NSG-533-IKC – Advanced Pharmacology Module V: Pain Management Discussion

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Often we see a great deal of misinformation in the care of patients with diabetes, and often this misinformation is centered around the role and choice of medications.  Many patients, especially newly diagnosed patients, are prescribed medications that do not fit into the scheme of the ADA / AACE guidelines / best evidence based practices – for instance, starting on Januvia (sitagliptin) or Jardiance (empagliflozin) or Byetta (exenatide) as initial monotherapy without a compelling indication or reason.

In this discussion, please talk about how patients get put on these medications and why/how they should be transitioned to more evidence based treatments.

• Is it okay to start a patient on a drug (particularly an oral drug) other than metformin as an initial drug?  Please cite possible circumstances where this could be reasonable.
• What anti-diabetic medications have compelling evidence for use in select populations, possibly as initial therapy, and is this benefit a “class” effect?
  • (eg. SGLT2Is – Patients with type 2 diabetes and a high risk of cardiovascular disease had reduced risk of a cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke relative to those randomized to receive placebo)
• How can patients and practitioners be convinced to change their behavior and opt for more evidence based approach to therapy?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

Consider the following scenarios:

LW is a 32 year old female patient who comes to your medical clinic for primary care.  She has been on hormonal contraceptives for years, although she’s just been married and has stopped her pills in hopes of becoming pregnant.  Her PMHx includes obesity, HTN (diagnosed 3 years ago), familial hypercholesterolemia, and PCOS.  Her current medications are as follows: Metformin 2000 mg PO daily, Lisinopril 10 mg PO daily, rosuvastatin 5 mg PO daily, and a multivitamin.

GD is an 82-year-old patient is taking 2 mg of terazosin for BPH every morning. He comes in complaining of dizziness, generalized muscle weakness and persistent lower urinary tract symptoms (LUTS).

How should you advise these patients and manage their medications?  What was the process you went through to assess the current medications and to recommend an updated regimen?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

Benzodiazepines are commonly prescribed medications for several indications, including anxiety and sleep disorders. Let’s discuss their use in our health care systems and the impact on our patients.
Things to consider might include (just getting you thinking):

Safety: How could the side effect profile affect your patients?
Efficacy: Are benzodiazepines efficacious for anxiety and sleep?
Use: Are they under or over prescribed? How can we ensure safe use of these medications?

Consider the following cases:

KT is a 24 year old female completing her studies. While home for spring break, she presents to her primary care physician because she has been worried about her academic, professional, and personal future since class restarted in late August. She is constantly worried about passing all of her exams and that she is going to be the only one of her friends that graduates school without a ring on her finger.

• How would you help her assuming she meets the criteria for GAD?

WD is a 49-year-old male who suffered a myocardial infarction one week ago. Upon discharge, it was noted that WD appeared depressed. At a follow-up visit with his physician a week later, WD met criteria for a diagnosis of major depressive disorder. His past medical history includes: treatment refractory hypertension, diabetes mellitus (type II), and severe uncontrolled narrow angle glaucoma

• How would you help him assuming he meets the criteria for MDD?

JM is a 42 year old female who was referred for management of insomnia. She reports that she is unable to sleep at all during the week (difficulty going to sleep and staying asleep) and sleeps all day on Sunday. She currently takes temazepam (Restoril) 30 mg HS (recently increased from 15mg). She also experiences depression due to an abusive relationship with her boyfriend as well as her current lack of employment. She reports poor sleep hygiene (reads and watches TV in bed), drinks 6-8 cups of coffee throughout the day and does not pay attention to how late she eats or exercises.

• What non-pharmacological and pharmacological therapies would you recommend for JM?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

Calcium and Vitamin D supplementation are essential to bone health and the management of osteopenia and osteoporosis.  In the past few years, information regarding the potential risks of too much calcium (such as cardiovascular disease and/or events) have been emerging.

• Using an article from a medical journal, evaluate and discuss the risks and benefits of calcium supplementation for a patient with a bone disease.
• What would you recommend for is a 59-year-old postmenopausal woman with a T-score of − 2.3. Her past medical history is unremarkable and she only takes a multivitamin with additional calcium and vitamin D. Her family history is remarkable for a mother who had osteoporosis and died of breast cancer and a father who has diabetes

When faced with a choice between 2 or more possible answers, using a “STEPS” analysis may be a useful clinical decision making tool.  The goal is to provide information for each agent and compare the results to aid in your decision.

S:  safety – are there any serious drug interactions?  Possible serious side effects or adverse drug reactions?

T – tolerability – consider any adverse drug effects or side effects that may be concerning to the patient such as:  diarrhea, headaches, rash, etc.

E – efficacy – is one agent more efficacious than the other for the infection?

P – price – does the patient have insurance?  will cost inhibit adherence or access to the medication?

S – simplicity – which regimen is simpler?  Once a day dosing will likely have better adherence rates than three times a day dosing.  Also, three days of an antibiotic may be preferable to 7-10 days.  Depending on the drug you choose, the frequency and duration will vary.

Here’s an example table

1.  Which one would you choose and why?

2.  Identify the available treatment strategies for CAP in an adult outpatient with comorbidities. Create your own “steps” analysis comparing the use of the available treatment regimens. Be prepared to compare and contrast your ideas with your classmates.

Reference:  Evaluating the safety and effectiveness of new drugs

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section. 

Often infections have several treatment possibilities, depending on both patient specific and disease specific characteristics.  Below is a very short case, and I want you as a class to compare and contrast the listed treatment options.  The focus will be on safety and efficacy of the regimens, all considered possible choices by the Infectious Disease Society of America’s treatment guidelines for Acute Uncomplicated Cystitis.

