Safety Profile of Drugs
What are the possible complications to the pregnant woman and her fetus?
Lisinopril-hydrochlorothiazide like other ACEs are not safe during pregnancy; they trigger low amniotic fluid levels leading to fetal health development complications from growth restrictions to poor lung development, skull deformity and facial deformities. They are also linked to kidney failure and low blood pressure among newborns. Bismuth subsalicylate as is the case of salicylate products are also harmful to the fetus and the mother with risks being bleeding, perinatal mortality and ductus arteriosus closure (Webster et al., 2019).
Importance of Laboratory Values and Change in Medication
Laboratory values tell the current state of health for specific conditions, risks and patient overall health to help determine the appropriate medication and effectiveness. Some values can indicate damage to organs,, especially for patient with HTN who are prone to that and help with interventions. The positive HCG urine does point towards confirmation of pregnancy and considering the lack of safety in pregnancy that her medications show, it is an indication that changes in medicine would be appropriate (Croke, 2019).
In this case, the target is to prescribe Labetalol, first-line therapy for pregnant women with HTN. The medication is taken on a daily basis, via oral route and has a 6-8 hours half-life. Its mechanism of action is inhibition of vasoconstriction through blood vessel receptors blockage. Metabolism occurs via glucoronide metabolites conjugation; elimination is done via feces and urine. Contraindications are noted for those with cardiac failure, using beta-blocker medication and having asthma. So far, no warnings noted. Prilosec, a PPI would be appropriate for GERD since PPI safety during pregnancy is approved. The mechanism of action is inhibition of acid production by acting on K+/H+ ATP pump. Its half-life is 60 minutes, after which it clears from the system in 3 to 4 hours. The drug is contraindicated to drugs showing sensitivity to it, including some HIV medication. Metabolization occurs in the liver, which elimination mechanism resemble that of Labetalol (Croke, 2019).
Ethnopharmacology
Ethnopharmacology would apply in the sense that there would be consideration of how her background, ethnicity, would affect effectiveness of medication. This explains why clinical guidelines recommend different HTN medication for African Americans compared to others. In Place of ACE, it is recommended that African Americans be put under a calcium channel blocker or thiazide diuretic, meaning her drugs would need to change (Akunne & Adedapo, 2019). .
Health Maintenance/Preventive Education
Counseling and education over pregnancy, HTN and risks during pregnancy are important. This is in addition to educating patient over drug action, side effects and when to seek medical attention. Monitoring via frequent visits is needed (Croke, 2019).
Referrals
The focus would be managing the GERD and HTN of patient, but refer her for pregnancy management to a gynecologist. Referral to a hypertensive specialists would be made if HTN proves difficult to manage.
References
Akunne, O.O., & Adedapo, A.D.A. (2019). Antihypertensive prescription among black patients without compelling indications: Prescription, effectiveness, quality and cost of medication. BMC Health Serv Res 19, 373, n. p. https://doi.org/10.1186/s12913-019-4202-2
Croke L. (2019). Managing chronic hypertension in pregnant women: ACOG Releases Updated Practice Bulletin. Am Fam Physician, 100(12), 782-783. https://pubmed.ncbi.nlm.nih.gov/31845773/
Webster, K., Fishburn, S., Maresh, M., Findlay, S. C., Chappell, L. C., & Guideline Committee (2019). Diagnosis and management of hypertension in pregnancy: summary of updated NICE guidance. BMJ (Clinical Research ed.), 366, l5119. https://doi.org/10.1136/bmj.l5119
List the additional questions you would need to ask this patient. Explain.
- What was the first day of your last menstrual period (LMP)?
- Have you experienced headaches, dizziness, or visual disturbances?
What is the safety profile of Lisinopril-hydrochlorothiazide and bismuth subsalicylate in pregnant women? What are the possible complications to the pregnant woman and her fetus?
