Medication Classification Review

The Macstrak Project

Medication

Classification


IssuesMacstrak follows drug interventions by drug

class rather than the specific agent (e.g. B blocker po rather than metoprolol)

• to get reliable data first need to ensure understanding of where data captured on Macstrak form

• need to know proper drug classes • need to know the generic as well as trade names • accuracy in form completion improves as staff become

more comfortable with knowing the drug classes• teaching resources available for staff on Macstrak

website


In this presentation

1. Review – where data collected on Macstrak forms

2. Understand – description of each drug class

3. Review– tables of generic versus brand name

4. Learn – resources available for on-going support


Yes Thrombolysis Here EMS Other Hosp

Dose: (mg/units)

Duration: (min)

Pt.Weight: (kg)

Reperfusion Therapy: No Not Indicated: ECG Not Diag. ST Up Transient Too Late Given (Other Hosp)

Risk: Risk of ICB Risk Other Bleed Other: ……………......

Drug: TNK/rtPASKr-PA (reteplase)Other

Adjuvant: ASA Heparin GP2b/3a Inhibitor blocker IV Clopidogrel Other ...............................

and/or Primary/Rescue PCI Here Transfer Reperfusion Therapy Decided by: EP Consultant

Yes Thrombolysis Here EMS Other Hosp

Dose: (mg/units)

Duration: (min)

Pt.Weight: (kg)

Review - Macstrak Form

Three sections where medications tracked on the CCU form:1. ACS Initial Management – Adjuvant Therapy


Acuity: Shift: Diuretics……………………… Inotropes IV………………….. ETT/Vent…………………….. PA Line………………………. TTVP………………………… IABP………………………….ACS: RSCP - Ischemia – Definite….

– Probable… CK (+ve)………………...…… Troponin (+ve)……………….. NTG IV………………………. Heparin – UFH……………..... – LMWH……………. Other Antithrombin………...… GP 2b/3a Inhibitor IV……...… Clopidogrel (or thienopyridne)..… Cardiac Cath……………….... PCI…………………………... Outcomes: VF/Sustained VT………….… Infarction (new/repeat)*(1) …... Thrombolysis (new/repeat)*(2)..

Stroke*(3) ……………………. Major Bleed*(4) ……………… Transfusion………………….. Crs1: ……………………….... Crs2: ……………………..….. None of the Above……….….. RN Initials ………………..….

Date: D N D N ND


Three sections where medications tracked on the CCU form:

1. ACS Initial Management – Adjuvant Therapy

2. Course in CCUNone of the Above needs to be markedif no medication/treatments are given – lets us know that the information is not missing.


Discharge Meds: ASA Clopidogrel (thienopyridine) Heparin (UF or LMW) Nitrates (po/top) B Blocker ACEI A2 Blocker Statin None of the Above

Review - Macstrak FormThree sections where

medications are tracked on the CCU form:

1. ACS Initial Management – Adjuvant Therapy

2. Course in CCU3. CCU DischargeNone of the Above needs to be marked

if no medication is given – lets usknow that the information is not missing.



One section where medications are tracked on the ER form:

1. Course in ER

ACS Management: (all) ASA Heparin UFH Heparin LMWH Clopidogrel (thienopyridine)

GP2b/3a Inhibitor IV Other Antithrombin NTG IV NTG topical/po Blocker IV Blocker po Calcium Antagonist (any) ACEI A2 Blocker Research Protocol None of the Above

None of the Above needs to be markedif no medication is given – lets usknow that the information is not missing.Optional fields are available to track specific medications if your unit wishes.



One section where medications are tracked on the Ward form:

1. Course in Ward

Drugs: PTA PTW Ward Disch

ASA ……………………………………………………. Coumadin ………………………………………. Heparin UFH ……………………………. Heparin LMWH ………………………… Clopidogrel (thienopyridine) ……..……. GP 2b/3a Inhibitor (IV) …………… Other Antithrombin …….…………… Oral Hypoglycemic ………………… Insulin ………………………………………………. Statin …………………………………………………. Other Antilipid …………………………... Bronchodilator …………………………… Digoxin ……………………………………………. Any Antiarrhythmic ………………. Calcium Antag …………………………… ACEI .…………………………………………………… A2 blocker ………………………………………. Other Vasodilator ……...………………. Diuretic ……………………….……………………... Nitrates top/oral ………………………….. Nitrates IV ……………………………….……... Blocker - Any …………………………... Blocker - Carvedilol …………... Study Drug - antiplatelet …... - antithrombin . - other …………………. Smoking ………………………………………….. ……………………………..….. HRT ……………………………………………………. ……………… ……………..….. Optional Fields: Crs1: …………………………….. Crs2: …………………………….. Crs3: …………………………….. Crs4: …………………………….. None of the Above …………………..

