Mrs. Agonistou
Mrs. Agonistou is a 78 year old woman presenting with flank pain and a history of hypertension (Ramipril/Metoprolol) and NIDDM (Metformin) is discharged home with a CT-proven 5 mm UVJ stone –she is started on Hydromorphone, Acetaminophen, and Tamsulosin.
After the first dose of all three she has an orthostatic syncopal episode and returns with a BP of 85/70 and a HR of 90.
- What do you think happened?
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Important Note
When you’re adding ANY new medication in the ED — even well-considered, evidence-based ones — it’s important to keep in mind both drug-drug interactions and the realities of aging physiology.
Discussion: Mrs. Agonistou
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good tip to always remember age related physiologic changes
drug interaction and age sensitivity
okk
Agree with caution when starting new medications in elderly who usually are on a plethora of other meds…
I agree
combination of hydromorph, flomax, ramipril and metroplol all caused the syncope. It’s important to research the medications prescribed to the elderly but it’s something that is not done or missed by allot of physicians who prescribe drugs.
good thing to remember with flomax
ok
ok
agreed
agreed
good point
–
nice
AGREE. NO GOOD EVIDENCE FOR USE OF FLOMAX.
Got it
there is no good evidence for tamsulosin
NO GOOD EVIDENCE THAT FLOMAX IS HELPFUL
;
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great
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OK
Agree
agree
Way too much medication. Flomax can make you dizzy on top of dilaudid in an elderly patient.
Good point
important to look at all possible interactions
Ok
ok
ok
Side affects
good point
Brilliant ideas
Great points
Great points
Read/or ask a colleague about meds AE and Use drug interaction Apps
good info
good points
Agree
ok
x
ok
great
great pointe
.
Pharmacology.
this that she returned to the ed allows us to correct the mistake
Care has to be taken when giving medications to the elderly.
polypharmacy allows these unforeseen circumstances
tamulosin has at best limited use in this indication and is probably useless
In a healthy geriatric patient with good follow up, it may be reasonable to have a patient centered discussion of the risks and benefits of the treatments available to them for there condition, so long as the patient clearly understands the weight of potential risks and is aware of the red flags on when to stop therapies and seek follow up.
Combination of the drugs
agree
good point
Tamsulosin is known for this
her blood pressure was so low!
physician should have seen the potential risk for hypotension
no need for flomax at this tiem – increase po fluid intake
Never give strong analgesics to elderly. Would probably have done well with acetaminophen or ibuprofen.
be careful with polypharmacy in elderly especially
Careful administration of narcotics to the elderly on multiple meds. Side effects are amplified in the elderly.
Multiple drugs increase risks of interactions, geriatrics are highly sensitive
good points
evaluate medication
drug interaction
ss if family involved. Enlist them to assist with medications \
check
nta
Need to re-evaluate medication régime.
polypharmacy
have to be careful about polypharmacy
k
Good point.
Palliative care pearl – “The hand that prescribes the opioid should also prescribe the stool softener”
When in doubt, call the pharmacist
Had this happen in our urgent care recently. Great re-cap!
Always review the medication management plan with drug interactions and perform quick cognitive assessment of elderly on every visit.
drug interactions
polypharm
Polypharm
It’s critical to consider all current medications and potential side effects/pitfalls prior to adding new medications, particularly in an elderly population.
polypharm!
combination of meds caused low B/P
When in doubt contact a pharmacist
meds – maybe should have given in dept to see how responded
Tamsulosin, metoprolol and hydromorphone. All proponents of vasodilation.
makes sense
Poor old bird can’t handle the synergistic effects of the drugs is the bottom line
.
the risks seem to out way the potential benefits involved in adding an agent with little evidence of significantly improving outcome
yep
forgot about the lack of ability to compensate when beta blocked. easy to forget.
always discuss the side effects of the medications and what needs to be done when it occurs with the patient.
have to talk bowels when we talk pain meds
Just would like to know the reason to prescribe Tamsulosin: Tamsulosin is indicated for the treatment of the signs and symptoms of benign prostatic hyperplasia (BPH) Tamsulosin hydrochloride capsules are not indicated for the treatment of hypertension.
There is some evidence — though now mostly questioned — that the alpha-antagosism of tamsulosin causes relaxation of the ureteric smooth muscle and facilitates stone expulsion.
Have to pay attention to patient’s current med program and consider drug interactions when introducing new meds.
We must take encunta vasodilation
you have to think vasodilation
iportant to evaluate drug interaction
🙂
Iatrogenic issue
Combination of med
good she returned
Cool.
side effects of new medication
Combination of meds caused decrease in BP.
Always helpful to discuss with the pharmacist about patients meds particularly with multiple diseases and multiple meds.
Probably a combination of the tamusolin, the metroprolol and the hydromorphone caused her to have a drop in her BP.
Agree with the above comment re lack of strong evidence for tamsulosin
not sure there is much evidence for the tamsulosin anyway
Probably a good thing she was forced to return. Maybe the second physician recognized that she wasn’t given sennokot and prevented her fecal impaction.
Good point about consideration of the beta blockade effect of metoprolol in this case.