Clinical Pharmacy (CASE PRESENTATION II)

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A CASE PRESENTATION OF A PATIENT WITH A DIAGNOSIS OF OSTEOARTHRITIS :)

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Clinical Pharmacy CASE PRESENTATION BY: STEPHANIE OLIVEROS LAURETE

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CASE PRESENTATION OF A PATIENT WITH A DIAGNOSIS OF OSTEOARTHRITIS WITH SEVERAL COMPLICATIONS

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CASE: A 65/M patient with Osteoarthritis, maintained for the past 12 weeks on Etoricoxib 60 mg b.i.d . p.o . was admitted due to a Transient Ischemic Attack. He was noted to be hypertensive with a BP of 160/100mmHg; FBS of 140 mg/ dL ; Total Cholesterol of 280 mg/ dL (HDL of 40 mg/ dL , LDL of 240 mg/ dL , TGL of 200 mg/ dL ); creatinine of 1.3 mg/ dL ; CXR reveled Atherosclerotic Aorta; ECG reads as LVH by voltage criteria. Medications started were as follows: ASA 325 mg LD p.o . then 100 mg OD p.o .; Metformin 500 mg t.i.d . a.c . ; Rosuvastatin 20 mg tab OD; Citicholine 1gm IV q 8H; Paracetam 3gm IV q 6H; Duxaril t.i.d . Comment on the the medications prescribed, alternative choices, interactions and pitfalls in the therapy.

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PATIENT PROFILE AND MEDICAL RECORDS DATA DEMOGRAPHIC DATA: AGE: 65 yrs old SEX: Male

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PATIENT PROFILE AND MEDICAL RECORDS DATA CHIEF COMPLAINT: He has Osteoarthritis . He was admitted due to a Transient Ischemic Attack . Transient Ischemic Attack ( TIA) is a stroke that comes and goes quickly. It happens when the blood supply to part of the brain stops briefly. High blood pressure is the number one risk for TIAs and stroke. The other major risk factors are: Atrial fibrillation, Diabetes, Family history of stroke, High cholesterol, Increasing age, especially after age 55. Osteoarthritis is an inflammation of the joints that results when cartilage between bones deteriorates, causing the bones to rub together.

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PATIENT PROFILE AND MEDICAL RECORDS DATA MEDICATION ETORICOXIB, twice a day orally for 12 weeks . Etoricoxib is a type of medicine known as a non-steroidal anti-inflammatory drug (NSAID ) that is used to treat Acute gout, Rheumatoid arthritis & Osteoarthritis. NSAIDs work by blocking the action of a substance in the body called cyclo-oxygenase . Cyclo-oxygenase is involved in producing prostaglandins, in response to injury or certain diseases. These prostaglandins cause pain, swelling and inflammation. Because NSAIDs block the production of these prostaglandins, they are effective at relieving pain and inflammation . Not to be used in patient with HYPERTENSION .

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PATIENT PROFILE AND MEDICAL RECORDS DATA PATIENT EXAMINATION: BP: 1 60 / 100 mmHg STAGES OF BLOOD PRESSURE READINGS: Normal : Less than 130/85 High normal : 130/85 to 139/89 Hypertension Stage 1 : 140/90 to 159/99 Hypertension Stage 2 : 160/100 to 179/109 Hypertension Stage 3 : 180/110 to 209/119 Hypertension Stage 4: 210+/120+

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PATIENT PROFILE AND MEDICAL RECORDS DATA LABORATORY TESTS: BLOOD PATIENT VALUE NORMAL VALUE CREATININE 1.3 mg/ dL 0.7 to 1.3 mg/ dL FASTING BLOOD SUGAR (FBS) 140mg/ dL 79.2 to 110 mg/ dL

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PATIENT PROFILE AND MEDICAL RECORDS DATA LABORATORY TESTS: LIPID PROFILE PATIENT VALUE NORMAL VALUE TOTAL CHOLESTEROL 280 mg/ dL NMT 200 mg/ dL HDL 40 mg/ dL more than 40 mg/ dL LDL 240 mg/ dL NMT 129 mg/ dL TRIGLYCERIDES 200 mg/ dL NMT 150 mg/ dL

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PATIENT PROFILE AND MEDICAL RECORDS DATA LABORATORY TESTS: Chest X-ray (CXR) Atherosclerotic Aorta Atherosclerotic aorta is a serious condition of aorta (the main artery of your body). It is characterized by the presence of atherosclerotic plaque in aorta and causing the narrowing of it.

