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YEAR 3 drug of the week > year 3 drugs of the week > Flashcards

year 3 drugs of the week Flashcards

1
Q

what are ramipril, enalapril and lisinopril examples of?

A

Angiotensin-converting enzyme (ACE) inhibitors

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2
Q

ACE inhibitors MoA

A

block ACE — prevent it from converting angiotensin I to its active form angiotensin II; decrease aldosterone secretion

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3
Q

what are 3 indications for ACE inhibitors?

A
  • hypertension
  • heart failure
  • secondary prevention CVD
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4
Q

ACE inhibitor dosing

A

dosing individual to each medication — start low and increase to maximum dose tolerated by the patient

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5
Q

what are 4 contraindications to ACE inhibitors?

A
  • severe aortic stenosis
  • severe hyperkalaemia
  • symptomatic hypotension
  • history of angioedema
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6
Q

ACE inhibitors cautions

A
  • moderate renal impairment
  • mild hyperkalaemia
  • asymptomatic hypotension or at risk of hypotension
  • ethnicity — higher rate of angioedema in black patients than in non black patients
  • may be less effective in lowering BP in black peoples than in non black patients

cautions from passmed: avoid in pregnancy and breastfeeding, caution in renovascular disease (may result in renal impairment), aortic stenosis (may result in hypotension), hereditary of idiopathic angioedema

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7
Q

what is generally recommended before initiating ACE inhibitor treatment?

A

correct dehydration, hypovolaemia or salt depletion

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8
Q

what are side effects of ACE inhibitors?

A

common (not exhaustive):

dry cough, dizziness, dry mouth, electrolyte imbalance (hyperkalaemia), GI discomfort (diarrhoea/constipation), headache, hypotension, nausea

from passmed: cough, angioedema, hyperkalaemia, first dose hypertension (more common in patients taking diuretics)

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9
Q

what should be monitored during ACE inhibitor treatment and checked before starting/increasing dose?

A

renal function and electrolytes

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10
Q

ACE inhibitors in pregnancy?

A

recommended during 1st trimester and contraindicated during the 2nd and 3rd trimesters

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11
Q

what percentage of people on ACEi get a dry cough?

A

10% — if it occurs the only way to stop it is to discontinue the medication and start another class of drugs

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12
Q

what are bisoprolol, atenolol, and betaxolol?

A

beta blockers

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13
Q

how do beta blockers work?

A

block the B1 receptors of the autonomic nervous system — slows the heart rate and reduces contractility of the heart

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14
Q

cardioselective beta blockers are 20x more potent at blocking what?

A

beta 1 receptors than b2 (located in the bronchial smooth muscle of the airways, which has the potential to cause bronchoconstriction)

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15
Q

what are 4 indications for beta blockers?

A
  • hypertension
  • heart failure
  • secondary prevention CVD
  • atrial fibrillation
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16
Q

beta blocker dosing

A

dosing individual to each medication — start low and increase to max dose tolerated by the patient

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17
Q

what are some contraindications to beta blockers?

A
  • asthma (risk of bronchospasm)
  • hypotension
  • marked bradycardia
  • severe peripheral arterial disease
  • uncontrolled heart failure
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18
Q

beta blocker cautions

A
  • diabetes (symptoms of hypoglycaemia may be masked)
  • history of obstructive airways disease (introduce cautiously)
  • portal hypertension (risk of deterioration in liver function)
  • symptoms of thyrotoxicosis may be masked
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19
Q

what are some side effects of beta blockers?

A

common (not exhaustive):

  • coldness of the peripheries
  • headaches
  • syncope
  • erectile dysfunction
  • dizziness
  • hypotension
  • sleep disturbances
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20
Q

beta blocker monitoring?

A

monitor lung function in patients with a history of obstructive airway disease

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21
Q

what can sudden cessation of a beta blocker cause?

A

a rebound worsening of myocardial ischaemia — therefore gradual reduction of dose is preferable when beta blockers are to be stopped

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22
Q

what are losartan and valsartan examples of?

A

angiotensin receptor blockers (ARBs)

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23
Q

ARB MoA

A
  • reduce the action of angiotensin II to prevent blood vessel constriction
  • angiotensin II also stimulates salt and water retention in the body, so reducing this action also reduces BP
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24
Q

what are 3 indications for ARBs?

