Prescription refills may continue after discontinuation

SAN FRANCISCO – Pharmacies refilled prescriptions for 1.5% of electronically discontinued medications, risking potential harm in 12% of cases, a study of 30,406 patients showed.

A retrospective study of records on 83,902 medications that had been electronically discontinued by physicians showed that 1,218 medications continued to be dispensed for 1,128 patients an average of one time in the year after discontinuation, Dr. Adrienne S. Allen reported at the annual meeting of the American College of Physicians.

Courtesy of ©PhotoDisk

Dr. Allen and her colleagues manually reviewed 416 charts to look for high-risk events and found suggestions of potential harm in 50 patients, including clinical reactions in 18 patients, laboratory abnormalities in 17, medication duplication in 8, and documented allergy in 7, said Dr. Allen, an internist in group practice in Danvers, Mass.

The continued refilling of discontinued prescriptions was seen for all drug classes and was most likely to affect patients with multiple prescriptions, nonwhite patients, and patients on Medicare or Medicaid (Ann. Intern. Med. 2012;157:700-5). Dr. Allen received a Junior Investigator Recognition Award at the meeting for her study.

Clinicians need to realize that dispensing of discontinued medication "does occur," Dr. Allen said. "Systemic intervention is needed to ensure that patients receive the correct medication."

Electronic health records with direct links to pharmacies make it easier to prescribe electronically, but most electronic health records do not transmit discontinuation orders to pharmacies, she noted.

The investigators studied records from 1 year in an integrated group practice with a common electronic health record that was separate from the group pharmacy’s computer system. They looked at medications commonly used in primary care: statins, antihypertensive medications, oral hypoglycemics, antiplatelet medications, and anticoagulants.

Among the 10 most commonly discontinued medications, dispensing continued for 1.4% of patients who had been using lisinopril or simvastatin, 1.2% of patients on hydrochlorothiazide, 1% on atenolol, 2.1% on amlodipine, 2.5% on metoprolol, 0.9% on metformin, 1.1% on enalapril, 1.5% on irbesartan, and 1.6% on warfarin.

The main reason for discontinuing a prescription was a dose adjustment. Other reasons included a change to an alternative medication, clinical intolerance, no further need for the drug, patient preference, or a laboratory abnormality.

Compared with white patients, black patients were 50% more likely and patients of other races were 60% more likely to have a discontinued medication dispensed. Patients covered by Medicaid were 40% more likely, and patients covered by Medicare were 70% more likely, to have a discontinued medication dispensed, compared with patients who had commercial insurance.

Patients on 15 or more medications were twice as likely to continue receiving a discontinued medication, compared with patients with fewer prescriptions.

Clinical reactions that suggested potential harm from the continued dispensing included hypotension in six patients; bradycardia, cough, or light-headedness in three patients each; and atrial flutter, GI upset, or myalgia in one patient each.

Laboratory abnormalities that suggested potential harm from refilling discontinued prescriptions included elevated liver function tests in five patients, hyponatremia or hypokalemia in four patients each, hyperkalemia in two patients, and increased levels of creatinine or uric acid in one patient each.

Dispensing of duplicate medications involved two statins in three patients, one patient each who got two sulfonylureas, two angiotensin-converting enzyme inhibitors, or two angiotensin receptor blockers, and two patients who got duplicate angiotensin-converting enzyme inhibitor/angiotensin receptor blocker medications. Medications continued to be dispensed despite records of allergy in seven patients, with allergy documented by cough in five patients and by rash or elevated creatinine phosphokinase in one patient each.

The National Institutes of Health funded the study. Dr. Allen reported having no relevant financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Pharmacies refilled prescriptions for 1.5% of electronically discontinued medications, risking potential harm in 12% of cases, a study of 30,406 patients showed.

A retrospective study of records on 83,902 medications that had been electronically discontinued by physicians showed that 1,218 medications continued to be dispensed for 1,128 patients an average of one time in the year after discontinuation, Dr. Adrienne S. Allen reported at the annual meeting of the American College of Physicians.

Courtesy of ©PhotoDisk

Dr. Allen and her colleagues manually reviewed 416 charts to look for high-risk events and found suggestions of potential harm in 50 patients, including clinical reactions in 18 patients, laboratory abnormalities in 17, medication duplication in 8, and documented allergy in 7, said Dr. Allen, an internist in group practice in Danvers, Mass.

The continued refilling of discontinued prescriptions was seen for all drug classes and was most likely to affect patients with multiple prescriptions, nonwhite patients, and patients on Medicare or Medicaid (Ann. Intern. Med. 2012;157:700-5). Dr. Allen received a Junior Investigator Recognition Award at the meeting for her study.

Clinicians need to realize that dispensing of discontinued medication "does occur," Dr. Allen said. "Systemic intervention is needed to ensure that patients receive the correct medication."

Electronic health records with direct links to pharmacies make it easier to prescribe electronically, but most electronic health records do not transmit discontinuation orders to pharmacies, she noted.

The investigators studied records from 1 year in an integrated group practice with a common electronic health record that was separate from the group pharmacy’s computer system. They looked at medications commonly used in primary care: statins, antihypertensive medications, oral hypoglycemics, antiplatelet medications, and anticoagulants.

