Challenge
MV is an 87-year-old female PACE participant with a past medical history of atrial fibrillation, chronic heart failure with reduced ejection fraction (HFrEF), hypertension, hypokalemia, glaucoma, and falls with vitamin D deficiency.
The participant’s current medication regimen includes:
- Aspirin 81mg, daily
- Diltiazem extended-release 240mg, daily
- Furosemide 40mg, daily
- Metoprolol tartrate 50mg, twice daily
- Potassium chloride 20mEq, daily
- Timolol maleate 0.5%, daily
- Vitamin C/vitamin E/zinc oxide/cupric oxide/lutein/zeaxanthin 250-90-40-1mg, daily
During a polypharmacy call requested by the PACE prescriber, medication-related problems in consideration of co-morbidities and possible prescribing cascades were both identified and addressed by the CareKinesis clinical pharmacist:
- Non-dihydropyridine calcium-channel blockers (CCB), such as diltiazem, are recommended to be avoided in chronic heart failure (CHF) because of potential negative inotropic actions, which may further depress cardiac function. Diltiazem also associated with peripheral edema (incidence of 5 to 15%, dose-related).
- The participant is currently taking furosemide 40mg for fluid retention. Diltiazem may be worsening her edema, resulting in the need for a higher strength of furosemide.
- The participant is hypokalemic and is taking potassium supplementation. The loop diuretic, furosemide, has diminished natriuretic effects, resulting in increased risk of hypokalemia, especially with higher doses.
- The participant is taking metoprolol tartrate 50mg twice daily. Her blood pressure and heart rate are stable and at goal. However, per the ACC/AHA Guidelines for Heart Failure Management, regarding beta-blockers, metoprolol succinate (extended-release, ER) is the formulation that has an approved indication for heart failure with proven reduction in morbidity and mortality. Since daily dosing, changing to the ER formulation would also reduce pill burden.
- The participant is a known recurrent faller and has a past medical history of vitamin D deficiency, however is not currently taking vitamin D supplementation.
Recommendations
Based on the identified medication-related problems, the following recommendations were discussed with the PACE prescriber to optimize the participant’s current treatment regimen and mitigate risks of medication- and fall-related adverse effects.
- Consider a gradual dose reduction to taper and discontinue diltiazem due to its risk of negative ionotropic effects. If clinically warranted, a dihydropyridine CCB, such as amlodipine, can be used in place of diltiazem. It is important to know that amlodipine is also associated with peripheral edema (incidence of 2 to 11%, dose-related; 15% for females). As older adults have decreased clearance of amlodipine, lower doses of 2.5mg to 5mg daily are recommended. Excess accumulation may increase the risk of peripheral edema, hypotension and constipation.
- Depending on the participant’s response to the modification of diltiazem therapy, consider a decrease in the furosemide dose.
- Depending on the participant’s response to the modification of furosemide therapy and potassium level, adjust potassium supplementation dose.
- For morbidity and mortality benefits in CHF, and to reduce pill burden, consider changing metoprolol tartrate 50mg twice daily to the equivalent, metoprolol succinate ER 100mg daily. Continue to closely monitor blood pressure and heart rate, adjust dose as appropriate.
- Consider obtaining a 25-OHD level and if < 30 ng/mL, consider initiating supplementation with cholecalciferol.
Benefit/Outcome
The PACE prescriber agreed to discontinue the non-dihydropyridine CCB, diltiazem, because of its risk of negative ionotropic effects in CHF. However, it was determined that dihydropyridine CCB therapy is indicated for the treatment of hypertension, therefore amlodipine 5mg daily was initiated. The prescriber will closely monitor and plans to adjust furosemide and potassium supplementation doses accordingly in consideration of the possible prescribing cascade.
For the morbidity and mortality benefit in CHF and advantage of reduced pill burden, the prescriber agreed to change to metoprolol succinate ER 100mg daily.
Since the participant is a known recurrent faller and is at risk of fractures, the prescriber ordered a 25-OHD level to obtain an update on her vitamin D status, and will supplement as appropriate.
Conclusion
Although the participant’s MedWise Risk Score™ is considered low risk and remained unchanged, the personalized recommendations and appropriate medication changes made optimized therapies for the participant’s co-morbidities and eliminated prescribing cascades.
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