NURS 6521 Pharm Week 3 Discussion Pharmacotherapy for Cardiovascular Disorders

Sample Answer for NURS 6521 Pharm Week 3 Discussion Pharmacotherapy for Cardiovascular Disorders Included

NURS 6521 Pharm Week 3 Discussion Pharmacotherapy for Cardiovascular Disorders

A Sample Answer for The Assignment: NURS 6521 Pharm Week 3 Discussion Pharmacotherapy for Cardiovascular Disorders

Title: NURS 6521 Pharm Week 3 Discussion Pharmacotherapy for Cardiovascular Disorders

Asthma is one of the most common conditions affecting more than 20 million individuals in the United States and over 150 million across the globe. It takes up to $14 billion to treat asthma annually. Particularly hard hit are adolescents and children between the ages of 10 to 18 years. Studies show that up to 14% of children and adolescents in the inner city are diagnosed with asthma. A larger percentage of asthmatic patients in the emergency rooms are children and adolescents. Consequently, most patients hospitalized as a result of asthma or asthma-related problems are also children.

As such, appropriate interventions must be implemented to help in managing asthma among children and adolescents hence reducing their visits to the ER or hospitalization. In the same line, Sentara Home Care Services came up with an innovative program to help in improving asthma management among children and adolescents through home-based strategies such as “Life Coaches” where they are educated on the proper use of medication and lifestyle behaviors for both the patient and their families. This paper reviews different pieces of literature for a better understanding of the significance of Sentara’s Asthma Disease Management plan in increasing the control of asthma and decrease ER/unscheduled PCP visit’s for children/adolescents.

Methods

Quite a significant number of internet sources were available talking about different approaches that can be utilized in managing asthma among children and adolescents. However, only peer-reviewed articles directly relating to the study PICOT questioned were used for this paper. These articles were arrived at by use of several inclusion and exclusion criteria. For instance, the inclusion criteria included studies that had been published within the last 5 years, in English, with participants who are children and adolescents.

The studies however could be either experimental or literature review. Exclusion criteria included articles published more than 5 years, in languages other than English. Consequently, relevant keywords such as asthma,  Sentara’s Asthma Disease Management plan, children and adolescents, and decreased ER/unscheduled PCP visits were utilized. A wide variety of search engines were used for this study, such as Google Scholar, PubMed/MEDLINE, and Cochrane. Generally, only peer-reviewed articles and experimental studies covering the significance of Sentara’s Asthma Disease Management plan in increasing the control of asthma and decrease ER/unscheduled PCP visit’s for children/adolescents, were used for this study.

Introduction

The processes that a medicine goes through in the body after administration are referred to as pharmacokinetics. Absorption, distribution, metabolism, and excretion are all included in this. Pharmacodynamics, on the other hand, deals with the effects that drugs have on the body, such as adverse effects. Variables like a patient’s genetics, gender, ethnicity, age, behavioral factors, medical history, and concurrent drugs all have an impact on pharmacokinetics and pharmacodynamics. According to the case study, these variables especially age do indeed change the drugs pharmacokinetics and pharmacodynamics (Rosenthal. & Burchum, 2018).

Age influencing pharmacodynamics and pharmacokinetics

The patient is of advanced age whereby it has been stated that they are 74 years old this is indeed can affect the pharmacodynamics and pharmacokinetics related to the drug. In advanced age you find the boy’s physiology has changed thus affecting the pharmacokinetics and elements such as absorption, distribution, metabolism and excretion.

One of the most significant impacts in old age is whereby you’ll have a decreased glomeruli filtration rate which determines the level of drug elimination. Since it is decreased it could lead to the drug being retained in the system and leading to toxicity (Sieder et al., 2016).

In old age there is also decreased gastrointestinal motility thus leading to delayed absorption rate. This leads to delayed onset of pharmacological effects of drugs thus making them less effective. The peak drug concentrations are also affected hence the drug doesn’t reach its maximum capacity for effect (Mangoni & Jarmuzewska, 2019).

Age also increases the body fat which could lead to increase the volume of distribution increases. Therefore if the drug has to be distributed to a wider area than affection it will affect its expected performance thus not delivering the desired therapeutic effect. Due to the increased body fat there is also decreased body water levels thus leading to the drug’s elimination half-lives also getting increased (Sieder et al., 2016).

Having an advanced age also affects metabolism which mostly occurs in the liver. This occurs in due to the decreased required enzymes that may no longer be available due to the physiological changes that occur because of age. This also leads to decreased clearance hence the already metabolised drug aren’t cleared from the system (Mangoni & Jarmuzewska, 2019).

