Feb 23, 2024 NURS 6521: Basic Pharmacotherapeutic Concepts
NURS 6521: Basic Pharmacotherapeutic Concepts NURS 6521: Basic Pharmacotherapeutic Concepts Pharmacokinetics involves sequential processes, including absorption, distribution, metabolism, and excretion that occur in the body following drug administration (Arcangelo & Peterson, 2018). On the other hand, pharmacodynamics is the effect of a particular drug on the body. It includes side effects, physiological processes, and drug reactions. Unique patient features, including sex, age, and health condition, influence the two processes. My focus for this discussion purpose from my experience will be a 48-year-old male with diabetes mellitus Type 2. Scenario: 48-year-old male with diabetes type 2 who was diagnosed with diabetes since the age of 20 but recently started going into diabetic ketoacidosis frequently. Patients presents with blood glucose of 690. Patient takes multiple medications including Lyrica, Metformin, Atorvastatin, and Lisinopril for hypertension, renal disease, gout, coronary artery disease, and neuropathy. I do not recall all the medications he was on. Due to the complications of diabetes, these patients are usually prone to cardiovascular diseases, stroke, kidney diseases, vision alterations, among other diseases. Therefore, these patients are usually on many other drugs apart from the ones specified for diabetes mellitus. Struggling to Meet Your Deadline? Get your assignment on NURS 6521: Basic Pharmacotherapeutic Concepts done on time by medical experts. Don’t wait – ORDER NOW! Meet my deadline Factors affecting pharmacokinetics Liver metabolizes many drugs but with diabetic there is a decreased CYP 3A4 which is hepatic enzymatic activity and protein levels due to taking other medications for other complications brought about by diabetes (Uehara et al 2017). More often, these patients also experience an increase in glomerular infiltration rate causing excretion concerns related to micro vascular and macro vascular changes and renal function loss (Trevisan & Dodesini, 2017). There is also the effect of distribution due to the process of glycation where albumin has decreased affinity for some fatty acids decreasing efficiency of fatty acid grafted drugs (Gajahi Soudahome et al., 2018). Due to the different drugs that this patient was taking, there was the effect of decreased membrane permeability influenced by insulin induced capillary perfusion affecting absorption (McConell et al., 2020) Pharmacodynamics Metformin activates the enzyme adenosine monophosphate kinase (AMPK) which inhibits enzymes involved in gluconeogenesis and glycogen synthesis in the liver blocking the enzyme pyruvate carboxylase, while stimulating insulin signaling and glucose transport in muscles (Hunter et al., 2018). By blocking this enzyme, lactic acid accumulates causing lactic acidosis. This could happen with high doses of metformin or with patient with decreased renal clearance. This patient takes Lisinopril, ACE inhibitor, which lowers blood pressure by inhibiting the enzymes Angiotensin I and II which constricts blood vessels. Renal function can be decreased with chronic use of ACE inhibitors thus renal dosing is highly advised. Personalized Care This patient was seeing different doctors for diabetes, renal disease, and hypertension. Her medications were not revised by these providers hence the complications due to polypharmacy. For her personalized care, I would recommend her medications to be revised by the providers, a goal placed to focus on decreasing A1C, avoiding sedentary lifestyle including diet change, at home glycemic control, improved physical activity, and regular follow ups. References Uehara, S., Uno, Y., Nakanishi, K., Ishii, S., Inoue, T., Sasaki, E., & Yamazaki, H. (2017). Marmoset Cytochrome P450 3A4 Ortholog Expressed in Liver and Small-Intestine Tissues Efficiently Metabolizes Midazolam, Alprazolam, Nifedipine, and Testosterone. Drug Metabolism and Disposition, 45(5), 457–467. https://doi.org/10.1124/dmd.116.074898 McConell, G. K., Sjøberg, K. A., Ceutz, F., Gliemann, L., Nyberg, M., Hellsten, Y., Frøsig, C., Kiens, B., Wojtaszewski, J. F. P., & Richter, E. A. (2020). Insulin‐induced membrane permeability to glucose in human muscles at rest and following exercise. The Journal of Physiology, 598(2), 303–315. https://doi.org/10.1113/jp278600 Trevisan, R., & Dodesini, A. R. (2017). The Hyperfiltering Kidney in Diabetes. Nephron, 136(4), 277–280. https://doi.org/10.1159/000448183 Gajahi Soudahome, A., Catan, A., Giraud, P., Assouan Kouao, S., Guerin-Dubourg, A., Debussche, X., le Moullec, N., Bourdon, E., Bravo, S. B., Paradela-Dobarro, B., Álvarez, E., Meilhac, O., Rondeau, P., & Couprie, J. (2018). Glycation of human serum albumin impairs binding to the glucagon-like peptide-1 