Patient Profile for Odham, Sue
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General Information
ID: slm01202005
Prescriber: Simpson, Barry M.D.
Name: Odham, Sue K.
Address: 112 East Burborn Street
City: Newnan
State: Georgia
Zip: 30482
Country: USA
Phone: 345.435.2144
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Current Conditions
• anxiety
• arterial thromboembolism prophylaxis
• asthma
• dementia
• dysfunctional uterine bleeding
• females
• hiatal hernia
• osteoporosis prophylaxis
• renal impairment
• vertigo
• Hypertension (discovered 2/02/2005)
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Current Allergies
No allergies noted
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Current Medications
• Medication
• Albuterol; Ipratropium Dosage: 2.5mg/.5mg Sig: 2cc AM, NOON, PM
• Antivert® Dosage: 25mg Sig: tab 1 daily
• Bayer® Adult Low Strength Enteric Coated Aspirin Dosage: 81mg Sig: tab 1 daily
• Budesonide Dosage: 0.5mg with Albuterol/Ipratropium Sig: in breathing treatment TID
• Citracal® Sig: tab 1 daily
• Medroxyprogesterone Dosage: 5mg Sig: tab 1 daily
• Namenda® Dosage: 10mg Sig: tab 2 AM and PM
• Premarin® Dosage: 0.9ng Sig: tab 1 daily
• Reminyl® Dosage: 8mg Sig: tab 2 AM and PM
• Theophylline Dosage: 300mg Sig: tab 1 daily
• Tranxene® Dosage: 3.75mg Sig: tab 1 AM, Noon, 5PM daily
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Dosing Parameters
Gender: Female
Birthdate: 08/21/1930
Weight: 77.73 kgs
Height: 160.02 cm
Ideal Body Weight: 55.05 kgs
Body Surface Area: 1.86 m²
Serum Creatinine: 0.9 mg/dL
Creatinine Clearance: 47.66 mL/min
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Notes
Title: Initial Interview & Assessment
Date: 01/20/2005
This 74 year old white female presents with signs and symptoms of dementia. She is sometimes hostile to family members, especially when her routine is disrupted. She still will play bridge and other card games and works cross-word puzzles after 6 years of demonstrating signs of dementia. She answered the questions on the Geriatric Depression Scale, but when I questioned the family it was obvious that she had not been as truthful as possible. Multiple examples of depression and compulsive actions make it a subject that has to be addressed with drug therapy. This is not currently being done. She is on multiple drugs for Alzheimer’s that interact with other medications currently prescribed as well as other comorbid conditions that prohibit the use of these drugs. Unusual continuance of HRT on this 74 year old female due to bleeding when stopped is very suspicious as well as contributing to the potential for dementia. Use of long acting benzodiazepine therapy exacerbates the pulmonary problems (asthma) as well as balance, gait and cognition. Many of these drugs must be stopped. The lack of necessary laboratory tests and the absence of the patient, only husband and daughter were present, make continuing this assessment unnecessary. The necessary laboratory tests are going to be completed and another visit scheduled in a week to complete my analysis.
Title: Follow-up Visit after Completion of Needed Information and Laboratory Test
Date: 02/01/2005
A delightful morning was spent interviewing and testing the patient. I was impressed at the alertness and personality of this lady. Although I did observe some short term memory loss, it was almost like she prioritized the information she wanted to remember and discarded that which she determined unimportant, a characteristic that is uncommon for a patient with Alzheimer’s Disease, especially well into the sixth year of diagnosis. Testing on the MMSE shows an almost perfect score of 29 out of 30 possible points. She was very personable and cooperative and seemed to enjoy our visit very much. A review of her TSH value of 0.692 demonstrates ample thyroid function which rules out cognitive problems from hypothyroid functions. I had her husband and the patient’s sitter fill out the Cornell Scale for Depression in Dementia. The patient scored an 8. This shows enough depression to be concerned about and warrants treatment. Moving away from benzodiazepine use and into use of an SSRI-SNRI would provide many benefits in correcting the depression and the anxiety episodes experienced by the patient. Review of her Comprehensive Metabolic Profile and Lipids panel shows a very healthy patient with a LDL of 113 but a ratio of only 1.8. Since she does not present with any of the comorbid conditions that would indicate treatment for this problem, only periodic monitoring of the Lipids is necessary. Review of Serum B12 and Folic Acid levels shows that use of old standard B12, B6 and Folic Acid regimen may improve her lipid levels and also improve her motor functions and overall well being. With a B12 of 355 and Folic Acid of 18.7, treatment would surely be considered appropriate. This regimen lowers homocystine and methylmalonic acid levels and therefore increases HDL while lowering LDL and Cholesterol. It usually works in the geriatric patient.
