What medication would be most likely discontinued in a 72-year-old woman with congestive heart failure, hypertension, gout, hypothyroidism, and chronic pain, who is taking multiple medications including hydrocodone-acetaminophen and oxycodone-acetaminophen, at a follow-up visit with normal blood pressure?

Discontinue Omeprazole in This Patient

The primary care provider should most likely discontinue omeprazole at today's visit. This patient is taking two opioid-acetaminophen combination products (hydrocodone-acetaminophen AND oxycodone-acetaminophen) simultaneously, which represents dangerous polypharmacy and should be consolidated into a single opioid regimen, but the most straightforward medication to discontinue is the proton pump inhibitor (omeprazole), which lacks clear indication in this case and contributes to unnecessary polypharmacy. 1

Primary Concern: Duplicate Opioid Therapy

This patient is receiving two separate opioid-acetaminophen combination products concurrently, which is inappropriate and potentially dangerous. 1

• Taking both hydrocodone-acetaminophen and oxycodone-acetaminophen simultaneously creates:

  • Risk of excessive acetaminophen dosing (maximum 3-4 grams daily) 1
  • Increased opioid-related adverse effects including sedation, cognitive impairment, falls, and respiratory depression 1
  • Unnecessary complexity in the medication regimen 1

• The opioid regimen should be consolidated to a single agent rather than using two different combination products 1, 2

• However, abrupt opioid discontinuation carries significant risks and requires careful tapering (25-50% every 2-4 days) 2, making this a more complex intervention than simply stopping omeprazole

Most Appropriate Medication to Discontinue: Omeprazole

Omeprazole represents the medication most appropriate for immediate discontinuation because: 1

• No clear indication is provided - the patient has no documented history of peptic ulcer disease, GERD symptoms, or NSAID use requiring gastroprotection 1

• Proton pump inhibitors contribute to polypharmacy burden without demonstrated benefit when used without indication 1

• Discontinuation carries minimal risk compared to stopping other medications 1

• The patient is already taking 12 medications, placing her at high risk for adverse drug events and drug-drug interactions 1

Why Not Discontinue Other Medications

Cardiovascular Medications (Contraindicated to Stop)

The patient's heart failure medications are all evidence-based and should NOT be discontinued: 1

• Sacubitril-valsartan is a cornerstone therapy for heart failure with reduced ejection fraction 1
• Carvedilol (beta-blocker) reduces mortality and hospitalization in heart failure 1
• Furosemide manages congestion 1
• Digoxin may provide symptomatic benefit 1

Amlodipine could potentially be reconsidered given her blood pressure is 135/80 and she's on multiple antihypertensives, but this requires careful evaluation and is not the most obvious choice 1

NSAIDs and Heart Failure: Critical Interaction

If this patient were taking NSAIDs, they would be the absolute priority for discontinuation due to: 1, 3, 4

• NSAIDs cause sodium and water retention, worsening heart failure (Class III harm recommendation) 1, 3
• NSAIDs blunt diuretic effects and worsen renal function 1, 3
• The combination of NSAIDs with ACE inhibitors/ARBs (she's on sacubitril-valsartan) and diuretics creates high risk for acute kidney injury 3
• In patients with heart failure, NSAIDs should be avoided entirely 1, 3, 4

However, this patient is not documented to be taking NSAIDs.

Opioid Consolidation (Second Priority)

After discontinuing omeprazole, the next priority is consolidating the duplicate opioid therapy: 1

• Opioids in elderly patients increase risk of falls, cognitive impairment, and addiction 1
• The prescriber should convert to a single opioid regimen rather than using two separate combination products 1, 2
• Consider whether opioids are still indicated, as chronic pain may be better managed with acetaminophen (up to 3g daily) in elderly patients 1, 4
• If opioids must be discontinued, taper gradually by 25-50% every 2-4 days to avoid withdrawal 2

Deprescribing Approach in This 72-Year-Old

This patient exemplifies polypharmacy (12 medications) requiring systematic review: 1

• Polypharmacy is defined as ≥5 medications and dramatically increases adverse drug event risk 1
• The "prescribing cascade" may have led to medications being added to treat side effects of other medications 1

Systematic deprescribing priorities in this patient: 1

1. Medications without clear indication (omeprazole) - discontinue immediately 1
2. Duplicate therapy (two opioid combinations) - consolidate 1
3. High-risk medications in elderly (opioids, if not providing functional benefit) - consider tapering 1
4. Medications that worsen comorbidities (if NSAIDs were present, they would worsen heart failure) 1, 3

Common Pitfalls to Avoid

• Never abruptly discontinue opioids in physically dependent patients - taper gradually 2
• Do not discontinue evidence-based heart failure medications (sacubitril-valsartan, carvedilol, furosemide) without specialist consultation 1
• Recognize that acetaminophen clearance is reduced in heart failure patients, requiring dose monitoring 5
• Avoid adding NSAIDs for pain management in this patient with heart failure, as they cause sodium retention and worsen cardiac function 1, 3, 4