Category - Pharmacist

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Medication Discontinuation in Dementia Patients
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Opioids and Allergies
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Make Sure the Pharmacist Knows…

Medication Discontinuation in Dementia Patients

Understanding the progressive nature of dementia can help in the decision to continue or discontinue dementia medications in patients on hospice care for end-stage dementia.  Goals change as patients progress from mild to severe dementia.  In mild to moderate dementia, the primary goal is to slow the progression of the disease.  As dementia nears its end stages, the goal of care generally shifts to the control of dementia symptoms, especially when patients qualify for hospice care.

Neither the cholinesterase inhibitors nor the NMDA receptor antagonists have been proven beneficial in end-stage dementia.  Both classes of medications have the potential to cause significant adverse effects in declining patients whose bodies are less able to efficiently metabolize these medications.  Diarrhea, loss of appetite, nausea, symptomatic slow heart rate, and fainting are all potential side effects of cholinesterase inhibitors; memantine puts patients at greater risk for dizziness, headache, confusion and constipation.  When such medications are added to others commonly prescribed for patients admitted to hospice for dementia, the rates of these and other adverse effects often increase.  Though some patients gain a small benefit from the continuation of dementia medications, the potential dangers of continuing dementia medications must be considered.

The decision to continue or discontinue dementia medications can at first appear difficult, but a simple discontinuation plan can guide therapy options and ease caregiver concerns.  A prudent plan often includes a gradual discontinuation of dementia medications, monitoring patients for any new or worsening symptoms.  Some symptoms are better managed with other medications commonly used to manage dementia symptoms at end of life.  More often than not, patients do well with the discontinuation, have less risk of adverse effects from their remaining medications, and are well managed with conventional symptom management.

References:

Buckley JS, Salpeter SR. A risk-benefit assessment of dementia medications: systematic review of the evidence. Drugs Aging. 2015; 32(6):453-467.

Yang Z, Zhou X, Shand Q. Effectiveness and safety of memantine treatment for Alzheimer’s disease. J Alzheimers Dis. 2013; 36(3):445-458.

Minett TS, Thomas A, Wilkinson LM, Daniel SL, Sanders J. Richardson J, Littlewood E, Myint P, Newby J, McKeith IG. What happens when donepezil is suddenly withdrawn? An open label trial in dementia with Lewy bodies and Parkinson’s disease with dementia. Int J Geriatr Psychiatry. 2003; 18(11):988-93.

Opioids and Allergies

Hospice patients often communicate allergies to medications.  When the medication is an opioid, hospice staff often have to determine whether the reaction that the patient believed to be an allergy is truly an allergy and whether the reaction necessitates the avoidance of certain opioids.  True allergies involve an immune response; other reactions can fall into the category of either side effects or pseudoallergy, which is generally the result of histamine release but no actual immune response.  Given a patient’s reaction history, sometimes it can be difficult to determine which medications are safe and which are not, but some simple collection of reaction information can provide some guidance.

 

Pseudoallergy: If the following symptoms occur with respect to opioid administration, they are likely related to a pseudoallergy rather than a true drug allergy:

  • Generalized flushing, itching, and/or sweating
  • Mild hypotension
  • Itching, flushing, or hives at injection/application site

Such reactions can be managed with the following:

  • Try nonopioid analgesics for mild pain
  • Avoid codeine, morphine, and meperidine
  • Use a more potent opioid at appropriate doses (drugs listed below from least to most potent):
    • Meperidine < codeine < morphine < hydrocodone < oxycodone < hydromorphone  < fentanyl
  • If opioid in question is effective against pain and symptoms are mild, consider administering it with an antihistamine
  • Consider a reduction in dose, if tolerated
  • Avoid parenteral administration and/or slow down the rate of administration

 

Allergy: A true allergy to an opioid often displays one or more of the following:

  • Bronchospasm
  • Breathing, speaking, and/or swallowing difficulties
  • Angioedema
  • Severe hypotension
  • Urticaria

When there is a history of such symptoms related to a certain opioid:

  • Do not administer the offending agent
  • Try a nonopioid analgesic if pain is mild
  • Try an opioid from a different chemical class and monitor closely (see below for general opioid drug classes)

 

Drug Class Specific Agent Brand Names
Phenylpiperidines  

Meperidine

Fentanyl

 

Demerol®Duragesic®, Sublimaze®
Diphenylheptane Methadone Dolophine®
Phenanthrines MorphineCodeine

Hydrocodone

Oxycodone

Oxymorphone Hydromorphone

MS Contin®, Roxanol®Tylenol #3®

Vicodin®, Lortab®, Norco®

Percocet®, OxyContin®, Oxyfast®

Numorphan®, Opana®

Dilaudid®

Make Sure the Pharmacist Knows…

Meeting the Conditions of Participations (CoPs) medication review requirements is important.  However, even more important is ensuring that the pharmacist performing the reviews is aware of all pertinent patient co-morbidities.  A complete list of co-morbidities is valuable in order to ensure that all potential disease-state/medication interactions are detected and the appropriate interventions are made.  Nursing staff can greatly assist in this transmission of information.  If staff is conscientious to double check patient charts for several of the most common disease states that interact with medications, patient care can be significantly improved.  Some of the most important disease states to communicate to the individual performing the medication review(s) are:

  • Renal disease (include disease stage or renal lab values)
  • Hepatic disease (type and severity)
  • Congestive heart failure (include stage, if available)
  • Heart block (include degree of heart block)
  • Benign prostate hyperplasia (BPH)
  • Asthma
  • Parkinson’s disease
  • Arrhythmias
  • Hypertension

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