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Discussion questions
W3 DQ2
Describe the overall process of drug development. Analyze a clinical trial of a medication that has been approved by the FDA within the past year. Compare the drug to another drug in the same class. Does this new drug seem necessary? Debate whether this medication should or should not have been approved.
The Federal Drug Administration (FDA) is the regulatory body that reviews and approves or denies the addition of each new drug submission. The steps for development and marketing new drugs are as follows:
1) Stage 1- Preclinical trials: Discovery and development is the beginning of this phase. Once developed a new drug is tested in vitro or in test tubes and controlled environments outside living organisms or on animals to determine pharmacological activity, therapeutic potential, toxicology, and safety parameters that will become the recommendations for use. The developing company can file an application for investigational new drug (IND) through the FDA if a therapeutic benefit is discovered to be present. If FDA approves the IND application, the developer can proceed to Clinical Investigation. Stage one generally takes between 1-3 years.
2) Stage 2- Clinical Investigation: This stage will have at least 3 clinical trials and could take anywhere from 2-10 years. Pediatric and pregnancy testing are not always done in this timeframe.
a) Clinical Phase I involves testing new compound on relatively small groups of otherwise healthy individuals to determine tolerance, absorption, distribution, metabolism, and excretion of the drug.
b) Clinical Phase II is focused on testing with patients who have a particular disease process to determine safety and effectiveness in these patients who are generally on other medications and may have additional co-morbidities.
c) Clinical Phase III is designed to test drug efficacy when used in specific applications for a targeted group of patients.
3) Stage 3-Once all phases of clinical trials are completed results are reviewed along with a new drug application (NDA) by the FDA. This process can take anywhere from 2 months to 10 years and the FDA can ask for further information at any point in the process. When it is initially submitted the FDA has 60 days to determine if the NDA meets requirements to be considered for review at all.
4) Stage 4- Post-marketing studies continue monitoring after the drug has hit the market. This is where processes like adverse reaction reporting can play a role in the further use or removal from the market for new drugs. (Woo and Robinson, 2016)
Shingrix is a recombinant, adjuvanted vaccine against the virus that causes shingles and is specifically indicated for the prevention of herpes zoster (shingles) in adults aged 50 years and older. The FDA approval of Shingrix was based on a randomized, placebo-controlled, observer-blind clinical study conducted in 18 countries. The increased effectiveness has not displayed additional side effects other than what is typical with many vaccines. Adverse effects associated with the use of Shingrix may include, but are not limited to, the following: pain, redness or swelling at injection site, myalgia, fatigue, headache, shivering, fever and gastrointestinal symptoms. Increased effectiveness for a larger number of patients without additional adverse effects indicates that this is a good drug and approval was appropriate.
Shingrix (Zoster Vaccine Recombinant, Adjuvanted). (n.d.)., Federal Drug Administration, Retrieved January 22, 2018, from http://www.centerwatch.com/drug-information/fda-approved-drugs/drug/100232/shingrix-zoster-vaccine-recombinant-adjuvanted-
Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for advanced practice nurse prescribers (4th ed.). Philadelphia, PA: F.A. Davis.
W4DQ1
Select a medication used for the treatment of chronic hypertension, malignant hypertension, heart failure, or dyslipidemia. Share the mechanism of action of this medication and hints for monitoring, side effects, and drug interactions, including CAM, of which one should be aware. In addition, share a time when the use of this medication resulted in a positive or negative outcome in a patient for whom you were caring. Include the name of the medication in the subject line so that the medications can be followed. Include references using APA format.
Thiazide diuretics are a class of drugs commonly recommended as first-line treatment for raised blood pressure because they significantly reduce death, stroke and heart attacks (Musini, Nazer, Bassett & Wright JM, 2014).
Thiazide diuretics are an FDA-approved class of drugs that inhibit reabsorption of 3% to 5% of luminal sodium in the distal convoluted tubule of the nephron. By doing so, thiazide diuretics promote natriuresis and diuresis. It exerts its diuretic effect via blockage of the sodium-chloride (Na/Cl) channel in the proximal segment of the distal convoluted tubule (DCT). When the Na/Cl channel is blocked, decreased levels of sodium cross the luminal membrane, thus decreasing the action of the sodium-potassium (Na/K) pump and decreasing Na and water passage to the interstitium. The method of activation of thiazide diuretics is to cause a change in Na concentration distal to the DCT. Subsequently, ionic channels and pumps work to balance Na levels that have been disrupted. Three thiazide diuretics are commonly used: hydrochlorothiazide (HCTZ), chlorthalidone, and indapamide (Akbari & Khorasani-Zadeh, 2019).
Thiazide diuretics are administered orally as tablets. They should be taken in the morning with food. The dosage should be increased based on the individual therapeutic needs of the patient. For patients suffering from fluid buildup and edema, dosing is started at 50 mg to 100 mg and 50 mg to 200 mg, respectively. Adverse effects of thiazide diuretics stem from the ionic imbalance caused due to the initial Na loss in the DCT. Adverse effects include hypokalemia, hyponatremia, metabolic alkalosis, hypercalcemia, hyperglycemia, hyperuricemia, hyperlipidemia and sulfonamide allergy. Adverse effects of taking these medications also include a possible increased risk of developing acute pancreatitis. It is hypothesized that thiazides have a toxic effect on the pancreas and cause increased pancreatic secretions and pancreatic ischemia. If symptoms of acute pancreatitis are observed the patient must immediately stop use of the thiazide diuretic and they should not be re-prescribed this medication by their physician. Thiazide diuretics are contraindicated for use in patients with anuria and sulfonamide allergies (Akbari & Khorasani-Zadeh, 2019).
As a nurse working in step down unit, I usually take care of patients who suffer from hypertension and are prescribed thiazide diuretic. The most common prescription I see is Hydrochlorothiazide. It is a relatively safe and effective drug for the treatment of hypertension and heart failure. It is often prescribed to them for long periods, and hence, their electrolyte levels need to be monitored. In addition, polypharmacy must be avoided, especially in the elderly. Patients need to be educated on the adverse effects of these agents and their presentation. For those patients with heart problems and susceptibility to arrhythmias, the levels of potassium must be closely followed. Also, the patient needs to be weighed at each visit to ensure that the fluid overload is resolving. Patients prone to hypokalemia must be educated on the consumption of foods that are rich in potassium. Finally, the patient’s lipid levels need to be followed as thiazides have been known to cause hyperlipidemia.
Reference
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Akbari, P. , Khorasani-Zadeh, A. (2019). Thiazide Diuretics. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK532918/
Musini VM, Nazer M, Bassett K, Wright JM. (2014). Thiazide diuretics for the treatment of high blood pressure. Retrieved from
https://www.cochrane.org/CD003824/HTN_thiazide-diuretics-for-the-treatment-of-high-blood-pressure
W4DQ2
Using treatment guidelines and available evidence, determine the appropriate therapeutic options for a patient with hypertension. Discuss how ethnic, genetic, or cultural differences affect how you treat the patient and explain any adverse effects or drug interaction associated with the agents used to treat cardiovascular disease. Give examples of how you would modify your approach based on these factors.
Hypertension is the most common modifiable risk factor for cardiovascular disease and death, and lowering blood pressure with antihypertensive drugs reduces target organ damage and prevents cardiovascular disease outcomes (Oparil & Schmieder, 2015). Hypertension (HTN) has multiple causes and treatment options. A total of 69 drugs in 15 different classes, many of which are also available in single pill combinations, have been approved for the treatment of hypertension in the United States. It is important to screen for contributing factors and conditions prior to treatment. Basic testing for primary hypertension includes fasting blood glucose, complete blood cell count, lipids, basic metabolic panel, thyroid stimulating hormone, urinalysis, electrocardiogram with optional echocardiogram, uric acid, and urinary albumin/creatinine ratio. If other conditions exist, obtaining health history, medication history, and baseline testing for any comorbidities is essential in choosing the correct treatment and avoiding drug interactions. After initiation of antihypertensive drug therapy, regardless of atherosclerotic cardiovascular disease (ASCVD) risk, the recommended BP target is less than 130/80 mm Hg. A recent systematic review and network meta-analysis showed continuing reduction in cardiovascular disease (CVD) risk (major cardiovascular events, stroke, coronary heart disease, and all-cause mortality) at progressively lower levels of achieved SBP. Non-pharmacological interventions include lifestyle changes. These are recommended for most adults newly classified as having stage 1 hypertension (130 to 139/80 to 89 mm Hg), and lifestyle changes plus drug therapy are recommended for those with existing CVD or increased CVD risk (Carey & Whelton, 2018).
For adults without a compelling indication for use of a specific drug, clinicians should initiate therapy with thiazide diuretics, calcium-channel blockers, angiotensin-converting enzyme inhibitors, or angiotensin-receptor blockers. Thiazide diuretics (especially chlorthalidone) and calcium-channel blockers are the preferred options for first-line therapy in most U.S. adults because of their efficacy. In black patients, including those with DM, thiazide diuretics and calcium-channel blockers are recommended as first-line agents, whereas β-blockers and renin–angiotensin system inhibitors are less effective at lowering BP (Carey & Whelton, 2018).
Among the antihypertensives interacting with other cardiovascular drugs, aspirin was most frequently involved in drug-drug interaction (DDI). Aspirin/enalapril, aspirin/atenolol, aspirin/furosemide, aspirin/spironolactone, aspirin/carvedilol, and aspirin/metoprolol were the common interactions identified. Aspirin blocks the prostaglandins production and could decrease the effectiveness of antihypertensives. Digoxin had caused more than 50% of DDIs with furosemide and hydrochlorothiazide. The combination of digoxin/spironolactone, digoxin/enalapril, and digoxin/furosemide was also the potential drug pairs causing drug interactions. Spironolactone could increase digoxin concentration by reducing its clearance (Subramanian, Adhimoolam & Kannan, 2018). As a provider, we have to be aware of this drug-drug interaction in order to provide better patient care and mitigate patient’s harm. The knowledge about the drug interaction may render the framework for prevention. Computer-based screening could add potential knowledge and help the treating provider to determinate clinically significant interactions.
References
Carey, R., Whelton, P. (2018). Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Synopsis of the 2017 American College of Cardiology/American Heart Association Hypertension Guideline. Retrieved from https://annals.org/aim/fullarticle/2670318/prevention-detection-evaluation-management-high-blood-pressure-adults-synopsis-2017
Oparil, S., Schmieder, R. (2015). New Approaches in the Treatment of Hypertension. Retrieved from https://www.ahajournals.org/doi/full/10.1161/circresaha.116.303603
Subramanian, A., Adhimoolam, M., & Kannan, S. (2018). Study of drug-Drug interactions among the hypertensive patients in a tertiary care teaching hospital. Perspectives in clinical research, 9(1), 9–14. doi:10.4103/picr.PICR_145_16
W5DQ1
Select an antiarrhythmic, antiplatelet, anticoagulant, or hypertensive (effecting the cardiovascular or renin systems) medication. Share the mechanism of action of this medication and hints for monitoring, side effects, and drug interactions, including interactions with CAM, of which one should be aware. Discuss evidence and treatment guidelines to determine appropriate therapeutic options for a patient with a cardiovascular or renal disorder. Include the name of the medication in the subject line so that the medications can be followed. Include references using APA format.
