Drug-Drug Interaction: the Relevance of Application of Orlistat - Essay Example

Case study reflection 2 pages per case 8 total By Drug-drug interaction The diagnosis of diabetes often causes the interaction of diabetic drugs with other drugs prescribed for other diseases that exists concurrently in the body of the patients. In this case study, the tests were channeled towards the relevance of application of orlistat in the metformin-associated Lactic Acidosis interaction. Lactic acidosis is a rare but, a grave complication involving metformin treatment with a high death rate. In most reported cases, a preexisting disease must have existed, especially some signs of renal impairment. The case presents a study of metformin-associated lactic acidosis-MALA, in which the interactions of drug that is, orlistat in the long run and cimetidine in the short run, may have triggered the woman’s condition (British Medical Association, 1988, pp56-87). The case involves a 59-year-old woman having had diabetes type 2 for 14 years, presented a history of 3 months of unclear abdominal pain and 4-5 daily loose movements of bowel. Her condition had worsened for over 4 days before her admission to the hospital. On the admission day, she exhibited signs of weakness, dizziness, and blurred vision. In addition, her husband had observed inaudible speech and an abridged level of consciousness (Ehrman, 2009, pp234-345). When the diagnosis of metformin-associated lactic acidosis with cardiovascular collapse and acute prerenal renal failure was made, it was discovered that she needed She required a vigorous rehydration, infusion of sodium bicarbonate, support of inotropic, and the therapy of renal replacement. Empirically, all cultures of blood, urine, and feces were sterile. Three years later she was dialysis independent and the stability of became real having a creatinine of 250 μmol/l. The study aims at answering the question of what initiates MALA in patients who previously had normal renal functions. Though the approach of handling this condition is unknown, the available options have been supportive and usually focus stopping the drug, correcting the acidosis and treating the coexisting conditions which in most instances are renal impairment. The therapy of renal impairment eliminates lactate and metformin from the blood. Metformin is absorbed comparatively rapidly in the intestines, and is not metabolized. And 90% of the drug is removed through glomerular filtration and secretions in the tubules. It has a half-life of 1.5-5 hours (Dong, 2006, pp34-45). When compared with phenformin, it yields a negligible increase in producing lactate, which seems to be past the extra hepatic splanchnic bed, with animal studies favoring the small intestine as the site of origin. There are few drugs which interact with metformin, with the relevant interaction being its competitive inhibition for renal tubular secretion by cimetidine, resulting in reduction of metformin renal clearance (Tyrrell, & Carter, 2008, pp34-54). Most MALA cases occur in conditions of impaired renal function when plasma levels of metformin are anticipated. Although most studies relate the level of metformin to the degree of acidosis and to the outcome; the current work suggests that it is not necessarily the case. Most frequently, the common adverse effect of orlistat therapy is gastrointestinal upset. Orlistat helps in realizing weight loss, and better glycemic control in diabetic patients and lower levels of cholesterol, and systolic blood pressure in both diabetic and non-diabetic patients (Tan, & See, 2011, pp234-241). In conclusion, the mixture of metformin and orlistat should be monitored closely, especially when the patient is also taking cimetidine. 2. Drug prescribing in renal function A BNF case study mainly involves a man with management of the steady chronic kidney disease, hypertension and obesity. A 61 year old Caucasian man is mainly reviewed for the administration of steady chronic kidney disease, hypertension and obesity. He has never smoked and he does not depict diabetes or corresponding important proteinuria. His blood pressure is 145/95mmHg which was 165/102mmHg six months ago, serum potassium of 4.4mmol/litre, serum creatinine was 260micromol/litre, eGFR was 23mL/minute/1.73m2 and height 175cm. his medications mainly encompass lisinopril 20mg daily, bendroflumethiazide 2.5mg daily and simvastatin 40mg daily (Angell, 2005, pp87-89). The mass of body according to the BNF online calculator to the body mass index is 32kg/m2. Prescribing in the Renal impairment within the BNF states that numerous drugs, information on dosage modifications for the renal impairment in the BNF that is mainly expressed in the form of the eGFR (Haber, 2010, pp123-134). Nevertheless, within this patient with the