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Medication
Classification
The Macstrak Project
Issues
Macstrak follows drug interventions by drug class rather than
the specific agent (e.g. B blocker po rather than metoprolol)
•
to get reliable data first need to ensure understanding of where data
captured on Macstrak form
•
need to know proper drug classes
•
need to know the generic as well as trade names
•
accuracy in form completion improves as staff become more comfortable
with knowing the drug classes
•
teaching resources available for staff on Macstrak website
The Macstrak Project
In this presentation
1.
Review – where data collected on Macstrak forms
2.
Understand – description of each drug class
3.
Review– tables of generic versus brand name
4.
Learn – resources available for on-going support
The Macstrak Project
Review - Macstrak Form
Reperfusion Therapy:
No
Yes
and/or
Not Indicated:
Risk:

ECG Not Diag.
Risk of ICB
ST Up Transient
Risk Other Bleed
Too Late
Given (Other Hosp)
Other: ……………......
Thrombolysis 
Here
EMS
Other Hosp
Drug:
TNK/rtPA
Dose: (mg/units)
SK
Duration: (min)
r-PA (reteplase) Pt.Weight: (kg)
Other
Adjuvant:
ASA
Heparin
GP2b/3a Inhibitor
 blocker IV
Clopidogrel
Other ...............................
Primary/Rescue PCI 
Here
Transfer
Reperfusion Therapy Decided by:
EP
Consultant
Three sections where medications tracked on the CCU form:
1. ACS Initial Management – Adjuvant Therapy
The Macstrak Project
Review - Macstrak Form
Date:
D
Acuity:
Shift:
Diuretics………………………
Inotropes IV…………………..
ETT/Vent……………………..
PA Line……………………….
TTVP…………………………
IABP………………………….
ACS:
RSCP - Ischemia – Definite….
– Probable…
CK (+ve)………………...……
Troponin (+ve)………………..
NTG IV……………………….
Heparin – UFH…………….....
– LMWH…………….
Other Antithrombin………...…
GP 2b/3a Inhibitor IV……...…
Clopidogrel (or thienopyridne)..…
Cardiac Cath………………....
PCI…………………………...
Outcomes:
VF/Sustained VT………….…
Infarction (new/repeat)*(1) …...
Thrombolysis (new/repeat)*(2)..
Stroke*(3) …………………….
Major Bleed*(4) ………………
Transfusion…………………..
Crs1: ………………………....
Crs2: ……………………..…..
None of the Above……….…..
RN Initials ………………..….
N
D
N
D
N
Three sections where
medications tracked
on the CCU form:
1. ACS Initial
Management –
Adjuvant Therapy
2. Course in CCU
None of the Above needs to be marked
if no medication/treatments are given – lets
us know that the information is not missing.
The Macstrak Project
Review - Macstrak Form
Three sections where medications are
tracked on the CCU form:
1. ACS Initial Management –
Adjuvant Therapy
2. Course in CCU
3. CCU Discharge
Discharge Meds:
ASA
Clopidogrel (thienopyridine)
Heparin (UF or LMW)
Nitrates (po/top)
B Blocker
ACEI
A2 Blocker
Statin
None of the Above
None of the Above needs to be marked
if no medication is given – lets us
know that the information is not missing.
The Macstrak Project
Review - Macstrak Form
ACS Management: (all)
ASA
Heparin UFH
Heparin LMWH
Clopidogrel(thienopyridine)
GP2b/3a Inhibitor IV
Other Antithrombin
NTG IV
NTG topical/po
 Blocker IV
 Blocker po
Calcium Antagonist(any)
ACEI
A2 Blocker
Research Protocol
None of the Above
One section where medications are
tracked on the ER form:
1. Course in ER
None of the Above needs to be marked
if no medication is given – lets us
know that the information is not missing.
Optional fields are available to track specific
medications if your unit wishes.
The Macstrak Project
Review - Macstrak Form
Drugs:
PTA
PTW Ward Disch
ASA
Coumadin
Heparin UFH
Heparin LMWH
Clopidogrel (thienopyridine)
GP 2b/3a Inhibitor(IV)
Other Antithrombin
…………………………………………………….
……………………………………….
One section where medications are
tracked on the Ward form:
…………………………….
…………………………
……..…….
……………
…….……………
Oral Hypoglycemic
Insulin
Statin
Other Antilipid
Bronchodilator
Digoxin
Any Antiarrhythmic
…………………
1. Course in Ward
……………………………………………….
………………………………………………….
…………………………...
……………………………
…………………………………………….
……………….
Calcium Antag
ACEI
A2 blocker
Other Vasodilator
Diuretic
Nitrates top/oral
Nitrates IV
 Blocker - Any
 Blocker - Carvedilol
……………………………
.……………………………………………………
……………………………………….
……...……………….
……………………….……………………...
…………………………..
……………………………….……...
