Medication Management

ReviewMr Michael Tsu

Clinical Report & Findings➜Potential poor compliance and

poor pain management

➜1-2 Standard Drinks per week

➜Ceased smoking – 2006

➜Complaining of constipation

➜Severe nausea from chemotherapy

➜Blood pressure: 133/82 mmHg

➜Height: 180 cm

➜Weight: 78 kg. IBW: 76.1 kg

BMI : 24.1

CLCR : 101 mL/minNORMAL RENAL FUNCTION

MEDICAL DIAGNOSES

Ewing’s SarcomaInsomnia

Clinical Report & Findings

Test Result Reference Range

Potassium 4.3 mmol/L 3.4-4.9 mmol/L

Creatinine 90 micromol/L 60-105 umol/L

Albumin 39 g/L 32-45 g/L

TSH 2.5 mIU/L 0.4-5mlU/L

Neutrophils 0.4 2–7.5x109/L

Clinical Report & FindingsMedication Strength and Dosage Indication

Endone 5mg (Oxycodone)

1 tds or qid Break through pain

OxyContin 15mg (oxycodone)

1 q12h Regular pain relief

Stilnox CR 12.5mg (Zolpidem)

1 n Good night’s sleep

CHEMOTHERAPY

Vincristine Ewing’s Sarcoma Post-Operative Chemotherapy

Doxorubicin

Cyclophosphamide

Ondansetron Antiemetics – CINV

Metoclopramide

Neulasta (pegfilgrastim)

6 mg SC once each cycle, given about 24 hours after the end of chemotherapy.

Neutropaenia rescue

Clinical Issues to ConsiderOpioids

Constipation

Neutropaenia

Anticipatory Nausea

Sleep Issues – Stilnox

➔ Mrs Daniels should be educated on

the importance and use of a simple blood glucose monitor (eg.

AccuChek Active).

➔ Daily dose of metformin should be revised to 1000 mg (renal impairment) (AMH, 2011)

➔ Renal function should be closely monitored on a monthly basis.

AMH 2011 suggests that metformin should not be used if

CrCl < 30 mL/min due to increased risk of lactic acidosis.

➔ An alternative agent to gliclazide such as a DPP-IV inhibitor eg. sitagliptin can be considered.➔ Combination product with

metformin (Janumet 50/1000 d) could improve compliance and

simplify regimen, but should not be used in renal impairment.

➔ Therefore, replace Diamicron with Januvia 50 mg d.

FINDINGS RECOMMENDATIONS

OPIOIDS

• Mrs Daniels is not achieving optimal glycaemiac control, as indicated by recently measured HbA1C of 8.6%.

• She does not undertake HBGM.

• Dose of metformin is too high for Mrs Daniels, given her renal impairment (CrCl = 31.6 mL/min) and that metformin clearance is dependent upon renal elimination.

• Mrs Daniels is significantly obese (BMI 35.3), which may be contributed to by Diamicron, which commonly causes weight gain as a side effect.

• Not adherent to prescribed regimen of Diaformin, and taking Diamicron 3/4 months.

• Diet is poorly balanced, with lack of fruits and vegetables.

AMH, 2011

➔ Michael should be trialled on Coloxyl with Senna (docusate

+ senna) to relieve opioid-induced constipation, and should be maintained on this if effective.

➔ If efficacy is not demonstrated within several days, alternatives

should be considered:- Glycerol suppositories

- Osmotic laxative (eg. Actilax 25mL bd)

- Movicol (1-3 sachets daily)- Small volume enema eg. Microlax

➔ Switching to a combination product of an oral opioid with

naloxone (eg Targin) may be useful if an optimised laxative regimen is

inadequate.

➔ SC Methylnaltrexone is another alternative (Single dose repeated once after 24 hours if ineffective,

then alternate days, max. 1 dose/24h

FINDINGS RECOMMENDATIONS

CONSTIPATION

• Michael has been complaining of constipation.

