Hospital Pharmacy Perspective: HF Medication Review

MAY 18, 2017


Sheryl Chow, PharmD, BCPS; Akshay Desai, MD; Peter L. Salgo, MD; and Orly Vardeny, PharmD, MS, explain the importance of hospital pharmacy medication reconciliation in the management of heart failure.

Peter L. Salgo, MD: One other thing that you haven’t mentioned is how to manage folks who have had some heart failure, have been on medications, and come in with an exacerbation. And again, you’re going to work up the etiology of that. But isn’t part of the exacerbation, potentially, reviewing the medications they’re on and whether those are the best medications and whether they’re following through and taking them?
Orly Vardeny, PharmD, MS: Or whether they’re even on those medications is a question that needs to be addressed right away.
Peter L. Salgo, MD: This is the old medicine reconciliation moment that was addressed. By the way, I can remember when it was first presented to us and everybody said, “Oh, we don’t have to do that. We know what they’re taking.” Lo and behold, we didn’t. We didn’t know what they were taking. We knew what they were supposed to be taking. There’s a big difference. How do you get at that? How do you take a patient who has medicines that you think they’re taking and actually ascertain whether they’re taking them and how much? That’s a tough thing to do, isn’t it?
Sheryl Chow, PharmD, BCPS: Right. You have to rely on the patient’s own past history. You have to rely on family members to help fill in the gaps, but ideally, medication reconciliation is lining the indication with the medication. And you’d be surprised, so many patients will be coming into the hospital on proton pump inhibitors and have absolutely no indication. So, that’s what the process is all about—just discontinuing those which the patient doesn’t need anymore and then adding those which the patient does need.
Peter L. Salgo, MD: It would seem to me that one thing you have to consider is, are they taking the medicines that we think they’re taking in the first place? And then, don’t you have to assess whether those the right medications, in the first place, at all? Did we give the right prescription? Did somebody else actually start out on the right cocktail? Is that fair?
Orly Vardeny, PharmD, MS: And that is, a lot of times, the toughest part—figuring out exactly what they’re taking—because they may not know to tell you exactly what they’re taking or even know what some of the medications are for. So, one approach is to have them go to the medicine cabinet, take all of their bottles, stick them in a bag, and bring them in to clinic or the hospital. Then we can look and see exactly, bottle by bottle, what they are taking. Half a tablet, full tablet, what exactly is the patient doing?
Akshay Desai, MD: A piece of that is not just the things that we gave them. A lot of people take medicines that aren’t prescribed by physicians, that they’ve decided might be helpful for traditional medicine reasons or for holistic reasons. And people don’t think of supplements as medications. We don’t ask about those often, and some of those might actually make heart failure worse.
Orly Vardeny, PharmD, MS: Exactly.
Akshay Desai, MD: And then there are things we use over-the-counter. A classic example is that nonsteroidal anti-inflammatory drugs (NSAIDs) can actually make heart failure worse, too. So, for drugs like ibuprofen or naproxen, these are medicines that if you have severe heart failure, you probably don’t want to be taking a lot of them because they might make you hold on to fluid.
Orly Vardeny, PharmD, MS: And patients might think that Tylenol is the same thing, and they may not realize the difference. They may say they’re taking Tylenol when they’re taking an NSAID.
Peter L. Salgo, MD: When I see a patient come in with a bag like that, I just say, “Thank you. Yes, you’re going to have to go through this, but thank you.” Or they come in with a very detailed list that their daughter, son, wife, husband has actually made up and typed or handwritten, but is something where they’re keeping track. It’s really tough out there. I have a sense, also, that there are OTC medicines, not just the NSAIDs, that are being pushed on television and in the health food stores, that people are taking,, and they’re not even aware they should be telling you about them. Do you see that?
Akshay Desai, MD: We see it all the time. And often physicians, because of the limited time in the clinic setting (and this is where I think it’s really helpful to have a multidisciplinary team), in a 15-minute clinic encounter, what the patient initially tells you is sort of what most people go by. And I think you need to deliberately ask, “Are you taking supplements? Are you taking vitamins? Are you taking things that I haven’t given you as part of your daily routine?” Because a lot of these things do contain substances that may make heart failure worse.
Peter L. Salgo, MD: We see it all the time, pre-op.
Orly Vardeny, PharmD, MS: I was going to say that patients may take things that they don’t even realize are harmful. They think these are inert for cough and cold. They have an upper respiratory infection and they take something that has a decongestant in it. It’s not so great in the heart failure setting, and they may not realize that that is bad.
Peter L. Salgo, MD: Again, could we do a better job? Could we, in our heart failure patients, before we send them home or if they’re at home, at least give them a piece of paper and give them a bullet point list of some of the real big offenders? “Please stay away from them.” Is this not our job, too?
Orly Vardeny, PharmD, MS: Definitely. We do that, actually, as part of planning for a discharge, if you wanted to segue into that topic.
Peter L. Salgo, MD: We can do that, too. But I see this every day. I see people who are trying to do their best. I don’t think anybody is trying to get sick, and they’re trying to do the right thing and take the right medications. They come in on cocktails that make your head explode or, in this case, your heart explode.
 
