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RUNNING HEAD: ADVERSE DRUG SIDE EFFECTS.
ADVERSE DRUG SIDE EFFECTS.
Name
Institution
Adverse Drug Side Effects.
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Adverse Drug Side Effects.
Q1. Assess Mr. Buchanan’s medication chart. Identify and explain three significant risks
that may be associated with the use of the medicines (home or inpatient use) for Mr.
Buchanan.
Risks.
1. Hydrocortisone- Cardiotoxicity causing arrhythmias and palpitations.
Mr. Buchanan uses hydrocortisone which is a low to middle potent steroid. Research
shows that the drug causes cardiac arrhythmias and palpitations patients prescribed on oral
hydrocortisone. This adverse effect is due to the increased sensitization of mineralocorticoid
receptor associated with oral hydrocortisone use. Hence, hydrocortisone activates the ReninAldosterone-Angiotensin system (RAAS), which, eventually, stimulates the production of
aldosterone. Aldosterone works on the renal distal convoluted tubule and the collecting duct
to increase the reabsorption of sodium and water (Gagliardi et.al, 2014). Conclusively, the
body develops sodium and water retention. An increase in the total extracellular fluid volume
results in hypertension as a compensatory effect by the vessels. Thus, the increased
palpitations and arrhythmias caused by hydrocortisone.
Glucocorticoids are known to act on the amygdala, thereby, increasing tension,
emotions, and anxiety. People with anxiety disorders such as Obsessive Compulsive Disorder
(OCD) have an increased risk of suffering from the anxiety attacks associated with
hydrocortisone. The combination of increased apprehension as a result of adrenal corticoid
sensitization may increase the cardiovascular toxicity in a patient (Louise et.al, 2014). Intense
emotions and tensions associated with anxiety may activate the adrenal medulla which
produces adrenaline. Adrenaline worsens the clinical picture by increasing the blood pressure
in the both the cardiac and systemic arteries. This condition is likely to increase the cardiac
toxicity and the cardiac arrhythmias may result in the death of the patient.
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2. Aspirin- Increases the susceptibility of spontaneous bleeding.
Aspirin belongs to the drug category of nonsteroidal anti-inflammatory drugs
(NSAIDs), and functions through the inhibition of the cyclooxygenase (COX) pathway. The
paramount adverse effect of aspirin results from its antithrombotic effects. The use of minimal
doses of aspirin may increase the clotting time of blood. Mr. Buchanan has an increased
susceptibility of spontaneous bleeding. Easy scarring may occur as a side effect of using
aspirin for a long time. Other manifestations may include hemarthroses, gastrointestinal
bleeding, ecchymoses, petechiae, subarachnoid and subconjunctival hemorrhages. Aspirin is
an acetylated salicylate, hence, it always inhibits both the cyclooxygenase 1 and 2 pathways
(Ademi et.al, 2013). The inhibition of cyclooxygenase-1 (COX-1) causes an inhibition of
thromboxane A2. It is crucial to note that thromboxane 2 potentiates the platelet aggregation
process of clotting. Eventually, the inhibition of thromboxane 2 causes the antithrombotic
effect of aspirin. It is crucial to note that aspirin has a higher risk of causing bleeding
compared with other NSAIDs because of its irreversible binding characteristic to COX. Other
NSAIDs such as diclofenac bind to COX reversibly, therefore, they do not have a higher risk
of causing spontaneous bleeding.
3. Mr. Buchanan may develop digoxin toxicity due to the drug interaction between
NSAIDs and digoxin.
Careful analysis of Mr. Buchanan’s medication chart shows that the patient has a very
high risk of developing digoxin toxicity. According to the chart, the patient is receiving doses
of digoxin. Further, the report shows that the patient has been receiving aspirin and nurofen.
Aspirin and nurofen are NSAIDs. The medical name for nurofen is ibuprofen, a non-selective
COX inhibitor. It is crucial to note that the concomitant administration of NSAIDs and
digoxin leads to an increase in the serum levels of digoxin. The mechanism of action of this
interaction is because the NSAIDs are able to block the digoxin transporter located on the
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apical membranes of cells. Digoxin toxicity has both cardiac and extra-cardiac symptoms.
Increased digoxin serum levels cause arrhythmias, palpitations, bradycardia, and hypotension.
It has an effect on the cardiac's conduction system. Other systemic manifestations include
neuralgia, dizziness, diarrhea and abdominal pain.
Q2. Describe the strategies a nurse may take to prevent/manage the specific risks you
have identified in Question 1. Your answer should focus on Mr. Buchanan’s needs
rather than a discussion on the actual medicines.
Strategies.
1. Hydrocortisone toxicity management- psychosocial advice, reduction of
hydrocortisone dosages, and the use of physical exams to evaluate the susceptibility of
developing toxicity.
