Case 1

1. Enumerate 4 risk factors

a. Age (64 y/o)
b. Female sex (99% of cases are seen in female)
c. Late menopause (56 y/o; median age is 52 y/o)
d. 2 pack year smoking
e. Alcohol consumption - dapat daw moderate to severe so di ko sure ‘to kasi
occasional lang sabi. Anyway 4 lang naman hinihingi
f. Diet (fatty foods) - still controversial but there are articles saying that this is also a
risk factor

2. What is the stage of disease?

a. Stage IIIA (T2N2M0)

3. Give TWO goals of treatment in her breast cancer.

a. Prevention of loco-regional recurrence and distant metastasis
b. Prolong survival

4. What parameter will you obtain for the dose of her chemo agent?
a. Body Surface Area
b. Nutrition (to consider drug elimination)

5. What scoring system will you follow to check for the activity of your patient?
a. Eastern Cooperative Oncology Group (ECOG) performance status

9. Identify the cytoprotective agents that is appropriate for her and give the chemo agent.

9.1 ​Mesna​ binds acrolein to its free sulfhydryl groups forming the nontoxic stable compound.
This drug is used for what chemo agent she received? ​Cyclophosphamide

9,2​ ​AMIFOSTINE​ is metabolized to free thiol that binds to free radicals generated by tumor.
This drug is used for ​CYCLOPHOSPHAMIDE

9.3​ The Biologic effect of Methotrexate can be reversed by ​LEUCOVORIN

SUMMARY OF CASE MANAGEMENT

Problem No 1. Breast Mass
Impression: Breast CA
Evidence:
Subjective:
- 64 year old, G1P1
- Menopause 8 years ago

Objective:
- BP = 140/80 mmHg, PR = 80/min, RR = 18/min, T = 36.7 o​​ C, ECOG = 0
- Palpation of the breast mass = irregularly shaped mass approximately 2x4 cm, located
at the RUQ, firm, fairly movable with palpable axillary lymph node on the ipsilateral side
- Biopsy = invasive ductal carcinoma
- Radical Mastectomy = involvement of 5/21 harvested axillary lymph node

Pharmacological Mgt

A chemotherapy regimen, or schedule, usually consists of a combination of drugs given in a

specific number of cycles over a set period of time. Chemotherapy may be given on many
different schedules depending on what worked best in clinical trials for that specific type of
regimen. It may be given once a week, once every 2 weeks (also called dose-dense), once
every 3 weeks, or even once every 4 weeks. There are many types of chemotherapy used to
treat breast cancer. Common drugs include:

· Capecitabine (Xeloda)
· Carboplatin Cisplatin
· Cyclophosphamide
· Docetaxel (Taxotere)
· Doxorubicin

A patient may receive 1 drug at a time or a combination of different drugs given at the same
time. Research has shown that combinations of certain drugs are sometimes more effective
than single drugs for adjuvant treatment. The following drugs may be used as adjuvant therapy
for early-stage and locally advanced breast cancer:

· AC (doxorubicin and cyclophosphamide)

· EC (epirubicin, cyclophosphamide)
 · AC or EC (epirubicin and cyclophosphamide) followed by T (doxorubicin
and cyclophosphamide, followed by paclitaxel or docetaxel, or the reverse)
· CAF (cyclophosphamide, doxorubicin, and 5-FU)

Hormonal therapy ​(endocrine therapy) is an effective treatment for most tumors that test
positive for either estrogen or progesterone receptors (called ER-positive or PR-positive. This
type of tumor uses hormones to fuel its growth. Blocking the hormones can help prevent a
cancer recurrence and death from breast cancer when used either by itself or after
chemotherapy.

● Tamoxifen.​ Tamoxifen is a drug that blocks estrogen from binding to breast cancer
cells. It is effective for lowering the risk of recurrence in the breast that had cancer, the
risk of developing cancer in the other breast, and the risk of distant recurrence.
● ​Aromatase inhibitors (AIs).​ AIs decrease the amount of estrogen made in tissues
other than the ovaries in postmenopausal women by blocking the aromatase enzyme.
● ​Ovarian suppression. ​Ovarian suppression is the use of drugs or surgery to stop the
ovaries from producing estrogen. There are 2 methods used for ovarian suppression:
· Gonadotropin or luteinizing releasing hormone (GnRH or LHRH) drugs stop the
ovaries from making estrogen, causing temporary menopause.

o ​Goserelin (Zoladex)
o ​Leuprolide
● Surgery to remove the ovaries, which also stops estrogen production.

Hormonal therapy for women after menopause

Women who have gone through menopause and are prescribed hormonal therapy have several
options:

· Tamoxifen for 5 to 10 years

· An AI for 5 to 10 years
· Tamoxifen for 5 years, followed by an AI for up to 5 years.

Non-pharma management
The treatment for any type of cancer needs a multidisciplinary team. Cancer care teams include a variety
of other health care professionals, such as physician assistants, oncology nurses, social workers,
pharmacists, counselors, nutritionists, and others. For people older than 65, a geriatric oncologist or
geriatrician may also be involved in care.

After surgery, the next step in managing breast cancer is to lower the risk of recurrence and to get rid of
any remaining cancer cells. Cancer cells that are undetectable are believed to be responsible for a cancer
recurrence as they can grow over time. ​Adjuvant therapies are given after surgery and may include
radiation therapy, chemotherapy, targeted therapy, and/or hormonal therapy. Radiation therapy may be
recommended after mastectomy if patient have a larger tumor, cancer in the lymph nodes, cancer cells
outside of the capsule of the lymph node, or cancer that has grown into the skin or chest wall, as well as
for other reasons. For those who need therapy after a mastectomy, it is usually given 5 days a week for 5
to 6 weeks. Radiation therapy can be given before or after reconstructive surgery.

Reconstructive (plastic) surgery​: Women who have a mastectomy may want to consider breast
reconstruction. This will recreate a breast using either tissue taken from another part of the body or
synthetic implants. Patient may be able to have reconstruction at the same time as the mastectomy
(immediate reconstruction) or at some point in the future (delayed reconstruction). An external breast
prosthesis or artificial breast form provides an option for women who plan to delay or not have
reconstructive surgery. These can be made of silicone or soft material, and fit into a mastectomy bra.
Breast prostheses can be made to provide a good fit and natural appearance for each woman.

Women with a very high risk of developing a new cancer in the other breast may consider a bilateral
mastectomy​. This includes women with BRCA1 or BRCA2 gene mutations and women with cancer in
both breasts. For women not at very high risk of developing a new cancer in the future, having a healthy
breast removed in a bilateral mastectomy neither prevents cancer recurrence nor improves a woman’s
survival.

An important part of cancer care is ​relieving a person’s symptoms and side effects9​. This includes
supporting the patient with his or her physical, emotional, and social needs. It focuses on reducing
symptoms, improving quality of life, and supporting patients and their families. It works best when it is
started as early as needed in the cancer treatment process. Treatments for managing symptoms and side
effects vary widely and often include medications, nutritional support, relaxation techniques, emotional
support, and other therapies.

Integrative medicine​, which may be helpful to manage symptoms and side effects, is the combined use
of medical treatment for the cancer along with complementary therapies, such as mind-body practices,
natural products, and/or lifestyle changes. The following are several complementary options to help
manage side effects during and after breast cancer treatment:
· ​Music therapy, meditation, stress management, and yoga for reducing anxiety and
stress.

· ​Meditation, relaxation, yoga, massage, and music therapy for depression and to
improve other mood problems.
 · ​Meditation and yoga to improve general quality of life.

· ​Acupressure and acupuncture to help with nausea and vomiting from chemotherapy.

Case 2
Guide Questions:
1. Give the diagnosis: FOLIC ACID DEFICIENCY

2. Give any two signs and symptoms that will support the diagnosis
- Dyspnea on exertion
- Easy fatiguability
- Palpitations
- Lack of appetite
- Pale palpebral conjunctivae
- Pale nailbeds
- Systolic murmur during inspiration

3. Give any two lab findings that will support the diagnosis
- MCV of more than 100 (112 fL)
- Hct 25.5% (nv: 37-48% women)
- WBC 2000/uL with hypersegmented PMN (hypersegmented PMN often are induced by
vit b12 or folic acid deficiency)

4. What are the three risk factors of folic acid deficiency present in this case?
- Pregnancy
- History of excessive alcohol intake
- Being undernourished (maybe related to consuming vitamin-poor diet)
5. Why does symptoms of folic acid deficiency appear quickly?
- Since the patient is pregnant, the patient is prone to have folic acid deficiency. It is
because developing baby needs more folic acid during their development. The mother
also absorbs it more slowly. A lack of folate during pregnancy is linked to major birth
defects that affect the brain, spinal cord, and spine (neural tube defect)
6. What is the main difference between the clinical manifestation of vitamin B12 deficiency and
folic acid deficiency?
- Classic triad of clinical findings associated with vitamin B12 deficiency is weakness and
fatigue, glossitis, and paresthesias. In Folic acid deficiency, there is no presence of
paresthesia or any tingling sensation.

7. The gynecologist requested an ultrasound to determine fetal status. What specific

abnormality can this examination detect as a consequence of a nutrient deficient mother?
A detailed ultrasound is a part of routine prenatal checkup and it can detect 95% of neural tube
defect cases. At around 18-20 weeks Spina Bifida may be detected.

8. What should be the daily dose of FA in this case?

The recommended dietary allowance for pregnant women is 600 micrograms/day. This included
folate from the food eaten or supplements taken.

9. What are the two main reasons for giving High dosage supplementation in this patient?
1. Folic acid reduces the risk for birth defects of a baby’s brain and spine such as spina
bifida and anencephaly and by 50% or more. It can also protect against birth defects that
may form before a woman knows she is pregnant.
2. Folic acid is used to treat deficiencies, which can cause certain types of anemia and
other problems because folate deficiencies are more common in people who have
digestive problems, kidney or liver disease, or alcohol abuse which can be seen in the
patient.

10. When will reversal of the RBC morphology be observed after start of treatment?
Reticulocyte count will be increased in 3-4 days, followed by a fall in MCV and a rise in Hb
levels within 10 days.

11. When will hypersegmented neutrophils disappear from the blood smear?
Hypersegmented neutrophils tend to disappear in 10-14 days.

12. When will reticulocyte count increase after start of supplementation?

-The reticulocyte count promptly increases after treatment, peaking at 1 week following folic acid
administration.

13. If the deficiency is due to Vitamin B12 deficiency instead but the treatment given is folic acid,
what will be the two consequences?
-Purely neurologic presentations will prevail, whereas the hematological manifestations seem to
have diminished

14. What two important patient education should be given with regards the MAIN problem of this
patient?
-Since the patient is pregnant, she should increase her dietary intake of folate-containing foods
(from 200-400 microg/day to 500-800 microg/day). She should also take folic acid supplements.
-Patient should also completely avoid alcoholism
as alcohol abuse causes the liver to run out of stored nutrients, causing the body to draw
nutrients out of the bloodstream to make up the difference thus leading to folic acid deficiency.

SUMMARY OF CASE MANAGEMENT:

Impression:​ Pregnancy, Uterine, G4P2, 20 weeks AOG, Megaloblastic Anemia

Subjective:

·​ ​Undernourished

·​ ​First prenatal check-up at 20 weeks AOG

·​ ​No regular prenatal check-ups during her two previous pregnancies

·​ ​7 years history of excessive alcohol intake

·​ ​3 years history of cocaine use

rd​ rd​
·​ ​3​ child was anencephalic, born at 36 weeks AOG, died at 3​ hour of life

·​ ​Dyspnea on exertion

·​ ​Easy fatigability

·​ ​Palpitations

·​ ​N/V

·​ ​Lack of appetite since her pregnancy started

Objective

·​ ​BP – 100/70 (hypotensive)

·​ ​PR – 100 bpm (tachycardia)

·​ ​Pale palpebral conjunctivae and pale nail beds

·​ ​+ systolic murmur

·​ ​Anemia – low RBC and Hct, high MCV

·​ ​Leukopenia with Hypersegmented PMN

·​ ​Thrombocytopenia – low platelet count

Management of the case including rationale (Pharma and Non-pharma)

PHARMACOLOGIC MANAGEMENT
Folic Acid
Women who are pregnant are advised to take ​600 mcg of folic acid per day from fortified foods
or supplements. ​Women with a history of previous pregnancy complicated by neural tube defects usually
take 4 mg per day beginning ​one month before ​and ​continuing for up to 3 months after conception​.
(webmd.com)
Side effects:​ There are ​no serious side effects when taking folic acid. Most adults do not
experience any side effects when used in doses less than 1000 mcg daily. In rare cases, individuals
report an upset stomach; other rare side effects are abdominal cramps, diarrhea, rash, sleep disorders,
irritability, confusion, nausea, stomach upset, behavior changes, skin reactions, seizures, gas, excitability.
But usually, if a person takes more folate than needed, there is no cause for concern. It is because folic
acid is water-soluble, any excess will be naturally passed in urine.
Other info: (your choice if you’ll write this :) )
MOA​: Necessary for formation of coenzymes in metabolic systems (purine and pyrimidine synthesis
required for maintenance in erythropoiesis); stimulates platelet production in folate deficiency anemia. It also
enhances elimination of formic acid in methanol toxicity via provision of coenzyme to folate dehydrogenase.
Absorption: ​Proximal part of small intestine. ​Metabolism​: Liver. ​Elimination: ​Urine.
• Oral preparations of folic acid are inexpensive and stable. Several effective pathways of specific
and nonspecific folate absorption operate throughout the small intestine; hence, oral replacement is the preferred
mode of folic acid therapy.
• Parenteral folic acid preparation is also available; it may be considered in severe malabsorptive
states. Larger doses, often given parenterally in specialized regimens, are required for patients with hereditary folate
malabsorption
• Recommended daily allowance (RDA)
o Males: 400 mcg/day PO
o Females: 400-800 mcg/day PO
o Pregnant women: 600 mcg/day PO
o Nursing women: 500 mcg/day PO
o Upper limit: 1 mg/day PO
o Neural Tube Defects Prophylaxis
o Females of childbearing potential: 400 mcg/day PO
o Pregnant women: 600 mcg/day PO
o Females with high risk or family history of neural tube defects: 4 mg/day PO
o Folic Acid Deficiency: 0.4-1 mg PO/IV/IM/SC once daily

NON-PHARMACOLOGIC MANAGEMENT
Patients should consume foods that are naturally high in folate which include dark green leafy
vegetables (such as spinach, broccoli, and lettuce), okra, asparagus, fruits (such as bananas, melons,
and lemons) beans, yeast, mushrooms, meat (such as beef liver and kidney), orange juice, and tomato
juice. Be careful not to overcook these, as the folic acid content can drop considerably when exposed to
heat.
Pregnant women should completely avoid alcohol, and everyone else with a folate deficiency
should decrease their alcohol intake.

Case 3

1. What are the subjective (history) and objective (physical exam, labs, ancillary
procedures) that point to the diagnosis of hypertension and dyslipidemia?

Subjective Findings:
● Family history - Father is hypertensive
● Smoker (7 pack-years)
● Fond of eating fast food and sweets
● Occasional alcoholic beverage drinker
● Not being able to go to the gym as often as he used to

Objective Findings:
 ● BP = 150/90
● BMI = 31 (obese II)
● Apex beat located at 6th left ICS
● CXR = heart is slightly enlarged
● 12-Lead ECG = Left Ventricular Hypertrophy
● Total Cholesterol = 220 mg/dl (borderline high)
● Triglyceride = 150 mg/dl (borderline high)
● LDL = 140 mg/dl (borderline high)
● HDL = 35 mg/dl
● HbA1c = 6%

2. Fill in the blanks in the table below that define Hypertension stage 2 and the treatment or
follow-up procedures.

BP Category SBP DBP Treatment or Follow-up

Hypertension > or = to o > or = to ​90 Recommended healthy lifestyle

Stage 2 140 r changes and BP lowering medication (​2
medications of different classes);
reassess in 1 month for effectiveness
If goal is met in 1 month, reassess in
3-6​ months
If goal is not met after 1 month,
consider different medications or
titration
Continue​ monthly​ follow-up until
control is achieved
Source: American Heart Association 2017 Guidelines
3. Describe the 4 drug classes for initial choice of the antihypertensive drug therapy as to:
prototype, mechanism of action, and important adverse effects.

4. Enumerate the 6 most important non-pharmacological interventions in the management

of high BP.
-DASH diet
-Reduced sodium intake
-Reduced caloric intake if weight loss is needed
-Moderate fat consumption from unsaturated fat sources
-Regular exercise

5. The patient in the case has a calculated 10 year ASCVD risk of 18.8% and is therefore
recommended to receive a moderate intensity statin. Describe moderate intensity statins
as to % LDL-C reduction and drug regimen.

Treatment Intensity % LDL-C Reduction Drug Regimen

Moderate Intensity 30 - 49% Atorvastatin 10 mg (20 mg)

Fluvastatin 40 mg BID
Rosuvastatin (5mg) 10 mg
Simvastatin 20-40 mg
 6. Fill in the blanks. For individuals without evidence of ASCVD who are more than or equal
to 45 years old and with 2 or more risk factors (as is presented with the case), statins are
recommended for primary prevention of ASCVD. For these patients, lipid determination
should be done after ​4-12 weeks/ 1-3 ​months of treatment and ​every 3 to 12 months
thereafter.

7. While on statin therapy, the patient presents with elevated AST/ALT that is more than or
equal to 3 times the upper limit of normal. What 3 things will do?
a. Discontinue statin and repeat then LFTs in a month
b. Discontinue any other hepatotoxic drugs
c. Give lifestyle modification such as losing weight, reducing alcohol intake and improving
diabetic control

SUMMARY OF THE CASE MANAGEMENT:

PROBLEM NO. 1 (chief complaint): ​for executive check-up

Impression: ​Metabolic Syndrome

Evidence pertaining to your impression (subjective/objective)

3 out of 5
1. Hypertriglyceridaemia - 150mg/dl
2. Low HDL - 35mg/dl
3. Elevated BP - 150/90

Subjective:
● Has not been watching what he eats (FOND OF EATING FAST FOOD AND SWEETS)
● Admits to not being able to go to the gym as he used to (means of exercise)
● Smokes 4 sticks a day, since 15 years old (PACK YEARS: 3)
● Occasional alcoholic beverage drinker (how often is occasional? Lawyer…)
Objective:
 ● Height: 170 cm, Weight: 90 kg
● BMI: 31.14 (OBESE)
● BP: 150/90
● CXR: Heart is slightly enlarged
● ECG: LVH by Sokolow-Lyon Index (R in V5 or V6 + S in V1 >35mm)
● HbA1C 6% ([4-5.6% N] [​5.7-6.4% higher chance: diabetes]​ [6.5% increase chance:
diabetes])
● Total Cholesterol: 220mg/dl ([​200-239 borderline high]​ [240 and above - high])
● LDL: 140mg/dl ([100-129 acceptable] [​130-159 borderline high]​ [160-189 high])
● HDL: 35 mg/dl (N: 40-59)
● Triglycerides: 150mg/dl ([​150-199 borderline high​] [200-499 high])

management of the case including rationale (pharma/non pharma)

Non pharma:
● Recommended healthy lifestyle changes
● Monthly follow-up until control is achieved
● Reduced sodium intake - Salt makes your body retain water. If you eat too much, the
extra water stored in your body raises your blood pressure.
● DASH diet - encourages you to reduce the sodium in your diet and eat a variety of foods
rich in nutrients that help lower blood pressure, such as potassium, calcium and
magnesium.
● Reduced caloric intake and practice regular exercise if weight loss is needed - for the
patient’s case; he is obese and needs weight loss.

Pharma
● Atorvastatin 10 mg (20 mg), Fluvastatin 40 mg BID, Rosuvastatin (5mg) 10 mg,
Simvastatin 20-40 mg - drug regimen for patient with 10-year ASCVD risk of 18.8% and
is recommended to receive a moderate intensity statin
● Thiazide diuretics - commonly recommended as first-line treatment for raised blood
pressure because they significantly reduce death, stroke and heart attacks.
● Calcium Channel Blockers - are drugs used to lower blood pressure. They work by
slowing the movement of calcium into the cells of the heart and blood vessel walls, which
makes it easier for the heart to pump and widens blood vessels.
● Angiotensin converting enzyme (ACE) inhibitors - are high blood pressure drugs that
widen or dilate the blood vessels to improve the amount of blood the heart pumps and to
lower blood pressure
● Angiotensin II receptor blockers - block the effect of angiotensin II, a chemical that
narrows blood vessels. By doing so, they help widen blood vessels to allow blood to flow
more easily, which lowers blood pressure. ARBs are generally prescribed for people who
cannot tolerate ACE inhibitors.
Case 4

CASE 4:

1. State the main clinical problem of this patient and state your bases.
A 57 year old male complained with excruciating pain of his left toe, which favors the diagnosis of
Acute Gout.

