CASE PRESENTATIONThe Prescriptive role of Pharm.D
Dr. Deepak Kumar BandariRPh, PharmD, CGPH, CPPC
Elsevier Student Ambassador – South AsiaDepartment of Pharmacy Practice
Vaagdevi College of Pharmacy
Dr. Palat has also contributed to the development of the curriculum for the Indian Association for PalliativeCare (IAPC) course on palliative care, and has been involved in opioid availability activities though theIAPC and the Pain and Palliative Care Society, Calicut (a WHO Demonstration Project). She facilitated thedevelopment of the Department of Palliative Medicine and the Diploma in Palliative Medicine, the first ofits kind in the country, at Amrita Institute of Medical Sciences, Kochi. With a special interest in pediatricpalliative care, Dr. Palat has played an important role in developing a unique pediatric palliative care
Dr. Gayatri Palat, MDAnaesthesiology and Palliative Medicine
Associate Professor, Pain and Palliative Medicine, MNJ Institute of Oncology and Regional Cancer Center Hyderabad.
palliative care, Dr. Palat has played an important role in developing a unique pediatric palliative carefellowship program at MNJ Institute of Oncology and currently leads the Special Interest Group –Pediatric Palliative Care of the Indian Association of Palliative Care.
Internationally, through her involvement with the IAEA (International Atomic Energy Agency), Dr. Palat hasparticipated in the initial planning of palliative care in the National Cancer Control Program for Sri Lanka,Indonesia and the Philippines. She is a director of the palliative care initiative in SE Asia of Two WorldCancer Collaboration, the Canadian branch of International Network for Cancer Treatment and Research(INCTR), which works with healthcare professionals in resource-challenged countries to reduce the burdenof cancer in South East Asian and African countries. She has also participated in the development of theEPEC-India curriculum to facilitate the implementation of palliative care in various institutions throughoutthe country.
Case Presentation – Patient’s Profile
Patient: Shantha
Age: 56-year-old
Weight: 115 kgs
Height : 155cms
BMI : 56 kg/m2
Date : 13-Jan-2016
Sex: Female
This Case was reported in the Out patient Department of Critical care unit in Continental Hospitals, Hyderabad
Referred to the Clinical Pharmacist for Pharmacotherapy Assessment &Diabetes Management
BMI : 56 kg/m2
Case Presentation – Patient’s Profile
Multiple medical conditions -
1. Type 2 diabetes diagnosed - 2005
2. Hypertension diagnosed – 2012
3. Hyperlipidemia
4. Asthma
5. Coronary Artery Disease
6. Persistent - Peripheral Edema &
7. Longstanding Musculoskeletal Pain secondary to a motor vehicle accident.
Her medical history includes –
Atrial fibrillation
Anemia
Knee Replacement &
Multiple emergency room (ER)
admissions for Asthma
Case Presentation - Patient’s Profile
Her diabetes is currently being treatedwith-
(Humalog 75/25)
Premixed preparation
75% Insulin Lispro ProtamineSuspension ( Intermediate acting ) +
25% Insulin Lispro Preparation (Rapid 25% Insulin Lispro Preparation (Rapidacting)
33 units before breakfast &
23 units before supper
She says she occasionally “takes a littlemore” insulin when she notes highblood glucose readings
Case Presentation - Patient’s Profile
Her other routine medications -
1. INSULIN 75 /25 (lispro protamine suspension + lispro preparation)2. FLUTICASONE - MDI - two puffs twice a day3. SALMETEROL MDI - two puffs twice a day4. NAPROXEN - 375 mg twice a day5. ASPIRIN - Enteric-coated, 325 mg daily6. ROSIGLITAZONE , 4 mg daily7. FUROSEMIDE , 80 mg every morning8. DILTIAZEM , 180 mg daily9. LANOXIN , 0.25 mg daily9. LANOXIN , 0.25 mg daily10. POTASSIUM CHLORIDE, 20 meq daily11. FLUVASTATIN , 20 mg at bedtime.
Medications she has been prescribed to take “AS NEEDED” include1. NITROGLYCERIN - Sublingual for chest pain (has not been needed in the past month)2. FUROSEMIDE, additional 40 mg later in the day if needed for swelling (on most days the additional dose is
needed) &3. ALBUTEROL - MDI , two to four puffs every 4–6 hours for shortness of breath.
