drug high points Flashcards
1
Q
which muscarinic agonist is contraindicated in narrow angle glaucoma and iritis
A
Cevimeline (Evoxac)
2
Q
which muscarinic agonist is linked to an increased incidence of UTIs
A
Cevimeline
3
Q
what topical muscarinic agonist is used to treat glaucoma
A
Pilocarpine
also approved for xerostomia from Sjogren syndrome or from salivary gland damage from radiation therapy
4
Q
treatment of Muscarinic poisoning
A
Atropine and supportive therapy
5
Q
drug of choice for treating poisoning by atropine and other drugs that cause muscarinic blockade such as antihistamines and phenothiazine antipsychotics but not tricyclic antidepressants (due to r/o causing seizures and cardiotoxicity)
A
Physostigmine
6
Q
drug sometimes used in diagnosis of MG or to distinguish between myasthenic or cholinergic crisis
A
Edrophonium (Enlon)
7
Q
what 3 reversible cholinesterase inhibitors are approved for management of Alzheimer Disease
A
Donepezil (Aricept)
Galantamine (Razadyne)
Rivastigmine (Exelon)
8
Q
which reversible cholinesterase inhibitor is approved for mgmt of Alzheimer Disease and Dementia of Parkinson Disease
A
Rivastigmine (Exelon)
9
Q
irreversible cholinesterase inhibitors are only approved for
what drug?
A
treatment of glaucoma
Echothiophate (Phospoline Iodide)
10
Q
pharm treatment of irreversible cholinesterase inhibitor poisoning
A
Atropine to reduce muscarinic stim
pralidoxime to reverse inhibition of cholinesterase
Benzodiazepine such as diazepam to suppress convulsions
Resp depression from cholinesterase inhibitors - mechanical ventilation
11
Q
drug of choice for MG
A
Pyridostigmine (Mestinon, Regonol)
12
Q
which drug is used in keratoconjunctivitis sicca
A
Cevimeline
13
Q
when should you take muscarinic agonists and cholinesterase inhibitors in relation to food and why
A
1 hr before meals or 2h after to decrease incidence of n/v
14
Q
what is the diff between cholinergic and muscarinic
A
they are the same. 2 diff terms mean the same
15
Q
what class
Bethanechol
Cevimeline
A
Muscarinic Agonists
16
Q
What class Pyridostimine physostigmine
A
reversible cholinesterase Inhibitors
17
Q
what class echothiophate
A
irreversible cholinesterase inhibitors
18
Q
what class Atropine Scopolamine Ipratropium (Atrovent) Dicyclomine Oxybutynin Solifenacen Darifenacin Tolterodine Fesoterodine Trospium
A
muscarinic Antagonists (can also be interchangeably called parasympatholytic drugs, antimuscarinic drugs, muscarinic blockers, anticholinergic drugs)
19
Q
what anticholinergic is safe to take in pregnancy
A
Oxybutynin
20
Q
Can you give antimuscarinic drugs to older adults
A
no
21
Q
antidote to anticholinesterase poisoning
A
Atropine
22
Q
what drug is used for treatment of sinus bradycardia
and AV block
A
Atropine
23
Q
what are the problems associated with xerostomia
A
dry mouth promotes tooth, gum problems and oral infections.
24
Q
Pt ed for Xerostomia
A
sipp fluids
chew sugar free gum
use salivary stimulants (citrus-flavored or tart sugarless candies, maltose lozenges)
salivary substitutes such as biotene dry mouth spray and Xylimelts are available OTC
Avoid sugary gum and hard candy
25
How can someone decrease urinary retention when taking atropine
void before taking med
same for all muscarinic antagonists
26
Pt ed on constipation
increase dietary fiber and fluids and physical activity
27
contraindications for taking muscarinic antagonists
```
glaucoma due to increased iop
intestinal Atony
MI
BPH - urinary retention
urinary tract obstruction
MG pt - can precipitate myasthenic crisis
use caution in pt with preexisting tachycardia
use caution in asthmatics
```
such as Atropine
28
Pt is taking a muscarinic antagonist. It is summer time and they have a trip planned with their family. What important education would you give
This can cause anhidrosis. Sweating is necessary for cooling and someone who cannot sweat is at risk for hyperthermia. Avoid activities that might lead to overheating
29
drug interactions for muscarinic antagonists due to their significant muscarinic blockade
tricyclic antidepressants (TCA)
antihistamines
phenothiazine antipsychotics
"Don't feed anyone on Atropine TAPAs!"
30
muscarinic antagonist that is used for motion sickness
Scopolamine
31
Muscarinic antagonist (anticholinergic) used to treat asthma, COPD, rhinitis caused by allergies or the common cold
Ipratropium (Atrovent)
32
anticholinergic for IBS or hypermotility
Dicyclomine (Bentyl)
33
pneumonic/ way to remember Atropine or anticholinergic adverse effects
Can't see, Can't pee, Can't Shit, Can't Spit
```
blurred vision/photophobia/elevated IOP
urinary retention
Constipation
Xerostomia
Anhidrosis
```
Tachycardia
Thickening of bronchial secretions and causes bronchial plugging
34
3 ways to reduce side effects for anticholinergics
1) using long acting formulas
2) using drugs that dont cross BBB
3) using drugs that are selective
35
highly selective M3 med for OAB
Darifenacin (Enablex)
36
Primarily M3 selective med for OAB
Oxybutynin
| Solifenacin
37
Nonselective drugs for OAB
Fesoterodine
Tolterodine
Trospium
38
M1 affects what when activated/blocked
salivary glands - > salivation -> dry mouth
| CNS ->enhanced cognition -> confusion/hallucinations
39
M2 affect what when activated/blocked
Heart - > Bradycardia ->tachycardia
40
M3 affects what when activated/blocked
Salivary glands -> Salivation->dry mouth
Bladder-> voiding ->urinary retention
GI smooth muscle -> increased tone/motility -> constipation
eyes -> miosis, accomodation, tearing ->mydriasis, blurred vision, dry eyes
41
what drug for OAB caused hallucinations and agitation that were prominent among pediatric and hallucinations, confusion and sedation with older adults pts
Oxybutynin (Ditropan XL, Gelnique, Oxytrol)
42
which two drugs for OAB has a side effect of Headache
Darifenacin and Solifenacin
43
Which drugs for OAB have the side effect of prolonging QT interval
Solifenacin
| Tolterodine
44
which OAB drug is not metabolized by CYP enzymes
Trospium
45
Which OAB has the lowest bioavailability and lacks CNS effects
Trospium
46
Which OAB has been associated with angioedema of the face, lips, tongue and larynx
Solifenacin
47
which OAB drugs should be avoided in severe liver impairment
Darifenacin
| Solifenacin
48
CYP3A4 inhibitors
azole antifungal drugs (ketoconazole, itraconazole)
certain protease inhibitors for HIV/AIDS (ritonavir, nelfinavir)
Macrolide abx such as Clarithromycin
49
drug interactions for Trospium
Trospium is eliminated by the kidneys, we can assume it may compete with other drugs that undergo renal tubular excretion.
