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NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion

NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion

Module III: Men’s and Women’s Health Discussion

 

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Consider the following scenarios:

LW is a 32 year old female patient who comes to your medical clinic for primary care.  She has been on hormonal contraceptives for years, although she’s just been married and has stopped her pills in hopes of becoming pregnant.  Her PMHx includes obesity, HTN (diagnosed 3 years ago), familial hypercholesterolemia, and PCOS.  Her current medications are as follows: Metformin 2000 mg PO daily, Lisinopril 10 mg PO daily, rosuvastatin 5 mg PO daily, and a multivitamin.

GD is an 82-year-old patient is taking 2 mg of terazosin for BPH every morning. He comes in complaining of dizziness, generalized muscle weakness and persistent lower urinary tract symptoms (LUTS).

How should you advise these patients and manage their medications?  What was the process you went through to assess the current medications and to recommend an updated regimen?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion.

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    • Men and Women’s Health Discussion
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    • Anna McMullen posted Sep 14, 2020 10:38 AM
    • Upon evaluating LW, I would assess the safety and necessity of her prescribed medications in relation to her medical history and her goals. LW wishes to get pregnant, therefore any medications that she is taking should be safe for pregnancy. LW also has HTN, and is taking Lisinopril 5mg po QD, so it is necessary for a medication to address her HTN be prescribed which is also safe for pregnancy. Currently, LW is taking metformin 200mg po QD, most likely for her PCOS since it is not indicated that she is T2DM; the necessity of this medication must be evaluated. She is also taking rosuvastatin 5mg po QD for familial hypercholesteremia, so the safety of this medication must be evaluated.  ACE inhibitors and ARBs are not considered safe during pregnancy, therefore lisinopril 5mg should be discontinued while LW is trying to conceive (Khalil et al., 2016). Women with pre-existing HTN should be carefully monitored throughout pregnancy and should have their BP stabilized before conception due to increased risk of preeclampsia; 22-25% of women with chronic HTN will develop preeclampsia during pregnancy (Khalil et al., 2016). Acceptable medications for the treatment of HTN during pregnancy are the beta-blocker labetalol and the alpha-2 agonist, methyldopa; however, labetalol is not considered safe to use during breast feeding, so if this is something LW plans to do, she may want to consider methyldopa as a first-line option (Khalil et al., 2016).LW should continue her multivitamin, ensuring that it has an adequate amount of folic acid, or consider switching to a prenatal multivitamin. Liu et al. (2018) found that women who supplemented with multivitamins with folic acid significantly reduced their risk of preeclampsia and gestational diabetes, both conditions that LW is at risk for developing during pregnancy.ReferencesBortnick, E., Brown, C., Simma-Chiang, V., & Kaplan, S. A. (2020). Modern best practice in the management of benign prostatic hyperplasia in the elderly. Therapeutic Advances in Urology, 12, 175628722092948. https://doi.org/10.1177/1756287220929486Herschorn, S., Staskin, D., Schermer, C. R., Kristy, R. M., & Wagg, A. (2020). Safety and tolerability results from the pillar study: A phase iv, double-blind, randomized, placebo-controlled study of mirabegron in patients ≥ 65 years with overactive bladder-wet. Drugs & Aging, 37(9), 665–676. https://doi.org/10.1007/s40266-020-00783-wLiu, C., Liu, C., Wang, Q., & Zhang, Z. (2018). Supplementation of folic acid in pregnancy and the risk of preeclampsia and gestational hypertension: A meta-analysis. Archives of Gynecology and Obstetrics, 298(4), 697–704. https://doi.org/10.1007/s00404-018-4823-4Terazosin (oral route) side effects – mayo clinic. (2020, August 1) NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion . Mayo Clinic. https://www.mayoclinic.org/drugs-supplements/terazosin-oral-route/side-effects/drg-20066315?p=1
    • Lundberg, G., & Mehta, L. (2018, May 14). Familial hypercholesterolemia and pregnancy – American college of cardiology. American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2018/05/10/13/51/familial-hypercholesterolemia-and-pregnancy
    • Khalil, A., O’Brien, P., & Townsend, R. (2016). Current best practice in the management of hypertensive disorders in pregnancy. Integrated Blood Pressure Control, Volume 9, 79–94. https://doi.org/10.2147/ibpc.s77344
    • Haas, J., & Bentov, Y. (2017). Should metformin be included in fertility treatment of pcos patients? Medical Hypotheses, 100, 54–58. https://doi.org/10.1016/j.mehy.2017.01.012
    • Astellas Pharma US, Inc. (2018). MYRBETRIQ (mirabegron extended-release tablets) for oral use [Prescribing Information (PI)]. astellas.us. https://astellas.us/docs/Myrbetriq_WPI.pdf
    • GD is currently taking terazosin 2mg po QD for BPH, although it is also commonly prescribed for HTN, and is experiencing one of the most common side effects, dizziness, as well as muscle weakness and LUTS (Terazosin (Oral Route) Side Effects – Mayo Clinic, 2020). Due to GD’s age, the most commonly prescribed medications for BPH may not be appropriate. Alpha blockers pose an increased risk for the elderly patient, as they may also cause dizziness, orthostatic hypotension, and may lead to falls and subsequent injuries (Bortnick et al., 2020). Though 5-alpha reductase inhibitors (5-ARIs) may also commonly be considered, Bortnick et al. (2020), discussed that there is a significant risk of depression, self-harm, and suicide in elderly adults following administration. Phosphodiesterase inhibitors (PDE5I) are now approved for males with BPH and ED, however, men over the age of 75 have shown increased risk of dizziness and diarrhea and there is no mention of GD experiencing ED (Bortnick et al., 2020). Anticholinergics are another class of medications that address LUTS, however, their side-effect profile also poses increased risk for the elderly patient, including increased risk of CNS side-effects including confusion and dizziness, and should therefore be avoided (Bortnick et al., 2020). Mirabegron, the only beta-3 adrenergic agonist available, is an appropriate medication that should be considered for GD, as it will address the LUTS he is experiencing, and lacks the negative side-effects of anticholinergic alternatives (Haas & Bentov, 2017). The PILLAR study (Herschorn et al., 2020) evaluated the safety and efficacy of mirabegron in adults with overactive bladder (OAB) aged 65 years and older and found that side-effect profile in this population was comparable to placebo. Although mirabegron is not currently indicated for BPH, its safety has been evaluated in a urodynamic study with men with bladder outlet obstruction (BOO) and LUTS; it was found that mean maximum flow rate and mean detrusor pressure were not affected (Astellas Pharma US, Inc., 2018).  Mirabegron provides an alternative for elderly patients, such a GD, that are trying to minimize LUTS while also minimizing side-effect profile.
    •             Total cholesterol in the general population while pregnant can increase 25-50% and LDL can increase up to 66%, therefore, women with familial hypercholesterolemia, such as LW,  may see even greater increases while pregnant making management important (Lundberg & Mehta, 2018). Statin therapy, such as the rosuvastatin that LW is prescribed, is contraindicated during pregnancy, as well as non-statin alternatives such as ezetimibe, niacin, and fibrates that have been shown to increase teratogenicity (Haas & Bentov, 2017). Bile acid sequestrants, such as cholestyramine, colestipol, and colesevelam, are currently the only class of medications currently acceptable during pregnancy since they are not absorbed systemically and therefore pose no fetal risk (Lundberg & Mehta, 2018) NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion.
