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Pharm > Exam 3 Review SHeet > Flashcards

Exam 3 Review SHeet Flashcards

1
Q

Thiazide Diuretics

A

hydrocholorthiazide
P: Hydodiuril
other drugs end in “zide”
Used most for hypertension tx d/t low cost and short acting (half life: 1-2 hrs)
act on distal convoluted tubule in nephron

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2
Q

Indication for use of hydrocholothiazide

A

Used in CHF, HTN & edema patients

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3
Q

MOA for hydrocholothiazide

A

Inhibits Na/Cl pump = decrease Na/Cl absorption and increase excretion of Na/Cl and eventually H2O
Modest diuresis
Some K and Mg excreted also
Check electrolyte levels and BP before admin

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4
Q

Cautions for hydrocholothiazide

A

Gout (Inhibits uric acid secretion)
Women have a greater decrease in K than men
Hypercalcemia
Do not give to severe renal impairement, diabetics (Increase blood sugar), hyperlipidemia, lupus & sulfa patients

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5
Q

Adverse effects of hydrocholorthiazide

A 
Orthostatic hypotension, dizziness
Drowsiness
N/GI upset - take with food if discomfort
Electrolyte imbalance
Increase blood glucose
Headache
Rash
Hyperuricemia (Blocks uric acid secretion
Hyperlipidemia
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6
Q

Nursing implications for hydrocholothiazide

A

Take in the AM
Monitor I&O
Avoid high Na foods and increase K foods
Monitor electrolytes and blood sugars
Caution with position changes = orthostatic hypotension
Men can have possible ED
Be aware of hyponatremia s/s – craving salt, cramps, wt loss

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7
Q

Drug Interactions with hydrocholorothiazide

A

Many

High Na foods decrease effectiveness

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8
Q

Potassium sparing diuretics

A

Na channel blockers: triamterene (P) Dyrenium

Aldostersone antagosnists: spironolactone (P) Aldactone

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9
Q

triamterene (Dryenium) and spironolactone (Aldactone) characteristics

A

Weaker diuresis and antihypertensive effects when used alone

Usually used with other K wasting diuretics to maintain K levels

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10
Q

Indications for use of triamterene (Dryenium) and spironolactone (Aldactone)

A

HTN, edema, and cirrhosis

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11
Q

MOA of spironolactone (Aldactone)

A

Works in the distal tuble
Increase Na and H2O loss while keeping K
Aldosterone antagonist

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12
Q

MOA of triamterene (Dyrenium)

A

Works in distal tubule
Increase sodium, Cl, H20, Ca, and bicarb loss but keeps K and Mg (Watch for arrhythmia’s)
Inhibits uric acid secretion = increase uric acid levels
Independent of aldosterone

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13
Q

Cautions with triamterene (Dyrenium) and sprironolactone (Alactone)

A

Renal insufficiency, pre existing hyperkalemia
Liver disease
Diabetes (Increase BS)
Pts on ACE inhibitors (Increase K), NSAIDS or K supplements (Increase K)
No Mrs. Dash (Increase K)

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14
Q

Adverse effects of triamterene and spironolactone

A 
Hyperkalemia (Muscle cramping, arrhythmias, tingling/numbness, confusion
Electrolyte imbalance
Hypotension
N/V/D
Weakness, fatigue
Headache
Gynecomastia
Nephrotoxic – triamterene (rare)
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15
Q

Nursing implications/education of triamterene and spironolactone

A

Take in the AM or early PM (if bid) to prevent nocturia
I&O
Monitor electrolytes and BS
Caution with position changes = orthostatic hypotension
Men can have possible ED
Be aware of hyponatremia s/s= craving salt, cramps, wt loss

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16
Q

Loop diuretics

A

furosemide (Lasix)
other drugs end in “zide”
Cause a greater natriuresis than thiazides
PO and IV form - PUSH IV SLOW (tinnitus or CV collapse)
Short onset: 15-30 min, lasts 6-8 hours
Furosimide less bioavailablility than other d/t increase protein bound
Torsemide less renal cleared so easier on kidneys/renal patients

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17
Q

MOA of furosemide (Lasix)

A

Act in loop of henle
Inhibit Na/K/Cl channel = prevents reabsorption of Na/Cl and eventually H2O
Increase K/Ca/Mg excretion

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18
Q

Cautions with furosemide (Lasix)

A

Gout
Impaired glucose intolerance
Renal disease
Elderly and PG pts

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19
Q

Adverse effects of furosemide (Lasix)

A 
Hypokalemia
Orthostatic Hypotension
Dehydration
Hypomagnesium
Ototoxicity
Hyperuricemia
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20
Q

Drug interactions with furosemide (Lasix)

A

Other ototoxic drugs - amnioglycosides (abx), aspirin
Beta Blockers - increase level
Many others - see book

