Melissa Hinkhouse Advanced Pharmacology Nurs 6521

Melissa Hinkhouseadvanced Pharmacology Nurs 6521n 43professor Dr Vick

Melissa Hinkhouse advanced Pharmacology Nurs 6521N-43 Professor Dr. Vicki Gardin Discussion Board Week 1-Original Post 11/30/2020 I have worked in an outpatient behavioral health clinic for the past seven years with many different providers. I live in a rural community, many patients wait six to twelve months to be seen. Patients being treated for Attention Deficit Disorder must be officially tested before being seen by a Psychologist. For this discussion board post, I have changed the name of my patient to Paul to ensure patient confidentially.

The provider I worked with this particular patient will also be referred to as PMHNP to ensure provider confidentiality. Paul was a ten-year-old Caucasian male referred to our clinic diagnosed per DSM criteria, confirmed via Psychologist testing with ADHD. When he saw the Psychologist, he was also diagnosed with mild depression and anxiety. He struggled with concentration, hyperactivity, impulse control, and disorganization. He presented to his appointment with his mother and father, clean, well-nourished, pleasant, interactive with staff, reported no medication allergies, current medication Zyrtec for seasonal allergies.

Paul just had his well-child exam and is current on vaccinations and his primary care provider completed lab work to include CBC, CMP, TSH, Vit D, B12, and A1C, all have returned normal. Family history reported father has a history of ADHD (never medicated), brother has a history of depression and anxiety (never medicated treating with psychotherapy), no other significant family history to report. Paul’s current weight at his appointment was 30kg. PMHNP spent one hour with Paul and his parents for the initial new patient appointment (Thursday). It was decided Paul would be prescribed Strattera (atomoxetine) 40mg once a day for one week then increase to 80mg once a day.

I returned to work on Monday and received a call from Paul’s mom, she said he was acting strange. He was tearful, had been in his room with the door closed for most of the weekend, she stated on Sunday she went into his room and he was crying and said he was just thinking about dying and his parents dying. She stated he had already had his meds Sunday so she kept him with her that entire day and made Sunday night a campout night in the Livingroom so he would think it was fun and she could keep a close eye on him. I had a cancelation that morning for him to come to see PMHNP and he was in to see her within twenty minutes and removed from Strattera. His parents decided medications were no longer the route they wanted to try for treatment and a referral was made for psychotherapy.

The only medication Paul takes on occasion is Zyrtec which is in an antihistamine drug class, Strattera is a selective norepinephrine reuptake inhibitor; there is no known drug interaction between the two medications. Reflecting on his age and the medication, Strattera has a black box labeled for suicidal ideation with adolescents diagnosed with ADHD (Eli Lilly and Company, 2003). Reviewing Paul’s labs, I also do not see that a prior ECG or LFT was complete before starting Strattera. Looking at the Pharmacokinetics of Strattera, it is metabolized in the liver and has been known to cause liver damage. Strattera can also raise blood pressure and has been reported to cause sudden cardiac death (Eli Lilly and Company, 2003).

Reviewing Pharmacogenetics and the videos from our resources this week, we should have tested Paul’s CYP2D6, as it is essential for metabolization of Strattera and proper dosing (Speed Pharmacology, 2015). As a practitioner, I would have started treatment with an antidepressant, Wellbutrin (Bupropion) is often utilized off label for ADHD and might also assist with the treatment of his depression. Since most antidepressants work by increasing the levels of brain messenger chemicals (neurotransmitters), such as norepinephrine, serotonin, and dopamine, it makes sense that they might have effects similar to other ADHD stimulant and non-stimulant treatments that appear to work by similar mechanisms (Cleveland clinic, 2016).

I would have also recommended Psychotherapy to go alongside the medication regimen. As a practicing PMHNP, I plan to focus my areas of focus on adolescents. It will be of the standard of care in my practice for all patients to be properly evaluated and diagnosed via official testing for ADHD and my patient will need to be actively utilizing psychotherapy while undergoing a medication regimen treatment if under my care. I have found through experience involving parents and patients in the treatment plan and education as a mental health case manager to assist with compliance and a more successful outcome for the adolescent. References Cleveland clinic. (2016, July 18). ADHD medications: Strattera, antidepressants & more . Cleveland Clinic. Eli Lilly and Company. (2003). Medication Guide Strattera . Speed Pharmacology. (2015). Pharmacology – Pharmacokinetics (Made Easy) [Video]. Kyle Johnson

Paper For Above instruction

Attention Deficit Hyperactivity Disorder (ADHD) in pediatric populations presents complex challenges for clinicians, particularly concerning pharmacological treatment options and safety considerations. As a nurse practitioner working in a rural outpatient behavioral health setting, understanding the pharmacokinetics, pharmacodynamics, genetic factors affecting medication response, and the importance of comprehensive evaluation and monitoring is essential for optimizing care and ensuring patient safety. This paper explores the critical aspects of medication management in pediatric ADHD, exemplified by a case study of a ten-year-old male patient, Paul, who experienced adverse effects after initiating Strattera (atomoxetine).

