| Patient ID | Conditions | Medications | DTP Recommendation | Grade |
|---|---|---|---|---|
| 9 | Hyperlipidemia Edema Hypokalemia Type 2 diabetes Angina CHF |
Aspirin 81 mg Atorvastatin 80 mg Clopidogrel 75 mg Furosemide 80 mg Sitagliptin (Januvia, Merck) 100 mg Potassium 20 mEq Metoprolol tartrate 25 mg Canagliflozin (Invokana, Janssen) 300 mg Vitamin D3 1000 IU Vitamin C 500 mg Multivitamin Glucosamine and chondroitin Dulaglutide (Trulicity, Lilly) 0.75mg/0.5mL Nitrostat 0.4 mg |
Switch from dulaglutide and canagliflozin (Tier 3) to insulin glargine injection (Lantus, Sanofi) 100 U/mL (Tier 2) for cost savings | 1 |
| Switch from metoprolol tartrate 25 mg twice daily to metoprolol succinate 50 mg due to CHF | 3 | |||
| Start lisinopril 5 mg once daily due to CHF and type 2 diabetes | 4 | |||
| Assess patient-reported burning upon urination and trouble initiating urination | 2 | |||
| Start gabapentin 300 mg once daily; titrate to lowest effective dose due to patient-reported diabetic neuropathy | 2 | |||
| Switch from vitamin D 1000 IU once daily to calcium 600 mg + vitamin D 400 IU twice daily for prevention of osteoporosis | 1 | |||
| 17 | Hyperlipidemia Depression Anxiety Type 2 diabetes Hypertension Insomnia GERD |
Atorvastatin Citalopram Clonazepam Insulin lispro injection (Humalog, Lilly) Insulin glargine injection Lisinopril Mirtazapine Omeprazole Venlafaxine Multivitamin Aspirin Zinc Calcium + d3 Vitamin E Cinnamon Hydrocodone bitartrate/acetaminophen (Norco, Actavis Pharma) |
Re-evaluate need for mirtazapine due to xerostomia and Beers Criteria recommendation | 2 |
| Discontinue citalopram to avoid QT prolongation | 2 | |||
| Evaluate possibility of switching to oral diabetic therapy due to cost issues | 1 | |||
| Increase atorvastatin from 10 mg to 40 mg to improve therapy | 2 | |||
| PGx recommendation: Discontinue citalopram 20 mg and initiate sertraline 50 mg to avoid adverse events; DDGI involves citalopram, omeprazole, and CYP2C19 | 3 |
CHF = congestive heart failure; CYP = cytochrome P; DDGI = drug-drug-gene interactions; DTP = drug treatment problems; GERD = gastroesophageal reflux disease; ID = identification; PGx = pharmacogenetic.