Pharmacologic Decision-Making and Evidence-Based Prescribing
Scenario 1: Prescription Error Identification and Correction
Accurate prescribing is critical to patient safety. The first prescription error involves tamsulosin, which is written as “4 mg PO daily,” a dose significantly exceeding the standard. Tamsulosin is an alpha-1 adrenergic blocker used for benign prostatic hyperplasia (BPH) and should be dosed at 0.4 mg orally once daily, 30 minutes after the same meal each day. The mechanism of action involves selective antagonism of Alpha-1 receptors at the neck of the bladder and prostate, relaxing smooth muscle, enhancing urine flow (Fung et al., 2024). The corrected order is: Tamsulosin 0.4 mg PO daily, 30 minutes after the same meal. Disp: #30, Refills: 2.
The second prescription contains a misspelling—“levofloxcin” instead of levofloxacin—and the dosing must be verified for indication. Levofloxacin 750 mg once daily is appropriate for community-acquired pneumonia or complicated urinary tract infections (Podder & Sadiq, 2024). This fluoroquinolone antibiotic prevents bacterial DNA gyrase and topoisomerase IV from working, blocking replication and transcription. The corrected prescription is: Levofloxacin 750 mg PO daily x 5 days. Disp: #5, Refills: 0.
The third error involves the ciprofloxacin 0.3% “otic” solution for conjunctivitis. Otic solutions are for the ear, not the eye, and ophthalmic formulations must be used for ocular conditions. Ciprofloxacin inhibits Topoisomerase IV and DNA gyrase, which cause bacterial cell death (Thai et al., 2020). The corrected prescription is: Ciprofloxacin 0.3% ophthalmic solution. Apply one or two drops to the affected eye every two hours while awake, and then every four hours for five days. Disp: 5 mL bottle, Refills: 0.
The fourth prescription misstates Paxlovid’s formulation, listing ritonavir as the main component rather than nirmatrelvir. Paxlovid is a co-packaged antiviral that consists of nirmatrelvir (300 mg) and ritonavir (100 mg). Nirmatrelvir inhibits the SARS-CoV-2 3CL protease, while ritonavir slows its metabolism by inhibiting CYP3A enzymes (Hashemian et al., 2023). The corrected order is: Paxlovid (nirmatrelvir 300 mg with ritonavir 100 mg) PO BID x 5 days. Disp: 1 dose pack. Refills: 0.
Lastly, Depo-Provera is incorrectly prescribed as a monthly injection. Medroxyprogesterone acetate is a long-acting progestin contraceptive administered intramuscularly every 12 weeks. It prevents ovulation by suppressing gonadotropin release (Sathe & Gerriets, 2024). The corrected order is: Depo-Provera 150 mg/mL IM every 12 weeks. Disp: 1 mL, Refills: 3.
References
Fung, K. W., Baye, F., Baik, S. H., & McDonald, C. J. (2024). Tamsulosin use in benign prostatic hyperplasia and risks of Parkinson’s disease, Alzheimer’s disease, and mortality: An observational cohort study of elderly Medicare enrollees. PLoS ONE, 19(8), e0309222. https://doi.org/10.1371/journal.pone.0309222
Hashemian, S. M. R., Sheida, A., Taghizadieh, M., Memar, M. Y., Hamblin, M. R., Baghi, H. B., Nahand, J. S., Asemi, Z., & Mirzaei, H. (2023). Paxlovid (Nirmatrelvir/Ritonavir): A new approach to Covid-19 therapy? Biomedicine & Pharmacotherapy, 162, 114367. https://doi.org/10.1016/j.biopha.2023.114367
Podder, V., & Sadiq, N. M. (2024). Levofloxacin. In www.ncbi.nlm.nih.gov. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK545180/
Sathe, A., & Gerriets, V. (2024, February 29). Medroxyprogesterone. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559192/
Thai, T., Salisbury, B. H., & Zito, P. M. (2020). Ciprofloxacin. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/30571075/
Scenario 2: Gonorrhea in a Penicillin-Allergic Patient
FS, a 26-year-old female, presents with classic symptoms of gonorrhea, confirmed by culture. Due to her penicillin allergy, ceftriaxone is contraindicated. According to the CDC’s 2021 STI guidelines, an alternative regimen for treating gonorrhea in patients with severe beta-lactam allergies includes gentamicin 240 mg IM in combination with azithromycin 2 g PO (CDC, 2021). Gentamicin is an aminoglycoside that binds to the 30S ribosomal subunit and prevents the production of proteins, while azithromycin is a macrolide that binds to the 50S subunit, halting bacterial protein production (Chaves & Tadi, 2023).
