Case Studies respiratory track infection
SCENARIO 1:
25 year old lady presented to you with complain of upper respiratory track infection. Past medical history revealed that she was on oral contraceptive.
Rx
Tab. Citrizine dihydrochloride 5mg
(1 per oral. once a day)
Tab. Acetaminophen
(SOS)
Tab. Erythromycin 250mg
(1 per oral. 12 hours. 7 days)
INTERACTIONS:
i) Erythromycin decreases contraceptive effects of orally administered contraceptive by inhibiting the hydrolysis of contraceptive-conjugate in gut by killing normal flora of gut responsible for conjugate hydrolysis.
ii) Acetaminophen increases gastric irritation by inhibiting synthesis of prostaglandin responsible for the protection of gastric mucosa. Increased gastric acidity may result in acidic catalysis of erythromycin. Hence dose adjustment of erythromycin is required for desired therapeutic effect.
iii) Citrizine dihydrochloride is H1 antagonist may decrease gastric motility and decrease bioavailability of co-administered drug.
SCENARIO 2:
49 year old male is a patient of hypertension and is on following medication.
Rx
Tab. Carvedilol 2.5mg
(1 per oral once a day)
Tab. Terazosin 1mg
(1 per oral. O.N)
Tab. Simvastatin 10mg
(1 per oral. S.H)
Tab. Carbamezepine 200mg
(1/2 tablet per oral. p.d.s)
Tab. Aspirin 75mg
(1 per oral once a day)
Tab. Clopidogrel 75mg
(1 per oral once a day)
i) Find out interactions?
a) Carvedilol (beta1-antagonist) and Terazosin (alpha1- antagonist) synergized the cardio-vascular depressive effects leading to orthostatic hypertension.
b) Aspirin and Clopidogrel synergistically enhances gastric irritation effects.
c) Carbamezepine increases Aspirin metabolism by induction of hepatic metabolism enzymes and also act as displacer of aspirin from bounded plasma proteins.
ii) What does the use of Terazosin suggest?
a) Terazosin reduces peripheral resistance by blocking alpha1 adrenoreceptor in vascular smooth muscles hence increasing pulling of blood in venous bed, reducing cardiac pre and afterload and cardiac output to some extent. All events result in reducing blood pressure.
b) Terazosin also increases urinary outflow, thus used in patient with impaired urinary outflow (prostrate hypertrophy).
iii) What is use of Carbamezepine here?
Carbamezepine antagonizes CNS related side effects of Carvedilol which may be headache, confusion, schizophrenia and anxiety.
iv) Common use of statin? Which is the best statin give reason?
Statin is used to reduce the risk of coronary ischemia by inhibiting atherosclerosis by inhibiting intrinsic cholesterol synthesis. Best statin is atrovastatin because of its long lasting therapeutic effects.
v) Status of patient?
Hypertension, ischemic heart disease, obstruction in urine, mental disturbance
SCENARIO 3:
A 60 year old woman presented to you with prescription at your pharmacy with the complaint of pharyngitis, she was prescribed.
Tab. Erythromycin 250mg
(Thrice a day)
Post medication history of that patient revealed thatshe was on:
Tab. Atenolol 50mg
(Per day)
Tab. Simvastatin 20mg
i) Are you happy with antibiotic use?
No, because for such a minor indication there is no need of giving antibiotic i.e Erythromycin with such a high dose.
Also concomitant use of macrolide (erythromycin) with statin is associated with high risk of myopathy(statin induced) as macrolide is a potent Cyt P450 inhibitor and statins a re metabolized by this system.
ii) Command the use of statin?
Statin reduces the risk of deposition of fats (cholesterol) in vessels. Thus helps in keeping normal blood supply to heart.
iii) Command use of atenolol?
Atenolol is beta1-selective antagonist. It decreases cardiac activity and cardiac oxygen demand.
iv) Comment on the use of Atenolol and Simvastatin?
Post medical history indicatesthat patient had a problem of hypertension, therefore, Atenolol is used to control the B.P. Simvastatin is given to prevent the formation of clot, so to minimize the chance of myocardial infarction.
v) How would you counsel the patient regarding the use of Simvastatin?