Mr. Buchanan requires an optimal surveillance that would provide any medical
information regarding the management of hydrocortisone toxicity. The first step of nursing
care should include the recording of the anthropometric measurements and the general
physical signs of Mr. Buchanan. This would help evaluate the susceptibility of the patient to
the toxic effects of hydrocortisone (Jung et.al, 2014). Medical experts recommend that the
physical exams should also be used to evaluate the presence of any comorbidities associated
with hydrocortisone. This statement means that appropriate nursing care should include the
cardiovascular system assessment to indicate any risks for increased palpitations or
tachycardia.
Mr. Buchanan also requires minimal doses of hydrocortisone. Being a steroid, the drug
should exist at the therapeutic levels for toxicity to be prevented. It is crucial to note that
many adverse effects of hydrocortisone occur at drug concentrations higher than the
therapeutic levels. Part of the nursing care involves advising Mr. Buchanan on how to
appropriately monitor any incidences of hydrocortisone toxicity or any of its adverse
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reactions. Mr. Buchanan should be advised to report to the hospital in case, he experiences
any mood changes or starts having an awareness of his heartbeat. He should carry a steroid
treatment card anywhere he goes so that medical officials may understand the reason for his
presentation in case of any emergencies that lead to the impairment of his consciousness. The
substitution of hydrocortisone in the treatment is not an option because it is one of the least
potent steroids available.
2. Management of bleeding effect caused by aspirin- The use of psychosocial
therapy, hemostatic agents, and carrying out platelet counts so as to assess Mr. Buchanan’s
likelihood of having bleeding episodes.
The administration of aspirin increases the risk of spontaneous bleeding because of its
inhibitive effect on COX-1. There are pharmacological and non-pharmacological measures
that would ensure a reduction in Mr. Buchanan’s mortality rates in case he develops bleeding.
Pharmacological measures include the use of hemostatic agents (Tasson, 2014). Morphologic
manifestations of bleeding such as petechiae, ecchymoses and melena should make the nurse
start hemostatic therapy. One of the most effective agents is cryoprecipitate. Cryoprecipitate
treats bleeding that results from the deficiency of factor XIII. It works by increasing
fibrinogen in the intima of blood vessels, hence, reducing the risk of spontaneous bleeds
(Amarenco et.al, 2014). Low molecular weight heparin is also effective as a pharmacological
intervention of hemorrhages from aspirin use. It increases the activated partial thromboplastin
time (APTT).
Nursing care for Mr. Buchanan should include a psychosocial therapy session where
he would be advised to report any cases of spontaneous bleeds from cutaneous and
mucocutaneous surfaces. Part of the therapy session should involve advice about the
importance of adherence to the therapy and how to record the dosing intervals using methods
such as pill count to avoid accidental overdose. The nurse should obtain a complete blood
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count (CBC) that would provide the platelet counts. He or she should obtain the APTT,
bleeding time, and thrombin time levels of the Mr. Buchanan to assess the relative likelihood
of having a bleeding disorder.
3. Management of the side effects caused by the interaction between NSAIDs and
digoxin- Tests such as CBCs to help predict Mr. Buchanan’s response to the regimen. In
case of digoxin toxicity gastric decontamination should be used. Digoxin immune Fab
corrects the dysrhythmias resulting from digoxin toxicity.
As mentioned earlier, the drug interaction between NSAIDs and digoxin may increase
the serum concentration levels of digitalis in Mr. Buchanan’s blood. Digitalis toxicity mainly
has cardiovascular effects. Therefore, it is crucial for the nurse to carry out frequent tests that
may indicate any cases of cardiac toxicity (Pincus, 2016). These tests include
electrocardiograms (ECG)s and CBCs. Furthermore, renal function tests and serum digoxin
levels may determine the outcome of the drug interaction. Proper management should involve
the adjustment of Mr. Buchanan’s dose according to the serum digoxin levels. Management of
digoxin toxicity should include gastrointestinal decontamination (See et.al, 2013). This
process may include gastric lavage, the use of activated charcoal or use of cholesterol binding
resins such as cholestyramine. It is important to note that activated charcoal may not be
effective if Mr. Buchanan's toxicity has proceeded for more than four hours. Specific
management of dysrhythmias resulting from digoxin toxicity requires the use of digoxin
immune Fab. Supportive management includes the administration of maintenance of fluids,
warmth, and provision of oxygen and bed rest.
Q3. Briefly explain the importance of providing education to Mr. Buchanan in relation
to over-the-counter (OTC) medications.
