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Kendra Suder

PHAR592

IPPE Assignments SP20

2 goals:

1. I will concisely communicate 1 drug-related problem to another healthcare professional.

2. I will effectively use and interpret 2 hospital-specific dosing protocols.

Reflection:

I completed my final IPPE experience at Southwest General Hospital in Middleburg

Heights, Ohio. This site is a fairly busy mid-size hospital with about 350 beds and a residency

program. I completed two previous IPPEs at a much smaller hospital, so I knew that this site

would give me many opportunities to learn. I set out to accomplish two personal goals.

My first goal was to correctly utilize two of the hospital’s site-specific dosing protocols. I

was able to accomplish this goal easily as I was using dosing protocols on my very first day. The

one I became most acquainted with was the vancomycin protocol. This site’s dosing protocol

was very similar to the one I learned in my skills lab course when I practiced writing a

vancomycin consult. It utilized weight- and creatinine-clearance based dosing with trough goals,

so it was easy for me to interpret and use the protocol. I calculated loading and maintenance

doses for many patients using this protocol as well as some dose adjustments. Another dosing

guide I used was a heparin protocol. I have never seen a heparin protocol before, but it was easy

to follow this one as it was weight-based. While dosing a heparin patient, the pharmacist also

showed me how to order the APTT labs in the computer. I also briefly reviewed another dosing

protocol for tPA but I did not get a chance to practice it. I enjoyed using the dosing protocols and

they served as opportunities to review dosing and monitoring parameters for several medications.

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My second goal was to present a problem to a fellow healthcare provider using the SBAR

format. I was able to practice the SBAR format with pharmacists, but I was not able to execute

this communication technique in a real-life scenario. I also observed that many of the

pharmacists I worked with used a more abbreviated SBAR method to communicate with

physicians. Often, the physicians knew the background and history of the patient, so the

pharmacists would simply identify the patient and describe only the present issue or problem

followed by a concise recommendation. The physicians and pharmacists communicated very

efficiently with each other and the dynamic was free of any aggression or hostility for all of the

interactions that I observed. Additionally, the physician almost always asked the pharmacist to

input or change the relevant medication orders. I liked observing interactions such as these

because they serve as examples of how I would like to communicate as a pharmacist. Ideally, I

would have liked to practice more interprofessional communication, but I understand that

logistically this can be difficult to execute at a busy hospital.

I had other beneficial experiences at this site that were unrelated to my goals. I attended

my first P&T committee meeting, which was another good example of interprofessional

communication. I also attended several topic discussion presentations from pharmacists and

residents. These were more casual, usually involved less than eight people, and utilized handouts

and spoken words rather than slideshows. I much prefer this method of presentation to reading

from slides and I chose to do my topic presentation in this format as well. Other activities I did

included observing a cardiac catheterization, assisting the pharmacist in the warfarin clinic,

taking part in a rapid response team for a critically ill patient, and observing a cardioversion.

Many of these experiences were spontaneous and unexpected, and they were some of my

favorite parts of my time at this site.

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I would definitely recommend this IPPE site to other students. In fact, it is my favorite

institutional IPPE that I have done due to the positive, student-friendly environment and the

focus on learning. I could easily see myself coming back here for a residency in the future if I

choose to do so.

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Assignment #1:

# Intervention Rationale

1 A patient with type 2 diabetes and COPD

was admitted to the ICU for respiratory

distress. He was placed on

methylprednisolone, and after

approximately 5 days of therapy, his

breathing improved but his blood glucose

readings were consistently above 200

mg/dL. The methylprednisolone was

discontinued.

Steroids such as methylprednisolone are

known to raise blood glucose. Steroids are

appropriate to treat an inflamed airway, but

due to their side effects, treating for the

shortest possible duration is preferred. Since

this patient no longer was experiencing airway

inflammation, it was appropriate to discontinue

the methylprednisolone.

2 A patient with stage 5 CKD was initially

given ampicillin every 6 hours due to an

Enterococcus bloodstream infection. The

patient’s renal function has worsened

over the past 3 days, with most recent

labs being BUN 131, SCr 7.1, and

estimated CrCl 10. The dosing interval

for the ampicillin was changed to every 8

hours.

Ampicillin is a renally cleared antibiotic with

dosage adjustments based on creatinine

clearance. The recommended dosing interval

for a CrCl of 10-50 mL/min is 6-12 hours.

Given the severity of the bloodstream

infection, the pharmacist was reluctant to

change the interval to every 12 hours, so the

pharmacist decided on an 8-hour dosing

interval instead.

3 A 76-year-old male with a history of

heart failure and an MI was on

atorvastatin 20 mg at bedtime, and the

pharmacist increased this to 40 mg at

bedtime.

The patient had an MI, or an acute coronary

syndrome. Acute coronary syndromes are

considered clinical ASCVD, and the presence

of clinical ASCVD means that this patient is in

the first of four statin benefit groups. He is a

candidate for a high-intensity statin, which

would be either 40 or 80 mg of atorvastatin.

Due to his age, the pharmacist opted for 40 mg

of atorvastatin at bedtime. Statins should also

be given at night because the body’s

cholesterol production peaks at night.

4 A 70-year-old patient with a history of

type 2 diabetes and stage 5 CKD was

taking 20 units of insulin glargine SQ

once daily. His blood glucose readings

were consistently in the 200s despite use

of short acting regular insulin before each

meal, so his insulin glargine was

increased to 40 units SQ once daily.

This patient’s poor renal function excludes him

from taking renally cleared oral diabetes

medications such as sulfonylureas. Thus, he

must rely on insulin for glucose control. His

blood glucose has been consistently high while

in the hospital, and since he is already

receiving regular insulin multiple times daily,

increasing his basal insulin dose is appropriate.

5 A patient with a severe foot infection was

initially placed on clindamycin +

vancomycin + cefepime. An incision &

drainage was done on the blister and the

infection improved, so the pharmacist de-

escalated therapy to vancomycin at a

lower dose + piperacillin/tazobactam.

Because the patient showed improvement, de-

escalation was appropriate. The physician

considered vancomycin alone, but anaerobes

are likely to cause diabetic foot infections, the

pharmacist added piperacillin/tazobactam for

anaerobic coverage.

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6 A patient was placed on ceftriaxone 1 g

IV q24h for community-acquired

pneumonia. 1 of the 2 most recent

cultures have come back positive for a

rare MRSA strain. The patient has

completed 5 days of therapy. She is now

afebrile and her lungs are clear.

