Cardiovascular Pharmaceuticals

1
Cardiovascular Pharmaceuticals

• Irene Mueller, EdD, RHIA
• MHA
• 2010

2
Objectives First Hour

• Medications
• Heart
• Vessels

3
Objectives - 2nd hour

• Medications
• Vessels, continued
• Using the ICD-9-CM Table of Drugs
• Homework Answers
• Responses to Questions
• Resources

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CV System Pharmaceuticals

• Many can be used for
• Multiple Heart AND/OR vessel conditions
• Dosage, etc. variations
• Therefore, can be grouped many ways
• Many used in combination
• Many can interact with
• each other
• Other types of meds
• Following lists are most common
• Many other drugs

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Actions of Heart Drugs

• Possible actions of cardiac drugs
• change the rate of the heartbeat
• change the rhythm of the heartbeat
• change the amount of output of blood
• change the strength of contraction
• Inotropic and Cardiotonic
• Blood vessel/Blood drugs can help heart

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Classifications of Heart Drugs
ACE Inhibitors Anti-coagulants/Anti-platelets
Anti-anginals Anti-fibinolytics
Beta-adrenergic Blockers Anti-hyperlipidemics
Calcium channel Blockers Cardiac glycosides
Nitrites and Nitrates Diuretics
Anti-arrhythmic (-Dysrhythmic) agents Carbonic Anhydrase Inhibitors
Beta-adrenergic Blockers (Class II) Osmotic
Calcium channel Blockers (Class IV) Thiazide/Thiazide -like
Potassium channel Blockers (Class III) Thrombolytics
Sodium Channel Blockers (Class I)

Italics in vessel section
Bold in heart section

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Anti-anginals
Contraindications Interactions Side Effects
Anemia, severe alcohol Blurred vision
GI disease Viagra Dry mouth
Glaucoma Flushing
Intracranial pressure GI - Constipation
Low blood pressure Headache
Hypersensitivity reaction
Orthostatic hypotension
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Beta-adrenergic Blockers

• Reverse the sympathetic system effects
• Caused by exercise, mental exertions
• Decrease heart rate and force of contractions
• Decrease cardiac work oxygen consumption
• Often prevents myocardial ischemia and pain
• Long-term mgt of angina pectoris
• Can be combined with nitrates

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Types of CV Beta receptors

• Beta-1 (ß1) - heart
• Beta (ß2) - blood vessels
• Beta (ß3) - fat cells
• Block the effect of norepinephrine and
  epinephrine at receptor sites
• reduce heart rate (B1)
• reduce blood pressure by dilating blood vessels
  (B2)

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NS Beta-adrenergic Blockers

• Nonselective Blockers (beta 1 and 2)
• Labetalol (Normodyne) HTN
• Nadolol (Corgard) HTN, angina pectoris
• Pindolol (Visken) HTN
• Propranolol (Inderal)
• HTN, angina, arrhythmias, migraine
• Timolol (Blocadren) HTN, post MI

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Selective Beta-1 Blockers

• acebutolol (Sectral)
• HTN, ventricular arrhythmias
• atenolol (Tenormin) HTN, angina pectoris
• bisoprolol (Zebeta) HTN
• esmolol (Brevibloc) SV Tachycardia
• metoprolol (Lopressor) HTN, angina pect.

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Calcium Channel Blockers

• Can be used to treat
• Tachyarrhythmias, angina pectoris, HTN
• Decrease calcium entry into cells with actions
  potentials (heart and blood vessels)
• 2 effects in heart (conduction muscle)
• Decrease rate of SA node, AV conduction
• Decrease force of contractions
• Effect in vessels relaxation, vasodilation

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Calcium Channel Blockers

• verapamil (Calan, Isoptin)
• AV node/SV arrhythmias, angina
• diltiazem (Cardizem)
• More effective as anti-hypertensive
• nifedipine (Procardia)
• Vasodilator
• nicardipine (Cardene)
• Vasodilation, relax coronary artery spasm

• Newer
• amlodipene (Norvasc)
• bepridil (Vascor)
• felodipine (Plendil)
• Isradipine (DynaCirc)

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Nitrites and Nitrates

• Oldest/Most frequently used antianginals
• General dilation of systemic veins/arteries
• Vascular smooth muscle
• Ions are converted by enzymes to Nitric Oxide
• Lower doses more venous dilation

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Nitrites and Nitrates

• Decrease preload and afterload of heart
• Preload force of venous return to heart
• Afterload arterial pressure (blood pressure) L
  ventricle must work against to eject blood
• Reduce cardiac work/oxygen consumption
• Used prophylactically and during angina
• Also to tx CHF
• Nitrates relieve vasospasm in coronary art.

