NURS 6512 Pharmacotherapy for Cardiovascular Disorders
NURS 6512 Pharmacotherapy for Cardiovascular Disorders
The patient is dealing with a major cardiovascular issue based on the case study. All the current medication prescribed to the patient needs to be reviewed for appropriate changes. Cardiovascular disease counts as a major cause of disability and leads to a cause of death globally. The statistic indicates that approximately a person dies within approximately 36 seconds in the United States due to cardiovascular disease (Benjamin et al., 2019). Therefore, cardiovascular disease is the major cause of health disparities and increases the cost of health care. It is vital to consider the patient’s lifestyle, history, and review to manage HH’s illness effectively. This paper addresses the factors that influence a patient’s pharmacokinetics and pharmacodynamics process and gives changes that impact the recommended drug therapy.
Factor Influencing Pharmacokinetic and Pharmacodynamics Process in the Patient
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Based on the case study, the factor that I have selected is age, which can lead to drug toxicity and influence the pharmacokinetics of different medications. Age causes an increase in the altered metabolism and blood concentration of drugs (Giri et al., 2018). A decrease in renal function causes an alteration of drug pharmacokinetics such as glomerular filtration rate and reduces blood flow. Age-related changes that occur in a patient include physiological factors and temperature (Giri et al., 2018). The physiological factors cognition, ventricular aerial stiffness, endothelial function, and electric conduction (Rosenthal & Burchum, 2021). Most people are sensitive to antihypertensive medication due to sympathetic neuronal and baroreceptor response (Giri et al., 2018).
Glipizide is used to cure an adult with type 2 diabetes mellitus. The drug effectively promotes insulin release from the beta cells since it reduces glucose output from the liver (Addul-Ghani et al., 2021). For patients with inadequate metabolic control, the combination of metformin and Glipizide helps reach the goal of HbA1c within three months (Addul-Ghani et al., 2021). Glipizide is effective since it has a short life and effect duration, thus lowering the risk of long-lasting hypoglycemia (Addul-Ghani et al., 2021). Patients taking Glipizide with thyroid hormone, estrogen-containing contraceptives, thiazide diuretics, nicotinic acid, and calcium channel blockers have a high potential for hyperglycemia (Rosenthal & Burchum, 2021).
Metformin effectively improves glycemic control, which takes place without inducing hypoglycemia or causing obesity, thus considered a first-line pharmacologic treatment (Shurrab & Arafa, 2020). The drug inhibits gluconeogenesis by causing a block on the mitochondrial redox shuttle, thus acting in the liver (Shurrab & Arafa, 2020). Metformin is identified to cause gastrointestinal adverse effects such as nausea, diarrhea, and vomiting (Shurrab & Arafa, 2020). FDA labels warn against prescribing Metformin drug therapy for patients with acute heart failure when supplemented with hypoxemia and hypoperfusion.
Hydrochlorothiazide (HCTZ) is used to treat hypertension since it is a thiazide-type diuretic (Rosenthal & Burchum, 2021). The drug inhibits the sodium chloride co-transparent system leading to the distal of the convoluted tubules (Rosenthal & Burchum, 2021). A lower level of blood pressure is achieved due to the diuretic action. However, studies have declined hydrochloride as an ACE inhibitor for reducing the risk of cardiovascular disease (Handelsman et al., 2020). The adverse effect caused by the use of hydrochlorothiazide is the development of hyperglycemia (Rosenthal & Burchum, 2021). The drug therapy effectively manages latent diabetes and causes an increase in triglycerides and cholesterol (Rosenthal & Burchum, 2021). The combination of HCTZ with calcium channel blockers and ACE inhibitors effectively reduces hypertension.
Atenolol acts as a beta blocker that causes an effect on blood circulation and the heart. The drug helps treat hypertension and angina, effectively bind the beta-1 adrenergic receptors in the vascular smooth muscle (Habib et al., 2021). This affects the chronotropic actions of the endogenous catecholamine. The process leads to a decrease in myocardial contractility heart rate and lowers blood pressure. The drug therapy is limited for a patient with moderate severely impaired renal (Habib et al., 2021). The side effects of Atenolol use include causing weight gain and heart failure for some patients.
