Exam 3 Drugs Flashcards
Prototype for loop diuretics
Furosemide (Lasix)
Mechanism of action of Furosemide
Acts on ascending loop of Henle to block reabsorption
Pharmacokinetics of furosemide
Rapid onset
PO: 60 min
IV: 5 min
Therapeutic uses of furosemide
Pulmonary edema
Edematous states
Hypertension
Adverse effects of furosemide
Hyponatremia, hypochloremia, dehydration
Hypotension - volume loss, relaxation of venous smooth
muscle
Hypokalemia
Ototoxicity
Hyperglycemia
Hyperuricemia
Can furosemide be used during pregnancy?
No, because it’s too risky when trying to balance fluid/electrolytes of both mom and baby
What do we have to pay particular attention to when giving furosemide? Why?
Potassium levels
We have to expect pt to lose potassium when giving furosemide, bc it’s pulling fluid out of the body
But it must stay in it’s normal range b/c if it gets too low or high, pt will have cardiac rhythm issues.
Drug interactions for furosemide
Digoxin
Ototoxic drugs
Potassium-sparing diuretics
Lithium
Antihypertensive agents
Nonsteroidal anti-inflammatory drugs
Administration of furosemide
Oral or parenteral
How should furosemide be given IV?
Must be given slowly, over at least 2 min
Giving fast can cause hearing loss
3 other types of loop diuretics
Ethacrynic acid (Edecrin)
Bumetanide (Bumex)
Torsemide (Demadex)
Another name for Thiazides and Related Diuretics
Benzothiadiazides
Effects of Thiazides and related diuretics
Similar to those of loop diuretics:
- Increase renal excretion of sodium, chloride, potassium, and water
- Elevate levels of uric acid and glucose
Differences between thiazides and loop diuretics
Diuresis is considerably lower than that produced by loop diuretics
Not effective when urine flow is scant (unlike loop diuretics)
Prototype Thiazide
Hydrochlorothiazide (HydroDIURIL)
Pharmacokinetics of hydrochlorothiazide
Peaks in 4-6 hrs
Therapeutic uses of hydrochlorothiazide
HTN
Edema
Diabetes insipidus (helps with hormonal issues from diabetes)
Adverse effects of hydrochlorothiazide
Hyponatremia, hypochloremia, and dehydration
Hypokalemia
Hyperglycemia
Hyperuricemia
Impact on lipids, calcium, and magnesium
Effect of hydrochlorothiazide on breast feeding
Enters breast milk
Drug interactions for hydrochlorothiazide
Digoxin
Augments effects of hypertensive meds
Can reduce renal excretion of lithium (leading to accumulation)
NSAIDs may blunt diuretic effect
(Can be combined with ototoxic agents without increased risk of hearing loss)
Prototype for potassium-sparing diuretics
Spironolactone (Aldactone)
Mechanism of action for Spironolactone
Blocks aldosterone in the distal nephron
Retention of potassium
Increased excretion of sodium
Therapeutic uses of spironolactone
HTN
Edematous states
Heart failure (decreased mortality in severe failure)
Primary hyperaldosteronism
Can be used for hormonal issues:
Premenstrual syndrome
Polycystic ovary syndrome
Acne in young women
Adverse effects of spironolactone
Hyperkalemia
Benign and malignant tumors
Endocrine effects
Drug interactions of spironolactone
Thiazide and loop diuretics
Agents that raise potassium levels
Two other potassium sparing diuretics
Triamterene (Dyrenium)
Amiloride (Midamor)
Prototype for osmotic diuretics
Mannitol (Osmitrol)
Action of Mannitol
Promotes diuresis by creating osmotic force within lumen of the nephron
Pharmacokinetics of Mannitol
Must be given parenterally
Therapeutic uses of Mannitol
Prophylaxis of renal failure
Reduction of intracranial pressure
Reduction of intraocular pressure
Adverse effects of Mannitol
Edema
Headache
N & V
Fluid and electrolyte imbalance
Drug class of Digoxin (Lanoxin)
Cardiac (Digitalis) Glycosides
Effects of Digoxin (Lanoxin)
Positive inotropic action on the heart
Increases the force of ventricular contraction
Increases myocardial contractility
Hemodynamic benefits of Digoxin
Increased cardiac output:
- Decreased sympathetic tone
- Increased urine production
- Decreased renin release
Adverse effects of Digoxin (Lanoxin)
Cardiac dysrhythmias (predisposing factors= Hypokalemia elevated digoxin level, and heart disease)
Nausea
Vomiting
Anorexia
Fatigue
Visual impairments (seeing halos)
Therapeutic range of digoxin
0.5-0.8 ng/mL
When should digoxin be held?
