Case Study Week 7 : Evaluating and Managing Side Effects of Psychiatric Medications – Solution

Case Study Week 7 : Evaluating and Managing Side Effects of Psychiatric Medications

Instructions

Evaluating and managing the side effects of psychotropics is an important part of prescribing. Some side effects can be safely monitored and managed by a PMHNP. While others may require additional tests, collaboration with primary care providers, or even referrals to specialists. It is key to know which side effects are  to treat and which should really be treated by a different provider. Part of this answer may depend on the state in which you ultimately practice, as what you are allowed to prescribe may vary state by state.

For this assignment, you will review the PowerPoint

·         Evaluating and Managing Side Effects of Psychiatric Medications 

Locate your assigned case study and answer the questions which correspond to the FIRST letter of your LAST name. The answers to these questions will be located in the PowerPoint, but you will need to do additional research to support your decisions.

Then you will respond to the main postings of two other learners; at least one response should be to a peer who has answered questions different from yours.

Recall that your main posting should be submitted by Friday at 11:59 p.m., Eastern time. All responses to other learners discussion questions must be submitted no later than Sunday at 11:59 p.m, Eastern time in order to be considered for grading purposes.

If your LAST name begins with the letter A through N, please read the following and address the questions:

·         A 56 yr. old woman signs up with you as his new primary care physician. Her previous diagnosis included hyperlipidemia, hyperglycemia, moderate obesity and hypertension. His medications include: Paroxetine 20 mg for 10 years; Quetiapine 150 mg daily for 2 yrs.; Irbesartan 300 mg daily for 1 yr.; and Atorvastatin 10 mg daily for 1 yr.

·         Labs: FBS = 126, HgbA1C = 6.2, total cholesterol = 200, LDL = 105, HDL = 35, Tg =286. His present height equal 5 and weight = 210 lbs. His BP is 140/84.

·         She tells you that about 10 yrs. ago she became depressed and was started on Paroxetine and gained 30lbs after 1 yr. Her mood at that time was much improved and remained that way for about 2 yrs. At that time, Quetiapine was added, and she achieved remission of her depression. Six months after this she gained another 20lbs, developed mild hypertension, hyperglycemia and hyperlipidemia. All other lab including thyroid testing was normal. She tells you that she has a craving for carbohydrates and does little exercise since developing depression about 15 yrs. ago.

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Questions:

·         What advice or modifications to his treatment regimen would you recommend for your new patient? (Discuss a minimum of two). Please support your answer with research-based evidence.

·         If you suggested additional medication, look up your state’s prescribing laws. Are PMHNP’s able to prescribe the medication you recommended

Solution

Case Study Week 7 : Evaluating and Managing Side Effects of Psychiatric Medications

Evaluating and Managing Side Effects of Psychiatric Medications

Selective serotonin reuptake inhibitors (SSRIs) like fluoxetine and Paroxetine were first introduced in the US towards the end of the 1980s. According to Edinoff et al. (2021), SSRIs were first considered almost free of side effects compared to tricyclic antidepressants (TCAs) despite the former having the latter’s comparable efficacy. Over the years, however, healthcare providers have raised questions concerning the safety and tolerability of SSRIs when prescribed to patients with multiple comorbidities.

Therefore, this post purposes of evaluating and managing the side effects of psychiatric medications with a specific bias towards Paroxetine. To achieve the objective, the author utilizes the selected case assignment of a 56- year old woman who presents to the clinic with a previous diagnosis of hyperlipidemia, hyperglycemia, moderate obesity(BMI higher than 30), and hypertension (140/80).

Advice or Modifications to Her Treatment Regimen That A PMHNP Would Recommend For This New Patient

There is a need for the current PMHNP to recommend new therapeutic approaches and also modify her treatment regimen, considering that the patient has experienced side effects that put the patient’s health at a higher risk due to some of her prescribed medication like Paroxetine (Carvalho et al., 2016). The 56-year-old female patient has been on Paroxetine 20mg for a decade, Quetiapine 150 mg daily for two years, Irbesartan 300mg daily for one year, and Atorvastatin 10 mg for one year.

Most importantly, the fasting blood sugar at 126 indicates Type 2 diabetes, the glycated hemoglobin (A1C) test at 6.2 points towards prediabetes state while the total cholesterol of 200 puts her at high borderline cholesterol. To begin with, as the PMHNP, I would recommend the patient make simple lifestyle changes to bring the current high borderline cholesterol to normal ranges by lowering her intake of saturated fats, exercising more than four days a week, and losing weight.

If a smoker, smoking cessation is necessary, and consume alcohol in moderation (Janse Van Rensburg, 2019). Besides these non-pharmacological interventions to lower cholesterol and manage depression, the provider would also consider lowering the daily paroxetine dose to 7.5 mg as it does not cause weight gain (Portman, 2014). If adjusting the Paroxetine dose and taking the medication at bedtime does not alleviate the side effects, one should consider prescribing an alternative SSRI like Escitalopram with an initial dose of 10 mg daily since it offers efficacy comparable to Paroxetine.

According to Joint Committee on Administrative Rules (2021), prescribing a new medication like Escitalopram for the patient is in line with Illinois prescribing laws as section 1300.465 Full Practice Authority outlines that an Illinois- licensed advanced practice registered nurse may exercise full practice authority without a written collaborative agreement.

References

Carvalho, A. F., Sharma, M. S., Brunoni, A. R., Vieta, E., & Fava, G. A. (2016). The safety, tolerability, and risks associated with using newer generation antidepressant drugs: a critical review of the literature. Psychotherapy and psychosomatics, 85(5), 270-288.

Edinoff, A. N., Akuly, H. A., Hanna, T. A., Ochoa, C. O., Patti, S. J., Ghaffar, Y. A., … & Kaye, A. M. (2021). Selective Serotonin Reuptake Inhibitors and Adverse Effects: A Narrative Review. Neurology International, 13(3), 387-401.

Janse Van Rensburg, W. J. (2019). Lifestyle change alone sufficient to lower cholesterol in a male patient with moderately elevated cholesterol: a case report. American journal of lifestyle medicine, 13(2), 148-155.

Joint Committee on Adminstrative Rules(2021) Administrative Code URL: https://www.ilga.gov/commission/jcar/admincode/068/068013000D04650R.html Accessed August 25, 2021.

Portman, D. J., Kaunitz, A. M., Kazempour, K., Mekonnen, H., Bhaskar, S., & Lippman, J. (2014). Effects of low-dose Paroxetine 7.5 mg on weight and sexual function during treatment of vasomotor symptoms associated with menopause. Menopause (New York, Ny), 21(10), 1082.