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Han M, Xia J, Zhang M, Jin Y, He C, Wang Z, Tu F. Is dosage adjustment based on age necessary for intravenous lidocaine in patients undergoing general anesthesia: a prospective multi-arm comparative study. J Pharm Sci 2024:S0022-3549(24)00257-0. [PMID: 39032824 DOI: 10.1016/j.xphs.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/11/2024] [Accepted: 07/13/2024] [Indexed: 07/23/2024]
Abstract
It remains unclear whether dosage adjustment of intravenous lidocaine is necessary during general anesthesia for elderly patients over 75 years old. This study aimed to investigate the effects of age on the pharmacokinetics (PK) and safety of intravenous lidocaine in patients undergoing general anesthesia. A total of 599 plasma samples were collected from 76 general anesthesia patients across three age groups: 18-64, 65-74, and ≥ 75 years. Lidocaine was administered intravenously at a dose of 1.5 mg/kg for the 18-64 and 65-74 years groups, while the dose was adjusted to 1.0 mg/kg for the ≥ 75 years group. The plasma concentrations of lidocaine and its active metabolites were measured using a validated ultra-performance liquid chromatography-tandem mass spectrometry assay, and the data were analyzed using a noncompartmental analysis. The results revealed no significant age-related differences in the PK of lidocaine and its metabolites. Among the three age groups, over 90% of patient achieved a lidocaine concentration within a safe and effective range when the dosage was normalized to 1.5 mg/kg. In conclusion, age-based dosage adjustment was unnecessary for intravenous lidocaine in patients below 86 years undergoing general anesthesia.
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Affiliation(s)
- Mei Han
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, No. 1 Maoyuan South Road, Shunqing District, Nanchong 637000, Sichuan Province, China; Department of Pharmacy, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital, Sichuan University, No. 5 Telecom Road, Wuhou District, Chengdu 610041, China; Clinical Trial Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jina Xia
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, No. 1 Maoyuan South Road, Shunqing District, Nanchong 637000, Sichuan Province, China
| | - Mengyu Zhang
- Department of Pharmacy, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital, Sichuan University, No. 5 Telecom Road, Wuhou District, Chengdu 610041, China; Clinical Trial Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Ying Jin
- Department of Pharmacy, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital, Sichuan University, No. 5 Telecom Road, Wuhou District, Chengdu 610041, China; Clinical Trial Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Chaoqun He
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, No. 1 Maoyuan South Road, Shunqing District, Nanchong 637000, Sichuan Province, China; Department of Pharmacy, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital, Sichuan University, No. 5 Telecom Road, Wuhou District, Chengdu 610041, China; Clinical Trial Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Zhenlei Wang
- Department of Pharmacy, NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, West China Hospital, Sichuan University, No. 5 Telecom Road, Wuhou District, Chengdu 610041, China; Clinical Trial Center, West China Hospital, Sichuan University, Chengdu 610041, China.
| | - Faping Tu
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, No. 1 Maoyuan South Road, Shunqing District, Nanchong 637000, Sichuan Province, China.
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2
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Alghadeer SM, Almohammed OA, Alshaya AI, Alsaif S, Albogami S, Althunayyan SM. Adenosine response and failure to convert paroxysmal supraventricular tachycardia in the emergency department. Eur J Emerg Med 2023; 30:341-346. [PMID: 37310949 DOI: 10.1097/mej.0000000000001050] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND IMPORTANCE Although adenosine is the recommended first-line therapy for patients with paroxysmal supraventricular tachycardia (SVT), it may fail to restore normal sinus rhythm. The factors associated with this failure remain unclear. OBJECTIVE To assess the response rate to adenosine and identify the factors causing adenosine failure in the management of paroxysmal SVT. DESIGN, SETTING, AND PARTICIPANTS This retrospective study was conducted on adult patients diagnosed with paroxysmal SVT and treated with adenosine in the emergency departments of two large tertiary hospitals between June 2015 and June 2021. OUTCOME MEASURE AND ANALYSIS The primary outcome of the study was the patient response to adenosine, defined as the restoration of sinus rhythm documented in the patients' files. Backward-stepwise multivariate logistic regression was used to examine the predictors of adenosine failure based on the overall response to adenosine therapy. MAIN RESULTS A total of 404 patients, with a mean age of 49 (SD 15) years and a BMI of 32 (SD 8) kg/m 2 , and treated with adenosine for paroxysmal SVT, were included. Sixty-nine percent of patients were women. The overall response rate to any adenosine dose was 86% (n = 347). The baseline heart rate did not significantly differ between adenosine responders and non-responders (179.6 ± 23.1 vs. 183.2 ± 23.4). An association was observed between the history of paroxysmal SVT and successful response to adenosine (odds ratio = 2.08; 95% confidence interval 1.05-4.11). CONCLUSION The findings of this retrospective study suggested that the use of adenosine restored normal sinus rhythm in 86% of patients with paroxysmal SVT. Furthermore, a history of paroxysmal SVT and older age were associated with an increased chance of adenosine success.