She denies use of nicotine, alcohol, or recreational drugs No known drug allergies Up to date on her immunizations.
Case Presentation – Chief Complaints and History (Hx)
Shantha’s chief complaints now
1. Increasing exacerbations of asthma & the need for prednisone tapers.
2. She reports that during her last round of prednisone therapy, her blood glucosereadings increased to the range of 300–400 mg/dl despite large decreases in hercarbohydrate intake.
3. She reports that she increases the frequency of her fluticasone MDI, salmeterolMDI, & albuterol MDI to four to five times/day when she has a flare-up.
3. She reports that she increases the frequency of her fluticasone MDI, salmeterolMDI, & albuterol MDI to four to five times/day when she has a flare-up.
History (Hx):
1. Husband Out of work - Only source of income – State Government Pension.
2. Unable to purchase - fluticasone or salmeterol
3. Has only been taking prednisone & albuterol for recent acute asthmaexacerbations.
Case Presentation – Chief Complaints and History (Hx)
Shantha’s chief complaints
• Not been able to exercise routinely because of badweather & asthma
• The memory printout from her blood glucose meter for the• The memory printout from her blood glucose meter for thepast 30 days shows a total of 53 tests with a mean bloodglucose of 241 mg/dl - 90% above target.
Case Presentation – Subjective Findings
Physical Exam
• Well - appearing but obese
• Weight: 115kgs ; Height 5′1″
• Blood pressure: 130/78 mm Hg
• Pulse 88 beats /min• Pulse 88 beats /min
• Lungs: clear
• Lower extremities - pitting edema bilaterally
Shantha reports that-1. On the days her feet swell the most, she is active & in an upright position throughout the day.2. Swelling worsens throughout the day, but by the next morning they are “ skinny again.”3. She states that she makes the decision to take an extra furosemide tablet if her swelling is
excessive and painful around lunch time;4. Taking the diuretic later in the day prevents her from sleeping because of nocturnal urination.
Case Presentation – Objective Findings
Lab Results
• Hemoglobin A1c (A1C) = 7.0% (target: < 7%)
• Potassium: 3.4 mg/dl (3.5 – 5.3 mg/dl)
• Calcium: 8.2 mg/dl (8.3 –10.2 mg/dl)
• Lipid panel
– Total cholesterol: 211mg/dl (<200 mg/dl)– Total cholesterol: 211mg/dl (<200 mg/dl)
– HDL cholesterol: 52 mg/dl (>55 mg/dl,female)
– LDL cholesterol: 128 mg/dl (<100 mg/dl)
– Triglycerides: 154 mg/dl (<150 mg/dl)
• Liver function panel: within normal limits
• Urinary albumin: <30 μg/mg(<30 μg/mg)
Glycosylated Hemoglobin
Case Presentation – Pharmacist’s Assessment
Pharmacist - Assessment
1. Asthma - Poorly Controlled, Severe, Persistent2. Diabetes - control recently worsened by asthma exacerbations &
treatment3. Dyslipidemia - elevated LDL cholesterol despite statin therapy4. Edema - Persistent lower-extremity edema despite diuretic therapy5. Hypokalemia - most likely drug-induced5. Hypokalemia - most likely drug-induced6. Hypertension - blood pressure within target & stable7. Coronary Artery Disease - stable8. Obesity - ?9. Chronic pain - secondary to previous injury – stable10. Financial constraints - affecting medication behaviors11. Insufficient patient education12. Wellness, preventive, & routine monitoring issues
Case Presentation – Physician’s Plan
1. FLUTICASONE - MDI - two puffs twice a day2. SALMETEROL MDI - two puffs twice a day3. NAPROXEN - 375 mg twice a day4. ASPIRIN - Enteric-coated, 325 mg daily5. ROSIGLITAZONE , 4 mg daily6. FUROSEMIDE , 80 mg every morning7. DILTIAZEM , 180 mg daily8. LANOXIN , 0.25 mg daily9. POTASSIUM CHLORIDE, 20 meq daily9. POTASSIUM CHLORIDE, 20 meq daily10. FLUVASTATIN , 20 mg at bedtime.11. INSULIN 75 /25 (lispro protamine suspension + lispro preparation)
Medications she has been prescribed to take “AS NEEDED” include1. NITROGLYCERIN - Sublingual for chest pain (has not been needed in the past
month)2. FUROSEMIDE, additional 40 mg later in the day if needed for swelling (on most
days the additional dose is needed) &3. ALBUTEROL - MDI , two to four puffs every 4–6 hours for shortness of breath.
