Pharmacotherapy for Cardiovascular Disorders
Case Study
L.M. is an 80-year-old female admitted to the emergency department accompanied by her husband and admitted with delirium. L.M.’s husband highlights that she is compliant with her current medications. Although she is compliant with her pharmacological therapy, she does not adhere to her non-pharmacological interventions, which include self-monitoring her blood pressure and heart rate at home. L.M.’s past medical history reveals that she has suffered from atrial fibrillation for the past month, a gastroesophageal disease for the past 20 years, hypertension for the past ten years, osteoarthritis for the past seven years, and chronic kidney disease for the past five years. Her medications include metoprolol 25mg Q.D., multivitamin Q.D., omeprazole 20mg Q.D., digoxin 0.25 mg Q.D., warfarin 3mg Q.D. and paracetamol 650 mg TID. L.M.’s vital signs show a weight of 113 lbs, a height of 5’4″, a heart rate of 52 bpm, and a blood pressure of 101/58. Her laboratory results reveal Na+ 138, K+ 4.0, Cl- 99, CO2 27, BUN 33, Cr 1.2, Gluc 109, INR 3.8, and Dig 2.4. Hire our assignment writing services in case your assignment is devastating you. Our team of experts is ready to help.
Factors Influencing Pharmacokinetic and Pharmacodynamic Processes: Age
A patient’s age can affect a patient’s pharmacodynamic and pharmacokinetic processes. L.M. is 80 years old and is therefore considered to be geriatric. The elderly have decreased hepatic function, renal function, and acidity, which alter pharmacokinetic processes (Thürmann, 2020). Metoprolol, omeprazole, digoxin, warfarin, and paracetamol undergo hepatic metabolism. A decrease in liver function caused a decrease in the hepatic metabolism of these oral drugs taken by L.M., leading to increased circulation concentration. High concentration in circulation causes increased susceptibility to experiencing side effects and toxicity of the drugs. The renal system is vital in urination and the excretion of drugs from the body. Metoprolol, warfarin, digoxin, paracetamol, and omeprazole are mainly excreted through the renal system. L.M. is elderly and therefore has a decreased renal function leading to a higher concentration of these drugs in circulation hence severe side effects and toxicity. The elderly have increased acidity, leading to increased metabolism of drugs such as omeprazole that require an acidic P.H. to metabolize.
Impact of Changes in Processes on Recommended Drug Therapy
Changes in the pharmacokinetic and pharmacodynamic processes impact a patient’s recommended therapy. Therapy is adjusted by dose adjustments, dose increase or decrease, withdrawal of drugs, change in the duration of therapy, or alteration of dosing. L.M. is experiencing an altered level of consciousness and delirium despite being compliant with her drug therapy plan; therefore, her drug therapy plan needs improvement. L.M. takes digoxin 0.25mg Q.D. and has a laboratory result of dig 2.4 and a normal potassium level of 4.0. Toxic levels of digoxin are more than 2.4 ng/mL; therefore, L.M.’s digoxin level is almost on the toxic level. Digoxin toxicity presents neurological symptoms such as altered consciousness and delirium (Cummings & Swoboda, 2022). The decreased renal and hepatic function causes increased digoxin levels in the system; hence L.M. is experiencing toxic side effects. There is a need to decrease the dose or frequency of digoxin. L.M. has an INR of 3.8, yet the target value for INR in atrial fibrillation is 2.0 to 3.0 using warfarin (Patel et al., 2022). An INR of 3.8 suggests the patient is unresponsive to warfarin; therefore, there is a need to increase the dose or frequency of warfarin. The patient has a blood pressure of 101/58 mmHg, which is within the normal range showing that the dosage and frequency of metoprolol are effective. L.M. has a BUN of 33, which is above the normal value, showing kidney failure. Paracetamol causes nephrotoxicity; therefore, further damage to the kidneys, since L.M. has chronic kidney disease, should be prevented by lowering the dosage or frequency of paracetamol (Agrawal & Khazaeni, 2022).
Ways to Improve the Drug Therapy Plan
Digoxin is prescribed for the management of atrial fibrillation. I would decrease the frequency from 0.5 mg Q.D. to 0.5mg B.D. in addition, warfarin 3mg Q.D. will be altered to warfarin 4mg Q.D. for two days, followed by an INR check and further dose adjustment according to the results. Metoprolol is maintained at 25mg Q.D. However, the patient is encouraged to monitor her blood pressure daily at home to prevent and report any readings showing hypotension and hypertension. Omeprazole is prescribed for the management of hypertension. Elderly patients whose drug therapy plans include several medications tend to get confused. Therefore, I will withdraw omeprazole and educate the patient on non-pharmacological interventions for GERD, such as dietary modifications. Paracetamol is adjusted from 650mg TID to paracetamol 500mg TID. The patient should be advised on non-pharmacological ways to manage osteoarthritis, such as massage.
References
Agrawal, S., & Khazaeni, B. (2022). Acetaminophen Toxicity. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441917/.
Cummings, E. D., & Swoboda, H. D. (2022). Digoxin Toxicity. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470568/.
Patel, S., Singh, R., Preuss, C. V, et al. (2022). Warfarin. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470313/.
Thürmann, P. A. (2020). Pharmacodynamics and pharmacokinetics in older adults. Current Opinion in Anaesthesiology, 33(1), 109–113. https://doi.org/10.1097/ACO.0000000000000814.
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Question 
Case Study 1
LM is an 86-year-old female admitted to the emergency department with delirium. Her spouse is with her and verifies that LM adheres to the medications she is currently prescribed. She does not self-monitor her BP or heart rate at home.
Pharmacotherapy for Cardiovascular Disorders
PMH:
A Fib diagnosed 1 month ago
HTN x 10 years
CKD x 5 years
Osteoarthritis x 7 years
GERD x 20 years
Medications:
Digoxin 0.25 mg QD
Metoprolol XL 25mg QD
Warfarin 3 mg QD
APAP 650 mg TID
Omeprazole 20mg QD
Multivitamin QD
Allergies: NKDA
Social History:
Married to husband for 57 years
No smoking, alcohol, limited daily exercise (short walks each morning)
Family History:
None reported
Vitals: Labs:
Wt 113 lbs Ht 5’4” Na+ 138 K+ 4.0
BP 101/58, HR 52 Cl- 99 CO2 27
BUN 33 Cr 1.2
Gluc 109 INR 3.8
Dig 2.4
PE:
Elderly female with altered level of consciousness, no signs of bruising, bleeding, or other injury.
Write a 2- to 3-page paper that addresses the following:
Explain how the factor you selected might influence the pharmacokinetic and pharmacodynamic processes in the patient from the case study you were assigned.
Describe how changes in the processes might impact the patient’s recommended drug therapy. Be specific and provide examples.
Explain how you might improve the patient’s drug therapy plan and explain why you would make these recommended improvements.