Pharmacological Management Plan
CAMs Contraindicated with Current Prescription
Creatine
Creatine supplement is metabolized in the body to creatinine which is excreted through the kidneys. The body also produces its own creatinine; therefore, in individuals consuming creatine supplements, the total creatinine is high. Creatine supplementation results in water retention by skeletal muscle, therefore, decreasing an individual’s circulatory volume (Negro, Avanzato & D’Antona, 2019). This translates to the production of concentrated urine and reduced renal function. Lisinopril is an angiotensin-converting enzyme inhibitor that is used in hypertension. The resultant vasodilation caused by this drug causes reduced renal perfusion and thus reduced renal function. The result of the combination of creatine and Lisinopril is increased creatinine concentrations and decreased renal function. Creatine is hence contraindicated with Lisinopril.
Coenzyme Q10
This is a compound that is used by cells in the production of ATP, which is an essential component in the production of cellular energy. The body produces sufficient levels of coenzyme Q10, but these levels decrease with age and also conditions such as cancer, diabetes, heart disease, and brain disorders. Evidence suggests interactions between Coumadin and coenzyme Q10 when taken together. Concurrent consumption of coenzyme Q10 and Coumadin results in decreased response to the effects of Coumadin (Sharma, Fonarow, Butler, Ezekowitz & Felker, 2016). On stopping coenzyme Q10, a patient’s response to Coumadin reverts to previous states. This is because coenzyme Q10 has chemical properties that are similar to those of Vitamin K, which is the natural antidote for coumadin. Coenzyme Q1, therefore, predisposes the patient to recurrent thromboembolic events and is thus contraindicated.
Garlic
Coumadin is a blood thinner that results in decreased blood clotting. Garlic supplement has the potential of potentiating the effects of coumadin in minimizing blood clot formation (Reddy, 2017). As a result, concurrent consumption of coumadin and garlic increases the patient’s risk of bleeding and bruising. This is a moderate interaction but one that warrants caution; thus, garlic should be avoided.
CAMs Contraindicated with Diagnosis
Creatine
It causes retention of water by skeletal muscles, therefore, lowering the circulatory volume and blood pressure. It is, therefore, considered safe in hypertension. However, hypertension causes renal failure due to reduced renal perfusion. Creatine supplementation causes reduced circulatory volume with resultant reduced renal perfusion coupled with high levels of creatinine, resulting in renal failure. Creatine supplementation would, therefore, not be advisable in a patient with high blood pressure.
The water retention caused by creatine and, therefore, relative dehydration results in increased viscosity of blood and thus increased the likelihood of clot formation. In a patient with recurrent DVT, this would be an undesirable adverse effect; as a result, creatine is contraindicated.
Coenzyme Q10
This decreases the response to coumadin because it is chemically similar to vitamin k, the natural antidote for coumadin. Coenzyme Q10 thus reduces the therapeutic effect of Coumadin by lowering the patient’s risk of DVT, predisposing him to recurrent DVT episodes. Coenzyme Q10 is, therefore, contraindicated in the diagnosis of recurrent DVT.
Prescription for Back Pain
Taking the patient’s diagnosis and prescription, it is prudent to select pain medication that is relatively selective and with minimal effects on the kidneys, blood clotting, blood pressure, and blood sugar control. The following drugs would be appropriate:
Acetaminophen
Acetaminophen is a safe pain medication that can be used in patients with high blood pressure, recurrent DVT, and type 2 diabetes mellitus. It is metabolized in the liver and kidneys and has low toxicity at prescription doses. It is, therefore, appropriate for the management of back pain. The patient may take extra-strength Tylenol 500mg tablets at a frequency of one tablet twice a day. On administration of acetaminophen, the patient should be advised to reduce the amount of kava consumed to reduce the risk of hepatotoxicity (Stickel & Shouval, 2015).
Muscle relaxants
Back pain is also caused by recurrent muscle spasms that occur in the muscles of the back. As a result, muscle relaxants are effective in relieving back pain. The muscle relaxant is combined with pain medication such as acetaminophen. The patient may receive a prescription of baclofen tablets at a dose of 10mg each to be taken once daily.
Changes in Prescribed Drugs
The dose of Lisinopril will need to be reduced. This is because the creatine supplementation results in water retention in muscles and therefore reduced the circulatory volume and decreased blood pressure. As a result, the dose of Lisinopril required to lower blood pressure is lower.
The dose of coumadin will also need to be reduced with garlic supplementation. Garlic potentiates the effect of coumadin. Therefore, lower doses of Coumadin are required to reduce the risk of bruising and bleeding.
Creatine supplementation, combined with an exercise regime, has the effect of improving glycemic control in patients with type 2 diabetes mellitus. Creatine increases the sensitivity of cells to the effects of insulin and betters a patient’s lipid profile. The dose of glyburide, therefore, needs to be reduced to prevent the occurrence of hypoglycemia in the patient.
Follow-up Evaluations
Time-frame
The patient has chronic conditions that need lifelong follow-up to prevent the occurrence of complications and also to detect them promptly if they occur. The patient will need continuous clinic visits for type 2 diabetes mellitus, high blood pressure, and recurrent DVT. Following the advice on the supplements modification of prescription, he will need to come to the doctor’s office after three months for progress monitoring.
Strategies for Evaluating Side/ Adverse Effects
Strategies for Creatine Monitoring
The patient will have a test done to measure blood urea, electrolytes, and creatinine. If the levels of creatinine are unacceptably high, the patient will be advised to reduce the amount of creatine consumed. This test is also an indicator of renal function and can, therefore, be used to evaluate the response of the kidneys to the reduced dose of Lisinopril.
Strategies for Coenzyme Q10 And Garlic Monitoring
The patient’s INR will be measured and adjusted towards the desired range for effective DVT prophylaxis.
Strategies for Kava Kava Monitoring
Kava kava causes hepatotoxicity (Stickel & Shouval, 2015). Administration of acetaminophen with this supplement, therefore, warrants the monitoring of liver function. This will be done by carrying out liver function tests.
Strategies for Evaluating Effectiveness
Effectiveness in Type 2 Diabetes Mellitus
To determine the trend in the patient’s glycemic control over the three months, the patient’s HBA1c will be measured. This is a good measure of control over an extended period and will indicate the effectiveness of co-administration of the supplements with lower doses of medication. The patient may also receive a book in which he shall record daily measures of blood sugar.
Effectiveness in High Blood Pressure
The patient will receive a charting book in which to record daily blood pressure taken in the morning and the evening. Renal function tests will also be carried out and fundoscopy to assess the effects of the supplements on blood pressure.
Effectiveness in Recurrent DVT
The patient’s INR will be determined against the target INR for effective DVT prophylaxis. The patient will also undergo a physical examination to rule out bruises that may indicate excessive blood thinning.
References
Negro, M., Avanzato, I., & D’Antona, G. (2019). Creatine in skeletal muscle physiology. Nonvitamin And Nonmineral Nutritional Supplements, 59-68. Web.
Reddy, R. (2017). Effect of Allium sativum (Garlic) Extract on Blood Coagulation and Fibrinolysis. Advances in Pharmacology & Clinical Trials, 2(1). Web.
Sharma, A., Fonarow, G., Butler, J., Ezekowitz, J., & Felker, G. (2016). Coenzyme Q10 and heart failure. Circulation: Heart Failure, 9(4), e002639. Web.
Stickel, F., & Shouval, D. (2015). Hepatotoxicity of herbal and dietary supplements: an update. Archives of Toxicology, 89(6), 851-865. Web.