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
2
Q
what drugs are used in rhythm control?
A
FAB
Flecainide
Amiodarone
Beta-blockers (1st line)
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
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%
5
Q
state the drugs that cause QT prolongation (torsade de pointes)
A
- Sotalol
- Amiodarone
- Quinolones
- Haloperidol
- SSRIs
- TCAs
- Anti-fungals
- macrolides
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
7
Q
state the loading dose regimen for Amiodarone
A
200mg TDS for 7 days
200mg BD for 7 days
8
Q
state the maintenance dose regimen for Amiodarone
A
200mg OD for 7 days
9
Q
contra-indications for amiodarone
A
- pts with bradycardia
- pts with heart block
10
Q
briefly explain the side effects of amiodarone
A
‘TCHD-P2’
- Thyroid disorders = cause hypo/hyperthyroidism due to iodine contents
- Corneal microdeposits
- reversible on withdrawal
- STOP if vision is impaired
- Hepatotoxicity
- STOP if pt shows signs of liver disease; jaundice or abdominal pain
- Driving & skilled tasks = microdeposits may lead to blurred visions
- Photosensitivity toxicity
- Avoid sunlight
- wear sunscreen at all times even after 50 days of drug withdrawal
- Cause slate grey skin
- Pulmonary toxicity = to report on new-onset of cough or SOB
11
Q
monitoring parameters of amiodarone
A
- LFTs = before treatment & 6 months after
- Thyroid tests = before treatment & 6 months after
- Serum potassium levels = before treatment
- ECG & Transamineses levels = if using any IV
- Chest X-rays = before treatment
- Annual eye examination
12
Q
name the drug-causing interactions of amiodarone
A
- drugs that cause hypokalemia
- drugs that cause QT prolongation
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
14
Q
state the cause that leads to the drug interaction between:
Amiodarone + Lithium
A
risk of ventricular arrhthymias
15
Q
state the cause that leads to the drug interaction between:
Amiodarone + Statins
A
risk of myopathy
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
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
18
Q
what is the loading dose of digoxin?
A
adult - 125mcg to 250mcg OD (long half life)
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)
20
Q
what is the desired therapeutic range for digoxin?
A
0.7ng/ml to 2ng/ml
21
Q
what digoxin ranges would be considered toxic?
A
1.5ng/ml to 3ng/ml
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
23
Q
who is at risk of digitalis toxicity?
A
- pts with hypokalaemia
- elderly (reduce dose)
24
Q
pts who are at risk of hypokalemia or at risk what are they offered?
A
- K+ sparing diuretics
- K+ supplements
25
examples of K+ sparing diuretics
- spironolactone
- amiloride (weakest)
- eplerenone
26
what to do when digitalis toxicity occurs?
- withdraw digoxin
- refer to specialist for care
- life-threatening overdose; reverse digoxin-specific antibody fragments (DigiBind or DigiFab)
27
what are the drug interactions of digoxin?
'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
28
digoxin + beta blockers, effect?
increases the risk of AV node & increases digoxin plasma concentration
29
digoxin + anti-depressant, effect?
risk of arrhythmias
30
state the drugs that can increase the plasma concentration of digoxin
- macrolides = erythromycin
- ciclosporins
31
dipyridamole
- 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
32
tranexamic acid
- antifibrinolytic drug
- is used in surgeries, dental extraction and menorrhagia
- it prevents/reduces bleeding by impairing fibrin dissolution
- Side effect: GI causing N/V
33
examples for low molecular weight heparins
- enoxaparin
- dalteparin
- tinzaparin
34
what are the food-drug interactions with warfarin?
