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HEALTHLINE
August 2005
INDICATIONS/WARNINGS
Results Show Valsartan/Hydrochlorothiazide (Diovan HCT) Superior To Amlodipine
(Norvasc) At Reducing Blood Pressure In Patients With Moderate To Severe Hypertension
Patients with moderate to severe hypertension showed superior reductions in
blood pressure when they received 160 mg/25 mg Diovan compared with Norvasc (dose),
according to results from the VAST study.
The double-blind, active-controlled, parallel group VAST study was designed to
evaluate the efficacy of 160 mg/12.5 mg Diovan HCT, 160 mg/25 mg Diovan HCT and
10 mg Norvasc. A total of 1,088 patients with moderate to severe high blood
pressure and additional cardiovascular risk factors were randomized to receive
one of the three drug regimens for 24 weeks. At baseline, patients in all three treatment groups
had similar average systolic blood pressure and diastolic blood pressure.
Diovan HCT 160 mg/25 mg was superior to Norvasc at reducing systolic blood
pressure, as evidenced by the average 27.1 mmHg, -29.7 mmHg and 27.6 mmHg
changes in blood pressure observed in the 160 mg/12.5 mg Diovan HCT, 160 mg/25
mg Diovan HCT and Norvasc groups, respectively. However, the groups showed no
statistically significant differences in diastolic blood pressure.
Moreover, patients who received either dose of Diovan HCT had significantly
lower rates of treatment-related adverse events than those treated with
Norvasc.
In a sub-study of VAST, a significantly greater proportion of 160 mg/25 mg
Diovan HCT-treated patients achieved their blood pressure goal of 130/80 mmHg
as compared with Norvasc-treated subjects (60.8 percent vs. 50.9 percent).
Diovan is in a class of medications called angiotensin receptor blockers, known to be safe and
effective in elderly individuals. Diovan is also approved for treating patients with heart failure and
protects against the progression of kidney disease in persons with Type 2 diabetes.
References
Ruilope L, et al. Fixed-Dose Valsartan + Hydrochlorothiazide Combination Therapy Compared With Amlodipine
Monotherapy In Hypertensive Patients With Additional Cardiovascular Risk Factors: The VAST Study. Clinical
Therapeutics 2005 27:578-88. In addition, two new analyses of the VALUE trial demonstrated that Diovan may reduce the
development of heart failure Julius S et al. VALUE Study: Outcomes In 7080 Patients Treated With Monotherapy.
Presented June 19 at ESH 2005. and the onset of type II diabetes Kjedlsen SE, et al. Effects of Valsartan Preventing the
Development of Type 2 Diabetes in High Risk Hypertensive Patients: Analysis from the VALUE Trial. Presented June 18
at ESH 2005. in high-risk patients with hypertension when compared with amlodipine.
Top Ten Dangerous Drug Interactions In Long Term Care
One of the important components of a medication review is the identification of dangerous drug
interactions. To help improve medication use in long term care, the American Medical Directors
Association (AMDA) and American Society of Consultant Pharmacist (ASCP) have joined in
collaboration to identify the top 10 drug interactions involving long term care residents.
Medications chosen for the Top Ten list were based on their frequency of use in older adults in
long term care and the potential for adverse consequences if used together. However, due to
individual variability, not all adults taking these medications together will experience an adverse
affect. This list should be used to alert the health care team of potentially serious interactions and
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HEALTHLINE
August 2005
enable the team to take steps to choose alternative therapy, adjust doses, put monitoring tools in
place, or other corrective actions.
Drug Interaction
Impact
Warfarin –
NSAIDs/COX-2s
Potential for
serious GI Bleed
Avoid concomitant use.
Use Tylenol instead.
Monitor INR weekly.
Nursing monitor for S&S of
active bleed.
Warfarin –
Sulfa Drugs
Potential for
serious bleed
due to increased
effects of
warfarin
Avoid concomitant use. If
use is imperative, reduce
warfarin dose 50% during
antibiotic therapy and 1
week after.
Monitor INR every 3 days
until INR stable. Nursing
monitor for S&S of active
bleed.
Warfarin –
Macrolides
Potential for
serious bleed
due to increase
effects of
warfarin
Avoid concomitant use. If
use is imperative, reduce
warfarin dose 50% during
antibiotic therapy and 1
week after.
Monitor INR every 3 days
until INR stable. Nursing
monitor for S&S of active
bleed.
Warfarin –
Quinolones1
Potential for
serious bleed
due to increased
effects of
warfarin
Avoid concomitant use
with Penetrex, Cipro,
Noroxin,and Floxin. Focus
on newer agents.
Monitor INR every other
day. Adjust warfarin dose
as necessary. Nursing
monitor for S&S of active
bleed.
Warfarin –
Phenytoin
Increased effects
of warfarin and/or
phenytoin
Obtain baseline INR and
serum phenytoin
concentration.
