DQ-1 Protonix and drug-drug interactions with Warfarin for treatment of GI ulcer and deep vein thrombosis with elevated INR The background of this study includes a patient who was at high risk for ulcers and was prescribed Pantoprazole which is commonly used as prophylaxis of ulcers (Chandelia & Dubey, 2016). The patient was also taking Warfarin daily due to a discovery of a deep vein thrombosis of the circumflex vein, common femoral vein, superficial vein, and popliteal vein (Chandelia & Dubey, 2016). This patient was also in the ICU (Chandelia & Dubey, 2016). Initially, heparin was started on this patient and the healthcare team was able to keep the INR within normal limits of their heparin protocol (Chandelia & Dubey, 2016). However, when switching to Warfarin with a standard dose of 0.2 mg/kg (8mg/day) for this patient to maintain an INR of 2.5, there were some issues associated with it. On day 3 the INR came back elevated at 6.0, so there was a reduction of warfarin by 20% (Chandelia & Dubey, 2016). After two days, the INR was still elevated at 5.0, and another reduction by 20% without success (Chandelia & Dubey, 2016). At this time the healthcare team decided to look at the medications and foods the patient was eating. First, the healthcare team decided to compile a list of the patient's medications and foods and found that the patient was not receiving any garlic, mango, papaya or fish (Chandelia & Dubey, 2016). The patient's medications were ceftriaxone, vancomycin, and pantoprazole, but the team was unable to stop the antibiotics, so they decided to stop the pantoprazole. After three days post discontinuation of pantoprazole, the INR had dropped to 1.4 without any change in the dose of warfarin (Chandelia & Dubey, 2016). Most importantly, at this point, the healthcare team had to increase the warfarin dose back to the original 8mg/day to get the patient's INR into the therapeutic range (Chandelia & Dubey, 2016). There was an 87.5% reduction in the dose of warfarin when given with pantoprazole (Chandelia & Dubey, 2016). The rationale behind the drug to drug interaction is that warfarin undergoes metabolism by CYP1A2, CYP2C19, and CYP3A4 (Crader, Johns & Arnold, 2019). Pantoprazole has been shown to strongly inhibit CYP2C9 activity (Chandelia & Dubey, 2016). This metabolite inhibition and interaction is what causes the low metabolism of warfarin and leads to the elevated INR (Crader, Johns & Arnold, 2019). An alternate therapy suggested would be to use heparin subcutaneous injections through the hospital and at home until they need for pantoprazole has been resolved (Chandelia & Dubey, 2016). The issue is that the first and second-line proton pump inhibitors are inhibitors of CYP2C9 (Chandelia & Dubey, 2016). In this scenario, the only drug change that can occur is with warfarin to heparin and/or Lovenox (Chandelia & Dubey, 2016). Thought behind this is that in patients who can't tolerate oral warfarin, due to side effects, they c ...

1. DQ-1
Protonix and drug-drug interactions with Warfarin for treatment
of GI ulcer and deep vein thrombosis with elevated INR
The background of this study includes a patient who was at high
risk for ulcers and was prescribed Pantoprazole which is
commonly used as prophylaxis of ulcers (Chandelia & Dubey,
2016). The patient was also taking Warfarin daily due to a
discovery of a deep vein thrombosis of the circumflex vein,
common femoral vein, superficial vein, and popliteal vein
(Chandelia & Dubey, 2016). This patient was also in the ICU
(Chandelia & Dubey, 2016).
Initially, heparin was started on this patient and the healthcare
team was able to keep the INR within normal limits of their
heparin protocol (Chandelia & Dubey, 2016). However, when
switching to Warfarin with a standard dose of 0.2 mg/kg
(8mg/day) for this patient to maintain an INR of 2.5, there were
some issues associated with it. On day 3 the INR came back
elevated at 6.0, so there was a reduction of warfarin by 20%
(Chandelia & Dubey, 2016). After two days, the INR was still
elevated at 5.0, and another reduction by 20% without success
(Chandelia & Dubey, 2016). At this time the healthcare team
decided to look at the medications and foods the patient was
eating.
First, the healthcare team decided to compile a list of the
patient's medications and foods and found that the patient was
not receiving any garlic, mango, papaya or fish (Chandelia &
Dubey, 2016). The patient's medications were ceftriaxone,
vancomycin, and pantoprazole, but the team was unable to stop
the antibiotics, so they decided to stop the pantoprazole.
After three days post discontinuation of pantoprazole, the INR

