Assignment: Asthma and Stepwise Management Essay
. Patients with these disorders are frequently treated by advanced practice nurses. Because some patients require immediate treatment, you must be able to recognize and distinguish minor asthma symptoms from serious, life-threatening symptoms. Because symptoms and attacks are frequently triggered, advanced practice nurses must assist patients in identifying their triggers and recommending appropriate management options. As with many other disorders, there are different approaches to treating and managing asthmatic patients based on individual patient factors. The stepwise approach, which you investigate in this Assignment, is one method that supports clinical decision-making of drug therapy plans for asthmatic patients.
Pharmacokinetics involves the examination of how the body absorbs, distributes, and excrete medication (Katz et al., 2017). Nurse practitioners who are familiar with the processes by which the body metabolizes medication are more prepared to develop treatment that aligns with patient needs and the specific diagnosis. Pharmacodynamics refer to the manner in which the body is impacted by a drug and the transformation of body cells and structures that occurs as a result of the introduction of the drug (Arcangelo & Peterson, 2013). The specific pharmacodynamic results of drug administration are contingent on the individual patient factors. These factors can be examined through the lens of biomarkers that help nurse practitioners appropriate drug treatment.
One case that speaks to the importance of understanding pharmacokinetic and pharmacodynamic factors involves a 46-year-old female patient with hypertension and Type II diabetes who was prescribed metformin as part of managing her diabetic symptoms. Metformin works by inhibiting production of hepatic glucose and reducing intestinal glucose absorption (Gong et al., 2019). This leads to improved uptake and utilization of glucose. Metformin is not metabolized and is excreted unchanged in the urine. It is widely distributed into body tissues that include liver, kidneys, and intestinal tract (Gong et al., 2016). In this way, it acts to promote efficient use of existing insulin. Intestinal absorption is mediated by the plasma membrane monoamine transporter. In addition, hepatic uptake is mediated by OCT1 and OCT3 as expressed in basolateral membrane of hepatocytes.
Metformin also suppresses excessive hepatic glucose production by reducing gluconeogenesis. This increases insulin signaling and glucose uptake (Ho et al., 2019). Metformin can sometimes increase utilization of glucose in peripheral tissues, without causing hypoglycemia or hyperinsulinemia. This is true because it does not stimulate endogenous insulin secretion. Metformin use results in phosphorylation and activation of AMP-activated protein kinase in the liver. This in turn inhibits glucose and lipid synthesis with a minimal adverse effect profile.
Metformin is generally well tolerated by diabetic patients, which is a primary reason that it remains a first-line treatment option in concert with insulin and other nonpharmacologic treatments. The personalized care plan for this patient included Metformin 850 mg PO BID and daily measurement of blood glucose, along with referral to a nutritionist and recommendations for increased daily physical activity.
Gong, L., Goswami, S., Giacomini, K. (2016). Metformin pathways: Pharmacokinetics and pharmacodynamics. Pharmacogenetics and Genomics, 22(11), 820-827.
Ho, T., Huang, C., Tsai, Y., Lien, A., Lai, F. (2019). Metformin use mitigates the adverse prognostic effect of diabetes mellitus in chronic obstructive pulmonary disease. Respiratory Research, 10(2), 141-155.
Katz, N., Adams, E., et al. (2017). Challenges in the development of prescription opioid abuse-deterrent formulations. Clinical Journal of Pain, 23(8), 648-660.
Winkler, G. (2017). Metformin: New data for an “old” but efficient safe and reliable antidiabetic drug. Orville Health ,157(2), 882-891.
- Consider drugs used to treat asthmatic patients including long-term control and quick relief treatment options for patients. Think about the impact these drugs might have on patients including adults and children.
- Review Chapter 25 of the Arcangelo and Peterson text. Reflect on using the stepwise approach to asthma treatment and management.
- Consider how stepwise management assists health care providers and patients in gaining and maintaining control of the disease.