A
  • hypertension
  • congestive heart failure
  • diabetic nephropathy
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25
Q

ARB dosing

A

dosing individual to each medication — start low and increase to max dose tolerated by the patient

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26
Q

what are cautions for ARBs?

A
  • aortic or mitral valve stenosis
  • elderly (lower initial dose may be appropriate)
  • black african or african-caribbean origin
  • history of angioedema
  • renal artery stenosis
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27
Q

what are some side effects of ARBs?

A

common (not exhaustive):

  • abdominal pain
  • diarrhoea
  • dizziness
  • headache
  • hyperkalaemia
  • hypotension
  • nausea
  • postural hypotension
  • renal impairment
  • vertigo
  • vomiting
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28
Q

monitoring with ARBs?

A

measure renal function (serum creatinine and estimated GFR) and serum electrolytes before starting treatment, 1-2 weeks after starting treatment and 1-2 weeks after each dose increase

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29
Q

when should ARBs be avoided unless essential?

A

pregnancy

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30
Q

what can ARBs not be used with?

A

ACEi

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31
Q

what are the 2 types of calcium channel blockers? give examples

A
  1. dihydropyridines — nifedipine, amlodipine
  2. non-dihydropyridines — diltiazem, verapamil
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32
Q

CCB MoA

A

act on calcium channels and inhibits Ca influx in vascular smooth muscle — results in reduced cardiac contractility and vasodilation

non-dihydropyridines also block calcium going into the conducting cells in the heart, which has the effect of slowing down heart rate. therefore can help to control certain fast heart rhythms

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33
Q

what are the 2 indications for CCB?

A

hypertension and angina

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34
Q

CCB dosing?

A

dosing individual to each medication — start low and increase to max dose tolerated by the patient

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35
Q

what are 3 contraindications to CCB?

A
  • cardiogenic shock
  • significant aortic stenosis
  • unstable angina
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36
Q

in who should you be cautious with CCB?

A

elderly

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37
Q

what are side effects of CCBs?

A

common (not exhaustive):

  • dizziness
  • flushing
  • palpitations
  • headaches
  • peripheral oedema (usually leg swelling)
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38
Q

what should be monitored with CCBs?

A

BP

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39
Q

some CCBs are available as _____________ - be careful when prescribing these

A

modified release preparations

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40
Q

ankle oedema in CCBs?

A

this is often dose related so if troublesome to patient, try reducing dose. can also try switching CCBs (non-dihydropyridines potentially better). another alternative is switching drug class

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41
Q

name the 4 different types of diuretics and give examples

A
  1. LOOP — furosemide, bumetanide
  2. THIAZIDE — bendroflumethiazide, indapamide
  3. K SPARING — spironolactone
  4. OSMOTIC — mannitol
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42
Q

MoA of diuretics

A

increase Na excretion via digression ultimately reduced cardiac afterload

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43
Q

what are indications for diuretics?

A
  • heart failure
  • fluid overload
  • oedema, including pulmonary oedema
  • hypertension
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44
Q

what are the starting doses for diuretics?

A
  • furosemide — PO 40-120mg daily, IV 20-50mg (max 1.5g total)
  • bumetanide — PO 1-5mg OD
  • bendroflumethiazide — PO 2.5-5mg OD
  • spirinolactone — PO 25-100mg OD
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45
Q

what are contraindications for loop diuretics?

A
  • renal failure due to nephro/hepatotoxic or hepatotoxic drugs
  • severe hypokalaemia
  • severe hyponatraemia
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46
Q

what are contraindications for thiazide diuretics?

A
  • Addison’s disease
  • hypercalcaemia
  • hyponatraemia
  • refractory hypokalaemia
  • symptomatic hyperuricaemia
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47
Q

what are contraindications for K+ sparing diuretics?

