Medicines Optimisation 2

Frailty Case Study 1: Mr JK

The following case study is a summary of true events from an inpatient seen by a frailty pharmacist (names have been changed for confidentiality purposes). Please work through the case in the time provided, answering the questions that follow.

Mr JK (87yrs) was admitted to an acute hospital following a fall and long lie (14 hours) at home, being found by a friend who called the ambulance.

The patient was clerked as follows:

PC: Fall with long lie (14 hours)

HPC: No re-collection of fall, woke up on bedroom floor and found by friend.

PMH: Iron deficiency anaemia, THR (total hip replacement), OA of hip, htn (hypertension), depression, AF, PE, T2DM, IHD, COPD

SH: Retired, lives alone at home, wife recently deceased. Family visit regularly. No smoking or alcohol.

FH: Nil noted

MH:

1.     Edoxaban 30mg om → for PE and AF

2.     Trimbow 2 puffs BD (DPI)

3.     Bisoprolol 2.5mg BD

4.     Ferrous fumarate 210mg OD → iron supplement

5.     Isosorbide Mononitrate 10mg BD 8am and 1pm → for angina

6.     Omeprazole 20mg OM → for GI bleeding

7.     Sertraline 100mg OM → depression

8.     Simvastatin 20mg ON → prevention of CVD and AF

9.     Ondansetron 4mg OM → antiemetic

10.  Docusate sodium 100-200mg prn

11.  Macrogol sachets: 1 sachet BD prn

12.  Paracetamol 1g 4-6 hourly prn

13.  Metformin 500mg BD

14.  Solifenacin 5mg BD → for incontinence (overactive bladder)

15.  Salbutamol 100pMDI 2 puffs QDS prn

Previous acute courses of steroids noted for ieCOPD.

Last B12 injection given 5 months previously

OTC: B12 tablets

Relevant results:

CrCl= 50ml/min

Blood glucose= 4-6mmol/L

HbA1c= 34

QTc= prolonged (new finding on ECG)

Weight: 56.6kg (reduced from previous recording)

BP: 162/75mmHg

HR: 64

1.     What clinical investigation should be carried out initially for an unwitnessed fall, and which medication should be held until this has been performed?

• check alertness

• ask patient for consent

• ask patient to point where is painful

• physical examination

• if fallen from head, CT scan to check for internal bleeding

• if fallen to the back, X-ray for minor-major fractures

  STOP

• edoxaban (anticoagulant) → bleeding → change to LMH like enoxaparin

• bisoprolol → hypotension

• sertraline → dizziness and drowsiness

• ondansetron → MH doesn’t have indication of this so could stop

   

2.     What blood tests would you check to deem Mr JK's current prescriptions suitable? Briefly explain the relevance of each test accordingly.

• FBC → haemoglobin, mean cell volume, B12 deficiency → iron levels should go up by max 3 months

• LFT  

• U&Es

• stop DAMN for kidney issues

  → Diuretics, ace inhibitors, metformin, nsaids

• creatinine kinase → could be raised due to long lie

3.     Which of these medications could increase Mr JK’s risk of falls and why? (There can be multiple causes, so feel free to explain as many as you can!)

• sertraline - drowsiness, slow down (prolong QT interval) heart rate → this patient already has prolonged QT interval

• bisoprolol - slows down blood pressure

• edoxaban

• solifenacin - anticholinergic burden

• laxatives could cause electrolyte imbalances & rushing to bathroom may cause increased risk of falls

• metformin - could cause confusion and drowsines / considering his hba1c, diabetes is well controlled, might stop metformin

• ondansetron - use in patients post surgery but causes prolonged QT interval

4.     Considering this, do you think this is an example of appropriate or inappropriate polypharmacy?

• inappropriate

5.     Which physical measure should be undertaken on the ward after a fall and how is it measured? Why is this measure carried out?

• have them to lie down

• taken their bp

• ask them to stand up

• measure bp

• check if difference in initial standing up bp (within 1 min) → postural hypotension

• rugs? pets?

Mr. K has a NAD CT-B (no abnormality detected in the brain) reported, therefore his edoxaban prescription is continued. There is no postural hypotension noted. Haemoglobin levels are in range at 130g/L.

