Poly-Pharmacy Essay Paper
Poly-pharmacy is the use of five or more medications daily by an individual. However, these medications can vary from two to eleven concurrent medications. It is common in elderly patients with multiple chronic illnesses (Davies, et al, 2020). Chronic illnesses include asthma, diabetes, hypertension, heart failure, chronic obstructive pulmonary disease, hyperlipidemia, and osteoarthritis. Patient-related factors that can lead to poly-pharmacy are multiple medical conditions, multiple subspecialist physicians, having chronic mental health conditions, residing in a long-term care facility (Davies, et al, 2020). Systemic factors are poorly updated medical records, automated refill services, and prescribing to meet disease-specific quality metrics. However, some tools help identify potentially inappropriate medication use such as screening for older people’s prescriptions and screening tools to alert right treatment. These tools help in monitoring active patient prescriptions and deprescribing unnecessary medications. The physicians should consider the therapeutic objectives of medication, chronic diseases, slow disease progression, and health decline. Negative consequences of polypharmacy include decreased quality of life, increased mobility issues, increased mortality, and increased risk of adverse drug events, disability, falls, frailty, inappropriate medication use, and long-term care placement and medication non-adherence. Poly-Pharmacy Essay Paper
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Healthcare system causes of polypharmacy are decreased physician productivity, increased burden of the healthcare system, increased medication errors and decreased physician functionality. Reducing polypharmacy among elderly patients requires the intervention of a physician. They ought not to prescribe medicine for a patient currently on five or more drugs. Moreover, they should not continue medication indefinitely without a comprehensive review of their existing medication including over-the-counter dietary supplements. The physician should avoid prescribing medication without conducting a drug regimen review. When refilling medication, it is important to consider the benefits and the risks of continuation in the long term. The elderly patent in this scenario is a 68 years old female with type two diabetes mellitus, hypertension, hyperlipidemia, atrial fibrillations, lower limb swelling, chronic arthritic pain, and COPD. She is obese, has high blood pressure and random blood sugar, irregular heart rate, and abnormal WBC, INR, and creatinine. She takes metformin, aspirin, carvedilol, simvastatin, amlodipine, Coumadin, Spiriva handihaler, Tylenol, ibuprofen, and nitroglycerine. After the hospital visit, there was a change in her medication list to digoxin, atorvastatin, aspirin, Spiriva handihaler, Serevent Diskus, prednisolone, and amlodipine.
Safety Concerns Of The Pre-Hospital List
Metformin is a biguanide that decreases hepatic glucose production and increases the target cells’ insulin sensitivity. It is the drug of choice for patients with diabetes mellitus type two. Metformin undergoes tubular excretion in the urine unchanged; Anne’s low eGFR of approximately 39 ml/min may lead to a buildup of plasma metformin levels, which may cause lactic acidosis by inhibition of the Cori cycle. eGFR should be closely monitored as any further decline may necessitate cessation of metformin administration. However, it is not the best recommendation for this patient because of kidney and heart diseases. In addition, its co-administration with amlodipine increases the risk of hypoglycemia warranting the patient for close blood glucose monitoring. Poly-Pharmacy Essay Paper
Aspirin is acetylsalicylic acid that inhibits the synthesis of prostaglandins by cyclooxygenase. It also inhibits platelet aggregation and has antipyretic and analgesic properties. It is appropriate for this patient to relieve chronic arthritis pain. It is also good prophylaxis for coronary heart disease because the patient has hyperlipidemia. However, it has severe adverse effects such as GI pain and ulceration, bronchospasms, and angioedema. In addition, co-administration of aspirin with ibuprofen decreases its antiplatelet effect by blocking the active site of platelet cyclooxygenase. There should be a cautious co-administration with carvedilol because it increases serum potassium levels. Its co-administration with nitroglycerine sublingual enhances its desirable effects by increasing the additive vasodilation. Aspirin should be given at a low dose together with coumadin because they both increase anticoagulation. The drug has more disadvantages therefore, it is not appropriate for this patient.
Carvedilol is an alpha activity beta-blocker used for heart failure and hypertension. coadministration with amlodipine reduces its effects by blocking prostaglandin synthesis. It is a recommendable drug for the patient because of the high blood pressure, irregular heart rate, and atrial fibrillation.
