Evaluating and Justifying Drug Therapy Plans – A Patient-Centered Approach

Evaluating and Justifying Drug Therapy Plans – A Patient-Centered Approach

Case Study 1: Jamie, a 38-year-old Homeless Bipolar Patient with Acute Psychotic Episode

It is important to consider probable interactions between Jamie’s present medications and the appropriate management of bipolar disorder with an acute psychotic episode in treating Jamie. To start with, a combination of lithium and amitriptyline (Elavil) could lead to lithium toxicity due to increased risk and adverse effects such as tremors, nausea, and cognitive impairment (Hedya & Swoboda, 2019).

For the treatment plan, I would suggest:

1. Stop Elavil: Amitriptyline is a tricyclic antidepressant that is not normally advised for treating bipolar disorder, especially during an acute psychotic episode. Using TCAs can aggravate manic symptoms and increase the possibility of adverse reactions when used concurrently with lithium (Ferensztajn-Rochowiak & Rybakowski, 2023).
2. Optimize lithium therapy: Lithium is a first-line treatment for bipolar disorder that effectively controls acute manic episodes; however, it is essential to closely monitor levels of lithium and adjust the dose if necessary in order to maintain therapeutic levels (Evans & Carpenter, 2019).
3. Add atypical antipsychotic: Atypical antipsychotics like olanzapine risperidone or quetiapine are recommended for managing acute psychotic episodes in bipolar disorder (Evans & Carpenter, 2019). They can help control psychotic symptoms and are generally well-tolerated.
   1. Medication order: Olanzapine 10mg po q daily Lithium (dosage based on serum levels and therapeutic monitoring)
4. Provide supportive care: Besides medical therapy, it is also important to address homelessness in Jamie’s case as well as ensure he has access to appropriate housing, social support networks, and psychotherapy that will serve as a means of enhancing adherence and overall sense of wellness (Evans & Carpenter, 2019).
5. Monitor/ Follow-up: Regular monitoring of Jamie’s symptoms, medication adherence, and possible side effects is necessary. His response to therapy and tolerance of treatment will need dosage adjustments in his case.

References

Evans, S. M., & Carpenter, K. M. (2019). APA handbook of psychopharmacology. American Psychological Association.

Ferensztajn-Rochowiak, E., & Rybakowski, J. K. (2023). Long-term lithium therapy: Side effects and interactions. Pharmaceuticals, 16(1), 74. https://doi.org/10.3390/ph16010074

Hedya, S. A., & Swoboda, H. D. (2019). Lithium Toxicity. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499992/

Case Study 2: A 68-year-old Woman with Rheumatoid Arthritis, Crohn’s Disease, and Diabetes Type 2

It is important to consider her comorbidities and potential drug interactions while dealing with a 68-year-old woman who has rheumatoid arthritis (RA) and has been taking nabumetone (Relafen) 1000 mg once daily for two years, but the arthritis pain is increasing.

Appropriate Additional Therapy

Addition of a Disease-Modifying Anti-Rheumatic Drug (DMARD)

Since her RA symptoms control by nabumetone alone is poor, it might be considered to add conventional synthetic DMARDs like methotrexate or biologic DMARDs such as adalimumab (Humira) or etanercept (Enbrel). These medications are capable of reducing inflammation effectively, slowing the progression of the disease, and raising the quality of life (Benjamin et al., 2022).

Medication order: Methotrexate 7.5 mg orally once weekly, with folic acid supplementation. Or Adalimumab (Humira) 40 mg subcutaneously every two weeks.

Adjustment of Nabumetone Dosage

If the patient tolerates nabumetone well, increasing the dosage to the maximum recommended dose of 1500-2000 mg per day could be considered (Nabumetone prescribing information, 2008).

Monitoring

1. Complete blood count (CBC): Methotrexate and other DMARDs can cause bone marrow suppression, so regular monitoring of CBC is necessary (Benjamin et al., 2022).
2. Liver function tests (LFTs): Methotrexate and some biological DMARDs can cause hepatotoxicity, so monitoring LFTs is essential (Benjamin et al., 2022).
3. Renal function tests: Nabumetone and methotrexate are primarily eliminated by the kidneys, so monitoring renal function is crucial, especially in the presence of comorbidities like diabetes (NIH, 2020).
4. Gastrointestinal monitoring: Due to the patient’s history of Crohn’s disease, close monitoring for gastrointestinal side effects, such as ulceration or exacerbation of Crohn’s symptoms, is necessary.
5. Diabetes monitoring: Monitoring blood glucose levels and adjusting diabetes medications may be necessary, as some DMARDs can affect glucose metabolism (Rosenthal & Burchum, 2021).

