Therapeutic Strategy for Atrial Fibrillation Assignment Sample

Section 1: Practice

Afib (atrial fibrillation) can be denoted by the process of an irregular heart rhythm which formulates within the upper chambers (atria) of a person’s heart. The proper functioning of an individual’s heart and its electrical operations does not operate properly. The steady and regular pattern of heart’s electrical impulses does not happen in this condition, instead an unsteady and irregular pattern observed among patients 6. In this study, the case study of an Afib patient has been analysed which discusses the most appropriate medication recommendation for the patient. This case study holds the data of a 73 years old male patient of atrial fibrillation, Mr DH. He faced several challenges regarding increasing shortness of breath and palpitations every morning. While diagnostic tests have suggested that he is a patient of atrial fibrillation. The management strategy of this patient was selected as the Rhythm control strategy and assessed for anticoagulation. This particular section described the needed medications needed for this patient’s Afib management plan. Also, demonstrated the monitoring and patient support approaches appropriate for Mr DH.

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Intervention	Rationale	Medication recommendations	Monitoring	Patient support
Rhythm Control Planning	The formation of rhythm control practices are considered as a very significant intervention plan for Afib patients 6. Early control of Afib patients’ irregular heart rhythms can effectively decrease the risks of stroke and heart failure. In the case of Mr DH, the implementation of this particular strategy was done based on the purpose of restoring and maintaining sinus rhythm. The heart rate or rhythm control strategy, in this particular patient needs to be the first‑line treatment strategy.	The initial heart rate‑control monotherapy for Mr DH should include the offering of either a standard “beta‑blocker” or rate‑limiting “calcium‑channel blocker”. According to the NICE guidelines, sotalol becomes most effective for this patient as he is an older adult7. The initial dosage of sotalol for Mr. DH needs to be 80 mg oral tablets. It should be consumed orally and two times per day. In next stages it can be increased up to 320 mg per day.	The monitoring process of MR DH’s heart rhythm rates needs to be managed properly with some additional information. It was identified that the creatinine level of this patient is 142 micromol/l which suggests that sotalol should be prescribed for this patient on a daily basis7. The elevated rate of creatinine level means that monitoring of this patient's initial therapy needs to be controlled by regular tests of renal functions and QT interval tests.	MR DH should be aware of his situation and needs to understand all the medicine dosage properly to effectively manage self-administration of medicine.
Anticoagulation assessment	The second treatment plan of anticoagulation treatment also becomes vital for Afib older adults. This particular therapeutic procedure helps to prevent the risk of bleeding and stroke formation.	The direct‑acting oral anticoagulant Apixaban should be prescribed to the patient8. For the prevention of stroke and systemic embolism 2.5 mg of this drug daily needs to be consumed. According to the NICE guideline of anticoagulants, Apixaban in patients with age <70 years provide most effective benefits9.	The monitoring strategy needs to be conducted including renal function test and potassium levels checking process on a weekly basis.	The dosage level of medicines needs to be administered to MR DH for patient support.
Pre-existing Medications	The pre-existing medication of Mr DH includes Ramipril 5 mg at bedtime. The dosage can be changed based on his CKD1. While aspirin should be excluded from the prescription as it provides challenges to the anticoagulation treatment.	The dosage of ramipril needs to be reduced to 2.5 mg at bedtime.	Regular monitoring of glucose level needs to be done.	The changes in medicines needs to be stated to Mr DH.
Improvement in Lifestyle factors	For the improvement of Mr DH’s CKD, diabetes to increase quality of life, non-medicinal intervention provides most benefits.	Carbohydrate intake should be reduced. In addition, salt and smoking needs to be avoided.	Blood glucose test and BP test on a regular basis is needed.	To improve the lifestyle of Mr DH, the inclusion of family support will be very essential.

Table 1: Appropriate treatment practice for the patient

(Source: Self-created)

Section 2: Pharmaceutical Science

The Therapeutic Drug Monitoring (TDM) process may be equated with a set of tests that evaluate the concentration of specific drugs within a patient’s bloodstream. Contrary to this, not every medication administered by a doctor requires TDM. That’s why the assessed need of TDM is proposed by a physician in relation to other conditions of a body of a patient. In the case of Mr DH the patient data analysis also unveiled that his case includes the value of creatinine 142 micromol/l which means that it is above average². It finally proposes that he may have the Chronic Kidney Disease, CKD or what is abbreviated as the Chronic Kidney Disease. Contrary to this, the NICE guideline does not signify that a direct‑acting oral anticoagulant requires incorporation of a TDM method in instances where it transcends disorders for example, CKD, renal failure, etc. As a result, the analysis highlighted that the Direct‑Acting Oral Anticoagulant Apixaban must have another Therapeutic Drug Monitoring process.

According to Van der Linden et al. ¹, the development of new oral anticoagulants (NOACs) are previously done using methods which do not need the implementation of any types of therapeutic drug monitoring¹. However, it was identified that the presence of conditions such as CKD, renal failure, organ functioning issues such as Aifb requires an additional TDM practice. In this process, the requirement of plasma level assessments become very important for the case of Mr DH.

