DD is a 67-yr-aged male who has been hospitalized for the previous couple months for complications similar to a poor fall. He experienced formulated high white blood mobile counts, an increasing fever, and other indications of an infection. DD has a documented daily life-threatening sulfa allergy. The team requested empiric cefepime and vancomycin. Two days afterwards, lifestyle results indicated that the bacterium Stenotrophomonas maltophilia was causing the suspected pneumonia. The medical center, anxious about this unheard of bacterium, phone calls the pharmacy for recommendations for remedy.
Problem: What must the pharmacist advocate?
Solution: S maltophilia is a rare, gram-detrimental bacterium that can be life-threatening. It is an emerging worldwide opportunistic pathogen, and it most typically happens as a nosocomial pneumonia an infection but can be a standard colonizer in the respiratory tract. The initial-line remedy is co-trimoxazole simply because of prevalent sensitivity and its solid capacity to take care of S maltophilia. Nevertheless, since of DD’s everyday living-threatening sulfa allergy, co-trimoxazole is contraindicated.1 As a consequence, the pharmacist must suggest levofloxacin (Levaquin), which is a commonly employed 2nd-line agent. Levofloxacin is reported to have similar therapy success prices, but the pointers do not suggest levofloxacin as initial-line remedy because of prevalent, overuse-connected quinolone resistance. Info point out that people who are not quinolone naïve, this kind of as those with cystic fibrosis, have less therapy success when using quinolones when compared with co-trimoxazole.
ME, a 41-calendar year-aged guy, was identified with HIV approximately 6 several years in the past. His antiretroviral remedy regimen features darunavir/cobicistat (Prezcobix) and dolutegravir (Tivicay). Immediately after reviewing ME’s modern laboratory benefits, the physician diagnoses diabetes and hypertension and prescribes metformin 500 mg twice each day and lisinopril 5 mg everyday. The doctor also suggests life style variations for the patient, which includes a lot more bodily action. ME has trouble breathing and wheezes all through the day, and physical exercise would make it even worse. The medical professional prescribes fluticasone and albuterol for the patient’s persistent bronchial asthma. Around 2 weeks later, the individual offers to the emergency department for considerable fatigue and nausea. On evaluation, the medical doctor notices purple extend marks on ME’s pores and skin and various compact bruises. She also notices that ME has formulated a moon facies and a hump between his shoulders. The medical professional suspects a drug interaction.
Question: What ought to the pharmacist endorse?
Reply: Inhaled corticosteroids (fluticasone) and pharmacokinetic boosters (darunavir/cobicistat) are identified to interact. ME’s reaction originated from a cytochrome P450 3A4 conversation concerning cobicistat and fluticasone. The interaction will increase cortisol concentrations in just the human body when inhibiting its clearance, major to adrenal suppression. As a final result, ME formulated Cushing syndrome.2 Bruising very easily, a fatty hump concerning the shoulders, and moon facies are common displays of the disorder. Clients with HIV are susceptible to a substantial quantity of drug interactions, for the reason that they are likely to establish comorbidities as they age. It is significant to review a patient’s healthcare record right before initiating new medications. To stay clear of this response, the most popular substitute to fluticasone is beclomethasone. Pharmacists can use the free of charge Liverpool HIV Drug Interactions Checker to discover medications that should not be coadministered with antiretroviral therapy regimens.
- Co-trimoxazole. Well being Hub. Updated July 2021. Accessed January 26, 2022. https://www.healthhub.sg/a-z/medications/174/Co-Trimoxazole
- Elliot ER, Theodoraki A, Jain LR, et al. Iatrogenic Cushing’s syndrome due to drug interaction between glucocorticoids and the ritonavir or cobicistat made up of HIV therapies. Clin Med (Lond). 201616(5):412-418. doi:10.7861/clinmedicine.16-5-412
About the Authors
Dylan Decandia and Karisse Lora are PharmD candidates at the University of Connecticut School of Pharmacy in Storrs.
Jeannette Y. Wick, MBA, RPh, FASCP, is the director of pharmacy skilled progress in the Department of Pharmacy Practice at the University of Connecticut School of Pharmacy in Storrs.