Archives

Management of Hypercoagulable States 2025 Revision

About this Course

UConn has developed web-based continuing pharmacy education activities to enhance the practice of pharmacists and assist pharmacists in making sound clinical decisions to affect the outcome of anticoagulation therapy for the patients they serve. There are a total of 17.25 hours of CPE credit available. Successful completion of these 17.25 hours (13 activities) or equivalent training will prepare the pharmacist for the Anticoagulation Traineeship, which described below in the Additional Information Box.

The activities below are available separately for $17/hr or as a bundle price of $199 for all 13 activities (17.25 hours). These are the pre-requisites for the anticoagulation traineeship. Any pharmacist who wishes to increase their knowledge of anticoagulation may take any of the programs below.

When you are ready to submit quiz answers, go to the Blue "Take Test/Evaluation" Button.

Target Audience

Pharmacists who are interested in making sound clinical decisions to affect the outcome of anticoagulation therapy for the patients they serve.

This activity is NOT accredited for technicians.

Pharmacist Learning Objectives

At the completion of this activity, the participant will be able to:

  1. Describe inherited hypercoagulable states.
  2. Describe acquired hypercoagulable states.
  3. Apply management strategies for various hypercoagulable states including Antithrombin III Deficiency, Protein C or S Deficiency, Factor V Leiden, Prothrombin gene mutation, Hyperhomocysteinemia and Antiphospholipid Antibody Syndrome.

Release Date

Released:  07/15/2025
Expires:  07/15/2028

Course Fee

$25.50

ACPE UAN

ACPE #0009-0000-25-044-H01-P

Session Code

25AC44-XYX89

 

Accreditation Hours

1.5 hour of CE

Bundle Options

If desired, “bundle” pricing can be obtained by registering for the activities in groups. It consists of thirteen anticoagulation activities in our online selection.

You may register for individual topics at $17/CE Credit Hour, or for the Entire Anticoagulation Pre-requisite Series.

Pharmacist General Registration for 13 Anticoagulation Pre-requisite activities-(17.25 hours of CE)  $199.00

In order to attend the 2-day Anticoagulation Traineeship, you must complete all of the Pre-requisite Series or the equivalent.

Additional Information

Anticoagulation Traineeship at the University of Connecticut Health Center, Farmington, CT

The University of Connecticut School of Pharmacy and The UConn Health Center Outpatient Anticoagulation Clinic have developed 2-day practice-based ACPE certificate continuing education activity for registered pharmacists and nurses who are interested in the clinical management of patients on anticoagulant therapy and/or who are looking to expand their practice to involve patient management of outpatient anticoagulation therapy. This traineeship will provide you with both the clinical and administrative aspects of a pharmacist-managed outpatient anticoagulation clinic. The activity features ample time to individualize your learning experience. A “Certificate of Completion” will be awarded upon successful completion of the traineeship.

More Information About Traineeship

Accreditation Statement

ACPE logo

The University of Connecticut, School of Pharmacy, is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit for the online activity ACPE UAN #0009-0000-25-044-H01-P will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

Grant Funding

There is no grant funding for this activity.

Requirements for Successful Completion

To receive CE Credit go to Blue Button labeled "take Test/Evaluation" at the top of the page.

Type in your NABP ID, DOB and the session code for the activity.  You were sent the session code in your confirmation email.

Faculty

Youssef Bessada, PharmD, BCPS, BCPP
Assistant Clinical Professor
UConn School of Pharmacy
Storrs, CT

Katelyn Galli, PharmD, BCCP,
Assistant Clinical Professor
UConn School of Pharmacy
Storrs, CT

Faculty Disclosure

In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

Drs. Bessada and Galli have no relationships with ineligible companies and therefore have nothing to disclose.

Disclaimer

The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

Program Content

Program Handouts

Post Test 

View Questions for Hypercoagulable States

Post-Test Questions:
1. Which of the following factors would more likely indicate an inherited thrombophilia?
a. A relative with a known clotting disorder
b. Active combination oral contraception use
c. Recent travel overseas on a long flight

2. Which of the following conditions is more likely to be an acquired form of thrombophilia?
a. Antiphospholipid antibody
b. Factor V Leiden
c. Prothrombin gene mutation

3. Which of the following are the most appropriate next steps following a ‘normal’ functional assay for AT III deficiency?
a. Administer vitamin K PO 5mg once and discontinue anticoagulation
b. Confirm functional assay results with an antigenic assay
c. Continue anticoagulation and consider alternative diagnosis

4. Which of the following pharmacotherapy is associated with acquired protein s deficiency?
a. Oral contraceptives
b. Unfractionated heparin
c. Vitamin K

5. A patient develops microthrombi in extremities two days after starting warfarin 10mg for 2 doses. His INR is 1.8. Which of the following is the most appropriate initial management?
a. Bridge warfarin with apixaban 5mg
b. Vitamin K administration
c. Warfarin 10mg again to hit goal INR

6. A patient screens positive for prothrombin gene mutation, but has no signs of active thrombosis. What is the best treatment plan?
a. Begin chronic oral anticoagulation with a DOAC to prevent future thrombotic events
b. Consider prophylactic doses of anticoagulation should the patient ever have surgery
c. Start warfarin therapy with a goal INR of 2.5-3.5 given increased risk of VTE

7. Which of the following could result in a false negative result for a factor V leiden functional assay?
a. Current use of apixaban therapy
b. Multivitamins containing vitamin K
c. O negative blood types

8. Which of the following therapies is associated with lowering homocysteine levels in the blood?
a. Apixaban
b. Folic acid
c. Warfarin

9. Following a PE a patient is started on apixaban therapy. She is ultimately found to have positive lupus anticoagulant in the plasma. Why can we not definitively give an antiphospholipid antibody syndrome diagnosis?
a. Her laboratory values need to be confirmed by an additional test in 3 months
b. Her positive lupus anticoagulant is likely secondary to her apixaban use
c. She needs to meet at least 2 clinical criteria to qualify for diagnosis

10. Which of the following options is the most appropriate management strategy for a patient diagnosed with Antiphospholipid Syndrome?
a. Apixaban
b. Dabigatran
c. Warfarin

Risk Management in Anticoagulation 2025 Revision

About this Course

UConn has developed web-based continuing pharmacy education activities to enhance the practice of pharmacists and assist pharmacists in making sound clinical decisions to affect the outcome of anticoagulation therapy for the patients they serve. There are a total of 17.25 hours of CPE credit available. Successful completion of these 17.25 hours (13 activities) or equivalent training will prepare the pharmacist for the Anticoagulation Traineeship, which described below in the Additional Information Box.

The activities below are available separately for $17/hr or as a bundle price of $199 for all 13 activities (17.25 hours). These are the pre-requisites for the anticoagulation traineeship. Any pharmacist who wishes to increase their knowledge of anticoagulation may take any of the programs below.

When you are ready to submit quiz answers, go to the Blue "Take Test/Evaluation" Button.

Target Audience

Pharmacists who are interested in making sound clinical decisions to affect the outcome of anticoagulation therapy for the patients they serve.

This activity is NOT accredited for technicians.

Pharmacist Learning Objectives

At the completion of this activity, the participant will be able to:

1. Discuss the education and training needs of pharmacists who participate in anticoagulation services.
2. Discuss the documentation needs of a pharmacists-run anticoagulation service or clinic.
3. Identify corporate infrastructure needs to support anticoagulation services or clinics.
4. Explain the necessary implementation strategies for establishing, strengthening and sustaining an anticoagulation stewardship program.

Release Date

Released:  07/15/2025
Expires:  07/15/2028

Course Fee

$17

ACPE UAN

ACPE #0009-0000-25-037-H04-P

Session Code

25AC37-PVX33

 

Accreditation Hours

1.0 hour of CE

Bundle Options

If desired, “bundle” pricing can be obtained by registering for the activities in groups. It consists of thirteen anticoagulation activities in our online selection.

You may register for individual topics at $17/CE Credit Hour, or for the Entire Anticoagulation Pre-requisite Series.

Pharmacist General Registration for 13 Anticoagulation Pre-requisite activities-(18.25 hours of CE)  $199.00

In order to attend the 2-day Anticoagulation Traineeship, you must complete all of the Pre-requisite Series or the equivalent.

Additional Information

Anticoagulation Traineeship at the University of Connecticut Health Center, Farmington, CT

The University of Connecticut School of Pharmacy and The UConn Health Center Outpatient Anticoagulation Clinic have developed 2-day practice-based ACPE certificate continuing education activity for registered pharmacists and nurses who are interested in the clinical management of patients on anticoagulant therapy and/or who are looking to expand their practice to involve patient management of outpatient anticoagulation therapy. This traineeship will provide you with both the clinical and administrative aspects of a pharmacist-managed outpatient anticoagulation clinic. The activity features ample time to individualize your learning experience. A “Certificate of Completion” will be awarded upon successful completion of the traineeship.

More Information About Traineeship

Accreditation Statement

ACPE logo

The University of Connecticut, School of Pharmacy, is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit for the online activity ACPE #0009-0000-25-037-H04-P will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

Grant Funding

There is no grant funding for this activity.

Requirements for Successful Completion

To receive CE Credit go to Blue Button labeled "take Test/Evaluation" at the top of the page.

Type in your NABP ID, DOB and the session code for the activity.  You were sent the session code in your confirmation email.

Faculty

Youssef Bessada, PharmD, BCPS, BCPP
Assistant Clinical Professor
UConn School of Pharmacy
Storrs, CT

Faculty Disclosure

In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

Dr. Bessada has no relationship with an ineligible company and therefore has nothing to disclose.

Disclaimer

The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

Program Content

Program Handouts

Post Test 

View Questions for Risk Management in Anticoagulation

1. What are the four most important ways to reduce risk?
A. Education, strong policy development, complete documentation, and continuous quality improvement
B. Physician involvement, light workload, time management, and malpractice insurance
C. The newest anticoagulation management software, coworker education, and quality improvement

2. How can pharmaists BEST teach application, analysis and synthesis of new knowledge particularly of situational cases?
A. Lecture and post-lecture reading assignments
B. Case presentation and practice-based learning
C. Observation of the student;s in-clinic skills

3. When should Continuous Quality Improvement activities should be completed?
A. Regularly at cadence of stewardship committee
B. No less often than every five years
C. Annually in the month designated by your accreditor

4. What happens when a physician reviews and approves a pharmacist’s recommendations?
A. The physician assumes all the risk
B. The pharmacist still carries risk
C. The pharmacist can only bill for the lab test

5. Why does provider education initially take precedence over patient education?
A. Patients can twist provider education in a malpractice claim if they realize the provider lacks confidence
B. The health system is only responsible for provider educationunder current accreditation standas
C. Effective provider education is the foundation for standardized, effective patient education

6. When is a Decision Pathway BEST used to minimize risk?
A. With a low-risk DVT protocol for anticoagulation management
B. As you complete coding and billing for various clinic visits
C. With a collaborative practice agreement or policy for DOAC dose-adjustment

7. Which of the following lists include ALL of the elements of provider education?
A. Disease state management, malpractice risk defense, thrombolytic administration
B. Medication management, malpractice risk defense, IV administration technique
C. Disease state management, medication management, patient care management

Challenging Topics in Anticoagulation 2025 Revision

About this Course

UConn has developed web-based continuing pharmacy education activities to enhance the practice of pharmacists and assist pharmacists in making sound clinical decisions to affect the outcome of anticoagulation therapy for the patients they serve. There are a total of 17.25 hours of CPE credit available. Successful completion of these 17.25 hours (13 activities) or equivalent training will prepare the pharmacist for the Anticoagulation Traineeship, which described below in the Additional Information Box.

The activities below are available separately for $17/hr or as a bundle price of $199 for all 13 activities (17.25 hours). These are the pre-requisites for the anticoagulation traineeship. Any pharmacist who wishes to increase their knowledge of anticoagulation may take any of the programs below.

When you are ready to submit quiz answers, go to the Blue "Take Test/Evaluation" Button.

Target Audience

Pharmacists who are interested in making sound clinical decisions to affect the outcome of anticoagulation therapy for the patients they serve.

This activity is NOT accredited for technicians.

Pharmacist Learning Objectives

At the completion of this activity, the participant will be able to:

  • DISCUSS management techniques for challenging patient types including alcoholism, pregnancy, and patients with Antiphospholipid Antibody Syndrome
  • DISCUSS the evidence for 12 week follow up visits and how to determine which patients are appropriate
  • IDENTIFY anticoagulation therapy for selected challenging cases

Release Date

Released:  07/15/2025
Expires:  07/15/2028

Course Fee

$34.00

ACPE UAN Code

0009-0000-25-041-H01-P

Session Code

25AC41-PFX62

Accreditation Hours

2.0 hours of CE

Bundle Options

If desired, “bundle” pricing can be obtained by registering for the activities in groups. It consists of thirteen anticoagulation activities in our online selection.

You may register for individual topics at $17/CE Credit Hour, or for the Entire Anticoagulation Pre-requisite Series.

Pharmacist General Registration for 13 Anticoagulation Pre-requisite activities-(17.25 hours of CE)  $199.00

In order to attend the 2-day Anticoagulation Traineeship, you must complete all of the Pre-requisite Series or the equivalent.

Additional Information

Anticoagulation Traineeship at the University of Connecticut Health Center, Farmington, CT

The University of Connecticut School of Pharmacy and The UConn Health Center Outpatient Anticoagulation Clinic have developed 2-day practice-based ACPE certificate continuing education activity for registered pharmacists and nurses who are interested in the clinical management of patients on anticoagulant therapy and/or who are looking to expand their practice to involve patient management of outpatient anticoagulation therapy. This traineeship will provide you with both the clinical and administrative aspects of a pharmacist-managed outpatient anticoagulation clinic. The activity features ample time to individualize your learning experience. A “Certificate of Completion” will be awarded upon successful completion of the traineeship.

More Information About Traineeship

Accreditation Statement

ACPE logo

The University of Connecticut, School of Pharmacy, is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit for the online activity ACPE UAN 0009-0000-25-041-H01-P will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

Grant Funding

There is no grant funding for this activity.

Requirements for Successful Completion

To receive CE Credit go to Blue Button labeled "take Test/Evaluation" at the top of the page.

Type in your NABP ID, DOB and the session code for the activity.  You were sent the session code in your confirmation email.

Faculty

Caroline Chen, PharmD Candidate 2027
UConn School of Pharmacy
Storrs, CT

Lydia Andusko, PharmD Candidate 2027
UConn School of Pharmacy
Storrs, CT

Abigail Serrano, PharmD Candidate 2027
UConn School of Pharmacy
Storrs, CT

Jeannette Y. Wick, RPh, MBA, FASCP
Director, Office of Pharmacy Professional Development
UConn School of Pharmacy
Storrs, CT

Faculty Disclosure

In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

Ms. Wick, Ms. Chen, Ms. Andusko, and Ms. Serrano have no relationship with ineligible companies and therefore have nothing to disclose.

Disclaimer

The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

Program Content

INTRODUCTION

As the previous modules have demonstrated, it's inevitable that anticoagulation pharmacists will see patients who present management conundrums. Sometimes, the patient is a heavy consumer of alcohol or has actual alcohol use disorder (AUD). Other times, the patient may be pregnant or have antiphospholipid antibody syndrome. In each of these cases, the clinical team needs to pay careful attention. This section of the Anticoagulation Certificate Program is designed to help anticoagulation pharmacists develop the skills necessary to deal successfully with patients who need anticoagulation but have conditions that complicate selection of appropriate anticoagulation. Using case studies, we will navigate some of the more prevalent challenges.

 

CASE #1: ALCOHOL USE DISORDER

Jean Thomas is a 67-year-old male recently diagnosed with atrial fibrillation (AFib). He currently takes several medications: lisinopril, hydrochlorothiazide, simvastatin, doxazosin, and diltiazem. He has a past medical history of hypertension, hyperlipidemia, benign prostatic hypertrophy, obesity, prediabetes, and alcohol use disorder (AUD). The anticoagulation clinic has seen Jean for six weeks with occasional international normalized ratio (INR) levels above 3 necessitating multiple changes to his warfarin dose. The SIDEBAR provides some information about assessing patients’ alcohol intake.1

 

SIDEBAR: Is patient-reported alcohol intake consistent with the amount they actually drink?2

Studies have found that physicians often mentally double patients’ reported alcohol consumption to obtain a more accurate estimate. Evidence suggests that self-reports are often underestimates of alcohol intake. Patient reasoning for this includes that they

  • Do not keep track of how much they drink
  • Are worried about the doctor judging them
  • Don’t want their health problems attributed to alcohol

 

Evidence indicates that the Alcohol Use Disorders Identification Test (AUDIT-C) is a suitable screening tool for most community-dwelling individuals. Clinicians can access this tool here: https://www.mentalhealth.va.gov/coe/cih-visn2/Documents/Provider_Education_Handouts/AUDIT-C_Version_3.pdf.

 

Indirect non-specific biomarkers can be useful in validating patient alcohol intake. An example of a short-term biomarker is ethanol in breath or urine, which indicates recent alcohol use. Long-term biomarkers include elevated mean corpuscular volume, gamma-glutamyl transferase (downregulated with chronic alcohol use), and the hepatic markers aspartate aminotransferase and alanine transaminase.

 

While tests evaluating these biomarkers can portray a patient’s alcohol consumption, establishing trust in patient-provider relationships is critical in making the most accurate clinical assessments. A PRO TIP is to approach patients non-judgmentally and non-confrontationally.

 

PAUSE AND PONDER: Which is TRUE regarding anticoagulants and alcohol use?

  1. Alcohol use disorder (AUD) is a labeled contraindication to warfarin
  2. Warfarin’s interaction with alcohol has been well studied
  3. The team should discuss alcohol use openly with patients

 

An important aspect of developing a treatment plan based on a patient’s alcohol consumption is providing open, non-judgmental counseling. The clinical team, including prescribers and pharmacists, should discuss alcohol use openly with all patients to form an optimal treatment plan. Clinicians should acknowledge that their patients may drink regularly or have AUD because alcohol consumption is considered a risk factor for the development of AFib.3

 

Although many clinicians believe warfarin’s labeling lists alcoholism specifically as a contraindication to its use, it does not.4 This misconception may contribute to undertreatment or improper treatment of AFib in patients who use alcohol. A study found that rates of oral anticoagulant therapy (including warfarin) initiation were lower in patients with AUD.5

 

The potential interactions between warfarin and alcohol have been poorly studied. It is known that alcohol is not significantly metabolized by cytochrome P450 enzymes, as many drugs like warfarin are. Alcohol is primarily metabolized by alcohol dehydrogenase and to a much lesser extent by CYP2E1, CYP1A2, and CYP3A4.6 However, many additional compounds found in alcohol, like hops, flavonoids, and flavor additives, may affect warfarin’s pharmacokinetics or pharmacodynamics.

 

Some of the literature sources and guidelines note the possibility of alcohol’s effects such as an increased INR.7 Although there are not many available sources on the subject, small-scale studies have noted that8,9

  • Drinking wine daily with meals has no effect on therapeutic hypoprothrombinemia.
  • Heavy consumption of wine during fasting has no significant effect on one-stage prothrombin activity, levels of warfarin, or hypoprothrombinemia.

 

Guidelines recommend that patients with AFib should reduce or discontinue alcohol consumption to lessen AFib recurrence and burden.10 Clinicians may treat patients that are hepatically impaired, whether due to their alcohol consumption or not. In these cases, warfarin’s metabolism and synthesis of clotting factors can be impaired.4

 

Other conditions affecting patients’ liver function complicate their treatment plans. Because AFib is a common diagnosis in those with liver cirrhosis, anticoagulation therapy needs to be carefully considered. Liver cirrhosis is considered a non-modifiable bleeding risk factor in AFib patients.3 A study found that direct oral anticoagulants (DOACs) are safer than warfarin in patients with decompensated liver cirrhosis, and that DOACs are contraindicated in Child-Pugh class C patients (liver impairment associated with a 45% 1-year survival rate).3 Dosing warfarin in patients with liver cirrhosis is especially difficult because the coagulopathy associated with this disease state commonly causes elevations in INR.3

 

Heavy alcohol intake is a significant risk factor for GI bleeding, and warfarin may increase that risk. Warfarin’s package insert lists it as contraindicated in patients with bleeding tendencies associated with active ulceration or overt bleeding of the gastrointestinal tract.4

 

An additional concern clinicians may have is the risk of falls and bleeding in patients who are frequently inebriated. Evidence from literature dispels this concern, demonstrating that the incidence of severe bleeding is not significantly impacted by the occurrence of falls.11 However, it is worth noting that patients treated intensively (INR range of 2.5 to 3.5), bleeding is more likely to occur.11

 

In summary, for AFib patients taking warfarin, alcohol use itself is not cause for concern. However, alcohol use lends itself to other comorbid conditions that may impact the way that AFib is treated. The clinical team must counsel warfarin patients about healthy lifestyle choices and reducing alcohol intake in the interest of their overall health. If patients communicate with clinicians about their heavy alcohol use or binge drinking, the team can monitor closely and determine the patient’s individual response. The team must also encourage patients to report changes in alcohol intake openly and honestly. When changes occur, increasing monitoring frequency in patients who binge drink frequently is warranted. A PRO TIP is to track each patient’s INR levels over time, noting what has changed in the patient’s alcohol intake or diet to better make informed clinical decisions going forward.

  

CASE #2: PREGNANCY

It's Friday afternoon and the clinic is about to close. Jules, a 32-year-old female receiving long term warfarin after experiencing a second deep vein thrombosis two years ago, phones to say she just took a pregnancy test and—oops!—she has an unplanned positive. So, what do we do now, and what are we going to do later?

 

PAUSE AND PONDER: Under what conditions might a prescriber use warfarin in a patient who is pregnant?

  1. Only during the first trimester, then patients should be switched to a DOAC
  2. Never, warfarin is absolutely contraindicated in all trimesters of pregnancy
  3. In women with mechanical heart valves, who are at highest risk of thromboembolism

 

Let’s start with this, just in case you are thinking that a DOAC is the way to go: clinicians should avoid prescribing oral direct thrombin inhibitors (dabigatran) and factor Xa inhibitors (rivaroxaban, apixaban) in patients who are pregnant or lactating. The data concerning their effects on the woman, fetus, and breastfeeding neonate are insufficient to determine safety.12

 

Warfarin crosses the placenta, and fetal plasma concentrations are similar to maternal concentrations. Since the fetus’s liver enzyme system is immature, the fetus is severely overdosed by these levels.13 Patients who are at highest risk for venous thromboembolism during pregnancy are those with a mechanical heart valve. Subsequently, warfarin is only approved by the Food and Drug Administration for use in pregnant women if they have mechanical heart valves, because they are at high risk of thromboembolism.14

 

The team’s goals for therapy in pregnant women are

  • Treat and prevent thrombosis during the pregnancy, as pregnancy itself increases risk of thrombosis.
  • If warfarin is used, it must be stopped and changed to low molecular weight heparin (LMWH) for at least the first trimester of pregnancy. Pregnant women without mechanical heart valves, that still require anticoagulation, should remain on LMWH therapy for the duration of the pregnancy.
  • Discontinue anticoagulation rapidly at the time of birth to prevent bleeding events.