As mentioned in the history, Mr. Buchanan constantly uses over-the-counter (OTC)
medications to alleviate most of his symptoms. Mr. Buchanan should receive education about
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the possibility of getting adverse side effects from drug interactions. Mr. Buchanan should
understand that many drugs are able to alter the way the distribution or absorption rates of
other drugs. Therefore, Mr. Buchanan should be advised to consult a doctor before initiating a
certain dosage of a drug. It is also crucial to note that Mr. Buchanan medications chart has
many drugs that depend on the P450 enzyme metabolizing system. For instance, both warfarin
and simvastatin utilize the P450 cytochrome system for metabolism. Hence, he has a higher
susceptibility to developing side effects due to drug interactions. Most OTC drugs may
interfere with the P450 enzymes. Furthermore, Mr. Buchanan should be advised that OTC
drugs rarely have accurate dosages and dosage intervals. A patient has a higher susceptibility
to developing mortality and morbidity due to an overdose.
Q4. The doctor has ordered an initial intravenous dose of amiodarone in the STAT
medicine order section, then to continue with oral dosing. Explain why Mr. Buchanan
has been ordered this regime. Your answer should include relevant pharmacokinetic
concepts.
Notably, amiodarone is very effective in the treatment of arrhythmias. It works by
sparing potassium ions that cross through the membrane, hence, the name membranestabilizing agents. Mr. Buchanan had a fast irregular cardiac rhythm during his hospital stay,
in short, he developed arrhythmias which would have been fatal if left unattended. He
received a loading intravenous (IV) dose of amiodarone to quickly stabilize the cardiac
rhythm. Amiodarone is lipophilic (Price et.al, 2014). Hence, cardiac muscles and adipose
tissue rapidly absorb amiodarone from the plasma. The reason for the loading dose was to
quickly manage the arrhythmias that would have been fatal if left unattended. Amiodarone
has a lower oral bioavailability, ranging from 20 to 70%. The reason for the oral maintenance
doses is to ensure that only minimal amounts of amiodarone get absorbed into the systemic
circulation for optimal effect (Mitric et.al, 2016). Amiodarone potentiates the inhibiting effect
Adverse Drug Side Effects.
of warfarin on vitamin K-dependent clotting factors. Mr. Buchanan would have numerous
bleeding episodes if he would have been receiving IV maintenance doses of amiodarone.
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References.
Ademi, Z., Liew, D., Hollingsworth, B., Steg, P., Bhatt, D. L., & Reid, C. M. (2013). Is It
Cost‐Effective To Increase Aspirin Use in Outpatient Settings for Primary or
Secondary Prevention? Simulation Data from the REACH Registry Australian Cohort.
Cardiovascular therapeutics, 31(1), 45-52.
Amarenco, P., Davis, S., Jones, E. F., Cohen, A. A., Heiss, W. D., Kaste, M., & Bladin, C. F.
(2014). Clopidogrel plus aspirin versus warfarin in patients with stroke and aortic arch
plaques. Stroke, 45(5), 1248-1257.
Gagliardi, L., Nenke, M. A., Thynne, T. R. J., von der Borch, J., Rankin, W. A., Henley, D.
E., ... & Torpy, D. J. (2014). PP02-1: Continuous Subcutaneous Hydrocortisone
Infusion Therapy in Addison's Disease; Effects on Health Status in a Randomized
Placebo-Controlled Clinical Trial, 99(11), 4149-4157.
Jung, C., Greco, S., Nguyen, H. H., Ho, J. T., Lewis, J. G., Torpy, D. J., & Inder, W. J.
(2014). Plasma, salivary and urinary cortisol levels following physiological and stress
doses of hydrocortisone in normal volunteers. BMC endocrine disorders, 14(1), 1.
Louise Rushworth, R., Slobodian, P., & Torpy, D. J. (2015). Interruptions to supply of high‐
dose hydrocortisone tablets and the incidence of adrenal crises. Clinical
endocrinology, 83(6), 999-1000.
Mitrić, G., Udy, A., Bandeshe, H., Clement, P., & Boots, R. (2016). Variable use of
amiodarone is associated with a greater risk of recurrence of atrial fibrillation in the
critically ill. Critical Care, 20(1), 1.
Pincus, M. (2016). Management of digoxin toxicity. Australian Prescriber, 39(1), 18.
Price, S. D., Holman, C. A. J., Sanfilippo, F. M., & Emery, J. D. (2014). Impact of specific
beers criteria medications on associations between drug exposure and unplanned
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hospitalization in elderly patients taking high-risk drugs: A case-time-control study in
Western Australia. Drugs & aging, 31(4), 311-325.
See, I., Shehab, N., Kegler, S. R., Laskar, S. R., & Budnitz, D. S. (2013). Emergency
Department Visits and Hospitalizations for Digoxin Toxicity.
Tassone, A. (2014). Aspirin lowers occurrence of new venous blood clots: study. Australian
Journal of Pharmacy, 95.