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Prescribing - Cardiology Flashcards

1
Q

What drug class if Digoxin?

A

Cardiac glycosides

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2
Q

How does Digoxin Work?

A

Na+ K+ ATPase membrane pump inhibitor.

Increase in intracellular sodium. This leads to a subsequent rise in intracellular calcium through the Na+ Ca2+ exchanger

Causes positive inotropic effect

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3
Q

When is Digoxin used?

A

Ventricular rate control in supraventricular arrhythmias

atrial fibrillation and atrial flutter

Heart Failure

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4
Q

What is the presentation of Digoxin Toxicity?

A

Confusion
Loss of appetite
Nausea and vomiting
Diarrhoea

Evidence of cardiotoxicity ( palpitations, arrhythmias, conduction disturbances;)

eosinophilia
Rash,

Blurred or yellow vision

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5
Q

How do you manage Digoxin Toxicity?

A

withdrawal of the drug and correction of electrolyte disturbances

If that doesn’t work then Digoxin Specific antibodies

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6
Q

What are contraindications to Digoxin?

A 
Caution in :
electrolyte disturbances (mainly Mg, Ca, K)

Thyroid disease

SRDS

Patients with recent MI

Avoid in:
Heart Block, WPW< Ventricular tachycardia or fibrillation
Myocarditis
Constrictive pericarditis

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7
Q

What does Digoxin Interact with?

A

Amiodarone (increased plasma digoxin concentration – halve dose of digoxin)
Calcium channel blockers (increased plasma digoxin concentration)
Drugs which cause hypokalaemia, Diuretics or PPI (due to hypomagnesemia) as they increase risk of cardio toxicity

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8
Q

How should Digoxin be monitored?

A

Monitor plasma digoxin concentration regularly if toxicity suspected, monitor renal function and adjust dose in renal impairment

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9
Q

What should be communicated to patients

A

Patients should be made aware of the symptoms of toxicity (nausea, vomiting, visual disturbance, confusion or dizziness)

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10
Q

What are examples of Thiazide diuretics?

A

Cendroflumethiazide

Hydrochlorothiazide

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11
Q

What are examples of Thiazide like diuretics?

A

Indapamide
Chlortalidone
Metolazone

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12
Q

How do thiazide like diuretics work?

A

Inhibits NA+ Cl- symporter in distal convoluted tubule. Meaning their reabsorption is inhibited and water does also not get reabsorbed. Causing reduction in blood volume and pressure.

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13
Q

what are side effects of Thiazide and Thiazide like diuretics?

A

Altered plasma-lipid concentrations (elevated LDL cholesterol)
Gout
Electrolyte disturbances
Hyperglycaemia

Impotense!!!

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14
Q

When are thiazide like diuretics contraindicated?

A

Caution if malnourished and have renal impairment

Caution in patients with PMH of Gout or Diabetes

Do not use in:
Addisons disease
active gout
refractory electrolyte disturbances

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15
Q

What are interactions of Thiazide and Thiazide like diuretics?

A

Other antihypertensives (increased hypotensive effect)

Antidiabetic drugs (reduced hypoglycaemic effect)

Lithium (increased plasma lithium concentration, risk of toxicity)

NSAIDs (impaired diuresis AND increased risk of nephrotoxicity)

Other drugs causing hyponatraemia (diuretics, antidepressants, carbamazepine)

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16
Q

What needs to be measured with Thiazide and Thiazide like diuretics?

A

U+E

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17
Q

What drug class if Frusemide?

A

Loop diuretic

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18
Q

How do loop diuretics work?

A

Inhibit Na+ K+ 2Cl- symporter in the thick ascending limb of the loop of Henlé.

Prevents the transport of sodium from the lumen of the loop of Henle into the basolateral interstitium.

Lumen becomes more hypertonic while the interstitium becomes less hypertonic.

Diminishes the osmotic gradient for water reabsorption throughout the nephron.

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19
Q

What are side effects of Frusemide?

A

GI disturbance
Postural hypotension
Electrolyte distubances
Tinnitus

Important:

Hyperglycaemia, Hyperuricaemia (gout)
Ototoxicity
Nephrotoxicity
Hepatic encephalopathy

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20
Q

What are contraindications for Frusemide?

A

Hypovolaemia
Hypotension
Prostatic hypertrophy
PMH of of diabetes or gout

Anuria
Severe hyponatraemia/hypokalaemia
liver cirrhosis
renal failure (nephrotoxic),

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21
Q

What are drug interactions of Frusemide?

