Patient Profile for Stewart, Lewis L.
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General Information
ID: lls06242005
Prescriber: Jameson, William M.D.
Name: Stewart, Lewis L.
Address: Country Club Road
City: Zebulon
State: GA
Zip: 30678
Country: USA
Phone: 347.382.3887
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Current Conditions
• agitation
• hypertension
• insomnia
• lactose intolerance
• mild pain
• nutritional supplementation
• renal impairment
• stroke
• vertigo
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Current Allergies
No allergies noted
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Current Medications
• Medication
• Ambien® Dosage: 10 mg Sig: tab 1/2 to 1 at bedtime for sleep
• Diovan HCT® Dosage: 160/12.5mg Sig: tab 1 daily
• Folic Acid Dosage: 400 mcg Sig: tab 1 at supper
• Haldol® Dosage: 5 mg Sig: tab 1 every evening
• Lactase Sig: tab 1 twice a day
• Lotrel® Dosage: 5/20 mg Sig: cap 1 daily
• Meclizine Dosage: 25mg Sig: tab 1 every 8 hours as needed vertigo
• Toprol XL® Dosage: 100mg Sig: tab 1 daily
• Tylenol® Extra Strength Dosage: 500mg Sig: tab 1 every 4 hours for pain
• Zocor® Dosage: 40mg Sig: one at bedtime
• Zyprexa® Dosage: 5 mg Sig: tab 1 daily
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Dosing Parameters
Gender: Male
Birthdate: 5/14/1930
Weight: 90.91 kgs
Height: 177.8 cm
Ideal Body Weight: 72.71 kgs
Body Surface Area: 2.12 m²
Serum Creatinine: 1.6 mg/dL
Creatinine Clearance: 41.03 mL/min
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Notes
Title: Initial Interview & Assessment
Date: 06/24/2005
This 75 year old white male presents with post CVA, severe depression, confusion, difficulty in walking and finding words. He has severe episodes of vertigo and weakness and muscle and joint pain, which further cause frustration. He is very emotional and sometimes cries during the interview when he has trouble finding the right words to express him self. He is currently on multiple psychotropic drugs that are exacerbating his problems. The multiple antihypertensive therapy includes several agents that are contraindicated in his current condition and exacerbate the depression and anxiety he exhibits. His average AM and PM blood pressures do not indicate a degree of control that all these agents should be producing. His average AM blood pressure was 142/64 and his PM blood pressure was 141/74. Consolidation of blood pressure medications will definitely reduce the depression and anxiety and lower the systolic levels slightly. The use of the hypnotic and neuroleptic therapies only exacerbate his ongoing problems and make his life miserable. He is just too old to be on statin therapy, and this will potentially shorten his life rather than extend it. I believe other measures to control his lipids should be tried first. Based on the latest research, use of statin drugs in patients over 70 years of age is considered risky. His depression is the basis of all his current problems, scoring a high 15 value on the Geriatric Depression Scale. I did not perform a Mini-Mental Status Exam on him due to the very high anxiety and depression which would have made his score invalid. I will attempt to do one in a few months after all the other drug therapy problems are resolved and his body has time to adjust to new drug therapy. He does have diarrhea from time to time and indicated a degree of lactose intolerance. The use of Lactase in treatment of the lactose intolerance seems to be working and he should continue the treatment. The anticholinergic drugs used for vertigo are contraindicated in this patient and only add to his major problem of depression and anxiety. I believe we should aggressively attack this problem to develop control and then many of his other somatic problems will disappear. Also, in the future more physical therapy may improve his ability to walk and move about. He does suffer from pedal edema and is on a hydrochlorthiazide drug which is contraindicated in this patient with a creatinine clearance of only 41cc/min. Use of loop diuretic therapy will resolve this problem. The use of a dihydropyridine calcium channel blocker also exacerbates edema problems. The use of multiple ACE drugs will increase his potassium levels, currently 4.6, to a dangerous level. Since daily monitoring is not possible, serious problems and even death can occur.
