From the Guidelines
The patient's current medication regimen, including rosuvastatin for hyperlipidemia, appears to be appropriate and effective in managing her symptoms, and no changes are recommended at this time. The patient is a 67-year-old female with multiple medical conditions, including hyperlipidemia, low vitamin D, left shoulder pain, lung nodule, and headaches, who presents to clinic today feeling much better overall. Her headaches have improved significantly with the new medication (amitriptyline) 1. She also reports that her anxiety is better controlled on her current medication. Regarding her left shoulder pain, which began over 2 months ago and was previously described as throbbing and constant (5/10 with episodes of 10/10), she now reports improvement with meloxicam. For her incidental lung nodule, she is now willing to proceed with the previously ordered CT scan of the chest after initially getting only a chest X-ray due to cost concerns.
The patient's current medication regimen is guided by the principles outlined in the 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of blood cholesterol, which recommends emphasizing a heart-healthy lifestyle and using statin therapy to reduce low-density lipoprotein cholesterol (LDL-C) levels in patients with clinical atherosclerotic cardiovascular disease (ASCVD) 1. The guideline also suggests considering the addition of non-statins to statin therapy in very high-risk ASCVD patients. However, in this case, the patient's symptoms are adequately controlled on her current regimen, and the potential benefits of adding or changing medications must be carefully weighed against the potential risks, particularly in older adults with multimorbidity, as highlighted in the European Society of Cardiology working group review on polypharmacy in older people with cardiovascular disease 1.
Some key points to consider in the patient's management include:
- The importance of a comprehensive individual geriatric risk assessment, taking into consideration health habits, cardiovascular risk factors, multimorbidity, physical/cognitive status, life expectancy, time to benefit or harm, and goals of care 1.
- The need to prioritize which long-term medications for the prevention/treatment of cardiovascular disease are most likely to produce benefit and least likely to harm the patient, and to use best clinical judgment in attempts to adhere to prescribing guidelines 1.
- The concept of time to benefit (or to harm) of cardiovascular drugs with respect to symptoms, quality of life, morbidity, and mortality, and the importance of incorporating this into therapeutic decisions 1.
Overall, the patient's current medication regimen appears to be effective in managing her symptoms, and no changes are recommended at this time, as the potential benefits of adding or changing medications must be carefully weighed against the potential risks.
From the FDA Drug Label
To reduce the risk of major adverse cardiovascular (CV) events (CV death, nonfatal myocardial infarction, nonfatal stroke, or an arterial revascularization procedure) in adults without established coronary heart disease who are at increased risk of CV disease based on age, high-sensitivity C-reactive protein (hsCRP) ≥2 mg/L, and at least one additional CV risk factor. As an adjunct to diet to: Reduce low-density lipoprotein cholesterol (LDL-C) in adults with primary hyperlipidemia.
The patient's Hyperlipidemia (HLD) is being managed with rosuvastatin, which is indicated for reducing the risk of major adverse cardiovascular events and lowering LDL-C in adults with primary hyperlipidemia.
- The patient reports that her headaches and anxiety are much better on the new medication, but there is no direct information in the drug label about rosuvastatin being used to treat headaches or anxiety.
- The patient's left shoulder pain is being managed with meloxicam, which is not mentioned in the provided drug label for rosuvastatin 2.
From the Research
History of Present Illness
- The patient is a 67-year-old female with a past medical history of hyperlipidemia, low vitamin D, left shoulder pain, lung nodule, and headaches.
- She reports that her headaches are much better on the new medication.
- The patient has a lung nodule that was previously identified on an X-ray of the left shoulder, and she was diagnosed with fibrosis after traveling to Mexico for a CT scan, although the images she brought appear to be X-rays, not a CT scan.
- A CT scan has been ordered, but due to cost concerns, she initially opted for a chest X-ray instead; however, she is now willing to undergo the CT scan of the chest.
Left Shoulder Pain
- The patient reports left shoulder pain that began over 2 months ago, describing it as throbbing and constant, with a pain rating of 5/10 and episodes reaching 10/10 at its worst.
- The pain does not radiate and has no associated symptoms, and she denies experiencing numbness or tingling.
- The pain is exacerbated by reaching back and lifting her arm.
- She has been taking meloxicam with some relief, and Tylenol provides temporary relief but is not sufficient 3, 4, 5, 6, 7.
Current Medications
- The patient is currently taking rosuvastatin, vitamin D, meloxicam, amitriptyline, and ferrous sulfate.
- She reports that her shoulder pain and headaches are better, and she does not need any changes to her medications at this time.
Treatment and Management
- The patient's treatment plan includes continuing her current medications and undergoing a CT scan of the chest to further evaluate the lung nodule.
- Her left shoulder pain is being managed with meloxicam, which has been shown to be effective in treating soft-tissue rheumatism of the shoulder 5.
- Meloxicam has also been found to have a favorable tolerability profile compared to other nonsteroidal anti-inflammatory drugs (NSAIDs) 4, 6, 7.