CASE
PRESENTATION
PATIENT’S PROFILE
Name: Mr. X
Date of Admission: 26/7/2009
Age: 72 years old
Race: Malay
Gender: Male
Diagnosis: COAD, hypertension
Weight: Cannot be assessed
Height: Cannot be assessed
Allergy: Unknown
Chronic Obstructive Pulmonary
Disease 1
progressive disease narrowing of the airways,
leading to the shortness of breath and
difficulty in breathing
"Progressive" means the disease gets worse
over time.
1 Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition.
COPD includes the terms
chronic bronchitis (clinical term) and
• condition with chronic or recurrent
excessive mucus secretion into the
bronchial tree with cough 1
emphysema (anatomic pathology)
• enlargement of the air spaces distal to the
terminal bronchioles, with destruction of
their walls
1. Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition.
2.
http://www.buzzle.com/articles/pathophysiology-of-copd.html
Causes
• Cigarette smoking is the primary modifiable
risk factor for the development of COPD.
• Long-term exposure to other lung irritants,
such as air pollution, chemical fumes, or dust,
also may contribute to COPD. 5
1 Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook,
seventh edition
Pathophysiology 1
The most important processes causing lung damage are:
Oxidative stress produced by
the high concentrations of free
radicals in tobacco smoke.
Cytokine release due to
inflammation as the body responds
to irritant particles such as tobacco
smoke in the airway.
Tobacco smoke and free radicals impair the activity of
antiprotease enzymes (such as alpha 1-antitrypsin)
Protease enzymes damage the cells and tissue
of lungs and other supportive tissues,
1 Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition
Healthy vs COPD
Symptoms 1
•
•
•
•
•
1.
A cough (large amount of mucus)
Chest tightness
Shortness of breath
Wheezing
Low energy
http://www.buzzle.com/articles/pathophysiology-of-copd.html
Hypertension
High blood pressure (HBP) or hypertension means
high pressure (tension) in the arteries. Arteries
are vessels that carry blood from the pumping
heart to all the tissues and organs of the body.5
1 Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition
Blood pressure is the force applied against the walls of the arteries as the
heart pumps blood through the body. The pressure is determined by the
force and amount of blood pumped and the size and flexibility of the
arteries.1
1.
http://www.healthline.com/sw/khs-understanding-asthma&usg
Classification 1
1. Essential (primary) - no specific medical
cause can be found to explain a patient's
condition. 90-95%
2. Secondary. Secondary hypertension indicates
that the high blood pressure is a result of
another condition, such as kidney disease or
tumours.
1.
http://www.nlm.nih.gov/medlineplus/ency/imagepages/9124.htm
Classification of BP for Adults 5
Classification
SBP (mm Hg)
DBP (mm Hg)
Normal
<120
And <80
Prehypertension
120-139
Or 80-89
Stage 1 hypertension
140-159
Or 90-99
Stage 2 hypertension
≥160
Or ≥100
1 Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition
High Blood - Pressure: The Silent Killer
Hypertension may result either from a
specific cause (secondary hypertension) or
from an underlying pathophysiology
mechanism of unknown etiology (primary or
essential hypertension).1
1 Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition
 Secondary hypertension may cause by chronic kidney disease, Cushing’s
syndrome, hyperthyroidism, hyperparathyroidism, primary alsosteronism,
pregnancy, obstructive sleep apnea, and coarctation of the aorta.
Some drugs that may increase BP:
~ Corticosteroids
~ Estrogens
~ Nonsteroidal antiinflammatory drugs (NSAIDs)
~ Amphetamines
~ Sibutramine
~ Cyclosporine
~ Tacrolimus
~ Erythropoietin
~ Venlafaxine
1 Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition
Multiple factors that contribute to the
development of primary hypertension, including:
 Humoral abnormalities involving the reninangiotensin-aldosterone system, natriuretic
hormone, or hyperinsulinemia
 Pathologic disturbance in the CNS, autonomic
nerve fibers, adrenergic receptors, or
baroreceptors
1. Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition
 Abnormalities in either the renal or tissue autoregulatory
processes for sodium excretion, plasma volume, and
arteriolar constriction. 1
Deficiency in the local synthesis of vasodilating substances
in the vascular endothelium, such as prostacyclin, bradykinin,
and nitric oxide, or increase in production of vasoconstricting
substances such as angiotensin II and endothelin I. 1
1. Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook,
seventh edition
High sodium intake and increased circulating
natriuretic hormone would inhibit intracellular
sodium transport, causing increased vascular
reactivity and increased BP. 1
 Increased intracellular concentration of calcium,
leading to altered vascular smooth muscle function
and increased peripheral vascular resistance. 1
1. Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition
Diabetes mellitus is a group of metabolic
disorders of fat, carbohydrate, and protein
metabolism that results from the defects in
insulin secretion, insulin sensitivity, or both. 1
1. Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition
 There are two major classifications of
diabetes mellitus:
i) Type 1 DM
ii) Type 2 DM
 They are differ in clinical presentation, onset,
etiology, and progression of disease. 1
DIAGNOSIS OF DIABETES…
Based on three criteria :
i) Fasting plasma glucose ≥ 126mg/dL
ii) A 2-hour value from a 75g oral glucose tolerance test
≥ 200mg/dL
iii) Casual plasma glucose level of ≥ 200mg/dL with
symptoms of diabetes
5
PATHOPHYSIOLOGY OF DM
1
Type 1 DM
Generally develops in childhood or early
adulthood and results from immune-mediated
destruction of pancreatic β-cells, resulting in
absolute deficiency of insulin.
1. Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh edition
Type 2 DM 1
 Characterized by the presence of both insulin
resistance and relative insulin deficiency.
 Insulin resistance is manifested by increased
lipolysis and free fatty acid production,
increased hepatic glucose production and
decreased skeletal muscle uptake of glucose.
1. Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, and Cecily V. Diporo, Pharmacotherapy Handbook, seventh
edition


