prn medications; its justified use: by dr prithvi puwar

PRN MedicationsIts Justified Use

Dr. Pruthvi Puwar

Physician

Sunshine Global Hospitals

Objective

• Identify which PRN medications are appropriate for inclusion in treatment orders

• Identify contraindications or adverse effects associated with common PRN medications

• Know when to evaluate the patient prior to ordering such medication

PRN medications ???

• Pro re Nata (Latin Phrase)

• In the circumstances or as the circumstance arises

• It is commonly used in medicine to mean as needed or as the situation arises

• In reference to dosage of prescribed medication that is not scheduled

Older adults take an average of5 prescription medications per month

CEAL

Those with 3+ chronic health conditionsAverage 6-7 prescription medications per month

CEAL

Assisted Living Patients

10 routine medications per day

3 PRN medications per day

Common Uses of PRN drugs

• Sleep• Pain• Cardiovascular: Hypertension• Sedatives• Pulmonary: Inhallers, Mucolytics• GI: Bowels, Heartburn

CaseHPI: 59 year old male admitted for chest pain,

breathing problem and acute alcohol intoxication. He also complains of hematemesis during his most recent drinking binge.

PMHx: AVNRT, Hepatitis C with jaundice and ascites, insomnia, depression and COPD

Outpatient medications: Combivent inhaler bid, ibuprofen 600mg po tid prn

• EKG on admission reveals AVNRT @111 bpm He is admitted to the medicine ward with the

following orders:-Oxygen, PUP, IV fluids-Ativan 2mg po q4hr prn withdrawal-Duolin neb q6h prn, Budecort neb q12hr, Deriphylline IV prn-Acetaminophen 1000mg q4hr prn pain-Ibuprofen 600mg po tid prn pain

1. Do you see any problems with these orders?

Case Contn… That night the patient subsequently requests pain

medication for his chest pain. It is determined by the night doctor that there is no

evidence of ACS. Since ibuprofen is ordered prn the night doctor instructs the

nurse to give this to the patient. The patient still complains of pain later that night, and the night

doctor writes an order for Fentanyl or Phenargan q6hr for pain.

2. Are these appropriate meds to give to the patient?

AnalgesicsOral Pain Severity SC/IM/IV Pain Severity

Adverse Effects

Non-Opiods

Acetaminophen325-650mg

Mild Ketorolac30-60mg

Moderate Caution in hepatic or renal impairment

Ibuprofen600-800mg

Mild PUD, GI bleed, renal toxicity

Opiods Tramadol 50-100mg

Mild to Moderate

Tylenol w/ codeine30mg-60mg

Mild to Moderate

Morphine Moderate to Severe

Constipation, Ileus, n/v, respiratory depression, urinary retention

Vicodin(5mg/500mg)

Moderate Dilaudid Severe Caution Hepatic or Renal Impairment

Percocet(5mg/325mg)

Moderate Fentanyl (IV or patch)

Severe

Case Contn.. The next day his BP has risen to 170/105mmHg. He is

given Nifedipine S/L by the team with a drop in his BP to 125/78.

3. What is likely contributing to the rise in BP?4. What side effects could occur from lowering the BP too much?5. How else could this patient have been treated?

Hypertension• Goal:

-To identify and treat the underlying cause-Prevent end-organ damage

• Common Causes:ReboundInadequate dosingDrug InteractionsAlcohol withdrawalHypoxemia, respiratory distressPain, AnxietyAutonomic response: urinary retention, constipation

Hypertension

Approach to evaluating the patient:-Determine patient’s baseline-Confirm accuracy, both arms, cuff size-Screen for underlying cause-Determine if hypertensive emergency or urgency is present

Case• One night the patient requests something for sleep and

receives Benadryl 25mg po, written as qhs prn by doctor at night. On day three of admission he develops urinary retention with a PVR of 300cc. A foley catheter is placed. You review his chart and notice a prior urology note indicating the patients prostate size on DRE is around 50g.

6. What could be contributing to the urinary retention?

• He remains hospitalized due to social issues including homelessness. On day 4 of admission you are called by the nurse due to the patient falling in his room. You evaluate his gait and notice he is unsteady in addition to being more somnolent than usual.

7. What could be contributing to the fall and gait impairment?

Sedatives

Ativan: common use in alcohol withdrawal-AE include sedation, respiratory depression-Caution in those with acute angle glaucoma, sleep apnea, respiratory issues, hepatic/renal impairment, h/o drug abuse or falls risk-Geriatric patients no more than 3mg/day

Anti-psychotics: Haldol (Typical), Atypical Antipsychotics (seroquel, risperidone)-anti-cholinergic side effects, QT prolongation-Not for use in dementia related psychosis (increased risk of death compared to placebo)

Case• The patient subsequently complains of

diarrhea the next day. Stool studies are sent, and the medical officer orders Ridol tablet for loose stools.

8. Is this an appropriate order?

• The patient subsequently does well and is discharged. Upon discharging the patient, you order the following outpatient medication regimen:– Ibuprofen 600mg po tid prn– Paracetamol 500mg 2 tabs q6hr prn– Deriphylline Retard q6hr – Benadryl 25mg po qhs – Librium tablet

9. Are these appropriate orders?

Case

• A surgical pt, post operatively remained in ICU for 2 days. Post stabilization he was shifted to wards. Subsequently 2 days later he became drowsy, arousable but falling asleep soon repeatedly.

• Drug chart checked• Electrolytes, ABG checked• Vitals ok• I/o maintained

Case• A middle aged female admitted for abdominal pain,

recently diagnosed hypertension, started with low salt diet Enalapril and alprazolam orally, and was treated for acute cholecystitis with IV ABs.

• Subsequently two days later developed Cough. • Physician called: examination normal• CXR ok• Blood invest. Normal • Started with cough syrup & gargles What Next?

Case

• A young female admitted with symtoms of heart burn and reflux disease..

• She is being treated with Rabiprazole, Metochlopramide injections and sucralfate syrup; started having eye blinking and legs spasms with face grimacing…

• Vitals and other examinations are normal.

Extra Pyramidal features…

Case

• A 16 year old male patient diagnosed to have P.Vivax malaria for his fever with chills and bodyache. He was treated with Falcigo injections and 4 days later he was sent home with multivits, paracetamol and primaquine tablet.

• Subsequently he reported back 3rd day with h/o passing reddish urine and weakness.

• What you think? G6PD

Summary• For all PRN orders, know the correct dosage,

common adverse effects and contraindications• Check the next day to see if your patient actually

received any of the meds not needed• Convert frequently administered PRN meds into

standing orders• Don’t just put in PRN orders to save Consultant

doctor the “trouble” of getting called at night• Evaluate underlying cause or condition requiring use

of a med and treat accordingly

Individualized Medication Plans Promote clinical condition-centered care in all aspects of medical care

Individualized Medication Plans Tailor medication schedule and use of PRN medications

Individualized Medication Plans Based on patient decision-making capacity, needs, and lifestyle choices

Raise Hands togetherFor practicing safe

medicine

Thank YOu