Clinical Decision Making Trina

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Clinical Decision Making
Nayling Levi
Chamberlain University
NR 567 Advanced Pharmacology for the Adult-Gerontology Acute Care Nurse Practitioner
Dr. Patrick Ryan
August 11, 2024

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Clinical Decision Making
Because of her diagnosis of Addison’s disease, Trina Pullman’s most appropriate
medication would be hydrocortisone. A dose of 50 mg IV every six hours is recommended at the
beginning, followed by a taper to an appropriate maintenance dose after his condition stabilizes.
This medication is chosen for its capability to treat adrenal insufficiency with its glucocorticoid
replacement needed in the management of low cortisol levels found in patients with Addison’s
disease (Sævik et al., 2020). Prompt initiation of this medication would prevent adrenal crisis.
The medication belongs to the class of corticosteroids. They generally mimic the effects
of cortisol, a hormone the adrenal cortex produces (Miller et al., 2021). The pharmacodynamic
action of hydrocortisone involves binding to glucocorticoid receptors, leading to anti-
inflammatory effects, increased gluconeogenesis, and modulation of the immune response.
Precisely for this disease, hydrocortisone would replace the deficient cortisol and, by so doing,
correct hypotension, normalize sodium levels, and reduce symptoms of adrenal insufficiency.
Notably, this medication also has mineralocorticoid activity, which helps in maintaining
electrolyte balance and blood pressure, making it a suitable choice for initial management until
the patient stabilizes (Miller et al., 2021).
The potential effect of the medication on Trina may include hyperglycemia,
hypertension, and fluid retention, more so because of her history of hypothyroidism and recent
gastritis. Gastritis may worsen with the use of the medication, but the risks are mitigated by her
use of Protonix, which protects the gastric lining. There are minimal drug interactions with her
existing medications.
Hydrocortisone costs are relatively modest, with the IV formulation priced at
approximately $10-$20 per vial, depending on the brand and pharmacy (Sbertoli et al., 2020).
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Comparatively, it is cost-effective while being efficient for the patient. It has an efficacy that is
well documented, with a rapid onset alleviating the symptoms quickly. To assess the efficacy of
treatment, monitoring her vital signs, electrolyte levels, and symptomatic improvement will be
essential. Should her condition not improve as expected, further diagnostic tests, such as repeat
cortisol levels or an ACTH stimulation test, may be warranted to evaluate her adrenal function
and adjust her treatment plan accordingly.
If the patient were pregnant, the treatment approach would need to be carefully
reconsidered. Hydrocortisone falls under the pregnancy risk rating of C meaning that it has risk
which has been proven in animals but has not been proven in human trials. Nevertheless, the
benefits may be worth the risks and the drug should be used in pregnancy in certain cases. For a
pregnant patient with Addison’s disease, it is necessary to consider the advantages and possible
drawbacks of hydrocortisone continuation; in some cases, an alternative treatment may be
required (Calina et al., 2019). Thus, it may be advisable to switch to a different corticosteroid
such as prednisone which belongs to Category C and has more reports regarding its use in
pregnancy. The patient as well as the fetus would require constant supervision, and the dose
ought to be reduced as much as is necessary to avoid adverse effects.
If the patient were a 75-year-old male, the treatment approach should also be adjusted.
Elderly patients are generally more susceptible to the side effects of corticosteroids, including
osteoporosis, hyperglycemia, and hypertension. The patient may be started on a lower dose of
hydrocortisone as long as adverse effects such as hypertension, high blood sugar, or edema are
closely monitored (Calina et al., 2019). In this age group, the patient might need further
management like calcium and vitamin D supplementation to avoid osteoporosis. Furthermore,

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the presence of other diseases typical of elderly patients should also be considered when
choosing a therapy strategy.

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References
Calina, D., Docea, A., Golokhvast, K., Sifakis, S., Tsatsakis, A., & Makrigiannakis, A. (2019).
Management of Endocrinopathies in Pregnancy: A Review of Current Evidence.
International Journal of Environmental Research and Public Health, 16(5), 781.
https://doi.org/10.3390/ijerph16050781
Miller, W. L., Flück, C. E., Breault, D. T., & Feldman, B. J. (2021). The adrenal cortex and its
disorders. In Sperling Pediatric Endocrinology (pp. 425–490). Elsevier.
https://doi.org/10.1016/B978-0-323-62520-3.00014-2
Sævik, Å. B., Åkerman, A. K., Methlie, P., Quinkler, M., Jørgensen, A. P., Höybye, C., ... &
Øksnes, M. (2020). Residual corticosteroid production in autoimmune Addison
disease. The Journal of Clinical Endocrinology & Metabolism, 105(7), 2430–2441.
https://doi.org/10.1210/clinem/dgaa862
Sbertoli, R., Hu, Z., Henke, J., Wu, E., Santosh, S., Osmon, S., ... & Santosh, S. (2020). Effect of
very low-dose hydrocortisone on shock reversal in patients with septic shock. Critical
Care Explorations, 2(4), e0096. https://doi.org/10.1097/CCE.0000000000000096

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Clinical Decision Making

Dr. Patrick Ryan

August 11, 2024

Clinical Decision Making

Because of her diagnosis of Addison’s disease, Trina Pullman’s most appropriate

medication would be hydrocortisone. A dose of 50 mg IV every six hours is recommended at the

action of hydrocortisone involves binding to glucocorticoid receptors, leading to anti-

inflammatory effects, increased gluconeogenesis, and modulation of the immune response.

the patient stabilizes (Miller et al., 2021).

The potential effect of the medication on Trina may include hyperglycemia,

Hydrocortisone costs are relatively modest, with the IV formulation priced at

and adjust her treatment plan accordingly.

drawbacks of hydrocortisone continuation; in some cases, an alternative treatment may be

ought to be reduced as much as is necessary to avoid adverse effects.

management like calcium and vitamin D supplementation to avoid osteoporosis. Furthermore,

choosing a therapy strategy.

Management of Endocrinopathies in Pregnancy: A Review of Current Evidence.

International Journal of Environmental Research and Public Health, 16(5), 781.

disorders. In Sperling Pediatric Endocrinology (pp. 425–490). Elsevier.

Øksnes, M. (2020). Residual corticosteroid production in autoimmune Addison

disease. The Journal of Clinical Endocrinology & Metabolism, 105(7), 2430–2441.

Care Explorations, 2(4), e0096. https://doi.org/10.1097/CCE.0000000000000096

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