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Volume 1, Number 1

ISSN 2046-6668

Remington PharmEd www.pharmpress.com/casestudies

Cases

In This Issue:  Secondary Prevention of Ischemic Stroke After Acute Care  Treatment of an Acetaminophen Overdose  Cardiac Testing: Coronary Angiography  Treatment of an Uncomplicated Urinary Tract Infection


Essential Student Textbooks from Pharmaceutical Press Basic Pharmacokinetics

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Application and Review of Pediatric Pharmacotherapy is designed as a self-assessment tool, comprising over 1,000 multiple choice questions, to enhance the reader’s knowledge of pediatric pharmacotherapy by allowing application of textbook information to case-based scenarios.

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Author: Mark L Glover, Associate Professor and Director, College of Pharmacy, Nova Southeastern University, FL

Essentials of Nonprescription Medications and Devices

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Editor: Blaine Templar Smith, Chair, Department of Pharmaceutical Sciences, Saint Joseph College, CT

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Author: Elaine D Mackowiak, Professor, Department of Pharmacy Practice, Temple University School of Pharmacy, Philadelphia, PA

Physicochemical Principles of Pharmacy, 4th Edition This text provides the physicochemical background to the design and use of pharmaceutical dosage forms. It is essential reading for students in pharmacy and the life sciences. ISBN: 978 0 85369 608 7 | Paperback | $65.00 9.69” x 7.44” | 512pp | 2006 (5th Edition Due August 2011)

Authors: Alexander T Florence, Former Dean, School of Pharmacy, University of London, UK and David Attwood, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, UK

www.pharmpress.com/textbooks Inspection copies are available to instructors. How to order: Mail: Pharmaceutical Press, 1573 St. Paul Avenue, Gurnee, Illinois 60031 Tel: +1 877 471 4747 (Toll Free – USA and Canada) Fax: +1 847 244 6689 Email: orders_americas@pharmpress.com Online: www.pharmpress.com

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Author: Jordan Braverman, Consultant in Health Economics, US

Author: Rajender Aparasu, Division of Pharmacy, Administration and Public Health, Department of Clinical Sciences and Administration, College of Pharmacy, University of Houston, TX

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Editors: Michael J McGraw, Senior Manager, Regulatory Affairs, Teva Neuroscience, Inc, US; Adam N George, Medical Information Manager, Cephalon Inc, US; Shawn P Shearn, Rigel L Hall and Thomas F Haws, Jr, GlaxoSmithKline, US

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Financial Analysis in Pharmacy Practice (pub date: June 2011) Author: Keith N Herist, Treasurer. The University of Georgia, GA

Health Policy and Ethics (pub date: June 2011) Editor: Jack Fincham, Professor of Pharmacy Practice & Administration, School of Pharmacy, University of Missouri-Kansas City, MO w w w . p h a r m p r es s .com/casestudies


Remington PharmEd Cases Remington PharmEd Editorial Board

From the Editor

Zubin Austin, BScPhm, MBA, MIS, PhD Associate Professor Associate Dean for Pharmacy Practice Leslie Dan Faculty of Pharmacy University of Toronto

Welcome to the inaugural issue of Remington PharmEd Cases, a periodical publication designed to provide pharmacy instructors with highquality, peer-reviewed case studies. For more than 100 years, Remington has been the definitive reference on the science and practice of pharmacy, widely used in education, healthcare, and corporate settings. In partnership with Remington, Pharmaceutical Press is developing a comprehensive online educational resource for pharmacy instructors and students—Remington PharmEd. Among many other elements, an extensive collection of peer-reviewed case studies will be featured on this website, which is scheduled to launch in Spring 2012. As a preview of the rich content to be included in Remington PharmEd, and for your use as a teaching tool, each issue of Remington PharmEd Cases will be distributed to all North American Schools of Pharmacy. It will include a varied selection of peer-reviewed case studies submitted by instructors like you. The level, as well as associated organ system, disease state, and curriculum topic, are clearly noted at the beginning of each case so that you can quickly identify those most suitable for your students. The case studies are highly templated to include Key Learning Objectives, Case Presentation, Assessment Question and Answers, and Further Reading. Please visit www.pharmpress.com/casestudies to register for electronic versions of the cases and to receive updates about Remington: The Science and Practice of Pharmacy. In addition to case studies, future editions of Remington PharmEd Cases will feature articles related to the creation and instruction of case studies, as well as other active-learning strategies. We invite you to submit case studies for publication in future editions of Remington PharmEd Cases and the Remington PharmEd website. For complete guidelines and to submit your cases, please visit www.pharmpress.com/casestudies. I very much hope that you find Remington PharmEd Cases to be a valuable teaching resource. Please do not hesitate to contact me with feedback or suggestions.

