Scholarly work: include an exemplar of a scholarly paper 4 pages in


ePortfolio #11

Scholarly work: Include an exemplar of a scholarly paper 4 pages in APA format) on the relevance of evidence based practice in primary care (you may use a previously submitted Assignment). Submit this to the Dropbox.

5 APA references not older than 5 years old.

No plagiarism.

 this is the continuation of the professional Portfolio you have been working on before. Please look at the example I gave you before.  

you can use any scholarly paper on the relevance of evidence based practice in primary care. You like.

Scholarly Work

Evidence-Based Management of Hypertension

Hypertension is a major risk factor of cardiovascular diseases that can lead to premature death. Evidence suggests that controlling hypertension diminishes the risk of heart diseases, risk of stroke, and related medical costs. Agarwal (2011) indicates that treatment of hypertension can follow a multi-pronged approach, including medication, changes in diet, and exercise. The objective of management is to lessen the blood pressure to less than 140/90 mm Hg. Various drugs of treating hypertension are available whereby a particular drug may be suitable or a combination of two contingents on the risk factors of patients. Hypertension medications include thiazide diuretics, angiotensin-converting enzyme inhibitors (ACE), Beta-blockers and long-acting calcium channel blockers, short-acting calcium channel blockers, and short-acting Alpha antagonists. Among this category of drugs, short-acting calcium channel blockers and short-acting Alpha antagonists should not be used as first choice of antihypertensive medications.

Evidence from randomized placebo-controlled trials indicates that benefits of antihypertensive drug treatment are to lessen the threat of cardiac events, deadly and non-fatal stroke, premature deaths in people with systolic or diastolic hypertension, and improve the quality of life (Agarwal, 2011). However, it is not apparent whether specific drugs when used as first-line agents, have direct pharmacological effects that increase the blood pressure or if they perform by other numerous secondary actions. Since most of the research studies have utilized a stepped care framework in which different drugs are used to complement first-line agents to decrease blood pressure to targeted levels, it is difficult to evaluate the impact of specific agents (Agarwal, 2011). This study hypothesizes that thiazides diuretics can be used as first-line medications while long-acting calcium channel blockers, ACE inhibitors and Beta-blockers as effective alternatives, short-acting calcium channel blockers, and short-acting Alpha antagonists should not be used as first choice antihypertensive medications.

Numerous hypertension trials have equated chlorthalidone, hydrochlorothiazide, or an aggregate of thiazide and triamterene or amiloride (potassium-sparing agents) with no drug or placebo treatment. Flack (2007) showed that dosages like thiazides lessen the risk of stroke; however, low dosage treatments decrease rates of coronary artery diseases. The study also confirmed that various types of thiazides are effective in managing hypertension. Systematic meta-analyses and reviews of randomized controls compared Beta-blockers as first-line agents and a placebo in the treatment of hypertension. The findings of one of the studies by Wright (2000) revealed that Beta-blockers reduced strokes but not blockage of coronary arteries or mortality. The study also showed that Beta-blockers are a different category of medications with fluctuating levels of sympathomimetic activity and cardioselectivity. Therefore, it was uncertain if the cardiovascular significance of various Beta-blockers represented a class effect.

A randomized placebo-controlled trial by Yusuf et al. (2000) demonstrated that ACE Ramipril was effective since it reduced cardiovascular events by 22% and mortality by 16% in patients at high risk. In this study, half of the sample was hypertensive and had myocardial infarction in the past. Additionally, 40% of the trial participants were taking Beta-blockers. When it comes to calcium channel blockers, a large randomized trial by Thakkar and Oparil (2001) likened calcium channel blocker with a no drug treatment in systolic hypertensive elderly patients aged 60 years and above. The trial revealed reduced proportions of heart disease events with active therapy by 31% equated to a control. Therefore, calcium channel blockers fall under the different categories of antihypertensive treatment agents with numerous hypothesized action mechanisms and may not have a class effect in hypertensive patients. Lastly, no major randomized trial has investigated the clinical outcomes of Alpha-agonist and Alpha-blockers such as clonidine and doxazosin, respectively, as a first-line treatment agent, with a placebo.

Various studies have also compared different antihypertensive agents. A study by UK Prospective Diabetes Study Group (1998) found that calcium channel blockers and ACE inhibitors showed high efficacy in decreasing blood pressure, but calcium channel blockers were likely to increase cardiovascular events up to five times when compared with ACE inhibitors. Another randomized trial by the ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group (2000) found that when Alpha-blockers were compared with diuretic chlorthalidone, the former was found to increase cardiovascular events, especially congestive heart failure than the latter. When it comes to tolerability, a study by Hansson et al. (2000) showed that low dosage of diuretics, Beta-blockers, ACE inhibitor, and calcium channel blockers were more tolerable and enhanced the quality of life than new drugs in the market.

