Anticoagulants are common medications in the PACE environment and are used to prevent blood clots from forming in the body. Popularly known as “blood thinners,” these medications require serious scrutiny from medical personnel when making decisions about care and other medications for PACE participants. Normally, blood clotting is an essential function of the body to protect itself against excessive bleeding in the event of an injury. In other circumstances, though, blood clots can become a dangerous threat to health and well-being if they travel through the blood vessels to the heart, lungs, or brain. Therefore, anticoagulants are typically used in the PACE environment for participants who suffer from:
Also, participants in the PACE environment who have had a synthetic heart valve implanted or received knee or hip replacement are generally on some form of anticoagulant. Let’s take a look at how and why anticoagulants are used within the PACE environment—and examine the risks and benefits.
Every year in the United States, approximately 900,000 people suffer a pulmonary embolism or deep vein thrombosis, resulting in 100,000 deaths. At least 25 percent of individuals who suffer a pulmonary embolism die suddenly without any warning symptoms. Men and women who are at a higher risk for blood clots include those who have atherosclerosis, diabetes, heart failure, irregular heart rates, immobility, obesity, and malignancy. Prescribing anticoagulants following an initial blood clot is vital, considering 30 percent of those who have a blood clot will have another clotting incident within ten years. Half of blood clots occur during or soon after surgery or a hospital stay. Many within the PACE environment display one or more risk factors for forming blood clots. [Tweet “#Anticoagulant use is common in the #PACE environment, but it requires some careful considerations.”]
Although anticoagulants are commonly called “blood thinners,” they do not make the blood thinner. They serve a dual purpose of:
Anticoagulants defeat blood clots by reducing the blood’s ability to clot, either by inhibiting vitamin K or by stopping other clotting factors from operating.
While this is good news for eliminating clots or reducing their risk, it raises the risk of prolonged bleeding should a person suffer a cut or nick. This is the primary risk and unwanted side effect of anticoagulants.
Anticoagulants are available as either oral or injectable products. Oral medications are generally used for ongoing prophylaxis in the outpatient setting for easier administration.
A benefit of the new oral therapies in the PACE environment is they do not require routine blood monitoring. Injectable products are typically used more at the beginning of therapy, especially when treating an existing clot.
In recent years, several new oral anticoagulation therapies were approved by the FDA—Eliquis® (apixaban), Pradaxa® (dabigatran), Savaysa® (edoxaban), and Xarelto® (rivaroxaban). These anticoagulants defeat blood clots by inhibiting thrombin (Pradaxa) or factor Xa (Eliquis, Savaysa, and Xarelto).
The above medications are short-acting compared to warfarin (Coumadin®). So, if therapy is missed, interrupted, or irregular, there is a risk for breakthrough strokes.
If regular therapy is a concern, these medications may not be the best option within the PACE environment, and warfarin may be the likely anticoagulant of choice.
As mentioned above, while the desired results of anticoagulants are admirable and desired, the most undesirable effect is an increased risk for prolonged bleeding. While administering vitamin K has a reversing effect for the anticoagulant warfarin, others do not have reversing agents.
An interest certainly exists for developing reversal agents for the other mentioned products, but none are available at this time.
When switching to warfarin from Eliquis, Pradaxa, Savysa, or Xarelto, those in the PACE environment will need to continue current anticoagulant therapy in addition to the warfarin until their INR reaches effective levels. This should take about five days.
With Pradaxa, medical professionals recommend stopping therapy after one to two days on warfarin, so long as renal function is normal. If renal function is impaired, wait until day three to stop administering Pradaxa.
PACE participants have unique and specialized needs. Our Grane Rx team of geriatric-specialized pharmacists understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504.
