Transitions of Care – What Would You Remember if You Just Escaped Death?

Transitions of care is an extremely vulnerable time for patients.  Patients can be easily overwhelmed due to different medications, new diagnosis, new location, new people, and multiple things to learn.  As healthcare professionals, it is easy to get into your work groove and forget to put ourselves in the shoes of our patients.

Hospitalization is one of the most stressful situations a patient can go through.  Imagine that you have some chest pain, get admitted to the hospital, and newly diagnosed with a myocardial infarction (heart attack).  If you make it through this situation and get discharged home, how would you feel, and what would your priorities be?

Photo courtesy of blogotron
Photo courtesy of blogotron

I think when we are educating these patients we forget an important aspect.  They are people, they have lives, families, commitments just like the rest of us.  If you nearly died, are in pain, couldn’t sleep well at night, would your focus be on whether you need to take metoprolol once or twice daily when you get home?  What about taking your statin at night, would that be important to you?  Or would you be thinking about; How much longer do I have to live? How many times am going to get to see my grandkids again? or will I get to go on that trip I’ve always wanted to do?”

Even when caregivers are involved, they will have many of those same fears about their loved ones.  Their focus is on their life, not their medications.  Remember that.

I’m a huge advocate for close follow up of patients after they get home and start to get back to their usual routine.  I think if you put yourself in the shoes of your patients, you’ll realize what their priorities are going to be.

Please check out 30 medication mistakes that every healthcare professional should know!

Improper Symbicort Administration Leads to Recurrent Thrush

63 year old female with a history of severe COPD.  She is a smoker and is currently taking the following medications: ipratropium/albuterol as needed, Symbicort (budesonide and formoterol) 160/4.5 two inhalations twice daily and Spiriva inhalation once daily.  Respiratory symptoms are fairly well managed

She presents to the clinic with poor appetite, cough, throat pain, and also complains of a gagging type feeling.  Upon assessment, she’s diagnosed with thrush and prescribed nystatin to treat the infection.  The infection totally resolves within a couple of weeks.

photo courtesy Patrick Lynch
photo courtesy Patrick Lynch

Fast forward a couple months later and the patient again presents with similar symptoms of irritated mouth and throat, difficulty swallowing.  Patient is again diagnosed with a candida infection and treated with nystatin for a period 2-4 weeks with consideration of a longer time period depending upon symptoms.

So what was missed initially in this case?  Upon investigation and careful questioning of the patient, it was discovered that she either was not educated or did not remember to rinse her mouth following administration of inhaled corticosteroids (which Symbicort contains).  This is a classic example of why patient education is so important as well as identifying that new symptoms or medical problems could be caused or worsened by medications!  In this case, the thrush could’ve possibly been prevented, saving our patient some pain and suffering.

If you’re new to the blog, please subscribe and check out 30 medication mistakes I see in my everyday practice as a pharmacist.

Eric Christianson, PharmD, CGP, BCPS

A Case of Persistent low blood pressure – Sepsis or Drug Induced? You decide.

Amanuel always goes way above and beyond on his case studies and I can’t say thank you enough to all the guest contributors who’ve shared their stories/cases!  It’s folks like him that have made this page what it is today!  Please reach out to him if questions or comments at the end of this post.  You can also find him on LinkedIn – I’m waiting for your case study!  Please contact me if you have a case that demonstrates the power of clinical pharmacy!  The case:

38 year old female patient with a history of multiple medical conditions, including pulmonary hypertension, HIV+ and surgeries.

The chief complaint and reason for this admission (1/2/15) to the hospital is presence of severe neck abscess for which she is being managed surgically and iv antibiotics.

Systemic Hypotension

The other major issue patient is experiencing and the subject of this discussion is persistent low blood pressure or (chronic systemic hypotension).

While sepsis has been suspected (and documented) as a likely cause for the most recent drops in her blood pressure, one needs to investigate further for other factors which may be contributing to its persistence (see table 1).(HINT: Patient is an immunocompromised patient on HAART therapy . She also has history of pulmonary hypertension that was treated with Phosphodiesterase -5 (PDE5) Inhibitor chronically.(see med lists on Table 2) 

Table 1.

