Rachael Woods
Major Case Study:
Heart Failure and Left Ventricular Assist Device as a Destination
Therapy
January 17th, 2014
Figure 1.1 (1)
Introduction:
A.S. is a 71-year-old Caucasian male who weighs 113.90 kg (250.6 lb) and has
a height of 182.88 cm (72in). A.S. was admitted for a left ventricular assist device
(LVAD) placement as a destination therapy treatment for congestive heart failure
class III, stage IV. A.S. was chosen for this study because his case was intriguing; few
dietitians are familiar with LVAD therapy and the associated nutritional
implications. This study began on December 5th, 2013, and ended on December 20th,
2013. The objective of this study is to closely examine the nutritional requirements
for patients who plan to undergo and who have undergone LVAD procedures as a
destination therapy.
Social History:
A.S. is currently retired. Prior to retirement, A.S. owned a business in
Wisconsin before moving to Florida 24 years ago, where he worked for an
automobile company dealing with parts and services. A.S. is married and has two
daughters, ages 42 and 44. A.S. is a devout Catholic. When asked what A.S.’s family
responsibilities are he replied with a laugh “laundry and grocery shopping”. A.S. is
very active in his 55 and up community, with a passion for politics. A.S. used to be a
smoker (quit 20 years ago) and drinks alcohol one to two times per month.
1
Normal anatomy/physiology of affected organs:
The heart is a component of the cardiovascular system that consists of
arteries, capillaries, and veins (2). Figure 1.2 illustrates the anatomy of the
cardiovascular system.
Figure 1.2 Anatomy of the heart (3)
The heart is a muscle responsible for pumping more than 6,000 liters of
blood throughout the body every day (4). The heart is composed of four different
chambers, the right atrium, the right ventricle, the left atrium, and the left ventricle
(2). Deoxygenated blood (denoted blue in Figure 1.2) enters the heart through the
right atrium via the superior vena cava and the inferior vena cava (2). The
contraction of the right atrium allows the blood to move from the right atrium into
2
the right ventricle, and the contraction of the right ventricle pumps blood through
the pulmonary artery into the lung tissues allowing oxygenation of blood (2).
Oxygenated blood (denoted red in figure 1.2) is returned from the lungs to left
atrium of the heart via the pulmonary vein. Similar to the right atrium, the
contraction of the left atrium allows the movement of blood into the left ventricle.
The contraction of the left ventricle pumps oxygenated blood into the aorta, which
provides blood to the entire body (2). Cells comprising the body’s tissues and organs
use oxygenated blood to provide the fuel for metabolism; deoxygenated blood is
returned to the heart via the veins and the process continues.
“Heart failure occurs when the heart is unable to pump blood at the rate
sufficient to meet the metabolic demands of the tissues or can only do so at an
elevated filling pressure”(4). There are many different factors that can lead to heart
failure; the three most common are coronary artery disease, high blood pressure,
and diabetes (5). Although the aforementioned factors are the most common there
are other possible causes as well including: cardiomyopathy (heart muscle disease),
heart valve disease (complications secondary to events such as myocardial
infarctions), arrhythmias, and congenital defects. When the heart loses its capability
to pump efficiently, it comes up with alternative mechanisms to compensate for its
losses. The following are three different mechanisms the heart uses to adapt to
insufficient function:
1. Frank-Starling mechanism: increased filling volumes (of blood) enlarge the
heart and increase cross bridge formation of muscle cells of the heart, which
increases contractility (4).
3
2. Hypertrophy: Heart muscle cells (sarcomeres) proliferate to increase muscle
size and enhance force of contractility. Enlarged hearts secondary to
hypertrophy require additional oxygen consumption to support the demands
of additional muscle tissue; therefore hypertrophied hearts are more
susceptible to deterioration (4).
3. Activation of neurohormonal systems: (three different mechanisms)
a. Norepinephrine increases heart rate and allows for greater
contractility and vascular resistance and thus increases blood
pressure (4)
b. Activation of the renin-angiotensin-aldosterone system, which allows
for increase water retention and thus increases blood pressure (4)
c. Release of natriuretic peptide (4)
Heart failure is categorized into four different stages and four different
classes. The stages and classes are provided below in Tables 1.1 and 1.2.
