What adjustments should be made to the medication regimen of a patient with Type 2 Diabetes Mellitus (DM), Hypertension, Dyslipidemia, Ischemic heart disease, candidemia, and Deep Vein Thrombosis (DVT) who is currently on multiple medications including Diovan (Valsartan), Plavix (Clopidogrel), and Concor (Bisoprolol)?

Medication Regimen Adjustments for Complex Multi-Morbid Patient

Continue the current enoxaparin dose adjustment to 70 mg subcutaneously every 12 hours as recommended, maintain dual antiplatelet therapy with aspirin and clopidogrel for the Type 2 MI, complete the 14-day anidulafungin course, and prioritize adding an SGLT2 inhibitor (empagliflozin/Jardiance) over resuming the current regimen given this patient's extensive cardiovascular disease burden. 1

Critical Medication Adjustments

1. Anticoagulation for Provoked DVT

• Enoxaparin 70 mg subcutaneously every 12 hours is appropriate for this patient's weight and renal function, representing therapeutic dosing for acute DVT management 2
• Continue therapeutic anticoagulation for at least 3 months given the provoked nature (bedbound status) of the DVT 3
• Monitor renal function and potassium within the first 3 months, then every 6 months if stable, as recommended for patients on anticoagulation with multiple comorbidities 2

2. Antifungal Therapy

• Complete the full 14-day course of anidulafungin 100 mg daily from the first negative blood culture (currently day 9 of 14) for candidemia management, as this represents appropriate duration for catheter-associated candidemia with source control 2

3. Cardiovascular Medications - Critical Reassessment Needed

Dual Antiplatelet Therapy:

• Continue aspirin 100 mg daily plus clopidogrel (Plavix) 75 mg daily for the Type 2 MI, as this patient has established ischemic heart disease with recent MI and prior PCI 2, 4
• Duration should be at least 12 months post-MI, though this patient's extensive vascular disease may warrant longer therapy 2
• Monitor closely for bleeding given concurrent therapeutic anticoagulation - this triple therapy (aspirin + clopidogrel + enoxaparin) significantly increases bleeding risk 4

Beta-Blocker:

• Continue Concor (bisoprolol) 2.5 mg daily - beta-blockers are Class I recommendation for at least 2 years post-MI and have demonstrated mortality benefit in this population 2, 5
• The current low dose is appropriate given this patient's age and multiple comorbidities 5

ARB Therapy:

• Continue Diovan (valsartan) 40 mg daily - ARBs are Class I recommendation for patients with diabetes, hypertension, and post-MI status to reduce cardiovascular mortality 2, 6
• This dose is suboptimal; consider titrating to 80-160 mg daily if blood pressure and renal function permit 6
• Monitor potassium and renal function closely given concurrent use with potential SGLT2 inhibitor and baseline renal considerations 6

4. Diabetes Management - Major Restructuring Required

SGLT2 Inhibitor - HIGHEST PRIORITY ADDITION:

• Strongly recommend adding or resuming empagliflozin (Jardiance) at 10 mg daily - this is a Class I recommendation for patients with type 2 diabetes and established cardiovascular disease 2, 1
• Empagliflozin has demonstrated:
  • 38% reduction in cardiovascular death 1
  • Reduction in heart failure hospitalization 1
  • Slowing of diabetic kidney disease progression 1
• This takes priority over resuming Ozempic (semaglutide) given the stronger evidence for mortality benefit in patients with established CVD and the patient's current acute illness 2, 1

Critical Safety Measures for SGLT2 Inhibitor:

• Discontinue empagliflozin at least 3 days before any planned surgery to prevent postoperative ketoacidosis 1
• Monitor for volume depletion and hypotension, especially given concurrent diuretic use and recent critical illness 1
• Reduce insulin dose by approximately 20% when initiating empagliflozin if glycemic control is adequate to prevent hypoglycemia 1
• Monitor for genital mycotic infections, particularly given recent candidemia 1

GLP-1 Receptor Agonist:

• Consider resuming Ozempic (semaglutide) 0.4 mg subcutaneously weekly once patient is stable and tolerating oral intake, as GLP-1 RAs have Class I recommendation for cardiovascular risk reduction in type 2 diabetes with established CVD 2, 7
• GLP-1 RAs demonstrate reduction in major adverse cardiovascular events, though the mortality benefit is less robust than SGLT2 inhibitors 2, 7

Metformin:

• Metformin should be first-line therapy and can be safely used in patients with stable heart failure if renal function is normal 2
• Not currently listed in home medications - strongly consider adding metformin 500-1000 mg twice daily if eGFR >30 mL/min/1.73m² and patient is hemodynamically stable 2

Insulin:

• Continue insulin therapy with dose reduction of approximately 20% when SGLT2 inhibitor is initiated 1
• Intensive insulin therapy remains important for glycemic control to prevent microvascular complications 2

5. Lipid Management

• Continue Atorvastatin, but clarify and optimize dose to 40-80 mg daily (current listing shows "10/20 mg") - high-intensity statin therapy is Class A recommendation for patients with diabetes and established CVD 2, 8
• Target LDL <70 mg/dL given very high cardiovascular risk 2, 8
• Consider adding ezetimibe 10 mg daily if LDL remains >70 mg/dL on maximally tolerated statin 2

6. Medications to Resume with Caution

Donepezil 10 mg:

• Resume at 5 mg daily initially, then titrate to 10 mg daily given recent critical illness and delirium 2
• The listed dose of "10 mg every 12 hours" appears excessive - standard dosing is once daily 2

Mirabegron (Betmiga) 50 mg daily:

• Hold temporarily given recent acute illness, candiduria (now resolved), and need to reassess urinary symptoms 2
• Can resume once patient is stable if overactive bladder symptoms persist 2

Escitalopram (Cipralex) 10 mg daily:

• Resume with caution - SSRIs increase bleeding risk when combined with antiplatelet agents 4
• Monitor closely for bleeding given triple antithrombotic therapy 4

7. Medications to Avoid or Discontinue

Quetiapine 50 mg at bedtime:

• Reassess need given recent delirium and fall risk in elderly patient with multiple comorbidities 2
• If continued for behavioral management, use lowest effective dose 2

NSAIDs:

• Strictly avoid - NSAIDs significantly increase bleeding risk with dual antiplatelet therapy and anticoagulation, and worsen renal function with ARB therapy 2, 6

Blood Pressure Target and Monitoring

• Target blood pressure <130/80 mmHg for this patient with diabetes, established CVD, and chronic kidney disease 2
• Monitor orthostatic blood pressure given history of autonomic neuropathy risk with diabetes and recent critical illness 2
• Reassess blood pressure medications every 4-12 weeks until stable at goal 2

Renal Function Monitoring

• Monitor serum creatinine, eGFR, and potassium every 4 weeks initially given:
  • ARB therapy (valsartan) 6
  • Planned SGLT2 inhibitor initiation 1
  • Therapeutic anticoagulation 2
  • Recent critical illness with electrolyte disturbances 2
• Once stable, monitor every 6-12 months depending on eGFR and rate of decline 2

Critical Drug Interactions to Monitor

• Clopidogrel + Escitalopram (SSRI): Increased bleeding risk - monitor closely 4
• Valsartan + SGLT2 inhibitor: Monitor potassium and renal function closely 6
• Triple antithrombotic therapy (aspirin + clopidogrel + enoxaparin): Very high bleeding risk - evaluate any signs of bleeding promptly 4
• Avoid combining valsartan with ACE inhibitors or aliskiren - dual RAS blockade increases risks of hyperkalemia, hypotension, and renal dysfunction 6

Regimen Simplification Strategy

Given this patient's cognitive impairment (Alzheimer's dementia) and complex medication burden:

• Consolidate dosing times where possible to improve adherence 9
• Consider fixed-dose combination products for blood pressure management if multiple agents needed 2, 9
• Prioritize medications with proven mortality benefit: SGLT2 inhibitor, beta-blocker, ARB, statin, antiplatelet therapy 2, 1
• Involve caregivers in medication administration and use medication organizers 9