🌸 Updated Script for Longitudinal Case
“Hi Dr. ____ , thanks for meeting with me today to discuss this referral. I’m Juliet, the clinical pharmacist, and today I’ll be discussing Riley Lee (or RL)., a 37-year-old cis-gendered woman who was referred for a comprehensive medication review focusing on polypharmacy, chronic bladder pain, and evaluation of UTI prophylaxis options. Our goal today is to optimizing symptom control while improving medication safety.
RL has an extensive and medically complex past medical history, and her primary and most limiting condition is her longstanding interstitial cystitis and bladder pain syndrome, which have been refractory to multiple therapies. She also has overactive bladder and chronic urinary retention, requiring a suprapubic catheter with monthly catheter changes.
These conditions contribute to chronic daily bladder pain with a typical baseline around 7 out of 10, characterized by bladder spasms, urgency, and right-sided pelvic discomfort. Her goal is to reduce this baseline pain below 7.”
I reviewed her recent course, and her symptoms have been consistent for several years with intermittent flares prompting ED visits. Recent pelvic floor physiotherapy has improved her pelvic floor relaxation by approximately 50%, but persistent bladder spasms remain her major barrier to functioning.
She also experiences recurrent UTIs, most commonly due to Klebsiella, and she has had a previous Pseudomonas infection in 2022.
Beyond her urologic conditions, RL also has several comorbidities that contribute to her overall complexity. She has chronic neuropathic low-back pain and sciatica, as well as chronic migraines occurring about four times per month.
Psychiatrically, she has depression, anxiety, borderline personality disorder, ADHD, binge-eating disorder, and a history of self-harm. She also previously underwent a lumbar puncture with a documented elevated opening pressure.
Other relevant conditions include morbid obesity with a BMI of 40.2, and she is a documented MRSA carrier.
Surgically, she has undergone multiple suprapubic catheter insertions, cystoscopies with bladder Botox, colonoscopies, gastroscopies, a hysteroscopy, a cholecystectomy, and several orthopedic surgeries.”
5) MEDICATION HISTORY:
Given the complexity of RL’s medication list, I’ll summarize her therapies by category and highlight the most clinically important points, including what I learned from interviewing her and reviewing the chart.
💗 Pain and Bladder Pain Medications
“For chronic bladder pain, RL uses several opioid and non-opioid agents:
Morphine SR 15 mg, prescribed TID PRN, but she typically takes one capsule daily on a self-directed basis for baseline bladder pain.
Morphine IR 5 mg, prescribed q6h PRN, in which she uses about once daily, mainly during suprapubic catheter changes and for 2–3 days afterward.
Tylenol #3, two tablets every four hours as needed — she uses this quite regularly, going through 40 tablets every two weeks, primarily for headaches and general pain control.
Cyclobenzaprine 10 mg at bedtime PRN for bladder spasms, although she reports minimal benefit from this medication.
Hyoscine butylbromide 10 mg q8h PRN for bladder spasms. She doesn’t use this often but she still finds it somewhat helpful, and prefers to keep it available.
She also uses multiple adjuvant pain medications:
Gabapentin 1200 mg TID for neuropathic low-back pain and sciatica
Nabilone 2 mg TID for nausea and additional pain control; she reports this is effective for her.
Ondansetron orally disintegrating tablets 4 mg, half to one tablet as needed, usually 1–2 times per week for breakthrough nausea
Metoclopramide 5 mg TID, mainly for headache-associated nausea.
💗 Mental Health and Sleep Medications
Moving on to her neuropsychiatric medications:
Duloxetine 90 mg every morning for depression and anxiety.
Lorazepam 1 mg SL PRN, used for acute anxiety; she typically uses about 10 tablets per week.
Hydroxyzine 10 mg, one to two capsules at bedtime as needed for insomnia associated with stress or fibromyalgia; used 1–2 nights per week.
Vyvanse 60 mg every morning for ADHD and binge-eating disorder.”
