C3.2 R5: Reconcile a patient’s medications on DISCHARGE (#1)

During my first week I had the opportunity to help take care of a patient (65 yo female) who was in for treatment of double-hit diffuse large B-cell lymphoma. During her admission, there were a few changes to her medication, in addition to adherence concerns as she missed a week of her SMX/TMP for PCP prophylaxis as there was confusion regarding blister packing. I made the following changes to her medications in collaboration with the doctor:
– Discontinued her ASA 81 mg PO daily that she was taking for primary CV prevention. She had a Hx of mitral valve prolapse, but in the absence of HF, A-fib or previous MI/stroke, there was no compelling indication.
– Increased her valacyclovir to 500 mg PO BID from PO daily as she was seropositive for HSV and suffered from an especially bad bout of mucositis (that was HSV-positive on swab) last cycle. The BID dose is usually for HIV-positive patients or leukemia patients, but given her aggressive regimen (daEPOCH-R), the doctor and I felt it prudent to increase the dose, also considering valacyclovir’s favourable safety profile.
– Increased her gabapentin from 600 mg PO QHS, adding 100 mg PO with breakfast and lunch, titrating q week to a target of 600 mg PO TID for fibromyalgia. There was a patient teaching point as well as I explained to her that one would develop tolerance to sedation as gabapentin is slowly titrated.

I made a med calendar for her, had her medications blister packed, prepared her discharge prescriptions, and explained the changes we made in hospital. What I hope to improve upon and apply in future is becoming more efficient with coordinating with the community pharmacy such that medications are delivered in good time when the patient goes home.


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