Interactive Case Studies

CASE 1

SR is a 39-year-old woman who has come to the pharmacy to pick up her prescription for escitalopram (Lexapro). SR tells the pharmacist that the escitalopram is helping with her generalized anxiety disorder symptoms but feels that her obsessive-compulsive disorder (OCD) symptoms are not fully controlled. Her therapist told her that sertraline (Zoloft) may be a better option for managing OCD. She wants to know if she should ask her doctor to change her prescription. You review her profi le and see that she takes 7.5 mg of daily escitalopram and 75 mcg of levothyroxine daily. She has no other notable medical history or allergies on file.

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What do you tell SR?

Clinical practice guidelines endorse selective serotonin reuptake inhibitors (SSRIs) as the preferred medication for the management of OCD. Although not all SSRIs are FDA approved for OCD, all appear to be equally effi cacious and should be considered and selected based on patient characteristics, tolerability, and preference.¹ Escitalopram and sertraline were directly compared for management of OCD in a 12-week, doubleblind, controlled randomized trial.² Despite the small trial size (n = 41), escitalopram was found to have comparable effi cacy to sertraline using the Yale-Brown Obsessive Compulsive Scale.2 SR appears to be deriving some benefit from taking escitalopram, but her current dose may be too low for the management of OCD. Doses are commonly initiated at 10 mg daily and titrated based on response and tolerability. Prior to considering a switch to sertraline, SR should talk with her provider about increasing the dose of her escitalopram to see if her OCD symptoms improve.

CASE 2

AE is a 36-year-old man who has smoked 1.5 packs of cigarettes per day since he was 19 years old. He asks the pharmacist if there is a medication that can help him feel “more ready to quit smoking.” AE is not ready to set a quit date but wants to try working toward this goal because smoking is aff ecting his health. He attempted to quit smoking cold turkey several years ago but relapsed. He has never attempted smoking cessation before with pharmacotherapy.

What advice can you give AE?

Evidence suggests that starting pharmacotherapy prior to being ready to quit smoking is effective. This shifts the goals of care away from the outcome of quitting smoking and toward minimizing the compulsion to smoke. Study results support using this strategy with varenicline (Chantix) and nicotine replacement therapy.¹ For AE, both varenicline and nicotine replacement therapy can be started with the ultimate goal of reducing smoking when he is ready. Varenicline is more effective in promoting abstinence and should be preferentially considered, assuming AE does not have any contraindications or other barriers. Two initiation approaches exist with varenicline: set a quit date 8 to 35 days after starting varenicline therapy or start varenicline with the goal of reducing the number of cigarettes smoked by 50% by week 4, an additional 50% by week 8, and continued reduction with the goal of abstinence by week 12.¹