Course Code: PHA 081
LAS # 2
CLINICAL PHARMACY &
PHARMACOTHERAPEUTICS 2 LABORATORY
Activity Title: MEDICATION THERAPY MANAGEMENT
(MTM) Neurologic and Psychiatric Disorders
Materials:
Pen, Notes & LAS
Objective: At the end of this activity, you should be able to:
References:
• https://serincenter.com/whatDiscuss the case and provide a systematic method of evaluation is-the-difference-betweenand
intervention for a patient’s pharmacotherapy
neurological-and-psychiatricdisorder
•
https://spectrum.diabetesjour nals.org
•
https://pie.med.utoronto.ca/V
IC/VIC_content/VIC
What Are Neurological Disorders
Neurological disorders occur because of malfunctions or damage
to the nervous system. That would include the brain, spinal cord,
and nerves.
The list of most notable neurological disorders would include
epilepsy, multiple sclerosis, Huntington’s disease, Parkinson’s
disease, and Alzheimer’s disease.
Treatment for these types of disorders falls under the purview of a neurologist. Typically, an MRI or
brain scam would be used to detect and diagnose the existence of one of these conditions in the brain.
If a patient gets such a diagnosis, the treatment options would include surgical procedures, physical
therapy, mental therapy, and medication.
What Are Psychiatric Disorders
Psychiatric disorders are typically associated with disturbed behavior and a patient’s emotional state.
Treatment for these types of disorders falls under the purview of a psychiatrist, psychologist, or
licensed therapist.
These types of disorders occur for a variety of reasons. The list of potential causes of psychiatric
disorders includes:
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
LAS # 2
CLINICAL PHARMACY &
PHARMACOTHERAPEUTICS 2 LABORATORY
•
Trauma (childhood abuse, death of family member, witnessing accidents, natural disasters)
•
•
Genetics (some people have a family history of mental illnesses)
Substance Abuse (drugs or alcohol)
•
Medical conditions like infections
•
Prenatal damage
Brain defects or injury
Common psychiatric disorders include Neurodevelopmental Disorders (ADHD, Autism), Bipolar and
Related Disorders (mania, depression), Anxiety Disorders (social anxiety, generalized anxiety,
panic, separation anxiety, and phobias), Stress-Related Disorders (PTSD), Dissociative Disorders
(amnesia), eating disorders (Anorexia, Bulimia), and addiction.
•
Case Presentation # 1- Cognitive Impairment, Depression, and Severe Hypoglycemia
Steve is a 67-year-old white widower and retired accountant. He
was referred for psychosocial evaluation at the diabetes clinic after
an emergency room (ER) visit to a local hospital. He arrived at the
ER with confusion and a severe hypoglycemic episode after taking
an overdose of insulin. He denied suicidal intent or alcohol abuse
and claimed to have mistakenly taken insulin lispro rather than his
insulin glargine dose. The ER staff was suspicious about his claim
because there had been eight similar ER visits for severe
hypoglycemia within the last 2 years. He explained these previous events as a result of mixing up the
types of insulin he injected.
After psychiatric assessment he was not judged to be a suicidal risk. He was discharged after his blood
glucose levels stabilized, and he promised to pursue outpatient mental health treatment. His
hemoglobin A1c (A1C) at the time was 7.9%—his lowest on record for several years. Generally, his blood
glucose levels displayed wide swings. He explained that high blood glucose levels made him feel more
apathetic about eating and depressed about his diabetes self-management.
Personal history
As a child, Steve attained developmental milestones at expected times. His father was in the Army, and
as a result, Steve had moved 32 times before he graduated from high school. He was an excellent
student throughout high school but only managed mediocre grades in college because of family conflict.
He dropped out of college in his junior year and moved to a South Pacific island for 1 year. After
returning to the United States, he earned an undergraduate degree in English and then a second degree
in accounting. After graduation, he married and worked for 20 years as an accountant in a group
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
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practice. Later, Steve started his own accounting firm, but he had difficulty keeping organized and
recalls being constantly late for business meetings and failing to complete projects on time. In
hindsight, Steve believes that he has struggled with depression on and off for > 30 years. He first recalls
feeling depressed after his diagnosis with diabetes 36 years ago. He felt more depressed after he lost
his 47-year-old sister to colon cancer in 1988, and then his 74-year-old father died from heart disease
in 1991. But, he says his life “really fell apart” when his 54-year-old wife died from lung cancer in 1995.
He contemplated suicide for 3 months but never acted. During this desperate period, he marginally
functioned, lost many business clients, and was forced to close his company. Overwhelmed by
depression, he moved to the West Coast to live with his mother and worked at unskilled jobs. Diabetes
complicated his emotional struggles, with blood glucose control fluctuating wildly and ranging from
episodes of ketoacidosis that required hospitalization to severe hypoglycemic events that resulted in
car crashes. Depression complicated his diabetes management, and after a hypoglycemia-related auto
accident in which he ran over several pedestrians, he decided to stop working and was approved for
social security because of psychiatric disability.
He came to the East Coast in 1998 to briefly visit his younger brother and decided to stay. Although he
still lives near his brother, he says they have had only sporadic contact since a falling out after Steve
“passed out” during a severe hypoglycemic episode. In 2000, Steve got engaged, but his fiancée left him
to marry the father of her child. He says he felt devastated by the loss of yet another woman who had
“become everything” to him. Since then, he has withdrawn socially and does not leave his apartment
unless it is necessary. He has trouble managing his money, keeping his apartment neat and orderly,
taking medications on time, and maintaining any structure in his day.
Medical history
Steve punctually arrives at the correct hour but often on the wrong day for his medical appointments.
He grapples with neuropathy, retinopathy, and unpredictable blood glucose levels. He monitors his
blood glucose levels 8–12 times/day and tries to be careful about what he eats. He also has sleep apnea,
and his sleep patterns are highly erratic. He frequently does not fall asleep until 4:00 A.M. and then may
only be able to sleep for 2 hours. Often, he will then nap for several hours in the afternoon. He began
continuous positive airway pressure treatment for his sleep problems in 2003 but did not tolerate
treatment. He has switched to bilevel positive airway pressure (biPAP) within the last 18 months but
only tolerates it for up to 3 hours each night.
Additional diagnoses include hyperlipidemia, hypertension, atrial fibrillation, Meniere's disease,
tinnitus, and arthritis.
His medication list includes atorvastatin, lisinopril, hydrochlorothizide, warfarin, meclizine, and folic
acid. He does not smoke and only rarely drinks alcohol. Only his paternal grandmother had diabetes.
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
LAS # 2
CLINICAL PHARMACY &
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Psychiatric history
Depression has plagued Steve since his diagnosis with diabetes. As noted earlier, his depression
intensified after the deaths of his sister and father, but he did not descend into a suicidal mood until
his wife died 10 years ago. Four years ago, he underwent electroconvulsive therapy (ECT), and although
he continues to have occasional suicidal ideation, he has not made an attempt and has had no further
psychiatric admissions. Both of his parents, his brother, and his sister suffered from depression. A
maternal aunt suffered from dementia. His mother also struggled with alcohol abuse until her death
from emphysema in 2004 at the age of 89.
At the time of referral, he was taking fluoxetine, 40 mg, and venlafaxine, 37.5 mg, prescribed by a
psychopharmacologist.
Questions:
1. Was Steve's insulin overdose accidental or a suicide attempt?

