Ch 16 Flashcards by Tess Williams

Therapeutic applications fo A1 antagonist

Essential HTN (causes vasodilation)

reversal of tox from a1 agonist (EPI) - cause HTN reverse with a1 antagonist

BPH

Raynaud disease

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symptoms of BPH

dysuria
increased frequency of daytime urination
nocturia
urinary hesitancy
urinary urgency
sensation of incomplete voiding
reduction in size and force of the urinary stream

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peripheral vascular disorder characterized by vasospasm in toes and fingers. local sensations of pain and cold

Raynaud disease

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Adverse effects of A blockade when using adrenergic antagonist

orthostatic hypotension (reduces musle tone in venous wall - blood pool sin veins and when pt stands, return of blood to heart is reduced -> decrease cardiac output and drops BP

Reflex tachycardia (baroreceptor reflex)

nasal congestion (dilates blood vessels of nasal mucosa)

inhibition of ejaculation

sodium retention and increased blood volume ( bp drops -> a1 blockers decrease renal blood flow ->kidney excretes less na and h20 -> bp is elevated

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to prevent the kidney from neutralizing hypotensive actions of A blocking agents what can you give

combine with diuretic in pt with htn

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A2 blockade and reflex tachycardia

A2 is blocked so norepinephrine are increased which stimulates heart rate to increase

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A1 blockade and reflex tachycardia

Baroreceptor reflex

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phentolamine and reflex tachycardia

blocks A1 and A2 so greater reflex tachycardia

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Alpha blockers and children

not approved except for

OraVerse - reversal of local anesthesia following dental surgery

Phentolamine - post extravasation

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Pregnant women and alpha blockers

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Breastfeeding women and alpha blockers

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older adults and Alpha blockers

esp vulnerable to first dose effects

with worsening of urinary incontinency in women and increase syncope in both genders

BEERS criteria identifies doxazosin, prazosin, terazosin not appropriate

diuretics and CNS depressants can cause additive adverse effects when given with alpha blockers

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Prazosin (Minipress)

selective blockade of A1 adrenergic receptors

approved only for HTN
benefits men with BPH

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Adverse effects of Prazosin (Minipress)

orthostatic hypotension - “first-dose” effect
reflex tachycardia
nasal congestion

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Pt education on first pass effect on Prazosin (Minipress)

About 1% of pt lose consciousness 30-60 min after their first dose. Avoid driving and other hazardous activities for 12-24 hours

Take first dose right before going to bed to eliminate risk for this

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How to minimize first dose effect (Prazosin)

the initial dose should be small (no more than 1mg) and doses gradually increased

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pt ed on orthostatic hypotension

sit or lie down if become dizzy. change positions slowly when changing from a supine or sitting to an upright position

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Terazosin uses

HTN
BPH

selective antagonist at A1 adrenergic

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Tarazosin adverse effects

orthostatic HTN
Reflex Tachycardia
nasal congestion
headache
first dose effect

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Doxazosin (Cardura, Cardura XL) uses

HTN
BPH

Cardura XL - only approved for BPH

selective inhibitor of A1 adrenergic

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Doxazosin (Cardura, Cardura XL) adverse effects

orthostatic hypotension
reflex tachycardia
nasal congestion
first- dose effect

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Tamsulosin (Flomax) approved for

BPH

A1 adrenergic antagonist

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Tamsulosin (Flomax) adverse effects

headache
dizziness
abnormal ejaculation
increased incidence of rhinitis

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Tamsulosin (Flomax) max benefits develop within

2 weeks

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Tamsulosin (Flomax) drug interactions

combined with cimetidine - increases flomax drug levels can cause tox combined with hypotensive drugs to include PDE-5 drugs such as viagra may cause a drop in BP

Alfuzosin (Uroxatral) approved for

BPH A1 blocker

Alfuzosin (Uroxatral) adverse effects

dizziness syncope and clinically sig hypotension is rare doses 4 times recommended can prolong QT which can be a problem in pt with mod to severe hepatic impairment - do not give to these pts

Alfuzosin (Uroxatral) drug interactions

CYP3A4 - erythromycin, clarithromycin, itraconazole, ketoconazole, nefazodone, HIV protease inhibitors such as ritonavir. - do not give combining with hypotensive agents could dramatically reduce BP. Avoid combos such as organic nitrates, antihypertensive agents, PDE 5 inhibitors such as viagra

Silodosin (Rapaflo) use

A1 adrenergic antagonist BPH

Silodosin (Rapaflo) adverse effect

greatly reduce or eliminate release of semen during orgasm dizziness lightheadedness nasal congestion

Phentolamine (OraVerse) use

diagnose and treatment of pheochromocytoma prevention of tissue necrosis after extravasion of IV vasopressors reversal of soft tissue anesthesia

