Chapter 2 - Case Study on Medication Management

In this Chapter, we will discuss the medication management through a few case studies in the following items:

Common medication issues Adverse drug reactions (ADRs) Drug-drug interaction (Can be pharmacokinetic or pharmacodynamic) Strategies for improving drug regime and adherence Medication errors in institutional setting Consideration in medical management in dementia person

Let's start!

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Common medication issues

Adverse drug reactions (ADRs)

Case 1

• A 74-year-old lady, live at home, cared by maid.
• Past history: Chronic insomnia, HT, hyperlipidemia, minor stroke.
• Admitted to hospital due to urinary tract infection with fever.
• Investigation: WBC 23, creatinine 140 (baseline 90) & Urine culture grew E Coli.
• Medical order: Started Augmentin IV, kept nil by mouth, all oral medications withheld.
• Fever subsided Day 2.

However, this lady developed acute confusion (delirium) Day 3 after admission.

• Further assessment: No focal CNS sign, no neck rigidity.
• Extensive investigations essentially unremarkable.
  • CT brain normal
  • Blood test – WBC down to 10
  • RFT – creat 100
• Drug history:
  • Amlodipine 10 mg om
  • Lipitor 10 mg nocte
  • Aspirin 80 mg daily
  • 15 tables of Zopiclone (bought over the counter) per night for 10 years
  • Gingo Biloba
• No history of TCM taken.

Can you guess WHY?

The answer is Zoplicone withdrawal.

• Diagnosis: Zoplicone withdrawal with delirium.
• Treatement: Zoplicone resumed and titrate down ➜ Delirium subsided.

Further information:

Lessons to learn

• Careful drug history.
• Withdrawal symptom may occur if stopping some drugs (e.g. drugs acting on CNS) abruptly.
• A high degree of suspicion is needed.

Case 2

• A 90-year-old lady, bedbound, ADL dependent with Clinical Frailty Scale 7.
• Past history: History of hip fracture and vertebral collapse, esophagitis and hiatus hernia, dementia.
• Drug history:
  • Denosumab 60 mg every 6 months SC
  • Calcichew 1 tab daily
  • Lansoprazole 15 mg daily
  • Senokot 15 mg nocte prn
• She was admitted to hospital due to UTI.
• Treated with antibiotics but complicated by coffee ground vomiting ➜ Lansoprazole increased to 30 mg QD.
• Complained of constipation ➜ Calcichew stopped.
• Upon discharge:
  • Lanzoprazole 30 mg daily
  • Senokot 15 mg nocte prn
  • Denosumab 60 mg every 6 months SC
• At follow up:
  • She has nil complaint.
  • Due for another dose of q6m Denosumab, RLFT and Bone profile recheck.

• Diagnosis: Hypocalcaemia due to denosumab in a patient with renal impairment and stopping calcium supplement.

Lessons to learn

Denosumab and hypocalcaemia

• Hypocalcemia is a recognized S/E of Denosumab.
  • Denosumab inhibits osteoclastic bone resorption, leading to hypocalcemia by reducing calcium mobilization from bone into bloodstream.
  • Risk factor:
    • Renal impairment
    • Vitamin D deficiency
    • Lack of prophylactic supplementation of calcium and/or vitamin D

Case 3

• 78 years old, male.
• Past health: BPH, HT, DM.
• Drug history:
  • Terazosin
  • Amlodipine
  • Metformin
• Suffered from flu with cough, fever, nasal congestion, running nose.
• Seen by GP ➜ Given Panadol, Piriton, nasal decongestion medications.
• Complained of abdominal distension and difficult to urinate for 1 day, leakage of small amount of urine continuously.
• Diagnosis: acute urinary retention with overflow incontinence, but why?
• Causes: Recent use of anti-histamine and decongestant.

Lessons to learn

Examples of important drug-disease interactions

Case 4

• 76 years old lady received a prescription for Allopurinol from the GOPC for Hyperuricemia.
• However, she began to experience serious side effects one month after taking the drug, including head swelling, fever and allergic reactions such as skin rashes.
• She was worsened into "Toxic Epidermal Necrolysis", where the skin ulceration, like a severe burns.
• She died after two months.

