PRN Medications. Indications & Use. Bindu Swaroop, MD Associate Clinical Professor Department of Medicine

Transcription

1 PRN Medications Indications & Use Bindu Swaroop, MD Associate Clinical Professor Department of Medicine

2 Objectives Identify which prn medications are appropriate for inclusion in admission orders Identify contraindications and adverse effects associated with common prn medications Known when to evaluate the patient prior to ordering or the nurse giving a prn medication 2

3 Common Uses Pain Sleep Cardiovascular: Hypertension Sedatives: ETOH withdrawal, agitation Pulmonary: Nebulizers, Mucolytics GI: Bowels, Heartburn, Constipation 3

4 Case Vignette HPI: 61 year old male admitted for chest pain and acute ETOH intoxication. He also complains of hematemesis during his most recent drinking binge. PMHx: AVNRT, Hepatitis C, insomnia, depression, COPD Meds: combivent inhaler bid, ibuprofen 600mg po tid prn EKG on admission reveals bpm 4

5 Case Vignette He is admitted to the medicine service with the following prn orders: -Ativan 2mg IV q4hr prn withdrawal -Albuterol neb q6h prn, Atrovent neb q6hr prn -Acetaminophen 650mg q4hr prn pain -Ibuprofen 600mg po tid prn pain 5

6 Case Vignette That night the patient subsequently requests pain medication for his chest pain. Since ibuprofen is ordered prn the night float instructs the nurse to give this to the patient. The patient still complains of pain later that night, and the night float writes an order for Morphine sulfate 2mg IVP q4hr prn pain. Are these appropriate meds to give to the patient? What other alternatives could have been given? 6

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8 Analgesics Oral Pain Severity SC/IM/IV Pain Severity Adverse Effects Non- Opiods Acetaminophen mg Mild Ketorolac 30-60mg Moderate Caution in hepatic or renal impairment Opiods Ibuprofen mg Tramadol mg Mild Mild to Moderate PUD, GI bleed, renal toxicity Norco (5-10mg hydrocodone/325 mg acetaminophen) Moderate Morphine Moderate to Severe Constipation, Ileus, n/v, respiratory depression, urinary retention Percocet (5mg oxycodone /325mg) Moderate Dilaudid Severe Caution Hepatic or Renal Impairment 8 Morphine IR Moderate Fentanyl (ICU) Severe

9 Case Vignette The next day his BP has risen to 170/105. He is given hydralazine 10mg IVP by the team with a drop in his BP to 125/ What is likely contributing to the rise in BP? 4. What side effects could occur from lowering the BP too much? 5. How else could this patient have been treated? 9

10 Hypertension Treatment- Inpatient Goal: -To identify and treat the underlying cause -Prevent end-organ damage Common Causes: Rebound Inadequate dosing Drug Interactions ETOH withdrawal Hypoxemia, respiratory distress Pain, Anxiety Autonomic response: urinary retention, constipation, SCI 10

11 Hypertension- Inpatient Management Approach to evaluating the patient: -Determine patient s baseline -Confirm accuracy, both arms, cuff size -Screen for the underlying cause -Determine if hypertensive emergency or urgency is present 11

12 Hypertension Treatment Hypertensive Urgency -SBP >180 or DBP >120 -gradual reduction of BP to 160/110 over hours -use ORAL meds *There is no proven benefit from rapid reduction of blood pressure in patients with severe asymptomatic hypertension 12

13 Hypertensive Emergency -evidence of end-organ damage -Immediate reduction of MAP: by 10 to 20 percent in the first hour then a further 5 to 15 percent over the next 23hrs -Use PARENTERAL agents (drips only, not IVP) -Transfer to ICU (There are exceptions: Aortic Dissection, Neurologic Emergencies, etc.) 13

14 Inpatient BP Management- Where s the Evidence? Intravenous Hydralazine for Blood Pressure Management in the Hospitalized Patient: Its Use is Often Unjustified Patrick Campbell, M.D., William L. Baker, Pharm.D., et.al Journal for American Society of Hypertension 94 patients (mean age, 69yrs, 89% with chronic hypertension) who received 201 intravenous hydralazine doses Baseline BP was 175/82 ± 25/16 mmhg and following hydralazine was reduced by 24/9 Only 2% of patients had evidence of an urgent hypertensive condition but 8% had adverse effects (hypotension) 48% of the doses were ordered between 11 pm and 7am. The internal medicine service ordered 52% of the intravenous hydralazine doses Seven (7.5%) patients were evaluated by a physician prior to hydralazine administration and 17 (18%) were evaluated post-dosing 14

15 Inpatient BP Management- Where s the Evidence? An Update on Inpatient Hypertension Management R. Neal Axon; Mason Turner; Ryan Buckley et.al Current Cardiology Reports; November 2015 most instances of elevated BP observed in the hospital are asymptomatic and may not require urgent action available evidence suggests a tendency for inpatient providers to overreact to asymptomatic elevated BP offering little benefit and risking potential harm Practice patterns, outcomes, and end-organ dysfunction for patients with acute severe hypertension: The Studying the Treatment of Acute hypertension (STAT) Registry N.Katz MD a. Joel M. GoreMD b. Alpesh Amin MD c et.al American Heart Journal, October institution, US registry of consecutive patients with acute severe hypertension (>180 SBP or >110 DBP)treated with IV meds in ICU or ED found marked variability in practice patterns and outcomes. This heterogeneity in care, along with high mortality and readmission rates, also highlights the importance of further investigation for this understudied clinical condition. 15

16 44% of respondents indicated that they would treat acutely elevated BP in an asymptomatic patient. The strong preference of trainees for hydralazine for hypertensive urgency in non intensive-care-unit patients is curious given that there do not appear to be any randomized controlled clinical trials with this medication for this indication.