The rare strain of MRSA found in the culture

is most likely a colonizer. The patient no

longer has any signs and symptoms of

infection, so discontinuing the ceftriaxone is

appropriate. Antibiotic overuse breeds resistant

organisms and does not benefit the patient.

Assignment #2:

SOAP Note #1 is on pages 5-10

SOAP Note #2 is on pages 11-15

SOAP Note 1 Problem List:

1. Asymptomatic bacteriuria

2. Bilateral pulmonary emboli/ respiratory failure/ Anticoagulation management

3. Hypertension (HTN)/ Chronic Kidney Disease (CKD)

4. Alzheimer’s Dementia

5. Probable osteoporosis/ reduced bone density

6. Depression/ anxiety/ Neuropathy

7. Hypothyroidism

8. Glaucoma

9. Omeprazole use with unknown indication

10. Seasonal allergies

S: HPI: LG is an 88YO Caucasian female with a history of dementia and recurrent urinary tract infections

who was brought to the ED by a family member 3 days ago due to altered mental status, sudden

weakness, and limpness. She has also experienced headaches and decreased appetite. At the ED, the

patient was shown to have dehydration and also complained of shortness of breath. She denied nausea,

vomiting, diarrhea, fever, chills, or chest pain. Approximately 6 months ago, she began taking a 90-day

course of nitrofurantoin for recurrent UTIs, and this medication was stopped in the ED because she was

placed on ceftriaxone empirically for a suspected UTI (and also due to her declining renal function). Due

to the patient’s shortness of breath, the physician ordered a chest CT scan which revealed bilateral

pulmonary emboli, so the patient was also started on anticoagulation therapy. PMH: Alzheimer’s dementia, recurrent UTIs, HTN, neuropathy, depression/ anxiety, glaucoma, vaginal

prolapse, bilateral hip replacements FH: None pertinent. SH: The patient denies smoking, alcohol use, or drug use. She lives with her children. ROS: Altered mental status, weakness, limpness, headaches, and decreased appetite. Negative for nausea,

vomiting, diarrhea, diarrhea, fever, chills, or chest pain. All other systems are normal.

O: Allergies: NKDA Vitals (most recent): Temperature 36.3 C, HR 77, RR 20, BP 102/69, SpO2 96% on oxygen mask,

height=160.02 cm, ABW= 78.5 kg, pain= none reported PE: Appears alert and oriented and in no acute distress. Regular heart rate and rhythm with a 2/6 murmur

indicating tricuspid insufficiency. Lungs are clear to auscultation. Skin is warm, dry, and intact with no

edema and no lymphadenopathy. All other systems normal.

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Pertinent Labs:

On admission (12/16) Most Recent

WBC 12.9 (high) Hgb 12.5 Hct 38.5 platelets 313 Na 139 K 4.6 Ca 9.9

Cl 108 CO2 22.2 BUN 32 (high) SCr 1.3 (high) glucose 189 (high) INR 1.3 Troponin C 0.173

WBC 10.9 Hgb 10.5 (low) Hct 32.8 (low) platelets 237 Na 141 K 4.4 Ca 9.1

Cl 112 (high) CO2 23.8 BUN 33 (high) SCr 1.2 (high) glucose 198 (high) INR 1.3 Troponin C 0.202

Urinalysis (12/16): Positive for blood in the urine, nitrite, leukocyte esterase, WBC clumps, and many

bacteria Culture & Sensitivity (from 12/18 urine culture- Escherichia coli >100,000 CFUs/mL):

Agent MIC Susceptibility

Ampicillin 8 S

Ampicillin/sulbactam < 2 S

Aztreonam < 1 S

Cefazolin < 4 S

Ciprofloxacin < 0.25 S

Gentamicin < 1 S

Nitrofurantoin > 512 R

Piperacillin/tazobactam < 4 S

Trimethoprim/sulfamethoxazole < 20 S

12/16: (2/2) blood cultures negative

Calculations: IBW= 52.27 kg, AjBW=62.76 kg, BMI=30.66, CrCl=32.11 mL/min (AjBW), eGFR= 40

mL/min

Current Home Medications (confirmed):

Aspirin 81 mg, 1 tab PO QHS

Calcium 600 mg + D3, 1 tab QD

Cetirizine 10 mg, 1 tab PO QD

Donepezil 10 mg, 1 tab PO QD

Gabapentin 100 mg, 1 cap PO TID

Latanoprost 0.005%, 1 gtt OU BID

Levothyroxine 75 mcg, 1 tab PO QD

Memantine 10 mg, 2 tabs PO BID

Nitrofurantoin 100 mg, 1 cap PO QD

Omeprazole 20 mg, 1 cap PO QD

Paroxetine 20 mg, 1 tab PO QD

Potassium chloride 20 mEq, 1 tab PO BID

Timolol maleate 0.5%, 1 gtt OU QHS

Triamterene 37.5/ HCTZ 25 mg, 1 tab PO QD

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1. Asymptomatic bacteriuria

A: Assessment statement: The patient has asymptomatic bacteriuria as evidenced by the absence of urinary

symptoms despite a urine culture positive for E. coli (>100,000 CFU/mL) and altered mental status. The

patient also experienced sudden weakness and limpness, elevated WBC (12.9) upon admission, and a

recently decreased appetite, but she is afebrile and has no CVA tenderness, nausea/vomiting, or flank

pain. Urinalysis on 12/16 showed cloudy, yellow urine with albumin 100 mg/dL and positive for blood,

nitrite, leukocyte esterase, WBC clumps, and many bacteria with occasional mucous. The E. coli cultured

in the urine was notably resistant to nitrofurantoin, and 4/4 blood cultures on 12/16 were negative for any

pathogens. The patient has been taking nitrofurantoin 100 mg PO BID since 6/12 for recurrent urinary

tract infections and still takes this medication at home. On 12/16 she received ceftriaxone, 1g IV in the

ED and her nitrofurantoin was not given. Since starting empiric therapy, her WBC decreased to 10.9 (as

of 12/18). P: Goals: 1) Prevent unnecessary antibiotic use, 2) Prevent future infections, 3) Improve patient’s quality of life Pharmacologic: D/C nitrofurantoin. Initiate cephalexin, 250 mg PO QD for 90 days.

