Case Studies

ANSWERS

CASE ONE:
Six statins are currently approved for marketing in the United States by the FDA. Although they all share the same mechanism of action for lowering cholesterol, they are not all equally potent reducers of LDL cholesterol levels at FDA-approved doses. According to the insurance provider’s letter, the 40 mg of atorvastatin MD receives in her Caduet will be replaced with an adequate LDL cholesterol–lowering equivalent dose of simvastatin (80 mg). Thus, the pharmacist can tell MD that her LDL cholesterol levels should not be affected by the statin switch. The pharmacist also should explain to MD that although pravastatin’s LDL-lowering efficacy may be sufficient for her cousin, it does not lower LDL cholesterol enough to enable MD to reach her own LDL goal and therefore is not an option. Finally, MD should be reminded that she will still receive her amlodipine, however, not as part of a combination tablet.

CASE TWO:
Osteoporosis is due to an imbalance of bone formation and resorption and may lead to complications such as fractures. Diagnosis is typically made by measuring the T-score, which compares a patient’s bone mineral density with that of a young healthy person of the same sex. A T-score <–2.5 is diagnostic for having osteoporosis. Based on MK’s T-score at the hip (–2.6), she is considered to have osteoporosis and should receive treatment to prevent fractures. The pharmacist should tell the patient that her alendronate will help to keep her bones strong so that she would be less likely to get a fracture if she were to fall again. Alendronate prevents bone loss and should be taken in addition to calcium and vitamin D. MK should take alendronate in the morning with a full glass of water (~8 ounces) at least 30 minutes before eating, taking other medications, or drinking anything besides water. The patient should remain upright (either sitting or standing) for 30 minutes, not 2 hours. This is to prevent any esophageal irritation that might result from direct contact of alendronate on the esophagus. MK also is taking lansoprazole, which may have a drug interaction with her calcium. Calcium is better absorbed in an acidic stomach environment, but MK likely has reduced calcium absorption due to her acid suppression. She might benefit from switching to a calcium citrate form (plus vitamin D), which does not require as much acidity in the stomach for absorption.