Drug Nutrient Interactions case study 1

Case Questions:

Instructions: Please complete each question listed below. Be thorough in answering these questions.
With any calculations, please show your work. Use any resources available to complete these questions;
Make sure to look up any unfamiliar terms or concepts. Must reference all answers in AMA format at
the end of the document under a page titled references. Answers can be typed directly onto this
document leave the question and place answers below each question. Please uploaded case study to
Canvas prior to due date.

I. Understanding the Disease and Pathophysiology (4pts)

1. Identify each of the medical diagnoses for Mr. Keiser.
Metabolic Alkalosis- when a pathophysiological event leaded to the accumulation of a base or loss of
acid from the extracellular fluid. It can increase arterial blood pH and plasma bicarbonate
concentration1.
Mild dehydration- occurs from losing more fluid than you are in-taking so the body cannot fulfill its
normal functions2.
Coronary Artery Disease- occurs when the major blood vessels supplying the heart with oxygen,
nutrients and blood become diseased or damaged. Plaque (cholesterol-containing deposits) in the
arteries and inflammation can narrow the coronary arteries and decrease blood flow and cause angina,
shortness of breath or a heart attack3.
Type 2 Diabetes- body either resists insulin or does not produce enough to metabolize glucose4
Peripheral neuropathy- results from damage to the peripheral nerves causing weakness, numbness and
pain in hands and feet. Can result from traumatic injuries, infections and metabolic problems. It of
often associated with diabetes5.
Renal insufficiency- when the kidneys are unable to filter waste from the blood and it builds up,
interrupting the bloods normal chemical makeup6.
2. Identify which of these may affect cardiac function, liver function, and renal function.
Metabolic alkalosis- affects renal function1
Mild dehydration- can affect kidney function and lead to kidney stones7. It can also affect heart
function and blood pressure8.
Coronary Artery Disease- affects the heart and surrounding arteies3.
Type 2 diabetes- can increase the risk coronary heart disease, heart attack, stroke, atherosclerosis and
high blood pressure. Diabetes can also damage the small blood vessels that filter waste in the kidneys
and cause nephropathy5.
Renal insufficiency- affects the kidneys but can also lead to chest pain or pressure6.
3. Are there also normal changes in renal function that occur with aging?
Yes, as the kidney ages the glomerular filtration rate and renal blood flow decrease. GFR decreases
due to the glomerular capillary plasma flow rate reducing. In addition, the reduction of resistance
from afferent arteriolar (the blood vessels bringing blood to the kidneys) can cause an increase in the
glomerular capillary hydraulic pressure. Loss of renal mass, along with other structural changes and
changes in the renin-angiotensin aldosterone system also account for loss of renal function9.
4. Define polypharmacy. Do you think that Mr. Keisers medications represent polypharmacy? Why is
polypharmacy a concern in the elderly?
Polypharmacy-the use of multiple drugs or more than are medically necessary or multiple drugs to
treat a single ailment10.
Yes, I think that Mr. Keisers medications represent polypharmacy.
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Drug Nutrient Interactions case study 1

He is on more than one hypertensive medication: Diovan and Furosemide. Sodium Bicarbonate and
Prilosec are both used to treat stomach ulcers and lower stomach pH. Diovan and Zocor and
Isosorbide mononitrate are all used for the treatment/prevention of heart disease. Trazadone and
Neurontin are both used to treat psychiatric disorder such as mood swings, anxiety and depression.
However, Neurontin is also used as a treatment for neuropathy. Diovan has interactions with
potassium, calcium and vitamin D which could be in his multivitamin. The Sodium bicarbonate in
conjunction with the Prilosec could be the reason(s) for the alkalosis. Trazadone needs to be cautioned
with cardiac disease and decreased renal function but he take it11
Polypharmacy is a problem in the elderly because often times they are unaware of what they are
taking and why. They can experience adverse drug effects (ADE) especially with anticoagulants,
NSAIDs, cardiovascular medications, antibiotics and diuretics from not eating the proper foods with
their medications or taking them at inappropriate times. They can also experience drug to drug
interactions from being unaware of what medications they are taking and why and subsequently being
prescribed other medications that will interfere with one another10.
II. Understanding the Nutrition Therapy (2pts)
5. Describe the potential nutrition complications secondary to pharmacotherapy.
Prilosec- can potentially decrease the absorption of iron, vitamin B12 and calcium and lead to
deficiency especially since he is taking it daily11.
Diovan, Prilosec and sodium bicarbonate all require the decrease11
Neurontin can increase his appetite and weight which is an issue because he has diabetes and his
weight should be monitored and he already has a BMI of 45.5 classifying him as obese11
With Furosemide potassium needs to be increased however it needs to be decreased with Diovan11
If potassium is not increased with Furosemide then hypokalemia can occur11
6. Describe the potential effect of nutrition on the action of the medications.
Diovan- vitamin K, potassium and sodium can decrease its action11
Prilosec- absorption of iron, vitamin B12 and calcium can be decreased11
Furosemide- potassium11
Citrus can affect the action of Trazodone and Zocor11

