Hiding in Plain Sight: A Pharmacotherapy Workup Uncovering Overlooked Drug Therapy Problems in a Man with Advanced Prostate Cancer, Hypertensive Heart Disease and Urosepsis

Abstract

Up to 70–80% of men with prostate cancer carry concurrent hypertension or hypertensive heart disease, and advancing disease frequently brings castration-resistant progression, cancer-associated thrombosis, transfusion-dependent anaemia and infection — a pharmacotherapeutic burden that multiplies the opportunities for drug therapy problems in a single admission. A 67-year-old man with a six-year history of hypertension and known prostate cancer (post bilateral orchidectomy, 2020) was transferred to the surgical ward after a sudden collapse, with general weakness and abdominal pain. He was found to have advanced, castration-resistant prostate cancer with hypertensive heart disease, severe anaemia (hae­moglobin 9.1 g/dL), gastroenteritis and urosepsis, and was started on an eleven-drug regimen spanning androgen-axis therapy, empiric antibiotics, anticoagulation, analgesia and transfusion support. Applying the Pharmacists' Patient Care Process/Pharmacotherapy Workup to this regimen surfaced ten discrete drug therapy problems, including an apparent absence of the corticosteroid co-therapy mandated for abiraterone, a guideline-discordant anticoagulant choice for cancer-associated thrombosis, a clinically significant NSAID–anticoagulant combination, additive orthostatic-hypotension risk from tamsulosin and tizanidine, a cardiac-unfavourable analgesic choice, and — most strikingly — a post-transfusion haemoglobin trend that moved in the wrong direction. Pharmacist-led separation of oral iron and zinc restored their intended therapeutic effect, pain from gastroenteritis and metastatic disease was adequately controlled, blood-pressure monitoring was intensified around the tamsulosin–tizanidine combination, and the patient reported marked humanistic benefit from routine pharmacist follow-up; the anticoagulant-selection and corticosteroid-adequacy questions are carried forward as unresolved recommendations for the treating team. A single, complex oncology-surgical admission can conceal several clinically important, evidence-supported drug therapy problems within a medication list that looks unremarkable at first read; a structured pharmacotherapy workup — rather than opportunistic review — is what actually surfaces them.