Number 1 Post: BW

The medication regimen for Eric Johnson will require multiple drugs to treat the patient's illnesses. The patient's diagnoses are pneumonia, chlamydia, and seasonal allergies. 

Q1. What are the recommended medications to start this specific patient on? Please provide the drug class, generic & trade name, and the initial starting dose. 

For this specific patient, the medication of choice to treat chlamydia and pneumonia will be doxycycline (Vibramycin) and loratadine (Claritin) for seasonal allergies. The dose schedule for doxycycline (Vibramycin) will be 100mg PO twice daily for seven days (Rosenthal et al., 2021, p. 764). For the patient's seasonal allergies, loratadine (Claritin) 10 mg will be taken PO every day for allergy relief. 

Q2. Discuss the mechanism of action of each of the drugs.

The reasoning to choose doxycycline over azithromycin for the treatment of the patient's chlamydia is that there can be better effectiveness with the doxycycline than the azithromycin. The mechanism of action of doxycycline is done by inhibiting protein synthesis. According to Mizushima et al., (2021) "The treatment with doxycycline 100 mg twice daily for 7 days was superior to that with azithromycin 1 g (para. 4). Doxycycline is a long-acting tetracycline. According to Rosenthal et al., (2021) "The tetracyclines suppress bacterial growth by inhibiting protein synthesis" (p. 676). The way that doxycycline inhibits protein synthesis is by binding to the 30S ribosomal subunit which inhibits transfer RNA to the messenger RNA-ribosome complex in the bacterial cell (Rosenthal et al., 2021, p. 676). 

The reasoning behind prescribing loratadine (Claritin) to this patient is to help the patient have relief of symptoms without the sedating effects of other antihistamines. According to Sighu & Akhondi (2021) "Loratadine selectively inhibits H1-receptors primarily located on respiratory smooth muscle cells, vascular endothelial cells, the gastrointestinal tract, and immune cells" (para. 4). This allows loratadine to manage allergic rhinitis and urticaria without the sedating effects of first-generation antihistamines.  

Q3. Discuss the side effect profile of each medication you listed. 

With doxycycline, there are multiple side effects that the patient will need to be taught. Doxycycline can cause hepatotoxicity and gastrointestinal irritation. The irritation of the GI tract can cause nausea, vomiting, diarrhea, and possibly esophageal ulcers (Rosenthal et al., 2021, p. 677). 

With loratadine, the side effects are rare but may include "headaches, dizziness, and GI distress" (Sidhu & Akhondi, 2021, para. 10). While it is rare, there is the potential for lethargy with the use of loratadine. For this purpose, the patient must know not to take any other CNS depressant medications that could affect the patient's lethargy (Sidhu & Akhondi, 2021).  

Q4. Are there any interactions between any of the medications you prescribed?

There are no known drug interactions between loratadine and doxycycline. Loratadine should not be taken with alcohol or other CNS depressant medications such as narcotics and barbiturates (Rosenthal et al., 2021). Doxycycline should not be used with antacids and magnesium laxatives because of nonabsorbable chelates with metal ions and doxycycline (Rosenthal et al., 2021). Doxycycline should also not be given with digoxin or warfarin because of increased GI absorption that increases INR levels and increased digoxin levels (Rosenthal et al., 2021). 

Q5. What other non-pharmacological interventions would be suggested?

The patient will need to rest and drink fluids while the doxycycline combats pneumonia and chlamydia. For the patient's fever, the patient will be educated on the use of acetaminophen (Tylenol) for fever reduction. The patient should be told to not consume more than 4000 mg of acetaminophen per 24 hour period to reduce liver toxicity (Rosenthal et al., 2021, p. 502). One suggestion of a non-pharmacological intervention for the treatment of the patient's allergies will be to include the use of local honey for the treatment of the patient's seasonal allergies. In a study performed by Munstedt & Manle (2020), it was found that the use of local honey can relieve seasonal allergic rhinitis. According to Munstedt & Manle (2020) "Another cohort study of 23 patients showed that after regular consumption of local honey 12 patients (52.2%) were free of complaints after treatment while in nine patients (39.1%) the situation improved considerably" (p.584). While the patient has already been tested for chlamydia, it will be important to educate this patient on talking with his sexual partner and to potentially treat the partner as well. McDonagh et al., (2020) explain, "A recent review identified patient barriers to testing including lack of knowledge, perceived low risk, embarrassment, fear and stigma and facilitators including increased awareness and self-sampling" (p. 571). This patient should be educated on the potential risks of not treating this infection and how to not be reinfected with the disease in the future.  

