The Dreaded Drugs

If you are like most physicians, there is a group of drugs that you prescribe regularly and feel very comfortable with. While deep down we know they are not always safe, we use them so often, we may not think twice about ordering them.

Then there are those medications that we tend to shy away from – drugs like immunosuppressants, psychotropics, and others that are best prescribed by specialists familiar with their side effects. But, truth be told, it is our so-called "safe" drugs that land patients in the emergency department most of the time.

A recent article in the New England Journal of Medicine (titled Emergency Hospitalizations for Adverse Drug Events in Older Americans) cites four medications or medication classes as being responsible for 67% of hospitalizations related to adverse drug reactions (N. Engl. J. Med. 2011;365:2002-12). Specifically, warfarin, insulins, oral antiplatelet agents, and oral hypoglycemic agents were implicated in 67% of these hospitalizations. Conversely, a mere 1.2% of emergency medication-related admissions resulted from would be considered high-risk medications.

Most of us have admitted sweet little elderly ladies with atrial fibrillation who presents with black stools and a hematocrit in the teens. In some cases, they got confused an accidentally doubled up on a few doses of warfarin or received a medication that prolonged the INR. Add on occasional antiplatelet agents prescribed for recent cardiac stents and you have a recipe for disaster.

Then there are patients who have a new-onset seizure related to severe hypoglycemia. A few days of diarrhea caused dehydration with a resultant decline in renal function that makes the oral hypoglycemic agent they take hang around longer, and voila: a blood sugar of 30! And don’t forget that patient who’s been a little depressed and not eating much, but dutifully continues to take his insulin as prescribed.

The take-home lesson here is that we as physicians have a long way to go educating our patients:

• We should make sure that everyone we put on warfarin has a warfarin diet sheet explaining what their should be eating while on this medication.

Additionally, acute alcohol ingestion can increase the INR, while chronic daily consumption of alcohol increases metabolism of warfarin and can lower the INR, so we should counsel our patients accordingly.

Vitamin E, cranberry juice, and green tea have the potential to raise INR, as do CoQ10 and numerous commonly used herbs, such as ginseng, and ginger. Even horseradish, licorice, and omega-3 acids may affect the INR, so it is easy to see why so many people wind up in the ED with warfarin toxicity.

Patients should also be advised that since many medications have the potential to interact with warfarin, they should always check with their pharmacist or primary care doctor when prescribed a new medication, especially if it is prescribed by a specialist who might be less familiar warfarin interactions.

• We need to educate our patients on the significance of black, tarry stools. I can’t count the number of times patients have noticed black stools for more than a week and never reported it to their physician, thinking it was because of something they ate.

• People with diabetes should have an action plan on sick days and should know how to check their blood sugar regularly. While this is a typically deemed a primary care issue, there are situations in which it is clear that our patients will need an action plan immediately, such as directly after discharge.

The New England Journal of Medicine article also notes that more than 99,000 emergency hospitalizations for adverse drug events occurred each year from 2007 through 2009 for U.S. adults aged 65 years of age or older. Obviously, all physicians have a lot more educating to do.

Dr. A. Maria Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.

If you are like most physicians, there is a group of drugs that you prescribe regularly and feel very comfortable with. While deep down we know they are not always safe, we use them so often, we may not think twice about ordering them.

Then there are those medications that we tend to shy away from – drugs like immunosuppressants, psychotropics, and others that are best prescribed by specialists familiar with their side effects. But, truth be told, it is our so-called "safe" drugs that land patients in the emergency department most of the time.

A recent article in the New England Journal of Medicine (titled Emergency Hospitalizations for Adverse Drug Events in Older Americans) cites four medications or medication classes as being responsible for 67% of hospitalizations related to adverse drug reactions (N. Engl. J. Med. 2011;365:2002-12). Specifically, warfarin, insulins, oral antiplatelet agents, and oral hypoglycemic agents were implicated in 67% of these hospitalizations. Conversely, a mere 1.2% of emergency medication-related admissions resulted from would be considered high-risk medications.

Most of us have admitted sweet little elderly ladies with atrial fibrillation who presents with black stools and a hematocrit in the teens. In some cases, they got confused an accidentally doubled up on a few doses of warfarin or received a medication that prolonged the INR. Add on occasional antiplatelet agents prescribed for recent cardiac stents and you have a recipe for disaster.

Then there are patients who have a new-onset seizure related to severe hypoglycemia. A few days of diarrhea caused dehydration with a resultant decline in renal function that makes the oral hypoglycemic agent they take hang around longer, and voila: a blood sugar of 30! And don’t forget that patient who’s been a little depressed and not eating much, but dutifully continues to take his insulin as prescribed.