1. Pomegranate & cranberry juice = increases INR
2. Miconazole (daktarin gel) = increases INR
3. Vit K rich foods - leafy greens = decreases warfarin efficacy = decreases INR
35
state the drug interactions of warfarin that INCREASES the effect of warfarin
1. clarithromycin
2. erythromycin
3. antifungals (miconazole)
4. amiodarone
5. corticosteriods
6. SSRIs
7. St John Worts
36
state the drug interactions of warfarin that DECREASES the effect of warfarin
1. Rifampacin
2. Phenobarbitone
3. Phenytoin
4. Griseofulvin
5. Mercaptopurine
6. Azathioprine
7. Carbamazepine
8. Vitamin K
9. Alcohol
37
examples new generation of anticoagulants (DOACs)
- apixaban
- dabigatran
- edoxaban
- rivaroxaban
38
state the initial and maintenance dose of apixaban for the treatment of VTE/PE
initial: 10mg BD for 7 days
maintenance: 5mg BD
39
what are the factors in which you would recommend reducing the dose of apixaban? & state the dose reduction
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
40
state the initial and maintenance dose of rivaroxaban for the treatment of VTE/PE
initial: 15mg BD for 3 weeks
maintenance: 20mg OD
take with food
41
what are the factors in which you would recommend reducing the dose of rivaroxaban? & state the dose reduction
dose reduction = 15 mg OD
Factors
1. CrCl is 15-49ml/min
42
side effect of rivaroxaban
back pain
43
what are the drug interactions of rivaroxaban (INCREASES the plasma concentration of rivaroxaban)?
CYP enzymes inhibitors
- itra
- Ketoconazole
44
what are the drug interactions of rivaroxaban (DECREASE the plasma concentration of rivaroxaban)?
CYP enzyme inducers
- Carbamazepine
- Phenytoin
- Rifampacin
- St John Worts
45
state the initial and maintenance dose of dabigatran for the treatment of VTE/PE
- 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
when would avoid the use of dabigatran?
if pts CrCl is less than 30 ml/min
47
what are the factors in which you would recommend reducing the dose of dabigatran?
Factors
1. > 80 years old
2. CrCl is 30-50 ml/min
3. Concurrent use of verapamil
48
state the initial and maintenance dose of edoxaban for the treatment of VTE/PE
60mg OD
49
what are the factors in which you would recommend reducing the dose of edoxaban?
Factors
1. Bwt < 61 kg = 30mg OD
2. CrCl is 15-50
3. 'DECK'
Dronedarone
Erythromycin
Ciclosporin
Ketoconazole
50
examples of ace-inhibitors
ramipril
enalapril
lisinopril
perindopril
51
side effects of ACEi
1. Persistent cough (switch to ARBs)
2. Angioedema
3. Hyperkalemia
4. Hepatic failure
5. Renal impairment
5. Dizziness and headaches
52
side effects of ARBs
1. Hyperkalemia
4. Hepatic failure
5. Renal impairment
5. Dizziness and headaches
* same as ACEi except for angioedema & persistent cough
53
examples of ARBs
- candesartan
- losartan
- Irbesartan
54
describe the drug interactions of ACEi
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
name the 3 classifications of beta blockers
1. Cardioselective BB
2. Water-soluble BB
3. Intrinsic sympathomimetics BB
56
describe the use of cardioselective beta blockers & examples
'BAtMAN'
Bisoprolol
Atenolol
Metoprolol
Nebivolol
*less likely to cause bronchospasms = can be used for asthmatics if needed
57
describe the use of water-soluble beta blockers & examples
water 'CANS'
Celiprolol
Atenolol
Nadolol
Sotalol
*less likely to cross the blood-brain-barrier to cause nightmares
58
describe the use of intrinsic sympathomimetic beta blockers & examples
'POACh'
Pindolol
Oxprenolol
Acebutolol
Celiprolol
* less likely to cause cold extremities
59
side effects of beta blockers
1. bradycardia
2. heart failure
3. Mask symptoms of hypoglycemia
4. hyperkalemia
5. bronchospasms CI in asthmatics
60
state the drug interactions of beta blockers
- causes heart block = concurrent use of amiodarone and digoxin
61
side effects of CCB
1. gingival hyperplasia - swollen gums
2. dizziness
3. vasodilatory effects - swollen ankles, flushing and headaches (common in dihydropyridines)
4. complete AV block
62
side effects of nicorandil
GI and mucosal ulceration
63
state the counselling points of nitrates for S/L and transdermal patches use and give examples.