💗 Migraine Medications
For migraine management, she takes:
Propranolol 80 mg twice daily for migraine prophylaxis.
Sumatriptan 5 mg nasal spray, one spray BID PRN for acute migraine attacks — she uses this around four times per month.”
💗 Bladder & GI Medications
For GI therapies:
She is on Rabeprazole 20 mg twice daily for acid reflux. She reports that her symptoms are well controlled
💗 Other Medications
Colchicine 0.6 mg daily, originally prescribed for knee pain, and she has noted that knee pain has resolved,
💗 Past Medications Worth Mentioning
I also want to quickly highlight a few past therapies relevant to today’s assessment:
She previously used Methenamine for UTI prophylaxis for two months without benefit.
She was prescribed Solifenacin, which she found effective, but it was not financially accessible due to lack of coverage.
She has used Pyridium in the past, which was helpful but too expensive for her to continue.
💗 OTCs and Supplements
“She does not take any over-the-counter medications or supplements at this time.”
6. Allergies
“RL has an extensive allergy and intolerance profile, which significantly limits safe antibiotic and medication options. These include:
Latex — rash
Diamox / acetazolamide — severe vomiting
Ciprofloxacin — hives
TMP-SMX — itching
Tramacet — hives and urticaria
Clindamycin — dizziness and vomiting
Clindamycin/benzoyl peroxide topical — swelling
Macrolides — arrhythmia and hives
Topiramate — rash
Tramadol — rash
“There is also a recorded allergy to Macrobid on her BPMH, but this was not documented elsewhere, and I was not able to clarify this with her during the encounter, so this requires follow-up
7. Social History
Next, I’ll review her social history.
Some elements of her social history are documented, and others still need to be clarified at a future visit.
What we do know is that RL is not currently working and experiences significant financial limitations, which directly impact her ability to access expensive non-benefit medications.
There is no documentation of recreational drug use, and there are no notes indicating alcohol use, nicotine use, caffeine intake, or cannabis use. These are areas I plan to clarify with her at our next follow-up, since they can meaningfully affect bladder pain, sleep, anxiety, and migraine control.
8. Immunizations
In terms of preventitive care, her immunizations are mostly up to date. She has completed her Hepatitis A and B series and receives annual influenza vaccinations. Her last tetanus booster was in 2012, so she is due for a Td/Tdap update. She has received two COVID-19 vaccinations but would have been due for her next booster in October 2025. There are no documented adverse vaccine reactions.”
🌼 VITAL SIGNS (March 23, 2025)
“Her most recent vital signs from March 23rd are reassuring. Her temperature was 36.7°C, heart rate 67, respiratory rate 16, and oxygen saturation 98% on room air. Her blood pressure was 134 over 68.
Overall, she is afebrile, well-oxygenated, and hemodynamically stable. Her systolic blood pressure is slightly above the most recent hypertension thresholds, but I don’t think we should prioritize BP management today given the urgency of her bladder pain, polypharmacy concerns, and UTI prophylaxis needs.
However, this is something I would like us to revisit at follow-up, along with calculating her Framingham cardiovascular risk score to guide future decisions around antihypertensive therapy.
🌸 REVIEW OF SYSTEMS — Polished Script
“Next, I’ll briefly summarize her review of systems.
For CNS, she is alert and oriented, with no acute neurologic complaints. She engaged appropriately during assessment. Her migraines are chronic and stable rather than new.
HEENT is unremarkable — no visual or hearing changes, sinus pressure, or dental concerns.
Cardiovascular-wise, she denies chest pain, palpitations, dyspnea on exertion, or peripheral edema.
Respiratory-wise, there is no cough, wheeze, or shortness of breath. Lung exams across multiple encounters have been normal.
Gastrointestinally, she has baseline intermittent nausea related to migraines and medications. She experienced a few days of mild diarrhea while on ertapenem, which has resolved. No vomiting, dyspepsia, or abdominal pain.
