Pharmacotherapy for Cardiovascular Disorders
The assigned case study illustrates an 89-year-old female patient with multiple falls resulting in injuries in the long-term care facility. The patient has been in a wheelchair for over the past six months, unable to walk independently. Consequently, the patient reports pain in her lower limb when walking even for a shorter distance such as within the long-term care facility. She also reports a history of Alzheimer’s disease, diabetes, hypertension, hypothyroidism, and osteoarthritis. To manage these conditions, the patient current list of medication include metformin, glyburide, furosemide, levothyroxine, celecoxib, amlodipine, and donepezil. Currently, the patient is only concerned about moderate to severe pain which only comes when she is walking. The purpose of this discussion is to elaborate on how the patient old age affects pharmacokinetic and pharmacodynamic factors and to develop the most effective treatment plan for the patient.
Impact of Age on Pharmacokinetic and Pharmacodynamic Processes
The patient is 89 year old, which mean that most of her physical and biological functioning have been reduced. It is thus very important to consider pharmacodynamic and pharmacokinetic factors affected by advanced age to determine the right drug and dosage for the management of the patient’s condition. For instance, older patients tend to have delayed or impaired absorption of several drugs administered orally. This reduces the volume of distribution of the specific drug, which might shift towards the accumulation of higher drug concentrations in the fat stores reducing their efficacy and safety. Studies also show that with aging, the first-pass metabolism of drugs is decreased, which is responsible for the increased bioavailability of certain drugs that undergo extensive first-pass metabolism such as furosemide (Peeters et al., 2019). Recent studies also revealed reduced efficacy of furosemide among older patients because of reduced tubular secretion due to reduced renal plasm flow. Drugs that undergo renal clearance after liver metabolism like amlodipine should also be monitored closely for toxicity as a result of decreased renal function among elderly patients, especially those with kidney complications.
Regarding the pharmacodynamic factors affected by aging, studies show that receptors and their binding sites exhibit limited functioning with advanced age reducing their sensitivity to most drugs. For instance, the elderly patient presents with a history of diabetes, which worsens her already decreased sensitivity of insulin receptors impairing glucose control, in addition to reducing her sensitivity to other administered diabetes medications (Hassan et al., 2022). As such, keen consideration must be taken when reviewing the patient’s treatment plan.
Changes in the Pharmacokinetic and Pharmacodynamic Processes
Advanced age is associated with several changes in the pharmacodynamic and pharmacokinetic processes. For instance, changes in the patient’s pharmacokinetic process like decreased liver and kidney function may lead to increased distribution volume of drugs that are lipid-soluble hence prolonging the elimination half-life of the drug (Stader et al., 2020). Consequently, changes in the pharmacodynamic processes like reduced sensitivity to drugs from various classes like anticoagulants, and cardiovascular agents can also reduce their efficacy in elderly patients. Clinicians must thus take keen note of these changes, in deciding on which drugs are most effective in managing the patient’s conditions, and the right doses required for the optimal outcome while reducing risks of harm. For instance, the patient is taking celecoxib, which should be monitored closely for toxicity as the drug has been reported to be metabolized and excreted poorly in an elderly patient with risks of kidney disease (Sychev et al., 2021). Additionally, as a result of the increased risks of side effects, with reduced effectiveness of most drugs in advanced age due to these changes, non-pharmacological interventions such as diet, meditation, therapy, exercise, and yoga among others are recommended to promote positive outcome, when used with medication.
Improved Drug Therapy
When we grow older, we tend to develop an increased risk of several health complications as a result of decreased physiological functions which increases the risks associated with polypharmacy (Tamargo et al., 2022). To avoid such risks, certain prescription measures must be applied to increase the effectiveness and reduce the risks of every medication recommended. For instance, in the management of the patient’s ambulatory pain, I will recommend adding 1g paracetamol administered orally after every 6 to 8 hours when necessary. I will maintain the twice-daily dose of celecoxib 200 mg given the patient present state. Studies also show that celecoxib is beneficial in reducing pain associated with a movement among elderly patients when administered with paracetamol. I will also advise the patient to continue taking furosemide 40mg every morning and amlodipine 10mg once daily since they are considered second-line for management of HTN, and should only be changed when they are unable to stabilize the patient’s hypertension. Her diabetes is also well controlled, hence the need to continue taking glyburide 5mg and metformin 500mg each twice daily. She should also continue taking levothyroxine 0.88mg every morning for hypothyroidism and donepezil 10mg twice daily for her Alzheimer’s disease. Physiotherapy should also be recommended to help with her movement.
The elderly patient in the provided case study presents with several comorbidities such as Alzheimer’s disease, diabetes, hypertension, hypothyroidism, and osteoarthritis. She is however concerned about moderate to severe pain which is associated with movement. As such, it is necessary to add paracetamol to the current treatment plan for the patient’s ambulatory pain, in addition to physiotherapy to help with her movement.
Hassan, D., Peeters, L. E., Koch, B. C., & Versmissen, J. (2022). DiffErenCes in AntihypertenSive Drug Blood Levels in Patients with HypertensiON (DECISION): Protocol for a Prospective Observational Study Comparing Pharmacokinetics and Pharmacodynamics Between Young and Elderly Patients. High Blood Pressure & Cardiovascular Prevention, 29(3), 239-243. https://doi.org/10.1007/s40292-022-00505-w
Peeters, L. E. J., Kester, M. P., Feyz, L., Van Den Bemt, P. M. L. A., Koch, B. C. P., Van Gelder, T., & Versmissen, J. (2019). Pharmacokinetic and pharmacodynamic considerations in the treatment of the elderly patient with hypertension. Expert opinion on drug metabolism & toxicology, 15(4), 287-297.
Stader, F., Kinvig, H., Penny, M. A., Battegay, M., Siccardi, M., & Marzolini, C. (2020). Physiologically based pharmacokinetic modeling to identify pharmacokinetic parameters driving drug exposure changes in the elderly. Clinical pharmacokinetics, 59(3), 383-401. DOI: 10.1007/s40262-019-00822-9.
Sychev, D. A., Ostroumova, O. D., Pereverzev, A. P., Kochetkov, A. I., Ostroumova, T. M., Klepikova, M. V., & Ebzeeva, E. Y. (2021). Advanced Age as a Risk Factor of Drug-Induced Diseases. Safety and Risk of Pharmacotherapy, 9(1), 15-24.
Tamargo, J., Kjeldsen, K. P., Delpón, E., Semb, A. G., Cerbai, E., Dobrev, D., … & Niessner, A. (2022). Facing the challenge of polypharmacy when prescribing for older people with cardiovascular disease. A review by the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. European Heart Journal-Cardiovascular Pharmacotherapy.