    •  According to Haas & Bentov (2017) metformin has historically been prescribed for patients with PCOS for the whole duration of pregnancy, reportedly lowering pregnancy loss, reducing gestational DM, and not increasing birth defects. However, Hass & Bentov (2017) also found that there has been increased concern over the use of metformin during pregnancy and in their research found that there is no clear advantage in the use of metformin in fertility treatment for PCOS patients and that its use during pregnancy may have long-term consequences on offspring. Therefore, I would recommend that LW discontinue the use of metformin.
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    • Kelly Miskovsky posted Sep 18, 2020 9:11 AM
    • Hi class,GD returns to your clinic after several months of taking tamsulosin, presenting with prostate enlargement and a PSA of 5 ng/mL. What changes would you make to his medications and why?LW was able to successfully get pregnant and now returns to your clinic for her postpartum checkup. She states that she wants to go back on her birth control pills. She mentions she just started taking Augmentin for a sinus infection. What recommendations would you make?
    • Last post Sep 20, 2020 11:34 PM by Tomiko Edmonds
    • GD has now been switched to finasteride, which has been effective in treating his BPH for the last several months. He now comes to your clinic also complaining of erectile dysfunction. What changes would you make to his medications?
    • Some additional scenarios to consider for this weeks module. 
    • Women’s and Men’s Health DiscussionSubscribe
    • Kathryn Mosholder posted Sep 16, 2020 9:46 PM
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    • 32 yr old Female with obesity, HTN, family hypercholesterolemia, and PCOs. 82 yr old Male with BPH Case StudyAt this point, our patient is most likely experiencing dizziness and generalized muscle weakness as side effects from taking terazosin since both these are common side effects. His persistent lower urinary tract symptoms are probably a combination of many factors, such as possible infection and dehydration(Chisholm-Burns, 2019). I would assess patient do vital signs, draw labs and take a urine sample to check for infection and other conditions that might be contributing to his signs and symptoms.  My recommendation would be to switch him to a reductase inhibitor and an adrenergic antagonist; however, we would need to know his prostate size do to the fact that he might need a TURP as well (Chisholm-Burns, 2019).Chisholm-Burns, M.,Schwinghammer, T., Malone, P., Kolesar, J., Bookstaver, P., & Lee,Dimitropoulos, K., & Gravas, S. (2016). New therapeutic strategies for the treatment of maleOfori, B., Rey, E., & Bérard, A. (2007). Risk of congenital anomalies in pregnant users of statin    Podymow, T., & August, P. (2008). Update on the Use of Antihypertensive Drugs inSilva, J., Silva, C. M., & Cruz, F. (2014). Current medical treatment of lower urinary tract more1 UnreadUnread12 ViewsViews
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    • Last post Sep 20, 2020 11:33 PM by Pawn Johnson-Hunter
    • symptoms/BPH: do we have a standard?. Current opinion in urology, 24(1), 21–28. https://doi.org/10.1097/MOU.0000000000000007
    • Pregnancy. Hypertension, 51(4), 960-969. https://doi.org/10.1161/hypertensionaha.106.075895
    • drugs. British journal of clinical pharmacology, 64(4), 496–509.          https://doi.org/10.1111/j.1365-2125.2007.02905.x
    • lower urinary tract symptoms. Research and reports in urology, 8, 51–59.           https://doi.org/10.2147/RRU.S63446
    •             K. Pharmacotherapy principles & practice (pp. 807-819).McGraw Hill Education.
    • References
    • Unfortunately for men, “BPH is the most common benign neoplasm in men who are at least 40 yrs of age,” Pharmacology text. Benign prostatic obstructions help slow all flow through the urinary tract system by blocking the bladder neck, therefore causing LUTS. “Two-thirds of males reported at least one LUTS complaint during their lifetime. They are directly related to the aging process, and influence patients’ lives to various degrees” (Dimitropoulos & Gravas, 2016, para. 1). research is ongoing Silva, Silva & Cruz (2014) suggest “a combination of PDE5i with alpha-blockers provides better symptomatic control than alpha-blockers alone.” PDE5’s assist with side effects of alpha-blockers such as erectile dysfunction, low sex drive, and retrograde ejaculation, an example being Sildenafil while alpha-blockers assist with BPH symptoms such as urinary hesitancy, nocturia, and urinary frequency an example being Tamsulosin. According to Chisholm-Burns, Schwinghammer, Malone, Kolesar, & Bookstaver (2019),s all patients should be treated individually per their signs and symptoms and severity of BPH. Patients with mild BPH need comparative assessment but no medication regiment in this stage (Chisholm-Burns, 2019). Patients with moderate to severe BPH should be treated with Tadalafil or Tadalafil and an adrenergic antagonist if the prostate is less than 30g (Chisholm-Burns, 2019). If the prostate is more significant than 30 g, treat a with reductase inhibitor or a reductase inhibitor and adrenergic antagonist (Chisholm-Burns, 2019).
    •             This patient would like to get pregnant and is taking metformin 2000mg PO daily, Lisinopril 10mg PO daily, Rosuvastatin 5mg PO daily, and a multivitamin. This patient has several comorbidities, and she would like to get pregnant. Metformin 2000mg is ok to take during pregnancy, and she can remain on the multivitamin. Metformin has a side effect of weight loss, so it is essential to monitor the patient for too much weight loss when pregnant.  The concerns are Lisinopril and Rosuvasatatin since both are contraindicated during pregnancy. According to Podymow & August (2008), “Labetalol, a nonselective β-blocker with vascular α1-receptor blocking capabilities, has gained wide acceptance in pregnancy.” Another medication that has gained acceptance is Methyldopa and to use labetalol as a second-line agent. Taking Rosuvastatin during pregnancy can be dangerous because cholesterol is essential to fetal development and statins inhibit cholesterol production, it is hazardous to take statins during pregnancy (Ofori, Rey, Berard, 2007) NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion.
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    • Dianne Cohen posted Sep 17, 2020 6:51 PM
    • 32-year-old female patientFirst, her daily multivitamin should be replaced with prenatal vitamins that also supply the necessary amounts of folic acid to prevent neural tube defects in the baby (Moore et al., 2020). Next, I would address the Lisinopril which is an angiotensin enzyme converting inhibitor (ACE inhibitor). Magee and von Dadelszon write that due to its toxic renal effects during pregnancy, a safer alternative such as methyldopa with a proven research-based safety record warrants its use(2018).  In conclusion, the medical management of women attempting to become pregnant is often complicated by an extensive medical history. Whenever possible, it is best to use evidenced-based research when prescribing medications and consult with the obstetrician in order to provide the best possible care for mother and baby.References     I would begin my evaluation of my male patient with a complete medical history including all current prescription and non-prescription medications. For example, an over the counter diuretic may increase urgency, and antihistamines commonly found in allergy medicines can lead to urinary retention thus both mimicking lower urinary tract symptoms (LUTS) (Alcarez et al., 2016). Appropriate labs based on patient history include a urinalysis and culture to rule out an infection that also causes LUTS. According to Carbone et al., blood work should include the prostate-specific antigen (PSA) especially if the patient refused a DRE which can also identify an enlarged prostate and other underlying conditions (2016). In conclusion, selecting a medication to treat BPH requires careful consideration and periodic reevaluation especially in the elderly population. Initially, Terazosin probably was an appropriate choice but due to the patients advanced age and presenting symptoms it requires a vigorous and thorough reevaluationReferences   https://docs.google.com/document/d/1hVA1-Kcbb-g-sCVdViw0Izuyy3e8DVsJ_7BqvMFMUeU/edit?usp=sharing
    • Woodard, T., Manigault, K., McBurrows, N., Wray, T., Woodard, L., (2016). Management of Benign Prostatic Hyperplasia in Older Adults. The Consultant Pharmacist, 31(8).
