WK5-Pharmacology

Question 1

What is the main issue we address in medication management for CV patients?

Answer 1

Addressing neurohormonal and haemodynamic response.

e.g. when CO falls = decreased perfusion of vital organs (inc. kidney)
- response - compensatory hormones release (angiotensin/adrenaline)

Question 2

What are ACE inhibitors?

Answer 2

“-prils”
Common names: perindopril (Coversyl), Ramipril (tritace), fosinopril (monopril), enalopril (renitec), captopril (acenorm), lisniopril (fibsol)

Inhibits conversion of AngT I to AngT II - reduces vasoconstriction, Na+ retention and aldosterone release

Indications: HTN, HF

SE: hypo, dizziness, hyperkalaemia, dry cough

Question 3

What are ARBs?

Answer 3

Angtiotensin II receptor blocker

Common names: Irbesartan (Avapro), Candesartan (Atacand), Telmisartan (Micardis), eprosartan (teveten)

MOA: blocks binding of AngT II to AngT receptors
- used instead of ACEI? (ACEI SE: dry cough)
- lowers BP, monitors body’s response to low CO
- avail. in combo products

SE: hypo, dizziness, headache, hyperkalaemia

Question 4

What are BB?

Answer 4

Beta-blockers “lol”
–> limits affect of adrenaline on heart
Common names: Atenolol (Noten), Metoprolol (minax), propranolol (deralin)

Indications: HTN, prevent angina, HF, regulate HR

MOA: block B receptors in heart (bronchi, periphery), reduces workload on heart = reduces O2 decrease in afterload

SE: hypo, diziiness, fatigue, vivid dreams

Question 5

What are Ca2+ channel blockers?

Answer 5

2 GROUPS
1. dihydropyridines: Amlodipine (norvasc), Lercandipine (Zanidip)
* mainly act on arteriolar SM = reduce periph vasc res and BP
* minimal effect on myocardial cells

2. Nondihydropyridine: Diltiazem (cardizem), Verapamil (Anpec)
   * act on cardiac/arteriolar/smooth muscle
   * decrease cardiac contractility, HR, conduction (verapamil>diltiazem)

Indications: HTN, angina, irregular beat
SE: headache, flushing, fatigue, constipation

Question 6

What are anti-platelets?

Answer 6

Aspirin (astrix)
Clopidogrel (plavix)
Ticargrelor (brilinta)
Prasugrel (effient)

Indications: POST stent (DAPT) and ACS
AE: bleeding, increased bleeding time, GI irritation

Question 7

What are cholesterol lowering medicines?

Answer 7

“statins”
Atorvastatin (lipitor)
Rosuvastatin (crestor)
Simvastatin (lipex)
Pravastatin (pravachol)
Fluvastatin (vastin)

MOA: inhibits HMG-CoA reductase enzyme that synthesises cholesterol in liver
* reduces total cholesterol concentration, increase blood cholesterol uptake, decrease LDL and TG, small increase in HDL
* pleiotropic effects (plaques stabilisation, decrease inflam response)

SE: headache, trouble sleeping, myalgia (myopathy, rhabdomyolysis)

Question 8

What are nitrates?

Answer 8

Glyceryl trinitrate (GTN) - anginine
GTN spray (used in 1st aid for angina)

Indication: prevent/Tx angina

MOA: nitric oxide mediates vasodilation (predom. venodilators) = decrease preload/afterload (decrease venous return to heart)

AE: mainly due to vasodilatory effect (ortho hypotension, headache, flushing, palpitations, fainting)

Question 9

What are the 4 main meds in the European update to HFrEF guidelines?

Answer 9

1. ACE-1/ARNI (AngT neprilysn inhibitor - new med “Entresto”)
2. BB
3. MRA (magnetic resonance angiography)
4. SGLT2i (new med)- block glucose reabsorption into kidney

Question 10

How if HFrEF managed with medications?

Answer 10

Medication titration
* increased to target dose or max. tolerated dose

ACEI or ARB or ARNI + BB and MRA are titrated

e.g. BB - regular doses until titrated

Question 11

What are anti-coagulants?

Answer 11

Warfarin (marevan, Coumadin) - Vit K antagonist

NOACS:
Rivaroxaban (Xarelto) and Apixaban (eliquis) = Factor Xa inhib.
Dabigatran (pradaxa) = direct thrombin inhibitor

Indications: AF, prosthetic heart valves (warfarin), prevention/Tx of VTE (DVT, PE)

SE: bleeding (internal/external)

Question 13

What is cardiac glycoside -digoxin?

Answer 13

indication: AF, atrial flutter, HF

MOA: increase release stored intracellular Ca causing increased myocardial contraction foruce
–> reduces SNS - slows ventricular rate

SE: N&V, blurred vision, bradycardia, arrhythmia, dig toxicity

Ex considerations:
* rest - possible non-specific ST-T wave changes
* possible ST depression

Question 14

What are antiarrhythmic agents - Class III?

Answer 14

Amiodarone + Sotalol = RHR & ExHR decrease, potential hypo, no effect on Ex capacity

Amiodarone - slows AV and bypass tract conduction/prolongs refracotry period of myocardial tissues + weak BB

Indication: Tx and prophylaxis of serious tachy-arhyth refractory to other Tx e.g. VT, AF and SVT

Sotalol: non-selective BB also prolongs refractory period of atria, vetricles and bypass tract

Indication: Tx/prevention of arrhythmias e.g. atrial, SVT

Question 15

What are the three drugs that are part of “triple therapy”?

