Pharm Quiz 4 Flashcards
1
Q
What is the most effective diuretic?
A
Loop diuretics
2
Q
When is Furosemide indicated?
A
Pulmonary Edema associated with CHF
Edema of hepatic, cardiac, or renal origin that has been unresponsive to other diuretics.
HTN that cannot be controlled with other diuretics
3
Q
What diuretic compliments Furosemide?
A
Thiazide diuretic
4
Q
Transient side effect of Furosemide:
A
Hearing loss
5
Q
Drug interaction with Furosemide:
A
Digoxin with hypokalemia can lead to ventricular dysrhythmias
NSAIDs
6
Q
What are three other loop diuretics?
A
Ethacrynic Acid
Torsemide
Bumetanide
7
Q
Hydrochlorothiazide Dose
A
12.5-25mg/day
8
Q
Where does Hydrochlorothiazide act?
A
It acts in the early segment of the distal convoluted tubule, which means it is dependent on flow of urine.
9
Q
Spironolactone MOA
A
Blocks action of Aldosterone, which promotes sodium uptake in exchange for potassium secretion. The effects of Spironolactone are delayed because they act on the cells.
10
Q
Spironolactone Dose
A
25-200 mg/day
11
Q
What is Spironolactone used for?
A
It is usually used in combination with a thiazide or loop diuretic.
It also decreases mortality and hospital admissions with HF patients.
12
Q
Side effect of Spironolactone:
A
Steroid derivative that can cause gynecomastia, menstrual irregularities, and impotence.
13
Q
Triamterene and Amiluride
A
Directly inhibits secretion of Potassium. Only produce moderate diuresis. Usually used in conjunction with loop or thiazide diuretics.
14
Q
What does Angiotensin II do?
A
Vasoconstricts and stimulates Aldosterone release
15
Q
How does Angiotensin II change vascular and cardiac structure?
A
Hypertrophy
Remodeling
Thickens blood vessel walls`
16
Q
Renin
A
Catalyzes angiotensin I from angiotensinogen
17
Q
How does the RAAS act?
A
Vasoconstriction and renal retention of water and sodium.
18
Q
Characteristics of ACE inhibitors:
A
Oral
Administered with food
Prolonged half lives
Prodrugs
Excreted by kidneys
19
Q
Lisonopril dose
A
10-40 mg/day
20
Q
What are benefits of ACE inhibitors?
A
Do not interfere with cardiovascular reflexes, which means they are good for exercising.
Orthostatic hypotension is minimal after first dose.
Used safely for bronchial asthma.
21
Q
How are ACE inhibitors useful for HF?
A
Improve cardiac afterload by relaxing vessels.
Decrease pulmonary congestion.
Promote excretion of water.
Prevent pathologic cardiac changes.
22
Q
What do ACE inhibitors prevent?
A
MI prevention and recovery
Prevents diabetic and nondiabetic nephropathy (decreases GFR pressure)
Reduce risk of diabetic retinopathy
23
Q
Black Box Warning ACE inhibitors, ARBs, Alisirken
A
Fetal injury
24
Q
ACE inhibitors AE:
A
Renal failure with stenosis
Cough
Hyperkalemia
Angioedema
Neutropenia
25
ACE inhibitors drug interactions
Lithium
NSAIDs reduce effects
26
Losartan Dose
50-100mg/day
27
ARB MOA
Block angiotensin II receptors
28
What ARBs are approved for HF?
Valsartan and Candesartan
29
What ARBs are approved for diabetic nephropathy?
Irbesartan and Losartan
30
What ARB is approved for MI?
Valsartan
31
What ARB is approved for stroke prevention?
Losartan
32
What ARB reduces the risk of MI, stroke, and death?
Telmisartan
33
Aliskiren
Binds with renin to prevent angiotensinogen into angiotensin I.
Did not improve outcomes in hospitalized patients with HF.
34
Eplerenone
Selective aldosterone receptor blocker with little to no effect on other steroid receptors.
35
Eplerenone Indication:
No information on whether it reduces morbidity and mortality, so only give to patients who have not responded to traditional antihypertensives.
36
What do CCBs do?
They work on arteries, decrease contractility, decrease SA and AV node speed, and are directly related to B-Adrenergic effects.
37
Nifedipine
Dihydropyridine that only works on vessels.
38
Verapamil and Diltiazem
Non-dihydropyridine that work on the vessels and the heart.
39
What are the direct effects of Verapamil?
Arterial Dilation
Coronary perfusion
Reduces HR
Decreases force of contraction
40
What is the net effect of Verapamil?