Bases:
● 57, Male
● Complains of excruciating pain on left big toe
● Pain worsened after consuming chicharon bulaklak, peanuts and different kinds of liquor
● With comorbidities that may be associated with higher incidence of gout: Diabete mellitus
type II, hypertension and hypercholesterolemia
● Flare triggering drug: Hydrochlorothiazide
● On PE: erythematous, tender, edematous, and warm to touch left big toe
● Serum Uric Acid: 7.5mg/dl (↑; NV: 3.1-7.0mg/dl)

2. What is the pathophysiology involved in gout. (May use flow chart)

3. What is the main diagnostic test for gout?

Diagnostics

Diagnostic arthrocentesis (Synovial Fluid -used to rule out pseudigout or infectious arthritis
Analysis) -stronglynegative birefringent needle-shaped MSU
crystals both intra- and extracellularly
-thick chalky/opaque fluid; WBC 2,000-60,000/ul;
good string sign

Joint Imaging -Joint swelling early in disease

-Cystic changes with well defined erosions and
overhanging sclerotic margins in late disease
-Soft tissue masses(tophi) in advanced disease

Serum Uric Acid levels -May be low or normal at the time of attacks
-Hyperuricemia defined as:
> 7 mg/dL (men)
> 6 mg/ dL (pre-menopausal women)

24-hr uric acid collection - >800 mg/24h (over-producers)

- <600 mg/24h (under-excretors)

4. What are the risk factors for gout in this patient?

- Male
- Age: 57
- Lifestyle choices: Alcohol use and consumption of food that causes gout (chicharon bulaklak and
peanuts)
- Use of hydrochlorothiazide
- Health problems like hypertension, hypercholesterolemia, and DM type 2

5. What are the goals in the management of the main clinical problem of this patient?

a. The goal of therapy is to reduce uric acid levels to less than 6-7 mg/dL (men)
- Promote a healthy lifestyle by means of ​no alcohol consumption esp. during an acute
gout attack, stop smoking, and ​restricting dietary ​intake of ​purine-rich ​meat, nuts and
seafood.
- Consider alternative antihypertensive agents other than ​hydrochlorothiazide​.

6. MEDICATIONS FOR ACUTE FLARE OF GOUT

For acute attacks, assess ​pain intensity​ of the patient:
If mild/moderate pain, initiate ​monotherapy​: - NSAID (or coxib)
- Colchinine 500 mcg bid or qds
- Corticosteroid (i.a., oral, i.m., i.v.)
If severe pain, initiate ​combination therapy​: - Colchicine + NSAID or Oral corticosteroid
- NSAID or Colchicine or Oral corticosteroid + Intra-articular corticosteroid
 MODE OF ACTION ADVERSE CONTRAINDICATION
EFFECT

NSAIDs

INDOMETHACIN ● Potent nonselective Headache, CKD, Stomach and

COX inhibitor Dizziness, Intestinal ulcer, Seizures,
● inhibit Confusion, GI Pregnancy, Salicylates
phospholipase A effects and NSAID allergies
and C, reduce
neutrophil migration,
and decrease T-cell
and B-cell
proliferation.

IBUPROFEN Reversible COX inhibitors Headache, CKD, Stomach and

and thus inhibit the Dizziness, Intestinal ulcer, Seizures,
synthesis of PGs but not of Confusion, GI Pregnancy, Salicylates
LTs effects and NSAID allergies

CELECOXIB ● Inhibit PG synthesis Less GI side CKD, Stomach and

without affecting the effects Intestinal ulcer, Seizures,
COX-1 isoenzyme No impact on Pregnancy, Salicylates,
(GIT, kidneys, platelet NSAIDS and COX2
platelets) aggregation inhibitor allergies
● COX-2 is induced at No
inflammation sites cardioprotective
and is constitutively effect
active in the kidney Increased CV
thrombotic
events

COLCHICINE

COLCHICINE ● Binding to Diarrhea, Rhabdomyolysis, Renal

intracellular protein Nausea, impairment, severe liver
tubulin. Vomiting, disease,
● the inhibition of Hepatic G6PD deficiency, Anemia
leukocyte migration necrosis, Acute
and phagocytosis. renal failure,
● inhibits the formation DIC, Bone
of leukotriene B4 marrow
and IL-1β depression.,

CORTICOSTEROID

GLUCOCORTICOID ● Reduction of Osteoporosis, Infectious arthritis,

cytokines, Hypertension, Bacteremia, Periarticular
chemokines, Diabetes, cellulitis/ulceration,
adhesion molecules Weight gain, Osteomyelitis
 and other Increased
inflammatory infection,
proteins Thinning of the
● Prevent recruitment skin, Bruising
of inflammatory cells easily
to sites of
inflammation

7. If the above medications are contraindicated in this patient, what is the final recourse? Give the
adverse effects and things to monitor when giving this option.
Corticosteroid injection (Intra-articular injection of 10 mg triamcinolone acetonide) is an effective
alternative first-line therapy for patients in whom NSAIDs and colchicine are contraindicated.

The most commonly occurring adverse effects following intra-articular injection are calcinosis, post
injection flare, headache, and arthralgia.
Things to monitor:

1. Monitor ​blood pressure​ and ​serum​ ​sodium​ and p

​ otassium​ levels.

2. Monitor patients for hypothalamic-​pituitary​-adrenal (HPA) ​axis suppression, ​Cushing syndrome​,

and ​hyperglycemia​.

3. Monitor ​bone​ density in long-term use

8. When do you give uricosuric lowering therapy to this patient? When starting ULT, what
prophylaxis should be given and what is its purpose?
ULT should be given if the patient already has tophi or chronic gouty arthritis. ​When starting ULT,
Colchicine at doses of 0.6 mg once or twice daily for a minimum of six months can be used as prophylaxis
against acute gout attacks while low-dose NSAIDs (25 mg indomethacin twice a day or naproxen 250
mg/day) can be used for prophylaxis in colchicine-intolerant patients. Prophylaxis should be given to
prevent the predictable attacks triggered when gout patients begin ULT.

9. What are the current drugs used to lower uric acid? In a tabulated form, state the mechanism of
action, adverse effects and things to monitor.

DRUGS MOA ADVERSE EFFECT THINGS TO MONITOR

URICOSURIC DRUGS

Probenecid Inhibits the reabsorption of uric acid at the -​GI irritation

Sulfinpyrazone proximal convoluted tubule, thereby promoting its -Rash
- ​employed to excretion and reducing serum uric acid -Nephrotic syndrome
decrease the body pool has occurred after the
of urate in patients with use of probenecid
tophaceous gout -Both may rarely cause
or in those with aplastic anemia
increasingly frequent
gouty attacks.

URICOSTATIC
DRUGS

Allopurinol Decrease uric acid -​precipitating gout (the -Serum Uric Acid
- The preferred and synthesis (inhibit reason to use -CBC
standard-of-care xanthine oxidase, the concomitant colchicine -Fluid input and output
therapy for gout during enzyme that catalyses or NSAID) -SGOT, SGPT
the period between the conversion of -GI intolerance -Creatinine, BUN
acute episodes is hypoxanthine to (including nausea, -Signs and symptoms
allopurinol xanthine then uric acid) vomiting, and diarrhea) of hypersensitivity
-peripheral neuritis
and necrotizing
vasculitis
-bone marrow
suppression and
aplastic anemia may
rarely occur
-Hepatic toxicity and
interstitial nephritis
-allergic skin reaction
characterized
by pruritic
maculopapular lesions
-exfoliative dermatitis
-In very rare cases,
allopurinol has become
bound to the lens,
resulting in cataracts

Febuxostat Febuxostat is a potent -As with allopurinol, -Serum Uric Acid

- Febuxostat is a and selective prophylactic treatment -SGOT, SGPT
non-purine xanthine inhibitor of xanthine with colchicine or -Creatinine, BUN
oxidase inhibitor that oxidase, thereby NSAIDs should be
was reducing the formation started at the beginning
approved by the FDA in of xanthine and uric of therapy to avoid gout
2009. acid without affecting flares.
- well tolerated in other enzymes in -increased liver
patients the purine or pyrimidine enzymes
with a history of metabolic pathway -diarrhea, headache,
allopurinol intolerance and nausea
 URICASE

Pegloticase Degrades uric acid -Gout flare can occur -Serum uric acid
-the newest (Converts uric acid to during treatment with -CBC
urate-lowering therapy allantoin) pegloticase, especially -SGOT, SGPT
to be approved for the during the first 3–6 -Creatinine, BUN
treatment of refractory months of treatment,
chronic gout. requiring prophylaxis
with NSAIDs or
colchicine.
-Immune response to
pegloticase
-Anaphylaxis
-Nephrolithiasis,
arthralgia, muscle
spasm, headache,
anemia and nausea
-Rare SE: upper
respiratory tract
infection, peripheral
edema, urinary tract
infection, and diarrhea
–Hemolytic anemia in
patients with G6PD
deficiency

10. What is the target serum acid level when giving ULT?
Uricosuric Lowering Therapy attempts to normalize serum uric acid to <300-360 umol/L (5.0-6.0
mg/dL) to prevent recurrent gouty attacks and eliminate tophaceous deposits.
Q
II. Summarize the management for this patient including your choice of drugs for the patient’s
other co-morbidities. State your rationale for every choice of medication
● Colchicine initial dose 1.2mg OD followed by a single dose of 0.6 mg - indicated for terminating
acute gouty attack and can also be used as prophylaxis in between attacks
● Allopurinol initial dose 100mg OD, titrated upward - this is the preferred and standard of care
therapy for gout during the period between acute episodes. This is the first line agent for chronic
gout. It reduces total uric acid body burden by inhibiting xanthine oxidase.
● Metformin 1000mg BID - for the management of the patient’s type 2 DM. this is the first-line agent
and most effective oral medication for DM. This reduce microvascular complications, does not
cause hypoglycemia, and does not cause weight gain but rather it causes mild weight reduction
● Vitamin B complex - to correct for the 20-30% reduction of vitamin B12 from metformin
● Chlorthalidone 12.5mg OD, Captopril initial dose 75mg OD and maintenance dose 150mg OD -
this is for the patient’s hypertension. The combination of thiazide and ACE inhibitor is
recommended for stage 1 hypertension. Chlorthalidone is more efficacious than
 hydrochlorothiazine as a diuretic, and with the combination of captopril as the ACEi will attenuate
the diuretic induced potassium loss from the diuretic. ACE inhibitors are also preferred to patients
with ischemic heart disease and this also slows the development of diabetic glomerulopathy and
other chronic renal diseases.
● Atorvastatin 10mg OD - for the patient’s dyslipidemia. This is recommended for patients with
cardiovascular risk factors and diseases. Atorvastatin is preferred because of its longer half-life
thus having a greater cholesterol lowering effect. This drug can also be given any time of the day
thus optimizing adherence

III. LIFESTYLE MODIFICATION

Avoidance of purine rich foods (Organ meats, Sardines, Salmon) and alcohol may help lower uric acid
levels and prevent significant fluctuations in serum uric acid that may precipitate acute attacks. Obesity
and increased fat distribution are risk factors for gout.
● Eating a healthy balanced diet of low-fat proteins, low-fat dairy and vegetables will help maintain
a healthy weight which is beneficial for the prevention of gout attacks as well.

