(TECHNICIANS) 4:30-5:30PM

Transcription

1 E5. HIGH RISK PATIENTS, HIGH RISK MEDICATIONS: A FOCUS ON ANTICOAGULATION AND HEART FAILURE (TECHNICIANS) 4:30-5:30PM ACPE UAN: L01-T 0.1 CEU/1.0 hr Activity Type: Knowledge-Based Learning Objectives for Pharmacy Technicians: Upon completion of this CPE activity participants should be able to: 1. Describe cardiac conditions such as coronary artery disease, atrial fi brillation, and heart failure 2. Identify medications that are useful in these conditions 3. List the monitoring and risks of anticoagulants such as warfarin or newer agents 4. Discuss lifestyle changes that are recommended for patients with these conditions Speaker: John Beyer, PharmD, MBA Dr. Beyer received his Doctor of Pharmacy and his Master of Business Administration from Drake University College of Pharmacy and Health Sciences. Dr. Beyer is currently the PGY1 Pharmacy Practice Resident at the University of Iowa Hospitals and Clinics in Iowa City, Iowa and Adjunct Instructor of Pharmacy Practice with the University of Iowa College of Pharmacy. His interests include academia and pharmacy education, health-system pharmacy administration, infectious disease and stewardship, psychiatry, and internal medicine. Dr. Beyer s current research is a clinical scoring tool for predicting antimicrobial-resistant bacteria in patients admitted to the hospital from the emergency department for urinary tract infections. Speaker Disclosure: John Beyer reports no actual or potential confl icts of interest in relation to this CPE activity. Off-label use of medications will not be discussed during this presentation. FEBRUARY 13-15, 2015 IOWA EVENTS CENTER DES MOINES, IOWA

2 John Beyer reports no actual or potential conflicts of interest associated with this presentation. 1

3 Upon completion of this activity pharmacy technicians will be able to: 1. Describe cardiac conditions such as coronary artery disease, atrial fibrillation, and heart failure 2. Identify medications that are useful in these conditions 3. List the monitoring and risks of anticoagulants such as warfarin or newer agents 4. Discuss lifestyle changes that are recommended for patients with these conditions 2

4 Cholesterol and fat in blood creates plaque in arteries Plaque buildup called atherosclerosis Narrowing of the arteries causes less blood flow to heart and oxygen is deprived to heart, called ischemia Plaque can rupture, causing a clot, which can lead to a heart attack (myocardial infarction or MI) Leads to chest pain with or without activity, fatigue, shortness of breath Atherosclerotic Plaque What is Cardiovascular Disease? (n.d.). Retrieved January 21, 2015, from is Cardiovascular Disease_UCM_301852_Article.jsp Risk factors for CAD High blood pressure (hypertension) Diabetes Smoking Family History Age LDL and HDL cholesterol have also been considered important factors in CAD Plaque Rupture What is Cardiovascular Disease? (n.d.). Retrieved January 21, 2015, from is Cardiovascular Disease_UCM_301852_Article.jsp 3

5 Which is the good cholesterol? Which is the bad cholesterol? What are the goals for each? New American College of Cardiology and American Heart Association guidelines for prevention of cardiovascular risk Assesses age, gender, total cholesterol, HDL cholesterol, race, blood pressure, smoking, and diabetes for risk If risk is high enough, recommend initiating therapy First line therapy is HMG CoA Reductase Inhibitors or statins ASCVD Risk Calculator Goff, D. C., Lloyd Jones, D. M., et. Al. (2014) ACC/AHA Guideline on the Assessment of Cardiovascular RiskA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 63(25_PA), doi: /j.jacc

6 High intensity statins Atorvastatin (Lipitor) 80 mg or 40 mg Rosuvastatin (Crestor) 20 or 40 mg Moderate intensity statins Atorvastatin 10 mg or 20 mg Rosuvastatin 5 mg or 10 mg Simvastatin (Zocor) 20 or 40 mg (80 mg no longer recommended) Pravastatin (Pravachol) 40 mg or 80 mg See ACC/AHA guidelines for complete list Goff, D. C., Lloyd Jones, D. M., et. Al. (2014) ACC/AHA Guideline on the Assessment of Cardiovascular RiskA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 63(25_PA), doi: /j.jacc Patients who had an ASCVD (atherosclerotic cardiovascular disease) event, 81 mg baby aspirin is recommended ASCVD event defined as nonfatal MI or stroke Doctor should recommend this despite OTC availability Lower fat, cholesterol diet to prevent further plaques Exercise to promote healthy lifestyle, increase HDL Weight management What is Cardiovascular Disease? (n.d.). Retrieved January 21, 2015, from is Cardiovascular Disease_UCM_301852_Article.jsp 5

