SPW02 Case Studies
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Transcript of SPW02 Case Studies
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7/31/2019 SPW02 Case Studies
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Case 1
Mrs CD (67 years old) was admitted over the weekend to the acute medical ward you cover
as a clinical pharmacist. She was prescribed amoxicillin + clavulanic acid 500/125 one tablet
three times 4 days ago by her GP for a suspected UTI.
Presenting Complaint (PC)
CD now appears very confused, is feverish and complaining of abdominal pain.
Past Medical History(PMHx)
Type 2 diabetes 15 years
Hypertension 5 years
On Examination (O/E)
Temperature 38.50C
Blood pressure 170/105Weight 65 kg
Height 52
Extremely tender abdomen; confused.
Medication on Admission
Metformin 500 mg three times a day
Glipizide 5 mg twice a day
Cilazapril 5mg + Hydrochlorothiazide 12.5 mg one daily
Lab results
(Normal range)WCC 20 x 109/L (4 11 x 109/L)
CRP 100 mg/L (< 8 mg/L)
Creatinine 250 mol/L (50 - 110 mol/L)
Potassium 4.5 mmol/L (3.5 5.0 mmol/L)
Blood glucose 3 mmol/L (4.2 6.1)
HbA1C 6% (5 8%)
Urine dipstick proteinuria +++
Culture and sensitivity from urine sample taken 4 days ago by her GP are available when CD
was admitted to hospital and confirm presence ofEscherichia coli in urine resistant to co-
amoxiclav, amoxicillin and trimethoprim, sensitive to ciprofloxacin and gentamicin.
Impression
Acute pyelonephritis
Plan
Stat dose of IV gentamicin given in ED (5 mg/kg) followed by IV ciprofloxacin
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When you reach the ward on Monday CD has had 3 doses of IV ciprofloxacin 400 mg. You
have a chat with Mrs CD when you are looking at her prescription and she mentions that she
occasionally takes diclofenac (50 mg) for pain in her feet and took one tablet 3 times a day
for the last week. CD says that she has not told the Drs this as she felt so unwell over the
weekend.
Problems
Outline:
current problems that Mrs CD has
potential future problems that you think Mrs CD may experience
[include objective and subjective evidence]
Need to get her IBW (shes overwight) so we can get an accurate creatinine clearance
Current problem:
o Treatment for acute pyelonephritis
o Risk factors were:
Diabetes
Female
Old
o Why?
Proteinuria
WCC and CRP high
Fever
Abdominal pain
Confusion
o Renal impairment seen
15 ml/min seen
Potential problems:
o Chronic renal failure
Pyelonephritis (especially recurrent infections) are a risk factor
(acute tubular nephritis)
Gentamycin and diclofenac may cause renal damage
Have diabetes and hypertension (risk factors)
Creatinine is currently high
o Hypoglycemia
Glucose low
Glipizide (sulphonurea) may be accumulated
Could also be due to just infection
Dont eat properly
But her glucose control is good, HbA1c is good
o Pain in her feet (neuropathy with diabetes?)
