Speaker Disclosure. Objectives. Outline. Local Opinion Leaders. Presented by R. Slavik, IH Pharmacy Live Rounds (Mar 1 st and 6 th, 2013)

Transcription

1 Heart Failure Translating Knowledge into Practice Speaker Disclosure The speaker has no actual or potential conflicts of interest to disclose DSEM KT Study Richard Slavik Sarah Murray Sean Gorman Dawn Dalen Nicole Bruchet Brett Hamilton Outline Local opinion leaders Epidemiology of HF Pharmacists role in HF Key Pharmacist Interventions (KPIs) DRP Tracker Data Medications that can exacerbate HF Medications that are beneficial in HF Practical tips on ACEI/ARBs/BB Patient education/discharge counseling Objectives To review the care of patients with heart failure (HF) including: Role of the pharmacist Key pharmacist interventions (KPIs) Medications that can exacerbate HF Practical use of ACEI, ARBs, BB Patient education/discharge counseling Local Opinion Leaders KGH Dawn Robb RIH Kim Winters PRH/SOH Karen Lapointe VJH Chelsea Argent SLH/OMH Ian Petterson KBH Michael Conci KLH Liz Edwards EKH/GDH Darren Feere Epidemiology of HF Prevalence: 500,000 in Canada affects 10% of patients > 75 yo Incidence: doubles with each decade of life expected to double by year th most common non surgical 1 reason for admission in IH 1300 cases and 8500 acute bed days Significant impact on symptoms, morbidity, ED visits, hospitalizations, QOL, and mortality 1

2 Pharmacists Role in HF Pharmacist direct patient care or collaborative care has been show to: Improve patient adherence Improve patient satisfaction Reduce ED visits Reduce HF admissions Reduce all cause admissions Pharmacists Role in HF Discontinue medications exacerbating HF Promote proven, effective medications Initiate ACEI or ARB, and BB in all eligible patients Titrate to target doses Monitor for achievement of therapeutic goals Prevent or manage adverse drug effects and drug and food interactions Educate patients about their disease, medications, diet, and lifestyle Key Pharmacist Interventions 1. Discontinue non dihydropyridine calcium channel blockers in patients with systolic HF (e.g. verapamil, diltiazem) 2. Discontinue class I antiarrhythmic medications in patients with systolic HF (e.g. propafenone, dronedarone, etc.) 3. Initiate ACEI or ARB, titrate to target doses 4. Initiate BB, titrate to target doses 5. Educate patients: establish relationship salt and fluid intake review disease alcohol consumption review medications physical activity promote medication adherence cardiac risk factor modification daily weight monitoring preventative health strategies Project Alignment CPhA Blue Print for Pharmacy Practice CSHP Vision 2015 CSHP clinical pharmacy Key Performance Indicator (cp KPI) Working Group MOHS KRAs and CCM groups IH SET goals, objectives IH Pharmacy Clinical Priorities Quality Actions Value Index = Prevalence x [Quality Aggregate] Effort to Manage Quality Aggregate Evidence base: Strength of evidence Effectiveness: Impact on outcomes Safety: Impact on safety Efficiency: Avoidance of waste Modifiability: Link between pharmacist and change Reliance: Pharmacist best suited for task CJHP 2011;64(1): Monthly Count DRP Tracker Data ( ) Jan 1/09 Jan 10 Jan 11 Dec 31/12 Time Feb 1/12 2

3 DRP Tracker Data HF ranks #11 in disease prevalence for Rx interventions 87,369 resolved DRPs documented (Jan 2009 Dec 2012) 2.7% of resolved DRPs are for HF (2322/87,369) HF ranks #6 in disease prevalence for DSEM interventions 31.9% of resolved DRPs are DSEM diseases (27,894/87,369) 8.3% of all resolved DSEM DRPs are for HF (only 2322/27,894) HF ranks #6 in disease prevalence for KPI interventions 25.0% of all resolved DRPs are KPIs (21,891/87,369) 3.2% of all KPIs are resolved for HF (719/21,891) DRP Tracker Data AIMS study showed a statistically significant, clinically important increase after DSEMs: DSEM DRP/total DRP (27.9% to 31.9%, p<0.05) KPI/total DRP (21.7% to 25.8%, p<0.05) In HF subgroup, AIMS failed to show a statistically significant benefit: DSEM DRP/total DRP (2.56% to 1.92%, p=ns) KPI/total DRP (0.90% to 0.66%, p=ns) Medications That Exacerbate HF Beta blockers (in decompensated HF) Calcium channel blockers (e.g. verapamil, diltiazem) Antiarrhythmic medications (e.g. propafenone, flecainide, sotalol, dronedarone) NSAIDS COX 2 Inhibitors Corticosteroids Chemotherapy (e.g. doxorubicin, daunorubicin) Thiazolidinones (e.g. pioglitazone) Biologic agents (e.g. Infliximab, etanercept, etc.) Medications That Benefit HF Proven Benefit Diuretics ACEI BB ARB DIG ALD Antag ISDN/ Hydralazine Hemodynamics? Symptoms NYHA Functional Class Hospitalizations?? Quality of Life? * X? * Mortality? * X * Economics???? *In patients with contraindications to ACEI ACE Inhibitors Indication Patients diagnosed with HF and EF < 40% Patients diagnosed with HF complicating MI Contraindications Hypersensitivity (e.g. angioedema) History of serious ADE (e.g. neutropenia) Pregnancy Bilateral renal artery stenosis or unilateral kidney RAS Volume depletion requiring fluid therapy Symptomatic hypotension or SBP < 100 or MAP < 65 Serum potassium > 5 mmol/l Serum creatinine > 200 micromol/l or CrCl < 30 ml/min* *Relative contraindication requires close monitoring ACE Inhibitors Agent Initial dose Target dose Captopril 6.25 mg TID 50 mg TID Enalapril mg BID mg BID Ramipril mg BID 5 mg BID Fosinopril* 5 10 mg DAILY 40 mg DAILY Trandolapril mg DAILY 4 mg DAILY Perindopril* 2 mg DAILY 8 16 mg DAILY Lisinopril# mg DAILY mg DAILY *Effects on mortality have not been evaluated # ATLAS trial failed to show mortality difference between 5 mg/day and 35 mg/day Titration Strategy: Double the dose every 2 weeks as tolerated to target dose 3

4 Angiotensin Receptor Blockers Indication Patients diagnosed with HF and EF < 40%, or HF complicating MI who have intolerable cough or angioedema on ACE Inhibitor Contraindications Hypersensitivity History of serious ADE Pregnancy Bilateral renal artery stenosis or unilateral kidney RAS Volume depletion requiring fluid therapy Symptomatic hypotension or SBP < 100 or MAP < 65 Serum potassium > 5 mmol/l Serum creatinine > 200 micromol/l or CrCl < 30 ml/min* *Relative contraindication requires close monitoring Angiotensin Receptor Blockers Agent Initial dose target dose Valsartan 40 mg BID 160 mg BID Candesartan 4 mg DAILY 32 mg DAILY Losartan* 25 mg DAILY 50 mg DAILY *Effects on mortality have not been evaluated versus placebo Titration Strategy: Double the dose every 2 weeks as tolerated to target dose Beta Blockers Indication Patients diagnosed with HF with or without EF < 40% Contraindications Hypersensitivity Asthma or reactive airway disease Shock (hypovolemic, cardiogenic, septic) Severe sepsis Symptomatic hypotension or SBP < 100 or MAP < 65 Symptomatic bradycardia or heart rate < 60 bpm 2 nd /3 rd degree heart block (without pacemaker) Decompensated HF (IV inotropes in past 24 hours, symptomatic hypoperfusion or pulmonary congestion) Beta Blockers Agent Initial dose target dose Carvedilol mg BID 25 mg BID Bisoprolol 1.25 mg DAILY 10 mg DAILY Metoprolol* 6.25 mg BID 100 mg BID *Regular release product not proven for mortality reduction in HF Titration Strategy : Start low and go slow Ideally initiate before discharge, double the dose every 2 weeks as tolerated to target dose. Patients may feel worse initially, do not abruptly D/C Education/ Discharge Counseling Establish relationship with patient Review disease Review medications Promote medication adherence Daily weight monitoring Salt and fluid intake Alcohol consumption Physical activity Cardiac risk factor modification Preventative health strategies Review Disease Chronic symptoms Fatigue, reduced exercise tolerance, SOB(OE), swelling of feet, ankles or legs Identification of an acute exacerbation Worsening fatigue, cough, SOB, swelling, needing to sleep upright and unexplained weight gain When to contact a health provider Severe lightheadedness, dizziness, SOB, chest pain/pressure, palpitations 4

5 Review Medications Names, doses, indication, regimen, titration Expected benefits Potential adverse drug events (ADEs) Prevention/management of ADEs Drug interactions (i.e. meds to avoid) Need for follow up/monitoring Assessment of Medication Adherence the extent to which a person s behavior taking medication, following a diet, and/or executing lifestyle changes corresponds with agreed recommendations from a health care provider. Non fulfillment (~12.5%) Patient never fills prescription Non conforming (~12.5%) Patient does not take medications as prescribed e.g. skipping doses, taking medications at incorrect times or at incorrect doses, taking more than prescribed Non persistence (~25%) Patient stops taking a medication after starting it, without being advised by a health professional to do so; first six months Barriers to Adherence Cost Regimen complexity Beliefs about medication Lack of knowledge of disease, medication, adverse effects Lack of patient satisfaction Lack of provider trust Communication issues Weight and Salt/Fluid Intake Daily weight monitoring Helps prevent HF exacerbations Do in AM before breakfast > 2 kg in 48 hours OR > 2.5 kg in 1 week, increase your diuretic dose as instructed or contact your healthcare provider Salt and fluid intake Excessive intake may worsen HF NO added salt, NO salty snacks, NO processed foods Routine fluid restriction not required except during exacerbations but usually < 2 L per day During exacerbations may limit to 1 L per day Alcohol and Physical Activity Alcohol consumption Chronic, excessive alcohol consumption or binge drinking can damage the heart and worsen HF No good evidence on safe amount of alcohol Avoid alcohol or limit to one alcoholic drink per day Physical activity Rest during acute exacerbations Moderate physical activity prevents de conditioning and decline in health status Suggest min 3 5 times per week for NYHA class I III Cardiac Risk Factor Modification Maintain active lifestyle Maintain target body weight Avoid smoking Prevent/control hypercholesterolemia Prevent/control diabetes Control hypertension Control cardiac co morbidities (e.g. IHD, AF) 5

6 Preventative Health Strategies Annual physical examination Annual influenza vaccination Pneumococcal vaccination up to date Adhere to prescribed care and follow up Session Review Local opinion leaders Epidemiology of HF Pharmacists role in HF Key Pharmacist Interventions (KPIs) DRP Tracker Data Medications that can exacerbate HF Medications that are beneficial in HF Practical tips on ACEI/ARBs/BB Patient education/discharge counseling Online clinician and patient resources available at Recent CCS HF Update 2012 Questions? Can J Cardiol 2013;29: Available online at: 282X(12) /abstract 6