2. had dropped to 1.4 without any change in the dose of warfarin
(Chandelia & Dubey, 2016). Most importantly, at this point, the
healthcare team had to increase the warfarin dose back to the
original 8mg/day to get the patient's INR into the therapeutic
range (Chandelia & Dubey, 2016). There was an 87.5%
reduction in the dose of warfarin when given with pantoprazole
(Chandelia & Dubey, 2016).
The rationale behind the drug to drug interaction is that
warfarin undergoes metabolism by CYP1A2, CYP2C19, and
CYP3A4 (Crader, Johns & Arnold, 2019). Pantoprazole has
been shown to strongly inhibit CYP2C9 activity (Chandelia &
Dubey, 2016). This metabolite inhibition and interaction is what
causes the low metabolism of warfarin and leads to the elevated
INR (Crader, Johns & Arnold, 2019).
An alternate therapy suggested would be to use heparin
subcutaneous injections through the hospital and at home until
they need for pantoprazole has been resolved (Chandelia &
Dubey, 2016). The issue is that the first and second-line proton
pump inhibitors are inhibitors of CYP2C9 (Chandelia & Dubey,
2016). In this scenario, the only drug change that can occur is
with warfarin to heparin and/or Lovenox (Chandelia & Dubey,
2016).
Thought behind this is that in patients who can't tolerate oral
warfarin, due to side effects, they could take pantoprazole and a
lower amount of warfarin by 87.5% in order to achieve the same
INR.
References:
Chandelia, S., & Dubey, N. K. (2016). Warfarininduced raised
international normalized ratio is further prolonged by
pantoprazole. Indian Journal of Critical Care Medicine, 20(2),
127–128. https://doi-org.lopes.idm.oclc.org/10.4103/0972-
5229.175934
Crader, M..F, Johns, T. & Arnold, J.K. (2019). Warfarin Drug
Interactions. StatPearls Publishing. Retrieved from:

3. https://www.ncbi.nlm.nih.gov/books/NBK441964/
DQ-2
Polyethylene glycol mechanism of action is that it is an osmotic
agent that binds water and retains the water in the stool (Jacobs
et al., 2019). The effectiveness of polyethylene glycol is
contributed to the lack of enzyme metabolism of the drug in the
intestinal tract (Jacobs et al., 2019). Polyethylene glycol is also
shown to increase stool weight, soften stool, increase frequency,
and helps facilitate evacuation (Jacobs et al., 2019).
Polyethylene glycol pharmacokinetics is that it is administered
orally in water as a solution, and mostly stays in the GI tract
and is eliminated the same way (Jacobs et al., 2019). Some
studies have shown 0.2% has been absorbed systemically but
then quickly excreted in urine (Jacobs et al., 2019). As a side
note, Polyethylene glycol is not fermented within the GI tract
by colonic microflora (Jacobs et al., 2019).
The indications for Miralax is for occasional constipation in
adults 17 years and older (5B Constipation and bowel cleansers,
2016). Also, polyethylene glycol is safe to use during pregnancy
since it is not systematically absorbed (Jacobs et al., 2019).
Drug interactions with polyethylene glycol are extensive when
the drugs are taken by the oral route (Jacobs et al., 2019). This
is mostly due to the increase in movement in the GI system,
which decreases the time allowed for the absorption of oral
medications (Jacobs et al., 2019). Closer monitoring of oral
drugs when polyethylene glycol is recommended as well as
titration for the efficacy of desired effects and outcomes (Jacobs
et al., 2019).
Side effects include bowel obstruction, nausea, vomiting,
abdominal pain, and irritable bowel syndrome (5B Constipation
and bowel cleansers, 2016). Contraindications include bowel

