Background An 85 year old female was admitted to hospital through the Emergency Department for dehydration and an axis fracture caused by a fall. Medical history included: hypertension, hypothyroidism, hip replacement, breast cancer operated in 2009, stroke in 2011 and cognitive impairment (CI). Home medication included: levothyroxine 50 mcg QD, clopidogrel 75 mg BID, irbesartan/idrochlorothiazide 300/25 mg QD, venlafaxine 150 mg QD, omeprazole 20 mg QD, paroxetine 5 mg BID, atorvastatin 10 mg QD, carvedilol 12.5 mg QD, buproprione 150 mg QD, iron supplement 80 mg QD and quetiapine 25 mg BID. No known drug allergy. Two previous admissions for falls this year (before the implementation of the medication review project in May 2017).

Purpose To assess the medication review of a fragile patient.

Material and methods The pharmacist completed an accurate list of the patient’s home medication and identified medication discrepancies (MDs) using 2015 Beers and STOPP/START criteria (version 2) for any potentially inappropriate drugs in the elderly, Micromedex database for drug-drug interactions (DDIs) and ATC classification for therapeutic duplications.

Results After the comprehensive review of the patient with 11 drugs as home treatment, the following MDs were identified: five drugs classified as being potentially inappropriate drugs (Beers/STOPP/START criteria), nine major DDIs (carvedilol with paroxetine and bupropione: hypotension; clopidogrel and omeprazole: thrombotic risk; concomitant use of paroxetine, bupropione, venlafaxine: risk of serotonin syndrome; clopidogrel and paroxetine and venlafaxine: risk of bleeding; clopidogrel, a CYP2B6 inhibitor, which can increase bupriopione concentrations causing convulsions); and two therapeutic duplications (N06). The following recommendations were made by the pharmacist: suspend paroxetine (anticholinergic effect and risk of falls); bupropione (risk of falls); quetiapine (risk of cerebrovascular event and mortality in patients with CI); and omeprazole (risk of Clostridium difficile infection, fractures and interactions with clopidogrel). Monitor blood pressure to assess treatment (irbesartan/idrochlorothiazide and carvedilol).

Conclusion Medication review programmes conducted by pharmacists are effective strategies which ensure patient safety and improve quality of care. This hospitalisation, which is representative of many admissions of elderly fragile patients, could have been prevented if risk factors (combinations of CNS side-effects and hypotension action associated with falls, anticholinergic drugs and dehydration) had been identified previously.

No conflict of interest