1. S
Carrie Recker
University of Pi.sburgh
School of Pharmacy
PharmD Candidate, Class of 2016

2. S
SubjecAve/ObjecAve

3. RH
S 61 year old
S Male
S 100% Giant Eagle Pharmacy Patient

4. Allergies
S Penicillin
S Beta-Blockers
S ACE Inhibitors
S Aspirin

5. Chronic Conditions
S Acid Reflux
S Asthma
S Seasonal Allergies
S Diabetes
S Gout
S High Cholesterol/Dyslipidemia
S Chronic BronchiAs

6. Past Surgical History
S Gastric Bypass- 2011

7. Asthma
Montelukast 10 mg
1 tab by mouth
every evening
*Pt not sure of
indicaAon
Ventolin HFA 108
mcg/act
2 puffs four Ames a
day as needed for
wheezing
*Pt uses about
once a week
Symbicort®
160-4.5 mcg/act
2 puffs twice a day
*Using unAl runs
out and will then
start Flovent
Flovent®
HFA 220 mcg/act
2 puffs twice a day

8. Congestion
Ipratroprium-
Albuterol 0.5-2.5
mg/3ml
1 vial via nebulizer
four Ames a day
*Uses as needed
every four hours

9. Diabetes Mellitus, Type II
Novolog®
FlexPen 100 unit/ml
Inject
subcutaneously as
directed per sliding
scale
*Was using more due
to recently
completed
prednisone course
increasing blood
glucose
Lantus®
SoloStar 100 unit/ml
inject 50 units
subcutaneously
every morning and at
bedAme
*Only using 55 units
in the AM per MD’s
orders due to blood
sugar being too low
in the morning

10. High Blood Pressure
Losartan 100 mg
1 tab by mouth
every day
Hydralazine 25 mg
1 tab by mouth
three Ames a day
*Blood pressure
was ge_ng too
low, taking twice a
day now
DilAazem ER 240
mg
1 tab by mouth
every day
*Taking two 120
mg tabs unAl he
runs out
Spironolactone 50
mg
1 tab by mouth
twice a day

11. Fluid Retention
Furosemide 40 mg
1 tab by mouth
twice a day
High Cholesterol
AtorvastaAn 10 mg
1 tab by mouth
every day

12. Gout
Colcrys®
0.6
1 tab by mouth two
Ames a day unAl
pain is relieved or
unAl nausea/
diarrhea starts
*Takes as needed
Acid Reflux
Omeprazole 20 mg
1 cap by mouth
twice daily

13. Vitamin Supplement
Cyanocobalamin
1000 mcg/ml
Inject 1 ml
monthly as
directed
*Due to gastric
bypass surgery
BronchiAs
Mucinex®
12 hour 200 mg
1 tab by mouth
every 12 hours

14. S
Plan

15. Drug Therapy Problems
1. Hyperglycemia
2. Orthostatic Hypotension
3. Antiplatelet Therapy
4. Immunizations

16. 1. Hyperglycemia
S Pt reports blood glucose of 400-500 mg/dL while on prednisone
1. Increase blood glucose monitoring to 6-8
Ames/day to get a clearer picture of blood
glucose levels throughout the day
2. ConAnue to adjust NovoLog® meal-Ame
doses per sliding scale
3. Consider adding back the Lantus® evening
dose at 0.2 units/kg and adding 4 units every
3 days if AM reading >130 mg/dL

17. 2. Orthostatic Hypotention
S PaAent reports an improvement in this, but sAll occurring with
less severity
1. ConAnue to check blood pressure daily
S Check while si_ng and then while standing
2. Consider removing some blood pressure agents if blood
pressure readings are stable while si_ng
S Ex: Decreasing hydralazine to once a day or completely
removing if necessary

18. 3. Antiplatelet Therapy
S May benefit paAent in primary
prevenAon of cardiovascular morbidity
(MI, stroke)
1. Determine 10-year CVD risk (> 10%)
2. Consider iniAaAon of clopidogrel 75 mg
daily

19. 4. Immunizations
S Zostavax
S Indicated in all paAents >/= 60 years old
S 0.65 ml subcutaneously
S No readministraAon required
S Prevnar 13
S Previously vaccinated with PPSV23: 0.5 ml
intramuscularly at least one year aler
receiving PPSV23

20. S
Discussion

21. Gastric Bypass
S Roux-en-Y gastric bypass
S Creates a small stomach pouch and
connects it to the small intestine
S Increases feeling of fullness after
consumer less food à decreases
caloric intake

22. Gastric Bypass
UpToDate

23. Gastric Bypass
S MedicaAon ConsideraAons
S Avoid bisphosphonates and NSAIDs (Aspirin)- increase risk
of ulceraAon
S Some medicaAons may have decreased absorpAon
S Enalapril, ketoconazole, lamotrigine, memormin, metoprolol tartrate,
niacin, olanzapine, queAapine, ramipril, zolpidem
S Immediate release formulaAons should be used when
possible- ER/DR forms are not completely absorbed
S AlternaAve dosage forms- *liquid
S Gastric pH is typically increased

24. Gastric Bypass
S Nutrient ConsideraAons
S Deficiencies in fat soluble vitamins
(A,D,E,K) and calcium
S Increased risk of developing anemia
due to decrease in iron, folate, B12
S Indefinite use of a mulAvitamin and
calcium (citrate) supplement

25. References
1. Lantus package insert. Bridgewater, NJ: Sanofi; 2015 Feb.
2. Cefalu WT, Bakris G, Blonde L, et al. Standards of medical care in diabetes-2015. J Clinic
Appl Res Edu. 2015;38(supp 1):S1-S94.
3. Zostavax package insert. Whitehouse StaAon, NJ: Merck; 2006.
4. Prevnar 13 package insert. Philadelphia, PA: Pfizer; 2010.
5. UpToDate. Bariatric surgical operaAons for the management of severe obesity:
descripAons. h.p://www.uptodate.com.pi..idm.oclc.org/contents/bariatric-surgical-
operaAons-for-the-management-of-severe-obesity-descripAons?
source=search_result&search=gastric+bypass&selectedTitle=2~107 (accessed June 9,
2015).