BM is a 71-year-old male admitted to the hospital in the early afternoon for treatment of left lower extremity cellulitis. He has had poor oral intake for several days with subjective fever at home. He has a PMH of type 2 diabetes, diabetic neuropathy, hypertension, depression, and osteoporosis. The medication reconciliation was just completed, and the physician wants to restart as many of BM’s home medications as appropriate. The patient has not taken any of their home medications today. 

Home medications:

Lisinopril 20mg PO daily

Amlodipine 5mg PO daily

Farxiga 10mg PO daily

Metformin 500mg PO BID

Fosamax 70mg PO weekly (last dose one week ago)

Escitalopram PO 10mg daily

Vitals/Labs:

Temp: 101 F

BP: 140/85 mmHg

SCr 4.0 mg/dL (eGFR ~ 20 mL/min)

K+: 5.1 meq/L

Anion gap: 16 mmol/L

EKG QTc = 420 msec

Which of the following would be appropriate to restart today at the patient's home regimen?

A. Metformin

B. Fosamax

C. Lisinopril

D. Escitalopram

Answer with Rationale

Medication reconciliation is an essential part of the admission process. The pharmacist has an important role in preventing medication errors, ensuring patient safety, and promoting continuity in transitions of care. In evaluating what medications are appropriate to restart upon admission, consider potential drug interactions, lab abnormalities, risks for adverse events, and the patient’s ability to take medications appropriately. 

Answer A is incorrect. BM currently has an anion gap which could indicate the presence of anion gap metabolic acidosis (AGMA). Metformin has a boxed warning for lactic acidosis, one of the potential causes of AGMA. In addition, her eGFR is below 30mL/min which would make metformin currently contraindicated due to an enhanced risk of lactic acidosis. 

Answer B is incorrect. Fosamax has the potential to cause mucosal irritation, such as erosive esophagitis and ulcerations in the mouth and throat. While it has been one week since the last administration, it is the afternoon and it should be administered first thing in the morning on an empty stomach with a full glass of water with the patient remaining upright for at least 30 minutes. Home bisphosphonates for osteoporosis are rarely given in the hospital due to these requirements. IV bisphosphonates can be used for hospitalized patients when treating hypercalcemia of malignancy. 

Answer C is incorrect. While BM's blood pressure is elevated, it is currently inappropriate to restart lisinopril given his acute kidney injury with eGFR ~ 20mL/min.  In addition, his serum potassium level is 5.1 meq/L likely due to the AKI which could be exacerbated by reinitiating the lisinopril. 

Answer D is correct. Escitalopram is an SSRI and should not be stopped abruptly as this could cause a discontinuation syndrome. Some symptoms could include flu-like symptoms, insomnia, nausea, and anxiety. Our patient's QTc is normal and therefore would not prevent escitalopram from being restarted. Other classes of medications that should not be abruptly discontinued if possible include other antidepressants, antiepileptic drugs, antipsychotics, DOACs, and beta blockers. 

Brand/Generic: alendronate (Fosamax), amlodipine (Norvasc), dapagliflozin (Farxiga), escitalopram (Lexapro), gabapentin (Neurontin) lisinopril (Prinivil, Zestril), metformin (Glucophage, Glumetza, Riomet)

NAPLEX Content Domains Covered:

2.A.1 Drug names and therapeutic classes

2.A.4 Prescription regulations (eg, boxed warnings, risk evaluation and mitigation strategies)

2.A.5 Safety and effectiveness (eg, laboratory parameters, vital signs)

3.A Medication history, allergy history, and reconciliation

3.C.2 Appropriateness of therapy (eg, medications, contraindications, warnings, evidence-based decision making)

3.C.3 Interactions (eg, drug-drug, drug-condition, drug-food, drug-allergy, drug-laboratory)

3.C.5 Adverse drug reactions

3.D.2 Safety