I was not taught officially how to do a medication reconciliation (med rec) as a crit care fellow. You pick it up tacitly and I was aided by the brilliant pharamacists in the ICUs, but with patients spending days in the ED waiting for a bed, all resuscitative services must be capable of determining which meds to stop and which to keep going. I am lucky enough to be joined by my partner in crime, Josh Farkas to discuss this topic…
This is the provisional text from Josh's IBCC Chapter. Please peer review and comment below. In 1 week, this will be replaced by a link to the live chapter.
When a patient is admitted to the ICU, which of their outpatient medications should be continued? This is a rather mundane task, which is often delegated to an intern. However, these decisions can be quite important.
It's not possible to provide a complete guide to how to manage every medication in every patient. The goal of this chapter will be to provide a general framework for doing this, as well as a discussion of some considerations regarding common medications.
(#1) Figure out what the patient is actually taking at home
- Medication lists may not correspond with reality.
- PRN medications (e.g. PRN lorazepam) – are they taking it regularly, or occasionally?
- Best source: patient/family.
- Other sources: collateral information from pharmacy (are they filling prescriptions?).
- Nursing home patients will have an accurate MAR – make sure to get it.
(#2) Figure out WHY patients are on various medications
- Ideally every prescription would have an indication attached to it, but they don't.
- Indications matter, for example a patient could be taking aspirin for:
- (1) No good reason (primary prevention)
- (2) Coronary stents, or other intravascular stents.
- (3) AERD (aspirin exacerbated respiratory disease, discussed here).
- Indication will drive the dose and importance of continuing aspirin (more on this below).
(#3) Consider renal and/or hepatic failure
- ICU patients often have organ failures, especially renal failure.
- Any home medications that are continued must be re-dosed based on organ failures.
(#4) Avoid nephrotoxic & deliriogenic medications as able
- ICU patients are at high risk of renal failure and delirium.
- Common nephrotoxins to hold: NSAIDs, ACEi, ARB
- Common deliriogenic medications to hold: PRN benzodiazepines (if not using frequently)
(#5) When in doubt, err on the side of holding medications
- Patients are often on numerous medications, many of which are unnecessary (e.g. medications directed towards management of a chronic problem). It's generally beneficial to discontinue extraneous medications for the following reasons:
- Avoids interactions between new medications started in ICU.
- Reduces unnecessary burdens on nursing & pharmacy care.
- Focuses attention on more important medications.
- Simplifies management overall (e.g. if there is a potential adverse drug reaction, being on fewer medications may clarify which medication is causative).
(#6) We should probably run the final med list through an interaction checker program
- Ideally this would be built into the hospital's EMR system, but it usually isn't done well.
- MedScape and Epocrates seem to be better, but may be overly sensitivity in detecting an excessive number of interactions.
beta-blockers
- General principles:
- The indication for the beta-blocker is an important determinant of how important it is:
- (a) Beta-blockers for rate control of atrial fibrillation or heart failure management are more important to continue.
- (b) Beta-blockers initiated solely as management for chronic hypertension are less important to continue.
- Beta-blocker discontinuation theoretically may cause a surge in sympathetic tone affecting the heart, with an increased risk of myocardial infarction.
- Beta-blockers will impair perfusion for patients in shock, and may also block the heart's ability to respond to hemodynamic challenges (e.g. could be dangerous in a patient with submassive pulmonary embolism and threatened massive PE).
- The indication for the beta-blocker is an important determinant of how important it is:
- Beta-blockers are generally contraindicated in patients with shock or bradycardia.
- Ultimately determined on patient-by-patient basis, depending on hemodynamics and predicted clinical trajectory.
diltiazem
- Most often used for management of atrial fibrillation.
- In hemodynamically robust patients, should usually be continued to prevent AF with rapid ventricular response.
- When in doubt, hold and follow heart rate / blood pressure.
ACE-inhibitors / Angiotensin-receptor blockers (ARBs)
- These impair the ability of the kidney to adapt to hypoperfusion, thereby increasing the risk of acute kidney injury in response to hypoperfusion.
- ACE-i and ARBs should generally be held upon ICU admission
- Exceptions where continuing the ACE inhibitor makes sense:
- (a) Anuric patients on chronic dialysis, who are not at risk for worsening renal function.
- (b) Hemodynamically stable patient with severe heart failure, in whom the ACEi is being used to treat heart failure.
most other antihypertensives
- Judgement determined based on severity of HTN versus acute hemodynamic challenges. When in doubt it's generally better to hold long-acting antihypertensives (err on the side of a slightly higher Bp). It's somewhat easier (and perhaps safer) to allow the Bp to drift a little high and then treat with PRN antihypertensives (versus inducing hypotension which requires as vasopressor).
- Dihydropyridine calcium channel blockers (e.g. amlodipine, nifedipine extended release) can often be continued. These are among the more benign antihypertensives.
- Clonidine should not generally be discontinued if possible (may cause withdrawal hypertension).
digoxin
- Hold further doses & check a digoxin level.
statins
- Discontinue statins in patients who are on other drugs that may cause myopathy (e.g. daptomycin).
diuretic
- May be held initially if the patient is hemodynamically unstable.
