1. King Saud University
College of Pharmacy
Dept PHCl 429
Presentation Code: 04
T.A. Ghadah Assiri, MSc
2. Patient Information
› Name: A.S
› Age: 55 years
› Gender: male
› Race: African American
› Height: 172 cm
› Weight: 73 Kg
3. Chief Complaint (CC)
› A.S present to clinic complaining of “epigastric abdominal
pain, vague abdominal discomfort and dizziness”
4. History of Present illness (HPI)
› Epigasteric abdominal pain, vague abdominal discomfort and
dizziness. His pain started 1 year ago he took OTC antacid with
no improvement the pain come between 1-3 am and relived
by food He describes it of being moderately to severe.
› He complains of postprandial bloating and darkening of stool
one week ago.
5. History of Present illness (HPI)
› Also he suffers from moderate throbbing head pain unilateral
and temporal , the pain stay for 2 hours in the morning.
› The patient had hypertension 5 years ago which is
uncontrolled due to issue of non-compliance.
6. Past Medical History (PMH)
› Hypertension (Stage 1) diagnosed 5 years ago.
7. Medication History
› Current prescribed medication :1. Furosemide 40 mg orally twice daily started × 5 years
› Current non-prescribed medications:1. Ibuprofen 200 to 400 mg orally qid , prn
2. Maalox 30 ml orally after meal and at bed time
3. Bismuth subsailcylate occasional use (1-2 times a week )
8. Medication History
a- Current prescribed medications:
b- Current Non-prescribed medications:
200 to 400
**after meal and at bed
10. Family History (FH)
› His father died at age of 59 of shock due to severe GI bleeding
2ry to untreated PUD.
› The Mother died in a motor vehicle accident 4 years ago.
11. Social History (SH)
› He is a manger in a stress job, married with two grown
› He smokes 1ppd of cigarettes for 10 years .
12. Physical Examination (PE)
Slightly pale , thin male in moderate distress
BP average 185 96 , HR 90 , RR 20 , T 37 C , Wt 73 Kg , Ht 172 cm
Mild tenderness , no masses
Non-tender, melenic stool found in rectal valut , stool heme +ve
Memory intact ; no nystagmus ; no tremor ; or ataxia ; (-) Romberg : CN II-XII
INTACT ; SENSORY INTAVT ; DTRs : 2+ throughout : babinski (-) bilaterallly .
14. General overview about the case
The patient has 5 main problems , almost all of them are
15. General overview about the case
1. Untreated Peptic Ulcer.
2. Untreated Anemia.
3. Untreated Headache.
4. Uncontrolled Hypertension.
5. Untreated Smoking.
16. NSAID Induced Duodenal Ulcer
17. SOAP Assessment
› Subjective :• He complains clinic of epigasteric abdominal pain, vague
abdominal discomfort and dizziness.
• He noticed darkening of stool one week ago.
• The pain come between 1-3 am and relived by food, he
describes it of being moderately to severe.
• Manager of stressful job.
• His father died at age of 59 of shock due to severe GI
bleeding 2ry to untreated PUD.
A.S 55 year-old African-American male appears slightly pale
suffer from epigastric abdominal pain which is releived by
food he has many risk factor for peptic ulcer his endoscopy
shows multiple gastric ulcer , he tried to releive pain by otc
antacid but its not effective in contrast bismuth subsalycilate
worsen his case and cause bleeding , his fecal blood test gives
positive heme and his hemoglobin level is low
He has NSAID induced duodenal ulcer with secondary gasteric
ulcer and ulcerative bleeding , he also needs further tests for
Patient needs initial treatment by high dose PPI to prevent
complication and treat the symptoms .
20. SOAP Assessment
› Assessment :• Drug related problem (DRP):
Category/Subcategory: Indication / Need Additional Drug Therapy
• Statement :
A.S 55 year-old African-American male who suffers from
epigastric abdominal pain 1 year ago which not relieved by using
OTC antacid (Maalox & Bismuth subsalicylate ) needs additional
21. SOAP Assessment
› Assessment :• Drug related problem (DRP):
Category/Subcategory: Safety (Adverse drug reaction) / Undesirable
• Statement :
A.S 55 year-old African-American male who takes OTC bisthmus
subsalicylate for epigasteric abdominal pain , but his condition become
worse and develops bleeding as a side effect which increase risk of
recuurance. He needs to stop using it.
