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Natural Products > 12 - Heart Failure > Flashcards

12 - Heart Failure Flashcards

1
Q

What do we tell patients about NHPs?

A
  • These products do have the potential to interact with prescription medications
  • These products do have possible detrimental effects on the body
  • They need to be looked at as seriously as Rx and OTC meds
  • Please talk to your pharmacist and please tell all your HCPs about your NHP use
  • Include them on your medication lists
  • Educate patients on reliable sources of information
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2
Q

___% of HF patients used a herbal product

A

38

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3
Q

____% of ppl with CVD diagnosis used herbal products once daily

A

17

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4
Q

___% patients use CAM for their heart disease

A

82

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5
Q

Why worry about HF patients taking NHPs?

A

Drugs may cause or exacerbate HF by causing direct myocardial toxicity (cardiomyopathy), by negative isotropic effects; be exacerbating hypertension by delivering a high sodium load; by causing fluid retention; or by drug-drug interactions that limit the beneficial effects of HF meds

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6
Q

What are HF patients at an increased risk of?

A
  • Polypharmacy
  • Have multiple co-morbid conditions & prescribers & pharmacists
  • Delicate fluid/electrolyte balance
  • Elderly (majority of HF patients) have renal/hepatic impairment
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7
Q

Why are NHPs not taken seriously?

A
  • Patient’s don’t think they are medicine
  • They don’t tell other HCPs
  • Other health care professionals don’t ask (don’t want to know) or don’t know ?
  • Non-Rx meds are often left out of med histories
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8
Q

List some concerns that you may have for an HF patient taking NHPs

A
  • Potential for bleeding or clotting
  • NHPs can increase or decrease BP
  • NHPs can cause/exacerbate fluid retention
  • Stimulants (ex. weight loss products) affect HR
  • On drugs with narrow therapeutic index (ex. digoxin)
  • NHPs with diuretic properties can cause hypokalemia
  • Dehydration with stimulant laxatives (diarrhea)
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9
Q

List examples of PUFA (polyunsaturated fatty acids)

A
  • ALA
  • DHA
  • EPA
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10
Q

Which PUFA’s are associated with proposed CV benefit?

A
  • DHA

- EPA

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11
Q

What are PUFA found in?

A

fish oils, flax seed (to a lesser extent other nuts), canola oil and soybeans

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12
Q

Dose of PUFA

A

3-4 g/day

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13
Q

SE of PUFA

A
  • fish burp
  • halitosis (bad breath)
  • heartburn
  • dyspnea
  • nausea
  • loose stools and rash
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14
Q

PUFA has proposed benefit in what type of fish

A

baked/broiled NOT fried

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15
Q

What is the proposed mechanism of action for Omega 3’s?

A

May reduce risk of coronary outcomes and overall mortality by:

  • Lower TG levels (at higher doses)
  • Prevent serous arrhythmias
  • Decrease platelet aggregation (but maybe only at higher doses)
  • Lower BP
  • Lower resting HR
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16
Q

Currently, are Omega 3’s recommended for primary or secondary prevention of CVD?

A

secondary

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17
Q

Would you recommend omega 3’s to a patient?

A

You could providing it is not harming them.

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18
Q

What is Coenzyme Q-10 ?

A

A vitamin like compound found in the body: Found in high concentration in the mitochondria of the heart, liver & kidney.

  • resembles vitamin K
  • will increase clotting
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19
Q

What is the proposed MOA of Coenzyme Q-10?

A

Plays an important role in the production of ATP (used by cells as a fuel to produce energy). Inhibition of ATP production can cause cell death and tissue damage.

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20
Q

Patients with HF have lower serum levels of ___________

A

coenzyme Q-10

*so replacing coenzyme Q10 might improve cellular energy production and prevent cell death in people with HF

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21
Q

What is coenzyme Q-10 found in?

A

meats and seafood (small amounts)

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22
Q

What are some other uses of Coenzyme Q10?

A
  • prevent statin-induced myopathies
  • prevent doxorubicin-induced cardiotoxicity
  • immune stimulation in HIV/AIDS pts
  • treatment of muscular dystrophy
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23
Q

Toxicity of Coenzyme Q10 ?

A

No

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24
Q

Is coenzyme Q10 effective for HF?

