1. Write Peer Comment:
   • Length: A minimum of 180 words, not including references
   • Citations: At least one high-level scholarly reference in APA from within the last 5 years
   • Relate original post to a different study/reference

1. Explain the cause of this patient’s difficulty in maintaining her balance.

Diazepam (valium) belongs to the benzodiazepine medication class, which is used for anxiety disorders, alcohol detoxification, muscle spasms, motor neuro disorders, seizures, and some other indications (Dhaliwal, Rosani, & Saadabadi, 2022). Hypotension and syncope are the two common adverse effects of diazepam; especially in the older generation whose renal function and clearance may decrease, the risk of diazepam accumulation may increase and cause this population to have a higher risk of experiencing the adverse effects (Dhaliwal, Rosani, & Saadabadi, 2022). Thus, the nurse practitioner needs to consider lessening the dosage in the older population.

1. Diazepam experiences a significant first-pass effect. What is the first-pass effect, and how can first-pass metabolism be circumvented?

According to the article by Herman and Santos, the first-pass effect occurs after the medication is absorbed in the body and then metabolized at a specific location (mainly in the liver) which results in the reduction of its active form before reaching the site of action or the body circulation (Herman & Santos, 2022). 

Diazepam is metabolized in the liver into its active form, which is desmethyldiazepam, by enzymes YP2C19 and CYP3A4 (Dhaliwal, Rosani, & Saadabadi, 2022). Diazepam’s peak plasma concentration is about 1 to 1.5 hours and its half-life can reach 46 to 100 hours (Dhaliwal, Rosani, & Saadabadi, 2022). In urgent situations such as active seizures, to prevent the first-pass effect and achieve fast results, intravenous diazepam can be administered.

1. What is likely to cause the signs of confusion after taking cold medication?

As the elderly population’s pharmacokinetic functions decrease, medications can accumulate in the system and delay excretion (Healthy Aging, 2023). Diphenhydramine is the first-generation antihistamine used in different conditions such as allergies, colds, insomnia, etc. can cause serious adverse effects in older people, including “confusion, blurred vision, constipation, problems urinating, and dry mouth” (Healthy Aging, 2023). Diphenhydramine can cross the blood-brain barrier easily and can depress the H1 receptors in the central nervous system; however, this action may be increased in the elderly and cause unwanted effects (Sicari & Zabbo., 2023). 

1. How is warfarin metabolized? Does warfarin cross the placental barrier?

Warfarin is a common anticoagulant used for prophylaxis or treatment of venous thrombosis and thromboembolic events (Patel, Singh, Preuss, & Patel., 2023). Warfarin is metabolized in the liver with the help of the enzyme CYP2C9 (Patel, Singh, Preuss, & Patel., 2023). According to the article by Patel and their co-authors, warfarin can be used for pregnant women with a history of mechanical valves due to the high risk of thromboembolism in this population despite warfarin crossing the placental barrier (2023).

1. Explain the hepatic drug metabolism of children 1 year and older. How do they compare with the hepatic drug metabolism of infants and adults?

Children 1 year and older can metabolize most drugs as the liver enzymes mature at that time (Brian J. Anderson, 2019). In addition, children’s basal metabolism rate is 1.5 – 2 times higher than adults so medications can be metabolized faster (Brian J. Anderson, 2019). Also, children have more liver blood flow compared to adults. The first-pass effect in children can be increase (Brian J. Anderson, 2019).  

1. Explain protein binding in neonates.

Neonates have low serum albumin in their blood stream, as well as the endogenous compounds so the drug-protein binding in neonates is limited (Rosenthal & Burchum, 2019). This can lead to high drug levels in neonates’ bloodstream and increase the risk for toxicity; thus, dosage calculation should be considered thoughtfully (Rosenthal & Burchum, 2019).

References

Brian J. Anderson, J. L. (2019). Pharmacokinetics and Pharmacology of Drugs Used in Children. A Practice of Anesthesia for Infants and Children (Sixth Edition).

Dhaliwal, J. S., Rosani, A., & Saadabadi, A. (2022). Diazepam. StatPearls.

Healthy Aging. (2023). Learn More: Ten Medications Older Adults Should Avoid Or Use With Caution. Retrieved from https://www.healthinaging.org: https://www.healthinaging.org/tools-and-tips/learn…

Herman, T. F., & Santos, C. (2022). First Pass Effect. StatPearls.

Patel, S., Singh, R., Preuss, C. V., & Patel., N. (2023). Warfarin. StatPearls.

Rosenthal, L. D., & Burchum, J. R. (2019). Lehne’s Pharmacotherapeutics for Advanced Practice Nurses and Physician Assistants. Elsevier.

Sicari, V., & Zabbo., C. P. (2023). Diphenhydramine. StatPearls .