NURS 6521 Week 3: Cardiovascular System
101 min read
NURS 6521 Week 3: Cardiovascular System
Alterations of the cardiovascular system can cause serious adverse events and may lead to death when not treated in a timely and safe manner. Unfortunately, many patients with cardiovascular disorders are unaware until complications appear. Consider hypertension. An estimated 68 million people in the United States have this disorder (CDC, 2012). However, about 30 percent of these patients are not treated at all, and of those who are treated, less than 50 percent have properly controlled blood pressure levels (University of Maryland Medical Center, 2009). In clinical settings, patients often present with symptoms of hypertension and other cardiovascular disorders making it essential for you, as the advanced practice nurse, to be able to recognize these symptoms and recommend appropriate drug treatment options.
This week you examine the impact of changes in pharmacokinetic and pharmacodynamic processes on patient drug therapy for cardiovascular disorders. You also explore ways to improve drug therapy plans for these disorders.
Learning Objectives
By the end of this week, students will:
Evaluate the influence of patient factors on pharmacokinetic and pharmacodynamics processes
Analyze the impact of changes in pharmacokinetic and pharmacodynamic processes on patient drug therapy
Evaluate drug therapy plans for cardiovascular disorders
Understand and apply key terms, concepts, and principles related to prescribing drugs to treat cardiovascular disorders
Photo Credit: GIPhotoStock/Cultura/Getty Images
Learning Resources
This page contains the Learning Resources for this week. Be sure to scroll down the page to see all of this week’s assigned Learning Resources. To access select media resources, please use the media player below.
Required Readings
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Chapter 19, “Hypertension” (pp. 257-272)
This chapter examines the relationships between the cardiovascular, nervous, and renal systems. It then describes diagnostic criteria for hypertension patients, drugs used to treat hypertension and possible adverse reactions, monitoring patient response, and patient education.
Chapter 20, “Hyperlipidemia” (pp. 275-286)
This chapter explores causes of hyperlipidemia, treatments for hyperlipidemia patients, and methods for monitoring patient response. It also reviews strategies for risk assessment and patient education.
Chapter 21, “Chronic Stable Angina” (pp. 289-303)
This chapter begins by exploring factors that contribute to chronic stable angina, types of drugs used in treatment, and diagnostic criteria for initiating drug therapy. It also examines methods for monitoring patient response to treatment and educating patients on self-care.
Chapter 22, “Heart Failure” (pp. 305-322)
This chapter examines the process of prescribing drugs to treat heart failure and explores effects of prescribed drugs, proper dosages, and possible adverse reactions.
Chapter 50, “Pharmacotherapy for Venous Thromboembolism Prevention and Treatment, Stroke Prevention in Atrial Fibrillation, and Thromboembolism Prevention with Mechanical Heart Valves” (pp. 863-886)
This chapter covers drug therapy options for three disorders requiring anticoagulants: venous thromboembolism, atrial fibrillation, and ischemic stroke. It also explains the process of initiating and managing drug therapy for patients with these disorders.
Required Media
Note: The approximate length of this media piece is 10 minutes.
Optional Resources
Refer to the Optional Resources listed in Week 1.
Discussion: Pharmacotherapy for Cardiovascular Disorders
As the leading cause of death in the United States for both men and women, cardiovascular disorders account for 7 million hospitalizations per year (NCSL, 2012). This is the result of the extensive treatment and care that is often required for patients with these disorders. While the incidences of hospitalizations and death are still high, the mortality rate of cardiovascular disorders has been declining since the 1960s (CDC, 2011). Improved treatment options have contributed to this decline, as well as more knowledge on patient risk factors. As an advanced practice nurse, it is your responsibility to recommend appropriate treatment options for patients with cardiovascular disorders. To ensure the safety and effectiveness of drug therapy, advanced practice nurses must consider aspects that might influence pharmacokinetic and pharmacodynamic processes such as medical history, other drugs currently prescribed, and individual patient factors.
Consider the following case studies:
Case Study 1:
Patient AO has a history of obesity and has recently gained 9 pounds. The patient has been diagnosed with hypertension and hyperlipidemia. Drugs currently prescribed include the following:
Atenolol 12.5 mg daily
Doxazosin 8 mg daily
Hydralazine 10 mg qid
Sertraline 25 mg daily
Simvastatin 80 mg daily
Case Study 2:
Patient HM has a history of atrial fibrillation and a transient ischemic attack (TIA). The patient has been diagnosed with type 2 diabetes, hypertension, hyperlipidemia and ischemic heart disease. Drugs currently prescribed include the following:
Warfarin 5 mg daily MWF and 2.5 mg daily T, TH, Sat, Sun
Aspirin 81 mg daily
Metformin 1000 mg po bid
Glyburide 10 mg bid
Atenolol 100 mg po daily
Motrin 200 mg 1–3 tablets every 6 hours as needed for pain
Case Study 3:
Patient CB has a history of strokes. The patient has been diagnosed with type 2 diabetes, hypertension, and hyperlipidemia. Drugs currently prescribed include the following:
Glipizide 10 mg po daily
HCTZ 25 mg daily
Atenolol 25 mg po daily
Hydralazine 25 mg qid
Simvastatin 80 mg daily
Verapamil 180 mg CD daily
To prepare:
Review this week’s media presentation on hypertension and hyperlipidemia, as well as Chapters 19 and 20 of the Arcangelo and Peterson text.
Select one of the three case studies, as well as one the following factors: genetics, gender, ethnicity, age, or behavior factors.
Reflect on how the factor you selected might influence the patient’s pharmacokinetic and pharmacodynamic processes.
Consider how changes in the pharmacokinetic and pharmacodynamic processes might impact the patient’s recommended drug therapy.
Think about how you might improve the patient’s drug therapy plan based on the pharmacokinetic and pharmacodynamic changes. Reflect on whether you would modify the current drug treatment or provide an alternative treatment option for the patient.
With these thoughts in mind:
By Day 3
Post an explanation of how the factor you selected might influence the pharmacokinetic and pharmacodynamic processes in the patient from the case study you selected. Then, describe how changes in the processes might impact the patient’s recommended drug therapy. Finally, explain how you might improve the patient’s drug therapy plan.
By Day 6
Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days who selected a different case study than you did, in one or more of the following ways:
Provide alternative recommendations for drug treatments.
Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
Validate an idea with your own experience and additional research.
Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Submission and Grading Information
Grading Criteria
Submission
Post by Day 3 and Respond by Day 6
To participate in this Discussion:
Week 3 Quiz
This week’s Quiz covers the content you have explored this week. The Quiz may include the following topics:
Drug classifications by indication—ACE-I, ARB, anticoagulants, antiplatelet, beta blockers, calcium channel blockers, cardiovascular system, DRI
Drug dosage calculations
Drug interactions
By Day 7
You have 60 minutes to complete this 26-question Quiz.
This quiz is a test of your knowledge in preparation for your certification exam. No outside resources including books, notes, websites, or any other type of resource are to be used to complete this quiz. You are expected to comply with Walden University’s Code of Conduct.
Submission and Grading Information
Submit Your Quiz by Day 7
2 months ago
Brandy Barrett
Week 3 Initial Post
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Week 3 Initial Post
Nurs 6521
Case Study 2
Patient HM has an extensive cardiovascular history. There is a history of atrial fibrillation, ischemic attack (TIA), type 2 diabetes, hypertension, hyperlipidemia, and ischemic heart disease. The patient is prescribed a list of medications that include:
Warfarin 5 mg daily po MWF and 2.5 mg daily T, TH, Sat, Sun
Aspirin 81mg daily po
Metformin 1000 mg PO
Glyburide 10 mg PO BID
Atenolol 100 mg PO daily
Motrin 200 mg 1-3 tablets every 6 hours as needed for pain
Cardiovascular disease affects many people worldwide annually. Kendir et al. 2018 state that cardiovascular diseases are the most common cause of death from non-communicable diseases (p.46). Cardiovascular disease can refer to many diseases that affect the heart, and it’s vessels. Our patient HM had many diagnosed cardiovascular disorders. Atrial fibrillation which is an arrhythmia the heart due to loss of coordination of electrical and mechanical activity in the atria (Arcangelo, Petterson, Wilbur, & Reinhold, 2017, p.864). Clots or thrombi can develop from atrial fibrillation causing strokes or ischemic attacks. Unfortunately, HM had a history of ischemic attacks (TIA). According to Arcangelo et al. 2017, an ischemic stroke is described as a sudden or progressive onset of focal neurologic sign due to the inadequate blood supply to the brain (p.868). Having hyperlipidemia which is a high blood level of cholesterol further makes heart disease worse because the cholesterol builds up in vessels affecting blood flow. Hypertension heightens the potential of developing cardiovascular disease and chronic kidney disease. Hypertension can go for a long period of time going undetected because it can be asymptomatic. Finally, HM was diagnosed with type II diabetes, which is caused when adipose and muscle cells become less sensitive to the actions of insulin or the pancreas produces less insulin than the body needs (Arcangelo, Petterson, Wilbur, & Reinhold, 2017,p.785).
Patient Factor
The disorders that HM has been diagnosed with can happen at any age, however, in elderly patients, they may have a poorer prognosis because medications are not always processed by the body as well or as intended. The development and worsening of cardiovascular disease are associated with many factors such as genetics, lifestyle choices/behaviors, ethnicity, and age. With so many other factors as a person ages, it is worsening the disease because that is a factor that cannot be changed. With the patient HM’s medical history as a provider, you have to be cautious when prescribing because medications are absorption may be affected because of age.
Drug Therapy Plan
The patient’s medical history puts him at higher risk of having a heart attack or stroke from complications of cardiovascular disease. With this patient, we want to control his diabetes, hypertension, hyperlipidemia, and atrial fibrillation keeping levels within normal limits without over prescribing to this patient. The first thing that was noticed when looking at the patient’s medication list is that he is talking two medications with anticoagulant effects. Warfin which is a strong anticoagulant and aspirin. When taking Warfin routine lab work is needed to check the PT, INR, and aPTT levels in the blood to determine if the medication dose needs to be adjusted. Added aspirin in could cause increased bleeding, the elderly population with underlying malignancy and those taking interacting drugs that increase warfarins effect are at high risk for bleeding and should receive lower initial doses (Arcangelo, Petterson, Wilbur, & Reinhold, 2017,p.874).
HM has type two diabetes and is taking Atenolol 100mg daily which is a beta-blocker. Arcangelo et al. 2017 stated, in diabetic patients, beta-blockers can mask all symptom of hypoglycemia except sweating (Arcangelo, Petterson, Wilbur, & Reinhold, 2017,p.266). Being on this medication, the patient would have to consistent with monitoring his glucose levels and educated well on signs and symptoms of hypoglycemia. This patient may benefit better from an Angiotensin II Receptor Blocker such as losartan. For diabetics, losartan is a better choice because it is more effective than atenolol in lower cardiovascular morbidity and mortality in diabetic patients with hypertension and left ventricular hypertrophy (Arcangelo, Petterson, Wilbur, & Reinhold, 2017,p.267). Being that HM is elderly, his initial dose should be losartan 50 mg Po daily. Starting at 50 mg daily leaves enough room to adjust up if needed depending on the patient’s blood pressure (Kizior,2018).
Reference:
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017).
Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins
Kendir, C., van den Akker, M., Vos, R., & Metsemakers, J. (2018). Cardiovascular disease
patients have increased risk for comorbidity: A cross-sectional study in the Netherlands. The European Journal Of General Practice, 24(1), 45–50. https://doi-org.ezp.waldenulibrary.org/10.1080/13814788.2017.1398318
Kizior, R. (2018). Saunders Nursing Drug Handbook 2019. Elsevier – Health Sciences Division.
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2 months ago
Antoinette Joseph
Week 3- Case Study 3
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Main Post
Case Study Selected
Patient CB has a history of strokes and has been diagnosed with type 2 diabetes, hypertension, and hyperlipidemia. Drugs currently prescribed are Glipizide 10 mg po daily, HCTZ 25 mg daily, Atenolol 25 mg po daily, Hydralazine 25 mg qid, Simvastatin 80 mg daily, Verapamil 180 mg CD daily
Pharmacological Evaluation
Glipizide 10 mg PO daily
Glipizide is classified as a sulfonylurea (Connective Rx, 2018) which is being utilized to treat the patient’s diabetes. This medication should be administered 30 minutes before meals (Connective Rx, 2018). Dosing starts at 5mg by mouth daily with a max of 40mg per day, and maintenance is usually 10mg-15mg once a day (Connective Rx, 2018). The mechanism of action for glipizide is to lower the blood sugar by stimulation of the pancreatic islet cells, which in turn causes an increase in insulin secretion (Connective Rx, 2018). There is a decrease in efficacy of the medication if there is a decrease in the number of functioning beta cells or a low number of viable cells. This medication is highly protein bound, metabolized by the liver, excreted in the urine, has a half-life of 2-4 hours, and duration of action of 12-24 hours (Connective Rx, 2018). Special considerations include hepatic impairment in which the initial dose should be decreased to 2.5mg by mouth daily (Connective Rx, 2018). Patients with renal impairment have an increased predisposal to hypoglycemic reactions requiring close monitoring of blood glucose levels (Connective Rx, 2018). Within the current drug regime currently prescribed for the patient, drug to drug interactions are present with atenolol and hydrochlorothiazide (HCTZ). Atenolol can hide the symptoms of hypoglycemia which causes the need to monitor blood glucose levels more frequently. HCTZ can decrease insulin sensitivity and glucose tolerance.
Hydrochlorothiazide (HCTZ) 25 mg daily
Hydrochlorothiazide (HCTZ) is classified as a thiazide diuretic (Connective Rx, 2018) that is being used to treat the patient’s hypertension (HTN). Initial dosage is 12.5mg – 25mg PO once daily with a maximum dosage of 50 mg daily prescribed in one or two doses (Connective Rx, 2018). The mechanism of action for HCTZ is to decrease the excretion of sodium, chloride, and water by inhibiting sodium ion transport across the renal tubule epithelium (Connective Rx, 2018). The main mechanism of action occurs with the inhibition of the chloride reabsorption to the distal portion of the ascending limb or previous parts of the distal tubule (Connective Rx, 2018). Dosage adjustments must be made with renal patients based on the creatinine clearance (Connective Rx, 2018). HCTZ is excreted unchanged in the urine. 61% of it excreted within 24 hours and it has a half-life of 5.6 – 14.8 hours (Connective Rx, 2018). Caution must be considered in individuals with diabetes due to the impaired glucose tolerance that occur with this medication. The administration of glipizide and HCTZ can cause decreased insulin sensitivity (Connective Rx, 2018).
