Hypertension, and Hyperlipidemia – a Pharmacology Case Study

All around the world, people suffer from hundreds and hundreds of different disease processes. In this particular case, a client is a man who originates from northern Iraq, otherwise known as Kurdistan. The patient shall be referred to by his initials, 'A.A.....' Born in 1958, A.A. is 60 years old and is married with a total of nine now-grown children. A.A. is a medium build man with a height of 5'9' and a weight of 160 pounds. This patient has dealt with Type I diabetes for over half of their life and now also struggles with high cholesterol levels and hypertension.

As a result, A.A. is on a number of prescribed medications that he takes almost every day. These medications include Metoprolol, Lisinopril, Rosuvastatin, Insulin Lispro, and Insulin NPH. In this particular case study, A.A.'s various disease processes will be described, along with how he manages to cope with each disorder. In addition, a detailed description of his medications and daily routine will be discussed.

As stated earlier, the patient deals with a number of various disease processes, including type 1 diabetes, hyperlipidemia, and hypertension. Diabetes mellitus, in the most simple terms, is described as an accumulation of glucose in the blood and urine due to defective glucose metabolism (Martini, Nath, & Bartholomew, 2015). More specifically, type 1 diabetes is described as "inadequate insulin production by the pancreatic beta cells" (Martini et al., 2015, pp. 608-651). In fact, in type 1 diabetes, the body's immune system attacks the insulin-producing beta cells of the pancreas, and more than 90% of the beta cells are destroyed (Brutsaert, 2017).

This means that the beta cells contained in the pancreas are not producing enough of the hormone insulin because there are very few of them left. The purpose of insulin is to lower blood glucose levels by increasing the rate of glucose uptake into our body's cells (Martini et al., 2015). Without insulin, glucose remains in the bloodstream and cannot get to the cells to provide them with energy. "The most recent information from 2014 indicates that 29.1 million Americans have diabetes. Of these, 25–30% are taking insulin" (Davidson, 2015, pp. 123-135).

According to the Open Heart journal article, "Hypertension (HTN) is a largely asymptomatic disease affecting around 50 million Americans and one billion people worldwide" (DiNicolantonio et al., 2015, pp. 1-12). Hypertension is defined as "a persistent systolic BP (SBP) of 140 mm Hg or more, diastolic BP (DBP) of 90 mm Hg or more, or current use of antihypertensive medication" (Lewis, Dirksen, Heitkemper, Bucher, & Harding, 2014a, p. 709-729).

Hypertension can be identified as either primary or secondary, primary meaning that an individual's blood pressure is elevated without any identified cause, and secondary meaning that there is a specific cause that can be identified and possibly corrected (Lewis et al., 2014a). In this patient's case, it is possible that hypertension developed as a result of his diabetes, as they are often correlated, making it a form of secondary hypertension (Lewis et al., 2014a). For patients with both diabetes and hypertension, a target blood pressure of "less than 130/80 mm Hg" is recommended (Lewis et al., 2014b, pp. 1153-1187 ). Hypertension is often called the "silent killer" because it is often asymptomatic and does not show any real signs of damage until it becomes severe and target organ damage occurs (Lewis et al., 2014a, pp. 709-729).

Hyperlipidemia is an increase in cholesterol levels, specifically LDL, as a result of the defective function of the LDL receptors (Lewis et al., 2014c). According to the text, "Patients with diabetes have an increase in lipid abnormalities…The ADA recommends target values of LDL cholesterol less than 100 mg/dL, triglycerides less than 150 mg/dL, and HDL cholesterol greater than 50 mg/dL" (Lewis et al., 2014b, pp. 1153-1187 ). In any individual, a low LDL level, low triglycerides, and a high HDL cholesterol level is preferred (Lewis et al., 2014c). According to the Journal of International Medical Research, "…low HDL-cholesterol (C) and high LDL-C levels have been reported to be independent risk factors for developing cardiovascular disease. Therefore, patients with diabetes and both of these risk factors require careful and strict management of LDL-C and HDL-C levels, in addition to adequate control of blood glucose" (Katabami et al., 2014, pp. 457-467). Treatment strategies for elevated cholesterol, and hyperlipidemia, include a low-fat diet, exercise, and lipid-lowering medications (Lewis et al., 2014c).