4. obstruction, renal insufficiency, hepatic impairment, and avoid
prolonged use (5B Constipation and bowel cleansers, 2016).
In terms of use of polyethylene glycol for the use of
constipation and the incidence of C. Diff, studies have shown
that out of seven hundred and fifty tests, five hundred and
thirty-five C. Diff tests were done where the patient had
ingested polyethylene glycol 48 hours prior to the test,
compared to the control group, causes an unnecessary rise in the
testing of patients (Carter & Malani, 2018). This study
theorized that the increase in test frequency also led to a rise in
false-positive tests due to colonization and not infection, and
unnecessary treatment of C-Diff (Carter & Malani, 2018). A
secondary thought in the study was that if the increase of
unnecessary treatment occurred, so did the risk of creating
antibiotic resistance, leading to worse outbreaks as 20% of C-
diff infections are hospital-acquired (Carter & Malani, 2018). A
proposed solution was to create a questionnaire for staff to
complete that includes the signs and symptoms of C. Diff as
well as information regarding laxatives and stool softeners and
last administration date (Carter & Malani, 2018).
References:
5B Constipation and bowel cleansers. (2016). MPR - Physician
Assistants’ Edition, 23(2), 54–55.
Carter, K. A., & Malani, A. N. (2019). Laxative use and testing
for Clostridium difficile in hospitalized adults: An opportunity
to improve diagnostic stewardship. American Journal of
Infection Control, 47(2), 170–174. https://doi-
org.lopes.idm.oclc.org/10.1016/j.ajic.2018.08.008
Jacobs, C., Brar, T., Riverso, M., Perbtani, Y. B., & Yang, D.
(2019). Abdominal Pain due to Opioid-Induced Constipation.
ACG Case Reports Journal, 6(11), 1–2. https://doi-
org.lopes.idm.oclc.org/10.14309/crj.0000000000000288
DQ-3

5. There are frequent drugs that interact with antacids. One of the
drugs that frequent is in high alert for antacids interactions is
tetracycline. People that may suffer from an upset stomach are
often told to take some sort of antacid. Antacids contain
calcium, magnesium, aluminum, sodium bicarbonate, iron and
zinc. Antacids are known to alter and increase the Ph of the
stomach content. This creates a problem towards the absorption
of tetracycline. With higher Ph the less the breakdown of
tetracycline and the slower the absorption
(Deglin,Vallerand,Sanoski,2018). Magnesium can bind to the
tetracycline antibiotic and decrease its absorption. This may
have an effect on magnesium concentrations as well. Low body
magnesium can have some side effects. Some side effects of low
magnesium are nausea, fatigue, numbness, tingling, unwanted
muscle contraction (Beware Mixing Antibiotics With
Magnesium,2015). Magnesium deficiencies can worsen existing
medical conditions. Studies have shown that having
hypomagnesemia and electrolyte imbalance may lead to
recurrent acute asthma episodes (Mohammad,Abdulazez,
Mahmoud, Emam, (2014). The patient must wait 1 to 2 hours
after taking tetracycline in order to begin supplementation of
magnesium or calcium. This will ensure that maximum
absorption of tetracycline can enter the patient’s body. If I were
the provider, I will instruct the patient to take their prescribed
antacid only when needed. I will also inform the patient that
antacids need to be taken 3 hours apart from antibiotic therapy.
In the case where the patient is having difficulty coordinating
the specific instructions, I will probably switch the antibiotic
therapy to something less controversial such as Keflex.
Reference
Bai, G. P., & Ravikumar, P. (2013). Study of prevalence of
hypomagnesemia and its impact on the severity of acute asthma.
Journal of Evolution of Medical and Dental Sciences, 30, 5693.
Deglin, J. H., Vallerand, A. H., & Sanoski, C. A. (2018).
Daviss drug guide for nurses. Philadelphia: F.A. Davis (380-
385).

