Exam 3 Drugs

Furosemide

Patho: Inhibit sodium + chloride reabsorption from the loop of Henle + the distal tubule

why:

• More potent than thiazides
• Cause rapid diuresis ——>decrease volume, cardiac output + BP
• Hypertension, heart failure, renal disease, edema, pulmonary edema

side effects:

• Electrolyte Imbalances: Potassium (3.5-5.0 K), Sodium, Calcium, Magnesium
• Hyperglycemia
• Photosensitivity
• Hypotension
• Dehydration

Caution:
Administer slowly, ototoxicity
• Give in morning so don’t have to pee all night

HYDROCHLOROTHIAZIDE

patho:
inhibit reabsorption of sodium + chloride
• Excretion of sodium, chloride, and water

why:
Hypertension, Peripheral edema, cirrhosis
• not for immediate diuresis + used with normal functioning

side effects:

Electrolyte Imbalances: Calcium, Potassium, Sodium
• Hyperglycemia
• Hypovolemia + hypotension
• Photosensitivity

pearls:

Monitor urine output (UOP)
• Give with meals to decrease GI upset
• Replace K as needed <3.5 mEq/L
• Monitor renal function + weigh daily

SPIRONOLACTONE

patho:

• Act on distal tubule to promote sodium + water excretion + potassium retention
• Blocks aldosterone (salt water hormone)

why:

• Hypertension, edema, Heart Failure, ascites, hyperaldosteronism
• Not as powerful as loop

side effects:

• Hyperkalemia (Potassium >5 mEq/L)
• NVD
• Dizziness, weakness, HA
• Dry mouth
• Gynecomastia

contraindicated:
Severe kidney/liver disease
• Avoid foods high in potassium: green leafy veggies, melons, bananas

Osmotic-Mannitol

patho: 

Pull water into the renal tubule without sodium loss
• Very intense diuresis

why:
Cerebral edema, acute renal failure, shock

side effects:

Sudden drop in fluids: hypoTN, lightheadedness, confusion, HA

caution:
Renal disease, anuria, intracranial bleeding, dehydration
• Only given IV
• Perform neuro assessment + LOC

ACETAZOLAMIDE (DIAMOX)

Patho
• Block the effects of carbonic anhydrase
• Slow down movement of hydrogen ions
• More sodium + bicarbonate lost in urine
Why
• Used as adjunct for more intense diuresis
• Edema with Heart Failure, acute pulmonary edema, liver disease, renal disease
Side effects
• Electrolyte Imbalance: metabolic acidosis, hypokalemia, confusion
CI
• allergy, pregnancy, renal+ hepatic disease
Drug
• Salicylates + lithium

AACE INHIBITORS-LISINOPRIL

Why
• Inhibits RAAS system
• ACE converts Angiotensin I II
• Powerful vasoconstrictor
• Inhibits conversion
• Decrease in constriction + BP
Patho
• dry persistent cough
• angioedema
• Hyperkalemia
Side effects
• Monitor for hypotension + move slowly
• Monitor K+ levels
• Assess for angioedema
• Not suddenly stoprebound hypertension
Pearls

ANGIOTENSIN RECEPTOR BLOCKERS (ARBS)-
LOSARTAN

Why
• HTN
Patho
• Blocks angiotensin II receptors in smooth muscle + adrenal
cortex
• Block release of aldosterone
• Prevent peripheral vasoconstriction
Side effects
• Angioedema
• Hyperkalemia (suppression of aldosterone)
• Renal failure

Beta Blockers

Uses
• Stable Angina pectoris
• Hypertension, heart failure, cardiac dysrhythmias
• Performance anxiety
Patho
• Inhibition of Beta 1 receptors in SNS
• Blocks norepinephrine + epinephrine
• Reduction in HR
• Reduction in force of contraction
• Reduce velocity of impulse conduction
Side effects
• Bradycardia + heart block
• Reduce CO, HF
• Non selective Beta 2: bronchoconstriction
• Blood sugar masking

CALCIUM CHANNEL BLOCKERS

Patho
• Lower Heart rate + blood pressure
• Blocks movement of calcium, less nerve impulses
• Arterial SMC: vasodilation
• SA node: slowing of HR (chronotropic)
• AV node: slowing of conduction (dromotropic)
• Myocardium: reduction in contractility (ionotropic)
• Types
• Dihydropyridines: act only on arterial SMC
• Amlodipine + Nifedipine
• Non-dihydropyridines: arterial SMC + cardiac calcium channel
• Verapamil + Diltiazem

NON-DIHYDROPYRIDINES: VERAPAMIL + DILTIAZEM

MOA:

Dilation of
arterioles
• Reduction of
HR
• Reduction of
AV
conduction
• Reduction of
contractility

Uses:

• Angina
pectoris
• HTN
• Dysrhythmias

Side effects:
Cardiac:
bradycardia
+ heart block

drug interactions:
Beta
Blockers
(BB) +
Digoxin

Dihydropyridines

Therapeutic doses: only effect arteries
May be used for angina + HTN
• hypoTN
• Ankle edema
• Gingival hyperplasia
• Proteinuria

ADRENERGIC BLOCKERS- PRAZOSIN (MINIPRESS)

Block post-synaptic alpha 1 receptor sites
• Dilates peripheral arteries
• Lowers peripheral resistance + blood pressure
Alpha 1 Receptors
• Arteries, bladder, urethra,
• Hypertension, BPH, + Raynaud's
Adverse effects
• Orthostatic hypoTN= give at night
• Reflex tachycardia
• Rebound hypotension= take at same time everyday
• Nasal congestion
• Impotence

VASODILATORS

Arterial vasodilation: Hydralazine
• Decrease afterload: reducing workload
• May increase perfusion of heart
Venous Vasodilation: Nitroprusside, Nitroglycerine, Isosorbide
• Reduces venous return
• Reduces preload
Selectivity is important
Uses:
• HTN, HF, MI, angina pectoris
Side effects
• Postural hypoTN
• Reflex tachycardia
• Expansion of blood volume-combine with diuretic
• HA

Antianginal-Nitrates (Nitro-Bid, nitrostat)

Why:

• chest pain associated with angina

Patho:

• vasodialation to increase O2: veins + large arteries

• does not dilate coronary arteries

• improve blood delivery to heart muscle + decrease work of the heart —> decreasing demand of O2

• decrease preload + afterload

Side Effects:

CNS: HA,
dizziness,
weakness
• CV: hypoTN,
flushing, pallor,
increase
perspiration

CI:

Hepatic/renal
disease,
hypoTN,
hypovolemia,
ICP

Pearls:

Sublingual:
under tongue
until dissolved
• 1 tab for pain up
to 3 times
• Store: dark,
tighly caped
bottle
• Check BP
before and after
administering

HMG-CoA Reductase Inhibitors- ATORVASTATIN
(Lipitor)

Why:
Hyperlipidemia
•Primary prevention: at risk for CAD
•Secondary prevention: stabilizes fatty plaques in those with CAD

Patho:
•Blocks enzyme HMG-CoA; rate limiting step for cholesterol synthesis
•Plaque stabilization, reduction in plaque inflammation
Side Effects
•GI: flatulence, abdominal cramps, constipation
•Neuro: Dizziness, HA
•Liver: elevated enzymes, pruritis, muscle cramps* + fatigue, hepatotoxicity
drug-to-drug 
•Grapefruit juice (increases risk for toxicity), fibrates (myopathy)

Pearls
•Monitor liver levels: should lower LDL and increase HDL
•Report muscle pain immediately*
•Pregnancy- Category X

Bile Acid Sequestrants-
Cholestyramine

Why
• Prevention of CAD by decreasing serum cholesterol levels, usually combo with statin
• Gallstone dissolution
• Pruritis associated with partial biliary obstruction
Patho
• Bile made + secreted in Liver stored in Gallbladder
• Once emulsified, fats + lipids absorbed in intestines
• Bile acid resins binds to the bile acid to form an insoluble substance (can’t be absorbed)
• Excreted in feces
• Decreases bile acid= Liver uses Cholesterol to make more bile= decrease cholesterol
Side effects
• Constipation
• Increase risk for bleeding related to vitamin K malabsorption
• Vitamin A + D Deficiencies
Drug-to-Drug
• malabsorption of fat-soluble vitamins (AK, E, D), TZD, diuretics, digoxin, warfarin, thyroid hormones, corticosteroids
Pearls
• Comes in gritty powder, must be dissolved, taken with lots of fluids

Cholesterol Absorption Inhibitors- Ezetimibe (Zetia)

Why:

Lower serum
cholesterol levels
• Treat familial
hypercholesterolemi
a
• Treat homozygous
sitosterolemia

Patho:

Works in the small
intestine to inhibit
the absorption of cholesterol

Side Effects:

GI: abdominal pain,
diarrhea
• Muscle aches + pain

Drug-to-drug:

Caution combo with
statin
• Cholestyramine,
fenofibrate,
gemfibrozil, warfarin

Niacin

• Vitamin B3: inhibits release of free fatty acids from adipose tissues
• Increases rate of triglyceride removal from plasma
• SE: GI disturbance, flushing*, hepatotoxic

