Mrs. P. is an 80-year-old woman recently discharged from a 24-hour observation stay at the hospital after being diagnosed with acute bronchitis. She has a history of heart failure, hypertension, osteoarthritis, GERD, and hyperlipidemia. She has no history of smoking. While in the hospital she was prescribed doxycycline, prednisone 15 mg to taper, and a tiotropium inhaler. Her current list of daily medications prior to hospitalization includes metoprolol succinate 12.5 mg, pantoprazole 40 mg, atorvastatin 10 mg, lisinopril 10 mg, furosemide 40 mg, potassium chloride 20 meq bid, acetaminophen 650 mg bid for pain and tramadol 25 mg as needed. She lives alone but will reside temporarily with her daughter while she recovers. Her discharge report indicated resolving bronchitis, no exacerbation of heart failure, and stable arthritic pain. Today she reports 1 week after discharge with her daughter for a primary care appointment, and they both were concerned about the number of medications she was prescribed and wanted her medications reviewed. In further review, she was found to have lost weight over the past 6 months of 5 lbs and her current BMI is 25. She states that the weight loss may be due to a change to a healthier diet and reducing sodium as instructed. She also reports no symptoms of GERD for the past 6 months and minimal arthritic pain because of regular use of acetaminophen and daily walking in the halls of her independent living facility. Upon examination her lungs are clear to auscultation and no evidence of lower extremity edema.
Discuss the following:
1) In reviewing her medication list and current symptoms and clinical signs, which
medication could the nurse practitioner consider de-prescribing.
2) Once the patient has completed the prednisone taper, which medication could the nurse
practitioner begin to reduce given the patient’s reported symptoms.
3) Given the absence of an exacerbation of heart failure and compliance with a reduced
sodium diet, what other medication(s) adjustments could the nurse practitioner consider at
this time.
- In reviewing Mrs. P’s medication list and current symptoms and clinical signs, the nurse practitioner could consider deprescribing certain medications. Considering her resolving bronchitis and clear lung examination, the tiotropium inhaler may no longer be necessary. Acetaminophen 650 mg bid for pain can also be reconsidered since she reports minimal arthritic pain due to regular use of acetaminophen and daily walking. The nurse practitioner could assess if she still needs to continue taking it regularly or if it can be taken on an as-needed basis.
- Once Mrs. P has completed the prednisone taper, the nurse practitioner could consider reducing or discontinuing the use of prednisone given the patient’s reported symptoms. Prednisone is a corticosteroid and is often prescribed to reduce inflammation and manage symptoms associated with acute bronchitis. Since her bronchitis is resolving and her lungs are clear, the nurse practitioner could assess if the prednisone can be safely discontinued or if a lower dose is appropriate based on her symptoms.
- Given the absence of an exacerbation of heart failure and Mrs. P’s compliance with a reduced sodium diet, the nurse practitioner could consider adjusting her heart failure medication, specifically furosemide (a loop diuretic). Furosemide is commonly prescribed to manage fluid retention in heart failure patients. However, if there is no evidence of lower extremity edema and her heart failure is stable, the nurse practitioner could consider reducing the dose or frequency of furosemide to avoid over-diuresis and potential electrolyte imbalances. This adjustment should be done cautiously, monitoring her response and ensuring that her fluid status remains stable.
It is important for the nurse practitioner to carefully assess Mrs. P’s overall clinical condition, consider the risks and benefits of deprescribing, and consult with other healthcare professionals, such as the primary care physician or a pharmacist, before making any medication adjustments or deprescribing decisions.