Home CPD An update on atrial fibrillation

An update on atrial fibrillation

CPD

November 29, 2018

CPD credits

Accreditation Code : CAP1811A

Group 1 : 0.75 CPD credits

Group 2 : 1.5 CPD credits

This activity has been accredited for 0.75 hours of Group 1 CPD (or 0.75 CPD credits) suitable for inclusion in an individual pharmacist's CPD plan, which can be converted to 0.75 hours of Group 1 CPD (or 1.50 CPD credits) upon successful completion of relevant assessment activities.

Case scenario

Mr Jones, a 59-year-old man, was recently discharged from hospital following an admission for breathlessness and palpitations. His 12-lead electrocardiogram (ECG) confirmed fast atrial fibrillation, and a transthoracic echocardiogram showed a dilated left atrium and mitral stenosis. His past medical history includes hypertension treated with amlodipine 5 mg daily. He also currently takes aspirin 75 mg daily and simvastatin 40 mg daily.

He presents to your community pharmacy with new prescriptions for:

metoprolol 50 mg twice daily
warfarin 1 mg and 3 mg tablets as per international normalised ratio (INR)
simvastatin 40 mg at night.

He asks you about the changes in his medication.

Learning objectives

After successful completion of this CPD activity, pharmacists should be able to:

Discuss the prevalence and sequelae of atrial fibrillation
Describe key steps in the diagnosis of atrial fibrillation
Discuss key features of latest evidence-based guidelines for the management of atrial fibrillation
Discuss the importance of pharmacist-led patient education on atrial fibrillation.

Competencies (2016) addressed: 1.1, 1.5, 3.1, 3.2, 3.5.

Accreditation code: CAP1811A

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MEDICINE AND ROUTE	VARIOUS ADVERSE REACTIONS
*Cladribine (Mavenclad) - oral*	Lymphopenia, herpes zoster, headache
*Dimethyl fumerate (Tecfidera) – oral*	Gastrointestinal upset, flushing, lymphopenia, PML, hepatotoxicity
*Fingolimod (Gilenya) – oral*	Bradyarrhythmia (cardiac monitoring required on initiation and treatment interruption), skin cancers, visual pain and changes, macular oedema (increased risk with history of uveitis or diabetes), lymphopenias, PML
*Teriflunamide (Aubagio) – oral*	Nausea, diarrhoea, alopecia, rash, paraesthesia, peripheral neuropathy, interstitial lung disease
*Alemtuzumab (Lemtrada) – intravenous*	Autoimmune disorders (e.g. thyroid autoimmunity, immune thrombocytopenic purpura, cytopenias and nephropathies), routine monitoring required. Infusion-related reactions. Risk of listeria meningitis, prophylaxis and dietary restrictions required
*Natalizumab (Tysabri) – intravenous*	PML (risk increased with previous or concurrent immunosuppressant use, treatment duration exceeding 2 years and seropositive for anti-JC serum antibodies), infusion-related reactions, hepatotoxicity
*Ocrelizumab (Ocrevus) – intravenous*	Neutropenia (usually transient), infusion and hypersensitivity reactions
*Interferon beta 1a (Avonex) – intramuscular*	Myalgia, headache, flu-like symptoms (reduced with paracetamol beforehand and night-time administration), depression, leucopenia, hepatotoxicity
*Interferon beta 1a (Rebif) – subcutaneous*
*Interferon beta 1b (Betaferon) – subcutaneous*
*Peginterferon beta 1a (Plegridy) – subcutaneous*
*Glatiramer acetate (Copaxone) – subcutaneous*	Injection site reactions Immediate post-injection reactions (chest pain, dyspnoea, flushing, palpitations)

ADULTS	CHILDREN<14 YEARS OLD	TREATMENT DURATION
Ethambutol 15 mg/kg up to 1,200 mg daily	Child <14 years 20 mg/kg up to 1,200 mg once daily	2 months
Pyrazinamide 25 mg/kg up to 2,000 mg	Child <14 years 35 mg/kg up to 2,000 mg once daily	2 months
Isoniazid 10 mg/kg up to 300 mg daily	Isoniazid 10 mg/kg up to 300 mg once daily	6 months
Rifampicin 10 mg/kg up to 600 mg daily	Child <14 years (>50 kg) 600 mg once daily Child <14years (<50 kg) 15 mg/kg up to 450 mg once daily	6 months
*Pyridoxine 25 mg with each dose of isoniazid	Child *Pyridoxine 6.25–12.5 mg with each dose of isoniazid	Duration of isoniazid treatment

