Medication Management
2. M.P. has no known allergies. Her current medications are memantine (Namenda) 10 mg BID, aspirin 81 mg once daily, alendronate (Fosamax) 10 mg daily, esomeprazole (Nexium) 20 mg daily, lovastatin (Mevacor) 20 mg with dinner, megestrol 40 mg/mL (Megace) 5 mL (200 mg) BID, levothyroxine (Synthroid) 0.1 mg daily, multivitamin daily, beclomethasone (Vanceril) metered-dose inhaler (MDI) one puff daily, albuterol 2.5 mg/ipratropium 0.5 mg (DuoNeb) via nebulizer Q 4 hr PRN for wheezing or shortness of breath, acetaminophen 325 to 650 mg Q 6 hr PRN for mild pain or fever, olanzapine (Zyprexa) 5 mg HS PRN for agitation, milk of magnesia 30 mL PO daily for constipation, and a bisacodyl (Dulcolax) suppository 10 mg Q 3 days PRN if no bowel movement. What is your assessment of M.P.'s medication regimen? Which medications are the hospice required to provide, and which might be discontinued?
Hospices are required to provide (pay for) medications related to the terminal diagnosis for the palliation of symptoms within the hospice plan of care (POC). The POC is the individualized plan of treatment developed for each patient formulated at the start of care and updated regularly by the interdisciplinary group (IDG). The Conditions of Participation mandate that the IDG be composed of a physician, registered nurse, social worker, and a pastoral or other counselor.13 A registered nurse coordinates the implementation of the POC. Some hospice program IDGs have incorporated a pharmacist into the group to review medication issues.
The large array of medications being taken by M.P. is similar to the lists of medications of many hospice patients. These patients are often elderly, have a long history of several chronic medical conditions, and have been taking multiple medications for past and present medical conditions. In most cases, the medication lists of patients who are admitted into a hospice program have seldom been reviewed, updated, or modified in light of the present medical situation. Admission to a hospice program represents a change in the level of care and is a most appropriate time for a review of all medications to ascertain the necessity of each, with the goal of optimizing efficacy and minimizing the potential for adverse effects, medication errors, and inappropriate costs.
Because M.P. is to be enrolled into a hospice program, her care should not be focused on curative treatments, but rather on the management of discomforting symptoms and on improving her quality of life in the time remaining. M.P.'s medications should be analyzed with the goal of simplification. Unnecessary medications should be discontinued and alternatives added to manage two or more symptoms concurrently. The following changes should be considered:
Acetaminophen. This analgesic is often helpful in relieving mild pain, particularly in immobile elderly patients. A trial of around-the-clock acetaminophen could be helpful.
Albuterol/ipratropium combination. The hospice program is not required to pay for medications related to M.P.'s COPD because it is not related to her LCD for Alzheimer's disease. Nevertheless, this combination inhalation formulation should be continued if she is able to participate in her nebulizer treatments and they improve her breathing.
Alendronate. This bisphosphonate drug can be discontinued because the treatment of osteoporosis is not an important consideration at this terminal stage of her life nor is it in the hospice plan of care. Thus, hospice would not cover it. Furthermore, M.P. is bed-bound; alendronate should be ingested in the upright position, and patients should remain upright after taking the medication to decrease the risk of alendronate-induced
esophageal irritation. Pain that she may experience from osteoporosis can be treated with analgesics.
Aspirin. The low-dose aspirin is intended to decrease the risk of cardiovascular clotting. The aspirin will not increase M.P.'s comfort or quality of life. Although the aspirin would not be covered by her Medicare benefit, it can be continued unless her primary care provider prefers its discontinuation.
Beclomethasone MDI. This patient is not functioning well cognitively (i.e., not oriented to time, person, or place) and would be unable to effectively time the inhalation of a breath to the actuation of her MDI. A systemic corticosteroid (e.g., prednisone) might improve her COPD symptoms and also improve her appetite and sense of well-being. The potential for adverse effects is modest with short-term corticosteroid use.