Chlamydia trachomatis is a common co-infection with gonorrhea and should be empirically treated. In this case, azithromycin 2 g provides dual coverage. The complete treatment plan is 240 mg of Gentamicin IM once. Disp: 1 dose. Refills: 0, and Azithromycin 2 g PO once. Disp: 4 × 500 mg tablets. Refills: 0.
Following treatment, FS should be advised to refrain from having sex for at least seven days and till her sexual partner(s) have also been treated. Patient education should emphasize STI prevention, condom use, retesting in three months, and notifying partners. This aligns with CDC recommendations for safer sex practices and reducing reinfection risk (Workowski et al., 2021).
References
CDC. (2021). Syphilis – STI treatment guidelines. CDC. https://www.cdc.gov/std/treatment-guidelines/syphilis.htm
Chaves, B. J., & Tadi, P. (2023, April 10). Gentamicin. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557550/
Workowski, K. A., Bachmann, L. H., Chan, P. A., Johnston, C. M., Muzny, C. A., Park, I., Reno, H., Zenilman, J. M., & Bolan, G. A. (2021). Sexually transmitted infections treatment guidelines, 2021. MMWR Recommendations and Reports, 70(4), 1–187. https://www.cdc.gov/std/treatment-guidelines/STI-Guidelines-2021.pdf
Scenario 3: Warfarin and Bactrim Drug Interaction
JH, a 68-year-old male recently started on warfarin for DVT, presents with an INR of 6.9 after being prescribed Bactrim DS for a urinary tract infection. Bactrim contains sulfamethoxazole and trimethoprim, which inhibit the cytochrome P450 enzyme CYP2C9, thereby reducing the metabolism of the S-isomer of warfarin, leading to increased anticoagulant effects (Kemnic & Coleman, 2022). This interaction is well-documented and particularly dangerous given warfarin’s narrow therapeutic window.
Since the patient has no active bleeding but exhibits minor bruising, the appropriate response is to discontinue Bactrim immediately and hold warfarin for 48 hours. Daily INR monitoring should continue until levels fall below 3. If bleeding risk increases or INR does not decrease, vitamin K 1 mg PO may be administered (Patel et al., 2024). Warfarin can be started again at a reduced dosage after the INR stabilizes. The adjusted prescription is: Hold warfarin x 2 days, then resume Warfarin 4 mg PO daily—disp: #30, Refills: 3, and Vitamin K 1 mg PO once. Disp: #1, Refills: 0.
His other medications, sertraline and lisinopril, do not require adjustment at this time. This case highlights the importance of pharmacist consultation and prescriber awareness when managing patients on anticoagulation therapy (Singh & Saadabadi, 2023).
References
Kemnic, T. R., & Coleman, M. (2022, November 28). Trimethoprim sulfamethoxazole. NIH.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513232/
Patel, S., Preuss, C. V., Bhutani, J., & Patel, N. (2024). Warfarin. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470313/
Singh, H. K., & Saadabadi, A. (2023, February 13). Sertraline. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK547689/
Scenario 4: Vancomycin Dosing and Monitoring
A 70 kg patient has been prescribed vancomycin 15 mg/kg IV every 12 hours, resulting in a dose of 1050 mg. Since the pharmacy stocks vancomycin as 1 g per 20 mL, 21 mL is needed to prepare a 1050 mg dose. With an infusion rate of 10 mg/min, this dose should be administered over 105 minutes.
A trough level drawn 30 minutes before the fourth dose is nine mcg/mL, which is subtherapeutic for severe infections such as MRSA bacteremia, where target trough levels should be 15–20 mcg/mL (Rosenthal & Burchum, 2020). Therefore, the dose should be increased to 17 mg/kg, approximately 1200 mg for this patient. The revised order is: Vancomycin 1200 mg IV every 12 hours, infuse over 2 hours. Disp: 10 doses. Refills: 0.
Vancomycin is usually administered intravenously due to its poor oral bioavailability. Oral vancomycin is only effective for localized gastrointestinal infections, such as Clostridioides difficile colitis, because it remains within the gut without systemic absorption (Patel et al., 2024). Proper dosing and therapeutic drug monitoring are essential to avoid nephrotoxicity while ensuring therapeutic effectiveness (Kyriakopoulos & Gupta, 2024).
References
Kyriakopoulos, C., & Gupta, V. (2024, July 27). Renal failure drug dose adjustments. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK560512/
Patel, S., Preuss, C. V., & Bernice, F. (2024). Vancomycin. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459263/
Rosenthal, L. D., & Burchum, J. R. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Elsevier Health Sciences.
