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Mastering pharmacy case studies.

Introduction

If you are training to become a pharmacist, you will have had experience with pharmacy case studies. But why are pharmacy case studies so important?

As a qualifying pharmacist, case studies bring together the threads of study over the past four years. This includes your study of subjects such as:

• Pharmacology
• Pharmaceutical chemistry
• Pharmaceutics
• Clinical pharmacy practice

In practice, pharmacists are expected to draw on this knowledge and clinically apply it where necessary. These subjects feed into one another where knowledge of one subject became necessary to advance in a second subject and so forth. University staff overseeing the course structure put that structure together with these factors in mind. Pharmacy case studies are an important component, often toward the end of your pharmacy degree, that aim to establish the most relevant details that play a role in the career of a qualified pharmacist.

Case studies give pharmacy students an opportunity to test their understanding of a specialist topic. This may be anything from the formulation and dosing of medicines; to a drug’s mechanism of action, drug interactions, and clinical appropriateness for a medicine in a given scenario for a patient with specific factors to keep in mind. Evidently, this takes practice. There are many possible case study scenarios to consider. It can be difficult to always get things right.

Case studies are, then, a special kind of barometer through which we measure the professional competency of pharmacy students .

That is why pharmacy case studies are popular in degree programs – forcing students to think critically about a given topic – whether it be blood diagnostics, epidemiology, treatment options, or drug monitoring – tying together their past year’s study and how to apply this knowledge to (potentially) real-life situations.

Below, we’ve put together an introductory case study to provide you with a clear example of what kinds of questions can be asked and how best you should approach each question. With enough practice, clinical case studies become that much easier. And with time, students learn to enjoy case studies – as they are often your first direct experience of learning real and relevant facts that have an impact on your long-term professional career.

Pharmacy Case Study – Osteoporosis

A 49-year old woman with osteoporosis has been taking Fosamax for 6-months. She visits her GP complaining of acid reflux and pain radiating down her esophagus.

• What is the active ingredient of Fosamax?
• What is the mechanism of action of this medicine?
• Suggest a reason why this patient is taking Fosamax.
• How should the GP respond to the patient’s symptoms?
• What foods and/or medicines should the patient avoid?

Explanation

The questions ask more about the medicine – how it works, what it’s indicated for, how the GP should respond to patient symptoms and what interactions, from both food and drug sources, the prescriber and pharmacist must consider.

A – The active ingredient of Fosamax is alendronate; a bisphosphonate drug.

B – Alendronate works by inhibiting osteoclast-mediated bone resorption (the process whereby bone is broken down and minerals are released into the blood).

C – As a 49-year old woman, the patient is likely post-menopausal. Bisphosphonates are routinely prescribed to prevent osteoporosis in these patients.

D – The patient may be improperly administering the medicine. Patients who do not follow the correct protocol of administering bisphosphonates are likely to experience specific symptoms, particularly relating to the esophagus and GI tract. Patients should be counseled to take the medicine in the morning on an empty stomach, whilst remaining upright, and taken with a full glass of water. This eases the bisphosphonate through the digestive tract without irritating the esophageal wall. Patients should avoid taking and food or medicines, both before and for at least 30-minutes after taking the bisphosphonate.

E – Two groups of medicines should be avoided. First, NSAIDs should be avoided; as they increase the risk of gastrointestinal side effects. Second, patients should avoid foods or supplements that contain multivalent ions such as magnesium, aluminum, or calcium. This category includes dairy products and antacids. As we learned above, bisphosphonates should be avoided with these medicines/foods for at least 30-minutes after the bisphosphonate has been taken (on an empty stomach).

Practice More Pharmacy Case Studies

The more pharmacy case studies you practice , the better prepared you are for the needs and demands that present during the licensing end of your pharmacy program. Pharmacy case studies help guide students through the must-know clinical facts about drugs and medicines; both theoretical and practical knowledge.

Clinical case studies are one of the ways in which students make the transition between an experienced, knowledgeable student and a clinical professional whose expertise can be trusted in the real world. Case studies bring pharmacy students to the next level. The more practice you put in, the better results you can expect as you progress through the licensing stage of your nascent career. That, in the end, is what matters.

That’s about it for our discussion of case studies! Check back to our pharmacy blog soon for more exclusive content to help you master the science of drugs and medicines and build your long-term career.