Case 5 (Fermin)
Gregorio, Gungon, Isidro, Jabat, Javellana​, ​Lantion, Lao

1. Given the above information, what is your assessment of the patient’s condition?

Salient Features:

30 year old, male

Involved in a motor vehicle accident 6 months ago
Lost his girlfriend in the accident
6 months – extremely pessimistic about life, generally sad, gets out of bed to drink and hasn’t
been working

Past Medical History:

· ​(+) Allergic rhinitis
· ​(+) Chronic knee pain​ due to ACL injury ​x 1 year
· ​Alcohol dependence x 3 years
· ​Bipolar disorder I x 4 years

Family History:
· ​Mother – hypertensive
· ​Father – hypertensive, ​generalized anxiety disorder

Alcohol/ Substance use

· ​Drinks ​one bottle of Smimoff vodka (750 mL) daily
· ​Occasional illicit use of Marijuana

Medications:
· ​Loratadine​ 10 mg OD – antihistamine
· ​Etoricoxib​ 120 mg OD PRN – NSAID
· ​Lithium Carbonate​ 300 mg PO in the morning, and 600 mg at bedtime – mood stabilizer

Physical Examination:
· ​Conscious and coherent, with ​signs of acute distress
· ​BP:130/90 mmHg
· ​HR: 110 bpm
· ​RR: 20 cpm
· ​T: 37°C
· ​Pain level: 0/10
· ​Increased cardiac rate
· ​(+) Enlarged liver
· ​(+) tremors in the hands

Laboratory Test Results:

CO2: 25 mEq/L ↓
LDH: 200 IU/L ↓
AST: 260 IU/L ↓
ALT: 130 IU/L ↓

Impression:

Alcohol Withdrawal Syndrome

● History of alcohol dependence x 3 years
● Drinks 1 bottle of Smimoff vodka (750 mL) daily
● Sympathetic NS activation (​↑​ Heart rate, ​↑​ BP)
● Tremors in the hands
● Low AST, ALT, LDH
● Hepatomegaly
Depression
● Extremely pessimistic about life, generally sad, drinks in a daily basis, not working for 6
months
Marijuana Abuse
● Occasional illicit drug use of Marijuana
 ● Altered pain sensitivity – Pain Scale of 0/10

2. What signs and symptoms of Alcohol withdrawal is this patient’s presenting with?

Upon presentation, the patient shows signs of acute distress. His blood pressure
is increased, along with his heart rate. Hand tremors were also noted.

3. WHich of the laboratory findings supported your diagnosis?

AST: 260 IU/L (5-30 U/L) ​Inc​. (May indicate Alcohol Induced Liver Damage)
ALT: 130 IU/L (5-30 U/L) ​Inc​. (May indicate Alcohol Induced Liver Damage)
ALDH: 200 IU/L (50-150 U/L) ​Inc​.
ALP: 41 IU/L (50-100 I/L) ​Dec​.
Lithium: 0.3 mEq/L (Therapeutic Levels 0.6-1.2 mEq/L) ​Dec​.

4. How should alcohol withdrawal be managed for this patient?

Ruling out alternative diagnoses​ — Alcohol withdrawal remains a clinical diagnosis. It may be
necessary to perform extensive testing, including lumbar puncture and cranial CT, to rule out
other diagnostic considerations with confidence. This is particularly true when the presentation
includes altered mental status and fever. Conditions, such as infection (eg, meningitis), trauma
(eg, intracranial hemorrhage), metabolic derangements, drug overdose, hepatic failure, and
gastrointestinal bleeding, can mimic or coexist with alcohol withdrawal. A premature diagnosis
of alcohol withdrawal can lead to inappropriate use of sedatives, which can further delay
accurate diagnosis.

Symptom control and supportive care — ​ Once comorbid illnesses have been excluded or
adequately treated, the management of alcohol withdrawal is directed at alleviating symptoms
and identifying and correcting metabolic derangements. Benzodiazepines are used to control
psychomotor agitation and prevent progression to more severe withdrawal. Supportive care,
including intravenous fluids, nutritional supplementation, and frequent clinical reassessment
including vital signs, is important. Clinicians must avoid complacency when treating patients with
alcohol withdrawal.

Patients should be placed in a quiet, protective environment. Mechanical restraint may be

necessary temporarily for patients suffering from delirium tremens (DT) in order to protect both
the patient and caretakers. Clinicians should follow their facility's guidelines for documentation
and implementation of physical restraints. Once adequate chemical sedation is achieved,
physical restraints should be removed, as resistance against restraints can increase
temperature, produce rhabdomyolysis, and cause physical injury.

Volume deficits can be calculated and replaced accordingly, or, if there are no contraindications,
isotonic intravenous fluid can be infused rapidly until patients are clinically euvolemic. Thiamine
and glucose should be administered in order to prevent or treat Wernicke's encephalopathy.
Multivitamins containing or supplemented with folate should be given routinely, and deficiencies
of glucose, potassium, magnesium, and phosphate should be corrected as needed. Initially (first
day or two), treatment should be intravenous as gastrointestinal absorption is impaired in many
patients who abuse alcohol chronically.

Some clinicians treat alcohol withdrawal patients with an intravenous infusion of a combination
of thiamine, folate, and a multivitamin in isotonic saline with 5 percent dextrose. The multivitamin
makes the fluid appear yellow, and thus, this treatment combination is sometimes referred to as
a “banana bag”. Use of this treatment has not been well studied, and it may not meet the
specific requirements for fluid, glucose, and other substrates of many patients with alcohol
withdrawal.

During the early phases of withdrawal alcoholic patients are often given nothing by mouth (ie,
NPO) to prevent aspiration. However, nutritional support is essential as alcoholic patients are
frequently malnourished and have high metabolic needs due to their excited autonomic state.
Initially, parenteral glucose supplementation is sufficient, but additional nutrition may be needed
for patients who remain unable to eat for more than a day or two. Patients considered at high
risk for complications should be monitored in an intensive care unit.

5. What are some risks of not appropriately managing alcohol withdrawal?

● Withdrawal seizures​ — Withdrawal-associated seizures are generalized tonic-clonic
convulsions that usually occur within 12 to 48 hours after the last alcoholic drink, but may
occur after only two hours of abstinence. The seizures occur predominantly in patients
with a long history of chronic alcoholism, as evidenced by their typical onset during the
fourth and fifth decades of life.
● Alcoholic Hallucinosis ​- Alcoholic hallucinosis refers to hallucinations that develop
within 12 to 24 hours of abstinence and typically resolve within 24 to 48 hours which is
the earliest point at which delirium tremens typically develops. Hallucinations are usually
visual, although auditory and tactile phenomena may also occur. Patients are aware that
they are hallucinating and often very distressed.
● Delirium Tremens​ - Approximately 5 percent of patients who undergo withdrawal from
alcohol suffer from DT. DT is defined by hallucinations, disorientation, tachycardia,
hypertension, hyperthermia, agitation, and diaphoresis in the setting of acute reduction
or abstinence from alcohol. DT typically begins between 48 and 96 hours after the last
drink and lasts one to five days.
 6. WHat psychiatric illness relate to alcohol dependence?
- Alcohol dependence can cause signs and symptoms of depression, anxiety, psychosis,
and antisocial behavior both during intoxication and during withdrawal.

7. What are the goals of management?

** Alcoholism can be treated pharmaceutically, but there is no medical cure for it.
Short Term Goals Long Term Goals

● Alleviate any pain felt at the moment.
● Relief from Allergic Rhinitis
● Watch out for / treat withdrawal
symptoms from alcohol if signs are
observed
● Complete abstinence from Alcohol
○ Weaning off alcohol through
the use of medication
● Control Bipolar behaviors
○ Suppress / treat depression.

8. Give pharmacologic management in this case

Pharmacological Intervention:

Alcohol Withdrawal Syndrome

Detoxification
- ​A patient who presents in a medical setting with an alcohol-withdrawal syndrome should
be considered to have a potentially lethal condition. Although most mild cases of alcohol
withdrawal never come to medical attention, severe cases require general evaluation; attention to
hydration and electrolytes; vitamins, especially high-dose thiamine; and a sedating medication
that has cross-tolerance with alcohol.
- ​To block or diminish the symptoms, a ​short-acting benzodiazepine​ can be used at a dose
of 15-30 mg every 6-8 hours according to the stage and severity of withdrawal; some authorities
recommended a long-acting benzodiazepine unless there is demonstrated liver impairment.
Anticonvulsants​ such as carbamazepine have been shown to be effective in alcohol withdrawal,
although they appear not to relieve subjective symptoms as well as benzodiazepines. After
medical evaluation, uncomplicated alcohol withdrawal can be treated effectively on an outpatient
basis. When there are medical problems, a history of seizures, or simultaneous dependence on
other drugs, hospitalization is required.
Complete abstinence is the objective of long-term treatment and this is accomplished mainly by
behavioral approaches.
1. ​Disulfiram​ has been useful in some programs that focus behavioral efforts on ingestion of
the medication. Disulfiram blocks aldehyde dehydrogenase, the second step in ethanol
metabolism, resulting in the accumulation of acetaldehyde, which produces an unpleasant
flushing reaction when alcohol is ingested.
2. ​Naltrexone​, an opioid receptor antagonist that blocks the reinforcing properties of alcohol,
is an adjunct in the treatment of alcoholism. Chronic administration of naltrexone resulted in
decreased rate of relapse to alcohol drinking in the majority of published double-blind clinical
trials. It works best in combination with behavioral treatment programs that encourage adherence
to medication and abstinence from alcohol. Animal studies have demonstrated that alcohol
causes the release of endogenous opioids in brain reward systems and the disinhibition or
activation of DA neurons, a condition common to all drugs of abuse. Blocking opioid receptors
prevents this dopaminergic effect and results in less stimulation or reward from alcohol.
3. ​Acamprosate​, is a competitive inhibitor of the N-methyl-D-aspartate (NMDA)-type
glutamate receptor. The drug appears to normalize the dysregulated neurotransmission associated
with chronic ethanol intake and thereby to attenuate one of the mechanism that lead to relapse.

