Pharmacology and Clinical guidelines Flashcards
basis of tment for all HF pts due to LVSD?
ACEI titrated to target dose or max tolerated dose if lower, in combination with a beta blocker e.g. bisoprolol or carvedilol in stable HF with LVSD, or nebivolol if stable mild to moderate HF in those older than 70.
K+ sparing diuretics and K+ supplements should be discontinued on starting ACEI, but low dose spiro can be continued as long as serum K+ monitored carefully.
beta blocker must be started at very low dose and titrated slowly over wks-mnths, with symptoms possible deteriorating initially and requiring adjustment of concomitant therapy.
beta blocker effec of lowering BP- may cause dizziness and postural hypotension-advise to initially take at night
why might initiating an ACEI in pts with HF already on high dose of loop diuretics have to be done under specialist supervision?
can cause profound 1st dose hypotension, and although temporary withdrawal of loop diuretic reduces the risk, may cause severe rebound pulmonary oedema.
describe the use of adenosine in evaluating arrythmias
adenosine= rapid IV injection slows AVN conduction. This can interrupt re-entry circuits involving the AVN and restore normal sinus rhythm in those with paroxysmal supraventricular tachycardias.
can also help evaluate atrial activity by slowing down AV conduction, so aid diagnosis of narrow or broad complex tachycardias.
why can adenosine NOT be used to treat AF or atrial flutter?
these do not involve the AVN as part of their re-entry circuit, and adenosine works by slowing conduction through the AVN by reducing Ca2+ and hyperpolarising cells via K+ efflux.
in which patients on warfarin might we aim for a higher INR?
those with metallic heart valves (NOT tissue)
NICE guidance on pirfenidone for treating idiopathic pulmonary fibrosis (fibrosing alveolitis)?
available if FVC is between 50% and 80% of the value expected for you
drug should be stopped if disease worsens- so if FVC falls by 10% or more in 12 mnths.
how does pirfenidone work in the tment of mild to moderate IPF?
immunosuppressant thought to be anti-fibrotic and anti-inflammatory, reducing fibroblast proliferation, production of fibrosis related cytokines, and the increased biosynthesis and accumulation of ECM in response to cytokine GFs e.g. TGF-beta.
describe the use of sotalol in arrhythmias
non-cardioselective beta blocker, with additional class III anti-arrhythmic activity. Used for prophylaxis in paroxysmal SVTs, suppresses ventricular ectopic beats and non-sustained VT (lasts for 30s or less). Has been shown to be more effective than lidocaine in terminating spontaenous sustained VT due to CAD or cardiomyopathy. BUT may induce torsades de pointes (polymorphic VT) in susceptible pts following QT interval prolongation, MUST monitor for HYPOKALAEMIA.
step 1 tment for mild intermittent asthma?
inhaled short acting beta 2 agonist as required e.g. salbutamol (ventolin), terbutaline
step 2 tment for asthma?
regular preventer therapy:
add inhaled corticosteroid 200-800 micrograms/day, 400= appropriate starting dose for many pts, to as required short acting beta 2 agonist therapy.
step 3 tment for asthma?
inital add-on therapy:
add inhaled long acting beta 2 agonist e.g. salmeterol, formoterol, may be combined with steroid in same inhaler e.g. symbicort- formoterol and budesonide.
if good response, continue
if benefit but control still inadequate, continue and increase inhaled steroid to 800 micrograms/day if not already on this dose.
if no response to LABA, stop and increase inhaled steroid dose to 800.
if control still inadequate despite increased steroid dose, try trial of other therapies: LKT receptor antagonist e.g. montelukast, or SR theophylline (xanthine bronchodilator)
the anti-muscarinic bronchodilator tiotropium bromide (Spiriva Respimat) is indicated in those who are currently treated with the maintenance combination of inhaled corticosteroids (≥800 µg budesonide/day or equivalent) and long-acting β2 agonists and who experienced one or more severe exacerbations in the previous year.
step 4 tment for asthma?
persistent poor control
increase inhaled corticosteroid up to 2000 micrograms/day
addition of 4th drug e.g. LKTRA, SR theophylline, beta 2 agonist tablet
step 5 tment for asthma?
continuous or frequent use of oral steroids
use in lowest dose providing adequate control
maintain high dose inhaled corticosteroid at 2000
consider other tments to minimise use of steroid tablets
functional properties of statins in the tment of CVD?
reduce LDLs anti-inflammatory improve endothelial cell function reduce thrombotic risk plaque reduction
ACS protocol?**
ACS= unstable angina, STEMI and NSTEMI anti-platelet: aspirin 300mg and clopidogrel/prasugrel/ticagrelor beta blocker ACEI atorvastatin 80mg heparin/fondaparinux
