Pharmacy
Medication Optimization
Hospice
Patient Case
Pharmacy
Medication Optimization
Patient Case: Addressing Pain Control with Drug-Drug Interactions
Desiree Massari
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Lucy is a 97-year-old woman recently admitted to hospice care.
As her Precision Pharmacist, I identified that she had a medication regimen extremely concerning for adverse drug events.
Lucy had a history of chronic pain that was not well controlled. She explained to her nurse on initial assessment that she had also been experiencing some dizziness on standing. I kept these complaints in mind when I used the GalenusCare safety analytics tool to guide recommendations and interventions to improve the safety of Lucy’s regimen.
Pain Control and Drug-Drug Interactions
Lucy was using hydrocodone with acetaminophen 3 times daily as well as tramadol as needed for pain. These are common medications used in the treatment of pain although the use of these 2 medications together may increase the risk of opioid overdose. While tramadol is often viewed as a safer option, clinically it acts the same as an opioid with the added risk of serotonin syndrome due to its mechanism of action.
Hydrocodone and tramadol also have in common that they both require activation by a drug metabolizing enzyme called CYP2D6. The activity of CYP2D6 can be influenced by both a patient’s genetics as well as other medications they are taking. For example, Lucy was using duloxetine. Duloxetine is used for pain as well as mood disorders such as depression and anxiety. In addition, duloxetine needs CYP2D6 for metabolism. When duloxetine is taken with hydrocodone and tramadol, it will prevent the pain medications from using CYP2D6 to become active for pain control.
Since Lucy was taking hydrocodone multiple times per day, it would be difficult to separate her pain medications from duloxetine to avoid this interaction. Therefore, in order to better control Lucy’s pain, I determined that it may be best to stop tramadol and hydrocodone and use an alternative medication to treat her pain.
Upon admission, GalenusCare assesses the need for a comfort SyMPTOM (Symptom Management Pack for Timely Optimized Medications) kit to treat symptoms associated with end-of-life. This kit includes liquid morphine, which does not require activation by the CYP2D6 enzyme. In addition to recommending to discontinue the orders for tramadol and hydrocodone, I provided dose conversion calculations for the use of liquid morphine to better treat Lucy’s pain.
Other Drug-Drug Interactions
Lucy’s second complaint involved experiencing dizziness on standing. Another interaction I was able to identify using the GalenusCare safety analytics tool was between duloxetine and metoprolol. This interaction would lead to higher levels of metoprolol when taken at the same time as duloxetine.
Metoprolol is a medication that is used to lower the heart rate and blood pressure. One of the common symptoms of low blood pressure is dizziness on standing, like Lucy was experiencing. Since Lucy was already taking other medications in the afternoon, I changed the time of administration of duloxetine from the morning to the afternoon. Separating duloxetine from metoprolol by these couple hours helped to avoid the interaction.
Since changing time of administration is within a pharmacist’s scope of practice, I would be able to make and implement this change. The GalenusCare Precision Compliance Packaging would reflect this change so that the duloxetine was placed in the afternoon pocket, the safest time for her to take this medication. This change would also be documented for the care team in the patient’s electronic health record for continuity of her care.
Summary
Through the use of the GalenusCare safety analytics tool and the utilization of a SyMPTOM kit and Precision Client Packaging, I was able to reduce Lucy’s level of concern from extremely concerning (level 5) to very concerning (level 4). We will continue to follow Lucy to ensure that her pain is well controlled and her dizziness improves with these changes.
