CASE STUDY 1

A female who is 45 years old, resident of Lahore was brought to the hospital. She previously has hypertension and presenting complaints are as follows; -chest pain (left sided) -Nausea -Vomiting She was diagnosed to be suffering from left ventricular failure.
Vitals: B.P is 150/95 mmHg Temp. is 99 F Pulse is 90beats/min Aspirin Simvastatin Heparin Cardilol Omeprazole Spironolactone Captopril 300mg half tab/day 20mg 1h.s 5000 I.V.or I.U. q.6hr. 6.25mg 1 tab. per oral half bid. 20mg 1 capsule per oral .o.d 40mg 1 tab per oral once daily 25mg tab per oral t.i.d

Question : Design a pharmaceutical care plan.

ANSWER PHARMACEUTICAL CARE PLAN

DRUGS:

Drugs Spironolactone

Dose given 40 mg/ day

Interaction Dose is very high. Decrease/lower the dose

Recommended 25 mg/ day

INTERACTIONS:

Interacting Drug Omeprazole and aspirin

Severity Severe

Effect Antagonist

Captopril and aspirin

Moderate

Aspirin in a blood thinner. Captopril is an ACE inhibitor

Monitoring and management Omeprazole may be stopped for some while. And then continued if necessary under strict monitoring. Closely monitor the heart functioning and blood pressure. In case of any afflictions, manage accordingly.

PATIENT RELATED: Ask the patient for muscle pain and twitching as simvastatin has side effect.

Laboratory tests:
Plasma electrolytes (Na+, K+, Creatinine) Cholesterol level Blood pressure ECG.

CASE STUDY 2
A 56 year old man was brought to the emergency room following a massive cerebrovascular accidently. He was unconscious, markedly or severely dehydrated and had Kussmaul respiration. Following is his plasma and urine electrolyte profile.
Plasma electrolyte: Na K Cl CO2 Urea Creatinine 137mmol/L 8.7mmol/L 103mmol/L 8mmol/L 78.9mmol 650mic.mol/L

Urine electrolyte: Na Urea 69mmol/L 150mmol/L

Question # 01 Comment on patients Sodium Status. Question # 02 What is the type of renal impairment? Question # 03 Why is k-level high? Question # 04 What do you expect the urine output to be?

ANSWERS:
1) Comment on patients sodium status.
Sodium level in the plasma is in the normal range of 135-147 mmol/L.

2) What is the type of renal impairment?

On the basis of RIFLE criteria of classification, the patient is suffering from renal failure as plasma and urine levels of sodium are being considered. Plasma level of urea and creatinine are too high, indicating low excretion of nitrogenous wastes.

To find the Renal problem, we use RIFLE classification, which is based on serum creatinine, glomerular filtration rate and urinary output. R = RISK of renal dysfunction I = INJURY to kidney F = Failure of kidney function L = Loss of kidney function E = End stage kidney disease In kidney failure, volume overload, hyperkalemia, metabolic acidosis, overt uremic symptoms may appear. Since the serum creatinine is 650 mmol/L that is more than 353.6 mmol/L, and also having hyperkalemia and metabolic acidosis indicates that the patient is suffering from Kidney failure.

3) Why potassium level is high?

As the patient is severely dehydrated, and also because of the renal failure, there is metabolic acidosis. Kussmaul respiration also causes low level of CO2 and also leads to metabolic acidosis (H+ raised in the plasma). For compensation, kidney restores K+ ions (less excretion of K+ ions) that leads to high level of potassium ions.

4) What do you expect the renal flow to be? Category Failure GFR criteria Increase creatinine three times or GFR decreases >75% UO criteria UO<0.3 ml/kg/hr times 24 hours or anuria times 12 hours.

