Deakin University HNN215: Quality Use of Medicines Case Study Analysis

This case study analyzes the medication management of Ms. Candice Tong, a 56-year-old female admitted to Deakin Hospital with upper abdominal pain, nausea, and vomiting, and a history of hypertension, hyperlipidemia, and depression. The assignment identifies and discusses two key issues related to the quality use of medicines: hypotension and contraindication, considering the patient's medication regime, including Clarithromycin, Ramipril, Felodipine, Atorvastatin, Esomeprazole, Ibuprofen, and Citalopram. The analysis explores the risks associated with these medications, such as drug interactions and adverse drug reactions, particularly the risk of hypotension due to multiple anti-hypertensive drugs, and the potential for relative contraindications. The study further presents strategies for preventing hypotension, including monitoring vital signs and advising the patient on lifestyle modifications, and strategies for preventing contraindications through medication reconciliation and proper drug administration practices. The case study also examines the interactions between Ibuprofen and other medications, including SSRIs and Ramipril, and provides advice on the safe use of over-the-counter medications, emphasizing the importance of patient education and awareness of potential risks. The student provides detailed references to support the analysis.

Running head: QUALITY USE OF MEDICINES
QUALITY USE OF MEDICINES
Name of the Student
Name of the University
Author’s Note:

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Answer to Question Number 1:
In this scenario, two issues related to the quality use of medicines have been identified
and they are 'Hypotension' and 'Contraindication’. Hence, these two issues will be discussed
in the following sections.
Hypotension:
One of the significant risks for Ms Tong is Hypotension. Ms Tong is taking
'Clarithromycin', 'Ramipril', 'Felodipine', and 'Atorvastatin'. All of these drugs have a side
effect of hypotension. Ms Tong had a history of hypertension, and at present, her blood
pressure (BP) is 100/60 and therefore, administration of multiple anti-hypertensive medicines
poses a significant risk of hypotension. Investigators have discovered Clarithromycin to be
related to the increasing danger of hypotension or shock (Henneman & Thornby, 2012).
Additionally, ‘Ramipril’, and 'Felodipine' also increase the risk of hypotension. Statins are
both less systolic and more diastolic and have an impact on pre-hypertension patients, normal
blood pressure, and people not reducing BP (You et al., 2017). Some tiny trials have explored
the anti-hypertensive impacts of statins on BP in patients, which indicate comparatively tiny
but clinically significant decelerating impacts. In a meta-analysis of Briasoulis et al. (2013)
proposed the decrease in systolic BP in patients receiving statins to be minor but statistically
important.
Adverse drug reaction or Contraindication:
Contraindication is referred to as a particular situation in which a procedure, surgery,
or drug should not be used because of the adverse health reaction it presents (Fugate &
Rabinstein, 2015). Contraindication can be divided in to two subcategory which are relative
and absolute Contraindication. Relative Contraindication is the situation when caution should
be taken while prescribing or administering two or more drugs. On the other hand, absolute

2QUALITY USE OF MEDICINES
Contraindication can be referring to the case when a substance or event has a life-threatening
implication (Fugate & Rabinstein, 2015). Ms Tong has a significant risk of suffering from
relative Contraindication. Ms Tong has been prescribed with both 'Clarithromycin' and
'Atorvastatin'. Studies have reported that the co-administration of Clarithromycin with statins
(HMG-CoA reductase inhibitors) (Hirota & Ieiri, 2015) have the adverse side effects of
muscle disease like myopathy and muscle tissue destruction (Li et al., 2015). Thus, Ms Tong
has a significant risk of relative Contraindication.
In addition to this, Ms Tong was also prescribed with 'Esomeprazole'. It has been
reported that certain drugs raise the side effects of the esomeprazole. Clarithromycin is one of
those drugs and it raises the side effects of esomeprazole (Eljaaly, Alshehri, Bhattacharjee,
Al-Tawfiq, & Patanwala, 2019). In this case, Ms Tong also might suffer from the case study
of relative Contraindication.
Answer to Question Number 2:
Strategies for the prevention of 'Hypotension’:
 Evaluate the ABCDE strategy for patients. Monitor essential signs, full EWS charts in
accordance with local procedures and make sure that senior assistance is called if
necessary. The frequency of EWS findings should be modified according to local
protocols for each patient (Ren et al., 2017).
 Regular monitoring of vital signs of the patient’s average blood pressure level. It
should be greater than 100 mm Hg of systolic blood pressure (Thomopoulos, Parati &
Zanchetti, 2017).

