Home Medicines Review

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Home Medicines Review
Sample Case Study

Patient Details
Name: Mr Michael Portman Age: 81 yrs
Address: Melbourne Weight: 75kg
Referring GP: Dr Coleman Height: 169 cm
Patient Information from HMR Referral
Allergies or adverse reactions: metformin (diarrhoea)
Smoking status: Ex-smoker
Quitting Stage:
Alcohol consumption: Social drinker-up to 4 glasses of beer on most days
Reason for referral for HMR
• Routine
Patient History (Social/Medical) from HMR Referral
Medical History
• Hypertension, type 2 diabetes, gout, OA, GORD, COPD
• Influenza vaccine (Fluvax) annually
• Pneumococcal vaccine (Pneumovax 23) last year
Current Medications
Medication Dose (according
to Mr Portman)
Purpose/comments (according
to Mr Portman)
Allopurinol 300mg 1 mane Pain in feet
Amlodipine 10mg 1 mane Blood pressure
Digoxin 250mcg 1 mane heart
Enalapril 10mg 1 mane Blood pressure
Gliclazide SR 30mg 1 mane Diabetes
Omeprazole 20mg 1 mane Indigestion
Paracetamol 500mg 1-2 prn pain
Arthri-Relief 1500mg 1 daily prn pain
Salbutamol 100mcg/dose
MDI
prn Breathing

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Relevant Test Results
2 months ago serum creatinine was 130 micromol/L (reference range: 50-110
micromol/L)
GP stated that all electrolytes and LFTs NAD
BP 2 months ago 140/85 mmHg
HbA1c result 12 months ago 8.3%
Information from Patient Interview
Whilst at Mr Portman’s home, the following information is obtained:
• Lives with his wife
• Glucosamine has been effective for his OA since he ceased celecoxib. He is
taking a product called Arthri-Relief which also contains various herbs as well as
potassium
• During the week whilst his wife does volunteer work he spends time with some
friends at the local hotel
• Mr Portman indicated that his breathing has improved since he stopped smoking
two years ago. His inhaler technique was poor. He has out of date prescriptions
for salbutamol MDI and a fluticasone 250mcg/dose MDI
• Currently taking allopurinol 300mg daily but has a recent prescription from Dr
Coleman for allopurinol 100mg
QUESTIONS
Consider the patient needs or concerns, medication-related problems and
medication management issues.
1. What further information would assist in making your assessment of this patient?
Explain reasons for obtaining this information. Who/where would you obtain this
information?
2. Based on the information provided, identify potential and actual medication
related and disease-related problems, and patient concerns. Suggest how these
could be addressed and/or monitored.
3. Write a letter or report to the referring GP, outlining your key findings for this
patient and your suggestions or recommendations.

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Sample answers
Question 1
Consider the patient needs or concerns, medication-related problems and medication
management issues
What further information would assist in making your assessment of this patient?
Explain reasons for obtaining this information. Who/where would you obtain this
information?
Prior to the interview with Mr Portman:
A copy of the dispensing history for the previous six months from the pharmacy to check that he
is having his prescriptions dispensed in a timely manner according to the dosage as prescribed.
From the referral, Mr Portman’s serum creatinine two months ago was 130 micromol/L
(reference range: 50-110micromol/L). Using the Cockcroft-Gault equation, his creatinine
clearance (CrCl) is calculated at 36mL/min. This result places him in the range of mild renal
impairment (range 25-50mL/min).1
When the interview appointment is made, check with Mr Portman whether he would prefer his
wife to be present during the interview. Mrs Portman may assist her husband manage his
medicines.
From the GP Dr Coleman
An assessment of cognitive function, such as results from a Mini Mental State Examination
(MMSE)
At the interview:
To assess adherence and persistence, patient medication understanding and management, the
following information would be useful:
• Knowledge on how Mr Portman has been using his medications and if he knows what
each of his medicines is for.
• Any problems taking all of the medications and details of what is done if a dose is
missed.
• Are there any concerns or difficulties about any of the medicines, such as difficulty
swallowing tablets, opening bottles or opening packs and pressing tablets out or foil?
• Medicine storage
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• Any old/out of date medicines not used any more for disposal.
• Previous problems with any medications i.e. metformin-induced diarrhoea. As
metformin-induced diarrhoea is often dose-related it would be useful to know the dose
being taken when this adverse event occurred.
• Any other additional medicines taken.
