Respond to the 2 following discussion posts separately with separate reference lists.
References to be no older than 5 years.
1. [Yanelis Okoye] Q1. Please briefly discuss the first-line treatment recommendations from JNC8 and the AHA/ACC for a patient with no other significant comorbidities.
The recommendation for the eight joints Committee (JNC8) is that initial drug therapy for an African American patient should start with a thiazide-type diuretic or a calcium channel blocker (CCB) or the combination of both (Hernandez-Villa, 2015). Another article breaks the same recommendation more and states that even for the same patient with no major comorbidities, the thiazide-type shows more effectiveness than the ACE in black population (James et al., 2014). According to the AHA/ACC 2017 guideline initiation of hypertension should start with patient with patient on BP equal or higher than 140/90 mmHg and recommended as well initiated with the same medication mention by JNC8(Whelton et al., 2017). The patient needs a complete assessment from the start; the patient is noncompliant with the treatment plan from a previous primary care. We need to start with an assessment of what steps the patient will take and the physician to ensure a suitable treatment plan a medical history and laboratory analysis should be done with an EKG, and depending on the result, the patient should be referred to a Cardiologist for further checkup.
Q2. What are the recommended medications to start this specific patient on? Please provide the drug class, generic & trade name, an initial starting dose.
All medication by Rosenthal and Burchum, 2021
Calcium Channel Blocker
Generic name: Amlodipine
Trade Name: Norvasc
Initial starting dose: 2.5 mg( elderly)/ 5 mg to 10 mg once a day maximum dose daily. If started by 2.5 mg dose can be increased over 7-14 days depending on the patient’s response.
Thiazide diuretics medication
Generic name: Chlortalidone
Trade Name
Initial starting dose: Start by 25 mg to 100 mg once a day should be taken with food in the morning.
HMG-CoA
Generic name: Atorvastatin
Trade Name: Lipitor
Initial starting dose: start at 10 mg at bedtime with a maximum of 80 mg with or without food but at the same time every day.
Q3. Please discuss the mechanism of action of each of the drugs you listed.
A Calcium Channel Blocker Amlodipine (Norvasc) is a dihydropyridine calcium antagonist peripheral arterial vasodilator that acts directly on the vascular smooth muscle to decrease blood pressure. This medication Inhibits calcium ion influx across cell membranes selectively, with a greater effect on vascular smooth muscle cells than on cardiac muscle cells (Rosenthal and Burchum, 2021).
Thiazide diuretic like chlortalidone mechanism of action prevents the body from absorbing sodium (salt)and chloride on the nephron more specific on the early segment of the distal convoluted tube; where the thiazide act causing the retention of water (edema) and hypertension increasing urine output (Rosenthal and Burchum, pag 294, 2021).
The mechanism of action on Atorvastatin is inhibits 3 hydroxy- methyglutaryl-coenzyme A reductase by preventing the conversion to the coenzyme to mevalonate. This medication decreases the cholesterol production in the liver. They are mainly metabolized by CYP3A4 and the isoenzyme of cytochrome P450 (Rosenthal & Burchum, 2021) and eliminated in liver (Mclver & Siddique, 2021).
Q4. Please discuss the side effect profile of each medication you listed.
Amlodipine’s side effects will monitor drossiness, water retention, headaches, nausea, and vomiting ( Rosenthal & Burchum, 2021)
A Thiazide diuretic should not be used if the patient cannot urinate or is allergic to sulfa drugs, caution on a patient with a history of diabetes, gout renal impairment, or a low sodium diet. Also not recommended on pregnancy since it can cause the effect on the baby like jaundice, bruising, bleeding, or electrolyte imbalance not breastfeeding. Monitor for hyperglycemia for diabetes and hyperuricemia for gout attack (Akbari & Zadeh, 2022)
On HMO-CoA, side effects are uncommon; some patients can develop headaches, rash, GI onset feeling like flatulence or abdominal pain. Contraindication on pregnancy, also on viral or alcoholic hepatitis and fatty liver since is metabolized by the liver (Rosenthal and Burchum, page 360, 2021)
Q5. Are there any interactions between any of the medications you prescribed?
