Check Programme

Case one

A 75 years old man has had multiple hospital admissions over the last 2 years. The discharge summaries list the following ongoing problems – COPD, heart failure, atrial fibrillation, hypertension, type 2 diabetes, hypercholesterolaemia, gastrooesophageal reflux, prostatic hypertrophy, inguinal hernia and depression. His most recent admission was two months ago when he had worsening shortness of breath, and the discharge diagnosis was infective exacerbation of COPD. His previous two admission discharge diagnoses were also infective exacerbation of COPD, but in addition had congestive cardiac failure as co-diagnoses. His discharge prescription from his last hospital admission was salmeterol 2 puffs bd; budesonide 2 puffs bd; prednisolone 10mg daily; digoxin 0.25mg daily; warfarin according to INR; frusemide 40mg bd; enalapril 10mg daily; spironolactone 25mg daily; diltiazem SR 180mg daily; glibenclamide 5mg bd; metformin 500mg bd; simvastatin 10mg daily; ranitidine 150mg bd; aspirin 150mg daily; oxybutynin 5mg bd; diazepam 2mg daily and sertraline 100mg nocte. You last saw him two weeks ago when his shortness of breath was stable. His pulse was 65bpm with atrial fibrillation, his JVP was normal, his chest was clear and he had no swelling of his ankles. He continues to smoke and you exhorted him (yet again) to stop. You continued all his medications. You now receive a phone call from your local pharmacist to suggest a medication review as she is concerned about his polypharmacy. She also says she wants to sell him nicotine patches to try to help him give up smoking and wants your approval for this.

HK Pract 2001;23:510-512

Question 1
What would your response to the pharmacist's call be?

Answer 1
The patient has been prescribed 17 different medications. It would be hard to argue that a review of all these medications should not be undertaken! It is obviously a different question as to whether or not the review is likely to lead to a reduction in medications.

It is important for the patient to give up smoking, although nicotine replacement therapy is perhaps not very likely to assist in his case. However there is also an obvious irony in considering adding another drug to his regimen at the same time as undertaking a medication review with the aim of reducing his medications.

Question 2
In your discussion with the pharmacist, she suggests you create a priority list of the medications, ranking each as essential, highly desirable, could possibly be done without or could easily be done without.

Do you think this will be a useful exercise? If so, rank each medication as best you can according to these categories.

Answer 2
It will probably be a useful exercise, although you may not have all the information required to make these judgements. On the information so far provided, the list might look like this:

Salmeterol

Probably essential in view of the recent hospital admissions, but respiratory function test results should be reviewed for evidence of bronchodilator response. If there was no response the necessity for salmeterol would be more questionable.

Budesonide - as for salmeterol

Prednisolone

As for salmeterol, but the necessity should be looked at more closely because of its long term adverse effects.

Digoxin

Essential for control of the ventricular rate in atrial fibrillation.

Warfarin

He is probably at moderately high risk of embolism from his atrial fibrillation, and the risk of embolism would possibly be greater than the risk of harm from the warfarin, e.g. bleeding. However the harm/benefit analysis probably does not favour warfarin so strongly as to mean the warfarin is essential. Warfarin should therefore be categorised as highly desirable.

Frusemide

The discharge diagnosis of cardiac failure suggests frusemide is essential. However the results of recent chest x-rays and echocardiographs, if available, should be reviewed to ensure the diagnosis of cardiac failure is correct.

Enalapril - as for frusemide

Spironolactone

This is probably not required for symptom control in his case, and was possibly commenced in hospital on the basis of trials demonstrating modest prolongation of life in patients with cardiac failure. As his prognosis will probably be determined by his airways disease rather than his cardiac failure, this drug would be best categorised as could possibly be done without.

Diltiazem

It is not clear why he is taking this drug. It might have been commenced for control of his hypertension, or he might have had angina in the past, as coronary artery disease is the most likely underlying cause of his cardiac failure. Depending on his past history, this drug can be categorised as could possibly or easily be done without.

Glibenclamide

It is important to review the control of his diabetes since treatment began. It should be borne in mind that because of this patient's likely rather poor prognosis from his COPD and cardiac failure, it may not be as essential to meticulously control his blood glucose levels as it would be for a patient with an otherwise better prognosis. The necessity for this drug very much depends on the difficulty in control of his diabetes.

Metformin - as for glibenclamide

Simvastatin

His poor prognosis from his COPD and his cardiac failure make it unlikely that lowering his cholesterol will make any difference to his long term outlook unless he has extreme hypercholesterolaemia. This drug can be classified as could possibly, or even easily done without.

Ranitidine

The necessity for this drug depends on the severity of his symptoms, and how well non-drug treatments were tried before he commenced the ranitidine. He also might not need ranitidine if he is able to stop taking aspirin. This drug could possibly be done without.

Aspirin

This was presumably prescribed because it was assumed his cardiac failure is caused by coronary artery disease. The necessity depends on the strength of the evidence that he has significant ischaemic heart disease. It is likely that it could possibly be done without.

Oxybutynin

The necessity for this drug depends on the severity of the symptoms of his prostatic hypertrophy. It usually produces at best a modest improvement in symptoms and it is likely that it could possibly, or even easily be done without.

Diazepam

This was presumably prescribed for him when he was in hospital and might have been for night sedation. It is very likely that it could easily be done without.

Sertraline

The necessity for this drug depends on the severity and longevity of his depression at the time it was commenced, the clinical judgement as to whether or not it has improved his symptoms of depression and whether or not it is causing any adverse effects. It is likely it is possible it could be done without.

Question 3
Who should be responsible for making the decision as whether or not the different medications should be continued - you or the hospital?

Answer 3
It presumably depends on who has the more comprehensive contact with the patient, and the records which will be needed to make the decisions. The hospital is more likely to have the records for the principal diagnoses COPD, atrial fibrillation and cardiac failure, and it will probably be more appropriate for the decisions about their treatment to be made at the hospital. However as you are more likely to have the records for the other conditions such as his diabetes, hypertension, hypercholesterolaemia, reflux disease, prostatism and depression, it will probably be more appropriate for you to make the decisions about the need or otherwise for continuation of the medications for those conditions.

Royal Australian College of General Practitioners