CASE STUDY 3
Last year a 65 year old male found himself increasingly short of breath while walking since long. He was referred to cardiologist for cardiologic investigation. A physical examination did not reveal any abnormalities but chest X-ray revealed cardiomegaly without evidence of pulmonary edema. A subsequent ECG revealed a reduction in ejection fraction. A diagnosis of CHF was made and cardiologist prescribed Lisinopril 2.5mg daily o.n. and this is increased over a period of several weeks to 20mg daily.
Question # 01 Comment on clinical findings. Question # 02 What is the purpose of Lisinopril? Question # 03 How the patient should be counseled with respect to take Lisinopril for the 1st time?

ANSWERS:
1) Comment on clinical findings.
Shortness of breath. Further investigations showed: Reduced Ejection Fraction. Cardiomegaly. Shortness of Breath indicates impaired oxygenation. Body`s need for oxygenation is not being fulfilled and on physical work like walking, the demand for oxygen is increased. Reduced Ejection Fraction indicates that heart is not functioning properly. (Failing) Heart failure is a condition in which the heart has not the ability to pump enough blood to the body tissues; whereas congestive heart failure is a specific subset of HF characterized by Left Ventricular Systolic Dysfunction and volume excess presenting as an enlarged blood congested heart. So, the diagnosis is correct.

2) What is the purpose of Lisinopril?

Lisinopril is ACE inhibitor. ACE inhibitors are now considered first choice treatment as they prevent the production of Angiotensin , a substance in the blood that causes vessels to tighten and raise B.P. Our objective is to lower blood pressure and afterload. So; ACE inhibitor (i.e. lisinopril) is used for this purpose.

3) How the patient should be counseled with respect to take Lisinopril for the 1st time?
Patient should be advised to monitor his blood pressure regularly 9both sitting and standing). Cough is a common side effect of ACE inhibitor. So, the patient should be instructed to consult the cardiologist if condition worsens.

CASE STUDY 4
A 60 year old lady was on Amlodipine 5mg o.d and Atenolol 50mg b.i.d since a long time. She complaint her cardiologist about her swollen feet and feeling of numbness.
Question # 01 Give the reason for swollen feet. Question # 02 Numbness is associated with --------------? Question # 03 How would you response as a pharmacist?

ANSWER:
1) Give the reason for swollen feet. Ca+2 Channel Blockers are pharmacologically complex. They reduce calcium intake in to smooth muscle cells causing coronary and pulmonary vasodilation and lower B.P. One of the major side effects of Ca+2 Channel Blockers is `Peripheral Odema`. This peripheral odema is responsible for swollen feet of 60 years old lady. Amlodipine is the reason for swollen feet. 2) Numbness is associated with --------------? -blockers (Atenolol) inhibit nor-epinephrine release peripherally. In the vascular system, -receptors blockade opposes 2 mediated vasodilation. Blocking 2 receptors in arteriolar smooth muscle may decrease the peripheral blood flow and may cause old extremities. 3) How would you response as a pharmacist? Advise the patient: To avoid sitting or standing without moving for prolonged period of times. Exercise regularly. Loose weight (if needed). Elevate legs above the level of heart while lying down. Take low salt diet, which may reduce swelling. The dose of atenolol must be lowered to normalize the numbers in extremities. Instead of 50mg B.D; once daily dosing must be given. Also ask the lady to cover up wall to avoid cold extremities.

CASE STUDY 5
A 53 year old man had sustained previous myocardial Infarction presented with gradually increasing fatigue, breathlessness and odema. He was being treated with furosemide 80 mg three times daily, lisinopril 50 mg, TID, Aspirin 50 mg O.D, Isosorbide mononitrate 20 mg, and sitting Blood pressure was 110/70 mgHg. Echocardiography showed a dilated heart with 32% ejection fraction. Routine tests showed Na 128 mmol/L, K5.8mmol/L, Urea 9mmol/L, Creatinine 155mmol/L.
Question # 01 What the patient is suffering from? Question # 01 Optimize the drug therapy. Question # 01 Design a Pharmaceutical care plan for this patient.

ANSWERS:
1) What the patient is suffering from?
The patient is suffering from cardiac failure as ejection fraction is low.

2) Optimize the drug therapy.