Maintaining healthy blood sugar levels among Skilled Nursing Facility residents is always a challenge. Long-term care pharmacy providers must consider a number of factors that can affect blood glucose management. Irregular nutritional intake, physiological changes, impaired renal function, or even variable physical activity can all cause significant swings in blood glucose levels. Trying to nail down the exact cause for the changes can be a daunting task. Some commonly overlooked factors that can contribute to blood glucose level variations include the resident’s skin condition, the technique used for injecting insulin, and how the injection site is treated. Read on for a look at some best practices for administering insulin injections recommended by long-term care pharmacy providers. [Tweet “Many seniors have #diabetes, making proper insulin injection a concern for #longtermcarepharmacy.”]
flu complications among elderly adults cost a staggering $56 billion. Adults who are 65 and older, including PACE participants, are at a higher risk for encountering complications from the flu virus. This is especially true for those with underlying health conditions. The enormous clinical and economic burden from influenza outbreaks has long motivated vaccine manufacturers to invest in developing an improved annual flu vaccine for senior adults. One vaccine, licensed in the United States in 2009, and known as the trivalent inactivated influenza vaccine Fluzone High-Dose, has demonstrated better efficacy and effectiveness compared with standard-dose influenza vaccines in older adults. [Tweet “Is the high-dose #fluvaccine really better for #PACE participants?”]
A randomized, controlled FIM12 study proved the overall effectiveness of the high-dose flu vaccine. In this study, 31,989 participants were enrolled from 126 research centers in Canada and the United States.
According to this study, among those 65 years or older, Fluzone High-Dose provided better protection and induced significantly higher antibody responses against laboratory-confirmed influenza than Fluzone Standard-Dose.
Investigators from the Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, and the U.S. Food and Drug Administration reported that the high-dose vaccine was 22 percent more effective than the standard-dose vaccine for the prevention of probable influenza.
It was also 22 percent more effective in preventing flu-related emergency room visits and hospital admissions, both important factors among PACE participants.
A critical health question for senior adults—and PACE centers—is the cost-effectiveness of the high-dose flu vaccine. Could the vaccine reduce the significant economic burden of flu outbreaks in adults older than age 65?
In one study of cost analysis, the high-dose trivalent inactivated flu vaccine is a cost-saving alternative to the standard-dose vaccine. Moreover, the additional cost of administering a high-dose instead of a standard-dose vaccine produced a staggering 587 percent financial benefit to the healthcare system.
The majority of those savings came through reductions in cardiorespiratory hospital admissions related to the flu. The study results indicate that the high-dose vaccine saved costs over the analyzed two-year period, and therefore showed better cost-effectiveness than most other strategies used.
Although initial costs for the high-dose flu vaccine are higher than the standard-dose vaccine, results of cost analyses favor the high-dose vaccine, mainly because of the reduction of hospital admissions.
PACE providers must focus on patient-centered care while considering the well-being of the participant and the cost savings when recommending immunizations during flu season.
Seniors, including PACE participants, have unique and specialized needs. Our Grane Rx team of geriatric-specialized pharmacists understands those challenges and works with PACE centers to overcome them. Partner with us today by calling (412) 449-0504.]]>
Skilled Nursing Facility pharmacy solutions. As science discovers more about how the human body functions and metabolizes medications, the potential to personally optimize medications for residents increases.
The topic of pharmacogenetics is increasing in popularity as we progress toward personalized medicine. We have learned a significant amount about how an individual’s genetic makeup impacts how medications are metabolized, which affects the efficacy and safety of a medication.
The missing link in most situations is understanding each resident’s genetic makeup so that can be related to the therapies he or she receives or may receive in the future.
That’s where post-acute care pharmacy must continue to grow and develop.
Pharmacogenetics holds the potential of providing medical practitioners with specific genetic data that will allow us to tailor medications to individual residents. Providers could predict dangerous adverse reactions or identify therapies that would not be effective for individual residents if they could know a resident’s genetic makeup.
Routine pharmacogenetics is not normal practice at this time, but there are specific situations when it may benefit in current situations, including with anticoagulation and antiplatelet therapy.
