Section 1: Introduction -- The List Nobody Reviews

Every report in this series has addressed a single dimension of medication safety: interactions, renal dosing, herbal risks, deprescribing, pregnancy, antibiotics, pain, diabetes, hypertension. In clinical practice, these dimensions do not present one at a time. They present simultaneously, in the same patient, on the same medication list, at the same consultation.

This report presents ten Caribbean patients. Each has a realistic medication list, a clinical profile, and a set of problems that no single report in the series covers alone. The analysis for each patient applies every check described in Reports 1 through 9: drug-drug interactions, Beers Criteria flags, anticholinergic burden scoring, prescribing cascade identification, therapeutic duplication detection, renal dose adjustment, hepatic adjustment, herbal interaction screening, deprescribing opportunities, pregnancy and lactation safety, antibiotic appropriateness, and analgesic safety.

These are the analyses that ElesRx performs automatically. This report performs them manually, step by step, so the reader can see how each check contributes to the clinical picture.

Case 1: The Woman Whose Medication List Grew While Nobody Was Looking

Patient: 76-year-old woman, Kingston, Jamaica Conditions: Hypertension, type 2 diabetes, osteoarthritis, insomnia, dyspepsia eGFR: 41 mL/min/1.73m2

Medication list: 1. Lisinopril 20 mg daily 2. Hydrochlorothiazide 25 mg daily 3. Amlodipine 10 mg daily 4. Metformin 1000 mg twice daily 5. Glibenclamide 5 mg twice daily 6. Diclofenac 50 mg three times daily (OTC) 7. Omeprazole 20 mg daily 8. Diazepam 5 mg at night 9. Amitriptyline 25 mg at night 10. Cerasee tea daily

Analysis:

Drug interactions (Report 1): Lisinopril + hydrochlorothiazide + diclofenac = triple whammy (Report 2, Section 4). Diclofenac opposes lisinopril's antihypertensive effect. Diclofenac + aspirin-like GI risk in a patient already on omeprazole for dyspepsia.

Beers Criteria (Report 1): Diazepam -- long-acting benzodiazepine, flagged for adults aged 65 and older (falls, cognitive impairment). Amitriptyline -- ACB Score 3, flagged (anticholinergic burden). Glibenclamide -- highest hypoglycaemia risk sulfonylurea. Diclofenac -- flagged (GI bleeding, renal, cardiovascular risk in elderly).

Anticholinergic burden (Report 1): Amitriptyline (3) + diazepam (0, but sedative load) = ACB 3. If any other anticholinergic is added (e.g. oxybutynin for urinary symptoms), the score escalates rapidly.

Prescribing cascades (Report 1): Omeprazole was likely started for diclofenac-induced dyspepsia. Remove the diclofenac, and the omeprazole may no longer be needed. Amlodipine at 10 mg is likely causing ankle oedema -- if furosemide appears on the next prescription, that is a cascade.

Therapeutic duplication (Report 1): Diazepam and amitriptyline are both prescribed for insomnia -- duplicated sedative intent with compounding CNS depression risk.

Renal adjustment (Report 2): eGFR 41. Metformin at 2000 mg/day exceeds the recommended maximum at this eGFR (1000 mg/day at eGFR 30-44). Hydrochlorothiazide is losing efficacy below eGFR 45. Diclofenac should be avoided entirely at this eGFR.

Herbal interaction (Report 3): Cerasee adds hypoglycaemic effect to metformin and glibenclamide -- contributing to unpredictable glucose lowering.

Deprescribing (Report 4): Omeprazole (if indication was NSAID gastroprotection and NSAID is stopped). Diazepam (long-term -- taper). Amitriptyline (unclear indication -- review). Glibenclamide (check HbA1c -- may be overtreated).

Actions required: - Stop diclofenac. Substitute paracetamol (Report 7). - Reduce metformin to 1000 mg/day (eGFR 41). - Review omeprazole -- if NSAID is stopped, taper and stop. - Begin diazepam taper (3-6 months). - Review amitriptyline indication -- if insomnia only, taper and substitute melatonin. - Check HbA1c -- if below 6.5%, reduce or stop glibenclamide. - Document cerasee use and factor into glucose management. - Consider switching hydrochlorothiazide to furosemide if diuresis still needed at eGFR 41.