 

Warfarin therapy during the first trimester of pregnancy is associated with an increased risk of prematurity, miscarriage, and stillbirth. Warfarin is a known teratogen. Warfarin therapy also increases risk of congenital abnormalities of the fetus, including nasal hypoplasia, cleft lip/palate, and skeletal abnormalities, among others.15 Mechanical valve thrombosis is prevented more effectively with warfarin compared to unfractionated heparin (UFH) or LMWH in patients with mechanical heart valves. Table 1 summarizes the data. Consequently, after the first trimester, guidelines recommend restarting warfarin therapy in pregnant patients who meet this criteria.16 Exposure to warfarin after the first trimester has been linked to some minor developmental slowing, but babies usually catch up developmentally later in childhood.15

 

Table 1. Risk of Mechanical Valve Thrombosis by Treatment Regimen17

Treatment Regimen Risk of Mechanical Valve Thrombosis
Warfarin only 2.7%
LMWH only 8.7%
Unfractionated Heparin Only 11.2%
Sequential strategy (LMWH in 1st trimester followed by warfarin) 5.8%

 

Clearly, the fact that warfarin is the best agent to prevent mechanical valve thrombosis is complicated by the risk to the fetus when using warfarin in the first trimester. As soon as pregnancy is detected, patients with mechanical heart valves taking warfarin should immediately discontinue warfarin and start LMWH twice daily.18 This transition period carries a high risk of mechanical valve thrombosis. Evidence suggests that the recommended therapeutic dose of enoxaparin 1 mg/kg twice daily is not sufficient to bring patients to the desired peak anti-Xa levels. Patients started on enoxaparin 1 mg/kg had to be rapidly titrated according to peak monitoring parameters, which leads to the recommendation to start LMWH at higher than the therapeutic dose recommendation, shown in Table 2.18

 

Table 2. Initial Dosing of LMWH in Pregnant Patients with a Mechanical Heart Valves

Low Molecular Weight Heparin Dose
Enoxaparin 2.5 mg/kg/day
Dalteparin 250 units/kg/day
Tinzaparin 25 units/kg/day

 

Ultimately, LMWH dosing in patients with mechanical heart valves should be guided by target Anti-Xa levels, as seen in Table 3. Pregnant patients initiated on twice daily LMWH therapy should be frequently monitored for peak Anti-Xa levels; a PRO TIP is to draw levels 3 to 4 hours after dose is taken.

 

Table 3. Target Anti-Xa Levels for Pregnant Patients with Mechanical Heart Valves18

Type of Mechanical Heart Valve Target Anti-Xa Levels
Aortic valve prosthesis 0.8-1.2 international units/mL
Mitral and right-sided valve prosthesis 1.0-1.2 international units/mL

 

Due to ease of dosing and proper administration in the outpatient setting, use of LMWH is recommended over UFH.19 Risk of adverse events is lower and therapeutic response is more predictable with LMWH.20 UFH can be used, but is not recommended. Once patients with mechanical heart valves are outside of the crucial first trimester window (around the 13th week of pregnancy), patients can be transitioned back onto warfarin, with close INR monitoring.18 It is important to note that a patient’s warfarin dosing may not be the same as it was pre-pregnancy due to changes in anticoagulant factors during pregnancy.21 Two weeks before scheduled delivery or 36 weeks of pregnancy at the latest, clinicians should transition patients back onto a heparin-based therapy.18

 

Some evidence suggests that low-dose aspirin therapy, in combination with warfarin therapy, reduces the risk of mechanical valve thrombosis, but carries a higher risk of bleeding. Pregnant patients with mechanical heart valves should be started on low dose aspirin therapy early in pregnancy, so long as aspirin therapy is not contraindicated.18 If aspirin therapy is used, it should be stopped three days prior to planned delivery. Figure 1 summarizes anticoagulation in pregnant patients with mechanical heart valves.

 

Figure 1. Summary of Anticoagulation in Pregnant Patients with Mechanical Heart Valves

 

The CHEST guidelines don’t mention AFib in pregnancy, but the European Society of Cardiology (ESC) suggests changing anticoagulation to adjusted dose LMWH in the first trimester (as soon as pregnancy is confirmed). Warfarin has been proven to reduce the risk of stroke in these patients, although clinicians currently use DOACs preferentially. Pregnant patients cannot take DOACs, so warfarin is recommended after the first trimester to prevent stroke in patients with AFib.22 Warfarin can be resumed or initiated after the first trimester up until the last month of pregnancy when patient should be returned to LMWH prior to birth.23,24 This follows the recommendations for anticoagulation in patients with mechanical heart valves.

 

Patients receiving therapeutic doses of LMWH have an almost 2-fold increased risk of postpartum hemorrhage in instances of spontaneous labor compared to planned induction of labor.19 If the patient goes into labor unexpectedly while still taking warfarin therapy (or within two weeks of last warfarin dose), a cesarean section may be required to reduce fetal bleeding complications from labor.18 The newborn may need to receive vitamin K (IM or IV instead of by mouth, as is the current standard of care) and fresh plasma upon delivery.20 If the patient goes into labor spontaneously within 24 hours of last LMWH or UFH dose, providers can consider protamine after monitoring the PTT and/or anti-Xa levels if the patient is at risk for life threatening hemorrhage.18 Table 4 indicates how protamine can be dosed in the pregnant woman immediately prior to giving birth.25

 

Table 4. Protamine Dosing after Spontaneous Labor

Anticoagulant Protamine Dose
Heparin 1 mg per 100 unit of heparin
Enoxaparin 1 mg protamine per 1 mg enoxaparin
Dalteparin or tinzaparin 1 mg of protamine per 100 unit of LMWH administered in last 3-5 half lives

*Maximum single dose of protamine is 50 mg

ABBREVIATION: LMWH = low molecular weight heparin

 

A key concern prior to delivery is epidural administration of analgesics for the mother, as using injectables while a patient is anticoagulated is risky. For this reason, many obstetricians will schedule and induce labor in anticoagulated patients. The European Society of Anesthesiology currently recommends waiting at least 12 hours after cessation of prophylactic LMWH or at least 24 hours after cessation of greater-than-prophylactic dose LMWH therapy before inserting an epidural catheter.26 To ensure the patient has access to an epidural prior to birth, the team should attempt to discontinue LMWH therapy 24 hours before scheduled induction. In high-risk patients, clinicians can use an UFH infusion while the patient is hospitalized and discontinue it six hours before an induced delivery. If an epidural catheter needs to be placed, there must be a four to six hour interval between the last dose of UFH and epidural placement.26

 

After birth, anticoagulation is a little easier. If the patient is anticoagulated again after delivery and an epidural is still in place, clinicians must wait a minimum of 12 hours after the last anticoagulant dose before removing the catheter.18 Additionally, clinicians must wait an additional four hours after the epidural catheter is removed before administering LMWH or UFH therapy.26 Patients can be transitioned back onto warfarin five to seven days after delivery.18

 

Multiple options are available for breastfeeding women who need anticoagulation. UFH molecules are too large to pass into breast milk and warfarin has not been found to pass into breast milk. A PRO TIP is that warfarin dosing may differ in the post-partum period from pre-pregnancy due to differences in anticoagulation factors, so frequent monitoring is required. While LMWH products do pass into the breastmilk, their oral bioavailability is very low and has not been shown to cause fetal harm. However, the CHEST guidelines recommend against using DOACs in breastfeeding women as they cross into the breastmilk and there is not enough data to show degree of fetal harm.19

 

CASE #3: ANTIPHOSPOHLIPID SYNDROME

Stella is a 42-year-old female with a history of multiple miscarriages and deep vein thrombosis (DVT) after a major motor vehicle accident six weeks ago. Stella has recently been diagnosed with antiphospholipid antibody syndrome.

 

PAUSE AND PONDER: A colleague reviewing Stella’s case notices that keeping her INR in range has been difficult and has required a wide variation in weekly warfarin dosing. What does your experienced colleague recommend?

  1. Continue to adjust her warfarin based on the point-of-care (POC) testing values
  2. Maintain the same dose for two weeks regardless of the POC testing level
  3. Try a different monitoring approach

 

Antiphospholipid syndrome (APS) is an autoimmune disease that manifests as a persistent presence of antiphospholipid antibodies (aPLA) coinciding with thrombotic events or pregnancy complications. Table 5 lists a few antiphospholipid antibodies and their abbreviations.27 Classified APS cases must meet at least two criteria – one clinical and one laboratory. The clinical criterion is met through the presence of either pregnancy morbidity or vascular thrombosis. The laboratory criterion is met through high or medium titers of aCL, LA, or aβ2GPI antibodies. Positive titers must be measured at least 12 weeks apart to meet the criterion. In recent years, new antibodies and increased awareness have changed diagnosis and definition of APS, resulting in constantly changing classification criteria.28

 

Table 5. Antiphospholipid Antibody Abbreviations

Antiphospholipid Antibody Abbreviation
lupus anticoagulant antibody LA
anti-cardiolipin antibody aCL
anti-beta-2-glycoprotein I IgG & IgM antibody aβ2GPI

 

The antibodies cause a prothrombotic state, contributing to miscarriages and thrombosis.29 Thrombotic outcomes may be due to aPLA contributions to increased thrombus formation and platelet activation.30 Approximately 80% of APS cases are characterized by thrombosis (venous or arterial) and the remaining 20% of cases are characterized by obstetric complications (such as miscarriages or fetal death). APS is associated with the highest risk of thrombosis in cases of triple positive aPLA or LA, aCL, and aβ2GPI positivity. Cases in which aCL is detected in isolation are associated with the lowest risk. APS generally occurs more often in women than in men, and prevalence increases in patients with systemic lupus erythematosus or venous thromboembolism (VTE).27

 

The primary treatment for APS is use of anticoagulants.27 However, APS is a rare disease with varying presentations and limited information on diagnosis and classification, resulting in constantly evolving management strategies.31

 

For primary antithrombotic prophylaxis, or prevention of a first thrombosis, low-dose aspirin (75-100 mg/day) is recommended. Studies show that low-dose aspirin can reduce thrombotic event occurrence 2-fold; however, these are primarily observational studies. For high-risk situations (such as severe injuries or pregnancy), LMWH can be used.27

 

For patients with APS and a first thrombotic event, warfarin is the preferred anticoagulant treatment. The target INR is 2.0 to 3.0. DOACs are first-line treatment for first thrombotic events in the general population, but in patients with APS they are not recommended due to decreased efficacy compared to warfarin, seen in increased recurring thromboses.32 DOACs can be considered in cases where patients are adherent to warfarin therapy and are unable to achieve INR target range or patients are contraindicated to use warfarin.31 Warfarin is also considered first-line for secondary antithrombotic prophylaxis or prevention of recurrent thrombotic events following a first thrombosis.33

 

Warfarin is considered embryotoxic, and is contraindicated in pregnancy as discussed in the previous section. Pregnant women with thrombotic APS should switch from warfarin to LMWH before the 6th gestational week and continue therapy until delivery. However, patients with strong indications for warfarin can consider re-initiation in the second and third trimester after embryogenesis.27

 

As stated above, warfarin is essential in APS treatment. However, APS can interfere with INR measurements, usually elevating them falsely. This may be due to antiphospholipid antibodies reacting with thromboplastin.34 The INR elevation is more prevalent in POC testing, possibly due to the proposed interaction between antiphospholipid antibodies and test reagents (such as commercial thromboplastins). Thus, venipuncture (VP) testing may be preferred as a more accurate measurement of INR in clinical settings to attain therapeutic warfarin dosing.35

 

However, POC testing has numerous benefits compared to VP testing. In some situations, it is operationally valuable to consider using POC testing, such as for patients on whom it is difficult to perform VP testing,34 or during situations that require global precautions, like the COVID-19 pandemic. Generally, POC testing improves patient convenience and accessibility.35

 

POC testing, VP testing, and another test—CoaguChek XS—can be performed on the same day to correlate the different test results. CoaguChek measures chromogenic factor X level (cFX). cFX is generally unaffected by APS as it is not phospholipid-dependent, but this test may not be readily available and may require sending specimens to another laboratory. A cFX goal of 20% to 40% correlates with a goal INR of 2.0 to 3.0. Several same-day samples can be collected and correlated to adjust the goal INR matched to the patient’s elevated levels.34 Clinicians might consider POC testing use if the variation between POC tests and VP tests is less than or equal to 0.5 in INR readings. To assess validity of the correlation between paired tests, sampling can be repeated every three to six months.35

 

As an example, the clinic started a 31-year-old female patient with APS on warfarin with an initial INR goal of 2.0 to 3.0. Table 6 shows repeated test results. Her POC testing INR was adjusted to account for the natural elevation due to APS. After the first correlation point, her POC INR goal was set to 2.5 to 3.0, and after the second correlation point it was increased to 2.5 to 4.0. However, her VP INR remained at 2.0 to 3.0.34

 

Table 6. Repeated Tests Results for a 31-year-old Woman with Antiphospholipid Syndrome

Correlation Point VP INR POCT INR cFX
1 2.1 2.5 34%
2 2.4 3.0 --
3 2.8 4.1 --

 

Anticoagulation pharmacists should note aberrant INR tests, such as values at or above 4.8 and call patients back for additional testing. Additionally, APS may affect different POC devices and different laboratory equipment differently. The clinic will need to re-correlate if it receives new devices or if the lab has to change reagent in their INR machines.35 The correlation process is individualized and cannot be extrapolated between patients.34 Few formal evaluations of the reliability of testing methods exist, highlighting an area which requires more research.

 

CASE #4: MONITORING FREQUENCY

Shirley is a 68-year-old female with a prosthetic mechanical atrial valve. She has been in the therapeutic INR range with the same dose (no changes) for the past five months; she is remarkably stable.

 

PAUSE AND PONDER: When reminded to return in four weeks for INR monitoring, she says “Ugh, why do I keep having to come back? Can I come back less often?” How would you respond?

  1. It’s dangerous to go more than four weeks without testing
  2. Testing every four weeks is the standard
  3. Maybe we could have you come in less often

 

In the United States, common practice is to monitor a patient’s INR for warfarin dose adjustments every four weeks. To compare, in the United Kingdom, anticoagulant prescribers commonly use intervals of up to 90 days.36Although many clinicians feel most comfortable continuing to monitor monthly, returning every four weeks for INR monitoring creates a large burden for anticoagulated patients. Clinicians must empathize with patients and utilize alternatives when it is clinically safe to do so. This may come in the form of extended intervals between INR monitoring or at home POC testing. The 2012 CHEST guideline revision suggested an INR testing frequency of up to 12 weeks with a level of evidence of grade 2B (weak recommendation, moderate quality of evidence) in patients who have demonstrated periods of stable INR control.36

 

The initial evidence for extended intervals dates back to 2011.37 In a groundbreaking trial, Warfarin Dose Assessment every 4 weeks versus every 12 Weeks in Patients with Stable International Normalized Ratios, researchers enrolled 126 participants in a 4-week follow-up arm and 124 participants in the 12-week follow-up arm. The trial size was fairly small. Eligible participants had to have been enrolled in a clinic and receiving the same maintenance dose for at least six months. The trial was blinded in the sense that all participants had blood drawn every four weeks, but the researchers discarded the 4- and 8-week draws in the extended interval group. The researchers used a surrogate marker, time-in-therapeutic range (TTR) to measure control and quality of therapy. Participants in the 4-week monitoring group (55%) were more likely to have dose adjustments than those in the second group (37%). Groups had similar numbers of subsequent out-of-range next INR values (27.3% in the 4-week arm, 28.4% in the 12-week arm). Major bleeding events were also similar, but rates of clinically relevant non-major bleeding (0.02 per 100 patient-years versus 0.09 per 100 patient-years) and emergency department visits (0.07 per 100 patient-years versus 0.19 per 100 patient-years) were lower for eligible patients with extended INR testing intervals than for those with shorter INR testing intervals.37 The researchers concluded that extending the warfarin dosing assessment interval to every 12 weeks is probably safe for patients on stable doses if they continue to have supportive contact at least every four weeks.37

 

The ACCP recommends monitoring every 12 weeks in patients who are stable, which is indicated by at least three months of consistent results with no required adjustment of vitamin K antagonist dosing. However, instances in which the INR becomes subtherapeutic or supratherapeutic at these every 12 week appointments, the clinical team should increase the monitoring frequency until the patient achieves a stable INR again.38

 

One proposed model adjusts follow-up frequencies based on the appropriateness for each patient. A 2019 single-arm prospective cohort study titrated patients on a stable dose of warfarin up to the 12-week recall interval to assure that appropriate patients had their follow-up times extended. Qualifying patients had achieved their target INR of 2.0 to 3.0 for six months. The follow-up interval was first extended to 5 to 6 weeks, then 7 to 8 weeks, then 11 to 12 weeks, after which the researchers repeated the 11 to 12-week follow-up interval. If patients met an exclusion criterion (such as drug interaction, procedure, or hospitalization) or their INR was out of range, they would return to the usual care follow-up time (four weeks). Only restabilized patients would be re-titrated to the 12-week interval. This study suggests a future controlled trial design for methods of extending a stabilized patient’s INR follow-up interval.39

 

SIDEBAR: Point-of-Care Testing 40,41

Not all providers feel comfortable switching their patients to 12-week monitoring. Since their patients might be seeking alternatives to returning to the clinic every four weeks, providers should know what other options are available. POC testing offers an alternative to patients who wish to avoid returning to the clinic for INR monitoring and dose adjustment every four weeks. Although the POC testing systems can be quite pricey, the time the patient saves by reducing clinic visits may be worth it.

 

  • Patient Self-Testing (PST): Patients test their own INR at home, data is reported to the clinic remotely, and a clinician adjusts the dose if necessary.
    • Reduces patient burden by limiting trips to the anticoagulation clinic, and also limits provider burden
    • Studies show that patients who monitored frequently (mostly weekly) had a greater TTR.
    • Depends on the individual patient’s health literacy
    • Increased convenience can be pricy–a trade off
    • Overall - a safe option for patients that meet the criteria, even if it is not the most cost effective
  • Patient Self-Monitoring (PSM): Patients test their INR at home and are allowed to adjust their dose in response to the INR based on predetermined protocols.
    • Lessens burden on providers who are no longer consistently monitoring a patient’s INR and making adjustments
    • Requires extensive patient education
    • Success also depends on a patient’s ability to afford and manage these POC devices and calculate dose adjustments
    • Has been proven superior to PST in reducing mortality.
    • Overall - this might not be the most cost-effective option but is safe

 

The 2018 American Society of Hematology guideline includes a conditional suggestion for recall intervals no longer than 4 weeks for patients undergoing dose adjustment due to out-of-target-range INR measurements. However, for patients experiencing periods of stable INR control, a longer recall interval is strongly recommended, generally 6 to 12 weeks. Additionally, patient self-testing (PST) - a form of home POC testing - is recommended over other INR testing approaches with the exception of patient self-management (PSM). PSM is a form of POC testing in which the patient tests their INR at home and self-adjusts vitamin K antagonist dosing.41

 

CONCLUSION

Pharmacists who work in anticoagulation will see patients like those described in this module. A PRO TIP is to think of each patient as an individual, ask questions, and avoid making judgments.

Download PDF

Post Test 

View Questions for Challenging Topics in Anticoagulation

1. Patrick James, who goes by “PJ,” is a 33-year-old male who works in construction. He is obese and reports that he does not drink during the week but goes bar-hopping on Fridays and Saturdays, often staying out til 2 or 3 AM. He also watches sports on Sundays and drinks beer with the guys. He says, “I only have a few drinks, maybe six over the whole weekend.”  It’s Wednesday afternoon. What is the BEST way to assess his chronic alcohol use?

A. Assume that his actual alcohol intake is twice what he reports

B. Sit with him and work through the AUDIT-C AUD screening tool

C. Order blood work for long-term biomarkers to determine if they are abnormal

 

 

 
2. After your assessment of PJ, you realize he is a heavy drinker who binges all weekend. Which counseling point is critical when you prescribe warfarin for PJ?

A. “You should carry a small notebook with you and record all of your drinks and the time that you drank them.”

B. “We need to train you to use a self-testing device so you can adjust your warfarin dose on the weekends.”

C. “I understand that you drink and we’ve talked about the risks. We will need to monitor your INR often.

 

 

 
3. Under what conditions might a prescriber use warfarin in a patient who is pregnant?

A. Only during the first trimester, then patients should be switched to a DOAC

B. Never, warfarin is absolutely contraindicated in all trimesters of pregnancy

C. In women with mechanical heart valves, who are at highest risk of thromboembolism

 

 

 
4. Emily is a 29-year-old woman who is at risk for mechanical valve thrombosis. She is scheduled to deliver on October 11. On what day should you tell her to stop her low-dose aspirin?

A. October 1

B. October 8

C. No need to stop the aspirin

 

 

 
5. Which of the following patients is the BEST candidate for INR testing every 12 weeks?

A. A 72-year-old woman who has been stable on warfarin for five years

B. A 33-year-old male who appears to be a binge drinker

C. A 24-year-old woman who is in her second trimester of pregnancy

 

 

 
6. Michael is a patient whose INR results have been stable for three months and has not necessitated any dose adjustments. What does the ACCP recommend as a monitoring interval for Michael?

A. Every 5 weeks

B. Every 7 weeks

C. Ever 12 weeks

 

 

 
7. In the ground-breaking 2011 trial that explored longer intervals between INR testing, what did the researchers measure?

A. aβ2GPI positivity

B. point-of-care INR

C. time-in-therapeutic range

 

 

 
8. When reminded to return in four weeks for INR monitoring, one of your patients says “Ugh, why do I keep having to come back? Can I come back less often?” She has been stable for 5 months. How would you respond?

A. It’s dangerous to go more than four weeks without testing

B. Testing every four weeks is the standard

C. Maybe we could have you come in less often

 

 

 
9. Roberta experienced a thrombosis and has been diagnosed with antiphospholipid syndrome. What is the recommended prophylaxis going forward?

