CASE PRESENTATION

CASE PRESENTATION

PATIENT’S PROFILEName: Mr. XDate of Admission: 26/7/2009Age: 72 years oldRace: MalayGender: MaleDiagnosis: COAD, hypertensionWeight: Cannot be assessedHeight: Cannot be assessedAllergy: Unknown

Chronic Obstructive Pulmonary Disease 1

progressive disease narrowing of the airways, leading to the shortness of breath and difficulty in

breathing"Progressive" means the disease gets worse over

time.

1 Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition.

COPD includes the terms chronic bronchitis (clinical term) and• condition with chronic or recurrent

excessive mucus secretion into the bronchial tree with cough 1

emphysema (anatomic pathology)• enlargement of the air spaces distal to the

terminal bronchioles, with destruction of their walls

1. Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition.2. http://www.buzzle.com/articles/pathophysiology-of-copd.html

Causes

• Cigarette smoking is the primary modifiable risk factor for the development of COPD.

• Long-term exposure to other lung irritants, such as air pollution, chemical fumes, or dust, also may contribute to COPD. 5

1 Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition

Pathophysiology 1

The most important processes causing lung damage are:

Oxidative stress produced by the high concentrations of free radicals in tobacco smoke.

Cytokine release due to inflammation as the body responds to irritant particles such as tobacco smoke in the airway.

Tobacco smoke and free radicals impair the activity of antiprotease enzymes (such as alpha 1-antitrypsin)

Protease enzymes damage the cells and tissue of lungs and other supportive tissues,


Healthy vs COPD

Symptoms 1

• A cough (large amount of mucus)• Chest tightness• Shortness of breath• Wheezing• Low energy

1. http://www.buzzle.com/articles/pathophysiology-of-copd.html

Hypertension

High blood pressure (HBP) or hypertension means high pressure (tension) in the arteries. Arteries are vessels that carry blood from the pumping heart to all the tissues and organs of the body.5


Blood pressure is the force applied against the walls of the arteries as the heart pumps blood through the body. The pressure is determined by the force and amount of blood pumped and the size and flexibility of the arteries.1

1. http://www.healthline.com/sw/khs-understanding-asthma&usg

Classification 1

1. Essential (primary) - no specific medical cause can be found to explain a patient's condition. 90-95%

2. Secondary. Secondary hypertension indicates that the high blood pressure is a result of another condition, such as kidney disease or tumours.

1. http://www.nlm.nih.gov/medlineplus/ency/imagepages/9124.htm

Classification of BP for Adults 5

Classification SBP (mm Hg) DBP (mm Hg)

Normal <120 And <80

Prehypertension 120-139 Or 80-89

Stage 1 hypertension 140-159 Or 90-99

Stage 2 hypertension ≥160 Or ≥100


High Blood - Pressure: The Silent Killer

PATHOPHYSIOLOGY OF HYPERTENSION

Hypertension may result either from a specific cause (secondary hypertension) or from an underlying pathophysiology mechanism of unknown etiology (primary or essential hypertension).1


SECONDARY HYPERTENSION 1

Secondary hypertension may cause by chronic kidney disease, Cushing’s syndrome, hyperthyroidism, hyperparathyroidism, primary alsosteronism, pregnancy, obstructive sleep apnea, and coarctation of the aorta.

Some drugs that may increase BP: ~ Corticosteroids ~ Estrogens ~ Nonsteroidal antiinflammatory drugs (NSAIDs) ~ Amphetamines ~ Sibutramine ~ Cyclosporine ~ Tacrolimus ~ Erythropoietin ~ Venlafaxine


PRIMARY HYPERTENSION 1

Multiple factors that contribute to the development of primary hypertension, including:

Humoral abnormalities involving the renin-angiotensin-aldosterone system, natriuretic hormone, or hyperinsulinemia

Pathologic disturbance in the CNS, autonomic nerve fibers, adrenergic receptors, or baroreceptors

1. Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition

Abnormalities in either the renal or tissue autoregulatory processes for sodium excretion, plasma volume, and arteriolar constriction. 1

