Drug Therapy Review: Identified Drug-Related Problems and Resolutions

Problem 1: Hypoglycemia Risk from Inappropriate Dextrose Administration

The 25% dextrose IV "SOS" (as needed) regimen is inappropriate for a patient with recurrent hypoglycemia and must be replaced with scheduled glucose monitoring and a structured prevention strategy. 1

The patient presented with hypoglycemic seizure (FBS 67 mg/dl) and HbA1c of 6.7%, indicating his glucose-lowering regimen is too aggressive 1
Immediate action: Discontinue "SOS" dextrose orders and implement scheduled blood glucose monitoring every 4-6 hours 1
The American Diabetes Association recommends medication reduction when HbA1c is substantially below target (<6.5%) to prevent recurrent hypoglycemia 1, 2
Critical pitfall: Reactive dextrose administration treats symptoms but fails to address the underlying medication-induced hypoglycemia 1

Root Cause Analysis Required:

Identify which antidiabetic medications the patient was taking prior to admission (sulfonylureas, insulin, or other agents) 1
If sulfonylureas were used: discontinue immediately due to high hypoglycemia risk, especially in alcohol-dependent patients with irregular oral intake 1, 3
If insulin was used: reduce dose by 20-25% initially and reassess based on glucose trends 2
Alcohol dependence syndrome significantly increases hypoglycemia risk through impaired hepatic gluconeogenesis 1, 4

Problem 2: Hypokalemia Exacerbated by Furosemide

The patient's potassium of 3.3 mEq/L is dangerously low and will worsen with continued furosemide, creating risk for cardiac arrhythmias and seizure recurrence. 5

Furosemide causes potassium depletion, especially with brisk diuresis, and the FDA label explicitly warns that hypokalemia may develop with inadequate oral electrolyte intake 5
Immediate action: Administer IV potassium chloride to correct to >4.0 mEq/L before continuing diuretics 5
The combination of hypokalemia and levipil (levetiracetam) may reduce seizure threshold 5
Ongoing management: Add oral potassium supplementation (20-40 mEq twice daily) and monitor serum potassium every 2-3 days 5

Additional Electrolyte Concerns:

Furosemide may also cause hypomagnesemia and hypocalcemia, both of which lower seizure threshold 5
Check magnesium and ionized calcium levels immediately given the seizure history 5
The FDA label states that all patients receiving furosemide should be observed for signs of electrolyte imbalance including muscle cramps, weakness, and arrhythmia 5

Problem 3: Inappropriate Proton Pump Inhibitor Use

Veloz (rabeprazole) 20 mg IV daily lacks clear indication and should be discontinued to reduce polypharmacy burden. 1

No evidence of active gastrointestinal bleeding, peptic ulcer disease, or NSAID use is documented 1
The American Diabetes Association emphasizes reducing medication complexity when regimen burden becomes an obstacle to adherence 1
Action: Discontinue veloz unless specific indication emerges (e.g., stress ulcer prophylaxis if mechanical ventilation required) 1
Common pitfall: Reflexive PPI prescription in hospitalized patients without reassessment of necessity 1

Problem 4: Ceftriaxone Dosing in Renal and Hepatic Impairment

While ceftriaxone 1 gram IV twice daily is appropriate for urinary tract infection, monitoring is required given splenomegaly, ascites, and pleural effusions suggesting hepatic dysfunction. 6

Ceftriaxone undergoes both renal (40-70%) and biliary (30-60%) elimination 6
Patients with ascites show significant changes in volume of distribution but not substantially different half-lives (9.7 vs 8 hours) 6
The patient's creatinine of 0.66 mg/dl suggests preserved renal function, but ascites indicates possible hepatic impairment 6
Action: Continue current dose but monitor for drug accumulation if hepatic function worsens (rising bilirubin, worsening coagulopathy) 6
Duration: Limit to 7-10 days for uncomplicated UTI (albumin 3+, pus cells 6-8) 6

