Pharm Cases Flashcards
Case #1: a 74 year old has dysphagia and hypokalemia and HTN. H&H 11/34. HCTZ. Amlodipine. Atorvastatin. 3 DOC considerations?
DOC1: stop HCTZ since that can cause hypokalemia
DOC2: start KCl IV since she has dysphagia and the pills are about the size of waffles
DOC3: eythropoetin for low H&H since used for anemia in CKD
what are the most two common SE associated with K loss?
nausea/diarrhea
if someone has hypokalemia what are the 4 diuretics would you consider?
K sparing:
- spirolactone
- eplenerone
- amiloride
- tiamterene (adjunct)
if someone has hyperkalemia….what should you do?
get a EKG to check for T wave changes
what is the name of the drug that can increase risk of gyneocomastic in men?
spirolactone
which two drugs are thought to decrease myocardial remodeling secondary to aldosterone?
k sparing
- spirolactone
- eplenerone
what is a weak diuretic usually combined with others as adjunct?
tiamterene, adjunct k+ sparing
Case#2: 60 year old with stage 4 CKD who needs to reduce his serum phosphate levels. HTN. T2DM. Hyperlipidemia. Lisinopril. Atorvastatin 20 mg. two DOC considerations?
elevated serum phosphate level secondary to stage 4 CKD
DOC: sevelamer TID with every meal
DOC2: consider uping atorvastatin to 40mg since stage 4 CKD, he may do ok on just the 20 mg
benefit of sevelamer: this drug reduces LDL by 30% which is good because this pt has hyperlipidemia
what is a benefit of taking sevelamer? how must it be taken?
benefit: reduces LDL by 30% as benefit to lowering phosphorus levels (good for people with high phosphate AND dyslipidemia)
must be taken WITH meals!!
can you crush, break, chew or break the sevelamer tablets?!
NO….DONT DO IT!!!
just dont.
where does selvelamer bind phosphate?
BINDS PHOSPHORUS IN THE INTESTINAL TRACT
if you have high phosphate levels, what 3 foods should you avoid?
red meds, nuts, seeds
what is one major side effect of sevelamer that you want to be aware of before prescribing to patients because it is common?
ask the pt if they have a hx of chronic constapation because this can be a side effect of this medication and can lead to a BOWEL OBSTRUCTION!!
Case #3: a 70 year old pt with CKD that has progressed from 45 to 30 ml/min. HTN. COPD. Osteoarthritis. Ibuprophen 800 mg BID. Lisinopril 20 mg. Advair. 3 DOC considerations?
DOC: take off ibuprophen since that increase HTN
DOC 2: give corticosteroid injections for pain instead of Ibuprophen
DOC 3: lower the dose of linsinopril in eGFR is less than 30 (2.5 mg)
what effect do NSAIDS have on BP and how do they accomplish this? (2 things and causes 1 thing)
- NSAIDS inhibit prostaglandins that cause dilation so you get renal artery constriction which activates RAAS
- increased retention of Na/H2O
Get decreased profusion to renal afferent arterioles
what is a risk of taking tramadol?
seizure
case #4: 65 y/o patient with gout, HTN, osteoarthritis, angina. At his follow up his eGFR is 34 ml/min. uric acid is fine. Allopurinol. Amlopdipine. Atenolol 50 mg. NTG. Acetaminophen. what are the four drug choices to take into consideration?
DOC1 stop atenolol because 50% of active drug is renally excreted so if CKD progresses, the metabolism of atenolol decrease so more will remain in his system
DOC2: SWITCH ATENOLOL TO ACE
DOC3 try decreasing the dose of allopurinol because it accumulates in CKD and is nephrotoxic
DOC4: HD statin because of CKD
DOC5: clopidogrel antiplatelet therapy due to gout because of angina
allopurinol is toxic to the _____
KIDNEYS! consider this when patients are taking it for gout!
what do you need to keep in mind about atenolol and CKD?
50% of this drug are renally excreted in the ACTIVE form, so if your kidney is shot, the active form stays in the body which is NOT GOOD!
ACE inhibitors exert their force on what part of the kidney SPECIFICALLY?
dilate the EFFERENT arteriole and decrease pressure in the glomerulus, this is what its good for CKD
exert their effect on ARTERIOLES
case #5 65 y/o patient with gout, HTN, ANGINA and now has been diagnosed with T2DM with a A1c of 11. eGFR of 25 ml/min. uric acid ok. allopurinol. amlodipine. atenolol 50mg. NTG. Ibuprofen 800 mg. what are the four DOC considerations for this?
stage 4 CKD with end organ damage
DOC1: switch atenolol for ACE 2.5 mg because his eGFR is below 30
DOC2: STOP IBUPROPHEN, increases BP
DOC3: atorvastatin because CKD
DOC4: clopidogrel antiplatelet because of gout for AV nicking from HTN
- consider decreasing allopurinol because of CKD*
- if angina wasn’t controlled consider adding amlodipine*
ASA can cause a increase in _______, so you should use clopidigrel in patients with gout instead!
