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ACCP and PDC White Coat Series
“Practice Your Clinical Skills”
Presenter: Olga Klibanov, PharmD, BCPS
September 26, 2013
Setting: You are a pharmacist at an ambulatory care clinic. A patient is scheduled to come in for follow up next
week and the physician is asking you to prepare recommendations regarding the patient’s pharmacotherapy.
SUBJECTIVE
HPI: CM is a 23 y/o African female from Angola, who has been in the United States since 02/2013. In April 2013 she
presented to the ED with a productive cough that has been worsening over the past several months. She has also
had abdominal pain, night sweats, decreased appetite, and weight loss. She was hospitalized and subsequently
diagnosed with extensive pulmonary tuberculosis (TB). A HIV test was also performed at that time and reported as
positive. She was started on TB therapy in the hospital and referred to our clinic for outpatient management of her
HIV. Her TB therapy and clinical response is monitored by the Health Department.
The following data are from her most recent clinic visit, on 8/15/2013
Allergies: NKDA
Medications:
1. isoniazid (INH) 900 mg twice a week by directly observed therapy (DOT) (start date: 4/29/13)
2. rifampin (RIF) 600 mg twice a week by DOT (start date 4/29/13)
3. pyrazinamide (PZA) 2,000 mg twice a week by DOT (4/29/13 – 6/24/13)
4. ethambutol (EMB) 2,000 mg twice a week by DOT (4/29/13-6/24/13)
5. vitamin B-6 50 mg twice a week by DOT (start date: 4/29/13)
PMH:
1. HIV (diagnosed 04/2013)
2. Tuberculosis (diagnosed 4/2013)
Surgical history: C-section x 1
Family history: non-contributory
Social history:
Married (husband also found to be HIV-positive, with a positive PPD)
1 child (HIV status unknown)
(-) tobacco, (-) EtOH, (-) illicit drugs
ROS: unremarkable
OBJECTIVE:
Vitals: 5’4, 113lbs, T 98.4 F, BP 115/77, P 83
PE:
GEN: well developed and nourished, appropriately groomed, in no apparent distress
EENT: PERRLA
Resp: normal respiratory rate and pattern with no distress, normal breath sounds with no rales, rhonchi, wheezes,
or rubs
CV: normal S1 and S2, no S3/S4 gallop, rubs or clicks; no edema
Neuro: A&Ox3, cranial nerves II-XII grossly intact
Psych: appropriate affect and demeanor
Labs: see attached.
Your main task: To provide a recommendation regarding initiating this patient on antiretrovirals, with appropriate
adjustments to her TB medications.
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To help with your decision making, below is a list of thought-provoking questions for you to answer.
Useful list of online references:
DHHS HIV guidelines: http://aidsinfo.nih.gov/contentfiles/lvguidelines/adultandadolescentgl.pdf
Opportunistic infection guidelines: http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf
1.
Is CM a candidate for highly active antiretroviral therapy (HAART) at this time? (i.e., if a patient is
diagnosed with TB concurrently with HIV, at which point should HIV therapy be initiated?)
2.
CM’s baseline antiretroviral resistance testing (Genosure) indicates that she is resistant to one of the
antiretrovirals (rilpivirine). How common is it for a treatment-naïve patient to be resistant to an
antiretroviral medication (what is the estimated incidence in the U.S.)? Should baseline resistance testing
be performed in all patients prior to starting HAART?
3.
Which HAART regimens are “First Line” in treatment-naïve patients? Which ones are once-daily vs. twicedaily (may impact adherence rates)?
4.
Which HAART regimens are co-formulated as a “one pill a day” option? Is CM a candidate for any of
these?
5.
CM’s TB therapy is currently in the “continuation phase”. How long should she continue INH/RIF?
6.
What changes (if any) would you make in her TB medications?
7.
What role does vitamin B-6 play in TB therapy?
8.
Is CM a candidate for any other medications to prevent opportunistic infections (OIs)? At which point
would you recommend initiating OI prophylaxis?
9.
CM’s husband does not have active TB, but did test positive for latent TB (positive PPD). Is he at a high risk
for activating the TB disease? Should he receive treatment for latent TB? If so, what regimen would you
recommend for CM’s husband (include drugs, doses, duration).
10. Outline your final recommendation for CM:
HIV:
Medications:
Goals of Rx:
Monitoring for efficacy:
Monitoring for toxicity:
TB:
Key counseling points:
Medications:
Goals of Rx:
Monitoring for efficacy:
Monitoring for toxicity:
Key counseling points:
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