CASE STUDY

FOR
PHARMACEUTICAL
CARE

DRUG-RELATED DRUG-THERAPY PROBLEMS
NEEDS
Appropriate Unnecessary drug therapy
indication

Effectiveness Wrong drug

Dosage too low
Drug Interactions
Safety Adverse drug reaction
Dosage too high
Drug interactions

Compliance Inappropriate compliance

1
 Untreated indication Needs additional drug therapy

 Mary Blythe is a white female in her mid-30s

who is a new patient in your pharmacy. You
have never filled a prescription for her before.
Today, Mary presents you with a new
prescription for Serzone (nefazodone) 150 mg
tablets, Sig: 1 tablet twice daily, refill x3,
signed by Dr. R. Dennis, a local family
physician.

Mary also wishes to purchase a bottle of Afrin

(oxymetazoline) Nasal Spray.

As you gather the usual demographic and

insurance data, you learn that Mary has
prescription insurance through her husband’s
employer and has $ 10 co-pay on each
prescription.
She is employed as a real estate agent in a local
office and she has a 14-year-old son.

There is nothing in Mary’s mood, behavior, dress,

or appearance to suggest that anything is

2
abnormal. She appears to be about 5`5`` tall and
her weight appears normal for her height.

The questions need to be asked for applying

pharmaceutical care:

1. How should the pharmacist begin to develop a

therapeutic relationship with the patient so
that he is able to start collecting the data
needed to identify any drug therapy
problems?

2. What data need to be collected to determine

if:
a. there is an appropriate indication for
each drug;
b.the drug therapy is effective;
c. the drug therapy is safe;
d.the patient is able to comply with the drug
therapy;
e. There are any untreated conditions that
should be treated with drug therapy?

3
  The pharmacist is then interviewing Mary
Blythe.

There are three key concepts in the interview:

1. The interview is organized; related questions
are asked together.
2. The pharmacist uses the interview as an
opportunity to educate the patient about
pharmaceutical care and to market it directly
to the patient.
3. The pharmacist employs the seven screening
questions to evaluate Mary’s symptoms.
(Location, quality, quantity, timing, setting,
modifying factors, associated symptoms)

The interview assumes that the pharmacist has

already collected routine demographic and
insurance information.

The pharmacist has just completed routine

medication counseling on Mary’s new Serzone
prescription and is confident that Mary
understands how to take her Serzone.

The pharmacist now intends to evaluate whether

she is a possible candidate for a pharmaceutical
care interview and work-up.

4
If she is, the pharmacist intends to perform a
comprehensive interview and explore all of
Mary’s conditions and medications.

 After finishing the interview, the pharmacist

has gathered much information needed to
identify her drug therapy problems.
The pharmacist begins by looking at Mary’s
medication list and her list of diseases and
symptoms.

Mary’s medications include:

a. Serzone 150 mg by mouth twice daily.
b.Vancenase AQ 2 sprays by nasal inhalation
twice daily when she has difficulty
breathing.
c. Tylenol occasionally for headache.
d.Afrin Nasal Spray 2 sprays twice daily.
e. Benadryl 4 capsules at bedtime.

Mary has been taking all these medications

for at least several months.
Mary’s conditions and symptoms include:
a. depression,
b.multiple environmental allergies with
considerable nasal congestion,

5
 c. difficulty sleeping,
d.blood pressure of 90/60 (her usual b.p. was
110/70)

 Comparing Mary’s drugs and conditions, it

appears that each drug has an acceptable
indication.
Serzone is medically indicated for depression;
Vancenase AQ, Benadryl, and Afrin for
allergies and congestion;
Tylenol is for headaches.

The pharmacist concludes that Mary does not

have any problems caused by a lack of
medical indication.

There is no evidence of recreational drug use

or addiction and it does not appear that
avoidable adverse effects are being treated
with additional drug therapy.

The role of non-drug therapy and the multiple

therapies for Mary’s allergies remain to be
clarified to see if there are problems.

When looking at Mary’s conditions and

symptoms, it appears that the depression,

6
 allergies, and insomnia are being treated, but
her low blood pressure is not.

It is not yet clear, however, if Mary needs

additional drug therapy to treat any of her
conditions.

CLINICAL AND ADVERSE

RESPONSES

 Mary’s clinical and adverse responses to her

medications are evaluated to see if further
drug therapy is indicated.