• Constipation is a common complaint in Px taking regular, chronic opioids due to the local μ-opioid agonist effect in the gut.

• Has tried a ‘whole container’ of Metamucil to no benefit.

• Bulk-forming laxatives eg. Psyillium husk (Metamucil) are not recommended for opioid-induced constipation and may even worsen (cause obstruction esp. if dehydrated). (AMH, 2011).

AMH, 2011

➔ Considering Michael’s significant

neutropaenia, despite post-chemo GC-SF therapy, dose revision of cyclophosphamide may be appropriate to achieve an acceptable neutrophil count.

➔ Mr Tsu should be educated on the critical importance of watching out for signs of infection such as fever, sore throat, cough etc. and should report immediately to the hospital in such situation (febrile neutropaenia – fever >38.5 °C).

➔ Regular neutrophil counts should be conducted to avoid neutropaenic crisis and potentially life-threatening risk of systemic infection.

➔ Broad-spectrum antibacterials (empirical therapy) may be considered if Mr Tsu presents with febrile neutropaenia.

FINDINGS RECOMMENDATIONS

NEUTROPAENIA• Michael was recently commenced

on a chemotherapy regimen comprised of doxorubicin, vincristine and cyclophosphamide for post-operative treatment of Ewing’s sarcoma.

• Cyclophosphamide is commonly associated with neutropaenia. Neutrophil nadir occurs about 7-14 days after a single dose with recovery 1 2 weeks later (AMH, 2011).

• Mr Tsu’s recent blood count shows significant neutropaenia (0.4 x 109 cells / L)

• Michael has been receiving pegfilgrastim 6 mg SC 24h post-chemo as neutropaenia rescue.

• Pegfilgrastim is a pegylated form of filgrastim, a GC-SF (longer t½ cf. filgrastim).

AMH, 2011

➔ Nausea is due to the stimulation of

the 5HT3 receptors peripherally and possible centrally CTZ

➔ Despite optimum antiemetic therapy, Px experience N and V prior to chemo

➔ Lorazepam antinauseant, anxiolytic and amnestic properties

➔ Important to give prophylactic antiemetics prior to the initial dose of chemo so that learned behaviour doesn’t develop e.g. metoclopramide 10 to 20 mg, 30-60 mins prior to chemo FOLLOWED by metoclopramide 10-20 mg orally q6h prn or ondansetron 8 mg orally 1-2 hrs before chemo FOLLOWED by 8 mg q12h for 2-3 days

➔ Recommend a BZD e.g. alprazolam, diazepam or lorazepam prn (not more frequently than 6 hourly)

FINDINGS RECOMMENDATIONS

ANTICIPATORY NAUSEA• Michael is feeling really anxious

about his next course of chemo

• Vomited so much last time

• Smells and sounds of the hospital make him feel queasy

• Hospital provides Ondansetron and Metoclopramide during chemo cycles

AMH, 2011

➔ Improving the management of Michaels

pain would improve the insomnia he currently suffers from as he links his disturbed sleep with the pain

➔ No pharmacological methods should be included such as stimulus control, sleep restriction (sleep diary), sleep hygine and CBT to reduce anxiety may be of benefit

➔ The duration of therapy should be for the shortest time possible (Therapeutic guidelines)

➔ However, although there is a potential for tolerance it is acceptable to remain on Stilnox provided there are no AE’s and it is monitored regularly

➔ The optimisation of his opioid pain therapy , using the lowest, effective dose for analgesia should improve his daytime drowsiness

FINDINGS RECOMMENDATIONS

SLEEP ISSUES - STILNOX• Michael suffers from insomnia

which is related to the chronic and breakthrough pain

• Michael currently takes Stilnox (Zolpidem) 12.5 mg CR nocte

• Michael is complaining that he always feels drowsy and feels that his sleep is not refreshing

• Stilnox has been in use for over a year (initiated August 2010)

AMH, 2011