A
  • Addison’s disease
  • anuria
  • hyperkalaemia
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48
Q

cautions of loop diuretics

A
  • can exacerbate diabetes (but hyperglycaemia less likely than with thiazides)
  • can exacerbate gout
  • hypotension and hypovolaemia should be corrected before initiation
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49
Q

cautions of thiazide diuretics

A
  • diabetes
  • gout
  • risk of hypokalaemia
50
Q

cautions of K+ sparing diuretics

A

elderly

51
Q

common (not exhaustive) side effects of loop diuretics

A
  • dizziness
  • electrolyte imbalance
  • fatigue
  • muscle spasms
  • nausea
52
Q

common (not exhaustive) side effects of thiazide diuretics

A
  • constipation
  • diarrhoea
  • dizziness
  • electrolyte imbalance
  • fatigue
  • hyperglycaemia
  • hyperuricaemia
  • nausea
  • postural hypotension
53
Q

common (not exhaustive) side effects of K+ sparing diuretics

A
  • dizziness
  • electrolyte imbalance
  • GI disorder
  • hyperkalaemia (discontinue)
  • leg cramps
  • nausea
54
Q

what should be monitored whilst taking diuretics?

A

electrolytes and renal function should be monitored during treatment. daily weights may be measured in certain indications to measure effect

55
Q

acute kidney injury and diuretics?

A

diuretics should, in most cases, be held if a patient has an AKI. loop diuretics may be continued in certain circumstances eg. if a patient has heart failure and there is a risk of fluid overload

56
Q

when should patients be advised to take diuretics and why?

A

morning/lunchtime to avoid needing to urinate overnight

57
Q

aspirin MoA

A

irreversible COX1 inhibitor

58
Q

clopidogrel/prasugrel/ticagrelor MoA

A

irreversibly bind to P2Y12 ADP receptors and prevent ADP binding to P2Y12 receptors

59
Q

what are indications for antiplatelets?

A
  • primary and secondary prevention of CVD
  • ACS
  • prevention of atherothrombotic and thromoembolic events
60
Q

what are the starting doses of aspirin, clopidogrel and ticagrelor?

A

aspirin - PO 75mg OD
clopidogrel - PO 75mg OD
ticagrelor - PI 90mg BD

61
Q

aspirin contraindications

A

active peptic ulceration, bleeding disorders, under 16 years (risk of Reye’s syndrome), haemophilia

62
Q

clopidogrel contraindications

A

active bleeding

63
Q

ticagrelor contraindications

A

active bleeding, history of intracranial haemorrhage

64
Q

aspirin cautions

A
  • asthma
  • elderly
  • G6PD deficiency
  • history of gout
  • HTN
  • may mask symptoms of infection
  • previous peptic ulceration
  • thyrotoxicosis
65
Q

ticagrelor cautions

A
  • asthma
  • bradycardia
  • COPD
66
Q

how long before elective surgery should aspirin/clopidogrel/ticagrelor be stopped?

A

aspirin - 14 days before
clopidogrel - 7 days before
ticagrelor - 5 days before

67
Q

what are some side effects of aspirin, clopidogrel, ticagrelor?

A

common (not exhaustive):

  • aspirin — dyspepsia, haemorrhage
  • clopidogrel — diarrhoea, GI discomfort, haemorrhage
  • ticagrelor — constipation, diarrhoea, dyspepsia, dyspnoea, gout, gouty arthritis, haemorrhage, nausea
68
Q

owing to an association with Reye’s syndrome, manufacturer advises aspirin-containing preparations should not be given to children under 16 years, unless specifically indicated eg. for ________ disease

A

Kawasaki

69
Q

What does digoxin do?

A

Increases the force of contraction of the muscle of the heart by inhibiting the activity of ATPase

Inhibiting ATPase increases calcium in heart muscle and therefore increases the force of heart contractions

Also reduces conductivity within the AV node

70
Q

What are 2 indications for digoxin?

A

Atrial fibrillation and heart failure

71
Q

Digoxin dosing?

A

Starting doses: dependent on indication but should be in micrograms

72
Q

What are contraindications to digoxin?