“Genitourinary-wise, she continues to experience her chronic baseline symptoms related to interstitial cystitis and her suprapubic catheter — including bladder discomfort and intermittent urgency. She reports no new fever, dysuria, systemic symptoms, or new or worsening GU concerns to suggest a new UTI or acute infection.
Musculoskeletal-wise, her chronic neuropathic low-back pain is stable. She reports no new weakness, numbness, or joint swelling.
Dermatologically, no rashes, lesions, or skin changes were noted.
Overall, outside of her GU symptoms and chronic pain, her review of systems is largely unremarkable.”
🌸 LABS — Polished Script
“Looking at her most recent labs:
Her CBC is completely normal — white count, hemoglobin, and platelets are all within range, with no leukocytosis or anemia.
Her electrolytes are also normal overall. Potassium was mildly elevated at 5.3, which is clinically insignificant in the context of stable renal function and no ECG changes.
Her CRP was 4, which is reassuring and suggests a resolving infection rather than persistent inflammation.
Her kidney function is excellent, with a creatinine of 65 and eGFR of 105. This indicates that her chronic opioid therapy and previous UTI treatments have not caused renal impairment, and it gives us flexibility with medication options if needed.”
🌸 1) Bladder Pain & Spasm Management
“So based on her medication history, symptoms, and the laboratory findings we just reviewed, I’d like to move directly into my recommendations. Instead of listing every drug therapy problem individually, I’ve organized my plan by her three highest-priority areas: (1) management of interstitial cystitis and bladder pain, (2) polypharmacy and medication safety, and (3) long-term UTI prophylaxis. This structure reflects both the referral question and what is most clinically meaningful for her right now.”
For her chronic bladder pain and bladder spasms, I recommend that she continue to use hyoscine as needed. She reports partial benefit, and it is one of the few spasmolytics she tolerates.”
She previously trialed immediate-release oxybutynin for two months but experienced no improvement in urgency or bladder spasms. She later had significant symptom improvement on solifenacin, but solifenacin is not covered without Special Authority. BC’s criteria require documented severe intolerance to oxybutynin leading to discontinuation. In her case, oxybutynin was ineffective but not intolerable, so she does not meet eligibility for coverage despite solifenacin’s superior effectiveness for her.
Because of this, I have two recommendations for her.
💗 A) Initiate low-dose amitriptyline (primary recommendation)
“Amitriptyline is recommended as a second-line oral therapy in the American Urological Association (AUA) guidelines for IC/BPS and is commonly used for chronic pelvic and bladder pain. It works by modulating pain signaling, relaxing the bladder, and reducing mast-cell–mediated inflammation. It may also help with sleep, which is one of her major challenges.”
“For IC/BPS, we use much lower doses than for depression — typically 5–10 mg at bedtime, with slow titration only if tolerated, targeting 10–25 mg nightly. Starting low minimizes anticholinergic and sedating effects, and we would monitor for dry mouth, constipation, dizziness, and morning grogginess.”
“Amitriptyline is also more easily financially accessible, which is important for her.”
💗 B) Broader benefits — supports future deprescribing
“One key advantage of introducing low-dose amitriptyline is that it may help with several of her overlapping conditions simultaneously. Although our primary target is bladder pain, amitriptyline also has well-documented benefits for neuropathic pain, sleep, and low mood.”
“This is particularly relevant for her because her chronic pelvic pain, neuropathic low-back pain, anxiety, and sleep difficulties all interact and amplify each other.”
“If she responds well, this may allow us to gradually simplify her regimen in the future. For example:”
Gabapentin 1200 mg TID — may become eligible for dose reduction
Lorazepam (up to 10 tabs/week) — reduced reliance through improved sleep/anxiety
Hydroxyzine — decreased need due to improved nighttime sedation
“These are long-term goals — I would not reduce any agents today — but initiating amitriptyline lays the groundwork for safe, staged deprescribing while improving her overall symptom burden.”
