polypharmacy question

[cyanocobalamin]

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How would you change a patient's meds who is on all these meds, a 50s M with a hx of schizoaffective disorder

Fentanyl 100 mcg IV q3days
Phenytoin Sodium 200 mg po bid
Benztropine 0.5 mg po tid
Apiprazole 10 mg po qam
Apiprazole 20 mg po qhs
Thorazine 350 mg po qhs
Albuterol 2 puffs po q4-6h prn
Combivent 1-2 puffs po qid
Nebulized Respiratory Therapy
Lactulose 45 mL po tid
Effexor 100 mg po qam
Effexor 150 mg po qhs
Trazodone 50 mg po qhs
Ranitidine 150 mg po bid
Ambien 10 mg po hs prn insomnia
Amitriptyline 25 mg po bid
Gabapentin 900 mg po tid
Celcoxib 100 mg po bid prn pain
Lidocaine HCl viscous solution 2% soln 15 mL po qid
Calcium Carbonate/Vit D 250mg/125U 2 tabs po bid
Cyanocobalamin 1000 mcg IM q28days
Folate 1 mg po qam
Glucosamine/Chondroitin 400 po tid
Omega 3 fatty acids 1 cap po bid
Thiamine 100 mg po qam
Nystatin Syrup 100,000/ml 5 cc po qid

New meds:

Coumadin 3mg po qd

some of his axes:

I: SAD, EtOH remission
II: ?ASPD
III: hepatitis, r/o hepatic encephalopathy, COPD, chronic back pain, neck pain, GERD, thrombus
IV: poor social support, CMI, institutional living
V: GAF 22

 

[john182]

How would you change a patient's meds who is on all these meds, a 50s M with a hx of schizoaffective disorder

Wow! That looks like a complete mess!

 

[OldPsychDoc]

I love this.
A lot would depend on he's presenting right now. Stable? Increased voices? Depressed? Behavioral problems? Physical illness? Side effects? Is he totally gorked out?Also--I presume that patch is fentanyl, not reminyl...

Bottom line--never use 2 meds when one will do, aim for q day dosing, and minimize drug-drug interactions.

The FIRST thing I'd do though is dump the amitriptylline. He looks medically compromised, so there's no reason to have something so deliriogenic on board. You can increase the Effexor to 300 and give it all q am. Same with the aripiprazole. Maybe dump the thorazine, trazodone, and ambien and substitute quetiapine at bedtime. That would be a start. Of course, you really should try to figure out how he got to this--he may have a great provider who's really struggling to help him and they've already gone through all the easy stuff--or he may be in and out of the hospital, seeing multiple docs, and accumulating chart weeds.

How would you change a patient's meds who is on all these meds, a 50s M with a hx of schizoaffective disorder

Reminyl 100 mcg/h apply to skin q3days
Phenytoin Sodium 200 mg po bid
Benztropine 0.5 mg po tid
Apiprazole 10 mg po qam
Apiprazole 20 mg po qhs
Thorazine 350 mg po qhs
Albuterol 2 puffs po q4-6h prn
Combivent 1-2 puffs po qid
Nebulized Respiratory Therapy
Lactulose 45 mL po tid
Effexor 100 mg po qam
Effexor 150 mg po qhs
Trazodone 50 mg po qhs
Ranitidine 150 mg po bid
Ambien 10 mg po hs prn insomnia
Amitriptyline 25 mg po bid
Gabapentin 900 mg po tid
Celcoxib 100 mg po bid prn pain
Lidocaine HCl viscous solution 2% soln 15 mL po qid
Calcium Carbonate/Vit D 250mg/125U 2 tabs po bid
Cyanocobalamin 1000 mcg IM q28days
Folate 1 mg po qam
Glucosamine/Chondroitin 400 po tid
Omega 3 fatty acids 1 cap po bid
Thiamine 100 mg po qam
Nystatin Syrup 100,000/ml 5 cc po qid

 

[Anasazi23]

The most interesting part of this is the pt's age....50? That's a lot of implied problems for a 50 year old. Is he HIV+ ?



This is a recipe for serotonin syndrome and akithesia.

Lose at least the Remeron and/or Elavil for sure - for starters.

Without knowing anything about this patient, it appears he has a seizure disorder, some sort of dementing process, asthma/COPD, thought disorder, inc. LFTs or constipation, duodenal/gastric ulcers, insomnia, chronic? pain and possibly HIV or other immunocompromising state. It appears that there's room to move on the psychotropics at least. Again, without knowing the patient, it appears there's too many antidepressants on board, although we don't know the dose of the Trazodone....it's hard to believe he's not sleeping with all those meds at night. I assume the gabapentin's being dosed at least BID + HS...which is often sufficient for decent sleep. Ambien and trazodone on top seem like a lot, not to mention the extra 5HT you're adding.