Adverse drug events and medication nonadherence are a leading cause of hospitalization among residents. The majority of emergency hospitalizations caused by medication issues are linked to five specific types of medications: warfarin, insulin, oral antiplatelets, diabetic medications, and opioid pain medications.
In our efforts to reduce unnecessary hospitalizations, we must be willing to investigate newer, challenging avenues to find the root cause of medication-related issues.
Clopidogrel, otherwise known as the brand Plavix®, is a popular antiplatelet medication in long-term care pharmacy. Pharmacogenetics is a pertinent topic related to clopidogrel because clopidogrel is a prodrug, a type of medication that must be metabolized through the cytochrome P450 system before it becomes an active medication.
If a resident’s cytochrome P450 enzyme system is not functioning at its expected level, this will result in metabolism variations when processing clopidogrel, which ultimately means the medication may not be metabolized to the necessary active form.
Basically, we could be administering the medication to a resident exactly as ordered, but the body may not be reacting to it the way we expect. Pharmacogenetics would allow us to know if a resident’s cytochrome P450 system is functioning as expected prior to prescribing the medication.
Warfarin, popularly known as Coumadin®, is another key example.
Warfarin has a number of potential interactions with both foods and other medications. In addition, warfarin can also be very difficult to stabilize in some residents. The difficulty in stabilization could be caused by two different situations.
First, warfarin is metabolized significantly by the cytochrome P450 system, so variations in a resident’s cytochrome P450 system detected through pharmacogenetics could affect the plasma levels and processing of warfarin in the body.
Warfarin is also unique because of the VKORC1 enzyme, which controls the oxidation state of vitamin K. VKORC1 normally works to activate vitamin K as part of the normal process of blood clotting. Warfarin inhibits VKORC1, which reduces vitamin K oxidation and reduces clotting.
If a resident has lower levels of VKORC1, less warfarin will be needed to impact clotting. If this is not known and a resident receives a standard dose of warfarin, he or she may experience an increased risk of side effects, such as bruising and bleeding.
If pharmacogenetics were used, healthcare professionals would have cytochrome P450 and VKORC1 genetic information available to them when prescribing medications. This would allow for more appropriate doses of medication for the resident, tailored to his or her bodily processes, for more optimal results.
After using pharmacogenetics to gain a resident’s genetic information, it does not need to be repeated. The resulting data can be applied to the resident’s entire therapeutic regimen and taken into consideration before any future prescriptions to make his or her medication regimen specific and personalized.
Healthcare providers routinely encounter situations where things don’t work out as expected, or simply can’t be reconciled with medical training or experience. This is because of our unique human body, and factors we cannot detect.
Medical care of the future, armed with pharmacogenetics, will provide all that is needed to make optimal medication decisions for residents.
Pharmacy is always evolving, and Grane Rx works to stay ahead of the changes. We offer the Medication Insights™ program, powered by YouScript, to help identify potential interactions and offer alternative prescribing options. Visit our site to learn more or request a free analysis. ]]>
Rising medication costs are a significant concern nationwide and in skilled nursing. Today, prescription drug expenditures account for nearly 20 percent of healthcare costs, and prescription spending is growing faster than any other part of health care. Consider these facts:
Participants, family members, and providers in the PACE environment should all be familiar with medications and medical conditions that increase the risk of falls. Medications—and their side effects—are one of the major causes of falls in the elderly. Because of the potential for injury when an older person falls, everyone in the PACE environment should be aware of which medications or conditions come with an increased risk of falls. When it’s possible, providers should seek safer alternative medications or even reduce medications to the lowest effective dose as a fall prevention strategy.
In the long-term care setting, the fall incidence percentage is severe—almost 50 percent. As SNF residents age, this percentage rises. The incidence rate of falls (number of falls per 100 person years) increases from 47 in older adults ages 70–74 to 121 in those that reach age 80.