 


Sheryl Chow, PharmD, BCPS; Akshay Desai, MD; Peter L. Salgo, MD; and Orly Vardeny, PharmD, MS, explain the importance of hospital pharmacy medication reconciliation in the management of heart failure.

Peter L. Salgo, MD: One other thing that you haven’t mentioned is how to manage folks who have had some heart failure, have been on medications, and come in with an exacerbation. And again, you’re going to work up the etiology of that. But isn’t part of the exacerbation, potentially, reviewing the medications they’re on and whether those are the best medications and whether they’re following through and taking them?
Orly Vardeny, PharmD, MS: Or whether they’re even on those medications is a question that needs to be addressed right away.
Peter L. Salgo, MD: This is the old medicine reconciliation moment that was addressed. By the way, I can remember when it was first presented to us and everybody said, “Oh, we don’t have to do that. We know what they’re taking.” Lo and behold, we didn’t. We didn’t know what they were taking. We knew what they were supposed to be taking. There’s a big difference. How do you get at that? How do you take a patient who has medicines that you think they’re taking and actually ascertain whether they’re taking them and how much? That’s a tough thing to do, isn’t it?
Sheryl Chow, PharmD, BCPS: Right. You have to rely on the patient’s own past history. You have to rely on family members to help fill in the gaps, but ideally, medication reconciliation is lining the indication with the medication. And you’d be surprised, so many patients will be coming into the hospital on proton pump inhibitors and have absolutely no indication. So, that’s what the process is all about—just discontinuing those which the patient doesn’t need anymore and then adding those which the patient does need.
Peter L. Salgo, MD: It would seem to me that one thing you have to consider is, are they taking the medicines that we think they’re taking in the first place? And then, don’t you have to assess whether those the right medications, in the first place, at all? Did we give the right prescription? Did somebody else actually start out on the right cocktail? Is that fair?
Orly Vardeny, PharmD, MS: And that is, a lot of times, the toughest part—figuring out exactly what they’re taking—because they may not know to tell you exactly what they’re taking or even know what some of the medications are for. So, one approach is to have them go to the medicine cabinet, take all of their bottles, stick them in a bag, and bring them in to clinic or the hospital. Then we can look and see exactly, bottle by bottle, what they are taking. Half a tablet, full tablet, what exactly is the patient doing?
Akshay Desai, MD: A piece of that is not just the things that we gave them. A lot of people take medicines that aren’t prescribed by physicians, that they’ve decided might be helpful for traditional medicine reasons or for holistic reasons. And people don’t think of supplements as medications. We don’t ask about those often, and some of those might actually make heart failure worse.
Orly Vardeny, PharmD, MS: Exactly.
Akshay Desai, MD: And then there are things we use over-the-counter. A classic example is that nonsteroidal anti-inflammatory drugs (NSAIDs) can actually make heart failure worse, too. So, for drugs like ibuprofen or naproxen, these are medicines that if you have severe heart failure, you probably don’t want to be taking a lot of them because they might make you hold on to fluid.
Orly Vardeny, PharmD, MS: And patients might think that Tylenol is the same thing, and they may not realize the difference. They may say they’re taking Tylenol when they’re taking an NSAID.
Peter L. Salgo, MD: When I see a patient come in with a bag like that, I just say, “Thank you. Yes, you’re going to have to go through this, but thank you.” Or they come in with a very detailed list that their daughter, son, wife, husband has actually made up and typed or handwritten, but is something where they’re keeping track. It’s really tough out there. I have a sense, also, that there are OTC medicines, not just the NSAIDs, that are being pushed on television and in the health food stores, that people are taking,, and they’re not even aware they should be telling you about them. Do you see that?
Akshay Desai, MD: We see it all the time. And often physicians, because of the limited time in the clinic setting (and this is where I think it’s really helpful to have a multidisciplinary team), in a 15-minute clinic encounter, what the patient initially tells you is sort of what most people go by. And I think you need to deliberately ask, “Are you taking supplements? Are you taking vitamins? Are you taking things that I haven’t given you as part of your daily routine?” Because a lot of these things do contain substances that may make heart failure worse.
Peter L. Salgo, MD: We see it all the time, pre-op.
Orly Vardeny, PharmD, MS: I was going to say that patients may take things that they don’t even realize are harmful. They think these are inert for cough and cold. They have an upper respiratory infection and they take something that has a decongestant in it. It’s not so great in the heart failure setting, and they may not realize that that is bad.
Peter L. Salgo, MD: Again, could we do a better job? Could we, in our heart failure patients, before we send them home or if they’re at home, at least give them a piece of paper and give them a bullet point list of some of the real big offenders? “Please stay away from them.” Is this not our job, too?
Orly Vardeny, PharmD, MS: Definitely. We do that, actually, as part of planning for a discharge, if you wanted to segue into that topic.
Peter L. Salgo, MD: We can do that, too. But I see this every day. I see people who are trying to do their best. I don’t think anybody is trying to get sick, and they’re trying to do the right thing and take the right medications. They come in on cocktails that make your head explode or, in this case, your heart explode.
 
 
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