Questions for Mrs. Daniels
Has the doctor told you how long to take the Keflex for?
Has the doctor explained what the Keflex is for?
How have her blood sugar levels been recently?
Does she feel she is experiencing any effects from any of the medications?
Does she have any additional symptoms that she feels may be concerning?
Does she have a penicillin allergy?
Medication
Keflex
Neo-Cytamen
Diaformin
Diamicron
Plavix
Caltrate
Temtab
Tritace
Pravachol
Monopril
Keflex:
Strength and Dosage
500mg
qid
1000mcg s/c once per month
500mg 2 bd
80mg 1 bd
75 mg q
600mg d
10mg n
2.5mg d
20mg n
20mg d
Date commenced
To start today
Prescribed Oct 2009
Cephalexin 500mg QID
Cephalosporin
Bactericidal- inhibit cell wall synthesis
Work against beta-haemolytic Streptococci, Staphylococci, including coagulase positive, coagulase
negative and penicillinase producing strains, Streptococcus (Diplococcus) pneumoniae, Escherichia
coli, Proteus mirabilis, Klebsiella sp.
Indications: Skin and soft tissue infections. Caused by Staphylococci and/or Streptococci.
Precautions: Impaired renal function Keflex should be administered with caution in the presence of
markedly impaired renal function. Careful clinical and laboratory studies should be made because
safe dosage may be lower than that usually recommended.
Adverse Reactions Adverse drug reactions reported with cephalexin are very rare (< 0.01%) and are
listed below.
Hepatobiliary disorders. Cholestatic jaundice, transient hepatitis, elevated ALT, elevated AST.
Immune system disorders. Allergic reactions, urticaria, angioedema.
Renal and urinary disorders. Reversible interstitial nephritis.
Neo-Cytamen
Hydroxocobalamin (vitamin B12) as chloride 1000mcg s/c once per month
Vitamin B12 is essential for normal growth, haemopoiesis, production of all epithelial cells and
maintenance of myelin throughout the nervous system. Whenever nucleic acid synthesis occurs and
therefore whenever cell reproduction occurs, vitamin B12 is required.
Contraindications Known sensitivity to hydroxocobalamin or any other ingredient in Neo-B12
Injection.
Known sensitivity to cobalt.
Interactions Concurrent administration of chloramphenicol and hydroxocobalamin may impair the
therapeutic response to hydroxocobalamin in vitamin B12 deficient patients. The haematological
response should be carefully monitored in patients receiving both these drugs.
Serum concentrations of hydroxocobalamin may be lowered by oral contraceptives.
Vitamin B12 concentrations in the blood may be reduced following administration of large and
continuous doses of folic acid. Folic acid administration may impair the therapeutic response to
hydroxocobalamin.
Diaformin
Metformin 500mg 2 bd
Metformin is a biguanide with antihyperglycaemic effects, lowering both basal and postprandial
plasma glucose. It does not stimulate insulin secretion and therefore does not produce
hypoglycaemia.
Contraindications Diabetic ketoacidosis, diabetic precoma.
Renal failure or renal dysfunction (e.g. creatinine clearance < 60 mL/minute)
Acute conditions with the potential to alter renal function such as dehydration, severe infection,
shock, intravascular administration of iodinated contrast materials (see Precautions).
Precautions Renal function. As metformin hydrochloride is excreted by the kidney, it is
recommended that creatinine clearance and/or serum creatinine levels be determined before
initiating treatment and regularly thereafter
Creatine Clearance:
Using ideal bodyweight (56 kg): 32 mL/minute
Using actual bodyweight (95 kg): 53 mL/minute
Diamicron
Gliclazide; sulphonylurea
Excretion. Approximately 70% of the administered dose appears to be excreted in the urine and 11%
in the faeces.
Contraindications Severe renal or hepatic insufficiency
Plavix
Clopidogrel 75mg
Clopidogrel is a specific and potent inhibitor of platelet aggregation.
Contraindications Hypersensitivity to clopidogrel or any of the excipients.
Severe liver impairment.
Precautions
Pharmacogenetics. Clopidogrel is a prodrug. Inhibition of platelet aggregation by clopidogrel is
mainly due to an active metabolite. The metabolism of clopidogrel to its active metabolite can be
impaired by genetic variations in CYP2C19 and by concomitant medications that interfere with
CYP2C19.
Renal impairment Experience with clopidogrel is limited in patients with severe renal impairment.
Therefore clopidogrel should be used with caution in this population.
Hepatic impairment Experience is limited in patients with moderate hepatic disease who may have
bleeding diatheses. Clopidogrel should therefore be used with caution in this population.
Temtabs
Temazepam 10mg
Benzodiazepine
Impaired renal/ liver function and blood dyscrasias. Patients with impaired renal or hepatic
function should use benzodiazepine medication with caution and dosage reduction may be
advisable. In rare instances some patients taking benzodiazepines have developed blood dyscrasias,
and some have had elevations of liver enzymes. As with other benzodiazepines, periodic blood
counts and liver function tests are recommended. The use of temazepam may worsen hepatic
encephalopathy; therefore, temazepam should be used with caution in patients with severe hepatic
insufficiency and/or encephalopathy.
Tritace 2.5mg
Ramipril 2.5mg tablets
Mechanism of action. Ramipril is a prodrug which, after absorption from the gastrointestinal tract, is
hydrolysed in the liver to form the active moiety, ramiprilat. Ramipril and ramiprilat inhibit
angiotensin converting enzyme (ACE) which is identical to kininase II.
