Mrs. M is an 87-year-old female residing in a skilled nursing facility. Her medication list includes:
- Apixaban 5 mg BID (for atrial fibrillation)
- Docusate 100 mg BID
- Senna 8.6 mg BID
- PEG 17 g daily
- Calcium carbonate 500 mg TID
- Lisinopril 10 mg daily
- Metoprolol tartrate 25 mg BID
- Donepezil 10 mg daily
- PRN oxycodone 5 mg
Her most recent labs show a serum creatinine of 1.7 mg/dL. She has lost ~15 lbs in the past few months and is now 100 lbs (45.5 kg). The nursing staff reports that she is having loose stools 2–3 times per day, and has had a few near-falls when urgently trying to get to the bathroom.
She’s on three scheduled agents: PEG, senna, and docusate. Given her current loose stools and risk of falls, the bowel regimen is too aggressive. Docusate in particular is ineffective, especially in the presence of more active agents like PEG and senna. It could be safely discontinued. You might also consider discontinuing the Senna as well to try to reduce pill burden and restart if constipation becomes a problem. I would also want to double-check the timing of donepezil as this can occasionally be a contributor to GI symptoms and weight loss.
Per FDA labeling for atrial fibrillation, the dose of apixaban should be reduced to 2.5 mg twice daily if a patient meets at least two of the following criteria: age 80 or older, body weight 60 kg or less, or serum creatinine of 1.5 mg/dL or higher. Mrs. M meets all three—she is 87 years old, weighs 45.5 kg, and has a serum creatinine of 1.5 mg/dL. Despite this, she remains on the standard dose of 5 mg twice daily, which puts her at an increased risk for bleeding.
With the fall risk, it would be reasonable to assess blood pressure given the metoprolol and lisinopril use.
It is also unclear why the patient is taking calcium carbonate three times daily. This seems excessive and would cause the need for another medication administration time, given the TID order. I would question if this could be discontinued.
What else would you like to address in this case scenario?
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