Patient should take cholesterol restricted diet.
Patient should the regular exercise.
vi) what is the best time to take the statins? give the reason?
Statins should be taken at night. It off-sets a nocturnal increase in cholesterol synthesis.
SCENARIO 4:
65 year old male history of congestive heart failure and diabetes mellitus.
Rx
Tab. Diltiazem 90mg SR
(1 daily)
Tab. Lisinopril 5mg
(1 daily)
Tab. Atenolol 50mg
(1 daily)
Tab. Aspirin 75mg
(1 daily)
Tab. Simvastatin 10 mg
(1 daily)
Human insulin regular
(20 units’ morning and evening)
Tab. Metformin 500mg
(Thrice a day)
i) Find out interactions?
a) Beta blocker (atenolol) and insulin: Enhanced hypoglycemic response. Beta blocker inhibits glucose recovery from hypoglycemia, inhibition of symptoms of hypoglycemia (except sweating), increased blood pressure during hypoglycemia.
b) Diltiazem, atenolol and simvastatin leads to hypoglycemia.
c) Insulin and metformin interacts pharmacologically and leads to hypoglycemia.
ii) Timing of each medicine?
a) Insulin morning and evening during just or before meal.
b) Diltiazem and lisinopril after breakfast (9 am)
c) Metformin before lunch (1 pm)
d) Aspirin, simvastatin after dinner ( 9 pm)
e) Atenolol just before sleep.
iii) Rationale of each drug use?
a) Diltiazem and atenolol used to decrease cardiac oxygen demand.
b) Aspirin and simvastatin used to maintain proper blood supply to heart.
c) Lisinopril is used to excrete excessive water.
d) Insulin and metformin are used as anti-diabetic.
SCENARIO 5:
Rx
Tab. Bendroflumethiazide 2.5mg
(1 daily)
Tab. Frusimide 40mg
(twice daily)
Tab. Enalpril 10mg
(1 daily)
Tab. Digoxin 125ug
(thrice daily)
Tab. Warfarin 5mg
(1 daily)
Tab. Co-proxamol
(1 prn)
i) Find interaction?
a) Frusimide and enalpril pharmacodynamically results in marked disturbance of electrolyte balance (hyperkalemia).
b) Digoxin may decrease gastro intestinal absorption of orally administered drugs.
c) The action of oral anti coagulant may be increased.
ii) Time of medication?
a) Warfarin early morning before or during breakfast.
b) Digoxin, frusimide and enalpril after breakfast ( 9 am)
c) Digoxin and bendroflumethazine after lunch (1 pm)
d) Digoxin and frusimide after dinner ( 9 pm)
iii) Status of patient?
a) Congestive heart failure
b) Angina pectoris
c) Odematous state.
iv) Why co-proxamol is prescribed?
Co-proxamol is prescribed to overcome the pain associated with congestive heart failure. It is centrally and peripherally acting analgesic agent.
v) Comment on the condition of the patient on the drugs prescribed?
Congestive heart failure: Bendroflumethiazide and Frusemide are given to cause diuresis to prevent the edema associated with CHF.
Analpril is ACE inhibitor and is given to decrease worn-load of the heart.
Digoxin causes +ve inotropic, chronotropic effect i.e. to increase the strength of contraction of myocardial muscles to increase the cardial output.
RATIONALE:
a) Bendroflumethiazide:
It is a loop diuretic and will cause hypokalemia so:
Monitor K-levels.
Give a K supplement if necessary.
It is a safe drug and does not cause any abrupt fall in B.P. even if dose increased by 2.5 g/day.
b) Frusemide:
It is a loop diuretic and will cause hypocalemia so:
Monitor K-levels.
Give K supplement.
c) Analpril:
It will cause severe hypotension, which can occur after initial doses of any ACE-inhibitor in patienes who are hypovolemic due to diuretics, salt restriction, or GIT fluid losses. So it shoukd be given at night.
d) Digoxin:
Carefully monitor the patient because he is already on diuretic therapy associated with electrolyte imbalance otherwise it will enhance the arrhythmic potential of Digoxin.
e) Warfarin
Closely monitor the coagulation indices. Continue use of anti coagulant(oral) and thiazide diuretic because of displacement of Warfarin with Albumin. Bendroflumethiazide enhances the effect of Warfarin.
