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Drugs and Labs, what needs to be monitored?

Drugs and Labs, what needs to be monitored?. Jennifer Rodgers, MSN, ARNP Wichita State University. DRUGS & LABS. We are a testing society Over 1100 tests to pick from RIGHT TEST RIGHT PATIENT Don’t get a test you don’t want the answer too Is the patient willing to participate?.

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Drugs and Labs, what needs to be monitored?

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  1. Drugs and Labs, what needs to be monitored? Jennifer Rodgers, MSN, ARNP Wichita State University

  2. DRUGS & LABS • We are a testing society • Over 1100 tests to pick from • RIGHT TEST RIGHT PATIENT • Don’t get a test you don’t want the answer too • Is the patient willing to participate?

  3. DRUGS & LABS • Insurance companies demand we have a code for every test • Be cost effective- What test will give me the most information with the least amount of $$$? • Understand lab values & also validity and sensitivity of the tests you are ordering

  4. DRUGS & LABS • Let the guidelines, patient clinical picture, & your experiences guide you • Remember NO test takes the place of a thorough history and physical exam • If you do it in the right order History & PE will guide you

  5. DRUGS & LABS • 84 Year Old Male Severe COPD, Weight Loss, Chronic Hypoxemia, HTN, History of Afib & Pulm. Embolism on Coumadin • HPI: Over past 2 months has been slowly declining several hospitalizations for COPD Exac. weakness, 20 # weight loss, fatigue • Presented to the office with hemoptysis & weakness

  6. 84 YEAR OLD MALE • PE: Pale, Ill appearing increased dyspnea from baseline • Lab Hgb 8.0 INR>80 seconds • VS Afebrile 110/60 110 SpO2 90% on 4 Liters

  7. 84 YEAR OLD MALE • Obviously Admit, Reverse Coumadin with FFP & Vitamin K • Coumadin needs careful monitoring & patient education • So often the elderly are the ones taking this unpredictable medicine

  8. PROTIME w/INR • International Normalized Ratio System • Factors that can alter: Heparin/LMH/ Coumadin, Liver Failure/Tumor, DIC, Vit K deficiency, ETOH intake, Malabsorption Disorders, Diet, Other medications

  9. THERAPEUTIC INR WITH COUMADIN TREATMENT • DVT prophylaxis1.5-2.0 • ORTHO. SURGERY2.0-3.0 • DVT2.0-3.0 • A-FIB prophylaxis2.0-3.0 • PE2.0-3.0 • Prosthetic Valve2.5-3.5 Adapted from: Mosby’s Manual of Diagnostic & Laboratory Tests. (2nd Ed.). (2002). 112.

  10. HOW TO MONITOR? • ½ Life is 20-60 hours • Peak time 5-7 days • Bridge with LWH or SQ Heparin • Timing of Lab Test has to match half life of drug • Have a system for adjusting or reversing otherwise you will chase your tail!

  11. Coumadin with Hypercoagulation • How to reverse or adjust? • > 7 OR symptomatic FFP/Vit. K 5-10 mg • 4-7 Hold X 1 day decrease by 20% • 3.6-4 Hold X 1 day decrease by 15% • 3-3.5 decrease by 10% • 3 day ½ life • Follow protimes closely, Patient Education

  12. COUMADIN OTHER THOUGHTS • If you can’t regulate someone think about why? • Where metabolized? > Liver • Problem in the Liver? • 84 year old male • ? Why so hypercoagulable

  13. COUMADIN OTHER THOUGHTS • 84 Year old male- Remember unintentional weight loss, then developed persistent nausea to the point could not eat or drink, even water bothered • +RUQ pain • What tests do we want? GB Sono>stones • HIDA Scan> normal GB • CT Abd Pelvis>Large Hepatic Lesion

  14. COUMADIN OTHER THOUGHTS • So….Liver Bx + for Cancer with Mets • Sad outcome>however after being stable on Coumadin therapy for 5 years, that explains hypercoagulation, wt. loss, general decline in condition • Remember to always put the puzzle together, look at whole patient not just abnormal lab test!

  15. COUMADIN OTHER THOUGHTS • 92 year old female on Coumadin for Afib • INR remains 1.0 seconds even after adjusting dose • Nursing Home confirms she is getting the medication daily • On 10 Mg Coumadin/daily still normal INR???

