Sample Consults

This man calls me at the office one day after seeing a front page profile that the Griffin Daily News ran about me and my practice. He was crying and terrified that he was dying and nobody seemed to know what was wrong with him. His muscle pains and lack of control had reached the point that the Physical Therapy office had discharged him that day because he couldn’t stand up to do the exercise. His attending physician had diagnosed him with Arthritis as the problem and started NSAID therapy. After a few weeks and continuing deterioration the physician sent the patient to a Neurologist who diagnosed Perpherial Neuropathy and Arthralgia of which she prescribed three different anti-convulsant type drugs to be taken concurrently. This only made things worse and affected his sleep as well as his gait. Upon questioning the patient I learn that he had been on several Statin drugs over the past year and was presently on Crestor of which I told him to stop immediately. He informed me he had stopped a few weeks back because he had given up. I made an appointment to see him the next day even though he had not completed my normal assessment forms prior to the visit. He took the Physician’s referral letter for a Drug Therapy Consult to his attending physician for her approval and was denied. He was told that she didn’t need any help in practicing medicine. He then took it to the neurologist an was told that what could a pharmacist tell a neurologist about patient care. Anyway he came I referred him to one of my support physicians who made all the changes I recommended. Two months later I saw him for a follow-up with his wife and he had no problems walking, sitting or standing. He sort of scared me for a minute while I was talking to his wife, he drops to the floor and then pops back up and stands to show me how good he can move about. I asked him had he driven his truck any and he said he was back full time driving. I asked him did he have any leg pain while driving and he said that he did later in the day. But, his wife exclaimed that he was driving 10 and 11 hours a day. His drug bills were reduced about $800.00 a month and his wife was so impressed with his progress she scheduled an appointment for me to review her.

Patient Profile for Barry Sample Patient

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General Information

ID: jbt02152006

Prescriber: Doctor DoLittle M.D.

Name: Barry Sample Patient

Address: 500 Circle Dr.

