Medication Use Systems
Case 1: Identification and Resolution of Drug Therapy Problems
Introduction:
The objective of this exercise is to provide practice and self-evaluation in recognizing
and resolving drug therapy problems (DTP’s). We want you to learn the habit of asking
the four questions listed in the Instructions below.
This case is not, however, primarily intended to teach new clinical pharmacology. We
have actually tried to choose familiar issues in drug therapy to illustrate common DTP’s.
You may need to refer to a clinical pharmacology reference for some examples, but we
expect you to become familiar with the drugs as a means to the end of identifying DTPs.
Also, we have made no attempt to hide the DTPs from you. On the contrary, we want you
to see them. Again, we designed this case to teach a thought process and to challenge
you, but not to trick you. Practice asking the four questions, whether you find the
therapeutic content easy or hard.
Access
Effectiveness
Safety
1. No therapy for a valid
indication.
2. Ineffective drug.
4. Contra-indicated drug.
3. Sub-therapeutic dose.
5. Adverse drug reaction or
side effect
6.Excessive Dose.
7 No medically valid
indication
8. Drug-laboratory
interaction
Instructions
In the following brief cases please decide the following:
a) Is there a DTP? Is it potential or actual? Why?
b) Does it involve (a) access, (b) effectiveness or (c) safety?
c) Which (if any) of the eight classes of potential DTP do you suspect may be
involved?
d) What could be done to correct the DTP?
Resources.
To do these exercises correctly, you need to know the terminology used in Chapter 10 of
the course text and in Lecture 2. Please read Chapter 10 in PME-IDO (the course text) up
to “Professional Dialog”, especially the sections on DTP’s Resources The table above is
an abbreviated version of Table 10.2. It is here as a “handy reminder” but is not complete
enough to explain the subject matter for the first time. For more about DTP’s, see
Chapter 3 in Cipolle RJ, et al., Pharmaceutical care practice.
You may also need a drug information reference such as Lacy, et al, Drug Information
Handbook or the Clinical Pharmacology reference on CD by Gold Standard Multimedia.
Exercise 1-1.
Name: Sarah Bellum
Age: 28
Wt. 135 lb.
Ht. 5'5"
Sex: Female Race: African American
Medical History: Asthma
Social History: Smoking NO; Alcohol NO; Single
Medication
Dose
Schedule
TheoDur
300 mg
BID
Ventolin Aerosol
2 puffs
PRN
Azmacort
4 puffs
BID
When Ms. Bellum comes in to get her medicine refilled, you notice she is somewhat
early for her TheoDur and her Ventolin. When you ask about it she relates that when she
feels "wheezy" she sometimes takes an extra TheoDur tablet in addition to using the
Ventolin about every 4 hours. You then pull up her refill history and notice that she is
over two months over due for her Azmacort refill.
Exercise 1-2
Name: Yolanda deFree
Age: 46
Wt.137 lb.
Ht. 5'7"
Sex: Female
Race: White
Medical History: None
Social History: Smoking NO; Alcohol NO
Medication
Cimetidine
Dose
300 mg
Schedule
BID
Ms deFree comes in to get her first refill of Cimetidine, and when you are filling the
prescription she asks, “ How long does it take for this stuff to work, I feel like I’m
wasting my money -- this drug hasn’t done anything for me.”
You ask, “For what reason are you taking Cimetidine?”
“For my hemorrhoids,” she timidly responds. You ask, “Do you have any problems with
your digestion, you know, heartburn or pain?” She says, “No. I have an iron stomach and
a sore butt.”
Exercise. 1-3
Name: Sandy Beach
Sex: Male
Race: Caucasian
Medical History: Hyperlipidemia
Age: 46
Wt. 161 lb.
Social History: Smoking NO, Alcohol Use
Moderate
Dose
Medication
Ht. 5'6"
Schedule
Inderal
20mg
BID
Lovastatin
40mg
1 QD
When he comes to get his medications refilled, Mr. Beach complains of muscle soreness
of some days’ duration. In response to your questions, he says he hasn't increased his
physical activity lately to cause this.
Exercise. 1-4
Name: Norman Conquest
Age: 46
Wt. 161 lb.
