Impact of Drug Interactions and Adverse Events on Therapeutic
Drug Categories
Impact of Drug Interactions and Adverse Events on Therapeutic
A 60-year-old Caucasian woman with newly diagnosed peptic ulcer disease, generalized anxiety disorder, and iron deficiency anemia. She also has a long history of asthma and depression. She is a strong believer of herbal medicine. She takes St. John’s wort for her depression, iron pills for her anemia, and alprazolam (Xanax) as needed for her anxiety. During her asthma exacerbation, she is instructed to take prednisone for at least 5 days. She also takes esomeprazole (Nexium) for her peptic ulcer disease. Three months later, she experienced severe fatigue, shortness of breath, dizziness, and swelling/soreness in the tongue. Her asthma is well controlled with the occasional use of albuterol (Proventil) inhaler. During her physical exam, her physician suspected that she had bacterial vaginosis and gave her a prescription for a 1-week course of metronidazole (Flagyl). She drinks at least two to three cans of beer per day.
Diagnosis: Drug–Drug Interactions
St. John’s wort is known to inhibit which of her medication that is known to be metabolized by cytochrome P-450 (CYP3A4) and could potentially cause her to experience significant fatigue?
Which of her medication could interfere with the absorption of her iron pills?
Which of her medication could potentially cause her to develop vitamin B12 deficiency?
How does metronidazole interfere with alcohol?
If she was given a prescription for ketoconazole, which of her medication could interfere with its absorption?
DQ2 Prescription Writing
Overview
A prescription is an order from a physician, a nurse practitioner, or physician assistant to a pharmacist that indicates the medication that a patient is to take. If the prescription is poorly written, this can lead to medication error. Here are some statistics:
Medication errors occur in approximately 1 in every 5 doses given in hospitals.
One error occurs per patient per day.
Approximately 1.3 million injuries and 7,000 deaths occur each year in the U.S. from medication-related errors.
Drug-related morbidity and mortality are estimated to cost $177 billion in the U.S.
These are estimates from various sources and studies and provide shocking evidence about prescriptions. It is no wonder why malpractice insurance is so expensive.
Initial Post
Please review your course materials and research to evaluate the proper ways to write prescriptions.
For your initial post, share one piece of knowledge that you have found along with the resource information. Practice writing a prescription and submit that along with your post for your peers to evaluate.
NU641 Advanced Clinical Pharmacology
Week 3 Discussion
Heart Failure
Answer the following questions in three well-developed paragraphs (450–500 words) using APA formatting, integrating two evidence-based resources to include clinical practice guidelines as well as the course textbook.
Topic: Heart Failure
Michael, age 62, is a male who is new to your practice. He is reporting shortness of breath on exertion, especially after climbing steps or walking three to four blocks. His symptoms clear with rest. He also has difficulty sleeping at night (he tells you he needs two pillows to be comfortable). He tells you that 2 years ago, he suddenly became short of breath after hurrying for an airplane. He was admitted to a hospital and treated for acute pulmonary edema. Three days before the episode of pulmonary edema, he had an upper respiratory tract infection with fever and mild cough. After the episode of pulmonary edema, his blood pressure has been consistently elevated. His previous physician started him on a sustained-release preparation of diltiazem 180 mg/d.
Medical History:
His medical history includes moderate prostatic hypertrophy for 5 years, adult-onset diabetes mellitus for 10 years, hypertension for 10 years, and degenerative joint disease for 5 years.
Medications:
His medication history includes hydrochlorothiazide (HydroDIURIL) 50 mg/d, atenolol (Tenormin) 100 mg/d, controlled-delivery diltiazem 180 mg/d, glyburide (DiaBeta) 5 mg/d, and indomethacin (Indocin) 25 to 50 mg three times a day as needed for pain. While reviewing his medical records, you see that his last physical examination revealed a blood pressure of 160/95 mm Hg, a pulse of 95 bpm, a respiratory rate of 18, normal peripheral pulses, mild edema bilaterally in his feet, a prominent S3 and S4, neck vein distention, and an enlarged liver.
Diagnosis: Heart Failure Class II
List specific goals of treatment for Michael.