    • Yuan, J. Q., Mao, C., Wong, S. Y., Yang, Z. Y., Fu, X. H., Dai, X. Y., & Tang, J. L. (2015). Comparative Effectiveness and Safety of Monodrug Therapies for Lower Urinary Tract Symptoms Associated With Benign Prostatic Hyperplasia: A Network Meta-analysis. Medicine, 94(27), e974. https://doi.org/10.1097/MD.0000000000000974
    • Carbone, A., Fuschi, A., Al Rawashdah, S. F., Al Salhi, Y., Velotti, G., Ripoli, A., Autieri, D., Palleschi, G., & Pastore, A. L. (2016). Management of lower urinary tract symptoms associated with benign prostatic hyperplasia in elderly patients with a new diagnostic, therapeutic, and care pathway. International Journal of Clinical Practice, 70(9), 734–743. https://doi-org.wilkes.idm.oclc.org/10.1111/ijcp.12849
    • Alcaraz, A., Carballido-rodríguez, J., Unda-urzaiz, M., Medina-lópez, R., Ruiz-cerdá, J.,L., Rodríguez-rubio, F., García-rojo, D., Brenes-bermúdez, F.,J., Cózar-olmo, J.,M., Baena-gonzález, V., & Manasanch, J. (2016). Quality of life in patients with lower urinary tract symptoms associated with BPH: change over time in real-life practice according to treatment–the QUALIPROST study. International Urology and Nephrology, 48(5), 645-656. https://dx.doi.org.wilkes.idm.oclc.org/10.1007/s11255-015-1206-7
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    • At this point, if  I  successfully ruled out all possible explanations for the patient’s current condition, I would turn my focus to the Terazosin. Terazosin is a nonselective alpha 1 receptor antagonist which was originally developed as an antihypertensive agent. It has the ability to block a wide distribution of alpha receptors in the vascular and central nervous system which in elderly individuals can cause hypotension, fatigue, and dizziness (Yuan et al., 2015) A more appropriate choice based on the patient’s age and symptoms is Tamsolosin which has less effect on blood pressure possibly due to its higher selectivity for alpha 1 receptors (Woodard, 2016). It works by relaxing the muscles in the prostate and bladder allowing urine to flow easily. My recommendation is Tamsulosin 4mg, daily taken thirty minutes after eating NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion.
    • Next, a complete physical exam facilitates a correct diagnosis and should include a digital rectal exam (DRE) since there is suspected prostate involvement.  Benign prostatic hyperplasia is a nonmalignant overgrowth of the prostate gland that is commonly seen in aging men. An enlarged prostate impairs the bladder’s ability to fully empty and contributes to LUTS (Carbone et al., 2016).
    • 82-year-old male patient
    • Shun Zhang, Haoyan Tu, Jun Yao, Jianghua Le, Zhengxu Jiang, Qianqian Tang, Rongrong Zhang, Peng Huo, & Xiaocan Lei. (2020). Combined use of Diane-35 and metformin improves the ovulation in the PCOS rat model possibly via regulating the glycolysis pathway. Reproductive Biology and Endocrinology, 18(1), 1–11. https://doi.org/10.1186/s12958-020-00613-z
    • Moore, C. J., Perreault, M., Mottola, M. F., & Atkinson, S. A. (2020). Diet in Early Pregnancy: Focus on Folate, Vitamin B12, Vitamin D, and Choline. Canadian Journal of Dietetic Practice & Research, 81(2), 58–65. https://doi-org.ezproxy.fau.edu/10.3148/cjdpr-2019-025
    • Magee, L. A., & von Dadelszen, P. (2018). State-of-the-Art Diagnosis and Treatment of Hypertension in Pregnancy. Mayo Clinic Proceedings, 93(11), 1664–1677. https://doi.org/10.1016/j.mayocp.2018.04.03
    • Lundberg, G., & Mehta, L. (2018). Familial Hypercholesterolemia and Pregnancy. American College of Cardiology.     https://www.acc.org/latest-in-cardiology/articles/2018/05/10/13/51/familial-hypercholesterolemia-and-pregnancy
    • Berry, D., Thomas, S., Dorman, K., Ivins, A., Abreu, M., Young L., & Boggess, K. (2018). Rationale, design, and methods for the medical optimization and management of pregnancies with overt Type 2 Diabetes (MOMPOD) study. BMC Pregnancy and Childbirth, 18(1), 1–12. https://doi-org.ezproxy.fau.edu/10.1186/s12884-018-2108-3
    • Finally, I would arrange a nutritional consult to teach suggested dietary pre-pregnancy recommendations. Additionally, effective methods for controlling cholesterol levels, since the majority of studies contraindicate the use of statins during pregnancy. According to Lundberg and Mehta, they are also known to have a teratogenic effect on the fetus (2018).
    • Next, my attention would focus on metformin. Traditionally, it is the treatment of choice outside of pregnancy (Berry et al., 2018). Interestingly, polycystic ovarian syndrome (PCOS) is known to cause infertility, and metformin in limited studies demonstrated an increase in fertility  (Shun Zang et al., 2020). However, since there is insufficient research regarding its effects on mother and baby, the possible risks outweigh any benefit and it should be avoided. Additionally, I would recommend that when she becomes pregnant, switching to insulin is the preferred method for controlling blood sugar. According to Berry et al., it is proven to be the safest method for mother and baby (2018).
    • The primary care provider should begin with a thorough medical history, vital signs, a list of all prescription and non-prescription medications, and a physical exam. Since the patient is attempting to conceive, pre-pregnancy care is included to optimize the health of the mother and reduce any potential adverse effects to her, or her future baby NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion.
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    • Augusta Ibeh posted Sep 16, 2020 10:26 PM
    • (A) QUESTION:            Metformin has been effectively used for women with PCOS since they have pregnancy complications like abortion, gestational diabetes mellitus and high blood pressure. LW will be advised not to stop metformin once she is pregnant since evidence has shown that abrupt stopping of metformin during pregnancy might predispose the patient to pregnancy loss Johnson (2014). Buschur, E., & Kim, C. (2012, October). Guidelines and interventions for obesity during pregnancy. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4151459/#:~:text=The revised guidelines also recommend,4] (Table 2).Johnson, N. P. (2014). Metformin use in women with polycystic ovary syndrome. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4200666/            Terazosin hydrochloride (Hytrin)is an alpha-1-selective adrenoceptor blocking agent     Abbott Laboratories (2009). Terazosin was approved by Food and Drug Administration (FDA) in 1987 for the treatment of high blood pressure and for the treatment of lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia in 1993 in 1993 (Yang and Raja (2020). Other off label treatments of terazosin are used to the alleviation of nightmares linked with post-traumatic stress disorder and urinary tract stones Yang & Raja (2020).            Common side effects of terazosin include; dizziness, headache, weakness, postural hypotension and nasal congestion, orthostatic hypotension, atrial fibrillation, anaphylaxis, intraoperative floppy iris syndrome but is rare Yang & Raja (2020).            With these adverse side effects, Mr. GD who is 82 years old should be taking off of terazosin and alternative drug considered for the of his benign prostatic hyperplasia (BPH).ReferenceYang CH, Raja A. Terazosin. [Updated 2020 May 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545208/
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    • Last post Sep 20, 2020 9:53 PM by Augusta Ibe
    • Abbott Laboratories (2009) HYTRIN – terazosin hydrochloride tablet Abbott … https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/019057s022lbl.pdf
    • Terazosin can be given at bedtime and patients instructed to get up slowly from the bed or chair to prevent fall related to orthostatic hypotension. Patients can be started on a low dosage and monitored to see how they will react to the drug.