body mass index greater than underlying 30kg/m2 either the absolute glomerular filtration rate or the corresponding creatinine clearance, which is computed from the Cockcroft and Gault that ought to be utilized in the place of the prevailing eGFR in order to adjust drug doses. For hypothetically toxic with a small safety margin, the creatinine clearance ought to utilized in the adjustment of the drugs doses coupled with the plasma drug concentration and corresponding clinical response. The man is overweight in regard to his height and real body weight will mainly overestimate his underlying creatinine clearance. Moreover, his ideal body weight can solely be computation. In regard to the BNF online calculator for the creatinine clearance and the value is utilized in adjusting drug doses. Prescribing notes on the Hypertension recommend optimal blood pressure mainly target the patients with renal impairment is a systolic blood pressure and a diastole of 130/80mmHg respectively. BNF ought to be avoided in case the eGFR is less than the corresponding 30mL/minute /1.73m2 since it is ineffective (Irwin & Rippe, 2008, pp234-278). This patient’s GFR, which is absolute and corresponding creatinine clearance that is less than 30mL/minute thus making the BNF, ought to be ceased. In regard to the monograph for the lisinopril the underlying dose of the lisinopril is titrated to the maximum of 40mg daily in case the eGFR is between 10 and 30mL/minute /1.73m2. The underlying GFR and corresponding creatinine clearance is amidst 10 and 30mL/minute the underlying dose of the lisinopril can mainly be titrated to the maximum of 40mg daily. Nevertheless, the patients who are over 55 years of age might respond less to the corresponding treatment with the ACE inhibitor. The prescribing notes on the ACE inhibitors advice that the renal function and corresponding electrolytes ought to be monitored during the treatment with the lisinopril, hyperkaleamia and other supplementary side impacts are common with the impaired renal function and might limit the dose of the lisinopril that is utilized. Even though ACE inhibitors rarely exacerbate renal impairment especially in patients with the renovascular disease thus the patient possess no features of the renovascular disease. Uremia affects all organ system and corresponding entire aspect of the drug disposition by the body. Kidney is the main regulator of the internal fluid environment thus the physiologic alteration is related with the renal disease has vast impacts on the pharmacology of numerous drugs. Even though blood urea nitrogen (BUN) and serum creatinine levels can be utilized in the markers of the renal function, it is normally prone perturbations that occur with aging. BUN reflects the concentration of urea in the blood. Urea mainly emanates from ingested protein and the malnourished older patient might not consume adequate nitrogen in order to produce suitable in BUN (Nolte, & Mckee, 2008, 84-97). Serum creatinine is mainly produced by the muscle and in case the patient has a markedly diminished muscle mass that may be due to the chronic illness then adequate creatinine then it reflects an alteration in the capability of the kidney to excrete this substance. Therefore, overdependence on the normal-appearing BUN and creatinine in older patients can severely underestimate the degree of the renal impairment The Cockcroft-Gault formula is normally employed in the approximation of the renal function in older patients who are to be administered to potentially nephrotoxic drugs such as aminoglycosides or the corresponding drug that are primarily excreted by the kidneys such as digoxin (Schrier, 2008, pp234-254). 3. Acute Coronary syndrome and the diabetes patient The evidence base for the efficacy of lipid modifying therapy in prevention of recurrent cardiovascular events in patients with coronary heart disease The case study is of the 53-year old patient that was scheduled for L2-S1 spine revision and new instrumentation. The patient was admitted the day before surgery after being found unconscious on the floor at home. At the hospital admission, the patient was sleepy but arousable imaging of the severe back pain. Magnetic resonance imaging of the spine depicted L3-L4 compression facture with the spinal sterosis. The patient had a history of seizure disorder, postlaminectomy syndrome, diabetes, morbid obesity and drug abuse. After eight hours of the eventful surgery in susceptible position, the trachea was extubated and the underlying patient was transferred to the postnesthesia care unit in steady condition. On the postoperative day 1, the patient reported generalized muscle pain that is chest and back, nausea and vomiting. The patient was hypotensive, tachycardia, dehydrated, oliguric and corresponding dark tea