Phentolamine (OraVerse) adverse effects

orthostatic Hypotension reflex tachycardia !!! nasal congestion inhibition of ejaculation

if reflex tachycardia is esp severe with phentolamine, the HR can be reduced with

B Blocker

what pt population is phentolamine contraindicated

angina pectoris and myocardial infarction

Overdose of phentolamine can produce ____ and what should you give?

profound hypotension give norepinephrine Epi could activate B2 which could cause vasodilation and worsen hypotension

which 2 drugs block a1 and a2 receptors

Phentolamine | Phenoxybenzamine -irreversible and only for pheochromocytoma

Pt ed on A1 adrenergic antagonist for self monitoring

monitor HR and BP | hold the drug and notify provider for sustained bradycardia or hypotension develops

A1 adrenergic Antagonists for HTN

Doxazosin prazosin terazosin on the BEERS list

A1 adrenergic antagonists for BPH

``` Doxazosin terazosin alfuzosin silodosin tamsulosin ```

B blockade used to

reduce HR reduce contractility reduce velocity of impulse conduction through AV node

3 B blockers approved for Heart failure

Carvedilol bisoprolol metoprolol

in heart failure when would you not initiate or increase dose of a b blocker

during a exacerbation

long term use of a B blocker can sensitize the heart to catecholamines, if withdrawn abruptly

anginal pain or ventricular dysrhythmias may develop (referred to as rebound excitation)

B blocker approved for asthmatics

B1 selective blocker such as metoprolol

B2 blockade in diabetics

at risk for hypoglycemia

Neonates born to a mother on B blockers esp Betaxolol

3-5 days after birth closely monitor for Bradycardia (B1 blockade) Resp distress (B2 blockade) Hypoglycemia (B2 blockade)

Propanolol category

B Blocker First gen nonselective B Blockade

Pharm effect Propanolol

B1 decrease HR decrease contractility suppress impulse conduction AV node all equals reduction in cardiac output B2 bronchoconstriction vasoconstriction reduced glycogenolysis

therapeutic uses Propanolol

HTN angina cardiac dysrhythmias MI

Contraindications for Propanolol

pt with preexisting AV block greater than first degree Sinus Brady preexisting heart failure asthma COPD Diabetics - use caution with history of depression pregnancy history of anaphylaxis

CNS side effects Propanolol

``` depression insomnia nightmares hallucinations depression ```

B blocker approved for pregnancy

labetalol other methyldopa nifedipine

Metoprolol (Lopressor) class

B Blocker second gen selective B1

preferred B blocker for asthmatics or diabetics or history of anaphylaxis

Second gen B1 selective Metoprolol (Lopressor) side note - still dm will not have tachycardia to warn of hypoglycemia

Metoprolol (Lopressor) uses

HTN angina Heart failure MI

Metoprolol (Lopressor) adverse effects

bradycardia reduced cardiac output AV heart block rebound excitation with abrupt withdrawal

which 2 B Blockers block alpha adrenergic receptors in addition to B receptors

labetalol | carvedilol

Which b blockers have high lipid solubility meaning they penetrate BBB and eliminated primarily by hepatic metabolism

propanolol metoprolol Nebivolol

``` Nadolol pindolol propanolol sotalol timolol ```

first gen non selective b blocker

``` Acebutolol Atenolol Betaxolol Bisoprolol Esmolol Metoprolol ```

Second Gen B Blocker Cardioselective Maebba - pneumonic

Carvedilol Lebetalol Nebivolol

3rd Gen B Blocker Vasodilating action

Children and B Blockers

yes

Pregnancy and B Blockers

Labetalol drug of choice acebutolol pindolol sotalol are considered alternative safest

Breastfeeding and B blockers

no and Betaxolol is worst

older adults and B Blockers

commonly prescribed | if hepatic and renal impairment, pay attention to which you prescribe

Black box warning sotalol (Betapace)

When starting or restarting Sotalol - pt should be inpatient on continuous EKG for min of 3 days Creatinine clearance should be established prior Betapace cannot be subbed for Betapace AF when treating A fib

How is Esmolol and sotalol differ from other b blockers

very short half life and not used for HTN esmolol - IV therapy for SVT Sotalol - treat ventricular dysthythmias (A-fib or A-flutter)

Because of their ability to block a adrenergic receptors, carvedilol and labetalol can cause

postural hypotension

what b blocker protects from resting heart rate from dropping too low and why

Pindolol - partial agonist a b adrenergic receptor (p 116) | It is a intrinsic sympathomimetic activity (IMA) partial agonist

what pt population cannot have pindolol

history of MI

which B Blockers carry the black box for abrupt discontinuation may cause exacerbation of angina and increase risk for MI

Atenolol metoprolol nadolol timolol

other signs diabetics need to key into for signs of hypoglycemia

hunger fatigue poor concentration