Cardiovascular system
اسم المريض: اشواق ابراهيم العمر: 50سنة Classic Angina Rx Tenormin®100mg tab1 tab dailyGlyceryl Trinitrate (Angised ®) 0.5 mg sublingual tab.PRNGlyceryl Trinitrate '5' patches 1 patch to be applied for 16 hours daily and removed at nightAspirin 100mg enteric coated tab 1tab. dailyQ1-What is the main indication for sublingual glyceryl trinitrate (GTN)?
And what instruction should be given to the patient with regard to the use and storage of GTN sublingual tab.?
[ rapid symptomatic relief of angina ,anal fissures ,left ventricular failure ,extravasation]
[When angina starts, 500micrograms glyceryl trinitrate (one tablet) should be taken and if symptoms do not resolve, may be repeated at five minute intervals for a total of three doses. If symptoms have not resolved after a total of three doses, the patient should seek prompt medical attention.
The patient should preferably rest in the sitting position because of the risk of symptomatic postural hypotension.
Your Glyceryl Trinitrate tablets will be presented in a glass airtight container with a foil-lined cap. Keep them in this.
• After use reclose the bottle cap tightly.
• Do not put cotton wool, other drugs, or anything else in the bottle with the tablets.• Store the tablets below 25°C in a dry place, protected from light. Once the container is opened the tablet should be used for only a limited time {6month-1 year}
In any event do not use the tablets after the expiry date shown.
Q2-If the patient found difficulty in dissolving the SL tab. .!!!
What alternative dosage form of GTN that provide rapid relief of symptom? Where (site) it should be applied? What happen if the SL tablets left out of the bottle on a table?
[transdermal patches applied to lateral chest wall ,upper arm , thigh ,abdomen ,or shoulder]
Sublingual, buccal, or spray products are the products of choice for acute anginal attack.
Oral, ointment, and transdermal patches products are acceptable for the long-term prophylaxis of angina.
S.L tablet of GTN left out of the bottle on a table will lose its effectiveness in just a few hours
Q3- What is the main indication for GTN patches?[it provides prophylactic treatment of attacks of angina pectoris]
And what instruction should be given to the patient with regard to the site of application. Why the Dr. recommend to left off the patch for several consecutive hours (about 8 hours )in each 24 hours ? [transdermal patches applied to lateral chest wall ,upper arm , thigh ,abdomen ,or shoulder , siting replacement patch on different area ]
[due to tolerance during the use]
Classic Angina Rx Glyceryl Trinitrate (Angised ®) 0.5 mg sublingual tab. PRN Isosorbide dinitrate (Isordil®) 10mg tab. 1tab. T.i.dAspirin 100mg enteric coated tab 1tab. daily. Paracetamol tab.O/N
Q4-What is main indication for oral isosorbide dinitrate (ISDN)? Knowing that nitrate can produce tolerance, how should the patient be instructed about his medication so as to minimize tolerance?
[ prophylaxis& treatment of angina ,left ventricular failure ]
[Tolerance can be limited by maintaining a nitrate-free interval (NFI) of about 10 to 12 hours daily
Nitrate dosing schedule should be arranged to permit NFI during the night because angina is more likely to occur during the work day. Therefore: He should take his oral nitrate at 7 am, noon, and 5 pm because his exercise –induced angina is likely to occur during daylight hours.
He may need to adjust his schedule if he arises earlier than 7 AM because early –morning angina is common.
Q5-knowing that nitrate can cause headache? How should you educate the patient about this effect? [Nitrate induced headache is usually transient, typically lasting several days to few weeks . Patients should therefore be encouraged to persevere with the therapy, using simple analgesics (Paracetamol) when required to control any headaches)
What other side effects might be caused by nitrate? [ dizziness ,throbbing headache
,hypotension, fainting ]
Q6-If the patient has erectile dysfunction. Could he safely take sildenafil (Viagra®) Tadalafil (Cialis®), or Vardenafil (Levitra®)? Why?
[Nitroglycerin should not be used within 24 hours of taking sildenafil or vardenafil or within 48 hours of taking tadalafil because of the potential for life-threatening hypotension]
What is the other indication for sildenafil and tadalafil (other than erectile dysfunction)?