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Nitrites and Nitrates

• amyl nitrite (Vaporole)
• erythrityl Tetranitrate (Cardilate)
• isosorbie Dinitrate (Isordil)
• nitroglycerin (Nitrol, Notrostat, Nitrong,
  Nitro-Bid, Transderm-Nitro
• pentaerythritol Tetranitrate (Peritrate)

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Nitroglycerin

• Sublingual
• Almost immediate onset, but short duration
• Acute anginal attacks
• Ointment (2)
• Extended release tablets/capsules
• Transdermal patches
• IV Emergencies/surgeries in hospital

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Anti-arrhythmics

• 4 classes
• Class 1 Sodium channel blockers
• Class 2 Beta-adrenergic blockers
• Described in anti-anginals
• Class 3 Potassium channel blockers
• Class 4 Calcium channel blockers
• Described in anti-anginals

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Anti-arrhythmics

• Dromotrophics irregular rhythms
• Chronotropics too fast or too slow
• Several ions regulate electrical system
• Sodium, Potassium, Calcium
• Arrhythmias disturb movement of ions
• Drugs can help restore normal movement
• Anti-arrhythmics do NOT cure causes

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Sodium Channel Blockers (Class 1)

• Interfere with movement of sodium ions
• Slow conduction velocity
• Tx
• Supraventricular tachycardias
• Ventricular arrhythmias
• Side effects/Contraindications
• Specific to each drug

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Sodium Channel Blockers

• quinidine (chinchona bark)
• procainamide (Procanbid)
• disopyramide (Norpace)
• lidocaine (Xylocaine)
• phenytoin (Dilantin)
• Newer
• flecainide (Tambocor), moricizine (Ethmozine),
  propafenone (Rythmol)

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Potassium Channel Blockers

• Decrease frequency of arrhythmias
• bretylium (Bretylol)
• Adrenergic neuronal blocker
• amiodarone (Cordarone)
• Blocks alpha, beta, calcium receptors
• sotalol (Betapace)
• Non-selective beta blocker

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Other Anti-arrhythmics

• quinidine sulfate (Class 1)
• decreases the of atrial muscle contractions
• used to treat Afib
• Pronestyl
• ventricular arrhythmias w/premature contractions
• Afib
• Lidocaine (Xylocaine) (Class 1)
• IV - prevents controls Vfib, pt w/recent severe
  MI
• (SE) drowsiness, disorientation, confusion,
  convulsions, coma

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Cardiac Glycosides

• Derived from Digitalis plants
• Oleander, Lily of valley, Cane toads
• Increase force of contractions (Inotropic)
• Lowers ventricular rate
• w/o increasing oxygen consumption
• Kidney function improves, reducing edema
• Decrease heart rate and AV conduction
• Increase kidney function, reduces edema

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Cardiac Glycosides
Contraindications Interactions Side Effects
Hypothyroidism Adrenergics Arrhythmias
Lactation, Pregnancy Antacids Dizziness
MI Anti-arrhythmics Electrolyte imbalance
Impaired kidneys Diuretics GI upset
Monitor Neomycin Headache
High/low potassium Phenobarbital Irritability
Irregular rhythm Rifampin Lethargy
Slow heart rate Sulfa drugs Muscle weakness
Discontinue if noted Seizures
Tremors
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Cardiac Glycosides

• Digitalization, then maintenance
• Low potassium increases toxic effects
• High potassium antagonizes tx effects
• High calcium enhances action
• Tx CHF

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Cardiac Glycosides

• deslanoside (Cedilanid-D) IM, IV
• digitoxin (Purodigin) PO, IV
• digoxin (Lanoxin) PO, IV
• side effects (overdose of digoxin) - nausea,
  vomiting, objects appear brighter, bradycardia

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Diuretics

• Used to tx CV conditions
• HTN, Edema (CHF)
• Diuretic actions
• Stimulate urine production
• inc glomerular filtration
• Decrease sodium reabsorption (diuresis)
• Five major classes of Diuretics