What drug(s) would you prescribe? Please provide rationales.
What are the parameters for monitoring the success of your selected therapy?
Discuss specific patient education based on the prescribed therapy.
Describe one or two drug–drug or drug–food interactions for the selected agent(s).
List one or two adverse reactions for the selected agent(s) that would cause you to change therapy.
What would be the choice for the second-line therapy?
What over-the-counter or alternative medications would be appropriate for Michael?
What dietary and lifestyle changes should be recommended for Michael?
NU641 Advanced Clinical Pharmacology
Week 4 Discussion
Gastrointestinal Case Study
Answer the following questions in three well-developed paragraphs (450–500 words) using APA formatting, integrating two evidence-based resources to include clinical practice guidelines as well as the course textbook.
Overview: Gastrointestinal Case Study
Joshua George is a 42-year-old white man presenting with a 2-month history of intermittent mid-epigastric pain. The pain sometimes wakes him up at night and seems to get better after he eats a meal. J.G. informs you that his doctor told him that he had an infection in his stomach 6 months ago. He never followed up and has been taking over-the-counter antacids and histamine receptor antagonists (H2Ras) for 2 weeks without relief. He takes no other medications. He is concerned because the pain is continuing. He has no other significant history except he is a 20 pack-year smoker and he drinks 5 cups of coffee a day. He eats late at night and goes to bed about 30 minutes after dinner. He is allergic to penicillin.
Diagnosis: Peptic Ulcer Disease
List specific goals for treatment for J.G.
What drug therapy would you prescribe for J.G.? Please provide your rationales.
What are the parameters for monitoring success of the therapy?
Discuss specific patient education based on the prescribed therapy.
List one or two adverse reactions for the selected agent that would cause you to change therapy.
What would be the choice for second-line therapy?
What over-the-counter and/or alternative medications would be appropriate for J.G.?
What lifestyle changes would you recommend to J.G.?
Describe one or two drug–drug or drug–food interaction for the selected agent.
NU641 Advanced Clinical Pharmacology
Week 5 Discussion
Pain Management Case Study
Answer the following questions for A and B in three well-developed paragraphs (450–500 words) using APA formatting, integrating two evidence-based resources to include clinical practice guidelines as well as the course textbook.
As an Advanced Nurse Practitioner (ANP), you are working in an acute care setting.
Jason Tyler is a 65-year-old male admitted to the hospital with history of chronic cancer pain using Morphine SR 60 mg PO q8h. On admission, morphine 2 mg IV q4h was ordered. The patient reports his pain only went from a 9 to an 8 after the morphine dose and is asking for more pain medication. The staff begins to question the motivation of the patient and if addiction is present. The resident decides to start a PCA for his pain. In a few hours, the patient is comfortable, resting in bed.
A: Answer the following questions and provide your rationales for your choices.
J.T.’s behavior is best described as: (Please provide the definition for your choice and your rationales)
Tolerance
Addiction
Pseudo addiction
Dependence
During his hospital stay, J.T. went into acute renal failure. He is increasingly lethargic and is experiencing confusion and some hallucinations. The physician believes the morphine metabolites may be responsible and would like to convert to an alternative regimen. What would be your recommendation?
Change opioid to fentanyl patch 50 mcg q72h.
Decrease morphine SR dose to 60 mg PO q8h.
Switch to hydromorphone 8 mg orally q4h as needed.
Add haloperidol 1 mg PO q6h.
Tolerance will not develop to which adverse opioid effect?
Respiratory depression
Sedation
Constipation
Nausea
B: What pieces of the holistic assessment are missing from this scenario: (Answer the following questions and provide your rationales)
As a healthcare provider, what else do you need to understand about this patient related to pain management?
In your response please provide the teaching you would provide to JT.
What is meant by the DEA Drug Classification Schedule? Explain each category/classification.
NU641 Advanced Clinical Pharmacology
Week 6 Discussion
Infection Case Study
Answer the following questions in three well-developed paragraphs (450–500 words) using APA formatting, integrating two evidence-based resources to include clinical practice guidelines as well as the course textbook.
