What three prioritized changes would you make to the medication regimen?

D. G. is a 74-year-old African American woman who arrives at the emergency room complaining of shortness of breath, palpitations (for two days), and lower extremity edema. Her medical history includes diabetes mellitus, hypertension, heart failure with reduced ejection fraction, and osteoarthritis. She had a left heart catheterization and coronary angiography last year and has no significant coronary artery disease. She has a biventricular pacemaker/implantable defibrillator for heart failure symptom treatment and sudden cardiac death prevention. The patient’s current medications are losartan 100 mg/d, metoprolol succinate 50 mg/d, metformin 500 mg twice daily, spironolactone 25 mg/d, furosemide 40 mg/d, and naproxen 500 mg twice daily.

Vital Signs

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  • Blood pressure of 140/80 mm Hg
  • Respiratory rate of 30 bpmand heart rate of 120 bpm
  • ECG shows atrial fibrillation with a rapid ventricular response
  • Echocardiography reveals a moderately dilated left atrium, left ventricular systolic ejection fraction of 35% (unchanged), chronic kidney disease (baseline serum creatinine 1.01 mg/dL), and moderate mitral regurgitation.

Pertinent Laboratory Values

  • Hemoglobin 12 g/dL, hematocrit 36%, platelets 300,000/microliter, and serum creatinine 1.20 mg/dL (estimated creatinine clearance 39 mL/min).
  • Her weight is 60 kg (increased from 55 kg), and height is 5 feet 3 inches.
  • She does not smoke and does not drink alcohol.
  • Dietary habits include one can of Ensure daily, with other meals provided by a social service agency (Meals on Wheels).

Social Concerns

Social concerns include the fact that she lives alone, but a son visits every one to two weeks and transports her to physician appointments. She is living on a limited budget. With regard to her medication adherence, her son states that she occasionally forgets to take her afternoon medications, but overall, she is considered to be reasonably adherent with her drug regimens.

Diagnosis: Atrial Fibrillation, Acute Onset

  1. List specific goals of treatment for D. G.
  2. What drug therapy would you prescribe for stroke prevention in atrial fibrillation? Why?
  3. What are the parameters for monitoring success of the anticoagulant therapy?
  4. Discuss specific patient education based on the prescribed therapy.
  5. List one or two adverse reactions for the selected agent that would cause you to change therapy.
  6. What would be the choice for the second-line therapy?
  7. What over-the-counter (OTC) or alternative medications would be appropriate for D. G.?
  8. What lifestyle changes would you recommend to D. G.
  9. Describe one or two drug-drug or drug-food interactions for the selected agent.

Directions

  1. Craft a therapeutic plan.
  2. Using Beers Criteria and rational drug prescribing, review the medications and diagnoses listed for D. G. What three prioritized changes would you make to the medication regimen? Include a detailed and evidence-based rationale for all changes, including, but not limited to, monitoring, drug-drug interactions, drug-disease interactions, pharmacokinetics/pharmacodynamics, age, gender, and culture.
  3. What would be your pharmacological-related patient education?
  4. Would you order any laboratory testing? Provide rationale for all decisions.
  5. Describe a follow-up plan of care with rationale.