Family Medicine & Pharmacy Podcast

Management of Onychomycosis in Canada in 2014 http://www.ncbi.nlm.nih.gov/pubmed/25775640 Drug name: Brand: SA SA Criteria SA Approval period Direction SE Monitoring Ciclopirox 8% Penlac (nail lacquer) No Not covered N/A Nail lacquer: Apply bid to adjacent skin and affected nails daily. Remove with alcohol every 7 days (treat 4 weeks) dermatitis, dry skin, local burning sensation Efinaconazole Jublia (nail lacquer) Not covered Not covered N/A Apply to affected toenails once daily for 48 weeks Ingorwn nail (2%), dermatitis Terbinafine tablets Lamisil tablets Yes Severe onychomycosis PLUS functional disability PLUS positive KOH or dermatophyte culture of nail from a licensed lab. First approval: Three months Renewals: If required, up to three months. 250mg once daily for 6 weeks (fingernail); 250mg once daily for 12 weeks (toenails) Headache (13%), diarrhea (6%), nausea, liver enzyme disorder (3%) Monitor AST/ALT prior to initiation, repeat if used >6 weeks Itraconazole Sporanox Yes 1. Immunocompromised pts/ Or 2. Pulse treatment for severe onychomycosis with functional disability PLUS confirmed lab results for candida or dermatophyte infection. 1. Immunocompromised pts approval is indefinite 2. 3 months approval for 2nd group of pts (No need for SA approval if prescribed by HIV/AIDS Dr) Fingernail involvement: 200mg capsule twice daily for 1 week. repeat 1 week course after 3 week off time Toenails due to Trichophyton rubrum or T mentagrophytes: 200mg once daily for 12 consecutive weeks With or without fingernaikl involvement: 200mg once daily for 12 consecutive weeks Canadian labelling “Pulse dosing”: 200mg twice daily for 1 week, then repeat 1 week course twice with 3 week off time between each course Diarrhea, nausea, headache, skin rash Liver function in patients with pre-existing hepatic dysfunction, and in all patients being treated for longer than 1 month fluconazole Diflucan Yes 1. Immunocompromised patients. OR2. Exceptions on an individual basis for fungal infections resistant to first-line medications. 1 day to indefinite (no need for HIV and AIDS Dr to apply for SA) The post Onychomycosis appeared first on Family Pharm Podcast.

We are back! (Or your money back!) In this episode, Billy and Tina discuss the PharmaCare coverage status of different classes of diabetes medications. Sources: BC PharmaCare Formulary: https://pcbl.hlth.gov.bc.ca/pharmacare/benefitslookup/ BC PharmaCare Special Authority: http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pharmacare/prescribers/special-authority CDA Formulary Listings for Diabetes Medications in Canada by provinces and territories (Jan 2016): http://www.diabetes.ca/getmedia/c87009a8-29b6-4061-a52a-963d0b077e47/pt-formulary-listing-jan-18-2016.pdf.aspx *In case the link doesn’t work: pt-formulary-listing-jan-18-2016 Class drugs Other therapeutic considerations coverage SA criteria Biguanide metformin covered Alpha-glucosidase inhibitor (acarbose) acarbose Improved postprandial control, GI side-effects delisted Incretin agent: DPP-4 Inhibitors linagliptin (Trajenta) SA same as onglyza sitagliptin (Januvia) delisted saxagliptin (Onglyza) SA As part of a combination treatment for type 2 diabetes mellitus, 1) When insulin NPH is not an option AND 2) After inadequate glycemic control on maximum tolerated doses of dual therapy of metformin AND a sulfonylurea. Incretin agent: GLP-1 receptor agonists liraglutide (Victoza) GI side-effects not listed Insulin rapid acting (Humalog, novorapid, apidra) No dose ceiling, flexible regiments partial coverage short acting (Humulin R, Novolin Toronto) covered NPH covered Premixed (Humulin 30/70, Novolin 30/70, 40/60, 50/50) covered Premixed (Humalog mix 25, mix 50, Novomix 30) partial coverage glargine (Lantus) SA A) Type 1 DM or B) Type 2 DM > 17 years old, and 1) requiring insulin and is currently taking insulin NPH and/or pre-mix insulin daily at optimal dosing AND 2) Has experienced unexplained nocturnal hypoglycemia at least once a month despite optimal management OR 3) Has experienced or continues to experience severe, systemic or local allergic reaction to existing insulin treatment. detemir (Levemir) SA same as Lantus new glargine (Toujeo) not listed Insulin secretagogue: Meglitinide repaglinide (gluconorm) Less hypoglycemia in context of missed meals but usually requires TID to QID dosing not listed Insulin secretagogue: Sulfonylurea glyburide Gliclazide and glimepiride associated with less hypoglycemia than glyburide covered gliclazide SA (listed everywhere else in Canada) Treatment failure or intolerance to at least one other sulfonylurea drug (e.g., glyburide, tolbutamide) at adequate doses. SGLT2 inhibitors canagliflozin (Invokana) UTI, genital infections, hypotension, hyperlipidemia, caution with renal dysfunction and loop diuretics, dapagliflozin not to be used if bladder cancer, rare diabetic ketoacidosis (may occur with no hyperglycemia) 1 year manufacturer coverage with special plan dapagliflozin (Forxiga) 1 year manufacturer coverage with special plan empagliflozin (Jardiance) not listed TZD rosiglitazone CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect delisted pioglitazone SA same as onglyza Weight loss agent (orlistat) orlistat GI side effects not listed Combination Drugs sitagliptin and metformin (Janumet) delisted linagliptin and metformin (Jentadueto) SA same as onglyza The post Diabetes Medications and BC Coverage Information appeared first on Family Pharm Podcast.