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Question 
DIRECTIONS. APA. References not older than 5 years.
For each of the scenarios below, answer the questions using your learning resources, Medscape, and clinical practice guidelines (ie, JNC 8, AHA, ACC, etc). Lecturio is an optional resource but highly recommended. Be sure to thoroughly answer ALL questions. When recommending medications, write out a complete medication order. What would you send to a pharmacy? Include drug, dose, route, frequency, special instructions, # dispensed (days supply), and refill information. Also, state if you would continue, discontinue, or taper the patient’s current medications. Review and discuss ALL labs and possible interactions. Use at least 3 sources for each scenario and cite sources using APA format; include in-text citations. You do not need an introduction or a conclusion paragraph. Please also review the assignment rubric.
Pharmacologic Decision-Making and Evidence-Based Prescribing
To Prepare:
Review the assignment rubric and case studies. Be sure to answer ALL thoroughly
Explain the problem and discuss how you would address the problem.
When recommending medications, write out a complete prescription for each medication. What order would you send to a pharmacy? Include drug, dose, route, frequency, special instructions, # dispensed (days supply), refills, etc. Also, state if you would continue, discontinue or taper the patient’s current medications.
Answer questions using your learning resources, Medscape, and clinical practice guidelines (ie, JNC 8, AHA, ACC, etc). Lecturio is an optional resource, but highly recommended. Include at least three references to support each scenario and cite them in APA format. Please include in-text citations. You do not need an introduction or a conclusion paragraph.
Assignments require evidence-based literature (primary resources and clinical guidelines) to support decisions/recommendations. Also, sources should be from within the last 5 years. Please review the rubric each week for EACH assignment to maximize points. The course resources (Lecturio) should be used as a starting point, but further research on the topic should include the most recent, up-to-date clinical resources and guidelines.
References MUST include applicable clinical guidelines to support and provide a rationale for ALL RECOMMENDATIONS. Please review the following course announcements: Scholarly Sources Expectations and Evidence-Based Literature.
WEEK 9 ASSIGNMENT (covers weeks 9-11)
SCENARIO 1
What are the errors in the following prescriptions (5 total)? Rewrite each prescription correctly. What is each medication classification? What is the mechanism of action (MOA)?
tamsulosin 4 mg po daily, 30 minutes after the same meal each day #30 2 RF
levofloxcin 750 mg po daily for 5 days #5 0 RF
ciprofloxacin 0.3% otic solution for bacterial conjunctivitis; instill 1-2 drops into eye every 2 hours while awake for 2 days then 1-2 drops every 4 hours while awake for the next 5 days #1 bottle 0 RF
Paxlovid 300 mg ritonavir plus 100 mg nirmatrelvir po BID x 5 days #1 dose pack 0 RF
Depo-Provera 150 mg IM inject once monthly #1 3 RF
SCENARIO 2
FS is a 26-year-old sexually active female who presents with a 5-day history of yellow vaginal discharge, pelvic discomfort, and burning with urination. She reports unprotected intercourse with a new male partner over the past month. A gonorrhea culture returns positive. FS has documented allergies to latex and penicillin. What is the recommended first-line treatment for gonorrhea in this patient? What additional sexually transmitted infection should be empirically treated, and with which medication? Provide complete medication orders. How long should she abstain from sex to avoid reinfection, and what patient education should be provided?
SCENARIO 3
JH is a 68-year-old male recently discharged from the hospital following a diagnosis of deep vein thrombosis (DVT). He was started on warfarin 5 mg PO daily with INR monitoring. At his follow-up clinic visit 6 days post-discharge, he reports that his primary care provider prescribed Bactrim DS (sulfamethoxazole/trimethoprim 800/160 mg) twice daily for 7 days to treat a urinary tract infection. Today, his INR is 6.9. He has minor bruising on his arms but no active bleeding. Additional medications include sertraline 100 mg po daily for depression and lisinopril 10 mg po daily for hypertension. What is the mechanism behind this interaction? How should JH’s medication therapy be adjusted? Provide complete medication orders.
SCENARIO 4
A patient is prescribed vancomycin 15 mg/kg IV every 12 hours for a 70 kg patient. The pharmacy stocks vancomycin 1 g per 20 mL vials.
How much vancomycin (mg) should be administered per dose?
How many milliliters of vancomycin solution should be drawn up for each dose?
If the infusion rate is 10 mg/min, how long will it take to administer one dose?
A trough level is drawn 30 minutes before the 4th dose, and the result is 9 mcg/mL. Is the current dosing regimen appropriate based on the trough level? Would you increase, decrease, or leave the dose the same?
Why is vancomycin usually given IV and not PO?