Seloken

[AuF]

Undrar om det är något landsting som har seloken som generell ordination för amb.ssk, och i så fall på vilken indikation ?

[Niklas Karlsson]

AMI har vissa landsting där trycket är över 90 efter nitro

[Gosta]

Har det i Remote clinical protocols som beta1-selective blocker.
Vi har inte sett någon praktisk prehospital användning för det i akuta fall, utom senare efter stabilisation.
I våra paramedic protocols and clinical guidelines har vi "Remote Clinical Extension Protocols". Dessa inkluderar en massa GP pharmaceutica och procedurer som annars endast skulle utföras av läkare antingen på sjukhus eller klinik. Det är tiden till definitive care, graden av behov, och operatörens kliniska kompetens som dikterar när "Remote Clinical Extension Protocols" används. Lite off thread, sorry, men ett svar om hur det har fungerat där jag arbetat.
Ledsen för språkblandningen. Jag har inte skrivit på svenska på ganska många år. Tar detta som lite practice.
Hälsningar,
Gösta

[Tobbe]

Vi har det på generell ordination. Kriterierna är samma som SLAS förespråkar. Och alla ssk i ambulans kan administrera det.

[Novisen]

Nydebuterade FF, cirkulatoriskt "stabila" VT, PSVT, AMI och instabil angina KAN väl vara lämpliga tillfällen att ge Seloken. Flera studier pekar även på långsiktiga fördelar med att ge Seloken i ett tidigt förlopp vid AMI. Finns ingen anledning att vänta till akuten. Dessutom ser man mindre VF om Seloken sätts in tidigt. Frågan är om patienten behöver sitt blodtryck och sin kronotropi till nått viktigare. Seloken kan även bli aktuellt i smådoser i kombination med Furix och Propofol/Dormicum/Morfin vid intracelebrala händelser.

[Gosta]

Hej Novisen,
Vi har tillgång till både selektiv och nonselektiv B blocker prehospitalt. Remote guidelines (som beskrevs i tidigare inlägg) kan användas också i Sydney med omnejd om tiden och situationen så kräver. Oftast (men inte i alla fall) i city ambulanser brukar man befinna sig på ED innan det blir dags med B1 blocker vid AMI med tach eller hypertension. Endast IC Paramedics men ej Paramedics har certifiering att beordra administration av dessa läkemedel. När jag skrev “efter stabilisation” så kanske det var fel term, jag gillar den inte i alla fall. Jag menade att det brukar vara drog nummer tre eller liknande efter morphine och GTN till exempel, och i de flesta fall inte ges prehospitalt. Kanske det borde ändras här? Skall ta upp saken. Dina exempel är helt enligt Australiens MIMS och ses som indikationer också här.
Hälsningar,
Gösta

[Rookie.]

Hej ambulanare.

Hur ser ni på Seloken vid inferiora- och eller bakväggsinfarkt. Är detta en kontrainikation enligt er eller är det ffa nitro som man ska se upp med vid ovanstående infarkter ?

[Gosta]

Hej ambulanare.

Hur ser ni på Seloken vid inferiora- och eller bakväggsinfarkt. Är detta en kontrainikation enligt er eller är det ffa nitro som man ska se upp med vid ovanstående infarkter ?

Hej Rookie,
Här har du indikationer, kontraindikationer och precautions från Australian MIMS
Det är alltså inte kontraindikerat, men en del presentationer som kan ske tillsammans med olika typer av infarkter är kontraindikationer (inte infarkterna).
Ser det annorlunda ut i Sverige?

Vad betyder ffa? Ursäkta om det är en dum fråga.

Hälsningar,
Gösta

Indications
Oral therapy. Hypertension; angina pectoris; suspected or definite myocardial infarction; migraine prophylaxis.

Intravenous therapy. Disturbances of cardiac rhythm, in particular supraventricular tachyarrhythmias.



Contraindications
Bronchospasm. Beta-Adrenergic blockade of the smooth muscle of bronchi and bronchioles may result in an increased airways resistance. These drugs also reduce the effectiveness of asthma treatment. This may be dangerous in susceptible patients.

Therefore, beta-blockers are contraindicated in any patient with a history of airways obstruction or a tendency to bronchospasm. Use of cardioselective beta-blockers can also result in severe bronchospasm. If such therapy must be used, great caution should be exercised. Alternative therapy should be considered.

Allergic disorders (including allergic rhinitis) which may suggest a predisposition to bronchospasm.

Right ventricular failure secondary to pulmonary hypertension.

Significant right ventricular hypertrophy.

Sinus bradycardia (less than 45 to 50 beats/minute).

Second and third degree atrioventricular (A-V) block.

Shock (including cardiogenic and hypovolaemic shock).

Hypersensitivity to metoprolol tartrate, related derivatives, or any of the excipients in Betaloc. Cross sensitivity between beta-blockers can occur.

Noncompensated congestive heart failure (see Precautions).

Sick-sinus syndrome.

Severe peripheral arterial circulatory disorders.

Myocardial infarction patients with a heart rate of <45> 0.24 seconds, a systolic blood pressure of < 100 mmHg and/or moderate to severe noncompensated heart failure.

