Response to teacher case study
Type of document Essay
1 Page
Subject area Pharmacology
Academic Level Master
Style APA
Number of references 3
Order description:
Please respond to my teacher asking to my post if we should continue the three medication Synthroid 100 mcg daily
Nifedipine 30 mg daily
Prednisone 10 mg daily
Pharmacotherapy for Hepatobiliary Disorders
Review of Case Study:
Patient HL comes into the clinic with the following symptoms: nausea, vomiting, and diarrhea. The patient has a history of drug abuse and possible Hepatitis C. HL is currently taking the following prescription drugs:
Synthroid 100 mcg daily
Nifedipine 30 mg daily
Prednisone 10 mg daily
History of Present Illness and Medical History
Patient presents with symptoms of diarrhea, nausea and vomiting. Learning from HL’s medical history, HL appears to have some possible chronic conditions based on his current medications; Synthroid 100 mg daily, Nifedipine 30mg daily, and prednisone 10mg daily. Also, the history states that HL has a history of drug abuse and possible Hepatitis C that could have possibly started years ago or more recently.
Synthroid is a hormone replacement that is used to treat hypothyroidism, thyroid cancer and goiter (Drugs.com, 2017). Synthroid can have adverse effects if not taken properly or if misused. Diarrhea is a common side effect of Synthroid, but nausea and vomiting along with appetite changes are a severe/adverse side effect of Synthroid, and should be reported the health practitioner immediately (Drugs.com, 2017). In a healthy adult age 50 years or less with a weight of 70kg or more; it is recommended that the initial dose of 100-125 mcg/day be taken for a few months. In elderly patients, the starting dose should be 25-50mcg day and gradual increase of decrease of dose many be needed. Thyroid should be checked every 6-8 weeks (Drugs.com, 2017). In addition, care should be taken if patient has any history of heart disease, coronary artery disease or blood clots. Assuming this patient is under 50 years old, the current dosage is appropriate, however lab workup is needed to verify if the TSH levels are within normal therapeutic levels.
Nifedpine is a calcium channel blocker that is used to treat hypertension and chest pain (angina). The initial dose is 30-60mg orally once a day for the extended release and 10mg for the immediate release tablets. Vomiting, nausea and diarrhea are not common side effects for this drug (Drugs.com, 2017). Nifedipine has also been linked to several instances of clinically apparent acute liver injury. Prednisone is a corticosteroid that prevents the release of substances in the body that causes inflammation it also suppresses the immune system (Drugs.com.2017). Prednisone treats many different conditions such as allergic disorders, skin conditions, ulcerative colitis, arthritis, lupus, psoriasis, or breathing disorders. Prednisone should be taken with care if you have a thyroid issue. Also, a side effect of prednisone is pancreatitis which presents with severe pain in your upper stomach, nausea and vomiting. Though this case study did not give much information on why HL is on prednisone, the possible use will be for the management of Hepatitis C-related arthropathy, which is one of the most common extrahepatic manifestations of hepatitis C virus (HCV) infection (Kemmer and Sherman, 2010). Prednisone is prescribed as an alternative option for HCV patients who are unresponsive to NSAIDs or have advanced liver disease, such as cirrhosis, and in those who have contraindications to their use (nephrotoxicity); short-term, low-dose prednisone (5 to 10 mg) is usually prescribed. Nifedipine will increase the level or effect of prednisone by affecting hepatic/intestinal enzyme CYP3A4 metabolism, and should be used with caution.
Assessment and Diagnostics
A comprehensive history and physical examination is required to create a full picture of any underlining issues that is causing the patient’s symptoms. Medication reconciliation is needed to be conducted for potential drug interactions. In addition, diagnostic workup is needed for further evaluation. Drug Screen test, Urinalysis, abdominal ultrasound, Blood tests such as liver panel, CBC, CMP, TSH, Hepatitis C RNA test, genotype test, and antibody test for HCV will be ordered to determine the cause of the symptoms.
Primary Diagnosis: Hepatitis C Virus
Hepatitis C is a serious liver infection caused by the hepatitis C virus that usually result from infected person-to-person contact of blood and bodily fluids, sexual intercourse or sharing of needles associated with illicit drug/substance use. It can be acute or chronic. The symptoms of HCV are sometimes very difficult to recognize. HCV is progressive in nature, and in most cases, symptoms are asymptomatic, but may present major problems. It is often undiagnosed due to the symptoms present as flu-like illness. Usually, elevated liver enzymes and a positive antibody test for HCV (anti-HCV) mean that an individual has hepatitis C. Symptoms include fatigue, mild fever, muscle and joint aches, nausea, vomiting, loss of appetite, vague abdominal pain, and sometimes diarrhea. Diarrhea develops during acute hepatitis C. Although this initial phase of infection generally causes no symptoms at all, approximately 20 to 30 percent of people notice symptoms about 1 to 3 months after contracting the virus (Centers for Disease Control and Prevention, 2016). From the data collected, the patient has a history drug abuse, the current medications such as prednisone and presenting symptoms may suggest the diagnosis of Acute Hepatitis C.
