CASE PRESENTATION

Of A Patient With

Breast Cancer, Hypertension and Hyperlipidemia

I. Discussion of the Patient

A. Patient Information
Name: F. DC. A.
Age/Sex: 64/F
Religion: Catholic
Occupation: Housewife
Date of Admission: 11/15/16
Date of Discharge: 11/21/16
Attending Physician: Dr. F. Albano

B. Chief Complaint
Breast Mass (Left)
Sensation of breast pain

C. History of Present Illness

The patient was admitted with a chief complaint of a palpable breast mass (L) and a
sensation of breast pain. The patient has undergone excisional biopsy but she wasn’t able
to get the result. Modified radical mastectomy was performed last November 2016.

D. Past Medical History

(+) Hypertension
(+) Hyperlipidemia
(+) Surgery Excision Biopsy Left Breast

E. Family History
(+) Ovarian cancer sibling

F. PSHx
Menstrual History
Menarche: Around 13 y/o
Menopause: Around 49 y/o
First Child at age 34
Number of pregnancies: 6
(+) Breastfeeding
(+) Second hand smoker
(+) Alcohol intake (teen years), intake of carcinogenic foods (e.g. BBQ, canned goods)

G. Drug History
Date Monitoring
Medications Indications Dosing Duration
Ordered Parameters
11/15/16 Losartan Antihypertensive 100 mg Monitor CBC, HOLD on
12:00 PM potassium electrolytes, liver the day of
and kidney function operation
with long term (11/16/16)
therapy.
Monitor BP prior to 11/21/16
a scheduled dose.
Monitor drug
effectiveness
11/15/16 Simvastatin Antihyperlipidemic 20 mg Obtain baseline and HOLD on
8:00 PM periodic liver the day of
function during the operation
first year and yearly (11/16/16)
thereafter.
Monitor cholesterol 11/21/16
levels throughout
the therapy.
11/15/16 Clopidogrel Antithrombotic 75 mg Carefully monitor HOLD on
8:03 PM bisulfate for and immediately the day of
report signs and operation
symptoms of GI (11/16/16)
bleeding.
Periodic platelet 11/21/16
count and lipid
profile
11/17/16 Amodipine Antihypertensive 10mg Monitor BP for 11/21/16
7:45 AM besylate therapeutic
effectiveness.
Monitor for signs
and symptoms of
dose-related
peripheral or facial
edema that may not
be accompanied by
weight gain; rarely,
severe edema may
cause
discontinuation of
drug.
Monitor BP with
postural changes.
Monitor more
frequently when
additional
antihypertensives
or diuretics are
added.
Monitor heart rate;
dose related
palpitations may
occur.
Pre-op/Maintenance/Post-op Medications

Date Ordered Medications Indications

Pre-op Medications
11/16/16 Midazolam HCl 5mg/ml Sedative-hypnotic;
9:00 AM Anxiolytic
11/16/16 Atropine sulfate 0.5mg/ml Antisecretory; Antiarrythmic
11/16/16 Fentanyl citrate 100µg Narcotic Analgesic
11/16/16 Propofol 10mg/ml Sedative-hypnotic; General
anesthesia
Maintenance Medications
11/16/16 Succinylcholine chloride 80mg Skeletal muscle relaxant
11/16/16 Atracurium besylate 25mg Skeletal muscle relaxant
11/16/16 Fentanyl citrate 50µg Narcotic Analgesic
Post-op Medications
11/16/16 Cefuroxime 750mg tab Antibacterial
11:45 AM
11/16/16 Nalbuphine HCl 10mg/amp Anesthetic Adjunct
11/16/16 Ketorolac 30mg/amp Non-opioid analgesic

Take Home Medications:

1. Cefuroxime 500mg tablet TID for 7 days
2. Celecoxib 200mg capsule TID

Present Medication
1. Amlodipine 10mg once a day in the morning
2. Losartan 100mg once a day at noon
3. Simvastatin 20mg once a day at night
4. Clopidogrel 75 mg once a day at night

H. Physical Examination
GEN: Conscious
VITAL SIGNS:
BP: 130/80
HR: 65/min
RR: 18/min
BT: 36 O C
HEENT: Normal
CVS: Normal in Size and Shape
ABDOMEN: Left mass, Left upper chest quadrant mass

I. Relevant Baseline Laboratory Results and Diagnostic Tests

a. Blood Chemistry Result
Date: 11/20/13

A. Routine Chemistry Result Found Values Reference Values

FBS 5.13 7-10mmol/L
BUN 4.22 6-18mmol/L
Creatinine 115.30 50-170 mmol/L
Uric Acid 0.32 0.24-0.77 mmol/L
Cholesterol 6.35 0-5.2 mmol/L
B. Special Blood Chemistry
Triglycerides 1.08 < 1.7 mmol/L
HDL 1.44 0-1.68 mmol/L
LDL 4.70 0-3.35 mmol/L
SGOT 20.11 10-40 IU/L
SGPT 23.96 0.49U/L

b. FBS, Creatinine, SGPT

11/09/16
Specimen: Blood
Test Name Results Reference Value
Glucose-FBS 108.5 60.0-10 mg/dL
Creatinine 1.14 Female: 0.6-1.1
mg/dL
SGPT/ALT 15.5 Female: <34.0 µL

c. Complete Blood Count (Hematology)