colored urine was noted. The patient’s initial differential diagnosis entailed but was not restricted to the hypovolemia, sepsis, acute coronary syndrome, allergic reaction, acute renal failure, disseminated intravascular coagulation, thromboembolism, diabetic, ketoacidosis and myoglobinuria. The following abnormal laboratory values were found: urea 98mg/dL, creatinine 3.1mg/dL, potassium 6.2 mmol/L and lactic acid 4.1 mmonl/L (normal 30-220U.L), MB isoenyme (Katz, Jekel, Elmore, Wild, & Lucan, 2014, 90-97). The present guidelines focus on LDl- cholesteroal targets and to a lesser extent, HDL-cholesterol and the non HDL-cholesterol in high triglyceride levels. This depict that vascular events decreased when LDL-cholesterol was reduced to less than 1.8mmol/l and CRP to less 2mg.l. Apolipoprotein B as a therapeutic target especially in populace with diabetes such as the patient described above. The evidence is increasing to suggest that this measure of LDL particle number is superior to LDL concentration within its predictive capability (Tyrrell, & Carter, 2008, pp74-91). The measurement of LDL particle through apolipoprotein B levels is especially relevant when is an increase is more atherogenic small, dense rather massive buoyant LDL particles. People with diabetes frequently have typical symptoms related with coronary atherosclerosis such as in this patient or indeed more often have silent ischemia. The presence of diabetes increases both case fatality rates with acute coronary syndromes and subsequent long-term prognosis (Goldsmith, Jayawardene, & Ackland, 2013, pp34-42). The patient was categorized as being at high risk after his nonST elevation myocardial infarction and was treated appropriately with an early invasive strategy with angiography and subsequent stent deployment. Even though he had no other major coronary stenoses at angiography certainly he has diffuse coronary atherosclerosis (Nolte, & Mckee, 2008, pp67-83). On the underlying background of lifestyle therapy he require an aggressive approach to LDL-cholesterol lowering with the statin, with an LDL cholesterol targt suggested by recent trials to be around 1.8mmolL. The pending data from the case study in regard to people with diabetes, a case could made for combined therapy with a statin and micronized fenofibrate, especially in case has features of typical dyslipidemia related with diabetes entailing low HDl-cholesterol and high triglycerides (Upchurch, Lovric, & Hyland, 2012, pp37-45). In conclusion, the recent advancement in prognosis for the patient with Apolipoprotein B has attributed to improved treatment of the Acute Coronary sydrome and the diabetes patient. The potential acute clinical benefit of the LDL – apheresis for patients with acute coronary syndrome might be relating to the procedures impacts rheology. 4. Poly phamacy For the ploy pharmacy case study the patient is a 68 years old woman is known to have Type 2 diabetes, Angina, Heart failure and oesteoarthritis. She recently lost her husband and was prescribed Amtriptyline 25mg because she felt depressed. She came to see her general practitioner complaining of difficult walking even to her neighbours house and not sleeping well. She takes the following drugs since 2009 Novomix 30 15 units BD, Frusemide 80mg BD, Nifedipine 10mgBD, Enallapril 5mg OD, Amiodarone 100mg OD, Isosorbide dinitrate 10mg bd, Amitriptyline 25mg nocte, Nifedipine slow release 10mg bd and Piroxicam 20mg OD. Her worsening shortness of breath and cardiac arrhythmia as evidence of an adverse drug event and was mainly attributed by the use of piroxicam and amitriptyline thus demanding medication review. Medications that ought to be reviewed are amitriptyline, piroxicam, nifedipine and isosorbide dinitrate. Dosage and frequency alterations in regard to the medication regimen are highly recommended. Insufficient doses to enalapril and isosorbide dinitrate was realized in her treatment. Identification of the concordance and compliance problems calls for further biochemistry and cardiac investigations. Administering of new medication for her that include paracetamol, a beta-blocker, low dose aspirin and spironolactone and the most common medication substitutions were mainly paracetamol for piroxicam, a selective serotonin reuptake inhibitor (SSRI) for amitriptyline and isosorbide mononitrate for isosorbide dinitrate. The patient is not doing well despite the fact that she is trying to live independently and in the control of her own life, circumstance appear to be conspiring against her. She is breathless, unable to walk far distance, feels pain and thus feels down and is not sleeping well at night. She is already taking seven diverse types of medicines and the underlying clues within this vignette point to the symptoms of the heart failure and