Optional fields are available to track specific
medications if your unit wishes.
…………………………...
…………...
Study Drug- antiplatelet
- antithrombin
- other
Smoking
HRT
…...
.
………………….
…………………………………………..
……………………………..…..
…………………………………………………….
……………… ……………..…..
Optional Fields:
Crs1: ……………………………..
Crs2: ……………………………..
Crs3: ……………………………..
Crs4: ……………………………..
None of the Above
RN Initials
…………………..
……………………………………..
None of the Above needs to be marked
if no medication is given – lets us
know that the information is not missing.
The Macstrak Project
Thienopyridines - What & How
• oral anti platelet therapy
• indications:
– ACS
– stents
– aspirin is not tolerated
– dual anti platelet therapy desired
• ADP-receptor antagonist
• binds irreversibly to P2Y12 receptors, modify the platelet P2Y12 receptor
therefore ADP can’t bind to it
• reduces platelet aggregation that persists for the life of the platelets
The Macstrak Project
Thienopyridines -Who
Generic Name
Brand Name
clopidogrel
ticlopidine
prasugrel
Plavix®
Ticlid®
Effient *
* Drug has not yet come to market.
The Macstrak Project
GP2b/3a inhibitors -What
•
anti platelet therapy IV
•
indications:
– ACS
– PCI
•
final step in platelet aggregation - binding of fibrinogen between two
platelets at the GP2b/3a receptor, inhibitors block this final pathway,
decreasing platelet aggregation regardless of the mechanism by which
the platelets are activated
•
issue for all these therapies has been determining effective dosing
The Macstrak Project
GP2b/3a inhibitors - How
The Macstrak Project
GP2b/3a inhibitors - Who
Generic Name
Brand Name
abciximab
eptifibatide
tirofiban
Reopro®
Integrillin®
Aggrastat®
The Macstrak Project
UF Heparin - What & How
• antithrombin
• indications:
– ACS
– atrial fibrillation
– deep vein thrombosis
– pulmonary embolism
• UF Heparin binds to the enzyme inhibitor antithrombin (AT) causing a
conformational change that results in its activation through an increase in the
flexibility of its reactive site loop
• activated AT then inactivates thrombin, with also a lesser effect on factor Xa
The Macstrak Project
LMW Heparins - What & How
• antithrombin
• indications:
– ACS
– atrial fibrillation
– deep vein thrombosis
– pulmonary embolism
• sub group of proteins included in UFH
• although all different protein groups - they have a greater effect on anti
factor Xa
• PT/PTT cannot be used to follow
• they are not bound to acute phase reactants therefore dose response is
more predictable
The Macstrak Project
Heparins - Who
Generic Name
Brand Name
heparin (unfractionated)
enoxaparin
dalteparin
tinzaparin
Hepalean®
Lovenox®
Fragmin®
Innohep®
The Macstrak Project
Other Antithrombins–What & How
• mostly direct thrombin inhibitors but a variety of targets
• indications:
– heparin-induced thrombocytopenia (HIT)
– PCI
– ACS
• most are intravenous only exception coumadin
• new oral agents in development
The Macstrak Project
Other Antithrombins - Who
Generic Name
Brand Name
argatroban
bivalirudin
lepirudin
danaparoid
Argatroban ®
Angiomax®
Refludan®
Organon®
fondaparinux
warfarin
dabigatran
Arixtra ®
Coumadin®
Pradaxa *
* Drug has not yet come to market.
