Pharmacotherapy for Cardiovascular Disorders

Pharmacotherapy for Cardiovascular Disorders

The case presented is of an 86-year-old female admitted to the emergency department with delirium. She is a known hypertensive, having been diagnosed with the disease ten years ago. She has also had chronic kidney disease for five years, osteoarthritis for seven years, GERD for twenty years, and atrial fibrillation for one month. She is currently on Digoxin 0.25 mg every six hours, Metoprolol XL 25mg every six hours, Warfarin 3 mg every six hours, APAP 650 mg every eight hours, Omeprazole 20mg every six hours, and Multivitamin every six hours.

Pharmacokinetic and pharmacodynamic processes are processes that influence pharmacotherapeutic choices during the care processes. Several factors may influence these processes. Gender, age, and ethnicity, among others, are factors that influence pharmacokinetic and pharmacodynamic processes. Age and aging are the most important influences apparent in the case presented.

Age and its Influence on the Pharmacokinetic and Pharmacodynamic Processes.

The aging process defines the natural progressive and gradual change that begins in childhood and proceeds till death. Age is one of the factors that may influence the pharmacokinetic and pharmacodynamic processes in the patient in the case presented. The aging process is accompanied by significant physiological changes that may affect the pharmacokinetic parameters of absorption, distribution, metabolism, and excretions, as well as, the pharmacodynamic processes (Drenth‐van Maanen et al., 2019). To begin with, age-related changes to the GI tract can affect absorption. Decreases in blood supply to the GI tract coupled with alterations in the gastric pH that are normative to the aging process may sometimes lower the degree of absorption of some medications (Drenth‐van Maanen et al., 2019). While this may sometimes have no significant overall impact on the patients, its effects may be profound when the patients are also taking other medications that alter their GI physiology (Drenth‐van Maanen et al., 2019). Medications such as antacids that raise the gastric pH may alter gastric homeostasis, resulting in vitamin B12 malabsorption.

Similarly, age-related changes to the distribution of xenobiotics also occur. The increases in body fat content and concomitant decrease in total body water that accompanies old age may affect how some medications are biodistributed in the body (Kuprash et al., 2020). In this respect, highly lipophilic drugs will be more likely to be distributed to the tissues and will, therefore, have longer shelf lives. The aging process also affects the metabolizing and elimination capacities of the body. As one age, the metabolizing capacity of the liver is reduced. These reductions are accustomed to reduced blood flow to the liver and senility. This means that some medications will take longer to be metabolized. Additionally, the first-pass effect seen in some medications is also likely to be reduced. In this regard, there is a high risk for drug toxicity, often warranting dose reduction (Kuprash et al., 2020). Likewise, age-related decreases in renal functionalities also pose a risk for drug accumulations and consequent toxicity. Consistently, age may also influence the pharmacodynamic processes. Kuprash et al. (2020) note that age-related changes to pharmacodynamic processes usually result in drug sensitivity and alterations in the body’s homeostasis. In this case, patients will have increased responses to some medications.

How the Changes may Impact the Recommended Therapy

The patient in the case is 86 years of age and is on diverse medications for the management of her illnesses. The apparent physiologic changes in the patient, coupled with her disease state, may warrant the revision of the medication regimen recommended to her. The GI alterations accustomed to old age and apparent in the patient may necessitate dosing revisions for omeprazole. Ompeprazole, an irreversible inhibitor of the proton pump, may cause prolonged suppression of gastric acidity. It should thus be used only when necessary in geriatric patients with acidity problems. In the patient’s case above, the dosage of omeprazole is 20mg every six hours. This may result in considerable hypoacidity and consequent vitamin B12 malabsorption. Revision of this dosing to 20mg every 24 hours may help in preventing such problems.

