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pharming_in_koreaBefore I share my presentation, I want to note that in Dr. Oh’s lab, the patient case studies focus on ALL of the patient’s drug-related problems. Included for every drug-related problem identified, there is the FARM section (similar to SOAP; discussed in detail by Lena in a previous post) and the Rationale section, which includes epidemiology, etiology, pathophysiology, treatment/pharmacotherapy, pharmacology, PK, PD, and clinical trials information. So it can become a massive presentation. Two drug-related problems are addressed in this case study for a total of 30 pages. Rationale section has been omitted on this post for the purpose of keeping it a reasonable length.
Case Studies:
Peritoneal Dialysis-related Peritonitis
Objectives | 1. Understand the epidemiology, etiology, pathophysiology, signs and symptoms, and the diagnosis of peritoneal dialysis (PD)-related peritonitis. |
| 2. Be able to apply appropriate treatment goals and approach for PD-related peritonitis. |
| 3. Be able to assess appropriateness and make evidence-based pharmacologic recommendations for PD-related peritonitis and provide appropriate patient counseling. |
| 4. Understand the monitoring parameters of pharmacologic interventions for PD-related peritonitis. |
n Chief Complaint (CC)
• Turbid peritosol and abdominal pain
n History of Present Illness (HPI)
• Ms. K is a 47 yo female with ESRD on continuous ambulatory peritoneal dialysis (CAPD), who presents to the SNUH nephrology outpatient clinic complaining of mild abdominal pain and turbid peritosol.
• She has been managed on outpatient basis for CAPD since 2011.
• About one year ago she had a first case of PD-related peritonitis, which was cleared with abx therapy. Since then, she has had multiple PD-related infections.
• She presents today, (8/8/2013) three days after completing a course of abx therapy (on 8/5/2013) for her most recent peritonitis.
• With a suspicion of relapse and tunnel tract biofilm, she was admitted today to the nephrology ward for further evaluation.
n Past Medical History (PMH)
• h/o azotemia (9/2004)
• Dyslipidemia on med (dx 2006)
• ESRD on CAPD (dx 5/2011, SCr: 9.6 mg/dL)
– s/p CAPD cath. insertion (5/2/2011)
• h/o multiple PD-related infections
– 7/11/2012 PD-related peritonitis à cleared
• s/p Tricef (cefradine) 250mg PO q12h x 3 days (7/11/2012-7/13/2012)
• s/p cefazolin 1g IP q24h + Cefazime (ceftazidime) 1g IP q24h x 3 days (7/13/2012-7/15/2012)
• bcx/peritosol cx: (-/-)
• s/p vancomycin 1g IP q5days + imipenem/cilastatin 1g IP q12h x 28 days (7/16/2012-8/13/2012)
– 5/25/2013 PD Catheter-related infection (exit site infection)
• s/p Bactroban (mupirocin) dressing + Tricef (cefradine) 250mg PO q12h x 3 days (5/25/2013-5/27/2013)
• s/p cefazolin 1g IP q24h + ceftazidime 1g IP q24h x 3 days (5/25/2013-5/27/2013)
• wound cx: pseudomonas aeruginosa (ciprofloxacin “S”),
bcx/peritosol cx: (-/-)
• s/p ciprofloxacin PO 250mg 1 tab q12h x 3 wks (5/31/2013-6/18/2013)
– 7/15/2013 Relapsed PD-related peritonitis
• s/p cefazolin 1g IP q24h + Cefazime (ceftazidime) 1g IP q24h x 1 week (7/15/2013-7/22/2013)
• bcx/peritosol cx: (-/-)
– 7/22/2013 Relapsed PD-related peritonitis
• s/p vancomycin 1g IP q5days + imipenem/cilastatin 1g IP q12h x 2 wks (7/22/2013-8/5/2013)
• peritosol cx: ordered 8/5/2013
n Family History (FH)/Social History (SH)
• Family history:
– Pt lived in China since 2009; returned to Korea 1/2013 for CAPD management
– Son: Alport syndrome on PD
– Daughter: hematuria
• Social history:
– Alcohol hx: (-)
– Smoking hx: (-)
n Allergies and Adverse Drug Reactions
• NKDA
n Compliance History
• Practical impediment: none
• Attitudinal barrier: under-insured (cost issue); pt prefers PD, does not want HD
• Knowledge deficit: none
n Medication Profile (on admission)
• Mevalotin 40mg (Pravastatin) 1 tab PO daily pc (since 7/13/2013)
• Dianeal PD-2 1.5% 2L bag IP 4x daily (since 5/2/2011)
• Feroba you* SR (ferrous sulfate 256mg) 1 tab PO BID (since 7/13/2013)
• Beecom (vitamins B and C) 1 tab PO daily pc (since 7/13/2013)