Hydralazine drug causes direct relaxation of the arteriolar smooth muscle. This is considered an antihypertensive agent and phthalazine derivative (Sangshetti et al., 2019). A reverse antihypertensive effect is likely to be experienced due to vasodilation (Sangshetti et al., 2019). This is caused by hydralazine followed by a reflex sympathetic response. The drug therapy is effective when combined with isosorbide dinitrate in reducing hypertension. The side effects of using hydralazine cause a lupus-like syndrome in rare cases. However, the drug leads to discontinuation of the drug (Sangshetti et al., 2019).
Simvastatin is used as an adjunct to diet thus used as an oral HMG-CoA reductase inhibitor. A patient using Simvastatin gain a reduction in dyslipidemia and a decline in cholesterol production (Di Bello et al., 2020). The cholesterol synthesis is catalyzed by converting HMC-CoA to mevalonate, completely inhibited by hepatic hydroxymethyl-glutaryl coenzyme A (HMG-CoA) reductase (Di Bello et al., 2020). The agent effectively reduces the lipoprotein level and lowers the plasma cholesterol. The side effect of using Simvastatin 80mg is that it has a higher risk of possible rhabdomyolysis and myopathy after 12 months of use (Di Bello et al., 2020).
Verapamil is used to treat hypertension, atrial tachyarrhythmia, and angina pectoris and is classified in the class of calcium channel blockers. It helps block the cardiac muscle cells and influx of calcium ions into the vascular smooth muscle in the membrane depolarization (Savage et al., 2020). The action helps in decreasing the oxygen consumption and the cardiac work. The drug is also effective in causing a reduction in atrial–ventricular conduction. This helps in controlling the supraventricular tachyarrhythmia (Savage et al., 2020). The side effect of using verapamil include causing transient serum enzyme elevation to be mild to moderate and the liver injury from mild (Savage et al., 2020).
Improving Drug Therapy Plan
The patient can experience congestive heart failure (CHF) when there is a combination of verapamil, atenolol, and Hydrochlorothiazide (HCTZ) (Rosenthal & Burchum, 2021). For effective control of stroke, it is important to control blood pressure. It is important to avoid duplicitous therapy, which causes harm. Interaction between verapamil and Simvastatin leads to an increase in the blood level of Simvastatin (Di Bello et al., 2020). The act leads to kidney damage and rhabdomyolysis and causing liver damage. Atenolol can cause an increase in the duration of hypoglycemic symptoms along with Glipizide (Habib et al., 2021).
It is important to ensure that a patient is educated on the need to consider frequent blood glucose monitoring. This is a result of atenolol due to the symptom of hypoglycemia. The symptom of hypoglycemia include heart palpitations, rapid heartbeat, and tremor (Rosenthal & Burchum, 2021).
Abdul-Ghani, M., Puckett, C., Adams, J., Khattab, A., Baskoy, G., Cersosimo, E., … & DeFronzo, R. A. (2021). Durability of triple combination therapy versus stepwise addition therapy in patients with new-onset T2DM: 3-year follow-up of EDICT. Diabetes care, 44(2), 433-439. https://diabetesjournals.org/care/article-abstract/44/2/433/35501
Benjamin, E. J., Muntner, P., Alonso, A., Bittencourt, M. S., Callaway, C. W., Carson, A. P., … & American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. (2019). Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation, 139(10), e56-e528. https://www.ahajournals.org/doi/abs/10.1161/cir.0000000000000659
Di Bello, E., Zwergel, C., Mai, A., & Valente, S. (2020). The innovative potential of statins in cancer: new targets for new therapies. Frontiers in Chemistry, 8, 516. https://www.frontiersin.org/articles/10.3389/fchem.2020.00516/full
Giri, B., Dey, S., Das, T., Sarkar, M., Banerjee, J., & Dash, S. K. (2018). Chronic hyperglycemia mediated physiological alteration and metabolic distortion leads to organ dysfunction, infection, cancer progression and other pathophysiological consequences: an update on glucose toxicity. Biomedicine & Pharmacotherapy, 107, 306-328. https://www.sciencedirect.com/science/article/pii/S0753332218322406
Habib, S., Alam, M., Mustafa, M., & Verma, A. K(2021). Role of Beta-Blockers as an Effective Cardio protective Agents, an insight in to Tackling with Cardiovascular Diseases (CVDs) and Hypertension. https://www.researchgate.net/profile/Abhishek-Kumar-Verma-2/publication/354694288
Handelsman, Y., Jellinger, P. S., Guerin, C. K., Bloomgarden, Z. T., Brinton, E. A., Budoff, M. J., … & Wyne, K. L. (2020). Consensus statement by the American association of clinical Endocrinologists and American College of Endocrinology on the management of dyslipidemia and prevention of cardiovascular disease algorithm–2020 executive summary. Endocrine Practice, 26(10), 1196-1224. https://www.sciencedirect.com/science/article/pii/S1530891X20482047
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants. Elsevier.