Ht. 5'6"
Sex: Male
Race: Caucasian
Medical History: HTN, Hyperlipidemia Social History: Smoking NO, Alcohol Use
NO
Medication
Dose
Inderal
Schedule
20mg
BID
Lovastatin
40mg
1 QD
Mr. Conquest comes to get his medications refilled and mentions that both he and his
doctor are disappointed that his hyperlipidemia has not responded as well as they would
have liked.
Exercise 1-5
Name: Desi Killibrium
Sex: Male
Medical History: None
Age: 70
Wt. 165 lb.
Ht. 5'8"
Race: White
Social History: Smoking NO; Alcohol NO
Medication
Amitriptyline
Dose
50 mg
Schedule
1 QD
As Mr. Killibrium walks up to the pharmacy counter you notice his gate is a bit
unbalanced and his arms are bent at the elbows and held slightly out from his body. You
find this peculiar because you don’t recall Mr. Killibrium having this problem.
He and his wife approach the counter and he initiates a conversation but you can’t
understand him because his speech is slurred and he isn’t making much sense. His wife
recognizes the tension and interjects, she says he needs a refill of his Amitriptyline
because he has been acting strange and it should help him get back to normal.
Exercise. 1-6
Name: Lotta Brass
Age: 61
Wt. 170 lb.
Ht. 5'
Sex: Female
Race: Caucasian
Medical History: Atrial Arrhythmia Social History: Alcohol Use NO Smoking NO
Medication
Dose
Schedule
Coumadin
5mg
1 QD
Digoxin
0.125mg
1 QD
Calan SR
240mg
1 QD
Ms. Brass comes to your pharmacy with complaints of being constipated and asks for
your recommendation for a laxative
Exercise. 1-7
Name: Donald Duzzwell
Age: 37
Sex: Male
Race: White
Medical History: Schizophrenia, Bipolar disorder
Social History: Smoking NO; Alcohol NO
Medication
Lithobid
Thorazine
Risperidone
Levaquin
Dose
300 mg
300 mg
6 mg
500 mg
Wt. 160 lb.
Ht. 6'1"
Schedule
1 QD
1 QD
1 QD
1 QD (14-days)
You are working in a busy chain pharmacy where you and another pharmacist are on
duty. Mr. Duzwell, a man with stabilized chronic psychiatric disorders, comes in. You
greet him and ask how he is doing. His response is positive and he mentions he still
enjoys volunteering at the community center.
The other pharmacist began processing his new prescription for Levaquin.
You
overheard the pharmacist explain to Mr. Duzwell that he had meet his HMO’s
prescription cap for three brand name products. The pharmacist said that Mr. Duzwell
would have to pay out-of-pocket for the antibiotic, which would cost $65.00. Mr.
Duzwell acted confused and replied that he did not have $65.00. The pharmacist
apologized and Mr. Duzwell turned and walked out of the pharmacy.
Exercise. 1-8
Name: Howie Doone
Sex: Male
Medical History: None
Age: 34
Wt. 165 lb. Ht. 5’8”
Race: Hispanic
Social History: Smoking NO; Alcohol NO
Mr. Doone’s wife, Lorna had been in your pharmacy recently with a prescription to be
filled and a scary story to tell. A wasp had stung her husband, Howie, while he was
working in the yard. Within minutes he had become agitated and flushed. His neck and
face were swollen and it was extremely difficult for him to breathe. He was treated at the
ED where the physician told him he had a severe anaphylactic reaction. The MD said he
was hypersensitive to wasp stings and told him that he would prescribe epinephrine as an
emergency medication. He told Mr. Doone to keep the epinephrine nearby whenever
there was a risk of a sting.
Later, Mr. Doone had come in to pick up his prescription. You had handed Mr. Doone his
prescription for an EpiPen and asked if he had any questions. He replied that he was in a
hurry and had no questions. Now, he has telephoned and said that he got the wrong
prescription. When he opened the bag, all he found were some tubes marked Epi-Pen. He
is annoyed, and says that his doctor told him he needed to have the medicine nearby at all
times. He asks, “I come back right now can you give me the correct pills?”
Exercise. 1-9
Name: Carrie Onn
Sex: Female
Medical History: UTI
Age: 67
Wt.
180 lb. Ht.
