Pharmacotherapy Bedside Guide 1st Edition

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 Pharmacotherapy
Bedside Guide

Christopher P. Martin, PharmD, MS, BCPS

Clinical Assistant Professor
College of Pharmacy, The University of Texas at Austin
Austin, Texas

Robert L. Talbert, PharmD, FCCP, BCPS, FAHA

Professor, College of Pharmacy, University of Texas at Austin
Pharmacotherapy Division
Austin, Texas
Professor, School of Medicine, University of Texas Health Science Center at San Antonio
Pharmacotherapy Education & Research Center (PERC)
San Antonio, Texas

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 Dedication
To Jennifer, Trevor and Mason, without your love and support
this would have remained an unrealized dream. –Chris
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 contents

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Section 1 Cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Section 2 Infectious Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Section 3 Endocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Section 4 Neurology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Section 5 Gastroenterology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Section 6 Pulmonology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Section 7 Nephrology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Section 8 Rheumatology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Section 9 Psychiatry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Section 10 Gynecology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Section 11 Hematology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Section 12 Critical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Section 13 Fluids and Electrolytes . . . . . . . . . . . . . . . . . . . . . . . . 249
Section 14 Pain Management . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Section 15 Urology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283

vii
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 Contributors

Andrea L. Coffee, PharmD, MBA, BCPS Susan J. Rogers, PharmD, BCPS

Scott & White Healthcare Assistant Clinical Professor
Temple, Texas University of Texas at Austin
Section 10 Clinical Pharmacy Specialist Neurology
South Texas Healthcare System
Jason M. Cota, PharmD, MSc, BCPS Audie L. Murphy Veterans Hospital
Assistant Professor San Antonio, Texas
Department of Pharmacy Practice Chapters 4.2, 4.3 and 4.4
University of the Incarnate
Word Feik School of Pharmacy Laurajo Ryan, PharmD, MSc, BCPS, CDE
San Antonio, Texas Clinical Associate Professor
Chapters 2.1 and 2.2 University of Texas at Austin College of Pharmacy
University of Texas Health Science Center
Nicole L. Cupples, PharmD Pharmacotherapy Education Research Center
Clinical Pharmacy Specialist Department of Medicine
Psychiatry, San Antonio State Supported Living Center Austin, Texas
San Antonio, Texas Chapters 3.1 and 5.2
Section 9
Jeffrey S. Stroup, PharmD, BCPS, AAHIVE
Phillip Lai, PharmD, BCPP Associate Professor of Medicine
Community Care Oklahoma State University Center for Health Sciences
Austin, Texas Tulsa, Oklahoma
Section 9 Section 12

Cynthia Mascarenas, PharmD, MSc, BCPP John Tovar, PharmD

Clinical Pharmacy Specialist Associate Professor
South Texas Veterans Health Care System Department of Pharmacy Practice
San Antonio, Texas Feik School of Pharmacy
Clinical Assistant Professor Univeristy of the Incarnate Word
Pharmacy Education and Research Center San Antonio, Texas
The University of Texas Health Science Center at San Antonio Chapters 2.1 and 2.2
San Antonio, Texas
Section 9 Nathan P. Wiederhold, PharmD
Associate Professor
Troy Moore, PharmD, MSc, BCPS University of Texas at Austin College of Pharmacy
Assisant Professor Clinical Assistant Professor
Division of Schizophrenia and Related Disorders UT Health Science Center San Antonio
Department of Psychiatry San Antonio, Texas
University of Texas Health Science Center at San Antonio Chapter 2.3
Clinical Pharmacy Specialist in Psychiatry
South Texas Veterans Health Care System
San Antonio, Texas
Section 9

ix
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 Preface

Albert Einstein is quoted as saying “If you can’t this patient is already taking? Will cost of the medi-
explain it simply, you don’t understand it well cation be a barrier?
enough.” Provision of good medical care is anything We developed this pharmacotherapy reference
but simple. The decision of which pharmacotherapy with Einstein’s words in mind. The exclusive use of
to employ in the course of patient care is one of tables and algorithms provides a structure to display
many complex decisions to be made. The clinician many complex variables in one place. We focused
must simultaneously consider a multitude of vari- on including information that is routinely clinically
ables. What are the possible benefits of the drug relevant to produce a reference that, while not com-
treatment options relative to the risk for the patient prehensive, is high yield. Inside you will find answers
presented by this disease? What does the evidence to many of the questions posed above and some
say about which treatment should be used? How clinical pearls weaved in along the way. We hope this
does the patient’s age, gender, race, or comorbid reference helps you provide the best care for your
diseases affect the choice of pharmacotherapy? patients. Any feedback to improve future editions is
What possible harm could this medicine bring to my most welcome.
patient? Are there any interactions with medicines Chris and Bob, editors

xi
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 Section

1 Cardiology

1.1 Hypertension 3
1.1.1 Antihypertensive Drug Dosing 3
1.1.2 Compelling Indications and Contraindications for Antihypertensives by Class 5
1.1.3 Guideline Recommendations for Drug Therapy of Primary Hypertension Without
Compelling Indications 6
1.1.4 Estimated Antihypertensive Blood Pressure Reduction by Drug Class 7
1.1.5 Antihypertensive Precautions and Adverse Effects by Class 8
1.1.6 Selected Cardiovascular Drug Interactions 10
1.1.7 Pharmacotherapy for Acute Hypertension 12

