Case Spotlight

Clinical Pharmacy

Geriatric

Summary

  • 78 year old female with DM, HTN, GERD, Mood Disorder, OA, PVD, and hypothyroidism.
  • PCP is hoping to reduce medication list for improved compliance, chronic illness optimization, and reduction in potential side effects/drug-to-drug interactions.
  • Specialist made recommendations for reducing current medication regimen and suggested other medications that may be more effective.

eConsult transcript

PCP submission:

78 year old female with DM, HTN, GERD, Mood Disorder, OA, PVD, Hypothyroidism. 

Medications: Zolpidem 10 mg PRN, bisacodyl 5 mg, levothyroxine 0.025 mg, isosorbide ER 60 mg, trulicity 0.75 mg/0.5 mL, magnesium citrate, lisinopril 40 mg, ibuprofen 200 mg daily, gabapentin 100 mg daily, quetiapine EX 200 mg, HCTZ 25 mg, clopidogrel 75 mg, omeprazole 40 mg daily. 

Please review and comment on polypharmacy reduction.

Specialist response:

Thank you for this consult. If a patient like this walked into my office, I would have the following general thoughts:

  • Limit/avoid use of NSAIDs in setting of elderly woman on clopidogrel, given increased bleeding risk. Consider APAP 1gm TID prn and or diclofenac topical gel for localized pain.
  • Agree with taper of PPI, expect some rebound acid reflux upon cessation. Manage with famotidine and calcium carbonate chews.
  • Recommend limiting zolpidem dose to 5mg qhs to reduce fall risk. If possible consider tapering off and trying doxepin 3-10mg or trazodone 25mg in its place.
  • Consider further increase of trulicity if DM is not at goal.
  • Consider switching HCTZ to chlorthalidone 25mg, may be able to get BP to goal <140/90 with the switch. Collect BMP 1-2weeks after switching.
  • Indicated for a statin for secondary ASCVD risk reduction. Consider addition of statin. (e.g.; rosuvastatin 20mg or atorvastatin 40-80mg daily). Addition of statin and smoking cessation biggets modifiable risk factors for lowering ASCVD risk.
  • Also recommend routine assessment of the role of gabapentin. Is it continuing to provide benefit? If provider and pt are unsure, then consider a drug holiday to assess Thank you for this consult.

Tags: Polypharmacy, medication reconciliation, mood disorder, geriatric medications, med rec, medication management