session 340 easton e · sirturo (bedaquiline) has been approved by the fda for adults with...

Healthcare  Updates  

Objec1ves:    Par1cipants  will:  1.  Describe  new  medica1ons  available  for  latent  and  

drug-­‐resistant  Tuberculosis.    2.  List  2  op1ons  for  a  successful  colonoscopy  prep.    3.  List  the  differences  between  commonly  used  blood  

thinners.  4.      List  2  resources  for  healthcare  updates.  

Tuberculosis is either:

Active TB or

Latent TB

Ac#ve  TB    

New  drug  just  released:  Sirturo  

Sirturo (bedaquiline) has been approved by the FDA for adults with multi-drug resistant TB. -the first TB medication to be approved in 4 decades. -for active TB that does not respond to treatment with isonazid and rifampin. -adverse effects possible in liver and heart

January  2013:  

Latent  TB  posi1ve  reactor,  but  no  ac1ve  disease            

-­‐cannot  spread  TB  to  others    

5-­‐10%  will  get  ac1ve  TB  at  some  1me  in  their  life    

at  risk:  diabe1cs  and  AIDS,  immune  system  weakened  with  illness      

New  12  Weekly  Dose  Regimen  recommended  for:  

-­‐recent  exposure  to  a  person  with  infec1ous  TB  disease    -­‐persons  who  have  a  posi1ve  tuberculin  skin  test  or  a  posi1ve  blood  test  for  TB    (but  not  ac1ve  tb)    -­‐HIV-­‐infected  persons  who  are  otherwise  healthy  and  not  taking  an1retroviral  medicines.  

Latent  TB  treatment              

now:      

Drugs   Duration   Interval   Minimum doses  

Isoniazid   9 months   Daily   270  

Twice weekly*   76  

Isoniazid   6 months   Daily   180  

Twice weekly*   52  

Rifampin   4 months   Daily   120  

Isoniazid and Rifapentine  

3 months   Once weekly*   12  

CDC  GUIDELINES:    highest  risk                1.    Foreign-­‐born  persons  who  move  from  countries                              with  a  high  incidence  of  TB        

CDC  GUIDELINES  cont.  

2. Persons who were homeless, in prison, or from certain nursing home facilities 3. Healthcare workers who may have worked with a TB patient 4. HIV positive persons

Popula1on  of  Ohio:    

11.5  million  people        

Discussion:    

TB  Policies  for:      

ICF:    TB  control  according  to  American  College  of  Pulmonary  Physicians  and  American  Pediatric  

 Waiver:    no  regs  

Day  Programs:  infec1on  control  program        

MOST  IMPORTANT:  EMPLOYEES  

Why  a  2  step  skin  test?  •  in  some  persons  who  are  infected  with  tuberculosis,  the  ability  to  react  to  tuberculin  may  decrease  over  1me  and  they  may  have  a  false-­‐nega1ve  reac1on.  The  first  test  may  s#mulate  the  immune  system,  causing  a  posi1ve,  or  boosted  reac1on  to  the  second  test.    

Handy  millimeter  reference:  

Quan#  FERON-­‐TB  Gold:    TB  blood  test    (2005)  

 -­‐no  need  for  skin  test,  more  reliable  

 -­‐if  posi#ve,  s#ll  need  to  dis#nguish  if  ac#ve  or  latent,  just  like  TB  skin  test  

Colonoscopy  

Cancer  Distribu1on  

                   Signs  of  colon  cancer:    worsening  cons1pa1on,  blood  in  the  stool,  anemia,  

weight  loss,  fever,  loss  of  appe1te    

Higher  risk:    -­‐9  of  10  are  people  over  50  yrs  old    

 -­‐First-­‐degree  rela1ves  (parents,  siblings,  or  children)    -­‐Exis1ng  condi1ons:  inflammatory  bowel  disease  

(IBD),  ulcera:ve  coli:s,  Crohn's  disease      

Screening  for  people  with  DD  aWer  age  50  :    colonoscopy  every  10  years?  

 sigmoidoscopy?  

annual  fecal  occult  stool?    annual  CBC?  

Colonoscopy  preps    

Standard  preps:  

Ideas  for  people  with  DD:    

1.  Clear  liquid  diet  for  2  days,  at  least  1000  calories:  popsicles,  jello  jigglers,  flavored  tonic  water,  sodas,  

boullion,  sweet  tea    

2.  Mag  Citrate/  Mag  Citrate/  4  Dulcolax  tabs      

3.  4  Dulcolax  tabs  /Mirilax  238gm  /  64  oz.  Gatorade        

WHY blood thinners are prescribed:

TO Treat & Prevent BLOOD CLOTS

• Blood clot in a vein (DVT: deep vein thrombosis) • Blood clot in the lung (PE: pulmonary embolism)

• To prevent stroke with Atrial Fibrillation: irregular heartbeat

• To prevent heart attack or stroke (if at risk for heart attack, diabetes, TIAs, angina) • Previous heart attack or stroke (prevent another)

• Orthopedic surgeries such as knee or hip replacement

Blood  Clot  in  the  Leg  

varicose  veins  vs.  blood  clot    

Risk Factors for DVT:

• Previous clots • Severe infection • Heart failure • Oral contraceptives • Estrogen therapy or pregnancy • Immobility (bed rest, hospitalized, fractures) • Surgery • Cancer How many people in your care are at risk?

Possible  signs  of  DVT:   Score  

Ac1ve  cancer  (treatment  ongoing,  within  6  months  or  pallia1ve)   1  

Paralysis,  paresis  or  recent  plaster  immobiliza1on  of  a  lower  limb   1  

Recently  bedridden  for  longer  than  3  days  or  major  surgery  within  4  weeks   1  

Localized  tenderness  along  the  distribu1on  of  the  deep  venous  system   1  

En1re  leg  swollen   1  

Calf  swelling  >3  cm  compared  with  the  asymptoma1c  leg  (measured  10  cm  below  the  1bial  tuberosity)  

1  

Pidng    edema  (greater  in  the  symptoma1c  leg)   1  

Collateral  superficial  veins  (non-­‐varicose)   1    

Alterna1ve  diagnosis  as  likely  or  greater  than  that  of  DVT  (trauma,  Baker’s  cyst)   -­‐2  

• 3  points  or  more  =  high  probability,  about  75%  risk  of  DVT    • 1–2  points  =  moderate  probability,  about  17%  risk  of  DVT    • 0  points  =  low  probability,  about  3%  risk  of  DVT    

ATRIAL  FIBRILLATION  (A  fib)    

Rapid  and  disorganized  heartbeat.  The  rate  of  impulses  through  the  atria  can  range  from  300  to  600  bpm,  with  an    

irregular  heartbeat  50-­‐150.    Blood  clots  may  form  when  the  heart  will  beat  too  fast  or  out  of  rhythm,  and  can  travel  to  the  

brain  (STROKE).  

Most  common  causes    • Hypertension  (high  blood  pressure)    

• Coronary  artery  disease    • Heart  valve  disease    

• Heart  surgery    • Chronic  lung  disease    

• Heart  failure    • Cardiomyopathy    

• Congenital  heart  disease    • Pulmonary  embolism    

• Less  common  causes    • Hyperthyroidism    

• Pericardi1s    • Viral  infec1on  

How  many  people  in  your  care  are  at  risk?  

• Rapid and irregular heartbeat • Fluttering or “thumping” in the chest • Dizziness • Shortness of breath and anxiety • Weakness • Faintness or confusion • Fatigue when exercising • Sweating • Chest pain or pressure

Symptoms  of  A  fib:  

Types  of  Blood  Thinners  

1.  Anticoagulants, such as Warfarin (Coumadin), lengthen the time it takes to form a blood clot. New: Xarelto, Eliquis, Pradaxa - the standard treatment for DVT and Atrial Fib

1.  Antiplatelet drugs, such as Aspirin and Plavix, prevent blood cells called platelets from clumping together to form a clot.

