Transcript Medication And Health

Medication
and Health
Anne Liu
Pharmacy Doctor, Registered Pharmacist
CVS Pharmacist
October 6, 2007
Outline
 Health Management - Diet, Exercise, Stress
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Management, and Medication
Medication (Drugs) – evidence based medicines,
treatment guidelines, and top 20 prescription drugs
Risk Factors for Cardio-Vascular Disease (CVD) –
the leading cause of death in US and developed
countries
Drugs - used for diabetes, high cholesterol, and
hypertension
Drug Interactions
Drug Side Effects
Health - Diet
 Reduce salt intake
 Reduce fat intake
 Have balanced diet – “rainbow” food
Health - Exercise
 There are 1,440 minutes in every day. Schedule 30 of
them for physical activity!
 The best exercise is the one that you will do.
 Walking is an aerobic and weight-bearing exercise,
so it is good for your heart and
helps prevent osteoporosis.
Health – Stress Management
 Consequences of Stress
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An Epidemic Disease
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A Silent Killer
 Stress Free Management
1.
Meditation
2.
Laugh Out Loud
3.
Play Soothing Music
4.
Think Happy Things
5.
Take a Short Walk
6.
Slow/Deep Breaths
7.
Relax Body (Before/After Bed)
Top 20 Prescription Drugs
1
Lipitor
High Chol.
11 Lisinopril
2
3
4
5
Vicodin
Pain
High BP
High BP
Bac. Infect.
12
13
14
15
6
7
8
Synthroid
Toprol-XL
Norvasc
Amoxil
Nexium
Lexapro
Ambien
Zyrtec
Prevacid
Zoloft
High BP
Sleep
Allergy
Ulcer/reflux
Depression
Thyroid H. 16 Coumadin Bd. Thinner
Ulcer/reflux 17 Advair
Asthma
Depression 18 Lasix
High BP
9 Proventil
10 Singulair
Asthma
19 Fosamax
Asthma/alle 20 Protonix
30 Metformin
Diabetes
Osteoporo.
Ulcer/reflux
Cardio-Vascular Diseases (CVD)
 No. 1 cause of death in men and women
 More than 900,000 deaths annually in the
United States alone
 CVD – including
 Coronary heart disease (CHD)
 Stroke
 Peripheral vascular disease
Artherosclorosis
- Blockages in Blood Vessel
Artherosclorosis
- Blockages in Blood Vessel …
Risk Factors of CVS
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Smoking
Stress
Hypertension
Diet
Dyslipidemia
Physical inactivity
Obesity
Diabetes mellitus (considered a
coronary heat disease risk equivalent)
Calculate Bob’s 10-Year Risk of
Suffering CVD (Heart Attack/Stroke)
 Age: 59 years
 Total cholesterol (TC): 234 mg/dl
 HDL (good Cholesterol): 36 mg/dl
 Treatment for high blood pressure: 148/94
 Smoking history: a smoker
 Triglyceride (TG): 205 mg/dl
Using the attached Framingham Score Chart
His 10-Year Risk = _________ %
10-Year Risk for CVD
- Framingham Score
% Risk
Severity
Treatment
< 10 %
Low-Risk
Life style change
10 % to
20 %
> 20 %
Intermediate-Risk Life style change
BP & Cholesterol control
High-Risk
Life style change
BP & Cholesterol control
Medications (B blocker,
ACEI, Aspirin, Diabetes)
Prevalence of Diabetes
1994
2004
Diabetes
 Affects 20.8 million people in the U.S. (7%)
 6th leading cause of death - 65% of deaths
due to heart disease and stroke
 Leading cause of blindness, renal failure, and
non-traumatic lower-extremity amputations
Diabetes - Types
Type 1
Type 2
Onset
Sudden
Gradual
Age
Younger
Traditionally older
% of Patients
with Diabetes
Cause
5-10%
90-95%
Pancreas does
not produce
insulin
Insulin
Body does not use
insulin effectively
Treatment
drugs/insulin/other
injections
Diabetes - Diagnosis
