NURS 6521 Pharmacotherapy for Cardiovascular Disorders

NURS 6521 Pharmacotherapy for Cardiovascular Disorders

Pharmacotherapy for Cardiovascular Disorders

The case scenario concerns LM, an 89-year-old woman in a long-term care facility. She has a history of multiple falls that often result in bruises and skin tears. LM’s medical history is positive for HTN, Hypothyroidism, Alzheimer’s, Osteoarthritis, and Diabetes. She is currently on Amlodipine, Donepezil, Levothyroxine, Celecoxib, Furosemide, Metformin, and Glyburide. The purpose of this paper is to describe how the patient’s age affects the pharmacokinetic (PK) and pharmacodynamic (PD) processes and propose a medication plan.

Influence of Age on PK and PD Processes

Aging is characterized by changes in the human organs, which contribute to altered medication PK and PD processes. Changes in aging that affect drug absorption include decreased gastric acid production, gastric motility, the surface area of the small bowel, and splanchnic blood flow (Drenth‐van Maanen et al., 2020). Besides, aging is characterized by decreased first-pass metabolism, which leads to increased absorption of high-clearance drugs and reduced absorption of drugs from prodrugs. The increased proportion of body fat in aging leads to increased distribution of lipid-soluble drugs (Dücker & Brockmöller, 2019). Aging is associated with a decline in lean body mass and total body water, leading to decreased water-soluble drug distribution.

Older adults have decreased hepatic blood flow and hepatic mass and reduced cytochrome P450 enzyme activity, which reduces hepatic clearance. Furthermore, aging is characterized by decreased renal function, and older adults are prone to renal disease, which leads to decreased renal blood flow and glomerular filtration rate (Chou & Chen, 2021). This affects the elimination of drugs, and the accumulation of drugs in plasma increases the risk of toxicity.

Aging is associated with altered PD processes with drugs acting on the central nervous and cardiovascular systems. For instance, older adults have a reduced sensitivity of their cardiac β-1 and β-2 adrenergic receptors. Thus, they exhibit a reduced response to β-agonists, like dobutamine (β-1 agonist) and salbutamol (β-2 agonist) (Drenth‐van Maanen et al., 2020). Aging is also related to changes in homeostatic mechanisms, like impaired reflex tachycardia and regulation of temperature and electrolytes, which increases the risk for adverse drug reactions (ADRs) in older adults.

How Changes in the Processes Might Impact the Patient’s Recommended Drug Therapy

The peak diuretic response of furosemide may decrease due to impaired drug elimination caused by decreased renal function in aging. LM has a decreased renal function owing to the reduced GFR of 45 ml/min and elevated BUN and creatinine levels. Thus, the furosemide dose may be increased based on the PD effect. Amlodipine, Metformin, and Glyburide are excreted via the kidneys. Their dose may need to be lowered to avoid an accumulation of drugs in plasma since their elimination will be impaired by the decreased renal function (Barry & Hughes, 2021). Furthermore, Donepezil may require a dose reduction due to the increased sensitivity in the CNS that occurs with aging.

Improving the Drug Therapy

The patient’s drug therapy will need modification to accommodate the changes in PK and PD processes caused by aging in the patient. Donepezil will be reduced to 5mg QHS due to increased sensitivity to the drug among older adults. The patient’s lab tests suggest renal insufficiency. Therefore, Amlodipine will be decreased to 5 mg QD and Glyburide to 2.5 mg to prevent the accumulation of the drugs in the plasma, which can cause toxicity (Maher et al., 2021). Furosemide will be increased to 80 mg because of the decreased peak diuretic response caused by renal insufficiency. Levothyroxine increases the risk of atrial fibrillation in older adults (Gluvic et al., 2021). Thus the dose will be lowered to 50 mcg/day. Metformin will be stopped because it causes lactic acidosis in patients with renal insufficiency.

Conclusion

Physiological changes that occur in aging affect PK processes like drug absorption, metabolism, distribution, and elimination. Changes in body fat and lean mass composition affect drug distribution in older adults. The PD processes of CNS and cardiovascular drugs are also affected by aging. Thus, drug modification is essential in older patients to accommodate these changes.

References

Barry, H. E., & Hughes, C. M. (2021). An Update on Medication Use in Older Adults: A Narrative Review. Current Epidemiology Reports, pp. 8, 108–115. https://doi.org/10.1007/s40471-021-00274-5

Chou, Y. H., & Chen, Y. M. (2021). Aging and Renal Disease: Old Questions for New Challenges. Aging and disease, 12(2), 515–528. https://doi.org/10.14336/AD.2020.0703

Drenth‐van Maanen, A. C., Wilting, I., & Jansen, P. A. (2020). Prescribing medicines to older people—How to consider the impact of aging on human organs and body functions. British Journal of Clinical Pharmacology, 86(10), 1921-1930. https://doi.org/10.1111/bcp.14094

