Natsumi Pharm - Cardio, Heme Flashcards
Pregnancy Category of ACEi
Preg category D
Contraindicated in pregnancy and use caution in lactation
The first dose side effect of ACEi
Other significant side effects:
ACEi is contraindicated in:
Acute renal failure!
Dry cough, hyperkalemia, angioedema, impotence, dizziness
C/I: pregnancy, bilateral renal stenosis, hx of angioedema
Nutrition depletion of ACEi
Zinc, Na+
-pri ending
ACE inhibitors
Ramipril, Lisinopril
Common indication and drug-specific indication
C/I
Anti-hypertensive drugs
Lisinopril: CHF, post-MI to reduce mortality
Ramipril: Tx of CHF after MI
“R comes after L”
DO NOT use in blacks
Which antihypertensive drugs are better for blacks?
NOT for black?
Hydrochlorothiazide, amlodipine
Do NOT use: ACEi, ARBs, Losartan
Clonidine class and indication
Caution using this drug?
Side effect (2)
alpha-2 agonist
I: ADHD, HTN
Caution: first dose SUPER anti-HTN, use in office!
S/E: Depression & LL edema
Doxazosin, Terazosin
- Common indication
- First dose effect
- S/E (3)
- Pregnancy category
Alpha-1 antagonist:
Antihypertensive, BPH
1st dose effect - syncope
S/E: priapism, asthenia, dizziness, increased BUN
Pregnancy category C
*Priapism = long-lasting painful erection
-artan ending
ARBs
Irbesartan, Losartan, Valsartan
- Common indication and specific indication
- S/E (3)
- C/I
- Pregnancy category
ARBs - Antihypertensive
Irbesartan & Losartan - Diabetic nephropathy
Losartan - LVH
Valsartan - HF
S/E: Hyperkalemia, cough, rhabdomyolysis, impotence
DO NOT use in blacks
Pregnancy category D
Caution with Clonidine if withdrawn too quickly?
Which drug can clonidine increase the toxicity of?
Rebound hypertension if withdrawn too quickly
Increase cyclosporin toxicity with clonidine
Signs of hyperkalemia
Confusion, body weakness, uneven heartbeat, numbness and tingling in finger/toes
ARB and ACEi with ___ can cause hyperkalemia
K+ sparing diuretics or K+ supplements
Increased risk of hyperkalemia and hypotension!
Beta-blockers deplete which nutrition
CoQ10, Melatonin, Chromium
Atenolol, Metoprolol, Propranolol, Carvedilol
- Common indications and separate indications
- Beta-blocker side effects
- C/I
Beta-blockers - antihypertensive
Angina, MI: atenolol, propranolol, metoprolol
Propranolol - afib, migraine, hypertrophic subaortic stenosis, essential tremor, pheochromocytoma. Off label - anxiety and hyperthyroidism
Carvedilol - LV dysfxn post-MI & CHF
S/E: Depression, importance, nightmares, dyslipidemia, dysglycemia
C/I - asthma, COPD, diabetes
Caution with beta-blockers?
DO NOT abruptly stop, can cause tachycardia and rebound hypertension
Atenolol indication & caution
HTN, Diabetic nephropathy
Pregnancy category D
S/E: Depression, importance, nightmares, dyslipidemia, dysglycemia
C/I - asthma, COPD, diabetes
Metoprolol indication & caution
HTN in patients with LVH
Diabetic nephropathy
S/E: Depression, impotence, nightmares, dyslipidemia, dysglycemia
C/I - asthma, COPD, diabetes
Which drug is specifically for patients with HTN and LVH
Which one is not for blacks
Losartan and Metoprolol
Do NOT use Losartan with blacks
Propranolol indication and off-label indication
HTN, angina, CHF, afib, migraine, subaortic stenosis, essential tremor, pheochromocytoma
Off-label: hyperthyroidism and anxiety
S/E: Depression, importance, nightmares, dyslipidemia, dysglycemia
C/I - asthma, COPD, diabetes
Carvedilol indication & caution
LCH dysfunction post-MI, CHF
S/E: Depression, importance, nightmares, dyslipidemia, dysglycemia
C/I - asthma, COPD, diabetes
Beta-blockers with antidiabetics may cause what?
