Even a seemingly benign prescription such as Celebrex or Tramadol, or recommending OTC Acetominophen, for pain for a patient whom on first glance seems to be a candidate can spell trouble.
As it turns out, many of our elderly, and even not so elderly patients are on blood thinners now, and current guidelines are to proceed with caution, but what I have found out is IT IS BEST TO CHECK WITH THEIR PCP FIRST!
They do not want their patient on any of these prescription medications, and they would prefer that we, as their Podiatrist, ONLY administer CLINICAL treatments. Of course, these clinical treatments include: injections in the way of steroid plus local anesthetic, nerve blocks, padding & strapping, palliative care, topical pain relievers (lidocaine, emla, lidoderm- and even then- caution is advised in the cardiac labile patient), and orthoses.
Here is a review article that may enlighten us on this important topic. Some of it does admittedly get a bit lengthy, so I have reduced some of the more pithy and PCP-relevant content where you see "[...]."
Four common medications or medication classes were implicated alone or in combination in 67.0% of emergency hospitalizations1: warfarin(Drug information on warfarin) (33.3%), insulins(Drug information on insulins) (13.9%), oral antiplatelet agents (13.3%), and oral hypoglycemic agents (10.7%). High-risk medications were associated with only 1.2% of hospitalizations.1
Adverse drug events are also common among long-term–care and nursing home residents and contribute significantly to the morbidity, mortality, and health care costs in those populations. Living in a supervised and structured setting, therefore, does not guarantee protection for older adults from potential adverse drug events. Changes associated with aging, including loss of physiologic reserve, decline in hepatic and renal blood flow, and related metabolism, may render this population more vulnerable to adverse drug events. Long-term use of multiple drugs, or polypharmacy, is also common in older adults and poses a significant risk for untoward drug interactions.
By the year 2030, it is postulated that approximately 20% of the US population will be older than 65 years and that by the year 2030, approximately 40 to 60 million Americans will be members of this age group.2 With this demographic shift comes increased burden related to chronic illnesses such as diabetes, chronic obstructive pulmonary disease, emphysema, hypertension, glaucoma, and congestive heart failure. The combined effect of increased chronic disease burden and loss of physiologic reserve makes the aging population particularly susceptible to adverse drug events. Such events may be the result of prescribing errors, transcribing errors, and compounding errors, usually at the level of the pharmacy; and administration errors, usually at the level of nursing.
All physicians who treat older adults should be familiar with the risk factors mentioned here. These patients may take from 6 to 8 medications, sometimes prescribed by different professionals, as well as fortified over-the-counter medications. Primary care physicians, who see a large percentage of these patients, are in a particularly good position to take steps to help reduce adverse drug outcomes. I propose the following list of practical suggestions to help minimize adverse drug events in the aging population.
1. Review all medications at every patient encounter. This may mean having patients actually bring the prescriptions with them, commonly referred to in geriatrics as the “brown bag” approach. [...]
2. Make sure the patient has a concise list of medications and has a general understanding of why each drug has been prescribed. Many older adults have been given medications at one time and the provider may continue to prescribe the drug without any specific medical indication. Digoxin(Drug information on digoxin) is an example of an agent that may have been prescribed for a condition that has resolved. [...]
3. Ensure at every visit that a patient is taking medications as prescribed. Cognitive impairment or more significant dementia may impair an older adult’s ability to take medication or to tolerate medication administration. In such cases, if there isn’t already a family member or other caregiver enlisted to help make sure prescribing directions are followed, the suggestion should be emphatically made. If you suspect cognitive deficit of some kind and that it may be contributing to improper use of medication, screening for memory loss may be appropriate. [...]
4. Appreciate how the high cost of some medications may affect patient use of prescribed agents. Older adults, many of whom are on fixed incomes, may not be able to afford prescription medications, especially brand-name agents. [...]
5. Approach use of specific medications or drug classes with extreme caution. Certain medications for a variety of reasons may be inappropriate for routine use in older adults. Included in this group are long-acting benzodiazepines, certain NSAIDs, digoxin, and pherosulphate. In addition, routine use of tricyclic antidepressants, certain types of antihistamines, GI antispasmodics, and muscle relaxants may be potentially dangerous in older adults. I recommend that when any of these medications are prescribed, the prescriber reevaluate periodically the need for the drug and to discontinue it at the earliest possible time. The longer they are used, the more likely adverse outcomes will result. (See http://www.fmda.org/beers.pdf for a list of medications that are potentially harmful in older adults.)
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