SCENARIO 6:
60 year old female. History of rheumatoid arthritis, diabetes mellitus, congestive heart failure and chronic obstructive pulmonary disease
Rx
Tab. Diclofenac-K 50mg
(twice a day)
Tab. Verapamil 40 mg
(twice a day)
Tab. Spironolactone 40mg
(twice a day)
Tab. Atenolol 50mg
(1 daily)
Tab. Aspirin 75mg
(1 daily)
Tab. Glybenelamide 2mg
(morning and evening)
Tab. Metformin 500mg
(thrice a day)
Beclomethasone 200mcg (meter dose inhalator)
(thrice a day)
Inhalator Terbutaline (meter dose inhalator)
(2 puffs prn)
i) Interactions?
a) Inhalator steroid (beclomethasone) pharmacodynamically decreases therapeutic effect of anti-diabetic agents.
b) Spironolactone, verapamil and co current administration of diclofenac-k results in hyperkalemia.
c) Diclofenac-K and aspirin both cause gastric irritation.
ii) Rationale of each drug?
a) Diclofenac-K for rheumatoid arthritis
b) Verapamil, atenolol and aspirin for congestive heart failure.
c) Spironolactone for excretion of excessive fluid.
d) Glybenelamide and metformin as anti-diabetic agent
e) Beclomethasone for pulmonary inflammation
f) Terbutaline as bronchial muscles dilator
iii) Precautions to patient regarding inhaler corticosteroids?
a) Inhaler corticosteroids should be inhaled in proper dose via meter inhaler.
b) Inhaler corticosteroids used early morning prior to anti-diabetic agent.
SCENARIO 7:
A 38 years male admitted to hospital emergency.
Clinical findings: breathless, tachyphoeic, tachycardia (140 beats/min),
Chest x-ray: no area of consolidation. Excluded the diagnosis of pneumothorax.
Rx
Hydrocortisone 250mg i/v
Salbutamol nebulizer (1ml, 4 hourly)
Iprotropium 500meq nebulize (4 hourly)
Cefuroxime 1G in 1L of 0.9% NaCl once a period of 24 hrs
i) Find out interactions?
No significant interaction, except that an uncommon interaction appear to occur mainly in patients already predisposed to closed angle glaucoma. Increased IOP has been reported.
ii) Why hydrocortisone is prescribed?
Hydrocortisone is prescribed to minimize airway track inflammation and to restore the normal breathing i/v because of emergency condition.
iii) Rationale of Cefuroxime to this patient?
It is used to mitigate any suspected septic condition in respiratory track. It is used to treat community acquired Pneumonia, particularly in case when B lactamase producing H influenzae or Klebsiella pneumoniae.
iv) What caution must be kept in mind while giving Salbutamol and Ipratropium?
As no cases of glaucoma has been reported when either drugs are given by inhalation separately so caution must be kept in mind to use both drugs separately. Instead of their concurrent use by nebulizer.
SCENARIO 8:
50 year male history of acute myocardial infraction
Rx
Tab. Aspirin 150mg
Tab. Warfarin 5mg
Tab. Rovastatin 10mg
Tab. Atenolol 50mg
Tab. Amlodipine 5mg
i) Find interaction?
a) Aspirin and warfarin when used co-currently increases gastric irritation effects
b) Atenolol and amlodipine results in ortho-hypertension.
ii) Rationale of each medicine?
a) Aspirin and warfarin both used as blood thinner to help in keeping normal blood supply towards heart
b) Amlodipine as Ca-channel antagonist because of its Ca-channel blocking ability of skeleton muscles instead of myocardial muscles. Diltiazem is preferred.
c) Atenolol is used to decrease cardiac oxygen demand
d) Rosuvastatin is used to prevent fat deposition in vascular vessels particularly in coronary arteries. Thus minimizing risk of ischemic attack of heart.