She also got the triple whammy, a diuretic, NSAIDs and ACEI
Complicated = kidney involvementCheck BPAC to see what antibiotic we should choose
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Need to know how to calculate GFR by memory, also read NZF stuff on renal impairment
Options
Outline:
possible non-pharmacological treatments
possible pharmacological treatments possible pharmacological treatments if her condition changes
Non-pharmacological treatments
Reduce protein intake
Cranberry juice for prevention
NOT alkalisers, acute kidney damage makes pH balance hard anyways
o Acidosis is common, cant excrete protons
Pharmacological treatments
Gentamycin stat dose, dont need to adjust (first dose doesnt cause damage,and we need to base loading dose off weight, allows us to know Vd)
If continued, then dose reduction and monitoring is required
Good because its renally cleared, so its able to enter kidneys easily
Follow up with cipro- a good choice
o Renally eliminated, so lots would end up in the kidney
o Also need dose adjustment as well
o IV needed for her, need to be absorbed quickly, and since theyre sick,
cant vomit out IV (but can with oral)
o Continue IV dosing until her temperature normalises and her
symptoms are controlled
Renal failure
Regular monitoring (daily until stabilised)
Adjust for renally cleared drugs
Since changes in renal clearance are rapid, need to MONITOR doses of the
renally cleared drugs closely
o Change in clearance = beware
o Tends to overestimates as a result
Diabetes management
Withhold metformin until greater than 30 ml/min (risk of lactic acidosis)o Or insulin
Glipizide- withhold for at least 24 hours and start at a lower dose (maybe it
was accumulating, because blood glucose was low)
Glicazide is a good choice how, because its partially metabolised by the
liver, another pathway for the drugs to leave by
Continue cilazapril, renoprotective, but monitor BP, could be accumulating as
patient is hypotensive
Thiazide diuretics not effective here
o Ineffective if GFR is les than 30 ml/min, so withhold
Ineffective because they work distally, they cant reach there ifthey cant get excreted properly
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o If required for odema, use furosemide
o If required for hypertension, use other agents, like ATII antagonist,
dihydropyridine CCB or beta blockers
Pain
Strong opiate on admissiono Not NSAID
o Fentanyl is good option, no active metabolites
o Morphine and pethidine have some accumulation (especially
norpethidine which is active and accumulates)
o But morphine can be used short term though
NSAID to be stopped
o Neuropathic pain is likely, need a different type of agent
o Gabapentin
o TCAs (e.g. amitriptyline, not an approved condition though)
Pharmacological treatments if condition changes
Note: options should be broad (AND the co-morbidities)
Plans
Outline:
an initial treatment plan (choosing one of your possible options)
a long term treatment plan
what expectations you would have for your treatment
how you would monitor the outcomes of your treatment plans with Mrs CD
Initial
Treat the pain
o Fentanyl
Calculate GFR
Check current medications
o Withold metformin
o Witholg glicazide, consider alternative
o Maintain cilazapril, stop thiazide
o Stop NSAID
o Refer for neuropathic pain Infection
o Genta- stat, only once
o Cipro- then change to cipro
Long term
Continue to manage everything
What about statin? Shes got diabetes, hypertension. So a statin could be thought
about
Diretic used could be furosemide, as it works in renal impairment
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Expectation
Infection should resolve quickly, discharge on oral ciprofloxacin- treatment course
should be 10-14 days
Monitor temp, BP and blood glucose
Monitor renal function (as both inpatient and outpatient)
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Case 2
When Mrs CD was discharged 2 weeks later, her renal function had improved (SCr on
discharge 130 mol/l). Unfortunately, over the next 5 years she developed progressively
worsening chronic renal failure and had poor diabetic control. Six months ago it was decided
that she needed treatment with CAPD and CD has been at home for the last 4 months on this
treatment and is a regular visitor to your pharmacy to collect the following medication:
Metoprolol CR 95 mg daily
Cilazapril 5 mg daily
Simvastatin 20 mg daily
Humulin N 10 units sc twice a day
Calcium carbonate 500 mg 2 tablets three times a day
Calcitriol 0.25 g three times a week
Erythropoietin Beta 4,000 sc weekly
1. Briefly discuss the advantages and disadvantages of renal replacement therapy using
CAPD compared to haemodialysis.
Dialysis is where the filtraction of substances out of the body. Need a semi-permeable
membrane
Plus with counter current flow to maximise the diffusion gradient
Plus with ultrafiltration, which causes a water gradient by osmosis into the dialysis
fluid
Convection- holes allow solutes and larger molecules to pass through like urea
HD= muscle cramps, because elecrylyte balance and moving blood away from the musclesRisk of thrombosis and infection
