HAMDARD UNIVERSITY

FACULTY OF PHARMACY

ASSIGNMENT

Course Title: Pharmacy Practice-Va (Clinical Pharmacy) – Lab

Course Code: 605

Department: Pharmacy Practice

Topic: Case Studies

Submitted to: Dr. Hira Afshan

Submitted By:

Name Roll Number CMS Id

Munazza Asadullah Q-65 28-2018
TABLET OF CONTENTS
CASE STUDIES........................................................................................................................................3

DISEASE: CHRONIC KIDNEY FAILURE.......................................................................................3

SUBJECTIVE DATA:.........................................................................................................................3

OBJECTIVE DATA:...........................................................................................................................3

ASSESSMENT:..................................................................................................................................3

PLAN:.................................................................................................................................................4

DISEASE: CHRONIC OBSTRUCTIVE PULMONARY DISEASE................................................6

SUBJECTIVE:....................................................................................................................................6

OBJECTIVE:.......................................................................................................................................6

ASSESSMENT:..................................................................................................................................7

PLAN:.................................................................................................................................................7

MONITORING:..................................................................................................................................9

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 CASE STUDIES

DISEASE: CHRONIC KIDNEY FAILURE

SUBJECTIVE DATA:
A 61-year-old Caucasian man is reviewed for the management of stable chronic kidney disease,
hypertension, and obesity. He has never smoked, and does not have diabetes or significant
proteinuria. His medications include: lisinopril 20mg daily, Bendroflumethiazide 2.5mg daily,
simvastatin 40mg daily

OBJECTIVE DATA:
 Blood pressure = 145/95mmHg (6 months ago it was 165/102mmHg)
 Serum potassium = 4.4mmol/liter
 Serum creatinine = 260micromol/liter
 eGFR = 23mL/minute/1.73m2 
 Fasting total cholesterol = 3.4mmol/liter
 Liver function and other U + Es are normal
 Height = 175cm (5 feet 9 inches), weight = 98kg

ASSESSMENT:
Q.1 What is this patient’s body mass index?
According to the BNF online calculator, his body mass index = 32kg/m2
Q.2 What is this patient’s body surface area?
According to the BNF online calculator, his body surface area = 2.13m2.
Q.3 What is this patient’s absolute glomerular filtration rate?
The eGFR reported by the laboratory can be converted to the absolute glomerular filtration rate
using the following equation:

 GFRAbsolute = eGFR x (individual’s body surface area/1.73)

 GFRAbsolute = 23 X (2.13/1.73) = 28mL/minute 

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Q.4 What is this patient’s creatinine clearance?
According to the BNF online calculator for creatinine clearance (using the Cockcroft and Gault
formula), his creatinine clearance is 26mL/minute.
In this patient, the GFRAbsolute is similar to the calculated creatinine clearance, and either value can
be used to adjust drug doses.

PLAN:

Q.1 Which measures of renal function should be used to make drug dose adjustments in
this patient?
Prescribing in Renal Impairment in the BNF states that for most drugs, information on dosage
adjustments for renal impairment in the BNF is expressed in terms of eGFR. However, in this
patient with a body mass index greater than 30kg/m2, either the absolute glomerular filtration rate
or the creatinine clearance (calculated from the Cockcroft and Gault formula) should be used in
place of the eGFR to adjust drug doses. For potentially toxic drugs with a small safety margin,
the creatinine clearance should be used to adjust drug doses in conjunction with plasma-drug
concentration and clinical response.
Q.2 How will you optimize this patient’s antihypertensive treatment?
 The prescribing notes on Hypertension in recommend that the optimal blood pressure target
in patients with renal impairment is a systolic blood pressure < 130mmHg and a diastolic
blood pressure < 80mmHg, or lower if proteinuria exceeds 1g in 24 hours.
 As Bendroflumethiazide and lisinopril do not have a narrow therapeutic index, either the
GFRAbsolute or creatinine clearance can be used to adjust their doses in this patient. According
to the prescribing notes on Thiazides and Related Diuretics in section 2.2.1 of the BNF,
Bendroflumethiazide should be avoided if the eGFR is less than 30mL/minute/1.73
m2 because it will be ineffective. As this patient’s GFR Absolute and creatinine clearance is less
than 30mL/minute, the Bendroflumethiazide should be stopped.
 According to the monograph for lisinopril, the dose of lisinopril can be titrated to a maximum
of 40mg daily if the eGFR is 10-30mL/minute/1.73 m 2. As this patient’s GFRAbsolute and
creatinine clearance is between 10-30mL/minute, the dose of lisinopril can be titrated to a