```
Among these are
Vancomycin
Metformin
Digoxin
Procainamide
```
50
what is the only OAB drug not available in Extended release or long acting
Solifenacin
51
How is Solifenacin taken?
swallowed intact with liquid
| with or without food
52
which 2 OAB drugs don't effect CNS
Darifenacin (no effect on memory, reaction time, word recognition or cognition)
Trospium
53
antidote to antimuscarinic poisoning
physostigmine
54
how to differentiate between a true psychotic episode and antimuscarinic poisoning
a true psychotic episode is not associated with signs of excessive muscarinic blockade
-dry mouth
hyperthermia
dry skin, ect
55
```
Name that class
Epinephrine
Norepinephrine
Isoproterenol
Dopamine
Dobutamine
Phenylephrine
Albuterol
Ephedrine
```
Adrenergic Agonists
catecholamines and noncatecholamines
all are catecholamines except
Phenylephrine
Albuterol
Ephedrine
56
Catecholamines vs Noncatecholamines
Catecholamines
1) cant be taken orally (MAO and COMT)
2) Short duration of action
3) Do not act on CNS
57
what catecholamine is safe in pregnancy
Dobutamine
58
Which catecholamines/noncatecholamines has a adverse effect of hyperglycemia in diabetics and which receptor is responsible for this
Epinephrine
Isoproterenol
Albuterol
Ephedrine
B2
59
which catecholamine works on all 4 adrenergic receptors
Epinephrine
"The Es include everybody"
60
Which non-catecholamine works on all 4 adrenergic receptors
Ephedrine
"The Es include everybody"
61
What do you give for A1 adrenergic agonist extravates
phentolamine
62
what catecholamines can cause tissue necrosis if extravated
Epinephrine
norepinephrine
dopamine (if high doses)
63
Alpha1 receptors cause
Vasoconstriction of blood vessels
| Mydriasis
64
Alpha2 receptors cause
Reduction in sympathetic outflow to heart and blood vessels
| Severe pain
65
Beta1 receptors affect
Heart
| Kidney
66
Beta2 receptors affect
Lungs
Uterus
Liver and skeletal muscle – glycogenolysis which can cause hyperglycemia in DM II patients
67
Dopamine receptors
Dilation of renal vasculature
68
what drugs interact with catecholamines
MAO inhibitors (inactivates epi)
Tricyclic antidepressants -block uptake and prolong epi effects
several inhalation anesthetics - tachydysrhythmias
69
noncatecholamine that is used to reduce nasal congestion, raise BP and dilate the eyes. Also used coadministered with local anesthetics to delay anesthetic absorbtion
Phenylephrine
70
Adverse effects of Albuterol in high doses
| why?
Tremors
Tachycardia
high doses affect B1 in addition to B2
71
adverse effect that Ephedrine has but Epinephrine does not share
insomnia due to Ephedrine crossing CNS and Epinephrine not
72
Alpha adrenergic antagonists approved in children
OraVerse - agent for reversal of local anesthesia following dental surgery
phentolamine for prevention of tissue damage post extravation of iv vasopressors
73
Alpha Adrenergic antagonists approved during pregnancy
There are 3 but they are only approved for BPH so irrelevant. no others are approved
74
older adults are esp vulnerable to what side effect of alpha blockers
first dose effect.
75
Beers criteria specifically identifies what a1 blockers as innapropriate for older adults
doxazosin
prazosin
terazosin
due to high incidence of orthostatic hyypotension
76
Alpha blockers are associated with worsening of what in women and increases what for both genders in older adults?
urinary incontinence
| syncope
77
what is the most significant adverse effect associated with A2 blockade
reflex tachycardia
78
Phenoxybenzamine
| Phentolamine
nonselective A adrenergic blockers
79
```
Alfuzosin
Doxazosin
Prazosin
Silodosin
Tamsulosin
Terazosin
```
A1 selective adrenergic blockers
80
```
Carteolol
Nadolol
Pindolol
Propanolol
Sotalol
Timolol
```
1st gen nonselective B Blockers
81
Carvedilol
| Labetalol
Vasodilating B Blockers
acts on B1, B2, A1
82
```
Acebutolol
Atenolol
Betaxolol
Bisoprolol
Esmolol
Metoprolol
Nebivolol
```
2nd gen B1 selective Blockers
83
Prazosin is approved only for
HTN and BPH
84
which A blockers (adrenergic antagonists) have the first dose effect as an adverse effect
Prazosin
Terazosin
Doxazosin
These 3 also have orthostatic hypotension, reflex tachycardia and nasal congestion listed
85
what 3 A blockers are approved for HTN and BPH
Prazosin
Terazosin
Doxazosin
86
what are the 3 A blockers that are only approved for BPH
Tamsulosin (Flomax)
Alfuzosin (Uroxatral)
Silodosin (Rapaflo)
87
Max benefits of Tamsulosin develop within
2 weeks
88
What A blocker approved only for BPH does not interfere with ejaculation
Alfuzosin
89
What A blocker approved only for BPH can prolong QT
Alfuzosin with doses four times greater than recommended
90
first dose effects need to know
1% of pt lose consciousness 30-60 min after pt receiving initial dose. To minimize initial dose should be small (no more than 1mg in Prazosin). Subsequent doses gradually increased with little risk for fainting. Pt who are starting treatment should avoid driving or other hazardous activities 12 -24 hrs. Take first dose right before going to bed.
