One of the things I did most often when I started this blog nearly 7 years ago was snag a medication list and tell you what my top priorities are to investigate. I’m going to do a little throwback and go through one tonight with my top three priorities. Here’s the medication list:
- Amlodipine 5 mg daily
- Aspirin 81 mg daily
- Clopidogrel 75 mg daily
- Atorvastatin 80 mg daily
- Pantoprazole 40 mg daily
- Metoprolol tartrate 50 mg BID
- Lisinopril 40 mg daily
- Docusate 100 mg daily
- Miralax 17 gm as needed
- Acetaminophen 500 mg BID
- Diltiazem CD 240 mg once daily
- Apixaban 2.5 mg BID
Whoa boy…where do we start? First I would assess bleed risk. There are a couple of major reasons I’d do this first. The biggest reason is that this patient is on triple therapy. They have dual antiplatelet therapy and an anticoagulant. It is important to note that the apixaban dose is lower than the usual 5 mg BID.
The other big reason I am concerned about the anticoagulation/antiplatelet status is that diltiazem can potentially interact with apixaban and raise concentrations. Maybe this is why the dose being used for apixaban was lowered in the first place? Or maybe it was because of the combination of the interaction with diltiazem and the dual antiplatelet agents? I discuss the diltiazem/apixaban further in my latest Drug Interaction Book. (You can get the Audible book for FREE here if you haven’t ever tried one) Regardless, CBC and monitoring for bleed risk is absolutely a top priority.
Also associated with the diltiazem, I would want to inquire as to why this patient is on two calcium channel blockers. It would make the most sense to get rid of the diltiazem if possible and increase the amlodipine if necessary. The indication that diltiazem is being used for does make a difference, so it would be important to assess that prior to changes. Blood pressure and heart rate are going to be essential to know as well.
The last point I wanted to make is that calcium channel blockers are associated with constipation. It would be good to assess this and if we could reduce or discontinue one of these, this may allow us to use less constipation medication.
What else would you like to investigate with this medication list?
- 30 medication mistakes PDF
- 18+ Page Drug Interaction PDF
- 10 Commandments of Polypharmacy Webinar based on my experiences in clinical practice