Cardiovascular Drugs Flashcards
Name 7 classes of cardiovascular drugs
- Drugs for heart failure
- Drugs for angina
- Antihypertensives
- Drugs for arrhythmias
- Drugs for dyslipidaemia
- Drugs for pulmonary hypertension
- Drugs for other cardiovascular disorders
Name 4 classes of drugs for heart failure
- Aldosterone antagonists
- Loop diuretics
- Sympathomimetics (cardiovascular)
- Other drugs for heart failure
Name 2 aldosterone antagonists
- Eplerenone
- Spironolactone
Name 2 loop diuretics
- buMETANide
- Furosemide
Name 5 cardiovascular sympathomimetics
- Adrenaline (epinephrine)
- Dobutamine
- Dopamine
- Isoprenaline
- Noradrenaline
Name 4 miscellaneous drugs for heart failure
- digoxin
- ivabradine
- milrinone
- sacubitril with valsartan
Name 2 classes of drugs for angina
- nitrates
- other antianginal drugs
Name 3 nitrates
- glyceryl trinitrate
- isosorbide dinitrate
- isosorbide mononitrate
Name 3 miscellaneous antianginal drugs
- ivabradine
- nicorandil
- perhexiline
Name 7 classes of antihistamines
- thiazide and related diuretics
- other diuretics
- ACE inhibitors
- Angiotensin-II receptor blockers
- Calcium channel blockers
- Beta blockers
- Other antihypertensives
Name one thiazide diuretic
hydrOCHLOROTHIAZIDe
Name 2 thiazide-related diuretics
- Chlortalidone
- Indapamide
Name one miscellaneous diuretic
amiloride
Name 8 ACE inhibitors
- caPTOPRil
- enalapril
- fosinopril
- lisinopril
- perindopril
- quinapril
- ramipril
- trandolapril
Name 7 angiotensin-II receptor blockers
- candesartan
- eprosartan
- irbesartan
- losartan
- olmesartan
- telmisartan
- valsartan
Name 2 classes of calcium channel blockers
- dihydropyridines
- non-dihydropyridines
Name 6 dihydropyridine calcium channel blockers
- amLODIPine
- clevidipine
- felodipine
- lercanidipine
- niFEDIPine
- niMODIPine
Name 2 non-dihydropyridine calcium channel blockers
- diltiazem
- verapamil
Name 9 beta blockers
- atenolol
- bisOPROLOl
- caRVEDILOl
- esmolol
- labetalol
- metoprolol
- nebivolol
- propRANOLol
- sotalol
Name 8 miscellaneous antihypertensives
- clonidine
- diazoxide
- hydrALAZINe
- methyldopa
- minoxidil
- moxonidine
- prazosin
- sodium nitroprusside
Name 11 antiarrhythmics
- adenosine
- amiODAROne
- atropine
- digoxin
- diSOPYRAMIDe
- esmolol
- flecainide
- isoprenaline
- lidocaine
- sotalol
- verapamil
Name 4 classes of drugs for dyslipidaemia
- statins
- fibrates
- PCSK9 inhibitors
- other drugs for dyslipidaemia
Name 5 statins
- atorvastatin
- fluvastatin
- pravastatin
- rosuvastatin
- simvastatin
Name 2 fibrates
- fenofibrate
- gemfibrozil
Name 2 PCSK9 inhibitors
- alirocumab
- evolocumab
Name 3 miscellaneous drugs for dyslipidaemia
- colestyramine
- ezetimibe
- nicotinic acid
Name 4 classes of drugs for pulmonary hypertension
- prostacyclins
- endothelin antagonists
- PDE5 inhibitors
- Other drugs for pulmonary hypertension
Name 2 classes of prostacyclins
- Prostacyclin analogues
- Prostacyclin agonists
Name 2 prostacyclin analogues
- Epoprostenol
- Iloprost
Name 1 prostacyclin agonist
Selexipag
Name 2 endothelin agonists
- ambrisentan
- bosentan
- macitentan
Name 2 phosphodiesterase 5 inhibitors
- sildenafil
- tadalafil
Name 1 miscellaneous drug for pulmonary hypertension
Riociguat
Name 2 classes of drugs for cardiovascular disorders
- drugs for peripheral vascular disease
- drugs for orthostatic hypotension
Name 2 drugs for peripheral vascular disease
- oxerutins
- pentoxifylline
Name 2 drugs for orthostatic hypotension
- fludrocortisone
- midodrine
What is the drug class of digoxin?