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Diuretics
Contraindications Interactions Side Effects
Anuria Cardiac glycosides Anorexia
Breastfeeding Corticosteroids Hypersensitivity reactions (skin rash)
Known hypersensitivity Lithium Hyperuricemia
Pregnancy NSAIDs Hypokalemia
Oral hypoglycemics Hyponatremia
Hypotension
Nausea
Ototoxicity (loop)
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Classes of Diuretics
Carbonic anhydrase inhibitors
Organic acids (Loop)
Osmotic (Lumenal) (no ? uses)
Potassium-sparing
Thiazide/Thiazide-like

OTC (Xanthine derivatives)
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Carbonic Anhydrase Inhibitors

• Increase sodium and water excretion
• Not used as often today
• Still adjunct tx in CHF (Acetazolamide)
• Also used to tx
• Glaucoma
• Petit mal seizures
• dichlorphennamide, mathazolamide
• Acute mountain sickness (Acetazolamide)

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Organic Acid (Loop) Diuretics

• Inhibit sodium and chloride ion transport in loop
  of Henle
• Great loss of sodium, chloride, and water
• Usu. Hypochloremic alkalosis
• Tx
• Edema inpts resistant to thiazides
• Severe peripheral and pulmonary edema
• Edema of CHF

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Organic Acid (Loop) Diuretics

• bumetanite (Bumex) CHF edema, ascites
• ethacrynic acid (Ederin) CHF edema
• furosemide (Lasix) CHF edema, HTN
• torsemide (Demadex) CHF edema
• http//media-2.web.britannica.com/eb-media/23/9942
  3-004-BB1F574D.jpg

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Potassium-Sparing Diuretics

• Mild diuresis
• Inhibit potassium secretion in the distal
  convoluted tubules
• Primarily adjuncts to thiazide/loop diuretics
• Inhibit hypokalemia
• Hyperkalemia promoted in
• Impaired renal function/diabetic pts

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Potassium-Sparing Diuretics

• amiloride (Midamor) HTN
• spironolactone (Aldactone) HTN, Edema
• spironolactone
• w/thiazide (Aldactazide) HTN, Edema
• triamterene (Dyrenium) - Edema, HTN

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Thiazide/Thiazide-like Diuretics

• Largest group
• Inhibit sodium transport in the distal portion of
  the nephron
• Intense diuresis of sodium and water
• Increase excretion of chloride and potassium
• Produce alkalosis and hypokalemia
• Hyponatremia in elderly reported

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Uses of Thiazide Diuretics

• Edema of any cause
• immediate
• Mild/moderate HTN
• 4-6 weeks
• Decrease blood volume
• Relax smooth muscles in vessel walls

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Side Effects of Thiazides

• Drop in blood pressure
• Orthostatic hypotension
• Dizziness, faint
• Hypokalemia
• Hyperuricemia
• Hyperglycemia
• Muscle spasms/cramps

• Glucose changes in DM
• Nausea
• Diarrhea
• Constipation
• Anorexia
• Headache
• Impotence
• Elevation
• BUN
• Creatinine

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Thiazide Diuretics

• bendroflumethiazide (Naturetin)
• benzthiazide (ExNa)
• chlorothiazide (Diuril, Diurgen)
• hydrochlorothiazide (Exidrix, Ezide, HydroDIURIL,
  Oretic)
• methyclothiazide (Enduron, Aquatensin)
• polythiazide (Renese)
• trichlormethizade (Diurese, Metahydrin, Naqua)

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Thiazide-like Diruetics

• chlorthalidone (Hygroton)
• indapamide (Lozol)
• metalazone (Zaraxolyn)
• qinethazone (Hydromox)

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Classification of Vessel Drugs
Anti-coagulants/Antiplatelets Diuretics
Aspirin (Prostaglandin Inhibitor) Carbonic Anhydrase Inhibitors
Coumarins Osmotic
Heparin Thiazide/Thiazide -like
Thrombolytics
Antifibrinolytics Vasoconstrictors
Anti-hyperlipidemics Other Vasodilators
Anti-hypertensives Nitrites and Nitrates
ACE Inhibitors
Calcium channel Blockers
Vasodilators Bold in vessel section
Alpha-adrenergic Blockers Italics in heart sections
Angiotensin II receptor blockers (ARBs)

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Anti-coagulants (Veins)

• 4 stages in coagulation and clot resolution
• Anti-coagulant mechanisms
• Inhibit the function of preformed clotting
  factors (heparin - IV/SQ)
• Prevent synthesis of normal clotting factors
• Coumarin derivatives (PO)
• Mechanisms determines onset/duration of drug
  effects
• Used to prevent MIs

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Anti-coagulants
Contraindications Interactions Side Effects
Uncontrolled bleeding Acetaminophen, NSAIDs Bleeding (increased)
Pregancy (use with caution) Alcohol Blood irregularities
Anti-infectives GI disease
Barbiturates Kidney disease
Chloral hydrate Liver disease
Estrogen
Steroids anabolic and cortico-
Thyroid drugs
Tricyclic antidepressants
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Coumarin Derivatives

• Can be PO
• Warfarin sodium (Coumadin)
• Vitamin K antagonist
• Side effects
• Hematuria, petechiae
• Nausea, Diarrha, urticaria, alopecia

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Heparin (IV,SQ)

• Used to Prevent
• Venous thrombosis, esp. Pulmonary embolism
• Clots prior to blood transfusion, during open
  heart surgery
• Treat
• MI
• Thrombophlebitis
• Stroke
• Preferred anti-coagulant during pregnancy

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Antiplatelets (Arteries)

• Suppress aggregation of platelets
• Core of arterial thrombus
• Low-dose aspirin - Preventative
• Clopidgrogrel (Plavix)
• Previous MI
• Ticlopidine (Ticlid)
• More expensive than aspirin, same level of tx
• Dipyridamole (Persantin)

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Aspirin

• acetylsalicylic acid
• Hippocrates (460 B.C and 377 B.C)
• historical records of pain relief tx
• use of powder made from willow bark and leaves
  for headaches, pains and fevers
• 1829, scientists discovered called salicin in
  willow plants which provide pain relief
• Aspirin was patented on February 27, 1900 by Bayer

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Thrombolytics

• Dissolve existing clots
• Tx MI w/in 6 hours of symptoms onset
• 5 drugs
• streptokinase (streptase)
• alteplase (Activase)
• urokinase (Abbokinase)
• reteplase (Retavase)
• anistreplase (Eminase)

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Anti-fibrinolytics

• Help form blood clots
• Provide hemostasis
• Vitamin K antidote for anticoagulant overdose

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Anti-hyperlipidemics (Hypolipidemics)

• Atherosclerotic plaques usually in large/medium
  arteries
• Lifestyle changes first
• Diet changes needed even with meds
• Prophylactic tx, lifelong once begun
• Reduce cholesterol and LDL

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Anti-hyperlipidemics
Contraindications Interactions Side Effects
Biliary obstruction antacids abdominal pain
Elevated liver enzymes anticoagulants arrhythmias
Gallbladder disease cardiac glycosides asthenia
Lactation cimetidine constipation
Liver disease corticosteroids dizziness
Peptic ulcers cyclosporine headache
Pregnancy erythromycin myalgia
Renal dysfunction iron NV
sulfonylureas rash
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Anti-hyperlipidemics

• Bile Acid sequestrants
• HMG CoA Reductase Inhibitors (statins)
• Nicotinic Acid
• Fibric Acid Derivatives
• Estrogens

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Anti-hyperlipidemics

• cholestyramine (Questran, Prevalite) (BAS)
• colestipol (Colestid) (BAS)
• atorvastin (Lipitor)
• fluvastatin (Lescal)
• lovastatin (Mevacor)
• pravastatin (Pravachol)
• simvastatin (Zocor)

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Break Time
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Anti-hypertensives

• Treatment usually begins with
• lifestyle changes, then add
• diuretic or beta blocker, then
• add another med, etc.
• Compliance big problem, HTN asymptomatic
• ACE Inhibitors
• Vasodilators
• Alpha-adrenergic Blockers
• Angiotensin II receptor blockers (ARBs)

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ACE Inhibitors

• Angiotensin Converting Enzyme (ACE)
• Angiotensin is a vasoconstrictor
• Slow formation of angiotensin II
• Decrease blood volume/pressure
• Increase renal blood flow
• Interfere Less with mental/physical performance
  better Quality of Life better compliance
• SE nonprod cough, loss of taste, joint pain

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ACE Inhibitors (PO)

• benazepril (Lotensin)
• enalapril (Vasotec)
• fosinopril (Monopril)
• quinapril (Accupril)
• ramipril (Altace)
• Tx - CHF

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Alpha-adrenergic Blockers

• Alpha-adrenergics action similar to
  norepinephrine (smooth muscle contraction)
• Major alpha organ is blood vessels
• Alpha blockers effects
• Vasodilation, lower blood pressure
• SE nasal congestion, orthstatic hypotension,
  fainting