Deficiency in the local synthesis of vasodilating substances in the vascular endothelium, such as prostacyclin, bradykinin, and nitric oxide, or increase in production of vasoconstricting substances such as angiotensin II and endothelin I. 1


High sodium intake and increased circulating natriuretic hormone would inhibit intracellular sodium transport, causing increased vascular reactivity and increased BP. 1

Increased intracellular concentration of calcium, leading to altered vascular smooth muscle function and increased peripheral vascular resistance. 1


DIABETES MELLITUS

Diabetes mellitus is a group of metabolic disorders of fat, carbohydrate, and protein metabolism that results from the defects in insulin secretion, insulin sensitivity, or both. 1


There are two major classifications of diabetes mellitus: i) Type 1 DM ii) Type 2 DM

They are differ in clinical presentation, onset, etiology, and progression of disease. 1

DIAGNOSIS OF DIABETES…

Based on three criteria 5:i) Fasting plasma glucose ≥ 126mg/dLii) A 2-hour value from a 75g oral glucose tolerance test

≥ 200mg/dLiii) Casual plasma glucose level of ≥ 200mg/dL with

symptoms of diabetes

PATHOPHYSIOLOGY OF DM 1

Type 1 DMGenerally develops in childhood or early adulthood and results from immune-mediated destruction of pancreatic β-cells, resulting in absolute deficiency of insulin.


Type 2 DM 1

Characterized by the presence of both insulin resistance and relative insulin deficiency.

Insulin resistance is manifested by increased lipolysis and free fatty acid production, increased hepatic glucose production and decreased skeletal muscle uptake of glucose.


Medication Prescribed For Mr. X

Treatment of lower respiratory tract infections, skeletal infections, surgical prophylaxis and staphylococcal infections.

Beta lactams antibiotic – Act by inhibiting the formation of peptidoglycan cross-links in the bacterial cell wall.

Precaution: - hypersensitivity to b-lactam antibiotic - Renal impairment

Adverse effect: - Neutropenia - Agranulocytosis - GI upsets - rash[1] Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names Index,

17th edition, Lexi-Comp Inc.

Cloxacillin Capsule 500 mg qid ¹

http://en.wikipedia.org/wiki/Peptidoglycan

Interaction:

A. Drug – Drug interaction - Co-admin of probenecid or disulfiram may result in higher cloxacillin concentration. - Chloramphenicol and tetracycline antagonise bactericidal effect of cloxacillin.

B. Drug – Food interaction - delayed absorption in the presence of foods.

http://www.mimsonline.com/Page.aspx?menuid=alertr&Druglist=cloxacillin**chloramphenicol**

http://www.mimsonline.com/Page.aspx?menuid=alertr&Druglist=cloxacillin**tetracycline**

Pharmacological Category:

-Proton Pump Inhibitor

Uses:

-Treatment and maintenance of healing erosive esophagitis associated with GERD

Precaution:

-Relief of symptoms does not preclude the presence of a gastric malignancy.

-Long term medication will caused biopsy-proven atrophic gastritis(especially caused by the bacterium Helicobacter pylori)

Tablet Pentoprazole 40 mg bd ¹

[1] Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names Index, 17th edition, Lexi-Comp Inc.

Side Effect:

-Chest pain, Headache(9%), Rash(2%), Diarrhea (6%), N/V/C (2%), back pain and Others.

Storage:

-Store the tablet at controlled room temperature of 20˚C to 25˚C.

Mechanism of Action:

-Suppresses gastric acid secretion by inhibiting the parietal cell H / K ⁺ ⁺ATP pump.

Dosage:

-40 mg once daily for up 8 weeks (this is for who have erosive esophagitis associated with GERD.-20 mg once daily have been used in mild GERD treatment and maintenance therapy

Administration (Oral):

-Should be swallowed whole and do not crush or chew.

-may be taken with or without food but the best if taken before breakfast (coz of PPI)

Pharmacological Category:

-Antilipemic agent

-HMG-CoA Reductase Inhibitor

Uses:-Treatment of dyslipidemias (to reduce elevations in total cholesterol, LDL-C and triglycerides

-Primary prevention of cardiovascular disease.

