Craig I. Coleman, PharmD, and Christine G. Kohn PharmD Candidate
Case One
MK, a 68-year-old man, was discharged from the hospital after a myocardial infarction (MI) 2 weeks ago. At this routine office visit, MK is diagnosed with depression. His doctor considers prescribing a tricyclic antidepressant (TCA), but contacts his community pharmacist for a recommendation.
What should the pharmacist recommend to manage MK's post-MI depression?
Case Two
SL, a 25-year-old woman, presents to the clinic complaining of an increased frequency and urgency to urinate and dysuria over the past 3 days. She has no fever or flank pain and does not have a recent history of urinary tract infections (UTIs). A urine dipstick is positive for leukocyte esterase, white blood cells, and nitrates. Based upon the above symptoms and test results, and the fact that SL has no known urologic abnormalities, her doctor diagnoses her with an uncomplicated UTI. SL's doctor considers prescribing a fluoroquinolone, but asks you, the pharmacist, for a recommendation. SL has no known drug allergies.
How should the pharmacist handle this prescription?
ANSWERS
Case 1: Studies suggest that 1 in 5 patients become depressed during their initial hospitalization for an MI, and that a significant number of patients experience continued depression 1 month or longer after discharge. Furthermore, the medical literature suggests an unfavorable association might exist between post-MI depression and cardiac-related mortality, implying that proper diagnosis and treatment are important.
The American Academy of Family Physicians's guidelines (January/February 2009) for the detection and management of post-MI depression recommend that post-MI patients with depression be treated with selective serotonin reuptake inhibitors (SSRIs) rather than TCAs. This recommendation is based upon TCA's tendency to cause cardiac adverse effects, including heart rate and conduc tion disturbances.
Based upon the proven efficacy and the lack of cardiac toxicity associated with SSRIs, the pharma an SSRI be prescribed instead of a TCA. cist should recommend that Dr. Coleman is associate professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy.
Case 2: The choice between antibiotics to treat an acute uncomplicated UTI (or cystitis) should be individ ualized based on the presence of drug allergies, prior adherence to medications, and local practice and resistance patterns, as well as drug cost.
The most recent (March 2010) Infectious Diseases Society of America acute uncomplicated cystitis - treatment guidelines recommend nitrofurantoin (Macrobid) 100 mg twice daily for 5 days or trim ethoprim/sulfamethoxazole (Bactrim) 160/800 mg (1 double-strength tablet) twice daily for 3 days as first-line therapies, due to their efficacy and relative lack of drug resistance. (Note: the guidelines do warn against using trimethoprim/sulfamethoxazole if resistance in an area exceeds 20% or if it was used to treat a previous UTI in the past 3 months.)
Although fluoroquinolones (ciprofloxacin, levofloxacin, ofloxacin) are a potential treatment option, - they are not recommended as a first-line therapy due to high levels of resistance in many commu nities and their potential to foster further antibiotic-resistant bacteria.
The pharmacist might consider recommending nitrofurantoin or trimethoprim/sulfamethoxazole - (assuming that resistance levels in the community are not greater than 20%) instead of a fluoro quinolone.
Dr. Coleman is associate professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy. Ms. Kohn is a PharmD candidate from the University of Connecticut School of Pharmacy.
