Case presentation - SOAP Format

CASE PRESENTATIONThe Prescriptive role of Pharm.D

Dr. Deepak Kumar BandariRPh, PharmD, CGPH, CPPC

Elsevier Student Ambassador – South AsiaDepartment of Pharmacy Practice

Vaagdevi College of Pharmacy

Dr. Palat has also contributed to the development of the curriculum for the Indian Association for PalliativeCare (IAPC) course on palliative care, and has been involved in opioid availability activities though theIAPC and the Pain and Palliative Care Society, Calicut (a WHO Demonstration Project). She facilitated thedevelopment of the Department of Palliative Medicine and the Diploma in Palliative Medicine, the first ofits kind in the country, at Amrita Institute of Medical Sciences, Kochi. With a special interest in pediatricpalliative care, Dr. Palat has played an important role in developing a unique pediatric palliative care

Dr. Gayatri Palat, MDAnaesthesiology and Palliative Medicine

Associate Professor, Pain and Palliative Medicine, MNJ Institute of Oncology and Regional Cancer Center Hyderabad.

palliative care, Dr. Palat has played an important role in developing a unique pediatric palliative carefellowship program at MNJ Institute of Oncology and currently leads the Special Interest Group –Pediatric Palliative Care of the Indian Association of Palliative Care.

Internationally, through her involvement with the IAEA (International Atomic Energy Agency), Dr. Palat hasparticipated in the initial planning of palliative care in the National Cancer Control Program for Sri Lanka,Indonesia and the Philippines. She is a director of the palliative care initiative in SE Asia of Two WorldCancer Collaboration, the Canadian branch of International Network for Cancer Treatment and Research(INCTR), which works with healthcare professionals in resource-challenged countries to reduce the burdenof cancer in South East Asian and African countries. She has also participated in the development of theEPEC-India curriculum to facilitate the implementation of palliative care in various institutions throughoutthe country.

Case Presentation – Patient’s Profile

Patient: Shantha

Age: 56-year-old

Weight: 115 kgs

Height : 155cms

BMI : 56 kg/m2

Date : 13-Jan-2016

Sex: Female

This Case was reported in the Out patient Department of Critical care unit in Continental Hospitals, Hyderabad

Referred to the Clinical Pharmacist for Pharmacotherapy Assessment &Diabetes Management

BMI : 56 kg/m2

Case Presentation – Patient’s Profile

Multiple medical conditions -

1. Type 2 diabetes diagnosed - 2005

2. Hypertension diagnosed – 2012

3. Hyperlipidemia

4. Asthma

5. Coronary Artery Disease

6. Persistent - Peripheral Edema &

7. Longstanding Musculoskeletal Pain secondary to a motor vehicle accident.

Her medical history includes –

Atrial fibrillation

Anemia

Knee Replacement &

Multiple emergency room (ER)

admissions for Asthma

Case Presentation - Patient’s Profile

Her diabetes is currently being treatedwith-

(Humalog 75/25)

Premixed preparation

75% Insulin Lispro ProtamineSuspension ( Intermediate acting ) +

25% Insulin Lispro Preparation (Rapid 25% Insulin Lispro Preparation (Rapidacting)

33 units before breakfast &

23 units before supper

She says she occasionally “takes a littlemore” insulin when she notes highblood glucose readings

Case Presentation - Patient’s Profile

Her other routine medications -

1. INSULIN 75 /25 (lispro protamine suspension + lispro preparation)2. FLUTICASONE - MDI - two puffs twice a day3. SALMETEROL MDI - two puffs twice a day4. NAPROXEN - 375 mg twice a day5. ASPIRIN - Enteric-coated, 325 mg daily6. ROSIGLITAZONE , 4 mg daily7. FUROSEMIDE , 80 mg every morning8. DILTIAZEM , 180 mg daily9. LANOXIN , 0.25 mg daily9. LANOXIN , 0.25 mg daily10. POTASSIUM CHLORIDE, 20 meq daily11. FLUVASTATIN , 20 mg at bedtime.

Medications she has been prescribed to take “AS NEEDED” include1. NITROGLYCERIN - Sublingual for chest pain (has not been needed in the past month)2. FUROSEMIDE, additional 40 mg later in the day if needed for swelling (on most days the additional dose is

needed) &3. ALBUTEROL - MDI , two to four puffs every 4–6 hours for shortness of breath.