Simvastatin is a lipid-lowering agent that inhibits the rate-limiting step in cholesterol biosynthesis by competitively inhibiting HMG-CoA reductase. The drug co-administration with amlodipine increases the potential risk for myopathy. In addition, its coadministration with warfarin increases the effect of the other by affecting hepatic enzyme metabolism that results in increased INR and risks of rhabdomyolysis. . It is, therefore, appropriate to ensure close monitoring for toxicity from both drugs.
Amlodipine is a dihydropyridine calcium channel blocker that acts by blocking L-type calcium channels preventing activation of intracellular myosin light chain kinases, which causes peripheral vasodilation. This could worsen the bilateral pedal edema that the patient is experiencing. Its co-administration with carvedilol increases the anti-hypertensive channel blocking activity. Co-administer cautiously with metformin, warfarin, and simvastatin due to its severe adverse effects of drug interactions.
Coumadin is an anticoagulant that interferes with the hepatic synthesis of vitamin K-dependent clotting factors. It depletes functional vitamin K reserves, which reduces the synthesis of active clotting factors. It treats cardiac valve replacement and venous thrombosis. Cautiously co-administer Coumadin with aspirin and simvastatin due to their undesirable interactions.
Spiriva HandiHaler is an anticholinergic used in the maintenance treatment of bronchospasms associated with COPD. It is a long-acting muscarinic which inhibits the M3-receptor at smooth muscle leading to bronchodilation. The drug is safe for this patient because she has COPD. However, she needs an additional corticosteroid inhaler and a beta-blocker that would prevent frequent bronchospasms. Poly-Pharmacy Essay Paper
Tylenol is an analgesic that blocks the pain impulse and inhibits prostaglandin synthesis in the CNS. It is recommendable in patients with arthritis pain. Ibuprofen is an NSAID that inhibits the synthesis of prostaglandins in the body tissues, decreases the pro-inflammatory cytokine activity, and inhibits neutrophil aggregation thus contributing to anti-inflammatory activity. This drug is not safe in an elderly patient because it increases the risk of GI pain and ulceration. Ibuprofen inhibits PGE2 production (a potent renal vasodilator), this will lead to a vasopressin mediated retention of sodium ions and water to maintain renal perfusion (baroreceptor response). The direct result of this will be to cause increased preload which will worsen hypertension, increase work on the right side of the heart and worsen peripheral edema by increasing intravascular hydrostatic force. Therefore, it is not a commendable drug for this patient.
Nitroglycerine is an organic nitrate that causes systemic vasodilation decreasing preload. It relaxes the smooth muscles by dilation of the arterial and venous beds to reduce both preload and afterload. It lowers the blood pressure, increases the heart rate, and occasionally paradoxical bradycardia. Its co-administration with amlodipine and aspirin should be cautious because of their undesirable interactions.
Post-Admission List medication safety
The post-hospitalization list includes digoxin, atorvastatin, aspirin, spirivaSpiriva HandiHaler, Serevent Diskus, Prednisone, and amlodipine. Digoxin is an antidysrhythmic that causes parasympathetic stimulation of the autonomic nervous system with consequent effects on the sinoatrial node and the atrial ventricular nodes. Therefore, it allows the sympathetic outflow from the nervous system to the cardiac and peripheral sympathetic nerves. It treats atrial fibrillations and heart failure making it safe for this patient. However, it should be used cautiously together with atorvastatin and aspirin due to the severe interactions of the drug.
Atorvastatin is a lipid-lowering agent that inhibits the rate-limiting step in cholesterol biosynthesis by competitively inhibiting HMG-CoA reductase. Co-administration with prednisone decreases its effects by affecting the hepatic enzyme metabolism. Utilizing its maximum dosage of 80mg, therefore, helps reduce hyperlipidemia and reduce the risk of stroke in obese patients. Atorvastatin 80mg is safe for this patient because it meets the therapeutic objectives.
Aspirin is a safe drug for the patient because it helps in reducing arthritis pain and has anticoagulant effects that help in reducing the risk of stroke and coronary heart disease.
