Stefanie C. Nigro, PharmD, BCACP, CDE

AG is a 65-year-old woman who has type 2 diabetes. She recently started insulin therapy because of worsening glycemic control. AG's antidiabetic regimen includes 5 units of insulin aspart before breakfast, 20 units of insulin glargine at bedtime, and 1000 mg of metformin twice daily. She tests 4 times per day, at bedtime and before meals. AG wonders why her blood glucose is so high every morning. Upon review of her logs, the pharmacists notice that her bedtime readings average 89 mg/dL, with subsequent fasting readings averaging more than 200 mg/dL the past week. AG does not snack late at night and says that she takes her medications as directed every day. 

AG's morning hyperglycemia may be the result of either the dawn phenomenon or Somogyi effect. To distinguish the cause, instruct her to test her glucose levels around 3 AM. If AG is experiencing nocturnal hypoglycemia, it is most likely the Somogyi effect; her body compensates for low sugar by secreting glucagon, causing rebound hyperglycemia in the morning. This can be the result of not eating enough carbohydrates at night or taking too much insulin. The pharmacist should assess AG's insulin technique and verify her doses to ensure that she is using the insulin correctly. She may need a dose reduction of her insulin to improve her glucose readings. The pharmacist can recommend decreasing AG's glargine to 16 units at bedtime.

EG is a 51-year-old woman who has been experiencing hot flashes for the past 6 months. She mentions that she has not spoken to her physician because she heard these are normal menopause symptoms. However, during the past month, the symptoms have been disrupting EG's daily life and sleep. She smokes half a pack of cigarettes per day and has not been able to go to the gym to exercise because of COVID-19 facility restrictions. EG's past medical history includes osteopenia, but she is otherwise healthy. EG recently spoke to a neighbor who said that she also had hot flashes and that her physician prescribed a hormone tablet, which helped. EG wonders whether this treatment could work for her as well. 

Vasomotor symptoms, or hot flashes, are a common symptom of menopause. Because EG's symptoms are disrupting her life, hormonal replacement therapy (HRT), such as estrogen alone or in combination with a progestin, could be an option if the benefits of symptom reduction outweigh the risks. She should be screened for a history of cardiovascular and thrombotic disease, along with breast cancer. If appropriate, the lowest effective dose of HRT should be used for symptom relief.

 Treatment should be for the shortest duration possible. Lifestyle changes, such as exercising regularly, maintaining a healthy body weight, and refraining from smoking have also been shown to provide some relief from hot flashes.

 If HRT is not appropriate, EG should talk to her physician about trying serotonin-norepinephrine reuptake inhibitors or selective serotonin reuptake inhibitors for symptom management.

are PharmD candidates at the University of Connecticut School of Pharmacy in Storrs.

Stefanie C. Nigro, PharmD, BCACP, CDCES, 

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

1. ACOG Practice Bulletin No. 141: management of menopausal symptoms. 

. 2014;123(1):202-216. doi:10.1097/01.aog.0000441353.20693.78

2. Jull J, Stacey D, Beach S, et al. Lifestyle interventions targeting body weight changes during the menopause transition: a systematic review. 

. 2014;2014:824310. doi:10.1155/2014/824310

Articles

How would you answer these patients' questions?

August 2021 Interactive Case Studies

AP is a 67-year-old woman with a history of depression, gout, and hypercholesterolemia. Her primary care provider issued a prescription for doxycycline for the treatment of cellulitis. AP is concerned about stomach problems, as most oral medications cause her to experience bloating and diarrhea. She remembers that the pharmacist recently told her she can take 1 of her medications with food or milk to help minimize stomach issues. AP wants to know if she can take her new prescription for doxycycline with milk. 

Counsel AP to take her doxycycline on an empty stomach 1 hour before or 2 hours after meals. The calcium in dairy products, such as milk, can interfere with the absorption of doxycycline. Calcium ions can bind to doxycycline and form a chelate, thus reducing its absorption. This may also reduce the effectiveness of AP's cellulitis treatment.

 To be safe, she will need to change how she takes her medications for the duration of her doxycycline therapy.

Meyer FP, Specht H, Quednow B, Walther H. Influence of milk on the bioavailability of doxycyclie—new aspects. 

. 1989;17(4):245-246. doi:10.1007/BF01639529

JC is a 21-year-old woman who calls the pharmacy in a panic. She reports having unprotected sex with a new partner about 12 weeks ago and is concerned about possible HIV infection. JC called her primary care provider's (PCP) office to schedule an appointment for HIV testing but learned that her PCP is on vacation this week. JC is very anxious about this situation and has been having trouble sleeping. She wants to know if there is a reliable screening test she can take or if she needs to wait until her PCP returns from vacation. 

What advice should the pharmacist give JC?

Because it has been 3 months since JC had unprotected sex, she can purchase an at-home HIV testing kit, such as OraQuick. The FDA-approved saliva-based test is designed to detect antibodies to the HIV virus. Results are reported in 20 to 40 minutes, which should give JC the answers she needs without waiting for her PCP to return from vacation. If the test is positive, a health care provider should confirm the result. If the test is negative, it is likely that JC does not have HIV, assuming she followed the directions carefully. 

 are PharmD candidates at the University of Connecticut School of Pharmacy in Storrs.

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

How would you respond to these patients' questions?

July 2021 Interactives: Case Studies

New mom SN comes to the pharmacy counter with CN, her 6-month-old daughter who started teething this week. SN is concerned that CN is a little more irritable and crying more frequently because of the pain. SN wants to know if she can give CN Orajel that she used for herself after a root canal. While looking at the ingredients on the package label, the pharmacist notices that the active ingredient is benzocaine 10%. How should the pharmacist respond to SN?