Age impacting pharmacodynamics occurs through decrease in effect for beta-adrenergic agents. This is due to decrease in response in the vascular, cardiac, and pulmonary tissues due to a decline in some required proteins. There is also reduced sensitivity to drugs due to the body’s receptors undergoing physiological changes.

Therefore if the response and sensitivity is inhibited the desired therapeutic effect isn’t achieved. Homeostatic mechanisms are also seen to influence the pharmacodynamics in that in advanced age it is reduced. The mechanisms are seen to reduce in old age. Therefore in the case the drugs lead to adverse effects the body takes a longer period of time to return to the initial state (Sieder et al., 2016).

Changes in the Process that Impact the Patient’s Recommended Drug Therapy

Due to the old age the pharmacodynamics and pharmacokinetics has been impacted. The absorption has been delayed due to decreased gastric motility, on the distribution end the volume of distribution has increased due to the increased body fat and the metabolism due to decreased enzymes has also decreased.

The physiological changes in the glomeruli has decreased the glomeruli filtration rate hence decreasing excretion and could lead to toxicity. The pharmacodynamics due to decrease in sensitivity, decrease in response and reduced homeostatic mechanisms negatively affect it (Mancia et al., 2014).

Therefore encompassing all this there is a definite change in the recommended drug therapy in order to benefit the patient. The changes are in medication such as atenolol will be used in place of the beta-blocker metoprolol, starting at 25 to 200 mg per day. However, fast response is attainable with longer release modules and can be delivered thrice daily, thus it’s advised to begin new medication, notably such as beta-blockers, with prolonged release formulae.

Instead of ibuprofen that is contraindicated with warfarin patients should be prescribed acetaminophen orally 500mg thrice daily to manage the pain. I would also advise using lipid-lowering drugs other than statins to lower the low-density lipoprotein cholesterol levels (Mangoni & Jarmuzewska, 2019).

How to Improve the Drug Therapy Plan

Patients with a high risk of cardiovascular disease, a heart attack, or is known diabetic, such as this patient, are advised to begin taking a moderate-intensity statin with the aim of reducing LDL-C levels by 30% or more. For this patient, it is advised to utilize Ezetimibe, administered orally at a dose of 10 mg each day. Cardiovascular diseases, diabetes mellitus, left ventricular dysfunction and diabetic neuropathy can receive treatment by use of angiotensin converting enzyme inhibitors.

They can also be used to prevent strokes. Starting doses of ramipril range from 1.25 mg to 2.5 mg orally every day. This medication is also recognized to lessen myocardial infarctions, strokes, and fatalities. Moreover aside from changes in medications can make other alterations such as diet change, smoking cessation, weight loss, provision of health education from medical professionals and physical activity is required (Mayor, 2017).

Conclusion

The majority of deaths globally are currently caused by cardiovascular disorders, and diabetes is frequently found in these people. It is thought that people with type diabetes are more likely than non-diabetics to die from cardiovascular illnesses. In order to get the best results in the management of cardiovascular diseases which aims to maximize the benefits of available treatments while minimizing patient harm clinicians must possess basic knowledge of pharmacokinetics and pharmacodynamics (Rosenthal. & Burchum, 2018).

References

Hoover, L. E. (2019). Cholesterol management: ACC/AHA Updates guideline. Https://eds-a-       ebscohost-com-ezp.waldenulibrary.org/eds/pdfviwer/

Mayor, S. (2017). Pharmacokinetics: Optimizing safe and effective prescribing.             Https://onlinelibrary.wiley.com/doi/pdf/10.1002/psb.1551

Rosenthal, L.D. & Burchum. J.R. (2018). Lehne’s pharmacotherapeutics for advanced practice    providers. St. Louis, MO: Elsevier.

Sieder, S. T., Kalus, J. & Lanfear, D. E. (2016). Cardiovascular pharmacokinetics,            Pharmacodynamics and Pharmacogenomics for the clinical practitioner. Https://eds-a-  ebscohost-com.ezp.waldenulibrary.org/eds/delivery/

Mancia, G., Fagard, R., Narkiewicz, K., Redon, J., Zanchetti, A., Böhm, M., & Galderisi, M.       (2014). 2013 ESH/ESC Practice guidelines for the management of arterial hypertension:            ESH-ESC: The Task Force for the management of arterial hypertension of the European           Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Blood          Pressure, 23(1), 3-16.

