Patient Profile for Browning, Dennis R.
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General Information
ID: drb05232005
Prescriber: LaMont, Harold, M.D.
Name: Browning, Dennis R.
Address: 107 Bass Street.
City: Panacea
State: FL
Zip: 34339
Country: USA
Phone: 850.348.3829
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Current Conditions
• allergic rhinitis
• benign prostatic hyperplasia (BPH)
• bipolar disorder
• bone pain
• constipation
• depression
• diarrhea
• headache
• hypercholesterolemia
• hypogonadism
• local anesthesia
• muscle spasm
• neuropathic pain
• nutritional supplementation
• osteoarthritis
• Parkinson's disease
• renal impairment
• severe pain
• vertebral disc herniation
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Current Allergies
No allergies noted
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Current Medications
• Medication
• Amidrine® Sig: tab 1 every four hours as needed for headache
• Androderm® Dosage: 5mg Sig: patch 1 daily
• Benadryl® Dosage: 25mg Sig: two as needed for runny nose
• Celexa® Dosage: 40mg Sig: two in AM
• Chondroitin; Glucosamine Dosage: 500mg/400mg Sig: 1 three times a day
• Colace® Dosage: 100mg Sig: three after dinner
• Depakote® Dosage: 500mg Sig: three times a day
• Effexor® XR Dosage: 150mg Sig: two AM and 1 PM
• Fish Oil, Omega-3 Fatty Acids Dosage: 1000mg Sig: 1 three times a day
• Flexeril® Dosage: 10mg Sig: 1 every 8 hours as needed for muscle spasms
• GlycoLax™ Dosage: 17mg Sig: 17mg daily
• Imodium® Dosage: 2mg Sig: 2 as needed for diarrhea
• Lamictal® Dosage: 100mg Sig: 1 in AM
• Lidoderm® Dosage: 5mg patch Sig: apply for 12 hours.. remove for 12 hours and repeat
• Lipitor® Dosage: 40mg Sig: 1 at bedtime
• Mirapex® Dosage: 1mg Sig: 1 at bedtime
• Morphine Dosage: 30mg Immediate Release Sig: 1 four times a day
• Morphine Dosage: 30mg Extended Release Sig: 1 twice a day
• Psyllium Dosage: 500mg Sig: 3 two times a day
• Saw Palmetto Dosage: 900mg Sig: tab 2 twice a day
• Skelaxin® Dosage: 800mg Sig: tab 1 three times a day... (omit Flexeril)
• Vitamin C Dosage: 500mg Sig: 1 daily
• Vitamin E Dosage: 400 Units Sig: 1 daily
• Zetia® Dosage: 10mg Sig: 1 in AM
• Zyprexa® Dosage: 10mg Sig: tab 1 at bedtime
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Dosing Parameters
Gender: Male
Birthdate: 1/2/1938
Weight: 75.91 kgs
Height: 172.72 cm
Ideal Body Weight: 68.61 kgs
Body Surface Area: 1.91 m²
Serum Creatinine: 1.1 mg/dL
Creatinine Clearance: 63.24 mL/min
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Notes
Title: Initial Interview & Assessment
Date: 08/03/2005
This 67 year old white male presents with a long list of complaints and is currently on 24 different medications daily. He is in pain and frustrated with his current physical condition. He has suffered from severe back injuries and pain for several years. Efforts to try to control the pain have not been too successful. The inclusion of osteoarthritis of course adds to the problems with pain and mobility. He has had over the years multiple surgeries on his back and spine. An assessment using the Geriatric Depression Scale shows a score of 5 which places the patient in depression and anxiety. He currently is on several SSRI s, muscle relaxants, and antipsychotic drugs concomitantly. Use of Dopamine agonists, Mirapex, is not consistent with concomitant use of dopamine antagonists. Discussions with his wife during the interview revealed that the patient is in constant movement throughout the night. I am not surprised, with several SSRI drugs currently being used, and the antipsychotic drug all concomitantly place the patient at very high risk for tardive dyskinesia and other movement disorder problems such as serotonin syndrome. Concomitant use of testosterone patch and Saw Palmetto contradicts each other and places potential for therapeutic benefits from either at a low level. Concomitant use of two muscle relaxants, Flexeril and Skelaxin, both anticholinergic type drugs, are not recommended with other drugs currently being used. The use of these muscle relaxants combined with anticholinergic Benadryl surely does increase problems with constipation for which several medications are used. This constipation problem is also exacerbated by the use of the opiates currently used to control pain. Another problem with the muscle and joint pain may be due to the multiple use of statin Lipitor and Zetia. Just by nature of age sarcopenia is always present in the geriatric patient and becomes more dominant as we age. When drugs such as statin drugs are used, especially on a patient with numerous physical problems, rhabdomyolysis can exacerbate the muscle deterioration and lead to serious problems including liver and renal failure. The concomitant use of Lamictal and Depakote are contraindicated and the depakote will more than double the elimination half life of the Lamictal which makes many of the complaints subject to adverse events consistent with the Lamictal. A consolidation of many of these drugs is necessary for numerous health reasons and quality of life issues. I will discuss the various nutraceuticals in the recommendations section.
