Case Study: Patient with Heart Burn

Case Study diligent with Heart make outThe patient is a 45 year old male with a history of eight weeks complaint of heart burn that worsens with lying mountain after dinner. The patient states that the inconvenience oneself lasts thirty minutes to twain bits, and that it wakes him at night. Patient reports taking Maalox and Rolaids up to five quantify daily, however these moreover help for a short condemnation.Medical HistoryNo know wholeergiesHypertension for two yearsRheumatoid arthritis in transfer and feet for star yearSocial HistoryPatient is married with terce children. Patient drinks two beers daily for the past twenty years and smokes one shadescribe to per day for twenty years.Current medicationsPrednisone 20 mg viva voce dailyDiltiazem 240 mg orally dailyPiroxicam 30 mg orally dailyMulti- vitamin one orally daily bodily examinationT. = 99 RR=18 Pulse =77 BP = 127/76 weight unit 242 Height 59ENT EOMI, PERRLA, mild sputumCardiac normal S1 and S2 toilet table slight dyspneaAbdomen soft, with mild suffering (4 on 1-10 scale, with 10 cosmos worst) to upper quadrant below sternum.Genitourinary deferredRectal- deferredExtremities arthritic changes to handsSkin normalNeuro AAO times 3, normal DTRGastroesophageal reflux unsoundness is a condition in which fend content leaks backward from the abide into the esophagus. The symptoms ar heartburn, na manipulationa, and regurgitation this causes an inflammation of the esophagus and possibly the larynx. Complications female genitalia be esophageal ulcers, Barrett esophagitis, chronic cough, and can lead to infection and inflammation of the lungs. diagnosing is typically made by symptoms, endoscopy, and esophageal acid tests (Brunton, Chabner, Knollman, 2011).GERD is cause by a break down in the barrier between the esophagus and the stomach. thither are three main types of manipulation that physicians consider when tr take in reflux disease. The treatment will depend on the severity of the symptoms (Brunton, Chabner, Knollman, 2011). With any patient hapless from GERD, there are lifestyle changes and forageary changes that are military unitive in management of the disease (Brunton, Chabner, Knollman, 2011). Lifestyle changes that the patient can do are as followsStop smoking if tobacco products are used (Brunton, Chabner, Knollman, 2011) taking antacids (of aluminum hydroxide content) (PubMed, 2012)Avoid food consumption wi sharp 2 hours of going to bed (PubMed, 2012)Avoid caffeinated beverages, chocolate, nicotine, alcohol, and peppermint (PubMed).Monitor intake of risque and acidic foods (PubMed, 2012)Limit the do of high fatty foods in the diet (Brunton, Chabner, Knollman, 2011)Eat 5 to 6 small meals during the day, instead of 3 boastfully meals (PubMed, 2012)Monitor weight, as obesity attachs the symptoms of GERD (Brunton, Chabner, Knollman, 2011)Elevate the head of the bed exploitation a 6 to 8 inch block or a wedge nether the mattress to enhanc e acid clearance when reclining (PubMed, 2012)Eat lento and chew food thoroughly to enhance digestion (PubMed, 2012)*Avoid restrictive clothing, lifting arduous objects, straining, working in a bent position, and stooping (PubMed, 2012).* Chewing gum, this increases expectoproportionn production and natural acid reduction (PubMed, 2012).The symptoms may be bidled with the medications however, the aesculapian issue never goes away. Lifestyle changes are helpful in the general treatment and control (Brunton, Chabner, Knollman, 2011).DiagnosisDiagnosis and treatment consist of a physical examination and history, esophageal motility testing, esophageal acid test, endoscopy (esophago-gastro-duodenoscopy or EGD), and possible biopsy to diagnosis Barretts (Ananal, 2012). The esophageal acid test is considered the money standard for diagnosis (PubMed).Current medications and interactions related to GERDCalcium channel blockers are classifications of medications used to treat hyperte nsion. These do mediciness can weaken the lower esophageal sphincter, which can cause GERD (Hughes, Lockart, Joyce, 2007)Corticosteroids in change magnitude amounts have been associated with indigestion, heartburn, stomach pain and cramping, puke and diarrhea (Ananal, 2012).NSAIDs much(prenominal) as Piroxicam may cause ab cramping or ascetical pain, severe continuous heart burn and nausea. In combination with corticosteroids there is a higher risk of abdominal pain and the risk of stomach bleeding (Brunton, Chabner, Knollman, 2011).TreatmentTreatment can involve elevation of the upper body when sleeping, diet changes, and avoid certain foods, eating smaller more frequent meals, and stop smoking and alcohol use (Brunton, Chabner, Knollman, 2011). Medical treatment will include antacids taken one hour after meals Tums and Rolaids are not recommended for regular use due to being a