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21
Q

Nursing implications/Education on furosemide (Lasix)

A

Take in the AM or early PM (if bid) to prevent nocturia
I&O
Increase K foods
Monitor electrolytes and blood sugars
Caution with position changes = orthostatic hypotension
Men can have possible ED
Be aware of hyponoctremia s/s = craving salt, cramps, and wt loss

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22
Q

Beta Blockers

A

propranolol (Inderal)
Other drugs end in “olol”
Good absorption, onset 30 min, duration 6-12 hrs
Some large first pass effect: propranolol, labetalol
Some highly protein bound: propranolol, penbutolol, carvedilol
Takes 2-3 weeks for full effect of beta blockers to be achieved
Cardioprotective: BB occupy catecholemine receptors so they cant bind = Decrease sympathetic nervous system (HR/BP)

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23
Q

Indications for use of propranolol (Inderal)

A

HTN, angina, MI, irregular cardiac rhythyms
Stable CHF
Migraines, anxiety, substance withdrawl
Tremors (Mask s/s of hypoglycemia)

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24
Q

MOA of propranolol (Inderal)

A

Part of ANS - blocks beta 1 (Heart) and beta 2 (lungs) receptors
- Some are selective and others are non-selelctive
Vasodilation = decrease BP/HR
Decreased force of contractions (NOT good for Unstable CHF pts.)
Decreased renin secretion
Hard to increase HR with exercise/stress test
Bronchospastic disease (Never give COPD/asthma/resp pts)
Mask s/s of hypoglycemia

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25
Q

Adverse effects of propranolol (Inderal)

A 
Hypotension
Arrythmias
Bronchospams
Hypoglycemia 
Bradycardia, depression, ED, elevated liver enzymes, dizziness, fatigue, lethargy, hyperlipidemia
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26
Q

Nursing implications/Education for propranolol (Inderal)

A

Do not stop abruptly - can cause rebound HTN and MI
Check VS (esp HR) before administering
Change positions slowly (orthostatic hypotension)
Alert diabetics about hypoglycemia
Eat high fiber diet to avoid constipation
Lifestyle changes: Wacth Na intake, diet and exercise
Can cause sexual dysfunction (esp. in men)

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27
Q

Cautions and Contraindications Mnemonic for propranolol (Inderal)

A 
A: Asthma
B: block (Heart block)
C: COPD
D: Diabetes mellitus
E: Electrolyte (Hyperkalemia)
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28
Q

Ace inhibitors

A

captopril (Capoten)
other drugs end in “pril” (A-pril)
Most are prodrugs = need good liver function to metab into active form
Takes up to 4 weeks to get full effect

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29
Q

Indications for use of captopril (Capoten)

A

HTN, CHF, DM neuropathy, L ventricular dysfunction, Acute MI

Unlabeled uses: RA, dementia (Decrease inflammation in the brain)

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30
Q

MOA of captopril (Capoten)

A

Inhibit conversion of angiotensin I to angiotensin II = decrease aldosterone secretion
- leads to decrease Na and H2O rentention
Prevents breakdown of bradykinin (vasodilator) = Increase badykinin levels = Increase vasodilation
Decrease in K excretion (Know K levels before giving)

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31
Q

Effects of captopril (Capoten)

A

Decrease systemic vascular resistance
No change in HR
Increase renal perfusion/Decrease renal vascular resistance
- renal protective, give to DM pts to prevent nephropathy
Prevent ventricular remodeling

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32
Q

Cautions of captopril (Capoten)

A

Do not give to PG pts - Category D

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33
Q

Cautions of captopril (Capoten)

A

Do not give to PG pts - Category D
Renal insufficiency
Photosensitivity (Wear sunscreen to prevent burning)
Captopril and moexipril need to be taken on an empty stomach (Watch for proteinuria w/in first 2-4 wks)

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34
Q

Adverse effects of captopril (Capoten)

A

Cough
Orthostatic Hypotension
Hyperkalemia (Cramping, arrythmias)
Angioedema
ACE w/diuretic = 1st dose phenomenon (Decrease BP)
- Hold diuretic for a few days to get used to ACE then add diuretic again
Rach (rare), N/D/Constipation, leukopenia, myalgia, headache

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35
Q

Drug interactions of captopril (Capoten)

A

Increase levels of digoxin, lithium, and potassium
Decrease levels of ACE by antacids and indomethacin use
Potassium sparing diuretics
Potassium Supplements

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36
Q

Angiotensin II Receptor Blockers (ARBs)

A

losartan (Cozaar)
other drugs end in “sartan”, they “sartanly” resemble ACE
High 1st pass effect, highly protein bound, renal/hepatic elimination

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37
Q

MOA of losartan (Cozaar)