Title: Drug Therapy Evaluation & Recommendations
Date: 08/03/2005
Review of the drug therapy currently prescribed resulted in the following problem areas:
Amidrine - an old combination of drugs used to treat migraine headaches but portions of the drug conflict with other drugs currently being consumed. I do not find any value from continued use of this drug. This drug should be discontinued.
Androderm - use of testosterone patch comes with a long list of adverse events. The list varies from insomnia, headache, hepatic problems, BPH and myopathy. I believe until we have the overall drug therapy management under some kind of control this drug should be tapered off over the next month and wait and see if it is needed in 60 to 90 days.
Benadryl - use of anticholinergic antihistamine drugs are contraindicated in the geriatric patient and with all the other anticholinergic drugs currently consumed it should be discontinued at once. Use of non-anticholinergic Claritin or Zyrtec daily could be an alternative treatment for allergy symptoms.
Celexa - 80mg daily of this SSRI is an excessive dose. Used along with 450mg of Effexor XR another SSRI makes the current dose extremely excessive and will lead to involuntary movement disorders and many serious side effects. It is apparent that the antiepileptic drugs currently used to help control mood are not effective and many changes should be made in this therapy which I will discuss. A tapering starting with the Celexa is needed until it is discontinued, then a continuation of tapering of Effexor XR along with changes in the antiepileptic medications are going to be necessary to reach our mutual goal. This tapering process may not be pleasant since be body is acclimated to all this additional chemistry.
Chondroitin/Glucosamine - many studies show a high degree of benefits from the use of this drug in joint and muscle pain. A total of 1200mg Chondroitin and 1500mg of Glucosamine are required daily for therapeutic benefits. Some places have a “triple strength” size dose that will allow for two tablets to be taken each morning and the therapeutic parameters are met.
Colace - use of this stool softener I am sure is necessary due to the enormous amounts of anticholinergic drugs and opiates consumed each day. After we have tapered you off many of these unnecessary drugs, there should be a reduction in the amounts of stool softeners.
Depakote - Although 1500mg daily should benefit you, I question whether it really does, or are the effects simply subdued due to all the other contradicting medications you are currently taking.
Effexor XR - an excellent antidepressant-anxiolytic drug SSRI-SNRI action is probably needed but dose is excessive and contraindicated in view of others being used and numerous other medications that effect motor function. The use of this drug will probably be needed but in much smaller dosing.
Fish Oil - I am a firm believer in the use of antioxidants and this is an extra good choice. Continuation of this is encouraged.
Flexeril - Use of anticholinergic drugs in the geriatric patient is contraindicated due to other serious adverse events. This is also a contributing factor in your constipation problem. This drug needs to be tapered and discontinued eventually. If not taking routinely then it should not be taken any more.
Glycolax - another laxative that may be reduced or stopped once we reduce the overall drug therapy on the patient.
Lamictal - 100mg daily dose due to chemical changes in bioavailability by concomitant use of the Depakote will double the activity of the drug. Because of this all the complaints listed in this patient are potential adverse events associated with this drug incompatibility. This drug needs to be stopped and alternative methods to treat bipolar problems pursued. I will discuss this in my recommendations in detail.
Lidoderm - use of this drug is for off label reasons and places a seriously high risk of cardiac problems, cardiovascular collapse and probably cardiac arrest. The depth of the pain areas in your back exceed the distance that this peripheral nerve block drug will work.
Lipitor - with review of your lipid profile and the degree of pain you current endure I believe that a trial of assuming elevated homocystine and methylmelanonic acid levels and treating as such and reevaluate lipid profile in 4 months. The use of Vitamin B12 injection, B6 and Folic acid normally reduces cholesterol and LDL in most patients without the need for statin therapy. This greatly reduces the risk of rhabdomyolysis and liver and kidney failure.
Mirapex - use of this dopamine agonist is unnecessary in this patient. It is being used to treat side effects associated with the anticholinergic, antipsychotic and other psychoactive drugs. Making drastic modifications in these therapies will reduce these side effects. Actual benefit from continued use of this drug is none.
Morphine - use of this most potent opiate agonist may be necessary but I have great concerns that continued use at these dose levels will only lead to higher and higher dosing and serious adverse events and addiction. Also, the use of this drug in the amounts prescribed exacerbates more constipation problems. If at all possible some other means should be explored. I am well aware of the discomfort in making changes in this drug to some other pain control but attempts should be made. Use of Fentanyl patches may be an alternative and should be given a fair chance to see if success can be derived. Use of these patches give 24hour pain relief without the peaks and troughs now experienced with the morphine oral dosing. This may be a good alternative.
