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pre reg afsha CV > TLD > Flashcards

TLD Flashcards

1
Q

name the conventional thiazides

A
  • bendroflumethiazide
  • hydrochlorthiazide
  • chlorothiazide
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2
Q

name the TLD

A
  • indapamide
  • metolazone
  • chlortalidone
  • xipimide
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3
Q

contraindications of TLDs

A
  • refractory HYPOkalaemia
  • HYPOnatraemia
  • HYPERcalcaemia
  • Addison’s
  • sympatomtic HYPERuricaemia
  • severe liver disease
  • severe RI (CrCl <30)
  • pregnancy
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4
Q

why are TLDs contraindicated in pregnancy

A

risk of neonatal thrombocytopenia, bone marrow suppression, jaundice, electrolyte disturbances, hyperglycaemia, reduced parenteral perfusion

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5
Q

which 3 conditions can TLD exacerbate and therefore its use is cautioned

A

SLE
diabetes
gout

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6
Q

cautions for TLD

A
  • elderly
  • risk of exacerbation: diabetes, gout, SLE
  • severe CVD, or being treated with cardiac glycosides
  • mild to moderate HI
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7
Q

Why are TLDs cautioned in pt with severe CVD or being treated with cardiac glycosides

A

danger posed by hypokalaemia

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8
Q

adverse effects - electrolyte imbalances include the following…
when is it advisable to monitor

A
  • hyperglycaemia
  • hypokalaemia
  • hyponatraemia
  • hypomagnesemia
  • hypercalcaemia
  • monitor esp with high doses and long term use, and in people with RI
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9
Q

adverse effects of TLDs include

A
  • electrolyte imbalances
  • hypochloraemia alkalosis
  • mild GI disturbances
  • altered plasma lipid conc
  • cardiac arrhythmias
  • dizziness and headache
  • ED
  • choroidal effusion, acute transient myopia, acute secondary CAG
  • blood and lymphatic system disorders rarely occur
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10
Q

dose of indapamide for hypertension

A

2.5mg OD in the morning
or 1.5mg daily using MR prep

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11
Q

dose of xipimide for hypertension

A

20mg OD in morning

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12
Q

dose of chlortalidone for hypertension

A
  • starting: 25mg OD in morning
  • increase up to 50mg daily if necessary
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13
Q

dose of metolazone for hypertension

A
  • starting: 5mg OD in moring
  • maintenance: 5mg OD alternate days
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14
Q

monitoring requirements for all TLDs

A
  • electrolytes, esp if high dose or long term
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15
Q

TLD are ineffective in CrCl

A

under 30

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16
Q

interactions - drugs that concern blood pressure

A
  • ARBs/ACEi: can cause rapid fall in BP in a pt who is volume depleted
  • alpha blockers: enhanced hypotensive effect and increased risk of 1st dose hypotension
  • TCAs: increased risk of postural hypotension
17
Q

Use of lithium and TLDs

A

risk of increased levels and toxicity
monitor levels regularly if used together

18
Q

TLDs and aminoglycosides

A

increased risk of ototoxicity

19
Q

What monitoring is recommended if a pt is on high dose diuretic and an ACE/ARB is to be started

A
  • if dose of diuretic is >80mg furosemide or equivalent, ACEi/ARB should be initiated under close supervision, and in some cases diuretic dose may need to be reduced or discontinued at least 24h beforehand
  • if high dose diuretic cannot be stopped, close observation is recommended for at least 2h following 1st dose of ACE/ARB, or until BP is stable
20
Q

concomitant use of TLDs and NSAIDs

A

increased risk of nephrotoxicity and antagonism of diuretic effect

21
Q

Use of CCs and TLDs

A

may potentiate hypokalaemia effect

22
Q

use of insulin and oral anti-diabetics with TLDs

A

may require dose adjustment

23
Q

Use of alprostadil, CCBs, BBs, hydralazine, nitrates, anxiolytics, MAOIs, methyldomia, minoxidil with TLDs

A

enhances hypotensive effect

24
Q

amiodarone, disopyramide, fleicanide and TLDs

A

hypokalaemia caused by TLDs increases risk of cardiac toxicity of these drugs

25
Q

use of allopurinol with TLDs

A

concurrent use may increase incidence of hypersensitivity reactions to allopurinol

26
Q

monitoring requirements of TLDs

A

serum electrolytes esp if long term use or high dose or RI

27
Q

can digoxin be used with TLDs

A

caution as predicted to increase risk of digoxin toxicity

28
Q

how potent are the TLDs as diuretics

A

moderately potent

29
Q

MOA of TLDs

A

inhibit sodium reabsorption at beginning of distal convoluted tubule

30
Q

how soon after oral administration to TLDs work and what is their duration of action

A

typically within 1-2h oral admin, duration of action 12-24h

31
Q

what time of the day to administer

A

usually in a.m. to not disturb sleep

32
Q

in the management of hypertension, what dose of TLD would you expect and why

A
  • low dose TLD provides maximal or near maximal BP lowering effect with very little biochemical disturbance
  • higher doses cause more marked changes in plasma potassium, sodium, uric acid, glucose, lipids - with little or no advantage in BP control
33
Q

what are the 2 TLDs preferred in management of hypertension

A

chlortalidone and idapamide
(bendro also licensed but not 1st line anymore)

34
Q

characteristics of chlortalidone
- duration of action
- use in oedema
- useful in which pt?
- other indication

A
  • a TLD
  • longer duration of action than thiazides
  • can be given on alternate days to control oedema
  • useful if acute retention is likely to be precipitated by a more rapid diuresis or if pt dislikes the altered patter or micturition caused by other diuretics
  • can also be used under close supervision for treatment of ascites due to cirrhosis in stable pt
35
Q

characteristics of indapamide
- related to
- useful in which comorbid?

A
  • chemically related to chlortalidone
  • indapamide claimed to to lower BP with less metabolic disturbance
  • less aggravation of DM - use this diuretic in pt with DM
36
Q

characteristics of metolozone
- combination
- side effect

A
  • effective when combined with loop diuretic (even in renal failure)
  • profound diuresis can occur so monitor carefully
37
Q

which set of patients are particularly susceptible to adverse effects of TLDs?

A

elderly - caution

38
Q

why is regular monitoring of plasma sodium essential

A

fall in plasma sodium may be asymptomatic initially

39
Q

this thiazide has MHRA advice re the risk of non melanoma skin cancer, esp in long term use

+ advice to give

A

hydrochlorthiazide

advice pt to check for and report any new or changed skin lesions or moles. limit exposure to sunlight and UV rays and use adequate sun protection.

reconsider use of this in pt who have had PHx skin cancer. examine all suspicious moles or skin lesions.

pre reg afsha CV (37 decks)

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