5'8"
Race: African American
Social History: Smoking NO; Alcohol NO
Medication
Dose
Schedule
Dyazide
1 capsule
1 QD.
Trimethoprimsulfamethoxizole (TS)
1 tab
BID.x 3 days
Mrs. Onn’s record shows that she received the same therapy two weeks ago. Mrs. Onn
confirms that this is her second urinary tract infection in two weeks. She has not had
another in the past 12 months. She goes to an emergicenter and has happened to see a
different doctor this time. When you phone the emergicenter, the doctor on duty explains
that their treatment guideline calls for urinalysis but not urine culture. They respond that
a three-day course of TS is the recommended first line treatment.
Exercise. 1-10
Name: Homer deBrave
Age: 50 Wt.
180 lb. Ht.
5'8"
Sex: Male
Race: African American
Medical History: Hypertension
Social History: Smoking NO; Alcohol NO
Medication
Dose
Schedule
Nadolol
40mg
Cefaclor
250 mg
1 QD.
Every 8 hrs
Mr. deBrave comes into your pharmacy to get a new prescription for Ceclor. He
mentions he caught a bug that was going around the office. When filling his prescription
you pull up his medication history and notice he has not refilled his Nadolol in over 60
days. You ask him how the Nadolol is working and he confides that he has been
reluctant to take the medication. You take his blood pressure and it is 140/90, standing.
He comments that he took the medication as prescribed “for a while,” and feels much
better when he is not taking the prescribed dosage. While he was taking it, he
experienced fatigue, dizziness and occasional impotence, which he attributes to the
Nadolol.
Exercise. 1-11
Name: Luce Cannon
Age: 61 Wt.170 lb.
Sex: Female
Race: Caucasian
Medical History: Atrial Arrhythmia
Social History: Alcohol Use NO; Smoking Yes
Medication
Ht. 5'
Dose
Schedule
Coumadin
5mg
1 QD.
Digoxin
0.25mg
1 QD.
While in the pharmacy Ms. Cannon mentions she has been suffering because of her pain.
The joints of her hands and wrists are stiff and painful, especially in the mornings. She
also mentions it is difficult for her to prepare meals, do housework and other activities
that are important to her.
Exercise. 1-12
Name: Natalie Dresst
Age: 70
Wt. 175lb.
Ht.
5'6"
Sex: Female
Race: Asian
Medical History: Hypertension
Social History: Smoking NO; Alcohol NO
Medication
Dose
Schedule
Celebrex
200 mg
1 QD
Atenolol
50 mg
1 QD.
Lately, Mrs. Dresst has not been in good spirits, getting motivated to do anything is “real
work” and she complains that she just doesn’t get enjoyment anymore from her normal
pleasures. She tells you that her husband convinced her to see the doctor, who prescribed
something that would help her “blues.” She’s back for her one-month refill of the
Celebrex. The doctor said it would take a few weeks to take effect, but Mrs Dresst is
tired of waiting to feel better. She asks you if you have something stronger or that would
work sooner.
Exercise 1-13
Name: Vida Dawn
Sex: Female
Medical History: None
Age: 63
Wt.140 lb.
Ht. 5'6"
Race: White
Social History: Smoking NO; Alcohol NO
Medication
Coumadin
Dose
5mg
Schedule
1 QD.
Ms Dawn dropped off her empty bottle of Coumadin for a refill and said she would “shop
around” while she waited for it to be filled. When she returned to the counter, she had a
few items in her hand, which included a box of Alka-Seltzer®. You asked if the AlkaSeltzer was for her and she replied that it was. She reported that she had been treating
her headaches with aspirin for the past couple of weeks and now her stomach was upset.
Exercise 1-14
Name: Shirley Light
Sex: Female
Age: 22
Race: White
Wt.118 lb.
Ht. 5'4"
Medical History: Deep Acne Vulgaris
Medication
Accutane
Social History: Smoking NO; Alcohol NO
Dose
20 mg QAM, 10 mg QPM
Mrs. Light, an outgoing young woman who you have gotten to know over the past 5
months, because she has been purchasing Accutane to treat her acne, comes into the
pharmacy. You greet her and ask if she is here for a refill. She replies, “No I still have
another weeks worth of Accutane, I’m only here to pick up a pregnancy test.”