for jenn and alicia

1. Jennifer Kelleher
Alicia Parlon
Nasir Qadri

2. “I don’t want to worry about car trips longer
than 10 minutes!”

3.  FS is a 93 year old man presenting at an MTM
session. FS was started on immediate release
oxybutynin 5 mg PO daily and 1 tablet 30
minutes prior to leaving the house 4 years ago to
treat urinary incontinence secondary to BPH.
Recently he has been taking ½ tablet PO at
bedtime. He is currently being treated with
tamsulosin 0.8 mg PO daily and finasteride 5 mg
PO daily for BPH symptoms with some
improvement. FS has an extensive medication list
and multiple disease states. The patient has been
struggling the last few years with apprehension
and worry leaving the house not knowing if a
bathroom will be close by.

4.  HTN
 AFib
 Depression
 Hypercholesterolemia
 Urinary retention
 BPH
 Anxiety
 Arthritis
 Glaucoma
 Frequent heart burn
 Insomnia
 Obstructive sleep apnea
 Eye problems
 Pre-diabetic

5.  Appendectomy
 Cholecystectomy
 Edentulous, full dentures
 Angioplasty lower left leg
 Bilateral cataract surgery
 Partial colectomy - diverticulitis

6.  Only child
 Mother deceased age 34 Hodgkin’s
Lymphoma 1937, treated for a heart
condition for 2 years prior to death
 Father deceased age 49 stroke or MI, can’t
recall which but he had atherosclerosis

7.  Former smoker, cigarettes, pipes and cigars,
reports quitting 40-50 years ago
 Drinks 1-2 1.5% abv beers at supper
 Former US Marine
 Metallurgist, still working 1 day a week
 Widower 2008
 2 children (1 daughter, deceased and one son
who currently lives with him)

8.  NKDA
 Cucumbers (rash)

9.  warfarin 2 mg PO daily (2000)
 amlodipine 5 mg PO daily with food (2000)
 potassium chloride ER 10 mEq 2 tabs PO daily (1130)
 paroxetine 40 mg tablet PO daily (0630)
 finasteride 5 mg PO daily (1130)
 simvastatin 10 mg PO daily (2000)
 oxybutynin 5 mg ½ tab PO daily (2000)
 captopril 25 mg PO TID 1 hr before meals avoid antacids (0600,
1030, 1900)
 lorazepam 0.5 mg PO 1-4 x daily PRN
 latanoprost 0.005% sol 1 gtt OU HS (2200)
 furosemide 20 mg PO QAM (0630)
 acetaminophen 325 mg 2 tabs PO q4h PRN pain
 Tylenol PM® 500 mg (50mg diphenhydramine) 2 caplets PO HS

10.  tamsulosin 0.4 mg 2 caps PO daily (2000)
 erythromycin 5mg/gm ophthalmic ointment Apply a small
amount to lids BID PRN
 vitamin B1 100 mg tab PO daily (0630)
 vitamin B12 1,000 mg tab PO daily (1130)
 vitamin C 500mg/D3 1,000 IU 1 tab PO daily (0630)
 Prostate Health Essentials® 300 mg saw palmetto 1 tab PO daily
(2000)
 Preservision® 1 cap PO daily (0630)
 vitamin C with Rose Hips 500 mg 1 tab PO daily (1130)
 omega 3 Fish Oil 1,250 mg (EPA 500 mg /DHA 650 mg) 1 cap PO
BID (0630, 1130)
 acidophilus 1 cap PO daily (1130)
 vitamin D3 2,000 IU 1 cap PO daily (0630)
 Metamucil powder 1 tsp. PO mixed in 8 oz of water or juice BID
(0630, 2000)

11.  ROS: not available
 VS: WNL per viewing encounter notes from
primary care physician from 5/14/14 office
visit. Was unable to obtain this information
again since interviewing the patient.
 We would like to know all of his vital signs.