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Affiliation(s)
- Sultan M Alghadeer
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University
| | - Omar A Almohammed
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University
- Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University
| | - Abdulrahman I Alshaya
- Pharmacy Practice Department, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard - Health Affairs
| | - Sara Alsaif
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University
| | - Sara Albogami
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University
| | - Saqer M Althunayyan
- Department of Trauma, Prince Sultan bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
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Bottino R, Carbone A, D'Andrea A, Liccardo B, Cimmino G, Imbalzano E, Russo V. Pharmacokinetic determinants for the right dose of antiarrhythmic drugs. Expert Opin Drug Metab Toxicol 2022; 18:165-176. [PMID: 35209796 DOI: 10.1080/17425255.2022.2046733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Antiarrhythmic drugs (AADs) show a narrow therapeutic range and marked intersubject variability in pharmacokinetics (PK), which may lead to inappropriate dosing and drug toxicity. AREAS COVERED The aim of the present review is to describe PK properties of AADs, discussing the main changes in different clinical scenarios, such as the elderly and patients with obese, chronic kidney, liver, and cardiac disease, in order to guide their right prescription in clinical practice. EXPERT OPINION There are few data about PK properties of AADs in a special population or challenging clinical setting. The use and dose of AADs is commonly based on physicians' clinical experience observing the clinical effects rather than being personalized on the individual patients PK profiles. More and updated studies are needed to validate a patient centered approach in the pharmacological treatment of arrhythmias based on patients' clinical features, including pharmacogenomics, and AAD pharmacokinetics.
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Affiliation(s)
- Roberta Bottino
- Division of Cardiology, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Andreina Carbone
- Division of Cardiology, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Antonello D'Andrea
- Division of Cardiology, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy.,Department of Cardiology, Monaldi Hospital, Naples, Italy
| | - Biagio Liccardo
- Division of Cardiology, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy.,Department of Cardiology, Umberto I° Hospital Nocera Inferiore, Italy
| | - Giovanni Cimmino
- Division of Cardiology, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Vincenzo Russo
- Division of Cardiology, University of Campania "Luigi Vanvitelli," Monaldi Hospital, Naples, Italy
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4
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Chin KJ, Lirk P, Hollmann MW, Schwarz SKW. Mechanisms of action of fascial plane blocks: a narrative review. Reg Anesth Pain Med 2021; 46:618-628. [PMID: 34145073 DOI: 10.1136/rapm-2020-102305] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/30/2020] [Accepted: 01/04/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Fascial plane blocks (FPBs) target the space between two fasciae, rather than discrete peripheral nerves. Despite their popularity, their mechanisms of action remain controversial, particularly for erector spinae plane and quadratus lumborum blocks. OBJECTIVES This narrative review describes the scientific evidence underpinning proposed mechanisms of action, highlights existing knowledge gaps, and discusses implications for clinical practice and research. FINDINGS There are currently two plausible mechanisms of analgesia. The first is a local effect on nociceptors and neurons within the plane itself or within adjacent muscle and tissue compartments. Dispersion of local anesthetic occurs through bulk flow and diffusion, and the resulting conduction block is dictated by the mass of local anesthetic reaching these targets. The extent of spread, analgesia, and cutaneous sensory loss is variable and imperfectly correlated. Explanations include anatomical variation, factors governing fluid dispersion, and local anesthetic pharmacodynamics. The second is vascular absorption of local anesthetic and a systemic analgesic effect at distant sites. Direct evidence is presently lacking but preliminary data indicate that FPBs can produce transient elevations in plasma concentrations similar to intravenous lidocaine infusion. The relative contributions of these local and systemic effects remain uncertain. CONCLUSION Our current understanding of FPB mechanisms supports their demonstrated analgesic efficacy, but also highlights the unpredictability and variability that result from myriad factors at play. Potential strategies to improve efficacy include accurate deposition close to targets of interest, injections of sufficient volume to encourage physical spread by bulk flow, and manipulation of concentration to promote diffusion.
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Affiliation(s)
- Ki Jinn Chin
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Philipp Lirk
- Department of Anesthesiology, Brigham and Women's Hospital, Harvard Medical School, Cambridge, Massachusetts, USA
| | - Markus W Hollmann
- Department of Anaesthesiology, Amsterdam University Medical Centres, Amsterdam Medical Centre, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anaesthesiology (L·E·I·C·A), Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Stephan K W Schwarz
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
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Mangoni AA, Jarmuzewska EA. Incorporating pharmacokinetic data into personalised prescribing for older people: challenges and opportunities. Eur Geriatr Med 2021; 12:435-442. [PMID: 33417165 DOI: 10.1007/s41999-020-00437-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 12/09/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE We discuss the known age-associated changes in drug metabolism and elimination, the potential use of this information when selecting specific therapeutic strategies in older patients, and the steps required to fill the knowledge gap in this field. METHODS We conducted a narrative review that encapsulates the current knowledge regarding the main age-associated changes in drug metabolism and elimination and discusses their possible inclusion in current and future personalised prescribing tools for the older patient population. RESULTS Despite some progress in this field, the lack of specific information regarding the impact of frailty, pharmacogenomics, and drug-drug, drug-disease, and organ-organ interactions, particularly in subjects > 80 years, currently prevents the routine incorporation of pharmacokinetic data, barring measures of renal function, into personalised prescribing tools. CONCLUSIONS The incorporation of pharmacokinetic data into personalised prescribing, an approach based on the consideration of a number of patient's characteristics when selecting the right drug(s) and dose regimen(s) to maximize effectiveness and limit toxicity, remains a hypothetical construct in geriatric care. Pending the inclusion of frail and complex older patients in pre- and post-marketing studies, a better understanding of the key pharmacokinetic alterations of common medications in "real-life" patients, together with the implementation of effective strategies tackling inappropriate prescribing, is likely to improve clinical outcomes and reduce healthcare utilization in the older population.