COPD and breathing
• Demonstration of inhaler technique
• Use of spacer device now or in the past and understanding of appropriate cleaning
methods
• Smoking history. Cigarette smoking is the main cause of COPD. The risk for COPD in
smokers is dose related. Age at starting to smoke, total pack-years smoked and current
smoking status are all predictive of COPD mortality. Need to determine pack-year
history. Discuss with Mr Portman his thoughts around his smoking cessation and
whether or not he has ever been tempted to smoke again. Establish whether he has
developed any specific self management strategies to assist him cope with his smoking
cessation. Note that quitting smoking can prevent or delay the development of airflow
limitation or reduce its progression)4
• Frequency of difficulty breathing/shortness of breath and impact on quality of life (to
assess need for additional medication e.g. tiotropium)
Diabetes management
• Patient knowledge, understanding and management of diabetes (Note that the HbA1c
from twelve months ago was 8.3% and that the desired level for Mr Portman to aim for
would be ≤ 7%) (To assess degree of self-management appropriate and necessary and
need for further assistance or education by diabetes educator or practice nurse)
• Details about diet and exercise (To ascertain whether Mr and Mrs Portman understand
the importance of healthy eating and regular physical activity as critical components in
the management of type 2 diabetes)
• Occurrence of any symptoms such as dizziness, weakness, palpitations, hunger, blurred
vision, sweating or tremor and their management (To check to see if Mr Portman ever
experiences hypoglycaemia and is aware of its management)
• Management of diabetes in times of illness (to see if Mr Portman understands and has a
sick day protocol)5
• Self blood glucose monitoring and if so need to check on use of meter and knowledge
and understanding of results. Check of records, if kept. If Mr Portman is not currently
performing SBGM, ascertain how motivated he would be to commence. Confirm whether
or not Mr Portman has discussed SBGM with his GP or a diabetes educator in the past
and if so, what advice they have provided him, especially with regards to frequency of
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monitoring. Offer to show Mr Portman how to use a blood glucose meter (Self blood
glucose monitoring is recommended for all people with type 2 diabetes and a balance
should be reached considering the patient’s age, need for ideal control and ensuring
long term cooperation. Note that some recent studies have questioned the value of
SBGM)6.
• Confirm regular eye and feet check ups (to check to see if new symptoms or risks for
diabetic complications)
• Details of alcohol consumption (check whether or not Dr Coleman or any other health
professional has ever spoken to Mr Portman about his alcohol consumption and whether
or not he is aware of safe drinking levels and the possible adverse effects that excessive
consumption of alcohol can have on conditions such as diabetes, high blood pressure
and gout?). Explore Mr Portman’s beliefs and attitudes regarding his alcohol
consumption and discuss with him how he would feel about reducing his alcohol
consumption. Explore alternative venues for social interaction/meeting his friends rather
than at the hotel
Gout management
• Frequency of attacks and how long since previous attack
• Clarification of correct strength of allopurinol (to check that Mr Portman is aware that his
dosage of allopurinol has been reduced and that he should have the new prescription for
allopurinol 100mg dispensed and to take these instead of the 300mg tablets he has
taken in the past)
• Experienced any unusual skin rashes (A common adverse effect of allopurinol is rash)
• Patient understanding of factors which may aggravate or reduce the risk of gout (Mr
Portman should be warned that some foods appear to trigger attacks of gout. These
foods, such as certain meats, seafood and yeast contain high levels of purines. Soft
drinks and fruit juices also increase the risk of gout. Consumption of dairy products,
especially low-fat dairy products, and coffee is associated with a substantially reduced
risk of gout. If overweight, gradual weight loss may help lower uric acid levels and
reduce the risk of attacks. Drinking alcohol can also raise uric acid levels and increase
the risk of gout attacks.)7
Osteoarthritis
• Determine use of other medicines including Arthri-Relief (How often is it taken? Is it
effective?)