Atenolol 25mg daily
Atenolol is a selective beta-blocker that is also being utilized for blood pressure management. Initial dosing is 25-50mg by mouth daily with a maximum dosage of 100 mg per day (Connective Rx, 2018). The mechanism of action includes a beta-adrenergic antagonist countering the effects of the sympathetic neurotransmitters by fighting for the receptor sites (Connective Rx, 2018). Atenolol is minimally bound to plasma proteins, has little to no metabolism in the liver, 30% of it is excreted in the urine after 24 hours, and has a half-life of 6-7 hours (Connective Rx, 2018). Food reduces the bioavailability by 20% without impacting the overall bioavailability and it has a peak of 2-4 hours after administration. Renal adjustment dosing is done based on creatinine clearance values and 25mg to 50mg can be administered with each standard dialysis session (Connective Rx, 2018). Atenolol can enhance hypoglycemia by interfering with glycogenolysis (Connective Rx, 2018). Atenolol, taken in conjunction with Verapamil, can improve exercise tolerance; however, it can lead to a significant AV nodal blockade, which would manifest as bradycardia, heart conduction abnormalities, or a heart block (Connective Rx, 2018).
Hydralazine25mg QID
Hydralazine is classified as an Arteriole Smooth Muscle Drug being utilized to treat the hypertension. Initial dosing is 10 mg by mouth four times a day, which can be increased to 25 mg by mouth four times a day for the remainder of the week, and can be increased to a dosage of 80 mg by mouth four times a day the second and subsequent weeks (Connective RX, 2018). The max dosage is 300 mg per day (Connective RX, 2018). Hydralazine is a peripheral vasodilator which causes relaxation of arteriolar smooth muscle via a direct effect (Connective RX, 2018). The percentage that binds with plasma proteins is 87%, it is hepatically metabolized (plasma levels depend on the acetylation), it is excreted via the feces and urine (Connective RX, 2018). The half-life is 3-7 hours, it peaks at 1-2 hours, and lasts 2-4 hours (Connective RX, 2018). Renal dosing is based on creatinine clearance. Dosing can be in intervals of 12-24 hours for patients with intermittent hemodialysis or peritoneal dialysis (Connective RX, 2018). Patient education should include caution with driving when starting the medication to determine the effect of the medication on the patient. It can cause confusion and disorientation (Connective RX, 2018).
Simvastatin 80mg daily
Simvastatin is classified as a statin and being utilized to treat hyperlipidemia. Initial dosing is 10-20 mg daily in the evening with dose adjustments made to achieve lipid level targets (Connective RX, 2018). The maximum daily dose is 40 mg per day for initial therapy and 80 mg per day in individuals with chronic myopathy (Connective RX, 2018). Simvastatin impacts hyperlipidemia by impacting the De novo synthesis of cholesterol, enhancing clearance of LDL, decreasing the total cholesterol, LDL, triglycerides, and apolipoprotein B, while increasing HDL (Connective RX, 2018). It is contraindicated for hepatic impairment and initial dosing is decreased to 5 mg per day with renal impairment (Connective RX, 2018). It is activated in the liver, is 95% plasma protein bound, lipophilic, excreted in the feces (60%) and urine (13%) (Connective RX, 2018). It has a half-life of 1.9 hours, with a peak plasma level of 1.3-2.4 hours (Connective RX, 2018). Bioavailability can be impacted by the consumption of high fat meals (Connective RX, 2018). Caution must be taken with individuals with diabetes mellitus due to simvastatin usually worsening glycemic control during therapy and increasing the hemoglobin A1C (Connective RX, 2018). Simvastatin has a major interaction with verapamil in which the risk of myopathy is increased, including rhabdomyolysis (Connective RX, 2018). The dose should not exceed 10 mg per day in patients taking verapamil or clinicians should consider switching to another statin because verapamil increases the exposure of simvastatin two fold (Connective RX, 2018).
Verapamil 180 mg CD daily
Verapamil is classified as a Phenyaklamine Calcium Channel Blocker that is being used to treat the hypertension. Initial dosing is 80 mg by mouth three times a day, with dosage increases occurring at weekly intervals (Connective Rx, 2018). The maximum dosage is 480 mg per day; however, not much benefit has been observed greater than 360 mg per day (Connective Rx, 2018).Verapamil inhibits the influx of extracellular calcium ions across the vascular smooth muscle and the myocardial muscle cell membrane which deforms the channels (Connective Rx, 2018). Verapamil is impacted by the “first-pass” effect, binds to the plasma protein (90%), excreted by the kidneys (70%), and excreted fecally (16%). The onset is in 1-2 hours with duration of 8-10 hours (Connective Rx, 2018). A 33% decrease in the initial dose must be prescribed for individuals with hepatic impairment. Dosing adjustment has to be made with patients with renal impairments (Connective Rx, 2018). Grapefruit juice must be avoided because it increases the bioavailability of verapamil (Connective Rx, 2018). Drug to drug interactions have been mentioned above.
Changes to the Drug Regime
After reviewing the medication list, the one change that would be made is selection of a different statin. This change would be made because of the interaction of the statin with the verapamil. Data indicates the need to change the statin, if verapamil is being prescribed in individuals with high doses of simvastatin (Connective RX, 2018). The drug of choice would be Rosuvastatin Calcium.
Pharmacological Evaluation of the New Drug
Rosuvastatin calcium is a statin that is also utilized to treat hyperlipidemia (Connective Rx, 2018). Initial dosing is 10 mg daily with a maximum dose of 40 mg by mouth per day (Connective Rx, 2018). Rosuvastatin calcium decreases LDL cholesterol, triglycerides, total cholesterol , and apolipoprotein B, while increasing HDL (Connective Rx, 2018). 80 % of Rosuvastatin calcium is bound to the plasma protein, 90% is excreted un-metabolized in the fecal matter, and 10 % by the renal system (Connective Rx, 2018). Just like Simvastatin, caution must be taken with individuals with diabetes mellitus due to simvastatin usually worsening glycemic control during therapy and increasing the hemoglobin A1C (Connective Rx, 2018). The presence of food decreases the bioavailability by 20%; however, it does not impact the overall bioavailability. The medication peaks in 3-5 hours (Connective Rx, 2018). A decreased initial dose should be prescribed to Asians (Connective Rx, 2018). Unlike Simvastatin, Rosuvastatin calcium does not have a serious interaction with Verapamil, which is why this medication was chosen.
Treatment Optimization and Conclusion
The medication regime above would require optimization based on laboratory values, vitals sign readings, blood glucose readings, and the known interaction of verapamil and simvastatin. A lipid panel would be required to determine if the current dosage of simvastatin was effective and the equivalent dose of Rosuvastatin calcium would be prescribed (due to the drug-drug interaction). If is not effective, re-evaluation would be required due to the change from simvastatin to Rosuvastatin calcium. Blood glucose readings in conjunction with the vital sign reading would have to be reviewed for optimization of the glipizide, HCTZ, atenolol, verapamil, and Hydralazine. Both Rosuvastatin calcium and HCTZ decreases the body’s sensitivity to insulin, impacting the effects of glipizide; however, atenolol helps counteract those effects because is enhances the sensitivity of the cells to insulin. In order to create a balance between the diabetic management and blood pressure, the first adjustments would more than likely be made to the glipizide and atenolol since they are not maxed out, and they both benefit the diabetic management. An assessment of the patient compliance would be obtained. Identifying compliance would assist with the development of the education plan for the patient and family. A significant amount of patient education would be provided to ensure the patient is aware of the possible side effects, how to handle them, and the impact of not following the medication regime (Arcangelo, Peterson, & Reinhold, 2017). Education about the value of the required tests would also be provided to the patient and/or family.
References
Arcangelo, V. P., Peterson, A. M., & Reinhold, J. A. (2017). Pharmacotherapeutics for Advanced Practice: A Practical Approach. Ambler, PA: Lippincott Williams & Wilkins.
Connective Rx. (2018). Atenolol. Retrieved from PDR.net: https://www.pdr.net/drug-summary/Tenormin-atenolol-1128.3571
Connective Rx. (2018). Atenolol. Retrieved from PDR: https://www.pdr.net/drug-summary/Tenormin-atenolol-1128.3571
Connective Rx. (2018). Glipizide-Drug Summary. Retrieved from PDR: https://www.pdr.net/drug-summary/Glucotrol-glipizide-1635
Connective RX. (2018). Hydralazine. Retrieved from PDR: https://www.pdr.net/drug-summary/Hydralazine-Hydrochloride-Tablets-hydralazine-hydrochloride-738.119
Connective Rx. (2018). Hydrochlorothiazide. Retrieved from PDR: https://www.pdr.net/drug-summary/Hydrochlorothiazide-Tablets-hydrochlorothiazide-1973
Connective Rx. (2018). Rosuvastatin Calcium – Drug Summary. Retrieved from PDR: https://www.pdr.net/drug-summary/Crestor-rosuvastatin-calcium-2318
Connective RX. (2018). Simvastatin. Retrieved from PDR: https://www.pdr.net/drug-summary/Zocor-simvastatin-402.3285
Connective Rx. (2018). Verapmil. Retrieved from PDR: https://www.pdr.net/drug-summary/Calan-verapamil-hydrochloride-1693
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2 months ago
Tiffany Mason
week 3 initial post
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Tiffany Mason
Week 3 Initial post
Walden University
Case study 1
Patient AO has a history of obesity and has recently gained 9 pounds. The patient has been diagnosed with hypertension and hyperlipidemia. Drugs currently prescribed include the following:
Atenolol 12.5 mg daily
Doxazosin 8 mg daily
Hydralazine 10 mg qid
Sertraline 25 mg daily
Simvastatin 80 mg daily
Hypertension is a chronic condition caused by obesity, sedentary lifestyle, and an increase of salt intake (Nickson, 2015). Hypertension is called the silent killer because the condition can be asymptomatic, no signs or symptoms. (Nickson, 2015). It is a condition that can be treated and maintained if compliant with medications.
Hyperlipidemia is an increase in cholesterol levels. It is caused by genetic, and environmental factors and It does not cause any symptoms. Hyperlipidemia is a treatable condition if compliant with medication.
pharmacokinetic
Obesity is a disorder involving excessive body fat which leads to dangerous health problems. 93.3 billions of adults live with obesity in the US. (CDC). Drug administration in obese patients is difficult because the recommended dose of medication is based on pharmacokinetic data from standard weight data (Nickson, 2015). Organs involved in drug elimination can be affected by pharmacokinetics more difficult due to obesity (Nickson, 2015). Obesity affects drug distribution and elimination. Using total body weight will help.
Pharmacodynamic
Atenolol 12.5 mg daily, beta-adrenoreceptor blocking activity by reducing heart rate and cardiac output, decreasing blood pressure, and isoproterenol-induced tachycardia (Drug.com, 2017).The beta-blocking effects of atenolol measures by reduction of exercise tachycardia are within one hour after administration of a single dose(Drug.com, 2017).
Doxazosin 8 mg daily, reduces in systemic vascular resistance. Max reduction between 2-6 hours following a dose, a greater effect on blood pressure and heart rate in the standing position (Drug.com, 2017).
Hydralazine lowers blood pressure by peripheral vasodilating effects decreasing the arterial blood pressure(Drug.com, 2017). Hydralazine is rapidly absorbed orally and peaks plasma level 1-2 hours(Drug.com, 2017).
Sertraline 25 mg daily, blocks the uptake of serotonin into the human platelets. It is a potent and selective inhibitor of neuronal serotonin reuptake and has a weak effect on norepinephrine and dopamine neuronal reuptake (Drug.com, 2017).
Obesity is associated with comorbidities like uncontrolled hypertension. Drug therapy is needed to achieve blood pressure control. Obese hypertensive patients often have metabolic abnormalities. (Scholze & Sharma, 2001).
Bases of metabolic profile ace inhibitors, angiotensin receptor blockers, calcium channel clockers, moxonidine, and alpha-blockers can lower the blood pressure without worsening the metabolic abnormalities
(Scholze & Sharma, 2001).
Reference
Scholze, J, Sharma, AM. (2001). Treatment of hypertension in obesity. Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/11413801
Nickson, C. (2015). Obesity and pharmacokinetics. Retrieved from https://lifeinthefastlane.com/ccc/obesity-and-pharmacokinetics/
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017).Pharmacotherapeutics for advanced practice: A practical approach(4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Centers for Disease Control and Prevention.(2018). Retrieved from https://www.cdc.gov/obesity/data/adult.html
Drug.com (2017). Retrieve from https://www.drugs.com
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2 months ago
Abby Kolthoff
Case Study 1
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Case Study 1:
Patient AO is a 35-year-old, white male and has a history of obesity and has recently gained 9 pounds. The patient has been diagnosed with hypertension and hyperlipidemia. Patient states he doesn’t understand why his legs are swelling and has shortness of breath. Drugs currently prescribed include the following:
Atenolol 12.5 mg daily
Doxazosin 8 mg daily
Hydralazine 10 mg qid
Sertraline 25 mg daily
Simvastatin 80 mg daily
Pharmacological Evaluation
Patient AO is currently taking Atenolol which has been prescribed to treat his hypertension. Atenolol is a beta-blocker, has a bioavailability of 46%-60%, metabolized in the liver, and excreted in feces and urine. Atenolol was prescribed in conjunction to Hydralazine to treat the hypertension, Hydralazine is a vasodilator. The bioavailability of Hydralazine is 30%-50%, metabolized in the liver, and eliminated through the urine. Doxazosin is an Alpha blocker that is treating AO’s hypertension. Doxazosin has a bioavailability of 65%, metabolized extensively in the liver, and eliminated through feces and urine. Sertraline is an antidepressant, which is a serotonin reuptake inhibitor. Sertraline’s bioavailability is increased with the intake of food, metabolized by hepatic cytochrome P450 enzymes, and excreted through the urine and feces. Simvastatin is a statin, a lipid lowering agent which was prescribed to treat his hyperlipidemia. Simvastatin’s bioavailability is less than 5% and takes 4-6 weeks to have maximum effect. Metabolized in the liver and eliminated through feces and urine. (Drugs, 2017).
Changes to Drug Regimen
This patient is currently suffering from shortness of breath and lower leg swelling and needs to be treated with a diuretic. The patient will need to be treated with a loop or high-ceiling diuretic such as Furosemide. Furosemide is administered orally or parenterally. The half life is rather short which allows patients to know when the effectiveness will occur allowing them to know when they will have diuresis. Furosemide will help the patient expel the fluid that has built up in his stomach. By doing this it will also help with his shortness of breath (Whalen, Finkel, & Panavelil, 2015).
Furosemide has a bioavailability of 47-64%, with onset of 30-60 minutes, and duration of 6-8 hours. Furosemide is metabolized in the liver and eliminated through the urine.
Treatment Optimization
By giving AO Furosemide the patient needs to be aware that it may react with Sertraline and possible hyponatremia. Lab work should be ordered on this patient routinely to monitor for hyponatremia. Atenolol increases serum potassium and furosemide decreases serum potassium; again, the patient will need to have lab work done to monitor his potassium levels. By the patient taking Furosemide it will help decrease the 9lbs of fluid he has gained and help prevent further weight gain. The patient needs to be instructed to weight daily and to call his primary care provider if there is a 3lb weight gain/loss.
