|Medical Domain||Other Domains||Deprescribing Process||Follow-Up|
|Medical condition/multimorbidity overview: 74-year-old woman presents for routine cardiology clinic follow-up 6 months after single-vessel percutaneous coronary intervention and history of poorly controlled hypertension. She was extremely obese in the past and had lost substantial amount of weight over the past few years. Currently, essentially asymptomatic.|
Non-CV comorbidities: diabetes mellitus, prior stroke without sequelae, mild chronic obstructive pulmonary disease, sleep apnea.
On exam: well appearing. Pulse: 55 beats/min, BP: 110/50 mm Hg, BMI: 25
Normal physical exam. 1+ pedal edema; no orthostatic hypotension noted.
Tests: ECG: normal; Echocardiogram: ejection fraction 60% to 65%, otherwise normal.
Aspirin (81 mg), clopidogrel (75 mg), atorvastatin (40 mg)
Losartan (100 mg), atenolol (100 mg), HCTZ (25 mg), amlodipine (5 mg)
Alendronate (70 mg weekly), vitamin E, multivitamin, co-enzyme Q 10.
Number CV medications: 7
Total number of medications: 11
|Mobility/physical domain: walks 2–3 miles/day on treadmill with resistive exercises. Normal instrumental activities of daily living and activities of daily living.|
Mind/cognitive domain: normal.
Social domain: retired, lives with husband at home.
Matters most/goals of care: her primary concern is to avoid cardiovascular events (heart attack, stroke)
|Step 1: All medications were reviewed and reconciled.|
Step 2: Individual medication risk of adverse effects were assessed.
She was on 4 anti-HTN medications with systolic BP <120 mm Hg. Concern was regarding future adverse drug reactions. Also, the use of amlodipine and HCTZ can possibly be considered a prescription cascade.∗
Step 3: Assess candidacy for individual medication discontinuation or dose reduction. All 4 anti-HTN medications were candidates for removal or dose reduction along with clopidogrel (in 6 more months) and supplements.
Step 4: Prioritize drug discontinuation or dose reduction. Based on her concomitant conditions, it was decided to attempt to discontinue hydrochlorothiazide and amlodipine with dose reduction of atenolol and losartan. Vitamins and supplements discontinuation were discussed.
Step 5: Discontinue and implement monitoring protocol.
After a discussion regarding balancing the benefits of intensive BP treatment with associated risks and setting a systolic BP goal of 120–125 mm Hg, the deprescribing process was implemented over a period of 6 months.
|Hydrochlorothiazide and amlodipine were safely removed with dose reduction of the beta-blocker and angiotensin receptor blocker.|
At the end of 5 months with BP checks every 2–3 weeks, the systolic BP range was between 120 mm Hg and 125 mm Hg. Her BP regimen at the end of 6 months was losartan (50 mg), atenolol (25 mg).
The patient was advised to regularly check her BP going forward. She acknowledged the option to discontinue clopidogrel after a full year after coronary artery stenting but continue aspirin lifelong.
She agreed to discontinue vitamin E, and co-enzyme Q 10, but wished to stay on the single daily multivitamin tablet.
Overall, goal concordance was achieved between patient, family, and the health care team.
The patient had low blood pressure and was living independently in the community; her life expectancy was estimated to be >10 years. Primary deprescribing trigger: Avoid future anticipated adverse drug reactions, such as falls, syncope, renal insufficiency due to intensive blood pressure treatment, while decreasing her cardiovascular event risk. Secondary deprescribing trigger: Reduce polypharmacy; avoiding prescribing cascades.
BMI = body mass index; BP = blood pressure; CV = cardiovascular; ECG = electrocardiogram; HCTZ = hydrochlorothiazide; HTN = hypertension.
↵∗ See text regarding prescribing cascades.