Dr. Schlesselman is an assistant clinical professor at the University of Connecticut School of Pharmacy.
IC, a 71-year-old woman who is well known at Treat You Right Pharmacy, arrives at the pharmacy with a new prescription. As the pharmacist begins to enter the prescription into the computer, she notices that IC has filled multiple prescriptions for ophthalmic agents to treat glaucoma. This new prescription is yet another glaucoma agent. When the pharmacist confirms that IC is still using all of these medications, IC confirms that she is, and she complains that she is frustrated with her glaucoma treatment. She is already using 3 different ophthalmic products, with a fourth being added today. Despite therapy, her intraocular pressure has not been lowered. IC?s physician mentioned that IC will need to have surgery if the pressure does not respond to therapy.
The pharmacist inquires about IC?s adherence to the prescribed regimens with her eye drops. IC is adamant that she uses her medications every day, exactly as they were prescribed by her physician. IC explains that she administers all of the medications in the morning before she goes to play bridge. For medications that are administered twice daily, the second dose is administered before she goes to bingo in the evening.
The pharmacist asks IC to describe how she administers the eye drops. IC says that she usually remembers that she needs to administer them when her friend arrives to pick her up. IC states that she is usually in a rush to administer them ?so I get the best table at bridge or the ?winning? card at bingo.? She uses the new prescription to demonstrate her technique, instilling the prescribed 3 drops without delay between drops.
Can the pharmacist recommend an improved method for administration of IC?s multiple eye drops?
OH, a 50-year-old man, presents to his physician?s office with a chief complaint of severe toe pain. The pain started 5 days ago. At first, OH thought he might have hurt it while working at his construction job, but he does not remember any accidents at work in which he might have injured his toe. The pain has gotten progressively worse, rather than resolving. His toe hurts so much that he has difficulty sleeping, walking, or wearing a shoe. He has used acetaminophen without much relief.
On examination, the first joint of OH?s big toe is swollen, warm, erythematous, and extremely tender. No other joint abnormalities are noted. The remainder of the physical examination is within normal limits. Laboratory values are also within normal limits, except the uric acid, which was reported as 14 mg/dL.
The physician obtains an x-ray and synovial fluid aspirate of the toe. The x-ray shows soft tissue swelling without evidence of trauma or fracture. The synovial fluid shows numerous neutrophils and intracellular monosodium urate crystals.
The physician suspects OH has gout with hyperuricemia. He decides to start OH on ibuprofen and colchicine to relieve the acute gouty episode. He also will obtain a 24-hour urine collection for uric acid to determine if OH is an overproducer or underexcretor of uric acid. In the meantime, the physician also considers other possible causes for OH?s elevated uric acid levels.
According to his chart, OH?s current medications are simvastatin 20 mg daily, loratadine 10 mg daily, and hydrochlorothiazide 50 mg daily. OH confirms that he is still taking these medications as prescribed.
Which, if any, of OH?s medications might have altered his uric acid level?
To prevent dilutional effects, IC should wait at least 5 minutes between each drop. If a gel solution is administered, IC should administer it last and wait even longer between drops.
Hydrochlorothiazide use is associated with elevated uric acid levels and precipitation of acute gouty episodes. Thiazide diuretics are weak acids that are secreted by the proximal renal tubules. It is suspected that thiazide diuretics and uric acid compete for renal excretion. Due to this competition, higher doses and chronic use of hydrochlorothiazide are more likely to inhibit excretion of uric acid.