Pharm is AWESOME! Flashcards
1
Q
Warfarin aka, and medication class
A
Aka Coumadin. Oral anticoagulant, specifically a Vitamin K antagonist.
2
Q
Warfarin route
A
Route: usually oral
3
Q
Warfarin use
A
Use: Reduces ability to clot. Used in patients with A Fib, history of thrombosis, artificial valves. Prevention of recurrent MI, transient ischemic attacks, pulmonary emboli, DVT.
4
Q
Warfarin teaching
A
Teaching: Excessive Vitamin K rich foods should be avoided, but more importantly, Vitamin K foods (broccoli, spinach, liver) should be CONSISTENT –don’t add a lot or subtract a lot from usual diet. Monitor for signs of internal bleeding/vital signs.
5
Q
what increases risk of bleeding on warfarin
A
Increased risk of bleeding (increased efficacy) when on warfarin: acetaminophen, NSAIDS, antibiotics, antifungals, amiodarone, cranberry juice, gingko biloba, vitamin E, omeprazole, thyroid hormine, SSRIS
6
Q
What increases risk of clots on warfarin
A
Increased risk of clotting (decreased efficacy of warfarin): rifampin, carbamezapine, oral contraceptives, ginseng, st johns wort, vitamin K rich foods.
7
Q
Warfarin monitor
A
Monitor: PT/INR, monitor for medication induce hepatitis –look at liver enzymes, signs of jaundice.
8
Q
Warfarin overdose interventions
A
In overdose, D/C warfarin and administer Vitamin K. If bleeding not controlled by Vit K, administer fresh frozen plasma or whole blood.
9
Q
Warfarin category
A
Category X –not safe in pregnancy. If anti-coagulation in pregnancy is needed, heparin can be used.
10
Q
Warfarin therapeutic level time and range
A
Takes 3-5 days to reach therapeutic levels, can be taken indefinitely. Therapeutic INR is 2-3. Maybe up to 3.5 in heart valve disease. Level over 4 is concerning but not emergent.
11
Q
Lithium medication class
A
Lithium carbonate is a mood stabilizer used in the manic phase of bipolar disorder.
12
Q
Lithium therapeutic range
A
Lithium has a narrow therapeutic range 0.6 - 1.2 is generally considered therapeutic. 1.3 - 1.9 is no-mans land and maybe toxic or maybe fine. Over 2 is considered toxic.
13
Q
Lithium toxicity warning signs
A
Early: Diarrhea, n/v, excessive thirst, polyuria, muscle weakness, fine hand tremor, slurred speech, lethargy.
Advanced: ongoing GI distress, mental confusion, poor coordination, coarse tremor, sedation
Sever: extreme polyuria of dilute urine, tinnitus, EPS, blurred vision, ataxia, seizure, severe hypotension –coma, respiratory failure, death.
14
Q
Expected side effects of lithium and teaching
A
Some effects resolve within a few weeks.
Nausea, diarrhea, abdominal pain –take lithium with milk.
Fine hand tremors –can be made worse with caffeine and stress.
Polyuria and mild thirst. Important to maintain adequate fluid intake 2-3 L per day.
Maintain normal sodium intake.
Do NOT take with NSAIDs or anticholinergics.
Weight gain.
Renal toxicity, dose should be as low as can be effective. Renal function should be monitored periodically.
Goiter and hypothyroidism with long term treatment.
Bradydysrythmia, hypotension, electrolyte imbalance
15
Q
Magnesium sulfate use in preeclampsia
A
Prophylactic for seizures
16
Q
Magnesium toxicity signs
A
Nausea, flushing, headache, hypotension, abdominal pain, respiratory distress, absent or reduced deep tendon reflexes, hypocalcemia, somnolence, cardiac arrest, decreased urine output.
17
Q
Magnesium sulfate therapeutic range
A
4-7
18
Q
Intervention in magnesium toxicity
A
Stop mag, administer IV calcium gluconate bolus
19
Q
Magensium contraindications
A
Not for use in pts with myasthenia gravis
20
Q
Magnesium use in preterm labor
A
Tocolytic –mag sulfate is a CNS depressant and relaxes smooth muscle. It is a last-line drug for preterm labor as it has significant maternal side effects and incrases fetal mortality.