She denies use of nicotine, alcohol, or recreational drugs No known drug allergies Up to date on her immunizations.

Case Presentation – Chief Complaints and History (Hx)

Shantha’s chief complaints now

1. Increasing exacerbations of asthma & the need for prednisone tapers.

2. She reports that during her last round of prednisone therapy, her blood glucosereadings increased to the range of 300–400 mg/dl despite large decreases in hercarbohydrate intake.

3. She reports that she increases the frequency of her fluticasone MDI, salmeterolMDI, & albuterol MDI to four to five times/day when she has a flare-up.

3. She reports that she increases the frequency of her fluticasone MDI, salmeterolMDI, & albuterol MDI to four to five times/day when she has a flare-up.

History (Hx):

1. Husband Out of work - Only source of income – State Government Pension.

2. Unable to purchase - fluticasone or salmeterol

3. Has only been taking prednisone & albuterol for recent acute asthmaexacerbations.

Case Presentation – Chief Complaints and History (Hx)

Shantha’s chief complaints

• Not been able to exercise routinely because of badweather & asthma

• The memory printout from her blood glucose meter for the• The memory printout from her blood glucose meter for thepast 30 days shows a total of 53 tests with a mean bloodglucose of 241 mg/dl - 90% above target.

Case Presentation – Subjective Findings

Physical Exam

• Well - appearing but obese

• Weight: 115kgs ; Height 5′1″

• Blood pressure: 130/78 mm Hg

• Pulse 88 beats /min• Pulse 88 beats /min

• Lungs: clear

• Lower extremities - pitting edema bilaterally

Shantha reports that-1. On the days her feet swell the most, she is active & in an upright position throughout the day.2. Swelling worsens throughout the day, but by the next morning they are “ skinny again.”3. She states that she makes the decision to take an extra furosemide tablet if her swelling is

excessive and painful around lunch time;4. Taking the diuretic later in the day prevents her from sleeping because of nocturnal urination.

Case Presentation – Objective Findings

Lab Results

• Hemoglobin A1c (A1C) = 7.0% (target: < 7%)

• Potassium: 3.4 mg/dl (3.5 – 5.3 mg/dl)

• Calcium: 8.2 mg/dl (8.3 –10.2 mg/dl)

• Lipid panel

– Total cholesterol: 211mg/dl (<200 mg/dl)– Total cholesterol: 211mg/dl (<200 mg/dl)

– HDL cholesterol: 52 mg/dl (>55 mg/dl,female)

– LDL cholesterol: 128 mg/dl (<100 mg/dl)

– Triglycerides: 154 mg/dl (<150 mg/dl)

• Liver function panel: within normal limits

• Urinary albumin: <30 μg/mg(<30 μg/mg)

Glycosylated Hemoglobin

Case Presentation – Pharmacist’s Assessment

Pharmacist - Assessment

1. Asthma - Poorly Controlled, Severe, Persistent2. Diabetes - control recently worsened by asthma exacerbations &

treatment3. Dyslipidemia - elevated LDL cholesterol despite statin therapy4. Edema - Persistent lower-extremity edema despite diuretic therapy5. Hypokalemia - most likely drug-induced5. Hypokalemia - most likely drug-induced6. Hypertension - blood pressure within target & stable7. Coronary Artery Disease - stable8. Obesity - ?9. Chronic pain - secondary to previous injury – stable10. Financial constraints - affecting medication behaviors11. Insufficient patient education12. Wellness, preventive, & routine monitoring issues

Case Presentation – Physician’s Plan

1. FLUTICASONE - MDI - two puffs twice a day2. SALMETEROL MDI - two puffs twice a day3. NAPROXEN - 375 mg twice a day4. ASPIRIN - Enteric-coated, 325 mg daily5. ROSIGLITAZONE , 4 mg daily6. FUROSEMIDE , 80 mg every morning7. DILTIAZEM , 180 mg daily8. LANOXIN , 0.25 mg daily9. POTASSIUM CHLORIDE, 20 meq daily9. POTASSIUM CHLORIDE, 20 meq daily10. FLUVASTATIN , 20 mg at bedtime.11. INSULIN 75 /25 (lispro protamine suspension + lispro preparation)

Medications she has been prescribed to take “AS NEEDED” include1. NITROGLYCERIN - Sublingual for chest pain (has not been needed in the past

month)2. FUROSEMIDE, additional 40 mg later in the day if needed for swelling (on most

days the additional dose is needed) &3. ALBUTEROL - MDI , two to four puffs every 4–6 hours for shortness of breath.

