S.H., age 47, reports difficulty falling asleep and staying asleep. These problems have been ongoing for many years, but she has never mentioned them to her health care provider. She has generally “lived with it” and selftreated the problem with OTC Tylenol PM. Currently, she is also experiencing perimenopausal symptoms of night sweats and mood swings. Current medical problems include hypertension controlled with medications. Past medical history includes childhood illnesses of measles, chickenpox, and mumps. Family history is positive for diabetes on the maternal side and hypertension on the paternal side. Her only medication is an angiotensinconverting enzyme inhibitor and diuretic combination for hypertension control. She generally does not like taking medication and does not take any other OTC products. 1. List specific goals of therapy for S.H. 2. What drug therapy would you prescribe? Why? 3. What are the parameters for monitoring the success of the therapy? 4. Discuss specific patient education based on the prescribed therapy 5. List one or two adverse reactions for the selected agent that would cause you to change therapy. 6. What would be the choice for second-line therapy? 7. What OTC and/or alternative medicines might be appropriate for this patient? 8. What dietary and lifestyle changes might you recommend? 9. Describe one or two drug–drug or drug–food interactions for the selected agent.

1. The specific goals of therapy for S.H. would include improving her sleep quality, reducing the difficulty in falling asleep and staying asleep, managing her perimenopausal symptoms such as night sweats and mood swings, and addressing her hypertension.

2. For S.H., considering her difficulty with sleep, perimenopausal symptoms, and hypertension, a drug therapy approach that addresses multiple aspects of her condition would be ideal. A possible drug therapy option would be a selective serotonin reuptake inhibitor (SSRI) such as sertraline. SSRIs have been shown to be effective in managing perimenopausal symptoms, including mood swings, and they have shown positive effects on sleep patterns as well. Additionally, SSRIs are widely available, commonly prescribed, and have a good safety profile.

3. The parameters for monitoring the success of the therapy would include assessing S.H.’s sleep patterns and quality using subjective measures such as self-reported sleep duration, ease of falling asleep, and number of awakenings during the night. Additionally, objective measures such as a sleep study or actigraphy could be used to monitor her sleep architecture and any changes in sleep patterns. S.H.’s perimenopausal symptoms, specifically night sweats and mood swings, should also be evaluated regularly to determine the effectiveness of the therapy. Blood pressure monitoring should be continued to ensure that her hypertension is well-controlled.

4. Patient education based on the prescribed therapy would include providing S.H. with information about the potential benefits and side effects of SSRIs. It is important to explain that the therapeutic effects of SSRIs may take several weeks to be fully realized and that adherence to the prescribed medication regimen is crucial for optimal results. S.H. should be educated about the importance of following up with her healthcare provider regularly to monitor her progress and adjust the dosage if necessary. Additionally, she should be advised on the potential interaction between SSRIs and other medications she may be taking, as well as the importance of avoiding abrupt discontinuation of the medication.

5. One or two adverse reactions of sertraline that would cause a change in therapy could include serotonin syndrome, which is a potentially life-threatening condition characterized by confusion, rapid heart rate, high blood pressure, and hyperthermia. Another possible adverse reaction is sexual dysfunction, which may include decreased libido, erectile dysfunction, or difficulty achieving orgasm. If S.H. experiences either of these adverse reactions, a change in therapy may be necessary.

6. If the chosen therapy with sertraline does not adequately address S.H.’s sleep problems and perimenopausal symptoms, a second-line therapy option could be a low-dose hormone replacement therapy (HRT) specifically tailored to her perimenopausal symptoms. HRT has been shown to be effective in managing menopausal symptoms, including night sweats and mood swings, as well as improving sleep quality. However, since HRT carries certain risks, it should be considered as a second-line option and used cautiously, with close monitoring and regular follow-up.

7. In addition to the prescribed medication, S.H. may benefit from the use of over-the-counter (OTC) options such as melatonin. Melatonin is a hormone that helps regulate sleep-wake cycles and has been shown to be effective in managing insomnia. However, it is important to inform S.H. about the potential interactions between melatonin and her prescribed medication, as well as to discuss the optimal timing and dosage for melatonin use.

8. Dietary and lifestyle changes recommended for S.H. would include practicing good sleep hygiene, such as maintaining a regular sleep schedule, creating a relaxing bedtime routine, and avoiding stimulants such as caffeine or nicotine close to bedtime. S.H. should also be advised to avoid heavy meals, exercise, and excessive fluids close to bedtime, as these can interfere with sleep. It would be beneficial for S.H. to engage in stress-reduction techniques such as meditation or relaxation exercises to promote better sleep and manage her mood swings. Finally, addressing any underlying causes of her hypertension, such as promoting weight loss, reducing sodium intake, and regular exercise, should also be recommended.

9. One or two potential drug-drug interactions for sertraline include the concurrent use of a monoamine oxidase inhibitor (MAOI) or a serotonergic agent such as triptans or tramadol. These combinations can result in serotonin syndrome, as mentioned earlier. Another potential interaction would be with antihypertensive medications, as sertraline may potentiate the blood pressure-lowering effects of these medications. It is important for S.H. to inform her healthcare provider about all the medications she is currently taking to ensure appropriate management and monitoring of potential interactions.