TB is a 68-year-old male who presents to community pharmacy with new prescriptions for Pred Forte 1% and Vigamox 0.5% ophthalmic solution. He states that his eye doctor wants him to start these medications the day before his cataract surgery next week. While talking to him, you notice that his eyes are cloudy, and he seems to be squinting to read signs. He also requests refills on his prostate medications. You inform the patient that you would like to review his profile and will be back shortly.

New prescriptions:

Pred Forte 1%: 1 drop OU QID for 2 weeks. Start 24 hours before procedure.

Vigamox 0.5% ophthalmic solution: 1 drop OU q8H for 7 days. Start 24 hours before procedure.

Medications on profile:

Amlodipine 10 mg: 1 tablet PO QD #90 (Last dispensed: 2 months ago)

Metformin 1000 mg: 1 tablet PO BID #180 (Last dispensed: 2 months ago)

Toprol-XL 50 mg: 1 tablet PO QD #90 (Last dispensed: 3 months ago)

Flomax 0.4 mg: 1 capsule PO QD #90 (Last dispensed: 3 months ago)

Avodart 0.5 mg: 1 capsule PO QD #30 (Last dispensed: 1 months ago)

After reviewing TB's profile, what is the best course of action for the patient? Select all that apply.

A. Counsel the patient on his risk for floppy iris syndrome.

B. Counsel the patient to shake the Pred Forte eye drops well before using them.

C. Inform the patient that the metformin should be held for 48 hours after the procedure.

D. Contact the patient’s urologist to inform them that concomitant use of Flomax and Avodart is contraindicated in benign prostate hyperplasia (BPH).

E. Counsel the patient to wait 5 minutes between using the two eye drops.

TB is exhibiting signs and symptoms of cataracts, with cloudy lenses and light sensitivity. He will be having corrective surgery for this issue. Antibiotic and anti-inflammatory eye drops are commonly used pre- and post-operatively to prevent infections and reduce swelling associated with the procedure. While cataract surgery is usually a safe procedure, there are complications that can arise.

Answer A is correct. The patient is currently on Flomax, which is an alpha-1 blocker, which aids in the relaxation of smooth muscle in the bladder neck and prostate causing improved urine flow and decreased symptoms of BPH. However, there are also alpha-1 receptors in the eye, where blockade can result inhibition of the contraction of the iris dilator. As a result, this could lead to the complication of floppy iris syndrome during cataract surgery.

Answer B is correct. Pred Forte is a suspension eye drop; therefore, it should be shaken prior to use to ensure uniform dispersion of active ingredients.

Answer C is incorrect. Sometimes prior to major surgery lasting more than 2 hours or procedures involving administration of iodinated contrast, metformin may be held for 48 hours after to ensure kidney damage has not occurred, termed contrast-induced nephropathy (CIN). This procedure would not require holding of metformin and even if it was a procedure that required iodinated contrast, contacting the prescriber to discuss this option would be the best course of action. 

Answer D is incorrect. Tamsulosin, an alpha-1 blocker, helps relieve lower urinary tract symptoms (LUTS), such as straining to urinate, increased urinary frequency, and post-void residual volume. Avodart is a 5-alpha reductase inhibitor, which helps prevent the progression of BPH by inhibiting the conversion of testosterone to dihydrotestosterone, a proponent in prostate growth. These two classes can be used in conjunction to treat BPH. Relief of symptoms typically occurs within days of starting an alpha-1 blocker while maximum symptom relief usually takes 6 to 12 months with 5-alpha reductase inhibitors.

Answer E is correct. Patients should wait at least 5 minutes between different eye drops to minimize washing out of previous eye drops and maximize absorption.

Brands/Generics covered: Pred Forte (prednisolone acetate), Vigamox (moxifloxacin); Toprol-XL (metoprolol succinate); Flomax (tamsulosin); Avodart (dutasteride)

NAPLEX Competencies Covered:

Area 1 (Obtain, Interpret, or Assess Data, Medical, or Patient Information), 1.2 From patients, 1.4 Medical Records, 1.5 Signs or symptoms of medical conditions. Area 2 (Identify Drug Characteristics), 2.1 Pharmacology, mechanism of action, or therapeutic class, Area 3 (Develop or Manage Treatment Plans), 3.7 Adverse drug effects, toxicology, or overdose, Area 6 (Develop or Manage Practice or Medication-Use Systems to Ensure Safety and Quality), 6.4 Vulnerable populations, special populations, or risk prevention programs