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Alpha-adrenergic Blockers - PO

• doxazosin (Cardura)
• phentolamine (Regitine HCl)
• prazosin (Minipress)
• terazosin (Hytrin)
• Prescribed for Adults

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Angiotensin II receptor blockers (ARBs)

• Angiotensin II is a vasoconstrictor
• ARBs have effects that are similar to angiotensin
  converting enzyme (ACE) inhibitors
• ACE inhibitors act by preventing the formation of
  angiotensin II
• ARBS block the binding of angiotensin II to
  muscles on blood vessels

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Angiotensin II receptor blockers (ARBs)

• candesartan (Atacand)
• eprosartan (Teveten)
• irbesartan (Avapro)
• telmisartan (Micardis)
• valsartan (Diovan)
• losartan (Cozaar)
• olmesartan (Benicar)

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Vasoconstrictors

• Constrict the muscle fibers in blood vessel walls
  by direct action on vessels OR stimulate the
  vasomotor center in medulla
• stop superficial hemorrhage
• relieve nasal congestion
• Raise blood pressure
• Increase force of heart

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Vasoconstrictors

• norepinephrine (Levophed)
• tx hypotension
• metaraminol (Aramine)
• prolonged duration, raises bl pressure
• epinephrine (Adrenalin)

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Vasodilators

• Increase size of bl vessels
• Used to tx peripheral vascular disease, heart
  conditions (CHF), HTN
• Papaverine
• opium alkaloid, but NOT narcotic
• Alcohol - dilates blood vessels by depressing the
  vasomotor center of medulla
• can tx angina pectoris?

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(No Transcript)
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Using the Table of Drugs

• Coder must determine
• Adverse Effect vs Poisoning
• Decision Flow chart
• Taking less/stopping drug is
• NOT poisoning OR adverse effect
• 980 989 - Toxic effects of NON-medicinal
  substances follow Poisoning steps

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Table of Drugs

• Rows Drugs, medicinal substances
• Columns Poisoning code, E codes
• ALWAYS VERIFY in TL
• Instructional Notes
• Ex 960 Poisoning by antibiotics
• Exclusion Note 976.x should be used for local
  (topical) applications

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Adverse Effect

• Correct substance administered as prescribed
• Adverse effect (manifestation) sequenced 1st
• E code from Therapeutic use column 2nd
• CANNOT use E code from any other column
• Adverse Effect E codes MUST BE REPORTED

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Adverse Effect Documentation

• Dx statements of
• Toxic effect, toxicity, intoxication due to
  prescription drug (digitalis, lithium)
• w/o any further info
• Indicates Adverse Effect

• Other terms for AE
• Allergic reaction
• Cumulative effect (toxicity)
• Hypersensitivity
• Idiosyncratic reaction
• Paradoxical reaction
• Synergistic reaction

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Adverse Effects

• Toxicity
• Synergistic reaction
• Side effect
• Idiosyncratic reaction

• Because of
• Pt differences
• Age, sex, disease
• Genetic factors
• Drug-related
• Type
• Administration route
• Duration of tx
• Dosage
• Bioavailability

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AE Drug E codes

• When agent causes multiple adverse reactions,
  code the E code ONCE
• When 2 drugs are responsible, code individually
  unless there is a combo E code

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Unspec AE

• 995.2 Unspec AE effect of drug,
• CAN be used in OUTpatient setting
• Inappropriate for Inpatient setting
• Code SS or 796.0 w/ Ecode

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Late Effects of AE of Drugs

• Code residual condition
• 909.5
• E code (E930-E949)
• Chronic effects of drug taken for long time and
  still being taken current AE
• If delayed effects AFTER stopping LE

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Late Effects AE Examples

• Brain damage caused by penicillin allergy (while
  taking med)
• 348.9, E930.0
• Brain damage caused by penicillin allergy
  (stopped using 6 months ago)
• 348.9, 909.5, E930.0

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Poisoning

• Substance used incorrectly
• Error in prescription
• Drug overdose (Intentional/Accidental)
• Non-prescribed drug taken with correctly
  prescribed/taken drug
• Wrong administration method
• Wrong dosage given/taken
• Wrong medication given/taken

76
Poisoning

• Code from Poisoning column first
• Manifestation
• E code for how substance used
• Accident, Assault, Suicide, etc.
• CANNOT use E code from Tx Use column