A

Much like ACE, block binding of angiotensin II to receptors
AT1 receptors prevent vasoconstriction and aldosteron relsease
AT2 may have vasodilary effects
No effect on bradykinin pathway

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38
Q

Cautions of ARBs/losartan/Cozaar

A

Do not give pregnant women - Category D

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39
Q

Adverse effects of ARBs/losartan/Cozaar

A 
Hypotension
Angioedema (rare)
Thrombocytopenia
Rhabdomyolysis
Diarrhea, Dizziness, fatigue
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40
Q

Drug interactions with ARBs/losartan/Cozaar

A 
Termisartan with other hepatically cleared drugs
- increase digoxen and warfarin levels
Potassium sparing diuretics
Potassium supplements
Grapefruit (metab by CYP also)
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41
Q

Selective Aldosterone blockers

A

eplerenone (Inspra)
Less side effects than spironolactone because they are selective
Natuetic = Decrease Na and H2O retention

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42
Q

Indications for use of Selective Aldosterone Blockers/eplerenone/Inspra

A

HTN and Heart Failure after an MI

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43
Q

MOA for Selective Aldosterone Blockers/eplerenone/Inspra

A

Bind to mineralcorticoid receptors so aldosterone can’t bind = Decrease Na and H20 retention
K not excreted - watch K levels

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44
Q

Contraindications of selective aldosterone blockers/eplerenone/Inspras

A

Hyperkalemia, Diabetics with microalbuminuria, renal pts.

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45
Q

Adverse effects selective aldosterone blockers/eplerenone/Inspras

A

Hyperkalemia, Hyponatremia, Increase Triglicerides, dizziness, angina, MI

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46
Q

Drug interactions with selective aldosterone blockers/eplerenone/Inspra

A

Potassium supplements/potassim sparing diuretics = Increase K levels/ret
ACE/ARB’s = Increase K levels/ret
Grapefruit may increase effects of Inspra

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47
Q

Alpha 1 blockers

A

praxosin (Minipress) - given via patch, 1st dose effect
terazosin (Hytrin)
doxazosin (Cardura)
Indicated for HTN

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48
Q

Central ALpha 2 agonist

A

Not first line tx for HTN, usually added with other HTN meds
clonidine (Catapress)
methyldopa (Aldomet) - ok for pregnant patients, can darken urine

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49
Q

Alpha Beta blockers

A

Usually used in ICU via drip, lying flat

labetolol

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50
Q

Direct acting vasodilators

A

hydralazine
side effects: palpatations, tachy, angina
Usually also on BB to stop tachy

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51
Q

Direct acting vasodilators

A

hydralazine
side effects: palpatations, tachy, angina
Usually also on BB to stop tachy

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52
Q

Cardiac Glycosides

A 
digoxin
helps with a-fib/flutter/HR
60-80% oral absorp, 36 hour half life
Not recommended by dialysis
Give loading dose to speed up therapeutic effect
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53
Q

MOA for cardiac glycosides/digoxin

A

Inhibit Na-K-ATPase pump = Na & Ca can’t leave cell = Increase in Ca = Increase force of contraction

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54
Q

Effects of cardiac glycosides/digoxin

A

Increase force of contraction - positive inotrope
Depress SA node = Decrease HR (negative chronotrope)
Prolongs refractory period of AV node (negative dromotrope)

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55
Q

Cautions for cardiac glycosides/digoxin

A

Renal insuff
Can cause electrolyte imbalance - hypokalemia, hypercalcemia, hypomagnesemia
Contraindicated for v-fib, v-tach, heart block patients
Thyroid patients - need to know thyroid levels before admin and adjust dose
High bran fiber diets reduce absorption

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56
Q

Monitoring for cardiac glycosides/digoxin

A

Dig levels: therapeutic 1-2 ng/mL
Electrolyte levels (K/Ca/Mg)
Heart rate

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57
Q

Signs of digoxin toxicity

A 
N/V (extreme)
Arrythmias
Visual disturbances (Halos/yellow)
Fatigue, weakness, diarrhea
ANTIDOTE: digoxin immune fab (Digibind)
- IVP slow (15-30 min)
- does not change dig levels, can only tell if working by decrease s/s
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58
Q

Adverse effects of digoxin

A

Anorexia, N/V, abd discomfort
Headache, weakness, visual disurbances
Arrythmias, confusion, aggitation
Very similar to toxicity - get levels to determin dig tox

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59
Q

Drug interactions with digoxin

A

MANY, may increase digoxin levels

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60
Q

Patient education on digoxin

A

Take pulse before taking medication, Call MD if below 60 bpm
Do not d/c w/o approval from MD
NO OTC antacids, cough/cold, dietary supplements w/o approval from MD
Do not take with food - absorbes better on an empty stomach
Eat K rich foods, do not eat high fiber
Keep away from kids (Deadly)
Keep lab appointments
If missed dose, do not double up.

