Mrs Ruberry (76 years old, 55 kg, 155 cm) has recently had a seizure. Her GP ordered a blood test to determine her phenytoin blood concentration (see below) and at the consultation yesterday the GP subsequently decided to increase the dose of phenytoin. The GP is concerned about the poor control of Mrs Ruberry’s seizures and asks you to review her medications. The GP has supplied you with the following information on Mrs Ruberry’s labs and medicines.
Labs (from 2 days ago):
Phenytoin: 8 mg/L (10-20 mg/L)
Albumin: 43 g/L (35-50 g/L)
SeCr: 70 micromol/L (50-100 micromol/L)
Current medications:
Aspirin 100 mg PO mane
Phenytoin 500 mg PO nocte (previously 300 mg nocte – dose was increased yesterday)
Latanoprost eye drops – 1 drop in each eye nocte
Timolol 0.5% eye drops – 1 drop in each eye bd
Over a cup of tea with scrumptious homemade biscuits, Mrs Ruberry reluctantly admits that she has been forgetting her tablets of late. She explains that her cat Merkel had run away and consequently she had been very distraught. She didn’t want to tell her GP about forgetting her tablets as she felt that her GP would be judgemental. Fortunately, a kind stranger found her cat and returned Merkel to Mrs Ruberry last night. You take the opportunity to explain in detail the importance of good adherence to her medications (particularly phenytoin) and provide her with some alternative strategies that can help remind when to take the medications. You evaluate that Mrs Ruberry has good cognitive function and that medication management aids are not required. Mrs Ruberry is greatly relieved to have Merkel back and promises that she will be fastidious in taking her medications from now on.
i) Concisely discuss what you believe to be the most important medication-related issue with respect to the case detailed above. If you have more than one significant concern, please focus principally on the concern that you believe is of greatest importance. You must include a clear description of the medicine-related problem you have identified as most important (e.g. what specific medicine-related decision is problematic? what is the specific existing/future harmful consequence that is of principal concern?) and an explanation of the clinical and pharmacological reasoning that your concern is based upon (i.e. make a convincing argument that the issue identified is a real and significant problem).
ii) Concisely discuss what should be done now to address this medication-related issue? You must include an explanation of the clinical and pharmacological reasoning that your suggestions are based upon (i.e. make a convincing argument that this is the most appropriate way to handle the issue).
[Maximum 500 words, excluding references]