Preventing Heart Attacks and Strokes Every Day (PHASE) RCHC Medication Titration Algorithm

Transcription

1 Preventing Heart Attacks and Strokes Every Day (PHASE) RCHC Medication Algorithm Updated 9/13/2017 PHASE Populations DM: type 2 ASCVD: hx heart attack/cad, CVA, TIA, AAA, Sx PAD Lifestyle Modifications Physical activity 30m/d Weight control; BMI <25 DASH; dietary Na g/d Limit ETOH; Tobacco cessation Medications: Independent of BP control & LDL ASA¹: 81mg ACEI²: Lisinopril 10mg/d; add Thiazide HCTZ 12.5mg/d for Hx CVA Beta Blocker³ for CAD/SxPAD/AAA: Metoprolol ER or Atenolol 25mg/d BP s⁴ < 140/90: < 60 yrs &/or DM, CKD³ < 150/90: 60 yrs, no DM or CKD/nephropathy Statin Treatment Benefit Groups ACE-Inhibitor² / Thiazide Diuretic Lisinopril / HCTZ (Advance as needed) 20 / 25 mg x ½ 20 / 25 mg x 1 20 / 25 mg x 2 If ACEI intolerant or pregnancy potential Thiazide Diuretic HCTZ 25 mg 50mg Chlorthalidone 12.5 mg 25 mg ASCVD 75 yrs DM >75 yrs If not in control For ACEI intolerance due to cough, use ARB² LDL 190mg/dL⁵ LDL mg/dL 6,7 Use 2-4 week titration intervals to help patient reach goal ASAP Calcium Channel Blocker² Add Losartan 25 mg 50 mg 100 mg Add amlodipine 5 mg x ½ 5 mg x 1 10 mg Spironolactone or Beta-Blocker² Add Metoprolol ER 25 mg 50 mg 100 mg 200 mg Atenolol 25 mg 50 mg (Keep heart rate > 55) IF on thiazide AND egfr 60 ml/min/1.73m 2 AND K < 4.5 Add spironolactone 12.5 mg 25 mg Start Statin High Intensity Atorvastatin² 40-80mg er LDL by 50% See CAUTION/INFO Verify Start Statin Moderate Intensity Atorvastatin² 10-20mg er LDL by 30-50% See CAUTION/INFO Verify If recommended dose not tolerated, reduce to highest tolerated or other statin⁸ 1 ASA: 40-75y ASCVD, DM or 10y ASCVD >10%. Caution if on blood thinner (NSAID), hx GI bleed, or pregnancy potential. 2 Reproductive potential alert -> verify effective : ACE-I & ARBs (contraindicated in pregnancy), Calcium Channel Blockers & Spironolactone (Risk Category C); Beta-Blockers (Risk Category D); Statins (Risk Category X). ³ BP goal applies if egfr>30 & if LVEF>40%. For people >70y with CKD should be individualized taking into consideration fragility, comorbidities & albuminuria. 4 CKD: microalbuminuria or [(age/2) + egfr] <85. 5 Evaluate for 2ndary causes of hyperlipidemia. 6 Consider high-intensity statin If ASCVD >7.5% ( 7 Treating individuals <40y & >75y in with statins is optional; clinicians should evaluate potential ASCVD benefits, s and patient preferences. ⁸ LDL monitoring is an option to assist with adherence assessment; consider lower statin dose if LDL<40 x 2. Adapted from Kaiser Permanente Northern California Clinical Practice Guidelines for Coronary Artery Disease, Diabetes, Cholesterol, and Hypertension.

2 Medication Algorithm for Type 2 Diabetes ¹ V2.1 updated 7/12/2017 Hemoglobin A1c AM SMBG³ < 2% Above s²: < 65 yrs <7% yrs <8% Lifestyle Modifications > 2% Above Metformin + Basal Long Acting Insulin ⁴ 10 units SQ at hs 2 units q. 2 days until at target Contraindications: - egfr <30 - HF class LFTs>3xULN CAUTION: egfr < 45 Use Alternate Agent Start Metformin 500 mg: ½ tablet bid 1 tablet bid 2 tablets bid Titrate q. 1-2 weeks aiming for AM SMBG target³ Use optimal titration intervals to help patient reach goal ASAP Insulin therapy should not be delayed Educate about hypoglycemia Thiazoladinedione (Pioglitazone) $ At After 3 Not At Meglitinides Maintain Therapy no Risk of Severe Hypoglycemia yes Dual Therapy Add Alternate Agent⁵ A-glucosidase Inhibitors Contraindications: Severe sulfa allergy Use Meglintinides At Add Sulfonylureas ⁴ Glipizide 5 mg: ½ tablet bid 1 tablet bid 2 tablets bid Titrate q. 2 weeks until at target After 3 A1c 1% of yes no Add Basal Long Acting Insulin or Alternate Agent⁵ DPP-4 Inhibitor SGLT-2 Inhibitor GLP-1 Receptor Antagonist Maintain Therapy Add Basal Long Acting Insulin 10 units SQ at hs 2 units q. 2 days until at target Adapted from Kaiser Permanente Northern California Clinical Practice Guidelines for Coronary Artery Disease, Diabetes, Cholesterol, and Hypertension. ¹ Excluding Pregnancy for pregnant women and women intending pregnancy, use CDAPP guidelines. ² Individualize A1c goal based on of hypoglycemia, duration of DM, life expectancy, comorbidities, vascular complications, patient resources and support system. ³ Self Monitoring Blood Glucose targets: postprandial < 180mg/dL; bedtime mg/dl. ⁴ Carries increased of Hypoglycemia. Severe hypoglycemia = resulting or likely to result in seizures, LOC, or needing help from others. Mild hypoglycemia = recognized signs and symptoms or neuro-glycopenia (e.g. hunger or sweating) that the patient can effectively self-treat. ⁵ Choice dependent on patient and disease-specific factors. Each new class of non-insulin agents lowers A1c ~ 1%. If A1c target is still not achieved after 3 of dual therapy, proceed to three-drug combination.

3 Updated 9/2017 PHASE Medications Blood Pressure LDL Medication ACE inhibitor - Diuretic Lisinopril - HCTZ (Prinzide ) Thiazide Diuretics HCTZ (Hydrodiuril, Esidrix ) Chlorthalidone (Hygroton ) ACE Inhibitor Lisinopril (Prinivil ) ARB Losartan (Cozaar ) Calcium Channel Blocker Amlodipine (Norvasc ) Potassium Sparing Diuretic Spironolactone (Aldactone ) Beta Blockers Atenolol (Tenormin ) Metoprolol (Lopressor ) Metoprolol ER (Toprol ) Atorvastatin (Lipitor ) Moderate Intensity High intensity Preferred Dosage Forms Tab 20-25mg Tab 25mg Max. Rec mg HCTZ 50mg Labs Baseline; F/U; Monitoring 2 weeks K+ & SCr within 6m & 1wk after 2 weeks K+ & SCr within 6m & 1wk after Tab 25mg 25mg 2 weeks K+ & SCr within 6m & 1wk after Tab 5, 10, 20mg Tab 25, 50mg Tab 2.5, 5, 10mg Tab 12.5, 25mg 10-20mg 40, 80mg 40mg 1 week K+ & SCr within 6m & 1wk after or 50mg twice 1 week K+ & SCr within 6m & 1wk after Caution* egfr<30, K>5.5; Stage 4/5 CKD egfr<30, K>5.5; Stage 4/5 CKD 10mg 1 week None Pregnancy Risk Category C 25mg 1 week K+, SCr. within last month & 1wk after initiation & 2 wks after dose change Pregnancy Risk Category C If on thiazide; egfr<60 K>4.5 1 week None Pregnancy Risk Category D egfr<30; HR<55; asthma Avoid use with clonidine, verapamil, or diltiazem twice 1 week None Pregnancy Risk Category C egfr<30; HR<55; asthma 200mg 1 week* None egfr<30; HR<55; asthma 2 wk titration interval if hx HF 80mg 4 weeks ALT, CK, SCr; None SCr every 12 month ALT if clinically indicated

4 Medication Efficacy / Advantages Medications for Management of Type 2 Diabetes Caution/ side effects Hypoglycemic Weight Cost Maximum Recommended First line oral agent, monotherapy Biguanides metformin 2 (500, 850, 1000mg) ER 2 (500, 750, 1000mg) High/ CV event Neutral or 2,000mg 1-2 weeks Serum creatinine; repeat q 12 Do not use if HF class 3-4; LFTs>3xULN; or egfr<30. Maximum dose 1000mg if egfr Increased GI side effects -> consider extended release Long-term use associated with vitamin B12 deficiency Dual, second-line oral therapy Dual therapy; alternative agent Sulfonylureas (SU) glipizide 2 (2.5, 5, 10mg) glimepiride 2 glyburide ER (2.5, 5, 10mg) Glyburide/metformin 1, 2 ( mg, 2.5/5mg-500mg) Thiazolidinediones (TZD) pioglitazone 2 (15, 30, 45mg) Pioglitazone/metformin 4 (15/500/850mg) Meglitinides (Glinide) repaglinide 2 (0.5,1, 2mg) nateglinide 2 (60,120mg) Alpha-glucosidase inhibitors (AGI) acarbose 2 (25,50, ) miglitol 2 (25,50, ) DPP-4 Inhibitors alogliptin 3 (6.25, 12.5, 25mg) sitagliptin 4 saxagliptin 4 linagliptin 4 1, 3 alogliptin/pioglitazone 2 ( /30/45, 25-15/30/45mg) alogliptin/metformin 2 ( /1,000mg) High/ microvascular High / insulin sensitivity A1C lowering / pp glucose Intermediate High High Neutral 1 20mg twice 45mg 16mg 360mg 300mg mg 2 weeks Sulfa allergy Hypoglycemia Weight gain D/C SU with initiation of insulin Heart failure Edema Increased fractures Bladder cancer concerns Often poorly tolerated Modest efficacy ( % reduction A1C) Need to be dosed more than once/day Effective in reducing PPG with high carb intake Rare

5 Medication Efficacy / Advantages Hypoglycemic Risk Weight Cost Maximum Recommended Caution/side effects SGLT-2 inhibitors canagliflozin 4 dapagliflozin 4 empagliflozin 4 canagliflozin/metformin, Invokamet 4 empagliflozin/metformin, Synjardy 4 dapagliflozin/metformin, Xigduo 4 empagliflozin/linagliptin, Glyxambi 4 GLP-1 R Agonist (SQ pen injector) liraglutide, Victoza 3 dulaglutide 4 Intermediate/ may improve CV ; BP High/ CV 5mg 1.8mg 1.5mg genital mycotic infections Dehydration Fracture Polyuria LDL-C creatinine Possible of lower-limb amputation with canagliflozin GI side effects Pancreatitis Heart rate Long-acting Insulin, basal Insulin glargine, Basalgar 2, Lantus 4 insulin detemir, Levemir 4 $-$ 10U SQ HS or U/kg/d 10-15%, or 2-4U 1-2x/wk Hypoglycemia; duration 18-26hrs Training/monitoring requirements Insulin Intermediate-acting Insulin, NPH insulin isophane, HumulinN 3, NovolinN 3 Short-acting Insulin regular insulin, HumulinR 3, NovolinR 3, Afrezza 4 (inhalation) $ $-$ Hypoglycemia; duration 16-24hrs Hypoglycemia; duration 5-8hrs Fast-acting Insulin insulin lispro, Humalog 3 insulin aspart, Novolog 3 insulin glulisine, Apidra 3 $ Hypoglycemia; duration 3-4hrs Monitor blood glucose before breakfast and before meals 2-4 times/day 1 Generic available; 2 Partnership Healthplan of California formulary; 3 PHC formulary restrictions apply: quantity limit or step therapy previous claims for metformin, a secondary formulary oral antidiabetic agent &/or basal insulin required (see formulary); 4 PHC non-formulary TAR required; 5 PHC not available