References
Araoye MA, Chang MY, Khatri IM, Freis ED. Furosemide Compared With HydrochlorothiazideLong-term Treatment of Hypertension. JAMA. 1978;240(17):1863–1866. doi:10.1001/jama.1978.03290170045023
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Drugs. (2017, January 20). Retrieved from Drugs: https://www.drugs.com/
Laureate Education, Inc. (Executive Producer). (2012). Hypertension and hyperlipidemia. Baltimore, MD: Author.
Whalen, K., Finkel, R., & Panavelil, T. A. (2015). Pharmacology (Vol. 6th). Philadelphia, PA: Lippincott Williams & Wilkins.
Woollard M, Greaves I. 4 Shortness of breath. Emergency Medicine Journal 2004;21:341-350.
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2 months ago
christie haase
Scenario #3
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Scenario #3
Patient CB is a 59-year-old black male with a history of strokes. The patient has been diagnosed with type 2 diabetes, hypertension, and hyperlipidemia. Drugs currently prescribed include the following: Glipizide 10 mg PO daily, HCTZ 25 mg daily, Atenolol 25 mg PO daily, Hydralazine 25 mg QID, Simvastatin 80 mg PO daily, and Verapamil 180 mg PO CD daily.
A brief discussion of this patient’s current drug regimen follows to include recommended changes in prescriptions with parameters for expected outcomes and the effect of ethnicity on pharmacogenomics and treatment choices.
Glipizide is an oral antidiabetic agent that is metabolized in the liver and the kidneys with a maximum daily dose of 40 mg per day (Hamilton, 2018).
HCTZ (hydrochlorothiazide) is a combination thiazide diuretic/potassium-sparing diuretic; maximum doses are is contraindicated in patients with hyperlipidemia and diabetes (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). The combination allows reduces the incidence of hypokalemia: thiazide diuretics inhibit reabsorption of sodium and chloride (and potassium) in the loop of Henle, and distal tubule and potassium-sparing diuretics interfere with sodium absorption in the distal tubule decreasing potassium excretion tubule reabsorption (Arcangelo et al., 2017). Normal range of dosing is 12.5 to 25 mg per day with a maximum dose of 50 mg and is metabolized in the liver (Hamilton, 2018).
Atenolol is an antihypertensive cardioselective beta blocker (binds to beta-1 receptors located in the heart and kidneys) which is metabolized in the kidneys; it has a long half-life which allows for once per day administration (Hamilton, 2018), but also necessitates a gradual tapering of dosage when discontinuing therapy (Arcangelo et al., 2017). The dose is 25 to 50 mg per day with a maximum dose of 100 mg per day (Hamilton, 2018). Atenolol is also considered less effective for treating hypertension (HTN) and reducing cardiovascular events than other beta-blockers (Hamilton, 2018 & Arcangelo et al., 2017) and conceal signs and symptoms of low blood sugar in diabetic patients (Arcangelo et al., 2017).
Hydralazine causes smooth muscle relaxation and vasodilation which is results in a reduction of blood pressure (Arcangelo et al., 2017). It is metabolized in the liver and kidneys and has a maximum daily dose of 300 mg (Hamilton, 2018). Because fluid retention and tachycardia can occur, it is often given with a beta blocker or other cardiac drug such as verapamil to slow the heart rate (Arcangelo et al., 2017).
Verapamil is a calcium channel blocker (CCB) which work by inhibiting the movement of calcium across the cell membrane causing decreased heart rate and conduction (Arcangelo et al., 2017). This drug is considered first-line treatment for HTN in black Americans and is also used in ischemic heart disease (Arcangelo et al., 2017). CD, or controlled delivery, refers to a controlled dose meaning that the amount of drug delivered to the body is equal to the amount excreted with a goal of maintaining consistent amounts of drug available (Ummadi, Shravani, Raghavendra Rao, Reddy, & Nayak, 2013)and 180 mg is consistent with this use with the maximum dose of 400 mg per day for HTN and 480 mg per day for angina; it is metabolized in the liver (Hamilton, 2018).
Simvastatin is a lipid-lowering agent that inhibits HMG-CoA reductase in the liver which curbs cholesterol synthesis in the liver (Olsen, 2011) where it is also metabolized (Hamilton, 2018). The 80 mg dose per day this patient is taking is contraindicated in patients who are also taking verapamil (Hamilton, 2018).
The plan for this patient is to have a blood pressure of 130/80 or lower and to adjust medications in a way that optimizes outcome considering concomitant diagnoses of ischemic heart failure, diabetes, and hyperlipidemia (Laureate Education Inc., 2012). This patient takes four medications for HTN, and the first consideration is to evaluate ways to manage blood pressure more efficiently. Both thiazide-type diuretics and CCB are effective monotherapy for African American patients while reducing the risk of stroke (Abel et al., 2015, Arcangelo et al., 2017 & Laureate Education Inc., 2012). Neither one of these medications has been prescribed at the maximum dose before adding a third and fourth antihypertensive, for this patient being atenolol and hydralazine. Archangelo et al. (2017) and Hamilton (2018) assert that atenolol is not the most effective beta blocker for managing hypertension or reducing stroke. For this reason, I would recommend a trial 14-day titration off of atenolol because this drug also can disguise symptoms of hypoglycemia in diabetic patients (Arcangelo et al., 2017).
The next change to consider is the drug therapy for hyperlipidemia. A dose of greater than 10 mg of simvastatin per day is contraindicated in patients who also take verapamil, a CCB which is considered first-line therapy for African- Americans with hypertension and risk of stroke (Abel et al., 2015 & Arcangelo et al., 2017). The first step is to evaluate the patient’s risk for a future atherosclerotic cardiovascular disease (ASCVD) event; one of the risk factors is a thrombotic stroke (Arcangelo et al., 2017). Along with diet and activity modifications, which are also non-pharmacological interventions for HTN and diabetes, a bile acid resin such as cholestyramine at a starting dose of 4 grams daily (Hamilton, 2018); This drug should be used with caution in patients whose triglycerides are approaching 250 mg/dL as triglyceride levels can increase up to 15% while taking this drug (Arcangelo et al., 2017).
There are many unknown variables to consider when prescribing a drug regimen for this patient. While HTN, diabetes, and hyperlipidemia all contribute to increased morbidity and mortality, HTN is the is the primary focus of treatment (Arcangelo et al., 2017). This discussion created a learning experience and opens discussion for alternative treatment options as well as information unknown or not considered.
References
Abel, N., Contino, K., Jain, N., Grewal, N., Grand, E., Hagans, I., … Roy, S. (2015). Eighth joint national
committee (JNC-8) guidelines and the outpatient management of hypertension in the African-American
population. North American Journal of Medical Sciences, 2015(7), 438-445. https://doi.org/10.4103/1947-
2714.168669
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinh(Arcangelo et al., 2017)old, J. A. (Eds.). (2017).
Pharmacotherapeutics for advanced practice a practical approach (4th ed.). Philadelphia, PA: Wolters Kluwer.
Hamilton, R. J. (Ed.). (2018). Tarascon Pocket Pharmacopoeia (32nd ed.). Burlington, MA: Jones & Bartlett
Learning.
Laureate Education Inc. (2012). Hypertension and hyperlipidemia [Video file]. Retrieved from
https://class.waldenu.edu/bbcswebdav/institution/USW1/201930_27/MS_NURS/NURS_6521/adobePresenter
/Week03/media2/index.htm
Olsen, J. (2011). Clinical pharmacology made ridiculously simple (4th ed.). Miami, Fl: MedMaser Inc.
Ummadi, S., Shravani, B., Raghavendra Rao, N. G., Reddy, M. S., & Nayak, B. S. (2013). Overview on controlled
release dosage form. International Journal of Pharma Sciences, 3(4), 258-269. Retrieved from
http://ijps.aizeonpublishers.net/content/2013/4/ijps258-269.pdf
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RE: Week 3- Main question post (Case study 2)
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Week 3 Main Question Post
NURS-6521 Pharmacology
Sonya Howald
Patient HM has a history of atrial fibrillation and a transient ischemic attack (TIA). The patient has been diagnosed with type 2 diabetes, hypertension, hyperlipidemia and ischemic heart disease. Drugs currently prescribed include the following:
Warfarin 5 mg daily M, W, F and 2.5 mg daily T, TH, Sat, Sun
Aspirin 81 mg daily
Metformin 1000 mg po bid
Glyburide 10 mg bid
Atenolol 100 mg po daily
Motrin 200 mg 1–3 tablets every 6 hours as needed for pain
Subjective and Objective Information
Patient H.M. as described in the above case study is a 43-year old African-American female comes to your office for a new patient examination. She is new to the area and in need of a provider to help manage her medications. Other pertinent history includes chronic knee pain, a cardiac stent, and obstructive sleep apnea. Her glycosylated hemoglobin A1c (HbA1c) is 6.6; complete blood count and basic metabolic panel are unremarkable, International Normalized Ratio (INR), and a fasting blood glucose of 150. Her initial blood pressure was 148/90 and a second reading 15 minutes later was 152/94, pulse 92, and with a calculated body mass index (BMI) of 38. Fasting lipid panel reveals total cholesterol: 225, low-density lipoproteins (LDL): 165, high-density lipoprotein (HDL); 31, and triglycerides: 145. She denies any complaints, pain or issues.
Pharmacological Evaluation of Current Drug Treatment
H.M.’s medication regimen of taking warfarin and a baby aspirin daily for her history of atrial fibrillation (AF) and transient ischemic attack (TIA) is appropriate. Patient’s with AF who have a history of a stroke or TIA have the highest risk of a recurrent event. Furthermore, other risk factors H.M. has for stroke in AF are HTN and DM. The foundation for AF management is anticoagulation, rate control, and rhythm control for symptomatic patients (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). The INR goal in AF is 2.0-3.0, except in patients who are at significant risk for strokes such as those with artificial valves, rheumatic heart disease, and recurrent prior strokes. These higher risk individuals INR should be between 2.5-3.5 (Rosenthal, 2018).
While there is an array of pharmacological treatment options for type 2 diabetes, oral hypoglycemic agents such as metformin are the preferred first line of choice. A second oral agent such as a sulfonylurea, in H.M.’s case, glyburide, may be needed if the targeted HbA1c is not reached (Huether & McCance, 2017). Metformin works by decreasing hepatic glucose production and increasing sensitivity of peripheral tissues to insulin (Skidmore-Roth, 2018). Glyburide’s effect is to increase beta-cell insulin secretion from the beta cells in the pancreas (Glyburide Rx, n.d.).
And lastly, beta-adrenergic receptor blocker agents slow the sinus rate and decrease atrioventricular nodal conduction. The use of atenolol for H.M. is two-fold, to control her blood pressure and possibly for rate control of her AF. Atenolol selectively blocks beta-1 receptors, with little or no effect on beta-2 types (Rosenthal, 2018). Beta-1 receptors are mostly located in the heart and kidneys, and beta-2 receptors are mainly located in the lungs, liver, arteriolar smooth muscle, and pancreas. Therefore, by blocking beta-1 receptors, the effects are a decreased heart rate, cardiac contractility, and renin release (Arcangelo et al., 2017). However, I would have to disagree and highly advise against the use of ibuprofen taken as needed for pain.
The patient factor selected for this case study is obesity. The extent of simultaneous occurrence of type 2 DM and HTN depends on age, BMI and ethnicity. Moreover, many mechanisms have been suggested to explain why type 2 DM and HTN co-exist in the same individuals. Increased visceral adipose tissue and obesity are the most significant pathogenetic factors (Pavlou et al., 2018). Pathophysiologic changes in obese patients may alter the effects of drugs. Alterations in volume distribution and drug plasma concentrations may occur due to the increased ratio and distribution of fatty tissue to lean body mass. Theoretically, a decrease in the drug plasma concentration may result in failure of a given dosage of drug to achieve the desired therapeutic response (Chu, Lteif, & Young, 2017).
Proposed Changes to Medication Regimen
Advise against the use of ibuprofen. There is a major drug to drug interaction between ibuprofen and warfarin since ibuprofen may cause an increase in bleeding. There is also a moderate interaction between ibuprofen and glyburide as ibuprofen can increase the effects of glyburide and cause hypoglycemia. And it is also demonstrated that ibuprofen may reduce the effects of atenolol in lowering arterial blood pressure (Drugs.com, n.d.). An appropriate medication she could use to alleviate pain is acetaminophen.
I would also like to add a 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitor such as simvastatin 40 mg PO daily at bedtime to reduce this patient’s cholesterol levels. Statins block the conversion of HMG-CoA to mevalonate, an early and rate-limiting step in the production of cholesterol in the liver. Simvastatin reduces LDL and triglycerides and increases HDL (Drugs.com, 2018). Blocked production of cholesterol in the liver makes way for an increase in the amount of LDL cholesterol receptors on the liver, and as an outcome, more LDL cholesterol is taken up by the liver, thus, lowering LDL in the bloodstream. Also, a moderate increase in HDL transpires (Arcangelo et al., 2017). Simvastatin also appears to have very little to no interaction with H.M.’s medication regimen (Drugs.com, n.d.).
Treatment Optimization and Outcome
Paylou et al. (2018) suggest that when starting antihypertensive drugs in a diabetic patient, the choice between monotherapy or combination drug therapy depends on the severity of hypertension. In this case study, I believe lifestyle changes should be attempted first before adding a second antihypertensive medication. And as mentioned earlier, the effects of atenolol may have been decreased with the use of ibuprofen so by eliminating ibuprofen from H.M.; perhaps atenolol will be sufficient in treating her HTN and achieving a goal blood pressure < 140/90 mmHg. A BP target of <140/90 mmHg applies to most patients, even those with type 2 DM with and without renal impairment, according to most of the major medical societies such as the American Diabetes Association (ADA) and the Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High BP (JNC 8) (Pavlou et al., 2018).
Lifestyle changes include dietary changes (high in fruits and vegetables, whole grains and low-fat and cholesterol intake), exercise, smoking cessation, moderation of alcohol intake, and weight loss. Lifestyle changes should be initiated in conjunction with pharmacological therapies to optimize the effects of the medications in treating HTN, DM, and hyperlipidemia. In addition, I would want to repeat a basic metabolic panel in 4-6 weeks after starting simvastatin to monitor the patient’s potassium levels, and kidney function, as well as a hepatic panel as simvastatin must be used with caution in those with electrolyte imbalances, and it may also increase liver function tests such as ALT and AST. In addition, hepatotoxicity must be carefully monitored as warfarin, aspirin, glyburide, and simvastatin are all metabolized by the liver (Skidmore-Roth, 2018).
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Chu, C., Lteif, L., & Young, N. (2017). Obesity: The drug dose debate. Hawaii Journal of Medicine and Public Health, 76(6), 162-165. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5458583/
Drugs.com. (2018). Simvastatin. Retrieved from https://www.drugs.com/pro/simvastatin.html#s-34090-1
Drugs.com. (n.d.). Drug interaction report. Retrieved from https://www.drugs.com/interactions-check.php?drug_list=2311-0,273-0,1573-0,1185-0,1310-780
(Glyburide Rx). (n.d.). Glyburide (Rx). Retrieved December 12, 2018, from Medscape.
Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, MO: Mosby.
Pavlou, D., Paschou, S. A., Anagnostis, P., Spartalis, E., Spartalis, M., Vryonidou, A.,…Siasos, G. (2018). Hypertension in patients with type 2 diabetes mellitus: Targets and management. Maturitas, 112, 71-77. Retrieved from the Walden Library database.
Rosenthal, L. (2018). Atrial fibrillation. Retrieved December 11, 2018, from Medscape.
Skidmore-Roth, L. (2018). Mosby’s 2018 nursing drug reference (31st ed.). St. Louis, MO: Elsevier.
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2 months ago
LAURA TUCKER
Week 3 Main Forum
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Main Forum
Patient CB has a history of strokes. The patient has been diagnosed with type 2 diabetes, hypertension, and hyperlipidemia. Drugs currently prescribed include the following:
Glipizide 10 mg po daily
HCTZ 25 mg daily
Atenolol 25 mg po daily
Hydralazine 25 mg qid
Simvastatin 80 mg daily
Verapamil 180 mg CD daily
CB is a 65-year-old who walks into the office favoring his right side with a blood pressure of 102/62, respirations of 16, heart rate of 65 and states he feels ok today.
He is on glipizide 10 mg po every day which is to help control his diabetes by causing the pancreas to make more insulin it is in the sulfonylureas drug class (MedlinePlus Drug Information, 2017). He is also on hydrochlorothiazide 25 mg daily with is a diuretic that helps decrease blood pressure by excreting un needed water and salt though the urine (MedlinePlus Drug Information, 2017). He also takes atenolol 25 mg daily which is a beta blocker also used to treat blood pressure by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure (MedlinePlus Drug Information, 2017). He also takes hydralazine 25 mg qid which is a vasodilator which works by relaxing blood vessels, so blood can flow more easily through the body (MedlinePlus Drug Information, 2017). He also takes simvastatin 80mg daily which is a statin or HMG-CoA inhibitors which slows the production of cholesterol in the body (MedlinePlus Drug Information, 2017). His last medication is verapamil 180 mg CD daily which is a calcium channel blocker which works by relaxing blood vessels, so the heart does not have to work as hard. It also increases oxygen and blood supply to the heart which controls the heart rate (MedlinePlus Drug Information, 2017).
If I was to change anything it would be the beta blocker because he is a diabetic which the use of beta blockers is contraindicated (Laureate Education, 2012). I would state him on an ACE inhibitor because the combination of Ace inhibitor and thiazide would decrease his risk of strokes (Laureate Education, 2012). And with his history of a stroke it increases his risk of having another stroke along with the fact that he has hyperlipidemia. The other issue I would watch for is his creatinine clearance because being a diabetic can damage his kidneys and being on a thiazide is contraindicated if his creatinine clearance is less than 30 ml/min (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
An ACE inhibitor has an antihypertensive effect by inhibiting the ACE enzymes which turns angiotensin I into angiotensin II which is a strong vasoconstrictor. Adverse side effects include a dry cough, possible hypotension, rash, loss of taste, leukopenia, angioedema, neutropenia, and in less than 1% of patients agranulocytosis. Contraindications include pregnancy, patients with bilateral renal artery stenosis and unilateral stenosis. First line of medication is diabetic patients with protein in their urine and patients with congestive heart failure with systolic dysfunction (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
The factor I chose was age because it increases the risk for all of CB’s issues. As a patient gets older and has hyperlipidemia their risk of stroke increases especially since he has already had a stroke and the average age of a man being diagnosed with high blood pressure is around 60 years old (Laureate Education, 2012).
I believe by changing his treatment he will have a more optimal outcome and less contraindicated medications.
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins
Laureate Education, Inc. (Executive Producer). 2012. Hypertension and hyperlipidemia. Baltimore, Md Author
MedlinePlus Drug Information. (2017). Atenolol: MedlinePlus Drug Information. Retrieved from https://medlineplus.gov/druginfo/meds/a684031.html
MedlinePlus Drug Information. (2017). Glipizide: MedlinePlus Drug Information. Retrieved from https://medlineplus.gov/druginfo/meds/a684060.html
MedlinePlus Drug Information. (2017). Hydrochlorothiazide: MedlinePlus Drug Information. Retrieved from https://medlineplus.gov/druginfo/meds/a682571.html
MedlinePlus Drug Information. (2017). Simvastatin: MedlinePlus Drug Information. Retrieved from https://medlineplus.gov/druginfo/meds/a692030.html
MedlinePlus Drug Information. (2017). Verapamil: MedlinePlus Drug Information. Retrieved from https://medlineplus.gov/druginfo/meds/a684030.html
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2 months ago
Marie Lucien
Case 1Pharmacotherapy for Cardiovascular Disorders
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MAIN QUESTION POST
Pharmacotherapy for Cardiovascular Disorders
Cardiovascular diseases (CVDs) affect the heart and blood vessels, these include the heart and blood vessels as well as coronary heart disease, cerebrovascular disease, peripheral arterial disease; and rheumatic heart disease, congenital heart disease, deep vein thrombosis, and pulmonary embolism (Kendir, van den Akker, Vos, & Metsemakers, 2018). It is responsible for over 17 million deaths constitute 31% worldwide deaths. On the other hand, hypertension which is an elevated blood pressure affects more than 50 million Americans (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Treatment is vary depending on the personage in adults over 60 years old, when systolic pressure is 150 mm Hg or higher, or when the diastolic pressure is 90 mm Hg or higher. In younger patients, beneath the age of 60 years, treatment should start at 140 mm Hg or higher of systolic, or 90 mm Hg or higher of diastolic pressure. CVD is the leading cause of death in the United States. CVD is a group of disorders of the heart and blood vessels, and they include coronary heart disease, cerebrovascular disease, peripheral arterial disease; and rheumatic heart disease, congenital heart disease, deep vein thrombosis, and pulmonary embolism (Kendir, van den Akker, Vos, & Metsemakers, 2018). The purpose of this paper is to analyze the case study 1, the plan of care for a hypertensive patient Pharmacokinetics and pharmacodynamics.
Case Study 1
Patient AO has a history of obesity and has recently gained 9 pounds. The patient was diagnosed with hypertension and hyperlipidemia. Drugs currently prescribed include the following: Atenolol 12.5 mg daily, Doxazosin 8 mg daily, Hydralazine 10 mg qid, Sertraline 25 mg daily, and Simvastatin 80 mg daily.
Pharmacokinetics and pharmacodynamics
When taking care of a patient with hypertension and hyperlipidemia, the provider must be reviewing carefully the plan of care such as prescribing medications, diet, and lifestyle of the patient for compliance. In case study 1, AO is obese and has gained 9 pounds. To initiate drug therapy, the nurse practitioner (NP) has to assess the pharmacokinetics and pharmacodynamics of the patient (Franconi & Campesi, 2014). To ensure the safety and effectiveness of drug therapy, the NP must consider general aspects such as medical history, a drug to drug interaction, metabolism, smoking, alcohol consumption, stress, co-morbidities, and education amongst others (Franconi & Campesi, 2014). Also, individual patient factors such as genetics, gender, ethnicity, age, and behavior are essential. For example, hypertension is seen more in blacks (41.2%) compared to non-Hispanic whites (28.0%), and 25.9% Hispanics (Ferdinand et al., 2017). Research shows that the leading cause of this disproportion is noncompliance with medication which is a complex and various health care problem where compliance is well-defined as the extent to which patients can follow the recommendations for prescribed treatment. Also, advanced cases of cardiovascular disease, stroke, and kidney disease are also seeing in more significant numbers among the black community (Franconi & Campesi, 2014).
In the plan of care, one of AO’s current prescribed medication is atenolol. The medical history of AO’s must be review and updated by the NP before prescribe to prevent specific contraindications based on the patient’s history. Certain beta-blockers should not be giving to patients with bradycardia or COPD. According to Arcangelo, Peterson, Wilbur, and Reinhold (2017), side effects of beta-blockers, in general, include dizziness, drowsiness, and reduced heart rate. The NP has to ensure that medication compliance is monitored since immediate stopping beta blockers are not suggested due to an adverse effect on the patient health.
Furthermore, Hydralazine was also given; this medication, in particular, is beneficial in black patients with heart failure. The vital question, “Is AO an African-American?” Doxazosin was also prescribed. Doxazosin is an alpha-blocker recommended for patients with benign prostatic hypertrophy. Perhaps, the most frequent side effects of this medication are depression; close monitoring is needed, consequently the prescription of Sertraline, an antidepressant that when prescribed, the healthcare provider needs to educate on the risk of bleeding, suicidal ideation, and hepatic function. Therefore, lab work should order accordingly. Besides, Sertraline is known to have adverse effects on patient sex drive, erectile dysfunction, and ejaculation disorder in men (Ferdinand et al., 2017). Finally, simvastatin was ordered to treat the patient’s hyperlipidemia. Since some people are susceptible to hyperlipidemia due to genetic factors or faulty gene. Careful consideration of other medications should be evaluated as beta blockers are considered secondary factors that increase cholesterol levels (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). AO also needs to let the healthcare provider know of any allergic reactions to prevent a barrier to patient compliance.
Improving the drug therapy plan
To improve AO’s treatment, plan several steps can be taken with close monitoring. To begin, beta-blockers can be the reason for elevated hyperlipidemia. Also, beta-blockers are not usually used as a first-line treatment for hypertension. Hence, Atenolol should be stopped, as well as the Hydralazine it should preferably be given with a beta-blocker and a diuretic. The Hydralazine could put AO’s at risk of tachycardia, and if taken with a beta blocker, it can cause drug-induced lupus which is a painful condition (Almandil, 2016). Since the recommended first line of treatment for hypertension is diuretics, a dose of 12.5 mg of hydrochlorothiazide (HCTZ) should be initiated daily to decrease fluid retention since AO has recently gained 9 pounds. Thiazide diuretics are considered safe in diabetics, with a reduction in mortality from heart disease and stroke (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Although the patient is not a known diabetic, he or she does possess high-risk factors for the disease such as obesity, hypertension, and hyperlipidemia. It should be considered a genuine possibility that the patient either already has or will soon develop diabetes. Along with the HCTZ, I would add an ACE inhibitor such as Lisinopril 10-40 mg/day.
Simvastatin is an appropriate choice for hyperlipidemia, as the statin drug class is a recommended first-line treatment; the cholesterol levels dictate individual drug of choice (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). However, the patient needs education on avoiding grapefruit juice because it can increase the effect of Simvastatin, (Ferdinand et al., 2017). Nonetheless, instead of the simvastatin, I would begin AO on Atorvastatin 40 mg daily. Atorvastatin 40-80 mg or Rosuvastatin 20-40mg are also first-line treatments for hyperlipidemia. There is an FDA alert stating that Simvastatin should no longer be prescribed at 80mg/day doses due to the risk of myopathy (Domino, 2017). NPs should be informed that multiple drugs at the appropriate dose may successfully manage blood pressures with fewer side effects. Be mindful about dispense morning and nighttime doses for better 24-hour antihypertensive effect. Prescribing medications require special attention to the patient condition and medical history. The providers must take a detailed history to ensure the patient will receive the best medicine for their disorder (Domino, 2017). The patient is essential for compliance. For example, the patient should make aware that frequent urination is one of the side effects and should encourage to plan to stay close to the bathroom during the day and have good lighting at night to prevent fall in case needed to go to the toilet depending on the patient age. The caregiver should also include in teaching. Alternative therapy would be to encourage the patient to eat healthier and exercise at least 30 minutes per day, four to five days a week (Almandil, 2016). The patient would have to follow up every three months until stable, then every six months. Encourage patient to monitor blood pressure daily and record the reading to bring with him to evaluate progress. Lastly, close monitoring of lab work results especially a lipid panel to control LDL levels should be part of the treatment plan (Domino, 2017).
Conclusion
Providing a plan of care for a patient treatment require knowledge and understanding of the Pharmacokinetics and pharmacodynamics for a more suitable result. Patient Combination drug therapy along with appropriate lifestyle changes can lead to a substantial estimated reduction in CVD and can benefit many individuals globally. Therefore, strategies should be adopted for CVD prevention worldwide. While there are currently many barriers to widespread use of combination therapy, they are manageable and should provide support by active listening of patient concern and make an adjustment for easy compliance.
References
Almandil, N. B. (2016). Healthcare professionals’ awareness and knowledge of adverse drug reactions and pharmacovigilance. Saudi Medical Journal, 37(12), 1359–1364. https://doi-org.ezp.waldenulibrary.org/10.15537/smj.2016.12.17059
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins
Domino, F. J. (Ed.). (2017). The 5-Minute clinical consult (25th ed.). Philadelphia, PA: Wolters Kluwer
Ferdinand, K., Yadav, K., Nasser, S., Clayton-Jeter, H., Lewin, J., Cryer, D. & Senatore, D. (2017). Disparities in hypertension and cardiovascular disease in blacks: The critical role of medication adherence. The Journal of Clinical Hypertension, 1-10. doi:10.1111/jch.13089
Franconi, F. & Campesi, I. (2014). Pharmacogenomics, pharmacokinetics, and pharmacodynamics: interaction with biological differences between men and women. British Journal of Pharmacology, 171(3), 580-594. doi:10.1111/bph.12362
Kendir, C., van den Akker, M., Vos, R., & Metsemakers, J. (2018). Cardiovascular disease patients have increased risk for comorbidity: A cross-sectional study in the Netherlands. The European Journal of General Practice, 24(1), 45–50. https://doi-org.ezp.waldenulibrary.org/10.1080/13814788.2017.1398318
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2 months ago
Tiffanie Walton
WK3 Initial Post
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Patient AO has a history of obesity with a recent 9 lb. weight gain, newly diagnosed with hypertension and hyperlipidemia. Prescriptions ordered include:
Atenolol 12.5 mg daily
Doxazosin 8 mg daily
Hydralazine 10 mg QID
Sertraline 25 mg daily
Simvastatin 80 mg daily
Pharmacokinetics and Pharmacodynamics
A healthcare provider that is initiating medication therapy to a patient diagnosed with hypertension and hyperlipidemia should consider a few factors before communicating the prescription to the pharmacy. One known fact about this case is that AO is obese and has gained 9 pounds. In order to develop the appropriate therapy, we have to evaluate the pharmacokinetics and pharmacodynamics of the patient. In general, we must consider gender (anatomical and physiological differences), metabolism, smoking and drinking status; stress, co-morbidities, and education amongst others (Franconi & Campesi, 2014). According to Ferdinand et al. (2017), hypertension is seen more in blacks (41.2%) compared to non-Hispanic whites (28.0%), and 25.9% Hispanics. According to research conducted by these authors, the main cause of this disparity is nonadherence to treatment. In return, higher cases of cardiovascular disease, stroke, and kidney disease are also seen in larger numbers among the black community (Franconi & Campesi, 2014). Age is another important factor to consider. As we age and develop other medical issues, the less ability of the liver to metabolize drugs, the kidneys are less able to eliminate the drug, which in return can increase side effects (Alomar, 2014).
