A 76 year old female presents with the following list of medications, including high dose Ambien (zolpidem).
- Ambien 10-20 mg at bedtime as needed
- Prednisone 20 mg daily
- Warfarin 5 mg daily
- Ventolin HFA 2 puffs QID prn
- Glucotrol XL 10 mg daily
- Fosamax 70 mg weekly
- Lisinopril 20 mg daily
- KCL 20 meq daily
- Duonebs QID
- Singulair 10 mg daily
- Vicodin 5/325 BID prn
Just reviewing the medications, you should have quite a few questions to think about.
- The first thing that jumps out in my mind is the high dose Ambien as well as the age of the patient. This has to be looked at. As far as other medications contributing, I would look at the prednisone and assess why are we on it, how long is it supposed to be on board and if it is playing a role in contributing to insomnia.
- The next thing that I would look at is the respiratory medications and what diagnosis the patient has. Have no long acting respiratory medications would be a little unusual. It is certainly possible the prednisone could be for the respiratory issues.
- Fosamax is on board without Vitamin D or calcium.
- I would also look at the potassium supplement and if it is necessary without any diuretics on board.
- There are lots of labs to monitor here based upon the meds. Kidney function, INR, A1C, hemoglobin, potassium would be very important.
What else would you look at?
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Concurrent use of warfarin and either glipizide or glimepiride was associated with an increased risk of hospital admissions or emergency department (ED) visits related to hypoglycemia in patients aged 65 years and older with type 2 diabetes, according to results of an analysis published in the December 2015 British Medical Journal (BMJ).
Glipizide XL poses a problem b/c the therapeutic effect lasts so long as does accompanying hypoglycemia.
I think I’d want to do a spirometry, to get a good look at her lung function. All her asthma meds seem to be rescue meds except the prednisone. If it’s determined by questioning, that she indeed has asthma, I’d want to transition her to an inhaled corticosteroid, BID and taper the prednisone off. The duoneb is probably causing her to “waste” potassium because she is probably urinating more frequently, especially if she is also using her ventolin regularly. I would also want to look at lisinopril induced cough, which could be an asthma trigger. Unless she has a significant problem with her kidney function, and lisinopril is being used to treat HTN, I might suggest changing to a calcium channel blocker because of her reduced beta receptors caused by chronic beta agonist use. If lisinopril is being used to protect her kidney because of diabetes, I think I would suggest switching to an ARB. Also, since she is only on one diabetes medication, I’d want to know how long she’d been on prednisone, since prednisone can cause higher BS readings. Also prednisone is probably contributing to her osteoporosis. Also, I think she might benefit from seeing an allergist, to determine if allergy shots might help her, she’s still young enough to benefit. Also, want to know why she is on Warfarin. Does she have A-fib, or did she have a clot long ago while taking OCs or somthing, which would mean she may not need to be on it. Lots of questions to be asked!
excellent review.
Ambien is a highly lipophylic in nature. Concurrent use in with other drugs like warfarin & antidiabetic drugs may lead to increased free drug concentration there by hypoglycemia & ER visits
Close monitoring of the case is Paramount.
The use of Duonebs and albuterol (Ventolin) together may not be in the patients best interests. I would substitute a long acting steroid and bronchodilator inhaler for the Duo-nebs and look to reduce the oral prednisone dosage. I would also check to see how late in the evening the patient is receiving any albuterol.
Whoa 20mg of Ambien? If you believe the FDA, they make a rare GENDER based dose recommendation. She is female and should generally be dosed 5mg/day or half of recommended dose. Pharmacokinetic studies showed females for whatever reason have way more circulating Ambien than male counterparts.