Lisinopril, and all ACE inhibitors, are contraindicated during pregnancy. Studies have shown that this drug can lead to fetal morbidity and mortality, causing it to be classified as a pregnancy category C in the first trimester and category D in the second and third trimesters. Bismuth subsalicylate is a pregnancy category C. Adequate studies have not been conducted on the drug during pregnancy, therefore safety of usage during pregnancy has not been established (Woo & Robinson, 2020).
What is the importance of assessing laboratory values when prescribing medications? How might the laboratory values, in this case, impact your treatment plan?
It’s vital to assess laboratory values when prescribing medications to ensure safety. Some medications may have increased risk of drug toxicity, so evaluating levels is important to prevent adverse effects. In the case of Ms. BD, all laboratory values are within normal limits, with the exception of the positive urine hCG. Due to this positive result, treatment would need to include medications that are safe during pregnancy.
Would you make any changes to Ms. BD’s blood pressure and GERD medications? Explain. If yes, what would you prescribe? Discuss the medications safety in pregnancy, mechanism of action, route, the half-life; how it is metabolized in and eliminated from the body; and contraindications and black box warnings.
Ms. BD’s blood pressure and GERD medications would need to be changed due to lack of safety during pregnancy. I would prescribe Hydralazine 10 mg PO QID. After 4 days, the Hydralazine may be increased to 25 mg PO QID, if needed. Hydralazine’s mechanism of action is to function as a peripheral vasodilator. This medication is given by mouth and has a half-life of 3-7 hours. It is metabolized in the liver and eliminated at 12-14% in the urine. Hydralazine is recommended to be used cautiously in patients with cardiovascular disease (Woo & Robinson, 2020).
For treatment of GERD, I would recommend that Ms. BD take Tums OTC PRN as directed. Tums are chewable tablets with an unknown half-life. Minimal metabolism takes place, and elimination occurs primarily in the feces, but approximately 20% occurs in the urine. Tums are contraindicated in the presence of renal calculi or in
What health maintenance or preventive education do you provide in this client case based on your choice of medications/treatment?
Ms. BD should be instructed to take her hydralazine at the same time each day and not to miss doses. The medication should also be taken with meals for maximum absorption (Woo & Robinson, 2020).
Would you treat this patient or refer her? Explain. If you refer, where would you refer this patient?
I would refer Ms. BD to an OB/Gyn due to the pregnancy. An OB/Gyn will not only be ablet to manage her prenatal care, but he/she would be equipped to treat her GERD and HTN in a safe way during pregnancy.
References
Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5th ed.). F.A. Davis. https://digitalbookshelf.southuniversity.edu/reader/books/9781719641531/epubcfi/6/8[%3Bvnd.vst.idref%3Dtp]!/4/2/2/2[tp]/4%4051:72
Mrs. S.J. a 60 year old female with a past medical history of hypertension, dyslipidemia, and obesity with a family history of cardiac disease presents to the office with complaints of chest pain for 3 months that comes and goes. The pain does not radiate, but does come with shortness of breath, burning, and a tingling sensation that resides after a few minutes. Mrs. J denies diaphoresis, dizziness, nausea, vomiting, and fainting. She attempts to change reposition herself to decrease pain to no avail. Mrs. J is high risk for developing cardiac disease or having a heart attack; her father died of a heart attack at the age of 57. Her diet will need modifying as well as her physical activity.
A complete assessment for Mrs. J should include a complete set of vital signs, auscultation of the heart and lungs, assessment of her pulses. An assessment of her head, eyes, ears, nose, and throat for bruits and jugular vein distention (JVD); bowel sounds should be auscultated in all 4 quadrants, as well as palpating abdominal organs and lower extremities for edema (Lowry, 2017).
As the provider I would recommend starting Mrs. J on a daily aspirin of 81 mg to prevent the possibility of a stroke (Lowry,2017). I would also want to refer her to a cardiologist for collaborative care. I would also educate her on the importance of modifying her diet and physical activity level. I would also educate her on the signs and symptoms of heart attack or stroke.
Reference
Buttaro, T. M., Trybulski, J. A., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care: A collaborative practice. Elsevier.
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