Week 2 Case Studies: Drug Therapy Plans

Scenario 1: Cytochrome P450 Enzymes and Drug Metabolism

Cytochrome P450 enzymes, especially CYP3A4, are crucial in drug metabolism. Primarily found in the liver, these enzymes assist in the oxidation of drugs so that they become soluble and can be excreted from the body. More than half of all prescribed drugs are metabolized by the enzyme CYP3A4 (Zhao et al., 2021). Their function, therefore, enables clinicians to prevent harmful drug interactions besides enhancing therapeutic efficiency: Week 2 Case Studies: Drug Therapy Plans.

Using the Medscape Pill Identifier, the medication with the imprint “ATO 40,” an oval shape, white color, and tablet form, was identified as Atorvastatin 40 mg. The CYP3A4 enzyme metabolizes this drug. For a patient prescribed Atorvastatin, the appropriate prescription would be as follows: Atorvastatin 40 mg taken orally once daily in the evening (McIver & Siddique, 2020).

The patient may take it with or without food but should avoid grapefruit juice, as it inhibits CYP3A4 activity, potentially increasing the risk of drug toxicity. A 30-day supply with three refills would be dispensed (Rosenthal, 2020). This strategy is consistent with evidence-based practice and supports addressing the drug’s pharmacokinetics and patient-related factors. Safe prescribing will prevent drug accumulation and promote patient safety.

References

McIver, L. A., & Siddique, M. S. (2020, September 25). Atorvastatin. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430779/

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

Zhao, M., Ma, J., Li, M., Zhang, Y., Jiang, B., Zhao, X., Huai, C., Shen, L., Zhang, N., He, L., & Qin, S. (2021). Cytochrome P450 Enzymes and Drug Metabolism in Humans. International Journal of Molecular Sciences, 22(23), 12808. https://doi.org/10.3390/ijms222312808

Scenario 2: Lipid Management and Cardiovascular Risk Factors

JS, a 56-year-old female, presents with a fasting lipid profile and symptoms indicative of niacin-induced flushing. Her HDL was calculated as 60 mg/dL using the formula: Total Cholesterol – (LDL + Triglycerides/5). Additionally, her BMI was calculated at 30.2, categorizing her as obese. The target lipid profile for JS would be Total Cholesterol < 200 mg/dL, HDL > 50 mg/dL, LDL < 100 mg/dL, and Triglycerides < 150 mg/dL.

According to the patient’s history and clinical symptoms, it will be reasonable to cease niacin and initiate atorvastatin therapy to provide a better level of dyslipidemia management. The recommended and advised dosage of atorvastatin is 20 mg orally at night for the treatment (Peechakara & Mohit Gupta, 2019). Meals should be taken routinely, while lipid profiles and liver function tests should also be done routinely. The prescription will contain a 30-day supply with a three-instance refill option.

Monitoring the effectiveness of this therapy requires lipid panel assessments every 4 to 6 weeks. It is also worth noting that the patient should be subjected to liver function tests to identify possible adverse effects of the statin (Sun et al., 2023). With her obesity, hypertension, and dyslipidemia, JS has three risk factors for coronary artery disease and, thus, will require an aggressive approach to cardiovascular risk reduction (Powell-Wiley et al., 2021).

References

Peechakara, B. V., & Mohit Gupta. (2019, September 30). Vitamin B3. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526107/

Powell-Wiley, T. M., Poirier, P., Burke, L. E., Després, J.-P., Gordon-Larsen, P., Lavie, C. J., Lear, S. A., Ndumele, C. E., Neeland, I. J., Sanders, P., & St-Onge, M.-P. (2021). Obesity and Cardiovascular disease: a Scientific Statement from the American Heart Association. Circulation, 143(21), 984–1010. https://doi.org/10.1161/cir.0000000000000973

Sun, L., Wolska, A., Amar, M., Zubirán, R., & Remaley, A. T. (2023). Approach to the Patient With a Suboptimal Statin Response: Causes and Algorithm for Clinical Management. The Journal of Clinical Endocrinology and Metabolism, 108(9), 2424–2434. https://doi.org/10.1210/clinem/dgad153

Scenario 3: Hypertension Management in African American Patients

CL, a 48-year-old African American male, presents with elevated blood pressure readings of 159/91 mmHg and 165/95 mmHg, exceeding the JNC 8 guideline target of < 140/90 mmHg. His use of Advil Cold & Sinus, which contains pseudoephedrine, likely contributed to the elevated readings. Discontinuing this medication is essential.

For long-term control of hypertension, a thiazide diuretic, such as hydrochlorothiazide, is considered first-line therapy for African American patients with newly diagnosed high blood pressure (P & A, 2020). The dosage is 25 mg of hydrochlorothiazide orally once daily in the morning with food to reduce gastrointestinal side effects. A 30-day supply with three refills will be provided (Herman & Bashir, 2021).

Serial monitoring of blood pressure and potassium levels will be necessary to evaluate the effectiveness of the drug and to minimize side effects. This treatment plan is based on Samson’s (2019) study and aligns with JNC 8 recommendations for hypertension management, prioritizing patient safety and long-term health outcomes.