Eric Boyce, PharmD Professor of Pharmacy Practice Associate Dean for Academic Affairs Thomas J. Long School of Pharmacy and Health Sciences University of the Pacific

Stuart T. Haines, PharmD, FCCP, FASHP, FAPhA Professor Vice Chair for Clinical Services Pharmacotherapy Specialist University of Maryland School of Pharmacy Ian S. Haworth, PhD Associate Professor Pharmacology and Pharmaceutical Sciences University of Southern California School of Pharmacy

Paul W. Jungnickel, PhD, RPh Professor Associate Dean for Academic and Student Affairs Auburn University Harrison School of Pharmacy

Patrick McDonnell, PharmD Associate Professor of Pharmacy Practice Temple University School of Pharmacy

Victoria F. Roche, PhD Professor Senior Associate Dean for Pharmaceutical Sciences Creighton University School of Pharmacy and Health Professions

Susan M. Stein, DHEd, MS, BS Pharm, RPh Associate Professor Dean Pacific University School of Pharmacy S. William Zito, PhD Professor Pharmaceutical Sciences Associate Dean for Assessment St. John’s University College of Pharmacy and Allied Health Professions

March 2011

Volume 1, Number 1 ISSN 2046-6668

Contents 2. Secondary

Preventon of Ischemic Stroke After Acute Care Level 2 Lindsay B. Curtin, PharmD, BCPS Assistant Professor of Clinical Pharmacy Critical Care Pharmacotherapy Specialist University of the Sciences in Philadelphia Philadelphia College of Pharmacy

4. Treatment of an Acetaminophen Overdose Level 3 Mate M. Soric, PharmD Assistant Professor of Pharmacy Practice Northeastern Ohio Universities College of Pharmacy

6. Cardiac Testing: Coronary Angiography Level 2

Robyn Teply, PharmD, MBA Assistant Professor of Pharmacy Practice Creighton University School of Pharmacy and Health Professions

Kathleen Packard, PharmD, MS Assistant Professor of Pharmacy Practice Creighton University School of Pharmacy and Health Professions

8. Treatment of an Uncomplicated Urinary Tract Infection Level 1 Helen C. Pervanas, PharmD, RPh

Adrianne Brigido Executive Editor, Pharmaceutical Press adrianne.brigido@pharmpress.com

Assistant Professor of Pharmacy Practice Massachusetts College of Pharmacy and Health Sciences

Case Levels Level 1

Level 2

Level 3

Years 1 and 2 of PharmD Curriculum

Year 3 of PharmD Curriculum

Year 4 of PharmD Curriculum and Postgraduates

 Intermediate cases  Multiple choice questions, short- or long-answer questions  Mixture of single correct answers and ambiguous cases  Prior knowledge or clinical experience may be useful

 Complex cases  Short- or long-answer questions, potentially including the requirement to prepare a pharmaceutical care plan  Not necessarily an absolute answer; students may need to explain the rationale behind their final decision  Need to draw on a wide knowledge base and show understanding of the ethical, social, and/or legal issues involved in a particular course of action

 Simple cases  Multiple choice questions or short-answer questions  Single correct answer  Little prior knowledge required

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Level 2 Organ System: Circulatory / Nervous Disease State: Cardiovascular / Neurological Curriculum Topic: Pharmacy Practice / Pharmacist-Provided Care / Pharmacotherapy

Secondary Prevention of Ischemic Stroke After Acute Care Lindsay B. Curtin, PharmD, BCPS Assistant Professor of Clinical Pharmacy, Critical Care Pharmacotherapy Specialist, University of the Sciences in Philadelphia, Philadelphia College of Pharmacy

Key Learning Objectives 1. List the target blood pressure, hemoglobin A1c, total cholesterol, high-density lipoprotein (HDL), body mass index (BMI), waist circumference, and amount of physical activity recommended by the American Heart Association and American Stroke Association in the prevention of first and recurrent ischemic stroke.

 Married with two children  Tobacco use  Denies intravenous drug use  Alcohol use: occasional glass of red wine with dinner  Frequently eats processed foods and fast food; few fresh fruits and vegetables  Walks on the treadmill for 20 minutes 2 days per week

2. Choose appropriate class of antihypertensive medications for the secondary prevention of stroke.

Allergies

3. Differentiate between cardioembolic stroke and non-cardioembolic stroke and recommend the appropriate anticoagulant or antiplatelet medications for secondary prevention of ischemic stroke.

Medications

Case Presentation History of Present Illness MP is a 63-year-old male discharged from the hospital 4 days ago for an acute ischemic stroke. While in the hospital, a series of computed tomography (CT) scans confirmed that he suffered an ischemic stroke without hemorrhagic conversion. He received intravenous recombinant tissue plasminogen activator (rtPA) in the emergency department 2.5 hours after onset of slurred speech and unilateral weakness (National Institutes of Health Stroke Scale (NIHSS) score = 18). Before discharge he received one dose of warfarin, was prescribed warfarin, and ordered to follow up with the outpatient clinic for international normalized ratio (INR) checks.