diabetes that appear to be inadequately controlled. Besides her breathlessness, her exertional tolerance is extremely poor. Her insomnia at night may also be because of the orthopnoea and paroxysmal nocturnal dyspnea. This is may be due to the noctulia that occur due to her large dose of the loop diuretic. The patient is in pain and her current fracture depicts that she may have a degree of osteoporosis and osteoarthritis. There are myriad of plethora of drug thus depicting drug-response interaction amidst piroxicam, diabetes and heart failure. The patient symptoms are mainly associated to inadequately managed heart failure, inadequate dose of enalapril (Beckwith, & Franklin, 2007, pp93-109). She is on extremely large dose of diuretic frusemide 80mg twice daily, which appears to have been increased in response to her symptoms (Taylor, Paton, & Kapur, 2012, pp77-87). Nevertheless, there is ought to be application of maximally tolerated dose of ACE inhibitor and to utilize of a lower dose of loop diuretic. High doses frequently add morbidity in regard to precipitating polyuria, nocturia, urge incontinence, causing volume depletion. The role of the nifedipine is fascinating is presumed by prescribing the relief of angina. Interaction of the nidedipine and amiodarone mainly cause bradycardia. Nifedipine is a calcium channel blocker of the dihydropyridine type (Barker, Zieve, Fiebach, & Burton, 2007, pp237-247). The case history that the patient’s mood is depressed even though there is underlying little detail. She is not sleeping well at night and might be surmising that amitriptyline that was prescribed to treat presumed depression. The depression might actually be an adverse effect of piroxicam, a predictable class effect albeit uncommon. Some of the depression is mainly associated with amiodarone utilization. It is preferable to utilze piroxicam and other corresponding nonsteroidal anti-inflammatory drug for the treatment of acute symptoms at the expense chronic therapy (Wakelin, & Maibach, 2004, pp56-64). The independence might to threaten by her progressive symptoms and it is critical in the establishment whether drug induced side impacts that could be contributing to the underlying problems (Goldsmith, Jayawardene, & Ackland, 2013, pp237-241). Moreover, it is probably optimizing her regimen in order avoid drug associated problems might advance her quality of life and assist in maintaining independence. 5. Prescribing in children Case Study: Prenatal prescription corticosteroids and offspring diabetes Diabetes is increasingly becoming a challenge among the children in the world in entirety. The study investigates the role of Prenatal Prescription Corticosteroids in the development of diabetes among children. The exposure of foetus to excess glucocorticoids is suspected to contribute to the alteration of the multiple foetal development systems that may remain in force after delivery and pose risks for diseases. The results of this study showed that the exposure of prenatal to prescription corticosteroids is actually related to the small increment of type 1 diabetes among offspring and also depicted a 51% increment in type 2 diabetes, or increased blood glucose hazard ratio if compared to prenatally exposed children to prescription corticosteroids with those unexposed. The information gathered was in line with the overall monotonic in diabetes hazard ratios with increasing strength of the corticosteroid. The study was concluded with a view that there may be a relationship between the use of prenatal prescription corticosteroid and it justified further thorough research regarding the foetal exposure (Beckwith, & Franklin, 2011, pp131-143) . The exposure of the unborn child to excessive glucocorticoids is associated with the fluctuations in the homeostasis of insulin-glucose. These disturbances results from the anterior lobe of hypothalamus-pituitary and the immune system causing central and peripheral fluctuations that are suspected to persist after delivery, thus, may lead to the increase in risks of attack by chronic diseases like diabetes mellitus (Putman, 2011, pp143-151). The same case study conducted using rats and sheep also revealed conclusions to that effect. Various kinds of disorders such as autoimmune diseases and asthma have been treated using prescription corticosteroids when women are pregnant. Medications using corticosteroid are recommended to about 7% of pregnant women, subject to the preparation and the core symptom (Irwin & Rippe, 2008, pp234-278). Most importantly, there seem to exist uncertainty relating to the long-term consequences for children exposed prenatally and therefore, an increased proneness for diabetes mellitus should be well-thought-out. Thus, the relationship between prenatal exposure to prescription corticosteroids