calcium carbonate. Histamine antagonist, such as Zantac, should be taken 30 minutes to begin with bedtime to prevent nocturnal acid breakthrough. Proton pump debarors, such as Prilosec, should be taken, one hour before the morning meal. spume barriers such as Gaviscon, work as a barrier to stomach acids and may be taken as needed for symptom rest, three times daily (Ananal, 2012).Antacids and alginic acid (Gaviscon) are the doses of choice for quick relief of symptoms. These agents act primarily by rapidly increasing the ph of the gastric refluxate. Alginic acid reacts with sodium bicarbonate in saliva to hurl sodium alginates. The sodium alginate floats on the top of the gastric contents where it acts as a mechanical barrier, minimizing exposure of the esophagus to refluxate. H2 receptor blockers act by inhibiting histamine comment of the gastric parietal cells, thereby suppressing gastric acid secretion. They are to the highest degree effective in suppressing nocturnal acid secretion. Proton pump inhibitors (PPI) strongly inhibit gastric acid secretion. They act by irreversibly inhibiting the H+ K+ adenosine Triphosphatase pump of the parietal cell. By blocking the final common passageway of gastric acid suppression compared with H2 receptor blockers. When prescribed appropriately to patients with severe symptoms or refractory disease, the PPIs are more cost effective because of their high healing and remission rate and the consequent prevention of complications (Brunton, Chabner, Knollman, 2011).Prescriptions1DATE__6/12/2014_____Patient name________ (M/F) AGE__45____Address____________ Weight__242____Prilosec 40 mg launch pad 30 tamp one tablet by mouth each morning before the morning meal for acid reflux controlRefill__1__ signature______________generic sub __Yes__ DEA__________2DATE__6/12/2014_____Patient name________ (M/F) AGE__45____Address____________ Weight__242____Zantac 75 mg tablet 30Take one tablet by mouth e genuinely night 1 hour before bedtime for acid reflux controlRefill__1__ signature______________Generic sub __Yes__ DEA__________3DATE__6/12/2014_____Patient name________ (M/F) AGE__45____Address____________ Weight__242____Gaviscon 1 cuttable tablet as needed for heartburn relief 1 bottlefulTake one tablet by mouth three times daily as needed for relief of breakthrough heartburnRefill__1__ signature______________Generic sub __Yes__ DEA__________ReferencesAnanal, B. (2012). Peptic ulcer disease. Retrieved from Medscape.com http//www.medscape.com/ name/181753Brunton, L., Chabner, B., Knollman, B. (2011). Goodman GilmansThe pharmacological fundament of therapeutics (12 ed.). McGraw-Hill.Hughes, J., Lockart, J., Joyce, A. (2007). Do calcium antagonists contribute to gastro-oesophageal reflux disease and concomitant noncardiac chest pain? The British Pharmacological Society Journal. doi10.1111/j.1365-2125.2007.02851.xPubMed. (2012). Lifestyle changes as a treatment of gastroesophgeal reflux diseaseA survey of general practitioners. Retrieved from Pubmed.com http//www.ncbi.nlm.nih.gov/pmc/article /PMC1661628PubMed. (n.d.). Gastroesophageal reflux disease. Retrieved from PubMed health http//www.nebi.nlm.nih.gov/pubmedhealth/PMH6001311Identification of Didanosine ResultsIdentification of Didanosine ResultsDISCUSSIONThe procured take of didanosine was tested for its identification. The do doses sample showed compliance with the data given in B.P. and Clarkes which reflects its quality and purity. Quality and purity of sample was also confirmed by the manufacturer. The lipoidees such as soyalecithin and cholesterin and all other excipients provided by the provider confirmed by their identification test official in USP 24, IP and EP. All the excipients showed results in compliance with standard specifications.STANDARD CALIBRATION deviate OF DIDANOSINEFrom the scanning of drug in 7.4 pH phosphate buffer was think that the drug had max of 249 nm. From the standard calibproportionn curve of drug, it was concluded that drug obeys Beer-Lamberts law in concentration range of 0- 20mcg/mL.R2 = 0.9995Correlation coefficient values indicated the additive correlation between concentration and absorbance.PREPARATION AND CHARACTERIZATION OF LIPOSOMESAmong the divers(a) methods thin charter hydration method is widely used on a research lab scale. In this method the lipoids are casted as stacks of make from their constituent(a) solution exploitation flash rotary evaporator under reduced contract and then the film is dispersed in an aqueous medium. This method yields the liposomes with a involved size distribution. Also the liposomes that are make are multilamellar in nature with some unilamellar vesicles. (Vyas and Khar, 2002).Venkataram et al., 1990 have used PC to prepare liposomes in a drug to lipoid ratio of 1 10. The temperature during preparation has been unbroken 40C as the glass