Mangoni, A. A., & Jarmuzewska, E. A. (2019). The influence of heart failure on the         pharmacokinetics of cardiovascular and non‐cardiovascular drugs: A critical appraisal of           the evidence. British Journal of Clinical Pharmacology, 85(1), 20-36.

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

ORDER NOW FOR A CUSTOMIZED ACADEMIC PAPER on NURS 6521 Pharm Week 3 Discussion Pharmacotherapy for Cardiovascular Disorders

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.

Post a 1 page paper APA format 

•   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.

Readings

• Arcangelo, V. P., & Peterson, A. M. (Eds.). (2013). Pharmacotherapeutics for advanced practice: A practical approach (3rd ed.). Ambler, PA: Lippincott Williams & Wilkins.

o   Chapter 19, “Hypertension” (pp. 230–246) . 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.

o   Chapter 20, “Hyperlipidemia” (pp. 247–262). 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.

o   Chapter 21, “Chronic Stable Angina” (pp. 263–277) . 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.

o   Chapter 22, “Heart Failure” (pp. 278–297) . This chapter examines the process of prescribing drugs to treat heart failure and explores effects of prescribed drugs, proper dosages, and possible adverse reactions.

o   Chapter 49, “Anticoagulation Disturbances” (pp. 764–803) . 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.

• Drugs.com. (2012). Retrieved from http://www.drugs.com/. This website presents a comprehensive review of prescription and over-the-counter drugs including information on common uses and potential side effects. It also provides updates relating to new drugs on the market, support from health professionals, and a drug-drug interactions checker.

Media

•  Laureate Education, Inc. (Executive Producer). (2012). Hypertension and hyperlipidemia. Baltimore, MD: Author. This media presentation outlines hypertension and hyperlipidemia including contributing factors, evaluation, treatment, and implications.Note: The approximate length of this media piece is 10 minutes.

NURS 6521 Pharm Week 10 Discussion Hormone Replacement Therapy

In recent years, hormone replacement therapy has become a controversial issue. When prescribing therapies, advanced practice nurses must weigh the strengths and limitations of the prescribed supplemental hormones. If advanced practice nurses determine that the limitations outweigh the strengths, then they might suggest alternative treatment options such as herbs or other natural remedies, changes in diet, and increase in exercise.

Consider the following scenario:

As an advanced practice nurse at a community health clinic, you often treat female (and sometimes male patients) with hormone deficiencies. One of your patients requests that you prescribe supplemental hormones. This poses the questions: How will you determine what kind of treatment to suggest? What patient factors should you consider? Are supplemental hormones the best option for the patient, or would they benefit from alternative treatments?

To prepare:

• Review Chapter 56 of the Arcangelo and Peterson text, as well as the Holloway and Makinen and Huhtaniemi articles in the Learning Resources.
• Review the provided scenario and reflect on whether or not you would support hormone replacement therapy.
• Locate and review additional articles about research on hormone replacement therapy for women and/or men. Consider the strengths and limitations of hormone replacement therapy.
• Based on your research of the strengths and limitations, again reflect on whether or not you would support hormone replacement therapy.
• Consider whether you would prescribe supplemental hormones or recommend alternative treatments to patients with hormone deficiencies.

Post A 1 page paper APA format ( no title page)

1. a description of the strengths and limitations of hormone replacement therapy.
2. Based on these strengths and limitations, explain why you would or why you would not support hormone replacement therapy.
3. Explain whether you would prescribe supplemental hormones or recommend alternative treatments to patients with hormone deficiencies and why.

Drug therapy is affected by factors that affect pharmacokinetics (PK) and pharmacodynamics (PD), like age, gender, ethnicity, body weight, and genetics. The case study is about patient AO with a history of obesity and has gained 9 pounds. AO has a medical history of hypertension and hyperlipidemia. The current drug therapy includes Atenolol 12.5 mg OD, Doxazosin 8 mg OD, Hydralazine 10 mg QID, Sertraline 25 mg OD, and Simvastatin 80 mg OD. The purpose of this paper is to discuss how gender may influence the patient’s PK and PD processes and affect drug therapy.

How Gender Might Influence the PK and PD Processes in the Patient

The physiologic differences between males and females affect drug activity, including PK and PD processes. Females produce less gastric acid and have slower GI transit times than men. Consequently, medications that need an acidic environment for absorption have lower bioavailability in women. A prolonged GI transit time can reduce the absorption of drugs like metoprolol, verapamil, and theophylline (Mauvais-Jarvis et al., 2021). Drug distribution in the body is affected by body composition, BMI, plasma volume, and plasma protein-binding capacity.

