PROBLEM No.

1:

HYPERLIPIDEMIA
Cholesterol is one type of fat or lipid. This waxy white substance, contrary to its bad press, is an essential
element for our health. Cholesterol has no energy value, but serves as a building block for many important
compounds such as vitamin D, digestive bile, various sex hormones, and is a component of the outer membranes
of all body cells. Cholesterol comes from animal food sources in our diet but our body is also capable of making
a certain amount of cholesterol.
Any excess cholesterol that is not used by the body can negatively affect our arteries over time. This fatty
material begins to adhere as plaque to the walls of the arteries. Like badly rusted plumbing pipes, arteries can
become dangerously clogged with plaque, and then blood has a harder time flowing.
High cholesterol increases risk for cardiovascular disease and stroke. These risk factors include an inproper diet
high in saturated fats and cholesterol, obesity, and inactivity. Medical conditions such as diabetes mellitus,
hypothyroidism, kidney disease, liver disease, alcoholism, as well as certain medications, can cause elevated lipid
levels. Also, a family history of high cholesterol may mean that a person is genetically at risk for high lipids.

In general, there are two broad types of cholesterol that can be measured:
1. LDL or the "bad" cholesterol is the fraction of the total cholesterol that forms the plaque that can clog the
arteries. Optimal LDL level is less than 130mg per dL, or less than 100 per dL in high risk individuals.
2. HDL or the "good" cholesterol keeps cholesterol from building up in our arteries. Optimal HDL level is
greater than 40 mg per dL in men and greater than 50 mg per dL in women.

BASIS:
 Total Cholesterol = 6.03 ↑
 HDLC = .83↓
 LDLC = 4.14 ↑
 Triglycerides = 2.3 ↑
 53 years old, no exercise
 Overweight (BMI=26)
 Type II DM
 Hypothyroidism
 Family History: MI

TREATMENT OBJECTIVE:
 To lower the LDL, cholesterol and triglyceride levels
 Prevent other complications
PHARMACOLOGIC TREATMENT
 VLDL SECRETION INHIBITORS- ↓VLDL and LDL; inhibition of VLDL secretion, in turn
decreasing LDL; inhibition of choleterogenesis which ↑ hepatic uptake of LDL
 FIBRIC ACID DERIVATIVES - ↓VLDL, LDL and Triglycerides; ↑HDL; increases the clearance of
triglyceride by increasing lipoprotein lipase
 BILE ACID BINDING RESINS – useful only for hyperlipoproteinemia with ↑ LDL only; it binds with
the bile acid and thus excreted without being absorbed; increases the uptake of LDL and ILD from
plasma results from up regulation of LDL receptors in the liver
 HMG COA REDUCTASE INHIBITORS (STATINS) - ↓ LDL and TG; ↑ HDL; Inhibits rate-limiting
step in cholesterol biosynthesis by competitively inhibiting HMG-CoA reductase
 PROBUCOL - ↓HDL and LDL; inhibit sterol biosynthesis
 INHIBITORS OF INTESTINAL STEROL ABSORPTION(EZETIMIBE) – used in primary
hypercholestrolemia; selective inhibitor of intestinal absorption of cholestero and phytosterol causing
reduction of LDL levels.

NON-PHARMACOLOGIC TREATMENT
 Moderation in diet , more on fibers and less fat
 Weight reduction
 Increase physical activity
 Correct the secondary causes of hyperlipidemia

HYPOLIPIDEMIC AGENTS
Fibrates Statins Resins
(Gemfibrozil) (Simvastatin) (Colestipol)

Efficacy ++ +++ ++
Safety ++ ++ +
Suitability ++ +++ +
Cost ++ +++ +

PERSONAL DRUG
Statins (Simvastatin)
Simvastatin is a cholesterol-lowering drug. It inhibits an enzyme in the liver (HMG-CoA reductase) that is
necessary for the production of cholesterol. In the blood, statins lower total and LDL ("bad") cholesterol as well
as triglycerides. LDL cholesterol is believed to be an important cause of coronary artery disease. Lowering LDL
cholesterol levels slows and may even reverse coronary artery disease. Statins also increase HDL ("good")
cholesterol. Raising HDL cholesterol levels, like lowering LDL cholesterol may slow coronary artery disease. The
FDA approved simvastatin in December 1991.