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 Make sure the patient is clear and able to breathe; use a mask with a non – rebreathing
bag and elevated flow of oxygen at high concentrations of oxygen (Figueroa, Basford
& Low, 2010).
 Take care of the patients by raising their legs by tilting their bed may be useful to
boost cerebral perfusion (de la Torre, 2016).
 Ms Tong will be advised to partake in daily physical activity or exercise to increase
her BP. She will also be advised to change her position slowly at home as she might
feel dizzy while standing up quickly from sitting position. She will also be advised
drinking an adequate amount of liquid in the morning before a meal as it will help to
raise her BP (Ricci, De Caterina & Fedorowski, 2015).
Strategies for the prevention of 'Contraindication':
Many adverse drug reactions do not endanger life but interfere with everyday life, e.g.
back pain or joint pain. Instead of retaining data, it is suggested that patients are frequently
monitored using structured profiles by their nurses for any possible adverse drug reactions.
Then suitable professionals can address the problems identified (O’connor et al., 2016).
Nurses should always assure that institutional policies relating to the transcription of
medicinal drugs are followed. Transcription of medication as prescribed is not sufficient, but
the right dosage, right pathway, and time to the right medicines are prescribed for the proper
patient. Institutions must have medication reconciliation processes in place when a patient is
transferred from one organization to another or from one unit to another in the same
organization (Saw et al., 2016). The nurse should check each medicine for the right patient;
right drugs; proper dosages; right routes; and the right time as mention in prescription. The
health care providers should compare it to the Medication Administration Record (MAR). It
involves the correct labelling of medicinal products, readable documents or the accurate
recording of medicines. Any medicines not properly documented can lead to a mistake.

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Taking 10-20 minutes to note the reported symptoms of the patients alleviates
underreporting, promotes common decision making and detects issues worthy of attention
irrespective of aetiology. With little proof of possible adverse drug reactions, an inclusive
strategy to tracking future issues encourages an increase in health optimization (O’connor et
al., 2016).
Answer to Question Number 3 (a):
Administration of Ibuprofen tablets might enhance the incidence of a cardiovascular
event (Kim et al., 2016). The reaction to these therapies may be impaired for patients with
thiazides or diuretic loops when taking Non-steroidal anti-inflammatory drugs (NSAIDs) like
Ibuprofen. From the case study, it can be seen that Ms Tong has been taking Ibuprofen. In
hypertension, patients NSAIDs, including tablets of Ibuprofen, should be used with caution
(Albishri, 2019). The combined use of Selective serotonin reuptake inhibitors (SSRIs) and
NSAIDs could improve the threat of infection, even upper gastrointestinal (GI) bleeding. Ms
Tong has been prescribed with Citalopram in this scenario. The combined use of SSRIs and
NSAIDs may be increased (Anglin et al., 2014). In addition, NSAIDs inhibit prostaglandin
development and impair gastric mucous defence. A cohort study in over 26,000 patients
showed that the risk for severe GI bleeding by SSRI alone was increased by 3.6 times, while
the risk of SSRI was increased by over 12.2 times in combination with NSAIDs (Saleh et al.,
2014). Moreover, Ms Tong has been prescribed with Ramipril and Esomeprazole and
administration of Ramipril and Esomeprazole while taking ibuprofen leads to delay in the
recovery process of the ulcers and the GI bleeding. Avoid using Ibuprofen in conjunction
with any other NSAIDs, such as inhibitors of COX-2, for the risk of severe NSAID toxicities
such as GI bleeding, GI perforation, or peptic ulcer (Vostinaru, 2017).