Digoxin, a cardiac glycoside, has inotropic effects in addition to effects on cardiac output. It is used to treat heart failure and atrial fibrillation and has other off-label uses such as in fetal tachycardia, supraventricular tachycardia, cor pulmonale, and pulmonary hypertension. Digoxin is a cardiac glycoside derived from the purple foxglove flower. Digoxin has been in use for many years, but was not approved by the FDA for treatment of heart failure (HF) until the late 1990s. Digoxin acts by inhibiting the sodium-potassium adenosine triphosphatase pump, promoting sodium-calcium exchange; this results in an upsurge of intracellular calcium, thereby increasing myocardial contractility. Digoxin also has parasympathomimetic properties. By increasing vagal tone in the sinoatrial and atrioventricular (AV) nodes, it slows the heart rate and AV nodal conduction (Chen et al., 2015).
Some drug combinations can aggravate the cardiac adverse effects of digoxin, or reduce its efficacy. The adverse effects of digoxin are potentiated by renal impairment, which may be pre-existing or due to nephrotoxic drugs such as nonsteroidal antiinflammatory drugs (NSAIDs), angiotensin-converting-enzyme (ACE) inhibitors, angiotensin II receptor antagonists and ciclosporin. Some coadministered drugs such as macrolides and cardiovascular drugs (especially amiodarone) can cause digoxin overdose through pharmacokinetic interactions. The mechanism most often implicated is inhibition of P-glycoprotein, of which digoxin is a substrate. Hypercalcaemia and hypokalaemia inducing drugs, heart-rate lowering drugs, and drugs that prolong the QT interval or slow cardiac conduction can potentiate the cardiac adverse effects of digoxin. Plasma concentration of digoxin is not affected. Several drugs, including sucralfate, acarbose, cytotoxic agents, and enzyme inducers, can reduce digoxin plasma concentrations. This effect is attributed to decreased gastrointestinal absorption or increased elimination of digoxin. You should not take Digoxin if you are taking any herbal supplements belonging to the squill family, such as white quill or Mediterranean squill (Rxlist, n.d.).
The use of digoxin is limited because the drug has a narrow therapeutic index and requires close monitoring. Digoxin can cause many adverse events, is involved in multiple drug interactions, and can result in toxicity. Despite its limitations, however, digoxin has a place in therapy. In practice, patients treated with digoxin should be aware that digoxin has a narrow therapeutic margin and frequent and potentially severe adverse effects. Close clinical monitoring is necessary to detect early warning signs (bradycardia and gastrointestinal or neurological disorders). Digoxin assay alone is not always sufficient. Special care is required for patients with renal failure, the elderly and patients receiving potentially interacting drugs (Wiley, 2015).
References
Chen, C., Khusial, T., Patel, D., Singh, S., Yakubova, T., Wang, A., Nguyen, T. (2015). Digoxin Use in Modern Medicine. Retrieved from https://www.uspharmacist.com/article/digoxin-use-in-modern-medicine
Rxlist. (n.d.). Lanoxin. Retrieved from https://www.rxlist.com/lanoxin-tablets-drug.htm#description
Wiley, F. (2015). What Is Digoxin (Lanoxin)? Retrieved from
https://www.everydayhealth.com/drugs/digoxin
W5DQ2
Select a vasopressor that can be used in the ICU or a common cardiac medication used in your health care setting. Review the evidence and treatment guidelines for those medications (i.e., PDR). Discuss the mechanism of action and side effects of this agent. Also discuss the advantages and disadvantages of using this agent and its place in therapy (i.e., what type of patient would benefit the most). Identify ethnic, cultural, and genetic differences in patients that may affect the safety or efficacy of medications used to treat cardiovascular or renal disorders.
Dobutamine is a medication used in the ICU to manage low blood pressure. Dobutamine is approved by the Food and Drug Administration (FDA) for short-term use in patients with decreased contractility due to heart failure or cardiac surgical procedures leading to cardiac decompensation. Dobutamine can be used as temporary intravenous inotropic support until resolution of the acute inducing factors or the patient receives more definitive treatment, such as coronary revascularization, mechanical circulatory support, or heart transplant. Short-term intravenous inotropic support should be given to patients in cardiogenic shock to preserve systemic blood flow and protect from end-organ damage. Dobutamine can reasonably be given in continuous intravenous form for inotropic support to bridge patients with late-stage heart failure, stage D, that is refractory to guideline-directed medical therapy until patients who are candidates for and awaiting cardiac transplantation or mechanical circulatory support receive the appropriate long-term treatment. It can be used for hospitalized patients with severe systolic dysfunction and presenting with a low blood pressure and a cardiac output that is significantly decreased, to preserve systemic blood flow and protect from end-organ damage. It can also be reasonably given for the long-term in palliative patients with late-stage heart failure, stage D, who are not candidates for mechanical circulatory support or cardiac transplantation for symptomatic control, regardless of guideline-directed medical therapy. Intravenous inotropic dobutamine can be given off-label to patients in order to induce pharmacological stress during stress echocardiography if patients are not able to perform an exercise stress test. Dobutamine is used as a pharmacological agent because of its inotropic effects on the myocardium through binding and activating the beta 1 receptors. The medication is indicated clinically for decompensated congestive heart failure because of the sympathomimetic effects. Dobutamine increases contractility which leads to decreased end-systolic volume and therefore larger stroke volume. The larger stroke volume leads to an increase in cardiac output of the heart (Ashkar & Makaryus, 2019).
Dobutamine administration can lead to possible adverse reactions, mainly due to the sympathomimetic activity. These include increased heart rate and increased blood pressure, headache, ventricular ectopic activity, nervousness, nausea, vomiting, palpitations, and low platelet counts (thrombocytopenia (Cunha, n.d.)
Dobutamine is used cautiously in patients with history of hypertension (increased risk of exaggerated pressor response); MI; atrial fibrillation (pretreatment with digitalis glycosides recommended); history of ventricular atopic activity (may be exacerbated); hypovolemia (correct before administration); pregnancy or lactation (safety not established); Corn hypersensitivity, sulfite hypersensitivity (may cause allergic rection); geriatric (greater risk for hypotension); and renal failure (may produce myoclonia e.g., muscle spasms) (PDR, n.d.). Dobutamine is administered as an IV infusion. Overall, the effects of dobutamine are short lived. As soon as the infusion is stopped, the hemodynamic parameters are reversed.
References
Ashkar, H., Makaryus, A. (2019). Dobutamine. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK470431/
Cunha, J. (n.d.). Dobutamine vs Levophed. Retrieved from https://www.rxlist.com/dobutamine_vs_levophed/drugs-condition.htm
Prescribers Digital Reference (PDR). (n.d.). dobutamine hydrochloride – Drug Summary. Retrieved from https://www.pdr.net/drug-summary/Dobutamine-dobutamine-hydrochloride-3534
W6DQ1
Select a medication using the treatment guidelines for osteoporosis, thyroid disorder, or diabetes mellitus. Share the mechanism of action of this medication and hints for monitoring, side effects, and drug interactions, including interactions with CAM. In addition, share a clinical trial that supports the use of this agent. Include the name of the medication in the subject line so that the medications can be followed. Include references using APA format.
Approximately 10 million men and women in the U.S. have osteoporosis,1 a metabolic bone disease characterized by low bone density and deterioration of bone architecture that increase the risk of fractures.2 Osteoporosis-related fractures can increase pain, disability, nursing home placement, total health care costs, and mortality (Tu et al., 2018). The American College of Physicians (ACP) has recommended in an evidence-based clinical practice guideline that physicians offer pharmacologic therapy with a bisphosphonate. The guideline also recommends against bone density monitoring during treatment and makes specific recommendations for men with clinically recognized osteoporosis and older women with osteopenia (Crawford, 2017).
Bisphosphonates are antiresorptive treatments and are used in treatment and prevention of fractures in people at moderate or high fracture risk and prevent bone loss for men and women taking steroids like Prednisone. Bisphosphonates work by slowing cells that break down bone (osteoclasts) allowing cells that build bone (osteoblasts) more time to work and reduce the imbalance. There is good long-term safety data on the bisphosphonates; but as with any medication there are also side effects. The most common side effects include muscle aches, joint aches, stomach upset or heartburn. There are also some rare side effects that have been associated with long term use of bisphosphonates. These include osteonecrosis of the jaw (ONJ) and atypical femur fractures (Cody, 2016).
Co-prescribing acid-suppressive medications or anti-depressives with bisphosphonates to postmenopausal women battling osteoporosis increased their risk of fracture, according to a new study. The researchers said coexisting chronic conditions — such as diabetes, depression, and inflammatory joint disease — increase the severity of osteoporosis, and mixing medications used to manage the chronic conditions with bisphosphonates could result in clinically relevant and dangerous drug interactions (Nyandege, Slattum, Harpe, 2015).
References
Cody, K. (2016). What Are Bisphosphonates? Retrieved from https://americanbonehealth.org/medications-bone-health/what-are-bisphosphonates/
Crawford, C. (2017). AAFP Endorses ACP Guideline on Treating Osteoporosis. Retrieved from https://www.aafp.org/news/health-of-the-public/20170511acposteoguide.html
Nyandege AN, Slattum PW, Harpe SE. (2015). Risk of fracture and the concomitant use of bisphosphonates with osteoporosis-inducing medications. Ann Pharmacother. 2015 Feb 9. [Epub ahead or print]
Tu, K. N., Lie, J. D., Wan, C., Cameron, M., Austel, A. G., Nguyen, J. K., … Hyun, D. (2018). Osteoporosis: A Review of Treatment Options. P & T : a peer-reviewed journal for formulary management, 43(2), 92–104.
W6DQ2
You are tasked with developing an insulin protocol for your patient. Discuss some of the key components you would include. What will be your recommended blood glucose target range? Provide literature that would identify ethnic, cultural, and genetic differences in patients, and how this may affect the safety or efficacy of medications used. Support your recommendations with the most current evidence and treatment guidelines.
Developing and insulin protocol for patients involves multiple considerations. One of those considerations would be whether or not the patient still produces endogenous insulin to any degree. Other considerations taken into account are current medication, typical level of physical activity, patient health literacy, patient’s ability to follow complex directions, financial status, and the patient’s willingness and ability to self-monitor blood glucose multiple times each day, and the number of injections outlined in the plan each day. The patient age, average A1 C, lifestyle, and personal beliefs regarding food and medical treatment will also influence the plan. (American Diabetes Association [ADA], 2009)
The first step in developing the plan is to establish glycemic control goals. These goals are target levels for the patient’s A1 C, fasting glucose levels, and pre-or post-prandial glucose levels. According to APA, fasting plasma glucose levels should be between 70 and 130 mg/dL. Postprandial plasma glucose should be less than 180 mg/dL and a long-term goal should be achieving and A1 C level of less than 7%. These targets may be adjusted for children and other populations, such as athletes and the elderly, which may be at a higher risk for hypoglycemia. (ADA, 2009) The next step in planning is to start with the appropriate dose and choice insulin type. Individuals with type II diabetes are generally on oral anti-hyperglycemic agents prior to the addition of injectable insulin. The starting dose for type II diabetic patients is 10u/day or 0.1 to 0.2 units per kilogram per day, This will be adjusted by 10-15% or 2-4 units 1-2 weekly until fasting blood glucose targets are reached. If hypoglycemia is experienced the dose is reduced by 4 units or 10-20%. If blood sugar is still not well controlled after fasting blood glucose target is reached or if it does of insulin given is greater than 0.5 units per kilogram per day a dose of rapid acting insulin can be added prior to the largest meal of the day or the basal dose may be switched to premixed insulin given twice a day. It can be given as 2/3 dose in the am and 1/3 dose in the pm or ½ of the total dose in the am and pm. To add the pre-meal dose of rapid acting insulin start with 4 units or 0.1 units per kilogram, or 10% of the basal dose. If the resulting A1 C is less than 8% the basal dose may be reduced by the same amount. Adjustments to this rapid insulin injection are done in increments of 1 to 2 units or 10 to 15% once to twice weekly until postprandial blood glucose target is reached.