As patient is suffering from hypotension, hyperkalemia and increased level of urea (due to impairment of kidney function), this maybe an adverse effect of lisinopril (ACEI) which could not be replaced by ARBs because it also causes similar side effects. So we could recommend Hydralazine/ nitrate combination.

3) Design a Pharmaceutical care plan for this patient. Pharmaceutical care plan:
As the patient is suffering from fatigue, SOB and odema; the echocardiography shows a dilated heart with 32% ejection fraction which shows that the patient is suffering from CHF.

In the present therapy, the following interactions are there:

Drug Lisinopril

Interacti ng Drug Furosemi de

Severi ty level 3

Effects Effect of loading dose maybe decrease d. Loading dose effect maybe decrease d Hypotensi on and vasodilati on

Mechanis m Possibly, inhibition of angiotensi n2 production by ACE- Unknown

Managem ent Monitor the patient carefully

Furosemi de

Aspirin

No manageme nt necessary Monitor the patient carefully

Lisinopril

Aspirin

Inhibition of prostaglan din synthesis

Pharmacist`s Advices: o Some dietary modifications may also be necessary. His dietary intake of sodium and cholesterol must be restricted for not more than 100mmol per day (Roger walker). o The patients should be advised to exercise regularly at least.

CASE STUDY 6
Mr. SDK is an accountant 65 years of age. He has been suffering from HTN for the last 9years. On examination (O.E) B.P = 155/100 mmHg (6 month ago it was 169/105 mmHg). Ever since he has been using the following medication;
Atenolol 100mg/day Amlodipine 10mg/day Benazipril 40mg/day Simvastatin02mg/day Recently he went to see his physician as he is suffering from shortness of breath and swollen ankles. He also complained fatigue, weakness and itchy skin. Lab Report ; Na 148mmol/L K 4.8mmol/L Serum Creatinine 280mic.mol/L Question # 01 What is he suffering from? Question # 02 What is the cause of his affliction? Question # 03 How will you optimize the antihypertensive therapy?

ANSWERS:
1) What is he suffering from?
The patient is suffering from hypertension; he also might have a mild or moderate kidney functioning problem.

2) What is the cause of his affliction?

The cause of patients fatigue and weakness and itchy skin is benzopril . The side effects of atenolol also cause tiredness. Swollen ankles are due to amlodipine.

3) How will you optimize the antihypertensive therapy?

The patient must be told to control his weight. He should also be advised on a low lipid diet. A diet high in fruit and vegetables, legumes and whole grain cereal improves CV risk.

Drugs:
Patient needs to be treated for raised electrolytes and odema. For this purpose the patient should be given a diuretic. The patient should be given thiazide diuretic which is inexpensive and well tolerated by most patients. Bendroflumethiazide 125 mg daily. As the patient is over 55 years of age, he must be given a calcium channel blocker with thiazide diuretic (-blocker with thiazide diuretic is recommended as 1st line therapy in patients with age under 55 years of age). If initial therapy fails to control blood pressure, ACE inhibitor (A) or a blocker (B) is combined to a calcium channel blocker (C) or a diuretic (D). Subsequently a combination of A (or B) + C+D may be used. After these further therapies e.g.: an -blocker, spironolactone etc. should be added as necessary to achieve adequate control. As ACE-I are producing side effects in this patient (weakness, fatigue, itchy skin) due to long term use of medication( 9 years), so we will exclude Benazepril from the therapy.

CASE STUDY 7
A female patient of 80year of age is diagnosed as having chest pain left sided radiating from left shoulder to left hand. For more them 4 hrs. she is feeling nausea. In the emergency she was given Nalbuphin 1 v to relieve her of this severe pain. A 12 lead ECG was done that revealed AMI and left ventricular failure as final diagnosis.
H/O: HTN and smoking Vitals: B.P 160/100 mmHg Pulse 95 beats/min.