ADULTS	CHILDREN	TREATMENT DURATION
Isoniazid 10 mg/kg up to 300 mg daily	Isoniazid 10 mg/kg up to 300 mg once daily	6 months OR 9 months
Rifampicin 10 mg/kg up to 600 mg daily	Child <14 years (>50 kg) rifampicin 600 mg once daily Child <14 years (<50 kg) rifampicin 15 mg/kg up to 450 mg once daily	4 months
*Rifampicin 10 mg/kg up to 600 mg daily PLUS* Isoniazid 10g/kg up to 300 mg daily**	Child<14 years (>50 kg) Rifampicin 600 mg once daily *PLUS* Isoniazid 10g/kg up to 300 mg once dailyChild <14 years (<50 mg) Rifampicin 15 mg/kg up to 450 mg once daily *PLUS* Isoniazid 10g/kg up to 300 mg once daily	3 months
*Rifapentine 900 mg weekly PLUS* Isoniazid 15 mg/kg up to 900 mg weekly**	Child ≥12 years (>50 kg) Rifapentine 900 mg once weekly Child ≥12 years (32.1–50 kg) Rifapentine 750 mg once weekly Child 2–11 years (10–14 kg) Rifapentine 300 mg once weekly Child 2–11 years (14.1–25 kg) Rifapentine 450 mg once weekly Child 2–11 years (25.1–32 kg) Rifapentine 600 mg once weekly Child 2–11 years (32.1–50 kg) Rifapentine 750 mg once weekly Child 2–11 years (>50 kg) Rifapentine 900 mg once weekly PLUS Child≥12 years Isoniazid 15 mg/kg up to 900 mg once weekly Child 2–11 years Isoniazid 25 mg/kg up to 900 mg once weekly	3 months
*Pyridoxine 25 mg with each dose of isoniazid	Child *Pyridoxine 6.25–12.5 mg with each dose of isoniazid	Duration of isoniazid therapy

THERAPEUTIC AGENT	COMMON ADVERSE EFFECTS (>1%)	PRECAUTIONS	SELECTED COUNSELLING POINTS
Isoniazid	Nausea, rash, fever, peripheral neuritis, aminotransferases, hepatitis, acne, fatigue, alertness, antinuclear antibodies	Epilepsy, CNS toxicity with cycloserine, risk of peripheral neuropathy (malnutrition, diabetes, HIV infection, alcoholism)*	Best absorbed when taken on an empty stomach. Tyramine or histamine rich foods can cause tachycardia, postural hypotension, flushing, itch, headache or sweating – avoid if affected
Rifampicin	GI symptoms (nausea, vomiting, cramps), rash, LFTs, orange-red colouration of body fluids#	Contraindicated in jaundice, may worsen hepatic impairment, risk of hepatotoxicity in combination with hepatotoxic drugs (e.g. isoniazid), effectiveness of the pill	Best absorbed when taken at least half an hour before food. Take it regularly (allergy is more likely with intermittent dosing). Inform prescriber if: rash, fever and swollen glands, loss of appetite, nausea, vomiting, unusual tiredness, jaundice, dark urine or pale faeces
Rifapentine²⁷	Endocrine and metabolic disturbance, haematologic reactions, genitourinary symptoms, GI, CV, CNS, respiratory and ophthalmic symptoms, rash, LFTs, neuromuscular and skeletal symptoms, orange-red discolouration of body fluids#	Use with caution in hepatic impairment. Not recommended for use in patients with porphyria	Best absorbed with meals – high fat meals increase absorption
Ethambutol	Optic neuritis	Contraindicated in optic neuritis. May cause changes in vision. May precipitate gout	Vision may be affected (e.g. clarity and colour). Cease and inform prescriber of any changes to eyesight
Pyrazinamide	Hyperuricaemia, polyarthralgia, nausea	Contraindicated in acute gout and significant liver disease	Cease and inform prescriber if: continuous nausea, vomiting, unusual tiredness, yellowing of the skin or whites of eyes, dark urine or pale faeces
Pyridoxine	None listed	None listed	Avoid unnecessary use. Prolonged high doses may be toxic and cause peripheral neuropathy

	ACUTE MANIA		MAINTENANCE
DRUG CLASS	TGA APPROVED	PBS LISTED	TGA APPROVED	PBS LISTED
Olanzapine tablets or wafers	✔	✘	✔	✔
Olanzapine IM injection	✘	✘	✘	✘
Risperidone (tablets, oral solution)	✔	✔ (Adjunctive up to 6 months with mood stabiliser)	✘	✘
Risperidone long-acting injectable			✔	✔ (Refractory to treatment, + lithium or sodium valproate)
Quetiapine immediate-release	✔	✔ (Monotherapy only up to 6 months)	✔	✔
Quetiapine extended-release	✔	✔ (Monotherapy only up to 6 months)	✔	✔
Ziprasidone	✔*	*✔ (Monotherapy only up to 6 months)**	✘	✘
Aripiprazole tablets	*✔#**	✘	*✔ (Monotherapy only)**	✘
Aripiprazole long-acting injectable	✘	✘	✘	✘
Asenapine	*✔#**	*✔ (Up to 6 months)**	*✔#**	✔ (Monotherapy only)
Amisulpride	✘	✘	✘	✘
Brexpiprazole	✘	✘	✘	✘
Clozapine	✘	✘	✘	✘
Lurasidone	✘	✘	✘	✘
Paliperidone oral and long-acting injectable	✘	✘	✘	✘

