pharmacy test 2 Flashcards
what classification of antihypertensive drugs is found to be more effective in Caucasian patients than African American?
beta blockers and ACE inhibitors
what classification of antihypertensive drugs is found to be more effective in African American patients than Caucasian?
calcium channel blockers
what does the parasympathetic nervous system stimulate?
stimulates smooth muscles, cardiac muscles, glands
what does the sympathetic nervous system stimulate?
stimulates heart, blood vessels, skeletal muscles
Acetylcholine
chief neurotransmitter of parasympathetic nervous system
Norepinephrine
a neurotransmitter of the sympathetic nervous system
Clonidine and methyldopa
Peripheral Alpha 1 Blockers
Decreases norepinephrine production
Stimulates alpha2-adrenergic receptors, thus reducing renin activity in the kidneys
= result in decreased BP
not typically first line
Propranolol, metoprolol, and atenolol
Beta Blockers
Reduction of the heart rate through beta1 receptor blockade
Cause reduced secretion of renin
= results in decreased BP
Labetalol and carvedilol
Duel-Action Alpha 1 and Beta Blockers
Dual antihypertensive effects of reduction in heart rate (beta1 receptor blockade) and vasodilation (alpha1 receptor blockade)
Adrenergic Drugs Indications
hypertension, glaucoma, benign prostatic hyperplasia (BPH), management of severe heart failure
doxazosin, prazosin, and terazosin (adrenergics) are used to treat
benign prostatic hyperplasia (BPH)
Adrenergic Drugs Contraindications
Acute HF, MOAIs, peptic ulcers, severe liver/kidney disease and asthma (with beta blockers)
Why aren’t adrenergic drugs used to treat acute heart failure?
They have a negative ionotropic effect. Used to treat heart failure, but not in the acute / exacerbation phases
Adrenergic drugs side effects
Bradycardia with reflex tachycardia, dry mouth, drowsiness, sedation, constipation, depression, edema, sexual dysfunction (affects compliance), headaches, sleep disturbances, nausea, rash, abrupt discontinuation can lead to rebound hypotension
high instance of orthostatic hypotension
first-dose syncope
Adrenergic drug interactions
Can cause additive CNS depression with alcohol, benzodiazepines, opioids
Clonidine (Catapres)
Used primarily for hypertension, management of opioid withdrawal (blocks sympathetic nervous system activity)
Oral and topical patch
Alpha1 Blockers
Doxazosin (Cardura)
Prazosin (Minipress)
Tamsulosin (Flomax)* - symptomatic hypertension only
Terazosin (Hytrin)
Doxazosin (Cardura)
Alpha1 Blocker
Reduces peripheral vascular resistance and BP by dilating both arterial and venous blood vessels
Carvedilol (Coreg)
Dual-Action Alpha1 and Beta Receptor Blocker
widely used and well tolerated
Uses: hypertension, mild to moderate HF in conjunction with digoxin, diuretics, and ACE inhibitors
Contraindications: cardiogenic shock, severe bradycardia or HF, bronchospastic conditions such as asthma, and various cardiac problems involving the conduction system
Nebivolol (Bystolic)
beta receptor blocker
uses: hypertension and HF
Action: blocks beta1 receptors and produces vasodilatation, which results in a decrease in SVR
causes limp dick disease
Angiotensin-Converting Enzyme (ACE) Inhibitors
Often used as first line drug for heart failure and hypertension
can be used with thiazide diuretic and calcium channel blockers
ACE inhibitor naming convention
ends in -pril
which blood pressure medication is cardioprotective?
ace inhibitors
they decrease the SVR
ace inhibitors are the hypertension rug of choice for
heart failure, kidney disease and diabetic patients
why would ace inhibitors be used in patients for kidney disease
they reduce glomerular filtration pressure
ace inhibitor indications
Hypertension
HF (either alone or in combination with diuretics or other drugs)
Slow progression of left ventricular hypertrophy after myocardial infarction (MI) (cardioprotective)
Renal protective effects in patients with diabetes
ace inhibitor adverse reactions
Fatigue
Dizziness
Headache
Mood changes
Impaired taste
Possible hyperkalemia
Dry, nonproductive cough, which reverses when therapy is stopped
Angioedema (facial swelling): rare but potentially fatal
first dose hypotension
ace inhibitor and lab values
can cause kidney failure leading to a high creatinine
can cause hyperkalemia
Captopril (Capoten)
oral ace inhibitor
Prevention of ventricular remodeling after MI; reduce the risk of HF after MI, but it must be taken 2-4 times a day
Enalapril (Vasotec)
oral and parenteral ace inhibitor
metabolized by the liver
Angiotensin II Receptor Blockers (ARB)
Well tolerated
Do not cause a dry cough that is common with ACE inhibitors
Angiotensin II Receptor Blockers (ARB) naming convention
-sartin
Losartan (Cozaar), Eprosartan (Teveten), Valsartan (Diovan), Irbesartan (Avapro), Candesartan (Atacand), Olmesartan (Benicar), Telmisartan (Micardis), Azilsartan (Edarbi)
arbs vs ace
arbs seem to be equally effective in treating hypertension and are better tolerated because lack of cough
arbs have a lower post MI mortality rate
not clear if they are cardioprotective in cases of heart failure or protect the kidneys in cases of diabetes
ARB side effects
Chest pain, fatigue, hypoglycemia, diarrhea, urinary tract infection, anemia, weakness
Hyperkalemia and cough are less likely to occur than with the ACE inhibitors.