The study also examined pharmacologic agents with minor side effects and revealed that drugs varied by class and agents within the classes. For instance, a trial study involving a sample of 6600 participants in the age of between 70 and 84 revealed that 26% of patients who received calcium channel blockers experienced minor side effects such as ankle edema and 30% of those who received ACE inhibitors reported coughing. 9% of patients who received diuretics showed effects of cold hands and feet (Hansson et al., 2000). When it comes to the drugs with fatal adverse effects, diuretics showed life-threatening side effects that resulted in hospital admissions and disabling. However, trials that compared Beta-blockers with thiazides showed that the latter was associated with low rates of side effects.

This evidence confirms the hypothesis that thiazides diuretics can be used as first-line medications and long-acting calcium channel blockers, Beta-blockers, and ACE inhibitors as effective alternatives. This is due to the high tolerability and lessened side effects when compared to other classes of drugs. Short-acting calcium blockers should be avoided because they increase cardiovascular events.

Clinical Judgement

An Evidence-Based Management Plan for The Frail Elderly Patients

Patient Description

The patient is a 72-year-old Hispanic male diagnosed with nosocomial pneumonia, hypertension, and hepatitis C. The patient’s allergies include penicillin, sulfa, and iodine.

Medication for Nosocomial Pneumonia

  • Chloramphenicol 1g every 6 hours for 7 days
  • gentamicin 5 mg/kg daily in divided doses
  • Ceftriaxone 1g every 12 – 24 hours for 7 days.

Medication for Chronic obstructive pulmonary disorder

  • Carbinoxamine 4mg taken orally once a day
  • Triprolidine 1.25 mg taken daily once a day

Medication for Hepatitis C:

  • Daclatasvir 60mg taken orally once a day
  • Sofosbuvir 400mg taken orally once a day
  • Velpatasvir 100mg taken orally once a day
  • Glecaprevir 40mg taken orally once a day

Age-Related Changes Pharmacokinetics and Pharmacodynamics

Advancing age results in significant changes in body composition. Progressive reduction occurs in lean body mass and total water body, causing an increase in body fat (Mangoni & Jackson, 2003). Age-related pharmacokinetics changes that are present in this patient’s clinical situations include congestive heart failure, ACE inhibitors, and diuretics. Studies exploring potential age-related differences in cardiac functions in patients with heart failure display an increase in systematic vascular and decrease in heart rate in elderly patients (Mangoni & Jackson, 2003). These effects are related to increased concentrations of plasma noradrenaline and serum creatinine.

Some drugs in the category of ACE inhibitors are active compounds (lisinopril), but they are pro-drugs that undergo activation in the liver. In patients with hepatic congestion or severe heart failure, this biotransformation might be impaired (Mangoni & Jackson, 2003). ACE inhibitors are excreted from the body via the kidney through glomerular filtration and tubular secretion. In patients with renal impairments, the plasma concentration increases, and thus, the dose a patient receives must be adjusted accordingly.

In pharmacodynamics, significant age-related changes include an increase in acute and chronic antihypertensive effects with calcium channel blockers, a decrease in peak diuretic responses with a drug such as Furosemide, and no significant change with heparin drug. Other age-related changes include anticoagulant effect, chronotropic effect, analgesic effects, and cognitive functions (Mangoni & Jackson, 2003).

The American Geriatrics Society Beer’s Criteria

The AGS Beer Criteria is a tool that reduces the elderly’s drug-related problems since the elderly population experience the highest occurrence of adverse drug events, yet many of these events are preventable (American Geriatrics Society 2015 updated Beers Criteria, n.d.). Based on the AGS Beer criteria, drugs that should be discontinued in this patient’s treatment regime are carbinoxamine and triprolidine. Carbinoxamine is an anticholinergic that should be avoided since its use leads to dry mouth, constipation, and toxicity. On the other hand, triprolidine causes severe allergic reactions. Other drugs listed can be continued. In place of carbinoxamine, Loratadine may be used, and an alternative to triprolidine is pseudoephedrine.

Challenges Faced by Nurse Practitioners (NP)

As a nurse practitioner, two challenges regarding the regulation of complementary and alternative medications in the care of the frail elderly are toxicity and adulterants (Broom & Adams, 2007). Many consumers of complementary and alternative medications assume that these drug products are safe because they are regarded as natural. However, these medications can cause toxicity through drug interactions or by delaying the traditional care that is proven effective. Determining the safety of these medications has been hindered by a lack of scientifically collected data on adverse reactions since the evaluation of the safety and efficacy of these drugs has been significantly anecdotal (Broom & Adams, 2007). There is also the risk of adulteration or contamination of dietary supplements with toxic substances such as carcinogens in some imported products.

Specific Strategy to Assess Reconciliation

Complementary and alternative medications lack reliable scientific data concerning their safety and efficacy. As an NP, a particular strategy that I will consider is the use of reputable informational sources and efficacy to determine the safety and efficacy of these products. The first source that I will use is the U.S. Food and Drug Administration. This is a significant source that provides information about the regulation of CAM and other drug products (Broom & Adams, 2007). The U.S. Pharmacopoeia is another source that I will consider because it is a public standard-setting authority for over-the-counter, prescription, and other health care products that are produced and used in the U.S. The source also describes quality standards of CAM and other dietary products (Broom & Adams, 2007).

This an example from the example I uploaded previously for you, I just copy and past the section needed, but I did not put the reference page. I will try and upload it again here.  

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