Mrs AA is a married 35-year-old patient who attends your community pharmacy regularly. Six months ago, she underwent a liver transplant, on a background of fulminant
hepatic failure due to viral cirrhosis.
Today, she presents with a prescription for fluconazole 50mg once daily orally for seven days. She tells you this is to manage vaginal candidiasis. She would really like if this
could be relieved before she goes on holidays next week to Spain.
Mrs AA’s ongoing medication are presented below.
• Advagraf®(tacrolimus) 13mg mane po
• Cellcept® (mycophenolate mofetil) 1mg bd po
• Co-trimoxazole 480mg once daily po
Task: Prepare a pharmaceutical care plan for this lady.
Grid to help assess, plan and monitor
Key issue (medication,
medical condition,
demographic)
Therapeutic goal
Mrs LF is a married 35-year-old
patient
community pharmacy
This is the context
Six months ago, she
underwent a liver transplant
Maintain transplanted organ
viability – Maintain adequate
immunosuppression
Consider effects of antirejection regimen (would have
included steroids)
Potential or actual drugrelated problem
Action
Childbearing age
Contraception?
This patient likely used potent
oral steroids over the past six
months – risk of reduced bone
density
Consider bone density and
bone health. Discuss with
patient.
Recommend style of life re
osteoporosis (weight-bearing
exercise, good diet (calcium
and VitD), smoking? and
alcohol consumption?
Monitoring
Consider merit of DEXA scan.
Question whether patient was
using any calcium or vitamin D
Prevent opportunistic
infections
Prevent adverse drug reaction
a background of fulminant
hepatic failure due to viral
cirrhosis
Prevent recurrence, consider
whether there might be any
ongoing liver pathology
Today, a prescription
for fluconazole 50mg once
daily orally for seven days.
Treat the vaginal candidiasis.
She tells you this is to manage
vaginal candidiasis
Avoid fluconazole-related
adverse reactions.
Avoid drug-drug interactions.
Monitor hepatic function,
ultrasound
Typical fluconazole treatment
for this is 150mg stat po. What
other treatments have been
trialled and how effective were
they
There is an interaction
between fluconazole and
tacrolimus. Fluconazole
increases the serum
concentration of tacrolimus
and could expose the patient
to nephrotoxicity, QT
prolongation and torsade de
pointes
Discuss with patient and
contact prescriber
Potential need to monitor the
serum concentration of
tacrolimus while this patient is
using fluconazole to ensure it
does not react toxic levels. The
other alternative is to reduce
the dose of tacrolimus while
using fluconazole.
If previous treatment have not
been trialled, could also
consider clotrimazole
pessary/vaginal cream.
Check renal function before
starting fluconazole
Baseline ECG to review QT
interval, and perhaps monitor
throughout.
Check electrolytes (another
potential risk factor for QT
prolongation).
Re-check all parameters after
fluconazole stops
Take extra steps to monitor for
the onset of any opportunistic
infections
Fluconazole might also inhibit
metabolism of
sulfamethoxazole to its active
metabolite
She goes on holidays next
week to Spain.
Advagraf®(tacrolimus)
13mg mane po
Avoid adverse drug reaction,
maintain medication safety and
effectiveness
Maintain risk of transplanted
organ rejection
Avoid adverse drug reaction,
e.g. toxicity
Sun health – this lady is
vulnerable to photosensitivity
because she is using
tacrolimus. While she needs to
protect her skin from UV light
at all times, this might be even
more important if she is
holidaying in a sunny spot
Educate patient about skin/sun
health
This drug has a narrow
therapeutic index. Potential
problems include:
Hypertension
Nephrotoxicity
Neurotoxicity
Ensure timing of administration
of doses continues to be
consistent. Food affects
absorption – capsules usually
taken one hour
before food or two to three
hours after eating
Enquire when levels were last
checked, and when BP and
renal function were last
checked.
Review PMR
Ensure patient is maintained
on the same brand to avoid
different bioavailability
Food may affect absorption –
discuss this with patient in
terms of holiday health as food
Remind patient about
photosensitivity
Discuss sun protection, e.g.
factor, clothing
Routine checking of:
BP
Renal function
Perhaps yearly, check:
BP
Renal profile
Cholesterol
Diabetes (serum glucose,
HbA1c, fasting glucose
tolerance test)
BNF states monitoring:
Monitor blood pressure, ECG
intake might change during
that period.
Discuss with patient did she
previously not tolerate a higher
dose of tacrolimus?
(for hypertrophic changes—risk
of cardiomyopathy), fasting
blood-glucose concentration,
haematological and
neurological (including visual)
and coagulation parameters,
electrolytes, hepatic and renal
function.
Re-emphasise patient
counselling to report any signs
of myelosuppression (infection,
bruising, bleeding).
Perhaps yearly, check:
BP
Renal profile
Cholesterol
Diabetes (serum glucose,
HbA1c, fasting glucose
tolerance test)
Photosensitivity is a potential
side effect – need to consider
specially while in Spain!
Cellcept® (mycophenolate
mofetil) 1mg bd po
Maintain risk of transplanted
organ rejection
Avoid adverse drug reaction,
e.g. toxicity
Why is this patient using
mycophenolate?