- Generally reasonable to add back home diuretics as soon as possible. If this is forgotten, it will promote volume overload.
- Some patients won't produce much urine without diuretics – be conscientious of this and don't chase their low urine output with fluid.
inhalers for COPD/asthma
- Acutely ill patients are usually too sick to take medications via a metered-dose inhaler or dry power inhaler (this requires a fair amount of coordination and effort).
- It's generally best to hold all chronic inhalers at time of admission to the ICU.
- Patients without acute lung disease can often be treated with PRN albuterol nebulization.
- Patients with acute exacerbation of COPD can be treated with albuterol/ipratropium nebulization q6hours plus PRN albuterol.
proton pump inhibitors
- Generally continued (new evidence with SUP-ICU suggests that proton pump inhibitors don't actually increase the risk of C. difficile)
antiplatelet agents (e.g. aspirin, clopidogrel)
- Key factors to consider:
- (1) Strength of indication (e.g., status post coronary stent is strong indication, versus primary prevention being a weak indication).
- (2) Net state of anticoagulation and risk of DVT (aspirin has weak activity to prevent DVT, could be beneficial in patients at high risk for DVT who are at low risk of bleeding).
- For patients on aspirin for no specific indication (“primary prevention”) this should generally be stopped. Especially among intubated patients, unnecessary aspirin may promote stress ulceration.
- When in doubt, these can often be held for 24 hours to sort things out (these agents take several days to wear off anyway).
- 💡 When in doubt, hold antiplatelet agents, and document that someone should consider whether to resume them after 24 hours.
warfarin
- Check INR.
- Decision to continue warfarin depending on bleeding risk, requirement for procedures, and INR level.
NOACs
- NOACs are VERY problematic among patients who are critically ill, due to inability to reverse them. This is hugely problematic if:
- (a) There is spontaneous bleeding.
- (b) Procedures need to be done (especially neuraxial procedures such as lumbar puncture).
- 🚨 NOACs are renally cleared, so patients with acute kidney injury will on NOACs will often present with supra-therapeutic drug levels. These patients may remain functionally anticoagulated for days (even without any additional NOAC administration).
- General approach to NOACs:
- Hold them.
- Check an anti-Xa level.
- Further management depending on anti-Xa level, strength of indication for anticoagulation, and renal function. If anticoagulation is needed, then heparin may be started at some point (either heparin infusion or low molecular weight heparin). Note that NOACs may render a patient anticoagulated for days in the context of renal failure.
erythropoietin
- Erythropoietin hasn't been shown to be beneficial in ICU (has been trialed in RCTs).
- Generally hold for patients with active critical illness.
non-insulin diabetes medications
- Hold all of these (especially Metformin).
- Glycemic control in the ICU should be managed with insulin.
basal (long-acting) insulin
- In Type-I diabetes, this MUST be continued without any dose reduction. Hypoglycemia should be anticipated and managed with the administration of carbohydrate (e.g. tube feeding or IV dextrose).
- In Type-II diabetes:
- For shocked patients who are severely unstable: discontinue this and use IV insulin as needed (absorption of sq insulin may be erratic).
- For most patients, long-acting insulin should generally be considered. If there is concern regarding hypoglycemia, a 50% dose reduction may be reasonable. Follow glucose and avoid hypoglycemia.
steroid
- Chronic steroid should generally be continued. Patients on chronic steroid will be adrenally insufficient (to an extent proportional to the dose & duration of their steroid therapy). Dose escalation may be considered in patients under considerable stress:
- For patients with shock it's generally wise to transition to a full stress-dose of steroid (e.g. 50 mg IV hydrocortisone q6hr).
- For patients who are under stress but not shocked, a moderate increase in steroid dose may be reasonable (e.g. 10 mg prednisone daily –> 20 mg prednisone daily).
thyroid replacement (levothyroxine)
- Should be continued.
- Long half-life, so if the patient misses a few doses it's ok.
- Can convert PO to IV for patients who will be unable to take enteral medications for a while.
antiepileptic agents
- Should nearly always be continued.
- May require conversion to IV (note that levetiracetam has 1:1 conversion).
antidepressants (e.g. SSRIs and SNRIs)
- Should generally be continued.
- Discontinuation syndrome is possible, especially with SNRIs (e.g. effexor).
- (Exception obviously for serotonin syndrome.)
chronic opioids – full agonist
- Chronic opioids generally cannot be stopped in the ICU (due to the potential for withdrawal).
- For patients with tenuous mental status or hypercapnia, opioid doses may need to be scaled back (yet not stopped entirely).
- For patients with acute pain, consider the addition of non-opioid analgesics (e.g. ketamine infusion, acetaminophen) – rather than ramping up the opioid dose.
chronic buprenorphine for management of opioid use disorder
- (1) If at all possible, buprenorphine should be continued. (Can give sublingual bupe films on a ventilator – not ideal but it can be done).
- (2) Acute pain should be managed with non-opioid medications (e.g., acetaminophen, ketamine). There is a whole section on this in the chapter on opioid use disorder here.
