Case Studies

Case 1

FK is a 68-year-old man who comes to your pharmacy with several new prescriptions. The day before, he was discharged from the hospital, where he spent 2 weeks in the intensive care unit due to sepsis from a complicated exacerbation of chronic obstructive pulmonary disease. You notice one prescription is for omeprazole 40 mg daily, a medication he has never filled before. You ask FK if he had any gastrointestinal problems during his hospitalization and why omeprazole was prescribed. He denies any new health problems and says he is unaware of why this medication was started.

As FK’s pharmacist, what should you do regarding his omeprazole prescription?

Case 2

ML presents with a prescription for metronidazole 500-mg tablets to be taken twice daily for 7 days to treat bacterial vaginosis. She asks how long it will take for the prescription to take effect because she is flying to her sister’s wedding the next day. You begin discussing her prescription and how it will be important to abstain from alcohol while taking metronidazole and for up to 3 days after she is finished with the therapy. ML quickly replies that it won’t be possible to adhere to those restrictions until 2 days from now and that she will plan to start therapy then instead of today.

What alternative therapies could ML’s physician prescribe for her bacterial vaginosis?

ANSWERS

Case 1: Case 1: Patients who are hospitalized in the intensive care unit are often prescribed acid-suppressing therapy for the prevention of stress ulcers. Although the risk of bleeding from a stress ulcer is low, there is an associated mortality of 50%. Risk factors for stress ulcers include major trauma, severe head injury, multiple organ failure, burns, major surgeries, severe sepsis, shock, mechanical ventilation, coagulopathy, high-dose steroids, and tetraplegia. Histamine₂- receptor antagonists, proton pump inhibitors, antacids, and sucralfate can be used to prevent stress ulcers during a hospital stay. Appropriate discontinuation of therapy at discharge is important to avoid subsequent unnecessary therapy and adverse events associated with acid suppressive therapy (ie, increased risk of Clostridium difficile infection, pneumonia, and fractures). The pharmacist should call the prescribing physician to verify the indication for FK’s omeprazole prior to filling the prescription.

Case 2: The Centers for Disease Control and Prevention suggest that symptomatic bacterial vaginosis in nonpregnant females be treated with oral metronidazole (500 mg twice daily for 7 days), vaginal metronidazole gel (0.75%, 1 applicatorful daily for 5 days), or vaginal clindamycin cream (2%, 1 applicatorful daily for 7 days). Patients treated with metronidazole should abstain from alcohol or the use of ethanol-containing products for the duration of therapy and for 3 days afterward due to the risk of disulfiram-like reactions. Such interactions have been reported in patients who have taken oral, intravenous, and vaginal tablet forms of metronidazole. In ML’s case, it is probably best to recommend clindamycin vaginal cream instead so that therapy is not delayed and the patient can be safely treated.

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Diana M. Sobieraj is assistant professor of pharmacy practice and 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.