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Diagnosed with acute bronchitis

Mrs. P. is an 80-year-old woman recently discharged from a 24-hour observation stay at the hospital after being diagnosed with acute bronchitis. She has a history of heart failure, hypertension, osteoarthritis, GERD, and hyperlipidemia. She has no history of smoking. While in the hospital she was prescribed doxycycline, prednisone 15 mg to taper, and a tiotropium inhaler. Her current list of daily medications prior to hospitalization includes metoprolol succinate 12.5 mg, pantoprazole 40 mg, atorvastatin 10 mg, lisinopril 10 mg, furosemide 40 mg, potassium chloride 20 meq bid, acetaminophen 650 mg bid for pain and tramadol 25 mg as needed. She lives alone but will reside temporarily with her daughter while she recovers. Her discharge report indicated resolving bronchitis, no exacerbation of heart failure, and stable arthritic pain. Today she reports 1 week after discharge with her daughter for a primary care appointment, and they both were concerned about the number of medications she was prescribed and wanted her medications reviewed. In further review, she was found to have lost weight over the past 6 months of 5 lbs and her current BMI is 25. She states that the weight loss may be due to a change to a healthier diet and reducing sodium as instructed. She also reports no symptoms of GERD for the past 6 months and minimal arthritic pain because of regular use of acetaminophen and daily walking in the halls of her independent living facility. Upon examination her lungs are clear to auscultation and no evidence of lower extremity edema.

Discuss the following:

1) In reviewing her medication list and current symptoms and clinical signs, which
medication could the nurse practitioner consider de-prescribing.

2) Once the patient has completed the prednisone taper, which medication could the nurse
practitioner begin to reduce given the patient’s reported symptoms.

3) Given the absence of an exacerbation of heart failure and compliance with a reduced
sodium diet, what other medication(s) adjustments could the nurse practitioner consider at
this time.

Full Answer Section

- - Hypomagnesemia.
  - Potential for kidney disease (acute interstitial nephritis, chronic kidney disease).
  - Potential for nutrient deficiencies (e.g., B12, iron).
  - Increased risk of dementia (though more research is needed, it's a concern).
- Weight Loss: While she attributes weight loss to a healthy diet, unexplained weight loss in an older adult warrants careful consideration. Reducing medications that are no longer indicated is a safe step.
De-prescribing Strategy for Pantoprazole:
- Gradual Taper: Abrupt discontinuation of PPIs can lead to rebound acid hypersecretion and a return of GERD symptoms. A gradual taper is generally recommended. For pantoprazole 40 mg daily, options could include:
  - Reducing to 20 mg daily for 4-8 weeks, then
  - Reducing to 20 mg every other day for 4-8 weeks, then
  - Discontinuing or switching to an as-needed H2 blocker (e.g., famotidine) for breakthrough symptoms.
- Patient Education: Emphasize the reasons for de-prescribing, the potential benefits, and how to manage potential rebound symptoms (e.g., antacids, temporary H2 blocker). Encourage lifestyle modifications for GERD (e.g., avoiding trigger foods, eating smaller meals, not lying down after eating).
- Monitor for Symptom Recurrence: Closely monitor Mrs. P. for any return of GERD symptoms after tapering and discontinuation.

2) Once the patient has completed the prednisone taper, which medication could the nurse practitioner begin to reduce given the patient’s reported symptoms?

Once Mrs. P. has completed the prednisone taper (which is for acute bronchitis), the nurse practitioner could begin to reduce the acetaminophen 650 mg BID.

Reasoning:
- Minimal Arthritic Pain: Mrs. P. explicitly reports "minimal arthritic pain because of regular use of acetaminophen and daily walking." This suggests her pain is well-controlled and her baseline pain level might be low.
- Daily Walking: Her "daily walking in the halls of her independent living facility" indicates good functional mobility and a non-pharmacological approach to managing her osteoarthritis, which is positive.
- Polypharmacy and Liver Concerns: While acetaminophen is generally safe at recommended doses, in an 80-year-old with multiple medications, minimizing unnecessary polypharmacy is a goal. Chronic use of any medication warrants re-evaluation, and liver function should always be considered in older adults on long-term medications.
- Tramadol PRN: She also has tramadol 25 mg as needed, which she can use for breakthrough pain if needed, providing a safety net if the acetaminophen reduction leads to increased discomfort.
Reduction Strategy for Acetaminophen:
- Trial Reduction: Since her pain is minimal, a trial reduction could involve:
  - Reducing to acetaminophen 650 mg once daily, or
  - Reducing the dose to 325 mg BID if a smaller tablet is available or if she can split doses safely.
- Patient Education: Instruct Mrs. P. to monitor her pain levels closely. Emphasize that if pain increases, she should increase the acetaminophen back to 650 mg BID or use the PRN tramadol as instructed, and to report her pain levels at her next visit. Reinforce the importance of non-pharmacological pain management strategies like continued walking, gentle exercises, and heat/cold therapy.
- Monitor Pain and Function: Assess her pain intensity and impact on her daily activities at follow-up appointments.

3) Given the absence of an exacerbation of heart failure and compliance with a reduced sodium diet, what other medication(s) adjustments could the nurse practitioner consider at this time?

Given her stable heart failure, clear lungs, no lower extremity edema, and compliance with a reduced sodium diet, the nurse practitioner could consider adjusting the furosemide 40 mg daily and potentially optimizing her hypertension regimen with her lisinopril 10 mg and metoprolol succinate 12.5 mg.

Adjustment to Furosemide 40 mg daily:
- Reasoning: Furosemide (a loop diuretic) is a mainstay for managing fluid overload in heart failure. However, her current clinical picture (no exacerbation of heart failure, clear lungs, no edema, and compliance with a reduced sodium diet) suggests she may no longer require such a high or frequent dose of a strong diuretic. Maintaining her on an unnecessarily high dose could lead to:
  - Dehydration, especially in an 80-year-old.
  - Electrolyte imbalances (hypokalemia, hyponatremia), despite her potassium supplementation.
  - Exacerbation of orthostatic hypotension and increased fall risk.
  - Potential for acute kidney injury.
- Adjustment Strategy:
  - Gradual Reduction: A trial reduction could involve reducing furosemide to 20 mg daily, or even 40 mg every other day, depending on her baseline renal function and previous diuretic response.
  - Close Monitoring: Crucial to monitor weight, fluid status, blood pressure (especially orthostatic BP), electrolytes (Na, K), and renal function (BUN/Cr/GFR) very closely after any diuretic adjustment. Educate Mrs. P. and her daughter on signs of fluid overload (e.g., new shortness of breath, weight gain, swelling) and when to report them.
  - Continue Sodium Restriction: Reinforce the importance of strict sodium restriction, as this directly reduces her need for diuretics.

Sample Answer

1) In reviewing her medication list and current symptoms and clinical signs, which medication could the nurse practitioner consider de-prescribing?

Based on Mrs. P.'s current symptoms and clinical signs, the nurse practitioner could strongly consider de-prescribing the pantoprazole 40 mg.

Reasoning:
- No Symptoms of GERD: The most compelling reason is her explicit report of "no symptoms of GERD for the past 6 months." Proton pump inhibitors (PPIs) like pantoprazole are often initiated for acute GERD symptoms or complications and can become a source of polypharmacy and potential long-term risks in older adults when continued indefinitely without ongoing indication.
- Long-Term Risks in Older Adults: Chronic PPI use in older adults is associated with several adverse effects, including:
  - Increased risk of Clostridioides difficile infection.
  - Increased risk of community-acquired pneumonia.
  - Increased risk of bone fractures (hip, spine, wrist) due to impaired calcium absorption.