Past Medical History

 Atorvastatin 10 mg PO daily  Hydrochlorothiazide 12.5 mg PO daily  Metoprolol tartrate 12.5 mg PO BID  Warfarin 2.5 mg PO daily x 3 days (last dose: evening before at 6 pm)

Non-prescription Medications  None

Vaccine History  Childhood vaccines up-to-date  Tdap (3 years ago)  Influenza (4 years ago)

V i tals: A dmission Temp. (°C)

HR

BP

RR

(beats/min)

(mmHg)

(breaths/min)

70

162/90

18

Physical Examination

Family History  Father  (ischemic stroke)  Mother  history of hypertension and hypothyroidism

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 No known drug allergies

37.2°

 Hypertension  Dyslipidemia

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Social History

march 2011

 General: well-developed male in no acute distress; requires walking assistance; no speech deficits  Vital Signs: (see box above) height 6'2", weight 100 kg  Head, Eyes, Ears, Nose, Throat (HEENT): pupils equal, round, reaction to light and accommodation; extraocular muscles intact  Lungs: clear to auscultation and percussion (CTAP)  Cardiovascular: RRR, S1, S2, - S3, S4, - m/r/g  Abdomen: soft; non-tender, non-distended (NT/ND)  Genitourinary: deferred  Rectal: deferred w w w . p h a r m p r es s .com/casestudies


 Neurological: awake, alert, oriented (AAO) x 3; reflexes 2+ on left, 1+ on right  Extremities: (-) clubbing, cyanosis, edema (CCE); 5/5 strength in left upper extremity and lower extremity; 3/5 strength in right upper extremity and lower extremity

La b s : Ob ta ined at exam inat ion Na 145 mEqL

WBC 4000 cells/mm3

K 3.7 mEq/L

HgB 14.5 g/dL

C 104 mEq/L

Hct 44%

CO2 22 mEq/L

Plts 260,000 cells/mm3

BUN 15 mg/dL

Lipid panel (from hospitalization)

Scr 0.9 mg/dL

 TC 234 mg/dL

Glu 98 mg/dL

 HDL 31 mg/dL

INR 1.8

 TG 202

Further Reading 1. Adams HP, et al. (2007). Guidelines for the early management of adults with ischemic stroke. Stroke 38: 1655–1711. 2. Sacco RL, et al. (2006). Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack. Circulation 113: e409–449. 3. Brott T, et al. (1995). National Institute for Neurological Disorders and Stroke rT-PA Study Group (NINDS Trial). N Engl J Med 333: 1581–1587. 4. Zoppo GJ. (2009). Expansion of the time window for treatment of acute ischemic stroke: a science advisory. Stroke 40: 2945– 2948.

Please visit www.pharmpress.com/casestudies to register for electronic versions of the cases and to receive updates about Remington: The Science and Practice of Pharmacy.

Assessment Questions 1. Was rtPA an appropriate choice for MP given his timing of symptom onset and National Institutes of Health Stroke Scale Score? 2. What is the appropriate pharmacologic therapy for MP for the secondary prevention of ischemic stroke and why? 3. Which of the following is the most appropriate treatment plan for MP’s hypertension? a. Discontinue hydrochlorothiazide, increase metoprolol to 25 mg PO BID, and add lisinopril 5 mg PO daily b. Discontinue metoprolol, increase hydrochlorothiazide to 25 mg PO BID, and add lisinopril 10 mg PO daily c. Increase hydrochlorothiazide to 25 mg PO BID and change metoprolol to carvedilol 6.25 mg PO BID d. Increase metoprolol to 25 mg PO BID and add lisinopril 5 mg PO daily e. No change in therapy because the patient is still recovering from an ischemic stroke 4. What are the appropriate non-pharmacologic interventions for MP? (answers on page 10)

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Level 3 Organ System: Digestive System Disease State: Gastrointestinal / Mental Curriculum Topic: Pharmacy Practice / Pharmacist-Provided Care / Pharmacotherapy

Treatment of an Acetaminophen Overdose Mate M. Soric, PharmD Assistant Professor of Pharmacy Practice, Northeastern Ohio Universities College of Pharmacy

Key Learning Objectives 1. Describe the pathophysiology of acetaminophen overdose, including normal acetaminophen metabolism, toxic metabolite production, and the mechanism of cellular damage. 2. Identify patient risk factors for the development of liver injury or failure following an acute acetaminophen overdose. 3. Explain the most common signs and symptoms of acetaminophen overdose. 4. Use patient information to design a pharmaceutical care plan for the treatment of acetaminophen overdose, including rationale for treatment choices, administration instructions, and appropriate monitoring parameters.

Case Presentation History of Present Illness RG is a 27-year-old female (5'4" and 73 kg) presenting to the Emergency Department via EMS squad at 22:30. Earlier that evening, RG and her mother had a heated argument. Shortly thereafter at 20:45, her mother called 911 after discovering RG in her bedroom with two open 100-count bottles of extra-strength acetaminophen (500 mg) on the nightstand. The EMS squad counted 63 tablets remaining in the first bottle and found the second bottle empty. No other medication vials were present in the bedroom. RG explained that she had taken only four acetaminophen tablets for a severe headache after the argument with her mother. Currently, RG is complaining of nausea.

Social History  Smoker: 1.5 pack per day x 11 years  Denies drinking alcohol  Denies illicit drug use

Family History  Mother and sister are poly-substance abusers

V i tals: A dmission Temp.

