Sandra is a 55-year-old African American female that was prescribed Toprol XL 50 mg daily for high blood pressure. Her PMH consists of depression treated with venlafaxine 225 mg daily
SCENARIO 1
Mark Johnson is a 72 year old male recently prescribed warfarin 5 mg daily for DVT treatment. His PMH includes hypertension, hyperlipidemia and osteoarthritis. He is currently on HCTZ 25 mg po daily, celecoxib 200 mg po daily, fluvastatin 40 mg po daily, and Goody\’s Powder 1 packet as needed for pain. He has no known allergies. What changes in his medications would you make? What alternatives might you prescribe (include complete medication orders)? How would a CYP2C9 polymorphism affect drug therapy? How would you monitor therapy?
SCENARIO 3
Alex is a 52-year-old male following up on his labs that were drawn last week. He smokes 1 pack per day. He is currently on lisinopril 20 mg po daily, semaglutide (Ozempic) 0.5 mg SC qWeek, and St. John’s Wort. Fasting lipid profile shows total cholesterol 260, LDL cholesterol 160, HDL cholesterol 35, and Triglycerides 220. What treatment plan would you implement for Alex’s lipid profile? What is the goal Total Cholesterol (TC), HDL-C, LDL-C, and Triglyceride level for Alex? How would you monitor the effectiveness of your treatment plan? How many risk factors for coronary artery disease does this patient have? Identify them specifically.
SCENARIO 4
Sandra is a 55-year-old African American female that was prescribed Toprol XL 50 mg daily for high blood pressure. Her PMH consists of depression treated with venlafaxine 225 mg daily. She states that she only occasionally takes her little white pill because she does not like the side effects of fatigue and dizziness. Her blood pressure today is 158/92. What information would you provide to the patient at her visit? What is her goal blood pressure? How would you improve Sandra’s medication therapy (include a complete medication order)?
Experts Answer and Explanation
Public Health and Averting Diseases
Scenario 1: Mark Johnson
Mark Johnson, a 72-year-old male, is currently prescribed warfarin 5 mg daily for deep vein thrombosis (DVT). His medication list includes hydrochlorothiazide (HCTZ) 25 mg daily for hypertension, celecoxib 200 mg daily for osteoarthritis, fluvastatin 40 mg daily for hyperlipidemia, and Goody’s Powder as needed for pain relief (Krumme et al., 2024). While these medications address his chronic conditions, there are significant concerns regarding interactions between warfarin and his current medications (Wang et al., 2021).
The most notable issue is with Goody’s Powder, which contains aspirin, a drug known to enhance the anticoagulant effects of warfarin and increase the risk of gastrointestinal and internal bleeding. I would recommend discontinuing Goody’s Powder and replacing it with acetaminophen for pain management, as it does not interact with warfarin and poses a much lower risk of bleeding complications.
Another potential concern is the use of celecoxib, a COX-2 inhibitor, which may increase the risk of bleeding despite having a lower risk compared to other NSAIDs. To err on the side of caution, I would also suggest considering acetaminophen as an alternative for osteoarthritis pain management, given the patient’s warfarin therapy. Additionally, the presence of a CYP2C9 polymorphism in Mark could slow down the metabolism of warfarin, resulting in higher drug levels and increased risk of bleeding (Takeuchi et al., 2020).
In such cases, a lower dose of warfarin might be necessary, and regular INR monitoring would be essential to ensure safe and effective anticoagulation. I would recommend monitoring his INR every 2 to 3 days initially, then weekly once his levels stabilize. I would also educate Mark on the importance of avoiding NSAIDs or aspirin products and on the signs of bleeding, such as unexplained bruising or dark stools, which would necessitate prompt medical attention.
Scenario 3: Alex
Alex is a 52-year-old male who smokes one pack of cigarettes per day and presents with a concerning lipid profile, which includes total cholesterol of 260 mg/dL, LDL cholesterol of 160 mg/dL, HDL cholesterol of 35 mg/dL, and triglycerides of 220 mg/dL. His current medications include lisinopril 20 mg daily for hypertension, semaglutide 0.5 mg weekly for diabetes, and St. John’s Wort. Alex has several risk factors for coronary artery disease (CAD), including smoking, elevated LDL cholesterol, hypertriglyceridemia, and low HDL cholesterol.
To manage these risks, my primary goal would be to reduce his LDL cholesterol to below 100 mg/dL, increase his HDL to at least 40 mg/dL, and lower his triglycerides to below 150 mg/dL (Satyapreethi & Benerji, 2022). The best approach to achieving this would be to initiate statin therapy, which has been proven to lower LDL cholesterol and reduce the risk of cardiovascular events.
I would prescribe atorvastatin at a dose of 40 mg once daily in the evening, as this is an appropriate dose for managing elevated LDL levels in a patient with multiple risk factors (Woo et al., 2021). Along with prescribing atorvastatin, I would advise Alex to make significant lifestyle changes, such as quitting smoking, which could improve his HDL levels and further reduce his risk of CAD. I would also recommend dietary changes, including reducing saturated fat intake and increasing fiber, and encourage regular physical activity to help improve his lipid profile.