• (Completed on 8/5/2013 Vancomycin 1g IP q24h + imipenem/cilastatin 1g IP q24h x 2 wks)
n Physical Examination (PE)
• Height 167 cm,
• Weight 55 kg
• Gen acute ill-looking, alert and oriented
• VS BP 123/79 mmHg, PR 92, RR 18, BT 36.7℃
• Skin warm & dry, no abnormal skin rash
• HEENT L/R(++/++), isocoric, prompt
dehydrated tongue(-) LNE(-)
PI(-) PTH(-/-)
• Neck LNE(-/-) JVE(-/-)
• Chest Sym exp without retraction
CBS without crackle, wheezing
RHB without murmur
• Cor or CV RRR, normal S1, S2, no m/r/g
• Abd Guarding, soft, flat, NABS
T/RT(-/-), L/S/K(-/-/-)
shifting dullness(-/-)
• B&Ext CVAT(-/-) P/C/C(-/-/-)
• Neuro A&Ox3
• GU/Rect deferred
n Review of Systems (ROS)
• General weakness(+) Easy fatigue(-) Headache/Dizziness(-/-)
• Wt loss/gain(-/-) Fever/Chills(-/-)
• Cough/Sputum/Rhinorrhea(-/-/-) Sore throat (-)
• Chest pain/Discomfort/Palpitation(-/-/-) Dyspnea(-)
• Abd pain(+) Anorexia/Nausea/Vomiting/Diarrhea/Constipation(-/-/-/-/-)
• Frequency/Urgency/Dysuria/Nocturia (-/-/-/-) Residual urine/Foamy urine(-/-)
n Labs (on admission)
Na 140 mEq/L K 3.8 mEq/L Cl 103 mEq/L
Ca 8.8 mg/dL P 5.6 mg/dL Alb 3.5 mg/dL
BUN 41 mg/dL Scr 7.53 mg/dL TCO2 27 mEq/L
Uric acid 6.7 mg/dL hsCRP 1.14 mg/dL Platelet 236 x103/ul
Hgb 11.2 g/dL Hct 47.5% T. bili 0.9 mg/dL
AST 37 IU/L ALT 39 IU/L Alk phos 74 IU/L
Random Glu 97 mg/dL HbA1c 5.7% Free T4 1.29 ng/dL
TSH 2.00 uIU/mL Apo A1 122 mg/dL Apo B 149 mg/d
Tot chol 197 mg/dL TG 124 mg/dL HDL 45 mg/dL
Peritosol: WBC 306 /ul Poly 57% PTH (no data)
Residual urine function: ~200ml/day
n Microbiology • Mostly cx(-) peritonitis • 8/8/2013 peritosol cx: enterococcus faecium (vancomycin 'S') • 5/31/2013 wound cx: pseudomonas aeruginosa (ciprofloxacin 'S') |
n Identification of Real or Potential Drug Therapy Problems:
Medical problems | Current Medication | Drug-related Problem |
#1 Recurrent peritonitis, CAPD-related | -None -Dianeal PD-2 1.5% 2L bag IP 4x daily | -Indication for a drug but no drug prescribed -Hold CAPD to rest peritoneal membrane |
#2 Hyper- phosphatemia, CKD-MBD related | None | Indication for a drug but no drug prescribed |
#3 Anemia | Feroba you* SR (ferrous sulfate 256mg) 1 tab PO BID | Maintain |
#4 Dyslipidemia | Mevalotin 40mg (Pravastatin) 1 tab PO daily pc | Maintain |
#5 Malnutrition | Beecom (vitamins B and C) 1 tab PO daily pc | Maintain |
Patient Focused Approach of Pharmaceutical Care Plan Process
n Finding of Drug Related Problem #1 PD-related peritonitis
• Subjective info
– General weakness
– Abdominal pain
– Turbid peritosol
– Acute ill-looking
• Objective info
– Peritosol: WBC 306x103/ul, Poly 47%
– hsCRP 1.14 mg/dL
– peritosol cx: enterococcus faecium (vancomycin 'S')
• Current drug therapy
– Not on medication
n Assessment of Drug Related Problem
• Etiology/Risk Factors
– Indwelling PD catheter
– h/o recurrent peritonitis
• Severity of disease
– Severe d/t relapsed peritonitis, isolation of pseudomonas aeruginosa and enterococcus faecium
• Evaluate need for therapy and/or evaluate current therapy
– Need to antibiotic treatment to control and prevent spread of infection, prevent organ damage and preserve peritoneal membrane function
n Patient Specific Recommendation
• Goals of drug therapy1
– Eliminate underlying etiology of infection: potential touch contamination, PD technique
– Decrease s/sx of peritonitis: abdominal pain
– Prevent complications of peritonitis: relapse, catheter removal, permanent transfer to hemodialysis, death
– Increase quality of life
– Minimize side effects
• Non-drug therapy interventions1
– Hold CAPD
– Within one week, PD catheter removal
– Insert perm cath for temporary hemodialysis
– Observation: monitor cell count/differential and abdominal pain
– Reevaluate for PD or HD
• Drug therapy interventions
– Continue vancomycin 1g IP q5days + imipenem/cilastatin 1g IP q12h until PD catheter removal
– Tacenol ER 650mg (acetaminophen) 1 tab PO daily for abdominal pain
– Once PD cath removed, d/c Dianeal PD-2 1.5% 2L bag IP 4x daily
• Drug Preparation, Formulation, and Administration2
– Vancomycin Inj:
– Tan powder in clear vial
– Reconstituted 500 mg and 1 g vials are stable for at either room temperature or under refrigeration for 14 days.