Precaution:-Secondary causes of hyperlipidemia should be ruled out prior to therapy.

-Liver function must be monitored by periodic laboratory assessment if not may cause hepatic dysfunction.

Tablet Lipitor 10 mg on (atorvastatin) ¹

[1] Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names Index, 17th edition, Lexi-Comp Inc.

Side Effect:

-Chest pain, Headache(17%), Rash(4%), Diarrhea (4%), N/C (3%), Insomnia and dizziness.


-Inhibitor of 3-hydroxy-3-methylgluryl coenzyme A (HMG-CoA) reductase .

-Increase in the expression of LDL receptors on hepatocyte membranes and a stimulation of LDL catabolism.

Dosage:

-Initial: 10 to 20 mg once daily (for who have hypercholesterolemia)-then 40 mg once daily for patient >45% reduction in LDL-C

Administration (Oral):

-Should be swallowed whole and do not crush or chew.

-may be taken with food

-take the medicine on night

Monitoring Parameters:

-Lipid level after 2-4 weeks

Uses:

- constipation

Precaution:

-Do not take immediately before going to bed.

-Avoid prolonged use.

-Not be used for who has abdominal pain, nausea and vomiting.

Liquid Paraffin 15 ml tds ²

[2] British National Formulary

Side Effect:

-Rash, Abdominal pain, Nausea and Vomiting.


- Liquid Paraffin acts by softening and lubricating the faeces. The faeces can then move more easily through the bowel. By doing this it relieves constipation and reduces the pain of some conditions such as piles

Dosage:

-Take 15 ml for 3 times a day.

Combivent nebulizer 8 hourly Combivent- Salbutamol and ipratropiumSalbutamol- Act on β2 receptors β2 receptors stimulation activate adenyl cyclase increase in intracellular cyclic adenosine monophosphate (cAMP) relax bronchial smooth muscle

Ipratropium- competitively inhibit cholinergic receptor in bronchial smooth muscle block acetylcholine reduce cyclic guanosine monophosphate (cGMP) relax brochial smooth muscle

Precaution:immediate hypersensitivity reactions may occur after administration, as demonstrated by rare cases of urticaria, angioedema, rash, bronchospasm.

Drug-drug interaction: # Ipratropium-increase toxicity with anticholinergic or drug with anticholinergic effects (eg: atropine, TCA, antipsychotic drug). # Salbutamol- refer to MDI salbutamol

Adverse drug reaction: (Ipratropium)

# Glaucoma # Hypersensitivity reaction # Urinary retention # Blurred vision

Metered dose inhaler salbutamol 2 puff + prn Bronchodilator Short acting selective β2 - adrenergic agonist Act on β2 receptors β2 receptors stimulation activate adenyl cyclase increase in intracellular cyclic adenosine monophosphate (cAMP) bronchial smooth muscle relaxation Precaution:

# hypertension

# cardiac disorders (eg: arrhythmia, CHF)

# diabetes

# elderly patients.

Drug-drug interaction:

# salbutamol + nonpotassium sparing diuretics (eg: furosemide) hypokalemia # α- blocker, β-blocker decrease effect of sulbutamol

Drug-food interaction:

# Avoid or limit caffeine- may cause CNS stimulation

Adverse drug reaction:

# CNS stimulation

# Arrhythmia

# Seizure

# Hyperglycemia

# Hypokalemia

Step For Using Metered Dose Inhaler Take off the cap and shake the inhaler.

Breathe out all the way to empty the lungs as much as possible.

Hold the inhaler 1 - 2 inches in front of your mouth (about the width of 2 fingers).

Start breathing in slowly through your mouth, and then press down on the inhaler one time. (If you use a spacer, first press down on the inhaler. Within 5 seconds, begin to breathe in slowly.)

Keep breathing in slowly, as deeply as you can.

Hold your breath as you count to 10 slowly, if you can. This lets the medicine reach deep into your lungs.

Wait about 1 minute between puffs for inhaled quick-relief medicine (beta-agonists). There is no need to wait between puffs for other medicines.

