Polypharmacy and adverse drug events

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Target exams

Red flags

• An elderly patient with a fall, confusion, bleeding or a low glucose is having an adverse drug event until the drug chart proves otherwise — the medication list is the second investigation after the vital signs
• Glibenclamide (glyburide) and the long-acting sulfonylureas cause the deepest and most prolonged hypoglycaemia; a single 50 per cent dextrose bolus is never enough — admit, feed, and run a dextrose infusion
• A normal creatinine does not mean normal renal function in the elderly — low muscle mass flatters the estimate, and DOACs, digoxin, lithium and gabapentin accumulate silently; use estimated renal function (creatinine clearance by Cockcroft-Gault for the DOACs), never the raw creatinine
• Warfarin potentiated by a new interacting drug (ciprofloxacin, amiodarone, metronidazole, fluconazole) with an intracranial bleed and INR over 8 is an immediate prothrombin complex concentrate plus vitamin K problem, not a vitamin K alone problem
• The prescribing cascade hides in plain sight — a new drug prescribed for the side effect of an old one (metoclopramide for NSAID nausea, then levodopa for the Parkinsonism) inflates the count and the harm; audit for it
• Never stop a beta-blocker, a clonidine, an opioid or a benzodiazepine abruptly in the elderly — rebound tachycardia, hypertensive crisis, withdrawal seizure and delirium follow; taper