Case Studies

Case One

Oral Contraceptives and Smoking

QS is a 38-year-old woman who comes into the clinic requesting a prescription for oral contraception (OC). The physician asks you, the pharmacist, what product you would recommend for her. Upon further inquiry, QS states that she does not have any medical problems or a family history of venous thromboembolism. However, she reports currently smoking 16 to 20 cigarettes per day. Previously, QS was smoking up to 2 packs of cigarettes daily, but in the last month she has started chewing approximately 8 pieces of 4-mg nicotine gum per day to help her cut down.

What is the appropriate recommendation for QS?

Case Two

Toxoplasmosis and TMP-SMX Allergy

JK is a 35-year-old man who is HIV positive. For his antiretroviral therapy, he is taking Atripla (efavirenz/emtricitabine/ tenofovir) once daily. Recently, JK’s immunoglobulin G titer for Toxoplasma gondii was found to be positive, and his CD4 count was 82. It is determined that he should be given prophylaxis for toxoplasmosis. However, he has a known allergy to trimethoprim/sulfamethoxazole (TMP-SMX).

What prophylactic regimen can you give instead?

ANSWERS

Case 1: Concomitant smoking and OC use may place women at increased risk for thromboembolic events, as well as stroke and myocardial infarction. The benefits of OCs are considered to outweigh these risks in women younger than 35 years, even if they are heavy smokers, as long as they do not have a family history of thromboembolic disease. It is also reasonable to prescribe OCs to smokers older than 35 years, as long as they smoke fewer than 15 cigarettes/day (light smokers). However, OCs - should not be prescribed to women older than 35 years who smoke heavily (more than 15 ciga rettes/day). Of note, women using nicotine replacement therapy should be considered smokers regardless of actual cigarette use, because nicotine is released into their circulation. Based upon QS’s smoking status, OC is not appropriate for her at this time. If she is successful in - quitting or even significantly reducing her cigarette use, she could become an appropriate candi date, but should be strongly educated regarding the risks. Some literature suggests that products containing 20 mcg or less of ethinyl estradiol (or equivalent) may be safer in women smokers, but further clinical study is needed. For now, you should recommend that QS utilize nonhormonal means of contraception, such as condoms or diaphragms. Additionally, the pharmacist should verify that QS is using the nicotine gum properly. It should be chewed slowly until a tingling sensation arises, then “parked” between the cheek and gums until the sensation is gone. This cycle should be repeated with the gum being held in a different area - of the mouth each time. The gum is removed after 30 minutes or when the tingling stops completely.

Case 2: T gondii is usually acquired in susceptible patients through contact with undercooked meats or T gondii cat feces. The first-line prophylactic regimen for toxoplasmosis is a double-strength (160/800 mg) TMP-SMX tablet once daily. In patients who cannot tolerate TMP-SMX, an oral regimen of dapsone, pyrimethamine, and leucovorin may be considered. Current Centers for Disease Control and Prevention recommended doses are dapsone 50 mg once daily, pyrimethamine 50 mg once weekly, and leucovorin 25 mg once weekly. Prophylaxis can be discontinued in patients with a - CD4 count that is greater than 200 for 3 months; however, if it drops below 100 again, prophylaxis should be restarted.

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