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GPhC Exam '22 > CH2: CARDIO DRUGS > Flashcards

CH2: CARDIO DRUGS Flashcards

1
Q

what drugs are used in rate control?

A

1st line - Beta-blockers (except Sotalol)
CCB (only non-dihydropyridines) - verapamil and diltiazem

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2
Q

what drugs are used in rhythm control?

A

FAB

Flecainide
Amiodarone
Beta-blockers (1st line)

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3
Q

state the MoA of digoxin for AF

A
  • a positive inotropic drug, which means that it increases the force of the heartbeat + decreases the heart rate
  • is a narrow therapeutic drug
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4
Q

what is digoxin used for

A
  • non-paraxysamol AF
  • atrial flutter
  • sedentary patients
  • AF accompanied by heart failure (for sinus rhythm
  • can use if other rate control medications are not tolerated or suitable
  • in combination with beta-blocker if the LVEF <40%
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5
Q

state the drugs that cause QT prolongation (torsade de pointes)

A
  • Sotalol
  • Amiodarone
  • Quinolones
  • Haloperidol
  • SSRIs
  • TCAs
  • Anti-fungals
  • macrolides
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6
Q

state the anti-arrhythmic drugs with examples

A
  • Class 1: membrane stabilising drugs (Na + channel blockers)
    e.g. flecainide, lidocaine
  • Class 2: Beta-blockers
  • Class 3: K+ channel blockers
    e.g. amiodarone, sotalol
  • Class 4: rate limiting Ca2+ channel blockers
    e.g. verapamil, diltiazem
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7
Q

state the loading dose regimen for Amiodarone

A

200mg TDS for 7 days
200mg BD for 7 days

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8
Q

state the maintenance dose regimen for Amiodarone

A

200mg OD for 7 days

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9
Q

contra-indications for amiodarone

A
  • pts with bradycardia
  • pts with heart block
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10
Q

briefly explain the side effects of amiodarone

A

‘TCHD-P2’

  1. Thyroid disorders = cause hypo/hyperthyroidism due to iodine contents
  2. Corneal microdeposits
    • reversible on withdrawal
    • STOP if vision is impaired
  3. Hepatotoxicity
    • STOP if pt shows signs of liver disease; jaundice or abdominal pain
  4. Driving & skilled tasks = microdeposits may lead to blurred visions
  5. Photosensitivity toxicity
    • Avoid sunlight
    • wear sunscreen at all times even after 50 days of drug withdrawal
    • Cause slate grey skin
  6. Pulmonary toxicity = to report on new-onset of cough or SOB
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11
Q

monitoring parameters of amiodarone

A
  1. LFTs = before treatment & 6 months after
  2. Thyroid tests = before treatment & 6 months after
  3. Serum potassium levels = before treatment
  4. ECG & Transamineses levels = if using any IV
  5. Chest X-rays = before treatment
  6. Annual eye examination
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12
Q

name the drug-causing interactions of amiodarone

A
  • drugs that cause hypokalemia
  • drugs that cause QT prolongation
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13
Q

name the drugs that amiodarone increases their plasma concentrations & their risks.

A
  • warfarin = enhances its anti-coagulant effect
  • pheytoin
  • ciclosporin
  • digoxin = take half dose if taking with amiodarone
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14
Q

state the cause that leads to the drug interaction between:
Amiodarone + Lithium

A

risk of ventricular arrhthymias

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15
Q

state the cause that leads to the drug interaction between:
Amiodarone + Statins

A

risk of myopathy

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16
Q

state the cause that leads to the drug interaction between:
Amiodarone + Beta blockers

A
  • risk of brady cardia, myocardial depression and AC block
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17
Q

state the names of drugs that require close monitoring even after withdrawal of amiodarone.

A
  • sofosovir
  • daclatasivir
  • simeprevir
  • ledipasvir
    due to risk of heart block
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18
Q

what is the loading dose of digoxin?

A

adult - 125mcg to 250mcg OD (long half life)

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19
Q

monitoring requirements for digoxin

A

samples are taken every 6-12 hours after the dose.
1. plasma digoxin concentration
2. renal function
3. serum electrolytes (Na, Ca, Mg, K levels)

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20
Q

what is the desired therapeutic range for digoxin?

A

0.7ng/ml to 2ng/ml

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21
Q

what digoxin ranges would be considered toxic?

A

1.5ng/ml to 3ng/ml

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22
Q

what are the signs of digitalis toxicity?

A
  • SA/AV node and bradycardia
  • Diarrhoea and vomiting
  • Confusion, depression and dizziness
  • Blurred vision or yellow vision
  • Skin reactions
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23
Q

who is at risk of digitalis toxicity?