PREPARATIONS:
 Tablets: 5, 10, 20, 40, and 80 mg.
 Oral disintegrating tablets: 10, 20, 40, and 80 mg.

STORAGE:
 Tablets should be stored between 5-30 C (41-86 F).
 Oral disintegrating tablets should be stored between 20-25 C (68-77 F).

PRESCRIBED FOR: Simvastatin is used for reducing total cholesterol, LDL cholesterol, and
triglycerides, and for increasing HDL cholesterol. In patients with coronary heart disease, diabetes, peripheral vessel
disease, or history of stroke or other cerebrovascular disease, simvastatin is prescribed for reducing the risk of
mortality by reducing death from coronary heart disease, reducing nonfatal myocardial infarction (heart attack) and
stroke, and reducing the need for coronary and noncoronary revascularization procedures.
DOSING: The dose range for is 5-80 mg/day given preferably in the evening. The usual staring dose is
20-40 mg once daily. Dose adjustments are made at weekly intervals.
DRUG INTERACTIONS: Decreased elimination of simvastatin could increase the levels of simvastatin
in the body and increase the risk of muscle toxicity from simvastatin. Examples of drugs that decrease elimination of
simvastatin include erythromycin (E-
Mycin), ketoconazole (Nizoral), itraconazole(Sporanox), clarithromycin (Biaxin), telithromycin (Ketek),
cyclosporine (Sandimmune), nefazodone (Serzone), and HIV protease inhibitors such asindinavir (Crixivan)
and ritonavir (Norvir). Large quantities of grape fruit juice (>1 quart daily) also will increase blood levels of
simvastatin.
Amiodarone (Cordarone), verapamil (Calan Verelan, Isoptin), danazol(Danocrine),
cyclosporine, niacin (Niacor, Niaspan, Slo-Niacin), gemfibrozil(Lopid) and fenofibrate (Tricor) also may increase
the risk of muscle toxicity when combined with simvastatin. Patients taking amiodarone or verapamil should not
take more than 20 mg of simvastatin. Patients taking danazol or cyclosporine should not take more than 10 mg of
simvastatin.
Simvastatin increases the effect of warfarin (Coumadin) and the blood concentration of digoxin (Lanoxin).
Patients taking simvastatin and warfarin or digoxin should be monitored carefully for toxic effects of warfarin and
digoxin.
Cholestyramine (Questran, Questran Light) decreases the absorption of simvastatin. Therefore,
simvastatin should only be taken 2 hours before or at least 4 hours after cholestyramine administration.
 The dose of simvastatin should be reduced to 40 mg daily when combined with diltiazem (Cardizem,
Dilacor, Tiazac) because the combination may increases the risk of rhabdomyolysis (severe muscle injury).
SIDE EFFECTS: The most common side effects of simvastatin
areheadache, nausea, vomiting, diarrhea, abdominal pain, muscle pain, andabnormal liver tests. Hypersensitivity
reactions have also been reported. The most serious potential side effects are liver damage and muscle inflammation
or breakdown.
Simvastatin is a statin. Therefore it shares side effects, such as liver and muscle damage associated with
all statins. Serious liver damage caused by statins is rare. More often, statins cause abnormalities of liver tests, and,
therefore, periodic measurement of liver tests in the blood is recommended for all statins. Abnormal tests usually
return to normal even if a statin is continued, but if the abnormal test value is greater than three times the upper limit
of normal, the statin usually is stopped. Liver tests should be measured before simvastatin is started and periodically
thereafter or if there is a medical concern about liver damage. Liver tests should be performed before the 80 mg dose
of simvastatin is initiated, three months after initiation and then periodically thereafter.
Inflammation of the muscles caused by statins can lead to a serious breakdown of muscle cells
called rhabdomyolysis. Rhabdomyolysis causes the release of muscle protein (myoglobin) into the blood.
Myoglobin can cause kidney failure and even death. When used alone, statins cause rhabdomyolysis in less than one
percent of patients. To prevent the development of rhabdomyolysis, patients taking simvastatin should contact their
health care practitioner immediately if they develop unexplained muscle pain, weakness, or muscle tenderness.