Non-pharmacologic: Adequate hydration, reminders to drink Monitoring and Follow-up: Monitor for signs of anaphylaxis after first dose of cephalexin. Monitor daily:

hydration status, side effects and toxicities of cephalexin (diarrhea, vaginal yeast infections) and

resolution of signs/symptoms (dehydration, headache, decreased appetite, weakness). Follow-up with

primary care physician in 2 weeks. At follow-up appointment obtain CBC and assess for signs of liver

toxicity (i.e. jaundice, decreased appetite) and CNS effects (confusion). Follow-up monthly thereafter. At

the 3-month mark assess efficacy and safety again to determine whether therapy should be continued. Rationale: Due to the absence of urinary symptoms which are typical of cystitis and the absence of flank

pain and CVA tenderness usually seen in pyelonephritis, this patient likely has asymptomatic bacteriuria

rather than a true urinary tract infection. In the emergency department, LG was given ceftriaxone 1 g IV,

and this would be appropriate empiric therapy if the patient had a true UTI. In terms of definitive therapy,

Escherichia coli, which is a Gram-negative rod, was cultured from the urine. The organism was shown to

be sensitive to several antibiotics. However, according to the 2005 IDSA guidelines regarding

asymptomatic bacteriuria (and the 2019 update), asymptomatic bacteriuria should only be treated in

pregnant women, those undergoing a urologic intervention, and renal transplant recipients. This patient

does not fall into one of these groups, so the IDSA recommends careful observation and assessment of

other causes of the patient’s altered mental status. Administration of unnecessary antibiotics will place the

patient at risk for infections such as C. difficile, increased drug resistance, and serious or undesirable

adverse effects. Though antibiotics would be inappropriate to treat asymptomatic bacteriuria, this patient

is a candidate for prophylactic antibiotics. According to the 2019 AUA/CUA/SUFU guidelines on the

management of recurrent UTIs in women, antibiotics may be considered for UTI prophylaxis in women

of all ages with recurrent UTIs. Prophylaxis may be continuous or intermittent (post sexual intercourse)

and durations of 3-12 months have been used in practice. Options for continuous prophylaxis include

trimethoprim/sulfamethoxazole (TMP-SMX), cephalexin, nitrofurantoin, fosfomycin, or TMP. The 2019

Beers Criteria recommends avoiding nitrofurantoin in patients > 65 years with a CrCl of <30 mL/min, and

since this patient has a CrCl of approximately 32 mL/min, it is reasonable to stop her nitrofurantoin as her

kidneys will likely continue to decline. Additionally, the E. coli specimen previously mentioned was

resistant to nitrofurantoin, so the medication will likely be of no use in preventing future UTIs. TMP-

SMX and TMP are not good choices for prophylaxis due to adverse effects including nephrotoxicity.

Fosfomycin is high in cost and not commonly used. Therefore, cephalexin 250 mg daily is a reasonable

agent to use for continuous UTI prophylaxis in this patient. Its adverse effects are commonly GI-related,

and other effects such as blood glucose abnormalities can be managed with regularly scheduled meals. It

does have the potential to cause CNS effects such as dizziness and confusion, but because the

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prophylactic dose is low, these effects are likely to be minimal. After a 90-day course of therapy, the

patient can be re-assessed to determine whether a longer duration would provide further benefits. In terms

of nonpharmacologic therapy, adequate hydration is essential for LG since dementia patients have a

decreased sense of thirst making them prone to dehydration.

Patient Education: -Make sure to stay well hydrated

-The most common side effects of cephalexin are nausea, vomiting, and diarrhea. Take the medication

with food to help minimize stomach upset.

-Get medical help if you notice signs of an allergic reaction such as rash, feeling hot or flushed, or

difficulty breathing, especially with the first dose.

-Cephalexin may affect blood sugar. Caregivers, please make sure that the patient eats meals on a regular

basis.

-Cephalexin may cause vaginal yeast infections in women.

2. Bilateral pulmonary emboli/ Respiratory Failure/ Anticoagulation Management A: Assessment: Patient has had pulmonary emboli (PE) as evidenced by shortness of breath (SOB) and a

chest CT scan on 12/16 revealing bilateral pulmonary emboli and moderate clot burden. Imaging was also

significant for cor pulmonale with right ventricular enlargement. D-dimer level was not obtained. As of

12/19, she is also experiencing acute hypoxic respiratory failure, most likely exacerbated by her PE, and a

second chest CT revealed a small right pleural effusion, infiltrates, and collapsing of the right lung base.

The patient denies chest pain and she is negative for tachypnea, tachycardia, or distended neck veins. She

has been taking nitrofurantoin at home which carries a risk for pulmonary toxicity and may have

contributed to her SOB as well. In the ED, she received anticoagulation therapy, which decreased her

SOB, and is currently receiving enoxaparin 80 mg SQ QHS. For her respiratory failure, she is receiving

oxygen and is set to receive spirometry and bronchodilation. Her most recent INR is 1.3 and she is stable

except for episodes of hypotension/ syncope. At home, she is taking aspirin 81 mg QHS, most likely for

primary prevention. Recommend continue current interventions, obtain thorough family history, and re-

evaluate the patient upon discharge to determine appropriate oral long-term anticoagulation therapy based

on her renal function and insurance coverage. Based on the patient’s current renal function, either

apixaban or rivaroxaban would be appropriate, or warfarin if cost is a concern; to determine duration of

therapy, risk factors (including genetic) should be investigated and taken into consideration.

3. HTN/CKD A: Assessment: The patient has been diagnosed with hypertension as evidenced by statements in her past

medical history, and she also has undiagnosed CKD as evidenced by a calculated GFR of 40 mL/min. She

has been hypotensive (SBP ~100) and experiencing episodes of syncope while in the hospital, most likely

due to her PE. Home BP readings are not available. Her urinalysis showed albumin 100 mg/dL in the

urine, and her most recent BUN and SCr are 33 and 1.2 respectively. ACR and I&Os not completed. She

is currently taking triamterene 37.5 mg/ HCTZ 25 mg, 1 tab PO QD. Recommend monitoring BP daily

once discharged home, continue current therapy, and follow up with physician following resolution of

infection to monitor renal function and determine appropriate course of action for CKD.

