Medication Management

ReviewMr Edward Elric

Clinical Report & Findings

➜Not adherent to all medications

➜No Supplements

➜2 drinks a day

➜Non-smoker

➜Doesn’t have kids

➜FH+ father died from heart attack

➜Blood pressure: 140/70 mmHg

➜Height: 160 cm

➜Weight: 75 kg. IBW: 57.2 kg

BMI : 29.3

CLCR : 35.55 mL/minMILD IMPAIRMENT

MEDICAL DIAGNOSES•Heart failure

•Gout•Primary open angle glaucoma

•Depression

Hx: MI (2009)

Test Result Reference RangeUrea and Electrolytes

Sodium 137 mmol/L 138-145 mmol/L

Potassium 4.2 mmol/L 3.5-5.0 mmol/L

Chloride 105 mmol/L 95-110 μmol/L

Bicarbonate 25 mmol/L 22-32 mmol/L

Urea 13.4 mmol/L 2.2 – 7.7 mmol/L

Creatinine 147 μmol/L 60-120 μmol/L

Creatine Kinase 170 U/L 40 – 200 U/L

Calcium (corrected) 2.31 mmol/L 2.10-2.55 mmol/L

Magnesium 0.56 mmol/L 0.7-1.0 mmol/L

Phosphate 1.10 mmol/L 0.7 – 1.7 mmol/L

Urate 0.45 mmol/L 0.20 – 0.42 mmol/L

Clinical Report & Findings

Clinical Report & Findings

Liver Function Tests

Bilirubin (Total) 15 < 20 μmol/L

Albumin 37g/L 35-50 g/L

ALP 111 U/L 35-135 U/L

GGT 45 U/L < 60 U/L

ALT 32 U/L <36 U/L

AST 42 U/L <40 U/L

Immunology

C-reactive protein 7 mg/L <5 mg/L

Clinical Report & FindingsMedication Strength and

DosageDate commenced

Colgout 1mg stat then 0.5mg q6h.mdu Today

Celebrex 100mg bd Recently ceased

Zyloprim 300mg daily 2010

Astrix caps 100mg daily 2009

Endep 150mg nocte 2001

Avapro 300mg mane 2009

Dilatrend 25mg bd 2009

Lasix 40mg daily 2009

Voltaren tablets 50mg tds Ceased June 2011

Coversyl 5mg daily Ceased March 2010

Xalatan 1 drop in both eyes at night 2007

Refresh tears plus 1 drop in both eyes prn 2001

Lipitor 20mg daily 2009

Clinical Issues to Consider

Findings: Acute Gout Situation

Contributing factors to his gout attacks? Low dose Aspirin Diuretic (Lasix) 2-3 drinks of alcohol per day

Renal impairment reduces the elimination of colchicine- increasing risk of toxicity He has impaired renal function (CrCl: 35 mL/min)

Colchicine dose is too high: AMH 2011 recommends 1mg stat, then 500mg 1 hour later (max 1.5 mg per course)

Colchicine: high incidence of nausea and vomiting (studies show that these symptoms appear in most patients before achieving a 50% improvement in pain (Fravel & Ernst, 2011)

Recommendations: Acute Gout Situation

AMH 2011 recommends that colchicine only be used when NSAID’s and corticosteroids are contraindicated

Recommend that instead of the colchicine he starts on; 20mg of Prednisolone daily until symptoms abate (usually ~ 3-5 days) (Therapeutic Guidelines: Rheumatology 2010 Version2)

Corticosteroids are recommended for patients with renal impairment (Fravel & Ernst, 2011)

Prednisolone is ideal since the side effects associated with it generally only appear after long term therapy

Findings: Long-Term Gout Prevention

He is currently on Allopurinol 300mg daily

Quite non-adherent“Taking Zyloprim every now and then”

Recommendations: Long-Term Gout Prevention

Leave him on the Allopurinol 300mg D

Thanassoulis et al. (2010) proved that heart failure patients taking allopurinol 300mg daily for long term gout prevention were controlled well