Anthony Miller, a 59-year-old male, presents to the clinic with complaints of cough, shortness of breath, and increased sputum production. His past medical history is significant for COPD with chronic bronchitis, hypertension, diabetes, and hyperlipidemia. He reports that his sputum has increased in consistency and amount over the past few days. His last exacerbation was about 6 months ago, for which he received amoxicillin. This is his third exacerbation in the past year. He has a 40-pack year history of cigarette smoking and quit smoking 3 years ago. He does not take chronic steroids. Physical exam reveals rhonchi and expiratory wheezes. His vital signs are blood pressure 140/83 mm Hg, pulse rate 80 beats/min, respiration rate 20 breaths/min, and temperature 98.8°F. He has no known drug allergies. A sputum Gram stain in the office reveals purulent sputum (presence of WBCs). Chest x-ray findings are negative for pneumonia.
Diagnosis: Acute Exacerbation of Chronic Bronchitis—Please provide your rationales for each answer with supporting data
Which of the following would suggest the need for antibiotic therapy in A.M.?
Cough, history of smoking, and expiratory wheezes on physical examination
Elevated respiratory rate and shortness of breath
Increased dyspnea, increased sputum production, and increased sputum purulence
History of previous COPD exacerbations, cough, and fever
What is a likely pathogen associated with an acute exacerbation of chronic bronchitis in A.M.?
Mycobacterium tuberculosis
Pseudomonas aeruginosa
Staphylococcus aureus
Streptococcus pneumonia
What antibiotic would be most appropriate to treat an acute exacerbation of chronic bronchitis in A.M.?
Amoxicillin–clavulanate
Azithromycin
Linezolid
Sulfamethoxazole/trimethoprim
What is the mechanism of action of the medication of choice in question #3? Provide rationale.
What kind of counseling points would you provide for A.M.?
NU641 Advanced Clinical Pharmacology
Week 9 Discussion
Neurology
In your initial post, please answer all the questions and provide your rationales with supportive evidence in a well-developed paragraphs using APA formatting, integrating two evidence-based resources to include clinical practice guidelines as well as the course textbook. (Do not use lay press Internet sites.)
Accompanied by her boyfriend, Shaynah Anderson, age 23, visits your office. Her boyfriend states, “She hasn’t been herself the last month. She has headaches and is completely confused and tired for no reason.” Shaynah denies using illicit drugs and any recent traumatic injuries. She thinks her problem started approximately a month ago when she was at a club dancing. Her friends told her that she became confused and began tugging at her clothes. Then she fell down and was unconscious for a few minutes. When she awoke, she felt extremely tired and did not know what was going on. Her boyfriend recalls that she had been hit in the head with a softball during a game the day before they went dancing. Past medical history discloses insulin use since early childhood (currently 10 units NPH in the morning and 10 units regular insulin before meals), Prilosec at bedtime, and Ibuprofen (1 or 2 tablets twice a day) for headaches. She is interested in becoming pregnant in the next 12 to 24 months. The patient says she has no allergies and does not drink or use recreational drugs or tobacco.
On physical examination, Shaynah is 5 foot 4 inches and 130 lb. Her temperature is 37°C, pulse rate 78, blood pressure 118/76, and glucose level 90. Skin appears normal. Head and neck are normal, chest is clear for anterior and posterior sounds, cardiovascular RRR and (2) r/m/g, and laboratory values are within normal limits. EEG findings include sharp-wave discharges. At a follow-up visit 2 months later, patient and her boyfriend report that things have gotten worse. The boyfriend states that as patient was eating dinner one night and she had a seizure. She was completely stiff for a short time, and then her arms and legs began moving. He believes that she was unconscious for a few minutes, patient says she could not remember what had happened when she woke up.
Diagnosis: Generalized Tonic-Clonic Seizure
Which of the following should be true regarding your initial Adverse Effect Drugs (AED) regimen?
Initial combination therapy is warranted due to increased success rates.
Drugs that are taken two to three times daily are preferred due to a lower risk of seizure if a dose is missed.
Levetiracetam is the preferred agent for all seizure types and patients.
The risks of pregnancy must be discussed prior to starting any AED.
Which of the following is the most appropriate initial antiepileptic regimen for this patient?