analogue liraglutide. Journal of Biological Chemistry, 293(13), 4778–4791. https://doi.org/10.1074/jbc.m117.815274 Hunter, R. W., Hughey, C. C., Lantier, L., Sundelin, E. I., Peggie, M., Zeqiraj, E., Sicheri, F., Jessen, N., Wasserman, D. H., & Sakamoto, K. (2018). Metformin reduces liver glucose production by inhibition of fructose-1-6-bisphosphatase. Nature Medicine, 24(9), 1395–1406. https://doi.org/10.1038/s41591-018 NURS 6521: Basic Pharmacotherapeutic Concepts”> In 2011, more than 3.7 billion medication prescriptions were filled in US pharmacies (The Kaiser Family Foundation, 2011). With billions of medications administered each year for the treatment and management of various conditions, advanced practice nurses must become aware with popular drug therapies and their impact on patients. The primary concern when prescribing medications is ensuring patient safety. Nurses work more closely with patients than any other health care worker in many clinical settings, making it their obligation to support physicians with this task. As an advanced practice nurse responsible for patient safety, you must take into account the numerous patient characteristics that influence pharmacotherapeutics. This week, you will investigate the elements that influence pharmacokinetic and pharmacodynamic processes in patients. You will also look at patient variables that advanced practice nurses must take into account while designing medication therapy plans. Students will have completed the following tasks at the conclusion of this week: Examine the variables that influence the pharmacokinetic and pharmacodynamic processes in patients.Assess patient variables and history to develop tailored plans of careUnderstand and apply key pharmacotherapeutic terminologies, concepts, and principles.Understand and apply important vocabulary, concepts, and principles related to geriatric medication prescribing. Photo Credit: Daniel Kaesler/EyeEm/EyeEm/Getty Images Learning Resources This page contains the Learning Resources for this week. Be sure to scroll down the page to see all of this week’s assigned Learning Resources. To access select media resources, please use the media player below. Required Readings Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins. Chapter 2, “Pharmacokinetic Basis of Therapeutics and Pharmacodynamic Principles” (pp. 17-31)This chapter examines concepts related to pharmacokinetics and pharmacodynamics. It also explores patient factors that health care providers consider when prescribing drug therapy to patients. Chapter 3, “Impact of Drug Interactions and Adverse Events on Therapeutics” (pp. 33-51)This chapter explains drug-drug, drug-food, drug-herb, and drug-disease interactions. It also reviews patient factors that influence drug interactions and then covers adverse drug reactions. Chapter 4, “Principles of Pharmacotherapy in Pediatrics” (pp. 53-63)This chapter explores concepts relating to drug selection, administration, and interaction for pediatric patients. It also compares age-related pharmacokinetic differences in children and adults. Chapter 6, “Principles of Pharmacotherapy in Elderly Patients” (pp. 73-89) This chapter describes issues and factors that affect drug therapy for elderly patients. It then explores concepts relating to drug selection, administration, and management for elderly patients. Click here to ORDER an A++ paper from our Verified MASTERS and DOCTORATE WRITERS: NURS 6521: Basic Pharmacotherapeutic Concepts American Geriatric Society 2015 Beers Criteria Update Expert Panel. (2015). American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. Retrieved on 8/8/2018 from https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.13702 This article is an update to the Beers Criteria which includes lists of potentially inappropriate medications to be avoided in older adults as well as newly added criteria that lists select drugs that should be avoided or have their dose adjusted based on the individual’s kidney function and select drug–drug interactions documented to be associated with harms in older adults. Weitzel, K. W., Elsey, A. E., Langaee, T. Y., Benjamin, B., Nessl, D. R., Obeng, A. W.,…Johnson, J. A. (2014). Clinical pharmacogenetics implementation: Approaches, successes, and challenges. American Journal of Medical Genetics, 0(1): 56–67. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4076109/ Drugs.com. (2012). Retrieved August 22, 2012, from http://www.drugs.com/ This website presents a comprehensive review of prescription and over-the-counter drugs including information on common uses and potential side effects. It also provides updates relating to new drugs on the market, support from health professionals, and a drug-drug interactions checker. Required Media Laureate Education, Inc. (Executive Producer). (2012). Introduction to advanced pharmacology. Baltimore, MD: Author. Note: The approximate length of this media piece is 8 minutes. In this media presentation, Dr. Terry Buttaro, Associate Professor of Practice at Simmons School of Nursing and Health Sciences, discusses the importance of pharmacology for the advanced practice nurse. The following document provides credit for Laureate-produced media within this course: Credits (PDF) Optional Resources The following resources are highly recommended for your professional library. You are encouraged to review these resources each week. Explain the ethical and legal implications of the scenario you selected on all stakeholders involved, such as the prescriber, pharmacist, patient, and patient’s family. Describe strategies to address disclosure and nondisclosure as identified in the scenario you selected. Be sure to reference laws specific to your state. Explain two strategies that you, as an advanced practice nurse, would use to guide your decision making in this scenario, including whether you would disclose your error. Be sure to justify your explanation. Explain the process of writing prescriptions, including strategies to minimize medication errors. Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: NURS 6521: Basic Pharmacotherapeutic Concepts Vancomycin and Renal Impairment Collapse Initial Post Patient Scenario The patient scenario to be discussed for the purpose of this discussion post is a patient being treated with intravenousvancomycin for a Methicillin Resistant Staphylococcus Aureus (MRSA) infection in a spinal surgical incision. The patient had multiple comorbidities; however, the most pertinent comorbidity is end-stage chronic renal disease. Common practice in this setting is to order pharmacokinetic services to monitor and assist with management of vancomycin administration. The monitoring includes laboratory studies including blood chemistries and vancomycin levels. During the monitoring, it was discovered the patient had an extremely high level of vancomycin in the blood which required holding the next scheduled dose, and changing the amount of Vancomycin provided in the next dose. Factors Influencing Pharmacokinetics and Pharmacodynamics Vancomycin is a glycopeptide antibiotic that is hydrophilic and cannot pass through the cells membranes through simple diffusion resulting in a need to be administered intravenously to achieve a systemic result (Zaric, et al., 2018). Vancomycin reaches a peak level, which is 63 mcg/mL, in the blood and falls to about 23 mcg/mL in about two hours after the infusion, and then continues to decrease to 8mcg/mL about 11 hours after the end of the infusion in an individual without any renal impairment (Connective Rx, 2018). The concentration of vancomycin in the blood is also impacted by the degree of inflammation (Connective Rx, 2018). The pharmacokinetics factors, which is what the body does with the drug (Arcanfelo, Peterson, & Reinhold, 2017), influencing the patient’s response to the medication are influenced by the impaired kidney function. Approximately 80%-90% of vancomycin is excreted in the urine (Zaric, et al., 2018). Review of the pharmacodynamics, the way the drug impacts the body (Arcanfelo, Peterson, & Reinhold, 2017), reveals vancomycin inhibiting bacterial synthesis through binding to the precursor on bacterial cell walls (Connective Rx, 2018). Through the binding of vancomycin to the precursor unit of the bacterial cell wall, the outcome is RNA synthesis inhibition, alteration of the bacterial cell wall permeability, and bacterial cell death (Connective Rx, 2018). Severe adverse reactions related to the renal function include renal failure, azotemia, and interstitial nephritis (Connective Rx, 2018). Moderate adverse reactions include hypokalemia and hypotension (Connective Rx, 2018). Vertigo and dizziness are mild symptoms that can be related to kidney function (Connective Rx, 2018). In renal patients the doses have to be adjusted due to the possibility of accumulation of the medication causing nephrotoxicity (Connective Rx, 2018). Nephrotoxicity occurring as a result of monotherapy is usually reversible (Connective Rx, 2018). Personalized Plan of Care The plan of care for this patient was for him to have vancomycin on the days he would have dialysis to assist with the excretion of the medication. Labs were drawn frequently to monitor the kidney function and vancomycin trough levels and dose adjustments were made accordingly. Collaboration with the pharmacokinetics pharmacist and the provider was also crucial to the management of the outcome of the patient. Conclusion In conclusion, the above-mentioned patient was given vancomycin for a MRSA infection and he had a co-morbidity of ESRD. The ESRD impacted the excretion of