Pharmacotherapy II: Patient-Centered Pathophysiology (5).doc

University of Minnesota College of Pharmacy Phar 6122 Pharmacotherapy II: (Cardiovascular, Endocrine, GI) 9:05-11:00 am Monday, Wednesday 9:05-9:55 am Friday WDH 7-135 LSci 163 Miki Finnin, Pharm.D., BCPS Course Director Spring 2009 Last updated: 12/22/2008

2 Phar 6122: Pharmacotherapy II (5 Credits) Pathophysiology and Pharmacotherapy of Cardiovascular Disorders Pathophysiology and Pharmacotherapy of Endocrine Disorders Pathophysiology and Pharmacotherapy of Gastrointestinal Disorders Spring 2009 Course Director: Miki Finnin, Pharm.D., BCPS Assistant Professor/Residency Director University of Minnesota College of Pharmacy, Duluth 1110 Kirby Drive 127 Life Science Duluth, MN 55812 Phone (218) 726-6012 (College) Phone (218) 249-5913 (Hospital) Fax (218) 726-6500 E-mail: mfinnin@d.umn.edu Vista web-site available at: http://vista.umn.edu Cardiovascular Section: Course (6122) and Section (Cardiovascular) Director: Course Faculty, continued: Miki Finnin, Pharm.D., BCPS Scott Chapman, Pharm.D. (CV TC Coordinator) Assistant Professor/Residency Director Assistant Professor, College of Pharmacy University of Minnesota College of Pharmacy, Duluth Clinical Specialist, Critical Care and Cardiology 127 Life Science Department of Pharmacy Phone (218) 726-6012 (College) North Memorial Medical Center Phone (218) 249-5913 (Hospital) 3300 Oakdale Avenue N. Fax (218) 726-6500 Robinnsdale, MN 55422 E-mail: mfinnin@d.umn.edu Phone (763)-520-3961 Email: Scott.Chapman@NorthMemorial.com Robert J. Straka, Pharm.D., F.C.C.P. David Parra, Pharm.D., BCPS Professor Clinical Assistant Professor, University of Minnesota, ECP University of Minnesota College of Pharmacy, Minneapolis Dept. and 7-115D Weaver-Densford Hall Clinical Pharmacy Specialist in Cardiology Phone (612) 624-5663 Department of Cardiology Fax (612) 625-3927 Veterans Affairs Medical Center E-mail: strak001@umn.edu 7305 N. Military Trail http://www.courses.ahc.umn.edu/pharmacy/5822/ West Palm Beach, FL 33410-6400 Phone (561) 422-7395 Email: David.Parra@med.va.gov Endocrine Section: Section Director: Course Faculty, continued: Sarah Westberg, Pharm.D., BCPS Miki Finnin, Pharm.D., BCPS Assistant Professor Assistant Professor/Residency Director University of Minnesota College of Pharmacy, Minneapolis University of Minnesota College of Pharmacy, Duluth 7-174 Weaver-Densford Hall 127 Life Science Phone (612) 625-4632 Phone (218) 726-6012 (College) Fax : 612-625-9931 Phone (218) 249-5913 (Hospital) E-mail: swestber@umn.edu Fax (218) 726-6500 E-mail: mfinnin@d.umn.edu

