Transcript pharmacy presentation

A little About Ourselves:
 Names: Rakesh Dewan, Lily Liang, Janet Truong,
and Josh McPherson
 We are 2nd year pharmacy students from
the University of British Columbia
Purpose
 We will focus on the use of common medications
used for different cardiovascular conditions
 We hope to provide you with information that will
lead to a safe, effective, and positive medication
experience
Objectives
 Learn how different medications work
 Become aware of potential side effects and how
to manage them
 Dispel common myths about heart medications
Outline
 Statins
 ACE inhibitors
 ARBs
 Diuretics
 Beta-blockers
 Calcium channel blockers
 Blood thinners
 Nitrates
Cholesterol Lowering Drugs
HMG-CoA Reductase Inhibitors (AKA: “Statins”)
Examples:
Drug
Simvastatin
Atorvastatin
Fluvastatin
Pravastatin
Lovastatin
Rosuvastatin
(brand)
(Zocor)
(Lipitor)
(Lescol)
(Pravachol)
(Mevacor)
(Crestor)
Statins
 most effective and well tolerated LDL lowering agents
 38-54% reduction of LDL
 used in addition to dietary and lifestyle modifications to
lower LDL cholesterol
 lowering of LDL has been shown to reduce risk of heart
attack and stroke
 equally effective at heart attack and stroke prevention
How Statins Work
 HMG-CoA reductase is an enzyme that is responsible
for an important step in the production of cholesterol
in the liver.
 Statins block the action of HMG-CoA reductase
leading to lowered LDL (bad cholesterol)
HMG-CoA molecule
Mevalonate
HMG-CoA Reductase blocked by statins
Cholesterol
How Statins Work
 Primary action through lowering the liver
production of LDL
Side Effects
 Statins are generally well tolerated
 Upset stomach: can manage by taking Statin
medication with food
 Headache: can manage by treatment with non-
prescription pain medication (Tylenol or Advil)
 Unexplained muscle pain: Contact Doctor or
Pharmacist
Tips
 AVOID Grapefruit juice: grapefruit juice can
increase the side effects of most statins
 liver function test
 total cholesterol:
20% diet + 80% produced in liver
Skill Testing Question
Statins work by:
a) Blocking the actions of cholesterol
b) Inhibiting HMG-CoA which is an enzyme found in
the liver responsible for LDL production
c) Inhibiting HMG-CoA which is an enzyme found in
the kidney responsible for LDL production
d) Inhibiting HMG-CoA which is an enzyme found in
the liver responsible for HDL production
Inhibitors of Angiotensin
 Angiotensin Converting Enzyme (ACE) Inhibitors
 Angiotensin Receptor Blockers (ARBs)
 General Used For:
 High Blood Pressure
 Heart Failure
 Stable Angina
 Post Myocardial Infarction......
 BUT HOW DO THEY WORK, SIDE EFFECTS..??
Angiotension Converting Enzyme
Inhibitors (ACEI)
 What are some of these medications?
 Captopril (CAPOTEN)
 Enalapril (VASOTEC)
 Ramipril (ALTACE)
 Lisinopril (PRINIVIL, ZESTRIL)
 Quinapril (ACCUPRIL)
 Trandolapril (MAVIK)
 Benazepril (LOTENSIN)
25 mg
20 mg
5 mg
 “The Prils...”
2.5 mg
10 mg
ACEI: How Does It Work?
 To understand how ACE inhibitors and also how
ARBs work, one must understand the AngiotensinRenin Pathway......
20% of patients with hypertension
have abnormally HIGH
renin-angiotnesin
activity
ACE Inhibitors: A Closer Look
 Angiotensin Converting Enzyme (ACE) is a natural
enzyme found in our body that works to increase
blood pressure
 ACE Inhibitors work by
preventing this enzyme
from working, thereby,
decreasing diastolic/
systolic blood pressure
ACEI: But Are They Effective?
 in Post- MI patients:
 reduce afterload and preload
 prevent complications such as left ventricular
remodeling (aka hypertrophy) and HF
 shown to improve overall survival, decrease
development of severe heart failure, and reduce
