Pharmaceutical care of patients with OSTEOARTHRITIS

Transcription

1 Pharmaceutical care of patients with OSTEOARTHRITIS COURSE ACTIVITIES SUGGESTED CASE STUDY ANSWERS 1

2 Commentaries: Case Study 1 Part 1. What further information would you want to know and initial thoughts re diagnosis? Angela has been given a diagnosis of hip OA following x-ray. X-rays can be useful in diagnosing OA but the diagnoses is mainly determined by presenting symptoms and consideration of risk factors- persistent joint pain that worsens with use, age over 45yrs and morning stiffness lasting no more than half an hour (Pt 14) Her risk factors include several constitutional factors; aging,(although fairly young), female and morbidly obese and genetic predisposition. She has concomitant high blood pressure You would want to check her understanding of her condition? How frequently does she take her diclofenac? What eases/helps Angela s pain and what makes it worse? How would you respond to her question re diclofenac? Ascertain how often she has been taking diclofenac and has she been getting any pain relief with it? What are her latest BP readings? Has she had annual blood tests form the GPs?( Renal function?) Has she trialled without diclofenac- could be worth a trial bearing in mind concomitant BP and increasing age( GI risk) Could continue for a few days whilst initiating co-codamol and then trial without diclofenac What other care issues have you identified? interventions to achieve weight loss should be core treatment for people who are are obese ( pt 31) Consider holistically and education needs- explain that good pain control may allow her to undertake exercise which in turn may help weight and condition Off work (pt 13) and struggling with grand kids- may lead to feelings lacking in self worth and low esteem/social isolation(pt 12) Part 2. What Care issues does Angela have and how would you manage them? Opiate induced constipation and nausea- initiate senna Twice daily co-codamol resulting in sub-therapeutic paracetamol dosing and poor pain control combine with paracetamol and clear instructions not to exceed daily dosing 2

3 Felt stiffening up on stopping Diclofenac and though regular NSAID not ideal in concomitant age/hypertension risk factors Quality of Life issues may be more important to patient- would then need to manage risk factors by addition of PPI, regular monitoring of BP and renal function which may require liaison with surgery to arrange. Topical NSAIDS not appropriate for Hip joint Self management of pain- Use of Heat/cold/ TENS? When and to whom would you refer Angela? If not a prescriber and unable to above liaise with local GP re prescribing and monitoring- GP may also consider referral for surgery if approriate Any local self help groups such as Pain Association Scotland? Patients that are more educated more likely to use active coping strategies (Pt 20) Physio referral for exercise advice Dietician referral for management of obesity OT referral for House assessment/shower 3

4 Patient Profile CASE 1 Patient s Name: Gender: Contact s: Date of Birth: CHI Number: Address: address: Phone Number: Patient Profile General Health: Medical conditions: Allergies and Sensitivities: Patient Factors: Dispositions Compromised oral route of administration Physical impairment Yes No Visual impairment Yes No Patient Factors: Organ Function Hepatic function Renal function Lung function Immune status compromised: Patient Factors: Maternal Pregnant: Yes No Breastfeeding: Yes No Pharmaceutical Care Plan Priority PCP Priority: Low Priority Medium Priority High Priority Not 4

5 The Pharmaceutical Care Risk Assessment/Priority Profile Pharmaceutical care issues which affect the patient: Care issues with the appropriateness of the Care issue with the formulation of the Care issue with the dosage and frequency of the Care issue in relation to contraindications? Drug interaction with one or more medicines? Yes No Side effects with one or more medicines? Problems with concordance? Yes No Care issue in relation to polypharmacy? Pharmacokinetic risk factors? Yes No Not Pharmacodynamic risk factors? Yes No Not Disease risk factor? Yes No Not Taking one or more medicines with a narrow therapeutic range? Taking one or more black triangle medicines? Duplication of medication Summary: Are there any pharmaceutical care issues of note? Care Plan Care issue Desired Outcome Action Action by (Pharmacist, G.P., Patient) Response 5