This is planned to be an 8-part series highlighting the take-home points I picked up during the St. Paul’s Hospital CME Conference 2014. Pearls from Part 1 “Internal Medicine”: Alcoholism – Dr. Paul Farnan Screen alcohol use disorders routinely to catch those of whom do not appear to have a significant social or occupational impairment. Use assertive statements to convey the concern regarding someone’s alcohol use. Peer support is strongly recommended. Patients should try multiple meetings at different groups before concluding that they are not helpful, as the groups vary in their structure and member characteristics. Medical treatments may be considered in select patients: naltrexone, acamprosate, disulfiram. Gout – Dr. Hyon Choi Screen for HLA-B*5801 in Asians (esp. Chinese, Thai, and Korean patients) before starting alopurinol. Look for concurrent metabolic disorders. “Medication in the pocket” strategy for acute flares: colchicine 1.2mg po x1 then 0.6mg po in 1 hour. Use losartan or CCB for concurrent hypertension. Low-carb diet and avoid foods with highest purine content. Cellulitis – Dr. Val Montessori Non-purulent cellulitis, most likely caused by Group A Strep, treat with cephalexin (Keflex) 500mg po QID Purulent cellulitis, most likely Staph Aureus but still possibly GAS, treat with Septra DS PO BID, and cover GAS with Keflex. Complicated wounds, consult ID. HCV – Dr. Edward Tam New therapy more tolerable and has a 95% cure rate, but also exceedingly expensive. Refer all HCV RNA positive patients to hepatologists for assessment of treatment. This Changed My Practice – Dr. Steve Wong http://thischangedmypractice.com/ OSA – Dr. Pearce Wilcox Co-morbidities with metabolic syndrome -> screen for metabolic syndromes in patients with OSA, and vice versa   The post What I learned from St Paul’s CME 2014 Part 1 appeared first on Family Pharm Podcast.

After a 6-month hiatus, Tina – now a newly-hatched PHARMACIST! – and Billy teamed up to relaunch this pet project with a plan to make it more interactive and less sleep-inducing. Did it work with this unscripted episode? The post Family Pharm Podcast – RELAUNCHED! appeared first on Family Pharm Podcast.

Tina concentrates on the details of ADHD medications and invites your attention to the following: Non-pharmacological therapy behavioural therapy Stimulants methylphenidate amphetamines Non-stimulants atomoxetine clonidine other antidepressants and antipsychotics (to be covered in future episodes)   The post ADHD 2: medications appeared first on Family Pharm Podcast.

*This episode was recorded in January 2014. This is the topic that started it all. As Tina planned to study ADHD for school, we discussed how this would be useful information for other pharmacy students and medical trainees as well. We looked to the comprehensive CADDRA guideline for the assessment, differential diagnoses, and treatment strategies for ADHD. CADDRA Guideline: http://www.caddra.ca/pdfs/caddraGuidelines2011Chapter02.pdf ADHD Checklist on CADDRA ADHD Assessment Toolkit, page 8.20 http://www.caddra.ca/pdfs/caddraGuidelines2011_Toolkit.pdf   The post ADHD 1: CADDRA Guideline appeared first on Family Pharm Podcast.