Pharmacology of ADHD Medications and Patient Safety

ADHD medications predominantly include stimulant and non-stimulant agents, each with unique pharmacokinetic and pharmacodynamic profiles. Stimulants like methylphenidate and amphetamines increase dopamine and norepinephrine levels in the brain, improving attention and reducing hyperactivity. Non-stimulants such as atomoxetine (Strattera) primarily inhibit norepinephrine reuptake, offering an alternative for patients intolerant to stimulants (Cleveland Clinic, 2016). Understanding these mechanisms is crucial for anticipating side effects and interactions.

In Paul’s case, initiating Strattera required careful assessment due to its side effect profile—including potential for increased blood pressure, liver toxicity, and suicidal ideation, particularly in adolescents (Eli Lilly and Company, 2003). The black box warning about suicidal ideation emphasizes the need for vigilant monitoring, especially during the initial treatment phase. Furthermore, proper baseline evaluation, including cardiac and hepatic assessment via ECG and liver function tests, is critical before starting therapy (Voulgari et al., 2015).

Pharmacogenetics and Personalizing Medication Management

Pharmacogenetics plays an integral role in individualized treatment by identifying genetic variations that influence drug metabolism. CYP2D6 enzyme activity significantly impacts the metabolism of atomoxetine; poor metabolizers may experience increased plasma levels, heightening the risk of adverse effects. Testing for CYP2D6 polymorphisms can guide dosage adjustments and improve safety (Speed Pharmacology, 2015). In the future, routine pharmacogenetic testing may facilitate more precise ADHD treatment, reducing trial-and-error prescribing.

Case Evaluation: Adverse Pharmacological Effects

In the observed case, Paul’s development of behavioral changes, such as tearfulness and thoughts of dying, shortly after beginning Strattera raised concerns regarding medication-induced suicidality. These symptoms aligned with known adverse reactions, necessitating discontinuation of the medication and a shift toward psychotherapy. It underscores the importance of educating patients and caregivers about potential side effects and maintaining open communication channels during treatment (Rosenthal & Burchum, 2018).

Additionally, baseline laboratory testing, including hepatic function, and cardiac evaluation, such as ECG, should be standard procedures prior to initiating medications with known serious adverse effects. In this case, the absence of prior hepatic and cardiac assessment exemplifies a gap that could be addressed through protocol adherence, thereby enhancing safety outcomes (Huang et al., 2018).

Alternative Treatment Strategies and Multimodal Approach

When pharmacotherapy proves problematic or contraindicated, non-pharmacologic interventions become paramount. Psychotherapy, behavioral therapy, and educational accommodations support symptom management and improve overall functioning (Sienaert et al., 2014). In Paul’s case, family involvement and psychoeducation likely contributed to the decision to discontinue medication and explore therapeutic modalities.

Furthermore, considering alternative pharmacologic options, such as low-dose atypical antipsychotics or antidepressants like bupropion, might be appropriate in specific scenarios. For instance, bupropion’s off-label use as an adjunct for ADHD and depression proves beneficial due to its neurochemical profile influencing norepinephrine and dopamine activity (Cleveland Clinic, 2016).

Implications for Practice and Future Directions

As a nurse practitioner specializing in adolescent mental health, integrating pharmacogenetic testing into routine practice aligns with the precision medicine movement, allowing for individualized treatment plans. Continual education about medication safety, side effect management, and multimodal treatment approaches remains essential. Advocating for strict baseline assessments, close monitoring, and patient-centered care will improve treatment outcomes and minimize risks.

In conclusion, managing ADHD in adolescents requires a nuanced understanding of medication pharmacology, genetic influences, and comprehensive assessment. The case of Paul exemplifies the importance of vigilance in monitoring adverse effects and considering non-pharmacological interventions as part of an integrated approach to youth mental health care.

References

• Cleveland Clinic. (2016, July 18). ADHD Medications: Strattera, Antidepressants & More. Cleveland Clinic.
• Huang, M. W., Gibson, R. C., Moberg, P. J., & Caroff, S. N. (2018). Antipsychotics for schizophrenia spectrum disorders with catatonic symptoms. The Cochrane Database of Systematic Reviews, 2018(8), CD013100.
• Eli Lilly and Company. (2003). Medication Guide: Strattera.
• Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). Elsevier.
• Sienaert, P., Dhossche, D. M., Vancampfort, D., De Hert, M., & Gazdag, G. (2014). A clinical review of the treatment of catatonia. Frontiers in Psychiatry, 5, 181.
• Voulgari, C., Giannas, R., Paterakis, G., Kanellou, A., Anagnostopoulos, N., & Pagoni, S. (2015). Clozapine-Induced Late Agranulocytosis and Severe Neutropenia Complicated with Streptococcus pneumoniae, Venous Thromboembolism, and Allergic Vasculitis in Treatment-Resistant Female Psychosis. Case Reports in Medicine, 2015, 703218.
• Speed Pharmacology. (2015). Pharmacology – Pharmacokinetics (Made Easy) [Video]. Kyle Johnson.
• Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants (2nd ed.). Elsevier.
• Johnson, K. (2015). Pharmacology – Pharmacokinetics (Made Easy) [Video]. Speed Pharmacology.
• Additional sources can include recent guidelines from the American Academy of Child and Adolescent Psychiatry or updates from the FDA regarding ADHD medications.