Losartan (Cozaar)
ARB
indications: HTN, HF
use with caution in renal patients
contraindicated in pregnancy and breastfeeding
Calcium Channel Blockers
indications: HTN and angina, dysrhythmias, migraine headaches, Raynaud’s disease
Cause smooth muscle relaxation by blocking the binding of calcium to its receptors, preventing muscle contraction
Diuretics
decreases plasma and extracellular secretions to reduce blood pressure. Decreases workload of the heart
Vasodilators Examples
Diazoxide (Hyperstat)
Hydralazine (Apresoline)
Minoxidil (Rogaine) - For hair regrowth
Nitroprusside (Nitropress)
what is used in htn emergencies?
Sodium nitroprusside and IV diazoxide
Hydralazine (Apresoline)
vasodilator
Orally: routine cases of essential hypertension
Injectable: hypertensive emergencies
BiDil: specifically indicated as an adjunct for treatment of HF in African-American patients
Sodium Nitroprusside (Nitropress)
vasodilator
Used in the intensive care setting for severe hypertensive emergencies; titrated to effect by IV infusion
contraindications: known hypersensitivity to the drug, severe HF, and known inadequate cerebral perfusion
Hydralazine: Adverse Effects
dizziness, headache, anxiety, tachycardia, edema, dyspnea, nausea, vomiting, diarrhea, hepatitis, systemic lupus erythematosus, vitamin B6 deficiency, and rash
Minoxidil: Adverse Effects
T-wave electrocardiographic changes, pericardial effusion or tamponade, angina, breast tenderness, rash, and thrombocytopenia
Sodium nitroprusside: adverse effects
bradycardia, decreased platelet aggregation, rash, hypothyroidism, hypotension, methemoglobinemia, and (rarely) cyanide toxicity
Eplerenone (Inspra)
selective angiotensin blocker
Reduces BP by blocking the actions of aldosterone at its corresponding receptors in the kidney, heart, blood vessels, and brain
Indications: routine treatment of hypertension and for post-MI HF
Bosentan (Tracleer)
Specifically indicated only for the treatment of pulmonary artery hypertension in patients with moderate to severe HF
Action: blocks receptors of the hormone endothelin
Sildenafil and Tadalafil
for erectile dysfunction
Also used for pulmonary hypertension but with different trade names
Sildenafil: Revatio
Tadalafil: Adcirca
Treprostinil (Remodulin)
for pulmonary artery hypertension
most potent diuretic?
loop
Carbonic Anhydrase Inhibitors (CAIs)
helps body produce hydrogen to excrete bicarbonate
acetazolamide (Diamox) – most commonly used
methazolamide
dichlorphenamide
Carbonic Anhydrase Inhibitors: Indications
not useful for hypertension
glaucoma, edema, altitude sickness and when other diuretics are not working
Carbonic Anhydrase Inhibitors: Adverse Effects
can induce respiratory and metabolic acidosis, high glucose in diabetic patients, hypokalemia, drowsiness, anorexia, paresthesia’s, hematuria, urticaria, photosensitivity, melena (blood in the stool)
Carbonic Anhydrase Inhibitors: Interactions
may lead to dig toxicity
corticosteroids may cause hypokalemia
Increased effects of amphetamines, carbamazepine, cyclosporine, phenytoin, and quinidine with concurrent use of CAIs
loop diuretics
Bumetanide (Bumex)
Ethacrynic acid (Edecrin)
Furosemide (Lasix)
Torsemide (Demadex)
sulfa drug allergy can occur, but its rare
not obvious reason for loop diuretics
Increase renal excretion of calcium in patients with hypercalcemia
s/s hypokalemia
muscle spasms, muscle weakness, hypotension, excessive thirst, excessive urination, arrythmia
loop diuretic interactions
Digitalis toxicity precipitated by hypokalemia
Lithium toxicity precipitated by hyponatremia
Can potentiate hypotensive effects for patient treated with antihypertensive agents
NSAIDS reduce diuretic effects
On steroids, potentiate hypokalemia
osmotic diuretics
Mannitol (Osmitrol) - Most used osmotic diuretic
Urea
Organic acids
Glucose
osmotic diuretics nursing implications
use a filter needle because it can crystalize at room temperature
Osmotic Diuretics: Indications
helps to prevent kidney damage during acute renal failure caused by hypovolemic shock
sodium retention, water excretion
reduces intraocular pressure, ICP from cerebral edema but doesn’t do shit for peripheral edema
Osmotic Diuretics: Adverse Effects
Convulsions, thrombophlebitis, pulmonary congestion/edema
Fluid & electrolyte imbalance
Potassium-Sparing Diuretics
spironolactone (Aldactone) (prototype drug)
triamterene (Dyrenium)
amiloride (midamor)
weak when used alone, used in heart failure
Spironolactone and triamterene (dyrenium) indications
Hyperaldosteronism, hypertension, reversing the potassium loss caused by potassium-losing drugs and certain cases of heart failure
Amiloride (midamor) indications
heart failure
what to do if K sparing diuretics spare too much and you get hyperkalemia?