91
drug interaction for Alfuzosin
CYP3A4 inhibitors such as erythromycin, clarithromycin, itraconazole, ketoconazole, nefazodone, HIV protease inhibitors such as ritonavir
92
drug interaction for Tamsulosin
combined with cimetidine increases drug levels
combined with hypotensive drugs such as PDE-5 inhibitors (Viagra)
93
B Blockers for Heart failure
Carvedilol
Bisoprolol
metoprolol
94
Propanolol is contraindicated in
```
AV heart block
Heart failure
bradycardia
Asthma
COPD
dangerous in diabetics - use with caution
history of anaphylaxis
```
95
B Blockers in pregnancy -
```
other than labetalol
may put neonate at risk for 3-5 days
Bradycardia
resp distress
hypoglycemia
```
96
3 antihypertensives save in pregnancy
labetalol
methyldopa
nifedipine
97
What antihypertensive should be avoided in pt with history of anaphyhlaxis
Propanolol
blocks epinephrine being able to help in anaphylaxis
98
Drug interactions Propanolol
Verapamil and diltiazem - cardiac effects are identical to propanolol so can cause excessive cardiosuppression
99
what b blocker is safer for diabetics, asthmatics and for pt with history of anaphylaxis
Metoprolol
bc its a selective B1
100
2 B blockers that block A Adrenergic receptors in addition to B1 and B2
Labetalol
| Carvedilol
101
B Blockers considered safest in pregnancy and which is drug of choice
Lebetalol - DoC
acebutolol
pindolol
sotalol
102
which b blocker is most secreted in Breastmilk
Betaxolol
103
Black box for Sotalol (Betapace)
When starting or restarting solalol, pt should be in a facility that can provide continuous EkG monitoring and CPR for min of 3 days
104
What lab needs to be ordered prior to starting Sotalol
Creatinine clearance
105
how are Sotalol and Esmolol different from the other B Blockers
very short half life of 15 min
106
used for emergency treatment of SVT
Esmolol
107
B blocker approved for ventricular dysrhythmias and maintenance of NSR in pt with prev a-fib or A flutter
Sotalol
108
partial agonist that produces a limited degree of receptor activation while preventing strong agonists from binding to that receptor to cause full activation
keeps resting heart rate from not being reduced like a regular B Blocker
Intrinsic sympathomimetic activity
Pindolol
109
The abrupt discontinuation of these b blockers may cause exacerbation of angina and increase risk for MI
Atenolol
Metoprolol
Nadolol
Timolol
110
Use all B Blockers with caution in Pt with a history of
Depression and in pt taking CCBs
111
abrupt withdrawal of B blockers can cause
tachycardia
ventricular dysrhythmias
taper off gradually
112
B Blocking A adrenergic receptors, carvedilol and lebetalol can cause
postural hypotension.
move slowly when changing from a supine or sitting to a upright position
lie down if feel lightheaded
113
B1 blockade can mask early signs and symptoms of
hypoglycemia by preventing common tachycardia, tremors and perspiration. Pt need to rely on other indicators such as hunger and poor concentration to identify hypoglycemia
114
B2 blockade can prevent what in diabetics
glycogenolysis which is an emergency means of increasing blood glucose. Pt may need to reduce insulin dosage.
115
signs and symptoms of Heart failure
shortness of breath
night coughs
swelling of extremities
notify provider if occur while taking B Blockers
116
Clonidine class and what it is approved for
centrally acting A2 agonist
HTN
ADHD
Severe pain
117
Clonidine patch pt ed
apply patch to hairless, intact skin on the upper arm or torso
apply a new patch every 7 days
Contain metal and must be removed prior to MRI
118
How can someone minimize daytime sedation with Clonidine
Take the major portion of daily dose at bedtime
119
Pt monitoring for clonidine
have pt record BP daily and call clinic if hypotension develops
120
Pt ed on Clonidine
do not abruptly discontinue drug - may cause tachycardia and other dysrhythmias
carry an adequate supply of meds and a copy of prescription
Possible CNS depression. Avoid hazardous activities if alertness is reduced
Dry mouth can be significant. Use pt ed for dry mouth
Potential for rebound hypertension. Refill script promptly so they dont run out of medication. Warn them not to d/c without talking to PCP first
121
net result of cardiac suppression and vasodilation is
decreased BP (orthostatic hypotension is not a concern)
122
Hypotensive responses to clonidine begin when
30-60 min after administration
123
can you take clonidine while pregnant
no
124
what central acting A2 agonist has high abuse potential
Clonidine
125
Clonidine Tablet prep is called
Catapres
126
Clonidine in an extended release tablet used for mgmt of ADHD
Kapvay
127
A2 agonist used for HTN and ADHD
Guanfacine (Intuniv)
128
What med is an indirect A2 agonist?
Methyldopa bc it has to be converted to methylnorpinephrine to be a alpha 2 agonist
129
The principal mechanism of methyldopa is
vasodilation, not cardiosupression.
130
what A2 agonist does not decrease HR or Cardiac output
Methyldopa
131
How is methyldopa used in pregnancy
treatment of preeclampsia
132
what are the two most severe adverse effects for methyldopa
Hemolytic anemia and Hepatotoxicity
133
What labs need to be done for methyldopa before and periodically thereafter
Coombs
CBC for blood counts (Hgb, HCT, Red cell count)
LFTs
134
A coombs test should be performed before treatment and
6-12 months later
135
if a coombs test turns positive it usually occurs
6-12 mos later. Of those pts only 5% of those pts develop hemolytic anemia. If they do not develop hemolytic anemia, they can continue the drug.
136
If a pt taking Methyldopa develops hemolytic anemia
Melthyldopa should be withdrawn. it resolves after withdrawal. Coombs test may remain positive for months
137
can you use Central acting alpha blockers in older adults
no, beers says nobody over 65
138
most potent diuretic
Loop diuretics
| Furosemide (Lasix)
139
which diuretic can promote diuresis even when renal blood flow and GFR are low
Furosemide (Lasix)
140
if treatment with furosemide alone is insufficient, what can be added?
