Pahrmaceutical care practise- Multiple Sclerosis Case (MS)

Transverse Myelitis (TM) with possible Remote Multiple Sclerosis (MS) versus Recurring Transverse Myelitis (RTM) .

Areej Abu Hanieh

1130234 Birzeit Univers ity - palestine

*Demographic information : *Name : AA

*City : Anata

*Age : 15 years

*Gender : female

*Weight : 68 kg with a moon face.

*Height : 157 cm

*BMI for Children : 27.59

*Occupation: no - work

*Living arrangement: family

*Health insurance: health insurance .

*Reason for visit: for educational purpose .

2 MS vs TV - Areej 05-Feb-17

**Motion sickness , using mottilium (domperidone ), before 10 years.

*Before 2 years she was diagnosied with Acute flaccid paralysis , M/P

Guillian bare syndrome , CNS Lupus , Seizure disorder , Renal

impairment , DVT , Multiple sclerosis , transverse myelitis , in the

beginning of the treatment , was used , mottilium (domperidone ) ,

Ratidine (Ranitidine) ,Scobutyl (Hyoscine-N_Butyl Bromide) 10 mg ,

metocloropromide , for 4 days , without any improvement ,then she kept

alive by nasogastric and setup mechanical ventilator .

*Tracheostomy operation .

*Then they set up her on Lasix (Feurosemide) , Nifidepine for

hypertension .


*Rocephin (ceftriaxone) , Vancomycin , at meningitis dose

Acyclovir (zovirx). For the possibility of

meningioencephalopathy . while vancomycin and acyclovir where

stopped due to acute renal failure .

*Ceftriaxone , cloxacilin for 14 days , azithromycin for 3 days for

the possibility chest infection .

*Flucanozle adjusted to renal failure for yeast in urine .

*Phenytoin , Depalept (Valproic acid) for convulsions .

*Heparin , then shifted to Clexan (enoxaparin) , then shifted to

Coumadin (Warfarin) for DVT .

*Solu-medrol (methylprednisone) , cyclophosphamide monthly for

the possibility of the CNS – Lupus .

*Rituximab , that cause anaphylactic shock .


*Discharg medicines : *Prednitab (Prednisolone 20mg) 1x1 .

*Imuran (Azathioprine 50 mg) , 1 tablet in a day

*Cellcept (Mycohphenolic Acid 360mg) , 4 tablets in a day

*Coumadin (warfarin 1mg) ,1 tablet in a day .

*Calcium 600mg

*Alpha-D3 0.25mg

*Depalept (valproic acid 200mg)

*Omeprazole 20mg , one tablet in a day

*Osteotab (alendronate sodium 70mg)


*

*Patient behavior , Expectation from her

medications:

*Patient take medication because she believe that this

medecines is her choice to get better and be able to live

normal life again , and live like a normal girl , although she

take every day 8 tablets of different medications , but she got

stamina , her parents encourage here and help her take her

medications , to end the regiment , she suffer from

myoclonic that it is very painful for her , so she said , that

taking 8 tablets in a day is better and less painful than single

seizure for a couple of seconds, and she hope that she will

get better soon if she adhere the complete regiment as doctor

told her .


*Social drugs : one tea cup in a day

.

*Vaccination history : Childhood

vaccination , No recent vaccines .


*

*Blood Pressure : 114/80

*Heart rate : 100 BPM

*Temperature : 36.6


*


*

Drug Indication Date dosage Reponse

and Safety Myfortic (Mycophenolate

Sodium) 360mg

Multiple Sclerosis vs

tranverse myelitis

Before 6 months One Tab daily Good

Depalept (Sodium

Valproate)200mg

Myoclonic seizures Before 6 months Three tablets

daily

Good

Prednitab (Prednisolone)

20mg

Multiple Sclerosis vs

tranverse myelitis

Before 6 month

(tapering

regimen)

