Case study 1– Rheumatoid arthritis Mrs PJ is a 67-year-old woman who has recently attended the hospital’s rheumatology clinic. She has been diagnosed with rheumatoid arthritis. She has come to the community pharmacy where you work to collect her new prescription for sulfasalazine and diclofenac.estions 1. What is rheumatoid arthritis? 2. What are the risk factors for developing rheumatoid arthritis? 3. What are the clinical features of rheumatoid arthritis? 4. What investigations are performed to help confirm a diagnosis of rheumatoid arthritis?] 5. Sulfasalazine is a DMARD. Describe its mode of action for Sulfasalazine. What is DMARD? Describe other drugs considered as DMARD. 6. When you hand Mrs PJ her dispensed prescription, what information or help would you give her to ensure that she knows how to use her medications appropriately? Case study 2 – Gout Mr KT is a 58-year-old man who has been admitted to the surgical ward on which you work for a total knee replacement. He lives with his wife and two sons. He smokes 15 cigarettes a day and usually drinks about 35 units of alcohol a week. He is slightly overweight with a BMI of 27 kg/m2. His current medication includes amlodipine 5 mg daily bendroflumethiazide 2.5 mg daily paracetamol 1 g four times a day codeine phosphate 30 mg four times a day when required, enoxaparin 40 mg s.c. daily. Apart from hypertension, he has no other co-morbidities or relevant past medical history. His operation was a success and he is recovering well. However, during his stay he develops excruciating pain in the big toe of his right foot and his toe is very swollen. He is subsequently diagnosed with gout. Questions 1. What is gout? Briefly discuss the pathophysiology of the condition. 2. List three ways in which gout can manifest itself 3. List the risk factors for developing gout and discuss which risk factors Mr KT potentially may have for developing gout. 4. Describe the symptoms of gout. 5. What investigations should the doctors carry out to help them confirm whether Mr KT has gout? 6. During your rounds, Mr KT asks you if you could tell him what he could do to avoid another attack of gout. What lifestyle advice would you give him? 7. Mr KT requires treatment for his attack of gout. Please discuss the options available for treating an acute attack. For each option discussed, include the following information: dose, contraindications to use,potential side-effects. 8. Which option would you recommend for Mr KT? 9. When you are clinically checking Mr KT’s medication chart, you notice that he is on the following medication: amlodipine 5 mg daily, bendroflumethiazide 2.5 mg daily, paracetamol 1 g four times a day. Which of these medications can aggravate gout and why? 10. Mr KT’s acute attack of gout resolves and he is discharged home. His GP is aware of his problem with gout and after he experiences a second attack of gout, his GP decides that it would be prudent to start him on some long-term prophylaxis against future attacks. Why wasn’t Mr KT prescribed prophylactic treatment after his first attack? What options are available and which one is usually the drug of choice? Case study 3– Osteoarthritisario Mrs KR is a 70-year-old woman who weighs 80 kg and is 162 cm tall. Her BMI is 30 kg/m2. Mrs KR lives alone and has no immediate family in this country. Her past medical history includes osteoarthritis and hypertension. Her medication includes: lercanidipine 10 mg daily, bendroflumethiazide 2.5 mg daily, diclofenac 50 mg three times daily, paracetamol 1 g four times daily. Her blood pressure is 138/85 mmHg and her haemoglobin level is 13.1 g/dL (12–18 g/dL). She has been admitted to hospital complaining of abdominal pain and chest pain. After an ECG, which is normal and various other tests, a cardiac problem is excluded and it is decided that she requires an OGD. Questions 1. Mrs KR has had her blood pressure and haemoglobin level checked, why might the medical staff do this? 2. What advice would you give regarding the management of this problem? 3. Mrs KR is taking analgesics to manage the symptoms of her osteoarthritis. What is osteoarthritis? 4. What are the signs and symptoms of osteoarthritis? 5. What risk factors may predispose patients to getting osteoarthritis and which risk factors does Mrs KR have? 6. What non-drug recommendations could you give her regarding the management of osteoarthritis? 7. Mrs KR is using diclofenac, an NSAID to manage the symptoms of her osteoarthritis. How do NSAIDs work in the treatment of osteoarthritis? 