Review of her mean blood pressures did present some concern. The mean AM blood pressure of 154/94 and mean PM blood pressure of 132/86 indicates a need for antihypertensive treatment. Allowing the diastolic blood pressure to stay that high places the patient at high risk for either a severe CVA or TIA problems. Use of benzothiazepine calcium channel blocker would be the most friendly approach to controlling the blood pressure in this age female. Diltiazem time release along with the extended AUC due to age make use of this drug the choice in blood pressure control in the geriatric.
With an HgA1c of 5.9% in treating younger patients this may be considered a high value that should be addressed. Yet, in the geriatric all recent studies and standards of practice lean toward not as tight control in an effort to improve the patient quality of life. A 5.9% is an average mean blood sugar of under 150 which is well within the suggested range of the geriatric patient of 7% to 8% HgA1c.
Title: Drug Therapy Evaluation & Recommendations
Date: 02/01/2005
Review of the drug therapy currently prescribed resulted in the following problem areas:
Albuterol/Ipratropin - use of this asthmatic treatment seems unnecessary on a routine basis. The exacerbation of anxiety from this treatment may in some ways play a role in the cognitive problems exhibited in this patient. The less the albuterol is used, the less anxiety and potential for cognitive problems may be observed. A slow tapering of this treatment to a discontinuance is advised.
Antivert - use of anticholinergic antihistamine drug therapy is totally contraindicated in treating the geriatric patient. Exacerbation of many symptoms that mimic cognitive impairment will occur. Also, in combination with cholinergic drugs (cholinesterase inhibitor) Reminyl stops the action of both.
Budesonide - steroidal therapy in treating asthmatic attacks are excellent for acute problems,
but this patient does not have an ongoing acute respiratory problem. This drug should be tapered
and discontinued. Periodic use may be necessary for acute problems only.
Citracal - Use of calcium citrate is the salt of choice in supplemental calcium therapy in the
geriatric patient. Since the pH of the stomach increases to a more basic media, the use of the
carbonate salt is not recommended due to lack of absorption. The citrate salt of which Citracal is
a brand product will dissolve and be absorbed in a more basic media. Treatment should continue.
Medroxyprogesterone - I cannot understand the patient’s need for this drug. In the geriatric female, risks from continued use far outweigh benefits received. Many problems involving cognitive impairment, anxiety, agitation, frustration, anger and emotional outburst are all consistent with use of this drug. Although in some of the information the mention of vaginal bleeding when the HRT was removed precipitated continuance of therapy. A very slow taper to discontinue the therapy is needed…
Premarin - HRT in the geriatric patient does not help in treating osteoporosis, or dementia symptoms and in fact exacerbate these conditions. Use of HRT increases thromboembolic disorders by 10 fold. I feel that the combination of the two hormones may play a role in the cognitive function of this patient. This drug should be slowly tapered for discontinuance. If slow enough tapering occurs bleeding should not occu,r but if the patient starts to bleed, close monitoring of patient is necessary until bleeding subsides in a week or two.
Namenda - Although this drug gets a great deal of publicity in the press, no unbiased studies done either in the U.S. or abroad have shown any real statistical difference between the drug and the double blind placebo. It has a very long half-life in the geriatric patient taking some 50 to 60 hours to clear. This means that buildup of the drug is common in the geriatric which exacerbates more confusion, dementia and cognitive problems. A slow taper to discontinue is advised.
Reminyl - As with Namenda, unbiased studies in U.S. and abroad show no difference or benefits to the Alzheimer’s patient in its use. Although there are many stories circulating about the benefits, it has been consistent with my findings that it does not benefit the patient. A slow taper to discontinue is advised.
Theophyllin - Continued theophyllin use in this patient again exacerbates anxiety and many of the other cognitive problems experienced with this patient. Changes in the asthma therapy on this patient moving to use of Ipratropium Inhaler only and a slow taper of theophyllin may improve overall status of the patient.
Tranxene - Use of long acting benzodiazepine drugs in the geriatric patient is contraindicated due to residual CNS suppression. Also, in patients with respiratory problems use of benzodiazepine therapy is contraindicated. Use of the SSRI-SNRI (Effexor XR) will provide the antianxiety and antidepressant benefits and if given at bedtime will improve REM sleep which may help with cognition problems.
Aspirin - should be continued but use of 325mg Enteric Coated tablet should be considered in an effort for cardiovascular protection. Low dose aspirin may be alright but some studies show more protection with the regular dosing of aspirin.
Drug Therapy Management
Taper to stop Albuterol/ipratropium/Budesonide nebulizer to AM and PM for 7 days, then AM for 7 days, then every other AM for 7 days and Stop.
