CASE PRESENTATION The 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 Palliative Care (IAPC) course on palliative care, and has been involved in opioid availability activities though the IAPC and the Pain and Palliative Care Society, Calicut (a WHO Demonstration Project). She facilitated the development of the Department of Palliative Medicine and the Diploma in Palliative Medicine, the first of its kind in the country, at Amrita Institute of Medical Sciences, Kochi. With a special interest in pediatric palliative care, Dr. Palat has played an important role in developing a unique pediatric palliative care fellowship 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 has participated 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 World Cancer 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 burden of cancer in South East Asian and African countries. She has also participated in the development of the EPEC-India curriculum to facilitate the implementation of palliative care in various institutions throughout the country.

Dr. Gayatri Palat, MDAnaesthesiology and Palliative

MedicineAssociate Professor, Pain and Palliative Medicine, MNJ Institute of Oncology and Regional Cancer Center Hyderabad.

Case Presentation – Patient’s Profile

Patient: Shantha Age: 56-year-old 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

Weight: 115 kgs

Height : 155cms

BMI : 56 kg/m2

Date : 13-Jan-2016

Case Presentation – Patient’s ProfileMultiple medical conditions -1. Type 2 diabetes diagnosed - 20052. Hypertension diagnosed – 20123. Hyperlipidemia4. Asthma5. Coronary Artery Disease6. 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 treated with-

(Humalog 75/25)Premixed preparation 75% Insulin Lispro

Protamine Suspension ( Intermediate acting ) +

25% Insulin Lispro Preparation (Rapid acting)

33 units before breakfast & 23 units before supper

She says she occasionally “takes a little more” insulin when she notes high blood 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 daily 9. LANOXIN , 0.25 mg daily 10. POTASSIUM CHLORIDE, 20 meq daily 11. FLUVASTATIN , 20 mg at bedtime.  Medications she has been prescribed to take “AS NEEDED” include 1. 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 glucose readings increased to the range of 300–400 mg/dl despite large decreases in her carbohydrate intake.

3. She reports that she increases the frequency of her fluticasone MDI, salmeterol MDI, & albuterol MDI to four to five times/day when she has a flare-up.

 History (Hx):

4. Husband Out of work - Only source of income – State Government Pension.

5. Unable to purchase - fluticasone or salmeterol

6. Has only been taking prednisone & albuterol for recent acute asthma exacerbations.

Case Presentation – Chief Complaints and History (Hx)

Shantha’s chief complaints

• Not been able to exercise routinely because of bad weather & asthma

• The memory printout from her blood glucose meter for the past 30 days shows a total of 53 tests with a mean blood glucose 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

• 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 FindingsLab 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)– 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 AssessmentPharmacist - 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-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 education 12.Wellness, preventive, & routine monitoring issues

Case Presentation – Physician’s Plan1. 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 daily 8. LANOXIN , 0.25 mg daily 9. POTASSIUM CHLORIDE, 20 meq daily 10. FLUVASTATIN , 20 mg at bedtime.11. INSULIN 75 /25 (lispro protamine suspension + lispro

preparation)  Medications she has been prescribed to take “AS NEEDED” include 1. 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 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, and pathophysiology, what therapeutic endpoints would be needed to achieve these outcomes?

Are there potential medication related problems that prevent these endpoints from being achieved?

What patient self-care behaviours and medication changes are needed to address the medication-related problems? What patient education interventions are needed to enhance achievement of these changes?

What monitoring parameters are needed to verify achievement of goals and detect side effects and toxicity, and how often should these parameters be monitored?

Pharmacist’s Work Up of Drug Therapy (PWDT)

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, 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.

Reasonable Outcomes

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.

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.

Reasonable Outcomes

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 symptoms of orthostatic hypotension• 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 no more than twice a month, and symptoms responsive to inhaled β 2-agonist within 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’sMedication-Related Problems &

Proposed Interventions

1. No indication for a current drug2. Indication for a drug - but none

prescribed3. Wrong drug regimen prescribed

/ more efficacious choice possible

4. Too much of the correct drug5. Too little of the correct drug6. Adverse drug reaction/drug

allergy7. Drug-drug, drug-disease, drug-

food interactions8. Patient not receiving a

prescribed drug9. Routine monitoring (labs,

screenings, exams) missing10.Other problems, such as

potential for overlap of adverse effects

1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM8. LANOXIN9. POTASSIUM

CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE 14. ALBUTEROL 15. PREDNISOLONE 

Medication Related Problems

1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM8. LANOXIN9. POTASSIUM

CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE 14. ALBUTEROL 15. PREDNISOLONE

1. Type 2 diabetes diagnosed in 2005

2. Hypertension3. Hyperlipidemia4. Asthma5. Coronary Artery Disease6. Persistent - Peripheral

Edema &7. Longstanding

Musculoskeletal Pain secondary to a motor vehicle accident.

8. Atrial fibrillation 9. Anemia10. Knee Replacement &11. Multiple emergency room

(ER) admissions for AsthmaNone

No indication for a current drug

No indication for a current drug

Medication 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 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 to the drug regimen.