11/14/16
Specimen: Blood
Test Name Results Reference Value
Hemoglobin 128 Male: 135-180 g/L
Female: 129-160 g/L
Hematocrit 41 Male: 40-54%
Female: 36-42%
RBC 5.06 Male: 4.7-6.1 x1012/L
Female: 4.2-5.4 x1012/L
WBC 9.32 5.0-10.0 x109/L
Neutrophils 74 54-70%
Lymphocytes 22 20-40%
Monocytes 4 0-7%
Eosinophils - 1-3%
Basophils - 0.75%
Platelet Count 303 150-450 x109/L

d. Ultrasound Report
- Liver is normal in size and parenchymal echopattern. No focal mass lesion seen.
- Intrahepatic and extrahepatic ducts are not dilated.
- Gallbladder is normal in size and configuration with smooth and not thickened wall.
- No intraluminal intense echo noted.
 - Pancreas and spleen are normal in size and parenchymal echopattern. No focal mass
lesion seen.
- No paraaortic lymphadenopathy noted.
- Kidneys are normal in size and parenchymal echogenicity. No pelvocaliectasia nor lithiasis
noted.
- Urinary bladder is physiologically distended with smooth and not thickened wall. No
intravesical intense echo noted.
- Uterus is antaverted, normal in size and parenchymal echopattern. Endometrial stripe is not
thickened. Cervix is well coaptated.
- Ovaries are not visualized in this study due to intervening bowel gas.
- No evident adnexal mass noted.
- Clear cul-de-sac.
Impression:
- Negative ultrasound study of the hepatobillary tree, pancreas, spleen, kidneys and urinary
bladder.
- Normal anteverted uterus.
e. Surgical Intervention
Date of Operation: 11/16/16
Name of Procedure: Modified Radical Mastectomy
- This is a procedure in which the entire breast is removed, including the skin, areola, nipple,
and most axillary lymph nodes; the pectoralis major muscle is spared.
Intra-Operative Findings: Breast mass left
Post-Operative Diagnosis: Breast Carcinoma
Surgeon: Dr. F. Albano
Dr. Marcos

II. Brief Discussion of the Diseases

BREAST CANCER

a. Etiology and Incidence

Breast cancer is the most commonly diagnosed cancer among women, with approximately
182,000 women diagnosed with breast cancer annually in the United States, accounting for
approximately 26% of all incident cancers among women.

The cause of breast cancer is unknown, but the strongest risk factors for breast cancer are
female gender (this disease is about 100 times more common in women than in men. This
might be because men have less of the female hormones estrogen and progesterone, which
can promote breast cancer cell growth) and increasing age (usually in people aged 40 and
over). Additional risk factors include:

Endocrine factors:
 Early menarche (Onset of menses before age 13)
 Menses continuing after age 50
 Nullipara (no experience of childbirth)
 Late age at first birth (after age 30)
 Hormone Replacement Therapy
Genetic Factors:
 Personal and family history
 - A woman with cancer in one breast has a higher risk of developing a new cancer
in the other breast or in another part of the same breast.
- Having a first-degree relative (mother, sister, or daughter) with breast cancer
almost doubles a woman’s risk.
 Mutations of tumor suppresser genes
- About 5% to 10% of breast cancer cases are thought to be hereditary
- In some families with BRCA1 mutations the lifetime risk of breast cancer is as
high as 80%, but on average this risk seems to be in the range of 55% to 65%.
For BRCA2 mutations the risk is lower, around 45%.
 Environmental and lifestyle factors (e.g. drinking alcohol, being obese)
b. Pathophysiology of Breast Cancer

Sex

Heredity

Environmental Agents

Hormonal Factors Genetic Mutation

Immunologic Mechanisms

Activation of growth-promoting oncogenes

Inactivation of tumor-suppresor genes

Alterations in gene that controls apoptosis

Unregulated cell differentiation and growth

Cell proliferation and tumor formation

(Origin: Ducts or Lobules)

Carcinoma in situ; Noninvasive; Tumor has not yet

invaded the basement membrane of the breast
tissue)