Thiazide Diuretic
141
Furosemide can promote excessive loss of
sodium, chloride and water (dehydration)
142
what medication acts on the thick segment of the ascending loop of Henle
Furosemide (Lasix)
143
what diuretic works on the early distal convoluted tubule
Thiazides
144
What diuretic in the late distal convoluted tubule and collecting duct (distal nephron)
Spironolactone
145
adverse effects of loop diuretics and thiazides
```
Hyponatremia
Hypochloremia
dehydration
Hypokalemia
Hypotension
Ototoxicity
Hyperglycemia
Hyperuricemia
reduction of HDL
Increase in LDL and triglycerides
```
146
Rarely, loop diuretics cause hearing impairment. With _____, deafness is transient. With ______, irreversible hearing loss may occur
Furosemide
| Ethacrynic acid
147
diuretics and pregnancy
no
148
Diuretics and Breastfeeding
decrease milk production
| no data on drug transmission
149
Older adults and diuretics
most common cause of adverse med reactions and interactions in older adults. Monitor closely for dehydration and cardiac dysrhythmias
150
when taking Digoxin, what can increase risk for ventricular dysrhythmias
Hypokalemia
151
To reduce risk of dysrhythmias for pt taking Digoxin and a diuretic
Add a potassium sparing diuretic or potassium supplement
| monitor Potassium levels
152
The risk for furosemide induced hearing loss is increased by concurrent use of
other ototoxic drugs, esp aminoglycoside antibiotics (gentamycin). Combined use should be avoided
153
ethacrynic acid (Edecrin)
torsemide (Demadex)
Bumetanide (Burinex)
other loop diuretics
like furosemide (Lasix)
154
what 2 loop diuretics are approved for HTN
Furosemide (Lasix)
| Torsemide (Demadex)
155
Drug interactions for loop and thiazide diuretics
```
Digoxin
Ototoxic drugs
Potassium sparing diuretics
lithium
antihypertensive agents
NSAIDS
```
156
NSAIDS and loop diuretics
reduce sodium excretion and blunt diuretic effects of loop diuretics which exacerbate edema.
157
thiazide diuretics and gout
can make gout worse bc promotes elevated serum uric acid levels
158
spironolactone , sodium, potassium
```
increase sodium (promotes sodium uptake in exchange for potassium secretion)
decrease potassium
```
159
hydrochlorothiazide blocks the reabsorption of
sodium and chloride in the early segment of the distal convoluted tubule
160
GFR requirement for thiazides to promote diuresis
Cannot work if less than 15-20ml/min
161
effects of spironolactone take
24-48hrs to work
162
spironolactone endocrine effects
```
gynecomastia
menstrual irregularities
impotence
hirsutism
deepening of voice
```
163
what are agents that raise potassium
```
potassium supplements
salt substitutes that contain potassium chloride
potassium sparing diuretics
ACEs
ARBs
DRIs
potassium rich foods
```
164
what is Triamterene
potassium sparing diuretic
165
adverse effects of Triamterene
nausea, vomiting, leg cramps, dizziness
| blood dyscrasias occur rarely
166
What is Amiloride
potassium sparing diuretic
167
diuretic for heart failure
Spironolactone
| bc blocks aldosterone and reduces mortality and hospital admissions
168
which antihypertensives have the cough and angioedema as adverse effect and why?
ACE inhibitors
| Kinins
169
If pt cannot tolerate ACE, what is second line
ARB
170
except for ____ and ____, all oral ACE inhibitors can be administered with food
Captopril
| moexipril
171
With the exception of _____, all ACE inhibitors have prolonged half lives and can be administered just once or twice a day
Captopril which is given 2-3 times per day
172
With the exception of _____, all ACE inhibitors are prodrugs and must undergo conversion to their active form in the small intestine and liver.
Lisinopril is active as given
173
All ACE inhibitors are excreted by the ____with the exception of ______
kidneys. use renal dosing
| Fosinopril
174
ACE inhibitors reduce the risk for
| other drugs that do this are ____ and ____
cardiovascular mortality caused by HTN
B Blockers
diuretics
175
AFter MI, Pt should be put on ____ and stay on for at least 6 weeks.
Meds approved are
ACE inhibitors
trandolapril
lisinopril
Captopril
"TLC"
176
the only ACE inhibitor approved for nephropathy is
Captopril
177
Can ACE inhibitors be used for primary prevention of diabetic nephropathy?
no. They slow progression of established nephropathy but do not protect against early kidney damage
178
what ACE inhibitor is approved for reducing the risk for MI, stroke and death from cardiovascular causes in pt at high risk for a major cardiovascular event.
high risk defined as stroke, CAD, Peripheral vascular disease or diabetes combined with at least one other risk factor such as HTN, High ldl, low hdl or cigarette smoking
Ramipril (Altace)
| Perindopril (Aceon)
179
what ACE inhibitor can reduce the risk for diabetic retinopathy in some pts with type 1 DM who do not have htn, nephropathy or established retinopathy
Enalapril
180
what antihypertensive has First dose hypotension
ACE inhibitors - caused by widespread vasodilation secondary to abrupt lowering of angiotensin II levels
181
if hypotension develops what should the pt do
assume a supine position and seek med attention if it does not resolve
182
Factors that increase risk of cough in ACE inhibitors
Advanced age
female
Asian
183
Ace inhibitor cough begins to subside ___ days after d/c and is gone within ____ days
3
| 10
184
inhibition of aldosterone release can cause _____ retention by the kidney in ACE inhibitors
potassium
185
ACE inhibitors and pregnancy
Big fat negative
186
potentially fatal reaction for ACE inhibitors
Angioedema
187
Angioedema develops, how do you treat
subcutaneous epinephrine
188
If Neutropenia develops, _________ should be withdrawn immediately
ACE inhibitors
189
ACE inhibitors and drug interactions
Diuretics may intensify first dose hypotension
Hypotensive effects are often additive to other antihypertensives such as diuretics, sympatholytic, vasodilators, CCBs
increase risk for hyper-k - increased by potassium supplements, potassium sparing diuretics,
ACE inhibitors can cause lithium to accumulate to toxic levels. monitor frequently
NSAIDS - may reduce the antihypertensive effects of ACE inhibitors
190
lab monitoring for ACE inhibitors
consider checking creatinine 2-4 weeks after starting
191
how are ARBS different from ACE
pose a much lower risk for cough or hyperkalemia
| ARBs do not decrease cardiovascular morbidity as well as ACEs
192
what ARBs are approved for Heart failure
