Polypharmacy Cases

1. Polypharmacy Cases Donald R. Noll DO FACOI Edited by Edward Warren, MD, Chair Geriatrics Carolinas Campus, March 2012

2. HPI: New patient form the VA . He asks if his medication could be adjusted to help with urinary urgency. The recent decrease in the tolterodine dose, which was doing some good for his bladder, now wears off between doses. Otherwise, he is doing pretty well, the nursing staff reports no new issues. History: 73-year old patient with Paranoid psychosis, Post-Traumatic Stress Disorder (Korean War), DM, HTN, Obstructive Sleep Apnea, PVD, GERD, CAD, DJD, Hyperlipidemia, Dementia?, B12 Deficiency, Stoke with right sided weakness, left nephrectomy, appendectomy, and cholecystectomy. ROS: Denies chest pain, shortness of breath or bowel complaints. He complained of his bladder as in HPI. Exam: Vitals stable, weight 230 lbs. Lungs CTA, Heart rate RRR, Abdomen soft with normal bowel sounds, Extremities without edema, was examined in the wheel chair. INR=2.22, lipids show low cholesterol – consistent with malnutrition, LDL is only 47, and total cholesterol is 115. HgbA1C=6.8. There is no real dx to go with the Aricept medication on the chart, the problem list did not list Alzheimer’s Disease or Dementia. Medications: donepezil 5mg daily, B12 monthly, warfarin 4mg daily, losartan 25mg daily, rovusastatin 5mg daily, terazosin 10mg hs, etodolac 400mg daily, finasteride 5mg daily, risperidone 2mg hs, sertraline100mg daily, glyburide 5mg bid, isosorbidedinitrate 20mg daily, temazepam 30mg daily prn, tolterodine 2mg daily Progress Note

3. Polypharmacy Hyperchlosterolemia – on medication for this Delusional disorder/ psychosis/ post-traumatic stress disorder – stable Spastic Bladder – worse with recent dose reduction Benign Prostatic Hypertrophy – on medication Stroke / ASCVD / PVD – INR therapeutic HTN – adequate control Depression – adequate control Impressions

4. This patient is on 13 different scheduled medications. Considering the risks and benefits, the attending stopped two medications because they were deemed non-essential in an effort to lower the number of medications. Pick two medications to stop. Question 1 donepezil warfarin B12 Vitamin losartan rosuvastatin terazosin etodolac finasteride risperidone sertraline glyburide isosorbidedinitrate tolterodine

5. Is it reasonable to increase the dose of his anti-bladder spasm medication (tolterodine)? Yes No Question 2

6. Carbidopa-levodopa Atorvastatin Sertraline Enalopril Glipizide Finasteride Metoclopramide Question 3 A patient suffering from Parkinson’s Disease comes to you with this list of medications. One of these medications has side effects that are Parkinsonian. Pick one to stop.

7. Regarding Question 3, what type of drug interaction would best fit? Pharmacokinetic drug interaction Pharmacodynamic drug interaction Disease - drug interaction Question 4

8. What other medication is famous for worsening symptoms of Parkinsonism? Haloperidol Hydrochlorothiazide Antivert Lopressor Lipitor Question 5

9. Why is polypharmacy a growing problem and not likely to go away anytime soon? Physicians encouraged to give more aggressive treatment of diabetes mellitus, lipids, and HTN Multiple new drug treatments for dementia, CHF, and others. New preventative treatments being pushed: osteoporosis. Growth of Alternative Therapies (nutraceuticals and herbal medications) All of the above Question 6

10. A patient taking Coumadin is started on paroxetine to manage depression. The patient’s INR levels become elevated soon after, requiring a modest dose reduction of the Coumadin. What type of drug interaction in this? Pharmacokinetic drug interaction Pharmacodynamic drug interaction Disease – drug interaction Question 7

11. Which herbal treatment is associated with increased risk of bleeding and may interact with other medications that effect bleeding times? Kava St Johns Wort Ginsing Ginkgo Biloba Ephedra Question 8

12. With which of these does tramadol adversely interact? ACE inhibitors Calcium Channel Blockers Beta Blockers SSRI’s (selective serotonin reuptake inhibitors) HMG-CoA Reductase Inhibitors Question 9

13. When Insulin is added to a Beta Blocker, it causes refractory hypoglycemia, what type of drug interaction is this considered to be? Pharmacokinetic drug interaction Pharmacodynamic drug interaction Disease – drug interaction Question 10

14. A & E The donepezil has no clinical indication. The rosuvastatin has potential side effects of weakness and myopathy. He may have had hyperlipidemia in the past, but not now. A It is not likely to interact badly with any of the other meds and he needs the clinical benefit for quality of life. G Metoclopramide causes dyskinesia. None of the other meds are problematic in this context. C It would be a disease – drug interaction at most. A Most of the major tranquilizers can cause dyskinesia also. Dyskinesia is not Parkinson’s disease. It just looks similar and has a similar mechanism. E It is all of these. Be skeptical of all therapy: herbal, “natural”, and legitimate. Think for yourself about recommendations from national organizations. A This pharmacokinetic due to the Cytochrome P450 enzyme inhibition of the paroxetine, and the effect it has on warfarin protein binding. DGinko, and it does not even have any beneficial effects on the body or disease. D Tramadol also acts as an SSRI and leads to serotonin syndrome. B The Beta blocker causes the signs of diaphoresis and tachycardia to be blunted in hypoglycemia by depressing levels of epinephrine. That same mechanism blunts glucose formation and prolongs the hypoglycemia. This is all pharmacodynamic, an effect of the medication itself. Answer Key