Nancy is an 89-year-old female patient in a PACE program.
As her Precision Pharmacist, I found she had an extremely concerning medication regimen.
Nancy had a history of COPD, high cholesterol, seasonal allergies. high blood pressure, and chronic pain. She was taking 13 medications and so I used the GalenusCare safety analytics tool to help guide some deprescribing for Nancy. My goal was to optimize her medication regimen for efficacy and safety while reducing her pill burden. I found several opportunities for interventions to achieve this goal.
Often in the care of older adults, we talk about the risks associated with "anticholinergic" medications. These medications span different classes, indications, and mechanisms of action. What they all have in common is their drying effects. In the short term, these medications cause dry mouth, dry eyes, constipation, and urinary retention. When we become most concerned, is with long term use. Long term use of anticholinergic medications has been associated with an increased risk of falls and an increased risk of cognitive impairment, including causing and worsening dementia.
Through the use of the GalenusCare safety analytics tool, I was able to identify 2 medications with moderate and high anticholinergic risks. The tool takes into account not only individual risk, but cumulative risk of anticholinergic side effects. Both medications were opportunities for deprescribing.
The first medication I identified has a high risk of anticholinergic side effects. It is a medication used as needed for dizziness called meclizine. This medication is often thought to be safe due to it reducing dizziness and being available over-the-counter. However, long term use is associated with the risk of cognitive impairment and falls. This medication utilizes the drying properties to help with excess fluid in the ears which can affect balance. This medication may work well for patients where this is the cause of dizziness. However, it is recommended to use meclizine for the shortest duration possible due to its long term risks.
The second medication was another over-the-counter medication, this one used for seasonal allergies, called cetirizine. Of the over-the-counter non-drowsy seasonal allergy medications, cetirizine has the highest risk of causing anticholinergic and sedative side effects. Daily use of cetirizine may significantly increase this risk. In addition, I was able to see that the patient was already ordered a non-oral medication, fluticasone nasal spray, for seasonal allergies. Fluticasone is typically recommended as a first-line treatment for seasonal allergies because it works so well. In addition, because it works locally in the sinuses, fluticasone has a lower risk of causing side effect like cetirizine.
Based on these risks and the patient's other medications, I recommended that the doctor consider discontinuing both of these medications. Not only would this help to reduce the patient's risk of anticholinergic side effects, it would help to reduce the number of pills that she needed to take per day.
Finally, I was able to find one additional medication that may have been significantly contributing to the patient's risk of side effects and interactions. The patient was prescribed omeprazole, a proton pump inhibitor (PPI), for stomach acid symptoms. This medication is often started for acute symptoms and simply never stopped.
Chronic therapy with a PPI has been associated with reduced bone density, low magnesium levels, and an increased risk for c. difficile infection. In addition, omeprazole significantly inhibits a drug metabolizing enzyme called CYP2C19 which may affect the break down of other medications the patient may take in the future. Based on these risks, and the lack of a clear indication, I suggested discontinuing omeprazole therapy.
It is important to note here that PPI therapy should be tapered off and not stopped abruptly. Oftentimes, when PPI therapy is stopped the patient will experience what is known as rebound acid reflux. This sometimes leads to the PPI being restarted and the trial discontinuation being classified as a failure. Therefore, patients will remain on long term PPI therapy, however the rebound symptoms may have only occurred because the medication was stopped too quickly. Therefore, when making the recommendation to discontinue omeprazole I recommended a taper before full discontinuation.
I was able to make the recommendations to deprescribe 3 over-the-counter medications in this 89-year-old patient. Her medication regimen concern was able to be reduced from extremely concerning to very concerning once these changes were implemented. While this may seem like a modest reduction, the decrease in the level of concern has been associated with a lower risk of falls, emergency room visits, hospitalizations, and even premature mortality. We will continue to follow this patient and make additional recommendations to further optimize her regimen over time.
In this case, I was able to improve the safety of this patient's medication regimen by reducing the risk of adverse drug events, especially those caused by anticholinergic medications. This will help to reduce the risk of additional incurred medical costs associated with a fall or hospitalization. Overall, the patient was satisfied with the reduction in number of pills that she needs to take per day and the healthcare team was appreciative of the targeted approach to deprescribing.