Pharmacotherapy for Cardiovascular Disorders

Polypharmacy entails the use of more than one medication to treat one or more conditions. This week’s assigned case is of a patient with a history of strokes and type 2 diabetes mellitus, hyperlipidemia, and hypertension. His current medications list has glipizide, metformin, atenolol, hydralazine, hydrochlorothiazide (HCTZ), simvastatin, and verapamil.

Pharmacotherapy for Cardiovascular Disorders

The purpose of this paper is to discuss the pharmacology of the medications and explain appropriate modifications needed to his medications list.

Pharmacology of the Patient’s Medication List

The patient is on two oral hypoglycemics (glipizide and metformin), four antihypertensives (atenolol, hydralazine, HCTZ, and verapamil), and one lipid-lowering agent (simvastatin). Glipizide is a sulfonylurea thus an insulin secretagogue. It stimulates the release of insulin from pancreatic beta cells. It also has multiple effects on other tissues and thus can cause hypoglycemic attacks.

On the other hand, Metformin is a biguanide that sensitizes body tissues to insulin and has a lower risk of causing hypoglycemia. A major concern with this drug is acidosis. Atenolol is a cardio-selective beta-1 adrenergic blocker that works to slow heart rate and reduce blood pressure by blockade of beta receptors.

Verapamil is a calcium channel blocker used to cause dilation of the blood vessel through relaxation of smooth muscles and reduce blood pressure through calcium channel blockade in the heart (Rosenthal & Burchum, 2020).

Hydralazine is a direct vasodilator that relaxes smooth muscles by interfering with calcium movement into the cells. Its main adverse effect is a lupus-like syndrome. Hydrochlorothiazide promotes diuresis by inhibiting the sodium chloride ions transporter in the distal renal tubules. However, this leads to renal loss of potassium, thus hypokalemia.

Simvastatin is a statin that reduces serum low-density lipoprotein levels by preventing cholesterol synthesis in the liver. Despite its effectiveness in controlling serum lipid levels, this medication can cause rhabdomyolysis and lead to acute renal failure (Rosenthal & Burchum, 2020).

All these medications that the patient is on have the potential for drug-drug interaction. All these medications are indicated for the patient’s conditions, and stroke prevention has been covered by simvastatin. Simvastatin would prevent cardiogenic ischemic stroke by preventing the development of atherosclerotic plaques and embolization.

Modification of the Patient Medications List

Control of his blood pressure and blood glucose are also good strategies neat would prevent his stroke. However, evidence-based changes to his treatment would improve control of his blood sugar and pressure levels. Verapamil and atenolol would work together to cause profound blood pressure reduction (Rosenthal & Burchum, 2020).

An additional vasodilator such as hydralazine will further lower the blood pressure, thus risk of hypotension. Therefore, I would remove atenolol and hydralazine from this patient’s medications list and replace them with losartan.

The eighth joint national committee (JNC 8) published guidelines in 2014 that limited first-line treatments to four classes: angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, thiazide dietetics, and calcium channel blockers (James et al., 2014; Mahdavi et al., 2019). Beta-blockers were moved to the fourth line in hypertension management.

The recent guideline for the pharmacological treatment of hypertension in adults by the World Health Organization also supports the use of these drug classes for hypertension control (Al-Makki et al., 2022). The patient is diabetic, and the use of atenolol may mask hypoglycemia caused by the oral hypoglycemic blood sugars, thus poor control of his diabetes (Dungan et al., 2019).

JNC 8 guidelines argued that losartan had mortality benefits when used in a patient with other cardiovascular disease risks and beta-blockers are less effective in stroke prevention than other classes. The use of statins in this patient is supported by the American Heart Association, American College of Cardiology, and the American Diabetes Association recommendations.

The risk of hyperglycemia in HCTZ use makes it less appropriate for this patient who needs good blood glucose control. It also can potentially worsen hyperlipidemia in this patient (Herman & Bashir, 2022). Therefore, I will use a combination therapy of verapamil and losartan.

However, retention of simvastatin in this patient’s medication list removes verapamil from the list because verapamil will increase the statins level, thus a high risk of rhabdomyolysis and kidney injury (Mandumpal Chacko & Thambi Thekkekara, 2021). Metformin is an excellent oral hypoglycemic agent for this patient, but its effects would have been decreased by verapamil. Therefore, I will keep metformin on the list but monitor kidney functions regularly to prevent metformin toxicity.

For further stroke prevention, adding aspirin or clopidogrel would be appropriate, given that he has no evidence of arrhythmia. These are antiplatelet agents that will prevent spontaneous clot formation and growth of atherosclerotic plaques in this patient to reduce his risk of stroke.

