Drug Topics - June 16, 2008 - (Page 47)

47 tinuing the medication. Other concerning adverse effects include hypotension, hyperkalemia, angioedema, or renal insufficiency. Patients experiencing cough may benefit from an angiotensin receptor blocker (ARB). Hypotension, hyperkalemia, and renal insufficiency are just as likely to occur with ARBs and consideration should be given for the combination of hydralazine and isosorbide dinitrate for this population. These drug classes will be discussed more in later sections. Table 3 ACE inhibitor comparison ACE inhibitor Captopril Enalapril Fosinopril Lisinopril Perindopril Quinapril Ramipril Brand name Capoten Vasotec Monopril Prinivil, Zestril Aceon Accupril Altace Starting dose 6.25-12.5 mg tid 2.5 mg bid 5-10 mg daily 2.5-5 mg daily 2 mg daily 5 mg bid 1.25-2.5 mg daily Maximum dose(s) 50 mg tid 10-20 mg bid 40 mg daily 20-40 mg daily 8-16 mg daily 20 mg bid 10 mg daily Renal function and serum potassium within 1-2 weeks of initiation and periodically thereafter Monitoring parameters Beta-blockers Decreased cardiac output resulting from HF Trandolapril Mavik 1 mg daily 4 mg daily causes activation of the sympathetic nervous system. Long-term harmful effects of this comDiuretics pensation mechanism include increased ventricular pressures and volumes, LV hypertrophy and remodeling, peripheral The main role for diuretics in chronic HF management is for vasoconstriction, and potential arrhythmias. For this reason, symptom relief caused by fluid retention. Loop diuretics are B-blocking agents have come to represent another cornerstone the most common agents used within this category and cause drug class of chronic HF therapy. To date, three B-blockers have increased urinary sodium excretion followed by decreased been shown to reduce mortality in symptomatic HF patients: physical signs of fluid retention. Unlike other agents used in carvedilol, extended-release metoprolol (succinate), and biso- HF, diuretics act within hours or days. Currently, long-term prolol (Table 4), although the latter will not be discussed due to benefits of loop diuretics have not been assessed. Available loop limited availability in the United States. diuretic agents include furosemide, torsemide, and bumetanide More than 20 placebo-controlled clinical trials involving over with furosemide being the most commonly prescribed. Oral ad20,000 HF patients have demonstrated a decrease in mortal- ministration is preferred and should be started at low doses and ity due to sudden death and progressive HF with B-blockers. increased to adequate response without causing volume contracAlthough most trials included patients with mild or moderate tion. Administration when given intravenously can help dilate HF, benefits have also been shown with severe HF and those blood vessels in the lung, relieve congestion, and then cause a with LV dysfunction immediately post-myocardial infarction diuretic response within 30 minutes of administration and are (MI). Guidelines currently recommend the use of a B-blocker used more for acute exacerbations or refractory patients. in addition to an ACE inhibitor for all stable HF patients with Use of loop diuretics can also be associated with concerns decreased LVEF, even those with diabetes, chronic obstructive such as tolerance/resistance, electrolyte imbalances, hypotenlung disease, and peripheral vascular disease. Caution should sion, renal dysfunction, and neurohormonal activation. Diuretonly be used for patients with marked bradycardia, hypotension, ics are usually added to patients already on ACE inhibitors and diabetes with frequent hypoglycemia, or those with severe asth- B-blockers still experiencing fluid accumulation. Doses are typima. Unstable patients are defined as those undergoing treatment cally prescribed on a daily basis, although frequent adjustments in an intensive-care unit, show evidence of fluid imbalance, or may be required to help maintain fluid balance. Many patients who recently used an intravenous positive inotropic agent. may monitor their weight daily and make adjustments to their Due to potential adverse effects, B-blockers should be started diuretic as needed. at low doses and gradually titrated up with an attempt to reach Thiazide diuretics have less of a role in HF than the loop target doses shown to improve outcomes in clinical trials. Moni- diuretics as they are less potent at increasing sodium excretion. toring parameters for these agents include: bradycardia, hypotension, fluid overload, Table 4 and severe fatigue. Dose titrations may be Beta-blocker comparison limited due to these adverse effects, but Beta-blocker Brand name Starting dose Maximum dose(s) patients should remain on a B-blocker if Bisoprolol Zebeta 1.25 mg daily 10 mg daily possible. Even the smallest doses may still have mortality benefits. Carvedilol Coreg 3.125 mg bid 25 mg bid 50 mg bid for pts >85 kg Metoprolol succinate (ext release) Toprol XL 12.5-25 mg daily 200 mg daily

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Drug Topics - June 16, 2008 Contents Latebreakers Letters Latebreakers in Depth Pharmacists Lose in Final ESRD Rule New Drug Helps Palliative Patients on Opioids Take Care of Business Oral Treatment Reduces Multiple Sclerosis Flare-ups Beware of Inflammatory Masses From Implantable Infusion Systems Safer Therapeutic Options Emerging for Atrial Fibrillation Congressional Committee Chair Calls for Action Against Hospital Infections This Software System Helps Hospitals Manage Anticoagulation Therapy Rx Care Community Practice JP at Large Self-Care Cover Story Long-Term Care Chains and Business Technology Technology Update Continuing Education New Products Advertisers Index Classified Viewpoint

Drug Topics - June 16, 2008

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