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• Katia Gedeon

Module 7 Discussion: Case 6

• Case

           The case is of Mrs. P who is an 80-year-old woman that visits the hospital after being discharged from a 24-hour observation stay the hospital after an acute bronchitis diagnosis. Her medical history includes hypertension, heart failure, GERD, osteoarthritis, and hyperlipidemia.  Medications she was prescribed at the hospital include doxycycline, prednisone 15 mg to taper, and a tiotropium inhaler. Before a hospitalization, she took pantoprazole 40 mg, metoprolol succinate 12.5 mg, lisinopril 10 mg, atorvastatin 10 mg, potassium chloride 20 meq bid, furosemide 40 mg, tramadol 25 mg as needed, and acetaminophen 650 mg bid for pain. Her social support is her daughter and she will stay with her temporarily as she recovers. The discharge report shows resolving bronchitis, stable arthritic pain, and no exacerbation of heart failure. The concern for her and her daughter is the number of medications she is taking as they report after 1 week and they wanted the medication to be reviewed. She has lost weight in the last six months due to sodium as instructed and a healthier diet.

Medications to Consider De-Prescribing

Mrs. P’s bronchitis is clearing, and an auscultation examination reveals clear lungs, therefore she does not require prednisone, doxycycline, or tiotropium inhaler. The use of prednisone, tiotropium inhaler and doxycycline are all targeted at addressing the respiratory infection that led to bronchitis. But with the clearing of symptoms for a long time, these medications could be de-prescribed. She also lacks indications of lower extremity edema, necessitating the use of furosemide medicine for de-prescribing. Mrs. P has no symptoms of GERD, hence Pantoprazole should be stopped. Mrs. P reported minor arthritic pain due to consistent acetaminophen intake, hence Tramadol should be de-prescribed. These medications are de-prescribed based on the assessment that has shown reduction or elimination of signs and symptoms that they are supposed to treat (Mangin, 2019). This also helps reduce the overall medication burden for the patient as she and her carer have complained (Mangin, 2019).

Medications that could be reduced after the Patient Completes Prednisone Taper

Prednisone is an anti-inflammatory synthetic (artificial) steroid. It is used to treat asthma, inflammatory arthritis, serious allergies, and a variety of other ailments (Bernstein, 2020). Prednisone, like other corticosteroids, operates by reducing immune system activity. The drug is administered to the patient on a taper schedule, which means that the dosage must be gradually reduced until the medication is fully withdrawn. This is critical for the drug, as abrupt discontinuation would result in severe and dangerous side effects.  After Mrs. P  has finished her prednisone taper, the nurse must decrease the doxycycline antibiotic, as well as the tiotropium inhaler, as directed by the physician. The nurse practitioner could begin to reduce medication including the doxycycline antibiotic since the patient has shown no symptoms of GERD and improved respiratory symptoms. Moreover, the nurse practitioner could reduce the tiotropium inhaler as the patient’s lungs are clear of auscultation and show no evidence of lower extremity edema. A large number of prescribed medications is an issue that needs to be addressed and with the tapering completed, reducing doxycycline and tiotropium inhalers would help in reducing the amount of medication taken by the patient (Mangin, 2019).

Other Medication(s) Adjustments that could be considered

Furosemide, potassium chloride 20 meq bid, lisinopril, and metoprolol succinate need to be adjusted. Since all of these medications are used to treat hypertension and are also prescribed for patients with a history of heart failure, they must be modified. Mrs. P’s assessment of no worsening of heart failure, as well as her adherence to a low-sodium diet, indicates that her blood pressure is well within normal limits, and thus, all medications used to treat and control hypertensive need to be adjusted (Mangin, 2019).