Potential drug-related problem	Action plan	Monitoring (by team)
Diarrhea and hyponatremia May be contributed to by: - Escitalopram (other than low energy, patient has no major depressive symptoms) - Pantoprazole (likely no longer needed given gastrointestinal bleed was 7 mo earlier) - Telmisartan	Decrease escitalopram to 5 mg/d for 2–4 wk, then stop Stop pantoprazole and start rabeprazole 20 mg/d for 2 wk Decrease rabeprazole dose to 10 mg/d for 2–4 wk, then stop Use calcium carbonate or alginate or low- dose ranitidine as needed for rebound heartburn Decrease telmisartan dose gradually to 40 mg daily, then to 20 mg daily if possible	Bowel movements, stool consistency, need for loperamide Mood Withdrawal effects of SSRI discontinuation (e.g., sweating, nausea, insomnia, tremor) Rebound heartburn for 2–4 wk Blood pressure target: 120/60 mm Hg to 150/90 mm Hg
Orthostatic hypotension and dizziness May be contributed to by: - Metoprolol (no longer required given MI was 15 yr earlier and no other compelling indications) - Telmisartan	Decrease metoprolol to 25 mg/d for 2 wk, then to 12.5 mg/d for 1 wk, then stop If blood pressure is still below target range, reduce telmisartan dose (see tapering plan above)	Angina, tachycardia Orthostatic hypotension, dizziness Blood pressure target: 120/60 mm Hg to 150/90 mm Hg
Frequent falls and daytime fatigue and sleeping May be contributed to by lorazepam	Decrease lorazepam to 0.5 mg at bedtime for 2 wk, then to 0.25 mg at bedtime for 2 wk, then stop	Sleep Anxiety, tremor
Vitamin D deficiency (49 nmol/L) and increased risk of falls	Start vitamin D 1000 IU/d
Vitamin B12 deficiency (189 pmol/L)	Start vitamin B12 1000 μg/d
Risk of adverse effects with prednisone	Consider slowly tapering prednisone dose (e.g., from 5 mg twice daily to 7.5 mg once daily for 1 mo, then to 5 mg once daily for 1 mo, and so on)

Note: MI = myocardial infarction, SSRI = selective serotonin reuptake inhibitor.