Psyllium - another laxative which may be stopped after adjustment of drug therapy. I am sure it is necessary at the present just from review of current drug regimen.
Saw Palmetto - use of this drug with testosterone patch is contraindicated and each negate any therapeutic benefits for each. Both the testosterone patch and Saw Palmetto should be discontinued. Use of Proscar has fewer side effects and will control problems from BPH,. although you may not have BPH after a few months off the testosterone patch.
Skelaxin - a very heavy anticholinergic drug that only exacerbate numerous problems listed with this patient. This drug should be stopped.
Vitamin C - use of antioxidants is necessary for the geriatric but at this dose little benefit can be received. The patient should continue Vitamin C but at 2GM dosing daily
Vitamin E - although some studies show no benefit from use of vitamin E they were done on mega dosing. The use of 400U daily works as an antioxidant and should be continued.
Zetia - Use of cholesterol lowering drugs may not be necessary and a rest period is needed to determine how much contribution they have with the current adverse events currently being experienced.
Zyprexa - after discussion with the patient’s wife it is apparent that this highly anticholinergic antipsychotic drug is becoming a problem. Unintended movements are the first signs of the beginning of irreversible tardive dyskinesia. There is no diagnosis or condition that requires the need for antipsychotic drug therapy. This drug needs to be tapered and discontinued.
Drug Therapy Management
Stop Amidrine
Stop Androderm patch (taper 5mg every other day for 30 days and discontinue)
Stop Benadryl
Stop Celexa (taper 40mg in AM for 14 days, then every other day for 14 days and stop)
Stop Flexaril
Stop Skelaxin (taper twice a day for 7 days, once a day for 7 days, every other day for 7 days and discontinue
Stop Lamictal ( taper 50mg every day for 7 days then 50mg every other day for 7 days then discontinue)
Stop Lidoderm patch (taper apply every other day for 10 days and discontinue)
Stop Lipitor
Stop Mirapex (taper 1mg every other bedtime for 7 days and discontinue)
Stop Morphine (see dosing schedule listed below)
Stop Saw Palmetto
Stop Zetia
Stop Zyprexa ( taper 5mg at bedtime for 30 days, then 2.5mg at bedtime for 30 days, then 2.5mg every other bedtime for 30 days and discontinue
New Drug Therapy
Start:
Vitamin B12 1000mcg IM weekly for 4 weeks then monthly
Vitamin B6 200mg tablet daily
Folic Acid 1mg tablet daily
Zyrtec 10mg tablet daily as needed for allergies
Proscar 5mg tablet daily
Vitamin C 1000mg tab 2 each morning
Fish Oil 1000mg each morning
Vitamin E 400U each morning
Chondroitin/Glucosamine Triple Strength tab 2 each AM
Centrum Silver (or store like brand) tab 1 daily
Fentanyl Patch 25mcg apply every 3 days.. then taper Morphine Immediate Release to
30mg twice a day for 6 days then 30mg each morning for 6 days then 30mg every
other day for 6 days and stop) If breakthroughs are observed increase Fentanyl
patch to 50mcg every 3 days.
After 21 days start taper of Morphine 30mg extended release daily for 6 days, then
every other day for 6 days and discontinue. If breakthrough pain is observed
increase Fentanyl patch to 100mcg every 3 days.
Topamax 25mg daily and taper Depakote to 500mg twice a day for 7 days, then
Increase Topamax to 50mg daily and taper Depakote to 500mg daily for 7 days
then increase Topamax to 100mg daily and discontinue Depakote. If symptoms
continue increase Topamax in 25mg increments to a maxium of 200mg daily.
Effexor XR 150mg twice a day for 30 days, then Effexor XR 150mg at bedtime only
Remember that it will take time to see all the changes that the new drug therapy will produce. After completing the titration processes that are required, we should see big improvements relating to the complaints recorded. The additional vitamin supplements should also make you feel better after 30 days or so. I can assure you that coming off some of these drugs is not going to be fun. It is going to take a lot of self restraint on your part to make it happen. I can only design you a pathway to follow. I do know that continued use of the current drug therapy is going to lead to serious and life threatening results. I have seen some excellent outcomes for the combination of Topamax and Effexor XR and side effects are low. I am sure you are in a serotonin syndrome just based on the amount of antidepressants you are taking. I also am sure you need some help from this class of drug, just more realistic dosing. As we move away from all these drugs I am sure other problems may occur and when they do call me and we can make alterations and changes until we get your right dose. It is essential for you to follow the schedule .
Let me remind you that this drug therapy regimen is thoroughly thought out and should be followed in its entirety. Choosing only bits and pieces of it may keep us from reaching our mutual goal of improvement in your quality of life and health. I am as close as your phone, so if problems occur, please call me. I look forward to seeing you for a follow-up and reevaluation around the end of September or the first of October but would like a progress report weekly by phone.
