Case Analysis from Practice
Communication between members of the healthcare team is essential to achieve optimal therapy results. NAPHS Ask Team have encountered numerous cases where they had to communicate their recommendations efficiently to physicians.
Drug selection is key to optimize tailored patient therapy
1. B.M is an 88 year old old female admitted to the ICU with dehydration and urinary tract infection. She has a medical history of atrial fibrillation, ischemic heart disease and end-stage renal disease on dialysis (three times/week). She was prescribed Moxifloxacin as empiric therapy for UTI.
Moxifloxacin should not be used for urinary tract infection as it does not achieve good concentration in urine, and fluoroquinolones are not recommended in elderly.
Recommendation: Another agent is recommended such as; Ceftrixone because of its safety and microbial spectrum, or Ertapenem in case of ceftriaxone allergy or resistance.
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The patient was also on heparin infusion for AF and the consultant asked if she can be prescribed an oral anticoagulant.
In patients with ESRD and atrial fibrillation requiring dialysis, in whom a decision is made to anticoagulate, apixaban or warfarin is considered appropriate.
Recommendation: Apixaban can be used at a dose of 2.5 mg twice daily.
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2. Z.A is a 70 year old female visiting a cardiology clinic for her uncontrolled hypertension.
Her lab tests revealed that the patient has hypertriglyceridemia TGs 250 mg/dl, LDL 170 mg/dl and HDL 35 mg/dl. She was prescribed micronized Fenofibrate160 mg once daily.
Fenofibrate has low effect on LDL and statin is used for LDL management and also statin can lower triglycerides.
Recommendation: The physician was contacted to switch Fenofibrate to statin.
Case Analysis sheds the light on unaddressed indications
S.E is a 50 year old male, admitted to hospital for percutaneous transluminal angioplasty for peripheral artery disease.
On discharge, he was prescribed:
Aspirin 75 mg once daily, Clopidogrel 75 mg once daily, Rosuvastatin 20 mg once daily and Praxilene 200 mg three times.
Patients on dual antiplatelet therapy require stress ulcer prophylaxis by a Proton Pump Inhibitor (PPI) or an H2-Receptor Antagonist (H2RA).
Recommendation: The Physician was contacted, as the patient needs a PPI or an H2A for Stress ulcer prophylaxis.
Taking all patient factors into consideration is essential to avoid patient harm
1. A.E is a 60 year old male visiting a vascular clinic as he was complaining of leg pain while walking. He was diagnosed with Intermittent claudication and was prescribed Trental (pentoxifylline).
While taking the patient’s medical history, he stated that he was receiving treatment for peptic ulcer.
Pentoxifylline should be avoided in patients with a current or recent peptic ulcer.
Recommendation: The physician was contacted to switch Trental (pentoxifylline) to Praxilene (naftidrofuryl).
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2. S.O is a 38 year old female with a history of bronchial asthma, she is currently on controller inhalers. She was diagnosed with hyperthyroid disease and was prescribed propranolol for symptom control (tachycardia).
Propranolol is a non-selective Beta-Blocker that may precipitate bronchospasm and worsen asthma control.
Recommendation: The physician was contacted to switch propranolol to atenolol.
Proper medication administration = effective disease management
1. A 5 year old boy visited the pediatrician as he was complaining of vomiting and decreased oral intake. He was diagnosed with GERD and was prescribed esomeprazole 20 mg tablet with directions to crush the tablet and dissolve it in water.
Esomeprazole tablets are enteric coated and should not be crushed.
Recommendation: The physician was contacted to switch Esomeprazole tablets to granules.
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2. While talking to Mr. A.S for medication reconciliation during his visit to the cardiology clinic, he mentioned that he takes Aspirin Protect 100 mg (enteric coated tablet) after lunch.
Enteric coated, gastro-resistant aspirin interacts with food.
Recommendation: He was advised to take this dosage form of aspirin 30 minutes before food, and to drink a glass of liquid afterward.
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3. R.M is a 50 year old male with a history of diabetes, he recently started insulin as his diabetes was not controlled. He stated that he keeps his Lantus prefilled pen (insulin glargine) in the refrigerator after using it.
Refrigeration may affect the stability of insulin glargine pens after opening.
Recommendation: He was advised to keep the insulin glargine pen in room temperature after opening and to use it within 28 days.
References:
- Acute complicated urinary tract infection (including pyelonephritis) in adults – UpToDate. Accessed June 12, 2022. https://www.uptodate.com/contents/acute-complicated-urinary-tract-infection-including-pyelonephritis-in-adults?search=urinary tract infection in women&source=search_result&selectedTitle=4~150&usage_type=default&display_rank=2#H2417976538
- Apixaban. Lexicomp. Accessed June 12, 2022. https://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/3804162
- Hypertriglyceridemia in adults: Management – UpToDate. Accessed June 12, 2022. https://www.uptodate.com/contents/hypertriglyceridemia-in-adults-management?search=Effects of lipid-lowering drugs on serum lipid levels&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
- Pentoxifylline. Lexicomp. Accessed June 12, 2022. https://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/7467?cesid=9FXDvJjeZJG&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dpentoxifylline%26t%3Dname%26acs%3Dtrue%26acq%3Dpentoxi#
- Propranolol. Lexicomp. Accessed June 12, 2022. https://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/7576?cesid=1GFuzPmziz4&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dpropranolol%26t%3Dname%26acs%3Dfalse%26acq%3Dpropranolol#
- Esomeprazole. Lexicomp. Accessed June 12, 2022. https://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/6848?cesid=3nP0IVFWaoz&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Desomeprazole%26t%3Dname%26acs%3Dtrue%26acq%3Deosmop#
- Aspirin Protect [Package Insert]. Basel, Switzerland: BAYER; 2017. https://www.aspirin.me/sites/g/files/vrxlpx16276/files/2021-02/Aspirin-Protect-en.pdf
- Insulin Glargine. Lexicomp. Accessed June 12, 2022. https://online.lexi.com/lco/action/doc/retrieve/docid/patch_f/320047?cesid=9p4SzROAaEW&searchUrl=%2Flco%2Faction%2Fsearch%3Fq%3Dinsulin%2Bglargine%26t%3Dname%26acs%3Dtrue%26acq%3Dinsulin%2Bg#