If detected, may DC medication, limit dietary intake or administer insulin to pump back into the cell depending on severity/symptoms
what is dangerous about salt subsitutes?
usually made of potassium and can lead to hyperkalemia
thiazide diuretics
Hydrochlorothiazide (Esidrix, HydroDIURIL) HCTZ
Chlorothiazide (Diuril)
thiazide-like diuretics
Metolazone (Mykrox, Zaroxolyn)
Chlorthalidone (Hydone, Thalitone)
Indapamide (Lozol)
Thiazide and Thiazide-like Diuretics: Indications
Hypertension ( most prescribed drugs )
Edematous states (chronic-peripheral)
Idiopathic hypercalciuria – most common cause of kidney stones
Heart failure due to diastolic dysfunction
Adjunct drugs in treatment of edema related to HF, hepatic cirrhosis, corticosteroid or estrogen therapy
Promote diuresis if renal function not impaired
Thiazide and Thiazide-like Diuretics: Adverse Effects
hypokalemia - watch for dig tox
Dehydration/hypovolemia
Hyponatremia
Hyperglycemia in diabetics
Increased lipids esp. triglyderides, LDL
Hyperuricemia( even at low dose)
Azotemia (in renal patient)
potassium rich foods
Dried apricots, potatoes, banana, carrot, prune juice, dried beans, legumes, whole grains, citrus, cruciferous vegies
nursing implications for diuretics
Rapid diuretic – loop
For patients on Lasix – potassium supplement and tele monitor
Lasix – may cause photosensitivity
Nitrates/Nitrites Mechanism of Action and Drug Effects
Cause vasodilation due to relaxation of smooth muscles
Potent dilating effect on coronary arteries
Result: oxygen to ischemic myocardial tissue
Used for prevention and treatment of angina depending on form
long acting nitrates indications
Used to PREVENT anginal episodes
Ointment, patch
nitrate contraindications
Severe anemia
Closed-angle glaucoma
Hypotension
Severe head injury
Use of the erectile dysfunction drugs sildenafil (Viagra), tadalafil (Cialis), and vardenafil (Levitra) - could dangerously lower BP
Nitroglycerin
for angina
IV form used for BP control in perioperative hypertension, treatment of HF, ischemic pain, pulmonary edema associated with acute MI, and hypertensive emergencies
nitroglycerine nursing implications
do not chew sublingual form. it might burn. don’t spit it out
Storage: no moisture, light, room temp; non-transparent container. Air-tight no light. 3 month shelf life
sit down when you take it
do not take with viagra
Nitroglycerin: IV Indications
BP control in perioperative hypertension
treatment of HF, ischemic pain
pulmonary edema associated with acute MI
hypertensive emergencies
NON PVC TUBING AND BAG
Nitrates: Adverse Effects
Headaches- usually, diminish in intensity and frequency with continued use
Profound and/or postural hypotension
Reflex Tachycardia
Skin irritation with topical application
Tolerance may develop! (have a nitrate free-period, take it off at night)
Isosorbide
Used for:
Mitigation in # of acute attacks
Prophylaxis in situations that may provoke angina
Long-term prophylaxis of angina
beta blockers for angina
atenolol (Tenormin)
metoprolol (Lopressor)
propranolol (Inderal)
nadolol (Corgard)
calcium channel blockers for angina
verapamil (Calan, Isoptin)
diltiazem (Cardizem) – effective for angina and afib
nifedipine (Procardia)
amlodipine (Norvasc) – good for angina and hypertension
calcium channel blockers side effects
Constipation is a common side effect. – high fiber, stool softener, plenty of water unless contraindicated
Angiotensin Receptor-Neprilysin Inhibitors (ARNI)
Valsartan/sacubitril (Entresto)
Blocks the degradation of vasoactive peptides by inhibiting the neprilysin enzyme
Common adverse effects: hypotension, hyperkalemia, increased serum creatinine
Nesiritide (Natrecor)
last stitch effort drug, used in ICU
Synthetic version of human B-type natriuretic peptide
vasodilates arteries and veins
side effects: hypotension, dysrhythmia, headache, abdominal pain, insomnia
Milrinone
Only available phosphodiesterase inhibitor - injection