3 Gastrointestinal Section: Section Director: Course Faculty, continued: David Guay, Pharm.D., FCP, FASCP, FCCP, CGP Michael T. Swanoski, Pharm.D., FASCP Professor Assistant Professor College of Pharmacy, University of Minnesota University of Minnesota College of Pharmacy, Duluth Phone (612) 626-5981 111 Life Science, Duluth Fax (612) 625-3927 Phone (218) 726-6016 E-mail: guayx001@umn.edu Fax (218) 726-6500 E-mail: mswanosk@d.umn.edu All Sections: Paul Karow Hyewon Kim Lead Teaching Assistant, Duluth Teaching Assistant, TC Phone (507) 213-0538 E-mail: kimxx987@umn.edu E-mail: karo0023@d.umn.edu Amit Khatri Teaching Assistant, TC E-mail: khat0025@umn.edu Learning Objectives: Cardiovascular Course Objectives: At the conclusion of the section, learners should be able to… 1. Demonstrate a clear understanding of the basic pathophysiology associated with common cardiovascular diseases and syndromes. 2. Contrast and compare available pharmacotherapeutic options to manage patients with one or more common cardiovascular disorders. 3. Apply their knowledge of pharmacotherapy to design, initiate, modify and evaluate pharmacotherapeutic plans for specific patients with such conditions. 4. Be able to counsel patients receiving cardiovascular medications on their appropriate use. In order to consider this course a success, when presented with a cardiology patient case, you must be able to identify all pharmaceutical care problems like: 1. medications used with no medical indication 2. patient has medical conditions for which there is no medication prescribed 3. medication prescribed inappropriately for a particular medical condition 4. immunization regimen is incomplete 5. current medication therapy regimen contains something inappropriate (dose, dosage form, duration, schedule, route of administration, method of administration) 6. there is therapeutic duplication 7. medication to which the patient is allergic has been prescribed 8. there are adverse drug or device-related events or potential for such events 9. there are clinically significant drug-drug, drug-disease, drug-nutrient, or drug-laboratory test interactions or potential for such interactions 10. medical therapy has been interfered with by social, recreational, nonprescription, or nontraditional drug use by the patient or others 11. patient not receiving full benefit of prescribed medication therapy 12. there are problems arising from the financial impact of medication therapy on the patient 13. patient lacks understanding of medication therapy 14. patient not adhering to medication regimen Further, the student must be able to identify: 1. Reasonable pharmacotherapeutic goals for cardiology patients

4 2. Formulate COMPLETE recommendations for therapy 3. Design a medication monitoring plan including desired endpoints and monitoring frequency Endocrine Course Objectives: At the conclusion of the section, learners should be able to… 1. Demonstrate a clear understanding of the basic pathophysiology associated with common Endocrine conditions. 2. Contrast and compare available pharmacotherapeutic options to manage patients with one or more common Endocrine disorders. 3. Apply their knowledge of pharmacotherapy to design, initiate, modify and evaluate pharmacotherapeutic plans for specific patients with such conditions. 4. Be able to counsel patients receiving agents commonly used to manage their Endocrine conditions. Gastrointestinal Course Objectives: At the conclusion of the section, learners should be able to… 1. Demonstrate a clear understanding of the basic pathophysiology associated with common Gastrointestinal conditions. 2. Contrast and compare available pharmacotherapeutic options to manage patients with one or more common Gastrointestinal disorders. 3. Apply their knowledge of pharmacotherapy to design, initiate, modify and evaluate pharmacotherapeutic plans for specific patients with such conditions. 4. Be able to counsel patients receiving agents commonly used to manage their Gastrointestinal conditions. Required Texts The required readings for the course will be outlined in the course schedule and include chapters from "Pharmacotherapy: A Pathophysiologic Approach," 7th edition, DiPiro et al (eds)., McGraw-Hill, New York, NY Students are strongly urged to review the assigned readings prior to class to aid in the understanding of lecture material. Questions from the required readings may be included in course examinations (in addition to lecture and handout material). Supplemental readings will be made available to interested students by arrangements with the section directors. Such readings may be valuable for future reference. Supplemental references In addition to the required readings, the course schedule provides a listing of suggested readings designed to supplement and enhance the student’s understanding of the course content. These often will be made available via Vista when possible. Further suggested resources are: 1. Lexi-Complete™ available at: http://www.lexi.com/web/index.jsp . This PDA reference is a portable source for general information and drug dosing. 2. Goodman and Gilman’s. The Pharmacologic Basis of Therapeutics, 11th Ed., McGraw-Hill, New York, NY, 2006. This is a good source for information on basic pharmacology. Other Good Sources of Information Students are encouraged to utilize new and progressive methods for obtaining the latest and most up-to-date information. Specifically, there are numerous sources of information available on the Internet. As always,

