Therapeutics 1 Lab

Pharmacist’s Care Plan

Patient database

Name ( abbreviated) Gary Roberts Creatinine Clearance *After calculating a

Calculations: creatinine clearance you
Gender Male should determine the
staging/severity of a patient's
Height(cm) 177.8 cm chronic kidney disease.

Actual Weight(Kg) 95 CKD stage GFR level

(mL/min/1.73 m2)

ClCr = (140-68) Stage 1 ≥ 90

x 81.8 /72 x 1 Stage 2 60 – 89

Stage 3 30 – 59
 Stage 4 15 – 29

Age 68

Race not mentioned

Past Allergies NKDA

Past Adverse effects chest pain radiate to his jaw, nausea, diaphoresis
(extreme sweating)

Tobacco/Alcohol/Substance moderate alcohol intake

Use

BMI (Kg/m^2) 26.89

(Underweight/Normal/Overweight/Obese/Morbid
obesity)

IBW (Kg) 50+2.3(inche-60)= 73 —-> 95/73= 1.3 it`s >1.2 so

we need to calculate adj BW

Adjusted body weight (Kg) [0.4*(TBW-IBW)]+IBW

[0.4*(95-73)]+73= 81.8

Clcr ( ml/min) /stage 81.8 stage II

Case summary:

A 68 years old man with HTN, DM type2, dyslipidemia, CAD with PCI with a(DES) 3 years ago. admitted to the ED
complaining of chest pressure/pain lasting 20– 30 minutes occurring at rest. despite treatment with Aspirin, Metoprolol
tartrate, Simvastatin, Metformin, and SL NTG PRN CP. He describes the pain as substernal, crushing, and pressure-like
radiates to his jaw and is accompanied by nausea and diaphoresis. he states that the pain first started approximately 6
hours ago after he ate breakfast and was unrelieved by antacids or SL NTG × 3. He also experiencing intermittent chest
pain over the past 3 to 4 weeks with minimal exertion. his BP is uncontrolled, he has a high troponin serum
concentration, high blood glucose/HbA1c, phosphate slightly low, and the Assessment of ECG shows an Acute inferior
STEMI.
# Medical Drug therapy Therapeutic goals Recommendations & Monitoring Follow-up plan What will be plan B
condition problems interventions parameters, desired
endpoints, and (when should the
(non -pharmacological frequency patient return for
&pharmacological(plan A)) follow up )

acute simvastatin Rapid evaluation of eligibility Recommended lifestyle (1) relief of ischemic ● Monitor Pharmacolog
coronary ( we need high for reperfusion therapy is discomfort adherence to ycal:
syndrome intinsity statin) indicated in patients with modifications should include and
STEMI STEMI. the following: (2) return of ECG accomplishm EARLY
changes to baseline ent of PHARMACO
● quality of life ● Weight reduction: THERAPY
lifestyle
improvement Maintain normal body (3) absence or the
modification
weight (BMI 18.5–24.9 resolution of HF ● intranasal
diabetic drug s
● early restoration of kg/m2). A 14-kg weight signs and symptoms. oxygen (if
should be blood flow to the loss. ● BP be oxygen
modified infarct-related artery to (4) Troponin needs 3-
● Sodium restriction: Not 6h to rise and peak in monitored at saturation is
prevent infarct least monthly
(metformin more than 2.4 g of 12-24 h and needs 7- low)
expansion until it is
dose should be sodium or 6 g of 14 days to return to
increased ) controlled. ● SL NTG
● prevention of death and sodium chloride (NaCl) normal.
other complications per day. More should before
(5) this patient with frequent given
● prevention of coronary ● Dietary Approaches STEMI is at very monitoring
artery reocclusion (DASH) diet: A diet high risk for a should be ● aspirin
that is high in calcium, recurrent event, and considered in (81mg/day)
● relief of ischemic chest high in potassium, and further reduction of patients with should be
discomfort low saturated fat. The LDL to 70 mg/dL Stage 2 continued in
DASH diet should be considered. HTN. In this this patient
● resolution of ST- patient, the
segment and T-wave ● is rich in fruits, (6) prevent acute BP should be ● P2Y12
changes on ECG. vegetables, and low-fat ischemic episodes. rechecked in platelet
dairy products. 2–4 weeks
● control of hreat rate abd BP, inhibitor
cardiovascular (CV) risk ● Moderation of alcohol serum potassium, ● (clopidogrel)
factors, prevention of intake: Not more than 1 serum creatinine, 300 mg oral
additional CV events\ oz or 30 mL of ethanol BUN loading dose
per day followed by
● to control blood sugar (7) oxygen should be 75mg orally
● Exercise: ≥30 monitored
● control BP
minutes per day daily should
most days of the
be started for
week.
at least 12
● Continued smoking months
avoidance
● tirofiban (IV
● PCI to restore blood or
flow to the heart intracoronary
administratio
n) should be
Pharmacological: administered
before PCI
EARLY
PHARMACOTHERA ● (UFH)
PY
fondaparinux
● intranasal oxygen (if
oxygen saturation is should be
administered
 low) for 48 hours.

● SL NTG should ● IV atenolol

before given should be
administered
● aspirin should be before PCI
continued in this
patient

● P2Y12 platelet secondary

inhibitor prevention MI:
(clopidogrel) should
be started for at least
12 months ● simvastatin
● Abciximab (IV or should be
intracoronary DC and
administration) rosuvastatin
should be 40mg/day
administered before should be
PCI added

● (UFH) enoxaparin ● PO NON-

should be DHP CCB
administered for 48 (diltiazem )12
0 to 360 mg
hours.
sustained-
● IV metoprolol should release orally
be administered once daily to
before PCI replace
metoprolol
 ● aspirin
(81mg/day)
should be
secondary prevention MI: continued in
this patient

● ACEI
● simvastatin should be (enalapril)2.5
DC and atorvastatin to 5 mg
80 mg/ day should be initially;
added target dose
10 mg twice
● continue PO selective
daily should
B blocker
be added
(metoprolol) 25 to 50
mg orally every 6 ● SL NTG
hours . should be
given for
● aspirin (81mg/day) acute attack
should be continued ● (aldosterone
in this patient antagonist)
eplerenone
● ACEI (ramipril) 1.25
25 initially
to 2.5 mg initially;
target 50 mg
target dose10 mg
once daily should be
added

● SL NTG should be
given for acute attack
 ● (aldosterone
antagonist)
spironolactone 12.5
initially target 25-50
mg

● metformin dose should

be increased

Drug-Drug interactions

(Drug-Drug) Severe, moderate or minor Management

(Drug-Food )

(Drug –herbal )

interactions

enoxaparin - abciximab major Using enoxaparin together with abciximab may increase the risk of
bleeding, including severe and sometimes fatal hemorrhage. Talk to
your doctor if you have any questions or concerns. Your doctor may
already be aware of the risks, but has determined that this is the
best course of treatment for you and has taken appropriate
precautions and is monitoring you closely for any potential
complications. You should seek immediate medical attention if you
experience any unusual bleeding or bruising, or have other signs
and symptoms of bleeding such as dizziness; lightheadedness; red or
black, tarry stools; coughing up or vomiting fresh or dried blood
that looks like coffee grounds; severe headache; and weakness. It is
important to tell your doctor about all other medications you use,
including vitamins and herbs. Do not stop using any medications
without first talking to your doctor.

enoxaparin - clopidogrel major Using enoxaparin together with clopidogrel may increase the risk of
 bleeding, including severe and sometimes fatal hemorrhage. Talk to
your doctor if you have any questions or concerns. Your doctor may
already be aware of the risks, but has determined that this is the
best course of treatment for you and has taken appropriate
precautions and is monitoring you closely for any potential
complications. You should seek immediate medical attention if you
experience any unusual bleeding or bruising, or have other signs
and symptoms of bleeding such as dizziness; lightheadedness; red or
black, tarry stools; coughing up or vomiting fresh or dried blood
that looks like coffee grounds; severe headache; and weakness. It is
important to tell your doctor about all other medications you use,
including vitamins and herbs. Do not stop using any medications
without first talking to your doctor.

abciximab - clopidogrel major Ask your doctor before using abciximab together with clopidogrel.
This can cause you to bleed more easily. You may need a dose
adjustment in addition to special testing of your blood. Call your
doctor promptly if you have any unusual bleeding or bruising,
vomiting, blood in your urine or stools, headache, dizziness, or
weakness. It is important to tell your doctor about all other
medications you use, including vitamins and herbs. Do not stop
using any medications without first talking to your doctor.

metoprolol - food moderate Food can enhance the levels of metoprolol in your body. You should
take metoprolol at the same time each day, preferably with or
immediately following meals. This will make it easier for your body
to absorb the medication. Avoid drinking alcohol, which could
increase drowsiness and dizziness while you are taking metoprolol.
Metoprolol is only part of a complete program of treatment that
also includes diet, exercise, and weight control. Follow your diet,
medication, and exercise routines very closely.

diltiazem - eplerenone major DilTIAZem may increase the blood levels and effects of eplerenone.
You may need a dose adjustment or more frequent monitoring by
your doctor to safely use both medications. High blood levels of
 eplerenone can increase the risk of side effects including
hyperkalemia (high blood potassium), which in severe cases can
lead to kidney failure, muscle paralysis, irregular heart rhythm, and
cardiac arrest. You may be more likely to develop hyperkalemia
during treatment with eplerenone if you are elderly, dehydrated, or
have kidney disease, diabetes, or advanced heart failure. You should
seek medical attention if you experience nausea, vomiting,
weakness, confusion, tingling of the hands and feet, feelings of
heaviness in the legs, a weak pulse, or a slow or irregular heartbeat,
as these may be symptoms of hyperkalemia. It is important to tell
your doctor about all other medications you use, including vitamins
and herbs. Do not stop using any medications without first talking
to your doctor.

tirofiban - fondaparinux major Using tirofiban together with fondaparinux may increase the risk of
bleeding, including severe and sometimes fatal hemorrhage. Talk to
your doctor if you have any questions or concerns. Your doctor may
already be aware of the risks, but has determined that this is the
best course of treatment for you and has taken appropriate
precautions and is monitoring you closely for any potential
complications. You should seek immediate medical attention if you
experience any unusual bleeding or bruising, or have other signs
and symptoms of bleeding such as dizziness; lightheadedness; red or
black, tarry stools; coughing up or vomiting fresh or dried blood
that looks like coffee grounds; severe headache; and weakness. It is
important to tell your doctor about all other medications you use,
including vitamins and herbs. Do not stop using any medications
without first talking to your doctor.

clopidogrel - fondaparinux major Using clopidogrel together with fondaparinux may increase the risk
of bleeding, including severe and sometimes fatal hemorrhage. Talk
to your doctor if you have any questions or concerns. Your doctor
may already be aware of the risks, but has determined that this is
the best course of treatment for you and has taken appropriate
precautions and is monitoring you closely for any potential
 complications. You should seek immediate medical attention if you
experience any unusual bleeding or bruising, or have other signs
and symptoms of bleeding such as dizziness; lightheadedness; red or
black, tarry stools; coughing up or vomiting fresh or dried blood
that looks like coffee grounds; severe headache; and weakness. It is
important to tell your doctor about all other medications you use,
including vitamins and herbs. Do not stop using any medications
without first talking to your doctor.

aspirin - fondaparinux major Using fondaparinux together with aspirin may increase the risk of
bleeding, including severe and sometimes fatal hemorrhage. Talk to
your doctor if you have any questions or concerns. Your doctor may
already be aware of the risks, but has determined that this is the
best course of treatment for you and has taken appropriate
precautions and is monitoring you closely for any potential
complications. You should seek immediate medical attention if you
experience any unusual bleeding or bruising, or have other signs
and symptoms of bleeding such as dizziness; lightheadedness; red or
black, tarry stools; coughing up or vomiting fresh or dried blood
that looks like coffee grounds; severe headache; and weakness. It is
important to tell your doctor about all other medications you use,
including vitamins and herbs. Do not stop using any medications
without first talking to your doctor.

atenolol - diltiazem major Using atenolol and dilTIAZem together may lead to increased side
effects. This can cause fatigue, headache, fainting, swelling of the
extremities, weight gain, shortness of breath, chest pain, increased
or decreased heartbeat, or irregular heartbeat. If you take both
medications together, tell your doctor if you have any of these
symptoms. You may need a dose adjustment or need your blood
pressure checked more often to safely use both medications. It is
important to tell your doctor about all other medications you use,
including vitamins and herbs. Do not stop using any medications
without first talking to your doctor.
clopidogrel - tirofiban major Ask your doctor before using tirofiban together with clopidogrel.
This can cause you to bleed more easily. You may need a dose
adjustment in addition to special testing of your blood. Call your
doctor promptly if you have any unusual bleeding or bruising,
vomiting, blood in your urine or stools, headache, dizziness, or
weakness. It is important to tell your doctor about all other
medications you use, including vitamins and herbs. Do not stop
using any medications without first talking to your doctor.

aspirin - clopidogrel moderate Before using aspirin, tell your doctor if you also use clopidogrel.
This combination may cause unusual bleeding, severe abdominal
pain, weakness, and the appearance of black, tarry stools. If you
take both medications together, tell your doctor if you have any of
these symptoms. You may need a dose adjustment if you take both
medications. You should also avoid any other over-the-counter
NSAID products. It is important to tell your doctor about all other
medications you use, including vitamins and herbs. Do not stop
using any medications without first talking to your doctor.

aspirin - eplerenone moderate Using aspirin together with eplerenone may decrease the effects of
eplerenone. Contact your doctor if you experience signs of high
blood pressure which may include headache, blurred vision, trouble
concentrating, dizziness. And fatigue. If your doctor does prescribe
these medications together, you may need a dose adjustment or need
your blood pressure more often to safely use both medications. It is
important to tell your doctor about all other medications you use,
including vitamins and herbs. Do not stop using any medications
without first talking to your doctor.

enalapril - eplerenone moderate Using eplerenone together with enalapril may increase potassium
levels in the blood. High levels of potassium can develop into a
condition known as hyperkalemia, which in severe cases can lead to
kidney failure, muscle paralysis, irregular heart rhythm, and
cardiac arrest. You may be more likely to develop hyperkalemia
while using these medications if you are elderly, dehydrated, or
 have kidney disease, diabetes, or advanced heart failure. Regular or
long-term use of nonsteroidal anti-inflammatory drugs such as
ibuprofen or naproxen (Aleve) may also increase your risk. It is
important that you maintain adequate fluid intake during treatment
with these medications, especially if you are using them for
prolonged periods. In addition, talk to your doctor to see if you
should limit consumption of potassium-rich foods such as tomatoes,
raisins, figs, potatoes, lima beans, bananas, plantains, papayas,
pears, cantaloupes, mangoes, and potassium-containing salt
substitutes. You may need a dose adjustment or more frequent
monitoring by your doctor to safely use both medications. You
should seek medical attention if you experience nausea, vomiting,
weakness, confusion, tingling of the hands and feet, feelings of
heaviness in the legs, a weak pulse, or a slow or irregular heartbeat,
as these may be symptoms of hyperkalemia. It is important to tell
your doctor about all other medications you use, including vitamins
and herbs. Do not stop using any medications without first talking
to your doctor.