Monitor INR and phenytoin
concentrations. Nursing
monitor for S&S of active
bleed.
ACE Inhibitors –
Potassium
Supplements
Elevated serum
potassium
Draw K+ level prior to
initiation of ACE-I.
Adjust K+ supplementation
if concentrations increase.
ACE Inhibitors –
Spironolactone
Elevated serum
potassium
Draw K+ concentration
prior to initiation of
spironolactone.
Monitor K+ concentrations,
and renal function. Avoid
K+ supplements.
Digoxin –
Amiodarone
Digoxin toxicity
Draw digoxin
concentration prior to
initiation of amiodarone.
Decrease dose of digoxin
50%, then monitor Q week
for several weeks.
Maintain digoxin
concentration ≤1ng/mL to
avoid digoxin toxicity.
Nursing monitor for S&S of
toxicity.
Digoxin –
Verapamil
Digoxin toxicity
Monitor heart rate and
EKG-PR interval. Evaluate
selection of this
combination.
Monitor HR & EKG-PR
interval. Monitor for S&S
of digoxin toxicity.
Theophylline –
Quinolones1
Theophylline
toxicity
Obtain baseline
theophylline concentration
before initiation of
Quinolones1 (especially
Cipro and Penetrex).
Monitor theophylline
concentrations. Maintain
concentration between 515 mcg/mL. Monitor for
S&S of theophylline
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Prevention
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Management
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August 2005
toxicity.
1
Quinolones that interact include in descending order of greatest impact: enoxacin >ciprofloxacin>norfloxacin=ofloxacin.
Where S&S means signs and symptoms, K+ means potassium, HR means heart rate, INR means Internationalized Ratio
To review the complete report and its details go to http://www.scoup.net/M3Project/topten
PATIENT CARE
Treatment of Parkinson’s Disease
The prevalence of this disease is estimated to be between 6-8% of nursing home residents with
another 10-15% presenting with other movement disorders, primarily essential tremor. As with
many of the co-morbidities facing our elderly residents, this disease is also often misdiagnosed
and not optimally treated. Parkinson’s is defined by having two of four specific symptoms: resting
tremor, muscular rigidity, gait instability and bradykinesia.
Parkinson’s Disease is caused by a deficiency of the neurotransmitter dopamine and therefore
the administration of dopamine (in the form of levodopa) was thought to provide appropriate
therapy. As this medication had limited effect, and also induced nausea and vomiting, pairing it
with carbidopa (Sinemet) and assuring that residents receive at least 70 mg of carbidopa daily
became the gold standard for treating Parkinson’s patients.
As the disease progresses, so does the need to increase the dose of carbidopa/levodopa or
adding other therapies:
-
Eldepryl (selegiline) was initially expected to exhibit neuroprotective effects, but now is
used as an adjunct to treatment that may allow the reduction of the dose or intervals of
levodopa/carbidopa
-
The anticholinergic medications such as Artane and Cogentin are also used as adjunctive
therapy but due to their side effect profiles are not well tolerated by the elderly.
-
Dopamine agonists such as Parlodel, Permax and Requip are occasionally added initially
or used adjunctively.
-
The drug Comtan can be added to carbidopa/levodopa when there is a wearing off effect
of this drug. A new drug named Stalevo is a combination of carbidopa/levodopa and
Comtan.
Nearly all residents will face side effects from carbidopa/levodopa including drug induced
psychosis and hallucinations. It is typically not possible to lower the dose to reduce these
symptoms and psychoactive therapy often is necessary. The two classes of psychoactive drugs
shown to have the most benefit in these patients are the atypical antipsychotics, clozapine and
Seroquel in particular, as usually they do not worsen Parkinson’s symptoms like conventional
antipsychotics and the cholinesterase inhibitors (e.g. Aricept, etc.) because they help restore the
relative balance between acetylcholine and dopamine in the central nervous system.
Please contact your Consultant Pharmacist for more information on medication management in
residents with Parkinson’s Disease.
Copyright 2005
All Rights Reserved
Published by Omnicare, Inc.
distributed by PBM Plus, Inc.
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HEALTHLINE
August 2005
Resources:
Geriatric Pharmaceutical Care Guidelines, 2004
Clinical Pharmacology, 2005
Annals of Long Term Care
Editorial Board
Karen Burton, R. Ph., GCP, FASCP
Mark Coggins, Pharm. D., GCP, FASCP
Kelly Hollenack, Pharm. D. CGP
Philip King, Pharm. D., GCP, FASCP
Susan Kleim, B.S., Pharm., GCP, FASCP
Terry O’Shea, Pharm. D., GCP, FASCP
Elmer Schmidt, Pharm. D., GCP, FASCP
Barbara J. Zarowitz, Pharm. D., GCP, FASCP
Copyright 2005
All Rights Reserved
Published by Omnicare, Inc.
distributed by PBM Plus, Inc.
Page - 4