Men are generally heavier and have a higher BMI and larger organs than women. Thus, drug distribution is less in women, and they should receive lower doses to avoid unnecessary adverse reactions. In addition, females have larger fat stores than males, accounting for greater drug distribution volumes based on a drug’s hydrophilic or hydrophobic properties (Mauvais-Jarvis et al., 2021). Lipophilic drugs have a longer duration of action in females due to large volumes of adipose tissue than in men.

The metabolic processes in the phase II metabolism of drugs are typically accelerated in men leading to some drugs being cleared faster in men than women. Thus, women may need lower doses of drugs that undergo this metabolism. In addition, the Glomerular filtration rate (GFR) is higher in men, and when considering body size, GFRs are 10-25 % slower in females (Zucker & Prendergast, 2020). Drugs excreted unchanged in the urine are cleared slower in women, and they should receive lower dosages of these drugs based on GFR.

Regarding PD, Beta blockers have an enhanced BP-lowering effect when exercising in females. Some drugs have an enhanced effect in females, like opioids, SSRIs, and Typical antipsychotics, while TCAs have a reduced effect (Madla et al., 2021). Besides, Aspirin is associated with poor platelet inhibition and heart attack protection in females and poor stroke prevention in males. Digoxin is linked with increased mortality in females.

How Changes in the Processes Might Impact the Patient’s Recommended Drug Therapy        

If AO is a female, changes in PD and PK processes may affect drug therapy on the basis of gender. For example, Atenolol would be affected since it has greater sensitivity and improved effectiveness in women. However, if AO were a man, the metabolic process of Atenolol would be accelerated, causing the drug to clear faster, and he would need a higher dose or increased frequency (Mauvais-Jarvis et al., 2021).

In addition, the patient’s gender would affect the PD of Sertraline since it has greater sensitivity and better effectiveness in women. In depression treatment, men respond better to TCAs and women better to SSRIs. Therefore, if AO were female, Sertraline would be preferred (Madla et al., 2021). The tissue distribution rate of Simvastatin depends on the degree of lipophilicity. More lipophilic statins are associated with greater extrahepatic effects.

How You Might Improve the Patient’s Drug Therapy Plan

If AO were a female, I would maintain Atenolol at 12.5 mg but monitor BP and heart rate due to its high sensitivity in lowering HR and BP. Sertraline would also be maintained at 25 mg since it is more effective in women. However, if AO were a man, a TCA like Amitriptyline or Imipramine would be preferred since men respond better to TCAs (Madla et al., 2021). In addition, I would reduce Simvastatin to 40 mg OD because the high-fat stores in the patient would lead to a greater volume of distribution of the drug. Thus the patient would need lower doses owing to a longer duration of action caused by a large volume of adipose tissue.

Conclusion

Drug PK processes in females are affected by lower body weight, slow GI motility, reduced intestinal enzymatic activity, and slower GFR. Drug renal clearance is slower in females, and drugs excreted in the kidneys may need a dose adjustment. PD processes in women include greater sensitivity and better effectiveness in beta blockers, opioids, SSRIs, and typical antipsychotics. Due to the PD and PK differences, females are more likely than males to experience worse side/adverse effects.

References

Madla, C. M., Gavins, F. K., Merchant, H. A., Orlu, M., Murdan, S., & Basit, A. W. (2021). Let’s talk about sex: Differences in drug therapy in males and females. Advanced Drug Delivery Reviews, 175, 113804. https://doi.org/10.1016/j.addr.2021.05.014

Mauvais-Jarvis, F., Berthold, H. K., Campesi, I., Carrero, J. J., Dhakal, S., Franconi, F., … & Rubin, J. B. (2021). Sex-and gender-based pharmacological response to drugs. Pharmacological reviews, 73(2), 730-762. https://doi.org/10.1124/pharmrev.120.000206

Zucker, I., & Prendergast, B. J. (2020). Sex differences in pharmacokinetics predict adverse drug reactions in women. Biology of sex differences, 11(1), 1-14. https://doi.org/10.1186/s13293-020-00308-5

Resources

• Holloway, D. (2010). Clinical update on hormone replacement therapy. British Journal of Nursing, 19(8), 496–504.Retrieved from the Walden Library databases.This article examines the purpose, components, and administration of hormone replacement therapy (HRT). It also presents benefits, risks, potential side effects, and alternative treatment options of HRT.
• Mäkinen, J. I., & Huhtaniemi, I. (2011). Androgen replacement therapy in late-onset hypogonadism: Current concepts and controversies—A mini-review. Gerontology, 57(3), 193–202.Retrieved from the Walden Library databases.This article examines the role of testosterone levels in the development of hypogonadism. It also explores health issues that are impacted by testosterone levels and the role of testosterone replacement therapy.