Impact the patient’s recommended drug therapy
AO’s drug therapy, one of the medications ordered is atenolol. AO medical history will be important information because there are certain contraindications based on the patient’s history. Not all beta-blockers can be given to a patient with bradycardia or COPD. Beta-blockers side effects, including feeling dizzy, drowsy, and reduced heart rate (Arcangelo, Peterson, Wilbur, & Reinhold, pg. 262, 2017). Medication adherence is monitored since abruptly stopping beta blockers is not recommended (Arcangelo et al., p. 265, 2017). Hydralazine , this medication, in particular, is beneficial in black patients with heart failure (is AO African-American?) Doxazosin which is an alpha-blocker recommended for patients with benign prostatic hypertrophy, which leads me to believe that AO has a history of BPH (Arcangelo et al., p. 264, 2017). One of the side effects of this medication is depression, close follow-up is also needed, hence the prescription of Sertraline, an antidepressant that when taken, the healthcare provider needs to educate on the risk of bleeding, suicidal ideation, and hepatic function. In addition, men have seen adverse effects with libido, erectile dysfunction, and ejaculation disorder (drugs.com, 2017). Finally, simvastatin was ordered to treat his hyperlipidemia (due to an increase in serum cholesterol levels either due to genetics or environmental influences) (Arcangelo et al., p. 275, 2017). Since some people are susceptible to hyperlipidemia due to genetic factors (faulty gene), careful consideration of other medication should be evaluated as beta blockers are considered secondary factors that increase cholesterol levels (Arcangelo et al., p. 275, 2017). AO needs to let the healthcare provider know of any allergic reactions to any of the medications prescribed since this will alter the treatment therapy.
Alternative treatment options
In addition to pharmacological treatment, a recommendation that will be helpful for AO to control hypertension and hyperlipidemia is setting up a nutrition plan and exercise program to lose weight. Smoking and alcohol consumption should immediately be stopped (if smokes or drinks). According to Moyer (2012), a reduction in morbidity and mortality is seen in patients who indeed follow a healthy diet and exercise. The fact that AO is obese and has gained weight, and has been diagnosed with hypertension and hyperlipidemia, puts the patient at a higher to developing cardiovascular disease (Moyer, 2012).
References:
Alomar, M. (2014). Factors affecting the development of adverse drug reactions (review article). Saudi Pharmaceutical Journal, 22(2), 83-94. Retrieved from https://doi.org/10.1016/j.jsps.2013.02.003
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J.A. (Eds.). (2017). Hypertension In Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J.A. (Eds.). (2017). Hyperlipidemia In Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Ferdinand, K., Yadav, K., Nasser, S., Clayton-Jeter, H., Lewin, J., Cryer, D. & Senatore, D. (2017). Disparities in hypertension and cardiovascular disease in blacks: The critical role of medication adherence. The Journal Of Clinical Hypertension, 1-10. doi:10.1111/jch.13089
Franconi, F. & Campesi, I. (2014). Pharmacogenomics, pharmacokinetics, and pharmacodynamics: interaction with biological differences between men and women. British Journal Of Pharmacology, 171(3), 580-594. doi:10.1111/bph.12362
Moyer, V. (2012). Behavioral counseling interventions to promote a healthful diet and physical activity for cardiovascular disease prevention in adults: U.S. Preventive Services Task Force recommendation statement. Annals Of Internal Medicine, 157(5), 367-371. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22733153
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2 months ago
Collette Dillon
week three- case one
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NURS 6521-Advanced Pharmacology
INITIAL POST
In case one AO is obese and has gained 9 pounds recently. AO suffers from hypertension and hyperlipidemia and is taking Atenolol 12.5mg, Doxazosin 8 mg daily, Hydralazine 10 mg qid, Sertraline 25 mg daily, Simvastatin 80 mg daily. Behavioral factors play an important role in both patient’s diagnoses and his obesity. It is believed that obesity can affect all the aspects of pharmacokinetic such as absorption, distribution, elimination, and metabolism, (Thethi., Kamiyama, & Kobori, 2012). The pharmacokinetics of medication might also be affected in an obese person, in that the risk for adverse reactions increased seeing that the body can’t properly absorb, distribute, metabolized and eliminate the drug (Thethi et al. 2012)
Atenolol is absorbed in the gastrointestinal system and the blood level tends to peak at between two to four hours (Drug.com, 2018). Atenolol is not metabolized much by the liver and is excreted by the liver and only a small portion in a bind to protein Drug.com, 2018). Atenolol is considered a beta blocker that is used to decrease cardiac output and inhibits the release of renin (Drug.com, 2018). Doxazosin is used to treat mild to moderate hypertension and benign prostate hyperplasia. It has 65 percent absorption rate and metabolized in the hepatic system and is eliminated from the body through feces and urinary system (Drug.com 2018). The medication also has a very high binding protein rate. Hydralazine works by relaxing blood vessels, thus increasing oxygenated rich blood to the heart. Hydralazine has a high first-pass metabolism and is metabolized in the hepatic system. The half-life is 3 to 7 hours and is mainly excreted as metabolites in urine (Drug.com, 2018). As a vasodilator, hydralazine works by relaxing blood vessels (arterioles more than venules) and increasing the supply of blood and oxygen to the heart while reducing its workload (Drug.com, 2018). Sertraline inhibits the uptake of serotonin is used to treat disorders such as depression and obsessive-compulsive disorder. Sertraline has a high first past metabolism in the liver. Due to the high metabolism of Sertraline, only a small amount is excreted in urine. The plasma concentration of Sertraline reach is maximum concentration anywhere from 4.5 hours to 8.4 hours after being administered. Sertraline has a high protein binding rate of 98% (Food and Drug Administration, 2018). Simvastatin is rapidly absorbed and can reach its maximum plasma level is 4 hours. The elimination half-life of Simvastatin is 14 hours. Simvastatin has a high protein binding rate and is mainly eliminated from the body through feces and a small amount through the renal system (FDA,2018). Obesity can cause renal disorders, have major impacts on organs that are involved with the distribution, metabolism, excretion and elimination of medication, therefore, impacting how the medication is prescribed. For example, an impaired renal system, urinary system, and liver system can have an influence on the pharmacodynamic and pharmacokinetics of medication. This would be the case for the patient in the case study careful considerations must be given to the current obese status because some of the medication can cause increased appetite, lower blood pressure and have psychological impacts. Obesity can certainly play a role in medication that is weight base, there can be overdosing or underdosing which has an impact on adverse reactions. Obesity can also impact the renal system, therefore, impacting the excretion of medication from the body Further obesity can cause hypertension (Thethi et al, 2012)
Based on all the medical conditions which the AO is experiencing such as hypertension, hyperlipidemia, possible prostate issues because of the usage of Doxazosin and Sertraline which can be used for depression and obsessive-compulsive disorders. It can be inferred that AO might have some an obsession with food because obesity is one of the problems. So, it can be assumed that there are issues with eating. The main modification that the student would make to AO treatment is to lifestyle modification by encouraging change in eating habits and starting to exercise. According to the American Society for Metabolic and Bariatric Surgery (ASMBS, 2018) hypertension is often seen in 3 out of 4 obese patients. Obesity can also lead to other such conditions as cardiac disease, impotence, liver disease, kidney disease and depression amongst others (ASMBS, 2018). Some of these disorders are seen in AO in the case study, therefore if the obesity issue is resolved then some of the medical issues that are being experienced may resolve. According to Harvard School of Public Health (2018), exercise can lower one’s risk factors for f heart disease, diabetes, stroke, high blood pressure, osteoporosis, and certain cancers, as well as reduce stress and boost mood. Inactive (sedentary) lifestyles do just the opposite. With the change in lifestyle, careful monitoring is going to be needed with the management of AO medication to prevent any adverse reactions.
References
American Society for Metabolic and Bariatric Surgery (2018) Impact of obesity on your body and health. Retrieved from https://asmbs.org/patients/impact-of-obesity
Drug.com (2018). Atenolol tablets. Retrieved from https://www.drugs.com/pro/atenolol-
tablets.html#s-34090-1
Drug.com (2018). Doxazosin. Retrieved from https://www.drugbank.ca/drugs/DB00590
Food and Drug Administration (2018). Sertraline. Retrieved from
https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/019839s070,020990s032lbl.pdf
Harvard School of Public Health (2018). Physical activity: exercise can help control weight.
Retrieved from https://www.hsph.harvard.edu/obesity-prevention-source/obesity-causes/physical-activity-and-obesity/
Thethi, T., Kamiyama, M., & Kobori, H. (2012). The link between the renin-angiotensin-
aldosterone system and renal injury in obesity and the metabolic syndrome. Current hypertension reports, 14(2), 160-9. doi: 10.1007/s11906-012-0245-z
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2 months ago
Sarah Schoner
Week Three Scenario One
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Week Three: Pharmacotherapy for Cardiovascular Disorders
Sarah Schoner
Present Patient Situation
Patient AO recently has gained 9 pounds and has been diagnosed with hypertension and hyperlipidemia. Current medications include the beta blocker atenolol 12.5mg daily, an alpha-blocker doxazosin 8mg daily, a direct vasodilator hydralazine 10mg four times daily, an antidepressant sertraline 25mg daily, and the antilipidemic simvastatin 80mg daily.
Current Pharmacological Evaluation
Atenolol blocks beta-1 receptors and in higher doses beta-2 receptors which result in a decreased cardiac output and sympathetic outflow (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Atenolol peaks in 2 to 4 hours, is protein bound 6-16%, with a volume of distribution 50-75 L/kg (atenolol, n.d.). Atenolol is metabolized some extent in the liver and is eliminated in feces and urine (atenolol, n.d.). Doxazosin is also prescribed for the patient which causes dilation of the arterioles and veins resulting in the relaxation of smooth muscle by the medication’s effect of blocking alpha-1 receptors (Arcangelo, 2017). Doxazosin peaks for an antihypertensive response between 4-8 hours, it is 99% protein bound with a volume of distribution of 1-3.4L/kg (doxazosin, n.d.). Doxazosin is extensively metabolized in the liver and is eliminated through feces and urine (doxazosin, n.d.). Doxazosin and atenolol used in combination increase anti-hypertensive channel blocking (atenolol, n.d.). Vasodilators such as hydralazine work by widening the blood vessels to reduce blood pressure. Hydralazine is absorbed 90% in the GI tract, peaks in 1-2 hours, is metabolized by the liver through acetylation, and is eliminated in urine as metabolites (Hydralazine, n.d.). AO is also on sertraline an SSRI antidepressant that inhibits the uptake of serotonin (Sertraline, n.d.). Sertraline peaks in 4.5-8.4 hours, is 90% protein bound, metabolized by P450 hepatic cytochromes, and is excreted through urine and feces (sertraline, n.d.). Lastly AO, is also on simvastatin which blocks the alteration of HMG-CoA to mevalonate which slows the production of cholesterol in the liver (Arcangelo, 2017). Simvastatin peaks in 1.3-2.4 hours, is 95% protein bound and undergoes the first pass effect in the liver, it is converted into several metabolites and is eliminated in urine and feces (simvastatin, n.d.).
Adjustments to Drug Regimen
Beta-blockers generally are not indicated as the first line of treatment for hypertension, instead, they are the second line of treatment due to studies demonstrating a higher incidence of heart attacks and strokes when they are used as the first line of treatment for hypertension (Bell, Twiggs, & Olin, 2015). Atenolol and hydralazine in combination together increase the effects of atenolol through pharmacodynamic synergism (atenolol, n.d.). Hydralazine also is known to increase fluid and sodium retention which may be the reason for the patient’s recent 9-pound weight gain. Initial pharmacological treatment for hypertension includes thiazide diuretics, long-acting calcium channel blockers, angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers (Bell, 2015). I would recommend transitioning the patient off of the beta blocker, alpha 1 adrenergic blocker, and the peripheral vasodilator in favor of one of the first line antihypertensive treatment classes listed above. Thiazide diuretics have shown over time their ability to reduce hypertension while reducing the risk for a heart disease, stroke, and heart attacks (Bell, 2015). Thiazide diuretics result in less sodium and water retention thus decreasing the likelihood that weight gain will be attributed to excess fluid retention. AO is also on a larger dose of simvastatin. Simvastatin 80MG should only be used for individuals who have been taking 80mg chronically and have no evidence of myopathy or rhabdomyolysis (simvastatin, n.d.). Seeing as though this is a newer diagnosis for AO, I would recommend lowering the dose to 10-20mg per day and to encourage diet and exercise.
Most patients will require more than one medication to effectively manage their hypertension (Weber et al., 2013). An angiotensin II receptor blocker (ARB) or ACE inhibitor with either a thiazide diuretic or a calcium channel blocker is the recommended drug selection in hypertensive patients without other major conditions (Weber et al., 2013). For the purpose of this discussion, I will focus on an ARB in combination with a thiazide diuretic. Losartan works by blocking vasoconstriction and aldosterone-secreting effects of angiotensin II through blocking the ability of angiotensin II to bind to the angiotensin II receptors found in the tissue (Arcangelo, 2017). The starting dose of losartan potassium is 50mg once daily (Losartan, n.d.). Losartan reaches a peak within 1-1.5 hours and is 98.7% protein bound with a volume of distribution of 34L (losartan, n.d.). Losartan is metabolized by hepatic enzyme P450 and CYP2C9 (losartan, n.d.). Renal clearance of losartan is between 43-75 mL/min and total plasma clearance is 600mL/min with 4% being excreted through the urine as an active metabolite (losartan, n.d.). Hydrochlorothiazide is recommended to be initiated at 12.5-25mg per day with a target dose of 25-50mg per day (Bell, 2015). It inhibits the reabsorption of sodium in the distal renal tubules which cause increased secretion of water, sodium, potassium, and hydrogen ions (hydrochlorothiazide, n.d.). It reaches a peak effect in 4-6 hours and is 40-68%protein bound with a volume of distribution of 3.6-7.8L/kg (hydrochlorothiazide, n.d.). Thiazide undergoes minimal metabolism and is excreted through the urine (hydrochlorothiazide, n.d.).
Conclusion
While there are many antihypertensives that can be utilized to treat hypertension. Selecting those that best meet the needs of your patient and their underlying medical conditions will result in better patient outcomes. If the patient does not respond as anticipated to antihypertensive therapy, there are certainly several medications that can be utilized to treat their hypertension and in many cases in combination with current medication regiments. Additionally, if they develop other chronic medical conditions such as CAD, suffer a heart attack or a stroke, a thorough review of their medication regimen will be necessary to ensure optimum treatment is achieved.
