Pharmacotherapy for Gastrointestinal and Hepatobiliary Disorders
Review of Case Study:
Patient HL comes into the clinic with the following symptoms: nausea, vomiting, and
diarrhea. The patient has a history of drug abuse, and possible Hepatitis C. HL is currently taking
the following prescription drugs: It is essential to complete a thorough health history and
examination before diagnosing HL. There are several necessary questions related to HL’s
medication list that should ask:
• Duration and reason for the Prednisone?
• Recent recreational drug use?
• Duration of the symptoms/ weightloss?
• Description and number of the stools/emesis per day?
• Synthroid 100 mcg daily
• Nifedipine 30 mg daily
• Prednisone 10 mg daily
History of Present Illness and Medical History
Patient presents with symptoms of diarrhea, nausea, and vomiting. Learning from HL’s
medical history, HL appears to have some possible chronic conditions based on his current
medications; Synthroid 100 mg daily, Nifedipine 30mg daily, and prednisone 10mg daily.
Synthroid is a hormone replacement that is used to treat hypothyroidism, thyroid
cancer and goiter (Drugs.com, 2017). Synthroid can have adverse effects if not taken correctly or
if misused, thorough assessment and review of patients understanding of medication regimen is
needed. Diarrhea is a common side effect of Synthroid. N/V are classified as severe/adverse
reaction and should be reported the health practitioner immediately (Drugs.com, 2017). Healthy
adults age 50 years or less with a weight of 70kg or more; initial dose of 100-125 mcg/day be
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taken for a few months. HL’s medical history and chronicity of the hepatitis could warrant
decreasing the current dose of Synthroid. Thyroid levels should be checked every 6-8 weeks
(Drugs.com, 2017). No warnings were identified with the use of Synthroid and Hepatitis C upon
review.
Nifedipine is a calcium channel blocker that is used to treat hypertension and chest
pain (angina). There are no warnings with Hepatitis C and the use of calcium channel blockers.
Initial dose recommended 30-60mg orally (Drugs.com, 2017). Nifedipine has also been linked to
several instances of clinically apparent acute liver injury, and dosing should be decreased for
patients with any chronic illness involving the liver and function. HL’s dose is appropriate for
treatment and current health status (Drugs.com, 2017).
Prednisone is a corticosteroid that prevents the release of substances in the body that
causes inflammation it also suppresses the immune system (Drugs.com.2017). Prednisone treats
many different conditions such as allergic disorders, skin conditions, ulcerative colitis, arthritis,
lupus, psoriasis, or breathing disorders. Prednisone should be taken with care if you have a
thyroid issue, and I recommend discontinuing this medication. Side effect of prednisone is
pancreatitis, which presents with severe pain in your upper stomach, nausea, and vomiting.
Prednisone often prescribed for HCV patients who are unresponsive to NSAIDs or have
advanced liver disease, such as cirrhosis, and in those who have contraindications to their use
(nephrotoxicity); short-term, low-dose prednisone (5 to 10 mg) is usually prescribed. Nifedipine
will increase the level or effect of prednisone (Drugs.com, 2017).
Assessment and Diagnostics
A comprehensive history and physical examination are required to create a full picture of
any underlining issues that is causing the patient’s symptoms. Medication reconciliation is
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needed to be conducted for potential drug interactions. Also, the diagnostic workup is required
for further evaluation. Drug Screen test, Urinalysis, abdominal ultrasound, Blood tests such as
liver panel, CBC, CMP, TSH, Hepatitis C RNA test, genotype test, an antibody test for HCV will
be ordered to determine the cause of the symptoms. Imaging of the GI tract for abnormalities
should be considered for thorough examination and ROS.
Primary Diagnosis: Hepatitis C Virus
Hepatitis C is an acute liver infection caused by a virus that usually results from infected
person-to-person contact of blood and bodily fluids, sexual intercourse or sharing of needles
associated with illicit drug/substance abuse (Arcangelo & Peterson, 2013) . classifications can be
acute or chronic (Arcangelo & Peterson, 2013). HCV is progressive, and in most cases,
symptoms are asymptomatic but may present significant problems. It is often undiagnosed due to
the symptoms present as a flu-like illness. Usually, elevated liver enzymes and a positive
antibody test for HCV (anti-HCV) mean that an individual has hepatitis C. Symptoms include
fatigue, mild fever, muscle and joint aches, nausea, vomiting, loss of appetite, vague abdominal
pain, and sometimes diarrhea. Diarrhea develops during acute hepatitis C. Although this initial
phase of infection causes no symptoms at all, approximately 20 to 30 percent of people notice
symptoms about 1 to 3 months after contracting the virus (Centers for Disease Control and
Prevention, 2016). From the data collected, the patient has a history drug abuse, the current
medications such as prednisone and presenting symptoms may suggest the diagnosis of Acute
Hepatitis C.
Differential Diagnosis
• Drug Dependence and Abuse: The signs and symptoms displayed by a person
depend on what substances the person has abused. Symptoms may include altered mental status,
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CNS suppression, nausea, vomiting, diarrhea, anxiety, hallucinations, chest pain, and abdominal
pain. Most patients with substance abuse commonly exhibit behavioral symptoms that can cause
harm to self or others and requires an emergent medical intervention(Arcangelo & Peterson,
2013). Referral to dependence counselor or addiction specialist is warranted to rule out acute
relapse.
• Gastroenteritis is irritation/inflammation of the stomach and intestines caused by
food contaminated with bacteria, viruses, parasites, or toxins. Symptoms may include cramping,
nausea, vomiting, or diarrhea. The illness usually spreads easily from contact with a sick person
or eating or drinking contaminated food or beverages also will spread the disease. Most
otherwise healthy patients recover in a few days by drinking plenty of fluids and resting.
Antibiotics treat gastroenteritis caused by bacteria or some parasites. In most cases, nausea,
vomiting, and diarrhea will resolve within 24 to 48 hours (Arcangelo & Peterson, 2013).
-Offering the patient an antiemetic would be an appropriate intervention and may provide
comfort.
Plan and Treatment Recommendations
According to the American Association for the Study of Liver Diseases and the Infectious
Diseases Society of America (2016), the recommendations for treatment and management per
HCV Guidelines:
Regular laboratory monitoring every four to six weeks for six months to 12 months is
also recommended to determine spontaneous clearance of HCV infection versus persistence of
infection (Drugs.com, 2017).
HL’s symptomology and presentation it is my belief the patient can be classified as genotype
1a (without cirrhosis) (Drugs.com, 2017). Guidelines for the diagnosis and management of HCV
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infection were originally released jointly by the American Association for the Study of Liver
Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) in 2016 and are
updated on a continuous basis, following availability of new medications or release of major
treatment trials. Regimen selection for patients with genotype 1 infection should take into
account the efficacy, duration, and adverse reactions, potential drug interactions, the patient's
history of prior treatment, and the stage of fibrosis before selecting the best medication to treat
(Arcangelo & Peterson, 2013)
References:
Arcangelo, V. P., & Peterson, A. M. (2013). Pharmacotherapeutics for Advanced Practice: A
practical approach. Ambler, PA: Lippincott Williams and Wilkins.
American Association for the Study of Liver Diseases and the Infectious Diseases Society of
America (2016). Management of Acute HCV Infection. Retrieved July 9, 2018 from
http://www.hcvguidelines.org/unique-populations/acute-infection
Centers for Disease Control and Prevention (2016). Hepatitis C FAQs for the Public.
Retrieved July 9, 2018 from https://www.cdc.gov/hepatitis/hcv/cfaq.htm
http://symptoms.webmd.com/default.htm#conditionView
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Hypertension if left without treatment can causes nausea and vomiting as presenting
symptoms. This nausea and vomiting can also be a sign of a heart attack a comprehensive lab
work-up to ensure there is no damage to the heart must be complete for the visit to be thorough
in diagnosing and treatment. Multiple or continuous blood pressure measurements should be
ordered if they could be responsible for the symptoms.
Arcangelo, V. P., & Peterson, A. M. (2013). Pharmacotherapeutics for Advanced Practice: A
practical approach. Ambler, PA: Lippincott Williams and Wilkins.
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