Name: MG 07/22/ 2011

Age: 53 y/o
Sex: male

Rx:
Simvastatin 20 mg tablet
#30 tablets

Sig. Take 1 tablet daily at night for 30 days

PROBLEM No. 2:

HYPERTENSION
Hypertension is the most common cardiovascular disease; its prevalence increases with advancing age.
Elevated arterial pressure causes pathological changes in the vasculature and hypertrophy of the left ventricle.
Hypertension is the principal cause of stroke, is a major risk factor for coronary artery disease and its complications,
and is a major contributor to cardiac failure, renal insufficiency, and dissecting aortic aneurysm. Hypertension is
defined as a sustained increase in blood pressure ≥140/90 mm Hg, a criterion where risk of hypertension-related
cardiovascular disease is high enough to merit medical attention. The risk of fatal and nonfatal cardiovascular
disease in adults is lowest with systolic BP <120 mm Hg and diastolic BP <80 mm Hg and increases progressively
with higher systolic and diastolic blood pressures. Recognition of this continuously increasing risk provides a simple
classification of hypertension (Table 32–1). Isolated systolic hypertension (sometimes defined as systolic BP >140–
160 mm Hg with diastolic BP <90 mm Hg) is largely confined to people >60 years of age. At very high blood
pressures (systolic ≥210 and/or diastolic ≥120 mm Hg), some patients develop fulminant arteriopathy characterized
by endothelial injury and marked intimal proliferation, leading ultimately to arteriolar occlusion and the syndrome
of immediately life-threatening hypertension. This is associated with rapidly progressive microvascular
occlusive disease in the kidney (with renal failure), brain (hypertensive encephalopathy), congestive heart failure,
and pulmonary edema, and typically requires emergent, in-hospital management for prompt lowering of blood
pressure.

BASIS:
 BP- 148/84 mmHg
 Overweight (BMI=26); 70.3 kg/ 2.6569
 Smoker and T2DM
 Hederofamilial Disease: T2DM and MI

TREATMENT OBJECTIVE
 TO HAVE THE TARGET BP CONTROL: <130/80 MMHG

PHARMACOLOGIC TREATMENT
 DIURETICS – lower blood pressure by depleting the body of sodium and reducing blood
volume
 SYMPATHOLYTIC AGENTS – lower blood pressure by reducing peripheral vascular
resistance, inhibiting cardiac function and increasing venous pooling in capacitance vessels
 VASODILATORS – reduce pressure by relaxing vascular smooth muscle, thus dilating
resistance vessels and to varying degrees increasing capacitance as well
  ACE INHIBITORS - blocks the conversion of angiotensin I to angiotensin II. It's desirable for
angiotensin I to remain in that state as it serves the purpose of excreting sodium (salt) in the
urine. Sodium is a water- holding molecule its excretion will also imply the loss of excess
water from the bloodstream.
 ANGIOTENSIN II ANTAGONISTS – relax smooth muscle and thereby promote
vasodilation, increase renal salt and water excretion, reduce plasma volume and decrease
cellular hypertrophy; prevent ACE-mediated degradation of bradykinin and substance P

NON-PHARMACOLOGIC TREATMENT
 Weight reduction
 DASH diet – (Dietary Approaches to Stop Hypertension) - Eating more fruits, vegetables, and
low-fat dairy foods, Cutting back on foods that are high in saturated fat, cholesterol, and total
fat, Eating more whole grain products, fish, poultry, and nuts, Eating less red meat and sweets,
Eating foods that are rich in magnesium, potassium, and calcium
 Increasing aerobic exercises
 Stop smoking
 Regular practice of relaxation

CLASSIFICATION OF ANTIHYPERTENSIVE DRUGS

ACE ANGIOTENSIN II
INHIBITORS ANTAGONISTS
Efficacy +++ +++
Safety +++ +++
Suitability +++ ++
Cost ++ ++