• Pain severity and location and efficacy of management
• Details of ‘prn’ paracetamol use
• Determine current mobility and level of activity (Exercise is strongly recommended for
people with osteoarthritis. It keeps joints and muscles healthy and flexible and helps
prevent other health problems)8
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Hypertension and heart function
• Patient knowledge and understanding of current blood pressure (to check that Mr
Portman has an awareness of his BP measurement and his desirable target BP)
• Any instances of feeling faint or dizzy, especially when rising from a sitting or lying
position? (to identify medication-related postural hypotension and falls risk)
• Home blood pressure monitoring? If so, demonstration of technique
• Discussion of salt intake (to check that Mr Portman is aware that moderate sodium
restriction, achieved with a no-added-salt diet, will be complementary to his
antihypertensive drug therapy)
• Any swelling of feet/ankles (to determine if Mr Portman suffers from CCB-induced ankle
oedema)
• Patient knowledge of use of digoxin (to check whether Mr Portman is aware of the
reason why he is taking digoxin and if he suffers from any adverse effects or signs of
toxicity)
Gastro-oesophageal reflux disease
• Duration and efficacy of therapy with omeprazole (long term use can cause vitamin B12
deficiency)
• Any foods which particularly cause problems (Mr Portman should be advised that some
foods may precipitate symptoms. Anecdotal evidence suggests limiting alcohol, high fat
meals, chocolate and coffee may be beneficial)9
• Timing of symptoms in relation to food, bedtime or another activity? (patients with
nocturnal symptoms may benefit from night-time dosing or bd use)9
• Use of antacid therapy
References
1. Rossi S editor. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2010. p. xv
2. Diabetes Australia and Royal Australian College of General Practitioners. Diabetes Management in General
Practice: Guidelines for Type 2 Diabetes 15th edition 2009/10 p. 58
3. Respiratory Expert Group. Therapeutic guidelines: Respiratory. Version 4. Melbourne: Therapeutic Guidelines
Limited; 2009 p. 115
4. Global Initiative for Chronic Obstructive Lung Disease Global Strategy for Diagnosis, Management and Prevention
of CPD. Updated 2009. Available from: http://www.goldcopd.com/Guidelineitem.asp?l1=2&l2=1&intId=2003
Accessed 9 February 2010
5. Diabetes Australia and Royal Australian College of General Practitioners. Diabetes Management in General
Practice: Guidelines for Type 2 Diabetes 15th edition 2009/10 p. 50
6. Diabetes Australia and Royal Australian College of General Practitioners. Diabetes Management in General
Practice: Guidelines for Type 2 Diabetes 15th edition 2009/10 p. 28
7. Arthritis Australia Information Sheet ‘Gout and diet’. Available from
http://www.arthritisaustralia.com.au/images/stories/documents/info_sheets/english/colour/Gout%20and%20diet.pdf.
Accessed 9 February 2010.
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8. Arthritis Australia Information Sheet ‘Osteoarthritis’. Available from
http://www.arthritisaustralia.com.au/images/stories/documents/info_sheets/english/colour/Osteoarthritis.pdf.
Accessed 9 February 2010
9. Gastrointestinal Expert Group. Therapeutic guidelines: Gastrointestinal. Version 4, Melbourne: Therapeutic
guidelines Limited; 2006 p. 48-49
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Question 2
Consider the patient needs or concerns, medication-related problems and medication
management issues
Based on the information provided, identify potential and actual medication-related and
disease-related problems, and patient concerns. Suggest how these could be addressed
and/or monitored.
Potential medication related problems
1. Renal impairment A creatinine clearance of 36mL/min suggests that Mr Portman has
mild renal impairment (25-50mL/min being the range for mild impairment).1 This has the
potential to affect the dosage of renally cleared medications such as gliclazide, digoxin
and allopurinol.
2. Digoxin The medical history provided contains no reference to an indication for digoxin
therapy. Indications for its use are atrial fibrillation and flutter, SVT and heart failure.2
The digoxin dose of 250 micrograms daily is high for an older patient with age-related
renal decline. Lower serum levels of digoxin are now considered safer and the optimal
range is 0.5–0.8 micrograms/L.3 (for patients with heart failure). If there is an ongoing
need for digoxin, suggest dose adjustment considering Mr Portman’s renal function
(CrCl= 36 mL/min). A serum digoxin level should be ascertained and the dosage
adjusted accordingly, with an appropriate dose for Mr Portman likely to be in the range of
62.5-125 micrograms once daily.2
Actual medication related problems
1. Allopurinol Mr Portman is currently taking allopurinol 300mg daily but has recently been
prescribed 100mg tablets. Allopurinol, a xanthine oxidase inhibitor, is the drug most
commonly used for prevention of recurrent gout. It reduces uric acid levels by inhibiting
the metabolism of xanthine to uric acid. It has a renally excreted active metabolite,
oxypurinol, so caution is required when the patient has renal impairment. Treatment with
allopurinol should be limited to patients with appropriate indications and used only at the
minimum dose necessary.4
Gout is common in renal impairment, due to reduced clearance or uric acid and renal
impairment also has consequences for the dosing of allopurinol. Mr Portman should be
advised that he should be taking allopurinol 100mg daily, the recommended maintenance
dose for someone with his level of renal impairment. The aim should be to check the
serum uric acid level after four weeks and adjust the dose to achieve a uric acid
concentration less than 0.36mmol/L.4
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A common adverse effect of allopurinol is a maculopapular or itchy rash5 so Mr Portman
should be questioned about any recent skin problems and cautioned to report any skin
rash to GP immediately.