Depression
· ​Following initiation of antidepressant drug treatment there is generally a “therapeutic lag”
lasting 3-4 weeks before a measurable therapeutic response becomes evident. This is the reason
that electroconvulsive therapy may be the treatment of choice for agitated, depressed patients
with a high risk of suicide. Some patients may respond to antidepressant treatment sooner than
3-4 weeks; others may require > 8 weeks for an adequate response. ​In general, if a patient does
not respond to a given antidepressant after an 8-week trial on an adequate dose, then switching to
another antidepressant with a different mechanism of action is a reasonable next step (e.g., SSRI
to SNRI). If a partial response has been observed, other drugs may be added to the primary SSRI
or SNRI medications; these additive medications include the antidepressant drug bupropion,
thyroid hormone (triiodothyronine), or an atypical antipsychotics (aripiprazole or olanzapine)
(Shelton, 2007).
· ​After the successful initial treatment phase, a 6-12 month maintenance treatment phase is
typical, after which the drug is gradually withdrawn. If a patient has experienced two separate
episodes of major depression or is chronically depressed (i.e., > 2 years), lifelong treatment with
an antidepressant is advisable​. Certain psychotherapies such as cognitive behavioral therapy or
behavioral activation therapy are suitable options for many patients and may reduce the risk for
relapse (DeRubeis et al., 2008).
· ​Finally, in addition to ​electroconvulsive therapy​, other non- pharmacological
interventions have been developed; these include ​transmagnetic stimulation of the brain and deep
brain stimulation​ (Rakofsky et al., 2009).
· ​The challenge of management of the depressive episode through the “therapeutic lag” is
compounded by the early emergence of side effects. Most of the adverse reactions are well
tolerated. A significant aspect of effective management of depression is informing the patient
about the time course of both the therapeutic and side effects of medications and encouraging
persistence with treatment.
· ​Another important issue in the use of antidepressants is a phenomenon known as the
“switch” from a depressed episode to a manic or hypomanic episode (Goldberg and Truman,
2003), a significant challenge in managing bipolar illness. For this reason, antidepressants are not
recommended as monotherapy for bipolar illness.
· ​However, patients with bipolar illness may present with major depressive episodes early
in the course of their illness. SSRIs and bupropion may be somewhat less likely to induce the
switch from depression to mania than antidepressants from other pharmacological classes.

1. SSRI (Selective Serotonin Reuptake Inhibitors)

- ​Effective in treating major depression. SSRIs also are anxiolytics. SSRI initially blocks
reuptake and results in enhanced and prolonged serotonergic neurotransmission. Increased
synaptic availability of serotonin stimulates a large number of postsynaptic 5-HT receptor
subtypes, as well as somatodendritic and presynaptic terminal receptors that regulate
serotoninergic neuron activity and serotonin release

2. SNRI (Serotonin and Norepinephrine Reuptake Inhibitors)

- ​SNRI inhibit both SERT and NET. Depending on the drug, the dose, and the potency at
each site, SNRI cause enhanced serotonergic and/or noradrenergic neurotransmission. Similar to
the action of SSRIs, the initial inhibition of SERT induces activation of 5-HT1A and 5-HT1D
autoreceptors. This action decreases serotonergic neurotransmission by negative feedback
mechanism until these serotonergic autoreceptors are desensitized. Then, the enhanced serotonin
concentration in the synapse can interact with postsynaptic 5-HT receptors.

3. TCA (Tricyclic Antidepressants)

- ​TCAs inhibit both norepinephrine and serotonin uptake. It also have antimuscarinic and
antihistaminic effects.

4. 5HT2 Antagonist
- ​The efficacy of trazodone may be somewhat more limited than the SSRIs; however, low
doses of trazodone (50-100 mg) have been used widely both alone and concurrently with SSRIs
or SNRIs to treat insomnia. When used to treat depression, trazodone typically is started at 150
mg/day in divided doses with 50 mg increments every 3-4 days. The maximally recommended
dose is 400 mg/day for outpatients and 600 mg/day for inpatients.
- ​Both mianserin and mirtazapine are quite sedating and are treatments of choice for some
depressed patients with insomnia. The recommended initial dosing of mirtazapine is 15 mg/day
with a maximal recommended dose of 45 mg/day. Since the t1/2 is 16-30 hours, the
recommended interval for dose changes is no less than 2 weeks.
- ​The most potent pharmacological effects of trazodone are blockade of the 5-HT2 and α1
adrenergic receptors. Trazodone also inhibits the serotonin transporter, but is markedly less
potent for this action relative to its blockade of 5-HT2A receptors. Similarly, the most potent
pharmacological action of nefazodone also is the blockade of the 5-HT2 family of receptors.
- ​Both mirtazapine and mianserin potently block histamine H1 receptors. They also have
some affinity for α2 adrenergic receptors, which is claimed to be related to their therapeutic
efficacy, but this point is questionable. Their affinities for 5-HT2A, 5-HT2C, and 5-HT3
receptors are high, though less so than for histamine H1 receptors.

5. MAOI (Monoamine Oxidase Inhibitors)

- ​MAOIs inhibit the catabolism of norepinephrine and serotonin.
- ​As irreversible inhibitors of both MAO- A and MAO- B, these drugs have pronounced
effects on the body’s ability to metabolize endogenous monoamines (e.g., 5-HT, NE, and DA)
and exogenous monoamines (e.g., tyramine). The protection of exogenous monoamines leads to
significant drug and food interactions. More recently, reversible and selective inhibitors of
MAO- A and MAO- B have been developed (Livingston and Livingston, 1996), and these have
fewer side effects and fewer interactions with food and other drugs.

Marijuana Abuse
· ​Marijuana abuse and addiction have no specific treatments. Heavy users may suffer from
accompanying depression and thus may respond to antidepressant medication, but this should be
decided on an individual basis considering the severity of the affective symptoms after the
marijuana effects have dissipated. The residual drug effects may continue for several weeks.
· ​Treated with antiemetics such as ​Nabilone​ and ​Dronabinol

Reference:
Goodman and Gilmans The Pharmacologic Basis of Therapeutics 12th Edition

9. Give non-pharmacologic management in this case

Patients experiencing alcohol withdrawal syndrome should be first and foremost
motivated to continue pharmacologic therapy, in conjunction with non-pharmacologic
therapy. Examples for non-pharmacologic management for AWS could be the following:

a. Individual Psychotherapy
 This can be administered in the OPD setting or the indoor setting. It
provides privacy for the patient to discuss sensitive problems and this
allows to address co-morbid conditions such as depression.

b. Group Therapy
This allows patients to hear experiences from others dealing with the
same issues as they are, and it is more economical.

c. Alcoholic Anonymous (AA)

AA meetings are structured around 12 steps that focus on the following:
acceptance that alcoholism is a disease of addiction, surrender to a greater
power, better understanding of the consequences of use and its effect on
relationships both inside and outside of the family.

d. Behavior Therapy
i. Aversive Therapy
Aims to reduce the reinforcing properties of drinking from positive
to negative through unconditioned stimulus that is paired with reinforcing
conditioned stimulus. The goal is to make the client experience an aversive
conditioned response to alcohol.
ii. Cue Exposure
Avoid exposure of conditioned craving responses such as seeing
bottles of alcohol or being exposed to people who are drinking alcohol
e. Relaxation Training
The patient may be taught something else to cope with the stress that he
is experiencing, as to avoid alcohol drinking. The goal is to keep the patient calm
and remain thinking clearly

f. Contingency Management
The principle is to provide incentives for compliance with alcohol
treatment and positive reinforcement from friends and family to achieve sobriety.
The programme involves the following: analysis of drinking behavior, basic skills
training, problem-solving training, drinking refusal training and social, recreational
and vocational counseling.

g. Cognitive Behavior Therapy

This is found to be one of the most effective tools in the
non-pharmacologic management of AWS. CBT Focuses on identifying and
changing maladaptive thoughts and behaviors that contribute to the compulsive
intake of alcohol.

h. Family Therapy
 Alcoholism also affects the family, work-place and the like. By doing so,
education about the factors crucial for the patient’s recovery can be conveyed.
Family as a support system can provide this to the patient and will maintain the
patient’s motivation in continuing treatment.
Reference
Weiss RD, Kueppenbender KD. Combining psychosocial treatment with
pharmacotherapy for alcohol dependence. J Clin Psycho- pharmacology. 2011;
26 Suppl 1 : S37-542.

10. Enumerate patient care and monitoring of the patient

the 2001 CANMAT guidelines recommend that patients follow-up, “most treatments should lead
to some clinical improvement within 4 to 8 weeks,” but the guidelines do not recommend a
specific time at which first follow-up should occur.

The 2006 Canadian Psychiatric Association clinical guidelines for the management of anxiety
disorders state that regardless of the type of treatment chosen, the patient should receive an
adequate trial and be appropriately monitored for at least 12 month and follow-up of initially
monitoring patients with anxiety disorders every 2 weeks

Patients with AWS should be admitted to a telemetry unit with pulse oximetry used to measure
oxygen saturation (SaO2); administer oxygen if SaO2 falls below 92%. A patient with moderate
to severe AWS may be admitted to the intensive care unit or critical care unit for close
monitoring and care.

Closely monitor the patient’s vital signs, heart rhythm and rate, respirations, fluid and electrolyte
balance, blood glucose level, skin, elimination, mental and neurologic status, and nutritional
status. Bleeding tendencies from liver damage may necessitate vascular volume substitution or
blood transfusions if the patient’s iron and blood volumes are diminished.

Provide an appropriate diet as tolerated. During times of nausea or vomiting, restrict oral intake.
If the patient has epigastric distress, encourage deep breathing and relaxation. Administer
antiemetics as needed and offer ice chips, cool cloths, and a fan for comfort if the patient
desires.

Provide education about alcohol abuse, dependency, and withdrawal to the patient and family to
give them a better understanding of AWS and help them cope with the situation. Education can
be verbal or provided by pamphlets, handouts, videos, and Internet sources. Additional
education topics may include the risk that alcohol abuse could worsen associated diseases
(such as infectious diseases, cancer, diabetes, neuropsychiatric disorders, cardiovascular
conditions, and liver and pancreatic disease).