PERSONAL DRUG
Captopril
Captopril is an oral drug and a member of a class of drugs called angiotensin converting enzyme (ACE)
inhibitors.ACE inhibitors are used for treating high blood pressure, heart failure, and for preventing kidney
failure due to high blood pressure and diabetes. Other ACE inhibitors
include enalapril (Vasotec), quinapril (Accupril), ramipril(Altace), fosinopril (Monopril), benazepril (Lotensin), lisin
opril (Zestril, Prinivil), moexipril (Univasc) and trandolapril (Mavik).
 Angiotensin II is a very potent chemical that causes the muscles surrounding blood vessels to contract,
thereby narrowing the vessels. The narrowing of the vessels increases the pressure within the vessels causing high
blood pressure (hypertension). Angiotensin II is formed from angiotensin I in the blood by the enzyme angiotensin
converting enzyme or ACE. ACE inhibitors are medications that slow (inhibit) the activity of the enzyme ACE and
decrease the production of angiotensin II. As a result, blood vessels enlarge or dilate, and blood pressure is reduced.
The lower blood pressure makes it easier for the heart to pump blood and can improve the function of a failing heart.
In addition, progression of the blood vessel disease within the kidney caused by high blood pressure or diabetes is
slowed. The FDA approved captopril in April 1981.
PREPARATIONS: Tablets: 12.5, 25, 50, 100 mg
STORAGE: Captopril should be stored at room temperature, 15 to 30 C (59 to 86 F) and away from
moisture.
PRESCRIBED FOR: Captopril is used alone or in combination with other drugs for the treatment of high
blood pressure and heart failure. Captopril also is used for improving survival and preventing heart failure and
hospitalizations for heart failure after a heart attack. Like other ACE inhibitors, captopril may slow the progression
of kidney failure in patients with diabetes or high blood pressure.
DOSING: The recommended dose of captopril is 25-150 mg two or three times daily. The maximum dose
is 450 mg daily. It should be taken on an empty stomach one hour before or two hours after meals since absorption
of captopril is reduced when it is taken with food.
DRUG INTERACTIONS: The use of ACE inhibitors with potassium supplements, salt substitutes or
diuretics , for example, spironolactone(Aldactone), that increase potassium in the blood may lead to excessive
potassium levels (hyperkalemia). Potassium levels should be monitored whenever ACE inhibitors are used in
combination with these drugs.
There have been reports of increased lithium (Eskalith, Lithobid) levels when lithium is used in
combination with ACE inhibitors. The reason for this interaction is not known, but the increased levels may lead to
toxicity from lithium.
There have been reports that aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) such
as ibuprofen (Advil, Children's Advil/Motrin, Medipren, Motrin, Nuprin, PediaCare Fever,
etc.), indomethacin(Indocin, Indocin-SR), and naproxen (Anaprox, Naprelan, Naprosyn, Aleve) may reduce the
effects of ACE inhibitors.
SIDE EFFECTS: Captopril generally is well tolerated, and side effects are usually mild and transient.
A dry, persistent cough has been reported commonly with the use of captopril and other ACE inhibitors. Coughing
resolves after discontinuing the drug. Other side effects include abdominal
pain, constipation, diarrhea, rash, dizziness, fatigue, headache, loss of taste, loss of
appetite, nausea, vomiting, fainting and numbness or tingling in the hands or feet. Captopril and other ACE
inhibitors also may cause kidney failure and increased levels of potassium in the blood. Serious but, fortunately,
very rare side effects are liver failure and angioedema (swelling of lips and throat that can obstruct breathing).
Name: MG 07/22/ 2011
Age: 53 y/o
Sex: male

Rx:
Captopril 12.5 mg tablet
#14 tablets
Sig. Take 1 tablet before meal every 12 hours for 7 days
Problem 3

DIABETE MELLITUS

Type 2 diabetes mellitus is a disorder that disrupts the way your body uses glucose (sugar).
All the cells in your body need sugar to work normally. Sugar gets into the cells with the help of a hormone
called insulin. If there is not enough insulin, or if the body stops responding to insulin, sugar builds up in the blood.
This is what happens to people with diabetes mellitus.
There are two different types of diabetes mellitus. In type 1 diabetes mellitus, the problem is that the
pancreas (an organ in the abdomen) does not make enough insulin. In type 2 diabetes mellitus, the pancreas does not
make enough insulin, the body becomes resistant to normal or even high levels of insulin, or both.