She feels that her depression has responded

well to Serzone and she does not complain of
any adverse effects that she would attribute to
Serzone.

Her insomnia is only partly controlled and

her allergies and nasal congestion are not well
controlled at all.

The breathing difficulty is her major

complaint.

7
 Also, her blood pressure is quite low and she
is not receiving drug or non-drug therapy for
it.

Before the pharmacist decides that Mary

needs additional drug therapy for her
complaints, however, he must determine if
any of these symptoms could have been
caused by drug therapy.

The insomnia does not appear to be drug

induced, nor does it appear to be related to
excessive caffeine intake.

The nasal congestion may well be due to rebound

congestion caused by excessive use of Afrin over
several months.

The pharmacist is also aware that Serzone has

alpha-adrenergic blocking properties that
may be partially responsible for both Mary’s
congestion and low blood pressure.

8
The pharmacist decides that Mary does not
require additional drug therapy, but that
additional non-drug therapy may prove helpful
for her insomnia.

By now, the pharmacist is reasonably

confident that all Mary’s drugs carry an
indication and that all her conditions that
should be managed by drug therapy are being
so treated.

The pharmacist now moves on to consider

issues related to safety, efficacy, and
compliance.

SAFETY AND EFFICACY

 The first step is to consider for each of Mary’s

medications:
1. the dose,
2. dosage interval,

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 3. duration of therapy, and
4. dosage form

 Serzone - 300 mg per day is at the low end of

the dosing range.

There does not appear to be any reason to

increase the dose – Mary has a good
therapeutic response to Serzone.

But, Mary’s congestion may be caused by the

Serzone, so perhaps a decrease in dose could
be considered.

Mary has been taking her Serzone twice a day

for several months and seems to have no
problem taking the tablets correctly.

The pharmacist concludes that there are no

apparent problems with Serzone dosing.

 Vancenase AQ, Benadryl, Afrin Spray, and

Tylenol

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A variety of problems immediately becomes
apparent.

The true dose of Vancenase AQ is unclear

since Mary only uses it when she feels she
needs to.

This suggests a compliance problem and an

example of how pharmacists can find one
problem while looking for another.

Mary’s complaint of poor breathing, it is clear

that Mary has a problem related to her
Vancenase AQ  poor compliance may be a
factor, so it may poor inhaler technique. The
technique was not evaluated.

Mary claims to be taking 4 (four) capsules of

Benadryl at bedtime.

It means she is taking 100 mg total each night,

since 25 mg capsules are the most widely
available over the counter.

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 Mary is taking the equivalent of an entire
day’s dose of Benadryl at one time  she does
not have any apparent evidence of adverse
effects from such a large dose, the pharmacist
would conclude that this is an excessive dose.

Benadryl’s anticholinergic activity may be

worsening Mary’s breathing through
excessive drying of her nasal mucosa.

In addition, hypotension is reported as an

uncommon side effect of Benadryl.

Mary has taken Benadryl for several months

and has done so, in part, as a sleep aid.
This suggests that the duration of therapy
may be a potential problem for Mary. Finally,
there is no evidence that the dosage form is
problematic here.

Afrin Nasal Spray is also found to be causing a

problem.

The inhalation technique is not clear, it is

apparent that she has been using the spray for

12
 long enough to have developed symptoms
consistent with rebound congestion.

The duration of therapy is excessive and she

still complains of trouble breathing. The safer
therapy should be used for her long – term
allergy control.

The Tylenol is the final medication to be

evaluated.

The actual dose that Mary takes is not clear.

The pharmacist would be well advised to
ensure that Mary’s single – dose use of
Tylenol is not damaging to her liver.

The other factors related to duration of

therapy, dosage form, and dosage schedule
are not problems for Mary.

The last two possible areas for dosing-related

problems do not appear to be relevant for
Mary.

Dosing problems due to storage  OK

13
 There is no evidence of a drug interaction
resulting in a problem related to drug dosing.

CORRECT DRUGS

 After completing an evaluation of Mary’s

drug dosing, the pharmacist can now move on
to consider if Mary is on the correct drug for
each of her conditions.

There are no apparent contraindications to

Mary’s Serzone; her depression is not
refractory to it.

Serzone is:
1. clearly indicated for depression;
2. no dosage form problems exist;
3. There is no reason to believe that Mary
should be switched to a more effective
drug.

The pharmacist can safely conclude that

Serzone is a good choice for Mary’s
depression.

