A 82 year old male has a medical history of osteoarthritis, diabetes, BPH, gastroparesis and Parkinson’s disease. He is complaining of nausea and stomach upset after meals. Current medications include:
- Sinemet 25/100 mg 2 tablet three times daily
- Requip 0.5 mg BID
- Protonix 40 mg once daily
- Aspirin 81 mg daily
- oxybutynin 5 mg TID
- Diphenhydramine 50 mg HS
- Metformin 500 mg BID
- Acetaminophen 500 mg PRN
- Atorvastatin 10 mg daily
- Senna S 1 BID
This is a situation set up for the classic prescribing cascade. We have a new or exacerbated symptom of possible gastroparesis. The most common medication I see used in the setting of gastroparesis is metoclopramide. The major issue with metoclopramide is that it does block dopamine receptors and could exacerbate this gentleman’s Parkinson’s disease.
What I would like to address first is the use of the anticholinergics. Remember that anticholinergics can slow down the GI tract and possibly contribute to constipation and/or gastroparesis. Identifying why this patient is using diphenhydramine (likely for insomnia) and finding an alternative would be an appropriate consideration. Also looking at BPH and how/why this patient is on the oxybutynin would be another important aspect in trying to rule out drug induced gastroparesis.
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Try domperidone..better than metoclopramide for PK patients. Sure, things like reducing or stopping the Benadryl for sleep and changing the oxybutynin to a safer urinary antimuscarininc like Detrol are good pharmacy practices to pursue.
Patient is missing an ACE or ARB for Diabetes
Last time I checked, domperidone was not an approved drug in the United States, and physicians who want to prescribe have to request an expanded access investigational new drug application.