Case Studies (December 2014)
CASE 1
DS is a 21-year-old woman who comes to your pharmacy and states that she is planning a trip to Johannesburg, South Africa, in 8 months. She plans on being there for 3 weeks and is looking for advice on what vaccinations she should have. DS reports being up-to-date on all of her standard vaccinations (ie, tetanus, diphtheria and pertussis, varicella, human papillomavirus, measles, mumps and rubella, and influenza) and has previously received her hepatitis B vaccination series. Upon further questioning, DS states that she has no plans to travel outside of Johannesburg.
As the pharmacist, what recommendations do you have for DS?CASE 2
LZ is a 58-year-old man who comes to the pharmacy with a prescription for celecoxib 400 mg, 2 tablets orally (initially), and then 1 tablet orally every 12 hours for 7 days. Upon questioning LZ, you learn that this medication was prescribed to him by his primary care physician to treat acute gout attacks. LZ explains he has been experiencing severe pain in, and a “small bump” (tophus) on, his big toe, and that it is his third acute gout attack this year. He shows you a printout of his recent lab results, which he received after his most recent office visit. The results show that LZ has a serum urate level of 9.2 mg/dL. According to his profile, LZ takes only allopurinol 300 mg orally every day.
As the pharmacist, what recommendation regarding LZ’s pharmacotherapy could you make?
ANSWERS
Case 1: According to the Centers for Disease Control and Prevention (CDC) Travelers’ Health website (wwwnc.cdc.gov/travel/destinations/list), persons planning short-term travel to South Africa should receive hepatitis A, hepatitis B, and typhoid fever vaccinations (or series) and should potentially be given medication for malaria prophylaxis. In many states, pharmacists can administer CDC-recommended vaccinations, although many require a prescription.
The pharmacist should recommend that DS receive the hepatitis A vaccination series and the typhoid vaccination prior to traveling to South Africa. Hepatitis A vaccination is available as an intramuscular injection given twice, 6 months apart. Typhoid vaccination may be given either intramuscularly or orally and should be completed ≥2 or ≥1 week(s), respectively, before travel. DS does not require malaria prophylaxis because, according to the CDC website, Johannesburg does not fall in a malaria-endemic region of South Africa.
As the pharmacist, you should recommend that DS see her primary care physician or attend a travel clinic as soon as possible to receive prescriptions or vaccinations.
Case 2: According to the most recent American College of Rheumatology guidelines for the management of gout, daily doses of allopurinol greater than 300 mg are recommended in patients experiencing acute attacks, with serum urate levels above 5 mg/dL. Evidence shows that higher doses of allopurinol—up to a maximum dose of 800 mg daily—can reduce the serum urate level to <5 mg/dL and can durably improve signs and symptoms of gout. Allopurinol monotherapy at daily doses of 300 mg or less often fail to help more than half of gout sufferers achieve target serum urate levels.
As the pharmacist, you should fill LZ’s celecoxib prescription, as it is the correct dosage for an acute gout attack. You should also contact his physician to recommend up-titrating his allopurinol dose in order to achieve a serum urate level <5 mg/dL.
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Dr. Zaccaro is an MBA candidate and Yunes Doleh is a PharmD candidate at the University of Connecticut School of Pharmacy. 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.
