The Hospice Clinician Blog

A nationwide study of adverse drug events (ADEs) in patients 65 years of age and older found that warfarin, insulins, oral antiplatelet agents and oral hypoglycemic agents account for 71% of all ADE-related emergency department visits and subsequent hospitalizations. This study was recently published in the New England Journal of Medicine and serves as a reminder to use caution with these agents when prescribing them to hospice patients.

The study found many results that we would intuitively expect:

• The risk of ADEs increased as patients got older (nearly half of the hospitalizations were patients ≥ 80 years) and as the number of medications in their regimen increased.
• Most hospitalizations related to hematologic agents (e.g., warfarin and antiplatelet agents) were for acute hemorrhages, and most resulted from unintentional overdoses.
• Almost all hospitalizations related to insulins and oral hypoglycemic agents were for hypoglycemia, and most resulted from unintentional overdoses.
• There is particular danger in combining warfarin with an oral antiplatelet agent, and insulin with an oral hypoglycemic agent.

In the hospice patient population, we treat patients that are at particularly high risk for ADEs, for a number of reasons:

• Increased age
• High numbers of medications and complicated regimens
• Cognitive impairment
• Fluctuating physiologic function, illness, renal/hepatic function, and food intake

The substantial contribution that these four medications/medication classes make to hospitalizations in older adults is a reminder of the need for careful consideration of risks and benefits for individual patients. Anticoagulation and antiplatelet therapy should be discontinued when a patient is admitted to hospice, unless treating an active, symptomatic clot like a DVT. Sliding-scale insulin regimens and long-acting sulfonylureas should be completely avoided (see our Beers Criteria articles), and other insulins and oral hypoglycemic agents should only be continued as long as the patient is eating full, regular meals. Once food intake declines, discontinue antidiabetic therapy altogether.

Hospice patients continuing their anticoagulant, antiplatelet or antidiabetic therapy should be carefully counseled about early recognition of serious side effects, like hemorrhage and hypoglycemia.

Reference:

Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency Hospitalizations for Adverse Drug Events in Older Americans. N Engl J Med 2011; 365: 2002-2012.

Posted on April 17, 2012

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