re-infarction and heart failure hospitalization
rates
• benefits begin within first few days of therapy
ACE Inhibitors: Side Effects
 Dry Cough!
-> SOLUTION?
 Sore Throat/ Fever?
 Others: metallic taste feeling, rash
possibly, hypotension (low blood
pressure)
Ace Inhibitors: Tips
 Important that Doctor and Pharmacist are aware
of all prescription, non-prescription, and natural
health medications
 NSAIDs (Non-Steroidal Anti-Inflammatory
Drugs)
 Others: Iron, Lithium, Diuretics, Allopurinol to
name a few
ACEI: What Do You Think?
 ACEIs are known to increase potassium levels in the
blood, would a diuretic that is not potassium sparing:
a) Increase the potassium further in the blood
b) Decrease the potassium in the blood to balance it with
the ACEI
c) Do nothing
Angiotension Receptor Blockers (ARBs)
 What are some of these medications?
 Candesartan(ATACAND)
 Eprosartan (TEVETEN)
 Irbesartan (AVAPRO)
 Losartan (COZAAR)
 Olmesartan (BENICAR)
 Telisartan (MICARDIS)
 Valsartan (DIOVAN)
Do you see a pattern in the naming?
ARB: How Does It Work?
 Recall the renin-angiotensin pathway......
ARBs Inhibitors: A Closer Look
 Again, the main action is to relax the arteries in
order to allow for more blood flow....
 Uses are similar to ACEI, recall....hypertension,
post-MI, heart failure, stable angina....often
useful if ACEI intolerable
 Benefits? similar to ACEI; first-line in non-blacks
and for patients with diabetes or ischemic heart
disease
ARBs: Side Effects
 Digestive Nausea, vomiting, diarrhea
 Body: headache, dizziness
 What about cough??
 Others: metallic taste, hypotension, rash
Side effects are usually mild and transient 
ARBs: Tips
 Important that Doctor and Pharmacist are aware of
all prescription, non-prescription, and natural health
medications
 Diuretics: may occasionally experience an excessive
reduction of blood pressure after initiation of therapy; can
be minimized by discontinuing the diuretic prior to
initiation of treatment and/or lowering the initial dose of
ARB
 Potassium Supplements/ Drugs that Increase
Potassium (ie. Potassium sparing diuretics).....
ARBs: What do You think?
 Which of the following is FALSE?
a) ARB stands for Angiotensin Receptor Blocker
b) ARBs can cause coughing, just like ACEIs
c) ARBs are useful for the management of
hypertension
What else?
 What else can I do?
 Manage a health weight
 Regular exercise: 23 ½ hours??
 Healthy eating
 Medication compliance
 Find Heart Disease Resource Groups!
Diuretics
3 classes – “water pill”
I. Thiazides
II. Loop Diuretics
III. Potassium Sparing Diuretics
How do diuretics lower blood pressure?
Removal of sodium (salt) and water from the body
I. Thiazide Diuretics
 Common Examples:
 Hydrochlorothiazide
 Indapamide
 Chlorothiazide
 Metoazone
 How do Thiazides work?
 A: They act on the DCT and inhibit Na+ and Cl- transporters
 USES: High blood pressure
I. Thiazide Diuretics
 Where do Thiazides work?
What percentage of
sodium reabsorption
happen in the DCT?
II. Loop Diuretics
 Common Examples:
 Furosemide (Lasix)
 How do Loop Diuretics work?
 A: Similar to Thiazides except they act on the ascending
loop of Henle
 USES: High blood pressure, and edema associated with
heart failure
II. Loop Diuretics
 Where do Loop Diuretics work?
What percentage of sodium
reabsorption happens in the
ascending loop of Henle?
III. Potassium Sparring Diuretics
 Common Examples:
 Amiloride
 Triamterene
 Spironolactone
 How do Potassium Sparring Agents work?
 A: Prevent the loss of potassium and interferes with the
sodium-potassium exchange sites in the CT
 USES: High blood pressure, combination with other diuretic
drugs to prevent hypokalemia
Diuretics
 Common Side Effects:







Upset stomach/Abdominal pain
Frequent Urination
Dryness of mouth
Thirst
Dizziness
Photosensitivity*
Low potassium levels*
Diuretics
 Helpful Tips:
 Take with food
 Take medication early in the day, or at a flexible time to




suit you
Drink lots of water
Rise slowly from a seat or lying position
Apply sunscreen*
Potassium rich foods*
II. Beta-Blockers
 Common Examples:






Propanolol
Pindolol
Labetaolol
Metoprolol
Bisoprolol
Atenolol
 How do Beta-Blockers work?
 A: reducing heart rate and blood pressure
 USES: High blood pressure, angina, and heart failure
II. Beta-Blockers
 Common Side Effects:
 Drowsiness
 Fatigue
 Dizziness and lightheadedness
 Dryness of the mouth, eyes and skin
 Cold hands and feet
II. Beta-Blockers
 Helpful Tips:
 Rise slowly from a seat or lying position
 Drink lots of water
 Prepare ahead of time
 Exercise
Calcium Channel Blockers
Drug
Amlodipine
Nifedipine
Felodipine
Diltiazam
Verapamil
(Brand)
_
(Norvasc)
(Adalat)
(Plendil)
(Cardizem)
(Isoptin)
Calcium Channel Blockers
 Used alone or in combination with other medications
for the treatment of:
- hypertension
-angina
-irregular heart beats
-migraines
-Reynaud's syndrome
-Brain aneurysm complications
How Calcium Channel Blockers Work
 When a muscle fibre is stimulated, calcium
channels open and allow calcium to rush in
 Calcium activates a protein called calmodulin
 Calmodulin bound to calcium starts the pathway
that leads to muscle contraction
 Calcium channel blockers block the calcium
channels that are present on the muscle fibres of
vasculature and the heart
 End result is less contraction of vasculature and
heart muscles leading to dilated vasculature or
decreased force of heart contraction
How Calcium Channel Blockers Work
block
calcium
influx
decreased
muscle
contraction
dilated
blood vessels
and softer
heart
contractions
Side Effects
 Dizziness:
changing positions slowly may help to avoid sudden
dizziness
 Flushing:
strategies to help cool down may include the use of fans,
layering clothes, or applying cool water to over-heated
areas
 Ankle Swelling:
support socks or stockings and elevation of the legs may be
helpful
Tips
 Grapefruit juice may increase the levels of calcium
channel blockers leading to increased risk of side
effects
 Some herbal supplements may counteract the desired
effects of calcium channel blockers
 Some herbal supplements may lead to additive
decrease in blood pressure leading to increased side
effects.
Skill Testing Question
While on a Calcium Channel Blocker:
a) Grapefruit juice should be regularly consumed to
ensure effective therapy
b) Blood vessels are usually constricted due to calcium
channel blocker
c) Herbal supplements that are known to decrease
blood pressure may lead to more side effects
(dizzyness, flushing, etc.)
d) A common side effect is joint and muscle pain
Blood Thinners: Anti-Coagulants
 Delay the clotting time through inferring with a series of
chemical reactions that result in blood clots in arteries and
veins.
 Oral examples:
 Warfarin (Coumadin)
 Dabigatran (Pradax)
 Rivaroxaban (Xarelto)
Warfarin
 How does it work?
 Inhibit the synthesis of vitamin K dependent clotting factors by
blocking vitamin K reduction enzyme activity.
Warfarin
 Side effects:
 Gas
 Fatigue, dizziness
 Decreased clotting time for wounds
 Easily bruised
 GI bleeds
 Tips of taking warfarin:
 Regular INR blood test
 Unexpected bleedings (e.g increased frequency of nose
bleeds)
 Take on an empty stomach
 Same time daily
Warfarin
 Special Dietary consideration:
1) Vitamin K:
-high intake can reduce the effectiveness of warfarin
-daily dietary needs are 80 mcg (recommended 90-120mcg)
- mainly in dark leafy green vegetables.
Examples: Cabbage, brussel sprouts, collard greens, kale, lentils,
soybean oil, spinach, turnip greens, asparagus, cheese, beef liver,
green tea.
*Does that mean I have to cut off from green vegetables?
-No
Or considering eating more low Vitamin K greens:
- Green beans, peas, celery, cucumber, pepper, zucchini.
Warfarin
2) Alcohol:
- >3 drinks daily can increase the effect of warfarin.
1 drink = 5 ounces of wine, 12 ounces of beer,
1 ½ ounces of liquor
*Best to avoid all alcoholic beverages.
3) Vitamin E:
-avoid high doses (1,000 IU increases the risk of bleeding, 800 IU
may be safe, more studies needed).
4) Herbal Supplements:
Examples: garlic, ginkgo biloba, St. John’s Wort, arnica, wheat
grass, bilberry, ginger.
*check with pharmacist
5) OTC:
- Limit use of Advil, Motrin, Aleve, Aspirin.
Game of Truth……….or False
1)
Warfarin reduces already formed clots.
False
Dabigatran (Pradax)
 How does it work?
 Direct reversible inhibition of thrombin that mediates a
coagulation cascade producing blood clotting.
Dabigatran
 Side effects:
 nausea, diarrhea
 Upset stomach, stomach pains
 Heart burn, indigestion
 Easily bruised (mild)
 Interactions:
 herbal supplement and OTC similar to those of warfarin.
 antacids
 Tips:
 With or without food
 Swallow whole
 Outside stable for 30 days.
Warfarin or Dabigatran?
 Advantages of Dabigatran:
 Less incidences of bleedings
 Less INR monitoring are needed
 Less dosage adjustment are needed.
 May have less drug interactions.
 Less food interaction, especially no restrictions on Vit K
foods.
 Disadvantages of Dabigatran:
 Twice daily dosing rather than one daily dosing in
Coumadin.
 Relative new drug, long term effects are no known
 More expensive, not covered by Pharmacare.
Blood Thinner: Platelet
Aggregation Inhibitor
 Inhibit platelets from clumping together to form blood
clots in vessels.
 Oral examples:
 Acetylsalicylic acid (Aspirin, Anacin, Entrophen)
 Clopidogrel (Plavix)
 Dipyridamole (Parsantine)
ASA (Aspirin)
 How does it work?
 Permanent blockage of COX-1, leading to inactivation of COX system and
subsequent blood clotting.
 COX-1 derives TXA2, which induces platelet aggregation.
ASA
Does that mean I have no functional platelets while I am ASA?
-New platelets are continuously produced
-10-20% platelet replaced
-ASA inhibition for 1 hour out of 24 hour cycle
- low percentage of platelets are inactivated.
ASA
 Side effects:
 Heart burn, upset stomach
 Nausea
 increased risk of GI bleeds
 Things to avoid/limit:
 1) NSAIDs (Aleve, Advil, Motrin)