Among the 10 most commonly discontinued medications, dispensing continued for 1.4% of patients who had been using lisinopril or simvastatin, 1.2% of patients on hydrochlorothiazide, 1% on atenolol, 2.1% on amlodipine, 2.5% on metoprolol, 0.9% on metformin, 1.1% on enalapril, 1.5% on irbesartan, and 1.6% on warfarin.

The main reason for discontinuing a prescription was a dose adjustment. Other reasons included a change to an alternative medication, clinical intolerance, no further need for the drug, patient preference, or a laboratory abnormality.

Compared with white patients, black patients were 50% more likely and patients of other races were 60% more likely to have a discontinued medication dispensed. Patients covered by Medicaid were 40% more likely, and patients covered by Medicare were 70% more likely, to have a discontinued medication dispensed, compared with patients who had commercial insurance.

Patients on 15 or more medications were twice as likely to continue receiving a discontinued medication, compared with patients with fewer prescriptions.

Clinical reactions that suggested potential harm from the continued dispensing included hypotension in six patients; bradycardia, cough, or light-headedness in three patients each; and atrial flutter, GI upset, or myalgia in one patient each.

Laboratory abnormalities that suggested potential harm from refilling discontinued prescriptions included elevated liver function tests in five patients, hyponatremia or hypokalemia in four patients each, hyperkalemia in two patients, and increased levels of creatinine or uric acid in one patient each.

Dispensing of duplicate medications involved two statins in three patients, one patient each who got two sulfonylureas, two angiotensin-converting enzyme inhibitors, or two angiotensin receptor blockers, and two patients who got duplicate angiotensin-converting enzyme inhibitor/angiotensin receptor blocker medications. Medications continued to be dispensed despite records of allergy in seven patients, with allergy documented by cough in five patients and by rash or elevated creatinine phosphokinase in one patient each.

The National Institutes of Health funded the study. Dr. Allen reported having no relevant financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – Pharmacies refilled prescriptions for 1.5% of electronically discontinued medications, risking potential harm in 12% of cases, a study of 30,406 patients showed.

A retrospective study of records on 83,902 medications that had been electronically discontinued by physicians showed that 1,218 medications continued to be dispensed for 1,128 patients an average of one time in the year after discontinuation, Dr. Adrienne S. Allen reported at the annual meeting of the American College of Physicians.

Courtesy of ©PhotoDisk

Dr. Allen and her colleagues manually reviewed 416 charts to look for high-risk events and found suggestions of potential harm in 50 patients, including clinical reactions in 18 patients, laboratory abnormalities in 17, medication duplication in 8, and documented allergy in 7, said Dr. Allen, an internist in group practice in Danvers, Mass.

The continued refilling of discontinued prescriptions was seen for all drug classes and was most likely to affect patients with multiple prescriptions, nonwhite patients, and patients on Medicare or Medicaid (Ann. Intern. Med. 2012;157:700-5). Dr. Allen received a Junior Investigator Recognition Award at the meeting for her study.

Clinicians need to realize that dispensing of discontinued medication "does occur," Dr. Allen said. "Systemic intervention is needed to ensure that patients receive the correct medication."

Electronic health records with direct links to pharmacies make it easier to prescribe electronically, but most electronic health records do not transmit discontinuation orders to pharmacies, she noted.

The investigators studied records from 1 year in an integrated group practice with a common electronic health record that was separate from the group pharmacy’s computer system. They looked at medications commonly used in primary care: statins, antihypertensive medications, oral hypoglycemics, antiplatelet medications, and anticoagulants.

Among the 10 most commonly discontinued medications, dispensing continued for 1.4% of patients who had been using lisinopril or simvastatin, 1.2% of patients on hydrochlorothiazide, 1% on atenolol, 2.1% on amlodipine, 2.5% on metoprolol, 0.9% on metformin, 1.1% on enalapril, 1.5% on irbesartan, and 1.6% on warfarin.

The main reason for discontinuing a prescription was a dose adjustment. Other reasons included a change to an alternative medication, clinical intolerance, no further need for the drug, patient preference, or a laboratory abnormality.

Compared with white patients, black patients were 50% more likely and patients of other races were 60% more likely to have a discontinued medication dispensed. Patients covered by Medicaid were 40% more likely, and patients covered by Medicare were 70% more likely, to have a discontinued medication dispensed, compared with patients who had commercial insurance.

Patients on 15 or more medications were twice as likely to continue receiving a discontinued medication, compared with patients with fewer prescriptions.

Clinical reactions that suggested potential harm from the continued dispensing included hypotension in six patients; bradycardia, cough, or light-headedness in three patients each; and atrial flutter, GI upset, or myalgia in one patient each.

Laboratory abnormalities that suggested potential harm from refilling discontinued prescriptions included elevated liver function tests in five patients, hyponatremia or hypokalemia in four patients each, hyperkalemia in two patients, and increased levels of creatinine or uric acid in one patient each.

Dispensing of duplicate medications involved two statins in three patients, one patient each who got two sulfonylureas, two angiotensin-converting enzyme inhibitors, or two angiotensin receptor blockers, and two patients who got duplicate angiotensin-converting enzyme inhibitor/angiotensin receptor blocker medications. Medications continued to be dispensed despite records of allergy in seven patients, with allergy documented by cough in five patients and by rash or elevated creatinine phosphokinase in one patient each.

The National Institutes of Health funded the study. Dr. Allen reported having no relevant financial disclosures.

[email protected]

On Twitter @sherryboschert