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61
Q

Natriuretic Peptides

A

nesiritides (Natrecor)

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62
Q

MOA of Natriuretic Peptides/nesiritides (Natrecor)

A

Promotes smooth muscle relaxation and dilation of vein and arteries
Decrease vascular resistance
Decrease fatigue and dyspnea
Decrease aldosterone levels = Decreased Na and H2O
Given by IV bolus and infusion

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63
Q

Cautions with Natriuretic Peptides/nesiritides (Natrecor)

A

Watch for hypotension

Arrythmias and hypotension are #1 adverse effect

64
Q

Phosphodiasterase inhibitor

A

inamrinone (Inocor)

Peak 10-15 min

65
Q

MOA for Phosphodiasterase inhibitor/inamrinone (Inocor)

A

Inhibit breakdown of CAMP = Increase Ca = Increase contraction of the heart
ST use for pats on diuretics, dig and vasodilators
Positive inotropic effect = Increase contraction
Vasodilation effect
Given by IV infusion

66
Q

Adverse effects for Phosphodiasterase inhibitor/inamrinone (Inocor)

A

hypotension, nausea, thrombocytopenia (low platelets), hepatotoxicity (ICU/monitors)

67
Q

Phospodiasterase inhibitor

A

inamrinone (Inocor)

Peak 10-15 min

68
Q

MOA for Phospodiasterase inhibitor/inamrinone (Inocor)

A

Inhibit breakdown of CAMP = Increase Ca = Increase contraction of the heart
ST use for pats on diuretics, dig and vasodilators
Positive inotropic effect = Increase contraction
Vasodilation effect
Given by IV infusion

69
Q

Adverse effects for Phospodiasterase inhibitor/inamrinone (Inocor)

A

hypotension, nausea, thrombocytopenia (low platelets), hepatotoxicity (ICU/monitors)

70
Q

Phospodiasterase inhibitor #2

A

milrinone (Primacor)

Peak 10-15 min

71
Q

MOA for Phospodiasterase inhibitor/milrinone (Primcor)

A

Inhibit breakdown of CAMP = Increase Ca = Increase contraction of the heart
ST use for patients on diuretics, dig, and vasodilators
Positive inotropic effect = Increase contraction
Vasodialtion effect
Propmt increase in CO

72
Q

Adverse effects for Phospodiasterase inhibitor/milrinone (Primcor)

A

hypotension, headache, ventricular arrythmias, thrombocytopenia

73
Q

Nitrates

A 
nitroglycerin
Rapidly absorbed when SL or transdermal
Dry mouth will decrease absorption
Transdermal absorption increase with exercise, Increase body temp or applied to broken skin
Gradual release with transdermal
74
Q

Indications for use of Nitrates/nitroglycerin

A

Angina

75
Q

MOA for Nitrates/nitroglycerin

A

Dilate veins and arteries = decrease venous return = decrease myocardial tension = decrease O2 demand = arterial dialation

76
Q

Cautions with Nitrates/nitroglycerin

A

Orthostatic hypotension
Caution with glaucoma pts = Increase introcular pressure
Caution with ED meds (Viagra, Cialis, Levitra) = Severe hypotension

77
Q

Adverse effects of Nitrates/nitroglycerin

A 
Headache (d/t vasodilation in brain, migraines)
Flushing
N/V
Tachycardia
Hypotension, Syncope
Rash
Blurred vision
Dizziness, vertigo
78
Q

Education with Nitrates/nitroglycerin

A

Tolerance develops with continuous use = need nitrate free period of 8-12 hours/day
Trandermal patch: Nitro-Dur, Minitran
- apply to clean, dry, hairless skin; apply to chest, thigh or upper arm
- Do not cut or tear
Topical ointment (Nitro-bid)
- Apply to clean, dry, hairless skin, do not rub in
- avoid getting on hands
SL tablets: Nitrostat
- Do not chew or swallow
- Take one q5 min x3, if pain is unresolved go to ER
- Keep in cool, dry place
- Replace on a yearly basis
SL Spray
- Highly flammable, keep fire and cigarettes away
- Spray onto tongue or under tongue - do not inhale

79
Q

Education with Nitrates/nitroglycerin

A

Tolerance develops with continuous use = need nitrate free period of 8-12 hours/day
Trandermal patch: Nitro-Dur, Minitran
- apply to clean, dry, hairless skin; apply to chest, thigh or upper arm
- Do not cut or tear
Topical ointment (Nitro-bid)
- Apply to clean, dry, hairless skin, do not rub in
- avoid getting on hands
SL tablets: Nitrostat
- Do not chew or swallow
- Take one q5 min x3, if pain is unresolved go to ER
- Keep in cool, dry place
- Replace on a yearly basis
SL Spray
- Highly flammable, keep fire and cigarettes away
- Spray onto tongue or under tongue - do not inhale

80
Q

Nursing Implications with Nitrates/nitroglycerin

A

Always check BP before admin
Pts. should be sitting or lying when given
Watch for orthostatic hyptension
Treat headaches with aspirin or acetaminophen
Gradually wean/taper dose when d/c
Transdermal not used for acute angina.

