Case Studies

Case one

GB is a 42-year-old man who comes to the clinic for a scheduled visit. GB is overweight and admits to exercising very infrequently. He has a medical history of hypertension and hyperlipidemia for which he takes hydrochlorothiazide and rosuvastatin, respectively. Recent laboratory results show GB has a fasting blood glucose of 172 mg/dL, an A1C of 7.6%, and a serum creatinine of 1.1 mg/dL. He does not complain of polyuria, polydipsia, or other common signs of diabetes. Following repeat laboratory results a few weeks later showing similar glucose abnormalities, GB’s physician diagnoses him with type 2 diabetes and decides to initiate pharmacologic treatment.

What is the most appropriate initial pharmacologic treatment for GB?

Case Two

CK is a 23-year-old woman who presents to her physician with a positive result (15 mm induration) on her purified protein derivative (PPD) tuberculin skin test. She denies signs or symptoms such as cough, blood-tinged sputum, fever, or weight loss, and her chest x-ray is unremarkable. CK’s physician diagnoses her with latent tuberculosis (TB). CK states she is enrolled in classes at a local college and admits to having a very busy schedule and difficulty managing stress. She is concerned about her ability to be adherent to an extended duration treatment regimen. The physician asks you for your recommendation on an appropriate regimen to treat CK’s latent TB. CK has no other medical conditions and is not currently taking any prescription medications.

Which latent TB treatment regimen would you recommend for CK?

ANSWERS

Case 1: Case One Answer: C The 2012 American Diabetes Association guidelines now recommend that most newly diagnosed type 2 diabetes patients be initiated on metformin therapy along with lifestyle modifications. - Exceptions include the presence of a contraindication to metformin, patients that are highly symp tomatic, or those who have severe glucose abnormalities, in which case insulin therapy (with or without additional agents) should be considered.

Case 2: Answer: Case Two Latent TB occurs when an infected individual harbors live bacteria ( does not present with any of the signs or symptoms consistent with active infection. At any time, however, an individual with latent TB can experience activation of the bacteria, exhibit symptoms indicative of TB, and become contagious. Although the standard of care for treating patients with latent TB consists of isoniazid daily for 9 months, the Centers for Disease Control and Prevention (CDC) issued new guidelines in December 2011 stating that isoniazid and rifapentine taken once weekly for 3 months (12 once-weekly doses) is as effective for treating latent TB as isoniazid for 9 months. Moreover, in clinical trials comparing the 2 regimens, more patients completed the 3-month isoniazid and rifapentine regimen. The CDC suggests this shorter regimen be considered for all patients who are 12 years or older (use in children aged 2-11 years should be considered on a case-by-case basis) and otherwise healthy, including patients with HIV not taking antiretrovirals. Based on CK’s concerns about being adherent to an extended duration regimen, isoniazid and rifapentine once weekly for 12 weeks seems appropriate.As GB has no contraindications to metformin, is asymptomatic, and does not have a severe glu cose abnormality, metformin should be initiated at a daily dose of 500 mg taken with the largest meal of the day. This dose could then be titrated up by 500 mg every week, up to 2000 mg daily or the maximum tolerated dose. GB’s physician and pharmacist should also stress the importance of lifestyle modifications. This should include a diet low in carbohydrates, calories, and fat, and enriched with fruits, vegetables, and fiber. Furthermore, it is recommended that patients engage in moderately intense aerobic physical activity for at least 150 minutes per week.

Read the answers

Dr. Coleman is associate professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy. Mr. Caranfa is a PharmD candidate from the University of Connecticut School of Pharmacy.

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References:

1. Kirkwood CK, Melton ST. Insomnia, drowsiness, and fatigue. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2012:867-883.

2. Morin AK, Jarvis CI, Lynch AM. Therapeutic options for sleep maintenance and sleep-onset insomnia. Pharmacotherapy. 2007;27:89-110.

3. Shimp LA. Disorders related to menstruation. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed. Washington, DC: American Pharmacists Association; 2012:147-158.

4. St. John’s wort and depression. National Institutes of Health/National Center for Complementary and Alternative Medicine website. http://nccam.nih.gov/health/stjohnswort/sjw-and-depression.htm. Accessed February 12, 2012.

5. Yanni EA. Jet lag. Centers for Disease Control and Prevention website. http://wwwnc.cdc.gov/travel/yellowbook/2012/chapter-2-the-pre-travel-consultation/jet-lag.htm. New York, NY: Oxford University Press; 2012.

6. Herxheimer A, Petrie KJ. Melatonin for the prevention and treatment of jet lag. Cochrane Database Syst Rev. 2002;(2):CD001520.

7. Dennehy CE, Tsourounis C. Botanicals (“herbal medications”) and nutritional supplements. In: Katzung BG, ed. Basic and Clinical Pharmacology. 10th ed. New York, NY: Lange/McGraw Hill; 2007:1060-1062.