PP+401+-+7

=Patient developing nitrate tolerance=

//Vivian is a regular customer in her late 60’s who is visually impaired. She has a long relationship with your pharmacy and a history of angina and hypertension. Her recent dispensing history is as follows://

Problem
Patient was not put on beta-blocker first line? No nitrate-free period leading to tolerance (isosorbide during the day and GTN patch at night) Anything for relief of acute angina attacks? (isosorbide has a slow onset of action) Simvastatin taken in the morning (should be at night) Drug interaction: Diltiazem (3A4 inhibitor) and simvastatin (3A4 substrate) Recently started on aspirin and simvastatin (particular reason?)

Questions to Ask
The patient wants a refund on her nitrate patch as it is not working and she is getting angina attacks Check technique and when she applies and takes off her patch. //technique is correct and states that she applies the patch at 8 and takes it off at 8, which is revealed that she replaces her patch everyday at 8am (rather than apply at 8am and remove at 8pm)// Ask her to describe her attacks and when they happen mostly. //if occurs at night, suggest that she applies her patch at 8pm and remove at 8am// Check if she has emergency acute angina attack relievers and plan. //does not currently use a tablet or spray//

What to do
- Educate her that she requires a 10-12 hour break everyday from patch (even though patch may last 24 hr) - put on patch at night and take off in the morning since she experiences symptoms mostly during the night (eg on at 8pm, off at 8 am) - right now since she is tolerant and has risk factors of CV events, she needs acute angina attack drugs such as nitrate spray and an emergency plan (sit down, spray 1 spray under tongue, wait for 5 mins, if no relief after repeating 2 times call ambulance) - nitrate tolerance should subside within a day, up to a week