ASA can cause a increase in URIC ACID, so you should use clopidigrel in patients with gout instead!
what is the only loop dieuretic that is ALSO K sparing!
wow thats crazy
ethacrynic acid
what is a benefit of ethacrynic acid and why it might be a good option for a patient with gout?
it can decrease UA levels so might be a good option for someone with gout
case #6 72 y/o pt with HTN, angina, stage 4 CKD and has just developed herpes zoster. eGFR 25 ml/min. what are the 3 DOC consideration?
DOC1: acyclovir 800 mg 3x daily instead of 5x times daily because of CKD
DOC2: follow up in a week when her rash is gone and change BB to lisinopril 2.5 mg because eGFR is less than 30
DOC3: put on ASA because of angina
order a lipid panel
what is the dosing for acyclovir in a CKD pt vs a regular pt?
herpes zoster acyclovir since stage 4 800 mg x3 times a day, instead of 800 mg 5x a day
what is a good pain control source for herpes zoster?
lidocaine pain patch
case#7 30 y/o who was hiking in the dessert and became lost. he was found 2 days later and brough to the ED. his uring output over the last 2 hours has been 12 ml. he lost 20 pounds over the last two days. he is disoriented. BUN 70. what is the DOC? what are 3 tests to do?
elevated BUN indicates dehydration
DOC1: IV fluids and electrolytes so pt will need to be admitted
get UA, BUN, and CrCl and watch BUN and CrCl
case #9 35 y/o patient with persistent BP 180/110 range with mild reduction in BP taking HCTZ, lisinopril, amlodipine atorvastatin 20 mg. you are concerned she has renal artery stenosis.
renal artery stenosis without organ damage primary cause of HTN. 2 test, 2 medication considerations?
- DUPLEX SCAN/ultrasound of renal arteries
- CT ANGIOGRAM SCAN WITH DYE…..PT WITH CKD INCREASES THE RISK SINCE THERE IS DYE
DOC1: increase atorvastatin 40 mg
DOC2: discontinue lisinopril since contraindicated in renal artery stenosis
REFER NEPHROLOGIST
case #11 a 75 y/o pt with HF and dependent edema that is not responsive to 80 mg furosemide. Angina is well controlled. A-V nicking with muffled heart sounds. eGFR 45 ml/min. HTN, angina, hyperlipidemia. Amlodipine, ASA, atovastatin 20 mg daily, FeSO4, furosemide 80 mg BID. what are three DOC considerations? diet?
DOC1: Add metolazone for 3 days short term 5 mg; thiazide use for quick burst that doesn’t lose effectiveness until less than 20 ml/min
DOC2: Add ACE since patient not on one and they have HF
DOC3: increase atorvastatin to 40 mg because of HF
DOC4: DASH DIET
are loops and thiazides often used together?
yes they are
of the thiazides which one has been show in studies to be more effective in decreasing periphreal edema?
metalozone
case 12 65 y/o with CKD and anemia that is not controlled on iron supplement. HTN, CKD, COPD, dyslipidemia. Lisinopril, amlodipine, FeSO4, formoterol/budesonide inhaler, atorvastatin 20 mg daily. eGFR 30 ml/min. H+H 9/27. what are 2 DOC considerations? what are they right on the line of?
DOC1: SQ erythropoetin 3x week to bring up H+H
DOC2: increase atorvastatin to 40 mg
keep in mind eGFR is 30ml/min so right on the line of needing ACE reductions
a major side effect of statins is______ so you need to check a ________ value
a major side effect of statins is MYOPATHY so you need to check a CREATINE KINASE (CK) value
case #8 70 year old with hearing loss, HTN, and HF. She went to rage and ate a ton of salty food and presents to your office with 2+ pitting edema bilaterally. She has gained 10 pounds. Muffled heart sounds. GFR 20 ml/min down from 45 ml/min. Linsinopril 20 mg. Atorvastatin 20 mg. ASA 81 mg. three DOC considerations?
progression of HF and CKD to stage 4
DOC1: torsemide because it takes high doses to cause hearing loss
DOC2: lower lisinopril dose to 2.5-5mg since below
which loop diuretic has the longest half life and the highest availability?
torsemide…
…yes more so than furosemide
what does furosemide cause in high doses?
OTOTOXICITY IN HIGH DOSES
what is the ratio of dosing between the IV and oral dosing of furosemide? If they are getting 20 mg IV, what is the oral dose?
1:2
if giving 20 mg IV in the hospital then they need 40 mg oral dose to go home with?
what is the ratio of dosing for torsemide IV and oral?
1:1
the IV and oral doses are the same!!