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Affiliation(s)
- Arduino A Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Bedford Park, SA, 5042, Australia. .,Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | - Elzbieta A Jarmuzewska
- Department of Internal Medicine, Polyclinic IRCCS, Ospedale Maggiore, University of Milan, Milan, Italy
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De Cassai A, Bonanno C, Padrini R, Geraldini F, Boscolo A, Navalesi P, Munari M. Pharmacokinetics of lidocaine after bilateral ESP block. Reg Anesth Pain Med 2020; 46:86-89. [PMID: 32868484 DOI: 10.1136/rapm-2020-101718] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/17/2020] [Accepted: 08/03/2020] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Erector spinae plane (ESP) block is an emerging interfascial block with a wide range of indications for perioperative analgesia and chronic pain treatment. Recent studies have focused their attention on mechanisms of action of ESP block. However, the pharmacokinetics of drugs injected in ESP is, as of now, uninvestigated. The aim of this brief report is to investigate the pharmacokinetics of lidocaine in a series of 10 patients. METHODS We are reporting a case series of 10 patients undergoing bilateral ESP block for multilevel lumbar spine surgery.ESP was performed with 3.5 mg/kg of lidocaine based on ideal body weight. Lidocaine concentration was dosed at 5, 15, 30 min and at 1, 2 and 3 hours. RESULTS Tmax was 5 min for all the patients. Cmax ranged from 1.2 to 3.8 mg/L (mean: 2.59 mg/L). AUC0-3 was high (76%, on average) suggesting an almost complete bioavailability. Age had a negative correlation with T½ of lidocaine. CONCLUSIONS Lidocaine pharmacokinetic after ESP block is well-described by a two-compartment model with a rapid and extensive rate of absorption. Nevertheless, its peak concentrations never exceeded the accepted toxicity limit. Elimination half-life was slightly prolonged, probably due to the advanced age of some patients.
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Affiliation(s)
- Alessandro De Cassai
- UOC Anesthesia and Intensiva Care Unit, Padua University Hospital, Padova, Italy
| | - Claudio Bonanno
- Department of Medicine, DIMED, Università degli Studi di Padova, Padova, Italy
| | - Roberto Padrini
- Department of Medicine, DIMED, Università degli Studi di Padova, Padova, Italy
| | - Federico Geraldini
- UOC Anesthesia and Intensiva Care Unit, Padua University Hospital, Padova, Italy
| | - Annalisa Boscolo
- UOC Anesthesia and Intensiva Care Unit, Padua University Hospital, Padova, Italy
| | - Paolo Navalesi
- UOC Anesthesia and Intensiva Care Unit, Padua University Hospital, Padova, Italy.,Department of Medicine, DIMED, Università degli Studi di Padova, Padova, Italy
| | - Marina Munari
- UOC Anesthesia and Intensiva Care Unit, Padua University Hospital, Padova, Italy
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Zullo AR, Olean M, Berry SD, Lee Y, Tjia J, Steinman MA. Patient-Important Adverse Events of β-blockers in Frail Older Adults after Acute Myocardial Infarction. J Gerontol A Biol Sci Med Sci 2019; 74:1277-1281. [PMID: 30137259 PMCID: PMC6625583 DOI: 10.1093/gerona/gly191] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We evaluated the burden of adverse events caused by β-blocker use after acute myocardial infarction (AMI) in frail, older nursing home (NH) residents. METHODS This retrospective cohort study used national Medicare claims linked to Minimum Data Set assessments. The study population was individuals aged ≥65 years who resided in a U.S. NH for ≥30 days, had a hospitalized AMI between May 2007 and March 2010, and returned to the NH. Exposure was new use of β-blockers versus nonuse post-AMI. Orthostasis, general hypotension, falls, dizziness, syncope, and breathlessness outcomes were measured over 90 days of follow-up. Odds ratios (ORs) with 95% confidence intervals (CIs) for outcomes were estimated using multinomial logistic regression models after 1:1 propensity score-matching of β-blocker users to nonusers. RESULTS Among the 10,992 NH propensity score-matched residents with an AMI, the mean age was 84 years and 70.9% were female. β-blocker users were more likely than nonusers to be hospitalized for hypotension (OR = 1.20, 95% CI 1.03-1.39) or experience breathlessness (OR = 1.10, 95% CI 1.01-1.20) after AMI. With the exception of falls, other outcome estimates, though imprecise, were compatible with a potential elevated risk of orthostasis (OR = 1.14, 95% CI 0.96-1.35), syncope, (OR = 1.24, 95% CI 0.55-2.77), and dizziness (OR = 1.28, 95% CI 0.82-1.99) among β-blocker users. CONCLUSIONS Considered alongside prior evidence that β-blockers may worsen functional outcomes in NH residents with poor baseline functional and cognitive status, our results suggest that providers should exercise caution when prescribing for these vulnerable groups, balancing the mortality benefit against the potential for causing adverse events.