Billy looked at the following guidelines to summarize the approach to a child with gastroenteritis:  UK NICE Guideline: Diarrhoea and vomiting in children under 5 (Issued: April 2009) http://guidance.nice.org.uk/cg84 CPS Guideline: Oral rehydration therapy and early refeeding in the management of childhood gastroenteritis (Posted: Nov 1, 2006) http://www.cps.ca/documents/position/oral-rehydration-therapy History: onset of diarrhea and/or vomiting (gastro is sudden in onset) duration of vomiting and diarrhea (diarrhea 5-7 days, max 2 weeks; vomiting 1-2 days, max 3 days) sick contact pathogen exposure travel history History suggestive of increased risk of dehydration: young age (esp <6mo) low birth weight infants >5 diarrhea in 24h >2 vomiting in 24h no oral intake signs of malnutrition Think about differential diagnosis if: fever >38 in children younger than 3 months fever >39 in children older than 3 months (fever workup required) shortness of breath or tachypnoea altered conscious state neck stiffness bulging fontanelle in infants non-blanching rash blood and/or mucus in stool bilious (green) vomit severe or localised abdominal pain abdominal distension or rebound tenderness.   SSx of dehydration and shock Table 1 in NICE Increasing severity of dehydration No clinically detectable dehydration Clinical dehydration Clinical shock Symptoms (remote and face-to-face assessments) Appears well Red flag Appears to be unwell or deteriorating – Alert and responsive Red flag Altered responsiveness (for example, irritable, lethargic) Decreased level of consciousness Normal urine output Decreased urine output – Skin colour unchanged Skin colour unchanged Pale or mottled skin Warm extremities Warm extremities Cold extremities Signs (face-to-face assessments) Eyes not sunken Red flag Sunken eyes – Moist mucous membranes (except after a drink) Dry mucous membranes (except for ‘mouth breather’) – Normal heart rate Red flag Tachycardia Tachycardia Normal breathing pattern Red flag Tachypnoea Tachypnoea Normal peripheral pulses Normal peripheral pulses Weak peripheral pulses Normal capillary refill time Normal capillary refill time Prolonged capillary refill time Normal skin turgor Red flag Reduced skin turgor – Normal blood pressure Normal blood pressure Hypotension (decompensated shock) Table 2 in CPS TABLE 2 Clinical assessment of degree of dehydration * Mild (under 5%) Moderate (5-10%) Severe (over 10%) Slightly decreased urine output Slightly increased thirst Slightly dry mucous membrane Slightly elevated heart rate Decreased urine output Moderately increased thirst Dry mucous membrane Elevated heart rate Decreased skin turgor Sunken eyes Sunken anterior fontanelle Markedly decreased or absent urine output Greatly increased thirst Very dry mucous membrane Greatly elevated heart rate Decreased skin turgor Very sunken eyes Very sunken anterior fontanelles Lethargy Cold extremities Hypotension Coma *Some of these signs may not be present   SSx of hypernatremic dehydration: jittery increased muscle tone hyperreflexia convulsions drowsiness or coma Labs: No routine blood work Serum sodium, potassium, urea, creatinine, glucose if IV fluids or signs of hypernatremia Blood gas if shock suspected Stool culture if: blood and/or mucus in stool immunocompromized septicemia suspected travel history diarrhea not improved by day 7 uncertainty about diagnosis of gastroenteritis Blood culture if antibiotic started Watch for HUS in E. coli O157:H7 Treatment: Figure 1 in CPS No dehydration continue breastfeeding and other milk feeds encourage fluid intake discourage the drinking of fruit juices and carbonated drinks, especially in those at increased risk of dehydration (see 1.2.1.2) offer ORS solution as supplemental fluid to those at increased risk of dehydration (see 1.2.1.2). Dehydration ORT Contraindications IVF indicated (shock, deterioration, persistent vomiting despite NG tube) paralytic ileus monosaccharide malabsorption use low-osmolarity ORS solution (240–250 mOsm/l)[5] (eg Pedialyte, Gastrolyte in Canada) for oral rehydration therapy give 50 ml/kg for fluid deficit replacement over 4 hours as well as maintenance fluid give the ORS solution frequently and in small amounts consider supplementation with their usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks) if they refuse to take sufficient quantities of ORS solution and do not have red flag symptoms or signs (see table 1) plain water discouraged by CPS consider giving the ORS solution via a nasogastric tube if they are unable to drink it or if they vomit persistently monitor the response to oral rehydration therapy by regular clinical assessment IVF   indications: Shock a child with red flag symptoms or signs (see table 1) shows clinical evidence of deterioration despite oral rehydration therapy a child persistently vomits the ORS solution, given orally or via a nasogastric tube. Initial bolus 20mL/kg of NS, then another one if still shocked If no response to 2 boluses, consider other causes of shock. Consult PICU. IVF therapy Use NS or D5NS If shocked: add 100mL/kg for fluid deficit to maintenance If no shocked: add 50mL/kg for fluid deficit to maintenance Early oral rehydration recommended. Switch to ORT as early as tolerated. IVF in Hypernatremic dehydration Urgent consult to specialist Use NS or D5NS still replace slowly over 48 hours, aiming at reducing serum sodium at a rate of less than 0.5mmol/L per hour   Maintenance after rehydration   Encourage breastfeeding, milk, and fluids Consider giving 5mL/kg of ORS after each large watery stool If dehydration recurs, restart ORT Antibiotic indications: suspected or confirmed septicaemia extra-intestinal spread of bacterial infection younger than 6 months with salmonella gastroenteritis patient malnourished or immunocompromised with salmonella gastroenteritis Clostridium difficile-associated pseudomembranous enterocolitis giardiasis dysenteric shigellosis dysenteric amoebiasis cholera Do not use antidiarrhoeal medications. Home care Red flags for dehydration (seek medical attention): appearing to get more unwell changing responsiveness (for example, irritability, lethargy) decreased urine output pale or mottled skin cold extremities Also seek medical attention if length of illness beyond the usual course: diarrhoea: 5–7 days and in most children it stops within 2 weeks vomiting: 1 or 2 days and in most children it stops within 3 days If not dehydrated: to continue usual feeds, including breast or other milk feeds to encourage the child to drink plenty of fluids to discourage the drinking of fruit juices and carbonated drinks plain water also discouraged by CPS to offer ORS solution as supplemental fluid with clinical dehydration: that rehydration is usually possible with ORS solution premixed ORS preferred due to risk of error (CPS) to give 50 ml/kg of ORS solution for rehydration plus maintenance volume over a 4-hour period to give this amount of ORS solution in small amounts, frequently to seek advice if the child refuses to drink the ORS solution or vomits persistently to continue breastfeeding as well as giving the ORS solution not to give other oral fluids unless advised not to give solid foods. after rehydration: drink plenty of their usual fluids, including milk feeds if these were stopped avoid fruit juices and carbonated drinks until the diarrhoea has stopped reintroduce the child’s usual diet give 5 ml/kg ORS solution after each large watery stool if you consider that the child is at increased risk of dehydration Disease prevention washing hands with soap (liquid if possible) in warm running water and careful drying are the most important factors in preventing the spread of gastroenteritis hands should be washed after going to the toilet (children) or changing nappies (parents/carers) and before preparing, serving or eating food towels used by infected children should not be shared children should not attend any school or other childcare facility while they have diarrhoea or vomiting caused by gastroenteritis children should not go back to their school or other childcare facility until at least 48 hours after the last episode of diarrhoea or vomiting children should not swim in swimming pools for 2 weeks after the last episode of diarrhoea. The post Gastroenteritis in Children appeared first on Family Pharm Podcast.

