Respond in one or more of the following ways:
1))Provide alternative recommendations for drug treatments.
2))Offer and support an alternative perspective using readings from your own research
3))Validate an idea with your own experience and additional research.
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
Mr. CB is at increased risk of cardiovascular disease (CVD) due to his multiple risk factors, and he has vascular disease already due to his history of strokes. The patient is currently being treated for his hyperlipidemia, hypertension, and diabetes with medications. Several factors can influence the pharmacokinetics and pharmacodynamics of drug effectiveness.
Ethnicity is a factor in cardiovascular disease. If patient CB is African-American, there are factors in their ethnic background that may predispose certain diagnosis and render certain medications ineffective. “African-Americans have physiologic characteristics that contribute to this risk, including low circulating rennin levels with excessive levels of angiotensin II; endothelial dysfunction as a results of reduced bradykinin and nitric oxide; abnormal sympathetic nervous system activation; and higher levels of intracellular calcium stores” (Arcangelo,& Peterson, 2013, p.244). With these physiological considerations, medication therapy should be targeted at achieving controlled blood pressure while preserving kidney function. “Thiazide diuretics are recommended as initial monotherapy and in combination therapy for African Americans. Calcium Channel Blockers (CCBs) are recommended as an acceptable alternative to thiazide diuretics. CCBs are preferred over ACEIs because of the increased risk of stroke, myocardial infarctions, and other vascular conditions associated with ACEIs” (Sessoms, Reid, Williams, & Hinton, 2015, p. 7). ACE should be avoided in African American as the effect might not be as beneficial as other therapies; however as Mr. CB has diabetes an ACE inhibitor would be preferred over other therapies.“Patients with CVD and diabetes have abnormal indices of angiogenesis and endothelial damage irrespective of ethnicity. The former, as angiopoetin-2, are restored by treatment with high-dose atorvastatin irrespective of ethnicity or diabetic status, and so seems unlikely to have a role in the increased risk of CVD in South Asians. However, this improvement was blunted in the diabetics regardless of ethnicity” (Jaumdally, Lip, Varma, & Blann, 2011, p. 576). Although, ethnicity is a factor in medication treatment, the provider must realize that controlling diabetes and hyperlipidemia is essential to preventing worsening of CVD.
Improvement of Drug Therapy
Mr. CB has multiple risk factors and the first medication to add would be Aspirin 81mg daily. Aspirin is a general help in prevent of CVD and Strokes especially with those with diabetes. “Although the benefit of aspirin treatment is clear in secondary CVD prevention, the evidence in primary prevention remains unclarified” (Nansseu, & Noubiap, 2015, p. 8). Research agrees that aspirin should be used in conjunction with other medications to prevent CVD. Another change in therapy would be to stop simvastatin and verapamil and start atorvastatin and amlodipne. “Similarly, atorvastatin combined with amlodipine improved insulin sensitivity in studies in 42 patients with hypertension in a randomized, single-blind, placebo-controlled, crossover trial in patients with hypertension. Insulin sensitivity was increased relative to baseline by 3% with combination therapy and 4 % with amlodipine, but decreased by 2%with atorvastatin alone; these increases were significantly greater than those observed with atorvastatin alone” (Curan, 2010, p. 195). Simvastatin and Verapamil also have an interaction of possible liver damage and muscle breakdown and should not be used together. Hydrochlorothiazide is a great medication for BP therapy; however it does potentiate hyperglycemia and could be stopped. Atenolol would need to be stopped due to the relationship between some beta-blockers with hyperglycemia and increased lipid levels. Instead Coreg could be used instead as it is neutral and also one of the better beta-blockers in relation to blood pressure control. “Carvedilol (coreg) is a nonselective-blocker whose vasodilating activity has been attributed to adrenergic receptor blockade. A number of recent studies have reported that carvedilol exerts neutral effects on glucose and lipid metabolism” (Deedwania, 2011, p.54). an ACE inhibitor could also be used instead of a beta-blocker as the patient has no history of rhythm disturbance and an ACE would be preferred for blood pressure therapy with diabetics. The hydralazine would be stopped, it is a four times a day medication and patient is at risk of poly-pharmacy and noncompliance. Blood pressure should be monitored for possible need to add medication therapy. Although this is an overhaul of the medications for Mr. CB, the most effective medications that work together should be used as he has multiple risk factors, strokes, and risk of a cardiovascular event.
Arcangelo, V. P., & Peterson, A. M. (Eds.). (2013). Pharmacotherapeutics for advanced practice: A practical approach (3rd ed.). Ambler, PA: Lippincott Williams & Wilkins.
Curran, M. (2010). Amlodipine/atorvastatin: a review of its use in the treatment of hypertension and dyslipidaemia and the prevention of cardiovascular disease. Drugs, 70(2), 191-213 23p. doi:10.2165/11204420-000000000-00000
Deedwania, P. (2011). Hypertension, Dyslipidemia, and Insulin Resistance in Patients With Diabetes Mellitus or the Cardiometabolic Syndrome: Benefits of Vasodilating [beta]-Blockers. Journal Of Clinical Hypertension, 13(1), 52-59 8p. doi:10.1111/j.1751-7176.2010.00386.x
Sessoms J, Reid, K,Williams, I, & Hinton, I (2015) Provider Adherence to National Guidelines for Managing Hypertension in African Americans. International Journal of Hypertension, 1-7 7p. doi:10.1155/2015/498074
Jaumdally, R. J., Lip, G. H., Varma, C., & Blann, A. D. (2011). Impact of High-Dose Atorvastatin on Endothelial, Platelet, and Angiogenic Indices: Effect of Ethnicity, Cardiovascular Disease, and Diabetes. Angiology, 62(7), 571-578 8p. doi:10.1177/0003319711401904
Nansseu, R. N, & Noubiap, N.N, (2015) Aspirin for primary prevention of cardiovascular disease. Thrombosis Journal, 131-10 10p. doi:10.1186/s12959-015-0068-7
Hypertension is a devastating disease process known as the silent killer because it usually progresses undetected until an adverse event occurs including myocardial infarction, heart failure, or stroke (Arcangelo & Peterson, 2013). “Hypertension in African Americans is a major clinical and public health problem because of the high prevalence and premature onset of elevated blood pressure, as well as the high burden of co-morbid factors that lead to pharmacological treatment resistance” (Flack, Nassar, & Levy, 2011, p. 84). These comorbid factors include obesity, hyperlipidemia, diabetes mellitus, depressed glomerular filtration rate, and albuminuria. Even more specific, blood pressure control rates are lower in African Americans men, than in other major race/ethnicity-sex groups.
Case Study One
Case study one consist of a patient with a history of obesity and has recently gained nine pounds. The patient has been diagnosed with hypertension and hyperlipidemia. Drugs currently prescribed include the following: Atenolol twelve point five mg daily, Doxazosin eight mg daily, Hydralazine ten mg qid, Sertraline twenty five mg daily, and Simvastatin eighty mg daily. In regard to ethnicity, pharmokinetics, and pharmodynamics, there are factors to be considered when prescribing treatment. We will review case study one assuming that the patient is African American.
The patient has a history of obesity and recent weight gain. First line defense for this patient should be lifestyle modification of diet and exercise. Next a first line pharmaceutical choice would be a thiazide, or thiazide-like medication. The choices could be chlorthalidone twelve point five mg to one hundred mg qd, or hydrochlorothiazide twelve point five to twenty five mg (Drugs.com, 2012). The prescribed choice of Atenolol is sufficient because African Americans respond safer beta-blockers than ACE inhibitors. ACE inhibitors also may cause angioedema, occurring more frequently in African Americans (Arcangelo & Peterson, 2013). According to Drugs.com, the beginning dose of Atenolol should be fifty mg, and the patient is prescribed in the case as twelve point five mg daily (Drugs.com, 2012). This should be increased to fifty mg with follow up at one month interval, or as needed. The preferred method of treatment for African American Hypertension is the “combination is a calcium antagonist/angiotensin-converting enzyme inhibitor or, alternatively, in edematous and/or volume overload states, a thiazide diuretic/angiotensin-converting inhibitor” (Flack et al., 2011, p. 92). The drug Doxazosin is not suggested as initial drug of choice for monotherapy, but is accepted in combination treatment, with the dose of eight mg being at a medium dose strength (Drugs.com, 2012). The hydralazine may not be needed with use of diuretics and other antihypertensives.
In regard to the hyperlipidemia, the dose of Simvastatin is a high end dose of eighty mg. Usual dosing starts at five to forty mg, but with the patient being obese and hypertensive, the starting dose should be forty mg, along with exercise and diet (Drugs.com, 2012). Consideration for monitoring will be liver monitoring with liver function test initially six weeks after starting, then every six months. Lastly, Sertraline is an antidepressant in a group of drugs called selective serotonin reuptake inhibitors. The dose range is suggested at fifty to one hundred mg qd. The patient is prescribed twenty five mg, which is warranted because of possible liver injury in relation to the Simvastatin (Drugs.com, 2012). If the liver function testing remains within normal limits, the dose of anti-depressant may be increased to promote improved quality of life through becoming more active, and exercise.
In concluding, it is always important to never forget the basics, and most logical treatment protocol before starting medications. Hard work in exercise and diet modification can go along ways in correcting hypertension and hyperlipidemia. However, if medications are needed, we must also remember patient factors such as age, ethnicity and gender when prescribing for the safest, most productive treatment possible.
Arcangelo, V. P., & Peterson, A. M. (2013). Pharmacotherapeutics for advanced practice: A practical approach (3rd ed.). Ambler, PA: Lippincott Williams & Wilkins.
Drugs.com. (2012). Retrieved from http://www.drugs.com/
Flack, J., Nassar, S., & Levy, P. (2011). Therapy of hypertension in African Americans. American Journal of Cardiovascular Drugs, 11(2), 83-92.