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2 in 1: Heart failure with renal impairment

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My rotation workingfor our dispensing for discharge service has come to an end. I have slowlymanaged to get used to working at a busy pace in an acute admissions ward. Thepatients I see range from exacerbations of COPD, to ACS, to heart failure.

As part of my rotationobjectives, I had to do a case based presentation on a patient where I made afew interventions on. I decided to choose heart failure, as this was somethingI had limited experience with. I therefore did some research on this topic. Ifound out heart failure accounts for 2% of all inpatient bed days and around900,000 people in the UK have heart failure today. Symptoms includebreathlessness, fatigue and fluid retention.

Heart failuretreatment consists of ACE-inhibitors and beta-blockers. Second line treatmentwould be aldosterone antagonists, angiotensin II receptor antagonists,hydralazine and nitrates. It is also important to note that heart failurepatients can also be managed in the community and it is important to bear thisin mind when completing drug histories in order to get an accurate and up todate list of medicines.

One of theinterventions I made in this case was that, when looking at the creatinine levelsfor this patient, I saw it was slightly high. I worked them out to have acreatinine clearance of 28 ml/min. A community heart failure nurse recentlystarted this patient on bendroflumethiazide. I then checked the dose of this inthe BNF, and saw that thiazides and related diuretics are ineffective if eGFRis less than 30ml/min. When I informed the medical team of this, it was decidedto stop bendroflumethiazide as the patient was on a very low dose anyway, togetherwith it being ineffective.

To treat the fluidoverload that the patient was admitted with, the patient was started onfurosemide on admission. When I looked up loop diuretics in the BNF, I also sawthat high doses of loop diuretics might be needed in renal impairment. Thiswould explain why my patient was started on furosemide 80mg twice daily andthen increased to 120mg in the morning and 80mg midday after a few days as thedose was not sufficient. High doses of furosemide IV should also not exceed therate of 4mg/min as high doses or rapid administration can cause tinnitus ordeafness especially in renal failure.

I think it is a goodidea to do case presentations as a band 6 Pharmacist as it allows you to takemore time on a patient and look into the reasons why doctors might change amedication or increase a dose. It also means that you can either rememberthings you learnt at university or learn new things altogether. My nextrotation is production, which is something I have never done before and ameager to find out what production in pharmacy really involves!

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