6 Case study 2 Part 1. What are you initial thoughts re Hamish and what care issues does he have? Whilst Hamish is still fairly young and is male rather than female he does have history of environmental/lifestyle risk factors for OA (pt 4) with his PTI job history and previous trauma He is not experiencing locking though is getting inactivity pain and stiffness=gelling (Pt 15) and meets diagnostic criteria for peripheral joint OA (pt 14) though this needs to be confirmed by a GP. X-rays not reuired but may help confirm diagnosis. Marital relationship being affected and he s getting frustrated-poorer mental heath status common in many patients with OA (pt 18) Used to working in a can do whatever environment and struggling to come to terms with being unable to achieve past fitness levels Using regular ibuprofen what benefit is he getting/ any side effects? Part 2. What would you recommend for Hamish and when would you refer? Referral to GP for diagnosis Attempt to provide pain relief in meantime and some key messages NSAIDS should be used at lowest effective dose for shortest time possible ( pt 48) ideally for inflammatory flare-up. Explanation re GI symptoms and use of NSAID- possibly trial of topical NSAID ( pt 45) as small peripheral joint (knee) rather than systematic ibuprofen. Introduce trial ( at least days) of regular paracetamol 2 four times daily explaining short acting nature of paracetamol hence need to take regularly ( pt 43) Important to keep active and learn to pace activities rather than all or nothing - self help books or leaflets may help Utilise heat and cold therapies Identify if overweight and encourage weight loss if required with appropriate advice. Consider good shock absorbing footwear. Advise that evidence although around glucosamine benefit in OA is minimal there has been some limited evidence around pain reductionhe could trial OTC 6

7 Patient Profile CASE 2 Patient s Name: Gender: Contact s: Date of Birth: CHI Number: Address: address: Phone Number: Patient Profile General Health: Medical conditions: Allergies and Sensitivities: Patient Factors: Dispositions Compromised oral route of administration Physical impairment Yes No Visual impairment Yes No Patient Factors: Organ Function Hepatic function Renal function Lung function Immune status compromised: Patient Factors: Maternal Pregnant: Yes No Breastfeeding: Yes No Pharmaceutical Care Plan Priority PCP Priority: Low Priority Medium Priority High Priority Not 7

8 The Pharmaceutical Care Risk Assessment/Priority Profile Pharmaceutical care issues which affect the patient: Care issues with the appropriateness of the Care issue with the formulation of the Care issue with the dosage and frequency of the Care issue in relation to contraindications? Drug interaction with one or more medicines? Yes No Side effects with one or more medicines? Problems with concordance? Yes No Care issue in relation to polypharmacy? Pharmacokinetic risk factors? Yes No Not Pharmacodynamic risk factors? Yes No Not Disease risk factor? Yes No Not Taking one or more medicines with a narrow therapeutic range? Taking one or more black triangle medicines? Duplication of medication Summary: Are there any pharmaceutical care issues of note? Care Plan Care issue Desired Outcome Action Action by (Pharmacist, G.P., Patient) Response 8

9 Case study 3 What are you initial thoughts re Emma and what care issues does she have? Age sex and occupational risk factors for OA (pt3) Little need for X-ray as symptoms fairly clear No evidence for benefit of Cod Liver Oil (pt=26)although some find it helpful Home care issues re dependence- ability to carry out tasks may limit ability to cook/ look after self etc- worth referral for an OT /self aids assessment Use of heat ( place hands in warm water) Could trial regular paracetamol and/or topical NSAID Avoid systemic NSAID where possible due to age Refer to GP if not improving Hand OA often improves with time although deformities will remain 9

10 Patient Profile CASE 3 Patient s Name: Gender: Contact s: Date of Birth: CHI Number: Address: address: Phone Number: Patient Profile General Health: Medical conditions: Allergies and Sensitivities: Patient Factors: Dispositions Compromised oral route of administration Physical impairment Yes No Visual impairment Yes No Patient Factors: Organ Function Hepatic function Renal function Lung function Immune status compromised: Patient Factors: Maternal Pregnant: Yes No Breastfeeding: Yes No Pharmaceutical Care Plan Priority PCP Priority: Low Priority Medium Priority High Priority Not 10

11 The Pharmaceutical Care Risk Assessment/Priority Profile Pharmaceutical care issues which affect the patient: Care issues with the appropriateness of the Care issue with the formulation of the Care issue with the dosage and frequency of the Care issue in relation to contraindications? Drug interaction with one or more medicines? Yes No Side effects with one or more medicines? Problems with concordance? Yes No Care issue in relation to polypharmacy? Pharmacokinetic risk factors? Yes No Not Pharmacodynamic risk factors? Yes No Not Disease risk factor? Yes No Not Taking one or more medicines with a narrow therapeutic range? Taking one or more black triangle medicines? Duplication of medication Summary: Are there any pharmaceutical care issues of note? Care Plan Care issue Desired Outcome Action Action by (Pharmacist, G.P., Patient) Response 11