You may read this local news for your information.

Lessons to learn

• Carbamazepine (Tegretol) – another drug also needs to check HLA before prescription.
  • All Asians given carbamazepine should be tested HLA 1502 due to the risk of Steven Johnson Syndrome (SJS) and toxic epidermal necrosis (TEN) as advised by FDA.

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Drug-drug interaction (Can be pharmacokinetic or pharmacodynamic)

Pharmacokinetic nature of drug-drug interaction

• Effects of one drug on the absorption, distribution, metabolism, or excretion of another drug.
• Interactions→ changes in serum drug concentrations → change clinical response.
• The most frequent pharmacokinetic drug-drug interactions involve several isoenzymes of the hepatic cytochrome P450 (CYP) and drug transporters e.g. the P-glycoprotein.

Drugs which affect cytochrome p450 isoezymes

Induction of metabolism of one drug by another

Inhibition of metabolism on one drug by another

Case 1

• 60 years old lady.
• Past history: Double valve replacement, on warfarin for many years, aim INR 2.5 to 3 by cardiologist.
• Drug history: Lasix, Slow K, Diltiazem
• Developed sore throat for 2 days, with exudates over the tonsils, fever+.
• Seen by GP ➜ Given Panadol, cough syrup, azithromycin – 5-day course.
• Noticed to have nose bleeding and bruising next morning.

Do you know why?

• Blood test:
  • INR >5
  • Platelet count normal
  • Hb 12 drop to 9 g/dl
• Diagnosis: Warfarin overdose due to drug-drug interaction by macrolides antibiotics.

Lessons to learn

Warfarin and Macrolides

• Examples of macrolides antibiotics are azithromycin, clarithromycin, erythromycin.
• Macrolides reduce the metabolism and clearance of warfarin ➜ 🡱 levels and effects of warfarin like bleeding.

Case 2

• 70 years old man.
• Known HT, IHD, DM & renal impairment (Creatinine around 100 baseline).
• Admitted to ward due to heart failure.
• Investigation:
  • BNP 5000
  • Echo – shows HFrEF (EF 35%)
• Treated with Lasix, Slow K, Acertil, Aldactone, Metaprolol Zok, Aspirin.
• Discharge from ward 3 days later, then follow up 3 weeks later in OPD.
• No complaint from the patient.
• Blood test repeated showing K 6.5, Creatinine 120 (The blood test was not hemolyzed).
• ECG SR with peak T waves.





• Diagnosis and treatment
  • Aldactone and ACEi interaction.
  • Slow K supplements ➜ severe hyperkalaemia.
• Patient was admitted to hospital for urgently correcting hyperkalaemia.

Lessons to learn

ACEI and aldactone

• ACEI (Acertil, Lisinopril, Ramipril, Enalapril etc) interact with Spironolactone (Aldactone).
• Both have potassium increasing effects.
• So when adding together, a very high level K may occur.
• Close monitoring of K is needed.

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Strategies for improving drug regime and adherence

Case 1

• 80 years old man, walk with stick, live alone.
• Past history: HT, Hyperlipidemia, dementia, DM, parkinsonism, BPH.
• Seeing different private doctors with drugs:
  • Aspirin 80 mg daily
  • Diamicron 80mg om, 40mg pm
  • Metformin 250 mg tds
  • Amlodipine 5 mg BD
  • Prazosin 1 mg tds
  • Sinemet 25/100 half tab QID
  • Artane 1 mg bd
  • Lipitor 10 mg nocte
• Patient admitted to hospital due to hyperglycaemia (hstix >20), malaise and polyuria.
• Blood test show HbA1c 9.5%, fasting blood sugar 12.
• Patient said he frequently forgot to take drugs especially those need to take more than 2 times per day.
• He has poor cognitive function with MoCA 5/30 (dementia range).
• No one alone to supervise him in taking medications.
• Geriatrician was consulted.