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PATIENT PROFILE AND MEDICAL RECORDS DATA LABORATORY TESTS: Electrocardiogram (ECG) Left Ventricular Hypertrophy (by voltage criteria) Left ventricular hypertrophy ( LVH ) is the thickening of the myocardium (muscle) of the left ventricle of the heart . Causes: While ventricular hypertrophy occurs naturally as a reaction to aerobic exercise and strength training, it is most frequently referred to as a pathological reaction to cardiovascular disease, or high blood pressure .

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CLINICAL FINDINGS The prescribed pharmacotherapy for Osteoarthritis which is Etoricoxib caused high blood pressure to the patient as one of its possible side effects. The pathophysiological mechanisms that can explain the Transient Ischemic Attack is Hypertension. Values above the recommended range: BP Blood Sugar Total Cholesterol HDL LDL Triglycerides Conclusion: The patient must stop his current drug therapy due to his elevated blood pressure that lead to Transient Ischemic Attack and other complications. MY OWN POINT OF VIEW.

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CLINICAL RECOMMENDATIONS NEWLY PRESCRIBED MEDICATIONS: ASA 325 mg LD p.o . then 100 mg OD p.o . Metformin 500 mg t.i.d . a.c . Rosuvastatin 20 mg tab OD Citicholine 1gm IV q 8H Paracetam 3gm IV q 6H; Duxaril t.i.d . Given by the Patient’s Physician

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MEDICATION EVALUATON 1) ASPIRIN Acetylsalicylic acid (ASA) is used to relieve pain, fever, and inflammation in various conditions such as lower back and neck pain, the flu, common cold, burns, menstrual pain, headache, migraines, osteoarthritis, rheumatoid arthritis, sprains and strains, nerve pain, toothache, muscle pain, bursitis (inflammation of a bursa, a fluid-filled sac located around joints and near the bones), and following surgical and dental procedures. Side effects: bruising more easily confusion dizziness fainting nausea or vomiting pain, buzzing or ringing in ears severe or continuing abdominal or stomach pain, cramping, or burning unusual tiredness or weakness

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MEDICATION EVALUATON 1) ASPIRIN can interact with: ACE inhibitors (e.g., fosinopril , lisinopril , ramipril ) alcohol antacids anticoagulants (e.g., heparin, warfarin ) antidiabetes medications (e.g., glyburide , insulin) corticosteroids (e.g., prednisone) digoxin Methotrexate NSAIDs ; e.g., diclofenac , ibuprofen, indomethacin , naproxen other antiplatelet medications (e.g., clopidogrel , ticlopidine ) phenylbutazone probenecid spironolactone Do not take this medication if you: are allergic to ASA or any ingredients of the medication are in your last trimester of pregnancy are prone to bleeding have an active peptic ulcer

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MEDICATION EVALUATON 2 ) METFORMIN is an oral antidiabetic drug in the biguanide class. It is the first-line drug of choice for the treatment of type 2 diabetes, in particular, in overweight and obese people and those with normal kidney function. Metformin works by suppressing glucose production by the liver. It is the only antidiabetic drug that has been conclusively shown to prevent the cardiovascular complications of diabetes. It helps reduce LDL cholesterol and triglyceridelevels , and is not associated with weight gain. S ide effects: feeling short of breath, even with mild exertion; swelling or rapid weight gain; or fever, chills, body aches, flu symptoms. headache or muscle pain; weakness; or mild nausea, vomiting, diarrhea , gas, stomach pain.