Because of the body compensating, the main effects are simply arterial dilation.
41
What is Verapamil used for?
Angina Pectoris
HTN
Afib/Aflutter
Paroxysmal Supraventricular Tachycardia
42
Drug interactions with Verapamil:
Digoxin, B-Blockers, grapefruit juice,
43
How is the barrow-reflex triggered?
By immediate-release Nifedipine, which can lead to increased mortality in patients with MI and unstable angina d/t reflexive effects.
44
What is Nifedipine indicated for?
Angina pectoris w/ a BB
HTN
45
Adverse effects of CCBs:
Flushing
Dizziness
Peripheral edema
Gingival hyperplasia
Rash
46
What CCB is preferred for patients with a AV block, HF, Bradycardia, or SNS?
Nifedipine
47
Stage 1 HTN
130-139 or 80-89
48
Stage 2 HTN
>140 or >90
49
How can the barrow-reflex be overcome?
Usually with a BB. Once reset it will not oppose medications as much.
50
What drugs work on the brainstem and sympathetic ganglia?
Clonidine and Mecamylamine that suppress sympathetic action
51
What are the top two drugs for chronic HTN if there are no compelling indications?
Thiazide diuretic have been shown to decrease mortality and morbidity the most then Verapamil. (pg 21171)
52
Step-down therapy
After 1 year medications should be reduced or eliminated.
53
What medications should be avoided for patients with HF?
Diltiazem and Verapamil since they decrease contractility
Anti-dysrhythmics
NSAIDs
54
What medications should be avoided for patients with AV block?
BBs and CCBs since they decrease AV
55
What medication should be avoided for patients with CAD and post-MI?
Hydralazine can precipitate a reflex tachycardia --> anginal attack.
56
What medications should be avoided for patients who have dyslipidemia?
BBs and diuretics may exacerbate
57
What medications should be avoided for patients who have diabetes?
Thiazides promote hyperglycemia and BBs mask symptoms of hypoglycemia.
58
What should HTN patients with renal insufficiency be given?
ACEs and ARBs usually with a diuretic.
59
What is the preferred medication for diabetes?
ACEs and ARBs
60
First choice medication for African Americans?
Diuretics
61
What medications do AAs not respond as well to?
ACEs and BBs unless indicated by another condition
62
What dose should be given for elderly patients?
Start with half and increase slowly
63
What is the definition of chronic hypertension before pregnancy?
Developed before the 20th week of gestation
64
What are the drugs of choice when starting during pregnancy?
Methyldopa, Labetalol, Nifedipine
65
When does BP need to be treated in pregnancy?
>180S and >110D
66
What is preeclampsia?
BP >140/90 and proteinuria >300 that develops after the 20th week of gestation
67
Do anti-hypertensives help preeclampsia?
Studies have failed to demonstrate any benefits from antihypertensive drugs.
68
What are the consequences of HF?
Tachycardia
Increased Contractility
Increased venous tone
Increased Arteriolar tone
Cardiac Dilation
69
What balances out sympathetic tone?
ANP and BNP
70
NYHA Scheme
Class 1 -no changes in activity
Class 2 -slight limitation of patient activity
Class 3 -mild activity causes symptoms
Class 4 -symptoms occur at rest
71
ACC/AHA Scheme
Stage A -high risk but no changes
Stage B -Structural changes but no symptoms
Stage C -structural changes with symptoms
Stage D -refractory HF requiring intervetions
72
Can Thiazide diuretics be used for HF?
Only work if GFR (CO) is high
73
What is the first-line treatment for HF?
ACEs usually combined with a diuretic and BB
74
Why do ACEs help HF?
Dilate veins and arteries
Suppress Aldosterone --> more H20 and Na excretion
Elevate kinins --> prevention of remodeling
75
Why are ARBs useful for HF?
They improve LV EF, increases exercise tolerance, reduce HF symptoms. However, they do not increase bradykinin levels (decreased remodeling and decreased coughing).
76
Entresto
Newly approved ARB that decreases RAAS and increases Bradykinin.
77
When should ARBs be given?
When patients still have symptoms with BB and ACE.
78
How does Aldosterone negatively impact HF?
Increases remodeling
Increases fibrosis
Increases SNS
Promotes baroreceptor dysfunction
79
Spironolactone BB
Tumorigenesis
80
What BB are used for HF?
Metropolol ER, Cavedilol, Bisoprolol
81
Digoxin
Reduces symptoms but does not decrease mortality. Second-line for HF.
82
Bidil
Isosorbide dinitrate and Hydralazine combination used only for black patients.
