Pharmacology – A Class Act

1. Pharmacology – A Class Act St. Louis, MO March 22, 2014

2. Choosing a route of administration • Remember—topical drugs CAN have systemic absorption and side effects • Most of the time this is NOT a problem • A few exceptions to mention:

3. Beta-blocker eye drops for glaucoma—second-line therapy--Lower intraocular pressure by 20-25% with once or twice daily dosing • Betoxolol (Betoptic, Betoptic S), timolol (Betimol, Timoptic, Timoptic XE, Istalol, TimopticOcudose),levobunolol (Betagan), carteolol (Ocupress), metipranolol (Optipranolol) • Highly lipid-soluble and cross the blood-brain barrier • Can cause bradycardia and anhedonia • So what can you use instead?

4. The “oprosts”—first line therapy for glaucoma—Prostaglandin analogs • The “oprosts”—bimatoprost (Lumigan, Latisse for thick, long eyelashes), latanoprost (Xalatan), travoprost (Travatan, Travatan Z) • Prostaglandin analogues—lower Intraocular pressure by 25-30%

5. Long-term use of topical prostaglandin analogs • **Latisse (bimatoprost) for thick, long eyelashes • Conjunctival hyperemia • Darkening of the iris • Increasing the length and number of eyelashes • Iris pigment changes occur most frequently in patients with green-brown, yellow-brown, or blue-gray-brown irides

6. Vaginal monistat and warfarin • Check the INR within 4 days of adding or subtracting any drug, regardless of the route of administration • TELL your patients to let you know if they pick something up OTC • Vaginal monistat can double the INR

7. Premarin vaginal cream/estrogen vaginal suppositories (Vagifem) • If used within 2 hours of sex, can cross the male urethra and feminize the husband • 98.7% of vaginal estrogen stays in the vagina; only 1.3% can be absorbed systemically—not enough to cause systemic side effects

8. Pre- and Post-menopausal females and hormones • Use of a hormone patch does NOT increase fibrinogen or clotting factors • Reduces risk of clotting complications • Especially useful in smokers, overweight, and older women

9. Notes on “timing” of drugs • Any drug that is given once a day works best in the first 12 hours—even tho’ drug “levels” are maintained throughout the 24 hour period (exception to rule, insulin glargine (Lantus) has a steady state for 24 hours) • Once a day BP drugs—given in a.m.? Work best from 8 a.m. to 8 p.m. fine for most people; however, remember that BP rises fastest in the early a.m.—strokes and MIs • Dippers vs. non-dippers • BID dosing or give anti-HBP drug at bedtime

10. Notes on timing of drugs • Proton Pump Inhibitors • Give 30-60 minutes before the first meal of the day or if given BID, give 30-60 minutes before breakfast and dinner • The PPIs STOP the acid pump that kicks in after you eat • Giving the pill AFTER a meal defeats the purpose—the pump has already started

11. ASA at night • Some new studies are showing that aspirin taken at night may decrease platelet aggregation in a.m. (American Heart Association Annual Meeting, November 2013) • Separate low-dose aspirin from ibuprofen by 30 minutes)—don’t take together or the effect of aspirin on platelets will be negated (FDA Advisory, 9/2006)

12. Notes on OTC drugs • OTC famotidine (Pepcid) is the best H2 blocker –less drug interactions, more acid suppression • Double the recommended OTC dose on the box for the best results—remember that the H2 blockers work best at suppressing vagally-induced histamine—i.e. histamine produced overnight. • So give Pepcid at hs

13. OTC Aspirin-- role in inflammation IN ADULTS: • Preventing heart disease—arterial clots (not venous clots)—platelets play a major role in arterial clots, not DVTs • Preventing colon polyps (triggered by production of prostaglandins) and other solid tumors; may also inhibit metastasis in cancer patients (Rothwell) • Aspirin is no longer recommended for pain management or for hyperthermia

14. OTC herbal products • SJW—interacts with 60% of all drugs and makes them LESS effective; dig, cyclosporin, tamoxifen, HAART, COCs…and the list continues… • Ginseng—sodium and water retention with increased BP; estrogen-like properties (gynecomastia), platelet inhibition, (dysfunctional uterine bleeding in PMF, prolonged periods in younger women) • Many herbal products elevate liver enzymes—KAVA, germander, skull cap, mistletoe, sassafras • Many herbal products interfere with platelet aggregation—gingko, grapeseed extract, garlic, SJW

