Transcript Warfarin 2.5 mg po once daily

Heart Failure
Done by :
Taqwa shaban
Amal razmak
Aya hamad
Amal al-jarrah
Heart failure:
HF is a complex clinical syndrome that results from any
structural or functional impairment of ventricular
filling or ejection of blood.
Systolic HF (( systolic dysfunction)) :
* Impaired ejection
* Decreased contractility
Signs and symptoms :
- Low EF (<45%)
- Cardiomegaly
- S3
- Normal wall thickness
- Hypokinesis
- Symptoms primarily those of reduced cardiac output
Chief Complaint
“I’ve been more short of breath lately. I can’t seem to walk
as far as I used to, and either my feet are growing or my
shoes are shrinking!”
History Of Present Illness (HPI)
Rosemary Quincy is a 68 yo African-American female who
presents to her family medicine physician for
evaluation of her shortness of breath and
increased swelling in her lower extremities.
She reports that her shortness of breath has been gradually
increasing over the past 4 days.
She has noticed that her shortness of breath is particularly
worse when she is lying in bed at night, and she has to
prop her head up with three pillows in order to sleep.
She also reports exertional dyspnea that is usual for her,
but especially worse over the past couple of days.
Past Medical History (PMH)
-Hypertension × 20 years
-CHD with history of MI in 2005 (PCI performed and bare
metal stents placed in LAD and RCA)
-Heart failure (NYHA FC III)
-Type 2 DM × 25 years
-Atrial fibrillation
-COPD (stage 3)
Family History (FH)
Father died of lung cancer at age 71, mother died of MI at
age 73
Social History (SH)
Reports occasional alcohol intake.
States she has been trying to follow her lowcholesterol and low-sodium diet.
Former smoker (35 pack-year history; quit
approximately 10 years ago).
Medications ( Meds) :
-Valsartan 160 mg po BID
-Furosemide 40 mg po BID
-Warfarin 2.5 mg po once daily
-Carvedilol 3.125 mg po BID
-Pioglitazone 30 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, two inhalations by mouth q 4–6 hours PRN shortness of
breath
-Tiotropium DPI 18 mcg, one inhalation by mouth daily
-fluticasone/salmeterol DPI 250 mcg/50 mcg, one inhalation by mouth
BID
DRUGs
Valsartan
DOSING
CLASS
160 mg po BID ARBs
INDICATION
HT & HF (PCI)
Furosemide
40 mg po BID
Loop Diuretic
HT & HF
Warfarin
2.5mg po once
Anticoagulant
daily Vitamin K Antagonist
Prophylaxis
(PCI)
3.125 mg po BID
B-blocker
HF, MI & Atrial
fibrillation
Pioglitazone
30 mg po once
daily
Antidiabetic agent
(Thiazolidinedione)
Type 2 diabetes
Glimepiride
2 mg po once daily
Antidiabetic agent
(Sulfonylurea)
Type 2 diabetes
20 mEq po once
daily
Electrolyte
supplement
Prevention of
hypokalemia
Atorvastatin
40 mg po once
daily
Antilipemic Agent
CHD
Aspirin
81 mg po once
daily
Antiplatelet
agent(NSAID)
MI (PCI)
Carvedilol
Potassium chloride
DRUGs
DOSING
CLASS
INDICATION
Albuterol MDI
2 inhalations q 4_6
h PRN shortness of
breath
B2 Agonist
Bronchospasm
Tiotropium DPI
18 mcg
1 inhalations daily
Anticholinergic
Agent (long
acting)
COPD
Fluticasone/
Salmeterol DPI
250 mcg/50mcg
1 inhalations BID
B2 Agonist (long
acting)
COPD
Review of symptoms (ROS)
- Approximate 7-kg weight gain over the past week.
- worsening shortness of breath with exertion and three-pillow
orthopnea.
- chronic, dry (nonproductive), hacking cough, which she describes as
usual without recent worsening.