Clopidogral Rosuvastalin Lisinopril Spironolactone Furosemide Neo-k Ranitidine Carvedilol Aspirin

75mg P.0.0.d 10mg P.0 5mg P.0 0.d 40mg P.0 b.i.d 40mg 1.v b.i.d. 500mg P.0 t.i.d 150 mg i.v o.d p.o b.i.d 500mg p.o1/2 o.d

Question: Design a care plan. Comment on whole situation.

ANSWER:
Comments: As patient is 85 years old renal functions must be taken into account. As this poly pharmacy can worsen the kidney impairment if present. Dose of diuretics must be adjusted according to renal function. Diuretics should not use continuously on long term basis for gravitational edema. Elders are particularly susceptible to side effects. ACE inhibitors (Lisinopril) should be initiated under specialist supervision and with careful clinical monitoring in those with age more than 70 years.

Lisinopril should be used with caution because patient may have silent and undiagnosed renal vascular disease. Blood pressure and potassium level should be monitor. INTERVENTIONS: For Aspirin and Lisinopril, if adverse effects noted changed from Aspirin to non-Aspirin anti platelet agent. Decrease the dose or change from ACE to Angiotensin II receptor blocker. PLANS FOR MANAGEMENT: For Aspirin and lisinopril monitor blood pressure and hemodynamic parameters and note adverse effects. Avoid aspirin as patient is taking clopidogrel and if patient is having sever effects and is at risk then, LAB TESTS: RFTs LFTs Serum electrolytes PRECAUTIONS: Avoid smoking Restrict excess salt intake Avoid processed food. CHART FOR POTENTIAL DANGERS:

Drug Aspirin

Interactin g Drug Clopidogrel

Effects

Aspirin

Furosemide

Risk of life threatening bleeding in high risk patient with transient ischemia or stroke. Diuretic 5

Significan ce Level 1

Mechanis m Unknown

Unknown

Aspirin

Lisinopril

Aspirin

Spironolact one

effect of loop diuretics can be impaired if hepatic disease is present. Hypotensio n and vasodilator y effect of ACE inhibitors can be decreased Salicylate block spironolact one induced natriuresis.

Inhibition of prostagland in synthesis.

Aspirin

Carvedilol

BP lowering effect of lisinopril is attenuated with Aspirin

Aspirin block renal tubular secretion of unconjugat ed metabolite of spironolact one Aspirin block PG synthesis involved in antihypertensiv e action of Carvedilol.

CASE STUDY 8
A 53 year old man comes to his primary care doctor complaining of tightness in chest when he digs. It eases when he has a rest. On investigation he has a raised serum glucose conc. He is considered to be a newly diagnosed non-insulin dependent type-II diabetic.
Question # 01: What cardiovascular investigation and treatment should this patient receive? Question # 02: What treatment should this patient receive?

ANSWERS:
1) What cardiovascular investigation and treatment should this patient receive?
Patient`s BP should be monitored. INVESTIGATIONS: A 12-lead electrocardiogram should be done. Patient should be examined for signs of hypertensive or diabetic target organ damage, including Albuminuria. Chest X-ray Exercise Tolerance Test Patient`s Serum Electrolyte and Lipid Profile and Blood Sugar level should be measured.

2) What treatment should this patient receive?

He should receive GTN Spray or Sublingual tablet for chest symptoms; that are all most certainly of Angina. He should take Aspirin daily and a statin if his lipid profile is abnormal. A -blocker may also be useful to control blood pressure and prevent further episodes of Angina but many prescribes would wait until there is evidence of other therapies. In view of his relatively young age, referral to a cardiologist for possible angiography would be considered. In emergency, patient should receive nitrates and other drugs will be recommended after final diagnosis. As patient is known (newly diagnosed) to have Non-Insulin Dependent Diabetes, he must be given oral hypoglycemic agent and sugar level in plasma must be monitored.

CASE STUDY 9
The following patients are admitted for treatment of Myocardial Infarction; Patient-I has asthma. Patient-II is a man previously treated for infarction. Patient-III has rheumatoid arthritis.
Question: What standard contraindications are there to standard treatment?

ANSWER:
PATIENT-:
An asthmatic should not receive a -blocker without careful consideration and supervision because of the risk of bronchoconstriction with Aspirin.

