patient with a history of hypertension, heart failure, GERD, osteoarthritis, and hyperlipidemia
In this case, Mrs. P. is an 80-year-old patient with a history of hypertension, heart failure, GERD, osteoarthritis, and hyperlipidemia who has recently been discharged from a hospital after an acute bronchitis diagnosis. Mrs. P. has been prescribed prednisone 15 mg for the taper, doxycycline, and a tiotropium inhaler. Current medications before the hospitalization include metoprolol succinate 12.5 mg, pantoprazole 40 mg, atorvastatin 10 mg, Lisinopril 10 mg, furosemide 40 mg, potassium chloride 20 meq bid, acetaminophen 650 mg bid for pain and tramadol 25 mg as needed. During follow-up care, the patient reported no exacerbation of heart failure, resolved bronchitis, and manageable arthritic pain. Further review revealed reduced weight by 5 lbs over the last six months, clear lungs upon auscultation, and no lower extremity edema.
Question 1:
Mrs. P. is concerned about polypharmacy, and deprescription would allow the nurse practitioner to withdraw some medications that are no longer beneficial. Auscultation reveals that her lungs are clear during follow-up care, implying that acute bronchitis infection has cleared. As a result of these findings, the nurse practitioner should discontinue doxycycline because it is a tetracycline antibiotic used to kill and stop the growth of bacteria (Wang et al., 2020). Since bacterial pathogens are associated with the etiology of acute bronchitis, resolving symptoms reveals that doxycycline has achieved its purpose and should be stopped. The tiotropium inhaler, used to manage acute bronchitis symptoms such as wheezing, coughing, and breathing difficulties, should be stopped because the illness has resolved. The prednisone 15 mg to taper should be discontinued. This medication should not have been prescribed in the first place because it is a systemic corticosteroid used to relieve symptoms in upper respiratory tract infections by stopping the inflammation in the nasal and throat linings. Acute bronchitis is an acute lower respiratory infection, and randomized clinical trials have shown that steroids should not be used since they have no effect (Hay et al., 2017).
Pantoprazole is a proton pump inhibitor that reduces the production of gastric acid. The medication is used in the treatment of GERD. Having used the medication for six months and not experiencing GERD symptoms within that duration are valid reasons to deprescribe this medication. Even though the patient also reports no exacerbation of heart failure, metoprolol succinate 12.5 mg should continue being used because the initial dose was usually 25 mg PO q Day, which was eventually reduced to 12.5 mg/day. The patient reports that she has the lowest weight and that using atorvastatin 10 mg, a statin, should only be stopped once the clinician determines that the patient’s total cholesterol is within the normal range. Lastly, the nurse practitioner should discontinue the use of furosemide 40 mg because there is no evidence of lower extremity edema due to congestive heart failure exacerbations (Eid et al., 2020).
Question 2:
The medication the nurse practitioner could reduce after Mrs. P completes the prednisone taper is the tiotropium inhaler. While prednisone is a steroid that inhibits the inflammation in the nasal and throat linings, the tiotropium inhaler is a bronchodilator whose mechanism of action is to open and relax the airways to facilitate breathing (Koenigsberg & Stukus, 2023). It manages symptoms such as shortness of breath, wheezing, coughing, and chest discomforts, which also occur in acute bronchitis. The nurse practitioner should reduce the tiotropium inhaler since the patient’s bronchitis has resolved and the lungs are clear.
Question 3:
Metoprolol succinate 12.5 mg and Lisinopril 10 mg are the medications prescribed to manage exacerbations of heart failure. Metoprol succinate is a beta blocker that blocks beta1 receptors, reducing the heart’s oxygen demand. Furthermore, Lisinopril is an ACE inhibitor that reduces aldosterone and plasma angiotensin II and gradually increases plasma renin activity to lower blood pressure (Borghi et al., 2020). Given that Mrs. P. has no heart failure exacerbations, complies with a reduced sodium diet, and maintains her blood pressure within normal limits, these two medications should be adjusted. However, the nurse practitioner needs to base this decision on laboratory findings. Furthermore, the medicines should not be discontinued as blood pressure could increase again. Lisinopril should only be stopped if the patient’s renal function declines.
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