Medication sick day guidance (in nursing home resident)

Polypharmacy guidance: Appropriate prescribing making medicines safe, effective and sustainable 2026-2029
National

Case summary

Background (age, sex, occupation, baseline function)

  • 83-year-old male 
  • Nursing home resident 
  • Registered blind 

History of presentation/reason for review

  • Nausea and vomiting (twice two nights ago, and once the following morning) 
  • Dapagliflozin, furosemide, macrogol, metformin, ramipril and senna suspended until 48 hours after nausea and vomiting resolved. Staff asked for advice from Advanced Nurse Practitioner (ANP) before suspending. ANP advised them to follow sick day guidance and in addition withhold laxative therapy. 

Current medical history and relevant co-morbidities

  • Ankle oedema – 5 months ago
  • Depression – 4 years ago
  • Benign prostatic hyperplasia – 7 years ago
  • Ischaemic heart disease – 12 years ago
  • Type 2 diabetes mellitus – 18 years ago
  • Hypertension – 18 years ago

Current medication and drug allergies (include over the counter (OTC) preparation, traditional medicines and herbal remedies)

Allergies or adverse drug reactions (ADRs): nil  

Current medications:

  • Atorvastatin 80mg tablets: one tablet daily 
  • Co-codamol 30mg/500mg tablets: one or two tablets up to four times a day 
  • Dapagliflozin 10mg tablets: one tablet daily 
  • Finasteride 5mg tablets: one tablet daily 
  • Furosemide 40mg tablets: one tablet daily 
  • Lansoprazole 30mg capsules: one capsule daily 
  • Macrogol 3350 sachets: one or two sachets daily 
  • Metformin 500mg tablets: one tablet twice daily 
  • Mirtazapine 30mg tablets: one tablet daily 
  • Ramipril 10mg capsules: one capsule daily 
  • Senna 7.5mg tablets: one or two tablets at night 
  • Tamsulosin 400 micrograms modified-release capsules: one capsule daily 
  • Prescribed prochlorperazine for duration of the acute illness of nausea and vomiting 

Over the counter medicines: nil 

Lifestyle and current function

  • Does not smoke or drink alcohol
  • Eats a normal diet and fluids   
  • Requires help of one staff member for personal care, washing and dressing 
  • Mobility - able to transfer using a walking aid and two staff. Wheelchair for longer distances 
  • Clinical Frailty Score (Rockwood) 6 (moderately frail) 
  • Mini Mental State Examination (MMSE) score 20, referred to Older Adult Community Mental Health Team (OA CMHT)  

“What matters to me” (ideas, concerns and expectations of treatment)

  • Individual understood why medication was withheld as had been counselled on sick day guidance at previous medication review  
  • Wants to ensure that his medication is restarted as soon as possible where appropriate 

Observations, examinations and results 

Blood results from three months ago: 

  • Weight 87kg, Height 173cm, BMI 29kg/m2 
  • BP 145/85mmHg, pulse 65bpm
    • Urea and Electrolytes:
    • Potassium 4.0mmol/L (3.5-5.3mmol/L)
    • Sodium 140mmol/L (133-146mmol/L)
    • Urea 5mmol/L (2.5-7.8mmol/L)
    • Creatinine 70micromol/L, eGFR > 60ml/min/1.73m2, calculated creatinine clearance 87ml/min 
  • HbA1c 53mmol/mol (7.0%)
  • Cholesterol 8mmol/L (<5.0mmol/L)

Most recent relevant consultations

  • With the nursing home staff, they have created his personalised medicines list in the Polypharmacy: Manage Medicines website/app
  • Family/welfare power of attorney (POA) informed  
  • Commenced on a fluid intake and output chart for monitoring  
  • No further nausea or vomiting since yesterday morning 
  • Restarted the temporarily withheld medicines

7 steps: Person specific issues to address

1.  Aims: What matters to the individual about their condition(s)?

Review diagnoses and consider:

  • Therapeutic objectives of drug therapy
  • Management of existing health problems
  • Prevention of future health issues, including lifestyle advice 

Ask person to complete PROMs (Questions to answer before medicines review) before their review

Person specific issues to address

  • Wants to have medication restarted as soon as possible   

 