Sangshetti, J., Pathan, S. K., Patil, R., Ansari, S. A., Chhajed, S., Arote, R., & Shinde, D. B. (2019). Synthesis and biological activity of structurally diverse phthalazine derivatives: A systematic review. Bioorganic & Medicinal Chemistry, 27(18), 3979-3997. https://www.sciencedirect.com/science/article/pii/S0968089619310193
Savage, R. D., Visentin, J. D., Bronskill, S. E., Wang, X., Gruneir, A., Giannakeas, V., … & McCarthy, L. M. (2020). Evaluation of a common prescribing cascade of calcium channel blockers and diuretics in older adults with hypertension. JAMA Internal Medicine, 180(5), 643-651. https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2761272
Shurrab, N. T., & Arafa, E. S. A. (2020). Metformin: A review of its therapeutic efficacy and adverse effects. Obesity Medicine, 17, 100186. https://www.sciencedirect.com/science/article/pii/S2451847620300063
An elderly African American male patient in the case study laments having a painfully sluggish heart rate. The patient had lightheadedness in the mornings as well. He began using Diltiazem CD six weeks ago to help manage his high blood pressure, and his dose of metoprolol was decreased from 75 to 50 mg twice a day. His lab tests revealed digoxin toxicity upon admission, as recommended by the patient’s PCP, as well as significantly decreased diastolic blood pressure, bradycardia, elevated levels of potassium, low hct, high creatinine, INP, BUN, INP, and glucose levels. This paper explores the relationship between pharmacodynamic and pharmacokinetic processes and patient age, as well as how these processes impact the medications that the patient is prescribed.
Pharmacokinetic and Pharmacodynamic Processes
The patient is considered elderly because he is 74 years old. According to research, aging is marked by a reduction in the performance of several regulatory mechanisms within the body’s tissues that are in charge of ensuring coordination and integration between cells and organs (Thürmann, 2020). As a result, in some physiologically stressful conditions, they can end up not sustaining homeostasis. Reduced homeostasis has varied impacts on distinct regulatory systems in different individuals, leading to increased interindividual variability in older adults.
Reduced liver and kidney clearance and extensive distribution volume of medications soluble in lipid medium are a few of the most prevalent pharmacokinetic alterations linked to aging (van den Anker et al., 2018). The aforementioned modifications also cause most medicines’ elimination half-lives to be lengthened. Aging is associated with a higher sensitivity of most pharmacological agents, including psychotropic, cardiac, and anticoagulant medicines. This is regarding pharmacodynamic alterations. The sensitivity, however, may differ based on additional elements including the patient’s body weight and coexisting medical disorders.
Impact on the Patient’s Recommended Drug Therapy
The patient is more likely to have impaired renal and hepatic clearance of several medications due to his senior age, as well as lower water-soluble drug distribution volume and a longer elimination half-life. For instance, the patient had decreased renal clearance of digoxin, which resulted in higher bioavailability and the lethal levels seen in the test results. The pharmacodynamic modifications of enhanced sensitivity to the medication further aggravated the elevated blood levels of digoxin (Angraal et al., 2019). Digoxin, which slows the conduction of electrical impulses in the AV node and stimulates the parasympathetic nervous system, can suppress the atrioventricular node in large dosages, which lowers the patient’s heart rate.
Life-threatening complications including metabolic acidosis, hypotension, and bradycardia have also been linked to calcium channel blockers like diltiazem due to decreased renal clearance and enhanced bioavailability (Alshaya et al., 2022). Due to the similar modifications in the pharmacokinetic and pharmacodynamic processes, the patient’s reported dizziness is related to metoprolol poisoning. Due to increased warfarin bioavailability brought on by decreased hepatic clearance, the patient’s INR was high (Sanghai et al., 2020). The raised blood sugar levels were caused by reduced sensitivity to Humalog. Moreover, the patient had symptoms of hyperkalemia, which, especially when combined with the use of diuretics like HCTZ, may have contributed to the loss of renal function. For senior people, medications including lisinopril, Imdur, Lantus, famotidine, multivitamins, and electrolyte supplements are thought to be safe.
