Drug Therapy 

Introduction to Drug Therapy

In the present case of Jolene, it is seen that due to the problems on the farm, she is been helping out on the farm. She has a history of an accident which caused deep vein thrombosis due to which she was not able to breathe and she is given anticoagulant for the same. She had an episode of tonic-clonic seizures which was due to the accident for which she was given medication and at present, she is diagnosed with depression for which she was given medication and she is in the first trimester of her pregnancy. The aim of the present essay is to discuss the underlying pathophysiological concepts and pharmacology of the drugs involved and discusses intervention according to the priority.

Pathophysiology

The first thing that the patient has undergone is the accident which has caused the formation of an embolus in the blood circulation which has caused deep vein thrombosis and with time it was seen that the embolus was lodged in the respiratory system causing her to have difficulty in breathing. The pathophysiology in the present case is due to the fracture that had taken place as a result of the accident. The fractures occurred in the tibia and fibula of the patient though it was fixed with the help of plates and pins there would have been the formation of a blood clot (Auer &Riehl 2017). As the blood gets circulated, the clot was detached from its original position and can get lodged in the small blood vessels. The most common site of lodgment of the embolism is the respiratory system in case the fracture is originated from lower extremities. The factors that are contributing to the formation of thrombosis are venous stasis, injury to the blood vessel and hypercoagulability (Stone et al. 2017). Valves present in the veins regulate the flow of blood at the same time it is responsible for the stagnation of blood. This with other factors is responsible for the increased ratio of procoagulants to anticoagulants which increase the risk of thrombus formation and due to impaired anticoagulant property that is formed in the blood the formation of thrombus is promoted(Stone et al. 2017).

The next thing that is seen is the development of tonic-clonic seizures which was diagnosed to be the result of the accident and resultant injury that might have occurred in the brain and associated structure like the spinal cord. An epileptic episode of tonic-clonic seizure is a transient occurrence of signs and symptoms which can be due to the excessive or abnormal but synchronous neuronal activity in the brain which can have various consequences like cognitive, psychological and social problems (King-Stephens 2018). In the present case, it is attributed to the accidents which can cause changes in the brain structure and function such that when there is an insult to the brain it cannot handle and result in the epileptic episode. Traumatic brain injury can cause focal and diffuse insult to the brain which can be a result of contusion or hematomas in the cortical areas or in adjacent areas which creates pressure in the cortical area (Tubi et al. 2019). The seizures can occur immediately after the accident or can be late depending on the area affected. In Jolene, it was late which means that temporal lobe of her brain could have been affected as it is the most commonly affected followed by frontal lobe(Tubi et al. 2019).

Suffering from the accident and not being able to fully recover from the condition and further she was having breathlessness which was a result of the clot lodged in her respiratory system and later she had a fainting spell followed by an epileptic episode. The body trying to recover from this has caused emotional and psychological trauma due to which Jolene is now facing the symptoms of depression which can be considered normal (Giummarra et al. 2018).

Medications

In the given case study, no specific medications are mentioned which are given to Jolene. The first medication that is given to the patient is anti-coagulant which is prescribed for the management of deep vein thrombosis. The anti-coagulant that can be prescribed to the patient is heparin. It is one of the most commonly prescribed anti-coagulants which is indicated in case of clotting disorders and deep vein thrombosis (Robinson et al. 2018). It is acidic anionic which is obtained from liver, lung and mast cells of other vertebrates. It acts by inhibiting the reactions which lead to the formation of clots in the blood and even after the formation of thrombosis, it works by inactivation of thrombin and conversion of fibrinogen to fibrin does not happen (Onishi et al. 2016). It destroys the existing clot by endogenous thrombolytic activity. It has poor first-pass metabolism and it is most commonly administered as an intravenous infusion. It has the high binding capacity to low-density lipoproteins and is metabolized in the liver and is excreted by reticuloendothelial systemof the body through a small amount is excreted unchanged in urine (Hassan et al. 2019). The half-life is dose-dependent and it varies from one hour to 150 minutes. There are a few side effects which are associated with heparin are easy bleeding and brusability increases (Li et al. 2017). It can also cause pain and redness at the site of administration.