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MEDICATION EVALUATON 2 ) METFORMIN Can interact with: Lantus ( insulin glargine ) Lasix ( furosemide ) Synthroid ( levothyroxine ) Metformin is contraindicated in people with: lactic acidosis kidney disorders lung disease liver disease

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MEDICATION EVALUATON 3) ROSUVASTATIN Rosuvastatin is a member of the drug class of statins , used in combination with exercise, diet, and weight-loss to treat high cholesterol and related conditions, and to prevent cardiovascular disease. It is a competitive inhibitor of the enzyme HMG- CoA reductase , having a mechanism of action similar to that of other statins . Side effects: constipation heartburn dizziness difficulty falling asleep or staying asleep depression joint pain cough memory loss or forgetfulness confusion

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MEDICATION EVALUATON 3) ROSUVASTATIN can interact with: Anticoagulants cimetidine Cyclosporine Ketoconazole Additional medications for high cholesterol such as clofibrate Specific HIV protease Spironolactone Aluminum and magnesium hydroxide Rosuvastatin is contraindicated in people with: hypersensitivity to rosuvastatin active liver disease elevation of serum transaminases pragnant

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MEDICATION EVALUATON 4 ) CITICHOLINE Citicoline seems to increase a brain chemical called phosphatidylcholine . This brain chemical is important for brain function. Citicoline might also decrease brain tissue damage when the brain is injured. Side effects: Citicoline has a very low toxicity profile in animals and humans. Clinically, doses of 2000 mg per day have been observed and approved. Minor transient adverse effects are rare and most commonly include stomach pain and diarrhea . Can interact with: Carbidopa Entacapone Levodopa Citicoline is contraindicated in conditions like: - Unconciousnesa -Pregnancy -Brain surgery -Breast feeding

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MEDICATION EVALUATON 5) PIRACETAM is a cognitive enhancer and memory enhancing supplement. Many people across  the world use the nootropic , piracetam , to effectively retain knowledge and improve memory. Piracetam is utilized by both younger and older healthy individuals. It may enhance, elevate, and improve cognitive functions and abilities linked and associated to the central nervous system, memory development and memory processes. Side effects: anxiety Insomnia Irritability Headache Agitation Nervousness tremor

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MEDICATION EVALUATON 5) PIRACETAM Drug interactions: Inhibits and reverse suckling of RBCs. Contraindicated with: Cerebral vascular accidents and cerebral insufficiencies, ischemic or even hemorrhagic acute accidents. Hypersensitivity, severe renal impairment, hepatic impairment. Behavior and psychotic problems in old age. Mental retardation in children.

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MEDICATION EVALUATON 6 ) DUXARIL ( Almitrine bismesylate 30 mg+raubasine 10 mg) Indications: Minor, age-related neurological disorders; same visual & inner ear disorders related to circulation Antiemetics & Antivertigo Almitrine and raubasine work together to increase the amount of oxygen brought to the brain and neurosensory tissue, by increasing the oxygen content of arterial blood. Almitrine bismesylate is a pharmacologically unique respiratory stimulant. It enhances respiration after both acute and chronic administration by acting as an agonist of peripheral chemoreceptors located on the carotid bodies. Raubasine is an antihypertensive drug used in the treatment of high blood pressure. It acts as a α1-adrenergic receptor antagonist with preferential actions over α2-adrenergic receptors.

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MEDICATION EVALUATON 6 ) DUXARIL ( Almitrine bismesylate 30 mg+raubasine 10 mg) Side effects: weight loss peripheral neuropathy Mild GI disorders sleep disturbances Drowsiness can interact with: MAOIs almitrine -containing prep. Contraindications: Concurrent usage with MAOIs

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CLINICAL FINDINGS The six prescribed drugs have the potentials to help the patient with his condition. And the given dosing administration are all in its proper and recommended regimen. The patient must visit his physician for check-up after 2 weeks in order to make sure that he get the best benefit among the prescribed drugs. And to examine if there are potential side effects and complications. MY OWN POINT OF VIEW.

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Thank you! God bless 

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