Medication Use Systems Case 1: Identification and Resolution of Drug Therapy Problems

Transcription

1 Introduction: Medication Use Systems Case 1: Identification and Resolution of Drug Therapy Problems The objective of this exercise is to provide practice and self-evaluation in recognizing and resolving drug therapy problems (DTP s). We want you to learn the habit of asking the four questions listed in the Instructions below. This case is not, however, primarily intended to teach new clinical pharmacology. We have actually tried to choose familiar issues in drug therapy to illustrate common DTP s. You may need to refer to a clinical pharmacology reference for some examples, but we expect you to become familiar with the drugs as a means to the end of identifying DTPs. Also, we have made no attempt to hide the DTPs from you. On the contrary, we want you to see them. Again, we designed this case to teach a thought process and to challenge you, but not to trick you. Practice asking the four questions, whether you find the therapeutic content easy or hard. Access Effectiveness Safety 1. No therapy for a valid indication. 2. Ineffective drug. 3. Sub-therapeutic dose. 4. Contra-indicated drug. 5. Adverse drug reaction or side effect 6.Excessive Dose. 7 No medically valid indication 8. Drug-laboratory interaction Instructions In the following brief cases please decide the following: a) Is there a DTP? Is it potential or actual? Why? b) Does it involve (a) access, (b) effectiveness or (c) safety? c) Which (if any) of the eight classes of potential DTP do you suspect may be involved? d) What could be done to correct the DTP?

2 Resources. To do these exercises correctly, you need to know the terminology used in Chapter 10 of the course text and in Lecture 2. Please read Chapter 10 in PME-IDO (the course text) up to Professional Dialog, especially the sections on DTP s Resources The table above is an abbreviated version of Table It is here as a handy reminder but is not complete enough to explain the subject matter for the first time. For more about DTP s, see Chapter 3 in Cipolle RJ, et al., Pharmaceutical care practice. You may also need a drug information reference such as Lacy, et al, Drug Information Handbook or the Clinical Pharmacology reference on CD by Gold Standard Multimedia. Exercise 1-1. Name: Sarah Bellum Age: 28 Wt. 135 lb. Ht. 5'5" Sex: Female Race: African American Medical History: Asthma ; Single TheoDur 300 mg BID Ventolin Aerosol 2 puffs PRN Azmacort 4 puffs BID When Ms. Bellum comes in to get her medicine refilled, you notice she is somewhat early for her TheoDur and her Ventolin. When you ask about it she relates that when she feels "wheezy" she sometimes takes an extra TheoDur tablet in addition to using the Ventolin about every 4 hours. You then pull up her refill history and notice that she is over two months over due for her Azmacort refill. Exercise 1-2 Name: Yolanda defree Age: 46 Wt.137 lb. Ht. 5'7" Sex: Female Medical History: None Cimetidine 300 mg BID Ms defree comes in to get her first refill of Cimetidine, and when you are filling the prescription she asks, How long does it take for this stuff to work, I feel like I m wasting my money -- this drug hasn t done anything for me. You ask, For what reason are you taking Cimetidine?

3 For my hemorrhoids, she timidly responds. You ask, Do you have any problems with your digestion, you know, heartburn or pain? She says, No. I have an iron stomach and a sore butt. Exercise. 1-3 Name: Sandy Beach Age: 46 Wt. 161 lb. Ht. 5'6" Sex: Male Race: Caucasian Medical History: Hyperlipidemia Social History: Smoking NO, Alcohol Use Moderate Inderal 20mg BID Lovastatin 40mg 1 QD When he comes to get his medications refilled, Mr. Beach complains of muscle soreness of some days duration. In response to your questions, he says he hasn't increased his physical activity lately to cause this. Exercise. 1-4 Name: Norman Conquest Age: 46 Wt. 161 lb. Ht. 5'6" Sex: Male Race: Caucasian Medical History: HTN, Hyperlipidemia Social History: Smoking NO, Alcohol Use NO Inderal 20mg BID Lovastatin 40mg 1 QD Mr. Conquest comes to get his medications refilled and mentions that both he and his doctor are disappointed that his hyperlipidemia has not responded as well as they would have liked. Exercise 1-5 Name: Desi Killibrium Age: 70 Wt. 165 lb. Ht. 5'8" Sex: Male Medical History: None

4 As Mr. Killibrium walks up to the pharmacy counter you notice his gate is a bit unbalanced and his arms are bent at the elbows and held slightly out from his body. You find this peculiar because you don t recall Mr. Killibrium having this problem. He and his wife approach the counter and he initiates a conversation but you can t understand him because his speech is slurred and he isn t making much sense. His wife recognizes the tension and interjects, she says he needs a refill of his Amitriptyline because he has been acting strange and it should help him get back to normal. Exercise. 1-6 Amitriptyline 50 mg 1 QD Name: Lotta Brass Age: 61 Wt. 170 lb. Ht. 5' Sex: Female Race: Caucasian Medical History: Atrial Arrhythmia Social History: Alcohol Use NO Smoking NO Coumadin 5mg 1 QD Digoxin 0.125mg 1 QD Calan SR 240mg 1 QD Ms. Brass comes to your pharmacy with complaints of being constipated and asks for your recommendation for a laxative Exercise. 1-7 Name: Donald Duzzwell Age: 37 Wt. 160 lb. Ht. 6'1" Sex: Male Medical History: Schizophrenia, Bipolar disorder Lithobid 300 mg 1 QD Thorazine 300 mg 1 QD Risperidone 6 mg 1 QD Levaquin 500 mg 1 QD (14-days) You are working in a busy chain pharmacy where you and another pharmacist are on duty. Mr. Duzwell, a man with stabilized chronic psychiatric disorders, comes in. You greet him and ask how he is doing. His response is positive and he mentions he still enjoys volunteering at the community center.

