Therapeutics 1 Lab

Pharmacist’s Care Plan

Lab Number

Case Title DM

Patient Database
Name ( abbreviated) Sarah Martin
Gender female

Height(cm)
1ft=12 inch —> 5 feet =x

X=60+8 inch =68 inch

= 172.72 cm

Actual Weight(Kg) 109kg

Age 45 y.o

Race white American

Past Allergies Penicillin - hives

Past Adverse effects terrible headache

Tobacco/Alcohol/Substance alcoholic
Use

BMI (Kg/m^2) (Underweight/Normal/Overweight/Obese/morbid obesity)

BMI=Weight/height

BMI=109 kg/1.7272*1.7272m = 109/ 2.983219

BMI=36.5377 Kg/m^2

IBW (Kg) IBW=45kgs+2.3(height-60 inches)

IBW=45kgs+2.3(68inches-60inches)
 IBW= 63.4 kg

Adjusted body weight (Kg) TBW/IBW= 1.7

ABW=(0.4(TBW-IBW)) +IBW

ABW=(0.4(109Kgs-63.4 kgs))+63.4 kgs

ABW= 81.63 kg

Clcr ( ml/min) /stage Clcr = 71.82 ml/min.

Stage 2

Creatinine Clearance Calculations:

((140-age)*weight )/(72* serum crcl )*0.85

= (140-67)*58.34 )/(72* 0.7 mg/dl)*0.85

= 71.82 ml/min

Case summary:

Sarah Martin is a 45-year-old white woman who comes to the pharmacy for a diabetes education class taught by the pharmacist. the
pharmacist checked her blood sugar before the class begins, and she was diagnosed with type 2 -DM about 6 months ago. she was trying to
control her disease with diet and exercise, but she did not succeed, She monitors her blood sugar once a day.

she had HTN, Type 2 DM, bipolar disorder, Dyslipidemia, Morbid obesity. and she taking: Metformin 1000 mg PO BID with food,
Lisinopril 20 mg PO once daily, Zyprexa 5 mg PO QHS, Carbamazepine ER 200 mg PO BID, Lorazepam 1 mg PO TID PRN, Fluoxetine
20 mg PO Q AM, Pravastatin 40 mg PO once daily. she allergic to Penicillin—hives.

Medical Drug therapy Therapeutic goals Recommendations & Monitoring Follow-up plan What will be
condition problems interventions parameters, (when should the patient plan B)
desired return for follow up )
(non -pharmacological endpoints and
&pharmacological(pla frequency
n A))

Type 2 DM ● nonadheren ● Desirable Non -Pharmacological BP, BUN, serum ● Monitor ● if blood
HTN ce to plasma creatinine, Blood adherence to and glucose
lifestyle glucose and ● patient education glucose level, achievement of and
Bipolar modificatio A1C levels
disorder ● MNT Diet: meal A1C level (every lifestyle A1C
n A1C < 7% plan low in fat, 3 months until modifications levels
Dyslipidemia ● uncontrolle ● Reducing high in fiber, low declined to the ● quarterly visits to
are still
– moderate in normal level), uncontr
Morbid obesity d glucose long-term primary health
level with microvascular calories. MNT in serum electrolytes care provider is
olled

metformin and D.M-I is to reach (K, Ca, Mg, Na), recommended.

initiate
optimal dose to lipid profile (TG, rapid
macrovascular LDL , TC/HDL), insulin
● uncontrolle complications. carbohydrate ● Daily
d BP with consumption. hepatic function, measurement of lispro
lisinopril ● Preventing For D.M-II focus renal function, blood glucose 100u/ml
acute is on calorie baseline level as directed
● uncontrolle complications reduction to measurement of
d lipid from high achieve weight CK, body weight, ● daily evaluations
profile with blood glucose loss. DM symptoms for examination of
Pravastatin levels. and complications foot for any sores,
● and DASH diet: (Peripheral cuts, or scrapes,
● moderate ● Minimizing A diet that is skin dryness.
Vascular Disease
D-D/ hypoglycemic increased and Foot ulcer,
lisinopril episodes. calcium, and ● Weekly
foot sensory
with potassium, and assessments of
testing and
Zyprexa ● Maintaining lower saturated weight and blood
Neuropathy, eye
(olanzapine the patient's fat intake, rich in health/ pressure by the
) that overall quality fruits, Retinopathy, patient
causes of life. vegetables, and kidney health
elevate low-fat dairy monitoring/ ● A1C level every
blood ● reduce LDL products. for Nephropathy). 3months
glocose. level to decreasing BP by
normal <100 monitor bipolar ● monitoring BP at
8–14 mm Hg. least every month
mg/dl disorder and her
● Weight mental health. until controlled.
● reduce TG Management:
level to ● monitoring serum
The preferred lipids, urinary
normal <150 way to lose
mg/dl microalbumin,
weight method and serum
● reduce total is a slow creatinine tests at
cholesterol progressive least every year.
level to weight loss of 1
normal <200 – 2 lbs/week. ● Patients should be
mg /dl advised to avoid
● Physical rising abruptly
● increase HDL Activity: at least from a sitting or
level to 30 minutes of recumbent
normal > 50 moderate aerobic position and to
mg /dl activity spread notify their
over at least 3 physician if they
● reduce CRP days a week with experience
level to no more than 2 dizziness,
normal < 0.8 days between lightheadedness,
mg /dl activity. syncope,
● reduce BP to ● Immunization: orthostasis, or
goal <140/90 annual influenza tachycardia.
vaccine and
pneumococcal
vaccination.

● Psychological
Assessment and
Supervision and
advise her to
meet a
psychiatrist.

● discontinue
alcohol
consumption.

● keeping smoking
cessation

● sterols and fiber

should be
promoted to
decrease LDL
(20% to 25%) &
fibers (10 -25
g/day) .

● Sodium
restriction (Not
more than
2.4g/day sodium
 or 6g/day sodium
chloride).

● advice her to
reduce water
intake before
sleeping, until
controlled.

Pharmacological:

● continue with
Metformin1000
mg BID with
food

● continue
Lisinopril 20mg
QD and titrate to
40mg QD

● initiate
hydrochlorothiaz
ide 25mg QD in
the morning,.

● initiate insulin
Glargine (sc)
Vial,
3mL ,100unit /ml
until the A1C
 level =<7%.

● D/C Pravastatin
40 mg QD and
initiate
rosuvastatin
40mg QD.

● d/c
Carbamazepine
ER 200mg BID

● d/c Zyprexa 5
mg PO QHS

Drug- Drug interactions

(Drug –Drug) Severe,moderate Management

or minor
(Drug-Food )

(Drug –herbal )

interactions

Alcohol (contained in major Excessive alcohol intake should be avoided during treatment with metformin. Diabetes patients in
alcoholic beverages) general should avoid consuming alcohol if their blood glucose is not well controlled, or if they
(ethanol), metformin have hypertriglyceridemia, neuropathy, or pancreatitis. Alcohol should not be consumed on an
empty stomach or following exercise, as it may increase the risk of hypoglycemia. Patients should
contact their physician immediately if they experience potential signs and symptoms of lactic
 acidosis such as malaise, myalgia, respiratory distress, increasing somnolence, and nonspecific
abdominal distress (especially after stabilization of metformin therapy, when gastrointestinal
symptoms are uncommon). With more marked acidosis, there may also be associated
hypothermia, hypotension, and resistant bradyarrhythmias. Metformin should be withdrawn
promptly if lactic acidosis is suspected. Serum electrolytes, ketones, blood glucose, blood pH,
lactate levels, and blood metformin levels may be useful in establishing a diagnosis. Lactic
acidosis should be suspected in any diabetic patient with metabolic acidosis lacking evidence of
ketoacidosis (ketonuria and ketonemia).

metformin- food major Metformin should be taken with meals, and excessive alcohol intake should be avoided during
treatment. Diabetes patients in general should avoid consuming alcohol if their blood glucose is
not well controlled, or if they have hypertriglyceridemia, neuropathy, or pancreatitis. Alcohol
should not be consumed on an empty stomach or following exercise, as it may increase the risk of
hypoglycemia. Patients should contact their physician immediately if they experience potential
signs and symptoms of lactic acidosis such as malaise, myalgia, respiratory distress, increasing
somnolence, and nonspecific abdominal distress (especially after stabilization of metformin
therapy, when gastrointestinal symptoms are uncommon). With more marked acidosis, there may
also be associated hypothermia, hypotension, and resistant bradyarrhythmias. Metformin should
be withdrawn promptly if lactic acidosis is suspected. Serum electrolytes, ketones, blood glucose,
blood pH, lactate levels, and blood metformin levels may be useful in establishing a diagnosis.
Lactic acidosis should be suspected in any diabetic patient with metabolic acidosis lacking
evidence of ketoacidosis (ketonuria and ketonemia).

lorazepam, moderate Caution and close monitoring for development of hypotension is advised during coadministration
hydrochlorothiazide of these agents. Some authorities recommend avoiding alcohol in patients receiving vasodilating
antihypertensive drugs. Patients should be advised to avoid rising abruptly from a sitting or
recumbent position and to notify their physician if they experience dizziness, lightheadedness,
syncope, orthostasis, or tachycardia.

LORazepam -food moderate Patients receiving CNS-active agents should be warned of this interaction and advised to avoid or

fluoxetine,
hydrochlorothiazide
lorazepam, lisinopril
hydrochlorothiazide, lisinopril moderate
limit consumption of alcohol. Ambulatory patients should be counseled to avoid hazardous
activities requiring complete mental alertness and motor coordination until they know how these
agents affect them, and to notify their physician if they experience excessive or prolonged CNS
effects that interfere with their normal activities.
moderate Caution is recommended if SSRIs or SNRIs are prescribed in combination with diuretics,
particularly in the elderly. Patients should be advised to seek medical attention if they experience
potential signs and symptoms of hyponatremia such as nausea, vomiting, headache, malaise,
lethargy, irritability, difficulty concentrating, memory impairment, confusion, weakness, muscle
spasm, and unsteadiness (which may lead to falls). More severe and/or acute cases may include
hallucination, syncope, seizure, coma, respiratory arrest, and death. Discontinuation of
SSRI/SNRI therapy should be considered in patients who develop symptomatic hyponatremia, and
appropriate medical intervention instituted as necessary. Patients should also have their blood
pressure and pulse monitored before and during SSRI/SNRI therapy, especially during the first
few weeks and following a dosage increase. Patients should be advised to avoid rising abruptly
from a sitting or recumbent position and to notify their doctor if they experience dizziness,
lightheadedness, syncope, orthostasis, or tachycardia. Patients should also avoid driving or
operating hazardous machinery until they know how the medications affect them. Dose reduction
or drug discontinuation should be considered in patients who experience a sustained increase in
blood pressure or pulse rate during SSRI or SNRI therapy.
moderate Caution and close monitoring for development of hypotension is advised during coadministration
of these agents. Some authorities recommend avoiding alcohol in patients receiving vasodilating
antihypertensive drugs. Patients should be advised to avoid rising abruptly from a sitting or
recumbent position and to notify their physician if they experience dizziness, lightheadedness,
syncope, orthostasis, or tachycardia.
Monitoring of blood pressure, diuresis, electrolytes, and renal function is recommended during
coadministration. The possibility of first-dose hypotensive effects may be minimized by initiating
therapy with small doses of the ACE inhibitor, or either discontinuing the diuretic temporarily or

lorazepam, Alcohol
(contained in alcoholic
beverages) (ethanol)
fluoxetine, Alcohol
(contained in alcoholic
beverages) (ethanol)
hydrochlorothiazide, Alcohol
(contained in alcoholic
beverages) (ethanol)
hydrochlorothiazide,
metformin
lisinopril, metformin
increasing the salt intake approximately one week prior to initiating an ACE inhibitor.
Alternatively, the patient may remain under medical supervision for at least two hours after the
first dose of the ACE inhibitor, or until blood pressure has stabilized.
moderate Patients should be advised to avoid alcohol during benzodiazepine therapy.
moderate Patients receiving CNS-active agents should be advised to avoid or limit consumption of alcohol.
Ambulatory patients should be counseled against driving, operating machinery, or engaging in
potentially hazardous activities requiring mental alertness and motor coordination until they know
how these agents affect them, and to notify their physician if they experience excessive or
prolonged CNS effects that interfere with their normal activities.
moderate Caution and close monitoring for development of hypotension is advised during coadministration
of these agents. Some authorities recommend avoiding alcohol in patients receiving vasodilating
antihypertensive drugs. Patients should be advised to avoid rising abruptly from a sitting or
recumbent position and to notify their physician if they experience dizziness, lightheadedness,
syncope, orthostasis, or tachycardia.
moderate Close clinical monitoring is recommended if diuretics are coadministered with antidiabetic agents.
Patients should be advised to monitor their blood glucose and to promptly notify their doctor if
they experience possible signs of lactic acidosis (such as malaise, myalgia, respiratory distress,
hyperventilation, slow or irregular heartbeat, somnolence, abdominal upset) or loss of glycemic
control. Dose adjustments of metformin may be required. Likewise, patients should be observed
for hypoglycemia if diuretics are withdrawn from their therapeutic regimen.
moderate Close monitoring for the development of hypoglycemia is recommended if ACE inhibitors are
coadministered with metformin, particularly in patients with advanced age and/or renal
impairment. Dosage adjustments may be required if an interaction is suspected. Patients should be
apprised of the signs and symptoms of hypoglycemia (e.g., headache, dizziness, drowsiness,

