What medications can be discontinued or optimized in this patient's regimen?

Medication Optimization in This Patient

This patient has significant polypharmacy with multiple opportunities for deprescribing, particularly duplicate therapies for GERD and an excessive constipation regimen that should be simplified to polyethylene glycol as first-line therapy. 1

Immediate Discontinuations

Duplicate GERD Therapy

• Discontinue either famotidine OR pantoprazole - the patient is on both famotidine 40 mg daily and pantoprazole 40 mg twice daily, representing unnecessary duplication of acid suppression 1
• Pantoprazole 40 mg twice daily is excessive for typical GERD; standard dosing is once daily 1
• Recommend: Discontinue famotidine and reduce pantoprazole to 40 mg once daily 1

Sucralfate

• Discontinue sucralfate - this medication provides "gastric protection" but is redundant with proton pump inhibitor therapy and adds unnecessary pill burden 1
• Sucralfate requires four-times-daily dosing and must be taken on an empty stomach, significantly increasing treatment complexity 1

Excessive Constipation Regimen

• Discontinue the stepped constipation protocol (milk of magnesia, bisacodyl suppository, Fleet enema) and replace with scheduled polyethylene glycol 2, 3
• The current "as needed" stepped approach is overly complex and reactive rather than preventive 4
• Polyethylene glycol 17 grams daily has Grade A evidence for chronic constipation management and is superior to milk of magnesia 2, 3
• Discontinue senna-docusate combination - docusate (stool softener) lacks quality evidence for efficacy, and scheduled polyethylene glycol is more effective than senna 2, 4

Medications Requiring Careful Evaluation

Zolpidem

• Consider discontinuing zolpidem - this Schedule IV controlled substance carries significant risks in older adults including falls, cognitive impairment, and complex sleep behaviors 1, 5
• The American Geriatrics Society Beers Criteria identifies zolpidem as potentially inappropriate in older adults 1
• Non-pharmacologic sleep interventions should be prioritized first 1

Oxycodone-Acetaminophen

• Evaluate necessity and consider deprescribing - this is a high-priority medication for adverse drug events per the US Department of Health and Human Services 1
• The patient has multiple other pain management options (pregabalin for neuropathic pain, lidocaine patch for back pain, acetaminophen scheduled) 1
• If pain control is adequate with other agents, taper and discontinue 1

Acetaminophen Duplication

• Consolidate acetaminophen dosing - the patient has two separate acetaminophen orders (650 mg every 6 hours PRN for pain AND 650 mg every 4 hours PRN for fever) 1
• This creates risk of exceeding the 3000 mg/day maximum dose 1
• Recommend: Single order for acetaminophen 650 mg every 6 hours as needed, maximum 3000 mg/24 hours 1

Medications to Continue with Monitoring

Atorvastatin 80 mg

• Continue but monitor - this is the maximum dose and carries increased myopathy risk, particularly with the patient's age and multiple medications 6
• The dose is appropriate for secondary prevention in established cardiovascular disease but requires monitoring for muscle symptoms 6

Potassium Chloride

• Verify indication - the order states "for hyperkalemia" which is incorrect; potassium supplementation treats hypokalemia, not hyperkalemia 1
• If the patient is on furosemide and develops hypokalemia, continuation is appropriate 1
• If this was ordered in error for hyperkalemia, discontinue immediately 1

Amiodarone

• Continue with appropriate monitoring - while this carries a black box warning, it is indicated for abnormal heart rhythm and requires ongoing monitoring rather than discontinuation 1

Clinical Approach to Deprescribing

The prescribing cascade should be avoided by recognizing that new symptoms may represent adverse drug events rather than new conditions requiring additional medications 1

When discontinuing medications after chronic use:

• Proton pump inhibitors can be stopped abruptly or tapered based on patient preference 1
• Zolpidem should be tapered gradually to avoid rebound insomnia 1
• Opioids require structured tapering protocols 1

Medication regimen complexity should match the patient's self-management abilities 1

Summary of Recommended Changes

1. Discontinue: Famotidine, sucralfate, milk of magnesia, bisacodyl suppository, Fleet enema, senna-docusate 1, 2, 3
2. Reduce: Pantoprazole from 40 mg twice daily to 40 mg once daily 1
3. Add: Polyethylene glycol 17 grams daily scheduled for constipation prevention 2, 3
4. Consolidate: Acetaminophen to single order with clear maximum daily dose 1
5. Strongly consider discontinuing: Zolpidem, oxycodone-acetaminophen (if pain controlled with alternatives) 1
6. Verify indication: Potassium chloride (correct the "hyperkalemia" indication error) 1

This approach reduces pill burden from 30+ medications to approximately 23-24 medications while maintaining therapeutic efficacy and reducing adverse event risk 1