HR

BP

RR

(°C)

(beats/min)

(mmHg)

(breaths/min)

36°

101

144/89

15

Physical Examination  General: patient in some distress; looks older than stated age  Skin: moist mucus membranes  Abdomen: bowel sounds present  Neurological: alert & oriented (A&O) x 3

Allergies/Adverse Drug Reactions  Hydromorphone (nausea)  Lisinopril (nausea)  Nitroglycerin (muscle twitching)

L abs : Obtained at 22: 35

Allergies

Na 139 mmol/L

Glu 4.3 µmol/L

INR 1.0

 None

K 4.3 mmol/L

Ethanol neg

AST 41 U/L

Past Medical History

Cl 102 mmol/L

Pregnancy neg

ALT 36 U/L

 Major Depressive Disorder x 9 years  History of suicidal gestures  Irritable Bowel Syndrome (IBS), constipation predominant x 1 year

CO2 25 mmol/L

APAP 132 µmol/L

Alk Phos 77 U/L

BUN 7.85 mmol/L

THC pos

T Bili 13.7 µmol/L

SCr 53 µmol/L

Albumin 38g/L

Medications  Sertraline 200 mg daily x 3 months  Lubiprostone 8 µg twice daily x 6 months

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Assessment Questions 1. Describe the metabolism of acetaminophen, both at therapeutic and toxic doses, and the effects of its metabolites on hepatocytes. 2. What are the most common signs and symptoms of acetaminophen overdose? 3. List three risk factors for the development of liver injury or failure following a toxic ingestion of acetaminophen. 4. Approximately what single dose of acetaminophen is likely to cause toxicity in patients with no additional risk factors? 5. Design a pharmaceutical care plan for the treatment of RG’s acute condition. (answers on page 10)

Further Reading 1. Dart RC, et al. (1997). Acetaminophen (paracetamol). In Dart RC, ed. Medical Toxicology. Philadelphia: Lippincott Williams and Wilkins, 723–738. 2. Dart RC, et al. (1997). N-Acetylcysteine. In Dart RC, ed. Medical Toxicology. Philadelphia: Lippincott Williams and Wilkins, 223–227. 3. Dart RC, et al. (2006). Acetaminophen poisoning: an evidencebased consensus guideline for out-of-hospital management. Clin Toxicol 44: 1–18. 4. Rowden AK, et al. (2005). Updates on acetaminophen toxicity. Med Clin N Am 89: 1145–1159. 5. Wolf SJ, et al. (2007). Clinical policy: critical issues in the management of patients presenting to the emergency department with acetaminophen overdose. Ann Emerg Med 50: 292–313.

Please visit www.pharmpress.com/casestudies to register for electronic versions of the cases and to receive updates about Remington: The Science and Practice of Pharmacy.

Call for Case Study Submissions Introducing Remington Case Studies For more than 100 years, Remington has been the definitive textbook and reference on the science and practice of pharmacy. In partnership with Remington, Pharmaceutical Press is developing a new online educational resource for pharmacy instructors and students. A core element of this resource will be peer-reviewed case studies, providing an immensely valuable teaching tool to you and your colleagues. We’re inviting pharmacy faculty members and practitioners to submit case studies for peer-review. Take advantage of the opportunity to have your work affiliated with Remington, the most trusted name in pharmacy science and education. Selected case studies will be included in this publication, Remington PharmEd Cases, and will be available for free to faculty members at all North American Schools of Pharmacy. For more information on the submission process, please visit www.pharmpress.com/casestudies.

Pharmaceutical Press Case Studies Award Program

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Level 2 Organ System: Circulatory Disease State: Cardiovascular Curriculum Topic: Pharmacy Practice / Pharmacist-Provided Care / Pharmacotherapy / Medication Safety

Cardiac Testing: Coronary Angiography Robyn Teply, PharmD Assistant Professor of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions

Kathleen Packard, PharmD Assistant Professor of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions

Key Learning Objectives 1. Assess the appropriateness of the patient for the chosen cardiac test, coronary angiography.

Review of Systems (prior to exercise stress test)  Within normal limits, with the exception of the cardiovascular issues stated previously

2. Identify drug-therapy changes that may be required for a coronary angiography; explain why they are necessary.

V i tals: A dmission

3. Provide examples of precautionary measures that should be taken in the case of a contrast-dye allergy or contrastinduced nephropathy.

Temp. (°C)

(beats/min)

(mmHg)

36°

59

123/82

Case Presentation History of Present Illness GS is a 58-year-old white male who weighs 96.6 kg and is 5'1" tall. He recently underwent an exercise stress test that resulted in ST-segment changes. He complained of increasing chest pain during the procedure.