Condition
Fasting Plasma
Glucose
Postprandial
Plasma Glucose
(not eat for 8 hrs)
(after eating a meal)
Pre diabetes
>100 mg/dl,
but <126 mg/dl
>140 mg/dl,
but <200 mg/dl
Diabetes
≥ 126 mg/dl
≥ 200 mg/dl
Diabetes – Goal of Therapy
A1c
Glucose sticking
to RBC
<7%
 Diet
 Exercise
 Medication
Fasting Blood
Glucose
Postprandial
Blood Glucose
(not eat for 8 hrs)
(after eating a meal)
90 – 130 mg/dl
< 180 mg/dl
Drugs to Treat Diabetes
Glipizide
Glipizide XL
Glyburide
Glyburide,
micronized
Glimeperide
Acetohexamide
Chlorpropamide
Tolazamide
Tolbutamide
Repaglinide
Nateglinide
Acarbose
Miglitol
Metformin XR
Metformin/Glyburide
Metformin/Glipizide
Pioglitazone
Rosiglitazone
Sitagliptin
Sitagliptin/Metformin
Rosiglitazone/Metformin
Rosiglitazone/Glimeperie
Pioglitazone/Metformin
Pioglitazone/Glimeperide
Exenatide (Byetta™)
Pramlintide (Symlin)
Insulin
Regular insulin
NPH insulin
Regular 70/30
Regular 50/50
Insulin Lispro
Lispro 75/25
Lispro 50/50
Insulin Aspart
Aspart 70/30
Insulin Glulisine
Insulin Glargine
Insulin Detemir
Inhaled insulin
High Cholesterol
 Affects 65 million US adults
 Independent risk factor for CHD
CHD #1 killer in the US
 Total cholesterol (TC) >200 mg/dL
 LDL (Bad) >130 mg/dL
 HDL (Good) <40 mg/dL
Drugs to Treat High Cholesterol
Primary
Metabolic
Effect
Effects of
Lipoprotein
Metabolism
Primary
used for
Side Effects
Cannot be
used on
HMG-CoA
Reductase
Inhibitors
(Lipitor)
inhibits
cholesterol
synthesis
Decrease
LDL (bad
Cholesterol)
High LDL
Myopathy
(muscle pain)
Decrease liver
function
liver disease
Bile Acid
Sequestrants
Remove
bile acids
And then
remove
Cholesterol
Decrease
LDL (bad
Cholesterol)
High LDL
GI distress
Constipation
Decreased
absorption of
other drugs
TG >400mg/dL
Rel: TG
>200mg/dL
(may further
increase TG)
Decrease TG
formation in
liver
Decreases
VLDL
Increase HDL
(good
cholesterol)
High LDL
Low HDL
Flushing
Hyperglycemia
Hyperuricemia
Upper GI
distress
liver disease,
severe gout
Rel: diabetes,
PUD,
hyperuricemia
(Cholesteryamine)
Nicotinic
Acid
(Niaspan)
Drugs to Treat High Cholesterol …
Primary
Metabolic
Effect
Effects of
Lipoprotein
Metabolism
Fibric Acid
Derivatives
(Tricor)
Increases
lipoprotein
lipase
activity
Decreases
VLDL
increases HDL
synthesis
Ezetimibe
inhibits
intestinal
cholesterol
absorption
Decrease
LDL (bad
Cholesterol)
High LDL
Decrease
triglyceride
Small
Decrease
LDL (bad
Cholesterol)
High TG
(Zetia)
Fish oil
(Omega-3
fatty acid)
Primary
used for
Side
Effects
Dyspepsia
High
Gallstones
triglycerides
Myopathy
with high
LDL/HDL
(muscle pain)
ratio
Cannot be
used on
severe renal
or hepatic
disease
Some
GI distress
And some
report
headache
liver disease
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LDL Cholesterol Goals and Cut Points for Therapeutic
Lifestyle Changes (TLC) and Drug Therapy in Different Risk
Categories
Risk Category
LDL Goal (mg/dL)
LDL Level at Which
to Initiate
Therapeutic
Lifestyle Changes
(mg/dL)
LDL Level at Which
to Consider
Drug Therapy
(mg/dL)
CHD or CHD risk
equivalents
(10-year risk >20%)
<100
(optional: <70)
≥100
≥130
(100-129: drug
optional)
2+ risk factors
(10-year risk ≤20%)
<130
(optional: <100)
≥130
10-year risk 10%20%:≥130
10-year risk
<10%:≥160
0-1 risk factors
<160
≥160
≥190
(160-189:LDLlowering drug
optional)
Take Home Points
 High total cholesterol, high LDL (bad), low
HDL (good), and possible high triglyceride are
linked to the risk of heart attack and possible
stroke.
