BY DAY 3 OF WEEK 1
Post a description of the patient case from your experiences, observations, and/or clinical practice from the last 5 years. Then, describe factors that might have influenced pharmacokinetic and pharmacodynamic processes of the patient you identified. Finally, explain details of the personalized plan of care that you would develop based on influencing factors and patient history in your case. Be specific and provide examples.
BY DAY 6 OF WEEK 1
Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described. In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.
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Discussion Week One: Pharmacokinetics & Pharmacodynamics
One patient case from experience on a med/surg unit involves an admission for Alcohol withdrawal, which happens to be a prevalent chief complaint for hospital admissions. This patient was a chronic alcoholic and did reasonably well the previous night, but the withdrawal symptoms began to worsen this particular night. When caring for these types of patients, there is a tool called CIWA-AR (Clinical Institute Withdrawal Assessment Alcohol Scale Revised) that measures the severity of withdrawal symptoms. Depending on the score, there may be indications for pharmacological intervention such as Lorazepam (Ativan) which the physician prescribes. Throughout the night, the patient became increasingly aggressive, combative, anxious, and agitated, posing safety issues to himself and the staff. Orders from the CIWA-AR protocol were ineffective, the patient refused to take anything by mouth, and the hospitalist needed additional PRN medication to calm the patient down. Parenteral Lorazepam was added to the CIWA-AR protocol since oral was not an option. Throughout the night, the patient met the requirements for three parenteral doses of Lorazepam. Notably, each injection took quite some time to take effect; the patient continued with restlessness and agitation, but eventually, after the third dose, the medication was effective. The next day, upon arrival to the unit, the day shift nurse shared concerns that the patient had been highly lethargic, tired, and sedated that morning. The patient regained baseline cognitive status late that afternoon but slept most of the day.
Pharmacokinetics has four significant processes, absorption, distribution, metabolism, and excretion. However, body systems and organs must function adequately to produce therapeutic results. For example, physiologic and anatomic factors at the absorption site must function properly, and blood flow to the tissues must be adequate for distribution to be effective. Metabolism requires proper functioning of the hepatic microsomal enzyme system of the liver, and the kidneys must be healthy and functional for proper excretion to occur (Rosenthal & Burchum, 2021). Alcohol abuse causes severe alterations to the body, specifically hepatic changes such as a fatty liver and thickening and scarring of the liver, fibrosis can lead to cirrhosis, and cancer is a possibility (The Journal for Nurse Practitioners, 2019). Changes in the liver from alcohol abuse impact pharmacokinetics, specifically the breakdown of drugs; This explains why it took so long for the liver to process the Lorazepam, prolonging the desired effect and producing effects that indicate the drug could have been building up instead of breaking down and excreting. Ultimately, the physiologic changes that alcohol abuse has on the liver, impact the normal drug metabolism process.
Pharmacodynamics is the physiologic effects that drugs have on the body, and this process involves dose-response relationships, dose size, and response intensity (Rosenthal & Burchum, 2021). Lorazepam is a benzodiazepine, an anti-anxiety medication most commonly used for alcohol withdrawal management. Common side effects are dose-related and present as drowsiness, lethargy, ataxia, dysarthria, and dizziness (NCBI, 2017). Considering the patient scenario, there was an increase in the dosing size since the patient had three parenteral doses of Lorazepam. The intensity of the response was evident through increased lethargy, drowsiness, and sedation.
As for a personalized care plan, every patient admitted to the hospital for alcohol withdrawal will start on a tapered Lorazepam regimen. For example, 1MG every 8 hours for one day, 0.5MG every 8 hours for one day, 0.25MG every 8 hours for one day, and so on. There will also be a PRN order as needed, and the CIWA protocol will remain; ideally, CIWA scores will be so low that PRN orders are unnecessary. This protocol will be more effective because there is an automatic intervention to assist with a more proactive and safe withdrawal process instead of waiting for withdrawals to start. From experience and observation, when patients immediately start on a Lorazepam regimen, they are less likely to experience severe withdrawal symptoms, which causes a more therapeutic response to withdrawals.
References
Alcoholic Liver Disease: Implications for the Advanced Practice Provider. (2019). The Journal for Nurse Practitioners, 15(7), 506-510.
https://doi.org/10.1016/j.nurpra.2019.04.002Links to an external site.
National Library of Medicine. National Center for Biotechnology Information. (2017). LiverTox: Clinical and Research Information on Drug-Induced Liver
Injury. https://www.ncbi.nlm.nih.gov/books/NBK548563/
Rosenthal, L. D. & Burchum, J. R. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.)
St. Louis, MO: Elsevier
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Collapse SubdiscussionYesnely Fernandez Perez Hello Tyriss,
The four major pharmacokinetic processes are absorption, distribution, metabolism, and excretion. Yet, therapeutic effects need normal operation of the body’s systems and organs. Normal metabolism requires a healthy hepatic microsomal enzyme system, and healthy kidneys depend on regular excretion (Li, et al., 2019). Alcoholism alters the liver, which has consequences for medication metabolism and pharmacokinetics. Pharmacodynamics is the scientific discipline concerned with how medications work within the human body. Studying the correlation between dosage and response, as well as the relative strengths of the two, is the focus of this field of study (Rosenthal & Burchum, 2021). Alcohol withdrawal symptoms are often treated with lorazepam, a benzodiazepine anti-anxiety medicine.
References
Li, Y., Meng, Q., Yang, M., Liu, D., Hou, X., Tang, L., Wang, X., Lyu, Y., Chen, X., Liu, K., Yu, A.-M., Zuo, Z., & Bi, H. (2019). Current trends in drug metabolism and pharmacokinetics. Acta Pharmaceutica Sinica B, 9(6), 1113–1144. https://doi.org/10.1016/j.apsb.2019.10.001Links to an external site.
Rosenthal, L. D. & Burchum, J. R. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.) St. Louis, MO: Elsevier
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Collapse SubdiscussionLilia Cristina Becerra-Hatcher Hello Tyriss. Thank you for sharing your experience. As you mentioned, Lorazepam is commonly used for alcohol withdrawal. Benzodiazepines vary in clinical applications, and all have depressant actions in the central nervous system and increase the effects of GAB. A benzodiazepine is better absorbed orally due to high lipid solubility (Rosenthal DNP ACNP, Laura et al., 2020).
As you indicated, liver disease patients can have reduced drug metabolism. Regarding benzodiazepines, Lorazepam, temazepam, and oxazepam are recommended for patients with liver impairment due to their low metabolic alterations, and accumulation is not likely to occur after repeated dosing (Rosenthal DNP ACNP, Laura et al., 2020). Per my personal experience and in your scenario, it is evident that the increased dosing size intensified the patient’s response to the drug by showing increased drowsiness, lethargy, and sedation.
The misused of alcohol has been the cause of death by liver disease, psychological problems, malnutrition, and socio-economic disparities. The management of the patient’s withdrawal should be according to the degree of dependency. The care plan should include preventing delirium and seizures and planning for discharge to a program where the patient can sustain abstinence. Depending on the patient’s needs, besides CIWA protocol, a B-adrenergic blocker such as atenolol to improve vital signs and an antiepileptic drug such as carbamazepine could be added to the treatment (Rosenthal DNP ACNP, Laura et al., 2020). According to the patient’s socio-economic factors, if the patient cannot attend an alcohol prevention program in person, case managers should give the patient information about resources such as telemedicine at discharge. Telemedicine has effectively treated patients with substance abuse issues and has shown positive patient outcomes (Kruse et al., 2020).
References
Kruse, C., Lee, K., Watson, J. B., Lobo, L. G., Stoppelmoor, A. G., & Oyibo, S. E. (2020). Measures of effectiveness, efficiency, and quality of telemedicine in the management of alcohol abuse, addiction, and rehabilitation: Systematic review. Journal of Medical Internet Research, 22(1), e13252. https://doi.org/10.2196/13252Links to an external site.
Rosenthal DNP ACNP, Laura, Burchum DNSc FNP-BC CNE, Jacqueline, & . (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician (2nd ed.). Saunders.
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Collapse SubdiscussionBillie Lanham Hello Tyriss, I really enjoyed reading your post!
Some additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patient may include age, race, comorbid conditions, compliance to medications, diet, nutrition, smoking, illicit drug abuse as well as pathological changes occurring due to the alcohol consumption. Comorbidities such as renal dysfunction can interfere with the patient’s ability to excrete drugs (pharmacodynamics) which affects the efficacy of the drugs. The patients nutritional and immune status as explained by (Mary Bradle, 17 June 2022) may also affect the drug metabolism and efficacy due to cell mediated immunity and enzymes which play a critical role in metabolism of drugs. Age is also a factor that affects drug metabolism. This is because in the pediatric population their gastric PH changes rapidly throughout childhood which can affect oral drugs where by some are either activated or inactivated by the gastric PH which will affect the efficiency of the drug.
Older patients too have challenges when it comes to pharmacokinetics and pharmacodynamics due to various issues such as decreased receptors for drugs due to the aging process of the body, decreased enzymatic activity and cellular response thus affecting drug efficacy.
The care plan could focus on the main principals of management which are to relieve symptoms, prevent seizures and prevent Delirium tremetens which is explained by (Ildiko Katalin Pribek, 19 January 2021). Non pharmacological management should include monitoring of heart rate, breathing rate and depth, SPO2 level, temperature and lethargy using a RASS (Richmond Agitation Sedation Scale) sedation score which should be at 0 to 2, seizure activity, CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol Scale Revised) score should be accessed on a daily basis to monitor patient’s progress even before administration of Ativan.
Pharmacological management should be provided by use of Benzodiazepines such as Lorazepam (Ativan) given IV to prevent seizures, Phenobarbital given as a slow injection diluted in 10ml of normal saline with a maximum dosage of 60mg/min. With medical management the patient has to be evaluated every 15 minutes to 1 hour which is to prevent respiratory depression by the drugs.
REFERENCES
Ildiko Katalin Pribek, I. K. (19 January 2021). Evaluataion of the course and treatment of alcohol withdrawal syndrome with the CIWA-AR: A
systematic review based meta analysis. Elsevier.
Mary Bradle, T. H. (17 June 2022). Correlation Between and Nursing satisfaction with CIWA-Ar, mMINDS, and SEWS Scoring tools for
assesment of severe alcohol withdrawl syndrome in ICU Patients. Annals of Pharmacotherapy.
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Collapse SubdiscussionChijiamara Kalu Response Post I
Hi Tyriss,
I appreciate your contribution on this discussion. You presented an intriguing case about your patient who was suffering from alcohol withdrawal.The Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) is a 10-item validated evaluation tool used to quantify the severity of alcohol withdrawal syndrome (AWS) and to guide clinical treatment with benzodiazepines such as Lorazepam (Melkonian et al., 2019). However based on the description you gave about the patient, this patient might have developed high tolerance to BZDs. Tolerance to benzodiazepines can develop after prolonged use; additionally, patients who have tolerance to other CNS depressants such as alcohol and barbiturates may have some cross-tolerance to BZDs.
In reference to the personalized care for this patient, I expected that the Nurse would escalate the situation to the physician than continue administering Ativan based on the CIWA score in addition to the PRN dose that were given. The physician may recommend a non-invasive method such as temporary restraint or approve an adjunct medication with Ativan to achieve desired therapeutic effect. Incorporating a BZD with another drug may improve withdrawal outcome; Carbamazepine may reduce withdrawal symptoms as well as the risk of seizures; and Clonidine and Beta blockers may reduce the central nervous system component of withdrawal symptoms (Rosenthal et al., 2021). In the description, some vital information about the patient were withheld such as age, other medical history such as hepatic and kidney condition, and vital signs to know if the patient is hemodynamically stable for continued parenteral sedative medications and renal statues to elicit efficient metabolism and the desired drug efficacy. Some of which might have contributed to not having a desired effect of the drug. Some drugs’ effectiveness can be enhanced by an individual’s metabolic state. (Rosenthal et al., 2021).
References:
Melkonian, A., Patel, R., Magh, A., Ferm, S., & Hwang, C. (2019). Assessment of a hospital-wide CIWA-AR protocol for management of alcohol withdrawal syndrome. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(3), 344–349. https://doi.org/10.1016/j.mayocpiqo.2019.06.005
Rosenthal, L. D., Burchum, J. R., & Rosenthal, L. D. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier.
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Collapse SubdiscussionChijiamara Kalu Response Post I
Hi Tyriss,
I appreciate your contribution on the discussion. You presented an interesting case about your patient going through Alcohol withdrawal. The Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) is a 10-item validated evaluation tool used to quantify the severity of alcohol withdrawal syndrome (AWS) and to guide clinical treatment with benzodiazepines such as Lorazepam (Melkonian et al., 2019). However based on the description you gave about the patient, this patient might have developed high tolerance to BZDs. Tolerance to benzodiazepines can develop after prolonged use; additionally, patients who have tolerance to other CNS depressants such as alcohol and barbiturates may have some cross-tolerance to BZDs.
In reference to the personalized care for this patient, I expected that the Nurse would escalate the situation to the physician than continue administering Ativan based on the CIWA score in addition to the PRN dose that were given. The physician may recommend a non-invasive method such as temporary restraint or approve an adjunct medication with Ativan to achieve desired therapeutic effect. Incorporating a BZD with another drug may improve withdrawal outcome; Carbamazepine may reduce withdrawal symptoms as well as the risk of seizures; and Clonidine and Beta blockers may reduce the central nervous system component of withdrawal symptoms (Rosenthal et al., 2021). In the description, some vital information about the patient were withheld such as age, other medical history such as hepatic and kidney condition, and vital signs to know if the patient is hemodynamically stable for continued parenteral sedative medications and renal statues to elicit efficient metabolism and the desired drug efficacy. Some of which might have contributed to not having a desired effect of the drug. Some drugs’ effectiveness can be enhanced by an individual’s metabolic state. (Rosenthal et al., 2021).
References:
Melkonian, A., Patel, R., Magh, A., Ferm, S., & Hwang, C. (2019). Assessment of a hospital-wide CIWA-AR protocol for management of alcohol withdrawal syndrome. Mayo Clinic Proceedings: Innovations, Quality & Outcomes, 3(3), 344–349. https://doi.org/10.1016/j.mayocpiqo.2019.06.005
Rosenthal, L. D., Burchum, J. R., & Rosenthal, L. D. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier.
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Collapse SubdiscussionRandall Alan Jessup Week 1 Discussion initial
Randall Jessup
Master of Science in Nursing (MSN), PMHNP Walden University
NURS-6521C-3/NURS-6521N-3-Advanced Pharmacology-2023-Spring-QTR
Advanced Pharmacology
Dr. Tarah Coronado Instructor Manager
Patient one.
I have been a Utilization Review or a case manager for the past 15 years. The only person I have administered medications to in that time is myself.
Pharmacokinetics Deals with the absorption, distribution, excretion, and metabolism of a medication. Scientist dealing in pharmaceuticals study this field to increase the efficiency of the delivery of the medication while at the same time attempting to decrease the risk of toxicity to the patient during the medications use.
Pharmacodynamics describes the relationship of the drug concentration at the site of action and its effect on patients as it relates to the duration of the course of medication use and the intensity of the therapeutic or adverse effects. (2020 Lecturio Medical Online Library)
Pharmacokinetics and Pharmacodynamics of Drugs
One medication that I have seen many patients on as a Utilization review nurse is the anti-Diabetes medication Glipizide one patient was taking (10 mg twice daily) he was being treated for type two diabetes and was obese. This medication is in the sulfonylurea class. Its acts as a blocker of potassium channels in the beta cells and causes the pancreas to increase the output of insulin which in turn pulls down blood glucose levels. This medication is absorbed fast and completely by the stomach. Eating can delay uptake by 30 minutes. It is metabolized in the hepatic system and excreted in the urine usually within 10-24 hours. Its half-life is about 2-4 hours. (Roerig, 2006)
This medication class Sulfonylureas (SU) has been around since 1942 and by 1984 second-generation SUs had been released including Glipizide. The UK Prospective Diabetes Study (UKPDS) conducted in 1999 found that intensive treatment with SU class of drugs produced almost no benefit in the long-term treatment of type 2 diabetes and the most concerning finding from that study was the increase in weight gain in already obese patients which could lead to cardiovascular complications with these patients. Further research over a twenty-year period revealed that raising insulin to combat higher blood sugar, with the resulting increase in weight gain and a subsequent increase in the incidence of cardiovascular issues gave little advantage versus risk. (Fung & Teicholz, 2018)
The patient from the start of this discussion might want to consider speaking with his provider about the possibility of changing his Glipizide to a different anti-diabetic medications which may be more neutral on weight gain or even one that causes weight loss as there are several on the market that could show benefit in this area, as he would need to lose weight to help decrease his risk of a cardiac event.
Lecturio. (2020, June 15). Pharmacokinetics and pharmacodynamics: Online medical library. The Lecturio Online Medical Library. Retrieved February 27, 2023, from https://www.lecturio.com/magazine/pharmacokinetics-and-pharmacodynamics/
Roerig. (2006, September). GLUCOTROL XL – glipizide tablet, extended release … GLUCOTROL XL – glipizide tablet, extended release. Retrieved February 27, 2023, from https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/020329s22lbl.pdf
Fung, J., & Teicholz, N. (2018). The diabetes code: Prevent and reverse type 2 diabetes naturally. Greystone Books.
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Collapse SubdiscussionBillie Lanham Initial Discussion Post
Nurses come across various patients with different clinical needs, thus the need to understand medication pharmacodynamics and pharmacokinetics during prescription. Rosenthal and Burchum(2021) postulate that clinical pharmacokinetics is essential since it enhances patient drug therapy efficacy and decreases toxicity. Pharmacodynamics refers to physiologic and biochemical drug effects on an individual’s body and the effects caused by this relationship. The discussion post will focus on patient care experience, pharmacokinetic and pharmacodynamic factors influencing the patient, and the personalized plan care for the patient
Patient Case Experience
The patient case experience is with a 70-year-old Caucasian female who presented to our clinic. The patient’s chief complaint was, “I have not been feeling good.” After examining her, it was evident that the patient was hypertensive and experienced sinus tachycardia but did not experience pain. However, her history proved that she previously had medical issues, including chronic obstructive pulmonary disease, chronic kidney disease, hypertension, and depression. Patient stated, due to her hypertensive condition, she took an ace inhibitor and serotonin reuptake inhibitor for hypertension and depression consecutively.
Pharmacokinetic and Pharmacodynamic Factors Influencing the Patient
The patient’s chronic kidney disease makes it necessary to determine the patient’s pharmacokinetic and pharmacodynamic effects on the patient. According to Pugh et al. (2019), chronic kidney disease is a common cause of uncontrolled hypertension, with their interaction having an adverse effect which may lead to adverse cardiovascular conditions. Hence, it will be necessary to consider these situations when administering new medications to the patient. Also, it is necessary to assess the patient’s compliance with medication.
Personalized Plan Care for the Patient
The best-personalized care for the patient will be through admitting her to monitor how she takes medication and how they interact (Reddy et al., 2020). Close patient monitoring will help the nurses realize when the medication regimen fails and intervene to prevent adverse effects.
Conclusion
Nurses must have all the patients’ information when dealing with pharmacokinetics and pharmacodynamics in clinical settings to have an effective treatment plan. That is because some diseases medication may affect the patient’s compliance. Hence by admitting the patient, it will be easier to monitor the patient closely to prevent adverse effects as well as know exactly what she is taking and when she is taking it until she can stabilize.
References
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO:
Elsevier.
Pugh, D., Gallacher, P. J., & Dhaun, N. (2019). Management of Hypertension in Chronic Kidney Disease. Drugs, 79(4), 365–379.
https://doi.org/10.1007/s40265-019-1064-1
Reddy, P. K., Kuchay, M. S., Mehta, Y., & Mishra, S. K. (2020). Diabetic ketoacidosis precipitated by COVID-19: A report of two cases and review of
literature. Diabetes & Metabolic Syndrome, 14(5), 1459–1462. https://doi.org/10.1016/j.dsx.2020.07.050
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Collapse SubdiscussionTarah Marie Coronado Thank you for your post Billie. Lets assume this patient is on lisinopril and sertraline. Do either of these drugs have any required dose adjustments for renal impairment?
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Collapse SubdiscussionBillie Lanham Mrs. Coronado,
A patient with renal impairment will require a different dosage. Dosage is based on creatinine clearance. So, with Lisinopril, if a patient has a creatinine clearance of less than 10ml/min, the starting dose would be 2.5mg/day. 10-30ml/min. the dose would be 2.5-5mg. 31-80ml/min. the dose would be 5-10mg. The dosage and frequency of administration should be adjusted depending on the blood pressure response. However, with Sertraline, there is no need for adjustment with renal impairment.
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Collapse SubdiscussionTyriss Gordon Hello Billie,
Thank you so much for you post, you discussed some really important issues. As a dialysis nurse, I can truly understand how important medication management is for this population of patients. Chronic Kidney Disease is a multi-system condition, and treatment and management of the disease requires special attention and expertise from both the patient and provider’s. Patient’s need adequate education in regards to medication to ensure administration is correct and to prevent adverse events (Rosenthal & Burchum, 2021). There are significant challenges with providers regarding Chronic Kidney Disease and Hypertension that involve discrepancies in practitioner limits for prescribing, and access to rapid changes and often conflicting guidelines for prevention and management (Garabedian et al., 2022). When you look at this case scenario, there are so many factors that could have contributed to this patient not feeling well. Is blood pressure medication being taken correctly? Is she compliant with dialysis treatments and if so, is there enough fluid being removed? Are all medications prescribed therapeutic and conducive to optimal patient outcomes? Your method of personalized was indeed necessary, monitoring provides a method of safe and effective therapy (Rosenthal & Burchum, 2021). As advanced nurse practitioners, one must be knowledgeable and have a strong sense of awareness when caring for patient’s with unstable conditions. Great post Billie!
References
Garabedian, P. M., Gannon, M. P., Aaron, S., Wu, E., Burns, Z., & Samal, L. (2022).
Human-Centered Design of Clinical Decision Support for Management of Hypertension
With Chronic Kidney Disease. BMC Medical Informatics and Decision Making, 22(1), 217.
https://doi.org/10.1186/s12911-022-01962-y
Rosenthal, L. D. & Burchum, J. R. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice
Nurses and Physician Assistants (2nd ed.) St. Louis, MO: Elsevier
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Collapse SubdiscussionEmily Ann Bennett Billie, I appreciate your post, as mine also had to do with chronic kidney disease. Chronic kidney disease directly affects the rate that drugs can exit the system, therefore remaining in the system longer than would be anticipated as seen by the average patient (Lea-Henry et al, 2018). Knowing this information, patients with less functioning kidney’s must be dosed differently, more oftentimes less frequently, to prevent an overdose or over effective medicine (Roberts et al, 2018). While this does make dosing more difficult for the provider, it is important the patient be prescribed the right dosage as closely as possible in occurrence with what their kidney is excreting.