PATIENT-:
A previous infarct may have been treated with streptokinase and a repeat dose should be avoided. Tissue plasminogen activator should be used instead.

PATIENT-:
Thrombolytics are contraindicated if there is a serious risk of bleeding. A patient with Rheumatoid Arthritis may be receiving NonSteroidal Anti-Inflammatory drugs (NSAIDs) or Steroids and enquiries must be made into any history of GI bleeding. NSAIDs would be also not prescribed with ACE inhibitors because of the risk of impaired renal function. Aspirin is not contraindicated with NSAIDs and may be useful but will increase the risk of GI bleeding.

CASE STUDY 10
A patient with rheumatoid arthritis treated with Naproxen has coronary disease.
Question:
Is there any harm or benefit in adding aspirin to the treatment?

ANSWER:
Aspirin is more beneficial than any other non-steroidal antiinflammatory agent in modifying platelet activity and reducing mortality and morbidity in coronary heart disease. There is an increased risk of gastrointestinal bleeding if two agents are given at the same time but at low doses of aspirin, this should not be a major consideration. There is some evidence, however that some NSAIDs interfere with the action of aspirin by blocking access to the active site on the COX-1 enzyme. Such agents should be avoided. Diclofenac does not

block the receptor and Ibuprofen has a short duration of action and is acceptable 2hours after the daily dose of Aspirin.

CASE STUDY 11
A 70 years old with chronic asthma and mild heart failure, has been prescribed NAPROXEN 250mg T.D.S. As a result of inflammation and pain in joints. He has been using the following medications:
Furosemide 40mg each morning Ramipril 5mg once daily Prednisolone 5mg once daily Salbutamol inhaler 2 puffs 4times a day Salmetrol inhaler 50g 1 puff twice daily Beclomethasone inhaler 250g inhaler 2 puffs twice daily Co-proxamol 1 tab s.o.s Patient is still breathless. Question # 01 Should this patient be given Naproxen? Question # 02 What is the effect of Prednisolone and why it is prescribed? Question # 03 What precautions must be observed after the use of inhalers?

ANSWERS:
1) Should this patient be given Naproxen?
NSAIDs like naproxen can induce asthma and HF by inducing bronchospasm and causing fluid retention respectively. Naproxen can also cause GIT disturbances when given with steroids and patient is also receiving steroids so patient should not give Naproxen.

2) What is the effect of Prednisolone and why it is prescribed?

It enhances the action of 2 receptors by influencing or modifying molecular events. It suppress the release of arachidonic acid and thus leads to production of prostaglandins and leukotriens. It is given because of its bronchodilatory effect.

3) What precautions must be observed after the use of inhalers?

It is important to check that inhaler continue to be used correctly because inadequate inhalation result in lack of response to the drug. Oropharyngeal side effects are common with the steroids higher inhalations. Measures to minimize this can be tried such as using the large volume spacer device and rinsing the mouth with water. If no response then seek for doctor advice.

CASE STUDY12
A 60 years old man was brought to emergency of hospital for heavy chest pain. Examination revealed that he is suffered from MI. He was kept in hospital for 7 days. Past history revealed that he was a smoker as well as a diabetic. On discharge his BP was 95/65. Heart rate 60 beats /min.
Vitals:

BP HR

95/65mmHg 60 beats/min.
75mg PO OD 75mg PO OD 50mg 1 tab PO B.I.D 10mg 1 tab P.O H.S 70/30 20 units in morning and 30 units at 1 tab PO B.I.D

Aspirin Clopidogrel Atenolol Simvastatin Human insulin night Lisinopril Lab investigation Serum sodium Serum Potassium Serum Creatinine LDL

141 mmol/l 4.2 mmol/l 121mol/l 15mmol/l

Question # 01: What should be advised to the patient? Question # 02: Find the interactions and their management. Question # 03 What important issues must be discussed with patient? Question # 04 Write rationale of each drug. Question # 05 Comment on the use of Simvastatin?

