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The Macstrak Project
Medication
Classification
The Macstrak Project
Issues
Macstrak follows drug interventions by drug class rather than the specific agent (e.g. B blocker po rather than metoprolol)
• to get reliable data first need to ensure understanding of where data captured on Macstrak form
• need to know proper drug classes
• need to know the generic as well as trade names
• accuracy in form completion improves as staff become more comfortable with knowing the drug classes
• teaching resources available for staff on Macstrak website
The Macstrak Project
In this presentation
1. Review – where data collected on Macstrak forms
2. Understand – description of each drug class
3. Review– tables of generic versus brand name
4. Learn – resources available for on-going support
The Macstrak Project
Yes Thrombolysis Here EMS Other Hosp
Dose: (mg/units)
Duration: (min)
Pt.Weight: (kg)
Reperfusion Therapy:
No Not Indicated: ECG Not Diag. ST Up Transient Too Late Given (Other Hosp) Risk: Risk of ICB Risk Other Bleed Other: ……………......
Drug: TNK/rtPASKr-PA (reteplase)Other
Adjuvant: ASA Heparin GP2b/3a Inhibitor blocker IV Clopidogrel Other ...............................
and/or Primary/Rescue PCI Here Transfer Reperfusion Therapy Decided by: EP Consultant
Yes Thrombolysis Here EMS Other Hosp
Dose: (mg/units)
Duration: (min)
Pt.Weight: (kg)
Review - Macstrak Form
Three sections where medications tracked on the CCU form:1. ACS Initial Management – Adjuvant Therapy
The Macstrak Project
Acuity: Shift: Diuretics……………………… Inotropes IV………………….. ETT/Vent…………………….. PA Line………………………. TTVP………………………… IABP………………………….ACS: RSCP - Ischemia – Definite….
– Probable… CK (+ve)………………...…… Troponin (+ve)……………….. NTG IV………………………. Heparin – UFH……………..... – LMWH……………. Other Antithrombin………...… GP 2b/3a Inhibitor IV……...… Clopidogrel (or thienopyridne)..… Cardiac Cath……………….... PCI…………………………... Outcomes: VF/Sustained VT………….… Infarction (new/repeat)*(1) …... Thrombolysis (new/repeat)*(2)..
Stroke*(3) ……………………. Major Bleed*(4) ……………… Transfusion………………….. Crs1: ……………………….... Crs2: ……………………..….. None of the Above……….….. RN Initials ………………..….
Date: D N D N ND
Review - Macstrak Form
Three sections where medications tracked on the CCU form:
1. ACS Initial Management – Adjuvant Therapy
2. Course in CCUNone of the Above needs to be markedif no medication/treatments are given – lets us know that the information is not missing.
The Macstrak Project
Discharge Meds: ASA Clopidogrel (thienopyridine) Heparin (UF or LMW) Nitrates (po/top) B Blocker ACEI A2 Blocker Statin None of the Above
Review - Macstrak FormThree sections where
medications are tracked on the CCU form:
1. ACS Initial Management – Adjuvant Therapy
2. Course in CCU
3. CCU DischargeNone of the Above needs to be markedif no medication is given – lets usknow that the information is not missing.
The Macstrak Project
Review - Macstrak Form
One section where medications are tracked on the ER form:
1. Course in ER
ACS Management: (all) ASA Heparin UFH Heparin LMWH Clopidogrel (thienopyridine)
GP2b/3a Inhibitor IV Other Antithrombin NTG IV NTG topical/po Blocker IV Blocker po Calcium Antagonist (any) ACEI A2 Blocker Research Protocol None of the Above
None of the Above needs to be markedif no medication is given – lets usknow that the information is not missing.
Optional fields are available to track specific medications if your unit wishes.
The Macstrak Project
Review - Macstrak Form
One section where medications are tracked on the Ward form:
1. Course in Ward
Drugs: PTA PTW Ward Disch
ASA ……………………………………………………. Coumadin ………………………………………. Heparin UFH ……………………………. Heparin LMWH ………………………… Clopidogrel (thienopyridine) ……..……. GP 2b/3a Inhibitor (IV) …………… Other Antithrombin …….…………… Oral Hypoglycemic ………………… Insulin ………………………………………………. Statin …………………………………………………. Other Antilipid …………………………... Bronchodilator …………………………… Digoxin ……………………………………………. Any Antiarrhythmic ………………. Calcium Antag …………………………… ACEI .…………………………………………………… A2 blocker ………………………………………. Other Vasodilator ……...………………. Diuretic ……………………….……………………... Nitrates top/oral ………………………….. Nitrates IV ……………………………….……... Blocker - Any …………………………... Blocker - Carvedilol …………... Study Drug - antiplatelet …... - antithrombin . - other …………………. Smoking ………………………………………….. ……………………………..….. HRT ……………………………………………………. ……………… ……………..….. Optional Fields: Crs1: …………………………….. Crs2: …………………………….. Crs3: …………………………….. Crs4: …………………………….. None of the Above …………………..