6. Hala A. Mohammad, Mohammad T. Abdulfttah, Ali O.
Abdulazez, Ahmed M. Mahmoud, & Rasha M. Emam. (2014). A
study of electrolyte disturbances in patients with chronic stable
asthma and with asthma attacks. Egyptian Journal of Chest
Disease and Tuberculosis, 3, 529.
https://doi.org/10.1016/j.ejcdt.2014.03.010
The meme I chose to represent geography in Europe was
the Patrick Man Ray scene meme. (actual scene for context:
https://www.youtube.com/watch?v=Z0Pq7Y8gt-8 ).
This Brexit meme makes fun of the fact that the United
Kingdom voted to leave the EU on a specific day, March 29th,
2019. However, when that day comes the UK is not ready, as
they have not decided whether they want a hard exit or soft exit.
As a result, the UK voted to extend their Brexit day until later
in the year, October 31st.
Of course, there is much more than simply “leaving” the EU.
The UK has its citizens living or spending extended periods of
time in other EU countries. Should the UK leave the EU while
its citizens are away, it would complicate things for them while
away. Also, the UK and the EU have not agreed on what to do
with the border between Northern Ireland and Ireland. The two
different countries are currently both part of the EU. As a
result, the two countries have a soft border. People, goods, and
livestock can pass through easily. If the UK were to exit the
EU, the border would have to become stricter, or hard. This is
something the UK, Ireland, and the EU all do not want. This
would cause issues with travel and trade between the two
countries. The United Kingdom is still having difficulty

7. creating a deal that would satisfy both the will of the people
(referendum vote) and the country’s identity after they
withdraw.
Personally, I don’t think delaying the withdrawal date will help
Parliament come to a deal decision. It will only give lawmakers
more time to think of reasons to disagree with one another.
Overall, I think my meme gives a funny perspective of
America’s view on the Brexit ordeal: The UK votes to withdraw
from the EU. The withdrawal date comes. Britain does not want
to leave.
326 words
Europe Meme and written explanation
Due – Friday 12 PM (Eastern Time)
Points - 5
Instructions
Prepare a Meme that illustrates a concept of Geography in
Europe. Provide a written explanation of the Meme (300 words,
minimum). You may submit the items separately.
Please be creative. Ask me if you need clarifications.
Include Resources.
DQ-1
Protonix and drug-drug interactions with Warfarin for treatment
of GI ulcer and deep vein thrombosis with elevated INR

8. The background of this study includes a patient who was at high
risk for ulcers and was prescribed Pantoprazole which is
commonly used as prophylaxis of ulcers (Chandelia & Dubey,
2016). The patient was also taking Warfarin daily due to a
discovery of a deep vein thrombosis of the circumflex vein,
common femoral vein, superficial vein, and popliteal vein
(Chandelia & Dubey, 2016). This patient was also in the ICU
(Chandelia & Dubey, 2016).
Initially, heparin was started on this patient and the healthcare
team was able to keep the INR within normal limits of their
heparin protocol (Chandelia & Dubey, 2016). However, when
switching to Warfarin with a standard dose of 0.2 mg/kg
(8mg/day) for this patient to maintain an INR of 2.5, there were
some issues associated with it. On day 3 the INR came back
elevated at 6.0, so there was a reduction of warfarin by 20%
(Chandelia & Dubey, 2016). After two days, the INR was still
elevated at 5.0, and another reduction by 20% without success
(Chandelia & Dubey, 2016). At this time the healthcare team
decided to look at the medications and foods the patient was
eating.
First, the healthcare team decided to compile a list of the
patient's medications and foods and found that the patient was
not receiving any garlic, mango, papaya or fish (Chandelia &
Dubey, 2016). The patient's medications were ceftriaxone,
vancomycin, and pantoprazole, but the team was unable to stop
the antibiotics, so they decided to stop the pantoprazole.
After three days post discontinuation of pantoprazole, the INR
had dropped to 1.4 without any change in the dose of warfarin
(Chandelia & Dubey, 2016). Most importantly, at this point, the
healthcare team had to increase the warfarin dose back to the
original 8mg/day to get the patient's INR into the therapeutic
range (Chandelia & Dubey, 2016). There was an 87.5%

