10/8/2014 1 PHARMACOLOGY AND MEDICAL CARE CONSIDERATIONS FOR PHYSICAL REHABILITATION Cardiopulmonary Conditions and Diabetes Douglas DeRitis, RPh, PharmD & Colleen DeRitis, MA, OTR/L Agenda • Cardiopulmonary Conditions – (Cardiac Disease, Coronary Artery Disease, Myocardial Infarction, A- fibrillation, COPD) – Pharmacological Issues and Barriers – Implications for Rehabilitation – Documentation to support Rehab Progress/Limitations • Diabetes • Medical Considerations • Sensory Issues (Peripheral Neuropathy, Vision Problems) • Foot Inspection and Care • Pharmacological Issues and Barriers – Glucose Testing – Insulin Usage – Medication Management – Adaptive Devices • Implications for Rehabilitation • Documentation to support Rehab Progress/Limitations To review… Process of Pharmacokinetics • Absorption • Distribution • Storage • Elimination – Metabolism – Excretion
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10/8/2014
1
PHARMACOLOGY AND MEDICAL
CARE CONSIDERATIONS FOR
PHYSICAL REHABILITATION
Cardiopulmonary Conditions and
Diabetes
Douglas DeRitis, RPh, PharmD & Colleen DeRitis, MA, OTR/L
Agenda
• Cardiopulmonary
Conditions
– (Cardiac Disease,
Coronary Artery Disease,
Myocardial Infarction, A-
fibrillation, COPD)
– Pharmacological Issues
and Barriers
– Implications for
Rehabilitation
– Documentation to
support Rehab
Progress/Limitations
• Diabetes
• Medical Considerations
• Sensory Issues (Peripheral
Neuropathy, Vision Problems)
• Foot Inspection and Care
• Pharmacological Issues and Barriers
– Glucose Testing
– Insulin Usage
– Medication Management
– Adaptive Devices
• Implications for Rehabilitation
• Documentation to support Rehab
Progress/Limitations
To review…Process of Pharmacokinetics
• Absorption
• Distribution
• Storage
• Elimination
–Metabolism
– Excretion
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Cardiac Disease
Cardiovascular Disease
• Incidence of heart disease has decreased
• Other conditions present and increase with
age:
– Hypertension
– CHF
– CAD
• Consider co-existing conditions
• Know the classes of cardiac meds
Diagnosis of Cardiac Problems
• Blood serum levels
• Creatine Phosphokinase(CPK)
– Elevated after MI during 4 hrs and peaks at 36 hrs.
• Lactate dehydrogenase (LDH)
• LDH- tissue breakdown
• LDH- MI: peaks in 3 to 4
days, may remain elevated
for up to 10 days.
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Cardiac Output
• Cardiac Output = stroke volume (SV) x heart
rate (HR)
• Influenced by meds that effect heart
• Male 5.6L/min
• Female 4.9 L/min
Factors effecting heart disease• Smoke
• Blood Pressure
• Cholesterol
• Lack of exercise/Inactivity
• Stressors
• Genetics
• Diet
• Diabetes/Other pre-existing conditions
• Age
• Obesity
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Hypertension
• Pharmacology:
– Lowest dose of drug choice
– Diuretics
• Sensitive
• Non-sensitive
• START LOW & GO SLOW!
Blood Pressure Disorders
• High blood pressure, or hypertension
• High blood pressure for adults 140 mm Hg or greater systolic pressure and 90 mm Hg or greater diastolic pressure
• Pre-hypertension- 120 mm Hg – 139 mm Hg systolic pressure and 80 mm Hg – 89 mm Hg diastolic pressure
• Normal=Less than 120 mm Hg systolic pressure and Less than 80 mm Hg diastolic pressure
• Precautions
Coronary Artery Disease
Due to arteriosclerosis process
• Thickening of inner vessels
• Fatty tissue cause
– Decrease in coronary blood flowdecrease
myocardial O2 demand and supply ischemia
– Can also be due to other reasons
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Arteriosclerosis
– Progressive destruction of the arterial structure
– Development of plaque lesions
• Fatty Streak
• Fibrous Plaque (typical)
• Complicated Plaque
– Calcification necrosis
– Hemorrhage
– Thrombus
– Aneurysm
Angina
• Chest pain or discomfort
• Heart muscle does not get enough blood.
• Pressure or a squeezing pain in your chest.
– Indigestion.
– May also feel pain in shoulders, arms, neck, jaw or back.