If you were the Geriatrician, what are your actions?
Let's consider drug review to simplify the drug regime, referral to community services and use medication tools!

• Drugs regimes were modified to limit to QD and BD.
  An example of how to modify drug regime to enhance adherence:
  

  

• Patient was referred to ICDS (Integrated Care and Discharge Support) program with case manager to do home visit to monitor his drug compliance.
• Drug box was given to patient by ICDS case manager to enhance adherence.

➜ Patient drug adherence improved & DM control became satisfactory.

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Medication errors in institutional setting

Case 1

• 90 years old lady, bedbound, no relative, live in a small private RCHE without CGAT.
• Past history: CVA with vascular dementia, HT, renal impairment but no history of DM.
• Clinical Frailty Scale 8.
• Dysphagia, requiring puree as diet.
• Admitted to acute hospital due to hypoglycemia (Hstix 1.5 in ambulance).
• Immediately given D50 injection, put on dextrose infusion to maintain euglycaemia in ward for 3 days.
• Toxicology screening showed gliclazide (Diamicron) in blood.
• Review history again – patient had no DM and was NOT on any DM drugs.
• There were other residents in RCHE on DM drugs but they were not her roommates.
• The RCHE staff denied wrong medications given to index patient.

Can you guess what is happening?

• Results after thorough investigation:
  • Contamination of the mortar in RCHE which was used to grind the drug tablets
    

    
    Mortar for grinding tablets

  • It was likely that there was Diamicron residue left on the mortar which belonged to other residents. When the staff grinded the tablets of the index resident, the drugs were contaminated by Diamicron residue of the previous residents.
  • Since the index resident had anorexia of ageing with poor intake, a small amount of Diamicron could lead to florid hypoglycaemia!
  • It often takes at least a few days for hypoglycaemia to improve as the half-life of Diamicron is prolonged in renal impaired older patients.
• The patient hypoglycaemia finally subsided after 3 days in hospital ➜ discharge back to RCHE.
• RCHE staff practice was reviewed by CGAT nurses & advised to:
  • Buy more mortars so that each resident has its own mortar.
  • Use a paper to hold the drugs during grinding to minimize contamination of the mortar. Staff has to make sure no drug residues are left on the mortar before grinding tablets of other residents.
• Outcome
  • No more drug contamination incident in that RCHE.
  • Experience is shared with other RCHEs to avoid similar mistakes happening in other RCHEs.

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Consideration in medication management in dementia person

Case 1

• A 90-year lady with advanced dementia, BPSD and delusional ideas. She always thought her daughter wanted to poison her, so she refused to take oral medications. She had Parkinson disease and Alzheimer's disease. She was on Sinemet 25/100 mg half tab BD and donepezil 5 mg daily.
• After discussion with Geriatrician about this problem,
  • oral Sinemet and donepezil were stopped.
  • PD drugs change to rotigotine transdermal patch once daily.
  • Donepezil changes to rivastigmine transdermal patch once daily.
• The patient accepted the use of transdermal patch without drug non-adherence. It also reduced carer stress as the daughter did not need to struggle to give oral medicine to patient.

Lessons to learn

• We need to understand the situation of each dementia patient.
• Personalized approach is needed to overcome the drug management problem in these patients.
• Make use of transdermal route (if available) if appropriate for selected patients.

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Reference

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- End of Chapter 2 -

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Chapter 3 - Medication Safety

Below videos are the basic knowledge about medication use. Do you have such queries before?

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3. Understanding Drug Labels


4. How to Take Medication on an Empty Stomach?


5. Can All Medications Be Cut or Crushed?


6. What If I Miss a Dose of Medication?


7. Dietary Restriction When Taking Medication


8. Are Anti-Inflammatory Drugs the Same as Antibiotics?


9. Guidelines for Medication Purchases


10. Is More Supplement Consumption Better?

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Proper Storage of Medications

In general,

• store medications in a COOL, DRY place away from direct sunlight.
• always keep medications in their ORIGINAL containers to maintain proper labelling and dosage information.
• do not mix different medications in the same containers.
• keep medications out of reach of children and pets to prevent accidental ingestion.
• DO NOT store medications in the bathroom or kitchen where heat and humidity levels fluctuate.
• DO NOT keep medications in the car.