15. Generics vs. Brand names As a general rule, classes of drugs have the same generic “last” name • “Statins”—Lower LDL-cholesterol • “Prils”—ACE inhibitors (BP + more) • “Triptans”—treatment of acute migraine headache • “Sartans”—ARBs (angiotensin receptor blockers)—BP + more • “Prazoles”—Proton Pump Inhibitors, GERD • The “afils” – pulmonary hypertension • The “conazoles”—antifungal • The “olols”, “alols”, “ilols” • “Dipines”—calcium channel blockers (BP+) • The “coxibs”—COX-2 inhibitors • The “cyclovirs”—antiherpetic drugs

16. The ACE inhibitors—the “prils” • Captopril (Capoten)(1981) • Enalapril (Vasotec)(1983) • Fosinopril (Monopril) • Lisinopril (Prinivil, Zestril) • Perindopril (Aceon) • Moexipril (Univasc) • Benazepril (Lotensin) • Quinapril (Accupril) • Trandolapril (Mavik) • Ramipril (Altace)

17. “Sartans”—Angiotensin II Receptor Blockers—the ARBS • Angiotensin receptor blockers (bypass ACE) and work by blocking the angiotensin II receptors on tissues • Who are they? The “Sartan Sisters”… • losartan—Cozaar; yes, peds; 6 and over • valsartan—Diovan—yes; 6 and over • candesartan—Atacand—peds, yes. Ages 1 and over • irbesartan—Avapro—peds, nope • telmisartan—Micardis—no in kids • olmesartan—Benicar; yes in kids • eprosartan –Tevetan—peds? nope • azilsartan – Edarbi; no kids

18. ACES and ARBS • ACE inhibitors = ARBS for blood pressure control and they are both relatively safe. • The side effect of angioedema is less likely with the ARBs. • The ARBs may be better after a myocardial infarction, whereas both ACE inhibitors and ARBs protect after strokes. • There is absolutely no evidence to support combining ACE inhibitors with ARBs. (American Society of Hypertension, March 2013)

19. Is there a “better” ACE inhibitor? • Good question…yes, and it has nothing to do with reducing systemic blood pressure • Evidence suggests that centrally acting ACE inhibitors (i.e. ramipril, trandolopril, captopril, fosinopril, and lisinopril), all cross the blood brain barrier (ie, lipid-soluble), and have been shown to slow cognitive decline in patients with dementia. (Gao Y et al. Effects of centrally acting ACE inhibitors on the rate of cognitive decline in dementia. BMJ Open 2013 Jul 22)

20. Pediatric hypertension • Primary hypertension in children has been shown to correlate with family history of hypertension, low birth weight, and excess weight. • With the increasing prevalence of childhood weight problems,increased attention to weight-related health conditions including hypertension is warranted. • And the weight is not just about blood pressure!

21. Pediatric Type 2 diabetes • The incidence of Type 2 diabetes in kids is increasing exponentially • There’s NO good news about this • The combination of obesity and type 2 diabetes = more rapid progression to long-term side effects—HBP, CAD and … • Progression to chronic kidney disease (CKD) much faster than kids with Type 1 diabetes

22. Three “prils” approved for kids over 6 • Fosinopril (Monopril)—approved for kids over 6 and weight greater than 50 kg • Lisinopril (Prinivil, Zestril)—kids 6 and over • Benazepril (Lotensin)—kids 6 and over

23. New BP recommendations – primary (old name—essential) hypertension • Chlorthalidone (Thalitone), amlodipine (Norvasc), and lisinopril (Prinivil, Zestril) all lower blood pressure equally and outcomes are similar between these three drugs (ALLHAT Study)

24. Chlorthalidone vs. HCTZ • Chlorthalidone (Thalitone) is superior to hydrochlorothiazide (HCTZ); decreases cardiovascular risk • Works in patients with lower glomerular filtration rates than HCTZ. HCTZ has no effect with GFRs less than 45 mL/min; chlorthalidone is okay with GFRs down to 30 mL/min. • Downside: more hospitalizations for hypokalemia and hyponatremia with chlorthalidone vs. HCTZ. • (Dhalla LA et al. Chlorthalitone vs. hydrochlorothiazide for the treatment of hypertension in older adults. Ann Intern Med 2013 Mar 19;158:447)

25. “Stacking” diuretics is the new trend • When spironolactone is add-on therapy in CHF (chronic heart failure) patients, hyperkalemia is a high risk. If spironolactone is added to a diuretic that “wastes” potassium, the results improve—so chlorthalidone or furosemide can be stacked with spironolactone. Metazolone (Indapamide) can also be stacked with spironolactone in patients with a low GFR.

26. A note on the CCBs • The majority of CCBs, including amlodipine (Norvasc) can cause significant peripheral edema (felodipine /Plendil is the worst offender) • Irsradipine (DynaCirc) does not. Switch if the patient is non-compliant due to the edema. You can combine calcium channel blockers together—isradipine and verapamil for example but watch out for gingival hypertrophy. • And always watch for constipation with verapamil—regardless of age

27. An interesting side effect of the CCBs • Fertility issues

28. Beta-blockers no longer recommended for primary hypertension • Beta-blockers have become obsolete for cardiovascular protection in hypertensive patients. Their “era” did not include percutaneous interventions, statins, platelet therapies and ACE inhibitors or Angiotensin Receptor Blockers (ARBs). • Studies show that adding a beta-blocker to current anti-hypertensive therapies does NOT improve outcomes. • P.S. beta blockers are still useful for nonhypertensive indications—like inhibition of remodeling in patients with systolic heart failure. (REACH Registry JAMA 2012;308:1340)

29. Beta-blockers • All antihypertensive agents are NOT created equal…case in point—the beta blockers • The beta blocker atenolol (Tenormin) is the worst of the bunch as a beta blocker used for hypertension. Atenolol raises the central blood pressure (the pressure experienced by the heart, brain, and kidneys) DESPITE lower brachial pressure. This paradoxical effect is a bad one. Atenolol has a risk ratio of 1.26 for cardiovascular disease compared to all of the other beta blockers.

30. Beta-blocker-plus drugs • The beta-blocker “plus” drugs. The term means that beta blockade is accompanied by other important actions. Carvedilol (Coreg) provides alpha-one blocking effects with peripheral vasodilation. Nebivolol (Bystolic) also boosts nitric oxide production and is a potent vasodilator. As a result of the “plus” factor, carvedilol and nebivolol do not increase central blood pressure (as does Atenolol). • So, choosing one of these as an “add-on” or first-line therapy for hypertension may be useful

31. Important clinical note… • The ASCOT-LLA trial compared atorvastatin/placebo with atorvastatin/beta-blocker for cardioprotection. Significant endpoints were better in the statin-placebo group compared with the statin/beta-blocker group. • The results suggest that the beta blockers interfere with the statins effects on cardiovascular protection.

32. What’s not to love about the ACE inhibitors?

33. Side effects, of course… • Hypotension—start low and go slow • Hypoglycemia (low blood sugar)—only in diabetics on antiglycemic agents; not a problem in normoglycemic patients; instruct your patients to carry some extra hard candy with them for any initial hypoglycemic episodes

34. Side effects, of course… • Hyperkalemia (high potassium) (excreting sodium and water and retaining potassium) • Add a thiazide diuretic to the ACE inhibitor • Capozide (captopril + thiazide) • Prinizide (lisinopril + thiazide) • Zestorectic (as above) • Lotensin HCT (benazepril + hydrochlorothiazide)

35. ACE, ARBs and serum creatinine levels Serum creatinine may rise 10% to 30% from baseline within the first two weeks of starting therapy with either an ACE inhibitor or ARB (angiotensin-receptor blocker). Pts with normal renal function starting either class of angiotensin blocking drugs experience a rise of about 0.2 mg/dL over a two- to three-week period, returning to baseline in the 4th week. (Greene JH. Restricting dietary sodium and potassium intake: a dietitian’s perspective. In Daugirdas JT. Handbook of Chronic Kidney Disease Management. Philadelphia, PA: Lippincott Williams & Wilkins;2011:81-96)

36. ACE, ARBs and serum creatinine levels • If the patient has renal insufficiency to begin with, expect a rise in serum creatinine of 0.5 mg/dL over a four-week period. Patients with renal artery stenosis, extensive atherosclerotic cardiovascular disease, or dehydration may experience a progressive increase in serum creatinineto 2.0 mg/dL. Discontinuing the ACE or the ARB is the appropriate course of action. • (Greene JH. Restricting dietary sodium and potassium intake: a dietitian’s perspective. In Daugirdas JT. Handbook of Chronic Kidney Disease Management. Philadelphia, PA: Lippincott Williams & Wilkins;2011:81-96)

37. Since ACE inhibitors conserve potassium…What about K+ containing foods? • May contribute to hyperkalemia and cardiac arrhythmias but usually only in patients with renal insufficiency or in patients who are also on K+ sparing diuretics such as spironolactone (Aldactone) and eplerenone (Inspra) • Avoid excessive potassium intake when on the above drugs or with renal insufficiency • Advise patients to decrease potassium intake until they can get their potassium checked

38. Risk factors for moderate hyperkalemia (≥ 5.6 mmol/L) • Patients older than 65 • CHF • SCr greater than 1.6 mg/dL • BUN greater than 18 mg/dL DOSING REDUCTION or D/C with the following: • Hyperkalemia greater than 5.6 mmol/L • Age greater than 70 • BUN greater than 25 mg/dL • Serum K+ greater than 6 mmol/L

39. High K+ containing foods≥200 mg/serving • Avocado • Artichoke • Broccoli • Carrots • Cantaloupe • Potatoes • Dried beans, canned mushrooms • Apricots • Bananas • Pumpkin • Spinach • Oranges • Health.harvard.edu/heartextrafor K+ content of 1,200 foods

40. Bummer. • Unfortunately chocolate also fits into the category of high-potassium foods, as does peanut butter, nuts, seeds, milk, and yogurt. • (Greene JH. Restricting dietary sodium and potassium intake: a dietitian’s perspective. In Daugirdas JT. Handbook of Chronic Kidney Disease Management. Philadelphia, PA: Lippincott Williams & Wilkins;2011:81-96)

41. Other potential K+ boosters… • Check K+ level no later than one week after starting spironolactone (low risk patients check at 7 days; moderate and high risk patients check at 4 and 10 days, after a dose increase or if diuretic doses are increased) • Stop taking any K+ supplements • Go easy on the NSAIDS (decrease GFR) with retention of fluids and electrolytes • Herbal or natural remedies with hefty doses of potassium include noni juice, Siberian ginseng, hawthorn berries, (Harvard Heart Letter, December 2004)

42. One last note…drugs and herbal products that increase potassium • Don’t use Bactrim/Septra for UTIs when patients are on ACE inhibitors—it also increases K+ and can lead to life-threatening arrhythmias • NSAIDS conserve K+ due to vasoconstriction of the afferent arteriole (ibuprofen, piroxicam, and naproxen are the biggest offenders) • KCl supplements (as salt substitutes)

43. Side effects, continued… • Cough (gender differences with F > M) • ACE inhibitors block angiotensin converting enzyme; but as ACE is inhibited, bradykinin goes UP…bradykinin is a potent bronchospastic agent • Women have more bradykinin to begin with, therefore the gender disparity in the cough

44. Side effects, continued… • Life-threatening angioedema (“Does my voice sound funny to you?”) • Usually within the first month (but not the first week); almost all cases within the first year • An exception or two

45. ARBs as a safe haven for the side effects of the “prils” • Are the “sartans” safe for patients with a history of angioedema from the “prils”? • Appears to be about an 5 to 8% rate of cross-reactivity • Given this limited percentage, switching to an ARB should not be considered an absolute contraindication in all patients with ACE-inhibitor induced angioedema • Switch cautiously • (Prescriber’s Letter 2004; 11(7))

46. ACE vs. ARB • New and important infofrom American Society of Hypertension meeting 2013 • All ACE are = in lowering BP • ACE = ARB and both relatively safe; ARBs with less angioedema • ARBs may be better after MI • Both protect after strokes • No evidence to support combing ACE + ARB

47. ACA/AHA new recommendations for prevention and treatment of high cholesterol • The American College of Cardiology/American Heart Association guideline on the Treatment of Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults has been released and it basically uses the KISS method—KEEP IT SIMPLE, STUPID. In other words, instead of a plethora of cholesterol-lowering drugs, a long-list of recommendations, and never-ending caveats, the focus is now on just 4 at-risk groups: (P.S. this has stirred up quite the controversy)

48. The NEW recommendations for statin therapy 1) The so-called “secondary” prevention group consisting of individuals who have already experienced a cardiovascular event—TIA, PAD, Angina, ACS, ischemic stroke 2) The population of individuals with an LDL-cholesterol level of ≥190 mg/dL

49. New recommendations for statin therapy 3) Individuals with type 2 diabetes aged 40-75 without a history of a prior cardiovascular event and a LDL-cholesterol level between 70 and 189 mg/dL, and,

50. New recommendations for statin therapy • Individuals with a 10-year or greater risk of a cardiovascular event as calculated by the Cardiovascular Risk Calculator. Log on to the Framingham Heart Study online and click on the cardiovascular risk assessment calculator to determine risk. • Based on blood pressure, gender, total cholesterol, and HDL cholesterol…so have all of that information handy to determine the likelihood of having a major coronary event in the next 10 years.