A. low-dose aspirin

B. dabigatran

C. warfarin

 

 

 
10. Which of the following is a concern when dealing with patients who have APS?

A. APS can interfere with INR measurements, usually lowering them falsely.

B. APS can interfere with INR measurements, usually elevating them falsely.

C. DOACs are generally ineffective in patients who have APS.

 

 

 
11. Which of the following is a significant concern in patients who drink often or heavily and take anticoagulants?

A. Interaction between warfarin and alcohol

B. Falls

C. Comorbid liver cirrhosis

 

 

 

References

References

  1. Grüner Nielsen D, Andersen K, Søgaard Nielsen A, Juhl C, Mellentin A. Consistency between self-reported alcohol consumption and biological markers among patients with alcohol use disorder - A systematic review.Neurosci Biobehav Rev. 2021;124:370-385. doi:10.1016/j.neubiorev.2021.02.006
  2. Ltd, Zero-One Design. General Insurance Article – Make Mine a Double. Actuarial Post. www.actuarialpost.co.uk/article/make-mine-a-double-14840.htm
  3. Gîrleanu I, Trifan A, Huiban L, et al. Anticoagulation for Atrial Fibrillation in Patients with Decompensated Liver Cirrhosis: Bold and Brave?.Diagnostics (Basel). 2023;13(6):1160. Published 2023 Mar 18. doi:10.3390/diagnostics13061160
  4. Warfarin tablet. Prescribing information. Teva Pharmaceuticals; 1954. Updated August 2021. Accessed March 2, 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0cbce382-9c88-4f58-ae0f-532a841e8f95
  5. Vanhanen M, Jaakkola J, Airaksinen JKE, et al. Alcohol use disorder and initiation of oral anticoagulant therapy in patients with atrial fibrillation: A nationwide cohort study.Gen Hosp Psychiatry. doi:10.1016/j.genhosppsych.2025.01.017
  6. Tan CSS, Lee SWH. Warfarin and food, herbal or dietary supplement interactions: A systematic review. Br J Clin Pharmacol. 2021;87(2):352-374. doi:10.1111/bcp.14404
  7. Havrda DE, Mai T, Chonlahan J. Enhanced antithrombotic effect of warfarin associated with low-dose alcohol consumption.Pharmacotherapy. 2005;25(2):303-307. doi:10.1592/phco.25.2.303.56955
  8. O'Reilly RA. Lack of effect of mealtime wine on the hypoprothrombinemia of oral anticoagulants. Am J Med Sci. 1979;277(2):189-194.
  9. O'Reilly RA. Lack of effect of fortified wine ingested during fasting and anticoagulant therapy. Arch Intern Med. 1981;141(4):458-459.
  10. Writing Committee Members, Joglar JA, Chung MK, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines [published correction appears in J Am Coll Cardiol. 2024 Mar 5;83(9):959. doi: 10.1016/j.jacc.2024.01.020.] [published correction appears in J Am Coll Cardiol. 2024 Jun 25;83(25):2714. doi: 10.1016/j.jacc.2024.05.033.].J Am Coll Cardiol. 2024;83(1):109-279. doi:10.1016/j.jacc.2023.08.017
  11. Bezak B, Vachalcova MB, Kissova V, et al. Risk of bleeding after ground-level falls in elderly patients with atrial fibrillation and warfarin therapy.Bratisl Lek Listy. 2023;124(2):128-132. doi:10.4149/BLL_2023_020
  12. American College of Obstetricians and Gynecologists' Committee on Practice Bulletins–Obstetrics. ACOG Practice Bulletin No. 197: Inherited Thrombophilias in Pregnancy [published correction appears in Obstet Gynecol. 2018 Oct;132(4):1069. doi: 10.1097/AOG.0000000000002924.]. Obstet Gynecol. 2018;132(1):e18-e34. doi:10.1097/AOG.0000000000002703
  13. Vitale N, De Feo M, De Santo LS, Pollice A, Tedesco N, Cotrufo M. Dose-dependent fetal complications of warfarin in pregnant women with mechanical heart valves. J Am Coll Cardiol. 1999;33(6):1637-1641. doi:10.1016/s0735-1097(99)00044-3

‌14. Warfarins tablet. Prescribing information. Teva Pharmaceuticals; 1954. Updated August 2021. Accessed March 2, 2025. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=0cbce382-9c88-4f58-ae0f-532a841e8f95

  1. Gheysen W, Kennedy D. An update on maternal medication‐related embryopathies. Prenatal Diagnosis. 2020;40(9):1168-1177. doi:https://doi.org/10.1002/pd.5764
  2. Chan WS, Anand S, Ginsberg JS. Anticoagulation of Pregnant Women With Mechanical Heart Valves: A Systematic Review of the Literature. Arch Intern Med.2000;160(2):191-196. doi:10.1001/archinte.160.2.
  3. Scheres LJJ, Bistervels IM, Middeldorp S. Everything the clinician needs to know about evidence-based anticoagulation in pregnancy. Blood Rev. 2019;33:82-97. doi:10.1016/j.blre.2018.08.001
  4. Lester W, Walker N, Bhatia K, et al. British Society for Haematology guideline for anticoagulant management of pregnant individuals with mechanical heart valves. Br J Haematol. 2023;202(3):465-478. doi:10.1111/bjh.18781
  5. Bates SM, Rajasekhar A, Middeldorp S, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: venous thromboembolism in the context of pregnancy. Blood Adv. 2018;2(22):3317-3359. doi:10.1182/bloodadvances.2018024802
  6. ACOG Practice Bulletin No. 196: Thromboembolism in Pregnancy: Correction. Obstet Gynecol. 2018;132(4):1068. doi:10.1097/AOG.0000000000002923
  7. Uppuluri E, Idrees N, Shapiro N. Warfarin dosage in a postpartum woman while breastfeeding: A case report. Pharmacotherapy. 2024; 44: 343-347. doi:10.1002/phar.2917
  8. Amin A. Oral anticoagulation to reduce risk of stroke in patients with atrial fibrillation: current and future therapies. Clin Interv Aging. 2013;8:75-84. doi:10.2147/CIA.S37818
  9. Ghada Sayed Youssef. Management of atrial fibrillation during pregnancy. Escardioorg. 2019;17(15). https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-17/management-of-atrial-fibrillation-during-pregnancy
  10. Regatiz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy: The Task Force for the Management of Cardiovascular Diseases during Pregnancy of the European Society of Cardiology (ESC). European Heart Journal. 2018; 39(34):3165-3241. doi:10.1093/eurheartj/ehy340
  11. Protamine. Lexi-Drugs. Lexicomp. Wolters Kluwer. Updated October 14, 2024. Accessed March 4, 2024. https://online.lexi.com
  12. Gogarten W, Vandermeulen E, Van Aken H, et al. Regional anaesthesia and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol. 2010;27(12):999-1015. doi:10.1097/EJA.0b013e32833f6f6f
  13. Capecchi M, Abbattista M, Ciavarella A, Uhr M, Novembrino C, Martinelli I. Anticoagulant Therapy in Patients with Antiphospholipid Syndrome. J Clin Med. 2022;11(23):6984. doi:10.3390/jcm11236984
  14. Dabit JY, Valenzuela-Almada MO, Vallejo-Ramos S, Duarte-García A. Epidemiology of Antiphospholipid Syndrome in the General Population. Curr Rheumatol Rep. 2022;23(12):85. Published 2022 Jan 5. doi:10.1007/s11926-021-01038-2
  15. Sammaritano LR. Antiphospholipid syndrome. Best Pract Res Clin Rheumatol. 2020;34(1):101463. doi:10.1016/j.berh.2019.101463
  16. Pastori D, Menichelli D, Cammisotto V, Pignatelli P. Use of Direct Oral Anticoagulants in Patients With Antiphospholipid Syndrome: A Systematic Review and Comparison of the International Guidelines. Front Cardiovasc Med. 2021;8:715878.
  17. Tektonidou MG, Andreoli L, Limper M, et al. EULAR recommendations for the management of antiphospholipid syndrome in adults. Ann Rheum Dis. 2019;78(10):1296-1304. doi:10.1136/annrheumdis-2019-215213
  18. Sayar Z, Moll R, Isenberg D, Cohen H. Thrombotic antiphospholipid syndrome: A practical guide to diagnosis and management. Thromb Res. 2021;198:213-221. doi:10.1016/j.thromres.2020.10.010
  19. Rodziewicz M, D'Cruz DP. An update on the management of antiphospholipid syndrome. Ther Adv Musculoskelet Dis. 2020;12:1759720X20910855. doi:10.1177/1759720X20910855
  20. Dush A, Erdeljac HP. INR Management of an Antiphospholipid Syndrome Patient With Point-of-Care INR Testing. J Pharm Pract. 2020;33(3):390-391. doi:10.1177/0897190019838192
  21. Masucci M, Li Kam Wa A, Shingleton E, Martin J, Mahir Z, Breen K. Point of care testing to monitor INR control in patients with antiphospholipid syndrome. EJHaem. 2022;3(3):899-902. doi:10.1002/jha2.522
  22. Holbrook A, Schulman S, Witt DM, et al. Evidence-based management of anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e152S-e184S. doi:10.1378/chest.11-2295
  23. Schulman S, Parpia S, Stewart C, Rudd-Scott L, Julian JA, Levine M. Warfarin dose assessment every 4 weeks versus every 12 weeks in patients with stable international normalized ratios: a randomized trial. Ann Intern Med. 2011;155(10):653-W203. doi:10.7326/0003-4819-155-10-201111150-00003
  24. Wigle P, Hein B, Bernheisel CR. Anticoagulation: Updated Guidelines for Outpatient Management. Am Fam Physician. 2019;100(7):426-434.
  25. Porter AL, Margolis AR, Staresinic CE, et al. Feasibility and safety of a 12-week INR follow-up protocol over 2 years in an anticoagulation clinic: a single-arm prospective cohort study. J Thromb Thrombolysis. 2019;47(2):200-208. doi:10.1007/s11239-018-1760-9
  26. Guidance on the Use of Point-of-Care Testing of International Normalized Ratio for Patients on Oral Anticoagulant Therapy. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; July 2014.
  27. Witt DM, Nieuwlaat R, Clark NP, et al. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy. Blood Adv. 2018;2(22):3257-3291. doi:10.1182/bloodadvances.2018024893

Patient Safety: Polypharmacy in Vulnerable Older Adults: Why, Who, When, What, and How to Safely Deprescribe

Learning Objectives

 

After completing this knowledge-based continuing education activity, pharmacists will be able to

  1. Describe the risk of suboptimal medication use, including polypharmacy, in frail, older populations
  2. Recognize facilitators and barriers when managing polypharmacy
  3. Identify instances of inappropriate polypharmacy
  4. Apply an action plan for meaningful deprescribing

After completing this knowledge-based continuing education activity, pharmacy technicians will be able to

  1. Describe polypharmacy and its impact on frail, older population
  2. Recognize facilitators and barriers when managing polypharmacy
  3. Identify recommended strategies for deprescribing
  4. Infer when to refer patients for action plans to implement meaningful deprescribing

      Multi-colored tablets and capsules floating over a cartoon hand

      Release Date:

      Release Date: July 15, 2025

      Expiration Date: July 15, 2028

      Course Fee

      FREE

      ACPE UANs

      Pharmacist: 0009-0000-25-049-H05-P

      Pharmacy Technician: 0009-0000-25-049-H05-T

      Session Codes

      Pharmacist: 25YC49-HLK

      Pharmacy Technician: 25YC49-KHL

      Accreditation Hours

      2.0 hours of CE

      Accreditation Statements

      The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit for the online activity ACPE UAN 0009-0000-25-049-H05-P/T  will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

       

      Disclosure of Discussions of Off-label and Investigational Drug Use

      The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

      Faculty

      Lisa A. Rosenberg, PharmD, BCGP
      Clinical Initiative Manager
      CareKinesis, AnewHealth
      Moorestown, NJ
       

      Faculty Disclosure

      In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

      Lisa A. Rosenberg, PharmD, BCGP has no relationships with ineligible companies and therefore have nothing to disclose.

      ABSTRACT

      Earlier thought was “more care is better,” and prescribers were perceived as ignoring their patients’ interests if they did not prescribe certain medications. The Choosing Wisely Campaign brought awareness about potentially doing more harm than good within healthcare. Healthcare providers are encouraged to have conversations with patients about potentially unnecessary treatments and overuse. The Beers criteria by the American Geriatrics Society and Screening Tool of Older Persons’ Prescriptions (STOPP) criteria describe potentially inappropriate medications (PIMs) in older adults. As healthcare providers engage patients and caregivers in the medication use process, conversations about deprescribing ought to occur to mitigate potential harm and overuse. To improve the safety of medication use, as with prescribing, deprescribing should be a patient-centered approach. Pharmacists must identify the right patient and the right time to consider deprescribing, and upon identifying the right medication, use an evidence-based strategy to safely deprescribe. This continuing education activity describes best practices for deprescribing with a focus on why and how to safely do so in the vulnerable older adult population.

      CONTENT

      Content

      INTRODUCTION

      The number of older adults (aged 65 years and older) is expected to exceed 1.5 billion by 2050.1 Multimorbidity is expected to affect 65% of older adults aged 65 to 84 years and up to 82% of those aged 85 years or older.1 With multimorbidity, the number of medications taken by the vulnerable older adult population increases. Along with drug-disease and drug-drug interactions, age-related physiological changes that alter pharmacokinetics and pharmacodynamics increase the risk of adverse drug events (ADEs).2

       

      Throughout this continuing education activity, consider a hypothetical patient, Ms. Polly, who is an 85-year-old female. Enrolled in a Program of All-Inclusive Care for the Elderly (PACE), she has been able to live safely at home. Table 1 lists her current medication regimen.

       

      Table 1. Medication Regimen
      Acetaminophen/diphenhydramine PM 25/500 mg, 2 tablets nightly PRN for insomnia

      Alendronate 70 mg weekly for osteoporosis

      Amlodipine 10 mg daily for hypertension

      Aspirin 81 mg daily for heart attack prevention

      Cetirizine 10 mg daily for allergies

      Donepezil 10 mg daily for Alzheimer’s disease

      Fluticasone nasal spray 2 sprays in each nostril daily for allergies

      Furosemide 20 mg daily for peripheral edema

      Gabapentin 300 mg twice daily for neuropathic pain

      Glipizide ER 5 mg daily for pre-diabetes

      Ibuprofen 200 mg three times daily for pain

      Omega-3 Fish Oil 1000 mg twice daily for hyperlipidemia

      Oxybutynin 5 mg twice daily for overactive bladder

      Pantoprazole 40 mg daily for GERD

      Paroxetine 30 mg daily for depression

      Potassium chloride 10 mEq daily for potassium deficiency

      Pravastatin 40 mg daily for hyperlipidemia

      Propranolol 40 mg twice daily for hypertension

      Senna-docusate 8.6-50 mg, 2 tablets daily for constipation

      ABBREVIATIONS: GERD = gastroesophageal reflux disease; mEq = milliequivalent; mg = milligrams; PRN = as needed

       

      Ms. Polly’s healthcare needs have become more complex with her increasing confusion, declining ability to perform activities of daily living, and a recent fall. Her daughter continues to be her main caregiver and has requested more help from PACE; thus, the prescriber has reached out to the clinical pharmacist for assistance. This CE activity will review best practices for deprescribing with a focus on why, who, when, what, and how to safely deprescribe medications in the vulnerable older adult population.

       

      WHY, WHO, AND WHEN TO DEPRESCRIBE

       

      WHY: Older Adults Have Specific Needs

      Since older adults have differing health and functional statuses, prescribers must individualize medication selection for these patients. Prescribing the right medication and dose for the right indication at the right time while providing benefit and avoiding ADEs is challenging. Comorbidities and complexity of medication regimens may result in suboptimal medication use. Suboptimal medication use comprises (1) underprescribing, (2) polypharmacy or overuse, and (3) high-risk prescribing, such as potentially inappropriate medications (PIMs), prescribing cascades, and anticholinergic and sedative effects.2

       

      Estimates suggest that as many as 65% of older adults in the United States are exposed to polypharmacy and 29% to PIMs.3,4 Polypharmacy is generally defined as the use of five or more medications and often occurs because of a prescribing cascade, which means the culprit medication causes an ADE that is mistaken for a new medical condition for which a subsequent medication is initiated as treatment. “Hyperpolypharmacy” or “excessive polypharmacy” is generally considered the use of 10 or more medications.5 Polypharmacy is associated with undesirable outcomes: frailty, cognitive decline, functional decline, falls, fractures, emergency department (ED) visits, hospitalizations, and mortality.3,5,6

       

      Evidence suggests that older age and indicators of poor health (i.e., multiple chronic conditions, cognitive decline, frailty) are risk factors for polypharmacy. The number of medications in a patient’s regimen may be the single most important predictor of ADEs.6 The likelihood of taking inappropriate medication increases with the number of drugs prescribed. Experts consider medications inappropriate in older adults when they pose individual or cumulative adverse event risk.

       

      The Choosing Wisely Campaign brought awareness and encouraged conversations between healthcare providers and patients about medication overuse and potentially doing more harm than good within healthcare. This partnership between the American Board of Internal Medicine (ABIM) Foundation and specialty societies was formed in 2012. At the time, the healthcare field and society generally thought that more care was better, and patients tended to perceive prescribers as ignoring their patients’ interests if they did not prescribe certain medications.7

       

      Understanding suboptimal prescribing allows healthcare providers to mitigate the risk of poor health outcomes in vulnerable older adults. Deprescribing is the process of healthcare professional-supervised medication withdrawal with the goal of managing polypharmacy and improving outcomes.8 Pharmacists review medication regimens comprehensively to identify and consider discontinuation of high-risk medications and those that cause more harm than benefit. Deprescribing encourages a proactive and systematic approach to mitigate potential medication-related problems (MRPs). This approach is preferable over a reactive approach (i.e., discontinuing an offending medication after an ADE occurs).

       

      PAUSE AND PONDER: Why should healthcare providers re-evaluate medications periodically?

       

      According to the World Health Organization, the global ADE-related mortality rate increased approximately 3.3-fold from 2001 to 2019, with the highest rates occurring in those aged 75 years and older.9 A systematic review of 14 hospital-based observational studies in older adults found an ADE to occur more often with an increased number of medications.10 More than 50% of ADEs could be prevented with safe prescribing practices.5 Safe medication use requires that healthcare providers ensure regimen appropriateness, considering treatment initiation, treatment optimization, and cessation of unnecessary or inappropriate medications.

       

      WHO: The Age-Friendly Movement

      The Institute for Healthcare Improvement in partnership with The John A. Hartford Foundation, American Hospital Association, and the Catholic Health Association developed the Age-Friendly Health Systems initiative to improve the care of older adults and the lives of caregivers. This framework—the Age-Friendly 4Ms, depicted in Figure 1—is a patient-centered approach to medication optimization that addresses polypharmacy and deprescribing. Conversations with healthcare providers can be re-framed to discuss “What Matters” to the patients and caregivers. Medications impact all the “M” domains: What Matters, Mentation and Mobility.11,12

       

      Figure 1. Age-Friendly Health Systems 4Ms Framework11

       

      Reasons for deprescribing may vary from patient to patient. When reviewing common goals for deprescribing, consider the perspectives of the patient, the caregiver, and the healthcare team. Identify which reasons for deprescribing may be most relevant or meaningful to each party involved in the patient’s care. Examples include

      • reducing medication regimen complexity and pill burden to improve adherence
      • reducing anticholinergic burden to improve and/or preserve cognitive function
      • reducing fall and fracture risk
      • reducing hospitalizations
      • reducing mortality
      • reducing costs

       

      These deprescribing goals improve patients’ quality of life. Deprescribing considers not only single medications but also the aggregate interaction risk from multiple medications.13

       

      Deprescribing often presents challenges due to barriers faced by healthcare providers and patients. Healthcare providers’ may have limited time and lack of training which serves as the most significant barriers. Patient-related barriers to deprescribing include satisfaction with medications, reluctance, resistance to change, and opposition to alternative treatments. Despite these challenges, many barriers can be addressed through education, communication, and shared decision-making.

       

      Although many patients express not wanting to take medications, their beliefs and acceptance of polypharmacy and discontinuing medications is poorly understood. To further understand patients’ views, preferences and willingness, researchers from the University of South Australia and University of Sydney developed the Patients’ Attitudes Towards Deprescribing (PATD) questionnaires, including the revised PATD for older adults and caregivers and the revised PATD for cognitively impaired individuals (rPATDcog).14-16

       

      A population-based survey of Medicare beneficiaries 65 years and older using PATD questions found most older adults are open to having one or more medications deprescribed and two-thirds want to reduce the number of medications taken.17 A multi-center cross-sectional survey found older adults and caregivers are open to deprescribing, with more than 90% willing to discontinue a medication if a healthcare provider initiates the conversation.18

       

      While primarily used for research, providers may use the revised PATD questionnaire clinically to target patients and caregivers who are willing to discontinue medications. The original work is available here: https://www.australiandeprescribingnetwork.com.au/925-2/.16 Understanding attitudes and willingness may enhance shared decision-making conversations about deprescribing.

       

      PAUSE AND PONDER: How do you determine which medications to deprescribe?

       

      WHEN TO DEPRESCRIBE

      Older adults are often high-risk for potential MRPs due to pharmacokinetic (the body’s effect on a medication) and pharmacodynamic (a medication’s effect on the body) changes. However, advanced age is not an independent risk factor for MRPs. Elements of high-risk patients who may benefit from deprescribing include the following19:

      • Polypharmacy: Use of multiple medications is the strongest risk factor for MRPs. Table 2 lists common types of potential MRPs.
      • Multimorbidity: Having multiple chronic conditions increases the risk of drug-disease interactions.
      • Renal impairment: Reduced renal function increases ADE risk.
      • Transitions of care: Medication management by multiple prescribers can result in miscommunication and medication discrepancies, such as inadvertent continuation.
      • Nonadherence: Patients may be nonadherent to their medication regimens due to experiencing real or perceived adverse effects and/or lack of benefit, complexity, burden, and cost.
      • Limited life expectancy/end of life care: Goals of care change from slowing disease progression and prolonging life to improving quality of life. Patients may no longer benefit from preventive medications and use certain medications for symptomatic management.
      • Frailty and dementia: Frailty—an age-related syndrome of physiologic decline—is associated with increased adverse events and risk of harm, such as falls, which can be detrimental. ADEs may worsen or exacerbate these syndromes (i.e., fatigue or cognitive impairment).

       

      Table 2. Types of Potential Medication-Related Problems
      Adverse Drug Events

      Adverse Drug Interactions

      Excessive Duration

      Inappropriate/Unnecessary Medications

      Ineffective Therapy

      No Indication

      Nonadherence

      Suboptimal Dosing

      Supratherapeutic Dosing

       

       

      Aging is not an identical experience for every person, so frailty—declining mental and physical resilience, or the ability to bounce back and recover from events like illness and injury—is a more appropriate measure of health status than age alone. Frailty has been associated with poor patient outcomes. The Edmonton Frail Scale is a validated, reliable, and multidimensional screening tool for all healthcare settings. The free tool with a training course is available here: https://edmontonfrailscale.org/. It assesses nine domains: cognition, general health status, functional independence, social support, medication use, nutrition, mood, continence, and functional performance. The highest level of frailty is a score of 17.20 Assessing frailty severity can help with shared decision-making and determining goals of care.

       

      PAUSE AND PONDER: How can you use prescribing clinical tools for deprescribing?

       

      WHAT TO DEPRESCRIBE

      While few studies have measured the clinical implications of underprescribing, evidence has shown an association between polypharmacy and PIMs. A systematic review of 38 clinical trials found that deprescribing interventions in community-dwelling older adults (aged 65 years and older) may provide small reductions in use of PIMs and mortality.6 Prescribers and pharmacists should periodically reevaluate any medication initially prescribed for a clinical indication since benefits, risks, conditions, and comorbidities change over time, which may result in inappropriate use. Medication review should consider the following factors: goals of care, remaining life expectancy, treatment targets, time until benefit, number needed to treat (NNT, a statistical measure that indicates how many patients need to be treated with a specific intervention to prevent one additional adverse outcome), number needed to harm, and ADEs.21

       

      Collaborative approaches and numerous clinical application tools highlighted below are available for safe prescribing and to reduce medication overuse. Focusing on medications and potential ADE risk, healthcare providers can employ these clinical tools to identify medications for potential deprescribing.

       

      Risk-Benefit Analysis

      Older adults are vulnerable to ADEs associated with “high-risk” single medications and medication classes, including anticoagulants, benzodiazepines, cardiovascular agents, digoxin, hypoglycemics, nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, psychotropics, and those with anticholinergic effects. “High-risk” medication combinations—for example, angiotensin-converting enzyme inhibitors, diuretics, and NSAIDs in patients with chronic kidney disease (known as the “triple whammy”)—augment ADE risk.13

       

      In a “Less is More” special communication about polypharmacy and deprescribing, experts proposed grouping medications into two categories for older adults to determine if the likely benefit outweighs potential risk/harm, while noting that medications may fall into both categories.13

       

      “Disease and/or symptom control medications” are used to manage active disease and symptoms and help maintain quality of life.13 Discontinuing these medications could result in symptom return or functional decline due to disease worsening. Examples include analgesics, anti-anginals, anti-heart failure medications, and levothyroxine. Dose reduction of disease/symptom control drugs may be appropriate if symptoms are mild or intermittent, but these should be discontinued if altogether ineffective. Notably, aggressive treatment may be inappropriate for hypertension or diabetes management in some older adults, as this could increase the risks of hypotension or hypoglycemia, respectively.13

       

      Preventive medications are intended to prevent future morbid events.13 Their use should be guided by assessment of absolute risks and benefits of treatment for individual patients, taking into consideration the time required for benefit (known as "time to benefit"), patient preferences, and estimated life expectancy. For example, osteoporosis guidelines recommend a “drug holiday” (temporary discontinuation of therapy) from bisphosphonates depending on fracture risk after five years of treatment to mitigate risk of atypical femoral fractures and osteonecrosis of the jaw. Despite discontinuation, bisphosphonates’ anti-fracture effects persist because this medication class has long half-lives and remain stored in bone for up to 10 years. Another example is statins, which are commonly used for primary prevention of cardiovascular events. Evidence suggests that statin discontinuation after eight years does not increase cardiovascular event risk.13

       

      Choosing Wisely Campaign

      The American Board of Internal Medicine’s global Choosing Wisely (CW) Campaign encourages patient engagement and healthcare provider conversation to choose care that is evidence-based, necessary, and free from harm. Since 2012, a compilation of more than 600 evidence-based statements from approximately 80 healthcare organizations advise healthcare providers, patients, and caregivers about optimization, appropriateness, and avoidance of unnecessary medical testing and treatments, available at https://www.choosingwisely.org/.7,22,23,24

       

      The American Society of Consultant Pharmacists (ASCP) convened a task force in 2018 under the CW campaign to further help pharmacists initiate and implement deprescribing. The task force reinforced deprescribing in older adults by reviewing and providing evidence-based references. ASCP’s guidance provides ten statements focused on avoiding DDIs and prescribing cascades and encouraged medication reviews to mitigate potential ADEs25:

      1. DO NOT initiate medications to treat new and emerging symptoms without first ascertaining that the new symptom is not an ADE related to an already prescribed medication.
      2. DO NOT continue medications at care transitions without reviewing and reconciling to verify accurate and complete medication lists in concert with current medical problems.
      3. DO NOT recommend highly anticholinergic medications in older adults without first considering safer alternatives or non-pharmacologic measures.
      4. DO NOT use anticholinergics concomitantly with cholinesterase inhibitors for dementia.
      5. DO NOT use two or more medications known to increase bleeding risk (e.g., antiplatelets, direct oral anticoagulants [DOACs], warfarin, aspirin, NSAIDs, corticosteroids, selective serotonin reuptake inhibitors), without evaluating the potential risks and benefits.
      6. DO NOT prescribe or routinely continue medications for older adults with limited life expectancy without consideration to individual goals of care, presence of comorbidities, and time to benefit for preventive medications.
      7. DO NOT use three or more central nervous system-active medications (e.g., antidepressants, antipsychotics, benzodiazepines, antiepileptics, Z-drugs, opioids, gabapentinoids).
      8. DO NOT combine opioids with benzodiazepines or gabapentinoids to treat pain and DO re-evaluate routinely for deprescribing during chronic use.
      9. DO NOT prescribe tramadol without consideration of the potential risks and harms related to serotonergic excess, seizures, falls, and drug-drug interactions (DDIs).
      10. DO NOT use strong CYP3A4 and P-glycoprotein inhibitors or inducers with DOACs and DO periodically assess for such DDIs.

