Case Studies

Dr. Coleman is an assistant professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy.

Iron Deficiency Anemia

A 48-year-old woman presents to an ambulatory care clinic complaining of weakness, headache, and mild fatigue. Her physician diagnoses her with a mild case of iron deficiency anemia due to poor diet and decides to initiate oral iron replacement. He sees the pharmacist on duty and asks for advice about which formulation of oral iron to use. The physician notes, “I have been using a ferrous gluconate tablet 3 times daily in my patients because this preparation seems to cause less stomach upset, but I do not always get the results I want.”

What advice can the pharmacist provide to the physician?

Nonerosive Reflux Disease

PI comes to the pharmacy with a prescription for lansoprazole (Prevacid) 30 mg once daily. PI tells the pharmacist that about 5 months ago, he started taking lansoprazole for mild heartburn (without esophagitis) with good response. PI notes that after 3 months, his physician let him stop “because he did not like taking pills every day.” Last week his heartburn symptoms returned, however, and his physician gave him this new prescription for lansoprazole. PI asks, “How long will I have to take these pills this time?”

How should the pharmacist respond?

ANSWERS

CASE ONE:

Gastrointestinal side effects from iron supplementation are strongly and positively correlated with the amount of elemental iron administered; therefore, it is not surprising that the physician sees less stomach upset with ferrous gluconate because it contains a lower amount of elemental iron than other preparations (gluconate: 28-36 mg/tablet; sulfate: 65 mg/tablet; fumarate: 106 mg/tablet). The pharmacist should make the physician aware that prescribing one ferrous gluconate tablet 3 times daily will not provide his patients with the recommended daily amount of elemental iron (150-200 mg/day) required to treat iron deficiency anemia, and consequently, may explain why his patients do not always respond adequately to treatment. The pharmacist might suggest the patient take one ferrous sulfate 325-mg tablet 3 times daily (perhaps with 250 mg of ascorbic acid to increase absorption) in order to provide her with the amount of elemental iron she needs.

CASE TWO:

An attempt to stop antisecretory medications, such as proton pump inhibitors and histamine-2 antagonists, is reasonable in patients being treated for heartburn and who have a good response to initial therapy. If symptoms recur in a patient within 3 months, however, the heartburn is often best treated with continuous or maintenance therapy. If symptoms reappear more than 3 months after stopping therapy, repeated courses of acute treatment (roughly 8 weeks in duration) may be effective. Therefore, the pharmacist should inform PI that it is likely that he will continue to be prescribed lansoprazole even if his symptoms disappear in order to prevent symptom recurrence and the development of esophagitis.

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