NR565 Week 2 Discussion Drug Management Overview

Gertrude Green, a 73-year-old lady with a history of atrial fibrillation, presents to the clinic. She hopes to have another option rather than warfarin (Coumadin) because she does not like the fact that she must check her INR regularly. She is on warfarin 5 mg every day, diltiazem 120 mg twice daily, and sitagliptin 50 mg every day currently. She has type 2 diabetes mellitus, hypertension, and moderate renal insufficiency, which is indicated by an eGFR between 30 and 45mL/min/1.73m2 and a creatinine clearance. She is stable with a BP of 136/81 mmHg and a HR of 91 while in AF rhythm. She is not allergic to any drugs and is leading a healthy life, with no smoking or drinking alcohol.

Clinical Practice Guideline Assessment

The 2024 ACC/AHA/HRS guidelines state that the use of DOAC over warfarin is preferred in stroke prevention in non-valvular AF patients who do not want to have their INR monitored regularly. With DOACs such as apixaban, dabigatran, rivaroxaban, and edoxaban, the patient does not need to make major changes to his dietary habits, as these medications have fixed doses (Chen et al., 2020). The patient’s kidney function should be evaluated before prescribing these agents. If the patient has a creatinine clearance of 15 to 30 mL/min, then apixaban is the preferred choice because of its safer profile and lower risk of bleeding compared to warfarin.

Professional Assessment and Pharmacological Plan

Because of Ms. Green’s moderate kidney problems, apixaban is the perfect DOA for her. She should be prescribed apixaban 2.5 mg twice a day because of her renal function. Memon et al (2022) explain that apixaban prevents strokes better and has fewer major bleeding risks in elderly patients with renal insufficiency than warfarin does. It is important to switch from warfarin to apixaban at the right time to reduce the risk of clots or bleeding. Apixaban may be started at an INR less than 2.0. It is important to check her renal function regularly, at least once a year, or more frequently if there is a change in her kidney function.

Additional Considerations

It is important to go over Ms. Green’s list of medications before starting apixaban because some medications may interact with apixaban and raise its levels, such as diltiazem. It is important to explain adherence, bleeding symptoms, and follow-up visits to Ms. Green (Aremu et al., 2022). Discussing healthy eating and physical activity may also help reduce her risk of cardiovascular events. In short, a switch to apixaban for Ms Green is in accordance with the guidelines and allows her to avoid regular INR monitoring. This is a decision that keeps her safe from both strokes and excessive bleeding, which aids her quality of life.

Related discussion for your help: NR 565 Week 1