Physical Examination
General
African-American female in moderate respiratory
distress
Vital sign (VS (
BP 134/76 mm hg (sitting; repeat 138/80),
HR 65 (irreg irreg)=> normal 60-100
respiratory rate (RR) 24 => normal (16-20)
, T 37°C,
O2 sat 90% RA,
Ht 5′5″ = 165.2 cm ,
Wt 79 kg (Wt 1 week ago: 72 kg)
Skin
Color pale and diaphoretic; no unusual lesions noted
Head, Eyes, Ears, Nose and Throat (HEENT)
PERRLA;
Pupils,Equal,Round,Reactive to
Light ,Accommodation
lips mildly cyanotic;
dentures
Neck
(+) JVD (Jugular Venous Distention) at 30° (7 cm) => normal <4 cm
; no lymphadenopathy or thyromegaly
Lungs/Thorax
Crackles bilaterally, 2/3 of the way up; no expiratory wheezing
Heart
Irregularly irregular; (+) S3; displaced PMI
Abdomin
Soft, mildly tender, nondistended; (+) HJR ( hepatojugular reflux); no
masses, mild hepatosplenomegaly; normal BS
Genit/Rect
Guaiac (−), genital examination not performed
MS/Ext
3+ pitting pedal edema bilaterally; radial and pedal pulses are of poor intensity
bilaterally
Neuro
A & O × 3 (alert & oriented to person,place,time), CNs intact. No motor deficits
ECG
Atrial fibrillation, LVH
Chest X-Ray
evidence of congestive failure with cardiomegaly, interstitial edema,
and some early alveolar edema. There is a small right pleural effusion.
No evidence of infiltrates; evidence of pulmonary edema suggestive of
congestive heart failure; enlarged cardiac silhouette
Echocardiogram
LVH, reduced global left ventricular systolic function, estimated EF
20%; evidence of impaired ventricular relaxation, Stage 1 diastolic
dysfunction
Labs
Na 131 mEq/L (135-145)
Hgb 13 g/dL (13-17) Mg 1.9 mEq/L (1.5-2)
K 3.5 mEq/L (3.5-5)
Hct 40% (37-52)
Ca 9.3 mg/dL (8.4-10.2) HbA1C 6.1% (3.9-5.3)
Cl 99 mEq/L (95-105)
(50 -450)
3
3
Plt 192 × 10 /mm
Phos 4.3 mg/dL (2.44.1)
CO2 28 mEq/L (23-30)
(4-10)
AST 34 IU/L (8-46)
3
3
WBC 9.1 × 10 /mm
ALT 27 IU/L (7-55)
BUN 32 mg/dL (5-20)
SCr 2.3 mg/dL (baseline
SCr 2.1 mg/dL) (0.6-1.1)
Glucose 124 mg/dL (70100)
BNP 776 pg/mL (BNP
drawn 2 months prior:
474 pg/mL) (<100)
INR 2.3 (2-4)
Labs
Test
Result
Na
131
135-145
BUN
32
5-20
SCr
2.3
0.6-1.1
glucose
124
70-100
BNP
776
<100
Phos
4.3
2.4-4.1
HbA1c
6.1%
3.9-5.3
CCl = 24.2
Normal range
Assessment
Admit to hospital for acute exacerbation of heart failure.
Clinical Pearl
The presence of pitting edema is associated with a substantial increase in
body weight; it typically takes a weight gain of 10 lb to result in the
development of pitting edema.
Questions
1.a.
Create a list of this patient’s drug-related problems ?
Drug-Drug
Interactions
Related issue
Salmeterol with
carvedilol
B2 agonist with
mixed B antagonist
worsen dyspnea
Warfarin with
Aspirin
May lead to bleeding
Pioglitazone
Exacerbate heart
failure
1.b. What signs, symptoms, and other information
indicate the presence and type of heart failure in
this patient ?
signs
Shortness of breath over the
past 4 days .
Increased swelling in the
lower extremities.
Exertional dyspnea.
symptoms
HR 65 (irreg.irreg)
Displaced PMI
S3 sound present
Cardiomegaly
3+ pitting pedal edema
Interstitial edema
Early alveolar edema
Small right pleural effusion
Skin color pale & diaphoretic.
1.c.
What is the classification and staging of
chronic heart failure for this patient
stage 4 according to ( NYHA Functional Classification).
She has acute exacerbation of heart failure with left systolic
dysfunction.
1.d.
Could any of this patient’s problems have
been caused by drug therapy?
Pioglitazone is a 1ST generation sulfonurea which
exacerbate heart failure and cause pedal edema
with weight gain.
And intake of carvedilol with B2 agonist
worsening of COPD by antagonism.
There is also a glimepiride which increase CV
mortality.
2.a.
What are the goals for the pharmacologic
management of heart failure in this patient?
• Control the disease and prolonging survival by
improving quality of life .
• Relief symptoms of dyspnea & orthopnea .
• Decrease edema & swelling.
• Fluid restriction & Minimizing disability.
• Manage the acute exacerbation of her HF.
3.a.
What diuretic therapy should be recommended
for this patient initially for acute treatment of
her heart failure exacerbation?
• Use the same diuretic which is furosemide but
in IV/IM: 10 to 20 mg once over 1 to 2 minutes.
