Case 4 Pre-Lab Assignment_Stroke

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Texas A&M University *

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714

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Apr 3, 2024

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Phar 714 Rounds I Lab Week 12: Case 4-Stroke Learning Objectives Given a patient case identify drug therapy problems Practice collecting, assessing and documenting drug therapy problems Instructions: Complete IESC table for the following medications. Specific indications for this patient have been provided. Simvastatin Chlorthalidone
Indication : List the reasons the patient takes each medications? If you can determine why a patient was prescribed a medication, you will be able to determine whether therapy is necessary or unnecessary depending on different patient factors. Hint: Check “Labeled and non-labeled” indications in Lexi Comp Drug Name What is the indication based on the patients medical history? If undetermined, what are possible indications for the drug? Simvastatin Dyslipidemia Chlorthalidone Hypertension *Add more rows as needed EFFICACY: Each drug has different “efficacy” parameters. Some can be determined by objective lab measurements in a patients chart (blood pressure, heart rate, temperature, blood sugar, lab values, etc). Think about what objective measure you would look at to determine if the drug is working for the patient. Note that not all drugs will have a clear “efficacy” parameter that you can list and gather from the drug information. Desired pharmacological action resulting in the somewhat predictable benefit of a medication in a patient population with a specific disease or illness. Efficacy is used to describe benefits to a population Hint: Check “Monitoring Parameters” in Lexi-Comp Drug Patient is on What parameters would you need to evaluate to determine if the drug is effective? Simvastatin Lipid panel (total cholesterol<200, HDL>40, LDL<100, triglycerides<150) Chlorthalidone Monitor Blood Pressure<130/80 *Add more rows as needed Safety: Each drug has different “safety” parameters. Think of safety as “what are the side effects of these drugs” and what laboratory values or patient history information can help me determine if there are safety issues with the drug. Learning a drugs safety parameters will help you in determining if a drug is being used safely for a patient What side effects are you most concerned with in each drug. Hint Lexi-comp: Adverse Effects (Significant Considerations) and/or monitoring parameters Safety issues to consider: Drug-Drug Interactions, Drug-Disease Interactions, Renal function (adjustments), maximum dosing for each drug, dosing interval, side effects, etc.
Drug Patient is on For each drug, determine if there are common side effects or monitoring parameters you would need to evaluate to determine if the drug is being used safely Simvastatin Measure for increase in hepatic transaminase levels and hepatotoxicity. Measure for elevations in creatine kinase(CK) and muscle symptoms related to several muscle related effects such as myalgia   (muscle symptoms without significant creatine kinase [CK] elevations) , myopathy(unexplained muscle pain or weakness accompanied by a CK concentration >10 times the ULN), and rhabdomyolysis (CK >40 times the ULN often with acute renal failure secondary to myoglobinuria). DDI: CYP3A4 inhibitors (increase serum concentration) DFI: grapefruit juice Max dose: Simvastatin 80 mg/day is not recommended due to increased risk of myopathy. If patient is unable to achieve low-density lipoprotein cholesterol (LDL-C) goal with simvastatin 40 mg/day, switch to a high- intensity statin. Chlorthalidone Measure fluids ins and outs, serum electrolytes (hypokalemia, hypomagnesemia, hypercalcemia, and hyponatremia) and kidney function (works in the kidney) Chlorthalidone may cause hyperuricemia and precipitate gout or gouty arthritis. Sulfa derivatives such as chlorthalidone may cause acute transient myopia and acute angle-closure glaucoma   which is generally reversible. Max dose 25mg/day Altered kidney function: CrCl ≥10 mL/minute: No dosage adjustment necessary. The diuretic effect is diminished with CrCl <30 mL/minute, but small, short-term studies suggest antihypertensive effect may be preserved. Switching to a loop diuretic may be considered if BP is no longer controlled or if management of fluid overload is required. Alternatively, thiazides may augment diuresis when combined with a loop diuretic in patients unresponsive to monotherapy; closer monitoring of electrolytes is necessary when utilizing this approach. CrCl <10 mL/minute: Use not recommended due to lack of efficacy Beers Criteria: Diuretics are identified in the Beers Criteria as potentially inappropriate medications to be used with caution in patients 65 years and older because of the potential to cause or exacerbate syndrome of inappropriate antidiuretic hormone secretion (SIADH) or hyponatremia; monitor sodium concentration closely when initiating or adjusting the dose in older adults Sulfonamide allergy DDIs-NSAIDS, quinidine, ACE inhibitors, antidiabetic agents, bile acid sequestrants, SSRIs, antihypertensive agents *Add more rows as needed
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Convenience/Adherence: Before we make or recommend changes to a patient’s drug therapy, we have to ensure they are adherent to the medications a doctor has previously prescribed. Is the dosing interval consistent with how the drug should be taken? Was the drug being taken the way intended? Onset of Action (when would you expect the drug to take effect) Duration of action (how long would you expect the medication to work) Target Dosing: What is the target dose for the indication? Max dose for indication? Drug Patient is on For each drug, determine the proper dosing interval for each. Simvastatin Simvastatin 20 to 40 mg/day is considered a moderate-intensity statin (generally reduces LDL-C by ~30% to 49%). If LDL-C must be lowered ≥50%, select a high-intensity statin (atorvastatin or rosuvastatin). Assess response ~1 to 3 months after therapy initiation or dose adjustment and every 3 to 12 months thereafter. Onset of action: >3 days Chlorthalidone Usual dosage range: 12.5 to 25 mg once daily evaluate response after ~2 to 4 weeks and titrate dose, as needed; doses higher than 25 mg/day are not recommended due to greater adverse effects with minimal added antihypertensive benefit; if additional blood pressure control is needed, consider combination therapy. Patients with severe asymptomatic hypertension and no signs of acute end organ damage should be evaluated for medication titration within 1 week  Onset of Action: ~2.6 hours Duration of action: single dose- 24 to 48 hours and long-term dosing-48 to 72 hours