I want to start a patient on ____. What labs and pre-/post- follow up do I need?
Lisinopril
Get a baseline BMP, bring the pt back in 1-2 weeks for a labs only BMP check. Tolerate Cr increase above baseline of up to 30% within first 6-8 weeks. Monitor hyperkalemia from baseline, usually increases by less than 0.5 meq/L, if continue hyperkalemia, stop ACEi. Monitor for dry cough. We have ARBS on formulary, consider Rx ARB if ACEi intolerant.
Statin
Get baseline LFTs (no need to do CK unless the patient is symptomatic — ie myalgias) and then only bring the patient to recheck LFTs if patient complains of symptoms (ie: myalgias). Only need to recheck lipids after initiating statin if concerned about nonadherence.
Metformin
Get a baseline CMP (Cr and LFTs). We can rapid titrate in two ways, as long as it is tolerated by the patient; please make sure pt takes with food:
- 500mg x 4 days, 500mg BID x 4 days, 1000mg/500mg BID x 4 days, 1000mg BID x 4 days) and then see them in 2 weeks to assess symptoms.
- 850mg daily x 1 week, followed by 850mg BID maintenance.
- NOTE: 850mg tab is 3 cents/tab vs 500mg tab which is 10 cents/tab; 850mg BID is as effective as 1000mg BID (maximally effective dose is 1500-2000mg; max dose of 2550mg/day is only minimally more effective wrt glycemic reduction and can be less tolerable GI-wise.
- check Cr/lytes annually
Methotrexate
Get a baseline CBC, LFTs, PPD
Insulin
Please review the EHHOP guide to insulin regimens. Send the patient to Nursing in EHHOP, or VNS OR do insulin teaching yourself during a focused return visit
Albuterol trial
Albuterol is kept in the hutches (shelves) above the desk in the Nurses (aka: TS room) room. you can also check in the plastic container on the shelf behind where the CMs stand. The keys to the hutch are in the desk drawer of the TS room.
B12 injections
(unless patient wants to do oral repletion)
- You can find the B12 vials either in the hutch (overhead shelf) in the RN room adjacent to the TS room, it is unlocked. If you don’t see them, check the hutch in your TS room, which is locked but the keys are in the desk drawer. These injections are IM, so teach the patient to inject in a large muscle in their leg/arm/buttocks. Use the B12 vial in IMA to give the initial injection.
- Repletion: Given the initial 1,000mcg injection in clinic, teach patient how to self administer. Give patient supplies for 10 more doses of 1,000mcg following the schedule of: daily injections for first week, weekly for first month. These supplies include: needles (23-25 gauge, 1 inch needle, can use 1.5inch depending on BMI), 1mL syringes, alcohol swabs, gauze, and have the attending write an Rx for 10 vials of B12 1,000mcg/mL that the patient can pick up at Metropolitan Pharmacy. Please have the patient return following this initial repletion within 2-3 months to assess symptoms and repeat serum B12, also consider rechecking MMA/homocysteine These injections are IM, so teach the patient to inject in a large muscle in their leg/arm/buttocks. Use the B12 vial in IMA to give the initial injection.