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Mastering pharmacy case studies.

Introduction

If you are training to become a pharmacist, you will have had experience with pharmacy case studies. But why are pharmacy case studies so important?

As a qualifying pharmacist, case studies bring together the threads of study over the past four years. This includes your study of subjects such as:

• Pharmacology
• Pharmaceutical chemistry
• Pharmaceutics
• Clinical pharmacy practice

In practice, pharmacists are expected to draw on this knowledge and clinically apply it where necessary. These subjects feed into one another where knowledge of one subject became necessary to advance in a second subject and so forth. University staff overseeing the course structure put that structure together with these factors in mind. Pharmacy case studies are an important component, often toward the end of your pharmacy degree, that aim to establish the most relevant details that play a role in the career of a qualified pharmacist.

Case studies give pharmacy students an opportunity to test their understanding of a specialist topic. This may be anything from the formulation and dosing of medicines; to a drug’s mechanism of action, drug interactions, and clinical appropriateness for a medicine in a given scenario for a patient with specific factors to keep in mind. Evidently, this takes practice. There are many possible case study scenarios to consider. It can be difficult to always get things right.

Case studies are, then, a special kind of barometer through which we measure the professional competency of pharmacy students .

That is why pharmacy case studies are popular in degree programs – forcing students to think critically about a given topic – whether it be blood diagnostics, epidemiology, treatment options, or drug monitoring – tying together their past year’s study and how to apply this knowledge to (potentially) real-life situations.

Below, we’ve put together an introductory case study to provide you with a clear example of what kinds of questions can be asked and how best you should approach each question. With enough practice, clinical case studies become that much easier. And with time, students learn to enjoy case studies – as they are often your first direct experience of learning real and relevant facts that have an impact on your long-term professional career.

Pharmacy Case Study – Osteoporosis

A 49-year old woman with osteoporosis has been taking Fosamax for 6-months. She visits her GP complaining of acid reflux and pain radiating down her esophagus.

• What is the active ingredient of Fosamax?
• What is the mechanism of action of this medicine?
• Suggest a reason why this patient is taking Fosamax.
• How should the GP respond to the patient’s symptoms?
• What foods and/or medicines should the patient avoid?

Explanation

The questions ask more about the medicine – how it works, what it’s indicated for, how the GP should respond to patient symptoms and what interactions, from both food and drug sources, the prescriber and pharmacist must consider.

A – The active ingredient of Fosamax is alendronate; a bisphosphonate drug.

B – Alendronate works by inhibiting osteoclast-mediated bone resorption (the process whereby bone is broken down and minerals are released into the blood).

C – As a 49-year old woman, the patient is likely post-menopausal. Bisphosphonates are routinely prescribed to prevent osteoporosis in these patients.

D – The patient may be improperly administering the medicine. Patients who do not follow the correct protocol of administering bisphosphonates are likely to experience specific symptoms, particularly relating to the esophagus and GI tract. Patients should be counseled to take the medicine in the morning on an empty stomach, whilst remaining upright, and taken with a full glass of water. This eases the bisphosphonate through the digestive tract without irritating the esophageal wall. Patients should avoid taking and food or medicines, both before and for at least 30-minutes after taking the bisphosphonate.

E – Two groups of medicines should be avoided. First, NSAIDs should be avoided; as they increase the risk of gastrointestinal side effects. Second, patients should avoid foods or supplements that contain multivalent ions such as magnesium, aluminum, or calcium. This category includes dairy products and antacids. As we learned above, bisphosphonates should be avoided with these medicines/foods for at least 30-minutes after the bisphosphonate has been taken (on an empty stomach).

Practice More Pharmacy Case Studies

The more pharmacy case studies you practice , the better prepared you are for the needs and demands that present during the licensing end of your pharmacy program. Pharmacy case studies help guide students through the must-know clinical facts about drugs and medicines; both theoretical and practical knowledge.

Clinical case studies are one of the ways in which students make the transition between an experienced, knowledgeable student and a clinical professional whose expertise can be trusted in the real world. Case studies bring pharmacy students to the next level. The more practice you put in, the better results you can expect as you progress through the licensing stage of your nascent career. That, in the end, is what matters.

