| Relevant Evaluation Criteria | Scenario/Model Outcome | |
| Information Gathering | ||
| 1. Gather essential information about the patient’s symptoms, including: | ||
| a. description of symptom(s) (i.e., nature, onset, duration, severity, associated symptoms) | Patient reports that his cholesterol level has not decreased quite as much as needed, and that his PCP has given him a new prescription for an increased dosage of simvastatin. “I just need to comedown 8 or 10 more points.” | |
| b. description of any factors that seem to precipitate, exacerbate, and/or relieve the patient’s symptom(s) | None | |
| c. description of the patient’s efforts to relieve the symptoms | He follows a low-fat, low-cholesterol diet and exercises regularly. He also takes fish oil 3 g/day. | |
| 2. Gather essential patient history information: | ||
| a. patient’s identity | Robert John Nellsen | |
| b. patient’s age, sex, height, and weight | 67-year-old male, 6 ft 1 in, 186 lb | |
| c. patient’s occupation | Retired building contractor | |
| d. patient’s dietary habits | Low-fat, low-cholesterol diet | |
| e. patient’s sleep habits | He usually gets 7.5-8 hours of sleep per night; has insomnia 4-5 times per year. | |
| f. concurrent medical conditions, prescription and nonprescription medications, and dietary supplements | Stage 1 HTN, well controlled on hydrochlorothiazide 12.5 mg every day
Mild knee and right shoulder osteoarthritis, treated with as-needed ibuprofen and/or APAP |
|
| Centrum Silver 1 tablet every day | ||
| Enteric-coated fish oil 1 gram 3 times/day | ||
| Simvastatin 20 mg every day | ||
| g. allergies | NKDA; no known food or plant allergies | |
| h. history of other adverse reactions to medications | Intolerant of erythromycin (severe nausea and vomiting, requiring change in antibiotic) | |
| i. other (describe) | Patient comes to your pharmacy counter with two products, red yeast rice and garlic. He says that he does not want to increase his simvastatin dose, because when he was on a 40 mg dose several years ago, he felt quite fatigued much of the time. He wants to know which of the two natural medicines would be better for him to take to get his cholesterol down a little lower. | |
| Assessment and Triage | ||
| 3. Differentiate the patient’s signs/symptoms and correctly identify the patient’s primary problem(s). | Hyperlipidemia, uncontrolled
Osteoarthritis, mild and adequately treated with as-needed medications Hypertension, controlled Lack of education regarding dietary supplements |
|
| 4. Identify exclusions for self-treatment. | None | |
| 5. Formulate a comprehensive list of therapeutic alternatives for the primary problem to determine if triage to a medical practitioner is required, and share this information with the patient. | Options include:
(1) Continue the simvastatin and add garlic. (2) Stop simvastatin and begin red yeast rice. (3) Increase simvastatin dose and add coenzyme Q10 (CoQ10). (4) Take no action. |
|
| Plan | ||
| 6. Select an optimal therapeutic alternative to address the patient’s problem, taking into account patient preferences. | Fill prescription for increased simvastatin dosage and add CoQ10. | |
| 7. Describe the recommended therapeutic approach to the patient. | Simvastatin is known to decrease CoQ10 levels. This effect may be associated with side effects such as the fatigue he experienced with the 40 mg dose taken previously. Increasing the simvastatin will be the most effective way for him to decrease his cholesterol levels to the desired goal, and taking the CoQ10 may help him tolerate the medication better.
Encourage continuance of low-fat diet and regular exercise for control of hyperlipi-demia and HTN. |
|
| 8. Explain to the patient the rationale for selecting the recommended therapeutic approach from the considered therapeutic alternatives. | The red yeast rice product contains a statin very similar to the simvastatin that he is currently taking, so it would not be appropriate to take these together. Also, the red yeast rice alone may not provide a large enough cholesterol-lowering effect to maintain his present levels, much less decrease them further.
The evidence for garlic does support lipid-lowering effects, although the reductions are probably limited to about 5%. |
|
| Patient Education | ||
| 9. When recommending self-care with nonpre-scription medications and/or nondrug therapy, convey accurate information to the patient: | ||
| a. appropriate dose and frequency of administration | CoQ10 100mg/day | |
| b. maximum number of days the therapy should be employed | During time patient is on simvastatin | |
| c. product administration procedures | You may take the CoQ10 with meals if any gastrointestinal upset occurs. | |
| d. expected time to onset of relief | ||
| e. degree of relief that can be reasonably expected | You should monitor for occurrence of excessive fatigue after increasing the simvastatin dosage. | |
| f. most common side effects | ||
| g. side effects that warrant medical intervention should they occur | ||
| h. patient options in the event that condition worsens or persists | If he still experiences intolerable fatigue on the 40 mg dose of simvastatin, consider a recommendation to the physician to decrease the dosage back to 20 mg, and add garlic, a standardized product providing allicin about 4 mg/day. | |
| i. product storage requirements | Keep product in an appropriate storage area away from excessive heat and moisture, and out of reach of children and pets. | |
| j. specific nondrug measures | After choosing an appropriate, high-quality product, maintain therapy with that same product. | |
| 10. Solicit follow-up questions from patient. | Does it matter what brand I buy? | |
| 11. Answer patient’s questions. | Some products may not contain the stated amount of coQ10. It is a good idea to buy a product that has a quality assurance seal of approval (such as “U.S. Pharmacopoeia Verified”) or that is listed on www.consumerlab.com as having passed tests to confirm appropriate amounts. | |
Archive for December, 2011
Assessment of Patients Who Are Considering Use of a Natural Product
Comments Off
December 21, 2011 at 2:47 pm