The Pills That Play Tricks: A Look at Commonly Overprescribed Medications-Slides

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This educational presentation by Dr. Thomas Chen and Dr. Niti Patel focuses on hospital prescribing practices, particularly related to antihypertensives, gabapentinoids, opioids, and proton pump inhibitors (PPIs), while emphasizing pharmacogenomics and patient safety.<br /><br />Key points on inpatient hypertension management indicate that treating acute episodic hypertension with intravenous antihypertensives in hospitalized non-cardiac patients does not improve mortality, length of stay, or ischemic event rates. Use of PRN (as-needed) blood pressure meds correlates with worse outcomes including increased acute kidney injury, strokes, mortality, and longer hospitalization. Moreover, intensifying antihypertensive therapy during hospitalization or at discharge generally does not improve long-term blood pressure control.<br /><br />Regarding gabapentinoids (gabapentin and pregabalin), FDA-approved uses are limited primarily to neuropathic pain and seizures. Off-label uses for conditions like low back pain and acute zoster lack strong evidence. Gabapentinoids pose significant risks including respiratory depression (especially with opioids), increased mortality risk, dependence, and side effects such as dizziness and sedation. Tapering is advised when discontinuing these agents.<br /><br />Non-pharmacologic pain management (e.g., physical therapy, cognitive behavioral therapy, topical agents) is encouraged over muscle relaxants and other medications often prescribed more to appease patients or on-call demands. Muscle relaxants have limited long-term efficacy and substantial side effects.<br /><br />The discussion on opioids highlights the role of CYP2D6 genetic polymorphisms in metabolizing tramadol, codeine, hydrocodone, and oxycodone, affecting efficacy and safety. Poor metabolizers may exhibit inadequate analgesia, whereas ultrarapid metabolizers risk toxicity. Tramadol carries higher risks of dependence, serotonin syndrome, hypoglycemia, and mortality compared to codeine and NSAIDs, prompting caution with its use. Alternatives like morphine and hydromorphone (not heavily CYP2D6-dependent) may be preferable in certain patients.<br /><br />Finally, PPIs metabolism via CYP2C19 affects drug levels and clinical efficacy; poor metabolizers have increased drug exposure and better outcomes, while ultrarapid metabolizers have increased clearance and higher treatment failure risk. Dose adjustments or switching to less CYP2C19-dependent PPIs may be needed for refractory cases.<br /><br />The presentation underscores the importance of personalized prescribing based on evidence, pharmacogenomics, and cautious evaluation of risks versus benefits in hospitalized patients. It advocates for de-prescribing unnecessary medications to optimize patient outcomes and safety.

Keywords

hospital prescribing practices

antihypertensives

gabapentinoids

opioids

proton pump inhibitors

pharmacogenomics

patient safety

inpatient hypertension management

non-pharmacologic pain management

personalized medicine