       

      The American Geriatrics Society (AGS) also worked on the CW campaign to identify treatments that potentially have more risks than benefits in older adults, concluding the following26:

      • DO NOT use antipsychotics first-line to treat behavioral and psychological symptoms of dementia.
      • DO NOT use benzodiazepines or sedative-hypnotics first-line for insomnia, agitation, or delirium.
      • DO NOT use cholinesterase inhibitors for dementia without periodic assessment for perceived cognitive benefits and adverse gastrointestinal effects.
      • DO NOT use antidiabetics to achieve hemoglobin A1c less than 7.5% in most older adults; moderate control is generally better.
      • DO NOT use antimicrobials to treat bacteriuria in older adults unless they experience specific urinary tract symptoms.
      • DO NOT maintain long-term proton pump inhibitor (PPI) therapy for gastrointestinal symptoms without an attempt to stop or reduce PPI at least once per year in most patients.
      • DO NOT use NSAIDs for patients with hypertension, heart failure, or chronic kidney disease.
      • DO NOT use prescription appetite stimulants or high-calorie supplements for treatment of anorexia or cachexia (unexplained wasting) in older adults.
      • DO NOT prescribe medication without conducting a medication regimen review.

       

      Prescribing Cascades

      It bears repeating that providers should not initiate medications—prescription or over-the-counter (OTC)—or use a new medical device to treat new and emerging symptoms without first ascertaining that the new symptom is not an ADE of an already prescribed medication.24 This is the first CW statement endorsed by ASCP and it describes a prescribing cascade. Prescribing cascades are preventable, yet often unrecognized, even though researchers in the geriatric field first introduced the concept in the 1990s and then revisited and expanded upon it in 2017.27,28 They emphasized that “the identification and interruption of prescribing cascades is an important, actionable, and underappreciated opportunity to improve medication safety in older people.”27,28

       

      Prescribing cascades contribute to polypharmacy and adverse outcomes in vulnerable older adults. By becoming familiar with the common prescribing cascades, outlined in Table 3, pharmacists and pharmacy technicians can identify culprit and cascade medications. If culprit medications remain clinically indicated, prescribers should use the lowest possible dose, a safer alternative with fewer adverse effects, or non-pharmacologic therapy, rather than initiating a cascade medication to address the ADE.

      Table 3. Prescribing Cascades to Avoid or Amend29
      CULPRIT MEDICATION ADVERSE DRUG EVENT CASCADE MEDICATION
      ACE inhibitors Cough Cough suppressants
      Alpha-1 blockers Orthostatic hypotension Meclizine
      Amiodarone Tremor Lithium
      Hypothyroidism Thyroid hormones
      Amitriptyline Cognitive impairment Cholinesterase inhibitors
      Antipsychotics Cognitive impairment Cholinesterase inhibitors
      Extrapyramidal symptoms Benztropine
      Benzodiazepines Cognitive impairment Cholinesterase inhibitors
      Beta blockers Depression Antidepressants
      Bisphosphonates GERD PPIs/H2RAs
      Bupropion Insomnia Sedatives-hypnotics
      Calcium channel blockers Constipation Laxatives
      Peripheral edema Diuretics
      Cholinesterase inhibitors Insomnia Sedatives-hypnotics
      Urinary incontinence OAB anticholinergics
      Corticosteroids Insomnia Sedatives-hypnotics
      Diuretics Urinary incontinence OAB anticholinergics
      Dopaminergics Psychotic symptoms Antipsychotics
      Gabapentinoids Peripheral edema Diuretics
      Lithium Extrapyramidal symptoms Antiparkinsonians
      Tremor Propranolol
      Metoclopramide Extrapyramidal symptoms Antiparkinsonians
      NSAIDs GI bleeding or heartburn PPIs/H2RAs
      Hypertension Antihypertensives
      OAB anticholinergics Cognitive impairment Cholinesterase inhibitors
      SGLT2 inhibitors Urinary tract infections Antibiotics
      SSRIs/SNRIs Insomnia Sedatives-hypnotics
      Statins Myalgia NSAIDs/opioids
      Thiazide diuretics Hyperuricemia or gout Allopurinol/colchicine

      ABBREVIATIONS: GERD = Gastroesophageal reflux disease; GI = Gastrointestinal; H2RAs = Histamine-2 receptor antagonists; NSAIDs = Non-steroidal anti-inflammatory drugs; OAB = Overactive bladder; PPIs = Proton pump inhibitors; SGLT2 = Sodium glucose cotransporter-2; SNRIs = Serotonin norepinephrine reuptake inhibitors; SSRIs = Selective serotonin reuptake inhibitors

       

      Anticholinergic Medications

      Older adults are more sensitive to anticholinergic adverse effects, including confusion, dry mouth, blurry vision, constipation, and urinary retention. A large case-control observational study of 58,769 patients diagnosed with dementia and 225,574 matched controls found statistically significant associations of dementia risk with exposure to anticholinergic medications, such as antidepressants, antipsychotics, antiparkinsonians, antiepileptics, and bladder anticholinergics.30 Participants who took a single strong anticholinergic medication daily for three years had almost 50% increased odds of dementia within a 10-year period. Dementia risk was increased in patients taking more than one anticholinergic medication due to the cumulative impact.30 Pharmacists can use one or a combination of multiple validated expert anticholinergic scales to calculate aggregate anticholinergic scores. An anticholinergic burden score of three or higher is associated with increased cognitive impairment and mortality. The most frequently validated scale is the Anticholinergic Cognitive Burden (ACB) scale.31,32 An Anticholinergic Burden Calculator is available at no cost for use here: https://www.acbcalc.com/.

       

      A small longitudinal study of 69 participants found those who took an anticholinergic medication in combination with the cholinesterase inhibitor donepezil over a two year period declined by seven points on the Mini-Mental State Examination as compared with a three point decline in those taking donepezil alone.33 Thus, concomitant therapy with anticholinergics may counteract efficacy of cholinesterase therapy, resulting in a more rapid cognitive and functional decline.

       

      Revisiting the case, Ms. Polly is taking donepezil for Alzheimer’s disease. Her prescriber consults with the pharmacist to initiate memantine for her progressive dementia due to increasing confusion and declining function. Medication review identifies several medications with anticholinergic effects that may be worsening Ms. Polly’s cognitive function, including cetirizine, diphenhydramine, furosemide, oxybutynin, and paroxetine. The pharmacist recommends deprescribing anticholinergic medications for which risk outweighs benefit. With reducing aggregate anticholinergic burden, donepezil may be more effective. This avoids added polypharmacy by initiating memantine, effectively preventing a prescribing cascade. Following discontinuation of these medications, the pharmacy technician can follow up with Ms. Polly and her caregiver to assess if there has been improvement.

       

      Resources are available to assess polypharmacy and identify PIMs in vulnerable, older adults. The following section provides an overview, applicability, and utility in practice for the most common clinical tools: Beers Criteria, STOPP/START Criteria, STOPPFall Criteria, STOPPFrail Criteria, and the Medication Appropriateness Index.

       

      Beers Criteria

      The late Mark Beers, MD and his colleagues developed the Beers Criteria in 1991 with a mission to identify medications for which potential harm outweighed expected benefit and that should be avoided in long-term facilities. Since then, several updates have expanded the criteria to apply to older adults aged 65 years and older in ambulatory, acute, and institutionalized care settings, except end-of-life and hospice. Upon Dr. Beers’s death, AGS assumed responsibility for maintaining the criteria.

       

      The 2023 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults is a well-known, widely available clinical tool to support shared clinical decision-making. It is available for free in the Journal of the American Geriatrics Society.34 For ease of clinical practice application, the AGS provides a pocket card and an app, for a fee, available at https://geriatricscareonline.org/. To encourage engagement and conversation, AGS provides patient and caregiver educational resources that are available for free at https://www.healthinaging.org/.

       

      The AGS Beers Criteria lists medications and medication classes that the society and its geriatric expert panel consider potentially inappropriate for use in older adults. The criteria are structured by category with each section including a clear rationale and recommendation:

      1. Medications considered potentially inappropriate
      2. Medications potentially inappropriate in patients with certain diseases or syndromes
      3. Medications to use with caution
      4. Potentially inappropriate drug-drug interactions
      5. Medications to avoid or adjust dosages based on renal function
      6. Medications with strong anticholinergic effects

       

      Importantly, the identified medications are “potentially inappropriate” rather than “definitely inappropriate.” The key word is “potentially,” as the prescribing and deprescribing processes are to be patient centric. The AGS panel recognizes that harm is typically more pronounced in the “old-old” than in the “young-old” and in patients with complex multi-morbidity and frailty.34 The indicators are categorized based on whether they involve avoiding the initiation of a PIM or discontinuing one that is already prescribed. To apply the AGS Beers Criteria, prescribers and pharmacists must identify the PIMs and, when clinically appropriate, consider safer pharmacologic or nonpharmacologic alternatives.

       

      STOPP/START Criteria

      The Screening Tool of Older Person's Prescriptions (STOPP) and Screening Tool to Alert doctors to Right Treatment (START) criteria are additional resources for identifying potentially inappropriate prescribing in older adults. These aim to identify PIMs and potential prescribing omissions, respectively.35 The STOPP criteria are most helpful in the context of polypharmacy. The original version, published in 2008, included 65 STOPP criteria, which more than doubled in the third version, updated in 2023, with 133 STOPP criteria. These more expansive criteria assist pharmacists and pharmacy technicians in identifying and preventing more DDIs, drug-disease interactions, and potential ADEs during medication reviews.

       

      The STOPP criteria is divided into sections by organ systems—including cardiovascular, coagulation, central nervous, renal, gastrointestinal, respiratory, musculoskeletal, urogenital, and endocrine—with separate sections for drugs that increase fall risk, analgesics, and antimuscarinic or anticholinergic drugs.35 The criteria also address the need to clarify an indication for each medication, labeling the following as PIMs:

      • Any medication prescribed without a clinical indication
      • Any medication prescribed beyond recommended duration
      • Any duplicate medication class

       

      Additional variations of the STOPP criteria help healthcare providers to identify PIMs in older adults with a high risk of falls (STOPPFall) and in those with limited life expectancy (STOPPFrail).36,37 STOPPFall identifies medication classes considered to be fall-risk-increasing-drugs (FRIDs). To further assist in shared-decision making of deprescribing, practical decision trees based on the STOPPFall guidance are available online (https://kik.amc.nl/falls/decision-tree/).36

       

      While most prescribing tools are designed to identify and prevent PIMs in the general older population, STOPPFrail consists of 27 potentially inappropriate prescribing indicators to assist healthcare providers in deprescribing in frail older adults.37 Deprescribing in frail older adults may improve their quality of life through a reduction in adverse events, hospitalizations, and mortality. Medication review in this population should focus on deprescribing and symptom management, rather than preventive and intensive treatment. STOPPFrail is applicable in adults aged 65 or older who meet all the following criteria37:

      • End-stage irreversible pathology
      • Poor one year survival prognosis
      • Severe functional or cognitive impairment or both
      • Symptom control is priority rather than preventing disease progression

       

      Example criteria include37

      • Avoid antiplatelets for primary cardiovascular prevention due to lack of evidence
      • Bisphosphonates are unlikely to be beneficial for short-term osteoporosis treatment
      • Aim for antidiabetic monotherapy with less stringent glycemic control (i.e., hemoglobin A1c goal of less than 8%)

       

      End-of-Life Care

      Prescribers and pharmacists should re-evaluate medications and minimize the pill burden for patients receiving palliative care, particularly at end-of-life (i.e., life expectancy of less than three months). Prevention of long-term complications is no longer indicated.21 Rather, the goal is comfort care through symptom-specific medications (SSMs) to treat pain, dyspnea (shortness of breath), nausea, cognitive disturbances, anxiety, and depression. The number of SSMs increases while the number of medications intended to treat comorbidities decreases. Therefore, the definition of polypharmacy shifts for end-of-life care, focusing on inappropriate medication use.

       

      The shared decision-making process must still consider patient and caregiver preferences. While some patients may prefer only symptomatic treatment without life-prolonging measures, other patients may feel neglected following discontinuation of certain long-term medications.21 A literature review of 67 articles established preliminary recommendations for long-term medication classes shown in Table 4.21

       

      Table 4. Deprescribing at End-of-Life21
      MEDICATION CLASS RECOMMENDED ACTION PLAN GDR
      Anticoagulants Discontinue for deep vein thrombosis primary prevention No
      Antihyperglycemics Reduced dosages to prevent hypoglycemia Variable
      Antihypertensives Discontinue for hypertension Yes
      Antimicrobials Variable: goal is symptom control No
      Statins Discontinue No

      ABBREVIATIONS: GDR = gradual dose reduction

       

      Medication Appropriateness Index

      Unlike the previously mentioned clinical tools that are PIMs and medication class lists developed by expert consensus; the Medication Appropriateness Index (MAI) is patient centric. The MAI, developed more than 30 years ago, is a patient screening tool that measures potentially inappropriate prescribing in older adults. The 10 simple questions focus on indication, effectiveness, dosing, duration, and potential for interactions to ultimately rate medications as appropriate, marginally appropriate, or inappropriate.38,39 A MAI Calculator is available at no cost for use here: https://globalrph.com/medcalcs/medication-appropriateness-index-calculator/.

       

      HOW TO SAFELY DEPRESCRIBE

       

      Deprescribing Tools

      Once polypharmacy and PIMs are identified, many clinical tools are available to analyze benefit versus risk and guide pharmacy teams on how to safely discontinue specific medications and medication classes.

       

      Deprescribing.org

      https://deprescribing.org/resources/

      Canadian Medication Appropriateness and Deprescribing Network

      https://www.deprescribingnetwork.ca/professionals

       

      Deprescribing.org is a website developed by Canadian pharmacists that provides guidance, tools, and approaches for deprescribing.40 Included within these resources are evidence-based guidelines and easy to use algorithms to determine when and how to stop specific medication classes: antihyperglycemics, antipsychotics, benzodiazepines, cholinesterase inhibitors, memantine, and PPIs.40 The companion site, Canadian Medication Appropriateness and Deprescribing Network, provides additional guidance on commonly inappropriate medications for healthcare providers and patients, including a Deprescribing Educational Program and brochures.41

       

      US Deprescribing Research Network https://deprescribingresearch.org/resources-2/resources-for-clinicians/

      The US Deprescribing Research Network is a tool funded by the National Institute of Aging to develop and provide information on deprescribing for older adults.42 The network’s efforts center around four “cores” addressing the needs of different stakeholders (e.g., researchers, patients) and a series of working groups focusing on research and standardized outcome measures. Resources for healthcare providers promote education by providing guides for specific medication classes and reference the deprescribing tools described above.42

       

      Primary Health Tasmania https://www.primaryhealthtas.com.au/resources/deprescribing-resources/

      Primary Health Tasmania is a not-for-profit organization in Australia that provides a comprehensive guide to personalized deprescribing, including principles, assessment of benefit versus harm, and patient and healthcare provider perceptions. These in-depth guidelines recommend deprescribing strategies for an extensive list of common medication classes: allopurinol, anticholinergics, anticoagulants, antiepileptics, antihyperglycemics, antihypertensives, antiplatelets, antipsychotics, benzodiazepines, bisphosphonates, cholinesterase inhibitors, gabapentinoids, glaucoma ophthalmics, inhaled corticosteroids, long-acting nitrates, NSAIDs, opioids, PPIs, statins, and calcium and vitamin D.43

       

      MedStopper https://medstopper.com/

      MedStopper is an online clinical tool for polypharmacy that assists healthcare providers, patients, and caregivers in the shared decision-making process and prioritization of deprescribing.44 Upon entering a patient’s regimen, MedStopper arranges the medications from “more likely to stop” to “less likely to stop,” based on the criteria in Table 5. A team of clinicians and researchers affiliated with Canadian healthcare institutions, including the University of British Columbia and the Centre for Effective Practice developed this site and is grounded in evidence-based resources such as the Beers and STOPP/START Criteria. However, it remains in the Beta testing phase, so pharmacy teams should still use it with caution.44

       

      Table 5. Deprescribing Opportunities and Prioritization44
      Medication Conversation
      Potential to improve symptoms Is the medication helping symptoms?
      Potential to reduce the risk of future illness Does the effectiveness justify the potential adverse effects, inconvenience, and cost?
      Likelihood to cause harm Are symptoms caused by medications?

       

      Using the Edmonton Frail Scale, healthcare providers can identify patients as frail to adjust MedStopper’s “may cause harm” ranking. The specific indication for each medication affects the ranking categories for “may improve symptoms” or “may reduce future illness.” Categories are based on the rating levels of an unhappy, neutral, or happy face, with a color-coded discontinuation priority. Medications and indications also include links for resources, such as calculators for risk/benefit assessment, NNT, Beers Criteria, or STOPP Criteria. Healthcare providers can reference the tapering suggestions and symptom monitoring, as appropriate.44

       

      Go back and review Ms. Polly’s medication regimen in Table 1. Which medications may be inappropriate based on the numerous prescribing and deprescribing tools that are readily available? Figure 2 shows a snapshot of a suggested plan for deprescribing utilizing the MedStopper clinical tool.

       

      Figure 2. Deprescribing Plan Based on Stopping Priority by MedStopper

      NOTE: Incomplete medication regimen

       

      PAUSE AND PONDER: When do medications need a gradual dose reduction for discontinuation?

       

      Pharmacist-Led Deprescribing

      Research shows that comprehensive medication reviews may reduce PIM use and mortality in community-dwelling older adults aged 65 years and older.6 A narrative review of 25 global randomized controlled trials found that pharmacist-led deprescribing interventions had a beneficial effect on 69% of medication outcomes—including discontinuation, dose reductions, and medication changes—for patients with a mean age of 60 years or older residing in the community and nursing facilities.45

       

      Pharmacists must follow a stepwise, patient-centric approach to deprescribing, while performing a comprehensive medication review of prescription and OTC medications as depicted in Figure 3. Since prescribing and deprescribing clinical tools do not consider preferences, life expectancy, and goals of care, it is essential to understand “what matters” to the patient and/or caregiver.

       

      Figure 3. Stepwise Approach to Deprescribing

      ABBREVIATIONS: MRPs = medication-related problems

       

      Prescribers, pharmacists, and pharmacy technicians should assess if patients are not adhering to prescribed medications and, if not, why. Opportunities to deprescribe may be identified by asking just one question to a patient and/or caregiver. Pharmacy technicians are typically trained to ask, “do you have any questions for the pharmacist about your medication?” Instead, open-ended questions, such as “how do you feel about the number and types of medication you take?” or “how did your new medication help with your symptoms?” could gather more useful information. It is also important to ask if patients experience any adverse effects from their medications.

       

      What Matters and Shared Goals

      Deprescribing conversations ought to involve shared decision-making. Research shows older adults’ priorities are typically maintaining cognition, function, and independence over life extension.46,47 Patient preferences and health status change over time. Knowing a patient’s priorities and preferences about medication use helps align treatment decisions and guide deprescribing.

       

      To determine a patient’s health priorities and preferences, healthcare providers can use the universal health Outcome Prioritization Tool (OPT) which is nonspecific to diseases and treatments. This simple tool elicits the preferences of older adults by having them consider trade-offs and rank the relative importance of four health outcomes46,47:

      1. extending life (regardless of health)
      2. preserving independence/maintaining function and activities of daily living
      3. reducing or eliminating pain
      4. reducing or eliminating symptoms (e.g., dizziness, fatigue, nausea, shortness of breath)

       

      Several studies found that preserving independence and reducing pain were the most important health outcomes, whereas life extension was the least important.18,48,49 In the Older Patients’ Perceptions of Medicines and Willingness to Deprescribe survey, of the 50 participants, 76% wanted to keep their symptomatic medications and 61% wanted to keep their preventive medications.18

       

      The “What Matters to You?” study of 350 patients used the OPT to assess the most important health outcome for older adults.50 Patients with cognitive impairment more often prioritized life extension. Importantly, cognitively impaired patients may struggle to understand health outcomes and the “trade-off principle”—prioritizing one health outcome while accepting potential deterioration in other health outcomes—which makes patients weigh and prioritize health goals. Patients with declining health status are generally more accepting of further decline. A secondary outcome found that the OPT is feasible for intensive treatment decision-making. For those patients who are unable to prioritize the four health outcomes, the OPT is still useful to facilitate a conversation about patient preferences and trade-offs to align decision-making.50

       

      Considering Ms. Polly: how can the 4Ms aid in recommending oxybutynin discontinuation to her prescriber? “What matters to the patient is being able to continue to live in her home. Oxybutynin is anticholinergic and is negatively affecting her mentation and mobility as she has recent falls. Please consider a discontinuation trial of oxybutynin and non-pharmacologic options for overactive bladder.”

       

      Identifying Medications for Discontinuation

      Upon establishing goals of care, the next step is to engage the patient or caregiver and decide whether to deprescribe any medications. Common reasons for deprescribing include

      1. No active indication (e.g., health condition resolved)
      2. New or worsening condition
      3. Potential risks outweigh anticipated benefits
      4. Preventive indication with life-limiting conditions
      5. Lack of benefit or ineffectiveness
      6. Result of a prescribing cascade
      7. Nonadherence
      8. Interactions or ADEs

       

      Prescribers and pharmacists can use the available prescribing and deprescribing clinical tools, but they must also review all medications and assess the benefit versus risk for individualized patients.

       

      Developing an Action Plan

      Upon identifying medications to deprescribe, prescribers and pharmacists must collaborate to develop an action plan to implement, monitor, and follow-up. When deprescribing, withdraw medications one-by-one by prioritizing those that are inappropriate and/or increase the risk of harm. It is critical to continuously consider “what matters” to the patient. Multiple medications can be withdrawn simultaneously if patients are experiencing ADEs, medications are easy to discontinue, or if they have minimal withdrawal effects.

       

      If deprescribing is justified, prescribers, pharmacists, and pharmacy technicians need a plan of action for each medication (i.e., whether to abruptly stop or if gradual dose reduction (GDR) is necessary). Healthcare providers need to educate patients or caregivers on withdrawal symptoms to look for and emphasize the need to promptly report them.

