Pharm 2 exam 1

what are the two main purposes for diuretics?

to decrease edema and hypertension

what is diuresis?

inhibits sodium and water reabsorption from the kidney tubules

diuretics that act CLOSEST to the glomeruli have the GREATEST effect in causing:

hyponatremia/ excretion of sodium (natriuresis)

why do diuretics have an antihypertensive effect?

they promote sodium and water loss by blocking sodium and chloride reabsorption; low fluid=low bp

thiazide diuretics:

* promotes sodium, chloride, and water excretion BUT promotes calcium reabsorption
* should ONLY be used for pt. with normal renal function
* take in the AM, potassium supplements may be needed (check K levels)
* contraindicated with sulfa allergies
* EX. hydrochlorothiazide

loop diuretics:

* loss of sodium, water, potassium, calcium, and magnesium
* more potent for diuresis than thiazides
* Ethacrynic acid is used for pt. with sulfa allergies
* may result in gout due to uric buildup (colchicine is given for gout)
* EX. furosemide and bumetanide (sulfa derivatives)

osmotic diuretics:

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* used to decrease intracranial pressure and intraocular pressure (IOP) ;and to promote excretion of toxic substances
* prevents kidney failure
* typically used in hospitals; only available IV
* keep warm; ALWAYS use a filter
* EX. mannitol
* S/E: pulmonary edema, electrolyte imbalance, rapid shifts of fluids

carbonic anhydrase inhibitors:

* blockage of carbonic anhydrase enzyme
* carbonic anhydrase: used to maintain the body’s acid-base balance
* primarily used to decrease intraocular pressure in pt. with open-angle glaucoma

potassium sparing diuretics:

* primarily promotes sodium and water excretion and potassium retention
* monitor K levels (IMPORTANT) especially when given with an ACE inhibitor b/c both spare potassium (risk of hyperkalemia)
* take in the AM
* EX. spironolactone

what is aldosterone?

hormone that promotes sodium retention and potassium excretion

hypertension

systolic pressure over 120 and diastolic pressure over 80

* essential hypertension is the most common type

what are contributing factors to hypertension?

African Americans, diabetes, aging, stress, excessive alcohol, smoking, obesity, and family history of HTN

how do the kidneys affect blood pressure?

by the control of fluid volume and the renin-angiotensin-aldosterone system

what is a common risk from the use of antihypertensives in older adults?

orthostatic hypotension

when are antihypertensives usually ordered?

systolic pressure over 140

what is the most common diuretic used for mild hypertension?

hydrochlorothiazide (decreases excess fluid volume)

sub classes of sympatholytic drugs:

* central alpha 2 agonists
* selective alpha-adrenergic blockers
* adrenergic neuron blocker

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central alpha 2 agonists:

EX. clonidine, guanfacine, and methyldopa

* may cause peripheral edema; diuretic combo may help with this
* clonidine: dry mouth, dizziness, drowsiness

selective alpha-adrenergic blockers:

* used for pt. with lipid abnormalities and diabetes
* common S/E: orthostatic hypotension
* EX. prazosin
* do not take with NSAIDs or nitrates

adrenergic neuron blockers:

* blocks norepinephrine release form the sympathetic nerve endings which causes a decrease in norepinephrine release
* LAST choice of treatment due to significant orthostatic hypotension
* EX. reserpine
* S/E: vivid dreams, nightmares, and pseudoparkinsonism

what do direct-acting vasodilators do?

relaxes the smooth muscles of the blood vessels, mainly the arteries, causing vasodilation

* promotes an increase in blood flow to the brain and kidneys
* EX. hydralazine, minoxidil, and nitroprusside

what can be side effects of taking vasodilators?