RN Initials ……………………………………..

None of the Above needs to be markedif no medication is given – lets usknow that the information is not missing.

Optional fields are available to track specific medications if your unit wishes.


Thienopyridines - What & How

• oral anti platelet therapy

• indications:– ACS– stents– aspirin is not tolerated– dual anti platelet therapy desired

• ADP-receptor antagonist

• binds irreversibly to P2Y12 receptors, modify the platelet

P2Y12 receptor therefore ADP can’t bind to it

• reduces platelet aggregation that persists for the life of the platelets


Thienopyridines -Who

Generic Name

Brand Name

clopidogrel Plavix®

ticlopidine Ticlid®

prasugrel Effient *

* Drug has not yet come to market.


GP2b/3a inhibitors -What• anti platelet therapy IV

• indications:– ACS– PCI

• final step in platelet aggregation - binding of fibrinogen between two platelets at the GP2b/3a receptor, inhibitors block this final pathway, decreasing platelet aggregation regardless of the mechanism by which the platelets are activated

• issue for all these therapies has been determining effective dosing


GP2b/3a inhibitors - How


GP2b/3a inhibitors - Who

Generic Name

Brand Name

abciximab Reopro®

eptifibatide Integrillin®

tirofiban Aggrastat®


UF Heparin - What & How• antithrombin

• indications:– ACS– atrial fibrillation– deep vein thrombosis– pulmonary embolism

• UF Heparin binds to the enzyme inhibitor antithrombin (AT) causing a conformational change that results in its activation through an increase in the flexibility of its reactive site loop

• activated AT then inactivates thrombin, with also a lesser effect on factor Xa


LMW Heparins - What & How• antithrombin

• indications:– ACS– atrial fibrillation– deep vein thrombosis– pulmonary embolism

• sub group of proteins included in UFH

• although all different protein groups - they have a greater effect on anti factor Xa

• PT/PTT cannot be used to follow

• they are not bound to acute phase reactants therefore dose response is more predictable


Heparins - WhoGeneric Name Brand Nameheparin (unfractionated)

Hepalean®

enoxaparin Lovenox®

dalteparin Fragmin®

tinzaparin Innohep®


• mostly direct thrombin inhibitors but a variety of targets

• indications:– heparin-induced thrombocytopenia (HIT)– PCI– ACS

• most are intravenous only exception coumadin

• new oral agents in development

Other Antithrombins–What & How


Generic Name Brand Nameargatroban Argatroban ®

bivalirudin Angiomax®

lepirudin Refludan®

danaparoid Organon®

fondaparinux Arixtra ®

warfarin Coumadin®

dabigatran Pradaxa *

Other Antithrombins - Who

* Drug has not yet come to market.


β-blockers - What & How• beta (alpha) adrenergic receptor antagonists

• indications:– arrhythmias– AMI cardioprotection– decrease incidence of occlusion events

• fight or flight block the action of endogenous catecholamines (epinephrine – adrenalin and norepinephrine – noradrenaline) on β-adrenergic receptors part of the sympathetic nervous system

• cardioprotection, management of cardiac arrhythmias, blocks activation of clotting system

• reduces the sympathetic activation of platelets, and the clotting system (PAI-1)


β-blockers - WhoGeneric Name

Brand Name

acebutalol Sectral®

atenolol Tenormin®

carvedilol Coreg®

labetalol Trandate®

metoprolol Lopresor®

nadolol Corgard®

propanolol Inderal®

sotalol Sotacor®

bisoprolol Monocor®


ACE inhibitors - What• Angiotensin-Converting Enzyme inhibitor decreasing

the activation of the renin/angiotensin system

• indications:– prevention of cardiovascular events– CHF– hypertension– left ventricular dysfunction

• Reduces PAI-1 levels to decrease clot formation• reduces afterload, lowers arteriolar resistance,

decreases cardiac work and oxygen demand• lowers renovascular resistance, increases natriuresis

(excretion of sodium in urine)