Valsartan (Diovan)
| Candesartan (Atacand)
193
What ARBs are approved for managing nephropathy in hypertensive patients with Type 2DM
Irbesartan (Avapro)
| Losartan (Cozaar)
194
what ARB is approved for reducing cardiovascular mortality in post MI pt with Heart failure or LV dysfunction
Valsartan (Diovan)
195
What ARB is approved for reducing risk for MI, stroke, death from cardiovascular causes in pt 55 and older but only if they are intolerant of ACE inhibitors
Telmisartan (Micardis)
196
What ARB in pt with Type 1DM without established retinopathy, slows the development and progression of retinopathy
Losartan (Cozaar)
197
Angioedema and ARB
incidence is lower with ARBs than with ACEs
198
ARBS and pregnancy
no go
199
renal pt for ACES and ARBS
contraindicated in pt with bilat renal artery stenosis or stenosis in artery to a single remaining kidney
200
labs after starting ARBS
consider checking creatinine 2-4 weeks after starting
201
-pril
ACE
202
-sartan
ARB
203
What DRI is approved
Aliskiren
204
Aliskiren is approved only for
HTN
205
food and Aliskiren
dosing with a high fat meal makes availability much lower in an already low bioavailable drug
206
metabolism of Aliskiren
some metabolism by CYP3A4 but the extent is unknown
207
Adverse effects of Aliskiren
angioedema
cough
hyperkalemia ]
low risk for all
at high therapeutic doses - diarrhea
208
aldosterone Antagonists for HTN and Heart failure
Eplerenone (Inspra)
| Spironolactone
209
Side effect for Eplerenone and Spironolactone
Hyperkalmia
210
Eplerenone effect of potassium, sodium, water
retention of potassium
| increased excretion of sodium and water
211
other adverse effects of eplerenone
```
diarrhea
abd pain
cough
fatigue
gynecomastia
flu like syndrome
```
212
drug interactions Eplerenone
inhibitors of CYP3A4 can increase levels of eplerenone
weak inhibitors (Erythromycin, saquinavir, verapamil, fluconazole) can double levels
Strong inhibitors (ketonazole, itraconazole) can increase fivefold
213
combining eplerenone with ACE inhibitors or diuretics
can increase levels of lithium
214
which CCBS are nondihidropyridines?
| where do they work?
Verapamil and Diltiazem (Cardizem)
act on arterioles and the heart
lower HR
215
Verapamil and Diltiazem( nondihidropyridine CCBS) are approved for
```
Angina (Vasospastic and angina of effort)
Essential HTN (second after thiazide diuretics)
cardiac dysrhythmias (slow rate with a-flutter, a-fib and paoxysmal SVT)
```
216
Adverse effects of CCBS and which are different for nondihydropyridines vs dihydropyridines
Constipation - most common complaint in nondihydropyridines (more so in Verapamil than in Diltiazem (Cardizem))
dizziness - all
facial flushing - all
headache - all
edema of ankles and feet (secondary to vasodilation) - all
gingival hyperplasia - all
Bradycardia (AV node) - nondyhydropiridines
Decrease contractility (myocardium) - nondyhydropiridines
refelex tachycardia - dihydrapyridines
217
Drug and food interactions for Verapamil
Digoxin - both suppress AV node conduction - used together increases risk of AV block. Also Verapamil increases Digoxin plasma levels by 60% so watch for dig tox
B Blockers and Verapamil both decrease HR, AV conduction and Contractility.
Grapefruit juice - can inhibit intestinal and hepatic metabolism of drug and raise levels. Less risk with Verapamil but still a potential risk
218
How can you minimize risk or taking B Blockers with Verapamil
administer several hours apart
219
which CCBs carry the highest risk of grapefruit juice raising drug levels by inhibiting metabolism of drug
Felodipine
Nifedipine
"I fell near the grapefruit tree"
"CCBs with F in the words....sunny florida"
220
which CCB that has first pass effect in the liver
All of them
221
which nondihidropyridine CCBS causes less constipation
Diltiazem (Cardizem)
222
What cardiac dysfunction in pts can be exacerbated by a nondihidropyridine CCBS
bradycardia
sick sinus syndrome
heart failure
second degree and third degree AV block
223
CCB may cause what type of rash in older adults
eczematous rash
224
what CCB can be used in infants to convert certain cardiac dysrhythmias
Verapamil
225
which type of CCB would you prefer to use in someone who has AV block, heart failure, bradycardia or sick sinus syndrome
nifedipine (dijydropyiridine CCB)
226
A response that occurs with nifedipine that does not occur with verapamil
why is it a problem
how do you treat
reflex tachycardia - which increases cardiac oxygen demand which increases angina -
B Blocker
227
what dihydropyridines are approved for essential HTN and angina
Amlodipine
nifedipine
nicardipine
228
Which Dihydropyridine CCB are approved for HTN only
Isradipine
felodipine
nisoldipine
229
Baseline data for CCBs
BP and HR
LFTs
Kidney function (BUN)
GFR
230
What do you use to treat Verapamil tox
Atropine and glucagon for bradycardia
Norepinephrine for hypotension
231
s/s of verapamil tox
bradycardia
| hyptotension
232
which CCB has highest chance of reflex tachycardia
Nifedipine
233
which dihydropyridines have the lowest risk for reflex tachycardia and why
Felodipine
amlodipine
long acting drugs
234
antihypertensives that fall into the vasodilator category
Hydralazine
Minoxidil
selective arterial vasodilators
235
what pt education is important with vasodilators
increased risk for falls
symptoms of hypotension are lightheadedness and dizziness
Sit down or lie down if these occur
Failure to do so may result in fainting
minimize hypotension by avoiding abrupt transitions from supine or seated to and upright position
236
Hydralazine is inactivated by a metabolic process known as
acetylation which is genetically determined
| some are rapid acetylators and some are slow
237
what type of acetylators are likely to have higher blood levels of Hydralizine
slow
238
Regimen to manage HTN with oral hydralazine is usually combined with
B Blockers for reflex tachycardia
239
when used for treatment of Heart failure, hydralazine must be combined with
isosorbide dinitrate (Bidil) (dilates veins)
240
with long term therapy of Hydralazine, _____ delvelops
tolerance
241
Hydralazine induced hypotension
causes sodium and water retention and a corresponding increase in blood volume
a diuretic can prevent volume expansion
242
```
Pt taking hydralazine starts experiencing
muscle pain
joint pain
fever
nephritis
pericarditis
presence of antinuclear bodies
```
occurs most frequently in slow acetylators and rare in pt when dosage is below 200mg/day.