SOAP ANALYSIS - PWDT
Pharmacist’s Work Up of Drug Therapy (PWDT)
Desired Outcomes
Therapeutic Endpoints
Medication Related Problems Medication Related Problems
Pharmacist’s Interventions
Monitoring Plans
Patient Education
Pharmacist’s Work Up of Drug Therapy (PWDT)
What are reasonable outcomes for this patient?
Based on current guidelines and literature, pharmacology, andpathophysiology, what therapeutic endpoints would be needed toachieve these outcomes?
Are there potential medication related problems that preventthese endpoints from being achieved?
Pharmacist’s Work Up of Drug Therapy (PWDT)
these endpoints from being achieved?
What patient self-care behaviours and medication changes are neededto address the medication-related problems? What patient educationinterventions are needed to enhance achievement of these changes?
What monitoring parameters are needed to verify achievement ofgoals and detect side effects and toxicity, and how often should theseparameters be monitored?
1. Mortality outcomesAvoid respiratory, cardiovascular, thromboembolic, or diabetes-related premature death.
2. Morbidity outcomesa. Disease-related: Reduce morbidity resulting from uncontrolled blood glucose, blood pressure, dyslipidemia, and cardiovascular disease.
• Retard the progression of disease.• Prevent, recognize, and treat early any complications of chronic conditions,
Reasonable Outcomes
• Prevent, recognize, and treat early any complications of chronic conditions, such as Neuropathy (autonomic or peripheral), Eye disease (e.g., retinal vascular narrowing, hemorrhages), cardiac disease (e.g., LVH, CHF, MI), Nephropathy (e.g., proteinuria), and lower-leg amputation.• Prevent chronic symptoms of asthma (e.g., coughing or breathlessness at night, in the early morning, or after exertion).• Retain recognition of hypoglycemia symptoms.• Maintain near-normal lung function.• Maintain normal activity levels (including exercise and physical activity).• Prevent recurrence of Atrial Fibrillation.
b. Drug-related: Prevent, minimize, or manage drug-related morbidity.• Monitor for side effects or toxicity.• Monitor for drug-drug, drug-disease, and drug-food interactions.
3. Behavioral outcomesa. Obtain annual eye exams.b. Adhere to a medication regimen.c. Get routine and timely medical examinations and laboratory tests.d. Avoid stimulants or over-the-counter products that may affect blood glucose, blood pressure, asthma, or circulation, such as alcohol, caffeine, nicotine, and decongestants.
Reasonable Outcomes
pressure, asthma, or circulation, such as alcohol, caffeine, nicotine, and decongestants.
4. Pharmacoeconomic outcomesa. Keep drug and treatment costs within patient resources.b. Make cost-effective and efficient use of health care resources.
5. Quality-of-life outcomesa. Match, or minimally change, patient lifestyle and activities with treatment.b. Aim for no interference with work or daily activities because of disease symptoms.c. Work to ensure patient satisfaction with the pharmaceutical care and health care team.
Therapeutic Endpoints
• LDL cholesterol: <100 mg/dl HDL cholesterol: >55 mg/dl
• Triglycerides: <150 mg/dl Hb A1C: <7.0%
Self-monitoring of blood glucose: mean <140 mg/dl
• No episodes of severe hypoglycemia requiring emergency assistance
• Blood pressure: <130/80 mmHg, with minimal or no signs or symptomsof orthostatic hypotension
• Biochemical measures, such as potassium, calcium, magnesium, uric acid,• Biochemical measures, such as potassium, calcium, magnesium, uric acid,serum creatinine, and blood urea nitrogen: within normal levels
• Improvement in or no worsening of peripheral edema
• Daytime asthma symptoms less than twice a week, night time symptoms nomore than twice a month, and symptoms responsive to inhaled β 2-agonistwithin 15 min.