A
  • pts with hypokalaemia
  • elderly (reduce dose)
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24
Q

pts who are at risk of hypokalemia or at risk what are they offered?

A
  • K+ sparing diuretics
  • K+ supplements
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25
Q

examples of K+ sparing diuretics

A
  • spironolactone
  • amiloride (weakest)
  • eplerenone
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26
Q

what to do when digitalis toxicity occurs?

A
  • withdraw digoxin
  • refer to specialist for care
  • life-threatening overdose; reverse digoxin-specific antibody fragments (DigiBind or DigiFab)
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27
Q

what are the drug interactions of digoxin?

A

‘SCRAND’

  • St John Wort’s = Reduces digoxin plasma concentration
  • Calcium channel blockers = Increases digoxin plasma concentration
  • Rifampicin = Reduces digoxin plasma concentration
  • Amiodarone = Increases digoxin plasma concentration
  • NSAIDs = Increases digoxin plasma concentration
  • Diuretics = Increases digoxin plasma concentration
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28
Q

digoxin + beta blockers, effect?

A

increases the risk of AV node & increases digoxin plasma concentration

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29
Q

digoxin + anti-depressant, effect?

A

risk of arrhythmias

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30
Q

state the drugs that can increase the plasma concentration of digoxin

A
  • macrolides = erythromycin
  • ciclosporins
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31
Q

dipyridamole

A
  • 2nd line long-term treatment for TIA/stroke
  • antiplatelet
  • discard MR tablets 6 weeks after opening from the original container
  • to be taken 30-60 minutes before food
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32
Q

tranexamic acid

A
  • antifibrinolytic drug
  • is used in surgeries, dental extraction and menorrhagia
  • it prevents/reduces bleeding by impairing fibrin dissolution
  • Side effect: GI causing N/V
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33
Q

examples for low molecular weight heparins

A
  • enoxaparin
  • dalteparin
  • tinzaparin
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34
Q

what are the food-drug interactions with warfarin?

A
  1. Pomegranate & cranberry juice = increases INR
  2. Miconazole (daktarin gel) = increases INR
  3. Vit K rich foods - leafy greens = decreases warfarin efficacy = decreases INR
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35
Q

state the drug interactions of warfarin that INCREASES the effect of warfarin

A
  1. clarithromycin
  2. erythromycin
  3. antifungals (miconazole)
  4. amiodarone
  5. corticosteriods
  6. SSRIs
  7. St John Worts
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36
Q

state the drug interactions of warfarin that DECREASES the effect of warfarin

A
  1. Rifampacin
  2. Phenobarbitone
  3. Phenytoin
  4. Griseofulvin
  5. Mercaptopurine
  6. Azathioprine
  7. Carbamazepine
  8. Vitamin K
  9. Alcohol
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37
Q

examples new generation of anticoagulants (DOACs)

A
  • apixaban
  • dabigatran
  • edoxaban
  • rivaroxaban
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38
Q

state the initial and maintenance dose of apixaban for the treatment of VTE/PE

A

initial: 10mg BD for 7 days
maintenance: 5mg BD

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39
Q

what are the factors in which you would recommend reducing the dose of apixaban? & state the dose reduction

A

dose reduction = 2.5 mg BD
Factors (if pt meets 2/3 then reduce)
1. Bwt <60 kg
2. Age > 80 years old
3. CrCl is 15-29 ml/min
Creatinine > 133

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40
Q

state the initial and maintenance dose of rivaroxaban for the treatment of VTE/PE

A

initial: 15mg BD for 3 weeks
maintenance: 20mg OD
take with food

41
Q

what are the factors in which you would recommend reducing the dose of rivaroxaban? & state the dose reduction

A

dose reduction = 15 mg OD
Factors
1. CrCl is 15-49ml/min

42
Q

side effect of rivaroxaban

A

back pain

43
Q

what are the drug interactions of rivaroxaban (INCREASES the plasma concentration of rivaroxaban)?

A

CYP enzymes inhibitors
- itra
- Ketoconazole

44
Q

what are the drug interactions of rivaroxaban (DECREASE the plasma concentration of rivaroxaban)?

A

CYP enzyme inducers
- Carbamazepine
- Phenytoin
- Rifampacin
- St John Worts

45
Q

state the initial and maintenance dose of dabigatran for the treatment of VTE/PE

A
  • start after 5 days of LMWH
    initial dose is dependent on age
    age 18-74 = 150mg BD
    age 75-79 = 110mg to 150mg BD
    age 80+ = 110mg BD
46
Q

when would avoid the use of dabigatran?