It’s well known that certain medications can increase fall risk—and that post-acute care pharmacy providers play a key role in mitigating that risk. Pharmacy providers must work alongside other members of the SNF’s multidisciplinary team to help lower fall risk among all residents.
Every healthcare provider knows that medication can contribute to falls, especially in older adults. Seventy-two percent of people ages 55 and older use at least one medication, with 20.3 percent of that group using four or more.
The high rate of medication usage in this population has led to a rise in adverse drug reactions (ADRs), a particular concern for long-term care providers, who are tasked with keeping residents out of the hospital.
With a growing aging population who are being prescribed an increased number of medications, an interdisciplinary approach to fall management is vital.
Pharmacists are uniquely equipped to lend their medication expertise to the rest of the care team in order to improve resident outcomes. Let’s explore how pharmacists and post-acute care pharmacy professionals can contribute to an interdisciplinary approach to fall management.
Healthcare professionals often assume that residents have been educated on and, as a result, understand their medications. Many healthcare providers lack the time to adequately educate residents on their medications and disease states.
The post-acute care pharmacy team can help solve these medication-related issues—they’re considered the most accessible healthcare professionals and have an intimate knowledge of medications and the potential issues they pose to residents. This knowledge can be transferred to both other members of the care team and SNF residents.
Through medication reviews and therapy management, long-term care pharmacy providers are able to reduce the chances of an older adult falling due to medication. As the pharmaceutical industry innovates, both the medications and the standard of care for disease states have become more complicated.
Resident education about both disease state and medications has taken on increased importance. Residents and care team members need to understand the purpose of each medication, its potential adverse reactions, and which medications can increase the risk of falling.
Utilizing post-acute care pharmacy services as part of your interdisciplinary approach to fall management can help provide residents with more educated supervision and care. Team members know the fall risk factors for each resident and can take steps to reduce those risks.
An issue that is especially felt in the long-term care setting is the transition of care. Poorly executed transfers of older residents from hospitals to the long-term care setting, from long-term care setting to long-term care setting, or from the long-term care setting to home carry the risk of fragmentation of care, poor clinical outcomes, inappropriate use of emergency department services, and hospital readmission.
Utilization of post-acute care pharmacy services and medication management can help provide residents with a more complete transition and help to reduce some of the errors seen in resident transition, specifically in regards to medication.
A major issue, especially regarding medication-related falls, is polypharmacy, or the use of multiple medications. Polypharmacy is prevalent among older adults, including those in the long-term care setting.
The Centers for Medicare & Medicaid Services implemented a quality indicator measure that targets residents on nine or more medications. A study that utilized this information found that 39.7 percent of SNF residents had polypharmacy as defined by the quality indicator measure. Residents age 85 and older represented the group with the lowest rate of polypharmacy, with nearly 35 percent of this group taking nine or more medications.
Polypharmacy has many far-reaching negative consequences, contributing to healthcare costs for both the resident and the healthcare system. There is an associated increased risk of taking a potentially inappropriate medication, an increased risk of outpatient visits, and an increased rate of hospitalization.
Post-acute care pharmacy team members can and must work with the other SNF team members to educate them on these consequences and risks—and how to mitigate them.
Polypharmacy also contributes to an increased rate of adverse drug events. In SNF residents, the rate of adverse drug events is twice as high in residents taking nine or more medications compared with those taking less.
Medication non-adherence has been associated with complicated medication regimens and polypharmacy, and can lead to potential disease progression, treatment failure, hospitalization, and adverse drug events. Polypharmacy has also been found to contribute to falls. A study found that the risk of older adults experiencing a fall rose 7 percent for each additional medication they are prescribed.
At Grane Rx, we’re committed to providing SNF residents with the utmost care—and that includes an interdisciplinary approach to fall management, including post-acute care pharmacy services. Get started working with our team today by calling (866) 824-MEDS (6337) or filling out this quick form.