Treatment of lower respiratory tract infections, skeletal infections,
surgical prophylaxis and staphylococcal infections.
Beta lactams antibiotic – Act by inhibiting the formation of
peptidoglycan cross-links in the bacterial cell wall.

Precaution:
- hypersensitivity to b-lactam antibiotic
- Renal impairment

Adverse effect:
- Neutropenia
- Agranulocytosis
- GI upsets
- rash
[1] Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names Index, 17th
edition, Lexi-Comp Inc.

Interaction:
A. Drug – Drug interaction
- Co-admin of probenecid or disulfiram may result in higher cloxacillin
concentration.
- Chloramphenicol and tetracycline antagonise bactericidal effect of
cloxacillin.
B. Drug – Food interaction
- delayed absorption in the presence of foods.
Pharmacological Category:
-Proton Pump Inhibitor
Uses:
-Treatment and maintenance of healing erosive esophagitis associated
with GERD
Precaution:
-Relief of symptoms does not preclude the presence of a gastric malignancy.
-Long term medication will caused biopsy-proven atrophic gastritis(especially
caused by the bacterium Helicobacter pylori)
[1] Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names
Index, 17th edition, Lexi-Comp Inc.
Side Effect:
-Chest pain, Headache(9%), Rash(2%), Diarrhea (6%), N/V/C (2%), back
pain and Others.
Storage:
-Store the tablet at controlled room temperature of 20˚C to 25˚C.
Mechanism of Action:
-Suppresses gastric acid secretion by inhibiting the parietal cell H⁺ / K⁺ ATP
pump.
Dosage:
-40 mg once daily for up 8 weeks (this is for who have erosive esophagitis
associated with GERD.
-20 mg once daily have been used in mild GERD treatment and
maintenance therapy
Administration (Oral):
-Should be swallowed whole and do not crush or chew.
-may be taken with or without food but the best if taken
before breakfast
(coz of PPI)
Pharmacological Category:
-Antilipemic agent
-HMG-CoA Reductase Inhibitor
Uses:
-Treatment of dyslipidemias (to reduce elevations in total
cholesterol, LDL-C and triglycerides
-Primary prevention of cardiovascular disease.
Precaution:
-Secondary causes of hyperlipidemia should be ruled out prior to therapy.
-Liver function must be monitored by periodic laboratory assessment if not
may cause hepatic dysfunction.
[1] Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names Index,
17th edition, Lexi-Comp Inc.
Side Effect:
-Chest pain, Headache(17%), Rash(4%), Diarrhea (4%), N/C (3%),
Insomnia and dizziness.
Mechanism of Action:
-Inhibitor of 3-hydroxy-3-methylgluryl coenzyme A (HMG-CoA)
reductase .
-Increase in the expression of LDL receptors on hepatocyte membranes
and a stimulation of LDL catabolism.
Dosage:
-Initial: 10 to 20 mg once daily (for who have hypercholesterolemia)
-then 40 mg once daily for patient >45% reduction in LDL-C
Administration (Oral):
-Should be swallowed whole and do not crush or chew.
-may be taken with food
-take the medicine on night
Monitoring Parameters:
-Lipid level after 2-4 weeks
Uses:
- constipation
Precaution:
-Do not take immediately before going to bed.
-Avoid prolonged use.
-Not be used for who has abdominal pain, nausea and
vomiting.
[2] British National Formulary
Side Effect:
-Rash, Abdominal pain, Nausea and Vomiting.
Mechanism of Action:
- Liquid Paraffin acts by softening and lubricating the faeces.
The faeces can then move more easily through the bowel. By
doing this it relieves constipation and reduces the pain of
some conditions such as piles
Dosage:
-Take 15 ml for 3 times a day.
Combivent nebulizer 8 hourly
 Combivent- Salbutamol and ipratropium
Salbutamol- Act on β2 receptors
β2 receptors stimulation activate adenyl
cyclase
increase in intracellular cyclic adenosine monophosphate (cAMP)
relax bronchial smooth muscle
 Ipratropium- competitively inhibit cholinergic receptor in bronchial smooth