82
What are the benefits of Digoxin?
Sympathetic tone declines
Urine production increases
Renin release declines
83
Patient education regarding Digoxin:
Monitor pulses to look for dysrhythmias. Do not give for a HR below 50.
84
AE Digoxin:
Hypokalemia
84
What is the treatment for Digoxin dysrhythmias?
Lidocaine and Phenytoin
Fab antibody fragments decrease Digoxin toxicity.
85
What is the treatment for Stage A HF?
Treating risks
86
What is the treatment for Stage B HF?
ACE and BB
87
What is the treatment for Stage C HF?
ACE, Diuretic, and BB.
Give aldosterone-blocker if symptoms are moderate or severe or after a MI.
88
What is the treatment for Stage D HF?
They may need a heart transplant of LVAD.
BB and ACE may be tried but could start profound hypotension.
89
ASCVD Risk Factors
Diabetes = ASCVD
Black Race
Advancing Age
HTN
Smoking
90
What factors are included in the Framingham Risk Prediction Score:
Systolic BP
Total cholesterol
HDL
Age
Smoking Status
91
Who should be treated for ASCVD?
Pts with ASCVD
LDL >190
40-75 with diabetes and LDL 70-189
10 year risk of >7.5%
92
What is the treatment of choice for lowering Cholesterol?
If the goal is lowering the Cholesterol levels by 40%, then Atorvastatin or Lovastatin is best (HMG-Coa reductase inhibitor). Otherwise it doesn't matter.
93
What medications should be implemented if Atorvastatin is not enough?
Monoclonal antibodies
Bile acid sequestrants
Niacin
94
Metabolic Syndrome Diagnosis:
>2 of the following:
>150 TG
<50 HDL
Hyperglycemia
>130/85
Waist circumference >35
95
What is the treatment for high TGs?
Decrease LDLs first and if still necessary give a fibrate for TGs specifically.
96
When are the effects of statins seen?
2-6 weeks
97
What do statins accomplish?
Lower LDL, TGs (for a short time), and increase HDLs
98
What are some secondary effects of statins?
Promote plaque stability
Reduce inflammation at plaque site
Slow coronary calcification
Enhance ability of vessels to dilate
Decrease risk for thrombosis
99
Statin MOA
Normalizes cholesterol production
Produces more hepatocyte LDL receptors --> metabolism
Decrease production of apolipoprotein --> decrease VLDL and TG
100
What is the goal for LDL?
<100 or in patients with high CV risk <70
101
Rosuvastatin Indications
For patients with normal LDLs but have advanced age, high levels of C-reactive protein, and one other risk factor for CV.
Double the level in Asian patients.
102
When should diabetes patient have a statin?
>40 years
LDL >100
One other risk factor
103
Statin AE
Myopathy --> Myostisis--> Rhabdomyolysis (increased CK)
Hepatotoxicity (Fine to give to NASH)
Diabetes
104
Risk factors for Rhabdomyolysis
CKD
Low Vit D
Hypothyroidism
105
Atorvastatin Dose
10 mg
106
What statin should be used for patients with renal impairment?
Atorvastatin or Fluvastatin
107
Colesevelam
Bile Acid Sequestrant:
Better tolerated
Does not decrease absorption of DAKE
Does not decrease absorption of Digoxin, Warfarin
108
Bile Acid Sequestrant MOA
Increases LDL receptors on hepatocytes and prevent reabsorption of of bile acids
109
Gemfibrozil (Fibrate)
Decreases TG and increases HDL
110
Alirocumab and Evolucumab
Inhibits PCSK9 that binds to lipid receptors preventing metabolism
111
How are monoclonal antibodies administered?
SQ
112
What is the equation for total cholesterol?
TG + LDL +HDL
113
Hydralazine
Dilates arterioles and reflexively increases HR and contractility
114
Acetylators
Patients breakdown Hydralazine through acetylation
115
Hydralazine AE
Hydralazine-induced hypotension caused by water and Sodium retention.
Systemic Lupus Erythematosus like syndrome
116
What is Hydralazine combined with in patient with HF?
Isosorbide dinitrate (a drug that dilates veins)
117
Minodixil
Only used for severe hypertension d/t adverse effects
118
AE Minodixil
Reflex Tachycardia
Na and H2O retention
Hypertrichosis
119
Minodixil BB
Pericardial effusion
120
AV Block Degrees
1st Degree: conduction is slowed
2nd Degree: Only some impulses pass through
3rd Degree: All traffic in the AV node stops
121
Where does VT come from?