* reflex tachycardia and release of renin may result secondary to this drug so take a beta blocker!

what can hydralazine cause?

can cause drug-induced lupus with chronic and long-term use

* safe for pregnant women

what does minoxidil do?

can be used topically to treat hair loss; alopecia

what is nitroprusside used for?

very potent; thus used for hypertensive emergencies only!

what do ACE inhibitors do?

inhibit angiotensin-converting enzyme, which in turn inhibits the formation of angiotensin II and blocks the release of aldosterone

* EX. lisinopril


* usually ends in -pril


* take 1 hour before meals; food may decrease absorption

what is a common side effect of taking an ACE inhibitor?

a chronic dry cough

what side effect is a potentially dangerous side effect of ACE inhibitors?

swelling of the face, lips, and tongue (angioedema)

* treat immediate issues (airway!)

what are angiotensin II receptor blockers (ARBs)?

blocks angiotensin production and prevents the release of aldosterone but does not cause the dry constant cough that ACE inhibitors do

* usually end in -sartan

which group of individuals are recommended ARBs?

pt. with type 2 diabetes due to the inherent renal-protective effect

what do direct renin inhibitors do?

they bind with renin which causes a reduction of angiotensin

I ,angiotensin II, and aldosterone levels

what should be avoided when taking direct renin inhibitors?

avoid high fat meals and fruit juices

what are calcium channel blockers?

blocks the calcium channel in the smooth muscle cells, promoting vasodilation

* usually end in -pines
* Very Nice Drugs (verapamil, **nifedipine**, diltiazem)
* hold dose if HR is less than 60

what are the two types of antidiabetics drugs?

insulin and oral hypoglycemic drugs

what is insulin?

a protein secreted from the beta cells of the pancreas and is necessary for carbohydrate metabolism

what are oral hypoglycemic drugs?

synthetic preparations that stimulate insulin release or alter the metabolic response to hyperglycemia

what is diabetes mellitus caused by?

insufficient insulin secretion

* can be characterized by the 3 P’s
* polyuria: increase urine output; more than 3 L a day
* polydipsia: increased thirst
* polyphagia: increased hunger

what is type 1 DM?

the does not produce any insulin

what is type 2 DM?

the MOST common

the body produces insulin but not enough

1/3 of these pt. need insulin

what is secondary DM caused by?

medication and hormones changes

when do glucose levels become diabetes mellitus?

elevated above 200

where is insulin best absorbed?

the abdomen

what insulin can be given IV?

regular insulin

what is the most common side effect of insulin?

weight gain

what are some drugs that can increase blood sugar?

thiazide diuretics, steroids, and thyroid agents

what is the somogyi effect?

it is a hypoglycemic condition that usually occurs in the hours of 2-4 am; DECREASE bedtime dose if this occurs

what is the dawn phenomenon?

it is a hyperglycemic condition that usually occurs on awakening with headache, night sweats, and nightmares ; INCREASE bedtime dose if this occurs

what group of individuals should avoid ARBs, ACE inhibitors, or direct renin inhibitors?

african americans and pregnant women

what is the most accurate lab test for DM?

A1C test

when is glucose present in the urine?

above 180

* the urine test will be +

are type 1 diabetics able to take oral medications?

no

what are factors can raise blood glucose in type 2 DM pt.?

how does insulin lower potassium levels?

by transporting K back into cells

how can hyperglycemic/ketoacidosis reactions be characterized?

BG above 250

fruity breath and extreme thirst

how can hypoglycemic reactions be characterized?

BG below 60

cold, clammy skin and tremors

which serum lab value do ACE inhibitors cause an increase in?

potassium

where should insulin be stored?

in the fridge

what are examples of fast-acting insulins?

lispro, aspart, and glulisine

what is the onset, peak, and duration of lispro (humalog)?

15-30 min

30-90 min

3-5 hr

what is the onset, peak, and duration of aspart (novolog)?

10-20 min

40-50 min

3-5 hr

what is the onset, peak, and duration of glulisine (apidra) ?

20-30 min

55 min

1\.5 hr

what is an example of short-acting insulin?

regular insulin ( Humalin-R or Novalin-R)

* ONLY given IV

what is the onset, peak, and duration of regular insulin?

subcut: 30 min; IV: 15 min

subcut: 1.5-3.5 hr; IV: 15-30 min

sucut: 4-12 hr; IV:2-6 hr

what is an example of intermediate acting insulin?

insulin isophane (NPH) ; Humanlin-N or Novalin-N

* only one that is cloudy
* make sure pt. has a bedtime snack

what is the onset, peak, and, duration of NPH?

1\.5 hr

4-12 hr

14-24 hr

what are some examples of long-acting insulin?

glargine (lantus), detemir (levemir), degludec (tresiba)

what is the onset, peak, and duration of glargine?

