simple and
taking 8 or more medications had 4 times the rate of adverse drug effective methods, such as STOPP criteria and matching each medica-
events. Indeed, multiple studies have shown that adverse drug events tion with an indication, clinicians can decrease polypharmacy and
account for up to 10% of hospital admissions in older adults. improve patient outcomes.
ARTICLE INFORMATION Additional Contributions: We thank the patient for patients 65 years or older: the GerontoNet ADR risk
Author Affiliations: Department of Internal granting permission to publish this information. score. Arch Intern Med. 2010;170(13):1142-1148.
Medicine, University of Colorado, Aurora. 3. Grace AR, Briggs R, Kieran RE, et al. A comparison
REFERENCES of Beers and STOPP criteria in assessing potentially
Corresponding Author: Casey Carroll, MD, University
of Colorado, 12631 E 17th Ave, PO Box B178, Aurora, 1. Hajjar ER, Hanlon JT, Sloane RJ, et al. Unnecessary inappropriate medications in nursing home residents
CO 80045 ([email protected]). drug use in frail older people at hospital discharge. J Am attending the emergency department. J Am Med Dir
Published Online: April 24, 2017. Geriatr Soc. 2005;53(9):1518-1523. Assoc. 2014;15(11):830-834.
doi:10.1001/jamainternmed.2017.0911 2. Onder G, Petrovic M, Tangiisuran B, et al. 4. Steinman MA, Hanlon JT. Managing medications
Conflict of Interest Disclosures: None reported. Development and validation of a score to assess in clinically complex elders: “there’s got to be a
risk of adverse drug reactions among in-hospital happy medium”. JAMA. 2010;304(14):1592-1601.
jamainternalmedicine.com (Reprinted) JAMA Internal Medicine Published online April 24, 2017 E1