by clicking the arrows at the side of the page, or by using the toolbar.
by clicking anywhere on the page.
by dragging the page around when zoomed in.
by clicking anywhere on the page when zoomed in.
web sites or send emails by clicking on hyperlinks.
Email this page to a friend
Search this issue
Index - jump to page or section
Archive - view past issues
Australian Journal of Pharmacy : March 2005
tinuity of care, poor communication between healthcare professionals and the patient/ family, poor social support, the changing healthcare environment and a failure to take a holistic approach to the patient’s health. Drug-related problems Many of the issues related to adverse car- diovascular outcomes are drug-related and may be due to poor medication adherence, adverse drug effects, polypharmacy, use of contraindicated medications, and inadequate prescribing and dosing of medications known to reduce mortality and morbidity. Issues for consumers Consultations with consumers regarding the management of polypharmacy have also raised issues regarding communica- tion, the need for timely and independent advice and information, and a lack of appreciation of the practical difficulties consumers face when managing complex medication regimens on a long-term, day- to-day basis.23 In line with quality use of medicines (QUM) principles, consumers desire greater involvement in their care and care of their loved ones.24 Important factors related to medication use in cardiovascular conditions • Poor adherence, for example long-term statin use,25 • Poor patient knowledge. For example role of medications and self-care strate- gies in HF management.27,31 • Adverse effects. 32 statin-induced myopathy,35 post acute coronary syn- drome therapy,26 HF therapy,27–29 asymptomatic conditions such as hypertension.30 Examples of adverse effects involving CV medications include electrolyte disturbances with diuretics and potassium-sparing diuret- ics,33,34 pul- monary toxicity with amiodarone,36 potential adverse cardiovascular effects of hormone replacement therapy37 COX-2 inhibitors.38 and • Drug interactions, for example ‘triple whammy’ effect of ACE inhibitors, diuretics and NSAIDs on renal func- tion.39 Other commonly involved med- ications include warfarin as well as complementary and alternative med- ications (CAM). • Sub-optimal therapy including: low prescribing rates of medications known to reduce mortality and mor- bidity in HF, ACE inhibitors and beta- blockers,20,21,40,42 under-prescribing of beta-blockers post-myocardial infarct43 atrial fibrillation.44 low dose, for example statin use in high-risk CVD patients45 dose use of ACE inhibitors40,46,47 beta-blockers in HF.20,21,42,47 and low and use of inappropriate/contraindi- cated medications: this includes pre- scription medications such as non- dihydropyridine calcium antagonists in systolic HF48 counter medications such as bowel- cleansing products,50 anti-anginal medications,41 low use of and low warfarin use in therapy and clopidogrel therapy post stent implantation do not take into account recent trial data and guide- line recommendations (Schedule of Pharmaceutical Benefits August 2004); new medicines are costly and pro- motion can lead to a blow-out in medication costs (for example, the Australian COX-2 inhibitor experi- ence). The number of TGA regis- tered drugs has increased three-fold in the last decade. • Prescriber knowledge including lack of knowledge regarding benefits of ther- apy and previous training regarding use of beta-blockers in HF patients.51,52 Quality use of medicines in heart failure: an example of pharmacist involvement and COX-2 inhibitors49 in heart failure; over-the- decongestants, high salt content medications such as effervescent antacids, urinary alka- linisers and NSAIDs, and comple- mentary and alternative medications (CAM) such as licorice or willowbark. • Increasing medication complexity. It should be noted that: the majority of patients suffering a myocardial infarct will require four medications;26 HF is a multifactorial disease result- ing from activation of a number of neurohormonal systems. Complex drug therapy is required to attenuate these activated systems. HF patients are generally elderly with multiple co-morbidities requiring therapies.; a number of medications used in car- diovascular conditions have narrow therapeutic indexes, carry a high risk of medication misadventure and require intensive monitoring (for example warfarin and digoxin, and co-ordinated care). • Increasing costs. Some factors which may have repercussions for future ther- apies include: current subsidised benefits for statin Recent studies by Bennett et al provide local data47 that confirm many of the issues described above. These results high- light the importance of the Quality Use of Medicines (QUM) approach in the man- agement of heart failure patients. Using such an approach, a coordinated service, the St Vincent’s Hospital Heart Failure Service, was devised to involve the patient and community and hospital-based healthcare professionals. This service is led by a medical director and consists of HF specialist nurses, a pharmacist, occupa- tional therapist and physiotherapist. The pharmacist’s role included educa- tion regarding HF, the role of medication and self-care measures, detection of con- traindicated medications, promotion of dosage aids where appropriate, medica- tion review and liaison with other health- care professionals. A review of the HF service47 showed patients had a median age of 75 years, 66 per cent were male and 74 per cent had left ventricular ejections fractions <40 per cent with ischaemic cardiomyopathy the most common aetiology. Patients had an average of 7.3 diag- noses and were taking an average of 9.5 regular medications daily, two-thirds of which were cardiac medication. Many patients had a number of co-morbidities (Figure One). Twenty-five per cent of THE AUSTRALIAN JOURNAL OF PHARMACY VOL.86 MARCH 2005 ? 167