Current medications

🔄 Latest update — 2026-06-22 · post-ER BP changes (copy pending)

Mid-June, Dad's BP kept spiking and his tics flared; feeling the meds "weren't doing anything," he nearly left TRT. He escalated to TRT leadership, whose internal review found his BP medications had been under-dosed — unclear yet whether the written order was too low or administration didn't match it. He went to the ER, was stabilized, and returned the same day. BP has run 150–160 since, which is better. The resulting medication changes are not yet reflected in the per-drug detail below — Paul is getting the copy from Dad / TRT. Until then, treat the cardiac doses below as the 2026-06-08 baseline, not the current orders.

🔄 Latest update — 2026-06-08 · NP Alyssa, The Recovery Team

Alyssa is Dad's medication-responsible NP at TRT. What changed from the Haven baseline (see the call notes):

• ➕ Losartan 25 mg added — BP running high (160+ systolic). Low-dose ARB trial to see if it helps stabilize. Reassess once readings settle.
• ➖ Vistaril discontinued — "no more" per Alyssa.
• ➖ Trazodone effectively stopped — not taken in over a week.
• 🧬 GeneSight drawn today — pharmacogenomic test for psych-med metabolism (esp. duloxetine); results pending.
• 🧠 Neurologist referral needed — TRT doesn't have in-house neurology. Needs an outside Tourette's + motor-conditions specialist who accepts his insurance (the practical constraint Alyssa flagged).
• Indications clarified by Alyssa (prior Haven framing kept below for the trail): olanzapine → Tourette's · duloxetine → nerve pain + mood · NAC → inflammation.
• Unchanged: aspirin, clopidogrel, atorvastatin, metoprolol, amlodipine, pantoprazole.

"Is the taper done? Is he healed?" — the recurring family question

Dad has said (5/30, 6/4) that "the taper ended weeks ago" and that he's essentially healed. Read against the actual orders:

• The part he's right about: the acute benzodiazepine detox taper is finished. Benzo recovery isn't treated with benzos — the nervous system is stabilized on non-addictive alternatives and left to recalibrate. There is no benzo and no benzo-taper in the current regimen. The only order literally labeled a "taper" — the clonidine micro-taper — ended 5/30. So "the taper ended weeks ago" is, narrowly, true.
• The part that's a dangerous misread: taper done ≠ healed. He's still on a substantial active regimen — olanzapine and duloxetine (both scheduled, both notoriously hard to discontinue), the full cardiac block, NAC, and a 6-agent sleep stack that exists because PAWS is still being managed. Those comfort meds fading as he stabilizes is the evidence he's stabilized, not finished.
• Why it matters: detox is chemistry; recovery is the Phase 2 work that's barely begun. The real danger is an early / against-medical-advice discharge where a psych med lapses → kindling cascade. The most useful move is to let the clinicians deliver the "stabilized, not finished" message to him directly. See the 6/4 note.

Read this first — context that reframes the regimen

• Watchman + AFib. Dad has atrial fibrillation; the Watchman device (LAA closure) was placed after the mini-stroke. The cardiovascular block below makes perfect sense as post-Watchman + post-stroke + CAD management, not over-treatment.
• Tourette's since adolescence. Tics are not new — they're the original reason benzos entered the picture decades ago. NAC + clonidine are continuation, not surprise diagnosis.
• Allergies:
  • Shellfish: real, with childhood anaphylaxis that triggered cardiac arrest (likely Kounis syndrome). Highest-stakes item in his file.
  • Aspirin: historical childhood allergy of unclear origin. Has been on daily low-dose aspirin since the Nov 2023 CABG without issue. Currently tolerating; DAPT regimen is appropriate. Chart should read "historical, currently tolerated."
  • Epinephrine: reported as allergic. Childhood reaction was anaphylaxis-induced cardiac arrest, not an epi reaction. In future anaphylaxis, epi remains indicated — administer in ER with cardiac monitoring given his cardiac history. Honor avoidance in non-emergency contexts.