HT is a 31 year old female with acute, uncomplicated cystitis and no known drug allergies.  She has no significant PMH or medications.  Her urine culture shows a susceptible E. coli (susceptible to all treatments listed below).  Please compare the safety and efficacy of the following options.  What would make you choose one over another?

1.  nitrofurantoin 100 mg po BID x 7 days

2.  TMP/SMX DS (160 mg/800 mg) po BID x 3 days

3.  levofloxacin 250 mg po daily x 3 days

4.  cephalexin 500 mg po q12hrs x 7-14 days

I want you all to discuss and add to or dispute each other’s thoughts and ideas.

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section. 

JR is a 56 yo man with h/o asthma, HTN and hyperlipidemia. He presents to the ER today with h/o shortness of breath for 45 minutes at rest. He reports that he was feeling well and in his usual state of health until about an hour ago, when he smelled something burning. 20 minutes later, he began to feel short of breath and was wheezing. He tried using his albuterol inhaler without success, so he proceeded to the ER. Upon arrival, he was tachycardic, tachypneic, wheezing, using accessory muscles and hypertensive. His last admission for an asthma attack was 2 months ago. He denies a recent cold or URI and says the albuterol usually helps him when he feels an attack coming on and tends to use it on a daily basis. He generally has wheezing and shortness of breath on a daily basis. JR reports poor sleep due to waking about 2 times a week for shortness of breath. He has 2 cats, which sleep next to him on his pillow and he lives in an apartment complex. JR does not smoke, but his neighbor smokes. JR is a carpenter by occupation. He monitors his peak flow once a week at home. He reports that his peak flow generally runs about 325 L/min and his personal best is 480 L/min. His current peak flow is 175 L/min.

Medication Prior to Admission:

Albuterol MDI 2 puffs BID-QID PRN

Salmeterol Diskus 1 inhalation QID

Ipratropium bromide MDI 2 puffs QID

Lovastatin 20 mg po HS

Lisinopril 10 mg po QD

Questions:

1. Classify JR’s asthma severity and control based on signs and symptoms prior to this most recent exacerbation and visit to the ED.
2. Classify JR’s exacerbation severity based on PEF and symptoms.
3. Identify the various triggers in JR’s life that may exacerbate asthma and prevent control.
4. Which step should JR have been on prior to ER based on severity and current medications?
5. Which medications are dosed incorrectly and/or inappropriate for JR’s asthma severity?
6. Would a short-burst of oral corticosteroid be indicated at this time? If so, what dose and duration?
7. How would you assess that JR is well-controlled?
8. If JR is well-controlled, how would you step down in therapy?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

A 50yo African American woman presents to clinic feeling tired for the last 3 months.  She also has trouble breathing when walking 2-3 blocks.  She sleeps on 2 pillows at night to help with her breathing.  PMH:  HTN, arthritis.  Physical exam: edema present in both feet.  Medications:  HCTZ 12.5mg daily, verapamil SA 120 mg daily, ibuprofen 200 mg BID for arthritis in knee.  Vitals:  height 5’2″, 63kg, BP 134/84, HR 78, EF 30% per echocardiogram.  Her labs are normal including a creatinine of 1.1.  She denies chest pain or palpitations.  Her EKG reveals normal sinus rhythm with no evidence of ischemia or recent acute coronary syndrome.

1. How would you classify her heart failure?
2. What changes (modifications, additions, deletions) to her medications do you recommend that will:
   • Improve her symptoms?
   • Impact long term outcomes?
3. What monitoring parameters do you recommend?
4. What non-pharmacologic recommendations do you have?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight. Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

Bill is a 58yo male recently diagnosed with stable angina.  He has been experiencing chest pain about 2-3 times per week for the last month.  His chest pain typically occurs while walking, which he does about 3 times each week.  He has no other significant past medical history, takes no medications, has no drug allergies, and does not smoke.  His BP is 122/74, HR 72.  His labs are all normal.  His fasting lipid profile is Total Cholesterol 175, HDL 45, LDL 90, TG 125.  Waist circumference is 30”, and BMI is 24.  His family history is unremarkable.

1. What risk factors are present and are they modifiable?
2. What are the goals of therapy?
3. What medication(s) do you recommend to prevent Bill from experiencing angina-related chest discomfort and to increase exercise capacity?
4. What do you recommend to treat acute episodes of stable-angina-related chest discomfort?
5. What additional medications can improve outcomes (e.g. decreased cardiovascular mortality, non-fatal MI, cardiac arrest, etc.) in a patient like Bill who has stable angina?
6. What is your drug therapy monitoring plan?
7. What patient education should you provide?

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.

A 44-year-old woman has a 10-year history of type 2 diabetes. She is a nonsmoker with well-controlled hypertension. She is on :

-dietary management

-metformin 1000mg BID

-omega-3 1000mg  ii BID

lisinopril/hydrochlorothiazide 20/25 QD.

She has a family history of diabetes.

BP 134/78, BMI of 36.0, HbA1C 7.5%

FLP: LDL–C 95 mg/dL, triglycerides 350 mg/dL, and HDL–C 38 mg/dL

1. Based upon the case information and the patient’s lipid profile, describe your approach to therapy using each of the currently available guidelines:
   • 2013 ACC/AHA Blood Cholesterol Guidelines for ASCVD Prevention
   • 2014 NLA Recommendations for Patient-Centered Management of Dyslipidemia
   • 2016/2017 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for Additional LDL-lowering
2. Now that you have compared and contrasted the various approaches, how would you educate the patient on the medications you have chosen?

NOTE: If recommending therapy provide drug, dose and rationale please.

Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.