Mr.

JV, a 67 year old retired plumber, has recently moved to you area and has come to the pharmacy to collect his first prescription. He has a PMH of coronary heart disease (CHD) and has recently had a coronary stent inserted. The patient is also suffering from asthma and dyspepsia.

For Coronary Heart Disease: Coronary artery disease decreases blood supply to the heart from the blocked coronary artery. The lower blood flow may fail to meet the heart's demand for oxygen. Treatment aims to balance blood supply to the heart w/ heart oxygen demand, & prevent worsening of coronary heart disease. Treatment of coronary artery disease is highly individual, and must be based on a patient's symptoms and diagnostic test results.

For Asthma: Treatment of asthma has 2 aims: (a) relief of symptoms, (b) reduction of airways inflammation.

ASPIRIN
Alcohol may increase risk of GI ulceration and prolong bleeding time. Corticosteroids may decrease aspirin level. Decreased antihypertensive effect of beta-blockers. Unexpected hypotension may occur with nitroglycerin.

BETA-BLOCKER
Calcium channel blockers can lower of blood pressure & heart rate to dangerous levels when administered together with metoprolol. Verapamil will cause increase of blood plasma level of either drug. It is important to monitor cardiac function due to additive effects. May cause shortness of breath in asthmatic.

NITROGLYCERIN (NITRATES)
Possible additive hypotensive effect when used concomitantly w/ -blockers, antihypertensives. Aspirin may enhance vasodilatory and hemodynamic effects of nitroglycerin. Calcium Channel blocker: Symptomatic orthostatic hypotension may occur. Since alcohol also may intensify the blood pressure lowering effect of nitroglycerin, patients receiving nitroglycerin should be advised to drink alcoholic beverages with caution.

CALCIUM CHANNEL BLOCKERS

Beta-blockers: May result in increased hypotension resulting to bradycardia, peripheral edema, CHF, AV block and asystole because of additive depressant effects on myocardial contractility or AV contraction.

STATINS
Consumption of grapefruit or grapefruit juice inhibits the metabolism of statinsfuranocoumarins in grapefruit juice inhibit the cytochrome P450 enzyme CYP3A4, which is involved in the metabolism of most statins. Elevate function test (ALT, EST) Headache and dyspepsia frequently occur. Virapamil (Ca channel blocker) may increase risk of myopathy and rhabdomyolysis. Dont exceed 20 mg of statin

BETA 2-AGONIST
-blockers:Pulmonary effects of salmeterol may be blocked and may produce severe bronchospasm in patient with COPD. -blockers precipitate bronchospasm and increase the dose of B-agonist necessary to achieve bronchodilation.

CORTICOSTEROID May increase risk of GI distress and bleeding. Use together cautiously. May decrease salicylate level. Monitor patient for lack of salicylate effectiveness.

PROTON PUMP INHIBITORS

No known interaction with other medication taken

Aspirin: Take 75-325 mg once daily. Beta-Blockers (Metoprolol): Maintenance: 100-200 mg daily. Can be combined w/ other antihypertensive.

Nitroglycerin (Gen-Nitro (Sublingual tablet)): (Oral) 0.3 to 0.6 mg dissolved under the tongue or in buccal pouch at first sign of acute angina attack; repeat q 5 min (do not exceed 3 tabs in 15 min). Also may be used as a single dose 5 10 min before activity that might precipitate an angina attack.

Calcium channel blocker (Verapamil): (Oral) 40 160 mg tid. Do not exceed 480 mg/day. Statins (Simvastatin): Initial dose: 20 mg & may be adjusted at intervals of not <4 wk to a max of 80 mg once in the evening.

Beta 2-agonist (Salmeterol): (Inhalationtn) 1 inhalation (50mcg) bid, approx 12 hr apart. Corticosteroid (Prednisolone): 5 60 mg/day Esomeprazole: The dose for preventing NSAID-induced ulcers is 20 to 40 mg daily up to 6 months.

ASPIRIN:
Avoid drinking alcohol. Alcohol may increase your risk of stomach bleeding. Instruct patient to take drug with food or after meals & w/ full glass of water to reduce unpleasant GI reaction. Instruct patient to report ringing in ears or unusual bleeding, bruising, or persistent GI pain.

A-BLOCKERS:

etoprolol may worsen the symptoms of heart failure in ome patients. Check with your doctor right away if you e having chest pain or discomfort; dilated neck veins; xtreme fatigue; irregular breathing; an irregular heartbeat; hortness of breath; swelling of the face, fingers, feet, or wer legs; weight gain; or wheezing. ke this drug with meals. not stop abruptly.

A-BLOCKERS:

s medicine may cause changes in your blood sugar levels. s medicine may cause some people to become less alert an they are normally.

NITROGLYCERIN:
Advise patient that headaches are a common side effect of therapy and are also a marker of antianginal effectiveness. Caution patient not to crush, chew, or swallow sublingual tablets. Advise patient to discontinue nitroglycerin and notify healthcare provider if vision blurring and dry mouth occurs. Advise patient that stopping drug abruptly causes spasm of the coronary arteries.

CALCIUM CHANNEL BLOCKER:

Tell patient if dose is missed to take as soon as possible. If several hours have passed or if nearing time for next dose, tell patient not to double dose to catch up unless advised by healthcare provider. Advise patient that drug may cause dizziness and to use caution while driving or performing other tasks requiring mental alertness until effect of drug have stabilized.

CALCIUM CHANNEL BLOCKER:

Tell patient to swallow whole, do not cut, crush or chew. May cause nausea, headache, vomiting, dizziness, depression, constipation, irregular heartbeat, swelling of hands and feet.

STATINS:
Advise patient to control weight and to adhere to prescribed dietary regimen. Instruct patient to report the following symptoms to healthcare provider: any unexplained muscle pain, tenderness, or weakness, especially if accompanied by fever or malaise; yellowing of skin or eyes. Take drug in the evening. Have periodic blood test.

BETA 2-AGONIST (INHALATION): If rash and urticaria, appears which signal a hypersensitivity reaction, patient should inform prescriber. Instruct patient not to stop the medication once symptoms have been controlled. Continued daily use is necessary to continue control of symptoms. Use only twice a day or as instructed. May occur headache, tremors, fast heart and palpitations.

CORTICISTEROID:
Instruct patient to take medication with meals or snack to avoid GI irritation. Caution patient not to take with aspirin unless directed with health care provider.

PPI:
Instruct patient to take each dose on an empty stomach at least 1 hr before eating. Tell your doctor immediately if you have: heartburn combined with lightheadedness/ sweating/dizziness, chest pain or shoulder/jaw pain (especially with trouble breathing), pain spreading to arms/neck/shoulders, unexplained weight loss.