muscle
block acetylcholine
reduce cyclic guanosine monophosphate
(cGMP)
relax brochial smooth muscle
 Precaution:
immediate hypersensitivity reactions may occur after administration, as
demonstrated by rare cases of urticaria, angioedema, rash, bronchospasm.
 Drug-drug interaction:
# Ipratropium-increase toxicity with anticholinergic or drug with
anticholinergic effects (eg: atropine, TCA, antipsychotic drug).
# Salbutamol- refer to MDI salbutamol
 Adverse drug reaction: (Ipratropium)
# Glaucoma
# Hypersensitivity reaction
# Urinary retention
# Blurred vision
Metered dose inhaler salbutamol 2 puff + prn
Bronchodilator
Short acting selective β2 - adrenergic agonist
 Act on β2 receptors
β2 receptors stimulation activate adenyl cyclase
increase in intracellular cyclic adenosine monophosphate (cAMP)
bronchial smooth muscle relaxation
 Precaution:
# hypertension
# cardiac disorders (eg: arrhythmia, CHF)
# diabetes
# elderly patients.
Drug-drug interaction:
# salbutamol + nonpotassium sparing diuretics (eg: furosemide)
hypokalemia
# α- blocker, β-blocker
decrease effect of sulbutamol
 Drug-food interaction:
# Avoid or limit caffeine- may cause CNS stimulation
Adverse drug reaction:
# CNS stimulation
# Arrhythmia
# Seizure
# Hyperglycemia
# Hypokalemia
Step For Using Metered Dose Inhaler
Take off the cap and shake the inhaler.
Breathe out all the way to empty the lungs as much as possible.
Hold the inhaler 1 - 2 inches in front of your mouth (about the width of
2 fingers).
Start breathing in slowly through your mouth, and then press down on
the inhaler one time.
(If you use a spacer, first press down on the inhaler. Within 5 seconds,
begin to breathe in slowly.)
Keep breathing in slowly, as deeply as you can.
Hold your breath as you count to 10 slowly, if you can. This lets the
medicine reach deep into your lungs.
Wait about 1 minute between puffs for inhaled quick-relief medicine
(beta-agonists). There is no need to wait between puffs for other
medicines.
Rinse your mouth - help reduce unwanted side effects.
Tablet prednisolone 20mg OD
Systemic corticosteroid
 Antiinflammatory mechanism; beneficial effect- reduction in capillary
permeability to decrease mucus, inhibition of release of proteolytic enzymes from
leukocytes, and inhibition of prostaglandin.
 Precaution:
# Use with caution in patients with thyroid disease, hepatic impaired, renal
impairment, cardiovascular disease, diabetes, patients at risk of osteoporosis,
patients at risk of seizure, patients at risk of GI disease (peptic ulcer).
Drug-drug interaction:
# CCB (nondihydropyridine), azole antifungal, macrolide- may increase the
serum level of prednisolone
# Prednisolone may increase the hypokalemia effect of potassium wasting
diuretic (loop or diuretic)
# Concurrent use of NSAIDs and salicylate with corticosteroid- may increase GI
adverse effect.
# Antacids may reduce absorption of corticosteroid- separate administration by 2
hours.
# Prednisolone may cause reduction in warfarin effect.
Drug-food interaction:
#Avoid ethanol- may increase gastric mucosal irritation.
# Prednisolone interfere with absorption of calcium.
# Limit caffeine.
 Adverse drug reaction:
# Increase appetite
# Weight gain
# Peptic ulcer
# Hypokalemia
# Convulsion
# Diabetes mellitus
ACTRAPID HM PENFILL
HUMAN INSULIN SOLUTION FOR
INJECTION
WHAT ARE THE DIFFERENCES BETWEEN THE
TYPES OF INSULIN?
Types of
Insulin
Names of
Insulin
How Fast
They Start
Humalog/Lispro
Rapid Acting Novolog/Aspart 5 - 15 minutes
When the
Action
Peaks
How Long
They Last
30 - 90 minutes
1 - 3 hours
3 - 5 hours
Short Acting
Regular
1/2 - 1 hour
2 - 4 hours
6 - 8 hours
Intermediate
NPH
1 - 2 hours
6 - 10 hours
10 - 16 hours
1 - 2 hours
No peak action
24 - 36 hours
Lantus/Glargine
Long Acting Levemir/Detemir
COMPOSITION