Case 2: The Diabetic Man With the Hidden Herb

Patient: 63-year-old man, San Fernando, Trinidad Conditions: Type 2 diabetes, hypertension, diabetic neuropathy eGFR: 58 mL/min/1.73m2

Medication list: 1. Metformin 500 mg twice daily 2. Gliclazide 80 mg twice daily 3. Losartan 50 mg daily 4. Gabapentin 300 mg three times daily 5. Aspirin 81 mg daily 6. Guinea hen weed capsules (undisclosed)

Analysis:

Herbal interaction (Report 3): Guinea hen weed contains coumarin derivatives. Combined with aspirin, this creates additive antiplatelet and anticoagulant activity -- increased bleeding risk.

Renal adjustment (Report 2): eGFR 58. Gabapentin at 900 mg/day is at the upper limit for this eGFR. As renal function declines further, the dose will need reduction.

Beers Criteria (Report 1): Aspirin for primary prevention -- if this patient has no established cardiovascular disease, current evidence does not support continuation (Report 4, Drug 16). The bleeding risk is amplified by the undisclosed guinea hen weed.

Actions required: - Ask the three questions (Report 3) to identify guinea hen weed use. - Review aspirin indication -- if primary prevention only, consider stopping. - If guinea hen weed continues and aspirin continues, increase vigilance for bleeding signs. - Monitor gabapentin dose against eGFR annually.

Case 3: The Post-Partum Woman Still on Pregnancy Medications

Patient: 29-year-old woman, Bridgetown, Barbados Conditions: Hypertension (diagnosed in pregnancy), mild depression (post-partum) Post-partum: 4 months

Medication list: 1. Methyldopa 250 mg three times daily 2. Ferrous sulphate 200 mg twice daily 3. Paroxetine 20 mg daily 4. Combined oral contraceptive (ethinylestradiol/levonorgestrel)

Analysis:

Deprescribing (Report 4): Methyldopa should have been switched to a standard antihypertensive post-partum (Drug 9). It causes sedation and depression -- directly worsening the condition for which paroxetine was started. This is a prescribing cascade: methyldopa causes depression, depression is treated with an antidepressant, but removing the methyldopa might resolve the depression without the antidepressant. Ferrous sulphate -- check haemoglobin and ferritin. If normal, stop (Drug 20).

Breastfeeding (Report 5): Is the patient breastfeeding? If yes: combined OC reduces milk supply, particularly in the first 6 months (Report 5, Section 4). Switch to progestogen-only method. Paroxetine enters breast milk in low quantities and is generally considered compatible with breastfeeding, though sertraline has more safety data.

Antidepressant concern (Report 4): Paroxetine has the most severe discontinuation syndrome of any SSRI. If started 4 months ago for post-partum depression that was partly driven by methyldopa, switching the antihypertensive may allow re-evaluation of whether the antidepressant is still needed.

Actions required: - Switch methyldopa to labetalol, amlodipine, or lisinopril (if not breastfeeding and not planning another pregnancy). - Check haemoglobin and ferritin -- stop iron if normal. - If breastfeeding, switch combined OC to progestogen-only method. - After methyldopa is stopped, reassess depression at 4-6 weeks -- the mood may improve without the causative drug.

Case 4: The Elderly Man on Twelve Medications

Patient: 81-year-old man, Castries, St Lucia Conditions: Heart failure, atrial fibrillation, type 2 diabetes, COPD, gout, insomnia eGFR: 34 mL/min/1.73m2

Medication list: 1. Furosemide 40 mg twice daily 2. Spironolactone 25 mg daily 3. Lisinopril 10 mg daily 4. Digoxin 0.25 mg daily 5. Warfarin 5 mg daily 6. Metformin 500 mg twice daily 7. Salbutamol inhaler PRN 8. Ipratropium inhaler BD 9. Allopurinol 300 mg daily 10. Omeprazole 20 mg daily 11. Promethazine 25 mg at night 12. Colchicine 0.6 mg as needed for gout flares

Analysis:

Renal (Report 2): eGFR 34. Digoxin at 0.25 mg is too high -- maximum 0.125 mg/day in elderly with renal impairment; target level 0.5-0.9 ng/mL. Metformin at 1000 mg/day is at the threshold -- acceptable at eGFR 30-44 but requires 3-monthly monitoring. Colchicine at full dose is high-risk at this eGFR -- reduce 50% or avoid. Allopurinol at 300 mg/day was likely started without renal adjustment -- should have been started at 50 mg/day and titrated (Report 2, Section 3).

Potassium crisis: Spironolactone (potassium retention) + lisinopril (potassium retention) + eGFR 34 (reduced potassium excretion) = significant hyperkalaemia risk. Potassium must be monitored within 1 week and every 3 months.