Improving Patient’s Drug Therapy Plan
Due to the patient’s advanced age, it will be required to modify the dosages of the medications that have been influenced by changes in pharmacodynamic and pharmacokinetic processes to improve the treatment outcomes of the prescription pharmaceuticals (Christensen et al., 2019). The dosage should be decreased to 0.125 mg once daily beginning with digoxin (Angraal et al., 2019). To achieve the ideal therapeutic level, which is between 0.8 and 2.0 ng/mL, the patient’s serum concentration should be monitored. It seemed sensible to reduce the dosage of metoprolol from 75 mg to 50 mg. Nonetheless, the patient’s dizziness should be carefully watched for potential dose adjustments in the future. Due to the patient’s bradycardia, Diltiazem CD should be stopped (Alshaya et al., 2022). To assist treat hyperkalemia, HCTZ should be substituted with a potassium-sparing diuretic. In addition, the dosages of aspirin and warfarin should be changed while the patient’s INR is closely monitored (Sanghai et al., 2020). To improve treatment outcomes, the patient should nonetheless continue taking additional drugs as directed in addition to making lifestyle changes including exercising and eating a heart-healthy diet.
The patient in the case study offered has medication-related side effects, and the medication’s higher blood concentrations are blamed on pharmacokinetic and pharmacodynamic aging-related changes. The patient displayed signs of digoxin, Diltiazem CD, Hydrochlorothiazide, Warfarin, and metoprolol toxicity as a result of decreased renal and hepatic functioning. Since bradycardia might have fatal adverse effects, medications like Diltiazem CD have to be stopped. To encourage better results and lessen the negative effects related to polypharmacy, it was also required to take non-pharmacological measures such as nutrition and exercise into consideration.
Alshaya, O. A., Alhamed, A., Althewaibi, S., Fetyani, L., Alshehri, S., Alnashmi, F., … & Alshaya, A. I. (2022). Calcium Channel Blocker Toxicity: A Practical Approach. Journal of Multidisciplinary Healthcare, 15, 1851-1862. DOI:10.2147/JMDH.S374887
Angraal, S., Nuti, S. V., Masoudi, F. A., Freeman, J. V., Murugiah, K., Shah, N. D., Desai, N. R., Ranasinghe, I., Wang, Y., & Krumholz, H. M. (2019). Digoxin Use and Associated Adverse Events Among Older Adults. The American Journal of Medicine, 132(10), 1191–1198. https://doi.org/10.1016/j.amjmed.2019.04.022
Christensen, L. D., Reilev, M., Juul-Larsen, H. G., Jørgensen, L. M., Kaae, S., Andersen, O., Pottegård, A., & Petersen, J. (2019). Use of prescription drugs in the older adult population—a nationwide pharmacoepidemiological study. European Journal of Clinical Pharmacology, 75(8), 1125–1133. https://doi.org/10.1007/s00228-019-02669-2
Sanghai, S., Wong, C., Wang, Z., Clive, P., Tran, W., Waring, M., Goldberg, R., Hayward, R., Saczynski, J. S., & McManus, D. D. (2020). Rates of Potentially Inappropriate Dosing of Direct‐Acting Oral Anticoagulants and Associations With Geriatric Conditions Among Older Patients With Atrial Fibrillation: The SAGE‐AF Study. Journal of the American Heart Association, 9(6). https://doi.org/10.1161/jaha.119.014108
Thürmann, P. A. (2020). Pharmacodynamics and pharmacokinetics in older adults. Current Opinion in Anaesthesiology, 33(1), 109–113. https://doi.org/10.1097/aco.0000000000000814
van den Anker, J., Reed, M. D., Allegaert, K., & Kearns, G. L. (2018). Developmental Changes in Pharmacokinetics and Pharmacodynamics. The Journal of Clinical Pharmacology, 58(S10), S10–S25. https://doi.org/10.1002/jcph.1284
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