Usually from a previous MI
122
Rate controlled treatment of Afib
Metoprolol
Diltiazem (Cardiac selective CCB)
123
How restore Afib rate:
Ablation
Amiodarone, Sotalol
Cardioversion
Must take Warfarin 3 weeks before and 4 weeks after.
124
Long-term anticoagulant therapy for afib
Eliquis
Xarelto
Pradaxa
Savysa
125
Treatment for aflutter:
Cardioversion converts to SNS and patients will need long-term Class I or III agents to prevent recurrence.
Alternatives: Ablation or rate control with drugs that suppress AV conduction.
126
Drugs that suppress AV conduction:
Diltiazem, Verapamil, or a BB
127
What is SVT caused by?
A recurrent feedback loop where HR is 150-200.
128
SVT Treatment:
Valsalva Maneuvers
IV BB or CCB
BB or CCB to prevent recurrence (or Amiodarone as a last resort).
129
VT treatment:
Immediate Cardioversion
IV Amiodarone
Lidocaine
Long-term management: Amiodarone, Sotalol, ICD
130
Treatment for Torsades de Pointes (ventricular tachydysrhythmia)
Cardioversion and IV Mag
131
What dysrhythmias do not need to be treated?
Non-sustained, mildly symptomatic, and supraventriculars
132
Quinidine
Class Ia Na ion blocker --> slower impulse conduction and delayed repolarization.
It also is anti-cholinergic, so it should be given with a BB to prevent excessive ventricular stimulation.
Used for long-term suppression of supraventricular and ventricular rates.
133
How does Quinidine effect the EKG?
Widens the QRS complex and prolongs the QT interval.
134
Quinidine BB
May increase mortality in afib and aflutter
135
Quinidine Drug Interactions
Doubles amount of Digoxin
136
Mexiletine (oral analogue of Lidocaine)
Accelerates repolarization
Little effect on EKG
Used for sustained VT or PVCs
137
Class II Drug Propanolol
Closely related to CCBs
Used for excessive stimulation of the heart caused by exercise induced dysrhythmias, Sinus Tachycardia, and severe recurrent VT.
138
Class II Drug Amiodarone
Potassium channel blocker
Delay repolarization of fast potentials
Prolong QT elongation
139
Indications for Amiodarone
Hemodynamically unstable VT
Vfib
Converting Afib
First-line med for patients with HF for treating these.
140
BB Amiodarone
Lung and Liver toxicity
141
Amiodarone AE
Thyroid Toxicity
Ototoxicity
Dermatologic Toxicity
142
Amiodarone Drug Interactions
Diuretics
CCBs and BBs --> severe bradycardia
Statins
143
Class IV Drug Diltiazem and Verapamil
CCBs
Slows SA and AV and decreases contractility
144
Class IV Indications
Treat Afib and Aflutter IV within 2-3 minutes
145
Digoxin for dysrhythmias
Treats supraventricular dysrhythmias by decreasing speed of SA and AV nodes except for Perkinje fibers --> more dysrhythmias.
146
How does Digoxin effect the EKG?
Prolongs PR
Shortens QT
Inverted T wave
147
What drugs are used for variant angina?
Nitrates and CCBs
148
How does nitroglycerine decrease pain?
In stable angina dilates veins --> decreased preload --> decreased cardiac demands
In variant angina, it relaxes the blood vessels --> increased oxygenation
149
How should tolerance to Nitro be prevented?
Lowest Dose
At least 8 drug free hours/day
150
How should long-lasting Nitro be discontinued?
Slowly to prevent vasospasm
151
Isosorbide Mononitrate Isosorbide Dinitrate
Pharmacologically the same as nitroclycerin
152
How do BBs help angina?
Decrease cardiac oxygen demand leading to increased exercise tolerance.
Blunt reflex tachycardia from Nitro.
Increase time in diastole.
153
BB AE
Bradycardia
Decreased contractility and AV conduction means they should not be used by HF, SNS, or AV Block patients.
154
How do CCBs help angina?
Relax variant spasm
Relax peripheral vessels
155
Ranolazine AE
QT Prolongation
HTN
156
What do Verapamil and Diltiazem do differently than Nifedipine?
They decrease HR, contractility, and conduction which means they should not be used for patients with HF.
157
Drugs to prevent MI:
Anti-platelets
Cholesterol lowering
ACEs
158
Flow chart for treatment of Angina
Nitro w/ BB --> CCB -->Long acting nitrate --> CABG
159
What is the treatment flow chart for spastic angina?
CCB or long acting nitrate —> both —> CABG
160
What are anticoagulants used for?