Lea-Henry, T. N., Carland, J. E., Stocker, S. L., Sevastos, J., & Roberts, D. M. (2018). Clinical pharmacokinetics in kidney disease: fundamental principles. Clinical journal of the American society of nephrology, 13(7), 1085-1095.
Roberts, D. M., Sevastos, J., Carland, J. E., Stocker, S. L., & Lea-Henry, T. N. (2018). Clinical pharmacokinetics in kidney disease: application to rational design of dosing regimens. Clinical Journal of the American Society of Nephrology, 13(8), 1254-1263.
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Collapse SubdiscussionRahel D Woyessa Hi Billie, I enjoy reading your post. As you pointed out elderly patients need close monitoring and dose adjustment. The ability of older adults to metabolize drugs can be decreased and drug dosages may need to be adjusted for elderly patients (Rosenthal & Burchum, 2021). So many questions came to my mind while reading your post, did the patient took the correct medicine? How about the dose or was the frequency of the medications correct? Preparing to respond to your post, I learned that depressed patients display a higher incidence of hypertension compared with the general population because they are less likely to follow proper lifestyle recommendations and less adherent to antihypertensive and other drug therapies. According to Calvi et al., the other possible reason for blood pressure level abnormalities in depressed individuals is the use of antidepressant drugs, which can affect blood pressure levels by inducing hypertension, hypotension, and orthostatic hypotension. This represents a critical issue for patients and providers. Several classes of antidepressant drugs may affect blood pressure through various mechanisms, e.g., altering neural pathways involved in the vascular tone control, cardiac heart rate automatisms, or conduction mechanisms (2021). I regret documenting “refused” for blood pressure checks for our mental health patients when they refuse. Now, I learn how antidepressants affect blood pressure, I will take time to explain patients the importance of monitoring blood pressure if they’re on antidepressants.
References
Calvi, A., Fischetti, I., Verzicco, I., Belvederi Murri, M., Zanetidou, S., Volpi, R.,
Coghi, P., Tedeschi, S., Amore, M., & Cabassi, A. (2021). Antidepressant
Drugs Effects on Blood Pressure. Frontiers in cardiovascular medicine, 8,
- https://doi.org/10.3389/fcvm.2021.704281
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice
nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
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Collapse SubdiscussionChijiamara Kalu Response Post II
Hi Billie,
You shared an interesting case about a patient who came to you complaining of malaise with the exception of pain. It is critical you considered that this patient has a pre-existing medical condition and that she is taking medications for kidney disease, hypertension, and depression. This is why, for effective patient care, all prescribers should be knowledgeable about drug pharmacokinetics and pharmacodynamics. In your patient’s case, physiologic changes can alter drug responses, particularly her physiologic condition of decreased excretion due to kidney disease, and possibly altered electrolyte statues, which may lead to cardiac dysthymias (Rosenthal et al., 2021). In addition to the personalized care for this patient, it is important that her current medications be reviewed and reconciled to avoid drug-drug interactions because kidney disease can reduce drug excretion, causing drugs to accumulate in the body and cause drug toxicity if dosage is not reduced. Her age is also a big factor to be considered, because drug sensitivity varies with age. In the case of this patient, increased sensitivity in old age, multiple comorbidities, and treatment with multiple drugs can lead to organ dysfunction. (Rosenthal et al., 2021). Although most SSRIs are generally safe, some atypical antidepressants such as trazodone mimic SSRIs and are not safe in patients with hepatic and cardiac dysfunction. Research work by Calvi et al., 2021 showed that Trazodone is used in low doses to treat insomnia, particularly in the elderly, but its antidepressant activity appears at higher doses (150 mg/day). At low doses, trazodone acts primarily as a potent 5-HT2A receptor antagonist, but also as a weak H1-histamine receptor and 1-adrenergic antagonist; at high doses, SERT inhibition and 5-HT2C antagonism are the drug’s targets. Because of the potential arrhythmogenic effects, patients with hepatic or cardiac dysfunction should exercise caution for QT prolongation. A fatal overdose due to torsade’s de pointes was also reported.
References:
Calvi, A., Fischetti, I., Verzicco, I., Belvederi Murri, M., Zanetidou, S., Volpi, R., Coghi, P., Tedeschi, S., Amore, M., & Cabassi, A. (2021). Antidepressant drugs effects on blood pressure. Frontiers in Cardiovascular Medicine, 8. https://doi.org/10.3389/fcvm.2021.704281Links to an external site.
Rosenthal, L. D., Burchum, J. R., & Rosenthal, L. D. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier.
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Collapse SubdiscussionLilia Cristina Becerra-Hatcher I had the opportunity to work in multiple clinical settings and found that caring for patients with mental health illnesses such as substance abuse and other comorbidities can be challenging. When medicating these patients, it is essential to comprehend the pharmacokinetics of drugs, know how the patient will process the medications given, and how the drug applies its action to provide the best treatment. Drug-to-drug and disease-to-drug interactions knowledge are essential due to the risk of sentinel events that may lead to undesirable patient outcomes (Li et al., 2019).
A 20-year-old female was brought to the emergency department by local police due to violent behavior toward family members, and consequently, she was involuntarily committed (IVC). The patient was violent on arrival and received Ativan 2 mg IV and then Haldol 5mg IV. The patient was combated, and the staff could not de-escalate her; therefore, she received Ketamine 50 mg/ml IV. Labs were drawn, and a drug screening showed that the patient was positive for cannabis.
A nurse must assess the patient after receiving medications that reduce agitation and sedation, such as Ativan, Haldol, and Ketamine. A benzodiazepine such as Ativan binds to the GABA receptors in the limbic system and cortex. The Ativan was administered by the recommended sedation dosage of 2mg IV; this dose may take around 30min for adequate effect. On the other hand, Haldol blocks D2 dopamine receptors and is a first-generation antipsychotic that achieves satisfactory outcomes after 25 min. Ketamine stimulates opioid receptors, inhibits N-methyl and D-aspartate, and has a rapid action of 1-2 min when given in an IV route of 1-2 mg/kg (Zaki et al., 2022). Studies show that Ketamine is a faster effective sedative than Ativan and Haldol but has more adverse effects, such as tachycardia and hypertension (Zaki et al., 2022).
The psychiatrist later evaluated this 22 yo female patient. According to her family, the patient has been having trouble sleeping and has a family history of mental illness. The patient was diagnosed with bipolar disorder and placed on Lithium Carbonate 200 mg TID daily and Trazadone 50 mg hs daily. Lithium Carbonate is a mood stabilizer, and Trazadone is a sleep aid. The patient was also ordered Ativan 2mg IV PRN and Haldol 2 mg IV PRN for agitation while in the ED waiting for mental facility placement or discharge home according to assessment in the next 24-48 hours.
As a plan of care, the patient was a healthy young female without medical history. The patient should be educated about bipolar disorder, medication treatment, and side effects. If the patient is discharged home, the patient’s family should be included in the treatment teaching if possible. The patient and family must understand the medication schedule and adverse effects, such as Lithium toxicity, and other side effects, such as gastrointestinal issues, nausea, diarrhea, and hand tremors. Patients taking Lithium have a risk of hypothyroidism. Therefore, the patient should have calcium and TSH levels checked. Renal issues, such as urine concentration, can be seen in the long-term use of Lithium. Patients with kidney disease are at risk of lithium intoxication (Volkmann et al., 2020). Trazadone is an atypical antidepressant used to treat insomnia due to its sedative actions. A study shows that Trazadone is a safe and effective sleep aid for patients with mental health disorders and other comorbidities. Trazadone also improves recall abilities and concentration (Wang et al., 2020). The provider should educate the patient on Trazadone’s side effects, such as lethargy and hypotension.
An advanced practice nurse must understand how the patient’s pharmacokinetics and pharmacodynamics process can alter the response to treatment. The provider should tailor the therapy and education for the patient according to the patient’s needs.
References
Li, Y., Meng, Q., Yang, M., Liu, D., Hou, X., Tang, L., Wang, X., Lyu, Y., Chen, X., Liu, K., Yu, A.-M., Zuo, Z., & Bi, H. (2019). Current trends in drug metabolism and pharmacokinetics. Acta Pharmaceutica Sinica B, 9(6), 1113–1144. https://doi.org/10.1016/j.apsb.2019.10.001Links to an external site.
Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium treatment over the lifespan in bipolar disorders. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00377Links to an external site.
Wang, J., Liu, S., Zhao, C., Han, H., Chen, X., Tao, J., & Lu, Z. (2020). Effects of trazodone on sleep quality and cognitive function in arteriosclerotic cerebral small vessel disease comorbid with chronic insomnia. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00620Links to an external site.
Zaki, H. A., Shaban, E., Bashir, K., Iftikhar, H., Zahran, A., Salem, E.-D. M., & Elmoheen, A. (2022). A comparative analysis between ketamine versus combination of midazolam and haloperidol for rapid safe control of agitated patients in emergency department: A systematic review. Cureus. https://doi.org/10.7759/cureus.26162Links to an external site.
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Collapse SubdiscussionTarah Marie Coronado Thank you for your informative post Lilia. Please provide information on the typical signs and symptoms of Lithium toxicity and lithium toxicity levels.
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Collapse SubdiscussionLilia Cristina Becerra-Hatcher Response to Professor
Mrs. Coronado,
Typical lithium toxicity symptoms associated with high lithium levels are <1.5 mEq/L GI effects, lethargy, polyuria, muscle weakness, tremors, slurred speech, and thirst. In levels of 1.5-2 mEq/L, the patient experiences continuous GI effects, ECG variations, sedation, confusion, tremors becoming coarse, lack of coordination, and muscle contractions. With levels 2-2.5 mEq/L, the patient can present with critical ECG changes, hypotension, diluted urine, seizures, tinnitus, ataxia, and death that pulmonary complications can cause. Patients with levels > 2.5 will have oliguria and convulsions, finally leading to the patient’s death (Rosenthal DNP ACNP, Laura et al., 2020). The provider needs to inform the patient about lithium toxicity’s early signs and symptoms. At the beginning of the therapy, the provider should monitor levels every two to three days and then every three to six months. Since there is no antidote to reverse lithium toxicity, hemodialysis is recommended for patients with levels higher than 2.5 mEq/L (Rosenthal DNP ACNP, Laura et al., 2020).
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Collapse SubdiscussionLilia Cristina Becerra-Hatcher Please see references to my response
References
Rosenthal DNP ACNP, Laura, Burchum DNSc FNP-BC CNE, Jacqueline, & . (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician (2nd ed.). Saunders.
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Collapse SubdiscussionPenny Pitford Another potential contributing factor to the metabolism of the medication is the nutritional status of the patient. A twenty year is likely well-nourished or poorly nourished depending on diet choices. A malnourished patient can have compromised drug metabolism as the enzymes which break down the medication require cofactors and if they are lacking from the diet then the drug will not metabolize as expected (Rosenthal & Burchum, 2017). Research has shown that malnutrition can affect drug metabolism and clearance. It can increase the risk of acetaminophen-induced hepatoxicity (Zillen et al., 2021).
References
Rosenthal, L., & Burchum, J. (2017). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants – e-book (2nd ed.). Saunders.
Zillen, D., Movig, K., Kant, G., Masselink, J., & Mian, P. (2021). Impact of malnourishment on the pharmacokinetics of acetaminophen and susceptibility to acetaminophen hepatotoxicity. Clinical Case Reports, 9(11). https://doi.org/10.1002/ccr3.4611Links to an external site.
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Collapse SubdiscussionRandall Alan Jessup response 1
Ms. Pitford
I enjoyed your post, and loved that you brought up the nutritional aspect of the patient with behavioral health issues, as this has been a particular focus of mine for the past two years.
Often times as providers we ignore the patients diet when it comes to mental health. studies have found that the consumption of ketone bodies (or ketosis) through exogenous ketones, can help alleviate some of the symptoms associated with neuro-progressive disorders, such as schizophrenia, bipolar disorder, and major depression. As a result, glucose hypo-metabolism can be bypassed via beta-hydroxybutyrate, providing an alternative to glucose as a source of energy.
Of course the same level of benefit can be achieved through implementation of a strict keto diet and have also been achieved through use of a carnivore diet of strictly meat or animal products. A number of studies suggest that induced ketosis diet or exogenous ketone administration is also able to target molecules and signaling pathways that are also known to be abnormal in patients suffering from these illnesses, including Kelch-like ECH-associated protein/nuclear factor erythroid 2-related factor 2, Sirtuin-1 nuclear factor-κB p65, and nicotinamide adenine dinucleotide (NAD).
Children and adults with pharmacologically resistant epilepsy can be treated with diet-induced ketosis and/or the ingestion of ketone bodies (KB). In patients suffering from mild cognitive impairment, early Alzheimer’s disease, or Parkinson’s disease, and more recently, autistic spectrum disorders, researchers have demonstrated some success using this method in ameliorating symptoms. Nutritional ketosis has also been shown to reduce symptoms in some patients with schizophrenia (SZ), bipolar disorder (BPD), and major depressive disorder (MDD). In recent years, MDD, BPD, and SZ have been referred to as neuroprogressive disorders as inflammation in the peripheral and brain regions, nitroxidative stress, and disrupted tryptophan metabolism are all common factors contributing to progressive neuroanatomical and cognitive decline associated with each illness. There is a deficit in glutamatergic neurotransmission, neurotropin activity, and a higher level of cortisone production coupled with impaired glucocorticoid receptor function.
All in all a fascinating aspect of our role as advanced practice nurses is one of looking at the whole patient and the effects of their lifestyle choices and it is important to remember diet as well as recreational or self medicating illicit drug use in our assessment.
Reference
Morris G, Puri BK, Carvalho A, Maes M, Berk M, Ruusunen A, Olive L. Induced Ketosis as a Treatment for Neuroprogressive Disorders: Food for Thought? Int J Neuropsychopharmacol. 2020 Jun 24;23(6):366-384. doi: 10.1093/ijnp/pyaa008. PMID: 32034911; PMCID: PMC7311648.
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Collapse SubdiscussionRaechel Taylor Lilia,
I enjoyed reading your post. Many of the mental health patients that are seen in my facility are unable to obtain an IV access to administer any IV medications. If so, I’m sure we would use Ketamine more frequently. The first line of antipsychotic or antianxiety medication we administer is Ativan and Haldol also. Recently due to a severe adverse reaction to Haldol many physicians are changing to use Ativan and Benadryl. A 45yr-old male came in with severe violent outbreak and we administered Ativan and Haldol IM. The pt had a seizure less than an hour after administering the medication. Toxicities are the exaggerated symptoms of known pharmacologic effects and adverse drug reactions (Rahman, 2022). Later we found out this patient had been at another hospital and was given Haldol and possible toxicity occurred. Haloperidol is the first of the butyrophenone series of major tranquilizers, and it is also the most widely used (Pathan, etc., 2023).
References
Rahman S, Marwaha R. Haloperidol. [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560892/Links to an external site.
Pathan AS, Jain PG, Kumawat VS, Katolkar UN, Surana SJ. Neuroprotective Effects of P-Coumaric Acid on Haloperidol-Induced Catalepsy Through Ameliorating Oxidative Stress and Brain Dopamine Level. Journal of Pharmacology and Pharmacotherapeutics. 2023;0(0). doi:10.1177/0976500X221150837
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Collapse SubdiscussionYesnely Fernandez Perez Hello Lilia,
Drug-disease interactions are of critical importance because of the potential for sentinel events that might lead to negative patient outcomes (Li et al., 2019). The caregiver must monitor the patient’s degree of awareness after administering medicines like Ativan, Haldol, and ketamine. Drugs like Ativan (a benzodiazepine) calm the nervous system by interacting with GABA receptors in the brain’s emotional centers (Zaki et al., 2022). According to the assessment of the treatment plan, the patient was a young girl in perfect health. Patient education regarding bipolar disease, its treatment, and any potential adverse effects of drugs, is crucial. The medication schedule and any adverse effects should be reviewed with the patient and their loved ones. In this scenario, it is important to check the patient’s calcium and TSH levels. Long-term lithium usage is associated with a rise in the concentration of lithium in the urine, which may lead to renal problems.
References
Li, Y., Meng, Q., Yang, M., Liu, D., Hou, X., Tang, L., Wang, X., Lyu, Y., Chen, X., Liu, K., Yu, A.-M., Zuo, Z., & Bi, H. (2019). Current trends in drug metabolism and pharmacokinetics. Acta Pharmaceutica Sinica B, 9(6), 1113–1144. https://doi.org/10.1016/j.apsb.2019.10.001Links to an external site.
Zaki, H. A., Shaban, E., Bashir, K., Iftikhar, H., Zahran, A., Salem, E.-D. M., & Elmoheen, A. (2022). A comparative analysis between ketamine versus combination of midazolam and haloperidol for rapid safe control of agitated patients in emergency department: A systematic review. Cureus. https://doi.org/10.7759/cureus.26162Links to an external site.
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Collapse SubdiscussionBillie Lanham Discussion Response 2
Hello Lilia! I enjoyed your post! You have provided an excellent assessment of the patient’s pharmacokinetics and pharmacodynamics and outlined an appropriate care plan. Some additional patient factors that could have interfered with the pharmacokinetic and pharmacodynamic processes of the patient you described include her age, gender, weight, body composition, and any underlying medical conditions. Age could affect how the patient processes medications, as the body’s metabolism is slower in older individuals. In this case, the metabolism of drugs could have been higher due to the patient’s young age (20 years). Gender could also have an effect on how the patient responded to medications due to hormonal factors. According to Zucker and Prendergast (2020), women tend to process drugs much slower than men. Weight and body composition could also have had an effect on how the patient responded to the drugs. A person’s fat percentage can affect how much of a drug is absorbed into the body and its distribution.
If the patient has a comorbid condition, such as renal failure, heart failure, or liver failure, the personalized care plan should consider the possible drug interactions and changes in pharmacokinetics and pharmacodynamics. For example, if the patient has renal failure, the elimination of drugs can be affected, and the dose of the drugs should be adjusted to avoid drug toxicity and maximize the therapeutic effect (Papotti et al., 2021). The patient’s age can also affect the pharmacokinetic and pharmacodynamic processes. In the case of a younger patient, the absorption, distribution, metabolism, and excretion of drugs can be different, and the dose of the drugs should be adjusted accordingly. For example, in the case of Ativan and Haldol, a younger patient may require a lower dose due to their increased metabolic rate. In addition, if the patient is elderly, the pharmacokinetic and pharmacodynamic processes may be altered due to changes in the renal, hepatic, and cardiovascular functions (Drenth‐van Maanen et al., 2019). In this case, the dose of the drugs should be adjusted to account for the age-related changes.
References
Drenth‐van Maanen, A. C., Wilting, I., & Jansen, P. A. F. (2019). 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.14094Links to an external site.
Papotti, B., Marchi, C., Adorni, M. P., & Potì, F. (2021). Drug-drug interactions in polypharmacy patients: The impact of renal impairment. Current Research in Pharmacology and Drug Discovery, 2, 100020. https://doi.org/10.1016/j.crphar.2021.100020Links to an external site.
Zucker, I., & Prendergast, B. J. (2020). Sex differences in pharmacokinetics predict adverse drug reactions in women. Biology of Sex Differences, 11(1). https://doi.org/10.1186/s13293-020-00308-5Links to an external site.
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Collapse SubdiscussionMindy Brooke Inglis Lilia, I really enjoyed reading your post. It brought me back to my old ER days. Pharmacokinetics is so very important, especially when dealing with a drug such as lithium. If you really think about it, lithium is a metal. How much metal is acceptable in your body before it starts becoming toxic? How lithium actually works in the body is a bit of a mystery, but one thing is for certain, that we know it does work, especially for mood stabilization(Lithium, 2020). Lithium toxicity can be quite serious and even fatal if signs and symptoms are ignored. Lithium toxicity can include symptoms consisting of lethargy, weakness, confusion, tremors, vomiting, and slurred speech. It is imperative as a provider we stress the importance of having the patient’s serum lithium level checked often(Hedya et al., 2022).
Lithium. (2020). NHS. https://www.nhs.uk/medicines/lithium/Links to an external site.
Shireen A. Hedya; Akshay Avula; Henry D. Swoboda. (2022). Lithium Toxicity. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK499992/#:~:text=Lithium%20toxicity%20signs%20are%20obvious,%2Dthreatening%20condition%5B31%5D.
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Collapse SubdiscussionYesnely Fernandez Perez Pharmacokinetics And Pharmacodynamics
An older man was just brought to the facility; he suffers from both schizophrenia and hypertension. This 62-year-old patient had just checked in. The decision to provide medical care has been made so that individuals might get well from their many illnesses. The patient’s condition was so dire that the compound treatment had to be administered intramuscularly on a regular basis for quite some time before the diagnosis was made. The patient’s lithium level was extraordinarily high, as shown by a blood test, prompting several questions concerning the patient’s health. The patient showed increasing confusion during the operation, in addition to having quick and unexpected extrapyramidal adverse effects.
Because to the various factors that contribute to the aging process, the parameters of pharmacokinetic methods may change with time. This normal process slows the supplement’s absorption and distribution throughout the body and also modifies the supplement’s metabolic activity in the liver. This results in less drug being eliminated by the kidneys. McKearney and Coleman (2020) found that the pharmacokinetics of the elderly were significantly affected by a decrease in renal excretion. Hence, it is believed that the pharmacokinetics of the elderly are drastically different. Due to a reduced total number of nephrons, the filtration threshold is lower in the elderly. This is because life expectancy increases with age (Rosenthal & Burchum, 2021). Medications that undergo significant first-pass digestion, as benzodiazepines, benefit most from decreased hepatic digestion because of the resulting increased drug clearance
Thus, a specific treatment plan must be implemented as part of a care management strategy to reduce the patient’s lithium level as quickly as is clinically practicable. Thus, I would recommend gradually decreasing the patient’s lithium dosage while keeping a close eye on them for any indications of poisoning. I’ll also be monitoring the current lithium concentration. Those who are found to be taking lithium without an explanation should not be administered Lisinopril. To me, it was imperative that this be avoided at all costs. Individuals who are unable to use ACE inhibitors due to contraindications may benefit from ARBs as a second-line treatment (Ward & Citrome, 2018). Due to the unpredictable and stressful nature of patient care, I will switch to a less sedative prescription whenever the PRN medication is not being used.
References
McKearney, K., & Coleman, J. J. (2020). Prescribing medicines for elderly patients. Medicine, 48(7), 463–467. https://doi;org.ezp.waldenulibrary.org/10.1016/j.mpmed.2020.04.0Links to an external site.
Rosenthal, L.D., & Rosenjack Burchum, J. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Saunders.
Ward, K. M., & Citrome, L. (2018). Antipsychotic-Related Movement Disorders: Drug-Induced Parkinsonism vs. Tardive Dyskinesia—Key Differences in Pathophysiology and Clinical Management. Neurology & Therapy, 7(2), 233–248. https://doiorg.ezp.waldenulibrary.org/10.1007/s40120-0180105Links to an external site.
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Collapse SubdiscussionTarah Marie Coronado Thank you for your post Yesnely. It was very informative. As we age, our body changes and our kidneys and liver may start to show signs of impairment. Many drugs are either metabolized or excreted by one of these routes. Dose adjustments will need to be made if impairment of the kidneys or liver is present. If doses are not adjusted the concentrations of the drugs in the body will be effected and can cause adverse reactions. Lithium does have many possible adverse reactions and does have the potential to be toxic. Lithium can be affected by our salt and water intake. What is the normal Lithium level range?
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Collapse SubdiscussionLilia Cristina Becerra-Hatcher Thank you, Yesnely, for sharing your experience. In treating schizophrenia, an antipsychotic medication, and a mood stabilizer such as lithium is added to relieve mood fluctuation and aggression, according to the patient’s case. Studies showed that using mood stabilizers with an antipsychotic decreased hospitalization that are due to psychosis (Puranen et al., 2022).
As you mentioned in your patient’s case, renal function reduces in adults, and it is essential to prevent lithium toxicity by decreasing the dose even though a patient has been on it for long-term use. Medical conditions and the use of ACEIs, psychotropics, NSAIDs, and diuretics can result in drug interactions in adult patients. Concentrations of lithium levels >0.8 mmol/L create harmful effects in patients aged 75 years and older (Sun et al., 2017).
It is essential for a provider to perform a complete health assessment and involve other specialty services such as a psychiatrist, hospitalist, and other interdisciplinary services once the patient is admitted to the hospital to provide the appropriate treatment that will lead to positive patient outcome.
References
Puranen, A., Koponen, M., Lähteenvuo, M., Tanskanen, A., Tiihonen, J., & Taipale, H. (2022). Real‐world effectiveness of mood stabilizer use in schizophrenia. Acta Psychiatrica Scandinavica, 147(3), 257–266. https://doi.org/10.1111/acps.13498Links to an external site.
Sun, M., Herrmann, N., & Shulman, K. I. (2017). Lithium toxicity in older adults: A systematic review of case reports. Clinical Drug Investigation, 38(3), 201–209. https://doi.org/10.1007/s40261-017-0598-9Links to an external site.
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Collapse SubdiscussionNicole Lohaus Hi Yesnely,
Your scenario reminds me of when I worked as a mental health technician. Although it was not very often, some of the patients would need their lithium levels monitored. It probably was not until I was in my accelerated nursing program and learning about minimum effective concentration, toxic concentration, and therapeutic range that I fully understood the reason behind and importance of monitoring some drugs more closely than others. Lithium is definitely one of those medications as you described.
Lithium has been around for decades and has been studied pretty significantly to gain a better understanding for how it works. Due to concerns with toxicity, it did not get approved for use until 1970 in the United States. As a result, it is mandatory to monitor lithium levels (Rosenthal & Burchum, 2021). Lithium is useful not only for treating bipolar disorder but also for preventing suicide, unipolar depression episodes, mood swings, and perhaps dementia (Rosenthal & Burchum, 2021; Rybakowski, 2020). It is important to note that full therapeutic benefits are often not realized until after two to three weeks of treatment (Rosenthal & Burchum, 2021).
In addition to the patient factors you mentioned, there is another I identified that may have or could interfere with the pharmacokinetic and pharmacodynamic processes of this patient and would be important to keep in mind. Lab results, for example, although not provided, would be important to check. Why? As noted by Rosenthal & Burchum (2021), the process in which the kidneys excrete lithium is influenced by blood levels of sodium. When sodium levels are low, the kidney reduces the amount of lithium it excretes in an effort to make up for the low sodium. As a result, it would be necessary to check the patient’s sodium level to ensure it is within normal range. If it is low, this could be contributing to the toxic levels of lithium so it would be important to take steps to increase his sodium. If levels are within normal range, it would be important to ensure the patient continues to consume adequate amounts of sodium to prevent his levels from dropping. Other labs to check and diagnostic tests to run include electrocardiogram, basic metabolic panel, complete blood count, and toxicology (Rosenthal & Burchum, 2021; Rybakowski, 2020).
Another potential factor that could have an impact is polypharmacy. You briefly touched on this when discussing how ACE inhibitors should not be prescribed or taken when undergoing lithium therapy. According to MacLeod-Glover & Chuang (2020), ACEs, ARBs, beta-blockers, COX-2 inhibitors, NSAIDs, methyldopa, phenytoin, tetracycline, and thiazide diuretics all increase serum lithium concentration. Medications that tend to decrease serum lithium concentration when taken concurrently include aminophylline, theophylline, topiramate, caffeine, nifedipine, osmotic diuretics, sodium bicarbonate, and bulk-forming laxatives. Medications that could have pharmacodynamic impacts include antidepressants, antipsychotics, carbamazepine, diltiazem, verapamil, serotonin receptor agonists, and iodine or iodide salts. For this reason, it would be important to conduct a thorough medication reconciliation upon admission as well as when developing your personalized care plan.
Speaking of personalized care plan for this patient, in addition to reviewing his medications due to the number of interactions, another major concern would be the development of or exacerbation of renal impairment or failure. If renal impairment or failure were noted, it would be important to determine whether or not it was the result of lithium toxicity as it might help guide your care plan for this patient. If lithium levels were dangerously high, it might warrant looking into whether hemodialysis would be appropriate for this patient (Liu et al., 2022. It would also be important to weigh the risks and benefits of continuing the lithium based on the patient’s diagnosis and response to the medication. While discontinuing lithium can lead to increased relapse and suicide risk, continuing lithium could lead to further kidney damage and cardiac issues. Discussing the risks and benefits with exact certainty is not realistic but it would be a necessary conversation to have with the patient while taking into consideration his preferences. If the kidney damage were severe enough, the patient could be referred to a nephrologist to manage it and any associated complications (Kerckhoffs et al., 2018).
References
Kerckhoffs, A. P., Hartong, E. G., & Grootens, K. P. (2018). The perspectives of patients with
lithium-induced end-stage renal disease. International Journal of Bipolar Disorders, 6(1).
https://doi.org/10.1186/s40345-018-0121-0
Liu, Y.-H., Tsai, K.-F., Hsu, P.-C., Hsieh, M.-H., Fu, J.-F., Wang, I.-K., Liu, S.-H., Weng, C.-H.,
Huang, W.-H., Hsu, C.-W., & Yen, T.-H. (2022). Hemodialysis treatment for patients with
lithium poisoning. International Journal of Environmental Research and Public Health,
19(16), 10044. https://doi.org/10.3390/ijerph191610044
MacLeod-Glover, N., & Chuang, R. (2020). Chronic lithium toxicity. Canadian Family
Physician, 66(4), 258–261.
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice
nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Rybakowski, J. K. (2020). Lithium – past, present, future. International Journal of Psychiatry in
Clinical Practice, 24(4), 330–340. https://doi.org/10.1080/13651501.2020.1775855
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Collapse SubdiscussionTyriss Gordon Hello Yesnely,
Thank you so much for your post, I definitely learned a lot from what you discussed. As practitioners, we will need to be familiar with drug interactions and contraindications, serious reactions can occur from administering medications together that are incompatible. Of course, we are not computers, we cannot remember every single interaction, however when discussing adverse effects, we should concentrate on the adverse effects that are most common rather than putting unnecessary attention on side effects that rarely occur (Rosenthal & Burchum, 2021). Lithium is a mood stabilizer and requires close observation due to risks of toxicity. Dosing and monitoring are necessary, excessive concentrations exceeding 1.5 mEq/L can lead to death which is why it is extremely important to monitor lithium levels, especially during maintenance therapy (Rosenthal & Burchum, 2021). The aging process naturally causes physiologic changes to the renal system; nephrons decrease in numbers, and renal blood flow declines which can lead to alterations in reabsorption and elimination (McCance & Huether, 2019). Considering these changes, drugs have the potential to accumulate in the plasma, causing toxic reactions, Lithium is an example of this (McCance & Huether, 2019). All factors regarding metabolism and excretion of this drug are extremely important to consider, especially since Lithium is excreted primarily through kidneys. Great post Yesnely!
References
McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The Biologic Basis for Disease in Adults and Children (8th ed.). St. Louis, MO: Mosby/Elsevier
Rosenthal, L. D. & Burchum, J. R. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice
Nurses and Physician Assistants (2nd ed.) St. Louis, MO: Elsevier
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Collapse SubdiscussionRahel D Woyessa Hi Yesney, I enjoy reading your post. In addition to less drug excretion by the kidney due to old age, there are factors that can increase lithium levels: dehydration, low-sodium diet, fever, medications like thiazide diuretics, NSAIDs, ACE inhibitors, COX-2 inhibitors, and metronidazole (Osser, 2022). It is very important to discuss with patients about the factors that affect lithium levels so that patients notify the providers and to have lithium levels drawn when necessary. Lithium doses need to be adjusted for temporary while waiting for levels. According to Chokhawala et al., Lithium is not recommended for patients with heart disease. Lithium causes reversible T wave changes. A cardiology consult is important for patients with unexplained palpitations and syncope. Lithium is not recommended for pregnant women due to a risk for birth defects. Lithium also is not recommended for children under 12 (2022).
References
Chokhawala K, Lee S, Saadabadi A. Lithium. [Updated 2022 Jul 11]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519062/
Osser, DN. (2022). Lithium Levels – What increases and decreases them.
Psychiatric Times, 39(4).
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Collapse SubdiscussionTrista Shontae Ashburn Identified Patient
On my unit, we had a 66-year-old male who was admitted with schizoaffective disorder bipolar type. Upon admission, this patient was ambulatory and independent with all his activities of daily living. On day six of this patient’s admission, I was the charge nurse; during rounds, I noticed this patient had decompensated. He was weak and unsteady, requiring assistance. The assigned nurse reported that the patient had been that way the night prior but was getting worse. Patient’s vitals were BP-92/63, HR-132, R-16, o2 95% room air, and T-98.1. Review of the patient’s admission labs, his BUN, creatinine, and EFR were all within normal limits. The labs this patient had done the day prior showed a significant increase in his BUN and creatinine levels.
The patient’s condition continued to worsen vital signs were 91/56, HR-90, R-20, o2 87% room air, and T-98.5. The medical provider ordered us to send this patient to the local emergency department (ED) for evaluation. The patient was admitted for acute kidney injury (AKI) and a creatinine kinase level greater than 3,000. Upon review of the chart, the patient’s Seroquel had been increased from 200 mg at bedtime to 300 mg at bedtime on day three of admission. This had been the only change that had occurred with the patient’s treatment, it was determined this was the cause of the AKI.
Factors Influencing Pharmacokinetics and Pharmacodynamics
One factor influencing pharmacokinetics is excretion, excretion of medications primarily takes place through the kidneys (Rosenthal & Burchum, 2021). With Seroquel, 73% is excreted through urine (Mauri et al., 2018). Another factor affecting this patient was his age. It is recommended to titrate elderly patients slowly with Seroquel (Mauri et al., 2018). Seroquel does not indicate any clinical relevance with gender and pharmacokinetics (Mauri et al., 2018). Dopamine is noted to be a cause of psychosis; Seroquel is a second-generation antipsychotic that is classified as a dopamine blocker (Limandri, 2019).
Plan of Care
The first step in treating this patient is to stop the medication and prescribe another antipsychotic until the patient’s AKI resolves. Encourage fluid consumption, or consider IV fluids to aid in the treatment of AKI. Closely monitoring lab levels and focusing on the CMP to monitor kidney function is essential. If this patient must resume Seroquel to ensure safety and avoid the patient developing AKI again, the medication should be titrated slowly. If resumption of the drug was to occur, there must be frequent monitoring labs often and providing proper input and output. Patient safety is of the utmost importance.
References
Limandri, B. J. (2019). Clinical Use of Dopamine Modulators as Third-Generation Antipsychotic Agents. Journal of Psychosocial Nursing and Mental Health Services, 57(2), 7–11. https://doi.org/10.3928/02793695-20190116-02Links to an external site.
Mauri, M. C., Paletta, S., Di Pace, C., Reggiori, A., Cirnigliaro, G., Valli, I., & Altamura, A. C. (2018). Clinical Pharmacokinetics of Atypical Antipsychotics: An Update. Clinical Pharmacokinetics, 57(12), 1493–1528. https://doi.org/10.1007/s40262-018-0664-3Links to an external site.
Rosenthal, L., & Burchum, J. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Saunders.
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Collapse SubdiscussionRaechel Taylor Trista,
This is a great post. The 66yr-old male patient may have had some or many underlying medical conditions. The medical history of patients plays, in my opinion the most important factor in pharmacokinetics. Many elderly patients are on Seroquel for depressive and anxiety disorder along with anti-hypertensive medication. A physician explained to me the reason for the continuous infusion of IV fluids due to mechanism of action of medications and the hepatic system. Quetiapine has uses in several non-FDA-approved indications, such as generalized anxiety disorder (Maan, etc., 2022).
References
Maan JS, Ershadi M, Khan I, et al. Quetiapine. [Updated 2022 Sep 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459145/
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Collapse SubdiscussionAmy Sprayberry Pharmacokinetics and Pharmacodynamics
Discussion Response
Trista,
Thank you for the post. You stated that an increase in the dose of seroquel caused deterioration in the patient’s condition and acute kidney injury. According to Ortega-Ruiz et al., 2022), quetiapine causes both metabolic and neurological ADRDs. Somnolence is the major neurologic ADR, while extrapyramidal symptoms include tardive dyskinesia, akathisia, and dystonia. Metabolic ARDS include elevated total cholesterol, decreased hemoglobin, and elevated serum triglyceride levels
I would like to expound on quetiapine and the recommended dosage. Quetiapine is a second-generation antipsychotic medication used for treating schizophrenia and other mental illness such as bipolar disorder and depression. Ortega-Ruiz et al. (2022) posit that For bipolar disorder, quetiapine is specifically used in treating major depressive symptoms, moderate to severe manic episodes and for preventing the recurrence of depressive or manic episodes in type 2 bipolar disorder patients who have in the past responded to quetiapine treatment.
Quetiapine is administered as a suspension, solution, or in tablets with different doses depending on disease severity and patient demographics. The dose is titrated at the initiation of treatment to prevent the risk of adverse drug reactions (ADRS). 50mg is the initial dose, and it is increased over the subsequent days to 300mg, and then changed according to the tolerability of the patients and clinical response. The effective dose varies between 300 to 800 mg per day(Ortega-Ruiz et al., 2022).
My colleague has stated that excretion and age are factors influencing pharmacokinetics and pharmacodynamics of seroquel. I would like to expound on how seroquel is metabolized and excreted. According to Ortega-Ruiz et al. (2022), extensive metabolism of quetiapine occurs in the liver by the cytochrome P450 (CYP) system, presenting fewer than 5 percent of the original drug in the excretions, majorly in urine (around 73 percent) and feces (21percent).
I would like to emphasize that elderly patients are at a higher risk of adverse drug events as a result of age-related pharmacokinetic and pharmacodynamic changes, frailty, polypharmacy, and underlying comorbidities. In frail older patients, quetiapine has the likelihood of causing serious adverse drug events even in low doses (Muller et al., 2020).
References
Muller, L., Noseda, R., Bertoli, R., Bissig, M., & Ceschi, A. (2020). Off-label use of quetiapine in nursing homes: Does medical specialty of prescribing physicians play a role? British Journal of Clinical Pharmacology, 86(7), 1444-1445. HYPERLINK “https://doi.org/10.1111/bcp.14232” https://doi.org/10.1111/bcp.14232
Ortega-Ruiz, M., Soria-Chacartegui, P., Villapolas-Garcia, G., Abad-Santos, F., & Zubiaur, P. (2022). The Pharmacogenetics of Treatment with Quetiapine. Future Phamacology, 2(3), 276-286. HYPERLINK “https://doi.org/10.3390/futurepharmacol2030018” https://doi.org/10.3390/futurepharmacol2030018
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Collapse SubdiscussionEmily Ann Bennett Trista, this was a very informative post. Working in dialysis, I often see many patients with a similar story to this who develop AKIs. As you stated, the Seroquel must be discontinued immediately as it is too harsh on the patients already unstable kidney, which can rapidly develop from AKI to CKD. Patients who develop an AKI directly from a medication miscalculation are at a high risk for developing chronic kidney disease, and transgressing to end stage renal disease (Lea-Henry et al, 2018). Monitoring labs as well as monitoring fluid as closely as possible would be key for preventing the AKI to progress. Patient’s oftentimes do not realize how a small dosage change in medication can affect their kidney function so greatly, which is why it is important to double check dosages and educate the patient on symptoms they should be looking out for (Roberts et al, 2018).
Lea-Henry, T. N., Carland, J. E., Stocker, S. L., Sevastos, J., & Roberts, D. M. (2018). Clinical pharmacokinetics in kidney disease: fundamental principles. Clinical journal of the American society of nephrology, 13(7), 1085-1095.
Roberts, D. M., Sevastos, J., Carland, J. E., Stocker, S. L., & Lea-Henry, T. N. (2018). Clinical pharmacokinetics in kidney disease: application to rational design of dosing regimens. Clinical Journal of the American Society of Nephrology, 13(8), 1254-1263.
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Collapse SubdiscussionTrista Shontae Ashburn Thank you, Emily, I do agree that education is very important when adjusting medication, especially on what signs and symptoms to monitor for.
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Collapse SubdiscussionNicole Lohaus Nurses play a critical role in healthcare. They make up the largest segment of the healthcare workforce and are arguably the backbone of the industry. Although they work in collaboration with physicians, pharmacists, and other healthcare professionals, they are the main primary providers of patient care (Salmond & Macdonald, 2021). As a result, it is important for them to have a solid understanding of disease processes (pathophysiology) as well as the impact medications have on patients. Pharmacology is the study of medications/drugs and how they affect living things. Two branches of pharmacology include pharmacodynamics and pharmacokinetics. Pharmacodynamics studies the effects of drugs on the body and their mechanism of action, whereas pharmacokinetics studies what the body does to drugs or how drugs are absorbed, distributed, metabolized, and excreted by the body. Knowing the basics of pharmacology enables nurses to administer medications safely, keep track of medication effects, teach patients, and act morally and legally within pharmacological constraints (Rosenthal & Burchum, 2021). Within their scope of practice, advanced nurse practitioners (APRN) are able to prescribe medications (Sabatino et al., 2017). For this reason, it is absolutely imperative they have a solid understanding of pharmacotherapeutic processes and are always working to ensure they are adhering to prescribing parameters when treating their patients (Rosenthal & Burchum, 2021).
Patient case example
Ensuring patients receive the appropriate medications and the correct dosage in order to increase effectiveness and reduce toxicity in the body is one of the main objectives of any healthcare professional who administers medications. Throughout my experience working inpatient and in the emergency room, I have administered many medications and encountered a number of patient cases. One of the facilities I work for offers emergency room services as well as an inpatient detox program. Patients are admitted voluntarily to the detox program and typically stay three to five days depending on the substance they are detoxing from and the severity of their withdrawal symptoms. Given these patients struggle with addiction, the physicians and APRNs are very careful about what they prescribe. The order set for scheduled and PRN medications is the generally the same for all patients but are modified on a case-by-case basis given the patient’s health history and any allergies. Two of the main medications administered to these patients are phenobarbital and gabapentin. One patient in particular who comes to mind is a 41-year-old male who was admitted for detox from polysubstance abuse. He reported having been to intensive outpatient treatment a year ago for alcohol, benzodiazepines, and opiates. He was subsequently put on suboxone and then switched to methadone. He reported taking 140mg of Methadone daily and Clonazepam 1mg five times per day. He also reported buying benzodiazepines off the street. Health history included hypertension, post-traumatic stress disorder (PTSD), major depressive disorder (MDD), and generalized anxiety disorder (GAD). Known medications included metoprolol 40mg twice daily, lisinopril 20mg once daily, and citalopram 40mg once daily. Patient was allergic to sulfa.
This patient spent a few days in another facility after he crashed his car a few days prior while intoxicated. After being discharged from there he was transferred to our facility. Upon arrival, he was very sedated so loading doses of gabapentin 300mg and phenobarbital 250mg were held until he was more awake and alert. During my shift he woke up more and reported withdrawal symptoms which included nausea, headache, anxiety, tremors, and hallucinations. At this time loading doses of phenobarbital and gabapentin were administered. Phenobarbital was then scheduled to be administered every four hours going forward until discharge. There was also a PRN order for 100mg phenobarbital every hour for three hours. At some point the patient was told how often he could get the PRN order of phenobarbital so he began setting alarms on his phone and would use his call light to notify nursing staff. This went on for a few days before the APRN who helps manage these patients went in and told the patient if he is setting alarms for PRN medications, he does not need them.
Pharmacodynamics and pharmacokinetics
Although methadone and suboxone are opioids and phenobarbital is a barbiturate, each class of drug binds to and acts on the GABA receptor-chloride channel complex thus creating similar CNS effects. However, the dosing of phenobarbital required to suppress seizures produces only moderate CNS impairment (Rosenthal & Burchum, 2021). Given this patient was in detox due to his addiction to benzodiazepines and opiates, it is possible his tolerance to these, and subsequently similar medications, such as barbiturates, was higher. In fact, cross-tolerance has been noted among barbiturates, benzodiazepines, alcohol, and general anesthetics (Rosenthal & Burchum, 2021). It is hard to say with certainty whether this patient truly was not getting relief from the ordered dose of phenobarbital due to his potential increased tolerance or if he simply liked the way it made him feel. If increased tolerance was a contributing factor to him not getting relief, my initial thought after reading more about phenobarbital was since it has a half-life of four days, his symptoms should have subsided to the point of not needing a dose every two hours. However, Rosenthal & Burchum (2021) noted how it can take two to three weeks before serum levels reach therapeutic ranges.
The other primary medication given was gabapentin. Both phenobarbital and gabapentin are used to help prevent seizures. Although phenobarbital is not used as often anymore since newer, safer drugs have come to market, gabapentin remains relatively safe and well tolerated. It has several off label uses such as treating restless leg syndrome (RLS). This is also helpful for patients who are detoxing as they often experience this symptom. Not only can gabapentin be used to treat multiple issues, it also does not affect the metabolism of other drugs, nor does it activate or inhibit enzymes responsible for drug metabolism. Although not common, gabapentin can increase the risk of depression, suicidal ideation (SI), and changes in mood/behavior (Rosenthal & Burchum, 2021). Due to the patient’s history of MDD and GAD, it was important to frequently assess the patient while taking gabapentin during his admission.
Personalized care plan
The personalized care plan for this patient would include modifications to PRN orders for phenobarbital to include a CIWA metric that would outline dosing based off of the score, similar to how insulin is given on a sliding scale based off blood glucose reading. Although the phenobarbital dose was relatively low, it might have been beneficial to utilize other PRN orders based on symptoms the patient was experiencing such as Zofran for nausea, acetaminophen or Toradol for pain, Benadryl or hydroxyzine for anxiety, and trazadone for insomnia. There does not appear to be any significant interactions between the patient’s home medications and the ones being administered for withdrawal symptoms. However, the patient would be educated on various signs and symptoms to watch for and report to staff if he experienced them. Additionally, the patient would be educated on any medications prescribed to him upon discharge. For example, patients are generally prescribed a tapering dose of gabapentin. It would be important to reiterate the low but inherent risk of depression, SI, and changes in mood/behavior while on this medication and advise seeking medical attention if the patient experiences any of them. Arrangements would be made for patient to discharge to a residential sober living facility for individuals recovering from issues with addiction. While detoxing is an important step, it is easy for individuals to fall back into old patterns if they simply return home. To aid in this process, sober living facilities help individuals transition from rehab to independent living.
References
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice
nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Sabatino, J. A., Pruchnicki, M. C., Sevin, A. M., Barker, E., Green, C. G., & Porter, K. (2017).
Improving prescribing practices. Journal of the American Association of Nurse
Practitioners, 29(5), 248–254. https://doi.org/10.1002/2327-6924.12446
Salmond, S. W., & Macdonald, M. (2021). Invest in nursing: The backbone of health care
systems. JBI Evidence Synthesis, 19(4), 741–744. https://doi.org/10.11124/jbies-21-00089
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Collapse SubdiscussionKenneth Elad Fonguck Approximately a year ago, one of my patient’s whose tooth had to be extracted. Apparently, the tooth had developed an infection and the only remedy was immediate extraction. Tooth extraction is not a painful process per say. However, the real pain is felt couple of hours later. This patient was prescribed amoxicillin and Ibuprofen 800 mg, of which that later could be taken prn 4 hours.
Pharmacokinetics constitutes the description of absorption, distribution, metabolism, and excretion of drugs (Lykkesfeldt & Tveden-Nyborg, 2019). For any medication to reach its full potential, otherwise attaining its desired effect, all processes of pharmacokinetics including absorption, distribution, metabolism, and excretion must be reached. Since humans not the same, the way pharmacokinetics processes happen in one person would not necessarily be the same for the other. My patient took his pain med just ones and that was it. About 30 minutes later, his pain went from 9 to a 3, very bearable. Furthermore, complex biological processes including fluctuations in pH, gastric and intestinal movement, rate of blood flow, and bile salt secretion can impact the orally administered drug’s rate of absorption (Cheng & Wong., 2020). Blood flow, pH fluctuations, gastric and intestinal movement etc. in my patient’s system just proved to function differently from someone else who might feel pain continuously even after being administered the same pain medication. Ibuprofen is one of the most effective and widely used NSAID in treatment of dental pain. Dental practitioners have relied on ibuprofen and other NSAIDs to manage acute and chronic orofacial pain (Krasniqi et al., 2019).
Pharmacodynamics explains the effects a medication has on the body. Overtime, Ibuprofen and other NSAIDS have proven to offer some much-needed pain relief for dental issues, most especially to my patient as described by him. On a personal note, I would advise my patient not to dwell so much on medications to attain a satisfied pain relief level. There are a lot of non-pharmacological pain relief techniques that he can turn to. Non-pharmacological pain therapy refers to interventions that do not involve the use of medications to treat pain. The goals of non-pharmacological interventions are to decrease fear, distress and anxiety, and to reduce pain and provide patients with a sense of control (El Geziry et al., 2018). Examples of non-pharmacological pain relief techniques include acupuncture, meditation, massage, positioning, hot and cold etc. Except these techniques do not work, then can a resort to medications. In addition, my patient will be advised to complete his dose of the antibiotic due to the infection in the tooth.
References
Cheng, L., & Wong, H. (2020). Food effects on oral drug absorption: application of physiologically-based pharmacokinetic modeling as a predictive tool. Pharmaceutics, 12(7), 672.
El Geziry, A., Toble, Y., Al Kadhi, F., Pervaiz, M., & Al Nobani, M. (2018). Non-pharmacological pain management. Pain management in special circumstances, 1-14.
Krasniqi, D., Thaqi, E., Berisha, D., Bibaj, G., & Kryeziu, F. (2019). The use of Ibuprofen and our knowledge about it.
Lykkesfeldt, J., & Tveden-Nyborg, P. (2019). The pharmacokinetics of vitamin C. Nutrients, 11(10), 2412.
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Collapse SubdiscussionNicole Lohaus Hi Kenneth,
I enjoyed reading your post because it took me back to my days when I worked at a pediatric dental office – back when I thought I wanted to become a dentist! As you can see, that is clearly not the path I took. Anyway, I would be curious to know the age of this patient as that may have contributed to the development of his tooth infection. According to Coll et al. (2019), oral infections and associated complications are particularly common in the older population. In addition, they noted that chronic dental infections and manipulation of teeth (i.e. extractions) and supporting structures can increase the risk of infection or spread an existing infection into the patient’s bloodstream and affect other parts of the body.
A penicillin type antibiotic, amoxicillin has been in use since the 1970s and is one of the most commonly prescribed to treat various bacterial infections. When taken orally, it is absorbed quickly. Most amoxicillin is eliminated unaltered in the urine and thus has an impact on the kidneys. As a result, it would be important to take into consideration the patient’s kidney function prior to prescribing this medication (Huttner et al., 2020). Without knowing a little more detail about your patient, it is hard to know whether the benefits outweigh the risk but nonetheless, is an important consideration. I also imagine amoxicillin was playing a dual role in this case, first to treat the infected tooth but also to prevent the infection from potentially getting into the patient’s bloodstream and traveling to other parts of his body. Of particular concern would be if this patient had an artificial joint(s) or replacement heart valve(s) (Coll et al., 2019).
The other medication you discussed was ibuprofen which is a non-steroidal anti-inflammatory drug that has also been around for decades. Due to many unknowns about your patient, I thought I would share some general safety considerations when prescribing NSAIDs. According to Varrassi et al. (2020), the risk for upper gastrointestinal complications is associated with all NSAIDs, although it depends on dosage and duration of therapy and is generally lower with ibuprofen. Specific patient factors increase the risk of these effects to include H. pylori infection, severe illness, older than 65 years of age, alcohol or tobacco use, taking at least two NSAIDs simultaneously, history of peptic ulcers, and concomitant therapy of aspirin, anticoagulants, antiplatelets, SSRIs, and/or corticosteroids. Another consideration is cardiovascular safety. Prostaglandin production in the renal system is believed to be inhibited by NSAIDs, thus raising blood pressure and one’s risk of cardiovascular adverse events, especially in those with existing cardiac conditions. This leads into the next consideration which is renal safety. In addition to hypertension, prostaglandin synthesis inhibition could lead to acute kidney injury, peripheral edema, and weight gain. NSAIDs can interfere with hypertension medications so it would be important to assess what other medications this patient may be taking. Hepatic safe is the last consideration I am going to mention. Liver toxicity has been reported to be relatively low with ibuprofen and other NSAIDs (Varrassi et al., 2020).
When developing a patient’s care plan, understanding the safety considerations of medications such as ibuprofen and amoxicillin and obtaining a full health history from him/her are important as healthcare providers with prescribing privileges. Our oral cavities are a natural habitat for various bacteria, fungi, and viruses. Although not all microbes are dangerous, the extraction site is more susceptible to these microbes during the healing period. As a result, maintaining good oral hygiene is of particular importance during this time (Haque et al., 2018). While we would assume whoever extracted the tooth would have provided after-care instructions, it would not hurt to reiterate some of the important points such as maintaining good oral hygiene, finishing the full course of antibiotics prescribed, and avoid eating sharp and crunchy foods, drinking through a straw, and strenuous exercise for several days after. Your care plan for this patient also included offering non-pharmacological interventions as well which I appreciate. While pharmacological therapy absolutely has its place, there are other treatment options we should be educating our patients about when it comes to pain management as you mentioned.
References
Amatruda, J. G., Katz, R., Peralta, C. A., Estrella, M. M., Sarathy, H., Fried, L. F., Newman, A.
B., Parikh, C. R., Ix, J. H., Sarnak, M. J., Shlipak, M. G., & Health ABC Study (2021).
Association of Non-Steroidal Anti-Inflammatory Drugs with Kidney Health in Ambulatory
Older Adults. Journal of the American Geriatrics Society, 69(3), 726–734.
https://doi.org/10.1111/jgs.16961
Coll, P. P., Lindsay, A., Meng, J., Gopalakrishna, A., Raghavendra, S., Bysani, P., & O’Brien, D.
(2019). The prevention of infections in older adults: Oral Health. Journal of the American
Geriatrics Society, 68(2), 411–416. https://doi.org/10.1111/jgs.16154Links to an external site.
Haque, M., Sartelli, M., & Haque, S. (2019). Dental infection and resistance—global health
consequences. Dentistry Journal, 7(1), 22. https://doi.org/10.3390/dj7010022
Huttner, A., Bielicki, J., Clements, M. N., Frimodt-Møller, N., Muller, A. E., Paccaud, J.-P., &
Mouton, J. W. (2020). Oral amoxicillin and amoxicillin–clavulanic acid: Properties,
indications and usage. Clinical Microbiology and Infection, 26(7), 871–879.
https://doi.org/10.1016/j.cmi.2019.11.028
Varrassi, G., Pergolizzi, J. V., Dowling, P., & Paladini, A. (2019). Ibuprofen safety at the
Golden Anniversary: Are all NSAIDs the same? A narrative review. Advances in Therapy,
37(1), 61–82. https://doi.org/10.1007/s12325-019-01144-9
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Collapse SubdiscussionAmy Sprayberry Pharmacokinetics and Pharmacodynamics
Thank you, Kenneth, for your input on the subject matter. As you’ve discussed in your post, pharmacodynamics involves the study of a drug’s effect on an organism. The aspect of pharmacodynamics is achieved when drugs interact with other biological structures to produce change intended for the functioning of the target molecule. The interactions may include receptor binding, post-receptor binding, and chemical interactions (Marino, Jamal & Zito, 2022). In pharmacodynamics, there is great emphasis on dose-receptor relationship, where the concentration of the drug may tremendously impact outcomes. For example, a drug concentration for an elderly person may differ from that of a younger person. It is important that healthcare professionals consider pharmacodynamics aspects during drug dosing to establish the tolerance to the drug and diminishing effect.
I also support that healthcare professionals must consider pharmacokinetic processes when administering drugs. Different characteristics affect the pharmacokinetic processes, including age, gender, and current medication (Currie, 2018). In addition, pharmacodynamics is fundamental in helping to determine the effects of a particular drug in the body. It is also essential that providers establish the pathway across different age spectrums to provide the appropriate drug and dosage to achieve optimal outcomes. Therefore, I believe pharmacodynamics and pharmacokinetics must be considered when prescribing medications.
References
Currie, G. M. (2018). Pharmacology, part 2: Introduction to pharmacokinetics. Journal of Nuclear Medicine Technology, 46(3), 221–230. https://doi.org/10.2967/jnmt.117.199638
Marino M, Jamal Z, Zito PM. Pharmacodynamics. [Updated 2022 Jan 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507791/
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Collapse SubdiscussionAmy Sprayberry Pharmacokinetics And Pharmacodynamics
I identified a diabetic patient five years ago. The patient is a 58-year-old overweight man who leads an inactive lifestyle. He took oral anti-diabetic medications such as metformin and sulfonylureas to help regulate his blood glucose levels. He should make lifestyle adjustments, such as increasing his physical exercise and consuming a nutritious diet.
Factors that may have influenced the pharmacokinetic and pharmacodynamic processes of the patient include:
– Age: Because the patient is 58, his body may have trouble metabolizing and excreting the medications in the same manner that a younger individual would.
– Lifestyle: Sedentary living and obesity may impact the pharmacokinetics and pharmacodynamics of the patient’s medicines. Being overweight places additional pressure on the body when metabolizing and excreting medicines, which results in a slowed rate of metabolism and excretion (Mariadoss et al.,2022).
– Comorbidities: Comorbidities may also impact the pharmacokinetics and pharmacodynamics of the patient’s medicines. For example, kidney or liver failure can impair the body’s ability to process and excrete medications (Rai & Rozario,2023).
I would create a customized plan of care based on the patient’s background and determining factors, which would include:
– Monitoring blood glucose levels: This will help determine when the patient’s blood glucose levels are too high or too low and whether his medicines need to be changed.
– Lifestyle Changes: To help control his blood glucose levels, the patient should be urged to increase his physical exercise and make dietary adjustments.
– Medication Modifications: If the patient’s blood glucose levels are not sufficiently managed, his medication prescription may need to be modified to include a longer-acting medication or a mix of medications. (Rickert et al., 2023)
– Follow-up Care: The patient’s blood glucose levels should be monitored frequently to ensure that they stay within the goal range and that his medications function correctly.
References
Mariadoss, A. V. A., Sivakumar, A. S., Lee, C. H., & Kim, S. J. (2022). Diabetes mellitus and diabetic foot ulcer: Etiology, biochemical and molecular-based treatment strategies via gene and monotherapy. Biomedicine & Pharmacotherapy, 151, 113134.
Rai, G. S., & Rozario, C. J. (2023). Mechanisms of drug interactions II: pharmacokinetics and pharmacodynamics. Anaesthesia & Intensive Care Medicine
Rickert, M., Caughey, A. B., & Valent, A. M. (2023). Medications for Managing Preexisting and Gestational Diabetes in Pregnancy. Obstetrics and Gynecology Clinics, 50(1), 121-136.
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Collapse SubdiscussionKenneth Elad Fonguck Hello Amy,
You have been very straight to the point in your write up and I greatly enjoyed reading. Diabetes is a serious health concern nowadays. Ones a person is diagnosed with diabetes, acquiring other comorbidities such as hypertension and heart diseases , kidney, liver and lung issues are all accompanying occurrences. With diabetes, the key is making some lifestyle changes and medication compliance. Diabetes self-management education refers to the ongoing process of facilitating the knowledge, skill, and ability necessary to successfully manage the disease on their own. It is a critical element of care for all people with diabetes and has been shown to improve patient outcomes [11Links to an external site.] (Bamerjee et al., 2020). Managing diabetes is not an easy task especially as it has to do with making those choices for life. For non-diabetic patients, otherwise healthy individuals, natural insulin production checks and neutralizes any uncontrolled sugar in the body. In healthy individuals, meal ingestion leads to rapid insulin secretion into the portal vein, aiming to lower BG concentrations via a reduction of hepatic glucose production and an increase in peripheral glucose uptake [3Links to an external site.]. (Haahr & Heise., 2020). Eating by itself stimulates insulin production in healthy people, thus regularizing their BG for the most part.
The variability in glucose-lowering effect between insulin doses is important for patients with diabetes aiming for optimal glycaemic control with minimal hypoglycaemia [57Links to an external site.] (Haahr & Heise., 2020). In some cases, there exist varying degree of diabetes. For some patients, the pharmacokinetics of insulin is very rapid, thus hypoglycemia might easily set in. For such patients, insulin administration must be during meals.
References
Banerjee, M., Chakraborty, S., & Pal, R. (2020). Diabetes self-management amid COVID-19 pandemic. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14(4), 351-354.Haahr, H., & Heise, T. (2020). Fast-acting insulin aspart: a review of its pharmacokinetic and pharmacodynamic properties and the clinical consequences. Clinical Pharmacokinetics, 59, 155-172. -
Collapse SubdiscussionKenneth Elad Fonguck Hello Amy,
You have been very straight to the point in your write up and I greatly enjoyed reading. Diabetes is a serious health concern nowadays. Ones a person is diagnosed with diabetes, acquiring other comorbidities such as hypertension and heart diseases , kidney, liver and lung issues are all accompanying occurrences. With diabetes, the key is making some lifestyle changes and medication compliance. Diabetes self-management education refers to the ongoing process of facilitating the knowledge, skill, and ability necessary to successfully manage the disease on their own. It is a critical element of care for all people with diabetes and has been shown to improve patient outcomes [11Links to an external site.] (Bamerjee et al., 2020). Managing diabetes is not an easy task especially as it has to do with making those choices for life. For non-diabetic patients, otherwise healthy individuals, natural insulin production checks and neutralizes any uncontrolled sugar in the body. In healthy individuals, meal ingestion leads to rapid insulin secretion into the portal vein, aiming to lower BG concentrations via a reduction of hepatic glucose production and an increase in peripheral glucose uptake [3Links to an external site.]. (Haahr & Heise., 2020). Eating by itself stimulates insulin production in healthy people, thus regularizing their BG for the most part.
The variability in glucose-lowering effect between insulin doses is important for patients with diabetes aiming for optimal glycaemic control with minimal hypoglycaemia [57Links to an external site.] (Haahr & Heise., 2020). In some cases, there exist varying degree of diabetes. For some patients, the pharmacokinetics of insulin is very rapid, thus hypoglycemia might easily set in. For such patients, insulin administration must be during meals.
References
Banerjee, M., Chakraborty, S., & Pal, R. (2020). Diabetes self-management amid COVID-19 pandemic. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14(4), 351-354.Haahr, H., & Heise, T. (2020). Fast-acting insulin aspart: a review of its pharmacokinetic and pharmacodynamic properties and the clinical consequences. Clinical Pharmacokinetics, 59, 155-172.
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Collapse SubdiscussionMindy Brooke Inglis Case Study Discussion Board Week 1
A 45-year-old white male presents to the pre-op unit with a fractured right hip. The patient is scheduled to have a total right hip procedure. The patient has a medical history of idiopathic thrombocytopenic purpura, or ITP. ITP is an autoimmune blood clotting condition in which the body mistakenly attacks and destroys platelets. In ITP, the blood does not clot as it should, and patients with this condition are at risk for increased bleeding. ITP is a condition that generally affects women more than men and children more than adults(Idiopathic Thrombocytopenic Purpura, 2023). The patient states he is otherwise healthy with no other medical history besides the ITP. The patient states he was first diagnosed in his early twenties when his bloodwork came back with low platelets and he was then sent to a hematologist. The hematologist suggested treating the ITP with prednisone. The patient has now been taking prednisone for approximately 20 years. The patient states he is having problems with breaking bones and cracking teeth.
Pharmacodynamics of Prednisone
Prednisone is in a class of medications known as corticosteroids. This class of medications can help change the way the immune system works by acting as an inflammatory agent or through immunosuppression. When prednisone attaches to the cell surface receptors, it enters the cell nucleus and alters the genetic expression through DNA replication, and inhibits the production of cytokines which help produce the body’s inflammatory response(Puckett et al., 2022).
Pharmacokinetics of Prednisone
Prednisone is first processed in the liver where it then becomes its active form, prednisolone. It has a half-life of 2-3 hours. It is excreted through the kidneys in the urine. Data regarding toxicity is rare but extended use with high dosage can have many adverse effects. These adverse effects can include osteoporosis, fractures, adrenal insufficiency, fluid retention, abnormal fat deposits, impaired wound healing, increased blood pressure, increased risk of infection, weight gain, headaches, weakness, peptic ulcer disease, neuropathy, menstrual disorders, thinning hair, excessive appetite, acne, and hypokalemia(Prednisone, 2023).
Personalized Care Plan
It is important for this patient to have an individualized plan of care due to the adverse effects prednisone can have on the body. In this gentleman’s case, he is experiencing problems with fractures in his bones and teeth. It would be recommended to follow a well-balanced diet that includes lean proteins, low-fat dairy, fruits, vegetables, and whole grains. The patient needs to maintain a healthy weight and exercise daily. He also needs to take 1,000 to 1,200 mg of calcium and 600 to 800 IU of vitamin D each day(Calcium, Vitamin D, and Your Bones, 2022). The patient needs to refrain from smoking and limit alcohol intake. It is important that he visits his dentist regularly, brushes twice daily with a soft-bristled brush using fluoride toothpaste, and flosses daily.
References
Calcium, vitamin D, and your bones. (2022). MedlinePlus. https://medlineplus.gov/ency/patientinstructions/000490.htmLinks to an external site.
Idiopathic Thrombocytopenic Purpura. (2023). John Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/idiopathic-thrombocytopenic-purpuraLinks to an external site.
Prednisone. (2023). DrugBank Online. Retrieved March 1, 2023, from https://go.drugbank.com/drugs/DB00635Links to an external site.
Puckett, Y., Gabbar, A., & Bokhari, A. (2022). Prednisone. National library of medicine. https://www.ncbi.nlm.nih.gov/books/NBK534809/#:~:text=Go%20to%3A-,Mechanism%20of%20Action,volume%20of%20the%20immune%20system.Links to an external site.
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Collapse SubdiscussionRaechel Taylor Mindy,
Prednisone is a synthetic, anti-inflammatory glucocorticoid that derives from cortisone. It is biologically inert and converted to prednisolone in the liver (Puckett & Bokhar, 2022). Thankfully the patient has no further past medical history such as cardiac failure, hypertension, or arrhythmias. The patients’ long-term use of prednisone will help with post-surgical healing concerning inflammation. I’m curious to know if the patient was obese due to the increased appetite that prednisone can cause. In humans, the pharmacokinetics of prednisolone is complex. After oral intake, it exhibits rapid absorption and becomes almost completely (80%-100%) available (Bashar, etc., 2018). The patient’s diet should be adjusted like you mentioned. Great post.
References
Puckett Y, Gabbar A, Bokhari AA. Prednisone. [Updated 2022 May 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534809/Links to an external site.
Bashar T, Apu MNH, Mostaid MS, Islam MS, Hasnat A. Pharmacokinetics and Bioavailability Study of a Prednisolone Tablet as a Single Oral Dose in Bangladeshi Healthy Volunteers. Dose-Response. 2018;16(3). doi:10.1177/1559325818783932
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Collapse SubdiscussionPenny Pitford A 65-year-old male farmer diagnoses with bipolar 3 years ago on lithium and nortriptyline. No other previous health issues. Presents with lethargy, inability to coordinate movements, slurred speech, and inconsistent orientation. The patient’s wife says he was in the hay field this past week and forgot his water jug a couple of days ago. The patient was also found to have started consuming grapefruit juice more in the past few months. The patient was diagnosed 33 years ago and has not had any manic or depressed episodes in over 25 years.
Serum drug levels can be increased by grapefruit juice (Rosenthal & Burchum, 2017) It can affect the drug levels for as many as three days after a single serving of juice. Elderly age can affect liver function, affecting the metabolism of many medications (Rosenthal & Burchum, 2017). Therefore, a lower dose of medication can often serve the needs and avoid too high serum drug levels. The third strike, in this case, was the patient became dehydrated due to the hot environment and decreased water consumption. Research has proven that a dehydrated physiological state can lead to lithium toxicity (Cheng et al., 2019).
Due to the success of many years on this medication regimen. I would not change the medications. I would educate on the concerns of and effects of grapefruit juice consumption and instruct the patient to cut out this juice. I would also educate on the effects of age on the condition and recommend a slightly lower dose with close monitoring. Thirdly, I would educate on dehydration and lithium toxicity. I would express the importance of always staying hydrated even if it means taking a break, it is worth it for his health.
References
Cheng, S., Buckley, N., Siu, W., Chiew, A., Vecellio, E., & Chan, B. (2019). Seasonal and temperature effect on serum lithium concentrations. Australian & New Zealand Journal of Psychiatry, 54(3), 282–287. https://doi.org/10.1177/0004867419889160Links to an external site.
Rosenthal, L., & Burchum, J. (2017). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants – e-book (2nd ed.). Saunders.
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Collapse SubdiscussionPenny Pitford * Correction: The patient was diagnosed with bipolar 32 years ago.
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Collapse SubdiscussionMikayla Butkus Response #1
Hi Penny, thank you for sharing these informative insights into the effects of grapefruit juice and dehydration on lithium levels. These are very important factors to consider when obtaining a patient’s history and developing a plan of care. In addition to grapefruit juice, caffeine can also impact serum lithium levels. According to Carlo & Alpert, 2016, methylxanthines, like caffeine, have been shown to significantly increase lithium clearance. “As a result, the withdrawal of caffeine can lead to increased serum lithium concentration” (Carlo & Alpert, 2016, p. 455). This is important to consider because 90% of all adults in the world consumer caffeine daily and 88% have reported at least one past serious attempt to quit or reduce caffeine (Juliano et al., 2012). Lithium toxicity can occur at 1.5 mEq/L and symptoms of this include nausea/vomiting, lethargy, tremor, confusion, delirium, tachycardia, seizures, and coma (Hedya et al., 2022). Like you mention above, it is important to consider these factors when determining dosing and provide sufficient education to the patient regarding interactions and signs and symptoms of toxicity.
References
Bordeaux, B., & Lieberman, H. R. (2020). Benefits and risks of caffeine and caffeinated beverages. UpToDate. https://www.uptodate.com/contents/benefits-and-risks-of-caffeine-Links to an external site.and-caffeinated-beverages#H1
Carlo, A. D., & Alpert, J. E. (2016). Clinically relevant complications of drug-food interactions in psychopharmacology. Psychiatric Annals, 46(8), 448–455. https://doi.org/10.3928/00485713-20160613-01Links to an external site.
Hedya, Avula, & Swoboda. (2022). Lithium Toxicity. In StatPearls. StatPearls Publishing.
Juliano, L. M., Evatt, D. P., Richards, B. D., & Griffiths, R. R. (2012). Characterization of inindividuals seeking treatment for caffeine dependence. Psychology of addictive behaviors : journal of the Society of Psychologists in Addictive Behaviors, 26(4), 948–954. https://doi.org/10.1037/a0027246
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Collapse SubdiscussionKenneth Elad Fonguck Hello Penny
Thanks for sharing this very insightful piece. Lithium is a very highly recommended medication to treat bipolar disorder. As much as it the first drug of choice to tackle BD, it has some significant side effects and contraindications. However, lithium’s narrow therapeutic range (0.6–1.2 mmol/l) requires regular follow up of patient after every 2–3 months to prevent toxicity. The clinical manifestations of lithium toxicity are manifold, involving multiple systems and can be acute, acute–on–chronic, or chronic (Bhardwaj., 2021). The strength of lithium is something to be very conscious about. That is the more reason why labs are drawn every 2-3 months to check its serum concentration. As for the case of your 65 year old farmer, your advise not to change his medication regimen is simply the best because his lithium levels has been WNL.
Lithium recommendations in geriatric psychiatry patients are based on extrapolations from pharmacokinetics studies, anecdotal reports and clinical experience. Acute lithium toxicity is characterized by nausea, vomiting, diarrhea, dysrhythmia, cardiac conduction changes and
neurological manifestations such as coarse tremor, muscle weakness, cerebellar signs and delirium. Severe lithium toxicity can cause seizures; coma and permanent neurological effects such as dementia (Bhardwaj., 2021). With all these serious side effects, Lithium levels should always be checked as prescribed most especially before administration. This altered physiology plays a vital role in changing drug pharmacokinetics and pharmacodynamics. In some cases, the drug concentration will be reduced and requires a higher dose to compensate for the loss of the drug to show its therapeutic efficacy (Polaka et al., 2022). Pharmacokinetics ( absorption, distribution, metabolism, excretion) and pharmacodynamics (side effects and mechanism of action) of lithium should be given a high priority for any further studies.
References
Bhardwaj, A. (2021). Lithium carbonate toxicity in an elderly patient: a case report. International Journal of Basic & Clinical Pharmacology, 10(6), 766.Polaka, S., Tella, J. D., Tekade, M., Sharma, M. C., & Tekade, R. K. (2022). Impact of ageing on the pharmacokinetics and pharmacodynamics of the drugs. In Pharmacokinetics and Toxicokinetic Considerations (pp. 241-261). Academic Press. -
Collapse SubdiscussionMindy Brooke Inglis Penny,
I enjoyed reading your post and agree with your decision not to change the medication regimen. I too, think this issue stems more from a lack of education regarding the medication. I think too often in our healthcare system patients are prescribed new medications and are not properly educated on the dos and donts of the medicine. I think the lack of education is often due to time constraints and inadequate staffing within hospitals, doctor’s offices, and clinics. This man should be educated on the signs and symptoms of lithium toxicity including dehydration, headache, weakness, confusion, tremors, vomiting, and slurred speech. It is important as a provider we stress the need to have the patient’s serum lithium level checked often(Hedya et al., 2022). I also liked how you discussed the importance of staying away from drinking grapefruit juice when taking lithium. Grapefruit juice and lithium do not mix. Grapefruit juice inadvertently increases the concentration of lithium(Rosenthal & Burchum, 2017). I feel this finding just indicates the value of a thorough and quality assessment. Well done!
Rosenthal, L., & Burchum, J. (2017). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants – e-book (2nd ed.). Saunders.
Shireen A. Hedya; Akshay Avula; Henry D. Swoboda. (2022). Lithium Toxicity. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK499992/#:~:text=Lithium%20toxicity%20signs%20are%20obvious,%2Dthreatening%20condition%5B31%5D.
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Collapse SubdiscussionKacella Mills Hello Penny,
I enjoyed reading your discussion. Working in mental health myself, I often see instances similar to this where patients are unaware or not fully compliant with practices while taking lithium. Lithium is a very powerful, antimanic medication with a narrow therapeutic index (Hedya et al, 2022). In your scenario, this is an older patient therefore, the risk of adverse effects has increased. Risk factors for lithium toxicity include age older than 50 years (MacLeod & Chuang, 2020). With the longevity of being on lithium, providers should consider more frequent routine tests to prevent adverse effects. Monitoring patients on lithium should include electrolyte, urea, and creatinine levels every 3 to 6 months and calcium levels, thyroid-stimulating hormone levels, and weight every 6 to 12 months (MacLeod & Chuang, 2020). I agree that lithium treatment should be continued for this patient because it’s been so effective. However, as you stated, there is a need for more detailed patient education and increased monitoring to prevent toxicity.
References
MacLeod-Glover, N., & Chuang, R. (2020). Chronic lithium toxicity: Considerations and systems analysis. Canadian family physician Medecin de famille canadien, 66(4), 258–261.
Hedya, S., Avula, A., & Swoboda, H. (2022). Lithium Toxicity. https://www.ncbi.nlm.nih.gov/books/NBK499992/
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Collapse SubdiscussionEmily Ann Bennett A patient case from the last 5 years involved a 65 year old caucasian male diagnosed with End Stage Renal Disease requiring in center hemodialysis three times a week. This patient was also diagnosed with Diabetes Mellitus type 2, which went uncontrolled, and resulted in bilateral blindness and a double below the knee amputation. Post amputation, this patient was prescribed oxycodone to ease the pain. The patient however was not informed due to the pharmacodynamics of oxycodone, the medication was dialyzed out of the patient’s bloodstream (Leuppi-Taegtmeyer et al, 2019). The patient then developed severe pain and left his treatment early.
Pharmacodynamics is how the drug affects the body, in this case providing pain relief (Lea-Henry et al, 2018).. Pharmacokinetics is how the body affects the drug, in this case with the blood being cleaned through dialysis the body gets rid of the drug (Lea-Henry et al, 2018). With an acute kidney injury, chronic kidney disease, or end stage renal failure, the amount of drug the body is able to excrete is drastically changed (Roberts et al, 2018). In a typical patient with a kidney injury, the kidney is unable to clear the drug from the body, or can clear the drug from the body over a much slower time period. This allows the drug to stay in the system longer, which affects how frequently a prescribed medication needs to be taken.
A personalized care plan I would develop based on my patients needs involves ensuring they are prescribed a medication they can take to treat the pain during dialysis. There are medications that do not dialyze out of the patient’s bloodstream available, such as a fentanyl patch, that can provide relief during the entire treatment and allow the patient to remain in the clinic for their entire prescription.
Lea-Henry, T. N., Carland, J. E., Stocker, S. L., Sevastos, J., & Roberts, D. M. (2018). Clinical pharmacokinetics in kidney disease: fundamental principles. Clinical journal of the American society of nephrology, 13(7), 1085-1095.
Leuppi-Taegtmeyer, A., Duthaler, U., Hammann, F., Schmid, Y., Dickenmann, M., Amico, P., Jehle, A. W., Kalbermatter, S., Lenherr, C., Meyer Zu Schwabedissen, H. E., Haschke, M., Liechti, M. E., & Krähenbühl, S. (2019). Pharmacokinetics of oxycodone/naloxone and its metabolites in patients with end-stage renal disease during and between haemodialysis sessions. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association – European Renal Association, 34(4), 692–702. https://doi.org/10.1093/ndt/gfy285
Roberts, D. M., Sevastos, J., Carland, J. E., Stocker, S. L., & Lea-Henry, T. N. (2018). Clinical pharmacokinetics in kidney disease: application to rational design of dosing regimens. Clinical Journal of the American Society of Nephrology, 13(8), 1254-1263.
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Collapse SubdiscussionTarah Marie Coronado Thank you for your informative post Emily. How is fentanyl typically dosed?
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Collapse SubdiscussionRaechel Taylor Emily,
The pharmacodynamics for dialysis patients is different with the metabolism of drugs. I have worked with several patients who deal with this situation. The main medication that they aren’t absorbing is their antinausea medication for their gastroparesis. Pharmacodynamic actions include stimulating activity by directly inhibiting a receptor and its downstream effects and depressing activity by direct receptor inhibition and its downstream effects (Marino, etc., 2022). This action describes why the delayed response to medication is seen with patients on dialysis. A major concern is the concentration of insulin and absorption with dialysis patients. Concentrated insulin analogs have recently been approved and are available for clinical use in the management of diabetes mellitus (Clements, etc., 2017). This is a great post that makes you analyze the patient completely.
References
Marino M, Jamal Z, Zito PM. Pharmacodynamics. [Updated 2022 Jan 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507791/Links to an external site.
Clements, J. N., Threatt, T., Ward, E., & Shealy, K. M. (2017). Clinical Pharmacokinetics and Pharmacodynamics of Insulin Glargine 300 U/mL. Clinical pharmacokinetics, 56(5), 449–458. https://doi.org/10.1007/s40262-016-0464-6
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Collapse SubdiscussionPenny Pitford Very interesting post Emily. I have never worked in dialysis, yet I do know it is a tedious balance of what medications to give or not give to the patient before they go to dialysis. A research study of 233 dialysis-dependent US adults, the average number of pills was 19 per day(Paik et al., 2021). This could easily become an issue when you consider the competition between drugs if they are metabolized by the same metabolic pathway. This may decrease the rate at which they are metabolized. If the rate is decreased enough it can accumulate to dangerously high levels (Rosenthal & Burchum, 2017).
References
Paik, J. M., Zhuo, M., York, C., Tsacogianis, T., Kim, S., & Desai, R. (2021). Medication burden and prescribing patterns in patients on hemodialysis in the usa, 2013–2017. American Journal of Nephrology, 52(12), 919–928. https://doi.org/10.1159/000520028Links to an external site.
Rosenthal, L., & Burchum, J. (2017). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants – e-book (2nd ed.). Saunders.
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Collapse SubdiscussionMikayla Butkus Main Post
There are several factors that must be considered prior to prescribing medication to a patient. Many different factors influence the pharmacokinetic and pharmacodynamic processes of each individual patient. Pharmacokinetics is the study of how the body changes or affects a drug and includes absorption, distribution, metabolism, and excretion (Rosenthal & Burchum, 2021, p. 13a). Pharmacodynamics is the study of how the drug affects the body (Marino et al., 2022). Both processes are important to consider when creating a personalized plan of care.
A few years ago, I worked with a 73-year-old male caucasian patient with a history of Bipolar 1 Disorder and chronic liver disease. He had an allergy/intolerance to Quetiapine (Seroquel), which had been trialed previously. He also had a history of falls. There a several factors that must be considered before prescribing a medication to treat his Bipolar 1 Disorder. The first is the patient’s history of chronic liver disease. This is critical because many drugs are metabolized in the liver. If this system is impaired, these drugs can lead to increased adverse effects and possible overdose (Rosenthal & Burchum, 2021). The second factor to consider is the patient’s allergy to quetiapine (Seroquel). It is important to determine the type of reaction that occurred. Was it an anaphylactic reaction or a mild reaction such as vomiting? In the case of anaphylaxis, the drug is contraindicated (Rosenthal & Burchum, 2021). The third factor to consider is the patient’s age. The Beers Criteria, for example, is a list of potentially inappropriate medications to use in older adults and is widely used by clinicians, educators, and other healthcare professionals (American Geriatrics Society 2019 Beers Criteria Update Expert Panel, 2019). Many of the rationales for avoiding such medications include orthostatic hypotension, sedation, anticholinergic effects, and decreased ability to metabolize drugs which can lead to toxicity (American Geriatrics Society 2019 Beers Criteria Update Expert Panel, 2019). Due to the patient’s history of falls, it is important to try to avoid medications that are sedating. This aligns closely with rationale provided by the Beers Criteria, as discussed previously.
Based on the patient’s history and influencing factors, lithium, a mood stabilizer, would be the best treatment option for this specific patient. According to Menon et al., 2022, lithium is minimally metabolized in the liver and not protein bound so is “generally believed to be safe to use in patients with chronic liver disease” (p. 384). It is also one of the first line treatments for Bipolar 1 Disorder. Although hepatic dysfunction can also have renal impairment, lithium can be safely prescribed with close monitoring of therapeutic lithium levels (Menon et al., 2022). Lithium is often started at 300mg orally three times daily. The dose is then adjusted based on serum drug level and should not exceed 1800 mg/day. According to the Beers Criteria, it should be avoided in geriatric patients that are on Angiotensin-converting-enzyme inhibitors or Loop diuretics due to increased risk of lithium toxicity (American Geriatrics Society 2019 Beers Criteria Update Expert Panel, 2019). It is imperative that nurse practitioners consider the whole patient and develop a plan of care that is specific to that patient.
References
American Geriatrics Society 2019 Beers Criteria Update Expert Panel. (2019). American Geriatrics Society 2019 updated AGS Beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674–694. doi:10.1111/jgs.15767
Marino M, Jamal Z, & Zito PM. (2022). Pharmacodynamics. In StatPearls. StatPearls Publishing.
Menon, V., Ransing, R., & Praharaj, S. K. (2022). Management of Psychiatric Disorders in Patients with Hepatic and Gastrointestinal Diseases. Indian journal of psychiatry, 64(Suppl 2), S379–S393. https://doi.org/10.4103/indianjpsychiatry.indianjpsychiatry_18_22
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
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Collapse SubdiscussionKacella Mills Hi Mikayla,
I enjoyed reading your post. As we know, it is vital for providers to consider multiple factors of a patient’s history prior to developing a treatment plan. In your scenario, with this patient being geriatric, fall risk is a major concern in this population. At a prior in-patient facility where I have worked, there was both an adult and geriatric unit. I often found it more challenging to work with geriatric patients due to their presentation and treatment plan. These patients are often unmedicated due to their high risk of adverse effects. Their medication dosages were also often low, which resulted in symptom improvement to be minimally effective.
The use of such medications in elderly patients increases the likelihood of infirmities, declines performance, increases the likelihood of emergency department admissions, and increases their dependence on caregivers (Mervara et al, 2021). During aging, a decline in functional capabilities can increase the risk of toxicity (Merava et al, 2021). I agree that lithium would be an appropriate choice of treatment for this patient. As stated, lithium is considered the first-line medication in older aged patients with bipolar disorder in the maintenance treatment (Volkmann, 2020). However, due to concerns regarding tolerability and adverse events, lithium is prescribed less frequently in older individuals, although it is usually well tolerated by most of these patients (Volkmann, 2020). This could explain why the provider choose not to prescribe this medication.
References
Meraya, A. M., Banji, O. J. F., Khobrani, M. A., & Alhossan, A. (2021). Evaluation of psychotropic medications use among elderly with psychiatric disorders in Saudi Arabia. Saudi pharmaceutical journal : SPJ : the official publication of the Saudi Pharmaceutical Society, 29(6), 603–608. https://doi.org/10.1016/j.jsps.2021.04.021Links to an external site.
Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium Treatment Over the Lifespan in Bipolar Disorders. Frontiers in psychiatry, 11, 377. https://doi.org/10.3389/fpsyt.2020.00377
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Collapse SubdiscussionRhoda Kwabi Pharmacology is the study of drugs, which encompasses pharmacokinetics, pharmacodynamics, and pharmacotherapeutics (Trevor et al., 2009). Pharmacokinetics refers to how the body responds to drugs and involves absorption, distribution, metabolism, and excretion. Absorption occurs at the site of drug administration, distribution refers to where the absorbed drug is distributed to, metabolism takes place in organs such as the liver, and excretion involves the elimination of by-products. Pharmacodynamics involves the interaction of drugs with receptors to activate or inhibit them (Rosenthal & Burchum, 2021).
A patient presents to the clinic and presents with shortness of breath and has a medical history of congestive heart failure, hypertension, hyperlipidemia, and asthma. The patient is currently taking metoprolol 25mg, atorvastatin 10mg, furosemide 10mg, albuterol, and Tylenol as needed. Further assessment shows that the patient is non-compliant with medication and lifestyle, as the patient doesn’t exercise frequently and eats whatever is available. However, the patient doesn’t have any history of kidney disease, indicating that the patient can metabolize medication well if compliant with the regimen.
In this scenario, Tylenol is absorbed through the mouth and distributed to the blood, where it is metabolized by the liver and excreted. The pharmacodynamic action of Tylenol involves its binding to receptors on cells to relieve pain or inflammation.
To develop personalized care for this patient, educating the patient about being compliant with medication, encouraging physical activity, and promoting a healthy diet are crucial (Banerjee et al., 2019) Frequent visits to the primary physician are also important.References
Banerjee, B. D., Kumar, R., Thamineni, K. L., Shah, H., Thakur, G. K., & Sharma, T. (2019). Effect of environmental exposure and pharmacogenomics on drug metabolism. Current Drug Metabolism, 20(14), 1103-1113.
Rosenthal, L. D., & Burchum, J. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants-E-Book. Elsevier Health Sciences.
Trevor, A. J., Masters, S. B., & Katzung, B. G. (2009). Basic & Clinical Pharmacology: Vol. 11th ed. McGraw-Hill Professional.-
Collapse SubdiscussionNardos Gebeyehu Yalew Response #2
Rhoda,
I enjoyed reading your post. Most patients that are noncompliant with their medications tend to develop complications that further deteriorate their health and leave them worse than before. So nurses and advanced nurse practitioners must educate and stress the importance of medication compliance. Moreover, pointing out resources, giving patients educational
booklets with diet plans, and spending time to explain why the patient is on the specific medication, how it works, why they are being given the medication, and how the body uses said medication to improve their health is important. Therefore, I agree with your stated personalized care plan. Also, the patient has congestive heart failure, hyperlipidemia, and hypertension which are all comorbidities that affect the pharmacokinetic and pharmacodynamic process. The patient is practicing a sedentary lifestyle and eats without watching the type of food he consumes. This type of lifestyle can lead to obesity which according to Krogstad et al. (2021) results in obesity-related physiological changes that could alter drug disposition because it increases blood volume, increases cardiac output, alters gastrointestinal function, and causes inflammation. This type of interference causes alteration in the way the body metabolizes, distributes, and absorbed medication. With the patient in this scenario, without his medications, his body is working extra hard to meet the demands of his body. Since he is not taking his medications appropriately, and if he doesn’t correct his course, in the long run, he will need the dosages of his medications to be increased. If the patient has had liver failure, the pharmacokinetics and pharmacodynamics of this patient will be different. The patient is on acetaminophen which increases the risk of hepatotoxicity. Pharmacokinetics of Acetaminophen is rapidly absorbed from the gastrointestinal tract and extensively metabolized by the liver so, when patients have liver failure it results in hepatotoxicity (Gentile et al., 2020). Therefore, the personalized care plan for the patient would include administering activated charcoal, N-acetyl-cysteine (NAC), and a possible liver transplant if the case is severe. Overall, education is a critical part of providing care to patients.References
Gentile, J. A., Boone, L. B., Kyle, J. A., & Kyle, L. R. (2020, December 18). Drug considerations for medication therapy in cirrhosis. U.S. Pharmacist – The Leading Journal in Pharmacy. https://www.uspharmacist.com/article/drug-considerations-for-medication-therapy-in-cirrhosis
Krogstad, V., Peric, A., Robertsen, I., Kringen, M. K., Vistnes, M., Hjelmesæth, J., Sandbu, R., Johnson, L. K., Angeles, P. C., Jansson-Löfmark, R., Karlsson, C., Andersson, S., Åsberg, A., Andersson, T. B., & Christensen, H. (2021). Correlation of body weight and composition with hepatic activities of cytochrome P450 enzymes. Journal of Pharmaceutical Sciences, 110(1), 432–437. https://doi.org/10.1016/j.xphs.2020.10.027
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Collapse SubdiscussionRaechel Taylor A 72-year old female came to the emergency department with complaint of left sided generalized body pain, shortness of breath, and chest pain. Upon performing an EKG the patient was in atrial fibrillation with RVR. This new EKG finding was new to the patient although having a history of a-fib. Her medical history was extensive including sleep apnea, hypertension, fibromyalgia, and hyperlipidemia. The plan of care for the patient included Cardizem which is a calcium channel blocker (Talreja, 2022).
Pharmacokinetics is the process of medication in the blood stream and how the body processes the drug in terms of absorption, distribution, metabolism, and elimination. Pharmacodynamic is how drugs affect the body by playing on receptors of the molecular level of the body (Curie, 2018).
The factors that influenced pharmacokinetics and pharmacodynamic processes of this patient include the age of the patient, past medical history, environmental factors, and current medication regimen. The metabolic process of Cardizem is via the hepatic system. The patient had to be closely monitored for urine output, kidney function and blood pressure. In conclusion this patient was placed on a continues titrated infusion of Cardizem. She was admitted as ICU patient for continued close monitoring.
References
Currie GM. Pharmacology, Part 2: Introduction to Pharmacokinetics. J Nucl Med Technol. 2018 Sep;46(3):221-230. doi: 10.2967/jnmt.117.199638. Epub 2018 May 3. PMID: 29724803.
Talreja O, Cassagnol M. Diltiazem. [Updated 2022 Sep 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532937/
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Collapse SubdiscussionTarah Marie Coronado Thank you for your informative post Raechel. What are some adverse reactions of Cardizem?
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Collapse SubdiscussionChijiamara Kalu Main Discussion Post Week 1
Pharmacokinetics and Pharmacodynamics
A healthcare provider’s knowledge of pharmacokinetics and pharmacodynamics of drugs is critical for providing efficient and safe patient care. The study of drug movement throughout the body is known as pharmacokinetics, whereas pharmacodynamics is the study of drug biochemical and physiologic effects, as well as the process by which those effects are produced (Rosenthal et al., 2021). The kinetic process of drugs is dependent on certain factors, some of which are modifiable while others are not. These factors play an important role in the absorption, distribution, metabolism, and excretion of a drug. The concentration of a drug at its site of action is determined by these processes in action. The purpose of this discussion is to review a patient’s care plan who visited his PCP for a follow up appointment after ER admission.
Description of Patient Case
The patient selected for this care review is a 56- year-old AA male who went to the emergency department with complain of abdominal pain and melena that has lasted for 5 days. Patient’s history includes hypertension, Afib, and TIA .Patient’s prescribed medication are Hydrochlorothiazide and apixaban. Pt denied any other symptoms, but was found with slightly low Hemoglobin and Hematocrit but not critical for transfusion. The ED physician recommended EGD to investigate for abdominal bleed and possible biopsy to rule out H.pylori. Pt was discharged and advised to follow up with his primary care physician. At his follow up appointment patient’s record from his ED visit was reviewed and after further assessment patient admits that he has been taking other non-prescribed medication as suggested by his friend after he was discharged from the hospital for stroke- like symptoms. Pt admitted to taking Aspirin sometimes for pain and other natural remedies that he could not name. Further subjective assessment showed that this patient is a habitual user of NASIAD.
Pharmacokinetic and Pharmacodynamics of Ibuprofen (NASIAD)
Nonsteroidal anti-inflammatory drugs (NSAIDs) have a number of serious, potentially fatal adverse drug reactions, despite being among the most commonly prescribed/used medicines in the world. Because of the large number of patients who have been exposed to NSAIDs, their side effects are a serious public health concern. The patient is at risk of gastrointestinal and renal toxicity while taking NSAIDs, which has long been known. An increase in arterial blood pressure (BP) and the risk of heart failure exacerbation during NSAID administration (Varga et al., 2017). The patient had his EGD procedure showed ulcers at specific portions of his colon and actively bleeding. NSAIDs such as ibuprofen, naproxen, and other nonaspirin NSAIDs can reduce aspirin’s anti-platelet effects by blocking aspirin’s access to COX-1 in platelets. This pharmacodynamics process is important because patients taking low-dose aspirin to prevent MI or stroke may negate aspirin’s benefits (Rosenthal et al., 2021). Ibuprofen is generally well tolerated, has few side effects, and causes less gastric bleeding than aspirin. As a result, it is one of the safer NSAIDs to use with anticoagulants. Because this patient was taking an anticoagulant, the combination with Ibuprofen might have increased the risk of GI bleeding. All first-generation NSAIDs have been linked to an increased risk of GI bleeds and cardiovascular events, which can lead to hospitalization and death, according to a Black Box warning (Rosenthal et al., 2021).
Personalized Care Plan
The first plan of care for this patient was to educate him on the dangers of taking drugs without his doctor’s approval. Secondly a review of this home medications which includes all OTC, herbal and prescribed drugs. Most herbal drugs are not approved by the Federal Drug Administration (FDA) and most likely never reviewed for possible drug-drug interaction. In this case patient was advised to stop the herbal medication. Considering his history of A-fib and TIA patient was advised to continue taking apixaban. Aspirin was discontinued for him as well. Research showed that prior myocardial infarction, CAD, vascular disease, and diabetes increase the likelihood of receiving combined antiplatelet and anticoagulant therapy in patients with AFib. According to a review of the literature, this may result in increased major bleeding with little benefit in lowering AFib-related stroke or cardiovascular events. Also the combined use of aspirin and oral anticoagulant therapy in patients with atrial fibrillation and stable coronary artery disease (CAD) has been questioned due to an increased risk of major bleeding with little to no benefit in preventing ischemic events (So & Eckman, 2016).A coagulation test was also done to check for his PT and ApTT blood levels.
References:
Rosenthal, L. D., Burchum, J. R., & Rosenthal, L. D. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier.
So, C. H., & Eckman, M. H. (2016). Combined aspirin and anticoagulant therapy in patients with atrial fibrillation. Journal of Thrombosis and Thrombolysis, 43(1), 7–17. https://doi.org/10.1007/s11239-016-1425-5Links to an external site.
Varga, Z., Sabzwari, S. rafay, & Vargova, V. (2017). Cardiovascular risk of nonsteroidal anti-inflammatory drugs: An under-recognized public health issue. Cureus. https://doi.org/10.7759/cureus.1144Links to an external site.
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Collapse SubdiscussionNardos Gebeyehu Yalew Main Post
According to Rosenthal & Burchum (2021), the process of pharmacokinetics and pharmacodynamics play a critical role in how drugs are processed in the body. Pharmacokinetics encompasses four processes: absorption, distribution, metabolisms, and excretion while pharmacodynamics studies the biochemical and physiologic effects of the drugs on the body (Rosenthal & Burchum, 2021). As a nurse who has worked in the progressive care unit for the past 3 years, I have seen patients’ responses to specific medications abnormally due to pharmacokinetic and pharmacodynamic processes. For example, a patient I cared for a couple of months ago was a 65-year-old male, Mr. S, who came in with methicillin-resistant staphylococcal aureus (MRSA) in the blood, elevated white blood cells (WBC), fever, and generalized weakness. The patient has a history of diabetes mellitus, hypertension, neuropathy, and chronic kidney disease. The patient had no known medication or food allergies. After admitting the patient to the unit, I received intravenous vancomycin premixed in the pharmacy to be administered to the patient as a treatment for the MRSA infection in his blood. Upon hanging the vancomycin and starting the infusion within 4-5 minutes, the patient appeared flushed and had erythema. Additionally, the patient started complaining of itchiness and feeling warm all over his arms, legs, and chest. I immediately stopped the infusion, took a set of vitals, and contacted the doctor. The physician ordered a stat IV diphenhydramine, which was administered. The patient was experiencing Red Man Syndrome, now known as vancomycin flushing syndrome (VFS)/vancomycin infusing reaction (VIR), and showed signs and symptoms associated with this condition. According to Martel et al. (2022), vancomycin flushing syndrome (VFS) is caused by a rapid infusion of the glycopeptide antibiotic vancomycin and it is characterized by acute onset of pruritic, erythematous rash on the face, neck, and upper torso. Vancomycin flushing syndrome (VFS) is associated with the direct and non-immune-mediated release of histamine from mast cells and basophils (Martel et al., 2022). It is correlated with the dosage and infusion rate of vancomycin. Factors that influence the pharmacodynamics and pharmacokinetics of this patient include his age and chronic kidney disease. His renal function abnormality affected the absorption rate as well as the excretion rate of vancomycin in the body.
This patient’s personalized plan of care encompasses oral diphenhydramine administration an hour prior to infusion and initiating a slower rate of vancomycin administration. Additionally, the dosage of vancomycin needs to be adjusted based on the patient’s creatinine and BUN level to monitor the patient’s kidney function. Furthermore, monitoring vancomycin trough levels closely ensures that the patient is not developing resistance to the medication due to low doses, in addition to ensuring the patient does not develop nephrotoxicity and ototoxicity if the concentration is high.
According to Weller (2021) preventing initial reactions of the vancomycin infusing reaction (VIR) includes using slower rates of infusion which means infusing vancomycin at a rate no higher than 10 mg/minute or for one gram dose infusing over a minimum of 100 minutes which will result in slower rates, thus preventing the likelihood of the vancomycin infusing reaction (VIR). Overall, identifying the patient’s predisposition and medical history, preventing the initial reaction by starting the infusion rate slowly, and administering antihistamines an hour before infusing vancomycin can all aid in decreasing the development of the vancomycin-infusing reaction (VIR).
References
Martel, T. J., Jamil, R. T., & King, K. C. (2022, October 25). Vancomycin Flushing Syndrome. National Library of Medicine. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482506/
Weller, P. F. (2021, September 27). Vancomycin Hypersensitivity. UpToDate. Retrieved from https://www.uptodate.com/contents/vancomycin-hypersensitivity/printLinks to an external site.
Rosenthal, L. D., & Burchum, J. R. (2021). Pharmacokinetics, Pharmacodynamics, and Drug Interactions. Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed., pp. 13–22). Elsevier.
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Collapse SubdiscussionCatherine Edith Weisenberger Nardos,
Thank you for your input this week. I have worked in the emergency department for the past nine years. When we have a sepsis alert patient, it is common to use Vancomycin and Zosyn as a first line of defense. As an experienced nurse, I start the Zosyn first, then Vancomycin. However, I have found other nurses may Y line them together. According to Trissel’s IV compatibility chart, Vancomycin and Zosyn are y-site compatible (unable to cite). Utilizing a y-site for Vancomycin and Zosyn can increase the risk of acute kidney injury. For patients with known or unknown kidney disease, this can create future challenges (Luther et al., 2016). I have seen a reaction after a patient receiving Vancomycin and Zosyn, which was assumed to be a “red man.” Due to the patient receiving both antibiotics simultaneously while in the ED, we could not determine if he was allergic to one or both medications. The patient was treated with diphenhydramine and famotidine and later transferred to the intermediate unit for further evaluation. Due to the risk of reaction and acute kidney injury, I have taught other nurses to administer one at a time.
According to Rosenthal and Burchum, pharmacokinetics (PK) and pharmacodynamics (PD) play a dynamic role in how medications are processed, excreted, and affect the body(2021). Knowing these concepts will enhance a nurse practitioner’s on the proper administration of drugs.
References
Luther, M., Caffrey, A., Dosa, D., Lodise, T., & Laplante, K. (2016). Vancomycin plus piperacillin/tazobactam and acute kidney injury in adults: A systematic review and meta-analysis. Open Forum Infectious Diseases, 3(1). 1805. https://doi.org/10.1093/ofid/ofw172.1353Links to an external site.
Rosenthal, L. D., Burchum, J. R., & Rosenthal, L. D. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier.
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Collapse SubdiscussionTarah Marie Coronado Thank you for your informative post. Narrow therapeutic drugs may require specific dosing calculations or require extra attention with serum drug level monitoring. Medications that may require this extra attention due to their pharmacokinetic profile include lithium, vancomycin, or aminoglycosides. Vancomycin is an interesting drug in that it requires a trough range of 10-20mg/L. When vanco is infused too quickly adverse reactions can occur such as Red man syndrome. Vanco also requires a dose adjustment in renal insufficiency. The dose and frequency are often adjusted to decrease possible drug build up and toxicities. I enjoyed your plan of care and thought it was supportive in regards to patient factors that effect pharmacokinetics and dynamics. Nice job.
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Collapse SubdiscussionCatherine Edith Weisenberger Pharmacokinetics studies how a medication is absorbed, distributed, metabolized, and excreted in the body (Grogan, 2022). While pharmacodynamics is the study of how the body is affected by medication (Grogan, 2022). Considering the pharmacokinetics and pharmacodynamics of medications, as well as the patient’s past medical history and current medications, will assist a provider in determining the correct medicine for treatment.
I have worked in emergency medicine for nine years of my 24-year nursing career. Knowing emergency medications is pivotal to patient safety. Nurses must be ready for immediate intubation. Rapid sequence intubation (RSI) establishes a secure airway for patients who cannot safely breathe or manage their secretions. The process of RSI is to provide induction (induce unconsciousness), paralysis, and sedation management. It is essential to know the order of medications, their actions, and their effects on patients based on weight, age, and co-morbidities (Hampton et al., 2023). The order for RSI at my organization is etomidate for induction, rocuronium for paralytic, and fentanyl for sedation. Using the Broselow tape provides the most accurate information for diagnosing pediatric patients. For adults, it is based on weight and history if known. We have emergency antidotes for all medications available at all times. I have not seen any adverse effects of using etomidate and rocuronium for RSI. I have seen successful intubation with both for all varieties of traumas and medical emergencies.
The pharmacokinetics of etomidate is absorption within 30-60 sections with a peak at 1 minute, distribution of 2- 4.5L/kg, metabolized primarily by the liver, and excretion of 75% via kidneys (Williams et al., 2022). For rocuronium, absorption is 30-60 seconds, with distributions of 60 minutes for RSI dosing, metabolized at 75-80% by the liver and excreted by kidneys at 20-30% (Williams et al., 2022). It is vital to know to use these medications in the correct order, etomidate, then rocuronium.
In conclusion, awareness of the pharmacokinetics of medications will affect the outcome. Among most emergent intubations, RSI medications of etomidate and rocuronium have been the most effective and standard care plan for patients (Grogan, 2022).
References
Grogan S., & Preuss, C. Pharmacokinetics. [Updated 2022 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK557744/
Hampton, J., Hommer, K., Musselman, M., & Bilhimer, M. (2023). Rapid sequence intubation and the role of the emergency medicine pharmacist. American Journal of Health-System Pharmacy, 80 (4) 182-195. https://doi.org/10.1093/ajhp/zxac326Links to an external site.
Williams, L, Boyd, K., & Fitzgerald, B. [Updated 2022 Jun 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK535364/
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Collapse SubdiscussionRhoda Kwabi Response 1:
Hello Catherine,
Thank you for your post I enjoyed reading it! I would like to emphasize the importance of individualized medication administration based on a patient’s unique pharmacokinetics and pharmacodynamics. While general guidelines for medication administration are important, individual variations in absorption, distribution, metabolism, and excretion can greatly impact the effectiveness and safety of the medication (Rosenthal & Burchum, 2021). Additionally, a patient’s past medical history and current medications can influence their response to medication. Therefore, it is essential for healthcare providers to gather thorough patient information and consider it when selecting and administering medications. Also, as medication administration can have a significant impact on patient outcomes, ongoing education, and training in emergency medication administration protocols are necessary for healthcare providers to ensure safe and effective patient care (Sabatino et al., 2017). Thank you for sharing.
Regards,
Rhoda
References
Rosenthal, L. D., & Burchum, J. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants-E-Book. Elsevier Health Sciences.
Sabatino, J. A. , Pruchnicki, M. C. , Sevin, A. M. , Barker, E. , Green, C. G. & Porter, K. (2017). Improving prescribing practices. Journal of the American Association of Nurse Practitioners, 29 (5), 248-254. doi: 10.1002/2327-6924.12446.
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Collapse SubdiscussionMichelle Rogers Discussion Week 1, Initial Post
The pharmacokinetic and pharmacodynamic properties of medications are important to understand for any patient. A patient’s age, diet, genetics, and their metabolism can change how their body responds to medication that they take. The word kinetics in pharmacokinetics explains what it means. Kinetics refer to movement. Pharmacokinetics is the study of how a medication moves within the body. Dynamics refer to change or how something affects the body. Pharmacodynamics is the study of how medication affects the body and the mechanism of action of the medication. These two processes are essential for a prescriber to understand, so that they can prescribe the appropriate medications.
Ms. Jane Doe was my patient last year. Ms. Doe was a very friendly 59-year-old female patient who was alert and oriented. She was admitted to the unit I work on with a diagnosis of community acquired pneumonia (CAP) and was requiring oxygen during this stay. Ms. Doe was healthy and only had a history of mild anemia and mild asthma, which she did not take medication for. She had a history of an allergy to amoxicillin. Ms. Doe’s labs were within normal limits, except for an elevated white blood cell count of 15. Ms. Doe was able to produce a sputum sample that revealed that she had streptococcus pneumoniae, so her physician decided to keep her on her current regimen of intravenous (IV) cefazolin and oral azithromycin that had been prescribed in the emergency room. Cefazolin is a first-generation cephalosporin antibiotic. Cephalosporins work by weakening the bacterial cell wall and splitting the cell, thus destroying it (Rosenthal & Rosenjack Burchum, 2020). The route of elimination for cefazolin is renal. Azithromycin is a macrolide antibiotic. Macrolides work by interrupting the protein synthesis of cells (Patel & Hashmi, 2022). Azithromycin is secreted into the bile and excreted through the gastrointestinal system.
On day three, Ms. Doe was tolerating the treatment well and her condition was improving. Unbeknownst to hospital staff, Ms. Doe was also an alcoholic. She had been drinking for three years since her husband had passed. Her liver enzymes were not elevated, and she had said that she did not drink alcohol. Her friend came to visit her and had brought her vodka upon her request. Alcohol should never be consumed with cefazolin as it can have serious side effects that are similar to when someone consumes alcohol while taking disulfiram, also known as Antabuse. It causes the body to become intolerant to alcohol (Mergenhagen et al., 2020). The cefazolin inhibits the enzyme aldehyde dehydrogenase (ALDH). This causes a rapid rise in acetaldehyde in the blood stream and causes symptoms within minutes of consuming alcohol (Rosenthal & Rosenjack Burchum, 2020). Ms. Doe began to have reddened skin and began vomiting. She called the nurse, believing she was having an allergic reaction. As I was helping her, I noticed a small bottle of vodka in her trash and reported this to her physician. Her antibiotics were promptly stopped and she was started on levofloxacin IV. Levofloxacin is a third generation fluoroquinolone antibiotic. Fluoroquinolones disrupt the DNA replication in bacterial cells and disrupt the division of these cells (Rosenthal & Rosenjack Burchum, 2020). Levofloxacin is one of the many options that prescribers use as an initial therapy in treating community acquired respiratory infections. Ms. Doe continued to improve and was discharged on day six after being referred to psychiatry for her alcohol use and depression.
References
Mergenhagen, K. A., Wattengel, B. A., Skelly, M. K., Clark, C. M., & Russo, T. A. (2020). Fact versus fiction: A review of the evidence behind alcohol and antibiotic interactions. Antimicrobial Agents and Chemotherapy, 64(3). https://doi.org/10.1128/aac.02167-19Links to an external site.
Patel, P. H., & Hashmi, M. F. (2022). Macrolides. StatPearls (Internet). https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK551495/?report=readerLinks to an external site.
Rosenthal, L. D., & Rosenjack Burchum, J. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician (2nd ed.). Saunders.
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Collapse SubdiscussionTarah Marie Coronado Thank you for your post Michelle. Can you provide the typical dosing for levaquin when prescribing it for CAP?
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Collapse SubdiscussionMichelle Rogers Dr. Coronado,
I took your advice and downloaded epocrates. I upgraded it to epocrates+. This app is so helpful, so thank you! I think I will be able to use it when I start my practicum and currently, it will help me to double-check the orders that have been placed on my patients if I am not familiar with them. Typically, if a patient were outpatient and the prescriber wanted to order Levaquin, they would order levofloxacin 750mg PO once daily for seven days. For inpatient, this dose would be the same but in an IV form. They could then be switched to an oral form to complete their treatment outpatient (Community Acquired Pneumonia Treatment Options, n.d.).
References
Community acquired pneumonia treatment options. (n.d.). Epocrates Online. Retrieved March 3, 2023, from https://online.epocrates.com/diseases/17/community-acquired-pneumonia#treatment-optionsLinks to an external site.
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Collapse SubdiscussionEleanore Dillon Main Post
Working in the acute care setting of hospitals over the past years has made me realize there is quite a bit of pressure on doctors and nurse practitioners while prescribing different medications as so many factors go into each prescribed medication, both internal and external factors playing a role. What can make the hospital setting such a tough place to prescribe medications that I have noticed is that doctors and nurse practitioners have to keep in mind not only the acute issues that are going on with their patients but also their co-existing problems and the home medications that they are taking. Marinović et al., (2021) explain the transfer of care period for patients between different healthcare facilities is an important and critical time for patients and is when many unintentional prescription errors occur the most that leads to poor patient outcomes. Obtaining the exact medications that the patients are home can sometimes be a very difficult task as they are seen by many different doctors, they have multiple different medication lists that are not updated, family members are only able to remember some of their loved one’s medications, the list goes on but obtaining an up to date current medication list for patients in the hospital can be a very difficult task making prescribing new medication for their current condition an even tougher situation. Sabatino et al., (2017) explain that for new prescribers’ medication selection as well as dosage were what caused the most errors, in the acute setting this makes sense as it can be hard to know exactly what to prescribe and what will work for patients if their home and prior medications are not certain. Sabatino et al., (2017) also explain that lack of knowledge of the exact prescription information leads to prescription errors. Interestingly enough, Ross et al., (2021) explains that while scheduled medications have the ability for prescription error, there is a higher error margin for PRN prescriptions as these medications have many different uses and are prescribed by different providers for different uses with different parameters.
A scenario that I have came across many different times that have caused some problematic situations lie with PRN medications after orthopedic surgeries in particular. The orthopedic surgeon will prescribe a PO pain medication as well as a IV breakthrough pain medication for post-op, many times these patients are also seen and admitted by a hospitalist who at the time of admission prescribes PRN IV and PO pain medications. It is a tricky situation because after the operation many times these patients have multiple different types of pain medications, and I have seen many of times where patients receive an excessive amount of pain medications without the nurses being aware as they were giving one of the types that were prescribed PRN while another nurse was giving one of the other PRN pain medications. This scenario is especially problematic for the elderly who are having surgeries on their hips and knees as some of that population gets hit very hard by narcotics. The set of pain medications that are prescribed post-op by the orthopedic surgeon are usually part of a power-plan it is called, a set of generalized orders that gets initiated when the patient hits the floor from surgery. While those pain medications that are automatically prescribed PRN can be effective for some, and maybe too much for others like the situation explained above, other times it is not enough for many patients that are going through orthopedic surgery as they have an extensive history of prior medical conditions in which they were taking pain medications prior to the surgery building up their tolerance, making controlling their pain very difficult. While the automated power-plan is in place to be helpful, as explained above it has seemed to be more troubling and is being looked at to be adjusted to help avoid situations. Also again as mentioned above, on top of those prescribed medications, many of these patients have a laundry list of home medications that are sometimes reconciled prior if able and sometimes not.