Cardiac glycoside (arrhythmic agent)
What is the schedule of digoxin?
Schedule 4
Describe the availability of digoxin on the PBS.
Digoxin is available as a general schedule item on the PBS, and can be prescribed by a medical practitioner or a nurse practitioner.
What 5 formulations of digoxin are on the SA Formulary?
- 62.5 µg tablets
- 250 µg tablets
- 50 µg/mL oral solution
- 500 µg/2 mL injection
- 40 mg injection
What are 2 available brands of digoxin?
- Lanoxin
- Sigmaxin
What is the mechanism of action of digoxin in heart failure?
Inhibition of the sodium/potassium ATPase pump in myocardial cells causes a transient increase in intracellular sodium, which in turn promotes calcium influx via the sodium-calcium exchange pump, leading to increased contractility. This may also improve baroreflex sensitivity.
What is the mechanism of action of digoxin in supraventricular arrhythmias?
Direct suppression of the atrioventricular node conduction to increase effective refractory period and decrease in conduction velocity – positive inotropic effect, enhanced vagal tone, and decreased ventricular rate to fast atrial arrhythmias. Atrial fibrillation may decrease sensitivity and increase tolerance to higher serum digoxin concentrations.
Name 2 indications of digoxin
- AF and atrial flutter
- Heart failure
What is the 1 recommended Cautionary Advisory Label for digoxin?
5: ask your doctor or pharmacist before using any other medicine including over-the-counter medicines or health products.
Name 7 common side effects of digoxin
- Nausea
- Vomiting
- Diarrhoea
- Loss of appetite.
- Visual disturbances (such as blurred vision)
- Dizziness
- Headaches
What should be done if acute digoxin toxicity is suspected?
Urgently contact a clinical toxicologist or poisons information centre if acute digoxin poisoning is suspected.
Describe the time to onset daily acute digoxin poisoning.
Effects of acute digoxin poisoning can take up to 6 hours to occur after ingestion because the drug is being distributed into the myocardium and other tissues.
Describe the mechanism of acute digoxin toxicity
Acute digoxin toxicity is dose-related, and directly related to its pharmacological action. It is mediated by an increased intracellular calcium and increased activation of the parasympathetic nervous system due to significant inhibition of the sodium/potassium ATPase pump and atrioventricular nodal blockade. This in turn leads to increased automaticity and decreased conduction respectively.
Describe the time to onset of chronic digoxin toxicity.
Chronic toxicity generally takes much longer to present (months) compared to acute toxicity (hours).
Describe the time to onset of cardiac complications in digoxin overdose.
Cardiac complications tend to appear 8 to 12 hours after initial overdose.
What are 5 classes of effects in acute digoxin toxicity?
- Cardiovascular effects
- CNS effects
- Gastrointestinal effects
- Metabolic effects
- Visual effects
Which class symptoms of digoxin toxicity are the most common symptoms for children to experience?
Cardiovascular effects
What are 2 classes of symptoms of digoxin toxicity which are not commonly seen in children?
- CNS effects
- Gastrointestinal effects
Name 6 cardiovascular effects associated with digoxin toxicity
- Bradyarrhythmias: slow atrial fibrillation, second- and third-degree AV block
- Cardiac arrest
- ECG changes: ST depression (characteristic ‘reverse tick’ appearance), ectopic beats, first-degree atrioventricular (AV) nodal block (usually occur early)
- Hypotension
- Junctional, ventricular and atrial tachycardia
- Loss of consciousness
Name 3 central nervous system effects associated with digoxin toxicity
- Lethargy
- Confusion
- Delirium
Name 4 gastrointestinal effects associated with digoxin toxicity
- Nausea
- Vomiting
- Abdominal pain
- Diarrhoea
Describe the metabolic effects of digoxin toxicity.
Severe poisoning causes hyperkalaemia and associated ECG changes. Hypokalaemia and hypomagnesaemia can exacerbate this.
Name 3 visual effects of digoxin toxicity
- Halos
- Yellow or blurred vision
What should be done if acute digoxin poisoning is suspected?
Urgently contact a clinical toxicologist or poisons information centre (13 11 26).
Name 4 steps in the management of acute digoxin poisoning:
- Early activated charcoal if possible
- Closely monitor for (and treat) cardiovascular complications (life-threatening arrhythmias and myocardial depression)
- Give titrated digoxin-specific immune antibody fragments (digoxin immune Fab) if indicated
- Treat hyperkalaemia.