4. Alzheimer’s Dementia A: Assessment: LG has been diagnosed with Alzheimer’s dementia as evidenced by statements in her past

medical history; a brain CT scan on 12/16 was notable for brain volume loss, white matter changes, and

small vessel ischemia. The patient presented to the ED with altered mental status but this could be

attributed to her UTI. She is currently taking donepezil 10 mg, 1 tab PO QD, and memantine 10 mg, 2

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tabs PO BID. Recommend continue current therapy and follow up with physician for regular assessments

such as MMSE. 5. Probable osteoporosis/ reduced bone density A: Assessment: The patient has probable osteoporosis and reduced bone density as evidenced by a history of

falls. T-score was not available. She was seen in the ED on 8/28 for recurrent falls at home, and she has

also had bilateral hip replacements. She has been deemed a fall risk while inpatient for her UTI. At home,

she is taking calcium 600 mg + vitamin D, 1 tab PO QD. Recommend continue current therapy, reduce

fall hazards at home, and follow up with primary care physician to complete DXA scans and other tests as

appropriate if not previously completed.

6. Depression/ Anxiety/ Neuropathy A: Assessment: LG has depression, anxiety, and “questionable” neuropathy as evidenced by statements in

her past medical history. She has not complained of any bothersome symptoms, though her dementia and

mental status does create a communication barrier. She is currently taking gabapentin 100 mg PO TID

and paroxetine 20 mg QD. Because gabapentin has been associated with lung damage and the patient

recently experienced a PE and respiratory failure, the use of this medication should be re-evaluated.

Recommend continue current therapy pending a diagnostic workup for neuropathy. If the patient does not

have neuropathy, recommend discontinuing gabapentin and continuing paroxetine.

7. Hypothyroidism A: Assessment: The patient has been diagnosed with hypothyroidism as evidenced by statements in her past

medical history. TSH values and other information unavailable. She is currently taking levothyroxine 75

mcg, 1 tab PO QD. Recommend continue current therapy and re-evaluate if patient becomes symptomatic

or TSH levels change, and obtain TSH every 6-12 months if stable (obtain 6 weeks after any dosage

adjustments).

8. Glaucoma A: Assessment: The patient has glaucoma as evidenced by statements in her past medical history. No other

information is available. She is currently taking timolol maleate 0.5%, 1 gtt OU QHS. Recommend

continue current therapy and follow-up with physician/ ophthalmologist for eye exams as appropriate.

9. Omeprazole use with unknown indication A: Assessment: LG likely has either GERD or PUD as evidenced by statements in her past medical history

regarding the need for “GI prophylaxis” and her use of omeprazole 20 mg daily at home. Recommend

continue current therapy for now and follow with primary care provider to obtain diagnostic history, but

discontinue therapy if no clear diagnosis is present due to the potential for serious adverse effects.

10. Seasonal Allergies A: Assessment: LG has seasonal allergies as evidenced by statements in her past medical history. No other

information is available. She is currently taking cetirizine 10 mg QD and latanoprost 0.005% 1 gtt OU

BID. Recommend continue current therapy and re-assess if patient becomes symptomatic.

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References 1. Nicolle LE, Bradley S, Colgan R, et al. Infectious Diseases Society of America guidelines for the

diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis. Mar

2005;40(5):643-54. Epub 2005 Feb 4. Available from:

https://academic.oup.com/cid/article/40/5/643/363229

2. Nicolle LE, Gupta K, Bradley SF, et al. Clinical practice guideline for the management of

asymptomatic bacteriuria: 2019 update by the Infectious Diseases Society of America. Clin Infect

Dis [Internet]. 2019 May 2;68(10):e83-e110. Available from: https://www.idsociety.org/practice-

guideline/asymptomatic-bacteriuria/

3. Anger J, Lee U, Ackerman AL. Recurrent uncomplicated urinary tract infections in women:

AUA/CUA/SUFU guideline. J Urol [Internet]. Aug 2019;202(2):282-289. Available from:

https://www.auajournals.org/doi/10.1097/JU.0000000000000296

4. 2019 American Geriatrics Society Beers Criteria Update Expert Panel. AGS Beers Criteria for

Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. 2019;67(4):674-

694. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.15767

5. National Kidney Foundation. GFR calculator [Internet]. National Kidney Foundation, Inc. c2019.

Available from: https://www.kidney.org/professionals/kdoqi/gfr_calculator

6. Lexicomp [Internet]. Hudson (OH): Wolters Kluwer. c1978-2019. [updated 2019 Dec 19; cited

2019 Dec 20]; [about 8 screens]. Available from:

http://online.lexi.com.ezproxy.findlay.edu:2048/lco/action/home

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SOAP Note 2 Problem List:

1. Altered mental status/ Bipolar I Exacerbation/ Dehydration

1. Type 2 Diabetes Mellitus

2. Coronary Artery Disease (CAD)/ Hypercholesterolemia

3. Hypothyroidism

4. Hypertension

5. Resolved Vitamin B12 deficiency

6. Peripheral neuropathy

HPI: HK is a 70YO Caucasian female with a history of bipolar I disorder with psychotic features who

was admitted to the geriatric psychiatry unit for an evaluation due to altered mental status, delirium, and

paranoid behavior as well as dehydration. In September 2019, she spent 2 weeks in the ICU due to

delirium following anesthesia after a carotid endarterectomy. She was stable until last week when she

became delirious again. She has previously been stable on lithium + olanzapine + sertraline, but her

sertraline was discontinued during her ICU stay and restarted on 12/29/19. She has had 4 prior psychiatric

hospitalizations, her first being in 1975 following her first husband’s death, and has undergone several

sessions of ECT. She has a history of two instances of suicidal ideation and one suicide attempt in 2009

which led to her diagnosis of bipolar disorder.

PMH: Bipolar I disorder, type 2 diabetes mellitus x10-12 years, coronary artery disease, hypertension,

hypercholesterolemia, hypothyroidism, vitamin B12 deficiency, peripheral neuropathy

Surgical: Recent carotid endarterectomy, coronary artery bypass graft (CABG) x3, oophorectomy x1 FH: 15 years ago, 2 male cousins died by suicide within 4 years of one another

SH: The patient occasionally has wine. She quit smoking 33 years ago and quit caffeine 6 weeks ago. She

is not currently working and lives with her second husband. ROS: Positive for decreased sensation in the hands, “pocketing food” in the cheeks, and delayed

swallowing. Positive for a history of depressive episodes with psychotic paranoia, paranoid delusions, and

grandiose delusions. Negative for dizziness, weakness, chest pain, SOB, and extrapyramidal symptoms

(EPS).

O: Allergies: Bactrim, penicillins, and sulfa drugs; reactions unknown

Vitals (most recent): Temperature 36.6 C, HR 77, RR 18, BP 149/76, SpO2=94%, height=160 cm,

ABW= 69.5 kg, pain= none reported

PE: Appears alert in no acute distress. Periorbital edema and masked facies. Hearing aids bilaterally.

