adv pharmacology

provide recommendations for alternative drug treatments to address the patient’s pathophysiology. Be specific and provide examples

Week 9 Initial Post- Mel Mal,

COLLAPSE

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This case study presents a particularly hard case to untangle. The 46-year-old women is exhibiting the night sweats, hot-flushing, and genitourinary symptoms common in menopause. The patient is still getting a regular period, so these symptoms are most likely pre-menopausal, as periods stop in true menopause. In a patient with no familial history increasing the patient’s risk for breast cancer, an estrogen or combination estrogen/progestin therapy would most likely be initiated (Rosenthal et al. 2021). This therapy would likely reduce the uncomfortable symptoms, however in a patient with a family history of breast cancer, the therapy can increase the likelihood of breast cancer occurrence.

Luciano et al., found that both estrogen therapies and combined estrogen/progestin therapies increased the risk for breast cancer (2020). It is important to notice that this study notes that the risks for patients who take the therapy on a short-term basis are at a slightly lower risk, however this patient is young at 46 years old and would possibly need a long-term medication solution.

On the opposite side, Carr summarizes the North American Menopause society’s 2022 updated guidelines on hormonal replacement therapy and explains that a patient with menopausal symptoms can take combined hormone therapy until at least the mean age of menopause (53) without any significant increase in breast cancer (2022). With the newest recommendations, I would recommend that the patient start a combined estrogen and progestin hormone therapy for reduction in symptoms. With this recommendation is the caveat that the patient will need regular visits to re-evaluate the need for the therapy with hopeful cessation of treatment within three to five years to keep any increase in breast cancer risk to a minimum.

The lowest dose medication should be used for the shortest time period in order to reduce comorbidity risk so this patient recommendation will be to start Prempro 0.3mg/1.5mg daily and then reevaluate for effectiveness and need to increase dosage (Rosenthal et al., 2021).

The patient also needs adjustments in her hypertension medication. The patient is currently on Norvasc 10mg daily, and HCTZ 25mg daily. This therapy is within guidelines because she is on Norvasc, a calcium-channel blocker, and Hydrochlorothiazide, a thiazide diuretic, are being used to potentiate each other’s effects. In cases where a thiazide diuretic is ineffective in controlling HTN, a loop diuretic may be added. In this patient, we will recommend adding Furosemide to hopefully control the hypertension. This dosage will start low, at 20mg daily, (taken in the morning to decrease nocturia), with regular home blood pressure checks as well as in office re-evaluation to determine how effective the medication and dosage are (Rosenthal et al., 2021).

This patient would benefit from educational strategies that address medication adherence, as well as lifestyle and nutrition choices. The patient is 230 pounds, which most likely indicates an unhealthy weight. Education on cardio exercises, as well as eating a healthy and balanced diet to help control her weight would be a good starting point. The patient also needs specific education on the importance of taking her medications every day, with explanations that she will not have level and even control of her symptoms and blood pressure if she does not adhere correctly.

 

References:

-Carr, L. (2022). NAMS: New hormone therapy guidelines.  Contemporary OB/GYN,  67(9), 27. 

-Hill, D. A., Crider, M., & Hill, S. R. (2016). Hormone Therapy and Other Treatments for Symptoms of Menopause.  American Family Physician,  94(11), 884–889.

-Luciano de Melo Pompei, & César Eduardo Fernandes. (2020). Hormone Therapy, Breast Cancer Risk and the Collaborative Group on Hormonal Factors in Breast Cancer Article.  Revista Brasileira de Ginecologia e Obstetrícia,  42(5), 233–234. https://doi.org/10.1055/s-0040-1712941

-Rosenthal, L. D., & Burchum, J. R. (2021).  Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

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MI JON KIM

A 46-year-old woman presents typical symptoms and physical changes of menopause; hot flushing, night sweats, and genitourinary symptoms. Menopause, simply menstruation cease, means decreasing the body’s production of estrogen. Lack of estrogen in the body causes discomfort to women who never experience it before. Roberts and Hickey (2016) described the physiological changes during women’s menopause transition; “Vasomotor symptoms (VMS), genitourinary syndrome of menopause (GSM), sleep disturbance, sexual dysfunction and mood disturbance” (p. 53). Menopause in women begins at the approximate age of 51 to 52 years, with 95% of women entering menopause between the ages of 45 and 55 years (Rosenthal & Burchum, 2021). And they suggest the moderate dose estrogen-containing hormone replacement therapy (HRT) as the most effective treatment. The patient, however, has a family history of breast cancer and hypertension and is overweight (230 lbs.). Considering the hormonal replacement therapy for the patient needs the evaluation for the patient’s comorbidity and the interaction with the patient’s current hypertension medication adjustment with the blood pressure monitoring.

Types of treatment regimen you would recommend for treating the patient

There are three recommended treatment therapies for managing menopause; hormone replacement therapy (HRT), symptomatic medication management, and alternative therapy, including improving a healthy lifestyle, such as sleep hygiene, exercise, smoking cessation, and diet changes. First, “Estrogen used alone (estrogen replacement therapy [ERT]) or with the addition of progesterone (hormone replacement therapy [HRT]) is known to be effective in reducing menopausal symptoms including hot flashes, vaginal dryness, and urinary symptoms” (Pritchard, 2001, para 1). However, hormonal therapy increases the risk of cancer, hypertension, heart disease, and stroke. Low-dose HR of estrogen only or mixed with progesterone in a short period is recommended for healthy women between the ages of 50 to 59 (Roberts & Hickey, 2016). So, it should be informed for patients to decide the balance between benefits and risks. Second, there is a symptomatic medication to relieve the vasomotor symptoms (VMS) of hot flush & night sweats. Other than estrogen, some antidepressants- selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI)-can decrease the VSM (Rosenthal & Burchum, 2021). Lastly, the natural way of alternative therapy for handling menopause is more desirable because menopause is a normal process of aging. The goal for the menopause transition is to increase the quality of life by adjusting lifestyle through diet, exercise, and patterns of life.

Patient education strategy recommend for assisting the patient

Education is the most critical part of managing the menopause transition for women. One education strategy is to give patients the correct information, possible options, related benefits, and risks related to treatment. Suppose the patient fully understands the relationship between menopause and other health issues, such as hypertension, obesity, increased cholesterol level, risk of cardiovascular disease, and stroke ("Menopause and hypertension," 2008). In that case, the patient is willing to change unhealthy patterns of daily life. If they learn that estrogen binds to the receptor in the cell membrane, stimulates cell overgrowth & proliferation, and finally might develop cancer cells, they would choose natural ways of improving rather than hormonal replacement. The role of health providers is to advocate for people's quality of life and safety. Informed health decision-making is the essential strategy and priority in interactions between health providers and patients.

 

References

Menopause and hypertension. (2008, April 1). Hypertension. https://www.ahajournals.org/doi/full/10.1161/hypertensionaha.107.105742

Roberts, H., & Hickey, M. (2016). Managing the menopause: An update.  Maturitas, 86(2016), 53–58. https://doi.org/10.1016/j.maturitas.2016.01.007

Rosenthal, L. D., & Burchum, J. R. (2021).  Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

Pritchard, K.I. (2001). Hormone replacement in women with a history of breast cancer. Oncologist. 2001;6(4):353-62. doi: 10.1634/theoncologist.6-4-353. PMID: 11524554.