Systemic lupus erythematosus (SLE) - like syndrome
Hydralazine needs to be d/c
symptoms reversible but may take 6 months or more to resolve, sometimes years
243
What vasodilator has more diuretic effects and more vasodilation
Minoxidil
244
The only indication for cardiovascular reasoning for Minoxidil is
severe hypertension unresolved by other drugs
245
which vasodilator has a side effect of pericardial effusion progressing to tamponade
Minoxidil
246
which vasodilator has a side effect of hypertrichosis
Minoxidil - aka rogaine
excessive hair growth on face, arms, legs, back
247
what vasodilator is used in infants as young as 1 month for management of chronic HTN
Hydralazine
248
what vasodilator can be used in children and adolescents
Hydralazine
249
when considering use of hydralazine and minoxidil in preg
benefits need to outweigh risk
250
breastfeeding and vasodilators
no data
251
older adults and vasodilators
monitor for falls increased risk of polypharmacy and associated orthostatic hypotension
252
what drug class works to suppress rennin release
B Blockers
253
What drug class prevents conversion of angiotensinogen to angiotensin I
Direct Renin INhibitor (DRI)
254
What drug class prevents the conversion of angiotensin I to angiotensin II
ACE inhibitor
255
What drug class blocks receptors for angiotensin II
Angiotensin II receptor blockers (ARB)
256
what drug class blocks receptors for aldosterone
aldosterone antagonist
257
what drug class helps by neutralizing renal effects on BP (When BP falls, GFR falls too, which promotes retention of sodium, chloride and water. This increases blood volume and increases venous return to heart causing an increase in cardiac output which increases arterial pressure)
Diuretics
258
antihypertensive that suppress RAAS
ACE inhibitors
259
4 subcategories of sympatholytic (antiadrenergic) drugs used for HTN
1) B Blockers
2) A1 blockers
3) A/B blockers
4) Centrally acting A2 agonists
260
for initial therapy of Essential HTN without complicating factors
Thiazide diuretic
261
4 reasons why antihypertensive therapy fails when initiated
non-adherence
presence of excessive salt intake
wrong dosage
presence of secondary HTN
262
what is step down therapy
After BP has been controlled for at least 1 year, an attempt should be made to reduce dosages and number of drugs in regimen. Lifestyle mods should continue
263
although all classes of antihypertensives are effective in nephrosclerosis, what 2 classes work best
what should also be used
ACE
ARB
in most cases a diuretic is also used
264
in pt with advanced renal insufficiency, what diuretic would be ineffective and which would need to be avoided
Thiazide ineffective
Potassium sparing avoid
use loop
265
Preferred antihypertensive drugs in pt with diabetes
in pt with diabetic nephropathy ____ and ___ can slow the progression of ___ and reduce _____
ACE
ARB
CCB
Diuretics (in low doses)
in pt with diabetic nephropathy ACE and ARB can slow the progression of renal damage and reduce albuminuria
266
In both diabetic and non-diabetic pt, _____ and _____ can decrease morbidity and mortality
B blockers
| diuretics
267
B Blockers and diabetic pt
decrease morbidity and mortality
suppress glycogenolysis - increase blood sugar
mask signs of hypoglycemia such as tachycardia, tremors
268
what diuretics can promote hyperglycemia
Thiazides
| Loop
269
how do ACEs compare to CCBs in pt with HTN and DM
CCB had a higher incidence of MI in a study done
ACES are superior
270
African American lifestyle trend contribute to HTN
high incidence of salt sensitivity and cigarette use
271
Treatment for HTN in African American Population
Thiazide diuretic
CCBS and A/B blockers are effective
B blockers and ACE less effective
but if have a comorbid condition follow those recomendation
272
African American pt with HTN, DM, Protenuria
Ace
273
African American pt with Hypertensive nephrosclerosis
ACE is superior to CCB
274
By age 65, hypertensive in this group almost always presents as
isolated systolic HTN
| Diastolic is usually normal or low
275
HTN treatment recom for children age 1-18
ACEs
Diuretics
B Blockers
CCBS
276
2 Drug of choice in treating pregnant women with mild preeclampsia
labetolol
| methyldopa
277
drug of choice to prevent seizures in severe preeclampsia
Magnesium sulfate
278
what drug class/drug is safe in breastfeeding moms for HTN
B blockers such as metoprolol
| diuretics appear safe but suppress lactation
279
what drug classes are reasonable for older adults in HTN
ACE
diuretics
B Blocker
280
what drug classes should be avoided in older adults for HTN
Central acting alpha agonists
| peripheral alpha - antagonists
281
hypertension that was present before pregnancy or developed before 20th week gestation
chronic HTN
282
potential adverse outcomes of chronic HTN
```
placental abruption
maternal cardiac decompensation
premature birth
fetal growth delay
CNS hemorrhage
renal failure
```
283
With the exception of these 3 drug classes, antihypertensive drugs that were taken before pregnancy can be continued
ACEs
ARBs
DRIs
284
when drug therapy is initiated during pregnancy what is the choice agents
Methyldopa
| Labetalol
285
what is the treatment threshold for initiating treatment for HTN in pregnancy
SBP > 160 or DBP >110
286
Pt who have chronic HTN during pregnancy are at risk for developing
preeclampsia. Reducing BP does not lower this risk
287
Preeclampsia is a multisystem disorder characterized by
combo of
BP >140/90 and proteinuria >300mg in 24 hrs
that develops after 20th week gestation
288
If seizures develop in preeclampsia it is termed
eclampsia
289
Risk factors for preeclampsia
```
African Americans
chronic HTN
diabetes
collagen vascular disorders
previous preeclampsia
```
290
risk for fetus of preeclampsia
intrauterine growth restriction
premature birth
death
291
risk for mother in preeclampsia
```
seizures
renal failure
pulmonary edema
stroke
death
hemorrhage
encephalopathy
```
292
what antihypertensive meds avoid in Heart failure and why
Verapamil
Diltiazem
decrease myocardial contractility and can further reduce cardiac output
(vasodilators)
293
Antihypertensives to avoid in AV heart block
B blockers
Labetalol
Verapamil
Diltiazem
act on the heart to suppress AV conduction and can intensify AV block
294
Antihypertensive to avoid in CAD and in pt with history of MI
Hydralazine - reflex tachycardia can precipitate an anginal attack by increasing cardiac workload and increasing heart oxygen demand
295
What antihypertensives may exacerbate dyslipidemia
B Blockers