Decreased anti-glycemic control
Amlodipine indication & caution
CCB - HTN (arteriole dilator) and stable/Prinzmeta’s angina
CAUTION: emotional lability, depression, anxiety in petite elderly women
S/E: Peripheral edema, HA, stomach upset,
Contraindicated in sick sinus syndrome, 2nd/3rd degree AV block, hypotension, acute MI + pulmonary congestion
Verapamil indication, SE, CI
CCB - arrhythmia (works directly on the heart)
S/E: Peripheral edema, HA, stomach upset,
Contraindicated in sick sinus syndrome, 2nd/3rd degree AV block, hypotension, acute MI + pulmonary congestion
Diltiazem indication, SE, CI
CCB - arrhythmia (works directly on the heart)
S/E: Peripheral edema, HA, stomach upset,
Contraindicated in sick sinus syndrome, 2nd/3rd degree AV block, hypotension, acute MI + pulmonary congestion
CCB nutrient depletion for each specific CCB
Amlodipine - Potassium wasting & vitamin D
verapamil - vitamin E
Ditiazem - None known
Hydralazine indication & C/I, nutrient depletion
Other antihypertensive drug
C/I: coronary heart dz, mitral valvular rheumatic dz
Nutrient depletion: Vitamin B6
Epinephrine
- indication
- route of administration
- SE
Beta agonist
- Hypotensive crisis, bradycardia, HF, cardiac stabilization before pacemaker implantation, anaphylaxis
- IV in the hospital
Part of crash cart for BOTTOMED out BP
Pregnancy category C
Nitroglycerin
- indication
- route of administration
- SE
- C/I
Nitrate - angina (acute & prophylaxis)
Half-life of about 5 minutes; active metabolites with 40 minute half-lives
Dosed sublingually for symptomatic discomfort, up to 3 doses (q 5 min); then to ER!!!
Available as transdermal patch and ointment, too
S/E: Headache; fast, slow, pounding, or uneven heart rate; blurred vision or dry mouth; feeling light-headed, nausea, vomiting, sweating, pale skin fainting; or fever, sore throat, and headache with a severe blistering, peeling, and red skin rash
Contraindicated with concomitant use of cGMP PDE-5 inhibitors**
Isosorbide mononitrate
- indication
- route of administration
- SE
- C/I
Nitrate - angina prophylaxis only
Headache; fast, slow, pounding, or uneven heart rate; blurred vision or dry mouth; feeling light-headed, nausea, vomiting, sweating, pale skin fainting; or fever, sore throat, and headache with a severe blistering, peeling, and red skin rash
Contraindicated with concomitant use of cGMP PDE-5 inhibitors**
Nitrate vasodilator Nutritional Considerations
Folate, B12 and vitamin C (folic acid & C may decrease tolerance)
Consider: Arginine, Lysine, L-carnitine
Lidocaine
Class Ib anti-arrhythmics - Ventricular arrhythmias
Alternative (last resort) option anti-arrhythmic and anti-epileptic (status epilepticus)
Amide local anesthetic
No known nutrient depletions
Pregnancy category B
Flecanide
Class Ic - Paroxysmal supraventricular tachycardias (PSVT) or paroxysmal atrial fibrillation/flutter (PAF) with disabling symptoms or life-threatening ventricular arrhythmias
DO not use in people with hx of MI
No known nutrient depletions
Pregnancy category C
Black box warning: increased mortality.
Na+ channel blockers
Lidocaine and Flecanide
LAST RESORT after trying other anti-arrhythmic classes!
Class II antiarrhythmics
Beta blockers
Class III antiarrhythmics
K+ channel blockers - Amiodarone
Amiodarone
Indication
What should you monitor with this drug?