I would also recommend discontinuing St. John’s Wort, as it interacts with many medications, including statins, by inducing CYP3A4 enzymes, which may reduce the efficacy of atorvastatin (Nicolussi et al., 2020). I would plan to reassess Alex’s lipid profile after six weeks of statin therapy and monitor his progress with smoking cessation and lifestyle modifications. This approach aims to address his elevated cardiovascular risk through both pharmacologic and lifestyle interventions.
Scenario 4: Sandra
Sandra is a 55-year-old African American female who has been prescribed Toprol XL (metoprolol succinate) 50 mg daily for hypertension. However, she reports inconsistent use of the medication due to side effects of fatigue and dizziness. Her blood pressure reading today is 158/92 mmHg, which is above the recommended goal of less than 130/80 mmHg. Her inconsistent adherence to antihypertensive therapy is concerning, especially given that uncontrolled hypertension significantly increases her risk for stroke, heart attack, and kidney damage.
I would first take time to explain to Sandra the importance of maintaining a consistent medication regimen to control her blood pressure and reduce these risks (Choudhry et al., 2022). I would also provide reassurance that alternative treatments can help alleviate her side effects while still effectively managing her hypertension.
Given Sandra’s symptoms and her reported side effects from metoprolol, I would recommend switching her to an angiotensin II receptor blocker (ARB), such as losartan, which tends to cause fewer side effects than beta-blockers, particularly in African American patients (Ghafarzadeh et al., 2020). I would prescribe losartan 50 mg once daily, as it is an effective alternative for controlling blood pressure while minimizing adverse effects like dizziness and fatigue.
In addition to the medication change, I would emphasize the importance of lifestyle modifications, such as reducing sodium intake, increasing physical activity, and maintaining a healthy weight, as these changes can also contribute to better blood pressure control. To improve adherence, I would recommend self-monitoring of blood pressure at home and keeping a log to track her progress (Shimbo et al., 2020). I would schedule a follow-up appointment in two weeks to reassess her blood pressure and evaluate how well she is tolerating the new medication. This strategy aims to enhance Sandra’s medication adherence and improve her overall hypertension management.
References
Choudhry, N. K., Kronish, I. M., Vongpatanasin, W., Ferdinand, K. C., Pavlik, V. N., Egan, B. M., … & American Heart Association Council on Hypertension; Council on Cardiovascular and Stroke Nursing; and Council on Clinical Cardiology. (2022). Medication adherence and blood pressure control: a scientific statement from the American Heart Association. Hypertension, 79(1), e1-e14. https://doi.org/10.1161/HYP.000000000000020
Ghafarzadeh, M., Shakarami, A., Yari, F., & Namdari, P. (2020). The comparison of side effects of methyldopa, amlodipine, and metoprolol in pregnant women with chronic hypertension. Hypertension in Pregnancy, 39(3), 314-318. https://doi.org/10.1080/10641955.2020.1766489
Krumme, J., Kubsad, S., & Golladay, G. J. (2024). Advances in Pain Management and DVT Prophylaxis. In Surgical Management of Knee Arthritis: Advances in Technique and Technology (pp. 211-220). Cham: Springer International Publishing. https://doi.org/10.1007/978-3-031-47929-8_16
Nicolussi, S., Drewe, J., Butterweck, V., & Meyer zu Schwabedissen, H. E. (2020). Clinical relevance of St. John’s wort drug interactions revisited. British journal of pharmacology, 177(6), 1212-1226. https://doi.org/10.1111/bph.14936
Satyapreethi, A., & Benerji, G. V. (2022). A Study of Lipid Profile (Total Cholesterol, Tgl, Ldl) Among Clinical Hypothyroids and Subclinical Hypothyroids. International Journal of Health Sciences, (I), 11807-11819. https://dx.doi.org/10.53730/ijhs.v6nS1.7883
Shimbo, D., Artinian, N. T., Basile, J. N., Krakoff, L. R., Margolis, K. L., Rakotz, M. K., … & American Heart Association and the American Medical Association. (2020). Self-measured blood pressure monitoring at home: a joint policy statement from the American Heart Association and American Medical Association. Circulation, 142(4), e42-e63. https://doi.org/10.1161/CIR.000000000000080
Takeuchi, M., Kobayashi, T., Biss, T., Kamali, F., Vear, S. I., Ho, R. H., … & Ito, S. (2020). CYP2C9, VKORC1, and CYP4F2 polymorphisms and pediatric warfarin maintenance dose: a systematic review and meta-analysis. The Pharmacogenomics Journal, 20(2), 306-319. https://doi.org/10.1038/s41397-019-0117-x
Wang, M., Zeraatkar, D., Obeda, M., Lee, M., Garcia, C., Nguyen, L., … & Holbrook, A. (2021). Drug–drug interactions with warfarin: A systematic review and meta‐analysis. British journal of clinical pharmacology, 87(11), 4051-4100. https://doi.org/10.1111/bcp.14833
Woo, J. S., Hong, S. J., Cha, D. H., Kim, K. S., Kim, M. H., Lee, J. W., … & Kim, C. J. (2021). Comparison of the efficacy and safety of atorvastatin 40 mg/ω-3 fatty acids 4 g fixed-dose combination and atorvastatin 40 mg monotherapy in hypertriglyceridemic patients who poorly respond to atorvastatin 40 mg monotherapy: an 8-week, multicenter, randomized, double-blind Phase III Study. Clinical Therapeutics, 43(8), 1419-1430. https://doi.org/10.1016/j.clinthera.2021.07.001
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