Case Studies

Pharmacy Times, April 2014 Allergy & Asthma, Volume 80, Issue 4

Case studies dealing with insomnia and painful urination with flank pain.

Case 1

SC is a 33-year-old woman who comes to your pharmacy’s urgent care clinic complaining of frequent painful urination and flank pain over her kidneys. She denies having fever, chills, nausea, or vomiting, and seems well hydrated. SC has no notable medical history and does not take prescription medications. The nurse at the pharmacy-based clinic performs a urine dipstick urinalysis, which has a positive result for bacteria and pyuria (white blood cells in the urine), and sends out a urine specimen for culture. The nurse makes a diagnosis of pyelonephritis and decides that SC can be treated as an outpatient. The nurse asks the pharmacist for advice regarding an empiric antibiotic regimen to treat SC.

What antibiotic should the pharmacist recommend for empiric therapy in SC?

Case 2

CC, a 38-year-old man, goes to his primary care physician complaining of insomnia. Upon questioning, CC notes that he has been having difficulty falling asleep almost every night for the past 4 weeks, but once he falls asleep, he sleeps through the remainder of the night. As a result of this sleep pattern, CC reports waking up tired and feels that his performance at work is beginning to suffer. CC travels frequently (2 to 3 times per month) and recently had a severe case of viral colitis that he acquired on a trip overseas. The colitis resulted in a 1-week hospital stay a few weeks ago, but the condition has completely resolved. CC has no other significant medical history and takes no prescription medications. His physician would like to use pharmacotherapy to treat the insomnia.

What agent(s) would you recommend to treat CC’s insomnia?

ANSWERS

Case 1: Pyelonephritis is typically caused by a bacterium infecting the kidneys. Bacteria can move to the kidneys from the bladder or can be carried through the bloodstream from other parts of the body. Although many bacteria can cause pyelonephritis, Escherichia coli is most often the cause.

In patients suspected of having pyelonephritis or who are being treated for it on an outpatient basis, oral ciprofloxacin 500 mg twice daily for 7 days is an appropriate choice (as long as fluoroquinolone resistance in the area is not known to exceed 10%). Alternatively, ciprofloxacin 1000 mg extended release for 7 days or levofloxacin 750 mg once daily for 5 days is also acceptable.

Case 2: Insomnia symptoms occur in about 33% to 50% of adults. According to American Academy of Sleep Medicine guidelines, insomnia is defined as the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity, and results in some form of daytime impairment.

The primary goals of insomnia treatment are to improve sleep quality and quantity and improve associated daytime impairment. Guideline-recommended pharmacologic treatments include short-acting benzodiazepine receptor agonists (ie, zolpidem, eszopiclone, zaleplon, and temazepam) or ramelteon. While other potential agents exist, including sedating antidepressants (trazodone, amitriptyline, doxepin, mirtazapine), antiepilepsy medications (gabapentin, tiagabine), and atypical antipsychotics (quetiapine, olanzapine), these are most suitable for people who have comorbid conditions that may benefit from the primary action of these drugs (ie, depression, epilepsy/seizures, or psychosis). OTC sleeps aids (antihistamines) or natural products (valerian, melatonin) are not recommended for chronic insomnia because of their relative lack of efficacy and safety data. Regardless of the agent chosen, the lowest possible dose to treat the insomnia should be employed.

CC’s insomnia may be due to frequent travel or the recent stress of a significant illness. It appears that CC’s insomnia is characterized by difficulty falling asleep, and not staying asleep. Because CC does not suffer from any comorbid conditions that would benefit from a specific agent, a trial of a short-acting benzodiazepine seems appropriate. Zolpidem 5 mg once per night, taken immediately before bedtime and with at least 7 to 8 hours remaining before the planned time of awakening, should aid CC in falling asleep. If the 5-mg dose is not effective, the dose can be increased to 10 mg.

Read the answers

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Dr. Coleman is professor of pharmacy practice, as well as codirector and methods-chief at Hartford Hospital Evidence-Based Practice Center, at the University of Connecticut School of Pharmacy.