1. Should Medicines Be Kept in The Refrigerator?

Temperature Considerations

• Some medications are sensitive to temperature changes; check the label or consult your pharmacist for specific requirements.
• Refrigerate medications as directed, but do not freeze unless specified.
• Extreme temperatures (both hot and cold) can affect medication stability.

➜ Improper storage may cause: Loss of therapeutic effects/ Adverse effects

Light Sensitive Medications

• Light can cause oxidation, hydrolysis and loss of potency to some medications. This loss can be greatly minimized by protecting from light.
• Examples:
  • Tetracycline Antibiotics: Tetracycline antibiotics, including doxycycline and tetracycline, are highly susceptible to light degradation. When exposed to light, they can become less effective, making them less capable of treating infections.
  • Isotretinoin: Isotretinoin is a medication used to treat severe acne. It's highly light-sensitive and should be stored in a dark container or packaging to prevent degradation.
  • Nitroglycerin: Nitroglycerin is used to treat angina (chest pain) and heart conditions. It's stored in dark containers because exposure to light can cause the medication to lose its potency.
• Storage tips for light sensitive medications
  • Always follow the storage instructions provided on the medication label.
  • Keep light-sensitive medications in their original packaging, as it's designed to protect them from light exposure.
  • Store these medications in a cool, dry, and dark place. A medicine cabinet or a drawer is often a suitable location.
  • Check the medication's appearance and ask your pharmacist if you suspect light-induced degradation.

Medication Specific Storage

• Insulin:
  • Unopened insulin to be stored in the fridge until expiration date;
  • Opened insulin to be stored in the fridge or under room temperature and use within 28 days.

• Eye drops:
  • Store in a cool place, and some may require refrigeration after opening.

• Oral liquids/Suspension:
  • Some may require refrigeration; others can be stored at room temperature.

• Inhalers:
  • Keep away from direct heat or sunlight.

Childproofing Medications

• Use Childproof Caps: These caps are designed to be difficult for young children to open, reducing the risk of accidental ingestion.
• Lockable Medication Cabinets: Consider installing lockable medicine cabinets at home, especially in the bathroom.
• High Shelves or Storage: Store medications on high shelves or in places that are difficult for children to access.
• Educate Children: Educate older children about the potential dangers of medications and the importance of not taking medication without supervision.

Reference: "Medicine Safety: A Key Part of Child-proofing Your Home", Safe Kids Worldwide 2019

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Expiration of Medications

Factors Affecting Medication Expiry

• Chemical Stability: Medications degrade over time, which can result in a decrease in potency. This degradation is influenced by the chemical stability of the active ingredients.
• Packaging: The type of packaging and how well it seals out moisture, light, and air plays a significant role in how long a medication remains potent.
• Storage Conditions: Medications stored in proper conditions are more likely to last longer. Exposure to heat, humidity, and light can accelerate degradation.

Identifying Expired Medications

• Check the Expiration Date: The expiration date is printed on the medication packaging. It indicates the date until which the manufacturer guarantees the medication's full potency and safety.
• Observe Changes in Appearance: Some medications change in color, texture, or odor when they expire. Any noticeable changes may indicate that the medication is no longer safe or effective.
• Consult a Pharmacist: If you are uncertain about a medication's status, consult your pharmacist. They can offer guidance and assess whether a medication is still safe to use.

Safe Medication Disposal

• Do Not Flush: Avoid flushing medications down the toilet or drain. This can contaminate the water supply.
• Medication Recycle Programs: Junior Chamber International Tai Ping Shan and Mannings joint program of "Safe Disposal of Unused Medicines - 藥「勿」胡亂棄", providing a safe and environmentally friendly way to dispose of unused or expired medications.
  