III. Nutrition Assessment (6pts)

A. Evaluation of Weight/Body Composition
7. Mr. Keiser is 510 tall and weighs 210 lbs. Calculate his body mass index. How would you interpret this
value? Should any adjustments be made in the interpretation to account for his age?
Mr. Keisers BMI is 30.1
I would interpret this value as obese because he is over the 30 mark
For being 85 years old, this is relatively okay. He is just at the obese point but not over it very
much. I this he could be classified more as overweight than obese.
8. Calculate Mr. Keisers percent usual body weight. Interpret the significance of this assessment.
210/196=1.07=107% usual body weight. He is above his usual body weight this could be due to
inflammation.
9. In an older individual, what specific changes occur in body composition and energy requirements that may
need to be taken into consideration when completing a nutritional assessment?
In the elderly it is normal for fat mass to increase muscle mass to decrease without body weight
increasing. This is thought to be the result of changes in resting metabolic rate12. Because of
these changes elderly peoples energy requirements also decline. However, certain nutrients like

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protein, calcium and iron may need to increase even though overall energy intake is being
reduced. Saturated fat and sodium should also be reduced to reduce the risk of cardiovascular
disease13
B. Calculation of Nutrient Requirements (3pts)
1. Calculate energy and protein requirements for Mr. Keiser. Identify the formula/calculation method you used
and explain the rationale for using it. What factors should you consider when estimating his requirements?
95.23kg x 1.0g protein = ~95g protein per day
25kcal x 75.3= 1883kcal/day. This is the rule of thumb method; its a very generic form of
calculating needs that is used by many medical institutions. I used his ideal body weight to
calculate this because he has an elevated BMI.

C. Intake Domain (8pts)

1. Mr. Keisers daughter expressed concern regarding his fluid intake. Is this a common problem in the aging?
Explain.
Yes this is a problem because elderly people have a reduced sensation of thirst and so it
shouldnt be used a sign of dehydration14. Often times elders forget to drink enough, have
swallowing issues or dont want to drink due to incontinence. These, along with other reasons,
can lead elders to not getting enough fluids and often times leads to dehydration
1. There are several ways to estimate fluid needs. Calculate Mr. Keisers fluid needs by using at least two of
these methods. How do they compare? From your evaluation of his usual intake, do you think he is getting
enough fluids?
Method 1 Based on energy intake: 1mL of fluid per kcal- 1883 x 1mL= 1883mL/day
Method 2 Based on weight in kg: 20mL of fluid per kg= 20 x 95.5 = 1910mL/day
These values are roughly the same
No, I do not think that he is getting enough fluids and that could definitely contribute to his
dehydration. He would also feel much more awake and alert if he increased his fluid intake.
1. Evaluate Mr. Keisers usual intake for both caloric and protein intake. How does it compare to the Myplate
recommendations?
Mr. Keiser, according to the MyPlace recommendations is under on the amount of calories he
should be eating but he is over by about 80% on the amount of protein he should be eating.
I should however also note that he is severely under on his vegetable intake. As a diabetic he
needs to be consuming adequate amounts of fiber. Hes also missing a lot of vitamins and
minerals that vegetables contain.
1. From the information gathered within the intake domain, list Mr. Keisers possible nutrition problems using
the diagnostic term.
Excessive protein intake as evidenced by consuming approximately 11oz throughout the day as
evidenced by a high blood urinary nitrogen
Knowledge deficit as evidenced by not knowing what his medications for related to medical
history forms
1. Do you think Mr. Keiser needs to take a multivitamin? In general, do needs for vitamins and minerals
change with aging? What reference would you use to determine recommended amounts of the
micronutrients?
Yes, I think Mr. Keiser needs to take a multivitamin because he does not get enough calories nor
does he get enough vegetables or dairy. There was a lot of essential nutrients that are contained
in those food groups so it is essential that he still get them even if it was through a multivitamin
Older adults have an increased need for calcium, vitamin D, vitamin B12, fiber and potassium15