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics for Advanced Practice: A practical approach (4 ed.). Ambler, PA: Lippincott Williams & Wilkins.
atenolol (Rx). (n.d.). Retrieved from https://reference.medscape.com/drug/tenormin-atenolol-342356#10
Bell, K., Twiggs, J., & Olin, B. R. (2015). Hypertension: The Silent Killer: Updated JNC-8 Guideline Recommendations. Retrieved from https://cdn.ymaws.com/www.aparx.org/resource/resmgr/CEs/CE_Hypertension_The_Silent_K.pdf
doxazosin. (n.d.). Retrieved from https://reference.medscape.com/drug/cardura-xl-doxazosin-342343#10
Hydralazine. (n.d.). Retrieved from https://www.drugs.com/mmx/hydralazine-hydrochloride.html
hydrochlorothiazide. (n.d.). Retrieved from https://reference.medscape.com/drug/microzide-hydrodiuril-hydrochlorothiazide-342412#10
losartan. (n.d.). Retrieved from https://reference.medscape.com/drug/cozaar-losartan-342323#10
Losartan. (n.d.). Retrieved from https://www.drugs.com/pro/losartan.html
sertraline. (n.d.). Retrieved from https://reference.medscape.com/drug/zoloft-sertraline-342962#10
Sertraline. (n.d.). Retrieved from https://www.drugs.com/pro/sertraline.html
simvastatin. (n.d.). Retrieved from https://reference.medscape.com/drug/zocor-simvastatin-342463#10
Weber, M. A., Schiffrin, E. L., White, W. B., Mann, S., Lindholm, L. H., Kenerson, J. G., … Harrap, S. B. (2013, December 17). Clinical Practice Guidelines for the Management of Hypertension in the Community. The Journal of Clinical Hypertension, 16, 14-26. http://dx.doi.org/10.1111/jch.12237
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arfarin inhibits activation of clotting factors in the liver, depletes vitamin K by interfering with the conversion from its inactive to active form, and ultimately prevents clot formation (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 873). Warfarin is metabolized by the liver isoenzymes CYP2C9, CYP3A4, AND CYP1A2 and there are several drugs that interact with these enzymes that can increase or decrease the clearance of warfarin and affect the INR (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 874). The onset of effect and half-life of warfarin is long with variable onset and effect and the average half-life of 36 to 42 hours (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 873). Patient factors that can affect the dose response to warfarin can be influenced by age as the elderly seem to be more sensitive to warfarin, increased warfarin response can occur in patients with hepatic dysfunction, impaired renal function, and lower doses may be needed in patients with low serum albumin (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p.874).
HM is also prescribed atenolol 100mg by mouth daily. This beta-blocker antihypertensive will treat his hypertension as well as control his ventricular heart rate in relation to his atrial fibrillation. Atenolol is cardioselective and binds mostly to beta-1 receptors to regulate heart rate, renin release, and cardiac contractility (Laureate education, 2012). Beta blockers should be used cautiously in patients with diabetes mellitus, which HM does have because beta-blockers can mask all of the symptoms of hypoglycemia with the exception of sweating (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 266). Elderly patients present higher atenolol plasma levels with clearance about 50% lower than younger subjects and the half-life is longer in the elderly (Drugs.com, 2018). Careful consideration should be taken when choosing an antihypertensive for elderly patients as “decreased renal and hepatic function complicates hypertension treatment and increases the risk of adverse events in this population” (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 269). The course text states that use of the newer beta-blockers such as nebivolol and carvedilol may provide a better safety profile and better morbidity and mortality outcome (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 269). I think that this medication and dose is safe for HM to effectively control his blood pressure as well as his atrial fibrillation.
HM is prescribed metformin 1000mg by mouth twice per day as well as glyburide 10mg by mouth twice per day to treat his type 2 diabetes. Both of these medications are in the class of sulfonylureas that “correct derangements of carbohydrate, lipid, and protein metabolism” (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 788). These medications bind to receptors on beta cells causing potassium channels to close and calcium channels to subsequently open and the increase cytoplasmic calcium stimulates the release of insulin, ultimately decreasing blood glucose levels (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 788). In the elderly population, the greatest complication is hypoglycemia secondary to comorbidity, polypharmacy, and poor social situations” (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 788). These medications are contraindicated in patients with impaired renal function. In terms of elimination, after age 30, creatinine clearance decreases with each decade of life although the elderly generally have less muscles mass and typically produce less creatinine, the renal elimination is often decreased (Pharmacokinetics in the Elderly – Geriatrics, n.d.). For this reason, I would want to monitor the renal function of patient HM. Beta-blockers (which HM takes atenolol) can decrease the effectiveness of sulfonylureas so I would want to monitor his blood sugar and recommend that he monitors and keeps a log at home of his daily blood sugars.
The two over the counter medications that HM takes are aspirin 81mg daily and Motrin (ibuprofen) 200mg – 600mg every 6 hours as needed for pain. HM is prescribed the antiplatelet agent aspirin daily for cardiac protection and can prevent clot formation which HM is at risk for because he has atrial fibrillation. Aspirin prevents prostaglandin synthesis in platelets and other tissues by irreversibly modifying and inhibiting the enzyme COX and prevents platelet aggregation (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 882). Aspirin can lead to adverse effects such as GI upset and bleeding and should be used cautiously in patients taking anticoagulants as the risk of bleeding is increased (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 882).
HM takes Motrin (ibuprofen) for pain he has in his knees and back that he takes only when needed. Motrin is in the class of nonsteroidal anti-inflammatory drugs that works by inhibiting the syntheses of prostaglandin, prostacyclin, and thromboxanes which are all mediators of inflammation and pain (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 594). Motrin should be used cautiously in elderly or patients with renal or hepatic impairment as the most common adverse events of NSAIDs occur in the GI and renal systems (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 596). NSAIDs also have the potential to increase bleeding so they need to be used cautiously with warfarin and may also counteract the effect of antihypertensives (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 596). Clinical trials have shown an increased risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke with some NSAIDs as well as leading to worsening of preexisting hypertension (Drugs.com, 2018).
Changes to Current Drug Therapy
This patient does not have any specific contraindications to continuing Warfarin. I would continue to prescribe this medication to HM and continue to have his INR checked as recommended with dose adjustments. With this medication, I would continue to provide patient education regarding fall and injury prevention, risk for bleeding, dietary restrictions, and the importance of medication adherence. I would also discontinue Aspirin 81mg daily from HM’s current medication regimen. Aspirin is recommended as a concurrent therapy to warfarin for patients with prosthetic heart valves, not necessarily with atrial fibrillation. I think he will have good control of his anticoagulation with warfarin as long as he is within his therapeutic range and the aspirin may increase his risk for bleeding. I feel that the use of warfarin, aspirin, and Motrin is not the safest or most effective treatment plan for this patient. If HM continued daily aspirin, “for patients who take aspirin daily, ibuprofen must be taken 30 minutes to 2 hours after or 8 hours before the aspirin in order for the aspirin to be cardioprotective” (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 596). For these reasons, and to protect potential GI and renal adverse effects, I would discontinue the use of daily aspirin 81mg as well as the Motrin and recommend acetaminophen 325-500 mg every 4-6 hours if needed for pain as long as patient HM has normal liver functions.
Acetaminophen is a nonopioid analgesic and effects are believed to be due to activation of descending serotonergic inhibitory pathways (Acetaminophen, n.d.). The onset of action is less than an hour when given orally, lasts 4 to 6 hours, it is primarily absorbed in the small intestine and primarily metabolized in the liver and is subject to first-pass metabolism when given orally (Acetaminophen, n.d.). The half-life of acetaminophen is about 2 to 3 hours, but this may increase in patients with liver disease, and it is excreted through the urine (Acetaminophen, n.d.) Although, chronic doses of greater than 1.3 g daily of acetaminophen can increase the INR of a patient on warfarin, so I would suggest he only takes it when needed (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 594). I would provide HM with warning of hepatotoxicity with increased doses of acetaminophen or with chronic alcohol use. I would suggest HM avoid alcohol consumption as this could put him at risk for hepatotoxicity as well as affect his INR levels.
The Joint National Committee (JNC) guidelines for elderly patients above 80 years old recommends the goal of drug therapy of blood pressure less than 150/90 mm Hg and less than 140/90 in diabetic patients (Arcangelo, Peterson, Wilbur & Reinhold, 2017, p. 259). Atenolol should not be abruptly discontinued and if HM’s blood pressure and heart rate are well controlled with this medication, I would resume treatment of atenolol 100mg daily for HM and continue to monitor his blood pressures.
For HM’s hypoglycemic medications, HM is prescribed glyburide 10mg by mouth twice per day. The initial recommended dose for elderly patients is 1.25 mg per day with a maximum dose of 20 mg per day. Since this is within the daily maximum, I would continue the use of this medication, but adjust the dose with any signs of renal impairment. The metformin dose HM is currently taking is 1000 mg twice per day. The maximum dose is 2,550 mg per day in divided doses, so I would continue this medication as well if his blood glucose is controlled adequately.
Conclusion
Normal adult doses of medications often need to be adjusted in the elderly for pharmacokinetic reasons such as age-related changes in absorption, distribution, metabolism, and secretion. Changes that affect the absorption of medications in the elderly tend to be inconsequential despite age-related decrease in small-bowel surface area, slowed gastric-emptying, and an increased gastric pH (Pharmacokinetics in the Elderly – Geriatrics, n.d.). The distribution of the drug can be affected by the amount of body fat of the patient. With elderly patients, body fat generally increases or significantly decreases. For medications that are highly lipophilic, an increased body fat may increase their elimination half-lives (Pharmacokinetics in the Elderly – Geriatrics, n.d.). Although the rate of drug metabolism can vary greatly from one person to another, hepatic metabolism of many drugs through the cytochrome P-450 enzyme decreases with age (Pharmacokinetics in the Elderly – Geriatrics, n.d.). Hepatic clearance of drugs metabolized by phase I reactions are more likely to be prolonged in the elderly (Pharmacokinetics in the Elderly – Geriatrics, n.d.). First-pass metabolism also decreases by about 1% per year after age 40, therefore the elderly may have higher circulating drug levels (Pharmacokinetics in the Elderly – Geriatrics, n.d.).
The pharmacodynamics of medications can also be affected in the elderly in how the body responds to these medications. Sensitivity to medications may be greater or smaller in the elderly population and may be due to changes in drug-receptor interaction, in postreceptor events, in adaptive homeostatic responses, or pathologic changes in organs (Pharmacodynamics in the Elderly 0 Geriatrics, n.d.).
I believe this prescribed drug treatment for HM will be both safe and effective. As mentioned, I would like HM to monitor his symptoms at home as well as keep a log of his blood sugars and check his blood pressure if he is feeling dizzy, weak, or generally not well. I would recommend warfarin dose changes dependent on his INR checks. I would provide HM and his wife with education regarding safety, fall prevention, dietary restrictions, and bleeding risk of warfarin. I would also provide education regarding removing aspirin and Motrin from his medication list, why this was done, and the alternative therapy of acetaminophen and dosing instructions on this new medication. I would not anticipate any adverse outcome from this, although I would reinforce education regarding stroke signs and symptoms since this patient is at risk.
References
Acetaminophen. (n.d.). Retrieved December 12, 2018, from https://www.merckmanuals.com/professional/appendixes/brand-names-of-some-commonly-used-drugs?startswith=a#section_47
Arcangelo, V.P., Peterson, A.M., Wilbur, V., & Reinhold, J.A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach(4thed.). Ambler, PA: Lippincott Williams & Wilkins.
Drugs.com. (2018). Retrieved December 11, 2018, from https://www.drugs.com/pro/atenolol-tablets.html
Laureate Education, Inc. (Executive Producer). (2012). Hypertension and hyperlipidemia.Baltimore, MD: Author.
Pharmacodynamics in the Elderly – Geriatrics. (n.d.). Retrieved December 9, 2018, from https://www.merckmanuals.com/professional/geriatrics/drug-therapy-in-the-elderly/pharmacodynamics-in-the-elderly
Pharmacokinetics in the Elderly – Geriatrics. (n.d.). Retrieved December 9, 2018, from https://www.merckmanuals.com/professional/geriatrics/drug-therapy-in-the-elderly/pharmacokinetics-in-the-elderly
2 months ago
Kristin Pullins
Week 3 intial discussion post
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Week 3 Discussion: Pharmacotherapy for Cardiovascular Disorders
I chose case study number three for this week’s discussion:
Patient CB has a history of strokes. The patient has been diagnosed with type 2 diabetes, hypertension, and hyperlipidemia. Drugs currently prescribed include the following:
Glipizide 10 mg po daily
HCTZ 25 mg daily
Atenolol 25 mg po daily
Hydralazine 25 mg qid
Simvastatin 80 mg daily
Verapamil 180 mg CD daily
Patient situation:
CB, a 74-year old male, presents to your office with complaints of more frequent headaches, occasional blurry vision and a couple nose bleeds that he attributes to him blowing his nose a lot. These symptoms have been ongoing for approximate two weeks. He also reports he’s had a recent “head cold” over the last few weeks and has been using over-the counter nasal decongestants to alleviate his symptoms. From previous appointments CB has been encouraged to keep a log of his BP readings every AM and PM but states he has started to forget to do this and “can’t recall” what the readings have been lately. His BP is 174/98. Pulse: 96 Oxygen saturation 94% Respirations 18 and Temp 98.2
**for the purpose of a cardiac discussion I have left out Glipizide from my pharmacological evaluation/ changes to drug regimen**
Factor: Age
Hydrochlothiazide (HCTZ) is a thiazide diuretic that controls blood pressure by increasing urinary excretion of sodium and chloride, although it’s mechanism of antihypertensive effect is not completely understood (drugs.com, 2018c). HCTZ is not metabolized by the kidneys but is eliminated rapidly and it’s half-life can vary greatly from 5.6 to 14.8 hours (drugs.com, 2018c). HCTZ can be used as sole treatment of hypertension (HTN) or to enhance other drugs (drugs.com, 2018c). The initial dose for management of HTN should start at 25 mg once daily (drugs.com, 2018c). In this situation this patient was most likely receiving HCTZ as an enhancer to other drugs since he is also taking Atenolol, Hydralazine and Verapamil. HCTZ should be used cautionary in individuals with renal disease and impaired hepatic function (drugs.com, 2018c). In the elderly renal and hepatic function should be monitored closely to determine the safety of this drug for the patient. High-doses of HCTZ is also not indicated for individuals with hyperlipidemia and diabetes (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Atenolol is a beta 1 selective adrenergic blocker that is 50% absorbed by the gastrointestinal tract and peaks between two and four hours after ingestion (drugs.com, 2018a). The other 50% is excreted, unchanged, in feces (drugs.com, 2018a). Very little metabolism occurs in the liver and is excreted primarily by the kidneys (drugs.com, 2018a). A very small amount of the 50% that is absorbed is also protein bound (drugs.com, 2018a). Atenolol works by four ways: reducing heart rate and cardiac output during rest and exercise, reducing systolic and diastolic blood pressure at rest and during exercise, inhibiting isoproterenol induced tachycardia and by reducing reflux orthostatic tachycardia (drugs.com, 2018a). When used with HCTZ and hydralazine a large blood pressure fall results (drugs.com, 2018a). In the elderly the half-life of Atenolol is markedly longer and renal function should also be monitored closely in the elderly population to determine if this drug is safe for administration (drugs.com, 2018a). Atenolol should also be used cautiously in individuals with diabetes as it can mask symptoms of hypoglycemia (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Bradycardia and heart block can also occur with coadministration of Atenolol and Verapamil, these medications should be used with extra caution when administered together (drugs.com, 2018a).