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Affiliation(s)
- Andrew R Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Rhode Island
- Department of Pharmacy, Rhode Island Hospital, Providence
| | - Matthew Olean
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
- Department of Pharmacy, Rhode Island Hospital, Providence
- University of Rhode Island College of Pharmacy, Kingston
| | - Sarah D Berry
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
| | - Jennifer Tjia
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco and San Francisco VA Medical Center
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Mangoni AA, Bryant K, Jarmuzewska EA. Medication Management Issues in Old Age: A Call for Submissions to Current Clinical Pharmacology. ACTA ACUST UNITED AC 2019; 14:2-4. [PMID: 30968764 DOI: 10.2174/157488471401190301120237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Arduino A Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders, University and Flinders Medical Centre, Adelaide, Australia
| | - Kimberley Bryant
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders, University and Flinders Medical Centre, Adelaide, Australia.,Department of Orthopaedic and Trauma Surgery, College of Medicine and Public Health, Flinders University and Flinders, Medical Centre, Adelaide, Australia
| | - Elzbieta A Jarmuzewska
- Department of Internal Medicine, Polyclinic IRCCS, Ospedale Maggiore, University of Milan, Milan, Italy
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Conti CR. Epidemiology, Pathophysiology, and Therapeutic Targets in Stable Ischemic Heart Disease. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2019. [DOI: 10.15212/cvia.2017.0074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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10
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Mangoni AA, Jarmuzewska EA. The influence of heart failure on the pharmacokinetics of cardiovascular and non-cardiovascular drugs: a critical appraisal of the evidence. Br J Clin Pharmacol 2018; 85:20-36. [PMID: 30194701 DOI: 10.1111/bcp.13760] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/21/2018] [Accepted: 09/03/2018] [Indexed: 12/12/2022] Open
Abstract
Prescribing in heart failure (HF), a common disease state that predominantly affects the older population, is often a challenging task because of the dynamic nature of the condition, requiring frequent monitoring and medication review, the presence of various comorbidities, and the frailty phenotype of many patients. The significant alterations in various organs and tissues occurring in HF, particularly the reduced cardiac output with peripheral hypoperfusion and the structural and functional changes of the gastrointestinal tract, liver and kidney, might affect the pharmacokinetics of several drugs. This review critically appraises the results of published studies investigating the pharmacokinetics of currently marketed cardiovascular and selected non-cardiovascular drugs in HF patients and control groups, identifies gaps in the current knowledge, and suggests avenues for future research in this complex patient population.
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Affiliation(s)
- Arduino A Mangoni
- Discipline of Clinical Pharmacology, College of Medicine and Public Health, Flinders University and Flinders Medical Centre, Adelaide, Australia
| | - Elzbieta A Jarmuzewska
- Department of Internal Medicine, Polyclinic IRCCS, Ospedale Maggiore, University of Milan, Milan, Italy
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11
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Bader F, Atallah B, Brennan LF, Rimawi RH, Khalil ME. Heart failure in the elderly: ten peculiar management considerations. Heart Fail Rev 2018; 22:219-228. [PMID: 28164253 DOI: 10.1007/s10741-017-9598-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Chronic heart failure (HF) is a disease with significantly higher prevalence in the elderly or patients older than 65 years old. Typically, older patients have more risk factors for HF, more comorbidities, and are more likely to have recurrent admissions for acute decompensations. With HF burden on health care systems primarily related to hospital and nursing home costs, it is critical that elderly patients are approached with a clear understanding of certain unique clinical, laboratory, imaging, and pharmacokinetic differences that can alter their management and outcomes. Psychosocial factors have major implications on adherence to therapy as well as decisions on advanced care for elderly HF patients. In this article, we highlight ten peculiar management considerations when approaching older patients with HF. We discuss issues related to epidemiology, diagnostic challenges, pharmacotherapy, and palliative care; all of which can impact this unique population and, more importantly, the disease burden as a whole.
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Affiliation(s)
- Feras Bader
- Cleveland Clinic Abu Dhabi, United Arab Emirates, Heart and Vascular Institute, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE.
| | - Bassam Atallah
- Department of Pharmacy Services, Cleveland Clinic Abu Dhabi, United Arab Emirates, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
| | - Lisa F Brennan
- Levine College of Health Sciences, Wingate University School of Pharmacy, 515 N. Main Street, Wingate, NC, 28174, USA
| | - Rola H Rimawi
- , 34522 N. Scottsdale road, Suite 120, PMB 489, Scottsdale, Arizona, 85266, USA
| | - Mohammed E Khalil
- Cleveland Clinic Abu Dhabi, United Arab Emirates, Heart and Vascular Institute, Al Maryah Island, PO Box 112412, Abu Dhabi, UAE
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12
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Under-representation of elderly and women in clinical trials. Int J Cardiol 2017; 232:216-221. [DOI: 10.1016/j.ijcard.2017.01.018] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 12/27/2016] [Accepted: 01/03/2017] [Indexed: 11/23/2022]
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13
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Abstract
Chronic stable angina is a significant problem in older adults. The goal of therapy is to provide symptomatic relief, improve patient quality of life, and prevent subsequent angina or myocardial infarction that could lead to sudden death. The efficacy and safety of drugs such as beta-blockers and calcium channel blockers for managing chronic stable angina in older adults has not been rigorously investigated. Drug selection should be based on physiologic alterations, patient comorbidities, adverse reaction profile, and cost.
