Core Course – Stroke
Case study answers
Case 1 – Mr Ferguson
What care issues have you identified for this patient ?
It is important to go through all the questions on the needs assessment
tool for this patient on the first occasion after discharge from hospital to
ensure that
 discharge issues are followed up
 a baseline patient/carer knowledge and understanding of the
disease and medication is established
 care issues or potential care issues are identified
The most relevant points for this patient are that Mr Ferguson and/or his
wife understand that the secondary prevention medicines are to be
continued, what they for and how and when to take them. It is particularly
important that they know all the issues surrounding warfarin and have an
anticoagulant information booklet and are familiar with the contents.
It is important that they are aware of the monitoring and tests required for
warfarin, simvastatin and lisinopril and the reason for any dosage
changes.
Advice and recommendations ?
Pharmaceutical care issues
Desired Outcomes
Actions
Risk of interactions between:
Avoidance of
myopathy (increased
risk of with
Simvastatin and
Clarithromycin in
combination)
Counsel carer on
possible effects of
combination.
Advise prescriber and
carer to delay the
increase in statin dose
until after the antibiotic
course has finished to
reduce risk of side
effect.
Avoidance of INR
increase and
associated possible
side effects
Advise prescriber of
increase in simvastatin
dose leading to increase
in INR and the need for
increased frequency of
INR monitoring. Discuss
change to atorvastatin
which does not interact
with warfarin.

Simvastatin and
Clarithromycin

Simvastatin and warfarin

Clarithromycin and warfarin
Risk carer unclear of reasons
for changes to prescribed
medicines
Risk monitoring incomplete:
 Cholesterol levels/LFTs
 Blood pressure
 INR
Risk mood assessment not
been completed
Avoidance of INR
increase and
associated possible
side effects
Advise prescriber of
clarithromycin increasing
INR and the need for
increased monitoring
during and up to 2-3
weeks after the end of
the course.
Query choice of
antibiotic and indication? penicillin allergy.
Possibility of changing to
amoxycillin/ coamoxiclav which may be
less likely to interact with
warfarin
Carer understands
Inform carer of the
the issues and is
changes agreed with
clear about actions to prescriber and the
take
reasons for the changes
and the effects to
monitor for in the patient.
Standards and
Check that carer is
targets achieved
aware of frequency of
tests and desired
outcomes
Assessment
Check that carer is
completed and
aware and informed
appropriate action
taken (SIGN
guideline)
Case 2 – Local nursing home
Suggested discussion points
 Digoxin - supply in a liquid form.
 Aspirin - supply as dispersible tablets. EC tablets are more costly than
dispersible and the EC coating has not been proven to protect against
peptic ulceration.
 Phenytoin – supply as liquid. The dose will require to be altered as
phenytoin liquid 30mg/5ml is not bioequivalent to tablets/capsules.
(90mg of 30mg/5ml liquid is equivalent to 100mg tablets/capsules).
 Dipyridamole – cannot be given via an NG tube due to MR formulation.
If the capsules are opened and the contents put down the tube, the
tube will block. There is no clinical evidence that the plain tablets
crushed and given at a dose of 100mg three or four times a day is
effective. All the recent clinical trials were performed with 200mg MR
formulation and a past trial of dipyridamole at 100mg three times a day
in combination with aspirin showed no superiority over aspirin alone.
The tablets are difficult to crush due to the outer coating and may also
block the tube. Therefore patients with an NG tube should not receive
dipyridamole until they can swallow.
Case 3 – Mr Best
Suggested discussion points
Risk factors:
 Diabetic
 Overweight
 Previous TIA (10% risk of stroke within 7 days of TIA)
 Male and age
 High blood pressure
 Cholesterol may be raised
The following require to be reinforced with Mr Best:
 association between blood pressure and stroke risk
 increased likelihood of a more major stroke following a TIA
 link between symptoms/lack of symptoms and blood pressure
management
 BP target at 4-8 months after stroke in a diabetic of less than
130/80mm Hg
 HbA1c 9 months after discharge should be < or = 6.5%
The only indication for Clopidogrel in Mr Best is if he is allergic to Aspirin.
Clopidogrel 75mg has not been proven to be superior to Aspirin 75mg alone
or the combination of Aspirin 75mg plus Dipyridamole MR 200mg twice a day
for secondary prevention of stroke.
In patients with a previously healed peptic ulcer, there is no evidence that
clopidogrel is better tolerated than aspirin. This should be discussed with the
GP.