Oh, sure. That's what the average GP wants to hear. The # of times I have been told "Your practicing medicine w/o a license." is astounding.
Not a day goes by that I am not explaining the fall risk to an elderly patient on Gabapentin, Ambien, Benzodiazepines, muscle relaxants, antimuscarinics, etc
It's an incredibly complex balance of treating symptoms and illness with the risk of AMS/ falls/ etc. It can be challenging to understand the risk of confusion or a fall in the future when you're acutely suffering in the moment.
The red tape and inertia in community offices is a huge obstacle to pharmacists helping. We rarely speak to even a nurse that might understand why we are calling let alone the prescriber. If we even get a return call. And often staff call back to say “that’s ok, we know”. Very frustrating.
yeah I really wish clinicians were overall more mindful of the meds people are currently on before giving more meds…also I wish we had a universal med list software that could help us see what people were taking even if it was prescribed by another facility etc
This is tricky. Not all physicians update their med lists. It’s always best to trust the patient first. Just because doc prescribed it, doesn’t mean patient is taking it actively.
I’ll be honest, I think the percentage of patients I see in the ED who are at risk for polypharmacy and actually know their med list and can tell me everything is <10%.
It is hard to get some off those benzos though - I had one so upset she got into a cab in her gown to go home and get her own prescription to take in hospital
Back in residency, I had a patient who was a Catholic priest and he ended up in withdrawal because I tapered his benzos too abruptly. Growing up Catholic, I figure I am doomed to hell for this one alone
My primary care uses one EMR, I have two specialists on a different EMR, and another specialist on yet another EMR. Meds lists get out of sync all the time, luckily I’m youngish and know the importance of a home meds list.
…and it has been that way for decades. I used to work adult ICU 40 yrs ago and drs used to admit one specific drs pts with “altered mental status” and safely remove meds, detox them and dc them. I’m glad we have a more speak up culture now. Thanks for speaking up to those who need to hear.
I see this with neuropsychological assessment referrals. When I point it out, it is often discarded as a cause of cognitive concerns, even with sedatives.
I ESPECIALLY look at drugs that are really cleared if there’s been any change in renal function. Gabapentin, Keppra, cefepime, cefazolin, etc do not mix well with any AKI (or worsening CKD)
As an EEG reader, I have a very biased view of cefepime. If they’re getting an EEG for AMS and they’re on cefepime, it’s highly likely to see triphasics.
Flecainide. I hate that drug. I’ve seen multiple cases of toxicity presenting as “weak and dizzy,” mostly related to decreased renal function and no dose adjustments.
Baclofen is extra annoying because baclofen withdrawal is both dangerous and also another cause of altered mental status
So you could look bad because had poor PO intake, prerenal AKI, and kept taking baclofen or you could look bad because you had poor PO intake and *stopped* taking it
It was one of my first Problem Based Learning case studies in medical school. A teenager with depression was taking valerian to self manage and her mum found her with psychotic symptoms
A learning point that has stuck with me that natural or herbal doesn't mean safe or side effect free
As the one that gets consulted for this frequently (neuro) can let you know we never miss it, and then let the consulting team know about it in our best Dr Glaucomfleken.
Can confirm. Also fun to explain that the parkinsonian patient we were called to see really needs to stop the TID metoclopramide they have been taking for 5 years.
This sounds like it needed a doctor call to ask if they meant PRN.
Except once I called on a Viagra rx that read "every day as needed" and the MA just read it to me again, instead of seeing the contradiction there.
Oh Lordy, preach brother!
I read charts where the Home Medications goes on for 2 pages. Step 1, wash them out. Half the crap they're on is for side-effects of the other half. Clean house!!!
One of my least favorite ICD codes is R53.01 Weakness. Most of the time it's polypharmacy in an octogenarian.
Deprescribing is a skill and can be incredibly challenging across linguistic & cultural divides. Tbh, the most effective way seems to be physically removing the pill bottles. Which works great until well meaning, but somewhat distant, family members try to help with refills.