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14
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Zullo AR, Lee Y, Daiello LA, Mor V, John Boscardin W, Dore DD, Miao Y, Fung KZ, Komaiko KDR, Steinman MA. Beta-Blocker Use in U.S. Nursing Home Residents After Myocardial Infarction: A National Study. J Am Geriatr Soc 2016; 65:754-762. [PMID: 27861719 DOI: 10.1111/jgs.14671] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To evaluate how often beta-blockers were started after acute myocardial infarction (AMI) in nursing home (NH) residents who previously did not use these drugs and to evaluate which factors were associated with post-AMI use of beta-blockers. DESIGN Retrospective cohort using linked national Minimum Data Set assessments; Online Survey, Certification and Reporting records; and Medicare claims. SETTING U.S. NHs. PARTICIPANTS National cohort of 15,720 residents aged 65 and older who were hospitalized for AMI between May 2007 and March 2010, had not taken beta-blockers for at least 4 months before their AMI, and survived 14 days or longer after NH readmission. MEASUREMENTS The outcome was beta-blocker initiation within 30 days of NH readmission. RESULTS Fifty-seven percent (n = 8,953) of residents initiated a beta-blocker after AMI. After covariate adjustment, use of beta-blockers was less in older residents (ranging from odds ratio (OR) = 0.89, 95% confidence interval (CI) = 0.79-1.00 for aged 75-84 to OR = 0.65, 95% CI = 0.54-0.79 for ≥95 vs 65-74) and less in residents with higher levels of functional impairment (dependent or totally dependent vs independent to limited assistance: OR = 0.84, 95% CI = 0.75-0.94) and medication use (≥15 vs ≤10 medications: OR = 0.89, 95% CI = 0.80-0.99). A wide variety of resident and NH characteristics were not associated with beta-blocker use, including sex, cognitive function, comorbidity burden, and NH ownership. CONCLUSION Almost half of older NH residents in the United States do not initiate a beta-blocker after AMI. The absence of observed factors that strongly predict beta-blocker use may indicate a lack of consensus on how to manage older NH residents, suggesting the need to develop and disseminate thoughtful practice standards.
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Affiliation(s)
- Andrew R Zullo
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Yoojin Lee
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Lori A Daiello
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Vincent Mor
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island.,Center of Innovation, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - W John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California.,Division of Biostatistics, University of California, San Francisco, San Francisco, California
| | - David D Dore
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island.,Optum Epidemiology, Boston, Massachusetts
| | - Yinghui Miao
- Division of Geriatrics, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Kathy Z Fung
- Division of Geriatrics, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Kiya D R Komaiko
- Division of Geriatrics, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Michael A Steinman
- Division of Geriatrics, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California
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15
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Vitale C, Rosano G, Fini M. Are elderly and women under-represented in cardiovascular clinical trials? Implication for treatment. Wien Klin Wochenschr 2016; 128:433-438. [PMID: 27655475 DOI: 10.1007/s00508-016-1082-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 08/17/2016] [Indexed: 11/26/2022]
Abstract
Elderly and women have been often under-represented in randomised clinical trials testing the effect of treatments on cardiovascular diseases even though these diseases highly affect both of them.Compared to their younger counterparts elderly have a higher incidence of disease-related morbidities, take more medicines and account for more adverse drug-related events. Similarly women present several differences in pathophysiology, clinical manifestations and outcomes in comparison to their male counterparts. For these reasons the results of randomised clinical trials obtained in younger men cannot be simply translated in elderly and women and the conduction of research and clinical trials in these patient populations is a key aspect to acquire evidence-based knowledge in the understanding and management of their conditions and treatment.Although the under-representation of elderly and women has been discussed for several years and several international guidelines or recommendation have been published to suggest how to improve the recruitment of these two populations, their recruitment is still insufficient. In particular, frail elderly and those with co-morbidities are not included questioning the external validity and the safety of most treatments.Aim of this review is to critically analyse how current recommendations for treatments of cardiovascular disease are not adequately devised for elderly and women.
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Affiliation(s)
- Cristiana Vitale
- Department of Medical Sciences, IRCCS San Raffaele Pisana, via della Pisana, 235, 00163, Rome, Italy.
| | - Giuseppe Rosano
- Department of Cardiovascular and Cell Science Research, St. Georges Hospital, London, UK
| | - Massimo Fini
- Department of Medical Sciences, IRCCS San Raffaele Pisana, via della Pisana, 235, 00163, Rome, Italy
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16
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Hutchison LC, O'Brien CE. Changes in Pharmacokinetics and Pharmacodynamics in the Elderly Patient. J Pharm Pract 2016. [DOI: 10.1177/0897190007304657] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The use of pharmacologic agents in elderly patients is one of the most difficult aspects of patient care. An understanding of the common physiologic changes expected with aging is helpful to anticipate changes expected in pharmacokinetic parameters. Distribution, metabolism, and excretion are significantly altered for many drugs. In addition, pharmacodynamic variations in elderly patients may increase or decrease sensitivity to a medication independent of pharmacokinetic changes. These alterations are particularly noteworthy with cardiovascular and central nervous system agents. Current controversies regarding the application of estimation of renal function to drug dosing and use of the Beers criteria of medications potentially inappropriate in the elderly are discussed.