The second drug that can be prescribed to the patient is lacosamide for epilepsy. It is the drug which is indicated in patients with partial-onset seizures who are over the age of 17 years and is used as adjunctive therapy (Hoy 2018). Lacosamide acts by the way of inhibition of sodium channels which are responsible for inhibition of pain. It acts by selective inhibition of depolarization of neurons instead of blocking the signals when the neurons were at resting potential (Scott 2015). The hyperexcitability of the neurons and associated pain are related to the depolarization of the neurons. Lacosamide acts by binding to the collapsing response mediator protein-2, the action of which is related to the expression of phosphoprotein in the nervous system which is responsible for neuronal differentiation and outgrowth of axons. It can be administered orally as the bioavailability is 100% and peek occurs in about 1-4 hours. It is metabolized in the plasma is excreted as a byproduct of biotransformation and through urine. There are a few adverse effects that are associated with the administration of lacosamide and they are dizziness, double vision, nausea, vomiting, vertigo-like symptoms and others (Gowda&Hegde 2015).

The third drug that is administered to the patient for the post-traumatic depression that she has been diagnosed is Mirtazapine. It belongs to the class of drug which is a tetracyclic antidepressant and is often prescribed for the patients who have major depressive symptoms (Kinrys et al. 2019). Other indications of the drug include generalized panic, anxiety, tension headaches, post-traumatic stress disorder, sleeplessness and others. It acts on alpha-2 adrenergic receptors both auto and hetero in the central nervous system. The symptom of depression is alleviated by enhanced activity of noradrenergic and serotonergic activity (Papazisis et al. 2018). It increases the transmission of dopamine by acting as an antagonist on the dopamine receptors. When administered orally, the bioavailability is 50% and the peak concentration of blood is attained within 2 hours. It has high binding to plasma protein and is metabolized in the plasma and is mainly excreted by the kidneys. There are a few adverse effects that are associated with the administration of mirtazapine and they are drowsiness, weight gain, xerostomia, fatigue, weakness and others (Riediger et al. 2017).

Prioritized Interventions

In the present case of Jolene, it is seen that in the current visit she reflected that she believes that she is pregnant and after the test, her general practitioner confirmed that she was pregnant and was in the first trimester of her pregnancy. The first intervention that needs to be done is to make sure that the drugs that are given to the patient are re-evaluated as there can be adverse effects that are associated with the administration of the drug. The first drug that was administered was heparin which was for the diagnosis of deep vein thrombosis. The link between deep vein thrombosis and pregnancy is profound (Bates et al. 2016). Due to the accident, the patient has already developed the condition and pregnancy further increases the risk of blood clots and the risk of deep vein thrombosis increases. There are other factors that are related to the development of deep vein thrombosis during pregnancy like varicose veins, diabetes, urinary tract infection, age of gestation and parity (Devis&Knuttinen 2017). To reduce the chances of miscarriage, during pregnancy, the blood of the patient reaches the state of hypercoagulability and with the history of Deep vein thrombosis the risk of blood clot increases. The patient is already administered with heparin as an anticoagulant in normal cases of pregnancy it is seen that the use of anticoagulant has created no difference but with history, it is important that heparin therapy continued.

Jolene is diagnosed with adult-onset epilepsy for which is given medication lacosamide. The drug is known to have a carcinogenic effect and during pregnancy, it has teratogenicity effect. The most common outcome effect that can be seen is the formation of neural tube defect and early bleeding that is seen in neonates (Gaitatzis& Sander 2013). It also interacts with the folic acid and vitamin K which is usually given as supplementation during the pregnancy and minimizes the beneficial effect of the same on the fetus (Tomson et al. 2013). The pharmacological effect of the drug can cause exaggeration of the seizure activity during pregnancy. Seizures during the pregnancy can cause untoward outcome for the fetus and depending on the progress of pregnancy it can wither cause miscarriage or pre-term labour. The medication should be regulated and avoided during the phase of organogenesis which is seen during the second trimester. Epileptic attack can occur when there is stress and childbirth can be stressful and it is often advised that the patient is given anti-epileptic medication before delivery so that the seizure can be avoided during childbirth and the baby is not affected (Mcallister-Williams et al. 2017).

