A 76-year-old female is tired of taking so many medications. She reports to you that “I’d like to stop all my medications”. While she understands that she likely cannot stop all of them, she’d like to at least eliminate some of them. Here is her medication list with some thoughts as to which medications I would first target.
- Aspirin 81 mg daily
- Clopidogrel 75 mg daily
- Lisinopril 10 mg daily
- Metoprolol XL 25 mg daily
- Ferrous sulfate 325 mg daily
- Metoclopramide 10 mg QID
- Vitamin C 500 mg daily
- Atorvastatin 80 mg daily
- Omeprazole 40 mg BID
- Hydralazine 10 mg TID
- Famotidine 20 mg once daily
- Alendronate 70 mg weekly
- Vitamin D 1,000 units daily
While a diagnosis list is critical to help determine which medications are essential, you can always begin to formulate ideas about what you would look into further to try to reduce polypharmacy.
My first thought as I review these medications is the large number of GI medications that this patient is taking. Ideally, we’d like to avoid chronic metoclopramide. This medication is not the greatest in the elderly and she is taking it four times daily as well which leads to a much higher medication burden. She is also doing a twice-daily PPI. The possibility of omeprazole affecting clopidogrel is always something in the back of my mind as well.
The next target I’d review is the iron. Iron supplementation can often be discontinued. In my experience, many older patients get placed on iron after a procedure and a significant number of patients continue to take it long term. Assessing iron stores by checking ferritin and hemoglobin would be ideal to determine if this could be a medication we could get rid of. On top of the iron, I suspect vitamin C is being used to aid in the absorption of the iron. If this is the case, it could possibly be discontinued if iron stores are adequate.
The blood pressure regimen could use some cleaning up. I’m speculating she is at higher cardiovascular risk given the dual antiplatelet therapy and high-intensity statin therapy. It is interesting why we are using three low-dose blood pressure medications. Three times daily hydralazine seems like a good candidate to be discontinued as we can likely increase lisinopril. Checking the blood pressure and reviewing the medication history would be a great place to start here in determining if this is appropriate.
Lastly, I’d review osteoporosis risk and identify the length of alendronate use. If she has been on this for a period of 5 years+, it might be a good time to reassess if this continues to be necessary.
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