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Affiliation(s)
- Lisa C. Hutchison
- University of Arkansas for Medical Sciences College of Pharmacy, Department of Pharmacy Practice, Little Rock, Arkansas,
| | - Catherine E. O'Brien
- University of Arkansas for Medical Sciences College of Pharmacy, Department of Pharmacy Practice, Little Rock, Arkansas
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17
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Thadani U. Should ranolazine be used for all patients with ischemic heart disease or only for symptomatic patients with stable angina or for those with refractory angina pectoris? A critical appraisal. Expert Opin Pharmacother 2012; 13:2555-63. [DOI: 10.1517/14656566.2012.740458] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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18
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Boden WE, Finn AV, Patel D, Peacock WF, Thadani U, Zimmerman FH. Nitrates as an integral part of optimal medical therapy and cardiac rehabilitation for stable angina: review of current concepts and therapeutics. Clin Cardiol 2012; 35:263-71. [PMID: 22528319 PMCID: PMC6652630 DOI: 10.1002/clc.21993] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 03/08/2012] [Indexed: 12/12/2022] Open
Abstract
The goals of optimal medical therapy in patients with stable angina pectoris are to reduce the risk of cardiovascular mortality and future cardiovascular events, improve exercise capacity, and enhance quality of life. Whereas myocardial revascularization is frequently employed in the management of patients with stable angina, a variety of pharmacologic interventions are recommended as part of optimal medical management. The use of short- and rapidly-acting nitrates (eg, sublingual nitroglycerin spray and tablets) is at the core of the therapeutic armamentarium and should be integrated into optimal medical therapy for stable angina along with exercise therapy. The potential clinical implications from these observations are that prophylactic sublingual nitrates, when combined with cardiac rehabilitation, may allow the patient with angina to exercise to a greater functional capacity than without sublingual nitrates.
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Affiliation(s)
- William E Boden
- Department of Medicine, Samuel S. Stratton VA Medical Center and Albany Medical Center, 113 Holland Avenue, Albany, NY 12208, USA.
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19
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Abstract
Pharmacists have traditionally focused on the appropriate use of medications to enhance the functional status of the elderly patient. However, in the proper provision of pharmaceutical care, the influence of lifestyle factors on the use and misuse of medications cannot be ignored. The pharmacist collaborates with other members of the health care team to ensure that drugs are dosed according to known changes occurring with age such as pharmacokinetic and pharmacodynamic alterations. Also, medications that may decrease cognitive function, impair gait/balance, or reduce sensory stimulation must be avoided. The appropriate use of medications can improve the functional status and reduce morbidity in the elderly patient, and drug adherence issues should be addressed to ensure that the elderly patient can receive the optimal benefit from his or her medication regimen. Pharmacists, in collaboration with physicians and other health care providers, can help to ensure that a comprehensive approach to patient care occurs, one that involves medications, diet, and exercise as it embraces the mind, body, and spirit.
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20
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Chase D, O'Donnell D, Farouque O. Management of Cardiac Rhythm Disturbances in the Ageing Heart. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2008. [DOI: 10.1002/j.2055-2335.2008.tb00398.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- David Chase
- Department of Cardiology, Austin Health; Heidelberg, and University of Melbourne; Parkville Victoria
| | - David O'Donnell
- Department of Cardiology, Austin Health; Heidelberg, and University of Melbourne; Parkville Victoria
| | - Omar Farouque
- Department of Cardiology, Austin Health; Heidelberg, and University of Melbourne; Parkville Victoria
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21
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Mégarbane B, Aslani AA, Deye N, Baud FJ. Pharmacokinetic/pharmacodynamic modeling of cardiac toxicity in human acute overdoses: utility and limitations. Expert Opin Drug Metab Toxicol 2008; 4:569-79. [DOI: 10.1517/17425255.4.5.569] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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22
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Andrus MR, Loyed JV. Use of beta-adrenoceptor antagonists in older patients with chronic obstructive pulmonary disease and cardiovascular co-morbidity: safety issues. Drugs Aging 2008; 25:131-44. [PMID: 18257600 DOI: 10.2165/00002512-200825020-00005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
The incidence of and mortality from both chronic obstructive pulmonary disease (COPD) and cardiovascular disease (CVD) increase with age. In addition, the average age of patients with COPD and CVD is also increasing as a result of improvements in both pharmacological and non-pharmacological treatments. Coronary artery disease is a compelling indication for beta-adrenoceptor antagonist use in a population in whom beta-adrenoceptor antagonism is often viewed as contraindicated. beta-Adrenoceptor antagonists have been proven to improve cardiovascular morbidity and mortality but have been under-utilized in patients with COPD with concomitant CVD because of a fear of bronchoconstriction and adverse effects, particularly in the elderly. The advanced age of patients with COPD and CVD, along with the sheer number of patients with these diseases, necessitates that clinicians understand the treatment of these co-morbidities using seemingly conflicting therapy in the form of beta-adrenoceptor agonists and antagonists. We review changes in the pharmacokinetics and pharmacodynamics of beta-adrenoceptor antagonists in the elderly, the role of beta-adrenoceptor antagonists in CVD and the literature regarding the safety and mortality benefits of beta-adrenoceptor antagonists in elderly patients with COPD and concomitant CVD. We conclude that cardioselective beta-adrenoceptor antagonists appear to be safe to use in elderly male patients with mild-to-moderate COPD who have a compelling indication for beta-adrenoceptor antagonist therapy. Data in female patients are very limited. Nonselective beta-adrenoceptor antagonists should be avoided in general, except in patients with heart failure who might benefit significantly from the use of carvedilol. beta-Adrenoceptor antagonists have been shown to improve mortality in older patients with coexisting CVD and COPD.
