Optimizing Primary Care Medication Management- Evidence-Based Approaches and Rationales Question One: First-Line Treatment Recommendations
The American Heart Association/American College of Cardiology (AHA/ACC) and the Eighth Joint National Committee (JNC8) recommend lifestyle modifications as the first-line treatment for patients with hypertension and no major comorbidities. Lifestyle modifications include moderating alcohol intake, controlling dietary sodium intake, increasing physical activity, and achieving a healthy weight. Notably, lifestyle modifications effectively decrease blood pressure and improve cardiovascular health (Mahdavi et al., 2020).
Question Two: Recommended Medications to Start on Patients
Considering the patient’s high blood pressure and hyperlipidemia risk factors, the recommended medications are antihypertensive and lipid-lowering medications. The antihypertensive recommended for this patient, given the age of the patient and comorbidities, is enalapril. Enalapril is an angiotensin-converting enzyme inhibitor. The generic names used for this drug are Epaned, Vasotec, and Enalaprilat, with a starting dose of 5 mg once daily (Faruqi & Jain, 2020). The lipid-lowering medication warranted for this patient is atorvastatin, which is in the statin drug class. It uses the generic Lipitor, with a starting dose of 10 mg once daily (McIver & Siddique, 2019).
Question Three: Mechanism of Actions of the Listed Drugs
Enalapril is an angiotensin-converting enzyme inhibitor that reduces the angiotensin-II levels. As a result of this action, the total peripheral resistance reduces without an increase in cardiac oxygen demand. Also, there is an increase in serum renin levels and a decrease in aldosterone, which leads to a decrease in blood pressure in the body (Faruqi & Jain, 2020). Atorvastatin is a statin that inhibits 3-hydroxy-3-methylglutaryl-coenzyme A reductase, which decreases the production of cholesterol in the liver. Also, atorvastatin increases LDL receptor numbers on the surface of hepatic cells. Ultimately, this leads to a reduction of LDL cholesterol levels in the body (McIver & Siddique, 2019).
Question Four: Side Effects of the Listed Drugs
Common side effects that the patient may experience after taking atorvastatin include diarrhea, nausea, insomnia, pain in the extremities, urinary tract infection, dyspepsia, and arthralgia. Rare adverse effects of atorvastatin are rhabdomyolysis and myopathies, including muscle weakness and muscle aches (McIver & Siddique, 2019). On the other hand, enalapril’s common side effects include a non-productive cough, hyperkalemia, hypotension, cholestatic jaundice, and hypersensitivity. A rare adverse effect of enalapril is angioedema, which can involve the head and neck or the intestines, causing compromise of the airway and abdominal pain, respectively (Faruqi & Jain, 2020).
Question Five: Interactions between the Prescribed Medications
Enalapril and ACE inhibitors, in general, interact with many drugs and can cause toxicities, adverse effects, and therapeutic failures. Enalapril interacts with antipsychotic agents, barbiturates, levodopa, and loop diuretics, enhancing its hypotensive activity, while its adverse effects are enhanced when used together with drugs like allopurinol and lithium (Faruqi & Jain, 2020). On the other hand, atorvastatin interacts with specific drugs metabolized with the CYP5A4 enzyme system, like some antibiotics and antifungals. Also, CYP3A4 inducers may result in a decreased plasma atorvastatin concentration. Lastly, when administered with digoxin, atorvastatin may increase digoxin plasma concentration (McIver & Siddique, 2019).
Question Six: Other Non-Pharmacological Interventions
The main non-pharmacological interventions include dietary modification and weight management. Weight management is key for obesity and overweight individuals (Kodela et al., 2023). Through intermittent fasting, weight loss and hypertension can be achieved effectively. Dietary modification is achieved by the DASH dietary pattern, which involves a diet rich in low total and saturated fat, fruits, whole grains, vegetables, and low-fat dietary produce. Also, as Kodela et al. (2023) note, the DASH diet pattern involves reducing sodium in the diet and limiting the intake of processed foods.
References
Faruqi, A., & Jain, A. (2020). Enalapril. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557708/
Kodela, P., Okeke, M., Guntuku, S., Lingamsetty, S. S. P., & Slonovschi, E. (2023). Management of hypertension with non-pharmacological interventions: A narrative review. Cureus. https://doi.org/10.7759/cureus.43022
Mahdavi, M., Parsaeian, M., Mohajer, B., Modirian, M., Ahmadi, N., Yoosefi, M., Mehdipour, P., Djalalinia, S.,