fluoxetine, insulin glargine
FLUoxetine food
lisinopril food
insulin glargine food
Alcohol (contained in
nausea, hunger, tremor, weakness, sweating, palpitations), how to treat it, and to contact their
physician if it occurs. Patients should be observed for loss of glycemic control when ACE
inhibitors are withdrawn.
moderate Close monitoring for the development of hypoglycemia is recommended if these drugs are
coadministered with insulin, particularly in patients with advanced age and/or renal impairment.
The insulin dosage may require adjustment if an interaction is suspected. Patients should be
apprised of the signs and symptoms of hypoglycemia (e.g., headache, dizziness, drowsiness,
nausea, hunger, tremor, weakness, sweating, palpitations), how to treat it, and to contact their
physician if it occurs. Patients should be observed for loss of glycemic control when these drugs
are withdrawn.
moderate Patients receiving CNS-active agents should be warned of this interaction and advised to avoid or
limit consumption of alcohol. Ambulatory patients should be counseled to avoid hazardous
activities requiring complete mental alertness and motor coordination until they know how these
agents affect them, and to notify their physician if they experience excessive or prolonged CNS
effects that interfere with their normal activities.
moderate It is recommended that patients who are taking ACE inhibitors be advised to avoid
moderately high or high potassium dietary intake. Particular attention should be paid to the
potassium content of salt substitutes.
moderate Patients with diabetes should avoid consuming alcohol if their blood glucose is not well
controlled, or if they have hypertriglyceridemia, neuropathy, or pancreatitis. Patients with
well controlled diabetes should limit their alcohol intake to one drink daily for women and
two drinks daily for men (1 drink = 5 oz wine, 12 oz beer, or 1.5 oz distilled spirits) in
conjunction with their normal meal plan. Alcohol should not be consumed on an empty
stomach or following exercise.
moderate Patients should be counseled to avoid substantial quantities of alcohol in combination with
alcoholic beverages) statin medications and clinicians should be aware of the increased risk for hepatotoxicity
(ethanol), rosuvastatin in these patients.

metformin, insulin glargine
moderate A lower dosage of the insulin secretagogue or insulin may be required when used with
metformin. Blood glucose should be closely monitored, and patients should be educated on
the potential signs and symptoms of hypoglycemia (e.g., headache, dizziness, drowsiness,
nervousness, confusion, tremor, hunger, weakness, perspiration, palpitation, tachycardia)
and appropriate remedial actions to take if it occurs. Patients should also be advised to take
precautions to avoid hypoglycemia while driving or operating hazardous machinery.

Alcohol (contained in
alcoholic beverages)
(ethanol), insulin glargine
moderate Patients with diabetes should avoid consuming alcohol if their blood glucose is not well
controlled, or if they have hypertriglyceridemia, neuropathy, or pancreatitis. Patients with
well controlled diabetes should limit their alcohol intake to one drink daily for women and
two drinks daily for men (1 drink = 5 oz wine, 12 oz beer, or 1.5 oz distilled spirits) in
conjunction with their normal meal plan. Alcohol should not be consumed on an empty
stomach or following exercise.

References:

Pharmacotherapy Casebook.

Pharmacotherapy: A Pathophysiological Approach, ed. DiPiro et al, 11th edition.

https://www.drugs.com/drug_interactions