12.  Influenza 11/08/13
 Influenza A (H1N1) Monoval Vac IM
Suspension 01/23/10
 Pneumococcal 11/06/06, 08/10/12
 Td/DT 09/07/05
 Tdap 02/28/14
 Zoster 03/25/09

13.  “I don’t want to worry about car trips longer than
10 minutes!”
 Initially prescribed 5 mg oxybutynin daily and ½
tab 30 minutes prior to leaving the house on
longer trips
 Patient currently takes 2.5 mg PO daily HS
 Treated for BPH with tamsulosin 0.8 mg PO daily
and finasteride 5 mg PO daily
 FS feel “lousy” in the morning and complains of
dry mouth and other anticholinergic side-effects
 FS “feels lethargic in the morning and takes all
morning to get going for the last 3-4 years”

14.  No significant objective information
regarding specific patient complaint (patient
is apprehensive about going out in public and
having an accident)

15. FS is a 93 year old man generally well-controlled on his
current medication regimen. His chief complaint is a
significant annoyance affecting his quality-of-life. First line
therapy for urinary incontinence is lifestyle modification
such as fluid-diet management and second-line therapies
include anti-muscarinic medications and β3 adrenergic
antagonists.1 It is recommended that ER formulations are
used over IR formulations, if the drug is anticholinergic in
nature. Due to FS’s increasing age, and anticholinergic
symptoms especially when he wakes up, the following
should be addressed with the patient and his provider: the
time of day he takes his medication, the medication
formulation and MOA itself and life-style modifications he
can make to improve his symptoms. To ease the patient’s
concerns about having an accident when outside of his
pharmacy would like to recommend the patient begin
mirabegron 25 PO daily and D/C his oxybutynin.

16.  Goals of therapy
◦ Teach the patient life-style changes like bladder
training, bladder control strategies, and fluid
management
◦ Improve symptoms of urinary incontinence
◦ Improve the patient’s quality-of-life
 Treatment Plan
◦ Switch from and IR to an ER formulation of
oxybutynin if mirabegron not an option due to cost
◦ Recommend Myrbetriq® (mirabegron) 25 mg PO
daily a β3 adrenergic antagonist with no known
anticholinergic side effects, as an alternative to
oxybutynin

17.  Monitoring parameters
◦ Efficacy and safety
 Recommend FS use a diary to record how many times a day he uses the
rest room
 See if drying symptoms improve with an ER formulation or with
mirabegron
◦ Plan for follow-up
 Follow up in 2 weeks with PCP to see if symptoms have improved
 Patient education
◦ Take your medication as prescribed and do not miss doses
◦ Stay hydrated but be conscious if your water pill (furosemide) is
not working well or if you have increasing edema in your legs
◦ Use the rest room often at scheduled intervals even if you do not
feel as though you need to urinate
◦ Do not take other anticholinergic drug like Tylenol PM® as they
will exacerbate your dry mouth and feelings of fogginess because
they contain the ingredient diphenhydramine, also known as
Benadryl®

18. • Chronic urinary incontinence related to enlarged
prostate as evident by urgency and frequency.
• Anxiety related to embarrassment as evidence by
increased apprehension
• Acute pain related to skin irritation as evidence by
restlessness

19. • Effect on lifestyle and self esteem
• Effect on skin integrity
• Increased risk for infection
• Increase risk for skin breakdown
• Increased anxiety
• Decreased socialization/increased isolation

20. • Schedule voiding times to reduce incontinence
• Restrict fluids 2 to 3 hours before bedtime
• Limit caffeine and alcohol intake (diuretics)
• Bring extra clothes on trips
• Use of adult absorbing pads

21.  We all had a diverse discussion from varied
perspectives placing the needs of the patient first in
all instances
 All group members interviewed our patient by phone,
patient and FS was grateful for the opportunity and
initial feedback
 Our group worked well together – everyone was
professional, courteous and respectful
 Optimal medication management therapy and non-
pharmacological strategies were discussed and
reviewed effectively between the two health
professions
 With teamwork, communication and collaboration
between the two health professions we were able to
recommend a safe and effective patient-oriented plan

22.  Gormley EA, Lightner DJ, Burgio KL, et al.
American Urological Association. Diagnosis
and treatment of overactive bladder (non-
neurogenic) in adults: AUA/SUFU guideline.
Updated June 11, 2013. Accessed May 29,
2014.