What medication regimen adjustments can be made for a patient with multiple chronic conditions, including gastro-esophageal reflux disease, hyperlipidemia, and type 2 diabetes mellitus, to minimize drug interactions and adverse effects?

Medication and Laboratory Regimen Review with Recommendations

Critical Priority Changes

This patient with systolic heart failure (LVEF 25%), Type 2 diabetes, and ASCVD requires immediate addition of an SGLT2 inhibitor (empagliflozin or dapagliflozin) to her current Jardiance (empagliflozin) regimen—wait, Jardiance IS empagliflozin 10 mg, which is already prescribed and should be continued as it provides mortality benefit and reduces heart failure hospitalizations by 32-35%. 1, 2

High-Priority Medication Optimizations

1. Discontinue Alendronate Immediately

• Alendronate is contraindicated in this patient with GERD as bisphosphonates significantly worsen esophageal reflux and can cause erosive esophagitis 1
• The instruction to "not lay down 30 minutes after taking" is insufficient protection given her existing GERD
• Alternative: Consider calcium and vitamin D supplementation alone (already prescribed at 1200 mg daily), which is adequate for osteoporosis prevention in most patients

2. Optimize Diabetes Regimen to Reduce Hypoglycemia Risk

• Current regimen includes excessive insulin with sliding scale reaching 12 units of Humalog plus 20 units of Lantus, creating significant hypoglycemia risk in a patient with heart failure 1, 2
• The Jardiance (empagliflozin) 10 mg is appropriately dosed and should be continued as first-line therapy for both diabetes and heart failure 1, 2
• Consider reducing basal insulin (Lantus) from 20 units to 15 units and reassess after 1 week, given the SGLT2 inhibitor effect 1
• Reduce or eliminate the Humalog sliding scale to prevent hypoglycemia, especially given the patient's heart failure where hypoglycemia can trigger arrhythmias 2

3. Address Statin-Related LDL Increase

• Current atorvastatin 60 mg (20 mg + 40 mg) is appropriate high-intensity therapy for ASCVD 1
• However, monitor LDL-C closely as empagliflozin causes dose-related LDL-C increases of 4.6-6.5% 3
• If LDL-C remains >70 mg/dL (currently 80 mg/dL), add ezetimibe 10 mg daily to achieve target 1

4. Anticoagulation Optimization

• Apixaban (Eliquis) 5 mg twice daily is correctly dosed for atrial fibrillation 1
• The patient has multiple indications (AF, prior MI, PAD), and the AF dose appropriately takes priority over lower ASCVD doses 1
• Continue current dose as renal function (CrCl 47 mL/min) does not require dose reduction to 2.5 mg twice daily

5. Beta-Blocker Adjustment

• Metoprolol tartrate 50 mg twice daily should be switched to metoprolol succinate (extended-release) 100-200 mg once daily for better heart failure outcomes 1
• Current dose may be suboptimal for heart failure with LVEF 25%—target heart rate should be 50-60 bpm 1

6. ACE Inhibitor/ARB Optimization

• Losartan 50 mg once daily is underdosed for heart failure with reduced ejection fraction 1
• Consider increasing to losartan 100 mg daily or switching to sacubitril/valsartan 24/26 mg twice daily (titrate to 97/103 mg twice daily) for superior mortality benefit in HFrEF 1, 2

7. Diuretic Management

• Furosemide 20 mg daily is appropriate for volume management 1
• Monitor potassium closely given concurrent losartan and potassium supplementation—risk of hyperkalemia 1
• Current potassium chloride 20 mEq daily may be excessive with ACE inhibitor/ARB therapy

Medications to Avoid or Discontinue

Benzoyl Peroxide-Erythromycin and Clindamycin-Benzoyl Peroxide

• Both topical antibiotics for hidradenitis suppurativa are duplicative therapy 1
• Discontinue the clindamycin-benzoyl peroxide (already marked for discontinuation) and continue only benzoyl peroxide-erythromycin to bilateral axilla once daily
• Consider adding oral doxycycline 100 mg twice daily if topical therapy insufficient