Number 2 Post: JZ

For this week’s case study, we are reviewing a case of a 21-year-old male, with a history of seasonal allergies, who comes into the clinic with complaints of a stuffy nose, shortness of breath, fever 102 at home, a productive cough, and urinary burning with clear penile discharge. He admits to unprotected sex. His current vital signs are BP 125/75, HR 116, Temp. 102.5, O2 94%. He has no known drug allergies. After a clinic workup with rapid testing and a chest x-ray, he is diagnosed with pneumonia, chlamydia, and seasonal allergies.

The recommended medications to start this patient on depending on the patient’s comorbidities and risk factors. Being a young adult, with no known chronic health conditions other than seasonal allergies, an oral antibiotic for his pneumonia treated in the outpatient setting could be used at this time. For healthy patients who are appropriate for outpatient treatment, the recommended first-line treatment is with a macrolide class medication such as azithromycin (Zithromax) targeting the most common causal pathogen S. pneumoniae (Grief & Loza, 2018). Azithromycin is an antibiotic, which is available in 250 mg, 500 mg, or 600 mg tablet forms. For mild community-acquired pneumonia, 500 mg PO as a single dose on day 1, then 250 mg PO on days 2-5, with a total dose of 1.5 g (Lippincott Williams & Wilkins, 2021). Azithromycin binds to the 23S portion of the 50S bacterial ribosomal subunit. It inhibits bacterial protein synthesis by preventing the transit of aminoacyl-tRNA and the growing protein through the ribosome (Iqbal, 2022). Side effects include liver concerns and GI issues – nausea, vomiting, diarrhea, jaundice, and clay-colored stools.

Moreover, to treat this patient’s chlamydia, doxycycline (Oracea) could be given, which is an antibiotic that is from the tetracycline class. Oral tablets are available in 50 mg, 75 mg, 100 mg, or 150 mg tablets. Dose for adults and children aged 8 and weighing 45 kg or more is 100 or 120 mg PO every 12 hours on day 1, then 100 or 120 mg PO daily as a single dose or in two divided doses (Lippincott Williams & Wilkins, 2021). The bacteriostatic action of tetracyclines, like doxycycline, is intended to stop the growth of bacteria by allosterically binding to the 30S prokaryotic ribosomal unit during protein synthesis (Patel & Parnar, 2022). Side effects include GI issues – nausea, vomiting, diarrhea, bloating, constipation, clay-colored stool, hives, and itching, among others.

For this patient’s seasonal allergies, he complains of a stuffy nose and cannot remember what he formerly used for his allergies. As a practitioner, I would call the patient’s pharmacy or check with his doctor if it formerly provided the patient with relief. I would use caution in recommending medication as Sudafed as this medication could raise his heart rate further, and due to the fever, he already has an elevated heart rate. He could try fluticasone (Flonase) which is of the corticosteroid class. The patient can initially use 2 sprays (100 mcg) in each nostril once daily, as needed for symptom control (Lippincott Williams & Wilkins, 2021). Fluticasone is a steroid that works to reduce the chemical causes of inflammation, decreasing swelling in the nasal passages. Side effects include hypersensitivity reactions such as facial swelling, itching, and skin rash.

For his fever, acetaminophen (Tylenol) could be used at home. Controlling his fever could also reduce his heart rate once his temperature is controlled. Acetaminophen is an analgesic of the para-aminophenol derivative class, which can also be used for mild pain. The adult dose is 325-650 mg PO every 4-6 hours. Acetaminophen inhibits the synthesis of prostaglandins in the central nervous system, leading to its analgesic and antipyretic effects (Anderson & Nappe, 2021). Side effects include liver injury or failure, as well as skin or allergic reactions.

For the drugs described, it is important for the practitioner to note that azithromycin when taken with acetaminophen can cause a drug interaction. It slows the metabolism of acetaminophen. So, caution needs to be used in treating this patient’s fever. As an alternative, Ibuprofen or Motrin can be used as well. With doxycycline, a drug interaction can occur when taking doxycycline and penicillin together. It decreases the bactericidal action of penicillin. Drugs such as warfarin can decrease the action of acetaminophen. So, it is important for the practitioner to fully assess and reconcile the patient’s medications to avoid such interactions.

Non-pharmacological therapies that could be recommended could be for the patient to use a humidifier to help his nasal congestion, drink plenty of fluids, and to wear a condom during sexual intercourse. Education could benefit this patient, especially on symptoms of Sexually Transmitted Diseases and how to prevent the spread. If the patient continues to have seasonal allergies, seeing an Allergist could help. If the patient has not seen a specialist for his allergies, and just his Primary Care Physician – placing a referral could assist as well. All of these actions could help this patient work towards improved health.