Active substance: Human insulin, ( recombinant
DNA produced in Saccharomyces cerevisiae)
1 IU is corresponds to 0.035mg of anhydrous
human insulin.
INDICATIONS


Treatment of diabetes mellitus.
Initial stabilization of diabetes especially in
diabetes emergencies.
MODE OF ACTION
The blood glucose lowering effect of insulin is
due to :


Facilitated uptake of glucose following binding
of insulin to receptors on muscle and fat cells.
Simultaneous inhibition of glucose output from
the liver.
An average action profile after subcutaneous injections
indicates:
Onset: within half hour
Maximum: between 1 and 3 hours
Duration: approximately 8 hours.
DOSAGE
Dosage is individual and determine by the doctor
in accordance to the patient requirement.
 the average doses is in between 0.5 to 1.0UI/kg.
 This patient need to take 16IU for morning, 14
IU during afternoon and night.
 in geriatric patients, the primary aim of
treatment is to relief symptoms and to avoid
hypoglycemic events.

HOW TO ADMINISTER ACTRAPID?
1. Actrapid HM is usually
injected subcutaneously (SC)
onto the abdominal region,
thigh,gluteal region and
deltoid region.
2. SC injection into the
abdominal wall ensures a
faster absorption than other
injection sites.
3. Injection into a lifted skin fold minimises the risk of
intramuscular injection.
4. After the injection, the needle should remain under
the skin for at least 6 seconds.
5. Keep the push button fully depressed until after the
needle has been withdrawn from the skin.
6. Injection sites should be rotated within an anatomic
region in order to avoid lipodystrophy.
The above pictures shows lipodystrophy that
occur at the insulin injection sites.
7. The insulin penfill should be used by one
person only to avoid risk of passing diseases.
8. An injection should be followed within 30
minutes by a meal or snack containing
carbohydrates.
UNDESIREBLE EFFECTS



Hypoglycemia is a frequently occurring in
insulin therapy. The symptoms are include:
cold sweat, cool pale skin, nervousness,
confusion, difficulty in concentration, headache,
nausea and palpitation.
severe hypoglycemia may lead to
unconsciousness and may result temporary or
permanent impairment of the brain function and
even death.
Local hypersensitivity reaction may occur at the
injection sites during treatment with insulin.
OVERDOSE
Mild hypoglycemic episodes can be treated by
oral administration of glucose or sugary products.
 It is recommended for diabetic patients
constantly caries some sugar lumps, sweets, or
sugary fruit juices.
 For severe hypoglycemic episodes, patients can
be treated by IM or SC injection of glucagon (0.1
to 1.0mg) or glucose given by IV injection by
medical professionals.

