Answer discussion2

9

answer this discussion based on this:

Critique your colleague’s

From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other. 

References at least 2-3 no more than 5 years ago.

do not make negative critique

The patient’s chief complaint in this scenario is insomnia so she should be asked additional questions to decide how to best treat her. I would ask the patient to describe her current sleeping pattern. By asking this question the patient will hopefully be able to describe her insomnia such as how long she sleeps for, what time she usually sleeps, and if anything currently helps her to sleep. I would also ask the patient how long she has been experiencing issues with her sleep habits to determine if the patient had issues prior to her husband’s death. I would also ask the patient what time of day she takes her medications. The patient is currently taking Sertraline daily which could potentially affect her sleeping pattern. Another question I would ask the patient is what symptoms is she experiencing due to her insomnia. Assessing the patient's cognitive and physical symptoms may help determine the potential cause of her insomnia.

            If the patient has close family or friends in her life they should also be spoken to. It is not specified whether or not the patient has children, but if she does it would be important to speak with them. Since the patient’s husband is deceased, her children are most likely her next of kin. If her children help provide care for her they may be able to provide additional insight regarding the patient’s condition. It would be important to ask her children if they have any issues with insomnia to rule out any familial/biological causes. It would also be beneficial to speak with the patient’s Primary Care Physician who may be able to provide additional details regarding the patient’s health history and current medication use.

            A physical exam and additional diagnostic testing would be appropriate for this patient. A comprehensive physical exam should be performed to rule out any other possible health conditions that may be affecting the patient’s sleeping habits. Bloodwork may also be obtained to check the patient’s thyroid function (Pacheco, 2022). A sleep study, or a polysomnogram test, may also be done to “monitor brain wave activity, heart and breathing rates, oxygen levels, and muscle movements that occur prior to, during, and after sleep” (Pacheco, 2022).

            It is stated that the patient had no prior history of depression prior to her husband’s death but it is unclear whether or not the patient had insomnia prior. This patient is most likely suffering from insomnia related to her major depressive disorder (MDD). Significant life events or traumatic events such as the loss of a loved one can trigger depression (Chand & Arif, 2022). Insomnia is one of the most common sleep issues associated with depression in adult patients (Pacheco, 2022). 

            Two pharmacologic agents that would be appropriate for the patient’s antidepressant therapy would be Trazodone 25 milligrams and Fluoxetine 10 milligrams. Trazodone is a serotonin receptor antagonist and is commonly used in the treatment of insomnia secondary to antidepressant use (Fava & Papakostas, 2016). Fluoxetine belongs to a class of antidepressants called Selective Serotonin Reuptake Inhibitors (SSRIs) that work by increasing the activity of serotonin in the brain. SSRIs are used as a first-line treatment of MDD in most cases due to their favorable side-effect profile (Chand & Arif, 2022). Additionally, Fluoxetine has been found to safely reduce the severity of depression in diabetic patients without having an adverse effect on glycemic control which is important to consider since this patient is diabetic (Khazaie, et al., 2011). In this scenario, I would choose Trazadone as opposed to Fluoxetine since the patient is already on Sertraline and experiencing issues with insomnia.

            It is important to consider medication contraindications. Trazadone is contraindicated with the use of monoamine oxidase inhibitors (MAOIs), or use within 14 days of stopping MAOIs. There is also the risk of developing serotonin syndrome when co-administered with other serotonergic agents (U.S. Food and Drug Administration, n.d.). These contraindications should be discussed at length with the patient prior to prescribing.

            Medication monitoring is important while taking Trazodone. Baseline bloodwork may need to be obtained to check baseline liver function and then may be monitored periodically. A follow-up appointment should be made for the patient at the four-week mark to assess the effectiveness of the medication. At this point, if the patient is not experiencing a reduction in symptoms, it may be necessary to increase her daily dose to 50 milligrams and re-assess in another four weeks.

References

Chand, S. P., & Arif, H. (2022).  Depression. National Library of Medicine. Retrieved October 12, 2022, from  https://www.ncbi.nlm.nih.gov/books/NBK430847/

Fava, M., & Papakostas, G. I. (2016). Antidepressants. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.),  Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 27–43). Elsevier.

Khazaie, H., Rahimi, M., Tatari, F., Rezaei, M., Najafi, F., & Tahmasian, M. (2011). Treatment of depression in type 2 diabetes with Fluoxetine or Citalopram?.  Neurosciences (Riyadh, Saudi Arabia),  16(1), 42–45.

Pacheco, D. (2022).  Diagnosing insomnia. Sleep Foundation. Retrieved from  https://www.sleepfoundation.org/insomnia/diagnosis

U.S. Food and Drug Administration. (n.d.). Retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/017812s028,018421s027lbl.pdf