Due to reduced metabolizing and excretion capacities, dose adjustments are necessitated for APAP. APAP is hepatotoxic at higher doses. Its potential for hepatotoxicity is increased in the elderly due to the reduction in the liver metabolizing capacity (Offor et al., 2022). Metoprolol and digoxin doses may sometimes also require downward adjustments among the elderly groups. Pharmacodynamic changes that accompany the aging process may also necessitate dosing adjustments. Due to age-related increases in drug sensitivity, lower doses of warfarin may be sufficient to produce the required clinical effects.

Improving the Patient’s Drug Therapy.

The patient in the case is an 86-year-old female with hypertension, CKD, GERD, OA, and AF. Dosing adjustments will be necessary for all the medications she is taking. The omeprazole dose will be halved to manage GERD while maintaining the multivitamin to prevent apparent vitamin B12 malabsorptions. In the management of OA, the dose of APAP will be maintained. However, close monitoring for liver function test derangements is necessitated. In case of hepatotoxicity, lowering the dose or adding another analgesic may be necessary to maintain the required analgesia. In managing HTN and AF, warfarin, metoprolol, and digoxin doses may be halved. As per the subjective findings, the patient has CKD. A dose reduction of digoxin to 0.125 mg every 4-6 hours is necessary for older patients with CKD (Pugh et al., 2019). Reducing the doses of metoprolol to half is also necessary for older patients with heart and kidney problems.

 References

Drenth‐van Maanen, A. C., Wilting, I., & Jansen, P. A. (2019). Prescribing medicines to older people—how to consider the impact of aging on human organs and body functions. British Journal of Clinical Pharmacology, 86(10), 1921–1930. https://doi.org/10.1111/bcp.14094

Kuprash, L., Gudarenko, S., Kuprash, O., Gorchakova, N., & Khodakivska, O. (2020). Age peculiarities of pharmacokinetics and pharmacodynamics of medicines. Aging & Longevity, 1(1), 33–39. https://doi.org/10.47855/10.47855/jal9020-2020-1-6

Offor, S. J., Amadi, C. N., Chijioke-Nwauche, I., Manautou, J. E., & Orisakwe, O. E. (2022). Potential deleterious effects of paracetamol dose regime used in Nigeria versus that of the United States of America. Toxicology Reports, 9, 1035–1044. https://doi.org/10.1016/j.toxrep.2022.04.025

Pugh, D., Gallacher, P. J., & Dhaun, N. (2019). Management of hypertension in chronic kidney disease. Drugs, 79(4), 365–379. https://doi.org/10.1007/s40265-019-1064-1

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Heart disease remains the No. 1 killer in America; nearly half of all Americans have high blood pressure, high cholesterol, or smoke—some of the leading risk factors for heart disease…

—Murphy et al., 2018

Despite the high mortality rates associated with cardiovascular disorders, improved treatment options do exist that can help address those risk factors that afflict the majority of the population today.

As an advanced practice nurse, it is your responsibility to recommend appropriate treatment options for patients with cardiovascular disorders. To ensure the safety and effectiveness of drug therapy, advanced practice nurses must consider aspects that might influence pharmacokinetic and pharmacodynamic processes, such as medical history, other drugs currently prescribed, and individual patient factors.

Reference: Murphy, S. L., Xu, J., Kochanek, K. D., & Arias, E. (2018). Mortality in the United States, 2017. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db328.htm

To Prepare

Review the Resources for this module and consider the impact of potential pharmacotherapeutics for cardiovascular disorders introduced in the media piece.
Review the case study assigned by your Instructor for this Assignment.
Select one of the following factors: genetics, gender, ethnicity, age, or behavior factors.
Reflect on how the factor you selected might influence the patient’s pharmacokinetic and pharmacodynamic processes.
Consider how changes in the pharmacokinetic and pharmacodynamic processes might impact the patient’s recommended drug therapy.
Think about how you might improve the patient’s drug therapy plan based on the pharmacokinetic and pharmacodynamic changes. Reflect on whether you would modify the current drug treatment or provide an alternative treatment option for the patient.