DRUG CLASS	KEY INTERACTIONS	KEY MONITORING
Antipsychotics	Medicines that lower seizure threshold Anticholinergic agents CNS depressants (alcohol, benzodiazepines) Check CYP table for specific agent	Extrapyramidal adverse effects (particularly for older agents) Sedation Anticholinergic effects Hyperprolactinaemia Cardiovascular health (hyperglycaemia, weight gain), orthostatic hypotension, Routine full blood count and liver function Clozapine requires additional specific monitoring⁴⁷
MOOD STABILISERS
*Lithium*	Medicines that reduce renal clearance (e.g. NSAIDs) Serotonergic medicines Carbamazepine (increased risk of neurotoxicity) Medicines that cause hyponatraemia and/or affect electrolyte balance	Lithium toxicity: nausea/vomiting, extreme thirst, frequent urination, blurred vision, tremor, disorientation Adherence – avoid stopping abruptly Increased monitoring during periods of illness (care with hyponatraemia) Therapeutic drug monitoring e.g. every 3 months once stabilised Renal and thyroid function
*Sodium valproate*	Medicines metabolised by glucuronidation (e.g. lamotrigine) Olanzapine (increased dose of olanzapine may be required) Carbamazepine (increased risk of carbamazepinerelated adverse effects. Monitor clinical effect. Carbamazepine and valproate dose adjustment may be required)	Signs of jaundice, bruising, bleeding, abdominal pain Signs of hypersensitivity reactions, e.g. rash, fever Increased appetite and weight gain Care if used with other medicines that affect the clotting process Bone mineral density, vitamin D and calcium intake (long-term treatment)
*Carbamazepine*	Check CYP table (CYP3A4, CYP2C9, CYP2B6 inducer) Medicines metabolised by glucuronidation (e.g. lamotrigine) Valproate (increased dose of valproate may be required, see sodium valproate) Avoid grapefruit juice	Signs of hypersensitivity and skin reactions (people of Asian ancestry at higher risk): rash, sore throat, bruising, bleeding Periodic full blood count Bone mineral density, vitamin D and calcium intake (long term treatment) Sedation: increases the effect of alcohol
ANTIDEPRESSANTS
*SSRIs*	Check CYP table for specific agent Lithium: may contribute to serotonin toxicity Other serotonergic medicines e.g. opioids, St John’s Wort Other medicines that cause hyponatraemia Care if used with other medicines that affect the clotting process	Manic symptoms Serotonin toxicity: confusion, signs related to hypomania, agitation, fever, sweating, diarrhoea Care if used with other medicines that affect the clotting process Increased monitoring during periods of illness (care with hyponatraemia) Adherence – avoid stopping abruptly Check concerns with adverse effects, e.g. sexual dysfunction, dry mouth, drowsiness or insomnia (consider dose timing) Counsel regarding suicidal ideation
*SNRIs*	Lithium: may contribute to serotonin toxicity Other serotonergic medicines e.g. opioids, St John’s Wort Other medicines that cause hyponatraemia Care if used with other medicines that affect the clotting process	Manic symptoms Serotonin toxicity: confusion, signs related to hypomania, agitation, fever, sweating, diarrhoea Increased monitoring during periods of illness (care with hyponatraemia) Adherence – avoid stopping abruptly Cardiovascular health: blood pressure (particularly if using antihypertensive agents or hypertensive medicines) Check concerns with adverse effects, e.g. sexual dysfunction, dry mouth Counsel regarding suicidal ideation