That’s about it for our discussion of case studies! Check back to our pharmacy blog soon for more exclusive content to help you master the science of drugs and medicines and build your long-term career.

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Top 125 Drug Card Case Quiz

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Author(s): Jill M. Kolesar, PharmD, MS, BCPS, FCCP; Lee C. Vermeulen, BSPharm, MS, FCCP, FFIP

• 001 Case 001-Surgical Care
• 002 Case 002-Hypertension Case # 1
• 003 Case 003-Hypertension Case # 2
• 004 Case 004-Hypertension Case # 3
• 005 Case 005-Hypertension Case # 4
• 006 Case 006-Hypertension Case # 5
• 007 Case 007-Dyslipidemia Case # 1
• 008 Case 008-Dyslipidemia Case # 2
• 009 Case 009-Stable Ischemic Heart Disease
• 010 Case 010-Acute Coronary Syndromes
• 011 Case 011-Cardiovascular Respiratory Decompensation
• 012 Case 012-Chronic Heart Failure Case # 1
• 013 Case 013-Chronic Heart Failure Case # 2
• 014 Case 014-Venous Thromboembolism-Pulmonary Embolism Case # 1
• 015 Case 015-Venous Thromboembolism-Pulmonary Embolism Case # 2
• 016 Case 016-Stroke
• 017 Case 017-Arrhythmias
• 018 Case 018-Cardiac Arrest, Resuscitation
• 019 Case 019-Acne and Pediatric Dermatology Disorders
• 020 Case 020-Psoriasis
• 021 Case 021-Atopic Dermatitis
• 022 Case 022-Miscellaneous Dermatology
• 023 Case 023-Peptic Ulcer Disease, GERD Case # 1
• 024 Case 024-Peptic Ulcer Disease, GERD Case # 2
• 025 Case 025-Irritable Bowel Syndrome
• 026 Case 026-Diarrhea
• 027 Case 027-Constipation
• 028 Case 028-Crohn Disease
• 029 Case 029-Anemia
• 030 Case 030-CNS Infections
• 031 Case 031-Lower Respiratory Tract Infection
• 032 Case 032-Upper Respiratory Tract Infection
• 033 Case 033-Skin and Soft-Tissue Infections; Fungal (Multiple Patient Case)
• 034 Case 034-Infective Endocarditis
• 035 Case 035-Gastrointestinal Infections
• 036 Case 036-Intra-Abdominal Infections
• 037 Case 037-Urinary Tract Infection
• 038 Case 038-Skin and Soft Tissue Infection (Bacterial), Bone and Joint Infections
• 039 Case 039-Miscellaneous Bacterial Infections
• 040 Case 040-Sexually Transmitted Infections
• 041 Case 041-Sepsis and Septic Shock
• 042 Case 042-Fungal Infections Case # 1
• 043 Case 043-Fungal Infections Case # 2
• 044 Case 044-Viral Infections
• 045 Case 045-Parasitic Infections
• 046 Case 046-Infectious Endocarditis
• 047 Case 047-Viral Hepatitis, Hepatitis Vaccination
• 048 Case 048-Influenza and Influenza Vaccination (Multiple Patient Case)
• 049 Case 049-Foot and Nail Fungal Infection
• 050 Case 050-Vaccines Case # 1
• 051 Case 051-Vaccines Case # 2
• 052 Case 052-Travel Health (Multiple Patient Case)
• 053 Case 053-Human Immunodeficiency Virus Infection
• 054 Case 054-Systemic Lupus Erythematosus
• 055 Case 055-Solid Organ Transplantation
