Student Pulmicort flexhaler DMI (0.09 mg/actuat), Ventolin HFA

Student Name: Jagdeep Bhullar                                             Student
ID: 989244381                               

Case Name (including
Date): 1/30/18    

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Problem/ Disease

Pertinent Data
Collected (S/O)

Drug related problem (DRP) * identified

Assessment of the Drug related problem (DRP), immunization status
& preventative care needs, guidelines used

Plan (Treatment goals,
non-drug & optimal pharmacological Tx plan, patient education )

Rationalize your optimal pharmacologic plan.
List 3 alternatives.

Follow-up (Monitoring &
Evaluate effectiveness, ADR, etc.)

Diabetes

41 yo WM; BMI 43; Ht: 5’10”; Wt: 300 lbs; gained
13 lbs since last visit;
Polydipsia, fatigue, irritability, trouble
initiating sleep,
 
SH:
2 to 3 alcoholic drinks; 3 to 4 cups of coffee per
day.
 
Med
list: 
Glyburide 10 mg BID, Benazepril 10 mg qd,
Pravastatin 20 mg qd, , Pulmicort Flexhaler, Ventolin HFA, Aspirin 81 mg qd,
Ibuprofen 400 mg Q6H prn back pain, Glucosamine 2 tabs qd for knee pain.
 
Labs:
Glucose: 176 mg/dL
A1C: 8.5%
HDL: 34 LDL:120
TG: 240 (high)
eGFR 75.9
ALT 39 (High)
AST 41 (High)

Needs additional drug therapy

The patient is currently on Glyburide 10 mg BID
for his uncontrolled DM 2. Since the patient is experiencing weight gain,
which may also further complicate his co-morbidities, he should be considered
for alternative therapies. According to the ADA guidelines, the patient is
indicated for Metformin 500 mg BID which is first line therapy for his
disease state. However, due to the side effect profile which has previously
led to severe GI complications, alternatives such as GLP-1 should be
considered.
 