If pt’s heart rate is <60, notify provider and hold drug
Drug interactions of digoxin (Lanoxin)
Diuretics
ACE inhibitors and ARBs
Sympathomimetics
Quinidine
Verapamil
Half life of Digoxin (Lanoxin)
About 1.5 days
Most effective group of drugs to lower LDL cholesterol
HMG-CoA Reductase inhibitors (Statins)
Which drug class does Lovastatin (Mevacor) belong to?
HMG-CoA Reductase Inhibitors
Therapeutic uses of Statins
Hypercholesterolemia
Primary and secondary prevention of CV events
Post-MI therapy
Diabetes
Common adverse effects of statins
Headache
Rash
GI disturbances
Rare adverse effects of statins
Myopathy/rhabdomyolysis
Hepatotoxicity
Drug interactions of statins
Most other lipid-lowering drugs (except bile acid sequestrants)
Drugs that inhibit CYP3A4
Use in pregnancy
Dosing of statins
Should be once daily, in the evening
Which class does Colesevelam (Welchol) belong to?
Bile-Acid Sequestrants
Benefits to Colesevelam (Welchol)
Newest and better-tolerated drug
Does not decrease uptake of fat-soluble vitamins
Does not significantly reduce the absorption of statins, warfarin, digoxin, and most other drugs
Use of Colesevelam (Welchol)
Reduces LDL cholesterol (with modified diet and exercise)
Adverse effects of Colesevelam (Welchol)
Constipation
Bile-Acid sequestrant with more serious side effects
Ezetimibe (Zetia)
Which class is Gemfibrozil (Lopid) in?
Fibric Acid Derivatives (Fibrates)
Actions of Gemfibrozil (Lopid)
Decrease plasma TG content
Decrease VLDL levels
Increase HDL cholesterol
Drug interactions of Gemfibrozil (Lopid)
Displaces warfarin from plasma albumin
(Must measure INR frequently)
Uses of Gemfibrozil (Lopid)
Reduces high levels of VLDLs (in pts who have not responded to diet modification)
Adverse effects of Gemfibrozil (Lopid)
Rashes
Myopathy
Gastrointestinal disturbances
Gallstones
Liver injury
3 families of antianginal agents
Organic nitrates
Beta blockers
Calcium channel blockers
Which class does nitroglycerin belong to?
Organic nitrates
Uses of nitroglycerin
Acute anginal therapy
Sustained anginal therapy
Perioperative control of BP
Treatment of heart failure with MI
Unstable angina
Uncontrolled exacerbations of chronic angina
Which drug class does isosorbide mononitrate (Imdur) belong to?
Organic nitrates
Which drug class does isosorbide dinitrate (Isordil) belong to?
Organic nitrates
Which drug class does propanolol (inderal) belong to?
Beta blockers
Which drug class does metoprolol (Lopressor) belong to?
Beta blockers
Use of propranolol and metoprolol
Decrease cardiac oxygen demand
Adverse effects of propranolol and metoprolol
Bradycardia
Decreased AV conduction
Reduction of contractility
Asthmatic effects
(Use with caution in pts with diabetes)
Insomnia - bizarre dreams
Sexual dysfunction - depression
Which drug class does verapamil belong to?
Calcium channel blockers
Which drug class does diltiazem belong to?
Calcium channel blockers
Which drug class does nifedipine belong to?
Calcium channel blockers
Adverse effects of calcium channel blockers
Dilation of peripheral arterioles
Reflex tachycardia
Hypotension
Beta blockers
Bradycardia
Heart failure
AV block
Action of Heparin
Enhances antithrombin
Rapid-acting anticoagulant
Administration of unfractionated heparin
Injection only
IV (continuous and intermittent)
Deep subQ
Therapeutic uses of unfractionated heparin
Preferred anticoagulant during pregnancy
Pulmonary embolism
Stroke evolving
Massive DVT
Open heart surgery
Renal dialysis
Low-dose therapy postoperatively
Disseminated intravascular coagulation
Adjunct to thrombolytic therapy
Adverse effects of unfractionated heparin
Hemorrhage
Heparin-induced thrombocytopenia
Hypersensitivity reactions
When is unfractionated heparin contraindicated?