Table 1.1 American Heart Association Stages of Heart Failure (6)
Presence of heart failure risk
Stage A
High Risk
factors but no heart disease and
no symptoms
Heart disease is present but
there are no symptoms
Stage B
Asymptomatic
(structural changes in heart
before symptoms occur)
Structural heart disease is
Stage C
Symptomatic
present and symptoms have
occurred
Presence of advanced heart
disease with continued heart
Stage D
Advanced Disease
failure symptoms requiring
aggressive medical therapy
4
Table 1.2 Classes of Heart Disease according to the New York Heart Disease Association (7)
No limitation of physical
activity. Ordinary physical
Class I
Mild
activity does not cause undue
fatigue, palpitation, or dyspnea
(shortness of breath)
Slight limitation of physical
activity. Comfortable at rest but
Class II
Mild
ordinary physical activity
results in fatigue, palpitation, or
dyspnea
Marked limitation of physical
activity. Comfortable at rest,
Class III
Moderate
but less than ordinary activity
causes fatigue, palpitation, or
dyspnea
Unable to carry out any
physical activity without
Class IV
Severe
discomfort. Symptoms of
cardiac insufficiency at rest. If
any physical activity is
undertake, discomfort is
increased
Heart failure can manifest as left-sided heart failure, right-sided heart failure,
or both simultaneously. Left-sided heart failure can be attributed to ischemic heart
disease, hypertension, aortic and mitral valve diseases, and myocardial disease (4).
As with any disease, symptoms of left-sided heart failure worsen as the disease
progresses, Figure 1.3 on the following page illustrates the progression of
symptoms. Right-sided heart failure is most always caused by the progression of
left-sided heart failure; only in rare cases is there “pure” right-sided heart failure
(usually when patients have rare disorders involving the lungs) (4).
5
Figure 1.3 The Progression of Heart Failure Symptoms (4)
Decreased cardiac output
Decreased O2
delivery/perfusion
Cerebral hypoxia, can
lead to irritability, loss of
attention span,
restlessness, and coma &
death
Orthopenea, (dyspnea
when laying down)
paroxysmal noctural
dyspnea (severe form
occuring at night)
Reduction in renal
perfusion: activates
renin-angiotensinaldosterone system:
retaining sodium and
fluids
Perivascular and
interstitial edema,
worsening pulmonary
edema
Past Medical History:
Past medical history of A.S. includes: congestive heart failure (heart failure)
class III, stage IV, cardiomyopathy, coronary artery disease, chronic kidney disease,
throat and prostate cancer with radiation, hypertension, gastritis, atrial fibrillation,
right bundle branch block, ischemic heart disease, history of myocardial infarction.
Surgeries performed prior to this admission include: pacemaker placement and
stented coronary artery. Other information related to previous hospital admissions
were not documented.
6
Present Medical Status and Treatment:
There are numerous ways that heart failure can be treated. According to the
National Heart, Lung, and Blood Institute, heart failure can be treated by following a
heart healthy diet (such as the TLC diet), physical activity, medications, and
surgeries such as pacemaker implantation, implantable cardioverter defibrillators,
coronary artery bypass grafts, LVADs, and heart transplants (5). Of the above
treatments, A.S. followed a heart healthy diet, took medications, and received an
LVAD implantation.
Prior to admission, A.S. felt very lethargic, was experiencing shortness of
breath, and was not able to perform his normal daily activities. The cause for A.S.’s
lethargy was his hearts inability to pump blood effectively throughout his body.
When the heart is unable to pump blood through the body effectively, oxygen and
essential nutrients cannot be delivered to the organs, tissues, and cells of the body.
When the cells comprising tissues and organs are not able to get the oxygen and
nutrients they need from the blood, they are not able to carry out their normal
functions and so they become compromised, leaving the affected individual feeling
ill and tired. Shortness of breath and fatigue can also be caused by fluid retention
around the heart and the lungs. When blood becomes congested in the heart it
results in systemic venous pressure that can lead to widespread edema; excessive
fluid retention can cause pulmonary edema, which makes it difficult for those
affected by the disease to breathe (8).
Laboratory values are an essential component to any medical examination, as
abnormalities are not always externally visible. Throughout A.S.’s stay, lab values
7
related to A.S.’s electrolytes, glucose levels and renal function were closely
monitored for trends. Unfortunately, A.S. was not seen for the purpose of this study
before he had his LVAD placement and so possible fluctuations prior to surgery
could not be monitored. Tables 1.4 and 1.5 show some of A.S.’s abnormal lab values
throughout his admission, with the reference ranges denoted in parenthesis (9).
