Patient Case Mrs X Provided compliments of Mary Gunther, BScPharm, ACPR

Transcription

1 Patient Case Mrs X Provided compliments of Mary Gunther, BScPharm, ACPR ID: Mrs X is a female in her mid sixties admitted for a CHF exacerbation CC: 1. 2 week history of increasing weakness, weight gain, pedal edema, and SOBOE 2. Bilat pleuritic chest pain, worse on inspiration GP thought MSK cause, gave T3 s and cyclobenzaprine confusion, hallucinations 3. Severe achy foot pain x 3d (originating from swollen big toe on left foot) PMHx and Current Medications: CHF (LVEF = 45 50% in 2007) AFib HTN Furosemide 80 mg BID Metolazone 2.5 mg MWF ASA 81 mg daily Clopidogrel 75 mg daily Amiodarone 200 mg daily Bisoprolol 2.5 mg daily Amlodipine 10 mg daily Lisinopril 40 mg daily Dyslipidemia T2DM Hypothyroidism Depression Gout Chest Pain Rosuvastatin 10 mg daily Nil (diet controlled) Levothyroxine 0.1 mg daily Citalopram 40 mg daily Nil last flair was 3 years ago Cyclobenzaprine and T3 s PRN Review of Systems (done at admission) Vitals: BP = 115/45 HR = 90 (irreg) RR = 22 O2 = 92% on 4L (on 2 4L home O2 for 2.5 years) General: +++ obese, alert and oriented x3, NAD CV: S1/S2 irreg ireg, no S3/S4, + pedal edema Resp: decreased AE bilat, crackles R>L Labs: Na= 143 K= 3.5 SCr = 141 (BL ~ 120) Hgb = 119 Plt = 237 WBC = 11.7 A1C = 7.0% TSH = 3.11 Trop < 0.10 Lipids: TC = 3.7, TG = 1.52, HDL = 1.09, LDL = 1.91, TC/HDL = 3.4 Diagnostic Imaging CXR: cardiomegaly, vascular redistribution, c/w CHF CT head: no acute infarct, no hemorrhage ECG: AFib

2 Pharmacy Care Plan Worksheet Example (provided compliments of Mary Gunther, BScPharm, ACPR) MEDICAL CONDITIONS and/or DRPs List and prioritize each medical condition first, followed by any DRPs for a given condition. Although some medical conditions may not have a DRP, a care plan is still necessary for ongoing patient monitoring. DRP Categories: unnecessary drug additional drug required ineffective drug dose too low adverse drug reaction/interaction dose too high nonadherence AFib Mrs X is at risk of cardioembolic stroke (CHADS2=3) secondary to suboptimal antithrombotic GOALS OF THERAPY ALTERNATIVES RECOMMENDATIONS/ PLAN For each medical condition and/or DRP state desired goals of /timeframe. Goals: cure, prevent, slow/stop progression, reduce/eliminate symptoms, normalize a lab value. Consider realistic goals determined through patient discussion. Goals of are measurable or observable parameters that are used to evaluate the efficacy and safety of. To provide adequate stroke prophylaxis while not placing patient at an unreasonable risk of harm, on an ongoing basis Pt worried about bleeding (ICH in 2003) Compare relevant drug and non drug therapies that will produce desired goals. List the pros and cons of each. Indication Efficacy Adherence Safety Cost/coverage Alternatives to be weighed on relative risk of bleeding vs stroke on each regimen Continue ASA and clopidogrel PRO: no lab monitoring required; CON: same bleeding risk as warfarin, efficacy less than warfarin, cost, ASA alone PRO: lowest bleeding risk of all options; CON: Least effective option Warfarin PRO: effective for reducing stroke, also has bleeding risk similar to clopidogrel + ASA; CON: INR monitoring required (NOTE: dabigatran was not available for AFib at time of this case) In collaboration with the patient and other health care providers, select the best alternative and implement the plan. Provide a rationale for the chosen plan. Drugs: correct drug, formulation, route, dose, frequency, schedule, duration, medication management. Non drug: non drug measures, education, patient referral. Patient very worried about developing another ICH and would like to avoid warfarin. PLAN: Continue ASA and clopidogrel as per pt wishes (as discussed with internist Dr M) MONITORING PARAMETERS Determine the parameters for monitoring efficacy and safety for each. Clinical & laboratory parameters The degree of change The time frame?absence of stroke?absence of ICH Other bleeding (decreased Hgb, blood in stool/urine) FOLLOW UP Determine who, how and when follow up will occur. Dr M will follow up in HF clinic and assess if dabigatran will be option in the future Copyright 2011, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta 1

3 CHF Gout Mrs X is experiencing an acute CHF exacerbation additional Mrs X is experiencing a gout flare up additional drug Confusion/Delirium (recent onset) Mrs X is experiencing an adverse drug reaction (T3# and cyclobenzaprine reassessment Improve pt s presenting symptoms (weakness, weight gain, pedal edema, and SOBOE) back to her baseline within 1 week To reduce foot pain to an acceptable level within 24 hours To treat pt s chest pain (thought to be MSK) to the point that she is comfortable without causing adverse effects Diuresis alone (furosemide) will likely alone not be enough Cardioversion out of AFib (thought to be a significant contributor to acute decompensation) cardioversion increase in amiodarone NSAID (not viable alternative as should be avoided in CHF/AKI) Colchicine (how to dose? 0.6 mg Q2 3H until resolution vs fixed low dose eg. 0.6 mg Q12H) Prednisone (use as last option) Reduce doses of Tylenol 3 and cyclobenzaprine Acetaminophen alone NSAID Furosemide 80 mg IV BID until euvolemic Tried DC cardioversion unsuccessful Started on amiodarone infusion 60 mg/h x 6h, then 30 mg/h x 18h, then resume amiodarone 200mg daily NOTE: beta blocker dose not at target, but do not want to increase dose during acute CHF exaccerbation Colchicine 0.6 mg Q12H (pain only 5/10, will try lower dose first) NSAID not appropriate due to AKI and CHF/edema Pain not bothering pt at present d/c Tylenol 3 and cyclobenzaprine, will restart acetaminophent alone if pain recurs avoid NSAID given CHF and kidney function Daily improvement in SOB/edema Daily weights until return to dry weight (=130 kg, currently 135 kg) K+ level: keep above 3.5 mmol/l (currently 3.5) HR <80 bpm (ie. control of AFib) within 24h of amiodarone infusion Resolution of pain Watch for diarrhea and neutropenia Educate pt about diarrhea (may be tied to efficacy) Follow for recurrence of pain Ensure confusion/delirium resolves When euvolemic, pharmacist will ensure home doses of metolazone and furosemide PO resumed (Dr M will reassess home diuretics in clinic) When acute exacerbation resolves, will reassess to see if HR/BP can tolerate increased bisoprolol dose Resolved quickly; agent D/C d prior to discharge. As pt has infrequent flare ups, no chronic treatmentl needed Pt will see GP if pain recurs. Pt aware Tylenol 3 s and cyclobenzaprine likely to blame for confusion, and advised to avoid in future. Also reinforced avoiding NSAIDs. Copyright 2011, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta 2

4 Acute on Chronic Renal Failure (or AKI) To avoid any additional injury to the kidneys while the acute renal failure is resolving Hold furosemide Hold ACEI Hold ACEI until SCr back to baseline Continue furosemide (good cardiac output will likely help AKI resolve) Daily SCr until returned to baseline (~120 mcmol/l) Pharmacist will follow SCr and restart ACEI when appropriate HTN No issues To maintain BP <130/80 on an ongoing basis both in hospital and at home Continue current amlodipine, bisoprolol (Lisinopril temporarily on hold) BP < 130/80 (currently achieved) Patient monitors BP at home and is aware of targets No S/Sx of hypotension (dizziness, fainting) Continue to monitor BPs while in hospital Pt will follow up with Dr M for chronic management after discharge Dyslipidemia No issues To maintain lipid parameters in accordance with Canadian guidelines for high risk patients (LDL <2) on an ongoing basis Current LDL is at target No alternatives required Continue current rosuvastatin Lipid panel 1 2x/year No new muscle soreness/weakness No ALT, but no clinical s/s of liver problems No active f/u by pharmacist; low priority issue T2DM No issues To maintain A1C < 7.0% on an ongoing basis A1C checked and within desired range diet A1C 1 2x/year To be followed as outpatient (Dr M) upon discharge) Hypothyroidism No issues Depression No issues To maintain TSH within normal range (0.04 4) on an ongoing basis (hyperthyroid can worsen AF) To achieve and maintain a good enough mood to be able to function and have QOL acceptable to the patient TSH checked and within normal range levothyroxine Pt reports no problems with mood/affect treatment with citalopram TSH 1 2x/year Maintenance of pt s current mood/mental state Form adapted with permission from the Division of Pharmacy Practice, Leslie Dan Faculty of Pharmacy, University of Toronto, Will follow up with GP as per usual Will follow up with GP as per usual Copyright 2011, Faculty of Pharmacy & Pharmaceutical Sciences, University of Alberta 3

5 DOCUMENTATION FROM PATIENT CHART FOR MS. X Provided as example, compliments of Mary Gunther, BScPharm, ACPR Pharmacist Note ASA and Plavix September 14, :45h Asked by team to review evidence for combination use of ASA and clopidogrel in atrial fibrillation as compared to warfarin for benefit (stroke reduction) and risk (major bleeding). Data: Identified 2 recent major trials: ACTIVE A and ACTIVE W. ACTIVE A ASA + clopidogrel vs ASA alone. Found that combination of ASA+clopidogrel is associated with a decrease in vascular event risk that is equal to the increase in risk of major bleeding ACTIVE W ASA + clopidogrel vs warfarin. Found warfarin is superior to combination of ASA+clopidogrel in preventing vascular events, and has the same risk of major bleed. As per pt, her internist who follows her at the heart function clinic (Dr. M) suggested she take ASA + clopidogrel instead of warfarin for her high risk atrial fibrillation (CHADS=3) to reduce risk of ICH (pt had ICH while on warfarin in 2003 requiring ICU admission). Assessment/Plan: ASA + clopidogrel may carry the same major bleeding risk as warfarin, but without as significant of a benefit in the reduction of stroke. Will discuss with patient. M. Gunther, BSc Pharm ****** Pharmacist Note September 15, h Data: Met with patient to discuss relative risks of ASA alone vs ASA + clopidogrel vs warfarinsee previous note for additional details. Assessment/Plan: Pt very afraid of developing another ICH; discussed with patient that literature suggests ASA and clopidogrel does not appear to have a lower major bleeding rate than warfarin, so if she s unwilling to accept the bleeding risks of warfarin, perhaps she should consider ASA alone. Pt stated that she wanted us to consult with her internist at heart function clinic, Dr M, prior to making any decisions. Will contact Dr M and ask him to review. M. Gunther, BSc Pharm ****** Physician Note September 17, h Asked by team and pt to review antithrombotic for atrial fibrillation. Met with patient and have discussed results of ACTIVE A and ACTIVE W. Reluctant to put pt back on warfarin given prior ICH, but given CHADS=3, do not think ASA alone will be adequate. Pt is tolerating ASA + Plavix well will continue current treatment for now. Pt may be good candidate for dabigatran in future (equal to warfarin in stroke reduction, but lower risk of ICH). Will follow and reassess when pt sees me in clinic after discharge. Dr. M