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 maximum of 40mg daily.  However, patients over 55 years of age may respond less well to
treatment with an ACE inhibitor. The prescribing notes on ACE inhibitors in section 2.5.5.1,
BNF 58, advise that renal function and electrolytes should be monitored during treatment
with lisinopril; hyperkaliemia and other side-effects are more common in those with impaired
renal function and may limit the dose of lisinopril that can be used. Although ACE inhibitors
occasionally exacerbate renal impairment, particularly in patients with renovascular disease,
this patient has no features of renovascular disease.
 If lisinopril alone is inadequate at controlling blood pressure, then a dihydropyridine calcium
channel blocker or a loop diuretic can be added

Q.3 Should simvastatin be continued at the current dose?

As simvastatin does not have a narrow therapeutic index, either the GFR Absolute or creatinine
clearance can be used to adjust its doses in this patient. According to the BNF monograph for
simvastatin, doses above 10mg daily should be used with caution if the eGFR is less than
30mL/minute/1.73 m2. Although this patient’s GFRAbsolute and creatinine clearance is less than
30mL/minute, he is not experiencing any side-effects usually associated with statins. Therefore,
simvastatin can be continued at 40mg daily with appropriate monitoring. Alternatively, he could
be switched to either atorvastatin or Fluvastatin, which do not require dose adjustments during
renal impairment.    

Q.4 Which anti-obesity drug can be prescribed?

The prescribing notes on obesity advise that an anti-obesity drug should be considered in those
with a body mass index of 30kg/m 2 or more in whom at least 3 months of managed care
involving supervised diet, exercise and behavior modification fails to achieve a realistic
reduction in weight. Sibutramine is contra-indicated in uncontrolled hypertension or if the eGFR
is less than 30mL/minute/1.73 m2. Sibutramine is inappropriate for this patient because he has
uncontrolled hypertension and his GFRAbsolute and creatinine clearance is less than 30mL/minute.
Orlistat can be used in conjunction with other lifestyle measures to manage obesity and requires
no dose adjustment for renal impairment.

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 DISEASE: CHRONIC OBSTRUCTIVE PULMONARY DISEASE

SUBJECTIVE:

 A 38-year-old female amateur astronomer, all the while knowing better, has smoked since
she was 18 years old. She has been having trouble for years with the smoke and the light of
the cigarette impairing her ability to see the more distant galaxies through her telescope, but
she has not been willing to quit yet.
 Additionally, she has noticed a mild, occasionally productive cough for the past 3-4 months.
The cough is worse whenever she spends the night out in the country taking Astro photos
where she is exposed to the smoke of the nearby wild fires.
 She finally decides to visit her family physician who, after making appropriate patient-
centered inquiries as to how her astrophotography hobby is going, finds that she has been
smoking about one pack per day for the past 20 years.
 The cough has been present for almost a year. She has had no fever or chills. She does
admit to more shortness of breath when she exercises over the past six months.
 Her only other past medical history includes hypertension for which she is using lisinopril,
metoprolol, and hydrochlorothiazide.

OBJECTIVE:

You perform a physical exam and obtain a CXR in the office; the findings are normal. You had
the foresight to obtain a spirometry machine for your family medicine clinic, and the post-
bronchodilator study demonstrates the following:

 FEV1: 85% of predicted

 FEV1/FVC: 65%

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ASSESSMENT:

Q.1 How would you interpret these findings in light of her clinical picture?