• 056 Case 056-Erectile Dysfunction
• 057 Case 057-Benign Prostatic Hyperplasia
• 058 Case 058-Attention Deficit Hyperactivity Disorder
• 059 Case 059-Substance Use Disorders (Opioids)
• 060 Case 060-Substance-Related Disorders (Alcohol, Nicotine)
• 061 Case 061-Schizophrenia
• 062 Case 062-Depression Case # 1
• 063 Case 063-Depression Case # 2
• 064 Case 064-Panic Disorder
• 065 Case 065-Bipolar Disorder
• 066 Case 066-Anxiety Disorders Case # 1
• 067 Case 067-Anxiety Disorders Case # 2
• 068 Case 068-Sleep-Wake Disorders
• 069 Case 069-Diabetes Mellitus (Type 2) Case # 1
• 070 Case 070-Diabetes Mellitus (Type 2) Case # 2
• 071 Case 071-Diabetes Mellitus (Type 2) Case # 3
• 072 Case 072-Thyroid Disorders
• 073 Case 073-Obesity
• 074 Case 074-Migraine Headache
• 075 Case 075-Critical Care Pain, Agitation, Delirium
• 076 Case 076-Alzheimer Disease
• 077 Case 077-Multiple Sclerosis
• 078 Case 078-Epilepsy Case # 1
• 079 Case 079-Epilepsy Case # 2
• 080 Case 080-Parkinson Disease
• 081 Case 081-Pain Management Case # 1
• 082 Case 082-Pain Management Case # 2
• 083 Case 083-Pain Management Case # 3
• 084 Case 084-Brain Cancer
• 085 Case 085-Breast Cancer
• 086 Case 086-Lung Cancer
• 087 Case 087-Colorectal Cancer
• 088 Case 088-Prostate Cancer
• 089 Case 089-Hodgkin Lymphoma
• 090 Case 090-Lymphoma
• 091 Case 091-Acute Myeloid Leukemia
• 092 Case 092-Chronic Lymphocytic Leukemia
• 093 Case 093-Multiple Myeloma
• 094 Case 094-Myelodysplastic Syndrome
• 095 Case 095-Renal Cell Cancer
• 096 Case 096-Melanoma
• 097 Case 097-Ovarian Cancer
• 098 Case 098-Chemotherapy-Induced Emesis
• 099 Case 099-Cancer Pain
• 100 Case 100-Stem Cell Transplant
• 101 Case 101-Idiopathic Thrombocytopenic Purpura, Thrombotic Thrombocytopenic Purpura
• 102 Case 102-Glaucoma
• 103 Case 103-Bacterial Conjunctivitis
• 104 Case 104-Allergic Conjunctivitis
• 105 Case 105-Asthma Case # 1
• 106 Case 106-Asthma Case # 2
• 107 Case 107-Allergic Rhinitis Case # 1
• 108 Case 108-Allergic Rhinitis Case # 2
• 109 Case 109-Chronic Obstructive Pulmonary Disease
• 110 Case 110-Osteoarthritis
• 111 Case 111-Rheumatoid Arthritis
• 112 Case 112-Osteoporosis
• 113 Case 113-Gout
• 114 Case 114-Urinary Disorders – Male
• 115 Case 115-Urinary Disorders – Female
• 116 Case 116-Menopause Care
• 117 Case 117-Menstruation-Related Disorders
• 118 Case 118-Contraception
• 119 Case 119-Obstetric Care
• 120 Case 120-Family Medicine Case # 1 (Multiple Patient Case)
• 121 Case 121-Family Medicine Case # 2 (Multiple Patient Case)
• 122 Case 122-Family Medicine Case # 3 (Multiple Patient Case)
• 123 Case 123-Family Medicine Case # 4 (Multiple Patient Case)
• 124 Case 124-Family Medicine Case # 5 (Multiple Patient Case)
• 125 Case 125-Family Medicine Case # 6 (Multiple Patient Case)