🫀 Cardiovascular block

Six scheduled meds (losartan added 2026-06-08). Coherent post-Watchman + post-stroke + HTN + dyslipidemia management. With BP running 160+, the antihypertensive side is being actively escalated.

⚠️ Most of this block predates the detox. Per the Oct 2025 baseline, clopidogrel, metoprolol, amlodipine, atorvastatin (and pantoprazole) were all already on board — so the per-drug "Started" dates below are facility re-orders on admission, not true starts. The one genuine recent add is aspirin: it appears on the Oct 2025 list but per family wasn't consistently taken until now (the lifelong charted aspirin allergy is the likely reason), and adding it to long-standing clopidogrel is what makes this dual antiplatelet therapy.

Aspirin 81 mg — daily 9 AM

• Indication: Cardiovascular disease (post-Watchman DAPT)
• Started: 2026-05-13 — genuinely recent (per family). It appears on the Oct 2025 list, but he wasn't consistently taking it until now; the lifelong charted aspirin allergy likely explains the gap between "listed" and "taking." This is the one cardiac agent that really is new — and it's what turns long-standing clopidogrel into DAPT.
• Flag: Charted aspirin allergy is from childhood; post-MI he's been tolerating daily aspirin without problems (stepmom confirmed 5/27). Chart should be corrected to "historical allergy, currently tolerated."
• Long-term: Post-Watchman step-down to aspirin monotherapy is the standard 6-month protocol — and now safe given the tolerance confirmation. Confirm Watchman implant date with cardiologist to know when DAPT steps down.

Clopidogrel (Plavix) 75 mg — daily 9 AM

• Indication: "Blood Thinner / Hx of Stroke" — post-Watchman DAPT partner
• Started: long-standing — already on it in Oct 2025 (likely as antiplatelet monotherapy). The 2026-05-25 chart date is a facility re-order, not a true start.
• Modern ask: Has CYP2C19 pharmacogenomic testing been done? Up to 30% of patients are poor metabolizers (loss-of-function variants), in which case clopidogrel doesn't work as expected. Routine in modern cardiology.

Atorvastatin 40 mg — nightly 9 PM HS

• Indication: Hypercholesterolemia
• Started: long-standing — on atorvastatin 10 mg in Oct 2025, intensified to 40 mg (high-intensity) during this episode. The 2026-05-26 date is a facility re-order.
• Dose: 40 mg is high-intensity statin — appropriate for CAD + stroke history.
• Monitor: LFTs (baseline normal in 2025), CK if muscle pain develops (Dad has chronic back pain — could mask statin myopathy). Backup option if intolerant: bempedoic acid (Nexletol).

Metoprolol tartrate 50 mg — BID 9 AM + 9 PM

• Indication on chart: HTN. Real driver: AFib rate control + post-MI/post-stroke cardioprotection.
• Started: long-standing — already on metoprolol 50 mg in Oct 2025. The 2026-05-26 date is a facility re-order.
• Note: Tartrate (short-acting) BID is standard for rate control. Long-term consideration: succinate (extended release) for once-daily compliance once stable.

Amlodipine 5 mg — daily 9 AM

• Indication: HTN add-on
• Started: long-standing — but at 10 mg in Oct 2025; it's been halved to 5 mg since. Worth asking whether cutting it fed the BP elevation (150–160). The 2026-05-19 date is a facility re-order.
• Note: Calcium channel blocker. Common second-line HTN agent. Watch for ankle edema.

Losartan 25 mg — daily ⭐ new 2026-06-08

• Indication: Hypertension — BP running 160+ systolic at TRT
• Started: 2026-06-08 (NP Alyssa, TRT)
• Why: Angiotensin-receptor blocker (ARB). Added on top of amlodipine + metoprolol because BP wasn't controlled on those alone. 25 mg is a low starting dose — framed as a trial to see if it stabilizes, not a permanent fixture.
• Reassess: Recheck cuff readings over the next 1–2 weeks. If BP settles, this confirms the add was right; if it doesn't, the dose goes up or the driver gets re-examined (see the duloxetine BP note + open question below).