💗 C) Non-pharmacologic therapy: bladder instillations
“I also recommend proceeding with bladder instillation therapy, such as a lidocaine–heparin–bicarbonate instillation. These are well-supported by urology and help by calming the inflamed urothelium and reducing catheter-related irritation. They provide localized pain relief without adding to her systemic CNS-depressant load.”
“It is also worth noting that bladder instillations can be covered under MSP when performed by urology, making this a more financially feasible option compared with other bladder-directed medications.”
🌸 POLYPHARMACY & SAFETY
Next, I’d like to shift to polypharmacy and overall medication safety. RL is taking several medications with overlapping CNS-depressant effects.
Given her complex pain physiology, I’m not recommending abrupt deprescribing of everything today. Instead, I’m focusing on safe, targeted changes that we can implement now, and outlining a clear longer-term plan to gradually reduce her sedation burden while keeping her symptoms stable.”
1. Colchicine
First, I recommend discontinuing colchicine. RL confirmed it was originally prescribed for knee pain, and that the pain has fully resolved. I confirmed that she has no history of gout, pericarditis, or other inflammatory conditions where colchicine would be indicated. Continuing it provides no therapeutic benefit and exposes her to avoidable risks such as gastrointestinal upset and neuromuscular toxicity. Deprescribing this medication is low risk and simplifies her regimen without affecting symptom control
2. Cyclobenzaprine
Second, I recommend discontinuing cyclobenzaprine. She reports minimal benefit for bladder spasms, which is consistent with the limited evidence supporting its use in pelvic or bladder pain. Cyclobenzaprine is highly sedating; in her case, it could be contributing to daytime drowsiness, cognitive slowing, and additive CNS-depressant burden. Removing it eliminates a high-risk medication with very limited therapeutic value.”
3. Rabeprazole taper
“Third, I recommend beginning a structured taper of her rabeprazole. She is currently taking 20 mg twice daily, but she does not have an indication that warrants long-term or high-dose PPI therapy. Her reflux symptoms are well controlled, so there is no indication for indefinite PPI use.
“Continued long-term PPI use in someone without a strong indication exposes her to several avoidable risks. In her case, the most clinically relevant is her persistent low ferritin, which is likely being worsened by reduced gastric acidity impairing iron absorption. But beyond that, chronic PPI use is associated with increased risks of:
Hypomagnesemia
Vitamin B12 deficiency
Bone fracture from reduced calcium absorption
C. difficile
Community-acquired pneumonia
And potential alteration of the gut microbiome”
“These risks are especially important for RL because she has:
multiple antibiotic exposures → ↑ C. difficile risk
chronic pain and mobility limitations → ↑ fracture consequences
“For these reasons, deprescribing is appropriate. I recommend tapering gradually to reduce rebound acid hypersecretion. A reasonable taper would be:
→ Once daily for two weeks
→ Then every other day for two weeks
→ Then discontinue if tolerated
She can use an OTC H2-receptor antagonist as needed during the taper to manage breakthrough symptoms. This approach supports long-term safety while still allowing for symptom-responsive management.”
4. Nabilone 2 mg TID – very high dose; flag for reassessment
“Next, I want to highlight her nabilone use. She is currently taking 2 mg three times daily, for a total of 6 mg/day, which is the upper limit used in chemotherapy-induced nausea—a much shorter-term and highly supervised setting. For chronic daily use, this is considered a high dose.”
“Nabilone on its own is significantly sedating, but the main concern here is the interaction burden. It carries major interaction warnings with nearly all of her CNS depressant. In combination, these markedly increase the risk of oversedation, cognitive impairment, falls, and respiratory depression, especially with her chronic pain and fatigue.
“At the same time, she reports that nabilone has been one of the most helpful medications for both nausea and pain. Because of that, I’m not recommending discontinuation today, but I do think this is a medication that should be revisited once her more urgent issues are stabilized.”
