Readiness Tool (Pre-Application)

While the role of pharmacists is to focus on medication related matters, there is a requirement to understand common disease processes and their consequences. This is because some symptoms may appear to be related to medications, but could be due to underlying disease processes.

In this question, the symptoms of positional shortness of breath (orthopnoea) and the sudden onset of nightime shortness of breath (paroxysmal nocturnal dyspnoea) are classical symptoms of worsening heart failure. Thus option a) is incorrect (in fact the metoprolol is probably helping his shortness of breath by improving his heart failure). Option b) does not address the cause of the problem and the fact that salbutamol was effective for his nightime shortness of breath was more likely to do with his getting out of bed (changing his position to upright), rather than any effect of the salbutamol. Option c) may actually worsen the situation as prednisolone may contribute to fluid and sodium retention. Option d) is the only option that addresses the most likely cause of the problem and is the correct answer.

Many drug regimens contain multiple drug interactions. One of the clinical skills required as an accredited pharmacist is to be able to determine which of the drug interactions are more important. Those interactions that are more important are those that are having an impact on the patient in terms of signs (measurable things) or symptoms (what the patient tells you) or have a significant potential to do so.

In this question, the INR is normal but there is a degree of bradycardia (52 bpm) and some associated lethargy. Thus, although drug interactions with warfarin are always of concern, in this case, the drug interactions that may be present relating to warfarin (amiodarone and possibly diltiazem) are of less concern as the INR is normal. On the other hand, any interactions that impact on heart rate are more important as they may be contributing to the bradycardia and lethargy. Options b), c) and d) are examples of drug interactions that all may produce bradycardia. The correct answer is option a) as although there is an established drug interaction between amiodarone and warfarin, the situation is stable as evidenced by the appropriate INR.

In a medication review process, it is common to identify multiple issues in a particular case. One of the clinical skills that is required as an accredited pharmacist is being able to prioritise medication related issues. Most often, the issue with the greatest importance is the issue that the patient identifies as their main problem. Addressing the issue(s) that the patient identifies, makes the recommendations from the medication review “patient centred” and more likely to have an impact on the patient’s wellbeing.

In this question, the patient has a desire to lose weight (motivated by the “threat” of insulin) but is held back (at least partially) by knee pain. A high priority should therefore be placed on any recommendations that facilitate exercise and/or weight loss. Option a)- stopping the aspirin-would not impact on her quality of life or her weight/exercise capacity. Similarly, option c)- reducing the statin dose- may not result in any symptomatic improvement. Option d)- starting a sulphonylurea- may actually contribute to weight gain and it is highly likely that she has tried a sulphonylurea before. There is also the issue of beta cell failure to consider with sulphonylurea use, and this class may no longer be effective in this lady. Option b)- increasing her paracetamol dose- is the only option that has the potential to reduce her knee pain and would be the highest priority in this case.

In order to provide appropriate patient centred medication related recommendations, the overall clinical situation and the goals of care for individual patients should be taken into consideration. One of the clinical skills required as an accredited pharmacist is the ability to “look at the big picture” and ensure that any suggestions made are in keeping with the overall situation. In this case, the “big picture” is an elderly, debilitated man with a limited prognosis, who is relatively comfortable as his symptoms are being managed well, albeit with a large number of medications.

In this question, option a)- increasing the intensity of his near maximal heart failure management- may result in an improvement in his symptoms. However, these do not seem to be of major concern as the shortness of breath is rated as mild. Option b)- ceasing the laxative- is inappropriate given his bowel function is good. Option d)- stopping one of the antidepressants- should be considered in light of the purpose of the combination. Mirtazapine taken at night may be helping with sleep and any anxiety issues, while the escitalopram may be of use more specifically for mood. In the absence of any specific adverse effects and given the fact that he is well and comfortable, stopping one of these agents may result in either disturbed sleep or worsened mood. Option c) –stopping the stroke prophylaxis- seems in keeping with the palliative nature of his goals of care and would be the most appropriate option of the ones given.