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Affiliation(s)
- Miranda R Andrus
- Auburn University Harrison School of Pharmacy, Huntsville, Alabama 35801, USA
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23
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Endeshaw YW, Bloom HL, Bliwise DL. Sleep-disordered breathing and cardiovascular disease in the Bay Area Sleep Cohort. Sleep 2008; 31:563-8. [PMID: 18457244 PMCID: PMC2279747 DOI: 10.1093/sleep/31.4.563] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
STUDY OBJECTIVES To examine the relationship between sleep-disordered breathing (SDB) and cardiovascular disease among community-dwelling older adults. Previous studies have suggested relatively stronger associations between SDB and such morbidity in middle-aged, relative to elderly, populations. DESIGN Cross-sectional analysis of an elderly ambulatory, non-clinic-based cohort (Bay Area Sleep Cohort, BASC) SETTING: Community population studied in a sleep laboratory PARTICIPANTS One hundred twenty-nine older adults (mean [+/- SD] age = 72.6 [8.3]) (78 women; 51 men). INTERVENTIONS NA. MEASUREMENTS Complete clinical history including list of current medications, physical examination, selected blood chemistries, multiple blood pressure measurements, 12-lead electrocardiogram, and 2 consecutive nights of polysomnography. RESULTS Fifty-one individuals (40%) were taking 1 or more cardiovascular medications and 24 (19%) had an apnea-hypopnea index (AHI) of 10 or more per hour of sleep. Cardiovascular medication use was related to cardiac events or procedures, history of angina, higher systolic or diastolic blood pressure, and abnormal electrocardiogram. Logistic regression showed statistically significant association between cardiovascular medication use and AHI of 10 or greater per hour, independent of age, sex, and body mass index. Supplementary analyses indicated that rapid eye movement AHI of 10 or greater per hour was significantly associated with elevated diastolic blood pressure. CONCLUSIONS The results suggest that sleep-disordered breathing may contribute to increased cardiovascular morbidity in older adults.
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Affiliation(s)
- Yohannes W Endeshaw
- Division of Geriatrics & Gerontology, Emory University School of Medicine, Atlanta, GA 30329, USA.
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24
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Plakogiannis R, Ginzburg R. Possible Amiodarone−Warfarin Interaction: A Reemphasis on a Potentially Dangerous Drug−Drug Interaction. J Pharm Pract 2007. [DOI: 10.1177/0897190007311454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article reports two patients with delayed amiodarone— warfarin interaction resulting in a significant elevation in the international normalized ratio. One patient developed episodes of nosebleeds. Amiodarone is a potent inhibitor of the cytochrome P450 enzyme system. Warfarin undergoes metabolism via the same isoenzyme, potentially leading to prolongation of elevated international normalized ratio levels. A decrease in the warfarin dose is thus warranted when coadministered with amiodarone to circumvent the potential danger of this interaction, which can go unnoticed because several weeks of therapy may be necessary to discern an elevated international normalized ratio. The Naranjo probability scale indicated a possible relationship between the elevated international normalized ratio levels and the coadministration of amiodarone and warfarin. With the coadministration of warfarin and amiodarone, frequent and close monitoring of warfarin is paramount, especially in the initial weeks of therapy, in an effort to prevent supratherapeutic international normalized ratios and bleeding complications.
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Affiliation(s)
- Roda Plakogiannis
- Department of Pharmacy Practice, Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Long Island University, Clinical Pharmacy Specialist/Ambulatory Care, Bellevue Hospital Center, New York, New York,
| | - Regina Ginzburg
- St John's University College of Pharmacy, Clinical Pharmacy Specialist in Ambulatory Care, Institute for Urban Family Health, New York, New York
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25
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Wright JW, Mizutani S, Harding JW. Pathways involved in the transition from hypertension to hypertrophy to heart failure. Treatment strategies. Heart Fail Rev 2007; 13:367-75. [DOI: 10.1007/s10741-007-9060-z] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Accepted: 10/16/2007] [Indexed: 01/25/2023]
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Burapadaja S, Kawasaki N, Charumanee S, Ogata F. Effects of essential medicines on cardiovascular products available for the market in Thailand. Health Policy 2007; 84:67-74. [PMID: 17374418 DOI: 10.1016/j.healthpol.2007.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Revised: 01/26/2007] [Accepted: 01/28/2007] [Indexed: 10/23/2022]
Abstract
National List of Essential Medicines (NLEM) is an important policy on drugs, which also covers the drug availability. However, the link between the list and the availability of medicine products for the market is not clear. The objectives of this study were to examine the effects of essential medicines (EM) on the patterns and values of cardiovascular products available for the market in Thailand. Issues investigated were proportions of products, expansions of generic names, involvement of producers and relation between the numbers of EM generic names and production values of products. Data sources were NLEM, Thailand Index of Medical Specialities and drug statistics by Food and Drug Administration (FDA). Results revealed the availability of 623 products from 127 generic names. On average, EM products showed significantly greater proportions and EM generic names demonstrated larger expansions than non-EM. Domestic producers contributed to List A products by a significantly higher percentage than foreign, but only foreign producers introduced List D products. There was a positive and significant relation between the numbers of EM generic names and the production values of products. In conclusion, it was clear that EM had effects on the patterns and the values of cardiovascular products available for the market. Subsequent prices and expenditure due to the patterns and values of product availability could be low or high. These findings could be advantageous in using essential medicines as a means to avoid the negative consequences by addressing the significance of its kinds and numbers when selecting it in the list.
