Chapters Transcript Video Heart Failure Medications: Interactions, Side Effects & Resources for Patient Click here to view presentation deck Back to Symposium Thank you and good afternoon. Um Thank you for the introduction. I'm Kristen Wilson. I lead our clinical pharmacy services for Population Health. That's inclusive of our risk arrangements, our value based care strategy, um and also um reviewing our, our provider alignment and education. Um My goal for this afternoon and the time that we have um is to share um information relevant to um primary care when it comes to common medications commonly used for heart failure. So we'll be covering some of the medications that Lauren previously mentioned. Um in addition to a few others that um could still be used, even though um they may not necessarily have been lifted as high on the recommendations for the most recent guidelines. Next slide. Are you not addressed with that thing? The green button. Oops, sorry about that. So we've already covered our agenda. So I'll save another minute. So I just wanted to give us a framework. Um We've talked about the different types of, of heart failure, so I won't belabor that point. Um And also the Serial assessment of reclassification that's happened within the past few years with the updated guidelines. Um These guidelines are are from our A H A as well as ESC um these um specific criteria for um reduced uh ejection fraction, um improved injection traction, preserved. Um These are all important because there are specific medications that are used for each stage that the patient may be in and we'll talk a little bit about that as we move forward. All right. So highlighting here a lot of information for your reference, but I really wanted to call out the four pillars um as Lauren mentioned. So our RNAs, our Ace Arbs, that class, our beta blockers, Mras um and the SGLT twos and diuretics as needed are still included. Um within the past two years, um recommendations have really shifted previously, triple uh triple uh combination therapy was the recommendation. However, we've moved into quadruple therapy. So having as the backbone, the AC RR or re beta blocker, MRI and the SGLT twos, um this is also important because there, there's no um specific medication that needs to be started. First, we can start all four together and titrate to guideline directed medical management for each of these medications. Um as the patient, um their, their um heart failure worsens. We do move into um other modalities, other medications that can be used. Um But today, our focus will be more so on that top line. All right, additional therapies that can be used um based upon the patients staging or worsening of their heart failure, we have um Coron O that could be used for CIA, um, that we'll touch on briefly on digoxin. Um, there still is opportunity for it to be used. Um, we do still see this quite a bit, um, in primary care. All right. Um, for, for reference, I do have listed, um, the class and level guidelines for each of the categories of medications. Um, A and RBS. We can see that they are class one level A. So those are the top of the line that we'll use. Um And what we'll start to talk about here in a couple of seconds, um would be some of the contraindications side effects and things that we need to look out for in our patients. Um So just looking down into um section 78 and nine, just wanted to call forward that when patients are taking an RNE, it's a circuitry and Valsartan. Um The Valsartan component is an R and we want to make sure that we're very cautious in our patients who may already be taking an Ace inhibitor. Um Once sure that we don't co administer those within 36 hours of each other. And also if patients have history of angioedema um on an ace inhibitor, it is probable that that could occur um with the re so we wanna make sure that we're aware of that and also um taking those necessary precautions to not start patients on that if they have a history. Um And the same thing for the ace inhibitors. All right, beta blockers, Mras, again, all of our, our top class uh recommendations. Um, and patients though who have, um, cannot be maintained on their potassium levels, we do, um, you know, no longer recommend that that's used to avoid life-threatening, hyperkalemia. Um SGLT twos are newer entities um that are included in those, um, specifically Lyin and Dagli. Um, for example. All right. And then finally, just a few, um, to be recommendations including, um, some of the newer medications. All right. So what do we have here for each of the medication classes? Just walk through, um, some of the common ace inhibitors. Um, if there's renal dosing required in any adverse reactions or side effects, um, acute kidney injury is, um, very possible when patients are started on ace inhibitors. It's important to note that when patients aren't started on these medications, um, there's usually AAA bump in the patient's B UN or creatinine, um, that'll usually settle out, um, at about 20 to 30% of baseline. So even though we may see that bump, it's good to monitor that. Um, but we wanna make sure that it does resolve and if it does resolve, then we can safely maintain the medic, the patient on this very important therapy. Um, multiple interactions are listed here. Um, both for the Aces and the Arbs. These are, um, older medications, um, usually generic. So we really don't have many patient resources that are available when it comes to cost um and or support around adherence. Um Also just noting um Alyssa cr one of our