A repeat dose similar to the initial dose may be
given within 2 hours if there is an inadequate
response. Following the repeat dose, if there is
still an inadequate response the last IV dose
may be raised by 20 to 40 mg until there is an
effective diuresis.
•
Single doses NOT exceeding 200 mg.
3.b.
How should this patient’s pharmacotherapy be
adjusted for chronic management of her heart
failure?
• Change B blocker to metoprolol succinate to prevent
interaction with b2 agonist which is salmeterol.
• Titrate furosemide oral dose to 80 mg( max 600)
• Warfarin dosage should adjusted according to results
of International Normalized Ratio (INR) or prothrombin
time (PT).
• Increase the dose of glimepiride after stopping
pioglitazone .
Continue on Warfarin and Aspirin.
For HTN management associated with heart faliure :
Continue on valsartan& furosemide
For atrial fibrillation:
It managed by warfarin & carvedilol that replaced with metoprolol
succinate.
For Dyslipidemia:
Continue on atorvastatin.
For COPD management :
Continue on albuterol ,tiotropium,
Continue on fluticasone /salmetrol
For hypokalemia :
Continue on pottasium chloride supplements with monitoring
3.c.
What non pharmacologic therapy should be
recommended for this patient with respect to her
heart failure?
•
Dietary modifications such as low sodium & cholesterol
diet.
• Risk factor reduction including stopping alcohol
consumption and supervised regular physical activity.
• O2 therapy to be >90% if the pt has hypoxia.
• bed rest during exacerbation .
• Fluid restriction.
4. What drugs, doses, schedules, and duration are
best suited for the management of this patient?
Drug
Initial Daily
Dose(s)
Maximum
Dose(s)
Duration of action
Metoprolol
succinate
extended release
12.5 to 25 mg once
200 mg once
24 hr
Furosemide
20 to 40 mg once
or twice
600 mg
6 to 8 h
valsartan
40 mg twice daily
80 to 160 mg once
daily
5. What clinical and 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 , stable HR btw 50-100
HR/min,BP.
• Monitor kidney& liver function.
• monitor blood glucose
• Fluid intake – body weight (daily)-
• 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
6. What information should be provided to the
patient about the medications used to treat her
heart failure?
• Furosemide taking on empty stomach
• 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.
Pharmacist Care Plan (PCP)
Date
Medical problem
Tx issues
Pharmacotherapy goals
Recommendations
8/10
HF
Acute exacerbation
of systolic HF
inadequately drug
therapy
Manage symptoms,
Increase survival and QOL.
Start on metoprolol succenate initial
12.5 mg BID
Take Furosemide iv 40 mg with gradual
increment, when stable back to po 80
mg BID
continue on valsartan 160 mg po BID
continue on warfarin 2.5 mg po once
daily
continue on aspirin 81 mg po once daily
8/10
HTN
Bp above goal
Bp<120/80
Increase Furosemide oral dose to 80
mg
Continue on valsartan And metoprolol
succenate as described above
8/10
DM
Blood glucose
above goal
Decrease glucose to
100mg/ dl
Stop pioglitazone and increase
glimpiridine to 8 mg.
8/10
Dyslipidemia
Increased lipids
Decrease LDL and
increase HDL
Continue on Atorvastatin 40 mg po once
daily
8/10
COPD
management
stable
Decrease chronic cough
and hacking cough
(enhancing breathing)
Continue on Albuterol MD2 inhalation q
4-6 hours
continue on tiotropium DPI 18 mcg,
continue on fluticasone/salmetrol DPI
250 mcg/ 50mcg, h inhalation BID.
8/10
Atrial fibrillation
stable
Continue to be managed
Manage by warfarin 2.5 mg and
carvedilol 3.125 mg( replaced with
metoprolol succinate).
Physician
action
Goals
Monitoring
parameters
Freq
HF
electrolytes: Na
K
Every visit till
steady
BNP
Every visit
SCr
Every visit
HTN
BP
HR
Every day
DM
Sugar level
Every day
Dyslipidemia
Weight
HDL, LDL, TG
Daily once a
Atrial fibrillation
HR
Every day
COPD
Breathing,
Coughing
Every day
week
Achievement of
outcomes
comments
Goals
Monitoring
parameters
Freq
Valsartan
Monitor
pottasium
and SCr
Every visit
Furosemide
Monitor
electrolytes (
Na/K,
hyperuricemia,
nephrotoxicity
and
autotoxicity)
Every visit
Metoprolol
succinate
BP, HR baseline
and ECG
Daily once a
month
Achievement of
outcomes
comments
THE END