  

• Mixing with Unwanted Substances: Mix the medication with an undesirable substance (e.g., used coffee grounds or kitty litter) in a sealed container before disposing of it in the trash. This helps deter misuse.
• Remove Personal Information:Before disposing of medication containers, remove or obscure any personal information to protect privacy.

2. How to Handle Expired Medications?

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Improving Medication Safety

1. Technology

Electronic Health Records 醫健通 (eHealth)

• Electronic Health Records (EHR) are digital versions of patient health records that offer comprehensive and real-time information about a patient's medical history, diagnoses, medications, and treatment plans.
• It improves medication safety by providing healthcare providers with accurate and up-to-date patient information, allowing for better-informed decisions.
• It enhances communication between healthcare providers, including pharmacists, through eHR systems which helps in continuity of care and medication management.

Electronic Prescribing System

• Electronic prescribing system allows healthcare professionals to enter medication orders electronically, minimizing errors related to handwriting and transcription.
• Built in database allows a prompt system to identify and flag potential drug interactions and allergies when prescribing, improving medication safety.
• Potential errors such as therapeutic duplication can be prevented.

Unit dose packaging machine

• A unit dose packaging machine is an automated system that individually packages patient's medications in single doses.
• Each dose is sealed in a blister pack or pouch, clearly labelled with essential information.
• Advantages:
  • Accurate dosing
  • Medication Identification
  • Enhanced Medication adherence
  • Streamlined Medication Distribution

(Swisslog Inspire, n.d.)

Barcode Medication Administration (BCMA)

• BCMA is a technology that involves scanning barcodes on medications and patient wristbands to ensure the "Five Rights" of medication administration: right patient, right medication, right dose, right route, and right time.
• This technology reduces medication administration errors by verifying the medication's accuracy at the bedside.
• BCMA systems are commonly used in hospitals and long-term care facilities, and they improve documentation accuracy by recording each administration electronically.

Medication Management Apps (e.g. HAGo)

• Medication management apps includes mobile applications designed to help patients manage their medications effectively.
• They maintain personal health records, including medication lists and dosages, which can be shared with healthcare providers.
• These apps may send medication reminders and notifications to users' smartphones to ensure they take their medications as prescribed.
• Medication management apps can also provide educational resources and drug interaction information.

2. Medication Delivery Services

• Medication delivery refers to the process of delivering prescribed medications to patients, typically to their homes, long-term care facilities, or other remote locations.
• It has gained significant importance, especially during the COVID-19 pandemic, as it reduces the need for in-person visits to hospitals and pharmacies, ensuring patient safety.
  • Enhanced Adherence: Medication delivery services ensure that patients have a continuous supply of their medications, reducing the risk of missed doses and medication-related errors.
  • Reduced In-Person Contact: During public health crises like pandemics, medication delivery minimizes the need for patients to visit hospital/ pharmacies, decreasing their exposure to potential sources of infection.
  • Improved Medication Access: Medication delivery helps patients, especially those with limited mobility, gain easier access to their prescribed medications, promoting medication safety by reducing the risk of medication mismanagement.
  • Medication Accuracy: Automated prescription dispensing machines used in healthcare facilities for medication delivery reduce human error, ensuring accurate medication doses are delivered to patients.
  • Patient Convenience: The convenience of having medications delivered to one's doorstep can lead to better medication adherence, thereby improving safety.

3. Telepharmacy Services

• Telepharmacy Services involve the remote provision of Pharmacy Services by Pharmacists using telecommunications technology.
  • Medication Review: Through telepharmacy, pharmacists can remotely review patients' medication regimens, ensuring the appropriateness of prescribed medications and minimizing the risk of medication-related problems.
  • Medication Counseling: Pharmacists can counsel patients via telepharmacy, educating them about medication use, potential side effects, and proper administration, which enhances medication safety by promoting proper drug utilization.
  • Access to Expertise: Telepharmacy ensures that even patients in remote or underserved areas have access to expert pharmacy care, reducing the risk of medication errors due to a lack of pharmacy services.
  • Timely Intervention: Telepharmacy facilitates timely intervention by pharmacists in case of potential medication issues, such as adverse drug reactions or interactions, contributing to medication safety.
  • Continuity of Care: Patients receiving telepharmacy services benefit from regular interactions with pharmacists, which can lead to improved medication adherence and better patient safety.