A
  • Wolff-Parkinson-White syndrome
  • intermittent complete heart block or atrioventricular heart block
  • ventricular tachycardia or fibrillation
73
Q

Digoxin cautions

A
  • recent MI
  • thyroid disease
  • severe respiratory disease
  • hypokalaemia
  • hypomagnesaemia
  • hypercalcaemia
  • toxicity increased by electrolyte disturbances
  • elderly people (reduce dose)
74
Q

Side effects of digoxin

A

Common, not exhaustive:

  • arrhythmias
  • cardiac conduction disorder
  • cerebral impairment
  • diarrhoea
  • dizziness
  • eosinophilia
  • nausea
  • skin reactions
  • vision disorders
  • vomiting
75
Q

Digoxin monitoring

A
  • monitor serum electrolytes and renal function — toxicity increased by electrolyte disturbances
  • routine monitoring of serum digoxin is not recommended
  • consider checking serum digoxin levels if: — the person experiences adverse effects suggestive of toxicity (such as confusion, nausea, anorexia, or disturbance of colour vision)
76
Q

When can digoxin toxicity occur?

A

Even when the serum digoxin conc is within the therapeutic range (0.7 nano grams/mL and 2.0 nano grams/mL). Take blood samples at least 6 hours after the previous dose, but ideally 8-12 hours afterwards

77
Q

Name 4 DOACs

A

Apixaban, rivaroxaban, dabigatran and edoxaban

78
Q

How do the DOACs work?

A
  • apixaban, edoxaban and rivaroxaban — direct and reversible inhibitors of factor Xa
  • dabigatran — a reversible inhibitor of free thrombin, fibrin-bound thrombin, and thrombin-induced platelet aggregation
79
Q

Indications for DOACs?

A
  • stroke prevention in AF
  • DVT/PE treatment and prevention
80
Q

DOAC dosing?

A

All have different doses

Be aware all need renal adjustment. Often body weight dependant

81
Q

DOAC = antiplatelet or anticoagulant?

A

Anticoagulants

82
Q

DOAC contraindications?

A
  • Active, clinically significant bleeding
  • prosthetic heart valve
  • current/recent GI ulceration
  • significant risk of major bleeding
  • use with any other anticoagulant
83
Q

DOAC cautions?

A
  • elderly
  • low body weight
  • risk of bleeding
84
Q

Side effects of DOACs

A

Common, not exhaustive:

  • anaemia
  • haemorrhage
  • nausea
  • skin reactions
  • menorrhagia
  • vomiting
  • diarrhoea
85
Q

DOAC monitoring

A

Patients should be monitored for signs of bleeding or anaemia. Treatment should be stopped if severe bleeding occurs

No routine anticoagulant monitoring required (INR tests are unreliable)

86
Q

Warfarin MoA

A

Vitamin K antagonist — inhibits vitamin K dependent clotting factors (II, VII, IX, X) in addition to the anticoagulant proteins C and S

87
Q

Warfarin indications

A

Although no longer first line for many indications, it is first choice in patients with mechanical heart valves and valvular AF and in patients with end-stage renal failure

88
Q

Warfarin dosing

A

Variable starting dose. Dose may be variable day to day depending on INR

89
Q

Warfarin contraindications

A

Haemorrhagic stroke, clinically significant bleeding, pregnancy, within 48 hours postpartum, high risk of falls

90
Q

Warfarin interactions

A
  • metabolised by CYP450 in the liver — extensive list of interactions including phenytoin, metronidazole, and clarithromycin. Also many other antibiotics
  • also many food interactions — need to keep consistent levels of vitamins K containing products eg. Green leafy veg. Patients should be advised not to eat cranberries/drink cranberry juice also
91
Q

Warfarin side effects

A

Common (not exhaustive):

Bruising, epistaxis and bleeding for longer than expected for simple wounds

92
Q

Monitoring warfarin

A

INR is monitored. Firstly daily or on alternate days in early days of treatment, then at longer intervals (depending on response), then up to every 12 weeks. May take up to 5 days to achieve an INR within the therapeutic range. The treatment targets are usually INR 2-3: treatment of venous thromboembolism, AF, mitral valve disease and inherited symptomatic thrombophilia and INR 2.5-3.5: for mechanical heart valves

93
Q

Statins MoA

A

Competitively inhibit HMG CoA reductase, an enzyme involved in cholesterol synthesis, esp in the liver

94
Q

What are 3 indications for statins

A
  • hypercholesterolaemia
  • primary prevention of CVD
  • secondary prevention of CVD
95
Q