8. What are the contraindications and cautions for the use of diclofenac? 9. Critically appraise the alternative treatments available for osteoarthritis? 10. A year later, the GP refers Mrs KR to her consultant as she has been having difficulty walking and severe pain in her knee joint. The consultant discusses her condition and mentions the possibility of a knee replacement as the joint is badly affected. Knee replacement would involve major surgery. What are the risk factors for Mrs KR? Case study 4– Osteoporosis Mrs TY is a 77-year-old woman who has been admitted to the orthopaedic ward where you work as the clinical pharmacist. She slipped on the wet floor in a supermarket and has been diagnosed with a fractured hip. She is normally fit and well and doesn’t take any regular medication or have any relevant past medical history. She is 157 cm tall and weighs 49 kg. She lives alone, has never smoked and drinks a small glass of sherry most nights. Mrs TY is in considerable pain from her fracture. She is prescribed paracetamol 1 g four times daily and codeine 30 mg four times daily when required. She is still complaining of pain. Questions 1. What recommendations could you make to help manage her pain? 2. What are the contraindications and cautions for the analgesics you are recommending? 3. Are there any adjunctive treatments you would recommend to the doctor that should be prescribed? 4. What parameters would you monitor as you consider this woman’s pharmaceutical care? 5. Later in the week Mrs TY has surgery to repair her hip fracture. She is also diagnosed with osteoporosis. What is osteoporosis? 6. What is the difference between primary and secondary osteoporosis? 7. Which drugs may be implicated in the development of osteoporosis? 8. What are the signs and symptoms of osteoporosis? 9. What are the risk factors for osteoporosis and which does Mrs TY have? 10. What lifestyle advice could you offer to Mrs TY? 11. Discuss the options for the treatment of osteoporosis and decide which you think would be the most suitable for Mrs TY. 12. Before Mrs TY is discharged she is prescribed alendronate 70 mg once weekly and a calcium and vitamin D preparation, 1 tablet twice a day. What are the indications for alendronate? How does alendronate work? What are the side-effects of alendronate? Case study 4 – Glaucoma Mr George Smith, 61 years old, presents you with his repeat prescription. He is concerned that one of his medications is affecting his vision and asks you to identify the one that is likely to be causing this. His present medical history includes chronic obstructive pulmonary disease (COPD) and urinary incontinence. The pharmacy Patient Medication Record (PMR) includes latanoprost drops for glaucoma which was dispensed six months ago. Mr Smith’s current and past drug histories are as follows: Current drug history: Seretide 500 Accuhaler, one puff twice daily, salbutamol inhaler two puffs p.r.n., salbutamol nebuliser solution 5 mg, one 3–4 times daily, ipratropium bromide nebulising solution 500 micrograms/2 mL, one four times daily, tolterodine 2 mg twice daily, tetracycline 250 mg two twice dailyl, hypromellose 0.3% drops p.r.n. Past drug history: latanoprost 50 micrograms/mL one drop at night, tolterodine, first prescribed about six months ago for urinary incontinence by an urologist consultant. Patient’s COPD seems to be controlled on combination of inhalers and nebulizer solution. He would use salbutamol and ipratropium solution 2–3 times a day, but when his COPD got worse, he would increase to 4–6 times daily. Urinary incontinence appears to be under control at present but he has been experiencing extreme dry mouth and eyes. In recent weeks, he has noticed significant deterioration in his vision with slight redness in both eyes. He puts this down to ‘just getting old’. However he is due to see his eye consultant in six months’ time. The last appointment was about six months ago. The consultant decided to stop latanoprost eye drops and told him everything is normal. QuestionsQuestions 1. What is glaucoma, define different types and why is it important to be treated when diagnosed? 2. What are the risk factors for developing glaucoma? Identify the possible causes of worsening of his glaucoma condition. 3. Why are some drugs contraindicated in certain diseases even if they are given as eye drops? 4. How does latanoprost work in the treatment of glaucoma? Discuss the range of drugs and route of administration that can be used to treat this patient’s glaucoma.