81
Q

Nursing Implications with Nitrates/nitroglycerin

A

Always check BP before admin
Pts. should be sitting or lying when given
Watch for orthostatic hypotension
Treat headaches with aspirin or acetaminophen
Gradually wean/taper dose when d/c
Transdermal not used for acute angina.

82
Q

Nursing Implications with Nitrates/nitroglycerin

A

Always check BP before admin
Pts. should be sitting or lying when given
Watch for orthostatic hypotension
Treat headaches with aspirin or acetaminophen
Gradually wean/taper dose when d/c
Transdermal not used for acute angina.

83
Q

Beta adrenergic blockers

A

beta blockers, “olol” meds
Decrease HR/contractility/BP
All help reduce myocardial O2 demand
Extend release BB cause fatigue and lethargy

84
Q

Calcium Channel Blockers

A

Dihydropyridines: nifedipine (Procardia), amlodipine (Norvasc), nicardipine (Cardene)
- Increase vasodilation in periphery = cause edema (caution with CHF patients)
- DOes not effect conduction = does not effect HR
Non-dihydropyridines: verapamil (Calan), dilitazem (Cardizem)
- Affect conduction = decreased HR
- Used for arrythmias (a-fib/flutter)
- Cause vasodilation in periphery and coronary arteries = Decreased BP

Immediate relsease, rapid onset (30-60 min for most)
Large first pass effect
Highly protein bound

85
Q

MOA for Calcium Channel Blockers

A

Block slow Ca channels in cardiac and smooth muscles = decreased muscle contraction
Relaxes and dilated arteries
Slows cardiac impulse formation in conduction tissues

86
Q

Effects of Calcium Channel Blockers

A

Decrease peripheral vascular resistance (Vasodilation) = Decreased BP
Negative inotropic effects = Decreased contraction d/t decreased Ca
Decreased automaticity in SA and AV nodes (Negative dromotrope/non-dihydropyridines)
Decreased cardiac workload and myocardial O2 consumption
Good for chronic stable angina and variant (Prinzmetal) angina patients

87
Q

Cautions for Calcium Channel Blockers

A

Heart block and sick sinus syndrome (arrhythmias)
Renal and hepatic patients
PG women
TBI patient = Increase ICP
Do not give with dig and BB = Decrease CO
Do not give with grapefruit

88
Q

Adverse effects of Calcium Channel Blockers

A

Constipation - slows peristalsis with smooth muscle dilation
AV block
Edema
Hypotension, bradycardia
Steven Johnson Syndrome (esp w/verampamil and dilitazem)
Rash, arthralgias, impotence, ecchymosis

89
Q

Adverse effects of Calcium Channel Blockers

A

Constipation - slows peristalsis with smooth muscle dilation
AV block
Edema
Hypotension, bradycardia
Steven Johnson Syndrome (esp w/verampamil and dilitazem)
Rash, arthralgias, impotence, ecchymosis

90
Q

HMG - CoA Reductase inhibitors

A

“statin” meds
lovastatin (Mevacor) and simvistatin (Zocor) both pro-drugs
atorvastatin (Lipitor) most used
Large first pass effect
Highly protein bound
Mostly excreted in feces
Onset of action: 2 weeks, Max effect 4-6 weeks

91
Q

MOA of HMG-CoA Reductase Inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)

A

Inhibits HMG-CoA reductase enzyme responsible for biosynthesis of cholesterol in the liver
Liver will also make more HDL receptors on liver cells to remove more LDL cholesterol from bloodstream

92
Q

Effects of HMG-CoA Reductase inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)

A 
Decrease LDL (25-63%) and Decrease TGL
Increase HDL
93
Q

Cautions with HMG-CoA Reductase inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)

A

PG category X, avoid if breastfeeding also

Not for liver disease patients

94
Q

Adverse effects of HMG-CoA Reductase Inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)

A 
Rhabdomyolysis
Arthralgia, Myalgia
Progression of cataracts
Increased LFT's = hepatitis, jaundice
Fatigue, rash, cough, chest pain, N/V, abd pain, flatulance, dizziness, anemia, HA, gynecomastia, Sun sensitivity
95
Q

Monitoring HMG-CoA Reductase Inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)

