A 76-year-old female PACE participant has a past medical history of anxiety, cerebral vascular disease, chronic obstructive pulmonary disease (COPD), chronic pain, depression, hyperlipidemia, and type 2 diabetes. The participant’s pre-intervention MedWise Risk Score™ is 25 out of 50 (high).
The participant’s pertinent medications include*:
- Albuterol-ipratropium 100mg-20mcg/inh, 1 puff by mouth four times daily
- Azelastine 0.1%, 2 sprays in each nostril twice daily
- Apixaban 5mg, 1 tablet by mouth twice daily
- Budesonide-Formoterol 160mcg/4.5mcg/inh, 2 puffs by mouth twice daily
- Clorazepate 7.5mg, 1 tablet by mouth once daily
- Fluoxetine 40mg, 1 capsule by mouth once daily
- Gabapentin 300mg, 1 tablet by mouth three times daily
- Hyoscyamine 0.125mg tablet ODT, 1 tablet under the tongue every 4 hours as needed
- Lisinopril 40mg, 1 tablet by mouth once daily
- Lidocaine topical 5% film, 1 patch topically; leave on 12 hours then off for 12 hours
- Metoprolol Succinate 100mg, 1 tablet by mouth once daily
- Novolin® N U-100 insulin, 20 units subcutaneously twice daily
- Novolin R, Sliding scale as directed by prescriber
- Potassium Chloride 10mEq, 2 tablets by mouth three times daily
- Restasis® 0.05% emulsion, 1 drop in each eye every 12 hours
- Torsemide 20mg, 1 tablet by mouth once daily
*Medication list is not all-inclusive
Upon performing a comprehensive medication safety review requested by the PACE prescriber, the CareKinesis clinical pharmacist identified that the participant’s COPD and diabetes therapies may be modified to reduce medication burden and overall cost, and improve breathing and glycemic control. The pharmacist noted that the participant’s medication regimen included Restasis® without an appropriate indication, which costs hundreds of dollars per month. Additionally, the prescribed benzodiazepine, clorazepate, was identified as being potentially inappropriate, given its long half-life and potential adverse drug event (ADE) risk. The clinical pharmacist also noted the potential for an increased risk of adverse effects from higher than expected concentration of metoprolol, resulting from CYP2D6 competitive inhibition interaction due to co-administration with fluoxetine.
Clinical Pharmacist Recommendation(s):
After reviewing the participant’s medications, the clinical pharmacist provided the prescriber with the following recommendations for consideration:
- Consolidation of COPD therapy may help with reducing the medication burden and overall cost. Consider optimizing budesonide-formoterol (inhaled corticosteroid (ICS)/long acting beta agonist [LABA]) and albuterol-ipratropium (short acting beta agonist (SABA)/short acting muscarinic antagonist [SAMA]) inhaler therapy by switching to Trelegy™, a once daily inhaler that is formulated to include a long-acting muscarinic antagonist/long-acting beta2-agonist/inhaled corticosteroid (LAMA/LABA/ICS). This will assist with reducing the total number of inhalations per day and possibly boost compliance leading to improvement in her respiratory condition.
- Restasis is indicated for a confirmed diagnosis of Keratoconjunctivitis sicca. Given the high cost, recommend to evaluate the indication for therapy to determine if it is appropriate to change to alternative therapy, such as artificial tears or other ocular lubricants.
- Regular insulin is short-acting and has a duration of action between 4-12 hours (dose dependent). Given this pharmacokinetic profile, regular insulin may not be appropriate to utilize as a sliding scale, as it may increase the risk of hypoglycemia. Consider switching Novolin® R to a rapid-acting insulin, such as insulin aspart or insulin lispro, which have a rapid onset and a shorter duration of action, thus best used for mealtime coverage. Continue to monitor blood glucose levels and hemoglobin A1c, and adjust dosing as appropriate.
- The concentration of metoprolol may be higher than expected when concomitantly administered with fluoxetine, due to competitive inhibition of CYP2D6. As a result, the participant may experience an increased risk of adverse effects from metoprolol, such as hypotension and/or bradycardia. Recommend to monitor blood pressure and heart rate to determine if separation in doses is warranted. If the participant is experiencing side effects from metoprolol, consider dosing metoprolol succinate at bedtime. An alternative to mitigate the interaction and potential ADE risk is to consider switching the antidepressant, fluoxetine, which has a long half-life, to a preferred alternative, such as sertraline, which has a more favorable ADE profile, depending on previously tried therapies.
- Benzodiazepines should ideally be used for acute, short-term situations as on the Beers Criteria and chronic use can cause significant risk of confusion, cognitive impairment, dizziness, and falls. Additionally, clorazepate has a relatively long elimination half-life that varies between 20 and 160 hours. Lorazepam is a preferred benzodiazepine in older adults because it has a shorter half-life, compared to clorazepate, and does not undergo CYP450 metabolism. In an effort to decrease the use of a benzodiazepine, recommend to optimize antidepressant therapy which also has anxiolytic effects. If a benzodiazepine is necessary, consider switching to lorazepam, at lowest effective dose for shortest possible duration, as a preferred alternative.
- Based on her past medical history of diabetes and hyperlipidemia, as clinically appropriate, in consideration of goals of care, if well-tolerated, and if benefit outweighs risk, re-initiation of a moderate to high intensity statin, such as pravastatin 40mg or rosuvastatin 20mg, respectively. NOTE: As per medication history, previously prescribed pravastatin 40mg and unknown reason why discontinued, September 2019.
With the medication changes as noted below that the prescriber agreed upon and made based on the clinical pharmacist recommendations and appropriateness for the participant at the time, there has been a significant improvement in medication safety for the participant. The participant’s MedWise Risk Score was reduced to 18 out of 50, which is considered moderate risk. The medication burden and cost for the participant were also significantly reduced.
- Budesonide-formoterol and albuterol-ipratropium changed to Trelegy Ellipta™, a daily inhaler
- Restasis changed to propylene glycol, as needed dosing
- Insulin regular changed to as part formulation
- Metoprolol administration time changed from the morning to bedtime
- Clorazepate changed to lorazepam
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