Symptoms and Major Cases in Pharmacology - Essay Example

CASE Mary is a 61-year-old waitress who has worked in environment with heavy smoking for 25 years, she complained of asthma like symptoms and wasadvised to limit her exposure to secondhand smoke. She altered her schedule to a quieter shift in order to limit her exposure. For a period of six months she believed her condition was manageable. She also noticed swelling around her ankles, but attributed it to the demands of being on her feet all day. After migrating to Britain her shortness of breath began to intensify. The condition worsened until she was hospitalized. At this point, Mary was prescribed the corticosteroid known commercially as Advair. Initially, she was compliant with the recommended dose of two inhalations daily, but later began to forget. In her most recent clinic visit, this practitioner has diagnosed Mary with bacterial pneumonia following chest x-ray and isolated cultures from sputum samples. Cough was initially dry, but grew productive over the course of 24 hours. Spirometry was performed in which she achieved a forced expiratory volume of 62%. The chest x-ray revealed a flattened diaphragm, following this observation Mary was diagnosed with COPD. To treat her infection, she was given amoxicillin. CASE #2 Joseph (4 years old) was brought in by his parents with a high temperature and productive cough. He had no past medical history or allergies and took no prescription or over-the-counter medications. This was a comparatively difficult assessment based upon the prior experience of the practitioner considering that the questions were more directed at the parents than at the child, a frequent necessity of pediatric medicine. But the same overall structure familiar to the practitioner was maintained. As advised by Dorp (2008) the GP used simple language to communicate with the child to provide reassurance. Before asking questions she played with the child to try and gain trust. It is also advised to have a child friendly atmosphere during these assessments (Dorp 2008); but a dedicated area designed to be child friendly is not feasible at present. Following the consultation and examination, a chest infection was detected, and Paracetamol and Amoxicillin were prescribed. Literature Review COPD is not contingent upon a single organic condition; impaired airflow into the lungs with subsequent breathing difficulty can result from a selection of pathologies, including chest infections. It is often tested through spirometry (Celli, 2000; CDC, 2011). This condition is a risk for both men and women, and the rates of death can fluctuate dramatically. Some data exists suggesting that death rates are higher among Caucasians compared with people of African descent, or other races (Brehm & Celedon, 2007; Lederer et al. 2007; Siu et al. 2009). A thorough assessment of the most probable treatment options with respect to the case studies in question will depend upon the potential side effects of amoxicillin; which is part of a class of drugs that prevents correct formation of the bacterial cell wall (Chui-Lin et al. 2007; Drugs.com, 2014; Pinho, et al. 2001). ABSORPTION. An essential issue for nurses is the significance of pharmacodynamics of whatever the patient is taking. This includes Over The Counter (OTC) drugs as the most common type of drug interaction due to the absorption occuring in the gastro intestinal tract. Some drugs, (such as antacids) may reduce the absorption of common antibiotics, leading to a sub therapeutic dose (Courtenay and Griffiths, 2004). DISTRIBUTION. Conditions which effect fluid levels, odema, pleural effusion, ascites and dehydration will effect the volume of Amoxicillin due to its water solubility and distribution into bodily fluids (Caldwell p35). The prescribing professional may have to increase the dose or find an alternative route of administration with patients where fluid volume increases. Reverse may apply in patients whose volume has decreased. The rate and extent to which organs and tissues are perfused with blood will influence drug distribution (Courtenay and Griffiths 2005). Weight should be documented in the medical notes. COPD patients are often of very low weight so should require lower doses of Amoxicillin. The prescriber must be alert that the NICE guidelines are provisional and suggest 500mg without reflecting weight. The half-life of Amoxicillin is around 1-1.5 hours so the need for frequent dosing. And peak blood levels are one to two hours after administration. METABOLISM. One of the remarkable features of Amoxicillin is its comparative lack of toxicity. The prescriber needs to be aware that due to Amoxicillin being mainly water soluble and not needing as much metabolising by the liver as other drugs is a useful antibiotic to be used with patients taking multiple medications and co morbidities including liver disease. Conditions that alter the blood flow or change the extent of hepatic oxygenation may also influence the metabolic process. However patients with acute or chronic respiratory illness or those with severe cardiac failure not metabolise drugs efficiently. EXCRETION. As patients age their renal function an drug metabolism declines.Creatinine/Clearance 10-30ml/min max dosage Amoxicillin 500 micrograms twice daily; but this amount decreases with age. This is an important factor for precribers when addressing drug regimes. In patients with impaired renal function the excretion of Amoxicillin will be delayed. Depending on the degree of impairment it will be necessary to reduce the daily dosage by 10ml/min. The max dosage for Amoxicillin being 500mg/day (BNF 2013). Factors affecting clearance and dose requirements are age, renal disease, hepatic disease and drug interactions. Amoxicillin is an aminopenicillin that inhibits the synthesis of the bacterial cell wall. SIDE EFFECTS Nausea / vomiting Diarrhoea Skin rashes Rarely colitis Prior to amoxicillin, Mary has been prescribed the corticosteroid Advair to alleviate COPD symptoms some of these symptoms through the suppression of the natural inflammation response as a result of irritation of lung tissues. Active COPD is a condition requiring continuous management in order to prevent a worsening of these symptoms (GICOPD, 2007). The chest x-ray provided confirmation of the earlier diagnosis. In Josephs case an infection was diagnosed, due to positive cultures; as indicated by the productive cough. He required oral Paracetamol 240mg max QDS and Amoxicillin 125mg TDS. The GP prescribed suspension including oral syringes to aid administration (NPC, 2000). The parents were advised concerning the dose and duration of the medication and to keep it out of the childs reach. Side effects were explained and additional measures were described in the event that the child did not improve or symptoms