Evidence-based practice and implementation

Evidence-Based Practice

The following is the assessment of AB case, a first time visitor to the writer. The assessment will include checking the pharmacologic treatment, reactions to the drugs in the medicines consumed, advisory healthcare practices and exercises, and non-pharmacologic treatment. More information to be provided if need be.

Patient Background

AB, an overweight, 52--?year -- ?old, Hispanic, male comes for the first visit to your office for assessment of complaints about tiredness, nocturia x 2 -- ?3, and finding it difficult to do the required paperwork in the office (Masters, 2014). He informs that he is reportedly having diabetes type 2 for about six years when he first experienced same feelings of fatigue and nocturia x 2 -- ?3. The patient informs he has attended infrequent classes on diabetes that emphasized on importance of physical activity and weight loss (Masters, 2014). His was accompanied by his wife to these classes and he informs that she helped a lot in initializing changes in diet. He is now divorced, having had disagreements with his wife and mostly eats out since then, lunching out of food truck and his dinners are at restaurant (Masters, 2014). Metformin was suggested three 3 years ago, but on increasing the dose he developed nausea. He has hence almost stopped taking it and informs that he takes it infrequently as and so "when I remember." The last time he has taken, it was about one week ago (Masters, 2014). AB has forgotten his last A1C level or even when it last was checked.

Evaluation of Pharmacologic Therapy

Major Conditions are as follows: Hypertension, Type 2 Diabetes, Dyslipidemia, Osteoarthritis and Sleep Apnea (Masters, 2014).

According to James Beckerman (2013) these are amongst the various drugs for treating high blood pressure, including: Angiotensin-converting enzyme (ACE) inhibitors; Angiotensin II receptor blockers (ARBs); Diuretics; Beta-blockers; Calcium channel blockers; Alpha-blockers; Alpha-agonists; Renin inhibitors and Combination medications.

AB can normalize or at least control his sugar levels by regular exercising and diet at least it was possible six years ago as he has type 2 diabetes, while some cases of type 2 diabetes need diabetes medications or insulin therapy in addition to the diet control and physical exercises (Mayo Clinic, 2014). The other factors including the sugar level and other symptoms are considered before suggesting medications to a Type 2 Diabetes patient. There may even be a need of combination of drugs to control the situation at times (Mayo Clinic, 2014).

Different types of drugs used for type 2 diabetes include: Metformin, Sulfonylureas, Meglitinides and Thiazolidinediones (Mayo Clinic, 2014).

Insulin injection may also be necessary in certain cases of type 2 diabetes. Insulin therapy was not the first line of treatment earlier, and was usually the last resort. It has more benefits and hence is being administered even earlier than ever before these days, normal digestion interferes with insulin taken orally hence insulin is injected (Mayo Clinic, 2014). Depending on the condition and symptoms, the physician may prescribe a mixture of insulin types to use. The common dose is that of a longer acting injection taken at night by people with type 2 diabetes.

There are several types of insulin, and have different functions. The different options are: Insulin glulisine (Apidra), Insulin lispro (Humalog), Insulin aspart (Novolog), Insulin glargine (Lantus), Insulin detemir (Levemir) and Insulin isophane (Humulin N, Novolin N) (Mayo Clinic, 2014).

When change in lifestyle is not enough to achieve normal lipid goals for Dyslipidemia, addition of lipid-modifying pharmacotherapy is advised (Joel C. Marrs, 2010). Each individual requires a different treatment, combination, and administration will depend on expected benefits, drug tolerance profile, comorbid diseases, effects on quality of life, and affordability.

AB also complains of osteoarthritis of knee and according to recommendations by The American College of Rheumatology (ACR) the pharmacological suggestion in addition to one of the following drugs is advised (Lozanda, 2014). Acetaminophen: Oral NSAIDs; Topical NSAIDs; Tramadol; Intra-articular corticosteroid injections.

The ACR suggests against advising chondroitin sulfate, glucosamine, or topical capsaicin for knee osteoarthritis in certain conditions (Lozanda, 2014). The ACR has not offered an opinion on of intra-articular hyaluronates, duloxetine, and opioid analgesics.

CPAP (Continuous positive airway pressure) is a therapy in the sleeping position when a mask is worn over the nose and/or mouth. A machine delivers a continuous flow of air into the nose through the mask. This air pressure opens up the nasal airway to help breathing clearly. CPAP is commonly used for sleep apnea. An alternative method bi-level positive airway pressure, or BPAP, which is similar to CPAP may also be used in which the flow changes while exhaling and inhaling.

Inspire, a new device is used for people who cannot sustain CPAP. This device, Upper Airway Stimulator, is a pulse generator put on upper chest under the skin (Beckerman, 2014). A sensor detects the breathing pattern through the movement of the lungs. The stimulator then causes the stimulation to the neck by keeping the airways muscles open. It is remotely programmable device (Beckerman, 2014). It is generally opened for activation during sleep hours at night and switched off at wake up.

Non-Pharmacologic Therapy

A most important way of preventing and treating high blood pressure is maintaining a proper lifestyle. The most appropriate changes in lifestyle are (Hypertension/High Blood Pressure:

Weight loss for those who are overweight or obese.

Avoid smoking.

Diet control, through the DASH diet (eating more vegetables, fruits, and low fat dairy products, less total and saturated fat).

Reducing the intake of salts particularly sodium to less than 1,500 milligrams per day if high blood pressure is detected. Healthy adults should not exceed their sodium intake over 2,300 milligrams per day (about 1 teaspoon of salt).

Getting regular aerobic exercise (such as walking at least half an hour per day at a brisk pace, several days a week).

Limiting alcohol intake to two drinks per day for males, one drink per day for females.