The patient, A.A., is on a number of different medications that aim to treat each of his various disease processes. For instance, the patient takes Metoprolol, commonly known as Lopressor. He takes one 25 mg tablet of PO BID. Typical dosages of Metoprolol range from 25-100 mg (Burcham & Rosenthal, 2016a). Metoprolol is an antihypertensive that works to decrease blood pressure and heart rate (Vallerand et al., 2017a). It does so by producing a selective blockade of the beta-one receptors in the heart, thereby reducing "heart rate, the force of contraction, and the conduction velocity through the AV node" (Burcham & Rosenthal, 2016a, pp. 156-167). Common side effects of Metoprolol include bradycardia, hypotension, and reduced cardiac output (Burcham & Rosenthal, 2016a).

Adverse effects may include AV heart block or rebound cardiac excitation following an abrupt withdrawal (Burcham & Rosenthal, 2016a). The desired response of this medication is a lowered blood pressure that reaches normal limits, around 120/80, without the adverse effects of an extensively lowered heart rate or blood pressure (Burcham & Rosenthal, 2016a). Nursing implications of Metoprolol would include monitoring blood pressure and heart rate continuously during therapy and prior to administration (Burcham & Rosenthal, 2016a). If a patient were to have a low heart rate or low blood pressure, administering Metoprolol could be counterintuitive and could lead to complications (Burcham & Rosenthal, 2016a).

Lisinopril is another antihypertensive that the patient takes to lower his blood pressure. He takes one 5 mg BID by mouth. The usual maintenance dosing of Lisinopril to treat hypertension is about 10-40 mg once per day (Burcham & Rosenthal, 2016b). Lisinopril is an angiotensin-converting enzyme inhibitor and works by reducing levels of angiotensin II through inhibition of the angiotensin-converting enzyme (ACE), which catalyzes the conversion of angiotensin I to angiotensin II in the renin-angiotensin-aldosterone system (Burcham & Rosenthal, 2016b). By doing so, angiotensin II is not able to be created, and the blood pressure-lowering properties of the RAAS are not able to go into effect (Burcham & Rosenthal, 2016b).

Common side effects and adverse reactions of Lisinopril and ACE-inhibitors, in general, include first-dose hypotension, cough, hyperkalemia, renal insufficiency, and angioedema, which is swelling of the face (Burcham & Rosenthal, 2016b). With first-dose hypotension, "A precipitous drop in blood pressure may occur following the first dose of an ACE inhibitor…caused by widespread vasodilation" (Burcham & Rosenthal, 2016b, pp. 470-484). The desired effect of Lisinopril would be decreased blood pressure that is within normal limits and the prevention of adverse cardiovascular events (Burcham & Rosenthal, 2016b).

Nursing implications for this drug would include close monitoring of blood pressure during the first two hours after the first dose to assess for first-dose hypotension and assess for signs and symptoms of hyperkalemia, angioedema, and renal insufficiency (Burcham & Rosenthal, 2016b). Furthermore, it is important to assess blood pressure prior to administering any antihypertensive medication (Burcham & Rosenthal, 2016b).

When teaching this patient about Metoprolol and Lisinopril, two different antihypertensives, it is important to teach the patient about the actions of the drugs and the possible side effects of each. With Metoprolol, it is important to teach the patient about the possibility of cardiac excitation followed by an abrupt withdrawal and advise the patient to monitor blood pressure and heart rate daily at home as well (Burcham & Rosenthal, 2016b). Furthermore, due to the fact that this patient may not be familiar with medical terminology and actions, it is important to teach this patient how to take blood pressure and heart rate, and to explain to him, in more simple terms, its purpose.

To treat his hyperlipidemia, the patient takes Rosuvastatin, also known as Crestor, a 20 mg tablet PO nightly. The typical dosage for this drug is about 20-40 mg at bedtime (Burcham & Rosenthal, 2016b). This medication lowers total and LDL cholesterol levels while slightly increasing HDL cholesterol (Vallerand et al., 2017b). Common adverse effects of Rosuvastatin include headache, rash, and GI disturbances such as dyspepsia, cramps, flatulence, constipation, and abdominal pain (Burcham & Rosenthal, 2016b). Desired outcomes from this medication would include a decrease in LDL and total cholesterol levels, an increase in HDL cholesterol levels, and a decrease in triglyceride levels (Vallerand et al., 2017b).