21
Q
Thrombolytic vs Anti-thrombotics
A
Thrombolytics help dissolve existing clots by converting plasminogen to plasmin, which destroys fibrinogen and other clotting factors.
Anti-Thrombotics like antiplatelets and anticoagulants, affect the body’s ability to aggregate platelets or form clots.
22
Q
Common thrombolytics
A
–plase suffix. Alteplase (aka tPA), tenecteplase, reteplase.
23
Q
Therapeutic uses of thrombolytics
A
Treat:
acute MI (all)
Massive pulmonary emboli (alteplase only)
Acute ischemic stroke (alteplase only)
Restore patency to central lines (alteplase only)
24
Q
Complications and monitoring of thrombolytics
A
Bleeding –both internal and superficial. Must monitor wounds, limit pokes, monitor vitals and signs of intracranial bleeding (change in LOC, weakness), monitor H&H, aPTT and PT.
25
Contraindications for thrombolytics
active bleeding, recent trauma, aneurysm, AV malformation, peptic ulcer disease, hx hemorrhagic stroke, uncontrolled hypertension,
26
Carbamezapine medication class and common useage
Anticonvulsant, used to treat epilepsy as well as bipolar disorder, and trigeminal and glossopharyngeal neuralgias, diabetic neuropathy.
27
Carbamezapine common side effects
Can affect vision and balance, headahce.
28
Carbamezapine monitoring/teaching
Associated with leukopenia due to agranulocytosis, and increased infection risk. Teach prevention and s/sx of infection.
Promotes secretion of ADH and risk of fluid volume overload and hyponatremia.
Dermatitis, rash, stevens-johnson syndrome.
29
Vancomycin medication class
Cell wall synthesis inhibitor. Destroys bacterial cell wasll.
30
Vancomycin uses/routes
IV --MRSA, MRSE, and other streptococcoal infections
| PO --C. Diff
31
Vancomycin monitoring
Vanco has risk of renal and ototoxicity. Run vancomycin trough prior to administration to ensure within therapeutic level, monitor BUN and creatinine levels, monitor for hearing loss
32
Vancomycin reaction
Red man syndrome --a rash over neck and chest, flushing, tachycardia. Can be confused for allergic reaction but no respiratory involvement. Is a rate issue --run slowly, at minimum over 60 minutes.
33
Vancomycin precautions
Do not use in pts with corn allergies, use caution in pts with renal impariment or hearing loss.
34
Vancomycin therapeutic range
10-20
35
Prototype NSAIDS
```
1st gen Cox-1 and Cox-2 inhibitors
Ibuprofin
Aspirin
Meloxicam
Naproxen
Diclofenac
Indomethacin
Ketorolac
```
2nd gen Cox-2 inhibitor
Celecoxib
36
NSAIDs and inhibition of cyclooxygenase
Cox-1 inhibition can result in decreased platelet aggregation (do not use in bleeding risk pts) and kidney damage (do not use in renal pts).
Cox-2 inhibition can result in decreased inflammation, fever, pain, does not decrease platelet aggregation.
37
Consideration re: prescription of NSAIDs
Do not prescribe/administer more than 1 at a time
38
Albumin medication class
Blood product
39
Albumin action
Expands circulating blood volume by exerting oncotic pressure --stablizes vital signs, prevents hypotension and tachycardia.
40
Albumin risk
Fluid volume excess, pulmonary edema
41
Methotrexate medication class, use
Disease-modifying antirheumatic drug (DMARD). DMARD 1 = Non-biologic DMARD. Cytotoxic agent/immunomodulator. It is a chemo-ish drug. Used in rheumatoid arthritis and breast cancer tx.
42
Methotrexate monitoring
Monitor for s/sx infection, such as fever/sore throat.
Monitor liver function. Observe for anorexia, abdominal fullness, jaundice.
Monitor renal function. --elevated uric acid, BUN, creatinine, 2-3 L fluid daily. Allopurinol if uric acid level elevated.
Monitor for bone marrow suppression --CBC and platelets q3-6 months
Monitor for mouth and stomach ulcers. Coffee-ground emesis, tarry black stools. Frequent oral hygeine .
Avoid in pregnancy. Avoid becoming pregnant for 6 months after taking.
43
Amiodarone
Antidysthymic medication --Class III. Potassium channel blockers, prolong action potential and refractory period of cardiac cycle. Last line --used only when other treatments have failed due to toxic adverse effects.