“If we do consider a taper in the future, it would need to be done very gradually. In clinical practice, dose reductions are typically quite small—often around 0.25 mg per dose at a time—with close monitoring for withdrawal symptoms or worsening nausea or pain. Follow-up every few days during the adjustment period is usually recommended to ensure safety.”
“Given her current flare-related pain and recent infection, this is not the right moment to begin tapering, but I do recommend prioritizing a reassessment at a future visit when she is more stable.”
5. Tylenol #3 (codeine) – taper plan
Next, I want to address her Tylenol #3 use. Although prescribed as needed, she reports using it regularly—essentially as scheduled therapy. Given that she is already on morphine, adding codeine introduces unnecessary duplication of opioid therapy without providing additional analgesic benefit.”
“This combination increases the risk of sedation, constipation, drug interactions, and opioid-related adverse effects
“I’m not planning a change today, but once her bladder pain is more stable, I recommend a gradual dose reduction, with the goal of transitioning her toward safer scheduled options such as acetaminophen alone for headache management. We can initiate this taper at a future visit when her overall regimen is more stabilized.”
6. Lorazepam – minimize + plan for structured taper later
“Next, I want to address her lorazepam use. She currently takes up to 10 sublingual tablets per week for anxiety. Lorazepam significantly increases her risk of oversedation, respiratory depression, impaired cognition, and falls,
“I’m not recommending abrupt discontinuation today. However, I do suggest minimizing use where possible and developing a structured, gradual taper plan at follow-up to avoid benzodiazepine withdrawal and maintain stable anxiety control.”
“Importantly, if she responds well to low-dose amitriptyline, we may see improvements in her sleep and overall anxiety symptoms. This could support a safer, more successful lorazepam taper in the future by reducing her need for benzodiazepines.”
7. Metoclopramide – consider duration of therapy
“She takes metoclopramide three times daily for headache-associated nausea. Because long-term use is associated with tardive dyskinesia, especially in patients on multiple CNS-active medications, I recommend reassessing whether she continues to require daily scheduled dosing.”
“We could consider shifting this to as-needed use if appropriate, but I would explore this further at follow-up to ensure her migraine-related nausea remains adequately controlled.”
8. Morphine IR – restrict to catheter-change days
“She primarily uses morphine IR during monthly suprapubic catheter changes and for two to three days afterward—which is appropriate. I recommend explicitly limiting morphine IR to procedure-related pain only, so it is not used for baseline bladder pain, which is already addressed by her long-acting opioid.”
10. Hydroxyzine – minimize overlapping sedatives
She uses hydroxyzine at bedtime as needed for insomnia. Because hydroxyzine is a sedating antihistamine, it contributes to her overall CNS-depressant burden when combined with lorazepam, opioids, nabilone, or gabapentin. To reduce the risk of excessive sedation, confusion, and respiratory depression, I recommend avoiding hydroxyzine on days when she takes lorazepam or higher opioid doses.”
“In the longer term, if she tolerates and benefits from low-dose amitriptyline, we may see improvements in both sleep quality and nighttime pain. This could help reduce her reliance on hydroxyzine altogether, allowing us to gradually streamline her sedative medications while maintaining symptom control.”
11. Gabapentin – max dose; reassess at follow-up
She is currently taking gabapentin 1,200 mg three times daily, which is the maximum recommended daily dose. In combination with opioids, benzodiazepines, and cannabinoids, gabapentin significantly increases the risk of sedation and respiratory depression.”
“I’m not recommending a change today because it plays an important role in managing her neuropathic pain. But I do recommend reassessing the dose at a future visit, especially if we see improvement with amitriptyline. A gradual reduction may be possible once her overall pain management plan becomes more stable.”