AAP Guideline on Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months http://pediatrics.aappublications.org/content/128/3/595.long UK NICE guideline: Urinary tract infection in children http://guidance.nice.org.uk/cg54 Summary: For children with fever, UTI should be suspected. For children at a very low risk for UTI, or greater than 3 years of age, a bag urine for urinalysis is an appropriate first step. If the urinalysis is suspicious for UTI, such as being positive for leukocyte esterase or nitrite, or if the children is not at a very low risk for UTI, then a catheterized urine sample should be obtained for urine culture prior to starting empiric antibiotics. If the culture comes back negative, then antibiotics treatment covering UTI can be stopped. Febrile UTI is presumed to be pyelonephritis, and should be investigated with Bladder and Renal Ultrasound. If the ultrasound shows structural abnormalities, or if the child has recurrent febrile UTIs, a VCUG should be considered, especially in younger children.   The post Pediatric UTI appeared first on Family Pharm Podcast.

Antiplatelets: ASA Clopidogrel Anticoagulants: Warfarin Apixaban Dabigatran Rivaroxaban Clotting Cascade: Clotting Factor Song, by Emily Anne Nagler: Twelve, eleven, nine, it’s clotting factor time 8 and 9 to 10a 5, that’s how we stay alive Don’t forget to say: the tissue factor way 7 to 7a helps 10 go to 10a Then 2 to thrombin, and 1 to fibrin And that’s how it ends   The post A Fib 5: Antithrombotics appeared first on Family Pharm Podcast.

Tina discusses the following rhythm control medications for atrial fibrillation: Class 3 antiarrhythmics: blocks potassium channels and prolongs action potential duration Amiodarone Dronedarone Sotalol Class 1 antiarrhythmics: blocks sodium channels, which results in a slowed atrial conduction, lengthens atrial refractoriness, and suppresses automaticity propafenone flecainide Indiana University’s P450 Drug Interaction Table: http://medicine.iupui.edu/clinpharm/ddis/clinical-table/ References: CCS Guideline www.onlinecjc.ca/article/S0828-282X(12)00046-3/fulltext UptoDate uptodate.com  e-CPS www.e-therapeutics.ca/ RXFiles www.rxfiles.ca Lexicomp www.lexi.com The post A Fib 4: Rhythm Control Medications appeared first on Family Pharm Podcast.