Thrombocytopenia
Uncontrollable bleeding
During and immediately after surgery of eye, brain, or spinal cord
Antidote for OD of heparin
Protamine sulfate
What should be measured to determine if a pt has enough unfractionated heparin?
Activated partial thromboplastin tine (aPTT)
Therapeutic uses of Low-Molecular-Weight Heparins
Prevention of DVT following surgery
Treatment of established DVT
Prevention of ischemic complications
Administration of Low-Molecular-Weight Heparins
SubQ
Dosage based on body weight
Adverse effects and interactions of Low-Molecular-Weight Heparins
Bleeding (but less than with unfractionated heparin)
Immune-mediated thrombocytopenia
Severe neurologic injury for pts undergoing spinal puncture of spinal epidural anesthesia
What drug group does Enoxaparin (lovenox) belong to?
Low-Molecular-Weight Heparins
Which drug class does Dalteparin (Fragmin) belong to?
Low-Molecular-Weight Heparins
Action of Warfarin (Coumadin)
Oral anticoagulant
Use of Warfarin (Coumadin)
Oral anticoagulant with delayed onset
Vitamin K antagonist
Blocks synthesis of factors VII, IX, and X and prothrombin
*Long-term prophylaxis of thrombosis
- associated with PE
- thromboembolism in pts with prosthetic heart valves
- thrombosis during atrial fibrillation
Not useful in emergencies
What is monitored when a pt is taking warfarin?
Prothrombin time (PT)
Internal normalized ration (INR)
Adverse effects of Warfarin
Hemorrhage
Fetal hemorrhage and teratogenesis during pregnancy
What should be given for toxicity of warfarin?
Vitamin K
Drug interactions with warfarin
Drugs that increase anticoagulant effects
Drugs that promote bleeding
Drugs that decrease anticoagulant effects
Heparin
Aspirin
Acetaminophen
Which drug class does etexilate (Pradaxa) belong to?
Direct thrombin inhibitors
Which drug class does Bivalirudin (Angiomax) belong to?
Direct thrombin inhibitors
Mechanism of action of Bivalirudin (Angiomax)
Facilitates the actions of antithrombin
Prevents conversion of fibrinogen to fibrin
Prevents activation of factor XIII
Use of Bivalirudin (Angiomax)
Prevents clot formation (combined with aspirin) in pts with unstable angina who are undergoing coronary angioplasty
Adverse effects of Bivalirudin (Angiomax)
Bleeding
Back pain
Nausea
Headache
Which class of drugs does Lepirudin (Refludan) belong to?
Direct thrombin inhibitors
What is Lepirudin (Refludan) used for?
Argatroban: IV anticoagulant
Direct inhibition of thrombin
Prophylaxis and treatment of thrombosis in pts with HIT
Which drug class does Rivaroxanan (Xarelto) belong to?
Selective Factor Xa Inhibitors
Uses of Rivaroxanan (Xarelto)
Binds directly with factor Xa to cause inactivation
Oral, prevention of DVT and PE after ortho surgery
Prevention of stroke in pts with atrial fibrillation
Adverse effects of Rivaroxanan (Xarelto)
Bleeding (esp head bleeds)
Which drug class does aspirin belong to?
Antiplatelet drugs
Therapeutic uses of aspirin (ASA)
Ischemic stroke
Transient ischemic attack
Chronic stable angina
Unstable angina
Coronary stunting
Acute MI
Previous MI
Primary prevention of MI
Adverse effects of aspirin
Bleeding
GI bleeding and hemorrhagic stroke
Which drug class does Clopidogrel (Plavix) belong to?
Antiplatelet drugs
Therapeutic uses of Clopidogrel (Plavix)
Prevents blockage of coronary artery stents
Reduce thrombotic events in pts with acute coronary syndromes
Which drug class does Vorapaxar (Zontivity) belong to?
Antiplatelet drugs
Which drug class does Tirofiban (Aggrastat) belong to?