Invasive carcinoma; Tumor becomes invasive

travels along ducts and eventually breaks
through the basement membrane

Tumor invades adjacent lobules, ducts, facial

strands and mammary fat
 Systemic metastasis; Spread Spreads into the deep
to areas elsewhere in the lymphatics of the dermis
body that will compromise and nodes
vital organ functions Edema, node swelling
(e.g lungs, bones, liver, skin, dimpling of the skin (peau
and soft tissue) d’orange),
ulceration of the skin

c. Clinical Symptomatology

Many women with early breast cancer have no symptoms however, late stages show the
most common symptom of breast cancer is a new lump or mass. A painless, hard mass that
has irregular edges is more likely to be cancerous, but breast cancers can be tender, soft, or
rounded. Other possible symptoms of breast cancer include:
 swelling of all or part of a breast (even if no distinct lump is felt)
 swelling of lymph nodes in the axillary area
 breast skin irritation or dimpling
 nipple pain
 nipple retraction (turning inward)
 redness, scaliness, or thickening of the nipple or breast skin
 nipple discharge (other than breast milk)

d. Laboratory Findings

Screening tests: Screening exams, such as mammograms, find cancers before they start
to cause symptoms. Also, physical examination of the breast, and, possibly, other breast
imaging techniques, such as ultrasound and magnetic resonance imaging (MRI) provide
early detection which can be easier to treat and have better outcomes

Diagnostic tests: A biopsy is done when mammograms, other imaging tests, or the physical
exam shows a breast change that may be cancer. The surgeon makes an incision in the skin
and removes all or part of the abnormal tissue for examination under a microscope. A biopsy
is the only way to know for sure if it’s cancer.

e. Complications and sequelae

Mainly, complications of other organs arise when cancer cells spread to different areas of the
body. Other complications are commonly due to different treatments of breast cancer which
include:
 Chemotherapy. Chemotherapy attacks rapidly dividing cells. Cancer cells, along with
skin cells, and digestive tract cells are the most vulnerable to chemotherapy medication.
This can lead to hair loss, nausea, and vomiting. In premenopausal women, ovaries may
be damaged to the point that they stop producing hormones. This can cause early
menopausal symptoms such as vaginal dryness and hot flashes. Menstrual periods may
stop or become irregular. Getting pregnant may also become difficult. Women who
experience chemotherapy - induced menopause may also face a higher risk of
osteoporosis. The emotional distress of the experience may also cause the physical side
effects to feel more intense Some may have issues with concentration and memory loss,
 known as “chemo-brain,” “chemo-fog,” or “chemo-memory,” but this is usually short lived.
Psychological side effects of chemotherapy and breast cancer itself also include
depression, fear, sadness, feelings of isolation, sleep disturbances
 Radiation Therapy. Radiation therapy can result in more serious but slow-developing
and rare side effects. Serious complications include inflamed lung tissue, heart damage,
and secondary cancers. More common but less serious ones include skin burns,
irritation or discoloration, fatigue, and lymphedema.
 Hormone Therapy. Some types of hormone therapy lower estrogen levels in women,
and increase the risk for osteoporosis. Lower estrogen levels also may lead to vaginal
dryness and irritation.
 Mastectomy. complications include temporary swelling of the breast, breast tenderness,
hardness due to scar tissue that can form at the site of the incision, wound infection or
bleeding, swelling of the arm due to lymph node removal, called lymphedema, phantom
breast pain, including symptoms such as unpleasant itching, a sensation of “pins and
needles,” pressure, and throbbing

HYPERTENSION

a. Etiology and Incidence

Some people have high blood pressure caused by an underlying condition. This type of
high blood pressure, called secondary hypertension, tends to appear suddenly, and cause
higher blood pressure than does primary hypertension. Various conditions and medications
can lead to secondary hypertension, including:
 Obstructive sleep apnea
 Kidney problems
 Adrenal gland tumors
 Thyroid problems
 Certain defects in blood vessels you're born with (congenital)
 Certain medications, such as birth control pills, cold remedies, decongestants, over-
the-counter pain relievers and some prescription drugs
 Illegal drugs, such as cocaine and amphetamines
 Alcohol abuse or chronic alcohol use
 Hyperlipidemia

The age-adjusted prevalence of hypertension was 34%, 25.4%, and 23.2% for men and
31%, 21%, and 21.6% for women among blacks, whites, and Mexican Americans,
respectively. Prevalence of hypertension was 12% for white men and 5% for white women
aged 18-49 years. However, the age-related BP rise for women exceeds that of men. The
prevalence of hypertension was reported at 50% for white men and 55% for white women
aged 70 years or older.

b. Pathophysiology
c. Clinical Symptomatology
If blood pressure is extremely high certain symptoms are: severe headache, fatigue or
confusion, vision problems, chest pain, difficulty breathing, irregular heartbeat, blood in
urine and pounding in your chest, neck, or ears.
b. Laboratory Findings
Hypertension often called as ‘silent killer’ because it is a disease that do not show early
symptoms and simultaneously is the single most significant risk factor for heart disease
and myocardial infarction, aneurysm, congestive heart failure, hypertrophy and chronic
kidney disease. The most frequent symptoms, headache, fatigue, dizziness and facial
flushing, are also very non-specific. Sub-occipital pulsating headaches, occurring early in
the morning and subsiding during the day, said to be characteristic, but any type of
headache may occur. Accelerated hypertension is associated with somnolence, confusion,
visual disturbances, nausea and vomiting (hypertensive encephalopathy.

c. Prognosis
The prognosis of hypertension is highly positive because it is almost always treatable with
dietary and lifestyles changes combined with medication. Patients will need to be
monitored several times a year to ensure that blood pressure has not spiked again and
that any treatments being used are still working. Sometimes medications or dietary habits
will need to be tweaked for optimum results.

d. Complications and Sequelae

Uncontrolled and prolonged elevation of BP can lead to a variety of changes in the
myocardial structure, coronary vasculature, and conduction system of the heart. These
changes in turn can lead to the development of left ventricular hypertrophy (LVH),
coronary artery disease (CAD), various conduction system diseases, and systolic and
diastolic dysfunction of the myocardium, complications that manifest clinically as angina or
myocardial infarction, cardiac arrhythmias (especially atrial fibrillation), and congestive
heart failure (CHF).

