Stefanie C. Nigro, PharmD, BCACP, CDCES

BB is a 39-year-old man who recently moved from another state and started going to a new physician. The physician ordered the varicella vaccine, and BB is hoping it can be administered in the pharmacy. During the intake, BB says he has Crohn disease that has been treated with ustekinumab (Stelara) 90 mg subcutaneously every 8 weeks for the past 6 months, as well as anxiety that has been treated with citalopram (Celexa) 20 mg orally daily for the past year. He is otherwise healthy and does not have medication allergies.

Q: Should the pharmacist administer the varicella vaccine?

AE is a 70-year-old Hispanic women, a nonsmoker, who has had worsening bone mineral density over the past 3 years. Her T score at the hip is –2.5 compared with –1.7 in 2019, and her T score at the spine is –3.8 compared with –3.6 in 2019. Three years ago, AE started taking alendronate 70 mg orally weekly for osteoporosis. In addition, she takes adequate doses of calcium citrate and      ergocalciferol. AE said she was nonadherent to bisphosphonate therapy 1 month prior to her most recent DEXA scan, adding that she traveled outside the United States and forgot to bring her medication but otherwise follows proper adherence. Her other lab results are unremarkable for her age. AE’s height is 62 in and she weighs 56 kg. AE has hypertension for which she takes amlodipine    (Norvasc) 5 mg orally daily. Her physician asks for recommendations on alternative osteoporosis medications for AE.

Q: What should the pharmacist recommend?


: Patients with high-level immunosuppression should not receive live vaccines, such as varicella, because of the increased risk of infection, according to the Infectious Diseases Society of America.      High-level immunosuppression includes patients who are receiving biologic immunomodulators (eg, ustekinumab), are receiving chemotherapy, are receiving daily corticosteroid therapy equivalent to 20 mg of prednisone or greater for at least 14 days, have a primary immunodeficiency, have HIV infection with a CD4 cell count less than 200 per mm

, and/or have received a solid organ transplant within the previous 2 months.

 Additionally, the package labeling for ustekinumab discourages administration of live vaccines after starting therapy.

 Live vaccines should have ideally been given before BB began therapy 6 months ago.

: Prior to suggesting alternative medications, the pharmacist and/or prescriber should first verify AE’s adherence and administration technique, such as taking it on an empty stomach, and identify whether any secondary causes of osteoporosis are present. Based on AE’s history and T score of less than –3.0, she is identified as “very high risk of fracture” per the American Association of Clinical Endocrinology/American College of Endocrinology.

 Guidelines suggest discontinuing her oral bisphosphonate and initiating an injectable therapy, such as abaloparatide (Tymlos), romosozumab (Evenity), teriparatide (Forteo), or zoledronic acid (Reclast), and the duration of therapy will be determined based on drug selection. A review of AE’s drug formulary and shared decision-making process can help identify which injectable is best. AE’s clinical status and fall risk should be assessed yearly.

Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update. 

. 2020;26(auppl 1):1-46. doi:10.4158/GL-2020-0524SUPPL

, is an associate clinical professor in the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy in Storrs.

Articles

Interactive Case Studies: November 2022 Issue

AL is a 29-year-old woman picking up ethinyl estradiol/norethindrone 1/20 (1 mg/20 mcg) tablets. While refilling the prescription, the pharmacist notices she recently picked up sumatriptan 10 mg nasal spray for acute migraine attacks. The pharmacist confirms AL’s migraine diagnosis, and AL mentions that since she has felt better using the spray. In fact, she brags she can predict her migraines because her arm starts tingling about an hour before her head begins to ache, alerting her to take sumatriptan.

 Based on this information, what should the pharmacist tell AL and her prescriber?