 
Immunizations:
–        
Influenza
–        
Hep B. (3 series)
–        
PPSV 23

Goal of therapy:
–        
Control
DM2-> A1c<7% -         Improve QOL     Initiate Liraglutide 0.6 mg qd for 1 week; then increase to 1.2 mg qd; if optimal glycemic response not achieved, may increase further to 1.8 mg qd.    D/C Glyburide.   Patient education: -         Administer into belly, upper arm, thigh, or buttocks. -         Rotate injection site in the same region. -         Attach new needle before each dose. -         Store unopened pens in a refrigerator. -         Store opened pens at room temperature or in a refrigerator. After opening, use or discard within 30 days. 1.      Canagliflozin 2.      Pramlintide 3.      Exenatide   The drug of choice was selected based on its SE profile which allows patient to lose weight and lower CV risk. Follow-up in 3 months. Monitor BG and A1c Monitor ISR and acute pancreatitis. Asthma S/sx are increasingly bothersome to the patient. Using SABA 2-3 x per day for past 2 months. SOB at night. Peak flow is 380, 65% is predicted, Pulmicort flexhaler DMI (0.09 mg/actuat), Ventolin HFA MDI 2 puffs QID PO PRN SOB. Dose too low The patient has been using his SABA more than the recommended amount with exacerbation of symptoms. According to NAEPP guidelines, patient's therapy should be adjusted to include a medium dose ICS.   Immunizations: -Influenza -Hep B. 3 series -PPSV23 Goal of therapy: -         Improve lung function -         Improve QOL -         Decrease usage of rescue inhaler   Increase dose of pulmicort flexhaler to 180mcg 2 inhalations PO BID. Continue Ventolin HFA MDI 2 puffs PO QID PRN SOB.   PE: -         Rinse and spit after using inhaler. -         If insomnia is experienced, don't take before bedtime. The patient is recommended for a step up.   Alternatives: -         Symbicort 80/4.5 -         Prednisone -         Methylprednisolone Monitor patient's inhaler technique. Follow-up in 2 weeks to test for improvements in FEV1/FVC ratio. GAD S: Irritability, being on edge, trouble initiating sleep; constant worries about health, work, and relationship.   O: SH: 2-3 alcohol drinks per week, denies drug use, 3-4 cups of coffee per day.  Needs additional drug therapy. Patient has symptoms aligned with GAD for the past 3 months that include irritability, constant worry, and trouble sleeping. According to NICE guidelines, patient should be initiated on the first line therapy, which is SSRI. GOT: -         Control anxiety -         Improve QOL   Start Sertraline 50 mg po qd.   Start CBT. Start exercise 30 mins for 3x a week. Decrease and eliminate, if possible, caffeine and alcohol consumption.   PE: -         The drug takes time to work, so do NOT stop you don't find immediate relief. -         Do NOT d/c drug w/o physician's approval. -         May experience dizziness, HA, and suicidal thoughts.   SSRI and CBT is first line for GAD. Sertraline is approved for the condition and has a safe ADR profile for the patient.   Alternatives: -         Citalopram -         Escitalopram -         Paroxetine     Monitor body weight, BMI, CBC, BP, HR.   Follow up in 4-6 weeks to ensure effectiveness of therapy. HTN 2-3 alcoholic beverages/week 3-4 cups of coffee/day   UACR 30mg/g BP 150/88   Benazepril 10 mg qd. Needs additional drug therapy Patient has uncontrolled BP on his current therapy of ACE-I. According to the AHA, the patient has Class 2 HTN and requires additional therapy. The patient's UACR also indicates the need for a renal protective agent such as Benazepril. GOT: Reduce BP to below 130/80 to minimize microvascular and macrovascular complications associated with the disease.   -         Increase Benazepril to 20 mg PO qd. -         Start Chlorthalidone 12.5 mg PO qd. -         Start a low sodium DASH diet. -         Increase exercise based on tolerance.   PE: -         Do not get up too fast, which may provoke an orthostatic hypotension episode. -         Drink plenty of fluids. Evaluate patient's compliance to current therapy before adjusting. A thiazide diuretic is added b/c it is first line therapy for HTN, which may add to the effects of the current therapy. Also, ACE-I can lead to hyperkalemia, which can be off set by the hypokalemic effects of the diuretic.     Alternatives: -         HCTZ 25 mg PO qd -         Amlodipine 5 mg PO qd -         Losartan 50 mg PO qd Monitor electrolytes, renal function (SCr, CrCL), signs of angioedema, BP, and UACR.   Follow-up in 1 month to asses therapy efficacy. Hyperlipidemia - 41 yo - TC: 202 mg/dL - HDL: 34 mg/dL - LDL: 120 mg/dL - TG: 240 mg/dL - eGFR 75.9 mL/min - ALT 39 - AST 41 - Pravastatin 20 mg QD - Aspirin 81 mg QD - 10 year ASCVD risk = 6.5% Dosage too low Patient is currently on a low intensity statin with less than desired results. According to the AHA/ACC guidelines, a patient with this age, LDL levels, DM disease state and ASCVD risk of 6.5 is recommended for moderate to high intensity statin. GOT: Get lipids under optimal levels to reduce the risk of future CVD events. Increase Pravastatin to 40 mg PO qd. Exercise more than 150 minutes per week. Increase fruits and vegetables and decrease fat from diet.   PE: -         Pravastatin may be taken at anytime of the day. -         Do not consume grapefruit juice while on this medication. Alternatives: -         Atorvastatin 10 mg. -         Simvastatin 40 mg -         Lovastatin 40 mg.   All of the above drugs are moderate intensity, so they should have similar effects. Current therapy was increased in dose b/c the patient was already tolerating the previous drug. Follow-up in 3 months.   Monitor FLP, ALT/AST, myalgia, BG/A1c. Obesity Wt: 300 lbs with BMI of 43. Constant hunger is an issue for the patient. Fatigue and limited physical activity. Needs additional drug therapy According to WHO guidelines, the patient is classified as a class 3 obese. His current physical stature doesn't help his comorbidities, including HTN, DM2 and dyslipidemia. Patient needs medications lower his weight. GOT: Lose 1-2 lbs/week.   New diabetic regimen. Exercise Diet rich in fibrous carbs and protein. Liraglutide, a GLP 1 agonist will slow down gastric emptying, increase insulin secretion, and decrease glucagon. All of which will help patient lose weight. Follow up in 3 months to assess weight loss progress.   Medication Reconciliation: