Factors that Influence Pharmacokinetic and Pharmacodynamic Processes in Pediatric Clients
Factors that Influence Pharmacokinetic and Pharmacodynamic Processes in Pediatric Clients
When pediatric clients present with mood disorders, the
process of assessing, diagnosing, and treating them can be quite complex.
Children not only present with different signs and symptoms than adult clients
with the same disorders, but they also metabolize medications much differently.
As a result, psychiatric mental health nurse practitioners must exercise
caution when prescribing psychotropic medications to these clients. For this
Assignment, as you examine the client case study in this week’s Learning
Resources, consider how you might assess and treat pediatric clients presenting
with mood disorders.
Note: This Assignment is the first of 10 assignments that
are based on interactive client case studies. For these assignments, you will
be required to make decisions about how to assess and treat clients. Each of
your decisions will have a consequence. Some consequences will be
insignificant, and others may be life altering. You are not expected to make
the “right” decision every time; in fact, some scenarios may not have a “right”
decision. You are, however, expected to learn from each decision you make and
demonstrate the ability to weigh risks versus benefits to prescribe appropriate
treatments for clients.
Learning Objectives
Students will: Assess client factors and history to develop personalized
plans of antidepressant therapy for pediatric clients
Analyze factors that influence pharmacokinetic and
pharmacodynamic processes in pediatric clients requiring antidepressant therapy
Evaluate efficacy of treatment plans
Analyze ethical and legal implications related to
prescribing antidepressant therapy to pediatric clients
Learning Resources
Note: To access this week’s required library resources,
please click on the link to the Course Readings List, found in the Course
Materials section of your Syllabus.
Required Readings
Note: All Stahl resources can be accessed through the Walden
Library using this link. This link will take you to a log-in page for the
Walden Library. Once you log into the library, the Stahl website will appear.
Stahl, S. M. (2013).
Stahl’s essential psychopharmacology: Neuroscientific basis and practical
applications (4th ed.). New York, NY: Cambridge University Press.
Note: To access the following chapters, click on the Essential
Psychopharmacology, 4th ed tab on the Stahl Online website and select the
appropriate chapter. Be sure to read all sections on the left navigation bar
for each chapter.
Chapter 6, “Mood Disorders”
Chapter 7, “Antidepressants”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New
York, NY: Cambridge University Press.
Note: To access the following medications, click on the The
Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the
appropriate chapter. Be sure to read all sections on the left navigation bar
for each chapter.
Review the following medications:
amitriptyline
bupropion
citalopram
clomipramine
desipramine
desvenlafaxine
doxepin
duloxetine
escitalopram
fluoxetine
fluvoxamine
imipramine
ketamine
mirtazapine
nortriptyline
paroxetine
selegiline
sertraline
trazodone
venlafaxine
vilazodone
vortioxetine
Magellan Health, Inc. (2013). Appropriate use of
psychotropic drugs in children and adolescents: A clinical monograph. Retrieved
from http://www.magellanhealth.com/media/445492/magellan-psychotropicdrugs-0203141.pdf
Rao, U. (2013).
Biomarkers in pediatric depression. Depression & Anxiety, 30(9), 787–791.
doi:10.1002/da.22171
Note: Retrieved from Walden Library databases.
Vitiello, B. (2012). Principles in using psychotropic medication
in children and adolescents. In J. M. Rey (Ed.), IACAPAP e-Textbook of Child
and Adolescent Mental Health. Geneva: International Association for Child and
Adolescent Psychiatry and Allied Professions. Retrieved from
http://iacapap.org/wp-content/uploads/A.7-PSYCHOPHARMACOLOGY-072012.pdf
Poznanski, E., &
Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA:
Western Psychological Services.
Note: Retrieved from Walden Library databases.
Required Media
Laureate Education (2016e). Case study: An African American
child suffering from depression [Interactive media file]. Baltimore, MD:
Author.
Note: This case study will serve as the foundation for this
week’s Assignment.
Optional Resources
El Marroun, H., White, T., Verhulst, F., & Tiemeier, H.
(2014). Maternal use of antidepressant or anxiolytic medication during
pregnancy and childhood neurodevelopmental outcomes: A systematic review.
European Child & Adolescent Psychiatry, 23(10), 973–992.
doi:10.1007/s00787-014-0558-3
Gordon, M. S., & Melvin, G. A. (2014). Do
antidepressants make children and adolescents suicidal? Journal of Pediatrics
and Child Health, 50(11), 847–854. doi:10.1111/jpc.12655
Seedat, S. (2014). Controversies in the use of
antidepressants in children and adolescents: A decade since the storm and where
do we stand now? Journal of Child & Adolescent Mental Health, 26(2), iii–v.
doi:10.2989/17280583.2014.938497
To prepare for this Assignment:
Review this week’s Learning Resources. Consider how to
assess and treat pediatric clients requiring antidepressant therapy.
The Assignment
Examine Case Study: An African American Child Suffering From
Depression. You will be asked to make three decisions concerning the medication
to prescribe to this client. Be sure to consider factors that might impact the
client’s pharmacokinetic and pharmacodynamic processes.