Tina discusses the following rate control medications for atrial fibrillation: Beta blockers Bisoprolol Metoprolol Atenolol Calcium channel blockers (non-dihydropyridines) verapamil diltiazem Digoxin   References: CCS Guideline www.onlinecjc.ca/article/S0828-282X(12)00046-3/fulltext UptoDate uptodate.com  e-CPS www.e-therapeutics.ca/ RXFiles www.rxfiles.ca Lexicomp www.lexi.com The post A Fib 3: Rate Control Medications appeared first on Family Pharm Podcast.

The CHADS2 and HAS-BLED predictive index are useful in assessing a patient’s thromboembolic risk and in predicting which antithrombotic therapy is most suitable; and that is either aspirin, clopidogrel, or anticoagulants. The 3 new anticoagulants may be simpler to use and may have less intracranial hemorrhage side effect than warfarin, there has been longer clinical experience with warfarin and an antidote is present if needed. As for rate control and rhythm control, there is no significant difference in controlling survival and mortality between the two. Therapy is chosen based on patient’s symptoms and preference. Rate control medications include BB, non-dihydropyridine CCB, and digoxin. And rhythm control includes dronedarone, flecainide, sotalol, and amiodarone. We will go over details of these medications in the next episode. Catheter ablation is mainly for symptom control. It may be first line for highly selected patients,  is often considered 2nd line after multiple drug therapy, or for patients who failed on multiple antiarrhythmic therapy and maintenance of sinus rhythm is still desired. Focused 2012 Update of the Canadian Cardiovascular Society Atrial Fibrillation Guidelines: Recommendations for Stroke Prevention and Rate/Rhythm Control http://www.onlinecjc.ca/article/S0828-282X(12)00046-3/fulltext The 2012 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Acute and Chronic Heart Failure http://www.onlinecjc.ca/article/S0828-282X%2812%2901379-7/abstract Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Catheter Ablation for Atrial Fibrillation/Atrial Flutter http://www.onlinecjc.ca/article/S0828-282X(10)00012-7/fulltext The post A Fib 2: CCS 2012 Treatment Guidelines appeared first on Family Pharm Podcast.

Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Etiology and Initial Investigations http://www.onlinecjc.ca/article/S0828-282X(10)00016-4/fulltext CHADS2 Score http://www.mdcalc.com/chads2-score-for-atrial-fibrillation-stroke-risk/ HAS-BLED Score http://www.mdcalc.com/has-bled-score-for-major-bleeding-risk/ Mayo Clinic on A Fib http://www.mayoclinic.org/diseases-conditions/atrial-fibrillation/basics/definition/con-20027014 The post A Fib 1: Etiology and Diagnosis appeared first on Family Pharm Podcast.

Tina revisits ACEI, ARB, BB, and Thiazides, which were covered previously with the hypertension episodes, and introduces a few new medications as well: Mineralocorticoid Receptor Antagonists: spironolactone and eplerenone Loop diuretic: furosemide Digoxin Vasodilators: hydralazine and isosorbite dinitrate For a quick summary of the CCS 2013 recommendations: ACE inhibitors: all asymptomatic patients with an EF < 35% all symptomatic HF patients and EF < 40% ARB: if intolerant to ACEI add to ACEI if intolerant or contraindicated for BB add to ACEI and BB if NYHA class II-IV HF and EF ? 40% deemed at increased risk of HF events BB: all HF patients with an EF ? 40% initiated at a low dose and titrated to the target dose or maximal tolerated dose MRA: patients > 55 years with mild to moderate HF during standard HF treatments with EF ? 30% (or ? 35% if QRS duration > 130 ms) and recent (6 months) hospitalization for CV disease or with elevated BNP or NT-proBNP levels after an MI with EF ? 30% and HF or EF ? 30% alone in the presence of diabetes EF < 30% and severe chronic HF (NYHA IIIB-IV) despite optimization of other recommended treatments Diuretics: for congestive symptoms When acute congestion is cleared, the lowest dose should be used that is compatible with stable signs and symptoms persistent volume overload despite optimal medical therapy and increases in loop diuretics, cautious addition of a second diuretic (a thiazide or low dose metolazone) may be considered as long as it is possible to closely monitor morning weight, renal function, and serum potassium Digoxin: patients in sinus rhythm who continue to have moderate to severe symptoms, despite optimized HF therapy patients with chronic atrial fibrillation (AF) and poor control of ventricular rate Isosorbide dinitrate and hydralazine: black Canadians with HF-REF non-black HF patients unable to tolerate an ACE inhibitor or ARB Drug information from: Drug monographs CPS: http://www.e-therapeutics.ca/ Therapeutic Choices: http://www.e-therapeutics.ca/ Rx Files: http://www.rxfiles.ca/rxfiles/modules/druginfoindex/druginfo.aspx The post CHF 2: medications appeared first on Family Pharm Podcast.