Clonidine 0.1 mg — BID 9 AM + 9 PM, PRN

• Indication: Elevated BP / Anxiety / Restlessness / TICS
• Started: 2026-05-26 · End: 2026-05-30 (4-day taper — completed, no longer in regimen)
• Hold rule: Hold if BP <100/60 or HR <65
• Note: The tics justification ties to his lifelong Tourette's. Clonidine is a real Tourette's med (off-label but well-evidenced) in addition to its BP role. Taper finished 5/30; not mentioned in Alyssa's 6/8 update.

🧠 Psychiatric scheduled

Olanzapine (Zyprexa) 10 mg — nightly 9 PM HS

• Indication (TRT, 2026-06-08): Tourette's — per Alyssa, a longstanding tic med he "came in with," not a new start. Prior Haven framing: Mood (post–Baker Act stabilization). Both can hold — atypical antipsychotics treat tics and also serve mood/agitation.
• Started: long-standing, but for a different reason than "tics" — he was on olanzapine 5 mg for "Depression/Sleep" in Oct 2025, doubled to 10 mg during the crisis and later relabeled "Tourette's." So "longstanding tic med he came in with" is half-right: longstanding yes, but originally a mood/sleep agent — the tic indication is a re-label. The 2026-05-19 date is a facility re-order/uptitration.
• Dose: 10 mg is upper-mid — mood/agitation territory. Sleep-only doses are 2.5–5 mg.
• Concerns specific to Dad:
  • Metabolic: Olanzapine is the worst atypical for insulin resistance + dyslipidemia. Dad's 2025 baseline (insulin 57, A1c 5.8%, LDL-P 1789, atherogenic pattern B) is already on the edge. Length of use is the lever.
  • QT prolongation: Modest. CAD + AFib + Watchman → baseline EKG is non-optional. (Likely on file from April ER admission — confirm.)
  • Sedation + falls: Standard. Compounded by the sleep stack below + amlodipine (orthostatic risk).
• Modern asks:
  • Continuous glucose monitor (Dexcom Stelo / Libre Lingo — both OTC now) for real-time data on his metabolic baseline + olanzapine effect.
  • Why olanzapine over quetiapine (Seroquel)? Quetiapine has a better metabolic profile and is more commonly chosen in detox settings. Worth asking.
  • GLP-1 (semaglutide/tirzepatide) as metabolic rescue if weight/A1c worsen on olanzapine.

Duloxetine (Cymbalta) 40 mg — BID 9 AM + 9 PM

• Total daily dose: 80 mg — full therapeutic dose, not a starter
• Indication (TRT, 2026-06-08): Nerve pain + mood. Prior Haven framing: Depression. As an SNRI, duloxetine genuinely covers both — neuropathic/chronic pain and mood — which is why the framing shifted. It is not a Tourette's/tic drug (worth keeping straight when describing the regimen to family).
• Started: long-standing — already on duloxetine 40 mg in Oct 2025 (for "Depression"); now 40 mg BID (80 mg/day). Not a fresh 2026 start, so the classic black-box initiation window (below) is less applicable than for a naïve start — most relevant to the recent dose increase.
• SI monitoring window: Black-box warning is most active days 1–14 of treatment. That window for Dad: 2026-05-22 → 2026-06-05. Confirm explicit daily SI check-ins with his counselor through that window.
• Concerns specific to Dad:
  • BP elevation: Duloxetine reliably raises BP. With BP now running 160+ and losartan just added (6/8), it's worth asking whether the duloxetine is part of why BP's been stubborn — he's on amlodipine + metoprolol + losartan and still elevated. Cuff readings on a schedule. (See open question below.)
  • Discontinuation syndrome: Notoriously hard to stop — brain zaps, severe withdrawal. The exit plan is as important as the entry plan.
  • Hepatotoxicity: Baseline LFTs normal. On-drug rechecks at 4–6 wk then quarterly.
  • Bipolar unmasking: Worth screening, especially given the Baker Act episode.
• ✅ GeneSight (CYP2D6) — back + interpreted. Intermediate metabolizer → duloxetine runs high; the genetics argue against escalating (lower, or switch — Pristiq bypasses CYP2D6). full read →

