High risk combination – antiplatelet and anticoagulant

Background (age, sex, occupation, baseline function)

• 81-year-old female
• Retired primary school teacher
• Lives alone (widowed four years ago)

History of presentation/reason for review

• Attends with her daughter who has noted that she is struggling with medication packets and medication regimen. She is asking if a compliance aid is suitable

Current medical history and relevant co-morbidities

• Suspected transient ischaemic attack (TIA) - transient left arm and face weakness resolved - one year ago
• Atrial fibrillation (AF) - two years ago
• Ischaemic heart disease
  • Non-ST elevation myocardial infarction - three years ago, angiogram, no stents, managed medically
• Depression following husband’s death - four years ago
• Hypertension – 14 years ago
• Hypothyroidism – 35 years ago

Current medication and drug allergies (include over the counter (OTC) preparation, traditional medicines and herbal remedies)

Allergies or adverse drug reactions: nil

• Atorvastatin 20mg tablets: one tablet daily
• Bendroflumethiazide 2.5mg tablets: one tablet daily
• Citalopram 20mg tablets: one tablet daily
• Citalopram 10mg tablets: one tablet daily
• Clopidogrel 75mg tablets: one tablet daily
• Co-codamol 30/500 tablets: take one or two tablets four to six hourly as required for pain
• Edoxaban 60mg tablets: one tablet daily
• Levothyroxine 100microgram tablets: one tablet daily
• Levothyroxine 25microgram tablets: one tablet daily
• Lisinopril 20mg tablets: one tablet daily
• Omeprazole 20mg capsules: one capsule daily
• Zopiclone 3.75mg tablets: one tablet at night

Over the counter medicines: nil

Lifestyle and current function

• Supported by two daughters who live locally with shopping and domestic tasks
• Clinical Frailty Score (Rockwood) 6 (moderately frail)
• Mobile with a stick for short distances
• House on one level
• Short walks outside if accompanied
• No power of attorney
• Non-smoker, occasional alcohol at celebrations and special occasions

“What matters to me” (ideas, concerns and expectations of treatment)

• Finding multiple medicines challenging to take
• Supported by daughters but feeling much more isolated since COVID-19 lockdown. Previous social interactions have not restarted and some worries about going out
• Not walking as far and not feeling as able to walk as far
• Keen to remain as independent as possible at home
• Worried over risk of fall after fracture several years ago which occurred the year before husband’s death. He was unwell at the time, and this was very stressful. Both were in hospital concurrently at one point

Observations, examinations and results 

• Weight 52kg, Height 160cm, BMI 20kg/m²
• BP last three readings: 142/63mmHg, 118/45mmHg, 138/56mmHg
• Urea and electrolytes:
  • Urea 10mmol/L (2.5-7.8mmol/L)
  • Creatinine 118micromol/L (60-120micromol/L)
  • eGFR 38ml/min/1.73m²
  • Calculated creatinine clearance 27ml/min
• Recent thyroid function tests (TFTs) within normal range

Most recent relevant consultations

• Suspected urinary tract infection (UTI) six months ago, presented with confusion and dysuria, and treated empirically with antibiotics

Person specific issues to address

• Reduce falls risk
• Maintain independence
• Reduce risk of further cardiovascular events
• Reduce risk of stroke
• Simplify medication if possible

 

Person specific issues to address

• Levothyroxine

 

Person specific issues to address

• Citalopram check ongoing need
• No indication for combination of clopidogrel and edoxaban

 

Person specific issues to address

• Co-codamol 30/500mg high strength. Check pain control adequate and well managed. High dose codeine so consider constipation 

 

Person specific issues to address

• High risk combination Clopidogrel not stopped when edoxaban started – increased bleeding risk (also citalopram) Stop clopidogrel
• Omeprazole may reduce efficacy of clopidogrel – change to lansoprazole 15mg if remaining on clopidogrel
• Citalopram 30mg is above the recommended dose for over 65s. Risk of QT prolongation at this dose in this group. Reduce dose if ongoing need
• Variable blood pressure readings. Check postural BP. Consider medication adherence. Watch for potential steep blood pressure drop if adherence improves
• Consider if blood pressure over treated
• Edoxaban: creatinine clearance 27ml/min and weight less than 61kg therefore reduce to 30mg
• Zopiclone is a sedative and increases falls risk. High risk, advise stopping

Person specific issues to address

• All medicines are formulary choices
• Advised to dispose of medicines through the community pharmacy 
• Advised to only order what is needed, do not stockpile medicines  

 

Agreed plan

• Stop clopidogrel
• Stop zopiclone combined with advice on sleep hygiene and normal sleep patterns in older age
• Reduce edoxaban to 30mg
• Reduce citalopram to 20mg and consider non-pharmacological options for mood (e.g. restarting social activities) with a view to stopping
• Change co-codamol to paracetamol regularly with as required codeine, and review pain management
• Postural blood pressure check and ongoing review of blood pressure
• Discuss compliance aids including medication charts
• Weight borderline - discuss whether nutrition adequate and compare with previous weights
• Signpost to options to increase physical activity
• Possible episode of delirium recently. Check baseline cognitive function
• Prompt regarding power of attorney