Table 1.4 Laboratory findings (12/5)
Electrolytes
K: 3.3 (3.6-5 mEq/L)
Glucose
124 (70-99 mg/dL)
BUN, Creatinine
WNL
Table 1.5 Laboratory findings (12/16)
Electrolytes
Cl: 94 (101-111 mEq/L)
Glucose
94 (70-99 mg/dL)
BUN, Creatinine
32(5-20 mg/dL); 1.48(0.6-1.2 mg/dL)
Glucose can be elevated during times of stress and while taking certain medications
(such as steroids) (10). Stress is most likely the cause for elevated blood glucose in
A.S., as he does not have a history of diabetes and was not receiving steroids during
the time that the above labs were drawn. Potassium, BUN, and Creatinine can be
elevated secondary to renal disease (9). This is most likely the reason for A.S.’s
8
elevated BUN and Creatinine as he has a history of chronic kidney disease. The last
lab on the above tables that was out of range was Chloride. Chloride can be low for
many different reasons including heart failure (11). Chloride being decreased
secondary to heart failure is most likely the case for A.S. as his primary reason for
admission to the hospital was for treatment of heart failure via LVAD therapy.
As mentioned previously, medication therapy plays a large role in controlling
congestive heart failure. It is important to note how medications interact with the
body, with each other, and how they affect nutrition status. A.S. was on many
different medications throughout his hospital stay. The medications that A.S.
received during the days of this study are listed in appendix 1.
Observable physical and psychological changes:
The first time A.S. was seen for the purpose of this study was about two and a
half weeks post-op of his LVAD placement (surgery was on November 19th, and he
was first seen for study on December 5th); A.S. was not ambulating and appeared to
be very tired and frail. His wife was present in the room and was able to assist with
the interview process. Throughout A.S.’s stay at the hospital, his physical and
psychological changes were evident; with each visit, his physical and mental status
greatly improved. The second time A.S. was seen, he was able to answer all of his
questions himself, and was ambulating. As the visits continued, A.S. became more
talkative and began telling more personal stories about his life; such as the
hardships he faced struggling with heart failure until he had the LVAD placement,
rather than just talking about his eating patterns.
9
Treatment:
A.S. was admitted to have a surgical procedure performed: LVAD placement.
While some individuals receive LVAD treatment as a bridge to heart transplantation,
others such as A.S. receive LVADs as a destination therapy. LVADs are used as a
destination therapy in patients who are not candidates for heart transplantation.
Because A.S. received the LVAD implant as a destination therapy, the purpose of the
treatment was to prolong his survival and enhance his quality of life (12).
Medical Nutrition Therapy:
Nutrition History:
A.S. monitors his fat and sodium intake at home, but does not follow any
particular diet. A.S.’s wife does the grocery shopping and typically prepares dinner.
He and his wife go out to dinner one to two times per week. On a typical day, A.S.
eats cereal for breakfast at around 9:00 am. A typical lunch for A.S. is an unspecified
sandwich, hot dog, or peanut butter and jelly sandwich at around 1:30 pm. A typical
dinner for A.S. consists of turkey breast, meatloaf, chicken, hamburgers, or pizza if
he and his wife go out to dinner. A.S. eats all of his meals at his dining room table
(not in front of the television although the television can be seen from the table). A.S.
participated in a Weight Watchers diet about one year ago and reported that he
successfully lost 55 pounds.
During the first visit of the study with A.S., a 24-hour recall was performed.
Table 1.6 lists the foods as recalled by A.S. and the nutritional breakdown of each.
10
Table 1.6 24-hour recall
Food Product
Kcals
Carbohydrate
Protein
Fat
Ensure Plus
350 kcals
15g
13g
11g
Pudding
140 kcals
24g
4g
4g
Jello
64 kcals
16g
1g
0g
Ensure Plus
350 kcals
13g
51g
11g
0 kcals
0g
0g
0g
904 kcals
68g
69g
26g
Diet Tea
Total
During the visit at which the 24-hour recall was performed, A.S. was on a full-liquid
diet. A.S. was not very receptive to this diet order; consuming just 25% and
reporting a lack of interest in the foods he was being served. The diet was
prescribed because A.S. was intubated four days prior and was receiving enteral
nutrition during his intubation. The general protocol for diet advancement post
enteral nutrition is to progress from clear liquid to full liquid to solid foods (9).