Arcangelo, V. P., & Peterson, A. M. (Eds.). (2013). Pharmacotherapeutics for advanced practice: A practical approach (3rd ed.). Ambler, PA: Lippincott Williams & Wilkins.

• Chapter 56, “Menopause and Menopausal Hormone Therapy” (pp. 884–895)This chapter presents various options for menopausal hormone therapy and examines the strengths and limitations of each form of therapy.

SAMPLE APPROACH

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.

The promotion of safety and quality in the treatment of patients with different conditions is important in nursing practice. Nurses and other healthcare providers utilize their knowledge in pharmacokinetics and pharmacodynamics to select treatments that will optimize outcomes while minimizing the potential of patient harm.

Factors such as age, gender, ethnicity, and genetics among others influence the pharmacokinetics and pharmacodynamics of the medications prescribed to patients. Therefore, this essay examines the influence of age on LM’s pharmacokinetic and pharmacodynamics processes. The essay also discusses the impact of the changes in the patient’s recommended drug therapy and how the treatment can be improved.

Effect of Age on Patient’s Pharmacokinetic and Pharmacodynamics Processes

The selected factor that affects the pharmacokinetic and pharmacodynamics of LM processes is age. Age significantly affects pharmacokinetics of drugs. Aging is associated with decreased small-bowel surface area, reduced gastric emptying, and elevated gastric PH. Changes such as an increase in the gastric PH affects the absorption of drugs such as calcium and enteric coated medications (Koren et al., 2019).

Aging also results in the decrease in the total body water and increase in the total body fat. The increase in body fat volume increases the total volume of distribution of lipophilic drugs and their elimination half-lives. Aging also lowers hepatic metabolism of most drugs. The decrease in cytochrome P-450 lowers the metabolism of drugs in the liver. This also affects first-pass metabolism of drugs before they enter the circulatory system.

Aging is also associated with a decline in renal elimination of medications. The elderly patients have reduced glomerular filtration rate, which affects the elimination of drug metabolites from the body (Drenth-van Maanen et al., 2020; Koren et al., 2019; Peeters et al., 2019). As a result, there is an increased risk of drug toxicity due to the accumulation of the metabolites in the body. These pharmacokinetic changes affect the treatment options and health status of LM.

Aging also affects pharmacodynamics of drugs. Pharmacodynamics refers to the study of the drug effect on the body. Aging is associated with reduced pharmacodynamics processes. One of the mechanisms contributing to the reduced pharmacodynamics is the limited functioning of drug receptor sites. There is also the reduction in the available drug receptors for drug binding. This reduces the effect of the drug on the body while increasing its blood bioavailability (Kratz & Diefenbacher, 2019). An example is seen in patients diagnosed with diabetes. They have low insulin receptors, which result in the elevated blood glucose levels.

The effect of aging on pharmacodynamics can also be seen from the exaggerated response to some drugs among this population. For example, older adults tend to show exaggerated responses to drugs that stimulate the central nervous system. The observation is because of the increased sensitivity to drugs by this population. In addition, aging reduces Gs protein interactions in the elderly patients. The decrease lowers cardiac, pulmonary, and vascular tissue to drugs such as those used in the treatment of hypertension(Stader et al., 2020). Therefore, nurses should consider these changes when prescribing drugs to elderly patients and other vulnerable populations.

Impact of the Changes in Processes on Patient’s Recommended Drug Therapy

The changes in the pharmacokinetic and pharmacodynamics processes affect the patient’s recommended drug therapy. A decline in the drug metabolism in the liver affects the selection of drugs for the patient. Nurses and other healthcare providers should prescribe medications that do not undergo first-pass metabolism to preserve optimum hepatic function. A decline in renal function also affects the client’s recommended drug therapy(Peeters et al., 2019). Nurse practitioners prescribe medications that have other routes of excretion such as feces to promote renal functioning.