At each decision point stop to complete the following:
Decision #1
Which decision did you select?
Why did you select this decision? Support your response with
evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision?
Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve
with Decision #1 and the results of the decision. Why were they different?
Decision #2
Why did you select this decision? Support your response with
evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision?
Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve
with Decision #2 and the results of the decision. Why were they different?
Decision #3
Why did you select this decision? Support your response with
evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision?
Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve
with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your
treatment plan and communication with clients.
Topic 1 DQ 1
Oct 3-5, 2022
What would spirituality be according to your own worldview? How do you believe that your conception of spirituality would influence the way in which you care for patients?
According to Hart (1994, p. 23), spirituality is the way a person lives out their beliefs in daily life and the way they “respond to the end conditions of individual existence” (Bożek, Nowak, , & Blukacz, 2020).A sense of peace and well-being are generated by spirituality, which is defined by faith, a search for life’s meaning and purpose and a feeling of belonging with one another. Through spiritual connection life satisfaction may increase or make it easier to accommodate illness or disability. Although, the idea of spirituality encompasses a huge range of personal experiences and convictions. Every individual has a unique perspective on spirituality. We may develop more comprehensive and compassionate healthcare systems by addressing the spiritual needs of our patients.
Nurses are being required more and more to recognize and respond to spiritual issues because of the emphasis on holistic care and meeting the requirements of each individual patient. Physical healing, pain relief, and personal development might result from attending to the patient’s spiritual needs. The nurse must attend to the patient’s emotional as well as physical demands in order to meet their total needs.The way in which we provide patient care would be influenced by our personal understanding of spirituality. For example, my spiritual beliefs consist of treating everyone with respect, compassion, care and equality regardless of their health status, race, spiritual view, gender, etc. I can take that into consideration into my practice by providing culturally competent, holistic care so I can better understand what I can do to assist the patient’s physical, spiritual, and mental wellbeing. Further, hospitals are held liable by The Joint Commission (TJC) for upholding patient rights, which includes making accommodations for cultural, religious, and spiritual values. The bodies, minds, and spirits of patients must all be taken into consideration by healthcare practitioners and systems (Swihart, Yarrarapu, & Martin, 2021).
Bożek, A., Nowak, P. F., & Blukacz, M. (2020). The Relationship Between Spirituality, Health-Related Behavior, and Psychological Well-Being. Frontiers in Psychology, 11. https://doi.org/10.3389/fpsyg.2020.01997
Swihart, D.L., Yarrarapu ,S.N.S & Martin R.L. (2021). Cultural Religious Competence In Clinical Practice. StatPearls Publishing https://www.ncbi.nlm.nih.gov/books/NBK493216/
The patient in the case study is Katie, an 8-year-old Caucasian female who visits the clinic with her parents. Her PCP referred her for psychiatric assessment after Katie’s teacher mentioned that she could have ADHD. The teacher completed the “Conner’s Teacher Rating Scale-Revised” tool, which shows that Katie has poor concentration levels, easy distractibility, poor memory, and spelling, reading, and calculation difficulties. Her attention span is limited, and she only pays attention to things she is interested in. Furthermore, Katie shows minimal interest in school work, rarely completes her tasks and homework, and barely follows instructions. She is diagnosed with ADHD (inattentive presentation). The patient factors that will impact prescribing include age, ADHD presentation, medication adverse effects, potential drug interactions, and treatment preferences (Nazarova et al., 2022).
Decision #1
Ritalin (methylphenidate) chewable tablets 10 mg orally in the Morning.
Why Did You Select This Decision?
Ritalin was selected because it is the first medication choice for the short-term management of ADHD in children and adolescents (Nazarova et al., 2022). Drechsler et al. (2020) explain that the psychostimulants Ritalin and amphetamine are the most effective agents in treating primary ADHD symptoms, and they have a good efficacy and adverse event profile.
Why Did You Not Select The Other Two Options Provided In The Exercise?
Wellbutrin has a slow onset of action than stimulants like Ritalin. Thus Ritalin was preferred over it due to its fast onset of action and better efficacy in treating ADHD symptoms (Coghill et al., 2021). Intuniv XR was not selected because the drug’s full effects on alleviating ADHD symptoms are usually seen after some weeks of administration Drechsler et al. (2020). Thus, it was not selected as the initial drug since the options included Ritalin, which has immediate symptom reduction.
What I Was Hoping To Achieve By Making This Decision
I anticipated that Ritalin would significantly lower Katie’s ADHD symptoms of inattention and distractibility immediately (Drechsler et al., 2020). I also hoped these would help improve her academic performance by increasing her concentration and attention.
Ethical Considerations Impact on Treatment Plan and Communication
The practitioner has a moral duty to promote the best outcomes for the patient without compromising her safety. This impacted the treatment since the practitioner had to select Ritalin since its efficacy is established and it has a good adverse event profile.