References

Benjamin, O., Goyal, A., & Lappin, S. L. (2022, July 4). Disease Modifying Anti-Rheumatic Drugs (DMARD). PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507863/

NIH. (2020). Nabumetone. PubMed; National Institute of Diabetes and Digestive and Kidney Diseases. https://www.ncbi.nlm.nih.gov/books/NBK548909/

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

Case Study 3: Sheila, a 26-year-old with a Head Injury, Tonic-Clonic Seizures, and Medication Side Effects

Based on the patient’s presenting symptoms, medication history, and laboratory findings, it appears that Sheila is experiencing phenytoin (Dilantin) toxicity. The following factors support this diagnosis:

1. Clinical symptoms: The “funny” eye movements, ataxia, double vision, nystagmus, and sleepiness are all signs of phenytoin toxicity that could be accompanied by diplopia, incoordination, poor vision, and sedation (Iorga & Horowitz, 2020; Katzung et al., 2021).
2. Low serum phenytoin level: The patient’s reported serum level of phenytoin was measured as 11 μg/mL, which is lower than the therapeutic range of 10-20μg/mL for seizure treatment.
3. Hypoalbuminemia: Sheila has an albumin of 2 g/dL below the normal range (3.5-5.0 g/dL). The drug-binding capacity of phenytoin is high, that is, about 90%; hence, hypoalbuminemia could result in an increased free fraction of the drug, leading to higher levels of its active form and possible toxicity.
4. Corrected phenytoin level: The corrected blood concentration should be determined taking into account the hypoalbuminemia using the following formula:

Corrected phenytoin level = Measured level + (0.2 × [4.5 – Serum albumin]) Corrected phenytoin level = 11 μg/mL + (0.2 × [4.5 – 2.0]) = 12.4 μg/mL

Phenytoin correction suggests a measured blood concentration within the reference range, at least with respect to this patient, because even though it appears low, it still lies within that reference interval.

Treatment Plan

1. Discontinue phenytoin (Dilantin) temporarily to allow for the elimination of the drug from the body (Iorga & Horowitz, 2020; Katzung et al., 2021).
2. Initiate an alternative anticonvulsant medication, such as levetiracetam or valproic acid, to maintain seizure control.
3. Correct the underlying hypoalbuminemia, if possible, through appropriate nutritional support or treatment of the underlying condition.

Monitor serum phenytoin levels and clinical symptoms closely (Miller, 2021).

1. Once the patient’s condition stabilizes, consider reintroducing phenytoin at a lower dosage with close monitoring of serum levels and adjustments as needed.

References

Iorga, A., & Horowitz, B. Z. (2020). Phenytoin toxicity. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482444/#:~:text=The%20neurotoxic%20effects%20are%20concentration

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.

Miller, C. (2021). Phenytoin toxicity treatment & management: Prehospital care, emergency department care, consultations. EMedicine. https://emedicine.medscape.com/article/816447-treatment

Case Study 4: Xavi’s Treatment Plan for Low Back Pain

When Xavi is treated for his lower back pain after a car crash, it is necessary to think about proper pain management while handling possible issues that might arise from the use of opioids. Below is what I would do:

Medication Management

1. Stop using Lortab (hydrocodone/acetaminophen) due to possibilities of misuse and addiction, especially given that it “just barely makes him comfortable,” as Xavi said.
2. Prescribe an NSAID for relief of pain and reduction in inflammation: Naproxen 500 mg orally twice daily medication order.
3. Consider if there are other ways for managing acute exacerbations, like muscle relaxants or short-term, low-dose opioid analgesics, with close monitoring and stringent guidelines.

Monitoring

1. Monitor gastrointestinal bleeding or any adverse effect on kidneys because of NSAID administration.
2. Observe closely for any signs of drug abuse, dependence, or even respiratory depression whenever an opioid pain reliever is prescribed (Arcangelo et al.,2017).
3. Make regular assessments on the levels of discomfort and activities performed to change the treatment plan when necessary.

Non-Pharmacological Interventions

1. Recommend physical therapy interventions such as exercise programs and modalities aimed at healing and promoting mobility and function in relation to the affected area.
2. Suggest the application of hot/cold packs, gentle range-of-motion exercises, and tolerable low-impact activities.
3. Encourage coping strategies through relaxation techniques or cognitive-behavioral therapy to minimize stress related to pain.

Education

1. Explain why Lortab should not be used anymore while highlighting the long-term effects of this kind of addiction (Stahl, 2020; Lehne, 2021).
2. Provide information regarding the safe usage of NSAIDs, including potential side effects and warnings.
3. Tell Xavi how he can play an active role in his pain management through non-pharmacological interventions and lifestyle changes.
4. Make sure that Xavi knows the importance of returning visits by explaining the progress of his treatment plans and adjusting them accordingly.

Follow-Up

1. Schedule an appointment with Xavi within a fortnight to assess his condition following the given treatment intervention.
2. Consult a pain management expert or physiatrist if this condition becomes chronic in nature.

By using a multimodal approach that includes appropriate medication management, non-pharmacologic interventions, and patient education, one can effectively address Xavi’s lower back pain while minimizing opioid risks and promoting global functional recovery.

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.

Lehne, R. A. (2021). Pharmacology for nursing care (10th ed.). St. Louis, MO: Elsevier.

Stahl, S. M. (2020). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge, UK: Cambridge University Press.

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

To Prepare:

• Review the case study posted in “Announcements” by your Instructor for this Assignment
• Review the information provided and answer questions posed in the case study
• When recommending a medication, write out a complete prescription for the medication
• Whenever possible, use clinical practice guidelines in developing your answers when possible
• Include at least three references to support your answer and cite them in APA format.