RN Initials ……………………………………..
None of the Above needs to be markedif no medication is given – lets usknow that the information is not missing.
Optional fields are available to track specific medications if your unit wishes.
The Macstrak Project
Thienopyridines - What & How
• oral anti platelet therapy
• indications:– ACS– stents– aspirin is not tolerated– dual anti platelet therapy desired
• ADP-receptor antagonist
• binds irreversibly to P2Y12 receptors, modify the platelet
P2Y12 receptor therefore ADP can’t bind to it
• reduces platelet aggregation that persists for the life of the platelets
The Macstrak Project
Thienopyridines -Who
Generic Name
Brand Name
clopidogrel Plavix®
ticlopidine Ticlid®
prasugrel Effient *
* Drug has not yet come to market.
The Macstrak Project
GP2b/3a inhibitors -What• anti platelet therapy IV
• indications:– ACS– PCI
• final step in platelet aggregation - binding of fibrinogen between two platelets at the GP2b/3a receptor, inhibitors block this final pathway, decreasing platelet aggregation regardless of the mechanism by which the platelets are activated
• issue for all these therapies has been determining effective dosing
The Macstrak Project
GP2b/3a inhibitors - How
The Macstrak Project
GP2b/3a inhibitors - Who
Generic Name
Brand Name
abciximab Reopro®
eptifibatide Integrillin®
tirofiban Aggrastat®
The Macstrak Project
UF Heparin - What & How• antithrombin
• indications:– ACS– atrial fibrillation– deep vein thrombosis– pulmonary embolism
• UF Heparin binds to the enzyme inhibitor antithrombin (AT) causing a conformational change that results in its activation through an increase in the flexibility of its reactive site loop
• activated AT then inactivates thrombin, with also a lesser effect on factor Xa
The Macstrak Project
LMW Heparins - What & How• antithrombin
• indications:– ACS– atrial fibrillation– deep vein thrombosis– pulmonary embolism
• sub group of proteins included in UFH
• although all different protein groups - they have a greater effect on anti factor Xa
• PT/PTT cannot be used to follow
• they are not bound to acute phase reactants therefore dose response is more predictable
The Macstrak Project
Heparins - Who
Generic Name Brand Nameheparin (unfractionated)
Hepalean®
enoxaparin Lovenox®
dalteparin Fragmin®
tinzaparin Innohep®
The Macstrak Project
• mostly direct thrombin inhibitors but a variety of targets
• indications:– heparin-induced thrombocytopenia (HIT)– PCI– ACS
• most are intravenous only exception coumadin
• new oral agents in development
Other Antithrombins–What & How
The Macstrak Project
Generic Name Brand Nameargatroban Argatroban ®
bivalirudin Angiomax®
lepirudin Refludan®
danaparoid Organon®
fondaparinux Arixtra ®
warfarin Coumadin®
dabigatran Pradaxa *
Other Antithrombins - Who
* Drug has not yet come to market.