A plan of care for elderly patients that end up receiving too much pain medication unintentionally post-op ideally starts from their admission, the nurse, doctor, NP, and medication technician working to get the most up-to-date medication list from the patient or family. Once that is obtained, discuss with both the hospitalist of the patient as well as the orthopedic surgeon what is already prescribed for pain from admission, what the orthopedic surgeon plans on prescribing for that specific case the patient’s pain goals. Once it is understood what will work best for the elderly patient, the nurse can make sure and communicate with both doctors if there are still a multitude of different pain medications in the PRN sections and which ones to discontinue to ensure that there is not many different ones being given with the hospitalist thinking the orthopedic surgeon has their pain covered and the orthopedic surgeon thinking the hospitalist has it covered. Keeping the patient if they are alert and oriented times four or if not the family in the loop as well is very important so that any adverse reactions from pain medication in the past are known, and the staff can obtain which medications have worked the best for the patient in the past. While this plan seems like common sense and knowledge, in the acute hospital setting getting something like this to actually happen can be so tough as we know due to the high-stress level and working conditions the healthcare field is currently experiencing.
Marinović, I., Bačić Vrca, V., Samardžić, I., Marušić, S., Grgurević, I., Papić, I., Grgurević, D., Brkić, M., Jambrek, N., & Mesarić, J. (2021). Impact of an integrated medication reconciliation model led by a hospital clinical pharmacist on the reduction of post‐discharge unintentional discrepancies. Journal of Clinical Pharmacy and Therapeutics, 46(5), 1326–1333. https://doi.org/10.1111/jcpt.13431
Ross, S. L., Bhushan, Y., Davey, P., & Grant, S. (2021). Improving documentation of prescriptions for as-required medications in hospital inpatients. BMJ Open Quality., 10(3)https://doi.org/10.1136/bmjoq-2020-001277
Sabatino, J. A. , Pruchnicki, M. C. , Sevin, A. M. , Barker, E. , Green, C. G. & Porter, K. (2017). Improving prescribing practices. Journal of the American Association of Nurse Practitioners, 29 (5), 248-254. doi: 10.1002/2327-6924.12446.
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Collapse SubdiscussionTrista Shontae Ashburn Response #2
Reply to Eleanore
You make a very valid point about difficulties with medication reconciliation. Patients often have multiple providers, including primary care and specialty care providers, who may manage their medications. Patients must be educated on the importance of being aware of their medication management. When patients are aware of and involved in their medication management, this allows them to control their care and, most importantly, ensure their safety (Härkänen & Vehviläinen-Julkune, 2020).
Nurses spend so much time providing direct patient care that they often notice patient condition changes before anyone else. Therefore, nurses must familiarize themselves with medications’ side effects and adverse effects to prevent adverse events. When prescribing medications, providers often account for the risks and benefits of using certain medications (Rosenthal & Burchum, 2021). Patient safety is vital.
References
Härkänen, M., & Vehviläinen-Julkune, K. (2020). Journal of Advanced Nursing. https://doi.org/10.1111/(issn)1365-2648Links to an external site.
Rosenthal, L., & Burchum, J. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.). Saunders.
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Collapse SubdiscussionTarah Marie Coronado Thank you for your post Eleanore. I believe that it can be very difficult to review the medications a patient is currently taking prior to surgery. Are there any specific pain medications that you see the IV and PO issues often?
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Collapse SubdiscussionEleanore Dillon Dr. Coronado,
Generally post-op the doctors are prescribing either dilaudid or morphine IV for breakthrough pain, while I do not pin any specific issues on either exact medication, the biggest issue we do run into is with IV breakthrough pain medication post-op. Almost every case these elderly patients receive obviously anesthesia, nerve blocks and in PACU they are often given strong pain medication. While PACU is very good at calling report usually, what I have been seeing most is the patients primary nurse forgets or doesnt keep in mind the pain medications that were given in PACU which is easy to do when you have the patient screaming in pain and or family members heckling you about the patients pain, so on the floor the IV breakthrough pain medicine is given and that is when the issue arises. The elderly patients accidentally get overdosed and have to be treated with narcan due to the overload of pain medicine in the short time from PACU and back up to the floor. PO pain medication I believe is the best option right after surgery back up on the floor if the patient is alert enough and able to swallow as it takes a little longer to kick in decreasing the chance of snowing the patient and lasts a little bit longer to help releive their pain.
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Collapse SubdiscussionKacella Mills Discussion: Pharmacokinetic and Pharmacodynamic Processes
Within my clinical experience, I have encountered a wide range of patient populations from pediatrics to generics, medical patients with either chronic or acute conditions, and my favorite, behavioral health. When considering how a patient’s pharmacokinetic and pharmacodynamic processes may alter his or her response to a drug, a particular event comes to mind. Working in an inpatient behavioral health setting, I have always enjoyed monitoring how patients respond to their specific medication treatment plans. Based on my observations, there can be circumstances where treating the behavioral population can be challenging when finding the right medications that effectively diminish the patient’s symptoms.
Looking back on my experience, I worked with one male patient who presented with severe manic symptoms but was only prescribed an oral antipsychotic. This medication regimen did not improve symptoms causing the provider to increase the dosage twice. This resulted in the patient acquiring neuroleptic malignant syndrome (NMS). NMS is considered a life-threatening syndrome associated with the use of dopamine-receptor antagonist medications or the rapid withdrawal of dopaminergic medications (Simon et al, 2022). Secondly, the patient started to gain weight rapidly. Antipsychotics are associated with body weight gain and metabolic disturbance (Bak, 2021). This all caused the patient’s family to become very discouraged and then transfer the patient to an alternative hospital.
As a nurse who has worked with this patient several times, I disagreed with the provider’s choice of drugs. Due to the severity of this patient’s symptoms, a mood stabilizer would be an appropriate choice of medication to be added instead of solely increasing the oral antipsychotic. In cases of psychotic symptoms, risky behaviors, and inadequate compliance to treatment, mood stabilizers should be used with antipsychotics (Atagun & Oral, 2021). To add, based on research, NMS is more common in males than females (Chang et al, 2022). This is something that should be taken into consideration when prescribing to specific populations. Poor patient outcomes as such should be taken as a learning lesson to strengthen the skills of a provider.
References
Simon, L. V., Hashmi, M. F., & Callahan, A. L. (2022). Neuroleptic Malignant Syndrome. In StatPearls. StatPearls Publishing.
Bak, M., Drukker, M., Cortenraad, S., Vandenberk, E., & Guloksuz, S. (2021). Antipsychotics result in more weight gain in antipsychotic naive patients than in patients after antipsychotic switch and weight gain is irrespective of psychiatric diagnosis: A meta-analysis. PloS one, 16(2), e0244944. https://doi.org/10.1371/journal.pone.0244944
Atagün, M. İ., & Oral, T. (2021). Acute and Long Term Treatment of Manic Episodes in Bipolar Disorder. Noro psikiyatri arsivi, 58(Suppl 1), S24–S30. https://doi.org/10.29399/npa.27411Links to an external site.
Chang, C.K., Payus, A.O., Noh, M.M. et al. (2022). Neuroleptic malignant syndrome secondary to olanzapine, a presentation with severe acute kidney injury requiring hemodialysis: a case report. J Med Case Reports 16, 366 (2022). https://doi.org/10.1186/s13256-022-03591-5
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Collapse SubdiscussionTarah Marie Coronado Thank you for your informative post. What specific mood stabilizer would you consider for this type of patient?
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Collapse SubdiscussionKacella Mills Hello Dr. Coronado,
Thanks for your feedback. Based on this patient’s clinical presentation, starting them on lithium would likely help to suppress their manic symptoms. Lithium has been the treatment of choice for patients with bipolar disorder for nearly 70 years (Volkmann et al 2020). During my experience, I have seen patients respond very well to this medication, therefore it has been proven to be highly effective.
References
Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium Treatment Over the Lifespan in Bipolar Disorders. Frontiers in psychiatry, 11, 377. https://doi.org/10.3389/fpsyt.2020.00377
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Collapse SubdiscussionEleanor Mary Grace Gillett-Chambers Hello Kacella Mills
Thanks for sharing your previous clinical experience with the class. I understand that some of these experiences may repeat or re-experienced in different facilities with different patients but having prior experience such like yours can really lead to positive patient outcome. The antipsychotic medications more so those targeting dopamine receptors have potential of causing weight gain and in chronic use cases can lead to neuroleptic malignant symptoms (Chang et al, 2022). The most important thing is understand how the neuroleptic malignant symptoms present and the steps that should be taken whenever the symptoms are noticed. The most effective way of managing neuroleptic malignant symptoms is to stop the medication however if there is risk of the patient developing severe withdrawal symptoms when the medication is stopped abruptly, the doses should be reduced. Concerning the weight gain, the client should have been informed early enough that the medication prescribed has potential of causing weight gain thus the patient should be advised to observe diet and practice regular exercise (Bak et al, 2021).
References
Bak, M., Drukker, M., Cortenraad, S., Vandenberk, E., & Guloksuz, S. (2021). Antipsychotics result in more weight gain in antipsychotic naive patients than in patients after antipsychotic switch and weight gain is irrespective of psychiatric diagnosis: A meta-analysis. PloS one, 16(2), e0244944. https://doi.org/10.1371/journal.pone.0244944
Chang, C.K., Payus, A.O., & Noh, M.M. (2022). Neuroleptic malignant syndrome secondary to olanzapine, a presentation with severe acute kidney injury requiring hemodialysis: a case report. J Med Case Reports 16, 366 (2022). https://doi.org/10.1186/s13256-022-03591-5Links to an external site.
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Collapse SubdiscussionEleanore Dillon Kacella,
I applaud you and your work in the mental health field as I know it can be very tough. Psychiatric medications are a class of medications that I believe are very tough to maintain, many doctors do not look fully into their dosage history and reactions to other medications and just put in quick dosage and medication changes without looking at the patient as a whole. While a dosage change may not seem like a giant treatment change, in psychiatric medications it really can be just as you explained the patient acquiring neuroleptic malignant syndrome. I have had so many patients in which they are on multiple different anti-psychotics with all different dosages, they end up in the hospital because their bodies are reacting poorly to the medications, but they have acquired all the new prescriptions and dosages from their primary care provider. The hospital that I am currently at does not have psychiatry in house so we use a tele-pysch service which I do not fully agree with either because the same thing kind of happens, they talk to the patient through a computer screen for maximum five minutes and ad some type of psychiatric medication without looking at the patients full history. One factor that may be obvious but I think gets overlooked on how a patient reacts to psychiatric medication is the prescriber looking closely at all of the patients medications that they are on for all different conditions as well as their history of medications taken and responses. Begum et al., (2020) explains that 60% of medical professionals who are prescribing anti-psychotic medications have minimal knowledge on the drugs action and adverse reactions against other medications. Just as you mentioned the sex of the patient as well as the age also can play major roles in how the patient reacts to different antipsychotic and psychiatric medications in general. One other aspect that can deeply impact how a patient is able to handle psychiatric medications is the function of their liver and kidneys, in the acute setting I have seen many patients who come in for something totally unrelated to their mental health issues, they continue their psychiatric medications as ordered but while in the hospital end up getting acute kidney injury from their current sickness that brought them in. With their temporarily injured kidneys, some of the psychiatric medications have caused adverse reactions to these patients that are new to them because their kidneys are not working at their baseline level. Kreyenbuhl et al., (2017) explain that there are specific clinical guidelines that are to be followed for monitoring metabolic parameters for those patients that are taking anti-psychotics but adherence to this monitoring standards are at an extremely low rate leading these patients to experience avoidable reactions, sometimes life-threatening.
Begum, F., Mutsatsa, S., Gul, N., Thomas, B., & Flood, C. (2020). Antipsychotic medication side effects knowledge amongst registered mental health nurses in England: A national survey. Journal of Psychiatric and Mental Health Nursing, 27(5), 521–532. https://doi.org/10.1111/jpm.12600
Kreyenbuhl, J., Dixon, L. B., Brown, C. H., Medoff, D. R., Klingaman, E. A., Fang, L. J., Tapscott, S., & Walsh, M. B. (2017). A randomized controlled trial of a patient-centered approach to improve screening for the metabolic side effects of antipsychotic medications. Community Mental Health Journal, 53(2), 163–175. https://doi.org/10.1007/s10597-016-0007-5
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Collapse SubdiscussionCatherine Edith Weisenberger Kacella,
Thank you for your input this week related to pharmacokinetics and pharmacodynamics. Both are to be considered when prescribing and administering medications. Pharmacokinetics describes how a medication moves throughout the body systems, while pharmacodynamics describes the changes the body goes through in response to the medication (Rosenthal & Burchum, 2021).
While working in emergency medicine, I have administered antipsychotics, mood stabilizers, and antidotes related to all these. When a patient arrives at the emergency department in an acute agitation state with harm to self or others (and as a last resort), we will administer what we call “B52”. This a combination of 25-50 mg Benadryl IM, 1-2 mg lorazepam IM, and 2.5-10 mg haloperidol IM. If available, these do base on various ages, weights, and past medical history. My hospital primarily administers 5 mg Haloperidol, 2 mg lorazepam, and 50mg diphenhydramine IM. Studies have found using lorazepam and haloperidol alone is just as effective. However, diphenhydramine was added to prevent extrapyramidal symptoms (ESP) (Jeffers et al., 2022).
References
Rosenthal, L. D., & Burchum, J. R. (2021). Pharmacokinetics, Pharmacodynamics, and Drug Interactions. Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed., pp. 13–22). Elsevier.
Jeffers, T., Darling, B., Edwards, C., & Vadiei, N. (2022). Efficacy of Combination Haloperidol, Lorazepam, and Diphenhydramine vs. Combination Haloperidol and Lorazepam in the Treatment of Acute Agitation: A Multicenter Retrospective Cohort Study, The Journal of Emergency Medicine, 62 (4), 516-523. https://doi.org/10.1016/j.jemermed.2022.01.009Links to an external site.
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Collapse SubdiscussionMikayla Butkus Response #2
Kacella, you are absolutely right, treating the behavioral health population can be very challenging. Unlike a bacterial infection that often requires a specific type of antibiotic, finding the most effective medication to treat behavioral health disorders requires trial and error. For example, lithium may be most effective medication for one patient, but this may not be the case for another. According to Arango et al., 2015, “no one treatment will be adequate for all patients” (p. 547). Like you, I am surprised that the patient was only on an antipsychotic. Typically, a mood stabilizer, like lithium or Depakote, is the first line of treatment (Lee & Swartz, 2017). If these medications are not effective, then an atypical antipsychotic can be added (Lee & Swartz, 2017). This is especially true for manic episodes. I wonder if this patient had failed responses to lithium and Depakote in the past. According to Jauhar & Young, 2019, “For people who are intolerant or unable to adhere to lithium use, maintenance treatment with antipsychotics is reasonable” (p. 7).
References
Arango, C., Kapur, S., & Kahn, R. S. (2015). Going beyond “trial-and-error” in psychiatric treatments: OPTiMiSE-ing the treatment of first episode of schizophrenia. Schizophrenia bulletin, 41(3), 546–548. https://doi.org/10.1093/schbul/sbv026Links to an external site.
Jauhar, S., Young, A.H. (2019). Controversies in bipolar disorder; role of second-generation antipsychotic for maintenance therapy. Int J Bipolar Disord 7, 10. https://doi.org/10.1186/s40345-019-0145-0
Lee, J., & Swartz, K. L. (2017). Bipolar I Disorder. In Johns Hopkins Psychiatry Guide https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/Links to an external site.787045/all/Bipolar_I_Disorder
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Collapse SubdiscussionRex Boyson Patulin Olpoc Pharmacokinetics is the mechanism of how the body affects the drug and pharmacodynamics is how the drug affects the body (Rosenthal & Burchum 2021). My patient was a 41-year-old male lawyer who was admitted due to an exacerbation of asthma and positive headache. He has been taking albuterol for this. He usually works until around midnight or 1 pm and rarely gets enough hours of sleep. He has a family history of hypertension and hypercholesterolemia on both sides. Vital signs reveal a BP of 180/90 mmHg. Total cholesterol is 250 mg/dL and LDL of 145 mg/dL. Propanolol was prescribed by the admitting resident physician. Patient had quite a few asthma attacks during admission until the providers had figure out that it was because of a drug–drug interaction – the propanol was reducing the effect of albuterol which was intended to dilate the bronchi. This is an example of pharmacodynamic interactions. Atorvastatin was also prescribed after doing hepatic panel. He was advised to avoid eating or drinking grapefruit products with this medication. According to the United States Food and Drug Administration (2021), grapefruit product is an inhibitor to the CYP3A4 in the small intestine, a specific isoenzyme form that comprises the cytochrome P450 enzymes (catalyze the majority of drug metabolism). Grapefruit can block CYP3A4’s action; therefore, more of the statin enters the plasma and remains in the body longer instead of being metabolized. Also, please note that each person has different amounts of the said isoenzyme. The inhibition of CYP enzyme is an example of pharmacokinetics. It was the pharmacist who informed the prescriber to relay the health teaching to the patient. A pharmacist is a good resource person for patients, medical providers, and other healthcare workers. Sabatino et al. (2017) found that pharmacist-led educational intervention resulted in (a) improvement of the FNP’s prescribing abilities, (b) majority of the students claiming that they were prepared to prescribe medications, and (c) perceptions as regards collaboration with a pharmacist in future practice was tagged important
References
United States Food and Drug Administration. (2021). Grapefruit juice and some drugs don’t mix. Department of Health and Human Services. https://www.fda.gov/consumers/consumer-updates/grapefruit-juice-and-some-drugs-dont-mix
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Sabatino, J. A. , Pruchnicki, M. C. , Sevin, A. M. , Barker, E. , Green, C. G., & Porter, K. (2017). Improving prescribing practices. Journal of the American Association of Nurse Practitioners, 29 (5), 248–254. https://doi.org/10.1002/2327-6924.12446
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Collapse SubdiscussionTarah Marie Coronado Thank you for sharing information on drug interactions Rex. Drug interactions are a very important part of prescribing. We have to be aware of what drugs the patient currently takes prior to prescribing something new. You discussed two great examples.
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Collapse SubdiscussionJaye Annoh Rex thank you for your post. I have administered albuterol in the emergency room countless times without issue, however I never considered possible drug interactions. When using albuterol, it is never desirable to have less of an affect. There are some drug-drug interactions that are needed, if the effects are the same direction. Drug-drug interactions (DDIs) occur when one drug alters the activity of another drug. Drug interactions may be both pharmacokinetic (PK) and pharmacodynamic (PD) in nature (Niu et. al., 2020). One example of a wanted DDI would be with pain medication or antibiotics.
Niu J, Straubinger RM, Mager DE. (2020). Pharmacodynamic drug-drug interactions. Clin Pharmacol Ther. 2019 Jun;105(6):1395-1406. doi: 10.1002/cpt.1434. Epub 2019 Apr 26. PMID: 30912119; PMCID: PMC6529235.
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Collapse SubdiscussionMichelle Rogers Rex,
I briefly worked in an outpatient setting to administer subcutaneous allergy shots. Propanolol and other betablockers have also been known to interfere with epinephrine. Epinephrine works by stimulating beta-1 adrenergic receptors in the heart and beta-2 adrenergic receptors in the lungs. Betablockers stop this effect, therefore making epinephrine less effective and increasing the risk of severe anaphylactic shock (Ledford, n.d.). This is not to say that patients who carry an epinephrine auto-injectors can not take betablockers, but other options should be considered for their treatment if possible.
References
Ledford, D. K. (n.d.). Epinephrine therapy & receiving beta blocker treatment. American academy of allergy, asthma, & immunology. Retrieved February 9, 2021, from https://www.aaaai.org/allergist-resources/ask-the-expert/answers/old-ask-the-experts/epi#:~:text=Noncardioselective%20beta%2Dblockers%2C%20in%20particular,adrenergic%20receptors%20in%20the%20heart.Links to an external site.
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Collapse SubdiscussionEleanor Mary Grace Gillett-Chambers Hello Rex Boyson Patulin Olpoc
Thank you for sharing with us your previous clinical experience for educational purpose. Indeed, having a better understanding of the pharmacokinetic and pharmacodynamics concepts is paramount in medical field especially for prescribers, dispensing pharmacists and even nurses who administer the drugs to patient (Rosenthal, & Burchum, 2021). I have come to understand the importance of asking patients about their previous or past medical histories and current medications they might be using. This is because the knowledge of past medical history and current medication would help the prescriber to understand how to develop a treatment regimen void of possible pharmacodynamics interactions based on past medical history and pharmacokinetic interactions based on current medication use (Sabatino et al., 2017). As for the experience you have shared, propranol and all other beta 2 blockers are contraindicated in patients with asthma attack due to risk of bronchoconstriction thus you did well to stop the medication and educating the patient about the same. Some food substances also interact with drugs thus patients need to be educated about the food to avoid while using certain medications (Rosenthal, & Burchum, 2021).
References
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Sabatino, J. A. , Pruchnicki, M. C. , Sevin, A. M. , Barker, E. , Green, C. G., & Porter, K. (2017). Improving prescribing practices. Journal of the American Association of Nurse Practitioners, 29 (5), 248–254. https://doi.org/10.1002/2327-6924.12446
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Collapse SubdiscussionEleanor Mary Grace Gillett-Chambers Pharmacokinetics and Pharmacodynamics
Patient Case Summary
The patient was 61-years-old Hispanic male with bipolar disorder and had been taking Lithium 300 mg once daily. On encountering the client, he reported stopping the Lithium intake citing its side effects as major contributor. He confirmed to have experienced blackouts, blurred vision, facial muscle spasms and excessive thirstiness while using Lithium. The client had chronic kidney disease and attending dialysis on weekly basis.
Factors Influencing Pharmacokinetic and Pharmacodynamic Processes of the Patient
The patient had developed Lithium toxicity owing the reported symptoms after taking Lithium. Lithium toxicity occurs when the levels of Lithium in the blood serum is above the therapeutic levels of roughly 1.5 mEq/L (Oruch et al., 2019). One of the contributing factors of Lithium toxicity development is underlying kidney disease, reduced fluid intake, and definitely taking higher doses or overdosing among others. The patient has chronic kidney disease thus the elimination or excretion of Lithium must have been impaired (Nation et al., 2018). The Lithium dose of 300 mg daily is also too much high for an individual with chronic kidney disease. The other factor that could have contributed to Lithium toxicity is age. The client is older than 60 years thus the rate of drug metabolism and excretion is reduced leading to accumulation of drugs in the body thus risk of toxicity (McCallum et al., 2019). The patient is also suspected to have not been taking sufficient fluids leading to concentration of Lithium in the blood.