PRODUCT	INGREDIENT(S)	ADMINISTRATION
*Duofilm*	Salicylic acid 16.7% Lactic acid 15%	Apply 2–4 drops daily using applicator
*Scholl wart removal system*	Discs containing salicylic acid 40%	Apply over wart, cover with plaster and change every 48 hours
*Scholl verucca and wart freeze remover kit*	Dimethyl ether and propane	Freezes warts. Follow manufacturer’s instructions. For adults and children >4 years
*Surgipack Caustic Pencil*	Silver nitrate 427.5mg Potassium nitrate 22.5mg	Wet tip of pencil with water before application
*Wart eze*	Dimethyl ether, propane, butane	Freezes warts. Follow manufacturer’s instructions. For adults and children >4 years.
*Wartie Freeze*	Dimethyl ether and propane	Freezes warts. Follow manufacturer’s instructions. For adults and children >4 years.
*Wartie Advanced*	Dimethyl ether plus conductive gel	Freezes warts. Adults and children aged 12+ years. Gel is claimed to increase freezing potential
*Wartner common wart remover and Plantar wart remover*	Dimethyl ether and propane	Freezes warts. Follow manufacturer’s instructions. For adults and children >4 years.
*Wart-Off Stick*	Salicylic acid 40%	Apply daily according to manufacturer’s instructions
*Wart-Off Paint*	Salicylic acid 20%, lactic acid 12.5%, podophyllum resin 10%	Apply daily according to manufacturer’s instructions
*Wart-Off Freeze Spray*	Dimethyl ether and propane	Freezes warts. Follow manufacturer’s instructions. For adults and children >4 years

TREATMENT OPTIONS	USE IN ACUTE FLARE MANAGEMENT
NSAIDs	Oral dose (at upper end of dosing range) until symptoms abate (typically 3–5 days)
Colchicine	Orally 1 mg, then 0.5 mg one hour later, as a single one-day course (total dose is 1.5 mg)
Corticosteroids	Prednisone/prednisolone, orally 15–30 mg daily until symptoms abate (typically 3–5 days)

TREATMENT OPTIONS	USE IN CHRONIC MANAGEMENT
*Allopurinol*	Allopurinol 50 mg orally, daily for 4 weeks; then increase the daily dose by 50 mg every 2–4 weeks or by 100 mg every 4 weeks to achieve the target serum urate concentration, up to a maximum maintenance dose of 900 mg daily
*Probenecid*	Probenecid 250 mg orally, twice daily for 1 week, then increase to 500 mg twice daily; increase the daily dose by 500 mg every 4 weeks to achieve the target serum urate concentration, up to a maximum maintenance dose of 2 g daily in divided doses
*Febuxostat*	Febuxostat 40 mg orally, daily for 2–4 weeks; then increase the daily dose by 40 mg every 2–4 weeks to achieve the target serum urate concentration, up to a maximum maintenance dose of 120 mg daily

Taking precautions

Vulnerable patients

A time for collaboration

Restricted access

Keep communication simple

Increased hygiene practices

Easier home deliveries

Roster changes

Options for delivery

Existing examples

Seek support

Where did the issue surrounding ibuprofen and COVID-19 originate?

What does this mean in the Australian context?

Information for pharmacists

Standard infection control precautions

Enhanced infection control precautions

The novel coronavirus?

HELP US HELP YOU

Pollutants

Air pollution and cardiac events

What are the symptoms of a coronavirus infection?

Tips for prevention

Local breakthrough

Combined response needed

Introduction

Learning objectives

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Epidemiology, pathophysiology and risk factors

Treatment strategies and guidelines

TABLE 1 – Multiple sclerosis treatment options

Treatment of RRMS

Symptom management

Falls risk

Bladder and bowel symptoms

Emotional health and cognitive changes

BOX 1 – Indications of cognitive impairment in PML

Comorbidities

Cardiovascular, cerebrovascular and peripheral vascular disease comorbidities

Autoimmune comorbidities

Gastrointestinal comorbidities

Pulmonary comorbidities

Ocular comorbidities

Lifestyle Modifications

Conclusion

Key points

Overview

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Transmission of TB

TB in Australia

BOX 1 – RISK FACTORS FOR TB IN AUSTRALIA

FIGURE 1 – Progression of TB

Diagnosis of TB

BOX 2 – SYMPTOMS OF TB

Prevention and control of TB in Australia

Treatment of TB

TABLE 1 – Oral treatment regimen for fully drug-susceptible TB

Mechanism of action

Treatment of latent TB

Directly observed therapy

Conclusion

TABLE 2 – Oral treatment regimens for latent TB

TABLE 3 – Common adverse effects, precautions and counselling points

Key points

Case scenario

Learning objectives

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Introduction

FIGURE 1 – Life course of bipolar disorder

BOX 1 – TERMINOLOGY GUIDE

Diagnostic challenges

Mental health co-morbidities

Medicine options at different stages of the illness

Acute mania

Maintenance treatment

TABLE 1 – Indications and PBS listings for atypical antipsychotic drugs in bipolar I disorder

Depressive phase treatment

Treatment preferences and adherence

TABLE 2 – Considerations for commonly used bipolar medicines

Role of the pharmacist

Case scenario continued