Pharmacy Times Interactive Case Studies: April 2023

Case 1

BC is a 66-year-old woman who presented to an outpatient appointment for a cardiac surgery evaluation. During CT imaging, an incidental finding showed a pheochromocytoma. Further biochemical testing confirmed elevated catecholamine levels. BC was then started on prazosin 1 mg by mouth twice daily, with a plan to continue it for 3 weeks to stabilize her blood pressure (BP) in preparation for the cardiac surgery. One week later, she presents to the emergency department with hypertension, shortness of breath, and tachycardia. The prazosin is held, and BC is admitted to the intensive care unit, where her BP continues to fluctuate between hypertension and normotension. The plan of care changes, and she needs to have an adrenalectomy before her cardiac surgery to stabilize her BP.

How should her BP be managed during the adrenalectomy?

Answer: In pheochromocytomas, the tumor causes the adrenal glands to hypersecrete norepinephrine, which binds to α receptors, triggering vasoconstriction.¹α1 antagonists are recommended as first-line management of preoperative hypertension because they directly reverse the effects of the tumor. Although prazosin is an α1 antagonist, it has a long duration of action (10 to 24 hours), and the dose cannot be acutely adjusted in cases of hypertension. The α1 antagonist phentolamine would be preferred because it has a shorter duration of action (10 to 30 minutes) and can be administered as a continuous intravenous infusion.² By using phentolamine as a continuous infusion during the adrenalectomy, a patient’s BP can be easily adjusted, and the infusion can be stopped should hypertension occur.² For these reasons, BC’s BP should be managed with phentolamine and not prazosin.²

Case 2

LM is a 32-year-old woman who is refilling her prescription. She tells the pharmacist that she has an upcoming appointment to have her intrauterine device removed so that she and her husband can start trying to have a baby. For the past 2 years, LM has taken sertraline (Zoloft) 50 mg daily to help manage her depression. After several medication trials and dose adjustments, she feels that this dose helps keep her symptoms well managed without causing many adverse effects. LM asks if it is safe to continue taking the medication if she becomes pregnant. She plans to discuss this with her obstetrician-gynecologist but wanted to ask the pharmacist’s opinion as well. Upon reviewing her profile, the pharmacist notices that LM also routinely fills levothyroxine 50 mcg daily but has no other past medical history.

What counseling should the pharmacistprovide LM about antidepressant useduring pregnancy?

Answer: There are risks associated with both treating and not treating depression during pregnancy. Untreated depression has been associated with fetal and maternal complications, such as preeclampsia and eclampsia, increased risk of preterm labor, and low birth weight. Similar risks are associated with antidepressant medications taken during pregnancy. Guidelines recommend that the decision to treat depression during pregnancy should be done with shared decision-making that considers the benefits and risks.¹ In general, life-threatening or refractory/severe/unstable depression favors treatment with antidepressants. However, if a patient has mild depression or has been stable for the past 6 months, consideration can be given to dose reductions and/or cessation of therapy via tapering with close monitoring of symptoms. Regardless of the decision, LM should be offered cognitive behavioral therapy because it has been shown to effectively manage symptoms.²

References

1. Yonkers KA, Wisner KL, Stewart DE, et al. The management of depression during pregnancy: a report from the American Psychiatric Association and the American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009;114(3):703-713. doi:10.1097/AOG.0b013e3181ba0632
2. Spinelli MG, Endicott J. Controlled clinical trial of interpersonal psychotherapy versus parenting education program for depressed pregnant women. Am J Psychiatry. 2003;160(3):555-562. doi:10.1176/appi.ajp.160.3.555

About the Authors

Kelley Greene is a PharmD candidate at the University of Connecticut School of Pharmacy in Storrs.

Stefanie C. Nigro, PharmD, BCACP, CDCES, is an associate clinical professor in the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy in Storrs.