Question

CASE STUDY:

Doreen is a 48-year old woman of Hispanic with a history of peptic ulcer disease a year ago; Doreen is married and has a 24-year-old daughter. Doreen eats a diet high in green leafy vegetables and enjoys green tea and grapefruit juice occasionally. Yesterday Doreen began experiencing severe pain in her calf; today the pain is worse so Doreen has come to the Emergency Room. Doreen’s lower leg is red, swollen and painful to the touch. Doreen is diagnosed with Deep Vein Thrombosis for which she is prescribed Dabigatran 150 mg BID; genetic testing is done and it is determined that Doreen has a wild type genotype for CYP 2C9. Doreen’s vitals are: BP – 100/60; HR – 110; RR – 18; T – 37. Doreen reports that she often takes Acetaminophen for headaches. Doreen’s CrCl rate is 40 mL/min and her weight is 59 kg.

What are your top 2 concerns for the use of Dabigatran in Doreen? Do NOT choose grapefruit juice. Explain your choice for each and provide one nursing intervention for each concern. Do NOT select grapefruit juice as it is in the next question (4 marks).

Answer 1

The patient who has a wild type of genotype for CYP2C9 or mutation the CYP2C9 gene can be problematic because it is an enzyme which aides in the metabolism of various drugs.When warfarin or anticoagulant is administered in the treatment of DVT, the patient is at high risk of developing side effects due to this gene.

In order to manage this the patients INR level has to be assessed and dose has to be reduced or adjusted accordingly

The second concern is the crcl is below the normal level,so the patient is at risk of renal problems

In order to manage it oral anticoagulant should be started two days prior to Dabigatron

The concomitant use of other drugs should be reduced or avoided