Rinse your mouth - help reduce unwanted side effects.

Tablet prednisolone 20mg OD

Systemic corticosteroid

Antiinflammatory mechanism; beneficial effect- reduction in capillary permeability to decrease mucus, inhibition of release of proteolytic enzymes from leukocytes, and inhibition of prostaglandin.

Precaution: # Use with caution in patients with thyroid disease, hepatic impaired, renal impairment, cardiovascular disease, diabetes, patients at risk of osteoporosis, patients at risk of seizure, patients at risk of GI disease (peptic ulcer).

Drug-drug interaction: # CCB (nondihydropyridine), azole antifungal, macrolide- may increase the serum level of prednisolone # Prednisolone may increase the hypokalemia effect of potassium wasting diuretic (loop or diuretic)

# Concurrent use of NSAIDs and salicylate with corticosteroid- may increase GI adverse effect. # Antacids may reduce absorption of corticosteroid- separate administration by 2 hours. # Prednisolone may cause reduction in warfarin effect.

Drug-food interaction: #Avoid ethanol- may increase gastric mucosal irritation. # Prednisolone interfere with absorption of calcium. # Limit caffeine.

Adverse drug reaction: # Increase appetite # Weight gain # Peptic ulcer # Hypokalemia # Convulsion # Diabetes mellitus

ACTRAPID HM PENFILL

HUMAN INSULIN SOLUTION FOR INJECTION

Types of Insulin

Names of Insulin

How Fast They Start

When the Action Peaks

How Long They Last

Rapid Acting Humalog/LisproNovolog/Aspart

5 - 15 minutes

30 - 90 minutes

1 - 3 hours3 - 5 hours

Short Acting Regular 1/2 - 1 hour 2 - 4 hours 6 - 8 hours

Intermediate NPH 1 - 2 hours 6 - 10 hours 10 - 16 hours

Long Acting Lantus/GlargineLevemir/Detemir 1 - 2 hours No peak action 24 - 36 hours

WHAT ARE THE DIFFERENCES BETWEEN THE TYPES OF INSULIN?

COMPOSITION Active substance: Human insulin,

( recombinant DNA produced in Saccharomyces cerevisiae)

1 IU is corresponds to 0.035mg of anhydrous human insulin.

INDICATIONS

Treatment of diabetes mellitus.

Initial stabilization of diabetes especially in diabetes emergencies.

MODE OF ACTION The blood glucose lowering effect of insulin

is due to :

Facilitated uptake of glucose following binding of insulin to receptors on muscle and fat cells.

Simultaneous inhibition of glucose output from the liver.

An average action profile after subcutaneous injections indicates:

Onset: within half hourMaximum: between 1 and 3 hoursDuration: approximately 8 hours.

DOSAGE Dosage is individual and determine by the

doctor in accordance to the patient requirement.

the average doses is in between 0.5 to 1.0UI/kg.

This patient need to take 16IU for morning, 14 IU during afternoon and night.

in geriatric patients, the primary aim of treatment is to relief symptoms and to avoid hypoglycemic events.

HOW TO ADMINISTER ACTRAPID?1. Actrapid HM is usually injected subcutaneously (SC) onto the abdominal region, thigh,gluteal region and deltoid region.2. SC injection into the abdominal wall ensures afaster absorption than other injection sites.

3. Injection into a lifted skin fold minimises the risk of intramuscular injection.

4. After the injection, the needle should remain under the skin for at least 6 seconds.

5. Keep the push button fully depressed until after the needle has been withdrawn from the skin.

6. Injection sites should be rotated within an anatomic region in order to avoid lipodystrophy.

The above pictures shows lipodystrophy that occur at the insulin injection sites.

7. The insulin penfill should be used by one person only to avoid risk of passing diseases.

8. An injection should be followed within 30 minutes by a meal or snack containing carbohydrates.

UNDESIREBLE EFFECTS Hypoglycemia is a frequently occurring in

insulin therapy. The symptoms are include: cold sweat, cool pale skin, nervousness,

confusion, difficulty in concentration, headache, nausea and palpitation.

severe hypoglycemia may lead to unconsciousness and may result temporary or permanent impairment of the brain function and even death.

