PROPANOLOL (I NDERAL, I NDERAL – LA GENERIC ) A CARDIOVASCULAR BETA BLOCKER TEAM 2 MEMBERS: Stella O. Akpuaka Bosede Adedire Tamika Missouri Amanda Rothenbecker

W HAT ARE C ARDIOVASCULAR AGENTS ? Wide variety of drugs used for management and treatment of several different conditions of the heart and blood vessels. Classes: Antihypertensives Thiazide Diuretics Beta Blockers ACE Inhibitors Calcium Channel blockers Angiotensin II Receptor Blockers Alpha 1 Blockers Alpha 2 Agonists

W HAT ARE B ETA BLOCKERS ?

N AME AND C LASSIFICATION Drug Name: PROPRANOLOL: generic Inderal; Inderal Long acting (LA) - Brand name Classification: KEY Beta Blocker Drug

P HARMACODYNAMICS All Beta blockers have similar mechanisms of action which is competitive blockade of Beta Adrenergic receptor. Effects of the Propranolol on the body includes: Highly selective to Beta 1 & Beta 2 receptors Decreasing heart rate Supraventricular conduction and cardiac output Decrease Cardiac work load and oxygen consumption Decrease the secretion of renin. Therapeutic level mg/ml (better effect)

P HARMACOKINETICS Lipid soluble (lipophilic) Excretion Hepatic (Liver) Absorptions rate % Availability after first pass % Peak time of concentration hrs Half life hrs; 8-11hrs for long acting Duration of action hrs Protein bound % Hepatic Metabolism D6 substrate

I NDICATION /R ECOMMENDED D OSAGE Hypertension: mg/day bid -tid; max dose 640mg Angina: mg/day; max dose 320 mg Essential tumor: 120mg/day; max dose 320 mg Off-label use: Migraine Prophylaxis

C ONTRAINDICATION The use of Propranolol is contraindicated in the following conditions: Sinus bradycardia Greater than first degree heart block Cardiogenic shock Pulmonary edema Severe Asthma or COPD Raynaud’s disease Pregnancy (second and third trimesters) Uncompensated heart failure Hypersensitivity

B-B LOCKERS

P ROPRANOLOL P RECAUTIONS Avoid in patients with anaphylactic allergic reactions May mask signs and symptoms of hypoglycemia Cautiously use in patients with hepatic/ renal impairment Cautiously use in patients with reactive airway

R EVIEW OF L ITERATURE Approved in 1967, Propranolol is one of the most frequently prescribed beta-adrenergic blocking agents to treat hypertension, angina, and arrhythmias. Usually used in combination with other cardiac drugs, for example: ACE inhibitors and diuretics to control blood pressure. Off-label uses include management of migraines, tremors, and anxiety

I MPLEMENTATION P LAN : P RESCRIBING AND C ULTURAL C ONSIDERATIONS Diuretics are the first line for African-Americans since Beta Blockers can be less predictable Asian American were less responsive to beta blockers than Caucasians Language Barrier- Providing patient with information on the regimen in the appropriate language, or with the help of a translator Language barriers and cultural barrier were are the top predictor of non adherence in elderly Chinese Americans

I MPLEMENTATION P LAN : A GE, E THNICITY Age : The polypharmacy that accompanies increased comorbidities in age decreases compliance. Medication information in a larger font Reinforcing regimen at follow up visits Asking patient to bring medication bottles to all appointment Remember that hypertension has increasing morbidity in younger populations. Beta Blockers should be avoided as first line in youth due to delayed growth and lipid panel abnormalities

I MPLEMENTATION P LAN : A DHERENCE A telephone follow-up to Medicare patients, by pharmacists, has shown to increase patient adherence with home antihypertensive medications Frequent dosing and increased cost decreases adherence Patient’s are more likely to be adherent to a regimen that is started during a hospital admission because they relate the medication to the disease

S PECIAL C ONSIDERATIONS Pregnancy and Lactation: Category C - Teratogenic and embryo toxic effects have been demonstrated in animals. Give drugs only if the potential benefit justifies the potential risk to the fetus. Pediatrics: Safety and effectiveness of beta blockers, with the exception of propranolol, has not been established in children. Geriatrics: There is potential for drug accumulation in the elderly, therefore, therapeutic doses must be small and titrated slowly in the elderly. Patients with liver impairments: Propranolol should be administered with caution to patients with impaired renal and hepatic function, half-life of propranolol may be increased in these patients.

E VIDENCED B ASED G UIDELINES The American Association of Cardiology (AAC) in conjunction with American Heart Association (AHA) emphasize education on risk reduction for coronary arterial disease. The AAC/AHA update recommend that all patient with cardiac disease be seen by a cardiologist before initiating a beta blocker. Beta blocker therapy should be used in all patient with left ventricular systolic dysfunction (ejection fraction <40%), with heart failure or prior myocardial infarction unless contraindicated. Allow one to two months for a drug trial with beta blockers to adjust dose and monitor for therapeutic response and adverse reactions.

R EFERENCES Albert, N. M. (2008). Improving medication adherence in chronic cardiovascular disease. Critical Care Nurse, 28 (5), Barner, J. C., Gabrillo, E. R., Godly, P. J., & Moczygemba, L. R. (2008). Development and implementation of a telephone medication therapy management program for Medicare beneficiaries. American Journal of Health- System Pharmacy, 65 (17), Edmunds, M. W. & Mayhew, M.S. (2013). Pharmacology for the Primary Care Provider. ( 4th ed.). St. Louis, MO: Mosby Elsevier. Flynn, J. (2011). Management of hypertension in the young: role of antihypertensive medications. Journal of Cardiovascular Pharmacology, 58 (2).

R EFERENCES Hao, J., Yang, M. B., Liu, H. & Li, S. K. (2011). Distribution of propranolol in periocular tissue: A comparison of topical and systemic administration. Journal of Ocular Pharmacology and therapeutics, 27 (5) Hsu, Y., Mao, C., & Wey, M. (2010). Antihypertensive medication adherence among elderly Chinese Americans. Journal of Transcultural Nursing, 21 (4), Johnson, J. (2008). Ethnic differences in cardiovascular drug response. New Drugs and Technologies, 118, Shamliyan, T., Choi, J. Y., Ramakrishnan, R., Miller, J., Wang, S. Y., Taylor, F. & Kane R. (2013). Preventive pharmacologic treatment for episodic migraine in adults. Journal of General Internal Medicine, 28 (9),