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Drug Nutrient Interactions case study 1

I would use the recommendation in the back of Nutrition Therapy and Pathophysiology by
Nelms. This book contains a breakdown of the requirements of men and women at various age
groups and stages of life.

Clinical Domain (25pts)

1. Mr. Keiser was diagnosed with mild metabolic alkalosis and dehydration. What is metabolic alkalosis? Read
Mr. Keisers history and physical. What signs and symptoms does the patient present with that may be
consistent with metabolic alkalosis and dehydration? Explain.
Metabolic Alkalosis- when a pathophysiological event leaded to the accumulation of a base or loss
of acid from the extracellular fluid. It can increase arterial blood pH and plasma bicarbonate
concentration1.
His dizziness and confusion can be a symptom of dehydration
1. What laboratory values report his medical history of renal insufficiency? What laboratory value(s) support
this diagnosis of metabolic alkalosis? Which are consistent with dehydration? What laboratory values
support his medical history of type 2 diabetes mellitus?
His high blood urinary nitrogen and creatinine support renal insufficiency16
The high blood pH, high HCO3 and high PCO2 support metabolic alkalosis17
A high hba1c and high glucose both support history of type 2 diabetes4

Laboratory Normal Mr. Keisers Value

Albumin 3.5-5 g/dL 3.4 g/dL

Potassium 3.5-5.5 mEq/L 3.4 g/dL

Osmolality 285-295 mmol/kg/H2O 310 mmol/kg/H2O

Glucose 70-110 mg/dL 172 mg/dL

BUN 8-18 mg/dL 32 mg/dL

Creatine 0.6-1.2 mg/dL 1.5 mg/dL

HbA1c 3.9-5.2% 8.2%

pH 7.35-7.45 7.47

pCO2 35-45 mm Hg 46 mm Hg

CO2 23-30 mmol/L 31 mol/L

HCO3 24-28 mEq/L 32 mEq/L

1. Using the following table, list all the medications that Mr. Keiser was taking at home. Identify the function
of each medication.

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Drug Nutrient Interactions case study 1

Medication Function Drug-Drug Interaction Drug-Nutrient

Interaction

Diovan (valsartan) Antihypertensive, rifampin, cyclosporine, Caution with vitamin K

congestive heart failure11 ritonavir, ritonavir,
NSAIDS, COX-
2 inhibitors, Dual
blockade of the RAS with
angiotensin receptor
blockers, ACE inhibitors,
or aliskiren, lithium18
supplements and salt
substitiutes, decrease Na,
decrease cal, avoid natural
licorice, could increase
glucose in diabetes,
caution with calcium or
vitamin D11

Prilosec (omeprazole) Antiulcer, antigerd, atazanavir and nelfinavir Can decrease absorption
antisecretory11 with proton pump of Fe, B12, Ca11
inhibitors is not
recommended, saquinavir
with proton pump
inhibitors, antiretroviral
drugs, ketoconazole,
atazanavir, iron salts,
erlotinib, and
mycophenolate mofetil,
digoxin, diazepam,
warfarin and
phenytoin, voriconazole18

Neurotin (gabapentin) Antiepileptic, post Hydrocodone, morphine, Caution with alcohol, can
herpetic neuralgia Aluminum Hydroxide, increase appetites and
treatment, treatment of Magnesium Hydroxide18 weight, caution with
moderate to severe decreased renal function11
restless leg syndrome,
mood stabilizer in bipolar
disorder, treatment for
neuropathy, hot flathes
and migrane11

Furosenide Antihypertensive, diuretic aminoglycoside Can be taken on empty

(k-depleting) 11 antibiotics, ethacrynic
acid, salicylates, cisplatin,
cisplatin, tubocurarine,
succinylcholine,
lithium, angiotensin
converting
enzyme inhibitors, angiote
nsin II receptor blockers18
stomach or with milk/
food if GI stress occurs,
need to increase
potassium and
magnesium, need to
decrease calories and
sodium11