References

Herman, L. L., & Bashir, K. (2021). Hydrochlorothiazide. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/28613517/

P, A., & A, K.-Z. (2020, January 1). Thiazide Diuretics. PubMed. https://pubmed.ncbi.nlm.nih.gov/30422513/

Samson, M. (2019, October 20). Hypertension Treatment & Management: Approach Considerations, Nonpharmacologic Therapy, Pharmacologic Therapy. Medscape.com. https://emedicine.medscape.com/article/241381-treatment 

Scenario 4: Nitroglycerin and the First-Pass Effect

Nitroglycerin is a cornerstone medication in the management of acute angina due to its vasodilatory effects. However, when administered orally, it undergoes a high first-pass effect, significantly reducing its bioavailability (Kim et al., 2020). This characteristic necessitates alternative routes of administration. Sublingual nitroglycerin is commonly used to bypass hepatic metabolism, achieving near 100% bioavailability and a rapid onset of action.

Other than sublingual, nitroglycerin may also be administered via transdermal patches or intravenously to bypass the first-pass effect. For acute episodes of angina, the prescription would read as follows: Nitroglycerin 0.4 mg sublingually PRN for chest pain (Duckworth, 2020). The patient may repeat the dose every five minutes up to three doses. If the pain continues after the three doses, they have to go to the emergency trunk immediately.

A pack provides 25 tablets and one cartridge, and the medicine should be stored in a cool and dark, air-tight container. This prescription guarantees quick reduction of symptoms and takes into account the tactical difficulties arising from the high first-pass effect; therefore, this is a good example of rational pharmacological management (Herman & Santos, 2023).

References

Duckworth, R. (2020, August 25). Nitroglycerin: Major actions and misconceptions. EMS1. https://www.ems1.com/ems-products/medical-monitoring/articles/nitroglycerin-major-actions-and-misconceptions-7j3y8hSw5MzSKU9S/

Herman, T. F., & Santos, C. (2023, November 3). First Pass Effect. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK551679/

Kim, K. H., Kerndt, C. C., & Schaller, D. J. (2020). Nitroglycerin. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/29494004/

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Case studies

For your week 2 assignment, evaluate drug treatment plans for patients with various disorders and justify drug therapy plans based on patient history and diagnosis.

To Prepare:

• Review assignment rubric and case studies. Be sure to thoroughly answer ALL cases.
• Explain the problem and discuss how you would address the problem.
• When recommending medications, write out a complete prescription for each medication. What order would you send to a pharmacy? Include drug, dose, route, frequency, special instructions, # dispensed (days supply), refills, etc. Also state if you would continue, discontinue or taper the patient’s current medications.
• Answer questions using your required learning resources, clinical practice guidelines, Medscape and JNC 8.
• Include at least three references to support each scenario and cite them in APA format. Please include in-text citations.
• You do not need an introduction or conclusion paragraph.

Cases:
SCENARIO 1
Why are cytochrome P450 enzymes (CYPs) important in drug metabolism? The majority of medications are metabolized by what CYP enzyme? Utilizing the Medscape pill identifier, enter the following characteristics to identify the medication.

What CYP enzyme metabolizes this medication? Write a sample prescription for it.

Imprint (ATO 40) Shape (Oval) Color (White) Form (Tablet) Scoring (None)

SCENARIO 2
JS is a 56-year-old female presenting with redness, warmth and tingling sensation in her neck and face. Current medications include semaglutide (Ozempic) 0.5 mg SC qWeek and Niacin 1,000 mg BID. She is 5’4” and weighs 175 lbs. Fasting lipid profile shows total cholesterol 200, LDL cholesterol 110, and Triglycerides 150.

Blood pressure readings of 139/91 and 140/89. What is the patient’s HDL? BMI? What are goal Total Cholesterol, HDL, LDL, and Triglyceride levels for JS? What treatment plan would you implement (include complete medication orders)?

How would you monitor the effectiveness of your treatment plan? How many risk factors for coronary artery disease does she have? Identify them specifically.

SCENARIO 3
CL is a 48-year-old African American male with blood pressure readings today of 159/91 and 165/95. He states he is taking Advil Cold & Sinus for a cold x 1 week. Additional medications include adalimumab 40 mg subcutaneous injection every other week, Wellbutrin XL 300 mg daily and pantoprazole 40 mg daily 30 minutes before breakfast.

How would you treat CL? What would you prescribe (include complete medication order)? What is his goal blood pressure per JNC 8?

SCENARIO 4
Does nitroglycerin have a high or low first pass effect? Please discuss why this is important to know and how it relates to bioavailability. What route has 100% bioavailability?

In addition to parenterally, how can this medication be given to counter the first pass effect? Write a sample prescription for this medication.

Resource:

• Rosenthal, L.D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for Advanced Practice Nurses (2nd ed.). St. Louis, MO: Elsevier.

Client’s Notes:

• ***The references can be the same for all the scenarios but must be 3 each. Medscape and JNC 8 can be used