Drug Topics - June 16, 2008 - (Page 49)

49 monitored even more closely. of amiodarone unless clearly warranted. Hydralazine/Isosorbide dinitrate Combination therapy with hydralazine and isosorbide dinitrate (HYD-ISDN) purports to decrease both preload and afterload via arterial and venous dilation, respectively. Additionally, effects of hydralazine help to decrease nitrate tolerance associated with continuous administration due to antioxidant effects. Although each medication is available as an individual agent, a combination was created known as BiDil that contains 37.5 mg of hydralazine and 20 mg of isosorbide dinitrate and requires three times daily dosing. This theoretical use became the foundation for trials using this combination in HF patients. Large-scale trials using the combination did not show great benefit for this drug. Post-hoc analysis of two trials, however, demonstrated particular benefit in the African-American subpopulation. A follow-up trial limited to this population showed that the addition of HYD-ISDN to standard therapy with an ACE inhibitor or a B-blocker was beneficial in HF. For now, guidelines recommend use of HYD-ISDN in African-American patients with NYHA class III-IV HF currently receiving standard therapy, as previously discussed. Patients with LV dysfunction unable to tolerate an ACE inhibitor or an ARB may also benefit from this medication, although this has not been established by clinical trials. Patients should be counseled that the most commonly reported adverse effects include headache and dizziness and adherence to therapy should be encouraged due to the dosing schedule. Vaccinations The Centers for Disease Control & Prevention currently recommends the inactivated influenza vaccine for all adults 65 years and older or persons from two to 64 years of age with underlying medical conditions. Additionally, the pneumococcal polysaccharide vaccination is recommended for patients with cardiovascular diseases. The ACC/AHA guidelines support these recommendations. Potential future therapy Nebivolol, a third-generation B-blocker, was recently approved in the United States for the treatment of hypertension. Available under the brand name Bystolic, this agent purportedly differs from other B-blocking agents as it combines highly selective B1-antagonism with nitric oxide mediated vasodilatory actions and beneficial effects on endothelial function. It is approved in Europe for essential hypertension as well as treatment of stable mild or moderate heart failure as an add-on to standard therapies in elderly patients over age 70. As other B-blockers with strong mortality evidence are available and widely used for the treatment of heart failure in this country, the support of use for nebivolol for heart failure is unknown at this time. As more data become available, however, its exact role may be further defined. Aliskiren, a new class of blood pressure agents known as a renin inhibitor, has also been approved in the United States for hypertension. Marketed under the brand name Tekturna, this agent is also being studied for possible use in heart failure due to its mechanism of action. The European Society of Cardiology announced results at its annual meeting in late 2007 that the agent showed reductions in B-type natriuretic peptide (BNP) levels, a marker associated with worsening outcomes for heart failure. For now, this agent is not currently indicated for the treatment of heart failure domestically, although this may change as ongoing research becomes available. Additional pharmacotherapy agents Anticoagulation Concern exists for HF patients and thromboembolic events due to the potential of increased risk of pooled blood, especially for those with severely decreased LVEF. For now, however, use of anticoagulation with warfarin in HF patients is not routinely recommended as the data remain unclear. Guideline recommendations reserve the use of this practice for patients with a prior thromboembolic event, prosthetic heart valve, LV thrombus, or those with atrial fibrillation. Overall risk of thromboembolism has been shown to be very small (1%-3%) in this population, regardless of LVEF. Antiarrhythmic drugs Risk of developing dysrhythmias is increased with patients having severe LV systolic dysfunction. Although some antiarrhythmic medications worsened HF and increased mortality, amiodarone and dofetilide remain safer options for managing arrhythmias in HF patients. Appropriate candidates for these agents are not yet clear as trials have shown rather neutral effects on mortality. While safe to use in patients with LV systolic dysfunction, current guidelines do not support the routine use Nonpharmacological therapy Lifestyle modifications A diagnosis of heart failure requires patients to make lifestyle adjustments in order to help prevent further progression of the disease and to minimize exacerbations. Although patients with HF may find it more challenging to exercise, physical inactivity contributes to deconditioning, which further decreases exercise tolerance and worsens HF symptoms. Patients who are stable should participate in regular physical activity to help improve exercise ability and improve quality of life. Diet restrictions, primarily sodium restriction, are also important lifestyle modifications for HF patients. No evidence exists that sodium intake prevents development of HF, but limiting intake assists with fluid management.

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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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