    •             Contraindication to terazosin include usage in geriatric population due to danger associated with syncope, postural hypotension can lead to falls, heart failure. All these will lead to increase mortality and morbidity among the elders Yang & Raja (2020).
    •             As an antihypertensive, terazosin acts by blocking smooth muscles of the blood vessels and the anti-obstructive urinary tract (ureters, bladder, urethral sphincter) causing them to relax.
    • (B) QUESTION:
    • Kumar, P., & Khan, K. (2012). Effects of metformin use in pregnant patients with polycystic ovary syndrome. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3493830/#:~:text=Metformin has been shown to, problems like early pregnancy loss
    • Reference
    •             LW will be advised to loss weight, childhood and adult obesity was noted to be increasing in the USA since 1980 Buchur and Kim (2012). This should be achieved through physical exercise, calorie reduction goals and use of structured meal plans. Obesity increases the risk to gestational diabetes, and this leads to both mother and fetus to complications such as gestational diabetes, high blood pressure, cesarean delivery, abortion, premature delivery, pre-eclampsia and eclampsia etc. Mother’s over-weight increases infants to spina bifida, heart defects, diaphragmatic hernia, low birth weight Buchur and Kim (2012).
    •             Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in women of reproductive age Kumar and Khan (2012). PCOS is one of the leading causes of the female subfertility. PCOS is a condition of the female that causes an imbalance in the female sex hormones, increase in testosterone, DHEA-S, androstenedione, prolactin, luteinizing hormone (LH) with low or high levels of estrogen (Kumar & Khan (2012).
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    • Shante Hunt posted Sep 16, 2020 7:51 PM
    • Assessment of LW would begin with a complete history and physical, and review of labs to determine hormone levels, Hgb A1c, and lipid panel for baseline results.  She has a history of PCOS which will make her chances of conception difficult, and contributes to obesity, hypertension, and diabetes.  I would counsel her on changes to her medications to include the following: Metformin would need to be discontinued as oral hypoglycemics are contraindicated in pregnancy.  Diabetes in pregnancy is responsible for “preeclampsia, congenital defects, pre-term delivery, macrosomia, and stillbirth (Alexopolous et al, 2019).  Based on this information I would counsel LW that she would need to adhere to a carbohydrate controlled diet, and refer her to a dietician.  She would need to closely monitor her blood sugars at home with target blood sugars of 95 mg/dL fasting, less than 140 mg/dL 1 hour post prandial, and less than 120 mg/dL at 2 hours post prandial (Alexopolous et al, 2019).  Insulin is the first line treatment for diabetes in pregnancy because it effectively regulates serum glucose levels and does not cross the placenta, so I would counsel her on the need to transition off of metformin to a basal insulin when she becomes pregnant. (Alexopolous et al, 2019).  LW also has a history of hypertension and is currently taking Lisinopril, however ACE inhibitors are teratogenic in pregnancy.  My recommendation for her would be to begin Labetalol or Nifedipine to control blood pressure and prevent preeclampsia (Anderson and Schmella, 2017).  With regard to her hypercholesterolemia, I would counsel that rosuvastatin is also contraindicated in pregnancy, and due to her familial history of hypercholesterolemia she may benefit from a bile acid sequestrant such as Questran to help manage her cholesterol levels (Mehta et al, 2020).  Although some studies note that there is no teratogenic risks of statin use in pregnancy (Keralis et al, 2016) more research is needed to make a final determination of safety.  It is important to note that all of LW’s existing conditions exacerbate each other in pregnancy and should be closely monitored and managed.GD is 82 years old, has BPH and lower urinary tract symptoms (LUTS).  He is currently taking terazosin and is complaining of dizziness and weakness.  Terazosin is an alpha adrenergic antagonist which causes hypotension; GD’s symptoms are consistent with hypotension.  I would recommend switching to a 5a reductase inhibitor such as finasteride as this class of medication does not have hypotension as a side effect, and can be used as long term treatment of LUTS in elderly patients (Fekete, 2015).ShanteReferences:Alexopolous, A., Blair, R., & Peters, A. (2019). Management of preexisting diabetes in pregnancy: a review. Obstetrical & Gynecological Survey, 74(10), 574-576 NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion. Doi: http://dx.doi.org.wilkes.idm.oclc.org/10.1097/OGX.0000000000000726Anderson, C., & Schmella, M. (2017). Preeclampsia: current approaches to nursing management: a clinical review of risk factors, diagnostic criteria, and patient care. American Journal of Nursing, 117(11), 30-40. Doi: http://dx.doi.org.wilkes.idm.oclc.org/10.1097/01.NAJ.0000526722.26893.b5    less0 UnreadUnread
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    • Last post Sep 20, 2020 4:42 PM by Robin Morgan
    • Mehta, L., Warnes, C., Bradley, E., Burton, T., Economy, K., Mehran, R., Safdar, B., Sharma, G., Wood, M., Valente, A., & Volgman, A. (2020). Cardiovascular considerations in caring for pregnant patients: a scientific statement from the American Heart Association. Circulation, 141(23), e884-e903. Doi: http://dx.doi.org.wilkes.idm.oclc.org/10.1161/CIR.0000000000000772
    • Keralis, D., Hill, A., Clifton, S., & Wild, R. (2016). The risks of statin use in pregnancy: a systematic review. Journal of Clinical Lipidology, 10(5), 1081-1090. Doi: http://dx.doi.org.wilkes.idm.oclc.org/10.1016/j.jacl.2016.07.002
    • Fekete, T. (2015). Review: dutasteride, fesoterodine, and finasteride are beneficial for lower urinary tract symptoms in older patients. Annals of Internal Medicine, 163(8), JC7-JC7. Doi: http://dx.doi.org.wilkes.idm.oclc.org/10.7326/ACPJC-2015-163-8-007
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    • Candace Whitman-Workman posted Sep 16, 2020 8:25 PM
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    • I would begin by assessing LW, including checking vital signs, blood sugar and a lipid panel.  Since pregnancy is the goal, I would check all current medications safe use during pregnancy.  Priya & Kalra (2018), indicate Metformin is a safe and effective drug.  Also, controlled blood glucose minimizes negative outcome to both the mother infant.Rusuvastatin is contradicted during pregnancy because the action in which it reduces cholesterol, synthesizes the cholesterol and potential other biological compounds, concern is present for fetal harm thereby suggesting it not be used.  In fact, no statin is recommended for use during pregnancy. Al-Maawali, A., Walfisch, A., & Koren, G. (2012). Taking angiotensin-converting enzyme inhibitors during pregnancy: is it safe?. Canadian family physician Medecin de famille canadien, 58(1), 49–51.Lepor, H. (2005). Pathophysiology of lower urinary tract symptoms in the aging male population. Retrieved from Urology: htps://www.ncbi.nlm.nih.gov/pmc/articles/PMCT477625/#udm139983561765712titleRay, J. G., Vermeulen, M. J., & Koren, G. (2007). Taking ACE inhibitors during early pregnancy: is it safe?. Canadian family physician Medecin de famille canadien, 53(9), 1439–1440.Terazosin. (2020, September 14). Retrieved from Medline Plus: https://medlineplus.gov/druginfo/meds/a693046htmlless1
    • Rosuvastatin pregnancy warnings. (2019, September 27). Retrieved from Drugs.com: https://www.drugs.com/pregnancy/rosuvastatin.html#:~:text=Rosuvastatin%20Pregnancy%20Warnings&text=Because%20HMG%2DCoA%20reductase%20inhibitors,cause%20fetal%20harm%20during%20pregnancy.
