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                                                       Medication Therapy Management Services

                                                440 North Second St., P.O. Box 1288, Eunice, LA 7053

                                          Phone (337) 457-4604 Fax (337) 546-0900 Cell (337) 344-2297

                                                        Charles S. Feucht, PharmD, FASCP

                                                              Senior Care Clinical Pharmacist

Patient Profile for: RMMF

Personal Information

Patient ID: 101509RMMF

Physicians: xxxxxxxx, MD,

xxxxxxxxx, MD, Cardiologist,

xxxxxxxxx, MD, Nephrologist

Patient Name: RMMF


City: xxxxxxxx

State: xx

Zipcode: xxxxx

Country: USA

Phone: xxxxxxxxx


Medical Information


Diagnosis: Medical Records were not requested from MD Hx & limited laboratory results supplied by daughter.





Limited scleroderma





Heart rate irregular and average bpm in low 60’s

Hx Atrial fibrillation

9-09-09 sinus bradycardia with PAC\'s on EKG

PR interval was .26 seconds



General complaints not listed as diagnosis:

Weight on 9/1 was 99.5# and 9-29-09 at 112# as of 10-15-09 at 109#

Scleroderma and edema in legs improved some since my visit to her home on October 8, 2009.

Intermittent pneumatic compression boot applications were increased to three times daily

Patient improved pain as of 10-15-09

Remains SOB

Allergies: No known allergies reported

Current Routine Medications:

Cardizem® 120 mg 1 tab by mouth daily

Cozaar® 25 mg1 tablet by mouth daily for Raynaud’s symptoms

Zocor® 20 mg 1 tab by mouth daily

ASA 81 mg every other day

Vitamin D 1.25mg 1 capsule daily by mouth

Levothyroxine 0.125mg(125mcg) 1 tablet by mouth daily

Torsemide 40mg 1 tablet by mouth daily

KCL 10 meq 1 po q day discontinued by Nephrologist since placed on Aldactone.

Aldactone® – 25mg 1 tablet by mouth daily

Multiple vitamin 1 tablet by mouth daily

Calcium500mg with Magnesium 250mg tablet by mouth daily with breakfast

Prilosec® 20mg 1 tablet by mouth daily.


As Needed Medications


Melatonin 3mg 1 by mouth at bedtime as needed for sleep.

Nitrobid® cream ½” to foot or hand as needed for Raynaud symptoms

Nasacor®t spray 1 puff to each nostril as needed

Refresh® eye drops to both as needed for dryness.

Normal saline spray to nostrils four times daily as needed for dryness and congestion.

Afrin® Nasal Spray for nosebleeds as needed.

Cholestyramine 4Gms in liquid for soft stools as needed.

Benfiber® twice daily in liquid or food as needed for constipation.

Dosing considerations:


88 y/o White Female

DOB: 1112-1921 Age: 88

Ht: 59” Wt: 99-111 lbs

Ideal Body Weight: 104 lbs.

Body Surface area: (Dubois) 1.37m2

Serum Creatinine: 1.4 to 2.2mg/dl

Estimated Creatinine Clearance: 13.3 - 21.7ml/min

(Cock-croft Gault )



Pharmacology Review and recommendations:

Initial review & assessment:

This 88 year old female presents with the above listed diagnosis and pertinent complaints obtained from her

daughter provided history. From interview with the daughter there is evidence of antidiuresis (loss of diuretic

effects with furosemide) with diuretic therapy changed to torsemide. Her renal (kidney) function is significantly

impaired as evidenced by a calculated estimated creatinine clearance (GFR- CrCl ) in the range of 13.3 to


The initial interview with Mrs. McGee’s daughter on 9-29-09 revealed the following facts:

Above listed diagnosis, loss of diuretic effectiveness with furosemide, and elevated BUN and creatinine levels

of BUN in the high 50s and creatinine levels ranging from 1.7-2.2 indicating acute renal failure and CKD. On 9-

23-09 she was change to torsemide. I fully agree with this change in therapy.

The Lasix® is shorter acting than the torsemide. Torsemide is less prone to development of antiduresis

(the diuretic resistance the daughter refers to) than furosemide. It is also less potassium, and calcium wasting.

The daughter’s request at this time was what other drugs would I recommend to treat her edema, reduce her

shortness of breath and improve quality of life above what the patient is experiencing now. Also The patient’s

daughter asked if the torsemide and furosemide could continue to be taken together. She indicated they are not

interested in heroics and wishes to know what could be done to give her more comfort at this time.

My initial recommendations at that time were:

Stop the Cozaar® – the risk of angioedema is significantly increased in this patient with CKD.

Stop the Zocor® – the risk of rhabdomyolysis and acute renal failure is significantly increased with the

combination of this and the ARB (Cozaar®) which has not improved Raynaud’s symptoms. The combination of

diltiazem and Zocor® poses a significant risk of renal failure and rhabdomyolysis outweighing any benefit.

Diltiazem and statins have shown a significant drug-drug interaction resulting in inhibition of metabolism of the

statin due to interference with the 3A4 cytochrome P450 pathway.

Stop the ASA - at qod dosing the ASA is ineffective as a anti-platelet inhibitor not lowering thromboxane A2

levels enough to therapeutic value and more benefit for stroke prevention would be seen with Fish Oil.

Continue: torsemide - dose may need to be increased initially to overcome the impaired delivery of diuretics to

the site of action, which leads to decreased diuretic activity. This impaired response to the diuretic

may be overcome by using higher diuretic doses to increase the delivery of the drug to the

site where it acts (nephron). Then when response has improved the dose can be lowered in 2-3 weeks

after the removal of Cozaar® and Zocor®.

