Clinical Therapeutics Oral Revalida Review Notes: CASE 1: Dr. Abraham Daniel C. Cruz

CLINICAL THERAPEUTICS ORAL REVALIDA REVIEW NOTES
USE AT YOUR OWN RISK! This is made as a review material for our upcoming revalida. All contents are from reference materials. Sources
are written at the end of every case. You can get your answers here or when in doubt, you can always put your own answers.
Sana wag na maulit yung dati. Please be responsible! God bless to all of us. J

CASE 1: Dr. Abraham Daniel C. Cruz Neurology Awake, oriented to time, place, person
Patient Presentation Warm, 2+ pitting edema in both lower extremities,
Chief Complaint Extremities radial and pedal pulses 2+ bilaterally
• “I get tired more easily than before” GU and Deferred
Rectal
History of Present Illness exam
• MB is a 65 year old female, a retired massage therapist, diagnosed
with chronic heart failure NYHA Functional Class II, ACCIAHA Stage Laboratory Tests
C two years ago, NSTEMI 5 years ago, s/p percutaneous coronary • BUN: 46 mg/dL (increased)
intervention, maintained aspirin/80 mg po daily, furosemide 20 mg po • Serum creatinine: 1.9 mg/dL (increased)
BID/metoprolol tartrate 12.5 Ing po BIDV, enalapril 10 mg po daily, • AST: 60 IU/L (increased)
spironolactone 12.5 mg once daily/ and digoxin 0.125 mg once daily. • ALT: 75 IU/L (increased)
Since she is retired, she relies only on her pension for her medication. • Alkaline Phosphatase: 156 IU/L (increased)
She states that sometimes, she misses her medications. She sought • LDL: 130 mg/dL (borderline high)
consult at the ER due to decreasing exercise tolerance and fatigue.
She relates that one week prior to consult, she felt some pain in both Diagnostic Tests
of her knees and in her lower back. Her neighbor told her that it might
• ECG: Nonspecific ST-T wave change
be the beginning of osteoarthritis, so she self-medicated with
• Chest X-ray: Cardiomegaly, Pulmonary vascular congestion
Celecoxib, The pain was relieved after three days but then the patient
began to notice that her feet was getting more swollen. Two days • Echocardiogram: Hypokinesis of the left ventricle (anterolateral
prior to consult, she attended a birthday party, and admits to eating wall)
and drinking more than she should have. One day prior to consult, • Left Ventricle EF: ~40%
she noticed that her face was puffy, more easily tired and seems to
be catching her breath, and that both her feet were swollen to the Questions
level of the ankle. 1. Describe the four clinical presentations of acute heart failure
and their specific treatment goals/
Past Medical History
• As above
Family History
• Father had diabetes and hypertension and died at the age of 75.
• Mother died from endometrial cancer at age at 70.
Social History
• Single. Lives alone. Retired.
• Tobacco/Alcohol/Substance Abuse
o Non-smoker, non-alcoholic beverage drinker, with no history of
illicit drug use
• Allergies/ Intolerance / Adverse Drug Events
o No known allergies
• Medications
o aspirin 80 mg po daily
o furosemide 20 mg po BID
o metoprolol tartrate 12.5 mg po BID
o enalapril 10 mg PO daily
o spironolactone 12.5 mg OD
o digoxin 0.125 mg OD
Review of Systems
• No pain, fever, nausea
Physical Exam
Weight: 170 lbs
Height: 5 ft 5 inches
Vital Signs Temp: 37°C; BP: 110/80; Pulse: 95; RR: 24
O2 saturation: 93% on 5L nasal cannula, not in pain
General Moderately distressed, needs to be propped up on
bed with one pillow
HEENT (+) Jugular vein distention
CHEST Chest Crackles at both lung bases
CV Regular rate and Rhythm, normal S1/S2, (+) S3, no
S4, 2/6 systolic murmur, PMI displaced laterally
Abdomen Soft, nontender, normoactive bowel sounds

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2. What are the three patient-related precipitating factors in heart 5. Excessive preload reduction due to over diuresis can lead to?
failure present in the case? • Decrease in CO
• Resulting in reflex increase in sympathetic activation
• Renin release
• Expected consequences of vasoconstriction
• Tachycardia
• Increased myocardial oxygen demand
6. In order to avoid over diuresis, what parameters should be

closely monitored?
• Monitor serum electrolytes such as potassium, sodium, and
magnesium frequently to identify and correct imbalances.
• Monitor serum creatinine and blood urea nitrogen daily at a minimum
to assess volume depletion and renal function.
7. Non-response to diuretic is defined as

• Defined as failure to achieve a weight reduction of at least 0.5 kg (or
negative net fluid balance of at least 500 mL) after several increasing
bolus doses
8. What strategies are used to overcome diuretic resistance?

In the case • Using larger oral doses,
1. Dietary/Fluid non-adherence • Converting to intravenous dosing
2. HF therapy non-adherence • Increasing the frequency of administration
3. Offending medications (COX2 and Beta blockers) • Combination of two diuretics with different sites of action within the
nephron
3. What are the goals of therapy for acute heart failure?
• Correct the underlying precipitating factor(s) 9. What are the three commonly used vasodilators in patients
• Relieve the patient’s symptoms presenting with acute heart failure?
• Improve hemodynamics • Nitroglycerin
• Optimize a chronic oral medication regimen • Nitroprusside
• Educate the patient, reinforcing adherence to lifestyle modifications • Nesiritide
and the drug regimen.
• Ultimate goal for a patient hospitalized: Return to a compensated
HF state and discharge to the outpatient setting on oral medications.
4. Based on the clinical presentation

• To what subset of acute heart failure clinical presentation does the
patient belong to?
o Subset II (Warm and Wet)
• What 2 classes of drugs are recommended for this subset?
o Loop diuretics
o Vasodilators
10. Inotropic agents are given in cases of acute heart failure with poor perfusion. Describe the mechanism of action of each drug
MOA Comments
Agonist mainly on B1 and B2 • Inotrope of choice for AHF
receptors and minimally on • Monitor: BP, HR, Urinary output and function, ECG
Dobutamine
a1 receptors • Monotherapy with dobutamine is reserved for patients with systolic BP >90 mmHg. However,
it is commonly used in combination with vasopressors in patients with lower SBP.
Direct stimulation of • Most commonly reserved for patients with low systolic BP and those approaching
adrenergic receptors, as well cardiogenic shock
Dopamine
as release of NE from • Monitor: BP, HR, UO and kidney function, ECG, extremity perfusion (higher doses only)
adrenergic nerve terminals • Associated with a risk for arrhythmias
• Milrinone has replaced inamrinone as the phosphodiesterase inhibitor of choice
• “Inodilator”: Both positive inotropic and vasodilating properties
They both work by inhibiting • Milrinone is a good option for patients requiring an inotrope who are also chronically
Milirone
phosphodiesterase III, the receiving β-blockers because the inotropic effects are achieved independent of β-
and
enzyme responsible for the adrenergic receptors.
Amrinone
breakdown of cAMP • BP, HR, UO and function, ECG, changes in ischemic symptoms (e.g., chest pain),
electrolytes
• Potential AE: hypotension, arrhythmias, and, less commonly, thrombocytopenia.
(Sources: Pharmacotherapy Principles & Practice, 4th edition, Chapter 6; Katzung Basic & Clinical Pharmacology 12th edition)

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CASE 2: Dr. Celia R. Ravelo Medications
Patient Presentation • Warfarin 2.5 mg po once daily
Chief Complaint • Metoprolol tartrate 25 mg po twice daily
• Chest pain with shortness of breath • Atorvastatin 40 mg po once daily
• HCTZ 25 mg po once daily
History of Present Illness • Aspirin 81 mg po daily
• DRF, a 60 year old male, was brought to ER by an ambulance due to • Ranitidine 150 mg po once daily
complaints of chest pain and shortness of breath (SOB). The • Centrum Silver vitamin po once daily
condition started about one hour prior to admission when he • Nitroglycerin 0.4 mg sublingually as needed for chest pain
experienced chest pain while doing paper works in his home office.
He also felt nauseous and was noted to have cold perspiration. He Review of Systems
self-medicated initially with sublingual nitroglycerin (NTG) but
• unexpected weight gain, (-) chills, diaphoresis and fatigue
afforded no relief hence he called his wife for help who called the
• (+) shortness of breath and wheezing
emergency. Upon arrival by the paramedics, another dose of NTG
• (+)pain and bilateral leg swelling; (-) palpitations
was given which afforded some relief. He denied any exertional chest
pain and stated that his SOB has been increasing in conjunction with • (+) light-headedness and headaches (-) numbness, vertigo
an increase in leg swelling. He claimed that he was compliant with all
hid medications. Occasionally, he feels fatigued and notices a rapid Physical Exam
heart rate when he is active in his yard. He has had several General Well-appearing, elderly male in mild
General
hospitalizations within the last 2-3 years secondary to atrial fibrillation distress. He is oriented to person, place and time.
with rapid ventricular response. His last check-up was 3 months ago BP:111/78 mmHg; PR:105 bpm; RR:20/min;
and his ECG indicated normal sinus rhythm. T:36.5
Vital Signs Weight 185 lb. (83.90 kg (dry weight 80 kg);
Past Medical History Height 68 in. (173 cm)
• AF Skin Warm and dry
• Hypertension (HTN) HEENT PERRLA, mucosal membranes dry
• Heart failure (HF) (EF 45% 1 month ago) Neck and (+) JVD; (-) carotid bruits
• Dyslipidemia Lymph Nodes
• Coronary Artery Disease (CAD) (s/p PCI and stent placement 3 years Chest Wheezes present (RLL and LLL)
ago) CV Irregularly irregular rhythm; slightly tachycardic;
no murmurs, rubs or gallops
• GERD (gastroesophageal reflux disease)
Abdomen Not tender, not distended; (-) hepatomegaly
Family History Neurology Alert and oriented x 3
Extremities Bilateral 1 + pitting edema
• Father had CAD and died of Ml at the age of 63.
GU Deferred
• Mother died of a stroke at the age of 74.
Rectal Deferred
• He has one younger brother and sister who are well.
Laboratory Tests
Social History/Work History
• Serum creatinine: 1.6 mg/dL (increased)
• Married and lives with his wife of 27 years
• Prothrombin: 20s (prolonged)
Tobacco/Alcohol/Substance Use • INR: 1.5
• Occasional glass of wine with dinner • LDL cholesterol: 104 mg/dL (Above desirable)
• No tobacco or illicit drug use • HDL cholesterol: 38 mg/dL (increased)
Allergies/Intolerances/Adverse Drug Events Questions

• No known drug allergies 1. Enumerate the clinical problems of this patient based on your
assessment
• Persistent Atrial Fibrillation
• Chronic Heart Failure and Angina
2. Tabulate the current medications of this patient to as follows:

Medication Mechanism of action Clinical indication Adverse effect/s
Warfarin Interferes with hepatic synthesis of Thromboembolism associated with pulmonary Hemorrhage, Tissue Necrosis,
vitamin K-dependent clotting embolism, AF, Venous thrombosis, Recurrent MI, Calciphylaxis,
factors (II, VII, IX, and X) Systemic Embolism Stroke Kidney damage/injury
Metoprolol Inhibit AV nodal conduction by Angina pectoris, Hypertension, Arrhythmias Hypotension, sinus bradycardia,
tartrate slowing AV nodal conduction and AV block, fatigue, heart failure
prolonging AV nodal refractoriness exacerbation
Cardioselective Beta blocker;
Blocks B1>B2
Atorvastatin HMG-CoA reductase inhibitor Atherosclerotic vascular disease (primary and Myopathy, hepatic dysfunction
secondary prevention), Acute coronary syndromes