You decide to go and speak to Mr K to clarify his medication history.

Mr. K reports that he is feeling very low after losing his wife the previous month, and his GP has just increased his sertraline dose to 100mg. He has not been eating very much, and notices that his clothes are becoming baggy. He is compliant with all his medications but struggles to use the Trimbow inhaler. His GP changed him over from the “puffer” shaped one which he liked. He needs to use docusate regularly but doesn’t like Macrogol as it causes flatulence. The tablet for bladder hasn’t made much difference, JK still gets up 2-3 times per night to empty his bladder which reduces his quality of sleep. JK can’t remember why he takes ondansetron, he has taken it for years and follows the doctors instruction. He doesn’t report any dizziness and doesn’t recall feeling dizzy before his fall. No complaints of nausea or vomiting. He has been taking iron tablets for about 8 years.

6.     Given this information, how would you optimise Mr K’s medication?

• find out why it has been changed, would prefer DPI (dry powder inhaler) but if the PMDI (pressurized metered dose inhaler) is needed then give it

• docusate → doesn’t like it → could stop it / adjust diet

• solifenacin (antimuscarinic) → not effective / change med →

• sertraline → monitor dosage and check side effects like drowsiness (prolongs QT interval) & support from family friends mental health clinic

• ondansetron (antiemetic) → discontinue (prolonges QT interval) / could be causing constipation - check if its from this (if it is, could also stop the laxatives)

• ferrous fumarate (iron supplements) → may reassess need and discontinue (causes constipation)

• metformin → might stop and later down the line … (renal function if below 30, could get lactic acidosis) & loosing weight

• simvastatin → may stop

 7.     Given patient’s history of steroid use and falls, what measure of protection should be considered?

• check vit d and calcium

• bone health monitoring

• fall risk assessment

JK’s haematinics return- MCV, folate and ferratin in normal range, and B12 > normal range.

Calcium levels are 2.17 mg/dL (2.2-2.6 mg/dL) and vitamin D = 39 nmol/L

Reference from local guideline:

• >50 nmol/l Satisfactory Vitamin D levels

• 30-50 nmol/l Vitamin D insufficiency

• <30 nmol/l Vitamin D deficiency

8.     What actions would you advise to take next?

• vitamin d supplementation

• calcium supplementation

• adcal-d3

• reassess diet

• stop iron tablets

While in hospital, Joe had a 24-hour tape to investigate the syncopal 실신 episodes had occurred. It was found he had an episode of tachycardia, which can cause syncope, as well as ectopic beats. He was arranged to have an outpatient Spiderflash* 7-day ECG (심전도 지속적으로 모니텅하는 장치) monitor and further follow-up if abnormal.

Joe was started on bisoprolol 2.5mg BD for this by the cardiology team.

Is there any possible rationale for the B-blocker being prescribed twice daily and are there any issues with taking a B blocker in the evening?

• bisoprolol in the evening → reduced heart rate and blood pressure during nighttime when the body's resting demands are lower, potentially causing dizziness or hypotension upon waking up to go to the bathroom which could worsen falls risk for this patient

• beta blockers also reduce production of melatonin so not the best idea to give it at night

• but, prolonged exposure to drug would help patient control his symptoms

*A Spiderflash is a small device that monitors ECG continuously during the day and night. It is useful for reporting occurrence of irregular heart rate and rhythm such as in paroxysmal AF.

 Joe L/S BP was repeated following feeling dizzy on standing in hospital which reported a significant postural drop of 32mmHg systolic. The doctors ask you how to manage this medically- what do you advise? What monitoring would you carry out?

• might reduce the dose of bisoprolol to 2.5mg once daily

• isosorbide mononitrate (nitrate to prevent angina 협심증 relaxing blood vessels) → might stop

Joe is finally ready for discharge. His observations are more stable and he is medically fit. The isosorbide mononitrate was stopped and he is stable on bisoprolol 2.5mg OM.

Thanks to the mental health referral, his low mood was recognised (arising from emerging dementia and on-going bereavement), and he was assigned a CPN (community psychiatric nurse) and ongoing monitoring of his condition.

The frailty team ensured he was safely secured a bed in respite care for ongoing support until he is ready for home.