Drug Therapy Management Flashcards

An 82-year-old resident with stable NYHA Class III heart failure, chronic kidney disease (Stage 3), and osteoarthritis is prescribed meloxicam 15 mg daily for knee pain. The consultant pharmacist's primary concern with this new order should be the increased risk of:

Answer: Worsening fluid retention and acute renal impairment.

Non-steroidal anti-inflammatory drugs (NSAIDs) like meloxicam inhibit prostaglandins, which can lead to sodium and water retention. In a patient with pre-existing heart failure, this can cause decompensation. NSAIDs also reduce renal blood flow, which can precipitate acute kidney injury, especially in patients with underlying chronic kidney disease.

A 78-year-old resident on long-term phenytoin for a seizure disorder is admitted to the skilled nursing facility after a fall. The resident exhibits nystagmus, ataxia, and slurred speech. A lab report shows a total phenytoin level of 25 mcg/mL (therapeutic range 10-20 mcg/mL) and a serum albumin of 2.8 g/dL (reference range 3.5-5.0 g/dL). What is the most accurate interpretation of this clinical scenario?

Answer: The low albumin level is causing a disproportionately high level of free, active phenytoin, leading to toxicity despite a only moderately elevated total level.

Phenytoin is highly protein-bound (around 90%) to albumin. In a state of hypoalbuminemia, there are fewer binding sites available, which results in a higher fraction of unbound (free) drug. The free drug is pharmacologically active, and this increased fraction can lead to clinical signs of toxicity even when the total drug concentration is only moderately elevated. A corrected phenytoin level should be calculated to estimate the true active concentration.

A consultant pharmacist is reviewing the regimen of a resident who has been taking omeprazole 40 mg daily for over three years for a history of 'indigestion'. There is no documented diagnosis of GERD, Barrett's esophagus, or a history of bleeding ulcers. A recommendation to attempt to deprescribe the omeprazole is most strongly supported by the increased long-term risk of which of the following?

Answer: Bone fractures and Clostridioides difficile infection.

Chronic use of proton pump inhibitors (PPIs) is associated with several potential adverse outcomes in older adults. The strongest evidence supports an increased risk of hip, wrist, and spine fractures due to decreased calcium absorption, as well as a higher risk of developing Clostridioides difficile-associated diarrhea due to the alteration of gut flora.

According to the 2023 American Geriatrics Society (AGS) Beers Criteria®, which statement best describes the rationale for avoiding the concurrent use of three or more central nervous system (CNS)-active drugs?

Answer: It significantly increases the risk of falls and fractures.

The AGS Beers Criteria® specifically cautions against the concurrent use of three or more CNS-active medications (such as benzodiazepines, opioids, antidepressants, antipsychotics, and anticonvulsants) because this combination is associated with an increased risk of falls and fractures due to additive effects like dizziness, sedation, and impaired psychomotor function.

A consultant pharmacist is performing a medication regimen review for a 75-year-old resident with dementia who is receiving risperidone for agitation. To ensure compliance with Centers for Medicare & Medicaid Services (CMS) regulations for psychotropic drug use in long-term care, the pharmacist must verify that the facility is:

Answer: Attempting a gradual dose reduction (GDR) unless it is clinically contraindicated.

CMS regulations (under F-Tag F758) mandate that residents receiving psychotropic drugs, including antipsychotics, must have their therapy managed to use the minimum effective dose for the shortest possible duration. This includes documented attempts at gradual dose reduction (GDR) unless a physician provides a valid clinical reason for why it is contraindicated.

An 84-year-old resident taking sertraline 100 mg daily for depression is started on scheduled tramadol 50 mg twice daily for moderate pain. Two days later, the resident develops acute confusion, agitation, myoclonus, and tachycardia. This adverse event is most likely an example of which medication-related problem?

Answer: A drug-drug interaction resulting in serotonin syndrome.

This clinical presentation is classic for serotonin syndrome. Sertraline is a selective serotonin reuptake inhibitor (SSRI), and tramadol also inhibits the reuptake of serotonin and norepinephrine. Using these two serotonergic agents together significantly increases the risk of excessive serotonin in the central nervous system, leading to the triad of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities.