SPW02 Case Studies

7/31/2019 SPW02 Case Studies

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Case 1

Mrs CD (67 years old) was admitted over the weekend to the acute medical ward you cover

as a clinical pharmacist. She was prescribed amoxicillin + clavulanic acid 500/125 one tablet

three times 4 days ago by her GP for a suspected UTI.

Presenting Complaint (PC)

CD now appears very confused, is feverish and complaining of abdominal pain.

Past Medical History(PMHx)

Type 2 diabetes 15 years

Hypertension 5 years

On Examination (O/E)

Temperature 38.50C

Blood pressure 170/105Weight 65 kg

Height 52

Extremely tender abdomen; confused.

Medication on Admission

Metformin 500 mg three times a day

Glipizide 5 mg twice a day

Cilazapril 5mg + Hydrochlorothiazide 12.5 mg one daily

Lab results

(Normal range)WCC 20 x 109/L (4 11 x 109/L)

CRP 100 mg/L (< 8 mg/L)

Creatinine 250 mol/L (50 - 110 mol/L)

Potassium 4.5 mmol/L (3.5 5.0 mmol/L)

Blood glucose 3 mmol/L (4.2 6.1)

HbA1C 6% (5 8%)

Urine dipstick proteinuria +++

Culture and sensitivity from urine sample taken 4 days ago by her GP are available when CD

was admitted to hospital and confirm presence ofEscherichia coli in urine resistant to co-

amoxiclav, amoxicillin and trimethoprim, sensitive to ciprofloxacin and gentamicin.

Impression

Acute pyelonephritis

Plan

Stat dose of IV gentamicin given in ED (5 mg/kg) followed by IV ciprofloxacin


2/10

When you reach the ward on Monday CD has had 3 doses of IV ciprofloxacin 400 mg. You

have a chat with Mrs CD when you are looking at her prescription and she mentions that she

occasionally takes diclofenac (50 mg) for pain in her feet and took one tablet 3 times a day

for the last week. CD says that she has not told the Drs this as she felt so unwell over the

weekend.

Problems

Outline:

current problems that Mrs CD has

potential future problems that you think Mrs CD may experience

[include objective and subjective evidence]

Need to get her IBW (shes overwight) so we can get an accurate creatinine clearance

Current problem:

o Treatment for acute pyelonephritis

o Risk factors were:

Diabetes

Female

Old

o Why?

Proteinuria

WCC and CRP high

Fever

Abdominal pain

Confusion

o Renal impairment seen

15 ml/min seen

Potential problems:

o Chronic renal failure

Pyelonephritis (especially recurrent infections) are a risk factor

(acute tubular nephritis)

Gentamycin and diclofenac may cause renal damage

Have diabetes and hypertension (risk factors)

Creatinine is currently high

o Hypoglycemia

Glucose low

Glipizide (sulphonurea) may be accumulated

Could also be due to just infection

Dont eat properly

But her glucose control is good, HbA1c is good

o Pain in her feet (neuropathy with diabetes?)

She also got the triple whammy, a diuretic, NSAIDs and ACEI

Complicated = kidney involvementCheck BPAC to see what antibiotic we should choose


3/10

Need to know how to calculate GFR by memory, also read NZF stuff on renal impairment

Options

Outline:

possible non-pharmacological treatments

possible pharmacological treatments possible pharmacological treatments if her condition changes

Non-pharmacological treatments

Reduce protein intake

Cranberry juice for prevention

NOT alkalisers, acute kidney damage makes pH balance hard anyways

o Acidosis is common, cant excrete protons

Pharmacological treatments

Gentamycin stat dose, dont need to adjust (first dose doesnt cause damage,and we need to base loading dose off weight, allows us to know Vd)

If continued, then dose reduction and monitoring is required

Good because its renally cleared, so its able to enter kidneys easily

Follow up with cipro- a good choice

o Renally eliminated, so lots would end up in the kidney

o Also need dose adjustment as well

o IV needed for her, need to be absorbed quickly, and since theyre sick,

cant vomit out IV (but can with oral)

o Continue IV dosing until her temperature normalises and her

symptoms are controlled

Renal failure

Regular monitoring (daily until stabilised)