Antiplatelet drugs (GP IIb/IIa receptor antagonists)
Which group of drugs does Eptifibatide (Integrilin) belong to?
Antiplatelet drugs (GP IIb/IIa receptor antagonists)
Action of Eptifibatide (Integrilin)
Causes reversible and highly selective inhibition of GP IIb/IIIa receptors
Uses of Eptifibatide (Integrilin)
ACS
Patients undergoing PCI
Antiplatelet effects reverse within 4 hours of stopping infusion
Which drug class does Alteplase (tPa) belong to?
Thrombolytic Fibrinolytic Drugs
Therapeutic uses of Alteplase (tPa)
MI
Ischemic stroke
PE
Major adverse effect of Alteplase
Bleeding (esp intracranial bleeding)
(Recent wounds, needle puncture sites, invasive procedure sites)
All post MI patients should take:
Beta blocker
ACE inhibitor
Antiplatelet drug or anticoagulant
Two groups of calcium channel blockers
Dihydropyridines
Non-Dihydropyridines
Sites of action of dihydropyridines
Act primarily on arterioles
Sites of action for non-dihydropyridines
Act on arterioles and on the heart
2 drugs in non-dihydropyridines group of CCBs
Verapamil
Diltiazem (Cardizem)
Action of Verapamil
Block calcium channels in blood vessels and act on vascular smooth muscle and the heart
Hemodynamic effects of verapamil
Direct effects on the heart and blood vessels
Reflex effects
5 direct hemodynamic effects of verapamil
- Reduces arterial pressure
- Increases coronary perfusion
- Reduces heart rate
- Decreases AV nodal conduction
- Decreases force of contraction
Indirect hemodynamic effects of verapamil
Baroreceptor reflex
Net effects of verapamil
Little or no effect on cardiac performance
*Vasodilation accompanied by reduced arterial pressure and increased coronary perfusion
Therapeutic uses of verapamil
Angina pectoris (Vasospastic & angina of effort)
Essential hypertension (first line agent)
Cardiac dysrhythmias
Adverse effects of verapamil
*Constipation (most common complaint)
* Dizziness, facial flushing, headache
Edema of ankles and feet
Gingival hyperplasia
Heart block
How can a pt relieve constipation from taking verapamil
Increasing dietary fiber and fluids
Drug interactions of verapamil
Digoxin
Beta-adrenergic blocking agents
What occurs with toxicity of verapamil
Severe hypotension
Bradycardia and AV block
Ventricular Tachydysrhythmias
Actions of Diltiazem
Blocks calcium channels in the heart and blood vessels
Lowers blood pressure
(Arteriolar dilation, direct suppressant/reflex cardiac stimulation = little net effect on the heart)
Therapeutic uses of Diltiazem
Angina pectoris
HTN
Cardiac dysrhythmias
Adverse effects of Diltiazem
Similar to verapamil (except less constipation)
Dizziness, flushing, headache
Edema of ankles and feet
Exacerbates *bradycardia, sick sinus syndrome, heart failure, and second-or third- degree heart block
Drug interactions of Diltiazem
Digoxin
Beta-adrenergic blocking agents
Which drug class does nifedipine belong to?
Dihydropyridines (CCBs)
Action of Nifedipine (Procardia)
Vasodilation by blocking calcium channels
Blocks in vascular smooth muscle
Very little blockade of heart Ca channels
What can Nifedipine (Procardia) not be used to treat?
Dysrhythmias
Indirect effects of nifedipine
Lowered BP activates baroreceptor reflex
Net effect of Nifedipine causing vasodilation by blocking calcium channels
Lowered BP
Increased HR
Increased contractile force
Therapeutic uses of Nifedipine
Angina pectoris
HTN
Adverse effects of Nifedipine
Flushing
Dizziness
Headache
Peripheral edema
Gingival hyperplasia
Chronic eczematous rash in older patients
*Reflex tachycardia = increased O2 demand, so can cause increased pain for angina patients
What can Nifedipine be combined with to prevent reflex tachycardia?
