PROPANOLOL (INDERAL, INDERAL – LA GENERIC)

A CARDIOVASCULAR BETA BLOCKER

TEAM 2 MEMBERS:Stella O. Akpuaka Bosede AdedireTamika MissouriAmanda Rothenbecker

WHAT ARE CARDIOVASCULAR AGENTS?

Wide variety of drugs used for management and treatment of several different conditions of the heart and blood vessels.

Classes:AntihypertensivesThiazide DiureticsBeta BlockersACE InhibitorsCalcium Channel blockersAngiotensin II Receptor BlockersAlpha 1 BlockersAlpha2Agonists

WHAT ARE BETA BLOCKERS?

NAME AND CLASSIFICATION

Drug Name:PROPRANOLOL: generic Inderal; Inderal Long acting (LA) - Brand

name

Classification:KEY Beta Blocker Drug

PHARMACODYNAMICS 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 receptorsDecreasing heart rate Supraventricular conduction and cardiac output Decrease Cardiac work load and oxygen

consumption Decrease the secretion of renin.

Therapeutic level -------50-100mg/ml (better effect)

PHARMACOKINETICS Lipid soluble (lipophilic) Excretion -------- Hepatic (Liver) Absorptions rate --- 90% Availability after first pass --- 30% Peak time of concentration ------1-1.5hrs Half life ------3-5 hrs; 8-11hrs for long acting Duration of action -----11hrs Protein bound --------93% Hepatic Metabolism -------2D6 substrate

INDICATION/RECOMMENDED DOSAGE Hypertension: 120-240mg/day bid -tid; max

dose 640mg

Angina: 120-160 mg/day; max dose 320 mg

Essential tumor: 120mg/day; max dose 320 mg

Off-label use: Migraine Prophylaxis

CONTRAINDICATION 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-BLOCKERS

PROPRANOLOL PRECAUTIONS 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

REVIEW OF LITERATURE 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

IMPLEMENTATION PLAN: PRESCRIBING AND CULTURAL CONSIDERATIONS

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

IMPLEMENTATION PLAN: AGE, ETHNICITY Age: The polypharmacy that accompanies

increased comorbidities in age decreases compliance. Medication information in a larger fontReinforcing regimen at follow up visitsAsking 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

IMPLEMENTATION PLAN: ADHERENCE 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

SPECIAL CONSIDERATIONS 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.

EVIDENCED BASED GUIDELINES 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.

REFERENCES Albert, N. M. (2008). Improving medication adherence in

chronic cardiovascular disease. Critical Care Nurse, 28(5), 54-64.

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), 1655-1660.

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).

REFERENCES 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). 453-459

Hsu, Y., Mao, C., & Wey, M. (2010). Antihypertensive medication adherence among elderly Chinese Americans. Journal of Transcultural Nursing, 21(4), 297-305. http://dx.doi.org/10.1177/1043659609360707

Johnson, J. (2008). Ethnic differences in cardiovascular drug response. New Drugs and Technologies, 118, 1383-1393.

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), 1225-1237.