In future, once adherence to allopurinol has improved, consider dropping the dose of Allopurinol to 150mg daily in consideration on renal impairment (as allopurinol is predominantly renally cleared)

Findings: Blood Pressure

Blood pressure : 140/70 mmHg

Most symptoms and signs of heart failure are related to water retention and consequent rise in cardiac filling pressures (Therapeutic Guidelines: Cardiovascular 2008 Version 5)

Reducing preload (by reducing blood pressure) is particularly important in systolic heart failure

Recommendations: Blood Pressure

Since he is non-adherent to his Lasix (this could be contributing to his peripheral oedema and increase in blood pressure) once he becomes adherent to the Lasix this may improve his blood pressure

In any case, due to the importance of reducing the preload on his heart- should consider adding another antihypertensive agent

Add a combination product: Irbesartan 150mg + HCT 12.5mg

HCT 150/12.5

DIURETIC EFFECT OF HCT NOT SEEN AT DOSES BELOW 25 MG

Findings & Recommendation: Statin

Cholesterol level should be reviewed regularly

If he does start on colchicine (there may be a CYP3A4 interaction which would lead to the reduced metabolism of colchicine and thus, potential toxicity) Atorvastatin is a CYP3A4 inhibitor

Findings: Antidepressant

Taking Endep (amitriptyline) 150mg at night since 2001 for depression

Tricyclic antidepressants such as amitriptyline have potential for cardiotoxicity and thus their use in Mr Elric who has heart failure and a previous history of MI is not recommended (Slordal, L. & Stidset, O., 2006)

Findings: Antidepressant

Tricyclic antidepressants such as amitriptyline have anticholinergic effects such as dry mouth, dry eyes and fluid retention

Mr Elric excessively uses his Refresh Tears Plus eye drops (more than 8 times a day) and this may be due to the anticholinergic effects caused by amitriptyline

The amitriptyline may also contribute to fluid retention which can worsen symptoms of heart failure

Recommendations: Antidepressant

We recommend that amitriptyline should be ceased and an SSRI should be initiated as long as an SSRI hasn’t previously been trialled

We recommend sertraline 50mg daily, increasing as necessary to a maximum of 200mg daily

Ceasing the amitriptyline may decrease the frequency of use of the Refresh tears plus

Findings: Adherence

Non-adherent with allopurinol and latanoprost therapy

Mr Elric doesn’t dispose of latanoprost drops after 28 days

Eye drop technique not correct

Recommendations: Adherence We recommend that it be explained to Mr Elric that he should take his

allopurinol tablets every day as prescribed as and use his latanoprost drops at night as prescribed as intermittent use of both of these drugs is ineffective in prophylaxis of both gout (allopurinol) and treatment of glaucoma (latanoprost)

We recommend that the disposal date printed on the pharmacy label for the latanoprost drops be noted to Mr Elric so he knows when to discard them. He should also be educated of the dangers of using drops past their expiry date.

We recommend that Mr Elric be advised of the correct eye drop technique for future use

Xal-Ease could be an option to promote proper use if he has difficulty in instilling drops correctly

Mr Elric is a good candidate for receiving his medication as a Webster pack to improve overall adherence to his medication regimen

AMH, 2011

Findings: Phenergan

Mr Elric was prescribed Phenergan (as well as a 1% hydrocortisone cream) for symptomatic relief of a rash he developed from Celebrex (assumably)

Recommendations: Phenergan

If it is decided by Mr Elric’s prescriber that he should remain on Colgout, Mr Elric should be well-informed that if he develops any rash or unusual symptoms, he should report to his GP or hospital immediately.

Rash is a common sign of acute colchicine toxicity (likely in Mr Elric due to concomitant atorvastatin, renal impairment, high dose and older age) and should not just be dismissed and treated with Phenergan and the hydrocortisone cream.

AMH, 2011

Recommendations: Lifestyle

Decreased alcohol intake can also assist in gout prevention and increased cardiovascular health

Exercise and weight loss can prevent gout, improve cardiovascular health and depression

Salt and fluid restriction are important for management of heart failure

Low purine diet can assist in gout prevention