Bisacodyl, Milk of Magnesia. Constipation in hospice patients is common because of decreased gastrointestinal motility with advanced age, decreased physical activity, lack of adequate fiber and fluid intake, and use of constipating medications (e.g., opioids, anticholinergics, psychotropic agents).36 The milk of magnesium, with an occasional bisacodyl suppository, is a good laxative regimen for this patient. If an opioid is later prescribed for M.P., a mild stimulant laxative (e.g., senna) with a stool softener (e.g., Colace) would be indicated. If stool softeners, stimulants, and saline laxatives are ineffective in resolving opioid-induced constipation, oral sorbitol or lactulose (10 g/15 mL) in 30-mL dosages can be prescribed up to four doses a day if needed. (Sorbitol would be preferred because it is more cost effective.) Mineral oil 30 mL daily is an option if the stool is hard; however, mineral oil would not be optimal for M.P. because of her recent history of aspiration pneumonia. In cases of refractory constipation, the oral ingestion of naloxone, an injectable opioid antagonist, can reverse opioid-induced constipation by antagonizing opioid effects within the gastrointestinal tract without affecting systemic analgesic because naloxone is poorly absorbed orally. The usual starting dose of naloxone for the management of opioid-induced constipation is 0.4 to 0.6 mg PO Q 6 hr. Naloxone doses of 2.4 mg PO Q 6 hr have been used, but have been associated with opioid withdrawal symptoms.37
Esomeprazole. This proton-pump inhibitor (PPI) would probably be unnecessary because alendronate-induce esophageal-gastrointestinal irritation would not be an issue subsequent to its discontinuation. If a PPI, however, is needed, nonprescription generic omeprazole is preferred because it is <20% of the cost of Nexium.38
Levothyroxine. This thyroid medication should be continued until M.P. is no longer able to swallow. This medication, however, would not be covered under her hospice Medicare benefit, which is based on her Alzheimer's disease, rather than other thyroid end-of-life disease (e.g., cancer).
Lovastatin. Cholesterol-lowering agents are not necessary during the last 6 months of life and should be discontinued. Lovastatin would not improve the quality of life of M.P. at this stage of her terminal illness and would not be covered by her hospice benefit.
Megestrol. The progesterone derivative, megestrol, in doses of 400 to 800 mg daily, can substantially stimulate appetite.39 If undernourished hospice patients have a desire to eat more, many hospice patients will provide megestrol, regardless of whether it will be covered by the Medicare hospice benefit. It is unclear, however, whether stimulation of appetite in a cognitively impaired patient will result in weight gain or improved nutritional status. Because the benefits in this situation are unclear, the potential of adverse effects (e.g., venous thrombosis) of megestrol needs to be considered, especially in M.P., who is not ambulatory and had been taking low-dose aspirin for prevention of cardiovascular clotting.
Memantine. Because the NMDA (N-methyl-D-aspartate) antagonist, memantine, has been modestly effective in improving performance in patients with moderate-to-severe Alzheimer's disease,40,41 it is probably of limited utility for M.P. It would be reasonable to discontinue M.P.'s memantine subsequent to discussion with appropriate hospice team members and M.P.'s family.
Multivitamins. and other nutritional supplements are unlikely to improve M.P.'s comfort or quality of life. The discontinuation of these drugs would simplify medication administration, decrease the potential for medication errors, and decrease costs.
Olanzapine. An antipsychotic (e.g., olanzapine, haloperidol, chlorpromazine) is often prescribed to manage the agitation and confusion encountered by patients with dementia. At the time of admission to hospice, patients may be receiving atypical agents (e.g., olanzapine). Small doses of the more typical antipsychotics, such as haloperidol (Haldol) and chlorpromazine (Thorazine), can also be very useful in treating opioid-induced nausea and vomiting42 and would be covered by M.P.'s Medicare Hospice Benefit. Chlorpromazine would be preferable when more sedation is desired.
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