2.  Need: Identify essential drug therapy

Identify essential drugs (not to be stopped without specialist advice)

  • Drugs that have essential replacement functions (e.g. levothyroxine) 
  • Drugs to prevent rapid symptomatic decline (e.g. drugs for Parkinson’s disease, heart failure) 

Person specific issues to address

  • None

 

3. Does the individual take unnecessary drug therapy?

Identify and review the continued need for drugs

  • what is medication for?
  • with temporary indications
  • with higher than usual maintenance doses
  • with limited benefit/evidence for use
  • with limited benefit in the person under review (see Drug efficacy & applicability (NNT) table)

Person specific issues to address

  • Mirtazapine: clarify date of last review and need for continued therapy. Increased risk of ADRs including sedation and falls 
  • Co-codamol: no known indication. Increased risk of ADRs in frailty. Consider paracetamol alone, reducing risk of constipation and need for laxative. If only taking one tablet, subtherapeutic dose of paracetamol

 

4.  Effectiveness: Are therapeutic objectives being achieved?

Identify the need for adding/intensifying drug therapy to achieve therapeutic objectives

  • to achieve symptom control
  • to achieve biochemical/clinical targets
  • to prevent disease progression/exacerbation
  • is there a more appropriate medication to achieve goals?

Person specific issues to address

  • Prochlorperazine: commenced for treatment of nausea and vomiting only  
  • Blood pressure: at target, could reduce ramipril
  • HbA1C: at target, potential to reduce metformin 

 

5. Safety: Does the individual have or is at risk of ADR/ side effects? Does the patient know what to do if they’re ill?

Identify individual safety risks by checking for

Identify adverse drug effects by checking for

  • specific symptoms/laboratory markers (e.g. hypokalaemia)
  • cumulative adverse drug effects (see ADR table)
  • drugs used to treat side effects caused by other drugs

Medication Sick Day guidance

  • Ensure discussion and clear information on which medicines to withhold at times of dehydrating illness

Person specific issues to address

  • Medication Sick Day Guidance followed: dapagliflozin, furosemide, metformin and ramipril temporarily paused during intercurrent illness 
  • Macrogol and senna also withheld
  • Reason for temporary suspension of medicines explained and understood by individual and POA

 

6.  Sustainability: Is drug therapy cost-effective and environmentally sustainable?

Identify unnecessarily costly drug therapy by

  • considering more cost-effective alternatives, formulary choices, safety, convenience

Consider the environmental impact of

  • Inhaler use
  • Single use plastics
  • Medicines waste
    • over-ordering
    • disposal
  • Water pollution 

Person specific issues to address

  • All medicines are formulary choices
  • Care home advised to dispose of medicines through community pharmacy and advised to only order what is needed

 

7.  Person-centredness: Is the person willing and able to take drug therapy as intended?

Does the person understand the outcomes of the review?

  • Consider Teach back

Ensure drug therapy changes are tailored to individual’s preferences. Consider

  • is the medication in a form they can take?
  • is the dosing schedule convenient?
  • what assistance is needed?
  • are they able to take medicines as intended?

Agree and communicate plan

  • discuss and agree with the individual/carer/welfare proxy therapeutic objectives and treatment priorities
  • include lifestyle and holistic management goals
  • inform relevant health and social care providers of changes in treatments across the transitions of care

Ask person to complete PROMs (Questions to answer after medicines review) after their review

Agreed plan

  • Nursing home staff ensured correct medicines were temporarily withheld
  • Restart: medicines once nausea and vomiting resolved, and the individual is eating and drinking normally for 48 hours
  • Stop: prochlorperazine when acute illness resolved 
  • Change: co-codamol tablets to paracetamol tablets 
  • Reduce: ramipril to 5mg once daily and metformin to 500mg once daily. Monitor response and adjust accordingly
  • Review: continued need for mirtazapine and laxatives at next consultation 

 

Key concepts in this case

  • Implementation of Medication Sick Day Guidance
  • Fluid intake and output monitoring during potentially dehydrating illness
  • Restarting medicines following sick daysaccording to Medication Sick Day Guidance
  • Review of medicines following acute illness is an opportunity to complete full review of long-term conditions and medicines