5 information on the Internet or sources other than material covered in the lectures and required readings should be viewed as supplementary material and not a primary source. Prerequisites: All students will have completed Physiology (Phar 6061), Medicinal Agents I (Phar 6154), Pharmacokinetics (Phar 6163), Pharmacology I (Phar 5101) and Pharmacotherapy I (Phar 6121). The student is responsible for this material to the extent that basic information taught in such classes will be built upon in this course. Thus, students are encouraged to review basic cardiovascular, endocrine, and gastrointestinal anatomy and physiology and specifically encouraged to review the section of Goodman and Gilman’s Pharmacological Basis of Therapeutics relevant to the classes of drugs covered. Instructors may briefly review this material but are not required to do so. Student Evaluation and Grading Phar 6122 Overall Course Grade: The overall 6122 course grade will be determined by the results of 7 online quizzes (within the CV and endocrine pharmacotherapy sections), 7 written exams (3 exclusively CV, 2 exclusively Endo, 2 exclusively GI), 1 final comprehensive and combined written exam (CV, Endo and GI) and 1 comprehensive and combined oral exam also covering CV, Endo, and GI sections. Exams will not be graded on a curve. The use of electronic devices such as Palm, other PDAs, pocket computers, programmable calculators, and other devices with electronic data bases is not permitted during quizzes, written or oral exams unless specified by course or section director. Within each section, exams will be comprehensive and build on previous knowledge covered in each section. The final grade for the Pharm 6122 course will be determined according to a formula. The overall course grade will be determined from contributions from each of the three sections. The following is provided to guide you in the relative contributions of each section to the final grade. Contribution (evaluation tool) Point (%) contribution from each section Minimum and evaluation tool Passing Grade CV section (5 quizzes, 3 exams) 38 > 60%* Endo Section (2 quizzes, graded case, 2 exam) (4+1+12)=17 > 60%* GI Section (two exams) (7.5+7.5)=15 > 60%* CV + GI +Endo 38+15+17= 70 Oral exam (CV, Endo, and GI**) 10 CV + GI + Endo + Oral exam 70+10= 80 6122 Final Written Exam (CV, Endo, and GI)*** 20 > 65% Final Grade 80+20 100 > 60% *Minimum passing grade refers to the indicated evaluation tools for each section **The oral exam accounts for 10% of the overall course grade. The oral exam will integrate and evaluate the application of knowledge gained from each of the three sections according to their approximate contributions to the lecture hours in the course at the time of the oral exam (55% cardiovascular, 25% endocrinology, and 20% GI). ***A comprehensive final exam for all three sections will contribute 20% toward the overall course grade. Approximate contributions of each section for this exam will be 40% GI, 40% endocrine and 20% CV.

6 NOTE: In order to pass this course (Phar 6122), each student must pass the final written examination with a grade of 65% or higher. In addition, each student must earn an overall grade of 60% or higher for the indicated evaluation tools (see * in table above). (There will be no exceptions to this rule). Failure will require the student to re-take the entire course (all three sections). The exams will be returned and reviewed at some point either during or outside of class time. This will be your only chance to comprehensively review your exam. If you have extenuating circumstances, you may schedule an appointment with the section director (or the Teaching Assistants, at the section director’s discretion) to review any of your exams. Grades will NOT be given out over the telephone. Letter Grade assignments appearing on your transcripts are as follows. Common rounding rules will be applied to the final grade ONLY (as per Microsoft Excel® where 0.5 and higher values are rounded up). A ≥ 93% A- 90-92% B+ 87-89% B 83-86% B- 80-82% C+ 77-79% C 73-76% C- 70-72% D 60-69% F < 60% Quizzes: Quizzes will be given online. Students will have access to the quiz for 30 minutes in a 20 hour period (noon to 8:00 am the following day). You will be able to take the quiz any time in that 20 hour period however once the quiz is opened you will have 30 minutes to complete. For Pharmacotherapy II (Phar 6122), there will be NO make-up quizzes in the CV section. We will, however, convert the lowest quiz score to 100% if the student takes the time to complete the on-line CV section evaluation. The standard make-up policy will apply to endocrine quizzes. Make-up Policy: Please note MAKE-UP EXAMINATIONS, QUIZZES AND OTHER ASSIGNMENTS WILL NOT BE OFFERED EXCEPT UNDER THE FOLLOWING CIRCUMSTANCES: illness, verified by a note from a licensed professional; a family emergency, verified by a note from the professional person in attendance; or a University-sponsored event, verified by a note from the leader of the sponsoring organization. Additional circumstances will be considered at the discretion of the course or section director, but are not likely to be granted. If a student is unable to attend the scheduled exam, the relevant section director must be notified (by email AND phone) at least 24 hours in advance of the exam time (where possible). If you do not receive a reply to your request prior to the examination time, please do NOT assume that your request has been granted; contact us again to confirm your request was received and processed. If an acceptable circumstance or adequate documentation is not provided, a grade of zero, on the exam, quiz, etc. will be assigned by the course or section director. Unless there are extenuating circumstances, students must contact the section or course director within 24 hours of the missed scheduled exam, quiz or other assignment in order to be considered for a make-up assignment. Unless there are extenuating circumstances, the make-up exam date is generally not more than one week after the original exam date. Workload Expectations:

7 The University of Minnesota defines one credit as equivalent to an average of three hours of learning effort per week (over a full semester) necessary for an average student to achieve an average grade in the course. For example, a student taking a three credit course that meets for three hours a week should expect to spend an additional six hours a week on coursework outside the classroom. You will get the most out of this course by actively participating in the assigned readings, pedagogical tools (quizzes, oral and written exams, review sessions, assignments, etc.). Disability Accommodations: Any student with a documented disability (eg. physical, learning, psychiatric, vision, hearing, etc.) who needs to arrange reasonable accommodations must contact the course directors as well as each section director for the course. Documentation of the need for accommodations should be received within the first week of the course and at least 7 days before any exam or test. It is assumed that Disability Services (TC: http://ds.umn.edu/, 612-626-1333, Duluth: Access Center, http://www.d.umn.edu/access/ , 218-726-8217) has been contacted to document the disability and quantify the necessary accommodations before the beginning of the Semester. All discussions concerning this issue will remain confidential. Class Etiquette: The instructors expect all students to conduct themselves in a professional manner consistent with the University of Minnesota Pharmacy Student Code of Ethical Responsibility and Professional Behavior. Students will not engage in disruptive classroom conduct. This refers to behavior that substantially or repeatedly interrupts either the instructor's ability to teach or student learning. The classroom extends to any setting where a student is engaged in work toward academic credit or satisfaction of program-based requirements or related activities. Honor Code: Each student is bound by the following specific provisions as part of the honor code: Academic misconduct is any unauthorized act which may give a student an unfair advantage over other students, including but not limited to: falsification, plagiarism, misuse of test materials, receiving unauthorized assistance and giving unauthorized assistance. Specifically, each student will be required to do their own work on all quizzes (on line or written), tests, oral and written exams. Exam Dates: Although the instructors do not foresee any circumstances that would require a change in examination dates for the class as a whole, exam dates remain subject to change. Course/Instructor Evaluation: Students will be given class-time to complete a written or online course evaluation to be completed near the conclusion of each section of this course. Section Director Office Hours: Dr. Finnin will be generally available every Monday, Wednesday, and Friday during the cardiovascular and endocrine sections outside of class and recitation times. She observes an open door policy, but appointments can also be made. Minneapolis students are strongly encouraged to call Dr. Finnin whenever they need help. The use of e-mail is highly encouraged for all students, bearing in mind a reasonable turn- around-time for replies. Dr. Finnin also plans to make 1-2 trips to Minneapolis to teach in person. Students are encouraged to seek additional help early if needed. Cardiovascular course faculty will be happy to meet with students by appointment to assist in your understanding of the material. Dr. Westberg (Section Director for Endocrine) will have ITV office hours during the endocrine section. These hours will be announced at the beginning of that section. Office hours are also available by appointment. Dr. Guay (Section Director for Gastroenterology) is available to meet with students on campus by appointment Monday through Friday. Office hours can be scheduled with Dr. Guay on an appointment basis (call (612) 626-5981 or email guayx001@umn.edu). Dr. Guay will be present at all lectures to

8 answer individual and group questions and to meet with course liaisons. If desired, Dr. Guay will meet with students after each lecture.