One tab daily Has serious side

effect

Calcimore (Calcium

Carbonate) 600mg

Calcium deffiency

Prevent osteoporosis

Before 6 months 2 Tab daily Good

Alfacal

(alfacalcidol)0.25mcg

Vitamin D deffiency Before 6 months One Tab daily Good

Coumadin (warfarin) 2mg DVT Before 2 years One Tab daily Has side effect

as bleeding

Omega – 3 supplements Before one

month

Day after another

Fenugreek , parsley UTI Before 2 weeks PRN Good

IVIG (IgG) Immunedeffiency Before 6 months 25 gr/day every 2

months

Good

Trufen (Ibuprofen) 200 mg Pain PRN (2 Tablets in

a day)

Good , affect on

warfarin


**ENT : blurred vision .

*GI : She has a stomach pain and burning in stomach (upper pyloric sphincter , Gastric ulcer) that increase with food taken.

*Heme : she has a high ESR (erythrocyte sedimentation rate) range , low RBC (red blood cells) , high MCH (mean corpuscular hemoglobin) , Low PLTS counting .

*GU : UTI (Urinary tract infection).

*Neurological : numbness .

*Muscoskeletal : legs pain due to obesity and DVT and edema , pain and defect in the cartilage in the femur – hip joint (Avascular necrosis ,Bone necrosis) for the right leg .general weakness in skeletal muscles , the pain scale 7 -8 .


Test Results Normal range

ESR 28 <20

WBC 4.3 5-10 x10^3/micro L

RBC 4.4 4.2 – 5.4 x10^6 micro L

Hb 13.4 12-16 g/dl

Hct 39 38-47 %

MCV 88 82-92 micro m^3

MCH 31 27-31 pg/ml

MCHC 35 32-36 %

PLTS 200 150 – 450 x10^3/microL

ALT (GPT) 5 4 – 36 U/L

Creatinine ,serium 0.7 0.6-1.2 mg/dL

INR 3.7 <1.1 for normal people

, warfarin use patient

2.0 – 3.0

Pt 41 11-14 seconds

Ptt 30 25 – 35 seconds

LAB Tests 11/10/2016


**Adverse effect of prednisolone , weight gain due to increase the

apetite , blurred vision ,peripheral edema ,irritability with

depression , numbness , facial hair growth , round face , moon face

(is high fat in the face due to long exposure for the corticosteroids),

menistrual irregularities , sweating , thining of the scalp hair, defect

in the cartilage in the femur – hip joint for the right leg. (bone

necrosis in right leg) , hoarseness .

*Drug – Drug Interactions (warfarin with ibuprofen ) , high INR

level , that she is in a real risk of bleeding while taking warfarin .

*adverse drug reaction , Bone pain with mycophenolate sodium.

* need additional drug therapy , the blurred vision and frequent

urination, headach and fatigue due to hyperglycemia .

*Additional drug therapy : need medication for UTI .

*Additional drug therapy : for Gastric Ulcer . 13 MS vs TV - Areej 05-Feb-17

*


*Drug –drug interaction between warfarin and

Ibuprofen :

Goal of therapy :

Has an INR between 2.0 -3.0.

- Ibuprofen should be stopped and replace it with

paracetamol at the minimum possible dose to avoid

bleeding , the dose per day should not exceed 1g (2

tablets in a day), or oxycodone in severe pain cases.

- Decrease weekly dosage by 10% or by 1 mg/d for 3 days of

next week (3 mg total); repeat PT in 1 week.

- The new regimen will be (Total dose = 11 mg) :

Day 1 2 3 4 5 6 7

Dose (mg) 2 1 2 1 2 1 2


*Risk of Hyperglycemia :

*The frequent urination , blurred vision , headache , and

fatigue , due to hyperglycemia due to prednisolone side

effect , better to do blood sugar tests , HBA1C and

Fasting blood sugar (FBS) .


*Decrease bone necrosis development:

- Pharmacological Treatment : Take medication to decrease

the pain like paracetamol , or using topical painkillers , such

as Diclofenac sodium topical (Rufenal 1%) , or Ibuprofen

topical (Isofen 1%)

- or use oxycodone in severe pain .

- Non Pharmacological Treatments : Reducing the weight and

stress on her affected bone can slow the damage. she might

need to restrict her physical activity or use crutches to keep

weight off her joint for several months.

