PACE CASE: Reduction in MedWise Risk Score™ through Pharmacist and Prescriber Collaboration”?

Challenge

MK is a 56-year-old male Program of All-Inclusive Care for the Elderly (PACE) participant with a medical history of diabetes, hypertension, hyperlipidemia, seasonal allergies, insomnia, gastroesophageal reflux disease (GERD), and benign prostatic hyperplasia (BPH). The participant recently experienced a heart attack and his MedWise Risk Score™ is 22 out of 50 (high risk).

The participant’s medication regimen includes:

  • Acetaminophen 500mg three times daily as needed for pain
  • Alogliptin 25mg once daily
  • Amlodipine 5mg once daily
  • Aspirin 81mg once daily for clot prevention
  • Atorvastatin 80mg once daily
  • Carvedilol 25mg twice daily
  • Fluticasone propionate 100mcg/act 1 puff twice daily
  • Hydralazine 100mg twice daily
  • Insulin glargine 60 units once daily
  • Isosorbide mononitrate ER 120mg once daily
  • Losartan 100mg once daily
  • Melatonin 10mg once daily
  • Omeprazole 10mg once daily
  • Sitagliptin 100mg once daily
  • Sucralfate 1g four times daily
  • Tamsulosin 0.4mg once daily

Assessment

Upon reviewing the participant’s medication regimen, the CareKinesis clinical pharmacist identified several areas of concern were identified and discussed during a polypharmacy call with the prescriber were duplication of therapy, potential prescribing cascade, competitive and noncompetitive inhibition interactions, and unnecessary therapy.

  • Alogliptin and sitagliptin are both DPP-IV inhibitors, therefore taking both is considered a duplication of therapy. Additionally, both medications are very costly, do not provide any additional cardiovascular (CV) benefit, and have poor HgbA1c lowering ability.
  • Atorvastatin is a lipophilic statin and may have a greater adverse effect on sleep quality since it crosses the blood brain barrier, causing adverse central nervous system (CNS) effects such as insomnia. Dosing it in the evening may contribute to the participant’s need for melatonin.
  • Omeprazole is a CYP2C19 inhibitor and CYP3A4 moderate substrate. Concomitant use with CYP2C19 and CYP3A4 substrates, such as melatonin and tamsulosin, respectively, may increase the concentration of these substrates and risk of adverse effects.
  • Sucralfate 1g four times a day is typically used for treatment of an ulcer and is recommended for four to eight weeks. The maintenance dose is 1g twice daily, if sucralfate is continued.

Recommendations

The CareKinesis clinical pharmacist recommended the following:

  • Discontinue alogliptin and sitagliptin, and start an SGLT-2 inhibitor for CV benefits since the participant recently had a heart attack
  • Change the time of administration for atorvastatin from the evening to the morning
  • Change omeprazole to pantoprazole to mitigate competitive and noncompetitive inhibition interactions, as pantoprazole is only a weak substrate of CYP2C19
  • Re-evaluate the continued need for sucralfate four times a day and consider decreasing to a maintenance dose of twice daily or discontinuing, if no longer warranted

Outcomes/Conclusion

The PACE prescriber addressed the recommendations as follows:

  • Alogliptin and sitagliptin were discontinued to mitigate adverse effects and decrease cost
  • Dapagliflozin was initiated for the management of diabetes and for its CV benefits
  • Atorvastatin time of administration was changed to morning to lower risk of insomnia
  • Omeprazole was changed to pantoprazole to mitigate competitive and noncompetitive interactions
  • The participant was referred to a gastroenterologist to determine if sucralfate was still necessary

After the recommendations were addressed, the participant’s MedWise Risk Score decreased from 22 (high risk) to 9 (low risk).

Reviewing the participant’s medication list periodically will allow the CareKinesis clinical pharmacist and PACE prescriber to identify any new issues and resolve them within a timely manner.

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