[ pulmonary hypertension ]
Classic angina and hypertensionRx Isosorbide mononitrate 20mg tab 1 tab .B.i.d ( 8 AM and 4 PM )Glyceryl Trinitrate (Angised ®) 0.5 mg sublingual tab. PRNAspirin 100mg enteric coated tab 1tab. daily.Moduretic® tab. 1 tab daily
Q7- What are the differences between isosorbide mononitrate (ISMN) and isosorbide dinitrate (ISDN)?[ISMN is the active metabolite of ISDN which is responsible for most of the activity: The advantage of ISMN is: twice daily dosing (or once daily with m/r products) which mean better compliance]
Q8-Why did the Dr. recommend to give the second dose after about 8 hours rather than 12 hours? [ to avoid nitrate tolerance ]
Q9-later on the Dr. replace the ISMN ordinary tab. By ISMN m/r (Imdur® 60mg tab. To be given once daily).What is the optimum time (morning, night…..) for administration? Why?
[ use in the morning ] [because the attack usually at work and to reduce tolerance]
Angina and hypertensionRx Nifedipine (Adalat®) 20mg m/r tab.1 tab B.i.dAspirin 100mg enteric coated tab 1tab. daily.
Q10-What are the main indications for nifedipine [ prophylaxis of angina ;hypertension ;Raynaud s phenomenon ]? What is its major site of action (vessel or myocardium)
[ on vessels ]
Q11- Do you recommend to maintain the patient on one brand name of m/r nifedipine? Why?
[ different versions of modified-release preparation may not have the same clinical effect .To avoid confusion between these different formulations of nifedipines , prescribers should specify the brand to be dispensed .m/r may not be suitable for titration in hepatic disease ]
Q12-What are the side effect associated with vasodilatation produced this drug
[ SE associated with vasodilation ,flushing ;headache ;ankle swelling ]
Q13-The patient return to the pharmacy in the 2nd day saying that the tablet had been passed unchanged with the stool? (What will you tell him )?[Tablet membrane may pass through GIT unchanged ,but being porous has no effect on efficacy]
Q14-During the treatment? The patient develops severe fainting and drop in BP after the ingestion of grapefruit juice? Rationalize and educate the patient about this effect?
Adverse effects such as headaches, facial flushing, and hypotension were more common after ingestion of grapefruit juice. It is postulated that compounds in grapefruit juice inhibit cytochrome P-450 metabolism. This interaction could increase both the efficacy and toxicity of some CCBs and other drugs.
اسم المريض:عباس خيون لعمر:45 سنة Angina RxAmlodipine 10mg tab1tab.daily.
Q15-What are the differences between Amlodipine and Nifedipine?
[Amlodipine longer duration of action and can be given once daily ]
Q16-3 weeks later the patient develop ankle edema? Rationalize and what are your recommendations for the physician?[because has more influence on vessels ;SE associated with vasodilation] [Edema (which occurs typically 2 or more weeks after starting treatment) may response to simple measures such as elevation of feet during the night, or to a reduction in dosage, but if it persists, the CCB should be withdrawn
Note: Edema may diminish upon conversion from a dihydropyridine CCB to a nondihydropyridine CCB such as Verapamil or diltiazem .
Q17-Is the use of diltiazem associated with lower incidence of this side effect?[ yes lower incidence ,because it works primarily on the heart]
subarachnoid hemorrhageRx Nimodipine (Nimotop®) 30mg tab60mg (i.e. 2 tablets) every 4 hours.
18-What is the difference between nimodipine and other CCBs? What is the main indication of it? At what time the treatment with it should be started after hemorrhage? And for how long it will continue?
[Nimodipine is related to nifedipine but the smooth muscle relaxant effect preferentially act on cerebral arteries, indicated in prevention and treatment of vascular spasm following aneurysmal subarachnoid hemorrhage]
[By mouth 60mg every 4hr starting within 4days of aneurysmal subarachnoid hemorrhage and continued for 21days]
اسم المريض:مهند كريم العمر: 47 سنةSupraventicular arrhythmiaRx Verapamil 40 mg tablet 1tab. t.i.d
Q19-Why does Verapamil (but not nifedipine or other dihydropyridine CCBs) is used for arrhythmia? [ because Verapamil work primarily on the heart reducing heart rate and cardiac output ;but nifedipines has little direct action on heart ,but greater effect on peripheral arterioles ]
What are the other indications for it? [angina ,HT, prophylaxis of cluster headache]
Q20-What is the common GI side effect of Verapamil? [constipation ]
Q21-Can we use Verapamil or diltiazem safely in patient with heart failure or in combination with beta-blockers? Why?