Summary sentence
“Overall, my focus today is on eliminating medications that are clearly no longer indicated, initiating safe and gradual tapers for long-term high-risk therapies, and creating a structured plan for more complex deprescribing at future visits. My priority is maintaining symptom control while reducing her cumulative CNS-depressant load wherever possible.”
“I also want to emphasize that deprescribing will be done strategically and gradually, rather than all at once. This allows us to clearly identify which changes may be contributing to any symptom worsening, minimizes withdrawal risk, and ensures she remains safe and supported with close follow-up.”
3) UTI Prophylaxis
““For her history of recurrent UTIs, I first reviewed her previous non-antibiotic prophylaxis. She completed a full two-month trial of methenamine without any reduction in infection frequency, so I do not recommend restarting it.”
“Because her infections are not temporally related to intercourse, post-coital prophylaxis would not be effective. In her case, long-term low-dose daily prophylaxis is the more appropriate approach.”
“Most first-line antibiotic prophylaxis options are not feasible for her. Trimethoprim–sulfamethoxazole is contraindicated due to her documented allergy. I also considered nitrofurantoin, but several factors make it inappropriate:
• many of her past urine cultures have grown Klebsiella, which is intrinsically resistant to nitrofurantoin
• she has a history of Pseudomonas infection
• she is an MRSA carrier, suggesting more resistant colonization patterns
• and there is a documented ‘Macrobid allergy’ in her BPMH that I have not yet been able to clarify.”
“I initially considered norfloxacin; however, upon further allergy review, she has a documented immediate hypersensitivity reaction to ciprofloxacin (hives). Because norfloxacin is also a fluoroquinolone, there is a potential risk of cross-reactivity. Immediate-type reactions warrant avoidance of the entire class unless allergy testing is pursued, so norfloxacin is not a safe option for her.”
“Given her organism history and extensive allergies, trimethoprim 100 mg PO at bedtime is a reasonable prophylactic option if her prior isolates demonstrate susceptibility. She is allergic to TMP-SMX, but not to trimethoprim alone. Trimethoprim monotherapy is guideline-supported, well tolerated, and avoids sulfonamide exposure.”
“If trimethoprim is not tolerated or isolates are resistant, off-label fosfomycin prophylaxis (3 g every 10 days) could be considered but we can table that for now.
“I also recommend initiating vaginal estrogen therapy, as the joint American and Canadian Urological Association guideline supports its use in peri- and post-menopausal women with recurrent UTIs. Local estrogen reduces UTI recurrence by restoring vaginal epithelial health and Lactobacillus predominance, and it can be safely combined with antibiotic prophylaxis.”
In addition to pharmacologic measures, optimizing catheter-related care remains essential. At follow-up, I recommend reviewing her catheter-care technique, confirming appropriate catheter-change intervals, and encouraging adequate hydration between flares to reduce mechanical irritation and biofilm formation.”
FOLLOW UP:
“For follow-up, I would like to see her again in about four to six weeks.”
“At that visit, we can reassess her bladder pain, her response to amitriptyline, and her overall symptom control. We can also review her opioid use, any changes after stopping colchicine and tapering her PPI, and whether her daytime sedation or cognition has improved.”
“I will also check in on her UTI pattern, any breakthrough symptoms, and how she is tolerating the trimethoprim and vaginal estrogen therapy prophylaxis if we move forward with that plan.”
“I would also like to revisit her blood pressure, calculate her Framingham cardiovascular risk score, and update her preventive care needs — specifically addressing her overdue tetanus booster and confirming MMR status — once her more pressing concerns are stabilized.”
“And finally, by the time of follow-up she may have begun bladder instillation therapy through urology. I’d like to assess whether the instillations are helping reduce catheter-related discomfort, bladder spasms, or post-procedure pain, and whether she feels any meaningful improvement in her day-to-day functioning.”
“From there, we can refine her long-term plan — including whether amitriptyline should be titrated, whether gabapentin can be safely reduced, and how to continue deprescribing in a gradual, symptom-guided manner.”