9 Phar 6122: Pharmacotherapy II Cardiovascular Section Course Information Spring 2009 Course Overview and Goals What is the importance of this class and what is expected of the student who completes this course? Cardiovascular pharmacotherapy is one of the most exciting areas of medical care. Each one of us will have some degree of personal experience with cardiovascular disease in our lifetime. New and innovative approaches for treating cardiovascular diseases are constantly being evaluated. As a pharmacist, you can have a major impact on the care of patients with cardiovascular disease through your development of an understanding of the appropriate use of drugs for such patients. The objectives of this course should provide the basis for a pharmacist to care for a patient with common cardiovascular diseases. Required texts (see above) Other Good Sources of Information Students are encouraged to utilize new and progressive methods of obtaining the latest and most up to date information. Specifically, there are numerous sources of information available on the Internet. As always, information on the Internet or sources other than material covered in the lectures and required readings should be viewed as supplementary material and not a primary source. However, the accuracy of information you may find on the Internet cannot always be verified. The following sources of information may be useful in further exploring areas of interest or in obtaining information that may be useful in completing group projects. Below are several Web sites that provide excellent information or will at least guide you in the right direction. 1. The former homepage for the CV section of Phar 6122. (http://www.courses.ahc.umn.edu/pharmacy/5822/homepage1.html) This is the web-site used in the past for this class. We will link to important pieces of this site through Vista. The site contains an excellent table or landmark trials in cardiology. 2. Theheart.org (http://www.theheart.org/index.cfm) outstanding source of new info re: to Cardiovascular Pharmacotherapy. You may register for free and receive updates via email on news or just search the site as needed. 3.Pharmacy Web Page (http://www.pharmweb.net/) This site provides information for pharmaceutical and other health-related organizations, including a schedule of future conferences and discussion groups. 4.Medicine Online (http://www.mol.net/medj.htm) or (http://www.mol.net/) Here you will have access to information such as the table of contents of the most recent publications of many medical journals. 5.Pharminfonet (http://www.pharminfo.com)This site is a source for several types of pharmaceutical information, and within this site is the cardiovascular disease resources at (http://www.pharminfo.com/disease/cardio/card_rsc.html). 6.Virtual Hospital (http://www.vh.org/)This is the University of Iowa’s virtual hospital. Here you can find examples of cardiovascular-related cases.

10 7. OnHealth (http://onhealth.com/ch1/condctr/cardio/item,14121.asp) This site is geared towards general public but it provides nicely detailed information about prevention, diagnosis and treatment of cardiovascular diseases. It is very useful for description of variety of cardiac procedures. 8. American Heart Association (http://www.americanheart.org/) This site is very useful for accessing various Guidelines to manage patients with heart disease, retrieve updated official statistics re: Cardiovascular disease, obtain official AHA statements on selected topics of CV importance etc. 9. Lexi.com (http://www.lexi.com/web/index.jsp) 10. Micromedex (http://www.biomed.lib.umn.edu/micromedex/index.html) This site can be used to search for summaries and detailed monographs of drugs, alternative medicine, toxicological management, reproductive risks, and acute/emergency care.

