Back to Basics: The Basics of Medication Monitoring
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1 DIAMOND PHARMACY SERVICES Back to Basics: The Basics of Medication Monitoring Presented by: Dr. Deborah Milito, Pharm. D., CGP. Director of Clinical and Consultant Services Skilled Division Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Purpose To review the basic information that is needed to monitor medications so that they are effective and safe to use. Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Objectives List Diagnosis, Indication, Dose, and Interval Identify Medications that need Lab Monitoring Identify Inappropriate Medications List Psychoactive Medications that need to be Behavior Monitored Identify Pain Assessment Monitoring Describe other Pharmacological Monitoring Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services 1
2 Diagnosis, Indication, Dose, and Interval Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Diagnosis, Indication, Dose, and Interval Medication Reconciliation Compare regimen against admission, transfer and discharge Discrepancies Duplications Omissions Unnecessary therapy Inappropriate doses Interactions Intervals Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Medications that Require Lab Monitoring Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services 2
3 Lab Monitoring for Common Medications Medication or Medication Class Recommended Test (s) Aldosterone antagonists (i.s. eplerenone [Inspra ] and Potassium and renal function spironolactone) ACEI (angiotensin converting enzyme inhibitor) or ARB Potassium, renal function, white blood cell count (ACEI) (angiotensin receptor blocker) Aliskiren Potassium and renal function Liver function (amiodarone), potassium (flecainide), thyroid function (amiodarone), Antiarrhythmics antiarrhythmic levels (flecainide, mexiletine) Renal function (apixaban, dabigatran, rivaroxaban), INR (warfarin), CYP2C9 and VKORC1 Anticoagulants, oral genotype (warfarin) Anticonvulsant level, liver function (carbamazepine, eslicarbazepine, ethosuximide, felbamate, valproate), complete blood count (carbamazepine, felbamate), renal function (carbamazepine, zonisamid), genotyping (carbamazepine), platelet count and coagulation Anticonvulsants tests (valproate), ammonia (valproate and topiramate, if symptomatic), bicabonate (topiramate, zonisamide), thyroid function (oxcarbazepine), sodium (oxcarbazepine, carbamazepine, eslicarbazepine) Atypical antipsychotics Glucose, lipids, complete blood count, potassium and magnesium Digoxin Digoxin Level, electrolytes, renal function Electrolytes (e.g., potassium, sodium, magnesium, calcium, bicarbonate), glucose, renal Diuretics function, uric acid Liver function, renal function, creatine kinase (if muscle symptoms occur), complete blood Fibrates (fenofibrate [Tricor, etc], gemfibrozil) count (gemfibrozil) Glitazones (rosiglitazone [Avandia ], pioglitazone [Actos ]) Liver function Source: Pharmacist s Letter / Prescriber s Letter Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Lab Monitoring for Common Medications Medication or Medication Class Recommended Test (s) Thyroid function, complete blood count, electrolytes, calcium, lithium level, pregnancy test, Lithium renal function Metformin Hemoglobin, hematocrit, red blood cell indices, renal function Niacin Liver function, uric acid, glucose, creatine kinase, potassium, phosphorus NSAIDs Electrolytes, renal function, complete blood count, liver function Proton Pump Inhibitors Magnesium Calcium (calcipotriol/calcipotriene), liver function (acitretin), lipids (acitretin), glucose Psoriasis medications (acitretin), pregnancy test (acitretin) Retinoids, systemic (isotretinoin) Lipids, liver function, glucose, pregnancy test Rheumatoid arthritis medications LFT'S Liver function, creatine kinase, lipids, thyroid stimulating hormone (if muscle symptoms Statins occur) Theophylline Theophylline Level Thyroid replacement (e.g., Levothyroxine) Thyroid stimulating hormone (sensitive TSH) Source: Pharmacist s Letter / Prescriber s Letter Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Inappropriate Medications Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services 3
4 Identify Inappropriate Medications AGS Beers Criteria Source: The American Geriatrics Society Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Identify Inappropriate Medications (continued) Source: The American Geriatrics Society Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Identify Inappropriate Medications (continued) Source: The American Geriatrics Society Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services 4
5 Identify Inappropriate Medications (continued) Source: The American Geriatrics Society Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Psychoactive Medications Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Psychoactive Medications Source: American Society of Consultant Pharmacist and MED PASS, Inc. Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services 5
6 Psychoactive Medications Source: American Society of Consultant Pharmacist and MED PASS, Inc. Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Pain Assessment Evaluations Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Pain Assessment Evaluations Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services 6
7 Pain Assessment Evaluations Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Other Pharmacological Monitoring Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Other Pharmacological Monitoring Timing of medication administration Donepezil Memantine Steroid / Beta Agonist Inhibitors Montelukast Proton pump inhibitors Discontinuation dates for medications Antibiotics Heparin s Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services 7
8 In Conclusion If all the basic information is present, then the medications that are being used are safe and effective for the residents Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services Questions Annual Educational Conference Thursday, April 23, Diamond Pharmacy Services 8
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