If the change does not accomplish the target A1C the patient may need rapid acting insulin bolus prior to the other meals of the day using the same calculation and adjustment formulas.
Type 1 diabetics are not on oral hyperglycemic agents and rely totally on injectable insulin. The starting dose of insulin is usually based on weight, with doses ranging from 0.4-0.5 units/kg per day of total insulin; higher amounts may be required for patients with obesity or a sedentary lifestyle, as well as during puberty. Basal insulin requirements are generally 40-50% of the total daily dose. (AACE, 2018) The treatment options are multiple daily injections of rapid acting insulin taken with meals combined with a daily basal rate, or continuous subcutaneous insulin infusion via subcutaneous pump. The basal dose once a day long acting form or twice a day intermediate acting form. The prandial doses are comprised of the 40-50% of the TDD, divided and administered prior to meals, and are rapid or short acting forms. Each individual dose should be determined by estimating carbohydrate content of meal for the best control. The advantage of continuous pumps is that these parameters can be programmed into the pump so that variable basal and prandial infusion rates can be set. Onboard calculators for meal insulin boluses and reminders can be set as well. Pumps also come with the ability to download pump data to a computer for tracking and adjustment purposes. (AACE, 2018)
It is important to be aware of cultural, financial, and genetic barriers that differ from patient to patient. Cultural motivators, religious beliefs, communication barriers, and financial constraints must all be considered when planning treatment. For example, some religions observe days of fasting, it is important for patients to know how to handle their insulin on these days and what additional self-monitoring may be necessary. The higher proportion of minorities affected by diabetes presents the possibility that there may be language barriers involved and that all material should be provided in a language that the patient can easily understand and that opportunities are presented for the patient to ask questions with a translator available. (Woo & Robinson, 2016)
American Association of Clinical EndocrinologistsAACE Diabetes Resource Center. (n.d.). Retrieved February 12, 2018, from http://outpatient.aace.com/type1-diabetes/treatment
Garber, A. J., Abrahamson, M. J., Barzilay, J. I., Blonde, L., Bloomgarden, Z. T., Bush, M. A., Umpierrez, G. E. (2018). Consensus Statement By The American Association Of Clinical Endocrinologists And American College Of Endocrinology On The Comprehensive Type 2 Diabetes Management Algorithm – 2018 Executive Summary. Endocrine Practice, 24(1), 91-120. doi:10.4158/cs-2017-0153
Woo, Teri Moser; Robinson, Marylou V. Pharmacotherapeutics For Advanced Practice Nurse Prescribers (Page 998). F.A. Davis Company. Kindle Edition.
W7DQ1
Anemia is a disorder that affects the oxygen carrying capacity of the blood. Anemia results from a lack of red blood cells or dysfunctional red blood cells. Insufficiency or dysfunction of the red blood cells will inhibit oxygen delivery to the body’s organs. General symptoms may include fatigue, skin pallor, shortness of breath, lightheadedness, dizziness, chest pain or a fast heartbeat. Treatment is based on the underlying cause of the anemia. (Woo & Robinson, 2016)
Iron deficiency anemia- seen in infants, children with rapid growth spurt, heavy menstruation, pregnant and lactating women, and malabsorption disorders. It may also be present in patients who are less than 1 week out from significant blood loss. Treatments include iron supplementation. There are varying forms of delivery and the choice should be based on what will work best for the patient. Contraindications include the use of iron with hemochromatosis or hemolytic anemia as this could lead to toxicity because the destruction of RBC releases iron into the blood stream. Common adverse side effects include GI irritation, anorexia, nausea, vomiting, constipation and dark, tar like stools. Drug to Drug interactions include chelation effect with levodopa, quinolones or competition for absorption with tetracycline, antacids, and cimetidine. Patients should be educated to not consume foods with high amounts of calcium or take antacids or competing drugs within 2 hours of taking iron. Educating the patient, including pregnant, lactating or menstruating women, to choose a diet rich in iron which includes red meat, fish and iron-enriched foods will help to prevent anemia in the future. (Woo & Robinson, 2016)
Folic Acid deficiency is not generally seen in developed countries however is most often related to low intake or over cooking of vegetables, especially green vegetables. It can also be present in patients who are taking drugs that interfere with folic acid synthesis and absorption. Folic acid deficiency can occur with phenytoin use, hyperthyroidism, hemolytic anemia, and increased demand during pregnancy. Administration of Folic Acid replacement supplements of folic, 1mg/day for initial dose and 0.4mg for maintenance doses are typical treatment. (Hollier, 2016) Demand for folic acid may increase with pregnancy or lactation and will need to be supplemented for healthy development of the fetus and to correct anemia in the mother. Supplementation is contraindicated if a patient has a vitamin B12 deficiency as it may mask symptoms of pernicious anemia which is treated with replacement of vitamin B12 rather than folic acid. Diets rich in folate, found in most green vegetables as well as liver, yeast containing foods and mushrooms. (Woo & Robinson, 2016)
Pernicious anemia as mentioned previously, is a malabsorption disorder caused when intrinsic factor in the gut is missing or dysfunctional and prevents the absorption of vitamin B12 which is essential in forming RBC’s. Replacement of vitamin B12 through IM or SC routes to bypass gut are the most reliable way to treat this disorder. Supplementation may be lifelong depending on cause, however if the cause is treatable normal function can return. Patients should have their potassium level monitored within 2 days of initiation of treatment and regularly thereafter while treatment continues. Diets rich in potassium and possibly potassium supplementation should be considered for those that develop hypokalemia. Common adverse drug side effects include diarrhea, itching, and hypokalemia. Patients who will inject themselves with the replacement need to be educated on clean technique and site rotation as well as the most appropriate sites for IM and SC. (Woo & Robinson, 2016)
Anemia of chronic renal failure is caused by the failure of the liver to produce erythropoietin in sufficient quantity to signal the production of new RBC’s. Drugs are used to elevate and maintain erythrocyte levels and decrease the need for transfusions, Hgb is checked weekly until target goal is reached and Iron levels are monitored for potential decreases. Darbepoetin alfa- initial dose of 0.45 mcg/kg SC once a week with dosage adjustments made after 6 weeks. Target goal is Hgb of 12 g/dL. Epoetin alfa- 50-100 U/kg 3 times a week has the same target goals. (Hollier, 2016) Possible adverse side effects of either medication are hypertension, increased risk of DVT, bone pain, stroke and pain or irritation at the injection site. Due to the risk for hypercoagubility patients may need heparin on dialysis. Education should include encouraging a diet rich in iron, high-quality protein, reduced sodium and reduced phosphorous. (Woo & Robinson, 2016)
Other genetic disease can cause forms of anemia with their own treatment modalities such as thalassemia and sickle cell anemia. These genetic diseases require a more complicated regimen and cannot simply be treated with supplementation.
Hollier, A. (2016). Clinical guidelines in primary care (2nd ed.). Scott, LA: Advanced Practice Education Associates Inc.
Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for advanced practice nurse prescribers (4th ed.). Philadelphia, PA: F.A. Davis.
W7DQ2
Select a medication and discuss the ethnic, cultural, or genetic differences in the use and consideration for cancer treatment. Share the mechanism of action of this medication and hints for monitoring side effects and drug interactions, including interactions with CAM. Elaborate on one drug-drug interaction and devise a plan to clinically manage the interaction. Include your references in APA format.
• Rituximab is a monoclonal antibody that is approved to be used alone or with other drugs to treat B-cell non-Hodgkin lymphoma (NHL) that is CD20 positive. It is also used to treat follicular lymphoma that has relapsed or is refractory, non-progressing NHL, NHL patients who have not had prior treatment and chronic lymphocytic leukemia (CLL). Rituximab is also used in the treatment of rheumatoid arthritis, an auto immune form of arthritis. It treats rheumatoid arthritis, granulomatosis with polyangiitis, and microscopic polyangiitis by blocking the activity of the part of the immune system that may damage the joints, veins, and other blood vessels. (Medline, 2017) Rituximab is a recombinant chimeric murine/human antibody directed against the CD20 antigen, a hydrophobic transmembrane protein located on normal pre-B and mature B lymphocytes. Following binding, rituximab triggers a host cytotoxic immune response against CD20-positive cells. (Cancer.gov, 2018) CD20 is present on cancer cells as well as normal B cells, however, not all normal B cells. The patients normal B cell may be damaged by rituximab but are later replaced. This may cause a transient immunodeficiency in the patient until replacement of normal B cells can be accomplished. (Olsen, 2015) In patients who have hepatitis B infection Rituximab may exacerbate the condition and could cause severe liver damage. General side effects can include Infusion site reaction, fever, lymphopenia, infection, pulmonary toxicity, cardiotoxicity, fatigue, nausea, vomiting, headache, muscle spasm, night sweats, pruritus, rash, insomnia, leukopenia, neutropenia, cough, thrombocytopenia, area, hypotension, myalgia, anemia, peripheral edema, elevated LDH, hypertension, anxiety, and hyperuricemia. (Epocrates, 2018) Period. In reaction to her, with 80% of these reactions occurring with the first infusion. Patients must be monitored closely after the first infusion and educated to report any signs and symptoms immediately. The list of drugs that interacts with rituximab is lengthy and the patient’s medication history must be reviewed thoroughly prior to starting this treatment. Drugs that are contraindicated include vaccines, and drugs that need to be avoided include other immunosuppressive oncologic agents, and milosuppressive agents. Caution must be used if the patient ultimately, the history of cardiovascular disease, pulmonary disease, if there is a high tumor burden, if the patient has hepatitis B, or any latent or chronic infection. (Epocrates, 2018)
• Dosing regimen will very based on whether the cancer is CD20 positive, relapsed, refractory, previously untreated, or non-progressing. Patient monitoring may very based on medical history or underlying conditions, however, all treatment modalities include obtaining baseline hepatitis B surface antigen, monitoring for signs and symptoms of hepatitis, or HBV reaction during and several months after treatment, CBC prior to each cycle of monotherapy or every 1 to 4 weeks if combo therapy is chosen, ECG during infusion and immediate post infusion if cardiac conditions, history, arrhythmias or angina are present. (Epocrates, 2018)
• Treatment for side effects, unless the side effect calls for discontinuation of the treatment, will be aimed at the symptom. For example, anti-emetics, Antihistamines, or analgesics may be appropriate to relieve discomfort and prevent treatment reactions such a pruritus, itching, nausea and pain.