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 Vancenase AQ

There are no contraindications and it is

indicated for her allergies.

Determining if her allergies are refractory or

if more effective therapy is available is
difficult due to the lack of compliance.
This makes it impossible to assess her
response to the drug.

The role of dosage form is not clear.

The pharmacist concludes that:

a. there are problems related to the

Vancenase AQ
b.There are not a result of the physician’s
choice of drug

Evaluation of Mary’s Afrin Spray, Benadryl, and

Tylenol follow a similar reasoning.

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 Certainly, there are problems with Mary’s
use of Afrin and Benadryl  but they are
not a result of drug selection.

There do not appear to be any problems

related to the choice of Tylenol.

COMPLIANCE PROBLEMS

 Mary seems to be completely compliant with

the Serzone, Afrin, and Benadryl – if
excessive use can be termed compliance.

Mary claims to use the Benadryl every night

and the Afrin twice daily.

Tylenol is taken only as needed  the

compliance does not appear to be a problem.

Mary does have a compliance problem with

her Vancenase AQ.

The exact cause of Mary’s lack of compliance

is not immediately clear.

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  Mary understands the
instructions
 The product is available
 Mary has prescription
insurance

The two causes for poor compliance are:

a. the patient’s inability to administer the
drug
b.A preference not to use it  she does not
think the drug works for her allergies.

It seems that the non-compliance is largely a

matter of patient preference.

ADVERSE REACTIONS

 The pharmacist’s evaluation of Mary’s drug

therapy is largely complete and assessment of
drug safety has been partially completed.

The pharmacist already suspects that Mary’s

congestion is largely due to misuse of Afrin

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coupled with the alpha-blocking effects of
Serzone.

The Serzone is the most likely cause of Mary’s

low blood pressure.

The excessive dose of Benadryl may play a

role in Mary’s breathing if the
anticholinergic, drying effects have
excessively dried out her nasal mucosa.

The hypotension is a reported side effect of

Benadryl  there is no direct evidence of
nasal drying.

Since hypotension is rare, it is more likely that

the Serzone and Afrin are responsible for
Mary’s complaints.

The pharmacist concludes that Mary shows

evidence of several adverse drug reactions,
but there is no evidence of drug interactions.

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 REVIEW OF SYSTEMS

The pharmacist performs a brief review of

systems.

Mary’s vital signs are abnormal as reflected

by low blood pressure  due to the Serzone.

There is no evidence to suggest that Mary has

renal or hepatic impairment or that her
medications have affected those organs.

Her fluid and electrolyte status is not

questioned since none of her medications has
major effects on that system.

The same holds true for Mary’s pulmonary,

hematological, endocrine, gastrointestinal,
neurological, dermatological, genitourinary,
musculoskeletal, and psychological systems.

Effects on her cardiac and eye, ear, nose, and

throat systems are suspected, as evidenced by
her hypotension and nasal congestion.

Serzone and Afrin are possible causes.

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 Based on this evaluation, Mary’s pharmacist
has identified the following drug therapy
problems in Mary:

a. Inappropriate compliance with Afrin Nasal

Spray and Vancenase AQ. In each case, this
is an actual drug therapy problem.

b.Adverse effects from Afrin and Serzone

causing nasal congestion and hypotension.
The pharmacist believes these to be actual
problems.

c. Dosage to high with Benadryl. Although

there is no direct evidence of a problem, the
pharmacist believes that this dosage is
potentially unsafe.

d.Duration of therapy too long with Benadryl.

Mary has been taking Benadryl as a sleep
aid for several months. Again, there is no
evidence of damage, so the pharmacist
labels this a potential drug therapy
problem.

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The pharmacist’s job now is to develop and
implement care plans for each of Mary Blythe’s
drug therapy problems.

These problems are:

1. Inappropriate compliance with Afrin Nasal

Spray and Vancenase AQ

2. Adverse effects from Afrin and Serzone,

resulting in nasal congestion and hypotension.

3. Dosage too high with Benadryl.

4. Duration of therapy too long with Benadryl.

The first thing the pharmacist must do is establish

an achievable, measurable, and professionally
responsible goal for each problem.

At this point, these goals are not necessarily

written down, but the pharmacist and others

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should be able to deduce the goals when reviewing
documentation of the care session.

Working together with Mary, the pharmacist

devises the following three goals for therapy:

1. Mary will not have complaints regarding the

signs and symptoms of allergies and nasal
congestion.