The patient has severe chronic obstructive pulmonary diseases because she has been experiencing frequent and multiple exacerbations. During the visit, she presents with wheezing. Therefore, a long-acting anti-muscarinic and long-acting beta-agonist with or without an inhaled corticosteroid are appropriate to help in bronco-dilation. Therefore, Spiriva HandiHaler 18 mcg (capsule) inhaled 1xD and Serevent Diskus 50 mcg (1 inhalation) 2xD are safe for this patient due to COPD.
Prednisone is a corticosteroid that prevents inflammation by controlling the rate of protein synthesis. It is safe for this patient because she is presenting with bronchospasms due to COPD. Amlodipine is a calcium channel blocker that helps in controlling blood pressure. However, it is not safe for the patient because it worsens lower limb edema.
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Safe And Effective List Of Medications
- Sitagliptin 50mg PO once daily for type two diabetes mellitus
- Losartan 50mg PO once daily for hypertension
- Digoxin 0.25 mg 1xD for atrial fibrillation and heart rate control
- Aspirin 81mg PO once daily for arthritic pain and an antiplatelet prophylaxis
- Methylprednisolone 8mg PO once daily for one week for acute exacerbation of COPD
- Serevent Diskus 50 mcg inhaler BID for treating COPD
- Atorvastatin 80mg PO once daily at bedtime for hyperlipidemia
Sitagliptin is a dipeptidyl peptidase inhibitor that increases and prolongs incretin hormone activity. The incretins increase insulin release and synthesis from the pancreatic beta cells and reduce glucagon secretion from pancreatic alpha cells. This drug is safe for the patient because she has kidney function.
Losartan is an angiotensin receptor blocker that works by blocking the vasoconstrictor and aldosterone-secreting effects of angiotensin II. The drug has both renal-protective and cardio-protective properties. Poly-Pharmacy Essay Paper
Serevent Diskus is a long-acting beta-agonist that is used as a maintenance drug for COPD. It works as a bronchodilator to ensure the airway remains patent. Methylprednisolone is a corticosteroid that prevents inflammation of the airway. Often, it relieves wheezing and difficulties in breathing during acute exacerbation of COPD.
Factors That Affect The Prescriber’s Decision As To Drug Dosages In Older People
Prescribing drugs for older people is problematic because they have many symptoms and diagnoses at old age. Often, drugs prescribed are contraindicated, wrong dose or have no therapeutic goal. Reviewing drugs regularly, reducing the number of prescribers per patient, regular auditing, and electronic prescription reduces the frequency of prescription errors (Rieckert, et al, 2018). However, elderly patients undergo physical and physiological changes in their bodies that affect drug pharmacokinetics and pharmacodynamics. In addition, they suffer old age-associated illnesses that result in polypharmacy.
Aging causes physiological changes that affect drug absorption, distribution, metabolism, and excretion. These changes can be due to renal impairment, hepatic failure, accumulation of adipose tissue. Inadequate production of liver enzymes due to chronic diseases such as hyperlipidemia affects drug metabolism. In addition, drug excretion in renal failure results in the accumulation of toxins especially in drugs with a low therapeutic window. Diseases that affect the liver and the kidneys result in the limitation of drug dosage. Multiple pathology and polypharmacy affect the prescriber’s decision to drug dosage due to interactions, adverse drug reactions, and length of hospital stay (Rieckert, et al, 2018). Some drugs have severe adverse effects on elderly patients compared to younger patients. This affects the drug prescription and its dosage altogether. For example, the majority of the elderly patients have gastric erosion, therefore, limiting the prescription of non-steroidal anti-inflammatory drugs such as ibuprofen due to its adverse effects.
Patient characteristics such as poor compliance to oral medication may influence a prescriber to select a once-daily drug. Causes of poor adherence may include reduced memory in old age, adverse drug reactions or side effects, and inadequate patient education on the need for drugs. The professional background of the prescriber equally affects drug decisions and dosages. Most experienced physicians and nurse practitioners understand more about drug interactions. Therefore, they are cautious when prescribing drugs in patients with multiple symptoms. In addition, they understand that majority of the drugs may have more than one indication therefore each symptom does not need a separate medicine.
