For my adult female patient presenting for a routine follow‑up with multiple chronic conditions and polypharmacy, should I modify her current medication regimen or management plan?

Medication Regimen Modifications for This Patient

Yes, I would make several critical changes to this patient's medication regimen, prioritizing the discontinuation of aspirin and ibuprofen while adding an SGLT2 inhibitor to address her HFrEF, CKD, and diabetes—changes that offer the greatest mortality and quality-of-life benefits across her multiple conditions. 1

Immediate Medication Changes

Discontinue Aspirin

• Stop aspirin 81 mg immediately in this patient already on rivaroxaban for atrial fibrillation 1
• The combination of aspirin plus anticoagulation significantly increases bleeding risk without additional cardiovascular benefit in patients >3 years post-PCI 1
• Dual therapy (aspirin + rivaroxaban) creates unnecessary polypharmacy and increases adverse event risk, particularly in older adults with CKD 1

Discontinue Ibuprofen

• Stop ibuprofen completely due to multiple high-risk interactions 1
• NSAIDs worsen heart failure, hypertension, and CKD—all present in this patient 1
• NSAIDs increase bleeding risk when combined with rivaroxaban 1
• Refer to primary care for alternative pain management strategies for osteoarthritis 1

High-Priority Addition

Add SGLT2 Inhibitor

• Initiate an SGLT2 inhibitor (e.g., empagliflozin or dapagliflozin) as this provides the single greatest mortality benefit across her multiple conditions 1
• SGLT2 inhibitors simultaneously address:
  • HFrEF: Reduces HF hospitalizations and cardiovascular mortality 1
  • CKD: Preserves kidney function and slows progression 1
  • Type 2 diabetes: Improves glycemic control (HbA1c 7.5%) 1
  • ASCVD: Reduces atherosclerotic complications 1
• Coordinate with diabetes provider before initiation as insulin glargine dose will likely need reduction to prevent hypoglycemia 1
• Verify the SGLT2 inhibitor is on her formulary to minimize financial toxicity 1

Medications Requiring Optimization (Not Immediate Changes)

Losartan Dose

• Current dose of 25 mg daily is suboptimal for HFrEF (LVEF 25%) 1
• Consider uptitration to target dose (50-100 mg daily) if blood pressure and kidney function tolerate 1
• Current BP 135/90 mmHg suggests room for optimization 1

Metoprolol Succinate Dose

• Current dose of 50 mg daily is below target for HFrEF 1
• Guideline-directed medical therapy for HFrEF typically requires higher beta-blocker doses 1
• Uptitrate gradually as tolerated by heart rate and blood pressure 1

Critical Polypharmacy Considerations

Avoid "Guideline Stacking"

• This 75-year-old patient with multimorbidity qualifies for numerous Class 1 recommendations, but simply adding all guideline-recommended therapies leads to polypharmacy, adverse events, treatment burden, and therapeutic confusion 1
• Prioritize therapies offering the largest absolute survival and quality-of-life benefit across her multiple chronic conditions 1
• The SGLT2 inhibitor represents the highest-yield addition given its benefits across HFrEF, CKD, diabetes, and ASCVD 1

Medication Reconciliation

• Schedule her next visit 30 minutes early to perform comprehensive medication reconciliation with a pharmacist, medical assistant, or nurse 1
• Have her bring all medication bottles (prescription, over-the-counter, supplements) to identify discrepancies 1
• 67% of medication histories contain at least one error, with 22% having potential for significant harm 2

Additional Preventive Measures

Vaccinations

• Administer influenza vaccine and COVID-19 booster today in clinic or pharmacy 1
• Patients with ASCVD and multimorbidity are at higher risk for viral complications 1

Advance Care Planning

• Provide advance care directive materials (Five Wishes booklet or Prepare for Your Care website) 1
• This patient is in a phase of life with reduced life expectancy where goals of care discussions are essential 1

Common Pitfalls to Avoid

Drug-Disease Interactions

• NSAIDs (ibuprofen) exacerbate CHF, CKD, and hypertension—all present in this patient 1
• Anticholinergic medications should be avoided given her age and multiple comorbidities 1

Bleeding Risk Assessment

• Older age, hypertension, and CKD increase both thromboembolism risk and bleeding risk 1
• Triple therapy (aspirin + rivaroxaban + NSAID) creates unacceptable bleeding risk 1

Kidney Function Monitoring

• CrCl 47 mL/min requires dose adjustments for multiple medications 1
• Rivaroxaban 15 mg daily is appropriately dosed for CrCl 30-50 mL/min 1
• Monitor kidney function regularly as CKD progression may necessitate further medication adjustments 1

Follow-Up Monitoring

Short-Term (2-4 weeks)

• Assess for SGLT2 inhibitor side effects (genital mycotic infections, volume depletion) 1
• Verify insulin dose adjustment occurred and check for hypoglycemia 1
• Reassess pain control after ibuprofen discontinuation 1

Medium-Term (3 months)

• Repeat HbA1c to assess glycemic control with SGLT2 inhibitor 1
• Monitor kidney function (serum creatinine, eGFR) 1
• Reassess HF symptoms and consider further GDMT optimization 1