Curbside Consultation

Inheriting Patients with Questionable Medication Regimens

 

Am Fam Physician. 2014 Jan 1;89(1):44-51.

Case Scenario

A 54-year-old man presents for his routine follow-up appointment at the office where I recently started working. I inherited him as part of a panel of patients who had belonged to one of the founding physicians, who recently retired after 38 years in practice. At the visit, the patient states that he is experiencing low energy and poor sleep, both of which have been ongoing for more than a year. The patient's medical history includes hypertension, hyperlipidemia, insomnia, anxiety, chronic low back pain, and gastroesophageal reflux disease. His medication list includes once-daily dosages of furosemide (Lasix), 20 mg; omeprazole (Prilosec), 20 mg; fluoxetine (Prozac), 20 mg; lisinopril (Zestril), 40 mg; and pravastatin (Pravachol), 40 mg. He also takes oxycodone (Roxicodone), 5 mg three times daily as needed, and alprazolam (Xanax), 0.5 mg three times daily as needed.

He has no known drug allergies. He has been receiving monthly prescriptions for oxycodone and alprazolam for the past five years. Periodic urine toxicology screening has been repeatedly negative for illicit substances, but consistently demonstrates benzodiazepines and oxycodone, as expected. What is the best management approach when inheriting a patient with a challenging medication regimen?

Commentary

Inheriting a patient on an inappropriate or questionable medical regimen is a scenario that every physician confronts when practicing continuity care. It can present frustrating challenges, especially for resident physicians, who, because of the nature of training programs, care for patient panels with high turnover rates. Regardless of the practice setting, several issues pertaining to certain medication categories should be considered.

In this example, the physician could question (1) the use of a loop diuretic, apparently prescribed to treat hypertension, without a clear, evidence-based indication such as congestive heart failure; (2) long-term use of a proton pump inhibitor (PPI) for reflux maintenance management; and (3) chronic use of a benzodiazepine and an opioid. Addiction issues, whether physical, psychological, or both, can present further challenges in weaning. Table 1 describes clinical considerations and suggested approaches for the four medication classes noted in the case scenario.111

View/Print Table

Table 1.

Selected Medication Classes to Review with Inherited Patients

Medication classHarms and clinical considerationsApproach to weaning

Benzodiazepines14

Central nervous system depressant

DEA schedule IV controlled substance: potential for dependence and abuse, especially in context of concurrent multisubstance abuse

Known to cause tolerance, with potential for withdrawal syndrome

Studies demonstrate cognitive impairment with prolonged use (> 1 year) that may be irreversible

Current guidelines recommend avoidance in older patients

Establish a formal narcotic agreement, with periodic random urine drug screening

Discontinuation must be tapered to avoid precipitating withdrawal syndrome

Adding imipramine (Tofranil) or melatonin to support progressive tapering may enable higher rates of sustained discontinuation

Consider alternative pharmacotherapies (i.e., sedating antidepressants, antiepileptics, antihistamines)

May be helpful to provide written information on associated risks and the plan for gradually reduced use

Loop diuretics5

Limited clinical indications for use (e.g., congestive heart failure)

Should not be used as an antihypertensive unless concomitant advanced chronic kidney disease (i.e., glomerular filtration rate < 30 mL per minute per 1.73 m2) is also present

Review old records to determine indication for use

No known concerns with discontinuation

Opioid analgesics6,7

DEA schedule II controlled substance: moderate to high potential for abuse and dependence

Risk of endocrinopathy associated with chronic use

Potential consequences for patient quality of life, including opioid-induced depression, osteoporosis, hyperalgesia, decreased libido, and concerns of diminished fertility (women) or erectile dysfunction (men)

Establish a formal narcotic agreement, with periodic random urine drug screening

Conduct a thorough review of pain history and any prior workup or interventions

Consider use of adjunctive therapies (e.g., gabapentin [Neurontin], amitriptyline)

Consider referral to a comprehensive pain management team

Proton pump inhibitors811

Prolonged use is appropriate only for specific indications (e.g., erosive esophagitis)

Prolonged use (> 1 year) may increase the risk of fragility fractures, osteoporosis, and Clostridium difficile colitis or other enteric infections

Weak or conflicting data also suggest increased risk of community-acquired pneumonia, interstitial nephritis (rare, idiosyncratic reaction), benign gastric polyps, hypomagnesemia, and vitamin B12 deficiency (in older patients)

No guidelines currently available for weaning

Potential for rebound acid hypersecretion or recurrence of GERD symptoms

On-demand proton pump inhibitor dosing strategy demonstrates equal effectiveness, lower cost, and superior patient satisfaction compared with continuous therapy for endoscopy-negative GERD

Schedule close follow-up when weaning older patients and other susceptible populations with comorbidities


DEA = U.S. Drug Enforcement Administration; GERD = gastroesophageal reflux disease.

Information from references 1 through 11.

Table 1.