There is also the consideration of drug dosages with the changes in the pharmacokinetics and pharmacodynamics. Accordingly, nurse practitioners lower the dosage and frequency of hepatotoxic and renal toxic medications in patients with advanced ages to minimize the risk of harm and drug toxicity (Thürmann, 2020). The reduction in drug absorption due to lowered gastric physiological processes also increases the need for prescribing drugs that are administered through other routes such as intravenously and intramuscularly.

Improving Patient’s Drug Therapy

I will improve the patient’s drug therapy by avoiding polypharmacy. The patient currently uses several drugs that predispose her to harm and medication errors. An effective approach to her treatment would be reducing the number of drugs taken at a time to promote her health, safety, and quality. The other way in which I will improve her drug therapy is by titrating the drug dosage upwards.

Elderly patients should be initiated on low dosage and increased upwards based on tolerance and efficacy (Koren et al., 2019). I will modify the patient’s current treatment. I will lower the dosage of celecoxib to minimize the risk of hepatotoxicity and renal toxicity. I will also stop glyburide and retain metformin. Metformin has the benefit of reducing the risk of cardiovascular mortality in patients with multiple comorbidities that include cardiovascular conditions (Guo et al., 2019).

Conclusion

Aging affects pharmacokinetics and pharmacodynamics processes. Advancing age lowers pharmacokinetic processes such as drug absorption, metabolism, and elimination. It also affects pharmacodynamics processes such as drug binding to their receptor sites. These changes affect the recommended treatment plan for the patient in the case study. Polypharmacy should be avoided in treating LM for safety and quality outcomes.

References

Drenth-van Maanen, A. C., Wilting, I., & Jansen, P. A. F. (2020). Prescribing medicines to older people—How to consider the impact of ageing on human organ and body functions. British Journal of Clinical Pharmacology, 86(10), 1921–1930. https://doi.org/10.1111/bcp.14094

Guo, L., Ma, J., Tang, J., Hu, D., Zhang, W., & Zhao, X. (2019). Comparative Efficacy and Safety of Metformin, Glyburide, and Insulin in Treating Gestational Diabetes Mellitus: A Meta-Analysis. Journal of Diabetes Research, 2019, 9804708. https://doi.org/10.1155/2019/9804708

Koren, G., Nordon, G., Radinsky, K., & Shalev, V. (2019). Clinical pharmacology of old age. Expert Review of Clinical Pharmacology, 12(8), 749–755. https://doi.org/10.1080/17512433.2019.1632188

Kratz, T., & Diefenbacher, A. (2019). Psychopharmacological Treatment in Older People. Deutsches Ärzteblatt International, 116(29–30), 508–518. https://doi.org/10.3238/arztebl.2019.0508

Peeters, L. E. J., Kester, M. P., Feyz, L., Van Den Bemt, P. M. L. A., Koch, B. C. P., Van Gelder, T., & Versmissen, J. (2019). Pharmacokinetic and pharmacodynamic considerations in the treatment of the elderly patient with hypertension. Expert Opinion on Drug Metabolism & Toxicology, 15(4), 287–297. https://doi.org/10.1080/17425255.2019.1588249

Stader, F., Kinvig, H., Penny, M. A., Battegay, M., Siccardi, M., & Marzolini, C. (2020). Physiologically Based Pharmacokinetic Modelling to Identify Pharmacokinetic Parameters Driving Drug Exposure Changes in the Elderly. Clinical Pharmacokinetics, 59(3), 383–401. https://doi.org/10.1007/s40262-019-00822-9

Thürmann, P. A. (2020). Pharmacodynamics and pharmacokinetics in older adults. Current Opinion in Anesthesiology, 33(1), 109. https://doi.org/10.1097/ACO.0000000000000814

NURS 6521 Pharmacotherapy for Cardiovascular Disorders

The case study provided presents an elderly African American male patient complaining of a slow heart rate. The patient also reported symptoms of dizziness during early mornings. He was put on Diltiazem CD six weeks ago, to help manage his hypertension, with the metoprolol dose reduced from 75 mg to 50 mg twice daily.

Upon admission, as recommended by the patient’s PCP, his lab works revealed significantly reduced diastolic blood pressure, bradycardia, elevated potassium levels, low hematocrit levels, high creatinine, Blood urea nitrogen (BUN), INP and glucose levels as well as digoxin toxicity. In this paper, the pharmacokinetic and pharmacodynamic processes affected by the patient’s age have been discussed in addition to how they impact medications diagnosed to the patient.