1.2 Ischemic Heart Disease 13

1.2.1 Pharmacotherapy for Chronic Stable Angina and Primary Prevention of ACS 13
1.2.2 Aspirin Efficacy and Harms in Primary Prevention 14
1.2.3 Pharmacotherapy for Acute NSTEMI 15
1.2.4 Pharmacotherapy for Acute STEMI 16
1.2.5 Pharmacotherapy for Treatment and Secondary Prevention of ACS 17

1.3 Dyslipidemia 20
1.3.1 Approximate LDL Lowering by Statins According to the Rule of 7 20
1.3.2 Comparative Antidyslipidemic Efficacy by Drug Class 21
1.3.3 NIH NCEP Adult Treatment Panel III LDL Cholesterol Goals 21
1.3.4 Antidyslipidemic Drug Dosing 22
1.3.5 Adverse Effects of Antidyslipidemic Drugs 23

1.4 Arrhythmias 24
1.4.1 Management Algorithm for Atrial Fibrillation 24
1.4.2 Rate and Rhythm Control Agents for Atrial Fibrillation 25
1.4.3 Antithrombotic Agents for Atrial Fibrillation 25
1.4.4 Guideline Recommendations for Antithrombotic Therapy for Primary Stroke
Prevention in Atrial Fibrillation 26
1.4.5 Antiarrhythmic Drug Indications and Dosing 27
1.4.6 Antiarrhythmic Drug Adverse Effects 28
1.5 Heart Failure 29
1.5.1 Pharmacotherapy for Heart Failure with Reduced LVEF 29
1.5.2 Digoxin Dosing for Heart Failure 32
1.5.3 Pharmacotherapy for Special Situations in Heart Failure Patients 33
1.5.4 Diuretic Algorithm for Treatment of Volume Overload in Acute Decompensated
Heart Failure 34
1.5.5 Pharmacotherapy for Acute Decompensated Heart Failure 35

A b b r e v i at i o n s
AAD Antiarrhythmic drug ESC European Society of Cardiology
ACC American College of Cardiology GFR Glomerular filtration rate
ACEI Angiotensin-converting enzyme HCTZ Hydrochlorothiazide
inhibitor HF Heart failure
ACS Acute coronary syndrome HR Heart rate
Afib Atrial fibrillation HTN Hypertension
AHA American Heart Association LVEF Left ventricular ejection fraction
AKI Acute kidney injury MI Myocardial infarction
ARA Aldosterone receptor antagonist NCEP National Cholesterol Education
ARB Angiotensin receptor blocker Program
BB Beta blocker NDCCB Non-dihydropyridine calcium channel
BP Blood pressure blocker

BPM Beats per minute NSTEMI Non-ST-elevation myocardial infarction

CABG Coronary artery bypass graft NTG Nitroglycerin

CAD Coronary artery disease PCI Percutaneous coronary intervention

CCB Calcium channel blocker SBP Systolic blood pressure

CKD Chronic kidney disease SDC Serum digoxin concentration

DBP Diastolic blood pressure SL Sublingual

DCC Direct current cardioversion STEMI ST-elevation myocardial infarction

DCCB Dihydropyridine calcium channel UFH Unfractionated heparin

blocker TdP Torsades de Pointes
DM Diabetes mellitus TEE Transesophageal echocardiogram
 1.1 | Hypertension 3

TABLE 1.1.1 Antihypertensive Drug Dosing

Daily Dose Range
Drug (Brand) Generic (mg/day) Doses Per Day
ACE Inhibitors
Benazepril (Lotensin) Y 10–40 1 or 2
Captopril (Capoten) Y 12.5–150 2 or 3
Enalapril (Vasotec) Y 5–40 1 or 2
Fosinopril (Monopril) Y 10–40 1
Lisinopril (Prinivil, Zestril) Y 10–40 1
Moexipril (Univasc) Y 7.5–30 1 or 2
Perindopril (Aceon) Y 4–16 1
Quinapril (Accupril) Y 10–80 1 or 2
Ramipril (Altace) Y 2.5–10 1 or 2
Trandolapril (Mavik) Y 1–4 1
ARBs
Candesartan (Atacand) N 8–32 1 or 2
Eprosartan (Teveten) N 600–800 1 or 2
Irbesartan (Avapro) N 150–300 1
Losartan (Cozaar) Y 50–100 1 or 2
Olmesartan (Benicar) N 20–40 1
Telmisartan (Micardis) N 20–80 1
Valsartan (Diovan) N 80–320 1
BBs—β1 Selective
Atenolol (Tenormin) Y 25–100 1
Betaxolol (Kerlone) Y 5–20 1
Bisoprolol (Zebeta) Y 2.5–10 1
Metoprolol tartrate (Lopressor) Y 100–400 2 or 3
Metoprolol succinate (Toprol XL) Y 50–200 1
Nebivolol (Bystolic) N 5–20 1
BBs—Nonselective—β1 and β2
Nadolol (Corgard) Y 40–120 1
Propranolol (Inderal) Y 160–480 2
Propranolol long-acting (Inderal LA) Y 80–320 1
Timolol (Blocadren) Y 10–40 1
BBs—Nonselective—β1, β2, and α1
Carvedilol (Coreg) Y 12.5–50 2
Carvedilol phosphate (Coreg CR) N 20–80 1
Labetalol (Normodyne, Trandate) Y 200–800 2
(Continued)