    • Priya, G., & Kalra, S. (2018). Metformin in the management of diabetes during pregnancy and lactation. Drugs in context, 7, 212523. https://doi.org/10.7573/dic.212523
    • Fact Sheet Lisinopril. (n.d.). Retrieved from Mother To Baby: https://mothertobaby.org/fact-sheets/lisinopril/
    • References
    • In GD’s case, terazosin is not recommended in patients over 65.  Terazosin (2020) list terazosin side effects to include both dizziness and weakness.  With the continuation of LUTs and the marked side effects GD is experiencing, I would discontinue the terazosin.  Also, I would want to perform a prostate exam, check GD for a UTI and get a PSA as I would be concerned for the development of prostate cancer.  I would also want to check a CBC to monitor for the possibility of an infectious process.  Once GD I fully evaluated, I would consider consulting a urologist as he may require a TURP or some other type of prostate resection.
    • Lisinopril, according to Vermeulen & Koren (2007), has been shown in some studies to cause heart abnormalities when used in the first trimester.  However, insufficient evidence exists and currently is not considered to be teratogenic during the first trimester.  During the 2nd and 3rd trimester, Vermeulen & Koren (2007), Al-Waawali, et al. (2012), and (Fact Sheet Lisinopril) both indicate Ace Inhibitors should not be used secondary to severe risk of birth defects.  Since Lisinopril has had some question in the first trimester and definitely contraindicated during the second and third trimesters, I would speak to the patient and consider changing the medication now.

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    • Pawn Johnson-Hunter posted Sep 16, 2020 10:53 PM
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    • One of the most common endocrine dysfunctions affecting a women’s ability to conceive is Polycystic ovary syndrome (PCOS). Huether et al., (2020) affirm the disorder is related to a genetic predisposition and an obesity-prone lifestyle related to insulin resistance and an excess of insulin and androgens (p. 786). For women who can become pregnant, the abnormality of PCOS predisposes both mother and baby to complications from the time of conception until birth.  Increased rates of gestational diabetes mellitus, pregnancy-induced hypertension, preeclampsia, cesarean-section delivery, and preterm birth have been reported among pregnant women with PCOS (Christ et al., 2019). These women are also at greater risk for uterine cancer due to an anovulatory lack of progesterone.Pre-pregnancy therapy for chronic hypertension patients with calcium channel blockers or angiotensin-converting enzyme inhibitors/angiotensin receptor blockers may positively influence cardiac profiles and the outcome of a future pregnancy with a reduced rate of complications (Vasapollo, 2020).In the case of Mr. GD, who is currently taking terazosin 2mg every morning for his BPH and still exhibiting symptoms, he possibly does not have effect emptying. Benign prostatic hyperplasia (BPH) is commonly treated with 5-alpha-reductase inhibitor/alpha-blocker combination therapy or with alpha-blocker monotherapy (Fu et al., 2018). Patients who continue to have complications related to BPH have better results with combination therapy.ReferencesFu, Y., Han, S., Wang, L., Gao, W., Wu, E., Cao, X., & Wang, J. (2018). Comparison of characteristics of benign prostatic hyperplasia (BPH) patients treated with finasteride and alpha blocker combination therapy versus alpha blocker monotherapy in china: an analysis of electronic medical record data. Advances in Therapy, 35(8), 1191–1198. Retrieved from https://doi-org.wilkes.idm.oclc.org/10.1007/s12325-018-0748-3Huether, S. E., McCance, K. L., & Brashers, V. L. (2020). 30. In understandingpathophysiology / Sue E. Huether, Kathryn L. McCance ; section editor, Valentina L.Brashers (p. 1032). St. Louis, MO: Elsevier.Vasapollo, B., Novelli, G. P., Gagliardi, G., Farsetti, D., & Valensise, H. (2020). Pregnancy complications in chronic hypertensive patients are linked to pre-pregnancy maternal cardiac function and structure. American Journal of Obstetrics and Gynecology, 223(3), 425.e1-425.e13. doi:10.1016/j.ajog.2020.02.043
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    • Haas, J., & Bentov, Y. (2017). Should Metformin be included in fertility treatment of PCOS patients? Medical Hypotheses, 100, 54–58. https://doi-org.wilkes.idm.oclc.org/10.1016/j.mehy.2017.01.012
    • Christ, J. P., Gunning, M. N., Meun, C., Eijkemans, JC. M., Rijn, B.BV., Bonsel, J. G., Laven, J. SE., & Fauser, B. MC. (2019, March). Pre-conception characteristics predict obstetrical and neonatal outcomes in women with polycystic ovary syndrome. The Journal of Clinical Endocrinology & Metabolism, 104(3), 809–818. Retrieved from https://doi-org.wilkes.idm.oclc.org/10.1210/jc.2018-01787
    • Other options for controlling her hypercholesterolemia include bile acid subqueststrants (BAS). Research conducted at the National Health Institute (NIH) confirms that colesevelam, a BAS drug, has had a positive effect on both hypercholesterolemia and diabetes; it also states that the medication is safe during pregnancy and can be taken safely with Metformin.
    • Our female patients’ comorbid clinical manifestations are typical in comparison to those seen on an assessment in PCOS. One may conclude that glucose intolerance or insulin resistance is related to the overstimulation of androgen, which correlates with her obesity. She has currently prescribed Metformin, a drug associated with type 2 diabetes mellitus can also be used to treat PCOS. Metformin is commonly used in PCOS patients with impaired glucose tolerance (Hass & Bentov, 2017, p1). She is also prescribed lisinopril, which is contraindicated in pregnancy and considered to be high-risk for women wanting to or at conception age due to its teratogenic effects. Dietary management in the pre-conceptive phase is essential to the management of hypertension in women looking to conceive. Calcium channel blockers are safe options if needed for the treatment of high blood pressure in this case:
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    • Gisselle Mustiga posted Sep 16, 2020 11:13 PM
    • Pregnant women and those intending to get pregnant need to be advised on pre and peri-pregnancy planning, especially those with pre-existing and/or chronic conditions and currently taking medications. For the provided scenario, LW is diagnosed with several conditions such as HTN, HLP, PCOS, and obesity, and also takes several medications. Her current medication regimen includes Metformin 2000 mg PO QD, Lisinopril 10 mg PO QD, Rosuvastatin 5 mg PO QD, and a multivitamin. Therefore, it is critical to ensure some safer alternatives that are not classified as category X as such category possesses teratogenic effects.The second scenario presents a patient with benign prostatic hyperplasia (BPH), a prevalent condition in men older than 40 years of age. Medical management is vital for GD, as he presents with bothersome symptoms such as dizziness, generalized muscle weakness and persistent lower urinary tract symptoms (LUTS). To begin, I would first determine GD’s AUA symptom score. Subsequently, I would examine his medical history for the presence of any other comorbidities or the use of antihypertensives and/or diuretics as their use could worsen hypotensive symptoms when taken together with alpha 1-blockers. However, all we know is that he is only taking the alpha 1-blocker Terazosin 2mg QAM. In order to ameliorate his symptoms of dizziness and malaise, which are likely side effects of Terazosin, I would reduce his dose, slowly up-titrate it, have him take it QPM, or convert it to the extended release version of the drug. Also, a combination therapy with a 5a-reductase inhibitors such as finasteride could be considered for GD because of its benefit in decreasing the prostate size and improving the symptoms associated with moderate or persistent LUTS (Davidian, 2016). Noteworthy, both alpha 1-blockers and 5a-reductase inhibitors are similar in efficacy, and can be combined if the voiding issues persevere.Avis, H. J., Hutten, B. A., Twickler, M. T., Kastelein, J. J., van der Post, J. A., Stalenhoef, A. F., & Vissers, M. N. (2016). Pregnancy in women suffering from familial hypercholesterolemia. Current opinion in lipidology, 20(6), 484–490. https://doi.org/10.1097/MOL.0b013e3283319127Davidian, M. H. (2016). Guidelines for the treatment of benign prostatic hyperplasia NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion. US Pharm, 41(8), 36-40.less0 UnreadUnread
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    • Chisholm-Burns, M. A., Wells, B. G., & Schwinghammer, T. L. (2016). Pharmacotherapy principles and practice. McGraw-Hill.
