What should a patient do if they accidentally doubled their morning dose of atorvastatin (calcium) 80 mg, Telmisartan 40 mg, and Ticagrelor 90 mg?

Management of Accidental Double Dose of Atorvastatin, Telmisartan, and Ticagrelor

For a patient who has accidentally doubled their morning dose of atorvastatin 80 mg, telmisartan 40 mg, and ticagrelor 90 mg, they should monitor for symptoms but do not need to seek immediate medical attention as a single double dose is unlikely to cause serious harm.

Immediate Assessment and Management

• The patient should remain calm as a one-time double dose of these medications is unlikely to cause severe toxicity in most patients 1, 2
• Monitor for symptoms of hypotension (dizziness, lightheadedness) due to doubled telmisartan dose, which could lead to orthostatic hypotension 2
• Watch for increased bleeding risk due to doubled ticagrelor dose, such as unusual bruising, nosebleeds, or blood in urine 3
• Be alert for muscle pain, tenderness, or weakness which could indicate statin-related myopathy from the doubled atorvastatin dose 1

Medication-Specific Concerns

Atorvastatin (160 mg taken instead of 80 mg)

• The primary concern with doubling atorvastatin is the increased risk of myopathy or rhabdomyolysis, especially when combined with ticagrelor 1, 4
• Monitor for muscle pain, weakness, dark urine, or unexplained fatigue 1
• The risk is heightened in elderly patients (65 years old) as mentioned in the FDA label 1

Telmisartan (80 mg taken instead of 40 mg)

• The main concern is excessive blood pressure lowering which could cause dizziness or syncope 2
• The patient should measure their blood pressure if possible and avoid sudden position changes 2
• Excessive doses may also affect kidney function, so increased fluid intake is advisable 2

Ticagrelor (180 mg taken instead of 90 mg)

• Increased bleeding risk is the primary concern with doubled antiplatelet medication 3
• The patient should avoid activities with high risk of injury for the next 24 hours 3
• The interaction between ticagrelor and high-dose atorvastatin increases the risk of statin-related adverse effects 4

Follow-up Actions

• Resume normal dosing schedule the next day - do not skip the next dose to "make up" for the double dose 1, 2
• If experiencing significant symptoms like severe dizziness, unusual bleeding, or severe muscle pain, contact healthcare provider or seek medical attention 1, 4
• For the next 24 hours, maintain adequate hydration to help clear the medications 2
• Avoid grapefruit juice which can increase atorvastatin levels 1

When to Seek Immediate Medical Attention

• Severe hypotension symptoms: fainting, severe dizziness, or inability to stand 2
• Signs of significant bleeding: blood in urine, stool, or vomit; severe bruising 3
• Symptoms of rhabdomyolysis: severe muscle pain, dark urine, fever, or feeling very unwell 1, 4
• Allergic reaction symptoms: swelling of face/lips/tongue, difficulty breathing, severe rash 1, 2

Special Considerations for This Patient

• At 65 years of age, this patient may be more susceptible to adverse effects, particularly hypotension from telmisartan and muscle effects from atorvastatin 1, 2
• The combination of doubled ticagrelor and atorvastatin poses a particular risk as both medications are metabolized by CYP3A4, potentially leading to increased statin levels 3, 4
• Monitoring kidney function through adequate hydration and watching for changes in urination is important 2, 5