Which precaution of digoxin has a boxed warning in the AMH?
Digoxin may worsen arrhythmia (proarrhythmic effect), CNS disturbances, rashes (usually all related to plasma concentration)
Certain plants and animals produce digoxin-like compounds which cause similar toxicity to digoxin. How are these managed?
These are managed the same as acute digoxin poisoning.
What are 10 risk factors for digoxin toxicity?
- Digoxin concentration >2ng/mL
- Increased age
- COPD
- Hypotension
- Renal impairment
- Electrolyte disturbances
- Dehydration/over diuresis
- Amyloidosis
- Low body weight
- Concurrent use with drugs which increase digoxin concentration
What are 10 drugs which may increase digoxin concentration
- amiODAROne
- Dronedarone
- ERYthromycin
- Itraconazole
- Lapatinib
- Propafenone
- Quinidine
- Ranolazine
- Ritonavir
- Verapamil
What should you always consider about drug interactions with digoxin?
Digoxin has many potential interactions which are often clinically significant due to its narrow therapeutic window.
What is the interaction between amiODAROne and digoxin?
amiODAROne increases the concentration of digoxin (halve digoxin dose).
What is the interaction between amphotericin B and digoxin?
Increased digoxin toxicity may occur if hypokalaemia occurs with amphotericin
What is the interaction between chloroquine and digoxin?
Chloroquine possibly increases the concentration of digoxin
What is the interaction between ciclosPORIN and digoxin?
ciclosPORIN increases the concentration of digoxin
What is the interaction between colchicine and digoxin?
There is a possibly increased risk of myopathy
What is the most relevant CYP450 enzyme with digoxin?
Digoxin is a minor CPY3A4 substrate
What is the interaction between daclatasvir and digoxin?
Daclatasvir increases the concentration of digoxin
What is the interaction between diltiazem and digoxin?
Diltiazem increases the concentration of digoxin
What is the interaction between diuretics and digoxin?
Diuretics can potentiate digoxin toxicity by inducing hypokalaemia
What is the interaction between dronedarone and digoxin?
Dronedarone increases the concentration of digoxin (halve digoxin dose)
What is the interaction between food and digoxin?
Digoxin peak serum concentrations may be decreased if taken with food. Meals containing increased fibre or foods high in pectin may decrease oral absorption of digoxin.
What is the interaction between hydroxychloroquine and digoxin?
Hydroxychloroquine potentially increases the concentration of digoxin
What is the interaction between itraconazole and digoxin?
Itraconazole increases the concentration of digoxin.
What is the interaction between lasmiditan and digoxin?
Lasmiditan is predicted to increase digoxin exposure (contraindicated)
What is the interaction between lercanidipine and digoxin?
Lercanidipine increases the concentration of digoxin
What is the interaction between digoxin and medicines that affect heart rate/rhythm?
Drugs that slow cardiac conduction, cause bradycardia or cause arrhythmias may potentiate the cardiac adverse effects of digoxin; use combinations carefully and monitor cardiac function.
What is the interaction between mefloquine and digoxin?
Mefloquine increases the risk of bradycardia
What is the interaction between niFEDIPine and digoxin?
niFEDIPine increases the concentration of digoxin
What is the interaction between nircardipine and digoxin?
Nircardipine increases the concentration of digoxin
What is the interaction between phosphate binders and digoxin?
Concomitant administration reduces gastrointestinal absorption of digoxin by up to 25%
What is it important to remember digoxin is a substrate of?
P-glycoprotein
What is the interaction between propafenone and digoxin?
Propafenone increases the concentration of digoxin (halve digoxin dose)
What is the interaction between quinine and digoxin?
Quinine possibly increases the concentration of digoxin
What is the interaction between siponimod and digoxin?
Both digoxin and siponimod can lower heart rate, and these effects could be additive (contraindicated)
What is the interaction between spironolactone and digoxin?
Spironolactone increases the concentration of digoxin
What is the interaction between St John’s Wort and digoxin?
St John’s Wort decreases concentration of digoxin (contraindicated)
What is the interaction between telmisartan and digoxin?
Telmisartan increases digoxin toxicity
What is the interaction between tepontinib and digoxin?
Tepotinib is predicted to increase the concentration of digoxin (contraindicated)