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  • Mur

    a- what would you do?
    is it reasonable to have 4 anti-anginal drugs prescribed together for an elderly?(>70 years old)
    bisoprolol 2.5 od
    GTN spray 2 sprays prn
    ISMO60mg 2 tabs od
    Nicorandil 10mg bd

    is the above combination communly prescribed in practice ALL TOGETHER( the 4 items)
    when interviewed, the patient said his angina is well controlled and did not report much side effects (i.e headaches sometimes, cold legs).

    also he is on furosamide 40mg od
    losartan 25mg od
    Bezafibrate 400mg 1 tab at night
    rantidine 150mg 1 bd
    gaviscon advance tabs

    what would be your action plan?
    1- put them on aspirin 75 mg
    2- start him on simvastatin? not sure if bezafibrate is needed here!
    3- he had compliance problem, so make sure to address it to his prescriber
    4- bisoprolol dose? i believe it is quite low to prevent angina attack

    thanks in advance
    Last edited by Rafael; 14, November 2008, 07:43 PM.
    [COLOR=Olive]xxxx They tried to break my back, but i survived. whatever doesn't kill you, will only makes you stronger xxxx

  • #2
    Re: Mur

    In the treatment of stable angina I was always taught that:
    All patients should be on aspirin (if no contra-indications and BP ok)
    All patients should be on a statin if cholesterol >3.5mmol/L (although in practice treat to target of <4)

    These measures are for secondary prevention of CVD.

    The general treatment algorithm is usually:

    All patients: GTN prn, then:

    (1) B-blocker (Atenolol 50-100mg if no asthma/PVD/CCF/COPD etc) + Dihydropyridine CCB (long acting) + Long-acting nitrate + Nicorandil


    (2) Rate-limiting CCB (Diltiazem if B-blocker C/I and no CCF) + Long-acting nitrate + Nicorandil


    (3) Nitrate (Imdur if CCF) + Dihydropyridine CCB (long acting) + Nicorandil

    Drugs are added in a stepwise manner. Therefore, yes, many patients end up on multiple drug therapy.

    Bisoprolol probably used because patient has a degree of heart failure, the management of which is discussed in the NICE guidelines (see flow diagram p.12)
    Last edited by pharmatron; 13, November 2008, 02:26 PM.


    • #3
      Re: Mur

      cheers pharmatron

      1-when bezafibrates are used opposed to statins?
      i know statins are effective in reducing cardiovascular risk as well as lowering cholesterol level, what about fibrates? have then been proven to reduce CVR?

      2-if a patient is already on fibrate, is there a reason to shift them to statin? or is fibrates used if statin did not effectively reduce cholesterol levels~?

      3- for a hypertensive old patient, what alginate prep are commonly prescribed for patients? i only noticed peptac and gaviscon advance but both of them have high Na content! BNF says TOPAL Tablets has low Na levels, tho i never seen it in practice. any ideas pharmacists?

      cheers in advance
      [COLOR=Olive]xxxx They tried to break my back, but i survived. whatever doesn't kill you, will only makes you stronger xxxx


      • #4
        Re: Mur

        The choice of lipid lowering agent depends on the underlying dyslipidaemia. The various groups of drugs available have variable efficacy depending on the lipid profile of the individual.

        Statins tend to be better at lowering LDL-C whilst fibrates tend to be better at reducing triglycerides. NICE suggests using a statin (e.g. simvastatin 40mg) first line in the secondary prevention of CVD; and if statins are not tolerated then consider fibrates, nicotinic acid, anion-exchange resins or ezetimibe.

        As for sodium content of antacids - see (What is the sodium content of medicines? - NeLM) and click on 'View complete report'


        • #5
          Re: Mur

          thanks again pharmatron
          that was really helpful
          [COLOR=Olive]xxxx They tried to break my back, but i survived. whatever doesn't kill you, will only makes you stronger xxxx


          • #6
            Re: Mur

            is there any reason why he was not put on furosemide + ramipril (if furosemide did not produce enough reduction in BP)? i mean losartan is a way more expensive and NICE recomments angiotension II receptor antagonists are ONLY used if patient could not tolerate ACEIs(i.e developed cough).

            i am quite confused, shall i consider it one of the 4 actions to be readdressed to the GP?
            as i am limited to 4, and i believe there are more and i need to priotarize, not sure if this is considered important (medicine management and reducing cost to NHS).

            any ideas plz?
            [COLOR=Olive]xxxx They tried to break my back, but i survived. whatever doesn't kill you, will only makes you stronger xxxx


            • #7
              Re: Mur

              As far as I know, current clinical guidelines would favour an ACE inhibitor first line and only recommend the use of A-II-antagonists where ACE-i aren’t tolerated.

              However, I seem to remember a couple of trials that looked at A-II-antagonists vs ACE-i – in the ELITE (Evaluation of Losartan in the Elderly) trial losartan was tolerated significantly better than captopril; however, ELITE-II did not show any significant difference between losartan and captopril in terms of mortality or morbidity.

              The following article provides an interesting review on the use of losartan, with special focus on elderly patients (IngentaConnect Losartan: A Review of its Use, with Special Focus on Elderly Pati...)

              However, as you are aware, GPs tend to prescribe whatever comes to mind, and don’t always follow an evidence-based approach. I’ve seen several scripts for rasilez over the last few days where the patients have never been on ACE-i or an A-II-antagonist and the GP in their wisdom has gone for a direct renin inhibitor – the first in it’s class and still black triangle!

              I suppose it’s only through using new drugs that experience with them grows and their potential can be measured…still I’d rather save the new, weird and wonderful treatments for patients in which all other avenues have been explored.


              • #8
                Re: Mur

                Sorry if I'm being a bit dumb but I thought the purpose of MUR's was to just check they were using their meds properly and are not suffering side effects. Thinking about changing their meds is more of a clinical review which we're not supposed to do, isn't it?