Normal heart rhythm. Diminished lung sounds anteriorly and posteriorly. All other systems normal.

Current Home Medications (confirmed):

Amlodipine 10 mg, 1 tab PO QD

Aspirin 81 mg, 1 tab PO QD

Clopidogrel 75 mg, 1 tab PO QD

Ezetimibe 10 mg, 1 tab PO QD

Gabapentin 100 mg, 1 cap PO TID

Olanzapine 10 mg, 1 tab PO QHS

Glimepiride 4 mg, 1 tab PO QD

Insulin glargine, 28 units SQ QHS

Levothyroxine 88 mcg, 1 tab PO QD

Lithium 300 mg, 1 tab PO BID

Losartan 50 mg, 1 tab PO QD

Rosuvastatin 40 mg, 1 tab PO QD

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Pertinent Labs:

On admission (12/29) Most Recent (1/1-1/2)

WBC 13.7 (high) Hgb 11.9 (low) Hct 36.3 platelets 227 Na 141 K 4.4 Ca 9.4 Cl 107 CO2 29.4 BUN 22 (high)

SCr 1.1 (high) glucose 132 (high)

Serum lithium 0.8 total cholesterol 93 mg/dL

HDL 28 mg/dL (low)

LDL 24 mg/dL

TG 204 mg/dL (high) free T4 1.26 ng/dL

free T3 1.6 pg/mL (low)

TSH 2.5 mIU/mL

WBC 18.1 Hgb 12.0 Hct 35.9 (low) platelets 227 Na 136 K 4.5 Ca 10.1

Cl 103 CO2 28.7 BUN 42 (high) SCr 1.2 (high) glucose 79

Serum lithium 1.3 (high)

Urinalysis: negative

Calculations: IBW= 52.4 kg, AjBW=59.24 kg, BMI=27.15, CrCl=40.8 mL/min (AjBW)

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1. Altered Mental Status/ Bipolar I Exacerbation/ Dehydration A: Assessment statement: The patient has altered mental status secondary to dehydration and a Bipolar I

depressive episode as evidenced by delusional thoughts, paranoid thoughts surrounding her husband, flat

affect, slow responses, poor eye contact, impaired focus and concentration, and poor attention. Her

urinalysis was negative, her most recent BUN is 42, she is not eating or drinking adequately, and her

lithium level was 1.3 mEq/L on 1/2/20.

P: Goals: 1) Remission of symptoms for the current episode, 2) Prevent relapses, 3) Improve psychosocial

functioning, 4) Minimize adverse effects and suicide risk, 5) Maximize adherence Pharmacologic: Continue sertraline at previous dose of 50 mg PO daily. Continue olanzapine 10 mg, 1

tab PO QHS and lithium 300 mg PO BID with meals.

Non-pharmacologic: Psychotherapy, fluid replacement, diet and exercise Monitoring and Follow-up: Monitor adherence on a medication log and monitor for mood episodes using

a mood chart or journal. Continue to manage comorbidities (diabetes, hypothyroidism). For lithium,

obtain serum concentration every 12 hours until dehydration resolves, then every 2 weeks until a

therapeutic level is reached (0.6-1.2 mEq/L and stable mood). Thereafter, monitor lithium levels every 3

months due to the patient’s age and comorbidities. Also monitor sodium levels, A1c, BUN, SCr and

weight every 3 months. Every 6 months, obtain thyroid panel, lipid panel, and ECG.

Rationale: Because this patient’s altered mental status and delirium presented acutely following a

surgery, and because she is not cognitively impaired at baseline per her medical records, she likely does

not have dementia. Rather, her mental status changes are likely due to a combination of dehydration and

her current bipolar depressive episode. CANMAT/ISBD 2018 guidelines list lithium or divalproex + an

SSRI as a first-line option for the acute treatment of bipolar I depression. HK is currently taking lithium

and recently restarted sertraline, so these two agents are a reasonable choice. However, the sertraline will

take approximately 4-6 weeks to exert its full antidepressant effects, so the efficacy of the regimen cannot

be assessed until then.

For maintenance therapy, the patient was previously controlled on a combination of olanzapine + lithium

+ sertraline. Olanzapine is a second-line antipsychotic agent per CANMAT/ISBD due to its adverse

effects. These include weight gain, new-onset type 2 diabetes, metabolic syndrome, and anticholinergic

effects. However, the guidelines do note that olanzapine has level 1 evidence for efficacy, and it has

previously been effective for this patient when used in a combination regimen. HK’s type 2 diabetes

seems to have been well-controlled at home based on her A1C, and her lipids also seem to be well-

controlled. Therefore, continuing olanzapine therapy due to its effectiveness and manageable adverse

effects for HK is reasonable. Though it is first-line for acute therapy as stated above, sertraline is not

specifically recommended for maintenance therapy (alone or in combination with other agents) per the

aforementioned guidelines. However, since HK has no contraindications to its use and is reported to have

done well on her previous regimen, continuing the sertraline after the resolution of her depressive episode

is justifiable. HK is also taking lithium as part of her maintenance regimen. Lithium is a first-line agent

per CANMAT/ISBD for maintenance of bipolar I disorder as monotherapy, but it is not first-line when

combined with olanzapine. However, it does have antidepressant and mood stabilizing effects which

explains its use in this patient. HK has been on lithium for many years, so long-term effects are a concern.

HK has hypothyroidism, which is likely a result of lithium use, and she is overweight, which may be

lithium-related weight gain. The patient did have a recent history of an elevated WBC count which is a

known side effect of lithium. Lithium is also nephrotoxic, and it should be avoided in patients whose CrCl

is less than 30 mL/min. HK’s most recent CrCl is about 40 mL/min. Switching HK to another mood

stabilizer such as divalproex would be beneficial to her in terms of reducing adverse effects. Divalproex

in particular is less nephrotoxic. However, dose adjustments and titrations of mood stabilizers can take

several weeks. Because HK has just restarted sertraline and is currently in a depressive episode, she is at

risk of switching to a manic state. She must be on a mood stabilizer at a therapeutic dose to prevent this.