the vancomycin resulting in toxic levels of vancomycin in the patient’s blood. The pharmacokinetics and pharmacodynamics significantly impact the action of the medication and magnitude of the impact on the body. The individualized plan of care for the specified patient created the possibility to limit any further renal impairment. References Arcanfelo, V. P., Peterson, A. M., & Reinhold, J. A. (2017). Pharmacotherapeutics for Advanced Practice: A Practical Approach. Ambler, PA: Lippincott Williams & Wilkins. Connective Rx. (2018). Vancomycin Hydrochloride. Retrieved from PDR.net: https://www.pdr.net/drug-information/vancomycin-hydrochloride-for-injection?druglabelid=3535 Zaric, R. Z., Milovanovic, J., Rosic, N., Milovanovic, D., Zecevic, D. R., Folic, M., & Jankovic, S. (2018). Pharmacokinetics of vancomycin in patients with different renal function levels. Open Medicine, 512-519. Case Description I had a family member with a history of CAD, and IDDM, who was in need of an aortic valve replacement. The TAVR procedure was completed successfully and was sent home on a regimen of Coumadin/Warfarin for anticoagulant therapy. This person had other underlying health problems (one of which was a herniated disc) of which he was unaware which resulted in weakness and frequent falling. His falls resulted in multiple skin tears and bruising, bleeding was always present and he related that to the warfarin. Upon speaking to him one day when he had a question about his meds, I noticed a bottle of Ibuprofen with his prescriptions. He stated he had been taking Ibuprofen for the pain in his back. I did explain that the Ibuprofen affected his Coumadin/Warfarin, and to speak with his PCP about an alternative. Pharmacokinetics /Pharmacodynamics In a study completed by Juel, Pedersen, Langfrits & Jensen, 2013, it was determined that there is a pharmacokinetic interaction between Coumadin/Warfarin and Ibuprofen which causes and inhibition of Coumadin/Warfarin metabolism. The level of anticoagulation with warfarin is usually monitored with international normalized ratio (INR), every one-point increase, increases bleeding risk by 54% (Choi, Kim, Son, Kim, Kim, Ahn, & Lee, 2010). According to Choi et al., 2010, and Juel, et al., 2013 both medications are metabolized by cytochrome P450. Personalized Plan of Care For initial Coumadin/warfarin therapy the INR must be checked routinely and monitored closely, as this was not the case with my family member. Perhaps an alternate anticoagulant should have been introduced. There are many other oral anticoagulants that are utilized, which would have been more beneficial to this individual. According to Arcangelo, Peterson, Wilbur & Reinhold (2017), direct-acting oral coagulants (DOACs) have a faster onset of action, have fewer drug-drug interactions, and have a predictable anticoagulant response. Along with any anticoagulant therapy, patient teaching explaining the effects of OTC medication. This family member was unaware at the time, that he also had pancreatic cancer, which would have also affected the pharmaceutical plan. References: Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins Choi, K. H., Kim, A. J., Son, I. J., Kim, K. H., Kim, K. B., Ahn, H., & Lee, E. B. (2010). Risk factors of drug interaction between warfarin and nonsteroidal anti-inflammatory drugs in practical setting. Journal of Korean medical science, 25(3), 337-41. Juel, J., Pedersen, T., Langfrits, C., & Jensen, S. (2013). Administration of tramadol or ibuprofen increases the INR level in patients on warfarin. European Journal of Clinical Pharmacology, 69(2), 291–292. https://doi-org.ezp.waldenulibrary.org/10.1007/s00228-012-1325-3 Case Scenario Over the years working as a nurse I have encountered many patients who state that sleep aids do not work for them. They often complain that the treatment for insomnia has the opposite effect for them. People who use these medications and fall fast asleep without difficulty would probably question how is this possible. The first time I had someone tell me that sleep aids did not work for them I to in the back of my mind questioned why. For the sake of privacy, I will call the patient that I am referring to Sam. Sam was a male Caucasian patient in his mid-60’s who was brought into the ED by his wife for new onset of confusion. Sam’s wife stated that he had been very forgetful lately doing things like driving to the store and not remembering the trip there, or where he parked, he seemed to have an increase in anxiety, and he was not sleeping many hours at all. Being that this behavior was out of the patient’s norm and recently started, she was concerned enough to convince him to come to the Emergency room. A neurologic workup was completed on Sam. He had a minor health history, and he was a social drinker. A week