2. Mary will have relief of her depressive

symptoms without acquiring new, bothersome
adverse drug effects.

3. Mary’s symptoms of insomnia will be controlled

to her satisfaction with minimal additional
medications.

Now, Mary and pharmacist agree on goals for

therapy, they work together to prioritize Mary’s
problems.

The problems which are actual problems:

1. Compliance,
2. Adverse effects.

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The potential problems: the dosage and duration
of Benadryl therapy  there is no evidence of
harm.

The pharmacist decides that Mary’s problems

with adverse effects of nasal congestion and
hypotension are acute, but not serious.
The other three problems are felt to be serious but
not acute. Therefore, Mary has one Priority II
problem, three Priority III problems, and no
Priority I problems.

Mary also is quite anxious to improve her nasal

congestion, and the pharmacist takes Mary’s
preferences into account when prioritizing her
problems.

Mary and the pharmacist develop a plan that will

result in appropriate compliance with Afrin and
Vancenase AQ and reduce the nasal congestion
caused by Afrin and Serzone.

The poor compliance  a Priority III problem, it

is closely related to her nasal congestion, so it will
be solved along with the Priority II problem.

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Mary’s blood pressure is worrisome, her
depression has responded well to Serzone and she
would like to stay on it if possible.

The pharmacist suggests to Mary that they inform

her physician of the pharmacist’s findings. Mary
agrees to this approach.

The hypotension is a Priority II problem  the

pharmacist feels that it is unlikely to be serious in
the short term and there does not appear to have
been any complications that developed as a result
of her blood pressure.

Mary asks the pharmacist to develop a care plan

that will be implemented only after she sees how
well her congestion responds to changes in the
AFRIN and Vancenase AQ.

Since the problems with Benadryl are potential

and this is a Priority III problem, the pharmacist
finds this acceptable.

HOW TO ACHIEVE GOALS

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The pharmacist must now decide how best to
achieve the goals that have been set.
The first thing  rule out the “do nothing”
option.

Mary’s problems are causing her significant

trouble breathing and there is a good reason to
believe that the benefits of an active intervention
outweigh the risk.

The pharmacist considers ways to achieve the

therapeutic goals.

The case of inappropriate compliance and adverse

effects caused by Afrin
 The pharmacist recommends that Mary
stop
taking Afrin.

Due to the current state of her breathing, and the

slow onset of Vancenase AQ
 Mary would likely have several days of
unacceptable symptoms and eventually
stop
complying with the care plan.

The pharmacist could recommend an oral

decongestant such as pseudoephedrine.

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This would result in the expense of additional
drug therapy and could interfere with proper
evaluation of Mary’s possible blood pressure
problems.

Instead, the pharmacist decides that slowly

tapering Mary off Afrin Spray is the best
approach.

The pharmacist will suggest:

 In the first week, Mary will use her Afrin no

more than twice daily and alternate nostrils for
each dose.

 The second week, Mary will continue to

alternate nostrils, but use the Afrin only once
daily.

 By the third week, the Vancenase AQ should

be fully effective and Mary should not need Afrin
at all.

If she still has congestion, she will use Afrin only

once a day in one nostril and not for more than 3

26
days. If this effective, the pharmacist will refer
Mary to her physician for a medical evaluation.

For Mary’s poor compliance with Vancenase AQ,

the pharmacist also considers several options.

 Changing to another nasal steroid or cromolyn

is not indicated because, given the compliance
problem, it is impossible to tell if Vancenase AQ
has been effective.

 Recommending an oral steroid would be

excessively risky at this time.

 The pharmacist elects to develop a dosing

reminder calendar for Mary and to educate her
on the proper use of her nasal inhaler.

Since Mary prefers to continue on her Serzone for

now, the pharmacist feels that the best approach is
to write Mary’s physician to relate what the
pharmacist has learned.

The alternative of not writing the prescriber is

ruled out since the pharmacist feels that Mary’s
blood pressure is potentially serious enough to

27
warrant medical intervention and, further, the
pharmacist wishes to maintain a positive, collegial
relationship with the physician.

Although Mary does not wish to change her

Benadryl use at this time, the pharmacist elects to
devise a care plan that can be implemented when
Mary is more open to further changes.

Several options are considered.

 Discontinuing Benadryl is ruled out since

Mary has been on it for several consecutive
months; it is also helping to control her allergies
and aiding her sleep.