22. SOAP Assessment
• Drug related problem (DRP):
Category/Subcategory: Safety (Adverse drug reaction) / Undesirable
A.S 55 year-old African-American male who takes Ibuprofen ( Nsaid )
OTC to treat headache which causing undesirable effect a duodenal
ulcer and may cause further complication , the drug must be stooped
and choose appropriate alternatives.
24. Therapeutic goal
› Short term goals :
1. Prevent complication (perforation, penetration, obstruction,
Promote ulcer healing Stop the ulcer bleeding.
› Long term goals :
1. Preventing recurrence and avoiding potential complications.
2. Reduce financial cost of treatment .
25. According to blatchford score, patient has high risk of bleeding.
27. Pharmacological Intervention
› Stop using ibuprofen to prevent further complication.
› Stop using bismuth subsalicylate to minimize the risk of
› Continue using Maalox to relieve symptoms
28. Pharmacological Intervention
29. Non-pharmacological Intervention
› Omega -3 fatty acids has anti-inflamatory effect help to
protect the stomach from ulcers.
› Acupuncture treatments.
› Endoscopy treatment.
› Injection therapy.
› Yoga practice to manage stress.
• Symptomatic improvement.
• The appearance of adverse events like: muscle cramps, muscle
weakness or limp feeling; seizures
Testing for H.pylori
Patients taking the test should stop taking PPIs for at least 2
weeks (they interfere with the test) and starve for 4 hours
Fecal Occult Blood Test
CBC & Hemoglobin
› Assess the adherence.
› Assess the signs and symptoms of progression of ulcer
› Follow up session should be scheduled 2-4 weeks after
initiating the therapy.
› If patient is H.pylori positive start eradicating regimen .
› Repeat endoscopy to confirm healing at 6 to 8 weeks.
› If ulcer healed decrease omeprazole dose gradually to
maintenance dose to prevent recurrence.
33. Patient Education
› Take omeprazole 1 hour before meals .
› Take vitamins and iron supplement 1-2 hours after taking
Omeprazole and Antacid .
› Avoid spicy food and xanthin containing beverage and, drinks
› Avoid heavy meals before bed time.
› Smoking increases the amount of acid produced by the stomach .
need smoking cessation plan .
› Encourage small frequent low caloric meals.
› Avoid ulcerating drug e.g NSAIDs,Corticosteroid.
› Eat Magnesium containing food like banana, Avocado and fish.
34. Reffrence :
Guidelines for prevention of NSAID-related ulcer
complications. Lanza FL, Chan FKL, Quigley EMM, Practice
Parameters Committee of the American College of
Gastroenterology. Guidelines for prevention of NSAID-related
ulcer complications. Am J Gastroenterol. 2009
Management of patients with ulcer bleeding.
Laine L, Jensen DM. Management of patients with ulcer
bleeding. Am J Gastroenterol. 2012 Mar;107(3):345-60.
› Management and Prevention of upper GI Bleeding Guidelines 2009
Management of Dyspepsia 2005 BY ACG Nicholas J. Talley, M.D.,
Ph.D., Mayo Clinic College of Medicine, 200 First Street S.W., PL6–
56, Rochester, MN 55905.
36. SOAP Assessment
› Subjective :• He has noticed slight darkening of his stool and dizziness.
Objectives :Stool heme (+).
Hgb 11.0 mg/dL Low.
Hct 33 Low.
MVC 79 Low.
MCH 26 Normal.
Its Microcytic Anemia ( MVC is below 80 Fl ).
37. SOAP Assessment
› Assessment :• DRP category and sub- category:
Indication/Need Additional Drug Therapy
• Medical problems:
A.S is a 55 years old African male suffering from anemia which need a
medical intervention , that due to GI bleeding secondary to untreated
38. Therapeutic Goals
› Short term goals :• Normalized lab value that related to anemia ( Hgb, Hct, MVC).