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
State the medical conditions you would AVOID the use of thiazide-like diuretics
- Diabetes
- Gout
- Pregnancy
- eGFR <30ml/min
65
What are the side effects of thiazide-like diuretics
- Hypokalaemia
- Hypercalcaemia
- Hyperurticaria
- Hyponatremia
- Hypomagnesia
- GI disturbances
66
name the TLD that is less aggravating to diabetic patients.
Indapamide
67
what are loop diuretics used for?
- HTN
- Chronic HF
- Pulmonary oedema
68
what are the side effects of loop diuretics?
- ototoxicity
- Hypo- Na+, Mg, Ca2+, K+,
- Hyperglycaemia
- Acute urinary retention
69
caution use of loop diuretics
- diabetes = due to hyperglycaemia
- prosthetic hyperplasia
70
what are the drug interactions of loop diuretics
- Avoid hypokalemia-inducing drugs = TLD
- Aminoglycosides = ototoxicity and nephrotoxicity
- Lithium = concomitant use of loop diuretics with Li= increases plasma lithium levels
71
name the K+ sparing diuretic that discolours urine to blue
triamterene
72
side effects of K+ sparing diuretic
1. Hyperkalemia = avoid use of ACEi/ARBs/K+ supplements
2. Increases risk of renal failure
73
State the medical conditions you would AVOID the use of spironolactone
1. Addisons disease = CI causes hyperkalaemia
2. Hyperkalaemia
74
side effects of spironolactone
1. Gynaecomastia = causing swollen breast tissue, pain, tenderness and menstrual disturbances
2. Hyponatremia
3. Hyperkalaemia
4. Loss of libido
75
drug interactions of spironolactone
1. Increases risk of renal function
2. Increases risk of hyperkalemia
3. Concomitant use of Lithium = increases risk of lithium.
76
what is the MHRA alert for spironolactone?
Avoid concomitant use of aldosterone antagonists and ACEi due to potentially causing fatal hyperkalemia
77
when to AVOID the use of alpha-blockers (doxazocin)
- elderly as it increases risk of falls
78
Advice on a patient with postural hypotension taking doxazosin
The use of alpha-blockers exacerbates postural hypotension
79
Advice on the use of doxazocin in pregnancy and breastfeeding
-Can be used during pregnancy
-Low risk of adverse SE in breastfeeding
80
side effects of alpha blockers
- drowsiness
- headaches
- postural hypotension
81
drug interactions of alpha-blockers
- Antihypertensives = bradycardia
- Concomitant use of PDE-5i (sildenafil) = hypotension
82
when to AVOID the use of CCBs
- Oedema
- Heart failure
83
name the CCB that can be used in HF?
amlodipine
84
side effects of CCB
- oedema
- flushing
- gingival hyperplasia
- complete AV block
- Headaches
85
when to AVOID the use of Beta blockers?
- antihistamines
- COPDs
- Pregnancy = causes bradycardia and hypoglycaemia
86
what are the side effects of beta blockers
- Bradycardia
-Hyperglycaemia
- Bronchospasm
- Heart failure
- mask symptoms of hypoglycaemia
87
drug-interactions of beta blockers
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
what are the contra-indications of beta blockers
- diabetes
- unstable HF
- 2nd/3rd degree AV block
- severe hypotension and bradycardia
89
when to AVOID the use of ACE inhibitors
- angioedema = esp in afro-carribean pts
- severe renal disease = nephrotoxic, DAMN
- pregnancy
90
side effects of ACE inhibitors
- dry mouth
- oral ulcer
- hepatotoxicity
- hyperkalemia = risk of T2DM, renal impairment
- hypoglycaemia
91
drug-interactions of ACEi
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
what is the drug-interaction of ACEi + Aliskiren
CI in T2MD, eGFR <60ml/min
93
what is the drug interaction of ACEi + Aliskiren?
CI in T2DM
eGFR < 60ml/min
94
what drug-interaction of ACEi + Lithium?
Increases levels of lithium in plasma = increases lithium toxicity
95
when to AVOID the use of ARBs
- pregnancy
- severe renal disease
96
side effects of ARBs
1. hyperkalemia
2. hepatotoxicity
97
drug interactions of ARBs
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
drug interaction of ARB and lithium
Increases plasma levels of lithium = increases lithium toxicity