– Imipenem/cilastatin Inj:
– Off-white powder in clear vial
– Powder for injection should be stored at <25°C (77°F). Reconstituted I.V. solutions are stable for 4 hours at room temperature and 24 hours when refrigerated. Do not freeze.
– Tacenol ER:
– White, oval oral tablet
– Store at controlled room temperature.
• Alternative Drug Therapy1
– Linezolid 200mg oral suspension daily
– Continuous ampicillin 125mg/L each bag + gentamicin 0.6mg/kg IP q24h
– Quinupristin/dalfopristin 25 mg/L in alternate bags
– Continuous daptomycin LD 100 mg/L each bag, then MD 250 mg/L each bag
• Insurance/Cost issues2
– Vancomycin CJC: 10,233 won/10ml/vial
– Cilapenem: 9,554 won/vial
– Tacenol ER: 51 won/1 tablet
n Monitoring Plan
• Effectiveness
Parameter frequency range
Peritosol WBC q2-3days decrease (<100/ul)
Peritosol Poly q2-3days decrease (<50%)
Abdominal pain daily reduced or absent
• Toxicity
Parameter frequency range
BUN/SCr q3-5days maintain (baseline)
Sr [vanco] >once weekly increase (trough >20mcg/mL,
Platelets q3-5days decrease (140-450 x103/uL)
WBC q3-5days decrease (3.4-10x 103/uL)
ALT weekly increase (11-54 U/L)
AST weekly increase (16-41 U/L)
Hypersensitivity reaction daily occur
n Patient Education Point (Lexicomp)
Brand/ Generic | Vancomycin CJC/Vancomycin |
MOA/ Use | It is used to treat bacterial infections. |
Admin- istration | Administer vancomycin 1g via intraperitoneal route every 5 days until PD catheter |
Storage | Reconstituted 500 mg and 1 g vials are stable for at either room temperature or under refrigeration for 14 days. |
Adverse effects | -Report immediately any chills, pain, swelling, or redness at injection site, or respiratory difficulty. -Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect: - Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat. - Chest pain. - Big change in balance. - Very bad dizziness or passing out. - Flushing. - Ringing in ears. - Change in hearing. - Hearing loss. - Fever or chills. - Very bad sore throat. - Pain when passing urine. - Change in the amount of urine passed |
DDI | Avoid other drugs that are toxic to your kidney. |
Others | IV solution is to be administered IP for local effect. |
Brand/ Generic | Cilapenem (imipenem/cilastatin) |
MOA/ Use | It is used to treat bacterial infections. |
Admin- istration | Administer Cilapenem 1g via intraperitoneal route every 12 hours. |
Storage | Imipenem/cilastatin powder for injection should be stored at <25°C (77°F). |
Adverse effects | Tell your doctor or get medical help right away if you have any of the following signs or symptoms that may be related to a very bad side effect: - Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat. - Very bad dizziness or passing out. - Very upset stomach or throwing up. - Very loose stools (diarrhea), even after drug is stopped. - Change in thinking clearly and with logic. - Feeling very tired or weak. |
DDI | Avoid other drugs that are toxic to your kidney. |
Others | IV solution is to be administered IP for local effect. |
Brand/ Generic | Tacenol ER (acetaminophen) 650mg |
MOA/ Use | It is used to ease pain and fever. |
Admin- istration | One tablet is 600mg. |
Storage | Store at room temperature. |
Adverse effects | -Tell dentists, surgeons, and other doctors that you use this drug. |
DDI | Make sure to discuss with your doctor or pharmacist before starting any new medications or getting vaccines, including over-the-counter medications, herbal supplements, and vitamin supplements, while you are on this medication. |
Others | N/A |
Patient Focused Approach of Pharmaceutical Care Plan Process
n Finding of Drug Related Problem #2. Hyperphosphatemia
• Subjective info
– None
• Objective info
– Phos 5.6 mg/dL
– Ca 8.8 mg/dL
• Current drug therapy
– Not on medication
n Assessment of Drug Related Problem6
• Etiology/Risk Factors
– CKD:↓ excretion of P
– Hypoparathyroidism