2. Gliclazide should be taken to be taken with food to minimise the risk of hypoglycaemia.6
3. Alcohol can mask the warning signs of hypoglycaemia. By inhibiting hepatic
gluconeogenic capacity, alcohol impairs the body’s ability to provide glucose and restore
low glucose concentrations toward normal. Excessive alcohol consumption may cause
severe hypoglycaemia and be unable to recognize an treat the symptoms of
hypoglycaemia.7 Mr Portman should be advised that binge drinking should avoided and to
have something to eat when he drinks alcohol, although he should be advised to avoid
potentially high fat bar snacks7
4. Allopurinol should be taken after food to decrease the chance of stomach upset and the
intake of lots of fluids should be encouraged to prevent kidney stones 5
5. The calcium channel blocker amlodipine can aggravate symptoms of GORD by
decreasing lower oesophageal sphincter pressure.
Drug interactions
1. Allopurinol – ACEI Concomitant allopurinol use with ACEIs has been associated with an
increased risk of hypersensitivity reactions and neutropenia. Monitor for any signs of
hypersensitivity and low white blood cell counts.
2. Digoxin – omeprazole Case reports of elevated serum digoxin with concomitant PPIs
have been published. Elevated gastric pH, which results in a reduction in digoxin
metabolism and an increase in unchanged digoxin absorption, has been suggested.
Monitor the patient for signs of digoxin toxicity. This is unlikely to be clinically significant.
Missing medication
1. Mr Portman has a diagnosis of COPD. Smoking cessation is the most important aspect
in managing this condition and it is good that Mr Portman has ceased smoking. No drug
therapy can modify the lung function decline in this condition; however the use of
bronchodilator therapy can improve symptoms and quality of life.
Whilst the fact that Mr Portman has stopped smoking will have possibly improved his
symptoms, his lung function should be assessed. The spirometric abnormality required
to diagnose COPD is a reduction in the post bronchodilator forced expiratory volume in 1
second to forced vital capacity (FEV1/FVC ratio) to less than 0.7-an obstructive pattern.8
The aim of drug treatment for COPD is two fold:
• To relieve symptoms, particularly breathlessness
• To prevent deterioration (acute and chronic)
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For symptom control there should be a stepwise approach to drug therapy, irrespective
of disease severity, until adequate control is achieved. 9
Depending on the severity of his symptoms and his overall lung function, Mr Portman
may benefit from the addition to his therapy of a longer acting bronchodilator such as
tiotropium bromide. Long acting anticholinergic therapy with this drug has been shown
to improve quality of life and reduce the frequency of exacerbations in comparison with
placebo and short acting anticholinergic drugs. It has the advantage that it can be given
once daily.10
The use of inhaled corticosteroids should only be considered in those patients who have
severe disease with an FEV1 < 50% and more than two exacerbations per year.11 Mr
Portman’s disease may not be severe enough to necessitate the use of inhaled
corticosteroids.
2. There is no lipid therapy indicated on Mr Portman’s list of medications from his GP.
Dyslipidaemia is common in patients with diabetes and is an independent risk factor for
the macrovascular complications of diabetes. It is important to identify and treat
dyslipidaemia and as with people without diabetes, first line therapy is with a statin plus
lifestyle interventions. Treatment should be based on results of lipid tests with reference
to appropriate blood lipid targets. The target for Mr Portman should be a total cholesterol
of <4.0 mmol/L (the target recommended by the National Heart Foundation because
those with diabetes are considered a high risk group).12
Disease related problems
Diabetes
Type 2 diabetes is a progressive disease which requires monitoring. The risk of
developing macrovascular complications such as cardiovascular disease and
microvascular complications such as nephropathy, neuropathy and retinopathy can be
significantly reduced by early, intensive long term interventions targeting multiple risk
factors.13 The use of drug therapy for type 2 diabetes aims to control blood glucose
concentrations and prevent and treat these long term complications of the disease.
Reduction in macrovascular complications may depend on glycaemic control but also
depends on the modification of other risk factors such as smoking, hypertension and
dyslipidaemia. The fact that Mr Portman has stopped smoking is positive. Among the
lifestyle risk factors, smoking makes the largest contribution to the absolute risk of
macrovascular complications for people with diabetes.14
The objectives and priorities for the treatment of Mr Portman’s type 2 diabetes should be
tailored and focus on factors such as his lifestyle, age and psychological well-being. A
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management plan should be developed for him by the health professionals involved in
his care and should include:
• Addressing treatment targets
• A healthy eating plan (to be discussed in conjunction with his wife)
• An exercise program
• Ways to reduce cardiovascular risk factors such as blood pressure and lipids,
noting the positive impact of smoking cessation already achieved
• Appropriate medication
• Education in self monitoring and coping with situations that may impact on blood
glucose control
• Screening for and prevention of complications of diabetes
The recommended target for glycaemic control is an HbA1C of less than or equal to 7%.
