Case Studies (June 2015)

CASE 1

MR is a 31-year-old woman in the second trimester of her pregnancy, with no significant medical history. She comes to your pharmacy with a prescription for 30 tablets of Vicodin 5/300 mg, with instructions to take it every 4 to 6 hours as needed. Upon questioning MR, you learn this medication was prescribed for mild back pain she has been experiencing for the past 2 months. She has not tried any other treatment options for the pain and has no known drug allergies.

As the pharmacist, what other options could you recommend to MR?

CASE 2

LM is a 38-year-old woman who comes to your pharmacy with a prescription for oral terbinafine (Lamisil). Upon consultation, you learn LM was recently diagnosed with onychomycosis on her right big toe. She is concerned about taking an oral medication for her condition and says she would prefer a topical treatment. LM’s medical history is significant for liver cirrhosis and diabetes.

As the pharmacist, would you dispense oral terbinafine for LM?

ANSWERS

Case 1: An estimated 1 of every 7 pregnant women in the United States are prescribed opioids at some point in their pregnancy. Opioids should not be considered first-line therapy for pain in pregnancy because they may be associated with an increased risk of certain birth defects (eg, spina bifida, hydrocephaly, congenital heart defects) during early pregnancy, and neonatal withdrawal (or abstinence syndrome) when taken later in pregnancy—even in nonaddicted mothers. Opioids should only be used for severe pain and even then, for short durations during pregnancy. Since nonsteroidal anti-inflammatory drugs are to be avoided during pregnancy, acetaminophen is typically the first-line agent. MR should be counseled to take 1000 mg of OTC acetaminophen every 6 to 8 hours, with a maximum dose of 3 g per day). Nonpharmacologic modalities could also be recommended to manage her pain.

Case 2: The 2 FDA-approved oral agents for onychomycosis are terbinafine and itraconazole (Sporanox). Both medications require liver function tests and are not recommended for patients with active or long-term liver disease. Although less effective than oral agents, topical antifungal agents are considered safer for patients with liver disease. Currently, 3 topical agents are available: ciclopirox nail lacquer (Penlac), efinaconazole 10% solution (Jublia), and tavaborole 5% solution (Kerydin). With the use of ciclopirox, cure rates of approximately 7% after 48 weeks have been reported. Nail debridement by a physician is recommended if this agent is used, in addition to once-weekly removal of excess lacquer buildup with rubbing alcohol. With the use of efinaconazole and tavaborole, cure rates of 17% and <10% have been reported, respectively. Each agent requires a complete coating of the nail once daily for 48 weeks. Due to LM’s liver disease, terbinafine is not an appropriate choice of therapy. Topical efinaconazole might be recommended, however. She should be advised to apply 1 drop to the affected toenail and to evenly spread the solution over the entire toenail and surrounding areas by using the accompanying brush applicator. It is important to note that since LM has onychomycosis on her big toenail, she should be counseled to apply a second drop of efinaconazole to the end of the toenail.

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Dr. Kohn is an assistant professor at the University of Saint Joseph School of Pharmacy, Hartford, Connecticut. 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.

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