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You are working in a community pharmacy located in the outpatient clinic area of a large health system. This building is also attached to the inpatient portion of the medical center. Your pharmacy fills prescriptions for patients being seen by several different outpatient clinics, as well as all discharge prescriptions for any of the inpatients. Since you are linked within the health system, you have access to portions of the electronic medical record.

You receive the following electronic outpatient order from the infectious disease clinic for a 61 YOM patient, Donald Smith (DOB 2/5/58):

  • Trimethoprim 160 mg/sulfamethoxazole 800 mg

  • One tablet daily for PCP/PJP prophylaxis

  • Dispense: #30 with 11 refills   Bradley Allen, MD

As you are verifying the order, a drug interaction warning pops up on your screen. You review DS’s current medications:

  • Amlodipine 10 PO mg daily  Atorvastatin 40 mg PO daily

  • Aspirin 81 mg PO daily  NTG 0.4 mg SL tab prn for chest pain

  • Carvedilol 25 mg PO BID  Oxycodone 5 mg IR PO q12h prn for pain

  • Lisinopril 20 mg PO daily

  • Warfarin 7.5 mg PO MWF/5 mg TRSS (stable on this dose × 2 years)

     

  • Your chart review reveals the following:

  •  

    PROBLEM LIST:

  • HIV/AIDS—newly diagnosed

  • CAD s/p 2VCABG

  • HF (last EF 41%)

  • Atrial fibrillation

  • HTN

  • HLD

  •  

    ALLERGIES: NKDA

  •  

    RECENT LABS:

  • Na 138 K 3.7 Cl 99 HCO3 23 BUN 16 SCr 1.0 Glu 104

  • WBC 7.85 Hgb 11.6 Hct 34.9 Plt 143 INR 2.5

  • CD4 185 HIV RNA 300,000 copies/ml HIV Genotype: Pending HLAB5701: Pending

Based upon your review, you decide to call the prescriber regarding the need to inform and address the drug interaction alert. Please be prepared to provide recommendations for changes and/or treatment options. You will have 5 minutes to interact with your prescriber and then be provided up to 2 minutes of feedback.

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