N-Acetylcysteine (NAC) 300 mg — daily 9 AM

• Indication (TRT, 2026-06-08): Inflammation (per Alyssa). Prior Haven framing: Tics. NAC plausibly serves both — glutamate modulation for tics/craving plus antioxidant/anti-inflammatory effects. Keep both on the chart.
• Started: 2026-05-23 · Until further notice
• Modern relevance: NAC has emerging evidence for both tics in Tourette's and craving reduction in substance use disorders. Glutamate modulation. Real medication-grade intervention.
• Dose ask: 300 mg/day is on the low end of research dosing. Craving + tics trials use 600–1200 mg BID. Worth asking Dr. Ignatov about escalation.

😴 Sleep stack

Was six sleep-relevant agents — now effectively four as of 2026-06-08 (Vistaril discontinued, trazodone not taken in over a week). The lightening is good news: this was a real fall-risk cocktail for a 63yo on amlodipine + olanzapine.

• Melatonin 5 mg HS — scheduled, nightly
• Olanzapine 10 mg HS — scheduled, already counted above (sedation is one of its jobs)
• Trazodone 50 mg HS PRN — insomnia. Effectively stopped — not taken in over a week (per Alyssa, 6/8). Still on the PRN list but unused.
• Vistaril (hydroxyzine) 50 mg q6h PRN — discontinued 2026-06-08 ("no more" per Alyssa).
• Valerian root 500 mg q6h PRN — anxiety/insomnia
• Passion flower 1500 mg q6h PRN — anxiety/insomnia

Asks for Phase 2:

• Sleep stack consolidation as PAWS subsides — six agents is more than necessary long-term.
• Sleep architecture assessment (sleep medicine consult) if not resolving.
• Non-pharmacological options at home: CBT-I, Alpha-Stim (FDA-cleared for insomnia/anxiety in MDD), CES (cranial electrotherapy stimulation).

🤕 Pain

The original opioid prescription was for chronic back pain. The non-opioid armamentarium:

• Lidocaine 4% patch — nightly 9 PM PRN · back pain · "remove in morning"
• Acetaminophen 500 mg q6h PRN · pain/fever — max 3 doses/day. Do NOT give within 2 hours of Ibuprofen.
• Ibuprofen 200 mg × 3 tablets q6h PRN · pain · for temp >100.4°F. ⚠️ Bleed risk on DAPT — review with team given aspirin + clopidogrel.

Phase 3 prep: PT referral, dry needling, trigger point, possibly RFA. Avoid reintroducing opioid path. Mind-body options (yoga, CBT-for-pain).

🧴 GI block (active)

• Pantoprazole 40 mg — daily 9 AM · GERD · long-standing — already on it in Oct 2025 (the "started TODAY 2026-05-27" was a facility re-order). Doubles as GI cover for the antiplatelets.
• (All GI PRNs below — calcium carbonate, Mylanta, Pepto, Miralax, Colace, Loperamide, Dicyclomine, Milk of Magnesia, Ondansetron PO+IM — covering the typical post-detox GI dysregulation.)

Long-term considerations on PPI:

• B12 + iron + magnesium monitoring (PPI affects absorption)
• Bone density baseline (DEXA) — PPI + Xanax history + low DHEA + falls risk = real osteoporosis vector
• Microbiome impact (long-term PPI affects gut diversity)
• Ferritin was 31 (low end) in 2025; calcium PRN further blocks iron absorption — recheck

💊 Supplements + general health

• Multivitamin with minerals — daily 9 AM (30 days)
• Thiamine 100 mg — daily 9 AM (30 days) · for Wernicke's prophylaxis (substance-use protocol)
• Vitamin C 500 mg PRN — daily · "immunity booster"

🆘 PRN inventory (situational, on standby)

~25 PRN agents on the orders sheet covering predictable PAWS + comorbidity symptoms. Most are situational and may never be used heavily. Notable:

• Narcan (naloxone) 4 mg intranasal · overdose rescue · safety net
• Ondansetron 4 mg PO + 2 mg/ml IM · nausea
• Calcium carbonate 500 mg chewable q6h PRN · acid reflux (may interfere with iron — see PPI note above)
• Mylanta, Pepto Bismol, Milk of Magnesia, Miralax, Colace, Loperamide · full GI coverage
• Dicyclomine 20 mg PRN · abdominal cramping
• Loratadine 10 mg PRN · allergies (NOT with Vistaril)
• Flonase 2 sprays daily PRN · nasal congestion
• Hydrocortisone 1% topical, Nystatin cream, Triple antibiotic, Orajel · skin/wound/mouth
• Biotene mouth spray QID PRN · dry mouth (commonly caused by anticholinergic effects of duloxetine + Vistaril)
• Cough drops · cough

🚨 Drug-drug interactions + flags

• Aspirin + clopidogrel (DAPT) = post-Watchman protocol, time-limited. Watch for GI bleed signs (black stools, coffee-ground emesis). Pantoprazole helps. Ibuprofen worsens — avoid on this stack.
• Olanzapine + duloxetine = both modestly QT-prolonging. Additive sedation early on. Generally tolerated. EKG matters.
• Duloxetine + ibuprofen/aspirin = SNRIs increase bleed risk on antiplatelets/NSAIDs. Already on DAPT — be cautious with ibuprofen PRN.
• Vistaril + Loratadine = both antihistamines, additive sedation + anticholinergic effects. Order explicitly flags "Do NOT Give with Vistaril/Hydroxyzine."
• Clonidine + metoprolol = additive BP/HR lowering. Hold rule on clonidine helps.

📋 Open questions for the care team

1. BP — 150–160 after the mid-June under-dosing fix (med-change copy pending). Ran 160+ and triggered the crisis; TRT found the meds under-dosed and the ER stabilized him. On amlodipine + metoprolol + losartan. Get the new med copy; is duloxetine (which reliably raises BP) contributing? Recheck cadence + threshold to escalate?
2. Allergies — verified on file. Aspirin (historical childhood, tolerated post-CABG), epinephrine (NOT a real allergy; childhood reaction was Kounis-syndrome anaphylaxis from shellfish), shellfish (anaphylactic, cardiac-arrest history).
3. Watchman implant date: Determines when DAPT steps down to aspirin alone (45 days–6 months post-implant per typical protocol).
4. EKG on file? Likely from April ER admission. Confirm + repeat cadence on olanzapine.
5. Kindling prophylaxis: No gabapentin (or other anticonvulsant) in regimen. Why not? Dad has 30y Xanax history + cold-turkey event 4/9 — kindling-vulnerable.
6. NAC dose escalation: 300 mg/day is sub-research. Standard for tics + craving is 600–1200 mg BID. Why not higher?
7. MOUD path: No buprenorphine / naltrexone visible. Opioid history is documented (~6 months hydrocodone + morphine). Is naltrexone/Vivitrol on the table for Phase 2/3?
8. CYP2C19 PGx for clopidogrel — answered by GeneSight. Ultrarapid (*17/*17) → activates clopidogrel fully, not a non-responder. GeneSight →
9. GeneSight (CYP2D6) for duloxetine — back + interpreted. CYP2D6 intermediate → duloxetine runs high (don't escalate; lower or switch — Pristiq bypasses CYP2D6). full read →
10. Bipolar screen given Baker Act + SNRI start.
11. Discontinuation roadmap for olanzapine + duloxetine (both have exit difficulty).
12. DEXA scan: baseline for osteoporosis vector (PPI + long Xanax history + low DHEA + falls risk).
13. Lp(a) — missing from 2025 baseline. One-time genetic CAD marker.
14. Vascepa (icosapent ethyl) evaluation given OmegaCheck 3.0% (high SCD risk) + high TG + CAD.
15. Quetiapine vs olanzapine trade given metabolic baseline.
16. Sleep stack consolidation roadmap for Phase 2.
17. Ketamine / esketamine (Spravato) if duloxetine doesn't land within 6–8 weeks.

This is a family advocate's running record for productive questions with the care team. Not medical advice.