City: Close by

State: GA

Zip: 30292

Country: USA

Phone: 876.234.8798

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Current Conditions

• hypercholesterolemia

• hypertension

• insomnia

• moderate pain

• muscle cramps

• nutritional supplementation

• osteoarthritis

• prostate cancer

• radiation therapy

• renal impairment

• sinusitis

• vertebral disc herniation

• vitiligo

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Current Allergies

• Codeine

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Current Medications

• Medication

• Aleve® Dosage: 220 mg Sig: tab 2 twice a day

• Allegra® Dosage: 180 mg Sig: tab 1 daily

• Atenolol; Chlorthalidone Dosage: 50/25 Sig: daily

• Crestor® Dosage: 20 mg Sig: daily

• Cyanocobalamin, Vitamin B12 Dosage: Drops 1mg Sig: dropperful daily

• Garlic Dosage: 400 mg Sig: daily

• Hydrocodone;Acetaminophen Dosage: 5/500mg Sig: tab 1 every 4 hr for pain

• Lunesta™ Dosage: 2 mg Sig: tab 1 or 2 at bedtime for sleep

• Nasonex® Sig: spray each nostril twice a day

• Preventive Nutrition® Coenzyme Q-10 Dosage: 60 mg Sig: tab daily

• Protopic® Sig: apply to skin as needed

• Therapeutic Multivitamin with Minerals

• Tylenol® PM Dosage: 500mg/25mg Sig: tab 2 at bedtime for sleep

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Dosing Parameters

Gender: Male

Birthdate: 4/13/1934

Weight: 104.09 kgs

Height: 180.34 cm

Ideal Body Weight: 74.8 kgs

Body Surface Area: 2.28 m²

Serum Creatinine: 1.5 mg/dL

Creatinine Clearance: 47.79 mL/min

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Notes

Title: Initial Interview & Assessment

Date: 02/15/2006

This 71 year old mentally alert white male presents a multitude of muscle and joint problems. He has muscle aches and pains to the extent that he is presently in physical therapy for treatment. A review of his drug therapy indicates serious potential problems that contribute and exacerbate these muscle conditions as well as probable cause of these problems. He stopped taking Crestor 20mg daily a month back or around the time he started PT. He is self employed owning a dump truck company and is concerned about the pain in his hip muscles he experiences when sitting for a while and then trying to stand up. Although there is no dizziness that accompanies this gait problem it seems to be all muscle related and probably due to the use of “statin” drug therapy. He is currently self-medicating with numerous neutraceuticals which I will suggest changes to later on in this report. His attending physician stopped his antihypertensive/diuretic medication this past week when he presented at her office with a blood pressure of 120/80. I do not have any average blood pressure values at this time. I gave him a Blood Pressure Log sheet to start recording his AM and PM blood pressures with pulses starting tonight and reporting back the results of these tests in about 7 days. An addendum to this report will be posted when he supplies me with his results. He complains that when he sits for a long while, which he demonstrated in my office by standing after about 45 minutes, that his ability to adjust to standing is both painful and slow. During our discussion he indicated that his hands are swollen in the mornings and require some exercise before he can open and close his fist. This may be corrected with the addition of a low dose loop diuretic. The physical therapy seems to be working and his pain is not as bad as a month or so back. He is currently taking large amounts of acetaminophen both throughout the day with Tylenol Arthritis Strength and at night with Tylenol PM. The daily amount of acetaminophen exceeds all safety parameters of 3000mg daily. His daily intake exceeds 4000mg and has to be stopped. Additionally, upon the advice of the nurse in the physician’s office he started taking 400mg of Naproxen Na. twice a day for pain. With a Creatinine Clearance of 47cc/min the continued use of this has to stop. Use of NSAID drug at this time is not a doable approach to analgesia. He had Prostate Cancer in 2001 and was treated with radiation and seems to have no problems from this procedure at this time. An assessment of the patient with the validated “Geriatric Depression Scale” shows a value of 4. This is borderline depression but treatment with the SSRI-SNRI, Effexor XR, may reduce his anxiety about his condition, improve his depression and improve his sleep habits to a degree that use of hypnotic therapy may not be necessary. Along with the use of Effexor XR for these listed reasons the effects on muscle neuropathy may also improve and hasten his return to work. Use of the Lunesta may cause some long term effects in cognition that we surely do not want to occur. Also, use of Vitamin B12, Vitamin B6 and Folic Acid should improve his lipid profile by reduction of homocystine and Methylmalonic acid levels thus reduction of lipids. Use of this combination will also improve muscle function and an overall sense of well being. A 90 day trial of Chondrotin/Glucosamine 1200/1500mg three times a day may also improve his muscle and joint pains. Supplemental analgesic therapy of Tramadol and Tylenol Extra Strength should improve his quality of life. An additional dose of Aspirin 325mg EC daily for platelet inhibition is necessary in this patient.

Title: Drug Therapy Evaluation & Recommendations

Date: 02/15/2006

Review of the drug therapy currently prescribed resulted in the following problem areas:

Aleve - Use of NSAID drug therapy in this patient for pain is contraindicated due to reductions in renal clearance CrCl of 47cc/min. Use of Tramadol & Tylenol are more geriatric friendly and can be used in place of other analgesics.

Allegra / Nasonex Spray - Although not taking these drugs presently if the need occurs due to allergy problems, daily doses are permitted.

Atenolol/chlorthalidone - use of beta blockers in the geriatric patient should be discouraged as serious problems with depression, Raynaud’s Syndrome are common place. Also other muscle pain and fatigue are results for the use of beta blockers in the geriatric. Based on a CrCl of 47cc/min use of chlorthalidone are not advised due to changes in GFR resulting in poor outcomes. Since this drug was stopped last week due to a blood pressure reading in the office of 120/80, I reserve comment as to need for blood pressure therapy until I receive the results of the Blood Pressure Log next week.