Section 3: Pharmacology

Rhythm Control Planning: Sotalol

Mechanism of Action

Sotalol medicine is referred to as a very vital beta blocker that assist in altering the signals of the human body primarily the heart. It has a handy role in preventing even more rise of the heart rate. This particular factor emerged as the leading cause of selecting the drug for an Afib patient Mr DH.

Pharmacokinetics

Sotalol drug is not metabolism in a human being unlike most other drugs in the market. The following examples of clinical research identified that between 80-90% of a particular dosage of sotalol is eliminated through the urine³. Furthermore, it was found that the half-life of this drug is 10 to 20 hours.

Potential cautions

The potential risk factors of this particular drug or any kind of beta-blocker drugs are connected with the patients with kidney failure^3. This drug is metabolised in a person’s body and removed through the urine. As for Mr DH, a kidney issue might be concern because this drug may accumulate in his system. 

Contra-indications

For the first time Afib patient, based on NICE guidelines it becomes very important for a beta blocker to be in place for the patient. After reading the high level of complexity related with breathing for Mr. DH, this drug was chosen for management therapy.

Anticoagulation Assessment: Apixaban

Mechanism of Action

It was identified that the drug apixaban only inhibits the factor Xa selectively. It was identified that the presence of its free and bound forms helps in the inhibition of antithrombin III Label⁴. It also helps in the inhibition process of prothrombinase Label. Ultimately it provides a prevention mechanism of thrombus formation.

Pharmacokinetics

The studies regarding apixaban’s pharmacokinetics characteristics have shown that this medicine absorbs rapidly within the human body. The maximum concentration of this drug includes 3 to 4 h after oral consumption. The half-life is approximately 12 h.

Potential cautions

The potential threats of this drug in a CKD patient are identified as risk of bleeding. According to the findings of an observational study, 5 mg apixaban increases the risks of bleeding by 1.6 times⁴.

Contra-indications

According to the investigations mentioned clinical, the dose of this particular anticoagulant apixaban for the patient Mr DH with CKD and diabetes is set to 2.5 mg per day. It will reduce on the side effect developed by the drug.

Exclusion of Aspirin

Mechanism of Action

With the help of the pharmacological description of aspirin, its active form was described as the suppressor of prostaglandins and thromboxanes⁵. The cyclooxygenase (COX) enzyme can be deactivated by this particular drug product. This particular enzyme attains a very critical status in the thromboxane synthesised during the operations of a human being. 

Pharmacokinetics

The pKa value of this individual compound was determined to be 3.5. In most of the cases, cases it is, found in the stomach of a human. The final metabolic phase includes the sort of the aspirin and its absorption in small part of the intestines.

Potential cautions

Since aspirin puts a halt to the COX enzyme in blood, the whole process of thromboxane synthesis inactivated⁵. It ultimately contradicts the activities of the drug apixaban prescribed in the case of Mr DH.

Contra-indications

Because of these reasons, this drug was removed from the existing medication list of Mr DH. Also, the removal of aspirin will increase the effects of the anticoagulating drugs prescribed to this patient.

Reference List

1. Angiolillo, D.J., Prats, J., Deliargyris, E.N., Schneider, D.J., Scheiman, J., Kimmelstiel, C., Steg, P.G., Alberts, M., Rosengart, T., Mehran, R. and Bhatt, D.L., 2022. Pharmacokinetic and pharmacodynamic profile of a novel phospholipid aspirin formulation. Clinical Pharmacokinetics, 61(4), pp.465-479.
2. Fang Z, Zhang H, Guo J, Guo J. Overview of therapeutic drug monitoring and clinical practice. Talanta. 2024 Jan 1;266:124996.
3. Frost C, Garonzik S, Shenker A, Barrett YC, LaCreta F. Apixaban single‐dose pharmacokinetics, bioavailability, renal clearance, and pharmacodynamics following intravenous and Oral administration. Clinical Pharmacology in Drug Development. 2021 Sep;10(9):974-84.
4. Making decisions using NICE guidelines | NICE guidelines | NICE guidance | Our programmes | What we do | About [Internet]. NICE. Available from: https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/making-decisions-using-nice-guidelines#prescribing-medicines
5. Mubarik A, Kerndt CC, Cassagnol M. Mechanism of Action.
6. National Institute For Health and Care Excellence. Chronic Heart Failure in adults: Diagnosis and Management | Guidance | NICE [Internet]. Nice.org.uk. NICE; 2018. Available from: https://www.nice.org.uk/guidance/ng106
7. Recommendations | Atrial fibrillation: diagnosis and management | Guidance | NICE [Internet]. www.nice.org.uk. 2021. Available from: https://www.nice.org.uk/guidance/ng196/chapter/Recommendations
8. Recommendations | Atrial fibrillation: diagnosis and management | Guidance | NICE [Internet]. www.nice.org.uk. 2021. Available from: https://www.nice.org.uk/guidance/ng196/chapter/recommendations#direct-acting-oral-anticoagulant-treatment-options
9. Van der Linden L, Hias J, Vanassche T. The value and limitations of new oral anticoagulant plasma level assessments. European Heart Journal Supplements. 2022 Feb 1;24(Supplement_A):A32-41.