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This month’s case focuses on how a physician handled continuing a patient’s medication after she was released from a hospital stay. It’s a reminder that when a Boxed Warning is involved, extra care should be taken when prescribing that particular medication.
Just the Facts
The patient, Ms B, 73, had been seeing a rheumatologist since the early 2000’s, and had been diagnosed with rheumatoid arthritis. As of 2016, Ms B was taking the corticosteroid prednisone to compensate for the effects of a pituitary tumor that had caused adrenal insufficiency.
Starting in 2012, Ms B began seeing an internist, Dr R. Over the next 4 years, Dr R treated the patient for a variety of issues, including an earache, cat bite, cough, pre-operative clearance for hand surgery, and hip pain.
In late November 2016, Ms B contacted Dr R with complaints of high fever, weakness, and difficulty moving. The physician recommended that she go to a hospital emergency department, which she did. The emergency department physician diagnosed the patient with severe community-acquired pneumonia, sepsis secondary to pneumonia, and effusion. The hospital physician consulted with an intensive care unit physician and pulmonologist who recommended treating the patient with levofloxacin.
Ms B was admitted to the hospital as an inpatient for 5 days, with Dr R listed as the admitting physician. During this time, the patient was administered 750mg of levofloxacin every 48 hours for 5 days, and continued on her existing medications, including prednisone. Dr R examined Ms B in the hospital between November 24 and November 26, 2016.
The hospital physicians adjusted Ms B’s prednisone dose after noting findings consistent with an inflammatory response to poorly controlled rheumatoid arthritis. The plaintiff’s arthritis was improved after that, and she was discharged from the hospital on November 28, 2016, in stable condition, with a prescription for prednisone, and instructions to follow up with Dr R, her internist.
She saw Dr R the day after she was discharged, November 29, and he provided her with a continuation prescription for levofloxacin, one 750mg tablet every 48 hours for 6 days. She filled the prescription and took the medication. Within a month, Ms B suffered from an acute rupture of the gluteus medius tendon, requiring her to undergo 2 major surgeries leaving her unable to walk without assistance, and suffering from numerous disabilities.
Tendon rupture is a known risk of fluoroquinolones such as levofloxacin, and the risk is increased in patients over the age of 60 and in those taking corticosteroids, such as prednisone. This information has been the subject of a Boxed Warning which was added to the dispensing information in 2008.
