Case Studies

Case 1

AR, a 55-year-old African American man, comes to your pharmacy to fill a new prescription. He tells you that he recently received a diagnosis of primary hypertension from his doctor and was given a prescription for lisinopril 10 mg once daily. He has no other comorbidities, such as diabetes or chronic kidney disease.

As the pharmacist, should you dispense this medication?

Case 2

BF is a 49-year-old man who comes to the pharmacy with a new prescription for flecainide 50 mg every 12 hours. He had recently been released from the hospital for an episode of paroxysmal atrial fibrillation (AF) and was discharged with instructions to begin taking flecainide for rhythm control. Upon review of the patient’s profile, you notice he is also on carvedilol, lisinopril, aspirin, and atorvastatin. After talking to the patient, you learn he had a myocardial infarction (MI) a few years ago.

As the pharmacist, do you fill the prescription for this patient?

ANSWERS

Case 1: According to the 2014 Joint National Committee (JNC 8) guidelines, angiotensin-converting enzyme (ACE) inhibitors such as lisinopril are not recommended as first-line agents in the black population. For patients of African descent without chronic kidney disease, the guidelines recommend initiation of a calcium channel blocker (CCB) or a thiazide-type diuretic over an ACE inhibitor or an angiotensin-receptor blocker (ARB).

This recommendation from JNC 8 is based on evidence from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, which showed thiazides and CCBs to be more effective in improving cerebrovascular, heart failure, and combined cardiovascular outcomes compared with an ACE inhibitor in a black subgroup analysis. The trial also showed a 51% higher rate of stroke in black patients who were given an ACE inhibitor over a CCB as initial therapy.

As the pharmacist, you should consider contacting the patient’s physician to recommend changing lisinopril to a CCB (eg, amlodipine) or a thiazide-type diuretic (eg, hydrochlorothiazide).

Case 2: According to the 2014 American Heart Association/American College of Cardiology/Heart Rhythm Society AF Guidelines, it is not recommended to dispense flecainide to this patient. Flecainide—a class 1C antiarrhythmic agent—is a first-line agent for rhythm control in AF patients; however, its use is contraindicated in patients with structural heart disease, a history of MI, or left ventricular dysfunction.

Dofetilide, dronedarone, and sotalol are alternative first-line agents for AF rhythm control. Dronedarone or sotalol should be recommended to BF with caution because his medications (specifically carvedilol and lisinopril) suggest he might have a decreased left ventricular ejection fraction. Amiodarone can also be considered, but due to its potential toxicities, it should be used after other agents have failed or are contraindicated.

Because of BF’s history of MI, it is important that the pharmacist not dispense the medication to him. The patient’s doctor should be called and informed of the situation, and a medication change should be recommended after getting a more detailed history.

Read the answers

function showAnswer() {document.getElementById("answer").style.display = 'block';document.getElementById("link").style.display = 'none';}

Dr. Patel is a pharmacist, Dr. Mearns is health economics and outcomes research fellow at Hartford Hospital Evidence-Based Practice Center, and Dr. Coleman is professor of pharmacy practice, as well as codirector and methods-chief at Hartford Hospital Evidence-Based Practice Center, at the University of Connecticut School of Pharmacy.