A higher target level may be more appropriate for Mr Portman due to his age. His most
recent HbA1c result provided was 8.3%, from twelve months ago. A repeat of this test
should be performed to ascertain Mr Portman’s more recent control, as it will show an
average of blood glucose control over the past 10 to 12 weeks.
Mr Portman should be encouraged to monitor his blood glucose levels at home on a
regular basis, aiming for the results to be between 4-8 mmol/L to ensure that his
diabetes is well controlled. Mr Portman should be encouraged to consider purchasing a
blood glucose meter so that he can self monitor his blood glucose levels. Dr Coleman’s
advice on SBGM for Mr Portman should be obtained with respect to his views on Mr
Portman’s, suitability and capability. He may have discussed the role of SBGM in
diabetes self management with Mr Portman in the past. It is noted that in the past Mr
Portman had an adverse effect to metformin and that his current therapy is with the
sulphonyurea, gliclazide. If diabetic control is not achieved by with the current dose of
gliclazide SR 30mg daily the dose may be increased, however any increase in dose
should take into account his mildly impaired renal function. It is noted that Mr Portman
suffered an adverse reaction to metformin in the past. An option for his therapy would be
to trial the re-introduction of metformin at low dose to see whether or not diarrhoea reoccurs. If Mr Portman tolerates metformin on re-trial, the dose should be adjusted
according to his renal function and be a maximum of 1g daily.
The overall management of Mr Portman’s diabetes should also include referral to a
podiatrist to monitor the condition of his feet and provide preventive treatment as
required and an optician or ophthalmologist for regular assessment of his vision. A
consultation with a dietician may be useful if further advice is required regarding meal
planning and dietary requirements.
Mr Portman needs to be able to identify the symptoms of hypoglycaemia such as
sweating, palpitations and hunger and how to deal with them with glucose intake
followed by ingestion of complex carbohydrates. He should also be aware of the factors
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that might predispose him to a hypoglycaemic event such as missing a meal, ingesting
insufficient carbohydrate, doing too much exercise or ingesting too much alcohol. He
should also be counselled on management of his diabetes when suffering from
concurrent illness.
Osteoarthritis and Pain Management
Mr Portman suffers with osteoarthritis for which he is currently prescribed ‘prn’
paracetamol. There is excellent evidence to support the prescribing of paracetamol in
regular divided doses to a maximum of 4 g/day as first line pharmacological therapy for
treating persistent pain in people with hip or knee OA.15
He should be encouraged to adopt lifestyle changes which promote joint protection such
as resting inflamed joints, using proper movement techniques for activities of daily living
and balancing activity with periods of rest. Exercise has been shown to reduce pain and
improve function in osteoarthritis of the knee and hip and so Mr Portman should be
encouraged to make exercise a part of his everyday life16, especially with its added
benefits for his diabetes and reduction of his overall cardiovascular risk.
Mr Portman also takes Arthri-Relief 1500mg, which in addition to glucosamine sulphate
1500mg contains several herbs and minerals and 193.5mg K+ (369mg KCl).17 This
equates to 4.9 mmol K+. He takes one tablet every day.
Glucosamine is commonly used to treat osteoarthritis pain and the evidence for its
effectiveness relates to osteoarthritis of the knee. Two studies found that in comparison
with placebo, 1.5 g glucosamine sulphate daily is modestly effective in treating
symptoms of osteoarthritis of the knee, reduces radiological progression of the disease
but has no effect on the use of rescue analgesics.18.
Hypertension
Mr Portman’s most recent blood pressure result from his GP was 140/85 mmHg. For
patients with type 2 diabetes, blood pressure control reduces both macro and
microvascular complications. 19 It is noted that Mr Portman has been prescribed the
ACE inhibitor enalapril at the dose of 10mg daily, an appropriate choice as this group of
drugs are the preferred initial pharmacological agent in most patients. ACE inhibitors
have a beneficial effect on both renal and cardiovascular function. The BP target for Mr
Portman is 130/90mm/Hg (125/75 mmHg if he has proteinuria >1g/day) so his most
recent result is marginally higher than this. It is recommended that patients with diabetes
have their BP measured every six months. To assist Mr Portman in achieving target BP
readings he should be encouraged to maintain a healthy weight with attention to his diet
and physical activity. His blood pressure should continue to be regularly monitored and
an increase in dose of enalapril to 20mg daily considered if the target cannot be reached
at a dose of 10mg daily.
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Cardiovascular Risk
Mr Portman’s cardiovascular risk is at increased absolute cardiovascular risk as he has
diabetes and is over 60 years of age.20
Recent research has suggested that in people with diabetes, there is no unequivocal
evidence of benefit for primary prevention with low dose aspirin in reducing
cardiovascular events.21 The evidence on harms remains inconsistent. Considering Mr
Portman’s GORD, the benefits and risks of anti-platelet therapy with aspirin should be
addressed by the GP.