worsened. Amoxicillin is indicated in the BNF for Children (BNFc) (2013) and licensed for infections and Paracetamol for pyrexia and pain. The BNFc advises oral Amoxicillin for children 1�5 years, 125 mg every 8 hours and oral Paracetamol for children 4�6 years 240 mg every 4�6 hours (max. 4 doses in 24 hours), however best practice would have been to use the childs weight to determine the dosage (Drug facts & Comparisons, 2001; King et al. 2000; RCN, 2010). The product literature for Amoxicillin states that the daily dosage for children is 40 - 90 mg/kg/day in two to three divided doses (not exceeding 3 g/day) depending on the indication, the severity of the disease and the susceptibility of the pathogen. Children weighing more than 40 kg should be given the usual adult dosage. Calculation by body-weight in an overweight child may result in much higher doses being administered than necessary; in such cases, the dose should be calculated from an ideal weight for height (BNFc, 2013). Product literature for Paracetamol advises doses for children based on age and the BNFc advises Paracetamol and Amoxicillin doses based on age, not weight, to reduce inconsistencies in prescribing. (Peacock et al. 2011). Generally, detectable serum levels are retained for eight hours following an oral dose of amoxicillin (Rxlist.com, 2014). In the case of Mary, it has been stated that she took the corticosteroid Advair at the recommended dosage of twice daily (Drugs.com, 2014), to reduce reactivity of the airways to allergens (Brown et al 2010; Janson, 2013). But she later grew complacent, until the rate at which she used her inhaler became erratic. For the second case study, the parents must be recruited for the sake of compliance, but there are still questions regarding the dosage. Although not in this case, many medications prescribed for children are actually not licensed for use in children. Licensed medications that are prescribed outside of their license are termed off-label prescribing as pharmaceutical companies do not typically conduct tests on children. Once qualified the practitioner will be able to prescribe off-label and/or for children as long as it is in her scope of competence (NMC 2006, Practice Standard 18). When prescribing licensed drugs for unlicensed indications: �Advice the child and/or caregivers of these realities and gain consent for the drugs use. �Explain that in these circumstances the patient information leaflet (PiL) will not have information about the use of the drug. �Record in the patients notes the above and reasons for prescribing outside the licensed indications for the drug. Will (Dorp 2008). NMC Practice Standard 17 was updated in 2009 and now allows a NISP to prescribed unlicenced medications on the same basis as Doctors, dentists and supplementary prescribers. The Medicines and Healthcare products Regulatory Agency (MHRA) operates a system of licensing to confirm quality standards (NPC, 2000). Presently, the most vital medical issue is the bacterial pneumonia experienced by Mary. An incomplete dose of any antibiotic will fail to kill the potential pathogens in question, while creating an environment where the organisms can replicate at a slow rate until a resistant strain appears which will then be favored over other organisms by virtue of the persistent levels of antibiotics in their environment. The patients (and their caregivers) must be made to understand the necessity of completing the full course of antibiotics. Mary may require additional attention or reminders. A day planner for Mary is recommended which will remind her when precisely to take amoxicillin; the safest course of action being to wipe out the pathogens as expediently as possible to prevent the conditions favoring antibiotic resistance, dangerous for Mary herself and those around her. Subsequent characteriztion of Marys infection identify the pathogen as pneumococcal pneumonia as a result of cultures conducted on sputum samples resulting from regular productive coughing. As a consequence, a reasonable prescription of amoxicillin would be 450 mg taken orally three times a day. This is on the high end of the recommended dosage, as a result of Marys comparatively advanced age. It is assumed that her immune response will have lessened, so it is a logical prescription. Determining these risk factors is essential to any medical practice attempting to manage this illness (Borja & Rigau, 2004; ISCAP study group, 2004). Ultimately, it is necessary to work through the available options as part of developing an understanding of the influences that must govern prescription management. Treatment should be given with consideration of long term health. Proactive measures in this case are necessary in the interest of preventing the worsening of COPD, as a result of chest infections (Casaburi et al. 2002), and subsequent complications (Trayner & Celli, 2001; Tashkin et al. 2001). This reflection on a witnessed consultation with Joseph has made the practitioner aware of many issues surrounding prescribing for children including consultation methods, calculating medication doses, medication licenses and off label prescribing. It has also highlighted to the practitioner the potential for inconsistencies in prescribing doses for children based on age or weight. At the time of writing the practitioner has highlighted this to the pharmacy lead and medical mentor in the area and has requested guidance for all prescribers concerning this discrepancy. At this point in the practitioners career, even on completion of the NISP, the practitioner would not feel it was in her scope of practice to prescribe for children. But the possibility remains that it will be necessary to expand our knowledge concerning pediatric patients in the future. This casework will provide valuable experience in this eventuality. For Mary, another therapeutic option is therapy to improve her exercise tolerance )ODonnell et al. 2001; Mayo, 2009). Visitations Upon returning for a refill of her prescription, Mary demonstrated improvement. She has taken a new position in a London Hotel restaurant compliant with smoking laws, and more reasonable hours. She has devised a pneumonic device whereby she is reminded to take both amoxicillin and Advair when she arrives, and leaves work. The acute symptoms of her infection show indication of remission. But it is unlikely that her COPD will improve without pulmonary rehabilitation; both at work and at home Mary explains a system she has devised where she can access her most commonly needed items with an absolute minimum walking distance, in order to avert fatigue. Josephs acute symptoms persisted for over a week. Joseph is compliant with the drug treatment, and has expressed an interest in recovery in order to play sports. 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