A

Antihypertensives (increased hypotensive effect)

NSAIDs (impaired diuresis AND increased risk of nephrotoxicity)

Aminoglycoside antibiotics and vancomycin (increased risk of ototoxicity)

Lithium (increased plasma lithium concentration, risk of toxicity)

Thiazide diuretics (increased risk of electrolyte disturbance)

Pregnancy

Digoxin (risk of cardiotoxicity)

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22
Q

What drug class is Spironolactone?

A

Aldosterone-dependent potassium sparing diuretics

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23
Q

How does Spironolactone work?

A

Antagonist to aldosterone receptors in the renal tubules.

Inhibits Na+/K+ exchange in the distal tubule and collecting ducts, promoting potassium retention and sodium and water loss.

Causing weak diuresis, potassium retention and hypotensive effect

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24
Q

What are the side effects of Spironolactone?

A

GI upset
Hyperkalaemia

Important:

Gynaecomastia/hypogonadism, impotence in males, menstrual irregularities in females

Acute renal failure

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25
What are contraindications to Spironolactone?
Avoid in hyperkalaemia, hyponatraemia, anuria and Addison’s disease
26
What are the drug interactions of Spironolactone?
Drug affecting RAAS (increased risk of hyperkalaemia) ACE inhibitors ARBs direct renin inhibitors Other potassium sparing diuretics e.g. amiloride, triamterene (increased risk of hyperkalaemia) Potassium supplements Antihypertensives (increased hypotensive effect) NSAIDs (increased risk of nephrotoxicity) Lithium – excretion is inhibited by spironolactone
27
What should be communicated to the patient when prescribing Spironolactone?
take this medication with or after food. Avoid salt substitutes as they have high potassium Do not take NSAIDs
28
What drug class is Amiodarone
Anti-arrythmic (class III)
29
How does Amiodarone work?
Prolongs the cardiac action potential seen as an increase in the QT interval on the ECG
30
What are side effects of Amiodarone?
``` Bradycardia Hyper/hypothyroidism Jaundice Trrmour D + V ``` Peripheral neuropathy and myopathy!! Optic neuritis!!
31
When is Amiodarone contraindicated?
caution in heart failure avoid in thyroid disorders SAN heard block or bradycardia
32
Amiodarone interacts with which medicines?
Antiarrythmics- increased risk of myocardial depression Antihypertensives - bradicardia and AV block risk Digoxin - increases digoxin concentration, must half digoxin dose Warfarin- increased anticoagulatory effect TCA - increases risk of ventricular arrhythmia statins - increases myopathy risk
33
What needs to be checked on Amiodarone?
Ongoing monitoring: LFT TFT ECG before starting: CXR K+
34
What should be communicated to patients?
Avoid exposure to direct sunlight and sun lamps during treatment and for several months after wear high factor sunscreen Advise patients that this medication can produce changes in their eyes which may cause them to be dazzled by car headlights when driving at night.
35
What drug class is Bisoprolol?
B Blocker
36
what are cardioselective BBlockers ?
Atenolol, Metoprolol, Nebivolol
37
What are non cardioselective BBlockers
Carvedilol, Propranolol
38
How do BBlockers work?
is an antagonist to B adrenoreceptors meaning there is a reduction in contractility (negative intropy), reduce heart rate (negative chronotropy), reduce blood pressure, reduce cardiac work
39
what are side effects of BBlockers
common: Dizziness, fatigue, cold hands, impotence, headache Important: Hypotension raynauds and intermittent claudication bradycardia
40
What are contraindications to BBlockers
Asthma Heart block Hypotension Har failure (needs monitoring as can exacerbate) Diabetes - may mask symptoms of a hypo
41
What are the interactions of BBlockers?
Alcohol (increased hypotensive effect) Other antihypertensives (increased hypotensive effect) Anti-arrhythmics (bradycardia, myocardial depression, ventricular arrhythmias) Clonidine (increased risk of rebound hypertension when stopping beta blockers)
42
what is important to communicate to patients ?
Explain to patients that they should not stop taking this medication unless told to do so by their doctor.
43
What drug class if Doxazosin
Alpha 1 blocker
44
how do Alpha 1 blockers work
alpha adrenoreceptor antagonist causing Vascular smooth muscle relaxation, vasodilatation and reduction in arterial blood pressure
45
When are alpha 1 lockers used?
Hypertension Benign prostatic hyperplasia (α1 specific) Raynaud’s syndrome (prazosin)
46
what are side effects of alpha 1 blockers
``` Anxiety back pain influenza-like symptoms; paraesthesia sleep disturbance vertigo ``` Postural hypotension!!!