A

if pts CrCl is less than 30 ml/min

47
Q

what are the factors in which you would recommend reducing the dose of dabigatran?

A

Factors
1. > 80 years old
2. CrCl is 30-50 ml/min
3. Concurrent use of verapamil

48
Q

state the initial and maintenance dose of edoxaban for the treatment of VTE/PE

A

60mg OD

49
Q

what are the factors in which you would recommend reducing the dose of edoxaban?

A

Factors
1. Bwt < 61 kg = 30mg OD
2. CrCl is 15-50
3. ‘DECK’

Dronedarone
Erythromycin
Ciclosporin
Ketoconazole

50
Q

examples of ace-inhibitors

A

ramipril
enalapril
lisinopril
perindopril

51
Q

side effects of ACEi

A
  1. Persistent cough (switch to ARBs)
  2. Angioedema
  3. Hyperkalemia
  4. Hepatic failure
  5. Renal impairment
  6. Dizziness and headaches
52
Q

side effects of ARBs

A
  1. Hyperkalemia
  2. Hepatic failure
  3. Renal impairment
  4. Dizziness and headaches
  • same as ACEi except for angioedema & persistent cough
53
Q

examples of ARBs

A
  • candesartan
  • losartan
  • Irbesartan
54
Q

describe the drug interactions of ACEi

A
  1. increases risk of renal impairment with:
    - NSAIDs, ARBs and K+ sparing diuretics
  2. increases risk of hyperkalemia with
    - NSAIDs, ARBs, K+ sparing diuretics, beta blockers and heparins
  3. increases risk of volume depletion
    - Diuretics exacerbate volume depletion if used with ACEI
  4. Increases lithium plasma concentration levels if used with ACEi/ARbs
55
Q

name the 3 classifications of beta blockers

A
  1. Cardioselective BB
  2. Water-soluble BB
  3. Intrinsic sympathomimetics BB
56
Q

describe the use of cardioselective beta blockers & examples

A

‘BAtMAN’
Bisoprolol
Atenolol
Metoprolol
Nebivolol

*less likely to cause bronchospasms = can be used for asthmatics if needed

57
Q

describe the use of water-soluble beta blockers & examples

A

water ‘CANS’
Celiprolol
Atenolol
Nadolol
Sotalol

*less likely to cross the blood-brain-barrier to cause nightmares

58
Q

describe the use of intrinsic sympathomimetic beta blockers & examples

A

‘POACh’
Pindolol
Oxprenolol
Acebutolol
Celiprolol

  • less likely to cause cold extremities
59
Q

side effects of beta blockers

A
  1. bradycardia
  2. heart failure
  3. Mask symptoms of hypoglycemia
  4. hyperkalemia
  5. bronchospasms CI in asthmatics
60
Q

state the drug interactions of beta blockers

A
  • causes heart block = concurrent use of amiodarone and digoxin
61
Q

side effects of CCB

A
  1. gingival hyperplasia - swollen gums
  2. dizziness
  3. vasodilatory effects - swollen ankles, flushing and headaches (common in dihydropyridines)
  4. complete AV block
62
Q

side effects of nicorandil

A

GI and mucosal ulceration

63
Q

state the counselling points of nitrates for S/L and transdermal patches use and give examples.

A

ex. RIN; ranolazine, ivabradine and nicorandil

S/L tabs prep
- once opened to be discarded after 8 weeks
- pt must have a nitrate-free period to avoid tolerance
- BD dosing is to be given 8 hourly instead of 12 hourly to allow for the nitrate-free period.

transdermal patches; remove patch every 8-12 hours

64
Q

State the medical conditions you would AVOID the use of thiazide-like diuretics

A
  • Diabetes
  • Gout
  • Pregnancy
  • eGFR <30ml/min
65
Q

What are the side effects of thiazide-like diuretics

A
  • Hypokalaemia
  • Hypercalcaemia
  • Hyperurticaria
  • Hyponatremia
  • Hypomagnesia
  • GI disturbances
66
Q

name the TLD that is less aggravating to diabetic patients.

A

Indapamide

67
Q

what are loop diuretics used for?

A
  • HTN
  • Chronic HF
  • Pulmonary oedema
68
Q

what are the side effects of loop diuretics?