The Macstrak Project
β-blockers - What & How
• beta (alpha) adrenergic receptor antagonists
• indications:
– arrhythmias
– AMI cardioprotection
– decrease incidence of occlusion events
• fight or flight  block the action of endogenous catecholamines
(epinephrine – adrenalin and norepinephrine – noradrenaline) on βadrenergic receptors part of the sympathetic nervous system
• cardioprotection, management of cardiac arrhythmias, blocks activation
of clotting system
• reduces the sympathetic activation of platelets, and the clotting system
(PAI-1)
The Macstrak Project
β-blockers - Who
Generic Name
Brand Name
acebutalol
atenolol
carvedilol
labetalol
Sectral®
Tenormin®
Coreg®
Trandate®
metoprolol
nadolol
propanolol
Lopresor®
Corgard®
Inderal®
sotalol
bisoprolol
Sotacor®
Monocor®
The Macstrak Project
ACE inhibitors - What
• Angiotensin-Converting Enzyme inhibitor decreasing the activation of
the renin/angiotensin system
• indications:
– prevention of cardiovascular events
– CHF
– hypertension
– left ventricular dysfunction
• Reduces PAI-1 levels to decrease clot formation
• reduces afterload, lowers arteriolar resistance, decreases cardiac work and
oxygen demand
• lowers renovascular resistance, increases natriuresis (excretion of sodium
in urine)
The Macstrak Project
ACE inhibitors - How
The Macstrak Project
ACE inhibitors - Who
Generic Name
Brand Name
benazepril
captopril
cilazapril
enalapril
fosinopril
lisinopril
quinipril
ramipril
Lotensin®
Capoten®
Inhibace®
Vasotec®
Monopril®
Prinivil®, Zestril®
Accupril®
Altace®
The Macstrak Project
A2 blockers - What & How
• angiotensin receptor blocker
• indications:
– hypertension - intolerance to ACE inhibitors
• modulate the renin-angiotensin-aldosterone system by blocking
activation of angiotensin II AT1 receptors  causes vasodilation
• effects are similar to ACEI but no cough as do not inhibit the breakdown
of bradykinin or other kinins
The Macstrak Project
A2 blockers - Who
Generic Name
Brand Name
candesartan
irbesartan
losartan
telmisartan
valsartan
Atacand®
Avapro®
Cozaar®
Micardis®
Diovan®
The Macstrak Project
Statins - What & How
•
cholesterol lowering agent - reduces inflammation
•
indications:
– reducing LDL cholesterol
– ACS secondary prevention
– CAD primary prevention high-risk groups
•
statins block an enzyme (HMG-CoA reductase) involved in producing
cholesterol within liver cells
•
stimulates LDL receptor  results in an increased clearance of lowdensity lipoprotein (LDL) from the bloodstream and a decrease in
blood cholesterol levels
The Macstrak Project
Statins - Who
Generic Name
Brand Name
fluvastatin
lovastatin
pravastatin
simvastatin
atorvastatin
Lescol®
Mevacor®
Pravachol®
Zocor®
Lipitor®
The Macstrak Project
Diuretics - What & How
• Increase natriuresis – renal excretion of sodium
• indications:
– heart failure
– hypertension
• act at a variety of targets within the nephron
• each class has a different specific mechanism of action, but typically
share outcome of changing the way the kidneys handle salt - inhibit
sodium re-absorption lowering blood pressure and cardiac workload
The Macstrak Project
Diuretics - Who
Generic Name
Brand Name
furosemide
ethacrynic acid
bumetanide
chlorothiazide
hydrochlorothiazide
indampimide
metolazone
chlorthalidone
spironolactone
Lasix®
Edecrin®
Burinex®
Diuril®
HydroDiuril®, Esidrix®
Lozol®
Zaroxolyn®
Hygroton®
Aldactone®
The Macstrak Project
Nitrates - What
• vasodilation - venous
• indications:
– AMI
– ischaemic heart disease
– heart failure
– pulmonary edema
– hypertension
• increase venous capacitance  reduces venous return, reducing preload
• dilate coronary blood vessels  improves O2 supply to the myocardium
• dilate peripheral arteries  reduces afterload and work done by the heart
The Macstrak Project
Nitrates - How
The Macstrak Project
Nitrates - Who
Generic Name
Brand Name
nitroglycerin IV
isosorbide dinitrate SL
Nitroglycerin IV ®
Isordil®
nitroglycerin ointment
nitroglycerin patches
Nitrobid®, Nitiol®
Transderm-Nitro®,
Nitro-Dur®,Nitrodisc®
isosorbide dinitrate po
Isordil®
The Macstrak Project
Inotropes - What & How
• positive inotropic agents increase myocardial contractility
• indications:
– cardiogenic shock - hypotension
– AMI
– CHF
• effects are dose-dependant
• increases cardiac output and blood pressure
The Macstrak Project
Inotropes - Who
Generic Name
Brand Name
dopamine
dobutamine
epinephrine
norepinephrine
milrinone
isoproterenol
Intropin®
Dobutrex®
Epinephrine®
Levophed®
Primacor®
Isuprel®
The Macstrak Project
Calcium Antagonists - What &
How
• negative inotropic effect - decreases myocardial contractility, increases
vasodilation
• indications:
– hypertension
– angina
– atrial fibrillation/flutter
• block volt-gated calcium channels in muscle cells – calcium levels drop –
less muscle contraction
• Decrease blood pressure, reduces afterload decreasing amount of
oxygen required by heart
• does not decrease the responsiveness of the heart to input from the
sympathetic nervous system
The Macstrak Project
Calcium Antagonists - Who
Generic Name
Brand Name
amlodipine
diltiazem
nicardipine
nifedipine
verapamil
felodipine
Norvasc®
Cardizem®
Cardene®
Procardia®
Isoptin®
Plendil®
The Macstrak Project
Resources
The following are ways to ensure staff knowledge of drug classifications and
drug penetrance is at suggested guideline levels:
•
Macstrak unit manual – make available at nursing station – available
on website
•
Medication List – post in rooms or nursing station – available on
website
•
Macstrak Quarterly or Macstrak Nursing News – available on
website
•
Reports – review penetrance
•
Audits – Project Office will notify coordinator if on-going issues
The Macstrak Project