Hypotension.

Untreated phaeochromocytoma (see Precautions).

Continuous or intermittent inotropic therapy acting through beta receptor agonism.

Precautions
Cardiac failure. beta-Blockade depresses myocardial contractility and may precipitate cardiac failure in some patients with a history of cardiac failure, chronic myocardial insufficiency, or unsuspected cardiomyopathy. In patients without a history of cardiac failure, continuing depression of the myocardium may lead to cardiac failure. If signs of cardiac failure are present, the patient should be fully digitalised and/or given a diuretic and carefully monitored. If cardiac failure persists, Betaloc should be discontinued gradually (see Precautions).

beta-Blockers should not be used in patients with untreated congestive heart failure. This condition should first be stabilised.

Note. Although congestive heart failure has been considered to be a contraindication to the use of beta-blockers, there is growing literature on the experimental use of beta-adrenergic blocking drugs in heart failure. As further trials are needed to identify which patients are most likely to respond to which drugs, beta-blockers should not normally be prescribed for heart failure outside specialist centres.

Prinzmetal angina. There is a risk of exacerbating coronary artery spasm if patients with Prinzmetal or variant angina are treated with a beta-blocker. If this treatment is essential, it should only be undertaken in a coronary or intensive care unit.

Conduction disorders. Very rarely a pre-existing A-V conduction disorder of moderate degree may become aggravated (possibly leading to A-V block). Betaloc should be administered with caution to patients with first degree A-V block (see Contraindications).

Phaeochromocytoma. In patients with this condition, an alpha-blocking drug (e.g. phentolamine or phenoxybenzamine) should be administered before the beta-blocker to avoid exacerbation of hypertension.

Diabetes. Betaloc should be used with caution in patients with diabetes mellitus, especially those who are receiving insulin or oral hypoglycaemic agents. Diabetic patients should be warned that beta-blockers affect glucose metabolism and may mask some important premonitory signs of acute hypoglycaemia, such as tachycardia.

In patients with insulin or noninsulin dependent diabetes, especially labile diabetes, or with a history of spontaneous hypoglycaemia, beta-blockade may result in the loss of diabetic control and delayed recovery from hypoglycaemia. The dose of insulin or oral hypoglycaemic agent may need to be adjusted. Diabetic patients receiving Betaloc should be monitored to ensure diabetes control is maintained.

Allergic conditions. Allergic reactions may be exaggerated by beta-blockade (e.g. allergic rhinitis during the pollen season and allergic reactions to bee and wasp stings). Beta-Blockers should be avoided if there is a risk of bronchospasm.

In patients taking beta-blockers, anaphylactic shock assumes a more severe form and may be resistant to normal doses of adrenaline. Whenever possible, beta-blockers should be avoided in patients who are at increased risk of anaphylaxis.

Hyperthyroidism. Special care should be exercised in those patients who are hyperthyroid and also receiving beta-blockers because beta-blockers may mask the clinical signs of developing or continuing hyperthyroidism, resulting in symptomatic improvement without any change in thyroid status. Where Betaloc is administered to patients having, or suspected of developing thyrotoxicosis, both thyroid and cardiac function should be closely monitored.

Peripheral vascular disease. beta-Blockade may impair the peripheral circulation and exacerbate the symptoms of peripheral vascular disease (see Contraindications).

Intravenous therapy. The intravenous administration of metoprolol tartrate to patients with a systolic blood pressure below 100 mmHg (13.3 kPa) should be carried out with special care as it can result in a further significant decrease of blood pressure.

Concomitant therapy with calcium antagonists. The concomitant use of calcium antagonists with myocardial suppressant and sinus node activity (e.g. verapamil and to a lesser extent diltiazem) and beta-blockers may cause bradycardia, hypotension and asystole. Extreme caution is required if these drugs have to be used together.

A calcium antagonist of the phenylalkylamine type (e.g. verapamil) should not be administered intravenously to patients receiving metoprolol because there is a risk of cardiac arrest in this situation. Patients taking oral calcium antagonists of this type in combination with metoprolol should be closely monitored.

The combination of beta-blockers with dihydropyridine calcium channel blockers with a weak myocardial effect (e.g. felodipine, nifedipine) can be administered together with caution. In case excess hypotension develops, the calcium antagonist should be stopped or the dosage reduced.

Clonidine. Concurrent use of beta-blockers and clonidine should be avoided because of the risk of adverse interaction and severe withdrawal symptoms. If administered concomitantly, the clonidine should not be discontinued until several days after the withdrawal of the beta-blocker.

Antiarrhythmic drugs. Care should be taken when prescribing beta-blockers with antiarrhythmic drugs. Interactions have been reported during concomitant beta-blocker therapy with the class IA agents disopyramide, and less frequently quinidine; class IB agents, tocainide, mexiletine and lignocaine; class IC agents, flecainide and propafenone (not available in Australia); the class III agent, amiodarone; and the class IV antiarrhythmic agents (e.g. verapamil).

Catecholamine depleting agents. Concomitant use of drugs such as reserpine and guanethidine requires careful monitoring since the added effect of a beta-blocker may produce an excessive reduction of the resting sympathetic nervous tone.