• Severity of disease
– Mild (Phos 5.6-7.0 mg/dL)
• Patient’s Phos 5.6 mg/dL
• No s/sx of:
1. Organ damage from CaPO4 deposition
2. Renal osteodystrophy (CKD-MBD)
3. Hypocalcemia
4. Arrhythmia
5. Hypotension
6. ↓ bone mineral density (not measured)
7. Seizures
8. Red eye
9. Pruritus
• Evaluate need for therapy and/or evaluate current therapy
– Need to treat to prevent precipitation of calcium phosphate in the vital organs (blood vessels, eyes, heart, lungs, kidney)
n Patient Specific Recommendation
• Goals of drug therapy
– ↓ Sr Phos to target 3.5-5.5 mg/dL (target range 3.5-5.5 mg/dL for dialysis pts per K/DOQI guidelines)
– Prevent s/sx (listed above)
– Prevent long-complications of CKD: osteopenia, bone fracture, cardiovascular calcification
– Prevent morbidity and mortality
• Drug therapy interventions
– Cicibon (calcium carbonate) 500mg 1 tab PO TID pc
• Non-drug therapy interventions
– ↓dietary phosphate intake: avoid dairy, beer, many processed foods, fish, organ meats, dried beans, nuts
– Compliance with Cicibon
• Drug Preparation, Formulation, and Administration
– White, round oral tablet in sealed bottle
– Store at room temperature of 25°C (77°F)
• Alternative Drug Therapy
– Calcium acetate (Phoslo) 667mg 1 to 2 tabs PO TID pc (↓Phos and↑Ca)
– Lanthanum (Fosrenol) 750 to 1500mg/day divided pc (↓Ca and Phos)
– Renagel (Sevelamer) 800mg 1 tab PO daily pc (↓Phos only)
• Insurance/Cost issues
– Insurance coverage: yes
– 30 won/1 tablet
n Monitoring Plan
• Effectiveness
Parameter frequency range
Sr Phos daily decrease to 3.5-5.5 mg/dL (CKD-5)
Sr Ca daily increase to 8.4-9.5 mg/dL
PTH daily need to measure
• Toxicity
Parameter frequency range
Sr Ca daily increase >9.5 mg/dL (8.4-9.5mg/dL)
PTH daily decrease <150mg/mL
n Patient Education Point (Lexicomp)
Brand/ Generic | Cicibon (calcium carbonate) |
MOA/ Use | It binds and lowers high phosphate levels. |
Admin- istration | One tablet is 500mg. Take 1 tablet three times daily with meals. |
Storage | Store at room temperature. |
Adverse effects | Tell your doctor or get medical help if you experience very bad side effects related to: - Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat. - Change in thinking clearly and with logic. - Very upset stomach or throwing up. - Very hard stools (constipation). - Not hungry. - Mood changes. - Muscle weakness. - Feeling very tired or weak. |
DDI | Make sure to discuss with your doctor or pharmacist before starting any new medications or getting vaccines, including over-the-counter medications, herbal supplements, and vitamin supplements, while you are on this medication. |
Others | Don’t take any calcium-containing medications or supplements while on this medicine. |
n References
1. International Society for Peritoneal Dialysis (ISPD) Guidelines. Peritoneal dialysis-related infections recommendations: 2010 update. Perit Dial Int. 2010 Apr;30:393-423
2. druginfo.co.kr. Vancomycin. Cilapenem. Tacenol. Accessed 9/5/2013
3. Uptodate.com. Cinical manifestations and diagnosis of peritoneal dialysis. Accessed 9/5/2013
4. The clinical profiles and risk factors and outcome of CAPD peritonitis: a single center study.
Korean J Nephrol. 2001;20(4):683-694
5. Tylenol. Package Insert. http://www.tylenolprofessional.com/assets/TYL_PPI.pdf. Accessed 9/5/201
6. Uptodate.com. Treatment of hyperphosphatemia in chronic kidney disease. Accessed 9/5/2013
7. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis. 2003;42(4 Suppl 3):S1-105
8. Beling.net. Parathyroid gland. Beling.net/articles/about/Parathyroid_gland. Acessed 9/6/2013
9. Drug Bank. Calcium carbonate. Drugbank.ca/drugs/DB06724. Accessed 9/6/2013
10. Braun J, Asmus H, Holzer H, Brunkhorst R, Krause R, Schulz W, et al. Long-term comparison of a calcium-free phosphate binder and calcium carbonate-phosphorus metabolism and cardiovascular calcification. Clin Nephrol. 2004 Aug;62 (2):10-15
-Tae