Past Medical History  Hyperlipidemia  Hypertension  Recurrent deep vein thrombosis (most recently, 2 months ago)  Type 2 diabetes mellitus

Past Surgical History  Appendectomy 10 years ago

Social History  Smokes one pack per day  Occasional alcohol use  Denies illicit drug use  Works as a truck driver  Lives with his wife

HR

Physical Examination L abs : obtained prior to Stress Test Measurement

Laboratory Value

Reference Range

Na

140 mEq/dL

135–147

K

3.9 mEq/dL

3.5–5.0

Cl

100 mEq/dL

95–105

CO2

26 mEq/dL

22–28

BUN

18 mg/dL

8–18

SCr

1.2 mg/dL

0.6–1.2

Glucose

105 mg/dL

70–110

Hgb

14.0 g/dL

13.7–16.9

Hct

41.3%

40–49

200 x 103/microL

140–420

PTT

26 seconds

25.9–34.9

INR

2.3

0.8–1.2

Platelets

Allergies

BP

 Contrast dye (hives)

Medications

 Within normal limits

 Atorvastatin 80 mg daily  Lisinopril 20 mg daily  Metformin 500 mg twice a day  Metoprolol succinate ER 50 mg daily  Omeprazole 20 mg daily  Warfarin 5 mg daily

Initial Assessment and Plan

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 Patient to undergo coronary angiography to investigate potential cause for chest pain and resulting positive stress test.  Patient scheduled for angiogram in one week.

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Assessment Questions 1. Is GS an appropriate candidate for a coronary angiography? Explain why or why not. 2. What changes, if any, would you make to GS’s current drug regimen prior to this test? Provide complete explanation of the changes and why they need to be made. 3. Which of the following are risk factors for contrast-induced nephropathy? a. Diabetes mellitus b. Hyperlipidemia c. Diabetes mellitus and metformin d. Metformin and hyperlipidemia e. Diabetes mellitus, metformin, and hyperlipidemia 4. What, if any, precautions need to be taken prior to the coronary angiography? (answers on page 12)

Further Reading 1. Chilton R, et al. (2008). Cardiovascular Testing. In: DiPiro J, et al., eds. Pharmacotherapy: A Pathophysiologic Approach, 7th edn. New York: McGraw-Hill. 2. Hirsh J, et al. (2008). Executive Summary: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edn). Chest 133(Suppl. 6): 71S–109S. 3. Scanlon PJ, et al. (1999). ACC/AHA Guidelines for Coronary Angiography. A report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Committee on Coronary Angiography). Developed in collaboration with the Society for Cardiac Angiography and Interventions. J Am Coll Cardiol 33(6): 1756–1824.

Please visit www.pharmpress.com/casestudies to register for electronic versions of the cases and to receive updates about Remington: The Science and Practice of Pharmacy.

Call for Case Study Submissions Introducing Remington Case Studies For more than 100 years, Remington has been the definitive textbook and reference on the science and practice of pharmacy. In partnership with Remington, Pharmaceutical Press is developing a new online educational resource for pharmacy instructors and students. A core element of this resource will be peer-reviewed case studies, providing an immensely valuable teaching tool to you and your colleagues. We’re inviting pharmacy faculty members and practitioners to submit case studies for peer-review. Take advantage of the opportunity to have your work affiliated with Remington, the most trusted name in pharmacy science and education. Selected case studies will be included in this publication, Remington PharmEd Cases, and will be available for free to faculty members at all North American Schools of Pharmacy. For more information on the submission process, please visit www.pharmpress.com/casestudies.

Pharmaceutical Press Case Studies Award Program

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Level 1 Organ System: Urinary Disease State: Bacterial / Gynecological / Sexual Curriculum Topic: Pharmacy Practice / Pharmacist-Provided Care / Pharmacotherapy

Treatment of an Uncomplicated Urinary Tract Infection Helen C. Pervanas, PharmD, RPh Assistant Professor of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences

Key Learning Objectives

V i tals: A dmission

1. Explain the pathophysiology and risk factors associated with an uncomplicated urinary tract infection (UTI).

Temp. (°C)

(beats/min)

(mmHg)

(breaths/min)

2. Identify the signs and symptoms associated with an uncomplicated UTI.

37°

72

118/72

17

3. Discuss treatment options for an uncomplicated UTI.

Case Presentation Chief Complaint “I have a hard time going to the bathroom.”

HR

BP

RR

Physical Examination  General: pleasant young woman in no acute distress  Vital Signs: (see box above) height 5'2", weight 58 kg  Head, Eyes, Ears, Nose, Throat (HEENT): pupils equal, round, reactive to light and accommodation (PERRLA)  Abdomen: soft, non-tender, bowel sounds normal  Genitourinary: no lesions or discharge, cervix appears normal

History of Present Illness NA is a 31-year-old white female who presents to an ambulatory clinic with the complaint of burning upon urination, dysuria, and urinary frequency, which she has been experiencing for the past 2 days. She denies nausea, fever, vaginal discharge, or vaginal bleeding.

Past Medical History

L abs : U rinalysis Urine Color: straw Appearance: turbid Urine Ketones: negative

 UTI 2 years ago that was effectively treated with trimethoprimsulfamethoxazole (TMP-SMX).