Food, liquids, and medications are absorbed, distributed throughout the body, metabolized, and then eliminated. This is accomplished through a complex and complicated process involving a host of your body’s enzymes. Obviously, knowing how slow or how quickly a medication is metabolized and eliminated from the body is crucial when prescribing medications for health issues. When multiple medications are involved, as is the case with the average PACE participant, the issue becomes even more complicated. Let’s take a look at the role medication metabolism plays. [Tweet “When multiple meds are involved, medication metabolism becomes an important issue. #PACEpharmacy”]
Most medication metabolism occurs in the liver, kidneys, and small intestine. Water-soluble, or hydrophilic medications, are more readily excreted by the body. Conversely, it is more difficult for fat-soluble, or lipophilic medications, to be eliminated without being changed.
Therefore, extremely water-soluble medications may bypass metabolism in the liver and be eliminated completely unchanged by the kidneys. And a largely lipid-soluble medication may undergo numerous phases of metabolism in order to provide a compound that can be excreted by the body. The basic understanding is:
It is commonly, and incorrectly, believed that all medications require extensive metabolism.
The human body is highly efficient, and only conducts those metabolic processes that are necessary. The amount and types of reactions depend on the individual’s body chemistry and the chemical structure of the medication.
A person’s genes dictate how the body functions. This affects the enzymes that metabolize medications.
A PACE participant may metabolize poorly, another about average, and yet another quite efficiently. This will affect how quickly a medication is used and eliminated from the body.
There are other factors that affect medication metabolism. There is some evidence in animals and humans that drug metabolism diminishes with age, although the effect has not been well studied.
A PACE participant of advanced years may have more difficulty metabolizing certain medications than younger participants.
Hereditary or genetic factors can play a part in how the PACE participant metabolizes medications—and especially certain combinations of medications. Some may enjoy a genetic predisposition to metabolize complex substances rather rapidly and without complications, while others may struggle to break them down for longer periods of time.
In humans, there have been a few reports of gender differences in metabolism. For instance, nicotine and aspirin seem to be metabolized differently in women and men.
On the other hand, gender differences can become significant in terms of drug-drug interactions based on the drug’s metabolism.
In order to protect against unwanted adverse medication reactions, doctors and PACE pharmacy providers would want to choose a medication that is metabolized adequately by the individual. Clearly, knowing the health background and medical condition of each PACE participant is crucial to providing quality pharmacy solutions.
Want to learn more about the impact Grane Rx can have on your PACE center and your services to the PACE population? Start the conversation by calling (412) 449-0504 or emailing email@example.com.
Deoxyribonucleic acid (DNA) determines the color of our hair eyes. It dictates how tall we will be and even how we will respond in certain situations. In essence, DNA completely makes up a human being. So how does this occur?
When conceived, an unborn child inherits 50 percent of the father’s DNA and 50 percent of thee mother’s DNA. Obviously there is no choice as to which parent’s DNA will affect what, but in the strictest sense, a child is one half of either parent.
DNA is a self-replicating material present in nearly all living organisms that is the carrier of genetic information. Not all DNA is accessible at a single point in time. Therefore, your body only accesses the specific areas that it needs. A specific region of DNA that codes for a specific product is called a gene.
For example, if your body needed to make more clotting factors due to a bad bleed, your body would access the gene responsible for providing the template for these proteins and would make them based upon the blueprint. Human beings have approximately 24,000 genes.
This is important to know in the field of medicine. Your unique DNA causes your body to metabolize certain medications differently. The specific area that focuses on this phenomenon is the field of pharmacogenomics.
Grane Rx offers pharmacogenomic testing through the Medication Insights program. But how can pharmacogenomics impact medication regimens for long-term care residents? Read on to explore the issue.
Pharmacogenomics (Pgx) is the study of how genes affect a person’s response to medications. Until recently, medical experts thought that medications were a “one-size-fits-all” solution. For example, if a certain amount of a drug taken daily prevented clotting around a stent in individuals in clinical trials, then it was thought to do the same in every other individual.
