MARCH 01, 2005
Lauren S. Schlesselman, PharmD

CASE 1: MS, a 21-year-old college student, is required to have a complete physical examination prior to participating in tryouts for the school's baseball team. Since he has no significant medical history and is in excellent physical shape, MS considers the examination a waste of his time.

On examination, the physician notes that MS appears to be a well-developed, well-nourished man in no apparent distress. His vital signs are within normal limits. During physical assessment, no abnormal findings are noted.

Before completing the paperwork to permit MS to try out for the team, the physician explains to MS that he still needs some blood work done. He informs MS that the lab results will be back the following day, so MS can return for the paperwork then.

When the lab results are returned, the physician is surprised to read that MS has elevated aminotransferases. All other results are within normal limits. The physician calls MS with the results. He explains that MS will need further lab work, including evaluation for possible hepatitis.

Upon further workup, it is determined that MS has hepatitis C, genotype 2a. Since MS feels healthy, he urges the physician to sign the health forms and not to worry about the diagnosis. The physician instead sits MS down for a discussion on how to avoid spreading the disease and implications for his future life. After the enlightening discussion, MS agrees to initiate therapy.

With MS'genotype, what is the anticipated duration of therapy with pegylated interferon and ribavirin?

CASE 2: PT, a 55-year-old obese woman, presents to her local pharmacy. Along with filling her prescription for atenolol, PT wishes to purchase a tube of miconazole vaginal cream and a case of bottled water. She explains to the pharmacist that this is the third tube of antifungal cream that she has purchased in the last month. PT states that she is very frustrated by her inability to eliminate her vaginal yeast infection. She considers it almost as annoying as the unquenchable thirst that she has been experiencing.

The pharmacist asks PT to describe how and when she is administering the miconazole cream. PT confirms that she administers the cream immediately prior to retiring for the evening. Administering the cream is the last thing she does at night so gravity does not cause some of the cream to "leak out."

Convinced that PT is using the vaginal cream properly, the pharmacist wonders why PT is unable to cure the infection after 2 courses of antifungal treatment. She is also concerned about PT's unquenchable thirst. The pharmacist reviews PT's medication profile for possible causes. The only medication on her profile is the atenolol prescription she is refilling.

The pharmacist then asks PT if her physician has ever evaluated her for or diagnosed her with diabetes mellitus. PT appears surprised. "Yes, as a matter of fact, during my last appointment my doctor told me that I have diabetes. I was supposed to see a dietitian, but I do not need anyone telling me how to eat. I am going to eat whatever I want,"she says.

The pharmacist recommends that PT make an appointment to see her physician as soon as possible. She explains that she is concerned that PT's diabetes mellitus is not controlled, particularly if PT is not following dietary changes.

Why does the pharmacist suspect that PT's diabetes mellitus is not controlled?

Dr. Schlesselman is a clinical pharmacist based in Niantic, Conn.

Click Here For The Answer -----------> [-]

CASE ONE: Genotype 1, the most common type in the United States, is usually treated for 12 months. Studies show that patients with genotypes 2 or 3 can be offered 6 months of pegylated interferon and ribavirin therapy.

CASE TWO: Recurrent genital yeast infections and unquenchable thirst are both symptoms of increased glucose levels associated with diabetes. Since no medications were prescribed, PT's physician must have been attempting to control her diabetes with dietary changes. Unfortunately, PT was unwilling to make such changes. The pharmacist should refer PT back to the physician for initiation of medications (and counseling on lifestyle modifications and risks associated with diabetes).