Differential Diagnosis
Drug Dependence and Abuse: The signs and symptoms displayed by a person depend on what substances the person has abused. Symptoms may include altered mental status, CNS suppression, nausea, vomiting, diarrhea, anxiety, hallucinations, chest pain, and abdominal pain. Most patients with substance abuse commonly exhibit behavioral symptoms that can cause harm to self or others, and requires an emergent medical intervention. Though the patient has a history of substance abuse, the patient’s symptoms didn’t include behavioral, CNS suppression or altered mental status. The patient appears alert, and oriented, and so would rule it out as the major culprit.
Spontaneous Bacterial Peritonitis: is an acute bacterial infection of ascitic fluid, and is a complication in patients with liver cirrhosis. Symptoms include fever, chills, abdominal pain, diarrhea, worsening encephalopathy, ascites that does not improve with diuretic, new-onset of renal failure, and ileus. There was no indication on the patient’s medical history of taking diuretics, and only symptom noted was diarrhea. The patient didn’t present with ascites or ileus, so would rule it out.
Gastroenteritis: is irritation/inflammation of the stomach and intestines caused by food contaminated with bacteria, viruses, parasites, or toxins. Symptoms may include cramping, nausea, vomiting, or diarrhea. The illness usually spreads easily from contact with a sick person or eating or drinking contaminated food or beverages also will spread the illness. Most people recover in a few days by drinking plenty of fluids and resting. Antibiotics treat gastroenteritis caused by bacteria or some parasites. In most cases, nausea, vomiting, and diarrhea get better within 24 to 48 hours.
Plan and Treatment Recommendations
According to the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (2016), the following are the recommendations for treatment and management per HCV Guidelines:
Regular laboratory monitoring is recommended in the setting of acute HCV infection. Monitoring HCV RNA (e.g., every 4 weeks to 8 weeks) for 6 months to 12 months is also recommended to determine spontaneous clearance of HCV infection versus persistence of infection.
If the practitioner and patient have decided that a delay in treatment initiation is acceptable, monitoring for spontaneous clearance is recommended for a minimum of 6 months. When the decision is made to initiate treatment after 6 months, treating as described for chronic hepatitis C is recommended. Treatment is determined by the genotype of the HCV, there are six genotypes. Based on patient HL’s symptoms, and diagnostic workup, the patient most likely fall under the genotype 1a (without cirrhosis).
Combination of elbasvir (50 mg)/grazoprevir (100 mg) daily for 12 weeks; for patients in whom no baseline NS5A RASs§ for elbasvir are detected.
Combination of ledipasvir (90 mg)/sofosbuvir (400 mg) daily for 12 weeks or 8 weeks for patients who are non-black, HIV-uninfected, and whose HCV RNA level is <6 million IU/mL
Combination of paritaprevir (150 mg)/ritonavir (100 mg)/ombitasvir (25 mg) with dasabuvir (600 mg) daily for 12 weeks as part of an extended-release regimen or plus twice-daily dosed dasabuvir (250 mg), with weight-based ribavirin.
Taking simeprevir (150 mg) with sofosbuvir (400 mg) daily for 12 weeks.
Combination of sofosbuvir (400 mg)/velpatasvir (100 mg) daily for 12 weeks
Taking daclatasvir (60 mg*) with sofosbuvir (400 mg) daily for 12 weeks; the dose of daclatasvir may need to increase or decrease when used concomitantly with cytochrome P450 3A/4 inducers and inhibitors, respectively.
An alternative treatment, is the combination of elbasvir (50 mg)/grazoprevir (100 mg) with weight-based ribavirin; for patients who have baseline NS5A RASs§ for elbasvir daily for 16 weeks.
If a decision has been made to initiate treatment during the acute infection period, monitoring HCV RNA for at least 12 weeks to 16 weeks before starting treatment is recommended to allow for spontaneous clearance.
Owing to high efficacy and safety, the same regimens that are recommended for chronic HCV infection are recommended for acute infection.
For patients in whom HCV infection spontaneously clears, treatment is Not Recommended.
Counseling is recommended for patients with acute HCV infection on nutrition, hydration, avoiding hepatotoxic insults, including hepatotoxic drugs (e.g., acetaminophen) and alcohol consumption, and reducing the risk of HCV transmission to others.
Referral to an addiction medicine specialist is recommended for patients with acute HCV infection related to substance use.
References
American Association for the Study of Liver Diseases and the Infectious Diseases Society of
America (2016). Management of Acute HCV Infection. Retrieved from http://www.hcvguidelines.org/unique-populations/acute-infection
Centers for Disease Control and Prevention (2016). Hepatitis C FAQs for the Public.
Retrieved from https://www.cdc.gov/hepatitis/hcv/cfaq.htm
Daley, M. (2015). Stool Symptoms of Hepatitis C. Retrieved from
http://www.livestrong.com/article/203883-stool-symptoms-of-hepatitis-c/
Drugs.com (2017). Drugs by Condition. Retrieved from http://www.drugs.com/
Dryden-Edwards, R. (2016). Drug Dependence and Abuse. Retrieved from
http://www.emedicinehealth.com/drug_dependence_and_abuse/article_em.htm#drug_dependence__abuse_overview
Green, T. (2016). Spontaneous Bacterial Peritonitis. Retrieved from http://emedicine.medscape.com/article/789105-overview
Kemmer, N. & Sherman, K. (2010). Hepatitis C-related arthropathy: Diagnostic and treatment considerations. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3103264/
Medscape (2017). Drug Interaction Checker. Retrieved from http://reference.medscape.com/drug-interactionchecker
WebMD (2015). Gastroenteritis. Retrieved from