His insulin overdose was best explained by inattention or by accident, not suicidal intent as he had
mistakenly taken insulin lispro rather than his insulin glargine. His past suggested that he had experienced
difficulties with complicated cognitive processes even in his college years. Around the same time frame, he
had also seen an increase in short-term memory issues and a loss in attention span.
2. What are the causes for his cognitive impairment?

He may have suffered from cognitive deterioration due to depression, which may have been made worse by
ECT, age, three decades of diabetes, and frequent episodes of acute hypoglycemia. In fact, he said he had
become more depressed in the previous six months.
3. How do his depression and cognitive problems affect his diabetes self-management?

It is widely accepted that depression can create more difficulties in maintaining treatment adherence and
that the hardships of managing diabetes can lead to depression. Moreover, there are a lot of things, like family
and personal problems, which made it hard for Steve to become adherent to his medications. Steve lost his
appetite when depressed and increased his risk of hypoglycemia.

References: Zrebiec, J. (2006). Case Study: Cognitive Impairment, Depression, and Severe
Hypoglycemia. Retrieved from:
https://www.researchgate.net/publication/244936330_Case_Study_Cognitive_Impairment_Depression_
and_Severe_Hypoglycem
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4933534/


SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
LAS # 2
CLINICAL PHARMACY &
PHARMACOTHERAPEUTICS 2 LABORATORY
4. Discuss all the medications of Steve.

