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Australian Journal of Pharmacy : March 2005
pharmacy ed counselling casebook neous reactions, particularly urticaria, rash and puritus, are also a common adverse effect of clopidogrel (141 reports).9 Prescribers and pharmacists should be aware of the risk of haemorrhagic complications with clopidogrel, especially when it is used in combination with other anti-thrombotic agents. Resistance to antiplatelet drugs The antithrombotic effects of aspirin are variable among indi- viduals and this might explain, in part, why the absolute risk of recurrent vascular events in patients receiving aspirin therapy remains relatively high (8 per cent–18 per cent after two years). Although formal diagnostic criteria are lacking, aspirin resistance generally describes the failure of aspirin to produce an expected biological response or the failure of aspirin to prevent atherothrombotic events. Aspirin resistance has been reported to occur in 5 per cent to Scenario A DAM Plonchnik is a regular client of your pharmacy. He is 52 years old, has been a widower for five years and lives alone in a unit. He is on a disability pension and hence obtains his prescription on a concession card via the PBS. He does not have children, but has a brother and sister who live nearby. His doctor was very keen for you to do a medication review as he is on multiple medications and he (Mr Plonchnik) thinks that you (his pharmacist) are a trusted friend with respect to his health. You arrange an appointment and visit him in his unit which is poorly presented and not particularly well kept. Medical history Mr Plonchnik suffers from hypertension dyslipidaemia, maturity onset diabetes; has suffered an acute mycocardial infarct (AMI) six years ago and again two years ago. He has recently suffered two strokes and at times speaks slowly and walks in an uncoordinated manner to some extent, however he believes he is improving. He needs to be retested before he can drive again, so at present walks or takes the bus. He is 180cm tall and weighs 122Kg; BMI = 37.7kg/m2 (which places him in the seriously obese category) His blood pressure has remained at around the 145/85 mmHg level over the last few readings. He stopped smoking about 12 years ago and stopped alcohol last year after his stroke. Mr Plonchnik is at high risk of further strokes and/or MIs. He is obese, has diabetes, has already suffered cerobrovascular and cardiovascular events has hypertension and is recovering from stroke. Medications • Plavix (clopidogrel) 75mg 1 mane • Monopril Plus) 20mg/12.5mg 208 ? THE AUSTRALIAN JOURNAL OF PHARMACY VOL.86 MARCH 2005 (fosinopril/hydrochlorothiazide) 1 mane • Norvasc (amlodipine) 10mg 1 mane • Betaloc (metoprolol) 100mg 1 bd • Zocor (simvastatin) 40mg 1 nocte • Diaformin (metformin) 500mg bd pc • Temaze (temazepam) 10mg tablets, 1 n prn Diabetes Mr Plonchnik has a fairly new Optium glucose meter, which he was taught how to use in hospital and he tests his blood glucose levels two to three times a day. He explained verbally how he uses his machine but it was not demonstrated. He does not have a diary to record his glucose readings for his GP. HbA1c tests either were not carried out or were not available and should be recommended to the GP. Cardiovascular Mr Plonchnik is aware of the sugar and fat content of foods, however, he eats mainly packaged frozen dinners, which he microwaves. He needs encouragement to reduce his weight; could he be referred to a dietitian? Clopidogrel, amlodipine, simvastatin, metformin and temazepam all appear to have been recently commenced (presumably during hospital admission). He indicates that he has never taken low-dose aspirin. He commenced Monopril Plus about nine months ago, replacing lisinopril 20mg. There are no data on his lipid levels. It would be useful to have standard pathology tests including potassium and serum creatinine. Could his risks be reduced by combining his clopidogrel with low-dose aspirin (keeping in mind the results of the MATCH study11 for aspirin? 45 per cent of the general population, therefore, its detection is potentially of clinical importance.12 In the past few years, the concept of aspirin resistance has been largely emphasised in the medical literature, although its defini- tion is still uncertain. It may be that ‘aspirin-resistant’ should be considered as a description for those individuals in whom aspirin fails to inhibit thromboxane A2 production, irrespective of the results of unspecific tests of platelet function, such as the bleed- ing time, platelet aggregation, or the PFA-100 system. Less well known than aspirin resistance, but certainly better characterised, is the issue of ‘clopidogrel resistance’, which is probably mostly caused by inefficient metabolism of the prodrug clopidogrel to its active metabolite. At present, aspirin and clopidogrel resis- tance should not be looked for in the clinical setting because there is no definite demonstration of an association with clinical events conditioning cost-effective changes in patient management.13 )? or substituting the clopidogrel