Hydralazine is a direct vasodilator that works by relaxing the vascular smooth muscle by interfering the calcium movements within the smooth muscle (drugs.com, 2018b). Decreased arterial blood pressure and peripheral vascular resistance and an increased heart rate, stroke volume and cardiac output result (drugs.com, 2018b). Hydralazine is taken orally and is rapidly adsorbed and metabolized by the gastrointestinal mucosa and liver with a half-life of two-eight hours (Davis’s Drug Guide, n.d.). Hydralazine should be used with caution in individuals with renal impairment an may require a lower dose (drugs.com, 2018b).
Verapamil is a calcium-channel blocker that decrease the influx of calcium causing a prolonged effective refractory period in the atrioventricular (AV) node and a slower AV conduction, decreasing systemic vascular resistance is also noted (drugs.com, 2018e). Verapamil is administered orally and is more than 90% absorbed and 90% bound to plasma proteins (drugs.com, 2018e). Verapamil also had a rapid biotransformation during first pass and bioavailability ranges from only 20-35% (drugs.com, 2018e). Verapamil, like other antihypertensives, should be used cautiously in the elderly/ individuals with impaired renal and hepatic function (drugs.com, 2018e). Hepatic insufficiency can prolong half-life by up to 14-16 hours and these individuals may only require one third of the dose a normal individual needs (drugs.com, 2018e). Constipation can also a problem in elderly patients (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Simvastatin is a HMG-CoA reductase inhibitor that works by blocking the conversion of HMG-CoA to mevalonate which leads to an increase in the number of low-density lipoproteins (LDL) cholesterol receptors on the lover which further leads to a decreased amount of LDL cholesterol in the bloodstream (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Simvastatin is taken orally and metabolized in the liver with a half-life of 2-5 hours (Epocrates, n.d.). Simvastatin should also be used with caution in those with renal impairment (drugs.com, 2018d).
As mentioned above, all medications should be used with caution in individuals with impaired renal and hepatic functions as metabolism and excretion could be affected. Dosing may have to be reduced in these individuals to prevent adverse effects/ severe hypotension.
Drug Regimen change
From the patient’s report of frequently using nasal decongestants for the same length of time he has been experiencing symptoms of hypertension I would recommend he stop the nasal decongestants and monitor his blood pressure closer at home. I would want to see him back within a week after these were stopped with his blood pressure log.
-I would keep the HCTZ but would not increase the dose due to contraindications of high doses in individuals with hyperlipidemia and diabetes.
-I would take him off the Atenolol since beta blockers are inferior in the prevention of strokes and should be used cautiously in individuals with diabetes (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
-I would increase his Hydralazine dose to 50mg 4 times daily. Once a maintenance dose was established the dose could be administered twice daily to ensure compliance (Davis’s Drug Guide, n.d.).
-I would change his statin from Simvastatin 80 mg to 20mg daily of Atorvastatin. Simvastatin should not administered in a dose larger than 10mg when given with Verapamil (drugs.com, 2018d). Simvastatin, when used in a dose of 80 mg can lead to myopathy and is not recommended (drug.com, 2018d).
Atorvastatin is taken orally and is rapidly absorbed and reaches peak plasma concentrations in one-two hours (News Medical Life Sciences, n.d.). Atorvastatin undergoes a high intestinal clearance and first pass affect and should not be taken with food as absorption rate can be decreased by 25% (News Medical Life Sciences, n.d.). Atorvastatin is also more than 98% protein bound (News Medical Life Sciences, n.d.). Elimination occurs via hepatic biliary excretion (News Medical Life Sciences, n.d.). Lower doses may also be needed in elderly and those with hepatic insufficiencies (News Medical Life Sciences, n.d.).
-I would continue his dose of Verapamil to avoid too many changes but would consider
increasing the dose in the future is his blood pressure is still not well controlled.
Since CB is taking three different medications to control his blood pressure I would
not feel comfortable adding another medication unless I could ensure he was being complaint with the medication regimen and his diet. Adherence should be questioned after a third drug is added and blood pressure control is still not met (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). CB should be watching his sodium intake, taking all his medications as prescribed, exercising/ losing weight and keeping a daily blood pressure log that he brings to all appointments.
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017).
Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Davis’s Drug Guide. (n.d.). Hydralazine. Retrieved from https://www.drugguide.com/ddo/view
/Davis-Drug-Guide/51383/all/hydrALAZINE#2
Drugs.com. (2018a). Atenolol. Retrieved from https://www.drugs.com/pro/atenolol-tablets.html
Drugs.com. (2018b). Hydralazine. Retrieved from https://www.drugs.com/pro/hydralazine.html
Drugs.com. (2018c). Hydrochlorothiazide. Retrieved from https://www.drugs.com
/pro/hydrochlorothiazide.html
Drugs.com. (2018d). Simvastatin. Retrieved from https://www.drugs.com/pro/simvastatin.html
Drugs.com. (2018e). Verapamil. Retrieved from https://online.epocrates.com/u/107143
9/simvastatin/Pharmacology
Epocrates. (n.d.). Simvastatin. Retrieved from https://online.epocrates.com/u/107143
9/simvastatin/Pharmacology
News Medical Life Sciences. (n.d.). Lipitor (Atorvastatin) Pharmacokinetics.
Retrieved from https://www.news-medical.net/health/Lipitor-(Atorvastatin)-Pharmacokinetics.aspx
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RE: Main post, scenario 2, second attempt
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For this week’s main post, I chose case study 2. In this case patient HM has a history of atrial fibrillation and one episode of transient ischemic attack (TIA). HM’s clinical diagnostic history is: type 2 diabetes, hypertension, hyperlipidemia and ischemic heart disease. Drugs currently prescribed include the following: warfarin 5 mg daily M, W, F and 2.5 mg daily T, TH, Sat, Sun, aspirin 81 mg daily, metformin 1000 mg po bid, glyburide 10 mg bid, atenolol 100 mg po daily and Motrin 200 mg 1–3 tablets every 6 hours as needed for pain.
Warfarin: This a vitamin K antagonist anticoagulant that inhibits the clotting factors in the liver that depends on vitamin k for synthesis. Warfarin half-life is 36 to 42 hours, but the full effect of the medication won’t be seen for 8 to 14 days when prothrombin is depleted. The anticoagulant effect of warfarin is monitored by INR lab (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). Ansell et at., 2008 in Arcangelo, Peterson, Wilbur, & Reinhold (2017) also said warfarin does not affect the function of existing clotting factors and has no effect on an existing thrombus.
Aspirin: This is an antiplatelet medication used to treat and prevent ischemic stroke. Aspirin prevents prostaglandin synthesis in platelets by modifying and inhibiting the enzyme COX. The onset is within 5 minutes from oral administration. With no higher benefits from higher doses over lower doses and with an increased risk of Gastrointestinal bleeding, a low dose of 81 mg daily is preferred (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Metformin: Is a biguanide which, accordingly to Arcangelo, Peterson, Wilbur, & Reinhold (2017), is not considered hypoglycemic agent and does not cause hypoglycemia when administered as monotherapy and do not promote hyperinsulinemia or weight gain. The authors also mentioned Its mechanism of action is by inhibition of the hepatic production of glucose and improves the peripheral sensitivity to insulin.
Glyburide: This is a second-generation sulfonylurea, a major group of oral hypoglycemic agents used to treat type 2 diabetes. The mechanism of action is by binding to receptors on beta cells, causing ATP dependent potassium channels to close and subsequently open up, increasing cytoplasmic calcium, which stimulates the release of insulin (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Atenolol: This is beta-adrenergic blocker medication used in this patient to treat hypertension. Its mechanism of action of reducing BP happens by blocking central and peripheral beta receptors, resulting in decreased cardiac output and sympathetic outflow (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
Motrin: A propionic Acid NSAID medication used to treat pain. There are two mechanism in which NSAIDs wield their anti-inflammatory effects; by inhibiting the conversion of arachidonic acid to prostaglandin, prostacyclin and thromboxanes and the other is by interfering with protein kinase activation (Arcangelo, Peterson, Wilbur, & Reinhold, 2017).
The factor I decided to use for this discussion is behavior. Patient behavior is very important when treating some of the diseases currently present in HM medical history. Hyperlipidemia, and Diabetes Mellitus (DM) are two of the preventable diseases present in the patient’s medical history.
DM type 2 is a preventable disease related with lack of exercising and obesity that can alter the pharmacokinetic and pharmacodynamics of many other chemicals in the body (Vahabzadeh & Mohammadpour, 2015). The authors also stated that different metabolic pathways are involved in the transformation of drugs and toxins, therefore their pharmacokinetics may be affected by DM mostly due to changes in enzymes and drug transporters. “Diabetes can influence the plasma protein-binding of some drugs, possibly via glycosylation or displacement of proteins by plasma Free Fatty Acids (FFA), since the amount of FFA is raised in diabetic patients (Vahabzadeh & Mohammadpour, 2015). The article also mentions that multiple studies have been performed in human populations proving, despite some discrepancies, that not only DM itself can negatively affect the metabolic capacity of the liver, but also some other factors such as gender and age were involved in the pharmacokinetics and pharmacodynamics alterations.
The other modifiable disease present in Pt. HM is hyperlipidemia. There is a clear reference between dyslipidemia and cardiovascular disease. Mainly this disorder is treated with medication, but medication by itself is not enough to completely cure the disease and there are circumstances, such as during pregnancy, liver disease and intolerance to the side effects of the statins, where the need for another way to decrease cholesterol in the system is imperative. A change in behavior is very important to treat dyslipidemia disorders, where patient may have to observe what he eats and how he eats it. Increase in physical activity is a must in the prevention of cardiovascular diseases also present in our study patient. The mechanism of exercise-induced lipid lowering is unclear, but it’s believed that practicing exercise increases blood lipid consumption, thus decreasing lipid levels (Wang & Xu, 2017).
DM and Hyperlipidemia can damage organs in the body, ranging from vessel obstructions to damage to important organs involved in the drug metabolism. These damages may present a problem for the prescribing provider and the patient (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). As HM’s provider I would encourage an increase in physical activity and weight loss program. These changes in the patient’s body may call for a close monitoring of the patient laboratory results and weight. A decrease in medications dosages may be necessary as the patient weight starts to decrease to the point of total cancelation of the medication once the patient’s blood glucose and cholesterol levels reach normal values.
Improvements to the patient’s drug plan
I would continue some of the medications and replace others. I would maintain warfarin for the preventive treatment of clot formation which, in the case of this patient, is at increase risk due to his history of atrial fibrillation. INR should be monitored according to protocols to maintain a goal between 2-3. Aspirin 81 mg daily will also be maintained for ischemic stroke prevention. Metformin 1000 mg and Glyburide 10 mg BID will be maintained for the maintenance of diabetes mellitus type 2. Atenolol will be maintained as treatment for HM hypertension. Although a combination of thiazide diuretic and an ACE inhibitor has proven efficacy in treatment of hypertension in patients with diabetes mellitus, a beta-adrenergic blockers and calcium channel blockers also can be beneficial in treating hypertension when treating patients with diabetes. Beta blockers reduce cardiovascular events and are useful in a multidrug regimen like in the case of the patient in the scenario. Controlling hypertension is key to reducing cardiovascular risk in patients with diabetes (Whalen & Stewart, 2008).
I would also discontinue ibuprofen as the patient’s pain management medication, since this medication is processed by the kidneys and may increase risk of bleeding since the Pt is taking other medications that may cause bleeding like aspirin and warfarin. For the treatment of pain, I will prescribe Tylenol 650 mg orally every 6 hours as needed. The patient would be advised not to go over 4000 mg daily to prevent overdose and liver damage. “Acetaminophen does not adversely affect platelet aggregation or the gastric mucosa” (Arcangelo, Peterson, Wilbur, & Reinhold, 2017) though this medication is relatively non-toxic, a 4% of the drug is converted to a toxic metabolite is usually inactivated by glutathione pathways. However, once the glutathione stores are depleted this metabolite can cause fatal liver necrosis, especially during overdoses or chronic ingestion.
Conclusion.
Its very important to monitor patient’s response to medication regimes, especially when multi-drug management is in place. Medications ordered correctly can provide an array of benefits, but when little to no consideration of the pharmacokinetics and pharmacodynamics are in place, it can be detrimental for the patient.
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapeutics for Advanced Practice A Practical Approach. Philadelphia: Wolters Kluwer.
Vahabzadeh, M., & Mohammadpour, A.-H. (2015). Effect of Diabetes Mellitus on the Metabolism of Drugs and Toxins. Journal of Clinical Toxicology.
Wang, Y., & Xu, D. (2017). Effects of aerobic exercise on lipids and lipoproteins. U.S. National Library of Medicine.
Whalen, K. L., & Stewart, R. D. (2008, December 1). Pharmacologic Management of Hypertension in Patients with Diabetes. American Family Physician, 1277-1282. Retrieved from American Family Physician: https://www.aafp.org/afp/2008/1201/p1277.html
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Discussion Post 3-Pennington, V-Initial Post
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NURS 6521C: Advanced Pharmacology
Discussion Post 3
Initial Post
December 11, 2018
Case Study 1:
Patient AO is 75 years old and has a history of obesity and a recent unexpected weight gain of 9 pounds. The patient admits to shortness of breath on exertion but can regain composure with rest. Vital signs: BP 180/95, HR 101, RR 18, Temp 98.3. Assessment findings include 2+ palpable radial and pedal pulses, no jugular vein distention and 1+ pitting edema on bilateral lower extremities. Lungs are clear but diminished in the bases bilaterally, and heart sounds are regular with S1/S2 noted through auscultation. The patient has been diagnosed with essential hypertension and hyperlipidemia. Drugs currently prescribed include the following: Atenolol 12.5 mg daily, Doxazosin 8 mg daily, Hydralazine 10 mg qid, Sertraline 25 mg daily, and Simvastatin 80 mg daily. The patient was diagnosed with hypertension which can be managed pharmacologically but additionally the patient help the medical management by reducing the number of modifiable risk factors such as obesity, smoking or high salt intake in their diet. According to Whalen, Finkel, and Panavelil (2015), the reduction of cardiovascular and renal mortality and morbidity is the primary goal of antihypertensive pharmacological therapy. AO is over the age of 80 which puts him in the geriatric cohort which leads to some additional research and modeling of his medication to ensure that he will not have any adverse effects from the regime prescribed by the practitioner. According to Al Odhayani, Tourkmani, Alshehri, Alqahtani, & Mishriky (2017), geriatric patients are at risk for polypharmacy and multiple medications in the same drug class but go undiscovered during appointments, and finally, geriatric patients are at higher risk for adverse events related to physical changes that affect the pharmokinetics and pharmacodynamics of the medications that have been prescribed to help them.