Statins dosing

A

Usually once daily. Certain statins (simvastatin and pravastatin) need to be taken at night, the others don’t

96
Q

Statins cautions

A

Patients at higher risk of muscle toxicity eg. The elderly, liver disease or high alcohol intake

97
Q

Statins interactions

A

Metabolised by CYP450 in the liver — therefore potentially a number of interactions. Key examples are clarithromycin (hold the statin for the antibiotic course length) and grapefruit juice (patients cannot drink this)

98
Q

Statins side effects

A

Common (not exhaustive)

  • myalgia, nausea, constipation diarrhoea, flatulence and headache
  • need to inform patients to seek medical attention if signs of muscle toxicity
99
Q

Statins monitoring

A

Pre-treatment cholesterol levels and liver function, repeated at 3 months and then 12 months. After this annually

100
Q

QRISK assessment and statins

A

The QRISK assessment tool should be used to estimate a patient’s 10 year risk of developing CVD — this can be used to guide if a statin should be prescribed

101
Q

What are the 4 types of laxatives?

A
  1. Bulk-forming. Eg. Ispaghula husk
  2. Stimulant. Eg. Bisacodyl, senna, sodium picosulfate
  3. Faecal softener. Eg. Docusate (also a stimulant), glycerol
  4. Osmotic. Eg. Lactulose, macrogol
102
Q

Bulk-forming laxative MoA

A

Increase bulk of stool by helping to retain fluid, encourages peristalsis

103
Q

Stimulant laxative MoA

A

Stimulate peristalsis and increases mobility of large intestine

104
Q

Faecal softener laxative MoA

A

Increase fluid content of stool making them easier to pass

105
Q

Osmotic laxative MoA

A

Increase amount of water in bowel, making stool easier to pass

106
Q

Indication for laxatives

A

Constipation

107
Q

Laxative dosing

A

Generally bulk-forming should be tried first. If unsuccessful add in/switch to osmotic. Next option would be stimulant

Dosing different for each medication, some best taken at night/in the morning

108
Q

Laxative cautions

A

Risk of electrolyte imbalance with prolonged use, need to maintain adequate fluid intake

109
Q

Laxative interactions

A

Nil of note

110
Q

Laxative side effects

A

Common (not exhaustive):

GI discomfort, nausea

111
Q

Laxatives pharmacokinetics

A
  • bulk-forming — a number of days for onset of action
  • stimulant — 8-12 hours onset of action
  • faecal softener — 1-2 days onset of action
  • osmotic — up to 48 hours onset of action
112
Q

What class of drugs do these belong to?

Alendronate, zoledronate, risedronate, ibandronate

A

Bisphosphonates

113
Q

How do Bisphosphonates work?

A

Slow down the process of bone breakdown by osteoclasts, whilst allowing osteoblasts to continue to enhance bone density

114
Q

What are 3 indications for bisphosphonates?

A
  • osteoporosis
  • Paget’s disease
  • patients with bone metastases
115
Q

Dosing for Alendronate, zoledronate, risedronate, and ibandronate

A

Alendronate = 70mg once weekly PO
Zolendronate = 5mg yearly IV
Risedronate = 35mg once weekly PO
Ibandronate = 150mg once monthly PO

116
Q

What are cautions for bisphosphonates?

A
  • elderly
  • active GI bleeding
  • recent Hx of GI ulcers
  • dysphagia
117
Q

Bisphosphonates: directions for administration

A

Doses should be taken with plenty of water whilst sitting or standing, on an empty stomach at least 30 minutes before breakfast (or another oral medicine); patient should stand or sit upright for at least 30 mins after administration

118
Q

What are some common (not exhaustive) side effects of bisphosphonates?

A
  • Nausea
  • oesophageal ulcer — discontinue
  • oesophagitis — discontinue
  • gastritis
  • abdominal pain
119
Q

Bisphosphonates monitoring

A
  • correct calcium/vitamin D levels before commencing
  • monitor serum calcium throughout
  • monitor renal function. Should not be sued with CrCl<30-35ml/min (check each medication)
120
Q

Bisphosphonates safety information

A

YEAR 3 drug of the week (1 decks)

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