Infrequent use
take ASA 1st.
 2) Alcohol
 3) Curry powder, paprika and licorice (large amount)
 3) Herbal supplements examples: Glucosamine, ginkgo
biloba, ginseng

*check with pharmacist.
ASA
 Tips:
 75mg -325mg daily used in practice.
 Don’t crush EC tablet
 Full glass of water (8 ounces)
 Avoid laying down for 10 minutes after use
 Should not be taken in event of a stroke.
 Cool facts:
 Can prevent vascular death by 15% and nonfatal vascular
events by 30%.
Clopidogrel (Plavix)
 How does it work?
 Permanent inhibition of adenosin diphosphate (ADP)
binding to platelet receptors on platelet membrane that
causes aggregation.
Clopidogrel
 Side effects:
 Easily bruised
 Fatigue, dizziness and headache
 Diarrhea, constipation
 Increased risks of GI bleeding
 Skin related reactions (rashes, itchiness) *due to nature of reaction may
resemble that of allergic reaction, consult your pharmacist or doctor before continuing or discontinuing.
 Interactions:
 1) NSAIDs (Advil and Aleve)
 2) Herbal Examples: blueberry, anise, garlic, ginger, ginkgo
biloba, ginseng, green tea

Check with pharmacist*
 Tips:
 Take with or without food.
Anti-coagulants or antiplatelets
 Question: Aren’t they both anti-clotting agents, don’t
they do the same thing? Should I take both?
 Different mechanisms in blood clotting formations.
 Ongoing debate on which is more effective in prevention
of stroke or thrombus.
 Decision for taking combination therapy is highly
dependent on the medical condition and should only be
made in discussion with your doctor.
Are there non-drugs measures I can do
to prevent blood clots in blood vessels?
 Avoid squatting, sitting or crossing your
legs for long periods of time.
 inactive for long time, walk around for few
minutes every one to two hours.
 flex your ankles, curl your feet or toes more
often through the trip.
 Exercise.
 Prevent dehydrations.
 Limit your salt intake.
Nitroglycerin (Nitrates)
Prevention vs. Treatment
Nitrate (Nitroglycerin): How Does It
Work?
 Vasodilator that works by relaxing the blood vessels,
decreasing the need for the heart to work as hard and
lessen its need of oxygen.
Nitroglycerin: Treat or Prevent?
 Why do we have all these different dosage forms?
 Short-acting: treating attacks of angina and can
prevent angina if taken few minutes before engaging in
activities that can trigger angina (sublingual tablet or
sprays)
 Long-acting: Prevention of angina attacks, not for
emergency relieve. (Transdermal patches, ointment, and
extended releases capsules.
Nitrate (Nitroglycerin): How To
Take?
 Pumpspray?
Nitrate (Nitroglycerin): How To
Take?
 Patch?
Nitrate (Nitroglycerin): How To
Take?
.
 Ointment?
 Every 6 to 8 hours if necessary, and wiped off at bedtime to provide a nitrate-
free interval; may require as much as 10 to 12.5 cm and/or application every
4 hours.
 Apply to nonhairy skin area may be used; some patients prefer the chest.

Sublingual Tablets?
 Sudden Attack?
 Preventative Use?

.
Nitrate (Nitroglycerin): Side Effects
& Interactions
Side Effects:
 Headache is most common.
 Others: flushing, dizziness, weakness, palpitations Nausea,
vomiting, diarrhea
Side effects are usually mild and transient 
Interactions:
 Alcohol
 Phosphodiesterase 5 inhibitors: sildenafil (Viagra)
 Herbals: long list (ginger, ginseng, licorice)….check with pharmacist if
unsure
Nitrate (Nitroglycerin): Tips
 Avoid taking alcohol
 Store in tight sealing container
 Protect from light
 Use your dosage form correctly
 Can I crush/ chew my SL Tablets?
Last T or F
 Nitroglycerin (short-acting) can be taken multiply
times throughout the day without serious side effects.
True
THE END
 Thank you for listening!
 Any questions?
Now we have a question for YOU...