Drug Topics - June 16, 2008 - (Page 51)

51 also be started on ACE inhibitor therapy as he has heart failure symptoms and reduced LVEF. Both the B-blocker and ACE inhibitor chosen should be titrated up to target dose at subsequent follow-up visits as tolerated. Additionally, PL likely needs to be changed from a thiazide to a loop diuretic such as furosemide due to recent fluid accumulation. Although HCTZ can be used successfully to treat HTN, it is not considered first line for effective fluid management. Scenario 2 JP is a 62-year-old female with a history of heart failure for the past six years. She is currently on lisinopril 40 mg daily, carvedilol 25 mg twice daily, furosemide 40 mg twice daily, and spironolactone 25 mg daily. Her most recent ejection fraction per echocardiogram was 25% about six months ago. She monitors her weight daily and has recently complained of an 11-pound weight gain, increased shortness of breath, increased orthopnea, and lower extremity swelling over the past week. She self-increased her furosemide dose to 80 mg twice daily two days ago, but the swelling has not improved. Her vital signs are as follows: blood pressure 142/62 and pulse of 78 beats/minute. She has no other complaints at this time. What next step could be recommended for JP to help her increased symptoms and swelling? JP may have become resistant to her furosemide at this time as she has not responded to self-titration of her dose. Addition of a second-line diuretic such as metolazone for short duration typically enhances the effectiveness of the loop diuretic and assists with fluid loss. JP should also be questioned about her use of sodium or over-the-counter agents that are known to contribute to increased fluid retention and diuretic resistance. Had her symptoms been more significant or her vitals less stable, a referral to emergency care may have been warranted for further assessment of an acute HF exacerbation. Scenario 3 TM is a 58-year-old African American recently diagnosed with cardiomyopathy and HF. His most recent ejection fraction was estimated at 30%-35%. He also has COPD with a 40-pack/year history of smoking and hypertension for the past 15 years. His current medications include tiotropium one puff daily, albuterol two puffs four times daily as needed, ramipril 5 mg daily, metoprolol succinate 25 mg daily, and furosemide 40 mg daily. Are TM’s current drugs appropriate? What other agents may help? Metoprolol succinate is more selective than carvedilol and may be preferred for patients with concurrent respiratory disease. The remaining regimen is also appropriate for heart failure and COPD and his metoprolol succinate should be increased as tolerated to a maximum dose of 200 mg daily. In addition, TM may benefit from the addition of hydralazine and isosorbide dinitrate as he is African American. Trials have shown mortality benefits in this population when this medication is added in combination with standard heart failure therapy. Additionally, TM should be counseled regarding smoking cessation as this habit worsens prognosis of both his heart and lung conditions. Conclusion Management of HF patients requires understanding of the role of each drug class, importance of medication adherence, and ability to assist patients with their regimen. References available upon request TEST QUESTIONS Write your answers on the answer form appearing on page 53 (photocopies of the answer form are acceptable) or on a separate sheet of paper. Mark the most appropriate answer. 1. In heart failure (HF), the body loses its ability to meet metabolic demands due to which of the following: a. b. c. d. Decreased cardiac output Decreased neurohormonal processes Excessive perfusion to tissues Overactive left ventricle 3. Neurohormonal changes are commonly linked to HF pathophysiology. Which of the following processes is most commonly implicated? a. b. c. d. Renin-angiotensin-aldoseterone system Sympathetic nervous system Endothelin All of the above are implicated in HF 2. Which of the following is true with regards to epidemiology of HF? a. Overall, the disease has a rather low incidence. b. At five years post diagnosis, it has about a 10% mortality rate. c. It is the most common reason for hospitalization in the elderly. d. In general, HF does not contribute much financial healthcare burden. 4. Patients with undiagnosed HF may initially pres- ent with which of the following most common symptoms? a. b. c. d. Dyspnea Chest pain Headache Orthostatic hypotension

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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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