Although many practitioners use the progression from clear liquids to full liquids to
solid foods, there is currently not any scientific literature stating that solid foods
cannot be initiated as soon as the gut is functioning and tolerating some liquids (9).
During the first visit, A.S.’s nutrition problem was diagnosed as inadequate
protein energy intake related to decreased ability to consume sufficient protein
energy as evidenced by intake less than recommended needs. This diagnosis was
11
formulated on the premises of the full liquid diet that was only fractionally
consumed. The caloric needs for those with heart failure are as follows (8):

Basal energy expenditure calculated using the Harris-Benedict
Equation

Add to basal value an additional 15%-25% for minimal physical
activity

Add another 10%-20% for hypermetabolism of severe heart failure

Determine carbohydrate (40%-60%), protein (10%-15%), and fat
(30%-40%) adjust based on concurrent conditions

Major surgery or sepsis increases energy requirements by 20%-50%
Based on the above criteria A.S.’s estimated energy needs during the visit on
December 5th were 3,200 kcals: (BEE =2050kcals + 20% for minimal activity = 2500
+ 10% for hypermetabolism = 2700 + 20% for surgery= ~ 3200 kcals/day and 80120g protein/day). The hospital that housed A.S. used a different method for
calculating caloric and protein needs but still obtained similar results (used kcal/kg
method using adjusted body weight). Based on A.S.’s estimated caloric and protein
needs and the information provided by A.S.’s intake from his 24-hour recall, A.S. was
not consuming enough kcals or protein to meet his needs which is why the
aforementioned nutritional diagnosis was made.
Formal education in the form of written literature was not given to A.S.
during the first visit of this study, however verbal information was given. The
importance of adequate calories and protein consumption for wound healing was
12
discussed. The topic of fat, sodium, and fluid restriction were not discussed at the
time because A.S. was on a full liquid diet.
Eventually A.S.’s diet was advanced to a Solid Regular Coumadin/Warfarin
Cardiac diet with Wolk Shake supplements three times a day, and this was observed
during the second visit of this study. A.S. was much more receptive to this diet than
the previously prescribed diet consuming 100%. The purpose of this diet was to
limit the amount of fat, sodium, and vitamin K A.S. was receiving. The cardiac diet is
used in the clinical setting to manage symptoms of hypertension and fluid retention
secondary to diseases associated with the heart (13). A.S. was also on a vitamin K
monitored diet because he was receiving Coumadin. Vitamin K assists in blood
coagulation and so the dosage of Coumadin and vitamin K consumption must be
closely monitored to ensure that there is a balance between the two. Having a
balance prevents blood clotting (too much vitamin K and not enough Coumadin) and
extreme thinness of blood (not enough vitamin K and too much Coumadin) (14).
Wolk Shakes are produced onsite by the hospital. The purpose of this supplement is
to increase calories and protein consumption in those patients who would benefit
from additional calories and protein if the diet alone is not providing an adequate
amount for weight gain and wound healing (15).
During the second visit of the study A.S. did not have any acute nutrition
related problems and so a formal nutrition diagnosis was not made secondary to
100% food/beverage intake and 100% Wolk Shake intake three times a day.
Formal education in the form of written literature was not given to A.S.
during this visit as he was consuming enough calories and protein to meet his needs.
13
A.S. also appeared to have a decent knowledge base regarding the parameters of the
cardiac diet as he stated he limited salt and fat intake prior to admission.
Prognosis:
Based on A.S.’s length of stay at the hospital and the physiological and
psychological advancements that were observed, it appears that the prognosis for
A.S. is quite good. However, as with any major surgery, there are some risk factors to
consider when determining the overall prognosis for A.S. The most common
complications post LVAD implantations are infection and sepsis (18%-59% of
recipients) (12). Stroke is another common risk factor associated with LVAD
therapy; the risk increases as long as the device remains in the patient’s body (12).