SOAP ANALYSIS - PWDT

Pharmacist’s Work Up of Drug Therapy (PWDT)

Desired Outcomes

Therapeutic Endpoints

Medication Related Problems Medication Related Problems

Pharmacist’s Interventions

Monitoring Plans

Patient Education

What are reasonable outcomes for this patient?

Based on current guidelines and literature, pharmacology, andpathophysiology, what therapeutic endpoints would be needed toachieve these outcomes?

Are there potential medication related problems that preventthese endpoints from being achieved?


these endpoints from being achieved?

What patient self-care behaviours and medication changes are neededto address the medication-related problems? What patient educationinterventions are needed to enhance achievement of these changes?

What monitoring parameters are needed to verify achievement ofgoals and detect side effects and toxicity, and how often should theseparameters be monitored?

1. Mortality outcomesAvoid respiratory, cardiovascular, thromboembolic, or diabetes-related premature death.

2. Morbidity outcomesa. Disease-related: Reduce morbidity resulting from uncontrolled blood glucose, blood pressure, dyslipidemia, and cardiovascular disease.

• Retard the progression of disease.• Prevent, recognize, and treat early any complications of chronic conditions,

Reasonable Outcomes

• Prevent, recognize, and treat early any complications of chronic conditions, such as Neuropathy (autonomic or peripheral), Eye disease (e.g., retinal vascular narrowing, hemorrhages), cardiac disease (e.g., LVH, CHF, MI), Nephropathy (e.g., proteinuria), and lower-leg amputation.• Prevent chronic symptoms of asthma (e.g., coughing or breathlessness at night, in the early morning, or after exertion).• Retain recognition of hypoglycemia symptoms.• Maintain near-normal lung function.• Maintain normal activity levels (including exercise and physical activity).• Prevent recurrence of Atrial Fibrillation.

b. Drug-related: Prevent, minimize, or manage drug-related morbidity.• Monitor for side effects or toxicity.• Monitor for drug-drug, drug-disease, and drug-food interactions.

3. Behavioral outcomesa. Obtain annual eye exams.b. Adhere to a medication regimen.c. Get routine and timely medical examinations and laboratory tests.d. Avoid stimulants or over-the-counter products that may affect blood glucose, blood pressure, asthma, or circulation, such as alcohol, caffeine, nicotine, and decongestants.

Reasonable Outcomes

pressure, asthma, or circulation, such as alcohol, caffeine, nicotine, and decongestants.

4. Pharmacoeconomic outcomesa. Keep drug and treatment costs within patient resources.b. Make cost-effective and efficient use of health care resources.

5. Quality-of-life outcomesa. Match, or minimally change, patient lifestyle and activities with treatment.b. Aim for no interference with work or daily activities because of disease symptoms.c. Work to ensure patient satisfaction with the pharmaceutical care and health care team.

Therapeutic Endpoints

• LDL cholesterol: <100 mg/dl HDL cholesterol: >55 mg/dl

• Triglycerides: <150 mg/dl Hb A1C: <7.0%

Self-monitoring of blood glucose: mean <140 mg/dl

• No episodes of severe hypoglycemia requiring emergency assistance

• Blood pressure: <130/80 mmHg, with minimal or no signs or symptomsof orthostatic hypotension

• Biochemical measures, such as potassium, calcium, magnesium, uric acid,• Biochemical measures, such as potassium, calcium, magnesium, uric acid,serum creatinine, and blood urea nitrogen: within normal levels

• Improvement in or no worsening of peripheral edema

• Daytime asthma symptoms less than twice a week, night time symptoms nomore than twice a month, and symptoms responsive to inhaled β 2-agonistwithin 15 min.