Could she not tolerate full dose
of tacrolimus? Usually due to
nephrotoxicity or neurotoxicity
Co-trimoxazole 480mg once
daily po
Avoid opportunistic infection
while immunosuppressed
BNF states monitoring:
Monitor full blood count every
week for 4 weeks then twice a
month for 2 months then every
month in the first year
(consider interrupting
treatment if neutropenia
develops).
There is an interaction
between tacrolimus and cotrimolxazole (potential
increased risk of
nephrotoxicity).
This drug also carries potential
to cause photosensitivity =
same advice regarding sun
Ensure routine monitoring of
kidney function and full blood
count is ongoing.
Noting that trimethoprim is a
component ingredient, and
that it can cause
hyperkalaemia, it might be
wise to also ensure routine
health generally and especially
in Spain, as above.
monitoring of serum
potassium.
Can also cause blood dyscrasias
Additional information gaps
Gap
What anti-rejection regimen was used for the
first six months post-transplant and did the
patient use corticosteroids
What has this lady already tried to manage
candidiasis, if anything
How to resolve
Check PMR, speak to patient and doctor
Relevance
Consider bone health, consider need to check
glycaemic profile
Speak with patient, check PMR
When was the full blood count last checked, was
it within normal limits?
Check patient record, speak with patient or team
Fluconazole 50mg daily for 7 days seems like a
lot. Potential to try a single 150mg dose or to try
local administration of clotrimazole pessary(s)
and cream. Local clotrimazole would reduce the
likelihood of an infection
Important to monitor with the med’s being used
to prevent transplant rejection.
Q1
Mrs AA is a 55 year old lady who has attended your pharmacy for the past decade to collect her
medication. She tells you that she was diagnosed with diabetes at the hospital today and would like
some advice about this. She wants to collect her regular prescription medication while she is here.
Her patient medication record shows the following:
–
Flutiform 50/5 (fluticasone/formoterol) metered dose inhaler, 1 puff twice daily, dispensed
monthly.
Salbutamol metered dose inhaler, 2 puffs as required , dispensed monthly
Evorel Conti 50/170m Transdermal Patch, 1 path every 3-4 days, dispensed monthly.
Deltacortril 40mg gastroresistant tablets, reducing dose as instructed, dispensed in June and
in May.
Task: Develop a pharmaceutical care plan for this lady.
Q2
AB, 34 year-old lady who suffers from chronic plaque psoriasis for the past few years, presents to
your pharmacy with a prescription for ciclosporin 2.5 mg/kg/daily. She was previously treated for this
condition with topical betamethasone 0.1% and acitretin with no response. The acitretin was
discontinued one month ago.
She currently suffers from diabetes treated with metformin and repaglinide, she is obese (BMI 33
kg/m2, weight 90kg, height 165 cm) and a heavy smoker (20 cigarettes per day).
Task 1 of 2: Develop a pharmaceutical care plan for this patient.
Two months later, AB presents to your pharmacy with a prescription for Clarithromycin LA 500 mg
once daily for seven days. This is to manage a lower respiratory tract infection.
Task 2 of 2: Describe how you would manage this
Q3
Ms HP is a 27-year-old lady who frequently attends your pharmacy to collect her prescribed
medications.Today she telephones you and tells you that she has had dreadful vomiting and
diarrhoea for the past 10 hours.
Although the diarrhoea has now eased a little, she is unable to keep any oral food or drink down. She
wonders if she sends her partner to the pharmacy, could you provide him with Imodium?
You access the lady’s patient medication record, displayed below. All items are dispensed and
collected monthly.
Item
Microlite®
Indication
Oral contraceptive pill
Gliclazide modified release 30mg Type 2 diabetes
once daily
Metformin 1g bd
Type 2 diabetes
Ramipril 10mg once daily
Hypertension
Paroxetine 30mg once daily
Anxiety and depression
The notes report that Ms HP has a body mass index of 29kg/m2.
Develop a pharmaceutical care plan for this lady.
Q4
Mrs AB is a 59 year old lady who attends your pharmacy every month. Today, she presents with a
new prescription from the ophthalmologist and tells you she was recently diagnosed with glaucoma.
Today’s prescription reads:
Azarga (Brinzolamide 10mg/ml and timolol 5mg/ml) eye drops
Insert 1 drop into both eyes twice daily.
Upon reviewing Mrs AB’s patient medication record, you establish that this lady experiences
osteoporosis. Her long-term medications are:
Calcium carbonate 1000mg twice daily
Vitamin D3 400 units twice daily
Prepare a pharmaceutical care plan for this lady.
Q5
Mrs Day, 32-years-old, presents to the pharmacy today. She requests a good vitamin or tonic and
mentions that she is feeling run down and has noticed mouth ulcers. She has also noticed that her
psoriasis seems to be less well controlled recently with lesions presenting more often and excessive
scales. She is planning her summer holidays to the sun in the coming weeks and does not want to be
embarrassed by what she calls “the state of her skin”.
You know this lady as she collects her monthly prescription here, as follows:
Medication and Indication:
Methotrexate 15mg once per week – Psoriasis and associated peripheral arthritis
Folic acid 5mg three days per week – Associated with methotrexate use
Prepare a pharmaceutical care plan for this lady.