Case Studies

CASE 1

CC is a 39-year-old man who presents to the pharmacy after being bitten by a tick. CC expresses concern about potentially acquiring a tick-borne illness. He says that he was hiking in Connecticut 3 days ago and noticed a tick on his leg today. After he presents the tick to you in a plastic baggy, you correctly identify it as being of the black-legged species (Ixodes scapularis). Based on its engorgement, it has likely been attached for at least 2 days. CC reports that he does not take any medications and he has no known drug allergies.

As the pharmacist, what recommendations do you give to the patient?

CASE 2

CG is a 38-year-old man who comes to your pharmacy with a new prescription for Delzicol delayed-release capsules (mesalamine) 800 mg to be taken every 8 hours. CG has minor rectal bleeding, left-sided abdominal pain, and constant urgency to have a bowel movement. He says his doctor recently gave him a diagnosis of mild ulcerative proctitis. CG has no other relevant medical history.

As the pharmacist, what could you recommend regarding CG’s pharmacotherapy?

ANSWERS

Case: According to the Infectious Diseases Society of America guidelines on Lyme disease, 1-time antibiotic chemoprophylaxis (oral doxycycline 200 mg) is recommended as first-line preventive therapy for Lyme disease after a recognized tick bite. There is no recommended alternative to doxycycline administration (due to a lack of clinical data), and prophylaxis is recommended only if all the following criteria are met:

• The attached tick can be identified as I scapularis and is estimated to have been attached for ≥36 hours.
• Prophylaxis can be started within 72 hours after the tick was removed.
• The local rate of infection of these ticks with Borrelia burgdorferi, the bacterium that cause Lyme disease, is ≥20%. In the United States, these areas only include New England, the Mid-Atlantic states, and parts of Minnesota and Wisconsin.
• Doxycycline is not contraindicated.

As the pharmacist, you should recommend that CC contact his physician or go to a walk-in clinic to receive a prescription for a single dose of oral doxycycline 200 mg, which should be taken within 72 hours after the tick was removed.

Case 2: According to current American College of Gastroenterology Ulcerative Colitis Practice Guidelines, patients with mild to moderate distal colitis (including proctitis) can be treated with oral aminosalicylates, topical mesalamine (enema or suppository), or topical steroids (oral budesonide, or hydrocortisone foam or suspension); however, topical mesalamine agents are often superior to oral aminosalicylates or topical steroids in this setting (level of evidence: A).

Because CG is suffering from symptoms of mild to moderate ulcerative proctitis, a mesalamine suppository (Canasa 1000 mg) may be the best treatment option. As the pharmacist, you might consider contacting CG’s physician to recommend changing CG’s treatment from Delzicol to Canasa.

Read the answers

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Eric Zaccaro is an MBA candidate, and Yunes Doleh is a PharmD candidate, at the University of Connecticut School of Pharmacy. 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.