Levetiracetam 500 mg PO daily
Phenytoin 100 mg PO three times daily
Pregabalin 50 mg PO three times daily
Clobazam 5 mg PO twice daily
The patient fails to respond and has significant side effects to her initial therapy. Her initial therapy is to be discontinued. Which of the following would be the most appropriate replacement?
Valproic acid 500 mg twice daily
Lamotrigine 100 mg twice daily
Lacosamide 100 mg twice daily
Rufinamide 200 mg twice daily
After several different AEDs, the patient ends up on carbamazepine and phenytoin. The carbamazepine serum concentration on week 2 of therapy was 6 mcg/mL. The patient presents after 8 weeks of therapy with increased seizures and she is found to have a serum concentration of 2 mcg/mL. Which of the following is a likely cause?
Autoinduction of CYP3A4.
Patient has the HLA-B*1502 subtype.
The oral contraceptive that she recently started.
Co-administration with alcohol.
Despite the use of oral contraception, the patient becomes pregnant. Her AED regimen consists of valproic acid and lacosamide. What is the most appropriate treatment intervention?
Discontinue valproic acid and continue lacosamide monotherapy.
Discontinue lacosamide and continue valproic acid monotherapy.
Continue combination therapy.
Discontinue valproic acid and add phenytoin.
NU641 Advanced Clinical Pharmacology
Week 11 Discussion
Dermatology Case Study
Answer the following questions and provide rationales with supporting evidence for your choices using APA formatting. Integrate two evidence-based resources to include clinical practice guidelines as well as the course textbook.
Jason Ferguson is a 15-year-old boy who weighs 110 pounds. Jason is seeking treatment for a very itchy rash consisting of linear streaks of papules, vesicles, as well as blisters on his arms, legs, and face. He tells you he was hiking in the woods two days ago on trails that were lined with patches of shiny weeds that had three leaves. He tried using calamine lotion and over-the-counter hydrocortisone cream but has had no relief from the itching.
Diagnosis: Contact Dermatitis (Poison Ivy)
List specific goals of treatment for J. F.
What drug therapy would you prescribe? Why?
What are the parameters for monitoring the success of the therapy?
Discuss specific patient education based on the prescribed therapy.
List one or two adverse reactions for the selected agent that would cause you to change therapy.
What would be the choice for second-line therapy?
What over-the-counter and alternative medications would be appropriate for J. F.?
What lifestyle changes would you recommend to J. F.?
Describe one or two drug–drug or drug–food interactions for the selected agent.
NU641 Advanced Clinical Pharmacology
Week 12 Discussion
Bacterial Vaginosis
In your initial post, answer all the questions and provide rationales for your answers with supporting evidence using APA formatting. Integrate two evidence-based resources to include clinical practice guidelines as well as the course textbook.
Read the scenario and answer the following questions:
R.S. is a 32-year-old Caucasian woman who seeks treatment for a vaginal discharge that she has had for the past month. She is sexually active and has had the same partner for the past 6 months. She reports noticing an odor, especially after sexual intercourse. Her history reveals that she has been using a commercial douche on a bi-weekly basis during the past year for hygienic purposes in an attempt to prevent vaginal infections. She denies any other associated symptoms.
The physical examination reveals a white vaginal discharge. Microscopic examination of the vaginal discharge shows clue cells, and the pH is 5.5.
Diagnosis: Bacterial Vaginosis
List specific goals of treatment for this patient.
What drug therapy would you prescribe? Why?
What are the parameters for monitoring the success of the therapy?
Discuss specific patient education based on the prescribed therapy.
List one or two adverse reactions for the selected agent that would cause you to change therapy.
What would be the choice for second-line therapy? Provide rationale
What OTC or alternative medications would be appropriate for this patient?
What dietary or lifestyle changes should be recommended?
Describe one or two drug–drug or drug–food interaction for the selected agent.
NU641 Advanced Clinical Pharmacology
Week 13 Discussion
Ophthalmic Disorders
In your initial post, answer all the questions and provide rationales for your answers with supporting evidence using APA formatting. Integrate two evidence-based resources to include clinical practice guidelines as well as the course textbook.
