Case Studies

Case 1

TJ, a 68-year-old man, presents to the pharmacy with a prescription for ibuprofen 600 mg 3 times daily. He explains that he had been experiencing pain and tenderness in his knee for several months, and was just diagnosed with osteoarthritis (OA) of the knee by his physician. Upon reviewing his profile, you notice that his current medications include metoprolol, lisinopril, and atorvastatin. You ask him about his past medical history and discover he experienced a myocardial infarction (MI) about 4 years ago.

How should the pharmacist proceed in respect to TJ’s ibuprofen prescription?

Case 2

JR, a 76-year-old woman who is a regular at the pharmacy, comes in today to pick up her monthly prescriptions. Her past medical history is significant for hypertension and hyperlipidemia. She explains to you that her granddaughter is expecting her first child soon, and she has heard there are some vaccinations she should get before spending time around the baby. She knows she is up-to-date on all her childhood vaccinations, but is unsure about which others she should receive.

What advice do you provide JR about recommended vaccinations at this time?

ANSWERS

Case 1 Answer:

The patient’s medication profile suggests a history of cardiovascular disease. Studies examining the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in post-MI patients have found that NSAIDs, including ibuprofen, are associated with an increased risk of all-cause mortality, coronary death, and MI for at least 5 years after the index event. Consequently, the pharmacist should consider recommending an alternative therapeutic option for TJ’s osteoarthritis.

In addition to NSAIDs, the 2012 American College of Rheumatology guidelines recommend acetaminophen, tramadol, or corticosteroid injections as first-line therapy options for initial management of OA of the knee. The pharmacist might consider recommending a change in therapy to acetaminophen 1000 mg 2 to 4 times daily. If it is determined that the patient should be initiated on an NSAID despite the associated risks, it may be suggested that naproxen be the NSAID of choice, as it has been shown to have the lowest cardiovascular risk of the studied NSAIDs.

Case 2 Answer:

Infants younger than 6 weeks cannot receive the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine and those younger than 6 months cannot receive the influenza vaccine. Consequently, infants are at greater risk of contracting these illnesses and should be protected through passive immunity by immunizing those who have close contact with them. The CDC recommends that adults who spend time around these children should receive the adult booster version of the diphtheria, tetanus, and acellular pertussis vaccine (Tdap) and the influenza vaccine to minimize the risk of infecting the infant. Due to JR’s age, she should receive the trivalent inactivated influenza vaccine (she could receive the live vaccine if she were under 50). She should also receive the adult Tdap vaccine instead of the simple Td booster as it has added protection against pertussis (whooping cough).

In addition to these vaccines that are meant to help protect the newborn, there are others she may consider due to her age. JR should consider getting the pneumococcal polysaccharide vaccine if she has not yet, since she is older than 65 years, as well as the herpes zoster vaccine, since she is older than 60 years.

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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. Ms. Erhard is a PharmD candidate at the University of Connecticut School of Pharmacy.