Applying Pharmacology- Evaluating and Justifying Drug Therapy Plans Through Case Studies

Applying Pharmacology- Evaluating and Justifying Drug Therapy Plans Through Case Studies

Scenario 1: Mary’s Hypothyroidism and Iron Deficiency Anemia

Mary, a 35-year-old woman, has been diagnosed with hypothyroidism and iron deficiency anemia. Her lab results indicate a TSH of 20 (indicative of hypothyroidism), a low MCV (78), MCHD (26), ferritin (9), and high TIBC (418), suggesting iron deficiency anemia (Garofalo et al., 2023). Her current medications include kelp tablets, ibuprofen as needed, and an oral contraceptive (ethinyl estradiol/norgestrel).

Treatment for Hypothyroidism

The recommended treatment for Mary’s hypothyroidism would be levothyroxine (synthetic thyroid hormone). Levothyroxine is the preferred medication for hypothyroidism as it directly replaces the deficient thyroid hormone (T4) and normalizes the serum TSH levels (Mayo Clinic, 2022). The initial starting dose of levothyroxine for an adult with hypothyroidism is typically 1.6 mcg/kg/day.

For Mary, with an assumed weight of 70 kg, the starting dose would be

• Levothyroxine 112 mcg (1.6 mcg/kg x 70 kg) PO once daily

Monitoring Response

After initiating levothyroxine therapy, Mary’s TSH levels should be monitored every 4-8 weeks until the TSH normalizes. The goal is to achieve a TSH level within the normal range (0.4-4.0 mIU/L). Once the TSH is within the normal range, monitoring can be done annually or semi-annually.

Patient Education

Mary should be educated on the importance of taking levothyroxine consistently, on an empty stomach, and at the same time each day, preferably in the morning. She should be advised to avoid taking levothyroxine with supplements containing calcium, iron, or antacids, as these can interfere with absorption. Potential side effects, such as weight loss, palpitations, and muscle cramps, should also be discussed.

Treatment for Iron Deficiency Anemia

To address Mary’s iron deficiency anemia, oral iron supplementation is recommended. A common prescription would be:

• Ferrous sulfate 325 mg (65 mg elemental iron) PO once daily

Monitoring Response

Mary’s hemoglobin, hematocrit, MCV, and ferritin levels should be monitored periodically to assess their response to iron therapy (National Heart, Lung, and Blood Institute, 2022). The goal is to normalize these parameters and replenish iron stores, as indicated by a ferritin level > 30 ng/mL.

Patient Education

Mary should be advised to take the iron supplement on an empty stomach, preferably with vitamin C-rich beverages like orange juice. Potential adverse effects, for example, nausea, constipation, and black stool, should be explained, and she has to know them and inform if any signs of overload are noticed.

Drug Interactions

As to drug interaction, Mary must be informed about the possibility of a slower absorption of levothyroxine while she is taking iron supplements at the same time. It is suggested that the medication be administered separately, with a minimum of 4-hour time gap, and that food or other medications be consumed after the end of the treatment. However, it is also possible that by taking ibuprofen (a non-steroidal anti-inflammatory drug) together with iron pills, subjects may suffer from gastrointestinal side effects.

Scenario 2: Joe’s Type II Diabetes Mellitus and Chronic Kidney Disease

Joe is a 48-year-old male diagnosed with type II diabetes mellitus (T2DM) and hypertension. His lab results show a fasting blood glucose of 225 mg/dL, HgA1C of 7.5%, and a creatinine of 2.0 with an eGFR of 28, indicating chronic kidney disease (CKD).

Treatment Plan

The treatment plan will include some lifestyle modifications as well as therapeutic interventions. The patient’s diet and active lifestyle will play a significant role in the plan.

Medication Management

As such, in the presence of hyperglycemia of 7.5% HgA1C, metformin would not be a proper pharmaceutical agent to be prescribed due to the probability of local lactic acidosis (CDC, 2021). The Sodium-Glucose Co-transporter 2 Inhibitor (SGLT2i) or the Glucagon-like Peptide-1 Receptor Agonist (GLP-1 RA) would be the alternative recommended due to their advantages. These categories of medications are relatively renoprotective and constitute a safer alternative in chronic kidney disease with cardiovascular benefits.

