Patient: John Doerksen
John Doerksen, a 65-year-old male, has a past medical history of heart failure, hypertension, gastroesophageal reflux disease (GERD), insomnia, major depressive disorder (MDD), hyperlipidemia, and epilepsy. Initially, his MedWise Risk Score™ was 34 (high).
Abigail Wright, PharmD, a clinical pharmacist for LLW Consulting, conducted a MedWise Safety Review (MSR) to help improve John’s quality of life. The MSR focused particularly on pain management, deprescribing, and optimizing pharmacotherapy.
Initial Medication List:
- Albuterol sulfate HFA 90mcg per actuation aerosol inhaler, 2 puffs every 4 hours as needed
- Amlodipine 10mg, 1 tablet by mouth daily
- Aspirin 81mg, 1 chewable tablet by mouth daily
- Atorvastatin 40mg, 1 tablet by mouth daily at bedtime
- Clopidogrel 75mg, 1 tablet by mouth daily
- Colace 100mg, 1 capsule by mouth daily
- Ferrous sulfate 325mg, (65 mg iron) 1 tablet by mouth daily
- Levetiracetam 500mg, 1 tablet by mouth twice a day
- Lasix 20mg, 1 tablet by mouth twice a day
- Loratadine 10mg, 1 tablet by mouth once daily as needed
- Melatonin 10mg, 1 tablet by mouth daily
- Gabapentin 100mg, 1 capsule three times daily
- Omeprazole 20mg, delayed release, 1 capsule by mouth daily
- Trazodone 50mg, ½ tablet by mouth daily at bedtime
- Tylenol extra strength 500mg, 2 tablets by mouth every 8 hours as needed
- Ondansetron 4mg, 1 tablet by mouth every 4 hours as needed
- Sertraline 50mg, 1.5 tablets by mouth daily
Based on the reduction in John’s risk score, he could see up to $5,185 in healthcare cost savings.1
Patient Assessment:
The clinical pharmacist recognized several medication-related problems evidenced by John’s high MedWise Risk Score. Of note, John had a very high sedative burden resulting from the following medications: gabapentin, levetiracetam, ondansetron, sertraline, and trazodone. The patient also had a high competitive inhibition burden caused by clopidogrel, omeprazole, sertraline, and trazodone.
Using the MedWise Science Platform, the pharmacist identified several potential multi-drug interactions. Clopidogrel is primarily metabolized to its active metabolite by the CYP2C19 enzyme. John is also taking omeprazole which, when taken concomitantly, decreases exposure to clopidogrel’s active metabolite, resulting in risk for therapeutic failure.
Additionally, sertraline and clopidogrel interact at enzymes CYP2B6, CYP2C19, and CYP3A4. Moving the time of administration for one of these medications can help prevent this interaction.
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Clinical Pharmacist Recommendations: After reviewing the medications and subjective information, the clinical pharmacist provided the following recommendations for prescriber and patient consideration, to be implemented over the course of one month: Consider changing omeprazole to famotidine to prevent the interaction with omeprazole and clopidogrel at the CYP2C19 enzyme. Consider changing the time of administration of sertraline from morning to lunch to prevent the interaction between clopidogrel and sertraline at CYP2B6, CYP2C19, and CYP3A4. Consider changing the PRN loratadine to fexofenadine, which decreases competitive inhibition burden and anticholinergic burden. |
Prescriber Responses: John’s prescriber returned the following responses:
Accepted with changes (discontinued omeprazole)
No response
No response |
Noted Outcomes:
Implementation of this round of recommendations and then of additional smaller adjustments proved beneficial. Over the course of these recommendations, the patient’s MedWise Risk Score was improved, though not all recommendations were followed.
It is a constant give and take with regards to optimizing a patient’s medication regimen in a nursing home setting, which requires patience and a firm background in pharmacology and pharmacokinetics. Tools like MedWise Science help pharmacists provide stronger recommendations to physicians. Even though all recommendations were not followed, the patient’s risk score has improved from a 34 to 29, showing that even small changes can positively impact patient outcomes.
Medication Risk Stratification and MedWise Risk Score
Risk stratification determines who is at highest risk for ADEs and assigns a MedWise Risk Score between 0 and 50. The MedWise Risk Score is an indicator that helps pharmacists personalize patient regimens to improve safety and reduce preventable ADEs.