An 80-year-old female PACE participant has a high medication burden of 15 chronic medications. She and her PACE center physician feel that she is on too many medications now that she is on a comfort/palliative care pathway. Her physician wishes to reevaluate her medication regimen and reduce her medication risk score, which is currently 16/50 (moderate).
Her current medication regimen includes:
- Spironolactone 25mg QD
- Pregabalin 75mg TID
- Polyethylene glycol 3350 17g in 8oz of liquid QD
- Pantoprazole 20mg QD
- Lorazepam 0.5mg QHS PRN
- Lisinopril 10mg QD
- Levothyroxine 88mcg QD
- Insulin degludec 18 units QD
- Fexofenadine 60mg QD
- Ferrous sulfate 325mg BID
- Duloxetine 60mg QD
- Carvedilol 12.5mg BID
- Bumetanide 0.5mg QD
- Atorvastatin 40mg QHS
- Aspirin 81mg QD
Her most current lab values are as follows:
SCr: 1.7 mg/dl
CrCl: 36 ml/min
HDL: 39 mg/dl
LDL: 101 mg/dl
TG: 201 mg/dl
Hgb: 12 g/dl
TC: 192 mg/dl
TSH: 1.34 mg/L
K: 5.2 mEq/L
- Recommendation: Potential adverse drug reaction, consider discontinuing aspirin
- The participant is currently prescribed aspirin 81mg daily for the primary prevention of cardiovascular complications. Per the 2019 update to the Beers Criteria, aspirin is not recommended at any dose for participants >70 years old for primary prevention due to lack of evidence of benefit versus risk of bleeding. Salicylic acids can have a direct irritant effect on the lining of the stomach and can contribute to gastrointestinal bleeding, even at low doses. Aspirin also decreases platelet aggregation and prolongs bleeding time. It is, however, noted that the risk of CV events increases as patients age and this population is under-represented in the literature, making it challenging to apply these study findings. Therefore, aspirin must be considered on a case-by-case basis for primary prevention in PACE. Please evaluate the participant’s comorbidities and determine if low-dose aspirin is necessary.
- Recommendation: Evaluate risks vs. benefits of atorvastatin therapy, consider discontinuation
- The patient is on a high-intensity statin for the primary prevention of cardiovascular events. Overall, evidence for statin therapy for primary prevention in older adults is lacking. Consider discontinuing the medication, as the participant is now on a comfort pathway.
- Recommendation: Based on potassium levels, consider reducing spironolactone dose and optimizing alternative antihypertensives
- The participant is prescribed spironolactone and lisinopril, both of which increase the risk of hyperkalemia. The risk increases with renal impairment. The participant’s current estimated CrCl is 36 mL/min.
- Consider reducing the dose of spironolactone. Carvedilol and/or bumetanide doses may be optimized. Monitor potassium to ensure levels have returned to baseline.
- Recommendation: Consider discontinuing iron supplementation as a result of recent lab data
- The participant is currently prescribed 325mg of ferrous sulfate BID. The participant reports that iron contributes to her constipation and occasional stomach pain. Based on recent labs, it appears that the participant’s anemia has resolved. Ferrous sulfate may be discontinued at this time. Continue monitoring Iron studies.
- Recommendation: Discontinue pantoprazole due to potential long term adverse effects
- The long term use of PPIs may result in bone fractures, C. difficile, gastritis, and new onset ischemic stroke. Further, while PPI therapy reduces stomach acid, it may also decrease the absorption of iron. Consider discontinuing pantoprazole, if appropriate. If acid suppression therapy is still indicated, consider an H2-receptor antagonist, such as famotidine.
The physician accepted all recommendations including the discontinuation of aspirin, atorvastatin, and ferrous sulfate, and reduction of spironolactone dose. In doing so, the participant’s constipation resolved and she no longer needs the polyethylene glycol. The fexofenadine for allergies was changed to “as needed” since her allergies are seasonal. The participant was reluctant to discontinue the pantoprazole, which was continued for GI symptom management.
These interventions reduced her pill burden to 9 scheduled medications. Her medication risk score went from 16 to less than 10, and she reports improved quality of life as a result of these medication changes.