  16. COUMADIN OTHER THOUGHTS • Look further….she was getting the medication daily, but on further investigation she was pocketing pills and not swallowing anything!!! • Then you discuss with DPOA, patients wishes risk/benefit of the meds

  17. DRUGS & LABS • 78 year old female 2 months S/P CABG presents with lethargy, bradycardia, has been in nursing home since surgery, prior to that leaving independently at home • She has been getting progressively weak, less interactive with staff, decreased appetite

  18. DRUGS & LABS • What drug might be the cause? • What do you know about Amiodarone?

  19. AMIODARONE • Very effective Anti-arrhythmic that slowly loads into multiple tissues in the body it is slow to “load” & slow to clear • Not excreted by liver or kidneys but through body tissue containing Amiodarone cells i.e. skin, GI etc. • So even when stopped remains in the body weeks to months

  20. AMIODARONE • This 78 year female developed Afib post CABG & was started on Amiodarone • ? Cause of symptoms • 1-3 % of patients can develop thyroid dysfunction after starting on Amiodarone (hyper or hypo) • So…look at whole patient

  21. AMIODARONE • Check TSH Sensitivity 89-95% Specificity 90-96% • 78 year old female TSH 30.6 (2-10) • Confirm with Free T4 • This patients symptoms & decline were from Amiodarone induced hypothyroidism • Start levothyroxine, slow to load recheck 6-8 weeks, not sooner • Stop Amiodarone!!

  22. AMIODARONE OTHER THOUGHTS • 78 year old female 1 month later, much improved ambulating, eating, alert, nearly back to baseline • It can also Cause Pulmonary Toxicity/Fibrosis 4-9% • Review side effects!!

  23. DRUGS & LABS • TSH-Used to differentiate between primary hypothyroidism & secondary (pituitary) hypothyroidism • 2-10 nml range • Goal in suppression (HYPER) therapy <2 • If screening & TSH abnormal check free T4 • REMEMBER INVERSE TSH < = hyper TSH> = hypo

  24. DRUGS & LABS • Free T4-unbound T4 that enters the cell & is metabolically active >true reflection hormonal status • If < FT4=hypothyroid <0.8 ng/dl • >FT4=hyperthyroid >2.4 ng/dl

  25. DRUGS & LABS • If can’t keep euthyroid on levothyroxine • TSH too high- Adherence? Dose too low? Drug Interaction? • TSH too low- Dose too high? Taking more than prescribed?

  26. WHAT ABOUT STATINS? • Work by inhibiting HMG Co-A reductase >reduces the livers ability to make cholesterol • In addition, reduce plaque size in the artery, decrease clot formation, & decrease CRP levels • Impact LDL, Triglyercides, & to a small degree HDL

  27. WHAT ABOUT STATINS? • Causes LFT elevation 1 in 100 patients • Causes myopathy in 1 in 1000 patients • Most serious avoid rhabdomyolysis • In patient with normal liver (no fatty liver, cholestatic or obstructive jaundice, chronic hepatitis, alcoholic hepatitis, or inflammatory disease of the heart or skeletal muscle) should have normal LFT’s

  28. WHAT ABOUT STATINS? • In patients with asymptomatic hepatocellular dysfunction, an elevation of ALT or AST 2-3 times normal therapy should not be started or if taking statin discontinued. • Pre-treatment baseline LFT’s CK • Recommendations are to obtain LFT’s within 6 weeks of initiating therapy

  29. WHAT ABOUT STATINS? • aspartate aminotransferase (AST) test is the most sensitive marker of the impact of statins and other dyslipidemic agents. • AST should not be elevated more than 2-3 times the ULN.

  30. WHAT ABOUT STATINS? • Avoid concomitant use of clarithromycin, fluconazole, erythromycin, ketoconazole, rifampin, itraconazole, terbinafine, verapamil, and amiodarone. • The combination of these medications and lipid-lowering agents will significantly increase the possibility of Statin Induced Myopathy.

  31. INCREASED RISK FOR STATIN INDUCED MYOPATHY • > 80 years old (women>men) • Small Frame & Fragility • CKD, Diabetes • Polypharmacy • Perioperative Periods • Alcohol Abuse (independent predisposing factor) • Follow ATP III guidelines & don’t exceed recommended doses & treat cautiously in pts at increased risk http://www.nhlbi.nih.gov/guidelines/cholesterol/statins.pdf retrieved 05/21/10

  32. WHAT ABOUT THE STATINS? • If myopathy occurs, obtain CK level & compare to pre-statin level • If >10 times normal dc statin • If 3-10 times normal < dose or give drug holiday & follow until resolved • Thyroid disease predisposing factor to myopathy also check TSH

  33. WHAT ABOUT RHABDO?MOST COMMON SYMPTOMS • Muscular: muscle pain, weakness, tenderness, and stiffness. These symptoms occur 50% of the time with muscular symptoms and signs occurring in the large muscles of the thighs, calves, and lower back. The affected muscles become swollen and tender on palpation.[2-4] • Urinary: The most significant diagnostic feature is the change in color of the urine. Dark urine, typically brown, is often the first clue to the diagnosis of rhabdomyolysis.[2-4] • Constitutional: These symptoms vary widely. The most common symptoms are generalized malaise, fever, tachycardia, nausea, and vomiting.[2-4] Pasternak RC, Smith SC Jr, Bairey-Merz CN, Grundy SM, Cleeman JI, Lenfant C. ACC/AHA/NHLBI clinical advisory on the use and safety of statins. J Am Coll Cardiol. 2002;40:568-572