The Macstrak Project
β-blockers - What & How• beta (alpha) adrenergic receptor antagonists
• indications:– arrhythmias– AMI cardioprotection– decrease incidence of occlusion events
• fight or flight block the action of endogenous catecholamines (epinephrine – adrenalin and norepinephrine – noradrenaline) on β-adrenergic receptors part of the sympathetic nervous system
• cardioprotection, management of cardiac arrhythmias, blocks activation of clotting system
• reduces the sympathetic activation of platelets, and the clotting system (PAI-1)
The Macstrak Project
β-blockers - Who
Generic Name
Brand Name
acebutalol Sectral®
atenolol Tenormin®
carvedilol Coreg®
labetalol Trandate®
metoprolol Lopresor®
nadolol Corgard®
propanolol Inderal®
sotalol Sotacor®
bisoprolol Monocor®
The Macstrak Project
ACE inhibitors - What
• Angiotensin-Converting Enzyme inhibitor decreasing the activation of the renin/angiotensin system
• indications:– prevention of cardiovascular events– CHF– hypertension– left ventricular dysfunction
• Reduces PAI-1 levels to decrease clot formation• reduces afterload, lowers arteriolar resistance,
decreases cardiac work and oxygen demand• lowers renovascular resistance, increases natriuresis
(excretion of sodium in urine)
The Macstrak Project
ACE inhibitors - How
The Macstrak Project
ACE inhibitors - Who
Generic Name
Brand Name
benazepril Lotensin®
captopril Capoten®
cilazapril Inhibace®
enalapril Vasotec®
fosinopril Monopril®
lisinopril Prinivil®, Zestril®
quinipril Accupril®
ramipril Altace®
The Macstrak Project
A2 blockers - What & How• angiotensin receptor blocker
• indications:– hypertension - intolerance to ACE inhibitors
• modulate the renin-angiotensin-aldosterone system by blocking activation of angiotensin II AT1 receptors causes vasodilation
• effects are similar to ACEI but no cough as do not inhibit the breakdown of bradykinin or other kinins
The Macstrak Project
A2 blockers - Who
Generic Name Brand Namecandesartan Atacand®
irbesartan Avapro®
losartan Cozaar®
telmisartan Micardis®
valsartan Diovan®
The Macstrak Project
Statins - What & How
• cholesterol lowering agent - reduces inflammation
• indications:– reducing LDL cholesterol– ACS secondary prevention– CAD primary prevention high-risk groups
• statins block an enzyme (HMG-CoA reductase) involved in producing cholesterol within liver cells
• stimulates LDL receptor results in an increased clearance of low-density lipoprotein (LDL) from the bloodstream and a decrease in blood cholesterol levels
The Macstrak Project
Statins - Who
Generic Name
Brand Name
fluvastatin Lescol®
lovastatin Mevacor®
pravastatin Pravachol®
simvastatin Zocor®
atorvastatin Lipitor®
The Macstrak Project
Diuretics - What & How
• Increase natriuresis – renal excretion of sodium
• indications:– heart failure– hypertension
• act at a variety of targets within the nephron
• each class has a different specific mechanism of action, but typically share outcome of changing the way the kidneys handle salt - inhibit sodium re-absorption lowering blood pressure and cardiac workload
The Macstrak Project
Diuretics - Who
Generic Name
Brand Name
furosemide Lasix®
ethacrynic acid Edecrin®
bumetanide Burinex®
chlorothiazide Diuril®
hydrochlorothiazide
HydroDiuril®, Esidrix®
indampimide Lozol®
metolazone Zaroxolyn®
chlorthalidone Hygroton®
spironolactone Aldactone®
The Macstrak Project
Nitrates - What
• vasodilation - venous
• indications:– AMI– ischaemic heart disease– heart failure– pulmonary edema– hypertension
• increase venous capacitance reduces venous return, reducing preload
• dilate coronary blood vessels improves O2 supply to the myocardium
• dilate peripheral arteries reduces afterload and work done by the heart
The Macstrak Project
Nitrates - How
The Macstrak Project
Nitrates - Who
Generic Name
Brand Name
nitroglycerin IV Nitroglycerin IV ®
isosorbide dinitrate SL
Isordil®
nitroglycerin ointment
Nitrobid®, Nitiol®
nitroglycerin patches
Transderm-Nitro®, Nitro-Dur®,Nitrodisc®
isosorbide dinitrate po
Isordil®
The Macstrak Project
Inotropes - What & How
• positive inotropic agents increase myocardial contractility
• indications:– cardiogenic shock - hypotension – AMI– CHF
• effects are dose-dependant
• increases cardiac output and blood pressure
The Macstrak Project
Inotropes - Who
Generic Name
Brand Name
dopamine Intropin®
dobutamine Dobutrex®
epinephrine Epinephrine®
norepinephrine Levophed®
milrinone Primacor®
isoproterenol Isuprel®
The Macstrak Project
Calcium Antagonists - What & How
• negative inotropic effect - decreases myocardial contractility, increases vasodilation
• indications:– hypertension– angina– atrial fibrillation/flutter
• block volt-gated calcium channels in muscle cells – calcium levels drop – less muscle contraction
• Decrease blood pressure, reduces afterload decreasing amount of oxygen required by heart
• does not decrease the responsiveness of the heart to input from the sympathetic nervous system
The Macstrak Project
Generic Name
Brand Name
amlodipine Norvasc®
diltiazem Cardizem®
nicardipine Cardene®
nifedipine Procardia®
verapamil Isoptin®
felodipine Plendil®
Calcium Antagonists - Who
The Macstrak Project
Resources
The following are ways to ensure staff knowledge of drug classifications and
drug penetrance is at suggested guideline levels:
• Macstrak unit manual – make available at nursing station – available on website
• Medication List – post in rooms or nursing station – available on website
• Macstrak Quarterly or Macstrak Nursing News – available on website
• Reports – review penetrance
• Audits – Project Office will notify coordinator if on-going issues