Page 56 - Demo

CONTINUING PROFESSIONAL DEVELOPMENT
MEDICATION REVIEW
Ceasing sertraline: can be an anxious experience
BY ASSOCIATE PROFESSOR MARK NAUNTON MPS & LOUISE DEEKS MPS
Mrs LC is an 80-year-old female who was referred for a Residential Medication Management Review (RMMR) by her general practitioner (GP) after nursing staff became concerned about her challenging behaviour. The GP wanted to determine whether any of her medicines could be contributing to this deterioration. He had recently switched her from sertraline to mirtazapine and added risperidone. Her medical history included:
• type 2 diabetes
• osteoporosis
• hyperlipidaemia
• vertebral fracture
• frequent falls
Clinical assessment
• chronic inflammatory demyelinating polyneuropathy
• dementia
• depression
• atrial fibrillation.
At review, the nursing staff reported Mrs LC had been much more disturbed over the past 2–3 weeks. During the pharmacist’s visit, Mrs LC was unable to sit still. She was constantly moving, walking around the facility and shouting at the other residents. The nursing care plan revealed Mrs LC was not sleeping well and was often heard crying during the night. She had experienced two falls in the past week.
InspectionofMrsLC’smedicationchartidentifiedthatsertraline100 mghad beenceasedbyherGP3 weeksbeforethemedicationreview,duetoalack ofeffect.Onthesamedaythatsertralinewasceased,mirtazapine15 mgwas prescribedwiththeviewtoincreasethedoseto30 mgatnight.However, four doses had been omitted since it was commenced. In addition, it was noted that medication packs containing sertraline were still present in the medication trolley and there were six occasions when this appeared to have been administered to Mrs LC after the GP had discontinued it. The staff notes suggested there were days when Mrs LC was less anxious and this seemed
to correlate with the administration in error of sertraline. The GP had also commenced risperidone a week after the sertraline was ceased.
The nurses explained that Mrs LC was uncooperative with medication administration and was unwilling to swallow medicine with water, preferring to suck her tablets. Nursing staff also reported that Mrs LC often removed her rivastigmine patch, which was challenging for them to re-apply.
Nursing staff observations on the morning of the RMMR visit were:
• urinalysis negative for urinary tract infection, but demonstrated glycosuria
• blood pressure 110/80 mmHg.
Her medication profile is shown in Table 1.
Issues identified
The review identified the following issues:
• Possible serotonin discontinuation syndrome, shown by deterioration of behaviour since sertraline was stopped abruptly and mirtazapine was started.
• Mirtazapine dose not titrated as intended by the GP.
• The use of risperidone, an atypical antipsychotic, in a patient with a diagnosis
of dementia.
54 Australian Pharmacist January 2017 I ©Pharmaceutical Society of Australia Ltd.
Table 1. Medication profile for Mrs LC
Prescribed medicines
Dose and frequency actually taken
Cholecalciferol capsules
1,000 IU daily
Glimepiride tablets
4 mg daily
Mirtazapine 15 mg tablets
15 mg at night
Mycophenolate mofetil capsules
500 mg twice daily
Paracetamol tablets
500 mg when required
Paracetamol SR caplets
1,330 mg twice daily
Prednisolone tablets
10 mg daily
Risedronate tablets with calcium carbonate 500 mg (Actonel Combi)
35 mg risedronate once a week and
500 mg calcium carbonate daily (6 days per week)
Risperidone tablets
0.5 mg at lunch
Rivastigmine transdermal patches
9.5 mg daily (applied to chest at review)
Warfarin tablets
4.5 mg at night
Dr Mark Naunton is a practising accredited consultant pharmacist, Associate Professor at the University of Canberra and a Director of MedicineSmart@UC. Louise Deeks is a practising pharmacist and research assistant at the University of Canberra.
LEARNING OBJECTIVES
After reading this article, pharmacists should be able to:
• Identify situations where antidepressants may be stopped abruptly • Describe the symptoms of serotonin discontinuation syndrome
• Describe the methods of switching antidepressants.
Competencies addressed: 1.3.1, 1.3.2, 2.1.1, 2.1.3, 2.2.1, 2.3.1, 2.3.2, 4.2.1, 4.2.2, 4.2.3, 6.1.1, 6.1.2, 7.1.1, 7.1.2, 7.1.3, 7.2.1, 7.2.2.
Accreditation number: CAP1701E
This article has been independently researched and peer reviewed.