Medication Review in the Nursing Home: Can Stopping One Drug Make All the Difference?
INTRODUCTION
Frail older adults frequently receive care at different locations in the health care system. Prescribing by multiple providers can lead to polypharmacy and an increased risk of adverse drug events. In this article, we present the case of a frail older patient with heart failure recently admitted to long-term care and enrolled in hospice due to the refractory and debilitating nature of her symptoms. With discontinuation of a single medication, rosiglitazone, her condition dramatically improved. She was discharged from hospice, moved from the nursing home to an assisted living facility, and continues to do well 11 months later. This case illustrates the critical role of medication review at every point of transition in the health care system in order to provide high-quality care to frail elders.
CASE INFORMATION
A 79-year-old woman with diabetes and ischemic cardiomyopathy was admitted to a skilled nursing facility for long-term care following an inpatient stay for congestive heart failure (CHF). In the 6 months prior to admission, persistent dyspnea on exertion had led to a significant decline in her functional status prompting her to move in with her son. During this time period, the patient had been hospitalized on three occasions for CHF exacerbations.
The patient’s most recent hospitalization occurred 2 weeks prior to nursing home admission when she presented to the local emergency department in respiratory distress. Chest radiography showed pulmonary edema, and transthoracic echocardiography revealed her ejection fraction to be 25%. She was admitted to the Coronary Care Unit and aggressively diuresed. Eventually, her dyspnea improved, but she had become even further deconditioned. The patient, along with her family and the inpatient medical team, decided against any further invasive diagnostic procedures or interventions, and she was discharged to a skilled nursing facility for further supportive care.
The patient’s past medical history also includes hypertension, chronic renal insufficiency, myelodysplastic syndrome, and hypothyroidism. She was discharged to the long-term care facility on the following medications: simvastatin 40 mg orally every day at bedtime, omeprazole 20 mg orally every day, ferrous sulfate 325 mg orally three times a day, aspirin 81 mg orally every day, levothyroxine 75 mcg orally every day, isosorbide dinitrate 60 mg orally every 8 hours, hydralazine 100 mg orally every 8 hours, erythropoietin 20,000 units subcutaneously every week, amlodipine 10 mg orally every day, carvedilol 25 mg orally twice a day, furosemide 80 mg orally three times a day, candesartan 32 mg orally every day, and rosiglitazone 4 mg orally every day.
On arrival at the nursing home, the patient was alert and speaking in full sentences. Her blood pressure was 107/68, heart rate was 60, respirations were 18, and O2 saturation was 97% on 2 liters of oxygen via nasal cannula. She had no jugular venous distention, but a cardiac examination revealed an S3 gallop. A few crackles were noted in the bilateral bases, but the remainder of her lung examination was clear. Trace pitting edema was present in both lower extremities. Her Mini-Mental State Examination score was 29/30. Serum creatinine level was elevated at 2.3.
The patient complained of difficulty walking and performing daily activities, and of severe fatigue. She felt that her current quality of life was quite poor due to her limited functional status and frequent hospital admissions. She requested that her care focus on symptom relief and specifically requested not to return to the hospital. Hospice was asked to assist in her care.
On review of admission medications, rosiglitazone was stopped due to concern that this may be exacerbating her symptoms. No other medications were added, changed, or discontinued. Between admission and nursing home day 4, the patient vigorously diuresed, losing 9 pounds of body weight. On nursing home day 5, she became somnolent and febrile and was found to have a urinary tract infection, for which she was placed on antimicrobial therapy. Her renal function deteriorated, and by nursing home day 10 her serum creatinine was 8.7. The diuretics and angiotensin II receptor antagonist were stopped and the patient was orally hydrated, assisted by her family and the nursing staff.
By nursing home day 24, the patient’s creatinine had returned to her baseline of 1.6. Her weight stabilized at 132 pounds, representing a 21-pound weight loss over 6 weeks. Her cognitive function returned to normal and her dyspnea resolved. Over the next 3 months, she became independent in all of her activities of daily living, was discharged from hospice, and moved from the nursing home to an assisted living center. The angiotension II receptor antagonist and low-dose furosemide were resumed without difficulty, and her diabetes remained under control without pharmaco- therapy. After 11 months, she continues to do very well and has not required readmission to the hospital.
