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Evaluation of Drug Treatment Plan for Mark Johnson: Nursing Paper
Case studies are a useful way for you to apply your knowledge of pharmacokinetics and pharmacodynamic aspects of pharmacology to specific patient cases and health histories. Eevaluate drug treatment plans for patients with various disorders and justify drug therapy plans based on patient history and diagnosis. To Prepare:
Review the case studies and answer ALL questions.
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.
Use clinical practice guidelines in developing your answers. Please review all Required Learning Resources. Use the Medscape app or website and JNC 8 to complete assignment.
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. SCENARIO 1 Mark Johnson is a 72 year old male recently prescribed warfarin 5 mg daily for DVT treatment. His PMH includes hypertension, hyperlipidemia and osteoarthritis. He is currently on HCTZ 25 mg po daily, celecoxib 200 mg po daily, fluvastatin 40 mg po daily, and Goody's Powder 1 packet as needed for pain. He has no known allergies. What changes in his medications would you make? What alternatives might you prescribe (include complete medication orders)? How would a CYP2C9 polymorphism affect drug therapy? How would you monitor therapy?
Evaluation of Drug Treatment Plan for Mark Johnson
Medication Changes and Rationale:
Given Mark Johnson's current medication regimen and health history, the following changes and recommendations are warranted:
1. Warfarin: Continue at 5 mg daily. However, close monitoring of INR (International Normalized Ratio) is essential due to the risk of bleeding, especially considering his age and potential interactions with other medications.
2. Hydrochlorothiazide (HCTZ): Continue at 25 mg daily for hypertension management.
3. Celecoxib: Continue at 200 mg daily for osteoarthritis pain management, but consider switching to a non-NSAID analgesic if there are concerns about bleeding risk associated with warfarin. An alternative could be Acetaminophen (Tylenol) 500 mg orally every 6 hours as needed for pain, with a maximum of 3000 mg per day.
4. Fluvastatin: Continue at 40 mg daily to manage hyperlipidemia, which is critical in reducing cardiovascular risk.
5. Goody's Powder: Discontinue due to increased bleeding risk when combined with warfarin. Recommend Acetaminophen as mentioned above.
Complete Medication Orders
1. Warfarin
- Drug: Warfarin
- Dose: 5 mg
- Route: Oral
- Frequency: Once daily
- Special Instructions: Monitor INR weekly until stable, then monthly; advise patient to report any signs of bleeding.
- # Dispensed: 30 days supply
- Refills: 2
2. Hydrochlorothiazide (HCTZ)
- Drug: Hydrochlorothiazide
- Dose: 25 mg
- Route: Oral
- Frequency: Once daily
- Special Instructions: Monitor blood pressure regularly.
- # Dispensed: 30 days supply
- Refills: 3
3. Celecoxib
- Drug: Celecoxib
- Dose: 200 mg
- Route: Oral
- Frequency: Once daily
- Special Instructions: Monitor for gastrointestinal symptoms or signs of bleeding; consider alternative analgesia if needed.
- # Dispensed: 30 days supply
- Refills: 3
4. Acetaminophen
- Drug: Acetaminophen (Tylenol)
- Dose: 500 mg
- Route: Oral
- Frequency: Every 6 hours as needed
- Special Instructions: Do not exceed 3000 mg in 24 hours.
- # Dispensed: 30 days supply
- Refills: PRN
5. Fluvastatin
- Drug: Fluvastatin
- Dose: 40 mg
- Route: Oral
- Frequency: Once daily
- Special Instructions: Monitor lipid levels every 3 months.
- # Dispensed: 30 days supply
- Refills: 3
CYP2C9 Polymorphism Considerations
CYP2C9 polymorphisms can significantly affect warfarin metabolism, leading to variations in drug efficacy and safety. Patients with certain polymorphisms may require a lower dose of warfarin due to decreased metabolic clearance, increasing the risk of bleeding if standard dosing is used. It is crucial to genotype patients for CYP2C9 variations where available and adjust dosages accordingly based on INR monitoring.
Monitoring Therapy
1. INR Monitoring: Regularly monitor INR levels to ensure they remain within the therapeutic range (typically between 2.0 and 3.0 for DVT treatment). Adjust warfarin dosage based on INR results.
2. Blood Pressure Monitoring: Regularly check blood pressure to ensure hypertension management remains effective.
3. Lipid Levels Monitoring: Monitor lipid levels periodically due to fluvastatin therapy.
4. Assess for Signs of Bleeding or Adverse Effects: Educate the patient on signs of bleeding (e.g., unusual bruising, blood in urine/stool) and gastrointestinal symptoms from NSAIDs or other medications.
References
1. Dwyer, K., & O'Connor, A. (2020). Pharmacogenomics and Warfarin Therapy. Clinical Pharmacology & Therapeutics, 107(3), 680-690.
2. Johnson, M., & McCarthy, K. (2021). Management of Anticoagulation Therapy in Older Patients. Journal of the American Geriatrics Society, 69(4), 1028-1036.
3. American College of Cardiology/American Heart Association Task Force on Practice Guidelines. (2014). AHA/ACC Guideline for the Management of Patients with Atrial Fibrillation. Circulation, 130(23), e199-e267.