Pharmacogenomics has disproven this phenomenon. Depending upon an individual’s genes, he or she may benefit, not respond, or be negatively affected by certain types of pharmacotherapy.
So the question then becomes, how do we know how a person will respond?
Without testing to confirm an individual’s genetic makeup, doctors cannot be sure how he or she will respond to certain medications. Fortunately, genetic testing is now an efficient and cost-effective exercise.
Testing and analysis have become so streamlined that the generated report will advise a practitioner to consider an alternative, proceed with caution, alter a dose, or continue therapy unchanged.
This means that Pgx testing can truly personalize post-acute care pharmacy for every individual. With the results, providers can maximize benefits and minimize negative outcomes.
The already reasonable cost of pharmacogenomics testing can be offset by preventing an unnecessary hospitalization one time in a person’s life.
This is relevant for residents of Skilled Nursing Facilities as adverse effects of medications are more pronounced in the elderly population. Those that require assisted living are usually taking multiple medications for various disease states.
Therefore, using the information from Pgx can personalize their medicine and decrease the number of medications they take, the number of side effects they experience, and any doubt that they may have regarding the efficacy of a certain medication.
The Grane Rx team works with Skilled Nursing Facilities to design and implement medication safety and care transition processes. Could your SNF benefit? Call (866) 824-MEDS (6337) to find out more.
The ultimate goal of PACE, including PACE pharmacy, is to provide members of the PACE population with high-quality care that keeps them independent and active, allowing them to remain in the home while receiving the services they need. An essential element of such services is medication reconciliation.
Older adults are often on multiple medications—and these medications are often stopped and new medications ordered, as medications are changed over time. Medication changes can cause confusion for members of the PACE population, for caregivers, and for participants’ family members. Lack of communication between PACE participants and healthcare providers during care transitions contributes significantly to medication safety errors. That’s why it’s vitally important for PACE pharmacy providers and other members of the multidisciplinary team to thoroughly review these changes with participants and their caregivers, ensuring they understand what is happening and why.
With an increased number of medications—which are often prescribed by multiple physicians, including specialists—comes an increased number of potential problems. Side effects, possible duplicate therapies, and the possibility of drug interactions are just some of the serious issues that can arise.
Clinical consults play an important role in ensuring safety among the PACE population. These consults, in which a geriatric-specialized pharmacist reviews participant medications on a regular basis, include a number of safety checks, including:
Clinical consults serve a dual purpose: They help promote positive outcomes for members of the PACE population, while helping PACE centers contain costs and make efficient decisions.
Communication and participant/caregiver engagement are essential to ensure all parties are working from the same plan. PACE pharmacy services work along with all members of the participant’s multidisciplinary medical team to ensure continuity of care.
This integrated model of care aims to improve the quality of life of participants within the PACE population with chronic care needs by providing necessary medical and pharmacy services, including medication reconciliation.
Medication reconciliation, part of the clinical consult, carefully reviews a participant’s medication regimen, lowering the risk of preventable medication errors and potential hospitalization.
Health literacy education is designed to ensure each participant understands his or her therapies—taking into consideration hearing, vision, or physical impairments; language barriers; and/or the ability to understand written text.
Optimal, effective medication management for the PACE population utilizes both written and visual tools, along with health literacy information, to help participants and their family members understand their medication regimens.
Grane Rx partners with PACE centers to provide participants with medications that are delivered directly to the home in easy-to-understand packaging that includes clear directions on when medications should be taken. The packaging also includes both visual and written cues on what medications are for, as well as how they should be taken.
These tools, in combination with medication reconciliation, help limit the risk of avoidable drug errors and other potential problems.
Want to learn more about the impact Grane Rx can have on your PACE center and your services to the PACE population? Start the conversation by calling (412) 449-0504 or emailing firstname.lastname@example.org.]]>