Download Continue on atorvastatin 40 mg po 1ce daily.

Heart Failure
PHARMACIST CARE PLAN
By: Dalya Abu Al-Sindyan
Lina Darwish Msllam
Chief Complaint
I’ve been more short of breath lately, I can’t seem to
walk as far as I used to, either my feet are growing or
my shoes are shrinking.
History Of Present Illness (HPI)
▪ Rosemary is a sixty eight years old African-American female, she
report that her shortness of breath has been gradually increasing
over the past four days and it is particularly worse when she is
lying in bed at night and she also reports exertional duspnea that
is usual for her and increased swilling in her lower extremities.
PMH
▪ Hypertension X 20 years.
▪ CHD with history of MI in 2005.
▪ HF (NYHA FC III).
▪ DM type 2.
▪ Atrial Fibrillation
▪ COPD (Stage 3)
Family History
▪ Father died of lung cancer at age 71.
▪ Mother died of MI at age 73.
Social History
▪ Alcohol intake.
▪ Low cholesterol and sodium diet.
▪ Former smoker.
Medications
▪ Valsartan 160 mg po BID.
▪ Furosemide 40 mg po BID.
▪ Carvedilol 3.125 mg po BID.
▪ Warfarin 2.5 mg po once daily.
▪ Glimepiride 2 mg po once daily.
▪ Potassium chloride 20 mEq po once daily.
▪ Atorvastatin 40 mg po once daily.
▪ Aspirin 81 mg po once daily.
▪ Albuterol MDI, 2 inhalations q 4-6 hours PRN shortness of breath.
▪ Tiotropium DPI 18 mcg /50 mcg, 1 inhalations BID
▪ Pioglitazone 30 mg po once daily.
ROS
▪ Seven kg weight gain over the past week.
▪ Worsening shortness of breath.
▪ Orthopnea chronic, dry hacking cough.
Physical
Examination
▪ GEN:
▪ African-American female in moderate respiratory distress.
▪ VS:
▪ BP 134/76 (Sitting 138/80), HR 65, RR 24, T 37 ºC, O2 sat
90% RA, WT 79 kg.
▪ Skin:
▪ Color pale and diaphoretic.
▪ HEENT:
▪ PERRLA lips mildly cyanotic; dentures.
▪ Nick:
▪ JVD at 30º (7 cm).
▪ Lungs:
▪ Crackles bilaterally.
▪ Echocardiogram:
▪ LVH reduced global left ventricular systolic function, EF 20%
▪ Heart:
▪ Irregularly Irregularl (s3); displaced PMI.
▪ APD:
▪ Soft, myldlu tender, nondistended, (+) HJR.
▪ GENIT/RECT:
▪ Guaiac (-).
▪ MS/EXT:
▪ 3+ pitting pedal edema bilaterally.
▪ NEURO:
▪ A & O x 3, CNs intact. No motor deficts.
▪ ECG:
▪ Atrial fibrillation, LVH.
▪ Chest X-Ray:
▪ pleural effucion, evidence of pulmonary edema.
Discussion
▪ Create a list of this patient drug
related problems
Drug-Drug Interactions
Related issue
solution
Salmetrol with carvediolol
B2 agonist with mixed b
antagonist worsen
dysponea
Replace carvediolol with
selective cardiotonic
nebivolol
Warfarin with Aspir
May lead to bleeding
Give small dose with
monitor
Pioglitazone
Excerbate heart faliure
Stop it
Signs & Symptoms
▪ What signs symptoms & other
information indicate the presence and
type of heart failure in this patient?
Signs
▪ Shortness of breath for the last 4 days .
▪ Increased swelling in lower extremities.
▪ Exertional dyspnea.
▪ Note:
▪ These are symptoms of Left sided-HF & listed as
stage ii /iii HF (NYHA functional classification) or
stage C (ACC/AHA(38)
Symptoms
▪ HR 65 (irreg irreg), displaced PMI
▪ S3 sound present.(systolic HF)
▪ 3+ pitting pedal edema , Alveolar edema
▪ Decreased pleural effusion.
▪ Skin color pale & diaphoretic.
Physical Examination
▪ Labs: BNP greater than 100 pg/mL (776pg/ml).
▪ ECG Atrial fibrillation ,and LV hypertrophy.