Pharmacokinetic and Pharmacodynamic Processes

The patient being 74 years of age renders him elderly. Research findings report that aging is characterized by a decline in the functioning of several regulatory processes in the human body that are responsible for providing functional integration between organs and cells (Thürmann, 2020). As such, they may end up failing to maintain homeostasis when in certain situations of physiological stress. Different regulatory systems in different patients are impacted differently by the reduced homeostatic ability, hence the creased interindividual variability among older adults.

Some of the most common pharmacokinetic changes associated with aging include reduced hepatic and renal clearance, and increased distribution volume of drugs soluble in lipid medium (van den Anker et al., 2018). The above changes also lead to the prolonged elimination half-life of most drugs. Concerning pharmacodynamic changes, aging has been associated with increased sensitivity of most drug classes including psychotropic, cardiovascular, and anticoagulant agents. However, the sensitivity might vary depending on other factors such as the patient’s body weight and comorbid medical conditions.

Impact on the Patient’s Recommended Drug Therapy

Due to the patient’s advanced age, he is more likely to experience reduced hepatic and renal clearance of certain drugs, with reduced volume of distribution of water-soluble drugs and prolonged elimination half-life. For instance, the renal clearance of digoxin was reduced in the patient, with increased bioavailability hence the toxic levels from the lab findings.

The high serum concentration of digoxin was also exacerbated by the pharmacodynamic changes of increased sensitivity to the drug (Angraal et al., 2019). In high doses, digoxin can inhibit the atrioventricular node, by stimulating the parasympathetic nervous system and slowing down the conduction of electrical impulses in the AV node, hence reducing the patient’s heart rate.

Reduced renal clearance and increased bioavailability leading to toxicity of Calcium channel blockers like diltiazem have also been associated with life-threatening events such as hypotension, metabolic acidosis, and bradycardia (Alshaya et al., 2022). Metoprolol toxicity, due to the same changes in pharmacokinetic and pharmacodynamic processes is associated with dizziness reported by the patient. The patient’s INR was high due to the increased bioavailability of warfarin as a result of reduced hepatic elimination (Sanghai et al., 2020).

Reduced sensitivity to Humalog, contributed to the elevated blood sugar levels. The patient also displayed signs of hyperkalemia, which might be contributed to the decline in renal function, especially with the use of diuretics such as HCTZ. Lisinopril, Imdur, Lantus, famotidine, and multivitamins in addition to electrolyte supplements are considered safe for elderly patients.

Improving Patient’s Drug Therapy Plan

To improve the therapeutic outcome of the prescribed drugs, it will be necessary to adjust the doses of the drugs that have been impacted by the changes in pharmacokinetic and pharmacodynamic processes due to the patient’s advanced age  (Christensen et al., 2019). Starting with digoxin, the dose should be reduced to 0.125 mg once daily(Angraal et al., 2019). The patient’s serum level should be monitored to attain an optimal therapeutic level of between 0.8-2.0 ng/mL. Reducing the dose of metoprolol from 75mg to 50 mg was well thought out.

The patient dizziness should however be monitored closely for future dose adjustment. Diltiazem CD should be discontinued due to the patient’s bradycardia (Alshaya et al., 2022). HCTZ should also be replaced by a potassium-sparing diuretic to help manage hyperkalemia. The doses of warfarin and aspirin should also be adjusted with close monitoring of the patient’s INR (Sanghai et al., 2020). The patient should however continue taking other medications as prescribed with life modification including exercise and a heart-healthy diet to promote positive treatment outcomes.

Conclusion

The patient in the provided case study present with adverse events of prescribed medication whose increased serum concentrations are attributed to pharmacokinetic and pharmacodynamic changes with age. Due to reduced renal and hepatic functions, the patient presented with symptoms of digoxin, Diltiazem CD, HCTZ, Warfarin, and Metoprolol toxicity.

It was thus necessary to discontinue drugs such as Diltiazem CD, due to the life-threatening side effects of bradycardia. Considering non-pharmacological interventions such as exercise and diet was also necessary to promote positive outcomes and reduce adverse effects associated with polypharmacy.

References

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

NURS 6521 Pharmacotherapy for Cardiovascular Disorders

The case study provided presents an elderly African American male patient complaining of a slow heart rate. The patient also reported symptoms of dizziness during early mornings. He was put on Diltiazem CD six weeks ago, to help manage his hypertension, with the metoprolol dose reduced from 75 mg to 50 mg twice daily. Upon admission, as recommended by the patient’s PCP, his lab works revealed significantly reduced diastolic blood pressure, bradycardia, elevated potassium levels, low hematocrit levels, high creatinine, Blood urea nitrogen (BUN), INP and glucose levels as well as digoxin toxicity.