Local hypersensitivity reaction may occur at the injection sites during treatment with insulin.

OVERDOSE Mild hypoglycemic episodes can be treated

by oral administration of glucose or sugary products.

It is recommended for diabetic patients constantly caries some sugar lumps, sweets, or sugary fruit juices.

For severe hypoglycemic episodes, patients can be treated by IM or SC injection of glucagon (0.1 to 1.0mg) or glucose given by IV injection by medical professionals.

STORAGE Actrapid HM Penfill which is not in use should

be stored at 2⁰C to 8 ⁰C in a refrigerator. If in use, should not kept in the refrigerator,

keep in room temperature for up to 4 weeks. Keep protected from light. Keep out from the reach of children. Remove the needle after each injection. Keep out from exposed to heat or direct

sunlight and should never be frozen.

Insulin product which has been frozen must not be used.

Never use insulin after the expiry date or the solution is not clear.

A. FELODIPINE 15 mg OD Indication- lowering blood pressure

-To be taken once daily without food.

-Calcium channel blocker- act by inhibits calcium ion from entering the slow channel s or select voltage sensitive areas of vascular smooth muscle and myocardium during depolarization causing relaxation of coronary vascular smooth muscle and coronary vasodilation.

Precaution :

1. peripheral edema is the most common SE occurs w/in

2-3 weeks of starting therapy.

2. May cause hypotension with reflex tachycardia

resulting in MI

Drug for HTN

Common adverse effect: - headache - peripheral edema - tachycardia - flushing

Interaction:

A. Drug – Drug interaction - Cimitidine, erythromycin,itroconazole and ketoconazole cause

increase plasma concentratin of felodipine. - Phenytoin, carbamazepine, rifampicin and barbiturate cause decrease

plasma concentration of felodipine. B. Drug – Food interaction - Ethanol will increase felodipine absorption, greater hypotensive effect. - Grapefruit juice increase effect of felodipine lead to severe

hypotension if concurrent use.

B. PRAZOSINE 4 mg tds

Indication: for treatment of hypertension.

-Starting dose is best taken with dinner, at least 2-3 hr before retiring. Maintenance doses may be taken with or without meals. -Is alpha adrenergic blocker- act as antagonist of α adrenergic receptors which lower blood pressure by relaxing blood vessels.

Precaution: - First dose may cause orthostatic hypotension and syncope associated

with the body's poor ability to control blood pressure without active alpha-adrenergic receptors. Patients on prazosin should be told not to stand up too quickly, since their poor baroreflex may cause them to faint as all their blood rushes to their feet.

Common side effect:

- orthostatic hypotension - syncope - priapism

Interaction:

Drug –Drug interaction - May increase plasma concentrations of digoxin - Risk of 1st dose hypotension is increased in patients receiving β-

blockers or calcium-channel blockers.

http://www.mimsonline.com/Page.aspx?menuid=alertr&Druglist=prazosin**digoxin**

C. FUROSEMIDE 40 mg OD

Diuresis agent used for treatment of hypertension.

Is a loop diuretic- Furosemide inhibits reabsorption of Na and chloride mainly in the medullary portion of the ascending Loop of Henle. Excretion of potassium and ammonia is also increased while uric acid excretion is reduced. It increases plasma-renin levels and secondary hyperaldosteronism may result. Furosemide reduces BP in hypertensives as well as in normotensives. It also reduces pulmonary oedema before diuresis has set in.

Precaution: - may cause prostate enlargement - may lower serum calcium and magnesium level

Adverse effect:

- abdominal discomfort - orthostatic hypotension - dizziness and headache - git disturbances

Interaction:

Drug – Drug interaction - it enhances toxicity of aminoglycoside, cephalosporine, salicyclates

and lithium. - decreased effect by probenecid - orthostatic hypotension increased if used together with alcohol,

barbiturate, and narcotic.

