NSG-533-IKC – ADVANCED PHARMACOLOGY DISCUSSIONS

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NSG-533-IKC – Advanced Pharmacology Discussions

NSG-533-IKC – Advanced Pharmacology Discussions
State Legal Requirements for CRNP Prescriptive Authority
Course Outcome: Fulfill legal requirements for writing prescriptions as a CRNP in this Commonwealth of Pennsylvania in accordance with § §  21.283—21.287 (relating to CRNP).
Link: http://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/049/chapter21/subchapCtoc.html&d=reduce
The link provided for the Pennsylvania Code outlines the legal requirements that govern nurse practitioners in Pennsylvania. Although each state may vary somewhat with regards to its requirements, the basic framework is provided. Each student should take some time to familiarize themselves with these requirements and determine if the requirements in their own state may vary.
If there are any questions or comments, please post as necessary. This Section is Not Graded
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Introductions
Contains unread posts
Please introduce yourself to the class.
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Unread for topic Introductions:(48)
View profile card for Pawn Johnson-Hunter
Pawn Johnson-Hunter
Sep 7, 2020 1:30 AM
Module I: GI Topics Discussion
Must post first.
Proton pump inhibitors are a class of novel drugs that are the most potent acid suppressors on the market today.  Since omeprazole’s introduction in 1990, they have been clinically proven to be better than H2RAs.  Over the past decade their use has been scrutinized because of several harmful disease associations.
C. difficile infection: FDA’s analysis of over 28 studies revealed that patients taking PPIs were at a 1.4-2.75 times greater risk of developing an infection
Fractures: FDA reviewed several studies and have concluded that PPIs in high doses, multiple daily doses, and/or continued therapy for longer than a year increase a person’s risk of osteoporosis related fracture
Magnesium: PPIs may decrease magnesium level, which can lead to muscle spasms, arrhythmias, seizures, and fatigue.  This typically occurs after long-term administration of PPIs, usually longer than a year.  Treatment may require magnesium replacement and PPI discontinuation
Dementia: Although several theories exist to possibly explain the mechanism, the association needs to be validated in large cohorts and tested in case-control studies. For now, it is probably safe to say a causal link is plausible.
H. Pylori infection causes gastritis, PUD, gastric cancer and mucosa-associated lymphoid tissue (MALT) lymphoma and the association between the presence of H. pylori and NSAIDs and an increased incidence of PUD is well documented.
How would you handle a patient who wants to begin long-term PPI use?
What would your discussion with them entail?
In what patients or disease states would you not recommend PPI use?
What if H. Pylori is found to be present?
 
The following FDA warning appears in the clopidogrel package insert: “Drug interactions: Co-administration of Plavix with omeprazole, a proton pump inhibitor that is an inhibitor of CYP2C19, reduces the pharmacological activity of Plavix if given concomitantly or if given 12 hours apart. ” Plavix (clopidogrel) [package insert] Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership Bridgewater, NJ. 2009.
Evidence-based guidelines such as those provided by the AGA state: “PPI therapy does not need to be altered in concomitant clopidogrel users as there does not appear to be an increased risk for adverse cardiovascular events”. (Strong recommendation, high level of evidence) Am J Gastroenterol 2013; 108:308–328; doi:10.1038/ajg.2012.444.
This leaves the provider to make a professional decision.
You may wish to read the portion of clopidogrel’s package insert [link below] regarding pharmacogenomics as well as the article found in Medscape [link below] regarding genetics in pharmacotherapy before answering the last question. Pharmacogenomics is, and will become, an increasingly bigger part of care as we move forward.
https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020839s044lbl.pdf
https://www.medscape.com/viewarticle/888159_2
 
After reviewing the package insert for clopidrogel and available evidence regarding this combination, what would you recommend if a patient is taking esomeprazole and clopidrogel together?
 
Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.
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View profile card for Kelly Miskovsky
Kelly Miskovsky
Sep 8, 2020 2:26 PM
Module II: Diabetes/Endocrine Topic Discussion
Contains unread posts
Must post first.
Often we see a great deal of misinformation in the care of patients with diabetes, and often this misinformation is centered around the role and choice of medications.  Many patients, especially newly diagnosed patients, are prescribed medications that do not fit into the scheme of the ADA / AACE guidelines / best evidence based practices – for instance, starting on Januvia (sitagliptin) or Jardiance (empagliflozin) or Byetta (exenatide) as initial monotherapy without a compelling indication or reason.
In this discussion, please talk about how patients get put on these medications and why/how they should be transitioned to more evidence based treatments.
Is it okay to start a patient on a drug (particularly an oral drug) other than metformin as an initial drug?  Please cite possible circumstances where this could be reasonable.
What anti-diabetic medications have compelling evidence for use in select populations, possibly as initial therapy, and is this benefit a “class” effect?
(eg. SGLT2Is – Patients with type 2 diabetes and a high risk of cardiovascular disease had reduced risk of a cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke relative to those randomized to receive placebo)
How can patients and practitioners be convinced to change their behavior and opt for more evidence based approach to therapy?
Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.
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Unread for topic Module II: Diabetes/Endocrine Topic Discussion:(2)
View profile card for Dianne Cohen
Dianne Cohen
Sep 19, 2020 11:19 PM
Module III: Men’s and Women’s Health Discussion
Contains unread posts
Must post first.
Consider the following scenarios:
LW is a 32 year old female patient who comes to your medical clinic for primary care.  She has been on hormonal contraceptives for years, although she’s just been married and has stopped her pills in hopes of becoming pregnant.  Her PMHx includes obesity, HTN (diagnosed 3 years ago), familial hypercholesterolemia, and PCOS.  Her current medications are as follows: Metformin 2000 mg PO daily, Lisinopril 10 mg PO daily, rosuvastatin 5 mg PO daily, and a multivitamin.
GD is an 82-year-old patient is taking 2 mg of terazosin for BPH every morning. He comes in complaining of dizziness, generalized muscle weakness and persistent lower urinary tract symptoms (LUTS).
How should you advise these patients and manage their medications?  What was the process you went through to assess the current medications and to recommend an updated regimen?
Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.
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Unread for topic Module III: Men’s and Women’s Health Discussion:(6)
View profile card for Gisselle Mustiga
Gisselle Mustiga
Sep 21, 2020 9:52 PM
Module IV: Psychiatric Disorders (Depression, Anxiety, Sleep) Discussion
Contains unread posts
Must post first.
Benzodiazepines are commonly prescribed medications for several indications, including anxiety and sleep disorders. Let’s discuss their use in our health care systems and the impact on our patients.
Things to consider might include (just getting you thinking):
Safety: How could the side effect profile affect your patients?
Efficacy: Are benzodiazepines efficacious for anxiety and sleep?
Use: Are they under or over prescribed? How can we ensure safe use of these medications?
Consider the following cases:
KT is a 24 year old female completing her studies. While home for spring break, she presents to her primary care physician because she has been worried about her academic, professional, and personal future since class restarted in late August. She is constantly worried about passing all of her exams and that she is going to be the only one of her friends that graduates school without a ring on her finger.
How would you help her assuming she meets the criteria for GAD?
WD is a 49-year-old male who suffered a myocardial infarction one week ago. Upon discharge, it was noted that WD appeared depressed. At a follow-up visit with his physician a week later, WD met criteria for a diagnosis of major depressive disorder. His past medical history includes: treatment refractory hypertension, diabetes mellitus (type II), and severe uncontrolled narrow angle glaucoma
How would you help him assuming he meets the criteria for MDD?
JM is a 42 year old female who was referred for management of insomnia. She reports that she is unable to sleep at all during the week (difficulty going to sleep and staying asleep) and sleeps all day on Sunday. She currently takes temazepam (Restoril) 30 mg HS (recently increased from 15mg). She also experiences depression due to an abusive relationship with her boyfriend as well as her current lack of employment. She reports poor sleep hygiene (reads and watches TV in bed), drinks 6-8 cups of coffee throughout the day and does not pay attention to how late she eats or exercises.
What non-pharmacological and pharmacological therapies would you recommend for JM?
Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section.
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Unread for topic Module IV: Psychiatric Disorders (Depression, Anxiety, Sleep) Discussion:(15)
View profile card for Pawn Johnson-Hunter
Pawn Johnson-Hunter
Sep 27, 2020 9:54 PM
Module V: Pain Management Discussion
Must post first.
There are hundreds of opioid conversion calculators available online, though they are not all of good quality.  I would like to direct you to one of the opioid conversion calculators that I find to be most useful and evidence based.  Locate http://opioidcalculator.practicalpainmanagement.com/ and evaluate the following case using the calculator as necessary. Discuss your approach to the overall case and results of your calculation.
A 79 year old white male is taking hydrocodone/APAP 10/325 for lower back pain (pt diagnosed with degenerative disc disease several months ago). The physician had written a prescription for Vicodin® 10/325  i-ii Q4-6h prn pain with a quantity of 120.  Her expectation was that this would last the patient for one month.  The patient is now requesting refills about every 10-14 days.  He states he has been taking 2 tabs Q4h (12 tablets per day) because “the pain is so bad I just can’t stand it!”.
What is the problem with the way the patient is taking this medication versus the way it was prescribed
Based on your assessment, it is determined this patient should be converted to extended release morphine for better, more consistent pain control. Perform this conversion and provide an appropriate recommendation (drug, dose, frequency).
Migraine is a major neurological disease that affects more than 36 million men, women and children in the United States. There is no cure for migraine. Most current treatments aim to reduce headache frequency and stop individual headaches when they occur. Let’s look at a case example:
CM is 20 years old female with severe, prolonged 2 to 3 day migraines twice per month. She has difficulty sleeping and is mildly anxious. She occasionally utilizes an inhaler for asthma.
Provide an evaluation of CM’s condition including non-pharmacological interventions and treatment options
Is Cm a candidate for prophylactic therapy, and if so, what option would be best suited to her?
Post your initial response by Wednesday at midnight. Respond to one student by Sunday at midnight.  Both responses should be a minimum of 150 words, scholarly written, APA formatted, and referenced.  A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section. 
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