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HCTZ Inhibition of the Na/Cl transporter in Hypertension, Mild heart failure, Nephrolithiasis, Hypokalemic metabolic
the distal convoluted tubule Nephrogenic DI alkalosis, hyperuricemia,
hyperglycemia, hyponatremia
Aspirin Cyclooxygenase inhibitor Prophylaxis for TIA and MI, Fever, Arthritis, Bleeding, thrombocytopenia,
Thromboembolism Reye’s syndrome, salicylate
toxicity
Ranitidine H2 Receptor Antagonist GERD, PUD Vitamin B23 deficiency,
Reduces gastric acid secretion by Non ulcer dyspepsia arrhythmias, thrombocytopenia,
reversible binding to H2 receptors Stress-related gastritis liver toxicity
Centrum Multivitamin Helps support heart, brain and eyes Upset stomach, GI disturbances,
silver Unusual taste in the mouth
vitamin
3. In a tabulated form, differentiate the different types of AF and their specific treatment goals
Types Description Treatment Goals
Have episodes that start suddenly and spontaneously, last minutes to Ventricular rate control, prevention of
hours, or rarely as long as 7 days and terminates suddenly and thromboembolism, maintenance of sinus
spontaneously. (Pharmacotherapy principles and Practice) rhythm (if ventricular rate control is not
Paroxysmal
sufficient to control symptoms)
Paroxysmal is often initiated by small reentrant or rapidly firing foci in
sleeves of atrial muscle that extend into the pulmonary veins (Harrison’s)
Some patients with paroxysmal AF have episodes that do not terminates Ventricular rate control, prevention of
spontaneously but require intervention, and this Is known as persistent AF. thromboembolism, and conversion to sinus
(Pharmacotherapy principles and Practice) rhythm
Persistent
Persistent AF has longer duration, exceeding 7 days, and, in many cases
will continue indefinitely unless cardioversion is performed. (Harrison’s)
Approximately 1/3 of patients with AF progress to the point of permanent Ventricular rate control and prevention of
AF; these patients are subsequently never in normal sinus rhythm, but thromboembolism
rather always in AF (From Pharmacotherapy principles and Practice)
Permanent
Defined as continuous AF lasting 12 months or longer Ventricular rate control, prevention of

Long Standing
(From Pharmacotherapy principles and Practice) thromboembolism, and conversion to sinus
persistent AF
rhythm
What type of AF is presented in the case and which treatment goals apply? Persistent Atrial Fibrillation – For the acute management of
Atrial Fibrillation, stabilize and control first the ventricular rate of the patient. Give anticoagulants to prevent risk for stroke.
Additional readings: Goal of therapy of AF

• Ventricular rate control
• Termination of AF and restoration of sinus rhythm (commonly referred to as “cardioversion” or “conversion to sinus rhythm”)
• Maintenance of sinus rhythm, or reduction in the frequency of episodes of paroxysmal AF
• Prevention of stroke
• Stroke Prevention. All patients with paroxysmal, persistent, or permanent AF should receive therapy for stroke prevention, unless compelling
contraindications exist
4. In a tabulated form, enumerate the different types of drugs for ventricular rate in control in AF, discuss the MOA and drug-drug
interaction based only on the drugs being taken by the patient and adverse effects
Drugs MOA Adverse effects Drug-drug interaction
Beta adrenoreceptor blockade Hypotension, sinus bradycardia, AV block, HCTZ may cause hypotension
Beta Inhibit AV nodal conduction by heart failure exacerbation Aspirin may blunt ACEI and Beta
Blockers slowing AV nodal conduction and blocker vasodilating effect
prolonging AV nodal refractories
Beta blocker CCB IV: Hypotension, sinus bradycardia Inhibits clearance of warfarin, and
Oral: Blue-gray skin discoloration, photosensitivity, some statins
corneal microdeposits, pulmonary fibrosis,
Amiodarone
hepatotoxicity, sinus bradycardia, hypo-
/hyperthyroidism, peripheral neuropathy, weakness,
AV block
Calcium channel blockade Hypotension, sinus bradycardia, heart failure Increases concentration of
Inhibits AV nodal conduction by exacerbation, AV block atorvastatin
Diltiazem slowing AV nodal conduction and
prolonging AV nodal Ranitidine increases serum
refractoriness Diltizem concentration
Calcium channel blockade Hypotension, heart failure exacerbation, Increases concentration of
Verapamil
bradycardia, AV block, constipation (oral) atorvastatin

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Inhibits AV nodal conduction by
slowing AV nodal conduction and
prolonging AV nodal
refractoriness
Inhibits AV nodal conduction by: Nausea, vomiting, anorexia, green-yellow Atorvastatin and aspirin may alter
1.Vagal stimulation halos around objects, ventricular arrhythmias digoxin levels and increase risk for
Digoxin 2.Directly slowing Av nodal toxicity
conduction and prolonging AV
nodal refractoriness
Which of these drugs would be most appropriate for the patient in

this case. State your rationale?
• Metoprolol tartrate 25 mg PO twice daily is a beta blocker that help
control ventricular rate, improve symptoms, and possess a low-risk
profile. (Harrison’s) It mainly acts as a sympatholytic. Drugs with this
action reduces β-adrenergic activity in the heart (Katzung)

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5. Tabulate the different drugs that can be used to prevent thromboembolism in patient with AF and discuss their advantages and
disadvantages, indication, and contraindications
Drug Advantages Disadvantages Indications Contraindications
INR monitoring is not required, Dabigatran should not be
and the drug’s onset of action FDA approved direct
Dabigatran-associated used in patients with ESRD
is rapid, eliminating the need thrombin inhibitor for
bleeding, there is no antidote (CrCl under 15 mL/min [0.25
for bridging with unfractionated stroke prevention in
to reverse dabigatran’s mL/s) or advanced liver
Dabigatran or low molecular weight patients with nonvalvular
effects disease (impaired baseline
heparins. In addition, there is a AF
clotting function).
lower likelihood of drug
interactions with dabigatran
than with warfarin
Noninferior to warfarin for May require adjustment Oral factor Xa inhibitor,
prevention of stroke or when used in combination was approved by the FDA
with dual P-gp and strong in 2011 for prevention of Contraindicated in patients
systemic embolism in patients
cytochrome P-450 3A4 stroke or systemic with end-stage renal disease
Rivaroxaban with AF, and compared with
inducers or inhibitors. embolism in AF. (CrCl <15 mL/min [0.25
warfarin, rivaroxaban was
mL/s]
associated with a lower risk of
intracranial and fatal bleeding.
In patients with moderate
kidney disease (CrCl 30–50
mL/min [0.50–0.83 mL/s]),
the dose should be reduced
to 2.5 mg orally twice daily.
Superior to warfarin for
prevention of stroke or Oal factor Xa inhibitor, was Apixaban should not be
systemic embolism in patients Apixaban dose should be approved by the FDA in administered to patients with
with AF, with lower bleeding reduced to 2.5 mg orally 2012 for prevention of severe liver disease.
Apixaban
risk. twice daily when any two of stroke and systemic
the following characteristics embolism in patients with
are present: serum AF.
creatinine greater than 1.5
mg/dL (133 μmol/L), 80
years of age or older, body
weight less than or equal to
60 kg (132 lb).

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6. What will you evaluate after administering all drugs to normalize the rhythm of this patient? How will you monitor these outcomes?
• Monitor the patient to determine whether the goal of ventricular rate control is met: heart rate <80 beats/min for most patients, though a target
heart rate of less than 110 beats/min may be reasonable as long as patients remain asymptomatic and LV systolic function is preserved.
• Monitor ECG to assess continued presence of AF and to determine whether conversion to sinus rhythm has occurred.
• In patients receiving warfarin, monitor INR approximately monthly to make sure it is therapeutic (target: 2.5; range: 2.0–3.0).
• Monitor patients for adverse effects of specific drug therapy. Monitor patients receiving oral anticoagulation for signs and symptoms of bruising
or bleeding.

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7. Create a sound therapeutic plan for this case based on the clinical problems presented. Include the pharmacologic agent, target/goal,
monitoring plan.
Clinical problem Pharmacologic agent Goal Monitoring
Edema
The goal is to have the patient reach a Daily weight monitoring even in the absence of
(bilateral 1+ Loop diuretics (furosemide)
euvolemic state symptoms to assess fluid status because body
pitting edema)
weight changes are a sensitive marker of fluid
The goal is to reduce pulmonary
Loop diuretics (Furosemide) retention or loss; Serum electrolytes monitoring
congestion
To stabilize and control ventricular
Beta blockers ECG, blood pressure, heart rate, and
heart rate thus lengthen diastolic filling
(Metoprolol Tartrate) respiratory rate monitoring
time and increase stroke volume
Shortness of
Calcium Channel Blocker
breath ECG, blood pressure, and heart rate monitoring
(Verapamil or Diltiazem)
Serum digoxin level, ECG, Heart Rate,
For ventricular rate control
Ventricular Rate (apical impulse), Renal
Cardiac Glycoside (Digoxin)
function, Serum electrolytes (especially K and
Mg)
To stabilize and control ventricular
ECG, blood pressure, heart rate, and
Beta blockers heart rate thus lengthen diastolic filling
(Metoprolol Tartrate) respiratory rate monitoring
time and increase stroke volume
Irregularly Calcium Channel Blocker
ECG, Blood pressure, and heart rate monitoring
irregular heart (Verapamil or Diltiazem)
rhythm Serum digoxin level, ECG, Heart Rate,
For ventricular rate control
Ventricular Rate (apical impulse), Renal
Cardiac Glycoside (Digoxin)
function, Serum electrolytes (especially K and
Mg)
Possible Coumadin Prevent occurrence of
PT, INR
thromboembolism (Warfarin) thromboembolism
Lower LDL level
HMG-CoA reductase Also indicated for suspected ACS

Aggressive monitoring of lipids with SGPT and
Dyslipidemia Inhibitors patients; Reduce the risk for coronary
blood sugar every 6-8 weeks (Harrison’s)
(Atorvastatin 80mg) events, it lowers risk for thrombosis;
Promotes maintained integrity of the
fibrous cap (Harrison’s)
Based on the 2015 CPG Guidelines for dyslipidemia a treatment goal of LDL level of </= 70 mg/dL is recommended, and high intensity statins like
Atoravastatin 80 mg is recommended
Nitrates Monitor for tachycardia, flushing, headache,
For relief of chest pain
As necessary for chest pain and hypotension
Unstable Angina Recommended to achieve a rapid
Aspirin (160 mg) Watch out for dyspepsia, nausea, bleeding.
platelet inhibition
Statins Same as above
Decrease gastric acid secretion for Watch out for headache, fatigue, dizziness, and
GERD H2RAs (Ranitidine)
symptomatic relief of GERD either constipation or diarrhea
Comments: PPIs can’t be used because it can alter the metabolism of the ongoing warfarin therapy of our patient
(Sources: Pharmacotherapy Principles & Practice, 4th ed, Chapter 9; Katzung Basic & Clinical Pharmacology 12th ed; Harrison’s Principles of Internal Medicine 20th ed)

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CASE 3: Dr. Angelico L. Alejo o Positive rapid urease test for H. Pylori
Patient Presentation o Positive H. pylori serology test
Chief Complaint o On and off epigastric pain
• “My stomach burns, but if I eat something it decreases in intensity” o Follows a pain-food-relief pattern
o EGD reveals a non-bleeding shallow ulcer with no visible vessel
History of Present Illness in the proximal duodenum
o Coffee and alcohol intake
• PJ came into the ER complaining of feeling a little weak and dizzy,
with nausea (no vomiting), lethargy and epigastric pain described as o Excessive NSAID intake
burning. He has experienced symptoms like this off and on before,
but not this severe. He denies any melena, frank blood in stool,
throwing up blood, chest pain or any other symptoms. Because of the
nausea he has not eaten much or drank much in the last 3 days.