A

evidence is lacking

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25
Q

Dose of coenzyme Q10?

A

60-200 mg/day divided 2-3x/day

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26
Q

SE of coenzyme Q10?

A

GI side effects

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27
Q

List 2 drug interactions with Coenzyme Q10

A
  • Warfarin (decreased effect due to structural similarity to Vitamin K)
  • Potentiate the anti-hypertensive effects of some blood pressure lowering drugs
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28
Q

Is Coenzyme Q10 recommended by any HF guidelines?

A

No - data is conflicting

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29
Q

Are vitamin D supplements recommended for HF?

A

For now, advise patients to get an appropriate amount of Vitamin D, but not recommend it specifically for treating HF

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30
Q

Is Vitamin E recommended for HF?

A

No not at all!
Adverse effects!
-Patients on vitamin E had higher risk of developing HF and HF hospitalization
-Patient on Vitamin E were associated with a 50% increase in chronic HF hospitalization or death in patients with LV dysfunction.

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31
Q

Hawthorn: cardiac glycoside like _____, flowering shrub of the rose family

A

digoxin

32
Q

Proposed mechanism of Hawthorn?

A
  • Might reduce BP and HR (watch with other anti-HTNs)
  • Positive inotropic and vasodilatory effects (don’t use with nitrates)
  • Thought to increase myocardial perfusion and reduce afterload
  • Enhances digoxin’s activity - duplicate therapy?
  • Inhibits synthesis of thromboxane A2, increase risk of bleeding in patients on anti-platelets or anticoagulants
33
Q

Should you recommend Hawthorn for HF?

A

No

  • not been studied well
  • lots of drug interactions
  • no mortality benefits shown
34
Q

List examples of herbal diuretics

A
  • dandelion
  • corn silk
  • stinging nettle
35
Q

Should you advise use of herbal diuretics for HF?

A

No - not a lot of evidence
-Advise patients not to use as there is no reliable evidence that they reduce edema in patients with HF

*If they have deem, they should be on a Rx diuretic

36
Q

What is L-Carnitine?

A
  • Amino acid cofactor in skeletal muscles and the heart
  • Generates energy within the cells causing a positive inotropic effect
  • HF patients have lower levels of Carnitine in their heart tissue
  • Preliminary evidence: improves symptoms, ejection fraction, and exercise tolerance.
37
Q

What is L-Arginine?

A
  • Amino acid necessary for protein synthesis
  • Is a substrate for the NOS enzyme
  • L arginine through NO synthase produces nitric oxide
38
Q

What does nitric oxide cause?

A

vasodilation, improved endothelial function, increased coronary blood flow, hypotension

39
Q

L-arginine interacts with ________

A

nitrates

40
Q

L-arginine found in ?

A

meat and fish

41
Q

Is L-arginine recommended?

A
  • No consistent results found in clinical trials: HF patients seem to have improved kidney function and increased fluid elimination. Some patients have improved functional status, exercise tolerance and QOL
  • Some evidence that it decreases the activity of ACE
  • Usually safe
42
Q

What is St. John’s Wort used for?

A

-depression, anxiety, sleep disorders

43
Q

St. John’s Wort is an inducer of what?

A

CYP 3A4

44
Q

Bc it induces CYP 3A4, what will it interact with?

A

amiodarone, apixiban, rivaroxaban, beta blockers, CCB, ACEi, ARBs, Statins

45
Q

How does St. John’s Wort interact with warfarin?

A

decreases prothrombin time, increases clotting

decrease effectiveness of warfarin

46
Q

How does St. John’s Wort interact with digoxin?

A

decreases digoxin levels

47
Q

What is ginseng?

A
  • immune system stimulant

- hypertensive and hypotensive effects

48
Q

How does ginseng interact with warfarin?

A

varying case reports, may decrease efficiency

49
Q

How does ginseng interact with digoxin?

A

ginseng can falsely increase or decrease digoxin levels

50
Q

What is ginseng used for in Chinese medicine?

A

CHF

51
Q

What is saw palmetto ?

A

used for treating BPH (lacking evidence)

52
Q

Saw palmetto may have what effects?

A

Antiplatelet effects
(increases bleeding)
Interacts with warfarin and ASA

53
Q

What is gingko biloba used for?