77
Poisoning by Interaction

• Tx drug and non-prescription drug or alcohol
• Poisoning code for EACH substance
• Manifestation, if documented
• E code for EACH substance

• Ex Coma due to Adverse reaction to Valium taken
  correctly, but with 2 martinis
• 980.0
• 969.4
• 780.01
• E860.0
• E853.2

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Poisoning E codes

• Cause not stated undetermined E code

79
Substance Abuse/Dependence

• Acute condition due to alcohol/drug
  abuse/dependence Poisoning code
• Code acute manifestation
• Code abuse/dependence
• E code
• Ex Acute pulmonary edema due to accidental
  heroin overdose/pt dependent
• 965.01, 518.4, 304.00, E850.0
• Chronic conditions are NOT poisoning

80
Late Effects of Poisoning

• Same LE rules
• Residual coded first
• 909.0
• E929.2

81
Specific Drug NOT in Table

• American Hospital Formulary Service (AHFS)
• Index from brand names, etc to
• Hospital Pharmacist is valuable resource
• ICD-9-CM Appendix 3 has list of AHFS by drug
  functions (no brand names)
• May have to research drug name to find type and
  then find type in Appx 3

82
Drug Resources

• Mayo Clinic
• http//www.mayoclinic.com/health/drug-information/
  DrugHerbIndex
• Medicinenet.com
• http//www.medicinenet.com/medications/article.htm
  
• MedlinePlus
• http//www.nlm.nih.gov/medlineplus/druginformation
  .html

83
Drug Resources

• NLM. NIH. Drug Information Portal.
• http//druginfo.nlm.nih.gov/drugportal/drugportal.
  jsp
• PDRHealth. Drugs and Supplements.
• http//pdrhealth.com/drugs/drugs-index.aspx

84
Adverse Effects vs Poisoning
Condition due to Drug, Med. Bio? NO Code Condition
Yes
Med used exactly as prescribed? NO Code as Poisoning Add code for condition Add E code (Optional)
Yes
Alcohol/non-prescr. drug also taken? NO Code condition Add Tx use E code (E930-E949)
Yes
Code as Poisoning Add code for condition Add E code (Optional)
85
Drug Coding

• Hypokalemia resulting from reaction to Diuril
  given by mistake in Drs office
• Electrolyte imbalance due to interaction between
  lithium carbonate and Diruil, both taken as
  prescribed
• Toxic encephalopathy due to excessive use of
  aspirin

86
Drug coding

• Coumandin intoxication due to accumulative effect
  resulting in gross hematuria
• Severe bradycardia due to accidental double dose
  of digoxin
• Lightheadedness due to interaction between
  Aldomet and peripheral vasodilating agent (both
  taken as presc.)

87
Drug Coding

• Bradycardia due to eating oleander leaves
• Systemic hypocalcemia and hypodalemia due to
  using lye in housecleaning
• Extrapyramidal disease due to attempted suicide
  by overdose of Thorazine six months ago

http//biology.clc.uc.edu/graphics/steincarter/flo
rida/Oleander200220small.JPG
88
Questions ? ? ?
ILEMten_at_gmail.com
Thank You !
89
Resources

• Beaman, N. Pharmacology Clear and Simple. 2008.
  PhiladelphiaF. A. Davis.
• Fulcher, E. M., Soto, C. D., and Fulcher, R. M.
  Pharmacology Principles and applications.
  Saunders, 2003.
• Hitner Nagle. Basic Pharmacology. 4th ed.
  Glencoe,1999.

90
Resources

• ICD-9-CM Official Guidelines for Coding and
  Reporting, October 1, 2009
• http//www.cdc.gov/nchs/data/icd9/icdguide09.pdf
• Inotropic and Cardiotonic Drugs. Heart Rhythm
  Society.
• http//www.hrsonline.org/PatientInfo/Treatments/Me
  dications/HFDrugs/
• Kapitanyan, Su, Landry. 2009. Plant Poisoning,
  Glycosides Cardiac.
• http//emedicine.medscape.com/article/816781-overv
  iew

91
Resources

• Klabunde, R. Cardiovascular pharmacology
  concepts.
• http//www.cvpharmacology.com/index.html
• Medicinenet. Angiotensin II Receptor Blockers
  (ARBs). 2010.
• http//www.medicinenet.com/angiotensin_ii_receptor
  _blockers/article.htm
• WebMD. Heart Disease Medications.
• http//www.webmd.com/heart-disease/guide/heart-dis
  ease-medications-index