We turned our attention to chronic congestive heart failure (CHF) and reviewed “The 2012 Canadian Cardiovascular Society Heart Failure Management Guidelines Update“. National Institute of Health provided a great summary on CHF for patients and the public: http://www.nhlbi.nih.gov/health/health-topics/topics/hf/ For a basic anatomy review of the circulatory system: Anatomy of the heart. Source: Wikimedia.  For another diagram showing the heart in relation to the body, click here. And an over-simplification of the pathophysiology of left vs right heart failure is that when the left ventricle fails, not enough oxygenated blood gets pumps to the body to meet its demand. Instead, blood gets backed up into the lungs and cause fluid buildup in the lungs. This pressure can further back up into the right heart, such that the right ventricle and right atrium cannot accommodate a normal amount of venous return, and fluid can accumulate in the body to cause edema. Wikipedia strikes a good balance of depth and readability on this topic: http://en.wikipedia.org/wiki/Heart_failure The CCS guideline suggests the following investigations for CHF: CXR, echocardiography, BNP, labs (CBC, electrolytes, creatinine, urinalysis, glucose, thyroid function), and further testing (nuclear imaging, catheterization, stress test, MRI, CT, endomyocardial biopsy) if appropriate. The CCS guideline on treatment of chronic CHF: ACE inhibitors for: all symptomatic HF patients and EF < 40%. all patients with an EF < 35% Angiotensin receptor blocker: if patient intolerant to ACEI add to ACEI if intolerant or contraindicated for BB add to ACEI and BB if patient has NYHA class II-IV HF and EF ? 40% deemed at increased risk of HF events Beta blocker: all HF patients with an EF ? 40% initiated at a low dose and titrated to the target dose or maximal tolerated dose Mineralocorticoid receptor antagonist: EF <30% and one of the following: past MI and HF diabetes severe chronic HF (NYHA IIIB-IV) despite optimized treatment age >55 with HF symptoms on treatment and recent hospitalization for CV disease in the past 6 months (or if QRS duration > 130ms and EF <35%) with elevated BNP or NT-proBNP levels Diuretics: loop diuretic, such as furosemide, for most patients with HF and congestive symptoms. When acute congestion is cleared, the lowest dose should be used that is compatible with stable signs and symptoms persistent volume overload despite optimal medical therapy and increases in loop diuretics, cautious addition of a second diuretic (a thiazide or low dose metolazone) may be considered as long as it is possible to closely monitor morning weight, renal function, and serum potassium Digoxin: patients in sinus rhythm who continue to have moderate to severe symptoms, despite optimized HF therapy patients with chronic atrial fibrillation (AF) and poor control of ventricular rate Isosorbide dinitrate and hydralazine: black Canadians with HF-REF non-black HF patients unable to tolerate an ACE inhbitor or ARB The post CHF 1: CCS 2012 Guideline appeared first on Family Pharm Podcast.

Classes of insulin and different treatment regimens are discussed in the third episode of a 3-part series on diabetes. This episode also marks the conclusion of our coverage of the “Big Three” of modern medicine (hypertension, dyslipidemia, and diabetes), and with it, we make an official announcement of the launch of the Family Pharm Podcast to the world (aka Facebook)!   Class Drug Onset Peak Duration Very Rapid-acting Insulin Analogues insulin aspart (NovoRapid) 10–15 min 60–90 min 4–5 h insulin glulisine (Apidra) insulin lispro (Humalog) Rapid-acting Insulin insulin regular (Humulin R, Novolin ge Toronto) 30–60 min 2–4 h 5–8 h Intermediate-acting Insulin insulin NPH (Humulin N, Novolin ge NPH) 1–2 h 5–8 h 14–18 h Long-acting Insulin Analogues insulin detemir (Levemir) 1.5 h Flat, no discernible peak 24 h insulin glargine (Lantus) Mixed (regular/NPH) Human Insulin insulin regular/insulin NPH Humulin 30/70, Novolin ge 30/70, 40/60, 50/50 Combination of individual components Mixed Insulin Analogues insulin lispro/lispro protamine Humalog Mix25, Humalog Mix50 10–15 min Not available Not available Mixed Insulin Analogues insulin aspart/aspart protamine NovoMix 30 10–15 min 60–90 min 15–18 h Classes of insulin preparations. Adapted from Therapeutic Choices 6th edition. CDA guideline on insulin for Type 1 diabetes, including description of basal-bolus regimen by carb counting: http://guidelines.diabetes.ca/Browse/Chapter12 Examples of insulin regimens from CDA: http://guidelines.diabetes.ca/Browse/Appendices/Appendix3 Self monitoring: http://guidelines.diabetes.ca/executivesummary/ch9 The post Diabetes 3: Insulin and Official Launch appeared first on Family Pharm Podcast.

