Blog

  Along any major street in a large city, prices for regular…

  Along any major street in a large city, prices for regular unleaded gasoline are very similar. The similarity of prices does not occur because of collusion; it results when one carrier sets a fare, and the other carriers feel compelled to match it. This is an example of  

Based on the information that the patient reported, the foll…

Based on the information that the patient reported, the following actions could be recommended to address MRPs: I: START prescription for nitroglycerin SL tabs, 0.4 mg, one tab at onset of chest pain prn, can repeat every 5 min (max 3 doses), call 911 if no relief after first dose E: INCREASE Trulicity to 1.5 mg once weekly Note: other recommendations could be made, but this one would minimize medication burden since not starting a new med AND maximize cadiovascular benefit of GLP-1 A sulfonylurea would not be a particularly good option due to lack of CV benefit, risk of hypoglyecmia, and other factors S: (none applicable) – of note, you may have mentioned the drug interaction (atorvastatin/gemfibrozil) here, but since gemfibrozil is no longer an active medication, the interaction is not relevant A: RESTART / pickup refill for atorvastatin 80 mg daily and ensure taking daily (education provided to patient)     ****NOTES REGARDING BETA BLOCKER AND ACE-I: This patient should remain on the beta blocker and ACE inhibitor since they had a recent MI. Compared to patients with HF, there is less evidence for titrating the beta blocker to any specific HR in patients who are post-MI. You could consider increasing the dose to maximize beta blocker post-MI, but you would need to do so cautiously to ensure tolerability (BP may decrease and is already well within the goal range). The benefit of beta blockers post-MI is greatest within the first 1-3 years after the MI (this patient is still within the one year time frame). The ACE inhibitor also has benefit in patients with diabetes if the patient has an elevated albumin-to-creatinine ratio (preserving renal function), although we do not know if that is the case since we cannot see labs in this community setting. ***NOTE REGARDING CLOPIDOGREL / DUAL ANTI-PLATELET THERAPY: Clopidogrel should NOT be discontinued based on the information available. While the MINIMUM duration of dual anti-platelet therapy is 6 months, the IDEAL length is AT LEAST one year unless the patient is high risk for bleeding, which we have no information to suggest from this case. Often, we need information that we do not have in order to make a risk/benefit call like this.