11 6122 Cardiovascular Section Grade Distributions The grade for the CV section will be determined by the results of 5 quizzes and 3 written exams. The oral and a final examination will contribute to the 6122 course grade as described above. The CV section will contribute to the oral exam in proportion to the lecture hours devoted to the CV section with in 6122. Evaluation tools Minimum passing grade 5 Quizzes 1.6 X 5 quizzes 8 points Exams (one, two 10+10+10=30 30 points and three) CV section (less 30+8= 38 points > 60% oral and course final exam) * There will be NO make-up quizzes in the CV section. Course Instructor Evaluation Students will be asked to complete an on-line evaluation of the CV section of the class and have their lowest quiz grade converted to a 100% score. 6122 Endocrine Section Grade Distributions The grade for the Endocrine section will be determined by the results of 2 quizzes, 1 case study and 2 written exams. The oral and a final examination will contribute to the 6122 course grade as described in the full course syllabus. Evaluation tools Minimum passing grade 2 Quizzes (2 points each) 4 points 2 Exams (6 points each) 12 points Diabetes Case Study 1 point Endocrine section (less oral and course final 4 + 12 + 1 17 points > 60% exam) 6122 GI Section Grade Distributions The grade for the GI section will be determined by the results of 2 written exams. The oral and a final examination will contribute to the 6122 course grade as described in the full course syllabus. Evaluation tools Minimum passing grade 2 Exams (7.5 points each) 15 points > 60%

12 Helpful Abbreviations This list includes many, but not all of the abbreviations commonly found in the notes from the cardiovascular pharmacotherapy course, Pharm 5822. These are abbreviations you will see not only from your classroom work, but also during your clinical rotations. You are not required to memorize this list, rather you will find that as the course progresses, recognition and understanding of the abbreviations will gradually become part of your knowledge base. See also: http://www.courses.ahc.umn.edu/pharmacy/5822/glossary.html ACE-I - angiotensin converting enzyme inhibitor ACLS - advanced cardiac life support Afib/Aflut - atrial fibrillation/flutter AMI - acute myocardial infarction APAP - acetominophen/ Tylenol ASA - aspirin ASCVD - atherosclerotic coronary vascular disease AV - atrioventricular BB - beta-blocker BCLS - basic cardiac life support BP - blood pressure BPH - benign prostatic hypertrophy BPM - beats per minute, breaths per minute BSA - body surface area CABG - coronary artery bypass graft CAD - coronary artery disease CCBA- calcium channel blocker CCU - coronary care unit CHF - congestive heart failure CI - cardiac index C/O - complain of CO - cardiac output COPD - chronic obstructive pulmonary disease CP - chest pain CPR - cardiopulmonary resuscitation CRP- C-reactive protein (acute phase reactant- also hs-CRP for high sensitivity) CXR - chest x-ray DBP- diastolic blood pressure DCC - direct current cardioversion DLIS - digoxin-like immune substance DOE - dyspnea on exertion DVT - deep vein thrombosis ECASA - enteric-coated aspirin ER - extended release FH - family history GERD- gastro-esophageal reflux disease GP IIb/IIIa Inhibitors – Glycoprotein IIb/IIIa Inhibitors H/O- history of HR - heart rate Hs-CRP is C-reactive protein (acute phase reactant) HPI - history of present illness HTN - hypertension

13 IR - immediate release ISDN- isosorbide dinitrate JVD - jugular venous distention LAD - left anterior descending artery LBBB - left bundle branch block LBW - lean body weight LD - loading dose LMWH - low molecular weight heparin LVD - left ventricular dysfunction MAP - mean arterial pressure MD - maintenance dose MI - myocardial infarction MOA - medications on admission MPTA - medications prior to admission MS - morphine sulfate N, V, D - nausea,vomiting, diaphoresis NS - not significant NSR - normal sinus rhythm NTG - nitroglycerin NTP - nitroprusside PCWP - pulmonary capillary wedge pressure PE - pulmonary embolism PL - placebo PMH - past medical history PND- paroxysmal nocturnal dypnea PPD - packs per day PSVT - paroxysmal supraventricular tachycardia PTCA - percutaneous transluminal coronary angioplasty PUD- peptic ulcer disease PVC - premature ventricular complex R/O - rule out RAP - right arterial presssure RBBB - right bundle branch block RR - respiratory rate RR - risk ratio (statisical term) RCA - right coronary artery SH - social history S/P- status post SBP- systolic blood pressure SOB - shortness of breath SSCP - substernal chest pain SR - sustained release SV - stroke volume SVR - systemic vascular resistance TBW - total body weight UO - urine output USOH - usual state of health VF - ventricular fibrillation VRR - ventricular response rate VTach/VT - ventricular tachycardia WNL - within normal limits

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