The third intervention that is most importantly required is patient education and referral which is required for the patient-centred approach as well. The care plan and referral should be such that it is customized to the needs of the patient taking into consideration the beliefs and preferences. The patient is regularly visiting her general practitioner for her follow-ups and is compliant towards her medication. The general practitioner should educate the patient regarding the implication of her condition and how the medication might have an effect on her health as well as that of her child (Buttigieg et al. 2019). The GP should inform her regarding the things that she might need to avoid and be precautionary of during the course of her pregnancy. An appropriate referral is a part of person-centred care approach and in the present case, it is required that the patient is referred to obstetrics and gynecologist so that appropriate supplements and alteration to her regular medication in terms of dose and frequency can be made (Giessler et al. 2019). In the recent visits, the patient said she is depressed by the recovery that is happening and being pregnant can add to the stress and it is required that the patient is referred to a psychologist.

Conclusion on Drug Therapy

The present case was of Jolene who had a history of an accident which had caused her deep vein thrombosis, post-traumatic epilepsy and eventually her depression. She was given medication for the same and she was taking follow-up with her general practitioner. Fracture in her leg caused the formation of the clot which was responsible for the deep vein thrombosis while the injury to the frontal or temporal lobe was related to the seizure. Now the patient is pregnant and it is required that the medication that is given is evaluated which is customized to the needs of the patient. She requires referral to the gynecologist for the same and to a psychologist for the treatment of her depression.

References for Drug Therapy

Auer, R &Riehl, J 2017, ‘The incidence of deep vein thrombosis and pulmonary embolism after fracture of the tibia: An analysis of the National Trauma Databank’ Journal of Clinical Orthopaedics and Trauma, vol. 8, no. 1, pp. 38–44, doi: 10.1016/j.jcot.2017.01.007.

Bates, S, Middeldorp, S, Rodger, M, James, A, & Greer, I 2016, ‘Guidance for the treatment and prevention of obstetric-associated venous thromboembolism’ Journal of Thrombosis and Thrombolysis, vol. 41, no. 1, pp. 92–128, doi: 10.1007/s11239-015-1309-0.

Buttigieg, S, Tomaselli, G, Byers, V, Cassar, M, Tjerbo, T, &Rosano, A 2019, 'Corporate social responsibility and person-centered care: A scoping review' Journal of Global Responsibility, vol. 10, no. 4, pp. 289–306, doi: 10.1108/JGR-01-2019-0006.

Devis, P &Knuttinen, MG 2017, 'Deep venous thrombosis in pregnancy: Incidence, pathogenesis and endovascular management' Cardiovascular Diagnosis and Therapy, vol. 7, no. Suppl 3, pp. S309–S319, doi: 10.21037/cdt.2017.10.08.

Gaitatzis, A & Sander, J 2013, 'The long-term safety of antiepileptic drugs' CNS drugs, vol. 27, no. 6, pp. 435–455, doi: 10.1007/s40263-013-0063-0.

Giessler, K, Golub, G, &Afulani, P 2019, 'Providers and women's perspectives on person-centered maternity care: A mixed methods study in Kenya' International Journal for Equity in Health, vol. 18, no. 1, p. 83, doi: 10.1186/s12939-019-0980-8.

Giummarra, MJ, Lennox, A, Dali, G, Costa, B, &Gabbe, BJ 2018, ‘Early psychological interventions for posttraumatic stress, depression and anxiety after traumatic injury: A systematic review and meta-analysis’ Clinical Psychology Review, vol. 62, pp. 11–36, doi: 10.1016/j.cpr.2018.05.001.

Gowda, R &Hegde, V 2015, 'Efficacy and side effect profile of lacosamide in refractory focal onset epilepsy patients' Epilepsia, vol. 56, pp. 214–214.

Hassan, AM, Prasad, VN & Fidelis, N, 2019. Drugs used in thromboembolic disorders: An insight into their mechanisms. Asian Journal of Cardiology Research, pp.1-12.http://www.journalajcr.com/index.php/AJCR/article/view/30096.

Hoy, S 2018, 'Lacosamide: A Review in focal-onset seizures in patients with epilepsy' CNS Drugs, vol. 32, no. 5, pp. 473–484, doi: 10.1007/s40263-018-0523-7.

