Low BP secondary to
bisoprolol (indication unclear; to our knowledge, patient does not have history of AF, MI, or angina) candesartan
|
| BP (target of 120/60 mm Hg to 150/80 mm Hg) |
Dizziness, light-headedness, fatigue, and dry mouth can be caused by
metoclopramide (contributes to dizziness, light-headedness) trazodone (contributes to all) cetirizine (contributes to all), which patient states is not helping with watery, itchy eyes betahistine dihydrochloride (contributes to fatigue and dry mouth) dimenhydrinate (contributes to all)
|
Stop metoclopramide (see below) Reduce trazodone dose to 25 mg/d at bedtime; if tolerated, reduce to 12.5 mg/d at bedtime, then as occasion requires (will counsel about sleep hygiene) Stop cetirizine Taper betahistine dihydrochloride (to twice daily for 2 wk, then once daily for 1 wk, then stop) Stop dimenhydrinate
| Dizziness, light-headedness, fatigue, dry mouth Nausea, vomiting, or bloating with stopping metoclopramide Sleep pattern Worsening of watery, itchy eyes Worsening of vertigo or dizziness |
Risk of exacerbation of parkinsonism increased with metoclopramide |
Stop metoclopramide Start domperidone if nausea, vomiting, or bloating worsens After metoclopramide is stopped, revisit dosing and timing of levodopa to maximize effectiveness*
| Nausea, vomiting, or bloating |
Unclear value of rosuvastatin (no apparent CVD or cerebrovascular disease; patient has history of hemorrhagic stroke for which statin secondary prevention effectiveness is controversial) |
Confirm with family doctor that the patient does not have CAD or CVD; if so, then need to consider whether to add ASA for secondary prevention Stop rosuvastatin (if for primary prevention)
| NA |
Patient’s nausea
possibly secondary to betahistine dihydrochloride, cetirizine (including anorexia), or rosuvastatin not relieved by pantoprazole (which does not appear to be indicated for heartburn), which might be contributing to low vitamin B12 level (needs treatment)
|
Taper betahistine dihydrochloride (as above) Stop cetirizine (see below) Stop rosuvastatin (see above) Switch to 10 mg/d of rabeprazole for 2 wk, then stop (provide written information about aluminum-magnesium antacid or calcium carbonate antacid for rebound heartburn) Add 1000 μg of vitamin B12 daily
| Worsening of vertigo or dizziness Nausea Fatigue or dry mouth Eye itchiness and wateriness Rebound heartburn (2–4 wk) |
Patient’s low mood
might be due to use of β-blockers: bisoprolol (indication unclear as, to our knowledge, patient does not have history of AF, MI, or angina); timolol systemic absorption might be treated with mirtazapine or citalopram
|
Confirm with family doctor that patient does not have CAD or CVD; if she does, then need to consider whether to add ASA for secondary prevention If no, stop bisoprolol (already at lowest dose) Consider adding either 7.5 mg/d of mirtazapine at bedtime or 5 mg of citalopram and increase gradually as tolerated
| Heart rate, angina with taper BP (target of 120/60 mm Hg to 150/80 mm Hg) Improvements in mood, anxiety, interest in social activities Improvements in sleep and insomnia, dizziness, etc, with antidepressant initiation |
Patient at risk of fracture with falls (taking 150 mg of risedronate monthly and vitamin D) and would benefit from addition of calcium | Add up to 1000 mg of calcium carbonate antacid twice daily (check dietary intake) | GI side effects, constipation |
Itchy and watery eyes
|
| Eye itchiness and wateriness |
Routine blood glucose monitoring not needed (diet controlled) | Stop routine blood glucose tests | NA |