Case 1: Beta-interferons (IFN-bs), including IFN-b-1b (Betaseron), are first-line treatments (as is glatiramer acetate) for patients with RRMS (characterized by clearly defined relapses with full recovery or with sequelae and residual deficit upon recovery, but no disease progression during the relapses). Other commonly used treatments include natalizumab and mitoxantrone; however, due to their associated toxicities, these agents are typically reserved for those who fail IFN-bs or glatiramer. The pharmacist should counsel AP that, because most of the immune response in RRMS occurs early in the disease course, it is commonly accepted that treatment should begin early. Although IFN-bs will not stop the disease or make her feel better, they will decrease her relapse rate and slow the progression of the disability associated with RRMS. The pharmacist should also counsel AP that side effects, including reactions at the site of injection and flu-like symptoms, will likely occur. These side effects are best treated with OTC ibuprofen. Acetaminophen may also be used to treat these side effects, but its routine use should probably be avoided, as it may increase the risk of asymptomatic liver dysfunction commonly associated with IFN-b use.
Case 2: The treatment of acne is based on severity, which varies according to the number, type, and distribution of lesions. Monotherapy with a topical retinoid (eg, adapalene) is appropriate for mild forms of acne. For moderate forms of acne, combination therapy is often necessary. Erythematous and pustular (inflammatory) lesions require treatment with an agent possessing antimicrobial properties to decrease colonization of Propionibacterium acnes. Although topical retinoids are effective in normalizing keratinization, preventing comedone formation, and improving penetration of other topical agents, they do not possess antimicrobial properties. Given the severity of acne and evidence of inflammatory lesions, the optimal regimen for LM is a combination of a topical retinoid and an antimicrobial agent. LM should be counseled on the unique role of each medication and the importance of initiating both therapies now. LM should apply the topical agents to acne-prone areas of her face—not limited to individual existing lesions, because therapy is largely preventive. The pharmacist should inform LM that her acne may worsen upon initiation of therapy, but she should notice an overall improvement within 1 to 2 months.
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