9. reduction in the dose of warfarin when given with pantoprazole
(Chandelia & Dubey, 2016).
The rationale behind the drug to drug interaction is that
warfarin undergoes metabolism by CYP1A2, CYP2C19, and
CYP3A4 (Crader, Johns & Arnold, 2019). Pantoprazole has
been shown to strongly inhibit CYP2C9 activity (Chandelia &
Dubey, 2016). This metabolite inhibition and interaction is what
causes the low metabolism of warfarin and leads to the elevated
INR (Crader, Johns & Arnold, 2019).
An alternate therapy suggested would be to use heparin
subcutaneous injections through the hospital and at home until
they need for pantoprazole has been resolved (Chandelia &
Dubey, 2016). The issue is that the first and second-line proton
pump inhibitors are inhibitors of CYP2C9 (Chandelia & Dubey,
2016). In this scenario, the only drug change that can occur is
with warfarin to heparin and/or Lovenox (Chandelia & Dubey,
2016).
Thought behind this is that in patients who can't tolerate oral
warfarin, due to side effects, they could take pantoprazole and a
lower amount of warfarin by 87.5% in order to achieve the same
INR.
References:
Chandelia, S., & Dubey, N. K. (2016). Warfarininduced raised
international normalized ratio is further prolonged by
pantoprazole. Indian Journal of Critical Care Medicine, 20(2),
127–128. https://doi-org.lopes.idm.oclc.org/10.4103/0972-
5229.175934
Crader, M..F, Johns, T. & Arnold, J.K. (2019). Warfarin Drug
Interactions. StatPearls Publishing. Retrieved from:
https://www.ncbi.nlm.nih.gov/books/NBK441964/
DQ-2
Polyethylene glycol mechanism of action is that it is an osmotic
agent that binds water and retains the water in the stool (Jacobs

10. et al., 2019). The effectiveness of polyethylene glycol is
contributed to the lack of enzyme metabolism of the drug in the
intestinal tract (Jacobs et al., 2019). Polyethylene glycol is also
shown to increase stool weight, soften stool, increase frequency,
and helps facilitate evacuation (Jacobs et al., 2019).
Polyethylene glycol pharmacokinetics is that it is administered
orally in water as a solution, and mostly stays in the GI tract
and is eliminated the same way (Jacobs et al., 2019). Some
studies have shown 0.2% has been absorbed systemically but
then quickly excreted in urine (Jacobs et al., 2019). As a side
note, Polyethylene glycol is not fermented within the GI tract
by colonic microflora (Jacobs et al., 2019).
The indications for Miralax is for occasional constipation in
adults 17 years and older (5B Constipation and bowel cleansers,
2016). Also, polyethylene glycol is safe to use during pregnancy
since it is not systematically absorbed (Jacobs et al., 2019).
Drug interactions with polyethylene glycol are extensive when
the drugs are taken by the oral route (Jacobs et al., 2019). This
is mostly due to the increase in movement in the GI system,
which decreases the time allowed for the absorption of oral
medications (Jacobs et al., 2019). Closer monitoring of oral
drugs when polyethylene glycol is recommended as well as
titration for the efficacy of desired effects and outcomes (Jacobs
et al., 2019).
Side effects include bowel obstruction, nausea, vomiting,
abdominal pain, and irritable bowel syndrome (5B Constipation
and bowel cleansers, 2016). Contraindications include bowel
obstruction, renal insufficiency, hepatic impairment, and avoid
prolonged use (5B Constipation and bowel cleansers, 2016).
In terms of use of polyethylene glycol for the use of
constipation and the incidence of C. Diff, studies have shown
that out of seven hundred and fifty tests, five hundred and

