PHARMACOTHERAPY FOR CARDIOVASCULAR DISORDERS – BN is a 74-year-old African American male who is seeing his PCP

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.

Case Study 

BN is a 74-year-old African American male who is seeing his PCP because he noticed when he woke up that his “heart was not beating right; it feels like it is going to slow.” He denies chest pain, SOB, N/V. He notes feeling dizzy earlier in the day. 6 weeks earlier his PCP started him on Diltiazem CD to further lower his BP to goal. His Metoprolol was lowered at that time as well from 75 mg to 50 mg BID. His PCP recommends he be admitted to the hospital.

Upon presentation to the hospital:

PMH:

• HTN x 7 years
• Type II DM
• CAD s/p angioplasty 2 years ago
• MI 3 years ago
• EF = 60%
• PVD s/p left femoral to posterior bypass
• Hx of A Fib x 4 years

Medications:

• Digoxin 0.25 mg QD KCl 40 mEq QD Vitamin C 500 mg QD
• Diltiazem CD 180 mg QD ASA EC 325 mg QD Vitamin E 400 IU QD
• Metoprolol 5- mg BID Warfarin 5 mg QD Ibuprofen 200 mg 2 tabs prn headache
• Lisinopril 20 mg QD Famotidine 20 mg QHS Multivitamin QD
• Imdur 30 mg QD Lantus 26u QHS Ca++/Vit D 500mg/200 IU BID
• HCTZ 12.5 mg QD Humalog 8u with meals

 

PE:

• BP 110/50 Pulse 38 bpm Resp 14/min
• Rest of physical exam unremarkable

Labs:

• K+ 6.9 WBC 5,800/mm3
• Na+ 135 Hct 35%
• Cr 1.9 Dig 2.78
• BUN 35 INR 2.3
• Gluc 102

Pharmacodynamics and Pharmacokinetics in Older Patients

            The geriatric populations are at an increased risk for developing multiple comorbidities, including hypertension, diabetes mellitus, and cardiovascular diseases. Consequently, the treatment of this disease requires multiple medications. The mechanism and metabolism of the medications administered may shift among this patient as aging results in changes in physiology which impact the drug’s pharmacokinetics and pharmacodynamics processes. In patients’ cardiovascular diseases and other comorbidities, drug-to-drug interactions are a factor that may also affect the pharmacokinetic and pharmacodynamics process. This paper discusses how age as a factor in patient BN in the case study influences the pharmacodynamics and pharmacokinetic process, how the change influences the drug therapy, and how to improve the patient’s drug therapy.

Factors affecting pharmacodynamics and pharmacokinetic process in the patient

Age is a factor that will influence the pharmacodynamics and pharmacokinetic process of patient BN. Pharmacokinetics is a drug’s movement in the body, including absorption, distribution, metabolism, and excretion. In elderly patients, significant changes may occur, some of which are more clinically relevant. Aging causes a considerable decrease in the metabolism and excretion of many drugs. A reduction in metabolism and excretion rate may cause toxicity because the concentrations of chronically used medications increase by 5 to 6 half-lives. According to Thürmann (2020), age reduces the small-bowel surface area, slows gastrointestinal motility, and increases gastric Ph. This may result in delayed absorption and onset of action. For example, the onset of action for Lisinopril may be affected because of the decreased absorption and bioavailability. Aging also causes an increase in body fat and reduces total body water. This is associated with increased volume distribution and increased elimination of half-lives for some drugs, such as metoprolol.

Pharmacodynamics is the study of the drug’s interaction with the body. In geriatric patients, the efficacy of the same drug concentrations on different action sites may vary compared to those in younger populations. The changes observed are attributed to drug-receptor interactions, adoptive homeostatic responses, post-receptor events, and pathologic changes in different organs (Thürmann, 2020). There is also increased sensitivity to anticholinergic drug effects. Medications such as antidepressants, antihyperglycemics, antidepressants, antihypertensive, and urinary antimuscarinic agents have an anticholinergic effect, and as such, patients using such drugs must be monitored frequently.