How The Patient’s Age Affected My Drugs Selection
The patient has multiple diagnoses that are common in old age. However, the factors that influence my choice of drugs for the patient are multiple diseases such as diabetes hypertension, hyperlipidemia, atrial fibrillations, COPD, and arthritis pain. Complications such as renal failure and heart failure determined the choice of drug. For example, losartan and Sitagliptin are cardio and renal protective.
Follow-Up That Mary Ann Needs
The patient has a series of chronic diseases; COPD, arthritic pain, hyperlipidemia, coronary heart disease, diabetes mellitus, hypertension, and obesity. Therefore, she requires strict follow-up to maintain a healthy status. She should be on follow-up with a nutritionist to maintain a healthy diet that helps in losing weight, controlling blood glucose, blood pressure, and cholesterol levels. A physical exercise specialist will help her engage in physical activity that will help in weight loss and protect the heart. A cardiologist will help the patient regulate the heart rate and control the atrial fibrillations.
The patient seems to have an impending renal disease that needs to be on a nephrologist’s close monitoring. She also needs a physician to help her monitor her hypertension, diabetes, hyperlipidemia, arthritic pain, and COPD. From the clinical symptoms and lab findings, the patient had metabolic syndrome. This disease is often associated with depression and other mental health diseases. Therefore, the patient requires a psychotherapist evaluation to assess the mental health status and start cognitive-based therapy that will enable the patient to change her lifestyle habits. In addition, the therapist will train the patient on the need of taking the medication and attending follow-up clinics on time.
Patient education is an interactive learning process designed to support and enable patients to manage their life with diseases. Patient education reminds the patients of proper ways to self-manage care and avoids non-essential readmissions. Patent education can be through their family members and technology materials (Yen, P. H., & Leasure, A. R. 2019). The care provider should determine the patients learning limitations before engaging them. The education includes the definition of the disease, the risks associated, the mode of diagnosis, and treatment methods. For this patient, I will describe the metabolic syndrome using non-medical terms. I will explain the risk factors associated with the disease such as diabetes mellitus, hyperlipidemia, and hypertension. I will explain the complications of metabolic syndrome such as coronary heart disease, COPD, and chronic kidney disease. I will explain the treatment method of metabolic syndrome that includes weight loss, exercise, reducing the risk of type two DM, reducing cholesterol, reducing blood pressure, and quitting smoking. For COPD, I will explain to the patient the dangers of smoking and the improvement in the quality of life. The patient should also present in the hospital immediately after an acute onset of exacerbation. Poly-Pharmacy Essay Paper
Poly-pharmacy is the use of five or more medications daily by an individual. It is common in elderly patients with multiple chronic illnesses. Chronic illnesses include asthma, diabetes, hypertension, heart failure, chronic obstructive pulmonary disease, hyperlipidemia, and osteoarthritis. Patient factors and systemic factors influence polypharmacy among elderly patients. However, the physician ought not to prescribe medicine for a patient currently on five or more drugs. Moreover, they should not continue medication indefinitely without a comprehensive review of their existing medication. factors influencing elderly patients’ drug prescriptions are multiple diseases, polypharmacy, physiological changes, and contraindicated drugs. Patients with chronic diseases require frequent vital check-ups to monitor the effectiveness of the drugs as well as maintain a healthy lifestyle. In addition, patient education reminds the patients of proper ways to self-manage care and avoid non-essential readmissions.
Davies, L. E., Spiers, G., Kingston, A., Todd, A., Adamson, J., & Hanratty, B. (2020). Adverse outcomes of polypharmacy in older people: systematic review of reviews. Journal of the American Medical Directors Association, 21(2), 181-187.
Rieckert, A., Trampisch, U. S., Klaaßen-Mielke, R., Drewelow, E., Esmail, A., Johansson, T., … & Sönnichsen, A. (2018). Polypharmacy in older patients with chronic diseases: a cross-sectional analysis of factors associated with excessive polypharmacy. BMC family practice, 19(1), 1-9.
Yen, P. H., & Leasure, A. R. (2019). Use and effectiveness of the teach-back method in patient education and health outcomes. Federal practitioner, 36(6), 284. Poly-Pharmacy Essay Paper