Stop Antivert
Taper Theophyllin 300mg every other day for 10 doses and Stop
Taper Premarin 0.9mg every other day for 30 days and Stop
Taper Provera every other day for 60 days and Stop
Taper Namenda 10mg AM and PM for 15 days, then AM only for 10 days and Stop
Taper Reminyl 8mg AM and PM daily for 20 days then AM only for 10 days and Stop
Taper Trenxene 3.75mg AM and Noon for 30 days, then AM for 30 days, then Stop
New Drug Therapy
Atrovent Inhaler, 2 puffs AM, Noon, PM
Citracal 950mg tablet 1 AM and PM
Centrum Silver tablet daily
Effexor XR 37.5mg at bedtime x 5 days, then 75mg at bedtime x 5 days then 150mg at bedtime …. Then we will evaluate in 60 days for further titration
Aspirin EC 325mg tab 1 daily
Vitamin E 400U daily
Omega 3 Fatty Acid 1000mg (Fish Oil) cap 1 AM and PM
Diltiazem CD 120mg daily (keep monitoring AM and PM blood pressures daily and record)
Vitamin B12 1000mcg IM weekly for 4 weeks, then the 1st of each month thereafter
Vitamin B6 200mg tablet every AM
Folic Acid 1mg tablet every AM
Remember that it will take time to see all the changes that the new drug therapy will produce. After completing the titration processes that are required, we should see big improvements relating to the complaints recorded. The additional vitamin supplements should also make you feel better after 30 days or so. Further titration of the diltiazem dosing may be needed until we reach your dose. Continue to keep your blood pressure and pulse log. This is very important. Try to stay active and continue your card playing and crossword puzzles. Also, go out more and be with friends and keep those mental processes as active as possible. The changes in your asthma therapy may take a little time to get used to but should help with the anxiety. The Effexor XR should help a lot.
Let me remind you that this drug therapy regimen is thoroughly thought out and should be followed in its entirety. Choosing only bits and pieces of it may keep us from reaching our mutual goal of improvement in your quality of life and health. I am as close as your phone, so if problems occur please call me. I look forward to seeing you for a follow-up visit around the end of March or the first of April but would like a progress report in 30 days by phone.
Title: Follow-Up Visit
Date: 02/28/2005
A conversation with her husband this AM reviewed some confusion problems experienced by Sue. I concluded that possibly the increased titration of Effexor XR to 150mg and the tapering of the Tranxene to discontinue would require some more time. Sue has been sleepy during the day and has been napping numerous times. Upon awakening, she is somewhat confused and has asked for her mother. Since the long acting benzodiazepine, Tranxene, is still in its titration process downward for future discontinuance, this type of problem is not unusual. The rapid onset of action and very long half life of Tranxene along with the increase of Effexor XR may have exacerbated these episodes. Her husband states that he has seen much improvement in Sue over the past few weeks. These spells started around the time the Effexor XR was moved from 75mg at bedtime to 150mg at bedtime. Still taking the Tranxene 3.75mg in the morning could lead to cognitive problems and is probably the villain in this current behavior. Her blood pressures still average above 130/80 and she is currently on 120mg Diltiazem CD daily. I believe that an increase to 180mg daily may improve these values. There is no doubt that this is the right antihypertensive drug. We just have to find the correct dose which can only be achieved through trial and error. Her blood pressures are not in a dangerous area, but they are not the target values we are shooting for. Her breathing shows some congestion, so an increase in the Atrovent from three times a day to four times a day is advised. After we clear her system of the benzodiazepine effects, we can probably reduce the use of this inhaler.
New Proposed Drug Therapy
Atrovent Inhaler, 2 puffs around 8AM, 12noon, 4PM and 8PM
Citracal 950mg tablet 1 AM and PM
Centrum Silver tablet daily
Effexor XR 75mg at bedtime and we can reassess after 60 days for need for increase
Aspirin EC 325mg tab 1 daily
Vitamin E 400U daily
Omega 3 Fatty Acid 1000mg (Fish Oil) cap 1 AM and PM
Diltiazem CD 180mg daily (keep monitoring AM and PM blood pressures daily and record)
Vitamin B12 1000mcg IM the 1st of each month. Starting after today’s dose
Vitamin B6 200mg tablet every AM
Folic Acid 1mg tablet every AM
Reduce the Tranxene 3.75mg to every other morning for 10 days and discontinue completely
Title: Follow-Up Visit
Date: 03/11/2005
Today’s meeting to review the past two weeks blood pressures indicates a need for a dose titration upwards on the diltiazem CD. She is presently on 180mg of diltiazem CD daily and blood pressures both systolic and diastolic, were above the 130/80 parameters we are trying to achieve. Also, she is having some difficulty breathing and the Atrovent inhaler seems not to meet her needs. I believe that after we have all the excess hormones and other medications she had been taking completely discontinued, that in a few months, breathing difficulties should subside.
