case studies about few diseases and management.

1. Case study
Name : Dr Anjum Ahamadi
Pharm D
Sultan - ul - uloom college of pharmacy
Guided by : Dr S P Nayak , assistant professor , SUCP
hyd.

2. Case -1
• Chief complains: A 79-year-old man presented to hospital with a 3-day
history of increasing confusion and collapse.
• Medical history: History of chronic lumbosacral pain, treated with oxycodone
10 mg twice daily and amitriptyline 75 mg daily.
• Medication history : Tab Oxycodone 10mg BD ,Tab Amitriptylin 75mg HS ,
Tab Tramadol 100mg BD ,
• History of present illness: Five days before hospital admission he had been
prescribed tramadol 100 mg four times daily for worsening sciatica. On
admission the patient had a Glasgow Coma Scale of 11 and he was delirious
and hallucinating. There were no focal neurological signs. Over the next 2 days
he became increasingly unwell, confused and sweaty with pyrexia and
muscular rigidity.
• Laboratory ivestigations: Biochemical tests showed a metabolic acidosis
(base deficit of 10.7) and an elevated creatine kinase level of 380 IU/L.
• Infection assessment : There was no evidence of infection.
• Diagnosis : A diagnosis of probable serotonin syndrome was made.

3. Questions :
1. What is serotonin syndrome and what drugs are
most commonly
associated with it?
2. How is serotonin syndrome managed?

4. Answers :
1. Serotonin syndrome is often described as a clinical triad of mental
status changes, autonomic hyperactivity and neuromuscular
abnormalities. However, not all the symptoms are consistently
present in all patients with this disorder.
Symptoms: Range from diarrhoea and tremor in mild cases to
delirium, neuromuscular rigidity, rhabdomyolysis and hyperthermia in
life-threatening cases
Clinical manifestation: Disturbance of electrolytes, transaminases
and creatine kinase may occur. Clonus is the most important finding in
establishing the diagnosis of the serotonin
syndrome.

5. Differential diagnosis : Neuroleptic malignant syndrome, sepsis,
hepatic encephalopathy, heat stroke, delirium tremens and
anticholinergic reactions. Serotonin
syndrome may not be recognised in some cases because of its
protean manifestations.
Associsted drugs : A wide range of drugs and drug
combinations has been associated with the serotonin syndrome,
including MAOIs, tricyclic antidepressants, SSRIs, opioids, linezolid
and 5HT1 - agonists. Tramadol is an atypical opioid analgesic with
partial μ antagonism and central reuptake inhibition of serotonin
(5HT) and noradrenaline. At high doses it may also induce
serotonin release. Tramadol is reported as causing serotonin
syndrome alone (in a few case reports) and in combination with
SSRIs, venlafaxine and atypical antipsychotics.

6. 2. Management : Management of the serotonin syndrome
involves removal of the precipitating drugs and supportive
care. Many cases typically resolve within 24 h after
serotonergic drugs are stopped but symptoms may persist in
patients taking medicines with long half-lives or active
metabolites.
The 5HT2A-antagonist cyproheptadine and atypical
antipsychotic agents with 5HT2A-antagonist activity, such as
olanzapine, have been used to treat serotonin syndrome,
although their efficacy has not been conclusively established.

7. Case - 2
• Over view : A 42-year-old woman is on long-term treatment with
azathioprine 100 mg daily and bendroflumethiazide 2.5 mg daily. The
latter was discontinued after an episode of gout but she had three
further episodes over the following year. Her doctor considers
prescribing allopurinol as prophylaxis.
• Medication history : Azathioprine 100mg daily, Bendroflumethiazide
2.5 mg daily.

8. Questions :
Is this likely to cause a clinically significant interaction?
Answer:
Azathioprine is metabolised in the liver to mercaptopurine and then
converted to an inactive metabolite by the enzyme xanthine oxidase.
Allopurinol is an inhibitor of xanthine oxidase and will lead to the
accumulation of mercaptopurine which can cause bone marrow
suppression and haematological abnormalities such as neutropenia
and thrombocytopenia.
The dose of azathioprine should be reduced by at least 50% and
close haematological monitoring is required if allopurinol is used
concomitantly.

9. Case – 3
• Over view : A 68-year-old woman is on long-term treatment
with lansoprazole for gastro-oesophageal reflux disease and
warfarin for atrial fibrillation. She is admitted with haematemesis.
On direct questioning, she also revealed that she takes various
herbal medicines which contain chamomile, horse chestnut,
garlic, feverfew, ginseng and St John's wort.
• Medication history : Lansoprozole, Warfarin, Herbal
medication containing: chamomile, horse chestnut, garlic,
feverfew, ginseng and St John's wort.

10. Question :
What drug–herb interactions may have contributed to her presentation to
hospital?
Answer:
Garlic, feverfew and ginseng all inhibit platelet aggregation by
inhibiting the production or release of prostaglandins and
thromboxanes.
In addition, chamomile and horse chestnut contain
coumarin-like constituents which can potentiate the anticoagulant
effect of warfarin.
St John's wort is a potent enzyme inducer and may induce the
metabolism of lansoprazole via CYP2C19, thereby
reducing the effectiveness of lansoprazole.
Although the effects of herbs individually may be small, their
combined effects may lead to serious complications.

11. Thank you