We reviewed the CDA 2013 guidelines on antihyperglycemic therapy for type 2 diabetes (http://guidelines.diabetes.ca/executivesummary/ch13), and explored the pharmacological properties of each of the major classes: Biguanides: Metformin Sulfonylureas: chlorpropamide, gliclazide, glimepiride, glyburide, and tolbutamide Thiazolidinediones: pioglitazone and rosiglitazone Meglitinides: Nateglinide and repaglinide Alpha-glucosidase inhibitors: Acarbose Dipeptidyl Peptidase-4 inhibitors (DPP4 inhibitors): Saxagliptin and sitagliptin Glucagon Like Peptide-1 Analogues (GLP-1 analogues): Liraglutide and Exenatide Drug information: Drug monographs CPS: http://www.e-therapeutics.ca/ Therapeutic Choices: http://www.e-therapeutics.ca/ Rx Files: http://www.rxfiles.ca/rxfiles/modules/druginfoindex/druginfo.aspx The post Diabetes 2: antihyperglycemics appeared first on Family Pharm Podcast.

To round up the “Big Three”, we turned out attention on diabetes. We reviewed the CDA guidelines on diabetes management and summarized the most relevant points that we think all family doctors and pharmacists would find interesting. http://guidelines.diabetes.ca/  The CDA also prepared many apps and calculators that help HCPs make clinical decisions. As well, there are many other clinical practice guidelines on many different aspects of the care of diabetes that we cannot cover in this podcast. We recommend listeners to visit the CDA website to get a fuller picture than our synopsis here. The post Diabetes 1: CDA 2013 Guideline appeared first on Family Pharm Podcast.

