Custom Sublingual Medications for Heart Disease: Essential Treatment and Outreach Tools
Sublingual nitroglycerin is a Class I recommendation for treating angina, yet prescriptions are written for fewer than half of all patients living with chest pain. This fact baffled cardiologist Melissa Walton-Shirley, MD, who subsequently posted signs in her waiting room stating, “If you’ve ever had a diagnosis of angina pain due to heart artery blockage, angioplasty, heart bypass surgery, a stent, or a heart attack, please ask us about a nitro prescription.”
Compounding pharmacists can use the critical role of sublingual medications for heart disease as a jumping-off point for patient outreach. We can protect our patients by targeting those who may need sublingual nitrates while also taking the lead in screening for prevention and compliance.1
Sublingual Medications for Cardiovascular Disease
Management of cardiovascular disease includes diverse combinations of oral medications, but treatment of acute angina is best achieved with the rapid absorption and pain relief delivered by sublingual nitrates. Patients with stable angina can also use sublingual nitroglycerin prior to exercise, which prevents pain and encourages cardiac rehabilitation.
Calcium channel blockers such as verapamil and nifedipine can be used sublingually to treat angina. Verapamil is also approved as a class IV antiarrhythmic. However, sublingual delivery is typically used only in the clinical setting due to its potential to depress cardiac function.
Controversy Over Prevention Guidelines
The relative paucity of nitroglycerin prescriptions isn’t the only controversy in cardiovascular medicine. In August 2015, cardiologists from the Mayo Clinic and Johns Hopkins published a list of concerns about the currently used heart disease prevention guidelines established by the American Heart Association and the American College of College of Cardiology in 2013.2 In addition to clarifying treatment protocols for borderline patients, they noted the following issues:
- The current risk calculator, which uses key health indicators to determine a person’s chance for having a heart attack or stroke over the next 10 years, uses an algorithm that over-estimates the risk. As a result, medications such as statins may be over-prescribed, which puts people at an unnecessary risk for adverse reactions.
- The cardiologists from the Mayo Clinic and Johns Hopkins noted that the 2013 risk algorithm is insensitive to differences between races and ethnicities. Such insensitivities—and their implications for preventive therapies—are problematic. The existing evidence shows that disease patterns among people of Latin American, South Asian and East Asian origin are different from white and African American patients.
Concerns about racial and ethnic differences extend beyond risk assessment to treatment options for patients diagnosed with cardiovascular disease. Researchers from New York University Langone Medical Center reviewed the health records of nearly 60,000 hypertensive patients who received care at hospitals within New York City’s Health and Hospital Corporation from 2004 to 2009. They found that taking an ACE inhibitor helped white patients, but was associated with significantly poorer cardiovascular outcomes in African American patients.3
What Does This Mean for Compounding Pharmacists?
Compounding pharmacists are already trained to do what’s needed—reach out and treat each patient individually. This is the bottom line for cardiovascular management regardless of controversial guidelines. We can stay alert for ways to counsel patients who may need to add medications to their regimen or who are confused over disagreements among the experts.
Improving Compliance: One vital task we face as compounding pharmacists is helping patients improve compliance. You might think that a health condition as serious as cardiovascular disease would motivate medication adherence, but the numbers tell a shockingly different story. Sixty percent of patients with cardiovascular disease don’t adhere to medication recommendations after they’re discharged. Patients who don’t fill their discharge prescriptions within 120 days increase their risk of death by 80 percent. Of those that do comply, half stop taking their meds within six to 12 months.4
When we have the opportunity to reach out to these patients, direct communication is the key. We can discuss with them the gravity of their illness, the value of medications and concerns over side effects. We can dare to take the lead and discuss cultural beliefs that might interfere with compliance.
We can integrate actions into our daily business practice that improve compliance, such as:
- Pharmacists can use online tools and apps to set up for patients automatic text, email or phone reminders to take heart meds.
- Coordinate with visiting nurses and have a pharmacy tech or intern go with them on the first home visit following discharge.
- Recommend financial assistance options for patients who don’t refill prescriptions due to lack of insurance.
- Follow-up with a phone call when electronically-submitted prescriptions aren’t picked up by patients. The important difference is making it a personal call rather than an automated reminder, as this connection is likely to result in improving compliance.
- Beyond compliance issues, check in with patients receiving cardiovascular meds to see if they experience angina and ask if they use nitroglycerin. If not, reach out to their cardiologist to coordinate treatment and establish yourself as a team member.
Positioned to Make a Lifesaving Difference for Cardiovascular Patients
Cardiovascular patients who take sublingual meds, or who are candidates for nitrates, are likely to be overwhelmed by their health status. Information overload during hospitalization may interfere with their ability to comprehend medication instructions. Some patients may hear about conflicting guidelines in the news. On top of it all, there’s the almost unbelievable fact that a majority of coronary artery patients don’t take their meds. As compounding pharmacists, we’re in a position to serve as a potentially lifesaving resource.
Pharmaceutica North America provides superior-quality calcium channel blockers in the form of cost-effective bulk APIs. Please contact us to discuss how we can help you meet your patients compounding needs.
- “Nitro: Why Aren’t We Prescribing It?” March 2014, http://www.medscape.com/viewarticle/821702#vp_1 ↩
- “Experts Suggest Upgrades to Current Heart Disease Prevention Guidelines,” August 2015,
- “Popular Hypertension Drugs Linked to Worse Heart Health in Blacks Compared to Whites,” September 2015, http://www.sciencedaily.com/releases/2015/09/150915141035.htm ↩
- “Medication Adherence in Cardiovascular Disease,” 2010, http://circ.ahajournals.org/content/121/12/1455.full ↩