Hydroxyurea and its use in Sickle Cell Hydroxyurea, a drug which can be used for cancer but known mainly for its use in Sickle Cell Disease(SCD). With its unique name, it is a drug that’s known very well in the medical profession. Hydroxyurea is known to minimize the occurrence of pain crises and the indication for blood transfusions (Ballas, 2010). A vast majority a SCD have experienced more side effects from this supposed cure. However, with any drug, there can be ethical dilemma’s faced in regards to autonomy which is the patient’s choice, non-maleficence, the intent to do no harm, beneficence, the duty to do good to others, and lastly, justice to do what’s right and just. Often times healthcare specialists have the urge to heal the sick at all cost, and thereby unintentionally impinge on patient’s autonomy (Childress & Beauchamp, 2013). When it comes to this type of medication, the correlated side effects can emit more harm than good. Side effects including leukopenia, thrombocytopenia, alopecia, stomatitis, nausea and vomiting, infertility, severe bone marrow suppression, neuropathy, pulmonary fibrosis) can lead to long lasting effects and may impact the quality of life of Sickle Cell patients in the long-term (Yates, 2015). Long term effects can further lead and ongoing cycle of more pain, medication and emergency room visits with increased hospital stays. In order to manage this issue, proper apt monitoring should be done before prescribing Hydroxyurea medication for Sickle cell management. Healthcare professionals who wish to prescribe Hydroxyurea should first implement less invasive pain management options before resulting to Hydroxyurea. This paper will emphasize on the matters, the ethical aspects relevance and principles, cultural dynamic, nursing profession, and personal view regarding the risks of prescribing hydroxyurea for patients with sickle cell disease. SCD is a group of inherited or autosomal recessive red blood cell disorders. In this disorder most commonly seen in African Americans, healthy red blood cells which are meant to be round move through small blood vessels to carry oxygen to all parts of the body. Persons with SCD have red blood cells which hard and sticky and look like a C-shaped farm tool called a “sickle”. (Stanford, 2018). Consequently, the precise number is unknown, however there is an estimated count of 100,000 Americans with Sickle Cell Disease (CDC, 2018). This untimely death of red blood cells causes anemia as well as excruciating pain locally at vascular locations. This pain often times radiate due to the coagulation of RBCs. Since it was first discovered, mortality rates have substantially decreased due to disease diagnosing and early intervention in disease progression, however proper management for SCD stills needs improvement (NIH, 2018). Hydroxyurea, a myelosuppressive agent, it raises the level of HbF and the hemoglobin level. It usually decreases the rate of painful episodes by 50 %. It was first tested in sickle cell disease in 1984. It also decreases the rate of ACS episodes and blood transfusions by ~50 % in adults. ( NIH, 2018). Hydroxyurea was developed as an anticancer drug and has been used to treat myeloproliferative syndromes-leukemia, melanoma, and ovarian cancer. It was approved for use by FDA in adults ( NIH, 2018).There have been various new treatments for SCD patents, as a whole, however since Hydroxyurea is the most commonly used drug, providers in the health care system believe this is the best and only way out of this painful disorder; Hydroxyurea is all they know, even with its vast range of unsettling side effects. Issues & DimensionsHydroxyurea or Hydrea (HU) can be described as antineoplastic drug which was originally made for cancer patients. Now days SCD is known as the major indications for HU. The ultimate vision of HU was indicated to help cancer patients sustain life longevity, but it also has the ability to help the morphology of RBCs in sickling patients. HU is a medication that needs proper appraising before it is prescribed due to the numerous side effects that could potentially lead to more health concerns for patients specifically with SCD. These Side effects are very common in this group of drug known as antineoplastic drugs; This includes Leukopenia, thrombocytopenia, alopecia, stomatitis, nausea and vomiting, infertility, severe bone marrow suppression, neuropathy, pulmonary fibrosis, stroke, spleen enlargement, acute chest syndrome, and vision lost (Chemocare 2018 & NIH 2018). Sickle cell patient are already suffering from the unpredictable pain from the sickling of the cells. Therefor these additional side effects can be harmful. In addition, Sickle cell patients are at high risks for Splenomegaly and other organ enlargement as well as major bodily infections with HU (Salem, 2010). It is crucial for patients to be informed about these side effects so they can also play a vital role in choosing whether to take the drug or not. In addition, if HU is taken during pregnancy or if a patient is unknowingly pregnant, HU can cause major deformities due to its teratogenic effect (Yates, 2015). Appropriate education and guidance should be implemented as well as the option to seek alternative method. Though there may be a number of benefits from this so called treatment, the risks are very severe and most times overlooked. Policy Changes There are policies that should be enacted for health care professionals when aiding in care for patients with SCD. These policies should include but not limited to, like extended and detailed education on the administration of HU. There should be checklist that that physicians must adhere to before patients with SCD become candidates for HU. This checklist will allow patients to be informed on the risk and can choose to opt out and try alternative methods for treatment. This benefit would also aid in minimizing the unanticipated outcomes when treating patient with SCD. As stated previously, HU is known to cause organ failure. In a recent study, it revealed that long term use of HU use has been linked liver damage which is due to drug to the drug being hepatotoxic (NIH, 2018). This checklist can ensure active communication, listening and feedback between health care professionals and patients. The suggested policy change should come as followed:(a) SCD checklist with open ended questions allowing patients to properly describe symptoms and feelings towards disorder This allows for building a connection with the patient, and more importantly “rapport” so the patient isn’t afraid to express feelings. The provider should use words like ‘we’ which shows the patient that the provider is equally invested in their wellbeing of the SCD patient. Furthermore, words like ‘you’ can come off as judgmental and may discourage the SCD patient. (b) Dietary and lifestyle changes may also aid in this battle. Patients should be encouraged to exercise in moderation and encouraged to eat foods such as green leafy vegetables for RBCs production, calcium fortified, vitamin D, proteins, and water to promote cell hydration (Moore, 2018).