Polypharmacy icon of two pills

Background (age, sex, occupation, baseline function)

  • 65 years old
  • Male
  • Mild frailty (assessed 2 months previously) Rockwood 5

History of presentation/reason for review

  • Annual diabetic review

Current medical history and relevant co-morbidities

  • Transient ischaemic attack (9 and 15 years previously)
  • Type 2 diabetes mellitus – 14 years ago
  • Essential hypertension - 21 years ago
  • Ischaemic heart disease – 31 years ago
  • Angina pectoris
  • Acute myocardial infarction
  • Family history of IHD (noted 14 years ago)

Current medication and drug allergies (include OTC preparation and herbal remedies)

  • Alogliptin 25mg tablets – one tablet daily
  • Bendroflumethiazide 2.5mg tablets – one tablet daily
  • Citalopram 20mg tablets – one tablet daily
  • Clopidogrel 75mg tablets – one tablet daily
  • Furosemide 20mg tablets – one tablet daily
  • Irbesartan 300mg tablets – one tablet daily
  • Lercanidipine 10mg tablets – one tablet daily
  • Metformin 500mg tablets – one tablet twice daily
  • Simvastatin 40mg tablets – one tablet at night

Lifestyle and current function (including frailty score for >65yrs) alcohol/smoking/diet/physical activity

  • Frailty – mild
  • Lives with wife, who does all the housework, preparing meals and shopping
  • Mobilises with walking aid
  • House on two levels, and requires help with stairs
  • Eats a varied diet
  • Weight stable
  • Attends local optician

“What matters to me” (patient ideas, concerns and expectations of treatment)

  • Although pharmacy manages supply of his medication (all on serial prescription) he is reluctant to take medication.  “Can I stop any?”
  • Often forgets lunchtime dose of metformin

Results e.g., biochemistry, other relevant investigations or monitoring

  • Creatinine 101micromol/l; eGFR>60
  • Weight 84.8kg; height 1.8m; BMI 26.17
  • Calculated creatinine clearance 69 ml/min (IBW 75.3kg)
  • Urine albumin 3mg/ml, urine creatinine 9.1mmol/l, ACR 0.3mg/mmol
  • Recent LFTs, FBC normal
  • Last 3 blood pressures: 130/80mmHg, 126/78mmHg, 127/75mmHg
  • Serum cholesterol 4.3mmol/l, ratio 3.5
  • HbA1c 51mmol/mol

Most recent relevant consultations

  • Diabetic monitoring before annual review
  • Limited contact with practice due to COVID restrictions
  • Received all flu and COVID vaccines

 

7 Steps: Person specific issues to address for case study 4

1.  Aims: What matters to the individual about their condition(s)?

Review diagnoses and consider:

  • Therapeutic objectives of drug therapy
  • Management of existing health problems
  • Prevention of future health issues, including lifestyle advice 

 

Person specific actions

  • Simplify medication – “take less tablets”
  • Maintain limited mobility

 

2.  Need: Identify essential drug therapy

Identify essential drugs (not to be stopped without specialist advice*)

  • Drugs that have essential replacement functions
  • Drugs to prevent rapid symptomatic decline

* with advice from healthcare professional with specialist interest

Person specific actions

  • None considered essential

 

3.  Does the patient take unnecessary drug therapy?

Identify and review the continued need for drugs

  • what is medication for?
  • with temporary indications
  • with higher than usual maintenance doses
  • with limited benefit/evidence for use
  • with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific actions

  • Citalopram – started 4 years ago, no indication if ongoing need, although higher incidence of depression in diabetes.
  • Furosemide 20mg potentially unnecessary, if lercanidipine is causing swollen ankles

 

4.  Effectiveness: Are therapeutic objectives being achieved?

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

  • to achieve symptom control
  • to achieve biochemical/clinical targets
  • to prevent disease progression/exacerbation
  • is there a more appropriate medication to achieve goals?

Person specific actions

  • BP within target range, occasionally lightheaded but attributed to limited mobility. On triple therapy so review which most appropriate to reduce and stop.
  • Diabetes well controlled, mild frailty potentially at risk of hypoglycaemia and complications. However takes alogliptin, which is less effective than other options which have positive cardiovascular outcomes, such as SGLT-2i*.

 

5.  Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?

Identify individual safety risks by checking for

  • appropriate individual targets
  • drug-disease interactions
  • drug-drug interactions (see ADR table)
  • monitoring mechanisms for high-risk drugs
  • risk of accidental overdosing

Identify adverse drug effects by checking for

  • specific symptoms/laboratory markers
  • cumulative adverse drug effects (see ADR table)
  • drugs used to treat side effects caused by other drugs 

Medication Sick Day guidance

Person specific actions

  • Risk of falls due to anti-diabetic medicines and anti-hypertensives
  • Increased risk of acute kidney injury due to combination of diuretics and metformin, especially if acutely unwell.
  • Sick day guidance – withhold bendroflumethiazide, furosemide, irbesartan and metformin with dehydrating illness

 

6.  Sustainability: Is drug therapy cost-effective and environmentally sustainable?

Identify unnecessarily costly drug therapy by

  • considering more cost-effective alternatives, safety, convenience -

Consider the environmental impact of

  • Inhaler use
  • Single use plastics -
  • Medicines waste
  • Water pollution 

Person specific actions

  • None - prescribing in keeping with current formulary recommendations
  • Patient advised to dispose of medicines through community pharmacy
  • Advised patient to only order what is needed, do not stockpile medicines 

 

7.  Patient centeredness: Is the patient willing and able to take drug therapy as intended?

Does the person understand the outcomes of the review?

  • Consider teach-back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

  • is the medication in a form they can take?
  • is the dosing schedule convenient?
  • what assistance is needed?
  • are they able to take medicines as intended?

Agree and communicate plan

  • discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
  • include lifestyle and holistic management goals
  • inform relevant health and social care providers of changes in treatments across the transitions of care

Person specific actions

  • BP at target and lightheaded – stop lercanidipine as may also be contributing to swollen ankles
  • Diabetic control good, often forgets metformin dose at lunchtime. Reduce dose to 500mg twice daily.

Future steps:

  • If swollen ankles resolve, stop furosemide.
  • Substitute alogliptin for SGLT-2i*, due to ASCVD (and renal) benefits.
  • Discuss potential reduction of citalopram, if no symptoms.

 

Key concepts in this case

  • Falls risk
  • Mild frailty
  • Tight blood pressure control
  • Tight diabetic control
  • Less suitable medication with co-morbidities
  • Consider most appropriate anti-diabetic medication
  • Duration of treatment course (antidepressant)
  • Unnecessary indication – furosemide

 

Click on the table image to view a PDF version of the full 7 steps table.