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Therefore, it is reasonable to keep her on lithium, her current mood stabilizer. She is currently taking 600

mg total per day, which is a low dose, and this will help mitigate adverse effects. Additionally,

discontinuation of lithium may cause her to experience discontinuation-induced refractoriness, and she

may never again respond to lithium. If her renal function continues to decline and her CrCl approaches 30

mL/min, then discontinuation of lithium (via a slow taper) and starting a different mood stabilizer will be

necessary. Divalproex is ideal as it can be combined with antipsychotics in a similar manner to lithium

per the guidelines. In terms of non-pharmacologic therapy for HK, reminding her of the importance of

eating and drinking when she is depressed are critically important to prevent further dehydration and

lithium toxicity (her serum level is 1.3 mEq/L which is slightly elevated). She particularly cannot be on a

sodium- or fluid-restricted diet. Psychotherapy sessions need to be put into place for her as well, and these

should be continued long-term.

Patient Education: -Make sure to stay well hydrated. This is especially important if you are vomiting, have diarrhea, have a

fever, or are heavily sweating.

-Avoid alcohol or excessive caffeine. These can dehydrate you and affect your sleep and mood.

-Lithium may cause acne, alopecia, worsening psoriasis, decreased libido, dry mouth, or altered taste. Let

your doctor or pharmacist know if these become bothersome for you.

-Some people may gain weight on lithium therapy. Eat a balanced diet and incorporate mild exercise into

your routine. This will help you manage your diabetes as well.

-Take your medication consistently, even if you think you do not need it or your mood is better.

-Get medical help if you suddenly experience symptoms such as hand tremors, muscle twitching, slurred

speech, sleepiness, vertigo, confusion, loss of appetite, incontinence, vomiting or diarrhea.

2. Type 2 Diabetes Mellitus/ Overweight A: Assessment: HK has type 2 diabetes mellitus that was controlled at home as evidenced by an A1c of 7%

and blood glucose readings averaging between 75-136 while inpatient. Her glucose has been as low as 29

due to lack of food and fluid intake recently, so her antidiabetic medications have been held. HK is also

overweight as evidenced by a BMI of 27. At home, she has been taking metformin 1000 mg PO BID,

insulin glargine 28 units SQ daily, and glimepiride 4 mg daily. Recommend close monitoring of blood

glucose (one reading in the morning before breakfast and another reading 2 hours after a meal) at home

upon discharge, and if readings continue to be low, consider discontinuation of glimepiride due to its

propensity to cause severe hypoglycemia per AGS Beers criteria. Otherwise, continue current home

medications, and educate patient on diet and mild exercise to control weight. Also obtain A1c every 3

months.

3. CAD/Dyslipidemia A: Assessment: The patient has coronary artery disease and hypercholesterolemia as evidenced by a history

of CABG x 3 and carotid endarterectomy and labs as follows: total cholesterol 93 mg/dL, HDL 28 mg/dL

(low), LDL 24 mg/dL, TG 204 mg/dL (high). Pretreatment lipid panel not available. The patient is

currently aspirin 81 mg, 1 tab PO QD, clopidogrel 75 mg, 1 tab PO QD, ezetimibe 10 mg, 1 tab PO QD

and rosuvastatin 40 mg (high-intensity statin), 1 tab PO QD. Recommend continue dual antiplatelet

therapy. For dyslipidemia, recommend continue current therapy as long as patient tolerates the high-

intensity statin; also recommend diet and lifestyle modifications. If statin becomes intolerable then

moderate-intensity therapy (e.g., rosuvastatin 5 or 10 mg) can be considered.

4. Hypothyroidism

A: Assessment: HK has hypothyroidism as evidenced by statements in her past medical history and labs as

follows: free T4 1.26 ng/dL, free T3 1.6 pg/mL (low), and TSH 2.5 mIU/mL. She is currently taking

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levothyroxine 88 mcg, 1 tab PO QD. Recommend continue current therapy, re-evaluate if patient

becomes symptomatic, and obtain TSH every 6-12 months (maintain a goal TSH of 0.4–4.0 mIU/L).

5. HTN

A: Assessment: HK has hypertension as evidenced by statements in her past medical history. Home BP

readings are unavailable. SBP has ranged from ~103-166 while inpatient and the patient has been in poor

health due to hypoglycemia and dehydration predominantly. HK is currently taking amlodipine 10 mg, 1

tab PO QD and losartan 50 mg, 1 tab PO daily. Recommend to keep a log of daily BP readings at home,

continue current medications, and show log to primary care provider at next appointment.

6. Resolved Vitamin B12 Deficiency A: Assessment: The patient has previously had a vitamin B12 deficiency as evidenced by statements in her

past medical history. Her most recent vitamin B12 level was 1290 ng/mL on 12/29 and no supplements

were found in her medication history. Her folate level on 12/29 was 48.4 ng/mL. Metformin use may lead

to B12 deficiency, while kidney and liver dysfunction may lead to elevations in B12 levels, so

recommend obtaining methylmalonic acid (MMA) and homocysteine levels if B12 deficiency is

suspected in the future.

7. Peripheral neuropathy A: Assessment: HK has a history of peripheral neuropathy as evidenced by statements in her past medical

history. Upon admission she complained of decreased sensation in her hands but has not mentioned any

symptoms recently. She currently takes gabapentin 100 mg PO TID for neuropathy. Recommend continue

current therapy and re-evaluate if bothersome symptoms arise.

References 1. Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments

(CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the

management of patients with bipolar disorder. Bipolar Disord [Internet]. Mar 2018;20(2):97-170.

Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5947163/

2. American Geriatrics Society Beers Criteria Update Expert Panel. AGS Beers Criteria for

Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc [Internet].

2019;67(4):674-694. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.15767

3. Lexicomp [Internet]. Hudson (OH): Wolters Kluwer. c1978-2019. [updated 2020 Jan 1; cited

2020 Jan 3]; [about 8 screens]. Available from:

http://online.lexi.com.ezproxy.findlay.edu:2048/lco/action/home

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Assignment #3:

1. Vancomycin dosing: Recommend a loading dose and maintenance dose of vancomycin

for a 79 YO female with cellulitis with SCr 1.1, weight 88 kg, and height 5’5”.

Loading dose is 15-20 mg/kg using ABW, and doses are rounded to the nearest 250 mg

per hospital protocol.

15-20 mg/kg * 88 kg= 1320-1760 mg/kg

LD= 1750 mg IV x1

To determine the maintenance dose, the pharmacist needs to calculate the patient’s

creatinine clearance.

ABW= 88 kg. IBW= 45.5 kg + (2.3* 5 inches) = 57 kg

The patient is >30% over her IBW, so AjBW should be used for CrCl:

AjBW= 0.4(88-57) + 57= 69.4 kg

CrCl= [(140-79) (69.4 kg)/ (72*1.1)] * 0.85= 45.43 mL/min

Per the hospital nomogram, an appropriate maintenance dose and interval is 1250

mg IV q 18h. However, the hospital does not utilize 18-hour dosing intervals (and

the patient is elderly), so this was adjusted to 1250 mg q 24 h.