       

      Certain medications require a GDR or taper to prevent an adverse drug withdrawal event—meaning discontinuation results in clinically significant symptoms or signs—or worsened conditions.51 GDRs can identify the lowest effective dose, minimize symptom re-occurrence, and encourage patient willingness. For example, discontinuing benzodiazepines may cause agitation. If this withdrawal symptom is unfamiliar to healthcare providers, then a prescribing cascade may occur with initiation of an antipsychotic.43

       

      Most medications have limited evidence and few guidelines for deprescribing. If no guidance is available, it is safer to attempt a GDR over weeks to months to discontinue rather than abruptly discontinuing. If a deprescribing guideline is unavailable, taper and discontinue medications in reverse of guideline recommended treatment. For example, the prescribing information for donepezil recommends initiation of therapy at 5 mg daily for four to six weeks, then increase the dose to 10 mg daily. To taper donepezil, decrease the 10 mg daily dose to 5 mg daily for four to six weeks and then discontinue therapy. Pharmacists can recommend a GDR plan in consideration of pharmacokinetics (e.g., half-lives), pharmacodynamics, dose, and duration of medications.51

       

      To achieve successful deprescribing, a trusting relationship, ongoing communication, and adequate documentation is essential between prescribers, pharmacists, pharmacy technicians, patients, and caregivers. Using the word “trial” is reassuring to patients and caregivers since it implies patients can restart the medication if needed.

       

      Returning to Ms. Polly, the pharmacist can initiate the conversation with her daughter by saying, “I understand you feel overwhelmed. It seems now would be a good time to take another look at your mother’s medications. We can ease the burden of her medication regimen and simplify it for her. This trial of stopping a couple of her medications may help with her confusion and lower her fall risk.”

       

      CONCLUSION

      Deprescribing is an essential part of good prescribing and an important strategy. It ensure older adults are not taking suboptimal medications. Effective and safe deprescribing requires a patient-centered, shared decision-making approach with evaluation of preferences, level of functioning, life expectancy, and goals of care. Numerous clinical resources are available to reduce polypharmacy, assess benefit versus risk, and provide guidance and approaches for how to discontinue specific medications. Deprescribing inappropriate or unnecessary medications impacts clinical outcomes—such as reduction in hospitalizations, ED visits, falls and overall healthcare costs—mitigates ADEs, and improves quality of life. Simplifying more complex medication regimens may also improve patient adherence to essential medications.

       

      With a strong foundation in deprescribing principles and tools, it’s time to reevaluate Ms. Polly’s medication regimen one last time. What other medications should be considered for deprescribing to reduce polypharmacy, mitigate ADEs, and improve quality of life for both Ms. Polly and her daughter?

       

      Pharmacist Post Test (for viewing only)

      1. What is the primary goal of deprescribing?
      A. To discontinue preventive medications
      B. To increase medication adherence regardless of appropriate therapy
      C. To manage polypharmacy and improve outcomes

      2. Which of the following best characterizes the impact of polypharmacy and high-risk prescribing in older adults?
      A. Increases the risk of potential adverse drug effects
      B. Reduces the risk of hospitalization
      C. Optimizes disease prevention and management

      3. Which of the following is true regarding the “mentation” domain of the Age-Friendly 4Ms Framework?
      A. It focuses on ensuring older adults are physically active
      B. It involves assessing and addressing cognitive function, such as dementia and depression
      C. It refers only to medication adjustments in older adults

      4. You assess a patient using the Edmonton Frail Scale (EFS) and the result is 14/17, indicating severe frailty. Which of the following deprescribing strategies is most appropriate for this patient?
      A. Maintain all preventive medications to avoid complications
      B. Focus on medications that preserve functional independence
      C. Discontinue all medications at once to simplify the regimen

      5. You are reviewing medications for a frail 91-year-old woman who lives in a long-term care facility. She is on a statin, a bisphosphonate, memantine, and metformin. She has difficulty swallowing and advanced dementia. Which deprescribing action is MOST aligned with STOPPFrail guidance?
      A. Recommend changing the bisphosphonate to denosumab, a monoclonal antibody, due to difficulty swallowing
      B. Recommend discontinuing memantine since she has advanced dementia without discussing with her family
      C. Recommend discontinuing the statin and bisphosphonate due to limited short-term benefit

      6. Refer to the available AGS 2023 updated Beers criteria. Which deprescribing principle applies most appropriately to glipizide?
      A. Glipizide is on the Beers Criteria since may cause hypoglycemia and may not be indicated in pre-diabetes or limited life expectancy
      B. Glipizide is indicated as preventive treatment for pre-diabetes
      C. Glipizide is indicated to achieve glucose control of HgbA1c < 6.5% for older adults 7. Ms. Polly, an 85-year-old woman, started taking amlodipine six months ago. She now takes furosemide for new-onset peripheral edema and docusate-senna for constipation. Which concept does this scenario most likely illustrate?
      A. Appropriate polypharmacy
      B. Prescribing cascade
      C. Suboptimal dosing

      8. Ms. Polly, an 85-year-old woman, recently experienced a fall when she was walking to the bathroom in the middle of the night. She has shown increased confusion and difficulty performing activities of daily living. Which medication is the most appropriate to first target for deprescribing to reduce anticholinergic burden and support cognitive function?
      A. Donepezil
      B. Diphenhydramine
      C. Furosemide

      9. George, a 70-year-old man, is receiving palliative end-of-life care and having increasing difficulty adhering to his medication regimen. His medications include pravastatin (for primary prevention), lisinopril (for hypertension), and acetaminophen as needed (for arthritis pain). Which medication is the most appropriate to consider deprescribing first?
      A. Pravastatin
      B. Lisinopril
      C. Acetaminophen

      10. Ms. Polly, an 85-year-old woman, is currently taking donepezil for Alzheimer’s disease. Upon medication review, you identify that she is also taking paroxetine and propranolol. What is the most appropriate recommendation?
      A. If a beta blocker is indicated, consider changing propranolol to metoprolol. Then, consider attempting a gradual dose reduction of paroxetine to possibly discontinue or change to a safer alternative, such as sertraline.
      B. Consider discontinuing donepezil since it may no longer have benefit. If Ms. Polly’s caregiver is adamant about continuing, consider initiation of memantine for synergistic effects.
      C. Continue all medications with close monitoring since they treat her co-morbidities and consider additional medications if she is experiencing new symptoms.

      Pharmacy Technician Post Test (for viewing only)

      1. Which of the following is a primary goal of deprescribing in frail older adults?
      A. Enhance polypharmacy for preventive medications
      B. Reduce polypharmacy to avoid potential medication-related problems
      C. Optimize medication therapy for aggressive disease management

      2. What is the most significant predictor of adverse drug events in older adults?
      A. Number of medications
      B. Age older than 75 years
      C. Renal impairment

      3. Which of the following is a common patient-related barrier to deprescribing?
      A. Fear of forgetting to take medications
      B. Desire to stop all medications
      C. Belief that all medications are necessary

      4. Ms. Polly, an 85-year-old woman, lives at home with support from her daughter. She values staying independent. She’s currently prescribed oxybutynin for overactive bladder (OAB) and has experienced two recent falls. The pharmacist suspects the falls may be related to the oxybutynin. Using the 4Ms framework, which "M" should most strongly guide a recommendation to deprescribe oxybutynin?
      A. What Matters
      B. Mobility
      C. Mentation

      5. Which of the following describes a prescribing cascade?
      A. A method of simplifying medication regimens by using combination products
      B. Gradually decreasing medication dosages over time before discontinuing
      C. Initiating a new medication to treat an adverse effect caused by another medication

      6. You are handed two prescriptions for oxybutynin and paroxetine. The older adult asks you where he can find Tylenol PM (acetaminophen/diphenhydramine). Why is it important to check with the pharmacist if there are any potential drug-drug interactions with the new prescriptions prior to telling the patient where to find Tylenol PM?
      A. One of the new prescriptions may help the patient to sleep and he may not need the Tylenol PM
      B. Older adults are more susceptible to medication-related problems, such as adverse effects
      C. The Tylenol PM may negate the effect of one of the prescriptions, resulting in reduced efficacy

      7. A prescriber has prescribed an SSRI and NSAID for a 78-year-old woman with depression and osteoarthritis pain. She recently had a minor gastrointestinal (GI) bleed. According to Choosing Wisely recommendations, what is the best action?
      A. Add a PPI to prevent GI bleeding
      B. Discontinue the NSAID
      C. Continue both medications with no changes

      8. A patient's medication list is entered into Medstopper. The tool recommends stopping pantoprazole due to long-term use without indication. What is the likely prioritization factor influencing this recommendation?
      A. High cost
      B. Low likelihood of benefit and potential for harm
      C. No longer effective for symptom control

      9. You are conducting a medication reconciliation for an 88-year-old patient. She seems overwhelmed and says, “I feel like I’m taking pills all day long.” What is the most appropriate response to support deprescribing efforts?
      A. “Let me ask the pharmacist to review your medication list.”
      B. “You can stop taking the medications you think aren’t helping.”
      C. “Your doctor knows what’s best for you, ask them for help.”

      10. A patient tells you he stopped taking his blood pressure medication because it made him feel dizzy and weak. What is the best next step?
      A. This should not be deprescribed; advise the patient to restart it immediately
      B. Suggest taking half the dose so that his blood pressure remains controlled
      C. Refer the patient to the pharmacist for further evaluation and counseling

      References

      Full List of References

      1. World Health Organization. National Institute on Aging. National Institutes of Health. Global Health and Aging. NIH Pulication no. 11-7737. October 2011. https://www.nia.nih.gov/sites/default/files/2017-06/global_health_aging.pdf
      2. Hanlon JT, Schmader KE, Ruby CM, Weinberger M. Suboptimal prescribing in older inpatients and outpatients. J Am Geriatr Soc. 2001;49(2):200-209. doi:10.1046/j.1532-5415.2001.49042.x
      3. Keller MS, Qureshi N, Mays AM, Sarkisian CA, Pevnick JM. Cumulative Update of a Systematic Overview Evaluating Interventions Addressing Polypharmacy. JAMA Netw Open. 2024;7(1):e2350963. Published 2024 Jan 2. doi:10.1001/jamanetworkopen.2023.50963
      4. Tian F, Chen Z, Zeng Y, Feng Q, Chen X. Prevalence of Use of Potentially Inappropriate Medications Among Older Adults Worldwide: A Systematic Review and Meta-Analysis. JAMA Netw Open. 2023;6(8):e2326910. doi:10.1001/jamanetworkopen.2023.26910
      5. Lee GB, Etherton-Beer C, Hosking SM, Pasco JA, Page AT. The patterns and implications of potentially suboptimal medicine regimens among older adults: a narrative review. Ther Adv Drug Saf. 2022;13:1-41. doi:10.1177/20420986221100117
      6. Bloomfield HE, Greer N, Linsky AM, et al. Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis. J Gen Intern Med. 2020;35(11):3323-3332. doi:10.1007/s11606-020-06089-2
      7. Born KB, Levinson W. Choosing Wisely campaigns globally: A shared approach to tackling the problem of overuse in healthcare. J Gen Fam Med. 2018;20(1):9-12. Published 2018 Dec 21. doi:10.1002/jgf2.225
      8. Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol. 2015;80(6):1254-1268. doi:10.1111/bcp.12732
      9. Koyama T, Iinuma S, Yamamoto M, et al. International Trends in Adverse Drug Event-Related Mortality from 2001 to 2019: An Analysis of the World Health Organization Mortality Database from 54 Countries. Drug Saf. 2024;47(3):237-249. doi:10.1007/s40264-023-01387-0
      10. Alhawassi TM, Krass I, Bajorek BV, Pont LG. A systematic review of the prevalence and risk factors for adverse drug reactions in the elderly in the acute care setting. Clin Interv Aging. 2014;9:2079-2086. doi:10.2147/CIA.S71178
      11. Institute for Healthcare Improvement. Age-Friendly Health Systems. Accessed March 17, 2025. Available from: https://www.ihi.org/networks/initiatives/age-friendly-health-systems
      12. Monette PJ, Schwartz AW. Optimizing Medications with the Geriatrics 5Ms: An Age-Friendly Approach. Drugs Aging. 2023;40(5):391-396. doi:10.1007/s40266-023-01016-6
      13. Scott IA, Hilmer SN, Reeve E, et al. Reducing Inappropriate Polypharmacy: The Process of Deprescribing. JAMA Intern Med. 2015;175(5):827–834. doi:10.1001/jamainternmed.2015.0324
      14. Reeve E, Shakib S, Hendrix I, Roberts MS, Wiese MD. Development and validation of the patients' attitudes towards deprescribing (PATD) questionnaire. Int J Clin Pharm. 2013;35(1):51-56. doi:10.1007/s11096-012-9704-5
      15. Reeve E, Low LF, Shakib S, Hilmer SN. Development and Validation of the Revised Patients' Attitudes Towards Deprescribing (rPATD) Questionnaire: Versions for Older Adults and Caregivers. Drugs Aging. 2016;33(12):913-928. doi:10.1007/s40266-016-0410-1
      16. Australian Deprescribing Network. Patients’ Attitudes Towards Deprescribing questionnaires. Accessed March 17, 2025. https://www.australiandeprescribingnetwork.com.au/925-2/
      17. Reeve E, Wolff JL, Skehan M, Bayliss EA, Hilmer SN, Boyd CM. Assessment of Attitudes Toward Deprescribing in Older Medicare Beneficiaries in the United States. JAMA Intern Med. 2018;178(12):1673–1680. doi:10.1001/jamainternmed.2018.4720
      18. Arnoldussen DL, Keijsers K, Drinkwaard J, Knol W, van Marum RJ. Older Patients' Perceptions of Medicines and Willingness to Deprescribe. Sr Care Pharm. 2021;36(9):444-454. doi:10.4140/TCP.n.2021.444
      19. Steinman M, Reeve E. Editor: Schmader, KE, Givens J. Deprescribing. UpToDate. Wolters Kluwer. 2025. Accessed May 14, 2025.
      20. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526-529. doi:10.1093/ageing/afl041
      21. van Nordennen RT, Lavrijsen JC, Vissers KC, Koopmans RT. Decision making about change of medication for comorbid disease at the end of life: an integrative review. Drugs Aging. 2014;31(7):501-512. doi:10.1007/s40266-014-0182-4
      22. ABIM Foundation. Choosing Wisely. Accessed March 17, 2025. https://www.choosingwisely.org
      23. Baron RJ, Lynch TJ, Rand K. Lessons from the Choosing Wisely Campaign's 10 Years of Addressing Overuse in Health Care. JAMA Health Forum. 2022;3(6):e221629. Published 2022 Jun 3. doi:10.1001/jamahealthforum.2022.1629
      24. Beier MT, Brodeur MR. ASCP's 2021 Choosing Wisely® Recommendations: A Proud Accomplishment. Sr Care Pharm. 2022;37(5):171-180. doi:10.4140/TCP.n.2022.171
      25. American Society of Consultant Pharmacists (ASCP). Ten Things Physicians and Patients Should Question. Updated June 8, 2022. www.choosingwisely.org
      26. American Geriatrics Society (AGS). Ten Things Physicians and Patients Should Question. Updated April 23, 2015. Accessed May 14, 2025. https://www.healthinaging.org/sites/default/files/media/pdf/HIA_TIP_Choosing%20Wisely%202016.pdf
      27. Rochon PA, Gurwitz JH. Optimising drug treatment for elderly people: the prescribing cascade. BMJ. 1997;315(7115):1096-1099. doi:10.1136/bmj.315.7115.1096
      28. Rochon PA, Gurwitz JH. The prescribing cascade revisited [published correction appears in Lancet. 2017;389(10085):2192. doi: 10.1016/S0140-6736(17)31315-6.]. Lancet. 2017;389(10081):1778-1780. doi:10.1016/S0140-6736(17)31188-1
      29. McCarthy LM, Savage R, Dalton K, et al. ThinkCascades: A Tool for Identifying Clinically Important Prescribing Cascades Affecting Older People. Drugs Aging. 2022;39(10):829-840. doi:10.1007/s40266-022-00964-9
      30. Coupland CAC, Hill T, Dening T, Morriss R, Moore M, Hippisley-Cox J. Anticholinergic Drug Exposure and the Risk of Dementia: A Nested Case-Control Study. JAMA Intern Med. 2019;179(8):1084–1093. doi:10.1001/jamainternmed.2019.0677
      31. Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. BMC Geriatr. 2015;15:31. Published 2015 Mar 25. doi:10.1186/s12877-015-0029-9
      32. Boustani M, Campbell N, Munger S, Maidment I, Fox C. Impact of anticholinergics on the aging Brain: A review and Practical application. Aging Health. 2008;4(3):311-320. doi:10.2217/1745509x.4.3.311
      33. Lu CJ, Tune LE. Chronic exposure to anticholinergic medications adversely affects the course of Alzheimer disease. Am J Geriatr Psychiatry. 2003;11(4):458-461.
      34. By the 2023 American Geriatrics Society Beers Criteria® Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372
      35. O'Mahony D, Cherubini A, Guiteras AR, et al. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3 [published correction appears in Eur Geriatr Med. 2023 Aug;14(4):633. doi: 10.1007/s41999-023-00812-y.]. Eur Geriatr Med. 2023;14(4):625-632. doi:10.1007/s41999-023-00777-y
      36. Seppala LJ, Petrovic M, Ryg J, et al. STOPPFall (Screening Tool of Older Persons Prescriptions in older adults with high fall risk): a Delphi study by the EuGMS Task and Finish Group on Fall-Risk-Increasing Drugs. Age Ageing. 2021;50(4):1189-1199. doi:10.1093/ageing/afaa249
      37. Lavan AH, Gallagher P, Parsons C, O'Mahony D. STOPPFrail (Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy): consensus validation. Age Ageing. 2017;46(4):600-607. doi:10.1093/ageing/afx005
      38. Hanlon JT, Schmader KE, Samsa GP, et al. A method for assessing drug therapy appropriateness. J Clin Epidemiol. 1992;45(10):1045-1051. doi:10.1016/0895-4356(92)90144-c
      39. Hanlon JT, Schmader KE. The medication appropriateness index at 20: where it started, where it has been, and where it may be going. Drugs Aging. 2013;30(11):893-900. doi:10.1007/s40266-013-0118-4
      40. Deprescribing.org. Resources for Patients and Healthcare Providers. Accessed March 17, 2025. https://deprescribing.org/resources/
      41. Canadian Medication Appropriateness and Deprescribing Network. Deprescribing algorithms. Accessed March 17, 2025. https://www.deprescribingnetwork.ca/algorithms
      42. US Deprescribing Research Network. Resources for clinicians. Accessed March 17, 2025. https://deprescribingresearch.org/resources-2/resources-for-clinicians/
      43. Primary Health Tasmania. Medication management – deprescribing. Accessed March 17, 2025. https://www.primaryhealthtas.com.au/resources/deprescribing-resources/
      44. MedStopper Beta. Accessed March 17, 2025. http://medstopper.com
      45. Nguyen M, Beier MT, Louden DN, Spears D, Gray SL. The Effect of Pharmacist-Initiated Deprescribing Interventions in Older People: A Narrative Review of Randomized Controlled Trials. Sr Care Pharm. 2023;38(12):506-523. doi:10.4140/TCP.n.2023.506
      46. Stegmann ME, Festen S, Brandenbarg D, et al. Using the Outcome Prioritization Tool (OPT) to assess the preferences of older patients in clinical decision-making: A review. Maturitas. 2019;128:49-52. doi:10.1016/j.maturitas.2019.07.022
      47. Fried TR, Tinetti M, Agostini J, Iannone L, Towle V. Health outcome prioritization to elicit preferences of older persons with multiple health conditions. Patient Educ Couns. 2011;83(2):278-282. doi:10.1016/j.pec.2010.04.032
      48. Fried TR, Tinetti ME, Iannone L, O'Leary JR, Towle V, Van Ness PH. Health outcome prioritization as a tool for decision making among older persons with multiple chronic conditions. Arch Intern Med. 2011;171(20):1854-1856. doi:10.1001/archinternmed.2011.424
      49. van Summeren JJ, Haaijer-Ruskamp FM, Schuling J. Eliciting Preferences of Multimorbid Elderly Adults in Family Practice Using an Outcome Prioritization Tool. J Am Geriatr Soc. 2016;64(11):e143-e148. doi:10.1111/jgs.14415
      50. Festen S, van Twisk YZ, van Munster BC, de Graeff P. 'What matters to you?' Health outcome prioritisation in treatment decision-making for older patients. Age Ageing. 2021;50(6):2264-2269. doi:10.1093/ageing/afab160
      51. Bain KT, Holmes HM, Beers MH, Maio V, Handler SM, Pauker SG. Discontinuing medications: a novel approach for revising the prescribing stage of the medication-use process. J Am Geriatr Soc. 2008;56(10):1946-1952. doi:10.1111/j.1532-5415.2008.01916.x

      Anticoagulation Management Pearls 2025 Revision

      About this Course

      UConn has developed web-based continuing pharmacy education activities to enhance the practice of pharmacists and assist pharmacists in making sound clinical decisions to affect the outcome of anticoagulation therapy for the patients they serve. There are a total of 17.25 hours of CPE credit available. Successful completion of these 17.25 hours (13 activities) or equivalent training will prepare the pharmacist for the Anticoagulation Traineeship, which described below in the Additional Information Box.

      The activities below are available separately for $17/hr or as a bundle price of $199 for all 13 activities (17.25 hours). These are the pre-requisites for the anticoagulation traineeship. Any pharmacist who wishes to increase their knowledge of anticoagulation may take any of the programs below.

      When you are ready to submit quiz answers, go to the Blue "Take Test/Evaluation" Button.

      Target Audience

      Pharmacists who are interested in making sound clinical decisions to affect the outcome of anticoagulation therapy for the patients they serve.

      This activity is NOT accredited for technicians.

      Pharmacist Learning Objectives

      At the completion of this activity, the participant will be able to:

      • Describe effective patient-centric anticoagulation management strategies
      • Describe the components of an effective anticoagulation education session
      • Identify barriers to patient learning
      • Apply anticoagulation stewardship in the patient anticoagulation management plan

      Release Date

      Released:  07/15/2025
      Expires:  07/15/2028

      Course Fee

      $25.50

      ACPE UAN Code

      ACPE #0009-0000-25-036-H04-P

      Session Code

      25AC36-EXW48

      Accreditation Hours

      1.5 hours of CE

      Bundle Options

      If desired, “bundle” pricing can be obtained by registering for the activities in groups. This series consists of thirteen anticoagulation activities in our online selection.

      You may register for individual topics at $17/CE Credit Hour, or for the Entire Anticoagulation Pre-requisite Series.

      Pharmacist General Registration for 13 Anticoagulation Pre-requisite activities-(18.25 hours of CE)  $199.00

      In order to attend the 2-day Anticoagulation Traineeship, you must complete all of the Pre-requisite Series or the equivalent.

      Additional Information

      Anticoagulation Traineeship at the University of Connecticut Health Center, Farmington, CT

      The University of Connecticut School of Pharmacy and The UConn Health Center Outpatient Anticoagulation Clinic have developed 2-day practice-based ACPE certificate continuing education activity for registered pharmacists and nurses who are interested in the clinical management of patients on anticoagulant therapy and/or who are looking to expand their practice to involve patient management of outpatient anticoagulation therapy. This traineeship will provide you with both the clinical and administrative aspects of a pharmacist-managed outpatient anticoagulation clinic. The activity features ample time to individualize your learning experience. A “Certificate of Completion” will be awarded upon successful completion of the traineeship.

      More Information About Traineeship

      Accreditation Statement

      ACPE logo

      The University of Connecticut, School of Pharmacy, is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit 1.5 hours (or 0.15 CEUS) for the online activity ACPE #0009-0000-25-036-H04-P will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

      Grant Funding

      There is no grant funding for this activity.

      Requirements for Successful Completion

      To receive CE Credit go to Blue Button labeled "take Test/Evaluation" at the top of the page.

      Type in your NABP ID, DOB and the session code for the activity.  You were sent the session code in your confirmation email, and it is listed on this webpage above.

      Faculty

      Youssef Bessada, PharmD, BCPS, BCCP
      Assistant Clinical Professor
      UConn School of Pharmacy
      Storrs, CT

      Faculty Disclosure

      In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

      Dr. Bessada has no relationship with an ineligible company and therefore has nothing to disclose.