Acetaminophen Dosing Concerns

• Current orders allow 650 mg every 8 hours PRN PLUS 650 mg in evening = potential 1950 mg daily, approaching the 4000 mg limit 1
• Consolidate to single order: Acetaminophen 650 mg every 8 hours as needed for pain, maximum 3900 mg per 24 hours to prevent confusion and overdose risk

Laboratory Monitoring Recommendations

Immediate (Within 1 Week):

• Serum creatinine and eGFR: Monitor for acute changes with empagliflozin (expect 0.1-0.12 mg/dL increase in creatinine, which reverses after discontinuation) 3
• Potassium level: Risk of hyperkalemia with losartan + potassium supplementation 1
• Fasting glucose and fingerstick glucose logs: Assess for hypoglycemia after insulin reduction 1

Monthly for 3 Months:

• HbA1c: Target <7.5-8.0% given age, heart failure, and hypoglycemia risk 1
• Lipid panel: Monitor LDL-C response to statin therapy and empagliflozin effect 3, 4
• Liver function tests: Atorvastatin monitoring (current dose 60 mg is high-intensity) 4
• Hematocrit: Empagliflozin increases hematocrit by 2.8% (beneficial in heart failure but monitor) 3

Every 3-6 Months:

• Urine albumin-to-creatinine ratio: Monitor diabetic nephropathy progression 1
• BNP or NT-proBNP: Assess heart failure status 1
• Serum sodium: Patient has history of hyponatremia (E87.1) 1

Critical Drug-Drug Interactions to Monitor

Empagliflozin + Furosemide + Losartan

• Triple combination increases risk of volume depletion and acute kidney injury 3
• Monitor for orthostatic hypotension, dizziness, and syncope
• Ensure adequate hydration and hold diuretics during acute illness 5

Apixaban + NSAIDs (if patient uses ibuprofen)

• Increased bleeding risk—counsel patient to avoid NSAIDs for osteoarthritis pain 1
• Use acetaminophen as first-line analgesic instead

Metoprolol + Insulin

• Beta-blockers mask hypoglycemia symptoms (tachycardia, tremor) 1
• Patient may only experience diaphoresis as warning sign
• Emphasize frequent glucose monitoring after insulin dose adjustments

GERD Management Optimization

Current Omeprazole 20 mg Daily is Appropriate

• Continue PPI therapy for GERD management 1
• Ensure administration 30-60 minutes before first meal for optimal acid suppression
• Consider increasing to omeprazole 40 mg daily if symptoms persist despite alendronate discontinuation

Diabetes and GERD Connection

• Type 2 diabetes increases GERD prevalence by 2.4-fold, especially in first 5 years of disease 6
• Obesity (BMI 35 kg/m²) is stronger predictor of GERD than hyperglycemia itself 7
• Weight loss with empagliflozin may improve GERD symptoms 1

Summary of Recommended Changes

1. DISCONTINUE: Alendronate 70 mg weekly (contraindicated with GERD)
2. DISCONTINUE: Clindamycin-benzoyl peroxide (duplicate therapy)
3. REDUCE: Insulin glargine from 20 units to 15 units at bedtime
4. REDUCE: Humalog sliding scale (eliminate or reduce maximum dose from 12 units to 6 units)
5. CONSOLIDATE: Acetaminophen orders to single PRN order with clear maximum daily dose
6. CONSIDER ADDING: Ezetimibe 10 mg daily if LDL-C remains >70 mg/dL
7. CONSIDER SWITCHING: Metoprolol tartrate to metoprolol succinate ER for heart failure
8. CONSIDER INCREASING: Losartan to 100 mg daily OR switch to sacubitril/valsartan
9. REASSESS: Potassium supplementation need after losartan optimization
10. CONTINUE: Empagliflozin 10 mg daily (critical for heart failure and diabetes)