and offspring diabetes mellitus is further reconsidered in a large national cohort study. In this study, a dichotomous key was developed to describe and classify the prenatal exposure into three sets in accordance with the administration routes so as to streamline the increasing strengths of corticosteroid exposure. The basis for children prenatal exposure was determined by the mothers redeemtion of one or more corticosteroid prescriptions from start of gestation to birth (Child & Adolescent Mental Health Statewide Network (Camhsnet), 2003, pp111-123). Neglecting the treatment of women during pregnancy for conditions demanding steroids may constitute a greater risk for their children as compared to being medicated even when the associations presented by the study are causal. However, investigations into the long-term aftermaths in offspring of prenatal exposure to glucocorticoids and a potential association between prescription of corticosteroids and diabetes in offspring may affect the prescription patterns. This could possibly be the case for corticosteroids used to enhance the maturity of the foetal lungs during intrauterine growth restriction, where the dosage considered optimal and the number of repeat injections can as well be determined (Olfman, & Robbins, 2012, pp97-121). 6. Medication of my scope Case Study: A patient with uncontrolled type 2 diabetes and complex comorbidities whose diabetes care is managed by an advanced practice nurse Case synopsis A.B. is 69 year old man with type 2 diabetes for 5 years. He was diagnosed in 1997, he has had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating “borderline diabetes.” He remembers past instances of nocturia related to large pasta meals and Italian pastries. Initially, as diagnosis exposes, he was advised to lose weight (“at least 10 lb.”), there was no further action which was taken. A.B. has currently gained weight; he has developed suboptimal diabetes control, and foot pain. A.B. also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken chromium picolinate, gymnema sylvestre, and a “pancreas elixir” in an attempt to improve his diabetes control. He stopped these supplements when he did not see any positive results. Discussion The first role of the a nurse practitioner who provided care to A.B was to choose the most urgent health issues and draw a plan on how to tackle them based on the priorities that he could have set. Even though the sole reason for visiting the health practitioner was to seek the diabetes specialty care, the underlying issue of conducting additional tests on hypertension ought to be conducted on the on the very day (Cannon, & Ogara, 2007, pp67-71). The medication of the patient in the first encounter ought to have been aimed at reducing the level of blood sugar without facilitating gain of weight. Such drugs such as Thiazolidinediones effectively surpresses the resistance of insulin but lead to weight gain. A sulfonylurea or meglitinide can reduce postprandial elevations triggered by increased intake of carbohydrate, though they are also associated with some weight gain. Previously, when glyburide was prescribed, the patient showed signs and symptoms of hypoglycemia. Carbose, α,-Glucosidase inhibitors can help aid postprandial hyperglycemia rise by blunting the effect of the entry of carbohydrate-related glucose into the system (Wilson, 2009, pp67-71). Even though acarbose needs slow titration, has multiple gastrointestinal (GI) side effects, and reduces A1C by only 0.5–0.9%, it may be put into consideration as a second alternative therapy for A.B. but would not fully address his elevated A1C results (Davis, 2011, pp35-89). Metformin (Glucophage), which reduces the production of hepatic and enhances insulin resistance, is not interrelated with hypoglycemia and can lower A1C results by 1%. Although GI side effects can occur, they are usually self-limiting and can be further reduced by slow titration efficacy of dosage. The nurse practitioner advised the patient to undertake the medication with food to minimize GI side effects (Hong, & Herzog, 2008, pp87-99). The nurse practitioner should act as an educator to the patients and keep in touch with the patients so as to monitor his status continually. The nurse practitioner should help the patient in the designing of a plan that would ensure that the patient controls his weight and the blood sugar level. It therefore means that the diagnosis has a wider scope that the nurse practitioner must consider while outlining the prescription (Jackson, 2008, pp54-77). 