Mostly class III, but acts as class I, class II, class IV Mechanism of action may be due to a prolongation of the myocardial cell-action potential duration and refractory period (inhibits potassium channels—class III-like) non-competitive antagonism of α- and β-adrenoceptors (class II-like)
Reverse use-dependency: prolongation most pronounced at slow rates (undesirable), least pronounced at fast rates (desirable)
Inhibits repolarization
Useful in recurrent ventricular fibrillation and recurrent hemodynamically unstable ventricular tachycardia
Monitor - thyroid state
Amiodarone SE, C/I, nutrient depletion
Side effects: hypotension, pulmonary toxicities (potentially fatal), hyperthyroidism/hypothyroidism due to structural similarity to thyroxine, abnormal increase in hepatic enzymes, AV nodal block & bradycardia
Contraindicated in cardiogenic shock, second or third-degree heart block, severe SA node dysfunction with marked sinus bradycardia or syncope
Nutrient depletions: Vitamin B6
Pregnancy category D
Class IV antiarrhythmics
CCB
Class V antiarrhythmics
Digoxin, Potassium chloride
Digoxin
- Nutrient depletion
- drug interaction
Bradycardic and inotropic
Used in heart failure (has not been shown to improve survival, but may palliate symptoms, improve functional status, reduce hospitalizations), atrial fibrillation, to control ventricular rate in patients with long-standing atrial fibrillation
Class V anti-arrhythmic (“Other”)
Excreted primarily via kidneys, unchanged; gut, liver metabolism
Reduce dose in chronic kidney disease
Watch potassium levels! Hypokalemia increases myocardial localization of digoxin; may use potassium to decrease symptoms of digoxin toxicity
Interacts with β-blockers, calcium channel blockers, potassium-wasting diuretics, many antibiotics, verapamil, quinidine, amiodarone
Anti-digoxin antibodies are available for life-threatening digoxin toxicity
Depletes calcium
Pregnancy category C
Potassium chloride
Very narrow therapeutic window
Used in hypokalemia due to digitalis intoxication, familial periodic paralysis, diuretic use, cardiac arrhythmias
Side effects: hyperkalemia (contraindication), gastric/intestinal irritation and bleeding
Pregnancy category C
Furosemide
Diuretic that exerts effect in loop of Henle
Used in edema (all causes) and hypertension
Also used in malignant hypertension and volume-based hypertension in patients with advanced chronic kidney disease
Use in mild-moderate chronic hypertension not as useful (short half-life)
SE: Electrolyte imbalances, thirst; Tinnitus, loss of hearing (dose-related ototoxicity)
Furosemide nutrient depletion
Calcium Magnesium Potassium Vitamins B (1,6,12) Sodium Zinc Folic Acid CoQ10 Mixed tocopherols Vitamin C
Hydrochlorothiazide
Thiazide diuretic Until recently (JNC-8), was first step therapy for hypertension Hydrochlorothiazide (HCTZ), Hydrodiuril Used alone and/or in combination Treatment of chronic hypertension
SE: Blurred vision, headache (may idiosyncratically cause acute myopia & secondary angle-closure glaucoma)
Upset stomach, nausea, vomiting, diarrhea
Weakness, dizziness
Cramps, thirst
Hydrochlorothiazide Nutrient depletion
CoQ-10 Magnesium Sodium Potassium Zinc
Spironolactone
K+ sparing diuretic
Aldosterone receptor antagonist, significant androgen receptor blocking action; competitive inhibitor of testosterone and dihydrotestosterone
Used in edema, CHF, primary aldosteronism, essential hypertension, hypokalemia
Triamterene, Dyrenium
Blocks epithelial sodium channels in the late distal convoluted tubule (DCT) and collecting duct which inhibits sodium reabsorption from the lumen. This effectively reduces intracellular sodium, decreasing the function of Na+/K+ ATPase, leading to potassium retention and decreased calcium, magnesium, and hydrogen excretion.