  34. WHAT ABOUT RHABDO? • If suspected, stop Lipid Lowering agents • STAT lab LFT’s CK, & CPK • CPK most important diagnostic criteria • If >10 times normal cause for concern Phillips PS, Haas RH, Bannykh S, et al. Statin-associated myopathy with normal creatine kinase levels. Ann Intern Med. 2002;137:581-585. Pasternak RC, Smith SC Jr, Bairey-Merz CN, Grundy SM, Cleeman JI, Lenfant C. ACC/AHA/NHLBI clinical advisory on the use and safety of statins. J Am Coll Cardiol. 2002;40:568-572

  35. DRUGS & LABS • alanine aminotransferase (ALT) less sensitive to statin • Excellent for evaluating “fatty liver” or steatohepatitis • Usually related to medication, obesity, alcohol intake, starvation, diabetes, or high blood triglycerides

  36. DRUGS & LABS • AST-Think statins • ALT-Think diabetic meds like Avandia, Actos • Statins have best effect on lipids if taken at night.

  37. DRUGS & LABS • 85 year old female over past week increased fatigue, weakness, headache, blurred vision & diplopia • In addition, family has noticed increased confusion

  38. 85 YEAR OLD FEMALE • VS Afebrile 120/70 80 SR with Trigeminal PVC’s, SpO2 92% 2 Liters • PE Ill appearing elderly female, confused, lethargic • Patient then became unresponsive and the cardiac monitor revealed…..

  39. WHAT DRUG SHOULD WE BE THINKING ABOUT AS WE CODE THIS PATIENT?

  40. 85 YEAR OLD FEMALE • DIGOXIN…patient had been taking for the past 10 years without incidence. • 0.4% of all hospital admissions, 1.1% of outpatients, & 10-18% of nursing home patients on Digoxin develop toxicity. • 2007 Annual Report of the American Association of Poison Control Centers 2565 Digatalis exposures reported with 10 deaths • http://emedicine.medscape.com/article/814404-overview Retrieved 5/25/10

  41. Digoxin Toxicity • Normal Range 0.5-2 ng/mL • 50% mortality of Digoxin Level > 6ng/ml • Usually caused by dehydration, electrolyte imbalances, decreased renal function, or drug interactions, new onset hypothyroidism, & AMI

  42. Drugs/supplements that can cause Digoxin Toxicity • Amiodarone, Amiloride, Beta Blockers, Calcium Channel Blockers, Erythromycin, Cyclosporine, HTCZ, Spironolactone, Triameterene, Loop Diuretics, Amphotericin B, Succinylcholine • Ephedra (cardiac stimulation), natural licorice (sodium retention & potassium loss)

  43. DIGOXIN TOXICITY REVERSAL Treatment based on clinical course of patient Oxygen, cardiac monitoring, IV access Digibind if Altered mental status, arrhythmias with hemodynamic instability, Potassium >5, or Serum Dig. Level > 10 ng/ml

  44. DIGOXIN TOXICITY REVERSAL • Lidocaine & phenytoin in ventricular arrhythmias >depress ventricular automaticity without significantly slowing AV conduction • Quinidine, procainamide, and bretylium are contraindicated • Cardioversion is usually contraindicated, it may precipitate Vfib or Asystole

  45. DRUGS & LABS • When you see neutropenia, thrombocytopenia, leukopenia, or leukocytosis, always ask yourself is there a medication that is causing this? • Use resources or clinical PharmD. to research this if you don’t know the answer

  46. NEUTROPENIA REVIEW • An ANC of less than 1500 per microliter (1500/microL) is the generally accepted definition of neutropenia. • Neutropenia is sometimes further classified as: Mild if the ANC ranges from 1000-1500/microL Moderate with an ANC of 500-1000/microL Severe if the ANC is below 500/microL (Agranulocytosis ) • ANC (Absolute Neutrophil Count)=WBC X (% Neutrophils + % Bands)

  47. DRUG INDUCED NEUTROPENIA • Causative drug was given within 4 weeks of the onset of neutropenia. • Once drug discontinued, usually neutropenia is corrected within 30 days.

  48. DRUG CAUSES OF NEUTROPENIA • Chemotherapy • Immunosuppressive agents • B-lactam antibiotics • PTU • Carbamazepine, Phenothiazines, Phenytoin • Psychotropic Drugs

  49. DRUG CAUSES OF THROMBOCYTOPENIA • Platelet count <150,000 • Early signs Bruising, petechiae, epitaxis • Unfractionated Heparin, Thiazide diuretics, Cimetidine, Sulfonamides, Quinine, Phenytoin, Vancomycin, B-lactam antibiotics, Levaquin, Digoxin, Valporic acid • Improvement within 3-7 days after dc

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