Control and maintenance of type 2 diabetes requires: Healthy diet, Exercising Regularly, Insulin injectibles or therapy or other drugs as required and regular monitoring of Blood sugar (Mayo Clinic, 2014). These steps are tantamount to maintaining status quo or delay worsening of condition by controlling sugar levels.

It is very important to pay closest attention to dietary habits and physical well-being through regular exercising in order to control cholesterol rise (Joel C. Marrs, 2010). The NCEP ATP III recommendations advice avoiding nutrients that raise LDL-C, like cholesterol (

Interventions other than pharmacological, which need be followed by AB invariably to help aid regain health and well-being are following: Educating the afflicted properly, Heat and cold, Weight control under suggested values, Exercising, Physical therapies, Occupational therapy, Unloading in certain joints (e.g., knee, hip) (Lozanda, 2014).

Certain mild cases of apnea, as observed in present case need to make changes in lifestyle and adopt a rounded living pattern, some of which are detailed as Weight Loss, Avoiding alcohol consumption and avoiding intake of pills that aid sleeping (Beckerman, 2014). Others include Improvement in breathing pattern can be gained by changing the positions in which we sleep, which should be adopted by AB, Give up smoking. Smoking is conducive to swelling in the upper airway, which may causes worsening of both apnea and snoring. Sleeping with face up is not recommended and should be avoided.

Drug Interactions

Many new methods of learning about our health and well-being can be learned easily in contemporary times (Food and Drug Administration, 2013). AB should be aware about the implication of all medications he takes or rather does not take. AB has done the right thing though inadvertently, by opting for a second opinion, as he may require multiple medications. However, he has been negligent in being irregular and by not being aware of all medications. Such measures would have been helpful to understand the side effects and tolerability and interactions of intake of drugs suggested and taken (Food and Drug Administration, 2013).

Drug interactions may render the drug less effective, side effects may manifest, or a particular drug may be more effective than perceived. In some cases, there are harmful manifestations, too. It is important that persons in the position of AB always read the content and instructions on labels of drugs bought with or without prescriptions. (Food and Drug Administration, 2013). You can save yourself trouble from the side effects and interaction of drugs by using knowledge gained properly by consultation with a doctor and following such information judiciously. This is especially true in the case of patients like AB. The three studied outcomes of interactions are:

Drug-drug interactions are those that manifest in cases of multiple intakes and one drug interacts with other(s). The outcomes may be totally unexpected for the patient, as in the case of AB who found it nauseating and hence stopped taking it altogether, which through proper advice could have le to redemption of the situation (Food and Drug Administration, 2013). As an example, AB takes a combination of drugs for diabetes, and it gets mixed up with those for sleep. Consider the fact that mixing anti-allergic (an antihistamine) drug with that for one that helps you sleep (a sedative) can make you sluggish in reacting to things, for example it makes car driving much more difficult.

Drug-food/beverage interactions are foods or beverages reacting with drugs. It has been observed that some drugs mixed with alcohol makes one feel tired and slows down reflexes.

Drug-condition interactions are observed as those where certain drugs cause more harm than good under certain health conditions (Food and Drug Administration, 2013). For AB, taking a nasal decongestant is not advisable as he has high blood pressure and it may cause an undesired reaction.

AB is well advised to seek expert opinion before taking any drug even for minor ailments or afflictions. For each new drug that AB consumes or resorts to even if advised by doctor he should discuss them thoroughly, for all non-prescription and prescription medicines and drugs, food supplements, minerals, botanicals, vitamins, and herbals he takes take, as well as the normal daily foods he eats (Food and Drug Administration, 2013). AB should ask the pharmacist for the package insert for each prescription drug he takes. Possible drug interactions are clearly stated in the package insert provided.

The primary questions that AB needs to ask his pharmacist or doctor before taking a drug are: Are there any implications (good or harmful) with other drugs? Should I avoid certain foods, beverages or other products? What are potential signs of drug interaction I should be aware about? How does the drug work in physiologically? Where can I find relation between my condition and drug that I am taking (on the Internet or in health and medical literature)? Be informed about drugs safety and take them responsibly (Food and Drug Administration, 2013).

The drug insert or label tells you a lot about safe intake and workings of drugs: what is the function of the drug? procedure of administration of the drug; how to avoid the risks because of drug through interactions and undesired side effects; Asking your pharmacist or doctor for additional information if you need answers after reading the drug insert or label is a good practice (Food and Drug Administration, 2013). Be aware that certain OTC drugs contain similar active ingredients. Pay attention to the fact that excessive intake of an active ingredient is not advisable (Food and Drug Administration, 2013). Conditions of pregnancy and breast-feeding are delicate and every medicine should be only under strict care of physician involved in the case. That becomes more important to avoid allergic reactions.

AB has to be aware of interactions of following drugs: Hydrochlorothiazide 25mg po qd; Lisinopril 20mg po qd; Amlodipine 10mg po qd; Metformin 1500mg po qd

Simvastatin 20 mg po qd; Acetaminophen as needed; Continuous positive airway pressure (CPAP) nightly -- not using.

Recommendations for Total Management

The term "case management" signifies an approach in management of complex medical condition., Rosenberg and Sajdak (1998) explain case management as "... A collaborative procedure which monitors, coordinates, implements, plans, assesses, and evaluates the choices and services to achieve a person's health care needs making use of community and societal resources available to provide quality and economical results." This description comprises of a multidisciplinary, complex, process that involves the support and input from many players in the health care system, which includes patients, their societal support like the friends and family, all care providers, and vendors and/or other contributors in the health care system. All work collaboratively to seek the best possible outcomes for the patient (Rosenberg & Sajdak, 1998).