CASE 1

1. Levothyroxine Sodium 112 mcg tablet – Take 1 tablet once daily

  • N: Yes, indicated for hypothyroidism (PMHx). Lifelong therapy.

  • E: Dose seems reasonable, but no recent TSH available. Would confirm with labs to ensure therapeutic target.

  • S: Generally safe; risks if over/under-replaced include arrhythmia, bone loss, fatigue. No major interactions.

  • A: Simple once-daily dosing. Would clarify if taken on empty stomach and separated from iron/calcium to ensure absorption.

2. Rosuvastatin Calcium 10 mg tablet – Take 1 tablet once daily

  • N: Yes, appropriate given diabetes, hypertension, age, and CV risk.

  • E: Moderate-intensity statin; effectiveness unclear without lipid panel. Should be beneficial for ASCVD prevention.

S: Caution due to history of liver disease/↑LFTs (ALP, GGT elevated). Monitor for myopathy and hepatotoxicity.

  • A: Once daily, good adherence potential.

3. Pantoprazole Sodium DR 40 mg tablet – Take 1 tablet once daily

N: Likely appropriate due to past GI bleed from naproxen

  • E: Effective for acid suppression and ulcer prevention.

  • S: Long-term PPI risks = osteoporosis, hypomagnesemia, C. difficile, CKD. Would reassess if still needed.

  • A: Once daily, simple regimen.

4. Fluoxetine HCl 10 mg capsule – Take 2 capsules (20 mg) daily

  • N: Indicated for depression, though unclear if still needed with duloxetine also on board. Potential duplication.

E: Standard antidepressant dose; benefit unclear (patient still reports “loss of memory” and neuropathy

  • S: Interactions with duloxetine + tramadol (↑ serotonin syndrome risk). May impair cognition/falls.

  • A: Once daily, good adherence potential, but confusing if multiple antidepressants prescribed.

5. Gliclazide ER 30 mg tablet – Take 2 tablets (60 mg) once daily with food

  • N: Indicated for T2DM, but possibly unnecessary given patient also on insulin and semaglutide.

  • E: Ineffective; A1C 11.3% suggests poor control despite therapy.

  • S: High risk of hypoglycemia in older adults, especially with concurrent insulin.

  • A: Once daily with food; regimen complexity and hypoglycemia risk may impair adherence.

6. Semaglutide 0.25 or 0.5 mg pen – Inject 0.5 mg SC once weekly

  • N: Yes, indicated for uncontrolled T2DM.

E: GLP-1 RA expected to lower A1C, but current A1C remains very high (11.3%) suggesting adherence, titration, or tolerance issues.

  • S: Patient reported nausea/dizziness in neuro consult. Caution with hepatic history.

  • A: Weekly dosing, adherence-friendly if tolerated.

7. Insulin Glargine 100 units/mL pen – Inject 56 units SC once daily as needed

  • N: Yes, insulin required for uncontrolled T2DM.

  • E: High dose (56 U), yet A1C uncontrolled → ?adherence, technique, or diet issues.

  • S: Hypoglycemia risk (especially with gliclazide). Weight gain possible.

  • A: Daily injection, but note “as needed” wording on BPMH is unusual and may indicate inconsistent use.

8. Tramadol HCl 100 mg TBMP 24HR – Take 3 tablets (300 mg) every 24 hours (may take as needed with tramadol/acetaminophen)

  • N: Indicated for chronic pain, but need to assess ongoing benefit given multimodal therapy.

  • E: Despite high doses, patient still reports significant pain. Effectiveness limited.

  • S: Risks = serotonin syndrome (with duloxetine + fluoxetine), seizures, dependence. Total dose high.

  • A: ER once-daily but large pill burden; “as needed” with Tramacet adds confusion.

9. Gabapentin 300 mg capsule – Take 3–4 capsules (900–1200 mg) TID

N: Indicated for neuropathy, but neuro consult noted patient discontinued after spine injections

  • E: High dose, but neuropathic pain still uncontrolled.

  • S: Major risks: sedation, cognitive impairment, falls, dizziness.

  • A: TID dosing heavy burden, adherence unlikely.

10. Lorazepam 1 mg SL tablet – Dissolve 1 tablet under tongue at bedtime as needed

  • N: Possibly for sleep/anxiety, but questionable necessity in older adult.

  • E: May improve sleep short-term, but no long-term benefit for underlying issues.

  • S: High risk for sedation, falls, cognitive decline, dependence.

  • A: PRN dosing; still risky, especially with polypharmacy.

11. Metformin HCl 500 mg tablet – Take 1 tablet BID

  • N: Yes, first-line for T2DM.

  • E: Dose is relatively low; may be subtherapeutic given uncontrolled A1C.

  • S: Safe with eGFR 99

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    . Watch for GI intolerance.

  • A: BID dosing; fairly manageable.

12. Tramadol HCl 300 mg TBMP 24HR – Take 1 tablet every 24 hours (may take as needed with tramadol/acetaminophen 1T)

  • N: Duplicate therapy with Tramadol ER 100 mg ×3 (300 mg).

  • E: Pain remains uncontrolled despite duplication.

  • S: Daily 300 mg + additional 300 mg from 100 mg tabs = 600 mg/day → exceeds max recommended (400 mg/day). High risk of serotonin syndrome, seizures, overdose.

  • A: Complex regimen; very unsafe for adherence.

13. Duloxetine HCl 30 mg DR capsule – Take 1 capsule once daily

  • N: Reasonable for neuropathic pain, but overlap with fluoxetine.

  • E: Dose low for neuropathic pain (often 60 mg used). Pain uncontrolled.

  • S: Serotonergic interaction with fluoxetine + tramadol. Hepatic metabolism → caution with NAFLD.

  • A: Once daily, good adherence if tolerated.