      Disclaimer

      This activity may contain discussion of off label/unapproved use of drugs. The content and views presented in this educational program are those of the faculty and do not necessarily represent those of the University of Connecticut School of Pharmacy. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

      Program Content

      Program Handouts

      Post Test Evaluation

      View Questions for Anticoagulation Management Pearls

      1. The Joint Commission revised National Patient Safety Goal is intended to:
      a. Provide guidance on how to deal with providers and health systems who do not adhere to the standards
      b. Set standards on provider’s level of knowledge of anticoagulant medications
      c. Reduce the likelihood of patient harm associated with the use of anticoagulant therapy

      2. Which of the following would be a key area where using a multidisciplinary approach to anticoagulation management is necessary?
      a. Perioperative anticoagulation management
      b. Dosing warfarin in an outpatient clinic
      c. Identifying cost-barriers to DOAC management

      3. What is a practical and efficient way to ensure that DOAC dosing errors are minimized upon initiation?
      a. Implement a program where only pharmacists dose DOACs on discharge from the hospital
      b. Ensure regular updates of dosing policies & protocols with a changing clinical landscape
      c. Set an electronic medical record requirement for all DOAC discharge orders to be reviewed by the outpatient anticoagulation clinic

      4. How are clinician decision support tools best used in the anticoagulation management clinical setting?
      a. They should be leveraged to automate decision-making to reduce inter-provider variability
      b. They should be leveraged to assist decision-making using standardized protocols and pathways to minimize errors
      c. They should be leveraged to optimize decision-making and increase speed of discharges, clinic visits and decrease staff dependence

      5. Which of the following is an evidence-based benefit of utilizing a population health model to optimize anticoagulation management?
      a. Population health models have been linked to improved clinical outcomes and reduced times to intervention
      b. Population health models have been linked to automating patient monitoring to decrease the need for clinician oversight
      c. Population health models when combined with artificial intelligence will minimize the need for pharmacists in the future

      6. Which of the strategies is best when managing patients with language barriers?
      a. Ask patient to bring in family members who can help interpret
      b. Ask bilingual coworker to help interpret
      c. Use qualified interpreter

      7. Which of the following would be the most appropriate depiction of transitions of care?
      a. A transition of care anytime a patient’s clinical setting changes
      b. A transition of care is handled solely by the hospital discharge staff
      c. Provide transition of care assistance only to elderly patients who request it

      8. Which of the following statements are true regarding transitioning between anticoagulants?
      a. Transitions between anticoagulants should be done regularly to account for a patient’s changing clinical status, especially over time
      b. Literature suggests that transitioning between anticoagulants inherently increases risk of bleeding and clotting, and should be done with care
      c. All DOACs can be transitioned to and from warfarin and heparins using the same transition guidance

      Resilience vs. Resistance: Winning the Battle Against Vancomycin-Resistant Infections

      Learning Objectives

      After completing this continuing education activity, pharmacists will be able to

      •        EXPLAIN the common mechanisms of bacterial resistance and their impact on antibiotic efficacy
      •        RECOGNIZE the importance of early and effective management of resistant bacterial infections.
      •        IDENTIFY first- and second-line treatment options for VRE.

      After completing this continuing education activity, pharmacy technicians will be able to

      •        DESCRIBE proper storage, reconstitution, and other considerations for antibiotics used for resistant infections
      •        IDENTIFY strategies to prevent dispensing errors when handling antibiotics and increase awareness of high-risk medications
      •        RECOGNIZE common dosing of antibiotics used for resistant bacterial infections

      Release Date:

      Release Date:  June 5, 2025

      Expiration Date: June 5, 2028

      Course Fee

      Pharmacists: $7

      Pharmacy Technicians: $4

      There is no grant funding for this CE activity

      ACPE UANs

      Pharmacist: 0009-9999-25-07-H01-P

      Pharmacy Technician: 0009-9999-25-007-H01-T

      Session Codes

      Pharmacist: 25UC07-CBA96

      Pharmacy Technician: 25UC07-BAC49

      Accreditation Hours

      0.5 hours of CE

      Accreditation Statements

      The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit for the online activity ACPE UAN 0009-9999-25-007-H01-P/T  will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

       

      Disclosure of Discussions of Off-label and Investigational Drug Use

      The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

      Faculty

       

      Dominic Biello, PharmD,
      PGY-1 Resident
      UConn Health Center
      Farmington, CT

      Gillian Kuszewski, PharmD, BCPS, FCPA,
      Antimicrobial Stewardshhip Co-Chair
      UConn Health Center
      Farmington, CT

      Jenny Zhao, PharmD,
      PGY-1 Resident
      UConn Health Center
      Farmington, CT

      Faculty Disclosure

      In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

      Drs. Biello, Kuszewski and Chan and  have no relationships with ineligible companies and therefore have nothing to disclose.

       

      CONTENT

      Content

      Download PDF of Handouts

      Pharmacist Post Test (for viewing only)

      Pharmacist Learning Objectives:
      1. Explain the common mechanisms of bacterial resistance and their impact on antibiotic efficacy
      2. Recognize the importance of early and effective management of resistant bacterial infections
      3. Identify first- and second-line treatment options for vancomycin resistant enterococci (VRE)

      Pharmacist Questions:
      1. How do enterococci develop resistance to vancomycin?
      a. The terminus of the peptidoglycan cell wall changes
      b. Production of enzymes inactivate vancomycin
      c. Decreased outer membrane permeability

      2. What prevention strategy involves early and effective therapy intervention?
      a. Chlorhexidine bathing
      b. Environmental cleaning
      c. Antimicrobial Stewardship

      3. Common enterococcal infection sites include the urinary tract, bloodstream, heart, and intra-abdominal space. What is the recommended first line agent for infective endocarditis?
      a. High dose ampicillin
      b. Linezolid
      c. Tigecycline

      4. Which prevention strategy can reduce the risk of VRE by addressing the risk factor of transmission through healthcare workers?
      a. In vitro susceptibility testing
      b. Hand hygiene
      c. Active surveillance

      5. The most common phenotype seen in VRE isolates is Van A. What mechanism of resistance is the VanA phenotype responsible for?
      a. Increasing the efflux of antibiotics
      b. Ribosomal protection
      c. Changes in peptidoglycan cell wall

      6. A provider calls the pharmacy asking for antibiotic recommendations for a bloodstream infection (bacteremia) growing gram positive cocci. The patient has a history of enterococcal bacteremia previously treated with antibiotics. What antibiotic should be recommended to the provider?
      a. Ampicillin 2g every 4 hours
      b. Daptomycin 8-12 mg/kg once daily
      c. Nitrofurantoin 100mg twice daily

      Pharmacy Technician Post Test (for viewing only)

      Resilience vs Resistance:
      Winning the Battle Against Vancomycin-Resistant Infections
      Pharmacy Technician Learning Objectives:
      1. Describe proper storage, reconstitution, and other considerations for antibiotics used for resistant infections
      2. Identify strategies to prevent dispensing errors when handling antibiotics and increase awareness of high-risk medications
      3. Recognize common dosing of antibiotics used for resistant bacterial infections

      Pharmacy Technician Questions:
      1. A patient is receiving daptomycin 400 mg IV every 24 hours. As a technician, you want to compound today’s dose as well as tomorrow’s dose. Is this appropriate?
      a. Yes, reconstituted solutions of daptomycin are stable at room temperature for up to 48 hours
      b. No, reconstituted solutions of daptomycin are stable at room temperature for up to 12 hours
      c. No, reconstituted solutions of daptomycin are stable at room temperature for up to 5 hours

      2. What is a potential strategy to prevent medication dispensing errors?
      a. Build a culture that encourages error reporting
      b. Reducing the number of medications dispensed daily
      c. Require pharmacist double checks on every medication dispensed

      3. You see a label print for oritavancin. What would be an appropriate dosing you would expect to see?
      a. 1200 mg IV once
      b. 1200 mg IV every 12 hours
      c. 1200 mg IV every 24 hours

      4. Linezolid is reconstituted in the morning for patient administration. The nurse is unable to administer the medication because the patient is in the OR. How, and for how long can linezolid be stored after reconstitution?
      a. Store at room temperature 20ºC to 25ºC (68ºF to 77ºF) for up to 24 hours
      b. Store at room temperature 20ºC to 25ºC (68ºF to 77ºF) for up to 12 hours
      c. Store at room temperature 20ºC to 25ºC (68ºF to 77ºF) for up to 21 days

      5. Which of the following describes the medication dispensing error prevention strategy, encouraging error reporting?
      a. Calling a patient’s pharmacy to confirm dispense history
      b. Scanning the vial or patient label before administration
      c. Filling out safety incident paperwork

      6. What is a reasonable renally adjusted dose for tedizolid?
      a. Tedizolid does not need to be renally adjusted
      b. 200 mg IV or PO every 48 hours
      c. 100 mg IV or PO every 24 hours

      Pain Management: Relief Reimagined: Pain Strategies for Patients Battling Opioid Use Disorder (OUD)

      Learning Objectives

       

      After completing this continuing education activity, pharmacists and pharmacy technicians will be able to

      •        DESCRIBE pathophysiology of pain, OUD, and how both interact.
      •        EXPLAIN OUD prevalence, risk factors, and common etiologies.
      •        DISCUSS treatment strategies for pain management in those with OUD.

       

      Release Date:

      Release Date:  May 8, 2025

      Expiration Date: May 8, 2028

      Course Fee

      Pharmacists: $7

      Pharmacy Technicians: $4

      There is no grant funding for this CE activity

      ACPE UANs

      Pharmacist: 0009-9999-25-06-H08-P

      Pharmacy Technician: 0009-9999-25-006-H08-T

      Session Codes

      Pharmacist: 25UC06-ABC24

      Pharmacy Technician: 25UC06-XYZ48

      Accreditation Hours

      0.5 hours of CE

      Accreditation Statements

      The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit for the online activity ACPE UAN 0009-9999-25-006-H08-P/T  will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

       

      Disclosure of Discussions of Off-label and Investigational Drug Use

      The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

      Faculty

       

      Molly Csere, PharmD
      PGY-1 Resident
      UConn Health Center
      Farmington, CT

      Megan Mitchell, PharmD, MS
      Pharmacy Clinical Coordinator Pain Management and Palliative Care
      UConn Health Center
      Farmington, CT

      Mariam Zedan, PharmD,
      PGY-1 Resident
      UConn Health Center
      Farmington, CT

      Faculty Disclosure

      In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

      Drs. Csere, Mitchell and Zedan have no relationships with ineligible companies and therefore have nothing to disclose.

       

      CONTENT

      Content

      Download PDF of Handouts

      Pharmacist Post Test (for viewing only)

      CE Title: Pain Management: Relief Reimagined - Pain Strategies for Patients Battling Opioid Use Disorder (OUD)
      Pharmacist Post-Test

      Learning Objectives:
      1. Explain OUD prevalence, risk factors, and common etiologies
      2. Describe pathophysiology of pain, OUD, and how both interact
      3. Discuss treatment strategies for pain management in those with OUD

      1. Which of the following is considered a risk factor for Opioid Use Disorder?
      a. Previous diagnosis of bipolar disorder
      b. Family history of migraines
      c. Social norms discouraging substance use

      2. Which of the following is most likely to occur with continued use of opioids?
      a. Deregulation of pain, touch, and temperature receptors
      b. Physical and chemical changes in the brain
      c. Strengthening pain pathways in the brain

      3. Which medication has the highest receptor binding affinity (lowest Ki value)?
      a. Oxycodone
      b. Fentanyl
      c. Buprenorphine

      4. Which of the following risks increase when initiating opioid detoxification without initiating a medication for OUD?
      a. Resumed drug use
      b. Financial burden
      c. Social alienation

      5. Which of the following receptors is most associated with opioid pathophysiology?
      a. Beta-1
      b. Mu
      c. Alpha

      6. Compared to the duration of occupation at the receptor level, the duration of analgesia of buprenorphine is:
      a. Longer
      b. The same
      c. Shorter

      Pharmacy Technician Post Test (for viewing only)

      Pharmacy Technician Post-Test
      Learning Objectives:
      1. Explain OUD prevalence, risk factors, and common etiologies
      2. Describe pathophysiology of pain, OUD, and how both interact
      3. Discuss treatment strategies for pain management in those with OUD

      1. Patients with Opioid Use Disorder have an increased risk of:
      a. Falls and drowning
      b. Community-acquired pneumonia
      c. Road traffic tickets

      2. Which of the following senses are involved in the pathways that opioids block?
      a. Taste
      b. Temperature
      c. Balance

      3. Which of the following medication options for OUD is available in a sublingual formulation?
      a. Buprenorphine
      b. Methadone
      c. Naltrexone

      4. Which of the following risks increase when initiating opioid detoxification without starting a medication for OUD?
      a. Resumed drug use
      b. Financial burden
      c. Social alienation

      5. Which of the following receptors is most associated with opioid pathophysiology?
      a. Beta-1
      b. Mu
      c. Alpha

      6. Compared to the duration of occupation at the receptor level, the duration of analgesia of buprenorphine is:
      a. Longer
      b. The same
      c. Shorter

      Carbidopa-Levodopa: Revving Up Relief – Choose Your Formula!

      Learning Objectives

      After completing this continuing education activity, pharmacists will be able to

      •      DESCRIBE the role of carbidopa-levodopa in Parkinson's disease and the use of different carbidopa-levodopa formulations
      •      RECOGNIZE the differences between each carbidopa-levodopa formulation
      •      DISCUSS the appropriate patient who may benefit from transitioning to a different formulation of carbidopa-levodopa

      After completing this continuing education activity, pharmacy technicians will be able to

      •        DESCRIBE the functions of the carbidopa-levodopa and how it aids in treatment for patients with Parkinson's disease
      •        LIST different forms of carbidopa-levodopa
      •        IDENTIFY when to refer patients with questions about Parkinson's disease to a pharmacist

      Release Date:

      Release Date:  June 13, 2025

      Expiration Date: June 13, 2028

      Course Fee

      Pharmacists: $7

      Pharmacy Technicians: $4

      There is no grant funding for this CE activity

      ACPE UANs

      Pharmacist: 0009-9999-25-08-H01-P

      Pharmacy Technician: 0009-9999-25-008-H01-T

      Session Codes

      Pharmacist: 25UC08-TXJ88

      Pharmacy Technician: 25UC08-PJK42

      Accreditation Hours

      0.5 hours of CE

      Accreditation Statements

      The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit for the online activity ACPE UAN 0009-9999-25-008-H01-P/T  will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

       

      Disclosure of Discussions of Off-label and Investigational Drug Use

      The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

      Faculty

       

      Constance Chan, PharmD
      PGY-2, Ambulatory Care Pharmacist
      UConn Health Center
      Farmington, CT

      Kaitlyn Elliott, PharmD
      Pharmacy Clinical Coordinator
      UConn Health Center
      Farmington, CT

      Braylee Wardwell, PharmD
      PGY-2, Ambulatory Care Pharmacist
      UConn Health Center
      Farmington, CT

      Faculty Disclosure

      In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

      Drs. Chan, Elliott and Wardwell and  have no relationships with ineligible companies and therefore have nothing to disclose.

       

      CONTENT

      Content

      Download PDF of Handouts

      Pharmacist Post Test (for viewing only)

      Carbidopa-Levodopa: Revving Up Relief – Choose Your Formula! Pharmacist Test
      Learning Objectives: Pharmacists
      • Describe the role of carbidopa-levodopa in Parkinson’s disease and the use of different carbidopa-levodopa formulations
      • Recognize the differences between each carbidopa-levodopa formulation
      • Discuss the appropriate patient who may benefit from transitioning to a different formulation of carbidopa-levodopa

      Knowledge Questions
      1. What is the primary role of carbidopa-levodopa in the management of Parkinson's disease?
      a. Carbidopa and levodopa directly increase dopamine production in the brain
      b. Levodopa converts to dopamine in the brain, and carbidopa prevents its breakdown
      c. Carbidopa and levodopa work by inhibiting the breakdown of dopamine in the brain

      2. Which of the following factors can lead to reduced efficacy of carbidopa-levodopa in treating Parkinson’s disease?
      a. Decreased dopamine receptors in advanced disease stages
      b. Increased carbidopa leading to less peripheral conversion of levodopa
      c. Lowering the carbidopa-to-levodopa ratio to reduce side effects

      3. How does the formulation of carbidopa-levodopa controlled-release differ from the immediate-release version?
      a. It increases peak dopamine levels in the brain
      b. It reduces the amount of carbidopa needed to enhance levodopa absorption
      c. It provides a slower, more continuous release of levodopa

      4. What is a key difference between carbidopa-levodopa IR and foscarbidopa-foslevodopa?
      a. Carbidopa-levodopa IR causes peaks and troughs of levodopa, foscarbidopa-foslevodopa is formulated to give more consistent levodopa
      b. Carbidopa-levodopa IR is dosed once daily, while foscarbidopa-foslevodopa is dosed multiple times daily
      c. Carbidopa-levodopa IR is dosed using levodopa concentration levels, foscarbidopa-foslevodopa is dosed using carbidopa concentration levels

      5. Which of the following is a reason why we should consider switching a patient’s carbidopa-levodopa IR to carbidopa-levodopa ER (Crexont)?
      a. Patient is not experiencing “off” time
      b. Patient is experiencing “off” time ≥2.5 hours
      c. Patient is experiencing “on” time ≥2.5 hours

      6. AL is a 55-year-old with Parkinson’s disease. He takes carbidopa-levodopa IR 25mg/100mg two tablets four times daily. He has a hard time with his current number of pills and breakthrough symptoms between doses. Which of the following alternative dose of carbidopa-levodopa would be appropriate for AL?
      a. Carbidopa-levodopa ER (Crexont) 420mg three times daily
      b. Carbidopa-levodopa ER (Rytary) 195mg twice daily
      c. Foscarbidopa-foslevodopa (Vyalev) 0.27mg/hr

      Pharmacy Technician Post Test (for viewing only)

      Carbidopa-Levodopa: Revving Up Relief – Choose Your Formula! Technician Test

      Learning Objectives: Technicians
      • DESCRIBE the functions of the carbidopa-levodopa and how it aids in treatment for patients with Parkinson’s disease
      • LIST different forms of carbidopa-levodopa
      • IDENTIFY when to refer patients with questions about Parkinson’s disease to a pharmacist

      Knowledge Questions
      1. What is the primary role of carbidopa-levodopa in the management of Parkinson's disease?
      a. Carbidopa and levodopa directly increase dopamine production in the brain
      b. Levodopa converts to dopamine in the brain, and carbidopa prevents its breakdown
      c. Carbidopa and levodopa work by inhibiting the breakdown of dopamine in the brain

      2. Which of the following factors can lead to reduced efficacy of carbidopa-levodopa in treating Parkinson’s disease?
      a. Decreased dopamine receptors in advanced disease stages
      b. Increased carbidopa leading to less peripheral conversion of levodopa
      c. Lowering the carbidopa-to-levodopa ratio to reduce side effects

      3. How does the formulation of carbidopa-levodopa in Sinemet CR differ from the immediate-release version?
      a. It increases peak dopamine levels in the brain
      b. It reduces the amount of carbidopa needed to enhance levodopa absorption
      c. It provides a slower, more continuous release of levodopa

      4. Which of the following are approved dosage forms of carbidopa-levodopa?
      a. Sublingual tablets and extended-release capsules
      b. Intravenous infusion and immediate-release tablets
      c. Extended-release capsules and subcutaneous infusion

      5. Which of the following is a reason a patient may discuss with a pharmacist about switching from carbidopa-levodopa IR to carbidopa-levodopa ER (Crexont)?
      a. Patient is not experiencing “off” time
      b. Patient is experiencing “off” time >2.5 hours
      c. Patient is experiencing “on” time >2.5 hours

      6. Which of the following patients should be sent to pharmacist counsel window?
      a. Patient with questions about drug interactions between CD-LD IR and antibiotics
      b. Patient with questions about cost of CD-LD ER (Crexont) with their new insurance
      c. Patients with questions about putting their PD medications on automatic refill

      Patient Safety: Catch Me if You Can: Medication Errors and Their Impact

      Learning Objectives

       

      After completing this application-based continuing education activity, pharmacists will be able to

      1.     Describe details of common medication errors in hospital and community pharmacies
      2.     Differentiate between categories of medication errors
      3.     Calculate medication error rates
      4.     List approaches to learn from and prevent medication errors

      After completing this application-based continuing education activity, pharmacy technicians will be able to

      1.     Describe details of common medication errors in hospital and community pharmacies
      2.     Differentiate between categories of medication errors
      3.     Calculate medication error rates
      4.     List approaches to learn from and prevent medication errors

      A cartoon hand holding a cartoon figure with a circle head that contains a plus-sign in its center.

      Release Date:

      Release Date: June 15, 2025

      Expiration Date: June 15, 2028

      Course Fee

      $7 Pharmacist

      $4 Pharmacy Technician

      ACPE UANs

      Pharmacist: 0009-0000-25-035-H05-P

      Pharmacy Technician: 0009-0000-25-035-H05-T

      Session Codes

      Pharmacist: 25YC35-JWN25

      Pharmacy Technician: 25YC35-NWJ25

      Accreditation Hours

      2.0 hours of CE

      Accreditation Statements

      The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.  Statements of credit for the online activity ACPE UAN 0009-0000-25-035-H05-P/T  will be awarded when the post test and evaluation have been completed and passed with a 70% or better. Your CE credits will be uploaded to your CPE monitor profile within 2 weeks of completion of the program.

       

      Disclosure of Discussions of Off-label and Investigational Drug Use

      The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

      Faculty

      Mona El-Mouwfi, BS, PharmD Candidate 2026
      UConn School of Pharmacy
      Storrs, CT

      Jeannette Y. Wick, RPh, MBA, FASCP
      Director, Office of Pharmacy Professional Development
      UConn School of Pharmacy
      Storrs, CT

      Faculty Disclosure

      In accordance with the Accreditation Council for Pharmacy Education (ACPE) Criteria for Quality and Interpretive Guidelines, The University of Connecticut School of Pharmacy requires that faculty disclose any relationship that the faculty may have with commercial entities whose products or services may be mentioned in the activity.

      Ms. Wick and Ms. El Mouwfi have no relationships with ineligible companies and therefore have nothing to disclose.

       

      ABSTRACT

      Statisticians and risk managers widely consider medication errors to be the most preventable and most common cause of patient injury. By understanding common error scenarios, implementing safety protocols, and leveraging technology, pharmacy professionals can actively reduce risks and enhance the quality of care. This continuing education activity is designed to empower pharmacy professionals with the knowledge and tools needed to understand, measure, and address medication errors effectively.

      CONTENT

      Content

      INTRODUCTION

      Ray and Kai are pharmacists that work together in a very busy outpatient clinic pharmacy. On a typical day, they fill around 800 prescriptions, and they usually have help from three technicians. Unfortunately, if anyone calls out sick or with an emergency, they don't have backup coverage.

       

      Several times a week, patients return to the pharmacy and indicate that the prescriptions they received don't seem to be correct. Occasionally, Ray and Kai discover a medication error when patients indicate that their tablets or capsules don't look the same as a previous refill. Just yesterday, a mother returned to the pharmacy because her child’s liquid amoxicillin/clavulanate ran out before it should have. When Kai examined the label, she found a typographical error; it said, “take 5 mL three times a day” when it should have said, “take 2.5 mL three times a day.”

       

      When staff members in this pharmacy identify medication errors, they usually discuss the problem quietly with the involved staff and make a mental note to implement corrective action or pay closer attention. Their pharmacy’s workload, staffing, error rate, and method of dealing with medication errors is not much different than many pharmacies across our nation. Throughout this continuing education activity, this example and others will help learners apply the lessons that experts have learned from analyzing medication errors.

       

      Patient safety is a cornerstone of quality healthcare, and pharmacy professionals have an obligation to ensure patients receive safe and effective medications. Medication errors often stem from communication gaps, system complexities, or improper medication use. These errors not only compromise patient outcomes but also contribute to increased healthcare costs and increase risks of medication-related adverse effects.1

       

      The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) tallies and analyzes medication error reports from the National Medication Errors Reporting Program, which is administered by the Institute for Safe Medication Practices (ISMP). NCC MERP defines a medication error as “any preventable event that may cause or lead to inappropriate medication use or patient harm.” Medication errors occur at various stages of the medication-use process, from prescribing and dispensing to administration and monitoring.2 Recognizing these errors and implementing prevention strategies are essential to improving patient safety and advancing pharmacy practice.