• Hypothyroidism (4 years)
• Currently takes ibuprofen for headaches
Family History
• Father has a history of hypertension, and hyperlipidemia
• Mother is alive and well at age 62 years old
Social History
• 2nd year medical student who drinks a lot of coffee
• Drinks alcohol occasionally, (-) tobacco or illicit drug use
• Allergic to penicillin and alcohol (nausea and flushing)
Review of Systems
• (-) changes in bowel habit or change in color/consistency of stool
• dizzy and tired x 2 days
• anorexia
• (-) tinnitus, vertigo, or infections
• (+) occasional headache
Physical Exam 2.
General Well appearing and is in minimal distress
Location Gastric Ulcer Duodenal Ulcer
BP: 110/68mmHg, p 64 (sitting)
BP: 104/62mmHg, p 78 (standing) Risk of Malignancy is Higher risk for
RR: 12 cpm; T: 37.2oC malignancy unlikely malignancy
Vital Signs
Weight: 106 lbs. (48.1kg)
Height: 65inches (165cm) Disease of
Epigastric pain: 3/10 Disease of increased acid
PERRLA, EOMI; (-) sinus tenderness; weakened mucosal peptic action
TMs appear normal defenses on the duodenal
HEENT Thyroid glands smooth, (-) thyroid nodules, mucosa
lymphadenopathy, carotid bruit
Flat neck veins Weakened mucosal defenses play a role in
Pathophysiology both duodenal and gastric ulcers
CHEST Clear
CV RRR normal s1, s2; no s3 or s4 Acid hypersecretion may result in duodenal
Soft, nontender, (+) epigastric pain, sl worse on and gastric ulcer in the setting of normal
Abdomen mucosal defenses
deep palpation
Neurology Gross intact;DTR’s normal H. pylori - predisposes to ulceration, both by
acid hypersecretion and by compromise of
GU deferred
GU and Rectal mucosal defense mechanisms
Rectal: normal rectal tone; minimal stool in
exam
rectal vault, negative occult blood. Bleeding
Bleeding Perforation
Laboratory Tests Perforation Gastric outlet
Complications
• H. pylori serology: (+) Obstruction obstruction
• Stool for occult blood (-) Gastrocolic fistula Intractable pain
• EGD: non-bleeding shallow ulcer with no visible vessel in the malignancy
proximal duodenum
• Rapid urease test of ulcer biopsy: H. pylori+ 3. Goals of management
• Resolve symptoms, reduce acid secretion, promote epithelial healing
Questions • Prevent ulcer-related complications and recurrence
1. Give the complete diagnosis and the basis. • For H. pylori–related PUD, eradication of H. pylori is an additional
• Peptic ulcer disease-duodenal ulcer outcome
• Bases:

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4. Management
ACID INHIBITORY DRUGS
CLASS EXAMPLES MOA SIDE EFFECTS COST
Diarrhea, Headache, Abdominal

PROTON Omeprazole Inhibit both fasting and meal-stimulated secretion
Pain, Vitamin B12 deficiency Omeprazole
PUMP Lansoprazole because they block the final common pathway of
Increased risk of both nosocomial 27PHP/cap
INHIBITORS Pantoprazole acid secretion, the proton pump.
and CAP; Enteric infections
Magnesium Weak bases that react with gastric hydrochloric Diarrhea (Magnesium salts),
hydroxide or acid to form a salt and water. Their principal Constipation (Aluminum salts); MgOH+AlOH
ANTACIDS
Aluminum mechanism of action is reduction of intragastric May affect the absorption of other 6PHP/Tab
hydroxide acidity drugs
Cimetidine Exhibit competitive inhibition at the parietal cell

H2 Diarrhea, Headache, Fatigue ,
Ranitidine H2 receptor and suppress basal and meal- Ranitidine
RECEPTOR Myalgias, Constipation, Blood
Famotidine stimulated acid secretion in a linear, dose- 11php/TAB
BLOCKERS dyscrasia, Bradycardia
Nizatidine dependent manner
CYTOPROTECTIVE AGENTS
CLASS EXAMPLES MOA SIDE EFFECTS COST
Negatively charged sucrose sulfate binds to

Constipation, nausea, metallic
positively charged proteins in the base of ulcers
taste, and the possibility for
Sucralfate Sucralfate or erosion, forming a physical barrier that restricts 52PHP/ tablet
aluminum toxicity in patients with
further caustic damage and stimulates mucosal
renal failure
prostaglandin and bicarbonate secretion.
Stimulate mucus and bicarbonate secretion and

Diarrhea, Cramping, abdominal
enhance mucosal blood flow; It binds to a
Prostaglandin pain; Should not be used during Not available
Misoprostol prostaglandin receptor on parietal cells, reducing
analogues pregnancy or in women of child- locally
histamine-stimulated cAMP production and
bearing potential
causing modest acid inhibition
Bismuth
Bismuth coats ulcers and erosions, creating a Blackening of the stool and
Bismuth subsalicylate;
protective layer against acid and pepsin; It may tongue; Toxicity: Encephalopathy,
compounds Bismuth 656php/pack
also stimulate prostaglandin, mucus, and Ataxia, Headaches, Confusion,
subcitrate
bicarbonate secretion Seizures, tinnitus
potassium
H. PYLORI ERADICATION
• Eradication therapy with a PPI-based three-drug regimen should be considered for all patients who test positive for H. pylori and have an active
ulcer or a documented history of either an ulcer or ulcer-related complication.
• The first-line regimen should consist of triple drug therapy with a PPI plus clarithromycin and either amoxicillin or metronidazole.
o Amoxicillin should not be used in penicillin-allergic patients, and metronidazole should be avoided if alcohol is going to be consumed.
o A single daily PPI dose may be less effective than twice-daily dosing when used in a triple-drug regimen.
o Substitution of one PPI for another is acceptable and does not affect eradication rates.
• The duration of therapy for H. pylori eradication is controversial; US guidelines recommend either 10 or 14 days.
MEDICATION/DOSE/FREQUENCY DURATION
PPI + Clarithromycin 500mg bid + amoxicillin 1000mg bid 10 – 14 days
PPI + Clarithromycin 500mg bid +metronidazole 599mg bid 10 – 14 days
PPI + amoxicillin 1000mg TID then 5 days
PPI + Clarithromycin 500mg + tinidazole 500mg BID 5 days
Salvage regimen for patients who fail in one of the above regimens
Bismuth subsalicylate 525mg qid + metronidazole 250 mg qid + tetracycline 500mg qid + PPI 10-14 days
PPI + amoxicillin 100mg bid + levofloxacin 500mg daily 10 days

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5. Complications of Peptic ulcer disease
• Gastrointestinal Bleeding
o GI bleeding is the most common complication observed in PUD
o 15% of patients and more often in individuals >60 years of age
• Perforation
o Second most common
o Incidence in the elderly: increasing due to increased use of NSAIDs.
o Penetration is a form of perforation in which the ulcer bed tunnels into an adjacent organ
• Gastric Outlet Obstruction
o The least common
o Relative obstruction secondary to ulcer-related inflammation and edema in the peripyloric region often resolves with ulcer healing
o A fixed, mechanical obstruction secondary to scar formation in the peripyloric areas is also possible
• Intractable pain
• Malignancy
(Sources: Pharmacotherapy Principles & Practice, 4th ed, Chapter 18; Katzung Basic & Clinical Pharmacology 12th ed; Schwartz’s Principles of Surgery, 10th ed)

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CASE 4: Dr. Lylah D. Reyes Questions:
Patient Presentation 1. What are the risk factors for the development of hepatitis B?
History of Present Illness Give at least 2
• A 37-year old Filipino male consulted at the clinic for his regular Pharmacotherapy Principles and Practice
check-up. He claims to have episodes of easy fatiguability but other • Infants born to infected mothers
than that there were no other complaints. He denies having had dark • International travelers to endemic areas
urine, pale stools, and yellowish discoloration of his eyes and skin.
• Men having sex with other men
Past Medical History • Individuals with multiple heterosexual partners
• He has hypertension and has been taking Amlodipine 10 mg once a • IV drug users using unsterilized needles
day for 5 years now. It was 3 years ago when he was diagnosed to • Recipients of blood products
have hepatitis B infection with supportive treatment given. He denies • Household contacts with acute hepatitis B
any history of previous surgery. He has no known allergy to food and • Healthcare providers and public safety workers in contact with
medications. infected blood
Family History • Residents and staff of facilities for developmentally disabled persons
• His father is a known hypertensive. • Patients undergoing dialysis
• Her mother has chronic hepatitis B infection which was confirmed
prior to giving birth to him. Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis
Social History B: AASLD 2018 Hepatitis B Guidance
Groups at High Risk for HBV Infection Who Should Be Screened
• He is married for 10 years with 2 children. He had 5 sexual partners
prior to his marriage. He is a chef and runs his own restaurant. He is • Persons born in regions of high or intermediate HBV endemicity
an occasional alcohol drinker who only drinks alcohol during social (HBsAg prevalence of ≥2%)
gatherings. He is a non-smoker and denies illicit drug use. o North, Southeast, East Asia (all countries)
• U.S.-born persons not vaccinated as an infant whose parents were
Review of Systems born in regions with high HBV endemicity (≥8%)*
• (+) episodes of easy fatigability • Persons who have ever injected drugs*
• Men who have sex with men*
Physical Exam • Persons needing immunosuppressive therapy, including
chemotherapy, immunosuppression related to organ transplantation,
General General survey: Ambulatory, conscious, coherent,
and immunosuppression for rheumatological or gastroenterologic
Survey and well-oriented. Not in cardiorespiratory distress
disorders.
BP: 120/80 mmHg
• Individuals with elevated ALT or AST of unknown etiology*
CR: 78 beats/min
RR: 18 cycles/min • Donors of blood, plasma, organs, tissues, or semen
Vital Signs Temp: 36.9°C • Persons with end-stage renal disease, including predialysis,
Weight: 154 lbs hemodialysis, peritoneal dialysis, and home dialysis patients*
Height: 67 in • All pregnant women
pink palpebral conjunctivae, anicteric sclera, • Infants born to HBsAg-positive mothers*
HEENT pupils reactive tonight, no congested nasal • Persons with chronic liver disease, e.g., HCV*
turbinates and throat • Persons with HIV*
Neck No neck mass, no lymphadenopathy • Household, needle-sharing, and sexual contacts of HBsAg-positive
Chest symmetrical, clear breath sounds persons*
Heart normal rate, regular rhythm, no murmur • Persons who are not in a long-term, mutually monogamous
normoactive bowel sounds, flat, soft, liver and relationship (e.g., >1 sex partner during the previous 6 months)*
Abdomen • Persons seeking evaluation or treatment for a sexually transmitted
spleen not palpable
Extremities no edema, no lesions, with full and equal pulses disease*
no jaundice, no palmar erythema, no spider • Health care and public safety workers at risk for occupational
Skin angiomata exposure to blood or blood-contaminated body fluids*
• Residents and staff of facilities for developmentally disabled persons*
• Travelers to countries with intermediate or high prevalence of HBV
Laboratory Tests infection*
• Whole abdominal ultrasound (1 day prior to follow-up): No hepatic • Persons who are the source of blood or body fluid exposures that
mass lesion, normal biliary tract; no evidence of cholelithiasis; normal might require postexposure prophylaxis
pancreas; normal kidneys; mild splenomegaly • Inmates of correctional facilities
• Unvaccinated persons with diabetes who are aged 19 through 59
Jan 10 Current years (discretion of clinician for unvaccinated adults with diabetes
AST 70 IU/L 100 IU/L who are aged ≥60 years)*
ALT 71 IU/L 104 IU/L
Hbs Ag + +
Hbe Ag Non-reactive +
Anti Hbc total Non-reactive +
HBV DNA Not detectable 7956100

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2. Based on the above serological and HBV DNA tests of the patient, what is the current type and status of hepatitis B infection? Give
at least 2 basis.
• Current type: Chronic Hepatitis B, High infectivity Jan 10 Current
• Bases: AST 70 IU/L 100 IU/L
o HBsAg positive - indicates presence of infection ALT 71 IU/L 104 IU/L
o HBeAg positive - indicates high infectivity and replication Hbs Ag + +
o Anti-HBc positive - indicates the chronicity of Hepatitis. Hbe Ag Non-reactive +
- Assuming that IgG predominates at this time. Anti Hbc total Non-reactive +
- Also, the persistence of HBsAg since Jan. 10, 2019 (>6 HBV DNA Not detectable 7956100
months)
o HBV DNA 7,956,100
Diagnostic Criteria and Definitions for Chronic Hepatitis B

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3. What is the indication to require pharmacologic treatment in this • ALT and AST level indicating liver function
case? Give at least 2 o 104 IU/mL indicating a 2 fold increase in ALT
• The AASLD suggests antiviral therapy in the select group of adults o 100 IU/mL indicating a 2-2.5 fold increase in AST
with HBeAg- positive status and persistently elevated ALT of • Previous HBV therapy
more than 2x the normal value and an elevated HBC DNA level o Diagnosed 3 years ago to have hepatitis B with supportive
greater than 20,00 IU/mL. treatment given but was not specified.
• It was also suggested that patients who are infected with HBeAg- • Safety and efficacy profile of the medications to be used and the
negative chronic hepatitis B with exception of HBV DNA levels, likelihood of developing resistance should all be considered
therapy should be initiated when viral levels are > 2000 IU/mL.
• Adults with Chronic Hepatitis B and clinical evidence of Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis
compensated or decompensated cirrhosis or based on APRI B: AASLD 2018 Hepatitis B Guidance
score >2, regardless of ALT levels, HBeAg status or HBV DNA • Patient-specific factors that need to be considered in choosing
levels, or between peg-IFN, entecavir, and tenofovir include the following:
• Adults with Chronic Hepatitis B who do not have clinical evidence o Lack of resistance with long-term use: most important factor
of cirrhosis or based on APRI score <2 but are: o Desire for finite therapy
o Aged >30 years, AND o Anticipated tolerability of treatment side effects.
o Have persistently abnormal ALT levels, AND o Comorbidities: peg-IFN is contraindicated in persons with
o Evidence of high level HBV replication (HBV DNA >20,000 IU/mL) autoimmune disease, uncontrolled psychiatric disease,
regardless of HBeAg status. cytopenia, severe cardiac disease, uncontrolled seizures, and
o If HBV DNA test is not available: persistently abnormal ALT levels decompensated cirrhosis.
alone regardless of HBeAg status may be considered. o Previous history of lamivudine resistance (entecavir is not
preferred in this setting)
4. What are the goals of the treatment? Give at least 2 o Family planning: finite therapy with peg-FN prepregnancy or use
• Goals of the treatment are: of an oral antiviral agent that is safe in pregnancy (preferably
o Primarily to suppress HBV replication to achive undetectable TDF) is best.
serum levels by o HBV genotype: A and B genotypes are more likely to achieve
- Induction of a biomechanical response as manifested by a HBeAg and HBsAg loss with peg-IFN than non-A or non-B
decrease or normalization in ALT levels genotypes.
- Induction of a histological response as manifested by a o Medication costs.
decrease in liver inflammation as seen in liver biopsy scores.
o To delay the progression to liver cirrhosis 6. What are the recommended first line treatments for this case?
o To prevent the development of End Stage Liver Disease Give at least 2 antiviral agents with dose and duration of therapy.
• The AASLD recommends peg-IFN, entecavir, or tenofovir (TDF) as
• The goals of the treatment are to address the symptoms and the preferred initial therapy for adults with immune-active CHB
infection itself as confirmed by serological and HBV DNA tests, and • Entecavir
to reduce the risk of progression to cirrhosis and liver-related o 0.5mg once daily for patients 16y/o and above for patients with
complications, including hepatocellular cancer. compensated liver disease
o 1.0mg once daily is recommended for patients with lamivudine or
5. What factors will affect the selection of drug treatment for this telbivudine resistance or decompensated liver disease.
case? Give at least 4 o This drug should be given on an empty stomach at least 2 hours
Pharmacotherapy Principles and Practice before or after a meal
• Past medical history o Duration of treatment is for 6-12months
o Patient is hypertensive with daily intake of Amlodipine 10mg for • Tenofovir Disoproxil Fumarate
the past 5 years with no recent or previous surgeries and no o 300mg orally once daily taken on an empty stomach for 6-12
known allergies to food and medications months
• HBV DNA level • Pegylated Interferon alpha 2a
o Patient has a level of 7,956,100 o 180mcg, once a week, Subcutaneously for 48 weeks
7. Give the mechanism of action of at least 2 of the recommended first line agents
8. Give at least 1 adverse effect for each of the 3 recommended first line treatments for this case.
Drugs Mechanism of action Adverse effect/s
• Nucleoside reverse transcriptase inhibitors (NRTIs) are • Headache, fatigue, dizziness, and nausea; Lactic acidosis
active inhibitors of reverse transcriptase; activated (decompensated cirrhosis only)
Entecavir generally by phosphorylation to the triphosphate form by
cellular enzymes. It then competes with cellular
triphosphates, which are substrates for proviral DNA by
viral reverse transcriptase.
• Nucleotide analogue that inhibits reverse transcription of • Gastrointestinal complaints (nausea, diarrhea, vomiting,
pregenomic RNA to HBV DNA flatulence) are the most common adverse effects; headache,
Tenefovir
renal insufficiency; Nephrotoxicity, Fanconi syndrome,
osteomalacia, lactic acidosis
• A moiety of recombinant human interferon that acts by • Flu-like symptoms (fevers, chills, rigors, and myalgias); fatigue,
Pegylated binding to human type 1 interferon receptors. Activation mood disturbances (irritability, depression, and, rarely, suicidal
interferon- and dimerization of this receptor induces the body's innate ideation), cytopenia, autoimmune disorders in adults, anorexia
α2a antiviral response by activating the janus kinase/signal and weight loss in children
transducer and activator of transcription (JAK/STAT)
pathway.

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9. Give at least 4 parameters to be monitored to determine response to treatment and/or presence of adverse effects. Include the timing
or frequency of monitoring.
Pharmacotherapy Principles and Practice
• Obtain an ALT at baseline and then every 3 to 6 months during levels. Once anti-HBe appears, complete an additional 6 months of
hepatitis B treatment. hepatitis B therapy.
• Monitor HBV DNA levels every 3 to 6 months to determine treatment • Continue treatment in CHB HBeAg-negative patients until HBsAg is
response. lost.
• Monitor HBeAg and anti-HBe every 6 months to determine if • Monitor closely for hepatitis flare and viral relapse when discontinuing
seroconversion to anti-HBe occurred or HBeAg was lost in HBeAg- hepatitis B therapy.
positive CHB patients. • Obtain a CBC with differential every 4 weeks and thyroid- stimulating
• Monitor HBsAg every 6 to 12 months to determine if HBsAg was lost hormone (TSH) and fasting lipid panel every 12 weeks when
or anti-HBs developed in CHB HBeAg-negative patients with receiving pegylated interferon therapy for hepatitis B.
persistently undetectable serum HBV DNA levels. • Monitor serum creatinine for nephrotoxicity at baseline and every 12
• Revaluate at month 6 and either switch or add a more potent hepatitis weeks for patients receiving tenofovir or adefovir.
B antiviral agent to the current hepatitis B regimen if the HBV DNA • Monitor creatine kinase at baseline and periodically (every 12 weeks)
level has not decreased by 2 logs after 6 months of therapy, for patients taking telbivudine because muscle weakness and
• Continue treatment in CHB HBeAg-positive patients until HBeAg myopathy have occurred.
seroconversion has been attained along with undetectable HBV DNA
Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis B: AASLD 2018 Hepatitis B Guidance
10. Give at least 2 preventive measures that you can advise this patient to prevent the spread of HBV.
• Have your wife and children screened and or treated for HBV
• Do not share personal care items that might have been contaminated like toothbrushes and razors
• Even if the patient is married, avoid having multiple sexual partners, or, use latex condoms correctly and every time.
Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis B: AASLD 2018 Hepatitis B Guidance
Recommendations for Infected Persons Regarding Prevention of Transmission of HBV to Others
Persons Who Are HBsAg Positive Should: • Not share injection equipment
• Have household and sexual contacts vaccinated • Not share glucose testing equipment
• Use barrier protection during sexual intercourse if partner is not • Cover open cuts and scratches
vaccinated or is not naturally immune • Clean blood spills with bleach solution
• Not share toothbrushes or razors • Not donate blood, organs, or sperm
(Sources: Pharmacotherapy Principles & Practice, 4th ed, Chapter 24; Katzung Basic & Clinical Pharmacology 12th ed;
Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis B: AASLD 2018 Hepatitis B Guidance)

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CASE 5: Dr. Mark Jeremy P. Ramos Lips are pink, dry buccal mucosa and gums are
Patient Presentation moist and pink, smooth, with no lesions, no signs of
• This is a case of a 52 year old female, married, lives in Quezon City, swelling. Tongue is at midline, normal in size, pink,
sought consult at FEU-NRMF due to elevated creatinine levels. 8 Mouth and rough on surface, moist, symmetrical, no lesions
months prior to consult, annual PE lab findings incidentally Oral Cavity nor tremors. Hard and soft palate are pinkish with
revealed creatinine levels were elevated at 145 umol/L (eGFR 35.6 no palatal petechiae, no lesions; uvula is at midline,
mL/min/m2). She was advised to take Ketoanalogue 600 mg/tab tonsils are not enlarged; pharyngeal wall is pinkish
TID. with no exudates.
• 3 months prior to consult, the patient noted easy fatigability and Neck is normal in size, supple, symmetrical, no
occasional palpitations. Repeat creatinine level was at 180 umol/L neck vein engorgement, no mass, normal muscle
(eGFR 27.4mL/min/m2). She was started on Sodium Bicarbonate Neck development and tone, no tenderness; trachea in
cap TID. Ketoanalogue was continued. midline; thyroid gland is non-palpable. No carotid
• 2 days prior to consult, still with easy fatigability and palpitations, bruit noted, no limitation of movement
this time accompanied by body weakness. The patient decided to Skin is white, with no lesions, no dilated superficial
seek consult at our institution. blood vessels. bony
Thorax is elliptical, symmetrical without gross
Past Health History Lungs/Chest deformities. No tenderness, lung expansion is
• Hypertensive for 15 years, maintained on Telmisartan 40mg tab OD. symmetrical, no retractions, vesicular breath
usual BP 140160/80-100mmHg No history of Diabetes Mellitus, sounds. Negative bronchophony, egophony, and
Bronchial asthma, Pulmonary Tuberculosis, Thyroid, Liver disease, whisper pectoriloquy
blood transfusion or surgery, No history of allergy Adynamic precordium, no thrills, no murmurs nor
heaves. The apex beat is at the 5th Intercostal
Past Health History & Family History Heart space left mid clavicular line. With normal rate and
regular rhythm, S1 louder at the apex and S2 heard
• Father is a known hypertensive louder at the base
• Mother is a known hypertensive Abdomen Flat, normoactive bowel sounds
No gross deformities, with grade 2 pitting bipedal
Personal and Social History
Extremities edema, with full equal pulses on all extremities. No
• The patient is a college graduate, currently self-employed. She is cyanosis. CRT <2 seconds.
non-smoker and nonalcoholic beverage drinker. She denies history Neurologic Unremarkable
of sexually transmitted diseases. She denies any history of food and Examination
drug allergies. She is fond of eating sally, oily and fatty foods.
Drinking water is purified water. She lives with her husband in well-lit Laboratory Exams
and well-ventilated house. Garbage disposal is regular and
segregated. Hemoglobin 89 Low
HCT 0.28 Low
Physical Examination Platelet 221 Normal
WBC 8.2 Normal
Patient is conscious, coherent, in cardio respiratory
General Neutrophil 0.71
distress, cooperative, oriented to time, place,
Survey Lymphocytes 0.29
person, looks appropriate for her age
BP: 180/110 mmHg Creatinine 220 ug/L High
CR: 88 bpm
RR: 20 cpm Questions
Temp: 36.5 C 1. What is your main clinical diagnosis? What are your bases for
Vital Signs O2 Sat: 99% the diagnosis?
Weight: 48 kg • Main clinical diagnosis: Chronic Kidney Disease, Stage 4
Height: 152 cms • Basis for diagnosis:
BMI 20.8 o Repeat creatinine level: 180 umol/L (eGFR 27.4mL/min/m2).
Hair is black, evenly distributed. Normocephalic, o Persistent for more than 3 months
with no mass. Temporal arteries are not visible but
Head
palpable, with strong equal pulses, walls not • Chronic kidney disease (CKD) is defined as abnormalities in the
thickened structure or function of the kidney, present for 3 months or
Eyebrows are black, thin, evenly distributed, no lid more, with implications for health. Markers of structural abnormalities
edema, no ptosis. Eyelashes are thin, directed include albuminuria (30 mg/24 hours or more or an albumin:
outward, no matting: normal conjugate movements creatinine ratio (ACR) of >30 mg/g [or 3.5 mg/mmol for female
of the eyes in all six directions, no nystagmus; pale and 2.5 mg/mmol for male); hematuria or casts in urine
Eyes sediment; electrolyte and other abnormalities caused by renal
palpebral conjunctiva, whitish sclera, transparent
cornea, black iris with regular contours, pupils are tubular disorders; abnormalities detected by histology or imaging; or
2-3mm equally reactive to light and history of kidney transplantation.
accommodation, lens are transparent • Functional abnormalities are indicated by a decline in glomerular
Auricles are symmetrical and non-tender: auditory filtration rate (GFR) <60 mL/min/1.73m2 (0.58 mL/s/m2)
canals are patent, no discharge nor swelling or
Ears redness of the canal, tympanic membranes are 2. What is the pathophysiology of your diagnosis?
pearly white, intact, normal contour, visible cone of • Regardless of the initial cause of kidney damage, the result is a
light. decrease in the number of functioning nephrons. The remaining
Nose is symmetrical, no tenderness, patent nephrons hypertrophy to increase glomerular filtration and
vestibules, mucosa is pink, septum in midline, tubular function, both reabsorption and secretion, in an attempt
Nose intact, turbinate not congested, no discharge, no to compensate for the loss of kidney function. Initially, these adaptive
tenderness over the frontal and maxillary sinuses, changes preserve many of the clinical parameters of kidney function,
normal transillumination test. including creatinine and electrolyte excretion. However, as time

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progresses, angiotensin II is required to maintain the
hyperfiltration state of the functioning nephrons. Angiotensin II is
a potent vasoconstrictor of both the afferent and efferent arterioles
but has a preferential effect to constrict the efferent arteriole, thereby
increasing the pressure in the glomerular capillaries. Increased
5. What are the different GFR categories in kidney disease?
glomerular capillary pressure expands the pores in the glomerular
basement membrane, altering the size-selective barrier and
allowing proteins to be filtered through the glomerulus.
• Proteinuria increases nephron loss through various complex
mechanisms. Filtered proteins are reabsorbed in the renal
tubules, which activates the tubular cells to produce
inflammatory and vasoactive cytokines and triggers
complement activation. These cytokines cause interstitial
damage and scarring in the renal tubules, leading to damage and
loss of more nephrons. Ultimately, the process leads to
progressive loss of nephrons to the point where the number of
remaining functioning nephrons is too small to maintain clinical
stability, and kidney function declines.
6. What are the most common direct causes of chronic kidney

disease?
• The three most common causes of CKD in the United States are
diabetes mellitus (DM), hypertension, and glomerulonephritis.
Together these account for more than 75% of CKD cases (37% for
diabetes, 25% for hypertension, and 14% for glomerulonephritis).
3. What additional laboratory/diagnostics will aid in the

management of this case?
• Measurement of serum creatinine, urinalysis, blood pressure, serum
electrolytes, and/or imaging studies; CBC monitoring, lipid profile.
• Analysis for proteinuria, which is the primary marker of structural
kidney damage, even in patients with normal GFR.
• Protein excretion can be assessed by measuring urine albumin-to-
creatine ration (ACR), urine protein-to-creatinine ratio, or urinalysis
with a reagent strip test
• Albuminuria should be assessed with GFR
• Monitored for anemia
4. What is the estimated GFR of the patient’s latest creatinine level

based on Cockroft-Gault computation?
• CrCl (female)= (([140-age] x weight in kg)/ serum creatinine x 72)
0.85
• CrCl = (([140-52] x 48 kg)/ 220 x 72) 0.85
• CrCl = 20 ml/min
7. What are the most important predictors of chronic kidney

disease?
• Progression factors can be used as predictors of CKD. The most
important predictors of CKD include proteinuria, elevated blood
pressure, hyperglycemia, and AKI.
• Tobacco smoking also plays a role in progression of CKD.

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8. What will be the nutritional management of the patient? o Continue ketoanalogue 600mg/tab TID
• Reduction in dietary protein intake has been shown to slow the o Continue sodium bicarbonate cap TID
progression of kidney disease. Protein intake should be lowered to
0.8 g/kg/day in adults with diabetes or people with a GFR less Medication Mechanism of Action
than 30 ml/min/1.73 m2 (0.29 mL/s/m2) who are not on dialysis. Converted into essential amino acids in
• Protein intake should not exceed 1.3 mg/kg/day in any adult with the body via transamination, improve
Ketoanalogue
CKD. However, protein restriction must be balanced with the risk of nutritional deficiencies caused by
malnutrition in patients with CKD. protein restricted diets in CKD patients.
• Limiting salt intake to less than 2 g (90 mmol) of sodium per day Alkali supplementation to avoid
Sodium Bicarbonate
(equivalent to 5 g sodium chloride) will help to control blood metabolic acidosis
pressure and reduce water retention in CKD. Selective competitive antagonists of
Telmisartan (ARBs)
• Patients with CKD should be encouraged to increase physical angiotensin AT1 receptors
activity, with a goal of at least 30 minutes five times per week, to Hydrochlorothiazie Block Na/Cl transporter in
achieve a healthy weight, with a goal BMI of 20 to 25. (thiazides) renal distal convoluted tubule
Oral Iron
Iron combines with porphyrin and
9. Discuss your pharmacologic therapy for the patient with their Supplements
globin chains to form hemoglobin
corresponding mechanism of action. Include the current Ferrous Sulfate
medications.
• Current medications Additional readings:
o Ketoanalogue 600 mg/tab TID • The first-line treatment for anemia of CKD involves replacement of
o Sodium bicarbonate cap TID iron stores with iron supplements. When iron supplementation alone
o Telmisartan 40 mg/tab OD is not sufficient to increase Hgb levels, ESAs are necessary to
• Treatment plan: replace erythropoietin
o Increase the dosage of Telmisartan to 80mg/tab’
o Add second drug thiazide diuretic because of the grade 2 bipedal 10. When is renal replacement therapy indicated?
edema; Hydrochlorothiazde 12.5 – 50 mg/tab per day • Patients who progress to ESKD require RRT.
o Add oral iron supplements 200 mg of elemental iron (ferrous • The modalities that are used for RRT are dialysis, including
sulfate) delivered daily in divided doses to increase iron stores. hemodialysis (HD) and peritoneal dialysis (PD), and kidney
- When oral iron is not effective to increase iron stores IV iron transplantation.
should be administered.
(Sources: Pharmacotherapy Principles & Practice, 4th ed, Chapter 47; Katzung Basic & Clinical Pharmacology 12th ed)

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CASE 6: Dr. Jessica O. Cruz Extra ocular movements intact (EOMI)
Patient Presentation Neck and No masses, no adenopathies
Chief complaint: Lymph Nodes
• "I feel very bad...I think I am going through withdrawal. Chest Clear to auscultation, no rales, no wheezes
Cardiovascular Tachycardia, No rhythm anomalies detected, no
History of Present Illness murmurs, no gallops
• A 38 year old male is a known alcoholic, struggling with the habit for Abdomen Normal bowel sounds, (+) hepatosplenomegaly,
18 years. He has attempted to kick the habit several times to relapse (-) abdominal pain or tenderness
after a few months. He was sober one year ago but relapsed in six Neurologic (+) tremors, (-) seizures, (-) hallucinations, (-)
months. His family has recently left causing him to drink heavily since. exam delirium; oriented to person, place, and time
After a week of missing his his wife and kids, he decides he wants his GU and Rectal Deferred
family back and has stopped any alcohol for twenty four hours now.
He experiences a sleepless night, severe nausea, chills and anxiety. Laboratory Exams
He calls on his next door neighbor to bring him to the hospital and he • GGT: 110 IU/L (increased)
was admitted. • AST: 250 IU/L (increased)
• ALT: 123 IU/L (increased)
Past Medical History • Alkaline phosphatase: 128 IU/L (increased)
• Alcohol dependence-18 years
• Diagnosed with depression for 14 years Questions
• Diagnosed with hypertension for 4 months 1. What are the FOUR health problems/conditions in this case?
• Diagnosed with GERD for 5 years • Alcohol dependence and withdrawal
• Depressions
Family History
• Hypertension
• Maternal Grandmother diagnosed with Major Depressive Disorder • GERD
(MDD)
• Mother (Age 78): has dyslipidemia, osteoporosis, recently diagnosed 2. What are the signs and symptoms of withdrawal in the patient?
with uterine cancer Give 2
• Father: no known history as he abandoned his wife and kids when • Abrupt alcohol discontinuation in an individual with alcohol
the patient was only one year old dependence leads to a characteristic syndrome of motor agitation,
• Patient's brother committed suicide, 5 years ago, also afflicted with anxiety, insomnia, and reduction of seizure threshold.
MDD
• As ethanol level decrease
Social History
Tremor, nausea, vomiting, tachycardia (> 110
• History of alcoholism for 18 years, marked by brief periods of sobriety Early
beats/min), hypertension (> 140/90 mm Hg),
followed shortly by relapses. Latest sobriety one year ago with symptoms
headache, vivid dreams, insomnia
relapse six months after
• He is currently jobless, having been dismissed from government Peak (24 Seizure-activity (usually one or two grand mal type
employment two months ago for coming to work drunk. He presently hours) but can be numerous and possibly fatal)
lives alone after his wife and children left him.
72–96
• He denies smoking or intake of any recreational drugs. Patient drinks Delirium tremens
hours
about twelve to twenty bottles of beer regularly. On occasion he also
Onset at
takes other beverages such as whisky, of which he can consume Hallucinations, usually visual
any time
about half a bottle per drinking bouts.
Allergic History In this patient:

• Tachycardia, nausea, tremors, insomnia, depression, decreased
• Penicillin and Seafoods
energy
Medications prior to admission:
3. What is the main treatment goal for the alcohol withdrawal of
• Sertraline 300 mg OD (stopped taking few years ago) this patient?
• Atenolol 50 mg OD (currently taking) • The major objective of drug therapy in the alcohol withdrawal period
• Omeprazole 20 mg OD (currently taking) is prevention of seizures, delirium, and arrhythmias.
Review of Systems 4. What is the first line of drug of choice to achieve the main
• (+) tachycardia, nausea, tremors, insomnia, depression, decreased treatment objective? Give the DRUG CLASS not the prototypes
energy or examples for this number
• (-) chest pain, vomiting, convulsions, hallucinations, delusions, • Benzodiazepines are the treatment of choice for uncomplicated
headache, appetite changes, suicidal thoughts alcohol withdrawal.
Physical Examination 5. What is a specific example of the above used treatment of

• General: 38 year old, male, Asian, appears distraught, disheveled alcohol withdrawal. There are 3 cited in most literatures, give
• Vital signs: BP-148/97 mmHg: PR-110/min; RR-18/min; T-37C • The most commonly used benzodiazepines are lorazepam,
• Weight:65.3 kg diazepam, and chlordiazepoxide.
• Height:171 cm
6. What is the specific classification of the above agents in terms
Skin brown color, clear, no lesions or bruises of duration of action?
HEENT Pupils round and reactive to light and • Short-acting benzodiazepine: lorazepam
accommodation (PERRLA), • Long-acting benzodiazepine: diazepam, and chlordiazepoxide

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7. What vitamin should also be given to this patient because of his
chronic alcohol use? 13. What class of anti-depressant is sertraline?
• Thiamine or Vitamin B1 • Selective Serotonin Reuptake Inhibitor (SSRI)
8. What is the purpose for giving the above vitamin? Answer briefly 14. In general why are SSRIs the first line treatment for most cases
and to the point of MDD?
• American Psychiatric Association (APA) Guidelines recommend • At present, SSRIs are the most commonly prescribed first-line agents
thiamine be given routinely to patients being treated for moderate to in the treatment of both MDD and anxiety disorders. Their popularity
severe alcohol use disorders to treat or prevent adverse comes from their ease of use, tolerability, and safety in overdose.
neurologic symptoms. In addition, most SSRIs are now generically available and
inexpensive. (Source: Katzung Chapter 30, page 534)
9. What is the specific syndrome seen in chronic alcoholics
because of the deficiency of the above vitamin? 15. Give the MOST common side effect of SSRI
• Wernicke-Korsakoff syndrome is a relatively uncommon but • SSRIs enhance serotonergic tone, not just in the brain but throughout
important entity characterized by paralysis of the external eye the body. Increased serotonergic activity on the gut is commonly
muscles, ataxia, and a confused state that can progress to coma and associated with nausea, gastrointestinal upset, diarrhea, and other
death. It is associated with thiamine deficiency but is rarely seen in gastrointestinal symptoms. (Source: Katzung Chapter 30, page 53)
the absence of alcoholism.
Management
After a few days in the hospital, the patient is discharged free of Pharmacologic:
withdrawal symptoms. During his hospital stay, the patient • SSRIs (Sertraline 300 mg OD): first line treatment for MDD
realizes that he needs to remain abstinent to regain his family and • Atenolol 50 mg OD for hypertension
get a decent job. He is determined to start anew. He is unsure • Omeprazole 20 mg OD for GERD
however, if he can resist the urge to drink. • Naltrexone for alcoholism
• Benzodiazepines for withdrawal symptoms
• Vitamin B1 (Thiamine) to avoid Wernicke Korsakoff Syndrome
10. Give 1 pharmacologic management for alcoholism of this
patient Non-pharmacologic:
• Psychotherapy and Counseling
• Naltrexone
• DASH diet for hypertension
- Naltrexone decreases alcohol intake. Evidence suggests that it
both decreases craving for alcohol and alcohol-induced euphoria • Increased physical activity
(reduces positive reinforcement of drinking); Reduced risk of • Patient education on importance of adherence to the treatment plan
relapse in individuals with alcoholism
11. What is the mechanism of action of the agent given above?

Answer briefly and to the point
• Naltrexone is nonselective competitive antagonist of opioid receptors;
competitive opioid antagonist
12. Give 1 non pharmacologic strategies to help prevent relapse.

Answer briefly and to the point
• Although pharmacologic agents may help prevent relapse,
psychotherapy should be the core therapeutic intervention.
• Psychotherapy typically addresses one or more of the following tasks:
o Motivation enhancement to stop or reduce drug use
o Coping skills education
o Providing alternative reinforcement
o Managing painful affect (dysphoria)
o Enhancing social support and interpersonal functioning
On follow-up he is seen by the psychiatrist. In the interview he also

admits feeling depressed and hopeless; The doctor also reinstates
SERTRALINE in the medication regimen of the patient
(Sources: Pharmacotherapy Principles & Practice, 4th ed, Chapter 36; Katzung Basic & Clinical Pharmacology 12th ed)

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CASE 7: Dr. Loralie Ann C. Rivera Questions
Patient Presentation 1. Based on the Philippines CPG for CAP, what is your diagnosis
• LA 57 year old female who presents to the ER with a seizure. 5 days and include the risk stratification of this patient’s pneumonia
prior to consult, she was babysitting her grandson who was sick with • Community Acquired Pneumonia, Moderate risk
an upper respiratory tract infection and otitis media. She had been
complaining of being tired, SOB and coughing. Upon arrival at the
ER, she was given diazepam 5 mg IV for the active seizures which 2. What are the patient’s signs and symptoms supporting your
afforded relief. She has some mild to moderate chest discomfort, diagnosis and risk stratification?
difficulty of breathing but denies any chest heaviness and pain. • Altered mental state of acute onset: first seizure in the past year
• Chest radiograph: Right upper and lower lobe infiltrates (lower lobe
Past Medical History infiltrate is more defined): Multilobar infiltrates
• COPD for 15 years on Fluticasone/Salmetrol DPI 250 mcg/50mcg 1
inhalation 2x a day, Albuterol 1-2 puffs every 4-6 hours as needed for
SOB
• Tonic clonic seizures for 20 yrs on Carbamazepine XR 200 mg 2x a
day
• Hypertension for 10 years on Irbesartan 150mg OD
Family History
• Father died of lung cancer at age 55
• Mother age 79 with HTN, hypothyroidism
• Brother with COPD and hypertension
Social History
• She lives with her husband and has one daughter. She does not
work.
• She is a social drinker and is a 10 pack year smoker, no illicit drug
use. She is allergic to sulfa drugs.
Review of Systems
• Occasional headaches relieved with acetaminophen; occasional
tinnitus
• (-) vertigo
• This is the first seizure in the past year
• (-) syncope; (+) shortness of breath
Physical Examination
Breathing fast with increased work of breathing;
General
appears in moderate respiratory distress
BP – 130/80
PR – 105
RR – 24
Vital Signs T – 38.8 C
O2 Sat – 87%
Weight – 84kg
Height – 165 cm
HEENT PERRLA, EOMI; (-) sinus tenderness
Tachypneic, Wheezing bilaterally, worse on the
Chest/Lungs right side; decreased breath sounds over the upper
and lower right lobe
CV Tachycardic, regular rhythm, normal S1 and S2
Laboratory and Diagnostic Tests

• Chest Radiograph: Right upper and lower lobe infiltrates (lower lobe
infiltrate is more defined)
• Sputum culture: Pending; gram stain; moderate WBC’s. rare
squamous epithelial cells, no organism, seen.
• Blood culture: Pending

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3. What is/are the patient’s risk factors for having moderate risk 7. If you are suspecting for aspiration pneumonia, what antibiotic
pneumonia? is appropriate for this patient?
• Seizure, COPD, smoking, alcoholism • For suspected aspiration especially in those with depressed
sensorium or seizure episodes, a β-lactam with anaerobic
4. What is/are the organism/s most likely causing the patient’s activity or adding clindamycin or metronidazole to the regimen
pneumonia? is advised. In suspected aspiration, clindamycin or metronidazole
• Streptococcus pneumoniae covers for anaerobes. (PCPG CAP 2010)
• Haemophilus influenzae • If aspiration pneumonia is suspected and, a regimen containing
• Chlamydophila pneumoniae ampicillin-sulbactam is used, there is no need to add another
• Mycoplasma pneumoniae antibiotic for additional anaerobic coverage. (PCPG CAP 2016)
• Moraxella catarrhalis • Anaerobes and Streptococcus spp. are the primary pathogens if a
• Enteric Gram-negative bacilli patient aspirates their oral contents and develops pneumonia.
Antibiotics active against these organisms include penicillin G,
• Legionella pneumophila
ampicillin/sulbactam, and clindamycin.
• Anaerobes (among those with risk of aspiration)
• Preferred treatment regimen is a β-lactam/β-lactamase inhibitor
combination (ampicillin/sulbactam, amoxicillin/clavulanate,
5. What are the resistance issues associated with these
piperacillin/tazobactam/ticarcillin/clavulanate) (Pharmacotherapy
organisms?
principles and practice)
• M. pneumoniae lack a cell wall; therefore, β-lactam drugs have no
activity against this organism. 8. Should the patient be vaccinated? If so, what vaccinations
• The atypical organisms have not changed in recent years with should be used?
respect to antibiotic resistance.
• YES.
• β-Lactamase production in H. influenzae has remained relatively
steady over the last 5 to 10 years, and the rate is approximately 25%.
PCPG CAP 2010
• S. pneumonia has developed resistance mechanisms against many
• Influenza vaccination is recommended for the prevention of CAP.
classes of antimicrobials, and the mechanisms include the following:
• The mainstays of CAP prevention are pneumococcal and influenza
o Alteration of the penicillin-binding proteins (PBPs), inactivating β-
vaccinations
lactams
o Efflux or methylation of the ribosome-inactivating macrolides • Pneumococcal vaccine: The 23-valent pneumococcal
polysaccharide vaccine (PPSV23) is recommended for the high-risk
groups. In the 2009 update of the “Handbook on Adult Immunization
6. What would be the appropriate therapeutic regimen for this case
for Adult Filipinos,” vaccination of PPSV23 is recommended for
and its duration?
persons >50 years old.
• For moderate-risk CAP, a combination of an IV non- o Patient is 57 years old with COPD and hypertension
antipseudomonal β-lactam (BLIC, cephalosporin) with either an
extended macrolide or a respiratory fluoroquinolone is
recommended as initial antimicrobial treatment.
• Treatment duration for moderate risk bacterial pneumonia is 7-
10 days (Strong recommendation, Low Quality of Evidence,
NICE guidelines 2014)
• For moderate-risk and high-risk CAP or for those with suspected or
confirmed Gram-negative, S. aureus or P. aeruginosa pneumonia,
treatment should be prolonged to 28 days if with associated
bacteremia.
• A treatment regimen of 10 to 14 days is recommended for
Mycoplasma and Chlamydophila pneumonia while Legionella
pneumonia is treated for 14 to 21 days.
• A 5-day course of oral or IV therapy for low-risk CAP and a 10-day
course of IV for Legionella pneumonia is possible with new agents
such as the azalides, which possess a long half-life and achieve high
tissue levels that prolong its duration of effect.
• Influenza vaccine: Annual influenza vaccination is the most effective

method for preventing influenza virus infection and its complications.
Influenza vaccine is recommended for all persons at increased risk
for complications from influenza. However it is contraindicated on
patients with active neurologic disorder or a history of
developing neurologic symptoms or illness following a previous
dose and not indicated for hypertensive patients.