Digoxin toxicity: Furosemide causes hypokalaemia. Hypokalaemia potentiates digoxin toxicity. But spironolactone raises potassium. The balance is precarious and requires monitoring. Additionally, digoxin clearance is reduced at eGFR 34 -- the dose is too high.

Beers Criteria (Report 1): Promethazine -- ACB Score 3, flagged for elderly. Digoxin above 0.125 mg -- flagged. Colchicine in CKD -- flagged.

Anticholinergic burden (Report 1): Promethazine (3) + ipratropium (1) = ACB 4. Above the threshold associated with cognitive impairment.

Deprescribing (Report 4): Omeprazole -- check indication. Promethazine -- stop; address insomnia with sleep hygiene. Allopurinol -- do not stop (gout prophylaxis is needed) but adjust dose for renal function.

Actions required: - Reduce digoxin to 0.125 mg daily. Check level. Check potassium. - Check potassium urgently (spironolactone + lisinopril + eGFR 34). - Reduce allopurinol -- titrate from 50 mg/day based on urate target. - Stop promethazine. Address insomnia non-pharmacologically. - Review omeprazole indication -- taper if no high-risk indication. - Colchicine for acute flares: use reduced dose (0.3 mg) or short course only. - Monitor metformin against eGFR quarterly.

Case 5: The Young Woman on an Antiepileptic Planning Pregnancy

Patient: 31-year-old woman, Kingston, Jamaica Conditions: Epilepsy (well-controlled, seizure-free 3 years), migraines **Planning pregnancy in next 6 months

Medication list: 1. Sodium valproate 500 mg twice daily 2. Topiramate 50 mg twice daily (migraine prophylaxis) 3. Ibuprofen PRN (migraines)

Analysis:

Pregnancy (Report 5): Sodium valproate is the most teratogenic commonly prescribed drug -- neural tube defects in 1-2%, major malformations in 10%, neurodevelopmental disorders in 30-40%. Must be switched before conception. Topiramate is also teratogenic -- associated with cleft lip/palate. Both must be changed.

Actions required: - Urgent neurology referral for antiepileptic switch. Lamotrigine or levetiracetam are lower-risk alternatives. - Switch migraine prophylaxis from topiramate to propranolol. - Start folic acid 5 mg daily (high-dose, not standard 400 mcg, due to antiepileptic exposure history). - Counsel on avoiding ibuprofen in pregnancy -- switch to paracetamol (Report 7). - Ensure effective contraception until the switch is complete and seizure control is confirmed on the new regimen.

Case 6: The Warfarin Patient Who Drinks Cranberry Juice

Patient: 68-year-old man, Port of Spain, Trinidad Conditions: Atrial fibrillation, hypertension, benign prostatic hyperplasia INR: Unstable -- ranging from 1.8 to 4.2 over the past 3 months

Medication list: 1. Warfarin 5 mg daily 2. Amlodipine 5 mg daily 3. Doxazosin 4 mg daily 4. Tamsulosin 0.4 mg daily 5. Cranberry juice daily (undisclosed) 6. Ginkgo biloba capsules (undisclosed)

Analysis:

Herbal interactions (Report 3): Cranberry juice inhibits CYP2C9 -- elevates INR. MHRA advisory issued 2004. Ginkgo biloba has antiplatelet activity -- additive bleeding risk with warfarin. The combination of warfarin + cranberry + ginkgo explains the INR instability.

Beers Criteria (Report 1): Doxazosin -- alpha-blocker flagged for orthostatic hypotension and falls in elderly.

Therapeutic duplication (Report 1): Doxazosin and tamsulosin are both alpha-blockers. If doxazosin is for hypertension and tamsulosin for BPH, this is not a duplication -- but the combined alpha-blockade increases postural hypotension risk significantly. If doxazosin was started for BPH and tamsulosin added later, one should be removed.

Actions required: - Ask the three questions (Report 3) to identify cranberry and ginkgo use. - Counsel on cranberry-warfarin and ginkgo-warfarin interactions. - Discontinue ginkgo. Limit or standardise cranberry intake, or discontinue and recheck INR. - Review doxazosin -- if for hypertension, consider switching to a different class. If for BPH alongside tamsulosin, remove one. - Assess postural blood pressure (combined alpha-blockade risk).