Selected Medication Classes to Review with Inherited Patients

Medication classHarms and clinical considerationsApproach to weaning

Benzodiazepines14

Central nervous system depressant

DEA schedule IV controlled substance: potential for dependence and abuse, especially in context of concurrent multisubstance abuse

Known to cause tolerance, with potential for withdrawal syndrome

Studies demonstrate cognitive impairment with prolonged use (> 1 year) that may be irreversible

Current guidelines recommend avoidance in older patients

Establish a formal narcotic agreement, with periodic random urine drug screening

Discontinuation must be tapered to avoid precipitating withdrawal syndrome

Adding imipramine (Tofranil) or melatonin to support progressive tapering may enable higher rates of sustained discontinuation

Consider alternative pharmacotherapies (i.e., sedating antidepressants, antiepileptics, antihistamines)

May be helpful to provide written information on associated risks and the plan for gradually reduced use

Loop diuretics5

Limited clinical indications for use (e.g., congestive heart failure)

Should not be used as an antihypertensive unless concomitant advanced chronic kidney disease (i.e., glomerular filtration rate < 30 mL per minute per 1.73 m2) is also present

Review old records to determine indication for use

No known concerns with discontinuation

Opioid analgesics6,7

DEA schedule II controlled substance: moderate to high potential for abuse and dependence

Risk of endocrinopathy associated with chronic use

Potential consequences for patient quality of life, including opioid-induced depression, osteoporosis, hyperalgesia, decreased libido, and concerns of diminished fertility (women) or erectile dysfunction (men)

Establish a formal narcotic agreement, with periodic random urine drug screening

Conduct a thorough review of pain history and any prior workup or interventions

Consider use of adjunctive therapies (e.g., gabapentin [Neurontin], amitriptyline)

Consider referral to a comprehensive pain management team

Proton pump inhibitors811

Prolonged use is appropriate only for specific indications (e.g., erosive esophagitis)

Prolonged use (> 1 year) may increase the risk of fragility fractures, osteoporosis, and Clostridium difficile colitis or other enteric infections

Weak or conflicting data also suggest increased risk of community-acquired pneumonia, interstitial nephritis (rare, idiosyncratic reaction), benign gastric polyps, hypomagnesemia, and vitamin B12 deficiency (in older patients)

No guidelines currently available for weaning

Potential for rebound acid hypersecretion or recurrence of GERD symptoms

On-demand proton pump inhibitor dosing strategy demonstrates equal effectiveness, lower cost, and superior patient satisfaction compared with continuous therapy for endoscopy-negative GERD

Schedule close follow-up when weaning older patients and other susceptible populations with comorbidities


DEA = U.S. Drug Enforcement Administration; GERD = gastroesophageal reflux disease.

Information from references 1 through 11.

Successfully navigating these concerns requires establishing a strong and trusting relationship with the patient, exploring alternative treatment modalities, and communicating clearly with the patient about risks associated with continuing these medications. Often a de novo medication assessment that employs a model of shared decision making can effectively facilitate this partnership. The physician should attempt to obtain and review old records to identify the original rationale for instituting the medications, and to clarify any previous dosage changes or escalations. The patient must be actively engaged in the weaning process. If weaning is too challenging at present, the physician should revisit the concerns regularly over time, attempting to make the regimen as appropriate as possible.

The physician should also weigh various mitigating factors that may influence the approach, such as the patient's age, anticipated life expectancy, and level of resiliency. For example, an older patient with a longstanding commitment to PPI therapy for reflux symptoms may find discontinuation too onerous. It may be more prudent to focus on eliminating other higher-risk medications, such as benzodiazepines, and to defer conversation about the PPI. As is often the case, it is important to “pick your battles” to develop the best possible therapeutic relationship.

Address correspondence to Rebecca A. McAteer, MD, at rebecca.mcateer@gmail.com. Reprints are not available from the author.

Author disclosure: No relevant financial affiliations.

The author thanks Caroline Wellbery, MD, PhD, for her contributions to this article.

REFERENCES

show all references

1. Barker MJ, Greenwood KM, Jackson M, Crowe SF. Persistence of cognitive effects after withdrawal from long-term benzodiazepine use: a meta-analysis. Arch Clin Neuropsychol. 2004;19(3):437–454....

2. Chang F. Strategies for benzodiazepine withdrawal in seniors: weaning patients off these medications is a challenge. Canadian Pharmacists J. 2005;138(8):38–40.

3. Longo LP, Johnson B. Addiction: part I. Benzodiazepines—side effects, abuse risk and alternatives. Am Fam Physician. 2000;61(7):2121–2128.

4. Mugunthan K, McGuire T, Glasziou P. Minimal interventions to decrease long-term use of benzodiazepines in primary care: a systematic review and meta-analysis [published correction appears in Br J Gen Pract. 2013;63(606):12]. Br J Gen Pract. 2011;61(590):e573–e578.

5. Viera AJ, Hinderliter AL. Evaluation and management of the patient with difficult-to-control or resistant hypertension. Am Fam Physician. 2009;79(10):863–869.

6. Berland D, Rodgers P. Rational use of opioids for management of chronic nonterminal pain. Am Fam Physician. 2012;86(3):252–258.

7. Katz N, Mazer NA. The impact of opioids on the endocrine system. Clin J Pain. 2009;25(2):170–175.

8. Ament PW, Dicola DB, James ME. Reducing adverse effects of proton pump Inhibitors. Am Fam Physician. 2012;86(1):66–70.

9. Reimer C, Søndergaard B, Hilsted L, Bytzer P. Proton-pump inhibitor therapy induces acid-related symptoms in healthy volunteers after withdrawal of therapy. Gastroenterology. 2009;137(1):80–87.

10. Tsai HH, Chapman R, Shepherd A, et al. Esomeprazole 20 mg on-demand is more acceptable to patients than continuous lansoprazole 15 mg in the long-term maintenance of endoscopy-negative gastrooesophageal reflux patients: the COMMAND Study. Aliment Pharmacol Ther. 2004;20(6):657–665.

11. Abraham NS. Proton pump inhibitors: potential adverse effects. Curr Opin Gastroenterol. 2012;28(6):615–620.

Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Please send scenarios to Caroline Wellbery, MD, at afpjournal@aafp.org. Materials are edited to retain confidentiality.

A collection of Curbside Consultations published in AFP is available at http://www.aafp.org/afp/curbside.

Please send scenarios to Caroline Wellbery, MD, at afpjournal@aafp.org. Materials are edited to retain confidentiality.


 

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