Case Studies Week 7

Scenario 1: Buspirone Half-Life and Antidepressant Adjunct Therapy

Buspirone is an anxiolytic that is commonly used and has a short half-life of about two hours, requiring frequent dosing to maintain therapeutic effect. In this case, the patient receives a 15 mg dose at 8 AM. To find out the drug’s blood level at 2 PM, one needs to halve the drug’s concentration every two hours: Case Studies Week 7.

At 10 AM, the dose left is 7.5 mg; at noon, it’s 3.75 mg; and by 2 PM, it’s down to 1.875 mg (Ball et al., 2022). Such a calculation emphasizes buspirone’s pharmacokinetic shortcomings and dosing schedule requirements for maximal therapeutic effects.

Buspirone can be used in combination with antidepressant medication, particularly for patients presenting with symptoms of anxiety in addition to depression. Wilson and Tripp (2023) indicate that it might be useful to augment antidepressant treatment, primarily selective serotonin reuptake inhibitors, to enhance remaining anxiety symptoms. Three possible antidepressants are sertraline, venlafaxine XR, and escitalopram.

Sertraline

Sertraline is administered at a 50-mg dose, given orally once daily in the morning. A 30-day supply (#30) should be dispensed with three refills authorized. It may be taken with or without food. The patient should be monitored for GI upset and mood changes.

Buspirone can be continued without any changes as it is compatible with sertraline. Regular monitoring is important, with particular attention to any signs of serotonin syndrome, suicidal ideation, or sexual dysfunction. Follow-ups are recommended every 2–4 weeks initially to assess therapeutic response and tolerability (Singh & Saadabadi, 2021).

Venlafaxine XR

Venlafaxine XR is administered 75 mg, orally once daily with food. The patient should be provided with a 30-day supply (#30) with two refills. The blood pressure should be monitored while on this medication due to the risk of dose-dependent hypertension.

Buspirone may be continued without tapering because it is compatible with venlafaxine XR unless side effects are present. There should be a routine follow-up to check for signs of hypertension, agitation, or serotonin syndrome. The follow-up will assist in benefitting the patient’s safety and management regarding this medication.

Escitalopram

Escitalopram is prescribed at 10 mg, taken orally once daily in the morning or evening. A 30-day supply (#30) should be dispensed, with three refills authorized. The medication can be taken with or without food and requires monitoring for QT prolongation in patients with a history of cardiac arrhythmias. Buspirone can be continued as part of the treatment plan without any adjustments.

Regular monitoring should include checking for serotonin syndrome, adherence, and mood stabilization. Follow-ups are recommended to evaluate the effectiveness and safety of the treatment (Landy et al., Fundamentals of project management 2022).

Regular follow-ups are necessary to monitor efficacy, side effects (e.g., serotonin syndrome), and compliance. Adding buspirone to the treatment regimen can significantly improve symptom control, bringing treatment in line with evidence-based practice (Wilson & Tripp, 2023).

Scenario 2: Prescription Errors and Corrections

Accurate prescription writing is critical to patient safety and regulatory compliance. In this case, the following mistakes were observed in the prescriptions, though each one of them has implications for safety and efficacy: Correction of these errors benefits not only in terms of accurate drug delivery but also adheres to clinical pharmacology standards.

Methylphenidate (Concerta)

One major error involved methylphenidate (Concerta), which was prescribed at an inappropriate dose of 5 mg BID. As an extended-release formulation, Concerta is designed for once-daily dosing (Verghese et al., 2024).

Corrected Prescription: Methylphenidate (Concerta) 18 mg PO once daily in the morning #30 1 refill

Pegloticase (Krystexxa)

Similarly, the prescription for pegloticase (Krystexxa) listed “#1,” an inappropriate designation for an infusion medication. Pegloticase is typically administered as an 8 mg IV infusion every two weeks.

Corrected Prescription: Pegloticase (Krystexxa) 8 mg IV infusion once every two weeks #1 vial 0 refills (Padda et al., 2024).

Ubrelvy

In another case, Ubrelvy was prescribed at an excessively high dose of 200 mg, exceeding the manufacturer’s recommended maximum (Chiang & VanderPluym, 2021). The corrected dose aligns with clinical guidelines to minimize adverse events.