Dücker, C. M., & Brockmöller, J. (2019). Genomic Variation and Pharmacokinetics in Old Age: A Quantitative Review of Age- vs. Genotype-Related Differences. Clinical pharmacology and therapeutics, 105(3), 625–640. https://doi.org/10.1002/cpt.1057

Gluvic, Z., Obradovic, M., Stewart, A. J., Essack, M., Pitt, S. J., Samardzic, V., Soskic, S., Gojobori, T., & Isenovic, E. R. (2021). Levothyroxine Treatment and the Risk of Cardiac Arrhythmias – Focus on the Patient Submitted to Thyroid Surgery. Frontiers in endocrinology, 12, 758043. https://doi.org/10.3389/fendo.2021.758043

Maher, D., Ailabouni, N., Mangoni, A. A., Wiese, M. D., & Reeve, E. (2021). Alterations in drug disposition in older adults: a focus on geriatric syndromes. Expert opinion on drug metabolism & toxicology, 17(1), 41–52. https://doi.org/10.1080/17425255.2021.1839413

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Pharmacotherapy for Cardiovascular Disorders

…heart disease remains the No. 1 killer in America; nearly half of all Americans have high blood pressure, high cholesterol, or smoke—some of the leading risk factors for heart disease…

—Murphy et al., 2018

Despite the high mortality rates associated with cardiovascular disorders, improved treatment options do exist that can help address those risk factors that afflict the majority of the population today.

As an advanced practice nurse, it is your responsibility to recommend appropriate treatment options for patients with cardiovascular disorders. To ensure the safety and effectiveness of drug therapy, advanced practice nurses must consider aspects that might influence pharmacokinetic and pharmacodynamic processes such as medical history, other drugs currently prescribed, and individual patient factors.

Reference: Murphy, S. L., Xu, J., Kochanek, K. D., & Arias, E. (2018). Mortality in the United States, 2017. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db328.htm

Resources

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

Learning Resources

Required Readings

• Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.
  • Chapter 33, “Review of Hemodynamics” (pp. 285–289)
  • Chapter 37, “Diuretics” (pp. 290–296)
  • Chapter 38, “Drugs Acting on the Renin-Angiotensin-Aldosterone System” (pp. 297–307)
  • Chapter 39, “Calcium Channel Blockers” (pp. 308–312)
  • Chapter 40, “Vasodilators” (pp. 313–317)
  • Chapter 41, “Drugs for Hypertension” (pp. 316–324)
  • Chapter 42, “Drugs for Heart Failure” (pp. 325–336)
  • Chapter 43, “Antidysrhythmic Drugs” (pp. 337–348)
  • Chapter 44, “Prophylaxis of Atherosclerotic Cardiovascular Disease: Drugs That Help Normalize Cholesterol and Triglyceride Levels” (pp. 349–363)
  • Chapter 45, “Drugs for Angina Pectoris” (pp. 364–371)
  • Chapter 46, “Anticoagulant and Antiplatelet Drugs” (pp. 372–388)

Required Media

Cardiovascular Disorders

• Meet Dr. Norbert Myslinski as he discusses ACE inhibitors, angiotensin inhibitors, beta-blockers, calcium channel blockers, and diuretics as different categories of hypertension drugs. What potential drugs might be best recommended for patients suffering from hypertension? (8m)
• Walden University. (n.d.). Instructor feedback

• Links to an external site.. https://cdn-media.waldenu.edu/2dett4d/Walden/WWOW/1001/pulse_check/instructor_feedback/index.html#/

To Prepare

• Review the Resources for this module and consider the impact of potential pharmacotherapeutics for cardiovascular disorders introduced in the media piece.
• Review the case study assigned by your Instructor for this Assignment.
• Select one the following factors: genetics, gender, ethnicity, age, or behavior factors.
• Reflect on how the factor you selected might influence the patient’s pharmacokinetic and pharmacodynamic processes.
• Consider how changes in the pharmacokinetic and pharmacodynamic processes might impact the patient’s recommended drug therapy.
• Think about how you might improve the patient’s drug therapy plan based on the pharmacokinetic and pharmacodynamic changes. Reflect on whether you would modify the current drug treatment or provide an alternative treatment option for the patient.

By Day 7 of Week 2

Write a 2- to 3-page paper that addresses the following:

• Explain how the factor you selected might influence the pharmacokinetic and pharmacodynamic processes in the patient from the case study you were assigned.
• Describe how changes in the processes might impact the patient’s recommended drug therapy. Be specific and provide examples.
• Explain how you might improve the patient’s drug therapy plan and explain why you would make these recommended improvements.

Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The College of Nursing Writing Template with Instructions provided at the Walden Writing Center offers an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632

Links to an external site.). All papers submitted must use this formatting.

submission information

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.

1. To submit your completed assignment, save your Assignment as WK2Assgn_LastName_Firstinitial
2. Then, click on Start Assignment near the top of the page.
3. Next, click on Upload File and select Submit Assignment for review.

Rubric

NURS_6521_Week2_Assignment_Rubric