DRUG THERAPY PROBLEM WORKSHEET

Type of Problem Possible Causes Problem List Notes

Drugs without obvious medical indications
Correlation between drug Medications unidentified
therapy and medical • Orthostatic hypotension can
problems • be exacerbated by recent
• Doxazosin dose increase.
• Impulse control disorder is a
• side effect of
____________________.
Cognitive impairment and
daytime sleepiness can be
Untreated medical conditions exacerbated by
_____________________.
New medical condition requiring new drug therapy
Need for additional drug PD with motor fluctuations
Chronic disorder requiring continued drug therapy
therapy (wearing off and early morning
off)
Condition best treated with combination drug
therapy
May develop new medical condition without
prophylactic or preventative therapy or
premedication
Dose or frequency too low to produce desired
Dose too low •
response in this patient
Serum drug level below desired therapeutic range
Timing of antimicrobial prophylaxis not
appropriate
Medication not stored properly
Medication error

Dose too high Dose or frequency too high for this patient •

Serum drug level above the desired therapeutic

range
Dose escalated too quickly
Dose or interval flexibility not appropriate for this
patient
Medication error
Therapeutic duplication Receiving multiple agents without added benefit
History of allergy or ADE to current (or chemically
Drug allergy/adverse drug
related) agents
events
Allergy or ADE history not in medical records
Patient not using alert for severe allergy or ADE
Orthostatic hypotension Recent increase in Doxazosin
Falls dose may contribute to
Impulse control disorder orthostatic hypotension,
Cognitive impairment dizziness, and falls.
Daytime drowsiness
Pedal edema _________________ is
associated with pathologic
gambling.
Symptoms or medical problems that may be drug
induced
_________________ may
contribute to recent cognitive
decline.

Daytime drowsiness may be

exacerbated by
__________________ and
___________________.
Drug administered too rapidly
Medication error, actual or potential
 PATIENT DATABASE FORM
Patient Name: Patient ID: Location:
James Park
Age (or Date of Birth): Pharmacy: Room & Bed:
75-year-old
Height: 71 in. (180 cm) Weight: 180 lb. (81.8 kg) Sex (or Gender): Male

Physician: Race: Caucasian Religion:

Date of Admission / Initial Visit: Occupation:

Allergies/Intolerances/ADRs HPI, PMH, FH, SH, additional information…

❏No known drug allergies/ADRs Chief Complaint: “My movement has gotten worse and my Parkinson’s medications
do not seem to be as effective anymore
❏Not known/inadequate information Family History: Father died of lung cancer. Mother had Alzheimer’s disease and
died of complications related to pneumonia. And an older sister who is alive and
well.
Drug: Reaction: Social History: Attain a college education. He is married and lives with his wife for
50 years. He has three children aged 48, 43 and 40. He is a retired plumber.
Amantadine Livedo Reticularis Past Medical History:
 BPH (Benign Prostatic Hyperplasia) for 8 years
 Hyperlipidemia (10 years)
 Hypertension (10 years)
 Parkinson’s disease (5 years)

HPI:
 More difficulty arising out of bed, getting dressed, and feels unsteady
while walking. But he has not fallen. His wife confirms that walking and
performing activities of daily living seem to be more difficult for him. He
requires more assistance when arising out of a chair or the car.
 He notices that his Parkinson’s medications improve his movement but
this only lasts about 2 hours for each dose of carbidopa/levodopa. This
leaves him in an “off” state for several hours in between doses
 He is very “slow and stiff” upon awakening in the morning. He also
reports feeling very sleepy during the daytime.
 patient has developed a gambling habit over that past 6 weeks and
seems to be “obsessed” about any form of gambling but lottery tickets
in particular. On weekdays, he demands that she drive him to the
grocery store to purchase lottery tickets and on weekends, he will take a
cab to the local casino and spend the whole day there. They have lost a
substantial portion of their savings from his gambling activity.
 He seems to be depressed, more forgetful, and is increasingly confused
about the date and time