44
Amiodardone toxicity
pulmonary toxicity --dry cough, pleuritic chest pain, dypnea.
45
Sulfonamides and trimethoprim usage
Inhibit bacterial growth, used for UTIs (usually due to E. choli), otitis media, chancroid (chancre sores), pertussis, shigellosis, and pneumocystis jiroveci pneumonia (fungal pneumonia).
46
Common Sulfonamides and trimethoprim drugs
trimethoprim-sulfamethoxazole
sulfadiazine
trimethoprim
47
Considerations/teaching of sulfonamides and trimethoprim drugs
Can cause kidney damage --adequate water intake
Can cause photosenstivity --wear sunscreen
Can cause folic acid deficiency (interrupts folic acid synthesis in bacteria) --take folate
Can cause agranulocytosis --teach prevention and s/sx of infection, bleeding, report sore throat and pallor. Obtain baseline CBC and follow up periodically.
Can cause skin/urine to turn orange/yellow. Do not give to pregnant people in 1st tri or at term, breastfeeding people, infants under 2 months due to risk of kernicterus.
Hyperkalemia --monitor potassium levels.
Stevens-Johnson syndrome --discontinue and contact HCP if rash appears.
48
Tumor necrosis factor inhibitors
Targeted anti-neoplastic medications.
| etanercept, -ximab, -mumab, -zumab
49
Tumor necrosis factor inhibitor common SE
```
Rash, hypotension, wheezing, GI upset
Flu-like symptoms
Pulmonary emboli
Thromboembolism
Alopecia
Tumor lysis syndrome
Hemorrhage
Neutropenia
```
50
Tumor necrosis factor inhibitor consideration prior to administrator
must be tested to confirm no TB infection
51
Action of lactulose
Reduces serum ammonia levels by decreasing absorption of ammonia in the intestines --laxative.
52
Loop diuretics common use
In emergent need of rapid mobilization of fluid --pulmonary edema in HF pts even with renal impairment. Liver, kidney disease, hypertension. Also used in hypercalcemia.
53
Loop diuretics considerations
May cause: Dehydration, hyponatremia, hypochloremia, hypocalcemia, hypotension, ototoxicity, hypokalemia --NOT K SPARING.
54
Common loop diuretics
furosemide
Ethacrynic acid
Bumetanide
Torsemide
55
Thiazide diuretics common use
First line in essential hypertension if renal function NOT impaired
Edema of mild to moderate HF and liver, kidney disease.
Often used in combo with antihypertensives for BP control
Reduce urine production in DI patients
Promote absorption of calcium and can reduce postmenopausal osteoperosis risk.
56
Thiazide diuretics considerations
Dehydration and hyponatremia, hypokalemia --NOT K SPARING, hypochloremia, hyperglycemia.
57
Potassium sparing diuretics common use
Combined with loop or thiazide diuretics to spare K while treating hypertension and edema.
Administered for heart failure
58
Potassium sparing diuretics considerations
Take 12-48 hours to take effect.
| Hyperkalemia, endocrine effects (deepened voice and impotence in men, menstrual irregularities in women)
59
Common thiazide diuretics
Hydrochlorothiazide
chlorothiazide
methyclothizide
Thiazide-type:
Indapamide
Chlorthalidone
Metrolazone
60
Common potassium sparing diuretics
Spironolactone
Triamterene
Amiloride
61
Metronidazole aka and drug class
AKA Flagyl --antiprotozoal.
62
Common use of metronidazole
Oral or IV. Treats intestinal amoebas, giardia, trichomoniasis, c. diff, h. pylori
63
Metronidazole considerations/teaching
Causes GI discomfort, dark urine, neurotoxicity (parasthesia, ataxia, seizure), pseudomembranous colitis. DO NOT TAKE with alcohol. Inhibits warfarin, phenytoin, lithium actions.
64
Osmotic diuretics common use
Prevention of kidney failure in hypovolemic shock and severe hypotension.
Decreases ICP due to cerebral edema
Decreases intraocular pressure
Promotes sodium retention and water excretion in hyponatermic pts with fluid volume excess
Administered for oliguric phase of acute kidney injury.
65
Osmotic diuretics considerations/teaching
Notify HCP if signs of HF and pulmonary edema develop, possible rebound increased ICP, fluid and electrolyte imbalance, metabolic acidosis.