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Interactive Case Studies (August 2020)

How would you respond to these patients?

CASE 1: NS is a 55-year-old man who recently visited his primary-care provider (PCP) for a follow up. His medical history includes hypothyroidism, hypertension, and type 2 diabetes (T2D). He takes levothyroxine 75 mcg daily, lisinopril 20 mg daily, and metformin 1 gram twice a day. His PCP started NS on oral semaglutide 7 mg once daily for his uncontrolled T2D. After a week, NS called the pharmacy because he had difficulty falling asleep since starting the new medication. In addition, he is experiencing jitteriness and some minor unplanned weight loss. NS asks whether there are any interactions with his other medications that may have caused these adverse effects.

How should the pharmacist respond?

ANSWER: Concomitant use of oral semaglutide and levothyroxine can increase exposure to levothyroxine by 33%, according to a package insert. 1 Although the clinical relevance of this is unclear, it can be theorized that this interaction can precipitate signs and symptoms of hyperthyroidism, such as difficulty sleeping, an increased heart rate, irritability, and weight loss. NS appears to be experiencing such adverse effects. The pharmacis should ensure that NS is taking the semaglutide as directed. This includes taking the tablet in the morning at least 30 minutes before the first beverage, food, or other oral medication(s) of the day with no more than 4 ounces of plain water. Advise him to separate the administration of levothyroxine and semaglutide. In addition, tell him to take the levothyroxine at night, separated from other medications and supplements by at least 4 hours. 1 A small study shows that levothyroxine taken at bedtime improves thyroid hormone levels. 2 The pharmacist should also encourage NS to follow up with his PCP to have his thyroid-stimulating hormone levels checked and to rule out any other causes of his symptoms.

CASE 2: The ambulatory care pharmacist on staff for the day receives a consult from a provider who is looking to start an antidepressant for a female patient, DA. She has been experiencing worsening anxiety and insomnia because of the global pandemic. The patient takes zolpidem 5 mg at bedtime as needed for insomnia (taking an average of 3 doses per week) but has no documented history of antidepressant use. The provider would like to attempt prescribing zolpidem, as he thinks that it will improve with proper management of DA's anxiety. After a conversation with the provider, the patient expressed interest in trying an antidepressant but has concerns about weight gain. Upon review of her chart, the pharmacist learns that DA has no known drug allergies or contraindications to the use of antidepressants.

What recommendation should the pharmacist make to the provider to help this patient?

ANSWER: Selective serotonin reuptake inhibitors (SSRIs) are the preferred drug class for the management of generalized anxiety disorder. Three SSRIs have been shown to not only reduce symptoms but also improve remission rates. These include escitalopram, paroxetine, and sertraline. Escitalopram is the least likely to cause problems and should be considered. Paroxetine should ideally be avoided, because of DA's concern about weight gain. Sertraline is likely to worsen her insomnia. The recommended starting dose is 10 mg daily. Dose titration to 20 mg daily can be considered after 1 to 2 weeks based on DA's response and tolerability. Because symptom improvement may take several weeks, the pharmacist can recommend continuing zolpidem while initiating escitalopram. After 4 weeks, symptoms should be reassessed and deprescribing can be considered. The provider can consider tapering the zolpidem dose by 25% every week to reduce the chance of rebound insomnia.

Arian Novaj is a PharmD candidate at the University of Connecticut School of Pharmacy in Storrs. Stefanie C. Nigro, PharmD, BCACP, CDE, is an associate clinical professor at the University of Connecticut School of Pharmacy.

• Rybelsus. Prescribing information. Novo-Nordisk A/S; 2019. Accessed July 27, 2020. https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/213051s000lbl.pdf
• Bolk N, Visser TJ, Nijman J, Jongste IJ, Tijssen JGP, Berghout A. Effects of evening vs morning levothyroxine intake: a randomized double-blind crossover trial. Arch Intern Med. 2010;170(22):1996-2003. doi:10.1001/archinternmed.2010.436

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CASE STUDY 3–1

Common side effects would be included in all major compendia (e.g., Micromedex® 2.0, Clinical Pharmacology, or Facts & Comparisons) which would be a good initial search. In addition, some of the adverse effect specific resources (e.g., Meyler's Side Effects of Drugs) would be appropriate to consult for less common side effects.

