Clinical Pharmacy and Therapeutics. EditEd by. Roger Walker bPharm, Phd, FRPharmS, FFPH. Professor of Pharmacy Practice,. Welsh School of Pharmacy. Clinical Pharmacy and Therapeutics Commissioning Editor: Pauline Graham Development Editor: Nicola Lally Project Manager: Kerrie-Anne McKinlay. Trove: Find and get Australian resources. Books, images, historic newspapers, maps, archives and more.
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Coronary heart disease. Chronic heart failure. Respiratory disorders: Asthma. Chronic obstructive pulmonary disease. Neurological and psychological disorders:Insomnia.
Anxiety disorders. Affective disorders. Nausea and vomiting. Infections: Respiratory infections. Urinary tract infections.
Gastrointestinal infections. Infective meningitis. In patients who are penicillin sensitive, the triple therapy regimen considered consists of a proton pump inhibitor, clarithromycin and metronidazole. Telithromycin is a derivative of erythromycin that is not used in Helicobacter pylori eradication therapy. A25 D In patients affected by the human immunodeficiency virus HIV , the aim of treatment is to decrease the plasma viral load as much as possible for the longest possible time.
Before starting treatment or when changing drug therapy, viral sensitivity to antiretroviral agents should be established.
The onset of drug resistance is reduced by using combination of drugs so as to have a synergistic or additive effect. Care should be taken to ensure that the combination used does not have an additive toxicity as antiretrovirals are toxic. Common combinations include two nucleoside reverse transcriptase inhibitors and either an HIV-protease inhibitor or a non-nucleoside reverse transcriptase inhibitor.
In HIV, viral replication leading to accumulation of mutations results in the emergence of drug-resistant variants and consequently disease progression. It occurs in patients with hyperglycaemia and ketosis as a result of insulin deficiency. Normally diabetic patients with hyperglycaemia do not progress to diabetic ketoacidosis. Factors that could precipitate the condition include infection, dehydration, surgery, sustained strenuous exercise, trauma.
Patients with diabetic ketoacidosis present with a fruity odour of acetone on the breath, mental confusion, dyspnoea, nausea, vomiting, and dehydration. The condition may lead to coma. Retinopathy is a complication of diabetes that could lead to blindness.
Questions 27—31 Pulmonary oedema may result from the failure of a number of homeostatic mechanisms and it is a condition that can develop acutely and can be fatal.
It most commonly occurs as a result of chronic heart failure. Diuretics provide a dramatic improvement of the condition. A27 C Signs and symptoms of pulmonary oedema include dyspnoea, cough, orthopnoea, and tachypnoea. Owing to the accumulation of extravascular fluid in lung tissues, alveoli and in the extremities, the patient may present with an increase in weight.
A28 C An acute attack of pulmonary oedema may develop due to progressive heart failure or when the patient is not compliant with medication, particularly the diuretic therapy. It may also occur due to hypervolaemia, such as when compromised and non-compromised patients are exposed to an excessive fluid Test 1 Answers 39 infusion rate or to a high sodium intake.
Conditions that lead to an increased metabolic demand, such as high fever and hyperthyroidism, may also precipitate acute pulmonary oedema. A29 B Metolazone is a diuretic that is associated with profound diuresis, especially when it is combined with a loop diuretic.
Patients receiving metolazone should be monitored for electrolyte imbalance and outcome of therapy may be assessed by measuring change in body weight and urine production. A30 A Metolazone is a diuretic with actions similar to a thiazide diuretic, and bumetanide is a loop diuretic.
Metolazone has a long duration of action of about 12—24 h compared with intravenous bumetanide, which has a duration of action of 0. Diuretics increase diuresis and result in a reduction of blood volume. A31 B Once PS is stabilised, a long-term therapeutic plan should be carried out. Metolazone treatment should be withdrawn, after which a change from bumetanide to oral therapy should be attempted.
The patient should be advised about the importance of compliance with bumetanide, and that the unwanted effect of increased diuresis with oral treatment usually decreases with time.
The patient should be advised to take the drug in the morning. Potassium levels should be monitored and, if the patient is not taking any drugs with a potassium-sparing effect, then potassium supplements should be considered when bumetanide therapy is given long-term. Upon discharge the pharmacist needs to advise the patient on her condition and on her medication so as to avoid future deterioration.
She is showing signs of dehydration and uncontrolled blood glucose levels. A32 B Rehydration and control of hyperglycaemia are the primary aims. Her skin condition is a secondary complication of uncontrolled diabetes.
The antibacterial agent is continued and patient is started on an antidiabetic drug glibenclamide to control blood glucose levels. CA is also administered haloperidol an antipsychotic. A33 B In patients who are dehydrated, urine output is very much decreased. The extent of rehydration, which is being undertaken using intravenous infusion of sodium chloride, should be assessed by monitoring urine output. Regular blood glucose monitoring is required and, if necessary, antidiabetic therapy should be reviewed.