aspirin - tirofiban moderate Using aspirin together with tirofiban can cause you to bleed more
easily. Call your doctor promptly if you have any unusual bleeding
or bruising, vomiting, blood in your urine or stools, headache,
dizziness, or weakness. You may need a dose adjustment in addition
to special tests to safely use both medications. It is important to tell
your doctor about all other medications you use, including vitamins
and herbs. Do not stop using any medications without first talking
to your doctor.

diltiazem - nitroglycerin moderate Using dilTIAZem together with nitroglycerin can lower your blood
pressure. This can cause dizziness or feeling like you might pass out,
especially when getting up from a sitting or lying position. This may
be more likely to occur when you first start taking either of these
medications. Talk with your doctor before using dilTIAZem and
nitroglycerin together. You may need a dose adjustment or need
your blood pressure checked more often if you take both
 medications. It is important to tell your doctor about all other
medications you use, including vitamins and herbs. Do not stop
using any medications without first talking to your doctor

enalapril - nitroglycerin moderate Using enalapril and nitroglycerin together may lower your blood
pressure and slow your heart rate. This can cause a throbbing
headache, difficult or slow breathing, dizziness, fainting, and an
irregular heartbeat. If you take both medications together, tell your
doctor if you have any of these symptoms. You may need a dose
adjustment or need your blood pressure checked more often. It is
important to tell your doctor about all other medications you use,
including vitamins and herbs. Do not stop using any medications
without first talking to your doctor.

diltiazem - aspirin moderate Before using dilTIAZem, tell your doctor if you also use aspirin.
This combination may cause unusual bleeding or bruising,
headache, dizziness, or weakness. If you take both medications
together, tell your doctor if you have any of these symptoms. You
may need a dose adjustment or need your blood pressure checked
more often. It is important to tell your doctor about all other
medications you use, including vitamins and herbs. Do not stop
using any medications without first talking to your doctor.

enalapril - aspirin moderate Before taking aspirin, tell your doctor if you also use enalapril. You
may need dose adjustments or special tests in order to safely take
both medications together. If you are receiving therapy with this
combination you should check your blood pressure and may need
your kidney function monitored. It is important to tell your doctor
about all other medications you use, including vitamins and herbs.
Do not stop using your medications without first talking to your
doctor.

atenolol - food moderate You may take atenolol with or without food, but take it the same
way every time. Avoid consumption of large amounts of orange
juice to prevent any changes in your atenolol levels. Orange juice
 could decrease the effectiveness of atenolol.

enalapril - food moderate It is recommended that if you are taking enalapril you should be
advised to avoid moderately high or high potassium dietary intake.
This can cause high levels of potassium in your blood. Do not use
salt substitutes or potassium supplements while taking enalapril,
unless your doctor has told you to.

diltiazem - food moderate Alcohol can lower your blood pressure and add to the effects of
dilTIAZem. You may experience dizziness, lightheadedness,
fainting, or a rapid heartbeat if you drink alcohol with dilTIAZem,
especially when you first start taking the medication or just after a
dose increase. Grapefruit juice may also increase the effects of
dilTIAZem in some people by increasing its levels in the blood. You
may want to limit alcohol intake and avoid excessive consumption of
grapefruit and grapefruit juice during treatment with dilTIAZem.
However, if you have been regularly consuming grapefruit or
grapefruit juice with dilTIAZem, do not alter the amounts of these
products in your diet without first talking to your doctor or other
healthcare professional. Contact your doctor if your condition
changes or you experience increased side effects of dilTIAZem such
as headache, irregular heartbeat, swelling, unexplained weight gain,
or chest pain. Orange juice is not expected to interact.

References:

2) Pharmacotherapy: A Pathophysiologic Approach, 9e