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Family Medicine & Pharmacy Podcast

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Hypertension 3: antihypertensives

Listen to Tina the pharmacist discuss the 5 first-line antihypertensives: Thiazides ACE Inhibitors Angiotensin Receptor Blockers Beta Blockers Calcium Channel Blockers She lists the mechanism of action, dosing, side effects, drug interactions, and cautionary notes of each drug classes and their representative drug. This episode is wrapped up with Billy’s summary of the learning points from the 3-episode series on Hypertension: essential hypertension is a diagnosis of exclusion. we need to consider treatable causes of hypertension especially for people who do not have the usual risk factors. diagnosing a patient with hypertension is a careful process. for those without comorbidities or cardiovascular treatment, it can take a many as 5 visits averaging a BP of 140/90 to make a diagnosis. use home BP measurement if you suspect white coat hypertension. the treatment threshold for uncomplicated patients is 160/100, and threshold for those with end organ damage or increased CV risk is 140/90. a trial of lifestyle management to control BP is appropriate for most uncomplicated patients. it should always be a part of the management plan even for those who are on medication. Treatment target is 140/90, unless the patient has diabetes, for this the threshold is 130/80. For an elderly patient above 80 yo, systolic treatment target is 150 the first line agents are thiazides, ACEI, ARB, BB, and CCB. specific agents may be indicated for specific comorbidities antihypertensive are among the most commonly used medications, but one must not forget that they carry many potentially serious side effects and can interact with other medications. when in doubt, consult your favorite pharmacist The post Hypertension 3: antihypertensives appeared first on Family Pharm Podcast.

17mins

4 Nov 2013

Rank #1

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CHF 1: CCS 2012 Guideline

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.

20mins

5 Jan 2014

Rank #2

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CHF 2: medications

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.

21mins

11 Jan 2014

Rank #3

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Diabetes 1: CDA 2013 Guideline

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.

18mins

16 Dec 2013

Rank #4

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A Fib 5: Antithrombotics

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.

33mins

3 Mar 2014

Rank #5

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ADHD 1: CADDRA Guideline

*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.

16mins

31 Mar 2014

Rank #6

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Diabetes 2: antihyperglycemics

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.

23mins

22 Dec 2013

Rank #7

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Hypertension 2: CHEP 2013 Guideline cont.

We looked to the CHEP guidelines again for their recommendations on hypertension treatment thresholds, targets, lifestyle management, pharmacologic treatments, and suggested medications for specific comorbidities. Treatment guidelines on CHEP: http://www.hypertension.ca/chep DASH diet: http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3862329/k.4F4/Healthy_living__The_DASH_Diet_to_lower_blood_pressure.htm The post Hypertension 2: CHEP 2013 Guideline cont. appeared first on Family Pharm Podcast.

14mins

4 Nov 2013

Rank #8

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Gastroenteritis in Children

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.

19mins

22 Mar 2014

Rank #9

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A Fib 1: Etiology and Diagnosis

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.

17mins

9 Feb 2014

Rank #10