How to optimize medication regimen for a 71-year-old woman with osteoporosis, diabetes, depression, coronary heart disease, and chronic low back pain, taking multiple medications, including atorvastatin (lipid-lowering medication), sacubitril/valsartan (angiotensin receptor-neprilysin inhibitor), metformin (biguanide), dapagliflozin (sodium-glucose cotransporter 2 inhibitor), fluoxetine (selective serotonin reuptake inhibitor), tramadol (opioid analgesic), acetaminophen (non-opioid analgesic), denosumab (monoclonal antibody), calcium citrate/cholecalciferol (calcium and vitamin D supplement), and aspirin (nonsteroidal anti-inflammatory drug), with laboratory results showing hypercalcemia and impaired renal function?

Medication Optimization for a 71-Year-Old Woman with Multiple Comorbidities

The patient's calcium supplementation should be discontinued immediately due to hypercalcemia (Ca+ 10.6 mg/dL), and her vitamin B12 should be supplemented due to deficiency (197 pg/mL). 1

Assessment of Current Medication Regimen

Immediate Concerns

1. Hypercalcemia (Ca+ 10.6 mg/dL)

   • Patient is receiving excessive calcium supplementation:
     • Calcium citrate/cholecalciferol 600 mg/800 IU (1 morning, 2 afternoon) = 1800 mg calcium daily
     • Multivitamin with 500 mg calcium carbonate = 500 mg additional calcium
     • Plus 3-4 servings of dairy products daily (approximately 300-400 mg calcium per serving)
     • Total daily calcium intake: approximately 3200-3300 mg (far exceeding recommendations)

2. Low Vitamin B12 (197 pg/mL)

   • Current level indicates deficiency
   • No current B12 supplementation beyond multivitamin

3. Blood Pressure (104/64 mmHg)

   • Relatively low BP with reported positional dizziness
   • Multiple medications affecting BP: sacubitril/valsartan, nitroglycerin PRN

4. Polypharmacy Risk

   • 13 medications total, increasing risk of adverse drug events, drug interactions, and non-adherence 1

Medication-Specific Issues

Osteoporosis Treatment

• Denosumab is appropriate for osteoporosis (T-score -2.7)
• However, hypercalcemia is concerning and requires immediate attention 2, 3

Cardiovascular Medications

• Sacubitril/valsartan may be contributing to positional dizziness given current BP
• Aspirin 81 mg is appropriate for secondary prevention after STEMI 1
• Atorvastatin 40 mg is appropriate for secondary prevention

Diabetes Management

• Metformin and dapagliflozin combination carries risk of metabolic acidosis, especially with her elevated CO2 of 28 mEq/L 4

Pain Management

• Tramadol use in elderly increases fall risk 1
• Multiple pain medications (tramadol, acetaminophen, lidocaine patch)

Recommended Medication Changes

Immediate Actions

1. Discontinue all calcium supplementation

   • Stop calcium citrate/cholecalciferol supplements
   • Switch to multivitamin without calcium
   • Monitor serum calcium levels within 2 weeks

2. Add vitamin B12 supplementation

   • Start cyanocobalamin 1000 mcg daily or methylcobalamin equivalent
   • Recheck B12 levels in 3 months

3. Adjust blood pressure management

   • Consider reducing sacubitril/valsartan dose to 24/26 mg twice daily if positional dizziness persists
   • Monitor BP closely after adjustment

Pain Management Optimization

1. Reduce tramadol use

   • Taper tramadol to PRN use only
   • Maximize non-opioid options:
     • Continue acetaminophen 1000 mg twice daily
     • Continue lidocaine patch for localized pain

2. Consider non-pharmacological approaches

   • Physical therapy referral
   • Heat therapy for back pain 1

Diabetes Management Adjustment

1. Monitor for metabolic acidosis risk
   • Continue current regimen but educate patient about signs of acidosis
   • Ensure adequate hydration
   • Consider periodic monitoring of renal function and bicarbonate levels

Cardiovascular Management

1. Continue secondary prevention
   • Maintain atorvastatin 40 mg
   • Continue aspirin 81 mg
   • Monitor BP closely with any medication changes

Follow-up Plan

1. Short-term (2 weeks)

   • Check serum calcium levels
   • Assess BP and symptoms of dizziness

2. Medium-term (3 months)

   • Check vitamin B12 levels
   • Comprehensive medication review
   • Assess pain control and function

3. Long-term (6 months)

   • Bone mineral density follow-up
   • Reassess need for all medications

Key Considerations and Pitfalls

• Calcium supplementation: Excessive calcium can lead to hypercalcemia, kidney stones, and cardiovascular complications. The patient's dietary calcium intake should be assessed before restarting any supplementation.

• Polypharmacy in elderly: The risk of adverse drug events increases exponentially with the number of medications. Regular medication reviews are essential 1.

• Fall risk: Multiple medications (tramadol, sacubitril/valsartan) increase fall risk. The patient's positional dizziness warrants close attention.

• Drug interactions: Monitor for interactions between denosumab and calcium levels, especially after calcium supplementation is adjusted.

• Renal function: Although current renal function appears adequate, continued monitoring is important with multiple medications affecting kidney function.