Does this patient have Wernicke's encephalopathy, alcoholic dementia and Korsakoff's psychosis? Anyway, it looks to be a lot....don't be surprised at a delirium state in the near future, if it hasn't already happened. Without knowing the patient, a touch of pneumonia or UTI looks to send this guy into a delirious state.

 

[OldPsychDoc]

The most interesting part of this is the pt's age....50? That's a lot of implied problems for a 50 year old. Is he HIV+ ?

....

Does this patient have Wernicke's encephalopathy, alcoholic dementia and Korsakoff's psychosis? Anyway, it looks to be a lot....don't be surprised at a delirium state in the near future, if it hasn't already happened. Without knowing the patient, a touch of pneumonia or UTI looks to send this guy into a delirious state.

I just assumed he was a Vet... 😀

 

[Anasazi23]

I just assumed he was a Vet... 😀

LOL...me too, I had the exact same thought.

 

[NeuroDO]

I hear Lidocaine works wonders for Schizoaffective Disorder.

Please tell me this post is a joke and that there is not some poor man out there walking around on all these meds.

 

[OldPsychDoc]

I hear Lidocaine works wonders for Schizoaffective Disorder.

Please tell me this post is a joke and that there is not some poor man out there walking around on all these meds.

Actually, I've seen worse--you could possibly make up a rationale for this guy's treatment regimen. Not a GOOD one mind you, but it's possible...

 

[Anasazi23]

He developed a DVT?
Watch his INR (with the phenytoing/warfarin)...it might be subtherapeutic.

 

[cyanocobalamin]

He developed a DVT?
Watch his INR (with the phenytoing/warfarin)...it might be subtherapeutic.

Medicine was following the Coumadin and his last INR was just above 2. Alas, the patient's been discharged.

I: SAD, EtOH remission
II: ?ASPD
III: hepatitis, r/o hepatic encephalopathy, COPD, chronic back pain, neck pain, GERD, thrombus
IV: poor social support, CMI, institutional living
V: GAF 45

 

[50960]

I can't believe this guy still has a liver!! I assume the lactulose is for elevated ammonia?? ETOH abuse, all those meds. What were his LFT's like?

😎

 

[OldPsychDoc]

Medicine was following the Coumadin and his last INR was just above 2. Alas, the patient's been discharged.

I: SAD, EtOH remission
II: ?ASPD
III: hepatitis, r/o hepatic encephalopathy, COPD, chronic back pain, neck pain, GERD, thrombus
IV: poor social support, CMI, institutional living
V: GAF 45

Were we right about him being a Vet?

 

[Anasazi23]

Hepatitis = Hep C or B?

Lactulose might have been for constipation.

AST/ALT ratio?

 

[OldPsychDoc]

I can't believe this guy still has a liver!! I assume the lactulose is for elevated ammonia?? ETOH abuse, all those meds. What were his LFT's like?

😎

Actually, that's a relatively liver-friendly regimen...

Anybody got any more?

How about:

Baclofen 10 tid
Geodon 180 qhs
Cymbalta 60 bid
Tegretol 100 bid
Ultram 50-100 q 4-6 prn
Ativan 1-2 q 6 prn
Neurontin 1200 tid
Simethicone
Zelnorm

Guess the dx?

 

[50960]

Fibromyalgia!! LOL. I was referring to the hep status and the Etoh abuse mainly. I would still like to hear what the lab says.

🙂

 

[OldPsychDoc]

Fibromyalgia!! LOL. I was referring to the hep status and the Etoh abuse mainly. I would still like to hear what the lab says.

🙂

you got the fibro, but missed the impulsivity, disorganization and lability of the hypomanic state, the borderline rage (combined with absolute refusal to accept any med that might cause an ounce of weight gain), and the hx of cocaine dependence--all of which combine to make my life a countertransference hell at the moment.

as an award for your correct partial diagnosis, you may now have this patient on YOUR SERVICE! Congratulations!!!!

 

[Anasazi23]

1. Prednisone 20mg PO QD
2. Periodic Procrit TIW
3. Amitryptyline 200mg QD
4. Risperdal .5mg PO Qam, 1mg PO QHS**
5. Lexapro 20PO QD
6. Klonopin 1mg PO QD

*Hint: Admission for low HgB, +ileostomy with melena, Pt. is Jewish, on GMF.
** Why?

This one should be easy...

 

[cyanocobalamin]

Hepatitis = Hep C or B?

Lactulose might have been for constipation.

AST/ALT ratio?

HCV
Lactulose secondary to elevated ammonia
Don't know AST/ALT ratio

Were we right about him being a Vet?

Yes