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In this discussion, we would attempt to optimize the management of Patient HM which 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
We would consider how his age might influence the pharmacokinetic and pharmacodynamics processes and how these changes might impact the patient’s recommended drug therapy. Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay.
Age and Pharmacokinetics/Pharmacodynamics
Age has a significant effect on pharmacokinetic and pharmacodynamics of medications as a result of changes body organs. At an older age, there is a reduction in renal and hepatic clearance and an increase in the volume of distribution of lipid soluble drugs; this leads to increase in the elimination half-life, there may also be increased sensitivity to drugs including cardiovascular medications (Mangoni & Jackson 2004).
Atenolol, brand name Tenormin is a beta-adrenergic blocking agent, indicated for hypertension, angina pectoris and postmyocardial infarction. It is available in strengths of 25mg, 50mg, and 100mg tablets. Its mechanism of action is by competitively blocking the response to beta-adrenergic stimulation; it selectively blocks beta1-receptors. The onset of action is less than 1 hour and produces its peak effect between 2 to 4 hours. Its effect last 12 to 24 hours, therefore it is usually dosed once a day (Lexicomp) Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay.
Atenolol is poorly absorbed in about 50% (Lexicomp), the absorption may be further reduced in older patients because they have reduced gastric acid secretion, reduced splanchnic blood flow and possibly reduced absorptive capacity in the small intestine (Mangoni & Jackson 2004). Metabolism is limited and takes place in the liver, as age advance, there is a reduction in liver volume and liver blood flow, although changes in hepatic structure and enzymatic functions with aging is moderate, it will further reduce the metabolism of this medication (Mangoni & Jackson 2004). This may not result in significant changes to dosage since the drug is excreted unchanged as the unaltered molecule in the Feces (50%); and urine (40%) (Lexicomp).
Half-life (t1/2), in children and adolescents 5 to 16 years of age range from 3.5 to 7 hours. In adults patients with normal renal function, it ranges from 6 to 7 hours; this goes higher with renal impairment up to 15 to 35 hours in End-stage renal disease (ESRD) (Lexicomp). Reduced renal function in elderly subjects is as a result of a reduced glomerular filtration rate, with a pronounced effect on water-soluble diuretics, β-adrenoceptor blockers, and nonsteroidal anti-inflammatory drugs among others. This will likely cause toxicity of the drug and may necessitate a dose reduction (Mangoni & Jackson 2004). Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay.
Patient’s Drug Therapy Plan
According to guidelines, initial antihypertensive treatment should start with a thiazide diuretic as the first line of therapy, if BP goal is not achieved, then the practitioner may add a second medication. Second line antihypertensives include calcium channel blocker (CCB), angiotensin-converting enzyme (ACE) inhibitor, Beta blockers or angiotensin receptor blocker (ARB) (JNC 8, 2014). A thiazide diuretic is conspicuously missing from the treatment of this patient when compared with the JNC algorithm. The first modification I would propose to optimize the treatment of this patient would be the addition of a thiazide diuretic.
Contraindications of beta blockers include diabetes and hyperlipidemia. In diabetic patients, it may potentiate hypoglycemia and mask signs and symptoms (Lexicomp). The patient under review has both diabetes and hyperlipidemia, atenolol is therefore contraindicated and should be removed and replaced. ACE inhibitors would be a good option to replace atenolol, this class of medication which includes Lisinopril, Enalapril and Captopril is recommended in diabetic patients who have proteinuria (JNC 8, 2014) Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay.
The third modification to the management of this patient would be the addition of cholesterol lowering medication since the history of the patient indicates that the patient has hyperlipidemia but the list of drugs currently taken by the patient does not include any treatment. Statins are usually the first line therapy for hyperlipidemia; options include atorvastatin, lovastatin, and simvastatin among others. The addition of any of this will reduce the risk of cardiovascular incidents (Laurete Education Inc. 2012). Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay.
References
Arcangelo, V. P., & Peterson, A. M. (Eds.). (2013). Pharmacotherapeutics for Advanced Practice: A practical approach (3rd ed.). Ambler, PA: Lippincott Williams & Wilkins.