STORAGE
Actrapid HM Penfill which is not in use should be
stored at 2⁰C to 8 ⁰C in a refrigerator.
 If in use, should not kept in the refrigerator, keep
in room temperature for up to 4 weeks.
 Keep protected from light.
 Keep out from the reach of children.
 Remove the needle after each injection.
 Keep out from exposed to heat or direct sunlight
and should never be frozen.



Insulin product which has been frozen must not be
used.
Never use insulin after the expiry date or the solution
is not clear.
A. FELODIPINE 15 mg OD

Indication- lowering blood pressure
-To be taken once daily without food.
-Calcium channel blocker- act by inhibits calcium ion from entering the
slow channel s or select voltage sensitive areas of vascular smooth muscle
and myocardium during depolarization causing relaxation of coronary
vascular smooth muscle and coronary vasodilation.

Precaution :
1. peripheral edema is the most common SE occurs w/in
2-3 weeks of starting therapy.
2. May cause hypotension with reflex tachycardia
resulting in MI


Common adverse effect:
- headache
- peripheral edema
- tachycardia
- flushing
Interaction:
A. Drug – Drug interaction
- Cimitidine, erythromycin,itroconazole and ketoconazole cause
increase plasma concentratin of felodipine.
- Phenytoin, carbamazepine, rifampicin and barbiturate cause decrease
plasma concentration of felodipine.
B. Drug – Food interaction
- Ethanol will increase felodipine absorption, greater hypotensive effect.
- Grapefruit juice increase effect of felodipine lead to severe
hypotension if concurrent use.
B. PRAZOSINE 4 mg tds

Indication: for treatment of hypertension.
-Starting dose is best taken with dinner, at least 2-3 hr before retiring.
Maintenance doses may be taken with or without meals.
-Is alpha adrenergic blocker- act as antagonist of α adrenergic receptors
which lower blood pressure by relaxing blood vessels.

Precaution:
- First dose may cause orthostatic hypotension and syncope associated
with the body's poor ability to control blood pressure without active
alpha-adrenergic receptors. Patients on prazosin should be told not to
stand up too quickly, since their poor baroreflex may cause them to
faint as all their blood rushes to their feet.

Common side effect:
- orthostatic hypotension
- syncope
- priapism

Interaction:
Drug –Drug interaction
- May increase plasma concentrations of digoxin
- Risk of 1st dose hypotension is increased in patients receiving βblockers or calcium-channel blockers.
C. FUROSEMIDE 40 mg OD

Diuresis agent used for treatment of hypertension.

Is a loop diureticFurosemide inhibits reabsorption of Na and chloride mainly in the
medullary portion of the ascending Loop of Henle. Excretion of potassium
and ammonia is also increased while uric acid excretion is reduced. It
increases plasma-renin levels and secondary hyperaldosteronism may
result. Furosemide reduces BP in hypertensives as well as in normotensives.
It also reduces pulmonary oedema before diuresis has set in.

Precaution:
- may cause prostate enlargement
- may lower serum calcium and magnesium level

Adverse effect:
- abdominal discomfort
- orthostatic hypotension
- dizziness and headache
- git disturbances

Interaction:
Drug – Drug interaction
- it enhances toxicity of aminoglycoside, cephalosporine, salicyclates
and lithium.
- decreased effect by probenecid
- orthostatic hypotension increased if used together with alcohol,
barbiturate, and narcotic.
DRUG RELATED PROBLEM
1.
Combivent Nebulizer
[1,2]
beta-agonist
induced hypokalaemia
beta-agonist induced hypokalaemia may be
increased by concomitant treatment with
prednisolone and diuretic (Lasix).
Slow K tablet (2 tablets 600mg per day) can be
given to prevent hypokalaemia
[1] Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names
Index, 17th edition, Lexi-Comp Inc.
[2] MIMS Malaysia 113th edition 2008