A physician at a large primary care group asks a staff pharmacist about a 54-year-old woman with COVID-19 whose symptoms began 1 day earlier. The doctor prescribed a 5-day course of nirmatrelvir/ritonavir (Paxlovid) but noted the woman takes 300 mg of bupropion XL every day and recalled reading about a potential for drug-drug interaction between the 2 medications. The physician advised the patient to decrease the dose of bupropion by taking it every other day during treatment with Paxlovid to minimize the potential for toxicity. The doctor wants to know whether the pharmacist agrees with this recommendation.

AL appears to be experiencing migraine with aura. Approximately 25% of patients with migraines have language, motor, and/or sensory symptoms. The US Medical Eligibility Criteria for Contraceptive Use classifies a migraine with aura as “a condition that represents an unacceptable health risk if the contraceptive method is used.”

 Because AL takes an estrogen/ progestin contraceptive, she has an increased risk of stroke. However, the studies that form the basis for this conclusion are dated and were conducted on contraceptives with higher doses of estrogen.

 Therefore, the pharmacist should inform AL and her prescriber about the increased risk of stroke and ask whether AL has other risk factors for stroke such as hypertension or smoking. All parties should then share in the decision about whether AL should receive the contraceptive as prescribed or one containing only progestin.

1. Curtis KM, Tepper NK, Jatlaoui TC, et al. U.S. medical eligibility criteria for contraceptive use, 2016. 

. 2016;65(3):1-104. doi:10.15585/mmwr.rr6503a1external icon

2. Calhoun AH. Hormonal contraceptives and migraine with aura-is there still a risk? 

. 2017;57(2):184-193. doi:10.1111/head.12960

 The physician is correct in thinking bupropion could interact with Paxlovid. However, the consequence of such an interaction is not bupropion toxicity but loss of bupropion efficacy. Bupropion is metabolized by CYP2B6. Depending on dose, ritonavir, which is a CYP2B-inducer, can reduce bupropion plasma concentration.

 The interaction is considered weak because the ritonavir dose is low, and induction may take several days. Because treatment with Paxlovid lasts only 5 days, the pharmacist should tell the physician the bupropion dose does not need to be adjusted.

 The patient should be told not to decrease the bupropion dose but to take it daily as originally directed. If necessary, she should report any adverse effects or loss of efficacy to her primary care physician.

1. Park J, Vousden M, Brittain C, et al. Dose-related reduction in bupropion plasma concentrations by ritonavir. 

. 2010;50(10):1180-1187. doi:10.1177/0091270009359524

2. COVID-19 drug interactions. University of Liverpool. Accessed August 9, 2022. https://www.covid19-druginteractions.org/checker

 at the University of Connecticut School of Pharmacy in Storrs.

 is an associate clinical professor in the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy in Storrs.

How would you respond to these patient questions?

Case Studies: September 2022

AD is a man aged 33 years with a 5-year history of major depressive disorder (MDD). He has tried optimal doses of escitalopram and venlafaxine, failing to achieve relief with either. AD is now trying fluoxetine. During the most recent office visit, he said he is still experiencing distressing symptoms of MDD. The provider increased his dose of fluoxetine to 40 mg/d from 20 mg/d. Now, 3 months later, AD reports feeling well controlled on this new dose. He reports having improved sleep, increased motivation, and more energy. However, AD says he is now experiencing sexual dysfunction in his relationship.

: What medication-related interventions should the pharmacist recommend to mitigate this adverse effect (AE)?

: Sexual dysfunction is a common AE of antidepressants, especially selective serotonin reuptake inhibitors such as fluoxetine. Sexual dysfunction can affect quality of life, relationships, and self-esteem.

 This AE often leads to discontinuation of treatment, increasing the potential for relapse. It is generally thought that elevated serotonin levels diminish sexual function. Pharmacologic ways of mitigating this AE include reducing the dose or switching the antidepressant. Unfortunately, these options are not ideal for AD, because he finally found relief of his symptoms using this dose of fluoxetine. Another option is augmenting his regimen by adding bupropion. In a small study, patients treated with bupropion showed improvement in desire and frequency of sexual activity.

