Post a description of the patient case from your experiences, observations, and/or clinical practice from the last 5 years. Then, describe factors that might have influenced pharmacokinetic and pharmacodynamic processes of the patient you identified. Finally, explain details of the personalized plan of care that you would develop based on influencing factors and patient history in your case. Be specific and provide examples.
Within the past 5 years of practice, an interesting case of a patient I worked with was that of a 68 years old patient who was diagnosed with chronic kidney disease (CKD) on dialysis. He was a middle aged African American male with a longstanding history of uncontrolled Type 2 diabetes mellitus (T2DM) and one of the drugs he was prescribed was gabapentin.
Pharmacokinetics and Pharmacodynamics
Chronic Kidney Disease (CKD) is an increasingly common condition in patients with diabetes mellitus which alters the pharmacodynamics and pharmacokinetics of drugs. Therefore, when prescribing a drug to a patient with CKD, the prescriber should be knowledgeable about the medication, the extent of the physiology altered in a patient, and the principles which influence the dosing regimens. Lea-Henry et al., (2018) highlights that currently, there exists guidelines to inform knowledge and decision making in regards to dosing in CKD. However, most of the findings base on limited data that is limited hence, there is need to understand the principles that guide their pharmacokinetics. A decreased glomerular filtration rate (GFR) in CKD significantly impacts the pharmacodynamics and pharmacokinetics of drugs in CKD. Ultimately, this reduces the renal clearance and subsequent excretion of drugs (Lea-Henry et al., 2018). Therefore, if a prescriber fails to make appropriate dose adjustments, patients are at a higher risk of toxicity.
CKD alters the processes of drug absorption, distribution, metabolism, and excretion. For this patient, age was a determining factor in the pharmacokinetics and pharmacodynamics of the drug prescribed. Advanced age is associated with lower rates of GFR and creatinine clearance and vice versa. However, the levels of serum creatinine remain within the normal limits. In practice, Sabatino et al., (2017) mentions how clinicians often evaluate patients using the serum creatinine levels and in such patients, since the values are within the normal limits, the findings can be misleading. Therefore, the fact that tis patient had an advanced ae and an underlying diagnosis of CKD, he needed a proper dose adjustment to decrease the risk of drug toxicity.
Personalized Care Plan
Non-pharmacological approaches to chronic disease management such as lifestyle modification are considered an important intervention to prevent CKD progression. Lifestyle modification can perfectly be implemented through behavior change interventions in regards to diet and physical activity (Evangelidis et al., 2019). In diet therapy, the patient has to maintain a strict diet characterized by limited sodium intake, increased consumption of vitamins (folic acid, vitamin B, erythropoietin, and iron). To help the patient successfully navigate through the lifestyle changes, he will need the help of a dietician, nurse practitioner (NP), physician, and family members to work collaboratively. In regards to the dosing regimen, the usual dosing of gabapentin in adults/older adults starts with 300mg to a maximum of 2400mg daily. Based on the recommendations provided by Raouf et al., (2017), this patient’s dosing should be adjusted to a starting dose of 125mg to maximum 300mg daily.
Factors as advanced age and underlying chronic diseases such as chronic kidney disease impact the pharmacokinetics and pharmacodynamics of medications by reducing creatinine clearance and GFR. Ultimately, this decreases the mechanism by which the kidneys excrete drugs. Therefore, a prescriber must be knowledgeable of the renal physiological changes that occur with age and CKD to make an informed decision on the best drug modification strategies to prevent adverse events.
Evangelidis, N., Craig, J., Bauman, A., Manera, K., Saglimbene, V., & Tong, A. (2019). Lifestyle behaviour change for preventing the progression of chronic kidney disease: a systematic review. BMJ open, 9(10), e031625. https://doi.org/10.1136/bmjopen-2019-031625
Lea-Henry, T. N., Carland, J. E., Stocker, S. L., Sevastos, J. Roberts, D. M. (2018). Clinical Journal of American Society of Nephrology. Clinical Pharmacokinetics in Kidney Disease. 13(7) 1085-1095; DOI: 10.2215/CJN.00340118
Raouf, M., Atkinson, T. J., Crumb, M. W., & Fudin, J. (2017). Rational dosing of gabapentin and pregabalin in chronic kidney disease. Journal of pain research, 10, 275.
Sabatino, J. A., Pruchnicki, M. C., Sevin, A. M., Barker, E., Green, C. G., & Porter, K. (2017). Improving prescribing practices: A pharmacist‐led educational intervention for nurse practitioner students. Journal of the American Association of nurse practitioners, 29(5), 248–254. doi:10.1002/2327-6924.12446
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