Read a selection of your colleagues2esponses and respond to at least two of your colleagues on two different days 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 

1. Patient Case

I recall a patient, Mr. R, who was a 60-year-old male with a history of hypertension and diabetes, admitted to the hospital with chest pain. He was diagnosed with acute coronary syndrome and started on dual antiplatelet therapy with aspirin and clopidogrel.

Influencing Factors

At the time, I considered Mr. R’s age, gender, comorbidities, and medication history as the factors that might influence his pharmacokinetic and pharmacodynamic processes. As he was aging, drug absorption, distribution, metabolism, and excretion could have been affected (ThŠann, 2020). Moreover, his history of hypertension and diabetes could have altered his kidney and liver function, which could have impacted drug metabolism and excretion (Rosenkranz et al., 2020). Additionally, his concurrent use of other medications such as antihypertensives, hypoglycemic agents, and lipid-lowering agents could have interacted with the prescribed antiplatelet therapy.

Plan of Care

The personalized plan of care for Mr. R had considered his comorbidities and medication history. We had conducted a thorough review of his medication list to identify potential drug interactions. Serum drug level monitoring and dose adjustments were considered for drugs that were primarily metabolized by the liver or excreted by the kidneys. Moreover, monitoring of bleeding parameters was done regularly due to the increased risk of bleeding associated with dual antiplatelet therapy. As Mr. R had a history of hypertension and diabetes, lifestyle modifications, and regular monitoring of blood pressure and blood glucose levels were included in his plan of care. Additionally, education on medication adherence, drug interactions, and potential adverse effects was provided to Mr. R and his family. Wilhelmsen and Eriksson (2019) observed that to enhance medication adherence, healthcare administrators should prioritize proven interventions such as providing patient education, simplifying dosages, incentivizing financial gains, and implementing reminders.  

2.There are many factors that influence how individuals react to drugs. The same drug can have very different effects on people due to variability in body weight and composition, age, pathophysiology, tolerance, gender and race, genetics, variability in absorption, and comorbidities and drug interactions (Rosenthal & Burchum, 2021).

The patient that I will be sharing from my past experiences is a 63 year old male, long-term care resident with altered mental status, slight jaundice, and right lower quadrant pain. The patient has a past medical history to include chronic pain, thrombocytopenia, hyperlipidemia, chronic kidney disease, Type II Diabetes, and a history of CVA with left hemiparesis.  He has a past history of heavy ETOH use but has been sober for 2 years. He was taking over the counter acetaminophen up to 3 grams per day for pain for several years prior to admission to long term care 6 months ago. Labs were drawn and showed that his liver enzymes were elevated, kidney function was severely impaired, and his ammonia level was in the 130î Hepatic ultrasound was also ordered. He was diagnosed with metabolic encephalopathy and cirrhosis of the liver. He was started on Lactulose 30 mg Q2H and titrated up.  His ammonia levels climbed into the 170àand he started experiencing worsening altered mental status, jaundice, ascites, and had several falls.  He was titrated up to 120 ml TID. Lactulose is non absorbable by the body and reaches the colon unchanged. Once in the colon, it is broken down by bacteria which causes a decrease in the production of ammonia and an increase in the bacteria that trap and excrete ammonia in the feces (Sarangi, et al, 2017).  Rifaximin was also prescribed, a non-systemic antibiotic that has been shown to have minimal GI absorption due to research showing that this drug is ffective against ammonia producing bacteria in the gut araceni, et al, 2021).  The combination helped to lower his ammonia level to within normal limits.  The liver dysfunction he was experiencing coupled with chronic kidney disease was likely also causing variability of absorption of his regular medications as they were not able to be excreted due to the impairment.

I found this case to be interesting because Tylenol is such a widely used drug but it can have very dangerous consequences such as acute or chronic liver failure. Due to genetics, lifestyle factors such as alcohol abuse and multiple comorbidities, this patient was effected quite differently from the long term use of this drug than someone else might be. The liver becomes unable to process the Tylenol so it begins to build up in the body which can cause liver damage as well as a host of other problems.

Since the patient has multiple comorbidities, all of his medications would need to be monitored closely. The patient would need an individualized plan of care that would help him to be compliant with his medications. A large part of the plan of care for this patient is providing education on the importance of compliance with medications and laboratory tests such as electrolytes, liver and kidney function tests.  He also has chronic pain and is prescribed Oxycodone, Tizanidine and Gabapentin. The patient would need education about alternative pain relieving techniques and a possible dose reduction of pain medications to avoid build up of medications due to impaired kidney and liver function.  Lactulose can also raise blood sugar, so monitoring blood sugars closely and maintaining a healthy diet would also be important points to discuss.  

References 

Caraceni, P., Vargas, V., Sol E., Alessandria, C., de Wit, K., Trebicka, J., Angeli, P., Mookerjee, R.P., Durand, F., Pose, E., Krag, A., Bajaj, J.S., Beuers, U., & Ginì P. (2021).  The use of Rifaximin in patients with cirrhosis. Hepatology, 74(3). DOI:  https://doi.org/10.1002/hep.31708Links to an external site.

Rosenthal, L. D., & Burchum, J. R. (2021). Lehneàpharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

Sarangi, A., Goel, A., Singh, A., Sasi, A., & Aggarwal, R. (2017). Faecal bacterial microbiota in patients with cirrhosis and the effect of lactulose administration. BMC Gastroenterology, 17(1). https://doi.org/10.1186/s12876-017-0683-9Links to an external site..