DISCUSSION
This case illustrates the vital importance of a complete medication review for patients admitted to a long-term care facility. Inappropriate drug prescribing among the frail elderly has been described in both inpatient and outpatient settings.1 Care transitions are increasingly common for older adults, and medication errors are a significant hazard for persons transferring between different locations in the health care system.2,3 Adverse drug events due to medication changes have been identified in 20% of bidirectional transfers between acute care settings and long-term care facilities.4
Rosiglitazone is approved for the treatment of type 2 diabetes mellitus and belongs to a class of drugs known as thiazolidinediones (TZDs). The Food and Drug Administration issued a special warning in 2002 alerting providers to the possibility of fluid retention that may lead to or exacerbate congestive heart failure with the use of either rosiglitazone or pioglitazone;5 however, the exact relationship between TZDs and heart failure remains controversial. At least 14 cases of pulmonary edema in patients taking TZDs have been described in the medical literature.6-10 Health Canada reported eight cases of heart failure associated with rosiglitazone and pioglitazone, though detailed case descriptions were not provided.11 However, to our knowledge, this is the first reported case of a patient enrolled in hospice for end-stage CHF who was successfully discharged following discontinuation of rosiglitazone.
Fluid retention is known to be an adverse effect of TZD therapy, though the underlying mechanism remains poorly defined. A number of epidemiological studies have attempted to examine the relationship between TZDs and the risk of CHF more closely, but it is still not clear whether the fluid retention may be primarily peripheral and therefore unlikely to exacerbate heart failure.12-14 In one retrospective review of patients with chronic systolic heart failure who were treated with TZDs, 17.1% developed fluid retention over a 1-year period.14 All of these cases reversed after drug withdrawal. Baseline left ventricular size and function and baseline New York Heart Association (NYHA) functional class were similar between patients who developed TZD-related fluid retention and those who did not. Because this was a retrospective chart review, not enough information was available to reliably determine whether these patients were experiencing worsening of their heart failure or strictly peripheral fluid accumulation.14
In this case, the patient’s marked and sustained improvement in her cardiovascular status following discontinuation of rosiglitazone without other changes in her medical regimen provides the strongest support of an adverse drug reaction due to rosiglitazone; however, this cannot be definitively proven. The patient had been taking the same dose of rosiglitazone for approximately 17 months prior to her first episode of symptomatic pulmonary edema; however, a similar delay in onset of symptoms has been previously described.6 We hypothesize that the patient’s initial deterioration in renal function after stopping the rosiglitazone was due to intravascular volume depletion and relative hypotension caused by multiple factors: decreased oral intake related to altered mental status due to her urinary tract infection, and the persistent use of diuretics following discontinuation of the rosiglitazone, which was likely driving a significant amount of her fluid retention. With hydration and treatment of her infection, her renal function and mental status returned to baseline.
Product labeling for rosiglitazone states that it is not recommended in patients with NYHA Class 3 and 4 cardiac functional status due to the risk of fluid retention, which may exacerbate or lead to heart failure.15 Despite this strong warning, a recent study suggests that the use of TZDs in this population is common.16 Analysis of a large, cross-sectional sample of Medicare beneficiaries from 2000 to 2001 revealed that 16% of elderly diabetic patients admitted for CHF were discharged with an active prescription for a TZD, a significant increase from 2 years earlier.16 A consensus panel convened by the American Heart Association (AHA) and the American Diabetes Association (ADA) identified risk factors for heart failure in patients treated with TZDs including: history of heart failure (either systolic or diastolic), history of prior myocardial infarction or symptomatic coronary artery disease, hypertension, left ventricular hypertrophy, significant aortic or mitral valve heart disease, advanced age (> 70 years), long-standing diabetes (> 10 years), pre-existing edema or current treatment with loop diuretics, development of edema or weight gain on TZD therapy, insulin coadministration, and chronic renal failure (creatinine > 2.0 mg/dL).17 Our patient exhibited seven of these 11 risk factors; however, prior to her nursing home admission, none of her previous medical providers in multiple health care settings had attempted discontinuation of her TZD therapy.
CONCLUSION
In this case, a thorough medication review on admission to the long-term care facility identified a significant drug–disease interaction; the medication was promptly stopped and the patient enjoyed a highly favorable outcome. Medication review at every point of transition in the health care system is critical in order to provide high-quality care to frail elderly patients.