Urine Specific Gravity: 1.016 Urine Occult Blood: negative

Family History

Urine PH: 7.5

 Non-contributory

Urine Protein: trace

Social History  Married with two children  Drinks occasionally on the weekends

Urine Urobilinogen: 1.0 EU/dL Urine Nitrite: positive

Allergies

Leukocyte Esterase: negative

 No known allergies

Urine WBC/HPF: 0.1

Medications

Urine RBC/HPF: negative

 Drospirenone and ethinyl estradiol: one tablet PO daily

Urine Bacteria: 4+

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Assessment Questions 1. Which of the following is a risk factor in women for developing an uncomplicated UTI? a. Kidney disease b. Use of spermicidal agents

Call for Case Study Submissions Introducing Remington Case Studies

c. Alcohol use d. Frequent bathing 2. List the subjective signs and symptoms of NA’s UTI. 3. List the objective findings of NA’s UTI. 4. What is the most common pathogen associated with uncomplicated UTIs? a. Proteus mirabilis b. Escherichia coli c. Staphylococcus aureus d. Klebsiella pneumonia 5. True/False: Patients with a diagnosis of an uncomplicated UTI can be started immediately on an antibiotic medication before performing a urine culture. 6. What is a first-line medication treatment option for an uncomplicated UTI? 7. NA is given a prescription for trimethoprimsulfamethoxazole (TMP-SMX) 160 mg/800 mg, one tablet twice daily for 3 days. Which of the following is an important patient counseling point with regard to this prescribed medication? a. Take this medication with plenty of water b. This medication can cause photosensitivity; sunscreen recommended

For more than 100 years, Remington has been the definitive textbook and reference on the science and practice of pharmacy. In partnership with Remington, Pharmaceutical Press is developing a new online educational resource for pharmacy instructors and students. A core element of this resource will be peer-reviewed case studies, providing an immensely valuable teaching tool to you and your colleagues. We’re inviting pharmacy faculty members and practitioners to submit case studies for peer-review. Take advantage of the opportunity to have your work affiliated with Remington, the most trusted name in pharmacy science and education.

c. Finish all of the medication d. All of the above 8. What would be an appropriate alternative treatment option in a patient with a sulfa allergy? a. Ciprofloxacin 250 mg PO Q12h x 3 days b. Tetracycline 500 mg PO Q12h x 10 days c. Nitrofurantoin 100 mg PO Q12h x 3 days d. Ciprofloxacin 250 mg PO Q12h x 7 days (answers on page 12)

Please visit www.pharmpress.com/casestudies to register for electronic versions of the cases and to receive updates about Remington: The Science and Practice of Pharmacy.

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Selected case studies will be included in this publication, Remington PharmEd Cases, and will be available for free to faculty members at all North American Schools of Pharmacy. For more information on the submission process, please visit www.pharmpress.com/casestudies.

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Recommended Answers

Secondary Prevention of Ischemic Stroke After Acute Care (pp. 2–3) 1. Yes. According to the American Heart Association/American Stroke Association guidelines (Stroke 2007;38:1655–1711), this is a grade IA recommendation if administered within 3 hours of symptom onset in patients with moderate-to-severe stroke symptoms that are not independently resolving. The ischemic stroke without hemorrhage was confirmed on computed tomography (CT) scan, which we assume was appropriately performed prior to initiation of therapy. When administered, rtPA should be given as 0.9 mg/kg total dose (max of 90 mg). Ten percent of the total dose is initially administered as a bolus over 1 minute, and then the remaining 90% of the total dose is administered in an intravenous infusion over 60 minutes. 2. Antiplatelet therapy (aspirin 81–325 mg PO daily, extended-release dipyridamole [ERDP] + acetylsalicylic acid [ASA] 200/25 mg PO BID, or clopidogrel 75 mg PO daily). MP does not have atrial fibrillation, history of acute myocardial infarction with left ventricular (LV) thrombus, valvular heart disease, or LV dysfunction that would indicate ischemic stroke of cardiogenic origin, and thus an indication for warfarin. The patient’s stroke was of non-cardiogenic origin. For this indication, antiplatelet medications are recommended over anticoagulants (warfarin) (IA). Some studies show that ERDP + ASA or clopidogrel are preferred to ASA alone. Some studies show that ERDP + ASA causes more bleeding than clopidogrel. See further reading.

Recommended Answers

Objective

Treatment of an Acetaminophen Overdose (pp. 4–5) 1. The vast majority of acetaminophen is metabolized via sulfation and glucuronidation, resulting in nontoxic metabolites that can be excreted in the urine. About 5% of acetaminophen metabolism depends on CYP2E1, resulting in the formation of the toxic metabolite N-acetyl-p-benzoquinone imine (NAPQI). At normal doses, NAPQI can be detoxified by glutathione molecules, allowing for minimal hepatocyte damage. At toxic levels, however, glutathione levels can become depleted, resulting in NAPQI-induced hepatocyte damage or death caused by oxidative stress and mitochondrial destruction. 2. In general, many patients are asymptomatic, especially in the early phase of ingestion. Some may develop gastrointestinal complaints, such as nausea, vomiting, or right upper quadrant pain. Signs of liver damage, such as elevated transaminases, increased INR, jaundice, and encephalopathy, are usually delayed. In the most severe cases—fulminant hepatic failure—renal injury or death may occur. 3. Chronic acetaminophen ingestion, ethanol abuse, and history of liver damage are the most common risk factors; however, use of enzymeinducing medications and genetic glutathione deficiencies may also be risks. 4. A single dose of 15 g is likely to cause acetaminophen-induced liver toxicity. 5. See below.