Crestor - should never been used on this patient. Based on his renal clearance use of statin therapy is not an alternative and especially this one. Crestor has more problems with Rhabodmyolysis, which is occurring in this patient, as well as liver and renal failure. Although the Creatine Kinase (CK), value of 62, is an indicator of Rhabdomyolysis, in the geriatric this value does not seem to provide warning until there is renal and hepatic damage. It is obvious that a great degree of harm has occurred form this drug being used. The physical therapy, Vitamin B therapies and time should resolve this problem and he will be able to continue his normal activities of daily living.

Lunesta, Tylenol PM - are not geriatric friendly. Use of diphenhydramine with its very high anticholinergic activity increases the patient potential for falls, confusion and many other problems. Lunesta or any crutch for sleep becomes a habit and denies the patient of good REM sleep. Use of Effexor XR should resolve these issues and improve outcomes.

Neutraceuticals - use of Garlic, Current multivitamin, CoEnzyme Q-10, B12 drops and others may have some benefits, not many if any double-blind studies have been published to substantiate any real value to their use. Multivitamin use is necessary but needs to be formulated for the geriatric patient as I will suggest later in the report.

Hydrocodone/acetaminophen - was prescribed in the past but not used at this time. This drug is not needed in this patient.

Drug Therapy Management

Stop Aleve

Stop Atenolol/Chlorthalidone

Stop Crestor

Stop B12 drops

Stop Garlic

Stop Hydrocodone/acetaminophen

Stop Lunesta (using the tapering and stopping schedule listed below)

Stop CoEnzyme Q-10

Stop Multivitamin

Stop Tylenol PM

Stop All other Tylenol products (continue use following instructions below)

New Drug Therapy

Start Vitamin B12 1000mcg IM weekly for 4 weeks then each month

Start Vitamin B6 200mg daily

Start Folic Acid 1mg daily

Start Demadex 10mg daily

Start Tramadol 50mg and Tylenol Extra Strength every 6 hours for pain as needed

Start Effexor XR 37.5mg at bedtime for 5 doses, then 37.5mg at bedtime for 5 doses then 150mg at bedtime…

Then reduce Lunesta to 2mg every other bedtime for 5 doses and discontinue

Start Centrum Silver (or like store brand) daily

Start Chondrotin / Glucosamine (CVS triple strength) tab 2 three times a day

Remember that it will take time to see all the changes that the new drug therapy will produce. After completing the titration processes that are required, we should see big improvements relating to the complaints recorded. The additional vitamin supplements should also make you feel better after 30 days or so. Antihypertensive drug therapy is questionable and we will re-evaluate this in a few weeks. Continue to keep your blood pressure and pulse log. This is very important. I feel that the B vitamin regimen will lower your Homosystine level and allow for the lipid problem to adjust itself to parameters consistent with your age. I know they will make you feel better. The Effexor XR will make you sleep better and eliminate the anxiety you are experiencing.

Let me remind you that this drug therapy regimen is thoroughly thought out and should be followed in its entirety. Choosing only bits and pieces of it may keep us from reaching our mutual goal of improvement in your quality of life and health. I am as close as your phone, so if problems occur please call me. I look forward to seeing you for a follow-up visit around the end of March or the first of May but would like a progress report weekly by phone until we have all your medication dosages adjusted for you.

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Drug Interactions

Naproxen (Aleve®) and Atenolol; Chlorthalidone

Severity: Moderate

NSAIDs can reduce the hypotensive effects of antihypertensives. During antihypertensive therapy with beta-blockers, high levels of vasodilatory prostaglandins are produced in response to reflex-mediated pressor mechanisms (e.g., sympathetic tone). Concurrent use of beta-blockers with NSAIDs may result in loss of antihypertensive activity due to inhibition of prostaglandin activity and decreased renin activity. NSAIDs can cause sodium and fluid retention as well as increase peripheral vascular resistance. NSAIDs can decrease the diuretic, natriuretic, and antihypertensive actions of diuretics, possibly through inhibition of renal prostaglandin synthesis. Concomitant administration of NSAIDs with diuretics can also increase the risk for renal insufficiency secondary to decreased renal blood flow. Patients should be monitored for changes in the effectiveness of their diuretic therapy and for signs and symptoms of renal impairment. Among NSAIDs, indomethacin, naproxen, and piroxicam may have the greatest pressor effect, while the effects of sulindac and nabumetone may be significantly less.