Changes In dosage regimen
Drug
Start- stop date
Combivent Nebulizer 8
hourly
9/8-17/8
Combivent Nebulizer 2
hourly for 4 times then 4
hourly for 4 times
17/8-19/8
Combivent Nebulizer 4
hourly
19/8- 21/8
Combivent Nebulizer 8
hourly
21/8- Continue Use
Regimen of Combivent Nebulizer is changed from 8 hourly to 2
hourly for 4 times then 4 hourly for 4 times may due to the frequent
bronchospasms of the patient. After 2 days (19/8), the regimen
changes to 4 hourly and subsequent 8 hourly at 21/8 may due to the
conditions of patient more controlled and less frequent attacks.
2. PREDNISOLONE1
Increase the risk of hypokalaemia with diuretic (Lasix)
and β-agonists (Salbutamol)
 Prednisolone interfere with calcium absorption and
lower bone density lead to high risk of osteoporosis if
use for long term
 Calcium level and bone density of patients need to
monitor frequently and biphosphonates (Alendronate
5mg daily[3] ) can be used.
 Risk of peptic ulcer in patient
 Calcium channel blocker may increase serum level of
Prednisolone
 Need to ensure lowest effective dose is used in elderly

[1]Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names Index, 17th edition, Lexi-Comp
Inc.
[3] Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer and Cindy W. Hamilton, 2006. Pharmacotherapy
Handbook, 7th edition, The McGraw-Hill Companies, Inc
Changes In dosage regimen
Drug
Start- stop date
Prednisolone 20mg, OD
16/8-17/8
Hydrocortisone 200mg,
IV, QID
17/8
Hydrocortisone 100mg,
IV,TDS
17/8-20/8
Prednisolone 30mg, OD
20/8-23/8
Prednisolone 20mg, OD
23/8-Continue Use
Prednisolone has been changed to hydrocortisone IV
200mg may due to the severe inflammation of
respiratory tract. The hydrocortisone dose is decreased
to 100mg and later changed to oral prednisolone 30mg
when the inflammation is more controlled. The patient
continues to take Prednisolone 20mg for antiinflammation in respiratory tract.
3. S/C ACTRAPID



1
Decrease hypoglycemic effect with corticosteroid &
furosemide
Insulin decrease potassium serum concentration lead to
hypokalaemia
Dosage adjustment:
Drug
Start- stop date
S/C Actrapid14IU, tds
4/8-6/8
S/C Actrapid 8IU, tds
9/8-12/8
S/C Actrapid 10IU, tds
12/8-Discontinue
S/C Actrapid 18/16/16IU,
tds
13/8-17/8
S/C Actrapid 14IU, tds
16/8-18/8
S/C Actrapid 14/12/12, tds 19/8-20/8
S/C Actrapid 16/14/14, tds 20/8- Continue Use
[1]Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names Index, 17th edition, Lexi-Comp
Inc.
 The
dose of Actrapid is adjusted from time
to time.
 Possibilities:
1.
2.
3.
Dosing adjustment is made based on
patient’s glucose level.
Concomitant administration of
Frusemide. Frusemide will decrease
glucose tolerance and require increase
dose of insulin
Corticosteroid
4. CLOXACILLIN[2]
 Cloxacillin
is started since 2/8 and
discontinued on 11/8. It is started again on
17/8 and is still on-going(until 23/8).
 Prolonged use may result in fungal or
bacterial superinfection, including
diarrhea and pseudomembranous colitis
 Risk of blood disorder and GI disturbances
References:
1.
Charles F.Lacy et.al, 2008. Drug Information Handbook with International Trade Names Index,
17th edition, Lexi-Comp Inc.
2.
MIMS Malaysia 113th edition 2008
LASIX (FUROSEMIDE)



Patient at risk of hypokalaemia
[1]
→
Monitor potassium level daily
→
Slow-K (2 tablets [6oo mg/tab] per day)
Frusemide level might be decreased if taken
with food
Glucose tolerance may be decreased – need
dosing adjustment of insulin
Charles F. Lacy et al. Drug information handbook with international trade name index, 17th edition,
Lexi-Comp Inc., 2008-2009.

