Gastrointestinal and Hepatobiliary System

Gastrointestinal and Hepatobiliary System

Scenario 1: Prescription Errors and Corrections

The prescriptions in the list include five errors. (1) Linaglipton has been misspelled; the name of the drug is linagliptin which inhibits DPP-4 enzyme and elevates the incretin level which prevents the release of glucagon and promotes the release of insulin. Proper prescription:
Linagliptin 5 mg PO daily, Disp: #30 tabs, Refills: 5
. (2) Tresiba (insulin degludec) cannot be administered TID: it is a long-acting insulin given once a day. Correct:
Tresiba U 100,10 units SC daily injection, Disp: 1 box (5 pens), Refills: 1
. It is long-acting insulin which binds to albumin and is slow releasing. (3) Tiotropium is inhaled, not oral. Correct:
Tiotropium (Spiriva Respimat) 25 mg, inhale 2 puffs one time a day, Disp: 1 inhaler (60 doses). Refills: 1
(Brunton, Knollmann, & Hilal-Dandan (Eds.), 2018). It is a long-time muscarinic antagonist which relaxes the bronchial smooth muscles. (4) Qulipta is PRN instead of preventive. Correct:
Qulipta 60 mg PO q daily, Disp: 30, Refills: 1
. It is a CGRP receptor blocking, an agent employed in migraine prevention. This erroneous prescription is (5) Levothyroxine taken at the wrong dose of 88 mg rather than micrograms. Right:
Levothyroxine 88 mcg PO Day,

Disp: 30 tabs, Refills: 5
. It is an artificial thyroid hormone, which substitutes natural thyroxine Gastrointestinal and Hepatobiliary System.

Scenario 2: Asthma Management for PK

According to NHLBI guidelines, PK shows evidence of asthma not well controlled. She takes in albuterol >2 days/week, and has nocturnal symptoms. Although she is taking Flovent, her usage is unreliable, which shows the failure to take control. Step- up to combination inhaler is recommended. Discontinue Flovent and start on budesonide-formoterol (Symbicort 80/4.5 mcg), 2 puffs BID, Disp: 1 inhaler (120 inhalation), 0 refills at the beginning. Continue Albuterol (Proventil) 2 puffs q4-6h PRN. Allergic rhinitis can remain PRN on Fexofenadine and diphenhydramine. Follow-up after 4 weeks is involved in monitoring, as well as the review of the frequency of the symptoms, night awakenings, and rescue inhaler administration. An action plan against asthma should be supplied. Education encompasses inhaler type, compliance to routine medication, and triggers avoidance (Crook & MStat, 2024). Promote the use of a spacer with MDIs and recording a diary of symptoms. Her target is that her daytime symptoms should be controlled at 2 days/week, with no nocturnal symptoms and a small use of SABA. The Asthma Control Test (ACT) used monthly may be used to ascertain control and make therapy changes.

Scenario 3: Hypertension Management for ES

The blood pressure of ES is 142/89 mm Hg, and non-adherence to bisoprolol is indicative of the fear of side effects. According to JNC 8 and combined ACC/AHA recommendations, the BP goal of African American adult patients is below 140/90mmHg (Riaz, n.d.). The first-line treatment entails thiazide-type diuretics or calcium channel blockers. Beta blockers e.g. bisoprolol are not first-line, unless there is strong indication (e.g., post-MI, heart failure). Explain to the patient about the risks of hypertension (stroke, CKD, heart disease), the necessity to take medication and that side-effects might be manageable. Suggest bisoprolol withdrawal and amlodipine 5 to be begun 5 mg PO every day, Disp: #30, refills: 3. It is an anti-hypertensive, which is a calcium blocker of the dihydropyridine type that lowers peripheral resistance. Dot BP, HR and side effects (e.g. edema) after 2-4 weeks. Modifications on lifestyle (DASH diet, depleted sodium consumption, exercise, weight loss) ought to be enforced. Motivational interviewing can help enhance patient buy in. Inquire about checks (BMP, lipid panel) and cardiovascular risk re-evaluation every year.

Scenario 4: Diabetes Management for TF with CKD

TF has poorly controlled diabetes type II (a1C 8.5), and CKD (eGFR 28). His goal A1C is < = 8.0% considering age, comorbidities, and CKD (de Boer et al., 2022). Metformin may not be used because of eGFR <30. Glimepiride, glyburide contain Sulfonylureas which are risky in CKD (hypoglycemia). Exenatide is not recommended in eGFR Less than 30. Ozempic 0.25 mg SC QW x4 weeks and then to 0.5 mg WO, Disp: 1 pen (4 doses), Refills: 2 is the optimal one. The GLP-1 receptor agonist semaglutide has been shown to better glycemic control and provide CV/renal protection as well as small hypoglycemia risks. Teach about administration, potential GI adverse effects and hypoglycemic reactions, and hypoglycemic symptoms when prescribed with other drugs. Check A1C after 3 months, kidney status and weight. Promote behavioral change such as low-carb dieting and exercising. Intake of nephrotoxic agents should be avoided and keep the BP/LDL under control. He can continue medications (donepezil, lecanemab, atorvastatin) that are taken now. Screen yearly against diabetes complication of diabetes (retinopathy, neuropathy, nephropathy) Gastrointestinal and Hepatobiliary System. References Brunton, L. L., Knollmann, B. C., & Hilal-Dandan, R. (Eds.). (2018). Goodman & Gilman’s the pharmacological basis of therapeutics (p. 7). New York, NY, USA:: McGraw-Hill Education. Crook, J., & MStat, D. A. (2024). UTAH MEDICAID DUR REPORT APRIL 2024 SHORT-ACTING BETA-AGONIST UTILIZATION AMONG PATIENTS WITH ASTHMA: A RETROSPECTIVE REVIEW. de Boer, I. H., Khunti, K., Sadusky, T., Tuttle, K. R., Neumiller, J. J., Rhee, C. M., … & Bakris, G. (2022). Diabetes management in chronic kidney disease: a consensus report by the American Diabetes Association (ADA) and Kidney Disease: Improving Global Outcomes (KDIGO). Diabetes care, 45(12), 3075-3090. https://doi.org/10.2337/dci22-0027 Riaz, K., MD. (n.d.). Hypertensive heart disease: overview, etiology, epidemiology. https://emedicine.medscape.com/article/162449-overview#:~:text=The%20medical%20care%20of%20patients,treat%20to%20below%20those%20levels   Gastrointestinal and Hepatobiliary System