Combination pharmacotherapy for cardiovascular disease. (2005). Annals Of Internal Medicine, 143(8), 593-599
JNC 8 Guidelines for the Management of Hypertension in Adults Retrieved from http://www.aafp.org/afp/2014/1001/p503.pdf
Laureate Education Inc. (2012). Hypertension and Hyperlipidemia. Baltimore MD Author
Lexicomp. Product Monograph (Atenolol) Retrieved from https://fco.factsandcomparisons.com/lco/action/doc/retrieve/docid/patch_f/6393
Mangoni, A. A., & Jackson, S. H. D. (2004). Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. British Journal of Clinical Pharmacology, 57(1), 6–14. http://doi.org/10.1046/j.1365-2125.2003.02007.x
WHO Fact Sheets (Updated May 2017) Cardiovascular Diseases Retrieved from http://www.who.int/mediacentre/factsheets/fs317/en/ Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay
Pharmacotherapy For Cardiovascular Disorder
· Analyze the influence of patient factors on pharmacokinetic and pharmacodynamic processes
· Analyze the impact of changes in pharmacokinetic and pharmacodynamic processes on patient drug therapies
· Evaluate drug therapy plans for cardiovascular disorders
Cardiovascular / Respiratory Systems
CASE STUDY Assignment
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: Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay
• 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
To Prepare
· Review the Resources for this module and consider the impact of potential pharmacotherapeutics for cardiovascular disorders introduced in the media piece.
· Review the case study assigned by your Instructor for this Assignment.
· Select one the following factors: genetics, gender, ethnicity, age, or behavior factors. Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay.
· 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.
Write a 2- to 3-page paper that addresses the following:
· Explain how the factor you selected might influence the pharmacokinetic and pharmacodynamic processes in the patient from the case study assigned above.
· Describe how changes in the processes might impact the patient’s recommended drug therapy. Be specific and provide examples.
· Explain how you might improve the patient’s drug therapy plan and explain why you would make these recommended improvements.
Resources for reference
Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.
· Chapter 34, “Review of Hemodynamics” (pp. 335–340) Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay
· Chapter 35, “Diuretics” (pp. 341–349)
· Chapter 36, “Drugs Acting on the Renin-Angiotensin-Aldosterone System” (pp. 351–362)
· Chapter 37, “Calcium Channel Blockers” (pp. 363–369)
· Chapter 38, “Vasodilators” (pp. 371–373)
· Chapter 39, “Drugs for Hypertension” (pp. 375–388)
· Chapter 40, “Drugs for Heart Failure” (pp. 389–402)
· Chapter 41, “Antidysrhythmic Drugs” (pp. 403–418)
· Chapter 42, “Prophylaxis of Atherosclerotic Cardiovascular Disease: Drugs That Help Normalize Cholesterol and Triglyceride Levels” (pp. 419–439)
· Chapter 43, “Drugs for Angina Pectoris” (pp. 441–450)
· Chapter 44, “Anticoagulant and Antiplatelet Drugs” (pp. 451–472)
Pharmacotherapy for Cardiovascular Disorders
Cardiovascular diseases (CVDs) refer to numerous conditions that interfere with the functioning of the heart/or blood vessels. Some of the common CVDs include hypertension, heart failure, stroke, and coronary artery disease (CAD). In a case scenario where Patient AO is diagnosed with hypertension and hyperlipidemia, and has a history of obesity, understanding the genetics can help in the diagnosis and treatment of CVDs. High blood pressure or (hypertension) is manifested through a force exerted by the blood against the walls of the blood vessels while hyperlipidemia is the presence of too many lipids in the blood, which leads to the blockage of arteries after an increase in fatty deposits. Advanced practice nurses should understand the pharmacokinetic and pharmacodynamic processes of CVD in order to enhance drug therapy plan for their patients. Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay.
CVD present complex traits, and understanding the genetics of CVD requires consideration of interactions among genetic sex, race, as well as hormonal status. Genetics affect pharmacokinetics and pharmacodynamics process of CVD through controlling all features of cardiovascular system. Heritable risk factors contribute to higher blood pressure (BP) levels while genetic variants tend to create a cumulative effect of about 10 mmHg higher systolic BP levels before an individual attains the age of 50 years (Pazoki et al., 2018). A genetic variation may interfere with how the protein works in the body, leading to the accumulation of cholesterol in the arteries. Genetic risks are known since birth; hence, impossible to modify them (Pazoki et al., 2018). If a family member is found to be having CVD, other family members should go for screening, as they may be having the same disease without showing symptoms. Individuals with genetic risk can be identified early in life and are encouraged to undergo lifestyle modification.
