Psychotherapeutic agents are the pillars to disease treatment and symptoms alleviations. The major factors considered when choosing a suitable psychotherapeutic agency are safety, efficacy, and tolerability. This paper evaluates psychotherapeutic agents in view of the case of MM, a 60 year old African American female who presented at a clinic with three months lack of sleep. She works in a high stress environment as a chemical engineer. Tests and readings conducted revel the patients BP is 156/80, T = 98.8, SpO2 = 99%, TSH = 3.4, cholesterol = 200 mg/dl, LDL = 128 and HDL = 40mg/dl. She commonly experiences gastroesophageal reflux (manifested as heartburn) and indigestion after eating food. Based on a standard depression tool, the patient has depressive disorder and although she has the classical feelings of depression such as hopelessness, she denies any plans to injure herself or others. This paper covers the treatment goals, drug therapy, monitoring and evaluation, expected drug interactions and patient education.
Q1. List specific goals for treatment for MM
Q2. What drug therapy would you prescribe for MM. Why?
Drug therapy for insomnia is based on hypnotics such as non-benzodiazepines and benzodiazepines which have a high efficacy are safe and tolerable. These are the first line drugs in the management of sleep disorders. However, since the patient is suffering from both insomnia and depression, I would recommend antidepressants such as trazodone, mirtazapine or doxepin which have a sedative effect (Fagiolini et al., 2012). Using one drug to manage two conditions is a better strategy because it will reduce drug-drug interactions and reduce cases of drug resistance due to overuse. Tradodone is a serotin antagonist and reuptake inhibitor (SARIs) and will be prescribed at 150mg per day for the first week with 225mg maintenance dose for three weeks using extended release tablets. A reduced dosage of 150mg will be given in the last week before withdrawal from the drug. For the treatment of GERD, I would prescribe proton pump inhibitors (PPIs) such as lansoprazole, esomeprazole of rabeprazole which reduce gastric acid production. PPIs have a high efficacy and compare well with drugs being developed currently (Witterman et al., 2013). I would prescribe omeprazole/sodium bicarbonate which is a PPI, heals stomach ulcers, and has antacid properties. The dosage indicated will be 40mg/1500mg of omeprazole/sodium bicarbonate.
Q3. What are the parameters for monitoring success of therapy?
The parameters that will be used to monitor success of the adopted therapy will be based on the treatment goals highlighted and evaluation of side effects and adverse drug reactions. Reduced symptoms of GERD such as elimination of heartburn and healing of the esophagus will indicate success. Improvement of sleep quality and quantity and alleviation of the symptoms of depression such as improved wellbeing and self esteem will indicate success. The drugs used have potential side effects which will be monitored. If the therapy is not successful, or adverse drug effects that are life threatening are observed, the therapy will be discontinued in favor of alternative therapies.
Q4: Discuss specific patient education based on the prescribed therapy.
Q5. List adverse reaction for the selected agents that would cause you to change therapy
PPIs have various side effects such as nausea, diarrhea, dizziness and abdominal pain. However, only significant effects such as the observed decreased effect of clopidogrel on platelets, impact on bone metabolism, vitamin D and calcium would lead to withdrawal of the therapy (Lodato et al., 2010). Some of the adverse effects of trazodone that would make me withdraw the drug include chest pains, irregular heartbeats, difficult breathing, decreased coordination, syncope, and peripheral edema (Gershon, 2010). Other minor side effects of trazodone such as dry mouth, tiredness, sweating, and tinnitus are tolerable and would not warrant withdraw of the therapy when it is effective in alleviating symptoms of depression and insomnia.
Q6. What would be the best choice for second line therapy? Why?
Second line therapy would be used if the prescribed therapy is not effective or produces adverse side effects. The second line therapy for management of GERD would be H2 receptors antagonist which also reduce production of acid in the digestive tract. The most popular H2 receptors antagonist is cimetidine. Alternative therapies which will be prescribed for insomnia include benzodiazepines and non-benzodiazepines. These are the drugs used to treat insomnia but I recommended antidepressants due to their efficacy in tackling depression and sedative effect for insomnia. Alternative therapy for depression will be based on tricyclic antidepressants.
Q7. What over the counter or alternative medications would be appropriate for MM.
There are numerous drugs that are available over the counter which would benefit MM. antihistamines such as diphenhydramine and doxylamine can be used for the management of insomnia. Many antidepressants are available over the counter. Antacids which work by neutralizing acidity in the stomach are used as over the counter medication for GERD. Some common antacids include tums, galviscon and milk of magnesia. Cognitive behavior therapy is effective in the management of insomnia while counseling and guides self-help can alleviate depression (Siebern & Manber, 2010: Dirmaier et al., 2012).
Q8. Describe one drug-drug interaction for the selected agents
Drug interactions are potential causes of adverse drug reactions and reduced efficacy of drugs. One of the most common drug-drug interactions generated by PPIs such as trazodone is the loss of beneficial effects of clopidogrel and increasing risk of reinfraction (Juurlink et al., 2009). However, there are no known adverse drug-drug interactions between antidepressants and PPIs besides serotonin toxicity (Gillman, 2007).
Q9. As and APN what lifestyle changes would you recommend to MM
There are various lifestyle changes that are suited for MM to improve her health. To start with, MM smokes half a park of cigarettes per day. Smoking is a risk factor in various respiratory diseases such as COPD and I would recommend that the patient quits smoking. Working late night shifts and emotional stress are some risk factors associated with insomnia. I would recommend that the MM avoid night shifts and work related stress to promote the quality of sleep. Dietary interventions can alleviate GERD symptoms include weight loss and avoiding alcohol, acidic foods and fatty foods. The patient’s blood fat analysis revel undesired levels. For instance, MM has a HDL level of 40mg/dl while the ideal level for a woman should be above 60mg/dl. The patient’s level of LDL is 128mg/dl and a cholesterol level of 200mg/dl which are near ideal. Weight loss and controlling blood pressure will control the level of triglycerides. I would recommend a diet rich in fiber such as brown rice and whole wheat pasta for the patient to prevent metabolic syndromes and improve the patients well being.
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