Heart Education Awareness Resource and Training through eLearning (HEARTe)
Rationalisation of medication
The practice nurse discusses Molly’s medication with her before she goes. It is important to check that Molly is taking all these tablets and also any over the counter medications that she may be taking.
Ask your patient at each visit “has anyone changed, stopped or started any tablets for you since I saw you last?”. This simple question will remind them to inform you of any changes. Rationalisation of medications is an important part of Molly´s management plan which is to up-titrate evidence based therapies such as ACE inhibitor and Betablocker, while stopping or changing those which are of no benefit or indeed contra-indicated in heart failure.
Bin – stop medication
Mouth – continue medication
Prescription pad – review medication
Piolglitazone 15mg – Contra-indicated in heart failure as known to worsen symptoms and increase hospitalisations. This could be replaced if needed with other diabetic agents such as a sulphonylurea (eg Gliclazide).
Ibuprofen 400mg tds – NSAIDs may cause sodium and water retention and may worsen renal function. Best avoided in heart failure.
Lisinopril 20mg od- ACE inhibitors are beneficial in heart failure and this is the lower end of target dose. The dose could be increased to 30-35mg in future if needed.
Bisoprolol 10mg- Beta-blockers are beneficial in heart failure and this is the target dose
Aspirin 75mg- Should continue due to Molly having diabetes (NICE 2008).
Simvastatin 40mgs- Indicated due to diabetes and 10-year CVD risk (NICE 2008)
Paracetamol 500mg tds- No harmful effects on HF. Continue if needed.
Furosemide 80mg bd- Molly is not taking the furosemide because of her incontinence but this is making her retain fluid. Discuss with Molly regarding the importance of taking the tablets but that the timing is not so importance so can be changed depending on what she is doing.
Metformin 500mg bd- BNF “NICE recommends that the dose should be reviewed if eGFR less than 45 mL/min and to avoid if eGFR less than 30 mL/min”. Patient´s eGFR might improve with a reduction in furosemide. Close monitoring needed.
