Multimorbidity without frailty (acute pain, depression, COPD and high-risk combinations)

Background (age, sex, occupation, baseline function)

• 58-year-old woman
• Receptionist in local garage
• Provides support for elderly mother who lives alone and has early dementia
• Lives with husband who is out of work long-term

History of presentation/reason for review

• Ongoing ankle swelling
• Back pain difficult to manage and resistant to several strategies
• Occasional palpitations
• Persistent indigestion with heartburn
• Long-term financial worries. Increasing carer strain

Current medical history and relevant co-morbidities

• Coronary heart disease (CHD) non-STEMI - one year ago
• Atrial fibrillation (AF) – one year ago
• Diabetes type 2 - five years ago
• Hypertension – six years ago
• COPD – eight years ago
• Chronic back pain – 10 years ago
• Depression - two episodes, 11 years and four years ago
• Hypothyroidism – 24 years ago

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

Allergies or adverse drugs reactions (ADRs): nil known

• Amlodipine 10mg tablets: one tablet daily
• Aspirin 75mg dispersible tablets: one tablet daily
• Atenolol 50mg tablets: one tablet daily
• Bendroflumethiazide 2.5mg tablets: one tablet daily
• Citalopram 20mg tablets: one tablet daily
• Clenil® 100mcg metered dose inhaler: inhale one puff twice daily
• Co-codamol 8/500mg tablets: two tablets up to four times daily
• Diclofenac 50mg tablets: one tablet up to three times daily
• Furosemide 40mg tablets: one tablet daily
• Gabapentin 400mg capsules: one capsule three times daily
• Gliclazide 80mg tablets: one tablet twice daily
• Levothyroxine 50micrograms/5ml liquid: one 5ml spoonful daily
• Levothyroxine 25micrograms/5ml liquid: one 5ml spoonful daily
• Lisinopril 20mg tablets: one tablet daily
• Lisinopril 10mg tablets: one tablet daily
• Metformin 500mg tablets: two tablets three times daily
• Omeprazole 40mg capsules: one capsule daily
• Pioglitazone 30mg tablets: one tablet daily
• Salbutamol 100micrograms metered dose inhaler: inhale one or two puffs as required

Over the counter medicines: nil

Lifestyle and current function

• Smoking: 10–15 cigarettes a day
• Alcohol: 20 units/week

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

• Concerns dominated by the heart attack last year and fear of recurrence, “I don’t know what my mother and husband would do if I got too ill to work or look after her.”
• “I feel breathless whenever I have to rush or climbing the stairs; Do I really need to take so many pills; my ankles are getting really swollen

Observations, examinations and results 

Note: local laboratory reference ranges may vary

• Weight 95.2kg, Height 165cm, BMI 35kg/m²
• HbA1c 86 mmol/mol (10%)
• BP 150/85mmHg
• Spirometry shows mild obstruction
• No urinary protein detected
• eGFR 55ml/min/1.73m²

Most recent relevant consultations

• Flu-like illness leading to exacerbation of COPD two years ago
• Chest pain 12 months ago - found to be in AF on admission and troponin positive. Angiogram showed widespread coronary artery disease but not severe enough to warrant revascularisation. Echocardiography showed normal left ventricular systolic function
• On dual aspirin and clopidogrel for one year. Recently moved to aspirin monotherapy

 

Person specific issues to address

• Wants to be on the best medication for all her current conditions as does not want them to worsen. However, she does wonder if she needs all the medication to achieve this

 

Person specific issues to address

• Levothyroxine: for hypothyroidism

 

Person specific issues to address

• Gabapentin in pain management check indication - neuropathic pain or mechanical back pain. Query co-codamol or paracetamol and need for NSAID
• Citalopram: check ongoing indication
• Omeprazole: high dose, check indication, e.g. active peptic ulcer, oesophagitis, GI protection (clopidogrel, aspirin, diclofenac, citalopram)

 

Person specific issues to address

• Secondary prevention of coronary events: likely to derive macrovascular benefit from tight glycaemic control; consider statin and BP control
• Stroke prevention in AF: CHA2DS2-VASc score 4, consider replacing aspirin with anticoagulant; check rate control
• COPD management: check symptom control (including exacerbation rate) and inhaler technique. Review ICS (single ICS not licensed in COPD) and/or escalate bronchodilation
• Pain management: review symptoms, pain score and expectations. If gabapentin prescribed for back pain, then consider withdrawal; review NSAID
• Depression: review duration of treatment and ongoing need
• Hypothyroidism: check TFT result
• CKD: check and monitor for proteinuria
• Diabetes: HbA1c high despite three antidiabetics; check adherence.
• Pioglitazone use is cautioned in those with CVD, consider stopping and starting an SGLT-2i

 

Person specific issues to address

• Ankle swelling: potential ADR of amlodipine or pioglitazone. Query if furosemide still indicated.
• GI bleeding risk: NSAID, citalopram and aspirin (or anticoagulant if added)
• Acute kidney injury risk:
  
  • NSAID with CKD (eGFR 55ml/min), consider stopping NSAID
  • co-prescribed diuretic, ACE inhibitor/ARB and NSAID (‘triple whammy’)
  • co-prescribed thiazide and loop diuretic, thiazide and ACEI not appropriate
• Metformin: reduce to maximum daily dose of 2g
• Increase U&E monitoring
• Cardiac events risk: NSAID and CVD – diclofenac (ibuprofen and naproxen preferred); pioglitazone (ankle swelling and ischaemic heart disease)
• Risk of arrhythmia: QTc prolongation: omeprazole, citalopram and gabapentin
• Medication Sick Day Guidance given for metformin, furosemide, bendroflumethiazide, lisinopril, gliclazide, diclofenac and SGLT-2i

 

Person specific issues to address

• Opportunities for cost minimisation by changing liquid levothyroxine to tablets
• Change ICS MDI (no exacerbations recently) to long-acting bronchodilator in a lower carbon emission formulation e.g. tiotropium soft mist inhaler (Respimat®)
• Advised to dispose of medicines through the community pharmacy 
• Advised to only order what is needed, do not stockpile medicines  

 

Agreed plan

• Stop: aspirin, diclofenac, gabapentin, Clenil® MDI, pioglitazone
• Start: statin, DOAC for AF; tiotropium Respimat®, SGLT-2i (counsel accordingly)
• Reduce: metformin dose to 2g daily
• Change: co-codamol to paracetamol; levothyroxine liquid to tablets
• COPD management: check they understand how to monitor breathlessness score, advise regarding use of new inhaler and check inhaler technique and suitability
• Lifestyle management: smoking cessation, weight reduction, increased physical activity
• Non-medication interventions: signpost to social support, e.g. Alzheimer’s Scotland
• Pulmonary rehabilitation may be appropriate depending on breathlessness score
• Ensure regular review: diabetes, COPD, CVD, BP, pain management