Discussion Response – Primary Care Medication Management

Discussion Response – Primary Care Medication Management

Thank you for sharing your post! I agree with you. Beers criteria are mainly used in the primary medication management of the elderly. It helps to minimize the effects that the medications can have on the health of older adults. It groups medications into those that should be avoided in managing the elderly, those that should be used with caution, drug-drug interactions, and dose adjustments to produce the desired effects (Osei et al., 2016). Two factors are considered when safely calculating pediatric medication doses. These are the body surface area of the patient and the weight. During pregnancy, drugs, at some point, may become forms of teratogens. Teratogens can easily cause malformations. This is common during organogenesis (first trimester); the body of the mother is sensitive to any teratogens. On the other hand, a medication with a long half-life is beneficial to a patient who forgets to take her medication. Before the drug is eliminated from the system, its effect can still be felt in a patient’s body.

Patients have varying rates of drug metabolism, which is attributed to the different cytochrome P2D6 allelic variants. Some are ultra-rapid metabolizers, extensive metabolizers, intermediate metabolizers, or poor metabolizers. An ultra-rapid metabolizer, they have two copies of cytochrome P2C19, which increases the activity of this enzyme (Deshpande et al., 2016). Therefore, medication breakdown is broken down even before the desired effects are produced. To conclude, food can either increase or decrease the drug metabolism rate. It is important to consider food-drug interaction when prescribing ingestion drugs to the elderly. Studies have shown that grapefruit juice reduces drug metabolism rate by acting on the cytochrome P4503A4 found in the walls of the intestines (Guttman et al., 2020). With a combination of reduced drug metabolism and decreased activity of the liver and kidneys in the elderly, one is likely to go into systemic toxicity. Therefore, grapefruit juice should be avoided among elderly patients, or drug medication should be administered intravenously.

References

Deshpande, N., Sharanya, V., Murthy, H. V. V., Sasikala, M., Banerjee, R., Tandan, M., & Reddy, N. (2016). Rapid and ultra-rapid metabolizers with CYP2C19* 17 polymorphism do not respond to standard therapy with proton pump inhibitors. Meta Gene, 9, 159-164. https://doi.org/10.1016/j.mgene.2016.06.004

Guttman, Y., Yedidia, I., Nudel, A., Zhmykhova, Y., Kerem, Z., & Carmi, N. (2020). New grapefruit cultivars exhibit low cytochrome P4503A4-Inhibition activity. Food and Chemical Toxicology, 137, 111135. https://doi.org/10.1016/j.fct.2020.111135

Osei, E. K., Berry-Cabán, C. S., Haley, C. L., & Rhodes-Pope, H. (2016). Prevalence of beer criteria medications among elderly patients in a military Hospital. Gerontology and geriatric medicine, 2, 2333721416637790. https://doi.org/10.1177%2F2333721416637790

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Discussion Response – Primary Care Medication Management

Discussion Prompt
Post your answers to the 6 questions corresponding to this week’s content on primary care
medication management. Provide your responses and rationales. Support your rationales with
high-level evidence.

Discussion Response – Primary Care Medication Management

1. What is the Beer Criteria, and what is its significance in prescribing?
The Beers criteria were designed to help prescribers delineate between medications that can potentially negatively affect the geriatric population. The geriatric population is vulnerable to polypharmacy and drug interactions if not closely monitored by their provider. According to Rochon (2021): The criteria are a list of medications considered potentially inappropriate for use in older patients, mostly due to the high risk for adverse events. Medications are grouped into five categories: those potentially inappropriate in most older adults, those that should typically be
avoided in older adults with certain conditions, drugs to use with caution, drug-drug interactions, and drug dose adjustment based on kidney function (para 5). The Beers criteria should be used as a reference as it is continually monitored and updated for accuracy.
2. What is the safest method of calculating a medication dose for the pediatric patient?
Medications have similar effects on different people; however, the dose of a prescribed drug must match the patient's weight, especially in pediatric patients. Depending on if the child is less than 1 year old, greater than 1 year old, or an adolescent at 13 years old, providers must consider their patient’s weight and body surface area to establish a safe dose of medication. Rosenthal and Burchum (2018) state, “Pediatric doses have been established for a few drugs but not for most. For drugs that do not have an established pediatric dose, the dosage can be extrapolated from adult doses. The method of conversion employed most commonly is based on body surface area (BSA): Child BSA x Adult dosage divided by 1.73 m squared= Pediatric dosage” (p. 190).
3. At what time period in pregnancy can medication potentially have the greatest risk of causing malformations?
Only certain drugs are safe to use during pregnancy. Drugs are categorized on a scale of safest to least safe for providers represented by A, B, C, D, and X. Rosenthal & Burchum (2018) say, “ Gross malformations are produced by exposure to teratogens during the embryonic period (first trimester). This is when the basic shape of internal organs and other structures is being established” (p. 175). So, during the first trimester expecting mothers should be extra careful what they expose themselves to, and the providers must understand as much about the drugs they are prescribing as possible.

4. If your patient sometimes forgets to take her medication, what type of medication half-life would be beneficial?
If a patient sometimes forgets to take their medication, it would be worth considering prescribing an extended-release medication if available. A longer half-life would give the patient more time at the therapeutic level of the drug, which would benefit them.
5. Your patient is on the highest daily dose of his medication, and it is not giving him the desired effect. What type of metabolizer is he with this medication?
If a patient is on the highest dose of medication and is not giving the desired effect, they are a higher-level metabolizer. This would render the medication ineffective. Genetics have been found to play a role in drug metabolism. Ahmed et al. (2016) say, “Individuals carrying different CYP2D6 allelic variants have been classified as poor metabolizers, intermediate metabolizers, extensive metabolizers, and ultrarapid metabolizers” (p. 300).
6. What food item interacts with many medications and should be asked about its ingestion, especially in the elderly?
The foods we eat can have varying effects on the drugs we take. Some foods increase metabolism, and some decrease. Rosenthal & Burchum (2018) adds, “Grapefruit juice can inhibit the metabolism of certain drugs, thereby raising their blood levels. Four compounds have been identified as the responsible agents: two furanocoumarins and two flavonoids” (p. 128). The elderly already have decreased drug clearance as liver and kidney function are reduced with age. Grapefruit juice must be avoided in geriatric patients and the drugs that interact with its metabolism.

Reference

Ahmed, S., Zhou, Z., Zhou, J., & Chen, S. Q. (2016). Pharmacogenomics of Drug Metabolizing Enzymes and Transporters: Relevance to Precision Medicine. Genomics, proteomics & bioinformatics, 14(5), 298–313. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5093856/
Rochon, P. (2021). Drug prescribing for older adults. UpToDate. https://www.uptodate.com/contents/drug-prescribing-for-older-adults/print
Rosenthal, L., & Burchum, J. (2018). Lehne’s Pharmacotherapeutics for Nurse Practitioners and Physician Assistants. Elsevier, Inc.