Mallorie is a 55 year old breast cancer survivor recently diagnosed with; major depressive disorder, general anxiety disorder, and panic attacks.She was diagnosed with breast cancer in November 2013, and was treated with surgery and radiation. Six months following treatment she went into remission and it was confirmed that as of April 2014, she was free of cancer. As a cancer survivor, Mallorie is suffering. She has not been able to return to work, and finds it difficult to get out of bed every day. She feels grateful for having beat breast cancer, and cannot seem to reconcile her feelings of despair. This is compounded by the guilt she may feel for being a survivor, as many women that she knew undergoing treatment at the same time, were not as fortunate. Depression is a critical concern in cancer survivors. Depression may be related to; the fear of cancer recurrence, a transition in roles from breast cancer patient to breast cancer survivors, change in physical appearance, and prolonged effects of cancer therapy. The immediate period following remission, should be a time when the psychosocial well being of the patient is evaluated. It has been shown that spirituality and/or religious beliefs is a positive coping strategy that enables an individual to manage difficult life events. Being that Mallorie is atheist, she lacks an inherent resource that may assist in the improvement of her well-being and thus quality of life.
Case Study Review : Major Depressive Disorder & Anxiety Disorder cont'd
Following her monthly wellness visit to the Woman’s health clinical, expresses her inability to cope with her current situation. During her visit beings to cry uncontrollably, she cannot sit still and becomes extremely short of breath. Due to what is said in her interview, Mallorie is advised to admit herself to the mental health wellness unit at the nearby acute health centre. She agrees and is placed under strict observation for suicide precautions. It has been determined by members of her health care team that her current anti-depressants are not effectively managing her symptoms. In addition to her diagnosis of depression, Mallorie is subsequently diagnosed with anxiety disorder and panic attacks. She is given new medications and Electroconvulsive therapy as treatment for her depression.
Client states “I still can’t go to work. I still find it hard to get out of bed each day, but I force myself to do it. I do feel lucky to be alive, especially when I saw so many women at the radiation clinic who had their breast cancer come back. Some of them are died now, I saw their names in the paper in obituaries sections. I do feel grateful, I do. I just can’t seem to get myself to feel happy or go to work. I really can’t do anything; this makes me feel so guilty and my family is started to get frustrated with me. I really just want to end it all.”
1.Raloxifene (Keoxifene) 60 mg po once daily 2.Midazolam 2 mg IV bolus over 5 minutes before ECT
Midazolam 100 mcg/kg by slow titration as ordered during ECT procedure
3.Desvenlafaxine 50 mg once daily
4. Alprazolam 2 mg po bid
5.Sitagliptin 100 mg po once daily
Mallorie's Medication Regimen
Brand Name: Evista
Drug Class: selective estrogen receptor modulators (SERMs)
Mode of Action: Raloxifene is a nonsteroidal selective estrogen-receptor modulator (SERM) that binds to the estrogen receptors throughout the body. Binding of Raloxifene leads to: (1) Estrogen agonist effects in the bone to increase bone density and decrease bone loss; (2) Estrogen antagonist effect in breast tissue that decreases the risk of cancerous cell growth.
Indication: Used for the treatment and prevention of postmenopausal osteoporosis.Used as breast cancer prevention therapy; Decreases the risk of developing estrogen receptor positive breast cancer in women who have increased risk of developing invasive breast cancer
Mallorie has been prescribed Raloxifene 60 mg po once daily. As a breast cancer survivor Mallorie, has a higher risk of developing breast cancer again. As part of her breast cancer prevention therapy, Raloxifene will decrease her risk of recurrent breast cancer by approximately 50%. Raloxifene has been shown to decrease the risk of breast cancer in women after 4 years of treatment, via inhibition of subclinical tumors and /or prevention of new cancers.a Mallorie should ensure that she maintains her follow-up visits schedule, which may occur every 3-6 months for the 5 years after remission when rate of recurrence is greatest; then once a year after that.
Mallorie + Raloxifene
Mode of Action:As a Benzodiazepine, Midazolam binds to receptors on the NT gamma-aminobutyric acid (GABA), thereby increasing its activity and intensifying its effects in the CNS. Incresased GABA activity results in decreased anxiety, relaxation of muscles, and the induction of sleep
Indication:Midazolam is a short acting, potent sedative used for conscious sedation prior to and during diagnostic or therapeutic procedures. It possess anxiolytic properties and produces anterograde amnesia. Midazolam may be used as the sole agent in the induction of anaesthesia, as the premedication prior to induction of anaesthesia, or as a sedative component in combined anaesthesia. When used as an anesthetic induction agent, IV Midazolam achieves sedation in approximately 2 minutes without premedication with other sedatives or narcotics
Mallorie has been prescribed two differenct doses of Midazolam for the purpose of conscious sedation during electroconvulsive therapy (ECT). 2 mg IV bolus over 5 minutes for anaesthesia induction and 100 mcg/kg during the procedure. Midazolam has a rather quick onset of action of about 4 minutes; a half life of approximately 2 hours; a short duration of action of roughly an hour; and relatively quick inactivation and elimination. This pharmacokinetic profile makes Midazolam appropriate for the relatively short ECT treatment sessions. An adverse effect of Midazolam is anterograde amnesia; the inability to retain new information/make new memories. This effect may be beneficial for Mallorie as ECT may be traumatic event for her. The inability to remember the most recent past (ECT) may increase the effectivenenss of this treatment via Mallorie’s willingness to participate.
