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Renal Failure Result of Medication Interaction
ISSUE: What is a physician's duty to be aware of all medications a patient may be taking before prescribing treatment?
A 51-year-old consulted a gastroenterologist for treatment of her ulcerative colitis. Pursuant to his treatment plan, the physician's office notified her that she should undergo a colonoscopy. One week prior to the procedure, she went to his office for a pre-colonoscopy consultation, during which she explained that she had a difficult time tolerating many laxatives and recorded on her "new patient" form the brand name for lisinopril, an Angiotensin-converting enzyme (ACE) inhibitor she was taking to treat her hypertension. Working along with the patient to determine the best colonoscopy preparation, the gastroenterologist's nurse suggested, and the physician prescribed a sodium phosphate-based laxative available in pill form instead of as a liquid. The gastroenterologist's office phoned the prescription to a local pharmacy.
The laxative prescribed had a "black box" warning regarding the drug's potential for causing kidney damage as a result of possible interactions with ACE inhibitors, but the gastroenterologist did not read the prescribing literature for the laxative and, in any case, did not recognize the brand name of the medication recorded by the patient as being an ACE inhibitor. The pharmacy filled the prescription without providing the patient any warning, since they had no record of the patient's lisinopril prescription, which she obtained at another pharmacy chain.
The night before the scheduled procedure the patient took the pills per the instructions given to her by the nurse. By the next day she did not feel that the laxative had completely prepared her for the procedure and called the gastroenterologist's office to determine what course of action to take. The nurse asked the physician, who was on his way out the door to the surgical center to perform several endoscopic procedures, and he told her to call in another prescription for "whatever she had already taken." The colonoscopy was rescheduled for the following day and the patient was informed that another prescription for the laxative would be called in to the pharmacy. That night the patient took the second round of the laxative, as directed. The following morning she felt ill and drove to the emergency department, where she was ultimately diagnosed with renal failure due to phosphate nephropathy. The damage to her kidneys required that she undergo dialysis for the rest of her life or receive a kidney transplant.
The patient sued, alleging that the physician had a duty to inquire as to her current medications to avoid drug interaction. The physician argued that the pharmacy should have detected the potential interaction and that the prescription wasn't for a medication, but was simply for a laxative.
A 51-year-old consulted a gastroenterologist for treatment of her ulcerative colitis. Pursuant to his treatment plan, the physician's office notified her that she should undergo a colonoscopy. One week prior to the procedure, she went to his office for a pre-colonoscopy consultation, during which she explained that she had a difficult time tolerating many laxatives and recorded on her "new patient" form the brand name for lisinopril, an Angiotensin-converting enzyme (ACE) inhibitor she was taking to treat her hypertension. Working along with the patient to determine the best colonoscopy preparation, the gastroenterologist's nurse suggested, and the physician prescribed a sodium phosphate-based laxative available in pill form instead of as a liquid. The gastroenterologist's office phoned the prescription to a local pharmacy.
The laxative prescribed had a "black box" warning regarding the drug's potential for causing kidney damage as a result of possible interactions with ACE inhibitors, but the gastroenterologist did not read the prescribing literature for the laxative and, in any case, did not recognize the brand name of the medication recorded by the patient as being an ACE inhibitor. The pharmacy filled the prescription without providing the patient any warning, since they had no record of the patient's lisinopril prescription, which she obtained at another pharmacy chain.
The night before the scheduled procedure the patient took the pills per the instructions given to her by the nurse. By the next day she did not feel that the laxative had completely prepared her for the procedure and called the gastroenterologist's office to determine what course of action to take. The nurse asked the physician, who was on his way out the door to the surgical center to perform several endoscopic procedures, and he told her to call in another prescription for "whatever she had already taken." The colonoscopy was rescheduled for the following day and the patient was informed that another prescription for the laxative would be called in to the pharmacy. That night the patient took the second round of the laxative, as directed. The following morning she felt ill and drove to the emergency department, where she was ultimately diagnosed with renal failure due to phosphate nephropathy. The damage to her kidneys required that she undergo dialysis for the rest of her life or receive a kidney transplant.
The patient sued, alleging that the physician had a duty to inquire as to her current medications to avoid drug interaction. The physician argued that the pharmacy should have detected the potential interaction and that the prescription wasn't for a medication, but was simply for a laxative.
From your analysis of the case, assess whether the following statesments are true or false:
| * | When obtaining a medication history a physician need only inquire about prescription medications. | True or False |
| * | A physician must be familiar with or look up the actual composition of trade name medications listed by a patient. | True or False |
| * | If a prescribed medication has been taken by patient for an intended one-time use, it may be re-prescribed without further evaluation if it does not achieve the intended effect. | True or False |
Expand to check answers
GENERAL PRINCIPLE: A physician must obtain a complete history, identify the content of any unknown or unrecognized substance and learn of any potential interactions before providing a new medication prescription.
APPLIED PRINCIPLE: Numerous combinations of medications can produce adverse interactions and patients may be prescribed medications by physicians, dentists, non-physician providers or they may self-medicate with over-the-counter drugs and remedies. When providing a medication history patients may not consider some of the remedies, herbs and vitamins to be medication. Physicians may not think of procedure preparations such as laxatives as medications. Failure to consider potential interaction between these substances can result in patient harm.
The gastroenterologist was concerned with proper preparation of the patient for the procedure, but failed to check for potential adverse interaction between the ACE inhibitor and the laxative, even though it was an identified black box warning. Although many pharmacists will identify possible interaction, especially for regular customers, a physician cannot rely on this as the only safeguard.
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APPLIED PRINCIPLE: Numerous combinations of medications can produce adverse interactions and patients may be prescribed medications by physicians, dentists, non-physician providers or they may self-medicate with over-the-counter drugs and remedies. When providing a medication history patients may not consider some of the remedies, herbs and vitamins to be medication. Physicians may not think of procedure preparations such as laxatives as medications. Failure to consider potential interaction between these substances can result in patient harm.
The gastroenterologist was concerned with proper preparation of the patient for the procedure, but failed to check for potential adverse interaction between the ACE inhibitor and the laxative, even though it was an identified black box warning. Although many pharmacists will identify possible interaction, especially for regular customers, a physician cannot rely on this as the only safeguard.
| * | When obtaining a medication history a physician need only inquire about prescription medications. | False |
| * | A physician must be familiar with or look up the actual composition of trade name medications listed by a patient. | True |
| * | If a prescribed medication has been taken by patient for an intended one-time use, it may be re-prescribed without further evaluation if it does not achieve the intended effect. | False |