LR is a 53 year-old woman who presents to your retail pharmacy with a prescription for Premarin 0.3 mg PO once daily. She has been experiencing hot flashes, vaginal dryness, and mood changes. 

PMH:

HTN (Most recent blood pressure was 122/76 mmHg)

Hyperlipidemia (Most recent labs 3 months ago: LDL 72 mg/dL; HDL 55 mg/dL; Total cholesterol: 122 mg/dL

Hx of DVT in 2019

Rheumatoid Arthritis

Surgical history: Hysterectomy 2 years ago

Allergies:

Peanuts

Lisinopril

Medication list:

Micardis 80 mg PO daily

Pravachol 40 mg PO daily

Remicade 3 mg/kg IV every 8 weeks

What component of LR's medical history would present a contraindication with Premarin?

A. Hypertension

B. History of DVT

C. Remicade drug interaction

D. Peanut allergy

Answer with Rationale:

Menopause is a common disorder that women face starting usually in their late 40s/early 50s. The pathophysiology of menopause is from the lack of estradiol and progesterone with an increase in FSH. Many women often search for pharmacological help with their symptoms, but some lifestyle changes have been proven to help as well such as cooling products, decreasing smoking, and increasing their exercise. The pharmacological options for menopause are comprised of localized therapies (e.g. intravaginal creams) and systemic treatments. Systemic treatment with estrogens such as Premarin is generally reserved for patients that experience vasomotor symptoms. Although the systemic treatments have high efficacy, they have a number of important contraindications. Risk/benefit analysis must be assessed on each individual patient. 

Answer A is incorrect. Uncontrolled hypertension is a contraindication for Premarin because it can lead to increased risk of stroke and myocardial infarction, but LR currently has controlled blood pressure and would not exclude her from using Premarin.

Answer B is correct. LR’s history of a DVT although now resolved is an absolute contraindication to Premarin because of the increased risk of recurrent DVT or new  ischemic stroke.

Answer C is incorrect. There is no drug-drug interaction between Premarin and Remicade.

Answer D is incorrect. Premarin does not contain peanuts which may be confused with Prometrium which is contraindicated in patients with allergies to peanuts.

Brand/generics Covered:

Conjugated Estrogen (Premarin), Telmisartan (Micardis), Infliximab (Remicade)

Naplex Competencies Covered:

1.2 Medication History

1.5 Signs or symptoms of medical conditions

2.2 Brand, generic

3.6 Drug contraindications, allergies

3.8 Drug interactions