Case A is Wanda, a woman living in ALF.  On her medication list, she has Celebrex listed with diagnosis of gout.  Neither she nor staff can recall recent (or even distant) gouty attack. With Wanda’s permission, I called her son to explain why we should discontinue the Celebrex.  He agreed and appreciated the call.  Clinically, this was easy and obvious decision.  Still, it’s important to inform family and enlist their help in monitoring for recurring symptoms.

Case B is Shirley, the mother of good friends and a resident in ALF.  We assumed care after her previous MD/NP left facility. Found three meds to discontinue (she had been on bisphos for over 10 years, on tramadol TID with no compelling evidence that it helped, and on PPI with no history of GI symptoms for years).  My solution was to pace the taper/discontinuation of meds….and only after a long discussion with her daughter-in-law.  A solution might be to discontinue all three.  The reason is that Shirley thought very highly of her previous medical team and I wanted to avoid casting previous decision- making in a negative light. This is part of building trust with the patient, and we can’t assume we have this just because we’re connected in some other way.

Reducing meds

One thought on “Reducing meds

  • June 26, 2014 at 5:39 pm
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    Care is excellent here. My only caveat would be for us to spend more time questioning folks about when their last gouty attack actually occurred and how sure they are it was gout. Time to start getting people off of Allopurinol forever when they can’t even remember the last attack. Also nice to remember NOT to use Colchicine and Allopurinol together when they do have an attack, and – if they can tolerate it – 3-5 days of an NSAID provides complete and rapid relief in almost all cases without using any other agents. As far as stopping the other meds, my approach would differ slightly. Unnecessary is unnecessary. Although you may build some trust and not hurt feelings by stopping the 3 meds one at a time, you may also continue one of them just long enough to have an unwanted side effect that could have been avoided. I won’t say my way is right and the way described in the case is wrong, but I’ll say stopping all 3 all at once and establishing that I will only use medications that I can justify that their benefits are likely to outweigh the risks sets the stage for future encounters and trust in me that I wouldn’t have if I waited around to get to what I knew were unnecessary medications at some later time.

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