• Attain/maintain control of ventricular rate to <100 bpm

• Urinary albumin excretion: <30 g albumin/mg creatinine

• Serum digoxin: 1.5–2.0 ng/ml

Case Presentation – MRP’s and PI’s

Medication-Related Problems & Proposed Interventions

1. No indication for a current drug

2. Indication for a drug - but none prescribed

3. Wrong drug regimen prescribed / moreefficacious choice possible

4. Too much of the correct drug

5. Too little of the correct drug

1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM

5. Too little of the correct drug

6. Adverse drug reaction/drug allergy

7. Drug-drug, drug-disease, drug-food interactions

8. Patient not receiving a prescribed drug

9. Routine monitoring (labs, screenings, exams)missing

10.Other problems, such as potential for overlap ofadverse effects

7. DILTIAZEM8. LANOXIN9. POTASSIUM CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDNISOLONE

Medication Related Problems

1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN9. POTASSIUM CHLORIDE

1. Type 2 diabetes diagnosed in 20052. Hypertension3. Hyperlipidemia4. Asthma5. Coronary Artery Disease6. Persistent - Peripheral Edema &7. Longstanding Musculoskeletal Pain

No indication for a current drug

9. POTASSIUM CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDNISOLONE

7. Longstanding Musculoskeletal Painsecondary to a motor vehicle accident.

8. Atrial fibrillation9. Anemia10. Knee Replacement &11. Multiple emergency room (ER) admissions

for Asthma

None

No indication for a current drug

Medication Related ProblemsMedication Related ProblemsIndication for a drug (or device or intervention) but none prescribed

Peak flow meter

Calcium/vitamin D / HRT supplementation

Corticosteroid therapy

Postmenopausal woman

Furosemide can cause hypocalcemia.

Magnesium Supplementation

1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN9. POTASSIUM CHLORIDE Routine Use Of Magnesium In Diabetes.

Hypomagnesemia - Risk Factor - Atrial Fibrillation,

Hypertension, Insulin Resistance, Glucose Intolerance, Dyslipidemia,

Increased Platelet Aggregation

An added benefit - Constipation

Angiotensin-converting enzyme (ACE) inhibitor

Patients >55 years of age with diabetes & hypertension - ACE inhibitor - indicated

Diltiazem - calcium-channel blocker - addresses several needs

If additional antihypertensive, renal, or cardiac effects are indicated, an ACE inhibitor should be added tothe drug regimen.

9. POTASSIUM CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDNISOLONE


Too much of the correct drug

• Patient is using excessivedoses of Salmeterol &fluticasone as treatment for

1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN

fluticasone as treatment forasthma exacerbations (attimes when she can affordthem).

8. LANOXIN9. POTASSIUM CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDISOLONE


Too little of the correct drug

Potassium Chloride Supplement

1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN8. LANOXIN9. POTASSIUM CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL


Adverse drug reaction/drug allergy

1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN None 8. LANOXIN9. POTASSIUM CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDNISOLONE


Drug-drug, drug-disease, drug-food - interactions

Systemic Corticosteroid Therapy, Inhaled Corticosteroid Therapy,Loop Diuretics in postmenopausal woman: increased risk fordevelopment of osteoporosis

Furosemide, Prednisone in diabetes, w/ Insulin, Rosiglitazone:may increase blood glucose (DOSE-RELATED RESPONSE), thusdiminishing the pharmacodynamic activity of antidiabetes agents

1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEMdiminishing the pharmacodynamic activity of antidiabetes agents

Albuterol, Salmeterol in diabetes, w/Insulin, Rosiglitazone:sympathomimetics may increase blood glucose via stimulation ofBeta 2-receptors, leading to increased glycogenolysis &diminished pharmacodynamic activity of antidiabetes agents

Albuterol, Naproxen, Prednisone, Fluticasone in hypertension:may increase blood pressure (DOSE-RELATED RESPONSE)

7. DILTIAZEM8. LANOXIN9. POTASSIUM

CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDNISOLONE


Drug-drug, drug-disease, drug-food interactions

1. Naproxen in hypertension: INCREASE BLOODPRESSURE

2. Naproxen in diabetes: may INCREASE RISK OFNEPHROPATHY

3. Furosemide – HYPOMAGNESEMIA /

1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM3. Furosemide – HYPOMAGNESEMIA /