1-1.5 hr

none

24 hr

what is the onset, peak, and duration of detemir?

1-2 hr

6-8 hr

24 hr

what is the onset, peak, and duration of degludec?

1 hr

12 hr

42 hr

* the longest acting insulin!

what is the importance of tight glycemic control?

to control blood glucose to a “regular range” (below 7.0%)

what is an ADA ( American Diabetes Association) diet?

there is no specific diet BUT you should try eating non-starchy vegetables and lean protein

* foods that can help with glycemic control

what action do you take for hyperglycemia?

give insulin

check blood sugars

what action do you take for hypoglycemia?

eat fast-acting carbs or have a snack or meal

check blood sugars

what do sulfonylureas drugs do?

1st gen: stimulate pancreatic beta cells to secrete more insulin

2nd gen: increases the tissue response to insulin and decrease glucose production by the liver

* often end in -ide

what are some examples of sulfonylureas drugs?

Tolbutamide, Tolazamide, Chlorpropamide, Glipizide, Glyburide

what are some side effects of sulfonylureas drugs?

photosensitivity, weight gain, hypoglycemia

what are some teaching points for sulfonylureas drugs?

* avoid alcohol (disulfiram reaction: flushing,sweating,nausea, vomiting)
* NO sulfa allergies
* NO renal or hepatic dysfunction

what is biguanides (metaformin) used for?

* first line of therapy
* does NOT cause hypoglycemia
* BBW: can be worse with alcohol

what are common side effects of metformin?

diarrhea, weight loss, and b12 deficiency

what can be a side effect of diltiazem (calcium channel blocker)?

constipation

what do alpha-glucosidase inhibitors (acarbose) do?

delays carb (CHO) absorption in small intestines

what are some teaching points with alpha-glucosidase inhibitors?

* you MUST take with the first bite of food
* takes months to begin working ; causes bloating and flatulence
* DO NOT take with bowel problems (crohn’s, obstruction)

what should you give pt. who are taking alpha-glucosidase inhibitors?

sugary foods to maintain hypoglycemia with this class

what are some examples of thiazolidinediones?

Pioglitazone and Rosiglitazone

what are thiazolidinediones contraindicated with?

BBW: class II and IV HF due to fluid retention side effects

what are some meglitinide drugs?

Repaglinide and Nateglinide

meglitinide drugs:

* not currently on the ADA for tx of type 2 diabetes
* TONS of drug-drug interactions
* must be taken 30 minutes before meals, should skip if there is no meal

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what are some examples of Selective Sodium-Glucose Transporter 2 (SSGT2)?

Canagliflozin, Empagliflozin, Dapagliflozin, Ertugliflozin

what are Selective Sodium-Glucose Transporter 2 (SSGT2)?

* think of “flozins” since they are flowing glucose into the urine
* high sugar in the urine can cause UTI’s and genital fungal infections

what is a more complicated side effect of Selective Sodium-Glucose Transporter 2 (SSGT2)?

Fournier’s gangrene

what do amylin analogues (pramlintide) do?

injection pen

* can be used for type 1 and 2 DM
* Always given IN ADDITION TO insulin – insulin dose need to be reduced by 50%

what are some teaching points for amylin analogues?

* make sure to give subcut before every meal in the upper arm!
* causes GI distress; do not take if you have GI problems
* report severe hypoglycemia

what are examples of Dipeptidyl Peptidase 4 Inhibitors (DPP4)?

Sitagliptin (Januvia), Saxagliptin (Onglyza), Linagliptin (Tradjenta), Alogliptin

what do Dipeptidyl Peptidase 4 Inhibitors (DPP4) do?

an **oral** incretin med

* best used as 2nd line of therapy to metformin
* LOW risk of hypoglycemia; GREAT for obese and elderly pt.
* REPORT abdominal pain
* typically end in -tin

what is incretin?

gut hormones that are secreted from the enteroendocrine cells into the blood within minutes after eating

what are some examples of Glucagon-Like Peptide 1 Agonists (GLP1)?

Exanatide (Byetta), Dulaglutide (Trulicity), Semaglutide (Ozempic)

how are Glucagon-Like Peptide 1 Agonists (GLP1)? given?

given subcut- usually once a week