FCM WK4 CASE 3

FM & PH – Polypharmacy

In module Family Medicine and Public Health

Arthur McGrath is a 74-year-old man presenting to his GP after a cardiology outpatient appointment.

Polypharmacy ILOs

MAIN CASE

Guidance and Resources – Polypharmacy

Case Introduction – Polypharmacy

Further Case Information – Polypharmacy

Background Science – Polypharmacy

Case Conclusion – Polypharmacy

Formative Assessment – Polypharmacy

CASE COMPONENT

Guidance and Resources – Polypharmacy

In case FM & PH – Polypharmacy

Learning Resources

Here is a list of useful links for your information or reminders about what you have already covered in relation to this case. They are listed here for ease of reference and you may wish to return to this page after you’ve worked through the case, but review of any of this material before you start the case is not compulsory.

You will be directed to specific information contained within some of these links as you work through this case, but can come back to this list if you want further information or are interested to know more.

deafness (usually with high parenteral doses and rapid administration, and in renal impairment)

Mr McGath informs Dr Fellaini that he had been getting some slight ankle swelling and some shortness of breath when lying down which he mentioned to the cardiologist at clinic. He tells the GP that cardiologist thought may benefit from these ‘water tablets’. He has been fully counselled on the benefits and risks. Dr Fellaini examines Mr McGrath and finds a blood pressure of 124/78 and a heart rate of 70 beats per minute/regular. His weight is 70kg.

Dr Fellaini agrees to issue with a plan to check the kidneys in 2 weeks’ time with a blood test and urine sample.

Which of Mr McGrath’s medications can be associated with renal function deterioration? (Select FOUR)

· Aspirin 75mg one tablet daily

· Atorvastatin 40mg one tablet at night

· Bisoprolol 2.5mg once tablet daily

· Ramipril 5mg one tablet daily

· Amlodipine 10mg one tablet daily

· GTN spray 400mcg 1-2 sprays use as needed for chest pain

· Levothyroxine 100mcg one tablet daily

· Levothyroxine 25mcg one tablet daily

· ISMN 60mg one tablet daily

· Metformin 500mg one tablet three times a day

· Gabapentin 200mg one tablet three times a day

· Furosemide 40mg take one tablet daily

· Aspirin 75mg one tablet daily

.Correct answer.

· Ramipril 5mg one tablet daily

.Correct answer.

· Gabapentin 200mg one tablet three times a day

.Correct answer.

· Furosemide 40mg take one tablet daily

.Correct answer.

The GP suggests checking some other blood tests at the same time to monitor his other medications.

Which of the other medications require monitoring with blood tests?

· Aspirin 75mg one tablet daily

· Atorvastatin 40mg one tablet at night

· Bisoprolol 2.5mg once tablet daily

· Ramipril 5mg one tablet daily

· Amlodipine 10mg one tablet daily

· GTN spray 400mcg 1-2 sprays use as needed for chest pain

· Levothyroxine 100mcg one tablet daily

· Levothyroxine 25mcg one tablet daily

· ISMN 60mg one tablet daily

· Metformin 500mg one tablet three times a day

· Gabapentin 200mg one tablet three times a day

· Furosemide 40mg take one tablet daily

· Atorvastatin 40mg one tablet at night

Correct answer.

Liver function and cholesterol

· Ramipril 5mg one tablet daily

.Correct answer.

Renal function

· Levothyroxine 100mcg one tablet daily

.Correct answer.

Thyroid function

· Levothyroxine 25mcg one tablet daily

.Correct answer.

Thyroid function

· Metformin 500mg one tablet three times a day

.Correct answer.

HBA1c to monitor response

· Furosemide 40mg take one tablet daily

.Correct answer.

Renal function

2 weeks later

Mr McGrath is back at the GP surgery. His blood results are back, renal function is decreased slightly to give an egfr of 50 mL/minute/1.732. He has normal ACR.

His BP is 120/74.

His ankle oedema has settled and he feels better.

The GP examines Mr McGrath and finds:

· No postural drop (remind yourself of this from the dizziness case if you need to)

· Heart sounds normal

· HR 70 regular

· Chest clear, RR 16

· No ankle oedema

· Sat 97%

· Weight: 70kg

Is there anything else the GP needs to do to maximise heart failure therapy?

The GP would need to slowly titrate up the ace inhibitor and the beta blocker.

For further information about this, you can review NICE (2010) Heart Failure guidance

At 3 months

Mr McGrath is successfully titrated up to Ramipril 10mg one tablet daily and bisoprolol 10mg one tablet daily. His BP is 110/70 and heart rate 56 regular.

Chest and heart examination are normal

Weight: 68kg. He has lost weight due to reduction of fluid.

He mentions there are a few other things he also wants to discuss He outlines he wants to ask about a cough, a mole, burning leg pain and needs a repeat prescription.

How can the GP manage these in his existing appointment?

Appointments with GPs in England are scheduled on average at 10 minute intervals. Is this realistic in the present climate? (REF: The 2022 GP Compendium of Evidence p. 28, attached).
With an increase in the ageing population, complex-comorbidities and polypharmacy, the demand for GP appointments has never been greater. It is estimated that an average member of the public consults a GP six times a year, double the number of consultations from the previous decade. It is estimated that there has been a 24% increase in GP consultations since 1998.

Therefore the GP must assess whether the additional issues should be managed in the patient’s existing appointment or safely deferred to a later date. If multiple issues are managed within 1 appointment this is highly likely to extend the length of the surgery, leave remaining patients waiting beyond their original appointment time and result in less resource for home visits, reviewing test results and responding to clinical mail. How can this be justified? Think of the impact on the patient and population at the surgery.

Could any of these problems be deferred safely?

