26 Mar Discussion: Pharmacokinetics and Pharmacodynamics
ADVANCED PHARMACOLOGY
WK 1 Discussion: Pharmacokinetics and Pharmacodynamics
THE DISCUSSION QUESTION:
Read the following two discussion responses below and respond by suggesting additional patient factors that might have interfered with the pharmacokinetic and pharmacodynamic processes of the patients they described. In addition, suggest how the personalized plan of care might change if the age of the patient were different and/or if the patient had a comorbid condition, such as renal failure, heart failure, or liver failure.
RESPONSE GRADING RUBRIC:
• Response exhibits synthesis, critical thinking, and application to practice settings.
• Responds fully to questions posed by faculty.
• Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
• Demonstrates synthesis and understanding of learning objectives.
• Support each discussion response by at least three current, sources within the last 5 years (1 FROM LEARNING RESOURCES AND 2 FROM OUTSIDE)
• Communication is professional and respectful to colleagues.
• Responses to faculty questions are fully answered, if posed.
• Response is effectively written in standard, edited English.
DISCUSSION #1
By C. Bourn.
The purpose of this discussion is to describe a patient case from my experience describing factors that might have influenced pharmacokinetic and pharmacodynamic processes of the patient identified and explain details of the personalized plan of care that I would develop based on influencing factors and patient history.
Patient Case
A 50-year-old female patient was being hospitalized for cellulitis in her right leg. Other pertinent history includes, the patient is allergic to penicillin, over-weight, and is an insulin-dependent type-2 diabetic. She is considered non-compliant due to not being able to afford her insulin. Upon admission, her blood sugar was 400, creatinine 2.0, the patient was febrile, and reported significant pain in the right leg. The patient’s leg appeared reddened and swollen. Due to the degree of infection, this patient was admitted to the hospital for treatment with IV Vancomycin. After beginning treatment, the patient began to manifest signs of toxicity, and ultimately required hemodialysis.
Pharmacokinetic and Pharmacodynamic Processes
Pharmacokinetics is based on the four main processes: absorption, distribution, metabolism, and excretion (Rosenthal & Burchum, 2018). IV vancomycin is given directly into a vein and absorbed directly into the bloodstream, the standard infusion time is at least 1 hour, therefore absorption is bypassed allowing rapid onset. Vancomycin has a distribution phase of approximately 30 minutes to an hour and an elimination half-life of 6-12 hours (Rybak, 2016). Given Vancomycin is primarily excreted through the kidneys, this medication can be a high risk for patients with renal compromise. “About 80-90% of Vancomycin is excreted unchanged in the urine within 24 hours in patients with the normal renal function” (Vandecasteele & De Vriese, 2010, p. 761). As previously noted, the patient in the scenario suffers from uncontrolled diabetes which damages the kidneys over time which is proven by her elevated creatinine. Other patient factors that might impact the pharmacokinetics of Vancomycin include the patient being obese, this could be impacted by genetics and behavior such as diet. Vancomycin is typically dosed based on mg per kg, although one particular study found that basing a patients dose on ideal body weight rather than actual body weight was found to have initial Vancomycin trough concentrations closer to the recommended amount (Kubiak, Alquwaizani, Sansonetti, Barra, & Calderwood, 2015). Due to the patient’s weight, the patient may have been receiving a dosage that was too high, leading to toxicity at a faster rate.
Pharmacodynamics is the study related to how drugs affect the body. As the patient in this scenario received vancomycin, the drug began to build up in her body, ultimately leading to toxicity. In turn, the patient’s kidneys were greatly impacted and required hemodialysis to excrete the excess levels of vancomycin.
Plan of Care
Based on this scenario, patient factors, and patient history, special considerations must be accounted for when developing a plan of care. For example, adjustments in dosage should consider the patient’s body surface area, because the percent of body fat can change the distribution (Rosenthal & Burchum, 2018). Due to this patient’s renal compromise, potentially finding a different antibiotic that is not as toxic to the kidneys should be considered but we must remember the patient has a previous allergy to penicillin documented. Monitoring for toxicity should begin simultaneously with the start of the drug. This can be accomplished through many different labs and assessments. For this patient, I would consider drawing daily creatinine levels. If the creatinine increases by 0.5 from the start of the drug then the dose of vancomycin should be reduced (Bartlett, 2010). For long term treatment, weekly vancomycin trough values must be drawn. Further considerations include if the patient is on other nephrotoxic drugs such as aminoglycosides, diuretics, and statins and stopping those medications if able. Due to the patient being diabetic, strict blood sugar control should be monitored. Hyperglycemia alters the healing process and may require antibiotics longer than anticipated. Following discharge, it will be important to consider patient factors such as not being able to afford currently prescribed medications. However, while hospitalized it will be necessary for tight glucose control so that antibiotic treatment can work quickly and efficiently to clear the infection in her leg.
Conclusion
As an advanced practice nurse, it is important to consider how patient factors may influence both pharmacokinetic and pharmacodynamic processes. Ultimately, it is the responsibility of the provider and prescriber to obtain a thorough history and determine the safest, most effective plan of care including prescribing medications. Not only are physical factors considered but drug selection must also consider personal factors so that our patients can be adequately treated.
