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Three Silent Killers

Three Silent Killers. SNPhA & NOSA Webinar Presented by Anthony Dima-ala Michael Do Claire Hung Preceptor: Dominic Vu, Pharm.D., RPh. Diabetes Mellitus (DM). Claire Hung, SNPhA. Diabetes Statistics. Diagnosed in approximately 8.3% of Americans

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Three Silent Killers

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  1. Three Silent Killers SNPhA & NOSA Webinar Presented by Anthony Dima-ala Michael Do Claire Hung Preceptor: Dominic Vu, Pharm.D., RPh.

  2. Diabetes Mellitus (DM) Claire Hung, SNPhA

  3. Diabetes Statistics • Diagnosed in approximately 8.3% of Americans • Leading cause of new cases of blindness among adults aged 20 – 74 years • Comparing adults with diabetes to those without diabetes • 2 to 4 times higher risk for stroke • 2 to 4 times higher heart disease death rates "Diabetes Basics." American Diabetes Association. American Diabetes Association, n.d. Web. 31 Dec. 2013.

  4. Pathophysiology • Disease condition with high blood glucose • Inability to put circulating glucose back into cells for energy • Lack of or ineffective use of insulin by body http://urbanext.illinois.edu/diabetes2/subsection.cfm?SubSectionID=6 "Diabetes." Medline Plus. U.S. National Library of Medicine, 27 Dec. 2013. Web. 28 Dec. 2013.

  5. Etiology • Type 1 Diabetes • Occurs in ~5% of the diabetic population • Progressive insulin secretory and utilization defect • Autoimmune • Type 2 Diabetes • Most common form of diabetes • Improper use of insulin by body • Risk factors: obesity, smoking, family history, ethnicity "Diabetes." Medline Plus. U.S. National Library of Medicine, 27 Dec. 2013. Web. 28 Dec. 2013.

  6. Symptoms • Frequent urination • Frequent hunger and thirstiness • Extreme fatigue • Blurry vision • Weight loss (Type 1) • Tingling, numbness and pain in hands/feet (Type 2) "Diabetes Basics." American Diabetes Association. American Diabetes Association, n.d. Web. 31 Dec. 2013.

  7. Diagnosis • Fasting Plasma Glucose Test (FPG) • A1C • Oral Glucose Tolerance Test (OGTT) – uncommon • Each test usually needs to be repeated on a second day to confirm diagnosis "Diabetes Basics." American Diabetes Association. American Diabetes Association, n.d. Web. 31 Dec. 2013.

  8. Complications • Microvascular • Nephropathy • Retinopathy • Neuropathy • Macrovascular • Heart disease • Stroke "Diabetes Basics." American Diabetes Association. American Diabetes Association, n.d. Web. 31 Dec. 2013.

  9. Treatment Goals • Short-term • Control hyperglycemia and its symptoms • Long-term • Prevent complications • Improve life expectancy • Improve quality of life "Diabetes Management Guidelines." ADA 2013 Nutrition Guidelines. National Diabetes Education Initiative, n.d. Web. 30 Jan. 2014.

  10. ADA Recommendations for DM Patients • Healthy diet • Reduced caloric and fat intake • Consistent carbohydrate intake • Regular exercise • ≥150 min/week aerobic activity  • ≥3 days/week • Smoking cessation • Regular follow-up visits to doctor "Diabetes Management Guidelines." ADA 2013 Nutrition Guidelines. National Diabetes Education Initiative, n.d. Web. 30 Jan. 2014.

  11. Medication Treatment • Type I • Insulin injections • Type II • Oral medications • Decrease amount of glucose produced by liver • Sensitize tissues to insulin • Stimulate release of insulin • Block breakdown of starches • Block kidney reabsorption of glucose "Diabetes Management Guidelines." ADA 2013 Nutrition Guidelines. National Diabetes Education Initiative, n.d. Web. 30 Jan. 2014.

  12. Glucose Monitoring • Goal glucose levels • Preprandial : 70 – 130 mg/dL • Postprandial : < 180 mg/dL • A1C • American Diabetes Association: < 7% • American College of Clinical Pharmacy: < 6.5% • Self monitor glucose > 3 times daily when using insulin "Diabetes Management Guidelines." ADA 2013 Nutrition Guidelines. National Diabetes Education Initiative, n.d. Web. 30 Jan. 2014. Irons, Brian. "New Pharmacotherapies for Type 2 Diabetes." PSAP 2013 Cardiology/Endocrinology. American College of Clinical Pharmacy, 2013. Web. 13 Mar. 2014.

  13. Hypertension Anthony Dima-ala, SNPhA

  14. Hypertension Statistics • 67 million Americans, age >20 have elevated BP (BP > 140/90) • More than half of these patients do not have their BP under control • More than 348,000 American deaths in 2009 included high blood pressure as a primary or contributing cause • Almost 30% of American adults have pre-hypertension “High Blood Pressure Facts.” Center of Disease Prevention. Web. 19 Jan. 2014.