Nonsteroidal anti-inflammatory drugs (NSAIDs), to varying degrees, have been associated with an elevation in blood pressure (approximately 5 mmHg) when given over a period of weeks. This effect is most significant in patients receiving concurrent antihypertensive agents and long-term NSAID therapy. NSAIDs may decrease the effect of antihypertensive agents through various mechanisms, including renal and peripheral vasoactive pathways.[805] NSAIDs have been shown to attenuate the effects of diuretics, beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), vasodilators, central alpha-2 agonists, peripheral alpha-1 blockers, and angiotensin II blockers. Doses of antihypertensive medications may require adjustment in patients receiving concurrent NSAIDs.[4087] Concomitant volume depletion caused by diuretics and prostaglandin inhibition caused by naproxen may increase the risk of renal failure due to inadequate kidney perfusion. Elderly patients may be at increased risk of adverse effects from combined long-term NSAID therapy and antihypertensive agents, especially diuretics, due to age-related decreases in renal function and an increased risk of stroke and coronary artery disease.[3154]

Naproxen (Aleve®) and Mometasone (Nasonex®)

Severity: Moderate

Increased gastrointestinal (GI) effects are possible if naproxen is used with corticosteroids. Although some patients may need to be given corticosteroids and NSAIDs concomitantly, which can be done successfully for short periods of time without sequelae, prolonged concomitant administration should be avoided. Concomitant use of corticosteroids appears to increase the risk of adverse GI events due to NSAIDs.[1162] Nonsteroidal anti-inflammatory drugs should be used cautiously in patients receiving corticosteroids.

Naproxen (Aleve®) and Tacrolimus (Protopic®)

Severity: Moderate

Due to the inhibition of renal prostaglandins by naproxen, concurrent use with other nephrotoxic agents may lead to additive nephrotoxicity.[7020] Naproxen should be given with caution to patients taking aminoglycosides, amphotericin B [5062] [5068], systemic bacitracin [5062], cisplatin [5123], gold compounds [6859], ganciclovir [5173], pamidronate [7799], pentamidine [5612], tacrolimus [5342], tenofovir, PMPA [4917], foscarnet [5106], parenteral vancomycin [5198], or zoledronic acid [6318]. Monitor renal function carefully during concurrent therapy.

Tacrolimus, in the absence of overt renal impairment, may adversely affect renal function. Care should be taken in using tacrolimus with other nephrotoxic drugs.[5342] Assessment of renal function in patients who have received tacrolimus is recommended, as the tacrolimus dosage may need to be reduced (see Dosage). Patients with reduced renal function may have significant impairment of pemetrexed elimination, as most of the drug is eliminated unchanged in the urine. Pemetrexed should not be used in patients with a creatinine clearance less than 45 ml/minute.[5105] Other examples of drugs that can adversely affect renal function include acyclovir, adefovir, amphotericin B [5342], angiotensin-converting enzyme inhibitors (ACE inhibitors), systemic aminoglycosides [5342], carboplatin, cisplatin [5342], foscarnet [5118], ganciclovir [5342], nonsteroidal antiinflammatory drugs (NSAIDs) [5118], salicylates, bismuth subsalicylate, systemic bacitracin, pamidronate [7799], polymyxin B, IV pentamidine [5118] parenteral vancomycin [5118], and zoledronic acid [6318].