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Drug Nutrient Interactions case study 1
Medication Function
Zocor (simvastin) Antihyperlipidemic,
prevent or decrease risk of
cardiovascular disease,
slow progression of
atherosclerosis11
Isosorbide mononitrate Antiangina, vasodilator11
Trazodone Antidepressant,
heterocyclic, used for
treatment of insomnia,
aggression and panic
attacks11
Sodium bicarbonate Mineral supplement,
antacid, alkalizing agent11
NPH insulin/ regular Antidiabetic,
insulin hypoglycemic11
Multivitamin Prevent or treat vitamin
deficiency11
Drug-Drug Interaction
Strong CYP3A4
Inhibitors, Cyclosporine,
Or Danazol, itraconazole,
ketoconazole,
posaconazole,
voriconazole, erythromyci
n, clarithromycin or
telithromycin,
Gemfibrozil, Amiodarone,
Dronedarone, Ranolazine,
Or Calcium Channel
Blockers, niacin, Digoxin,
coumarin anticoagulants,
colchicine18
Sildenafil18
CYP3A4 inhibitors,
ketoconazole, indinavir,
and other CYP3A4
inhibitors,
Carbamazepine18
N/A
N/A
antacids, bisphosphonates,
levodopa, thyroid
medications, tetracyclines,
quinolones, ciprofloxacin,
hydantoins18
Drug-Nutrient
Interaction
Decrease fat, cholesterol
and calories if needed,
avoid grape fruit and
citrus related fruits11
Need to be take on empty
stomach w/ water, avoid
alcohol11
Avoid SJW, ginkgo,
ginseng or valerian,
caution with cardiac
disease and decreased
renal function11
Consider the sodium
content with decreased
sodium diet, take iron
separately 1hr before or 2
hrs after drug, caution
with calcium supply or
high milk intake, could
cause milk alkali
syndrome, increase thirst
and increase weight
(edema), monitor
electrolytes11
Diabetic meal plan to
balance meal plan with
insulin11
N/A
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Drug Nutrient Interactions case study 1

1. Identify all drug-drug interactions and then identify any drug-nutrient interactions for the medications.
See chart above
1. What medications are the most likely to have contributed to the abnormal lab values and this this diagnosis?
Why?
The sodium bicarbonate would have increased his blood pH
Diovan could have caused his high glucose
BUN and creatinine can increase with furosemide
1. What does the HbA1c measure? What can this value tell you about Mr. Keisers overall control over his
diabetes?
HbA1c measures average blood glucose over the past 2 or 3 months. It measures what
percentage of hemoglobin is coated with glycated19
Mr. Keisers A1C is very high- 8.2
This means that he is not controlling his diabetes very well. Because this test determines blood
glucose management over a period of time and this high level indicates that he has not controlled
it well at all.
1. From the information gathered within the clinical domain, list possible nutrition problems using the
diagnostic term.
Excessive carbohydrate intake
Inadequate fluid intake
1. List possible behavioral-environmental nutrition problems.
Mr. Keiser does not necessarily see diabetes control as a priority
His daughter thinks that his medications are his responsibility which is clearly a problem
He has to prepare his own breakfast and has corn flakes twice a week which is not conducive to a
diabetes patient
1. Select two high priority nutrition problems and complete PES statements for each.
Excessive carbohydrate intake related to uncontrolled diabetes as evidenced by a high HBA1C
and blood glucose
Inadequate fluid intake related to decreased thirst sensation as evidenced by mild dehydration
1. For each of the PES statements that you have written, establish an ideal goal (based on the signs and
symptoms) and an appropriate intervention (based on the etiology).
Goal 1- to reduce A1C and be within a normal range
Intervention 1- switch to low glycemic index carbohydrates
Goal 2- improve daily fluid intake
Intervention 2- consume at least 1mL of liquid her kg of body weight per day
1. Would you make diabetes education a priority in your nutrition counseling for Mr. Keiser? What methods
might you use to help maximize his glucose control? How would you assess the patients and daughters
readiness for change?
I would definitely make diabetes education a priority for Mr. Keiser. I do recognize that he is 85
so expecting him to completely change his lifestyle and eating patterns is unlikely but there are
so many complications that can be associated with uncontrolled diabetes that making him more
aware of ways to manage it will make him a lot more comfortable. I would suggest that he does
not eat fruit, bread and a starch for dinner at night. He should be choosing one of these items or
maybe two if one of them is the fruit. I would also introduce him to the exchange list so that he
and his daughter could make better decisions for his diabetes. I dont honestly think that his