Prioritized Medical Problem List Medication Profile

Parkinson's Disease Carbidopa/Levodopa 25/100 mg po three times daily (8:00am –

2:00pm – 8:00pm)
Pramipexole ER 3 mg po q 24 h
Rasagiline 1 mg po q 24 h
Hypertension Atorvastatin 40 mg po q 24 h
HCTZ 12.5 mg po q 24 h
Hyperlipidemia
Benign Prostatic Hyperplasia Doxazosin 8 mg po q 24 h (was increased 8 weeks ago from 4 mg
to 8 mg)
Multivitamin one tablet po q 24 h

Diphenhydramine 25 mg po prn seasonal allergies (recently takes

approximately 1-2 doses per day)
 Vital Signs, Laboratory Data, and Diagnostic Test Results
Normal Range or Units Today 8 weeks ago __ months ago
Date month/day/year
Weight lb (kg) 180 lb. (81.8 kg)
Temperature °C 36.4°C
Blood pressure mmHg
Supine BP 140/76 mm Hg;
Standing BP 100/56 mm Hg
Pulse rate beats/min 76 bpm
Respiratory rate breaths/min 16 breaths/ min
Na 140 mEq/L
135–145 mEq/L (135–145 mmol/L)
(140 mmol/L)
K 3.8 mEq/L
3.3–4.9 mEq/L (3.3–4.9 mmol/L)
(3.8 mmol/L)
Cl 101 mEq/L
97–110 mEq/L (97–110 mmol/L)
(101 mmol/L)
CO2/HCO3 23 mEq/L
22–26 mEq/L (22–26 mmol/L)
(23 mmol/L)
BUN 16 mg/dL
8–25 mg/dL (2.9–8.9 mmol/L)
(5.7 mmol/L)
Serum Creatinine (adult) Male: 0.7–1.3 mg/dL; female: 0.6–1.1 mg/dL 1 mg/dL
(male: 62–115 μmol/L; female: 53–97 μmol/L) (88.4 μmol/L)
Creatinine clearance (adult)
85–135 mL/min (1.42–2.25 mL/s)
Glucose (fasting) 98 mg/dL
65–109 mg/dL (3.6–6.0 mmol/L)
(5.44 mmol/L)
Total Ca 8.8 mg/dL
8.6–10.3 mg/dL (2.15–2.58 mmol/L)
(2.2 mmol/L)
Mg
1.3–2.2 mEq/L (0.65–1.10 mmol/L)
PO4
2.5–4.5 mg/dL (0.81–1.45 mmol/L)
Hemoglobin Male: 13.8–17.2 g/dL; female: 12.1–15.1 g/dL 16 g/dL (160g/L)
(male: 8.57–10.68 mmol/L; female: 7.51–9.38 mmol/L)
Hematocrit Male: 40.7–50.3%; female: 36.1–44.3% 46%
(male: 0.407–0.503; female: 0.361–0.443) (0.460
MCV 92.1 μm3
80.0–97.6 μm3 (80.0–97.6 fL)
(92.1 fL)
WBC 6.5 × 103 /mm3
4–10 x 103/mm3(4–10 x 109/L)
(6.5 × 109 /L)
WBC Differential % polymorphonuclear neutrophils (PMN)/ ////
eosinophils/basophils/lymphocytes/monocytes
Platelet 240 × 103 /mm3
140–440 x 103/mm3(140–440 x 109/L)
(240 × 109 /L)
Albumin 4.1 g/dL
3.5–5 g/dL (35–50 g/L)
(41 g/L)
Total bilirubin 0.8 mg/dL
0.3–1.1 mg/dL (5.1–18.8 μmol/L)
(13.7 μmol/L)
Direct bilirubin 0.1 mg/dL
0–0.3 mg/dL (0–5.1 μmol/L)
(1.4 μmol/L)
AST 36 IU/L
11–47 IU/L (0.18–0.78 μkat/L)
(0.6 μkat/L)
ALT 40 IU/L
7–53 IU/L (0.12–0.88 μkat/L)
(0.67 μkat/L)
Alkphos (adult) 64 IU/L
38–126 IU/L (0.63–2.10 μkat/L)
(1.1 μkat/L)
Total cholesterol <200 mg/dL (<5.17 mmol/L)
LDL cholesterol <100 mg/dL (<2.59 mmol/L)
HDL cholesterol >40 mg/dL (>1.03 mmol/L)
Triglycerides <150 mg/dL (<1.70 mmol/L)