A

memory (alzheimers and dementia)

54
Q

What does gingko biloba interact with?

A

Increased risk of bleeding with anti-platelet and anticoagulants. (interacts with warfarin)

55
Q

What is the active component in Garlic?

A

Allicin

56
Q

What does garlic do?

A

antimicrobial, immune system enhancer, lowers cholesterol, antihypertensive

57
Q

What does garlic interact with?

A
  • Inhibition of platelet aggregation
  • May increase prothrombin time
  • Increased risk of bleeding in people using anti platelet and anti coagulants
58
Q

D/C garlic 10 days before ____

A

surgery

59
Q

Garlic may have _____ effect

A

hypotensive

60
Q

What is Danshen used for?

A

Traditional Chinese medicine for treatment of coronary artery disease

61
Q

Interactions with Danshen?

A
  • May have digoxin like effects; do not use with digoxin
  • May have hypotensive effect
  • Anti-platelet effect; avoid with anti-platelets and anticoagulants
  • Reduces elimination of warfarin - increase risk of bleeding
62
Q

What is Echinacea?

A

Stimulate the immune system and prevent infections

63
Q

Persistent use of Echinacea may potentiate ________ effects of other drugs (ex. Amiodarone, statins, vibrates or niacin)

A

hepatotoxic

64
Q

Licorice (not twirlers) used as an ______

A

expectorant

65
Q

Licorice:

_______ effect can cause fluid retention and worsen HF and increase BP

A

Mineralocorticoid

66
Q

Licorice may cause _______

A

hypokalemia

67
Q

Licorice has an increased risk of?

A
  • Increased risk for ventricular arrhythmias especially torsades des pointes
  • Increased risk of bleeding with antiplatelets and anticoagulatns
68
Q

What is Motherwort used for?

A
  • Used for palpitations/tachycardia
  • Cardiac depressant effects
  • Anticoagulant (decreases fibrinogen)
  • Anti-platelet effects (increased risk of bleeding)
69
Q

List 3 drug interactions with Amiodarone

A

1) Echinacea
2) Kava-containing products
3) Digoxin-like substances

70
Q

What does digoxin interact with?

A
  • Chinese medicine containing Kyushin cross-reacts with Digoxin assays
  • Panax & Siberian Ginseng (false but no toxicity ?)
  • Hawthorn
  • Chinese silk vine
  • ST John’s Wort
  • Uzara root
  • Licorise
  • Danshen
71
Q

Which drugs interact with warfarin and cause an increased risk of bleeding?

A
  • Cinchona
  • Danshen
  • Devil’s Claw
  • Dong quai
  • Garlic
  • Gingko Biloba
  • Asian Ginseng
  • Papaya
  • Saw palmetto
  • Omega 3 PUFA
  • Motherwort
  • Hawthorn
72
Q

Which drugs interact with warfarin and cause a decreased risk of bleeding?

A
  • Coenzyme Q10
  • Asian & American Ginseng
  • Green tea
  • St. John’s Wort
73
Q

Do NOACs interact with NHPs?

A
  • Potential for NHP interaction lower than warfarin

- But NHPs with strong CYP3A4 and P-gp inducers (ex. St. John’s Wort) can decrease plasma concentration of NOACs

74
Q

What is the bottom line when using NHPs in HF?

A
  • NHPs are not appropriate as primary therapy, maybe adjunctive someday
  • Ensure these patients are on proven therapy to improve survival
  • Most of the data is from observational studies - need larger randomized clinical trials
  • Closely monitor for signs of improvement or deterioration
  • Majority of studies are before the era of ACEi, BB, and MRA
  • Optimal dose and duration need to be clarified
75
Q

Which of the following drugs is L-arginine most likely to interact with?

a) warfarin
b) digoxin
c) sildenafil
d) zopiclone

A

c) sildenafil (bc of nitric oxide)

76
Q

Which of the following NHPs have been recommended by the Canadian CV society?

a) Coenzyme Q10
b) Garlic
c) Omega 3 PUFA
d) Vitamin D

A

c) Omega 3 PUFA

77
Q

Which of the following herbs could decrease the effectiveness of warfarin?

a) gingko biloba
b) garlic
c) coenzyme Q10
d) devil’s claw

A

c) coenzyme Q10, looks like vitamin K, will cause clotting

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