HYPERLIPIDEMIA

Hyperlipidemia refers to any of several acquired or genetic disorders that resulting to high
level of lipids (fats, cholesterol and triglycerides) circulating in the blood. These lipids can
enter the walls of arteries and increase risk of developing atherosclerosis (hardening of
the arteries), which can lead to stroke, heart attack and the need to amputate.

a. Etiology

Hyperlipidemia may be primary [e.g. familial hyperlipidemia (FH)] or secondary meaning it

occurs as a consequence of other diseases that disturb lipid metabolism (e.g. diabetes
mellitus). Hyperlipidemia in association with insulin resistance is a common occurrence in
patients suffering from diabetes mellitus type II (DM 2).
In case of FH, the causative factors are inherited mutations in genes, deficiency of the
lipoprotein lipase enzyme (LPL) or disturbed functioning of LDL receptors. Acquired
hyperlipidemias are caused by diseases that interfere with lipid metabolism and uptake
into cells.
The prevalence of hyperlipidemia with respect to body mass index (BMI) between 1996
and 2006 is 14.2% in normal weight individuals, 22.3% in overweight individuals and
42.9% in the obese.
 Hyperlipidemia may present in the youth in familial cases but non-familial cases usually
present much later in life. It tends to be slightly more common in men than women.

b. Pathophysiology

Causative factors:
Inherited mutation in genes
Deficiency in lipoprotein lipase enzyme
Disturbed functioning of LDL
risk factors:
High fat diet
Sedentary lifestyle

Atherosclerotic plaque

Retention in LDL
Oxidation and non-
enzymatic glycation

Oxidized LDL recruits

monocytes into the artery wall

Monocytes transforms into

macrophages

↑ LDL oxidation

Repeated injury and repair within an atherosclerotic

plaque eventually lead to a protecting fibrous cap

Inability of LDL to bind to its receptor

Lack of LDL degradation and unregulated

biosynthesis of cholesterol

c. Clinical Symptomatology HYPERLIPIDEMIA

Hypertriglyceridemia is usually asymptomatic until triglycerides are greater than 1000-

2000mg/dL. Patients may report pain, which is commonly mid epigastric but may occur in
other regions, including the chest or back, yellowish fatty growths (xanthomas) around the
eyes or the joints, dyspnea, corneal arcus, and xanthelasmas.
d. Laboratory Findings

Screening for hyperlipidemia is done with a blood test called a lipid profile. It is important that
a person has nothing to eat or drink for 9-12 hours prior to having the sample drawn.

Screening should start at age 20, and if normal, it should be repeated at least every five
years. Normal levels for a lipid profile are less than 200mg/dL for the total cholesterol, less
than 100mg/dL for LDL, greater than 40 for men, greater than 50 for women (higher is even
better) for HDL, and less than 140 for triglycerides.

e. Complications and Sequelae

Hyperlipidemia refers to increased levels of lipids (fats) in the blood, including cholesterol and
triglycerides. It can significantly increase the risk of developing cardiovascular disease,
including disease of blood vessels supplying the heart (coronary artery disease), brain
(cerebrovascular disease), and limbs (peripheral vascular disease). These conditions can in
turn lead to chest pain, heart attacks, strokes, and other problems.

f. Prognosis

Patients with hyperlipidemia are at extremely high risk of developing premature coronary
artery disease (CAD) (30%). If the disease is inadequately managed, the prognosis is poor,
especially if other cardiovascular risk factors are present. If the patient complies with lipid-
lowering therapy, dietary modification, and lifestyle modification and if therapy is successful,
outcome is improved significantly.

III. Pharmacist’s Workup of Drug Therapy for Breast Cancer

PWDT Components FARM Notes

Findings Findings (F)

Subjective:

 Pain on the left breast

 Palpable breast mass on the left breast

Objective:
 Mammogram
 Excision Biopsy Left Breast

Desired Outcomes Assessments (A)

 Improve symptoms, improve quality of life,
Desired End Points and prolong survival.
 Drug-related Problems  Minimize need for reoperation
 Slow the disease process
 Prevention of disease recurrence

 NONE
Therapeutic Selection Resolutions/Recommendations (R)

 Receptor status of the breast cancer cells

must be known (may or may not have
three important receptors: estrogen
receptor (ER), progesterone receptor
(PR), and HER2) to give the most optimal
drug therapy for the patient.
 Conduct blood tests to avoid serious
complications of chemotherapy such as
neutropenia (vulnerability to infection),
leukemia (as cytotoxic drugs targets
dividing cells in the bone marrow) and
heart disease (doxorubicin may cause
permanent heart damage).

