Box 2: Complete assessment of medications for potential drug-related problems and resulting medication care plan
Potential drug-related problemAction planMonitoring (team)
Low blood pressure and orthostatic hypotension (and frequent falls)

  • May be contributed to by cardiovascular medications:

    • - Nitroglycerin patch

    • - Furosemide

    • - Amlodipine

    • - Acebutolol

    • - Quinapril

    • - Diltiazem

  1. Immediate:

    • - Stop nitroglycerin patch

    • - Decrease furosemide to 20 mg/d

    • - Stop amlodipine

  2. 1 wk later: decrease acebutolol to 100 mg twice daily; consider further decrease in future

  3. Future: if needed, consider reducing quinapril, because current daily dose is at maximum

  4. Future: consider reducing diltiazem ER to 240 mg/d if possible

  • Resolution of orthostatic hypotension

  • Angina/use of nitroglycerin as needed

  • Blood pressure target: 120/65 mm Hg to 140/90 mm Hg

  • Decrease in falls

  • Improvement in renal function: repeat serum creatinine once quinapril dose reduced

Orthostatic hypotension, poor balance, excessive sedation and frequent falls

  • May be contributed to by anticholinergic load:

    • - Amitriptyline

    • - Cyclobenzaprine

    • - Morphine

    • - Carbamazepine (not likely required for post-stroke seizure prophylaxis; may have drug accumulation owing to inhibition of cytochrome P450 3A4 enzyme by diltiazem and omeprazole)

    • - Oxazepam (diltiazem and furosemide considered above)

  1. Decrease amitriptyline to 50 mg at bedtime for 1 wk, then to 25 mg for 2 wk, then stop if possible

  2. Decrease cyclobenzaprine to twice daily (morning and bedtime); reduce frequency further if possible or reduce dose to 2.5 mg; eventually stop if possible (note: patient finds this medication most effective for pain control, so may be hardest to taper)

  3. Re-evaluate usefulness of morphine and taper or stop if possible

  4. Consider tapering carbamazepine to 100 mg twice daily and eventually stopping

  5. Once effect of above changes assessed, begin tapering oxazepam

  • Sleep initiation

  • Pain control

  • Resolution of orthostatic hypotension

  • Decrease in excessive sedation

  • Improvement in balance, decrease in falls

  • Seizure control

  • Thyroid-stimulating hormone levels (decrease in carbamazepine may alter levothyroxine requirements)

Reduced cognition

  • May be contributed to by anticholinergic load and CNS depressants (diltiazem, furosemide, amitriptyline, cyclobenzaprine, carbamazepine, morphine, oxazepam)

  • May not require treatment with galantamine once medication contributors tapered

  1. See above for recommendations to reduce anticholinergic load, and for tapering morphine and diltiazem

  2. Consider reassessing need for galantamine once above medication changes are made

Forgetfulness, difficulty finding words, apraxia
Constipation (stools infrequent, straining)

  • May be contributed to by anticholinergic load (plus other mechanisms for diltiazem and morphine)

  • Requires alternate treatment, because patient is not using current regimen successfully

  1. See above for recommendations to reduce anticholinergic load, and for tapering morphine and diltiazem

  2. Stop lactulose, fibre supplement, bisacodyl and suppository

  3. Start polyethylene glycol 3350, 15 mL in water daily

Reduced straining
Risk of hypermagnesemia and associated toxicity (e.g., hypotension and cramps)

  • May be contributed to by magnesium therapy given reduced renal function (creatinine clearance 30 mL/min)

Stop magnesiumConsider checking magnesium level
Risk of bradycardia, atrioventricular block

  • May be contributed to by combined use of acebutolol and diltiazem

  1. Consider further tapering of acebutolol and possible discontinuation (as above)

  2. Consider reducing diltiazem ER dose (as above) also or instead of step 1

  • Heart rate

  • Angina

Omeprazole: ongoing need unclear (duodenal ulcer several years ago but no heartburn)

  1. Stop omeprazole and start rabeprazole 10 mg/d (least expensive proton pump inhibitor on provincial drug formulary) for 2 wk, then stop

  2. Use calcium carbonate or alginate or low-dose ranitidine as needed for rebound heartburn

Rebound heartburn for 2–4 wk
Rosuvastatin: not needed twice daily given potency and half-life

  1. Reduce rosuvastatin to 20 mg once daily

  2. Consider requesting cholesterol levels from nursing home to confirm whether patient is at LDL target

LDL target < 2.0 mmol/L
Salbutamol: not needed if no shortness of breath and not being usedStop salbutamolShortness of breath
Levofloxacin: taken daily, but prescribed only for 10 days more than a month agoStop levofloxacin
Concomitant amitriptyline and levofloxacin use: can cause prolonged QT interval

  1. Taper and stop amitriptyline as suggested

  2. Stop levofloxacin

Glucosamine: benefit unlikely given questionable efficacy in osteoarthritis pain control and low dose (doses of 1.5 g/d in clinical trials) (3)Stop glucosamine
Patient at increased risk of falls but is not receiving prophylaxis for osteoporosis

  1. Start vitamin D 1000 IU/d

  2. Once constipation has resolved, start elemental calcium 500 mg twice daily (review options with patient)

  3. Consider bone density scan and bisphosphonate if indicated and if renal function improves

  • Note: CNS = central nervous system, ER = extended release, LDL = low-density lipoprotein.