▪ Nick: JVD at 30 is a result of right side HF
▪ Lungs bilateral crackles result from CHF.
Heart Failure Classification
What is the classification of heart failure
in this patient ?
• stage ii /iii systolic HF (NYHA functional
classification) or stage C (ACC/AHA(38))
• Stage I of diastolic HF.
• She has acute exacerbation of heart failure with
left systolic dysfunction.
Patient Problems Causes
Could any of this patient problems have
been caused by drug therapy ?
• Pioglitazone which is 1ST generation sulfonurea
tend to exacerbate heart failure (BB C.I) in
symptomatic patients & cause edema , weight
gain,also glimperide increase CV mortality.
• Intake of carvediolol with b2 agonist causes
antagonism and worsening of COPD..
Goals For Pharmacologic Management Of HF
What are the goals for pharmacologic
management of HF in this patient?
• Slowing progression of the disease, improving
quality of life, and prolonging survival reducing
long-term risk for hospitalizations
• Alleviating fluid retention, minimizing disability.
• Relief symptoms of dyspnea & orthopnea .
• Decrease edema & swelling.
• Manage acute exacerbation of her HF.
Diuretic Therapy
What diuretic therapy should be recommended for this
patient initially for acute tx of HF exacerbation?
• Use the same diuretic she takes furosemide as
I.V.: 20-40 mg/dose, may be repeated in 1-2
hours as needed and increased by 20 mg/dose
with each succeeding dose up to 1000 mg/day;
usual dosing interval: 6-12 hours [ACC/AHA
2010 guidelines ]
Pharmacotherapy
How should this patient pharmacotherapy be adjusted for
chronic management of her systolic heart failure ?
• Change B blocker to metoprolol succinate to
prevent interaction with b2 agonist
• Titrate furosemide oral dose to 80 mg( max 600)
• Warfarin dosage should be based on INR (2-3)or
prothrombin level
• Increase the dose of glimperide after stopping
pioglitazone
Non Pharmacologic Therapy
What non pharmacologic therapy should be recommended
for this patient with respect to her HF?
• Cha dietary modifications such as sodium and
fluid restriction & low cholesterol diet.
• Risk factor reduction including stopping alcohol
consumption, timely immunizations, and
supervised regular physical activity.
• Stop alcohol intake as it causes heart poisoning:
bed rest & o2 therapy to enhance acute phase.
Drug Plan
What drugs, doses ,schedules & duration of action are best
suited for the management of this patient ?
Drug
Initial Daily Dose(s)
Maximum Dose(s)
scaduals
Duration of action
Metoprolol
succinate
extended release
12.5 to 25 mg
once
200 mg once
24 hr
Furosemide
20 to 40 mg once 600 mg
or twice
valsartan
40 mg twice daily
80 to 160 mg once
daily
6 to 8 h
Drug Plan
What non pharmacologic therapy should be recommended
for this patient with respect to her HF?
• Continue on Warfarin 2.5 mg PO 1ce/day.
• Continue on aspirin 81 mg po once daily.
• HTN management associated with heart faliure :
• Continue on valsartan 160 mg po BID.
• Continue on furosemide 40 mg po BID.
• Atrial fibrillation:
• Managed by warfarin 2.5 mg & carvedilol 3.125mg (replaced with metoprolol
succinate)
• Dyslipidemia:
• Continue on atorvastatin 40 mg po 1ce daily.
Drug Plan
• DM Type ii management:
• Use insulin glargine 36 U subQ daily
• Use insulin lispro 12 U subQ TID with meals.
• COPD management :
• Continue on albuterol MDI 2 inhalation q 4-6 hr
• Continue on tiotropium DPI 18 mcg, 1/day
• Continue on fluticasone /salmetrol DPI 250 mcg/50 mcg, 1 inhalation BID.
• Hypokalemia :
• Continue on pottasium supplements with monitoring specially with furosemide IV.
Alternative Plan
• Add direct vasodilator as 1st line therapy for her HF b/c it has advantage
in African American over ACE-I & ARB’s which c/I in this case due to
presence allergy cough edema hyperkalemia & renal impairment : use
Isosorbide Dinitrate and hydralazine in comb : BiDil®‫آ‬
• No need to add digoxin for Afib as it’s managed.