Problem 5: Thiamine Dosing Inadequate for Alcohol Dependence Syndrome

Thiamine 100 mg IV once daily is insufficient for a patient with alcohol dependence syndrome at risk for Wernicke's encephalopathy, especially given slurred speech and neurological symptoms. 1

Slurred speech and involuntary jerking movements may represent early Wernicke's encephalopathy or alcohol withdrawal 1
Immediate action: Increase thiamine to 500 mg IV three times daily for 3-5 days, then transition to 100 mg IV/PO daily 1
Thiamine must be administered before any glucose-containing solutions to prevent precipitating Wernicke's encephalopathy 1
Critical error in current regimen: Dextrose is being given without adequate thiamine coverage 1

Problem 6: Missing Cardiovascular and Renal Protective Therapy

The patient has multiple cardiovascular risk factors (diabetes, chronic small vessel disease, bilateral carotid/vertebral narrowing) but is not receiving guideline-recommended cardioprotective medications. 1

MRI shows chronic small vessel disease and atherosclerotic narrowing, indicating high cardiovascular risk 1
The American Diabetes Association recommends that patients with established ASCVD receive agents that reduce cardiorenal risk 1
Action upon discharge: Initiate SGLT2 inhibitor (e.g., empagliflozin 10 mg daily) or GLP-1 receptor agonist for cardiovascular protection 1
Also required: Statin therapy (high-intensity) and antiplatelet agent given atherosclerotic disease 1
Metformin should be considered as first-line glucose-lowering therapy given cardiovascular benefits, unless contraindicated 1

Problem 7: Acetylcysteine Indication Unclear

Acetylcysteine 600 mg orally twice daily for COPD with whitish expectoration is reasonable as a mucolytic, but efficacy should be reassessed after 5-7 days. 1

Acetylcysteine may help with mucus clearance in COPD exacerbations 1
Action: Continue for acute exacerbation but discontinue if no symptomatic improvement after one week 1
Consider adding inhaled bronchodilators (short-acting beta-agonist and anticholinergic) if not already prescribed 1

Problem 8: Ondansetron Dosing and QT Prolongation Risk

Ondansetron 4 mg IV three times daily is appropriate for nausea, but ECG monitoring is required given hypokalemia and potential QT prolongation. 5

Ondansetron can prolong QT interval, especially with electrolyte abnormalities 5
The patient's hypokalemia (3.3 mEq/L) significantly increases risk of torsades de pointes 5
Action: Obtain baseline ECG and repeat after potassium correction 5
Reduce to twice daily dosing once nausea controlled to minimize QT risk 5

Problem 9: Polypharmacy and Medication Reconciliation

The current regimen includes 9 medications without documentation of home medications, creating risk for drug interactions and duplication. 1, 7

Immediate action: Obtain complete home medication list including all antidiabetic agents, antihypertensives, and supplements 7
Alcohol dependence increases risk of medication non-adherence and drug-alcohol interactions 7
Discharge planning must include medication reconciliation and simplification where possible 1
Fixed-dose combinations should be considered to improve adherence 1

Summary Algorithm for Resolution

Correct hypokalemia immediately (IV KCl to >4.0 mEq/L) before continuing furosemide 5
Increase thiamine to 500 mg IV TID for 3-5 days 1
Replace "SOS" dextrose with scheduled glucose monitoring every 4-6 hours 1
Identify and discontinue/reduce hypoglycemia-causing medications (sulfonylureas first, then insulin dose reduction) 1, 2
Discontinue veloz unless specific indication identified 1
Check magnesium, calcium, and obtain ECG given seizure history and ondansetron use 5
Plan discharge medications: SGLT2i or GLP-1 RA, statin, antiplatelet, and appropriate glucose-lowering therapy 1
Monitor ceftriaxone duration (7-10 days maximum for UTI) 6

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