Monitoring Parameters Monitoring (M)

 Watch for recurrence
Follow-up  Manage long-term and short-term
treatment adverse effects
 Follow up care plan may include regular
physical examination and other medical
test to monitor the recovery of the patient
during the coming months and years.
 Monitor potential complications of MRM
like wound infection at the incision site
 Monitor patient’s response to adjuvant
chemotherapy
 Monitor clinical signs of the serious
complications of chemotherapy (e.g.
leukemia and heart disease).

CORE Pharmacotherapy Plan

Condition:
 Breast cancer

Outcomes:
 Improve symptoms, improve quality of life, and prolong survival.
 Minimize need for reoperation
 Slow the disease process
 Prevention of disease recurrence
 Regimen:
 Docetaxel 80mg
 Doxorubicin 50mg

Evaluation:
 Patients should be asked about possible recurrence of symptoms
 Evaluate modification lifestyle or daily activities
 Monitor clinical signs of the serious complications of chemotherapy (e.g. leukemia and
heart disease).

PRIME Pharmacotherapy Problems

P = Pharmaceutical-based Problems
 Patient Non-compliance

R = Risk to Patient
 Side effects of chemotherapy such as hair loss, nausea, and vomiting.

I = Drug Interaction
 None

M = Mismatch between medications and conditions or patient needs

 No mismatch of medications and conditions or patient needs

E = Efficacy Issues
 Patient adherence to therapeutic lifestyle interventions is not guaranteed.

Pharmacist’s Work-up of Drug Therapy for Hypertension

PWDT Components FARM Notes
Findings Findings (F)

Subjective:
 severe headache
 chest pain
 difficulty in breathing
 pounding chest or neck
Objective:
 Blood Pressure
Desired Outcomes Assessments (A)
 Maintain BP within individually acceptable
range.
 Minimize the complications of Hypertension
 Adherence to drug therapy regimens should be
administered right after consultation and
therapeutic lifestyle should be followed
Desired End Points  practice healthy living and improve quality of
life.
Drug-related Problems NONE

Therapeutic Selection Resolutions/Recommendations (R)

 Should not take decongestants, ibuprofen,
naproxen, and antacids which is high sodium
contents they may rise the blood pressure.
 Lifestyle modifications include limiting alcohol
intake, increasing physical activity, and reducing
sodium intake.
 Adherence to medication because this is for
lifetime maintenance.

Monitoring Parameters Monitoring (M)

Follow-up  Monitor complications of hypertension
 Monitor levels of blood sodium levels and
potassium serum levels.
 Monitor blood pressure if there is a need for
significant change in drug or in dosing of the
medication.
 Monitor clinical signs and symptoms of
hypertension.
 Monitor patient response on medication

CORE PHARMACOTHERAPY PLAN

Condition:
Hypertension

Outcomes:
 Maintain BP within individually acceptable range.
 Minimize the complications of Hypertension

Regimen:
 Losartan 50 mg
 Amlodipine 10mg

Evaluation:
 Close monitoring of blood pressure
 Monitor patient’s response to therapy
 Monitor patient’s sodium intake
 Monitor healthy body weight
PRIME PHARMACOTHERAPY PLAN

P (Pharmaceutical-Based Problems)
 Patient non-compliance

R (Risk to Patient)
 Losartan – Increase risk of Hypotension, Renal impairment
 Amlodipine – Peripheral Edema, Risk of angina and acute MI

I (Drug Interaction)
 None

M (Mismatch between medications and conditions or patient needs)

 None

E (Efficacy Issues)
 Patient non-compliance

Pharmacist’s Work-up for Drug Therapy for Hyperlipidemia

PWDT Components FARM Notes
Findings Findings (F)
Subjective
 Chest pain
Objective
 Blood Test
Cholesterol: 6.35 mmol/L
HDL: 1.44 mmol/L
LDL: 4.70 mmol/L

Desired Outcomes Assessments (A)

 Minimize the risk of events by lowering the total
and
LDL cholesterol.
 Adherence to therapeutic lifestyle interventions (i.e
diet, fasting lipid panel, exercise) and drug therapy
regimens

Desired End Points  Improve practice of healthy living and diet

Drug-related Problems
Therapeutic Selection
 Supplement normal cholesterol levels (LDL, HDL,
triglycerides) and dietary therapies and exercises.
None
Resolution/Recommendations (R)
 Adhering to a "heart healthy" diet, regular exercise
habits, no smoking, and maintenance of a healthy
weight
 Read food labels and choose foods with low
cholesterol and saturated trans fat
  Limit intake of red meat and dairy products made
with
whole milk to reduce your saturated and trans-fat.
 Maintenance therapy of Simvastatin