1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM8. LANOXIN9. POTASSIUM

CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE 14. ALBUTEROL 15. PREDNISOLONE

Medication Related Problems

Too much of the correct drug

• Patient is using excessive doses of Salmeterol & fluticasone as treatment for asthma exacerbations (at times when she can afford them).

 

1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM8. LANOXIN9. POTASSIUM

CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE 14. ALBUTEROL 15. PREDISOLONE

Medication Related Problems

Too little of the correct drug

Potassium Chloride Supplement

1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM8. LANOXIN9. POTASSIUM

CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE 14. ALBUTEROL

Medication Related Problems

Adverse drug reaction/drug allergy

None

1. FLUTICASONE 2. SALMETEROL 3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZONE 6. FUROSEMIDE 7. DILTIAZEM8. LANOXIN9. POTASSIUM CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE 14. ALBUTEROL 15. PREDNISOLONE

Medication Related ProblemsDrug-drug, drug-disease, drug-food -

interactions

Systemic Corticosteroid Therapy, Inhaled Corticosteroid Therapy, Loop Diuretics in postmenopausal woman: increased risk for development of osteoporosis

Furosemide, Prednisone in diabetes, w/ Insulin, Rosiglitazone: may increase blood glucose (DOSE-RELATED RESPONSE), thus diminishing the pharmacodynamic activity of antidiabetes agents

Albuterol, Salmeterol in diabetes, w/Insulin, Rosiglitazone: sympathomimetics may increase blood glucose via stimulation of Beta 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)

1. FLUTICASONE

2. SALMETEROL

3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZ

ONE 6. FUROSEMID

E 7. DILTIAZEM8. LANOXIN9. POTASSIUM

CHLORIDE10. FLUVASTATI

N11. INSULIN12. NITROGLYCE

RIN13. FUROSEMID

E 14. ALBUTEROL 15. PREDNISOLO

NE

Medication Related ProblemsDrug-drug, drug-disease, drug-

food interactions

1.Naproxen in hypertension: INCREASE BLOOD PRESSURE

2.Naproxen in diabetes: may INCREASE RISK OF NEPHROPATHY

3.Furosemide – HYPOMAGNESEMIA / HYPOKALEMIA

4.Furosemide, prednisone, fluticasone, salmeterol, albuterol w/DIGOXIN: - potential for DIGOXIN TOXICITY.

5.DILTIAZEM w/DIGOXIN: - ELEVATE DIGOXIN LEVELS.

1. FLUTICASONE

2. SALMETEROL

3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZ

ONE 6. FUROSEMID

E 7. DILTIAZEM8. LANOXIN9. POTASSIUM

CHLORIDE10. FLUVASTATI

N11. INSULIN12. NITROGLYCE

RIN13. FUROSEMID

E 14. ALBUTEROL

Medication Related Problems

Patient not receiving a prescribed drug

• Salmeterol & fluticasone: not purchased because of financial constraints

1. FLUTICASONE

2. SALMETEROL

3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZ

ONE 6. FUROSEMID

E 7. DILTIAZEM8. LANOXIN9. POTASSIUM

CHLORIDE10. FLUVASTATI

N11. INSULIN12. NITROGLYCE

RIN13. FUROSEMID

E 14. ALBUTEROL

Outcomes & Endpoints – Monitoring Parameters

Routine Monitoring (Labs, Screenings, Exams)

Missing

Annual dilated eye exam is due

Annual microalbuminuria test is due

Consider screening for depression

1. FLUTICASONE

2. SALMETEROL

3. NAPROXEN 4. ASPIRIN 5. ROSIGLITAZ

ONE 6. FUROSEMID

E 7. DILTIAZEM8. LANOXIN9. POTASSIUM

CHLORIDE10. FLUVASTATI

N11. INSULIN12. NITROGLYCE

RIN13. FUROSEMID

E 14. ALBUTEROL15. PREDNISOL

ONE

Pharmacist Interventions Pharmacist Interventions

ASTHMA

1. Change Fluticasone & Salmeterol prescriptions to a single combination product

2. Limit use of albuterol inhaler (short-acting beta-agonist) to rescue only.

3. Consider addition of Leukotriene Inhibitor if symptoms are not controlled

4. Begin use of Peak Flow Meter every morning upon arising.

5. Develop & Implement - Asthma Action Plan

 

Pharmacist InterventionsPharmacist 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 - anticipating being on her feet most of the day

Limit Salt Intake

Minimize use - NSAIDs

Pharmacist InterventionsPharmacist Interventions

HYPOKALEMIA

• Increase potassium chloride supplement temporarily; reassess potassium level in 7–10 days.

• Titrate potassium dosage with decreasing use of Albuterol, Furosemide & Prednisone to attain & maintain potassium level of 3.5–5.0 mEq/l

 

Outcomes & EndpointsPharmacist 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 & EndpointsPharmacist Interventions

FINANCIAL CONSTRAINTS

• Apply for manufacturers’ indigent drug programs and State Health Insurance Programs for combination asthma product & other expensive medications.

Generic Equivalent Direct – Manufacturer Samples

Pharmacist InterventionsWellness , Preventive &

Routine Monitoring Issues

Initiate calcium/vitamin D supplementation Initiate magnesium supplementation Reduce 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

Asthma 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

Cancer Collaboration (TWCC), India.

Thank You…

QUESTION HOUR