Patient’s Blood Pressure over the course of 12 days post admission : 

Date SBP (mmhg) DBP (mmhg)
1/2/15 79 44
1/2/15 66 43
1/3/15 110 62
1/3/15 97 65
1/3/15 107 67
1/3/15  94 64
1/5/15 105 63
1/11/15 108 68
1/13/15 156 84

 As shown on table 1, we see some improvement in patient’s blood pressure over the course of 12 days. Based on well established data, concurrent use of protease Inhibitors (Ritonavir) and phosphodiesterase-5 inhibitors (Sildenafil) can cause significant elevation of the latter’s blood level, resulting in adverse events such as visual disturbance, hypotension, chest pain, syncope, among others.(I) In light of such well documented data, the issue was brought to the attention of the prescriber and Sildenafil was suspended on day 2 of the admission.

Whether the observed improvement in blood pressure is in response to treatment of sepsis (antimicrobials); administration of vasopressor agents (Norepinephrine) or due to discontinuation of Sildenafil is difficult to determine for certain. Patient remains febrile with elevated wbc several days after broad spectrum iv antibiotics were initiated. However, given that the change occurred sometime after Sildenafil was suspended one would lean to believe that stopping the drug may have played some role in the stabilization of the patient’s blood pressure. The finding and validity of such hypothesis can only be conclusive with the performance of a more thorough, large scale and evidence-based study involving multiple subjects with similar clinical/medical history.

Table 2. Patient’s Current Active Meds:

balsam Peru/castor oil/trypsin topical (Xenaderm) 1 apply Topical q12hr Dry skin
darunavir 800 mg G-Tube qDay HIV
docusate (Colace) 100 mg PO BID Constipation
emtricitabine 200 mg PO qDay HIV
enoxaparin 80 mg Subcutan q12hr PE
ezetimibe (Zetia) 10 mg G-Tube qHS Cholesterol
famotidine 20 mg PO qDay Prophylaxis for indigestion
fentaNYL 25 mcg Topical q72hr Analgesic
insulin aspart (insulin aspart Corrective dosing)   Subcutan q4hr Hyperglycemia
levETIRAcetam (Keppra) 1gm gtube q12hr Seizure
meropenem (Merrem) 500 mg IVPB q6hr infection
pravastatin 20 mg G-Tube qHS Cholesterol
raltegravir 400 mg G-Tube BID HIV
ritonavir (Norvir) 100 mg G-Tube qDay HIV
senna 8.6 mg PO BID Constipation
sertraline (Zoloft) 100 mg PO qPM Antidepressant
sildenafil 20 mg G-Tube q8hr Pulmonary hypertension
thiamine 100 mg PO or NG qDay Supplemental
vancomycin 1000mg iv a8hr infection

Another issue that needs to be addressed involves patient’s pulmonary hypertension, a chronic condition for which she has been treated with Sildanefil. While suspending the drug temporarily( as in this case) may not have that much adverse effect and in fact beneficial, stopping it indefinitely could worsen her medical condition long term, unless replaced with an alternative agent that has little or insignificant drug interaction portfolio. Likewise, given patient’s history of advanced stage of HIV where the CD4 count remains low (400 u/L), discontinuation of Ritonavir therapy at this stage would be contraindicated.

One viable option in which patient continues therapy uninterrupted with minimal risk for toxicity would be to re-initiate Sildenafil at a much reduced frequency. Some recommend reducing maximum dosage of Sildenafil to 25mg in any given 48-hour period (I & II)

Drug-Drug Interaction Details
Concurrent use of RITONAVIR and SILDENAFIL may result in an increased risk of sildenafil adverse effects (hypotension, syncope, visual changes, priapism).
Clinical Management:
Ritonavir may increase the bioavailability of sildenafil. Due to lack of a safe and effective dose recommendation, concurrent use of sildenafil (as Revatio®) and ritonavir is contraindicated in patients treated for pulmonary arterial hypertension (PAH)(II).
Monitor for increased incidence of sildenafil adverse effects, such as headache, flushing, visual disturbance, hypotension, syncope, and priapism.
Probable Mechanism:
inhibition of CYP3A4-mediated sildenafil metabolism

Looking for more free education you won’t find in a text book? Please check out my 30 medication mistakes I see in my practice as a clinical pharmacist, a 6 page PDF I give away to subscribers! – Eric Christianson, PharmD, CGP, BCPS


  1. Hall MCS & Ahmad S: Interaction between sildenafil and HIV-1 combination therapy (letter). Lancet 1999; 353:2071-2072.
  2. Muirhead G, Wulff M, Fielding A et al: Pharmacokinetic interactions between sildenafil and saquinavir/ritonavir. J Clin Pharmacol 2000; 50:99-107.



Is This DVT a Case Where Warfarin Should be Used?