Impact of the change in processes of the recommended drug therapy

As Thürmann (2020) discusses, aging is associated with increased gastric Ph, reduced stomach surface area, and reduced excretion of drugs. These changes impact the pharmacokinetic and pharmacodynamics processes of the recommended drug therapy for patient BN. For example, in the case of Lisinopril, the drug’s absorption level may increase in the small intestines but may reduce its bioavailability. Aging also decreases the overall hepatic metabolism for specific medications, decreasing the clearance rate to approximately 30 to 40%. As a result, there is an increased risk for higher toxic effects. For example, the hepatic metabolism of diltiazem may be reduced, which may increase the risk of toxicity

Aging is also associated with reduced renal elimination of some medications. The decrease in renal elimination has clinically significant implications for patient toxicity levels. For example, the renal elimination of digoxin and Lisinopril will reduce significantly. There is also an increased fat and decreased total water mass in old patients (Andres et al., 2019). This may affect the diffusion of certain medications. In the case of patient BN, the distribution and uptake of the metoprolol and digoxin may reduce, which may result in significant clinical implications. Aging is associated with changes in sensitivity to different drug concentrations, which may affect the pharmacodynamics process. For example, in inpatient BN, the response to diltiazem may differ from that of a younger patient.

Improving the patient’s drug therapy plan

Different approaches may help optimize the drug therapy plan for patient BN. Providers must choose the best drugs and correct dosage for older patients while monitoring for effectiveness and toxicity and patient education about adverse health outcomes (Sleder et al., 2015). For patient BN, some adjustments may be made. For instance, the diltiazem dosage may be decreased because of its decrease in mechanism and increased volume in distribution. The efficacy of the dose must be monitored, and if the slightest efficacy, then the drug dosage should not be increased. Digoxin must also be used cautiously because of its reduced renal elimination, which may increase toxicity. In addition, its clearance level also increases. Therefore, the dosage should be adjusted to start with at least 0.125mg and adjusted according to the response (Sleder et al., 2015). Metoprolol and Lisinopril also have reduced renal elimination and thus should be administered at lower dosages, and the dose increased until the lowest efficacy is achieved. In addition, educating the patients about the possible side effects of the medications is essential. With the drug therapy plan adjustment, optimal health outcomes for patient BN will be achieved.

Conclusion

In summary, age is a factor that affects pharmacodynamics and pharmacokinetic processes. Older patients experience pathologic changes in body organs, which affect the drug’s mechanism and metabolism. This is affected by certain factors, including increased gastric Ph, reduced bowel surface area, increased body fat, reduced total body water, reduced renal elimination, and reduced metabolism. Therefore, medications among the elderly must be first administered at lower dosages while monitoring the efficacy, toxicity, and side effects.

 

References

Andres, T. M., McGrane, T., McEvoy, M. D., & Allen, B. F. S. (2019). Geriatric    pharmacology. Anesthesiology Clinics, 37(3), 475–492. https://doi.org/10.1016/j.anclin.2019.04.007

Sleder, A. T., Kalus, J., & Lanfear, D. E. (2015). Cardiovascular Pharmacokinetics,    pharmacodynamics, and pharmacogenomics for the clinical practitioner. Journal of Cardiovascular Pharmacology and Therapeutics, 21(1), 20–26. https://doi.org/10.1177/1074248415590196

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

PHARMACOTHERAPY FOR CARDIOVASCULAR DISORDERS – BN is a 74-year-old African American male who is seeing his PCP because he noticed when he woke up that his “heart was not beating right; it feels like it is going to slow.” NURS-6521 Week 2: Assignment

Treating Heart Conditions with Medications – BN, a 74-year-old African American man, is visiting his primary care doctor because he felt that his heart wasn’t beating normally when he woke up. Assignment for Week 2 of NURS-6521.

