Optimizing Primary Care Medication Management- Evidence-Based Approaches and Rationales

Optimizing Primary Care Medication Management- Evidence-Based Approaches and Rationales

Question One: First-Line Treatment Recommendations

The American Heart Association/American College of Cardiology (AHA/ACC) and the Eighth Joint National Committee (JNC8) recommend lifestyle modifications as the first-line treatment for patients with hypertension and no major comorbidities. Lifestyle modifications include moderating alcohol intake, controlling dietary sodium intake, increasing physical activity, and achieving a healthy weight. Notably, lifestyle modifications effectively decrease blood pressure and improve cardiovascular health (Mahdavi et al., 2020).

Question Two: Recommended Medications to Start on Patients

Considering the patient’s high blood pressure and hyperlipidemia risk factors, the recommended medications are antihypertensive and lipid-lowering medications. The antihypertensive recommended for this patient, given the age of the patient and comorbidities, is enalapril. Enalapril is an angiotensin-converting enzyme inhibitor. The generic names used for this drug are Epaned, Vasotec, and Enalaprilat, with a starting dose of 5 mg once daily (Faruqi & Jain, 2020). The lipid-lowering medication warranted for this patient is atorvastatin, which is in the statin drug class. It uses the generic Lipitor, with a starting dose of 10 mg once daily (McIver & Siddique, 2019).

Question Three: Mechanism of Actions of the Listed Drugs

Enalapril is an angiotensin-converting enzyme inhibitor that reduces the angiotensin-II levels. As a result of this action, the total peripheral resistance reduces without an increase in cardiac oxygen demand. Also, there is an increase in serum renin levels and a decrease in aldosterone, which leads to a decrease in blood pressure in the body (Faruqi & Jain, 2020). Atorvastatin is a statin that inhibits 3-hydroxy-3-methylglutaryl-coenzyme A reductase, which decreases the production of cholesterol in the liver. Also, atorvastatin increases LDL receptor numbers on the surface of hepatic cells. Ultimately, this leads to a reduction of LDL cholesterol levels in the body (McIver & Siddique, 2019).

Question Four: Side Effects of the Listed Drugs

Common side effects that the patient may experience after taking atorvastatin include diarrhea, nausea, insomnia, pain in the extremities, urinary tract infection, dyspepsia, and arthralgia. Rare adverse effects of atorvastatin are rhabdomyolysis and myopathies, including muscle weakness and muscle aches (McIver & Siddique, 2019). On the other hand, enalapril’s common side effects include a non-productive cough, hyperkalemia, hypotension, cholestatic jaundice, and hypersensitivity. A rare adverse effect of enalapril is angioedema, which can involve the head and neck or the intestines, causing compromise of the airway and abdominal pain, respectively (Faruqi & Jain, 2020).

Question Five: Interactions between the Prescribed Medications

Enalapril and ACE inhibitors, in general, interact with many drugs and can cause toxicities, adverse effects, and therapeutic failures. Enalapril interacts with antipsychotic agents, barbiturates, levodopa, and loop diuretics, enhancing its hypotensive activity, while its adverse effects are enhanced when used together with drugs like allopurinol and lithium (Faruqi & Jain, 2020). On the other hand, atorvastatin interacts with specific drugs metabolized with the CYP5A4 enzyme system, like some antibiotics and antifungals. Also, CYP3A4 inducers may result in a decreased plasma atorvastatin concentration. Lastly, when administered with digoxin, atorvastatin may increase digoxin plasma concentration (McIver & Siddique, 2019).

Question Six: Other Non-Pharmacological Interventions

The main non-pharmacological interventions include dietary modification and weight management. Weight management is key for obesity and overweight individuals (Kodela et al., 2023). Through intermittent fasting, weight loss and hypertension can be achieved effectively. Dietary modification is achieved by the DASH dietary pattern, which involves a diet rich in low total and saturated fat, fruits, whole grains, vegetables, and low-fat dietary produce. Also, as Kodela et al. (2023) note, the DASH diet pattern involves reducing sodium in the diet and limiting the intake of processed foods.

References

Faruqi, A., & Jain, A. (2020). Enalapril. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557708/

Kodela, P., Okeke, M., Guntuku, S., Lingamsetty, S. S. P., & Slonovschi, E. (2023). Management of hypertension with non-pharmacological interventions: A narrative review. Cureus. https://doi.org/10.7759/cureus.43022

Mahdavi, M., Parsaeian, M., Mohajer, B., Modirian, M., Ahmadi, N., Yoosefi, M., Mehdipour, P., Djalalinia, S., Rezaei, N., Haghshenas, R., Pazhuheian, F., Madadi, Z., Sabooni, M., Razi, F., Samiee, S. M., & Farzadfar, F. (2020). Insight into blood pressure targets for universal coverage of hypertension services in Iran: the 2017 ACC/AHA versus JNC 8 hypertension guidelines. BMC Public Health, 20(1). https://doi.org/10.1186/s12889-020-8450-1

McIver, L. A., & Siddique, M. S. (2019). Atorvastatin. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430779/

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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. (See Post Expectations)
Mrs. Lyons is a 57-year-old African American female who recently developed headaches and had an elevated blood pressure reading at her work health fair. Her blood pressure was taken at the health fair, and the reading was 168/99. She has returned to the drugstore three times to take her blood pressure. The readings have been 145/90, 150/89, and 140/88. At the health fair, she was told her BMI is elevated. Her cholesterol levels were also done at the health fair, and the results were: total cholesterol level of 250, LDL 138, HDL 48, and Triglycerides 170.

She has not been to see a primary care provider in over 5 years. At her last office visit, which was 5 years ago, her blood pressure was (135/95). Her LDL and triglycerides were also elevated at that time. The patient was supposed to monitor her blood pressure at home and trial diet and lifestyle changes. She was supposed to return for a follow-up with her blood pressure log and for a recheck of her labs. She, unfortunately, did not do this.
Today in the clinic, her vital signs are:
BP 146/92, HR 90, Temp 98.4, RR 12, O2 98%, Height 5’5, Weight 220 lbs, BMI 36.6
She is not currently taking any medications. She has NKDA. Family history: her brother and sister both have been diagnosed with hypertension and DM. Diagnoses for the patient are HTN, Obesity, and Hyperlipidemia.
Q1. Please briefly discuss the first-line treatment recommendations from JNC8 and the AHA/ACC for a patient with no other major comorbidities.
Q2. What are the recommended medications to start this specific patient on? Please provide the drug class, generic & trade name, and initial starting dose.
Q3. Please discuss the mechanism of action of each of the drugs you listed.
Q4. Please discuss the side effect profile of each medication you listed.
Q5. Are there any interactions between any of the medications you prescribed?
Q6. What other non-pharmacological interventions would be suggested?