• Alleviate signs and symptoms.
› Long term goal :• Prevent recurrence of anemia.
40. Pharmacological Intervention
› Start :
› The hemoglobin concentration should rise by 2 to 4 g/dl after
41. Non-Pharmacological Interventions
› Advise the patient to eat more
foods that are rich in iron.
› Avoid Phosphate, Calcium, Tea
(tannic acid), Coffee, Colas,
Soy protein and Bran/fiber
which are inhibit Iron absorption.
Figure.2.1 “Iron-Rich Foods”
MedScape : http://www.medscape.com/viewarticle/452692_8
42. Monitoring and Follow-up
› Iron therapy should cause :
• Reticulocytosis in 5 to 7 days.
• Raise Hb by 2 to 4 g/dL every 3 weeks.
› Once normal, the Hb concentration and red cell indices should
be monitored at intervals.
• Every 3 month for 1 year, then after a further year, and again if
symptoms of anemia develop after that.
43. Patient Education
› Advise patient to expect iron to darken stools.
› The drug may cause constipation or nausea, to overcome this
problem advice the patient to drink water and eat fibers.
› Instruct patient to avoid eating eggs, milk, cheese, yogurt, tea
coffee within 1 h before or 2h after taking iron supplement.
› For maximum absorption take on empty stomach, but may take
with or after meals to minimize GI irritation.
› Vitamin C may enhance absorption.
› (1) Barbara g. , joseph t. , terry l. , cecily v.. Hematologic disorder. In:
cecily v. (eds.)pharmacotherapy handbook . 7th ed. new York : McGrawhill companies ; 2009. p(363-370)
› (2) THAD WILKINS, MD; NAIMAN KHAN, MD; AKASH NABH, MD; and
ROBERT R. SCHADE, MD, Georgia. Diagnosis and Management of Upper
http://www.aafp.org/afp/2012/0301/p469.html (accessed 3-april-2013).
› (3) Irene Alton, MS, RD. IRON DEFICIENCY ANEMIA. In: Jamie Stang, PhD,
MPH, RD (eds.)GUIDELINES FOR ADOLESCENT NUTRITION SERVICES. 1st
ed. Minneapolis: University of Minnesota;; 2005. p(101-108)
› (5) http://nassersite.com/drugdb/view.php?id=2207
45. Migraine headache
46. SOAP Assessment
“Throbbing head pain, unilateral, temporal, occurring in the morning, which lasts
for 2 hours, with photophobia and phonophobia”
A.S is a 55 years old African male. He developed migraine headache without aura, he
is receiving Ibuprofen around 3-4 times/week this caused adverse effects on him, he
needs different drug therapy since his previous drug therapy is unsafe.
Migraine headache without aura
Drug Related Problem
Safety / Adverse drug reaction (undesirable effect)
47. Therapeutic Goals
›Goals for acute migraine treatment:
• Treat migraine attacks rapidly and consistently without
• Restore the patient’s ability to function.
• Minimize the use of backup and rescue medications.
• Be cost-effective in overall management.
• Cause minimal or no adverse effects.
48. Therapeutic Goals
› Long term goals :
• Reduce migraine frequency, severity, and disability. (Aim for
fewer than 5 headache days per month.)
• Reduce reliance on poorly tolerated, ineffective, or unwanted
• Improve quality of life.
• Avoid escalation of headache medication use.
• Educate and enable patients to manage their disease.
• Reduce headache-related distress and psychological symptoms.
49. Therapeutic alternative
Isometheptene65 2 capsules at onset;
mg/dichloralrepeat 1 capsule
every hour as
325 mg (Midrin)
Maximum of 6
50. Non-pharmacological treatment
› Application of ice to the head and periods of rest or sleep,
usually in a dark, quiet environment, may be beneficial.
› Preventive management should begin with identification and
avoidance of factors that provoke migraine attacks.
