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Dr. Coleman is an assistant professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy.
AG is a 59-year-old white man with no medical history who comes in for his yearly physical at an ambulatory care clinic. He has no known drug allergies and is taking no medication. He has no family history for premature coronary artery disease and does not consume tobacco products. During the physical assessment, his blood pressure is measured at 130/82 mm Hg. The lipid panel comes back with the following: total cholesterol, 285 mg/dL; low-density lipoprotein (LDL) cholesterol, 155 mg/dL; high-density lipoprotein (HDL) cholesterol, 37 mg/dL; and triglycerides, 116 mg/dL. Due to AG's hypercholesterolemia, his physician refers him to a pharmacy-managed lipid clinic. Which of the following is the correct LDL cholesterol goal for AG, and what should the pharmacist recommend to AG to treat his hypercholesterolemia?
AI, a 68-year-old Caucasian woman with a smoking history that included a pack per day for 20 years, is admitted to the hospital for an exacerbation of her chronic obstructive pulmonary disease (COPD). AI complains of increased shortness of breath and sputum production. Upon review of AI's chart, it is found that this is her 4th exacerbation in the past 3 years. AI is currently receiving ipratropium bromide and albuterol sulfate (Combivent), 2 puffs every 4 hours as needed, and salmeterol 50 ?g inhalation twice daily. Spirometry was completed a few weeks prior and shows that AI has a forced expiratory volume/forced vital capacity (FEV1/FVC) ratio of <70 and a FEV1 of 42% of predicted. After 3 days of intravenous antibiotic therapy, AI is discharged with prescriptions for cefpodoxmine proxetil (Vantin) 200 mg twice daily, azithromycin (Zithromax) 250 mg once a day, and 40 mg of prednisone once a day, each for 7 days.
In what stage of COPD would AI be classified, and what changes (if any) should be made to her COPD medications?
AG is older than 44 years of age and has low HDL cholesterol (2 risk factors) and does not have proven coronary disease or a coronary artery disease risk equivalent (eg, diabetes mellitus). This makes his goal LDL <130 mg/dL, according to the National Cholesterol Education Program (NCEP) guidelines (www.nhlbi.nih.gov/guidelines/cholesterol/atp3_rpt.htm). The pharmacist should first recommend more exercise and weight management, including following a diet consisting of <7% of calories as saturated fat, cholesterol <200 mg/day, and increased amounts of soluble fiber (5-10 g/day) and plant stanols/sterols (2 g/day). In addition, drug therapy is likely warranted, although a 3-month trial of lifestyle modification without drug therapy also is reasonable. If and when drug therapy is initiated, even though AG has a low HDL, his elevated LDL should be the first problem addressed. Based upon NCEP guidelines, a moderate dose of a statin (eg, atorvastatin 20 mg) would be a reasonable first drug to start in AG.
According to the Global Initiative for Chronic Obstructive Lung Disease COPD guidelines (www.goldcopd.com/download.asp?intId=445) an FEV1/FVC ratio <70% is diagnostic of having COPD. Staging of the disease is done according to percent of predicted FEV1. The patient has an FEV1 >30% but <50% of predicted, which corresponds to stage 3 (severe) COPD. The fact that AI has severe disease and frequently experiences exacerbations suggests that she should have an inhaled corticosteroid added to her current regimen. This treatment has been shown to reduce the frequency of exacerbations and thus improve health status but does not modify the long-term decline in FEV1. The pharmacist should recommend a prescription for an inhaled corticosteroid be written for the patient as well. A combination product, such as fluticasone/salmeterol 250/50 ?g (Advair) twice daily, would be a reasonable recommendation.