Read the scenario and answer the following questions:
Ophthalmic Disorders
V.S., age 12 Hispanic male, presents with a feeling that there is sand in his eye. He had a cold a week ago and woke up this morning with his left eye crusted with yellowish drainage. On physical examination, he has injected conjunctiva on the left side, no adenopathy, and no vision changes. His vision is 20/20. Fluorescein staining reveals no abrasion. He is allergic to sulfa.
Diagnosis: Conjunctivitis
List specific goals of treatment for V.S.
What drug therapy would you prescribe? Why?
What are the parameters for monitoring the success of the therapy?
Discuss the education you would give to the parents regarding drug therapy.
List one or two adverse reactions for the selected agent that would cause you to change therapy.
What would be the choice for second-line therapy?
What over-the-counter or alternative medications would be appropriate for V.S.?
What dietary and lifestyle changes should be recommended for V.S.?
Describe one or two drug–drug or drug–food interactions for the selected agent.
NU641 Advanced Clinical Pharmacology
Week 2 Assignment
Interactive Hypertension Case Study
Instructions
Review the patient case study and answer the questions provided. You are expected to include two evidence-based practice articles to support your work. Additionally, you will need to include the national guidelines for any treatment plans/options. All papers must conform to the most recent APA standards.
Case Study
Darius, a 65-year-old black man, was referred to the clinic for evaluation of high blood pressure noted on an initial screening. He reports having headaches and nocturia. He states that he has gained 8 pounds over the last year.
Past medical history:
• Appendectomy 30 years ago
• Peptic ulcer disease 10 years ago
• Type 2 diabetes mellitus for 10 years
• Gout
Family history:
• Father had hypertension; died of myocardial infarction at age 55.
• Mother had diabetes mellitus and hypertension; died of cerebrovascular accident at age 60.
Physical examination:
• Height 69 in, weight 90 kg
• BP: 140/89 mm Hg (left arm), 138/82 mm Hg (right arm)
• Pulse: 84 beats/minute, regular
• Funduscopic examination: mild arterial narrowing, sharp discs, no exudates or hemorrhages
Laboratory findings:
• Blood urea nitrogen: 24 mg/dL
• Serum creatinine: 1.1 mg/dL
• Glucose: 95 mg/dL
• Potassium: 4.0 mEq/L
• Total cholesterol: 201 mg/dL
• High-density lipoprotein cholesterol: 30 mg/dL
• Triglycerides: 167 mg/dL
• Urinalysis: within normal limit (no proteinuria)
• Electrocardiogram and chest radiograph: mild left ventricular hypertrophy
Social history:
• Tobacco: 35 pack years
• Alcohol: 1 pint of vodka/week
• Coffee: 2 cups/day
Diagnosis: Stage 1 Hypertension
1. List specific goals for treating Darius’ hypertension.
2. What drug therapy would you prescribe? Why?
3. What are the parameters for monitoring success of the therapy?
4. Discuss specific patient education based on the prescribed therapy.
5. List one or two adverse reactions for the selected agent that would cause you to change therapy.
6. What would be the choice for second-line therapy?
7. What over-the-counter and/or alternative medications would be appropriate for Darius?
8. What lifestyle changes would you recommend to Darius?
9. Describe one or two drug–drug or drug–food interaction for the selected agent.
NU641 Advanced Clinical Pharmacology
Week 7 Assignment
Interactive Upper Respiratory Case Study
Jackieis a 45-year-old white female with past medical history of controlled hypertension, controlled asthma, and eczema. She has a four-day history of nasal congestion, headache, sore
throat, sneezing, and productive cough. She denies fever, nausea, vomiting, and myalgias. She has three children who recently went back to school following a summer vacation. No one else in her household is currently presenting with similar symptoms. She has no known drug allergies but is allergic to mums and ragweed. She calls her primary care provider’s office requesting a medication to treat her illness. She takes several medications, including the following:
• Mometasone 220 mcg—1 puff daily for asthma.
• Albuterol 90 mcg—1 to 2 puffs q4–6 hours as neededfor shortness of breath.
• Lisinopril 10 mg—one tablet by mouth daily forhypertension.
• Oxymetazoline hydrochloride 0.05% nasal spray—2sprays per nostril bid × 3 days.