Beta blocker
Action of ACE inhibitors
Decrease levels of angiotensin II and can dilate vessels
Increase levels of bradykinin, dilation can cause cough
Therapeutic uses of ACE inhibitors
Hypertension
Heart failure
MI
Diabetic and nondiabetic nephropathy
Prevention of MI, stroke, and death in pts at high cardiovascular risk
Adverse effects of ACE inhibitors
First-dose hypotension
Cough
Angioedema
Hyperkalemia
Dysgeusia and rash
Renal failure
Neutropenia
Fetal harm
Drug interactions of ACE inhibitors
Diuretics
Antihypertensive agents
Drugs that raise potassium levels
Lithium
Nonsteroidal anti-inflammatory drugs
How are ACE inhibitors administered?
Orally, expect for Enalapril (Vasotec)
Actions of ARBs
Block access of angiotensin II
Cause dilation of arterioles and veins
Prevent angiotensin II from inducing pathologic changes in cardiac structure
Reduce excretion of potassium
Decrease release of aldosterone
Increase renal excretion of sodium and water
Do not inhibit kinase II
Do not increase levels of bradykinin
Therapeutic uses of ARBs
HTN
Heart failure
MI
Diabetic nephropathy
If unable to tolerate ACE inhibitors:
Protection against MI, stroke, and death from CV causes in high risk pts
Adverse effects of ARBs
Angioedema
Fetal harm
Renal failure
Which drug class does Captopril (Capoten) belong to?
ACE inhibitors
Which drug class does Enalapril (Vasotec) belong to?
ACE inhibitors
Which drug class does Lisinopril (Prinivil) belong to?
ACE inhibitors
Which drug class does Losartan (Cozaar) belong to?
ARBs
Which drug class does Valsartan (Diovan) belong to?
ARBs
Which drug class does Telmisartan (Micardia) belong to?
ARBs
Which drug class does Aliskiren (Tekturna) belong to?
Direct renin inhibitors
Action of Aliskiren (Tekturna)
Binds tightly with renin and prevents division of angiotensinogen to angiotensin I
Adverse effects of Aliskiren (Tekturna)
Angioedema
Cough
GI effects
Hyperkalemia
Fetal injury
Which drug class does Eplerenone (Inspra) belong to?
Aldosterone antagonists
Mechanism of action of Eplerenone (Inspra)
Selective blockade of aldosterone receptors
Therapeutic uses of Eplerenone (Inspra)
HTN
Heart failure
Adverse effects of Eplerenone (Inspra)
Hyperkalemia
Drug interactions of Eplerenone (Inspra)
Inhibitors of CYP3A4
Drugs that raise potassium levels
Use with caution when combined with lithium
Which drug class does spironolactone (Aldactone) belong to?
Aldosterone antagonists
Mechanism of action of spironolactone (Aldactone)
Blocks aldosterone receptors
Binds with receptors for other steroid hormones
Therapeutic uses of spironolactone (Aldactone)
HTN
Heart failure
Adverse effects of spironolactone (Aldactone)
Hyperkalemia
Gynecomastia
Menstural irregularities
Impotence
Hirsutism
Deepening of the voice
Which drug class does Hydralazine (Apresoline) belong to?
Vasodilators
Action of Hydralazine (Apresoline)
Selective dilation of arterioles
(Postural hypotension is minimal)
Therapeutic uses of Hydralazine (Apresoline)
Essential hypertension
Hypertensive crisis
Heart failure
Adverse effects of Hydralazine (Apresoline)
Reflex tachycardia
Increased blood volume
Systemic lupus erythematous-like syndrome
Headache
Dizziness
Weakness
Fatigue
Drug interactions of Hydralazine (Apresoline)
Other antihypertensive agents
Avoid excessive hypotension
Combined with beta blocker to protect against reflex tachycardia and diuretics to prevent sodium and water retention and expansion of blood volume
Which drug class does Minoxidil (Loniten) belong to?
Vasodilators
Action of Minoxidil (Loniten)
Selective dilation of arterioles
More intense dilation than Hydralazine but causes more adverse reactions
Use of Minoxidil (Loniten)
Severe HTN that is unresponsive to safer drugs
Adverse effects of Minoxidil (Loniten)
Reflex tachycardia
Sodium and water retention
Hypertrichosis (hair growth)
Pericardial effusion
Drug class of sodium nitroprusside (Nitropress)
Vasodilator
Action of sodium nitroprusside (Nitropress)
Fastest-acting antihypertensive agent
Causes venous and arteriolar dilation
Administration and onset of sodium nitroprusside (Nitropress)
IV infusion (CCU)
Immediate onset (BP returns to pretreatment level in minutes when stopped)
Use of sodium nitroprusside (Nitropress)
Hypertensive emergencies
Adverse effects of sodium nitroprusside (Nitropress)
Excessive hypotension
Cyanide poisoning
Thiocyanate toxicity
What is Levothyroxine?