The pharmacist should advise against using Orajel to treat CN's teething pain. Although adults can still use Orajel, the FDA has recommended against the use of products containing benzocaine by children younger than 2 years because of the risk of a rare by potentially fatal blood condition called methemoglobinemia.

 Methemoglobinemia has been reported with benzocaine concentrations as low as 7.5%. The American Academy of Pediatrics does not recommend treatment with any teething creams because they usually wash out of the baby's mouth within minutes. Instead, they recommend giving children a teething ring chilled in the refrigerator or gently rubbing the child's gums with clean fingers to relieve teething symptoms.

1. Risk of serious and potentially fatal blood disorder prompts FDA action on oral over-the-counter benzocaine products used for teething and mouth pain and prescription local anesthetics. FDA. Updated May 31, 2018. Accessed March 22, 2021. https://www.fda.gov/drugs/drug-safety-and-availability/risk-serious-and-potentially-fatal-blood-disorder-prompts-fda-action-oral-over-counter-benzocaine

2. Teething: 4 to 7 months. HealthyChildren.org. Updated October 6, 2016. Accessed March 22, 2021. https://www.healthychildren.org/English/ages-stages/baby/teething-tooth-care/pages/Teething-4-to-7-Months.aspx

LD is a 70-year-old woman who calls the pharmacy with questions about the shingles vaccine. She wonders whether she needs the vaccine because she does not recall having had chicken pox as a child.

Chicken pox and shingles are caused by the varicella-zoster virus. Individuals can only get shingles if they have already had chicken pox. Those who never had chicken pox and have not received the varicella vaccine but are exposed to an individual with shingles can develop chicken pox. Once an individual has had chicken pox, he or she is susceptible to contracting shingles if exposed to the virus again. Encourage LD to receive the shingles vaccine, preferably Shingrix, because she is older than 50 years.

 Shingrix is more effective at preventing shingles than Zostavax and provides and provides longer immunity.

 LD should receive a 2-dose series of Shingrix, with doses spaced 2 to 6 months apart. Alternatively, LD can be tested for immunity to the varicella-zoster virus. If she tests negative, she should get the chicken pox vaccine.

1. Shingles vaccination. CDC. Updated January 25, 2018. Accessed March 23, 2021. https://www.cdc.gov/vaccines/vpd/shingles/public/shingrix/index.html?CDC_AA_refVal=https%3A3A%2F%2Fwww.cdc.gov%2Fvaccines%2Fvpd%2Fshingles%2Fpublic%2Findex.html

2. Tricco AC, Zarin W, Cardoso R, et al. Effi cacy, eff ectiveness, and safety of herpes zoster vaccines in adults aged 50 and older: systematic review and network meta-analysis. BMJ. 2018;363:k4029. doi:10.1136/bmj.k4029

How should pharmacists help these patients?

May 2021 Interactives: Case Studies

EP is a patient with epilepsy. He has been taking phenytoin at a therapeutic dose for
4 years. EP was recently prescribed valproic acid because he has had breakthrough seizures over the past few months. After taking valproic acid for several days, he calls the pharmacy expressing concern about some new adverse effects. EP describes feeling confused, dizzy, and off balance, and he says he has been slurring his words. He asks whether his new therapy can cause these symptoms.

SA, a 36-year-old man, presents with a 4-month history of heartburn and intermittent difficulty swallowing. The pain is not relieved by eating or by positional changes, and he has tried OTC famotidine and Tums (antacid tablets) with minimal relief. SA takes amlodipine 5 mg orally daily for hypertension and ibuprofen 200 mg as needed for occasional headaches. He has no known drug allergies. He wants to know whether he should try Prilosec (omeprazole) OTC.

Based on EP’s report, his symptoms are consistent with phenytoin toxicity. Both phenytoin and valproic acid are highly bound to plasma proteins. Valproic acid can displace phenytoin from its binding site on protein, leading to higher concentrations of unbound (eg, pharmacologically active) phenytoin. The pharmacist can advise EP to call his prescriber as soon as possible to have a free phenytoin level ordered. A modification to his antiepileptic drug therapy will likely be required.

The pharmacist should advise against further OTC therapies and refer SA to his primary care provider for further evaluation. There are several reasons why SA is not a good candidate for self-treatment. First, his symptoms have persisted for more than 3 months despite treatment with 2 OTC therapies.1 Second, SA has difficulty swallowing (dysphagia), a red flag that may indicate more severe disease, such as cardiac disease.2 The pharmacist can counsel on nonpharmacological interventions, such as avoiding eating close to bedtime and spicy foods, as well as eating smaller meals, but should discourage use of Prilosec OTC.

Perucca E, Hebdige S, Frigo GM, Gatti G, Lecchini S, Crema A. Interaction between phenytoin and valproic acid: plasma protein binding and metabolic effects. Clin Pharmacol Ther. 1980;28(6):779-789. doi:10.1038/ clpt.1980.235

Whetsel T, Garofoli G. Heartburn and Dyspepsia. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. Krinsky DL, ed. 20th ed. American Pharmacists Association: 2020.


Katz PO, Gerson LB, Vela MF. Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease. Am J Gastroenterol. 2013;108(3):308-328. doi:10.1038/ajg.2012.444

SINDORELA FRROKU-DIDO is a PharmD candidate at the University of Connecticut School of Pharmacy in Storrs.

STEFANIE C. NIGRO, PHARMD, BCACP, CDE, is an associate clinical professor at the University of Connecticut School of Pharmacy in Storrs.

Interactive case studies from April 2021.