Title: Drug Therapy Evaluation & Recommendations
Date: 06/24/2005
Review of the drug therapy currently prescribed resulted in the following problem areas:
Ambien - a benzodiazepine class of drugs should not be used in geriatric patients, especially where there is a problem with possible dementia and memory loss. Ambien causes a high risk of
Amnesia like symptoms and will add to the problems of cognition. This drug is not indicated in this patient. Use of dual action SSRI and SNRI will provide needed REM sleep as well as treat the depression and anxiety.
Diovan HCT - use of ACE drugs in the geriatric elevates potassium levels and places the patient at very high risk for hyperkalemia and possible death. Close monitoring of potassium levels are very important when using ACE Inhibitors in the very old patient. Use of hydrochlorthiazide in patients with Creatinine Clearance under 50cc/min provides no benefits as a diuretic without elevated risk. Use of loop diuretics should be used.
Folic Acid - Use of Folic Acid in this patient is necessary for both control of lipids as well as improvement in anemia protection and should be continued. This in combination with Vitamin B12 injections and Vitamin B6 should be added to regimen for these purposes.
Haldol - Use of neuroleptic drugs in this patient is unnecessary and places the patient at very high risk for increased dementia and memory loss symptoms as well as serious adverse events such as Tardive Dyskinesia and death.
Lactase - is essential for treatment of lactose intolerance. This drug should continue.
Lotrel - Another ACE drug along with a dihydropyridine calcium channel blocker both are not geriatric friendly and should be stopped. The amiodipine calcium channel blocker exacerbates edema symptoms and the half life is extended in the geriatric which makes potential buildup of the drug exacerbate additional adverse events. The use of benzothiazipine calcium channel blockers AUC is extended in the geriatric and therefore lower dosing can be used, fewer adverse events and better control of hypertension can be obtained.
Meclizine - use of any anticholinergic antihistamine in the geriatric is contraindicated and will increase potential for falls, memory loss and numerous serious adverse events. This drug should be stopped at once and has no place in the geriatric treatment.
Toprol XL - Use of beta blocker therapy in the depressed anxious patient is contraindicated and only exacerbates these condition. Use of other antihypertensive drugs is indicated. Although there is some merit in the cardioprotection of beta blockers, this may not be an alternative in the geriatric patient due to the increased sensitivity of serious adverse events. Changing to single antihypertensive agent Diltiazem should resolve many problems in this patient. Since the patient is on five different antihypertensive drugs, a titration process is essential to determine the appropriate dose of Diltiazem in this patient.
Tylenol Extra Strength - continued use of acetaminophen may be necessary for relief of mild pain experienced from osteoarthritis. Some of these pains may subside if the statin therapy is discontinued. Additionally, use of Tramadol in conjunction with acetaminophen for more serious pain should be available.
Zocor - use of statin drugs in patients over 70 years of age is considered contraindicated unless cholesterol levels exceed 300. Post stroke and age exacerbate rhabdomyloitis and the inclusion of statin drug therapy highly increases the potential risk for kidney and liver failure. The use of Vitamin B12, Folic acid and Vitamin B6 should maintain his lipids safely.
Zyprexa - as stated in the Haldol comments, the use of neuroleptic drugs are not indicated in this patient at all. Use will exacerbate all of his current cognitive problems and place him in high risk for serious adverse events.
Drug Therapy Management
Stop Ambien
Stop Diovan HCT
Stop Haldol
Stop Lotrel
Stop Meclizine
Stop Toprol XL ( use tapering procedure listed below)
Stop Zocor
Stop Zyprexa
New Drug Therapy
Start Diltiazem CD 240mg daily
Then taper to discontinue Toprol XL 100mg every other day for 4 doses and discontinue
Folic Acid 1mg daily
Vitamin B12 1000mcg IM weekly for 4 doses then each month thereafter
Vitamin B6 200mg tablet daily
Centrum Silver ( or comparable store brand) tab 1 daily
Demadex 5mg daily… monitor for edema control and need to titrate to 10mg daily
Effexor XR 37.5mg at bedtime for 5 days, then 75mg at bedtime for 5 days, then 150mg at bedtime for 30 days and we will reevaluate the need to continue titration up or down.
Lactase tablets twice a day
Tylenol Extra Strength every 4 hours as needed for mild pain
Tramadol 50mg twice a day only if needed for moderate to severe pain
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. I want for you to call me each week with your blood pressure results so I can see if a dose increase is necessary or not. This is very important until we reach your dose. The use of the Effexor XR may cause a little drowsiness the first week so be prepared for this as it will go away and not return after we have the drug in your system in therapeutic levels. Just put up with it as it will surely make you feel better within the next 30 to 60 days. Also we may have to adjust the dose of this as all people are a little different and have their own dose.
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 August or the first of September but would like a progress report by phone weekly.
Title: Drug Therapy Evaluation FLOLOW-UP
Date: 08/15/2005
I talked with the patient’s daughter today. She says he is much better and will get out of his room and go and sit on the porch which is something he had not been doing. His moods are much better and he is walking throughout the house using his walker and entering into family things. As he used to just sit in his room all day now he is alive and active. He is sleeping well at night and naps sometimes during the day. I explained that after the Effexor XR gets into his system well that the sleepy times during the day should go away. His average blood pressure for the past two weeks show AM blood pressure of 156/66 and average AM pulse of 70 with PM blood pressure of 140/71 and PM pulse of 65. In respect to a goal blood pressure of under 130/80 I believe a change in Diltiazem CD to 180mg AM and 180mg PM daily. This will an increase in overall daily dosing but may pull down the blood pressure a few more points into our goal range. I will re-evaluate blood pressures and overall condition in 30 days.
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Drug Interactions
Zolpidem (Ambien®) and Haloperidol (Haldol®)
Severity: Moderate
CNS depressant drugs may have cumulative effects when administered concurrently and they should be used cautiously with zolpidem. Clinical evidence of drug interactions between zolpidem and the antipsychotics [6473] is limited. Some single-dose interactions have been studied but reactions may differ during chronic therapy. Single-dose results indicate that haloperidol [6473] has no effect on the pharmacokinetics of zolpidem, but may have additive CNS depressant effects with multiple dose use from a pharmacodynamic interaction. Chlorpromazine [6473] and zolpidem together produced no change in pharmacokinetic parameters, but had an additive effect on loss of mental alertness and psychomotor function. Concurrent use of zolpidem with chlorpromazine or other phenothiazines [6473] should be undertaken with caution. Additive CNS-depressant effects may also occur with the antipsychotics clozapine, molindone, olanzapine, pimozide, quetiapine, or risperidone.
Haloperidol can potentiate the actions of other CNS depressants such as anxiolytics, sedatives, and hypnotics (e.g., benzodiazepines), dronabinol, THC, ethanol, general anesthetics, opiate agonists, buprenorphine, butorphanol, nalbuphine, pentazocine, or tricyclic antidepressants (TCAs).[5036] Caution should be exercised with simultaneous use of these agents due to potential excessive CNS effects. Limited data suggest that haloperidol may inhibit the metabolism of some tricyclic antidepressants [5080], however, the clinical significance of this interaction is uncertain. Due to the risk of additive QT prolongation and potential for serious arrhythmias, the concurrent use of haloperidol and levomethadyl is contraindicated.[5081] Haloperidol is also an inhibitor of hepatic CYP2D6, and coadministration with many TCAs (which are CYP2D6 substrates) may lead to elevated TCA serum concentrations, potentiating toxicity.[4718]
Zolpidem (Ambien®) and Meclizine
Severity: Moderate
Ethanol has an additive effect on psychomotor performance when given with zolpidem. [6473] Other CNS depressant drugs may also have cumulative effects when administered concurrently and they should be used cautiously with zolpidem. These agents include certain antiparkinsons drugs (entacapone, pramipexole, ropinirole, tolcapone), dronabinol, THC, droperidol, general anesthetics, opiate agonists, mixed opiate agonists/antagonists (buprenorphine, butorphanol, nalbuphine, pentazocine), pregabalin [7523], sedating H1-blockers, tramadol, trazodone, and any other anxiolytics, sedatives, and hypnotics (including barbiturates and benzodiazepines).[6473]
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, pregabalin [7523], ropinirole, tolcapone, tramadol, and psychotropic medications like haloperidol, risperidone or trazodone.
Zolpidem (Ambien®) and Olanzapine (Zyprexa®)
Severity: Moderate
CNS depressant drugs may have cumulative effects when administered concurrently and they should be used cautiously with zolpidem. Clinical evidence of drug interactions between zolpidem and the antipsychotics [6473] is limited. Some single-dose interactions have been studied but reactions may differ during chronic therapy. Single-dose results indicate that haloperidol [6473] has no effect on the pharmacokinetics of zolpidem, but may have additive CNS depressant effects with multiple dose use from a pharmacodynamic interaction. Chlorpromazine [6473] and zolpidem together produced no change in pharmacokinetic parameters, but had an additive effect on loss of mental alertness and psychomotor function. Concurrent use of zolpidem with chlorpromazine or other phenothiazines [6473] should be undertaken with caution. Additive CNS-depressant effects may also occur with the antipsychotics clozapine, molindone, olanzapine, pimozide, quetiapine, or risperidone.
Other drugs that can cause CNS depression, if used concomitantly with olanzapine, can increase both the frequency and the intensity of adverse effects such as drowsiness, sedation, dizziness, and orthostatic hypotension.[5517] Besides ethanol, clinicians should use other anxiolytics, sedatives, and hypnotics (including barbiturates) [5517], buprenorphine [5517], butorphanol [5517], dronabinol, THC [5517], nalbuphine [5517], opiate agonists [5517], pentazocine [5517], tramadol [5043], and trazodone [5517] cautiously with olanzapine.
Hydrochlorothiazide, HCTZ; Valsartan (Diovan HCT®) and Metoprolol (Toprol XL®)
Severity: Moderate
The antihypertensive effects of valsartan can be additive with other antihypertensive agents, including other diuretics. This additive effect can be desirable, but dosages must be adjusted accordingly. Valsartan tends to reverse the potassium loss, but not the serum uric acid rise associated with hydrochlorothiazide monotherapy. No pharmacokinetic drug interaction was observed between hydrochlorothiazide and valsartan.
Metoprolol is an antihypertensive agent, so its effects are additive with other antihypertensive agents.[6714] This interaction is often used advantageously in treating hypertension; however, lower doses of each agent may be necessary. Hypotension can be potentiated when beta-blockers are co-administered with dihydropyridine-type calcium-channel blockers, most notably rapid-release nifedipine. Nicardipine been reported to increase plasma concentrations and oral bioavailability of certain beta-blockers (e.g., metoprolol, propranolol). It is prudent to avoid using beta-blockers with guanethidine, reserpine, or other rauwolfia alkaloids that have a high incidence of orthostatic hypotension due to catecholamine depletion, since beta-blockers will interfere with reflex tachycardia, worsening the orthostasis.[5269]
Hydrochlorothiazide, HCTZ; Valsartan (Diovan HCT®) and Amlodipine; Benazepril (Lotrel®)
Severity: Moderate
The antihypertensive effects of valsartan can be additive with other antihypertensive agents, including other diuretics. This additive effect can be desirable, but dosages must be adjusted accordingly. Valsartan tends to reverse the potassium loss, but not the serum uric acid rise associated with hydrochlorothiazide monotherapy. No pharmacokinetic drug interaction was observed between hydrochlorothiazide and valsartan.