5 The other pharmacist began processing his new prescription for Levaquin. You overheard the pharmacist explain to Mr. Duzwell that he had meet his HMO s prescription cap for three brand name products. The pharmacist said that Mr. Duzwell would have to pay out-of-pocket for the antibiotic, which would cost $ Mr. Duzwell acted confused and replied that he did not have $ The pharmacist apologized and Mr. Duzwell turned and walked out of the pharmacy. Exercise. 1-8 Name: Howie Doone Age: 34 Wt. 165 lb. Ht. 5 8 Sex: Male Race: Hispanic Medical History: None Mr. Doone s wife, Lorna had been in your pharmacy recently with a prescription to be filled and a scary story to tell. A wasp had stung her husband, Howie, while he was working in the yard. Within minutes he had become agitated and flushed. His neck and face were swollen and it was extremely difficult for him to breathe. He was treated at the ED where the physician told him he had a severe anaphylactic reaction. The MD said he was hypersensitive to wasp stings and told him that he would prescribe epinephrine as an emergency medication. He told Mr. Doone to keep the epinephrine nearby whenever there was a risk of a sting. Later, Mr. Doone had come in to pick up his prescription. You had handed Mr. Doone his prescription for an EpiPen and asked if he had any questions. He replied that he was in a hurry and had no questions. Now, he has telephoned and said that he got the wrong prescription. When he opened the bag, all he found were some tubes marked Epi-Pen. He is annoyed, and says that his doctor told him he needed to have the medicine nearby at all times. He asks, I come back right now can you give me the correct pills? Exercise. 1-9 Name: Carrie Onn Age: 67 Wt. 180 lb. Ht. 5'8" Sex: Female Race: African American Medical History: UTI Dyazide 1 capsule 1 QD. Trimethoprimsulfamethoxizole (TS) 1 tab BID.x 3 days

6 Mrs. Onn s record shows that she received the same therapy two weeks ago. Mrs. Onn confirms that this is her second urinary tract infection in two weeks. She has not had another in the past 12 months. She goes to an emergicenter and has happened to see a different doctor this time. When you phone the emergicenter, the doctor on duty explains that their treatment guideline calls for urinalysis but not urine culture. They respond that a three-day course of TS is the recommended first line treatment. Exercise Name: Homer debrave Age: 50 Wt. 180 lb. Ht. 5'8" Sex: Male Race: African American Medical History: Hypertension Nadolol 40mg 1 QD. Cefaclor 250 mg Every 8 hrs Mr. debrave comes into your pharmacy to get a new prescription for Ceclor. He mentions he caught a bug that was going around the office. When filling his prescription you pull up his medication history and notice he has not refilled his Nadolol in over 60 days. You ask him how the Nadolol is working and he confides that he has been reluctant to take the medication. You take his blood pressure and it is 140/90, standing. He comments that he took the medication as prescribed for a while, and feels much better when he is not taking the prescribed dosage. While he was taking it, he experienced fatigue, dizziness and occasional impotence, which he attributes to the Nadolol. Exercise Name: Luce Cannon Age: 61 Wt.170 lb. Ht. 5' Sex: Female Race: Caucasian Medical History: Atrial Arrhythmia Social History: Alcohol Use NO; Smoking Yes Coumadin 5mg 1 QD. Digoxin 0.25mg 1 QD. While in the pharmacy Ms. Cannon mentions she has been suffering because of her pain. The joints of her hands and wrists are stiff and painful, especially in the mornings. She

7 also mentions it is difficult for her to prepare meals, do housework and other activities that are important to her. Exercise Name: Natalie Dresst Age: 70 Wt. 175lb. Ht. 5'6" Sex: Female Race: Asian Medical History: Hypertension Celebrex 200 mg 1 QD Atenolol 50 mg 1 QD. Lately, Mrs. Dresst has not been in good spirits, getting motivated to do anything is real work and she complains that she just doesn t get enjoyment anymore from her normal pleasures. She tells you that her husband convinced her to see the doctor, who prescribed something that would help her blues. She s back for her one-month refill of the Celebrex. The doctor said it would take a few weeks to take effect, but Mrs Dresst is tired of waiting to feel better. She asks you if you have something stronger or that would work sooner. Exercise 1-13 Name: Vida Dawn Age: 63 Wt.140 lb. Ht. 5'6" Sex: Female Medical History: None Coumadin 5mg 1 QD. Ms Dawn dropped off her empty bottle of Coumadin for a refill and said she would shop around while she waited for it to be filled. When she returned to the counter, she had a few items in her hand, which included a box of Alka-Seltzer. You asked if the Alka- Seltzer was for her and she replied that it was. She reported that she had been treating her headaches with aspirin for the past couple of weeks and now her stomach was upset. Exercise 1-14 Name: Shirley Light Age: 22 Wt.118 lb. Ht. 5'4" Sex: Female

8 Medical History: Deep Acne Vulgaris Medication Accutane Dose 20 mg QAM, 10 mg QPM Mrs. Light, an outgoing young woman who you have gotten to know over the past 5 months, because she has been purchasing Accutane to treat her acne, comes into the pharmacy. You greet her and ask if she is here for a refill. She replies, No I still have another weeks worth of Accutane, I m only here to pick up a pregnancy test.