9. Watchful waiting for prostatic hypertrophy : Has regular follow up with urologist who is in communication with his primary care provider Challenges 1. Polypharmacy challenge : ○ Balancing multiple medications while minimizing adverse effects ○ Ensuring optimal control of diabetes and comorbidities ○ Striving to enjoy his life, stay active, but manage his medications as prescribed 2. Heart attack history : ○ Mr. Reynolds survived a myocardial infarction (MI) in the past and struggled with deep depression for about a year after ○ His angina pectoris necessitates careful management ○ He finds that over time he worries about another heart attack 3. Prostate cancer diagnosis : ○ At age 78, Mr. Reynolds faces a new challenge: Stage 2 prostate cancer ○ The treatment plan must consider interactions with existing medications Clinical concerns: 1. Polypharmacy : ○ Rational prescribing aims for the fewest necessary medications Polypharmacy and cardiac disease Cardiovascular disease is determined by the symptoms a patient experiences relative to the functionality of their heart. While much of heart disease can be prevented by lifestyle, healthy nutrition, and exercise, it often requires pharmacological treatment to minimize heart damage and address symptoms. According to the Mayo Clinic (2024) heart disease can include: ● Coronary artery disease may impact the blood vessels : A common heart condition that results from cholesterol deposits that form plaques in the arteries delivering blood to the heart. The plaque can build up and result in atherosclerosis, which can then constrict blood flow to the heart and body. Coronary artery disease can lead to a heart attack, angina, or stroke. Symptoms vary and can include nausea, jaw pain, numbness in extremities, jaw pain, fatigue, and shortness of breath. ● Irregular heartbeats (arrhythmias) : this can present as a racing heartbeat or slow and irregular. Symptoms of arrhythmias include dizziness, fainting, lightheadedness, shortness of breath, chest fluttering, and chest pain. ● Congenital heart defects : if a person has a serious congenital heart defect, they are often noticed soon after a child is born, however there are some that are less serious that may not be diagnosed until adulthood, even older age. The symptoms of these health issues are typically not immediately life threatening but could be exacerbated with age and other conditions. Symptoms include noticeable tiring during activities such as exercise or housework, shortness of breath, and swelling of the ankles, feet, and/or hands. ● Heart muscle impairment or disease : Also known as cardiomyopathy, the early stages may not be symptomatic, but over time the symptoms worsen. Symptoms include dizziness, fainting, and lightheadedness; exhaustion; shortness of breath either when resting or engaged in an activity; waking
○ Balancing diabetes control, lipid management, and cardiovascular risk is crucial 2. Heart failure considerations : ○ Addressing heart failure risk: ▪ SGLT-2 inhibitors may benefit bother diabetes and heart failure ▪ Must reassess NSAID use to avoid heart failure exacerbation 3. Prostate cancer integration : ○ Collaborating with oncologists: ▪ Assessing drug interactions with prostate cancer treatments ▪ Monitoring for adverse effects during cancer therapy Reflection : Bob embodies the complexities of polypharmacy. His case underscores the need for personalized, evidence-based approaches and drug reconciliation throughout his various protocols. Clinicians must navigate intricacies of numerous medications and consult with a clinical pharmacist as needed, prioritize patient well-being, and adapt as new challenges arise. As Bob faces prostate cancer, the delicate management of medications continues, guided by patient-centered care, shared decision-making, and ongoing recommendations from compassionate clinicians. up short of breath; noticeable irregular heartbeats that pound, flutter, or feel fast; and swelling in the lower extremities—feet, ankles, or legs. ● Heart valve disease, or valvular heart disease : This can include damage to any of the four heart valves, the aortic, mitral, pulmonary, and tricuspid, impacting their ability to move blood through the heart. Symptoms of heart valve disease can be chest pain, fatigue, noticeable heartbeat change, shortness of breath, and swelling of the ankles or feet. Symptoms are dependent on the valve that is impaired. Heart valve damage causes can include: ○ Stenosis: the narrowing of the heart valve ○ Regurgitation or insufficiency: leaky heart valve ○ Prolapse: improperly closed valve ● Endocarditis : A heart infection that impacts the valves and the inner lining of the heart chamber. Symptoms can include fever, persistent, dry cough, shortness of breath, changes in heartbeat rate, skin rashes or irritation, malaise or fatigue, and leg swelling. Relative to cardiac disease, males experience increased rates of polypharmacy (as per Matthias et al., 2021). Matthias attributes the higher number of comorbidities among them as a potential reason for decreased longevity when compared to females. Hyperpolypharmacy is also notable amongst these patients: ● 80% of patients with congestive heart failure take 7 or more medications ● 60% of patients with coronary heart disease take 7 or more medications Heart failure patients are often prescribed the following (Matthias): ● Diuretic, angiotensin-converting enzyme inhibitor (ACEI) ● Angiotensin receptor blocker (ARB), beta-blockers (BB), aldosterone receptor antagonist (ARA) ● Digoxin ● Variety of other drugs to address symptoms and other conditions
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