Pharmacy Client Case Studies

See what clients have to say about our work and process. These case studies dive deep into problems pharmacies face, our solutions, and the short-and-long-term results that Digital Pharmacist’s clients are seeing.

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Prescription Mart is a specialty pharmacy that is owned by a PBM. Their pharmacy’s vision is “to provide customized clinical care to each patient and a personal touch to prescription delivery to create relationships that lead to better health.” Prescription Mart has over a dozen employees that actively fill prescriptions using DP’s automation tools and patient engagement platform. Prescription Mart is based out of Beaumont, Texas, but ships all across the country and has operated as a mail-order pharmacy since 1994. Other services this pharmacy offers includes Medication Synchronization and Medication Therapy Management.

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Interactives: Case Studies (January 2021)

Two interactive case studies are presented in the January 2021 issue of Pharmacy Times®.

RJ is a 68-year-old man with type 2 diabetes (T2D) who calls the pharmacy with concerns about hyperglycemia. His fasting blood glucose level increased to more than 200 mg/dL from an average of 133 mg/dL over the past week. Prior to this week, RJ’s blood sugar levels were greatly improving ever since he lost 8 lb. He noticed his blood sugar levels rising a week ago, after he started tamsulosin 0.4 mg daily, which was prescribed by his primary care physician (PCP) to help with his urinary symptoms. No other medications were started or discontinued during that time. RJ says that his PCP had never heard that this medication causes hyperglycemia but suggested that he call the pharmacy team to further inquire.

How should the pharmacist respond to RJ?

The pharmacist on duty at a local community pharmacy is working with AF, a pharmacy intern in his second professional year of pharmacy school. AF tells the pharmacist that he just finished reading the DAPA-CKD trial1 for his upcoming journal club presentation. He read the results and noted that the number needed to treat (NNT) for the primary outcome (eg, sustained decline in estimated glomerular filtration rate of at least 50%, end-stage kidney disease, or death from renal of cardiovascular cases) was 19. AF is unsure what this means and how it was calculated, as he missed his drug literature and evaluation class last week. The pharmacist reviews the results section of the paper and notes that over a median of 2.4 years, the primary outcome occurred in 197 of 2152 participants (9.2%) in the dapaglifloizin group and 312 of 2152 participants (14.5%) in the placebo group [HR, 0.61 (0.51-0.72); P < .001]. 1 AF asks the pharmacist to explain this concept to him.

What should the pharmacist tell him?

CASE 1: Hyperglycemia is not a listed adverse effect in the package insert for tamsulosin. There are, however, documented case reports suggesting that the 2 may be linked. 1 These reports note that hyperglycemia was induced 1 to 2 days after the initiation of tamsulosin in patients with T2D. Discontinuation led to full resolution of symptoms. It has been suggested that α1 receptors can contribute to glucose uptake through non-insulin—dependent pathways. 2 By blocking these peripheral receptors, glucose uptake is hampered. RJ should be screened to ensure that no other identifiable causes, such as illness, infection, or stress, can be contributing to his hyperglycemia. His PCP can recommend that RJ hold the dose of his tamsulosin for a few days to see whether his glucose levels return to normal.

• Borgsteede S, Bruggeman R, Hoefnagel R,M Huiskes, van PuijenbroekE. Tamsulosin and hyperglycaemia in patients with diabetes. Neth J Med . 2010;68(3):141-143.
• Boyda HN, ProcyshynRM, Pang CCY, Barr AM. Peripheral adrenoceptors: the impetus behind glucose dysregulation and insulin resistance. J Neuroendocrinol . 2013;25(3):217-228. doi:10.1111/jne.12002

CASE 2: The pharmacist can teach AF that the NNT is the number of patients who need to be treated with a specified intervention/drug for 1 patient to benefit from it. So in this case, 19 patients need to be treated with dapagliflozin over 2.4 years for 1 patient to benefit. The NNT is the inverse of the absolute risk reduction (ARR) and is calculated as NNT = 100/ARR (%).

The ARR is the absolute difference in outcome rates between the control group (14.5%) and the treatment group (9.2%). In this case, the ARR is 5.3%. Therefore, the NNT is 100/5.3 =18.867. Because NNTs are normally rounded up to the nearest whole number, the NNT for this trial would be 19.

• Heerspink HJL, Stefánsson BV, Correa-Rotter R, et al; DAPA-CKD Trial Committees and Investigators. Dapagliflozin in patients with chronic kidney disease. N Engl J Med. 2020;383(15):1436-1446. doi:10.1056/NEJMoa2024816

STEFANIE C. NIGRO, PHARMD, BCACP, CDE , is an assistant professor/clinical pharmacist at Massachusetts College of Pharmacy and Health Sciences in Boston.

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