Precautions
Hyperkalaemia. Because the ACE inhibitors decrease the formation of angiotensin II, which results
in decreased production of aldosterone, increase in serum potassium levels (> 5.5 mEq/L) are not
unexpected with this class of drugs. Hyperkalaemia is more likely in patients with some degree of
renal impairment, those treated with potassium sparing diuretics or potassium supplements and/or
consuming potassium containing salt substitutes. Diabetic patients, and particularly elderly diabetic
patients, may be at increased risk of hyperkalaemia. In some patients, hyponatraemia may coexist
with hyperkalaemia. It is recommended that patients undergoing ACE inhibitor treatment should
have measurement of serum electrolytes (including potassium, sodium and urea) regularly. This is
more important in patients taking diuretics.
Impaired renal function Ramipril can prevent progressive renal failure in patients with persistent
proteinuria in excess of 1 g/day. As a consequence of inhibition of the renin/ angiotensin/
aldosterone system, changes in renal function may be anticipated in susceptible individuals. In
patients with severe congestive heart failure whose renal function may depend on the activity of the
renin/ angiotensin/ aldosterone system, treatment with ACE inhibitors, including Tritace, may be
associated with oliguria and/or progressive azotaemia and (rarely) with acute renal failure and/or
death.
In clinical studies in hypertensive patients with unilateral or bilateral renal artery stenosis, increases
in blood urea nitrogen and serum creatinine were observed in 20% of patients. These increases are
usually reversible upon discontinuation of ACE inhibitor treatment and/or diuretic therapy. In such
patients, renal function should be monitored during the first few weeks of therapy.
Patients with unilateral renal artery disease present a special problem as deterioration of function
may not be apparent from measurement of blood urea nitrogen and serum creatinine.
Some hypertensive patients with no apparent pre-existing renal vascular disease have developed
increases in blood urea and serum creatinine which is usually minor and transient, especially when
There is insufficient experience in the use of Tritace in patients with severe renal impairment (i.e.
creatinine clearance less than 20 mL/minute/1.73 m2 body surface area).
Impaired hepatic function As Tritace is a prodrug metabolised in the liver to its active moiety,
particular caution and close monitoring should be applied to patients with impaired liver function.
The metabolism of the parent compound and therefore the formation of the bioactive metabolite
ramiprilat may be diminished, resulting in markedly elevated plasma levels of the parent compound
(due to the reduced activity of the esterases in the liver).
Pravachol
Pravachol is one of a new class of lipid lowering compounds, the HMG-CoA reductase inhibitors, that
reduce cholesterol biosynthesis.
Contraindications Hypersensitivity to any component of this medication.
Active liver disease or unexplained persistent elevations in liver function tests.
Monopril
Fosinopril 20mg
Why is she on two ACE inhibitors??
Interaction between cephalexin and metformin
Level of severity (from 1-5) = 4
Probable Mechanism :
A study in healthy volunteers showed that a single dose of cefalexin 500mg decreased the renal
clearance of metformin resulting in increase of Cmax and AUC by an average of 34% and 24%
respectively. Cefalexin may inhibit the renal tubular secretion of metformin resulting in higher
metformin serum concentrations. Monitor blood glucose levels and metformin toxicity.
Actions to be Taken :
1. Monitor patient clinically.
2. Monitor blood glucose.
3. Use combination with caution.
For presentation
Are you taking any other meds/supplements?
FGF megafol 0.5mg Mylanta qid
In a HMR always look for a reason as to why the doctor requested HMR:
-
declining renal function CrCl = 31.6mL/min
more htan 5 meds
are you taking meds regularly? No sometimes she forgets
what troubles have you been having with your meds?
Monopril developed dry cough and stopped taking it
Fosamax  stopped taking monopril, tritace and pravachol because CBF and not on doctors orders.
Have you discussed the option of Webster packing with pharmacist? NO
What are you taking Mylanta for ? some stomach upset after eating meals + heartburn
Have you been experiencing any unusual symptoms? Skin very dry especially around legs and feeet
sometimes they crack and bleed but cbf to apply cream
When do you take diabetes meds?
Takes diaformin after each meal (B, L +D) diamicron taken with breakfast + dinner.
When did you last check Blood sugar level? Doesn’t check it too tedious
Describe diet? Seeing dietitian but doesn’t stick to it because she doesn’t like to and eats take away
often . bowel movement are ok
Has she measured BP? Not herself
Do you live with anyone? Husband dead no children, father died at 70 from MI and mother from
diabetes related illness at 70 too.
Do you have a carer ? no kids and no carer
Trouble walking any balance/?
Gait disturbed , balance problems , moves around slowly, han rails in shower condition affects
movement dr. mentioned intermittent claudication.
How long ago did you start taking these medications? Are there any other medical conditions? Why
are they taking each of the meds?
Claridly understanding of what med does
Check why they take the meds multiple medications can be confusing
She’s got a stent and a pacemaker
Does she have any trouble sleeping? Yes gets up multiple times at night to take a slash and been on
temazepam for > 1month therefore bad.
Tried anything for the incontinence? No
When was the last time she saw an endocrinologist? It’s been a while
She also goes to another pharmacy. Bitch
What times do you take your meds?
5am FGF megafol
caltrate 2 after dinner
ostelin 1 after dinner
need to question cognitive function either laziness or cognitive issue
been prescribed Fosamax since 2010 but hasn’t been taking it.
Findings
Symptoms of osteomyelitis
Morning
Janument 50/500
Plavix 75
Ostelin
tritace
Keflex
Lunch
Dinner
Janumet 50/500
Caltrate
Ostelin
Bed
Diazepam
Crestor 5mg
Keflex
Keflex
Keflex