Wanda, I don't understand what you're trying to say. You stay home because you are afraid doctors will discontinue meds that are causing excessive side effects? And what do you mean about "deviants" doing surgery? I'm truly confused. Can you spell it out a bit more?
Our senior cohort group discusses side effects before I purchase meds or take meds & since I microdose & have for 50 years, any side effects are minimal.
I'm not having doctors do surgery. It's not worth it having to get an attorney to monitor you to make sure you treat pain ethically.
In '18, I had a 3 hr Moh's surgery on my nasal sidewall. The dermatologist had the self absorbed pompousness to complain that it was an ordeal to prescribe 1 opiate, so I should take Tylenol.
My face swelled up, 2 black eyes, my nose maserated. I'd never seen a sadist in real life before.
I don’t get what you’re getting at. AMS is a diagnosis of exclusion. It’s higher on the differential for elderly with infection as they are on more medications
that time I called nephrology about one of their acute renal failure patients acting altered and he asked "is he still taking Gabapentin?" and I said "f*ck"
Medicine is so specialized that each practitioner prescribes medications without regard to the other meds. There’s no one providing oversight. Family Medicine used to. Clinical Pharmacists should. As a Gero NP, my job would be to try untangle that mess for my patients’ well being.
While I agree that clinical pharmacists should, the demand by the PBMs to switch to mail order, the expansion of online discount suppliers, and the demise of the independent community pharmacy has meant that 1:1 patient - pharmacist relationships are now vanishingly rare.
They happen every day. There is usually messaging from the PBM if they are taking interacting medications. Pharmacists talk to patients every single day.
Uh, not every patient, and not for long enough. If something's really concerning I'll put in a note to counsel, but if the pt doesn't come in during my shift, idk if they get counseled.
Their pharmacist does. They know hen he renews his 30 day medicine every 45 days. We know when we talk to him about the risks of taking Gabapentin, Tramadol and Xanax. We know hen he uses his albuterol inhaler in 15 days instead of 30.
There are interventions every day. How successful are they?
I believe there are significant differences across age, location, race & social status of these processes that are supposed to occur. Differences between how or if this occurs as you stated in say CVS, home delivery, hospital, assisted living, nursing homes. There are deep cracks in this system IMHO
Oh lord! Many of my community clients are frequent ED visitors. Talk about trying to untangle psych meds. When I review their med lists I’m like “oh shit I hope you’re no taking all of these”.
Comments
polypharmacy concurrent with withdrawal comes up more often than people expect
It’s time for pharmacists to start doing their jobs because too many MD’s aren’t.
Not a day goes by that I am not explaining the fall risk to an elderly patient on Gabapentin, Ambien, Benzodiazepines, muscle relaxants, antimuscarinics, etc
Soo... How many benzos did they get before coming here..?
I ESPECIALLY look at drugs that are really cleared if there’s been any change in renal function. Gabapentin, Keppra, cefepime, cefazolin, etc do not mix well with any AKI (or worsening CKD)
So you could look bad because had poor PO intake, prerenal AKI, and kept taking baclofen or you could look bad because you had poor PO intake and *stopped* taking it
A learning point that has stuck with me that natural or herbal doesn't mean safe or side effect free
Except once I called on a Viagra rx that read "every day as needed" and the MA just read it to me again, instead of seeing the contradiction there.
I read charts where the Home Medications goes on for 2 pages. Step 1, wash them out. Half the crap they're on is for side-effects of the other half. Clean house!!!
One of my least favorite ICD codes is R53.01 Weakness. Most of the time it's polypharmacy in an octogenarian.
I'm not having doctors do surgery. It's not worth it having to get an attorney to monitor you to make sure you treat pain ethically.
My face swelled up, 2 black eyes, my nose maserated. I'd never seen a sadist in real life before.
Polypharmacy is a big deal
Also just had the same story but instead of "acting altered" it was "code stroke" and instead of "gabapentin" it was "baclofen"
“I’m saying he can’t stay on that dose” 🙅🏻♀️
There are interventions every day. How successful are they?
Changing work flows & processes with no regard for the customer— the patient.
I’m old enough to remember when the pharmacist would come to your house to give injections when you were sick.