       

      OVERVIEW OF MEDICATION ERRORS

      To truly appreciate medication errors’ impact on patients, pharmacy team members must recognize common terms and types of errors.

       

      Medication Error Terminology

      Several medication errors can arise in clinical and retail settings. To actively prevent patient injury through medication errors, it is important to know what to look for in practice. Terms to be familiar with in all pharmacy practice settings include3,4:

      • Adverse drug event (ADE): An injury resulting from medical intervention related to a drug
      • Adverse drug reaction (ADR): An unintended reaction occurring at the intended drug dose
      • High-alert medications: Drugs that bear a heightened risk of causing significant patient harm when used in error
      • Look-alike/sound-alike (LASA) medications: Medications with similar-looking or similar-sounding names and/or shared features of products or packaging, leading to potential confusion
      • Medication reconciliation: The process of creating the most accurate list possible of all medications a patient is taking—including drug name, dosage, frequency, and route—and comparing that list against the physician's admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points

       

      PAUSE AND PONDER: When an error is identified, how does your pharmacy respond?

       

      Defining and Classifying Medication Errors

      Table 1 lists common medication errors that may occur throughout the stages of medication use.4

      Table 1. Common Medication Errors4

      Error Type Description Examples
      Prescribing Errors occurring when ordering medication Wrong drug selection, incorrect dose/frequency, illegible handwriting, incomplete prescription, drug interactions
      Dispensing Errors occurring during medication preparation and distribution Wrong medication, wrong strength, wrong dosage form, incorrect labeling, look-alike/sound-alike drug confusion
      Administration Errors occurring during drug administration to the patient Wrong route, wrong dose, wrong rate, omission, administering to the wrong patient
      Monitoring Errors occurring due to lack of proper patient monitoring Failure to monitor for adverse effects, inadequate lab test follow-up, failure to adjust dose for renal/hepatic function

       

      Most medication errors are preventable and can also be classified by the severity of their impact on the affected patient. Leading organizations, such as NCC MERP, have developed taxonomies to classify medication errors in more detail, including nine categories labeled A through I. These categories range from circumstances that have the capacity to cause error (Category A) to errors that result in patient death (Category I). While categories E through I describe varying degrees of harm to the patient, categories A through D involve situations with no patient harm. These classifications help institutions analyze trends and implement targeted interventions.5

       

      Figure 1 displays NCC MERP’s medication error classifications with severity levels increasing from top to bottom.5

       

      Figure 1. Medication Error Classification5

       

      A patient comes in to pick up a prescription at Ray and Kai’s pharmacy and the line is out the door. As Kai retrieves the medication, she quickly confirms the patient’s last name and date of birth. Ray knows the patient and greets him; “Hey Charlie, how are the kids?” Kai then realized the prescription in hand was meant for a different patient by the name of Billy and was in the same bin. The correct medication is retrieved, and the patient safely receives what was actually prescribed, resulting in a near miss, rather than a full medication error.

       

      Later, Ray and Kai sit down to reflect on what could have happened if the mistake hadn’t been caught in time. If the pharmacy dispensed the wrong medication and the patient noticed and brought it back before taking it, this would be an error, no harm situation. However, if the patient took the incorrect medication and experienced harmful adverse effects, it would result in an error, harm situation. In a more severe scenario, if the patient took the wrong medication and had an allergic reaction or other fatal outcome, it would be considered error, death. After discussion, Ray and Kai decide to speak to the staff about the importance of verifying patient information in full at every encounter. They relay a PRO TIP: employees can place prescriptions for patients with similar names in separate bins to avoid confusion.

       

      Even the smallest and most routine tasks, such as verifying a patient’s identity, carry immense responsibility. Every action performed in a pharmacy setting has a direct impact on patient health. A moment of inattention or a skipped step can be the difference between preventing harm and causing irreversible consequences. That’s why it is crucial to approach every task, no matter how routine, with full attention and diligence

       

      Beyond preventing individual mistakes, classifying and analyzing medication errors is a key to improving patient care on a larger scale. Recognizing and labeling these errors—whether they are near misses, errors with no harm, or more serious mistakes—provides valuable insight into when and where they happen. By identifying patterns, pharmacies can implement targeted safety measures to minimize risks.4,5

       

      ANALYSE, DOCUMENT, PREVENT

      Medication Error Rates

      To identify and reduce medication errors effectively, individuals and institutions must track their occurrences systemically. One of the most effective ways to achieve this is by calculating the medication error rate, which provides valuable insight into areas requiring improvement.6 The formula for calculating the medication error rate is as follows:

      <<ADD IMAGE>>

       

      The numerator represents the total number of medication errors recorded during a given period, with each error event counted as one. The denominator consists of all medication orders or doses that were dispensed and administered.6 This formula applies across all pharmacy settings, including both community and hospital environments.

       

       

      For example, a hospital pharmacy dispenses 100,000 doses in a month and identifies 50 medication errors in that month. What is the medication error rate?

       

      Once calculated, error rates are a crucial tool for identifying trends and implementing targeted interventions. By analyzing the data, healthcare teams can pinpoint high-risk areas, set measurable goals, and put corrective measures into action to minimize errors. This proactive approach not only enhances patient safety; it also optimizes pharmacy workflow and overall efficiency.

       

      The pharmacy where Ray and Kai work is accredited. During an accreditation audit, one of the surveyors asks Ray about their medication error rate. Ray is unable to answer. The surveyor pushes a little and asks Ray to provide copies of all incident reports regarding medication errors. Ray finds two or three in which the medication error was serious enough to attract attention from the clinical staff or the clinic's risk manager. When the surveyor explains how to calculate a medication error rate, Ray listens carefully. Needless to say, the surveyor noted the lack of documentation about medication errors as a deficit in the survey and indicated that she did not believe that they only had three medication errors in the past year. When Ray and Kai meet to plan corrective action, they realize that without good documentation, they cannot make this calculation.

       

      To ensure accuracy and reliability, all pharmacy and healthcare organizations must foster a culture of transparency and promote non-punitive error reporting.6,7 Management must encourage staff to report errors without fear of retribution, allowing institutions to collect comprehensive data and develop effective mitigation strategies. Hospitals and community pharmacies can gain valuable insight into their performance by benchmarking their calculated error rates against institutions of similar size and complexity. Comparing rates with national standards or similar organizations helps ensure adherence to best practices and provides insight into additional potential interventions.7

       

      Documenting Medication Errors

      Pharmacists and technicians should know how to document and report incidents that occur in their pharmacy properly, usually following policies or procedures put in place by their institution and legal regulations. Unusual incident reports (UIRs) are a formal mechanism for documenting clinically significant medication errors and near misses.

       

      Following identification of an incident and corrective patient measures, all relevant personnel should be notified and asked to record their recall of events. These reports should include key details such as who was involved, when and where the incident occurred, type of error, contributing factors, and corrective actions taken.8 To prevent recurrence of an incident or find a systemic issue leading to incidents, errors should regularly be recorded regardless of severity or whether it reached the patient or not. A PRO TIP is to maintain a list of errors that should be documented and keep unused UIRs in an accessible place (e.g., pinned on all desktops or stored in designated folders), encouraging staff to fill them out. These forms should be completed in full and a PRO TIP is to include instructions on what steps to take following the incident (i.e., read over and include any forgotten details, ensure all relevant staff is notified). Investigative staff should thoroughly gather data pertaining to the incident, including records, UIRs, patient notes, and physical items used in the event.9 Staff should establish a clear chronology of events to determine the root cause and prevent future occurrences.

       

      Pharmacists and technicians should be well-versed in properly documenting and reporting incidents in their pharmacy, usually following institutional policies and legal regulations. UIRs serve as a formal mechanism for recording clinically significant errors and near misses. The following steps are necessary for proper documentation and reporting8-10:

      1. Identify and respond to the incident
        • When an error or near miss occurs, prioritize patient safety by taking corrective actions and notify all relevant personnel, including leadership.
      2. Thoroughly document the incident
        • UIRs should capture key details such as
          1. who was involved
          2. when and where the incident occurred
          3. type of error and contributing factors
          4. corrective actions taken and follow-up measures
        • All involved personnel should document their recollection of events promptly to ensure accuracy.
      3.  Encourage consistent reporting
        • To prevent recurrences and identify systemic issues, all errors—regardless of patient impact severity—should be recorded.
        • PROTIP: Maintain a list of errors that must be documented and keep unused UIRs easily accessible (i.e., pinned on desktops or stored in a designated folder) to encourage completion.
        • Forms should be fully completed, and staff should review their entries for accuracy before submission.
      4.  Investigate and analyze the incident
        • Investigative staff should collect all relevant data, including UIRs, records, forms, and any physical items used in the event.
        • Establish a clear chronology of events to determine the root cause and prevent future occurrences.

               

              UIRs are considered Quality Improvement data in healthcare organizations, making them confidential and generally protected from disclosure under laws like the Patient Safety and Quality Improvement Act.11 Organizations use these reports internally to enhance patient safety and do not share them with patients or lawyers. However, protection can vary based on state laws and institutional policies, so a PRO TIP for organizations would be to highlight their specific policies and require additional training and separate filings to ensure proper procedures to maintain confidentiality.

               

              Individuals must report serious medication errors resulting in patients harm or regulatory violations to state boards of pharmacy and should also report them to accreditation agencies (e.g., Joint Commission) and the FDA through the MedWatch program.8 Pharmacy personnel is expected to know how and when to use institution-specific forms and to revise these to simplify and encourage the error reporting process.

               

              Ray and Kai are motivated to track medication errors better. When they dust off their stack of unused UIR forms, they realize that their forms are skeletal and their organization would benefit from a better tool. One of their technicians, Tara, volunteers to look at a number of different forms and identifies four. The staff chooses to “pilot” two, meaning they will document all medication errors that occur over the next three weeks on both forms, and then analyze the results. At the end of the pilot, they choose one form but realize that they need to tailor it to their practice. Tara also notes that they could automate the form and include a picture of the dosage forms that were involved.

               

              Within three months, Ray and Kai realize from the pictures that a full 25% of their errors involve tablets that are white. Ray and Kai can share a PRO TIP with other organizations now. They create a whiteboard that lists most of their white tablets and the tablet markings. The technicians who handle inventory update the whiteboard when they change generics. Additionally, whenever Ray or Kai visually verify a prescription for a white tablet, they note the tablet marking on the prescription. In this way, they eliminate a good number of errors.

               

              Institutions may have different methods for documenting unusual incidents, so it is essential that pharmacy staff know how to access and properly complete these forms. Keeping UIR forms up to date ensures they remain effective and relevant. Attached are three different incident report forms; review them carefully and identify their similarities and differences (see Appendix).12-14

               

              Accurate medication error reporting is the underpinning of identifying risks and improving patient safety. However, traditional error-reporting systems often capture only a portion of actual incidents and do not usually account for adverse effects. This could be attributed to limitations in error-reporting, including but not limited to underreporting due to fear of punishment, time-consuming processes, and a lack of feedback and follow-up.15 Research suggests that the use of observation, when appropriate and feasible, could lead to more accurate detection of medication errors in practice.16,17 When applicable, institutions can use observation in combination with tracking error reports and greatly reduce the frequency of medication errors.

               

              A strong culture of safety in pharmacy practice encourages transparent error reporting and non-punitive responses. Employees should feel comfortable reporting mistakes without fear of disciplinary action, as this fosters a learning environment rather than a blame culture. Encouraging reporting allows institutions to7,18

              • identify error trends and implement preventative measures
              • provide additional training where needed
              • improve medication safety policies and procedures

               

              All people in positions of authority should encourage pharmacy personnel to report medication errors to their institutions and to the FDA, ISMP, or NCC MERP if appropriate.19

               

              System-Based Prevention Approaches

              Healthcare institutions implement structured systems to enhance workflow efficiency and minimize medication errors. These systems provide standardized protocols, technological advancements, and communications strategies that help pharmacy personnel ensure safe and accurate medication dispensing and administration.

               

              With advancements in technology, healthcare professionals frequently rely on automated systems to assist with medication safety. While these tools greatly reduce the potential for human error, they should be used to complement, not replace, pharmacist and technician expertise. Proper training and implementation of these tools are essential to their effectiveness. Key technologies that reduce medication errors include the following18,20,21:

              • Barcode scanning as an additional verification step in the dispensing and administration process ensures that the correct drug, dose, and patient matches the prescription and manufacturer specifications.
              • Computerized provider order entry (CPOE) and e-prescribing reduce errors by eliminating the risk of misinterpreting handwritten prescriptions. CPOE also alerts prescribers about potential drug interactions, allergies, and dosing errors before orders are processed.
              • Automated dispensing cabinets, commonly used in hospitals, help regulate medication storage, access, and tracking to prevent unauthorized or incorrect dispensing.

               

              To maximize these systems’ effectiveness, pharmacy staff must remain vigilant, ensuring that they do not blindly trust automation. As recommended by the ISMP, conducting manual double-checks judiciously, selective to certain high-risk tasks or medications, can further enhance patient safety.22

               

              Familiarizing all staff with institutional standard operating procedures (SOPs) is essential for ensuring consistent and safe practice. These guidelines outline step-by-step procedures for specific pharmacy operations, reducing deviations that could lead to medication errors.23 When adhered to properly, SOPs standardize processes (minimizing variability and human error), provide clear instructions for handling high-alert medications, and outline best practices for prescription verification, dispensing, and patient counseling.21,23 For example, a hospital SOP may require two licensed healthcare professionals to verify chemotherapy doses independently before administration. In a community pharmacy, an SOP may require mandatory counseling for first-time prescriptions of high-risk medications, such as opioids or anticoagulants. Having SOPs and checklists readily accessible ensures that pharmacy personnel can reference best practices quickly when dealing with complex or high-risk situations.

               

              SIDEBAR: A Word About CHECKLISTS

              When checklists are numerous in quantity and poor in design, pharmacy staff may experience a sense of checklist fatigue, becoming overwhelmed and disengaged with completing them. This could lead to rushed or skipped steps, negatively impacting performance and patient safety. The following lists some strategies to avoid feeling desensitized to the repetitive nature of checklists22,24,25:

              • Use checklists selectively by focusing on the most important or highest-risk tasks
              • Improve the design to be clear, concise, and easy to follow
              • Avoid unnecessary or redundant steps
              • Regularly ensure the checklists are up-to-date and effective
              • Address fatigue with staff and provide training and feedback on the importance of each step

               

              PAUSE AND PONDER: When reviewing a prescription, what red flags should prompt you to double check with a prescriber, pharmacist, or colleague?

               

              PHARMACY PRACTICE CONSIDERATIONS

              Each pharmacy practice type has its own unique concerns and considerations with regard to medication error reporting.

               

              Community Pharmacy

              In a retail or clinic pharmacy setting, like the one in which Ray and Kai work, pharmacists and pharmacy technicians must exercise caution throughout the prescription filling process to prevent errors. These errors can be minor and initially go unnoticed, but can lead to serious adverse events, hospitalizations, or even fatalities if not promptly identified and addressed.26

               

              The first stage of medication processing—receiving a prescription—creates a significant risk for errors. Whether prescriptions are transmitted electronically, by phone, or handwritten, pharmacy personnel may misread, misinterpret, or fail to recognize important details.27 Especially in high-volume settings, healthcare professionals should prioritize accuracy by seeking prescriber clarification when needed, rather than making assumptions or rushing through interpretation.  Errors can also originate from prescribers, and pharmacy personnel should have a high index of suspicion that every prescription is incorrect. Calling to clarify questionable doses or frequencies ensures patient safety and may also prompt prescribers to recognize and correct unintended mistakes.26 All three errors that Ray and Kai documented had been serious enough to result in an ADE or ADR. When they looked back at these errors, they realized that for two of them, if they had questioned the patients or called the prescribers, the errors may have been avoided entirely.

               

              Common errors that pharmacists and technicians should be vigilant about in community pharmacy include1,3,27,28

              • Misinterpreting abbreviations and symbols: Sloppy abbreviations and symbols can lead to dangerous dosing errors. Table 2 summarizes the Joint Commission’s “DO NOT USE” list of abbreviations that should be displayed in pharmacies.
              • LASA medications: Medications with similar names can be easily confused if not carefully verified.
              • Incorrect dosing and strength selection: Errors can occur by selecting the wrong strength of a medication or miscalculating pediatric or weight-based doses.

               

              Table 2. The Joint Commission’s “DO NOT USE” List28

              Do Not Use Potential Problem Use Instead
              U, u Mistaken for “0” (zero), the number “4” (four) or “cc” Write “unit
              IU Mistaken for IV (intravenous) or the number 10 (ten) Write “International Unit”
              Q.D., QD, q.d., qd

               

              Q.O.D., QOD, q.o.d., qod

              Mistaken for each other

               

              Period after the Q mistaken for “I” and the “O” mistaken for “I”

              Write “daily”

               

              Write “every other day”

              Trailing zero (X.0 mg) *

              Lack of leading zero (.X mg)

              Decimal point is missed Write X mg

              Write 0.X mg

              MS

               

              MSO4 and MgSO4

              Can mean morphine sulfate or magnesium sulfate

               

              Confused for one another

              Write “morphine sulfate”

               

              Write “magnesium sulfate”

              *Exception: A trailing zero is only allowed when necessary to indicate the exact level of precision, such as in laboratory results, imaging studies that report lesion sizes, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.

               

              Maintaining readily accessible reference lists can help pharmacy personnel cross-check potential medication errors before contacting prescribers. The ISMP has identified numerous LASA pairs that contribute to medication errors and has created lists of commonly confused abbreviations and symbols.29 Additionally, using TALL Man lettering (e.g., capitalizing part of a drug's name in upper case letters to differentiate similar drug names like hydrALAzine vs hydrOXYzine) when documenting or labeling LASA medications can minimize confusion.29

               

              In the hypothetical pharmacy, Ray notes that one of the technicians consistently fills prescriptions for dipyridamole with diphenhydramine. He has pointed this problem out to the technician several times and asked the technician to find the correct medication, but the problem continues. After learning about TALL Man lettering, he realizes that their computer system does not use this simple but useful intervention. He contacts the programmers and asks if they can make the changes, providing the ISMP's list of drugs for which this intervention could prevent many errors. A PRO TIP here is to ask the technician to use a highlighter to highlight the part of the drug name that follows "DIP-" on all drugs that begin with these three letters before filling prescriptions.

               

              Errors often arise during the later stages of prescription processing, including data entry, assembly, and pharmacist verification. Pharmacy personnel may rely too heavily on the auto-populated fields in electronic prescribing systems (e.g., McKesson, PioneerRx), assuming the information is correct without double-checking key details. This could lead to incorrect medication strengths, frequency, or refill quantities, ultimately causing billing issues or improper medication dispensing.27,20

               

              Dispensing the wrong formulation can occur if pharmacy staff select similar-looking bottles. Barcode scanning technology can help reduce assembly errors by ensuring use of the correct product. Pharmacists must physically inspect medications rather than relying solely on electronic systems. Pharmacy staff should attach medication guides, auxiliary labels, and other patient education materials as necessary. Pharmacy professionals must recognize that technology is a tool, not a replacement for human oversight. Systems may have glitches or auto-fill errors, and staff should remain vigilant to manually verify accuracy when needed. 20

               

              Over the few weeks after the accreditation survey, Ray and Kai see a number of minor medication errors in the pharmacy. During a counseling session, Kai learns that one patient has been taking a diuretic but has not been increasing the amount of potassium in her diet. The patient reports cramping and nausea. Kai realizes that the pharmacy staff stopped using colorful auxiliary labels, assuming that the key counseling points are covered in the multi-page handout that the computer prints with each prescription. Unfortunately, many patients simply throw that multi-page handout into the recycle bin (as did this patient). Kai realizes that using auxiliary labels is an opportunity to improve counseling and to increase the likelihood that patients will take medications correctly.

               

              The final step in the prescription process—dispensing the medication to the patient—requires uninterrupted attention to detail. Staff often overlook or rush this step in busy retail pharmacies, especially under pressure from patients who may be in a hurry. Patients who are eager to leave or have pressing time constraints may create an environment where staff feel rushed to complete the transaction quickly, potentially compromising safety. The Joint Commission requires two patient identifiers before dispensing a medication (e.g., full name and date of birth) to prevent mix-ups.26 Failing to confirm the patient’s identity may result in a patient receiving the wrong prescription, leading to serious consequences.

               

              While not all patients will ask for counseling, it is the pharmacy staff’s responsibility to offer counseling proactively, especially in critical situations. Pharmacy staff must remain alert to identify potential medication errors and recognize when pharmacist intervention is necessary. Pharmacy technicians are essential to this process. In our hypothetical pharmacy, Ray and Kai realize that the way that they've been dealing with medication errors isn't conducive to ideal teamwork. Further, they realize that they need to engage their technician support team so the pharmacist becomes involved in the process earlier when technicians see red flags.

               

              Common errors that require technician awareness and referral to the pharmacist include2,4,20

              • misuse or incorrect administration
              • first-time prescriptions, dose changes, or class switches
              • high-risk medications or drug interactions
              • duplicate therapy or overlapping prescriptions

               

              By actively engaging in patient education and ensuring clear communication at the point of dispensing, pharmacy professionals can significantly reduce medication errors and enhance patient safety. A PRO TIP comes from the Indian Health Service where pharmacy staff take a few minutes to remove medication from the bag, read the drug name, open the bottle, shake a few dosage units into the cap, and show it to the patient. Patients may identify medications that look different than they remember, which may signal a change in generic supplier or may identify an error. Although this process sounds time consuming, it actually takes just a few seconds for each bottle, and it prevents adverse outcomes in many cases.

               

              Hospital Pharmacy

              Hospital pharmacists and pharmacy technicians have serious responsibilities in ensuring safe medication use among high-risk patient populations. Like patients seen in the community, hospitalized patients often have complex conditions, multiple comorbidities, and require high-alert medications. But any event that precipitates hospitalization increases vulnerability to medication-related adverse events.21 Learners should note that many of these interventions apply in community centers as well.

               

              Similar to retail or clinic pharmacy, miscommunication between prescribers and pharmacy personnel remains a leading cause of medication errors in hospitals. Healthcare providers can reduce errors through effective communication, verification, and collaboration. Regularly confirming prescription details and clarifying discrepancies helps prevent errors before they reach patients. Pharmacy staff need to establish trust and employ open communication with prescribers to ensure patient safety in hospitals. A breakdown in interprofessional relationships can lead to medication errors, such as18,21

              • incorrect medication selection due to misinterpreted verbal or written orders
              • dosing errors, particularly in pediatric or renally impaired patients, when key patient information is not communicated
              • failure to adjust medications in response to changing renal or hepatic function, leading to toxicity or subtherapeutic dosing
              • missed allergy documentation, resulting in patients receiving medications that trigger adverse reactions

              By fostering a culture of open dialogue and verification, hospital pharmacy teams can minimize preventable errors and ensure optimal patient care.

               

              Consider a hospital pharmacy that employs nine pharmacists on three shifts, with a staffing ratio of one pharmacist to two technicians throughout the entire 24 hours. This pharmacy does a better job of documenting medication errors on unusual incident reports, but considerable room for improvement remains. Lisa is the pharmacist who works closely with the Performance and Quality Improvement (QPI) Department. Her liaison in QPI notifies Lisa that of the 46 medication errors reported in the last quarter, eight were associated with orders from a hospitalist, Dr. Backoff, who rotates shifts. The underlying cause seems to be miscommunication. Dr. Backoff is well known for his offensive behaviors; he humiliates people who ask questions, intimidates coworkers using insults or repeatedly bringing up past errors, excludes staff from opportunities to participate, and is generally so critical that people avoid him.30

               

              When staff call Dr. Backoff, he often fails to return the call. Over time, the situation has escalated to the point where staff are afraid to pick up the phone and call him when problems occur. As Lisa works with her QPI liaison, they realize that their workplace has no comprehensive policies and procedures targeting workplace bullying. Without clear guidelines and protocols, people who are targeted by bullies may feel powerless and unwilling to work with their bully.31 A PRO TIP is that this organization needs to develop training to address bullying, and Lisa and the QPI liaison need to speak to Dr. Backoff's supervisor immediately. The supervisor can refer Dr. Backoff to employee assistance program or implement corrective and disciplinary action.

