Now · Medications

Current medications

Source: Haven Doctor's Orders PDF, current as of 2026-05-27 01:01 PM ET. Original PDF →

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

Five scheduled meds. Coherent post-Watchman + post-stroke + HTN + dyslipidemia management.

Aspirin 81 mg — daily 9 AM

  • Indication: Cardiovascular disease (post-Watchman DAPT)
  • Started: 2026-05-13 · End: 2026-06-12 (30 days)
  • 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: 2026-05-25 · End: 2026-06-24 (30 days)
  • 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: 2026-05-26 · End: 2026-06-25 (30 days)
  • 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: 2026-05-26 · End: 2026-06-25 (30 days)
  • 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: 2026-05-19 · End: 2026-06-18 (30 days)
  • Note: Calcium channel blocker. Common second-line HTN agent. Watch for ankle edema.

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 days only — short taper)
  • 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.

🧠 Psychiatric scheduled

Olanzapine (Zyprexa) 10 mg — nightly 9 PM HS

  • Indication: Mood (post–Baker Act stabilization)
  • Started: 2026-05-19 · End: 2026-06-18 (30 days)
  • 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: Depression
  • Started: 2026-05-22 · End: 2026-06-21 (30 days)
  • 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. He's now on 3 antihypertensives + a beta-blocker. Cuff readings on a schedule.
    • 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.
  • Modern ask: Pharmacogenomic panel (GeneSight / Genomind) for CYP2D6 metabolism. Tells you a lot about duloxetine response + discontinuation strategy.

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

  • Indication: Tics
  • 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

Six sleep-relevant agents — heavy. Suggests insomnia is hard to manage; also 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, 30-day window
  • Vistaril (hydroxyzine) 50 mg q6h PRN — anxiety/restlessness/irritability; do NOT combine with Benadryl/Loratadine
  • 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 · started TODAY 2026-05-27. Plausibly the GI cover for DAPT + history of aspirin GI intolerance.
  • (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. Update charted allergies: Aspirin = historical childhood allergy, currently tolerated (post-MI). Epinephrine = NOT a real allergy; childhood reaction was Kounis-syndrome cardiac arrest from shellfish anaphylaxis. Shellfish remains anaphylactic with cardiac arrest history.
  2. Watchman implant date: Determines when DAPT steps down to aspirin alone (45 days–6 months post-implant per typical protocol).
  3. EKG on file? Likely from April ER admission. Confirm + repeat cadence on olanzapine.
  4. Kindling prophylaxis: No gabapentin (or other anticonvulsant) in regimen. Why not? Dad has 30y Xanax history + cold-turkey event 4/9 — kindling-vulnerable.
  5. NAC dose escalation: 300 mg/day is sub-research. Standard for tics + craving is 600–1200 mg BID. Why not higher?
  6. MOUD path: No buprenorphine / naltrexone visible. Opioid history is documented (6 months oxycodone + morphine). Is naltrexone/Vivitrol on the table for Phase 2/3?
  7. CYP2C19 PGx: Standard modern cardiology test for clopidogrel responsiveness.
  8. Pharmacogenomic panel (CYP2D6) for duloxetine.
  9. Bipolar screen given Baker Act + SNRI start.
  10. Discontinuation roadmap for olanzapine + duloxetine (both have exit difficulty).
  11. DEXA scan: baseline for osteoporosis vector (PPI + long Xanax history + low DHEA + falls risk).
  12. Lp(a) — missing from 2025 baseline. One-time genetic CAD marker.
  13. Vascepa (icosapent ethyl) evaluation given OmegaCheck 3.0% (high SCD risk) + high TG + CAD.
  14. Quetiapine vs olanzapine trade given metabolic baseline.
  15. Sleep stack consolidation roadmap for Phase 2.
  16. 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.