Title: Additional Information and Recommendations:
Date: 08/31/2005
A discussion with Mrs. Browning today over e-mail presented with the following questions and problems:
Use of Fentanyl patch has been approved by the Pain Specialist. The drug is on order and tapering of the Morphine dosing will begin as soon as the drug is delivered.
There are concerns over cooperation with the Psychiatrist who Mr. Browning will visit on September 6, 2005. It is necessary that the suggested changes occur as outlined in the report for a successful outcome. I indicated to Mrs. Browning my willingness to talk to the doctor if he would like further explanations.
There are concerns over the use of Vitamin E as it relates to recent studies showing possible harm from its use. These studies were done on mega doses of vitamin E and do not pertain to doses in the 400 to 800 units a day range. Vitamin E is an excellent antioxidant and used in appropriate dosing can provide excellent benefits in fighting cardiovascular disease and high lipids. The dose recommended is well within those parameters considering some you will find in other nutritional supplements recommended.
The correct Vitamin C product to use was also discussed. Although Rose Hips is a natural Vitamin C found in wild roses most commercial products that contain Rose Hips actually only contain minimal amounts. Although is sounds good to advertise Rose Hips in the product the amount normally contained in them provides no extra benefit. Just a regular CVS store brand Vitamin C, time release or not, consuming 2000mg each morning will meet the patient’s needs.
Concerns over the microgram and milligram in understanding dosing of some products that contain folic acid was discussed. I explained that it takes 1000 micrograms to make 1 milligram or that a microgram is one-thousandth of a milligram. Use of the 1mg Folic Acid recommended had taken into consideration other sources of Folic Acid. All the recent studies of the importance of Folic Acid in cognition, anemia and motor function in the geriatric patient makes a compelling case for maintaining high serum folate levels. High folate levels in the geriatric patient is a value that I believe is essential.
Concerns over stopping the Amidrine used for headaches and what to use in its place are an issue. I want to reiterate my recommendation. Side effects are high with the use of Amidrine in the geriatric patient. Some of these adverse events are currently being experienced by the patient, and that further supports discontinuing this therapy. The use of Tramadol plus acetaminophen should support his headache pain management with no problems. I advise the use of Tramadol 50mg plus acetaminophen 500mg every 4 to 6 hours as needed for mild to severe headaches.
I would like a follow-up call after your doctor visit on September 6, 2005.
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Drug Interactions
Acetaminophen; Dichloralphenazone; Isometheptene (Amidrine®) and Diphenhydramine (Benadryl®)
Severity: Moderate
Acetaminophen; dichloralphenazone; isometheptene contains the central nervous system depressant dichloralphenazone. The CNS depressant effects can be potentiated by ethanol or other CNS depressants including anxiolytics, sedatives, and hypnotics (including barbiturates and benzodiazepines), antipsychotics, buprenorphine, butorphanol, dronabinol, THC, entacapone, nalbuphine, opiate agonists, pentazocine, phenothiazines, pregabalin [7523], tolcapone, tramadol, tricyclic antidepressants, and sedating H1-blockers. In addition, dichloralphenazone is metabolized to chloral hydrate. A mutual inhibition of metabolism exists between ethanol and chloral hydrate. In rare instances, a disulfiram-like effect, characterized by tachycardia, palpitations, facial flushing, and dysphoria, has occurred with concomitant use of ethanol and chloral hydrate. Further, chronic ethanol use increases acetaminophen-induced hepatotoxicity by inducing cytochrome P450 (CYP) 2E1 leading to increased formation of the hepatotoxic metabolite and by depleting liver glutathione stores. Administration of acetaminophen should be limited or avoided altogether in alcoholics or patients who consume ethanol regularly. However, acute ethanol ingestion may reduce acetaminophen-induced hepatotoxicity by substrate competition for CYP2E1.
Because diphenhydramine can cause pronounced sedation,[6568] an enhanced CNS depressant effect may occur when it is combined with other CNS depressants [6568] including anxiolytics, sedatives, and hypnotics (such as barbiturates and benzodiazepines) [6946] [6948], buprenorphine [5278], butorphanol [5912], carisoprodol, clozapine [4989], dronabinol, THC, droperidol [5468], entacapone [5769], ethanol [6341] [6948], general anesthetics [6892], haloperidol [5036], methocarbamol, mirtazapine [5366], molindone [5553], nalbuphine [6778], nefazodone [5414], olanzapine [5517], opiate agonists, pentazocine [6777], phenothiazines [6946], pimozide [5250], pramipexole [5640], pregabalin [7523], procarbazine [5356], quetiapine [5855], risperidone [5144], ropinirole [5681], tolcapone |