Naproxen (Aleve®) and Garlic, Allium sativum (Garlic)

Severity: Moderate

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen decrease platelet aggregation. Garlic, Allium sativum, ginger, Zingiber officinale, and ginkgo, Ginkgo biloba, also have clinically significant effects on platelet aggregation; concurrent use with a NSAID may lead to a potential increased risk of bleeding.[1900] [2233] [6708] A case of fatal intracerebral bleeding has been reported with the combination of ginkgo and ibuprofen.[5211]

Garlic, Allium sativum may produce clinically-significant antiplatelet effects [2233]; until more data are available, garlic should be used cautiously in patients receiving drugs with a potential risk for bleeding such as diflunisal, NSAIDs, anticoagulants, platelet inhibitors like aspirin, ASA, or thrombolytic agents. In regard to warfarin, no substantial clinical data are available to support or deny a potential for interaction; the data are limited to a random case report.[5200] A case of spontaneous spinal epidural hematoma, attributed to dysfunctional platelets from excessive garlic use in a patient not receiving concomitant anticoagulation, has been reported.[2245] Patients who choose to consume garlic supplements while receiving the listed medications should be observed clinically for evidence of adverse effects.

Atenolol; Chlorthalidone and Vitamin A (found in Therapeutic Multivitamin with Minerals)

Severity: Moderate

Thiazide diuretics may cause photosensitivity [7476] and may increase the photosensitization effects of drugs like griseofulvin, phenothiazines, retinoids [5254], sulfonamides, sulfonylureas, tetracyclines, or photosensitizing agents used in photodynamic therapy. Prevention of photosensitivity includes adequate protection from sources of UV radiation (e.g., avoiding sun exposure and tanning booths) and the use of protective clothing and sunscreens on exposed skin.[7476]

Atenolol; Chlorthalidone and Mometasone (Nasonex®)

Severity: Moderate

Additive hypokalemia may occur when non-potassium sparing diuretics (loop diuretics or thiazide diuretics) are coadministered with other drugs with a significant risk of hypokalemia (e.g., amphotericin B, cisplatin, corticosteroids, corticotropin, ACTH).

Atenolol; Chlorthalidone and Calcium Salts (found in Therapeutic Multivitamin with Minerals)

Severity: Moderate

Aluminum hydroxide antacids have been reported to decrease the AUC of atenolol by 57%, whereas calcium salts (lactate, gluconate, and carbonate salts) have been reported to reduce the AUC of atenolol by 32%.[4384] Twelve hours after concurrent calcium and atenolol administration, inhibition of exercise-induced tachycardia is greater compared to atenolol alone. In another study, antacids has been shown to reduce the AUC of atenolol by 33%.[4382] Separate doses of atenolol and antacids or calcium salts by at least 2 hours to minimize this potential interaction.

Prolonged use of calcium salts with thiazide diuretics can lead to the milk-alkali syndrome.[4689] Exogenous calcium and thiazide diuretics each can cause hypercalcemia, and thiazide diuretics may cause metabolic alkalosis. These are pharmacodynamic interactions. While the use of a thiazide diuretic does not preclude administration of calcium salts, these two agents should not be administered together for prolonged periods without monitoring serum calcium and other serum electrolytes.

Rosuvastatin (Crestor®) and Niacin, Niacinamide (found in Therapeutic Multivitamin with Minerals)

Severity: Moderate

HMG-CoA reductase inhibitors have been administered safely with niacin (nicotinic acid) in some patients; however the risk of potential myopathy should be considered. Combination therapy with HMG-CoA reductase inhibitors and lipid-lowering doses of niacin (i.e., vitamin B3 as nicotinic acid) has been associated with myopathy and rhabdomyolysis.[4705] The manufacturer recommends that the benefit of combined use of rosuvastatin with niacin should be carefully weighed against the potential risks.[4705] During concurrent therapy, monitor for signs and symptoms of myopathy as well as periodic CK measurements.

Rare cases of rhabdomyolysis have been reported in patients taking niacin (nicotinic acid) in lipid-altering doses (i.e., >=1 g/day) and HMG-CoA reductase inhibitors (i.e., 'statins') concurrently.[5506] Patients undergoing combined therapy should be carefully monitored for myopathy or rhabdomyolysis, particularly in the early months of treatment or during periods of upward dose titration of either drug. Since compounds in went yeast, Monascus purpureus are pharmacologically similar to the HMG-CoA reductase inhibitors,[5911] clinicians and patients should use this dietary supplement cautiously in combination with niacin, particularly in non-prescription use.