  15. Why a “silent killer?” • Most patients do not have symptoms or warning signs • Most important physical finding is elevated BP

  16. Pathophysiology • The Renin-Angiotensin-Aldosterone System • Activation & regulation by kidney • Regulation of Na, K, and Blood volume • Renin release from juxtaglomerular cells in response to • Decrease renal artery pressure • Decrease kidney blood flow • Renin catalyzes angiotensinogen to angiotensin I in the blood • Angiotensin converting enzyme (ACE) converts angiotensin I to angiotensin II • Angiotensin II binds to AT1 & AT2 Receptor Hypertension. Dipiro J, Talbert R, Yee G, et al. Pharmacotherapy: a pathophysiologic approach. 8th ed. 2008. New York, NY: McGraw-Hill

  17. Pathophysiology (cont) • Angiotensin converting enzyme (ACE) converts angiotensin I to angiotensin II • Angiotensin II binds to AT1 & AT2 Receptor • AT1 Rc (BP regulation) • Brain, kidney, myocardium, peripheral vasculature, adrenal glands Hypertension. Dipiro J, Talbert R, Yee G, et al. Pharmacotherapy: a pathophysiologic approach. 8th ed. 2008. New York, NY: McGraw-Hill

  18. Risk Factors • Diet • Weight • Physical Inactivity • Alcohol Use • Tobacco Use • Sodium Intake Chobanian AV, Bakris GL, Black HR, et al. National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003; 42:1206.

  19. Symptoms • Asymptomatic* • Severe Headache • Nausea/Vomiting • Confusion • Vision changes • Nosebleeds “High Blood Pressure.” Medline Plus. U.S. National Library of Medicine, 19 Jan 2014.

  20. Chobanian AV, Bakris GL, Black HR, et al. National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003; 42:1206.

  21. Monitoring Tools • Electrocardiogram • Urinalysis • Blood Glucose & Hematocrit • Potassium • Creatinine • Calcium • Lipid profile Chobanian AV, Bakris GL, Black HR, et al. National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003; 42:1206.

  22. Goals of Therapy • Ultimate Goal • Reduction of cardiovascular & renal morbidity and mortality • Achieving systolic blood pressure (SBP) goal • Target BP goal: • <140/90 mmHg • <130/80 mmHg • Diabetes • Renal Disease Chobanian AV, Bakris GL, Black HR, et al. National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003; 42:1206.

  23. Hypertension Algorithm Chobanian AV, Bakris GL, Black HR, et al. National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003; 42:1206.

  24. Hypertension Algorithm (cont) Chobanian AV, Bakris GL, Black HR, et al. National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003; 42:1206.

  25. Lifestyle Modifications • Weight reduction (obese patients) • Dietary Approaches to Stop Hypertension • DASH diet • Physical activity • Moderation of alcohol consumption Chobanian AV, Bakris GL, Black HR, et al. National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003; 42:1206.

  26. JNC 8 update (New Recommendations) • Recommendation 1 (strong recommendation – Grade A) • Age > 60 yrs • Initiate pharmacologic treatment to lower BP • SBP > 150mmHg • DBP > 90mmHg • Treat to goal: BP <150/90mmHg • Recommendation 2 • Age < 60 yrs • Initiate pharmacologic treatment to lower BP • DBP > 90mmHg • Treat to goal: DBP < 90mmHg James PA, et al. JAMA 2013 Dec 18

  27. JNC 8 update (New Recommendations) • Recommendation 3 • Age < 60 yrs • Initiate pharmacologic treatment to lower BP • SBP > 140mmHg • Treat to goal: SBP<140mmHg • Recommendation 4 • Age > 18 yrsWITH CHRONIC KIDNEY DISEASE • Initiate pharmacologic treatment to lower BP • SBP > 140mmHg • DBP> 90mmHg • Treat to goal: BP < 140/90mmHg James PA, et al. JAMA 2013 Dec 18

  28. JNC 8 update (New Recommendations) • Recommendation 5 • Age >18 yrsWITH DIABETES • Initiate pharmacologic treatment to lower BP • SBP >140mmHg • DBP > 90mmHg • Treat to goal: BP <140/90mmHg • Recommendation 6 (moderate recommendation-grade B; for black patient with diabetes; weak recommendation – grade C) • General black population (including diabetes) • Initial anti-hypertensive treatment SHOULD include: • Thaizide-type diuretic OR • CCB James PA, et al. JAMA 2013 Dec 18

  29. JNC 8 update (New Recommendations) • Recommendation 7(Moderate Recommendation – Grade B) • General nonblack population (including diabetes) • Initial anti-hypertensive treatment SHOULD include (1): • Thiazide-type diuretic • Calcium Channel Blocker (CCB) • Angiotensin-converting enzyme inhibitor (ACEI) • Angiotensin Receptor Blocker (ARB) • Recommendation 8 (Moderate Recommendation – Grade B) • Age > 18yrs WITH CKD • Initial (or add-on) anti-hypertensive treatment SHOULD include (1): • ACEI • ARB James PA, et al. JAMA 2013 Dec 18