A

LFTs: baseline, 6 weeks, 12 weeks, q3months, then annually
- if LFT become 3x upper limit or greater, decrease or d/c dose
Fasting lipid profile

96
Q

Drug interactions with HMG-CoA Reductase Inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)

A

Grapefruit juice
Digoxin
Warfarin
Antifungals, erythromycin, many others

97
Q

Education with HMG-CoA Reductase Inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)

A

Report brown, orange, red urine = proteinuria
Take at bedtime (liver works hardest making cholesterol at night)
Report muscle pain, tenderness or weakness
Teach about low saturated fat/low cholesterol diet
Keep lab appointments
Stay away from grapefruit juice
Monitor ETOH use d/t liver tox
Be aware of photosensitivity

98
Q

Mnemonic for HMG-CoA Reductase Inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)

A

H: Hepatotoxicity (Side effect)
M: Myositis (rhabdo - side effect)
G: Girl, PG
C: Coumadin/cyclosporine (Interactions)

99
Q

Fibric Acid Derivative

A

fenofibrate (Tricor, Lipofen), gemfribrozil (Lopid)

100
Q

MOA for Fibric Acid Derivative/gemfibrozil (Lopid)

A

Increase lipoprotein lipase activity = catabolism of VLDL

101
Q

MOA for Fibric Acid Derivative/fenofibrate (Tricor, Lipofen)

A

pro-drug, inhibits TGL synthesis and accelerated removal of lipoproteins

102
Q

Adverse effects of Fibric Acid Derivatives/fenofibrate (Tricor, Lipofen), gemfibrozil (Lopid)

A 
Hepatotoxicity
Cholelithiasis (gall stones)
Anemia (watch CBC)
Increase glucose
Rhabdo
Fatigue, rash, a-fib, abd pain, n/v, decreased renal function
103
Q

Monitoring of Fibric Acid Derivatives/fenofibrate (Tricor, Lipofen), gemfibrozil (Lopid)

A

Lipid profile
Gemfibrozil:
- CBC q 3 mo for 12 mo d/t anemia
- LFT’s: Baseline, 6 weeks, 12 weeks, and then twice yearly

104
Q

Drug interactions with Fibric Acid Derivatives/fenofibrate (Tricor, Lipofen), gemfibrozil (Lopid)

A

Statins - increase risk of rhabdo
Warfarin - Increase anticoagulation response
Bile acid sequestrants = Decrease absorption of fibric acid derivatives

105
Q

Drug interactions with Fibric Acid Derivatives/fenofibrate (Tricor, Lipofen), gemfibrozil (Lopid)

A

Statins - increase risk of rhabdo
Warfarin - Increase anticoagulation response
Bile acid sequestrants = Decrease absorption of fibric acid derivatives

106
Q

Bile Acid Sequestrants

A

cholestyramine (Questran): powder, mix with 8oz of water and drink, 4-6x per day
colesevelam (WelChol): tabs/chew, most rx, least side effects, 2-3 times per day
colestipol (Colestid): 3-4x/day
Not absorbed orally, no metabolism
Completely excreted in feces
Max effect in 1 month

107
Q

MOA of Bile Acid Sequestrants/cholestyramine (Questran)/colesevelam (WelChol), colestipol (Colestid)

A

Bind to bile acids and increase their excretion = conversion of cholesterol into bile acid synthesis
Leads liver to increase catabolism of LDL
No breakdown of cholesterol so it gets excreted and not absorbed

108
Q

Cautions with Bile Acid Sequestrants/cholestyramine (Questran)/colesevelam (WelChol), colestipol (Colestid)

A 
Biliary Obstruction
Interferes with absorption of fat soluble vitamins (A,D,E,K)
Pts with hemorrhoids
PG Women
GI pts: Chrohns, IBS, diverticulitis
109
Q

Adverse effects with Bile Acid Sequestrants/cholestyramine (Questran)/colesevelam (WelChol), colestipol (Colestid)

A

Malabsorption of nutrients and meds
Hematuria
Constipation (esp. w/powder form)
Abd pain, cramping and distention (Increase fluids, stool softener)

110
Q

Drug interactions with Bile Acid Sequestrants/cholestyramine (Questran)/colesevelam (WelChol), colestipol (Colestid)

A

Decreased absorption of most meds

  • take other meds one hour before or 4 hours after
  • Separate from other oral meds
111
Q

Drug interactions with Bile Acid Sequestrants/cholestyramine (Questran)/colesevelam (WelChol), colestipol (Colestid)

A

Decreased absorption of most meds

  • take other meds one hour before or 4 hours after
  • Separate from other oral meds
112
Q

Nicotinic Acids

A 
Niacin
Well absorbed
Hepatically/renally cleared
Give at night
Max effect in 3-5 weeks
113
Q

MOA of Nicotinic Acids/Niacin

A

Inhibition of release of fatty acids from adipose tissues

Leads to decrease free fatty acids xport to liver and decrease synthesis of VLDL = Decrease LDL

114
Q

Effects of Nicotinic Acids/Niacin

A

Decrease TGL’s
Increase HDL’s
Similar to bile acid sequestrants in lowering LDL (10-15%)
When combines with other meds = 50-60% decreased LDL
When combines with 2+ other meds = 70-80% decrease LDL’s
Drug of choice for very high TGL pts.

