A 66 year old female has a past medical history of depression, Polymyalgia Rheumatica, GERD, hot flashes, hypertension, and DVT.  Her current medications include:

• Mirtazepine 15 mg daily
• Prednisone 20 mg daily
• Omeprazole 20 mg daily
• Premarin 0.625 mg daily
• Ibuprofen 400 mg three times daily
• Warfarin with goal INR of 2-3
• Lisinopril 10 mg daily

Here’s a few thoughts, and please feel free to add questions and comments below!

1. Long term prednisone can certainly cause multiple problems, but there are times when we don’t have any better options. I suspect that the prednisone would be being utilized for PMR in this case.  If so, I would make sure to assess that the prednisone is at minimum effective dose.
2. I would also like to avoid the ibuprofen in this patient on warfarin if at all possible.
3. Minimizing the dose of the Premarin would also be a desirable goal. Hot flashes can be awful for some patients, but long term estrogen has significant possible problems as well.  Since this patient does have depression, a potential trial of venlafaxine might be appropriate to help with hot flashes and depression depending upon what has been tried in the past.  The DVT history also gives me another reason to want to minimize the Premarin use.
4. Kidney function would also be important to follow given the use of the ibuprofen and lisinopril.

What else would you like to investigate?

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