Adjust for renally cleared drugs

Since changes in renal clearance are rapid, need to MONITOR doses of the

renally cleared drugs closely

o Change in clearance = beware

o Tends to overestimates as a result

Diabetes management

Withhold metformin until greater than 30 ml/min (risk of lactic acidosis)o Or insulin

Glipizide- withhold for at least 24 hours and start at a lower dose (maybe it

was accumulating, because blood glucose was low)

Glicazide is a good choice how, because its partially metabolised by the

liver, another pathway for the drugs to leave by

Continue cilazapril, renoprotective, but monitor BP, could be accumulating as

patient is hypotensive

Thiazide diuretics not effective here

o Ineffective if GFR is les than 30 ml/min, so withhold

Ineffective because they work distally, they cant reach there ifthey cant get excreted properly


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o If required for odema, use furosemide

o If required for hypertension, use other agents, like ATII antagonist,

dihydropyridine CCB or beta blockers

Pain

Strong opiate on admissiono Not NSAID

o Fentanyl is good option, no active metabolites

o Morphine and pethidine have some accumulation (especially

norpethidine which is active and accumulates)

o But morphine can be used short term though

NSAID to be stopped

o Neuropathic pain is likely, need a different type of agent

o Gabapentin

o TCAs (e.g. amitriptyline, not an approved condition though)

Pharmacological treatments if condition changes

Note: options should be broad (AND the co-morbidities)

Plans

Outline:

an initial treatment plan (choosing one of your possible options)

a long term treatment plan

what expectations you would have for your treatment

how you would monitor the outcomes of your treatment plans with Mrs CD

Initial

Treat the pain

o Fentanyl

Calculate GFR

Check current medications

o Withold metformin

o Witholg glicazide, consider alternative

o Maintain cilazapril, stop thiazide

o Stop NSAID

o Refer for neuropathic pain Infection

o Genta- stat, only once

o Cipro- then change to cipro

Long term

Continue to manage everything

What about statin? Shes got diabetes, hypertension. So a statin could be thought

about

Diretic used could be furosemide, as it works in renal impairment


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Expectation

Infection should resolve quickly, discharge on oral ciprofloxacin- treatment course

should be 10-14 days

Monitor temp, BP and blood glucose

Monitor renal function (as both inpatient and outpatient)


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Case 2

When Mrs CD was discharged 2 weeks later, her renal function had improved (SCr on

discharge 130 mol/l). Unfortunately, over the next 5 years she developed progressively

worsening chronic renal failure and had poor diabetic control. Six months ago it was decided

that she needed treatment with CAPD and CD has been at home for the last 4 months on this

treatment and is a regular visitor to your pharmacy to collect the following medication:

Metoprolol CR 95 mg daily

Cilazapril 5 mg daily

Simvastatin 20 mg daily

Humulin N 10 units sc twice a day

Calcium carbonate 500 mg 2 tablets three times a day

Calcitriol 0.25 g three times a week

Erythropoietin Beta 4,000 sc weekly

1. Briefly discuss the advantages and disadvantages of renal replacement therapy using

CAPD compared to haemodialysis.

Dialysis is where the filtraction of substances out of the body. Need a semi-permeable

membrane

Plus with counter current flow to maximise the diffusion gradient

Plus with ultrafiltration, which causes a water gradient by osmosis into the dialysis

fluid

Convection- holes allow solutes and larger molecules to pass through like urea

HD= muscle cramps, because elecrylyte balance and moving blood away from the musclesRisk of thrombosis and infection

Skin commensuals commonly seen

Anticoagulate

PD

Ultrafiltration and diffusion possible

Peritoneal membrane is a continuous single layer of mesothelial cells

Dwell time, how long it needs to stay in there, several hours

Indwelling catheter is kept in

Advantages

Dont need to make the arteriovenous fistulas

Dont have to come into the hospital, good for mobility

Disadvantages

Not recommended for diabetics, glucose used in fluid

Risk of infections, because carried out at home

The catheter can damage the peritoneal membrane

Make sure nothing grows into the cather, can block it

2. Discuss the reasons for the drug treatment that CD has been prescribed.


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Heart/BP

Metoprolol

o Hepatically cleared

Cilazapril

o Renoprotective as well

Simvastatin

o Hepatically cleared

o Recommended due to high CVD risk (diabetes + hypertension)