Changes are as follows:
Stop Diltiazem CD 180mg
Start Diltiazem CD 240mg daily (continue to log blood pressures
Hold Atrovent Inhaler
Start Albuterol/Atrovent nebulizer treatments 3 to 4 times a day only as needed for breathing difficulties. Please keep me informed with progress or lack of progress.
We will re-evaluate blood pressures and condition in two weeks.
Title: Follow-Up Visit
Date: 03/24/2005
Follow-up today shows that Sue has greatly improved in her sleep patterns and possibly in cognition. She is currently on 240mg of diltiazem CD daily, but still is running a mean blood pressure of 148/90 AM and 154/84 PM with mean pulse of 80. This is still a problem, and I believe if we extend the AUC by dividing the dosing into BID diltiazem CD dose twice a day, that the possibility of bringing the blood pressure into our goal range of less than 130/80 can be reached. She finishes the Provera on April 3, 2005, which will finish all her titrations from the start of our drug therapy management program. Although she still has respiratory difficulties that require the use of her breathing treatments, these are intermittent and might subside after a period of time. I will continue to monitor blood pressure values until we meet our goal.
Drug Change needed:
Stop Diltiazem CD 240mg daily
Start Diltiazem CD 180mg twice a day.
Will review in two weeks.
Title: Follow-Up Visit
Date: 06/09/2005
A review of her average blood pressure, AM and PM, for the past 30 days were impressive and I feel we have finally found her dose of diltiazem of 180mg twice a day. Her average AM blood pressure value is 145/78 with an average AM pulse of 76 and her average PM blood pressure value is 134/78 with an average PM pulse of 88. These values are consistent with the outcomes we were trying to reach and the patient is doing extremely well. The Effexor XR has been successfully titrated to 150mg at bedtime with excellent results. She had some breathing difficulties a few weeks ago and Pulmicort was prescribed of which she used for a few weeks. She is back to her usual four times a day Atrovent with an as necessary use of Combivent which she carries around in her pocketbook. The new Spiriva Handihaler has shown such a marked improvement over the use of Atrovent in all the recent studies with only once a day treatment is an alternative treatment for the bronchial problems experienced by the patient. The administration of the 18mcg dose, inhaled, each morning provides 24 hour support for the bronchospasms experienced. Although it is expensive a 30 day trial use should provide all the necessary drug support needed for this condition.
Drug Changes Needed:
Start Spiriva Handihaler 18mcg inhaled each morning
Stop Atrovent
Continue Combivent for the occasional unplanned attacks
Continue Diltiazem CD 180mg twice a day
Continue Effexor XR 150mg at bedtime.
Continue other initiated medications listed above and we will reevaluate in 90 days.
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Drug Interactions
Albuterol; Ipratropium and Budesonide
Severity: Moderate
Methylxanthine derivatives (e.g., theophylline, aminophylline) and corticosteroids may aggravate the hypokalemic effect that may be seen with beta-agonists. Consider checking potassium levels if clinically indicated. However, beta-agonists are commonly used in conjunction with aminophylline, theophylline, and corticosteroid therapy.
Albuterol; Ipratropium and Theophylline, Aminophylline (Theophylline)
Severity: Moderate
Methylxanthine derivatives (e.g., theophylline, aminophylline) and corticosteroids may aggravate the hypokalemic effect that may be seen with beta-agonists. Consider checking potassium levels if clinically indicated. However, beta-agonists are commonly used in conjunction with aminophylline, theophylline, and corticosteroid therapy.
Methylxanthine derivatives, (such as theophylline [5277] and aminophylline) and corticosteroids [3085] may aggravate the hypokalemic effect that may be seen with beta-agonists.[5197] Consider checking potassium levels if clinically indicated. However, beta-agonists are commonly used in conjunction with aminophylline, theophylline, and corticosteroid therapy.[5197]
Meclizine (Antivert®) and Clorazepate (Tranxene®)
Severity: Moderate
Meclizine may produce significant sedative effects.[6348] Enhanced CNS depressant effects may occur when meclizine is combined with other CNS depressants including anxiolytics, sedatives, and hypnotics, barbiturates, buprenorphine, butorphanol, dronabinol, THC, entacapone, ethanol [6341], general anesthetics, nalbuphine, opiate agonists, pentazocine, pramipexole, ropinirole, tolcapone, tramadol, and psychotropic medications like haloperidol, risperidone or trazodone.
Concomitant administration of clorazepate with CNS-depressant drugs, including opiate agonists, buprenorphine, butorphanol, nalbuphine, pentazocine, phenothiazines, barbiturates, dronabinol, THC, entacapone, ethanol, sedating H1-blockers, general anesthetics, tolcapone, tramadol, tricyclic antidepressants, or other anxiolytics, sedatives, and hypnotics, can potentiate the CNS effects (e.g., increased sedation or respiratory depression) of either agent.
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