51. Non-pharmacological treatment
› A headache diary that records the frequency, severity, and
duration of attacks can facilitate identification of migraine
› Patient also can benefit from adherence to a wellness program
that includes regular sleep, exercise, and good eating habits,
smoking cessation, and limited caffeine intake. Behavioral
intervention such as Relaxation Training, Biofeedback, and
Cognitive Behavioral Therapy
52. Non-pharmacological treatment
How to manage them
Rest or sleep in a quiet environment
Glare or flikering lights
Rest or sleep in a dark environment
Relaxation Training, Biofeedback,
Cognitive Behavioral Therapy
53. Pharmacological Intervention
1-2 tablet every 46 hours
Limit dose to 4
usage to 2
54. Monitoring and follow up
› Patients should be specifically assessed at follow-up visits to
determine if their acute migraine medications need to be
› Evaluate the effectiveness of therapy through the use of
patient diaries that record headache frequency, drug use, and
55. Patient Education
› Educate the patient about Keeping a headache diary that can help
identify frequency, severity, triggers, and response to treatment.
› Patients should be advised to adjust their lifestyle to avoid
exacerbating their migraine (e.g., avoid missing meals; avoid
dehydration; maintain adequate, regular sleep).
› A general exercise program should be considered part of
comprehensive migraine management.
› Patient should Learn and use stress management skills (relaxation
training, biofeedback and cognitive behavioral therapy).
› Patient should know that It may not be possible to eliminate the
primary headache completely.
56. Patient Education
› About Medication:
› Advise patients to take their medication early in their migraine
attack, where possible, to improve effectiveness.
› Educate the patient of the risk of chronic daily headaches is
increased if headache treatment medication are used more
than nine days a month.
› Fioricet may impair mental and/or physical abilities required
for the performance of potentially hazardous tasks such as
driving a car or operating machinery. Such tasks should be
avoided while taking this product.
57. Patient Education
› Alcohol and other CNS depressants may produce an additive
CNS depression when taken with Fioricet, and should be
› Butalbital may be habit-forming. Patients should take the drug
only for as long as it is prescribed, in the amounts prescribed,
and no more frequently than prescribed.
DiPiro, Joseph T. Pharmacotherapy: A Pathophysiologic Approach.
Neurologic Disorder “Headache“. 8th ed. New York: McGraw-Hill
Medical, 2011. 106-131.Pages(1066-1075)
59. Uncontrolled Hypertension
HTN (uncontrolled) x5 years.
The patient non-compliance with his medication.
AGE= 55 years old
BP= 158/96 mmHg
HR= 90 bpm
Na= 137 mg/dL
K= 4.0 mEq/dL
Cr= 1.4 mg/dL
BUN= 32 mg/dL
WEIGHT= 73 kg
HIGHT= 172 cm
Furosemide 40 mg orally twice daily, started x5 years
62. CV Risk factor
Age ( 55 years)
High stress job
Increase of Systolic Blood Pressure (SBP) > 20 mmHg
Increase of Diastolic Blood Pressure (DBP) > 10 mmHg
The patient is African American in stage I primary hypertension without comorbid
disease or drug is responsible for elevating BP.
His blood pressure barely controlled due to issues of compliance and
So its current therapy Not the best choice even if he compliant with his medication.
The Thiazide–type diuretics is first line therapy for this condition and particularly
The SBP is more than 15 mmHg above the goal and the DBP is more than 10
mmHg above the goal,(the goal is 140/90 mmHg) so the patient need for
combination therapy to attain and maintain BP goals, also he needs modification of
his lifestyle regarding to diet style, physical activity and restriction regimen.
64. Drug Related Problems (DRP):
Effectiveness (Needs Different Drug
More effective drug available
A.S 55-year-old-African-American male taking Furosemide 40 mg orally twice
daily, started x5 years for hypertension management but his BP out of the
established range for his specific condition, so he needs more effective drug to
reach the desired range <140/90 mmHg.
65. Drug Related Problems (DRP):
Patient forgets to take
A.S 55-year-old-African-American male with uncontrolled hypertension due to
issues of non-compliance.
He is a manager in high stress job and may forget to take within his busy life.
He need to improve adherence.