 AD should discuss this option with his provider to see whether he is a suitable candidate. His provider can further assess his sexual history and determine whether other treatments, such as cognitive behavioral therapy and/or use of sildenafil, may be suitable.

LR is a woman aged 75 years with late-onset Alzheimer disease. Her caregiver would like to explore pharmacologic options to combat LR’s dementia-related, chronic agitation. LR is not a threat to herself or others but fixates on different tasks and is irritable, according to her caregiver. LR’s active medications include memantine hydrochloride 10 mg/d, rivastigmine 9.5-mg/24-h patch once daily, and half a tablet of trazodone hydrochloride 50 mg at bedtime. Her other pertinent medical history includes a cerebrovascular accident in 2017.

: What should the pharmacist recommend for LR’s chronic agitation, assuming no contraindications exist?

: Behavioral and psychological symptoms of dementia (BPSD) are common. Many patients have at least 1 BPSD during the illness. Symptom-directed management should be considered before medications, when possible.

 Advise LR and/ or her caregiver on the use of aromatherapy, bright-light therapy, exercise groups, massage, or music. If there is no improvement in LR’s symptoms, the pharmacist can recommend initiating an antidepressant, such as escitalopram 5 mg/d by mouth.

 If needed, the dose can be titrated by 5 mg at weekly intervals to a maximum dose of 20 mg/d. If LR becomes a threat to herself or others, a second-generation antipsychotic, such as quetiapine, should be considered on an as-needed basis.

 is an associate clinical professor in the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy.

Scales K, Zimmerman S, Miller SJ. Evidence-based nonpharmacological practices to address behavioral and psychological symptoms of dementia. 

. 2018;58(suppl 1):S88-S102. doi:10.1093/geron/gnx167

Carrarini C, Russo M, Dono F, et al. Agitation and dementia: prevention and treatment strategies in acute and chronic conditions. 

 2021;12:644317. doi:10.3389/fneur.2021.644317

Cheung G, Stapelberg J. Quetiapine for the treatment of behavioural and psychological symptoms of dementia (BPSD): a meta-analysis of randomised placebo-controlled trials. 

How would you respond to these patients questions?

Case Studies: August 2022

SA is a 54-year-old-woman with type 2 diabetes who is being discharged from the hospital following a hyperglycemic emergency related to diet and poor insulin adherence. The patient is highly motivated to control her diabetes with the help of a dietitian. Prior to discharge, the pharmacist is asked to counsel SA on calculating mealtime insulin dose at lunch using a correction factor. The patient receives 24 units of insulin glargine U-100 at bedtime and 8 units of regular insulin before each meal, 3 times per day. SA’s prelunch glucose level consistently averages 240 mg/dL, and her target fasting plasma glucose is set at 120 mg/dL.

What correction dose should the pharmacist recommend?

CASE 1: The “rule of 1500” can be used to determine SA’s correction factor (CF): CF = 1500/total daily dose of insulin (eg, 1500/48 = approximately 31) This means for every 1 unit of regular insulin, SA’s blood glucose (BG) level is expected to be lowered by 31 mg/dL. Next, the difference between the prelunch BG and the target BG should be calculated (eg, 240 mg/dL – 120 mg/dL = 120 mg/dL). To find how much insulin to add to the lunch dose, divide the BG amount above target by the CF (eg, 120/31 = 3.9). Therefore, SA will add 4 extra units of regular insulin to her prelunch dose, bringing the total to 12 units. Inform SA that this calculation is necessary to avoid hyperglycemia. SA should also keep track of her pre- and postprandial BG levels for the next week to determine what changes, if any, may be made at a follow-up appointment.

Howard-Thompson A, Khan M, Jones M, George CM. Type 2 diabetes mellitus: outpatient insulin management. 

GS has some concerns about his newly prescribed medications. He is a 56-year-old Hispanic man who was recently discharged from the hospital after experiencing a myocardial infarction with stent placement. GS was instructed to begin taking aspirin 81 mg daily, atorvastatin 80 mg daily, metoprolol tartrate
25 mg twice daily, pantoprazole 40 mg daily, and ticagrelor 90 mg twice daily. Two days after starting these new medications, he began experiencing bloating and diffuse stomach discomfort. GS is gluten- and lactose-intolerant and is concerned that these new medications may be contributing to these symptoms. He wonders whether he can stop taking them all together to avoid feeling sick.

What steps can the pharmacist take to ensure these medications do not have gluten or lactose excipients?

CASE 2: The pharmacist should first verify which drug was dispensed to GS and by which manufacturer, then they can check the package insert or call the manufacturer to verify the inactive ingredient list. If GS’s medications contain gluten or lactose, alternative drug entities or manufacturers can be explored. Several resources can help. One such resource is GlutenFreeDrugs.com.

 However, this list is limited to a select number of drugs and manufacturers, and it is unclear how often it is updated. The National Library of Medicine’s Daily
Med is also useful.

 The advanced search offers the querent the ability to screen drugs by the absence or presence of active or inactive ingredients. Once a specific manufacturer or product is identified as gluten- or lactose-free, the pharmacist can inform the prescriber. The ultimate goal is for GS to continue to take his medications as prescribed to avoid further cardiac complications.

1. Welcome to gluten free drugs. GlutenFreeDrugs.com. Accessed May 24, 2022. https://www.glutenfreedrugs.com/

2. DailyMed. National Library of Medicine. Accessed May 25, 2022. https://dailymed.nlm.nih.gov/dailymed/index.cfm

Case Studies: June 2022

 A local provider calls the pharmacy asking about SJ, a 67-year-old female patient. SJ recently had pharmacogenetic testing done and was found
to have a CYP2C19 mutation; she is an ultra- metabolizer of this enzyme. The provider wants the pharmacist to help evaluate SJ’s medications and provide necessary recommendations. The pharmacist reviews SJ’s profile and notices the following medications: atorvastatin 80 mg once daily, clopidogrel 75 mg once daily, losartan 100 mg once daily, omeprazole 20 mg once daily, paroxetine 10 mg once daily, and voriconazole 200 mg twice daily.

: Pharmacogenetic testing is becoming popular and can provide information about specific differences in the expression of an enzyme that can affect the metabolism of a drug. Knowing this information can help clinicians choose and/or modify drug therapy. Ultrarapid metabolizers metabolize drugs at much faster rates than normal, so lack of therapeutic effect is a concern. Upon review of SJ’s medications, a dosage increase of omeprazole is required to achieve therapeutic levels in this patient. However, omeprazole can also interact with clopidogrel, decreasing its antiplatelet effect. Instead, the pharmacist can recommend switching to pantoprazole 40 mg daily. In addition, based on the enzyme mutation, voriconazole is unlikely to achieve therapeutic levels, so an alternative like posaconazole should be considered. No other medications would require adjustment, but SJ should nonetheless be monitored for adequate clinical response.

1. Guidelines. Clinical Pharmacogenetics Implementation Consortium. Updated March 26, 2021. Accessed April 14, 2022. https://cpicpgx.org/ guidelines/

AR, a 32-year-old woman, who is picking up her monthly oral contraceptive mentions that she has recently been feeling more anxious and
that her heart will not stop racing. She has been under more stress than normal at work and thinks that is the cause of her symptoms. AR says that the frequency and severity of her migraines have also increased during the past month, prompting her primary care provider (PCP) to add propranolol 20 mg twice daily for prophylaxis. Her current medications are drospirenone 3 mg/ ethinyl estradiol 0.02 mg daily, propranolol 20 mg twice daily; sumatriptan 100 mg as a single dose at the onset of a migraine, and adapalene 0.3%/benzoyl peroxide 2.5% gel, applied to affected skin once daily.

Other than stress, what medication-related problem could explain AR’s complaints?

: It is possible that AR may be experiencing early signs of hyperkalemia, whose symptoms include abdominal pain, arrhythmia or heart palpitations, chest pain, diarrhea, muscle weakness, and nausea.

 AR’s oral contraceptive contains drospirenone. Drospirenone is a spironolactone analogue with antimineralocorticoid activity that can spare potassium. In addition, nonselective β-blockers like propranolol decrease cellular uptake of potassium.

 Although the individual risk of hyperkalemia with both drugs is low, combined use can have an additive effect. To confirm, the pharmacist can recommend that AR follow up with her PCP as soon as possible to get a potassium level drawn. If her potassium is elevated, alternative pharmacologic migraine prophylaxis should be discussed.

1. Cleveland Clinic. Update October 5, 2020. Accessed March 24, 2022. https://my.clevelandclinic.org/health/diseases/15184-hyperkalemia-high-blood-potassium

2. Mandić D, Nezić L, Skrbić R. Severe hyperkalemia induced by propranolol. Med Pregl. 2014;67(5-6):181-184.

How would you handle these patients' questions?

Case Studies: May 2022

: A medical resident working in a hospital asks a clinical pharmacist about the use of empagliflozin in a patient with heart failure with preserved ejection fraction (HFpEF). Patient KE is a 58-year-old Black man with generalized anxiety disorder, HFpEF (EF 50%, NT-proBNP 400 pg/
mL), hypertension (BP 124/76 mmHg), and type 2 diabetes (HbA1c 7.8%). His HFpEF is treated with losartanandmetoprolol,and he takes escitalopram hydrochlorothiazide (HCTZ), and metformin. The medical resident wants to know whether the addition of empagliflozin could be beneficial ,given the results of the new EMPEROR-Preserved trial (NCT03057951).

: In the EMPEROR-Preserved study, the primary composite outcome of cardiovascular death or hospitalizations related to heart failure (HF) was reduced by 21% in patients receiving empagliflozin 10 mg daily compared with the placebo (NNT=31). This reduction was driven by a 29% reduction in HF- related hospitalizations. Use of empagliflozin did not reduce cardiovascular mortality or overall hospitalizations, nor did it improve HF-related quality of life, so it is important to clarify KE’s goals of therapy. Black patients were highly underrepresented in this study, so it is hard to draw firm conclusions about whether he specifically would benefit. However, because KE also has uncontrolled type 2 diabetes, use of a sodium-glucose cotransporter-2 inhibitor can provide glycemic benefits. If he begins taking empagliflozin, monitor his blood pressure closely. A dose reduction of HCTZ may be necessary because the combination could further reduce KE’s blood pressure.

Anker SD, Butler J, Filippatos G, et al. Empagliflozin in heart failure with a preserved ejection fraction. 

. 2021;385(16):1451-1461. doi:10.1056/NEJMoa2107038

: PL, a 36-year-old woman, began taking lamotrigine 6 months ago to manage her focal seizures. After several successful dose titrations, she has been seizure-free for the past 5 months on 100 mg daily of lamotrigine taken orally. At PL’s latest clinic visit, she said she experiences dizziness throughout the day and wants to know what she can do to minimize this adverse effect.

: Dizziness is an expected adverse effect (AE) of all antiepileptic drugs and is often dose-related. Because PL has been seizure-free, it is best to keep her on lamotrigine at the current dose, if possible. One way to mitigate the AE is to spread out the daily dosage over smaller but more frequent doses. For example, PL can try taking 50 mg orally twice daily to see whether that improves her symptoms. Other strategies include dosing the medication closer to bedtime or using an extended-release preparation because lamotrigine peaks 1 to 5 hours post dose. If PL’s symptoms do not improve, she should contact her neurologist or primary care provider for further evaluation.

Schachter SC. Managing side effects. Epilepsy Foundation. November 30, 2003. Accessed March 8, 2022. https://www.epilepsy.com/learn/professionals/diagnosis-treatment/treatment/9-steps-treatment/ managing-side-effects

, is an associate clinical professor in the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy.