What are the pharmacotherapy review steps?
- Gather relevant patient information
- Interpret information to identify actual or potential problems
- Develop a prioritised problem list
- Consider possible treatments and their appropriateness for the individual patient and individual patient goals
- Make a plan for treatment
- Describe the required follow up
What are the types of patient information?
- demographic
- ability to communicate
- presenting complaint & diagnosis
- past medical history
- social/lifestyle history
- allergies
- lab and diagnostic tests
- physical exam
- medication history
Medication related problems - DOCUMENT
D - drug selection
O - over or underdose prescribed
C - compliance
U - undertreated
M - monitoring
E - education or information
N - not classifiable
T - toxicity or adverse reaction
What are some key reasons for testing?
- assess the appropriateness of drug therapy
- assess drug adverse effects/toxicity
- monitor therapeutic effect
- compliance
Why is it not appropriate to give pure water in IV?
As the cells contain lower levels of ions, the water will move into the cell more and cause it burst
How to treat water imbalance - Depletion
- oral water if possible
- if oral is not possible then IV with glucose 5% or with sodium 0.9%
How to treat water imbalance due to Excess
- remove the cause
- consider fluid restriction
- some diuretic drugs
What are some symptoms of hyponatraemia (135-145mmol/L)
- usually asymptomatic until <125mmol/L
- Nausea
- headache
- hypervolaemia = oedema
- lethargy
- confusion
- muscle cramps
How is hyponatraemia classified?
according to Extra-Cellular Fluid status
What are the 3 ECF status?
- Hypovolaemic
- Euvolaemic
- Hypervolaemic
Causes of Reduced ECF = Hypovolaemic
- GIT loss = diarrhoea, vomiting
- Poor water intake
Causes of normal ECF = Euvolemic
- SIADH
- adrenal insuff.
Causes of increased ECF = hypervolemic
- congestive cardiac failure
- cirrhosis
- drugs = NSAIDs or corticosteroids
What are some medications can cause SIADH?
SSRIs, SNRIs and carbamazepine
What is an important consideration when treating Chronic Hyponatraemia?
can produce permanent CNS injury due to osmotic demeythlination
Describe the features of Hypernatraemia
- mild to moderate 145-159mmol/L
- rare occurance of sodium gain
What are some symptoms of Hypernatraemia?
- thirst
- restlessness
- confusion
- muscle twitching
- seizures
- coma
What are some treatment options for Hypernatraemia?
- correct cause
- oral fluid replacement with water
- IV fluid without sodium = may require 5% glucose
- If SEVERE = medical emergency + ICU
- If CHRONIC = replace water GRADUALLY as this can be a risk for cerebral oedema
Describe the features of Hyperkalaemia
MILD = 5.1 - 5.9mmol/L
MODERATE = 6.0-6.4mmol/L
- most serious electrolyte emergency
How is true excess of Hyperkalaemia caused?
drug induced, increased input or decreased output
How is apparent excess of Hyperkalaemia caused?
- metabolic acidosis
- insulin deficiency
- digoxin toxicity
- cell lysis
What are some signs and symptoms of Hyperkalaemia?
- muscles weakness
- paraesthesia
- palpitations
- dyspneoa
- bradycardia
- ECG changes
- cardiac arrest is possible
What is the treatment for Hyperkalaemia?
- If Asymptomatic consider = pseudohyperkalaemia
- remove or withhold drugs that contain potassium or causing this hyperkalaemia
- low potassium diet
- increase in renal potassium elimination = diuretic
How to treat severe or life-threatening Hyperkalaemia?
- protect heart
- reduce serum potassium level
- IV insulin and glucose infusion - remove potassium from the body
- oral sodium = removes potassium from the bowel lumen
- haemodialysis