47
When are alpha 1 blockers contraindicated?
Parkinsons if about to have cataract surgery (floppy iris) first dose may cause hypotension and collapse best taken at bedtime
48
What drug interactions do alpha 1 blockers have?
Other antihypertensives (increased hypotensive effect) MAOIs (enhanced hypotensive effect)
49
What is important to communicate to patients
fist dose at nighttime before bed - first dose hypotension | may cause in ability to perform skilled tasks
50
What drug class is rampril?
ACEi
51
How does ramipril work?
Inhibits ACE thus nhibits synthesis of potent vasoconstrictor peptide angiotensin II leading to vascular smooth muscle relaxation and vasodilatation reducing BP
52
What are side effects of Ramipril
Persistent dry cough hyperkalaemia and increase in serum creatinine (First dose) hypotension Important!! Acute renal failure, cholestatic jaundice/hepatitis Angioedema
53
What are contraindications for Ramipril?
caution with diuretics Pregnancy!!!
54
What are interactions for Ramipril?
Diuretics - hypotension and hyperkalaemia if pot. sparing potassium salts immunosuppressnts lithium
55
What needs to be measured when prescribing Ramipril?
U+E
56
What needs to be communicated to patients about Ramipril?
Explain need for blood U+E. If a dry cough occurs to go to GP Take first dose at night before bed.
57
What drug is class is Irbesartan?
angiotensin receptor blocker
58
How do ARBs work?
Antagonist at angiotensin receptor meaning theres Selective inhibition of potent vasoconstrictor peptide angiotensin II leading to vascular smooth muscle relaxation and vasodilatation
59
What are side effects of ARBs?
First dose hypotension acute renal failure! angioedema!
60
what are contraindications to ARBs?
pregnancy and breast feeding
61
what do ARBs interact with?
other antihypertensives and potassium sparing diuretics lithium
62
what needs to be monitored
U+E
63
what class is Glyceryl Trinitrate
Nitrates
64
How does GTN work
Nitrate binding to its receptor causes an intracellular reaction which causes a reduction in intracellular calcium causing smooth muscle relaxation and vasodilation.
65
What are side effects of GTN?
``` headache Postural hypotension Tachycardia Flushing Tolerance ```
66
What are contraindications to using GTN?
Hypothyroidism recent MI heart failure hypotension
67
What can GTN interact with?
antihypertensives
68
what should be communicated to patients?
Explain to patients how they should take their GTN – spray 1-2 times under the tongue and then close mouth. This medication is for use when the patient notices their angina symptoms – it is for relief of an acute attack.
69
Amilodipine drug class?
CCB
70
How does amilodipine work?
Inhibit influx of calcium ions into vascular smooth muscle cells through L-type calcium channels decreasing arterial smooth muscle contratility leading to vasodilatation
71
What are common side effects of Amilodipine?
``` Abdominal pain oedema dizziness fatigue flushing headache palpitation sleep disturbances ```
72
What are important side effects of Amilodipine?
Heart failure in patients with poor left ventricular function
73
What are contraindications for Amilodipine
elderly heart failure MI in last month
74
What drugs does amilodipine interact with?
Antihypertensives Simvastatin (inc. myopathy) Digoxin (inc. plasma concentration) Theophylline (inc. theophylline concentration)
75
Diltazem and Verapamil drug class?
Rate limiting CCB
76
How do rate limiting CCB's work?
Antagonist to L type calcium channels. Inhibiting calcium influx causing negative inotropic effect
77
what are common side effects?
``` Asthenia Constipation Oedema Dizziness Headaches Hypotension and bradicardia ```
78
what are important Side effects?
sino atrial and AV block in those taking digoxin or B Blockers
79
what are contraindications for ditazem/verapamil?
B Blockers!!! can cause systole, severe hypotension and heart failure antiarrythmics and antihypertensives verapamil shouldnt be used in VT
80
what is the name of a low molecular weight heparin?
Deltaparin
81
How do LMWH work?
The activate anti-thrombin this inhibits clotting factor Xa meaning that prothrombin does not get converted to thrombin does inhibiting coagulation
82
What are important side-effects of LMWH?
Haemorrhage heparin induced thrombocytopenia – this is immune-mediated and doesn't develop until 5 to 10 days afterwards hyperkalaemia
83
What are contraindications for low molecular weight heparin?
Elderly and those at risk of falls renal or hepatic impairment haemophilia and other haemorrhagic disorders recent haemorrhage peptic ulcer disease those with a particularly low body weight
