Aged care residents on drug ‘triple whammy’ face risk of acute kidney injury
About one in six people living in aged care who were on ibuprofen-type pain killers were at risk of acute kidney injury posed by a “triple whammy” mix with other medicines, new research finds.
Almost two out of three aged care residents take more than 10 medicines a day, yet these facilities do not have a pharmacist on staff to review drug interactions, say experts.
A submission to the Royal Commission into Aged Care Quality and Safety recommends that aged care facilities need at least one pharmacist for every 200 residents to regularly review each patient’s drug mix to avoid these issues.
In hearings, the commission has heard evidence of medicines such as psychotropics being over-prescribed. Witnesses have told of dying family members who didn’t receive adequate pain medication.
Last week, Sarah Jane Holland-Batt told the Brisbane hearings that her father hadn’t been regularly given his Madopar medication that controlled his Parkinson’s. It helped with balance and coordination, and allowed him to “walk without suffering falls”.
At other times, Ms Holland-Batt’s father was given Phenergan for nausea, which experts say shouldn’t be given at the same time as Madopar because it completely “negates the effects of Madopar”.
“The GP should have known that. The facility should have known that when … when they observed his charts. But, due to no one noticing that these two medications, my dad was, essentially, without any support for his Parkinson’s mobility issues,” Ms Holland-Batt said.
Although a neurologist said her father shouldn’t be on Phenergan, the specialist failed to tell the aged care facility. As a result, her father fell and broke his hip.
In her new research, Kim Lind from Macquarie University was shocked to find how many residents of aged care facilities were taking the triple whammy mix for lengthy periods.
“Some people were on this potentially deadly mix for a long time, about 20 per cent of their time in care,” Dr Lind said.
The triple whammy is the combination of three common drugs: NSAIDs (pain killers such as ibuprofen or Nurofen often used for arthritis or period pain); diuretics (sometimes called water pills); and high blood pressure/hypertension medicine.
Each of these medicines uses the kidneys to metabolise and excrete the drug.
With a team of other researchers, Dr Lind of Macquarie’s Centre for Health Systems and Safety Research reviewed the medication records of 10,367 residents in 68 aged care facilities in NSW and the ACT over three years.
In a paper published last week in Pharmacoepidemiology and Drug Safety, the researchers found 23 per cent of residents were taking at least one NSAID.
Of these, 3.2 per cent also took some by mouth and combined them with topical NSAIDs such as Voltaren cream. Dr Lind said the topical creams were safer for long-term use.
She said a problem was that existing medication systems were not designed to “red flag” this combination.
Kristin Michaels, the chief executive of the Society of Hospital Pharmacists of Australia, called for more pharmacists to be embedded in aged care because many residents took a complicated mix of medicines.
“Wherever there are medicines, you ought to have a pharmacist,” she said.
A submission by the hospital pharmacists to the Royal Commission found nearly every resident of an aged care facility had experienced at least one medication related problem.
Ms Michaels said drugs such as ibuprofen, while effective for pain relief, weren’t designed for use for more than one to two weeks. Yet once these pain killers were given, they were often continued without sufficient review or little regard to the interaction with other drugs.
“We are not jumping to say we need to restrict access. But it is about people ready and able to provide care, and then once pain drops, either deprescribing, or prescribing another medication. We simply don’t have this service [in aged care],” she said.
Most NSAIDs do not require a prescription. But “not everything for sale over the counter is safe,” said Dr Lind.
She said the warnings to be careful about mixing these pain killers with other drugs – and taking them for too long – were relevant to the general population.
Dr Lind and other pharmacists renewed the call for these pain killers to be removed from supermarket shelves, and to be sold only where pharmacists can advise on the risks.
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