Case study

Home Medicines Review

Home HMR
DRPs
interview Report
Mrs Stella Johns

 73 year old female, lives with husband

 Reason for referral
 5 or more medications
 medication with a narrow therapeutic index or medications
requiring therapeutic monitoring
 heart failure, hypertension, back pain
 BP 150/95
 Wt 65kg
 non-smoker; “sip” of whiskey at night
 immunisation – influenza, pneumococcal
Current medications

 ramipril 5mg daily

 frusemide 40mg mane and midday
 digoxin 250mcg mane
 paracetamol 500mg 1-2 prn
 simvastatin 20mg nocte

 Adherence good as per dispensing history

Lab results

 Sodium 137 mmol/L (135-145)  Chol 3.1 mmol/L (2.5 – 5.5)

 Potassium 3.9 mmol/L (3.4 – 5.0)  Trigs 1.39 mmol/L (0.50 – 1.70)

 Chloride 97 mmol/L (95 – 107)  HDL 1.1 mmol/L (>0.9)

 HCO3 24 mmol/L (21 -32)  LDL 1.4 mmol/L (<3.4)

 Anion gap 16 mmol/L (10 – 20)  Tot/HDL 2.8 mmol/L (<5.1)

 Urea 7.2 mmol/L (2.0 – 7.0)  LFTs wnls

 Creatinine 140mol/L (70 – 115)  TFTs wnls

 eGFR 34 mL/min/1.73m2 (>60)  FBC normal

 Uric acid 0.39 mmol/L (0.15 – 0.36)  Serum digoxin 1.2ng/mL (0.5 – 0.8)

 Gluc. Fast. 5.7 mmol/L (3.6 – 6.0)

Pre-interview check

Session 1
Question 1

Consider the patient needs or concerns, medication-

related problems and medication management
issues.

 What further information would assist in making your

assessment of this patient? Explain reasons for
obtaining this information. Who/where would you
obtain this information?

Explain reasons for these questions.

Preparation for HMR interview

 What would you do prior to the home

interview?

 dispensing history
 identify potential drug-related problems
 identify disease state management issues –
patient signs and symptoms that may indicate
sub-optimal control of conditions
 identify questions to ask patient
What resources would you use for
management of heart failure?
Heart Failure Guidelines

MJA 2006; 185 (10): 549-556

http://www.heartfoundation.org.au/document/NHF/CHF_2006_Guidelines_NHFA-CSANZ_WEB_PDF-1.2MB.pdf
Consumer information
Pre-interview check

 Drug-related problems  Disease state

 Drug interactions management issues
 ADRs
 Additional treatment  Questions to ask
 Compliance patient
 Inappropriate drug
 Dose too high
 Dose too low
 Drug use without
indication
Strand L et al. DICP 1990;24:1093-7.
Drug interactions
Adverse drug reactions
 statins – muscle pain and weakness

 ACE inhibitor - cough

 digoxin – toxicity
 loss of appetite, nausea and vomiting

 lower stomach pain; diarrhoea

 possible electrolyte imbalance (leading to unusual tiredness or

extreme weakness)
 slow or irregular heartbeat

 blurred vision or visual disturbances (e.g. coloured halos around

objects, yellow, green or white vision)
 drowsiness, confusion or mental depression, headache, fainting
Additional treatment

 HF management
 beta-blocker
 frusemide dose

 BP management

 pain management

 aspirin prophylaxis – consider CV risk

 Ca and vitamin D supplements

Compliance/adherence

 check dispensing history

 chronic condition self-management

 lifestyle interventions for HF
 daily weighs
How would you assess adherence?
Self Reported Morisky Score:
The subjects are asked “Thinking of the medications PRESCRIBED for you by
your doctor(s), please answer the following questions”.

Question Answer
Do you ever forget to take your medicines? No(0) Yes(1)

Are you careless at times about taking your No(0) Yes(1)

medicines?

When you feel better, do you sometimes stop No(0) Yes(1)

taking your medicine?

Sometimes, if you feel worse when you take No(0) Yes(1)

your medicine, do you stop taking them?

Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care 1986;24:67-74.
Inappropriate drug

 ?
Dose too high

 digoxin

 diuretic dose
Dose too low

 ACE I dose

 ? need for regular paracetamol

Drug use without indication
Potential drug-related problems

 sub-optimal management of heart failure

 High dose diuretic
 No beta-blocker, spironolactone
 Maximum tolerated dose of ACE inhibitor
 BP not to target
 High dose digoxin – elevated serum digoxin
 Pain management
 CV risk - ? need for aspirin prophylaxis
 Ca and vitamin supplement
DSM issues

 HF management

 HTN management

 chronic pain management

 osteoporosis prevention
Questions to ask patient

 complete medication list including OTC and CMs,

previous medications

 heart failure management

 Sx e.g. SOBOE, orthopnoea, ankle oedema, cough,
fatigue, weight increase
 lifestyle interventions and knowledge of self-Mx

 pain management

 dietary Ca and sun exposure (vitamin D)

Home interview

Session 2
Patient interview – what further
information did you detect?

 St John’s wort – “feeling down” – sister’s

supply

 Celecoxib (Celebrex) 200mg daily –

recommended by neighbour

 SOBOE, fatigue and nocturnal cough

Patient interview – communication aspects

 Identify communication aspects of interview

that were:

 optimal

 sub-optimal
Drug-related problems

Session 3
Question 2

 Based on the information provided, identify

potential and actual medication-related and
disease-related problems, and patient
concerns. Suggest how these could be
addressed and/or monitored.

 ALL actual or potential DRPs

 suggest interventions
 referenced
 QUESTION 2

Based on the information provided in the case study, identify potential and actual medication-related and disease-

related problems, and patient/resident concerns. Suggest how these could be addressed and/or monitored.

Problem Drug(s) Intervention

Patient interview – further information

 St John’s wort – “feeling down” – sister’s

supply

 Celecoxib (Celebrex) 200mg daily –

recommended by neighbour

 SOBOE, fatigue and nocturnal cough

Drug interactions
Drug interactions

 SJW – digoxin

 decrease serum digoxin levels by 25%

 SJW induces PGP  decreased absorption of

digoxin

 toxicity may occur on withdrawal of SJW

Clin Pharmacol Ther 2004;75(6):546-57.

Drug interactions

 SJW – simvastatin

 SJW induces CYP3A4  decreased serum levels

of simvastatin

 consider pravastatin – not substrate for CYP3A4

 ? clinically significance in this patient

Drug interactions – Triple Whammy

 ramipril – frusemide – celecoxib

 50% of cases of iatrogenic acute renal failure

reported to ADRAC
 fatality rate for ADRAC cases of renal failure with
the "triple whammy" is 10%
 episodes of renal failure appear to be precipitated
by mild stress (e.g. diarrhoea, dehydration)

ADRAC, Thomas M. Diuretics, ACE inhibitors and NSAIDs - the triple whammy. MJA 2000; 172: 184-5.
ACE inhibitor, diuretic and NSAID: a dangerous combination. Aust Adv Drug React Bull 2003;22(4):14-15.
Triple Whammy
Further DRPs
 SJW – digoxin interaction

 “Triple whammy” interaction

 Use of NSAID
 exacerbate HF

 increase BP

 GI and renal risk

 sub-optimal control
 patient symptoms indicate acute exacerbation of HF

 sub-optimal pain management

 indication of mood disorder

HF Treatment

 First line
 ACE inhibitors for all patients – maximum
tolerated dose
 diuretics
 beta-blockers
 spironolactone
  angiotensin 11 receptor antagonists
HF Treatment (cont)

 Second line
 digoxin (symptom relief and reduce
hospitalisation)
 hydralazine – nitrate (if intolerant or C/I to ACEI or
ARB)

 Others
 amlodipine & felodipine (treat comorbidities – HTN
or CHD)
NSAIDs and HF

 All NSAIDs reduce the effectiveness of

diuretics by promoting sodium and fluid
retention and increase the risk of renal
impairment with ACE inhibitors
HMR report

Session 4
Question 3

Write a letter or report to the referring GP,

outlining your key findings for this patient
and your suggestions or recommendations.

 consider priorisation
 clinical judgment
 written communication skills