| Diuretics
296
What antihypertensives should you avoid or use in caution in renal insufficiency
Potassium sparing diuretics
| also K supplements
297
Which antihypertensives can exacerbate asthma
B blockers such as labetalol
298
What diuretics promote hyperuricemia and can worsen gout
Thiazides
| Furosemide
299
What drugs used in HTN can cause potassium accumulation
K sparing diuretics
ACE inhibitors
DRIs
Aldosterone antagonists
300
Which drug can precipitate a lupus erythematosus like syndrome
Hydralazine
301
Which antihypertensive is hepatotoxic
Methyldopa
302
for routine therapy, Heart failure is treated with 3 types of drugs. There are other agents used as well
Diuretics
Agents that inhibit RAAS
B Blockers
other agents
Digoxin
dopamine
hydralazine
303
what class of drug is first line for all pt with signs of fluid volume overload
Diuretics
Thiazide if edema is not too great and pt has sufficient GFR
also principal adverse effect of thiazides is hypokalemia which increases risk for digoxin induced dysrhythmias
304
what diuretic for severe HF
Loop
305
what potassium sparing diuretic prolongs survival in pt with HF primarily by blocking receptors for aldosterone
Spironolactone
Eplerenone are also used from Aldosterone antagonists
306
how are ACE inhibitors beneficial in long term with HF
suppresses production of angiotensin (which negatively affects cardiac remodeling) also suppress degradation of kinin which is largely responsible for favorable influence on cardiac remodeling.
307
Why is ACE better than ARB
ACE suppress degradation of Kinin which helps with cardiac remodeling
308
What combo med is approved for HF pt in Stages II to IV in place of an ACE or an ARB
Sacubitril/valsartan (Entresto)
increases natriuretic peptides while suppressing neg effects of RAAS
309
Side effects of Entresto
similar to ARBS
angioedema
hyperkalemia
hypotension
310
what aldosterone antagonists can reduce symptoms of HF, decrease hospitalizations and prolong life
Spironolactone
Eplerenone
this would be added on to ACE and B blocker
prevent aldosterone from worsening cardiac remodeling
311
when can you not initiate or increase dosing of a B Blocker in HF
during an exacerbation/in fluid volume overload
312
DRIs and HF
approved for HTN but not HF
Aliskiren
313
B Blockers approved in HF
Carvedilol
Bisoprolol
Metoprolol (sustained release Toprolol XL)
314
new drug that is maxed out on B Blockers or have a contraindication to B Blocker use. Slows HR by about 10beat per min, does not have neg inotropic effects and does not cause QT prolongation
Ivabradine (Corlanor)
315
What drug is approved only in African Americans for treating HF
Bidil (Hydralazine and Isosorbide dinitrate)
316
what population does Digoxin may shorten life
women
317
Digoxin increases contractility which increases _____ and does what
cardiac output
1) sympathetic tone declines
2) urine production increases
318
Digoxin increases contractility which increases _____ and does what
cardiac output
1) sympathetic tone declines
2) urine production increases
3) renin release declines
reverses signs and symptoms of HF but does not correct the underlying problem of cardiac remodeling
319
the most common cause of dysrhythmias in pt receiving digoxin is
hypokalemia secondary to use of diuretics
320
hyperkalemia and digoxin
can decrease therapeutic responses
321
antidysrhythmic drugs used in someone who has a digoxin induced dysrhythmia
Phenytoin
| Lidocaine
322
what antidysrhythmic can cause plasma levels of digoxin to rise
Quinidine
323
when digoxin overdose is especially severe, digoxin levels can be lowered using
IV
PO
Digibind, Digifab
Cholestyramine
Activated charcoal
these suppress absorption from GI Tract
324
Pt who develop bradycardia or AV block from digoxin can be treated with
Atropine
325
GI side effects Digoxin from tox
Anorexia, nausea, vomiting
326
CNS and visual effect of digoxin from tox
fatigue
visual disturbances such as blurred vison, yellow tinge to vision, appearance of halos around dark objects.
327
what antihypertensives can increase potassium levels
ACE and ARB and CCB
328
what drugs act on the heart to increase rate and force of contraction and can add positive inotropic effects to digoxin
sympathomimetic drugs (Dopamine, dobutamine)
329
what drug used to treat SVT may increase serum concentration of Digoxin
amiodarone - consider reducing dig dose by 30-50%
330
Dig dosing and renal/liver function
primarily excreted by renal
| renal dosing needed
331
optimal rate for digoxin is
0.5-0.8 ng/ml
332
drugs to avoid in Stage C HF
antidysrhythmic agents -approved is Amiodarone and dofetilide
CCBS -approved is amlodipine
NSAIDS
333
Hold Digoxin for HR less than
50
334
Stage B heart failure _____ and _____ is recommended for all pt with a reduced ejection fraction
ACE plus B Blocker
335
Treatment for HF in Stage C has 4 goals
1) relief of pulmonary and peripheral congestive symptoms
2) improvement of functional capacity and quality of life
3) slowing of cardiac remodeling and progression of LV dysfunction
4) Prolongation of life
336
preferred method for lowering LDL cholesterol is
modification of diet combined with exercise
337
what meds for dyslipidemia are approved for kids
```
avoid use of statins in kids younger than 10
lovastatin
simvastatin
pravastatin
atorvastatin
```
338
statins and pregnancy
contraindicated
Ezetimibe and fibrates can be used but benefit should outweigh risk
339
breastfeeding and statins
no, benefit vs risk
340
Older adults and statins
good but cost benefit should be considered
341
what instrument calculates 10 year risk assess
Framingham risk prevention score
342
therapeutic lifestyle changes to lower LDL, choleseterol
diet
| exercise
343
stage A HF management
no symptoms of HF and No structural or functional cardiac abnormalities
reducing risk
control HTN, DM, Hyperlipidemia
cease behaviors that increase HF risk
smoking
alcohol abuse
344
what is the leading cause of cardiomyopathy
chronic consumption of alcohol
345
indicator for improvement of HF
BNP
346
combining a statin with ______ increases risk of statin related adverse events such as muscle injury, liver injury and kidney damabe
fibrates such as gemfibrozil and fenofibrate
347
CYP statins
atorvastatin
lovastatin
simvastatin
348
CYP inhibitors
```
macrolide antibiotics (erythromycin)
azole antifungal drugs (keotconazole, itraconazole)
HIV protease inhibitors (ritonavir)
amiodarone (antidysrhythmic)
cyclosporine (immunosuppressant)
Grapefruit juice
```
349
What LDL do you start statin treatment?
