Week 2 Case Study IBS Case Study
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Week 2 Case Study FNP Student South University
NSG 6005 Advanced Pharmacology Professor December 25, 2023
2
Week 2 Case Study In this case study, Aubre R., a 68-year-old patient who recently relocated from rural Tennessee, presents a complex medical profile. She is grappling with irritable bowel syndrome (IBS) characterized by abdominal cramping and alternating episodes of frequent diarrhea and occasional constipation. Aubre R. has a history of domestic violence, leading to anxiety that necessitated inpatient hospitalization eight years ago. Furthermore, she is experiencing urinary retention, insomnia, and hip pain following a hip fracture four years ago. She is prescribed the following medications: zolpidem 10 mg at bedtime, bethanechol 25 mg three times a day, metoclopramide 10 mg three times a day, amitriptyline 100 mg at bedtime, alprazolam 0.25 mg three times a day, hydrocodone/APAP 5/500 three times a day, and dicyclomine 20 mg four times daily.
This paper undertakes a detailed analysis of the case study featuring Aubre, aiming to address two key inquiries: first, elucidating concerns arising from the current drug regimen, and second, formulating recommendations to optimize care for this patient. Through the analysis of these factors, my goal is to offer practical insights and considerations relevant to medication management in clinical settings.
1.
What are your concerns about this drug regimen?
Aubre is experiencing polypharmacy, the use of multiple medications for various health issues, which is common in older individuals with multiple health problems. This can lead to adverse outcomes, including increased mortality, falls, longer hospital stays, and higher chances of readmission. The risk of harm rises with the number of medications, especially in older patients due to age-related factors (Masnoon et al., 2017). Certain medications among older
3
individuals may counteract each other, potentially causing increased or aggravated issues due to heightened drug sensitivity.
I am concerned about the negative impact of Aubre's current medication regimen on her Irritable Bowel Syndrome (IBS) and related symptoms. Bethanechol, used to enhance bladder muscle tone, may worsen her IBS symptoms, including cramping, due to side effects such as gastrointestinal stimulation. Methclopramide for motility is causing diarrhea, and dicyclomine and hydrocodone are linked to intermittent constipation episodes. Amitriptyline, with its anticholinergic effects, poses a risk of hypotension and works against the intended effects of her IBS medications, especially in older patients (Rosenthal & Burchum, 2021, Chapter 27).
Considering Aubre's advanced age, there are potential challenges with opioid metabolism
and benzodiazepine use. These factors, along with her elevated risk of falls due to pain, polypharmacy, and urgent bathroom visits, emphasize the critical importance of addressing her physical safety concerns arising from her current medication profile.
2.
What recommendations do you have for this patient ?
One of the initial modifications I propose for the patient's treatment plan involves a strategic reduction in the number of prescribed medications to mitigate potential risks associated with polypharmacy. Specifically, I recommend discontinuing the administration of dicyclomine and substituting it with peppermint oil, recognized as a first-line treatment for Irritable Bowel Syndrome (IBS) (Alammar et al., 2019).
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Given the classification of IBS as a disorder involving gut-brain interaction, exacerbated by stress and anxiety, I advocate addressing these components through a referral to Cognitive Behavioral Therapy (CBT) (GI Society, 2023). Simultaneously, I propose substituting amitriptyline with nortriptyline due to the latter's weaker anticholinergic properties (Rosenthal &
Burchum, 2021, Chapter 27). To complement these adjustments, the incorporation of a psyllium fiber supplement into the patient's daily regimen is advised (Black & Ford, 2021).
Furthermore, I recommend initiating the gradual discontinuation of Alprazolam as CBT commences. In lieu of Ambien, I suggest educating the patient on sleep hygiene techniques and prescribing an alternative such as Ramelteon, a melatonin agonist (Rosenthal & Burchum, 2021, Chapter 29)
While maintaining the Hydrocodone/ASAP medication, it is imperative to educate the patient on its usage, potential for abuse, and dependency risks. Additionally, proactive pain management strategies should be imparted to address pain before it intensifies to a level necessitating this opioid.
To ensure comprehensive oversight, a monthly evaluation of the patient's treatment progress for the initial three months is proposed, followed by subsequent monitoring at intervals of 3-6 months post-establishment of treatment. Additionally, routine laboratory assessments, including liver and kidney function, electrolyte status, and a baseline electrocardiogram (EKG), are recommended for a comprehensive understanding of the patient's physiological well-being.
5
References
Alammar, N., Wang, L., Saberi, B., Nanavati, J., Holtmann, G., Shinohara, R. T., & Mullin, G. E. (2019). The impact of peppermint oil on the irritable bowel syndrome: A meta-
analysis of the pooled clinical data. BMC Complementary and Alternative Medicine
, 19
(1). https://doi.org/10.1186/s12906-018-2409-0
Black, C. J., & Ford, A. C. (2021). Best management of irritable bowel syndrome. Frontline Gastroenterology
, 12
(4), 303–315. https://fg.bmj.com/content/12/4/303.info
Chau, D. (2008). Opiates and elderly: Use and side effects. Clinical Interventions in Aging
, Volume 3
, 273–278. https://doi.org/10.2147/cia.s1847
GI Society. (2023). Brain-gut connection and IBS
. GI Society Canadian Society of Intestinal Research. https://badgut.org/information-centre/a-z-digestive-topics/brain-gut-
connection-and-ibs/
Masnoon, N., Shakib, S., Kalisch-Ellett, L., & Caughey, G. E. (2017). What is polypharmacy? A systematic review of definitions. BMC Geriatrics
, 17
(1). https://doi.org/10.1186/s12877-
017-0621-2
Riehl, M., & Michigan Medicine. (n.d.). Antidepressants for the treatment of functional gastrointestinal disorders
[https://med.umich.edu/pdf/gi/Antidepressants-for-Functional-
Gastrointestinal-Disorders.pdf]. University of Michigan.
Rosenthal, L., & Burchum, J. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants - e-book
(2nd ed.). Elsevier.
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