Synthetic T4
Treatment of a thyrotoxic crisis (thyroid storm)
Potassium iodide
Methimazole
Beta blocker
Sedation
Cooling
Glucocorticoids
IV fluids
Drug of choice for hypothyroidism
Levothyroxine (Synthroid)
Half life of Levothyroxine (Synthroid)
7 days
When should Levothyroxine be administered?
In the morning at least 30-60 mins before breakfast
First line drug for hyperthyroidism
Methimazole (Tapazole)
Which class does Methimazole (Tapazole) belong to?
Thionamides
How long does Methimazole (Tapazole) take to fully work?
3-12 weeks
Uses of Methimazole (Tapazole)
Used alone for grave’s disease
Or with radiation therapy
Or before thyroid gland surgery
Class for Propylthiouracil (PTU)
Thionamides
Action of PTU
Inhibits thyroid hormone synthesis
Half life of PTU
90 mins
How long before full effects of PTU?
6-12 months
Uses of PTU
Grave’s disease
With radiation therapy
Before thyroid surgery
Thyrotoxic crisis
Adverse effects of PTU
Agranulocytosis (most serious)
Hypothyroidism
Pregnancy and lactation
*Severe liver damage
Use of radioactive iodine
Hyperthyroidism
(Grave’s disease)
Half life of radioactive iodine
8 days
How long until full effects of radioactive iodine?
2-3 months
Use of Lugol’s solution
Suppress thyroid function in preparation for thyroidectomy
Use of beta blockers for Grave’s disease
Can suppress tachycardia and other symptoms
Glucose for prediabetes pts
Impaired fasting glucose between 100-125 mg/dL
Impaired glucose tolerance test
(Pt is at increased risk for developing type 2 diabetes)
Common target values of blood glucose for diabetic patients
80-130 mg/dL before meals
<180 mg/dL 1-2 hours after meals
Goal for A1C for diabetic patients
Below 7%
Type of insulin, onset, and duration:
Insulin lispro (Humalog)
Short-duration, rapid-acting
Onset: 15-30 mins
Peak: .5-2.5 hours
Duration: 3-6 hours
Type of insulin, onset, peak, and duration:
Insulin aspart (NovoLog)
Short-duration, rapid-acting
Onset: 10-20 mins
Peak: 1-3 hours
Duration: 3-5 hours
Type of insulin, onset, peak, and duration:
Insulin glulisine (Apidra)
Short duration, rapid acting
Onset: 10-15 mins
Peak: 1-1.5 hours
Duration: 3-5 hours
Type of insulin, onset, peak, and duration:
Regular insulin (Humulin R, Novolin R)
Short duration, short acting
Onset: 30-60 mins
Peak: 1-5 hours
Duration: 10 hours
Type of insulin, onset, peak, and duration:
NPH insulin (Humulin N, Novolin N)
Intermediate duration
Onset: 60-120 mins
Peak: 6-14 hours
Duration: 16-20 hours
Type of insulin, onset, peak, and duration:
Insulin glargine (Lantus)
Long duration
Onset: 70 mins
Duration 18-24 hours
Type of insulin, onset, peak, and duration:
Insulin detemir (Levemir)
Long duration
Onset: 60-120 mins
Duration: 12-24 hours
Type of insulin, onset, peak, and duration:
Insulin glargine (Toujeo)
Ultra long duration: 24 hours
Which insulins can you mix?
NPH with short acting insulins
(Draw short-acting insulin up first)
Adverse effects of insulin treatment
Hypoglycemia
Hypokalemia
Lipohypertrophy
Allergic reactions
Class for Metformin (Glucophage)
Biguanides
Use of metformin (Glucophage)
Drug of choice for prevention of T2DM
Gestational diabetes
PCOS
Side effects of metformin (Glucophage)
GI disturbances
Lactic acidosis (potentially fatal, rare)
Characteristics of diabetic ketoacidosis
Hyperglycemia
Ketoacids
Hemoconcentration
Acidosis
Coma