Fantastic Guest Post tonight coutesy:

Kishan Patel

Wilkes University

Pharm.D Candidate Class of 2016

28 yo F was admitted to hospital for osteomyelitis and developed a clot after PICC line insertion. Her PMH includes Cystic Fibrosis, malnutrition, no hx of malignancies, and no previous DVT. She is 5 feet tall and weighs 58lbs. She is currently taking Pulmozyne, Hypertonic saline nasal spray, Bactrim, fat soluble vitamins (A,D,E,K) and appropriate arrangements have been made to treat the osteo with IV abx for 8 weeks at her home. She produces appropriate amount of urine and her Scr has been stable for the length of her hospital stay. The attending has made a decision to start the patient on Warfarin with Enoxaparin bridge and have the PCP manage her condition on an outpatient basis once the patient reaches therapeutic INR goal.

photo courtesy Alisa Machalek
photo courtesy Alisa Machalek

Some considerations:

Is this patient a good candidate for Warfarin?

What should be the starting dose, duration, and goal INR? When would you like to recheck her INR?

Any there interactions? How should they be managed?

This patient is a good candidate for Warfarin since it does not heavily rely on renal elimination and has reversible agents available in the case of emergency. However, as a good pharmacist, one should keep in mind that this patient has a childbearing age, and Warfarin is category X. Asking questions like, “Are you pregnant, Are you planning to become pregnant?” should always be included in the Warfarin educational counseling.

Since this is her first provoked DVT without any hx of malignancy, she should be treated for 3 months with goal INR of 2—3. I would personally start this patient on 5mg once daily for three days, check the INR on day 3, and then readjust therapy as needed. Please realize that this patient is on Bactrim, which will increase the INR when concurrently used with Warfarin. In contrast, fat-soluble vitamins contain vitamin K, which will work directly against Warfarin and lower the INR. Stopping her fat-soluble vitamins would not be a good choice because of the risk of malnutrition. She is 28 year old and only weights 58lbs. Start Warfarin nice n’ low, and readjust the therapy as needed.

If you’re interested in educating healthcare professionals via a case you’ve seen, please contact me!

Warfarin mistakes definitely made the list of my 30 medication mistakes – a free 6 page PDF based upon my real world experiences as a clinical pharmacist - Subscriber here to get it now! – Eric Christianson, PharmD, CGP, BCPS

My One Minute BCPS Study Guide

A few folks out there have created a BCPS study guide that I was extremely grateful to have as I prepared to take and pass my exam.  I wanted to give you my most important tips for passing the BCPS exam.

Tip 1: This has been stated by many pharmacists, but the key to passing this exam starts and ends with statistics.  In creating my practice exam, I felt like I had way too many study design/biostatistics/regulatory…questions, but just look at the percentage layout of the exam.  BPS lists that percentage as 25% of the exam.  That’s 50 out of 200 questions!  Don’t be caught off guard.

Tip 2: Know your weaknesses.  Creating a BCPS Study Guide should be individualized.  In my case, I am not an expert ICU or HIV pharmacist.  I hit those areas (along with statistics, did I get my point across in Tip 1!?) more than the rest.  Geriatrics is my baby, so I didn’t need to hammer that too hard :)

Tip 3: Study.  This is a simple one.  Any good BCPS study guide will have a heavy focus on the study aspect :)  In all seriousness, if it has been a while since you’ve been in school or have taken another certification exam, I would suggest you start studying sooner rather than later.  I believe that residents and younger graduates who did well in college will have an easier time getting into that groove.  They also may have an easier time being current on topics that they don’t use much in their practice versus the pharmacist that may not have intensely studied an HIV drug in 10-20 years.

Tip 4:  Answer every question! This is right from BPS website “It is to the candidate’s advantage to answer every question on the examination. There is no penalty in the scoring formula for guessing.”  You have to set a decent pace if you are a slow test taker and you have to answer every question!  I’m creating a 200 question practice exam to help you get a feel for how long the exam will take.

Tip 5: Odds are likely if you’ve been working clinically for a while, you will have a good grasp on basic lab values.  If you don’t know basic lab values, you will find yourself looking them up frequently which if you are a moderate to slow test taker may cost you dearly(see Tip 5).  I would suggest you memorize some basic ones if you haven’t already – BMP, CBC, LFT, and some of the major narrow therapeutic index drugs like phenytoin, digoxin, lithium etc.

The practice exam is nearing completion! – If you haven’t subscribed yet, please do so to be entered to one of 20 free BCPS practice exams I’m giving away!

Hope this one minute BCPS Study Guide will help you pass- Best of Luck and more info on this topic to come!  Please feel free to contact me if questions!

Interprofessional Medication Education