Integrated Case

November 28, 2002

Drug-Related Problems for Mrs. Smith

• Mrs. Smith is continuing to experience signs and Sx of Parkinson’s disease for which she may be receiving too low a dose of Sinemet and/or require additional therapy

• Mrs. Smith is at risk of developing another episode of TIA and/or stroke for which she requires drug therapy

• Mrs. Smith is experiencing Sx of short-term insomnia for which she may benefit from therapy

• Depression?

Parkinson’s diseaseHow does it present? • Four classical feature:• 1. Tremor• 2. Rigidity• 3. Bradykinesia• 4. Postural disturbances• Other Sx…Mrs. Smith’s disease progression:

Mrs. Smith’s RFs:

Parkinson’s DiseaseMrs. Smith’s disease progression:• started with unilateral hand tremor and progressed to

both hands• decreased motor activity or bradykinesia seen as

– difficulty initiating physical activities such as walking,– difficulty buttoning her clothes, and – picking up objects

• likely has masked facies and a slow gait

Mrs. Smith’s RFs:• age, rural area??

Parkinson’s diseaseIs Tx needed?

Tx Options:Levodopa + Carbidopa/benserazideSelegiline (Deprenyl)Anticholinergic medicationsAmantadine (Symmetrel)Dopamine agonistsCOMT inhibitor -Tolcapone (Tasmar) ; Entacapone

(Comtan)

Mrs. Smith’s management

• She is presently on Sinemet 100/25 tid• Options for management:

At risk for TIA and/or stroke

• What is TIA?

• RIND: reversible ischemic neurological deficit

• What is stroke?

• Thrombus vs. embolus

TIA / Stroke

General Risk FactorsHTN, prior TIA/stroke, age, male, smoking, etc.

(consider cardiac RF)

Mrs. Smith’s RF

Is Tx needed?

TIA / StrokeTx options - Prophylaxis• ASA• Ticlopidine• Clopidogrel• Warfarin• Dipyridamole• Sulfinpyrazone• tPA – for acute ischemic stroke (within 3

hours)

TIA / Stroke - Aspirin

efficacy and place in therapy:• Dutch TIA (30mg vs. 300mg ASA), UKTIA

(300mg vs. 1200mg ASA): effective in secondary prophylaxis at lower doses

• Decreases RR by 24% in secondary Px• Dose tried: 30mg daily – 600 mg bid• Side effects: GI upset, PUD• Convenience: daily• cost: cheap

TIA/Stroke

• What would be an appropriate agent for Mrs. Smith and why?

Mrs. Smith’s sleep problem• What is insomnia?

• Types of insomnia

Mrs. Smith’s sleep problem• Drug-induced causes:

• Reason for Mrs. Smith’s insomnia

• Is Tx needed?

Mrs. Smith’s sleep problem• Tx Options:

– Non-pharmacological options– benzodiazepines– antihistamines– Zopiclone– zaleplon– chloral hydrate– barbiturates

Non-pharmacological Strategies

• Good Sleep “Hygiene”

• alcohol use, caffeine, cigarette smoking, fluids

• chronic insomnia: counselling, behavioural & biofeedback, sleep deprivation, etc.

Comparison of BenzodiazepinesDrug t 1/2 onset oxidation active met

diazepamflurazepamoxazepamlorazepamtemazepamtriazolam

Comparison of BenzodiazepinesDrug t 1/2 onset oxidation active met

Diazepam 2-4ds quick yes yesFlurazepam 2-3ds inter-fast yes yesOxazepam 5-15h slow no noLorazepam 10-20h interm no noTemazepam 10-20h slow-inte no noTriazolam 2-5h quick-int yes no

Mrs. Smith’s sleep management

Depression

• How is it diagnosed?

• RF

Depression

Typical Signs and Sx:emotional Sx: no interest in life, social w/d,

worthlessnessphysical Sx: fatigue, insomnia/hypersomnia,

loss of wt. & appetite or weight gaincognitive Sx: difficulty concentrating, poor

memory, indecisivenessDoes Mrs. Smith have depression?

Depression – Goals of TxReduce Sx of acute episode and facilitate pt’s

return to same level of functioning: remissionAcute phase: Tx 6-12 weeks (to relieve Sx)

To prevent relapse: Tx 4-9 mos (continuation phase)

To prevent recurrence: Tx > 1 year (mtce phase)Consider risk of recurrence: after 1 episode: 50%

Depression – general approach to TxAntidepressants of equivalent efficacy in

grps of pts. in comparable doses Initial choice empirically done (consider

pt’s Hx of response, family Hx, depression subtype, concurrent medical conditions, DI, ADR, cost)

65-70% of pts will respond to first agentNon-pharmacological Tx: psychotherapy

(1st line if mild-moderate); combined has better efficacy

Depression – comparison of agentsSSRI (fluoxetine, fluvoxamine, paroxetine,

sertraline)NefazodoneVenlafaxineBupropionTCAs: 1st generation: amitriptyline

2nd generation: desipramineMoclobemideMAOI: phenelzine, tranylcypromine

Depression – comparison of agentsConsider MOA Efficacy equalOnset of effectPotential side effectsPotential drug interactions (see CANMAT

guidelines from readings)Switching between antidepressants (see

guidelines)

Pharmacy Care Plan• Clinical Outcomes

To control Sx of PD and decrease further disease progression

To prevent future TIAs and/or strokeTo help Mrs. Smith fall asleep at night and to

feel well rested• Pharmacotherapeutic Outcome

- appropriate anti-Parkinosonian medication…- Appropriate anti-platelet agent…- Ensure that she receives counselling re: good

sleep hygeine…

Pharmacy Care Plan• Pharmacotherapeutic Endpoints

– Improvement in initiating walking, buttoning blouse, picking up objects, in 3 days to a week and optimal in one month

– No TIAs/ stroke while on therapy (confusion, paresthesias, etc.)

– Able to fall asleep within ½ hour in 3-4 days

Pharmacy Care Plan

• Alternatives & AssessmentParkinson’s Disease:

TIA/Stroke:

insomnia:

Pharmacy Care Plan

• Therapeutic Plan

Pharmacy Care Plan

• Therapeutic Plan EndpointsSinemet: nausea, vomiting, wearing off

effect, on-off effect…ASA: nausea, no blood in stools (tarry

stools), no PUDSelegiline: insomnia, jitterinessDA agonist: nausea, orthostatic hypotension,

insomnia, dyskinesias…

Pharmacy Care Plan

• Monitoring PlanWork closely with patient, family, caregivers

and health care providers