Drug Topics - June 16, 2008 - (Page 50)

50 DRUG TOPICS JUNE 16, 2008 www.drugtopics.com CONTINUING EDUCATION Restrictions of less than 2 gm per day of sodium have been recommended. Patients should also be cautioned about using sodium substitutes as they contain potassium which may further increase risk of hyperkalemia. Fluid restrictions of less than 1.5-2 L/day have also been suggested, but are often not necessary except with end-stage HF or hyponatremia. Finally, use of alcohol and tobacco can contribute to exacerbations of HF. Patients should be encouraged to refrain from tobacco completely and alcohol use should be limited. Implantable cardioverter defibrillators Arrhythmias can lead to sudden cardiac death in heart failure patients. Implantable cardioverter defibrillators (ICDs) help reduce the incidence by detecting abnormal rhythms and either acting as a pacemaker for bradycardia or giving defibrillating shocks when tachycardia or arrhythmias are detected. The ACC/AHA guidelines recommend ICD therapy as primary prevention in patients with nonischemic cardiomyopathy with LVEF 120 msec on EKG). such as coronary artery disease, hypertension, or atrial fibrillation. Medication non-adherence, infection, anemia, and thyroid disease also precipitate exacerbations. Additionally, medications initiated that promote sodium and/or water retention (NSAIDs or thiazolidinediones) or those that affect contractility (B-blockers, non-dihydropyridine calcium channel blockers, or antiarrhythmics) contribute to AHF episodes. Patients experiencing exacerbations often develop signs and symptoms including dyspnea, fatigue, orthopnea, pulmonary congestion, weight gain, peripheral edema, or chest discomfort. AHF episodes often require emergency care and/or hospital admission to alleviate symptoms. Medication therapy management utilizes more intravenous dosage forms with diuretics, vasodilators, and inotropic agents. Goals during admission include optimizing volume status, identification of precipitating factors, optimization of chronic HF therapy, and patient education to prevent or decrease further admissions. Pharmacist role in chronic HF Pharmacists are in a position to play a crucial role in helping chronic HF patients. As pharmacists often see patients on a monthly basis, they can counsel patients about self monitoring, drug therapy and compliance, and can even monitor the patients through minor physical assessment. Additionally, as this disease state is treated with several different drug classes, educating the patients about their drug therapy becomes essential to meet overall goals. Pill burden also becomes more pronounced as many patients have additional medications for concomitant disease states creating problems with patients being able to afford their regimens. Pharmacists have the ability to recommend alternative, more cost-effective therapy if possible and help with applying for patient assistance programs through the drug manufacturers as needed. Patient case scenarios Scenario 1 PL is a 56-year-old male with a history of hypertension treated with diltiazem and HCTZ for the past several years with only modest control. He was recently hospitalized with worsening shortness of breath and sudden weight gain and pitting edema. He was diagnosed with cardiomyopathy from non-ischemic causes and his left ventricular ejection fraction (LVEF) was determined to be 30%. What recommendations should be made at this time for PL? PL has likely progressed to heart failure from uncontrolled HTN and is now symptomatic. At this point, his diltiazem (a non-dihydropyridine calcium channel blocker) should be discontinued due to its negative inotropic effects and the fact that his LVEF is no longer preserved. A B-blocker indicated for heart failure would be a better option at this point such as carvedilol or metoprolol succinate and this should be initiated prior to hospital discharge as long as PL is stable. He should Exacerbation management Many patients with HF will experience exacerbations, or acute heart failure (AHF). Although beyond the scope of this article, recognition of exacerbations and prompt treatment are extremely important to help decrease morbidity and mortality of this condition. Mortality rates of 5% have been estimated for patients hospitalized with AHF. Worsening chronic HF patients comprise the majority of hospital admissions for AHF. Exacerbations may be due to underlying concomitant disorders http://www.drugtopics.com

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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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