84
What drugs does LMHW interact with?
NSAIDS anti platelet ACE inhibitors and ARBs – increased risk of hyperkalaemia
85
What is the monitoring of low molecular weight heparin?
Platelet count and potassium should be checked at the start of treatment regular monitoring if treatment is over four days
86
What drug class is warfarin?
Vitamin K antagonist
87
How does warfarin work?
It is a competitive inhibitor to vitamin K reductase it depletes the active clotting factors 2, 7, 9 and 10 causes anticoagulation takes several days to work
88
What are common adverse effects of warfarin?
Haemorrhage and bruising
89
what are important side effects of warfarin?
Skin necrosis high-sensitivity (pyrexia) liver disfunction causing jaundice
90
What contraindications to warfarin?
Pregnancy peptic ulcers disease and anyone at risk of bleeding renal impairment
91
What is the monitoring of warfarin?
IN our should be checked regularly at the beginning of treatment done every day then progressively longer intervals until up to 12 weeks once the steady INR is achieved
92
What should be communicated to patients when taking warfarin?
Do not take any over-the-counter medicines especially aspirin without checking with the pharmacist make sure you inform anyone he wants to start you taking medication you are on warfarin do not get pregnant avoid drinking cranberry juice or eating lots of leafy green vegetables do not binge drink take warfarin at the same time everyday
93
What drugs interact with warfarin?
increase anticoagulant effect Alcohol NSAIDS and aspirin
94
What type of drug is Riveroxiban?
A factor XA inhibitor prothrombin is in converted thrombin meaning fibrongen isn't converted to fibrin
95
what are common side effects of riveroxiban
``` Abdominal pain constipation or diarrhoea dizziness dyspepsia pain in the extremities headaches ```
96
What are serious side-effects of riveroxiban
Haemorrhage hepatobiliary disorder renal impairment
97
What does rivaroxiban interact with
NSAIDS amiodarone verapamil triazole antifungals
98
What drug class is aspirin?
Antiplatelet
99
How does aspirin work?
Is an irreversibleinhibitor of cyclooxygenase enzymes reduces platelet aggregation
100
What is a typical dose of aspirin?
75 mg once daily
101
What are important side effects of aspirin?
Bronchospasm GI irritation – ulceration and bleeding
102
what are contraindications to Aspirin?
Asthma uncontrolled hypertension previous peptic ulcer avoid in active peptic ulcer disease, haemophilia and other breathing disorders
103
What drugs does aspirin interact with?
NSAID Anticoagulants SSRI
104
What should be communicated to patients about aspirin?
Advise patients to take tablet whole. Do not take indigestion remedies. To be taken with food. Not to be given to children under 12 increases risk of Reyes syndrome.
105
What replaces clopidogrel?
An anti platelet
106
How does clopidogrel work?
Is an inhibited ADP receptor inhibits platelet aggregation
107
What are common side effects of clopidogrel?
GI disturbances and bleeding disorders (including intracranial)
108
What drugs does clopidogrel interact with?
Other antiplatelet or anticoagulant fibrinolytic PPIs or H2 agonists NSAIDs
109
what drug class is simvastatin?
It's a statin
110
How do statins work?
Target the HMG CoA reductase as a competitive inhibitor. Meaning that hepatic cholesterol is synthesised less and up regulates LDL receptors and increased removal of hepatic LDL overall reducing LDL cholesterol reducing triglycerides and increasing HDL cholesterol
111
When are statins used?
Treatment of hypercholesterolaemia prevention of cardiovascular events in high-risk patients with atherosclerosis or diabetes mellitus
112
What are common side effects of statins?
Abnormal liver function tests (elevated transaminases) - stop If this occurs GI disturbance e.g. constipation and flatulence myalgia
113
What are important side effects of statins?
myositis hypothyroidism low body mass index Rhabdomolysis
114
When are statins contraindicated?
In active liver diseaseor history of liver disease | in pregnancy
115
What drug interactions are there with statins?
``` Myopathy risk increases with: amiodarone CCB antifungals colchicine ``` warfarin – may increase anticoagulant effect
116
What monitoring is required with statins?
LFTs - checked every three months if suspecting rhabdomyolysis check CKs TFT, CK, HBA1C, U+E at start
117
What is important to communicate to patients when taking statins?
Report properly any unexplained muscle pain, tenderness or weakness report any shortness of breath coffee or weight loss do not get pregnant on statins or one month after taking statins

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