Exercises. she may be referred to a physical therapist to

learn exercises to help maintain or improve the range of

motion in her joint.


*Decrease the weight :

- Non pharmacological intervention :

Decrease the amount of food she take , decrease the simple

sugar and fat taken , increase the numbers of meals in a day

, replace artificial snacks that has a lot of calories with

fruits and vegetables , replace the white bread with black

bread and high fibers , decrease the sugar in milk cup, do

exercises that suitable for her , like walking , swimming .

*Improve the vision for better life :

- I advise her to go to the doctor (Ophtalmogical

examination) and do an eye test ,wear glasses if it is

needed, to decrease eye blur development .have an

optimum reading distance when reading from books and

labtops , and better to follow , 20 ,20 ,20 rule, to decrease

eye stress , protect her eye from the sun .


*Decrease the edema in lower extremitis :

*1. Bed rest

*Decrease peripheral pooling (by raise the legs above body level).

*Augment blood volume in central circulation

*Increases sodium diuresis (Furosemide , Thiazide)

*2. Sodium restriction

*1-1.5 mEq/kg/day

*Avoid salty foods

*3. Water balance

*Daily intake = Urinary loss + Insensible water loss

*When diuresis occurs, avoid water restriction


*Diuretic therapy:

*1. Spironolactone 25mg

*The dose for people with edema and hypokalemia is (25-200 mg

daily)

*1 to 3 mg/kg/day P.O.

*Give her 100 mg daily (4 tablets daily) .

This treatment for Edema and hypokalemia .


*Gastric ulcer :

- Non pharmacological treatment :

Avoid these foods :

*Whole milk and chocolate milk

*Hot cocoa and cola

*Any beverage with caffeine

*Peppermint and spearmint tea

*Green and black tea, with or without caffeine

*Orange and grapefruit juices

*Spices and seasonings:

*Black and red pepper

*Chili powder

*Mustard seed and nutmeg

And she do not eat before bedtime , in addition better for here to eat small amount.


*Non pharmacological treatment :

- Given Ranitidine 150mg twice daily .

- 4 to 10 mg/kg/day administered in 2 divided doses,

every 12 hours.


*Sweating :

- Use over the counter persiperant combined with

deodorant , help control the sweating odor.

*The treatment of UTI : is trimethoprim/sulfamethoxazole , Alternative

antibiotics include amoxicillin/clavulanic acid .


*Menestrual Irrigularity (Amenorrhea):

1 - Non Pharmacological treatment :

- She should eat a properly balanced diet.

- She should restrict the amount of fat in their diet

- A moderate exercise program may restore normal menstruation.

- restore and maintain a healthy body weight.

- finding ways to deal with stress and conflicts may help.

2-Pharmacological treatment:

- Dydrogesterone (Duphaston, Abbott)

Duphaston 10 mg b.d. from day 11 to 25 to produce an optimum

secretory transformation of an endometrium that has been

adequately primed with either endogenous or exogenous estrogen.


**Monitor the INR by doing test after 7-14 days .

*Monitor the prednisolone dose every week for tapering regimen if it needed .

*Do an X-Ray image for the right hip to follow up the Avascular necrosis and prevent its exacarbation monthly.

*Monitor the vital sign and lab tests for MS medications especially corticosteroids and mycophenolate every 1 month.


Disease-Modifying Therapies

Nine disease-modifying therapies (DMT) have been approved for

treatment of relapsing-remitting multiple sclerosis (MS) in the adult

population, including 6 first-line therapies (glatiramer acetate [GA],

intramuscular [IM] and subcutaneous [SC] interferon [IFN] beta-1a,

and SC interferon-beta-1b, fingolimod, and teriflunomide) and 2

second-line therapies (mitoxantrone and natalizumab). In addition,

therapies such as rituximab, daclizumab, and cyclophosphamide

have been evaluated in phase II trials in adults with breakthrough

disease, as have add-on therapies such as monthly steroids and

intravenous immunoglobulin (IVIG).


*


Pahrmaceutical care practise- Multiple Sclerosis Case (MS)

Health & Medicine

Transcript of Pahrmaceutical care practise- Multiple Sclerosis Case (MS)