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daughter is ready to change or help him change. I understand where she is coming from saying
that she doesnt think its necessary at his age to really change anything but he will become very
unhappy and uncomfortable when he will inevitably experience the complications that come with
diabetes. I do think that Mr. Keiser wants to change though I just think that his daughter is
holding him back.

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Drug Nutrient Interactions case study 1

References
References

1. GALLA J. Metabolic Alkalosis. Jasnasnjournalsorg. 2017. Available at:

http://jasn.asnjournals.org/content/11/2/369.full. Accessed September 19, 2017.
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September 19, 2017.
3. Coronary artery disease - Overview. Mayo Clinic. 2017. Available at: http://www.mayoclinic.org/diseases-
conditions/coronary-artery-disease/home/ovc-20165305. Accessed September 19, 2017.
4. 2017. Available at: 8. http://www.mayoclinic.org/diseases-conditions/type-2-diabetes/symptoms-causes/dxc-20169861.
Accessed September 19, 2017.
5. 2017. Available at: 9. http://www.mayoclinic.org/diseases-conditions/peripheral-neuropathy/symptoms-causes/dxc-
20204947. Accessed September 19, 2017.
6. 2017. Available at: 10. http://www.mayoclinic.org/diseases-conditions/kidney-failure/basics/symptoms/con-20024029.
Accessed September 19, 2017.
7. Dehydration - Symptoms - NHS Choices. Nhsuk. 2017. Available at:
http://www.nhs.uk/Conditions/Dehydration/Pages/Symptoms.aspx. Accessed September 19, 2017.
8. Staying Hydrated - Staying Healthy. Heartorg. 2017. Available at:
http://www.heart.org/HEARTORG/HealthyLiving/PhysicalActivity/FitnessBasics/Staying-Hydrated---Staying-
Healthy_UCM_441180_Article.jsp#.WamAnD6GPIU. Accessed September 19, 2017.
9. THE AGING KIDNEY: PHYSIOLOGICAL CHANGES. Adv Chronic Kidney Dis. 2017;17(4).
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10. Maher R, Hanlon J, Hajjar E. Clinical Consequences of Polypharmacy in Elderly. Expert Opin Drug Saf. 2017;13.
doi:10.1517/14740338.2013.827660.
11. Pronsky Z, Elbe D, Ayoob K. Food Medication Interactions. Birchrunville (Penn.): Food-Medication Interactions;
2015.
12. St-Onge M, Gallagher D. Body composition changes with aging: The cause or the result of alterations in metabolic
rate and macronutrient oxidation?. Nutrition. 2010. doi:10.1016/j.nut.2009.07.004.
13. WHO | Nutrition for older persons. Whoint. 2017. Available at:
http://www.who.int/nutrition/topics/ageing/en/index1.html. Accessed September 19, 2017.
14. Dehydration in the elderly - British Nutrition Foundation. Nutritionorguk. 2014. Available at:
https://www.nutrition.org.uk/nutritionscience/life/dehydrationelderly.html. Accessed September 19, 2017.
15. Special Nutrient Needs of Older Adults. wwweatrightorg. 2015. Available at:
http://www.eatright.org/resource/health/wellness/healthy-aging/special-nutrient-needs-of-older-adults. Accessed
September 19, 2017.
16. Understanding Your Lab Values. The National Kidney Foundation. 2017. Available at:
https://www.kidney.org/atoz/content/understanding-your-lab-values. Accessed September 19, 2017.

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17. Acidosis/Alkalosis. Labtestsonlineorg. 2014. Available at:

https://labtestsonline.org/understanding/conditions/acidosis/start/2/. Accessed September 19, 2017.
18. Drug Information. Rxlistcom. Available at: http://Rxlist.com. Accessed September 19, 2017.
19. A1C test - Overview. Mayo Clinic. 2016. Available at: http://www.mayoclinic.org/tests-procedures/a1c-
test/home/ovc-20167930. Accessed September 19, 2017.

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