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MMI Scenario 28
Amisha is a 70-year-old asian woman. She has co-morbidities including hypertension, constipation, back pain, arthritis, hypertension, and she had a myocardial infarction two years ago. Her medicines include ramipril 10mg, amlodipine 10mg, bisoprolol 5mg, aspirin 75mg, clopidogrel 75mg, Bendroflumethiazide 2.5mg, co-dydramol 10/500mg, ibuprofen 400mg, lactulose, Senna. Her eGFR is 42mL/min/17.3m2, her creatinine is 148micromol/L. Discuss which medicines would need optimisation.
Example Answer
Secondary Prevention: It would be recommended to find out the duration of Amisha’s treatment with clopidogrel as her MI was 2 years ago. Usually, monotherapy with aspirin is recommended after 1 year of MI.
NSAIDs: Ibuprofen may increase Nisha’s blood pressure, so this would need reviewing. Additionally, ibuprofen and ramipril increase the risk of renal failure when taken together and her eGFR is sub-optimal, hence a further reason to review this medication. Finally, the use of an NSAID with anti-platelets also increases the risk of a GI bleed.
Analgesia: Review Nisha’s pain medication as co-dydramol may worsen her constipation and consider initiating regular paracetamol instead with some physiotherapy and alternative analgesia to ibuprofen.
NSAIDs: Ibuprofen may increase Nisha’s blood pressure, so this would need reviewing. Additionally, ibuprofen and ramipril increase the risk of renal failure when taken together and her eGFR is sub-optimal, hence a further reason to review this medication. Finally, the use of an NSAID with anti-platelets also increases the risk of a GI bleed.
Analgesia: Review Nisha’s pain medication as co-dydramol may worsen her constipation and consider initiating regular paracetamol instead with some physiotherapy and alternative analgesia to ibuprofen.