General anaesthesia. beta-Blockade may have beneficial effects in decreasing the incidence of arrhythmias and myocardial ischaemia during anaesthesia and the postoperative period. It is currently recommended that maintenance beta-blockade be continued perioperatively. The anaesthetist must be made aware of beta-blockade because of the potential for interactions with other drugs, resulting in severe bradyarrhythmias and hypotension, the decreased reflex ability to compensate for blood loss, hypovolaemia and regional sympathetic blockade, and the increased propensity for vagal induced bradycardia. Incidents of protracted severe hypotension or difficulty restoring normal cardiac rhythm during anaesthesia have been reported.

Modern inhalational anaesthetic agents are generally well tolerated, although older agents (ether, cyclopropane, methoxyflurane, trichlorethylene) were sometimes associated with severe circulatory depression in the presence of beta-blockade. If it is thought necessary to withdraw beta-blocker therapy before surgery, this should be done gradually and completed about 48 hours before surgery (see Abrupt withdrawal, Precautions).

Effects on the heart rate. If the patient develops increasing bradycardia (heart rate < 50 to 55 beats/minute) the dosage of Betaloc should be gradually reduced or treatment gradually withdrawn (see Contraindications).

Effects on the thyroid. The effects of beta-blockers on thyroid hormone metabolism may result in elevations of serum free thyroxine (T4) levels. In the absence of any signs or symptoms of hyperthyroidism, additional investigation is necessary before a diagnosis of thyrotoxicosis can be made.

Other metabolic effects. beta-Adrenoreceptors are involved in the regulation of lipid as well as carbohydrate metabolism. Some drugs affect the lipid profile adversely although the long-term clinical significance of this change is unknown and the effect appears to be less for drugs with intrinsic sympathomimetic activity.

Effects on the eye and skin. Various skin rashes and conjunctival xerosis have been reported with beta-blocking agents. Cross reactions may occur between beta-blockers, therefore substitutions within the group may not necessarily preclude occurrence of symptoms.

During long-term treatment with the beta-blocking drug practolol a specific rash bearing a superficial resemblance to psoriasis was occasionally described. In a number of the patients affected, this rash was accompanied by adverse effects on the eye (xerophthalmia and/or keratoconjuctivitis) of varying severity. This condition is called the oculomucocutaneous or practolol syndrome. On a few rare occasions serious otitis media, sclerosing peritonitis and pleurisy have been reported as part of this syndrome.

The oculomucocutaneous syndrome as reported with practolol has not been reported with metoprolol. However, dry eyes and skin rash have been reported with metoprolol. If such symptoms occur, discontinuation of metoprolol should be considered.

More recently, an association between Peyronie's disease (a fibrosing induration of the penis) and various beta-blockers has been suggested but is not proven.

Abrupt withdrawal. Care should be taken if beta-blockers have to be discontinued abruptly in patients with coronary artery disease. Severe exacerbation of angina and precipitation of myocardial infarction and ventricular arrhythmias have occurred following abrupt discontinuation of beta-blockade in patients with ischaemic heart disease.

Therefore, it is recommended that the dosage be reduced gradually over a period of 8 to 14 days during which time the patient's progress should be assessed. Betaloc should be temporarily reinstituted if the angina worsens.

If the drug must be withdrawn abruptly in these patients, close observation is required. In the perioperative period, Betaloc should not be withdrawn unless withdrawal is specifically indicated.

Impaired renal function. In patients with severe renal disease, haemodynamic changes following beta-blockade may impair renal function further. Beta-Blockers, which are excreted mainly by the kidney, may require dose adjustment in patients with renal failure.

Impaired hepatic function. Metoprolol is mainly eliminated by hepatic metabolism (see Pharmacokinetics). Therefore, liver cirrhosis may increase the systemic bioavailability of metoprolol and reduce its total clearance, leading to increased plasma levels.

Use in pregnancy. (Category C)

beta-Blockers may reduce placental perfusion and cause bradycardia in the fetus and newborn infant. Metoprolol crosses the placental barrier in pregnant women; in one study the concentration in the umbilical vein was almost the same as in maternal vein plasma.

During the late stages of pregnancy these drugs should only be given after weighing the needs of the mother against the risk to the fetus.

The lowest possible dose should be used and discontinuation of treatment should be considered at least two to three days before delivery to avoid increased uterine contractility and effects of beta-blockade in the newborn infant (e.g. bradycardia, hypoglycaemia).

Use in lactation. Metoprolol is excreted in human breast milk. Beta-Blockers taken by the mother may cause side effects, e.g. bradycardia, in the breastfed infant, although when the doses used are within the recommended therapeutic range, the very small amount of drug ingested by the infant renders such effects unlikely.

Experience suggests that Betaloc only need be discontinued during lactation if the infant's hepatic function is severely impaired.

Use in children. The safety and efficacy of metoprolol in children have not been established.

Effect on ability to drive or operate machinery. Betaloc may cause dizziness, fatigue or visual disturbances (see Adverse Reactions) and, therefore, may adversely affect the patient's ability to drive or use machinery.