NURS 6521 Week 7 Assignment Case Studies

Case Study

SCENARIO 1: Prescription Errors

1. acamprosate 666 mg take 2 tablets PO TID #1800 RF

• Errors
  • Excessive quantity (#1800 is too high for a 1-month supply)
  • Missing full drug name (should specify calcium salt form)
  • RF (refills) not clearly indicated—”RF” alone is vague
• Correct Prescription
  Acamprosate calcium 666 mg, take 2 tablets orally three times a day (TID), Disp: #180, Refills: 0
• Classification: GABA agonist/Glutamate antagonist
• MOA: Modulates glutamate and GABA neurotransmission to restore balance in alcohol dependence (Dharavath et al., 2023). 

2. lisdexamfetamine (Vyvanse) 30 mg PO QAM #30 1 RF

• • Errors
    • Missing duration (“#30” suggests 1-month supply, but needs clarification)
    • Full prescribing label should be more specific

• Correct Prescription
  Lisdexamfetamine dimesylate 30 mg, take 1 capsule orally every morning, Disp: #30, Refills: 1

• Classification: CNS stimulant
• MOA: Prodrug converted to dextroamphetamine; increases dopamine and norepinephrine in CNS (Couch et al., 2023).

3. naltrexone (Vivitrol) ER 380 mg IM inject once weekly #1 3 RF

• • Errors
    • Vivitrol is administered once monthly, not weekly
    • Dosing interval and quantity are incorrect
    • “#1” suggests one dose, not monthly therapy

• Correct Prescription
  Naltrexone extended-release (Vivitrol) 380 mg, inject 1 dose intramuscularly every 4 weeks into gluteal muscle, Disp: 1 dose per month, Refills: 3

• Classification: Opioid antagonist
• MOA: Blocks opioid receptors; reduces alcohol cravings and opioid effects (Tabanelli et al., 2023).

4. infliximab (Humira) 40 mg SQ inject every other week #2 1 RF

• • Errors
    • Humira is adalimumab, not infliximab
    • Infliximab is given IV, not SQ
    • Confusion between two separate biologics

• Correct Prescription (if meant Humira)
  Adalimumab (Humira) 40 mg/0.8 mL, inject subcutaneously every other week, Disp: #2 prefilled syringes, Refills: 1

• Classification: TNF-alpha inhibitor
• MOA: Blocks tumor necrosis factor (TNF) to reduce inflammation in autoimmune conditions (Jang et al., 2021).

5. colchicine 0.6 mg PO every 2 hours for acute gout flare #6 0 RF

• Errors
  • Toxic dosing—max is 1.8 mg/day (3 doses)
  • Lacks stop instructions (risk of toxicity)
• Correct Prescription
  Colchicine 0.6 mg, take 2 tablets at the first sign of flare, then 1 tablet in 1 hour, MAX 3 tablets in 24 hours, Disp: #6, Refills: 0
• Classification: Antigout agent
• MOA: Inhibits microtubule polymerization, reducing neutrophil activity and inflammation.

SCENARIO 2: ADHD, Depression, Anxiety, and Smoking Cessation

Recommended Medication: Bupropion SR

• Medication Order
  Bupropion SR 150 mg, take 1 tablet PO every morning for 3 days, then 1 tablet PO BID thereafter, Disp: #60, Refills: 0

• Monitoring
  • Mood changes, suicidal ideation
  • Seizure risk (especially in eating disorders or alcohol withdrawal)
  • Blood pressure (can cause HTN)
• Patient Counseling
  • Begin 1–2 weeks before quit date
  • May be combined with nicotine replacement
  • Do not crush or chew
  • Avoid alcohol or abrupt cessation of alcohol
• Answer: No, the patient does not need to quit smoking before starting bupropion. It’s initiated before the quit date to build up therapeutic levels (AHRQ, 2020).
• MOA: Inhibits norepinephrine and dopamine reuptake; antagonizes nicotinic acetylcholine receptors.

SCENARIO 3: Zolpidem + Depression/Insomnia

Zolpidem Half-Life Calculation

• 21:00 to 06:00 = 9 hours
• Half-life = 3 hours
• 9 hours = 3 half-lives →
  • 1st half: 10 → 5 mg
  • 2nd half: 5 → 2.5 mg
  • 3rd half: 2.5 → 1.25 mg
• Answer: Approx. 1.25 mg remains at 06:00

Antidepressant Options for Depression + Insomnia

1. Trazodone

• Order: Trazodone 50 mg PO at bedtime, Disp: #30, Refills: 1
• MOA: Serotonin antagonist and reuptake inhibitor; sedating at low doses
• Monitoring: Hypotension, priapism, sedation

2. Mirtazapine

• Order: Mirtazapine 15 mg PO at bedtime, Disp: #30, Refills: 1
• MOA: Central alpha-2 antagonist; increases NE and serotonin; antihistaminic sedative effect
• Monitoring: Weight gain, sedation, agranulocytosis (rare)

3. Doxepin (low-dose)

• Order: Doxepin 3 mg PO at bedtime, Disp: #30, Refills: 1
• MOA: TCA with selective histamine H1 antagonism at low doses
• Monitoring: Anticholinergic effects, ECG in elderly, sedation

SCENARIO 4: JL Medication Review

Current Medications

• Metformin 1000 mg daily
• Janumet 50/1000 mg BID
• Paroxetine 20 mg daily
• Venlafaxine ER 150 mg daily
• Buspirone 5 mg TID PRN
• Valacyclovir 500 mg daily
• Dicyclomine 10 mg QID PRN

Assessment/Actions

• Potential duplications:
  • Paroxetine + Venlafaxine = dual serotonergic agents (risk: serotonin syndrome)
  • Metformin + Janumet (Janumet already contains metformin)
• Discontinue
  • Paroxetine (due to interaction and duplication)
• Labs Needed
  • CBC, CMP, A1c, renal function, BP, thyroid panel
• Monitoring
  • Serotonin syndrome, dizziness, hypotension, blood glucose
• Possible Diagnoses (based on meds):

1. Type 2 Diabetes
2. Generalized Anxiety Disorder
3. Major Depressive Disorder
4. Recurrent Herpes Simplex Infection
5. Irritable Bowel Syndrome