Prescription Analysis
Atenolol is a beta adrenergic blocker assist in reducing blood pressure by blocking beta receptors located in the heart and kidneys as well as in the lungs, liver, and pancreas (Archangelo, Wilbur & Reinhold, 2017). The Beta 1 receptors aid in regulating heart rate, the release of renin and the contractility of the heart and located predominately in heart and kidneys whereas Beta 2 receptors are found in the lungs, liver, pancreas, and aretioral smooth muscle and these receptors control vasodilation and bronchodilation (Archangelo, Wilbur & Reinhold, 2017). Atenolol blocks the stimulation of beta 1 but does not usually affect beta 2 receptors which have an absorption rate between 50-60%, distribution does not cross the blood brain barrier, and is excreted 40-50% by the kidneys with the remaining unabsorbed medication being exected through fecal matter(Vallerand, Sanoski, & Quiring, 2019). According to Vallerand, Sanoski, and Quiring (2019), Atenolol is not recommended in patients with congestive heart failure and should be started slowly with lower initial doses in patients above the age of 65.
Doxasosine is an alpha-1 receptor blocker that acts on alpha 1 receptors by blocking the binding of norepinephrine to alpha 1 receptors located on the membranes of vascular smooth muscle cells causing relaxed, smooth muscle tone that reduces peripheral vascular resistance that leads to lower blood pressure(Whalen, Finkel, & Panavelil, 2015). Doxasosine is absorbed thoroughly after oral administration, requires protein binding 98-99% and is primarly metabolized by the liver and is not recommended for geriatric patients according to the Beers list because of the probability of hypotension and is not recommended to be administered concurrently with other antihypertensive medications(Vallerand, Sanoski, & Quiring, 2019).
Hydralazine is a direct vasodilator and not a single use medication for hypertension but is usually combined with a diuretic and a beta blocker, and together these medications decrease cardiac output, plasma volume and peripheral vascular resistance (Whalen, Finkel, & Panavelil, 2015). Hydralazine is absorbed rapidlyafter administration orally and is widely distributed throughout the entire body, and is metabolized by N-acetlytransferase in the gastrointestinal mucosa and the liver (Vallerand, Sanoski, & Quiring, 2019). Direct vasodilators cause increased levels of renin concentration in the plasma that results in sodium and fluid retention and also causes reflex tachycardia which is one reason why these medications are prescribed in conjunction with a diuretic for fluid retention and beta blocker for the tachycardia.
Simvastatin is an HMG-CoA Reductase inhibitor (Statin) are prescribed to patients with hyperlipidemia and blocks the conversion the conversion of HMG-CoA to mevalonate that reduces the amount of cholesterol produced by the liver(Whalen, Finkel, & Panavelil, 2015). There is an increase in the number of LDL receptors since the liver is not synthesizing LDL cholesterol-the liver pulls LDL cholesterol that is free floating in the blood stream onto the empty receptors reducing the amount of cholesterol in the bloodstream. Simvastatin is 85% absorbed but is metabolized rapidly in the liver and execreted in bile and fecal matter, and the medication is 95% protein binding (Vallerand, Sanoski, & Quiring, 2019). Containdications focus on patients with active liver disease and should not be prescribed to a patient that drinks a lot of alcohol, but there are no contraindications for geriatric patients.
Sertraline is a selective serotonin reuptake inhibitor (SSRI) and is an antidepressant that acts by binding to serotonin transporters and stops the reuptake of serotonin into the presynaptic neurons(Archangelo, Wilbur & Reinhold, 2017). This medication is well absorbed and distributed throughout the body with oral administration, with 98% binding to proteins, metabolized by the liver, and about 14% is exected in fecal matter(Vallerand, Sanoski, & Quiring, 2019). According to Archangelo, Wilbur, and Reinhold (2017), SSRIs can cause issues with the metabolizing of medications through the cytochrome P-450 system and through the inhibition of the system can cause an increase in the levels of medications. Medications affected by the the cytochrome P-450 system and specific isoenzyme inhibition caused SSRIs to include HMG-CoA reductase inhibitors such as simvastatin, calcium channel blockers, and beta blockers but Sertraline has a lower potential of interaction for these medications compared to other antidepressants (Archangelo, Wilbur & Reinhold, 2017).
Recommended Pharmacological Recommendations
AO appears through assessment findings to have developed fluid retention and possible congestive heart failure related to the assessment findings of SOB with exertion, edema and the weight gain of nine pounds. Further testing needs to be ordered to confirm this diagnosis, but changes to the medications prescribed to this patient might help reduce some of the symptoms. Atenolol, Hydralazine, and Doxazosin would all be discontinued and other therapies initiated to medically manage the patient’s hypertension diagnosis while managing the fluid overload but the prescriptions for Simvistatin and Sertraline will remain unchanged. According to Archangelo, Wilbur & Reinhold (2017), it is recommended to start the geriatric patient on a new beta blocker such as nebivolol and carvedilol because of a safer profile and improved morbidity and mortality outcomes. The changes in the patients prescription regime include the introduction of Nebivolol 5 mg by mouth daily, a combination of Lisinopril 10 mg and hydrochlorthiazide 12.5 mg by mouth daily along with Simvistatin 80mg by mouth daily, and Sertraline 25 mg by mouth daily.
Nebivolol is still a beta blocker but milder and not associated with the negative effects associated with heart failure and the dosage is the lowest dose possible for geriatric dosing. Pharmcokinetics are similar to Atenolol but this medication is metabolized using the liver and CYP2D6 enzyme system which is a contradiction for medications combined with SSRI’s because of the fact that the SSRI inhibition of the CYP2D6 enzyme system will increase the amount of this medication that will not be metabolized but Sertraline has a low indication so it was decided to keep this medication instead of introducing another medication for depression but patient will need close monitoring.
Hydrochlrothiazide is a thiazide diuretic that is used to manage hypertension and heart failure and functions by increasing sodium and water excretion by inhibiting the reabsorption of sodium (Vallerand, Sanoski, & Quiring, 2019). This medication is absorbed rapidly, distributed into extracellular space and excreted unchanged by the kidneys and this medication does not have a lot of precautions and is started at the lowest dose possible to ensure close monitoring for the geriatric patient(Vallerand, Sanoski, & Quiring, 2019).
Lisinopril is an ace inhibitor that lower blood pressure, reduces symptoms for patients with heart failure and the net result of the enzymatic inhibition action is systemic vasodilation that will replace hydralazine which was a direct vasodilator without the fluid retention side effects seen with hydralazine (Vallerand, Sanoski, & Quiring, 2019). The pharmacokinetics of lisinopril includes a 25% absorption rate after oral administration and a medication that is totally excreted by the kidneys with a recommendation of a lower dose for geriatric patients(Vallerand, Sanoski, & Quiring, 2019).
These new medications will help reduce the symptoms with a possible diagnosis of fluid overload that could be heart failure. It is essential to follow up with this patient within a few weeks to ensure that the medications are working and that they are not having any adverse reaction to the medication that has been ordered. The changes to the medication include two new medications that are excreted by the kidneys so it is essential to monitor serum creatnine levels and the patients urinary status. Liver function should be included to ensure that the level of liver function that is available for metabolism and execretion.
References:
Archangelo, V.P., Peterson, A.M., Wilbur, V & Reinhold, J.A. (Eds.).
(2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins
Al Odhayani, A., Tourkmani, A., Alshehri, M., Alqahtani, H., & Mishriky, A. (2017).
Original article: Potentially inappropriate medications prescribed for elderly patients through family physicians. Saudi Journal of Biological Sciences, 24, 200–207. https://doi-org.ezp.waldenulibrary.org/10.1016/j.sjbs.2016.05.006
Whalen, K., Finkel, R., & Panavelil, T. A. (2015). Lippincott illustrated reviews: Pharmacology
(6th ed.). Philadelphia, PA: Wolters Kluwer.
Vallerand, A. H., Sanoski, C. A., & Quiring, C. (2019). Daviss drug guide for nurses. Philadelphia,
AtPA: F.A. Davis Company.
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2 months ago
Chuck Weiss
Week 3 Main Discussion
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Case Study 2:
Patient HM has a history of atrial fibrillation and a transient ischemic attack (TIA). The patient has been diagnosed with type 2 diabetes, hypertension, hyperlipidemia and ischemic heart disease. Drugs currently prescribed include the following:
Warfarin 5 mg daily MWF and 2.5 mg daily T, TH, Sat, Sun
Aspirin 81 mg daily
Metformin 1000 mg po bid
Glyburide 10 mg bid
Atenolol 100 mg po daily
Motrin 200 mg 1–3 tablets every 6 hours as needed for pain
Patient Situation
Patient has history of atrial fibrillation and transient ischemic attack(TIA). Recently diagnosed with Type 2 diabetes, hypertension, hyperlipidemia, and ischemic heart disease. Current drug regimen is adequate but needs to haven drug regimen adjusted as well as new medications added. Case study does not give age, gender, race or behavior facts. We do not know patient’s allergies which will affect the medications that can or cannot be prescribed. Objectively the patent’s current list of medications is relevant for his medical history, but patient needs to have some medications removed and needs education on what over the counter mediations to avoid and why.
Current Pharmacological Evaluation
Pharmacologically this patient needs to be educated on the use of Motrin for pain. Motrin is contraindicated in patients on a blood thinner such as warfarin and aspirin, since Motrin is a non-steroidal anti-inflammatory that also can cause bleeding. It is recommended that this patient be take Tylenol for pain. Warfarin is an anticoagulated used to treat atrial fibrillation. “Warfarin decreases blood clotting by blocking an enzyme called vitamin K epoxide reductase that reactivates vitamin K1. Without sufficient active vitamin K1, clotting factors II, VII, IX, and X have decreased clotting ability.”(Reardon, G. 2013 p.167) A patient needs to have their prothrombin time checked every 1-4 weeks to make sure they are in therapeutics levels. Aspirin (ASA) is given as a second blood thinner, its action work by inhibiting or suppressing normal platelet function which decreases the formation of thrombi. Usually ASA is prescribed at 81mg PO daily unless contraindicated in patients with stomach ulcers or irritated bowels. Metformin is a first line medication given to patients who are type 2 diabetics, 1000mg PO bid is a standard maintenance dose for type 2 diabetics. Metformin works be decreasing glucose production in the liver and increasing the sensitivity of insulin in the patient’s body tissue.(Karch, 2013) Metformin is contraindicated in patients with liver disease as well as kidney failure. Patient’s should stop taking Metformin for 48 hours after having intravenous iodine radiographic studies in order to give the iodine time to be flushed out of the body. This medication along with diet should decrease this patient’s blood glucose levels. Glyburide (Glibenclamide) is another drug used for the treatment of type 2 diabetes. It is used in conjunction with Metformin to increase the bodies sensitivity to insulin. Closing monitoring of blood glucose levels (BGL)are important due the possibility of a sudden drop in BGL’s causing hypoglycemia. Caution is taken is using this medication in patients with liver and kidney failure as it is absorbed in the liver and excreted in the kidneys. Atenolol (Tenormin) is a beta-adrenergic blocker used to treat hypertension in patient’s by decreasing heart rate and the workload in the heart by inhibiting beta 1 receptors in your body. (Arcangelo, Peterson, Wilbur, & Reinhold, 2017) It is contraindicated in patients with type 2 diabetes because it can increase symptoms of diabetes. This drug would not be recommended in this patient due to their diagnosis of type 2 diabetes.
Drug Regimen Changes and Pharmacological Evaluation
As this patient’s provider, with the little information I have I would make multiple recommendations to the medication regimen. First, I would start with explaining to the patient that they can no longer take Motrin. As mentioned above this medication is contraindicated in patient’s on blood thinners. I would recommend Tylenol for pain, recommended dosage would be, 650mg PO TID as needed for pain. Warfarin and aspirin would be continued at the current prescription with the patient getting repeat prothrombin times to monitor clotting factors. Educating the patient on the need to watch the amount of leafy greens they eat because they contain vitamin K and can decrease the effectiveness of warfarin. Also, education on the fact that if they get a cut or a bruise, bleeding time is increased leading to larger bruises. I would continue the patient on metformin and glyburide with special instructions to monitor their BGL’s as well as education on eating healthier and exercising. I would take this patient off atenolol and place them on Lisinopril/ hydrochlorothiazide combination drug therapy. I would start them off at 20/12.5mg PO daily. Lisinopril/HCTZ is a combination drug that is recommended in patients with diabetes and HTN. It is an Ace inhibitor that inhibits the conversion of angiotensin I into angiotensin II. (Laureate Education, 2012). Hydrochlorothiazide is a diuretic that works by decreasing the kidneys ability to retain water. (Sica, DA 2011) This in turn decreases blood volume, decreasing cardiac output. As a combination drug it as an increased effect on patients with diabetes and hypertension by being effective without compromising the kidneys or liver. (Hickman, J. 2010) Since HCTZ is a diuretic it is important that the patient knows there can be a decrease in electrolytes in the body, and potassium levels should be monitored when first giving the medications. As for the hyperlipidemia I would recommend having the patient start with lifestyle changes such as diet and exercise for six months. (Laureate Education, 2012) If this doesn’t work I would start them on a statin like Zocor (Simvastatin). Simvastatin work by inhibiting 3-hydroxy-3-methylglutaryl (HMG) coenzyme A reductase. (Arcangelo et al., 2017, p. 281) This enzyme decreases the production of cholesterol in the liver decreasing cholesterol levels in the body. Due to the history of diabetes I would start the patient at a dose of 40mg PO daily to be taken at night. Research shows that statins taken at night are more effective the in the morning because the body produces more cholesterol at night. While on Simvastatin the patient needs to monitor their blood sugar for any fluctuations.
Conclusion
In conclusion, it is important to monitor for any unforeseen interaction in the new medications added to the patient. With the new regimen of medication added to the patients existing list the plan is to have the patient become normotensive as well as keeping their blood sugar within an acceptable range. Weekly then monthly monitoring of the patient’s prothrombin time as well as monitoring of their electrolyte levels and cholesterol levels. If the patient follows this regimen there should be little negative effect on any major organs while being able to lead a healthy lifestyle.
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (2017). Pharmacotherapuetics for Advanced Practice (4 ed.). Phil., Penn.: Lippincott, Williams & Wilkins.
Karch, A. M. (2013). Focus on Nursing Pharmacology (6 ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
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