Mohammad

IPE Student Presentation

June 11, 2014Jennifer Kelleher

Alicia ParlonNasir Qadri

“I don’t want to worry about car trips longer than 10 minutes!”

Chief Complaint

FS is a 93 year old man presenting at an MTM session. FS was started on immediate release oxybutynin 5 mg PO daily and 1 tablet 30 minutes prior to leaving the house 4 years ago to treat urinary incontinence secondary to BPH. Recently he has been taking ½ tablet PO at bedtime. He is currently being treated with tamsulosin 0.8 mg PO daily and finasteride 5 mg PO daily for BPH symptoms with some improvement. FS has an extensive medication list and multiple disease states. The patient has been struggling the last few years with apprehension and worry leaving the house not knowing if a bathroom will be close by.

History and Present Illness:

HTN AFib Depression Hypercholesterolemia Urinary retention BPH Anxiety Arthritis Glaucoma Frequent heart burn Insomnia Obstructive sleep apnea Eye problems Pre-diabetic

PMH

Appendectomy Cholecystectomy Edentulous, full dentures Angioplasty lower left leg Bilateral cataract surgery Partial colectomy - diverticulitis

Past Surgical History

Only child Mother deceased age 34 Hodgkin’s

Lymphoma 1937, treated for a heart condition for 2 years prior to death

Father deceased age 49 stroke or MI, can’t recall which but he had atherosclerosis

Family History

Former smoker, cigarettes, pipes and cigars, reports quitting 40-50 years ago

Drinks 1-2 1.5% abv beers at supper Former US Marine Metallurgist, still working 1 day a week Widower 2008 2 children (1 daughter, deceased and one

son who currently lives with him)

Social History

NKDA Cucumbers (rash)

Allergies

warfarin 2 mg PO daily (2000) amlodipine 5 mg PO daily with food (2000) potassium chloride ER 10 mEq 2 tabs PO daily (1130) paroxetine 40 mg tablet PO daily (0630) finasteride 5 mg PO daily (1130) simvastatin 10 mg PO daily (2000) oxybutynin 5 mg ½ tab PO daily (2000) captopril 25 mg PO TID 1 hr before meals avoid antacids (0600,

1030, 1900) lorazepam 0.5 mg PO 1-4 x daily PRN latanoprost 0.005% sol 1 gtt OU HS (2200) furosemide 20 mg PO QAM (0630) acetaminophen 325 mg 2 tabs PO q4h PRN pain Tylenol PM® 500 mg (50mg diphenhydramine) 2 caplets PO HS

Medication History

tamsulosin 0.4 mg 2 caps PO daily (2000) erythromycin 5mg/gm ophthalmic ointment Apply a small amount to

lids BID PRN vitamin B1 100 mg tab PO daily (0630) vitamin B12 1,000 mg tab PO daily (1130) vitamin C 500mg/D3 1,000 IU 1 tab PO daily (0630) Prostate Health Essentials® 300 mg saw palmetto 1 tab PO daily

(2000) Preservision® 1 cap PO daily (0630) vitamin C with Rose Hips 500 mg 1 tab PO daily (1130) omega 3 Fish Oil 1,250 mg (EPA 500 mg /DHA 650 mg) 1 cap PO BID

(0630, 1130) acidophilus 1 cap PO daily (1130) vitamin D3 2,000 IU 1 cap PO daily (0630) Metamucil powder 1 tsp. PO mixed in 8 oz of water or juice BID (0630,

2000)

Medication History cont.

ROS: not available VS: WNL per viewing encounter notes from

primary care physician from 5/14/14 office visit. Was unable to obtain this information again since interviewing the patient.

We would like to know all of his vital signs.

Physical Exam

Influenza 11/08/13 Influenza A (H1N1) Monoval Vac IM

Suspension 01/23/10 Pneumococcal 11/06/06, 08/10/12 Td/DT 09/07/05 Tdap 02/28/14 Zoster 03/25/09

Recent Immunizations

“I don’t want to worry about car trips longer than 10 minutes!”

Initially prescribed 5 mg oxybutynin daily and ½ tab 30 minutes prior to leaving the house on longer trips

Patient currently takes 2.5 mg PO daily HS Treated for BPH with tamsulosin 0.8 mg PO daily

and finasteride 5 mg PO daily FS feel “lousy” in the morning and complains of dry

mouth and other anticholinergic side-effects FS “feels lethargic in the morning and takes all

morning to get going for the last 3-4 years”

Subjective

No significant objective information regarding specific patient complaint (patient is apprehensive about going out in public and having an accident)

Objective

FS is a 93 year old man generally well-controlled on his current medication regimen. His chief complaint is a significant annoyance affecting his quality-of-life. First line therapy for urinary incontinence is lifestyle modification such as fluid-diet management and second-line therapies include anti-muscarinic medications and β3 adrenergic antagonists.1 It is recommended that ER formulations are used over IR formulations, if the drug is anticholinergic in nature. Due to FS’s increasing age, and anticholinergic symptoms especially when he wakes up, the following should be addressed with the patient and his provider: the time of day he takes his medication, the medication formulation and MOA itself and life-style modifications he can make to improve his symptoms. To ease the patient’s concerns about having an accident when outside of his pharmacy would like to recommend the patient begin mirabegron 25 PO daily and D/C his oxybutynin.

Pharmacy Assessment

Goals of therapy◦ Teach the patient life-style changes like bladder

training, bladder control strategies, and fluid management

◦ Improve symptoms of urinary incontinence◦ Improve the patient’s quality-of-life

Treatment Plan◦ Switch from and IR to an ER formulation of

oxybutynin if mirabegron not an option due to cost◦ Recommend Myrbetriq® (mirabegron) 25 mg PO

daily a β3 adrenergic antagonist with no known anticholinergic side effects, as an alternative to oxybutynin

Pharmacy Plan

Monitoring parameters◦ Efficacy and safety

Recommend FS use a diary to record how many times a day he uses the rest room

See if drying symptoms improve with an ER formulation or with mirabegron

◦ Plan for follow-up Follow up in 2 weeks with PCP to see if symptoms have improved

Patient education◦ Take your medication as prescribed and do not miss doses◦ Stay hydrated but be conscious if your water pill (furosemide) is not

working well or if you have increasing edema in your legs◦ Use the rest room often at scheduled intervals even if you do not feel

as though you need to urinate◦ Do not take other anticholinergic drug like Tylenol PM® as they will

exacerbate your dry mouth and feelings of fogginess because they contain the ingredient diphenhydramine, also known as Benadryl®

Pharmacy Plan cont.

• Chronic urinary incontinence related to enlarged prostate as evident by urgency and frequency.

• Anxiety related to embarrassment as evidence by increased apprehension

• Acute pain related to skin irritation as evidence by restlessness

Nursing Diagnosis

• Effect on lifestyle and self esteem• Effect on skin integrity • Increased risk for infection• Increase risk for skin breakdown• Increased anxiety• Decreased socialization/increased isolation

Nursing Assessment

• Schedule voiding times to reduce incontinence• Restrict fluids 2 to 3 hours before bedtime• Limit caffeine and alcohol intake (diuretics)• Bring extra clothes on trips• Use of adult absorbing pads

Nursing Plan

We all had a diverse discussion from varied perspectives placing the needs of the patient first in all instances

All group members interviewed our patient by phone, patient and FS was grateful for the opportunity and initial feedback

Our group worked well together – everyone was professional, courteous and respectful

Optimal medication management therapy and non-pharmacological strategies were discussed and reviewed effectively between the two health professions

With teamwork, communication and collaboration between the two health professions we were able to recommend a safe and effective patient-oriented plan

Collaboration

Gormley EA, Lightner DJ, Burgio KL, et al. American Urological Association. Diagnosis and treatment of overactive bladder (non-neurogenic) in adults: AUA/SUFU guideline. Updated June 11, 2013. Accessed May 29, 2014.

References