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Learn with case studies of ADR events

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Next case is a 53-year-old male with Urinary tract infection under ertapenem 1000 mg IV QD since 2016/2/25. He previously received two 7-day course of Cefixime 150 mg PO every 12 hours on 2/3 and 2/18. He developed Seizure and conscious change on 3/2. His urine culture grew E. Coli. His serum creatinine was elevated to 2.47 and his estimated Creatinine Clearance was about 36.1 mL/min. His neutrophil count was elevated to 85%. The assessment was to rule out ertapenem related seizure. Our reference Micromedex suggested the incidence rate was 0.5%. The plan was to Arrange brain CT and result showed no intracranial space occupying lesion, nor intracranial hemorrhage.
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We switched to Flumarin which is flomoxef 1 g IV every 8 hours from 3/2 to 3/4 and taper to every 12 hours from 3/4 through 3/15. Case No. 9 is a 61-year-old female with Bipolar I disorder, manic or mixed episode under valproate 1200 mg PO QD and quetiapine 600 mg PO QD. She developed Hyperammonemia her ammonia was up to 542 mcg/dl on 2016/8/15. Her serum valproic acid-free concentration was elevated to 18.7 and her ammonia was significantly elevated to 542 mcg/dl. Viral hepatitis panel showed Anti-HBc, Anti-HCV, also HBsAg were all negative. The assessment was to rule out valproate related hyperammonemia. Our reference Lexi-comp suggested the incidence rate is less than 1%.
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Our plan was to stop valproate and prescribed lactulose liquid 20-30 cc PO three times a day and switch valproate to lithium 300 mg PO three times a day and paliperidone 12 mg PO QD. Next case is a 8 year-old female with Osteosarcoma under neoadjuvant chemotherapy including High-dose Methotrexate 11640 mg from 2016/9/1 to 9/2, plus Cisplatin and Adriamycin from 9/10 to 9/12, Ifosphamide from 9/30 to 10/5. On 2016/10/24, patient received High-dose Methotrexate 12220 mg and her ALT was elevated. Her previous ALT level was 30 with normal range on 2016/10/23, but on the next day 10/24, her ALT was elevated to 92 and continued to rise to peak 935 on 2016/10/27. The assessment was to rule out methotrexate related ALT elevation.
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Our reference Lexi-comp suggested the incidence rate is about 14 to 15%. The plan was to prescribe leucovorin 28 mg IV STAT on 10/25 and 14 mg IV every 6 hours from 10/25 through 10/29. Additional silymarin 150 mg supplement PO three times a day was prescribed too since 10/27. Next case is a 64-year-old female with Neuralgia pain under carbamazepine 100 mg PO twice a day after meal from 2016/3/29 through5/10. She developed Drug reaction with eosinophilia and systemic symptoms (DRESS) with liver involvement. Her HLA-B 1502 showed negative reaction, but her ALT was elevated to 182 and L- dehydrogenase was also elevated to 960. Eosinophil was elevated to 18.1 on 2016/5/15. The assessment was to rule out carbamazepine related DRESS.
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The plan was to prescribed chlorpheniramine IV and methylprednisolone IV to overcome allergic reaction. Also prescribed fexofenadine, levocetirizine, prednisolone, hydroxyzine PO medication for allergic reaction. Her ALT slowly return to 35 and eosinophil return to 8.8 on 2016/6/22. Next case is a 73-year-old female with Hyperlipidemia under atorvastatin 10 mg PO every day from 2015/11/28. She developed drug reaction with myalgia. Her cholesterol was 229, LDL was 149, Triglycerol was 159,ALT was 9, AST was 15, Serum Creatinine was 1.15, Creatinine Kinase was 42. The assessment was to rule out atorvastatin related myalgia. Our reference Lexi-comp suggested the incidence rate is about 4 to 8%. The plan was to shift atorvastatin to a non-statin lipid-lowering ezetimibe 10 mg PO every other day.
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Symptom was resolved upon switching drugs to ezetimibe. Our next case is a 72-year-old male with Lacunar infarction in left caudate He was treated with Aspirin 300 mg PO stat on 2016/3/6 He later developed Urticaria over his neck and face. His ALT was 18, Serum Creatinine was 1.59, WBC was 124000, Hemoglobin was 15.4, Platelet was 381000, and brain CT shows larcunar infarction, which is stroke. The assessment was to rule out Aspirin related urticaria. The incidence rate is not defined. The plan was to Discontinued Aspirin and prescribed Chlorpheniramine 5 mg IV stat. Symptom was resolved upon discontinue aspirin. Now, we conclude our part I class. Thank you for your attention!

We will see 6 more examples in SOAP format in this video. Please observe each case and ponder why the plan, suggestion, and adjustment being given.

The eighth case

A 53-year-old male developed developed seizure and conscious change. He previously received ertapenem 1000 mg IV QD for UTI since 5 days ago. He also received two 7-day course of Cefixime 150 mg PO every 12 hours on 2/3 (27 days ago) and 2/18 (12 days ago). Urine culture grew E. Coli, serum creatinine was elevated to 2.47 and estimated creatinine clearance was about 36.1 mL/min. Neutrophil count elevated to 85%.

Below are some of the relevant information:

Ertapenem related seizure has an incidence rate of 0.5%.

Brain CT scan showed no intracranial space occupying lesion, nor intracranial hemorrhage.

The TVGH pharmacists switched to Flumarin (flomoxef 1 g IV every 8 hours) for the next 2 days and taper to every 12 hours for 12 days after that.

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Good Pharmacy Practice: Introduction to Clinical Pharmacy Services

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