 Changing to another agent, such as

doxylamine, offers no apparent advantage over
Benadryl.

 The pharmacist decides to gradually taper

Mary’s Benadryl 25 mg at a time at weekly
intervals.

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Once Mary has been tapered off Benadryl, she is
not to take more than 50 mg at bedtime when her
allergies are troublesome.

 For her insomnia, the pharmacist will

educate Mary on sleep hygiene and supply her
with a set of relaxation tapes that she can listen to
in bed to help her fall asleep.

IMPLEMENTATION

The pharmacist must implement a care plan for

each problem. The care plans related to Afrin,
Vancenase AQ, and Benadryl are all patient-
focused interventions.

The pharmacist needs only to educate Mary with

the necessary information and does not need to
contact the physician before proceeding.

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The pharmacist informs Mary about how nasal
decongestant can actually make nasal congestion
worse.

The pharmacist outlines the Afrin tapering

schedule that has been developed, including
alternating nostrils, and makes sure that Mary
agrees to it.

Next, the pharmacist asks Mary to demonstrate

her understanding of appropriate Afrin use by
repeating the care plan back to him, which she is
able to do.

For the Vancenase AQ, the pharmacist

demonstrates the appropriate use of the inhaler
and asks Mary to demonstrate it as well. The
pharmacist then provides education about how
nasal steroids prevent rather than treat allergic
symptoms and explains why regular use is
important.

Mary appears to understand.

The pharmacist knows that Mary will not make

any changes in her Benadryl use, he briefly

30
describes his suggestions and Mary agrees to take
under advisement.

The pharmacist also teaches Mary about good

sleep hygiene and she agrees to purchase the
relaxation tapes the pharmacist recommends.

Finally, the pharmacist informs Mary about the

importance of a follow-up session to monitor her
outcome. They agree that the pharmacist will
telephone Mary at home in one week, since proper
compliance with Vancenase AQ should give her
some relief after a week’s consistent use.

At that time, the pharmacist will inquire about the

clinical response of Mary’s congestion, how much
Afrin she is using, and her compliance with
Vancenase AQ.

The pharmacist will also evaluate whether

increased use of Vancenase AQ is causing any
problems, such as nasal dryness.

The pharmacist will then inquire into Mary’s

Benadryl use to see if she is now willing to
consider a dosage change, and will assess whether
the relaxation tapes are helping with her sleep.

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Finally, the pharmacist will look into Mary’s
blood pressure issues. If she is still complaining of
symptoms consistent with hypotension, the
pharmacist will ask Mary to return to the
pharmacy for a blood pressure check.

Depending on the results, the pharmacist may

then refer Mary to her physician.

As time goes on, the pharmacist will also verify

that Mary’s compliance with Vancenase AQ is
meeting the target goal for compliance and that
her use of Afrin is acceptable.

INFORMING THE PHYSICIAN

The last task of pharmacist is to inform the
physician about Mary’s possible adverse effect
with Serzone.

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Since the pharmacist is already writing a letter
about Serzone, the pharmacist elects to keep the
physician informed about Mary’s total
pharmaceutical care plans.

THE USE OF SOAP FOR

MARY’S PROBLEMS

Mary Blythe 12/29/02

Inappropriate compliance-overuse of Afrin Nasal

Spray and under-use of Vancenase AQ

Adverse drug reaction-nasal congestion from

overuse of Afrin

Subjective (S):

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 New patient to pharmacy requests Afrin Spray
in addition to Rx for Serzone.

She requests help in breathing better.

She complains of increased allergy symptoms

including nasal congestion and sinus problems
for the last year since moving here, with
continuous problems since then.

States she has had allergy problems for “years”

and is allergic to “just about everything-dogs,
cats, dust, grasses, and pollens.”

Was prescribed Vancenase AQ 2 sprays each

nostril BID, but only uses PRN when severe
congestion and she does not feel it helps much.

Uses Afrin Nasal Spray 2 sprays in each nostril

twice daily for months, also uses Benadryl 100
mg @HS for allergies and sleep.

She feels the Afrin helps some and possibly also

the Benadryl. She has never gotten “allergy
shots”. She quit smoking 2 years ago.

Objective (O):

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 None

Assessment (A):

Inappropriate use of Afrin likely causing

rebound congestion and aggravation of allergy
symptoms.