direct renin inhibitors um is another medication that we do have to monitor for because it can uh worsen um any potential kidney side effects. All right, the the angiotensin reception blocker and Neprilysin, the Securer Losartan that I mentioned um brand name is Ruto. Um We wanna make sure again, we're monitoring for acute kidney injury, but also angioma. If patients have a history of that, we don't want to challenge them with this medication also very specifically as it was listed in the guidelines. Ace inhibitors um can call interactions. Um in addition to Azal antifungals, that's something that's really important to keep in mind because sometimes patients are taking these medications for UTIs and other issues. Um Nsaids, diuretics, those all um have impact on the patient's kidneys and so it can cause um additional um some vaso constriction there which could also worsen the kidney function. Um And for your reference, I do have um several um patient resources. Um These resources include opportunities for patients to get their medications at lower or free cost through the manufacturer in addition to nurse resources um that support the patient with care management, medication adherence and compliance with their meds. All right, beta blockers too. The common ones we see, I mean, primary care carvedilol, metoprolol, no renal dos, dose adjustment is needed um, bronchial spasm and masking of hypoglycemia is something that can occur, um, when patients are taking these medications. So, we wanna make sure, um, that we're monitoring patients, blood glucose, especially those who have, um, diabetes or they're all already taking antiae agents. Um, in addition, those who already have a reactive airway disease and that, that, uh, bronchospasm can be, um, worsened with this medication. And again, another medication that great for our patients. I it's uh it's, they're mostly generic, all generic. And so there's really uh they're not cost prohibitive. Um So the patient resources here, um we don't really have too many at this point. All right, a Minera corticoid, um aldosterone receptor antagonist and Mras um hyperkalemia and gamma caia uh is common just for the spironolactone. Um I did want to specifically call out these uh medications in bold and italics. Um Sometimes these medications are used pretty commonly um in our space and we wanna make sure that we do not uh have the patients on these medications at the same time together because it is a contraindication. Um also um monitoring the patient's potassium um as well as o serum creatinine is very critical. And if we start to see, um as I have listed there, um hyperkalemia start to come in, we will have to adjust the dose and or um sometimes discontinue therapy, but we do have to monitor these um extremely closely because of that for the SGLT twos. Um DPO glyphs, Dagli Ficin and Lyin are the two that were recently approved um for this space. Um A K I bone fractures hypotension and volume depletion can occur. Um But again, really, um in those patients who who may already have some volume depletion going on, and we do want to monitor that renal function very closely. Um because of the, the concern with um lowering of uh blood glucose, this isn't an anti diabetic agent. We want to be very cautious in our patients who may be getting um already on insulin and so on urea because it could lower the um their blood glu glucose to unsafe levels. Um And also here um for seizure and also um for beringer ingram, they have information for patients when it comes to care management. Um in addition to um patient resources where they can connect with each other um to support each other and their heart failure journey. All right, we have our diuretics listed here. Um In the sake of time, we'll just briefly mention the ones that we usually see. Um It's interesting there are some potential interactions with cephalosporins. Um And again how the medications work within those renal tubules does lead to that, that type of interaction when it comes to worsening of kidney function or even hyperkalemia. All right. And um lastly, um we do have Rovio, one of our newer agents, a soluble Goyle cycle simulator um wanted to make sure that we're aware of the hypotension that this has caused it, that this may cause. Um We usually see this in more um advanced heart failure when patients have already maxed out on their other treatments. And this is an add on therapy that can be used, right? And the same for colon or again, um step up therapy after things have been maximized to help maintain control with for the patient. Um But it wanted to note this is contraindicated in those patients with acute decompensated heart failure. All right. And digoxin, um we still do see this in the community um while it's not specifically um listed as one of the top guideline directed therapy management, we still do see this from time to time. So I thought it was important to mention um in our older patients, this is considered a high risk medication. It's a narrow therapeutic index medication. Digoxin toxicity um can happen very commonly, especially in our patients who already have underlining um underlying renal dysfunction. Um We'll see visual disturbances, altered mental status. Those are some of the things that are hallmark signs that we probably have a bit too much of digoxin on board. All right. And with that, thank you. We'll take questions at the end. Published November 5, 2024 Created by Related Presenters Kristen Wilson, PharmD
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