References
Bartlett, J. G. (2010, June 18). Vancomycin dosing: Guidance for clinicians. Medscape Infectious Diseases . Retrieved from https://www.medscape.com/viewarticle/723551
Kubiak, D. W., Alquwaizani, M., Sansonetti, D., Barra, M. E., & Calderwood, M. S. (2015, November 13). An evaluation of systemic vancomycin dosing in obese patients . Open Forum Infectious Disease , 2(4). http://dx.doi.org/10.1093/ofid/ofv176
Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.
Rybak, M. J. (2016, January 1 ). The pharmacokinetic and pharmacodynamic properties of vancomycin . Clinical Infectious Diseases, 42, 35-39. http://dx.doi.org/doi.org/10.1086/491712
Vandecasteele, S. J., & De Vriese, A. S. (2010, February 24). Recent changes in vancomycin use in renal failure. Journal of the International Society of Nephrology , 77(9), 760-764. http://dx.doi.org/https://doi.org/10.1038/ki.2010.35
DISCUSSION #2
By S. Wright
Basic Pharmacotherapeutic Concepts, Ethical and Legal Aspects of Prescribing
Pharmacodynamics is the effect of a medication on a patient after they take a medication (Rosenthal & Burchum, 2018). Pharmacokinetics studies how the body processes a drug after a patient takes the medication (Rosenthal & Burchum, 2018). These processes are basic pharmacotherapeutic concepts that effect patients. Advanced practitioner nurses or APRNs study these concepts prior to becoming licensed and prescribing meds to patient in order to reach their selected therapeutic outcomes for patients.
My Patient case experience in the last five years
In my experience, I have worked in multiple cancer centers and critical care environments. One patient that is easy to recall in my memory is a 60-year-old female patient from Miami, Florida with breast cancer. This patient was in the hospital for multiple weeks for the management of his condition and providers studied his case in daily patient evaluation meetings. This patient was prescribed daily maintenance fluids, strict intake and output, and received a diet to follow. One of the meds the patient was prescribed was pertuzumab for cancer. This patient would have nausea and vomiting episodes after taking this med and had a lack of appetite and after studying pharmacokinetics, I can see how his body was affected by this medication.
Factors that influence Pharmacokinetic and Pharmacodynamic processes
There are many factors that effect a clinician’s decision to prescribe medications (Alomar, 2014). In my patient scenario, gender played a significant role in the treatment options for this patient. After taking a few doses of medication, this patient had increased episodes of nausea and vomiting. In our daily morning huddles, I was able to identify that cancer medications effect the male and female genders differently with pharmacokinetics. Females often weigh less than males and this can alter dosing by prescribers (Alomar, 2014).
The patients Age was another alternative factor that influences the pharmacodynamic processes (Alomar, 2014). In older patients, they are unable to metabolize drugs as fast as the younger age population. In the older population, co-morbidities like hypertension, and diabetes develop. This population has also a decrease in organ functions which increases the possibility of taking multiple medications which may affect pharmacokinetics.
Genetics plays an influential role in pharmacokinetics and pharmacodynamics. In my patients’ case she was obese, and had a family history of hypertension, diabetes, and substance abuse. Medications used to lower cholesterol and blood pressure are often used for weight loss in her family history. Diuretic medications were prescribed for her parents for their family history of high blood pressure. Ace inhibitors are often found to be effective for the African American population and this played a role in the selection of drugs by her APRNs (Alomar, 2014).
My patient’s Personalized plan of care based on influencing factors
After studying my patient’s family history and influential factors, I would increase teaching and education in my plan of care. Substance abuse prevention, Weight loss interventions and Diabetes management would all play an essential role in my plan of care for my patient. I would identify potential side effects of anti-hypertensive medications and this patient’s cancer meds. Diet modification would be essential if my patient is having side effects to the cancer medication (Darrow, Sarpatwari, Avorn & Kesselheim, 2015). Modification of dosages can also be necessary but I would have to review how well my patient can absorb her prescribed medications based on lab values. I would have to increase blood drawings as well as monitoring patients’ weight. For my patients emotionally ill family history, I would order additional psychologist consults to monitor for depression. Depression can affect a patients mentality on taking medications (Darrow, Sarpatwari, Avorn & Kesselheim, 2015)
Conclusion
APRNs play an essential role in healthcare by prescribing medications. Prior to prescribing medications, APRNs have to identify family history and influencing factors for patients. Safety remains as an important factor and plays a role in the reduction of medical errors. Pharmacokinetics and pharmacodynamics are processes that are used to identify how well a patient can tolerate medications(Drug Enforcement Administration). Collaboration of care between families and clinicians can increase therapeutic outcomes of patients with appropriate family history information.
References
Alomar, M. J. (2014). Factors affecting the development of adverse drug reactions. Saudi pharmaceutical journal, 22(2), 83-94.
Darrow, J. J., Sarpatwari, A., Avorn, J., & Kesselheim, A. S. (2015). Practical, legal, and ethical issues in expanded access to investigational drugs.
Drug Enforcement Administration. (2006). Practitioner’s manual. Retrieved from http://www.deadiversion.usdoj.gov/pubs/manuals/pract/index.html
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