CASE 6
(DR. JENNIFER T. CO)
Lim​ | ​Malinit​ | ​Mendoza​ | ​Mercado​ | ​Miral​ | ​Molano​ | ​Ocampo

CLINICAL DATA
A 25-year old nulligravid consulted because of on and off fever and weight loss of 6 months duration.
Other complaints include muscle aches, joint pain, sore throat, and mucopurulent vaginal discharge.
Pertinent PE findings:​ (+) tonsillopharyngeal congestion, cervical ectopy and purulent discharge

PERSONAL AND SOCIAL HISTORY:

Coitarche at 14 years old, with multiple sexual partners
OCP user for 3 years

LABORATORY TESTS:
Electrolytes: sodium 135 mEq/L (135 mmol/L), potassium 3.6 mEq/L (3.6 mmol/L), chloride 100 mEq/L
(100 mmol/L)
Bicarboblood urea nitrogen 14 mg/dL (5 mmol/L)
Creatine: 1.0 mg/dL (88 umol/L)
CBC: WBC 5.2 x 10​3​/mm​3 ​(5.2 x 10​9​/L), hemoglobin 11.5 g/dL (115 g/L or mmol/L), hematocrit
34.1% (0.341), platelets 151 x 10​3 ​mm​3 (151 x 10​9​/L), neutrophils 58% (0.58), bands 9% (0.09),
lymphocytes 32% (0.32), monocytes 1% (0.01), eosinophils 0% (0.00), basophils 0% (0.00)
CD4 count: 179 cells/mm​3
Gram stain: (+) gram-negative intracellular diplococci
NSS/KOH: negative for trichomonas vaginalis and pseudohyphae
DFA: (+) elementary bodies

1. What is the complete diagnosis?

Acquired Immunodeficiency Syndrome (AIDS) (with gonococcal and chlamydial
infection?)
2. When should ARVT initiated?
a. ARVT should start as soon as possible
​ he D
(T ​ epartment of Health and Human Services (HHS) guidelines on the use of HIV
medicines in adults and adolescents recommend that people with HIV start ART as
soon as possible. In people with HIV who have certain conditions, it's especially
important to start ART right away).

3. What 4 conditions increase the urgency to start ARVT?

a. Pregnancy - All pregnant women with HIV should take HIV medicines to prevent
mother-to-child transmission of HIV. The HIV medicines will also protect the health of
the pregnant woman. All pregnant women with HIV should start taking HIV medicines
as soon as possible during pregnancy. In general, women who are already taking
HIV medicines when they become pregnant should continue taking HIV medicines
throughout their pregnancies. When HIV infection is diagnosed during pregnancy,
ART should be started right away.

b. AIDS - People with AIDS should start ART immediately. A diagnosis of AIDS is
based on the following criteria: A CD4 count less than 200 cells/mm3. A low CD4
count is a sign that HIV has severely damaged the immune system OR Illness with
an AIDS-defining condition. AIDS-defining conditions are infections and cancers that
are life-threatening in people with HIV. Certain forms of lymphoma and tuberculosis
are examples of AIDS-defining conditions.

c. Certain HIV-related illnesses and coinfections - Some illnesses that develop in

people with HIV increase the urgency to start ART. These illnesses include
HIV-related kidney disease and certain opportunistic infections.

d. Early HIV infection - ​Early HIV infection is the period up to 6 months after infection
with HIV. During early HIV infection, the level of HIV in the body (called the viral load)
is often very high. A high viral load damages the immune system and increases the
risk of HIV transmission.

4. What are the 4 health facts on antiretroviral therapy in the Philippines?

a. ART suppresses HIV and prevents progression of the disease

According to the World Health Organization, standard ART consists of the combination of
antiretroviral (ARV) drugs which suppresses the HIV (human immunodeficiency virus)
and stops the progression and transmission of the disease.

b. ​It is available to those registered in HIV treatment hubs

Lifelong ART is applied to individuals who need to lower the viral load of patients and
improve their immune response. It is available to those registered in HIV treatment hubs.
The WHO recommends the therapy for all HIV patients without any restrictions of CD4
counts.

c. It will be provided to over 39,000 HIV patients

 Health secretary Paulyn Ubial recently bared plans to increase the 2017 budget from
P900 million to P1 billion to provide ART to over 39,000 individuals. This means the
government will spend around P25,641 for each patient.

d. Its drugs cost at least P2,700

The US Department of Health and Human Services said that each ART drug costs from
$54 (P2,700) to $1,197 (P59,840). Meanwhile, the US Centers for Disease Control and
Prevention pegged a treatment program costs $500,000 (P25.01 million) annually.

5. What is the standard HAART?

a. NNRTI or PI with 2NRTI

6. What is the DRUG OF CHOICE for gonorrhea? Give the dose and duration of treatment. Please
include the mechanism of action.
a. Ceftriaxone 250mg IM (with Azithromycin 1g PO x single dose). Ceftriaxone inhibits
cell wall synthesis by interfering with the synthesis of PEPTIDOGLYCAN, the major
structural component of bacterial cell wall.

7. What is the DRUG OF CHOICE for chlamydia? Give the dose and duration of treatment. Please
include the mechanism of action.

Recommended Regimens
· Azithromycin 1 g orally in a single dose
OR
· Doxycycline 100 mg orally twice a day for 7 days

Alternative Regimens
· Erythromycin base 500 mg orally four times a day for 7 days
OR
· Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days
OR
· Levofloxacin 500 mg orally once daily for 7 days
OR
· Ofloxacin 300 mg orally twice a day for 7 days

Mechanism of Action:
Azithromycin reversibly binds to the bacterial ribosome and inhibits protein synthesis. The drug
has an absolute oral bioavailability of 35−42% in healthy volunteers and people with cystic fibrosis and a
long half-life due to extensive uptake in tissue, particularly lung, tonsil and prostate. Tissue concentrations
exceed the minimum inhibitory concentration that would inhibit 90% of likely pathogens (MIC90) after a
single 500 mg oral dose. Mean concentrations in tissue are 10–100-fold higher than those reached in
serum and persist for several days. Azithromycin also accumulates in phagocytes, with levels up to 200
times greater than in serum, but penetrates poorly into cerebrospinal fluid and peritoneal fluid.

8. What 2 STI screening tests should be performed?

 a. Nucleic acid amplification test (NAAT)
NAAT is the recommended method of testing for chlamydia. NAAT is a molecular test
that detects the genetic material (DNA) of Chlamydia trachomatis. It is generally more
sensitive and specific than other chlamydia tests and can be performed on a vaginal
swab on women, or urine from both men and women, which eliminates the need for a
pelvic exam in women.

b. Enzyme Immunoassay
C. trachomatis EIA tests detect chlamydial LPS with a monoclonal or polyclonal antibody
that has been labeled with an enzyme. The enzyme converts a colorless substrate into a
colored product, which is detected by a spectrophotometer. Specimens can be stored
and transported without refrigeration and should be processed within the time indicated
by the manufacturer.

c. Culture
Besides NAAT, another test to detect gonorrhea is a gonorrhea culture, which grows the
bacteria. In men, a quick method that may be used in a clinic or healthcare provider's
office is the gram stain, which allows the healthcare practitioner to look at a sample from
the urethra for the presence of the bacteria using a microscope. While this method can
diagnose gonorrhea, it is not sufficient to rule out an infection in asymptomatic men. This
method is not reliable for samples from women since other bacteria normally found in the
female genital tract will look the same under the microscope.

9. Discuss one possible drug interactions for this case?

Azithromycin ​and ​Nelfinavir

Nelfinavir is used for the treatment of HIV infection in combination with other antiretroviral
agents. Co-administration of nelfinavir at steady-state with a single oral dose of azithromycin
resulted in increased azithromycin serum concentrations. Although a dose adjustment of
azithromycin is not recommended when administered in combination with nelfinavir, close
monitoring for known adverse reactions of azithromycin, such as liver enzyme abnormalities and
hearing impairment, is warranted.

Azithromycin
Drug Interactions Increases serum concentrations of digoxin, ciclosporin, terfenadine,
hexobarbital and phenytoin. Decreased rate of absorption w/ antacids containing aluminium and
magnesium. Increased risk of ergot toxicity. Potentially Fatal: Increased risk of cardiotoxicity w/
pimozide.

Doxycycline
Drug Interactions Concomitant use w/ isotretinoin is known to cause pseudotumour cerebri.
Prolonged prothrombin time w/ anticoagulants (e.g. warfarin). May interfere w/ the bactericidal
action of penicillin. Impaired absorption w/ antacids containing Al, Ca, or Mg, oral Zn, Fe salts,
and bismuth preparations. Increased metabolism w/ phenobarbital, carbamazepine, primidone
and phenytoin. Risk of breakthrough bleeding w/ oral contraceptives. Increased plasma
concentration of ciclosporin. Decreased half-life w/ hepatic enzymes inducers (e.g. rifampicin).
Potentially Fatal: Concurrent use w/ methoxyflurane may result to fatal renal toxicity.
 Erythromycin
Drug Interactions Rhabdomyolysis w/ or w/o renal impairment w/ HMG-CoA reductase inhibitors
(e.g. simvastatin). Increased risk of colchicine toxicity. Increased sedation w/
triazolobenzodiazepines and related benzodiazepines (e.g. alprazolam, midazolam). Theophylline
may decrease and cimetidine may increase erythromycin concentration. Hypotension,
bradyarrhythmia and lactic acidosis w/ Ca channel blockers (e.g. verapamil, amlodipine,
diltiazem). Increased systemic exposure of sildenafil. Increased or prolonged adverse effects w/
ciclosporin, carbamazepine, tacrolimus, alfentanil, disopyramide, rifabutin, quinidine,
methylprednisolone, cilostazol, vinblastine and bromocriptine. Increased risk of digoxin toxicity.
Increased bleeding w/ oral anticoagulants. Potentially Fatal: QT prolongation, cardiac
arrhythmias, ventricular tachycardia, ventricular fibrillation, torsades de pointes w/ cisapride,
pimozide, astemizole or terfenadine. Acute ergot toxicity w/ ergotamine and dihydroergotamine.