115
Q

Cautions for Nicotinic Acids/Niacin

A

Gout (Increase uric acid levels)
Diabetes (Increase BS)
Liver disease (hard on liver)
Gallbladder disease

116
Q

Adverse effects of Nicotinic Acids/Niacin

A 
Hyperglycemia
Hyperuricemia
Rhabdo
Flushing - treat with aspirin
Arrhythmias, GI upset, n/v, HA, hepatotoxicity, vision disturbances
117
Q

Monitoring of Nicotinic Acids/Niacin

A

LFT’s: baseline, 6 weeks, 12 weeks, then 2x yearly

118
Q

Drug interactions with Nicotinic Acids/Niacin

A

HMG-CoA reductase inhibitors (statins) and gemfibrozil = increase risk of rhabdo

119
Q

Misc Anti-lipid Meds

A

Ezetimbe (Zetia): Selective cholesterol absorption inhibitor
Combo drug: simvastatin/ezetimbe (Vytorin): excretes excess cholesterol that liver relseases
- #1 side effect: diarrhea and fatty stools
- Start low cholesterol diet 2 weeks before starting drug
Omega 3 Acid Ethyl Ester (Fish Oil)
- Unknown MOA
- Decrease TGL’s, antiplatelet effect

120
Q

Misc Anti-lipid Meds

A

Ezetimbe (Zetia): Selective cholesterol absorption inhibitor
Combo drug: simvastatin/ezetimbe (Vytorin): excretes excess cholesterol that liver relseases
- #1 side effect: diarrhea and fatty stools
- Start low cholesterol diet 2 weeks before starting drug
Omega 3 Acid Ethyl Ester (Fish Oil)
- Unknown MOA
- Decrease TGL’s, antiplatelet effect

121
Q

Heparin UF

A 
High Risk Drug
Not consistent sizes/shapes
Always monitor PTT
Not absorbed orally
Shart Half life (Usually give loading dose or IV Bolus
IV onset: Immediate, continous infusion needed for full effect
SubQ onset: 20-60 min
Hepatic metabolism, renal clearance
122
Q

Indications for Heparin UF

A

Prevent extension of a blood clot (DVT/PE)
Prophylaxis (Surgical patients, clot risk patients)
Maintain patency of IV’s
Off label tx: ACS, acute MI

123
Q

MOA for Heparin UF

A

Inactive factor X which prevents the conversion of prothrombin to thrombin
Inhibits conversion of fibrinogen to firbin
HAS NO EFFECT ON EXISTING CLOT

124
Q

Cautions for Heparin UF

A

Other anti-coag meds
Pts at risk for hemorrhage (peptic ulcers, liver disease, etc)
Allergies to beef or pork
Patients with recent epidural = Increase risk for bleeding

125
Q

Adverse effects of Heparin UF

A

Bleeding
Thrombocytopenia
Clotting, fever, chills, pruritis, anaphylaxis, osteoporosis (LT use >6mo)

126
Q

Monitoring Heparin UF

A

PTT

CBC (Platelets, H&H)

127
Q

Antidote for Heparin UF

A

protamine sulfate

128
Q

Heparin Protocol

A 
Draw baseline PT, PTT, CBC
Initial heparin bolus 60-80 units/kg
Begin heparin gtt at 7-18 units/kg
PTT q6h until 2 consecutive PTT are within 60-90 sec
CBC q3 days
129
Q

Nursing implications with Heparin UF

A

Always be on a pump
Patients on fall precautions
Frequent blood draws
Report any blood in urine, stools, gums, nose, wounds, etc.
Teach pts to use soft toothbrush and electric razor

130
Q

Nursing implications with Heparin UF

A

Always be on a pump
Patients on fall precautions
Frequent blood draws
Report any blood in urine, stools, gums, nose, wounds, etc.
Teach pts to use soft toothbrush and electric razor

131
Q

Low Molecular Weight Heparin

A 
Smaller, consistent size = stable drug
enoxaparin (lovenox)
dalteparin (Fragmin)
tinzaparin (Innohep)
Not absorbed orally, give SubQ
Relatively long half life
Extensive renal clearance
Weight based, protein bound
132
Q

MOA for Low Molecular weight Heparin/enoxaparin (Lovenox)