A. Normal
B. Moderate COPD
C. Restrictive lung disease
D. Mild COPD
E. Mild Asthma
Ans: D
 Since you are aware of the criteria for diagnosing COPD as outlined by the Global Initiative
for Chronic Obstructive Lung Disease (GOLD), you note that, with an FEV1/FVC of less
than 70% and an FEV1 over 80% of predicted, she has mild COPD. An FEV1/FVC less than
70% is not normal and indicates an obstructive pulmonary process consistent with COPD.
 The results are not consistent with moderate COPD.
 According to the GOLD criteria, moderate COPD would be expected to exhibit an FEV1 of
less than 80% of predicted. With a normal FEV1 and a decrease in her FEV1/FVC
suggesting obstruction, you would not expect this to represent a restrictive process. In
addition, the results do not reflect findings consistent with asthma unless the spirometry was
obtained during an acute asthma exacerbation; generally, spirometry would be normal for an
asthma patient not experiencing bronchoconstriction.
PLAN:

Q.1 What would you do?

A. Continue all medications unchanged.

B. Discontinue the beta blocker because she has COPD.

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C. Stop the angiotensin converting enzyme (ACE) inhibitor because this may be the cause of her
cough.
D. Hold her diuretic because she is often so far out in the country looking at stars that she fails
to empty her bladder as often as she should and may develop an overactive bladder
Ans: A
Beta blockers, ACE inhibitors, and thiazide diuretics are safe and may be used in most patients
with COPD. While physicians are often worried about using beta blockers in patients with
COPD because of concerns that they may worsen bronchoconstriction, the use of cardio selective
beta blockers have not been shown to worsen FEV1, COPD symptoms, or responsiveness to
inhaled beta agonists. This patient has a productive cough as well as a tobacco history and
spirometry consistent with mild COPD as the cause of her cough.
 She does not need to discontinue her ACE inhibitor.
 Thiazide diuretics are cheap, safe, and have been proven to be effective agents for the
treatment of hypertension, as well as being associated with improved cardiac outcomes. No
indication to stop using diuretics is present. While ACE inhibitors can cause a non-
productive cough, her history, symptoms and studies suggest COPD as the cause of her
cough so she can continue lisinopril for now.
 She would best be served by cutting back on the coffee and finding a bush where she can
empty her bladder when needed.

Q.2 Which one of the following would be the best option to improve her symptoms and
slow progression?

A. Begin inhaled medications to treat her pulmonary symptoms.

B. Begin counseling about the importance of tobacco cessation.
C. Offer to buy her a new telescope.
D. Begin counseling and start varenicline at this visit.
Ans: D
Counseling for tobacco cessation along with initiation of a pharmacologic agent to assist in
quitting has shown proven benefit.

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 Her symptoms are mild, and while use of an inhaled beta agonist would not be unreasonable,
it would not slow progression.
 While counseling is an excellent start toward moving this patient to smoking cessation, other
measures in addition to counseling should also be considered at this point.
 While this is a very tempting option, a new telescope is not very likely to help her symptoms.
Q.3 Of the following, which would be the wrong decision for you to make?
A. Encourage her to enroll in the tobacco cessation group counseling program at your clinic.
B. Begin a short acting inhaled beta agonist to be used as needed.
C. Start nicotine replacement therapy in addition to the varenicline.
D. Refer her to a quit line for further assistance.
Ans: C
Using nicotine replacement therapy in addition to varenicline, which is a partial nicotine receptor
agonist, has been shown to provide no additional benefit, and increases the risk of side effects.
They should not be prescribed together.
 Beginning tobacco cessation group counseling is definitely a good idea with proven
effectiveness, particularly if combined with pharmacologic modalities to assist with quitting.
 It would not be wrong to prescribe a short-acting inhaled beta agonist to help control
symptoms. However, her symptoms are mild and she would not likely receive significant
benefit from an inhaler at this stage.
 Self-help websites such as quit lines have proven effectiveness in helping smokers to quit.

MONITORING:
 After four weeks she returns to your office and has decreased her smoking to about 10
cigarettes per day. She thinks you are a fantastic doctor but she is still short of breath at the
gym and is now really motivated to quit.
 She asks if there is anything else that can be done to help her.

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