Mr Portman’s BMI of 26 kg/m² indicates that he is mildly overweight. Dependent on the
results of lipid studies, it may be appropriate to consider prescribing a statin, considering
his co-morbidities of type 2 diabetes and hypertension and that he is a regular alcohol
consumer. The aim should be for his total cholesterol to be less than 4.0 mmol/L.22
GORD
Mr Portman’s GORD symptoms should be ascertained a decision could be made on the
appropriateness of his omeprazole therapy. Attention to the lifestyle factors already
mentioned will have a positive impact on the management of his symptoms. Other
suggestions can include eating smaller meals, not eating before bed, raising the head of
the bed and avoiding tight clothing.23
Proton pump inhibitors such as omeprazole are effective in controlling symptoms and
healing inflammation, regardless of the severity of the disease. 23
If Mr Portman’s symptoms are controlled, consideration could be given a trail cessation
of omeprazole, or even a step down in dosage to ‘prn’ according to symptoms.24
As an infrequent adverse effect of long term proton pump inhibitor use is decreased
absorption of cyanocobalamin, a vitamin B12 level should be requested to determine
whether Mr Portman’s levels are within normal range.25 This is also a known
complication of long-term metformin.
References
1. Rossi S, editor. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2010. p. xv
2. Rossi S, editor. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2010. p 279
3. Rossi S, editor. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2010. p 280
4. Therapeutic Brief 21. Revisiting gout management in your veteran patients Veterans’ Medicine Advice and
Therapeutics Education Services: November 2009. Available from:
https://www.veteransmates.net.au/VeteransMATES/documents/module_materials/M21_TherBrief.pdf Accessed 10
February 2010
5. Rossi S, editor. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2010. p. 632
6. Rossi S, editor. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2010. p. 399
14
7. Endocrinology Expert Group. Therapeutic guidelines: Endocrinology Version 4, Melbourne: Therapeutic guidelines
Limited; 2009 p. 77
8. Respiratory Expert Group. Therapeutic guidelines: Respiratory. Version 4. Melbourne: Therapeutic Guidelines
Limited; 2009 p. 89
9. Respiratory Expert Group. Therapeutic guidelines: Respiratory. Version 4. Melbourne: Therapeutic Guidelines
Limited; 2009 p. 93
10. Respiratory Expert Group. Therapeutic guidelines: Respiratory. Version 4. Melbourne: Therapeutic Guidelines
Limited; 2009 p. 96
11.Therapeutic Brief 14. Simplifying inhaler devices for Chronic Obstructive Pulmonary Disease Veterans’ Medicine
Advice and Therapeutics Education Services: March 2008. Available from:
https://www.veteransmates.net.au/VeteransMATES/documents/module_materials/M14_TherBrief.pdf. Accessed 10
February 2010
12. Diabetes Australia and Royal Australian College of General Practitioners. Diabetes Management in General
Practice: Guidelines for Type 2 Diabetes 15th edition 2009/10.p. 60 Available from:
http://www.racgp.org.au/guidelines/diabetes. Accessed 10 February 2010
13.Therapeutic Brief 11. Building a comprehensive cycle of care for veterans with diabetes. Veterans’ Medicine
Advice and Therapeutics Education Services: June 2007. Available from:
https://www.veteransmates.net.au/VeteransMATES/documents/module_materials/M11_TherBrief.pdf Accessed 10
February 2010
14. Diabetes Australia and Royal Australian College of General Practitioners. Diabetes Management in General
Practice: Guidelines for Type 2 Diabetes 15th edition 2009/10. Available from
http://www.racgp.org.au/guidelines/diabetes. p. 55. Accessed 10 February 2010
15. Royal Australian College of General Practitioners. Guideline for the non-surgical management of hip and knee
osteoarthritis. Osteoarthritis recommendations July 2009 p 7 Available from
http://www.racgp.org.au/guidelines/osteoarthritis/recommendations. Accessed 10 February 2010
16. Rheumatology Expert Group. Therapeutic guidelines: Rheumatology. Version 1. Melbourne: Therapeutic
Guidelines Limited; 2006 p. 101
17. Arthri Relief product information Available from: http://health-bestbuys.com/product/Arthri-Relief/59 accessed 17
November 2009
18. Rossi S, managing editor. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd;
2010.p. 610
19. Diabetes Australia and Royal Australian College of General Practitioners. Diabetes Management in General
Practice: Guidelines for Type 2 Diabetes 15th edition 2009/10. p. 56. Available from:
http://www.racgp.org.au/guidelines/diabetes Accessed 10 February 2010
20. Absolute cardiovascular disease risk assessment. An initiative of the National Vascular Disease Prevention
Alliance. Available from
http://www.heartfoundation.org.au/SiteCollectionDocuments/A_AR_QRG_FINAL%20FOR%20WEB.pdf Accessed 10
February 2010.