Nursing implications for this drug include obtaining a diet history from the patient, evaluating serum cholesterol levels and triglycerides before initiating treatment and periodically thereafter, and monitoring liver function due to a potential increase in bilirubin (Vallerand et al., 2017b). It is important to teach the patient that this medication should be used in adjunct with healthy lifestyle choices, diet restrictions, exercise, and the cessation of smoking (Vallerand et al., 2017b). A.A. is an avid smoker, smoking about one pack per day, and it would be part of the priority teaching to explain to this patient the importance of smoking cessation and how it affects his cholesterol.

Another medication that the patient takes in order to control and lower his blood is Insulin Lispro, otherwise known as HumaLOG. He takes this medication through subcutaneous injection via his HumaLOG pen. He injects 15 units under the skin three times daily after meals. Typical dosing for this drug is indicated by about 0.5 – 1.2 units/kg/day for each individual patient (Vallerand et al., 2017c). Insulin is an anti-diabetic that lowers blood glucose by stimulating the uptake of glucose in muscle and fat (Vallerand et al., 2017c). The desired response of this drug would be the control of hyperglycemia in diabetic patients.

Insulin is a rapid-acting insulin with a more rapid onset and a shorter duration than regular insulin; therefore, it is often used at times when the patient knows they will be ingesting a higher carbohydrate diet or if they are expecting a rise in glucose levels (Vallerand et al., 2017c). Adverse effects of this medication include hypoglycemia, hypokalemia, and the possibility of allergic reactions (Burcham & Rosenthal, 2016d, pp. 667-702). Nursing implications include assessing for signs and symptoms of hypoglycemia, such as anxiety, restlessness, tachycardia, cold sweats, and cool, pale skin, assessing glucose levels prior to and after administration of the medication, and frequently monitoring glucose every 6 hours during therapy (Vallerand et al., 2017c).

In addition to Insulin Lispro, A.A. also takes NPH Insulin via subcutaneous injection. He is instructed to inject 70 units in the morning, and 30 units in the afternoon, making it a total of 100 units total per day. The recommended dose is typically 0.5-1 unit/kg/day (Vallerand et. al, 2017d).

NPH insulin also lowers blood glucose by stimulating the uptake of glucose in muscle and fat (Vallerand et al., 2017d). NPH insulin works very similarly to insulin; however, NPH insulin has a longer duration (16-24 hours) and is slow-acting (Burcham & Rosenthal, 2016d). The adverse effects of this medication would be the same as insulin: hypoglycemia, hypokalemia, and the risk of developing an allergic reaction (Burcham & Rosenthal, 2016d). The desired effect of this medication would be prolonged action and control of hyperglycemia. Unlike insulin, which provides immediate control at meal times to prevent postprandial hyperglycemia, NPH insulin is given "twice or three times daily to provide glycemic control between meals and during the night" (Burcham & Rosenthal, 2016d, pp. 667-702).

Nursing implications would be very similar to insulin and would include assessing the patient for symptoms of hypoglycemia, monitoring blood glucose every 6 hours during therapy, and teaching the patient about proper techniques for administration (Vallerand et al., 2017d). When teaching the patient about insulin, it is important to instruct the patient on the proper technique for administration and demonstrate how to draw up and inject the medication. Furthermore, advising A.A. to carry around a source of sugar and his treatment with him at all times is important to prevent complications and to teach him the signs and symptoms of hypoglycemia and hyperglycemia and what to do in each instance (Vallerand et al., 2017d).

During the teaching and discussion of each medication with A.A., mentioning the cost analysis of the medications and analyzing the cost of a one-month supply would be beneficial for the patient and allow him to plan accordingly based on his individual needs. This patient does not work and is provided for by his children; therefore, the more he can save on his medications, the better. As evidenced by the table below, without insurance, many of his medications are rather expensive and would cost quite a large sum. The insulins, in particular, are rather expensive, considering the fact that they do not have a generic price available. Generic versions of medications are generally cheaper and easier to afford. This patient has Medicare insurance, which makes his medications much easier to afford because he is only required to pay a certain amount of co-pay per medication. According to A.A., he receives his insulin through Shade Tree Clinic, which pays the price in full for him. The patient's overall cost per month is about $11.00.

In conclusion, the patient is coping with his disease processes well, and he has the support of his family and children to assist him in managing his medications. He understands that diabetes is a life-long disease process that involves daily self-management and a number of various lifestyle changes. He has dealt with this condition for several decades now and understands how deeply it affects his life. The patient is also managing his other conditions well and reports no complications. He reports that he is willing to do anything for the sake of his health, and his family is ready to assist him with whatever he may need.

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