Causes of Type 2 DM
Type 2 diabetes is thought to be caused by a combination of genetic and environmental factors. (See
"Pathogenesis of type 2 diabetes mellitus" and "Prediction and prevention of type 2 diabetes mellitus".)
Genetic causes — Many people with type 2 diabetes have a family member with either type 2 diabetes or other
medical problems associated with diabetes, such as high cholesterol levels, high blood pressure, or obesity.
The lifetime risk of developing type 2 diabetes is five to 10 times higher in first-degree relatives (sister,
brother, son, daughter) of a person with diabetes compared to a person with no family history of diabetes.
The likelihood of developing type 2 diabetes is greater in certain ethnic groups, such as people of Hispanic,
African, and Asian descent.
Environmental conditions — Environmental factors such as what you eat and how active you are,
combined with genetic causes, affect the risk of developing type 2 diabetes.
Pregnancy — A small number (about 3 to 5 percent) of pregnant women develop diabetes during
pregnancy, called "gestational diabetes." Gestational diabetes is similar to type 2 diabetes, but usually resolves after
the woman delivers her baby. Women who have gestational diabetes are at increased risk for developing type 2
diabetes later in life. (See "Patient information: Gestational diabetes mellitus".
Diabetes mellitus type 2 ± formerly non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset
diabetes ± is a metabolic disorder that is characterized by high blood glucose in the contextof insulin resistance and
relative insulin deficiency
BASIS
- MG, 53 year old, male
- PMH: Type 2 DM (5 years)
- SH: follows a good diabetic diet
- MH: Glyburide
- Lab: Glucose 7.5mmol (increase, NV: <5.6mmol/100mg/dL)
HbA1c: 7.0% (increase, NV:3.5-5.5%)

GOALS OF TREATMENT:

1. Eliminate symptoms related to hyperglycemia

2. Reduce or eliminate the long term microvascular and macrovascular complications of DM
3. Allow the patient to achieve as normal a lifestyle as possible

NON DRUG MANAGEMENT FOR DIABETESMELLITUS

It involves in three main steps:‡ Life style changes which are used to controlling diabetes.‡ Exercise
activities which controls the glucose levels.‡ Diet changes which controls the glucose levels.N o n d r u g
management involved in the controlling blood sugar level s or diabetes
t h r o u g h education, non drug administration, patient monitoring and encouragement, Includes the
nondrug activity like life styles changes, exercise and diet used to achieve it.
Glucose lowering agents

Anti-diabetic medications treat diabetes mellitus by lowering glucose levels in the blood. With the exceptions of
insulin, exenatide, and pramlintide, all are administered orally and are thus also called oral hypoglycemic agents or
oral antihyperglycemic agents. There are different classes of anti-diabetic drugs, and their selection depends on the
nature of the diabetes, age and situation of the person, as well as other factors

• Increase insulin secretion

• Reduce glucose production
• Increase insulin sufficiency
• Enhance GLP-1 action
• Oral Anti-diabetic Agents

Biguanides

Biguanides reduce hepatic glucose output and increase uptake of glucose by the periphery, including
skeletal muscle. Although it must be used with caution in patients with impaired liver or kidney function,
metformin, a biguanide, has become the most commonly used agent for type 2 diabetes in children and teenagers.
Amongst common diabetic drugs, metformin is the only widely used oral drug that does not cause weight gain.
PERSONAL DRUG

Metformin
Metformin is usually the first-line medication used for treatment of type 2 diabetes. It is generally
prescribed at initial diagnosis in conjunction with exercise and weight loss as opposed to in the past, where it was
prescribed after diet and exercise had failed. Initial dosing is 500 mg once daily, then if need be increased to 500 mg
twice daily up to 1000 mg twice daily. It is also available in combination with other oral diabetic medications. There
is an extended release formulation available, but it is typically reserved for patients experiencing GI side effects.

