A 59 year old female is on the following medications:
- Alprazolam 1 mg four times daily as needed
- Norvasc 10 mg daily
- Simvastatin 40 mg at bedtime
- Cyclobenzaprine 10 mg hs prn
- Tylenol PM as needed
- Lasix 20 mg daily
- Glucagon kit as needed
- Glipizide 5 mg daily
- Lantus 18 units daily
- Humalog 8 units TID
- Vicodin 5/325 1 tablet TID
- Levothyroxine 88 mcg daily
- Temazepam 15 mg hs
- Losartan 50 mg daily
- Effexor XR 187.5 mg once daily
- Zofran 4 mg as needed
- Lyrica 50 mg TID
Past medical history includes
- Anxiety
- HTN
- MI
- Spasms
- Inosmnia
- CHF
- DM
- OA
- Hypothyroid
- Neuropathy
- Falls
So where do we begin….anywhere of course!
Glucagon for hypoglycemia is always an order that I’m going to ask about. It likely indicates that they have had trouble with low blood sugars in the past. You want to know how frequently someone has had to use this. A1C assessment will be important as well. It would be nice to simplify this patient’s regimen if possible (reduce number of injections and/or DC glipizide if possible).
Anxiety and sleep is obviously an issue. She is on several sedating medications, including duplicate benzodiazepines. Eliminating some sedating medications that may not be working would be an important thing to look at. With a history of falls, this makes it that much more important.
Lots of prn’s to investigate. Very important to assess use and ask questions from there.
A beta-blocker would be indicated given the compelling indications, but I suspect this may have been tried in the past? Something that I would dig into further. BP, Pulse, hypoglycemia would all be important factors.
TSH, Kidney function, and electrolytes would all be important.
Norvasc/Zocor interaction is an imporant one to remember.
Pregabalin, edema risk is another consideration.
What else?
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Thank you so much. It’s a very interesting case. It would be necessary to monitor glucose level in diabetics and the risk of osteoporosis should be considered in patients on levothyroxine. Unnecessary medications such as Vicodin or Tylenol should be DC. Rhabdomyolysis should be considered with pregabalin and simvastatin
No DDI between Lyrica and Zocor. You meant Norvasc and Zocor.
Rhabdomyolysis risk is increased with the combination of zocor and pregabalin. Lexicomp 2016