Family Medicine & Pharmacy Podcast

We turned our attention to chronic congestive heart failure (CHF) and reviewed "The 2012 Canadian Cardiovascular Society Heart Failure Management Guidelines Update". National Institute of Health provided a great summary on CHF for patients and the public: http://www.nhlbi.nih.gov/health/health-topics/topics/hf/ For a basic anatomy review of the circulatory system: For another diagram showing the heart in relation to the body, click here. And an over-simplification of the pathophysiology of left vs right heart failure is that when the left ventricle fails, not enough oxygenated blood gets pumps to the body to meet its demand. Instead, blood gets backed up into the lungs and cause fluid buildup in the lungs. This pressure can further back up into the right heart, such that the right ventricle and right atrium cannot accommodate a normal amount of venous return, and fluid can accumulate in the body to cause edema. Wikipedia strikes a good balance of depth and readability on this topic: http://en.wikipedia.org/wiki/Heart_failure The CCS guideline suggests the following investigations for CHF: CXR, echocardiography, BNP, labs (CBC, electrolytes, creatinine, urinalysis, glucose, thyroid function), and further testing (nuclear imaging, catheterization, stress test, MRI, CT, endomyocardial biopsy) if appropriate. The CCS guideline on treatment of chronic CHF: ACE inhibitors for: all symptomatic HF patients and EF 55 with HF symptoms on treatment and recent hospitalization for CV disease in the past 6 months (or if QRS duration > 130ms and EF

Classes of insulin and different treatment regimens are discussed in the third episode of a 3-part series on diabetes. This episode also marks the conclusion of our coverage of the "Big Three" of modern medicine (hypertension, dyslipidemia, and diabetes), and with it, we make an official announcement of the launch of the Family Pharm Podcast to the world (aka Facebook)!   Class Drug Onset Peak Duration Very Rapid-acting Insulin Analogues insulin aspart (NovoRapid) 10–15 min 60–90 min 4–5 h insulin glulisine (Apidra) insulin lispro (Humalog) Rapid-acting Insulin insulin regular (Humulin R, Novolin ge Toronto) 30–60 min 2–4 h 5–8 h Intermediate-acting Insulin insulin NPH (Humulin N, Novolin ge NPH) 1–2 h 5–8 h 14–18 h Long-acting Insulin Analogues insulin detemir (Levemir) 1.5 h Flat, no discernible peak 24 h insulin glargine (Lantus) Mixed (regular/NPH) Human Insulin insulin regular/insulin NPH Humulin 30/70, Novolin ge 30/70, 40/60, 50/50 Combination of individual components Mixed Insulin Analogues insulin lispro/lispro protamine Humalog Mix25, Humalog Mix50 10–15 min Not available Not available Mixed Insulin Analogues insulin aspart/aspart protamine NovoMix 30 10–15 min 60–90 min 15–18 h Classes of insulin preparations. Adapted from Therapeutic Choices 6th edition. CDA guideline on insulin for Type 1 diabetes, including description of basal-bolus regimen by carb counting: http://guidelines.diabetes.ca/Browse/Chapter12 Examples of insulin regimens from CDA: http://guidelines.diabetes.ca/Browse/Appendices/Appendix3 Self monitoring: http://guidelines.diabetes.ca/executivesummary/ch9

We reviewed the CDA 2013 guidelines on antihyperglycemic therapy for type 2 diabetes (http://guidelines.diabetes.ca/executivesummary/ch13), and explored the pharmacological properties of each of the major classes: Biguanides: Metformin Sulfonylureas: chlorpropamide, gliclazide, glimepiride, glyburide, and tolbutamide Thiazolidinediones: pioglitazone and rosiglitazone Meglitinides: Nateglinide and repaglinide Alpha-glucosidase inhibitors: Acarbose Dipeptidyl Peptidase-4 inhibitors (DPP4 inhibitors): Saxagliptin and sitagliptin Glucagon Like Peptide-1 Analogues (GLP-1 analogues): Liraglutide and Exenatide Drug information: Drug monographs CPS: http://www.e-therapeutics.ca/ Therapeutic Choices: http://www.e-therapeutics.ca/ Rx Files: http://www.rxfiles.ca/rxfiles/modules/druginfoindex/druginfo.aspx