The nutritional prognosis for A.S. can be viewed as either positive or
negative. One positive is that with increasing BMI, the risk for mortality decreases
(good for A.S. as his BMI was 36.1) (16). Furthermore for some individuals with
heart failure, metabolites such as glucose and lactate will restore to normal levels.
Unfortunately, the prognosis for protein restoration isn’t as good. In patients with
heart failure, changes in myocardial metabolism occur resulting in decreased amino
acid levels in cardiac tissues (16) and LVAD therapy does not allow for the recovery
of these amino acid stores.
A.S. appeared to be very motivated to get better. The day of his discharge he
spoke of the struggles he faced throughout the progression of his disease and how
thankful he was for the advancements in technology that allowed him to get a
second chance at life. A.S. could not wait to get home to his family for the holidays
and finally begin to enjoy his retirement.
14
Summary and Conclusion:
This study allowed me to follow a patient from pre-surgery to post surgery,
and finally to discharge for the first time. Studying A.S. for an extended period of
time enabled me to observe the progression of the patient, and how nutrition
intervention played a role in those progressions.
The research that was performed throughout the case study allowed me to
strengthen my knowledge in cardiac nutrition beyond the topic of LVAD therapy.
This case study also allowed for me to research different methods of
calculating needs that are not necessarily used by the hospital. It was interesting to
learn how different equations can be used for different conditions, and how the
degree of those conditions has an effect on how the equation itself is manipulated.
The part that I liked most about this study was the ability to follow A.S.
throughout his stay. I felt that it really allowed me to get to know him as an
individual rather than just as a patient. I think this is important when it comes to
working in healthcare because healthcare providers have to be empathetic towards
their patients in order to provide them with the best care possible.
All in all I thought this case study provided me with a great experience. Sure,
there was a lot of time that was put into it, but there wasn't a second that I wasn't
learning. This study has definitely allowed me to strengthen my clinical knowledge
and has allowed me to become more confident in my capabilities as a future
Registered Dietitian.
15
Appendix 1: Medications (14)
Medication
Albuterol
Amiodarone
Purpose
Serves as
a
bronchod
ilator &
vasodilat
or
Antiarrhy
thmatic
agent
Table 1.5 A.S.’s Medications
Nutritional
Drug interactions
implications
Tenormin, Normodyne, Lopressor,
Corgard, Inderla, Lanoxin, Epipen,
Alupent, Xoponex, Asendin,
Norpramin, Adapin, Tofranil,
Nardil, Eldepryl, Parnate
Iodine, Trazodone, Coumadin,
Lipitor, Questran, Mevacor, Zocor,
Tagamet, Plavix, Crixivan, Norvir,
Alavert, Rheumatrex, Rifadin, St.
John’s wort
Other Side Effects
Nausea, diarrhea, dry
mouth, constipation,
dyspepsia, vomiting,
gastrointestinal
motility disorder,
stomatitis, dry throat,
heart burn,
gastrointestinal
distress, low
potassium
Uncontrollable shaking,
nervousness, headache, cough,
throat irritation,
muscle/bone/back pain, irregular
heartbeat, chest pain, rash, hives,
itching, swelling of
face/throat/tongue/lips/eyes/han
ds/feet/ankles/lower legs,
increased difficulty breathing,
difficulty swallowing, hoarseness
Anorexia, nausea,
vomiting, loss of
appetite, constipation,
altered taste, changes
in amount of saliva,
changes in ability to
taste and smell,
cannot drink
grapefruit juice
Headache, decreased sex drive,
difficulties falling asleep, flushing,
dry eyes, rash, restlessness,
intolerance to heat/cold, thinning
hair, excessive sweating, changes
in menstrual cycle, swelling in
neck, eye pain, swelling of
hands/feet/ankles/lower legs,
uncontrollable shaking, numbness
in arms and legs, muscle weakness
16
Bumetanide
Carvedilol
Loop
diuretic
with
rapid
onset,
used to
lower
blood
pressure,
treat
edema
Vasodilat
or,
reduces
periphera
l vascular
resistanc
e,
decreases
blood
pressure,
used to
treat
heart
failure
Prednisone, Lanoxin, Indocin,
Eskalith, hypertension medications
Nausea, vomiting,
loose stools, thirst,
constipation, low
potassium
Muscle cramps, weakness,
dizziness, sore throat with fiver,
ringing in ears, loss of hearing,
unusual bleeding/bruising, severe
rash w/peeling skin, difficulties
breating/swallowing
Tagment, Catapres, Neoral,
Lanoxin, Cardizem, Epipen, Prozac,
Insulin, MAOIs, Marplan, Nardil,
Parnate, Eldepryl, Paxil, Rythmol,
Serpalan, Rifadin, Calan
Diarrhea, nausea,
vomiting,
gastrointestinal pain,
hyperglycemia,
extreme hunger,
extreme thirst, weight
gain, melena,
periodontitis, GI
hemorrhage, cannot
consume alcohol
Weakness, blurred vision,
tiredness, lightheadedness,
dizziness, headache, joint pain,
difficulties falling asleep, cough,
numbness in arms and legs,
faintness, shortness of breath,
chest pain, irregular heartbeat,
rash, hives, itching
17
DocusateSenna
Humulin
Humalog
Stool
softener
No medicine interactions but can
affect absorption of some
medications
Gastrointestinal
cramping, esophageal
impaction, nausea,
duodenal bezoars
Faintness, brown discoloration of
urine
Lowers
blood
glucose
levels.
