Thank you for your informative post. I do agree that St. Johnâ€™s wort inhibit some medications that is known to be metabolized by cytochrome P-450 (CYP3A4). St Johnâ€™s wort according to National Institute of Health [NIH] 2022) is a plant that grows in the wild and has been used for centuries to treat mental health conditions, and widely prescribed for depression. It also limits the effectiveness of many medications and when used in combination with other anti-depressants it can lead to potentially life-threatening increase in the serotonin of the body. Drug to drug interactions are common in pharmacology. Woo et al., (2020) shared that there are limited number of drug metabolizing enzymes, and they can only metabolize one drug molecule at a time. Hence when several drugs are metabolized by a single enzyme, each of the drugs will be metabolized in proportion to the affinity of the drug-enzyme interaction. When drugs are mobilized and altered by chemicals, they form metabolites. The toxicity of a medication is dependent on the degree by which the level of metabolism is decreased or increased and the effect it has on the onset or duration of drugs. Because chemicals are changed during the process of metabolism and most of this occurs in the liver, it is imperative that prescribes become aware of any liver impairment before prescribing.The patient has been taking herbal medicine for a period is a strong believer. Since St. Johnâ€™s wort is metabolized by the liver and is known to have properties that inhibits the breakdown of drugs that are metabolized by the enzyme cytochrome P-450 (CYP3A4), prescribers must take a thorough medication history before prescribing to reduce the likelihood of this interaction occurring. Science-Direct (2018) shared that CYP3A4 is the most abundant human hepatic P450 and oxidizes about 27% of the drugs that are under development and used in patients.ReferencesScience-Direct. (2018). The time dependent effects of Saint Johnâ€™s wort on cytochrome P 450, uridine diphosphate-glucuronosyltransferase, glutathione S-transferase, and NAD (P) H-quinone oxidoreductase in mice. Journal of food and drug analysis, 26(1), 422-431. https://doi.org/10.1016/j.jfda.2017.01.004National Institute of Health. (2022). St. Johnâ€™s wort and depression: In depth. https://www.nccih.nih.gov/health/st-johns-wort-and-depression-in-depthWoo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5th ed.). Philadelphia, PA: F.A. Davis Company.
Your explanations regarding the case study are very thorough and well thought out. Patients utilize a variety of medications that include herbal medications. Metronidazole undergoes metabolism by the CYP 450 system and inhibitors such as St Johnâ€™s Wort can affect the concentration of metronidazole that can affect clearance of the medications (Woo & Robinson, 2020, p. 792). Nurse practitioners have the responsibility to perform thorough medication reconciliation at each patient visit. NPs need to educate patients regarding herbal medications and potential side effects that can occur with co-administration.Proton pump inhibitors such as Esomeprazole, are very effective in reducing acid production that patients are at risk for iron deficiency anemia, vitamin B12 deficiency, and calcium deficiencies (Ali et al., 2009; Lodato et al., 2010; in Woo & Robinson, 2020). Long-term use of PPIs causes changes in the cellular level of the gastric mucosal cells, placing patients at risk of developing gastric carcinoid tumors (Ali et al., 2009; Lodato et al., 2010: in Woo & Robinson, 2020), p. 529).References:Woo, T., & Robinson, M. (2020). Pharmacotherapeutics for Advance Practice Nurse Prescribers (5th ed), FA Davis Company, p. 529, 792.