Risk Cardiovascular Pharmacology, Pharmacology Cardiovascular risk, Pharmacology, Pharmacology Case Scenarios.

 Risk Cardiovascular Pharmacology, Pharmacology Cardiovascular risk, Pharmacology, Pharmacology Case Scenarios.

Evidence-based practice must be the good use of medications, a good understanding of pharmacology, and pharmacological safety. The advanced practice nurses are supposed to pinpoint the medication errors, compute the pharmacokinetics and drug metabolism, and establish a proper treatment plan based on the character of the patient and the clinical guidelines, which are readily accessible. The scenarios that follow cogitate on the differentiation of certain pharmacologic concepts used in cardiovascular care. These are defining the prescription errors, acquaintance with the first-pass Metabolism and bioavailability, the significance of the cytochrome P450 enzymes in the Metabolism of drugs and developing a treatment plan for the patient with dyslipidemia and cardiovascular risk factors.

Scenario 1

 Prevention and Remedies of Prescription Errors.

In clinical practice, medication orders must be precise since any prescription error may lead to the occurrence of adverse drug events and injuries to patients. The latter prescriptions are incorrect in terms of dose, route, or formulation. The mistakes will be indicated and corrected, and the drug classification and mechanism of action discussed.

Prescription 1

In clinical practice, medication orders must be precise since any prescription error may lead to the occurrence of adverse drug events and injuries to patients. The latter prescriptions are incorrect in terms of dose, route, or formulation. The mistakes will be indicated and corrected, and the drug classification and mechanism of action discussed.

Error Identified

The administration route is inappropriate. Evolocumab (Repatha) is not given intravenously but subcutaneously.

Correct Prescription

Drug: Evolocumab (Repatha) prefilled syringe 140mg/mL.

Sig: 140 mg injected subcutaneously every 2 weeks.

Dispensing: 28 days (2) prefilled syringes.

Refills: 1

Indication: Hyperlipidemia

Drug Classification

PCSK9 inhibitor

Mechanism of Action

Evolocumab blocks the action of the PCSK9 protein, which usually activates the breakdown of LDL receptors in the liver (Abduljabbar, 2024). The inhibition of this protein causes more LDL receptors to be left to clear LDL cholesterol in the blood, resulting in a low level of LDL in the bloodstream.

Prescription 2

Error Identified

The given combination of doses is not correct. The strength is available at 50 mg /12.5mg and not 50/25mg.

Correct Prescription

Drug: Losartan/Hydrochlorothiazide (Hyzaar) 50mg/12.5mg pill.

Sig: One tablet by mouth per day.

Dispense: #30 tablets (30-day supply)

Refills: 3

Indication: Hypertension

Drug Classification

Angiotensin II receptor blocker in combination with a thiazide diuretic.

Mechanism of Action

Angiotensin II is blocked by losartan, vasoconstriction is blocked, and blood pressure is reduced by losartan. Hydrochlorothiazide increases sodium and water loss through the kidneys and reduces the volume of blood and blood pressure (Mulla et al., 2024).

Prescription 3

Error Identified

It is highly overdosed and might cause toxicity. The correct dosage is 0.125mg per day.

Correct Prescription

Drug: Digoxin 0.125 mg tablet

Sig: Oral intake of 1 tablet per day.

Dispense: #30 tablets (30-day supply)

Refills: 1

Sign: Congestive heart failure / atrial fibrillation.

Drug Classification

Cardiac glycoside

Mechanism of Action

Digoxin inhibits the sodium-potassium ATPase of heart cells and increases the intracellular calcium (Nicole & Shetty, 2024). This augments the cardiac output, augments the myocardial contractions, and decelerates the conduction of the atrioventricular node.

Prescription 4

Error Identified

BiDil does not include isosorbide mononitrate but isosorbide dinitrate.

Correct Prescription

Drug: Hydralazine 37.5mg / Isosorbide dinitrate 20mg pill (BiDil)

Sig: 1 tablet by mouth 3 times per day.

Dispense: #90 tablets (30-day supply)

Refills: 1

Indication: Heart failure

Drug Classification

Vasodilator combination

Mechanism of Action

Hydralazine leads to decreased afterload that is induced by arterial vasodilation. Isosorbide dinitrate releases nitric oxide, which results in venous expansion and a decrease in preload, which helps in reducing cardiac workload.

Prescription 5

Error Identified

The route is incorrect. The patch is applied to the skin, as opposed to orally.

Correct Prescription

Medication: Clonidine 0.3mg/24-hour transdermal patch.

Sig: 1 area of clean, dry skin per week.

Dispense: #4 patches (28-day supply)

Refills: 1

Indication: Hypertension

Drug Classification

Central alpha-2 adrenergic agonist

Mechanism of Action

Clonidine also activates the alpha-2 receptors in the brainstem, which decreases the activity of the sympathetic nervous system and decreases blood pressure.