In order to this status, he needs fixed-dose combination product
66. Short term goals:
Increase the adherence and compliance of patient
Implementation of life style changes
Involve pharmacotherapy and patient education programe
67. Intermediate term goals:
Achieve desired target BP value (140/90 mmHg).
Long term goals:
Prevent CV risk and complications (Cerebrovascular events , heart
failure , kidney disease)
Reduce hypertension associated morbidity and mortality
Improve patient’s quality life
68. Therapeutic Alternative
Therapeutic Life Changes (TLC)
Thiazide-Type-Diuretics (Hydrochlorothiazide Esidrix 25mg PO Once
daily in the morning)
Angiotensin-Converting Enzyme(ACE) Inhibitors (Captopril Capoten
25mg PO Twice daily)
Calcium Channel Blocker (CCB) (Diltiazm Cardizem 120mg PO Twice
69. Non pharmacotherapy
Life style modification:
Maintain normal body weight( body mass index “BMI” = 18.524.9kg/m2)
Dietary Approach to Stop Hypertension(DASH) is a style of diet
including consume a diet rich in fruits , vegetables, and low fat
dairy products with a reduced content of saturated and total fat.
Reduce daily dietary sodium intake as much as possible, ideally to
=65 mmol/day (1.5g/day sodium, or 3.8g/day sodium chloride)
Regular aerobic physical activity at least 30 minutes/day
70. Pharmacotherapy Intervention
Initiate following drug instead of Furosemide.
Dose Frequency Rout Dosage
50 mg /
Once a daily
71. Monitoring the pharmacotherapy plan
Monitor for signs and symptoms of progressive hypertension –associated
target –organ disease (palpitation, Dizziness, dyspnea, sudden changes in
Routine goal BP values should be attained but the actual BP lowering can
occur at a very gradual pace over a period of several months to avoid
Monitoring BP response should be evaluated 2 to 7 weeks after initiating or
making a change in a therapy then every 6 to 12 months in stable patient.
For thiazide diuretic the response needs to be monitored 4 to 6 weeks later
because it will show better represent steady state BP values.
72. Monitoring the pharmacotherapy plan
Self-measurement of BP or automated BP monitoring can be useful
clinically to establish effective 24-hour control; BP at home needs to be
measured during the early morning hours.
Monitor the BUN/serum creatinine because of Diuretics use, to prevent
any kidney diseases may occur.
Monitor blood magnesium level periodically, because patient is Using
omeprazole together with chlorthalidone, this may cause
73. Follow up Evaluation
Check periodically to make sure that the blood pressure is in the
recommended range. If it is not, the treatment should be adjusted.
Patients with high blood pressure should see their providers at least once
per year and more frequently during medication adjustment phases.
Periodically, at the follow-up visits, the patient should be screened for
any complications may occur like damage to the heart, eyes, brain,
kidney, and peripheral arteries that may be related to high blood
Follow-up visits are a good time to let know about any side effects may
the patient is having from his medication. That may needs suggestions
for coping with side effects or may change the treatment.
74. Patient Education
Encourage the patient on the home BP monitoring to achieve
more adherences, see the prognosis of his disease and how
the therapy is effective.
Lifestyle modification should always be recommended to
provide additional BP lowering.
- Eat less salt.
- Follow the DASH eating plan (Dietary Approaches to Stop
75. Patient Education
Educate the patient on importance of compliance.
- Use reminder calls, text or emails as needed
- Preparing a dosing card containing only the most essential
elements of the patient’s medications including the name of the
pill, image, indication and time for drug taken.
- Give the patient clear instructions about medications
- Ask someone in the family or friends to be medication buddy
to help reminder him about daily dosing and getting
DiPiro, Joseph T. Pharmacotherapy: A Pathophysiologic Approach. Cardiovascular
Disorder "Hypertension“. 8th ed. New York: McGraw-Hill Medical, 2011. 106131.Pages(106-131)
European Society of Hypertension and of the European Society of Cardiology,
ESH-ESC-GUIDELINES FOR THE MANAGEMENT OF HYPERTENSION,2013.Print
Brotman, D. J. "The JNC 7 Hypertension Guidelines." JAMA: The Journal of the American
Medical Association 290.10 (2003): 1313-b-314. Print.
Micromedx phone application
77. Untreated Cigarette smoking
A.S smokes 1 ppd of cigarettes.
As smokes 1 ppd, this is equal to 20 cigarettes per day, so the
patient is nicotine depended because he smokes more than 10
cigarettes per day.
A.S is a 55 years old African-American male,
nicotine dependent smoker who smokes 1 ppd of
cigarettes x10 years.
The patient has Duodenal ulcer , HTN, Anemia
and migraine headache
He should be started on smoke cessation therapy.
81. Drug Related Problem (DRP)
Indication (Needs Additional Drug Therapy)
AS is a70 year old African-American male, nicotine dependent smoker who
smoke 20 cigarettes per day.
Currently, He don’t use medication for this condition and need to start on
smoking cessation drug.
82. Short term goals
83. Long term goals
Reducing the risks for developing smoke
induced diseases (lung cancer, COPD, CHD,
stroke, esophageal cancer, and others).
Improving the patient health in general.
Improve the patient life quality.
Increase in life expectancy and reduce smoking
induced mortality and morbidity.
84. Pharmacotherapy Alternatives
a) Start the patient in a single medication:
1-Nicotine replacement therapy(patch, gum,
inhaler, lozenge ,sublingual tablet)
Ex: (patch)dose: 21 mg/24 hr or15 mg/16 hr ,for
Dose: 1 mg twice per day following a 1 week
titration (risk of cardiovascular events).
85. Pharmacotherapy Alternatives
a) Start the patient in a single medication cont:
The dose of bupropion is 150 mg once per day for the first 3 days and
then increased to 150 mg twice per day. The patient should stop
smoking in the second week of treatment.
75 mg/day for 12 weeks.
( risk of arrhythmia in patients with cardiovascular disease.)
B) Advice patient for Smoking reduction rather
than smoking cessation
Apply the smoke cessation treatment
oAsk – patients about smoking status
oAdvise – patients about the health risks of
tobacco use and to quit
oAssess – patients’ readiness to quit
oAssist – patients that are ready to quit
Arrange – follow up
Cognitive and behavioral coping strategies:
delay, deep breathe, drink water, do something
Offer written information (eg. Quit Pack)
Offer Quit line referral or other assistance
Arrange follow up visit, if appropriate.
88. Pharmacological intervention
Start the patient on nicotine replacement therapy as
21 mg/24 hour.
2- Treatment duration should be more than 8 weeks.
89. Monitoring & Follow up
Ask AS to return to clinic soon after the quit date,
preferably during the first week to assess and
oQuitting cigarette smoking
oThe patient compliance to his medication .
oThe development of any drug adverse effects:
Skin erythema, skin irritation and sleep disturbance
90. Monitoring & Follow up
If withdrawal not controlled, consider combination nicotine
replacement therapy (oral NTR could be added).
If patient needs extra support, Consider a further follow-up
91. Patient Education
Educate the patient how to use nicotine patches. (Applied directly
to the skin once a day, usually at the same time each day. A apply
it to clean hairless aria, With the sticky side touching the skin,
press the patch in place with the palm of your hand for about 10
seconds. Wash your hands with water alone after applying the
patch. If the patch falls off or loosens, replace it with a new one …
Educate the patient about the possible adverse effects of nicotine
patches(skin irritation, sleep disturbance)
Educate the patient about the importance of compliance to his
medication and encourage him to complete his therapy for at least
Encourage the use of support services.
Educate the patient about the importance of the follow-up visits.
Supporting smoking cessation: a guide for health professionals.
2011. [e-book] South Melbourne: The Royal Australian College of
General Practitioners College House. pp. 1-53. Available through:
ng-cessation.pdf [Accessed: 27 Oct 2013].
"Treating Tobacco Use and Dependence: A Quick Reference Guide
for Clinicians." Treating Tobacco Use and Dependence: A Quick
Reference Guide for Clinicians. N.p., n.d. Web. 10 Nov. 2013.