11. thirty-five C. Diff tests were done where the patient had
ingested polyethylene glycol 48 hours prior to the test,
compared to the control group, causes an unnecessary rise in the
testing of patients (Carter & Malani, 2018). This study
theorized that the increase in test frequency also led to a rise in
false-positive tests due to colonization and not infection, and
unnecessary treatment of C-Diff (Carter & Malani, 2018). A
secondary thought in the study was that if the increase of
unnecessary treatment occurred, so did the risk of creating
antibiotic resistance, leading to worse outbreaks as 20% of C-
diff infections are hospital-acquired (Carter & Malani, 2018). A
proposed solution was to create a questionnaire for staff to
complete that includes the signs and symptoms of C. Diff as
well as information regarding laxatives and stool softeners and
last administration date (Carter & Malani, 2018).
References:
5B Constipation and bowel cleansers. (2016). MPR - Physician
Assistants’ Edition, 23(2), 54–55.
Carter, K. A., & Malani, A. N. (2019). Laxative use and testing
for Clostridium difficile in hospitalized adults: An opportunity
to improve diagnostic stewardship. American Journal of
Infection Control, 47(2), 170–174. https://doi-
org.lopes.idm.oclc.org/10.1016/j.ajic.2018.08.008
Jacobs, C., Brar, T., Riverso, M., Perbtani, Y. B., & Yang, D.
(2019). Abdominal Pain due to Opioid-Induced Constipation.
ACG Case Reports Journal, 6(11), 1–2. https://doi-
org.lopes.idm.oclc.org/10.14309/crj.0000000000000288
DQ-3
There are frequent drugs that interact with antacids. One of the
drugs that frequent is in high alert for antacids interactions is
tetracycline. People that may suffer from an upset stomach are
often told to take some sort of antacid. Antacids contain
calcium, magnesium, aluminum, sodium bicarbonate, iron and

12. zinc. Antacids are known to alter and increase the Ph of the
stomach content. This creates a problem towards the absorption
of tetracycline. With higher Ph the less the breakdown of
tetracycline and the slower the absorption
(Deglin,Vallerand,Sanoski,2018). Magnesium can bind to the
tetracycline antibiotic and decrease its absorption. This may
have an effect on magnesium concentrations as well. Low body
magnesium can have some side effects. Some side effects of low
magnesium are nausea, fatigue, numbness, tingling, unwanted
muscle contraction (Beware Mixing Antibiotics With
Magnesium,2015). Magnesium deficiencies can worsen existing
medical conditions. Studies have shown that having
hypomagnesemia and electrolyte imbalance may lead to
recurrent acute asthma episodes (Mohammad,Abdulazez,
Mahmoud, Emam, (2014). The patient must wait 1 to 2 hours
after taking tetracycline in order to begin supplementation of
magnesium or calcium. This will ensure that maximum
absorption of tetracycline can enter the patient’s body. If I were
the provider, I will instruct the patient to take their prescribed
antacid only when needed. I will also inform the patient that
antacids need to be taken 3 hours apart from antibiotic therapy.
In the case where the patient is having difficulty coordinating
the specific instructions, I will probably switch the antibiotic
therapy to something less controversial such as Keflex.
Reference
Bai, G. P., & Ravikumar, P. (2013). Study of prevalence of
hypomagnesemia and its impact on the severity of acute asthma.
Journal of Evolution of Medical and Dental Sciences, 30, 5693.
Deglin, J. H., Vallerand, A. H., & Sanoski, C. A. (2018).
Daviss drug guide for nurses. Philadelphia: F.A. Davis (380-
385).
Hala A. Mohammad, Mohammad T. Abdulfttah, Ali O.
Abdulazez, Ahmed M. Mahmoud, & Rasha M. Emam. (2014). A
study of electrolyte disturbances in patients with chronic stable
asthma and with asthma attacks. Egyptian Journal of Chest
Disease and Tuberculosis, 3, 529.

13. https://doi.org/10.1016/j.ejcdt.2014.03.010
Need help to reply three post.
DO NOT JUST REPEAT SAME INFORMATION, DO NOT
JUST SAY I AGREE OR THINGS LIKE THAT. YOU NEED
TO ADD NEW INFORMATION TO DISCUSSION.
1- Each reply should be at least 200 words.
2- Minimum One scholarly reference ( NO MAYO CLINIC/
AHA)
3- APA 6th edition style needs to be followed.
4- Each response should have reference at the end of each reply
5- Reference should be within last 5 years