In this paper, the pharmacokinetic and pharmacodynamic processes affected by the patient’s age have been discussed in addition to how they impact medications diagnosed to the patient.

Pharmacokinetic and Pharmacodynamic Processes

The patient being 74 years of age renders him elderly. Research findings report that aging is characterized by a decline in the functioning of several regulatory processes in the human body that are responsible for providing functional integration between organs and cells (Thürmann, 2020). As such, they may end up failing to maintain homeostasis when in certain situations of physiological stress. Different regulatory systems in different patients are impacted differently by the reduced homeostatic ability, hence the creased interindividual variability among older adults.

Some of the most common pharmacokinetic changes associated with aging include reduced hepatic and renal clearance, and increased distribution volume of drugs soluble in lipid medium (van den Anker et al., 2018). The above changes also lead to the prolonged elimination half-life of most drugs. Concerning pharmacodynamic changes, aging has been associated with increased sensitivity of most drug classes including psychotropic, cardiovascular, and anticoagulant agents. However, the sensitivity might vary depending on other factors such as the patient’s body weight and comorbid medical conditions.

Impact on the Patient’s Recommended Drug Therapy

Due to the patient’s advanced age, he is more likely to experience reduced hepatic and renal clearance of certain drugs, with reduced volume of distribution of water-soluble drugs and prolonged elimination half-life. For instance, the renal clearance of digoxin was reduced in the patient, with increased bioavailability hence the toxic levels from the lab findings.

The high serum concentration of digoxin was also exacerbated by the pharmacodynamic changes of increased sensitivity to the drug (Angraal et al., 2019). In high doses, digoxin can inhibit the atrioventricular node, by stimulating the parasympathetic nervous system and slowing down the conduction of electrical impulses in the AV node, hence reducing the patient’s heart rate.

Reduced renal clearance and increased bioavailability leading to toxicity of Calcium channel blockers like diltiazem have also been associated with life-threatening events such as hypotension, metabolic acidosis, and bradycardia (Alshaya et al., 2022). Metoprolol toxicity, due to the same changes in pharmacokinetic and pharmacodynamic processes is associated with dizziness reported by the patient. The patient’s INR was high due to the increased bioavailability of warfarin as a result of reduced hepatic elimination (Sanghai et al., 2020).

Reduced sensitivity to Humalog, contributed to the elevated blood sugar levels. The patient also displayed signs of hyperkalemia, which might be contributed to the decline in renal function, especially with the use of diuretics such as HCTZ. Lisinopril, Imdur, Lantus, famotidine, and multivitamins in addition to electrolyte supplements are considered safe for elderly patients.

Improving Patient’s Drug Therapy Plan

To improve the therapeutic outcome of the prescribed drugs, it will be necessary to adjust the doses of the drugs that have been impacted by the changes in pharmacokinetic and pharmacodynamic processes due to the patient’s advanced age  (Christensen et al., 2019). Starting with digoxin, the dose should be reduced to 0.125 mg once daily(Angraal et al., 2019). The patient’s serum level should be monitored to attain an optimal therapeutic level of between 0.8-2.0 ng/mL. Reducing the dose of metoprolol from 75mg to 50 mg was well thought out.

The patient dizziness should however be monitored closely for future dose adjustment. Diltiazem CD should be discontinued due to the patient’s bradycardia (Alshaya et al., 2022). HCTZ should also be replaced by a potassium-sparing diuretic to help manage hyperkalemia. The doses of warfarin and aspirin should also be adjusted with close monitoring of the patient’s INR (Sanghai et al., 2020). The patient should however continue taking other medications as prescribed with life modification including exercise and a heart-healthy diet to promote positive treatment outcomes.

Conclusion

The patient in the provided case study present with adverse events of prescribed medication whose increased serum concentrations are attributed to pharmacokinetic and pharmacodynamic changes with age. Due to reduced renal and hepatic functions, the patient presented with symptoms of digoxin, Diltiazem CD, HCTZ, Warfarin, and Metoprolol toxicity. It was thus necessary to discontinue drugs such as Diltiazem CD, due to the life-threatening side effects of bradycardia. Considering non-pharmacological interventions such as exercise and diet was also necessary to promote positive outcomes and reduce adverse effects associated with polypharmacy.

References

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