3. b. Diuretics alone or diuretics with angiotensinconverting enzyme (ACE) inhibitors are first-line therapies for the treatment of hypertension in patients who have had an ischemic stroke. MP is 4 days from discharge with an elevated blood pressure (BP); therefore, he requires a change in therapy to reach BP goals. The dose of hydrochlorothiazide should be optimized, and an ACE inhibitor added to the regimen. Metoprolol may be discontinued while adding the ACE inhibitor to ensure that MP does not become hypotensive. 4. Encourage compliance with the DASH (Dietary Approaches to Stop Hyertension) diet, namely reduction in daily sodium intake (less than 2.4 g daily) and a diet rich in fruits and vegetables. Encourage gradual increase in physical activity, such as brisk walking, for a goal of 30 minutes of moderate intensity on most days. MP’s regimen should be supervised due to the need for walking assistance. Goal body mass index should be 18.5 to 24.9 mg/m2 and a waist circumference of less than 40 inches. Minimize consumption of alcohol (<2 drinks a day for men and <1 per day for women).

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Assessment • Possible acetaminophen overdose • Possible suicide attempt vs. gesture Plans/Goals/Rationale Goal Minimize liver toxicity and avoid liver failure Plan • N-acetylcisteine PO: 10.2 g NAC diluted to 5% in cola or juice x 1 followed by 5.1 g NAC Q4h started 4 hours after initial dose x 17 additional doses. Serve in a covered container. • IV: 11 g NAC IV in 200 mL D5W over 1 hr, then 3.6 g NAC in 500 mL D5W over 4 hours, followed by 7.3 g NAC in 1 L D5W over 16 hours • Activated Charcoal: 25 to 100 g as a single dose, may give additional 25 g every 2 hours if needed (dependent upon time given after ingestion) • Psychiatry Consult: For possible suicide attempt Rationale • Though the APAP levels are low, the level was not drawn at the appropriate time point (4 hrs postingestion). • Because the possible benefits outweigh the potential risks, preventative NAC and activated charcoal should be initiated preventively. • Treatment may be discontinued if further APAP levels are negative.

Pharmaceutical Care Plan for RG Patient Profile

Medical History

Age

27 years

Allergies

None

Height

5'4"

Adverse Reactions

None

Weight

83 kg

Diagnoses

Severe depression, IBS, history of suicidal gestures

Sex

• Arrived at ED at 22:30 (approx 1.75 hours postingestion) • EMS counted 63 of 200 tablets remaining in two bottles of APAP 500 mg (possible ingestion of 68.5 g of APAP) • No other medication vials found in bedroom Relevant Labs: APAP 132 µmol/L (approx. 2 hrs post-ingestion) EtOH neg ALT 36 U/L AST 41 U/L THC pos INR 1.0 Alk Phos 77 U/L Pregnancy neg T Bili 13.7 µmol/L

Female

Other Information

Family history of poly-substance abuse

Medication History Medication

Strength

Regimen

Duration

Sertraline

200 mg

Daily

3 months

Lubiprostone

8 µg

Twice daily

6 months

Subjective and Objective Information Subjective • Chief complaint: nausea • Heated argument with mother at 20:45 • EMS found two open acetaminophen extra-strength (500 mg) bottles • Claims to have taken only four tablets for her headache • No known allergies • Does not drink alcohol

Evaluation Efficacy • Obtain a serum APAP level in approx. 2.25 hours and evaluate using the Rumack-Matthew Nomogram • Monitor liver function tests, INR, total bilirubin, serum creatinine, and electrolytes every 4 to 12 hours • Observe patient for jaundice, bleeding, right upper quadrant pain, nausea, and vomiting throughout hospitalization Safety • PO NAC: nausea and vomiting; if vomiting occurs less than 1 hour after an oral dose, repeat the dose • IV NAC:anaphylactoid reactions, such as wheezing, flushing, itching, and rash • Activated Charcoal: nausea, vomiting, constipation

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Recommended Answers

4. GS has a contrast-dye allergy; thus, he needs premedication with a regimen such as*:

Cardiac Testing: Coronary Angiography (pp. 6–7)

1. Yes • GS has indicators of ischemia (chest pain and positive stress test with ST-segment changes) and needs to be evaluated for potential intervention. • GS has risk factors for coronary artery disease (hypertension, hyperlipidemia, diabetes mellitus, and smoking). • There are no contraindications for the procedure (recent stroke, advanced physiologic age, severe anemia, severe hypertension, active gastrointestinal bleed, fever, patient non-compliance, anaphylaxis to radiographic dyes, active infection, severe electrolyte imbalance, or unstable condition). 2. Changes include: a. Discontinue warfarin 5 days prior to the procedure. i. Transition GS to low-molecular-weight heparin (LMWH) or unfractionated heparin leading up to the procedure due to the high risk of thromboembolic events (risk factor: recurrent venous thromboembolism within 3 months).