    • References
    • To begin with, I would counsel LW on lifestyle modifications that cover nutrition, exercise, and emotional wellbeing. Subsequently, I would address her current medication schedule. In the absence of T2DM, Metformin is used to treat PCOS symptoms and also improves the rate of ovulation, which in turn increases the likelihood of getting pregnant. It also has benefits during pregnancy as it reduces the risk of birth defects and other complications. As for the multivitamins LW is taking, I would suggest she switches them for a prenatal multivitamin with folic acid and DHA as it has been shown to increase the probability of getting pregnant and it also offers many benefits during pregnancy. On the other hand, ACE Inhibitors and Statins are classified as category X, therefore need to be revised. Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and prazosin as first line of treatment (Chisholm-Burns et al., 2016). In regards to LW’s HLP management, the only medications currently acceptable during pregnancy are bile acid sequestrants, since they are not systemically absorbed and therefore not felt to pose fetal risk (Avis et al., 2016), and Mipomersen, an antisense inhibitor of APoB synthesis.
    • Module III: Men’s and Women’s Health Discussion
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    • Robin Morgan posted Sep 16, 2020 9:16 AM
    • Module III: Men’s and Women’s Health DiscussionMy first recommendation for the best change of conception would be lifestyle modification. A diet eliminating pro-inflammatory foods like vegetable oils and sugar. As LW is obese making it harder to become pregnant, weight loss would be of great benefit. Adding exercise such as walking, or swimming is important.  This might be a good time to work on improving lifestyle as wanting to increase chances of conception might give LW a motivator. Improving overall health is important for becoming pregnant, and the overall health of the fetus. These modifications may not lead to pregnancy, and LW may need fertility treatment in order to become pregnant. If LW should choose fertility treatment in the future, lifestyle modification and improving diet greatly improves chances of success(Ionescu et al., 2018).GD is and 83-year-old man with Benign prostatic hyperplasia (BPH), who was started on Terazosin which relaxes the prostate and neck of the bladder. GD is complaining of dizziness, general muscle weakness and persistent lower urinary tract symptoms. GD has been taking his Terazosin in the morning. I would educate GD that dizziness and weakness can be a normal side affect of Terazosin, so taking this medication at bedtime is recommended. Also, it may take up to 4 to 6 weeks to feel the full benefit of Terazosin. Recently, modified-release formulations have been introduced that could reduce overall tolerability(“Terazosin,” 2017). I would start with GD switching his medication to bedtime and giving it a few more weeks to improve his symptoms. If after the schedule changes and if financially feasible, trying a modified release formula, GD is still not tolerating Terazosin, I would try switching him to another alpha blocker Tamsulosin. The next step would be trying 5-a-Reductaste inhibitor that actually decreases the size of the prostate, but this may take months to work. Eventually GD may have to advance to surgery for his BPH.ReferencesHaramburu, F., Daveluy, A., & Miremont-Salame, G. (2015). Statins in pregnancy. BMJ, 350(mar17 11), h1484–h1484. https://doi.org/10.1136/bmj.h1484Montplaisir, P. (2018). Is metformin a multifunctional medication for inducing ovulation and improving pregnancy outcomes in pcos? Journal of the American Academy of Nurse Practitioners, 23(10), 537–541. https://doi.org/10.1111/j.1745-7599.2011.00651.x
    • Terazosin. (2017). In Pharmacotherapyfirst drug information. The American Pharmacists Association. https://doi.org/10.21019/druginformation.terazosin
    • Ionescu, C., Popescu, I., Banacu, M., & Dimitriu, M. (2018). Lifestyle changes and weight loss: Effects in pcos. In Debatable topics in pcos patients. InTech. https://doi.org/10.5772/intechopen.73298
    • &na;. (1990). Ace inhibitors and pregnancy don??t mix. Reactions Weekly, &NA;(312), 1. https://doi.org/10.2165/00128415-199003120-00003
    • The process I used for assessing my patient’s current medications was evaluating each medication for risk versus benefit. I also have to look at cost, as some drugs especially newer ones such as modified release formulas may have a high price that may not be covered by insurance. I also want to make sure the medication will be easy to administer especially in older populations. With LW special consideration was taken in regards to the potential for a pregnancy.
    • In reviewing LW’s medications list looking at any modifications needed to help her remain healthy without any potential risks to her pregnancy should she successfully conceive, I would make the following recommendations. Metformin has shown women who continue metformin after pregnancy are less likely to miscarry. It is believed that treating the bodies insulin absorption may also affect the bodies other hormonal problems associated with PCOS(Montplaisir, 2018). Metformin can address insulin resistance, which may help regulate a woman’s hormones and restart ovulation. With this evidence I would continue the Metformin at the current dose she is tolerating. Ace inhibitors such as Lisinopril and angiotensin receptor antagonists such as losartan have shown fetal toxicity, these agents are a pregnancy category X(Haramburu et al., 2015). I would discontinue LC’s Lisinopril, and start her on Labetalol. Labetalol is a pregnancy category C drug and is commonly used in pregnancy, it does not compromise uteroplacental blood flow. Several studies have shown serious fetal abnormalities among pregnant woman taking Rosuvastatin during the first trimester of pregnancy. In other statins such as Simvastatin and Lovastatin the incidence of congenital abnormalities, spontaneous abortions, and fetal deaths did not exceed what would be expected in the general population. There is no controlled data in human pregnancy. Serum cholesterol and triglycerides increase during pregnancy, and cholesterol products are essential for fetal development(Haramburu et al., 2015). Atherosclerosis is a chronic process, discontinuation of lipid lowering drugs during pregnancy should have little impact on long term outcomes of primary hyperlipidemia therapy, therefore, I would discontinue the statin until after pregnancy. Multivitamins are sufficient to supplement an individual’s dietary needs, but when pregnant the baby is taking all of its nutrients from mom. Its easy for pregnant woman to become deficient in nutrients when baby is taking its share, therefore a prenatal vitamin would be started to increase moms’ nutrients to keep both mother and baby supplied should LW become pregnant NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion.
