Box 2: Complete assessment of medications for potential drug-related problems and resulting medication care plan
Potential drug-related problemAction planMonitoring (by team)
Diarrhea and hyponatremia

  • May be contributed to by:

    • - Escitalopram (other than low energy, patient has no major depressive symptoms)

    • - Pantoprazole (likely no longer needed given gastrointestinal bleed was 7 mo earlier)

    • - Telmisartan

  1. Decrease escitalopram to 5 mg/d for 2–4 wk, then stop

  2. Stop pantoprazole and start rabeprazole 20 mg/d for 2 wk

  3. Decrease rabeprazole dose to 10 mg/d for 2–4 wk, then stop

  4. Use calcium carbonate or alginate or low- dose ranitidine as needed for rebound heartburn

  5. Decrease telmisartan dose gradually to 40 mg daily, then to 20 mg daily if possible

  • Bowel movements, stool consistency, need for loperamide

  • Mood

  • Withdrawal effects of SSRI discontinuation (e.g., sweating, nausea, insomnia, tremor)

  • Rebound heartburn for 2–4 wk

  • Blood pressure target: 120/60 mm Hg to 150/90 mm Hg

Orthostatic hypotension and dizziness

  • May be contributed to by:

    • - Metoprolol (no longer required given MI was 15 yr earlier and no other compelling indications)

    • - Telmisartan

  1. Decrease metoprolol to 25 mg/d for 2 wk, then to 12.5 mg/d for 1 wk, then stop

  2. If blood pressure is still below target range, reduce telmisartan dose (see tapering plan above)

  • Angina, tachycardia

  • Orthostatic hypotension, dizziness

  • Blood pressure target: 120/60 mm Hg to 150/90 mm Hg

Frequent falls and daytime fatigue and sleeping

  • May be contributed to by lorazepam

Decrease lorazepam to 0.5 mg at bedtime for 2 wk, then to 0.25 mg at bedtime for 2 wk, then stop

  • Sleep

  • Anxiety, tremor

Vitamin D deficiency (49 nmol/L) and increased risk of fallsStart vitamin D 1000 IU/d
Vitamin B12 deficiency (189 pmol/L)Start vitamin B12 1000 μg/d
Risk of adverse effects with prednisoneConsider slowly tapering prednisone dose (e.g., from 5 mg twice daily to 7.5 mg once daily for 1 mo, then to 5 mg once daily for 1 mo, and so on)

  • Note: MI = myocardial infarction, SSRI = selective serotonin reuptake inhibitor.