Hyperlipidemia

Scenario 1:

1. The resources I will need are brochures and education tools, updated procedural information and testing methods, and information for the pharmacist including parameters and knowledge of the test results. The furnishings I will need are chairs, tables, posters, and drawers or cases to keep and transport supplies. The supplies I will need are anything used for collection of samples including syringes and vials, or kits and devices used for less aggressive testing of cholesterol.

2. Regulations include that the site must be licensed to perform testing and must have a “Certificate of Waiver” license if it performs only waived tests. The sites must adhere to manufacturer’s instructions to perform the test, including “Good Laboratory Practice” such as trained personnel, competency, and evaluation. Must also agree to permit announced inspections of the site.

3. OSHA covers every aspect of workplace hazard avoidance. Regulations include health care workers and needle stick precautions, consistent use of personal protective equipment, and work practice and engineering controls in needle stick precautions.

4. Lipoproteins commonly tested for are LDL, HDL, and VLDL. LDL and HDL are the most important when discussing with a patient.

5. It is best to measure her total cholesterol and HDL. LDL can shoot up significantly after a meal.

6. Yes, her age, smoking, high blood pressure, and close relative put her as a candidate for CHD.

7. She has 4 countable NCEP factors: age, relative, smoking, and hypertension

8. Her 10 year risk score is 8%.

9. Her BMI is on the high side and she is overweight being close to obese.

10. I would suggest for lifestyle modifications first and foremost. Advise her to quit smoking and begin developing a diet and exercise. I would also tell her to keep consistent on her office visits with the physician as well as medication she is on. These factors combined can help improve her symptoms and her future health.

11.
To whom it may concern (or Dr. Yada Yada),

I have tested and reviewed Ms. Yetter’s cholesterol and have provided copies of the results. As per the diagnosis, I suggest developing a diet that is consistent to improve her quality of life and to begin a medication regimen that would assist her in reaching her goals. Just as well, I suggest evaluating her medication profile once again and determining if these medications are best for her. I would also suggest motivating Ms. Yetter to quit smoking and exercise because she is on the verge of stage 1 obesity. If you have any questions, please feel free to give me a call.

Vikas Jain, Pharm.D.

12. I would tell her that the new prescription is a good statin aimed at decreasing her cholesterol when used appropriately with a developed diet. Also, I would explain which of her cholesterol numbers are high and what that could impact in her daily life, if not now then later. I would again stress the importance of medication compliance and lifestyle changes if that hasn’t already happened.

13. Ms. Yetter’s risk category is moderate but is close to the edge of moderately high. She can easily cross this line if she does not begin making some changes in her daily lifestyle.

14. Ms. Yetter’s goal for LDL should be to be below 130, but I would suggest her to be below 100. This is because she is moderate currently, but because she is close to moderately high, it would be better if she went the extra mile.

15. She needs to decrease her LDL by about 28-44% to be satisfactory and put her at between 100-130 mg/dL.

16. Therapeutic lifestyles to initiate today is reduce frequency of smoking and drinking. Also, develop a plan for portion control over a course of time. And lastly, to begin exercising anyway she sees possible. Because her knees hurt, walk only 15 minutes instead of 30 minutes twice a day or do elliptical which is easier on the knees.

17. Some monitoring plans I would have for the next visit are weight check, medication compliance check, see if she quit smoking and drinking or at least cut it, and also ask her how she’s feeling and if she’s been exercising at all.

18. At first, I would have her come back after 2 weeks to see how she is doing on her new routine. After a couple of visits, monthly visits would seem adequate.

19. I would let Ms. Yetter know that grapefruit juice blocks the breakdown of statins and therefore causes it to stay in the body longer. By accumulating high amounts of the drug, it could prove harmful and might be fatal.

20. As of now, Ms. Yetter’s medications are helping her get to her goals and bringing her levels where they need to be. To bring it a little closer, she can be given a product such as either Advicor or Niacin(decrease TC,LDL and increase HDL), or something to just decrease her triglycerides such as omega 3 fatty acids.

21. Since her HDL is just about normal and her LDL is decreasing a good amount, the best option would be to just target her TC. She can take over the counter fish capsules with normal dosing and this will help her decrease her TC levels closer to a normal goal level.

22. I would let Ms. Yetter know that I spoke with a nurse and left a message for your doctor. I will try calling back again later today or tomorrow, but if you haven’t heard from either, give your physician a call. I would also give her a handout/printout of our plan so she has it.

23. I would search Clinical Pharmacology for the interaction and the severity of it. I would double check with the physician and discuss possible alternatives if necessary and advise Ms. Yetter of the problem and that the situation is being resolved. Because the antibiotic is only for 2 weeks, a minor interaction might still prove otherwise beneficial versus the risk.

24. I would let Ms. Yetter know that there has been no strong evidence from research stating that CoQ 10 helps prevent the side effects of statins. If she does experience muscle aches and tenderness, she should let her physician know immediately and perhaps an alternative course of therapy might be recommended.

Scenario 2:

1. Some options would be a fibric acid derivative, niacin, or omega-3 fatty acids which all decrease triglycerides.

2. The best option for Mrs. Jones would be the fibric acid derivative. This is because she has already reached her LDL goal and still needs to raise her HDL goal along with decreasing her triglycerides. This class of medications will do just that.

3. I would tell Mrs. Jones that she is currently controlled taking Crestor and that any change in current therapy might alter her results. If she still wants to change therapies, then she should contact her physician to see what alternative statin options she would have. She must be sure to monitor her cholesterol levels to notice if any changes do occur.

Scenario 3:

1. First step is to ask the patient what it is for or what the doctor wrote it for. If they aren’t sure, or if there is still confusion, call the physician and ask them or their nurse to clarify whatever is doubtful or illegible. A lot of times you can tell what the prescription is by their age, or quantity, or even directions.

2. When a prescription is written by a physician, it is usually deemed medically necessary and this should be explained to the patient. If the patient is worried about price or has any other doubts, they should be advised to speak to their physician before substituting for an alternative therapy.

Scenario 4:

1. Niaspan is taken on an individual dosing schedule. For the first 4 weeks, the patient should take 500mg at bedtime after a low-fat snack. For the next 4 weeks, the patient should take 1000mg at bedtime in the same manner. After that, the patient should take either 1 1000mg or 2 500mg tablets at bedtime, but this dose can be titrated per the individual. If the dose is inadequate for the patient, they can go up to 1500mg or 2000mg in the same manner.

2. Many times a generic can be substituted for the brand product. However, the pharmacist or the patient must first call their physician to allow the change as Niaspan is a closely dosed medication. The products might affect the system differently so the physician might have him titer the dose to reach maximum efficacy if the substitution is allowed.