Mallorie + Midazolam
Brand Name: Pristiq
Drug class:serotonin-norepinephrine reuptake inhibitor (SNRI)
Mode of Action:Desvenlafaxine selectively inhibits the neuronal uptake of serotonin/norepinephrine via binding to their presynaptic transporters. Decreasing neuronal uptake of these neurotransmitters (NT), prolongs their activity as well as their concentration at the synapse, therefore enhancing the effects of both NTs in the brain.
Indication:Antidepressant used for the treatment of major depressive disorder. The underlying mechanism of depression is unclear, yet it is thought that because these NTs are involved in mood, an imbalance/insufficient amount of serotonin/norepinephrine contributes to the development of this condition.
Mallorie has been prescribed Desvenlafaxine 50 mg once daily. Desvenlafaxine has been included in Mallorie’s new medication regimen as her previous antidepressants were not effective in managing her symptoms of depression. It is important that if a monoamine oxidase inhibitor (MAOI) was part of her previous medication regimen, that she wait at least 14 days between discontinuation of the MAOI and initiation of Desvenlafaxine. This will decrease the risk of Serotonin Syndrome. Mallorie should be informed that it may take a few weeks before her symptoms improve, she should be advised against abruptly discontinuing her medication as this may lead to withdrawal syndrome. Steady state of this medication is achieved in approximately 4-5 days. Aa. Due to the statements that Mallorie made during her visit to the woman’s health clinic, she has been place under strict observations for suicide; it is imperative to note that there is an increased risk of suicide within the early phase of this medication. As Desvenlafaxine is formulated for extended release, Mallorie should be instructed to swallow her tablet whole; chewing, breaking, or crushing this medication will cause the drug to be released all at once.She should also be advised against taking pain medications such as; Aspirin, Ibuprofen, as these medications make increase her risk of bleeding and cause her to bruise easily.
Drug Class:BenzodiazepineMode of Action: As a Benzodiazepine, Alprazolam binds to receptors on the NT gamma-aminobutyric acid (GABA), where it enhances GABA activity and boosts its effects in the CNS. This results in decreased anxiety, sedation, relaxation of muscles.
Indication: Alprazolam is used for the treatment of generalized anxiety disorder, anxiety associated with depression, and panic attacks. Alprazolam is one of the most prescribed drugs for the treatment of anxiety, most likely due to its potency, quick onset of action of approximately an hour, tolerability, and effectiveness.
Mallorie has been prescribed Alprazolam 2 mg po bid for the treatment of generalized anxiety disorder and panic attacks. Mallorie should be cautioned against exceeding her daily dose Alprazolam as well as the concurrent use of alcohol and/or other CNS depressants while taking this medication. Concurrent use of other CNS depressants; such as, antihistamines/opiate analgesics; can lead to extreme sedation, excessive respiratory depression, and potentially coma or respiratory arrest. She should also be educated concerning the symptoms of withdrawal which may occur if she abruptly discontinues her medication. Due to reduced psychomotor performance, alertness, and increased reaction time; Mallorie should be advised that it is not safe for her to drive or operate dangerous equipment, especially in the early phase of treatment.
Mallorie + Alprazolam
Benzodiazepine Withdrawal Symptoms
Alert: Benzodiazepine Dependence
Usually caused by long-term use; however, use of this drug longer than 4 weeks, particularly at high doses also increases the risk of developing dependence. Because dependence develops within such a short time frame; patients may be at a higher risk for withdrawal syndrome, which may occur when this medication is discontinued abruptly or the dose is lowered. In order to prevent the incidence of dependence it is essential to monitor Mallorie so that it can be recognized. She should be evaluated for a decrease or complete resolution of anxiety/panic attack within 4 weeks of taking this medication. If her symptoms have not been controlled within this time, an increase in dose may be required. With control of symptoms, Mallorie should be gradually weaned off of this drug.
Brand Name: Januvia
Drug Class: Dipeptidyl Peptidase-4 Inhibitors (Gliptin)
Mode of Action: Sitagliptin acts by inhibiting DPP-4, which is an enzyme that inactivates incretins (metabolic hormones). Incretins are released after meals, and function to boost the secretion of insulin from the pancreas and suppress glucagon release. Thus Sitagliptin strengthens the actions of incretins leading to improved glycemic control via increased insulin sensitivity and stable blood glucose
Indications: Sitagliptin is an oral anti-diabetic medication for the treatment of type 2 diabetes. It aids in the regulation of insulin via increased concentrations of incretins. This is essential in the management of type 2 diabetes where there is a decrease in the amount of insulin produced and/or decreased insulin sensitivity.
Adverse Effects: headache, upper respiratory tract infection, inflammation of nose and throat, athralgia, decreased appetite, intestinal gas, acid reflux, stomach upset, stomach pain, pancreatitis, hypersensitivity reactions, urticaria, rash
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