The final medications list for this patient will include verapamil, losartan, metformin, glipizide, and aspirin. This will reduce the pill burden and increase the quality of blood pressure and glucose control while reducing the risk of stroke in this patient.

Conclusion

The patient has multiple conditions and is at risk of metabolic syndrome. His polypharmacy will contain two antihypertensives, two oral hypoglycemic agents, one lipid-lowering agent, and one antiplatelet for stroke prevention. HCTZ, atenolol, and hydralazine were removed from his medications list because of the risk of hyperglycemia and profound hypotension. Stroke prevention would be enhanced by two strategies: blood pressure and glucose control, use of antiplatelet, and lowering lipid levels.

References

  • Al-Makki, A., DiPette, D., Whelton, P. K., Murad, M. H., Mustafa, R. A., Acharya, S., Beheiry, H. M., Champagne, B., Connell, K., Cooney, M. T., Ezeigwe, N., Gaziano, T. A., Gidio, A., Lopez-Jaramillo, P., Khan, U. I., Kumarapeli, V., Moran, A. E., Silwimba, M. M., Rayner, B., … Khan, T. (2022). Hypertension pharmacological treatment in adults: A World Health Organization guideline executive summary. Hypertension79(1), 293–301. https://doi.org/10.1161/HYPERTENSIONAHA.121.18192
  • Dungan, K., Merrill, J., Long, C., & Binkley, P. (2019). Effect of beta-blocker use and type on hypoglycemia risk among hospitalized insulin-requiring patients. Cardiovascular Diabetology18(1), 163. https://doi.org/10.1186/s12933-019-0967-1
  • Herman, L. L., & Bashir, K. (2022). Hydrochlorothiazide. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430766/
  • James, P. A., Oparil, S., Carter, B. L., Cushman, W. C., Dennison-Himmelfarb, C., Handler, J., Lackland, D. T., LeFevre, M. L., MacKenzie, T. D., Ogedegbe, O., Smith, S. C., Jr, Svetkey, L. P., Taler, S. J., Townsend, R. R., Wright, J. T., Jr, Narva, A. S., & Ortiz, E. (2014). 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8): Report from the panel members appointed to the eighth joint national committee (JNC 8). JAMA: The Journal of the American Medical Association311(5), 507–520. https://doi.org/10.1001/jama.2013.284427
  • Mahdavi, M., Parsaeian, M., Mohajer, B., Modirian, M., Ahmadi, N., Yoosefi, M., Mehdipour, P., Djalalinia, S., Rezaei, N., Haghshenas, R., Pazhuheian, F., Madadi, Z., Sabooni, M., Razi, F., Samiee, S. M., & Farzadfar, F. (2019). Insight into blood pressure targets for universal coverage of hypertension services in Iran: The 2017 ACC/AHA versus JNC 8 hypertension guidelines. In Research Square. https://doi.org/10.21203/rs.2.12895/v2
  • Mandumpal Chacko, S., & Thambi Thekkekara, P. (2021). The combined effect of metformin and statin. In Metformin – Pharmacology and Drug Interactions. IntechOpen. https://doi.org/10.5772/intechopen.100894
  • Rosenthal, L., & Burchum, J. (2020). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants – E-book (2nd ed.). Saunders.

Pharmacotherapy for Cardiovascular Disorders Instructions

PHARMACOTHERAPY FOR CARDIOVASCULAR DISORDERS

To Prepare

  • Review the Resources for this module and consider the impact of potential pharmacotherapeutics for cardiovascular disorders introduced in the media piece.
  • Review the case study assigned by your Instructor for this Assignment.
  • Select one the following factors: genetics, gender, ethnicity, age, or behavior factors.
  • Reflect on how the factor you selected might influence the patient’s pharmacokinetic and pharmacodynamic processes.
  • Consider how changes in the pharmacokinetic and pharmacodynamic processes might impact the patient’s recommended drug therapy.
  • Think about how you might improve the patient’s drug therapy plan based on the pharmacokinetic and pharmacodynamic changes. Reflect on whether you would modify the current drug treatment or provide an alternative treatment option for the patient.

Write a 2- to 3-page paper that addresses the following:

  • Explain how the factor you selected might influence the pharmacokinetic and pharmacodynamic processes in the patient from the case study you were assigned.
  • Describe how changes in the processes might impact the patient’s recommended drug therapy. Be specific and provide examples.
  • Explain how you might improve the patient’s drug therapy plan and explain why you would make these recommended improvements.