Case 7: The Asthmatic on a Beta-Blocker

Patient: 55-year-old woman, Roseau, Dominica Conditions: Hypertension, asthma, anxiety eGFR: 72 mL/min/1.73m2

Medication list: 1. Atenolol 50 mg daily 2. Hydrochlorothiazide 12.5 mg daily 3. Salbutamol inhaler PRN 4. Beclomethasone inhaler 200 mcg BD 5. Alprazolam 0.5 mg twice daily 6. St. John's Wort capsules (undisclosed)

Analysis:

Drug-disease interaction: Atenolol is a beta-blocker. In asthma, beta-blockers can precipitate bronchospasm. While atenolol is beta-1 selective, selectivity is dose-dependent and incomplete. This patient is on a full dose. Alternative antihypertensives that do not affect the airways (amlodipine, losartan) are available.

Herbal interaction (Report 3): St. John's Wort induces CYP3A4 -- it can reduce the effectiveness of beclomethasone (a CYP3A4 substrate) and accelerate the metabolism of alprazolam (also CYP3A4), potentially causing benzodiazepine withdrawal symptoms.

Deprescribing (Report 4): Alprazolam -- review indication. If anxiety is chronic, switch to an SSRI (sertraline) and taper the benzodiazepine. If St. John's Wort is being taken for depression/anxiety alongside alprazolam, there is a serotonergic interaction risk if an SSRI is subsequently started.

Actions required: - Switch atenolol to amlodipine or losartan (avoid beta-blockers in asthma). - Ask the three questions to identify St. John's Wort use. - Counsel on St. John's Wort interactions and discontinue. - Plan alprazolam taper (very slow -- 10% every 2-4 weeks). - If SSRI is started, allow St. John's Wort washout first (1-2 weeks).

Case 8: The Patient With Chronic Pain and CKD

Patient: 70-year-old man, Spanish Town, Jamaica Conditions: Chronic back pain, CKD stage 3b, gout, hypertension eGFR: 38 mL/min/1.73m2

Medication list: 1. Lisinopril 10 mg daily 2. Amlodipine 5 mg daily 3. Allopurinol 100 mg daily 4. Tramadol 50 mg three times daily 5. Diclofenac 50 mg twice daily (OTC) 6. Omeprazole 20 mg daily 7. Sertraline 50 mg daily

Analysis:

Triple whammy (Report 2): Lisinopril + (no prescribed diuretic, but check for OTC use) + diclofenac. Even without a diuretic, diclofenac + lisinopril at eGFR 38 is high-risk for AKI.

Pain management (Report 7): Diclofenac should not be used at eGFR 38. Tramadol at 150 mg/day exceeds the recommended maximum at CrCl below 30 (though his eGFR is 38, CrCl may be lower depending on body habitus). Tramadol + sertraline = serotonin syndrome risk.

Serotonin syndrome risk (Report 7): Tramadol is a serotonin-norepinephrine reuptake inhibitor in addition to a mu-opioid agonist. Combined with sertraline (SSRI), there is a clinically significant risk of serotonin syndrome.

Deprescribing (Report 4): Omeprazole -- likely started for NSAID gastroprotection. If diclofenac is stopped, review the omeprazole.

Actions required: - Stop diclofenac immediately (eGFR 38 + lisinopril = AKI risk). - Assess serotonin syndrome risk -- tramadol + sertraline combination. - If tramadol is continued, reduce dose and monitor. If alternative analgesic is needed, consider paracetamol plus non-pharmacological approaches. - Review omeprazole once NSAID is stopped. - Monitor allopurinol dose against eGFR (100 mg is appropriate at eGFR 38).

Case 9: The Elderly Woman With Falling and Confusion

Patient: 83-year-old woman, Scarborough, Tobago Conditions: Hypertension, osteoporosis, insomnia, recurrent UTIs, constipation eGFR: 44 mL/min/1.73m2 Presenting complaint: Two falls in the past month, increasing confusion

Medication list: 1. Amlodipine 10 mg daily 2. Lisinopril 10 mg daily 3. Calcium carbonate 500 mg twice daily 4. Vitamin D 1000 IU daily 5. Nitrofurantoin 50 mg daily (UTI prophylaxis, 18 months) 6. Promethazine 25 mg at night 7. Senna 15 mg at night 8. Lactulose 15 mL twice daily

Analysis:

The falls and confusion have a pharmacological explanation. Promethazine (ACB 3) in an 83-year-old causes sedation, confusion, and impaired balance. It is the most likely drug contributor to both the falls and the cognitive decline.

Anticholinergic burden (Report 1): Promethazine (3) = ACB 3. Above the threshold for cognitive impairment in elderly. This alone may explain the presenting complaint.