Do not use in pts with active intracranial bleeding, anuria, severe pulmonary edema, severe dehydration, renal failure.
66
Digoxin AKAs and medication class
AKA digitalis, lanoxin. Cardiac glycoside.
67
Common uses of digoxin
Decreases heart rate
Second line treatment of heart failure
Second line treatment of atrial fibrillation
68
Digoxin considerations/teaching
```
Dysryhtmias due to interference with electrical condiction in myocardium --increased risk with hypokalemia (eat high K foods)
Cardiotoxicity causing bradycardia
GI effects (usually first manifestation of toxicity)
CNS effects --fatigue, weakness, vision changes and changes in color perception
```
69
Atropine drug class
Anticholinergic
70
Atropine common use
Pesticide and nerve agent poisonings, bradycardia, decrease saliva during surgery. Can be given as otic solution to treat uveal inflammation and early amblyoplia (lazy eye).
71
Isoproterenol drug class
Beta1 and beta2 adrenoreceptor agonist. Structurally an analog of epinepherine.
72
Isoproterenol common use
Bradycardia, heart block, cardiac arrest prior to defibrillation, bronchospasm during anesthesia. hypovolemic shock, septic shock, CHF.
73
Common adenosine uses
Paroxysmal SVT, atrial fibrillation, v tach with pulse.
74
Adenosine considerations/teaching
Can cause sinus bradycardia, hypotension, dypsnea, vasodilation. Adenosine administration is a fast push over 8 seconds. Must have ECG monitoring.
75
Verapamil and Diltiazem drug class
Antidysrhythmic Class IV, calcium channel blocker
76
Common antidysrhythmic Class IV Calcium channel blockers
Verapamil
| Diltiazem
77
Verapamil and Diltiazem common use
A fib, A flutter, SVT, hypertension, angina pectoris
78
Verapamil and Diltiazem considerations/teaching
```
Monitor for bradycardia, widened QRS and prolonged QT
Hypotension
Heart failure
Orthostatic hypotension
Constipation (verapamil)
Peripheral edema
NO GRAPEFRUIT JUICE
```
79
Lidocaine drug class
Antidysrhythmic Classs 1B
80
Antidysrhythmic Classs 1B drugs
Lidocaine
Mexiletine
Phenytoin
81
Action of Lidocaine, Phenytoin as antiarrythmia med
Blocks sodium channels and decreases rate of contractions in the heart
82
Lidocaine, Phenytoin common use as antiarrythmia med
Ventricular tachycardia without pulse
| Ventricular fibrillation
83
Lidocaine considerations/teaching
CNS affects: Drowsiness, altered mental status, parasthesia, seizure. Administer phenytoin to control seizure activity.
Respiratory arrest
84
Epinepherine drug class
Adrenergic agonist (catecholamines)
85
Epinepherine common cardiac uses
Beta1 receptors = heart stimulation and increased HR, contractility, rate of conduction through AV node. Activation of kidney receptors lead to renin release.
86
Epinepherine cardiac use considerations/teaching
Vasoconstriction, dysrhthmias, angina.
87
Acetylsalycilic acid toxicity treatment
Activated charcoal followed by IV sodium bicarb
88
Common ACE inhibitor uses
hypertension
Heart failure
MI
Diabetic and nondiabetic nephropathy
89
ACE inhibitor suffix
-pril
| "To draw an ace in a game of cards is a thrill"
90
ACE inhibitor considerations/teaching
```
Orthostatic hypotension
Dry cough
Hyperkalemia
Rash and altered sense of taste
Angioedema
Neutropenia
```
91
ARB suffix
-sartan
92
Common ARB uses
```
hypertension
Heart failure
MI
Diabetic nephropathy and retinopathy
Prevention of stroke
```
93
Direct renin inhibitor common med
aliskirin
| "Alli and kirin gang up on hypertension"
94
Calcium channel blocker common suffix and meds
-dipine (but also verapamil and diltiazem)
Nifedipine
Verapamil
Diltiazem
Amlodipine
95
Common use of nifedipine
Angina, hypertension
96
Nifedipine considerations/teaching
Monitor for increased HR, use beta blocker (metoprolol) to counter tachycardia.