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27
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Rich MW, Crager M, McKay CR. Safety and Efficacy of Extended-Release Ranolazine in Patients Aged 70 Years or Older With Chronic Stable Angina Pectoris. ACTA ACUST UNITED AC 2007; 16:216-21. [PMID: 17617747 DOI: 10.1111/j.1076-7460.2007.07119.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This analysis examined the safety and efficacy of extended-release ranolazine among patients aged 70 years or older (n=363) compared with patients younger than 70 years (n=1024) enrolled in 2 large multinational prospective clinical trials. The primary end points were exercise capacity and number of weekly angina episodes. Beneficial effects of ranolazine, relative to placebo, were generally similar for each of these outcomes among older and younger participants. For example, at a ranolazine dose of 1000 mg bid, mean exercise duration increased by 19.8+/-13.1 seconds (mean +/- SE) relative to placebo in patients younger than 70 years and by 32.4+/-19.7 seconds relative to placebo in patients 70 years or older. Adverse effects were more common in older than in younger patients, but the incidence of serious adverse effects attributable to ranolazine did not differ significantly between age groups. Outcomes were also similar at dosages of either 750 mg or 1000 mg bid. In conclusion, pooled data from 2 large randomized trials indicate that the efficacy of ranolazine is similar in older and younger patients but that adverse effects are more common in the elderly.
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Affiliation(s)
- Michael W Rich
- Cardiovascular Division, Washington University School of Medicine, St Louis, MO 63110, USA.
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28
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Thomas GN, Chan P, Tomlinson B. The Role of Angiotensin II Type 1 Receptor Antagonists in Elderly Patients with Hypertension. Drugs Aging 2006; 23:131-55. [PMID: 16536636 DOI: 10.2165/00002512-200623020-00004] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Hypertension is a major risk factor for stroke and coronary events in elderly people and clinical trials have shown that treatment of hypertension with various drugs can result in a substantial reduction in cerebrovascular and cardiovascular events. The angiotensin II type 1 (AT1) receptor antagonists are the newest class of antihypertensive agents to be used widely in clinical practice. AT1 receptor antagonists can generally be given once-daily. They are also extremely well tolerated with minimal first-dose hypotension and an incidence of adverse effects similar to that seen with placebo. Adverse event rates are significantly lower than with other classes of antihypertensive drugs including ACE inhibitors. These factors result in improved compliance and increased rates of continuance on therapy. AT1 receptor antagonists show similar efficacy in lowering blood pressure to other classes of antihypertensive agents and their antihypertensive effect is potentiated when they are given concomitantly with low-dose thiazide diuretics. AT1 receptor antagonists are eliminated predominantly by the hepatic route but most are not subject to extensive metabolism and interactions with other drugs are uncommon. This is an advantage in the elderly, who are often receiving multiple medications which increases the risk for adverse drug interactions. Dose adjustments are not usually required in the elderly unless there is plasma volume depletion. Although plasma AT1 receptor antagonist concentrations are generally higher in the elderly than in younger subjects, this pharmacokinetic difference may be balanced by decreased activation of the circulating renin-angiotensin-aldosterone system in the elderly. Recent clinical studies in high-risk hypertensive patients with left ventricular hypertrophy or in patients with diabetic nephropathy or heart failure have demonstrated that AT1 receptor antagonists can improve clinical outcomes to a similar or sometimes greater extent than other antihypertensive agents. Many of these studies have included large numbers of older patients and have confirmed the excellent tolerability profile of these drugs. Thus, AT1 receptor antagonists should be considered as a possible first-line treatment or as a component of combination therapy in patients with type 2 diabetes mellitus and microalbuminuria or nephropathy and as an alternative or additional treatment to ACE inhibitors in patients with heart failure or left ventricular dysfunction. AT1 receptor antagonists also appear to reduce the onset of new diabetes compared with some other antihypertensive drugs. The benefits in terms of organ protection have mainly been seen in studies using higher doses of particular AT1 receptor antagonists and it is not certain at present whether these results can be extrapolated to other members of the class. As the elderly are more likely to have developed organ damage related to hypertension or to have heart failure or diabetes as concomitant conditions, AT1 receptor antagonists represent an appropriate option for many elderly patients. The main disadvantage of these drugs is the cost of the medication but this may be offset by their improved tolerability with fewer adverse reactions and thus increased compliance, resulting in better blood pressure control and fewer clinical events. Overall, AT1 receptor antagonists are well tolerated and efficacious for blood pressure-lowering when given as a single daily dose in elderly patients and have many potential benefits in high-risk hypertensive subjects.
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Affiliation(s)
- G Neil Thomas
- Department of Community Medicine, The University of Hong Kong, Pokfulam, Hong Kong, China
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