References

Abduljabbar, M. H. (2024). PCSK9 Inhibitors: Focus on Evolocumab and Its Impact on Atherosclerosis Progression. Pharmaceuticals, 17(12), 1581. https://doi.org/10.3390/ph17121581

Mulla, S., Patel, P., & Siddiqui, W. J. (2024, February 26). Losartan. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526065/

Nicole, M., & Shetty, M. (2024, November 25). Digoxin. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK556025/

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Scenario 2

 Nitroglycerin and First-Pass Metabolism Pharmacokinetics.

Nitroglycerin is primarily used in angina, which dilates the blood vessels using the smooth muscle of the vessels and increases blood flow within the heart. However, oral nitroglycerin cannot be applied in acute angina because the agent is very much metabolized during the first pass in the hepatolysis process (Kim et al., 2023). Orally, the drug is absorbed through the gastrointestinal tract and delivered into the liver and subsequently the systemic circulation. During the process, a good percentage of the drug is expelled quickly, and this greatly reduces the medicinal action of the drug.

First-Pass Metabolism

The initial Metabolism of a drug before it gets access to the bloodstream is first-pass Metabolism, which is the Metabolism that is received by the liver after being swallowed.

Bioavailability

The ratio of absorption of a drug into the systemic circulation in an active form upon administration can be defined as bioavailability.

Route With 100% Bioavailability

When the drug is administered intravenously, the bioavailability is 100 percent because the drug does not undergo hepatic Metabolism (Stielow et al., 2023).

Avoidance of First-Pass Metabolism.

There is no transit of sublingual and transdermal routes via the gastrointestinal tract and hepatic portal. This helps the drug to be absorbed directly into the blood to have a faster effect of treatment.

Sample Prescription

Name: Nitroglycerin 0.4mg sublingual tablets.

Sig: Take one pill under the tongue when the chest pains strike. May repeat after every 5 minutes up to three times.

Dispense: #25 tablets

Refills: 1

Indication: Acute angina

References

Kim, K. H., Adnan, G., & Schaller, D. J. (2023, July 31). Nitroglycerin. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482382/

Stielow, M., Witczyńska, A., Kubryń, N., Fijałkowski, Ł., Nowaczyk, J., & Nowaczyk, A. (2023). The Bioavailability of Drugs—The Current State of Knowledge. Molecules, 28(24), 8038. https://doi.org/10.3390/molecules28248038

‌Scenario 3

Enzyme and Cytochrome P450: Drug Identification.

The cytochrome P450 enzymes are located mostly in the liver, and most of the drugs are metabolized. What makes learning about these enzymes important is that they define the interactions and safety of drugs in medication (Hossam Abdelmonem et al., 2024).

Cytochrome P450 Enzymes Location.

The cytochrome P450 enzymes are concentrated mainly in the liver, yet in lesser amounts in the intestines, kidneys, and lungs.

Pill Identification

Drugs.com pill identifier with the following characteristics:

Imprint: E 137

Color: Pink

Shape: Round

The drug is known as Amlodipine 5mg.

CYP is an enzyme that carries out Metabolism.

The CYP3A4 enzyme primarily metabolizes Amlodipine.

Transference to Medication Therapy Management.

The understanding of the enzyme that degrades a drug is helpful in the prediction of drug interactions by clinicians. CYP3A4 inhibitors have the ability to increase the concentration of Amlodipine, thereby increasing the risk of hypotension or edema (Jones et al., 2024).

Sample Prescription

Drug: Amlodipine 5 mg tablet

Sig: Once a day, swallow an oral tablet.

Dispense: #30 tablets (30-day supply)

Refills: 2

Indication: Hypertension

References

Hossam Abdelmonem, B., Abdelaal, N. M., Anwer, E. K. E., Rashwan, A. A., Hussein, M. A., Ahmed, Y. F., Khashana, R., Hanna, M. M., & Abdelnaser, A. (2024). Decoding the Role of CYP450 Enzymes in Metabolism and Disease: A Comprehensive Review. Biomedicines, 12(7), 1467. https://doi.org/10.3390/biomedicines12071467

Jones, K. E., Hayden, S. L., Meyer, H. R., Sandoz, J. L., Arata, W. H., Dufrene, K., Ballaera, C., Lopez Torres, Y., Griffin, P., Kaye, A. M., Shekoohi, S., & Kaye, A. D. (2024). The Evolving Role of Calcium Channel Blockers in Hypertension Management: Pharmacological and Clinical Considerations. Current Issues in Molecular Biology, 46(7), 6315–6327. https://doi.org/10.3390/cimb46070377

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Scenario 4

Heart and Blood Risk Evaluation and Cholesterol.