Orthostatic hypotension
peripheral edema
97
Alpha adrenergic blockers (sympatholytics) suffix
-zosin
98
Common uses of alpha adrenergic blockers
Primary hypertension
| Benign prostatic hypetension
99
Considerations/teachings for alpha adrenergic blockers
Orthostatic hypertension
100
Centrally acting alpha2 agonists common meds
Clonidine
Guanfacine
Methyldopa
101
Centrally acting alpha2 agonists common use
Primary hypertension, severe cancer pain
102
Centrally acting alpha2 agonists considerations/teaching
Cause drowsiness and sedation, dry mouth, can cause rebound hypertension if not tapered
103
Beta1 blockers common meds
Only affect heart.
| Metoprolol, atenolol, esmolol
104
Beta2 blockers common meds
Affect heart and lungs.
Propranolol
Nadolol
105
Alpha and beta blockers common meds
Alpha receptor blockade = adds vasodilation
Carvedilol
Labetaolol
106
Beta blockers common useage
Used in hypertension, angina, tachydysrhythmias, heart failure, MI
107
Beta1 blocker considerations/teaching
Bradycardia, decreased cardiac output and worsening heart failure, AV block, orthostatic hypotension, rebound myocardium excitation with long term use without taper
108
Beta2 blocker considerations/teaching
Bronchoconstriction
| masked hypoglycemia
109
Benzodiazepines class
sedative hypnotic anxiolytics
110
Benzodiazepines typical meds
```
Alprazolam
Diazepam
Lorazepam
Chlordiazepoxide
Clorazepate
Oxazepam
Clonazepam
```
111
Common use of benzodiazepines
Relief from anxiety and panic disorders, acute trauma disorder and PTDS, hyperarousal in dissociative disorders, seizure disorders, insomnia, muscle spasm, alcohol withdrawal treatment, anesthesia
112
Side effects/considerations of benzodiazepines
CNS depression --sedation, lightheadedness, ataxia, decreased cognitive function
Avoid operating heaving machinery
Avoid alcohol
Anterograde amnesia --difficulty remembering things after taking the med
Toxicity --respiratory depression, hypotension, cardiac or respiratory arrest
Paradoxical response --opposite expected response from med
Withdrawl after long term use
Do not use in pregnancy, in people with sleep apnea, respiratory depression, or glaucoma. Use with caution in older adult patients.
113
Which meds should not be taken with grapefruit?
```
Statins (ARBs)
Calcium channel blockers (dipines)
Cyclosporins (transplant anti-rejection)
Busprione (antianxiety)
Some corticosteroids
Amiodarone
some antihistamines (allegra, claritin)
```
114
Atypical anxiolytic/nonbarbituate anxiolytics
Buspirone
115
Common use of Buspirone
Panic disorder
Social anxiety
obsessive-compulsive disorder
Trauma and stressor disorders like PTSD
116
Side effects/considerations of buspirone
Dizziness, HA, nausea, lightheadedness, agitation,
take with food, avoid activities requiring alertness
May cause constipation --increase fluid and fiber
Monitor for suicidal ideation
Do not use with MAOIs or SSRIs
Interacts with St. Johns wort, erythromycin, ketoconazole, graprfruit juice
117
Common SSRIs
```
Paroxetine
Sertaline
Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
```
118
Common use of SSRIs
```
Generalized anxiety
Panic disoerder
OCD
Social anxiety
Trauma
Dissociative disorders
Depressive disorders
Adjustment disorders
```
119
Side effects/considerations of SSRIs
May cause nausea, diaphoresis, tremor, fatigue, drowsiness for first few weeks.
May cause sexual dysfunction, weight gain, GI bleeding, hyponatremia, serotonin syndrome, bruxism (grinding of teeth).
Monitor for signs of suicidal ideation
Do not use with MAOIs
Use with caution with antiplatelet and anticoagulant meds
120
Common SNRIs
Venlafaxine
Desvenlafaxine
Duloxetine
121
Common use of SNRIs
```
Major depression
Generalized anxiety
Social anxiety
Panic dorder
Pain due to fibromyalgia, osteoarthritis, low back pain, diabetic neuropathy
```
122
Considerations/SEs of SNRIs
```
Nausea, anorexia, weight loss
HA, insomnia, anxiety
Hypertension, tachycardia
Dizziness, blurred vision
Risk for suicide in children/adolescents
Sexual dysfunction
Serotonin syndrome
Bronchitis, dyspnea
Do not use in 3rd trimester or while breastfeeding
Do not take with SSRIs, MAOIs, TCAs.
