MSc Clinical Pharmacy Clinical Practice 2 – Multi-sector pathway Interventions recording form Student P number: P13243609 Intervention number : 1 Cohort: Basil Fluoxetine and Venlafaxine cross-tapering Intervention clinical theme: Depression Leading to CPD cycle? Yes Date of intervention 15/05/2015 Patient condition or A patient taking Fluoxetine 40mg presented a prescription for an antidepressant switch, which concern according to me, had procedural mistakes that could put patient at risk of serotonergic syndrome. Medical conditions - depression (severity unknown) Drugs prescribed - Venlafaxine MR 75mg OD for one week then increased to 150mg OD. OTC /herbal drugs (none) Summary of A recently new female patient (20y.o.) to the pharmacy came in with a new prescription for “Venlafaxine MR 75mg OD for one week then intervention increased to 150mg OD”. She had been taking Fluoxetine 40mg OD since the age of 17 up until this occasion. She had received instructions from the doctor to stop taking Fluoxetine and start Venlafaxine. When enquired, she did not know whether she should start the second after having stopped the first. After some research, I got in touch with the doctor for clarification. My concerns about this prescription were basically three: 1 Fluoxetine was not being correctly tapered down. Although its long half-live (NICE 2009, p.25,30) allows it to be stopped abruptly, that is not recommended at high doses (>20mg) (UKMi 2012, p.6) so, withdrawal should be gradual. 2 - Venlafaxine should not be started prior to Fluoxetine being stopped, and it should be started at a dose lower than 75mg. 3 - Venlafaxine dose should not be increased at one week intervals but at intervals of at least 2 weeks (Joint Formulary Committee 2015, p.261). Sources of Joint Formulary Committee (2015) British National Formulary. 68 ed. London: BMJ Group and Pharmaceutical Press. information used NICE (2009) Depression in Adults: The treatment and management of depression in adults - Clinical Guideline 90. @ www.nice.org.uk/guidance/cg90. - Taylor D et al. (2012) Maudsley Prescribing Guidelines in Psychiatry. 11th ed. Hoboken, NJ, USA: John Wiley & Sons. UKMi (2012) Switching between tricyclic, SSRI and related antidepressants. @ www.medicinesresources.nhs.uk/GetDocument.aspx?pageId=504038. Proposed or actual - Consider tapering and stop Fluoxetine first (UKMi 2012, p.5,6; Outcome of After a long conversation with the doctor the issue was course of action Taylor D et al. 2012, p.271). intervention resolved with him accepting to follow my suggestions. The - Then start Venlafaxine at 37,5mg OD for 2 weeks. change of antidepressants has been smooth with no significant - Increase Venlafaxine dose to 75mg Daily (either 35,5mg BD or inconvenience or side-effects for the patient. She is now taking 75mg MR OD) for another 2 weeks (Joint Formulary Committee 75mg of Venlafaxine MR OD and her symptoms/side-effects 2015, p.261). and dose are still being monitored every two weeks. - Carry on Venlafaxine dose titration (if necessary) at a minimum of 2 week intervals. ©
De Montfort University 2011. Do not amend without permission from the Leicester School of Pharmacy. Do not amend without permission from the Leicester School of Pharmacy.
Clinical Practice 2 – Multi-sector pathway Interventions recording form Intervention number : 2 Isosorbide mononitrate as a possible cause of GORD Leading to CPD cycle? No Patient condition or A patient with cardiovascular problems had been complained with ongoing gastro-oesophageal concern reflux for a while, which after reviewing his medication I believed could be due to isosorbide mononitrate. Medical conditions Coronary heart disease, angina, peripheral arterial disease, GORD Drugs prescribed - clopidogrel tablets, 75mg OD - atorvastatin tablets, 20mg OD - pantoprazole tablets, 40mg BD - bisoprolol tablets, 2,5mg OD - ramipril capsules, 5mg OD - warfarin tablets, 1mg according to INR - glyceryl trinitrate 400µg spray-pump, prn - isosorbide mononitrate MR tablets (Isoket retard), 40mg OD - warfarin tablets, 3mg according to INR OTC /herbal drugs -Summary of During an MUR, an elderly complained about having an almost-constant heartburn sensation. His heart condition is stabilised after a stroke in 2013. intervention He told the doctor a while ago, who ruled out the possibility of being H. pylori . He then tried pantoprazole 40mg OD initially, and 40mg BD later on, although with no significant improvement. He then referred the patient to the hospital for investigation where he was submitted to an endoscopy and diagnosed with gastro-oesophageal reflux. The patient told me that most of the times he takes the night-time dose of Pantoprazole with the morning one, because he does not get the symptoms during the night (he feels okay upon arising). He has been managing the condition that way, but still gets persistent stomach discomfort and reflux at times. What I found interesting was that his symptoms were mostly diurnal, whereas most people with GORD usually experience a worsening of the symptoms overnight due to lying-down. That led me to think that the problem could be due to something he eats/does/takes during the day. His caffeine/theine/alcohol intake is non-existent, and his diet is rich in starchy food but it is not fatty, chilli or spicy. Reviewing his medicines I realised that Isosorbide Mononitrate is known to cause “heartburn most likely due to a nitrate-induced sphincter relaxation” (SPC, p.4). Because MR formulations of this drug act for up to 12h (BNF, p.129), it could explain the absence of night-time reflux. Sources of - BNF 68 - British National Formulary. information used - CG 184 - Dyspepsia and gastro-oesophageal reflux disease. @ www.nice.org.uk/guidance/cg184/chapter/1-recommendations. - EHS CCG - East Sussex Economy Formulary. @ www.eastbournehailshamandseafordccg.nhs.uk/EasySiteWeb/GatewayLink.aspx?alId=366492. - SPC - Isosorbide Mononitrate 40 mg Tablets @ www.mhra.gov.uk/home/groups/spcpil/documents/spcpil/con1426827521229.pdf. Proposed or GP to consider tapering and stop Isosorbide Mononitrate (CG184, p.11) Outcome of GP explained the situation to the specialist who started actual course of as a measure to resolve the ongoing gastro-oesophageal reflux and GI intervention Isosorbide Mononitrate withdrawal, after which symptoms action symptoms patient has been complaining about. An anti-anginal drug like receded. Nicorandil was simultaneously instated to Nicorandil could be a good alternative; it is a K+-channel activator with minimise the risks of an angina attack. Pantoprazole dose nitrate-like properties, so “additional nitrates may not be needed” (SPC). was later changed to the minimum effective dose of 40mg This drug, however, is better be started by a specialist (EHS CCG, p.10) OM. therefore referral may be needed. © De Montfort University 2011. Do not amend without permission from the Leicester School of Pharmacy. Do not amend without permission from the Leicester School of Pharmacy MSc Clinical Pharmacy
Student P number: P13243609 Cohort: Basil Intervention clinical theme: GORD Date of 29/05/2015 intervention