Provide rationales for your answers:
1. Which of the following is the MOST appropriate drugto recommend?
a. Oxymetazoline hydrochloride 0.05% nasal spray—2 sprays per nostril bid until symptoms resolve.
b. Naproxen 220 mg—one tablet by mouth every12 hours as needed until symptoms resolve.
c. Dextromethorphan ER oral liquid—60 mg every12 hours until symptoms resolve.
d. Amoxicillin–clavulanic acid 500 mg every 8 hoursfor seven days.
2. Which of the following nonpharmacological therapiesis NOT recommended?
a. Steam inhalation
b. Increased water intake
c. Menthol lozenges
d. Saline gargle
3. Jackieis insistent on taking a complementary therapy tohelp treat her symptoms. What is the MOST appropriaterecommendation?
a. Echinacea purpurea tincture—0.75 mL
b. Fresh garlic—3 cloves
c. Acidophilus probiotic—1 tablet daily
d. Vitamin C—1 g
NU641 Advanced Clinical Pharmacology
Week 10 Assignment
Interactive Anxiety Case Study
Ivy, age 23, is a white woman who graduated from college last year. She began working as an accountant one month after graduating. Approximately two months ago, she moved into a two-bedroom apartment with another woman who works at the same accounting firm. She states that her roommate recommended that she sees a doctor to find out if she has anemiaor “some sort of fatigue syndrome.” She states that she has felt “restless” and “on edge” for most of the past nine months. She becomes easily fatigued and irritable and has difficultyconcentrating and falling asleep. She states that sometimes her mind “just goes blank,” and she is worried that her work performance is no longer excellent.
She reports that all herlife she had good grades in school and was very successful in everything she attempted. Although she has been “a worrier from the day I was born,” now she worries more than she ever has and feels nervous “all the time.” Ivyreports that she has a good relationship with her boyfriend, but they do not get to see each other very often because he is attending graduateschool 100 miles away. She reports having a satisfying sexual relationship with him. She denies having any problems with relationships with her parents, roommate, or peers. She denies having any financial worries unless she is fired from her job for poor work performance. She reports that she has always been healthy and has taken good care of herself. The only medication she takes is birth control pills, which she has taken for the past four years without any adverse effects.
Diagnosis: Generalized Anxiety Disorder
1. List specific treatment goals for Ivy.
2. What drug therapy would you prescribe? Why?
3. What are the parameters for monitoring the success ofthe therapy?
4. Describe specific patient monitoring based on the prescribedtherapy.
5. List one or two adverse reactions for the selected agentthat would cause you to change therapy.
6. What would be the choice for second-line therapy?
7. What dietary and lifestyle changes should be recommendedfor this patient?
8. Describe one or two drug–drug or drug–food interactionsfor the selected agent.
NU641 Advanced Clinical Pharmacology
Week 14 Assignment
Interactive Thyroid Case Study
Mariais a 29-year-old woman with a seven-month history of heavy, irregular menses, a 5-lb weight gain, constipation, and decreased energy. Her past history is unremarkable. She takes no prescription medications but uses iron and calcium supplements. She has a family history of thyroid disease. On examination, her weight is 152 lbs, her heart rate is 64 bpm, and her blood pressure is 138/86. Her thyroid gland is mildly enlarged, without nodularity. She has trace edema in her lower extremities, and her reflexes are slow.
Laboratory studies are as follows:
TSH is 15.3 mIU/mL (elevated), free T4is 0.3 mIU/mL (decreased), and total cholesterol is 276 mg/mL.
Diagnosis: Primary Hypothyroidism
1. List specific goals of treatment for Maria.
2. What drug therapy would you prescribe? Why?
3. What are the parameters for monitoring the success ofthe therapy?
4. Discuss specific patient education based on the prescribedtherapy.
5. List one or two adverse reactions for the selected agent that would cause you to change therapy.
6. What would be the choice for second-line therapy?
7. What over-the-counter and/or alternative medications would be appropriate for Maria?
8. What lifestyle changes would you recommend to Maria?
9. Describe one or two drug–drug or drug–food interactionsfor the selected agent.
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