The lack of use of Vancenase is resulting in

ineffective treatment of nasal allergy symptoms.

Plan (P):

The pharmacist counseled Mary on the

consequences of overuse of Afrin and under use
of Vancenase AQ.

Instructed her to use Afrin no more then twice

daily and to alternate nostrils for each dose for 1
week, then reduce to no more than once daily
and continue to alternate nostrils for the second
week.

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 She can then discontinue use.

If Afrin needed in the future for congestion, she

was instructed to use no more than once per
day, in only one nostril, and for not more than 3
days.

Mary agreed to try the Vancenase AQ on a

regular basis after discussion of mechanism and
efficacy and patient was then given a dosing
reminder calendar to check off doses used.
Inhaler technique tested after counseling and
was appropriate.

Follow-up (F/U):

Pharmacist will call patient at home in one

week.

Assess Vancenase AQ compliance, status of

Afrin use, and relief of nasal symptoms.

Check on ADR from Vancenase, especially nasal

dryness or irritation.

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 If no change or worsening in symptoms or
patient unable to tolerate Afrin taper, will then
refer to physician for medical evaluation.

Mary Blythe 12/29/02

Adverse drug reaction-nasal congestion

and hypotension possibly due to Serzone

Subjective (S):

As above

Additionally patient has been on Serzone 150

mg BID for 3 months for treatment of
depression that has been ongoing for “about a
year”.

She states that she is feeling much better and

the Serzone has been “a lifesaver”.

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 She would like to continue on this medication
due to the response she has seen.

No complaints of headache, stomach upset, or

drowsiness.

Still some insomnia is requiring Benadryl 100

mg at HS which seems to help.

States she feels dizzy occasionally, especially on

standing up.

This has been more of a problem the last few

months.

BP in doctor’s office runs “110/70 most of the

time”.

Objective (O):

BP: 90/60 mmHg, Pulse 78 bpm.

Assessment (A):

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 Serzone through alpha-receptor blocking
effects could be contributing to both nasal
congestion and hypotension. Although the
hypotension is an unusual side effect with this
medication, it is temporally associated with the
initiation of this medication in Mary.

Plan (P):

Pharmacist need to discuss the potential for the

Serzone to be contributing to symptoms with
Mary.

Pharmacist agreed with Mary not to

recommend to her physician that Serzone be
changed at this time.

Letter was written to physician making him

aware of BP, potential connection with
depression therapy.

Mary’s desire was to continue therapy and

proposed follow-up plan.

Follow-up (F/U):

39
 When talk with patient in one week, assess
depression status, change in nasal congestion,
sleeping, and dizziness.

Get BP readings if possible.

If continued dizzy and hypotensive, refer to

physician for assessment.

Mary Blythe 12/29/02

Dosage too high-dose and

duration of
Benadryl

Subjective (S):

As seen above.

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 Mary is taking Benadryl 100 mg @ HS for
allergies and insomnia.

She has taken this every night for months.

She acknowledges that this may be a residual

symptom from her depression.

Otherwise she feels well, has no problems with

morning drowsiness, or complaints of dry
mucosa, or other anti-cholinergic effects, and
states she does not want to change her use of
Benadryl at this time.

She quit smoking 2 years ago, does not drink

alcohol, and drink 4-5 cups of decaf coffee per
day.

Objective (O):

None

Assessment (A):

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 The dose and duration of Benadryl are
inappropriate for the treatment of either
allergies (not good 24-hour coverage) or
insomnia (development of tolerance).

Plan (P):

While Benadryl use is not optimal, it doesn’t

appear to be causing problems at present.

Mary agreed to consider reducing its use if

nasal congestion resolves.

Counseled Mary on appropriate sleep hygiene

and loaned her a set of relaxation tapes that
she can try to see if they help her fall asleep.

She agreed to buy a set if they help.

When she is willing to try in the future, I

instructed Mary that I would recommend
decreasing the Benadryl dosage by 25 mg per
night at weekly intervals.

Once she is off, I would recommend taking no

more than 50 mg at bed time when her
allergies are troublesome.

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Follow-up (F/U):

Discuss insomnia symptoms when call patient

in 1 week.

If nasal symptoms are improving, reintroduce

the thought of tapering off the Benadryl.

=====================================
====
Prof. Dr. Suwaldi Martodihardjo, M.Sc., Apt
Faculty of Pharmacy
Gadjah Mada University
Jogjakarta

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