Applied Pharmacotherapeutics

In the given clinical scenario, a patient named James E. Jones, aged 58 years has been admitted to the hospital with high severity lower lobe pneumonia. The patient problems are identified and four of them are listed below for care priorities and rationale for the treatment recommendations.

  1. Lower lobe pneumonia- It is a type of pneumonia in the intra-alveolar space defined by inflammatory exudate, resulting in accumulation that affects a wide and continuous region of the lung lobe. For the prevention of bacterial pneumonia, certain medications are used. It can take time to determine and select the right antibiotic to treat the species of bacteria causing pneumonia. In this case, the patient has been given antibiotics through IV route. Rash, scratching and diarrhea are the most common symptoms involved with using IV antibiotics (Ford et al., 2018). The doctor may have to control these adverse effects and, where appropriate, change the antibiotics. Lung damage and its systemic sequelae are guided by dysregulation of the body's immune response due to vascular barrier function collapse, adverse hyper inflammation, and microcirculatory dysfunction, which lead to the unfavorable outcome of patients with serious pneumonia. Therefore, severe pneumonia cases need to be stratified and care needs to be begun early in a proactive way, including resolution-enhancing techniques. Second, combinations of various preclinical models with appropriate sophistication and precision in terms of clinical conditions need to be used to better represent the patient with pneumonia. Thirdly, evidence from hospital registries, RCTs, patient 'nutrition' reviews, and preclinical mechanistic and therapeutic trials, to name a few, should be incorporated into a system-medicine method (Müller-Redetzky et al., 2015).
  1. Atrial fibrillation- An erratic heart rhythm (arrhythmia) characterized by the fast and irregular pounding of the atrial chambers of the heart in atrial fibrillation (AF or A-fib). Typically, it starts as brief bursts of abnormal pounding, which over time become longer or constant. A higher risk of heart disease, dementia, and stroke is linked with the condition. Changes in healthier lifestyles, such as loss of weight in individuals with obesity, greater physical exercise, and consuming less alcohol, will decrease the risk of atrial fibrillation and, if it happens, minimize its effect (Gusev & Boshkovska, 2019). Medicines to reduce the pulse rate to a near-normal range (identified as to rate control) or transform the rhythm to normal sinus rhythm (defined as rhythm control) are also handled with AF. Regular aerobic activity decreases the effects of atrial fibrillation and the quality of life-related to AF. The advantage of stroke reduction always exceeds the risk of bleeding, the risk of falling and consequent bleeding in vulnerable elderly people may not be deemed a deterrent to initiating or maintaining anticoagulation. In individuals who are overweight or fat, weight loss by at least 10 percent is associated with decreased atrial fibrillation burden (Koutoukidis et al., 2020). The patient here in the case study weighs 125kg so it is necessary that weight management is to be done for the patient. The impact of high-intensity interval training on minimizing the stress of atrial fibrillation is required. Early after the very first diagnosis of AF, rhythm control therapy implemented could retain atrial function and structure and sustain sinus rhythm most efficiently than the existing delayed rhythm control procedure (Kirchhof, et al., 2020).
  1. Aspirin- This medicine is required for blood-thinning and those at low risk of a heart attack. Experts usually prescribe an anti-clotting treatment for people at higher than low risk. Many persons have a greater chance of stroke with aspirin. While these drugs decrease the risk of heart attack, they increase the likelihood of significant bleeding. So, aspirin is not given for patients as a primary treatment thread. The chance of gastrointestinal bleeding can be raised by heavy drinking (Strate et al., 2016). In the case study, the patient takes standard alcohol twice a week but if by chance during the heavy alcohol consumption it can create a problem for the patient. A careful self-management of the drug and drinking style has to be done by the patient. Although it is safe for most people to take an occasional aspirin or two for headaches, muscle aches, or fever, frequent aspirin take may have severe side effects, like internal bleeding. In high-risk patients, low-dose aspirin is considered to minimize the risk of heart disease. There may now be a reason for this aspirin to decrease blood pressure only when administered at bedtime (Hadley et al., 2020).
  1. Drug-drug interaction of Simvastatin and Clarithromycin- Simvastatin is a reductase inhibitor of HMG-CoA and is a CYP3A4 substrate. Clarithromycin is a potent CYP3A4 inhibitor and a widely used macrolide antibiotic. If administered in combination with simvastatin, clarithromycin will increase plasma concentrations of simvastatin dramatically, thus raising the risk of rhabdomyolysis. At moment, pharmacokinetic information is provided on the relationship between the two drugs (Wang et al., 2020). Combining these drugs will increase the levels of simvastatin in the blood dramatically. Which will raise the risk of complications such as injury to the liver and an uncommon but extreme disorder called rhabdomyolysis causing skeletal muscle tissue degradation. Rhabdomyolysis is a severe condition, occurs from the death of muscle fibers and their components are released into the bloodstream. Severe conditions such as renal (kidney) failure may contribute to this (Hougaard et al., 2020). This indicates that waste and accumulated urine will not be collected from the kidneys. After a heart attack, skeletal muscle damage, or strenuous exercise, levels of CK may increase (Pal et al., 2018). Which has been already shown in the patient as 290 U/L. If clarithromycin is required, it is recommended (a) to prevent co-administration with simvastatin, lovastatin, or atorvastatin; (b) to withhold or decrease the dosage of the drug and to continue treatment with caution, to restrict the dosage.