To round up the "Big Three", we turned out attention on diabetes. We reviewed the CDA guidelines on diabetes management and summarized the most relevant points that we think all family doctors and pharmacists would find interesting. http://guidelines.diabetes.ca/  The CDA also prepared many apps and calculators that help HCPs make clinical decisions. As well, there are many other clinical practice guidelines on many different aspects of the care of diabetes that we cannot cover in this podcast. We recommend listeners to visit the CDA website to get a fuller picture than our synopsis here.

We explore pieces of important evidence that offer a contrasting view on lipid control from the national guidelines. We are also introducing a new EBM resource available to CMA members: InfoPOEMs, which highlights clinical studies that the editorial team finds relevant.  http://www.cma.ca/clinicalresources/infopoems Treatment group Tools for Practice 2013: “Is Diabetes a Coronary Heart Disease Equivalent?” http://www.acfp.ca/Portals/0/docs/TFP/20131021_093004.pdf “Though diabetes does confer an increased risk of CV events, it is not automatically equivalent to having experienced a myocardial infarction (MI) (and thus does not always warrant aggressive pharmacotherapy). CV risk should be predicted, and therapy guided, by taking into account individual risk factors.” InfoPOEM: “Limited data to guide lipid lowering in octogenarians” http://www.ncbi.nlm.nih.gov/pubmed/20952373 either extremes of cholesterol levels (low or high) are associated with increased mortality in patients >80 years old Non statin lipid medications Tools for Practice 2010: “Ezetimibe: Lowers LDL cholesterol but what else?” http://www.acfp.ca/Portals/0/docs/TFP/20111028_105411.pdf “Eight years after being licensed by the FDA, there is still no evidence that ezetimibe reduces cardiovascular outcomes. It may be worse than niacin and there is concern about a potential increased cancer mortality risk.” Tools for Practice 2012: “Niacin added to statins for cardiovascular disease? 1 + 1 = 1” http://www.acfp.ca/Portals/0/docs/TFP/20120502_095745.pdf “In patients with cardiovascular disease already on statin therapy, adding niacin does not improve cardiovascular events. Among lipid treatments, only statin monotherapy has strong evidence for CVD prevention (regardless of lipid levels).” Tools for Practice 2013: “Fibrates: Statin’s Trusty Sidekick or Lackluster Fallback?” http://www.acfp.ca/Portals/0/docs/TFP/20131007_090323.pdf “When used alone, fibrates reduce non-fatal coronary events, but have no effect on mortality or other CV events, including stroke. Current evidence suggests fibrates provide no advantage when added to statin therapy.” InfoPOEM: “Statins but not fibrates associated with lower risk of pancreatitis” http://www.ncbi.nlm.nih.gov/pubmed/22910758 statins significantly reduced risk of pancreatitis, where as fibrates did not Statin dosing and efficacy Cochrane 2014: “Statins for the primary prevention of cardiovascular disease” http://summaries.cochrane.org/CD004816/statins-for-the-primary-prevention-of-cardiovascular-disease "All-cause mortality was reduced by statins (OR 0.86, 95% CI 0.79 to 0.94); as was combined fatal and non-fatal CVD RR 0.75 (95% CI 0.70 to 0.81), combined fatal and non-fatal CHD events RR 0.73 (95% CI 0.67 to 0.80) and combined fatal and non-fatal stroke (RR 0.78, 95% CI 0.68 to 0.89). Reduction of revascularisation rates (RR 0.62, 95% CI 0.54 to 0.72) was also seen. [...] Evidence available to date showed that primary prevention with statins is likely to be cost-effective and may improve patient quality of life. Recent findings from the Cholesterol Treatment Trialists study using individual patient data meta-analysis indicate that these benefits are similar in people at lower (

