In this scenario, I review how medications can increase the blood clot risk. A 66 year old female is taking the following medications.
- Aspirin 81 mg daily
- Lamotrigine 100 mg BID
- Apixaban 5 mg BID
- Acetaminophen 500 mg BID
- Pantoprazole 40 mg daily
- Baclofen 10 mg BID
- Metoprolol 25 mg BID
- Conjugated estrogens 0.625 mg once daily
- Cyclobenzaprine 10 mg at bedtime
- Zolpidem 5 mg at bedtime
- Duloxetine 60 mg daily
- Famotidine 10 mg at bedtime
- Ibuprofen 400 mg TID PRN
I have quite a few concerns to review with this medication list. My first issue would be to review the blood clot risk. The patient is taking both apixaban and aspirin and is likely at risk or has a history of stroke or blood clots in some capacity. With having conjugated estrogens on board, we are continuing to put this patient at risk for blood clots. Reviewing the indication and the history of use of conjugated estrogens would be critical in an effort to try to get the patient to potentially taper off the medication.
Utilizing an NSAID is also risky with an anticoagulant on board. GI bleed risk can be problematic and it is obvious that the patient likely has some GI issues already as she is taking both famotidine and pantoprazole. In addition to the GI bleed risk, NSAIDs have a boxed warning for the risk of cardiovascular thrombotic events. We definitely have a couple of strikes against the NSAID in this scenario.
CNS sedation is going to be an adverse effect to monitor closely. The cumulative drug interaction effect of having baclofen, cyclobenzaprine, and zolpidem on board could lead to substantial sedation and potentially morning after hangover type effects that could impair functioning the next day. Assessing sleep issues and pain would be critical to see if we could start to reduce the sleeper or muscle relaxers. I’d probably start with trying to reduce the zolpidem first, if I had to pick one. If you are looking for more information on drug interactions, be sure to take advantage of my free (if you’ve never tried Audible before) 10+hour Audible book.
As far as monitoring goes for this medication list, CBC (includes hemoglobin), renal function, and vital signs would be my top monitoring parameters to assess.
What else would you like to ask in this case?