Pharmacotherapy for a 31 Year-Old Male Presenting with Insomnia

PLEASE I WILL PREFER WRITER 1747 TO COMPLETE THIS ASSIGNMENT. PLEASE FOCUS ON THE RUBRIC. COPY AND PASTE THE LINK BELOW FOR THE CASE STUDY https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/DT/week_11/index.html The Assignment: 5 pages Examine Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes. At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Pharmacotherapy for a 31 Year-Old Male Presenting with Insomnia.  Be sure to research each option using the primary literature. RUBRICS 1)Introduction to the case (1 page) Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient. 2)Decision #1 (1 page) Which decision did you select? Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature). Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. 3)Decision #2 (1 page) Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature). Pharmacotherapy for a 31 Year-Old Male Presenting with Insomnia.  Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. 4)Decision #3 (1 page) Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature). Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. 5)Conclusion (1 page) Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature. Optional Learning Resources Required Readings (click to expand/reduce) American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 Fernandez-Mendoza, J., & Vgontzas, A. N. (2013). Insomnia and its impact on physical and mental health. Current Psychiatry Reports, 15(12), 418. https://doi.org/10.1007/s11920-012-0418-8 Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192.

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/ Morgenthaler, T. I., Kapur, V. K., Brown, T. M., Swick, T. J., Alessi, C., Aurora, R. N., Boehlecke, B., Chesson, A. L., Friedman, L., Maganti, R., Owens, J., Pancer, J., & Zak, R. (2007). Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. SLEEP, 30(12), 1705–1711. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_Narcolepsy.pdf Morgenthaler, T. I., Owens, J., Alessi, C., Boehlecke, B, Brown, T. M., Coleman, J., Friedman, L., Kapur, V. K., Lee-Chiong, T., Pancer, J., & Swick, T. J. (2006). Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. SLEEP, 29(1), 1277–1281. https://j2vjt3dnbra3ps7ll1clb4q2-. wpengine.netdna-ssl.com/wp-. Pharmacotherapy for a 31 Year-Old Male Presenting with Insomnia. content/uploads/2017/07/PP_NightWakingsChildren.pdf Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(2), 307–349. https://jcsm.aasm.org/doi/pdf/10.5664/jcsm.6470 Winkleman, J. W. (2015). Insomnia disorder. The New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/NEJMcp1412740

Insomnia is a psychiatric condition that is recognized in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders or DSM-5. It is grouped together with nine other similar disorders or disorder groups that are collectively under the diagnostic category referred to as ‘Sleep-Wake Disorders’. The other disorders in this diagnostic category apart from insomnia disorder include narcolepsy, non-rapid eye movement (NREM) sleep arousal disorders, restless legs syndrome, and hypersomnolence disorder amongst others (Sadock et al., 2015; APA, 2013). This case study is that of a 3 year-old male diagnosed with insomnia. His HPI states that he has had insomnia for the past 6 months and the condition has been getting progressively worse with time. The symptoms began with the loss of a partner about six months ago. At the moment, he admits that the insomnia is affecting his daily activities including his work performance. He has a significant history of opiate abuse traceable to some pain prescription he had been given after an accident. However, he states that for the past four years he has not had an opiate prescription. He has used diphenhydramine before for the insomnia without good results. Currently, he claims to rely on alcohol before bedtime in order to get some sleep daily. His MSE is quite unremarkable in that he is oriented in all aspects and is appropriately groomed for the weather and time of the day. It is negative for delusions or hallucinations and insight and judgment are both intact. He does not accept having homicidal thoughts or suicidal ideation. Insomnia is characterised by insufficiency of sleep in terms of both its quality and quantity and is diagnosed under the code 307.42 (F51.01) as Insomnia Disorder (Levenson, 2015; APA, 2013). This paper presents a decision tree on the appropriate pharmacotherapy that could be prescribed by the psychiatric-mental health nurse practitioner (PMHNP) for this client.

Decision Point One

The decision that I selected after thorough subjective, objective, and mental status examination was to commence the client on trazodone (Desyrel) 50 mg q.h.s. Trazodone is actually FDA-approved to treat depression but is also used to treat insomnia and anxiety. It is a serotonin 2 antagonist/ reuptake inhibitor (SARI), an antidepressant and a hypnotic (Stahl, 2017). I selected this decision because a number studies have concluded positively about the hypnotic effectiveness of the drug trazodone in the pharmacotherapeutic treatment of insomnia. In a systematic review by Jaffer et al. (2017), it was found that an overwhelming 95.5% of the studies reviewed found trazodone effective in treating insomnia. This was 43 studies out of 45 in total. I did not select the other two options because even if zolpidem (Ambien) is FDA-approved for the treatment of insomnia, it has a wide side effect profile that may not be favorable to the client.  Pharmacotherapy for a 31 Year-Old Male Presenting with Insomnia.Likewise, hydroxyzine (Atarax) is known for the serious side effects of xerostomia and xerophthalmia (Stahl, 2017). With this information in mind, it was therefore clinically prudent to begin the client on trazodone as evidence-based practice because enough level 1 peer-reviewed evidence is available for its efficacy.