| what is treatment goal number
> or equal to 190 if no risk factor
100 goal without risk
70 with risk
350
statins in pregnancy
stop during pregnancy
351
statins available
```
atorvastatin
fluvastatin
lovastatin
pitavastatin
pravastatin
rosuvastatin
simvastatin
```
352
if a 30-40% drop in LDL is sufficient what statins
any will do
353
If LDL must be lowered more than 40%
atorvastatin
| simvastatin
354
statin in significant renal impairment
atorvastatin
355
what statin may produce twofold higher blood levels in Asians
rosuvastatin
356
when are bile acid sequestrants used
adjunct therapy to statins
357
colesevelam
cholestyramine
colestipol
Bile acid sequestrants
358
Baseline data for statin
```
total cholesterol
LDL
HDL
TGs
baseline LFT
CK
```
359
who should not use statins
pregnant
| pt with viral or alcoholic hepatitis
360
what bile acid sequestrant is drug of choice and why
colesevelam (Welchol)
1) better tolerated (less gi side effects)
2) does not reduce absorption of fat soluble vitamins (ADEK)
3) it does not significantly reduce absorption of statins, digoxin, warfarin and most other drugs
361
adverse effects of Ezetimibe (zetia)
```
myopathy
rhabdomylysis
hepatitis
pancreatitis
thrombocytopenia
```
362
benefit of Ezetimibe (zetia) over other bile acid sequestrants
no gi side effects
363
drug interactions for Ezetimibe (zetia)
statins - combined increase risk for liver damage
fibrates - increase risk for gallstones
bile acid sequestrants
cyclosporine - may greatly increase levels of ezetimibe
364
colesevelam and DM
promotes hypoglycemia
365
what type of oral iron preparations are absorbed three times more readily and are more widely used
ferrous iron salts
ferrous sulfate
ferrous gluconate
ferrous fumarate
ferrous aspartate
366
what is the major adverse effect of ferrous iron salts
GI disturbances - nausea, heartburn, bloating, constipation, diarrhea
367
treatment of choice for iron deficiency anemia and for preventing deficiency when iron needs cannot be met by diet alone to include pregnancy or chronic blood loss
Ferrous sulfate
368
who should not take oral iron by mouth
PUD
regional enteritis
ulcerative colitis
369
oral iron may impart a dark green or black color to stool. What needs to happen
this effect is harmless and is not a sign of GI bleeding
370
Iron and pt ed
Liquid iron can stain teeth
can be prevented by
1) diluting liquid preparations with juice or water
2) administering the iron through a straw or with a dropper
3) rinsing the mouth out after administering
371
Iron tox
death from iron is rare in adults
| in young children iron containing products is the leading cause of poisoning fatalities
372
for children the lethal dose of elemental iron is
2-10 g
373
_____ reduces absorption of iron
antacids
374
Coadministration of iron with _______, decreases absorption of both
tetracyclines
375
_______ promotes iron absorption but also increases its adverse effects
Ascorbic acid (Vit C)
offers no advantage over a simple increase in iron dosage
376
what is a pure elemental iron in the form of microparticles. because of the microparticles, absorbed slowly so risk for tox is reduced
Carbonyl iron
377
When iron therapy is successful, within 1 mth hgb levels will rise by at least 2g/dl. If they dont, what should the pt be evaluated for?
1) compliance
2) continued bleeding
3) inflammatory disease
4) malabsorption of oral iron
378
the most prominent consequences of vit B12 deficiency are
anemia and injury to nervous system
anemia rapidly reverses after vit B12 administration
neurologic damage takes longer to repair and in some cases may never fully resolve
379
additional effects of vit B12 deficiency are
gi disturbances
| impaired production of WBCs and Platelets
380
In the absence of ______, vit ___ is greatly reduced
intrinsic factor
| B12
381
causes of vit b12 def
regional enteritis
celiac disease
antibodies against Vit B12 intrinsic factor complex
Bariatric surgery
382
when vit b12 deficiency is caused by an absence of intrinsic factor
pernicious anemia
383
anemia in which large numbers of megaloblasts appear in bone marrow and macrocytes appear in blood
Megaloblastic anemia - B12 deficiency
384
the hematologic effects of vit B12 def can be reversed with large doses of
folic acid
385
early signs of Vit B12 def
paresthesias of hands and feet
| reduction in deep tendon reflexes
386
late developing signs of B12
loss of memory
mood changes
hallucinations
psychosis
if prolonged, damage can be permanent
387
cyanocobalamin
vit B12
388
treatment of severe vit B12 def
1) Im injection of vit B12 and folic acid
2) administration of 2-3 units of PRBCs (to correct anemia quickly)
3) transfusion of platelets
4) ABX if infection has developed
389
what can mask the fact that vit B12 def still exists
folic acid
390
causes of folic acid deficiency
```
poor diet (esp in pt who abuse alcohol)
malabsorption secondary to intestinal disease
pregnancy
lactation
hemodialysis pt
chronic hemolytic anemias
certain drugs can cause folate def
```
391
intestinal malabsorption disorder that decreases folic acid uptake
SPRUE
392
symptoms of folic acid def
megaloblastic anemia
leukopenia
thrombocytopenia
injury to oral and gi mujcosa
393
folic acid rec in preg
400-800ug each day
394
treatment of severe folic acid def
IM injection of folic acid and vit B12
then continue with oral folic acid 1000u-2000ug/day for 1-2 weeks
then 400ug/day