-
Atorvastatin
-
Belongs to a group of medicines called statins. It is use to lower cholesterol and in this case the patient has
been diagnosed with hyperlipidemia.
(Side effects)
Feeling sick or indigestion
Headache
Nosebleed
Sore throat

Lisinopril
-
-
-
Is an angiotensin-converting-enzyme (ACE) inhibitor and is used to treat high blood pressure.
- An angiotensin converting enzyme inhibitor (ACEI), preventing the conversion of angiotensin I to
angiotensin II.
(Side effects)
Dry, tickly, cough
- Itching or mild skin rash
- Blurred vision

Hydrochlorothiazide
-
-
Belongs to a class of drugs known as diuretics/"water pills." Lisinopril and hydrochlorothiazide combination
is used to treat high blood pressure (hypertension).
Indicated as adjunctive therapy in edema associated with congestive heart failure, hepatic cirrhosis, and
corticosteroid and estrogen therapy.
(Side effects)
Blood pressure that is lower than usual
Erectile dysfunction
Tingling hands, legs, and feet

Warfarin
-
-
-
Is an oral anticoagulant commonly used to treat and prevent blood clots. It is prescribed for patients with
irregular heartbeat.
- Competitively inhibits the vitamin K epoxide reductase complex 1 (VKORC1), an essential enzyme for
activating the vitamin K available in the body. Through this mechanism, warfarin can deplete functional
vitamin.
(Side effects)
Abdominal pain
- Change in way thing taste
- Loss of hair
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
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CLINICAL PHARMACY &
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
Meclizine
-
Is an antihistamine. It works to block the signals to the brain that cause nausea, vomiting, and dizziness.
A first-generation antihistamine (non-selective H1 antagonist). It also has central anticholinergic actions.
The blocking actions on these receptors give meclizine its antiemetic and anti-vertigo properties.
On rare occasions, there have been reports of blurred vision and anaphylactic reactions.
The potential anticholinergic actions of meclizine pose a risk to patients with asthma, glaucoma, or an
enlarged prostate gland. Caution is necessary with the use of the drug in such patients
(Side effects)
Drowsiness
Urinary retention
Dry mouth
-
-
-

-
Folic acid
-
A naturally occurring B vitamin, is needed in the brain for the synthesis of norepinephrine, serotonin, and
dopamine. Supplementation with folate may help reduce depressive symptoms and mild cognitive
impairment.
(Side effects)
Feeling sick
Loss of appetite
Bloating or wind

Fluoxetine 40 mg
-
Is a type of antidepressant known as a selective serotonin reuptake inhibitor (SSRI). It's often used to treat
depression, and sometimes obsessive compulsive disorder and bulimia. It works by increasing the levels of
serotonin in the brain.
Used to treat depression, obsessive-compulsive disorder (OCD), bulimia nervosa, premenstrual dysphoric
disorder (PMDD), and panic disorder.
(Side effects)
Being unable to sleep
Diarrhea
Feeling tired or weak
-
-

-
-
Venlafaxine 37.5 mg
Is from of a group of antidepressants called serotonin and noradrenaline reuptake inhibitors, or SNRIs. It
is thought to work by increasing the levels of mood-enhancing chemicals called serotonin and
noradrenaline in the brain. It's used to treat depression and sometimes anxiety and panic attacks.
(Side effects)
Sweating and hot flushes
Dry mouth
Being unable to sleep
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
LAS # 2
CLINICAL PHARMACY &
PHARMACOTHERAPEUTICS 2 LABORATORY
References:
 NHS website. (2022, April 28). Side effects of atorvastatin. nhs.uk.
https://www.nhs.uk/medicines/atorvastatin/side-effects-of-atorvastatin/

NHS website. (2022b, February 2). Side effects of lisinopril. nhs.uk.
https://www.nhs.uk/medicines/lisinopril/side-effects-of-lisinopril/
https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/040735s004,040770s003lbl.pdfv

Patel S, Singh R, Preuss CV, et al. Warfarin. [Updated 2022 Sep 21]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK470313/
Warfarin: MedlinePlus Drug Information. (n.d.-b). https://medlineplus.gov/druginfo/meds/a682277.html
Houston BT, Chowdhury YS. Meclizine. [Updated 2022 Jul 18]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK560645/
NHS website. (2022g, April 6). Side effects of folic acid. nhs.uk.
https://www.nhs.uk/medicines/folicacid/side-effects-of-folic-acid/
Fluoxetine (Oral Route). (2023b, February 7). Â.
https://www.mayoclinic.org/drugssupplements/fluoxetine-oral-route/description/drg-20063952
NHS website. (2022d, February 28). Side effects of fluoxetine. nhs.uk.
https://www.nhs.uk/medicines/fluoxetine-prozac/side-effects-of-fluoxetine/
Singh D, Saadabadi A. Venlafaxine. [Updated 2022 Oct 10]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK535363/ 
NHS website. (2023, February 23). Side effects of venlafaxine. nhs.uk.
https://www.nhs.uk/medicines/venlafaxine/side-effects-of-venlafaxine/
Psychopharmacology Institute. (n.d.).
https://psychopharmacologyinstitute.com/section/thepsychopharmacology-of-fluoxetine-mechanism-ofaction-indications-pharmacokinetics-and-dosing2051-4051
Olvera Lopez E, Parmar M, Pendela VS, et al. Lisinopril. [Updated 2022 Jul 12]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK482230/
University of Illinois. (2023c, February 12). Hydrochlorothiazide, oral tablet.
https://www.medicalnewstoday.com/articles/hydrochlorothiazide-oral-tablet