ANSWERS:
1) What should be advised to the patient?

Take low fat diet; avoid oily, fried, or processed food. Avoid sweets. Always take simvastatin at night. Check blood pressure and blood glucose regularly. Have walk daily Consult doctor regularly.

2) Find the interactions and their management. Drug Aspirin Interacti ng Drugs Atenolol Significan ce Level 2 (moderate) Effects BP lowering effect of blockers are attenuated by Aspirin. Mechanism Salicylate may inhibit biosynthesis of PG involved in antihyperten sive activity of Atenolol. Unknown Managemen t Monitor BP Changing to non-Salicylate antiplatelet agent or alternate therapy. Avoid Aspirin use in high risk patient with recent ischemic stroke or transient ischemic attack who is receiving clopidogrel. Monitor BP and hemodynamic parameters. In case of ADR reduce dose of aspirin to <100mg/day

Aspirin

Clopidogr el

1 (major)

Aspirin

Lisinopril

2 (moderate)

Risk of life threatening bleeding (intracrania l and GIT hemorrhag e) may be increase in patient with transient ischemic attack or stroke. The Inhibition of hypotensiv prostaglandi e and n synthesis. vasodilator y effect of lisinopril may be decreased.

Aspirin

Insulin

2 (moderate)

clopidogr simvastati el n

4 (moderate)

Serum glucose lowering action of insulin may be potentiated . Certain HMG-CoA reductase may interfere with clopidogrel platelets inhibition.

Basal insulin conc. is increased + acute insulin response to glucose load is enhanced. By competing for the same C4P 3A4 isoform, certain HMGCoA inhibitors may inhibit metabolic conversion of pro drug clopidogrel to active form.

or give alternative or angiotensin receptor blocker. Monitor blood glucose conc. and tailor the insulin regimen as needed Based on available data no special precautions are needed.

3) What important issues must be discussed with patient? Drug Aspirin Problem Associated with renal when given with ACE inhibitors (Lisinopril) May cause GI bleeding These often are considered unpleasant to taste. Comment Warn patient to use Paracetamol as their analgesic of choice. Advise on taking with food and water Encourage patient to use regularly.

Aspirin Beta blockers

Harm of smoking must be discussed with patient. Patient must be educated to take low fat diet. Encourage for having regularly exercise.

4) Write rationale of each drug. Drug Use Simvastatin It is powerful lipid lowering drug that can decrease LDL. It reduces the risk of cardiovasc ular events in MI. Clopidogrel Used to inhibit blood clots in CAD (nonsteroid myocardial infarction) Aspirin Antiplatelet activity in CVS disease. Lisinopril Treatment of CHF, heart attack, HTN, prevents Dose Start at 20mg Can be 5mgg -80mg Frequency Route Once in a Oral day at bed time

75mg orally

Oral

Woman aged 55 79 years low dose 75mg or 81mg. 2.5mg to 20mgstand ard 5mg

Once daily

Oral

Once daily

oral

Atenolol

renal and retinal complicatio ns in diabetes. Treat and reduce risk of heart complicatio ns after MI.

Normal RFs; 2550mg Impaired RFs; 50mg after dialysis.

Once daily

Oral or I/V

5) Comment on the use of Simvastatin?

It is powerful lipid lowering drug that can decrease LDL levels up to 50%. It is used in doses of 5mg to 80mg. In secondary prevention, 80mg / day reduces major cardiovascular events. It also reduces the risk of cardiovascular events in MI. It has now become apparent that patient with one or more risk factors for CVS diseases (such as diabetes, HTN positive family history) can be benefit from statins even they dont have substantially elevated cholesterol levels. As the case of this patient who has diabetes as well as MI, simvastatin has been prescribed for reducing the cardiovascular events in MI. Simvastatin should always take at bed time because (LDL) biosynthesis takes place at night and simvastatin inhibits its synthesis. Patient taking Simvastatin should avoid use of grapefruit juice and product contain grapefruit. Patient should be counseled for common problems arising due to use of simvastatin.