Antibiotic error (Report 6): Nitrofurantoin prophylaxis for 18 months without review. UTI prophylaxis should be reassessed at 6-12 months (Report 6, Error 9). Additionally, at eGFR 44, nitrofurantoin is approaching the threshold where efficacy diminishes and toxicity risk increases. Long-term use is associated with pulmonary fibrosis and peripheral neuropathy.

Beers Criteria (Report 1): Promethazine -- flagged. Nitrofurantoin long-term in CKD -- flagged.

Deprescribing (Report 4): Promethazine -- stop. Nitrofurantoin -- stop and reassess UTI frequency. Senna -- is it still needed? Was it started for opioid-induced constipation that has since resolved? If the patient is not on an opioid, the stimulant laxative should be reviewed.

Actions required: - Stop promethazine. Reassess cognition and falls risk at 2-4 weeks -- the confusion may resolve. - Stop nitrofurantoin. Monitor for UTI recurrence. If prophylaxis is still needed, switch to trimethoprim (with potassium monitoring given lisinopril). - Review senna and lactulose -- is the dual laxative regimen still needed? - Check postural blood pressure (amlodipine 10 mg + lisinopril in an 83-year-old with falls).

Case 10: The Complete Medication Review

Patient: 72-year-old woman, Montego Bay, Jamaica Conditions: Type 2 diabetes, hypertension, atrial fibrillation, osteoarthritis, GORD, diabetic neuropathy, insomnia, anxiety eGFR: 46 mL/min/1.73m2 HbA1c: 6.1%

Medication list: 1. Metformin 1000 mg twice daily 2. Glibenclamide 5 mg daily 3. Lisinopril 20 mg daily 4. Amlodipine 10 mg daily 5. Hydrochlorothiazide 25 mg daily 6. Warfarin 4 mg daily 7. Digoxin 0.25 mg daily 8. Gabapentin 300 mg three times daily 9. Omeprazole 40 mg daily 10. Amitriptyline 25 mg at night 11. Diazepam 5 mg at night 12. Ibuprofen 400 mg PRN (OTC) 13. Cerasee tea daily 14. Ginger capsules (OTC)

Full analysis:

Drug interactions (Report 1): - Lisinopril + hydrochlorothiazide + ibuprofen = triple whammy - Warfarin + ibuprofen = increased GI bleeding risk - Warfarin + ginger capsules = antiplatelet activity (Report 3) - Amitriptyline + diazepam = additive CNS depression

Beers Criteria (Report 1): - Glibenclamide (highest hypoglycaemia risk sulfonylurea) - Digoxin above 0.125 mg in elderly - Amitriptyline (ACB 3) - Diazepam (long-acting benzodiazepine) - Ibuprofen in elderly (GI, renal, CV risk)

Anticholinergic burden (Report 1): - Amitriptyline (3) = ACB 3. High.

Prescribing cascades (Report 1): - Omeprazole 40 mg -- was this started for ibuprofen-induced dyspepsia? If so, stopping ibuprofen removes the indication. - Amlodipine 10 mg -- check for ankle oedema. If present, do not add furosemide.

Renal (Report 2): - eGFR 46. Metformin at 2000 mg/day is acceptable at this eGFR but requires monitoring. - Digoxin at 0.25 mg -- reduce to 0.125 mg; check level. - Gabapentin at 900 mg/day -- at eGFR 46, approaching the threshold for dose reduction. CrCl should be calculated (Cockcroft-Gault) as it may be lower than eGFR suggests in a 72-year-old woman.

Herbal (Report 3): - Cerasee + metformin + glibenclamide = triple hypoglycaemic load. HbA1c is 6.1% -- patient is overtreated. - Ginger capsules + warfarin = additive antiplatelet activity.

Deprescribing (Report 4): - Glibenclamide with HbA1c 6.1% -- overtreated. Reduce or stop. - Omeprazole 40 mg -- step down to 20 mg; taper if NSAID is stopped. - Diazepam -- long-term; plan 3-6 month taper. - Amitriptyline -- review indication; taper if insomnia only.

Pain (Report 7): - Ibuprofen OTC at age 72 with eGFR 46, on warfarin, on ACE + diuretic = multiple contraindications. Stop. Substitute paracetamol. Consider topical NSAID for localised joint pain.

Diabetes (Report 8): - HbA1c 6.1% on metformin + glibenclamide + cerasee. Overtreated. Stop glibenclamide first. Recheck HbA1c in 3 months. Cerasee may be maintaining adequate control without the sulfonylurea.