• Diphenhydramine 25 mg intravenous pyelography (H1 antagonist) • Famotidine 20 mg at bedtime prior and morning of procedure (H2 antagonist) • Prednisone 50 mg orally 12 hours prior and morning of procedure *The regimen given for the allergic reaction is an example. Other H1 antagonists, H2 antagonists, and corticosteroids may be used.

Recommended Answers

Treatment of an Uncomplicated Urinary Tract Infection (pp. 8–9) 1. b. 2. Dysuria, burning pain upon urination, and urinary frequency 3. Urine is straw colored and turbid in appearance; trace of protein in urine; positive for nitrites; bacteria in urine 4+.

ii. Because GS is an outpatient prior to procedure, use LMWH enoxaparin therapeutic dose of 1 mg/kg subcutaneously twice daily or 1.5 mg/kg subcutaneously daily, and start enoxaparin 4 days prior to procedure, with the last dose given 24 hours prior to the procedure.

6. Trimethoprim-Sulfamethoxazole (TMP-SMX)

iii. Restart warfarin 12 to 24 hours after the procedure.

7. d.

iv. Restart enoxaparin 24 hours after the procedure.

8. a.

v. Continue enoxaparin until GS’s international normalized ratio (INR) is therapeutic (INR = 2–3) for two consecutive measurements at least 24 hours apart. b. Discontinue metformin 1 day prior to the procedure. i. Intravascular administration of iodinated contrast dye may cause acute renal failure in a small percentage of individuals, particularly in those patients with pre-existing, or a predisposition to, contrast-induced nephropathy. ii. Metformin, which is excreted by the kidneys (90%), may build up to dangerous levels due to contrast-induced nephropathy, causing the potentially fatal condition of lactic acidosis. iii. Restart metformin 48 hours postprocedure. 3. c

4. b. 5. True

Discussion Urinary tract infections (UTI) are a common medical condition resulting in 3.6 million ambulatory care visits per year.1 UTIs can occur in both men and women but are most common in women. One in three women will experience a UTI by the age of 24.2 A UTI, also referred to as Acute Bacterial Cystitis, involves the lower urinary tract affecting the bladder and urethra. Predisposing factors that introduce bacteria into the lower urinary tract in women include sexual intercourse, the use of a diaphragm with spermicidal agents, and the anatomical proximity of the female urethra to the perirectal area.3,4 Signs and symptoms of an uncomplicated UTI in women include dysuria, urinary urgency and urinary frequency, hematuria, and suprapubic pain. The most common bacteria found in uncomplicated UTIs is Escherichia coli (85%) and Staphylococcus Saprophyticus (5%–15%), followed by Klebsiella Pneumoniae and Proteus Mirabilis.5

is indicative of an infection.6 Laboratory findings during microscopic urinalysis may include pyuria, hematuria, bacteria, red blood cell casts, and leukocyte casts. To rule out an infection, a urine culture is advisable in patients with a negative dipstick test.6 Acute uncomplicated UTIs are most commonly treated empirically with antibiotics without urine culture to eradicate the bacterial pathogen. Recommended first-line therapy includes a 3-day course of trimethoprim-sulfamethoxazole (TMP-SMX).7 A 3-day course of TMP-SMX was found to be just as effective in eradicating bacteria from the urine as a 7- to 10-day course.8 Other antibiotic alternatives include a 3-day regimen of fluoroquinolones; 7-day treatment of nitrofurantoin; or a single dose of fosfomycin.7 Fluoroquinolones are not recommended as empiric first-line treatment for uncomplicated UTIs unless there is a documented resistance to TMP-SMX—above 10% to 20%—or the patient is allergic to sulfa medications.7

References 1. Schappert SM (1999). Ambulatory care visits to physician offices, hospital, outpatient departments, emergency department: United Sates, 1997. Vital and Health Statistics. Series 13. No 143. Atlanta: National Center for Health Statistics. (DHHS Publication no. (PHS 2000-1714). 2. Foxman B (2002). Epidemiology of urinary tract infections. Incidence, morbidity, and economic considerations. Am J Med 113 (suppl 1A): 5–13S. 3. Nicole LE, et al. (1982). The association of urinary tract infection with sexual intercourse. J Infect Dis 146: 574–583. 4. Fihn SD, et al. (1996). Association between use of spermicidal-coated condoms and Escherichia coli urinary tract infections in women. Am J Epidemiol 144: 512–520. 5. Ronald A (2002). The etiology of a urinary tract infection: traditional and emerging pathogens. Am J Med 113 Suppl 1A: 14S–19S. 6. Fihn ST (2003). Acute uncomplicated urinary tract infections in women. N Engl J Med 34: 259–266. 7. Warren JW, et al. (1999). Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. Clin Infect Dis 29: 745–758. 8. Hooton TM, et al. (1995). Randomized comparison trial and cost analysis of a 3-day trial antimicrobial regimen for acute cystitis in women. JAMA 273: 41–45.

Diagnosis of an uncomplicated UTI is based on the patient’s signs and symptoms. A urinary dipstick analysis can be used to detect the presence of nitrites or leukocyte esterase; a positive result

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