```
123
Examples of atypical antidepressants
```
Buproprion
Vilazodone
Mirtazapine
Reboxetine
Trazodone
```
124
Common use of atypical antidepressants
```
Depression
Alternative to SSRI and SNRIs
Aid for smoking cessation
Prevention of SAD
Alternative treatment for ADD
```
125
Considerations/SE of atypical antidepressants
HA, dry mouth, GI symptoms, increased HR, hypertension, restlessness, insomnia
Do not take with MAOIs
Do not use in pts with seizure or eating disorders
126
Common tricyclic antidepressants
```
Amitriptyline
Imipramine
Doxepin
Nortriptyline
Amoxapine
Trimipramine
Desipramine
Clomipramine
```
127
Common use of trycylic antidepressants
```
Depression
Depressive episodes of bipolar disorder
Neuropathic pain
Fibromyalgia
Anxiety
OCD
Insomnia
ADHD
```
128
Considerations/SEs of tricyclic antidepressants
Orthostatic hypotension
Anticholinergic effects
Sedation
Toxicity --monitor ECG, LOC
Decreased seizure threshold
Excessive sweating
Do not use in pts with seizure disorder, recent MI, known CAD, DM, kidney or liver disease or respiraotry disorder.
If at risk for suicide, only dispense 1 week at a time as overdose is very lethal
Do not use with MAOIs or St Johns Wort
Avoid use with anticholinergics and antihistamines, epinepherine, dopamine, alcohol, benzos, opioids
129
Common MAOIs
Phenelzine
Isocarboxazid
Tranlycypromine
Selegiline (Transdermal)
130
Common use of MAOIs
```
Depression
Bulimia
panic disorder
social anxiety disorder
generalized anxiety
OCD
PTSD
```
131
Considerations/SEs of MAOIs
CNS stimulation
Orthostatic hypotension
Hypertensive crisis
Tachycardia
Do not use with SSRIs, HF, cerebral vascular disease, carbamezapine, ephedrine, amphetamine,
Avoid tyramine rich foods (aged cheese and cured meat, avocado, fig, banana, smoked fish, protein supplemetns, soups, soy sauce, beer, red wine) and caffeine
132
Common first generation anti-psychotics
```
Chlorpromazine
Haloperidol
Fluphenazine
Thiothixene
Perphenazine
Thioridazine
```
133
Common uses for first gen anti-psychotics
Mostly control positive symptoms of psychotic disorders (hallucinations, delusions, bizarre behavior)
Also prevention of N/V
More commonly used with violent or aggressive pts because adverse side effects
134
Common SE/considerations for first gen anti-psychotics
Extrapyramidal side effects (EPS)
Acute dystonia --spastic tongue, neck, face, back
Parkinsonism --bradykinesia, rigidity, shuffling gain, drooling, tremor
Tardive dyskinesia --involuntary movement of tongue, face, lip smacking, arms, legs, trunk
Neuroleptic malignant syndrome --life threatening emergency. Muscle rigidity, high grade fever, dysrhythmias, BP fluctuations, change in LOC
anticholinergic effects
Gynecomastia
Seizures
Photosensitivity
Orthostatic hypotension
Sedation
Sexual dysfunction
Agranulocytosis
Severe dysrhythmias
Liver impariment
135
Common second and third generation antipsychotics
Risperidone
Olanzapine
Clozapine
Ziprasidone
136
Common uses of second and third generation antipsychotics
schizoprhenia
Psychotic episodes
Bipolar disorders
Impulse control disoders
137
Considerations/SEs of second and third generation antipsychotics
```
DM, loss of glucose control
Weight gain
Hypercholesterolemia
Orthostatic hypotension
Anticholinergic effects
Agitation
Dizziness
Sedation
Sleep disruption
Milkd EPS (tremor, akathisa --can't sit still)
Elevated prolactin levels
Sexual dysfunction
Do not give to patients with dementia, alcohol. Use caution in patients with cardiovascular or cerebrovascular disease, seizure disorder, DM, immunosupressant meds
```
138
ACE and ARB in pregnancy
Contraindicated for fetal toxicity