[ no can't give to patient with HF because they reduce cardiac output and heart rate ] [no not given in combination because of risk of hypotension and asystole]
Angina, Duodenal ulcer.S. cholesterol=270mg/dl Rx Simvastatin (Zocor) 20mg tab. 1tab. DailyOmeprazole 20mg cap One cap bid for one week. Clarithromycin 500mg 1 tab bid for one week. Amoxicillin 500 mg cap. 2 cap bid for one week.Tenormin®100mg tab 1 tab daily
Q22-To which group of Lipid-regulating drugs, Simvastatin belong? Is it effective more for cholesterol or Triglyceride reduction? [statin group ] [effective for cholesterol]
Q23-Knowing, that Statins can cause myopathy? What counseling should be given about this side effect?
[Advice the patient to report promptly unexplained muscle pain ,tendeness or weakness]
Q24- Knowing, that Statins can cause hepatotoxicity? How we can monitor the patient for this side effect? [Liver enzymes should be measured before treatment and repeated within 3 months and at 12 month of starting treatment]
25-At what time of the day (morning, night…) the single dose of statin is usually given? Why?
Statins are usually taken in the evening to achieve peak serum level during the night, when maximal cholesterol synthesis occurs. However atorvastatin which has longer half life may be administered without regard to time of the day
Q26-Could the grapefruit juice taken safely by patient take Simvastatin? Why? [avoid concomitant use ]
Q27-What is the problem in this Rx: what is your recommendation?
[problem in concomitant use of clarithromycin with simvastatin]
In patient requires a course of antibiotic therapy(like Clarithromycin, erythromycin, …..) which may interact with Statins , The statin may be discontinued during this period and restarted when the course has been completed.اسم المريض: ستار خضير العمر: 69سنة Benign prostate hyperplasia (BPH) Rx Terazocin 2 mg tab1 tab. daily
Q28-Why does α-blockers (like Terazocin) are used in BPH?
[ these drugs relax the smooth muscle in BPH producing an increase in urinary flow-rate and an improvement in obstructive symptoms ]
Q29-At what time of the day (morning, or bedtime) the first dose of α–blockers should be given? why? And what should the patient do if symptoms such as dizziness, fatigue, or sweating occur?
[First dose may cause collapse due to hypotensive effect ;therefore should be taken on retiring to bed]
[Patient should be warned to lie down until the symptoms abate completely ]
Angina associated with coronary vasospasm(prinzmetal's angina) also called (variant) anginaRx Diltiazem 120 mg m/r cap. 1 cap. B.i.dAspirin 100mg tab. 1tab. DailyGlyceryl Trinitrate (Angised ®) 0.3 mg sublingual tab. PRN
Q30-Are the CCBs valuable in this form of angina? [ Diltiazem is effective in most form of angina] ]
Q31- Do you recommend to maintain the patient on one brand name of m/r Diltiazem? Why?
[ No I didn’t ]
[Different versions of m/r preparations containing more than 60mg diltiazem hydrochloride may not have the same clinical effect. To avoid confusion between these different formulation ,prescriber should specify the brand to be dispensed.
اسم المريض:سمير فرحان العمر: 59سنةDeep Vein ThrombosisRx Heparin inj. 15000 unit S.C twice dailyWarfarin 5 mg tab 1 tablet daily
Q32-For how long we use heparin and warfarin concomitantly? Why? [for 3 days ,because warfarin need 3days to give its effect]
Q33-What is the laboratory test used to monitor heparin therapy?
[ APTT activated partial thromboplastin time ] and what is the laboratory test used to monitor warfarin therapy ? [ INR ,international normalized ratio ]
Q34-Can we use heparins during pregnancy? Which type is preferred (unfractionated heparin (UFH) or low molecular weight heparin (LMWH)) and why?
[ LMWH used because they have lower risk of osteoporosis and of heparin-induced thrombocytopenia , eliminated more rapidly in pregnancy ]
Q35-Give three examples for LMWH . What are the advantages of LMWH over UFH?
[ Dalteparin , Enoxaparin ,Tinzaparin sodium]
[advantages ,they are effective, have lower risk of heparin-induced thrombocytopenia, longer duration of action ]
Q36-What is the side effect of heparin on platelets count? How should this effect be monitored?
[ heparin induce thrombocytopenia ]
[regular monitoring of platelet count if given for longer than 4days