7. Management of Diabetic Neuropathy Case Study: A 68-Year-Old Man with Diabetes and Peripheral Neuropathy Case synopsis A 68 year-old man has a 3-year history of impaired glucose tolerance. His only alternative medical problem is hypertension which is treated with a small dose of an angiotensin-converting enzyme (ACE) inhibitor. He quit smoking 20 years ago. He has no dyslipidemia and has had stress electrocardiograms every 2 years with normal results. He does not drink alcohol. He had no obesity. He lost 10 lb and was able to normalize his blood glucose levels with this regimen. Approximately 3 months ago, he noticed some burning and tingling in his feet. He admitted that he had not felt as well as usual and that his walking was becoming more of a chore. He denied chest pain or shortness of breath. He denied any other symptoms and had no fever or chills, cough, bloody stools, or hematuria. When seen in the office, he had gained 5 lb. His physical examination was normal except for some hyperesthesia of both feet as well as decreased vibratory sensation. His thyroid, reflexes, and pulses were normal. He was not depressed. Discussion Diabetes forms the main cause of peripheral neuropathy in the western world. Bases on research estimates, over 60% of the diabetic people exhibits some elements of neuropathy with regards from detectable asymptomatic neuropathy to severe disabling painful disease to dense anesthesia. The extent and duration of hyperglycemia is the major victim prompting thorough investigations (Unger, 2007, pp25-33). The dysfunction of the sensory may reveal no symptoms such as tingling, numbness, or burning; or a sense of “walking on eggshells” or a “funny sensation” by normal sight triggered by the eye. The affection of the motor nerves has a conspicuous feature of claw-toe deformity. When the autonomic nerves are interfered with, this prompts lack of sweating, as well as dry and cracked skin which may result (Tesfaye, & Boulton, 2009, pp77-87). As a diabetes specialist nurse, the history of the patient is paramount. Particularly, this is significant since diabetes is just one of the many causes of peripheral neuropathy. A patient may exclude some of the neuropathies of exposure is the background history such as alcohol and substance abuse, HIV/AIDs, existence of toxins etc. it is therefore advisable that while prescribing for diabetes, the nurse should inquire further into the earlier occurrence of similar signs and symptoms in the family members of the patient that might aid in the identification of the familial neuropathies (Kasliwal, 2009, pp23-27). The complaints about painful burning feet, necessitates the need for differential diagnoses in addition the diagnosis for diabetes that could involve the tests for toxicity by alcohol, HIV/AIDs infection, malignant tumor, or amyloidosis (Haase, 2010, pp65-66). Should the carpal tunnel syndrome coexist with peripheral neuropathy, then, thyroid disease, rheumatoid arthritis, diabetes, and amyloidosis are highly probable. Onset of symptoms is another clue to the etiology of different neuropathies, with “entrapment” causes having a more gradual, chronic nature and mononeuritis being sudden and acute. A complete medical examination should be conducted to determine all aspects of any other symptoms while diagnosing diabetic neuropathy before a prescription can be made (Veves, Malik, & Veves, 2007, pp55-76). 8. Using Kolb’s cycle reflect Concrete experience will be demanded by attending a lecture on the management of acute exacerbation asthma. Observation and reflection would be applied in the situation by spending time studying asthma and related presentations of the breathlessness such as the pneumothorax, pneumonia, cardiac failure and anaphylaxis (Nelms, 2007, pp99-111). The abstract concepts would be taking into consideration how these other prevailing patients could mimic the presentation of asthma and which are the major discriminatory factors in regard to pathology, presentation and treatment. I would also carry out activity test by using the patient presenting with the breathlessness as an example either imagine the underlying case, be questioned by the existing colleague about the disease or checking the patient (Bantle, 2006, pp44-55). Moreover, I will strive working through the list of differential diagnoses utilizing my earlier reflections on the similarities and differences of the various situations, which might mimic asthma (Halliwell, 2013, pp33-39). Bibliography Mccall, T. B. (2007). Yoga as medicine: the yogic prescription for health & healing : a yoga journal book. New York, Bantam Books. Ehrman, J. K. (2009). Clinical exercise physiology. Champaign, IL, Human Kinetics Tyrrell, W., & Carter, G. (2008). Therapeutic footwear: a comprehensive guide. Edinburgh, Churchill Livingstone. Tan, R., & See, C. (2011). How to master your medical school finals: the complete guide to passing and excelling in your medical school exams. London, Kogan Page. Davis, W. (2011). 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