Decision #2
Change to Ritalin LA 20 mg orally daily in the MORNING.
Why Did You Select This Decision?
Ritalin was changed to long-acting (LA) to ensure the drug’s effects would be sustained the entire school day. The average duration of the clinical effect of the Ritalin immediate-release formulation is 3-4 hours (Steingard et al., 2019). Thus it could not sustain the effects, unlike the LA formulation, whose duration of clinical effect is up to 14 hours, making it a better option for this patient (Patrick et al., 2019).
Why Did You Not Select The Other Two Options Provided In The Exercise?
Continuing the initial Ritalin dose was not ideal because of its duration of clinical effect of 3-4 hours (Steingard et al., 2019). This would not be sustainable in maintaining the drug’s positive effect in promoting the patient’s attention and concentration the entire day. Besides, the patient was not switched to Adderall because Ritalin positively alleviated ADHD symptoms. Treatment guidelines recommend switching a drug if there is no improvement or when adverse effects are reported (Coghill et al., 2021).
What I Was Hoping To Achieve By Making This Decision
I hoped that changing Ritalin from Immediate release to long-acting formulation would help to maintain Katie’s concentration in class the whole day (Patrick et al., 2019). I also hoped that the teacher would report improvement in Katie’s attention in class and academic improvement.
Ethical Considerations Impact on Treatment Plan and Communication
The PMHNP had an ethical duty to uphold beneficence by selecting the treatment to improve patient outcomes. This impacted the treatment plan since the PMHNP had to change Ritalin to a LA formulation with more sustained outcomes than the immediate release.
Decision #3
Maintain current Ritalin LA dose and reevaluate in 4 weeks.
Reason for this Decision
Ritalin LA effectively sustained the patient’s attention span, leading to improved academic performance. Thus, maintaining the dose was the ideal option. Steingard et al. (2019) explain that the LA formulations have become the core of ADHD treatment.
Why Did You Not Select The Other Two Options Provided In The Exercise?
Ritalin LA was not increased to 30 mg since the initial dose effectively alleviated symptoms. Increasing the dose increases the risk of side effects Patrick et al., 2019. The patient had an HR of 92 and had no palpitations; thus, an EKG was unnecessary.
What I Was Hoping To Achieve By Making This Decision
I hoped Ritalin LA would continuously improve Katie’s attention span without compromising her safety (Drechsler et al., 2020).
Ethical Considerations Impact on Treatment Plan and Communication
The practitioner had to select the intervention that would promote the patient’s safety, which upholds nonmaleficence.
Conclusion
Katie presented with ADHD symptoms like inattention, poor concentration, and distractibility. Medication decisions may be influenced by the patient’s age, ADHD presentation, adverse drug effects, potential drug interactions, and treatment preferences (Nazarova et al., 2022). She was started on Ritalin IR, which effectively improved her ADHD symptoms. However, the drug’s effects were not sustained the whole day due to its short duration of clinical effect of 3-4 hours (Steingard et al., 2019). Consequently, the PMHNP switched Ritalin to LA since it has a longer duration of clinical effect of up to 14 hours. This would help sustain Katie’s concentration the whole day (Patrick et al., 2019). Wellbutrin and Intuniv were not prescribed since they take longer than Ritalin to demonstrate a positive effect in reducing ADHD symptoms.
References
Coghill, D., Banaschewski, T., Cortese, S., Asherson, P., Brandeis, D., Buitelaar, J., … & Simonoff, E. (2021). The management of ADHD in children and adolescents: bringing evidence to the clinic: a perspective from the European ADHD Guidelines Group (EAGG). European Child & Adolescent Psychiatry, 1-25. doi: 10.1007/s00787-021-01871-x
Drechsler, R., Brem, S., Brandeis, D., Grünblatt, E., Berger, G., & Walitza, S. (2020). ADHD: Current Concepts and Treatments in Children and Adolescents. Neuropediatrics, 51(5), 315–335. https://doi.org/10.1055/s-0040-1701658
Nazarova, V. A., Sokolov, A. V., Chubarev, V. N., Tarasov, V. V., & Schiöth, H. B. (2022). Treatment of ADHD: Drugs, psychological therapies, devices, complementary and alternative methods as well as the trends in clinical trials. Frontiers in pharmacology, 13, 1066988. https://doi.org/10.3389/fphar.2022.1066988
Patrick, K. S., Radke, J. L., Raymond, J. R., Koller, L., Nguyen, L. V., Rodriguez, W., & Straughn, A. B. (2019). Drug Regimen Individualization for Attention-Deficit/Hyperactivity Disorder: Guidance for Methylphenidate and Dexmethylphenidate Formulations. Pharmacotherapy, 39(6), 677–688. https://doi.org/10.1002/phar.2190
Steingard, R., Taskiran, S., Connor, D. F., Markowitz, J. S., & Stein, M. A. (2019). New Formulations of Stimulants: An Update for Clinicians. Journal of Child and adolescent psychopharmacology, 29(5), 324–339. https://doi.org/10.1089/cap.2019.0043