We return to the topic of dyslipidemia and examined the: "2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults" http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a Previous episodes on statins can be found here. Major differences between AHA 2013 guideline and CCS 2012 guideline: CCS 2012 AHA 2013 Treatment Threshold LR (FRS20%), history of CVD, DM aged >40: statins LDL >5 mmol/L: statins CVD: statins LDL > 4.9 mmol/L: statins DM aged 40-75: statins 10-year risk >7.5%: statins Treatment Target LDL >50% reduction LDL

In this episode, we listed the life-style management of dyslipidemia and lowering cardiovascular disease risk, and dived into the main classes of medications for lipid lowering: statins, niacin, fibrates, resins, and cholesterol absorption inhibitors. As an important side note, the signs and symptoms of statin-induced myopathies were discussed as well. CCS 2012 guidelines: http://www.onlinecjc.ca/article/S0828-282X(12)01510-3 DASH diet Mayo Clinic info sheet: http://www.mayoclinic.com/health/dash-diet/HI00047 Portfolio diet Original research: http://jama.jamanetwork.com/article.aspx?articleid=1104262 WebMD summary: http://www.webmd.com/cholesterol-management/features/portfolio-diet-lower-cholesterol Mediterranean Diet Mayo Clinic info sheet: http://www.mayoclinic.com/health/mediterranean-diet/CL00011 Coming up: AHA guidelines: http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437738.63853.7a.full.pdf+html Drug information from: Drug monographs CPS: http://www.e-therapeutics.ca/ Therapeutic Choices: http://www.e-therapeutics.ca/ Rx Files: http://www.rxfiles.ca/rxfiles/modules/druginfoindex/druginfo.aspx  

We covered the key points on risk stratification and treatment targets from the 2012 CCS guideline on dyslipidemia. We also briefly highlighted cardiovascular age and secondary causes of dyslipidemia. Below are a few useful links: 2012 Update of the Canadian Cardiovascular Society (CCS) Guidelines for the Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult: http://www.onlinecjc.ca/article/S0828-282X(12)01510-3 Framingham Risk Score worksheet, and cardiovascular age conversion chart: http://www.ccsguidelineprograms.ca/images/stories/Dyslipidemia_Program/Tools_Resources/FRSworksheets/Lipids_EN_FRS_worksheet_v2.pdf Dr. McCormack's graphical FRS tool: http://bestsciencemedicine.com/chd/calc2.html

We reviewed some evidence on the treatment of hypertension that are contradictory to the CHEP 2013 guidelines summarized in our previous episodes. Salt restriction for hypertension CHEP 2013: 1500 mg of sodium per day is recommended for adults age 50 years or less; 1300 mg per day if age 51 to 70 years; and 1200 mg per day if age greater than 70 years Tools for practice: "Cutting out the sodium: The bland supremacy?" http://www.acfp.ca/Portals/0/docs/TFP/20130204_084845.pdf "The impact of salt intake on CVD outcomes is controversial. Trials demonstrating beneficial trends enrolled patients with an average sodium intake of 3900 mg/day and reduced their intake on average by 900mg/day. More evidence with clinical outcomes is required to better define benefits/harms with different levels of daily sodium intake." Hypertension treatment target for diabetes CHEP 2013: BP target for diabetes is 130/80mmHg, and 140/90 for others Cochrane: "Blood pressure targets for hypertension in people with diabetes mellitus" http://summaries.cochrane.org/CD008277/blood-pressure-targets-in-people-with-diabetes "The only significant benefit in the group assigned to 'lower' systolic blood pressure was a small reduction in the incidence of stroke (ACCORD 1.1%ARR SBP