(c) Use of analgesics and physical therapy for the treatment of avascular necrosis.(d) If all the above therapies fail for the patient that’s when HU can be introduce., Alternative treatments which have been tested to be effected should also be considered. SCD patients should be able to have an open communication to discuss their treatment plans and not be forced on using just one. There is a lack of patient education when it comes to HU. The benefits are always discussed with the patient but the risks are often put aside. Patients come in variety of backgrounds but it’s the health care provider’s duty to be informed on the patient’s learning preference as well as conduct a thorough teach-back in order to thorough understanding.Nursing Profession When it comes to the nursing profession it is the nurse’s duty to incorporate advocacy for the patient. Being a Steward is known to promote efficient care for their patients and communities. Stewardship can be viewed as taking the initiative to advocate for someone such as the patient’s and persons involved in care. Advocating for patients ’means being a helping hand and filling in the blanks when a doctor misses some parts; it is important to be honest as well because it shows adherence to the principle of beneficence. It is the nurse’s duty to provide sustainable wellness for their patients. With that said the nurses focus should be on prevention. Secondary prevention aims to reduce the incidence of disease. It involves interventions that are applied when there is evidence of disease or injury and with SCD the goal is to minimize disease progression. Though SCD is inherited and cannot be ‘prevented’, health care providers can educate on actions to help minimize crisis. Patients are to be educated on such as lifestyle changes, dietary modification, support groups, wellness classes and outside resources which can id in healing and prevention. It is crucial for physicians to allocate more time with patients as well as informing them on other treatment modalities like non-pharmacologic treatments that will help stimulate the enrichment of RBCs. Adequate and a healthy balanced is vital when treating SCD. Food sources such as vitamin C and D are necessary for bone development and can aid in the enrichment of RBCs (Moore, 2018). This plays a vital role in the disease because SCD patients can lead to joint and bone issues. Ethical Relevance and PrincipleThe ethical relevance and principals involved in this issue includes Autonomy and nonmalifecence. Physicians should seek a patients input before implementing procedures and treatments. This allows the patient to has his/her autonomy at all times. It is the duty of the physician to educate on other pharmaceutical and non-pharmaceutical regimens instead trying to coheres patients into trying to newest FDA approved treatments for their condition or the treatments they are used to providing. It is health care professional’s obligation to practice the principle of non-maleficence which goes hand in hand with beneficence (Childress & Beauchamp, 2013). One can infer that it is unwarranted to prescribe medications that is known to do more harm than good especially when there are other options available. Other options should be exhausted before prescribing HU to their SCD patients. There should also be a clear line with transparency regarding the heavy risks associated with HU. Cultural Dynamic It is important to remember that pain is always subjective and healthcare professionals should treat each patient accordingly (Ballas, 2010). Pain also varies from culture to culture; Some culture tolerate pain very well while others may not. According to a study done by Ballas, “African–Americans report greater sensitivity (i.e., lower pain threshold) and reduced pain tolerance to a variety of quantitative sensory testing methods when compared with non-Hispanic whites, including thermal pain (Ballas, 2010). One can infer that African Americans tend to have more pain compared to the majority; Furthermore, one should note that the majority of SCD patients are of African American descent due to “resistance to falciparum malaria during a critical period of early childhood, favoring survival of the host and subsequent transmission of the abnormal hemoglobin gene (Ballas, 2010)”. In fact, it is said that one out of twelve African Americans carry the SCD trait. This is why physicians should be non-biased but mindful to the patient’s cultural background when prescribing treatments which can induce more pain such as HUT. The nurse is also frontline in patient advocacy and should continue to educate patient as well as making needs known so those needs can be met. The nurse should also transmit messages that are vital to healthcare providers that the health care providers could have missed. These messages include the patients’ cultural values as it is imperative to their care. Culture not only impacts pain threshold but dietary intake as well. Once a provider obtains proper assessment and history of patient’s background and food choices, the provider can inform them on better and healthier options which can greatly benefit the prognosis of SCD. Personal view & Conclusion All in All, SCD patient care should be approached holistically and carefully due to the nature of the disease. Hydroxyurea which is known as an antineoplastic drug, is known to cause more pain than benefits. There should be other methods implemented beforehand and HU should be used as the last resort. HU. There should be checklist that that physicians must adhere to before patients with SCD become candidates for HU. This checklist will allow patients to be informed on the risk and can choose to opt out and try alternative methods for treatment. In addition, there should be extensive education with patients about the risks and benefits that are associated with HU. Autonomy should be practiced to allow patients to be involved in their care and decision making. Providers should be open to agree with whatever decision a SCD patient chooses to make. Furthermore, patients should be educated on non-pharmacological methods, dietary and lifestyle changes to aid with healing and preventing crisis. Nurses should work as advocates for the patient and relay and information the provider may have missed. Beneficence and Non maleficence should always be the top priority when caring for any patient. Though I don’t know what it’s like to be in a position to have SCD, I know if I were in this position this would be something I would want for myself. It’s not easy having to be on medications but just imagine being on medications that can cause other harmful effects. Though stem cell transplant remains the cure for SCD , there are still up and developing treatments which should be tested out as well. Hopefully one day There will be enough research to find a medication or treatment that can be safe and effective and most importantly, minimized side effects for SCD patients.
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