An 85-year-old female PACE participant with a past medical history of arthritis, neck and back pain, hypertension, insomnia, and asthma called CareKinesis seeking a pharmacist’s help identifying one of her pills.
The participant’s medication regimen includes:
- Tylenol 325 mg, TID for pain
- Metoprolol 25 mg, daily
- Tramadol 50 mg, BID
- Trazodone 50 mg, daily
The participant has no known allergies. Her anticholinergic burden is 9 (very high), sedative burden is 12 (very high), and risk score is 28 out of 50 (high).
During the discussion, the pharmacist asked how the participant was doing. The participant indicated that she had not been feeling well and experiences daily pain in her neck/abdomen that she described as “unbearable,” preventing her from carrying out daily activities. She mentioned that the pain is worse at night and often interferes with her sleep.
The pharmacist recalled a conversation she had with the patient’s PACE provider about a week prior noting the interaction between metoprolol and tramadol. The interaction involved competitive inhibition at CYP2D6, which would likely inhibit tramadol from reaching full efficacy. When the pharmacist spoke with the provider to recommend an alternative beta-blocker, the provider did not want to change the regimen since the patient did not complain to her about uncontrolled pain.
After speaking with the participant, the pharmacist revisited the regimen change recommendation with the provider and discussed the implications for the patient. The pharmacist recommended switching the beta blocker from metoprolol to a cardioselective beta blocker that is not metabolized CYP enzymes (e.g., atenolol, betataxolol, bisoprolol). The pharmacist also revisited the participant’s interactions and implications, and noted that changing the standing Tylenol to an as needed order may result in better pain control. The provider agreed with the pharmacist’s recommendations and switched the beta-blocker to atenolol.
The pharmacist followed up with the provider a few weeks later and is told that the participant has improved pain control after adapting to the switch. The participant’s blood pressure is controlled, pain decreased from 7-9 out of 10 to 3-4 out of 10, and Tylenol is administered only as needed. The pharmacist also inquired about the participant’s sleep to assess the need for trazodone since the pain control has improved. The provider agreed to assess this need during the participant’s next visit in hopes of discontinuing the trazodone.
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