• Attain/maintain control of ventricular rate to <100 bpm
• Urinary albumin excretion: <30 g albumin/mg creatinine
• Serum digoxin: 1.5–2.0 ng/ml
Case Presentation – MRP’s and PI’s
Medication-Related Problems & Proposed Interventions
1. No indication for a current drug
2. Indication for a drug - but none prescribed
3. Wrong drug regimen prescribed / moreefficacious choice possible
4. Too much of the correct drug
5. Too little of the correct drug
1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM
5. Too little of the correct drug
6. Adverse drug reaction/drug allergy
7. Drug-drug, drug-disease, drug-food interactions
8. Patient not receiving a prescribed drug
9. Routine monitoring (labs, screenings, exams)missing
10.Other problems, such as potential for overlap ofadverse effects
7. DILTIAZEM8. LANOXIN9. POTASSIUM CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDNISOLONE
Medication Related Problems
1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN9. POTASSIUM CHLORIDE
1. Type 2 diabetes diagnosed in 20052. Hypertension3. Hyperlipidemia4. Asthma5. Coronary Artery Disease6. Persistent - Peripheral Edema &7. Longstanding Musculoskeletal Pain
No indication for a current drug
9. POTASSIUM CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDNISOLONE
7. Longstanding Musculoskeletal Painsecondary to a motor vehicle accident.
8. Atrial fibrillation9. Anemia10. Knee Replacement &11. Multiple emergency room (ER) admissions
for Asthma
None
No indication for a current drug
Medication Related ProblemsMedication Related ProblemsIndication for a drug (or device or intervention) but none prescribed
Peak flow meter
Calcium/vitamin D / HRT supplementation
Corticosteroid therapy
Postmenopausal woman
Furosemide can cause hypocalcemia.
Magnesium Supplementation
1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN9. POTASSIUM CHLORIDE Routine Use Of Magnesium In Diabetes.
Hypomagnesemia - Risk Factor - Atrial Fibrillation,
Hypertension, Insulin Resistance, Glucose Intolerance, Dyslipidemia,
Increased Platelet Aggregation
An added benefit - Constipation
Angiotensin-converting enzyme (ACE) inhibitor
Patients >55 years of age with diabetes & hypertension - ACE inhibitor - indicated
Diltiazem - calcium-channel blocker - addresses several needs
If additional antihypertensive, renal, or cardiac effects are indicated, an ACE inhibitor should be added tothe drug regimen.
9. POTASSIUM CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDNISOLONE
Medication Related Problems
Too much of the correct drug
• Patient is using excessivedoses of Salmeterol &fluticasone as treatment for
1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN
fluticasone as treatment forasthma exacerbations (attimes when she can affordthem).
8. LANOXIN9. POTASSIUM CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDISOLONE
Medication Related Problems
Too little of the correct drug
Potassium Chloride Supplement
1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN8. LANOXIN9. POTASSIUM CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL
Medication Related Problems
Adverse drug reaction/drug allergy
1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN None 8. LANOXIN9. POTASSIUM CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDNISOLONE
Medication Related Problems
Drug-drug, drug-disease, drug-food - interactions
Systemic Corticosteroid Therapy, Inhaled Corticosteroid Therapy,Loop Diuretics in postmenopausal woman: increased risk fordevelopment of osteoporosis
Furosemide, Prednisone in diabetes, w/ Insulin, Rosiglitazone:may increase blood glucose (DOSE-RELATED RESPONSE), thusdiminishing the pharmacodynamic activity of antidiabetes agents
1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEMdiminishing the pharmacodynamic activity of antidiabetes agents
Albuterol, Salmeterol in diabetes, w/Insulin, Rosiglitazone:sympathomimetics may increase blood glucose via stimulation ofBeta 2-receptors, leading to increased glycogenolysis &diminished pharmacodynamic activity of antidiabetes agents
Albuterol, Naproxen, Prednisone, Fluticasone in hypertension:may increase blood pressure (DOSE-RELATED RESPONSE)
7. DILTIAZEM8. LANOXIN9. POTASSIUM
CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDNISOLONE
Medication Related Problems
Drug-drug, drug-disease, drug-food interactions
1. Naproxen in hypertension: INCREASE BLOODPRESSURE
2. Naproxen in diabetes: may INCREASE RISK OFNEPHROPATHY
3. Furosemide – HYPOMAGNESEMIA /
1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM3. Furosemide – HYPOMAGNESEMIA /