Should be
taken
during a
meal
Cadura, Minipress, Hytrin, Flomax,
Hypoglycemia, redness, swelling,
Uroxatral, ACE inhibitors, Elspar,
Hypoglycemia, fat
and itching at injection site, rash
Tenormin, Coreg, Normodyne,
build up, weight gain,
and/or itching over entire body,
Lopressor, Corgard, Inderal,
constipation, monitor
shortness of breath, wheezing,
Betapace, Blocadren, Proglycem,
alcohol consumption.
dizziness, blurred vision, fast
diuretics, MAO inhibitors,
Meals should not be
heartbeat, sweating, difficulty
hormonal contraceptives, niacin,
skipped and a diabetic breathing/swallowing, weakness,
Sandostatin, Actos, Medrol,
diet should be
muscle cramps, abnormal
Deltasone, Asprin, Sulfa Antibiotics,
followed
heartbeat, swelling of arms, hands,
Thyroid medications
feet, ankles, or lower legs
Lowers
blood
glucose
quickly.
Should be
taken 15
minutes
before a
meal
ACE inhibitors, Lotensin, Capoten,
Vasotec, Monopril, Prinivil,
Univasc, Aceon, Accupril, Altace,
Mavik, Edarbi, Atacand, Teveten,
Avapro, Cozaar, Benicar, Micardis,
Diovan, Tenormin, Normodyne,
Lopressor, Corgard, Inderal,
Antara, Lopid, Niacin, Reyataz,
Prezista, Lexiva, Crixivan, Kaletra,
Viracept, Norvir, Invirase, Aptivus,
Catapres, Lanoxin, Norpace,
Hypoglycemia, weight
gain, constipation,
large weight gain over
a short period of time,
monitor alcohol
consumption. Meals
should not be skipped
and a diabetic diet
should be followed
Hypoglycemia, redness, swelling,
itching at injection site, change in
thickness of skin, rash and itching,
difficulty breathing, hives,
wheezing, fast heartbeat,
sweating, weakness, muscle
cramps, abnormal heartbeat,
shortness of breath, swelling of
the arms, hands, feet, ankles, or
lower legs,
18
diuretics, Prozac, Marplan, Nardil,
Eldepryl, Parnate, Sandostatin, oral
contraceptives, Actos, Avandia,
Decadron, Medrol, Deltasone,
NebuPent, Trental, Symlin, Aspirin,
Trisalate, Arthropan, Dolobid
Lactobacillus
Acidophillus
Treats/pr
events
diarrhea
(especiall
y helpful
for those
taking
antibiotic
s)
Immunosuppressant’s can increase
risk of getting sick. These include:
Imuran, Simulect, Neoral, Zenapax,
CellCept, Prograf, Orasone,
glucocorticoids
Prevents/treats
diarrhea. No known
reactions with foods
Pantoprazole
Treats
gastroeso
phageal
reflux
disease
(GERD)
Coumadin, Reyataz, Lanoxin,
diuretics, iron supplements,
Nizoral, Rheumatrex, Viracept
B12 deficiencies,
nausea, vomiting, gas,
severe diarrhea with
watery stools,
stomach pain,
weakened stomach
lining
Ranolazine
Antiangina
(chest
pain)
Biaxin, Sporanox, Nizoral, Crixivan,
Viracept, Norvir, Invirase,
Carbatrol, Dilantin, Mycobutin,
Rifadin, Priftin, St. John’s wort,
Thiamine deficiency,
folic acid deficiency,
elimination of
grapefruit juice from
Is likely safe for pregnant and
breastfeeding women, should not
be given to those with
compromised immune systems,
may cause problems with
individuals who have short bowel