NCI Drug Dictionary. (2017). Retrieved February 19, 2018, from https://www.cancer.gov/publications/dictionaries/cancer-drug/def/rituximab, US department of Health and Human Services, updated October 2017
Drugs, Herbs and Supplements: MedlinePlus. (n.d.). Retrieved February 19, 2018, from https://medlineplus.gov/druginfo/meds
Rituximab Drug Information. (n.d.). Retrieved February 19, 2018, from
https://online.epocrates.com/drugs/1622/rituximab
W8DQ2
Medroxyprogesterone acetate, commonly known as Depo-Provera is a sterile ugliest suspension administered by injection for the prevention of pregnancy. Medroxyprogesterone acetate is a derivative of progesterone and is active by the parenteral and oral routes of administration. In women with adequate endogenous estrogen, medroxyprogesterone acetate transforms proliferative endometrium into secretory endometrium. That inhibits the secretion of pituitary gonadotropin which prevents follicular maturation and ovulation. Indications for the use of this drug include abnormal uterine bleeding caused by hormonal imbalance, secondary amenorrhea, endometrial or renal carcinoma, contraception, and endometrial hyperplasia. (Harris, Nagy & Vardaxis,2016) The prolonged action of this drug and the difficulty in predicting the time of withdrawal bleeding following injection make the injectable form a less viable choice for patients who need therapy to treat secondary amenorrhea or dysfunctional uterine bleeding. Oral forms of this medication are preferred for these conditions. (Drugs, 2018) Injectable form of the drug, Depo-Provera, dosage is 150 mg delivered by intramuscular injection once every three months, or 104 mg delivered by subcutaneous injection once every three months. For many women the convenience of not having to remember a daily pill makes this drug very attractive for contraception. Contraindications for using Depo-Provera include hypersensitivity, active thromboembolism disorders, breast cancer, undiagnosed abnormal vaginal bleeding, hepatic dysfunction, cerebrovascular disease or stroke. The tablet form of this drug is contraindicated in patients with liver dysfunction or known or suspected genital cancers. It can be used in patients with diabetes, seizure disorder, migraines, cardiac or renal disease, asthma, and depression, but these patients require caution in prescribing and close monitoring. Adverse reactions in the CNS may include dizziness, migraine, lethargy, depression, nervousness, and asthenia. CV risks include hypertension, thrombophlebitis, pulmonary embolism, edema, thromboembolism, and stroke. In some cases, patients may develop intolerance of their contact lenses, nausea, vomiting, abdominal cramps, breakthrough bleeding, and dysmenorrhea. Other, more rare side effects include cervical erosion uterine fibromas, vaginal tendinitis, call aesthetic jaundice, tumors, gallbladder disease, and hyperglycemia. (Harris, Nagy & Vardaxis,2016) Many patients experience side effects related to the action of the drug in the prevention of contraception such as breast tenderness, enlargement, or secretion, decreasing libido, or weight gain. Drugs and interact with Depo-Provera may include anticoagulants, bromocriptine, and rifamycins. Patient on anticoagulants may need modification therapy, and patience on bromocriptine, or rifamycins should be instructed to use nonhormonal contraceptives during therapy with either of those drugs other reactions include the increased effect of caffeine and smoking which when combined with Depo-Provera may increase the risk of adverse cardiovascular effect. Patients should be encouraged to stop smoking and provided supportive information. (Harris, Nagy & Vardaxis,2016) Depo-Provera contains black box warnings regarding possible irreversible bone density mineral loss in adolescents and young adults. A thorough medical history including any past or present therapies should be obtained prior to his prescribing any medications. And patient education should always include the advice that the patient report unusual symptoms immediately and to stop the drug and notify the prescriber if visual disturbance, migraine, or signs and symptoms of cardiovascular involvement appear. Always reinforce that these types of contraceptives do not protect against HIV or other sexually transmitted diseases, and that this drug should be used for long-term birth control, then the recommended length of time it should be used is approximately 2 years unless other forms of birth control are inadequate and then it may be used as combination therapy. Remind the patient that the injections must be given every three months and advised that they set their next appointment before they leave the office. Finally encourage adequate intake of calcium and vitamin D to prevent bone mineral density loss. (Harris, Nagy & Vardaxis,2016)
Always keep in mind that religious beliefs can limit the patient’s contraceptive choices. For patients whom chemical contraception is forbidden Education for natural methods may need to be provided. Most religions also regard sex outside of marriage as taboo, and for cases where contraceptive drugs are being used to treat other conditions such as dysmenorrhea, this may present as stigmatizing for the patient. It is essential that complete confidentiality be maintained with all patients. Although some religions are cultures may allow for contraceptive therapies, there is still the consideration that some cultures forbid a woman from seeing any other man than the husband in what may be considered an intimate situation or discussing intimate details of personal lives so it is important to include cautions for these beliefs and respect the wishes of the husband and family with regard to who may be present in the exam room.(Henderson, 2018) In general it is always important to address communication issues whether it be language or medical literacy, we must make sure that the patient has the information they need to use contraceptives medications appropriately and that they know what signs and symptoms they need to report to the physician immediately. Unfortunately, there is a clash in our society as to the politics of contraception and in the future, this may present issues with coverage of contraception through the patient’s insurance. In these cases the most effective and least expensive method for the patient needs to be considered.
Depo-Provera – FDA prescribing information, side effects and uses. (n.d.). Retrieved February 25, 2018, from https://www.drugs.com/pro/depo-provera.html
Harris, P., Nagy, S., & Vardaxis, N. J. (2016). Mosbys dictionary of medicine, nursing and health professions. Chatswood, N.S.W.: Elsevier Australia.
Henderson, D. R. (n.d.). Ethnocultural Issues in Contraception. Patient. Retrieved February 25, 2018, from
https://patient.info/doctor/ethnocultural-issues-in-contraception
W11DQ1
Select an antimicrobial medication that inhibits bacterial protein synthesis. Share the antibacterial spectrum and hints for monitoring, side effects, and drug interactions, including interactions with CAM. Discuss ethnic, cultural, and genetic considerations that must be considered for treatment. In addition, share a clinical trial that supports the use of this agent. Include the name of the medication in the subject line so that the medications can be followed. Include references using APA format.
Tetracycline is used to treat infections caused by bacteria including pneumonia and other respiratory tract infections; ; certain infections of skin, eye, lymphatic, intestinal, genital and urinary systems; and certain other infections that are spread by ticks, lice, mites, and infected animals. It is also used along with other medications to treat acne. Tetracycline is also used to treat plague and tuleramia (serious infections that may be spread on purpose as part of a bioterror attack). It can also be used in patients who cannot be treated with penicillin to treat certain types of food poisoning, and anthrax (a serious infection that may be spread on purpose as part of a bioterror attack). Tetracycline is in a class of medications called tetracycline antibiotics. It works by preventing the growth and spread of bacteria. Tetracycline is also sometimes used to treat Lyme disease and malaria, and to prevent plague and tularemia in people who have been exposed to plague or tularemia germs. Tetracycline may cause side effects such as nausea, vomiting, diarrhea, itching of the rectum or vagina,swollen tongue, black or hairy tongue, sore or irritated throat, headache, blurred vision, seeing double, or loss of vision, skin rash, hives, swelling of the face, throat, tongue, lips, and eyes, difficulty breathing or swallowing, joint stiffness or swelling, unusual bleeding or bruising, chest pain, a return of fever, sore throat, chills, or other signs of infection, watery or bloody stools , stomach cramps, or fever during treatment or for up to two or more months after stopping treatment (Medline PLus, n.d.)
Tetracyclines and glycylcyclines inhibit bacterial protein synthesis by binding to the 30S bacterial ribosome and preventing access of aminoacyl tRNA to the acceptor (A) site on the mRNA-ribosome complex. These drugs enter gram-negative bacteria by passive diffusion through channels formed by porins in the outer cell membrane and by active transport that pumps tetracyclines across the cytoplasmic membrane (Medline PLus, n.d.).
Tetracycline may reduce the effectiveness of some oral birth control pills. Calcium supplements, iron products, laxatives containing magnesium, and antacids may make tetracycline less effective.It should be taken two hours after taking antacids, calcium supplements, and laxatives containing magnesium and two hours before or three hours after taking iron products and vitamins that contain iron. Consuming dairy products, such as milk, yogurt, cheese, and ice cream, may interfere with the absorption of tetracycline. This medication may make your skin more sensitive to sunlight. Avoid unnecessary or prolonged sun exposure while taking tetracycline (Drugs.com, n.d.).
In addition to its antimicrobial function, a large body of scientific literature has shown the neuroprotective characteristics of tetracyclines. Tetracyclines, such as minocycline, have been shown to suppress microglial activation, inhibit apoptosis of neuronal cells after glutamate excitotoxicity, scavenge reactive oxygen and nitrogen species, and suppress matrix metalloproteinase (MMP) activity. Tetracyclines have also shown efficacy as a neuroprotective agent in animal models of stroke, Huntingdon’s disease, Parkinson’s disease, ALS, Alzheimer’s disease, and spinal cord injury. Clinically, tetracyclines have been effective at improving clinical outcome after acute ischemic stroke, and are currently being evaluated in trials of Parkinson’s disease, spinal cord injury, schizophrenia, and other neurodegenerative diseases (Bowswer, Higgins, Draper & Tanaka, 2015).
References
Bowser, T., Higgins, P., Draper, M., Tanaka, K. (2015). Tetracycline compounds for treating neurodegerative disorder. retrieved from https://patents.google.com/patent/US20150174144A1/en
Drugs.com. (n.d.). Tetracycline drug interaction. Retrieved from https://www.drugs.com/drug-interactions/tetracycline.html
Medline Plus. (n.d.). tetracycline. Retrieved from https://medlineplus.gov/druginfo/meds/a682098.html
W11DQ2
Using the treatment guidelines, select an antimicrobial medication that interferes with the synthesis of the bacterial cell wall. Share the antibacterial spectrum and hints for monitoring, side effects, and drug interactions, including interactions with CAM. Discuss how you could integrate antibiotic resistance education to all patients for whom you prescribe an antibiotic. Include the name of the medication in the subject line so that the medications can be followed. Include references in APA format.
Cephalosporins are a large group of antibiotics derived from the mold Acremonium (previously called Cephalosporium). Cephalosporins are bactericidal (kill bacteria) and work in a similar way to penicillins. They bind to and block the activity of enzymes responsible for making peptidoglycan, an important component of the bacterial cell wall. They are called broad-spectrum antibiotics because they are effective against a wide range of bacteria. Since the first cephalosporin was discovered in 1945, scientists have been improving the structure of cephalosporins to make them more effective against a wider range of bacteria. Each time the structure changes, a new “generation” of cephalosporins are made. So far there are five generations of cephalosporins. All cephalosporins start with cef, ceph, or kef. Cephalosporins may be used to treat infections caused by susceptible bacteria, such as bone infections, ear infections (eg, otitis media), skin infections, upper respiratory tract infections and urinary tract infections. Cephalosporins are not usually used as a first-choice antibiotic. They tend to be reserved for use when other antibiotics (often penicillins) cannot be used. There are currently five “generations” of cephalosporins, with each generation differing slightly in their antibacterial spectrum (ie, how effective they are at killing certain types of bacteria). Within each generation, there are differences in terms of administration (such as oral or intravenous administration), absorption, excretion, and how long the activity of the cephalosporin lasts for in the body (Rxlist, n.d.).
First generation cephalosporins’ optimum activity is against gram-positive bacteria such as staphylococci and streptococci. Second-generation cephalosporins are more active against gram-negative bacteria, with less activity against gram-positive bacteria. Third generation cephalosporins followed the second-generation cephalosporins. No one third-generation cephalosporin treats all infectious disease scenarios. Fourth generation cephalosporins are structurally related to third-generation cephalosporins but possess an extra ammonium group, which allows them to rapidly penetrate through the outer membrane of gram-negative bacteria, enhancing their activity. They are also active against β-lactamase producing Enterobacteriaceae which may inactivate third-generation cephalosporins. Fifth generationt is active against methicillin-resistant Staphylococcus aureus (MRSA) and gram-positive bacteria. It also retains the activity of the later-generation cephalosporins and is effective against susceptible gram-negative bacteria (Rxlist, n.d.).
