Case Studies

Dr. Coleman is an assistant professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy.

CASE ONE:

AG is a 59-year-old whiteman with no medical historywho comes in for his yearlyphysical at an ambulatorycare clinic. He has no knowndrug allergies and is takingno medication. He has nofamily history for prematurecoronary artery disease and does not consume tobacco products.During the physical assessment, his blood pressure ismeasured at 130/82 mm Hg. The lipid panel comes back withthe following: total cholesterol, 285 mg/dL; low-density lipoprotein(LDL) cholesterol, 155 mg/dL; high-density lipoprotein(HDL) cholesterol, 37 mg/dL; and triglycerides, 116 mg/dL. Dueto AG's hypercholesterolemia, his physician refers him to apharmacy-managed lipid clinic.Which of the following is the correct LDL cholesterol goalfor AG, and what should the pharmacist recommend to AG totreat his hypercholesterolemia?

CASE TWO:

AI, a 68-year-old Caucasianwoman with a smokinghistory that included apack per day for 20 years,is admitted to the hospitalfor an exacerbation ofher chronic obstructivepulmonary disease (COPD).AI complains of increasedshortness of breath and sputum production. Upon review ofAI's chart, it is found that this is her 4th exacerbation in thepast 3 years. AI is currently receiving ipratropium bromide andalbuterol sulfate (Combivent), 2 puffs every 4 hours as needed,and salmeterol 50 ?g inhalation twice daily. Spirometrywas completed a few weeks prior and shows that AI has aforced expiratory volume/forced vital capacity (FEV1/FVC)ratio of <70 and a FEV1 of 42% of predicted. After 3 days ofintravenous antibiotic therapy, AI is discharged with prescriptionsfor cefpodoxmine proxetil (Vantin) 200 mg twice daily,azithromycin (Zithromax) 250 mg once a day, and 40 mg ofprednisone once a day, each for 7 days.

In what stage of COPD would AI be classified, and whatchanges (if any) should be made to her COPD medications?

ANSWERS

CASE ONE:

AG is older than 44 years of age and has low HDL cholesterol (2 risk factors) and does not have proven coronary diseaseor a coronary artery disease risk equivalent (eg, diabetes mellitus). This makes his goal LDL <130 mg/dL, according to the National Cholesterol EducationProgram (NCEP) guidelines (www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm). The pharmacist should first recommend more exercise and weightmanagement, including following a diet consisting of <7% of calories as saturated fat, cholesterol <200 mg/day, and increased amounts of soluble fiber(5-10 g/day) and plant stanols/sterols (2 g/day). In addition, drug therapy is likely warranted, although a 3-month trial of lifestyle modification without drugtherapy also is reasonable. If and when drug therapy is initiated, even though AG has a low HDL, his elevated LDL should be the first problem addressed.Based upon NCEP guidelines, a moderate dose of a statin (eg, atorvastatin 20 mg) would be a reasonable first drug to start in AG.

CASE TWO:

According to the Global Initiative for Chronic Obstructive Lung Disease COPD guidelines (www.goldcopd.com/download.asp?intId=445) anFEV1/FVC ratio <70% is diagnostic of having COPD. Staging of the disease is done according to percent of predicted FEV1. The patient has an FEV1 >30% but<50% of predicted, which corresponds to stage 3 (severe) COPD. The fact that AI has severe disease and frequently experiences exacerbations suggeststhat she should have an inhaled corticosteroid added to her current regimen. This treatment has been shown to reduce the frequency of exacerbationsand thus improve health status but does not modify the long-term decline in FEV1. The pharmacist should recommend a prescription for an inhaled corticosteroidbe written for the patient as well. A combination product, such as fluticasone/salmeterol 250/50 ?g (Advair) twice daily, would be a reasonablerecommendation.

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