Continue: Cartia XT® (diltiazem extended release) at current dose of 120mg daily. Dose may need to be

reduced if the Prilosec® is continued or liver enzymes are elevated.

Add: Fish Oil capsules start at 1200mg once daily if tolerated increase to twice daily for stroke prevention.

Add: Folic acid 1mg daily.

Add: Pain meds if needed Ultram® 50mg 1 po q8hrs for moderate to severe pain, Acetaminophen 325mg q8h

( These doses should not be exceeded due to current renal function. )

Add: Vitamin B12 1000mcg IM weekly x 6 weeks then monthly

Since my visit with the patient the nephrologists has discontinued her KCL and added spironolactone.

My recommendation concerning this issue as of 10-16-09:

If a combination of diuretics is necessary then metolazone (Zaroxolyn®) which is still effective at creatinine

clearance rates of 20ml/min would be a reasonable choice. It also provides a diuretic which acts at a different

site than the loop diuretic. The recent addition of the spironolactone while generally a good choice for CHF

patients even though the KCl supplement has been discontinued still poses a significant risk of development of




Specific Medication change recommendations since patient home visit with the patient and her daughter

on 10-8-09:


Drug Recommended changes:

Cartia XT® 120mg Continue this medication as is

Zocor® 20mg daily Stop – its my understanding this has already been held subsequent to my

initial recommendations.

Aspirin 81mg qod Stop - its my understanding this has already been held subsequent to my

initial recommendations.

Cozaar® Stop – its my understanding this has already been held subsequent to my

initial recommendations.

Prilosec® Begin discontinuation process. (See below)

Torsemide Continue at 40mg q day this should become more effective within two

week of discontinuation of the Cozaar and Zocor. If diuresis is still not at

level needed consider adding low dose metolazone (Zaroxolun ) 2.5mg

daily or increasing torsemide dose.



Calcium carbonate/magnesium to a calcium citrate product – carbonate forms

require an acidic stomach for proper absorption. Use along with Prilosec prevents absorption of

the calcium and increase the risk of forming a complex with levothyroxine and decreasing the

levothyroxine absorption. Calcium citrate is absorbed regardless of an acidic or basic stomach.




Fish Oil capsules Start at 1200mg once daily if tolerated increase to twice daily for stroke

prevention. (If nausea is a problem store capsules in freezer and take with

a meal.)

Folic acid 1mg daily.

Vitamin B12 1000mcg IM weekly x 6 weeks then monthly –

PRN (as needed ) Pain meds:

Ultram® 50mg 1 po q8hrs for moderate to severe pain.

Acetaminophen 325mg q8h for mild to moderate pain.

( These doses should not be exceeded due to current renal function. )

Additional recommendations:


? The only laboratory values available were a BMP, CBC, TSH and urinalysis

Because the patient was on a statin it is important to know the liver function as this will

effect diltiazem plasma levels and appropriateness of dosing for the calcium channel


? Separate calcium/magnesium supplement from the levothyroxine by at least 4-8 hours to prevent

calcium from blocking absorption of levothyroxine and be sure that the levothyroxine is taken with

lots of water to prevent the possibility of it swelling and choking the patient.



Prilosec® suggested discontinuation process:

Change Prilosec® to ac breakfast for the next 2 weeks this will make it more effective and then allow

the discontinuation process to begin.

PPIs(proton pump inhibitors) need to be given during the longest fasting state to enhance effectiveness

as this is when the greatest number of proton pumps in the GI lining are activated. Consider weaning of

this product if possible by implementing the following as long term use of PPI’s poses the following


? Incidence of C. difficile diarrhea is 3 times higher for patient on long term PPI therapy and twice as high

for patients on H2 antagonist long term than control patients on neither.

? Rebound acidity –from the body’s attempt to regain the low gastric pH and through more

gastric acid secretions exacerbating the GI condition

? Aspiration Pneumonia risk are increased - raising the pH of the gut for long times produce

a basic gut that complicates digestion, increase more gas and discomfort, slows down the breakdown of

foods and many drugs and increases potential risk for aspiration of this basic fluid into the lungs.

Discontinue the Prilosec® after changing it to before breakfast daily for the next 2 weeks. Start

Pepcid ® OTC 20mg by mouth every other day at bedtime or Zantac® 75mg every other day at

bedtime for 1week then discontinue it.(available over-the –counter).

(Note this is a maintenance dose and these product unlike the PPI’s should be given at bedtime when

used as maintenance dose.) Also implement the following non-drug interventions.

? Prohibit spicy and difficult to digest foods at or after the evening meal

? Have patient consume either 3 oz buttermilk and saltine crackers or a container of plain yogurt

(Rationale behind switching to short term titration with H2 antagonist – allows for successful titration without acid rebound problems necessitating

return to PPI therapy –long term use of H2 antagonist not recommended as these agents have higher anticholinergic properties and same risk as long

term PPI use.)


Please remember it will take sometime for the medication changes to produce beneficial results.

Both the discontinuation of medications and the addition of new medications will not show immediate

results but over time should begin to alleviate some of the problems you are now having and reduce the

risk of potential problems. Let me remind you that this drug therapy regimen is thoroughly

thought out and should be followed in its entirety. Choosing only bits and pieces of it may keep us

from reaching our mutual goal of improvement in your quality of life and health.

This new regimen is designed to avoid potential additive side effects and drug-drug interactions.

Piece-meal changes can result in significant side effects or drug interactions.

I am as close as your phone, so if problems occur please call me. I look forward to seeing

both you and your mother in her home for a follow-up visit around the end of November

but would like a progress report by the end of October by phone. However, if you have any problems

questions or concerns please don't hesitate to call.


Sincerely, Charles S. Feucht, Pharm D, FASCP












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