Additional Notes
MMSE (today): 25/30
MMSE (8 weeks ago): 28/30
UPDRS Part III motor (“on”) (8 weeks ago): 36
 PHARMACOTHERAPY CARE PLAN

Medical Problem Therapy Goals

Current Drug Regimen Therapeutic Recommendations Therapeutic Alternatives Rationale
List Desired Endpoints

Orthostatic Eliminate symptomatic Reduce dose of *Doxazosin Recommend increased salt Patient is predisposed
hypotension orthostatic WHAT DRUG? and fluid intake or using to orthostatic
hypotension or switch to alternative agent for compression stockings. hypotension due to
and dizziness. BPH, preferably an agent not having PD and also to
associated with orthostatic Consider fludrocortisone, *________________.
Improve QOL. hypotension. midodrine, or droxidopa WHAT DRUG?
if these fails. Recent increase in
*_________________
WHAT DRUG?
dose is likely to have
induced orthostatic
hypotension.
Impulse control Eliminate pathologic Discontinue *___________________ Known ADE of
Disorder gambling behavior. WHAT DRUG? __________________
agonists
Reduce caregiver WHICH DRUG
stress. CLASS?

Parkinson Eliminate end‐of‐dose Increase *_____________________ Addition of entacapone with More frequent dosing
disease with wearing‐off and early WHAT DRUG? each dose of will provide more “on”
motor morning off. dosing frequency carbidopa/levodopa or time.
fluctuations to _________ mg PO______ times converting to triple
(wearing off and Improve QOL. daily and titrate dose up as needed. combination product: Since the
early morning (Stalevo) __________________
off) WHAT BRAND? WHAT DRUG?
is discontinued,
Apomorphine SQ PRN for anticipate need to
rapid onset relief of “off ” increase dose of
periods. __________________
WHAT DRUG?
Cognitive Improve memory and Discontinue*___________________ May consider referral for
impairment eliminate confusion. WHAT DRUG? neuropsychiatric
evaluation.
Improve QOL and Recommend non-anticholinergic,
reduce caregiver non-sedating agent for seasonal
stress. allergies.
Depressed Improve mood. Continue to watch and monitor. May consider referral for
mood Assess for neuropsychiatric
Improve QOL. ____________________thoughts. evaluation

Daytime Eliminate daytime Discontinue Educate on proper sleep

sleepiness sleepiness. *_____________________________ hygiene.
WHAT DRUG?
Improve QOL.
Recommend non-anticholinergic,
non-sedating agent for seasonal
allergies.

Medical Problems Planned Monitoring & Follow-up Patient Education Summary Points
Orthostatic Document orthostatic intolerance. Educate patient that symptoms may be due to recent dose increase of
hypotension Monitor supine and standing BP and symptoms of dizziness. _____________________. WHAT DRUG?
Monitor and report any dizziness. Stand up slowly when rising out of car or
chair. Drink plenty of water.
Patient to consult with primary care physician for additional management of
BPH.
Impulse control Document as adverse drug reaction to _____________________. Educate patient and caregiver to report any persistent gambling behavior or
disorder Monitor for persistent gambling behavior. other odd behavior.
Educate that compulsive behavior is side effect of __________________
agonists.
Motor fluctuations Follow‐up within _____ month to assess for changes in “off ” times Educate patient on new carbidopa/levodopa dose frequency and to notice
(wearing off and and carbidopa/levodopa efficacy. changes in “on” and “off” times. Early morning “off” can be managed by taking
early morning off) Monitor according to UPDRS-(give meaning of abbrev) morning dose earlier or with glassful of water.
Unified Parkinson’s Disease Rating Scale
Cognitive Document to avoid ____________________________agents due to Educate patient on OTC drugs that can interfere with cognition (e.g.,
impairment cognitive impairment. diphenhydramine) and to consult with _______________________ before
Monitor using MMSE- (give meaning of abbrev) purchasing OTCs.
Mini Mental Status Exam
Depressed mood Watch and monitor _____________. Educate patient and caregiver to monitor for _______________ changes. Plan
is to watch and wait; and not make too many pharmacotherapy changes at
this time. Improvement in motor fluctuations can occasionally improve mood
Daytime sleepiness Document to avoid ____________________________agents due to Educate patient on OTC drugs that can cause drowsiness (e.g.,
daytime sleepiness. diphenhydramine) and to consult with ________________________ before
Monitor for daytime sleepiness. purchasing OTCs.
QUESTIONS:

1. a. What is the most recent Beers criteria for geriatrics?

American Geriatrics Society 2015 Updated Beers Criteria for Potentially Inappropriate Medication Use in
Older Adults

b. Indicate briefly the contents of each of the 5 subsets or tables of the recent Beers list.
Table 1 2015 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication
Use in Older Adults
Table 2 2015 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication
Use in Older Adults Due to Drug–Disease or Drug–Syndrome Interactions That May
Exacerbate the Disease or Syndrome
Table 3 2015 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medications
to Be Used with Caution in Older Adults
Table 4 2015 American Geriatrics Society Beers Criteria for Potentially Clinically Important Non-
anti-infective Drug–Drug Interactions That Should Be Avoided in Older Adults
Table 5 2015 American Geriatrics Society Beers Criteria for Non-Anti-Infective Medications That
Should Be Avoided or Have Their Dosage Reduced with Varying Levels of Kidney Function
in Older Adults

2. What is “on” and “off” phenomenon?

"On" and "Off" phenomenon refers to a switch between mobility and immobility in levodopa-
treated patients, which occurs as an end-of-dose or “wearing off” worsening of motor function or, much less
commonly, as sudden and unpredictable motor fluctuations

3. Give at least 5 “precipitant” drugs that interact with the “object” drug, Levodopa and their effects to
Levodopa.

Precipitant Drug Object Drug Interaction

(Alteration of GUT motility)
Metoclopramide Levodopa Rapid gastric emptying, Increase
rate of absorption.
Anti-cholinergics Levodopa Delayed gastric emptying,
Decrease rate of absorption.

4. What is Amantadine? (include Brand Name and its use for PD)

Amantadine (Symmetrel, PK-Merz) it is used to treat Parkinson's disease and its symptoms, including
dyskinesia by improving muscle control and reducing stiffness, this medicine allows more normal movements
of the body as the disease symptoms are reduced.

5. What is Safinamide? (include Brand Name and its use for PD)

Safinamide( Xadago) used to treat idiopathic Parkinson’s disease as add-on for people taking a stable
dose of levodopa (L-dopa) alone or in combination with other Parkinson drugs, to help with "off" episodes when
levadopa stops working.

6. What is “livedoreticularis” and what drugs can cause this?

Livedo Reticularis is a common skin finding consisting of a mottled reticulated vascular pattern that
appears as a lace-like purplish discoloration of the skin. The discoloration is caused by swelling of the venules
owing to obstruction of capillaries by small blood clots. Drugs that can cause Livedo reticularis are Adderall,
Amantadine, Bromocriptine , Beta IFN treatment, i.e. in multiple sclerosis, Rasagiline, Methylphenidate and
dextroamphetamine, Gefitinib
7. What is CoQ10 and its role in the treatment of PD?

Coenzyme Q10 (CoQ10) is a nutrient that occurs naturally in the body. It acts as an antioxidant, which
protects cells from damage and plays an important part in the metabolism. Research claims that High doses of
CoQ10 might be beneficial for people in the early stages of this progressive disorder of the nervous system
that affects movement.