Acetaminophen; Hydrocodone (Hydrocodone;Acetaminophen) and Diphenhydramine (found in Tylenol® PM)

Severity: Moderate

Concomitant use of hydrocodone with sedating H1-blockers can potentiate respiratory depression and/or sedation. In addition, chlorpheniramine and diphenhydramine inhibit CYP2D6, an enzyme responsible for the metabolism of hydrocodone.[4718] Close monitoring for side effects in patients receiving hydrocodone-containing products and chlorpheniramine or diphenhydramine is recommended.

Concomitant use of acetaminophen; hydrocodone with other CNS depressants can potentiate the CNS effects (e.g., sedation) or respiratory depression effects of both agents. CNS depressants include amoxapine, anxiolytics, sedatives, and hypnotics, clozapine, dronabinol, THC, droperidol, entacapone, general anesthetics, sedating H1-blockers, maprotiline, mirtazapine, molindone, nefazodone, olanzapine, opiate agonists, phenothiazines, pimozide, pramipexole, pregabalin, quetiapine, risperidone, ropinirole, skeletal muscle relaxants, tolcapone, tramadol and trazodone. If used concomitantly, the dosage of acetaminophen; hydrocodone and/or the other CNS depressant should be reduced.[6501]

Because diphenhydramine can cause pronounced sedation,[6568] an enhanced CNS depressant effect may occur when it is combined with other CNS depressants [6568] including anxiolytics, sedatives, and hypnotics (such as barbiturates and benzodiazepines) [6946] [6948], buprenorphine [5278], butorphanol [5912], carisoprodol, clozapine [4989], dronabinol, THC, droperidol [5468], entacapone [5769], ethanol [6341] [6948], general anesthetics [6892], haloperidol [5036], methocarbamol, mirtazapine [5366], molindone [5553], nalbuphine [6778], nefazodone [5414], olanzapine [5517], opiate agonists, pentazocine [6777], phenothiazines [6946], pimozide [5250], pramipexole [5640], pregabalin [7523], procarbazine [5356], quetiapine [5855], risperidone [5144], ropinirole [8018], tolcapone [5578], tramadol [5043], trazodone [5450], tricyclic antidepressants [6947], or with other sedating H1-blockers [6568].

Acetaminophen; Hydrocodone (Hydrocodone;Acetaminophen) and Eszopiclone (Lunesta™)

Severity: Moderate

Using eszopiclone with ethanol or other CNS depressants may have cumulative effects and can increase the risk for sedation.[7331] Eszopiclone should not be taken with alcohol. A dose reduction may be necessary if eszopiclone is co-administered with other CNS depressants [7331], such as: antiparkinson's drugs (e.g., entacapone [5769], pramipexole, ropinirole, and tolcapone [5578]); chloral hydrate [6948]; cannabinoids (e.g., dronabinol, THC); droperidol [5468]; general anesthetics; opiate agonists; mixed opiate agonists/antagonists (e.g., buprenorphine [5278], butorphanol [5912], nalbuphine [6778], pentazocine [6969]); pregabalin [7523], psychotropic agents; sedating H1-blockers; tramadol [5043]; tricyclic antidepressants; zaleplon [6634]; zolpidem [6473]; and other anxiolytics, sedatives, and hypnotics (including barbiturates and benzodiazepines).

Acetaminophen; Hydrocodone (Hydrocodone;Acetaminophen) and Acetaminophen (found in Tylenol® PM)

Severity: High

Many prescription and non-prescription medicines contain acetaminophen. Avoid concurrent use of products that contain acetaminophen as the maximum daily dose (e.g., 4 g/day for adults) may be exceeded. High dosages of acetaminophen on a chronic basis can cause depletion of glutathione stores, which can lead to a greater production of the hepatotoxic metabolite, NAPQI.[4925] Advise patients to carefully read the ingredients of any other medicines they are taking with acetaminophen; hydrocodone products.[4925]

Eszopiclone (Lunesta™) and Diphenhydramine (found in Tylenol® PM)

Severity: Moderate