What medico-ethical frameworks can the GP use to help balance the conflicting demands they face?

There are 4 key pillars of medical ethics:

· Autonomy

· Beneficence

· Non-maleficence

· Justice

Medical Protection: Essential learning: Law and ethics

The GP must weigh up the dilemma they face and justify their actions according to these principles.

The GMC reflects these principles in standards and ethics guidance for doctors in practice. Good Medical Practice 2013 outlines core guidance.

Further Case Information – Polypharmacy

In case FM & PH – Polypharmacy

Further assessment is completed by the GP and recorded in the notes as follows:

The GP deals with all of the issues presented by Mr McGrath. He finds this is likely self-limiting viral infection and advises as such. The ‘mole’ is a seborrheoic wart requiring no further treatment. He advises increase in gabapentin dose to 300mg three times per day and issues a new repeat prescription. He advises him to come back for a review if this change in medication does not resolve the pains in his legs.

At 6 months

Mr McGrath has his bloods checked as part of chronic disease management. He is brought in urgently as his eGFR has dropped to 18, although his electrolyte levels are normal.

When he attends, the GP explores the cause of the decline in renal function. He finds that Mr McGrath feels well with no current or recent illnesses. He has had no diarrhoea or vomiting, and is passing urine normally. He asks if anything has changed in his lifestyle or diet. Mr McGrath says not, but then asks if it is possible that ‘all those gabapentins’ he has been taking might have had something to do with it. The GP probes further and discovers that Mr McGrath has a friend who is taking 9 tablets of gabapentin per day, and so after the GP had increased his tablets to 300mg three times per day just before his holiday, he had since increased further such that he was now taking 900mg (3 tablets) three times per day (a total of 2700mg =2.7g) like his friend, which he had decided to start taking just last week.

The GP outlined that this may be the cause, as although the maximum dose is higher than that he is prescribed, with CKD stage 3, the maximum suggested dose is just 1.8g in divided doses. He suggests that he wean down this medication quickly over the next week, and repeat his blood tests. He suggests temporarily stopping his metformin until they can be sure that the kidneys are functioning back at their usual level.

Why does the GP suggest withholding metformin temporarily?

There is an increased risk of lactic acidosis if metformin given with renal impairment. NICE recommend that medication be stopped if sudden deterioration in renal function, and avoid if eGFR less than 30mL/minute/1.732

Background Science – Polypharmacy

In case FM & PH – Polypharmacy

There is some material which is useful to revise relating to issues demonstrated in this case. Please use the following links to revise your knowledge:

Patient safety

· 1MedLearn QEPEP: Clinical quality 2 – Healthcare culture and safety

· 1MedLearn QEPEP: Clinical quality 5 – Tools for safety

· TED Talks: Doctors make mistakes. Can we talk about that?

Safe prescribing

· 1MedLearn Year 4 Thyroid disease: Session- Safe prescribing

Chronic Kidney Disease

· 1MedLearn Year 4: CKD Background Science

Acute Kidney Injury (AKI)

· 1MedLearn Year 4: AKI Background Science

The BNF is the standard place for prescribing information, and contains more information about Gabapentin and Metformin.

CASE COMPONENT

Case Conclusion – Polypharmacy

In case FM & PH – Polypharmacy

Despite knowledge of drug interactions, adverse reactions do occur in patients on multiple medications for complex medical problems.

Taking steps to prevent this happening in the future by strengthening systems to protect patient safety is one of the domains of the GMC’s Good Medical Practice.

CASE COMPONENT

Formative Assessment – Polypharmacy

Which of these medications can contribute to renal impairment? (Select FIVE)

· Atorvastatin 40mg one tablet at night

. Ramipril 5mg one tablet daily

· Gabapentin 200mg one tablet three times a day

· Bisoprolol 2.5mg once tablet daily

· Levothyroxine 100mcg one tablet daily

· Furosemide 40mg take one tablet daily

· Metformin 500mg one tablet three times a day

· Amlodipine 10mg one tablet daily

· Indapamide 1.5mg MR one tablet daily

· Rosuvastatin 10mg once at night

· ISMN 60mg one tablet daily

· Atorvastatin 40mg one tablet at night

. Ramipril 5mg one tablet daily

.Correct answer.

· Gabapentin 200mg one tablet three times a day

.Correct answer.

· Bisoprolol 2.5mg once tablet daily

· Levothyroxine 100mcg one tablet daily

· Furosemide 40mg take one tablet daily

.Correct answer.

· Metformin 500mg one tablet three times a day

· Amlodipine 10mg one tablet daily

· Indapamide 1.5mg MR one tablet daily

.Correct answer.

· Rosuvastatin 10mg once at night

.Correct answer.

· ISMN 60mg one tablet daily

Which drugs need to be monitored with blood tests?

· Bisoprolol 10mg OD

· Paracetamol 500mg QDS

· Warfarin dose as per anticoagulation booklet

· Levothyroxine 100mcg one tablet daily

· Ramipril 5mg one tablet daily

· Gabapentin 200mg one tablet three times a day

· Furosemide 40mg take one tablet daily

· Rosuvastatin 10mg once at night

· Amlodipine 10mg one tablet daily

· Apixaban 2.5mg BD

· Atorvastatin 40mg one tablet at night

· Warfarin dose as per anticoagulation booklet

INR

· Levothyroxine 100mcg one tablet daily

TFT

· Ramipril 5mg one tablet daily

U+E

· Furosemide 40mg take one tablet daily

U+E

· Rosuvastatin 10mg once at night

U+E, LFT and Lipids

· Apixaban 2.5mg BD

FBC, LFT, U+E

· Atorvastatin 40mg one tablet at night

LFT and Lipids

Page updated

Google Sites

Report abuse