Corrected Prescription: Ubrelvy 50 mg PO at the onset of migraine, may repeat after 2 hours if needed #12 1 refill

Alprazolam

The alprazolam prescription contained a labeling error, mistakenly referencing Valium instead of alprazolam. The corrected prescription ensures accurate identification and dosing.

Corrected Prescription: Alprazolam 0.5 mg PO TID #90 0 refills

Zolpidem

Additionally, zolpidem was prescribed with excessive refills, contravening controlled substance regulations. The corrected prescription aligns with clinical and regulatory standards.

Corrected Prescription: (Zolpidem): Zolpidem 10 mg PO once at bedtime #30 0 refills

Scenario 3: Diagnosis and Treatment of Patient TL

Patient TL presents with daily leg muscle weakness and nocturnal cramping. A review of his medication history and lab results (elevated CK levels, low vitamin B12 at 150 pg/mL) suggests a dual diagnosis: vitamin B12 deficiency and potential statin-induced myopathy. The treatment plan includes discontinuation of Atorvastatin and Vitamin B12 Supplementation.

Discontinuation of Atorvastatin

Temporarily stopping atorvastatin allows for CK level reassessment. Reintroduction with a lower dose or an alternative statin (e.g., pravastatin) will be considered after 4 weeks (La & Ms, 2024).

Vitamin B12 Supplementation

Prescribed cyanocobalamin 1,000 mcg IM weekly for 4 weeks, followed by monthly maintenance doses. This replenishes B12 stores and alleviates neurological symptoms (National Institutes of Health, 2024). Monitoring includes regular CK levels, B12 levels, and symptom tracking.

Dietary counseling emphasizes foods rich in vitamin B12 (e.g., fortified cereals, meat, dairy). Regular follow-ups ensure the resolution of symptoms and successful treatment adjustment (Temova Rakuša et al., 2022).

Scenario 4: Nicotine’s Effects and Comprehensive Treatment

Nicotine use induces temporary relaxation and well-being by binding to nicotinic receptors in the brain, stimulating neurotransmitters like dopamine, norepinephrine, and acetylcholine. Dopamine increases the reward and reinforcement values which makes nicotine addictive. Norepinephrine enhances the attention span and acetylcholine enhances the cognitive and the mood of an individual (Hernández-Pérez et al., 2023). Such mechanisms give insights into why individuals suffering from ADHD, anxiety as well as depression use smoking as a method of self-prescribing drugs.

To manage these overlapping conditions and support cessation, bupropion serves as an effective choice (Clark et al., 2023). Its dual role as a norepinephrine-dopamine reuptake inhibitor (NDRI) and nicotinic receptor antagonist reduces nicotine cravings and withdrawal symptoms while addressing mood and attention issues.

Corrected Prescription: Bupropion SR 150 mg PO once daily for 3 days, then increase to 150 mg PO twice daily #60 (30-day supply) 2 refills

Special Instructions: Take at least 8 hours apart to lower seizure risks. Avoid bedtime dosing to reduce insomnia.

Smoking cessation need not precede bupropion initiation; gradual reduction is encouraged as the medication diminishes cravings. This approach enhances long-term success rates.

Monitoring and Follow-Up:

• Evaluate mood and anxiety improvements regularly.
• Monitor adherence and smoking reduction progress.
• Watch for insomnia, irritability, or dry mouth.

Evidence shows that behavioral counseling combined with pharmacotherapy yields better results (Ee et al., 2020). Smoking cessation programs provide more strategies that can help to support the progress and guarantee effective treatment from different sides, including mental and physical health disorders.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2022).  Seidel’s guide to physical examination: An interprofessional approach (10th ed.). Elsevier.

Chiang, C.-C., & VanderPluym, J. H. (2021). Ubrogepant in the Acute Management of Migraine: A Narrative Review. Journal of Pain Research, Volume 14(79), 1185–1192. https://doi.org/10.2147/jpr.s244249

Clark, A., Tate, B., Urban, B., Schroeder, R., Gennuso, S., Ahmadzadeh, S., McGregor, D., Girma, B., Shekoohi, S., & Kaye, A. D. (2023). Bupropion mediated effects on depression, attention deficit hyperactivity disorder, and smoking cessation. Health Psychology Research, 11(57), 81043. https://doi.org/10.52965/001c.81043

Ee, C., Lake, J., Firth, J., Hargraves, F., Manincor, M. de, Meade, T., Marx, W., & Sarris, J. (2020). An integrative collaborative care model for people with mental illness and physical comorbidities. International Journal of Mental Health Systems, 14(1), 1–16. https://doi.org/10.1186/s13033-020-00410-6