Calcium-channel blockers can have additive hypotensive effects with alpha-blockers and other antihypertensive agents. The antihypertensive effects of benazepril can be additive with other antihypertensive agents including other diuretics. This additive effect can be desirable, but the patient should be monitored carefully and the dosage should be adjusted based on clinical response. The concomitant use of dihydropyridine calcium-channel blockers and beta-blockers can reduce angina and improve exercise tolerance. When these drugs are given together, however, hypotension and impaired cardiac performance can occur, especially in patients with left ventricular dysfunction, cardiac arrhythmias, or aortic stenosis. Patients with hyponatremia or hypovolemia are more susceptible to developing reversible renal insufficiency when ACE inhibitors and diuretic therapy are given concomitantly. Benazepril causes a decrease in aldosterone secretion, leading to small increases in serum potassium levels. Benazepril attenuates diuretic-induced potassium loss (e.g. loop or thiazide diuretics). Use of potassium-sparing diuretics (e.g., spironolactone, triamterene, or amiloride), potassium supplements, potassium salts, or heparin may lead to significant increases in serum potassium concentrations, especially in patients with renal insufficiency or diabetes mellitus. Therefore, if concomitant use of these agents with benazepril is indicated because of documented hypokalemia, they should be used with caution and with frequent monitoring of serum potassium.
Haloperidol (Haldol®) and Metoprolol (Toprol XL®)
Severity: Moderate
In general, haloperidol should be used cautiously with antihypertensive agents due to the possibility of additive hypotension.[5036]
In general, neuroleptics like haloperidol should be used cautiously with antihypertensive agents due to the possibility of additive hypotension.[5036] Propranolol is significantly metabolized by CYP2D6 isoenzymes. A case report of 3 severe hypotension episodes (2 requiring cardiopulmonary resuscitation) has been reported in one 48 year old woman when propranolol and haloperidol have been coadministered.[4360] Additive hypotensive effects and haloperidol-mediated CYP2D6 inhibition may have contributed to this interaction. Conversely, haloperidol may inhibit the antihypertensive effects of guanethidine. Concurrent administration of haloperidol and methyldopa has been reported to result in dementia in some cases although the clinical importance of this interaction has not been established. Caution is advised during simultaneous use of antihypertensive agents and haloperidol.
Haloperidol (Haldol®) and Amlodipine; Benazepril (Lotrel®)
Severity: Moderate
In general, neuroleptics like haloperidol should be used cautiously with antihypertensive agents due to the possibility of additive hypotension.[5036] Propranolol is significantly metabolized by CYP2D6 isoenzymes. A case report of 3 severe hypotension episodes (2 requiring cardiopulmonary resuscitation) has been reported in one 48 year old woman when propranolol and haloperidol have been coadministered.[4360] Additive hypotensive effects and haloperidol-mediated CYP2D6 inhibition may have contributed to this interaction. Conversely, haloperidol may inhibit the antihypertensive effects of guanethidine. Concurrent administration of haloperidol and methyldopa has been reported to result in dementia in some cases although the clinical importance of this interaction has not been established. Caution is advised during simultaneous use of antihypertensive agents and haloperidol.
Haloperidol (Haldol®) and Hydrochlorothiazide, HCTZ; Valsartan (Diovan HCT®)
Severity: Moderate
In general, neuroleptics like haloperidol should be used cautiously with antihypertensive agents due to the possibility of additive hypotension.[5036] Propranolol is significantly metabolized by CYP2D6 isoenzymes. A case report of 3 severe hypotension episodes (2 requiring cardiopulmonary resuscitation) has been reported in one 48 year old woman when propranolol and haloperidol have been coadministered.[4360] Additive hypotensive effects and haloperidol-mediated CYP2D6 inhibition may have contributed to this interaction. Conversely, haloperidol may inhibit the antihypertensive effects of guanethidine. Concurrent administration of haloperidol and methyldopa has been reported to result in dementia in some cases although the clinical importance of this interaction has not been established. Caution is advised during simultaneous use of antihypertensive agents and haloperidol.
Haloperidol (Haldol®) and Olanzapine (Zyprexa®)
Severity: High
Haloperidol is a hepatic microsomal CYP2D6 substrate as well as a CYP2D6 inhibitor.[4718] Serum concentrations of drugs metabolized by 2D6, such as thioridazine, may become elevated if combined with haloperidol. Concurrent use of haloperidol with other antipsychotic agents, like clozapine, olanzapine, p |