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Pharmacotherapy Principles and Practice PCPG CAP 2010
• Prevention of both pneumococcal and influenza pneumonia by use of
vaccination is a national goal. Vaccination is used to prevent or
minimize the severity of pneumonia caused by S. pneumoniae or the
influenza virus.
• The 23-purified-capsular polysaccharide antigen vaccine
(PPSV23) for children 5 years of age and older and adults. Those
who should receive the polysaccharide vaccine include the following
o Anyone older than 6 years who has a long-term health
problem such as heart disease, lung disease, sickle cell disease,
diabetes, alcoholism, cirrhosis, and leakage of cerebrospinal
fluid.
9. Based on the Philippine CPG for Pneumonia, how will you PCPG CAP 2016
assess response to initial therapy?
• Temperature, respiratory rate, heart rate, blood pressure, sensorium,
oxygen saturation and inspired oxygen concentration should be
monitored to assess response to therapy.
• Response to therapy is expected within 24-72 hours of initiating
treatment. Failure to improve after 72 hours of treatment is an
indication to repeat the chest radiograph.
• Follow-up cultures of blood and sputum are not indicated for patients
who are responding to treatment.
10. Which oral antibiotics are recommended for de-escalation or

switch from parenteral therapy?
• The choice of oral antibiotics following initial parenteral therapy is
based on available culture results, antimicrobial spectrum, efficacy,
safety and cost. In general, when switching to oral antibiotics, either
the same agent as the parenteral antibiotic or an antibiotic from the
same drug class should be used.
(Sources: Philippine Clinical Practice Guidelines on Diagnosis, Empiric Management, and Prevention of CAP in Immunocompetent Adults, 2010 and 2016;
Pharmacotherapy Principles & Practice, 4th ed, Chapter 71)

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CASE 8: Dr. Miriam Louella D. Fermin Soft, non-tender, normoactive bowel sounds, no
Abdomen
Patient Presentation organomegaly
Chief Complaint Neurology Cranial nerves II-XII intact, slight delayed DTRS
• "I have no energy and I can't take care of my baby” Extremities Distal pulses 2+ bilaterally, no edema
History of Present Illness Laboratory Tests

• IPL is a 32 year old Filipina who was hospitalized 1 month ago for • TSH: 38.7 mIU/L (increased)
overt hypothypoidism. At that time she was found in the park • FT4: 0.4 ng/dL (decreased)
appearing confused and was brought to the emergency department.
Originally she was thought to be intoxicated but her toxicology
screens were all negative and she was found to be severely Questions
hypothyroid (TSH 130 ulU/ml) and free T4 <05.15 pmol/L). During 1. What signs and symptoms of hypothyroidism does the patient
hospitalization, she was diagnosed with myxedema coma and given have?
a single dose of 200 mg hydrocortisone. Oral Levothyroxine was
• Signs: Bradycardia, dry skin and scalp, delayed reflexes
started at a dose of 50 mcg/day. She was discharged 2 days later.
• Symptoms: Fatigue, weakness, constipation, weight gain,
She was diagnosed of Grave's disease 18 months ago while she was
menorrhagia, depression
pregnant, and after being controlled with Propylthiouracil and
Methimazole, she underwent thyroidectomy. was started in
Levothyroxine after her thyroidectomy but she stopped taking it
because she was too busy. She admits she feels down and
overwhelmed with having to take care of her child and work full time.

• Grave's disease S/P Thyroidectomy (12 months ago)
• Depression Menorrhagia (12 months)
• Gravida 1 Para 1 No abortion
Family History
• Father died of lung cancer at age 65.
• Mother died of vehicular accident at age 60.
Social History
• Patient works full time as a medical technologist at a level III private
hospital
Tobacco/Alcohol/Substance Use:
• Occasional alcoholic beverage drinker
• Smokes cigarette 1 pack/day since age 18
• Denies substance use
Current medications
• Propranolol 20 mg BID
• Levothyroxine 50 mcg OD
• Calcium carbonate 500 mg OD
• Multivitamins with Iron OD
Review of Systems
• Fatigue, weakness, constipation
Physical Examination
Fatigued-appearing, overweight, in no apparent
General
distress
BP: 120/90 mmHg,
HR: 60s
RR: 14
Vital Signs
T: 370
Weight: 154 lbs (70 kgs)
Height: 66 in (167.6 cm)
Skin Dry appearing skin and scalp, no rashes or lesions
Pupils 2-3 mm equally reactive to light and
HEENT
accommodation, full EOMs, TMS appear normal
Neck is supple and normal range of motion. Thyroid
Neck and
gland not palpable, well healed thyroidectomy scar
lymph nodes
noted
Chest Clear breath sounds, no shortness of breath
CV Slow cardiac rate with regular rhythm, no murmurs

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2. What is the cause of hypothyroidism in this patient? • Hypothyroidism also may result in increased systemic vascular
• Primary hypothyroidism secondary to iatrogenic cause (post- resistance, decreased cardiac output, and increased diastolic
thyroidectomy) blood pressure.
• The combination of thyroidectomy plus methimazole 12 months PTA • Hypothyroidism can cause significant neuropsychiatric problems,
could result to a very low, if not none at all, production of thyroid including a dementia-like state in the elderly
hormones despite the compensative increase of TSH by the pituitary • Maternal hypothyroidism can have dire consequences for developing
gland which could result to patient’s hypothyroidism manifestation. fetuses. Inadequately treated maternal hypothyroidism results in
increased risk of miscarriage and developmental impairment in
3. What medications can cause hypothyroidism? the child.
• Amiodarone, radiocontrast media, lithium, interferon-α, tyrosine • Myxedema coma is seen in advanced hypothyroidism. These
kinase inhibitors patients develop CNS depression, respiratory depression,
cardiovascular instability, and fluid and electrolyte
disturbances.
5. What are the triggers of myxedema coma?

• Myxedema coma often is triggered by an underlying acute medical
condition such as infection, stroke, trauma, or administration of
CNS depressant drugs.
6. What are the therapeutic goals in the treatment of

hypothyroidism?
• There are three major goals in the treatment of hypothyroidism:
o Replace the missing hormones
o Relieve signs and symptoms
o Achieve a stable biochemical euthyroid state.
7. Give pharmacologic management for hypothyroidism.

• Synthetic LT4 is the treatment of choice for almost all patients with
hypothyroidism. Levothyroxine is the gold standard for treating
hypothyroidism
o LT4 mimics the normal physiology of the thyroid gland, which
secretes mostly T4 as a prohormone.
o LT4 also has distinct pharmacokinetic advantages over T3. With a
7- to 10-day half-life, LT4 provides a very smooth dose-response
curve with little peak and trough effect.
• Synthetic levothyroxine is the preparation of choice for thyroid
replacement and suppression therapy because of its stability, content
uniformity, low cost, lack of allergenic foreign protein, easy laboratory
measurement of serum levels, and long half-life (7 days), which
permits once-daily administration.
8. What are the indications for LT4 therapy?

• LT4 replacement is indicated for patients with overt hypothyroidism
• Levothyroxine is also useful for secondary hypothyroidism; in this
case, monitoring of the free T4 index is needed. Despite clinical
symptoms, moderately elevated TSH values should only be
monitored if autoantibodies of thyroid or goiter can be identified.
• Levothyroxine administration is also recommended for the prevention
of recurrence after thyroidectomy (without hypothyroidism), for the
inhibition of nodular goiter development, for the treatment of
differentiated thyroid carcinoma, and for neck radiation (cancer
prophylaxis).
9. What are the risks of overtreatment and undertreatment of

LT4?
• Patients receiving LT4 therapy who are not maintained in a euthyroid
state are at risk for long-term adverse sequelae. In general,
overtreatment and a suppressed TSH are more common than
undertreatment with an elevated TSH.
• Patients with long-term overtreatment are at higher risk for
o Atrial fibrillation and other cardiovascular morbidities,
o Depression or mental status changes
4. Give sequelae of hypothyroidism
o Osteoporosis
• Hypercholesterolemia is associated with hypothyroidism, o Elderly patients being treated with LT4 have a dose-related risk of
increasing the long-term risk of cardiovascular disease and fractures even if the TSH is not suppressed below normal values
cardiovascular mortality. Study showed a direct correlation • Patients who are undertreated are at higher risk for
between degree of TSH elevation and rise in serum cholesterol. o Hypercholesterolemia and other cardiovascular problems,
depression or mental status changes and obstetric complications

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10. How do you monitor LT4 therapy?
• In most patients, measuring TSH every 6 to 12 months along with an
assessment of clinical status is adequate
• If the patient’s clinical status changes (pregnancy), more frequent
monitoring may be necessary. LT4 prescriptions should be written as
microgram doses to avoid potential errors when written as milligram
doses.
• Patient education is an important component of care. Educate
patients about the benefits of proper therapy, importance of
adherence, consistency in time and method of administration, and
importance of receiving a consistent LT4 product. Some patients take
excessive amounts of LT4 in an effort to “feel better” or as a weight
loss treatment. Explain to patients that excessive amounts of LT4 will
not improve symptoms more than therapeutic doses, can cause
serious problems, and is not an effective treatment for obesity.
(Sources: Pharmacotherapy Principles & Practice, 4th ed, Chapter 44; Katzung Basic & Clinical Pharmacology 12th ed; Harrison’s Principles of Internal Medicine 20th ed)

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CASE 9: Dr. Rommel Z. Dueñas
Patient Presentation 2. Based on the data base, what agent causes irritative or
History of Present Illness obstructive voiding symptom?
• A 64 year old male consults because of dribbling of urine with • Caffeine
nocturia, urgency and frequency. He consulted a surgeon where DRE
reveals a prostate gland of 25 g (0.9 oz). PSA was 1.4ng/ml. Urinary
flow is 10 ml/s and PVR is O ml. Diagnosis was benign prostatic
hypertrophy. The AUA symptom score of the patient was 9 and he
was started on alfusosin 10mg po. These were not accompanied by
weight loss and body weakness.

• Hypertensive with a highest SBP of 160mmHg and DBP of
100mmHg. He was given Prazosin
Family History
• Father suffered from alcoholism and died of prostate cancer at age
65.
• Mother passed away from a heart attack at age 57.