5. What are your recommendations? (Drug and Non-Drug)


Using pen insulin to avoid mixing up different types of insulin.
The patient should try to regulate his sleeping patterns, specifically avoiding long afternoon naps. Long sleep
time and an irregular sleep–wake rhythm are involved in declines in executive function and working memory
in older people. Thus in order to help improve his cognitive function, a good night sleep should be worked
on.
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
LAS # 2
CLINICAL PHARMACY &
PHARMACOTHERAPEUTICS 2 LABORATORY


Medications for controlling his blood glucose levels should be continued to prevent high blood sugar.
However, proper taking should be noted to avoid hypoglycemic attacks. There must be a use of continuous
glucose monitoring for the reduction of hypoglycemia.
The patient can be referred to hospital-based group for people suffering from depression and to one of the
clinic’s diabetes support group to enhance his social connection and lessen his depressive state while slowly
improving his diabetic condition. Psychosocial interventions will help in patients with depressive disorders.
References:
- American Diabetes Association; 9. Cardiovascular Disease and Risk Management. Diabetes Care 1 January
2017; 40 (Supplement_1): S75–S87. https://doi.org/10.2337/dc17-S012
- Hua J, Sun H, Shen Y. Improvement in sleep duration was associated with higher cognitive function: a new
association. Aging (Albany NY). 2020 Oct 20;12(20):20623-20644. doi: 10.18632/aging.103948. Epub
2020 Oct 20. PMID: 33082298; PMCID: PMC7655193.
- Okuda, M., Noda, A., Iwamoto, K. et al. Effects of long sleep time and irregular sleep–wake rhythm on
cognitive function in older people. Sci Rep 11, 7039 (2021). https://doi.org/10.1038/s41598-021-85817- y
- Lustman PJ, Freedland KE, Griffith LS, Clouse RE. Fluoxetine for depression in diabetes: a randomized
double-blind placebo-controlled trial. Diabetes Care. 2000 May;23(5):618-23. doi:
10.2337/diacare.23.5.618. PMID: 10834419.
- Nordmo, M. (2020, May 20). Effectiveness of Open-Ended Psychotherapy Under Clinically Representative
Conditions. Frontiers. https://www.frontiersin.org/articles/10.3389/fpsyt.2020.00384/full
- Summary of Revisions: Standards of Medical Care in Diabetes (2021)
Instructions:
1. Read and analyze the case.
2. Discuss the case with your group mates.
3. Answer the questions given related to the case (support your answer by providing the
reference/s).
4. Present and discuss your answers with your teacher as scheduled.
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
LAS # 2
CLINICAL PHARMACY &
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Case Presentation #2- Schizophrenia
Ms. L.O. is a 56 year-old female with a 30 year history of
Schizophrenia (multiple episodes) brought to the Psychiatric
Emergency Unit by her brother, David, following three weeks
of worsening auditory hallunications, disorganization and
increased agitation.
Psychiatric Emergency Management Assessment Notes
Day: 0 - 17:00 56 year-old female with a history of Schizophrenia, multiple episodes, currently in an
acute episode. Presents with increasing auditory hallucinations and disorganized thought content
since stopping olanzapine ~ 3 weeks ago. Psych Hx: Schizophrenia x 30 years, several past admissions
at multiple psychiatric facilities related to non compliance with oral medications. Medical Hx: HTN,
controlled with medication Meds: see pharmacy report Social Hx: Supported by ODSP, lives in group
home. Plan: admit to General Psychiatry for stabilization Restart medications Dr. S. Bingham, Staff
Psychiatrist
Nursing Notes on day of Admission
Day 0: 23:30 Patient transferred from PEMU at 19:30, admitted with increased auditory hallucinations
and disorganization. Patient oriented x 3. Ambulating well with no restrictions/gait aides. Observed
responding to internal stimuli. Acknowledged hearing voices, but unwilling to discuss content. When
asked, patient stated that medications are helpful in decreasing the volume and frequency of auditory
hallucinations, but she feels that they have "made [her] gain so much weight" and "feel so tired and
lazy." Patient accepted PRN doses of loxapine 25 mg at 20:30h for agitation with good effect. At 22: 00
patient requested and was given lorazepam 1 mg for insomnia. Currently sleeping.
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
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Previous admission note
ID: 55 year old woman from home RFR: cough, chest congestion x 7 days PMHx: hypertension,