Listen to Tina the pharmacist discuss the 5 first-line antihypertensives: Thiazides ACE Inhibitors Angiotensin Receptor Blockers Beta Blockers Calcium Channel Blockers She lists the mechanism of action, dosing, side effects, drug interactions, and cautionary notes of each drug classes and their representative drug. This episode is wrapped up with Billy's summary of the learning points from the 3-episode series on Hypertension: essential hypertension is a diagnosis of exclusion. we need to consider treatable causes of hypertension especially for people who do not have the usual risk factors. diagnosing a patient with hypertension is a careful process. for those without comorbidities or cardiovascular treatment, it can take a many as 5 visits averaging a BP of 140/90 to make a diagnosis. use home BP measurement if you suspect white coat hypertension. the treatment threshold for uncomplicated patients is 160/100, and threshold for those with end organ damage or increased CV risk is 140/90. a trial of lifestyle management to control BP is appropriate for most uncomplicated patients. it should always be a part of the management plan even for those who are on medication. Treatment target is 140/90, unless the patient has diabetes, for this the threshold is 130/80. For an elderly patient above 80 yo, systolic treatment target is 150 the first line agents are thiazides, ACEI, ARB, BB, and CCB. specific agents may be indicated for specific comorbidities antihypertensive are among the most commonly used medications, but one must not forget that they carry many potentially serious side effects and can interact with other medications. when in doubt, consult your favorite pharmacist

We looked to the CHEP guidelines again for their recommendations on hypertension treatment thresholds, targets, lifestyle management, pharmacologic treatments, and suggested medications for specific comorbidities. Treatment guidelines on CHEP: http://www.hypertension.ca/chep DASH diet: http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3862329/k.4F4/Healthy_living__The_DASH_Diet_to_lower_blood_pressure.htm

This is the first episode of the Family Pharm Podcast. In a series of 3 podcasts, we covered one of the most important disease entities in family practice and community pharmacies: hypertension. In episode 1, we focussed on the diagnosis of hypertension, and we also discussed briefly the secondary causes of hypertension, screening, and investigations. I have summarized the CHEP guidelines used in this podcast on my website: http://www.drbillylin.com/chep-summary/ CHEP guidelines on diagnosis, investigations, and management: http://www.hypertension.ca/chep level of CHEP recommendations explained (many of the guideline recommendations on diagnosis, lab investigations, and follow up are Level D): http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2560862/ CFPC endorses the CHEP guidelines for hypertension: http://www.cfpc.ca/ProjectAssets/Templates/Resource.aspx?id=1538&langType=4105 Canadian Task Force on Preventive Health Care guideline on screening: http://canadiantaskforce.ca/guidelines/screening-for-hypertension/  

Hi, my name is Tina Lien, and I am a 4th year pharmacy student at the University of British Columbia. And my name is Billy Lin, a family medicine resident at UBC. Welcome to episode 0 of what we hope to be a long and fruitful adventure, affectionately named: Family Pharm Podcast. (Pharm spelt with a PH, for pharmacy). The Family Pharm Podcast will cover many priority topics in family medicine and community pharmacy, drawing from the "CFPC 99 topics" as well as topics from the pharmacy bible "Therapeutic Choices". We plan to summarize the established clinical guidelines that will be used for Canadian pharmacy, med school, and family medicine licensing exams, and we hope these would be a good review for practicing clinicians and pharmacists as well. A sample of our priority topics include hypertension, dyslipidemia, diabetes, asthma, and depression. Each podcast will present an approach to one of these diseases, including its diagnosis, common signs and symptoms, and the treatment choices including pharmacologic and nonpharmacologic options. We will include a review of the relevant drug classes associated with each disease as well. Besides covering guidelines for exam preparation and general practice recommendations, when we feel more confident, we may also try to include evidence-based information especially if it conflicts with the guidelines. Things are always more interesting but much trickier when evidence and guidelines clash.  Given that we are strong believers in EBM, we do want to stay true to our scientific conscience whenever possible. Besides, if we don't shed light to some of the hot controversies, our colleagues and mentors in evidence-based practice might leave angry comments on iTunes Store, and we definitely don't want that! This podcast will of course be purely educational. None of what we say here should be taken as medical advice, and don't assume the guidelines are always based on high quality evidence. I mean, even TC and UpToDate have this disclaimer, so please don’t take this student podcast as anything more than it is. And what it is is a student podcast geared towards medical learners and pharmacy students, covering mostly guidelines and established clinical practices used by their exams. Occasionally, the podcast will be punctuated with EBM outbursts when we need an outlet. For a more regularly updated EBM podcast for primary care, we do recommend Mike and James' Best Sciences Medicine Podcast. So that’s all for today! Please stay tuned, relax, and keep your eyes on the road. Thanks for listening and we’ll talk to you next time.