before the ED visit he functioned normal going to work, shopping, and driving without any issues. Although a medication list was collected at the beginning of the visit new information came to light. The patient told his wife that he was had been taking his Ambien in the morning with his other medications. The patient was unaware that the Ambien was intended for sleep. The ED physician contributed the patient’s new confusion to the Ambien that he just started taking before the confusion started. Pharmacokinetics and Pharmacodynamics When prescribing medication, I understand that it is important to know how the drug works in the body and what effect it achieves. Pharmacokinetics is defined as “how the drug is absorbed, distributed and eliminated from the body” (Arcangelo, Peterson, Wilbur, Reinhold, 2017, p.17). Ambien is rapidly absorbed through the GI tract which means that taking the medication with food or while the stomach is full can slow down the onset of the medication. The medication is distributed throughout the body by binding to protein carriers at 92% (Kizior, 2018). Different medications are metabolized in different ways. When it comes to how the Ambien is broken down, it is metabolized by the liver and eliminated through urination (Kizior, 2018). The effectiveness of how the body receives the Ambien will determine how well it works for the Sam. Also, the overall health, gender, and age of the patient can play a role in how well the medication is excreted by the body. Sam is in his late 60’s, “older adults undergo physiologic changes that affect the absorption, distribution, and elimination of many agents” (Arcangelo, Peterson, Wilbur, Reinhold, 2017, p.30). Pharmacodynamics is defined as “the set of processes by which drugs produce specific biochemical or physiologic changes in the body” (Arcangelo, Peterson, Wilbur, Reinhold, 2017, p. 27). Many factors can play a factor in how a drug will affect a person such as age, race, gender, and genetics. Due to Sam’s age and the fact that he is a drinker it is possible that the effect of the medication was intensified causing his confusion. Personalized Plan When prescribing for Sam, I would take his not only his health history and social history into account but also his age. From the beginning, it is clear to see that Sam did not understand why he was taking Ambien because he was taking it at the wrong time of day. Thorough patient teaching would be performed so that Sam would understand to take the medication at night for his insomnia and not to drink while taking the medication. Also, I would have him take it on an empty stomach. I would decrease Sam’s dose if possible and include his wife in the education because he would need to be monitored while taking a hypnotic such as Ambien, “consistent monitoring of the elderly is needed when taking a long-acting hypnotic due to accumulation in the renal or hepatic system” (Arcangelo, Peterson, Wilbur, Reinhold, 2017, p.732). I would suggest other options for relaxation prior to medication. As a prescriber, I would take into consideration Sam’s age even if he seems healthy the body changes as it ages, “when prescribing you must be focused and attentive because every patient is different” (Laureate Education, 2012). Reference: Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins. Kizior, R. (2018). Saunders Nursing Drug Handbook 2019. Elsevier – Health Sciences Division. Laureate Education, Inc. (Executive Producer). (2012). Introduction to advanced pharmacology. Baltimore, MD: Author Misoprostol is a drug used for two different types of labor and delivery situations. It can be used to induce labor by softening the cervix and initiating contractions. It can also be used as a uterotonic during a postpartum hemorrhage. I worked as a labor and delivery nurse at a Trauma 1 center in Irvine, California, for many years. During that time, I witnessed many high-risk patients hemorrhage after delivering. In this event, it is crucial that the healthcare team acts fast and provides the patient with the necessary drugs to contract the uterus and stop the bleeding. However, it is essential to consider the patient’s vitals and medical history when deciding which uterotonic to use. Some uterotonics are contraindicated in patients with asthma or hypertension. Although other uterotonics have a faster absorption rate and longer duration, Misoprostol is safe for hypertensive or asthma patients. Misoprostol can be given vaginally, rectally, sub-lingual, or buccal. One study compared the effects of the drug when given rectally versus sub-lingual and found that intra-operative bleeding and postpartum hemorrhaging during a cesarian delivery were lower when given sub-lingual (Sweed et al., 2018). This is becaus
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