Cephalosporins generally cause few side effects. The most common side effects reported include abdominal pain, diarrhea, dyspepsia, headache, gastritis, and nausea and vomiting. Transient liver problems have also been reported. Rarely, some people may develop a super-infection due to overgrowth of a naturally occurring bacterium called Clostridium difficile, following use of any antibiotic, including cephalosporins. Symptoms may include severe diarrhea. Uncommonly, an overgrowth of the yeast, Candida albicans, may occur following cephalosporin use, resulting in the symptoms of thrush (Fookes & Pharm, 2018).
When prescribing Cephalosporins, clinicians must ask their patients about all prescription and nonprescription medications they are taking especially of: “blood thinners” (e.g., warfarin), live vaccines. Certain cephalosporins (your medication belongs to this class of drugs) can interact strongly with alcohol. Educate patients not to drink alcohol while using this medication and for 72 hours after the last dose has been injected. This drug may interfere with the effectiveness of birth control pills. This drug may cause false positive results in some diabetic urine testing products (cupric sulfate-type) (Rxlist, n.d.).
Antibiotic resistance has the potential to affect people at any stage of life. Antibiotic resistance does not mean the body is becoming resistant to antibiotics; it is that bacteria have become resistant to the antibiotics designed to kill them. To help prevent antibiotic resistance, clinicians should educate patients not to use antibiotics for viruses like colds or flu. Antibiotics don’t work on viruses. Educate patients to follow the directions carefully and to finish the medicine even if he/she feels better because when you stop treatment too soon, some bacteria may survive and re-infect you. Tell patients not to save antibiotics for later or use someone else’s prescription (Medline Plus, n.d.).
References
Fookes, C., Pharm, B. (2018). Cephalosporin. Retrieved from https://www.drugs.com/drug-class/cephalosporins.html
Medline Plus. (n.d.). Antibiotic Resistance. Retrieved from https://medlineplus.gov/antibioticresistance.html
Rxlist. (n.d.). Cephalosporins. Retrieved from https://www.rxlist.com/consumer_ceftriaxone_rocephin/drugs-condition.htm
W12DQ1
Using the treatment guidelines, select a medication for a fungal infection. Share the mechanism of action of this medication and hints for monitoring, side effects, and drug interactions, including interactions with CAM. Elaborate on one drug-drug interaction and devise a plan to clinically manage the interaction. Include the name of the medication in the subject line so that the medications can be followed. Include references in APA format.
Fluconazole (Diflucan) is used to prevent and treat a variety of fungal and yeast infections. Fluconazole works by blocking the ability of the fungi Candida and Cryptococcus to reproduce. It prevents growth of fungi by preventing production of the membranes that surround fungal cells. It is used to treat vaginal, oral, and esophageal fungal infections caused by Candida. It is used for treating uncomplicated, complicated, or recurrent vaginal Candida infections. It also may be effective in treating urinary tract infections, peritonitis, pneumonia and disseminated infections caused by Candida. It is used for treating cryptococcal meningitis, and prevention of Candida infections in patients treated with chemotherapy or radiation after bone marrow transplantation. The usual adult dose is 50-400 mg daily depending on the type of infection. Although symptoms of oral Candida infections may subside in a few days, treatment is continued for 2 weeks. Esophageal Candida infections are treated for 3 weeks or longer (University of Illinois-Chicago, Drug Information Group, 2018).
The more common side effects of fluconazole oral tablet depend on how much of the drug you need to take. These side effects can include: headache, diarrhea, nausea, dizziness, stomach pain, vomiting, changes in the way food tastes and severe rash in people with lowered immunity. If these effects are mild, they may go away within a few days or a couple of weeks. Serious side effects and their symptoms can include liver damage, severe rash in people with acquired immunodeficiency syndrome (AIDS) or cancer and Torsades de pointes (a life-threatening heart rhythm condition) longer (University of Illinois-Chicago, Drug Information Group, 2018).
Fluconazole can cause a serious heart problem. Your risk may be higher if you also use certain other medicines for infections, asthma, heart problems, high blood pressure, depression, mental illness, cancer, malaria, or HIV. Medicines that can cause unwanted or dangerous effects when used with fluconazole are antibiotic, antifungal, antiviral medicine, blood thinner, cancer medicine, cholesterol medication, oral diabetes medicine, heart or blood pressure medication, medicine for malaria or tuberculosis, medicine to prevent organ transplant rejection, medicine to treat depression or mental illness, NSAID (nonsteroidal anti-inflammatory drug), seizure medicine and steroid medicine (Multum, 2019).
In recent years, there is a growing concern of resistance to these azole antifungal medications. In humans, Candida species are responsible for the majority of fungal infections. Some Candida species are developing azole resistance which presents a serious problem for medical professionals. Studies have shown that around 5% of Candida species are resistant to fluconazole. This percentage is likely to increase over time, meaning that finding alternative antifungal remedies is a critical area of focus for research studies (Richards, 2019).
References
Multum, C. (2019). Floconazole. Retrieved from https://www.drugs.com/mtm/fluconazole.html
Richards, L. (2019). Diflucan: Dosage, Side Effects, and Natural Alternatives. Retrieved from https://www.thecandidadiet.com/diflucan/
University of Illinois-Chicago, Drug Information Group. (2018). Fluconazole, Oral Tablet. Retrieved from https://www.healthline.com/health/fluconazole-oral-tablet
W12DQ2
Select a medication and discuss the ethnic, cultural, or genetic differences in the uses for the treatment of a viral infection. Share the mechanism of action of this medication and hints for monitoring, side effects, and drug interactions. In addition, share a clinical trial that supports the use of this agent. Include the name of the medication in the subject line so that the medications can be followed. Include references in APA format.
Oseltamivir is an antiviral medication that blocks the actions of influenza virus types A and B in your body. Oseltamivir is an ethyl ester prodrug that requires hydrolysis to the active metabolite, oseltamivir carboxylate. Once in circulation, oseltamivir carboxylate acts extracellularly by selectively binding to an unoccupied area of viral neuraminidase (a surface glycoprotein on influenza A and B that catalyzes the cleavage of the linkage between a terminal sialic acid and adjacent sugar residue), resulting in competitive inhibition of the enzyme. By inhibiting the actions of viral neuraminidase, oseltamivir ultimately prevents the spread of virus in the respiratory tract. Some people using oseltamivir (especially children) have had sudden unusual changes in mood or behavior.It is not certain that oseltamivir is the exact cause of these symptoms. Possible side eefcts are sudden confusion, tremors or shaking, unusual behavior or hallucinations (hearing or seeing things that are not there). Common side effects may include: nausea, vomiting, headache or pain (PDR, 2019).
Medications known to interact with Tamiflu (oseltamivir) are entecavir, influenza virus vaccine, h1n1, live, influenza virus vaccine, live, trivalent, methotrexate, pemetrexed, probenecid, tafamidis, warfarin. Dose adjustment may be needed in those with kidney problems (Drug.com, 2019). A debate about the market-leading influenza antiviral medication, oseltamivir, which initially focused on treatment for generally mild illness, has been expanded to question the wisdom of stockpiling for use in future influenza pandemics. Although randomized controlled trial evidence confirms that oseltamivir will reduce symptom duration by 17–25 hours among otherwise healthy adolescents and adults with community-managed disease, no randomized controlled trials have examined the effectiveness of oseltamivir against more serious outcomes. Observational studies, although criticized on methodologic grounds, suggest that oseltamivir given early can reduce the risk for death by half among persons hospitalized with confirmed infection caused by influenza A(H1N1)pdm09 and influenza A(H5N1) viruses (Hurt & Kelly, 2016).
References
Drug.com. (2019). Tamiflu (oseltamivir) Drug Interactions. Retrieved from https://www.drugs.com/drug-interactions/oseltamivir,tamiflu.html
Hurt, A. C., & Kelly, H. (2016). Debate Regarding Oseltamivir Use for Seasonal and Pandemic Influenza. Emerging infectious diseases, 22(6), 949–955. doi:10.3201/eid2206.151037
PDR. (2019). Oseltamivir phosphate – Drug Summary. Retrieved from https://www.pdr.net/drug-summary/Tamiflu-oseltamivir-phosphate-2099
W13DQ1
Select a medication and apply evidence or treatment guidelines used for the treatment of asthma, COPD, or an acute exacerbation of COPD. Share the mechanism of action of this medication and hints for monitoring, side effects, and drug interactions, including interactions with CAM. Integrate information regarding where the medication is found in asthma or COPD guidelines. What other considerations need to be made when prescribing these medications in relation to other systems and receptors? Include the name of the medication in the subject line so that the medications can be followed. Include references using APA format.
Theophylline is used to treat lung diseases such as asthma. It must be used regularly to prevent wheezing and shortness of breath. Theophylline was first identified as having potential for asthma as a bronchodilator in 1921 and 1922, but general use as a bronchodilator was not seen until the 1930s. This medication belongs to a class of drugs known as xanthines. It works in the airways by relaxing muscles, opening breathing passages, and decreasing the lungs’ response to irritants. Theophylline must be used regularly to be effective. It does not work right away and should not be used to relieve sudden breathing problems. It is available under the following different brand names: Theo 24, Theochron, Elixophyllin, aminophylline, and Uniphyl (Cunha, 2018). Theophylline has two distinct actions in the airways of patients with reversible obstruction; smooth muscle relaxation (i.e., bronchodilation) and suppression of the response of the airways to stimuli (i.e., non-bronchodilator prophylactic effects). While the mechanisms of action of Theophylline are not known with certainty, studies in animals suggest that bronchodilation is mediated by the inhibition of two isozymes of phosphodiesterase (PDE III and, to a lesser extent, PDE IV) while non-bronchodilator prophylactic actions are probably mediated through one or more different molecular mechanisms, that do not involve inhibition of PDE III or antagonism of adenosine receptors. Theophylline increases the force of contraction of diaphragmatic muscles. This action appears to be due to enhancement of calcium uptake through an adenosine-mediated channel (Drugs.com, 2019).
For patients who are on chronic theophylline and unable to take oral medication during an acute exacerbation, the serum level should be assessed and intravenous theophylline administered at a maintenance infusion rate, adjusted if needed to achieve a peak serum concentration of 10 to 20 mg/L. For patients not previously receiving theophylline, a single intravenous loading dose of theophylline, 5 to 7.5 mg/kg, will provide a peak serum theophylline concentration of about 10 to 15 mcg/mL and may be justified for patients with severe acute symptoms that do not respond rapidly to routine measures. There is minimal risk for serious toxicity with such a dose, and a maintenance infusion may then be initiated if obvious clinical improvement results. Choice of a maintenance infusion rate depends on factors such as age, smoking status, and concomitant medical problems that may alter theophylline clearance. Measurement of serum concentrations is performed approximately four hours after initiation of continuous infusion and then every 12 to 24 hours. Theophylline has a narrow therapeutic index and wide interpatient variability in clearance. Consequently, dosing must be individually titrated to appropriate steady-state serum concentrations in order to achieve maximal benefit and safety (Hendeles & Weinberger, 2019). The clearance of Theophylline is decreased by an average of 30% in healthy elderly adults (> 60 yrs) compared to healthy young adults. Careful attention to dose reduction and frequent monitoring of serum Theophylline concentrations are required in elderly patients. Gender differences in Theophylline clearance are relatively small and unlikely to be of clinical significance. Significant reduction in Theophylline clearance, however, has been reported in women on the 20th day of the menstrual cycle and during the third trimester of pregnancy (Drugs.com, 2019).