Monitoring Parameters Monitoring (M)

• Monitor blood cholesterol levels, elevation of
transaminase level.
• Monitor LDL 3-6 months after dietary intervention
has started and annually thereafter
• Monitor complications of hyperlipidemia
(atherosclerosis, stroke, and heart attack)
• While on stable lipid therapy, individuals should be
tested at 6- to 12-month intervals

CORE Pharmacotherapy Plan

Condition:

Hyperlipidaemia or Dyslipidemia

Outcomes:

 Prompt resolution of the symptoms of disease after the introduction and initiation of
treatment
 Minimize the risk of first or recurrent complications by lowering the total and LDL
cholesterol
 Compliance to therapeutic lifestyle programs (e.g proper diet and exercise) and
drug-therapy regimens for reducing high cholesterol should start immediately.
 Improve and ensure safe and quality of life.

Regimen:

 Simvastatin 20mg once a day at bedtime

 Clopidogrel 75mg once a day

Evaluation:

 Short-term evaluation of therapy for hyperlipidemia is based on response to diet and

drug treatment as measured in the clinical laboratory by total cholesterol, LDL-C, HDL
cholesterol, and triglycerides.

 Lipid measurements should be obtained in the fasted state to minimize interference from
chylomicrons. Monitoring is needed every few months during dosage titration. Once the
patient is stable, monitoring at intervals of 6 months to 1 year is sufficient.
  Patients on therapy should have a fasting panel checked every 4 to 8 weeks until a
stable dose is reached; triglycerides should be checked at a stable dose to ensure they
have not increased.

 Patients receiving statins should have a fasting panel 4 to 8 weeks after the initial dose
or dose changes. Liver function tests should be obtained at baseline and periodically
thereafter based on package insert information. Some experts believe that monitoring for
hepatotoxicity and myopathy should be triggered by symptoms.

PRIME Pharmacotherapy Problems

Pharmaceutical-based problems (P)

 Patient non-compliance

Risk to patient (R)

 Liver damage. Patient may develop resistance to the medication due to inappropriate
patient medication-taking behavior.
 Constipation occurs in fewer than 10% of patients taking statins. Other adverse effects
include elevated serum aminotransferase levels (primarily alanine aminotransferase),
elevated creatinine kinase levels, myopathy, and rarely rhabdomyolysis.
 Cardiovascular diseases including coronary artery disease
 Stroke
 Cerebrovascular disease

Drug Interaction (I)

 None

Mismatch between medications and conditions or patient needs (M)

 None

Efficacy Issues (E)