transition temperature of PC is very low. The drug entrapment into the liposomes depends mainly on Drug Lipid ratio. In this study, the cholesterin and PC are selecte d as lipids in combination on basis of percent drug entrapped and rigidity ( perceptual constancy). S.Vemuri et al are stated that, cholesterol improves the fluidity of the bilayer membrane, reduces the permeability of weewee soluble molecules throught the membrane, and improve the stableness of bilayer membrane in the presence of biological fluids such as blood/plasma. The hydration feature of speech of lipid film was studied for different batches of liposomes and then liposomes were evaluated for % drug entrapment. From results of % drug entrapped of different batches of liposomes that were prepared and stability of liposomes under different temperature condition it was observed that as the percentage of cholesterol was increased there was subsequent increase in the stability and rigidity of liposomes but at the same time percentage drug entrapment reduced, Due to reduction in phosphatydilcholine. Formulation F4 containing 70% of PC and 30% cholesterol showed maximum drug entr apment (29.41%) with satisfactory stability and rigidity i.e. showed spherical shape with only 1.86% of drug leaching at 25 after 30 days. However, when PC was further increased to 80% keeping cholesterol to 20% there was increase in % drug entrapment but simultaneous decrease in stability and rigidity. The shape was wooly-minded and drug leaching was more i.e.10.25%.The data was also treated statistically by using one way analysis (ANOVA) and found to be satisfactory significant difference (PPREPARATION AND CHARACTERIZATION OF DIDANOSINE PROLIPOSOMESThe proliposomes of Didanosine were prepared by powder thin film hydration (New, 1990). Here modified rotary evaporator unit was used as described by Lee et al., 1999. Different common common immune carriers standardised lactose, sodium chloride and lactose string of beads were used for preparation of proliposomes. Were hydrated with distilled water and the liposomes was analysed for % drug entrapped for different batches of prol iposomes derived liposomes were as shown in the table 5.3. The Lipid aircraft carrier ratio was kept 1 10 as describe by Song et al., 2002.The proliposomes of lactose were quite ease flowing compared to the lactose that was used to prepare them and lactose proliposomes showed highest % drug entrapment (29.17). They were less uneasy. Also as the amount of lipid i.e. lecithin was increased the proliposomes powder was found to be very steaming. This is because the lipid is sticky at room temperature.In case of sodium chloride the carrier was very free flowing but the proliposomes powder was very sticky compared to that made with either lactose or sorbitol. The member size of the liposomes organise in sodium chloride and lactose beads was also greater than that formed with lactose. Here the carrier is non porous so majority of the lipid has to be deposited over the on the fold up of the carrier, thereby maximizing the possibility of agglomeration and also because sodium chloride is hygroscopic. So it can be said that such nonporous carriers are suitable only for high melting lipids. The results are in accordance with those observed by Payne et al.As the amount of lipid was increased in case of sodium chloride the proliposomes were found to be extremely sticky because they tend to agglomerate (Payne et al., 1986a). The entrapment of the proliposomes made by using sodium chloride as a carrier was very low compared to that of either lactose or lactose beads because of the effect of the monovalent cation Na+. Sodium ion has the effect of increasing the release of cyclosporine from the liposome hence it decreases the entrapment of drug in the liposomes (Al-Angary et al., 1995).The proliposomes of lactose beads were found to be very free flowing just alike(p) the lactose beads from which the proliposomes were prepared but the surface area gettable for coating less compared to lactose powder and sodium chloride so film formed is thick so it yields multilammelar liposomes.establish on the above results the carrier was finalized. In subsequent experiments Lactose was used as a carrier and the formulation was optimized by a 32 factorial design. The effect of the two independent variables viz. Drug Lipid ratio and Lipid letter carrier ratio was studied on dependant variables like entrapment and mean jot size. All other processing factors like vacuum applied, speed of whirling of round bottom flask temperature, amount of surfactant etc were kept constant. optimisation OF PROLIPOSOMESA prior knowledge and understanding of the process and the process variables under investigation are necessary for achieving a more realistic model. Based on the results of the preliminary experiments, drug lipid