Used in edema. Off-label use: hypertension in children/adolescents and anti-hypertensive diuretic induced hypokalemia.
Used primarily in a combination (used alone, much less effective in reducing hypertension)
SE: Hyperkalemia, tumorigenic.
DO NOT USE WITH ACEi, ARB
Besides HTN, what else can you use spironolactone for?
PCOS
Triamterene nutrient depletion
Folic acid
Zinc
Colesevelam
Indications for use: DMII (NIDDM) in conjunction with diet and exercise, heterozygous familial hypercholesterolemia, hyperlipidemia
Contraindications: history of bowel obstructions, TG > 500, history of hypertriglyceridemia-induced pancreatitis
Side effects: GI complaints
Pregnancy category B
Colesevelam nutrient depletion
CRAP LOAD!
Riboflavin Folic acid Vitamin B12 Vitamin B6 Mixed tocopherols/tocotrienols Coenzyme Q-10
Magnesium Vitamin K Vitamin D Vitamin A Carotenoids Essential fatty acids
Gemfibrozil
To be used in triad of LOW HDL + HIGH LDL + High Triglycerides**
To be used AFTER diet, exercise, weight loss, other pharmaceuticals (bile acid sequestrants, niacin) have been tried
Uses: Treatment of adult patients with very high elevations of serum triglyceride levels (Types IV and V hyperlipidemia) who present a risk of pancreatitis and who do not respond adequately to a determined dietary effort to control them. (Patients who present such risk typically have serum triglycerides over 2000 mg/dL.)
Warning: GALLBLADDER DISEASE, ABDOMINAL PAIN LEADING TO APPENDECTOMY AND OTHER ABDOMINAL SURGERIES,
SE: DVT, SOB, pulmonary embolism; Coughing up blood, Increase in homocysteine levels
Gemfibrozil nutrient depletion
Vitamin E, B12 Copper Zinc CoQ10 (Vitamins B6, folic acid) (because fibrates increase homocysteine)
Atorvastatin, Simvastatin
Statins with gemfibrozil causes?
FIrst dose effect?
The increased risk with niacin for myopathy!
Statins with gemfibrozil inceases rhabdomyolysis
The first dose gives you the biggest reduction; takes abourt 3 weeks to figure out how it wil affect the blood look at the lipid panel to adjust dosing
Metabolized primarily in the liver (CYP450!)
Simvastatin nutrient depletion
CoQ-10
Consider co-administration of L-carnitine, Vitamin C, omega-3 fatty acids
Atorvastatin
SE: Neuropathy; rhabdomyolysis; Memory loss; ; Blood sugar irregularities
Contraindicated in acute liver disease
Pregnancy category X
Ezetimibe
Used for: hyperlipidemia, including homozygous familial hypercholesterolemia (HoFH) and homozygous sitosterolemia
Contraindicated in patients with active liver disease, pregnant or nursing women, women who may become pregnant
No known nutrient depletions
Pregnancy category C
Vitamin K
Pro-coagulation
Clopidogrel
Anti-coagulant - anti-platelet agent
- Combo with aspirin to prevent stent thrombosis post-op
- Acute coronary syndrome, STEMI, recent MI, stroke, PAD
Aspirin
Anti-coagulant - anti-platelet agent
Warfarin
Anti-coagulant - Vitamin K recycling
Pentoxifylline
Anti-coagulant - Xanthine derivative
Heparin
Anti-coagulant - X factor inhibitor
Enoxaparin
Anti-coagulant - X factor inhibitor
Rivaroxaban
Anti-coagulant - Xa factor inhibitor
Dabigatran
Anti-coagulant -
Calcium EDTA
Chelator
mercury, lead, iron,
DMPS
Chelator
DMSA
Chelator
Penicillamine
Chelator, wilson’s dz for copper
Deferoxamine
Chelator
Epoitin alpfa
Aplastic anemia