4. Primary Healthcare resources

Community Pharmacy and Pharmacists

• Community Pharmacists are essential members of the healthcare team who play a vital role in promoting medication safety within the community.
• Their services extend beyond simply dispensing medications; they are often accessible and trusted healthcare professionals who provide critical services to enhance medication safety.
• Community Chain pharmacies in Hong Kong include Mannings and Watsons. There are also NGOs pharmacies, such as:
  • 醫護行社區藥房 Health In Action Community Pharmacy
  • 樂善堂社區藥房 Lok Sin Tong Community Pharmacy
  • 惠澤社區藥房 St. James' Settlement Philanthropic Community Pharmacy
  • 良躍社區藥房 A-Lively Community Pharmacy
  • 慈惠社區藥房 H.K.S.K.H.Lady MacLehose Community Pharmacy
  • 配安心藥房 SafeMed Dispensary
  • 康盈坊社區藥房 Health Union Community Pharmacy
  • 仁愛堂鄭丁港善心藥物中心
• Services Offered by Community Pharmacists
  • Medication Counseling: Community Pharmacists offer personalized medication counseling, ensuring that patients understand their medications, including proper dosages, administration, potential side effects, and interactions.
  • Medication Reviews: Pharmacists conduct medication reviews to identify and resolve issues like drug interactions, duplications, and potential adverse effects.
    They also aim to optimize medication regimens, especially for patients with chronic conditions, focusing on enhancing medication safety.
  • Adherence Support: Pharmacists help improve patient adherence by identifying barriers and suggesting strategies to overcome them.
  • Immunizations: Community Pharmacists may provide vaccinations, contributing to public health by preventing medication-related diseases.
  • Over-the-Counter (OTC) Guidance: They offer advice on the safe use of OTC medications and dietary supplements.
  • Health Education: Community Pharmacists educate patients on health and medication-related topics, further promoting medication safety.

Support Groups

Support groups provide a platform for patients to share their experiences, challenges, and strategies for managing their conditions and medications.

Collaborative Care Models and Co-Care

The Society of Hospital Pharmacists of Hong Kong (SHPHK)

• The SHPHK provides the latest drug news and discussion on different health topics.
• The Drug Education Resources Centre, DERC also publishes articles to educate the general public on some commonly used medications and vaccines.

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Medication Safety Technology Challenges

• Integration Challenges: Implementing medication safety technologies like eHR or BCMA systems can be technically complex and costly.
• User Adoption: Ensuring that healthcare providers and staff are proficient in using these technologies can be a significant challenge.
• Data Security Concerns: Safeguarding patient information and data is paramount but can be challenging due to the ever-evolving landscape of cybersecurity threats.

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Patient Engagement Challenges and Limitations

• Health Literacy: Low health literacy among some patient populations can hinder their understanding of medication instructions, potentially leading to errors.
• Cultural and Language Barriers: Patients from diverse cultural backgrounds may face language barriers, making it challenging to comprehend medication instructions.
• Socioeconomic Factors: Patients facing financial hardship may struggle to afford medications, leading to non-adherence and medication-related issues.

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Conclusion

• Proper storage of medications is essential to maintain their potency and ensure patient safety.
• Patients should always read and follow the storage instructions on medication labels and consult with a pharmacist or healthcare professional when in doubt.
• The use of smart technological solutions and community engagement are essential for a safer and more effective healthcare system.
• Collaboration between Primary Healthcare providers and community resources can foster a sustainable pharmaceutical care and better health outcomes.

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Reference

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- End of Chapter 3 -

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Chapter 1

Chapter 2

Chapter 3

Workshops

認識長者服藥注意要點

腦退化症照顧技巧篇

藥物失誤

體弱長者的家居護理