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.1–11
Selected Medication Classes to Review with Inherited Patients
Medication class | Harms and clinical considerations | Approach to weaning |
---|---|---|
|
| |
Loop diuretics5 |
|
|
|
| |
|
|
Selected Medication Classes to Review with Inherited Patients
Medication class | Harms and clinical considerations | Approach to weaning |
---|---|---|
|
| |
Loop diuretics5 |
|
|
|
| |
|
|
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 references1. 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 https://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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