7 Ensure patient is on appropriate statin therapy and is adherent to medications If aspirin is recommended, make sure patient understands which one, how to take it Assess for side effects to statins (muscle pain, fatigue) Statins can have side effects which deter patients from taking them Identify cost-related issues (i.e., rosuvastatin can be costly) Encourage positive lifestyle choices 6

8 Affects 5 million people in the United States Most common in adults over 60 Accounts for 6.5 million hospitalizations annually % 30 day readmission rates Poor prognosis for those admitted to the hospital 30-60% of patients discharged 5 from hospital are readmitted within 6 months of initial hospitalization Pneumonia Heart Attack Heart Failure Managed Care Digest. Retrieved January 21, 2015, from Dysfunction of left or right ventricle Heart unable to pump blood to meet demands of the body Measured by ejection fraction (EF), or percentage of blood pushed out of heart during systole Accompanied by other diseases like diabetes, coronary artery disease, and kidney problems About Heart Failure. (n.d.). Retrieved January 21, 2015, from Heart Failure_UCM_002044_Article.jsp Gray, Henry. Anatomy of the Human Body. Retrieved January 21, Philadelphia: Lea & Febiger, 1918; Bartleby.com,

9 Systolic Heart Failure Left ventricle cannot contract normally The heart cannot pump forcefully enough Diastolic Heart Failure Left ventricle cannot relax normally Heart cannot fill with blood properly Both lead to decreased cardiac output Blood backs up into the lungs causing pulmonary symptoms (shortness of breath, cough, wheezing, fatigue) Both treated with similar medications About Heart Failure. (n.d.). Retrieved January 21, 2015, from Heart Failure_UCM_002044_Article.jsp Right ventricle responsible for moving blood from body to the lungs Often occurs as a result of long-standing left-sided heart failure or pulmonary hypertension Usually manifests as systemic symptoms (GI swelling and distress, lack of appetite, ascites, dependent edema) More difficult to manage with medications About Heart Failure. (n.d.). Retrieved January 21, 2015, from Heart Failure_UCM_002044_Article.jsp A.D.A.M. Retrieved January 21, 2015, from Pharmacotherapy, American Heart Association 8

10 A ACE Inhibitors/Angiotensin II Receptor Blockers ACE-Is - Lisinopril, Captopril, Enalapril, Fosinopril ARBs Losartan, Olmesartan,Valsartan B Beta Blockers Carvedilol, Metoprolol Succinate, Bisoprolol C See You Pee or Diuretics Loop Furosemide, Bumetanide Aldactone Antagonists/K+ Sparing Eplerenone, Spironolactone D Digoxin Pharmacotherapy Dietary changes Decrease sodium intake and monitor fluid intake to avoid fluid backup Eating heart-healthy diet low in saturated and trans fats, cholesterol Healthy decisions Quit smoking, avoid alcohol and caffeine Be physically active, get adequate rest, and manage stress Monitor and record weight daily Take medications every day as directed Drug interactions and certain medications can worsen HF About Heart Failure. (n.d.). Retrieved January 21, 2015, from Heart Failure_UCM_002044_Article.jsp 9

11 Ensure patient is adherent to medications When was the last time they filled their heart failure medications? Refer them to the pharmacist if they are purchasing OTCs Certain OTCs can worsen heart failure or interact with medications Identify cost issues or barriers to taking medications About Heart Failure. (n.d.). Retrieved January 21, 2015, from Heart Failure_UCM_002044_Article.jsp 10

12 What life-threatening condition are patient with atrial fibrillation at risk of developing? Irregular rhythm or quivering of the atria of the heart Affects 2.7 million people in the United States Different causes include high blood pressure, coronary artery disease, and other unknown causes Symptoms of AF include fatigue, dizziness, rapid heartbeat Can lead to strokes, heart failure, additional arrhythmias Causes 15-20% of strokes What is Atrial Fibrillation (AFib or AF)? (n.d.). Retrieved January 21, 2015, from is Atrial Fibrillation AFib or AF_UCM_423748_Article.jsp Atrial Fibrillation. (n.d.). Retrieved January 21, 2015, from 11