Disrupt the coagulation cascade preventing thrombosis in the veins and atria of the heart by reducing the formation of fibrin.
161
What are antiplatelet used for?
They prevent platelet aggregation to prevent thrombosis in arteries.
162
What is Heparin's MOA?
Enhance the activity of antithrombin that inhibits thrombin and factor X.
163
What are LMWs' MOA?
Inactivate factor Xa
164
What are the indications for LMW?
Hip, abdominal, and knee surgery
Prevention of DVT
Prevention of unstable angina
165
How is LMW administered?
SQ but only needs to be adjusted based on weight or kidney function.
166
What is the reversal for Heparin?
Protamine Sulfate
167
Fondaparinux MOA
Selectively inhibits Factor Xa
168
Indications for Fondaprinux:
Knee, hip, or abdominal surgery
Treating acute PE or DVT (with Heparin)
More effective at treating DVT than LMW but may cause more bleeding.
169
MOA of Warfarin:
Suppresses production of factors VII, IX, and X by inhibiting the production of the active form of Vitamin K.
170
Indications of Warfarin:
Prevention of PE
Prevention of thrombus on prosthetic valves
Prevention of thrombus in Afib
171
What is the INR goal?
2-3 but cannot be adjusted quickly.
172
When should PT be monitored?
Daily for the 1st 5 days
2/week for the next 2 weeks
1/week for the next 4 months
Then 1-2/month
173
What foods contain Vit K?
Mayonnaise, canola oil, and soybean oil.
These foods do not need to be avoided but need to stay constant.
174
Dabigatran
Reversible direct thrombin inhibitor.
Standard doses, rapid onset, no need for monitoring, few drug-food interactions, low risk for bleeding.
175
Dabigatran and Xarelto Indications:
Prevention of stroke
Prevention of thrombus in Afib
Knee surgery
Treatment of DVT or PE
176
Xarelto MOA
Inhibits Factor Xa
177
Dabigatran and Xarelto Reversal Agents
Idarucizumab and Andexanet Alfa
178
Aspirin MOA
Inhibits Cyclooxygenase necessary to create TXA
179
Indications for Aspirin:
Ischemic Stroke
TIA
Both anginas
Stenting
MIs
180
When should patients take Aspirin for MIs?
If the have a 10% risk for cardiovascular or colorectal cancer, have a life expectancy of 10 years, and are willing to take Aspirin for 10 years.
181
Clopidogrel MOA
Prevent ADP aggregation. Not reversible.
182
Clopidogrel Indications:
Prevent blockage of coronary stents
Reduce thrombus events in patients with atherosclerosis.
Should always be given with Aspirin.
183
Clopidogrel BB:
Should not be used by poor metabolizers (determined by saliva test)
184
Vorapaxar MOA
Inhibits thrombin. Reversible.
185
Vorapaxar Indications:
Patients with history of MI or PAD. Used with Clopidogrel or Aspirin.
186
Dipyridamole Indications:
Always used with Warfarin for a heart valve replacemnt
187
Dipyridamole and Aspirin
Used for recurrent stroke
188
Cilostazol Indications
Intermittent claudication
189
How much iron does a pregnant woman need?
27 mg/day
190
What are the labs needed for a diagnosis of IDA?
Microcytic hypochromic erythrocytes
Absence of Hemosiderin
191
Dose of Ferrous Sulfate
500 mg
192
How quickly does iron improve HGB?
In 1 month it will raise by 2g/dl
193
What should be determined if the patient's HGB does not rise after a month?
Bleeding
Noncompliance
Inflammatory disease
Malabsorption
194
What is Vitamin B12 used for?
Synthesis of DNA which means it is required for all cells.
195
What causes B12 deficiency?
Celiac Disease
Bariatric surgery
Regional Enteritis
Development of antibodies against B12
196
Pernicious Anemia
Deficiency of B12 secondary to lack of intrinsic factor
197
Megaloblastic Anemia
Lack of B12 for DNA prevents RBC division. Severe anemia is the primary cause of death from B12 deficiency
198
What system is most likely to be affected by lack of B12?
Where a large number of cells turn over (bone marrow, GI)
Cause demyelination of neurons
199
B12 Dose
1000-2000 mcg/day for 1-2 weeks
200
Diagnosis of B12:
Megaloblasts and macrocytes in in peripheral blood
201
What are the causes of folic acid deficiency?
Alcohol use
Malabsorption secondary to intestinal disease (Sprue)
202
Folic Acid Dose
1-5mg daily then 400mcg daily for maintenance