    • LW is suffering from Polycystic Ovarian Syndrome (PCOS), A hormonal disorder causing enlarged ovaries with small cysts on the outer edges. This disease can cause infertility, diabetes, and liver disease(Ionescu et al., 2018). PCOS causes increased levels of testosterone, and low-grade inflammation. LW is 32 years old and wants to become pregnant. PCOS will make it hard to get pregnant due to irregular ovulation and poor egg quality. In this visit I would educate LW on the course of action to offer her and her husband a better chance at conception. I would also do a medication review and adjustment to ensure the best possible outcome should she become conceive.
    • Module III Discussion Post: Men’s & Women’s Health
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    • Gisselle Mustiga posted Sep 16, 2020 6:22 PM
    • Pregnant women and those intending to get pregnant need to be advised on pre and peri-pregnancy planning, especially those with pre-existing and/or chronic conditions and currently taking medications. For the provided scenario, LW is diagnosed with several conditions such as T2DM, HTN, HLP, PCOS, and obesity, and also takes several medications. Her current medication regimen includes Metformin 2000 mg PO QD, Lisinopril 10 mg PO QD, Rosuvastatin 5 mg PO QD, and a multivitamin. Therefore, it is critical to ensure some safer alternatives that are not classified as category X as such category possesses teratogenic effects.The second scenario presents a patient with benign prostatic hyperplasia (BPH), a prevalent condition in men older than 40 years of age. Medical management is vital for GD, as he presents with bothersome symptoms such as dizziness, generalized muscle weakness and persistent lower urinary tract symptoms (LUTS). To begin, I would first determine GD’s AUA symptom score. Subsequently, I would examine his medical history for the presence of any other comorbidities or the use of antihypertensives and/or diuretics as their use could worsen hypotensive symptoms when taken together with alpha 1-blockers. However, all we know is that he is only taking the alpha 1-blocker Terazosin 2mg QAM. In order to ameliorate his symptoms of dizziness and malaise, which are likely side effects of Terazosin, I would reduce his dose, slowly up-titrate it, have him take it QPM, or convert it to the extended release version of the drug. Also, a combination therapy with a 5a-reductase inhibitors such as finasteride could be considered for GD because of its benefit in decreasing the prostate size and improving the symptoms associated with moderate or persistent LUTS (Davidian, 2016). Noteworthy, both alpha 1-blockers and 5a-reductase inhibitors are similar in efficacy, and can be combined if the voiding issues persevere.Avis, H. J., Hutten, B. A., Twickler, M. T., Kastelein, J. J., van der Post, J. A., Stalenhoef, A. F., & Vissers, M. N. (2016). Pregnancy in women suffering from familial hypercholesterolemia. Current opinion in lipidology, 20(6), 484–490. https://doi.org/10.1097/MOL.0b013e3283319127Davidian, M. H. (2016). Guidelines for the treatment of benign prostatic hyperplasia. US Pharm, 41(8), 36-40.
    • Chisholm-Burns, M. A., Wells, B. G., & Schwinghammer, T. L. (2016). Pharmacotherapy principles and practice. McGraw-Hill.
    • References
    • To begin with, I would counsel LW on lifestyle modifications that cover nutrition, exercise, and emotional wellbeing. Subsequently, I would address her current medication schedule. Metformin, alone or with supplemental insulin, is an effective and safe treatment option for GDM. Metformin is also used to treat PCOS symptoms and also improves the rate of ovulation, which in turn increases the likelihood of getting pregnant. It also has benefits during pregnancy as it reduces the risk of birth defects and other complications. As for the multivitamins LW is taking, I would suggest she switches them for a prenatal multivitamin with folic acid and DHA as it has been shown to increase the probability of getting pregnant and it also offers many benefits during pregnancy. On the other hand, ACE Inhibitors and Statins are classified as category X, therefore need to be revised. Antihypertensive drugs known to be effective and safe in pregnancy include methyldopa, labetalol, diltiazem, clonidine, and prazosin as first line of treatment (Chisholm-Burns et al., 2016). In regards to LW’s HLP management, the only medications currently acceptable during pregnancy are bile acid sequestrants, since they are not systemically absorbed and therefore not felt to pose fetal risk (Avis et al., 2016), and Mipomersen, an antisense inhibitor of APoB synthesis.
    • Discussion 3Subscribe
    • Carlita Lockett posted Sep 16, 2020 1:58 PM
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    •      The 32-year-old female coming in for primary care would be advised to have her medications adjusted since it was determined that she is actively trying to become pregnant. All of her medical issues will continue to need to be addressed during the pregnancy so some substitutions must be made. In order to address her hypertension (HTN), the lisinopril would need to be changed to labetalol. This would need to happen because angiotensin-converting enzyme (ACE) inhibitors are contraindicated in anyone who is pregnant or trying to become pregnant. Also, she would have to stop taking the rosuvastatin because statins are contraindicated during pregnancy as well. Statins are contraindicated in pregnancy; however, as women delay pregnancy and statin use increases the risk of statin exposure in pregnancy is likely to rise (Clifton et al., 2016). For this reason, it is beneficial to stop taking rosuvastatin until a safe period after the baby is born. It would be appropriate for her to continue to take her multivitamin and Metformin as prescribed. I was able to come to this recommended regimen once it was established that she needed medications that were conducive to pregnancy. I looked at different classes of medications used to treat HTN and hypercholesterolemia and found which ones weren’t contraindicated in pregnancy. I chose the medication that was most commonly used and exhibited the least negative side effects.