A possible prescription for Joe could be:

• Empagliflozin 10 mg regularly in a single oral dose daily

Monitoring

It is essential to monitor Joe’s blood glucose levels (the fasting ones and after meals), HgA1C, renal function, and body weight in order to evaluate the effectiveness of therapy and fine-tune the medication dose accordingly if necessary, reaching the goal of HgA1C at <7%. Renal function must be closely followed, as Freedom Rx patch cannot be prescribed when eGFR is less than 30 mL/min/1.73m2.

Patient Education

Joe should be taught about the role of lifestyle alterations, including eating a balanced diet, engaging in regular exercises and body weight management, and disease prevention. He should be taught to use glucose-monitoring devices correctly and be educated on identifying and treating hypoglycemia (Rosenthal & Burchum, 2021; Arcangelo et al., 2017). Ultimately, the whole process will be summed up and clarified again. Adverse impacts of the SGLT2i medicine, like frequent urination, genital mycotic infections, and dehydration, are also as significant and should be mentioned.

Scenario 3: Jose’s Uncontrolled Type II Diabetes Mellitus

Jose is a 55-year-old truck driver with uncontrolled type II diabetes mellitus (T2DM). His lab results show a fasting blood glucose of 325 mg/dL and an HgA1C of 10.6%. He is currently taking metformin and glipizide but is allergic to sulfa medications.

Treatment Plan

For Jose’s uncontrolled T2DM, a distinct treatment plan containing a lifestyle intervention as well as medication therapy is highly indicated.

Medication Management

Jose has a Hemoglobin A1C (HgA1C) of 10.6%, which is abnormal, which indicates that the earlier treatment with metformin and glipizide was not enough. Therefore, Jose should consider additional pharmacological interventions. Having a sulfa allergic reaction, Jose could benefit from either a GLP-1 RA or an SGLT2i coadministered with his insulin therapy (Katzung et al., 2021; Richardson et al., 2021).

A possible prescription for Jose could be:

• Liraglutide 1.8 mg – subcutaneous injection given once a day
• Metformin 1000 mg PO twice daily (continue current dose, if applied)

Monitoring

Jose’s blood glucose levels (fasting and profiles after meals), HgA1c, weight, and any side or adverse effects should be closely monitored. The low range of HgA1C is the goal less than 7% of the time, which ensures there is no hypoglycemia. Monitoring him closely regarding his response and making necessary dose adjustments could help see improvements.

Patient Education

To Jose, it should be emphasized that he should eat a well-balanced diet, hence regular exercises and weight management. Education about the correct administration of the injectable GLP-1 RA drug, including injection technique and injection site, rotation, and storage instructions, is essential. The adverse effects of GLP-1 RAs, including nausea, vomiting, and diarrhea, must be considered with a physician. Jose has to watch early symptoms of hypoglycemia properly and should be taught to identify and manage this condition before it becomes life-threatening (Wexler, 2020). Additionally, since Jose is a commercial driver, he should be counseled on diabetes and its treatments and safety risks when driving. He should be provided with support and encouragement to do regular blood glucose level checks, especially before and during long drives, and be prompted to take action on hypoglycemia or hyperglycemia.

Scenario 4: Jenny’s Gastroesophageal Reflux Disease (GERD)

Jenny is a 63-year-old woman with complaints of frequent heartburn and coughing, especially at night. She has tried over-the-counter (OTC) Prevacid (lansoprazole) for the past two weeks, but her symptoms persist. The working diagnosis is gastroesophageal reflux disease (GERD).

Treatment Plan

Accordingly, Jenny’s GERD treatment should encompass a combination of lifestyle adjustments as well as drug therapy.

Lifestyle Modifications

Jenny should be advised to adopt lifestyle measures like not eating large meals, consuming caffeine and alcohol in limited quantities, maintaining a healthy BMI (Body Mass Index), and sleeping some hours after consuming a heavy meal (Johns Hopkins Medicine, 2019; Mayo Clinic, 2023). Elevating the head of the bed and avoiding tight clothing around the abdomen may also help reduce reflux symptoms.