- (3) Avoid full opioid agonists if possible. Consider working with anesthesia/pain service to manage complex pain issues that may arise in these patients.
- (4) Patient MUST be discharge on buprenorphine.
antipsychotics
- Should generally be continued if possible (if the patient is obtunded, may need to be held or dose-reduced).
- Clozapine should be continued if at all possible (if discontinued, then clozapine must be resumed with a gradual dose up-titration which is problematic).
parkinson's medications
- Rapid withdrawal of medications for Parkinson's disease may precipitate severe symptoms and possibly neuroleptic malignant syndrome.
- Ask patient/family what happens if patient misses their medications – this may help risk-stratify how severe of a problem will emerge if medications are stopped.
- In the context of severe Parkinson's disease, these medications need to be continued.
- When in doubt, work with pharmacy and/or neurology consultants.
- Whole section about parkinson's meds in IBNCC here.
baclofen & gabapentin
- These share some fundamental similarities:
- Cleared by the kidneys. In renal failure they will accumulate and may lead to obtundation (especially baclofen)
- Complete discontinuation may lead to withdrawal.
- In general:
- In the context of acute kidney injury: consider holding the drug temporarily (if the patient is somnolent) and then re-starting at a reduced dose
- In the context of normal kidney function: consider continuation of the patient's home dose.
deliriogenic medications
- This drug class includes the following:
- Benzodiazepines
- Antihistamines (e.g. diphenhydramine)
- Zolpidem
- Muscle relaxants (e.g. cyclobenzaprine)
- In general, these drugs cause delirium in the ICU and should be avoided.
- However, for patients who take these chronically (e.g. for sleep) it may be best to continue them. This is especially true of benzodiazepines (discontinuation may cause withdrawal, seizures, etc).
- Continuation and correct dosing of transplantation medications is EXTREMELY IMPORTANT.
- Patients generally are associated with a transplant center – discuss medication dosing with them.
- Information to gather prior to calling transplant center discussed here.
- Information to get from the transplant center:
- Recommended doses?
- What is their target levels (e.g., target tacrolimus level)
- Generally wise to consult with a local transplant physician if there is any doubt about medication dosing (especially if unable to reach the patient's outpatient transplantation docs).
- Whenever starting ANY drug in these patients, look for drug-drug interactions with immunosuppressive regimen using a pharmacopeia tool (e.g. MedScape or Epocrates).
Listener Feedback
Love it!
– 🚫 patch meds: erratic delivery, stuck w drug long after removing
-INR for warf, consider in context if hepatic failure before massive/repeated vit K dose
-baclofen intrathecal special call out, high risk
-SSRI resumption assoc w ⬇️ delirium, strongly consider
— H Andrew Wilsey, PharmD, BCCCP (@h_wilsey) February 10, 2024
Would add…
💊ask specifically about OTCs, herbals, supplements – patients don’t always think of as meds
💊Complete med rec includes allergies too
💊change NOAC to DOAC
💊Some EMRs will pull meds from outpatient pharm but may not be comprehensive
💊polypharmacy is common— Megan Rech, PharmD, MS (@MeganARech) February 10, 2024
I would add to always double check the date on nursing home MARs! I’ve had plenty of times where they for some reason send us a list that was printed months ago
— John Seaser (@JSeaser) February 10, 2024
– Re: drug intrxns – know the big offenders (eg azoles, phenobarb, phenytoin, warfarin, others)
– Levothyroxine – be aware PO:IV is not 1:1
– Dig – could continue if not bradycardic
– Anti-epileptics – check a level if appropriate (supra levels = encephalopathy)
(1/2)— Zahra (@zahranasr) February 10, 2024
Yes yes yes! Also good to confirm date of last doses:
1⃣ if considering drug-induced anything, ensure drug is actually on-board to avoid premature diagnostic closure
2⃣ some drugs e.g. methadone, lamotrigine should not always be restarted at full doses (consult pharmacy)— Sia Badie (@siamoxicillin) February 10, 2024
Additional Refs
More on EMCrit
- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
very interesting and helpful and also good info to pass along to ED RNs. heck was totally worth the read/listen just to add deliriogenic to my lexicon!
#3: needs a little more depth and I prefer not to use the term “organ failures”. Here’s a second draft: (#3) Consider drug metabolism in patients with acute organ dysfunction – ICU patients often have renal and/or hepatic dysfunction – Many medications are dependent on hepatic metabolism and/or renal clearance – Impaired metabolism and clearance can lead to drug accumulation with deliterious effects – Always renally dose medications based on CrCl or with guidance from your inpatient pharmacist – Use caution with any medication that affects the cardiovascular system (e.g. beta-blockers and anti-hypertensives). You can’t take the drug away once… Read more »
Very interesting post! Do you really stop beta blocker medication in all patients with shock e.g. septic shock?
If a patient with akute kidney injury takes ACEi and you discontinue it with what medication do you preferably subsidize if the patient gets hypertensive?
Thx!
Important medication: lamotrigine, if stopped for more than 6 days, CANNOT be recontinued at previous dose and must be retitrated due to risk for SJS/TEN.