King-Stephens, D 2018, 'Epilepsy: Anatomy, physiology, pathophysiology, and disorders' in Neuromodulation, vol. 2, pp. 619–623, Elsevier Ltd, doi: 10.1016/B978-0-12-805353-9.00081-4.

Kinrys, G, Gold, AK, Pisano, VD, Freeman, MP, Papakostas, GI, Mischoulon, D, Nierenberg, AA, & Fava, M 2019, ‘Tachyphylaxis in major depressive disorder: A review of the current state of research’ Journal of Affective Disorders, vol. 245, pp. 488–497, doi: 10.1016/j.jad.2018.10.357.

Li, H, Chen, Y, Deng, Y, Wang, Y, Ke, X, &Ci, T 2017, ‘Effects of surface charge of low molecular weight heparin-modified cationic liposomes on drug efficacy and toxicity’ Drug Development and Industrial Pharmacy, vol. 43, no. 7, pp. 1163–1172, doi: 10.1080/03639045.2017.1301948.

Mcallister-Williams, RH, Baldwin, DS, Cantwell, R, Easter, A, Gilvarry, E, Glover, V, Green, L, Gregoire, A, Howard, LM, Jones, I, Khalifeh, H, Lingford-Hughes, A, Mcdonald, E, Micali, N, Pariante, CM, Peters, L, Roberts, A, Smith, NC, Taylor, D, &Wieck, A 2017, ‘British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017’ Journal of Psychopharmacology, vol. 31, no. 5, pp. 519–552, doi: 10.1177/0269881117699361.

Onishi, A, St Ange, K, Dordick, JS &Linhardt, RJ, 2016.Heparin and anticoagulation. Frontier.Bioscience, 21, pp.1372-1392.http://www-heparin.rpi.edu/main/files/papers/570d6646d2b110.85691577.pdf.

Papazisis, G, Siafis, S, &Tzachanis, D 2018, ‘Tachyphylaxis to the sedative action of Mirtazapine' The American Journal of Case Reports, vol. 19, pp. 410–412.

Riediger, C, Schuster, T, Barlinn, K, Maier, S, Weitz, J, &Siepmann, T 2017, 'Adverse effects of antidepressants for chronic pain: A systematic review and meta-analysis' Frontiers in Neurology, vol. 8, p. 307, doi: 10.3389/fneur.2017.00307.

Robinson, R, Wirt, TC, Barbosa, C, Amidi, A, Chen, S, Joseph, RM, & Fleischer, AE 2018, 'Routine use of low-molecular-weight heparin for deep venous thrombosis prophylaxis after foot and ankle surgery: A cost-effectiveness analysis' The Journal of Foot and Ankle Surgery, vol. 57, no. 3, pp. 543–551, doi: 10.1053/j.jfas.2017.12.001.

Scott, L 2015, 'Lacosamide: A review in focal seizures in patients with epilepsy' Drugs, vol. 75, no. 18, pp. 2143–2154, doi: 10.1007/s40265-015-0514-7.

Stone, J, Hangge, P, Albadawi, H, Wallace, A, Shamoun, F, Knuttien, MG, Naidu, S, &Oklu, R 2017, 'Deep vein thrombosis: Pathogenesis, diagnosis, and medical management' Cardiovascular Diagnosis and Therapy, vol. 7, no. Suppl 3, pp. S276–S284, doi: 10.21037/cdt.2017.09.01.

Tomson, T, Landmark, CJ, &Battino, D 2013, March, ‘Antiepileptic drug treatment in pregnancy: Changes in drug disposition and their clinical implications’ Epilepsia, doi: 10.1111/epi.12109.

Tubi, MA, Lutkenhoff, E, Blanco, MB, Mcarthur, D, Villablanca, P, Ellingson, B, Diaz-Arrastia, R, Van Ness, P, Real, C, Shrestha, V, Engel, J, & Vespa, PM 2019, ‘Early seizures and temporal lobe trauma predict post-traumatic epilepsy: A longitudinal study’ Neurobiology of Disease, vol. 123, pp. 115–121, doi: 10.1016/j.nbd.2018.05.014.

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