• Can’tAdd spirlonlactone as it’s adviced for stage iii HF because crcl
Clinical & Laboratory Parameters
What clinical & laboratory parameters are needed to evaluate the
therapy for achievement of the desired therapeutic outcome and to
detect and prevent adverse events?
• Initially monitor patient for rapid relief of
symptoms related to the chief complaint of
orthopnea, dyspnea , oxygenation & fatique.
• Monitor for adequate perfusion of vital signs:
• asses mental status , Cr Cl , liver function test and a
stable HR btw 50-100 HR/min,BP.
• Monitor kidney& liver function.
• monitor blood glucose
• Fluid intake – body weight (daily)-
Monitor Adverse Effect Of Drugs
What clinical & laboratory parameters are needed to evaluate the
therapy for achievement of the desired therapeutic outcome and to
detect and prevent adverse events?
• Metoprolol succinate:
• BP, HR baseline and after Carvedilol 3.125 mg twice 25
mg twice each dose titration, ECG
• Furosemide :
• monitor electrolyte ,hyperuricemia , nephrotoxicity &
autotoxicity.
• Valsartan :
• Monitor potassium and serum creatinine
information should be provided
What information should be provided to the patient about medication
used to treat her HF ?
• Furosemide taking on empty stomach
• Digoxin: do not discontinue without consulting
prescriber.
• Grapefruit juice can increase the blood levels of
Atorvastatin. This can increase the risk of side
effects such as liver damage
Information Should Be Provided
What information should be provided to the patient about medication
used to treat her HF ?
• Furosemide taking on empty stomach
• Digoxin: do not discontinue without consulting prescriber.
• Grapefruit juice can increase the blood levels of Atorvastatin.
This can increase the risk of side effects such as liver
damage
• Take Metoprolol at the same time each day, preferably with
or immediately following meals
• Avoid taking potassium rich food.
• Glimepiride should be administered with breakfast or the
first main meal.
PCP
Date
8/10
8/10
8/10
8/10
8/10
8/10
Medical proplem
HF
Tx issue
Pharmacotherapy goals
Acute exacerbation of
Systolic HF
Manage symptoms
Inadequate drug increase survival & QOL.
therapy
HTN
BP above goal
BP<120/80
DM
Blood glucose above
goal
Dyslipidemia
Increased lipids
Decrease glucose to
100mg/dl
Decease LDL & increase
HDL.
COPD
management
Atrial fibrillation
stable
stable
Decrease chronich cough
& hacking cough,,
enhance breathing.
Continue to be managed
recommendations
Start on metoprolol succenate initial
12.5 mg BID
Take furosemide Iv 40mg with
gradual increment , when stable back
to PO 80mg BID
Continue on valsartan 160mg po BID
Continue on Warfarin 2.5 mg PO
1ce/day.
Continue on aspirin 81 mg po1ce
Increase furosemide oral dose to
80mg.
Continue on valsartan & metoprolol
succenate as described above.
Stop pioglitazone & increase
glimpiride to 8mg
Continue on atorvastatin 40 mg po
1ce daily
Continue on albuterol MDI 2
inhalation q 4-6 hr
Continue on tiotropium DPI 18 mcg,
1/day
Continue on fluticasone /salmetrol
DPI 250 mcg/50 mcg, 1 inhalation
BID.
Managed by warfarin 2.5 mg &
carvedilol 3.125mg (replaced with
metoprolol succinate)
Physician
action
PCP
Goals
Monitoring
parameters
Freq
HF
Electrolytes : Na K
Every visit till stidy
BNP
Every visit
SCr
Every visit
HTN
BP
HR
Every day
DM
Sugar level
Every day
Dyslipidemia
Weight
HDL, LDL,TG
Daily
Once a week
Atrial Fib
HR
everyday
COPD
Breathing ,cough
everyday
Achievements of
outcomes
comments
PCP
Goals
Monitoring
parameters
Freq
Valsartan :
Monitor potassium Every visit
and serum
creatinine
Furosemide :
monitor
electrolyte(Na/K
,hyperuricemia ,
nephrotoxicity &
autotoxicity
Every visit
Metoprolol
succinate:
BP, HR baseline
ECG
Daily
1ce amonth
Achievements of
outcomes
comments
Dalya & Lina
Therapy Lab (Tuesday)
09-10-2013