HYPOKALEMIA

4. Furosemide, prednisone, fluticasone, salmeterol,albuterol w/DIGOXIN: - potential for DIGOXINTOXICITY.

5. DILTIAZEM w/DIGOXIN: - ELEVATE DIGOXINLEVELS.

7. DILTIAZEM8. LANOXIN9. POTASSIUM

CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL


Patient not receiving a prescribed drug

• Salmeterol & fluticasone: not

1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN• Salmeterol & fluticasone: not

purchased because of financial constraints

8. LANOXIN9. POTASSIUM

CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL

Outcomes & Endpoints – Monitoring Parameters

Routine Monitoring

(Labs, Screenings, Exams)

Missing

1. FLUTICASONE2. SALMETEROL3. NAPROXEN4. ASPIRIN5. ROSIGLITAZONE6. FUROSEMIDE7. DILTIAZEM8. LANOXIN

Annual dilated eye exam is due

Annual microalbuminuria test is due

Consider screening for depression

8. LANOXIN9. POTASSIUM

CHLORIDE10. FLUVASTATIN11. INSULIN12. NITROGLYCERIN13. FUROSEMIDE14. ALBUTEROL15. PREDNISOLONE

Pharmacist Interventions


ASTHMA

1. Change Fluticasone & Salmeterol prescriptionsto a single combination product

2. Limit use of albuterol inhaler (short-acting beta-agonist) to rescue only.agonist) to rescue only.

3. Consider addition of Leukotriene Inhibitor ifsymptoms are not controlled

4. Begin use of Peak Flow Meter every morningupon arising.

5. Develop & Implement - Asthma Action Plan



DIABETES

Algorithms

Change Insulin Regimen

Bedtime - Glargine &

Premeal - Lispro

Rapid Acting

Long Acting



Dyslipidemia

Change Fluvastatin to Atorvastatin

Drug Interactions

Potency – LDL lowering ability

Half life



Persistent lower-extremity edema

Elevate Extremities – 20 – 30 minutes,two to three times / day

Wear Support Stockings - anticipatingbeing on her feet most of the day

Limit Salt Intake

Minimize use - NSAIDs



HYPOKALEMIA

• Increase potassium chloridesupplement temporarily; reassesspotassium level in 7–10 days.potassium level in 7–10 days.

• Titrate potassium dosage withdecreasing use of Albuterol,Furosemide & Prednisone to attain& maintain potassium level of3.5–5.0 mEq/l

Outcomes & Endpoints


HYPERTENSION

No changes at this time / consider addition or change to ACE inhibitor

CORONARY ARTERY DISEASE

No changes at this time

OBESITY

Refer - Santha for nutrition counseling & weight loss.

CHRONIC PAIN

Change ongoing pain medications to ACETAMINOPHEN 500–650 mg three times a day.Minimize use of NSAIDs by limiting it to “breakthrough” pain only

naproxen, 250 mg, or ibuprofen, 200 mg, as needed.

Outcomes & Endpoints


FINANCIAL CONSTRAINTS

• Apply for manufacturers’ indigent drugprograms and State Health InsurancePrograms for combination asthma productPrograms for combination asthma product& other expensive medications.

Generic Equivalent

Direct – Manufacturer

Samples


Wellness , Preventive &

Routine Monitoring Issues

Initiate calcium/vitamin D supplementation

Initiate magnesium supplementation

Reduce daily aspirin from 325 to 81 mgReduce daily aspirin from 325 to 81 mg

Screen for depression

Refer for annual eye exam

Refer for bone density scan

Refer for nutritional counseling

Patient Education


Patient Education

AsthmaAsthma

Diabetes

Lower-extremity edema

Nutrition

Medication education

References

Textbook of Clinical Skills for Pharmacists, 2nd Edition, Karen J.Tietze.

Textbook of Current Medical Diagnosis and Treatment (CMDT) – 2014.

Textbook of Applied Therapeutics : 2nd Edition, Koda and Kimble.

British National Formulary (BNF), 61st edition

Glen Lewis Stimmel, Professor, University of Southern California, US.

Dr. Navin Loganathan, Cover story : New Sunday Times, Malaysia.

Prof. Syed Azhar Syed Sulaiman, Dean – University Sains, Malaysia.

Jennifer Pham, University of Illinois, Chicago, US : Short profile.

Dr. Gayatri Palat, Director & Co founder, PRPCS – Two World’s CancerCollaboration (TWCC), India.

QUESTION HOUR

Thank You…

Case presentation - SOAP Format

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