ratio was found to be a major variable in determining PDE and Lipid carrier ratio in determining the PMD. Hence, these variables were selected to find the optimized condition for higher PDE and PMD using 32 factorial design. By using 32 factorial design s, 9 batches of didanosine liposomes were prepared varying the two independent variables at three directs as recorded in the table. The prepared batches were evaluated for % drug entrapment (PDE) and mean particle size, which were taken as dependent variables and the results were recorded in the table A full-blooded high drug entrapment was achieved in liposomes of variable X1 (drug Lipid = 115) and X2 (Lipid mail carrier = 115).EVALUATION STUDIES OF DIDANOSINE PROLIPOSOMESA) Microscopy of proliposomeThe microscopy of proliposomes revealed that the surface was peaceful due to the coating of the lipid and some of the particles were agglomerated. The pictures of proliposomes are as shown in Figure. afterwards hydration with deionized water a series of time-lapse photographs of proliposome hydration are as shown below in Figure. Here the shaping of liposomes form proliposomes is shown. The results indicate that the process of diarrhea/disintegration may make it by a progressive hydration of the lipid surface of the proliposome, taking the form of liposomes budding off from the central core of the proliposome until both hydration of the lipid and dissolution of the carrier is complete. Although only an imitation of the process of proliposome hydration (due to absence of hand chill to aid proliposome dispersion), this approach was thought to offer a reasonable recitation of the process (Payne et al., 1986b).Finally the liposomes are formed that are multilamellar with a heterogeneous size distribution. The photographs reveal the multilamellar nature (Figure). Also the Maltice crosses shown in Figure indicate that the vesicles are multilamellar in nature. Also there are many unilamellar vesicles.B) scan electron micrographs.The scanning electron micrographs of carriers and optimized batch of proliposomes made with different carriers were taken and are as shown in the Figure. From the SEM pictures it is evident that after coating the surface becomes somewhat smooth and the surface defects are no more ocular and a thick coating is also seen in proliposomes compared to the carrier alone. After coating of lipid on the surface the particles looks quite opaque and smooth compared to the carrier.EVALUATION STUDIES OF PROLIPOSOME DERIVED LIPOSOMESA) % Drug entrappedBy using 32 factorial designs, 9 batches of didanosine liposomes were prepared varying the two independent variables. Various methods have been account for determination of drug content in liposomes that involve separation of free drug from liposomes either by centrifugation or by dialysis or by sephadex column. Here the separation was affected by sephadex G25 column as reported by Guo et al., 2001. Here the PDE was calculated from the difference between the initial drug added and the drug detected after separation of the free drug. The results of various batches are as shown in the table.It was found that the % drug entrapped was highest when the Drug Lipid ratio was highest. Al so the Lipid Carrier ratio was found to affect the entrapment of the drug into the liposomes. It was found that the highest % entrapment for all three levels of X2 was obtained at +1 level of X1 that is 21.37% at 1 level, 26.73% at 0 level and 30.89% at +1 level of X2. Graphical presentation figure shows the effect of the independent variable (drug lipid ratio) on % drug entrapped. The results indicate that as the drug to lipid ratio increases the entrapment of the drug in the liposomes increases, as didanosine is a hydrophilic drug, which finds place deep down the core.B) Particle size analysisParticle size analysis results of various batches of proliposome derived liposomes are as shown in the table. The results are expressed as particle mean diameter. The particle size of the liposomes decreases as the amount of the carrier increases because there is a greater surface area available for thin lipid film formation which gives rise to a small particle size compared to a thick film that is formed when the amount of carrier is decrease (Hwang et al., 1997).The graph (figure) represents the relationship between lipid carrier ratio on mean particle size. Mean particle size decreases as the lipid carrier ratio increases because as the surface area increases thin film formation occurs that gives rise to smaller particle size.C) Stability StudiesThe optimized formulation was subjected to stability studies at 40C, 250C, 450C for 60 days. They were evaluated for physical appearance, entrapment efficiency, drug content etc. All the results obtained are within the limits and no major changes were identified physically.