Following is the medication list for the regimen that the patient will be taking after your proposed changes have been implemented

Medications

 

Ibuprofen

 

metformin

1g BD

gliclazide

60mg SR 1 Mane

rivaroxaban

20mg PO Daily

ezetimibe

10mg PO Daily

Azithromycin

500mg PO

candesartan

32mg PO Daily

amoxicillin

1g PO Q8H

clarithromycin

500mg BD

References for James E. Jones Case Study

Ford, A. C., Harris, L. A., Lacy, B. E., Quigley, E. M., & Moayyedi, P. (2018). Systematic review with meta‐analysis: The efficacy of prebiotics, probiotics, synbiotics, and antibiotics in irritable bowel syndrome. Alimentary Pharmacology & Therapeutics48(10), 1044-1060.

Gusev, M., & Boshkovska, M. (2019). Performance evaluation of atrial fibrillation detection. In 2019 42nd International Convention on Information and Communication Technology, Electronics and Microelectronics (MIPRO) (pp. 342-347). IEEE.

Hadley, G., Gbinigie, I. I., & Buchan, A. M. (2020). Stroke: Management and prevention. Medicine.

Hougaard Christensen, M. M., Bruun Haastrup, M., Øhlenschlæger, T., Esbech, P., Arnspang Pedersen, S., Bach Dunvald, A. C. & Thestrup Pedersen, A. J. (2020). Interaction potential between clarithromycin and individual statins—A systematic review. Basic & Clinical Pharmacology & Toxicology126(4), 307-317.

Koutoukidis, D. A., Jones, N. R., Taylor, C. J., Casadei, B., & Aveyard, P. (2020). Obesity, self-reported symptom severity, and quality of life in people with atrial fibrillation: A community-based cross-sectional survey. Nutrition, Metabolism and Cardiovascular Diseases. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S0939475320302842

Müller-Redetzky, H., Lienau, J., Suttorp, N., & Witzenrath, M. (2015). Therapeutic strategies in pneumonia: going beyond antibiotics. European Respiratory Review24(137), 516-524.

P., Camm, A. J., Goette, A., Brandes, A., Eckardt, L., Elvan, A. & Hamann, F. (2020). Early rhythm-control therapy in patients with atrial fibrillation. New England Journal of Medicine. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMoa2019422

Pal, S., Chaki, B., Chattopadhyay, S., & Bandyopadhyay, A. (2018). High-intensity exercise induced oxidative stress and skeletal muscle damage in postpubertal boys and girls: A comparative study. The Journal of Strength & Conditioning Research32(4), 1045-1052.

Strate, L. L., Singh, P., Boylan, M. R., Piawah, S., Cao, Y., & Chan, A. T. (2016). A prospective study of alcohol consumption and smoking and the risk of major gastrointestinal bleeding in men. PloS One11(11), e0165278.

Wang, J., Chi, C. L., Peter, W. L. S., Carlson, A., Loth, M., Pradhan, P. M., ... & Adam, T. J. (2020). A population-based study of simvastatin drug-drug interactions in cardiovascular disease patients. AMIA Summits on Translational Science Proceedings2020, 664.

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