 Patient non-compliance

IV. Discussion of the Medications

A. Docetaxel
Pharmacologic Class: Antineoplastic
MOA: Increases microtubule assembly and inhibits microtubule disassembly.
Arrests cell division in metaphase.
Contraindication: Hypersensitivity to docetaxel, patients with severe hepatic
impairment
ADR: Alopecia, Anemia, Peripheral neuropathy, Leukopenia, Neutropenia,
Asthenia
 Patient Information: Caution woman of childbearing to avoid pregnancy or breast-
feeding during therapy. Warn patient that hair loss occurs in almost 80% of
patients but is reversible when treatment stops.
B. Doxorubicin
Pharmacologic Class: Antineoplastic
MOA: Binds to DNA pairs. Inhibits DNA and DNA-dependent RNA synthesis.
Inhibits protein synthesis. Cell cycle specific for s-phase.
Contraindication: Hypersensitivity, active infection, severe hepatic impairment,
severe myocardial insufficiency, cardiomyopathy, CHF, impaired cardiac function
ADR: Alopecia, nausea/vomiting, anorexia, leukopenia, neutropenia, impaired
immunity, fatigue, cardiotoxicity
Patient Information: Advise the patient to watch for signs and symptoms of
infection and bleeding and to take temperature daily. Inform the patient that hair
loss may occur but it’s usually reversible.
C. Amlodipine Besylate
Pharmacologic Class: Calcium Channel Blocker
MOA: Inhibits transmembrane influx of extracellular calcium ions across
membranes of myocardial cells without changing serum calcium concentrations.
Contraindication: Hypersensitivity
ADR: Edema, pulmonary edema
Patient Information: Ask the patient if he/she has congestive heart failure or liver
disease. Instruct the patient not to drink alcohol when taking the medication
because this can increase certain side effects of amlodipine.
D. Losartan Potassium
Pharmacologic Class: Angiotensin Receptor Blocker (ARB)
MOA: Competitively inhibits the binding of angiotensin II to AT1 in many tissues
including vascular smooth muscle and the adrenal glands.
Contraindication: patient hypersensitive to drug, impaired renal or hepatic
function
ADR: Fatigue, hypoglycemia, anemia, UTI, chest pain
Patient Information: Advise the patient not to drink alcohol because this may
increase the risk of side effects, such as dizzy or faint. Instruct the patient to
avoid salt substitutes which contain potassium.
E. Simvastatin
Pharmacologic Class: Antihyperlipidemic
MOA: Inhibits the rate-limiting step in cholesterol biosynthesis by completely
inhibiting HMG-CoA reductase.
Contraindication: Hypersensitivity to simvastatin, active liver disease, pregnancy,
nursing mothers
ADR: Constipation, upper respiratory infection, flatulence, headache, abdominal
pain, vertigo
Patient Information: instruct the patient to take drug with evening meal to
enhance its absorption and cholesterol biosynthesis. Advise the patient to limit
alcoholic beverages when taking this drug to avoid the risk of liver problems.
F. Clopidogrel
Pharmacologic Class: Antiplatelet
MOA: Inhibits adenosine giphosphate (ADP)-induced pathway for platelet
aggregation.
 Contraindication: hypersensitivity, active pathologic bleeding (peptic ulcer,
intracranial hemorrhage)
ADR: upper respiratory tract infection, chest pain, headache, flulike syndrome,
pain, dizziness, diarrhea
Patient Information: Instruct the patient to limit alcoholic beverages to avoid risk
of stomach bleeding. This drug should not be taken by pregnant women unless
clearly needed. Avoid driving the other potential hazardous activities until
reaction to drug is known.
G. Ketorolac
Pharmacologic Class: NSAID
MOA: Inhibits prostaglandin synthesis
Contraindication: High risk of bleeding
ADR: GI bleeding, renal failure, thrombocytopenia
Patient Information: advise the patient to take plenty of water to avoid
constipation.
H. Nalbuphine
Pharmacologic Class: Opioid agonist-antagonist
MOA: Inhibits ascending pain pathways, thus altering response to pain.
Contraindication: Diarrhea associated with toxins, pseudomembranous colitis,
respiratory depression, acute asthma, bradycardia, respiratory impairment
ADR: sedation
Patient Information: Avoid alcohol use; may cause additive CNS effects. Counsel
the patient to avoid hazardous tasks, such as driving, because the drug may
cause dizziness and fatigue.
I. Fentanyl
Pharmacologic Class: Opioid Analgesic
MOA: Narcotic agonist-analgesic of opiate receptors; inhibits ascending pain
pathways thus altering response to pain.
Contraindication: Hypersensitivity, within 2 weeks of monoamine oxidase inhibitor
(MAOI) use
ADR: Asthenia, confusion, constipation, dry mouth, nausea, vomiting,
somnolence, sedation, muscle stiffness
J. Atracurium Besylate
Pharmacologic Class: Neuromuscular Blocker
MOA: Non-depolarizing skeletal muscle relaxant; cholinergic receptor antagonist
Contraindication: Hypersensitivity to drug or components, lack of ventilator
support, neuromuscular disease
ADR: Skin flush
K. Succinylcholine Chloride
Pharmacologic Class: Neuromuscular Blocker
MOA: Depolarizing skeletal muscle relaxant; depolarizes motor endplate at
myoneural junction, which causes sustained flaccid skeletal muscle paralysis.
Contraindication: Hypersensitivity, malignant hyperthermia, lack of ventilator
support, ocular surgery, penetrating eye injuries, multiple trauma, closed-angle
glaucoma
ADR: increased saliva, muscle pain following surgery, muscle twitching. Patient
Information: Succinylcholine should only be used in children in emergency
situations. Rare, serious side effects have occurred in children who have
 received succinylcholine. Discuss the benefits and risks of using succinylcholine
in pregnancy and breastfeeding.
L. Midazolam
Pharmacologic Class: Benzodiazepine
MOA: Binds receptors at several sites within the CNS, including the limbic
system and reticular formation; effects may be mediated through GABA receptor
system; increase in neuronal membrane permeability to chloride ions enhances
the inhibitory effects of GABA; the shift in chloride ions causes hyperpolarization
(less excitability) and stabilization of the neuronal membrane.
Contraindication: Hypersensitivity, acute alcohol intoxication, acute narrow angle
glaucoma.
ADR: decreased respiratory rate, apnea, drowsiness, nausea and vomiting.

I. General Evaluation of Therapy

Breast Cancer
 Patients should be asked about possible recurrence of symptoms
 Evaluate modification lifestyle or daily activities

Hypertension
 Evaluate modification lifestyle or daily activities
 Evaluate patient respond to therapy
 Evaluate BP response 2 to 4 weeks after initiating or making changes in therapy.
Once goals BP values are obtained, monitor BP every 3 to 6 months, assuming
no signs or symptoms of acute target-organ disease.
 Evaluate patients with a history of poor control, nonadherence, progressive
target-organ damage, or symptoms of adverse drug effects

Hyperlipidemia
 Evaluate modification lifestyle or daily activities
 Evaluation of short-term therapy for hyperlipidemia is based on response to diet
and drug treatment as measured by total cholesterol, LDL-C, HDL-C, and
triglycerides.
 In patients treated for secondary intervention, symptoms of atherosclerotic
cardiovascular disease, such as angina and intermittent claudication, may
improve over months to years.
 Patients receiving statins should have a fasting lipid panel 4 to 8 weeks after the
initial dose or dose changes. Obtain liver function tests at baseline and
periodically thereafter. Some experts believe that monitoring for hepatotoxicity
and myopathy should be triggered by symptoms.
 For patients with multiple risk factors and established CHD, evaluate for progress
in managing other risk factors such as BP control, smoking cessation, exercise
and weight control, and glycemic control (if diabetic).
 Evaluation of dietary therapy with diet diaries and recall survey instruments
allows information about diet to be collected in a systematic fashion and may
improve patient adherence to dietary recommendations.

