PACE Case: Risk Score Reduction Recommendations

A CareKinesis pharmacist provides recommendations to a 77-year-old female participant with a risk score classified as “very high” in hopes of reducing her medication-related risk. The participant has a history of psychosis with paranoia and anxiety, GERD, and irritable bowel syndrome, but has a normal renal function and no known drug allergies.

The participant’s medication regimen includes:

Risperidone 1 mg BID
Olanzapine 10 mg QHS
Metoclopramide 5 mg BID
Dicyclomine 20 mg QID
Esomeprazole 40 mg QD

The CareKinesis pharmacist notes the duplicate anti-psychotics, and confirms that the psychiatrist wants the participant on both medications and would not be changing since the participant is currently tolerating as is.

The participant is taking Metoclopramide for GERD, with a duration exceeding the recommended 12 weeks. Per the black box warning, the risk of developing tardive dyskinesia (TD) increases with duration of treatment and total cumulative dose. Therefore, physicians should avoid prescribing them to patients receiving other drugs that are likely to cause TD (e.g., anti-psychotics), and note that the risk is highest in elderly females.

Metoclopramide is a strong substrate of CYP2D6 which may lead to higher concentrations of Risperidone when administered together, putting the patient at higher risk of side effects from anti-psychotic. Dicyclomine, prescribed for IBS, is on the BEERS list and has an anticholinergic value of 3. The patient already has a diagnosis of psychosis, and Dicyclomine can contribute to delirium in geriatric population.

The CareKinesis pharmacist recommends a trial discontinuation of Dicyclomine, switching to administration when necessary; the medication was discontinued. The pharmacist also suggests discontinuing Metoclopramide, which was decreased to 5 mg every day for seven days, then stopped. Lastly, the pharmacist proposes increasing the participant’s proton pump inhibitors dose to help with any increase in GERD symptoms

Upon follow-up with the CareKinesis pharmacist, the participant is stable, the Dicyclomine and Metoclopramide have not been restarted, and her GERD is currently controlled on Nexium. Her risk score continues to trend downward on the recently released medication risk score chart in her profile.