NR 508 Week 1 TD and Quiz

NR 508 Week 1 TD and Quiz PART 1: Emily, a relatively healthy 5’5”, 32-year-old young woman weighing 190 pounds, presents to your clinic with hirsutism, anovulation, oligomenorrhea, and at times amenorrhea. Biochemical blood tests reveal elevated luteinizing hormone (LH, without a mid-cycle surge) and androgen elevation. She mentions that she also has a family history of irregular cycles, and that her grandmother experienced early menopause. She also states that she is sexually active, occasionally smokes (1 pack/month), and desires to be prescribed one medication to mitigate her symptoms, as well as, prevent her from becoming pregnant. • Please provide a list of differential diagnoses, as well as an indication of your primary diagnosis. • Once this has been completed, please indicate and describe your chosen pharmacological treatment with inclusion of dose and mechanism of action of your chosen prescription. “The diagnosis of PCOS is confirmed once other conditions with features similar to PCOS have been excluded, such as NCCAH, thyroid disease, and hyperprolactinemia” (Barbieri, R. & Ehrmann, D, 2017) “OCs containing one of the original progestins, norethindrone or norethindrone acetate, are also good options; while they are not as low in androgenicity, they have not been associated with excess VTE risk.” (Barbieri, R. & Ehrmann, D, 2016) Primary Dx: PCOS  Microgestin? Norethindrone? Clomiphene citrate? Metformin, Spironolactone, Differentials: NCCAH, thyroid dz, hyperprolactinemia, IF SEVERE hyperandrogenism and virillization, then consider androgen-secreting ovarian and adrenal tumors and ovarian hyperthecosis. Tx: Ortho Tri-Cyclen (norgestimate/ethinyl estradiol) 0.25 mg/35 mcg daily. Encourage patient to stop smoking and make her aware of all the risks involved with smoking and oral contraceptives. Or Yasmin “We typically start with an OC containing 20 mcg of ethinyl estradiol combined with a progestin with minimal androgenicity (such as norgestimate). Other progestins with minimal androgenicity or antiandrogenic properties include desogestrel and drospirenone, but both have been associated with a possible higher risk of venous thromboembolism (VTE) (table 1). OCs containing one of the original progestins, norethindrone or norethindrone acetate, are also good options; while they are not as low in androgenicity, they have not been associated with excess VTE risk.” “Although transdermal or vaginal ring preparations are potential options, they have not been well studied for the management of hirsutism and there are concerns about an excess risk of VTE with both regimens.” PRIMARY DIAGNOSIS: Polycystic Ovary Syndrome (PCOS) is a very common metabolic/endocrine disorder in women that causes an increased amount of androgen secretion, irregular menstrual cycles, and is commonly the cause of infertility (Azziz, 2017). Most often, true PCOS cases will present clinically with menstrual irregularity (oligomenorrhea, amenorrhea, or excessive bleeding), hyperandrogenism (acne and hirsutism), polycystic ovarian features (visualized via an ultrasound), and obesity (Solomon, McCartney, & Marshall, 2016). Many patients will also present with an increased luteinizing hormone and a normal or low follicle-stimulating hormone (Barbieri & Ehrmann, 2017). Emily presents to the office with classic features of PCOS. PCOS has become regarded as an intricate and complicated genetic trait because several genetic branches and environmental elements are combined, which then facilitates one developing the disorder (Azziz, 2017). Multiple studies have correlated an increase in PCOS cases with patients who have a close relative, such as a mom or sister that also has PCOS. According to Azziz (2017), 20 to 40 percent of women diagnosed with PCOS have a mother or sister who have been diagnosed as well. Patients diagnosed with PCOS have a higher risk of developing cardiovascular disease, metabolic syndrome, endometrial cancer, and type 2 diabetes (Barbieri & Ehrmann, 2017). Most patients are diagnosed during their adolescent years, however some are not diagnosed until they are peri- or postmenopausal (Solomon, McCartney, & Marshall, 2016). The clinical manifestations of PCOS may mimic those of puberty, menopause, or nonclassic congenital adrenal hyperplasia (NCCAH) therefore a definite diagnosis must be made. In order to rule out NCCAH, a 17-hydroxyprogesterone-plasma level should be obtained and results need to be less than 200ng/dL (Solomon, McCartney, & Marshall, 2016). One marker that can also be used to help identify PCOS is the mean platelet volume (MPV) (Lucidi, 2016). A patient newly diagnosed with PCOS will typically have high MPV levels (Lucidi, 2016). Treatment of PCOS includes a variety of options with the overall goals being to alleviate symptoms associated with excess androgen, manage metabolic issues including reducing the risks for cardiovascular disease and type 2 diabetes, impede endometrial hyperplasia and endometrial cancer, and restore ovulation for those who desire pregnancy (Barbieri & Ehrmann, 2016). For patients who are overweight, weight reduction via diet and exercise should be strongly encouraged. Weight loss helps improve hyperandrogenism and insulin resistance (Barbieri & Ehrmann, 2016). In fact, even a 5 to 10% reduction in weight can decrease risks for cardiovascular disease, reduce androgen levels, improve menstruation, and can possibly improve fertility (Solomon, McCartney, & Marshall, 2016). The mainstay pharmacologic treatment for PCOS is oral contraceptives (OCs), specifically estrogen-progestin combinations or combination oral contraceptives (COCs) (Solomon, McCartney, & Marshall, 2016). This combination quells androgen and gonadotropin secretion, which helps reduce hirsutism and acne (Solomon, McCartney, & Marshall, 2016). The estrogen in the combination helps stimulate the liver to produce sex hormone-binding globulin (SHBG), which helps decrease the amount of androgen available in the body (Solomon, McCartney, & Marshall, 2016). The use of an estrogen-progestin COC can help regulate bleeding, which can assist in preventing endometrial hyperplasia (Solomon, McCartney, & Marshall, 2016). The issue is that OCs/COCs increase the patient’s risk of developing an embolus, especially if the patient smokes and/or is obese (Solomon, McCartney, & Marshall, 2016). Metformin is can be ordered in conjunction with COCs because it decreases hyperinsulinemia and reduces serum testosterone significantly (Solomon, McCartney, & Marshall, 2016). However, the Endocrine Society Clinical Practice Guidelines is now saying that Metformin as a secondary treatment is less effective than using COCs and/or antiandrogens, such as spironolactone (Barbieri & Ehrmann, 2016). Spironolactone, an androgen-receptor antagonist, can be used as an additional treatment method, especially for those who suffer from extreme hirsutism and acne (Solomon, McCartney, & Marshall, 2016). Since Emily is requesting only one medication to treat her symptoms and provide contraceptive coverage, I would prescribe Drospirenone/ethinyl estradiol 3 mg/ 30 mcg 1 tab by mouth daily. Drospirenone is a spironolactone analog that encompasses antimineralocorticoid and antiandrogenic properties (Epocrates, 2017). The mechanism of action is that it suppresses FSH and LH, it changes the mucous membrane of the cervix and endometrium, and it prevents ovulation (Epocrates, 2017). Contraindications/precautions of this medication include thromboembolism, thrombophlebitis, cancer (specifically breast and endometrial), hepatic and renal impairment, hypertension, migraines, hyperkalemia, adrenal insufficiency, diabetes, and undiagnosed vaginal bleeding (Epocrates, 2017). Emily is overweight and smokes, therefore increasing her risks of developing cardiovascular disease and blood clots. Emily would be given information on smoking cessation and weight loss; it is imperative that she quits smoking and begins reducing her weight. If Emily was open to it, I would also suggest