Fenofibrates

• Inhibits triglyceride synthesis in liver-lower LDL
• Increased uric acid secretion, stimulate triglyceride breakdown

Omega 3 Fatty Acids

• Omega 3-acid ethyl esters (Lovaza): inhibits liver enzyme system to decrease
synthesis of triglyceride
• Omega 3-carboxylic acid (Epanova): fish oil mixture of free fatty acid approved
as an adjunct to diet to reduce Tri levels with severe hypertricyleridemia

Cardiac Glycosides: Digoxin

Troublesome drug
• Decreases morbidity but not mortality
• May cause increased mortality in women
• Narrow therapeutic range: 0.5-2 ng/mL

Therapeutic Uses:

Heart Failure
• Atrial fibrillation, Atrial flutter
• Cardiogenic Shock

Digoxin:

• + inotropic effect= squeezes harder
• Inhibits Na-K ATPase and calcium accumulates in
myocytes
• Competes with K+ for binding sites
• - Dromotropic effects: slows impulses AV node
• - Chronotropic effects: beats slower

Adverse Effects:

Dysrhythmias
• May mimic ANY dysrhythmia
• If in doubt, hold digoxin
Bradycardia
Monitor K+
Monitor dig levels for toxicity
• N/V, anorexia, vision changes (yellow/green halos)

Interactions:

Causes of Toxicity
• Hypokalaemia (<3.5 mEq/L)
• Loop diuretics
• Hypomagnesemia (<1.5 mEq/L)
• Hypercalcemia (>10.2 mg/dL)
• Elderly: decreased renal and liver function

Responsibilities:

Administration:
• Apical pulse one FULL minute < 60BPM , hold
• Distribution: 23% bound to albumin
• Elimination: renal
• Must check renal function
• Pearls
• S/S of toxicity
• Drug levels and electrolyte draws
• Measure pulse BEFORE taking and when to call MD

CLASS II: BETA BLOCKERS-PROPANOLOL

Why
• Supraventricular Tachycardia (SVT), Premature Ventricular Contractions (PVC’s)
Patho
• Block beta adrenergic receptors
• Causes depression of phase 4 of action potential
• Decrease HR, cardiac excitability, and cardiac output
• Slow conduction through AV node and prolong AV node repolarization
Side effects
• CNS: hypotension, bradycardia, AV block
• Resp: bronchospasm, dyspnea
• GI: NV
• Loss of libido, decreased exercise tolerance
Caution
• Thyroid dysfunction, hepatic, diabetes

POTASSIUM CHANNEL BLOCKERS- AMIODARONE (PO, IV)

Why
• First line for V-fib maintenance
• Results in prolonged electrical impulses in all heart
cells
Patho
• Block potassium channels and slow outward
movement of K during phase 3 of the action
potential—>prolonged
• Adverse: ↓HR, lung damage, visual impairment

CLASS IV: CALCIUM CHANNEL BLOCKERS

Only non-dihidopyridines
• Verapamil & diltiazem
• Slow SA node automaticity
• Delay AV conduction
• Reduction of myocardial contractility
• Block calcium ions across the cell membrane,
depression generation of action potentials
Adverse effects
• ↓HR, AV block, Heart failure, hypotension, constipation
Fall 2023 Heart Failure 30

Adenosine

Short half-life, termination of paroxysmal SVT
• Convert SVT to Sinus rhythm when vagal maneuvers are
ineffective

Antitussives

• suppress cough reflex by direct action on medullary cough center of brain

• Robitussin, Codeine

• contraindications: head injury, cough needed to ensure airway

• caution: avoid CNS depressants

Expectorants

• decrease viscosity + more productive cough

• Guaifensin (Mucinex)

• Caution: monitor for GI effects, dizziness

• Pearls: full glass of water 

Mucolytics

• increase or liquefy respiratory secretions in high risk patients

• acetylcysteine (Mucomyst)

• Cautions: bronchospasm (asthma patient), separate nebulizer - precipitate if mixed

Oral Decongestants 

Pseudoephedrine (Sudafed)
Decrease nasal congestion-swollen nasal membranes, rhinitis
alpha 1 agonist:
vasoconstriction of the respiratory tract mucosa
SE: insomnia, palpitations, nervousness
Cautions:
•Caution with cardiac patients, HTN, hyperthyroid
•Assess for adrenergic effects- HR, BP
•Monitor for rebound congestion, limit use 3-5 days

Topical nasal deocngestant sprays

immediate onset of action
Local effect, not generally systemic
alpha 1 adrenergic receptor agonist: vasoconstriction