schizophreina Meds: risperidone 4 mg HS, rampiril 2.5 mg QAM, lorazepam 1 mg QHS Allergies:
haldol, abilify, penicillin (reactions unknown) HPI: 7 day history of worsening cough, with sputum, ++
SOB, and fatigue. Patient reports she is unable to sleep due to cough/chest pain on coughing. No recent
hospitalizations or treatment with antibiotics. Social Hx: denies cigarettes, ETOH, reports occasional
marijuana use but none in last 3 weeks, denies other recreational substances. Investigations:
Temperature: 39 C, RR: 28 breaths per min, Chest xray shows consolidation consistent with
pneumonia, bloodwork pending IMP: 55 year-old female with 7 day history of worsening cough, chest
pain, SOB, fever and tachypnea. Chest X-Ray consistent with pneumonia. Likely CAP as no recent
hopsitalizations, contact with healthcare.
Current Admission Orders from General Psychiatry
Day 0: 17:30 Admit to General Psychiatry -Olanzapine 20 mg QHS -Ramipril 10 mg QAM -Zopiclone
7.5 mg QHS -Vitamin D 1000 units QAM -Loxapine 25 mg PO/IM Q2H PRN agitation, MAX: 100 mg in
24 hours -Lorazepam 1 mg PO/IM Q2H PRN agitation/insomnia, MAX: 6 mg in 24 hours
Patient Communication
"When my head hurts, I take 1 or 2 Tylenol extra strength."
"I take one for my blood pressure and another one to help me sleep. That one is blue."
"I take vitamin D 1000 for my bones."
"I take my medications myself. If I don't want to take them, I don't take them and I don't want to take
olanzapine. "
"At the group home, the staff remind me to take my medications, but they can't force me."
Medication Allergies: "I had a rash when I took Amoxicillin." "My hand wouldn't stop shaking when I
was taking Haldol." "Abilify made me feel like I was jumping out of my skin"
Food allergies: "I don't like bananas."
"Sometimes I smoke some pot if I can't sleep, but nothing stronger."
Pharmacy Communication
Pharmacy Report (Current Medications): Olanzapine 20 mg QHS Ramipril 10 mg QAM Zopiclone 7.5
mg QHS Medications dispensed every 2 weeks in blister packages.
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
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PHARMACOTHERAPEUTICS 2 LABORATORY
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
LAS # 2
CLINICAL PHARMACY &
PHARMACOTHERAPEUTICS 2 LABORATORY
Possible Drug Therapy Problems (DTPs)
•
Patient is at risk of developing a venous thromboembolism secondary to hospitalization and
requires prophylaxis. (Additional therapy required)
•
•
•
Patient is at risk of excess sedation and falls secondary to too much lorazepam. (Dose too high)
Patient is at risk of agranulocytosis secondary to olanzapine. (Adverse reaction)
Patient is experiencing signs of Type 2 Diabetes and requires treatment. (Additional therapy
needed)
•
Patient is experiencing worsening symptoms of schizophrenia secondary to ineffective therapy
with olanzapine. (Ineffective drug)
•
Patient is at risk of ongoing symptoms of schizophrenia (auditory hallucincations,
disorganization) and future hospitalizations secondary to medication non-adherence.
(Adherence)
•
Patient is at-risk of developing osteoporosis due to inadequate calcium intake and requires
additional therapy. (Additional therapy needed)
•
Patient is at-risk of hypotension and syncope due to an interaction between loxapine and
ramipril. (Adverse reaction)
•
Patient is at risk of a vascular event and requires treatment. (Additional therapy needed)
Possible Managements
•
•
•
•
Recommend restarting olanzapine and titrate to an increased dose of 25 mg QHS.
Initiate rosuvastatin 10 mg QHS
Initiate metformin 500 mg once daily and titrate to target dose of 1000 mg BID
Recommend treatment with a long-acting injectable medication: risperidone 25 mg
microspheres IM Q 2 weeks
•
•
•
Initiate valsartan 80 mg QAM.
Initiate ASA 81 mg for primary vascular prevention
Recommend treatment with a long-acting injectable medication: aripiprazole 400 mg IM Q 4
weeks
•
•
Recommend restarting olanzapine and titrate to patient's home dose of 20 mg QHS.
Initiate glargine 10 units QHS and metformin, titrate doses as appropriate.
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
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•
•
Initiate clozapine 12.5 mg and titrate, per protocol to a target dose of 300 mg QHS.
Refer patient to dietician and provide lifestyle counselling. Reassess in 2 to 3 months.
Possible Drug Therapy Problems (DTPs)
1. Patient is experiencing signs of Type 2 Diabetes and requires treatment. (Additional therapy needed)