II. General Recommendations

  Monitor for recurrence of tumor
 Manage long-term and short-term treatment adverse effects.
 Follow up care plan may include regular physical examination and other medical
test to monitor the recovery of the patient during the coming months and years.
 Adjuvant chemotherapy can cause significant toxicity. Optimize supportive
care measures such as antiemetics and growth factors to maintain dose
intensity.
 Monitor vital signs.
 After starting antihypertensive drug therapy, the patient should see his or her
doctor at least once a month until the blood pressure goal is reached.
 After the blood pressure goal is reached, the patient should see the doctor every
three to six months depending on whether he or she any diseases such as heart
failure.
 Monitor LDL 3-6 months after dietary intervention has started and annually
thereafter
 Nutritional counselling on patient regarding food or dietary intake.
 Recommend the consumption of fruits, vegetables, and low-fat dairy produts for
reduction of BP.

III. Discussion of Treatment

Treatment for Breast Cancer
Early administration of effective combination chemotherapy at a time of low tumor
burden should increase the likelihood of cure and minimize emergence of drug resistant
tumor cell clones. Combination regimens have historically been more effective than
single-agent chemotherapy. Anthracycline-containing regimens (eg, doxorubicin and
epirubicin) reduce the rate of recurrence and death as compared with regimens that
contain cyclophosphamide, methotrexate, and fluorouracil. The addition of taxanes,
docetaxel and paclitaxel, to adjuvant regimens comprised of the drugs listed above
resulted in reduced risk of distant recurrence, any recurrence, and overall mortality
compared with a nontaxane regimen in node-positive breast cancer patients. The use of
taxane-containing regimens in node-negative patients remains controversial. Initiate
chemotherapy within 12 weeks of surgical removal of the primary tumor. Optimal
duration of adjuvant treatment is unknown but appears to be 12 to 24 weeks, depending
on the regimen used.

Treatment for Hypertension

Hypertension can be managed through non-pharmacologic therapy and pharmacologic
therapy. Non-pharmacologic includes lifestyle modification: weight loss if overweight,
adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan, dietary
sodium restriction ideally to 1.5 g/day (3.8 g/day sodium chloride), regular aerobic
physical activity, moderate alcohol consumption (two or fewer drinks per day), and
smoking cessation. Initial drug selection depends on the degree of BP elevation and
presence of compelling indications for selected drugs. Angiotensin-converting enzyme
(ACE) inhibitors, angiotensin II receptor blockers (ARBs), calcium channel blockers
(CCBs), and thiazide diuretics are acceptable first-line options. Combination therapy is
recommended for patients with stage 2 hypertension, preferably with two first-line
agents. β-Blockers are used to either treat a specific compelling indication or as
combination therapy with a first-line antihypertensive agent for patients without a
compelling indication. Most patients with stage 1 hypertension should be treated initially
with a first-line antihypertensive drug or a two-drug combination. Combination therapy is
recommended

Treatment for Hyperlipidemia

Lower total and LDL cholesterol to reduce the risk of first or recurrent events such as MI,
angina, heart failure, ischemic stroke, or peripheral arterial disease. Begin therapeutic
lifestyle changes (TLCs) on the first visit, including dietary therapy, weight reduction, and
increased physical activity. Advise overweight patients to lose 10% of body weight.
Encourage physical activity of moderate intensity 30 minutes a day for most days of the
week. Assist patients with smoking cessation and control of hypertension. The objectives
of dietary therapy are to progressively decrease intake of total fat, saturated fat, and
cholesterol and to achieve a desirable body weight. Increased intake of soluble fiber (oat
bran, pectins, psyllium) can reduce total and LDL cholesterol by 5% to 20%. However,
they have little effect on HDL-C or triglycerides. Statins (atorvastatin, fluvastatin,
lovastatin, pitavastatin, pravastatin, rosuvastatin,and simvastatin) inhibit 3-hydroxy-3-
methylglutaryl coenzyme A (HMG-CoA) reductase, interrupting conversion of HMG-CoA
to mevalonate, the rate-limiting step in cholesterol biosynthesis. Reduced LD synthesis
and enhanced LDL catabolism mediated through LDL-Rs appear to be the principal
mechanisms for lipid-lowering effects. When used as monotherapy statins are the most
potent total and LDL cholesterol–lowering agents and among the best tolerated. Total
and LDL cholesterol are reduced in a dose-related fashion by 30% or more when added
to dietary therapy.