taking a baby aspirin every day because of its antiplatelet properties. DIFFERENTIALS Nonclassic congenital adrenal hyperplasia (NCCAH): Congenital adrenal hyperplasia (CAH) is an autosomal recessive disease caused by mutations within the gene CYP21A2 due to a deficiency in 21-hydroxylase (Nieman & Merke, 2015). CAH is typically identified during the neonate or early infancy period (Nieman & Merke, 2015). Nonclassic CAH, referred to NCCAH, is a particularly common autosomal recessive disease and is more common than CAH (Nieman & Merke, 2015). NCCAH is typically diagnosed later in life and presents with signs of increased androgens; for teens and adults this means oligomenorrhea, hirsutism, and acne (Nieman & Merke, 2015). NCCAH and PCOS are indistinguishable by clinical manifestations alone and therefore testing is needed (Nieman & Merke, 2015). A serum basal 17-hydroxyprogesterone result more than 200 ng/dL is indicative of a positive NCCAH diagnosis however, it must be confirmed with an ACTH stimulation test (Nieman & Merke, 2015). While clinical manifestations alone are not appropriate in distinguishing between PCOS and NCCAH, PCOS is seen more often than NCCAH (Nieman & Merke, 2015). Therefore, I do not believe this to be Emily’s primary diagnosis but I would need to test serum basal 17-hydroxyprogesterone and confirm it with ACTH testing to be positive. Cushing’s disease: Cushing’s disease is more commonly seen in women between the ages of 25 to 45 years old (Nieman, 2017). Most women who present with Cushing’s syndrome do so because of increased androgen secretion from an adrenal carcinoma (Nieman, 2017). Cushing’s syndrome can affect multiple body systems such as cardiovascular, reproductive, metabolic, dermatologic, musculoskeletal, infectious, and neuropsychiatric (Nieman, 2017). Some of these symptoms can present as PCOS, including irregular menstrual cycles, androgen excess, obesity, and glucose intolerance. Considering these symptoms mimic one another, it is important to rule out Cushing’s disease before making a definitive diagnosis of PCOS. Based on the information given, I do not believe Emily’s primary diagnosis to be Cushing’s disease because if it was, Emily should present with additional symptoms, such as muscle weakness and wasting, osteoporosis, and psychological/cognitive changes (Nieman, 2017). Biochemical testing is needed to rule out a Cushing’s diagnosis, such as a 24-hour urinary free cortisol (UFC) excretion test, a late-night salivary cortisol, or the dexamethasone suppression test (DST) (Nieman, 2017). Androgen secreting tumors (AST): Although rare, when positive, these neoplasms are generally seen in the second or third stages of life, between 25 to 40 years of age (Gershenson, 2017). ASTs comprise of 5 percent of ovarian neoplasms and include Sertoli-Leydig tumors, hilus tumors, and granulosa-theca cell or stromal cell tumors (Gershenson, 2017). These tumors are considered heterogeneous and include malignant and benign tumors that grow from stem cells surrounding oocytes and ovarian hormone producing cells (Gershenson, 2017). These tumors often produce androgen precursors and androgens; therefore their manifestations can include amenorrhea, oligomenorrhea, hirsutism, atrophy of breast tissue, acne, a deeper voice, clitoral enlargement, and male pattern baldness (Gershenson, 2017). Considering some of these manifestations are similar to PCOS and Cushing’s, androgen-secreting tumors must be ruled out. Most ASTs can be identified via transvaginal ultrasonography and nearly all patients who are symptomatic will have an adnexal mass that is palpable (Gershenson, 2017). Definitive diagnosis is made via histology (Gershenson, 2017). ASTs should be considered however; I do not believe this is Emily’s primary diagnosis. Azziz, R. (2017). Epidemiology and pathogenesis of the polycystic ovary syndrome in adults. UpToDate. Retrieved from Barbieri, R. & Ehrmann, D. (2016). Treatment of polycystic ovary syndrome in adults. UpToDate. Retrieved from Barbieri, R. & Ehrmann, D. (2017). Diagnosis of polycystic ovary syndrome in adults. UpToDate. Retrieved from Epocrates (2017). Epocrates, Inc. (Version 17.5.2) [Mobile application software]. Gershenson, D. (2017). Sex cord-stromal tumors of the ovary: Sertoli-stromal cell tumors. UpToDate. Retrieved from Lucidi, R. (2016). Polycystic ovarian syndrome treatment and management. Medscape. Retrieved from Nieman, L. (2017). Epidemiology and clinical manifestations of Cushing’s syndrome. UpToDate. Retrieved from Nieman, L. & Merke, D. (2015). Diagnosis and treatment of nonclassic (late-onset) congenital adrenal hyperplasia due to 21-hydroxylase deficiency. UpToDate. Retrieved from Solomon, C., McCartney, C., & Marshall, J. (2016). Polycystic ovary syndrome. The New England Journal of Medicine, (375.1)54-64. Retrieved from PART 2: You diagnose Emily with polycystic ovarian syndrome (PCOS) and decide to prescribe drospirenone-ethinyl-estradiol as a way to control both the PCOS symptoms, as well as to act as an oral contraceptive. • At what dose should this be prescribed? • What is the mechanism of drospirenone-ethinyl-estradiol, and why would, because of its mechanism, it be a good choice for her PCOS symptoms (Include the medication-altered physiology)? • How would you monitor for efficacy and toxicity? I would prescribe drospirenone/ethinyl estradiol 3 mg/ 30 mcg 1 tab by mouth daily (Epocrates, 2017). It may take 6 to 12 months before the patient starts noticing an improvement. This combination oral contraceptive (COC) is considered monophasic and is a low dose option. Drospirenone, the progestin, is a spironolactone analog that has antimineralocorticoid and antiandrogenic properties (Epocrates, 2017). Drospirenone does not contain estrogenic, androgenic, antiglucocorticoid, or glucocorticoid action (PDR, 2017). The estrogen component, ethinyl estradiol, is commonly used in oral contraceptives (OCs) (PDR, 2017). The initial mechanism of action is to prevent ovulation by inhibiting the hypothalamic-pituitary-ovarian negative feedback loop (Edmunds & Mayhew, 2013). A person receiving continuous, low-levels of progestin and/or estrogen will signal the pituitary and hypothalamus to suppress GnRH, FSH, and LH, therefore prevent ovulation (Edmunds & Mayhew, 2013). For Emily’s symptoms specifically, COCs are good for improving acne and hirsutism because it reduces serum-free testosterone (Carey & Allen, 2012). It decreases testosterone by preventing LH secretion from ovaries and boosting SHBG from the liver (Carey & Allen, 2012). Another reason COCs are useful is because they also prevent 5-alpha-reductase activity; without this, testosterone cannot be converted to dihydrotestosterone in the skin and hair follicles testosterone (Carey & Allen, 2012). Drospirenone/ethinyl estradiol is a good choice based on Emily’s request because it is a COC that contains a spironolactone analog; its antimineralocorticoid and antiandrogenic properties will eventually decrease her acne and hair growth. Drospirenone does not have much effect on carbohydrate metabolism, therefore it is not as likely to exacerbate sebaceous glands and acne (PDR, 2017). Drospirenone/ethinyl estradiol is a cost effective option as well, being that it can be obtained from CVS, Walgreens, and Walmart for under $35.00 per pack. Considering this medication is a spironolactone analog, it has the potential to cause hyperkalemia so serum potassium levels should be monitored. To ensure efficiency and safety, all medications should be checked for possible adverse interactions, even herbs and vitamins. I would make sure Emily understands that she is not to take any new medications without approval. Carey, M.S., & Allen, R.H. (2012). Non-contraceptive use and benefits of combined oral contraception. Obstetrician & Gynaecologist, 14(4), 223-228. Edmunds, M. W., & Mayhew, M. S. (2013). Pharmacology for the primary care provider (4th ed.). Retrieved from Epocrates (2017). Epocrates, Inc. (Version 17.5.2) [Mobile application software]. Martin, K. & Barbieri, R. (2016). Overview of the use of estrogen-progestin contraceptives. UpToDate. Retrieved from PDR (2017). PDR, LLC. (Version , A: 2.0.4.0) [Mobile application software] PART 3: Emily subsequently returns to your clinic 5 months later, and decides to inform you that within the first 3 months after treatment, she struggled with a severe bout of depression. Instead of returning to your clinic to be prescribed, yet another pharmaceutical, she consulted her herbalist who told her about the anti-depressant, over-the-counter, herbal formulation, St. John’s Wort. She decided to begin taking St. John’s Wort in conjunction with her prescribed oral contraceptive medication, and she has now reappeared at your clinic because she is pregnant, and is distraught about how this occurred since she took her oral contraceptive compliantly since its prescription. • Why then, is she pregnant? • Please include detailed pharmacological mechanisms of how this occurred, and your subsequent steps in her management. One of the precautions to consider when prescribing drospirenone/ethinyl estradiol is depression. Exogenous hormones can exacerbate depression; therefore women who have a history of depression should be monitored carefully while taking them (PDR, 2017). It is important that patients understand certain medications can decrease the effectiveness of this OC (Bayer Healthcare, 2015). Per Bayer Healthcare and the FDA, St. John’s Wort (SJW) causes activation of cytochrome P450 (hepatic enzymes) and the p-glycoprotein transporter, which can alter the effectiveness of OCs (Bayer Healthcare, 2010). Concurrent use of OCs and SJW can also cause breakthrough bleeding (Bayer Healthcare, 2010). The exact mechanism of action for SJW is still being debated. The active ingredient Hypericin is the standard marker for drug processing (PDR, 2017). However, it seems that hypericin needs to be used in conjunction with naphthodianthrones, hyperforin, and flavonoids to produce antidepressant effects (PDR, 2017). Ultimately, researchers believe effective antidepressant results are related to the combination of multiple neurotransmitters and steroid hormones (PDR, 2017). SJW activates the cytochrome P450 (CYP) 3 A4 enzyme (Berry-Bibee, Kim, Tepper, Riley, & Curtis, 2016). Both components of COCs are substrates of CYP3A4; because of this, pharmacodynamic and pharmacokinetic interactions can occur, interactions that can cause decrease effectiveness of other medication (Berry-Bibee, Kim, Tepper, Riley, & Curtis, 2016). To manage her care, first I would discontinue the OC and SJW, as well as review all other medications for teratogenic effects. I would obtain the date of her last menstrual period plus revisit gravida para and abortions. A PHQ-9 depression questionnaire would be documented to assess the severity of Emily’s depression. Security at home would also be addressed to rule out any domestic violence concerns. Emily would be instructed to comply with cessation of smoking and alcohol consumption. Lab work would be ordered, including an obstetric panel, CMP, TSH, HbgA1C, and UA with HCG quantitation. The obstetric panel includes a CBC with diff, antibody screen, RBC with reflex to identification, titer, antigen typing, ABO group and Rh typing, RPR with reflex to titer and confirmatory testing, hepatitis B surface antigen with reflex confirmation, and a rubella virus IgG antibody (Quest Diagnostics, 2017). Finally, I would start Emily on prenatal vitamins and refer her to an OB/GYN for evaluation and continued follow up. Bayer Healthcare Pharmaceuticals, Inc. (2010). Drospirenone and ethinyl estradiol. Retrieved from Bayer Healthcare Pharmaceuticals, Inc. (2015). Highlights of prescribing information. Retrieved from Berry-Bibee, E. N., Kim, M., Tepper, N.K., Riley, H. M., & Curtis, K. M. (2016). Co-administration of st. john’s wort and hormonal contraceptives: A systematic review. Contraception, 94(6), 668-677. PDR (2017). PDR, LLC. (Version , A: 2.0.4.0) [Mobile application software] Quest Diagnostics Inc. (2017). Obstetric panel. Retrieved from PEER: Hi Jessica! Great post! I agree that drospirenone/ethinyl estradiol is the appropriate course of treatment. Spironolactone is an androgen-receptor antagonist that can be used as an additional treatment method for PCOS, especially for those who suffer from serious hirsutism and acne (Solomon, McCartney, & Marshall, 2016). Drospirenone, which is the progestin in this COC, is a spironolactone analog that has antimineralocorticoid and antiandrogenic properties (Epocrates, 2017). Drospirenone/ethinyl estradiol is definitely the best choice for Emily since she wants one medication that can alleviate her symptoms and also provide protection against pregnancy. Even though unlikely at this dose, because drospirenone is a spironolactone analog it has the potential of causing hyperkalemia. Potassium levels should be obtained during the first month of treatment and as clinically indicated during the course of taking it. Patients should be educated on the symptoms of hyperkalemia. COCs can also increase LDH and triglycerides so alternative treatment methods should be explored for patients with or at risk for dyslipidemia (PDR, 2017). Epocrates (2017). Epocrates, Inc. (Version 17.5.2) [Mobile application software]. PDR (2017). PDR, LLC. (Version , A: 2.0.4.0) [Mobile application software] Solomon, C., McCartney, C., & Marshall, J. (2016). Polycystic ovary syndrome. The New England Journal of Medicine, (375.1)54-64. Retrieved from INSTRUCTOR: Hi Whitney, I agree with your reasoning behind why potassium levels should be checked routinely--how often would this be? If you found that she was hyperkalemic, what would be your next course of action? Hi Dr. Chotibut, Patients put on drospirenone/ethinyl estradiol should have their potassium levels checked within the first month of beginning the medication. Patients should be educated on the signs and symptoms of hyperkalemia, which include muscle weakness or paralysis, cardiovascular abnormalities including chest pain and extremity numbness, and persistent leg pain. If Emily was found to be hyperkalemic, the treatment plan would depend on the severity of the potassium level and if or what symptoms Emily was exhibiting. Considering the dose of drospirenone is low, if Emily had any issues they would most likely be mild. If she was mildly to moderately hyperkalemic I would stop the medication and repeat lab work in 2 to 3 days. I would also check to make sure she had not started taking any new medications that could increase potassium levels such as NSAIDS (Bayer, 2013). When her levels returned to normal I would start her on a new OC, such as one containing levonorgestrel instead of drospirenone (Bird et al., 2011). Levonorgestrel has not shown to affect potassium levels because it is a second generation OC (Bird et al., 2011). According to Plovanich, Weng, & Mostaghimi (2015), monitoring potassium levels routinely are not necessary if the patient is healthy. This idea stems from research spanning over 14 years that shows hyperkalemia rates from patients taking spironolactone for acne is insignificant and may not be worth the costs associated with frequent monitoring (Plovanich, Weng, & Mostaghimi, 2015). This makes sense because, as I mentioned before, the dose is low comparatively speaking. Thorough and accurate education on the symptoms of hyperkalemia should be acceptable for the portion of the population that does not have predetermined risk factors. Bayer (2013). Yaz prescribing information. Retrieved from Bird, S., Pepe, S., Etminan, M., Liu, X., Brophy, J., & Delaney, J. (2011). The association between drospireone and hyperkalemia: A comparative-safety study. BMC Clinical Pharmacology, 11(23). doi: 10.1186/. Retrieved from Plovanich, M., Weng, Q., & Mostaghimi, A. (2015). Low usefulness of potassium monitoring among healthy young women taking spironolactone for acne. Jama Dermatology, 151(9) 941-944. doi:10.1001/jamadermatol.2015.34. Retrieved from QUIZ: A patient who has chronic pain and who takes oxycodone (Percodan) calls the clinic to ask for a refill of the medication. The primary care NP notes that the medication refill is not due for 2 weeks. The patient tells the NP that the refill is needed because he is going out of town. The NP should: review the patient’s chart to see if this is a one-time or repeat occurrence. A patient takes a cardiac medication that has a very narrow therapeutic range. The primary care NP learns that the particular brand the patient is taking is no longer covered by the patient’s medical plan. The NP knows that the bioavailability of the drug varies from brand to brand. The NP should: contact the insurance provider to explain why this particular formulation is necessary. A man who has secondary hypogonadism associated with pituitary dysfunction will begin exogenous testosterone therapy. The patient asks the primary care NP about future chances of fathering children. The NP should tell him that: Fertility may improve with testosterone therapy. A patient has recurrent symptoms and tells the primary care NP that she can’t remember to take her medication all the time. The NP should: ask her about her lifestyle, her schedule, and her understanding of her condition A patient is diagnosed with lupus and reports occasional use of herbal supplements. The primary care NP should caution this patient to avoid: echinacea. The primary care NP sees a woman who has been taking HT for menopausal symptoms for 3 years. The NP decreases the dosage, and several weeks later, the woman calls to report having several hot flashes each day. The NP should: increase the HT dose A patient bursts into tears when the primary care NP diagnoses diabetes. The NP should: ask the patient about past experiences with anyone who has this diagnosis. . A patient comes to the clinic to discuss weight loss. The primary care NP notes a BMI of 32 and performs a health risk assessment that reveals no obesity-related risk factors. The NP should recommend: changes in diet and exercise along with short-term phentermine A primary care NP wishes to order a drug that will be effective immediately after administration of the drug. Which route should the NP choose? SL. The primary care NP has referred a child who has significant gastrointestinal reflux disease to a specialist for consideration for a fundoplication and gastrostomy tube placement. The child’s weight is 80% of what is recommended for age, and a recent swallow study revealed significant risk for aspiration. The child’s parents do not want the procedure. The NP should: initiate a discussion with the parents about the potential outcomes of each possible action. A primary care NP prescribes a COCP for a woman who is taking them for the first time. After teaching, the woman should correctly state the need for using a backup form of contraception if she: is having vomiting or diarrhea. A patient who is newly diagnosed with hypertension is to begin taking two antihypertensive medications. The primary care NP gives the patient written drug information and starts to discuss medication side effects. The patient interrupts and says, “I don’t want to know all that. Just tell me what to take and when.” The NP should: ask the patient about previous experiences with medication side effects. A 55-year-old woman has not had menstrual periods for 5 years and tells the primary care nurse practitioner (NP) that she is having increasingly frequent vasomotor symptoms. She has no family history or risk factors for coronary heart disease (CHD) or breast cancer but is concerned about these side effects of hormone therapy (HT). The NP should: tell her that starting HT now may reduce her risk of breast cancer. The current trend toward transitioning NP programs to the doctoral level will mean that: NPs will be better prepared to meet emerging health care needs of patients. A patient asks a primary care nurse practitioner (NP) about using over-the-counter medications to treat an upper respiratory infection with symptoms of cough, fever, and nasal congestion. The NP should: suggest using single-ingredient products to treat each symptom separately. A patient who takes warfarin (Coumadin) experiences excessive bleeding, even though serum drug levels are normal. The primary care NP should question this patient about the use of: ginkgo biloba. An important difference between physician assistants (PAs) and NPs is PAs: always work under physician supervision. A woman who began taking a COCP 2 months ago calls the primary care NP to report having nausea every day. She takes a pill at the same time each morning. The NP should tell her to: try taking the pill in the evening each day. A patient is taking drug A and drug B. The primary care NP notes increased effects of drug B. The NP should suspect that in this case drug A is a cytochrome P450 (CYP450) enzyme: inhibitor.  If drug A is a CYP450 enzyme inhibitor, it decreases the capacity of the enzyme to metabolize drug B, causing more of drug B to be available. A substrate is a drug acted on by the enzyme. If drug B is an enzyme inducer, it would cause increased metabolism of drug A. A postpartum woman will begin taking the minipill while she is nursing her infant. The primary care NP should instruct the patient: that this method does not increase her risk of thromboembolic events. ??A patient has a BMI of 35, a fasting plasma glucose of 120 mg/dL, elevated triglycerides, and a history of myocardial infarction. The primary care NP plans to initiate dietary and lifestyle counseling and should consider prescribing: phentermine and topiramate (Onexa).  Patients who take Onexa have shown improvement in blood glucose levels and triglyceride levels, so this combination is a good choice for this patient. The primary care NP should understand that a drug is at a therapeutic level when it is: between minimal effective concentration and toxic levels. A woman who is being treated with radiotherapy for breast cancer asks her primary care nurse practitioner (NP) about using dietary supplements to improve her chance of recovery. The NP should tell her that: vitamin C, taken at least 6 days per week, may lower her risk of cancer recurrence. A 52-year-old woman reports having hot flashes and intense mood swings. After a year of having irregular menstrual periods, she has not had a period for 6 months. The primary care NP should diagnose: perimenopause. The primary care nurse practitioner (NP) writes a prescription for an antibiotic using an electronic drug prescription system. The pharmacist will fill this prescription when: the electronic prescription is received. WEEK 1 SUMMARY FROM PROFESSOR: Emily is diagnosed with polycystic ovary syndrome (PCOS) and prescribed the oral contraceptive combination medication drospirenone-ethinyl-estradiol (Yaz or Yasmin). The key mechanism of oral contraceptive action is folliculogenesis inhibition through either suppression of pituitary gonadtrophin secretion or direct influence on ovarian function when the COC agent has weaker anti-gonadotrapin activity. An oral contraceptive can also lead to a decrease in circulating albumin levels, leading to a decrease in dehydroepiandrosterone sulphate (DHEAS), which is strongly bound to albumin and androgen production, a decrease in peripheral androgen production through an inhibition of 5α reductase and a subsequent decrease dihydrotestosterone levels. The combined effect is an overall decrease in gonadotropins and resulting androgens, which is a primary goal of PCOS treatment. In addition, the estrogen component of COC increases sex hormone binding globulin (SHBG) production by the liver, which in turn reduces the circulating levels of free testosterone and its bioavailability. Drospirenone, in conjunction with ethinyl estradiol, acts to suppress gonadotropins. This is achieved through inhibition of ovulation as described above. Drospirenone is chemically related to spironolactone and has antimineralocorticoid effects and antiandrogenic effects similar to progesterone. Spironolactone is an aldosterone antagonist, and a potassium-sparing diuretic. Because of this similarity with spironolactone, drospirenone also exhibits anti-mineralocorticoid activity. This property counteracts the estrogen-stimulated activity of the renin-angiotensin-aldosterone system, which can influence the regulation of water and electrolyte balance. Drospirenone is effective in treating the symptoms of PCOS due to the fact that it is an antagonist at the androgen receptor and an inhibitor of testosterone synthesis. These COCPs may cause potassium retention. As a result, caution should be used in women taking potassium-sparing diuretics, ACE inhibitors or ARBs, other aldosterone antagonists, heparin, or long-term NSAIDs. A serum potassium level should be checked during the first month of therapy in patients taking any of these drugs. Besides the oral contraceptive, a couple of you recommended metformin for Emily’s PCOS. The use of metformin in PCOS is associated with increased menstrual cyclicity, improved ovulation and a reduction in circulating androgen levels. The mechanisms for these actions include the reduction of circulating insulin levels and thus altered effects of insulin on ovarian androgen biosynthesis. This is likely due to reduced ovarian gluconeogenesis, which results in slowed androgen production. In part 3, we examined the use of the herbal supplement St. John’s Wort and its interference with the efficacy of Emily’s contraceptive. This is because this herb, which is claimed to be effective in the treatment of mild to moderate depression, appears to be a potent inducer of isozyme CYP450 3A4 There are over 50 human CYP450 enzymes identified, however, only 12 are involved in drug metabolism. Of those twelve, CYP3A4 is responsible for breaking down the majority of clinically relevant drugs. Metabolic breakdown is a key mechanism of drug inactivation and elimination from the body. When CYP450 expression is enhanced, their drug targets are inactivated and eliminated at an accelerated rate, which can have a significant impact on the therapeutic efficacy of the drug. This is can also be the case for enzyme inactivation, which can occur with some drugs as well. Enzyme inactivation can cause toxicity at doses that would normally be within an appropriate therapeutic range. Such pharmacokinetic drug interactions make patient education a critical part of a prescription drug regimen, as compounds that the patient may consider benign may have significant clinical effects. Great job everyone in honing in on Emily’s diagnosis with most of you selecting the appropriate medication(s). I was impressed with the entirety of many of your posts as you examined the relevant non-pharmacological considerations and implications of Emily’s PCOS and pregnancy in addition to the pharmacological issues. . . NR 508 Week 1 TD and Quiz PART 1: Emily, a relatively healthy 5’5”, 32-year-old young woman weighing 190 pounds, presents to your clinic with hirsutism, anovulation, oligomenorrhea, and at times amenorrhea. Biochemical blood tests reveal elevated luteinizing hormone (LH, without a mid-cycle surge) and androgen elevation. She mentions that she also has a family history of irregular cycles, and that her grandmother experienced early menopause. She also states that she is sexually active, occasionally smokes (1 pack/month), and desires to be prescribed one medication to mitigate her symptoms, as well as, prevent her from becoming pregnant. • Please provide a list of differential diagnoses, as well as an indication of your primary diagnosis. • Once this has been completed, please indicate and describe your chosen pharmacological treatment with inclusion of dose and mechanism of action of your chosen prescription. “The diagnosis of PCOS is confirmed once other conditions with features similar to PCOS have been excluded, such as NCCAH, thyroid disease, and hyperprolactinemia” (Barbieri, R. & Ehrmann, D, 2017) “OCs containing one of the original progestins, norethindrone or norethindrone acetate, are also good options; while they are not as low in androgenicity, they have not been associated with excess VTE risk.” (Barbieri, R. & Ehrmann, D, 2016) Primary Dx: PCOS  Microgestin? Norethindrone? Clomiphene citrate? Metformin, Spironolactone, Differentials: NCCAH, thyroid dz, hyperprolactinemia, IF SEVERE hyperandrogenism and virillization, then consider androgen-secreting ovarian and adrenal tumors and ovarian hyperthecosis. Tx: Ortho Tri-Cyclen (norgestimate/ethinyl estradiol) 0.25 mg/35 mcg daily. Encourage patient to stop smoking and make her aware of all the risks involved with smoking and oral contraceptives. Or Yasmin “We typically start with an OC containing 20 mcg of ethinyl estradiol combined with a progestin with minimal androgenicity (such as norgestimate). Other progestins with minimal androgenicity or antiandrogenic properties include desogestrel and drospirenone, but both have been associated with a possible higher risk of venous thromboembolism (VTE) (table 1). OCs containing one of the original progestins, norethindrone or norethindrone acetate, are also good options; while they are not as low in androgenicity, they have not been associated with excess VTE risk.” “Although transdermal or vaginal ring preparations are potential options, they have not been well studied for the management of hirsutism and there are concerns about an excess risk of VTE with both regimens.” PRIMARY DIAGNOSIS: Polycystic Ovary Syndrome (PCOS) is a very common metabolic/endocrine disorder in women that causes an increased amount of androgen secretion, irregular menstrual cycles, and is commonly the cause of infertility (Azziz, 2017). Most often, true PCOS cases will present clinically with menstrual irregularity (oligomenorrhea, amenorrhea, or excessive bleeding), hyperandrogenism (acne and hirsutism), polycystic ovarian features (visualized via an ultrasound), and obesity (Solomon, McCartney, & Marshall, 2016). Many patients will also present with an increased luteinizing hormone and a normal or low follicle-stimulating hormone (Barbieri & Ehrmann, 2017). Emily presents to the office with classic features of PCOS. PCOS has become regarded as an intricate and complicated genetic trait because several genetic branches and environmental elements are combined, which then facilitates one developing the disorder (Azziz, 2017). Multiple studies have correlated an increase in PCOS cases with patients who have a close relative, such as a mom or sister that also has PCOS. According to Azziz (2017), 20 to 40 percent of women diagnosed with PCOS have a mother or sister who have been diagnosed as well. Patients diagnosed with PCOS have a higher risk of developing cardiovascular disease, metabolic syndrome, endometrial cancer, and type 2 diabetes (Barbieri & Ehrmann, 2017). Most patients are diagnosed during their adolescent years, however some are not diagnosed until they are peri- or postmenopausal (Solomon, McCartney, & Marshall, 2016). The clinical manifestations of PCOS may mimic those of puberty, menopause, or nonclassic congenital adrenal hyperplasia (NCCAH) therefore a definite diagnosis must be made. In order to rule out NCCAH, a 17-hydroxyprogesterone-plasma level should be obtained and results need to be less than 200ng/dL (Solomon, McCartney, & Marshall, 2016). One marker that can also be used to help identify PCOS is the mean platelet volume (MPV) (Lucidi, 2016). A patient newly diagnosed with PCOS will typically have high MPV levels (Lucidi, 2016). Treatment of PCOS includes a variety of options with the overall goals being to alleviate symptoms associated with excess androgen, manage metabolic issues including reducing the risks for cardiovascular disease and type 2 diabetes, impede endometrial hyperplasia and endometrial cancer, and restore ovulation for those who desire pregnancy (Barbieri & Ehrmann, 2016). For patients who are overweight, weight reduction via diet and exercise should be strongly encouraged. Weight loss helps improve hyperandrogenism and insulin resistance (Barbieri & Ehrmann, 2016). In fact, even a 5 to 10% reduction in weight can decrease risks for cardiovascular disease, reduce androgen levels, improve menstruation, and can possibly improve fertility (Solomon, McCartney, & Marshall, 2016). The mainstay pharmacologic treatment for PCOS is oral contraceptives (OCs), specifically estrogen-progestin combinations or combination oral contraceptives (COCs) (Solomon, McCartney, & Marshall, 2016). This combination quells androgen and gonadotropin secretion, which helps reduce hirsutism and acne (Solomon, McCartney, & Marshall, 2016). The estrogen in the combination helps stimulate the liver to produce sex hormone-binding globulin (SHBG), which helps decrease the amount of androgen available in the body (Solomon, McCartney, & Marshall, 2016). The use of an estrogen-progestin COC can help regulate bleeding, which can assist in preventing endometrial hyperplasia (Solomon, McCartney, & Marshall, 2016). The issue is that OCs/COCs increase the patient’s risk of developing an embolus, especially if the patient smokes and/or is obese (Solomon, McCartney, & Marshall, 2016). Metformin is can be ordered in conjunction with COCs because it decreases hyperinsulinemia and reduces serum testosterone significantly (Solomon, McCartney, & Marshall, 2016). However, the Endocrine Society Clinical Practice Guidelines is now saying that Metformin as a secondary treatment is less effective than using COCs and/or antiandrogens, such as spironolactone (Barbieri & Ehrmann, 2016). Spironolactone, an androgen-receptor antagonist, can be used as an additional treatment method, especially for those who suffer from extreme hirsutism and acne (Solomon, McCartney, & Marshall, 2016). Since Emily is requesting only one medication to treat her symptoms and provide contraceptive coverage, I would prescribe Drospirenone/ethinyl estradiol 3 mg/ 30 mcg 1 tab by mouth daily. Drospirenone is a spironolactone analog that encompasses antimineralocorticoid and antiandrogenic properties (Epocrates, 2017). The mechanism of action is that it suppresses FSH and LH, it changes the mucous membrane of the cervix and endometrium, and it prevents ovulation (Epocrates, 2017). Contraindications/precautions of this medication include thromboembolism, thrombophlebitis, cancer (specifically breast and endometrial), hepatic and renal impairment, hypertension, migraines, hyperkalemia, adrenal insufficiency, diabetes, and undiagnosed vaginal bleeding (Epocrates, 2017). Emily is overweight and smokes, therefore increasing her risks of developing cardiovascular disease and blood clots. Emily would be given information on smoking cessation and weight loss; it is imperative that she quits smoking and begins reducing her weight. If Emily was open to it, I would also suggest taking a baby aspirin every day because of its antiplatelet properties. DIFFERENTIALS Nonclassic congenital adrenal hyperplasia (NCCAH): Congenital adrenal hyperplasia (CAH) is an autosomal recessive disease caused by mutations within the gene CYP21A2 due to a deficiency in 21-hydroxylase (Nieman & Merke, 2015). CAH is typically identified during the neonate or early infancy period (Nieman & Merke, 2015). Nonclassic CAH, referred to NCCAH, is a particularly common autosomal recessive disease and is more common than CAH (Nieman & Merke, 2015). NCCAH is typically diagnosed later in life and presents with signs of increased androgens; for teens and adults this means oligomenorrhea, hirsutism, and acne (Nieman & Merke, 2015). NCCAH and PCOS are indistinguishable by clinical manifestations alone and therefore testing is needed (Nieman & Merke, 2015). A serum basal 17-hydroxyprogesterone result more than 200 ng/dL is indicative of a positive NCCAH diagnosis however, it must be confirmed with an ACTH stimulation test (Nieman & Merke, 2015). While clinical manifestations alone are not appropriate in distinguishing between PCOS and NCCAH, PCOS is seen more often than NCCAH (Nieman & Merke, 2015). Therefore, I do not believe this to be Emily’s primary diagnosis but I would need to test serum basal 17-hydroxyprogesterone and confirm it with ACTH testing to be positive. Cushing’s disease: Cushing’s disease is more commonly seen in women between the ages of 25 to 45 years old (Nieman, 2017). Most women who present with Cushing’s syndrome do so because of increased androgen secretion from an adrenal carcinoma (Nieman, 2017). Cushing’s syndrome can affect multiple body systems such as cardiovascular, reproductive, metabolic, dermatologic, musculoskeletal, infectious, and neuropsychiatric (Nieman, 2017). Some of these symptoms can present as PCOS, including irregular menstrual cycles, androgen excess, obesity, and glucose intolerance. Considering these symptoms mimic one another, it is important to rule out Cushing’s disease before making a definitive diagnosis of PCOS. Based on the information given, I do not believe Emily’s primary diagnosis to be Cushing’s disease because if it was, Emily should present with additional symptoms, such as muscle weakness and wasting, osteoporosis, and psychological/cognitive changes (Nieman, 2017). Biochemical testing is needed to rule out a Cushing’s diagnosis, such as a 24-hour urinary free cortisol (UFC) excretion test, a late-night salivary cortisol, or the dexamethasone suppression test (DST) (Nieman, 2017). Androgen secreting tumors (AST): Although rare, when positive, these neoplasms are generally seen in the second or third stages of life, between 25 to 40 years of age (Gershenson, 2017). ASTs comprise of 5 percent of ovarian neoplasms and include Sertoli-Leydig tumors, hilus tumors, and granulosa-theca cell or stromal cell tumors (Gershenson, 2017). These tumors are considered heterogeneous and include malignant and benign tumors that grow from stem cells surrounding oocytes and ovarian hormone producing cells (Gershenson, 2017). These tumors often produce androgen precursors and androgens; therefore their manifestations can include amenorrhea, oligomenorrhea, hirsutism, atrophy of breast tissue, acne, a deeper voice, clitoral enlargement, and male pattern baldness (Gershenson, 2017). Considering some of these manifestations are similar to PCOS and Cushing’s, androgen-secreting tumors must be ruled out. Most ASTs can be identified via transvaginal ultrasonography and nearly all patients who are symptomatic will have an adnexal mass that is palpable (Gershenson, 2017). Definitive diagnosis is made via histology (Gershenson, 2017). ASTs should be considered however; I do not believe this is Emily’s primary diagnosis. Azziz, R. (2017). Epidemiology and pathogenesis of the polycystic ovary syndrome in adults. UpToDate. Retrieved from Barbieri, R. & Ehrmann, D. (2016). Treatment of polycystic ovary syndrome in adults. UpToDate. Retrieved from Barbieri, R. & Ehrmann, D. (2017). Diagnosis of polycystic ovary syndrome in adults. UpToDate. Retrieved from Epocrates (2017). Epocrates, Inc. (Version 17.5.2) [Mobile application software]. Gershenson, D. (2017). Sex cord-stromal tumors of the ovary: Sertoli-stromal cell tumors. UpToDate. Retrieved from Lucidi, R. (2016). Polycystic ovarian syndrome treatment and management. Medscape. Retrieved from Nieman, L. (2017). Epidemiology and clinical manifestations of Cushing’s syndrome. UpToDate. Retrieved from Nieman, L. & Merke, D. (2015). Diagnosis and treatment of nonclassic (late-onset) congenital adrenal hyperplasia due to 21-hydroxylase deficiency. UpToDate. Retrieved from Solomon, C., McCartney, C., & Marshall, J. (2016). Polycystic ovary syndrome. The New England Journal of Medicine, (375.1)54-64. Retrieved from PART 2: You diagnose Emily with polycystic ovarian syndrome (PCOS) and decide to prescribe drospirenone-ethinyl-estradiol as a way to control both the PCOS symptoms, as well as to act as an oral contraceptive. • At what dose should this be prescribed? • What is the mechanism of drospirenone-ethinyl-estradiol, and why would, because of its mechanism, it be a good choice for her PCOS symptoms (Include the medication-altered physiology)? • How would you monitor for efficacy and toxicity? I would prescribe drospirenone/ethinyl estradiol 3 mg/ 30 mcg 1 tab by mouth daily (Epocrates, 2017). It may take 6 to 12 months before the patient starts noticing an improvement. This combination oral contraceptive (COC) is considered monophasic and is a low dose option. Drospirenone, the progestin, is a spironolactone analog that has antimineralocorticoid and antiandrogenic properties (Epocrates, 2017). Drospirenone does not contain estrogenic, androgenic, antiglucocorticoid, or glucocorticoid action (PDR, 2017). The estrogen component, ethinyl estradiol, is commonly used in oral contraceptives (OCs) (PDR, 2017). The initial mechanism of action is to prevent ovulation by inhibiting the hypothalamic-pituitary-ovarian negative feedback loop (Edmunds & Mayhew, 2013). A person receiving continuous, low-levels of progestin and/or estrogen will signal the pituitary and hypothalamus to suppress GnRH, FSH, and LH, therefore prevent ovulation (Edmunds & Mayhew, 2013). For Emily’s symptoms specifically, COCs are good for improving acne and hirsutism because it reduces serum-free testosterone (Carey & Allen, 2012). It decreases testosterone by preventing LH secretion from ovaries and boosting SHBG from the liver (Carey & Allen, 2012). Another reason COCs are useful is because they also prevent 5-alpha-reductase activity; without this, testosterone cannot be converted to dihydrotestosterone in the skin and hair follicles testosterone (Carey & Allen, 2012). Drospirenone/ethinyl estradiol is a good choice based on Emily’s request because it is a COC that contains a spironolactone analog; its antimineralocorticoid and antiandrogenic properties will eventually decrease her acne and hair growth. Drospirenone does not have much effect on carbohydrate metabolism, therefore it is not as likely to exacerbate sebaceous glands and acne (PDR, 2017). Drospirenone/ethinyl estradiol is a cost effective option as well, being that it can be obtained from CVS, Walgreens, and Walmart for under $35.00 per pack. Considering this medication is a spironolactone analog, it has the potential to cause hyperkalemia so serum potassium levels should be monitored. To ensure efficiency and safety, all medications should be checked for possible adverse interactions, even herbs and vitamins. I would make sure Emily understands that she is not to take any new medications without approval. Carey, M.S., & Allen, R.H. (2012). Non-contraceptive use and benefits of combined oral contraception. Obstetrician & Gynaecologist, 14(4), 223-228. Edmunds, M. W., & Mayhew, M. S. (2013). Pharmacology for the primary care provider (4th ed.). Retrieved from Epocrates (2017). Epocrates, Inc. (Version 17.5.2) [Mobile application software]. Martin, K. & Barbieri, R. (2016). Overview of the use of estrogen-progestin contraceptives. UpToDate. Retrieved from PDR (2017). PDR, LLC. (Version , A: 2.0.4.0) [Mobile application software] PART 3: Emily subsequently returns to your clinic 5 months later, and decides to inform you that within the first 3 months after treatment, she struggled with a severe bout of depression. Instead of returning to your clinic to be prescribed, yet another pharmaceutical, she consulted her herbalist who told her about the anti-depressant, over-the-counter, herbal formulation, St. John’s Wort. She decided to begin taking St. John’s Wort in conjunction with her prescribed oral contraceptive medication, and she has now reappeared at your clinic because she is pregnant, and is distraught about how this occurred since she took her oral contraceptive compliantly since its prescription. • Why then, is she pregnant? • Please include detailed pharmacological mechanisms of how this occurred, and your subsequent steps in her management. One of the precautions to consider when prescribing drospirenone/ethinyl estradiol is depression. Exogenous hormones can exacerbate depression; therefore women who have a history of depression should be monitored carefully while taking them (PDR, 2017). It is important that patients understand certain medications can decrease the effectiveness of this OC (Bayer Healthcare, 2015). Per Bayer Healthcare and the FDA, St. John’s Wort (SJW) causes activation of cytochrome P450 (hepatic enzymes) and the p-glycoprotein transporter, which can alter the effectiveness of OCs (Bayer Healthcare, 2010). Concurrent use of OCs and SJW can also cause breakthrough bleeding (Bayer Healthcare, 2010). The exact mechanism of action for SJW is still being debated. The active ingredient Hypericin is the standard marker for drug processing (PDR, 2017). However, it seems that hypericin needs to be used in conjunction with naphthodianthrones, hyperforin, and flavonoids to produce antidepressant effects (PDR, 2017). Ultimately, researchers believe effective antidepressant results are related to the combination of multiple neurotransmitters and steroid hormones (PDR, 2017). SJW activates the cytochrome P450 (CYP) 3 A4 enzyme (Berry-Bibee, Kim, Tepper, Riley, & Curtis, 2016). Both components of COCs are substrates of CYP3A4; because of this, pharmacodynamic and pharmacokinetic interactions can occur, interactions that can cause decrease effectiveness of other medication (Berry-Bibee, Kim, Tepper, Riley, & Curtis, 2016). To manage her care, first I would discontinue the OC and SJW, as well as review all other medications for teratogenic effects. I would obtain the date of her last menstrual period plus revisit gravida para and abortions. A PHQ-9 depression questionnaire would be documented to assess the severity of Emily’s depression. Security at home would also be addressed to rule out any domestic violence concerns. Emily would be instructed to comply with cessation of smoking and alcohol consumption. Lab work would be ordered, including an obstetric panel, CMP, TSH, HbgA1C, and UA with HCG quantitation. The obstetric panel includes a CBC with diff, antibody screen, RBC with reflex to identification, titer, antigen typing, ABO group and Rh typing, RPR with reflex to titer and confirmatory testing, hepatitis B surface antigen with reflex confirmation, and a rubella virus IgG antibody (Quest Diagnostics, 2017). Finally, I would start Emily on prenatal vitamins and refer her to an OB/GYN for evaluation and continued follow up. Bayer Healthcare Pharmaceuticals, Inc. (2010). Drospirenone and ethinyl estradiol. Retrieved from Bayer Healthcare Pharmaceuticals, Inc. (2015). Highlights of prescribing information. Retrieved from Berry-Bibee, E. N., Kim, M., Tepper, N.K., Riley, H. M., & Curtis, K. M. (2016). Co-administration of st. john’s wort and hormonal contraceptives: A systematic review. Contraception, 94(6), 668-677. PDR (2017). PDR, LLC. (Version , A: 2.0.4.0) [Mobile application software] Quest Diagnostics Inc. (2017). Obstetric panel. Retrieved from PEER: Hi Jessica! Great post! I agree that drospirenone/ethinyl estradiol is the appropriate course of treatment. Spironolactone is an androgen-receptor antagonist that can be used as an additional treatment method for PCOS, especially for those who suffer from serious hirsutism and acne (Solomon, McCartney, & Marshall, 2016). Drospirenone, which is the progestin in this COC, is a spironolactone analog that has antimineralocorticoid and antiandrogenic properties (Epocrates, 2017). Drospirenone/ethinyl estradiol is definitely the best choice for Emily since she wants one medication that can alleviate her symptoms and also provide protection against pregnancy. Even though unlikely at this dose, because drospirenone is a spironolactone analog it has the potential of causing hyperkalemia. Potassium levels should be obtained during the first month of treatment and as clinically indicated during the course of taking it. Patients should be educated on the symptoms of hyperkalemia. COCs can also increase LDH and triglycerides so alternative treatment methods should be explored for patients with or at risk for dyslipidemia (PDR, 2017). Epocrates (2017). Epocrates, Inc. (Version 17.5.2) [Mobile application software]. PDR (2017). PDR, LLC. (Version , A: 2.0.4.0) [Mobile application software] Solomon, C., McCartney, C., & Marshall, J. (2016). Polycystic ovary syndrome. The New England Journal of Medicine, (375.1)54-64. Retrieved from INSTRUCTOR: Hi Whitney, I agree with your reasoning behind why potassium levels should be checked routinely--how often would this be? If you found that she was hyperkalemic, what would be your next course of action? Hi Dr. Chotibut, Patients put on drospirenone/ethinyl estradiol should have their potassium levels checked within the first month of beginning the medication. Patients should be educated on the signs and symptoms of hyperkalemia, which include muscle weakness or paralysis, cardiovascular abnormalities including chest pain and extremity numbness, and persistent leg pain. If Emily was found to be hyperkalemic, the treatment plan would depend on the severity of the potassium level and if or what symptoms Emily was exhibiting. Considering the dose of drospirenone is low, if Emily had any issues they would most likely be mild. If she was mildly to moderately hyperkalemic I would stop the medication and repeat lab work in 2 to 3 days. I would also check to make sure she had not started taking any new medications that could increase potassium levels such as NSAIDS (Bayer, 2013). When her levels returned to normal I would start her on a new OC, such as one containing levonorgestrel instead of drospirenone (Bird et al., 2011). Levonorgestrel has not shown to affect potassium levels because it is a second generation OC (Bird et al., 2011). According to Plovanich, Weng, & Mostaghimi (2015), monitoring potassium levels routinely are not necessary if the patient is healthy. This idea stems from research spanning over 14 years that shows hyperkalemia rates from patients taking spironolactone for acne is insignificant and may not be worth the costs associated with frequent monitoring (Plovanich, Weng, & Mostaghimi, 2015). This makes sense because, as I mentioned before, the dose is low comparatively speaking. Thorough and accurate education on the symptoms of hyperkalemia should be acceptable for the portion of the population that does not have predetermined risk factors. Bayer (2013). Yaz prescribing information. Retrieved from Bird, S., Pepe, S., Etminan, M., Liu, X., Brophy, J., & Delaney, J. (2011). The association between drospireone and hyperkalemia: A comparative-safety study. BMC Clinical Pharmacology, 11(23). doi: 10.1186/. Retrieved from Plovanich, M., Weng, Q., & Mostaghimi, A. (2015). Low usefulness of potassium monitoring among healthy young women taking spironolactone for acne. Jama Dermatology, 151(9) 941-944. doi:10.1001/jamadermatol.2015.34. Retrieved from QUIZ: A patient who has chronic pain and who takes oxycodone (Percodan) calls the clinic to ask for a refill of the medication. The primary care NP notes that the medication refill is not due for 2 weeks. The patient tells the NP that the refill is needed because he is going out of town. The NP should: review the patient’s chart to see if this is a one-time or repeat occurrence. A patient takes a cardiac medication that has a very narrow therapeutic range. The primary care NP learns that the particular brand the patient is taking is no longer covered by the patient’s medical plan. The NP knows that the bioavailability of the drug varies from brand to brand. The NP should: contact the insurance provider to explain why this particular formulation is necessary. A man who has secondary hypogonadism associated with pituitary dysfunction will begin exogenous testosterone therapy. The patient asks the primary care NP about future chances of fathering children. The NP should tell him that: Fertility may improve with testosterone therapy. A patient has recurrent symptoms and tells the primary care NP that she can’t remember to take her medication all the time. The NP should: ask her about her lifestyle, her schedule, and her understanding of her condition A patient is diagnosed with lupus and reports occasional use of herbal supplements. The primary care NP should caution this patient to avoid: echinacea. The primary care NP sees a woman who has been taking HT for menopausal symptoms for 3 years. The NP decreases the dosage, and several weeks later, the woman calls to report having several hot flashes each day. The NP should: increase the HT dose A patient bursts into tears when the primary care NP diagnoses diabetes. The NP should: ask the patient about past experiences with anyone who has this diagnosis. . A patient comes to the clinic to discuss weight loss. The primary care NP notes a BMI of 32 and performs a health risk assessment that reveals no obesity-related risk factors. The NP should recommend: changes in diet and exercise along with short-term phentermine A primary care NP wishes to order a drug that will be effective immediately after administration of the drug. Which route should the NP choose? SL. The primary care NP has referred a child who has significant gastrointestinal reflux disease to a specialist for consideration for a fundoplication and gastrostomy tube placement. The child’s weight is 80% of what is recommended for age, and a recent swallow study revealed significant risk for aspiration. The child’s parents do not want the procedure. The NP should: initiate a discussion with the parents about the potential outcomes of each possible action. A primary care NP prescribes a COCP for a woman who is taking them for the first time. After teaching, the woman should correctly state the need for using a backup form of contraception if she: is having vomiting or diarrhea. A patient who is newly diagnosed with hypertension is to begin taking two antihypertensive medications. The primary care NP gives the patient written drug information and starts to discuss medication side effects. The patient interrupts and says, “I don’t want to know all that. Just tell me what to take and when.” The NP should: ask the patient about previous experiences with medication side effects. A 55-year-old woman has not had menstrual periods for 5 years and tells the primary care nurse practitioner (NP) that she is having increasingly frequent vasomotor symptoms. She has no family history or risk factors for coronary heart disease (CHD) or breast cancer but is concerned about these side effects of hormone therapy (HT). The NP should: tell her that starting HT now may reduce her risk of breast cancer. The current trend toward transitioning NP programs to the doctoral level will mean that: NPs will be better prepared to meet emerging health care needs of patients. A patient asks a primary care nurse practitioner (NP) about using over-the-counter medications to treat an upper respiratory infection with symptoms of cough, fever, and nasal congestion. The NP should: suggest using single-ingredient products to treat each symptom separately. A patient who takes warfarin (Coumadin) experiences excessive bleeding, even though serum drug levels are normal. The primary care NP should question this patient about the use of: ginkgo biloba. An important difference between physician assistants (PAs) and NPs is PAs: always work under physician supervision. A woman who began taking a COCP 2 months ago calls the primary care NP to report having nausea every day. She takes a pill at the same time each morning. The NP should tell her to: try taking the pill in the evening each day. A patient is taking drug A and drug B. The primary care NP notes increased effects of drug B. The NP should suspect that in this case drug A is a cytochrome P450 (CYP450) enzyme: inhibitor.  If drug A is a CYP450 enzyme inhibitor, it decreases the capacity of the enzyme to metabolize drug B, causing more of drug B to be available. A substrate is a drug acted on by the enzyme. If drug B is an enzyme inducer, it would cause increased metabolism of drug A. A postpartum woman will begin taking the minipill while she is nursing her infant. T