1. Pharmaceutical Care PlanHypercholesterolemia Cases PresentationPrepared By:Marwah Mamoon 2011-2012

2. What is cholesterol? - Cholesterol is an essential substance manufactured by most cells in the body. it is used to maintain cell wall integrity and for the biosynthesis of bile acids and steroid hormones. Other major lipids in our body are triglycerides and phospholipids. Since cholesterol is a relatively water-insoluble molecule, it is unable to circulate through the blood alone, so it along with triglycerides and phospholipids are packaged in a large carrier-protein called a lipoprotein . Lipoproteins are water soluble, which allows transportation of the major lipids in the blood. -Cholesterol is transported from the arterial wall or other extra- hepatic tissues back to the liver by HDL. Esterified cholesterol from HDL can be transferred to apolipoprotein B-containing particles in exchange for triglycerides. Cholesterol esters transferred from HDL to VLDL and LDL are taken up by hepatic LDL receptors or delivered back to extra-hepatic tissue where metabolized to LDL. LDL can be cleared by hepatic LDL receptors or can enter the arterial wall & contributing to atherosclerosis. 3. Hypercholesterolemia- Defined as elevated total cholesterol, low-densitylipoprotein (LDL) cholesterol, or triglycerides; a low high-density lipoprotein (HDL) cholesterol; or a combination ofthese abnormalities.- Hypercholesterolemia is typically due to a combinationof environmental and genetic factors.- Environmental factors include: obesity and dietarychoices.- Genetic contributions are usually due to the additiveeffects of multiple genes however occasionally may bedue to a single gene defect . 4. Case PresentationStep no.1: Gathering information & creating patient databaseA.H. male patient is 69 years old , weight 85 kg,height 163cm ,BMI (31.9 he is obese) ,married; has3 boys & 2 girls, his work is farmer, he lives inHawler Shortan, he admitted to Rizgari hospital in31/10/2011 ,his phone number is 07502747735, thename of his physician is Mohammad Sader aldinMahmoud, Complain of chest pain on exertion for 1week duration. Present illness: A known case of Diabetes mellitus of4 years duration , Ischemic heart disease of 2years,Hypertension of 1.5 year , present with chestpain on exertion lasted for 5-10 min associated withsweating ,relived by rest & sublingual nitroglycerin. 5. PAST MEDIACL HISTORY 1- Illness:Item 1 - Diabetes Mellitus.Item 2- Ischemic heart disease.Item 3- hypertension. - Heavy Smoker for 17 years duration, quitItem 4 smoking since 2003, 2pockets/ day. 2-Surgical history: Nil 3- Family history:+ ve family history of Diabetus mellitus and IHD 4- Social history: ex-smoker, not drinker. 6. Drug History (dhx) 1-clopidogrel75 mg1X1 tab. 2- Atorvastatin 10mg1X1 3- bisoprolol 5mg 1X14- lisinopril5mg 1X15- Metformin850mg1x26- Glibenclamide 5mg 1x1 7- Aspirin 100mg1x1 * Drug related problem: Nil 7. Lab. Investigation 1- Chemical examination:- Blood Urea*76.9 mg/dl (15-55)mg/dl- serum creatinine *1.44mg/dl(0.6-1.4)mg/dl- Glucose *152mg/dl(70-105) mg/dl-Troponin T *0.155ng/ml(0.0-0.03)ng/ml- CK-MB * 9.47ng/ml(1.35-6.73)ng/mlLipids profile:- Cholesterol*280mg/dl( less than 200 mg/dl)- S. HDL*29mg/dl ( more than 35 mg/dl)- T.G*210mg/dl (less than 150mg/dl)- LDL* 209 mg/dl(less than 100) 8. 2- Hematological examination:- Hb 13 g/dl (12.5-17.5) g/dl- MCV85 fl (76-100) fl- WBC7.64 X10^3/l(4-11) 10^3/l- NEU 5.07 66.3%(2-8)- LYM 2.0727.1% (1-4)- MONO0.374.8%(0.2-1)- EOS0.12 1.6%(0.1-0.5)- BASO0.020.2% (0.0-0.2)- PLT349 X 10^3/l(150-400) 10^3/l- ESR 16mm/hr(1 17) mm/hr 9. 3- Other examination:- Chest X-raynormal.- ECG *T inversion V2-V6.- Echo normal Left Ventricular Systolic function.- Ejection Fraction 61% (normal morethan 50%)- Ultrasound-ve ( normal gallbladder, spleen & liver, small renalcyst) 10. Name of Data from data Additional data forPresentproblem base problem better supportingmedication problem- Ischemic- CoronaryHeart artery diseasedisease - High blood 1- Control blood 1-clopidogrel- DiabeticSugarpressure.2- bisoprolol.- Hypertensio -2- Control 3-atorvastatinn Hypercholestesymptoms.4-lisinoprilrolemia. 3- Control DM5- aspirin.- High blood 4- Stop smoking6-metforminpressure.5- Avoid salty diet. 7- 6- Control lipid Glibenclamide profile. 