Personalized Plan of Care Developed Based Patient History
The first thing that was done to the patient was stopping the Lithium and ordering the liver functions tests and Kidney functions tests. The patient was prescribed Lamotrigine as an alternative mood stabilizer (Sumatra et al., 2020). He was encouraged to take a lot of fluids. Since the patient had a medical insurance to cater for his medical expenses, the dialysis sessions were doubled thus he was supposed to attend dialysis twice a week as an attempt to eliminate any other chemical in his blood that could be potentiating toxicity (Oruch et al., 2019).
References
McCallum, L., Lip, S., & Padmanabhan, S. (2019). Pharmacodynamic Pharmacogenomics. Pharmacogenomics and Stratified Medicine, 19(3), 365-383. https://doi.org/10.1016/b978-0-12-386882-4.00018-9Links to an external site.
Nation, R. L., Bergen, P. J., & Li, J. (2018). Pharmacokinetics and pharmacodynamics of Lithium. Fundamentals of Pharmacokinetics and Pharmacodynamics, 16(4), 351-380. https://doi.org/10.1007/978-0-387-75613-4_14Links to an external site.
Oruch, R., Elderbi, M. A., Khattab, H. A., Pryme, I. F., & Lund, A. (2019). Lithium: A review of pharmacology, clinical uses, and toxicity. European Journal of Pharmacology, 740, 464-473. https://doi.org/10.1016/j.ejphar.2019.06.042Links to an external site.
Sumatra, S., Sumra, V., & Goldwin, G. (2020). Predicting pharmacokinetics in humans. Essential Pharmacokinetics, Pharmacodynamics and Drug Metabolism for Industrial Scientists, 16(2), 207-228. https://doi.org/10.1007/0-306-46820-4_12Links to an external site.
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Collapse SubdiscussionMichelle Rogers Eleanor,
I enjoyed reading your post and it brought back some memories for me. I spent several years working in a acute psychiatric hospital. I have met several patients who took lithium for their bipolar disorder. One thing I remember about lithium was that patients need to have a consistent sodium intake. Too much sodium can cause lithium levels to fall and too much sodium causes lithium levels to be higher.
With renal patients, I would have been very hesitant to prescribe lithium. Lithium contributes to kidney disease as it is nephrotoxic (McGrane et al., 2021). If the patient has end-stage renal disease (ESRD) and his kidneys will not get better, then this may be a safe option as his kidneys would no longer be functioning. The doses are potentially higher because dialysis clears a lot of lithium from the system because it is typically excreted through the kidneys. Therefore, 300mg per day would not be a large dose for a dialysis patient. However, this goes back to the first thing I mentioned. If the patient has not been consistent with their fluid or sodium intake, then their lithium levels are going to be altered.
Another factor may have influenced this patient’s compliance to his medications, fluid restrictions, and sodium restriction. Some of the side effects listed for lithium is polydipsia and polyuria (Rosenthal & Rosenjack Burchum, 2020). Hemodialysis patients are required to maintain a consistent fluid and sodium restriction. The patient may have become dehydrated to this. I agree with the provider’s choice to change this patient’s medication to a safer option. Lithium is highly effective but has such a narrow therapeutic window.
Again, thank you for writing about this. I am focusing on PMHNP and I am enjoying reading and learning more about the medications that I will potentially be prescribing.
References
McGrane, I. R., Omar, F. A., Morgan, N. F., & Shuman, M. D. (2021). Lithium therapy in patients on dialysis: A systematic review. The International Journal of Psychiatry in Medicine, 57(3), 187–201. https://doi.org/10.1177/00912174211028544Links to an external site.
Rosenthal, L. D., & Rosenjack Burchum, J. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician (2nd ed.). Saunders.
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Collapse SubdiscussionTarah Marie Coronado Thank you for your post. Age can be a huge factor in the pharmacokinetic and pharmacodynamic processes. As we age, our body changes and our kidneys and liver may start to show signs of impairment. Many drugs are either metabolized or excreted by one of these routes. Dose adjustments will need to be made if impairment of the kidneys or liver is present. If doses are not adjusted the concentrations of the drugs in the body will be effected and can cause adverse reactions. Lithium does have many possible adverse reactions and does have the potential to be toxic. Lithium can be affected by our salt and water intake. Great work.
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Collapse SubdiscussionNardos Gebeyehu Yalew Response #1
Eleanor,
I enjoyed reading your post regarding factors influencing the pharmacokinetics and pharmacodynamics of Lithium levels in this patient case scenario. I have also taken care of patients experiencing Lithium toxicity, and I agree with everything you have stated. The patient’s renal disease is a major contributing factor to this patient developing Lithium toxicity. Furthermore, the patient is elderly, which also plays a role because with age come changes in the body’s ability to absorb, metabolize, and distribute medications throughout the body. Kidneys are responsible for 95% of Lithium excretion additionally, the kidneys treat Lithium and sodium in a similar manner which is why sodium depletion can increase Lithium reabsorption (Hedya et al., 2022). Another reason this patient develops Lithium toxicity could be due to the types of food he consumes while on the medication. Therefore, patients that are on Lithium should monitor their sodium intakes and not make any changes in their intake because increased intake of sodium can deplete Lithium levels, while decreased intake can result in a rise in Lithium levels that could lead to toxicity.
Some interventions to add to this patient’s personalized care should include maintaining the same sodium intake and monitoring Lithium levels closely. According to McGrane et al. (2021), patients on dialysis should receive 300-900 mg lithium carbonate thrice weekly following dialysis and closely monitor levels of pre-dialysis serum Lithium concentration for at least two weeks after treatment initiation. Since this patient is older and has renal failure, I agree with the decision to stop the Lithium and initiate an alternative mood stabilizer. If this patient has had other comorbidities such as cardiovascular disease, the plan of care would mostly be similar. Lithium is not recommended in patients with cardiovascular disease due to its ability to cause reversible T wave changes and can unmask Brugada syndrome, which is a condition that affects the heart’s ability to conduct electrical signals through the heart (Chokhawala et al., 2022). If a patient has cardiovascular disease or other comorbidities and is experiencing Lithium toxicity, stopping the drug and hydration is the primary intervention.
In conclusion, for any patient experiencing Lithium toxicity, it is critical to stop the medication and give the patient hydration, and for those with renal disease, start hemodialysis to extract it out of the body and put the patient on different medication or closely monitor Lithium levels and restarting medication are the typical care plan.
References
Chokhawala, K., Lee, S., & Saadabadi, A. (2022, July 11). Lithium. National Library of Medicine. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK519062/
Hedya, S. A., Avula, A., & Swoboda, H. D. (2022, January 28). Lithium toxicity . National Library of Medicine. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK499992/
McGrane, I. R., Omar, F. A., Morgan, N. F., & Shuman, M. D. (2021). Lithium therapy in patients on Dialysis: A systematic review. The International Journal of Psychiatry in Medicine, 57(3), 187–201. https://doi.org/10.1177/00912174211028544
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Collapse SubdiscussionRex Boyson Patulin Olpoc Discussion Response 1
Hi Eleanor,
Thank you for your post. Based on your discussion, I assume that the patient was taking lithium for long-term treatment of his bipolar disorder. Just to add on the information you have shared, according to Mayo Clinic (2023), persons greater than 6 years old and weighing more than 30 kg have a dosage of 300 mg to 600 mg or 5 ml to 10 ml 2 to 3 times a day. I believe that this is for patients with no underlying kidney or liver disease. His dose of 300 mg once a day was below the recommended dose knowing his frequency was just once a day, but the fact that he has CKD could be the secondary reason why he was experiencing those symptoms and so the 300 mg OD is not relevant. As you have mentioned, he developed lithium toxicity which I am not surprised because of his underlying condition. Moreover, sodium also plays a role in the regulation of lithium levels in the body (although this does not directly or necessarily apply to your patient). According to McCance and Huether (2019), lithium is usually removed from normal kidneys, but when the body has low sodium, the kidneys will reabsorb sodium together with lithium. Thus, a person who is taking lithium should prevent themselves from getting dehydrated or avoid physical activities which then cause sweating. Again, thank you for sharing Eleanor.
References
Mayo Clinic. (2023, March 1). Lithium (oral route). https://www.mayoclinic.org/drugs-supplements/lithium-oral-route/proper-use/drg-20064603
McCance, K. L. & Huether, S. E. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby/Elsevier.
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Collapse SubdiscussionRahel D Woyessa Discussion post – week 1
I work at a federal prison; our operations and drug administrations are different from regular hospitals. We have ambulatory care, mental health, and inpatient medical units. We run pill lines in our ambulatory care and mental health units but our inpatient care units run the same as community hospitals.
I took care of a 40-year-old African American male, in one of our ambulatory care units 4 years ago; I refer him as Mr. M. He had to come to the pill line windows to take his medicine. Mr. M was diagnosed with hypertension that was not well controlled; his blood pressure was in the 200s/100s on a daily basis. He was on Amlodipine 10mg, Hydralazine 50mg, and a clonidine patch 0.1mg. at the time but he wasn’t compliant with his medications. He had missed his medicine for whatever reasons, he didn’t want to get up in the morning or if he is upset with another inmate or staff. I personally educated him on numerous occasions about the importance of medication compliance to prevent stroke and possible death but he continued to refuse.
He was admitted to ICU on multiple occasions for extended period of time to hypertensive crisis and cost taxpayers a lot of money. According to Rosenthal and Burchum, medications nonadherence costs the U.S. health care system approximately $240billion each year (2021).
I happen to care for him last week on a different unit but an ambulatory care setting. He is diagnosed with end stage renal disease and on dialysis at this time; he uses a wheelchair and appears 20 years older than his age. His current blood pressure medicine is only Carvedilol 12.5mg once a day. His last three blood pressures were: 101/63, 215/128, and 200/120 so it is still not controlled.
Factors that may have affected pharmacokinetics and pharmacodynamics processes: I’m going to discuss his current blood pressure medicine, Carvedilol 12.5 mg daily.
According to Singh and Preuss, carvedilol is a non-selective adrenergic blocker indicated for the chronic therapy of heart failure with reduced ejection fraction, hypertension, and left ventricular dysfunction following myocardial infarction in clinically stable patients. Carvedilol has peripheral vasodilating effect and it also maintains cardiac output by decreasing afterload in conjunction with a cardiac beta-blockade and decreases blood pressure. It is very useful for patients with renal disease. Hypotension is it’s most common adverse effect due to its vasodilating properties. Other adverse effects are dyspnea, bronchospasm, bradycardia, malaise, and asthenia. Adverse drug reactions include weight gain, depression, impotence, and memory loss. It is essential to recognize that abrupt discontinuation of carvedilol can lead to rebound hypertension (2022). As it is stated by Stafylas & Sarafidis, carvedilol is rapidly absorbed after an oral dose and its peak is with in 1 to 2 hours. Food delays its absorption if taken together. Carvedilol’s half life is from 7 to 10 hours in most people. In plasma, 98% of the drug is bound to plasma proteins, predominantly to albumin. Carvedilol is almost exclusively metabolized by the liver and its metabolism is affected by genetic polymorphism of cytochrome P-450 2D6 activity.
Communication: I will continue to educate the patient about the consequences of skipping his medication.
A personalized plan of care/ collaborative effort: Since we run pill lines, nurses need to check on him when he does not show up at the pill line and deliver his pills to him if necessary. I will enter a note in our 24-hour report for a float nurse to know to deliver his medicine in his room. I will contact administration to transfer him to an inpatient unit until his blood pressure is controlled.
Follow-up: I will also follow up on his chronic care visit more often.
References
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice
nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
Singh S, Preuss CV. Carvedilol. [Updated 2022 Sep 22]. In: StatPearls [Internet]. Treasure Island
(FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK534868/
Stafylas, P. C., & Sarafidis, P. A. (2008). Carvedilol in hypertension treatment. Vascular health
and risk management, 4(1), 23–30. https://doi.org/10.2147/vhrm.2008.04.01.23
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Collapse SubdiscussionJaye Annoh Rahel,
Thank you for your detailed post. I believe the education of these medications cannot be stressed enough. I have worked in the correctional setting, and it is more difficult to manage since two or more shifts deliver medications to the inmates. I found this particularly hard with antibiotics. Missing doses of antibiotics for patients can result in negative outcomes. It appears that delivering antibiotics to patients on schedule is important and consistent with efforts to improve quality (Patel et. al., 2019). With the constraints of staffing, complying with quality standards remains difficult. From your post, I see that you have taken additional care for the health of that inmate. Thank you for all you do.
Patel, C., Swartz, M., Tomasek, J., Vincent, L., Hallum, W., Holcomb, J. (2019). The effects of missed doses of antibiotics on hospitalized patient outcomes, Journal of Surgical Research, Volume 233, Pages 276-283, ISSN 0022-4804, https://doi.org/10.1016/j.jss.2018.08.015.
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Collapse SubdiscussionRandall Alan Jessup Week 1 Discussion Response 2
Rahel D Woyessa
Thanks for the discussion post on this interesting case. ESRD and HTN often go hand in hand. this patient’s care was complicated I am sure by the fact he is incarcerated.
Globally, chronic kidney disease (CKD) is on the rise, and it has an impact on incident cardiovascular disease (CVD). A majority of CKD patients suffer from hypertension, both as a cause and as an effect. Those with CKD should control their hypertension so that disease progression is slowed as well as CVD risk is reduced. There is no consensus among existing guidelines regarding the optimal blood pressure target (BP). When considering how to manage individuals, it is crucial to understand the evidence used to create these guidelines. The non-pharmacological interventions that may reduce BP in CKD are rarely sufficient to effectively control BP. The non-pharmacological interventions that may reduce BP in CKD are rarely sufficient to effectively control BP. The treatment of hypertension in patients with CKD often requires the use of a combination of anti-hypertensive medications. In addition to BP-dependent renoprotection, certain drugs can also provide cardioprotection and/or renoprotection.
Hypertension is more challenging to manage during hemodialysis and after kidney transplantation. Future treatments may be enhanced by new therapies. As BP targets are achieved, CVD risk is reduced and CKD progression is slowed, a personalized and evidence-based management plan remains crucial.
It is currently unclear which BP target is optimal, but existing guidelines base them on evidence favoring either renoprotective or cardioprotective interventions. The degree of risk reduction associated with pharmaceutical therapies aimed at achieving these targets also varies by patient characteristics. The degree of risk reduction associated with pharmaceutical therapies aimed at achieving these targets also varies by patient characteristics.(Pugh et al., 2019)references
Pugh, D., Gallacher, P. J., & Dhaun, N. (2019, March). Management of hypertension in chronic kidney disease. Drugs. Retrieved March 5, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6422950/
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Collapse SubdiscussionJaye Annoh Elderly Treatment
Having an in-depth understanding of the population you are caring for aids in providing the most effective treatment. Multiple factors affect the pharmacokinetic (PK) and pharmacodynamic (PD) processes of the patients. Elderly are susceptible to many adverse effects, because of the incidence of polypharmacy and higher prevalence of chronic diseases in this population, the chances of adverse reactions to the antibiotics are also greater. Thus, there should be a thorough and careful knowledge of the pharmacokinetic and pharmacodynamic aspects of prescribed drugs (Abraham, et. al., 2021).
Taking a closer look at an elderly patient being treated for Clostridium Difficile (C-Diff) and Methicillin-resistant Staphylococcus aureus, MRSA, the patient was given Vancomycin orally for C-diff and intravenously for MRSA. The (PK) of antibiotics may be significantly different in the elderly compared to young adults, especially for those that are renally cleared (Pea, 2018). Vancomycin is nephrotoxic making it important to verify the renal function of the patient using trough levels. Decline of renal function may significantly affect the PK of antibiotics in the patient. For treatment of the elderly, one would also want to consider the patient’s weight, reduced muscle mass, reduced adipose tissue and drug distribution that may be affected by secondary factors such as oedema caused by heart failure (Falcone, et.al.,2020). To understand the PD, important to know the medication’s site action. For C-diff, vancomycin treatment works effectively when given orally because the vancomycin given IV does not work in the digestive tract, while oral vancomycin would not work at other sites in the body.
Abraham, M. B. T., Krishnaprabha, C., Wilson, M. S., Davis, M. S., & Savo, M. S.(2021) Prescribing patterns and rational use of specific antibiotics in the elderly-review. International Journal of Pharmaceutical Research and Application, Volume 6, July- Aug 2021 ISSN: 2249-7781
Falcone, M., Paul, M., Tiseo, G., Yahav, D., Prendki, V., Friberg, L. E., … & Tinelli, M. (2020). Considerations for the optimal management of antibiotic therapy in elderly patients. Journal of global antimicrobial resistance, 22, 325-333.
Pea, F. (2018). Pharmacokinetics and drug metabolism of antibiotics in the elderly. Expert Opinion on Drug Metabolism & Toxicology, 14(10), 1087-1100.
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Collapse SubdiscussionTarah Marie Coronado Thank you for your interesting post Jaye. You did a great job discussing Vancomycin and the pharmacokinetics and dynamics behind it. Narrow therapeutic drugs may require specific dosing calculations or require extra attention with serum drug level monitoring. Vancomycin is a drug that requires these extra monitoring steps. Vancomycin is an interesting drug in that it requires a trough range of 10-20mg/L dependent on the type of infection. When vanco is infused too quickly adverse reactions can occur such as Red man syndrome. Vanco can also cause nephrotoxicity, as in your patient, and requires dose and frequency adjustments in renal impairment. The dose and frequency are often adjusted to decrease possible drug build up and toxicities. I enjoyed you discussing the differences in using this medication IV versus PO. Great work.
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Collapse SubdiscussionTrista Shontae Ashburn Response 1
Reply to Jaye
With elderly patients, it is essential to monitor for adverse effects of medications. Adverse effects are likely due to the aging process, chronic illnesses, and polypharmacy (Bouaoudate et al., 2022). Adverse effects of medications can increase patients’ hospitalization time and costly medical expenses. Jaye, your post is informative as it points out how IV vancomycin is ineffective for treating digestive tract disorders. If the proper treatment is not performed, it can also result in a delay in care.
As you mentioned, vancomycin is a nephrotoxic medication. Nephrotoxicity is reported to be one of the worst adverse effects of vancomycin (Wang et al., 2021). Some observations to make during treatment are renal function tests, and cloudy or pink urine, as these may be signs of nephrotoxicity (Vallerand & Sanoski, 2023). When prescribing medications, we must use evidence-based practice and follow guidelines to ensure our patients receive safe and effective treatment.
References
Bouaoudate, M., El harti, J., Abouqal, R., Abidi, K., & Zeggwagh, A. A. (2022). Polypharmacy-related polypathology in the elderly: A case study at Ibn Sina Hospital, Morocco. Tropical Journal of Pharmaceutical Research, 21(10), 2161–2166. https://doi.org/10.4314/tjpr.v21i10.17Links to an external site.
Vallerand, A. H., & Sanoski, C. A. (2023). Davis’s Drug Guide for Nurses (18th ed.). F.A. Davis Company.
Wang, Y., Dai, N., Wei, W., & Jiang, C. (2021). Outcomes and Nephrotoxicity Associated with Vancomycin Treatment in Patients 80 Years and Older. Clinical Interventions in Aging, Volume 16, 1023–1035. https://doi.org/10.2147/cia.s308878Links to an external site.
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Collapse SubdiscussionEleanore Dillon Peer response 1
Jaye,
You made many great points about the elderly population and the pharmacodynamic and pharmacokinetic processes that occur within that population. As you mentioned because of their age and much of the population with a number of co-morbidities this population is at such a high risk for adverse drug effects. Giarratano et al., (2018) explain that managing infections in the elderly population is a tough task as high age in itself is a major risk factor as well as the many different pharmacodynamics and pharmacokinetics the elderly population has. Since many of the elderly patients seen in the acute care setting and clinic setting have many different comorbidities, they often have a laundry list of medications that they are taking. Not only can all those different medications impact their systems in different ways, it can also put them at risk for adverse drug events. Oscanoa et al., (2017) explain that the elderly population receives the most medications putting them at high risk for adverse medication reactions, interestingly enough many of the adverse drug reactions are from drugs that were prescribed to help cure and alleviate diseases and conditions. As you mentioned there are many elderly patients that unfortunately acquire Clostridium Difficile from receiving antibiotics, as you mentioned antibiotics like vancomycin are very toxic to the renal system putting the elderly at risk for poor absorption of other medications. Another consideration for the elderly population and infection Giarratano et al., (2018) explain that as humans age the gastrointestinal tract goes through many different functional and pathological changes which leads to many different gastrointestinal functions changes such as delayed gastric emptying, reduced blood flow and major changes in the pH balance also which can also cause the elderly population to be even more at risk for infections like C.Diff. So while caring for the elderly population and managing infections not only is it important to take into account things like their renal systems being impacted, it is also important to keep in mind other systems that go through changes throughout the years of life such as the gastrointestinal tract.
References:
Giarratano, A., Green, S. E., & Nicolau, D. P. (2018). Review of antimicrobial use and considerations in the elderly population. Clinical Interventions in Aging, 13, 657-667. https://doi.org/10.2147/CIA.S133640Links to an external site.
Oscanoa, T. J., Lizaraso, F., & Carvajal, A. (2017). Hospital admissions due to adverse drug reactions in the elderly. A meta-analysis. European Journal of Clinical Pharmacology, 73(6), 759-770. https://doi.org/10.1007/s00228-017-225-3
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Collapse SubdiscussionRex Boyson Patulin Olpoc Response 2
Hello Jaye,
Thank you for your post. I can relate to patients with MRSA and C. diff being treated with vancomycin IV and vancomycin or metronidazole, respectively, in the skilled nursing facility where I worked before. My patients were also elderlies. I had one particular patient where she developed C. diff colitis infection for every time she had urgency, incontinence, and dysuria, she believed she had UTI and so she would request the doctor for antibiotic. Of course, we did the suspected UTI SBAR communication tool and most of the time she was indicated for urinalysis. We tried to educate her about the adverse effects of antibiotics for her UTI as a way to exercise good antibiotic stewardship, but she wanted things her way. She was prescribed with probiotics upon returning from the hospital aside from vancomycin by the medical director. According to Rosenthal and Burchum (2021), probiotics are dietary supplements with bacteria and yeast, e.g., lactobacilli and bifidobacterial and Saccharomyces boulardii, respectively, all of which are indicated for C. diff diarrhea (CDAD). On the other hand, I also encountered few patients who had MRSA pneumonia and was treated initially with IV vancomycin and was switched to oral linezolid 600 mg. According to the study done by Cua et al. (2022), oral linezolid was cost effective than IV vancomycin in treating MRSA pneumonia with comparable safety profile. This is just an additional information about treating MRSA, particularly, in patients with pneumonia, trying to get economic feasibility out of the alternative which is oral linezolid.
References
Cua, J., Takamura, K. Le, K. H., Serna, M., Roach, D., Zhu, E., & Pon, T. (2022). Cost comparison of oral linezolid and intravenous vancomycin for empiric treatment of suspected MRSA pneumonia. Journal of Contemporary Pharmacy Practice, 70 (2), 14–20. https://doi.org/10.37901/jcphp21-00005
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
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