By the 7th day of Week 2, create a 2- to 3-page paper covering the following points:

Explain how the chosen factor might affect how the patient from the case study processes medications in their body (pharmacokinetics) and how the medications affect their body (pharmacodynamics).
Describe how changes in these processes could impact the recommended drug treatment for the patient. Provide specific examples.
Suggest improvements for the patient’s drug treatment plan and explain why you think these changes would be beneficial.

Case Study

BN is a 74-year-old African American man who went to his doctor because he felt that his heart wasn’t beating normally when he woke up. He said it felt like his heart was slowing down. He didn’t have chest pain, shortness of breath, nausea, or vomiting. He mentioned that he felt dizzy earlier in the day. About six weeks ago, his doctor prescribed Diltiazem CD to further lower his blood pressure, and at that time, his Metoprolol dosage was reduced from 75 mg to 50 mg twice a day. The doctor recommended that he be admitted to the hospital.

When he got to the hospital:

Past Medical History (PMH):

High blood pressure for 7 years
Type II diabetes
Coronary artery disease (CAD) with angioplasty 2 years ago
Heart attack (MI) 3 years ago
Ejection fraction (EF) = 60%
Peripheral vascular disease (PVD) with surgery
Atrial fibrillation (A Fib) for 4 years

Medications:

Digoxin 0.25 mg daily
Potassium chloride (KCl) 40 mEq daily
Vitamin C 500 mg daily
Diltiazem CD 180 mg daily
Aspirin (ASA) EC 325 mg daily
Vitamin E 400 IU daily
Metoprolol 5 mg twice a day
Warfarin 5 mg daily
Ibuprofen 200 mg (2 tablets) as needed for headaches
Lisinopril 20 mg daily
Famotidine 20 mg at bedtime
Multivitamin daily
Imdur 30 mg daily
Lantus insulin 26 units at bedtime
Calcium + Vitamin D 500 mg / 200 IU twice a day
Hydrochlorothiazide (HCTZ) 12.5 mg daily
Humalog insulin 8 units with meals

Physical Examination (PE):

Blood pressure: 110/50
Pulse: 38 beats per minute
Respiration rate: 14 breaths per minute
Rest of the physical exam was normal

Lab Results:

High potassium (K+): 6.9
White blood cell count (WBC): 5,800/mm3
Low sodium (Na+): 135
Hematocrit (Hct): 35%
Elevated creatinine (Cr): 1.9
High digoxin levels: 2.78
Elevated blood urea nitrogen (BUN): 35
Elevated international normalized ratio (INR): 2.3
Normal glucose (Gluc): 102

Effects of Age on Medication Effects

The elderly, like BN, often face various health issues like high blood pressure, diabetes, and heart diseases. Treating these conditions involves several medications. However, as people age, their bodies change, affecting how medications are processed and how they work. This paper looks at how age impacts the way medications work in BN, considering both how his body processes the medications (pharmacokinetics) and how medications affect his body (pharmacodynamics). It also examines how these changes might affect the recommended treatment plan and suggests ways to improve it.

Age’s Impact on Medication Processes

Age can alter how medications work in BN. Pharmacokinetics is about how drugs move within the body – how they’re absorbed, distributed, metabolized, and excreted. In older patients, these processes can change significantly, with some changes having more clinical importance. Age can lead to reduced metabolism and excretion of many drugs. This reduction may cause toxicity as the concentrations of long-term medications increase over time. According to Thürmann (2020), aging leads to reduced surface area in the small intestine, slower digestion, and higher stomach pH levels. This might lead to slower drug absorption and onset of action. For example, Lisinopril’s effectiveness could be affected due to slower absorption. Aging also means more body fat and less total body water, which can affect how some drugs distribute and eliminate from the body. Metoprolol, for example, may have altered distribution due to these changes.

Pharmacodynamics refers to how drugs interact with the body. In older patients, the effects of the same drug concentrations on different sites may differ compared to younger individuals. This could be due to changes in drug-re