Skin commensuals commonly seen
Anticoagulate
PD
Ultrafiltration and diffusion possible
Peritoneal membrane is a continuous single layer of mesothelial cells
Dwell time, how long it needs to stay in there, several hours
Indwelling catheter is kept in
Advantages
Dont need to make the arteriovenous fistulas
Dont have to come into the hospital, good for mobility
Disadvantages
Not recommended for diabetics, glucose used in fluid
Risk of infections, because carried out at home
The catheter can damage the peritoneal membrane
Make sure nothing grows into the cather, can block it
2. Discuss the reasons for the drug treatment that CD has been prescribed.
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Heart/BP
Metoprolol
o Hepatically cleared
Cilazapril
o Renoprotective as well
Simvastatin
o Hepatically cleared
o Recommended due to high CVD risk (diabetes + hypertension)
Diabetes
Removed everything, only on insulin
o Better idea due to renal failure
Renal failure
Calciumo Soft tissue calcification causes the drop in calcium
o This is due to phosphate retention
Reduce phosphate in the diet
Or consider a phosphate binder
o A part of preventing hyperparathyroidism
Calcitriol
o The activation step of calcidiol to calcitriol occurs in the liver
o Obviously, cholecalciferol wont work
o Prevents osteomalacia (soft bones)
o Also prevent hypterparathyroidism EPO
o Normally produced by the kidneys as well
o Required for normal red cell production
One year after staring CAPD CD is admitted to your ward with suspected peritonitis. She has
had abdominal pain and a slight temperature over the last day or two and noticed last night
that the volume she drained was much less than normal and the drained fluid has become
cloudy. The medical team looking after CD asks for your advice on appropriate antibiotic
treatment.
3. What treatment would you recommend?
Quick empirical treatment with broad coverage
o Cefazolin (G+) and cefotaxine (G-)/gent (G-)
o OR vancomycin + gent
Give into peritoneal fluid, not IV to achieve high local concentrations
Think about dwell time, can give it intermittently to prevent too much absorption into
systemic circulation
o But need to have a long enough well time to get enough into the systemic
circulation
o Higher dose if intermittent, low dose if continuous
Also think about renal clearance, they cant clear it!
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o Higher doses if they have urine output
Should take a few days (48h), monitor symptoms
o Peritoneal fluids should become clear
Catheter related infections: oral?
4. Should CDs regular medication be altered while she is receiving your recommended
treatment?
Monitor glucose and adjust insulin as required
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Case 3
Mr RT is a 45 year old has been just discharged home from a renal transplant unit. He comes
into your community pharmacy and tells you that although he has pain from his operation he
is feeling well and getting his energy back. He is attending a transplant clinic three times
each week for review and adjustment of his medication. His discharge medication card notesthat he is taking the following medicines.
Ciclosporin 450 mg twice a day
Mycophenolate Mofetil 1 g twice a day
Prednisone 40 mg daily
Valganciclovir 450 mg every second day
Co-trimoxazole 480 mg once daily
Allopurinol 50 mg daily
Cilazapril 5 mg daily
Diltiazem CD 120 mg dailyHumulin N 10 units sc twice a day
Humalog 10 units sc three times a day
Simvastatin 20 mg daily
Ferrous sulphate 200 mg twice a day
Codeine phosphate 30 mg four times daily as required
Paracetamol 1 g four times daily as required
1. Using the list of mediation above identify RTs main medical problems (other than
his renal transplant).
Diabetes Iron depletion
o Probably caused due to renal failure
o Probably exacerbated by blood loss during surgery
o Short term
Hypertension/CVD
Recurrent gout
2. Identify the medicines which will have been started after his operation. Discuss the
function of each, any special precautions relating to use and side effects which RT is
likely to experience?
Ciclosporin
Mycophenolate
Prednisone
Valganciclovir
o Cytomegalovirus (especially with allograft)
Cotrimoxazole
o PCP prophylaxis
Pain
o Short term treatments
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See www.kidney.org.uk/Medical-Info/transplant/txinfect.html
3. Are there any changes to his medicines that you anticipate or would recommend?
How should these be managed? He uses a medication tray.
Add laxative (codeine) Need to slowly taper down the rejection drugs quite regularly (especially with
prednisone)
o Blister packing is a very good idea
Even if they use their own tray, its probably a good idea for us to pack them
Ciclo can be changed to tacrolimus (also a good idea for a second kidney after reject,
its stronger)
Beware of pregnisone, changes diabetes (down titration)
o Especially important for long term kidney survival
Monitor kidney function, and make dose adjustments on a regular basis
Oxypurinol build up needs to be accounted for in renal failure. Dose adjustments maybe required
4. Mr RT asks to receive an influenza vaccination in your pharmacy. What is your
recommendation?
Its not going to work, your immune system is currently being suppressed. Cant produce a
response against it. (its an attenuated vaccine, wont cause infection at least)
Note: diltiazem can be used as a ciclosproin sparer, this is via CYP inhibition (plus good for
addon for hypertension)