DRUG RELATED PROBLEM

1. Combivent Nebulizer[1,2]

beta-agonist induced hypokalaemia beta-agonist induced hypokalaemia may be increased by concomitant treatment with prednisolone and diuretic (Lasix). Slow K tablet (2 tablets 600mg per day) can be given to prevent hypokalaemia

[1] Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names Index, 17th edition, Lexi-Comp Inc.[2] MIMS Malaysia 113th edition 2008

Changes In dosage regimen

Regimen of Combivent Nebulizer is changed from 8 hourly to 2 hourly for 4 times then 4 hourly for 4 times may due to the frequent bronchospasms of the patient. After 2 days (19/8), the regimen changes to 4 hourly and subsequent 8 hourly at 21/8 may due to the conditions of patient more controlled and less frequent attacks.

Drug Start- stop dateCombivent Nebulizer 8 hourly

9/8-17/8

Combivent Nebulizer 2 hourly for 4 times then 4 hourly for 4 times

17/8-19/8

Combivent Nebulizer 4 hourly

19/8- 21/8

Combivent Nebulizer 8 hourly

21/8- Continue Use

2. PREDNISOLONE1

Increase the risk of hypokalaemia with diuretic (Lasix) and β-agonists (Salbutamol)

Prednisolone interfere with calcium absorption and lower bone density lead to high risk of osteoporosis if use for long term

Calcium level and bone density of patients need to monitor frequently and biphosphonates (Alendronate 5mg daily[3] ) can be used.

Risk of peptic ulcer in patient Calcium channel blocker may increase serum level

of Prednisolone Need to ensure lowest effective dose is used in

elderly

[1]Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names Index, 17 th edition, Lexi-Comp Inc.

[3] Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer and Cindy W. Hamilton, 2006. Pharmacotherapy Handbook, 7th edition, The McGraw-Hill Companies, Inc

Changes In dosage regimen

Prednisolone has been changed to hydrocortisone IV 200mg may due to the severe inflammation of respiratory tract. The hydrocortisone dose is decreased to 100mg and later changed to oral prednisolone 30mg when the inflammation is more controlled. The patient continues to take Prednisolone 20mg for anti-inflammation in respiratory tract.

Drug Start- stop datePrednisolone 20mg, OD 16/8-17/8Hydrocortisone 200mg, IV, QID

17/8

Hydrocortisone 100mg, IV,TDS

17/8-20/8

Prednisolone 30mg, OD 20/8-23/8Prednisolone 20mg, OD 23/8-Continue Use

3. S/C ACTRAPID1 Decrease hypoglycemic effect with corticosteroid &

furosemide Insulin decrease potassium serum concentration lead to

hypokalaemia Dosage adjustment:

[1]Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names Index, 17th edition, Lexi-Comp Inc.

Drug Start- stop dateS/C Actrapid14IU, tds 4/8-6/8S/C Actrapid 8IU, tds 9/8-12/8S/C Actrapid 10IU, tds 12/8-DiscontinueS/C Actrapid 18/16/16IU, tds

13/8-17/8

S/C Actrapid 14IU, tds 16/8-18/8S/C Actrapid 14/12/12, tds

19/8-20/8

S/C Actrapid 16/14/14, tds

20/8- Continue Use

The dose of Actrapid is adjusted from time to time.

Possibilities:1. Dosing adjustment is made based on

patient’s glucose level.2. Concomitant administration of

Frusemide. Frusemide will decrease glucose tolerance and require increase dose of insulin

3. Corticosteroid

4. CLOXACILLIN[2]

Cloxacillin is started since 2/8 and discontinued on 11/8. It is started again on 17/8 and is still on-going(until 23/8).

Prolonged use may result in fungal or bacterial superinfection, including diarrhea and pseudomembranous colitis

Risk of blood disorder and GI disturbances

References:1. Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names Index, 17th

edition, Lexi-Comp Inc.2. MIMS Malaysia 113th edition 2008

LASIX (FUROSEMIDE)

Patient at risk of hypokalaemia [1]

→ Monitor potassium level daily → Slow-K (2 tablets [6oo mg/tab] per day)

Frusemide level might be decreased if taken with food

Glucose tolerance may be decreased – need dosing adjustment of insulin

Charles F. Lacy et al. Drug information handbook with international trade name index, 17th edition, Lexi-Comp Inc., 2008-2009.

