Community pharmacists can play a pivotal role in managing surgical patients in the community, says Neetu Bansal, a lead surgical pharmacist in enhanced recovery, who has devised the following case study:

Mrs Dorothy Jones is 70 years old and has just been discharged from hospital following a hip replacement after a fall. Co-morbidities include type 2 diabetes, ischaemic heart disease, a myocardial infarction a couple of years of ago, and congestive cardiac failure.

On admission to hospital, her medications were:
• Metformin 1g bd*
• Gliclazide 80mg bd
• Aspirin 75mg od
• Clopidogrel 75mg od*
• Bisoprolol 2.5mg od
• Candesartan 4mg od*
• Simvastatin 40mg on
• Bumetanide 1mg bd*
(*Indicates medication held pre-operatively.)

Mrs Jones encountered a few complications in the post-operative period. Her blood pressure was low immediately post-operatively, so candesartan was withheld. When her renal function started to decline, metformin was withheld.

Her blood sugars (BMs) remained stable on gliclazide but there were issues with adequate pain control, so she was prescribed oxycodone MR 10mg bd with breakthrough oxynorm.

Renal function improved with IV hydration but her blood pressure remained low. Blood glucose levels were well controlled with gliclazide. After review by the ortho-geriatric team, she was started on bone protection therapy. For thromboprophylaxis, Mrs Jones was started on rivaroxaban for a total of five weeks.

Discharge medications were:
• Gliclazide 80mg bd
• Aspirin 75mg od
• Clopidogrel 75mg od
• Bisoprolol 2.5mg od
• Simvastatin 40mg on
• Bumetanide 1mg bd
• Rivaroxaban 10mg od
• Paracetamol 1g qds
• Oxycodone MR 10mg bd
• Oxycodone 5-10mg prn every 4-6 hours
• Alendronate 70mg once weekly
• Calcium and vitamin D supplements, 1 tablet bd.

A note on the discharge letter for the GP suggested reviewing analgesia and recommencing as appropriate any medications that were withheld during admission.

The patient presenting at six weeks post-discharge with a repeat prescription for the above medication offers an ideal opportunity for a MUR as there are lots of medication related issues. Can you identify them?

 

Suggested answers

  • Rivaroxaban should have been stopped. Treatment was only intended for five weeks post-surgery
  • Check patient’s blood glucose levels. Should metformin be restarted?
  • Check patient’s BP. If stable, can candesartan be restarted? Studies have shown beneficial effects of ACE inhibitors in reducing mortality associated with heart failure
  • Review opioids. Long-term use is associated with increased risk of falls
  • Undertake a NMS and counsel patient on the administration of bisphosphonates and the importance of compliance

 

For more information about the UKCPA, click here.

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