Monitoring parameters:

Obtain a trough before the 4th loading dose (or 5th total dose) of vancomycin and

aim for a trough goal of 10-15 mcg/mL based on infection severity.

Also for efficacy, monitor for resolution of the cellulitis and resolution of

signs/symptoms of infection.

For toxicity, monitor for hypotension, flushing, rash, chills, nephrotoxicity,

ototoxicity, and phlebitis. If Red Man Syndrome occurs (characteristic red rash on

face, neck, and limbs), dilute the antibiotic and/or extend the infusion time to 1.5-

2 hours.

2. Warfarin dosing: A 45 YO female with a goal INR of 2-3 comes in to the clinic with

INR 4.9 today. She has been taking 5 mg warfarin every day. Warfarin will be held for 2

days due to her high INR. Create a new dosing regimen for the patient.

Her INR is supratherapeutic, indicating that her total weekly dose (TWD) of

warfarin needs to be decreased by 10-15%.

TWD= 5 mg * 7 days= 35 mg

10-15% of 35= 3.5-5.25, so her new TWD should be between 29.75-31.5 mg

Considering that the patient has 5 mg tablets at home, a reasonable TWD would

be 30 mg.

Her new dosing regimen should be 5 mg warfarin by mouth daily except 2.5

mg (1/2 tablet) on Monday and Friday.

Monitoring parameters:

Check INR in 2 days, then resume warfarin. Thereafter, come back every 4 weeks to

check INR.

Monitor for signs/symptoms of excessive bleeding such as unusual bruising, pink or

brown urine, frequent nose bleeds, bleeding gums, or cuts that take a long time to stop

bleeding.

Monitor for chest pain, shortness of breath, headaches, dizziness, or falls, and get

medical help for serious or debilitating symptoms.

Inform physician of any diet or medication changes.

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3. Digoxin Dosing: An elderly female is taking digoxin for atrial fibrillation with rapid

ventricular rate. She does not have heart failure. Her renal function has rapidly declined

due to infection and her estimated GFR is 18 mL/min. Her current digoxin dose is 125

mcg daily and her digoxin level was 3.66 ng/mL taken 6 hours after her last dose. Based

on her current GFR, adjust her digoxin dose.

Her digoxin level is supratherapeutic. The target serum concentration for this

patient is 0.8-2 ng/mL.

Patients with GFR 10-50 mL/min should receive 62.5 mg every 24-36 hours. This

patient’s GFR is nearer to the lower end of this range, so an appropriate dose is

62.5 mg every 36 hours.

Monitoring parameters:

Draw serum concentrations at least 6-8 hours after the last dose.

Monitor for signs and symptoms of digoxin toxicity including confusion, loss of

appetite, nausea/vomiting/diarrhea, irregular pulse, arrhythmias, and vision changes.

Monitor heart rate and rhythm and get periodic ECGs.

Monitor potassium, magnesium, and calcium levels periodically.

Inform physician of any diet or medication changes.

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Assignment #4:

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Assignment #5: Topic presentation is on pages 19-22 CGRP Antagonists: Mechanism, Therapeutics, and Role in Migraine Treatment

Prepared by Kendra Suder, PharmD Candidate 2021 Headache & Migraine Pathophysiology Review

A trigger leads to the release of serotonin (5-HT) and norepinephrine (NE)

Vascular dilation activates the trigeminovascular system

Once this is activated, various signals/mediators perpetuate continued vascular dilation

The headache occurs once signals reach the cortex

Migraines involve sensitization of trigeminal neurons (first peripherally and then centrally)

Migraines may or may not be preceded by premonitory symptoms and/or aura o Treatment is the same regardless of the presence of aura

When is Migraine Prophylaxis Indicated?

> 4 attacks/month or > 8 headache days/ month

Can’t tolerate/ contraindication to/ overuse of/ spending significant money on acute medications

Patient preference; quality of life affected

Certain migraine conditions (i.e. hemiplegic migraine)

Goal of Prophylaxis: 50% decrease in attack frequency or number of headache days Non-CGRP Agents Used for Prophylaxis

Beta blockers, verapamil

Antidepressants: TCAs, venlafaxine

Anti-epileptics: Divalproex sodium, topiramate

Others

Image adapted from: https://www.medscape.org/viewarticle/416382_5

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Fig. 5. From: FA Russell, et al. Physiol Rev. Oct 2014;94(4):1099-1142.

What is CGRP?

Calcitonin gene-related peptide, a 37-amino acid neuropeptide

Binds to CLR-RAMP receptors and mediates effects through a variety of GPCRs

Role in other conditions besides migraine o Cardioprotective (protects against hypertension, hypertrophy, inflammation) o Promotes wound healing, protective effect on aging o But pro-inflammatory in arthritis, may promote obesity

In migraine: promotes vasodilation and mast cell degranulation o CGRP antagonists serve to block these effects

CGRP Monoclonal Antibodies (-mabs)

Common administration counseling points: o Inject in abdomen, thigh, or upper arm o Avoid tender, red, bruised, irritated, or infected skin o Refrigerate, protect from light, do not freeze or shake o Allow to come to room temperature for 30 minutes prior to use

Common adverse effects: antibody development, injection site reaction

Hepatic/renal impairment not anticipated to affect pharmacokinetics

Unknowns: Elderly populations, pregnancy/breastfeeding safety

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Name Target Dosing/ Administration/ t½

Cost (AWP)*

Unique features/ pearls

Erenumab-aooe (Aimovig)

Receptor 70 mg SQ once a month Some patients: 140 mg monthly (half-life 28 days)

$690 -Single-use autoinjector -Do not inject within 2 inches of navel -Stable at room temp. for up to 7 days -Causes constipation

Fremanezumab-vfrm (Ajovy)

Ligand 225 mg SQ once a month OR 675 mg q 3 months (half-life 31 days)

$690 -Prefilled syringe -For the 675 mg dose, give 3 consecutive injections at the same body site (but not the exact same location) -Stable at room temp. for up to 24 hours -Those with cardiovascular disease excluded from clinical trials

Galcanezumab- gnlm (Emgality)

Ligand 240 mg SQ loading dose, followed by 120 mg SQ once a month (half-life 27 days)