The take-home lesson here is that we as physicians have a long way to go educating our patients:

• We should make sure that everyone we put on warfarin has a warfarin diet sheet explaining what their should be eating while on this medication.

Additionally, acute alcohol ingestion can increase the INR, while chronic daily consumption of alcohol increases metabolism of warfarin and can lower the INR, so we should counsel our patients accordingly.

Vitamin E, cranberry juice, and green tea have the potential to raise INR, as do CoQ10 and numerous commonly used herbs, such as ginseng, and ginger. Even horseradish, licorice, and omega-3 acids may affect the INR, so it is easy to see why so many people wind up in the ED with warfarin toxicity.

Patients should also be advised that since many medications have the potential to interact with warfarin, they should always check with their pharmacist or primary care doctor when prescribed a new medication, especially if it is prescribed by a specialist who might be less familiar warfarin interactions.

• We need to educate our patients on the significance of black, tarry stools. I can’t count the number of times patients have noticed black stools for more than a week and never reported it to their physician, thinking it was because of something they ate.

• People with diabetes should have an action plan on sick days and should know how to check their blood sugar regularly. While this is a typically deemed a primary care issue, there are situations in which it is clear that our patients will need an action plan immediately, such as directly after discharge.

The New England Journal of Medicine article also notes that more than 99,000 emergency hospitalizations for adverse drug events occurred each year from 2007 through 2009 for U.S. adults aged 65 years of age or older. Obviously, all physicians have a lot more educating to do.

Dr. A. Maria Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.

If you are like most physicians, there is a group of drugs that you prescribe regularly and feel very comfortable with. While deep down we know they are not always safe, we use them so often, we may not think twice about ordering them.

Then there are those medications that we tend to shy away from – drugs like immunosuppressants, psychotropics, and others that are best prescribed by specialists familiar with their side effects. But, truth be told, it is our so-called "safe" drugs that land patients in the emergency department most of the time.

A recent article in the New England Journal of Medicine (titled Emergency Hospitalizations for Adverse Drug Events in Older Americans) cites four medications or medication classes as being responsible for 67% of hospitalizations related to adverse drug reactions (N. Engl. J. Med. 2011;365:2002-12). Specifically, warfarin, insulins, oral antiplatelet agents, and oral hypoglycemic agents were implicated in 67% of these hospitalizations. Conversely, a mere 1.2% of emergency medication-related admissions resulted from would be considered high-risk medications.

Most of us have admitted sweet little elderly ladies with atrial fibrillation who presents with black stools and a hematocrit in the teens. In some cases, they got confused an accidentally doubled up on a few doses of warfarin or received a medication that prolonged the INR. Add on occasional antiplatelet agents prescribed for recent cardiac stents and you have a recipe for disaster.

Then there are patients who have a new-onset seizure related to severe hypoglycemia. A few days of diarrhea caused dehydration with a resultant decline in renal function that makes the oral hypoglycemic agent they take hang around longer, and voila: a blood sugar of 30! And don’t forget that patient who’s been a little depressed and not eating much, but dutifully continues to take his insulin as prescribed.

The take-home lesson here is that we as physicians have a long way to go educating our patients:

• We should make sure that everyone we put on warfarin has a warfarin diet sheet explaining what their should be eating while on this medication.

Additionally, acute alcohol ingestion can increase the INR, while chronic daily consumption of alcohol increases metabolism of warfarin and can lower the INR, so we should counsel our patients accordingly.

Vitamin E, cranberry juice, and green tea have the potential to raise INR, as do CoQ10 and numerous commonly used herbs, such as ginseng, and ginger. Even horseradish, licorice, and omega-3 acids may affect the INR, so it is easy to see why so many people wind up in the ED with warfarin toxicity.

Patients should also be advised that since many medications have the potential to interact with warfarin, they should always check with their pharmacist or primary care doctor when prescribed a new medication, especially if it is prescribed by a specialist who might be less familiar warfarin interactions.

• We need to educate our patients on the significance of black, tarry stools. I can’t count the number of times patients have noticed black stools for more than a week and never reported it to their physician, thinking it was because of something they ate.

• People with diabetes should have an action plan on sick days and should know how to check their blood sugar regularly. While this is a typically deemed a primary care issue, there are situations in which it is clear that our patients will need an action plan immediately, such as directly after discharge.

The New England Journal of Medicine article also notes that more than 99,000 emergency hospitalizations for adverse drug events occurred each year from 2007 through 2009 for U.S. adults aged 65 years of age or older. Obviously, all physicians have a lot more educating to do.

Dr. A. Maria Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.