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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 300mg half tab/day
Simvastatin 20mg 1h.s
Heparin 5000 I.V.or I.U. q.6hr.
Cardilol 6.25mg 1 tab. per oral half bid.
Omeprazole 20mg 1 capsule per oral .o.d
Spironolactone 40mg 1 tab per oral once daily
Captopril 25mg ¼ tab per oral t.i.d
Question :
2. Design a pharmaceutical care plan.
ANSWER
PHARMACEUTICAL CARE PLAN
DRUGS:
Drugs Dose given Interaction Recommended
Spironolactone 40 mg/ day Dose is very high.
Decrease/lower the
dose
25 mg/ day
INTERACTIONS:
Interacting
Drug
Severity Effect Monitoring and management
Omeprazole
and aspirin
Severe Antagonist Omeprazole may be stopped for
some while. And then continued
if necessary under strict
monitoring.
Captopril and
aspirin
Moderate Aspirin in a
blood thinner.
Captopril is an
ACE inhibitor
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.
3. 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 137mmol/L
K 8.7mmol/L
Cl 103mmol/L
CO2 8mmol/L
Urea 78.9mmol
Creatinine 650mic.mol/L
Urine electrolyte:
Na 69mmol/L
Urea 150mmol/L
Question # 01
Comment on patient’s 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 patient’s 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.
4. 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 GFR criteria UO criteria
Failure Increase creatinine three
times or GFR decreases
>75%
UO<0.3 ml/kg/hr times 24
hours or anuria times 12
hours.
5. 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 ІІ, 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.
6. 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.
7. 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 --------------?
Β-blockers (Atenolol) inhibit nor-epinephrine release peripherally. In the
vascular system, β-receptors blockade opposes β2 mediated vasodilation. Blocking β2 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.
8. 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.
9. In the present therapy, the following interactions are there:
Drug Interacting
Drug
Severity
level
Effects Mechanism Management
Lisinopril Furosemide 3 Effect of
loading dose
maybe
decreased.
Possibly,
inhibition of
angiotensin 2
production
by ACE-І
Monitor the
patient
carefully
Furosemide Aspirin 5 Loading
dose effect
maybe
decreased
Unknown No
management
necessary
Lisinopril Aspirin 2 Hypotension
and
vasodilation
Inhibition of
prostaglandi
n synthesis
Monitor the
patient
carefully
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.
10. 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
Simvastatin 02mg/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 patient’s 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.
11. 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 (β-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 β-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 α-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.
12. 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 75mg P.0.0.d
Rosuvastalin 10mg P.0
Lisinopril 5mg P.0 0.d
Spironolactone 40mg P.0 b.i.d
Furosemide 40mg 1.v b.i.d.
Neo-k 500mg P.0 t.i.d
Ranitidine 150 mg i.v o.d
Carvedilol p.o ½ b.i.d
Aspirin 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.
13. 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 Interacting
Drug
Effects Significance
Level
Mechanism
Aspirin Clopidogrel Risk of life
threatening
bleeding in
high risk
patient with
transient
ischemia or
stroke.
1 Unknown
Aspirin Furosemide Diuretic effect
of loop
diuretics can
be impaired if
5 Unknown
14. hepatic
disease is
present.
Aspirin Lisinopril Hypotension
and
vasodilatory
effect of ACE
inhibitors can
be decreased
2 Inhibition of
prostaglandin
synthesis.
Aspirin Spironolacton
e
Salicylate
block
spironolacton
e induced
natriuresis.
3 Aspirin block
renal tubular
secretion of
unconjugated
metabolite of
spironolactone
Aspirin Carvedilol BP lowering
effect of
lisinopril is
attenuated
with Aspirin
2 Aspirin block
PG synthesis
involved in
anti-
hypertensive
action of
Carvedilol.
15. 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 β-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.
16. 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-І:
An asthmatic should not receive a β-blocker without careful consideration and
supervision because of the risk of bronchoconstriction with Aspirin.
PATIENT-ІІ:
A previous infarct may have been treated with streptokinase and a repeat dose
should be avoided. Tissue plasminogen activator should be used instead.
PATIENT-ІІІ:
Thrombolytics are contraindicated if there is a serious risk of bleeding. A patient
with Rheumatoid Arthritis may be receiving Non-Steroidal 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.
17. 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 anti-inflammatory 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.
18. 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 50µg 1 puff twice daily
Beclomethasone inhaler 250µg 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 β2 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.
19. 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.
20. 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 95/65mmHg
HR 60 beats/min.
Aspirin 75mg PO OD
Clopidogrel 75mg PO OD
Atenolol 50mg 1 tab PO B.I.D
Simvastatin 10mg 1 tab P.O H.S
Human insulin 70/30 20 units in morning and 30 units at night
Lisinopril 1 tab PO B.I.D
Lab investigation
Serum sodium 141 mmol/l
Serum Potassium 4.2 mmol/l
Serum Creatinine 121µmol/l
LDL 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.
21. 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 Interacting
Drugs
Significance
Level
Effects Mechanism Management
Aspirin Atenolol 2 (moderate) BP lowering
effect of β
blockers are
attenuated by
Aspirin.
Salicylate may
inhibit
biosynthesis of
PG involved in
antihypertensiv
e activity of
Atenolol.
Monitor BP
Changing to non-
Salicylate
antiplatelet
agent or
alternate
therapy.
Aspirin Clopidogrel 1 (major) Risk of life
threatening
bleeding
(intracranial
and GIT
hemorrhage)
may be
increase in
patient with
transient
ischemic
attack or
stroke.
Unknown Avoid Aspirin use
in high risk
patient with
recent ischemic
stroke or
transient
ischemic attack
who is receiving
clopidogrel.
Aspirin Lisinopril 2 (moderate) The
hypotensive
and
vasodilatory
effect of
lisinopril may
be decreased.
Inhibition of
prostaglandin
synthesis.
Monitor BP and
hemodynamic
parameters.
In case of ADR
reduce dose of
aspirin to
<100mg/day or
give alternative
or angiotensin
receptor blocker.
22. Aspirin Insulin 2 (moderate) Serum glucose
lowering
action of
insulin may be
potentiated.
Basal insulin
conc. is
increased +
acute insulin
response to
glucose load is
enhanced.
Monitor blood
glucose conc.
and tailor the
insulin regimen
as needed
clopidogrel simvastatin 4 (moderate) Certain HMG-
CoA reductase
may interfere
with
clopidogrel
platelets
inhibition.
By competing
for the same
C4P 3A4
isoform, certain
HMG-CoA
inhibitors may
inhibit
metabolic
conversion of
pro drug
clopidogrel to
active form.
Based on
available data no
special
precautions are
needed.
3) What important issues must be discussed with patient?
Drug Problem Comment
Aspirin Associated with renal
when given with ACE
inhibitors (Lisinopril)
Warn patient to use
Paracetamol as their
analgesic of choice.
Aspirin May cause GI bleeding Advise on taking with
food and water
Beta blockers These often are
considered unpleasant to
taste.
Encourage patient to use
regularly.
• 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 Dose Frequency Route
23. Simvastatin It is powerful
lipid lowering
drug that can
decrease LDL.
It reduces the
risk of
cardiovascular
events in MI.
Start at 20mg
Can be 5mgg
-80mg
Once in a day
at bed time
Oral
Clopidogrel Used to inhibit
blood clots in
CAD (non-
steroid
myocardial
infarction)
75mg orally Oral
Aspirin Antiplatelet
activity in CVS
disease.
Woman aged
55 – 79 years
low dose
75mg or
81mg.
Once daily Oral
Lisinopril Treatment of
CHF, heart
attack, HTN,
prevents renal
and retinal
complications
in diabetes.
2.5mg to
20mgstandard
5mg
Once daily oral
Atenolol Treat and
reduce risk of
heart
complications
after MI.
Normal RFs;
25-50mg
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 don’t have
24. 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.
