Cases – Medication Management Kenneth Brummel-Smith, MD Mariana Dangiolo, MD Copyright 2008, Florida State University College of Medicine. This work was supported by a grant from the Donald W. Reynolds Foundation. All rights reserved.

Case 1  75 yr old woman with Htn, OA, newly diagnosed Type 2 DM.  Functionally independent, cognitively intact.  LDL 143 mg/dl, creatinine 1.0 mg/dl, HgbA1C 8.7%  Meds: chlorpropamide, atorvastatin, calcium, lisinopril, ASA

Case 1  Remaining life expectancy 17 years  Time until benefit About 10 years for both DM and htn Statins – questionable but possibly 5years  Goals of care Prevent complications and maintain function  Treatment targets Substitute glipizide to prevent hypoglycemia  Costs glipizide $10/60 pills – chlorpropamide $18/60 lovastatin $31/60 pills – Lipitor $103/60

Case 2  72 y/o man with Stage D CHF, emphysema with FEV1 0.5 L, hypoxic and dyspneic at rest  Meds: furosemide, lisinopril, isosorbide, albuterol, ipratropium, inhaled fluticasone, & theophylline

Case 2  Remaining life expectancy Probably 6 months (2 end-stage diseases)  Time until benefit Decrease fluid overload – loop diuretic - daily CHF preventive drugs (lisinopril) – years? Inhaled corticosteroids and theophylline – preventive, not symptomatic  Goals of care Avoid further Dx testing and hospitalization Feel less SOB and less anxious and be at home

Case 2  Treatment targets Analgesics for pain, antianxiety agents, direct bronchodilators  Costs lisinopril $38/60 pills fluticasone $104/inhaler lorazepam $90/60 pills morphine

Case 3  83 yr old with moderately severe dementia (MMSE 13, Dep in most ADL), nursing home  Problems: incontinence, hypothyroidism, hyperlipedemia, depression, bradycardia, OA  Meds: Aricept, Namenda, Synthroid, Zetia, Celexa, VesiCare, Restoril, ibuprofen

Case 3  Remaining life expectancy Probably less than 4 yrs  Time until benefit Cognitive preservation - ? benefit Lipid drugs – minimum 5 years Bladder relaxant – immediate Osteoporosis - years  Goals of care Avoid further hospitalization Calm living space Prevent skin problems

Case 3  Treatment targets Discontinue Aricept, Actonel and Celexa Start timed voiding schedule  Costs (savings) Aricept $150/30 pills Actonel $84/4 pills Celexa $90/30 pills