What I was hoping to achieve by making the above decision was a reduction in the severity of the client’s symptoms and a return to normal day-to-day activities including work. In other words, the expected outcome for the decision was remission in the first four weeks of therapy and a return to normalcy, as indicated in the scholarly evidence available (Jaffer et al., 2017). In treating this client, there are ethical considerations that may impact both the treatment plan and the communication with the client. As such, I was guided by providing the greatest good for the client through avoidance of unwanted side effects. This would respect the bioethical principle of beneficence (Haswell, 2019). In the same way, my treatment plan was motivated by nonmaleficence in avoiding giving the client medications such as hydroxyzine that would cripple them with debilitating side effects.

Decision Point Two

After starting the client on trazodone 50 mg daily at bedtime, he returned to the clinic for review after a period of two weeks. He stated that the medication was helping him and that he was now sleeping well. However, he complained about the unpleasant side effect of priapism that was disturbing him for almost 15 minutes every morning and delaying him from going to work. He however denied having any visual or auditory hallucinations while taking the medication.

The decision that I made at this point was to decrease the dose of trazodone to 25 mg daily at bedtime. I made this decision because the effectiveness of trazodone an effective psychopharmacologic agent for insomnia is not in question (Jaffer et al., 2017; Stahl, 2017). However, priapism is a known side effect of the medication and a reduction in the dose by 50% would control the severity of the side effect (Stahl, 2017). Pharmacotherapy for a 31 Year-Old Male Presenting with Insomnia. Another reason for sticking with trazodone is that the patient has already shown that he is responding to treatment with the drug. The only thing that needs to be done now is to make him tolerate it better. That was the rationale behind reducing the dosage. I did not select the other two options because leaving the dose at 50 mg would have carried the risk of having the side effect of priapism continue and therefore jeopardise medication compliance. For this reason, I did not choose option 1. I would not also choose the other option of discontinuing trazodone for the very reasons that I have given above – that it is effective (Jaffer et al., 2017; Stahl et al., 2017) and the client is responding positively to it already. What I was hoping to achieve by the above decision was a reduction in the expression of the side effect of priapism and a continuation of the reduction in symptoms. Ethically, I was considering reducing adverse events for the client (nonmaleficence) and increasing the beneficial effects of the drug of choice (beneficence).

Decision Point Three

After the second decision of decreasing the dose of trazodone by half, the client returned for review after another two weeks. He confessed that trazodone was now very effective in allowing him to sleep comfortably. He however thought that the 25 mg dose was not sufficient to give him enough sleep throughout the night. He again denied ever having or experiencing auditory or visual hallucinations.

The decision that I took at this third decision point was to continue the current dose of trazodone of 25 mg at bedtime but to encourage the client to practice sleep hygiene. I would then follow him up after four weeks to assess his progress on treatment. The main reason why I selected this decision was that the patient confessed to the continued effectiveness of the trazodone, even after the reduction in the dosage. Encouragingly too, he had not reported having had priapism this time round. This meant that he was both responding to and tolerating the medication (Stahl, 2017). This is why I did not opt for the other two options available. Both alternative options required the stoppage of trazodone. This could not be done for the reasons that have been repeated above – efficacy and tolerability. Also, hydroxyzine has two very serious side effects of xerostomia and xerophthalmia that would cause the patient sure problems. If a choice were to be made between it and ramelteon, the latter would have been chosen from a patient safety perspective. Pharmacotherapy for a 31 Year-Old Male Presenting with Insomnia.  But this could not be done because the patient was already responding and tolerating trazodone. What I was hoping to achieve with this decision was a continued remission of symptoms and a complete stoppage of side effects. Ethically, I could not breach nonmaleficence (Haswell, 2019) by stopping trazodone and giving hydroxyzine yet I know very well that it would cause the patient harm.

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Conclusion

The condition that is known as insomnia is actually diagnosed in full as Insomnia Disorder in the DSM-5. It is under the diagnostic category of ‘Sleep-Wake Disorders’. The client in this case was a 31 year-old male who presented with this diagnosis, having had e symptoms for the past six months. The first decision made was to give him trazodone 50 mg daily at bedtime. When he came back with a positive report of a good response only spoilt by the side effect of priapism, the dose was reduced to 25 mg daily at bedtime. This was to control the side effect, and it worked. When he came back again he was fine, free of the priapism, and responding well to treatment. The dose was then not changed again but the patient was advised to practice sleep hygiene, since he had stated that he thought the 25 mg dose was little to give him enough sleep sometimes. For the moment, the treatment objectives were being achieved and he would be evaluated again after a period of four weeks. Pharmacotherapy for a 31 Year-Old Male Presenting with Insomnia.

References

American Psychological Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Jaffer, K.Y., Chang, T., Vanle, B., Dang, J., Steiner, A.J., Loera, N., Abdelmesseh, M., Danovitch, I., & Ishak, W.W. (2017). Trazodone for insomnia: A systematic review. Innovations in Clinical Neuroscience, 14(7-8), 24-34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842888/#:~:text=The%20majority%20of%20these%20studies,in%20the%20treatment%20of%20insomnia

Levenson, J.C., Kay, D.B., Buysse, D.J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179-1192.  https://doi.org/10.1378/chest.14-1617

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6^th ed. Cambridge University Press. Pharmacotherapy for a 31 Year-Old Male Presenting with Insomnia.