In patients with chronic asthma, including patients with severe asthma requiring inhaled corticosteroids or alternate-day oral corticosteroids, many clinical studies have shown that Theophylline decreases the frequency and severity of symptoms, including nocturnal exacerbations, and decreases the “as needed” use of inhaled beta-2 agonists. Theophylline has also been shown to reduce the need for short courses of daily oral prednisone to relieve exacerbations of airway obstruction that are unresponsive to bronchodilators in asthmatics. In patients with chronic obstructive pulmonary disease (COPD), clinical studies have shown that Theophylline decreases dyspnea, air trapping, the work of breathing, and improves contractility of diaphragmatic muscles with little or no improvement in pulmonary function measurements (Drugs.com, 2019).
Side effects of theophylline at peak serum concentration less than 20 mcg/mL include: Central nervous system excitement, headache, insomnia, irritability, restlessness, seizure, diarrhea, nausea, vomiting, increased urination (transient), exfoliative dermatitis, skeletal muscle tremors, fast heart rate, flutter, high calcium levels (hypercalcemia) (with concomitant hyperthyroid disease), difficulty urinating (elderly males with prostatism). Side effects of theophylline at peak serum greater than 20 mcg/mL include: heart attack (acute myocardial infarction), seizures (resistant to anticonvulsants), urinary retention (Cunha, 2018).
Theophylline should be used with extreme caution in patients with the following clinical conditions due to the increased risk of exacerbation of the concurrent condition: active peptic ulcer disease, seizure disorders, cardiac arrhythmias (not including bradyarrhythmias). The concurrent administration of caffeine to patients taking theophylline may produce excessive caffeine-like side effects, such as nausea, irritability or nervousness. Tobacco smoke contains substances that may speed the removal of Theophylline from the body; if you start smoking, the Theophylline may become less effective. Theophylline is very similar to aminophylline and oxtriphylline. Do not take medications containing aminophylline or oxtriphylline while using theophylline (Drugs.com, 2019).
References
Cunha, J. (2018). Theophylline. Retrieved from https://www.rxlist.com/consumer_theophylline_elixophyllin_uniphyl/drugs-condition.htm Drugs.com. (2019). Theopylline. Retrieved from https://www.drugs.com/pro/theophylline.html
Hendeles, L., Weinberger, M. (2019). Theophylline use in asthma. Retrieved from https://www.uptodate.com/contents/theophylline-use-in-asthma
W13 DQ2
A patient presents with shortness of breath (SOB). When community-acquired or hospital-acquired pneumonia is suspected, how do you select your antibiotic according to guidelines? What ethnic, cultural, and genetic differences must be considered in patients in order to ensure the safety or efficacy of the medication?
Guidelines on management of adults with hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) by the Infectious Diseases Society of America and the American Thoracic Society are as follows:
• Recommend that each hospital generate antibiograms to guide healthcare professionals with respect to the optimal choice of antibiotics.
• In an effort to minimize patient harm and exposure to unnecessary antibiotics and reduce the development of antibiotic resistance, the guidelines recommend that the antibiogram data be used to decrease the unnecessary use of dual gram-negative and empiric methicillin-resistant Staphylococcus aureus (MRSA) antibiotic treatment.
• Short-course antibiotic therapy is recommended for most patients with HAP or VAP regardless of microbial etiology, as well as antibiotic de-escalation.
• Suggest noninvasive sampling with semiquantitative cultures to diagnose VAP, rather than invasive sampling with quantitative cultures or noninvasive sampling with quantitative cultures.
• However, the panel recognizes that invasive quantitative cultures will occasionally be performed by some clinicians. For patients with suspected VAP whose invasive quantitative culture results are below the diagnostic threshold for VAP, the guidelines suggest that antibiotics be withheld rather than continued.
• Suggest that patients with suspected HAP (non-VAP) be treated according to the results of microbiologic studies performed on respiratory samples obtained noninvasively, rather than being treated empirically.
• For patients with suspected HAP/VAP, the guidelines recommend using clinical criteria alone, rather than using serum procalcitonin (PCT) plus clinical criteria, bronchoalveolar lavage fluid (BALF) sTREM-1 plus clinical criteria, or C-reactive protein (CRP) plus clinical criteria to decide whether to initiate antibiotic therapy.
• In patients with suspected VAP, include coverage for S aureus, Pseudomonas aeruginosa, and other gram-negative bacilli in all empiric regimens.
• If empiric coverage for MRSA is indicated, either vancomycin or linezolid is recommended.
• When empiric treatment that includes coverage for MSSA (and not MRSA) is indicated, the guidelines suggest a regimen including piperacillin-tazobactam, cefepime, levofloxacin, imipenem, or meropenem. Oxacillin, nafcillin, and cefazolin are preferred agents for treatment of proven MSSA, but are not necessary for the empiric treatment of VAP if one of the above agents is used.
• For patients being treated empirically for HAP, prescribe an antibiotic with activity against S aureus.
• For patients with HAP who require empiric coverage for MRSA, vancomycin or linezolid is recommended.
• For patients with HAP/VAP due to P aeruginosa, the guidelines recommend that the choice of an antibiotic for definitive (not empiric) therapy be based on the results of antimicrobial susceptibility testing.
• For patients with VAP or HAP, a 7-day course of antimicrobial therapy is recommended.
Traditionally, nosocomial pneumonias have been treated for 7-14 days. If the patient receives appropriate antimicrobial therapy for 2 weeks and does not respond (ie, improved infiltrates findings on chest radiograph), initiate a diagnostic workup to detect nonbacterial infections (eg, herpesvirus type 1 [HSV-1] pneumonitis) or noninfectious disease mimics (eg, bronchogenic carcinomas) (Cunha, 2018).
Guidelines consistently emphasize the importance of treating HAP with early and appropriate broad-spectrum antibiotics, and recent developments in this field have resulted in the availability of several additional treatment options. Telavancin shows potent activity against Gram-positive bacteria including MRSA and can be administered once daily; it was approved in the USA and European Union for the treatment of HAP after demonstrating non-inferiority to vancomycin. Ceftobiprole medocaril exhibits rapid antimicrobial activity against a broad range of both Gram-positive and Gram-negative pathogens, including MRSA. It was approved for the treatment of HAP (excluding ventilator-associated pneumonia) and community-acquired pneumonia in Europe in 2013. These new treatments may offer effective alternative therapeutic options for the management of HAP (Montravers, Harpan, & Guivarch, 2016).
References
Cunha, B. (2018). Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and Ventilator-Associated Pneumonia. Retrieved from https://emedicine.medscape.com/article/234753-overview#a14
Montravers, P., Harpan, A., & Guivarch, E. (2016). Current and Future Considerations for the Treatment of Hospital-Acquired Pneumonia. Advances in therapy, 33(2), 151–166. doi:10.1007/s12325-016-0293-x
W14DQ1
Select a medication and discuss the ethnic, cultural, or genetic differences that must be considered in its use to treat neuropathy. Share the mechanism of action of this medication and hints for monitoring, side effects, and drug interactions, including interactions with CAM. In addition, include a clinical trial related to the use of this medication for neuropathy. Include the name of the medication in the subject line so that the medications can be followed. Include references using APA format.
Neuropathic pain is caused by damage to nerves, either from injury or disease. Capsaicin cream, which contains a substance found in hot peppers, can cause modest improvements in peripheral neuropathy symptoms. It is thought to reduce chronic neuropathic pain by making nerves insensitive to pain messages. It is used only to treat localized areas of pain. The single application is designed to produce relief of pain for up to three months. A study conducted by Derry et al. (2017) involving 2442 participants found that the capsaicin treatment gave good levels of pain relief to a small number of participants with some types of neuropathic pain (pain after shingles, and nerve injury pain associated with HIV infection), and probably also in another type (painful feet because of damaged nerves caused by diabetes). About 4 in 10 people had at least moderate pain relief with capsaicin compared with 3 in 10 with control.
The mechanism of action of capsaicin is based on neuronal desensitization to noxious stimuli. Two forms of desensitization are apparent. One is a capsaicin‐induced loss of responsiveness. This is functional and it is reversible. On the other hand is a calcium‐dependent desensitization involving the activation of phosphatase and leading to the inactivation of capsaicin channel (Taiwo & Jolayemi, 2016). Although capsaicin is generally regarded as safe, there are some potential side effects of topical use. These side effects generally occur at the application site and most commonly include: burning, itching, redness, swelling, pain. These side effects are most often only short-term and should clear up with continued use. It’s important to note that they may worsen with the use of warm or hot water, or from exposure to hot weather. Also, due to the nature of capsaicin, additional side effects may occur with improper use especially if you inhale the cream. Inhaling capsaicin cream can cause respiratory distress, such as sneezing and trouble breathing. Capsaicin cream should never be applied to open wounds or cuts. Once you apply the medication, it’s important to wash your hands as it can burn sensitive areas such as the eyes or mouth (Lockett, 2018).
Do not use medications containing capsaicin while using capsaicin. Do not use other medicated skin products, including muscle pain creams or lotions, on areas where you have applied capsaicin. Taking capsaicin along with aspirin might reduce the effectiveness of aspirin. Taking capsaicin along with ciprofloxacin might increase the effects and side effects of ciprofloxacin. Using capsaicin along with cocaine might increase the side effects of cocaine, including heart attack and death. If taken with diabetes medications,it might cause your blood sugar to go too low. Monitor your blood sugar closely. The dose of your diabetes medication might need to be changed. Taking capsaicin along with medications used for lowering high blood pressure might reduce the effectiveness of these drugs and it can also slow clotting thus increasing the chances of bruising and bleeding. Taking it along with theophylline might increase the effects and side effects of theophylline (RxList, 2019).
References
Taiwo, A., Jolayemi, E. (2016). Capsaicin: Aromatic Basis and Mechanism of Action: An Example of Positive Inhibition. Retrieved from https://www.intechopen.com/books/aromatic-and-medicinal-plants-back-to-nature/capsaicin-aromatic-basis-and-mechanism-of-action-an-example-of-positive-inhibition
Derry S, Rice ASC, Cole P, Tan T, Moore R. (2017). Topical capsaicin (high concentration) for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD007393. DOI: 10.1002/14651858.CD007393.pub4
Lockett, E. (2018). Uses of Capsaicin Cream. Retrieved from https://www.healthline.com/health/capsaicin-cream
RxList. (2019). Capsicum. Retrieved from https://www.rxlist.com/capsicum/supplements.htm
W14DQ2
Select an antidepressant or antipsychotic medication and apply the available evidence and treatment guidelines to determine appropriate therapeutic options for a patient. Share the mechanism of action of this medication and hints for monitoring, side effects, and drug interactions, including interactions with CAM. Identify an additional (possibly off-labeled) use of the medication not related to depression or psychosis. Include the name of the medication in the subject line so that the medications can be followed. Include references using APA format.
Olanzapine is used to treat certain mental/mood conditions (such as schizophrenia, bipolar disorder). It may also be used in combination with other medication to treat depression. This medication can help to decrease hallucinations and help you to think more clearly and positively about yourself, feel less agitated, and take a more active part in everyday life. Olanzapine belongs to a class of drugs called atypical antipsychotics. It works by helping to restore the balance of certain natural substances in the brain (WebMd, 2019).
The exact mechanism of action of olanzapine is not known. It may work by blocking receptors for several neurotransmitters (chemicals that nerves use to communicate with each other) in the brain. It binds to alpha-1, dopamine, histamine H-1, muscarinic, and serotonin type 2 (5-HT2) receptors. Olanzapine was approved by the FDA in 1996 (Ogbru, n.d.)