A

Inhibit clot formation higher up in the clotting cascade than heparin
Prevent intrinsic and extrinsic pathways from coming together

133
Q

Cautions for Low Molecular Weight Heparin/enoxaparin (lovenox)

A

Other anticoagulant meds

Epidural/Spinal patients (Black Box Warning)

134
Q

Adverse effects of Low Molecular Weight Heparin/enoxaparin (Lovenox)

A

Bleeding
Thrombocytopenia
Pulmonary edema, fever, peripheral edema

135
Q

Antidote for Low Molecular Weight Heparin/enoxaparin (Lovenox)

A

protamine sulfate

136
Q

Teaching for Low Molecular Weight Heparin/enoxaparin (Lovenox)

A

Rotate injection sites (Stay away from belly button)
Teach good subQ techniques
Teach fall precautions at home
No need to follow PTT, still follow platelet counts
dalteparin (Fragmin) CANNOT be used in infants and women.

137
Q

Warfarin (Coumadin)

A

Well absorbed orally
Half life = 40 hours
Bound to albumin in plasma
Max effect in 3-4 days, effects 4-5 days after drug is d/c’d

138
Q

MOA of warfarin (Coumadin)

A

Blocks vitamin K at binding site

Inhibits clotting factors VII, IX, X, & II which are dependent on vitamin K

139
Q

Cautions of warfarin (Coumadin)

A

Other anticoagulant meds
Pts. w/active bleeding, open wounds, ulcers or bleeding disorders
Severe HTN, severe renal disease or hepatic dysfunction
Fall risk patients
PG women: category X
D/C 1 weeks prior to surgery

140
Q

Antidote for warfarin (Coumadin)

A

Vitamin K injection (push slow)

141
Q

Adverse effects of warfarin (Coumadin)

A

Hemorrhage

Rash, gangrene, skin ulcers, myalgia, n/v

142
Q

Monitoring PTT and INR with warfarin (Coumadin)

A

Therapeutic level is 1.5-4

143
Q

Drug interactions with warfarin (Coumadin)

A

Interacts with almost everything
Drugs that increase effects: Acetaminophen, NSAIDs, statins, quinolones, etc
Drugs that decrease effects: Oral contraceptives, corticosteroids, some PCNs, diuretics, etc

144
Q

Education for warfarin (Coumadin)

A

Teach s/s of bleeding
Take drug at same time and do not skip a dose
Do not take acetaminophen or aspirin - can affects action of warfarin
Be consistent with vitamin K foods
Inform health care providers, wear med ID bracelet

145
Q

Education for warfarin (Coumadin)

A

Teach s/s of bleeding
Take drug at same time and do not skip a dose
Do not take acetaminophen or aspirin - can affects action of warfarin
Be consistent with vitamin K foods
Inform health care providers, wear med ID bracelet

146
Q

Antiplatelet drugs

A

Aspirin and ADP inhibitors

147
Q

Aspirin MOA

A

Irreversibe inhibition of thromboxane A2 which induces platelet aggregation and vasoconstriction
Antipyretic, anti-inflammatory and analgesic effects

148
Q

Cautions with Aspirin

A

Other anticoag meds
Peptic ulcer disease
Bleeding disorders

149
Q

Adverse effects of Aspirin

A

GI upset
Thrombocytopenia
Bleeding

150
Q

Education with Aspirin

A

LT aspirin users will need blood work to monitor renal. hepatic and clotting functions
Read OTC labels to avoid products with aspirin or ibuprofen
If taking for CV reasons, avoid enteric coated
Take with food, milk or antacids to avoid GI upset

151
Q

ADP inhibitors

A 
clopidogrel (Plavix - to prevent MI)
ticlopidine (Ticlid - CVA pts)
50% absorbed, rapidly in GI tract
Metabolized in liver to active form
Eliminated by GI and kidneys
152
Q

Indications for ADP inhibitors

A

Reduces the occurence of artherosclerotic events (MI, CVA)
Peripheral artery disease
Pts. w/recent stent or CABG

153
Q

MOA for ADP inhibitors

A

Inhibits binding of adenosine diphosphate and activation of glycoprotein IIb/IIIa complex
Inhibits platelet aggregation

154
Q

Cautions for ADP inhibitors

A

Liver disease
Other anticoagulant/antiplatelet drugs
Active bleeding disorders

155
Q

Adverse effects of ADP inhibitors

A

Bleeding
Thrombocytopenia purpura
N/D, rash, fatigue, palpations, chest pain

156
Q

Education of ADP inhibitors

A

Do not stop abruptly, can cause rebound clotting = massive MI/CVA
Apply pressure to wounds to stop bleeding
Inform health care providers that pt is on drug
Fall precautions
Take with food to avoid GI upset
d/c 1 week prior to surgery

Pharm (11 decks)

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