A34 B Clinical features of hyperglycaemia include thirst, dry mouth, reduced skin turgor, polyuria, nocturia. A diabetic complication is an increased susceptibility to infection especially in the skin, vaginal area and peripheries. A35 C Ciprofloxacin may be administered at a dose of mg orally twice daily. As CA has been started on this antibacterial agent only the day before her Test 1 Answers 41 admission, there is no indication that warrants a need to increase the dose or review the therapy because the drug is ineffective.
The sodium chloride infusion is required to rehydrate the patient, and should be continued until normal urine flow is achieved. There is no apparent rationale for the use of haloperidol in this elderly patient.
Her state of confusion is due to her hyperglycaemic state, which has precipitated dehydration. Correction of these complications should improve her confusion. Haloperidol has a rapid effect on hyperactive states and initial doses may help to calm down the patient. However, continued use may precipitate hypoglycaemia. Continued treatment with haloperidol should be reviewed.
A36 A Glibenclamide and gliclazide are oral sulphonylureas that are used in diabetes to augment secretion of insulin. They are effective only in patients with residual pancreatic beta-cell activity. Gliclazide is a shorter-acting product. It has a duration of action of about 12 h whereas glibenclamide has a duration of action of up to 24 h. The shorter-acting product is less likely to cause hypoglycaemia.
CA is an elderly patient, who may present with a slower metabolism of the drug; she may be living alone and may have problems with maintaining regular meals. The dose of glibenclamide for elderly patients is usually 2.
A37 B CA should be advised to consume small, frequent regular meals that are low in fat and carbohydrate content. She should be educated on the foods to include in her diet and about the importance of having a regular schedule of food intake to avoid hypoglycaemic attacks. She should be reminded that she has to continue taking the glibenclamide tablet daily at breakfast to avoid recurrence of hyperglycaemia.
If CA continues to take her glibenclamide tablets and she skips meals, there is a higher risk of hypoglycaemia. Questions 39—41 Alcohol is a central nervous system depressant. Conditions that are associated with alcoholism include liver disease, cardiomyopathy, pancreatitis and gastrointestinal disease.
Signs and symptoms of alcohol withdrawal include tremor, tachycardia, diaphoresis, labile blood pressure, anxiety, nausea and vomiting, hallucinations and seizures.
A39 A Promethazine is a sedating antihistamine, which BD was probably using initially for the insomnia and sleep disorders that are associated with alcohol withdrawal syndrome. Side-effects that could occur with the use of promethazine, especially in overdosage include drowsiness, headache, and antimuscarinic effects such as blurred vision and urinary retention.
A40 C Promethazine is a sedating antihistamine that could be used in the symptomatic relief of allergy of nasal or dermatological origin, as a hypnotic and in motion sickness. It can be used in adults and children over 2 years. A41 D Long-acting benzodiazepines such as diazepam could be used in alcohol withdrawal to counteract the withdrawal symptoms. In alcohol withdrawal, Test 1 Answers 43 symptoms of the initial phases do not necessarily diminish as withdrawal advances.
When the patient is started on a benzodiazepine, advice on alcohol abstinence should be provided.
Also the patient should be referred to patient-support groups, to provide the necessary psychosocial support for the management of alcohol abuse.
Questions 42—44 A myocardial infarction, also referred to as a heart attack, is the necrosis of a portion of the cardiac muscle and occurs due to occlusion of the coronary artery, either because of atherosclerosis or thrombus or a spasm. The patient presents with a crushing chest pain that may radiate to the left arm, neck and epigastrium. Statins are used as lipid-lowering agents in conjunction with diet to reduce total cholesterol and low-density-lipoprotein cholesterol as a secondary prevention of the recurrence of cardiovascular disease.
They reduce morbidity and mortality in these patients. A42 B Simvastatin is a statin and it may cause rare but significant side-effects of myalgia, myositis and myopathy. Journal of Pharmacy Technology, ;9, British Journal of Rheumatology, ;32, Kay EA. British Journal of Rheumatology, ;32, Sandhu G. Academic detailing to influence non-steroidal anti-inflammatory drug use in general practice.
Australian Prescriber, ;16 Supplement 1, London: Department of Health, Journal Clinical Epidemiology, ;48, Improving antibiotic prescribing in office practice.
Journal of the American Medical Association, ;, Avorn J, Soumerai SB. Improving drug-therapy decisions through educational outreach. New England Journal of Medicine, ;, Zijestra, IF.
D thesis, University of Groningen, The Netherlands. Evaluation of generic-brand name knowledge. Impact of a drug bulletin on the knowledge, perception of drug utility, and prescribing behaviour of physicians.
Soumerai SB, Avorn J. Priority setting in the NHS: the drugs budget. Continued prescribing of inappropriate drugs in general practice.
Journal of Clinical Pharmacy and Therapeutics, ;20, Sapienza A. Price and utilization controls on drugs. Pharmaceutical News, ; 2, Little hope of avoiding recurrence of limited list problems? Pharmaceutical Journal, ;, Effect of restrictions on prescribing patterns for dextropropoxyphene.
British Medical Journal, ;, Payment restrictions for prescription drugs under Medicaid: Effects on therapy, cost and equity. New England Journal Medicine, ;,