Commonly reported side effects of olanzapine include: asthenia, dizziness, drowsiness, extrapyramidal reaction, hyperkinetic muscle activity, akinesia, cogwheel rigidity, drug-induced Parkinson’s disease, dyspepsia, mask-like face, and xerostomia. Other side effects include: abnormal gait, back pain, constipation, fever, orthostatic hypotension, weight gain, myoclonus, and personality disorder. See below for a comprehensive list of adverse effects (Drugs.com, 2019).
The co-administration of diazepam with olanzapine potentiated the orthostatic hypotension observed with olanzapine. Carbamazepine therapy (200 mg bid) causes an approximately 50% increase in the clearance of olanzapine. This increase is likely due to the fact that carbamazepine is a potent inducer of CYP1A2 activity. Higher daily doses of carbamazepine may cause an even greater increase in olanzapine clearance. The co-administration of alcohol (i.e., ethanol) with olanzapine potentiated the orthostatic hypotension observed with olanzapine. Fluoxetine causes a small (mean 16%) increase in the maximum concentration of olanzapine. Omeprazole and rifampin may cause an increase in olanzapine clearance. Given the primary CNS effects of olanzapine, caution should be used when olanzapine is taken in combination with other centrally acting drugs and alcohol. Antihypertensive Agents — Olanzapine, because of its potential for inducing hypotension, may enhance the effects of certain antihypertensive agents. Levodopa and Dopamine Agonists — Olanzapine may antagonize the effects of levodopa and dopamine agonists. Lorazepam (IM). Use of atypical antipsychotics such as olanzapine for the following off-label conditions has been documented in the scientific literature: attention-deficit hyperactivity disorder (ADHD), anxiety, dementia in elderly patients, depression, eating disorders, insomnia, obsessive compulsive disorder, personality disorder, post-traumatic stress disorder (PTSD), substance use disorders, and Tourette’s syndrome (Guzman, 2019).
References
Drugs.com. (2019). Olansapine side effects. Retrieved from https://www.drugs.com/sfx/olanzapine-side-effects.html
Guzman, F. (2019). Olanzapine Interactions. Retrieved from https://psychopharmacologyinstitute.com/publication/olanzapine-interactions-2163
Ogbru, O. (n.d.). olanzapine (Zyprexa, Zydis). Retrieved from
https://www.medicinenet.com/olanzapine/article.htm#what_is_olanzapine_and_how_does_it_work_mechanism_of_action
WebMd. (n.d.). Olanzapine. Retreieved from https://www.medicinenet.com/olanzapine/article.htm#what_is_olanzapine_and_how_does_it_work_mechanism_of_action
W15 DQ1
Select a medication and apply the available evidence and treatment guidelines to determine appropriate therapeutic options that have a drug-drug interaction with proton pump inhibitors or antacids. Describe the interaction and the clinical management of the situation. Provide rationale and justification for continuing both medications, or discuss alternative therapy that could eliminate the drug-drug interaction. Include references using APA format.
Proton pump inhibitors (PPIs) are a class of antisecretory agents used to treat various gastrointestinal conditions, such as gastroesophageal reflux disease, Helicobacter pylori–related disorders, and gastric and duodenal ulcers. Given the reputation of PPIs for being very effective and generally safe, significant overutilization of PPIs is a major concern. Not only are PPIs often administered for indications without evidence supporting their use, but these medications are also frequently prescribed at higher doses than necessary for treatment durations extending beyond recommended time frames (Kheloussi, 2017).
PPIs are generally regarded as a well-tolerated class of medications. However, several safety concerns have long plagued their reputation, including an increased risk of Clostridium difficile–associated diarrhea, community-acquired pneumonia, and bone fractures. More recently, concerns about dementia and chronic kidney disease have been raised, and debates regarding hypomagnesemia and a theoretical drug-drug interaction with clopidogrel have continued.
Clopidogrel plays an important role in cardiovascular risk reduction, but it is associated with GI bleeds, especially in patients at increased risk. GI protection with PPIs is often implemented in patients who are more likely to experience a GI bleed, including those with a prior upper-GI bleed; advanced age; concurrent use of anticoagulants, corticosteroids, or NSAIDs (including aspirin); and/or H pylori infection(Kheloussi, 2017).
PPIs are thought to inhibit the CYP2C19 enzyme, the primary pathway through which clopidogrel is activated. This interaction can theoretically decrease the antiplatelet effects of clopidogrel and increase the risk of adverse cardiovascular outcomes. The latest FDA recommendations suggest that pantoprazole is a safer choice than other PPIs, whereas omeprazole is thought to be the riskiest. In a study conducted by Bouzina & Tziomalos (2015), they concluded that omeprazole can attenuate the antiplatelet effect of clopidogrel, this interaction does not appear to translate into increased cardiovascular risk in patients treated with this combination. Other PPIs also do not appear to interact with clopidogrel. However, given the limitations of existing studies, the decision to administer PPIs to patients treated with clopidogrel should be individualized based on the patient’s bleeding and cardiovascular risk.
It is important to weigh the benefits and risks of antiplatelet therapy alone or in combination with a PPI when a decision about adding GI-protective therapy is being made. In patients at high risk for GI complications, the beneficial effects of PPI therapy may be greater than the decreased effectiveness of antiplatelet therapy, which was inconsistently demonstrated. For patients at lower risk for GI complications, an H2RA may be a reasonable treatment option, although this class has been shown to be less effective than PPIs for this indication (Kheloussi, 2017).
References
Bouziana, S. D., & Tziomalos, K. (2015). Clinical relevance of clopidogrel-proton pump inhibitors interaction. World journal of gastrointestinal pharmacology and therapeutics, 6(2), 17–21. doi:10.4292/wjgpt.v6.i2.17
Kheloussi, S. (2017). Appropriate Use and Safety Concerns of Proton Pump Inhibitors. Retrieved from
https://www.uspharmacist.com/article/appropriate-use-and-safety-concerns-of-proton-pump-inhibitors
W15DQ2
Select a medication and apply the available evidence and treatment guidelines to determine appropriate therapeutic options used for the treatment of constipation or diarrhea. Share the mechanism of action of this medication and hints for monitoring, side effects, and drug interactions, including interactions with CAM. Discuss any ethnic, cultural, and genetic differences in patients that should be considered in the treatment of constipation or diarrhea in order to ensure the safety and efficacy of the medication. Be sure to comment on your agent related to C. difficile. In addition, include a peer-reviewed article showing benefit of your agent. Include the name of the medication in the subject line so that the medications can be followed. Include references using APA format.
Lactulose is a type of sugar. It is broken down in the large intestine into mild acids that draw water into the colon, which helps soften the stools. Lactulose is used to treat chronic constipation. Lactulose is sometimes used to treat or prevent certain conditions of the brain that are caused by liver failure, which can lead to confusion, problems with memory or thinking, behavior changes, tremors, feeling irritable, sleep problems, loss of coordination, and loss of consciousness (Drugs.com, 2019).
Lactulose can be useful for chronic constipation as a third-line agent, once lifestyle modifications and increasing fiber intake have failed. Its osmotic effect and its effect on intestinal motility receive credit for its therapeutic efficacy. Lactulose, also known as 1,4 beta galactoside-fructose, is a non-absorbable synthetic disaccharide made up of galactose and fructose. The human small intestinal mucosa does not have the enzymes to split lactulose, and hence lactulose reaches the large bowel unchanged. Lactulose is metabolized in the colon by colonic bacteria to monosaccharides, and then to volatile fatty acids, hydrogen, and methane (Mukherjee & John, 2019).
Although the oral route (as a syrup) has been the standard mode of administration for the past several decades, it is also effective as a rectal enema. Because lactulose has insignificant absorption by the gut and undergoes rapid excretion by the kidneys, its effects remain localized to the gut microenvironment. Side-effects would include increased bowel sounds (borborygmi), increased flatus and a sensation of bloating. Since its intended use is to soften the stool quantity and increase the stool amount, its most significant side effect remains as diarrhea. The diarrhea is dose-dependent and decreases in severity with a reduction in the dose of lactulose. From a pharmacokinetic standpoint, lactulose has negligible systemic absorption. However, like most laxatives, it has a propensity to bring about large changes in the body’s fluid and electrolyte status. This activity would require periodic electrolyte monitoring, especially in the elderly and critically ill population. The effects are particularly profound regarding the sodium level, which commonly manifests as hypernatremia. In psychiatric patients on lithium therapy, there may be a risk for toxicity due to the decreased renal excretion of the drug as a result of volume depletion, which would require careful drug monitoring.
In certain situations, dose titration of the lactulose may also be required to prevent dehydration, diarrhea, and excoriation of the anal skin, requiring pharmaceutical intervention. Patients in the ICU who would require lactulose administered via an NG tube would need physical positioning designed to decrease the odds of aspiration (Mukherjee & John, 2019).
Lactulose has no known severe interactions with other drugs. Lactulose has no known serious interactions with other drugs. Moderate interactions of lactulose include: aluminum hydroxide, calcium carbonate, deflazacort, dichlorphenamide, sodium bicarbonate, sodium citrate/citric acid (RxList, 2019).
A study conducted by Shou et al (2015) aim to evaluate the efficacy and safety of lactulose in the intervention treatment of postpartum women with constipation. They concluded that Lactulose offered good therapeutic benefit and could be developed as an effective intervention to postpartum women with constipation. Furthermore, because of its various benefits in multiple disorders, the use of lactulose is not limited to only constipation and hepatic encephalopathy.
References
Drugs.com. (2019). Lactulose. Retrieved from https://www.drugs.com/mtm/lactulose.html
Mukherjee, S., John, S. (2019). Lactulose. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK536930/
RxList. (2019). Lactulose. Retrieved from https://www.rxlist.com/consumer_lactulose/drugs-condition.htm
Zhou, Y., Yang, X., Fan, L., Zhu, Y., Jiang, Y., Li, Z., … Wang, X. (2015). Observations on the curative effect of lactulose for postpartum constipation based on a large sample study. International journal of clinical and experimental medicine, 8(10), 19167–19171.
W16DQ1
Select an antidote for a medication overdose. Determine if there are any ethnic, cultural, or genetic differences that need to be considered using these medications. Discuss the mechanism of action of both agents, the risks of the overdose, and the dosing of antidotes. Share a patient case in which this antidote was used and discuss the success or failure of the agent. Include the name of the medication in the subject line so that the medications can be followed. Include references in APA format.
A patient self reported self administration of heroin daily. The provider notice signs of opioid withdrawal, including frequent yawning, piloerection, and dilated pupils at 6 mm diameter. A plan for naloxone taper was initiated to manage the acute symptoms of opioid withdrawal. The patient was also prescribed trazodone, clonidine, quetiapine, and dimenhydrinate as needed to treat any residual opioid withdrawal symptoms. The patient was discharged back to a shelter following completion of the 4-day buprenorphine/naloxone taper. Naloxone is a medication approved by the Food and Drug Administration (FDA) to prevent overdose by opioids such as heroin, morphine, and oxycodone. Opioids are substances derived from the opium poppy, or synthetic analogues with similar effects. Examples are morphine, heroin, tramadol, oxycodone and methadone .A new discovery shows that opioids used to treat pain, such as morphine and oxycodone, produce their effects by binding to receptors inside neurons, contrary to conventional wisdom that they acted only on the same surface receptors as endogenous opioids, which are produced naturally in the brain. However, when researchers funded by the National Institute on Drug Abuse (NIDA) used a novel molecular probe to test that common assumption, they discovered that medically used opioids also bind to receptors that are not a target for the naturally occurring opioids (NIDA, 2018). Opioids have the potential to cause substance dependence that is characterized by a strong desire to take opioids, impaired control over opioid use, persistent opioid use despite harmful consequences, a higher priority given to opioid use than to other activities and obligations, increased tolerance, and a physical withdrawal reaction when opioids are discontinued. Due to their effect on the part of the brain which regulates breathing, opioids in high doses can cause respiratory depression and death. An opioid overdose can be identified by a combination of three signs and symptoms referred to as the “opioid overdose triad”. The symptoms of the triad are: pinpoint pupils, unconsciousness, respiratory depression (World Health Organization, 2018).