• Patient is a retired public school teacher.
• He is a coffee drinker but nonalcoholic drinker. He stopped smoking
at the age of 50.
3. The AUA Symptom Score of 9 means what BPH stage is he now?
Current Medications
• Moderate
• Lovastatin 40 mg po
• Multivitamins one tab od po
• ASA 80 mg po daily
Pertinent Physical Examinations

• PR 97/min
• T=360
• BP 140/85 mmHg
• RR 22/min
• Weight= 53.4 kg
• Height=157.7 cm
Laboratory Tests
4. The patient was started on alpha adrenergic antagonists. Write
• Blood Chemistries, CBC, Urinalysis were requested. YES or NO on the effect of the drug on the following
characteristics
Questions
A. YES Relaxes prostatic smooth muscle
1. This laboratory tests PSA is used as a surrogate marker for the
B. YES Reduces size of enlarged prostate
diagnosis of BPH
C. YES Useful in patients with enlarged prostate
• Serum PSA: The combination of PSA and DRE of the prostate can D. NO Reduces the frequency of BPH related complications
be used to screen for prostate cancer, which could also cause an E. NO Reduces the frequency of BPH related surgery
enlarged prostate. Also, PSA is a surrogate marker for an enlarged
prostate due to BPH. A PSA >1.5 ng/mL (1.5 mcg/L) suggests that
3
a patient has a prostate volume greater than 30 cm (30 g or 1.05 oz). 5. Alfuzosin belongs to what generation of alpha adrenergic
• Urinalysis to rule out infection as a cause of the patient's voiding antagonists?
symptoms; also check urinalysis for microscopic hematuria, which • Second generation alpha adrenergic antagonist
typically accompanies BPH.
• Plasma blood urea nitrogen (BUN) and serum creatinine may be 6. TRUE or FALSE: Alfuzosin is the preparation with extended
increased as a result of long-standing bladder outlet obstruction. release
These tests are not routinely performed but rather are reserved for
those patients in whom renal dysfunction is suspected. 7. Write YES if the following describes the pharmacologic property
of Alfuzosin
A. YES Functionally uroselective
B. ___ Need for up titration (No)
C. ___ Dose reduction is mandatory among patients with renal
disease (Caution in patients with severe renal insufficiency, no
specific dosing recommendations)
D. ___ Dose reduction is mandatory among patients with liver
disease (Contraindicated in patients with moderate/severe hepatic
impairment, used cautiously in patients with mild hepatic
impairment)
E. Taken with meal for best oral absorption (After meals)

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8. Write A if the following is included in the behavioral 9. Write A if the following is a complication of untreated BPH
modification of patients with BPH And B if not included and B if not
A. A To lessen the symptoms of nocturia, patient should A. A Urosepsis
stop drinking fluids 3-4 hours before bedtime B. A Chronic renal failure
B. A Patient should avoid excessive caffeine C. A Gross hematuria
C. A Patient should be advised to lose weight D. A Bladder stones
D. A Patient should avoid taking antihistamine or E. A Lower and upper UTI
decongestants
Complications of Untreated BPH
Nonpharmacologic Therapy (Behavioral Modification) • Upper and lower urinary tract infection, urosepsis, urinary
• To reduce nocturia, patients should be instructed to stop incontinence refractory urinary retention, chronic renal failure,
drinking fluids 3 or 4 hours before going to bed and then void bladder diverticula, bladder stones, or recurrent gross
before going to sleep. During the day, timed voidings every 2 to hematuria.
3 hours and use of double voiding help to empty urine from the
bladder.
• Patients should avoid excessive caffeine and alcohol intake, 10. Finasteride is an inhibitor of what enzyme?
because these may cause urinary frequency. • Finasteride is a 5α-reductase enzyme (selective Type II
• Patients should avoid taking nonprescription medications isoenzyme) inhibitor
that can worsen obstructive voiding symptoms (antihistamines
or decongestants).
• Patients are also advised to lose weight, if overweight.
Because testosterone is converted to estrogen in adipose tissue,
an alteration in the testosterone:estrogen ratio occurs in
overweight men, similar to that which occurs in elderly males,
which may contribute to the development of BPH.

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28 31
(Source: Pharmacotherapy Principles & Practice, 4th ed, Chapter 52)

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29 31
CASE 10: Dr. Jennifer T. Co • Patients at stage 3 are considered to be high risk for acquiring
Patient Presentation opportunistic infections
Chief Complaint
• Generalized Rash
History of Present Illness

• A 25 y/o, HIV-positive female consulted due to generalized rash. 3
months prior to consult, she felt a firm, round, indurated, painless,
ulcer on her labia majora that spontaneously resolved. One month
prior to consult, patient reported having a non-pruritic rash on the
palms of the hands and the non-weight bearing parts of the soles of
the feet. She also complained of fever, lymphadenopathy, sore throat,
and fatigue

• Coitarche at 15 y/o, multiple sexual partners 4. What is the backbone of HAART?
• Highly active antiretroviral therapy (HAART) is a combination of 3-4
PE Findings agents namely:
• (+) blisters underneath the left breast o Nucleoside and nucleotide reverse transcriptase inhibitors
• (+) erythematous, hyperpigmented, macular rash on the palms and (NRTI): backbone
soles o Non-nucleoside reverse transcriptase inhibitors (NNRTI)
• (+) multiple dome-shaped papules with umbilicated center o Protease inhibitors
• (+) inguinal lymphadenopathy o Integrase inhibitors
• (+) white plaques 1x1 cm at the perineum o Fusion inhibitors
Laboratory Tests 5. What is the current DHHS guideline list regarding INSTI-based
3 3 9 regimens for patients with pre-ART CrCl of >70ml/min?
WBC: 5.2 x10 /mm (5.2 x 10 /L)
Hgb: 11.5 g/dL (115 g/L or mmol/L) • DHHS listed 4 INSTI-based regimens for ART-naive patients
Hct: 34.1% (0.341) however, the elvitegravir-based regimen is best recommended for
Platelets: 151 x 103mm3 (151 x 109/L) those who have a CrCl of >70ml/min. This regimen is to be taken
Neutro: 58% (0.58) once daily and is composed of the following combination:
CBC Bands 9% (0.09) o Tenofovir (Nucleotide analogue)
Lympho: 32% (0.32) o Emtricitabine (Nucleoside analogue)
Mono: 1% (0.01) o Elvitegravir (integrase inhibitor)
Eosino: 0% o Cobicistat (CYP3A4 inhibitor)
Baso: 0%
6. What is the recommendation for the use of elvitegravir?
Cr Cl 90 ml/min
• Elvitegravir (EVG) is primarily metabolized by CYP3A4, which
Viral load >20,000 copies/ml explains the need to take Cobicistat. Cobicistat thereby increases the
CD4 count 179 cells/mm3 concentration of EVG.
TP-PA Positive • Do not take EVG together with polyvalent cation-containing antacids
RPR Reactive or supplements lowers EVG plasma concentrations. If it cannot be
RPR titer 1: 256 avoided, take the antacid 2 hours before or 6 hours after taking in the
INSTI-based regimen
• Close monitoring of creatinine clearance is necessary
Questions • EVG INSTI regimen is not recommended for those whose CrCl is
1. What is the complete diagnosis? <70ml/min
• Stage 3 HIV with secondary syphilis • EVG INSTI regimen is not recommended for those whose CrCl <30
mL/min unless they are on chronic hemodialysis
2. What is the role of viral load in HIV patient management? • Regimen is not recommended during pregnancy
• Knowing the viral load or the burden (amount of virus in the blood) is
helpful for physicians in monitoring the disease progression and 7. What is the gold standard for the diagnosis of syphilis in this
efficacy of the ARV therapy. This is used as an adjunct to the case?
preferred way of monitoring which is CD4 Cell count. • Fluorescent Treponemal antibody absorption (FTA-ABS)
• HIV treatment response and disease progression is determined by
following: 8. What is the recommended regimen and the dose for the
o CD4 + lymphocyte count (CD4 + count) and percentage treatment of syphilis for the patient?
o HIV RNA (viral load) • Benzathine Penicillin 2.4 million Units, single dose
• **HIV patients are recommended to have their CSF examined to
3. What is the category of this patient based on her CD4+ count? check for neurosyphilis especially if their CD4+ count falls </=350/uL
• Patient’s CD4 count is 179 cells/mm, therefore, she is under as this entails a different treatment plan
Category 3: < 200 cells/uL
• CD4+ T-Lymphocyte Categories: (Source: CDC) 9. What is the peculiar drug reaction encountered among pregnant
o Category 1: greater than or equal to 500 cells/mL patients diagnosed with secondary syphilis treated with
o Category 2: 200-499 cells/uL benzathine penicillin?
o Category 3: less than 200 cells/uL
• Jarisch Herxheimer Reaction
• According to Harrisons, HIV patients aged 6 years old and above that o Cause: response of the body to the lipoproteins released by the
have a CD4+ count of less than 200 are considered to be at stage dying T. pallidum organisms

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o Manifestations: fever, chills, headache, tachycardia, increased
neutrophil count and vasodilation followed by hypotension,
uterine contractions, decreased fetal movements, and fetal heart
decelerations.
o Treatment: Supportive treatment (hydration, oxygen
supplementation, antipyretics) are carried out. This phenomenon
is expected to resolve within 12-24 hours.
10. For those who are allergic to penicillin, Give 1 alternative

regimen, dose, and duration.
• Tetracycline HCl (500 mg PO qid) or Doxycycline (100 mg PO bid)
for 2 weeks
• **for pregnant women: Either Erythromycin or Azithromycin is given
since Tetracycline and Doxycycline are contraindicated among them
11. How is the efficacy of penicillin therapy assessed?

• Efficacy is assessed through clinical manifestations and quantitative
VDRL or RPR titer. A fourfold decline is considered a good clinical
response.
12. When is the best time to repeat RPR titer?

• For HIV patients more frequent clinical and serologic examination (3,
6, 9, 12, and 24 months) is recommended regardless of the stage of
syphilis.
• For non-immunocompromised ptx with:
o Primary and secondary syph: 6, 12 mos
o Latent syph: 6, 12, 24 mos
(Sources: Pharmacotherapy Principles & Practice, 4th ed , Katzung Basic & Clinical Pharmacology 12th ed; Harrison’s Principles of Internal Medicine 20th ed))

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Clinical Therapeutics Oral Revalida Review Notes: CASE 1: Dr. Abraham Daniel C. Cruz

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CLINICAL THERAPEUTICS ORAL REVALIDA REVIEW NOTES

6. In order to avoid over diuresis, what parameters should be

7. Non-response to diuretic is defined as

8. What strategies are used to overcome diuretic resistance?

4. Based on the clinical presentation

Allergies/Intolerances/Adverse Drug Events Questions

2. Tabulate the current medications of this patient to as follows:

Defined as continuous AF lasting 12 months or longer Ventricular rate control, prevention of

Additional readings: Goal of therapy of AF

Which of these drugs would be most appropriate for the patient in

Lower LDL level

HMG-CoA reductase Also indicated for suspected ACS

Past Medical History

ACID INHIBITORY DRUGS

CLASS EXAMPLES MOA SIDE EFFECTS COST

Diarrhea, Headache, Abdominal

Cimetidine Exhibit competitive inhibition at the parietal cell

CLASS EXAMPLES MOA SIDE EFFECTS COST

Negatively charged sucrose sulfate binds to

Stimulate mucus and bicarbonate secretion and

Diagnostic Criteria and Definitions for Chronic Hepatitis B

6. What are the most common direct causes of chronic kidney

3. What additional laboratory/diagnostics will aid in the

4. What is the estimated GFR of the patient’s latest creatinine level

7. What are the most important predictors of chronic kidney

Allergic History In this patient:

Physical Examination 5. What is a specific example of the above used treatment of

11. What is the mechanism of action of the agent given above?

12. Give 1 non pharmacologic strategies to help prevent relapse.

On follow-up he is seen by the psychiatrist. In the interview he also

Laboratory and Diagnostic Tests

• Influenza vaccine: Annual influenza vaccination is the most effective

10. Which oral antibiotics are recommended for de-escalation or

History of Present Illness Laboratory Tests

Past Medical History

5. What are the triggers of myxedema coma?

6. What are the therapeutic goals in the treatment of

7. Give pharmacologic management for hypothyroidism.

8. What are the indications for LT4 therapy?

9. What are the risks of overtreatment and undertreatment of

Past Medical History

Personal and Social History

Pertinent Physical Examinations

History of Present Illness

Personal and Social History

10. For those who are allergic to penicillin, Give 1 alternative

11. How is the efficacy of penicillin therapy assessed?

12. When is the best time to repeat RPR titer?

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