11. Current treatment (Regimen)Name of drug Strength (Regimen)Indication Notes- Lisinopril 10mgTablet X1 - Bisprolol5mgTablet X1Morning beforemeal- Clopidogrel75mgTablet X1 - Heparin1cc (5000 IU)IV X4-Aspirin 100mg Tablet X1After meal- atorvastatin *20 mgTablet X1- Insulin 10 units1X3 Subcutaneously ,before meal- metformin500mg1X3Orally, aftermeal O22-4L / minNasal canalnitroglycerin0.4mg/ metered Repeated asSublingual doserequired 12. Step no.2: Identify the Problem*Subjective data: easy fatigue, palpitation,epigastric pain.*Objective data:-Observation: looking ill, sweating.-Vital signs: blood pressure 179/95 mmHg,Pulse rate: 100 BPM, temperature:37c ,respiratoryrate: 14 breaths/min.- Physical examination : well built, tachycardia,oldmale .- CNS: intact 13. Step no.3: Assessing the problem:* We should investigated the factors cause diseases& severity of diseases.Factors causeIHD Hyperchole diabetes hypertens sterolemiaiondiseases1-diabetes 2-Obesity 3-Physical inactivity 4-High blood pressure. 5-Smoking 6-Family history 7-Age 8-Gender 9-Hypercholesterolemia 14. Severity of diseases* Hypercholestrolemia: uncontrolled even takenatorvastatin 10mg/day* DM: uncontrolled even taken metformin & Glibenclamide* Hypertension: hes in stage II even taken lisinopril5mg/day.* IHD: low severity of unstable angina.(These are due to precipitation by smoking ,obesityand drugs). 15. Step no.4: Devloping the plan & Therapeutic goal: (1)- Essential Components of Therapeutic Lifestyle Changes (TLC) ComponentRecommendation LDL-raising nutrientsTotal fat range should be 2535% for most cases. Saturated fats Less than 7% of total calories. Dietary cholesterolLess than 200 mg/day. Therapeutic options for LDL lowering Plant stanols/sterols2 g/day Increased viscous1025 g/day (soluble) fiber Total calories Adjust caloric intake to maintain desirable bodyweight and prevent weight gain Physical activityInclude enough moderate exerciseto expend at least 200 kcal/day (2)- Control blood pressure (Less than 130/80 mm Hg) (3)- Control blood sugar (even with combination of 2 drugs but hes uncontrolled) 16. (4) Monitoring Aspirinlisinopril bisoprololclopidogrelEfficacy - Behring-blood - BP &HR. BehringparameterCoagulationpressure.- Glucose Coagulationmonitoring Timer (BCT)-renal functionlevel . Timer (BCT) - platelet test.- Lipid profile function -monitor K-- Wt. of Pat. analyzer level- LFT& RFT (PFA-100)Toxicity -epigastric- hypotension. -bradycardia- BleedingParameterpain.- renal function - Hypotension - Vertigomonitoring -peptic ulcer. impairment.- insulin - diarrhea -GIT - change the release & - Fatigue bleeding.taste. mask the -Headache. - coughsymptoms of -Muscle- hypokalemiahypoglycemia. aches. -angioedema- lipidemia-GIT symptoms. - nightmares - depression - fatigue 17. atorvastatinmetforminGlibenclamideEfficacy -Fasting lipid- Random Blood - Fasting bloodparameterprofile sugar or Fasting sugar .monitoring - Liver function test blood sugar .- Random Blood - HbA-1c test. sugar.- HbA-1c test.Toxicity - Muscle aches or - Lactic acidosis. - Hypoglycemiaparametermuscle weakness - gastric upset. - Increase weight.monitoring - Increase liver- Abdominal enzymedistension. - headache- Nausea. - gastrointestinal, - Headache. constipation, flatulence, dyspepsia and abdominal pain. 18. - Monitoring for ComplicationsEyes Dilated eye exam yearlyFeet should be examined at every visitUrinary microalbumin Yearly (5)Patient Education - Decrease salt intake. - Regular Exercise . - Avoid red meat. - Take your medication regularly. - Consult your physician if any problem occur. 19. Therapeutic goal (Objective) Short Time Goal:- Control blood pressure.- Control blood sugar.- Control lipid profile. (LDL) Less than 100 mg/dL , (HDL) Greater than 35 mg/dL, TG Less than 150 mg/dL.- Increase exercise tolerance near normal daily activity.- decrease attack of ischemia . Long Time Goal:- prevent complication of Ischemic diseases.- Maintain normal daily activity. 20. Step no.5: Evaluation the achievement ofoutcomes:1. Blood pressure & blood sugar control.2. Weight reduction.3. Fewer physician office visit.4. Elimination of adverse effects.5. Maintain activity which enhanced patientquality of life that limited by disease.6. Cost of medication control. 21. References:1- Patient information file from Rizgari hospital.2- pharmaceutical care plan arrangement fromour hospital ward lectures.3- Pharmacotherapy principles and practice,MacGraw-Hill-medical book ,ed.2008,ch9.4- BNF formulary57,march 2009.5- Pharmacotherapy handbook, 7th edition, ch9.6- American diabetes association,http://spectrum.diabetesjournals.org/content/16/1/41.full7- http://srspharma,Indian manufacturingcompany.