12 - Heart Failure Flashcards
What do we tell patients about NHPs?
- 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
___% of HF patients used a herbal product
38
____% of ppl with CVD diagnosis used herbal products once daily
17
___% patients use CAM for their heart disease
82
Why worry about HF patients taking NHPs?
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
What are HF patients at an increased risk of?
- Polypharmacy
- Have multiple co-morbid conditions & prescribers & pharmacists
- Delicate fluid/electrolyte balance
- Elderly (majority of HF patients) have renal/hepatic impairment
Why are NHPs not taken seriously?
- 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
List some concerns that you may have for an HF patient taking NHPs
- 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)
List examples of PUFA (polyunsaturated fatty acids)
- ALA
- DHA
- EPA
Which PUFA’s are associated with proposed CV benefit?
- DHA
- EPA
What are PUFA found in?
fish oils, flax seed (to a lesser extent other nuts), canola oil and soybeans
Dose of PUFA
3-4 g/day
SE of PUFA
- fish burp
- halitosis (bad breath)
- heartburn
- dyspnea
- nausea
- loose stools and rash
PUFA has proposed benefit in what type of fish
baked/broiled NOT fried
What is the proposed mechanism of action for Omega 3’s?
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
Currently, are Omega 3’s recommended for primary or secondary prevention of CVD?
secondary
Would you recommend omega 3’s to a patient?
You could providing it is not harming them.
What is Coenzyme Q-10 ?
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
What is the proposed MOA of Coenzyme Q-10?
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.
Patients with HF have lower serum levels of ___________
coenzyme Q-10
*so replacing coenzyme Q10 might improve cellular energy production and prevent cell death in people with HF
What is coenzyme Q-10 found in?
meats and seafood (small amounts)
What are some other uses of Coenzyme Q10?
- prevent statin-induced myopathies
- prevent doxorubicin-induced cardiotoxicity
- immune stimulation in HIV/AIDS pts
- treatment of muscular dystrophy
Toxicity of Coenzyme Q10 ?
No
Is coenzyme Q10 effective for HF?
evidence is lacking
Dose of coenzyme Q10?
60-200 mg/day divided 2-3x/day
SE of coenzyme Q10?
GI side effects
List 2 drug interactions with Coenzyme Q10
- Warfarin (decreased effect due to structural similarity to Vitamin K)
- Potentiate the anti-hypertensive effects of some blood pressure lowering drugs
Is Coenzyme Q10 recommended by any HF guidelines?
No - data is conflicting
Are vitamin D supplements recommended for HF?
For now, advise patients to get an appropriate amount of Vitamin D, but not recommend it specifically for treating HF
Is Vitamin E recommended for HF?
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.
Hawthorn: cardiac glycoside like _____, flowering shrub of the rose family
digoxin
Proposed mechanism of Hawthorn?
- 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
Should you recommend Hawthorn for HF?
No
- not been studied well
- lots of drug interactions
- no mortality benefits shown
List examples of herbal diuretics
- dandelion
- corn silk
- stinging nettle
Should you advise use of herbal diuretics for HF?
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
What is L-Carnitine?
- 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.
What is L-Arginine?
- Amino acid necessary for protein synthesis
- Is a substrate for the NOS enzyme
- L arginine through NO synthase produces nitric oxide
What does nitric oxide cause?
vasodilation, improved endothelial function, increased coronary blood flow, hypotension
L-arginine interacts with ________
nitrates
L-arginine found in ?
meat and fish
Is L-arginine recommended?
- 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
What is St. John’s Wort used for?
-depression, anxiety, sleep disorders
St. John’s Wort is an inducer of what?
CYP 3A4
Bc it induces CYP 3A4, what will it interact with?
amiodarone, apixiban, rivaroxaban, beta blockers, CCB, ACEi, ARBs, Statins
How does St. John’s Wort interact with warfarin?
decreases prothrombin time, increases clotting
decrease effectiveness of warfarin
How does St. John’s Wort interact with digoxin?
decreases digoxin levels
What is ginseng?
- immune system stimulant
- hypertensive and hypotensive effects
How does ginseng interact with warfarin?
varying case reports, may decrease efficiency
How does ginseng interact with digoxin?
ginseng can falsely increase or decrease digoxin levels
What is ginseng used for in Chinese medicine?
CHF
What is saw palmetto ?
used for treating BPH (lacking evidence)
Saw palmetto may have what effects?
Antiplatelet effects
(increases bleeding)
Interacts with warfarin and ASA
What is gingko biloba used for?
memory (alzheimers and dementia)
What does gingko biloba interact with?
Increased risk of bleeding with anti-platelet and anticoagulants. (interacts with warfarin)
What is the active component in Garlic?
Allicin
What does garlic do?
antimicrobial, immune system enhancer, lowers cholesterol, antihypertensive
What does garlic interact with?
- Inhibition of platelet aggregation
- May increase prothrombin time
- Increased risk of bleeding in people using anti platelet and anti coagulants
D/C garlic 10 days before ____
surgery
Garlic may have _____ effect
hypotensive
What is Danshen used for?
Traditional Chinese medicine for treatment of coronary artery disease
Interactions with Danshen?
- 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
What is Echinacea?
Stimulate the immune system and prevent infections
Persistent use of Echinacea may potentiate ________ effects of other drugs (ex. Amiodarone, statins, vibrates or niacin)
hepatotoxic
Licorice (not twirlers) used as an ______
expectorant
Licorice:
_______ effect can cause fluid retention and worsen HF and increase BP
Mineralocorticoid
Licorice may cause _______
hypokalemia
Licorice has an increased risk of?
- Increased risk for ventricular arrhythmias especially torsades des pointes
- Increased risk of bleeding with antiplatelets and anticoagulatns
What is Motherwort used for?
- Used for palpitations/tachycardia
- Cardiac depressant effects
- Anticoagulant (decreases fibrinogen)
- Anti-platelet effects (increased risk of bleeding)
List 3 drug interactions with Amiodarone
1) Echinacea
2) Kava-containing products
3) Digoxin-like substances
What does digoxin interact with?
- 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
Which drugs interact with warfarin and cause an increased risk of bleeding?
- Cinchona
- Danshen
- Devil’s Claw
- Dong quai
- Garlic
- Gingko Biloba
- Asian Ginseng
- Papaya
- Saw palmetto
- Omega 3 PUFA
- Motherwort
- Hawthorn
Which drugs interact with warfarin and cause a decreased risk of bleeding?
- Coenzyme Q10
- Asian & American Ginseng
- Green tea
- St. John’s Wort
Do NOACs interact with NHPs?
- 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
What is the bottom line when using NHPs in HF?
- 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
Which of the following drugs is L-arginine most likely to interact with?
a) warfarin
b) digoxin
c) sildenafil
d) zopiclone
c) sildenafil (bc of nitric oxide)
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
c) Omega 3 PUFA
Which of the following herbs could decrease the effectiveness of warfarin?
a) gingko biloba
b) garlic
c) coenzyme Q10
d) devil’s claw
c) coenzyme Q10, looks like vitamin K, will cause clotting
