Mina’s SPARRA score suggested that she might benefit from a medication review. The community pharmacist reviews Mina’s medications using the 7 step approach advocated in NHS Scotland’s Polypharmacy Guidance (see additional information). Rationalisation of medication is an important part of this and includes up-titrating evidence based therapies, whilst stopping or changing those that are of no benefit or contra-indicated in the presence of Mina’s multiple conditions. Mina is prescribed medication based on current clinical guidelines. Following the review, she is prescribed the following:
Heart Failure
Lisonopril 35mgs daily. ACE inhibitors dilate blood vessels and decrease the workload of the heart. They have been shown to improve ventricular function, reduce mortality and hospital admissions. Routine urea & electrolyte checks should be carried out to ensure no worsening of Mina’s renal function.
Furosemide 40mgs x twice daily (morning & lunch). Diuretics are prescribed if there is a diagnosis of fluid overload or congestion. Loop diuretics, such as furosemide, inhibit reabsorption of water and salt from the kidneys and reduce oedema. Mina should weigh herself daily to assess the degree of fluid retention and to ensure that she is receiving the optimal diuretic dose.
Bisoprolol 10mgs daily. Beta-blockers block the beta-adrenoreceptors in the heart, thus slowing the heart rate and reducing blood pressure. Evidence shows that beta-blockers increase ejection fraction and exercise tolerance, and reduce morbidity, mortality and hospital admissions. (N.B. Bisopropol is not licensed for those over 70 years of age.)
Spironolactone 25gs daily. Mineralocorticoid receptor antagonists antagonise the action of aldosterone. Aldosterone is important in maintaining water and electrolyte balance, and is responsible for sodium and water retention and potassium excretion. Although the drug may help reduce Mina’s oedema, she will be carefully monitored for hyperkalaemia and renal dysfunction while she is on the drug.
COPD
Salmeterol inhaler 2 puffs x twice daily. This is a long acting beta2 antagonist which produces bronchodilation. Treatment with beta2 agonists has been claimed to improve survival in COPD patients with heart failure and is recommended (Global Initiative for Chronic Obstructive Lung Disease, 2017. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: 2017 Report, available from GOLD COPD).
Pulse point
Mina is suffering from mild depression. However, anti-depressants should not be routinely used to treat mild depression in patients with chronic physical health problems, as the risk-benefit is poor. The impact of the other interventions, such as Joe going to the day centre and the befriending support offered, may relieve Mina’s depression without the need for medication. If her depression persists despite these interventions, then anti-depressant therapy may need to be considered. If Mina were to be prescribed anti-depressant medication, this would be a selective serotonin re-uptake inhibitor (SSRI) rather than a tricyclic anti-depressant, as tricyclics have known potential cardiovascular side-effects.
Page last reviewed: 28 Sep 2020