Diabetes

Removed everything, only on insulin

o Better idea due to renal failure

Renal failure

Calciumo Soft tissue calcification causes the drop in calcium

o This is due to phosphate retention

Reduce phosphate in the diet

Or consider a phosphate binder

o A part of preventing hyperparathyroidism

Calcitriol

o The activation step of calcidiol to calcitriol occurs in the liver

o Obviously, cholecalciferol wont work

o Prevents osteomalacia (soft bones)

o Also prevent hypterparathyroidism EPO

o Normally produced by the kidneys as well

o Required for normal red cell production

One year after staring CAPD CD is admitted to your ward with suspected peritonitis. She has

had abdominal pain and a slight temperature over the last day or two and noticed last night

that the volume she drained was much less than normal and the drained fluid has become

cloudy. The medical team looking after CD asks for your advice on appropriate antibiotic

treatment.

3. What treatment would you recommend?

Quick empirical treatment with broad coverage

o Cefazolin (G+) and cefotaxine (G-)/gent (G-)

o OR vancomycin + gent

Give into peritoneal fluid, not IV to achieve high local concentrations

Think about dwell time, can give it intermittently to prevent too much absorption into

systemic circulation

o But need to have a long enough well time to get enough into the systemic

circulation

o Higher dose if intermittent, low dose if continuous

Also think about renal clearance, they cant clear it!


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o Higher doses if they have urine output

Should take a few days (48h), monitor symptoms

o Peritoneal fluids should become clear

Catheter related infections: oral?

4. Should CDs regular medication be altered while she is receiving your recommended

treatment?

Monitor glucose and adjust insulin as required


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Case 3

Mr RT is a 45 year old has been just discharged home from a renal transplant unit. He comes

into your community pharmacy and tells you that although he has pain from his operation he

is feeling well and getting his energy back. He is attending a transplant clinic three times

each week for review and adjustment of his medication. His discharge medication card notesthat he is taking the following medicines.

Ciclosporin 450 mg twice a day

Mycophenolate Mofetil 1 g twice a day

Prednisone 40 mg daily

Valganciclovir 450 mg every second day

Co-trimoxazole 480 mg once daily

Allopurinol 50 mg daily

Cilazapril 5 mg daily

Diltiazem CD 120 mg dailyHumulin N 10 units sc twice a day

Humalog 10 units sc three times a day

Simvastatin 20 mg daily

Ferrous sulphate 200 mg twice a day

Codeine phosphate 30 mg four times daily as required

Paracetamol 1 g four times daily as required

1. Using the list of mediation above identify RTs main medical problems (other than

his renal transplant).

Diabetes Iron depletion

o Probably caused due to renal failure

o Probably exacerbated by blood loss during surgery

o Short term

Hypertension/CVD

Recurrent gout

2. Identify the medicines which will have been started after his operation. Discuss the

function of each, any special precautions relating to use and side effects which RT is

likely to experience?

Ciclosporin

Mycophenolate

Prednisone

Valganciclovir

o Cytomegalovirus (especially with allograft)

Cotrimoxazole

o PCP prophylaxis

Pain

o Short term treatments


10/10

See www.kidney.org.uk/Medical-Info/transplant/txinfect.html

3. Are there any changes to his medicines that you anticipate or would recommend?

How should these be managed? He uses a medication tray.

Add laxative (codeine) Need to slowly taper down the rejection drugs quite regularly (especially with

prednisone)

o Blister packing is a very good idea

Even if they use their own tray, its probably a good idea for us to pack them

Ciclo can be changed to tacrolimus (also a good idea for a second kidney after reject,

its stronger)

Beware of pregnisone, changes diabetes (down titration)

o Especially important for long term kidney survival

Monitor kidney function, and make dose adjustments on a regular basis

Oxypurinol build up needs to be accounted for in renal failure. Dose adjustments maybe required

4. Mr RT asks to receive an influenza vaccination in your pharmacy. What is your

recommendation?

Its not going to work, your immune system is currently being suppressed. Cant produce a

response against it. (its an attenuated vaccine, wont cause infection at least)

Note: diltiazem can be used as a ciclosproin sparer, this is via CYP inhibition (plus good for

addon for hypertension)

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SPW02 Case Studies