Hypertension (Report 9): - Three antihypertensives in a 72-year-old. Check postural blood pressure. If symptomatic, consider reducing to two agents.

Actions required (prioritised): 1. Stop ibuprofen immediately (triple whammy + warfarin bleeding risk + renal risk). 2. Reduce digoxin to 0.125 mg. Check level and potassium. 3. Stop or reduce glibenclamide (HbA1c 6.1% = overtreatment). 4. Counsel on ginger-warfarin interaction. Recheck INR. 5. Document cerasee use. Factor into glucose management decisions. 6. Step down omeprazole to 20 mg. Taper to stop if NSAID removed. 7. Begin diazepam taper. 8. Review amitriptyline indication. Taper if no current pain indication. 9. Recalculate CrCl for gabapentin dosing. 10. Reassess antihypertensive load -- postural BP check.

Medication count: 14 items (including OTC and herbal). After review: potentially reduced to 8-9, with dose adjustments on several others.

Section 2: The Pattern Across Ten Patients

Every case in this report shares the same structural features:

Medications accumulate. Drugs are added for new conditions, new symptoms, or new prescribers. They are rarely removed. The list grows year on year.

OTC and herbal products are invisible. In seven of ten cases, an undisclosed product contributed to the clinical problem. The three questions from Report 3 would have identified them.

Organ function changes but prescriptions do not. Renal function declines with age. Doses that were appropriate five years ago may not be appropriate today. Periodic eGFR checks linked to dose reviews are the intervention.

Beers-flagged drugs persist. Diazepam, amitriptyline, promethazine, glibenclamide, and digoxin above 0.125 mg appear repeatedly. They are started for valid reasons and continued indefinitely without review.

Prescribing cascades hide the cause. Omeprazole for NSAID-induced dyspepsia. Codeine for ACE inhibitor cough. Furosemide for amlodipine oedema. Removing the cause removes the cascade -- but only if the cascade is recognised.

Section 3: About ElesRx

Every analysis performed manually in this report is performed automatically by ElesRx. A clinician entering Patient 10's medication list receives: 4 drug-drug interaction flags, 5 Beers Criteria alerts, an ACB score of 3, 2 prescribing cascade identifications, 1 therapeutic duplication flag, 3 renal adjustment warnings, 2 herbal interaction flags, and 4 deprescribing prompts -- in a single analysis.

The ten cases in this report demonstrate the clinical value of comprehensive medication review. ElesRx makes that review available for every patient, at every consultation, in real time.

The tool is available at elesrx.com. ElesRx is a product of PIPPS Smart Apps, a division of J.C. Epiphany Limited (Jamaica, est. 1998).

Section 4: Methodology and References

4.1 Case construction

The ten cases in this report are composite clinical scenarios constructed from patterns commonly observed in Caribbean primary care practice. They are not based on individual patients. All medication lists, clinical profiles, and analyses are realistic representations of prescribing patterns documented in the literature and encountered in Caribbean clinical settings.

4.2 Cross-references

This report applies the analytical frameworks from all nine preceding reports. Specific cross-references are cited inline (e.g. Report 2, Section 4 for the triple whammy). The reader is directed to the relevant report for full detail on each check.

4.3 Author and conflict of interest disclosure

This report was authored by Juliet Duncan, BPharm, founder of J.C. Epiphany Limited and developer of ElesRx. The author has a commercial interest in ElesRx. This report is published without an access gate as a contribution to Caribbean clinical education. No external funding was received.

4.4 Citation

Duncan J. The Polypharmacy Case Files: Ten Patients, Ten Medication Reviews, Every Flag in One Place. ElesRx Clinical Reports, Report 10. Published 2026 at elesrx.com/reports/polypharmacy-case-files/. J.C. Epiphany Limited, Jamaica.

References

1. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: the process of deprescribing. JAMA Intern Med. 2015;175(5):827-834. doi:10.1001/jamainternmed.2015.0324

2. American Geriatrics Society 2023 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372

3. Lapi F, Azoulay L, Yin H, Nessim SJ, Suissa S. Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury. BMJ. 2013;346:e8525. doi:10.1136/bmj.e8525

4. Picking D, Younger N, Mitchell S, Delgoda R. The prevalence of herbal medicine home use and concomitant use with pharmaceutical medicines in Jamaica. J Ethnopharmacol. 2011;137(1):305-311. doi:10.1016/j.jep.2011.05.025