We explore pieces of important evidence that offer a contrasting view on lipid control from the national guidelines. We are also introducing a new EBM resource available to CMA members: InfoPOEMs, which highlights clinical studies that the editorial team finds relevant.  http://www.cma.ca/clinicalresources/infopoems Treatment group Tools for Practice 2013: “Is Diabetes a Coronary Heart Disease Equivalent?” http://www.acfp.ca/Portals/0/docs/TFP/20131021_093004.pdf “Though diabetes does confer an increased risk of CV events, it is not automatically equivalent to having experienced a myocardial infarction (MI) (and thus does not always warrant aggressive pharmacotherapy). CV risk should be predicted, and therapy guided, by taking into account individual risk factors.” InfoPOEM: “Limited data to guide lipid lowering in octogenarians” http://www.ncbi.nlm.nih.gov/pubmed/20952373 either extremes of cholesterol levels (low or high) are associated with increased mortality in patients >80 years old Non statin lipid medications Tools for Practice 2010: “Ezetimibe: Lowers LDL cholesterol but what else?” http://www.acfp.ca/Portals/0/docs/TFP/20111028_105411.pdf “Eight years after being licensed by the FDA, there is still no evidence that ezetimibe reduces cardiovascular outcomes. It may be worse than niacin and there is concern about a potential increased cancer mortality risk.” Tools for Practice 2012: “Niacin added to statins for cardiovascular disease? 1 + 1 = 1” http://www.acfp.ca/Portals/0/docs/TFP/20120502_095745.pdf “In patients with cardiovascular disease already on statin therapy, adding niacin does not improve cardiovascular events. Among lipid treatments, only statin monotherapy has strong evidence for CVD prevention (regardless of lipid levels).” Tools for Practice 2013: “Fibrates: Statin’s Trusty Sidekick or Lackluster Fallback?” http://www.acfp.ca/Portals/0/docs/TFP/20131007_090323.pdf “When used alone, fibrates reduce non-fatal coronary events, but have no effect on mortality or other CV events, including stroke. Current evidence suggests fibrates provide no advantage when added to statin therapy.” InfoPOEM: “Statins but not fibrates associated with lower risk of pancreatitis” http://www.ncbi.nlm.nih.gov/pubmed/22910758 statins significantly reduced risk of pancreatitis, where as fibrates did not Statin dosing and efficacy Cochrane 2014: “Statins for the primary prevention of cardiovascular disease” http://summaries.cochrane.org/CD004816/statins-for-the-primary-prevention-of-cardiovascular-disease “All-cause mortality was reduced by statins (OR 0.86, 95% CI 0.79 to 0.94); as was combined fatal and non-fatal CVD RR 0.75 (95% CI 0.70 to 0.81), combined fatal and non-fatal CHD events RR 0.73 (95% CI 0.67 to 0.80) and combined fatal and non-fatal stroke (RR 0.78, 95% CI 0.68 to 0.89). Reduction of revascularisation rates (RR 0.62, 95% CI 0.54 to 0.72) was also seen. [...] Evidence available to date showed that primary prevention with statins is likely to be cost-effective and may improve patient quality of life. Recent findings from the Cholesterol Treatment Trialists study using individual patient data meta-analysis indicate that these benefits are similar in people at lower (< 1% per year) risk of a major cardiovascular event.” InfoPOEM: “Statins of modest benefit for low- to moderate-risk persons (NNT ~ 80)”  http://www.ncbi.nlm.nih.gov/pubmed/21989464 for a patient group with a mean 10-year risk of cardiovascular death or MI around 6.2%, the NNT for all-cause mortality was 80, for any MI was 72, and for any stroke was 97 over 10 years of statin treatment InfoPOEM: “Statins for hyperlipidemia reduce all-cause mortality”  http://www.ncbi.nlm.nih.gov/pubmed/20934984 for patients with hyperlipidemia (LDL 180 mg/dL or 4.6mmol/L), and a mean follow up of 2.7 years, number needed to treat [NNT] to reduce 1 death = 67 Tools for Practice 2012: “How does high dose statin compare to low dose in people with heart disease?” http://www.acfp.ca/Portals/0/docs/TFP/20120522_090852.pdf “In patients with coronary heart disease, using high dose statins (compared to low-moderate dose) prevents one CHD event for every 91 patients but results in one in 47 patients discontinuing therapy due to adverse events. However, low-moderate dose statin (compared to placebo) provides 2-3 times greater benefit than increasing to high dose statin. Therefore, getting and keeping patients on any statin is key, with dose adjusted up to tolerable levels” Statin side effects InfoPOEM: “Does statins cause cognitive decline?” http://www.ncbi.nlm.nih.gov/pubmed/24000778 No. Statins are not associated with cognitive decline. Actually, in patients without baseline cognitive impairment, statin use is associated with slower cognitive decline. Tools for Practice 2013: “Statin-Induced Diabetes: Too Sweet a Deal?” http://www.acfp.ca/Portals/0/docs/TFP/20130527_014005.pdf “Statins modestly increase blood glucose, which leads to 1 in 250 or so patients crossing the “diabetic threshold” over 5 years. Pre-existing elevated sugars, other diabetes risk factors or higher doses may slightly increase the risk. This should not change statin prescribing as they reduce cardiovascular events and all-cause mortality in appropriate patients.” Additional tests InfoPOEM: “CRP of little value for risk stratification” http://www.ncbi.nlm.nih.gov/pubmed/23034020 “In patients with an intermediate 10-year risk of a cardiovascular event (10% – 20%), you would have to screen more than 440 with a C-reactive protein (CRP) test to prevent 1 [cardiovascular] event. This test is quite expensive: in the neighborhood of $100 or more at many laboratories (LOE = 2a)“ (Originally published on February 1, 2014) The post Dyslipidemia 4: EBM Special appeared first on Family Pharm Podcast.

We return to the topic of dyslipidemia and examined the: “2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults” http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a Previous episodes on statins can be found here. Major differences between AHA 2013 guideline and CCS 2012 guideline: CCS 2012 AHA 2013 Treatment Threshold LR (FRS<10%): consider lifestyle only IR (FRS 10-19%), if LDL <3.5mmol/L: consider lifestyle only Optional alternate target and secondary tests reasonable HR (FRS >20%), history of CVD, DM aged >40: statins LDL >5 mmol/L: statins CVD: statins LDL > 4.9 mmol/L: statins DM aged 40-75: statins 10-year risk >7.5%: statins Treatment Target LDL >50% reduction LDL < 2mmol/L for IR and HR groups No target Fixed dose statins based on initial risk assessment Pooled Cohort Equations to estimate 10-year CVD risk: http://www.cardiosource.org/science-and-quality/practice-guidelines-and-quality-standards/2013-prevention-guideline-tools.aspx Dr. McCormack’s discussion on patient centered EBM on KevinMD: http://www.kevinmd.com/blog/2013/12/cholesterol-guidelines-emphasize-patient-preference.html (Originally published on January 25, 2014) The post Dyslipidemia 3: AHA 2013 Guideline appeared first on Family Pharm Podcast.