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Roomies Collab Deck 1: Infectious Disease and CV > Drugs affecting the renin-angiotensin system > Flashcards

Drugs affecting the renin-angiotensin system Flashcards

1
Q

ACE inhibitors inhibit the conversion of (?) to (?)

A

Angiotensin I to angiotensin II

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2
Q

Why should potassium supplements and potassium-sparing diuretics be discontinued before introducing an ACE inhibitor?

A

Risk of hyperkalaemia

EXCEPT a low dose of spironolactone may be beneficial in severe heart failure

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3
Q

In severe heart failure what is the only potassium-sparing diuretic that you can used with an ACE inhibitor?

A

Low dose spironolactone

- Initially 25 mg once daily, then adjusted according to response to 50 mg once daily.

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4
Q

When you introduce an ACE inhibitor to patients with heart failure who are already taking a high dose of a loop diuretics (e.g. furosemide 80 mg daily or more), which side effect are you concerned about?

A

Profound first-dose hypotension

Temporary withdrawal of the loop diuretic reduces the risk, but may cause severe rebound pulmonary oedema.

Therefore, for patients on high doses of loop diuretics, the ACE inhibitor may need to be initiated under specialist supervision.

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5
Q

In which context does a patient with heart failure may need to be under specialist supervision you an ACE inhibitor is initiated?

A

Patients taking a high-dose of loop diuretics (e.g. furosemide 80 mg daily or more)

An ACE inhibitor can be initiated in the community in patients who are receiving a low dose of a diuretic or who are not otherwise at risk of serious hypotension; nevertheless, care is required and a very low dose of the ACE inhibitor is given initially.

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6
Q

What is the most appropriate initial drug for hypertension in Caucasian patients under the age of 55?

A

ACE inhibitor

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7
Q

What is the most appropriate drug for the treatment of hypertension in patients with diabetes?

A

ACE inhibitor

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8
Q

Which patients with hypertension DO NOT respond less well to an ACE inhibitor? (3)

A
  1. Black African or African-Caribbean origin
  2. Aged > 55 years
  3. Primary aldosteronism
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9
Q

Do ACE inhibitors have a role in the management of diabetic nephropathy?

A

YES

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10
Q

What are the 4 main indications for the use of ACE inhibitors?

A
  1. Heart failure
  2. Hypertension
  3. Diabetic nephropathy
  4. Prophylaxis of cardiovascular events
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11
Q

In which contexts should an ACE inhibitor be initiated under specialist supervision? (9)

A
  1. Severe heart failure
  2. Multiple or high-dose diuretic therapy
  3. Concomitant angiotensin II receptor antagonist or aliskiren
  4. Hypovolaemia
  5. Hyponatraemia (plasma sodium concentration below 130 mmol/L)
  6. Hypotension (systolic BP < 90)
  7. Unstable heart failure
  8. High-dose vasodilator therapy
  9. Known renovascular disease
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12
Q

Which drug increases the risk of renal damage when combined with an ACE inhibitor?

A

NSAIDs

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13
Q

What may happen if you prescribe an ACE inhibitor in patients with severe bilateral renal artery stenosis (or severe stenosis of the artery supplying a single functioning kidney)?

A

Reduction of glomerular filtration causing severe and progressive renal failure

ACE inhibitor treatment is unlikely to have an adverse effect on overall renal function in patients with severe unilateral renal artery stenosis and a normal contralateral kidney, but glomerular filtration is likely to be reduced (or even abolished) in the affected kidney and the long-term consequences are unknown.

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14
Q

ACE inhibitors can cause a very rapid fall in BP in (?)-depleted patients

A

volume

Patients taking high-dose diuretics need close observation after administration of the first dose of ACE inhibitor, for at least 2 hours or until the blood pressure has stabilised

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15
Q

Describe the close observation required of a patient who is taking a high-dose diuretic during their first-dose of an ACE inhibitor?

A

Close observation after the administration of the first dose of ACE inhibitor, for at least 2 hours or until the BP has stabilised

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16
Q

Why would you switch a patient from an ACE inhibitor to an ARB?

A

Persistent cough

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17
Q

Why would a patient develop a persistent cough when taking an ACE inhibitor?

A

Due to increased levels of bradykinin

ACE inhibitor inhibit the breakdown of bradykinin

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18
Q

Which angiotensin-II receptor antagonists (ARBs) are licensed as adjuncts to ACE inhibitors under specialist supervision, in the management of heart failure when other treatments are unsuitable? (2)

A

Candesartan cilexetil

Valsartan

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19
Q

Angiotensin-II receptor antagonists (ARBs) should be used with caution in…

A

renal artery stenosis

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20
Q

(?) is a renin inhibitor that is licensed for the treatment of hypertension

A

Aliskiren

- Oral: 150 mg once daily, increased if necessary to 300 mg once daily.