  30. Recommendation 9 • Main objective of hypertension treatment • Attain & maintain goal BP • If goal BP not reaching within A MONTH of treatment, • INCREASE dose of initial drug OR • ADD a second drug • thiazide-type diuretic, CCB, ACEI, or ARB • Continue to assess BP & adjust treatment regimen until goal BP is reached • If goal BP CAN NOT be reached with 2 drugs, • ADD and TITRATE a 3rd drug from the list above. • Do not use ACEI & ARB together in same patient • If goal BP CAN NOT be reached with 3 drugs or Contraindications, • Other classes from anti-hypertensive drugs can be used • Referral to hypertension specialist • Patients whom goal BP cannot be attained using strategy above. James PA, et al. JAMA 2013 Dec 18

  31. Treatment Algorithm James PA, et al. JAMA 2013 Dec 18

  32. Treatment Algorithm James PA, et al. JAMA 2013 Dec 18

  33. Basic Differences between JNC 7 & 8

  34. Glaucoma National Optometric Student Association (NOSA)

  35. What is Glaucoma? Glaucoma is a group of eye disorders leading to progressive damage to the optic nerve, and is characterized by loss of nerve tissue resulting in loss of vision.  Definition taken from American Optometric Association Website

  36. Cranial Nerve II The optic nerve is a bundle of about one million individual nerve fibers and transmits the visual signals from the eye to the brain.

  37. Glaucoma Statistics Glaucoma is the second leading cause of blindness in the U.S. Information from National Eye Institute

  38. Consequences of Glaucoma Initially affects peripheral vision, but can advance to central vision loss. If left untreated, glaucoma can lead to significant loss of vision in both eyes, and may even lead to permanent blindness.

  39. Risk Factors • Age—People over age 60 are at increased risk for the disease. For African Americans, however, the increase in risk begins after age 40. The risk of developing glaucoma increases slightly with each year of age. • Race—African Americans are significantly more likely to get glaucoma than are Caucasians, and they are much more likely to suffer permanent vision loss as a result. People of Asian descent are at higher risk of angle-closure glaucoma and those of Japanese descent are more prone to low-tension glaucoma. • Family history of glaucoma—Having a family history of glaucoma increases the risk of developing glaucoma. • Corticosteroid use—Using corticosteroids for prolonged periods of time appears to put some people at risk of getting secondary glaucoma.

  40. Glaucoma Drug Modalities • Outflow Enhancement • Prostaglandin Analogs (25-35%) • Miotics • Epinephrine • Aqueous Supression • Beta Blockers (25-30%) • Alpha-2 Adrenergic Agonists (20-25%) • Carbonic Anydrase Inhibitors (15-20%)

  41. Mechanisms of Action

  42. Cap Color Review

  43. Prostaglandins Mechanism of Action: • Interact on Fp receptors on ciliary body that causes rearrangement of fibers and enhances outflow. This increases uvealscleral outflow in between the muscle fibers Ocular Side Effects: • Conjunctival injection • Increased pigmentation of eyelashes, periorbital skin tissue, iris • “sunken sulcus syndrome”, perioribital fat dissipates Contraindications: • Uveitis, ocular simplex, CME, concurrent use of miotics

  44. Beta Blockers Mechanism of Action: • Blocks Beta 2 receptors on ciliary body epithelial cells and decrease aqueous production Ocular Side Effects: • Stinging • Can induce dry eye because of decreased tear production Contraindications: • Asthma, COPD, CHF, pregnancy, resting bradycardia

  45. Alpha Agonists Mechanism of Action: • Prevent NorE release to target tissue on Beta receptors which in turn causes decreased aqueous production • May also increase uvealscleral outflow Ocular Side Effects: • Ocular vasoconstriction • Follicular conjunctivitis • Contact blepharoconjuncitivitis Contraindications: • Pediatric glaucoma, people using MOA antidepressants

  46. Carbonic Anhydrase Inhibitors Mechanism of Action: • Inhibits……Carbonic anhydrase • Reduces ionic bicarbonate formation that reduces aqueous production Ocular Side Effects: • Stinging • Foreign body sensation • Can diminish corneal endothelial vitality Contraindications: • Fuch’s Endothelial Dystrophy • Renal and liver disease • COPD • Pregnancy • Sulfa allergy

  47. Combination Drops Available in US • Cosopt • 0.5% Timolol and 2% Dorzolamide • Combigan • 0.5% Timolol and 0.2% Brimonidine • Simbrinza • 1% Brinzolamide & 0.2%brimonidine tartrate

  48. Cost to Our Patients • Generic Timolol 5mL - $4 • Generic Latanoprost 2.5mL - $20 • Xalatan2.5 mL - $130 • Travatan Z 2.5mL - $115 • Brimonidine5mL - $25 • Azopt 10mL $150 • Combigan5ml – $100 • Cosopt Generic 10mL - $25 • Simbrinza 8mL - $100

  49. References • National Optometric Association • American Optometric Association • Dr. Greg Nixon The Ohio State University Glaucoma Class • Will’s Eye Manual Glaucoma • American Academy of Optometry • American Academy of Ophthalmology

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