Hernández-Pérez, A., García-Gómez, L., Robles, R. E., Ireri Thirion-Romero, Osio-Echánove, J., Sebastián Rodríguez-Llamazares, Baler, R., & Pérez-Padilla, R. (2023). Addiction to tobacco smoking and vaping. Addiction to Tobacco Smoking and Vaping, 75(3). https://doi.org/10.24875/ric.23000117

La, M., & Ms, S. (2024, January). Atorvastatin. PubMed. https://pubmed.ncbi.nlm.nih.gov/28613530/

Landy, K., Rosani, A., & Estevez, R. (2022). Escitalopram. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/32491666/

National Institutes of Health. (2024, February 27). Office of Dietary Supplements – Vitamin B12. Nih.gov. https://ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional/

Padda, I. S., Bhatt, R., Patel, P., & Parmar, M. (2024, February 28). Pegloticase. Nih.gov; StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK572054/

Singh, H. K., & Saadabadi, A. (2021). Sertraline. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/31613469/

Temova Rakuša, Ž., Roškar, R., Hickey, N., & Geremia, S. (2022). Vitamin B12 in foods, food supplements, and medicines—A review of its role and properties with a focus on its stability. Molecules, 28(1), 240. https://doi.org/10.3390/molecules28010240

Verghese, C., Patel, P., & Abdijadid, S. (2024, October 29). Methylphenidate. Nih.gov; StatPearls Publishing. https://ncbi.nlm.nih.gov/books/NBK482451///

Wilson, T. K., & Tripp, J. (2023, January 17). Buspirone. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/sites/books/NBK531477/

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

---

To Prepare:

• Review assignment rubric and case studies. Be sure to thoroughly answer ALL cases
• Explain the problem and discuss how you would address the problem.
• When recommending medications, write out a complete prescription for each medication. What order would you send to a pharmacy? Include drug, dose, route, frequency, special instructions, # dispensed (days supply), refills, etc. Also state if you would continue, discontinue or taper the patient’s current medications.
• Answer questions using your required learning resources, clinical practice guidelines, Medscape and JNC 8.
• Include at least three references to support each scenario and cite them in APA format. Please include in-text citations. You do not need an introduction or conclusion paragraph.

SCENARIO 1

• Buspirone has a half-life of approximately 2 hours. If a patient takes 15 mg at 8 am, what will the blood level be at 2 pm? Can buspirone be given as an adjunct to antidepressant therapy? Name 3 antidepressants you might prescribe for patients with co-existing depression and anxiety (include complete medication orders) and include patient monitoring.

SCENARIO 2
What are the errors (6 total) in the following prescriptions? Rewrite each prescription correctly.

• methylphenidate (Concerta) 5 mg BID before breakfast and lunch #60 1 refill
• pegloticase (Krystexxa) 8 mg IV infusion once per month #1 0 refill
• Ubrelvy 200 mg po prn onset of migraine #12 1 refill
• alprazolam (Valium) 0.5 mg po TID #90 0 refill
• zolpidem 10 mg qhs #30 6 refills
  

  Case Studies Week 7

SCENARIO 3

• Patient TL is experiencing symptoms of daily leg muscle weakness and feet cramping at night. He is currently on metformin 1000 mg po BID, Invokamet 50/500 mg BID with meals, atorvastatin 40 mg po daily and atomoxetine 40 mg po daily. Blood pressure is 118/78 and labs include: BG 90 mg/dL A1c 4.5% sCr 0.9 mg/dL eGFR 101 mL/min/1.73 m² total cholesterol 181 mg/dL LDL 95 mg/dL HDL 57 mg/dL TG 146 mg/dL B12 150 pg/mL CK 505 U/L What is your working diagnosis? What would you prescribe for TL and how would you improve his treatment? What would you monitor?

SCENARIO 4

• When a person uses nicotine, it causes temporary feelings of relaxation and well-being. Nicotine binds to nicotinic receptors in the brain, augmenting the release of numerous neurotransmitters. Name at least three of these neurotransmitters. Patients may self-medicate ADHD, anxiety and depression by smoking. Is there a medication that could treat ADHD, anxiety, depression and provide smoking cessation? Write a complete medication order for this medication. Does the patient need to quit smoking before starting treatment?