For patient with concurrent hypertension and diabetes:

® It is recommended to used thiazide group of diuretic [2]

® Eg: Hydrochlorothiazide (25 – 200 mg daily)

® However, the prednisolone may enhance the K-depleting effect ® Slow K

Joseph T. Dipiro et al. Pharmacotherapy. A pathophysiologic Approach, Seventh Edition, The McGraw-Hill Companies, Inc., Singapura, 2008.

FELODIPINE

Dose is high (15 mg )® For elderly: recommended starting dose

2.5 mg daily ® Increase by 5 mg daily in 2 weeks

interval® Usual dose: 2.5 – 10 mg® Side effects due to vasodilatation

(edema, flushing, dizziness and headache) occur more frequently

® It is suggested to use non-dihydropyridine group: verapamil and diltiazem

The dose is changed from 10 mg ®15 mg ® 20 mg ® 15 mg.

® The increment of dose: hypertension condition is not well-controlled.

® It is suggested to change drug: ARB (Losartan 50 mg daily)

® After that, the dose is decreased. This may be due to the condition is under control by the synergistic effect of other antihypertensive drugs.

® Decrement of dose can also reduce the incident and severity of possible side effects

PRAZOSIN The dose is changing from 1 mg tds ® 2 mg

tds ® 3 mg tds ® 4 mg tds ® This maybe due to the hypertension is

not well-controlled

Synergistic effect of antihypertensive effect with furosemide and felodipine

® Combination of 3 drugs cause postural hypotension, dizziness and lightheadedness

® Reduced to 1 mg or 2 mg three times a day once the condition is controlled [3]

Prazocinwww.Rxlist.com

Prazosin is the best of choice if the patient has concurrent hypertension and BPH.

Monitor blood pressure closely.® Desired BP: < 130/80 mmHg

PANTOPRAZOLE

Maybe used for prophylaxis of peptic ulcer caused by prednisolone. [4]

® Dose: 20 mg daily(currently 40 mg BD)

Normal dose for peptic ulcer treatment : 40 mg once daily

40 mg BD is used for Zollinger-Ellison syndrome

MIMS, 113th Edition, 2008.

Therapy is for 2 - 4weeks Long-term therapy may lead to bacterial

overgrowth in the GI tract

Potential of bronchitis, cough and dyspnoea happen® Alternative: omeprazole

LIPITOR Pantoprazole may increase the effects of

Lipitor

Potential respiratory adverse effect (bronchitis)® Alternatives: fibric acid (eg.

gemfibrozil) and niacin

It may cause constipation (up to 3%) ® May lead to another drug use: liquid

paraffin

SUMMARY

REFERENCE:[1] Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, Cecily V. Dipiro, Pharmacotherapy Handbook, 7th Edition, McGrawHill 2009.

RECOMMENDATION

CCB (Verapamil 40mg/tab)

Dose: 240-480mg in 2-3 divided dose (HUSM Formulary)

LOSARTAN + HYDROCHLOROTHIAZIDE

Dose: 50mg/12.5mg OD.

If after 3 weeks 100mg/25mg

(max effect after 3 weeks)

LOSARTAN

Dose: Usual starting dose 50mg OD (50mg/tab),

REFERENCE:[2] www.kck.usm.my/husm/pharmacy/formulary

Drug- drug interaction

PRESCRIPTION CASCADE

DRUG 2

ADR

DRUG 1

Other medication related problems

ROLE OF PHARMACISTS

By: GROUP F

NASYARUDDIN BIN SIMALIOOI KEAN LOON

SHAHMANAZREY CHE DANCHONG HUI SAN

CORINNE CHEW SHU LINGLAI MEI YEN

NOOR’IZAYU ABD RAZAKNOR HIDAYAH BINTI RUZALLE

TEH WEN YEN

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CASE PRESENTATION

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