HYPOKALEMIA
4. Furosemide, prednisone, fluticasone, salmeterol,albuterol w/DIGOXIN: - potential for DIGOXINTOXICITY.
5. DILTIAZEM w/DIGOXIN: - ELEVATE DIGOXINLEVELS.
7. DILTIAZEM8. LANOXIN9. POTASSIUM
CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL
Medication Related Problems
Patient not receiving a prescribed drug
• Salmeterol & fluticasone: not
1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN• Salmeterol & fluticasone: not
purchased because of financial constraints
8. LANOXIN9. POTASSIUM
CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL
Outcomes & Endpoints – Monitoring Parameters
Routine Monitoring
(Labs, Screenings, Exams)
Missing
1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN
Annual dilated eye exam is due
Annual microalbuminuria test is due
Consider screening for depression
8. LANOXIN9. POTASSIUM
CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDNISOLONE
Pharmacist Interventions
Pharmacist Interventions
ASTHMA
1. Change Fluticasone & Salmeterol prescriptionsto a single combination product
2. Limit use of albuterol inhaler (short-acting beta-agonist) to rescue only.agonist) to rescue only.
3. Consider addition of Leukotriene Inhibitor ifsymptoms are not controlled
4. Begin use of Peak Flow Meter every morningupon arising.
5. Develop & Implement - Asthma Action Plan
Pharmacist Interventions
Pharmacist Interventions
DIABETES
Algorithms
Change Insulin Regimen
Bedtime - Glargine &
Premeal - Lispro
Rapid Acting
Long Acting
Pharmacist Interventions
Pharmacist Interventions
Dyslipidemia
Change Fluvastatin to Atorvastatin
Drug Interactions
Potency – LDL lowering ability
Half life
Pharmacist Interventions
Pharmacist Interventions
Persistent lower-extremity edema
Elevate Extremities – 20 – 30 minutes,two to three times / day
Wear Support Stockings - anticipatingbeing on her feet most of the day
Limit Salt Intake
Minimize use - NSAIDs
Pharmacist Interventions
Pharmacist Interventions
HYPOKALEMIA
• Increase potassium chloridesupplement temporarily; reassesspotassium level in 7–10 days.potassium level in 7–10 days.
• Titrate potassium dosage withdecreasing use of Albuterol,Furosemide & Prednisone to attain& maintain potassium level of3.5–5.0 mEq/l
Outcomes & Endpoints
Pharmacist Interventions
HYPERTENSION
No changes at this time / consider addition or change to ACE inhibitor
CORONARY ARTERY DISEASE
No changes at this time
OBESITY
Refer - Santha for nutrition counseling & weight loss.
CHRONIC PAIN
Change ongoing pain medications to ACETAMINOPHEN 500–650 mg three times a day.Minimize use of NSAIDs by limiting it to “breakthrough” pain only
naproxen, 250 mg, or ibuprofen, 200 mg, as needed.
Outcomes & Endpoints
Pharmacist Interventions
FINANCIAL CONSTRAINTS
• Apply for manufacturers’ indigent drugprograms and State Health InsurancePrograms for combination asthma productPrograms for combination asthma product& other expensive medications.
Generic Equivalent
Direct – Manufacturer
Samples
Pharmacist Interventions
Wellness , Preventive &
Routine Monitoring Issues
Initiate calcium/vitamin D supplementation
Initiate magnesium supplementation
Reduce daily aspirin from 325 to 81 mgReduce daily aspirin from 325 to 81 mg
Screen for depression
Refer for annual eye exam
Refer for bone density scan
Refer for nutritional counseling
Patient Education
Pharmacist Interventions
Patient Education
AsthmaAsthma
Diabetes
Lower-extremity edema
Nutrition
Medication education
References
Textbook of Clinical Skills for Pharmacists, 2nd Edition, Karen J.Tietze.
Textbook of Current Medical Diagnosis and Treatment (CMDT) – 2014.
Textbook of Applied Therapeutics : 2nd Edition, Koda and Kimble.
British National Formulary (BNF), 61st edition
Glen Lewis Stimmel, Professor, University of Southern California, US.
Dr. Navin Loganathan, Cover story : New Sunday Times, Malaysia.
Prof. Syed Azhar Syed Sulaiman, Dean – University Sains, Malaysia.
Jennifer Pham, University of Illinois, Chicago, US : Short profile.
Dr. Gayatri Palat, Director & Co founder, PRPCS – Two World’s CancerCollaboration (TWCC), India.
QUESTION HOUR
Thank You…