Beta Blockers Hyper-adrenergic state Autonomic modulation
Medication Action Indication/Effect
Statins Decreased arthrosclerosis
Proangiogenic
Dyslipidemia
Improved pain-free walking
Reduced mortality
Aspirin Antiplatelet aggregation Decreased MI by 18%
Clopidogrel (Plavix) Antiplatelet aggregation Reduced risk of MI/vascular
death by 23.8% more than
aspirin
Beta Blockers
ACE inhibitors
Sympatholytic
Afterload reduction
Reduced risk of MI
Reduced mortality
Reduced ischemic events
Calcium channel blockers
Nitrates
Vasodilation Reduced claudication
Reduced angina
Signs of excessive potassium loss
• Dry mouth
• Increased thirst
• Irregular heartbeats
• Mood changes
• Muscle cramps
• Nausea
• Vomiting
• Tiredness
• Weakness
• Weak pulse
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ACE Inhibitors
• Blocks vasoconstriction by blocks ACE
( angiotensin converting enzyme ).
• Decrease BP, controls HTN
• Increases Na+ and H2O excretion which
decreases blood volume, holds onto K+
• Decreases release of aldosterone ( decreases
Na+, Cl-, H2O retention, decreases BP )
• Decreases release of vasopressin (pituitary)
ACE Inhibitors• Benazepril
• Captopril
• Enalapril
• Fosinopril
• Lisinopril
• Moexipril
• Quinapril
• Ramipril
• Trandolapril
Rehabilitation Implications and
Adverse Effects:
ACE Inhibitors
• Hypotension
• Rash
• Angioedema
• Cough
• Taste disturbance
• hyperkalemia
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Calcium Channel Blockers
• Amlodipine: dihydropyridine
• Diltiazem: benzothiazepine
• Nicardipine: dihydropyridine
• Nifedipine: dihydropyridine
• Verapamil:
phenyalkylamine
Calcium Channel Blockers
• Non-dihydropyridines: decrease force of
contraction of myocardium. This is called
negative inotropic effect. ( e.g. verapamil,
diltiazem )
• Dihydropyridines: slow down conduxtion of
electrical activity within the heart. This is
called negative chronotropic effect. ( e.g.
amlodipine, nifedipine, isradipine ); for a-fib,
a-flutter where rate control is essential.
Statins- HMG-CoA Reductase
Inhibitors
• Pravachol ( pravastatin )
• Zocor ( simvastatin)
• Lipitor ( atorvastatin )
• Crestor ( rosuvastatin )
• HMG-CoA plays a key role in
production of cholesterol in
the liver.
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HMG-CoA Reductase Inhibitors
• Muscle problems (rhabdomyolysis)
• Elevated liver enzymes
• Myalgias
• Less Common:
- neuropathy
- cognitive loss
- hepatic and pancreatic dysfunction
- sexual dysfunction
Heart Failure
• Types
– Right Ventricular Failure
– Left Ventricular Failure
– Non-Specific
• Symptoms
• Signs
Heart Failure
Stage A: identifies the patient who is at high risk for developing HF, but has no structural disorder of the heart.Stage B: patient with a structural disorder of the heart, but has never presented with symptoms.
Stage C: patient with past or current symptoms of HF associated with underlying structural heart disease.
Stage D: patient with end-stage disease who require specialized treatment strategies ( e.g. mechanical circulatory support, hospice ).
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Rehabilitation Implications:
Heart Failure
• Reduced exercise tolerance
• Impaired quality of life
• Reduced life expectancy
Heart Failure-Class of Drugs to Avoid
• Anti-arrhythmic agents: can exert cardio-depressant and pro-arrhythmic effects. ( only amiodarone has been shown not to adversely affect survival ).
• Calcium channel blockers: have been shown to be associated with an increased risk of cardiovascular events.
• NSAID’S: can cause sodium retention and peripheral vasoconstriction.
Medications in Heart Failure
Management
• Combination of 4 types of drugs
• Diuretic
• ACE Inhibitor
• Beta-blocker
• Digitalis (Digoxin)
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Cardiac Rehabilitation
• “sum of activity required to ensure cardiac patients the best possible physical, mental,
and social conditions so…they may…regain as normal as possible a place in the community
and lead an active life.”
Rehabilitation Implications
Monitoring Physical Activity
• HR
• BP
• Abnormal signs and symptoms
• Electrocardio-radiography
• Measurements
– Pre-exercise baseline
– 2-3 minute interval
– 5-6 minutes
• Ability to perform exercise
– Duration
Metabolic Equivalent (MET) Level
• How hard one is working to do the activity
• Estimates the amount of oxygen used by the body during physical activity
• 1 MET = the energy (oxygen) used by the body as you sit quietly, perhaps while talking on the phone or reading a book.
• The harder your body works during the activity, the higher the MET.
• 3 to 6 METs = moderate-intensity physical activity.
– Multidisciplinary, comprehensive intervention for patients with chronic respiratory diseases who are symptomatic and often have decreased daily life activities. Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to reduce symptoms, optimize functional status, increase participation, and reduce health care costs through stabilizing or reversing manifestations of the disease
– American Thoracic Society(ATS) Statement on Pulmonary Rehabilitation(2006)