Medication Management

While Jenny’s situation is different because she has symptoms of OTC lansoprazole, administration of a higher dose of proton pump inhibitor (PPI) is prescribed. PPIs are also the most potent drug for treating GERD, and they can heal these lesions and remove the associated symptoms.

A possible prescription for Jenny could be:

• Esomeprazole / 40 mg PO, once daily (Hou et al., 2020).

Monitoring

Jenny’s reaction to treatment can be evaluated by considering how her heartburn and chest congestion resolve to the standard conditions. She will be given a schedule to follow, allowing her symptoms to improve. If her condition does not improve within 4-8 weeks, the doctor will consider further evaluation or changes in the current treatment plan.

Patient Education

Jenny must be tutored to conform to Paul’s principles and take other lifestyle modifications. Patients in this condition should start a PPI medication about 30-60 minutes before a meal to ensure maximum absorption (John Hopkins Medicine, 2019; Mayo Clinic, 2023). Having in mind that PPIs may cause side effects (like headache and diarrhea), patients should be informed, and the risk of fractures should be disclosed to those using PPIs for more than a year. Further, Jenny’s advisor is inundated with the possibility that PPIs may interact with other medications she is taking, such as diltiazem and metformin. The intake of PPIs can result in the retardation of several other medications, and dosage modifications or substitution of treatments may be required.

References

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.

CDC. (2021, May 7). Make the Connection. Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/managing/diabetes-kidney-disease.html#:~:text=If%20you%20have%20diabetes%2C%20get

Garofalo, V., Condorelli, R. A., Cannarella, R., Aversa, A., Calogero, A. E., & La Vignera, S. (2023). Relationship between Iron Deficiency and Thyroid Function: A Systematic Review and Meta-Analysis. Nutrients, 15(22), 4790. https://doi.org/10.3390/nu15224790

Hou, M., Hu, H., Jin, C., & Yu, X. (2020). Efficacy and safety of esomeprazole for the treatment of reflux symptoms in patients with gastroesophageal reflux disease: A systematic review and meta-analysis. Iranian Journal of Public Health. https://doi.org/10.18502/ijph.v49i12.4807

John Hopkins Medicine. (2019). Gastroesophageal reflux disease (GERD). John Hopkins Medicine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/gastroesophageal-reflux-disease-gerd

Katzung, B. G., Kruidering-Hall, M., Tuan, R. L., Vanderah, T. W., & Trevor, A. J. (2021). Katzung & Trevor’s pharmacology examination and board review (13th ed.). McGraw Hill Professional.

Mayo Clinic. (2022, December 10). Hypothyroidism (underactive thyroid). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/hypothyroidism/symptoms-causes/syc-20350284

Mayo Clinic. (2023, January 4). Gastroesophageal reflux disease (GERD) – symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/gerd/symptoms-causes/syc-20361940

National Heart, Lung, and Blood Institute. (2022). Anemia – iron-deficiency anemia. Www.nhlbi.nih.gov. https://www.nhlbi.nih.gov/health/anemia/iron-deficiency-anemia

Richardson, C. R., Borgeson, J. R., Van Harrison, R., Wyckoff, J. A., Yoo, A. S., Aikens, J. E., Griauzde, D. H., Tincopa, M. A., Van Harrison, R., Proudlock, A. L., & Rew, K. T. (2021). Management of type 2 diabetes mellitus. In PubMed. Michigan Medicine University of Michigan. https://www.ncbi.nlm.nih.gov/books/NBK579413/

Rosenthal, L.D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses (2nd ed.). St. Louis, MO: Elsevier.

Wexler, D. (2020, October 28). Patient education: Type 2 diabetes: Treatment (Beyond the Basics). Www.uptodate.com. https://www.uptodate.com/contents/type-2-diabetes-treatment-beyond-the-basics/print

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Case studies are a useful way for you to apply your knowledge of pharmacokinetics and pharmacodynamic aspects of pharmacology to specific patient cases and health histories.

For this Assignment, you evaluate drug treatment plans for patients with various disorders and justify drug therapy plans based on patient history and diagnosis.