               

              Certain medications require heightened safety precautions due to their potential for severe patient harm if misused. The ISMP has a list of high-alert medications that require extra safeguards in hospital settings. An example of these are anticoagulants; even small dosing mistakes could lead to severe bleeding or thrombosis (clotting).32 Due to the serious risks associated with high-alert medications, pharmacy staff pharmacists and pharmacy technicians should double-check and arrange independent verification consistently.21

               

              Medication errors frequently occur during transitions of care, including hospital admission, transfers to other facilities (e.g., long-term care, rehabilitation), and discharge to home. These errors can result in unintentional medication discontinuation, dose and frequency errors, or discharge medication miscommunication, significantly increasing patients’ risk of harm.33  One of the most significant risks during transitions of care is unintentional medication discontinuation (mistakenly stopping an essential chronic medication). Dose and frequency discrepancies and miscommunications about discharge medications further increase the risk of ADEs post-hospitalization.34

               

              To prevent these errors proactively, hospital pharmacists and pharmacy technicians should21,33

              • conduct a thorough medication reconciliation at the time of admission, ensuring all home medications are accurately documented
              • maintain clear, updated medication lists through each stage of hospitalization
              • collaborate to ensure patients and caregivers receive comprehensive discharge counseling, with the technician reminding or prompting pharmacists if this step is missed, and reinforcing medication changes adherence instructions

               

              Lisa’s hospital has a structured transitions of care program. They hire pharmacy students to conduct medication reconciliation under a pharmacist’s supervision. Before pharmacy students can conduct medication reconciliation, they complete a comprehensive training program. Regardless, errors on the medication list still slip through.

               

              Lisa's hospital is not alone with this problem. Many hospitals find that errors occur even after medication reconciliation. A 2024 study of the medication reconciliation process and related medication errors indicates that these processes are “very heterogeneous,” meaning that in some areas, medication reconciliation was very good and in others, not so much.35 They found that error rates were unexpectedly high in some areas. This study looked at 929 prescriptions written for 182 patients. In 91% of cases, the reconciler had not specified the drug form. About 72% of medication administration errors pursuant to a faulty medication reconciliation exercise resulted in patients receiving the wrong release dose formulation (i.e., immediate release as opposed to extended release). The researchers indicated that medication error rates did not improve significantly over the period before they conducted routine medication reconciliation.35

               

              Lisa has heard coworkers talk about medication reconciliation as a useless process and seeing them roll their eyes when they look at a medication reconciliation report that has obvious errors. In the past, pharmacy staff did not consider a mistake on a medication reconciliation list to be a medication error. However, when a serious error slips through, Lisa’s QPI liaison suggests that they began tracking such errors on unusual incident reports. A PRO TIP here is to track errors in medication reconciliation and try to identify the areas where errors are most likely to occur in the medication reconciliation process. At this hospital, Lisa and the QPI liaison were able to confirm that they also had a problem with identification of the correct formulation. Over the following months, they were able to improve by using additional training and revising their medication reconciliation form to force technicians to ask about the formulation or to see the bottle.

               

              PAUSE AND PONDER: Can you think of any processes or policies in your workplace that can be improved to enhance patient safety?

               

              Pharmacist and Technician Responsibilities

              Pharmacy professionals have a responsibility to actively communicate with their colleagues and other healthcare providers to prevent errors. Effective collaboration within the healthcare team ensures safe medication practices by18

              • clarifying unclear or incomplete prescriptions before dispensing
              • confirming appropriate dosing adjustments for renal or hepatic impairment
              • coordinating medication reconciliation during transitions of care to prevent omissions or duplications

               

              Management needs to empower pharmacists and pharmacy technicians to voice concerns regarding potential medication errors. Addressing these concerns professionally and respectfully fosters a culture of teamwork and patient safety.

               

              A key responsibility of pharmacy professionals is to provide clear, understandable medication counseling to patients. However, it is unrealistic to expect that staff can counsel all patients on every detail of their prescription. Instead, pharmacists should prioritize the most critical points, especially on new prescriptions, including36

              • dosing instructions and adherence importance
              • common and serious adverse effects
              • drug interactions and contraindications
              • proper storage and administration techniques

               

              One effective counseling strategy is the teach-back method, where patients repeat the pharmacist’s instructions back in their own words. This ensures patients fully understand how to use their medication correctly. For example, when dispensing doxycycline, instead of simply stating “Take this with a full glass of water,” a pharmacist using the teach-back method would ask one simple question after explaining how to take the doxycycline: “Can you explain to me how you will take this medication to avoid stomach irritation? I need to be sure I covered everything.”18,21,26 

               

              When a serious medication error occurs, it is crucial to investigate the underlying causes to prevent future occurrences. Root-cause analysis (RCA) is a structured problem-solving method used to analyze errors after they have happened—including what, how, and why it happened—and can help determine what lessons could be learned and how to reduce the risk of recurrence and make care safer.3,21 For example, if a retail pharmacy dispenses the wrong insulin type and a patient is subsequently hospitalized, an RCA might reveal that the error stemmed from look-alike packaging and a lack of independent verification.

               

              Failure mode and effects analysis (FMEA) is a proactive approach to medication safety, identifying potential failures before they occur. By evaluating processes and pinpointing high-risk areas, institutions can implement safeguards to prevent errors before they reach patients.21 For instance, before introducing a new automated dispensing cabinet, an FMEA could help identify potential failure points, such as medication selection due to user interface design, allowing for preventive modifications.

               

              CONCLUSION

              Patient safety is a fundamental pillar in pharmacy practice, and reducing medication errors requires a proactive, systematic approach. Errors can occur at any stage of the medication use process, from receiving and interpreting prescriptions to dispensing and patient counseling. Recognizing common errors—such as abbreviations, LASA drugs, incorrect dosing, and transcription mistakes—helps pharmacy professionals to implement safeguards that prevent harm.

               

               

               

               

               

               

              Appendices 1-3

               

               

              Pharmacist Post Test (for viewing only)

              Patient Safety: Catch Me if You Can: Medication Errors and Their Impact

              Pharmacist Post-test

              After completing this continuing education activity, pharmacy technicians will be able to
              • Describe details of common medication errors in hospital and community pharmacies
              • Differentiate between categories of medication errors
              • Calculate medication errors rates
              • List approaches to learn from and prevent medication errors

              1. Which of the following examples of medication errors is correctly matched with its error type/stage of prescription processing?
              A. Wrong route of administration – Prescribing
              B. A prescription written with illegible handwriting – Dispensing
              C. Failure to adjust dose for renal/hepatic function – Monitoring

              2. Which of the following is an example of a high-alert medication that requires extra caution?
              A. Normal saline
              B. Loratadine
              C. Warfarin

              3. You need to calculate your pharmacy’s medication error rate for the past calendar week before the staff meeting. There have been eight errors and 6,400 medication orders that were dispensed for this week. What is the medication error rate?
              A. 0.13%
              B. 0.08%
              C. 8.13%

              4. Which of the following is a key benefit of encouraging incident reporting systems in pharmacies?
              A. Identifying trends to implement system-wide improvements
              B. Finding who is responsible and firing them immediately
              C. Reducing the daily workload for pharmacy staff

              5. Which of the following is an example of why it is important to maintain good relationships with other health professionals?
              A. It ensures that pharmacists thoroughly document allergies
              B. It facilitates clear communication, reducing risk of errors
              C. It allows pharmacy staff to bypass unnecessary verification steps

              6. Which of the following best differentiates a prescribing error from a dispensing error?
              A. A prescribing error occurs during medication order entry, while a dispensing error occurs during medication preparation or distribution
              B. Prescribing errors only occur in hospitals, while dispensing errors only occur in community or outpatient clinic pharmacies
              C. A prescribing error is always detected by the pharmacy technician, while a dispensing error is only noticed by the pharmacist

              7. A patient started thyroid medication 6 months ago and has been taking the same dose without any follow-up bloodwork. What type of medication error is this?
              A. Monitoring error
              B. Transition-of-care error
              C. Prescribing error

              8. Which of the following is the best strategy to prevent look-alike/sound-alike medication errors?
              A. Using only brand names during the prescription filling process
              B. Using TALL Man lettering and routine barcode scanning
              C. Storing similar-sounding medications together for easy access

              9. How can you use the medication error rate to identify areas for improvement and enhance patient safety?
              A. Analyzing error rate trends to pinpoint problem areas
              B. Creating predictive models that estimate future potential error rates
              C. Benchmarking error rates against comparable institutions

              10. In your very busy pharmacy, you identify that most medication errors are occurring at the point of prescription entry. What is an appropriate response?
              A. Provide additional training on prescription verification
              B. Add a verification call to the prescriber for all written prescriptions
              C. Stop accepting handwritten prescriptions in your pharmacy

              Pharmacy Technician Post Test (for viewing only)

              Patient Safety: Catch Me if You Can: Medication Errors and Their Impact

              Pharmacy Technician Post-test

              After completing this continuing education activity, pharmacy technicians will be able to
              • Describe details of common medication errors in hospital and community pharmacies
              • Differentiate between categories of medication errors
              • Calculate medication errors rates
              • List approaches to learn from and prevent medication errors

              1. Which of the following medication errors is correctly matched with its error type/stage of prescription processing?
              A. Wrong route – Monitoring
              B. Illegible handwriting – Dispensing
              C. Wrong drug selection – Prescribing

              2. When would you classify a medication error as a near miss?
              A. An error occurred, but did not reach the patient
              B. A potential error was identified, intercepted, and avoided
              C. An error occurred and reached patient, but the patient is fine

              3. The pharmacist you work with wants to calculate the percentage of prescription orders that were errors in the past calendar week. They ask you to calculate this number, telling you that there have been five errors out of 7,000 medication orders dispensed this week. What is the medication error rate?
              A. 0.07%
              B. 0.05%
              C. 1.40%

              4. How can you use the medication error rate to identify areas for improvement and enhance patient safety?
              A. Analyzing error rate trends to pinpoint problem areas
              B. Creating predictive models that estimate future potential error rates
              C. Benchmarking error rates against comparable institutions

              5. Which of the following is a common cause of medication errors in community pharmacy?
              A. Using auxiliary labels on all medications without reviewing their necessity
              B. Providing medication counseling for patients even when they are rushed
              C. Misinterpreting prescriptions due to abbreviations or unclear handwriting

              6. Which of the following scenarios would prompt you to refer a patient to the pharmacist to prevent a medication error?
              A. A patient picking up medication refill for her spouse
              B. A patient requesting an early refill on a maintenance medication
              C. A patient using new insurance information on a prescription refill

              7. Where can you find lists of high-alert medications and look-alike/sound-alike medications?
              A. American Pharmacist Association (APhA) practice guidelines
              B. Standards of operations forms
              C. Institute of Safe Medication Practices

              8. Which strategy can help prevent accidental medication discontinuation during transition of care?
              A. Medication reconciliation
              B. Automatic therapeutic substitution
              C. Discharging the patient as fast as possible

              9. Which strategy can help prevent medication errors in all pharmacy settings?
              A. Using auto-population options on electronic systems as often as possible
              B. Encouraging a double-check system for high-risk medications
              C. Relying solely on bar-code scanning as the final verification step

              10. In a hospital setting, when is there a high chance of medication errors occurring?
              A. During surgery
              B. During discharge
              C. During visitation hours

              References

              Full List of References

              References

                 

                1. Hodkinson A, Tyler N, Ashcroft DM, et al. Preventable medication harm across health care settings: a systematic review and meta-analysis. BMC Med. 2020;18(1):313. doi:10.1186/s12916-020-01774-9
                2. National Coordinating Council for Medication Error Reporting and Prevention. About Medication Errors. Accessed February 2, 2025. https://www.nccmerp.org/about-medication-errors
                3. Agency for Healthcare Research and Quality. Glossary. Patient Safety Network. Accessed February 2, 2025. https://psnet.ahrq.gov/glossary-0
                4. Technical Series on Safer Primary Care: Medication Errors. World Health Organization. December 13, 2016. Accessed February 2, 2025. https://www.who.int/publications/i/item/9789241511643
                5. National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP Index for Categorizing Medication Errors. Updated October 2022. Accessed February 2, 2025. https://www.nccmerp.org/sites/default/files/index-color-2021-draft-change-10-2022.pdf
                6. Allan BL. Calculating medication error rates. Am J Hosp Pharm. 1987;44(5):1044-1046.
                7. Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); April 2008.Accessed February 4, 2025. https://pubmed.ncbi.nlm.nih.gov/21328752/
                8. Institute of Medicine (US) Committee on Data Standards for Patient Safety, Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: Achieving a New Standard for Care. Washington (DC): National Academies Press (US); 2004.Accessed March 21, 2025. https://nap.nationalacademies.org/catalog/10863/patient-safety-achieving-a-new-standard-for-care
                9. Lawton R, McEachan RR, Giles SJ, Sirriyeh R, Watt IS, Wright J. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. BMJ Qual Saf. 2012;21(5):369-380. doi:10.1136/bmjqs-2011-000443
                10. The Confidentiality of Incident Reports: A Crucial Consideration. SafeQual. Accessed April 30, 2025. https://www.safequal.net/sb/the-confidentiality-of-incident-reports-a-crucial-consideration/
                11. U.S. Department of Health and Human Services. Understanding patient safety confidentiality. October 22, 2024. Accessed March 25, 2025. https://www.hhs.gov/hipaa/for-professionals/patient-safety/index.html
                12. Clinical incident report sample PDF form. FormsPal. Accessed March 27, 2025. https://formspal.com/pdf-forms/other/clinical-incident-report-sample/
                13. 7 Essential Elements of an Incident Report, and a Free Guide. Safety Evolution Blog. August 24, 2022. Accessed March 27, 2025. https://www.safetyevolution.com/blog/7-essential-elements-of-an-incident-report-and-a-free-guide
                14. Tariq A, Georgiou A, Westbrook J. Medication incident reporting in residential aged care facilities: limitations and risks to residents' safety. BMC Geriatr. 2012;12:67. Published 2012 Nov 2. doi:10.1186/1471-2318-12-67
                15. Flink E, Chevalier CL, Ruperto A, et al. Lessons Learned from the Evolution of Mandatory Adverse Event Reporting Systems. In: Henriksen K, Battles JB, Marks ES, Lewin DI, eds. Advances in Patient Safety: From Research to Implementation (Volume 3: Implementation Issues). Rockville (MD): Agency for Healthcare Research and Quality (US); February 2005.Accessed March 22, 2025. https://www.ncbi.nlm.nih.gov/books/NBK20547/
                16. Flynn EA, Barker KN, Pepper GA, Bates DW, Mikeal RL. Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities. Am J Health Syst Pharm. 2002;59(5):436-446. doi:10.1093/ajhp/59.5.436
                17. Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995;21(10):541-548. doi:10.1016/s1070-3241(16)30180-8
                18. Alhur A, Alhur AA, Al-Rowais D, et al. Enhancing Patient Safety Through Effective Interprofessional Communication: A Focus on Medication Error Prevention. Cureus. 2024;16(4):e57991. doi:10.7759/cureus.57991
                19. Mutair AA, Alhumaid S, Shamsan A, et al. The Effective Strategies to Avoid Medication Errors and Improving Reporting Systems. Medicines (Basel). 2021;8(9):46. doi:10.3390/medicines8090046
                20. Odukoya OK, Stone JA, Chui MA. E-prescribing errors in community pharmacies: exploring consequences and contributing factors. Int J Med Inform. 2014;83(6):427-437. doi:10.1016/j.ijmedinf.2014.02.004
                21. ASHP guidelines on preventing medication errors in hospitals. Am J Hosp Pharm. 1993;50(2):305-314.
                22. Independent double checks: Worth the effort if used judiciously and properly. ISMP. June 6, 2019. Accessed March 25, 2025. https://home.ecri.org/blogs/ismp-alerts-and-articles-library/independent-double-checks-worth-the-effort-if-used-judiciously-and-properly?utm
                23. Caetano BDL. SOP management in the pharmaceutical industry. SimplerQMS. Updated January 24, 2025. Accessed February 3, 2025. https://simplerqms.com/pharmaceutical-sop-management/
                24. Chance EA, Florence D, Sardi Abdoul I. The effectiveness of checklists and error reporting systems in enhancing patient safety and reducing medical errors in hospital settings: A narrative review. Int J Nurs Sci. 2024;11(3):387-398. Published 2024 Jun 8. doi:10.1016/j.ijnss.2024.06.003
                25. Grigg E. Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician Performance. Anesth Analg. 2015;121(2):570-573. doi:10.1213/ANE.0000000000000352
                26. Hong K, Hong YD, Cooke CE. Medication errors in community pharmacies: The need for commitment, transparency, and research. Res Social Adm Pharm. 2019;15(7):823-826. doi:10.1016/j.sapharm.2018.11.014
                27. Pervanas HC, Revell N, Alotaibi AF. Evaluation of Medication Errors in Community Pharmacy Settings: A Retrospective Report. J Pharm Technol. 2016;32(2):71-74. doi:10.1177/8755122515617199
                28. The Joint Commission. Official “do not use” list. September 2018. Accessed March 21, 2025. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/patient-safety/do_not_use_list_9_14_18
                29. Institute for Safe Medication Practices. FDA and ISMP Lists of Look-Alike Drug Names with Recommended Tall Man (Mixed Case) Letters. 2023. Accessed April 25, 2025. https://online.ecri.org/hubfs/ISMP/Resources/ISMP_Look-Alike_Tallman_Letters.pdf
                30. Knapp K, Shane P, Sasaki-Hill D, Yoshizuka K, Chan P, Vo T. Bullying in the clinical training of pharmacy students. Am J Pharm Educ. 2014;78(6):117. doi:10.5688/ajpe786117
                31. Customer Harassment, Bullying Affecting Pharmacists’ Ability to Do Their Jobs. US Pharmacist. February 2, 2022. Accessed March 11, 2025. https://www.uspharmacist.com/article/customer-harassment-bullying-affecting-pharmacists-ability-to-do-their-jobs
                32. Institute for Safe Medication Practices. ISMP list of high-alert medications. 2018. Accessed February 4, 2025. https://www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf
                33. Donaldson L, Ricciardi W, Sheridan S, Tartaglia R, eds. Textbook of Patient Safety and Clinical Risk Management. Cham (CH): Springer; 2021.Accessed February 4, 2025. https://pubmed.ncbi.nlm.nih.gov/36315660/
                34. Park J, Kim AJ, Cho EJ, et al. Unintentional medication discrepancies at care transitions: prevalence and their impact on post-discharge emergency visits in critically ill older adults. BMC Geriatr. 2024;24(1):1000. doi:10.1186/s12877-024-05517-w
                35. Schuster J, Saddawi A, Frisch A, et al. A comprehensive study of prescribing, administering and drug handling medication errors in ten wards of a university hospital after implementation of electronic prescribing, clinical pharmacists or medication reconciliation. Pharmazie. 2024;79(1):11-16. doi:10.1691/ph.2024.3579
                36. Center for Medicare & Medicaid Services. Drug diversion toolkit: Patient counseling—a pharmacist’s responsibility to ensure compliance. November 2014. Accessed February 4, 2025. https://www.cms.gov/files/document/patientcounselingbooklet111414pdf

                So Much STI Data: Information to help you stay current and informed – RECORDED WEBINAR

                The Arthur E. Schwarting Symposium is an educational conference focused on pharmacy practice for pharmacists in many settings.

                This year's symposium had an overall topic of Information Overload.

                Learning Objectives

                • Describe updated screening recommendations and epidemiological trends of sexually transmitted infections (STIs).
                • Review the Centers for Disease Control and Prevention’s STIs recommendations.
                • Explain the latest evidence-based STI updates.
                ·       Given medication shortages, outline the pharmacist's role in delivering targeted patient education and implementing strategies for responsible medication stewardship for STIs

                Activity Release Dates

                Released:  April 24, 2025
                Expires:  April 24, 2028

                Course Fee

                $17 Pharmacist

                ACPE UAN Codes

                 0009-0000-25-030-H01-P

                Session Code

                25RS30-KVX29

                Accreditation Hours

                1.0 hours of CE

                Accreditation Statement

                The University of Connecticut School of Pharmacy is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.

                Pharmacists and Pharmacy Technicians are eligible to participate in this application-based activity and will receive 1.0 CE Hour  for completing the activity  (ACPE UAN 0009-0000-25-030-H01-P), passing the quiz with a grade of 70% or better, and completing an online evaluation. Statements of credit are available via the CPE Monitor online system and your participation will be recorded with CPE Monitor within 72 hours of submission.

                Grant Funding

                There is no grant funding for this activity.

                Faculty

                Jennifer Girotto, PharmD, BCPPS, BCIDP
                Associate Clinical Professor
                UConn School of Pharmacy
                Storrs, CT

                    

                Faculty Disclosure

                • Dr. Girotto doesn't have any relationships with ineligible companies.

                 

                Disclaimer

                The material presented here does not necessarily reflect the views of The University of Connecticut School of Pharmacy or its co-sponsor affiliates. These materials may discuss uses and dosages for therapeutic products, processes, procedures and inferred diagnoses that have not been approved by the United States Food and Drug Administration. A qualified health care professional should be consulted before using any therapeutic product discussed. All readers and continuing education participants should verify all information and data before treating patients or employing any therapies described in this continuing education activity.

                Content

                Post Test Pharmacist

                1.) A 19-year-old female is at the clinic. She had recent unprotected sexual intercourse with her partner. She has not had any previous STI screenings. Which STIs are indicated for screening at this time?
                a. HIV, gonorrhea, and chlamydia
                b. Gonorrhea, chlamydia, and syphilis
                c. Chlamydia, syphilis, and HPV

                2.) Which of the following STIs have shown a continued increase in incidence based on 2023 data?
                a. Congenital syphilis
                b. Gonorrhea in the population
                c. Chlamydia cases in men

                3.) After completing gonorrhea treatment, when should a clinician re-screen the patient?
                a. 1 month after completing treatment
                b. 3 months after completing treatment
                c. 1 year after completing treatment

                4.) What is the guideline-based treatment recommendation for a 200 lb male patient with a confirmed gonorrhea and chlamydia co-infection?
                a. Ceftriaxone 500 mg IM x 1 and azithromycin 1000 mg PO x 1
                b. Ceftriaxone 250 mg IM x 1 and doxycycline 100 mg PO BID x 7 days
                c. Ceftriaxone 500 mg IM x 1 and doxycycline 100 mg PO BID x 7 days

                5.) Which population should receive seven days of treatment with metronidazole for trichomoniasis?
                a. Young males 15 – 24 years old
                b. Males 25 – 45 years old
                c. Females of any age

                6.) A pregnant patient is positive for primary syphilis. What is the guideline recommended treatment for her?
                a. 2.4 million units benzathine penicillin G IM x 1
                b. 2.4 million units benzathine penicillin G IM x 3 weekly doses
                c. 100 mg PO doxycycline 2 time daily doses for 28 days
                7.) Which of the following is a newly approved type of product that will increase patient access?
                a. OTC bacterial Pre-Exposure Prophylaxis
                b. OTC home screening tests for STIs
                c. OTC HIV Post Exposure Prophylaxis

                8.) What should pharmacists warn healthcare providers about regarding possible alternatives during a shortage of Bicillin LA for syphilis?
                a. Impact of HIV cases
                b. Adverse effects from the frequent use of the medication
                c. Antimicrobial resistance

                9.) You are working with emergency department physicians to manage a shortage of ceftriaxone. One concern is the treatment of gonorrhea. Which of the following would be a stewardship principle applied to this STI management choice?
                a. Use the most recent antibiotic approved for the indication
                b. Use alternative based on narrowest effect spectrum and incorporating local resistance data, if known
                c. Choose an alternative that will also cover other STIs just in case