21. De Beradis G, Sacco M, Strippoli GFM, Pellegrini F, Graziano G, Tognoni, G and Nicolucci A. Aspirin for primary
prevention of cardiovascular events in people with diabetes: meta-analysis of randomized controlled trials BMJ 2009;
339:b4531. Available from
http://www.bmj.com/cgi/reprint/339/nov06_1/b4531?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=as
pirin+and+diabetes&searchid=1&FIRSTINDEX=0&sortspec=date&resourcetype=HWCIT accessed 10 February 2010
22. Diabetes Australia and Royal Australian College of General Practitioners. Diabetes Management in General
Practice: Guidelines for Type 2 Diabetes 15th edition 2009/10. p. 60. Available from:
http://www.racgp.org.au/guidelines/diabetes p 60. Accessed 10 February 2010
23. Rossi S, editor. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2010. p. 465
24. Prescribing Practice Review 34 Proton pump inhibitors in primary care. National Prescribing Service; July 2006.
Available from:
http://www.nps.org.au/health_professionals/publications/prescribing_practice_review/current/proton_pump_inhibitors
_in_primary_care. Accessed 10 February 2010
25. Rossi S, editor. Australian Medicines Handbook. Adelaide: Australian Medicines Handbook Pty Ltd; 2010. p. 472
15
Question 3
Consider the patient needs or concerns, medication-related problems and medication
management issues
Write a letter or report to the referring GP, outlining your key findings for this patient and
your suggestions or recommendations.
A sample letter could be:
Candidate xxx
Address
Date
Phone: 12345677
Dr Coleman
Melbourne
Dear Dr Coleman,
Re: Home Medicines Review for Mr Michael Portman
Thank you for your referral for Mr Michael Portman who has a history of hypertension, type 2
diabetes, gout, osteoarthritis, GORD and COPD. I visited Mr Portman for a Home Medicines
Review on 10 February 2010. His wife was present during the interview.
His current medications as confirmed during the interview with Mr Portman are documented
below:

Medication Dose (according
to Mr Portman)
Purpose/comments
(according to Mr Portman)
Allopurinol 300mg 1 mane Pain in feet
Amlodipine 10mg 1 mane Blood pressure
Digoxin 250mcg 1 mane heart
Enalapril 10mg 1 mane Blood pressure
Gliclazide SR 30mg 1 mane Diabetes
Omeprazole 20mg 1 mane Indigestion
Paracetamol 500mg 1-2 prn pain
Arthri-Relief 1500mg 1 daily prn pain
Salbutamol 100mcg/dose MDI prn Breathing

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During the interview I discussed each of Mr Portman’s medicines with him. He understands the
reasons why he is taking each medicine and is now more aware of their actions and possible
adverse effects.
His recent dispensing history obtained from his local pharmacy indicates that his adherence to
his medicines is good. This was confirmed during our discussion. The only non prescribed
medication he takes is Arthri-Relief. However, he rarely uses the Salbutamol MDI and had an
out of date prescription for fluticasone 250mcg/dose MDI. He advised me that since stopping
smoking 2 years ago his ‘breathing has improved’. He demonstrated his inhaler technique to me
during the interview and it is poor. I provided him with advice on how to gain optimum benefit
from his inhaler device and recommended use of a spacer.
I completed an NPS ‘Medi List’ for Mr Portman, advising him to keep it up to date. We talked
about the management of his diabetes and the risks and complications associated with poor
glycaemic control and together with his wife discussed lifestyle issues such as diet, exercise
and alcohol consumption. Mr Portman’s current BMI is 26 kg/m².
I provided Mr Portman with the following written information:
• PSA Self Care Fact Cards on type 2 diabetes, high blood pressure, heartburn and
indigestion, osteoarthritis and weight and health
• Arthritis Australia Information Sheets on Gout and Gout and Diet
• Contact details for Diabetes Australia and Arthritis Australia
Findings from the interview
• Diabetes Control
Mr Portman does not self monitor his blood glucose levels. During my visit I demonstrated the
use of an Accu Check ® blood glucose meter to him and told him that they were available for
purchase. He was unaware of his blood glucose levels and his HbA1c result. I explained that
good control of his blood glucose levels was important to minimise the risk of him developing
complications related to his diabetes. At your next consultation with Mr Portman you may wish
to discuss options (e.g. frequency) for self blood glucose monitoring if you feel that it would be
appropriate for him
If his current dose of gliclazide proves insufficient in maintaining good control, it can be
increased; keeping in mind Mr Portman’s reduced renal function. His creatinine clearance was
calculated at 36mL/min based on the serum creatinine result provided. Mr Portman mentioned
that in the past metformin had given him diarrhoea. A re-trial of metformin (commencing at a
reduced dose and increasing as tolerated to a maximum of 1G daily) could also be considered.