SCENARIO 9:
55 year old male with history of kidney transplant in 1999. He is now on following medications.
Rx
Tab. Cyclosporine 100mg
(twice a day)
Tab. Prednisolone
(1/2 tablet, twice a day)
Tab. Atenolol 50mg
(per day)
Tab. Amlodipine 5mg
(per day)
Tab. Lisinopril 10mg
(per day)
i) Find interaction and manage them?
a) Amlodipine and lisinopril inhibits the metabolism of cyclosporine thus pharmacokinetically increases serum concentration of cyclosporine so dose adjustment of cyclosporine is required
b) Atenolol and amlodipine synergistically decreases cardiac activity
c) Cyclosporine and prednisolone markedly decreases immune system.
ii) The rationale of cyclosporine and prednisolone?
This combination is therapeutically beneficial for organ transplant, but toxicity can be enhanced so dosage of both drugs should be monitored if toxicity or rejection occurs.
iii) Reason of prescribing amlodipine, lisinopril and atenolol?
a) If any septic conditions appear immediately consult with doctor.
b) He should exercise.
c) Don’t use excessive nitrogenous diet.
iv) Test recommended during treatment
a) Renal function test
b) ECG
c) Liver tests.
SCENARIO 10:
A 48 year old female has a history of diabeteas mellitus, asthma and hypertentsion. She is on the following medications;
Rx
Propranolol 40mg daily
Lisinopril 10mg daily
Human insulin 70/30 20U in morning and 30U in evening
Prednisolone 5mg 1TDS for 7days.
Beclomethasone 200mg MDI 2 puff TDS
Metformin 500mg TDS
i) Find interactions and manage them.
• Propranolol is a non-selective β-blocker, which causes bronchoconstriction by non-selectively blocking β-2 receptors in bronchial smooth muscles, which may result in aggravated asthmatic conditions. So instead of propranolol, selective β-1 blocker as atenolol is preferable.
• Use of steroids (prednisolone and beclomethasone) may cause hyperglycemic condition which may counteract the hypoglycemic effect of insulin and metformin . So, alternative to steroids and dose adjustment is required.
• Antiviral agents as zidovodine and ribavirin are contraindicated while using steroids.
• Concurrent use of metformin and insulin may cause hypoglycemia. So dose adjustment or time adjustment is required.
SCENARIO 11 :
A 14 year old male child comes to the hospital with high grade fever (104 F). His mother revealed that her child experienced seizures along with high grade fever since the last two days. And he is quiet reactive to light and irritable. The doctor witnessed that child has neck stiffness.
CSF and blood samples were sent to the lab for culture.
QUESTIONS:
Q-1: What two physical tests should be done to confirm meningitis?
Answer: Two physical tests which should be done to confirm meningitis are :
1) : Kering’s test ( inability to straighten the raised leg because of pain due to reflex spasm of spinal muscle due to irritation of nerve passing across the inflamed meninges)
2) : Brudzinski’s sign.
Q-2: What empirical therapy should be suggested?
Answer: Penicillin( Amoxicillin) and Cephalosporin as Ceftriaxone i/v The culture report suggests presence of N. meningitidis.
Q-3: What definitive therapy do you suggest?
Answer: Amoxicillin alone or in combination with gentamycin.
Q-4: Design a pharmaceutical care plan for the patient.
Answer: Condition of this patient is meningitis. Overcome desire is to eradicate the causing pathogenic organism. Regimen prescribed for eradication is Penicillin (Amoxicillin) or Cephalosporin (Ceftriaxone) alone or with Aminoglycoside (Gentamycin). Physical tests as kering sign and brudzinski’s sign are conducted for evaluation of treatment.
Q-5: What do you suggest is the picture of CSF in this case?
Answer: Volume of CSF increases than normal volume.(70 ml to 150 ml) and protein content in it also increases ( 0.4 g/ml)
Q-6: What piece of advice would you like to give to his mother?
Answer: Use the medication at proper time and according to prescribed manner. Donot raise legs nad neck of the patient.