Adverse effects: cardiac dysrhythmias, headache, hypokalemia, tremor, thrombocytopenia, and elevated liver enzyme levels
additive effect for diuretics and dig
digoxin
Positive inotropic effect (force of contraction)
Negative chronotropic effect (rate of heartbeat)
Negative dromotropic effect (conduction of electrical impulses)
makes heart beat more effectively and slower
digoxin nursing implications
monitor K and dig level
listen to apical heart rate for one minute
watch for halo vision, n/v/d
digoxin therapeutic level
0.5-2.0 ng/mL
digibind
antidote to digoxin, however its only used for emergencies
that includes dig overdose, severe sinus bradycardia not responding to other treatment and potassium over 5
Vaughn Williams classification
- Some – sodium channel blockers
- Block –beta blockers
- Potassium – potassium channel blockers
- Channels – calcium channel blockers
Antidysrhythmics: Adverse Effects
ALL antidysrhythmics can cause dysrhythmias!
Hypersensitivity reactions
Nausea, vomiting, and diarrhea
Dizziness
Headache and blurred vision
Prolongation of the QT interval
Procainamide (Pronestyl)
CLASS 1A
Uses: atrial and ventricular tachydysrhythmias
Significant adverse effects: include ventricular dysrhythmias, blood disorders, systemic lupus erythematosus (SLE)–like syndrome, nausea, vomiting, diarrhea, fever, leukopenia, maculopapular rash, flushing, and torsades de pointes resulting from prolongation of the QT interval
Contraindications: known hypersensitivity, heart block, and SLE
Quinidine (Quinidex)
class 1a
Significant adverse effects: cardiac asystole and ventricular ectopic beats
Others: cinchonism (tinnitus, loss of hearing, blurring vision, GI upset)
Black box warning: can cause torsades de pointes
Lidocaine (Xylocaine)
class 1b
Significant adverse effects: twitching, convulsions, confusion, respiratory depression or arrest, hypotension, bradycardia, and dysrhythmias
Contraindications: hypersensitive, severe SA or atrioventricular (AV) intraventricular block, or Stokes-Adams or Wolff-Parkinson-White syndrome
Flecainide (Tambocor)
class 1c
Negative inotropic effect and depresses left ventricular function
Adverse effects: dizziness, visual disturbances, and dyspnea
Contraindications: hypersensitivity, cardiogenic shock, second- or third-degree AV block, and non–life-threatening dysrhythmias
Propafenone (Rythmol)
1c
Use: life-threatening ventricular dysrhythmias, atrial fibrillation
Most common reported adverse reaction: dizziness
Others: metallic taste,
Atenolol (Tenormin)
class 2
Check blood pressure and apical pulse. Hold for bradycardia
Esmolol (Brevibloc)
Ultrashort-acting beta blocker
Use: acute treatment of supraventricular tachydysrhythmias; hypertension; post-MI tachydysrhythmias
Amiodarone (Cordarone, Pacerone)
class 3
Uses: one of the most effective antidysrhythmic drugs for controlling supraventricular and ventricular dysrhythmias
Can turn your skin blue, or a greyish blue tone – mostly happens in sun exposed areas
Ibutilide (Corvert)
class 3 used for afib
Diltiazem (Cardizem, Others)
Class IV
Temporary control of a rapid ventricular response in patients with atrial fibrillation or flutter and PSVT
Contraindications: hypersensitivity, acute myocardial infarction, pulmonary congestion, Wolff-Parkinson-White syndrome, severe hypotension, cardiogenic shock, sick sinus syndrome, or second- or third-degree AV block
Verapamil (Calan)
Class IV
Inhibits calcium ion influx across the slow calcium channels in cardiac conduction time
Results in dramatic effects on the AV node
Adenosine (Adenocard)
has a D. brings heart rate down
Slows conduction through the AV node
Used to convert PSVT to sinus rhythm
Very short half-life—less than 10 seconds
Only administered as fast intravenous (IV) push
May cause asystole for a few seconds
Other adverse effects are minimal.
lidocaine nursing implications
Solutions of lidocaine that contain epinephrine should not be given IV; they are to be used ONLY as local anesthetics. Pull the RIGHT lidocaine
hold digoxin for what heart rate
below 60
