In my work as a consultant pharmacist (which I love!), I write recommendations to nurses and providers of long term care and assisted living facilities. I wanted to share some of the most recent recommendations I’ve found that can help you identify potential drug therapy problems in your practice. If you are looking for more information on how to become a consultant pharmacist in long term care, check out my course “Insider’s Guide to Long Term Care Consulting”.

Giving Calcium or Iron With Antibiotics

You should not administer calcium or iron supplements at the same time as quinolone antibiotics (like ciprofloxacin or levofloxacin) or doxycycline because these minerals can significantly interfere with the absorption of the antibiotics. Calcium and iron can bind to the medications in the gastrointestinal tract and form insoluble complexes, which prevent the antibiotics from being properly absorbed into the bloodstream. This decreases the effectiveness of the antibiotics and can lead to treatment failure or prolonged infection. To avoid this interaction, it’s recommended to separate the administration of calcium or iron supplements and these antibiotics by at least two hours before or four to six hours after taking the antibiotic. Another option is to hold the calcium or iron while the antibiotic course is completed.

INR Monitoring

I recently encountered a situation where INR monitoring was missed. It is incredibly important to have processes in place to ensure that we don’t miss this critical check in patients taking warfarin.

Anticholinergic Adverse Effects

An 82-year-old male resident in a long-term care facility was prescribed hydroxyzine 25 mg at bedtime for itching related to eczema. Within a few days, he began experiencing difficulty initiating urination and a noticeably decreased urinary stream. Staff also noted he was having fewer bowel movements, with increasing reports of bloating and abdominal discomfort. On evaluation, the resident was found to have urinary retention, likely worsened by the anticholinergic effects of hydroxyzine, which can impair bladder contractility. As a result, the primary care provider prescribed tamsulosin 0.4 mg daily to help relax the bladder neck and improve urinary flow. Additionally, his constipation management regimen was intensified, adding polyethylene glycol (MiraLAX) daily, in addition to his previous as-needed docusate. The hydroxyzine was later discontinued after recognizing it was the likely trigger for both the urinary and gastrointestinal symptoms.

Duplicate Calcium Channel Blockers

A 76-year-old female in a long-term care facility was prescribed amlodipine 10 mg daily for hypertension. During a recent medication reconciliation after a hospital stay, she was also started on diltiazem 120 mg daily for new-onset atrial fibrillation. This resident was continued on both until my review where amlodipine was successfully discontinued with blood pressure remaining at goal.

Discontinuing A PPI

An 80-year-old male resident had been taking omeprazole 20 mg daily for over six months after an episode of gastritis. During a medication review, it was noted he no longer had reflux symptoms and had no recent GI issues. To reduce unnecessary long-term PPI use and lower his risk for side effects like osteoporosis and infections, I recommended a gradual taper by switching to every other day dosing for two weeks, then discontinuing completely. The resident remained symptom-free without the need for antacids, and no rebound acid hypersecretion occurred.

There you have it, 5 recommendations in long term care that I’ve recently written. If you are looking for more insider tips on how to become a consultant pharmacist and important concepts to understand, check out my “Insider’s Guide to Long Term Care Consultant Pharmacy”.