Note: Zero mark for Wrong name, wrong dose, wrong drug, wrong strength, wrong direction

Care Plan
(i) Recommendations/ discussion points for prescriber

Pt concern- Review adherence/ Ask or discuss if you have no power on the drug
Wrong things (Condition- Suggest- Reason)
Medication reconciliation- Inform consequence, May not be aware
Target range- Suggest/ Discuss change/ Review adherence
Lifestyle- try

1. Does he need to continue? on the venlafaxine? Patient wishes to cease venlafaxine (1)
-May recommend dose reduction in case of ceasing the drug (1)

2. Suggest changing temazepam to prn (1) or replacing with Melatonin (circadin) (1)

3. Inform doctor about the triple whammy effect (1)

-Dr. may not be aware that patient is taking ibuprofen (OTC Nurofen) (1)

4. His BP is also outside of target range (0.5)

-A change to his anti-hypertensive meds could be discussed with consideration of a
peripherally acting calcium channel blocker being added. (1)
- Does he still need? the low dose of beta-blocker? (0.5)

5. Cease clopidogrel 1 year post-stent (1). Patient is 2 year post stent

6. Pantoprazole dose reduction review (0.5)
7. Paracetamol change to Panadol Osteo (1)
8. Pt is concerned about dizziness SE of prazosin – review compliance at follow-up (1)
9. Review compliance with Lipostat (Pravastatin) as his lipid level is elevated. (1)
10. His cholesterol requires reduction as he is at increased risk of a cardio vascular event,
possible change to a more potent lipid lowering drug such as atorvastatin(1) –Rosuvastatin
or simvastatin could be suggested.
11. Try diet and exercise for blood glucose and lipid reduction (1)

(ii) Patient Counselling

Concern- (Discuss- Answer- Monitoring or Refer)
Wrong things (Action- Reason)
Lifestyle
Target (Risk)

1. Lifestyle interventions: (2.5)

2. Mr Jones could benefit by some help with his diet, salt reduction and weight reduction,
exercise(1)
3. He is unable to exercise much due to his artificical leg; however a physiotherapist may be
able to help with some suitable exercises.
4. Monitor blood glucose levels (1). Purchase a blood glucose meter? (0.5)
5. Cardiovascular risk factor: His cholesterol requires reduction as he is at increased risk of a
cardiovascular event, having had stent put in.
6. In light of Mr. Jones’s concerns regarding venlafaxine, does he need to continue with it? He
needs to continue and discuss it with doctor (1)
 7. Discuss the issue of prazosin prior to getting it dispensed. Close supervision is required
when alpha blockers are added to other antihypertensive agents due to possible additive
hypotensive effects.
8. He needs to take prazosin as directed until reviewed by doctor. (1)
9. He must cease ibuprofen (1) due to the effect on blood pressure and also the triple whammy
effect on his already reduced renal function.
10. Advise about poor pain control. Time should spent with Mr Jones explaining the benefits of
regular doses of paracetamol. Panadol Osteo (paracetamol 665mg) 2 tablets three times a
day (8-hourly) could be suggested.
11. Taking 3 paracetamol at once is not recommended (1.5g, overdose).
12. He should make an appointment to see his GP in 2 weeks time. (1)

Potential/actual problems include: (2018 Assignment)

1. The dose of paracetamol is not optimised.
o Currently taking 2 at night with occasional daytime use.
o The Therapeutic Guidelines: Rheumatology state that for osteoarthritis:
o Only consider using an oral NSAID first line for patients at low risk of harms from
NSAID use.
 For patients with symptoms that persist throughout the day, consider a trial of regular dosing,
rather than ‘as necessary’ dosing. If response to paracetamol is inadequate, a judicious trial
of NSAID use may be considered instead of, or in combination with, paracetamol. This decision
should be based on an assessment of the benefit–harm profile for an NSAID in the individual
patient.

 So, suggest either paracetamol 1g qid (regular dose) OR paracetamol XR q8h (regular dose) to
control arthritis pain. If pain is then controlled, could trial a dose reduction in meloxicam with
a view to discontinuation.

2. The dose of meloxicam is not optimised.

 For OA the usual dose is 7.5 – 15 mg once daily, with a maximum daily dose of 15 mg
(Therapeutic Guidelines: Rheumatology). His current dose is split into twice daily dosing.
 Also, as above the TG say that for OA only to consider using an oral NSAID first line for patients
at low risk of harms from NSAID use (There is also a risk of gastrointestinal irritation/bleeding
with long term use of NSAIDs). This elderly patient would be at high risk of harm.
 Suggest once daily dosing for his meloxicam dose, while optimizing paracetamol baseline
therapy, and then if OA pain is under control trial a dose reduction of meloxicam with a view
to discontinuing the medication.

3. The patient is struggling to coordinate inhalation and actuation of his MDI devices and
the number of puffers they need to use.
· Suggest use of a spacer to assist with MDI use.
· Suggest a potential change to Trelegy Elipta = Umeclidinium + Vilanterol +
Fluticasone
o Reduces 2 puffers into one (Seretide and Spiriva) as per the patient’s
therapy goals

4. Dizziness may be caused by low blood pressure (patient is on perindopril AND

amlodipine); postural hypotension contributing to this?
o Consider reducing amlodipine dose with a view to discontinuing (do not stop
abruptly with CCB)
 5. Esomeprazole. The patient has not experienced GI symptoms for quite some time. Is this
medication still necessary? Trial dose reduction (20mg) and possible deprescribing if no
relapse upon reduction.

6. Cholesterol still high, consider increasing Simvastatin to 20mg daily.

7. He is having increasing difficulty remembering when to take his medicines.

· Suggest regimen simplification
o change simvastatin to atorvastatin, take in morning
o change perindopril and amlodipine to coveram and trial in morning
o change meloxicam to once daily
o change esomeprazole to morning
· If agreeable to the patient, consider suggesting a dose administration aid (e.g. Webster
pack, Sachets) to be supplied by his local pharmacy.

DRP Interaction Solution/ Monitoring

Ramipril High risk of triple whammy Replace ibuprofen with PCM for pain
Frusemide management.
Ibuprofen

Ibuprofen High risk of internal bleeding Replace ibuprofen with PCM for pain
Warfarin management.

Monitor INR.
Amiodarone Amiodarone increases digoxin level Monitor serum digoxin dose closely.
Digoxin Digoxin dose may be reduced based on
serum digoxin conc.
Amiodarone Amiodarone increases warfain Monitor pt’s INR. Dose adjustment is
Warfarin level, increases risk of bleeding acquired based on INR
(Amiodarone inhibits CYP450 2C9)

Amiodarone Amiodarone cause dose related Monitor serum electrolyte and any
Frusemide prolongation ofQT-interval. abnormalities corrected prior to
initiating therapy with amiodarone.
Co-administer with frudemide
produce hypoK+,

increases risk of ventricular

arrhythmias.
PPI PPI reduces the absorption of Monitor for signs of hypothyroidism (eg:
Levothyroxine levothyroxine (by increasing pH) lacking energy) and TFT (if needed).

May lead to hypothyroidism. Increase levothyroxine dose if necessary.

*Use PPI intermittently would not

affect this
Effective combination Patients studied
ACEI + thiazide-like diuretics Post stroke , diabetes
Hypertensive with Left Ventricular Hypertrophy. High risk
ARB + thiazide
hypertensives
CCB + ACEIs or ß-blocker +
Patients with Coronary Artery Disease
thiazide
CCB + thiazide High risk hypertensives
CCB + ACEI Medium risk hypertensives with no overt vascular diseases
ACEI + CCB High risk hypertensives
Thiazide-like diuretics + ACEI Very elderly (>80 years old)
CCB + thiazide or thiazide
Medium risk hypertensives
diuretics
CCB + ARB Medium risk hypertensives
CCB + ß- blocker Medium risk hypertensives

Preferred (based on outcome trials)

• ACEI / thiazide or thiazide-like diuretics
• ARB / thiazide diuretics
• ACEI / CCB

• ß-blocker / thiazide diuretics

• CCB / thiazide diuretics
• Thiazide diuretics / K+ sparing diuretics

• CCB/ thiazide or thiazide-like diuretics

• CCB/ARB
• CCB / ß-blocker

Acceptable (no outcome trial evidence yet)

• ß-blocker / thiazide-like diuretics
• DRI/diuretic

Coronary Artery disease (partial/complete block)

 Intensive lifestyle changes
(healthy diet, regular physical activity, smoking cessation and optimal management of risk
factors and weight)
 Pharmacotherapy which includes:
anti-platelet agents
statins to achieve target LDL-C.

In addition, ACEi, β-blockers and anti-anginal medications may be necessary to treat co-existing
hypertension, LV dysfunction and/or angina.

Anti-obesity drugs”
 Sympathomimetic (Phentermine) - this drug should not be used continuously for longer than 6
months at any one time.  Lipase Inhibitor - Orlistat.
 Glucagon-like peptide 1 Receptor Agonist – Liraglutide
for
 BMI >25.0 kg/m2 plus 2 CV risk factors or
 BMI ≥27.0 kg/m2 after failing to lose weight despite 6 months of lifestyle modification.

Antiplatelet agents and anticoagulants, Lipid modifying agents, Renin-angiotensin-aldosterone

system blockers-prevent future CV events
 Aspirin monotherapy at a dosing of 75-150 mg daily remains the initial antiplatelet agent of
choice.
 Dual antiplatelet therapy (DAPT) has been shown to reduce all-cause mortality, MI and
stroke post ACS whether this is managed medically, by PCI or surgically. The current
recommendation is for DAPT for 12 months post ACS.
 In patients with Stable CAD, NOACs are indicated for:
o Non-valvular AF both paroxysmal and persistent depending on the CHA2DS2-VASc
score.
o Valvular AF (excluding mechanical heart valves and rheumatic mitral stenosis)
 The routine use of ACEi/ARB in patients with Stable CAD without hypertension and normal
LV function is not recommended.
 Depressed LV function (LVEF <40%) to improve survival and other CV outcomes:
o ACEi/ARB
o β-blockers
o mineralocorticoid receptor antagonists - spironolactone and eplerenone
o angiotensin receptor neprilysin inhibitor - Sacubitril/Valsartan (Entresto)
Anti-ischemic therapy is used to treat the symptoms of angina. None have been shown to prevent
MI or death in patients with stable CAD.

These medications prevent attacks of angina by: decreasing myocardial oxygen consumption
(lowering heart rate, blood pressure, myocardial loading, or myocardial contractility) and/or
increasing myocardial oxygen supply (increasing coronary blood flow).
The available anti-ischemic therapy includes:
 β-blockers
 Nitrates
 Calcium channel blockers (CCB)
 Trimetazidine
 Ivabradine
 Ranolazine
 Nicorandil
Notes for Medication history
1. Looks into pt. bag, ask, indication? Dose? Frequency? Duration? + Are you still using this?
2. Complementary/ herbal medicine or vitamin or mineral supplement?
3. Injectables?
4. Anything not in the bag? Anything else?