ACE inhibitors - How


ACE inhibitors - WhoGeneric Name

Brand Name

benazepril Lotensin®

captopril Capoten®

cilazapril Inhibace®

enalapril Vasotec®

fosinopril Monopril®

lisinopril Prinivil®, Zestril®

quinipril Accupril®

ramipril Altace®


A2 blockers - What & How• angiotensin receptor blocker

• indications:– hypertension - intolerance to ACE inhibitors

• modulate the renin-angiotensin-aldosterone system by blocking activation of angiotensin II AT1 receptors causes vasodilation

• effects are similar to ACEI but no cough as do not inhibit the breakdown of bradykinin or other kinins


A2 blockers - WhoGeneric Name Brand Namecandesartan Atacand®

irbesartan Avapro®

losartan Cozaar®

telmisartan Micardis®

valsartan Diovan®


Statins - What & How• cholesterol lowering agent - reduces inflammation

• indications:– reducing LDL cholesterol– ACS secondary prevention– CAD primary prevention high-risk groups

• statins block an enzyme (HMG-CoA reductase) involved in producing cholesterol within liver cells

• stimulates LDL receptor results in an increased clearance of low-density lipoprotein (LDL) from the bloodstream and a decrease in blood cholesterol levels


Statins - WhoGeneric Name

Brand Name

fluvastatin Lescol®

lovastatin Mevacor®

pravastatin Pravachol®

simvastatin Zocor®

atorvastatin Lipitor®


Diuretics - What & How

• Increase natriuresis – renal excretion of sodium

• indications:– heart failure– hypertension

• act at a variety of targets within the nephron

• each class has a different specific mechanism of action, but typically share outcome of changing the way the kidneys handle salt - inhibit sodium re-absorption lowering blood pressure and cardiac workload


Diuretics - WhoGeneric Name

Brand Name

furosemide Lasix®

ethacrynic acid Edecrin®

bumetanide Burinex®

chlorothiazide Diuril®

hydrochlorothiazide

HydroDiuril®, Esidrix®

indampimide Lozol®

metolazone Zaroxolyn®

chlorthalidone Hygroton®

spironolactone Aldactone®


Nitrates - What• vasodilation - venous

• indications:– AMI– ischaemic heart disease– heart failure– pulmonary edema– hypertension

• increase venous capacitance reduces venous return, reducing preload

• dilate coronary blood vessels improves O2 supply to the myocardium

• dilate peripheral arteries reduces afterload and work done by the heart


Nitrates - How


Nitrates - WhoGeneric Name

Brand Name

nitroglycerin IV Nitroglycerin IV ®

isosorbide dinitrate SL

Isordil®

nitroglycerin ointment

Nitrobid®, Nitiol®

nitroglycerin patches

Transderm-Nitro®, Nitro-Dur®,Nitrodisc®

isosorbide dinitrate po

Isordil®


Inotropes - What & How

• positive inotropic agents increase myocardial contractility

• indications:– cardiogenic shock - hypotension – AMI– CHF

• effects are dose-dependant

• increases cardiac output and blood pressure


Inotropes - WhoGeneric Name

Brand Name

dopamine Intropin®

dobutamine Dobutrex®

epinephrine Epinephrine®

norepinephrine Levophed®

milrinone Primacor® isoproterenol Isuprel®


Calcium Antagonists - What & How

• negative inotropic effect - decreases myocardial contractility, increases vasodilation

• indications:– hypertension– angina– atrial fibrillation/flutter

• block volt-gated calcium channels in muscle cells – calcium levels drop – less muscle contraction

• Decrease blood pressure, reduces afterload decreasing amount of oxygen required by heart

• does not decrease the responsiveness of the heart to input from the sympathetic nervous system


Generic Name

Brand Name

amlodipine Norvasc®

diltiazem Cardizem®

nicardipine Cardene®

nifedipine Procardia®

verapamil Isoptin®

felodipine Plendil®

Calcium Antagonists - Who


ResourcesThe following are ways to ensure staff knowledge of drug

classifications anddrug penetrance is at suggested guideline levels:

• Macstrak unit manual – make available at nursing station – available on website

• Medication List – post in rooms or nursing station – available on website

• Macstrak Quarterly or Macstrak Nursing News – available on website

• Reports – review penetrance

• Audits – Project Office will notify coordinator if on-going issues

Medication Classification Review

Documents

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