Answer 15

1. aspirin
2. clopidogrel
3. rivaroxaban

All anti-platelets! Decrease blood clot activity

Most Pt’s not on triple therapy for long time! - there is ischaemic vs bleeding risk!!
~1 month, drop a drug (usually aspirin)

• not >6M, drop to 1 anti-platelet drug

Question 16

What are NSAIDs?

Answer 16

Anti-inflam Meds

Cause:
- Na+/fluid retention
-HTN
-increased workload on heart
- renal impairment

Ibuprofen - neurofen
Diclofenac - voltaren
Naproxen - aleve naprosyn
Indomethacin - arthrexin, indocid
Celecoxib - celebrex
Meloxicam - mobic

Question 17

What is the mechanism of NSAIDs?

Answer 17

1. ACE inhibitor dilates efferent arteriole + reduced GFR
2. diuretics reduce plasma volume and GFR
3. NSAIDs constrict blood flow into glomerulus via afferent arteriole and reduce GFR

This leads to renal failure –> filtration rate and effectiveness reduces

Question 18

What are alternatives to NSAIDS?

Answer 18

Paracetamol (500mg x 2) max 8/day

Panadol Osteo SR (66mg x 2) max. 6/day

Panadeine/forte + coloxyl and senna

Oxycodone (immediate/slow release)

Buprenoprhine patches

Try to avoid opioids in the beginning

Consider co-morbidities and cause of pain

Question 19

How do cardiac meds affect Ex?

Answer 19

• Ex capacity - decrease?
• med titration affects Ex tolerance
• ACEI, BB, digoxin, nitrates - improve functional capacity in long-term
• dose increases of meds can cause transient decrease in Ex tolerance
• temporary decrease in Ex intensity/duration may be needed for Sx of dizziness, dyspnoea and fatigue

Question 20

What are the similarities and differences with COPD and asthma?

Answer 20

Both chronic inflam. disease involving small airways and reduce airflow

COPD
* reduced airflow not fully reversible
* usually progressive
* abnormal response of lung to noxious particles/gas

Asthma
* variable airflow obstruction that is often reversible
* hyperresponsiveness, bronchoconstriction
* episodes of wheezing, SOB, chest tightness, coughing (esp. morning/night)

20% of people with COPD have asthma

Asthma&COPD overlap

Question 21

What are the key aspects of COPD management?

Answer 21

1. cease smoking
2. pharmocotherapy (technique and adherence!)
3. pulmonary rehab
4. action plan
5. self-management
6. comorbidities
7. nutrition
8. vaccination

Question 22

What are the main groups for COPD and Asthma?

Answer 22

Main goal: bronchodilate!

2 Categories:

1. beta agonists - stimulates Beta2 adrenoceptors
   - SABA = short acting. Salbutamol (ventolin), terbutaline (bricanyl)
   - LABA = long acting
   Eformoterol (Oxis)
   Salmeterol (serevent)
2. Muscarlinic Antagonist - relax smooth muscle
   - SAMA - short acting
   Ipratroplum (atrovent)
   - LAMA = long acting
   Tiotroplum (spiriva)
   Glycopyrronium (seebri)

Question 23

What are the Tx steps for COPD?

Answer 23

1. Short Acting bronchodilators - use when needed
2. long acting bronchodilator (beta agonist or muscarinic antagonist - used regularly
3. beta agonist + muscarinic - used regularly
4. Add inhald corticosteroid - used regularly

Question 24

What are the Tx steps for asthma?

Answer 24

1. As needed SABA only
2. low-dose regular preventer (+SABA when needed)
3. low-dose combination regular preventer (+reliever as needed)
4. higher-dose combination regular preventer (+reliever as needed)
5. add-on specialised Tx

Question 25

Define Good control of asthma.

Answer 25

All of:
- daytime Sx <2days/wk
- need for SABA reliever <2day/wk
- no activity limitations
- no Sx during night/waking

Question 26

Define partial control of asthma.

Answer 26

one or two of:
- daytime Sx >2days/wk
- need SABA reliever >2days/wk
- Any activity limitations
- Any Sx during night/waking

Question 27

Define poor control of asthma.

Answer 27

3 or more:
- daytime Sx >2day/wk
- need SABA reliever >2days/wk
- any activity limitations
- any Sx during night/waking

Question 28

What is SABA?

Answer 28

Short acting beta2 agonist
* salbutamol (ventolin, asmol, airmoir)

MOA: relax bronchial smooth muscle - stimualtes beta 2 adrenoreceptors

Indications: Sx relief of asthma/COPD - prevent Ex induced bronchoconstriction

AE (w increased dose): tachy

Question 29

What are sytemic corticosteroids?

Answer 29

Oral steroids:
* prednisone (panafacort, sone)
* prednisolone (panafarcortolone)

1. shorten Rx time, restore lung function quickly - reduce severity of COPD exacerbations
2. reduce Tx failure
3. long-term use not recommended - no greater efficacy & increases SE

Question 30

What are some considerations for Ex and anti-biotics?

Answer 30

Fluroquinolones (ciprofloxacin)

AE: tendonitis, tendon rupture (achilles)

Increased risk:
1. elderly
2. taking CS
3. renal impairment
4. strenuous Ex