SUMMARY OF CASE MANAGEMENT:

PROBLEM 1:
IMPRESSION: ​AIDS W/ CHLAMYDIAL INFECTION
EVIDENCE:
SUBJECTIVE-​on and off fever and weight loss of 6 months duration
muscle aches, joint pain, sore throat, and mucopurulent vaginal discharge.
(+) tonsillopharyngeal congestion
cervical ectopy and purulent discharge
Coitarche at 14 years old
multiple sexual partners
OBJECTIVE-​CD4 count: 179 cells/mm​3
Gram stain: (+) gram-negative intracellular diplococci
DFA: (+) elementary bodies

PHARMACOLOGIC MANAGEMENT

ARVT started as soon as possible

*standard HAART (highly active antiretroviral therapy): NNRTI or PI with 2NRTI

For Gonorrhea:
Ceftriaxone 250mg IM (with Azithromycin 1g PO x single dose

For Chlaymydia:
Azithromycin 1 g orally in a single dose
OR
Doxycycline 100 mg orally twice a day for 7 days

Alternative Regimens
Erythromycin base 500 mg orally four times a day for 7 days
OR
Erythromycin ethylsuccinate 800 mg orally four times a day for 7 days
OR
Levofloxacin 500 mg orally once daily for 7 days
OR
Ofloxacin 300 mg orally twice a day for 7 days

NON PHARMACOLOGIC MANAGEMENT

Eat healthy foods. Fresh fruits and vegetables, whole grains, and lean protein help keep you strong, give
you more energy and support your immune system.

Avoid raw meat, eggs and more. Foodborne illnesses can be especially severe in people who are
infected with HIV. Cook meat until it's well-done.

Get the right immunizations. Especially for pneumonia and the flu. Make sure the vaccines don't
contain live viruses.

Take care with companion animals. Some animals may carry parasites that can cause infections in
people who are HIV-positive. Wash hands thoroughly after handling pets or emptying the litter box.

Psychological and Social support

Case 7: ​MENOPAUSE
QUESTIONS
1. Which clinical presentation in this case are consistent with menopause?
History (Give at least 3):
-Hot Flushes
-Night Sweats
-Irritability
-Mood swings
-Vaginal dryness
-dyspareunia
PE (give atleast 1):
-Vaginal wall with signs of atrophy

Laboratory results (give at least 1)

-Increase lvl of of FSH, Inc. Cholesterol lvl, increased LDL, (+) atrophy on pap smear

2. What are the consequences of menopause on women’s health? Give at least 4

examples and give at least 1 risk factor for such consequence present in this case
Consequences of Menopause Risk factors present in this case

Coronary Artery Disease Inc. cholesterol lvls, Family Hx. of HPN,

Smoking Hx, Stress

Hyperlipidemia Inc. cholesterol lvls, Sedentary lifestyle

Osteoporosis Sedentary lifestyle; high caffeine

consumption

Weight Gain Inc. Cholesterol lvls, Smoking Hx, Sedentary

Lifestyle

3. What are the indications for Menopausal Hormonal Therapy? Give at least 2
1. Cardiovascular Disease
2. Osteoporosis
3. Vasomotor symptoms like hot flushes causing sleep disturbance
4. Vaginal dryness, dyspareunia

4. What are the benefits associated with the use of Menopausal Hormonal Therapy? Give
at least 3.
● ​Effective in treating moderate to severe vasomotor symptoms such as ​hot flushes
and sweating, relieves sleep disturbances or insomnia, prevents atrophic
vaginitis, vaginal dryness and other genitourinary symptoms
●​ ​Prevents osteoporosis
● ​Provides increased sense of well-being and improvement of climacteric

depression and psychopathologic states ​(for reference: p.1033 of Katzung 13th ed)
5. a. What is the cause or etiology of the consequences you enumerated above?
Estrogen plays an important role in well-being, cognition, mood, bone maintenance,
collagen formation and provides CV protection. Thus, marked reduction of estrogen in
menopause leads to increased risk for CVD, osteoporosis, thinning of the vaginal
epithelium resulting in Genitourinary Syndrome of Menopause or GSM (also called
vaginal atrophy or atrophic vaginitis); mood disorders coexisting with vasomotor
symptoms, and other metabolic diseases.
 b.Which menopausal HORMONAL therapy is most effective and appropriate for this
case in the management of the above symptoms? Give one agent including the dose/day
and duration of treatment?
For this case, the most effective and appropriate hormonal treatment would be combined
estrogen and progesterone. The administration of a progestational agent with estrogen prevents
endometrial hyperplasia and markedly reduces the risk of this cancer.

Sample Agent: Oral Conjugated Equine estrogen (CEE) 0.625 mg daily added with MPA
2.5-5mg during the last 10-14 days of each month for less than 5 years

Explanation:
Combined menopausal hormone therapy may be given as "cyclical", where the estrogen is
given daily and the progestogen is given for 10-14 days of the month, or "continuous" where
both estrogen and progestogen are given daily. "Cyclical" produces withdrawal vaginal bleeds
whereas "continuous" should not. ​(for reference:
https://www.menopause.org.au/hp/information-sheets/267-combined-menopausal-hormone-ther
apy-mht)

The most common cyclic or sequential method in the US involves estrogen administration with
0.625 mg of conjugated estrogens or 1.0 mg of micronized estradiol daily. A daily dose of 5–10
mg of medroxyprogesterone acetate (MPA) is added during the last 10-14 days of each month.
Women who object to the cyclic bleeding associated with sequential therapy can also consider
continuous therapy. Daily therapy with 0.625 mg of conjugated equine estrogens and 2.5–5 mg
of medroxyprogesterone will eliminate cyclic bleeding, control vasomotor symptoms, prevent
genital atrophy, maintain bone density, and show a favorable lipid profile with a small decrease
in LDL and an increase in HDL concentrations. ​(reference: p.1033 of Katzung 13th ed)
Short-term use (<5 years for estrogen-progestogen and <7 years for estrogen alone) is
appropriate for relief of menopausal symptoms among women without contraindications to such
use.​(p. 2386 Harrisons 19th ed)

As a general rule, cyclical hormone therapy is used for a woman who is in the
menopausal transition and is having some irregular spontaneous menses or is very
recently postmenopausal, but it can be continued longer if preferred. Continuous
hormone therapy is a convenience often preferred by older women. Early introduction of
continuous MHT close to the menopausal transition may lead to irregular, unscheduled
breakthrough bleeding. Breakthrough bleeding may occur in the first six months of any
MHT regimen but any unscheduled bleeding after that should be investigated.

6. What are the side effects of Menopausal Hormonal Therapy? Give at least 2 common
and 2 serious side effects for each of the following:
a. Estrogen
COMMON: ​nausea, breast tenderness, migraine headaches, hyperpigmentation
SERIOUS: ​increased risk for breast cancer, endometrial carcinoma, cholestasis, gallbladder
disease and hypertension, venous thromboembolism
b. Progesterone
COMMON: ​nausea, bloating, edema, migraine headaches, breast tenderness, acne
SERIOUS​: increased risk for breast cancer, stroke, heart attack, blood clots, pulmonary
embolism, deep vein thrombosis
7. A. What are the contraindications for Menopausal Hormonal Therapy? Give at least 3
●​ ​No absolute contraindications of hormonal therapy have been established.
●​ ​Relative contraindications:
○​ ​A history of breast cancer
○​ ​A history of endometrial cancer
○​ ​Porphyria
○​ ​Severe active liver disease
○​ ​Hypertriglyceridemia
○ ​Thromboembolic disorders (such as deep venous thrombosis and

pulmonary embolism
○​ ​Undiagnosed vaginal bleeding
○​ ​Endometriosis
○​ ​Fibroids
○​ ​Existing cardiac disease
○​ ​Systemic lupus erythematosus
○​ ​History of stroke
B. Give an alternative Menopausal Hormonal Therapy if the above agent is
contraindicated? Give the hormonal drug and the dose/day
●​ ​Androgen therapy
○​ ​Methyltestosterone 1.25 and 2.5 mg
○​ ​Dehydroepiandrosterone 25 to 50 mg/day
○​ ​Tibolone 2.5 mg/day

8. Give at least 3 examples of Non-Hormonal Therapy for menopause. Give each of their
dose/day
●​ ​Venlafaxine 75mg/day
●​ ​Desvenlafaxine 100mg/day
●​ ​Escitalopram 10-20mg/day
●​ ​Gabapentin 900mg/day
●​ ​Clonidine 25mcg BID
●​ ​Vitamin E 800 to 1000 IU per day in divided doses
●​ ​Isoflavone 60mg/day

9. What are the lifestyle modification strategies for postmenopausal women? Give at
least 4.
Aimed at reducing cardiovascular risk, osteoporosis, and depression
-​Physical activity recommendations​: at least 150 min/week of moderate intensity aerobic
physical activity, or at least 75 min/week of vigorous intensity aerobic activity. It should be
performed in bouts of 10 minutes duration. Muscle-strengthening activities should be done
involving major muscle groups on 2 or more days a week. Doing regular weight-bearing
exercise may also help prevent osteoporisus
-​Diet recommendations: ​consumption of whole-grain products, fruits, vegetables combined
with enough protein intake (25-30g/meal) from fish (codfish protein), egg, and dairy products
(whey protein). Vitamin D repletion. Limited consumption of saturated fats, red meat, refined
carbohydrates, energy-dense food, excess sugar and salt. Limit caffeine.
-​Quit smoking and avoid alcohol.
-​Regularly have cholesterol and blood pressure checked.
-​Reduce stress:​exercise, sharing concerns with friends, family, or a health care
professional/counsellor may help. Get good quality sleep. Participate in “mind-body” programs
where deep-breathing techniques, positive thinking, hypnosis, and meditaion through books and
music is taught. Pamper self such as through massage, manicure, or simple hair cuts.