A
  • ototoxicity
  • Hypo- Na+, Mg, Ca2+, K+,
  • Hyperglycaemia
  • Acute urinary retention
69
Q

caution use of loop diuretics

A
  • diabetes = due to hyperglycaemia
  • prosthetic hyperplasia
70
Q

what are the drug interactions of loop diuretics

A
  • Avoid hypokalemia-inducing drugs = TLD
  • Aminoglycosides = ototoxicity and nephrotoxicity
  • Lithium = concomitant use of loop diuretics with Li= increases plasma lithium levels
71
Q

name the K+ sparing diuretic that discolours urine to blue

A

triamterene

72
Q

side effects of K+ sparing diuretic

A
  1. Hyperkalemia = avoid use of ACEi/ARBs/K+ supplements
  2. Increases risk of renal failure
73
Q

State the medical conditions you would AVOID the use of spironolactone

A
  1. Addisons disease = CI causes hyperkalaemia
  2. Hyperkalaemia
74
Q

side effects of spironolactone

A
  1. Gynaecomastia = causing swollen breast tissue, pain, tenderness and menstrual disturbances
  2. Hyponatremia
  3. Hyperkalaemia
  4. Loss of libido
75
Q

drug interactions of spironolactone

A
  1. Increases risk of renal function
  2. Increases risk of hyperkalemia
  3. Concomitant use of Lithium = increases risk of lithium.
76
Q

what is the MHRA alert for spironolactone?

A

Avoid concomitant use of aldosterone antagonists and ACEi due to potentially causing fatal hyperkalemia

77
Q

when to AVOID the use of alpha-blockers (doxazocin)

A
  • elderly as it increases risk of falls
78
Q

Advice on a patient with postural hypotension taking doxazosin

A

The use of alpha-blockers exacerbates postural hypotension

79
Q

Advice on the use of doxazocin in pregnancy and breastfeeding

A

-Can be used during pregnancy
-Low risk of adverse SE in breastfeeding

80
Q

side effects of alpha blockers

A
  • drowsiness
  • headaches
  • postural hypotension
81
Q

drug interactions of alpha-blockers

A
  • Antihypertensives = bradycardia
  • Concomitant use of PDE-5i (sildenafil) = hypotension
82
Q

when to AVOID the use of CCBs

A
  • Oedema
  • Heart failure
83
Q

name the CCB that can be used in HF?

A

amlodipine

84
Q

side effects of CCB

A
  • oedema
  • flushing
  • gingival hyperplasia
  • complete AV block
  • Headaches
85
Q

when to AVOID the use of Beta blockers?

A
  • antihistamines
  • COPDs
  • Pregnancy = causes bradycardia and hypoglycaemia
86
Q

what are the side effects of beta blockers

A
  • Bradycardia
    -Hyperglycaemia
  • Bronchospasm
  • Heart failure
  • mask symptoms of hypoglycaemia
87
Q

drug-interactions of beta blockers

A
  1. Antihypertension = bradycardia
  2. Beta-blockers and amiodarone = causes heart block
  3. Beta-blockers and digoxin = causes heart block
  4. Verapamil IV = causes hypotension
  5. TLD = hyperglycaemia
88
Q

what are the contra-indications of beta blockers

A
  • diabetes
  • unstable HF
  • 2nd/3rd degree AV block
  • severe hypotension and bradycardia
89
Q

when to AVOID the use of ACE inhibitors

A
  • angioedema = esp in afro-carribean pts
  • severe renal disease = nephrotoxic, DAMN
  • pregnancy
90
Q

side effects of ACE inhibitors

A
  • dry mouth
  • oral ulcer
  • hepatotoxicity
  • hyperkalemia = risk of T2DM, renal impairment
  • hypoglycaemia
91
Q

drug-interactions of ACEi

A
  1. Increased risk of hyperkalaemia if used with; NSAIDs, heparin, beta-blockers, ARBs, K+ sparing diuretics
  2. Increased risk of volume depletion = diuretics exacerbates this
  3. Increased risk of renal failure
92
Q

what is the drug-interaction of ACEi + Aliskiren

A

CI in T2MD, eGFR <60ml/min

93
Q

what is the drug interaction of ACEi + Aliskiren?

A

CI in T2DM
eGFR < 60ml/min

94
Q

what drug-interaction of ACEi + Lithium?

A

Increases levels of lithium in plasma = increases lithium toxicity

95
Q

when to AVOID the use of ARBs

A
  • pregnancy
  • severe renal disease
96
Q

side effects of ARBs

A
  1. hyperkalemia
  2. hepatotoxicity
97
Q

drug interactions of ARBs

A
  1. Increased risk of hyperkalaemia if used with; NSAIDs, heparin, beta-blockers, ARBs, K+ sparing diuretics
  2. Increased risk of volume depletion = diuretics exacerbate this
  3. Increased risk of renal failure = ACEi, NSAIDs and K+ sparing diuretics
98
Q

drug interaction of ARB and lithium

A

Increases plasma levels of lithium = increases lithium toxicity

GPhC Exam '22 (16 decks)

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