13 Patients often take a blood thinner to reduce stroke risk Stroke risk is calculated to assess if medication is needed Most common anticoagulant used is warfarin (Coumadin) Newer oral anticoagulants are available for AF Rivaroxaban (Xarelto) Factor Xa Inhibitor Apixaban (Eliquis) Direct Factor Xa Inhibitor Dabigitran (Pradaxa) Direct Thrombin Inhibitor Pharmacotherapy Vitamin K antagonist (works on many clotting factors) Most common and used for multiple clotting disorders Warfarin requires special monitoring to ensure safety International Normalized Ratio (INR) is primary blood test Goal INR for AF is typically 2-3, checked every 1-6 weeks Bleeding can be reversed by Vitamin K or blood products Coumadin Tablets Generic Tablets What is Atrial Fibrillation (AFib or AF)? (n.d.). Retrieved January 21, 2015, from is Atrial Fibrillation AFib or AF_UCM_423748_Article.jsp Pharmacotherapy 12

14 INR affected by antibiotics, heart medications, and many other common medications (including OTCs!) Dark, leafy green vegetables, green tea, liver, and other Vitamin K containing foods all lower the INR Exercise, alcohol intake, tobacco use, and general health can affect INR One missed day or extra dose of warfarin can affect INR Therefore, it is very important to teach patients their lifestyle, medication, diet, and health changes can affect their INR, and will therefore need closer monitoring! What is Atrial Fibrillation (AFib or AF)? (n.d.). Retrieved January 21, 2015, from is Atrial Fibrillation AFib or AF_UCM_423748_Article.jsp Pharmacotherapy What symptoms would a patient be showing that would suggest they have a high INR? Low INR? 13

15 Three oral agents (both introduced in the last 5 years); new agent approved in January, edoxaban (Savaysa) No blood tests needed; few drug-drug/food interactions Does not cause more bleeding than warfarin, but does not have a reversal agent available Rivaroxaban (Xarelto) 20 mg once daily dosing, 15 mg for kidney problems Most severe side effect is internal bleeding Apixaban (Eliquis) 5 mg twice daily, renal adjustment difficult Most severe side effect is internal bleeding LexiComp, Xarelto Package Insert Jannsen, Eliquis Package Insert Pfizer Dabigatran (Pradaxa) only oral drug marketed in its class First oral medication other than warfarin approved for AF (and better than warfarin?) No special monitoring or blood tests needed 150 mg twice daily; adjusted for renal impairment Serious side effect is GI bleeding (worse than warfarin?); no reversal agent currently on the market Few drug-drug/food interactions LexiComp, Pradaxa Package Insert Boehringer Ingelheim 14

16 Ask patients if they are on any blood thinners and help the pharmacist identify drug interactions Ensure the correct dose, strength, and directions for any of these medications Dabigatran (Pradaxa) is dispensed in its original container Warfarin doses may change frequently ask the patient what their current dose should be Newer anticoagulants can be very costly check insurance to make sure the patient can afford them All of these are very important to take every single day! LexiComp, Pradaxa Package Insert Boehringer Ingelheim Name an important OTC medication patients with coronary artery disease are recommended to take. A. Calcium B. Aspirin C. Fish Oil D. Vitamin C 15

17 Name barriers to adherence to medications recommended for treatment of coronary artery disease. A. Cost of medications B. Quantity of medications C. Side effects D. All of the above Which of the following is a possible cause of heart failure? A. Heart Attack B. Diabetes C. Stroke D. Depression 16

18 Why are anticoagulants an important part of treatment for patients with atrial fibrillation? A. Prevent heart failure B. Prevent clots in the legs C. Prevent strokes D. Prevent high blood pressure Which of the following is LEAST likely to interact with warfarin? A. Trimethoprim/Sulfamethoxazole (antibiotic) B. Lisinopril (hypertension medication) C. Fluconazole (antifungal) D. Ginseng (supplement) 17

19 Centers for Medicare and Medicaid Services. (2014). Readmissions Reduction Program. Retrieved from Payment/AcuteInpatientPPS/Readmissions-Reduction-Program.html American Heart Association. (2014). Various pages. Retrieved from Goff, D. C., Lloyd Jones, D. M., et. al. (2014) ACC/AHA Guideline on the Assessment of Cardiovascular RiskA Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 63(25_PA), doi: /j.jacc Managed Care Digest. Retrieved January 21, 2015, from mmon/downloads/2012_2013hospsysdigest.pdf Atrial Fibrillation. (n.d.). Retrieved January 21, 2015, from Chisholm-Burns, Marie A. ( ). Pharmacotherapy Principles and Practice, Second Edition. McGraw-Hill. LexiComp Online. (2014). Lexi-Comp Inc. Various pages. Retrieved from 18