Write a 2- to 3- page paper that addresses the following:
- Describe long-term control and quick relief treatment options for asthma patients, as well as the impact these drugs might have on patients.
- Explain the stepwise approach to
- Explain how stepwise management assists health care providers and patients in gaining and maintaining control of the disease. Important information for writing discussion questions and participation Welcome to class
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The Expert Panel believes that regular follow-up contact is critical (Evidence B). Contact should be made at 1- to 6-month intervals, depending on the level of control; consider 3-month intervals if a step down in therapy is expected (Evidence D). Clinicians must determine whether asthma control has been maintained and whether therapy should be increased or decreased. Clinicians must also monitor and review the patient’s written asthma action plan, medications, and self-management behaviors (e.g., inhaler and peak flow monitoring techniques, actions to control aggravating factors) (See “Component 2: Education for a Partnership in Asthma Care,” figures 3-11 and 3-15.).
The Expert Panel recommends that, once asthma is well controlled and the control is achieved and maintained for at least 3 months, a reduction in pharmacologic therapy—a step down—can be considered. This will be helpful to identify the minimum therapy for
maintaining good control of asthma (Evidence D). Reduction in therapy should be gradual and closely monitored, because asthma can deteriorate at a highly variable rate and intensity. The patient should be instructed to contact the clinician if and when asthma worsens. Guidelines for the rate of reduction and intervals for evaluation have not been validated, and clinical judgment of the individual patient’s response to therapy is important. The opinion of the Expert Panel is that the dose of ICS may be reduced about 25–50 percent every 3 months to the lowest dose possible that is required to maintain control (Hawkins et al. 2003; Lemanske et al. 2001). Patients may relapse when the ICS is completely discontinued (Lemanske et al. 2001; Waalkens et al. 1993).
The Expert Panel recommends that, if asthma control is not achieved and maintained at any step of care (See figure 4-7.), several actions may be considered:
▪ Patient adherence and technique in using medications correctly should be assessed (Evidence B). See “Component 2: Education for a Partnership in Asthma Care” for discussion on assessing adherence. Key questions to consider asking patients include:
— Which medicines are you currently taking? How often?
— Please show me how you take the medicine.
— How many times a week do you miss taking the medication?
— What problems have you had taking the medicine (cost, time, lack of perceived need)?
— What concerns do you have about your asthma medicines?
▪ A temporary increase in anti-inflammatory therapy may be indicated to reestablish asthma control (Evidence D). A deterioration of asthma may be characterized by gradual reduction in PEF (approximately 20 percent), by failure of SABA bronchodilators to produce a sustained response, by a reduced tolerance to activities or exercise, and by the development of increasing symptoms or nocturnal awakenings from asthma. To regain control of asthma, a short course of oral prednisone (See figure 4-8a.) is often effective. If asthma symptoms do not recur and pulmonary functions remain normal, no additional therapy is necessary. However, if the prednisone burst does not control symptoms, is effective only for a short period of time (e.g., less than 1–2 weeks), or is repeated frequently, the patient should be managed according to the next higher step of care.
▪ Other factors that diminish control may have to be identified and addressed (Evidence C). These factors include the presence of a coexisting condition (e.g., rhinitis/sinusitis, gastroesophageal reflux, obesity), a new or increased exposure to allergens or irritants, patient or family barriers to adequate self-management behaviors, or psychosocial problems. In some cases, alternative diagnoses, such as VCD, should be considered.
▪ A step up to the next higher step of care may be necessary (Evidence A).
▪ Consultation with an asthma specialist may be indicated (See “Component 1: Measures of Asthma Assessment and Monitoring.”) (Evidence D). The Expert Panel recommends referral to an asthma specialist for consultation or comanagement if: there are difficulties achieving or maintaining control of asthma; immunotherapy or omalizumab is being considered; the patient requires step 4 care or higher; or the patient has had an exacerbation requiring a hospitalization. (See “Component 1: Measures of Asthma Assessment and Monitoring.”). Referral may be considered if a patient requires step 3 care