Drug-to-drug interaction on calcium channel is with Co-administration in CYP3A inhibitors results in increased systemic exposure to amlodipine and may require dose reduction. Monitor for hypotension and edema to determine the need for dose adjustment. Combine with sildenafil will monitor for hypotension with co-administration of simvastatin with amlodipine increases the systemic exposure of simvastatin. Limit the dose of simvastatin in patients on amlodipine to 20 mg daily (Daily Med, 2019).
Thiazide drug interactions are being seen with lithium, digoxin, insulin, or steroids medicine (Akbari & Zadeh, 2022)
Drug to drug interaction with lipid-lowering medications can cause muscle injury and liver, not give with Ezetimide since increased risk for liver damage, interaction with fibrates, macrolides, amiodarone can increase toxicity need to be used with caution and reduce statin dose (Rosenthal & Burchum, 2021)
Q6. What other non-pharmacological interventions would be suggested?
Lifestyle changes like exercising 2-3 times a week for at least 30 mins, alcohol reduction, the dash diet, sodium reduction or restriction, and weight reduction would complement medication treatment plans (Rosenthal and Burchum, 2021). Educating the patient is very important; the use of language which they can understand and reinforce the importance of medication compliance. Self-management behaviors such as salt restriction are crucial for hypertension and hyperlipidemia (Fu et al., 2020).
References
Amlodipine BESYLATE tablet. (2020). DailyMed. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=3d14c6b5-a70a-477f-b332-fa5b93a6296f
Akbari, P., & Zadeh, A. K. (2022). Thiazide diuretics – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK532918/
Rosenthal, L., & Burchum, J. (2021). Lehne’s Pharmacotherapeutics for advanced practice nurses and physician assistants – E-book (2nd ed.). Elsevier Health Sciences.
Hernandez-Vila, E. (2015). A review of the JNC 8 blood pressure guideline. Texas Heart Institute Journal, 42(3), 226-228. https://doi.org/10.14503/thij-15-5067
Mclver, L. A., & Siddique, M. S. (2021, September 9). Atorvastatin – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK430779/#:~:text=Go%20to%3A-,Mechanism%20of%20Action,cholesterol%20production%20in%20the%20liver
James, P. A., Oparil, S., & Carter, B. L. (2014, February 5). 2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults. JAMA Network | Home of JAMA and the Specialty Journals of the American Medical Association. https://jamanetwork.com/journals/jama/fullarticle/1791497
Fu, J., Liu, Y., Zhang, L., Zhou, L., Li, D., Quan, H., Zhu, L., Hu, F., Li, X., Meng, S., Yan, R., Zhao, S., Onwuka, J. U., Yang, B., Sun, D., & Zhao, Y. (2020). Nonpharmacologic interventions for reducing blood pressure in adults with prehypertension to established hypertension. Journal of the American Heart Association, 9(19). https://doi.org/10.1161/jaha.120.016804
Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., & Himmelfard, C. D. (2017). 2017 ACC/AHA/Aapa/Abc/Acpm/Ags/Apha/Ash/Aspc/Nma/Pcna guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension. https://www.ahajournals.org/doi/10.1161/hyp.0000000000000065
2. [Melissa Salazar] Mrs. Lyons is a 57-year old African American female presenting to the clinic with headaches and elevated blood pressure (BP) readings during a work health fair. She was also found to have elevated cholesterol levels. She was last seen five years ago, also with a slightly elevated BP and elevated low density lipoprotein (LDL) and triglyceride cholesterol levels. Current vital signs include a BP of 146/92, height of 65” and weight of 220 pounds, with a body mass index (BMI) of 36.
Given the current information, Mrs. Lyons appears to have stage I hypertension according to the eighth Joint National Committee (JNC8) guidelines (Brock, 2020). She also classifies as obese with her BMI (U.S. Department of Health & Human Services), and has high cholesterol.
According to the JNC8, for adults under the age of 60, medication should be initiated when the top blood pressure number (systolic) reads 140 mm Hg or higher, or when the bottom (diastolic) reading is 90 mm Hg or higher (Shackelford, 2021).