Side Effects:
- hypoglycemia
- shakiness
- dizziness
- headache
- hunger
- sudden change of behavior
- diarrhea

PRESCRIPTION:

Name: MG 07/22/ 2011

Age: 53 y/o
Sex: male

Rx:
Metformin 500 mg
# 31 tabs

Sig. Take 1 tab PO, OD

Love Lyn Padaca

Lic No.: 051985
PTR No.: 051985
Problem 4:

HYPOTHYROIDISM

 Is a syndrome resulting from deficiency of thyroid hormones and is manifested largely by a reversible
slowing down of all body functions.
 Iodine deficiency is the most common cause of hypothyroidism worldwide
 It can occur with or without thyroid enlargement (goiter).

Type Origin Description

• The most common forms include Hashimoto's thyroiditis

Primary Thyroid gland
• radioiodine therapy for hyperthyroidism.

• Pituitary gland does not create enough TSH to induce the

Secondary Pituitary gland thyroid gland to produce enough T3 and T4
• Damage to the pituitary gland by a tumor, radiation, or surgery

Tertiary Hypothalamus • Results when the hypothalamus fails to produce sufficient TRH

Signs and Symptoms

 Fatigue
 Sluggishness
 Increased sensitivity to cold
 Constipation
 Pale, dry skin
 A puffy face
 Hoarse voice
 An elevated blood cholesterol level
 Unexplained weight gain
 Muscle aches, tenderness and stiffness
 Pain, stiffness or swelling in your joints
 Muscle weakness
 Heavier than normal menstrual periods
 Brittle fingernails and hair
 Depression
Basis:
 PMH: Hypothyroidism for 20 years
 Levothyroxin, 0.15 mg QD
 TSH: 4.2mU/L

Treatment Objectives:
 To replace deficient thyroid hormone
 To prevent the severity of hypothyroid signs and symptoms
 To prevent further complications caused by hypothyroidism

Non-Pharmacologic Treatment
 Foods rich in iodine
 Exercise

Pharmacologic Treatment
 Levothyroxine
 Liothyronine
  Liotrix

Levothyroxine Liothyronine Liotrix

Efficacy +++ +++ ++

Safety +++ ++ ++

Suitability +++ + +

Cost + +++ +++

Personal Drug of Choice: Levothyroxine

 Preparation of choice for the thyroid replacement and suppression therapy.

 Is a synthetic form of thyroxine (thyroid hormone)
 Dosage: 25 – 50 mcg/day, once daily dosing.
 Route of Administration: Oral
 Administered in an empty stomach ( 30 min before meals / 1 hour before meal )
 Bioavailability: 100%
 Metabolism: Mainly in liver, kidneys, brain and muscles
 Half-life: 7 days
 Excretion: Through feces and urine

Adverse Effects
 heart palpitations
 abdominal pain
 Nausea
 Anxiousness
 Confusion
 Agitation
 Insomnia
 Weight loss
 increased appetite
 Allergic reactions - difficulty breathing, shortness of breath, or swelling of the face and tongue
  Acute overdose - fever, hypoglycemia, heart failure, coma and unrecognized adrenal insufficiency.

Drug Interaction:
 Calcium and iron supplements (w/in 4 hours)
 Soy products (w/in 3 hours)
 Grapefruit juice
 Aluminium and magnesium containing antacids
 Simethicone or Sucralfate
 Cholestyramine
 Colestipol
 Kayexalate

Name: M. G. Age: 53 y/o

Add: Marulas, Valenzuela Sex: Male

Rx Levothyroxine 25 mcg/day # 14 tabs

Sig: take 1 tablet, 30 min before meal / 1 hour after meal once daily

Katrina J. Ortiz Luis, M.D

Lic. No.: 12345
PTR No.: 1234

References:
Harrison’s Internal Medicine, 18th ed.
http://healthcenter.ucdavis.edu/topics/hyperlipidemia.html
http://www.medicinenet.com/captopril
http://www.medscape.com/