17 Inpatient HTN Management There is no RCT evidence demonstrating that antihypertensive drugs reduce mortality or morbidity in patients with hypertensive emergencies There is insufficient RCT evidence to determine which drug or drug class is most effective in reducing mortality and morbidity. Although physicians commonly treat acute hypertension in hospitalized patients, we can find no consensus recommendation supporting the practice. 17 reasonable to limit the use of parenteral therapy to situations in which acute target organ damage is suspected and not as a standing prn order targeted to elevated BP above a threshold level.

18 Hypertension Clinical Pearls Hypertensive treatment rarely requires immediate treatment in the middle of the night Avoid prn use of rapid acting agents (can precipitate ischemic events) For patients with sustained HTN, primary team should initiate treatment with long acting regimen 18

19 Case Vignette Later that night the patient requests something for sleep and receives Benadryl 25mg po, written as qhs prn per night float. On day three of admission he develops urinary retention with a PVR of 300cc. A foley catheter is placed. You review his chart and notice a prior urology note indicating the patients prostate size on DRE is 50g. What could be contributing to the urinary retention? What other alternatives could have been used for his insomnia? 19

20 Hypnotics Benadryl 25mg-50mg Temazepam (Restoril) 15-30mg (geriatric 7.5mg) Trazodone (unlabeled use) 25-50mg Zolpidem (Ambien) 5-10mg Beers high severity Beers high severity Okay in elderly Beers High Severity (avoid chronic use) Anti-cholinergic effects (confusion, dry mouth, urinary retention; caution in pts with glaucoma and BPH Same AE as any benzo; contraindicated in glaucoma caution in those with falls risk, hepatic or renal impairment Hypotension, increased bleeding risk if on NSAID s or warfarin, priapism, serotonin syndrome, caution post-mi or with h/o seizures HA, dizziness, somnloence; in elderly similar effects to benzo (derlium, fall, fractures) Melatonin Melatonin Agonist (Ramelteon) 20 Safe, Well Tolerated Tolerated No evidence of benefit; may help in certain subgroup of patients Somnolence; caution in hepatic impairment

21 Case Vignette He remains hospitalized due to social issues including homelessness. On day 6 of admission you are called by the nurse due to the patient falling in his room. You evaluate his gait and notice he is unsteady in addition to being more somnolent than usual. What could be contributing to the fall and gait impairment? 21

22 Sedatives Ativan: common use in ETOH withdrawal -AE include sedation, respiratory depression -Caution in those with acute angle glaucoma, sleep apnea, respiratory issues, hepatic/renal impairment, h/o drug abuse or falls risk Anti-Psychotics: Typical (Haldol) & Atypical (Seroquel, Risperidone) -anti-cholinergic side effects, QT prolongation -careful in dementia related psychosis (increased risk of death compared to placebo) 22

23 Case Vignette A review indicates the patient has continued to receive Ativan despite no further evidence of withdrawal due to complaints of anxiety and insomnia. A review of his chart reveals he was previously on mirtazapine but this medication had not been continued on admission. During rounds, it is noted that the tachycardia noted on admission has recurred. On exam he is also noted to have a unilateral, fixed, dilated pupil. What else could be contributing to the tachycardia? What is causing the anisocoria? 23

24 Review- Case Vignette HPI: 59 year old male admitted for chest pain and acute ETOH intoxication. He also complains of hematemesis during his most recent drinking binge. PMHx: AVNRT, Hepatitis C, insomnia, depression, COPD Meds: combivent inhaler bid, ibuprofen 600mg po tid prn EKG on admission reveals bpm 24

25 Review- Case Vignette He is admitted to the medicine service with the following prn orders: -Ativan 2mg IV q4hr prn withdrawal -Albuterol neb q6h prn, Atrovent neb q6hr prn -Acetaminophen 650mg q4hr prn pain -Ibuprofen 600mg po tid prn pain 25

26 Pulmonary Nebulizers: Albuterol (max dose 3mL q4hours): can cause tachycardia, arrhythmia, caution in patients with ischemia Atrovent: anti-cholinergic side effects; caution in those with glaucoma, BPH Mucolytics: Mucomyst: can cause bronchospasm; use minutes after bronchodilator administration 26

27 Nebulizer Associated Anisocoria 27

28 Case Vignette The patient subsequently complains of diarrhea the next day. Stool studies are sent, and the intern orders lomotil prn for loose stools. Is this an appropriate order? 28

29 Gastrointestinal Heartburn: Maalox (aluminum dioxide, magnesium hydroxide) or Maalox plus AE: constipation, cramps, fecal discoloration; aluminum intoxication Use with caution in renal impairment: hypophosphatemia or hypermagnesemia long list of drug interactions Must be administered one hour apart from other oral meds Diarrhea: do not use in those with C. diff colitis Loperamide (Immodium): caution in hepatic impairment Lomotil (diphenoxylate/atropine): anti-cholinergic side effects Constipation: see mini-lecture on residency website 29

30 Case Vignette The patient subsequently does well and is discharged. Upon discharging the patient, you order the following outpatient medication regimen: Ibuprofen 600mg po tid prn Norco 2 tabs q6hr prn Combivent inhaler q4hr prn Benadryl 25mg po qhs prn Librium taper Are these appropriate orders? 30

31 Summary For all PRN orders, know the correct dosage, common adverse effects and contraindications Check the next day to see if your patient actually received any of the PRN meds Convert frequently administered PRN meds into standing orders Don t just put in PRN orders to save night float the trouble of getting called Evaluate underlying cause or condition requiring use of a PRN med and treat accordingly Don t forget the importance of medication reconciliation! 31