The opioid antagonist, naloxone, inhibits all opioid receptors, but has highest affinity for m receptors. It blocks opioid receptor sites, reversing the toxic effects of the overdose. Naloxone is administered when a patient is showing signs of opioid overdose. The medication can be given by intranasal spray, intramuscular (into the muscle), subcutaneous (under the skin), or intravenous injection (Substance Abuse and Mental Health Services Administration, 2019). Initial dose: 0.4 mg to 2 mg IV; alternatively, may give IM or subcutaneously. If desired response is not obtained, doses should be repeated at 2 to 3 minute intervals. If no response is observed with a total dose of 10 mg, the diagnosis of opioid-induced or partial opioid-induced toxicity should be questioned (Drugs.com, 2019)
Ethnic differences in the prevalence, severity, and impact of a number of clinical pain conditions have been well documented. Black pain patients generally display greater pain-related symptoms, suffering, pain interference, and disability relative to White patients. Similarly, Black patients report higher levels of pain unpleasantness, greater emotional responses to pain, increased pain behaviors, and may not receive the same benefit from treatment as their White counterparts. These differences are mirrored in the laboratory, with Black participants reporting an enhanced sensitivity to a variety of evoked pain testing methods when compared to White participants. Black participants report greater sensitivity (i.e., a lower pain threshold) to a variety of quantitative sensory testing (QST) protocols including thermal pain, cold pressor pain, ischemic pain and electrical stimulation, as well as greater temporal summation and reduced conditioned pain modulation (CPM). Burton et al. (2017) concluded in their study that Non-hispanic black participants reported a significant pain reduction during the naloxone condition as compared to non-hispanic whites participants, suggesting paradoxical naloxone-induced analgesia selective to the NHB group.
Death following opioid overdose is preventable if the person receives basic life support and the timely administration of the opioid antagonist naloxone. Naloxone, which is effectively an antidote to opioid overdose, will completely reverse the effects of an opioid overdose if administered in time. Access to naloxone is generally limited to health professionals. In many countries there is still limited availability of naloxone even in medical settings, including ambulances. At least one country, Italy, has already made naloxone available in pharmacies without prescription. A recent survey in the United States found that the distribution of approximately 50 000 naloxone kits through local opioid overdose prevention programmes had resulted in more than 10 000 uses to reverse overdoses (WHO, 2018).
References
Burton, E. F., Suen, S. Y., Walker, J. L., Bruehl, S., Peterlin, B. L., Tompkins, D. A., … Campbell, C. M. (2017). Ethnic Differences in the Effects of Naloxone on Sustained Evoked Pain: A Preliminary Study. Diversity and equality in health and care, 14(5), 236–242. doi:10.21767/2049-5471.1000116
Drugs.com. (2019). Naloxone Dosage. Retrieved from https://www.drugs.com/dosage/naloxone.html#Usual_Adult_Dose_for_Opioid_Overdose
NIDA. (2018, May 10). Study upends conventional view of opioid mechanism of action. Retrieved from https://www.drugabuse.gov/news-events/news-releases/2018/05/study-upends-conventional-view-opioid-mechanism-action on 2019, December 23
Substance Abuse and Mental Health Services Administration. (2019). Naloxone. Retrieved fromhttps://www.samhsa.gov/medication-assisted-treatment/treatment/naloxone
World Health Organization. (2018). Information sheet on opioid overdose. Retrieved from https://www.who.int/substance_abuse/information-sheet/en/
W16 DQ2
A patient presents with acute alcohol withdrawal. Discuss how you would manage this patient, including any pharmacological agents you would recommend. Find an evidence-based protocol and discuss the treatment recommendations.
The alcohol withdrawal syndrome is a well‐known condition occurring after intentional or unintentional abrupt cessation of heavy/constant drinking in patients suffering from alcohol use disorders. Once comorbid illnesses have been excluded or adequately treated, the management of alcohol withdrawal is directed at alleviating symptoms and identifying and correcting metabolic derangements. Benzodiazepines are used to control psychomotor agitation and prevent progression to more severe withdrawal. Supportive care, including intravenous (IV) fluids, nutritional supplementation, and frequent clinical reassessment including vital signs, is important. Clinicians must avoid complacency when treating patients with alcohol withdrawal. Patients should be placed in a quiet, protective environment. Mechanical restraint may be temporarily necessary for patients suffering from delirium tremens (DT) in order to protect both the patient and caretakers. Clinicians should follow their facility’s guidelines for documentation and implementation of physical restraints. Once adequate chemical sedation is achieved, physical restraints should be removed, as resistance against restraints can increase temperature, produce rhabdomyolysis, and cause physical injury. Volume deficits can be calculated and replaced accordingly, or, if there are no contraindications, isotonic IV fluid can be infused rapidly until patients are clinically euvolemic. Thiamine and glucose should be administered in order to prevent or treat Wernicke encephalopathy. Multivitamins containing or supplemented with folate should be given routinely, and deficiencies of glucose, potassium, magnesium, and phosphate should be corrected as needed. Initially (first day or two), treatment should be IV as gastrointestinal absorption is impaired in many patients who abuse alcohol chronically. Some clinicians treat alcohol withdrawal patients with an IV infusion of a combination of thiamine, folate, and a multivitamin in isotonic saline with 5 percent dextrose. The multivitamin makes the fluid appear yellow, and thus this treatment combination is sometimes referred to as a “banana bag.” During the early phases of withdrawal, alcoholic patients are often given nothing by mouth (ie, kept “NPO”) to prevent aspiration. However, nutritional support is essential as alcoholic patients are frequently malnourished and have high metabolic needs due to their excited autonomic state. Initially, parenteral glucose supplementation is sufficient, but additional nutrition may be needed for patients who remain unable to eat for more than a day or two. Patients considered at high risk for complications should be monitored in an intensive care unit (ICU) (Hoffman & Weinhouse, 2019).
A psychometric research study conducted by Davis et al. (2018) was designed to evaluate the Alcohol Withdrawal Assessment Tool (AWAT). The Alcohol Withdrawal Assessment Tool (AWAT) is a 4-item assessment tool developed to standardize and simplify assessment and treatment of alcohol withdrawal. They concluded that the psychometric testing results of the AWAT suggest that the tool may be an effective alternative to previously published tools for healthcare professionals to utilize in the acute care setting to assess signs and symptoms of alcohol withdrawal. The tool is easy to use by clinicians and drives frequency of assessment and prescribed pharmacologic treatment. The tool is not intended to diagnose, but rather clinically inform and monitor patients at risk of alcohol withdrawal, which if left untreated could potentially be fatal.
Reference
Davis, C., Kenn, A., Holly, V., Balaguras, UJ., Miller, w. (2018). Alcohol Withdrawal Assessment Tool. Validity and Reliability Testing in Acute Care. Retrieved from https://journals.lww.com/cns-journal/Fulltext/2018/11000/Alcohol_Withdrawal_Assessment_Tool__Validity_and.7.aspx
Hoffman, R., Weinhouse, G. (2019). Management of moderate and severe alcohol withdrawal syndromes. Retrieved from https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes
New Discussion questions
Instructions
1- After Each question, write down references
2- 300 minimum words for each question, you can go up to 700 words.
3- 2-3 references for each question
4- References should be within 5 years
5- I am in acute care nurse practitioner program.
Discussion Questions
1- W8 DQ1 Hypogonadism affects many men and is known to be one of the main causes of infertility. Explain the pathophysiology. Discuss the treatment of testosterone including the benefits, risks, contraindications, potential drug interactions, and preparations of and dosing. Use evidence based, peer reviewed research to support your answer. Include references using APA format.
2- W9Q1 Choose a chronic or acute skin condition. Provide an overview of the underlying pathophysiology as well as the available pharmacologic treatment options available. Include the benefits, risks, contraindications, preparations, dosing, and potential drug interactions, including interactions with CAM. Find a peer-reviewed article from the literature that evaluates the treatment of this condition and share the recommendations.
3- W9Q2 Review the classes of steroids. Discuss the differences between the potencies/strengths of OTC and prescription steroids. Why would you recommend a patient use an OTC versus a prescription treatment? When would you recommend a cream vs. an ointment? Include references using APA format.
4- W10Q1 Select a medication used for pain management and review available evidence and treatment guidelines to determine appropriate therapeutic options. Share the mechanism of action of this medication and hints for monitoring, side effects, and drug interactions, including CAM. In addition, share an example where you have observed an adverse event from a pain medication and explain the management taken regarding this adverse event. If you do not have an example, select an adverse event from the pain medication and explain what interventions you could make to mitigate this adverse event. Include references using APA format.
5- W10Q2 Read and summarize the Topic Material “CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016.” Discuss any ethnic, cultural, or genetic differences that need to be considered for the use of opioids to treat chronic pain. How do you intend to use the guidelines in your future practice?
Assignments
1st one
Select a disease or condition. For example, sepsis, CAD, HCAP, HAP, hypertension, CHF, atrial fibrillation, depression, Parkinson’s disease, hyperlipidemia, COPD, asthma, and febrile neutropenia.
Write a 750-1,000 word paper discussing prescription and nonprescription medications/therapies for the treatment of the disease. Discuss monitoring and identify significant adverse effects and drug-drug interactions, as well as desired outcomes of the pharmacological agents used in the treatment of the disease. Determine an appropriate pharmaceutical treatment plan for the disease or condition. Incorporate considerations for various populations (geriatrics, pediatrics) depending on the disease you have selected.
You are required to cite three to five sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and nursing content.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
2ND ONE
This assignment uses a rubric. Review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
Choose a drug that has been approved by the FDA within the past year.
Write a 1,000-1,250 word paper in which you:
Describe the drug approved by the FDA. Include the pharmacodynamics and pharmacokinetic properties of the chosen drug.
Provide an overview of the disease state for which the drug is used.
Describe what is different about this agent compared to currently available therapies.
Discuss the potential risks associated with this agent and any monitoring parameters that are necessary.
Decide whether you would personally prescribe this agent or stick with currently available alternatives.
You are required to cite five to 10 sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and nursing content.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. Refer to the directions in the Student Success Center.
This assignment benchmarks the following competencies:
MS-NUR-ACNP
6.3: Assess the pharmacodynamics and the pharmacokinetic impact of pharmacologic therapies in the treatment of diseases and altered states.
7.3: Prescribe appropriate pharmacologic and nonpharmacologic therapies in the management of illness, disease, or injuries.
MS-NUR-FNP
6.3: Assess the pharmacodynamics and the pharmacokinetic impact of pharmacologic therapies in the treatment of diseases and altered states.
7.3: Prescribe appropriate pharmacologic and nonpharmacologic therapies in the management of illness, disease, or injuries.