89 year old patient has been battling with anxiety and insomnia over the previous few months. Also has a history of GERD, hypertension, allergies/congestion, constipation. Here’s the med list:
Ativan 0.25 mg twice daily as needed
diphenhydramine 25 mg daily at bedtime
omeprazole 20 mg daily
lisinopril 20 mg daily
metoprolol 25 mg twice daily
hydrochlorothiazide 25 mg daily
pseudoephedrine 60 mg every 4-6 hours as needed
clonidine 0.1 mg twice daily
docusate 100 mg twice daily
Senna 2 tablets twice daily
The first thing I would look at addressing is the current problem. With anxiety and insomnia, I’d be concerned that the(pseudoephedrine) Sudafed side effects are exacerbating conditions and causing potentially unnecessary use of other medications. Timing is very important as always. Are they taking the pseudoephedrine, how often, and when did they start taking it? I’d also look and see if any of the blood pressure medications have been increased with the timing of the pseudoephedrine.
We also have some issues with constipation. This is a perfect example of the potential of the prescribing cascade. Is Sudafed (pseudoephedrine) worsening hypertension causing the use of more blood pressure medications? Is it causing insomnia necessitating the use of the diphenhydramine? Is it causing or worsening anxiety and inciting the use of Ativan (lorazepam). Is the diphenhydramine causing the use of the laxatives (docusate and Senna)? Just a few thoughts on the importance of assessing as needed use. Please feel free to comment if something jumps out at you! – #allinthistogether
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Eric Christianson, PharmD, CGP, BCPS