For patient with concurrent hypertension and
diabetes:

It is recommended to used thiazide group of
diuretic [2]

Eg: Hydrochlorothiazide (25 – 200 mg daily)

However, the prednisolone may enhance
the K-depleting effect  Slow K
Joseph T. Dipiro et al. Pharmacotherapy. A pathophysiologic Approach, Seventh
Edition, The McGraw-Hill Companies, Inc., Singapura, 2008.
FELODIPINE

Dose is high (15 mg )

For elderly: recommended starting dose 2.5
mg daily

Increase by 5 mg daily in 2 weeks interval

Usual dose: 2.5 – 10 mg

Side effects due to vasodilatation (edema,
flushing, dizziness and headache) occur
more frequently

It is suggested to use non-dihydropyridine
group: verapamil and diltiazem

The dose is changed from 10 mg 15 mg  20
mg  15 mg.

The increment of dose: hypertension
condition is not well-controlled.

It is suggested to change drug: ARB
(Losartan 50 mg daily)

After that, the dose is decreased. This may
be due to the condition is under control by
the
synergistic
effect
of
other
antihypertensive drugs.

Decrement of dose can also reduce the
incident and severity of possible side
effects
PRAZOSIN


The dose is changing from 1 mg tds  2 mg
tds  3 mg tds  4 mg tds

This maybe due to the hypertension is
not well-controlled
Synergistic effect of antihypertensive
effect with furosemide and felodipine

Combination of 3 drugs cause postural
hypotension,
dizziness
and
lightheadedness

Reduced to 1 mg or 2 mg three times a
day once the condition is controlled [3]
Prazocin
www.Rxlist.com


Prazosin is the best of choice if the patient has
concurrent hypertension and BPH.
Monitor blood pressure closely.

Desired BP: < 130/80 mmHg
PANTOPRAZOLE

Maybe used for prophylaxis of peptic ulcer
caused by prednisolone. [4]

Dose: 20 mg daily(currently 40 mg BD)

Normal dose for peptic ulcer treatment

: 40 mg once daily

40 mg BD is used for Zollinger-Ellison
syndrome
MIMS, 113th Edition, 2008.



Therapy is for 2 - 4weeks
Long-term therapy may lead to bacterial
overgrowth in the GI tract
Potential of bronchitis, cough and dyspnoea
happen

Alternative: omeprazole
LIPITOR


Pantoprazole may increase the effects of
Lipitor
Potential
respiratory
(bronchitis)


adverse
effect
Alternatives: fibric acid (eg. gemfibrozil)
and niacin
It may cause constipation (up to 3%)

May lead to another drug use: liquid
paraffin
SUMMARY
REFERENCE:
[1] Barbara G. Wells, Joseph T. Dipiro, Terry L. Schwinghammer, Cecily V. Dipiro, Pharmacotherapy
Handbook, 7th Edition, McGrawHill 2009.
RECOMMENDATION
LOSARTAN
Dose: Usual starting dose 50mg OD (50mg/tab),
LOSARTAN + HYDROCHLOROTHIAZIDE
Dose: 50mg/12.5mg OD.
If after 3 weeks  100mg/25mg
(max effect after 3 weeks)
CCB (Verapamil 40mg/tab)
Dose: 240-480mg in 2-3 divided dose (HUSM Formulary)
REFERENCE:
[2] www.kck.usm.my/husm/pharmacy/formulary
Drug- drug interaction
PRESCRIPTION CASCADE
DRUG 1
ADR
DRUG 2
Other medication
related problems
ROLE OF PHARMACISTS
By: GROUP F
NASYARUDDIN BIN SIMALI
OOI KEAN LOON
SHAHMANAZREY CHE DAN
CHONG HUI SAN
CORINNE CHEW SHU LING
LAI MEI YEN
NOOR’IZAYU ABD RAZAK
NOR HIDAYAH BINTI RUZALLE
TEH WEN YEN