The patient was diagnosed with diabetes after having a HbA1c of 8.5%. The hemoglobin A1C (HbA1c)
test determines the amount of glucose (blood sugar) attached to your hemoglobin. A1C levels of less than
5.7% are considered normal, levels of 5.7% to 6.4% are considered prediabetes, and levels of 6.5% or
higher are considered diabetes. The higher the A1C within the 5.7% to 6.4% prediabetes range, the
greater the risk of developing type 2 diabetes (CDC, 2018).
The patient's FBG is also elevated above the normal range; elevated fasting blood glucose concentration
(hyperglycemia) is a risk factor for diabetes.
References:
 CDC. (2018, August 21). All About Your A1C. Centers for Disease Control and Prevention.
https://www.cdc.gov/diabetes/managing/managingbloodsugar/a1c.html#:~:text=Your%20A1C%20Result&text=A%20normal%20A1C%20level%20is
 WHO. Indicator Metadata Registry Details. (n.d.). Mean fasting blood glucose. Retrieved from
https://www.who.int/data/gho/indicator-metadata-registry/imr-details/2380
2. Patient is at risk of ongoing symptoms of schizophrenia (auditory hallucincations, disorganization) and
future hospitalizations secondary to medication non-adherence. (Adherence)

Patient is at risk of ongoing symptoms of schizophrenia (auditory hallucinations, disorganization) and
future hospitalizations secondary to medication non-adherence. (Adherence) -After quitting her
antipsychotic, the patient was admitted to the hospital for psychotic symptoms. Non-adherence to
medication is linked to a higher risk of psychosis recurrence and ongoing symptoms. Non-adherence to
medicine can result in relapse, which can result in repeated trips to the ER, readmissions, and a greater
need for clinician intervention, all of which result in higher costs to the system. medical systems (Eticha
et al., 2015).
Reference:
 Eticha, T., Teklu, A., Ali, D., Solomon, G., & Alemayehu, A. (2015). Factors Associated with Medication
Adherence among Patients with Schizophrenia in Mekelle, Northern Ethiopia. PLOS ONE, 10(3), e0120560.
https://doi.org/10.1371/journal.pone.0120560
3. Patient is at risk of a vascular event and requires treatment. (Additional therapy needed)

According to CDA recommendations, the patient's A1C supports the diagnosis of diabetes, and therapy is
recommended. in order to stop a vascular event. It is commonly known that individuals with T2DM and
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
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CLINICAL PHARMACY &
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pre-diabetes have a 2-3- rise in CVD risk by a factor of two (CPG for the Management of Type 2 Diabetes
Mellitus 2020). Since the majority of diabetics have a very high lifetime risk of developing a CVD event,
an early vascular protection plan is appropriate. It has been demonstrated that reducing the risk of CVD
events requires a comprehensive approach to all vascular preventative strategies (Canadian Diabetes
Association Clinical Practice Guidelines Expert Committee & Cheng, 2013).
References:
 Ministry of Health Malaysia Academy of Medicine Malaysia Malaysia Endocrine & Metabolic Society
Family Medicine Specialists Association of Malaysia Diabetes Malaysia MANAGEMENT OF TYPE 2
DIABETES
MELLITUS.
(n.d.).
https://mems.my/wpcontent/uploads/2021/01/CPG_T2DM_6thEdition_2020.pdf
 Canadian Diabetes Association Clinical Practice Guidelines Expert Committee, & Cheng, A. Y. Y. (2013).
Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of
diabetes in Canada. Introduction. Canadian Journal of Diabetes, 37 Suppl 1, S1-3.
https://doi.org/10.1016/j.jcjd.2013.01.009
4. Patient is at risk of excess sedation and falls secondary to too much lorazepam. (Dose too high)
 Lorazepam, a benzodiazepine, was discovered in the patient's urine, according to the findings of the Drug
of Abuse Screen.
5. Patient is at-risk of hypotension and syncope due to an interaction between Loxapine and Ramipril.
(Adverse reaction)
 Loxapine is an antipsychotic medication, whereas Ramipril is an ACE inhibitor. Antipsychotics may
interact with blood pressure medications such as ACE inhibitors, beta-blockers, calcium channel
blockers, and others, causing the heart to beat abnormally or severely lowering blood pressure.
Reference:
 Watson, S. (2022, January 21) WebMD. Schizophrenia Meds: Drug Interactions to Check On. Retrieved
from: https://www.webmd.com/schizophrenia/schizophrenia-meds-drug-interactions
Possible Managements
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 Initiate Rosuvastatin 10 mg QHS
Possible; Rosuvastatin, a statin medication, raises HDL while decreasing LDL, triglycerides, and total
cholesterol. It is recommended as the primary prevention of cardiovascular events for diabetics. According
to the American College of Cardiology's guideline on blood cholesterol management, patients with diabetes
mellitus between the ages of 40 and 75 should take a moderate-intensity statin. Furthermore, rosuvastatin
10 mg is one of the moderate-intensity statins recommended by the ACC/AHA guidelines for the abovementioned patient category based on age, risk factor, LDL cholesterol levels, and a 10-year ASCVD risk
assessment.
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
LAS # 2
CLINICAL PHARMACY &
PHARMACOTHERAPEUTICS 2 LABORATORY
-
 Initiate Metformin 500 mg once daily and titrate to target dose of 1000 mg BID
This is an alternative for Ms L.O.'s management. Because the patient has Type 2 Diabetes and requires
treatment because of Olanzapine (which causes an increase in glucose levels, thereby exacerbating the
diabetes), additional therapy is required. Metformin is used to treat type 2 diabetes alone or in combination
with other medications, including insulin (condition in which the body does not use insulin normally and,
therefore, cannot control the amount of sugar in the blood). It functions by reducing endogenous glucose
production. Since the patient also complains of weight gain due to effects of olanzapine, metformin is
increasingly the drug of first choice in overweight patients with type 2 diabetes because of this insulin-sparing
effect and because it does not increase weight—unlike insulin, secretagogues, or the thiazolidinediones.
Treatment is initiated at 500 mg with a meal and increased gradually in divided doses. Common schedules
would be 500 mg once or twice daily increased to 1000 mg twice daily. The maximal dosage is 850 mg three
times a day.

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Recommend treatment with a long-acting injectable medication: risperidone 25 mg
microspheres IM Q 2 weeks
Possible; Risperidone, a second-generation antipsychotic with long-lasting effects, is available as a single
injection. Long-acting risperidone administered intravenously has advantages in terms of bioavailability,
compliance, and medication administration. Poor adherence raises the risk of relapse, hospitalization, and
suicide, and it is a barrier to effective schizophrenia treatment (Bayle et al., 2015). Long-acting depot
preparation can assist you in continuing your antipsychotic treatment. Long-acting injectable antipsychotics
have the advantage of not requiring daily administration, having a lower risk of overdose, having fewer
chances of abrupt or rapid relapses, and preventing partial or nonadherence. This treatment plan calls for
starting with 2 mg of oral risperidone and gradually increasing to 4 mg on the second day for three weeks.
 Initiate Valsartan 80 mg QAM
If an ACE inhibitor is not a viable option for the patient, the next in line drug would be angiotensin receptor
blocker drugs, according to JNC7 guidelines. Ms Lo, for instance, had trouble sleeping due to a cough that
caused chest pain. According to an NCBI study, the most common side effect of ACE inhibitors is a dry, tickly,
and often bothersome cough. According to recent research, cough may develop in approximately 10% of ACE
inhibitor patients. This adverse effect is the reason why the patient should switch from ACE inhibitor to
ARBs. According to a study published in NCBI, ARBs do not cause cough, unlike ACE inhibitors.
 Refer patient to dietician and provide lifestyle counselling. Reassess in 2 to 3 months.
Possible; Patient had previously used olanzapine, a drug associated with an increased risk of weight gain and
insulin resistance. A dietician's medical nutrition therapy is recommended for all types of diabetes. A highfat diet is recommended to improve glucose metabolism and lower the risk of cardiovascular disease.
Furthermore, changing one's lifestyle is critical for managing dyslipidemia, and a low-fat, low-cholesterol
diet is recommended. Lifestyle changes involving food and exercise are frequently recommended as the first
line of treatment in psychiatric patients with metabolic syndrome caused by antipsychotics.
References:
 DeJongh B. M. (2021). Clinical pearls for the monitoring and treatment of antipsychotic induced
metabolic
syndrome.
The
mental
health
clinician,
11(6),
311–319.
https://doi.org/10.9740/mhc.2021.11.311
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
LAS # 2
CLINICAL PHARMACY &
PHARMACOTHERAPEUTICS 2 LABORATORY
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2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the
American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines.
J Am Coll Cardiol 2019;March 17
Clinical Practice Guideline for Schizophrenia and Incipient Psychotic Disorder
Gonzales-Santos, L., Oliva, R., Jimeno, C., Gonzales, E., Balabagno M., Ona, D., et al. (2020). Executive
Summary of the 2020 Clinical Practice Guidelines for the Management of Dyslipidemia in the
Philippines. Journal of the ASEAN Federation of Endocrine Societies 36(1).
https://doi.org/10.15605/jafes.036.01.01.
American Diabetes Association; 9. Pharmacologic Approaches to Glycemic Treatment: Standards of
Medical Care in Diabetes—2021. Diabetes Care 1 January 2021; 44 (Supplement_1): S111–S124.
https://doi.org/10.2337/dc21-S009
The American Psychiatric Association Practice Guideline for the Treatment of Patients With
Schizophrenia
Bertram G. Katzung - Basic & Clinical Pharmacology 14th edition
https://medlineplus.gov/druginfo/meds/a696005.html
https://www.medscape.com/viewarticle/488954#:~:text=Long%2Dacting%20injectable%20antipsych
otics%20have,struggle%2 0with%20daily%20medication%20administration.
DeJongh B. M. (2021). Clinical pearls for the monitoring and treatment of antipsychotic induced
metabolic syndrome. The mental health clinician, 11(6), 311–319.
https://doi.org/10.9740/mhc.2021.11.311
Overlack A. (1996). ACE inhibitor-induced cough and bronchospasm. Incidence, mechanisms and
management. Drug safety, 15(1), 72–78. https://doi.org/10.2165/00002018-199615010-00006
https://www.sciencedirect.com/topics/pharmacology-toxicology-and-pharmaceuticalscience/angiotensinreceptorantagonist#:~:text=ARBs%20have%20a%20low%20rate,in%20patients%20with%20uncompli
cated%20hypertension.&
text=Cough%20does%20not%20occur%20with,angioedema%20is%20rarely%20a%20problem
Cooper, S. J., Reynolds, G. P., With expert co-authors (in alphabetical order):, Barnes, T., England, E.,
Haddad, P. M., Heald, A., Holt, R., LingfordHughes, A., Osborn, D., McGowan, O., Patel, M. X., Paton,
C., Reid, P., Shiers, D., & Smith, J. (2016). BAP guidelines on the management of weight gain,
metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug
treatment. Journal of psychopharmacology (Oxford, England), 30(8), 717–748.
https://doi.org/10.1177/0269881116645254
Gonzales-Santos, L., Oliva, R., Jimeno, C., Gonzales, E., Balabagno M., Ona, D., et al. (2020). Executive
Summary of the 2020 Clinical Practice Guidelines for the Management of Dyslipidemia in the
Philippines. Journal of the ASEAN Federation of Endocrine Societies 36(1).
https://doi.org/10.15605/jafes.036.01.01.
https://medlineplus.gov/druginfo/meds/a694015.html
https://www.medscape.com/viewarticle/488954#:~:text=Long%2Dacting%20injectable%20antipsych
otics%20have,struggle%2 0with%20daily%20medication%20administration. *
https://bmcpsychiatry.biomedcentral.com/articles/10.1186/1471-244X-12-218#citeas Bertram G.
Katzung - Basic & Clinical Pharmacology 14th edition
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
LAS # 2
CLINICAL PHARMACY &
PHARMACOTHERAPEUTICS 2 LABORATORY


https://www.inhealthonline.com/health-coach-blog/what-is-lifestyle-therapy-and-why-is-it-thenewblockbustermedicine#:~:text=With%20an%20emphasis%20on%20nutrition,manage%20and%20i
mprove%20chronic%20dis ease
Hakami, A. Y., Felemban, R., Ahmad, R. G., Al-Samadani, A. H., Salamatullah, H. K., Baljoon, J. M.,
Alghamdi, L. J., Ramadani Sindi, M. H., & Ahmed, M. E. (2022). The Association Between
Antipsychotics and Weight Gain and the Potential Role of Metformin Concomitant Use: A
Retrospective Cohort Study. Frontiers in psychiatry, 13, 914165.
https://doi.org/10.3389/fpsyt.2022.914165
SWU PHINMA, College of Pharmacy 2020
Course Code: PHA 081
LAS # 2
CLINICAL PHARMACY &
PHARMACOTHERAPEUTICS 2 LABORATORY
GROUP 4
DY, GEORGELYN
ESMAIL, BOCAIRA
ESPINOSA, LAWRENCE
ESTRADA, SHIELA
ESTRERA, REJHE KAYE
BSPHA C-2
SWU PHINMA, College of Pharmacy 2020