10. What are the recommended evaluative modalities that should be conducted during
the annual consultation or follow-up of women on Menopausal Hormonal Therapy? Give
at least 4.
-​Ultrasonography​to measure endometrial thickness and ovarian volume
-​Mammography ​performed once every 2-3 years and annually after age 50 to monitor breast
cancer risk
-​Serum estradiol levels​(for those with implants and those whose symptoms persists despite
adequate dose) and ​serum FSH levels ​(for monitoring women taking oral preparations for
symptomatic control)
-​Pelvic exam​done to assess reproductive organs and check for the presence or severity of
vaginal dryness
-​Papanicolau test ​to check for cervical changes that may be indicative of malignancy
-​Lipoprotein profile (LDL, HDL, total cholesterol)​to check for CVD risk since menopausal
women are more prone to develop this.
-​Bone density​to measure bone thickness and strength
-​ECG or EKG

SUMMARY OF CASE MANAGEMENT

Problem #1: Frequent hot flushes and night sweats
Impression: Menopause
Evidence​:
Subjective:
-​ ​55 year old, with LMP last June 2017
-​ ​frequent hot flushes and night sweats with sleep deprivation
-​ ​irritability, mood swings
-​ v​ aginal dryness and dyspareunia

Objective:
-​ ​BP-130/80, CR-75bpm, RR-19 cpm, not in cardiorespiratory distress
-​ ​signs of atrophy of vaginal wall on speculum exam
-​ ​Elevated total cholesterol at 232 mg/dl, LDL at 128 mg/dl
-​ ​Elevated FSH at 76 mIU/ml
-​ ​TVS: thin endometrial stripe (4mm), small ovaries
-​ ​Pap smear: signs of atrophy, moderate inflammation

Management with Rationale:

- ​Hormone Replacement Therapy with Combined Estrogen and Progesterone (cyclical or

continuous)
o ​Cyclical: Oral Conjugated Equine estrogen (CEE) 0.625 mg daily added with
MPA 2.5-5mg during the last 10-14 days of each month for less than 5 years
o​ ​Continuous: Oral CEE 0.625 mg + MPA 2.5 mg 1 tab OD
Rationale: To address symptoms associated with reduced estrogen (CNS and
vasomotor symptoms like hot flushes, irritability; slow down progression and prevent
osteoporosis; reduce CVD risk; treat vaginal dryness and dyspareunia, etc.);
progesterone added to prevent endometrial hyperplasia since the patient still has a
uterus. The choice between cyclical or continuous depends on patient’s preference.
"Cyclical" produces withdrawal vaginal bleeds whereas "continuous" should not
(produces amenorrhea).​Short-term use (<5 years for estrogen-progestogen and <7
years for estrogen alone) is appropriate for relief of menopausal symptoms among
women without contraindications to such use.
- ​Advise patient on expected side effects of therapy; to monitor BP regularly, report any

untoward signs and symptoms

-​ ​Calcium carbonate 1500 mg + Vitamin D3 10 mcg tab, 1 tab BID
Rationale: As adjunct in the prevention of osteoporosis
-​ ​Advise on lifestyle modifications:
o​ ​Physical activity: 150 min/week of moderate intensity aerobic or 75 min/week of
vigorous intensity aerobic activity; Muscle-strengthening activities of major
muscle groups on 2 or more days a week.
Rationale: Aid in prevention of osteoporosis by inhibiting bone resorption; also aids in
reducing risk for CVD and other metabolic diseases like DM, as well as cancer
o​ ​Diet: Increase consumption of whole-grain products, fruits, vegetables
combined with adequate protein intake (25-30g/meal) from fish (codfish
protein), egg, and dairy products. Reduce caffeine consumption and limit
intake of spicy foods.
Rationale: To aid reduction of CVD risk, prevention of osteoporosis, reduction of
episodes of hot flushes.
o​ ​Quit smoking and avoid alcohol.
 Rationale: These vices further increases risk for CVD, DM, and other metabolic
diseases, cancer
o​ ​Reduce stress and get adequate rest and sleep.
Rationale: Promote well-being and aid in reducing risk for CVD, DM, cancers and
other diseases
-​ A
​ dvise on annual regular check-up including the following tests:

o​ ​Ultrasonography to measure endometrial thickness and ovarian volume

o​ ​Mammography performed annually after age 50 to monitor breast cancer risk
o ​FSH levels for monitoring women taking oral preparations for symptomatic
control
o ​Papanicolau test to check for cervical changes that may be indicative of
malignancy
o​ ​Lipoprotein profile (LDL, HDL, total cholesterol) to check for CVD risk
o​ ​FBS to screen for DM
o​ ​Bone density measurement to measure bone thickness and strength
o​ ​ECG

Case 8

1.Enumerate the signs and symptoms to support the diagnosis of this case. Include
confirmatory tests to be done.
· Month long history of coughing
· Blood tinge phlegm
· Fever, chills, easy fatigability and weight loss of 10lbs for the past month
· (+) tachypnea
· (+) cervical lymphadenopathies
· (+) bronchial breath sounds in upper chest
· Mild Anemia (based on cbc findings)
· Leukocytosis
· ​Chest Xray Finding suspicious of TB : Patchy infiltrates in the right and left upper lobe
Confirmatory Test to be done
· Sputum AFB smear
o ​For presumptive diagnosis of TB
· TB Culture and Drug Susceptibility Testing
o ​For Definitive Diagnosis of Tuberculosis
o ​The long turnaround time of results, limited access and cost of test, limit its routine use
· Rapid Diagnostic Testing (XPERT MTB/Rif)
o ​Detects presence of MTB and also detects rifampicin resistance

2. WHO (2013) Definitions of TB Cases

3. Pre-treatment evaluation

• Baseline serum ALT and creatinine before starting anti- TB treatment. In resource-limited
settings, baseline ALT and serum creatinine, at the least, should be requested for patients older
than 60 years old, and those with risk factors for liver or kidney disease before starting TB
treatment. (Strong recommendation, moderate quality evidence)
• Provider initiated counseling and testing (PICT) for HIV for all patients with TB, specially with
high-risk behavior for HIV and those from areas with high HIV prevalence (Strong
recommendation, moderate quality evidence)
• Screening for DM using FBS, RBS or 75g OGTT for all patients with TB (Strong
recommendation, moderate quality evidence), HbA1c not routinely recommended due to
standardization issues. (Strong recommendation, moderate quality evidence)
• Serum uric acid testing NOT routinely recommended before starting anti-TB treatment. (Strong
recommendation, moderate quality evidence)
• Baseline testing of visual acuity using Snellen and color perception charts are advised when
ethambutol is to be used. (Strong recommendation, low quality evidence)
 Drug MOA Side Effects Clinical Dose
application

Isoniazid inhibits Fever, skin rashes, First-line agent 5 (4-6)

synthesis of drug induced SLE for tuberculosis mg/kg,
mycolic acid and hepatitis, • treatment of not to
neuropathy latent infection • exceed
less 400mg daily
active against
other
mycobacteria

Rifampicin binds to the β orange color to First-line agent 10 (8-12)

subunit of urine, sweat, and for tuberculosis • mg/kg,
bacterial tears; rashes, atypical not to
DNA-dependent thrombocytopenia, mycobacterial exceed
RNA nephritis, acute infections • 600mg daily
polymerase and tubular necrosis eradication of
thereby inhibits meningococcal
RNA synthesis colonization,
staphylococcal
infections
Pyrazinamide disrupts Hepatoxicity, drug Sterilizing” agent 25 (20-30)
mycobacterial fever, nausea, used during first mg/kg,
cell membrane vomiting, 2 months of not to
metabolism and hyperuricemia therapy • allows exceed 2g
transport total daily
functions duration of
therapy to be
shortened to
6 months

Ethambutol blocks the Optic neuropathy, Given in 15 (15-20)

synthesis of Hepatotoxicity four-drug initial mg/kg,
mycolic acids combination not to
therapy for exceed 1.2g
tuberculosis until daily
drug
sensitivities are
known • also
used for
atypical
mycobacterial
infections
Streptomycin Irreversibly Ototoxicity, Used in 15 (12-18)
inhibits protein nephrotoxicity, tuberculosis mg/kg,
synthesis and vertigo and when an not to
binds to the 30S hearing loss injectable exceed 1g
subunit of drug is needed or daily
bacterial desirable and in
ribosomes. treatment of
drug-resistant
strains

4. Mechanism of Resistance

Drug Mechanism of Resistance

Isoniazid Resistance to isoniazid is associated with mutations resulting

in overexpression of ​inhA,​ w
​ hich encodes an
NADH-dependent acryl carrier protein reductase; mutation or
deletion of the ​katG​ gene; promoter mutations resulting in
overexpression of ​ahpC​ w​ hich is a putative virulence gene
involved in the protection of the cell from oxidative stress; and
mutations in ​kasA​.

Rifampicin Resistance results from any one of several possible point

mutations in ​rpoB​ ​which is the gene for the ß subunit of RNA
polymerase. Human RNA polymerase does not bind rifampin
and is not inhibited by it.

Pyrazinamide Resistance may be due to impaired uptake of pyrazinamide

or mutations in ​pncA​ that impair conversion of pyrazinamide
to it active form, pyrazinoic acid.
 Ethambutol Resistance to ethambutol is due to mutations resulting in
overexpression of ​emb​ gene products or within the ​embB
structural gene.

Streptomycin Resistance is due to a point mutation in either the ​rpsL​ gene

encoding the S12 ribosomal protein gene or the ​rrs​ gene
encoding the 16S ribosomal rRNA, which alters the ribosomal
binding site.

5. Effective Treatment Regimens

6. What strategy is currently being used by DOH to improve adherence to TB medication.

Explain

Directly Observed Treatment (DOT) - DOT is a method developed to ensure treatment

compliance by providing constant and motivational supervision to TB patients. DOT works by
having a responsible person, referred to as treatment partner, watch the TB patient take anti-TB
drugs every day during the whole course of treatment.

SUMMARY OF CASE MANAGEMENT

CC: ​Month Long History of coughing
Impression: ​Pulmonary Tuberculosis

Subjective
- Living in barracks at construction site
- Month long history of coughing
- Blood tinge phlegm
- Fever, chills, easy fatigability, and weight loss of 10lb for the past month
- 10 pack year smoker

Objective
- 35 y/o male
- Thin
- Tachypneic 22cpm
- Fever 38.3C
- Cervical lymphadenopathies
- Bronchial breath sounds in upper chest
- Decreased RBC and Hgb - anemic
- Increased WBC with decreased Lympho
- CXR: Patchy Infiltrate in the right and left upper lobe

Pharmacologic Management

Category I (2HRZE 4HR) treatment​, because it is a new case of PTB, patient is newly
diagnosed PTB and has never been treated with any PTB drugs.

Initial/Intensive Phase
Isoniazid 5mg/kg or 400mg
Rifampicin 10mg/kg or 600mg
Pyrazinamide 25 mg/kg or 2g
Ethambutol 15mg/kg

Continuation Phase
Isoniazid 5mg/kg or 400mg
Rifampicin 10mg/kg or 600mg

Non-pharmacological management
· Cessation of cigarette smoking and limit alcohol intake
· Avoid crowded places
· Observe proper cough etiquette
· Use disposable mask
· Ensure proper ventilation in the house
1. · Pre-treatment clinical evaluation (Liver and Kidney Function Tests, Visual acuity
test)
· Sputum AFB Smear, Sputum Culture, Rapid Diagnostic Testing