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• Gout and Allopurinol dose
I provided Mr Portman with advice and counselled him to commence taking the allopurinol
100mg tablets at a dose of one daily as prescribed by during his most recent consultation. Up
until now he has been continuing to take 300mg allopurinol daily without any ill effects. He
agreed to moderate his current alcohol intake.
• Digoxin therapy
From the information supplied, there is no apparent indication for the use of digoxin by Mr
Portman.
Whilst Dr Portman has no signs or symptoms of digoxin toxicity, suggest a serum digoxin level
as his current dose of 250 microgram daily is high for an older patient with reduced renal
function. The dose should be adjusted if necessary to maintain a digoxin level of 0.5-0.8
micrograms/L (if indicated for the treatment of heart failure).
• Osteoarthritis and Pain Management
Mr Portman indicated to me that his osteoarthritis is not currently well controlled with ‘prn’
paracetamol. I suggested a trial of taking paracetamol regularly at a dose of 1g qid or Panadol
Osteo 665mg 2 tds which may be more convenient for him.
He also takes Arthri-Relief 1500mg daily which in addition to glucosamine sulphate 1500mg
contains several herbs and minerals and 369mg KCl. He finds this effective. Monitoring of his
potassium levels should be continued.
• GORD
Calcium channel blockers such as amlodipine can cause dyspepsia. However Mr Portman’s
symptoms have been well controlled with omeprazole. We talked about the impact of lifestyle
interventions on his GORD and discussed the fact that a trial reducing his use of omeprazole to
a ‘prn’ basis as per NPS guidelines may be beneficial. As Mr Portman has been taking
omeprazole for some time, it may be useful to assess his vitamin B12 levels.
• COPD
Mr Portman’s states that he ‘has not had any breathing problems’ since stopping smoking 2
years ago. Whilst stopping smoking has obviously relieved his symptoms, he has discontinued
the use of his salbutamol inhaler. I also noted that he had an out of date prescription for a
fluticasone inhaler.
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His inhaler technique was poor and he will require continuing monitoring and advice if these
medications are continued. A spacer device or alternatively a turbuhaler or accuhaler may be
appropriate if Mr Portman’s lung function suggests that medication is required.
If Mr Portman’s condition deteriorates and he develops signs of breathlessness, it may be
appropriate for him to recommence using his salbutamol inhaler either as required or on a
regular basis. The addition of a long acting ß2 agonist may also be considered if he remained
symptomatic despite the use of salbutamol. The COPDX guidelines recommend the long-acting
anticholinergic tiotropium to decrease exertional dyspnoea and increase endurance by reducing
hyperinflation in patients with COPD. Long-acting β2 agonists are an effective and convenient
treatment for COPD, but do not significantly improve lung function.
• Cardiovascular risk
Recent research1 has suggested that in people with diabetes, there is no unequivocal evidence
of benefit for primary prevention with low dose aspirin in reducing cardiovascular events. The
evidence on harm remains inconsistent. Considering Mr Portman’s GORD, the benefits and
risks of anti-platelet therapy with aspirin should be taken into consideration.
Mr Portman’s BMI of 26 indicates that he is mildly overweight. Dependent of the results of lipid
studies, it may be appropriate to consider prescribing a statin, considering his co-morbidities of
type 2 diabetes and hypertension and that he is regular alcohol consumer. The aim should be
for his total cholesterol to be less than 4.0 mmol/L.
As the pharmacist responsible for undertaking this medication management review, I
understand that there may be sound clinical reasons why my recommendations may not be
considered appropriate of this patient. I would welcome advice on this and how these reports
can be made more useful to you. I would be pleased to provide supporting literature or
clarification of any issue raised in this report.
Yours Sincerely,
Pharmacist
1. De Beradis G, Sacco M, Strippoli GFM, Pellegrini F, Graziano G, Tognoni, G and Nicolucci A. Aspirin for primary
prevention of cardiovascular events in people with diabetes: meta-analysis of randomized controlled trials BMJ 2009;
339:b4531. Available from
http://www.bmj.com/cgi/reprint/339/nov06_1/b4531?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=as
pirin+and+diabetes&searchid=1&FIRSTINDEX=0&sortspec=date&resourcetype=HWCIT Accessed 10 February 2010

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