CASE STUDY 3–2

There are a variety of resources that could be consulted for this information including the text Drugs in Pregnancy and Lactation or some of the major compendia (possibly, Micromedex® 2.0 or Clinical Pharmacology).

The resources classify levofloxacin as an agent with unknown safety, but likely to be safe.

In order to best answer this question, the requestor should determine if the disease state has other treatment options which have more data available and if the infant is receiving any formula supplementation.

CASE STUDY 3–3

The student might start a search for general information in a toxicology text such as Goldfrank's Toxicologic Emergencies. That could be followed with a search in Micromedex® 2.0 to find some general toxicology information; specifically the POISINDEX component of that resource would provide comprehensive information on this topic.

The student would do best to search using the generic name of the medication, in this case using chlorpheniramine.

CASE STUDY 3–4

In a case you are not familiar with a term, a general Internet search might be a good start to help streamline your search. An Internet search shows that AMDUCA stands for Animal Medicinal Drug Use Clarification Act of 1994. Knowing that the term refers to a specific piece of legislation, you would be prompted to consider searching the American Veterinarian Medical Association web page or Food and Drug Administration web page.

CASE STUDY 3–5

Since this would be an off-label use, there may be less data in the tertiary resources. In this case it is likely more efficient to do a search in the secondary resources. Medline is a good place to start.

Initially conducting a search with no restrictions/limits ensures that valuable information is not missed.

If the initial search yields a significant number of results, then a restriction to human clinical trials would be beneficial. When conducting this search, it is important to realize that the term female sexual arousal disorder has changed over time, so maybe a more general search for female sexual dysfunctions will give more responses. In addition, searching for the specific drug sildenafil will yield useful data, but expanding the search using the class of drugs will provide more data.

CASE STUDY 3–6

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Pharmacy Case Studies for Pharmacists & Medical Sciences Students

Pharmacists and healthcare practitioners are required to demonstrate knowledge and understanding of the application of therapeutics in clinical practice. Pharmacists must ensure patient safety and achieve desired health outcomes through effective decision-making. The idea of designing these case studies is to meet the needs and challenges of a modern pharmacy undergraduate curriculum. Case studies are increasingly used in pharmacy undergraduate as well as postgraduate education.

Each chapter contains five case studies, increasing in complexity from those we would expect first-year students to complete (Level 1) through to cases designed for fourth-year/pre-registration students (Level M). The chapters have been designed to follow approximately the British National Formulary chapters for ease of use. Case study scenarios include both community and hospital pharmacy situations as suited to the disease and pharmaceutical care provision.

This section is only for Bangladeshi Pharmacy/Medical Students & Professionals !

Cardiovascular case studies by Narinder Bhalla

Case study level 1 – Angina Case study level 2 – Hypertension Case study level 3 – Atrial fibrillation Case study level Ma – Heart failure Case study level Mb – Myocardial infarction

Respiratory system case studies by Soraya Dhillon and Andrzej Kostrzewski

Case study level 1 – Asthma – community Case study level 2 – Asthma – acute on chronic Case study level 3 – Chronic obstructive pulmonary disease (COPD) with co-morbidity Case study level Ma – COPD Case study level Mb – Brittle asthma

Obstetrics, gynaecology and UTI case studies by Alka Mistry

Case study level 1 – Primary dysmenorrhoea Case study level 2 – Urinary tract infections in pregnancy Case study level 3 – Pelvic inflammatory disease Case study level Ma – Endometriosis management in secondary care Case study level Mb – Management of severe pre-eclampsia/ eclampsia

Liver disease case studies by Caron Weeks and Mark Tomlin

Case study level 1 – Alcoholic cirrhosis; alcohol withdrawal Case study level 2 – Alcoholic cirrhosis; management of bleeding risk and treatment for the maintenance of alcohol abstinence Case study level 3 – Hepatic encephalopathy and ascites Case study level Ma – Pulmonary tuberculosis Case study level Mb – Liver failure  

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Liver disease case studies: Case study level 1 – Alcoholic cirrhosis; alcohol withdrawal

Cardiovascular case studies: case study level mb – myocardial infarction, cardiovascular case studies : case study level 3 – atrial fibrillation.

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