syndrome
Headache, joint pain, blistering or
peeling skin, rash, hives, itching,
swelling of the eyes, face, lips,
mouth, throat, or tongue, difficulty
breathing/swallowing,
hoarseness,
irregular/fast/pounding
heartbeat, excessive tiredness,
dizziness, lightheadedness, muscle
spasms, uncontrollable shaking of
body, seizures, fever
Headache, dizziness,
fast/pounding/irregular
heartbeat, difficulty breathing,
fainting
19
Cordarone, Pacerone, Anafranil,
Norpramin,Tofranil, Emend,
Propulsid, Gengraf, Lanoxin,
Cardizem, Norpace, Tikosyn,
Erythrocin, Diflucan, Haldol,
Risperdal, Geodon, Avelox, Orap,
Betapace, Zagam, Calan
diet, nausea,
constipation
20
Spironolactone
Controls
high
blood
pressure,
heart
failure,
and
edema
Lotensin, Capoten, Vasotec,
Monopril, Prinivil, Univasc, Aceon,
Accupril, Altace, Mavik, Edarbi,
Teveten, Avapro, Cozaar, Benicar,
Micardis, Diovan, Advil, Aleve,
Lanoxin, Midamor, Dyrenium,
Lovenox, Eskalith, Decadron,
Medrol, Deltasone Potassium
supplements
Dizziness, unsteadiness, headache,
enlarged/painful breasts, irregular
menstrual periods, vaginal
bleeding, difficulty
Reduced sodium diet,
maintaining/achieving erection,
avoidance of
deepening of voice, increased hair
potassium rich
growth, drowsiness, tiredness,
foods/medications,
restlessness, muscle
vomiting, diarrhea,
weakness/pain/cramps,
stomach pain/cramps,
pin/burning/numbing in hands
nausea, loss of
and feet, inability to move
appetite, dry mouth
arms/legs, changes in heartbeat,
confusion, lack of energy, jaundice,
rash, hives, itching, difficulty
breathing/swallowing
21
Coumadin
Prevents
blood
clotting
Zovirax, Zyloprim, Xanax, Cipro,
Biaxin, Noroxin, Ketek, Tygacil,
Acova, Pradaxa, Angiomax,
Iprivask, Refludan, Diflucan, Onmel,
Nizoral, Monistat, Noxafil, Diflucan,
Onmel, Lamisil, Vfend, Pletal,
Plavix, Persantine, Effient, Ticlid,
Emend, Celebrex, Flector, Nalfon,
Advil, Indocin, Ponstel, Aleve,
Daypro, Feldene, Clinoril,
Cordarone, Rythmol, Norvasc,
Cardizem, Calan, Singulair,
Accolate, Zyflo, Xeloda, Gleevec,
Tasigna, Lipitor, Tagamet, Pepcid,
Zantac, Reyataz, Sustiva, Intelence,
Lexiva, Crixivan, Viracept, Norvir,
Invirase, Aptivus, Nuvigil, Provigil,
Carbatrol, Dilantin, Banzel, Rifadin,
Celexa, Pristiq, Cymbalta, Lexapro,
Prozac, Luvox, Savella, Paxil, Zoloft,
Neoral, Antabuse, Oxsoralen,
Flagyl, oral contraceptives,
Oxandrin, Actos, Inderal, Vibryd,
Monitor vitamin K
intake, gas, change in
the way things taste,
nausea, vomiting,
diarrhea, loss of
appetite,
Abdominal pain, bloating, loss of
hair, feeling cold or having chills,
hives, rash, itching, difficulty
breathing/swallowing, swelling of
face/throat/lips/eyes, hoarseness,
chest pain/pressure, swelling of
hands/feet/ankles/lower legs,
fever, infection, extreme tiredness,
lack of energy, pain in upper right
of stomach, jaundice, flu-like
symptoms
22
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