- the standard treatment for heart attack and stroke prevention

Coumadin  (Warfarin)  

New  an1coagulants  like  Pradaxa  

All  new  agents  compared  with  warfarin  

Advantages:  •  No  monitoring  required  

•  No  variability  •  Fast  onset  of  ac1on  •  Fast  offset    •  Lower  IC  hemorrhage  rates  (about  50%  lower  for  all)  

Disadvantages:  •  No  reversibility  •  No  monitoring    •  Expensive  (higher  1er  by  PBM)  

•  Not  once-­‐daily  in  AM  •  Less  clinical  experience    

•  No  data  for  cardiac  issues  other  than  NVAF  

Plavix:      

 for  people  who  have  suffered  from  a  recent  heart  ahack  or  stroke,  or  who  have  peripheral  arterial  

disease  

IVC filters (Intra Vena Cava filters) might be considered when anticoagulation is contraindicated. How they work: trap the blood clots from the legs to prevent traveling to lungs (pulmonary embolus) or brain (stroke). Types:

Discussion:  implica1ons  for  our  individuals  head  injuries    

(falls,  seizures,  SIB)  

What  are  your  guidelines  when  on  a  blood  thinner?  

Hypoglycemia:    a  MIS-­‐MATCH  

of  FOOD,  ACTIVITY,  AND  MEDS  

 Hypoglycemia:  can  cause  abnormal  heart  rhythms  

                                   and  sudden  cardiac  death    

blood  sugar  less  than  70  Hormones  released:  adrenalin,  cor1sol,  glucagon,  growth  

swea1ng,  tremor,  ↑  pulse,  nervous,  hunger    

blood  sugar  less  than  50  brain  not  func1oning  well:    

confusion,  ↓decision-­‐making  skills  ↓  reflexes    

 blood  sugar  less  than  30  coma,  death  

Cryer  PE,  Davis  SN  (2012):  Harrison's  Principles  of  Internal  Medicine;  Holt  RIG,  Hanley  NA  (2007):  Essen1al  Endocrinology  and  Diabetes.          

Hypoglycemia  unaware:    

-­‐on  Beta  Blocker  (atenolol,  metaprolol,  coreg,  inderal,  etc.)    

-­‐older  people    

-­‐have  diabe1c  neuropathy    

-­‐have  frequent  bouts  of  low  blood  sugar      

Other  new  info  

NEW  procedure  for  severe  asthma:    

Bronchial  thermoplasty  is  a  non-­‐drug  procedure  for  severe  persistent  asthma  in  pa1ents  18  years  and  older  whose  asthma  is  not  well  

controlled  with  inhaled  cor1costeroids  and  long-­‐ac1ng  beta-­‐agonists.    

Thermal  energy  is  applied  to  the  airway  wall    to  reduce  excessive  airway  smooth  muscle.  This  decreases  the  ability  of  the  airways  to  constrict.  

Bronchial  thermoplasty  

Superbugs:  acquired  during  hospitaliza1on      can  enter  a  pa#ent  through  surgical  wounds,  catheters,  and  IVs.  Uncontrolled,  they  con1nue  to  move  throughout  the  body,  

ahacking  a  person's  organs.    Includes:  enterococci,  staphylococci,  klebsiella,  acinetobacter,  

pseudomonas,  and  enterobacter,  which  have  developed  mul#ple  resistance  

Men  taking  calcium  supplements:  20  %  HIGHER  RISK  OF  HEART  ATTACK  

  Data from the National Institutes of Health-AARP Diet and Health Study, which enrolled almost 600,000 adults ages 50 to 71 in 1995 and 1996. Among the 388,229 participants included in the analysis, 56 percent of women and 23 percent of men reported using calcium supplements, while 58 percent and 56 percent reported taking multivitamins that contained calcium. Compared with men who did not take calcium supplements, those taking more than 1,000 mg per day had a 20 percent higher risk of dying from cardiovascular disease, National Cancer Institute in Bethesda, Md., and reported in JAMA Internal Medicine

Evidenced-­‐Based  Resources