The American Heart Association (AHA) and the American College of Cardiology (ACC) classify similar readings as Stage II hypertension. Despite the classification, both suggest the first line of treatment for a non-African American patient with no other major comorbidities suggest to initiate an Angiotensin-converting-enzyme (ACE) inhibitors, Calcium Channel Blocker (CCB), Angiotensin II receptor blockers (ARBs), or a thiazide diuretic, either alone or in combination. However, for an African American, only a thiazide or CCB is recommended, alone or combination (Flack, Calhoun, & Schiffrin, 2018).
My recommendation is to start Mrs. Lyons on the CCB amlodipine (Norvasc), and thiazide diuretic chlorthalidone (Thalitone) 25 mg, as well as atorvastatin for hyperlipidemia (Capriotti, Roman, S, & Schwarz, 2021). I was able to find a combination drug, CADUET® (amlodipine besylate/atorvastatin calcium) 2.5 mg/10mg for initial therapy (Viatris, 2022). I believe this would be helpful for compliance as history proves Mrs. Lyons did not follow up from the previous diagnosis five years ago.
Amlodipine is a dihydropyridine CCB that acts on the smooth muscle of the blood vessels to promote vasodilation primarily on arterioles (Rosenthal & Burchum, 2021). Chlorthalidone is a thiazide diuretic that acts on the distule tubule to block sodium (Na+) reabsorption and increase potassium (K+), chloride and water excretion (Rosenthal & Burchum, 2021). Atorvastatin (Lipitor) is an HMG-CoA reductase inhibitor used to lower cholesterol by rate-limiting the biosynthesis (Rosenthal & Burchum, 2021).
Side effects of amlodipine include reflex tachycardia, flushing, peripheral edema, dizziness and hypotension (Rosenthal & Burchum, 2021). Side effects of thiazide diuretics include; hyperglycemia, increased serum cholesterol and LDL, hypercalcemia, hyperuricemia (gout) and hypovolemia. Hypokalemic metabolic alkalosis and allergic reaction to sulfonamides may also occur (Debevec-McKenney, Florjanczyk, McBundy, & Popa, 2022). Side effects of atorvastatin contain gastrointestinal (GI) symptoms such as abdominal pain, nausea and diarrhea. More serious effects include myalgia, rhabdomyolysis and liver toxicity. It is also contraindicated in pregnancy (Rosenthal & Burchum, 2021).
There are no interactions between these medications when taken together. Caution should be taken to manage hypotensive occurrences. If this does occur, Mrs. Lyons may be taken down to one antihypertensive medication. It should be noted that atorvastatin should not be taken with grapefruit juice.
Mrs. Lyons can implement lifestyle changes to assist with weight loss and lowering her cholesterol and BP levels. She should start by adding some exercise such as walking for 30-40 minutes a day, 3-4 times a week. She should also decrease her sodium intake to less than 2,400 mg a day. The Dietary Approaches to Stop Hypertension (DASH) diet includes low sodium, saturated fat and sugar options. It not only will help with hypertension, but also the high cholesterol.
References
Brock, Z. (2020). Hypertension management: Advanced pharmacology.
Capriotti, T., Roman, A., S, & Schwarz, M. (2021, January/February). Appropriate treatment, health promotion for black women with HTN. The Clinical Advisor, 17-26.
Debevec-McKenney, E., Florjanczyk, U., McBundy, S., & Popa, V. (2022). Thiazide and thiazide-like diuretics. Retrieved from Osmosis.org: https://www.osmosis.org/learn/Thiazide_and_thiazide-like_diuretics?from=/playlist/nbkK1Qyt88V
Flack, J. M., Calhoun, D., & Schiffrin, E. L. (2018, February). The new ACC/AHA hypertension guidelines for the prevention, detection, evaluation, and management of high blood pressure in adults. American Journal of Hypertension, 31(2), 133-135. doi:10.1093/ajh/hpx207
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). St. Louis, Missouri: Elsevier.
Shackelford, K. (2021). JNC 8 and hypertension. Retrieved from Verywell health: https://www.verywellhealth.com/jnc-8-and-hypertension-1763953
U.S. Department of Health & Human Services. (n.d.). Calculate your body mass index. Retrieved from National Heart, Lung, and Blood Institute: https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm
Viatris. (2022). Move forward with brand-name Caduet. Retrieved from Caduet: https://www.caduet.com/