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St John's Wort increases the brain chemicals called serotonin. Taking John's Wort,
together with these depression medicines, can lead to excessive serotonin and severe side
effects such as heart trouble, shivering, and fear (Apaydin et al., 2016). St John's Wort is not
to be used with psychoactive or psychotropic medicines because of the increased risk of
negative impacts. In this scenario, Ms Tong has been prescribed with antidepressant
'Citalopram’ (Hoban, Byard, & Musgrave, 2015). Very little proof of pharmacodynamic
interactions is currently available. However, there is a significant potential for severe adverse
reactions because of the extensive use of these products. These interactions must, therefore,
also be taken into account as prospective safety risks (Maher et al., 2016).
Answer to Question Number 3 (b):
Due to the elevated incidence of use of OTC, doctors should be aware of OTC trends and
hazards linked to improper use of and storage of OTC medicinal products. Nurses need to be
involved in prevention attempts, treatment mistakes, misuse of OTC drugs and unattended
paediatric ingestion (American College of Preventive Medicine, 2011). Following critical
points need to be advised to Ms Tong:
 Discuss the prospective hazards of OTC drugs revealed during history taking with
patients. Read the full package label each time a dose is taken and follow its
directions. Pay attention, especially to the active substances on the name to avoid
using too much of the same active ingredient if you are taking more than one
medication (American College of Preventive Medicine, 2011). Education about OTC
medication handling and storage for parents and caregivers. Some products have a
single symptom, and others have various symptoms (e.g. headache, cough, and
blocked nose, cold medications which treat headache). "More" does not necessarily
imply better if the medication does not address circumstances. Choose a drug treating

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a particular symptom. All OTC medications can produce side effects or responses,
like prescription medicines (Makary & Daniel, 2016). Ms Tong should check the label
to see what is to be avoided in an OTC medication.
 Nurses should inform Ms Tong to put the whole container away after every use and to
leave it out of sight. To discard drugs, remove them from the containers and placed
them in a disposable container with a lid or a screened bag before placing them in the
garbage (American College of Preventive Medicine, 2011). There are many OTC
drugs with the same active substances, which imply that Ms Tong can get higher than
the recommended dose without even knowing it. Take more than one OTC
medication at the moment should be consumed by always comparing active
ingredients.
 The pharmacokinetic interactions recognized to date all indicate that SJW's
constituents induce a number of drug enzymes, but they also convey proteins such as
P-glycoprotein. It is therefore crucial that people who need a prescription medication
or have an adverse reaction be questioned for the use of over-the-counter medicines,
including herbal remedies. To obtain data on its security, it is also essential to report
all suspected negative responses and interactions with herbal remedies (Qato, Wilder,
Schumm, Gillet, & Alexander, 2016).

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American College of Preventive Medicine. (2011). Over-the-counter medications: use in
general and special populations, therapeutic errors, misuse, storage and disposal.
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Anglin, R., Yuan, Y., Moayyedi, P., Tse, F., Armstrong, D., &Leontiadis, G. I. (2014). Risk
of upper gastrointestinal bleeding with selective serotonin reuptake inhibitors with or
without concurrent non-steroidal anti-inflammatory use: A systematic review and
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Apaydin, E. A., Maher, A. R., Shanman, R., Booth, M. S., Miles, J. N., Sorbero, M. E.,
&Hempel, S. (2016). A systematic review of St. John’s wort for major depressive
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and Infection, 25(5), 620–622.

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Figueroa, J. J., Basford, J. R., & Low, P. A. (2010). Preventing and treating orthostatic
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