      In addressing the 82-year-old male I would advise him to take his medication in the evening because one of the geriatric side effects of terazosin can be dizziness caused by orthostatic hypertension NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion. Taking the pill in the evening could also reduce the risk of a fall caused by his generalized muscle weakness. I would also suggest that his dosage be reduced as he is on a dose 4x stronger than the starting dose for a male his age. GD is having persistent lower urinary tract symptoms which indicate that the terazosin may not be working as well by itself. I would introduce a 5 alpha-reductase inhibitor to help reduce the symptoms by using combination drug therapy. Alpha-blockers offer a more rapid onset and efficacy in the first year than finasteride, however, only 5 alpha-reductase inhibitors cause prostate regression and reduced risk of BPH complications over time (Dykes et al., 2019). To develop this updated regimen, I looked into the side effects and dosage associated with elderly patients using terazosin. Based on the information, I deduced that the dosage was too high causing adverse effects like dizziness and muscle weakness. It also showed that the medication was not working as well alone and he needed additional medication to complement his current regimen.     statin use in pregnancy: A     1090.Dykes, T., Harper, B., Jordan, A., Lokeshwar, S.D., Klaussen, Z., Neal,     modalities for the management of benign     529-539.less0 UnreadUnread
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    •      https://doi.org/10.21037/tau.2019.10.01
    •      prostatic hyperplasia. Translational Andrology and Urology, 8(5),
    •      D., Terris, M.K., & Webb, E. (2019). Epidemiology and treatment
    •      https://doi.org/10.1016/j.jacl.2016.07.002
    •      Systemic review. Journal of Clinical Lipidology, 10(5), 1081-
    • References:
      Clifton, S., Hill, A.N., Karalis, D.G., & Wild, R. (2016). The risk of
    • Karen Halter
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    • Karen Halter posted Sep 15, 2020 6:28 PM
    • Module 3 PharmTurning to GD, the simplest solution would to recommend that he take his terazosin at night to counteract the weakness and dizziness. If symptoms subside his dosage could be increased to 5 or 10mg and then monitor his LUTS symptoms. Alpha blockers are appropriate and effective treatment for LUTS/BPH. (Newer Medications for Lower Urinary Tract Symptoms (Luts) Associated with Benign Prostatic Hyperplasia (Bph), 2015) If on the other hand his symptoms do not improve by taking the medication at night perhaps a trial of mono therapy with a 5-ARI agent can be tried to see if results are improved. (Newer Medications for Lower Urinary Tract Symptoms (Luts) Associated with Benign Prostatic Hyperplasia (Bph), 2015)As a clinician I would be very cautious in multiple therapies in a patient of this age and I would monitor his symptoms very carefully with any change.  Newer medications for lower urinary tract symptoms (luts) associated with benign prostatic hyperplasia (bph). (2015). AHRQ. https://effectivehealthcare.ahrq.gov/products/prostatic-hyperplasia-medications/research-protocolStatins for the treatment of polycystic ovary syndrome. (2011). Cochrane. https://www.cochrane.org/CD008565/MENSTR_statins-for-the-treatment-of-polycystic-ovary-syndromeless0 UnreadUnread
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    • Last post Sep 16, 2020 1:56 PM by Karen Halter
    • Radosh, L. (2009). Drug treatments for polycystic ovary syndrome. https://www.aafp.org/afp/2009/0415/p671.html
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    • Infertility due to PCOS can be devastating and LW will need all the support that can be given. I would consider discontinuing the rosuvastatin. Raval concluded in his research that although statins could improve lipid profile, there was no evidence that they increased or improved fertility.  (Statins for the Treatment of Polycystic Ovary Syndrome, 2011)A review of LW’s lipid panel would be important to determine the need for continued therapy. Lifestyle changes would be discussed as well, and even though obesity is common in PCOS , I would recommend nutritional counseling and an exercise program. Metformin is the drug of choice in PCOS according to Radosh due to the effect on insulin resistance, menstrual irregularities, anovulation, and obesity. (Radosh, 2009)With regard to pregnancy, I would recommend weight loss, increase in activity, and 6 months without fertility treatment. If no pregnancy occurs a trial of clomphere in conjunction with metformin to induce ovulation should be tried. (Radosh, 2009) NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion
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    • Tomiko Edmonds posted Sep 15, 2020 10:43 PM
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    • When thinking of Women’s and Men’s health, while the genders have vast differences in their healthcare needs, understanding the unique characteristics is a particularly important part of providing individualized care. Looking at the patient’s medical history and current medications is an integral part of the patient history and physical examination. LW has several diagnoses’, one in particular which can make it difficult for her to realize her hopes of conceiving a child. A study of more than 45000 assisted reproductive embryo transfers showed that a higher BMI correlated with a reduced likelihood of successful pregnancy when autologous oocytes were used, but not when oocytes from lean donors were used, suggesting a direct effect of obesity on the oocyte, (Catalano & Shankar, 2017). The very fact that she has a diagnosis of Hypertension (HTN) also places her at risk for complications once she does conceive. Although HTN could be common, certain medications can be teratogenic in early pregnancy. Evidenced-based practice suggests that treatment be rendered where appropriate. Regardless of etiology, severe hypertension—defined as 160/110 mm Hg—is associated with serious maternal morbidity and mortality, and treatment with antihypertensive drugs is almost always indicated, (Malha & August, 2019). The combination of homozygous Familial Hypercholesterolemia and pregnancy can be a fatal condition to both mother and baby, (Russi, 2015).Each of the medications prescribed needs to be adhered to in order to help prevent complications in her goal to become pregnant and also to have a viable pregnancy. Family planning for those that are considered high risk should be discussed as well as a thorough review using evidenced-based practice guidelines as not to cause harm to the patient nor her potential child. Additionally, discussion on lifestyle changes to help manage her various diagnosis whether it be diet, exercise, or medication changes need to be addressed. Alcaraz, A., Carballido-Rodríguez, J., Unda-Urzaiz, M., Medina-López, R., Ruiz-Cerdá, J. L., Rodríguez-Rubio, F., García-Rojo, D., Brenes-Bermúdez, F. J., Cózar-Olmo, J. M., Baena-González, V., & Manasanch, J. (2016). Quality of life in patients with lower urinary tract symptoms associated with bph: Change over time in real-life practice according to treatment—the qualiprost study. International Urology and Nephrology, 48(5), 645–656. https://doi.org/10.1007/s11255-015-1206-7Chen, R., Chen, S., Liu, M., He, H., Xu, H., Liu, H., Du, H., Wang, W., Xia, X., & Liu, J. (2018). Pregnancy outcomes of pcos overweight/obese patients after controlled ovarian stimulation with the gnrh antagonist protocol and frozen embryo transfer. Reproductive Biology and Endocrinology, 16(1). https://doi.org/10.1186/s12958-018-0352-zMalha, L., & August, P. (2019). Safety of antihypertensive medications in pregnancy: Living with uncertainty. Journal of the American Heart Association, 8(15). https://doi.org/10.1161/jaha.119.013495
    • Russi, G. (2015). Severe dyslipidemia in pregnancy: The role of therapeutic apheresis. Transfusion and Apheresis Science, 53(3), 283–287. https://doi.org/10.1016/j.transci.2015.11.008
    • Guzmán, R., Fernández, J. C., Pedroso, M., Fernández, L., Illnait, J., Mendoza, S., Quiala, A. T., Rodríguez, Z., Mena, J., Rodíguez, A., Campos, M., Sánchez, C., Alvarez, Y., & Jiménez, G. (2019). Efficacy and tolerability ofroystonea regialipid extract (d-004) and terazosin in men with symptomatic benign prostatic hyperplasia: A 6-month study. Therapeutic Advances in Urology, 11, 175628721985492. https://doi.org/10.1177/1756287219854923
    • Catalano, P. M., & Shankar, K. (2017). Obesity and pregnancy: Mechanisms of short term and long term adverse consequences for mother and child. BMJ, j1. https://doi.org/10.1136/bmj.j1
  • References
  • GD has a diagnosis of Benign Prostatic Hyperplasia (BPH) which is a common condition in older men that can often result in lower urinary tract symptoms (LUTS), (Alcaraz et al., 2016) NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion. The medication Terazosin is an antihypertensive drug that may decrease blood pressure which may be causing his dizziness. Terazosin relaxes the smooth muscle of the prostate and bladder, facilitates bladder emptying, improves LUTS, increases maximum urinary flow, and reduces the residual volume of urine, the effects being dose-dependent, (Guzmán et al., 2019). Although the use of Terazosin may relieve symptoms, it does not shrink the prostate and further treatment may be needed in time. Education must be done with the patient on the treatment and side effects must be discussed so that he may know what is normal and what needs to be reported to his provider immediately. Again, the use of evidence-based practice guidelines is the route to take when assessing and prescribing medications to patients. Additionally, investigating updated protocols to treat the symptoms and the underlying causes should be explored with the patient to determine if he is a candidate and referrals should be made to a specialist when and if appropriate.
  • Additionally, her Polycystic Ovarian Syndrome is a common complication of obesity and often leads to difficulty in achieving successful pregnancies. Obesity is also associated with complications of reproduction, including maternal mortality; stillbirth; neonatal and infant death; infant large-for-gestational age; fetal malformations; maternal diabetes; pregnancy-induced hypertension; preeclampsia; and Caesarean section, (Chen et al., 2018) NSG-533-Advanced Pharmacology Module III – Men’s and Women’s Health Discussion.
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