100 mg/ml: $575 120 mg/mL: $690

-Auto-injector or prefilled syringe -Also approved for cluster headaches (different dosing)

*average wholesale price

CGRP Antagonists Place in Therapy: Summary

Patients who are a candidate for prophylaxis

Patients who have already tried or cannot take other therapies

Willing to give an adequate trial (at least 2 months)

Able to give injections

Can afford the medication New Agent: Ubrogepant (Ubrelvy)

Approved 12/23/19

Orally administered, small-molecule CGRP antagonist

Indicated for treatment of migraine only (not prophylaxis)

Common side effects: drowsiness, nausea, dry mouth

Metabolism: Substrate of BCRP/ABCG2, CYP3A4 (major), OATP1B1/1B3 (SLCO1B1/1B3), P-glycoprotein/ABCB1

Drug interactions! Contraindicated with use of strong CYP3A4 inhibitors

Thought that it may replace triptans in the treatment of acute migraine

Another oral agent called atogepant is in development

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References

1. Figure 1. Neurovascular hypothesis of headache. From: Medscape [Internet]. Medscape, c2019. New treatment options in migraine (updated Mar 2001; cited 2019 Dec 30];[about 1 screen]. Available from: https://www.medscape.org/viewarticle/416382_5

2. Silberstein SD. Preventive migraine treatment. Continuum (Minneap Minn) [Internet]. Aug 2015 [cited 2019 Dec 30];21(4 Headache):973-89. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4640499/

3. Russell FA, King R, Smillie SJ, Kodji X, Brain SD. Calcitonin gene-related peptide: physiology and pathophysiology. Physiol Rev [Internet]. Oct 2014;94(4):1099-142. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4187032/

4. Lexicomp [Internet]. Hudson (OH): Wolters Kluwer. c1978-2019. [cited 2019 Dec 30]; [about 12 screens]. Available from: http://online.lexi.com.ezproxy.findlay.edu:2048/lco/action/home

5. Allergan USA [Internet]. Ubrelvy (ubrogepant) [prescribing information]. Madison, NJ: Allergan USA Inc. December 2019. Available from: https://media.allergan.com/products/Ubrelvy_pi.pdf

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Assignment #6:

The following drug information question comes from a pharmacist:

“We have seen a lot of patients coming in who are on Remodulin. What are some of the common

adverse effects of this drug and how can we help manage them as pharmacists?”

Response:

Remodulin, generic name treprostinil, is a prostacyclin analog used to treat pulmonary

arterial hypertension (PAH). The Remodulin brand can be given via intravenous or subcutaneous

infusion, while other brands have different routes of administration.

Treprostinil has several significant adverse effects. One serious adverse effect is rebound

or worsening PAH. Pharmacists and physicians can help by adjusting doses gradually, especially

in those with renal impairment. Pharmacists should also counsel patients not to stop treprostinil

abruptly and to have back-up medication ready at all times, including a spare pump, tubing, or

inhalation device. If the infusion is interrupted for more than a few hours, re-titration may be

necessary. Another serious adverse effect is the potential for bloodstream infections and sepsis.

This risk is highest with the use of an indwelling central venous catheter, so pharmacists can

recommend switching patients to a continuous subcutaneous undiluted infusion instead. If an IV

infusion must be used, an implantable pump may have a reduced risk of infections compared to

an external pump. Treprostinil can also increase patient’s bleeding risk. Pharmacists can help

manage this by decreasing the dose of drugs that affect coagulation and bleeding such as aspirin,

clopidogrel, and warfarin. They can also counsel patients on signs and symptoms of bleeding

such as bruising, black tarry stools, coughing up blood, or bleeding from the gums. Patients

should seek medical attention for any bleeding that does not stop or for any head injuries.

Infusion site pain, jaw pain, limb pain, and headache are adverse effects that may be bothersome

for patients on treprostinil, and pharmacists can recommend that patients take acetaminophen for

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their pain. If the pain is severe and debilitating, opioid analgesics may be justifiable. Infusion site

reactions can also occur with treprostinil, and these may manifest as redness, induration, or skin

rash. Pharmacists can recommend changing the infusion site if a reaction occurs or using

antihistamines such as diphenhydramine. Severe infusion reactions may necessitate

discontinuation of treprostinil. Hypotension, flushing, vasodilatation, and syncope can occur with

treprostinil as well, especially in treatment-naïve patients. When initiating treprostinil, patients

need to be under continuous hemodynamic monitoring in an emergency department or other

qualified setting. For patients already on treprostinil, pharmacists should adjust any

antihypertensive medications and recommend that patients monitor their blood pressure daily at

home. Edema and fatigue can also be bothersome for patients, and these can be managed

through increased physical activity and diuretics, similar to a heart failure patient. Nausea,

vomiting, diarrhea, and abdominal distress can be managed by taking oral treprostinil tablets

with a meal containing at least 250 calories and 30-50% fat. Persistent nausea, vomiting or

headache may also indicate that the dose of treprostinil is too high in which case pharmacists can

recommend a dose reduction to the physician. For any restlessness and anxiety that patients

experience, pharmacists can recommend a short-term benzodiazepine or an SSRI such as

escitalopram for long-term management. With inhaled formulations of treprostinil specifically, a

cough or throat irritation may occur. Pharmacists can recommend hydration or throat lubrication

for patients in addition to reviewing proper inhaler technique. A final side effect of treprostinil is

hypokalemia. Pharmacists can recommend that patients have potassium levels drawn prior to

starting and while on treprostinil, and they can also counsel patients on signs and symptoms of

hypokalemia such as fatigue, muscle cramps, and heart palpitations which may indicate the need

for urgent medical attention.

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There are other less common adverse effects of treprostinil that were not discussed here,

but these can be managed using many of the same techniques. Treprostinil has many significant

adverse effects, and pharmacists are qualified to help patients manage these and improve their

quality of life.

References

1. Treprostinil [package insert on the Internet]. White Oak (MD): U.S. Food and Drug

Administration; 2002 May [updated 2018 Jun; cited 2019 Dec 28]. Available from:

https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/021272s026lbl.pdf

2. Lexicomp [Internet]. Hudson (OH): Wolters Kluwer. c1978-2019. [cited 2019 Dec 30];

[about 12 screens]. Available from:

http://online.lexi.com.ezproxy.findlay.edu:2048/lco/action/home

3. Malone PM, Malone MJ, Park SK. Drug information: a guide for pharmacists. 6th

Edition. New York (NY): McGraw Hill; 30 Dec 2019.