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Discussion: Pharmacotherapy for Cardiovascular Disorders

As the leading cause of death in the United States for both men and women, cardiovascular disorders account for 7 million hospitalizations per year (NCSL, 2012). This is the result of the extensive treatment and care that is often required for patients with these disorders. While the incidences of hospitalizations and death are still high, the mortality rate of cardiovascular disorders has been declining since the 1960s (CDC, 2011). Improved treatment options have contributed to this decline, as well as more knowledge on patient risk factors. 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.

Consider the following case studies:

Case Study 1:

Patient AO has a history of obesity and has recently gained 9 pounds. The patient has been diagnosed with hypertension and hyperlipidemia. Drugs currently prescribed include the following:

  • Atenolol 12.5 mg daily

  • Doxazosin 8 mg daily

  • Hydralazine 10 mg qid

  • Sertraline 25 mg daily

  • Simvastatin 80 mg daily

Case Study 2:

Patient HM has a history of atrial fibrillation and a transient ischemic attack (TIA). The patient has been diagnosed with type 2 diabetes, hypertension, hyperlipidemia and ischemic heart disease. Drugs currently prescribed include the following:

  • Warfarin 5 mg daily MWF and 2.5 mg daily T, TH, Sat, Sun

  • Aspirin 81 mg daily

  • Metformin 1000 mg po bid

  • Glyburide 10 mg bid

  • Atenolol 100 mg po daily

  • Motrin 200 mg 1–3 tablets every 6 hours as needed for pain

Case Study 3:

Patient CB has a history of strokes. The patient has been diagnosed with type 2 diabetes, hypertension, and hyperlipidemia. Drugs currently prescribed include the following:

  • Glipizide 10 mg po daily

  • HCTZ 25 mg daily

  • Atenolol 25 mg po daily

  • Hydralazine 25 mg qid

  • Simvastatin 80 mg daily

  • Verapamil 180 mg CD daily

To prepare:

  • Review this week’s media presentation on hypertension and hyperlipidemia, as well as Chapters 19 and 20 of the Arcangelo and Peterson text.

  • Select one of the three case studies, as well as one 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.

With these thoughts in mind:

By Day 3

Post an explanation of how the factor you selected might influence the pharmacokinetic and pharmacodynamic processes in the patient from the case study you selected. Then, describe how changes in the processes might impact the patient’s recommended drug therapy. Finally, explain how you might improve the patient’s drug therapy plan

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Pharmacotherapy for Cardiovascular Disorders

Case Study 1:

Patient AO has a history of obesity and has recently gained 9 pounds. The patient has been diagnosed with hypertension and hyperlipidemia. Drugs currently prescribed include the following:

  • Atenolol 12.5 mg daily

  • Doxazosin 8 mg daily

  • Hydralazine 10 mg QID

  • Sertraline 25 mg daily

  • Simvastatin 80 mg daily

Influence of AO’s behavior on pharmacokinetics and pharmacodynamics

One of the important factor to consider in cardiovascular health care is behavior. The Centres for Diseases Control and Prevention (CDC) (2015) identifies at least seven behaviors that increase people’s susceptibility to cardiovascular disorders. These include poor dieting, low physical activity, unchecked weight gain, consumption of alcohol and tobacco usage. Of these factors, this post examines poor diet and low physical activity as a combination of behaviors that influence the pharmacokinetics and pharmacodynamics processes for patient AO.

At least a third of Americans suffer from high blood pressure. Hypertension is a condition in which an individual experiences a continuous rise in blood pressure over time (Arcangelo, Peterson, Wilbur & Reinhold, 2017). On the other hand, hyperlipidemia refers to the increase in blood cholesterol. Both high blood pressure and elevation of blood cholesterol contribute to obesity. According to CDC (2015), foods with high amounts of fat and cholesterol expose one to heart diseases. Similarly, low or zero physical activity leads to high accumulation of fats and cholesterol in the body leading to obesity and related heart diseases.

In a study, Dong, Peng, Liu, Qian, Li, and Wu (2016) report that severe weight gain does alter the pharmacodynamics and pharmacokinetic processes. First, obese patients have a large deposit of adipose tissue that can conceal veins needed for IV cannulation. Therefore, intravenous administration of drugs becomes difficult for such patients. Moreover, low blood circulation at the subcutaneous level may impede absorption of drugs. Poor circulation also affects the concentration levels of chemical elements in the blood. Concentration is necessary to support the osmotic movement of drug agents into the blood. Lastly, due to low activity, poor blood circulation may slow down or thwart the transportation of drugs from the point of absorption to the point where the pharmacodynamics process begins.

Impact of changes in recommended drug therapy

The changes in the pharmacodynamics and the pharmacokinetic processes will render the drug therapy ineffective in treating hypertension and hyperlipidemia. Sankaralingam, Kim, and Padwal (2015) argue that the normal prescribing strategies of using fixed or weight-based dosing may not work for obese patients. The reason is that these dosing methods may yield minimal or no clinical effect on the therapy plan for the patient. Two possible explanations for this result are the slow rate of absorption and low volume of absorption of the drugs. Slow absorption renders the drug weak in attacking the agents of illness, in this case,  hypertension and hyperlipidemia. Low volume absorption means that the amount of the drugs that reach the point of action is insufficient to support the pharmacodynamics process. In extreme cases, weight-based dosing can result in toxicity due to drug overdose (Sankaralingam et al., 2015). This can result from an increase in the mg/kg ratio.

An effective drug therapy plan for patient AO

Prescription of different drugs usually depends on a variety of patient factors. Sankaralingam et al. (2015) call for more research into drug-specific pharmacological changes due to obesity and related factors. For a patient who is overweight, the dosage of weight-based medications may necessitate a review of the norm. The reason is that normal milligram-per-kilogram dosage may lead to either overdosing or under-dosing of such patients. In the case of patient AO, I would recommend a therapy plan that is empirical and patient-specific. In other words, the dosage quantities of each drug will be a factor of both weight and a thorough examination of how the patient’s weight influences the alterations of his hypertension and hyperlipidemia. 

 

 

References

Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds) (2017). Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.

Centers for Diseases Control and Prevention (CDC) (2015). Heart Disease Behaviour. Retrieved February 26, 2018, from https://www.cdc.gov/heartdisease/behavior.htm

Dong, D., Peng, X., Liu, J., Qian, H., Li, J., & Wu, B. (2016). Morbid Obesity Alters Both Pharmacokinetics and Pharmacodynamics of Propofol: Dosing Recommendation for Anesthesia Induction. Drug Metabolism and Disposition, 44, 1579-1583.

Sankaralingam, S., Kim, R. B., & Padwal, R. S. (2015). The impact of obesity on the pharmacology of medications used for cardiovascular risk factor control. Can J Cardiol., 31(2), 167-76.

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