However, evaluations into the genetics of CVD among men and women are hindered by the failure to incorporate the sex chromosomes within genome-wide association studies (Winham, De Andrade & Miller, 2015). Sex differences in cardiovascular disorders emanate from interactions among genetic, hormonal, as well as environmental factors, which create individual risks of the diseases Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay. Although hypertension is one of the major risk factors for developing CVD, there is no sufficient information on the ideal dosage of antihypertensive drugs, especially for the elderly. Accepting to change some lifestyle habits, in addition to having healthy dietary patterns can assist in counteracting genetic variations linked to obesity and CVD (Heianza & Qi, 2018).
Prescribing the right dose is critical in the treatment of cardiovascular diseases, as it relieves patients from a hospital stay, hospital readmission, and saving the costs of seeking medical attention. Due to changes in pharmacokinetics and pharmacodynamics processes, experts recommend on starting dosages, and later a stepwise increase of dosages, which would lead to enhanced BP control, as well as less adverse drug reactions among the elderly patients (Peeters et al., 2019). The changes happen because the disease is capable of transforming receptor binding, adjusting the binding proteins, as well as reducing receptor sensitivity.
The patient in this scenario was prescribed with Atenolol, Doxazosin, Hydralazine, Sertraline, and Simvastatin to manage cardiovascular disorders. Atenolol is mainly utilized as first-line treatment for hypertension, and can be used alone or with other medications (Wiysonge et al., 2017). Both Doxazosin and Hydralazine are vital in calming the arterial pressure Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay. The use of Simvastatin is meant to lower the cholesterol by blocking the production of cholesterol while Sertraline is an antidepressant. Simvastatin will assist in reducing fats, which have made the patient gain nine pounds. The medications are likely to alter the pharmacokinetic and pharmacodynamic processes within the body, leading to the recovery from cardiovascular disorders.
Patient AO is under medications but may require an improved drug therapy plan in order to detect and prevent medication-related problems. As an advanced practice nurse, I should improve the drug therapy plan by educating the patient concerning his/her therapy, any adverse effect, as well as actions to take in case a problem emerges. I should evaluate the patient’s drug therapy by checking whether he/she has taken the medications as prescribed by the pharmacist. Most medications should be utilized with caution due to age-related changes pharmacokinetics (Rochon, Schmader & Givens, 2019). Drug therapy problems require an assessment for severity, acuteness, as well as how fast the resolution of a particular problem should occur.
If there were a need to adjust the drug therapy, I would do so and explain to the patient the need to adjust the therapy. Polypharmacy, which involves taking multiple medications simultaneously, should be treated with caution, as it is linked to increased incidences of an adverse drug event, as well as increased hospital readmission (Rochon, Schmader & Givens, 2019). Genetically-determined hypertension and its complications are managed through adopting healthy lifestyle. Thus, I would recommend a change in behavior and adopting a lifestyle that encourages physical activity and healthy eating Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay. Developing a pharmaceutical opinion program can help in reaching patients who seem to be at a higher risk of medication-related problems.
References
Heianza, Y., & Qi, L. (2018). Impact of genes and environment on obesity and cardiovascular disease. Endocrinology, 160(1), 81-100.
Pazoki, R., Dehghan, A., Evangelou, E., Warren, H., Gao, H., Caulfield, M., … & Tzoulaki, I. (2018). Genetic predisposition to high blood pressure and lifestyle factors: associations with midlife blood pressure levels and cardiovascular events. Circulation, 137(7), 653-661.
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. Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay.
Rochon, P. A., Schmader, K., & Givens, J. (2019). Drug prescribing for older adults. UpToDate. Retrieved from https://www.uptodate.com/contents/drug-prescribing-for-older-adults#H32
Winham, S. J., De Andrade, M., & Miller, V. M. (2015). Genetics of cardiovascular disease: the importance of sex and ethnicity. Atherosclerosis, 241(1), 219-228.
Wiysonge, C. S., Bradley, H. A., Volmink, J., Mayosi, B. M., & Opie, L. H. (2017). Beta‐blockers for hypertension. Cochrane database of systematic reviews, (1). Assignment: Pharmacotherapy for Cardiovascular Disorders sample essay