 Medications (Lipitor, zocor, pravachol…..)
used to treat cholesterol reduces the risks of
heart attack and over all deaths
 Statins (Lipitor, zocor, pravachol..) are the
drugs of choice for high cholesterol
High Blood Pressure (BP)
BP
Classification
Normal
Systolic(1st Number) Diastolic(2nd Number)
(mm Hg)
(mm Hg)
< 120
< 80
Prehypertension
120 - 139
80 - 89
Stage 1
Hypertension
140 - 159
90 - 99
Stage 2
Hypertension
> 160
> 100
Treatment Guidelines for High BP (JNC7)
Not at goal BP (<140/90)
Lifestyle Modifications
or Diabetes/Chronic kidney
disease (< 130/80)
Stage 1 Hypertension
*Thiazide diuretics (most)
S. (140–159) or D.(90-99) May consider ACEI, ARB,
BB, CCB or combination
Stage 2 Hypertension
*2 drug combination (most)
S. (> 160) or D.(> 100)
Thiazide and ACEI or ARB
or BB or CCB
* Optimize dosages or add additional drugs until goal blood
pressure is achieved.
Drugs to Treat High BP
Generic Name
Brand Name
Calcium Channel Blocker (CCB)
Amlodipine
Norvasc
Diltiazem HCl
Cartia XT
Side Effects
Peripheral edema
Constipation
Tiazac
Cardizem
Nifedipine
Procardia
Adalat
Felodipine
Plendil
Verapamil HCl
Calan SR
Isoptin SR
B-Blocker (BB)
Atenolol
Tenormin
Metoprolol
Lopressor
Toprol XL
Propranolol
Inderal LA
Bradycardia (slow heart rate)
drug may mask signs of
hypoglycemia (caution in
diabetes)
Drugs to Treat High BP …
ACE Inhibitor (ACEI)
Ramipril
Altace
Enalapril
Vasotec
Lisinopril
Priniril
Dry cough
Zestril
Captopril
Capoten
Fosinopril
Monopril
Benazepril
Lotensin
Quinapril
Accupril
Angiotensin II Rceptor Antagonist
Losartan
Cozaar
Valsartan
Diovan
Irbesartan
Avapro
Diuretic
Loop Diuretic
Furosemide
Thiazide Diuretic
Hydrochlorothiazide
Potassium sparing
diuretic
Amiloride (Midamor)
Dry cough, postural hypotension
(caution when rising from lying or
sitting position or climbing stairs)
Lower potassium, so physician may
prescribe potassium supplement.
May have Photosensitivity
Drug Interactions
 Diazepam – Lexapro = increase CNS side
effects (drowsiness, dizziness, headache)
 Flagyl – Lexapro = Flagyl (3A4 inhibitor) may
increase the effect of lexapro (3A4 Substrate)
 Grape fruit juice (a 3A4 inhibitor), it will affect
the drug level which is metabolized by 3A4
(an enzyme).
 Flagyl – Alcohol = Increase flushing (red face)
 Skelaxin – Alcohol = increase CNS side
effects (drowsiness, dizziness, headache)
Drugs – Narrow Therapeutic Index
1 Coumadin
2 Depakne/Depakote
3 Dilantin (phenytoin)
4 Lanoxin (digoxin)
5 Lithium products
6 Synthroid
7 Tegretol (Carbamazepine)
8 Theophylline products
Questions
?