This is the case of measuring a patient with inappropriate lipids and other cardiovascular risk factors. The disorder has to be treated pharmacologically, and lifestyle changes have to be made (Wazir et al., 2023).

BMI Calculation

Height: 5’9″

Weight: 204 lb

BMI [?] 30.1 kg/m2

This is obesity (Class I) of the BMI.

Treatment Plan

Because of the large amount of LDL cholesterol in the patient, a high-intensity statin is recommended in an attempt to reduce the risk of cardiovascular complications.

Sample Prescription

Drug: Atorvastatin 40 mg tablet

Sig: orally, once daily in the evening in 1 pill.

Dispense: #30 tablets (30-day supply)

Refills: 2

Indication: Hyperlipidemia

Goal Lipid Levels

Total cholesterol: <200 mg/dL

LDL cholesterol: <100 mg/dL

HDL cholesterol: >40 mg/dL in men

Triglycerides: <150 mg/dL

Patient Monitoring

The surveillance must entail lipid profiles after 4-12 weeks of treatment, hepatic functions, assessment of muscle symptoms, and regular blood pressure and weight checking.

Patient Education

Patient should be encouraged to quit smoking, change his /her diet, maintain his/her weight, and practice regular exercise in order to decrease the risk of cardiovascular disease (Ghodeshwar et al., 2023).

Risk Factors of Coronary Artery Disease.

The patient has several cardiovascular risks:

  • Male sex
  • Age over 45 years
  • Smoking
  • Obesity
  • Hyperlipidemia

 

 

References

Wazir, M., Olanrewaju, O. A., Yahya, M., Kumari, J., Kumar, N., Singh, J., Abbas Al-itbi, A. Y., Kumari, K., Ahmed, A., Islam, T., Varrassi, G., Khatri, M., Kumar, S., Wazir, H., & Raza, S. S. (2023). Lipid Disorders and Cardiovascular Risk: A Comprehensive Analysis of Current Perspectives. Cureus. https://doi.org/10.7759/cureus.51395

Ghodeshwar, G. K., Dube, A., & Khobragade, D. (2023). Impact of Lifestyle Modifications on Cardiovascular Health: A Narrative Review. Cureus. https://doi.org/10.7759/cureus.42616

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Week 2 Assignment: Pharmacology Case Scenarios

Scenario 1

The following prescriptions contain errors.

  1. Identify one error in each prescription.
  2. Rewrite the correct prescription using the proper format.
  3. Identify the drug classification for each medication.
  4. Explain the mechanism of action (MOA) of each medication.

Prescriptions

  1. Repatha 140 mg IV every 2 weeks #1 1 RF
  2. Hyzaar (losartan/hydrochlorothiazide) 50/25 mg PO daily #30 3 RF
  3. Digoxin 1.25 mg PO daily #30 1 RF
  4. Hydralazine/Isosorbide mononitrate (BiDil) 37.5 mg/20 mg PO every 8 hours #90 1 RF
  5. Clonidine 0.3 mg patch PO once weekly #4 1 RF

Scenario 2

A patient with stable angina is prescribed nitroglycerin.

Answer the following questions:

  1. Explain why oral nitroglycerin is not clinically useful for treating angina.
  2. Define first-pass metabolism.
  3. Define bioavailability.
  4. Identify the route of administration that provides 100% bioavailability.
  5. Explain how sublingual and transdermal routes bypass first-pass metabolism.
  6. Write a sample prescription for nitroglycerin.

Scenario 3

Use the Drugs.com Pill Identifier with the following information:

  • Imprint: E 137
  • Color: Pink
  • Shape: Round
  • Form: Tablet

Answer the following questions:

  1. Identify the medication name.
  2. Identify the medication strength.
  3. Identify the CYP450 enzyme responsible for metabolizing this medication.
  4. Explain how this information is applied to medication therapy management.
  5. Write a sample prescription for this medication.

Scenario 4

A 47-year-old male presents for evaluation.

Patient Information

  • Smokes 1 pack per day
  • Current medications:
    • Lisinopril 40 mg daily
    • Liraglutide 0.6 mg daily
    • St. John’s Wort

Laboratory Results

  • Total cholesterol: 260 mg/dL
  • LDL: 180 mg/dL
  • HDL: 43 mg/dL
  • Triglycerides: 185 mg/dL

Physical Measurements

  • Height: 5’9″
  • Weight: 204 lb

Answer the following:

  1. Calculate the patient’s BMI using the Medscape BMI calculator.
  2. Develop an appropriate treatment plan.
  3. Identify the goal lipid levels for:
    • Total cholesterol
    • LDL
    • HDL
    • Triglycerides
  4. Explain patient monitoring requirements.
  5. Provide patient education related to cardiovascular risk reduction.
  6. Identify the patient’s coronary artery disease risk factors.