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21
Q

Aliskiren is a (?) inhibitor that is licensed for the treatment of hypertension

A

renin

  • Oral: 150 mg once daily, increased if necessary to 300 mg once daily.
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22
Q

Aliskiren is a renin inhibitor that is licensed for the treatment of (?)

A

Hypertension

  • Oral: 150 mg once daily, increased if necessary to 300 mg once daily.
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23
Q

Why should you give combination therapy with two drugs that affect the renin-angiotensin system? (3)

A

Increased risk of:

  1. hyperkalaemia
  2. hypotension
  3. renal impairment

Exception: selected patient with heart failure whom other treatments are unsuitable, only under specialist supervision with close monitoring of BP, renal function and electrolytes (potassium)

24
Q

Renin converts (?) to (?)

A

angiotensinogen to angiotensin I

25
Q

What is the only indication for the use of aliskiren?

A

Essential hypertension

- Oral: 150 mg once daily, increased if necessary to 300 mg once daily.

26
Q

What are the contraindications for the use of the renin inhibitor, aliskiren?

A
  1. Concomitant treatment with an ACE inhibitor or ARB in patients with eGFR < 60 mL/minute/1.73 m^2
  2. Concomitant treatment with an ACE inhibitor or an ARB in patients with diabetes mellitus
  3. Hereditary angioedema
  4. Idiopathic angioedema
27
Q

Which two drinks can greatly decrease aliskiren concentrations and plasma renin activity?

A

Apple juice

Orange juice

28
Q

What are the common side effects of the renin inhibitor aliskiren? (4)

A

Arthralgia
Diarrhoea
Dizziness
Electrolyte imbalance

29
Q

Patients with a history of (?) need to be closely monitored during treatment with aliskiren

A

angioedema

30
Q

What are the indications for the use of the ARB, azilsartan medoxomil? (2)

A

Hypertension
- Oral: Initially 40 mg once daily, increased if necessary to 80 mg once daily.

Hypertension with intravascular volume depletion
- Oral: Initially 20–40 mg daily, increased if necessary to 80 mg daily.

31
Q

What are the contraindications for all angiotensin-II receptor antagonists (ARBs)? (2)

A
  1. The combination of an ARB with aliskiren in patients with an eGFR < 60 mL/minute/1.73 m^2
  2. The combination of an ARB with aliskiren in patients with diabetes mellitus
32
Q

In which contexts should you consider stopping an angiotensin-II receptor antagonist (ARB) in an elderly patient because the prescription is potentially inappropriate (STOPP criteria)?

A
  1. Hyperkalaemia

2. Persistent postural hypotension i.e. recurrent drop in systolic BP >/= 20 mmHg (risk of syncope and falls)

33
Q

What are the common side effects of angiotensin-II receptor antagonists?

A
  1. Abdominal pain
  2. Asthenia (weakness)
  3. Back pain
  4. Cough
  5. Diarrhoea
  6. Dizziness
  7. Headache
  8. Hyperkalaemia
  9. Hypotension
  10. Nausea
  11. Postural hypotension
  12. Renal impairment
  13. Vertigo
  14. Vomiting
34
Q

Should angiotensin-II receptor antagonists be used during pregnancy?

A

NO (unless essential)

  • they may adversely effect fetal and neonatal BP control and renal function
  • neonatal skull defects and oligohydramnios have been reported
35
Q

Which electrolyte needs to be monitored in all patients taking an angiotensin-II receptor antagonist (ARB)?

A

Potassium

Especially in the elderly and in patients with renal impairment

36
Q

What are the indications for the use of the ARB, candesartan cilexetil? (5)

A
  1. Hypertension
  2. Hypertension with intravascular volume depletion (initial starting dose is half of just hypertension - 4 mg once daily instead of 8 mg)
  3. Heart failure with impaired left ventricular systolic function when ACE inhibitors are not tolerated
  4. Heart failure with impaired left ventricular systolic function in conjunction with ACE inhibitor (under expert supervision)
  5. Migraine prophylaxis (unlicensed)
37
Q

In addition to the contraindications for all ARBs, what is an additional contraindication specifically for candesartan cilexetil?

A

Cholestasis

38
Q

In addition to the side effects for all ARBs, what is an additional common side effect specifically for candesartan cilexetil?

A

Increased risk of infection

39
Q

What is the only indication for use of the ARB eprosartan?

A

Hypertension

40
Q

In addition to the side effects for all ARBs, what are 2 additional common side effect specifically for eprosartan?

A

Gastrointestinal disorder

Rhinitis

41
Q

What are the indications for the use of the ARB, irbesartan? (4)

A
  1. Hypertension
  2. Hypertension in patient receiving haemodialysis
  3. Renal disease in hypertensive type 2 diabetes mellitus
  4. Renal disease in hypertensive type 2 diabetes in patients receiving haemodialysis
42
Q

In addition to the side effects for all ARBs, what is an additional common side effect specifically for irbesartan?

A

Musculoskeletal pain

43
Q

What are the indications for use of the ARB losartan potassium?

A
  1. Diabetic nephropathy in type 2 diabetes mellitus
  2. Chronic heart failure when ACE inhibitors are unsuitable or contra-indicated
  3. Hypertension (including reduction of stroke risk in hypertension with left ventricular hypertrophy)
  4. Hypertension with intravascular volume depletion
44
Q

In addition to the side effects for all ARBs, what are 3 additional common side effects specifically for losartan potassium?

A

Anaemia
Hypoglycaemia
Postural disorders

45
Q

What is the only indication for the ARB, olmesartan medoxomil?

A

Hypertension

46
Q

In addition to the contraindications for all ARBs, what is an additional contraindication specifically for olmesartan medoxomil?

A

Biliary obstruction

47
Q

In addition to the side effects for all ARBs, what are 10 additional common side effect specifically for irbesartan?

A
  1. Arthritis
  2. Bone pain
  3. Chest pain
  4. Dyspepsia
  5. Haematuria
  6. Hypertriglyceridaemia
  7. Hyperuricaemia
  8. Increased risk of infection
  9. Influenza like illness
  10. Oedema
48
Q

What are the indications for use of spironolactone? (8)

A
  1. Oedema
  2. Ascites in cirrhosis of the liver
  3. Malignant ascites
  4. Nephrotic syndrome
  5. Oedema in congestive heart failure
  6. Moderate to severe heart failure (adjunct)
  7. Resistant hypertension (adjunct)
  8. Primary hyperaldosteronism in patients awaiting surgery
49
Q

What are the contraindications for use of spironolactone? (3)

A

Addison’s disease
Anuria
Hyperkalaemia

50
Q

What is the mode of action of spironolactone?

A

Aldosterone antagonist

Competitively binding to the aldosterone receptor which increases sodium and water excretion and potassium retention

51
Q

In which contexts should you consider stopping an aldosterone antagonist (e.g. spironolactone) in an elderly patient because the prescription is potentially inappropriate (STOPP criteria)?

A

When taking concurrent potassium-conserving drugs without monitoring serum potassium

Risk of dangerous hyperkalaemia

52
Q

What should you monitor in patients taking spironolactone?

A

Electrolytes

In severe heart failure monitor potassium and creatinine 1 week after initiation and after any dose increase, monthly for first 3 months, then every 3 months for 1 year, and then every 6 months

53
Q

What are the two indications for use of the ARB telmisartan?

A
  1. Hypertension
  2. Prevention of cardiovascular events in patients with established atherosclerotic cardiovascular disease, or type 2 diabetes mellitus with target organ damage
54
Q

In addition to the contraindications for all ARBs, what are 2 additional contraindication specifically for telmisartan?

A

Biliary obstructive disorders

Cholestasis

55
Q

What are the indications for the use of the ARB, valsartan?

A
  1. Hypertension
  2. Hypertension with intravascular volume depletion (initially half the dose than if they were not volume depleted - 40 mg instead of 80 mg)
  3. Heart failure when ACE inhibitors cannot be used, or in conjunction with an ACE inhibitor when a bet-blocker cannot be used
  4. Myocardial infarction with left ventricular failure or left ventricular systolic dysfunction
56
Q

In addition to the contraindications for all ARBs, what are 2 additional contraindication specifically for valsartan?

A

Biliary cirrhosis

Cholestasis

57
Q

When prescribing an ARB for hypertension by the patient has intravascular volume depletion, what should the initial dose be?

A

Half of the dose that you would give if they were not volume depleted

ARBs that you can give:

  • valsartan
  • losartan potassium
  • candesartan cilexetil
  • alisartan medoxomil

Roomies Collab Deck 1: Infectious Disease and CV (84 decks)

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