Case Studies

Dr. Schlesselman is an assistant clinical professor at the University of Connecticut School of Pharmacy.

CASE ONE

DM, a 45-year-old man, is apatient at the ambulatorycare clinic. During this visit(his third to the clinic), thepharmacist checks his bloodpressure, obtaining a readingof 155/85 mm Hg. The chartshows that he had similarreadings on previous occasions.

According to the chart, he has no significant medical historyand is not currently taking any medications. The pharmacistrecognizes that, according to the Seventh Report ofthe Joint National Committee on Prevention, Detection,Evaluation, and Treatment of High Blood Pressure (JNC 7)guidelines, DM has stage 1 hypertension. She also knowsthat his goal blood pressure is <140/90 mm Hg. DM admitsto using additional salt on his food and eating canned foodproducts. The pharmacist advises DM on lifestyle modifications,including reducing his sodium intake to <6 g of sodiumper day.

Two months later, DM returns to the clinic for his appointment.His blood pressure reading is 158/91 mm Hg. DMadmits that he did not adhere to the lifestyle modificationsrecommended at his last appointment. Since DM's bloodpressure continues to increase, treatment will be initiated.According to JNC 7 guidelines, what is the recommendedfirst-line treatment for DM?

CASE TWO

TD, a 26-year-old man,presents to the retail-basedclinic with a chief complaintof nasal congestion, sneezing,and nasal itching. Heexplains that his symptomshave lasted for 6 weeks andhe "just can't take this anylonger." He says that hissymptoms, occurring nearly every day of the week, are sobothersome that he is unable to function at work or to sleepat night. At first, he thought he had developed a cold, butnow that the symptoms have persisted for more than 1month, he felt he should seek help.

The clinician suspects that TD has allergic rhinitis. Giventhat TD's symptoms have lasted for more than 4 weeks andoccur more than 4 days per week, the clinician has classifiedTD's symptoms as persistent. She has classified hissymptoms as moderate-to-severe since they impair hissleep and daily activities. The clinician cannot recall thetreatment guidelines for initiating therapy for moderate-toseverepersistent allergic rhinitis, so she asks the pharmacistwhat would be an appropriate agent to choose for TD.What should the pharmacist recommend?

ANSWERS

CASE ONE:

With a patient without any compelling indications, such as DM, the recommended first-line therapy is a thiazide diuretic.

CASE TWO:

For moderate-to-severe persistent allergic rhinitis, the Allergic Rhinitis and its Impact on Asthma guidelines recommend initiation ofintranasal steroids. If symptoms are not improved after 2 to 4 weeks, the dose of intranasal steroid can be increased, antihistamines can be added torelieve itching or sneezing, ipratropium can be added to control rhinorrhea, or decongestants can be used to reduce nasal blockage.

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