Phenylephrine (Coricidin)
• Caution with cardiac patients, HTN, hyperthyroid
• Assess for adrenergic effects- HR, BP
• Monitor for rebound, limit use 3-5 days

Antihistamines

Competitively blocking H1 receptors which
reduces the effect of histamine
Medications
• 1st Generation: diphenhydramine (Benedryl)
• 2nd Generation: loratadine (Claritin)
Management of:
• Seasonal allergic rhinitis (hay fever)
• Itchy, watery eyes
• Motion sickness
• Sleep disorders
• Urticaria (hives)

Side effects
• 1st: sedation, confusion,
anticholinergic
• 2nd: headache
Cautions:
• Respiratory disease due to
thickening of bronchial secretions
• Monitor for anticholinergic effects

Medication Inhalation Devices

Metered Dose Inhaler (MDI)
Uses a chemical propellant to push the medication out
• Spacer if Needed
Dry Powder Inhale
• Delivers medication without using chemical propellants, but it requires strong and fast inhalation.
Nebulizer
• Delivers fine liquid mists of medication through a tube or a mask that fits over the nose and mouth, or with a
mouthpiece, using air or oxygen under pressure.
Pearls
• Two different, wait 5 min between
• Two doses, wait 1-2 min between

Bronchodialators: Beta 2 agonists

• Dilates bronchi and increases rate
and depth of respirations
• Long-term control (prophylactic)=
LABA
• Achieve and maintain control
of persistent constriction
• Quick relief (rescue) = SABA
• Used during periods of acute symptoms

Side effects:

Tachycardia*
Palpitations*
Tremor*
Cardiac arrhythmias
Nervousness + anxiety
Insomnia

Nursing considerations :
• Assess lungs sounds pre/post
• Vital Sign pre/post
• Teach use of inhalers

Bronchodialators: Anticholinergics

• Acetylcholine (ACh) causes
  bronchial constriction and
  narrowing of the airways

• Anticholinergics block the
  parasympathetic nerve

• Result —>bronchoconstriction is
  prevented, airways dilate

• Useful for patients unable to
  tolerate B2 agonists—but not
  as effective

Ipratropium (Atrovent)
–short acting
Tiotropium (Spiriva) –
long acting
Not used for acute
asthma exacerbations

Cautions:
Increase in
anticholinergic effects
when combined with
other anticholinergics

Xanthine’s: Theophylline

Stimulate the CNS to promote
bronchodilation
Cause smooth muscle relaxation in
respiratory tract
Relief and prevention of bronchial asthma
+ bronchospasm for COPD
Theophylline-narrow therapeutic index:
10-20 mcg/dL
• Toxicity: tachycardia, tonic-clonic seizures
Avoid caffeine

side effects:

• tachycardia

• palpitations

• ECG changes

• nervousness and anxiety

• irritable

Corticosteroids

Reduces inflammation by decreasing
number of mast cells in airway
May be combined with
bronchodilator
Uses: COPD, Asthma
Acute: IV
PO, IM, PO, rectal, ocularly, Inhaled
*Inhalation does not produce systemic effect

Antileukotrienes(Leukotriene receptor antagonists): Montelukast (Singulair)

• prevent leukotrienes from attaching to recpetors on cells in the lungs and in circulation

• not for acute asthma attacks

• prophylaxis and chronic treatment of asthma

• monitor/assess: HA, n/v/d, elevated LFTs, myalgia

Sulfamethoxazole/ trimethoprim (Bactrim)

Class: AntibacterialAntibacterial
 Use/actionUse/action::
UTI, bacteriostatic-folic acid inhibitUTI, bacteriostatic-folic acid inhibit
 Side effects:Side effects:
Photosensitivity, anemiaPhotosensitivity, anemia
 Monitoring:Monitoring:
renal function, CBC and K+renal function, CBC and K+
levelslevels
s/s of superinfection: fever, chills,s/s of superinfection: fever, chills,
↑HR↑HR
 Nursing considerations:Nursing considerations:
↑ hydration to prevent formation of↑ hydration to prevent formation of
renal calculi, don’t use if have sulfarenal calculi, don’t use if have sulfa
allergyallerg

Nitrofurantoin (Macrobid)

Class: Urinary antiseptic \
 Use/actionUse/action: UTI, bacteriostatic: UTI, bacteriostatic
 Side effects: nausea,
Fluctuance, diarrhea and Headache
Monitoring:
LFT’s, CBC & renal functionLFT’s, CBC & renal function
Pulmonary sensitivity (cough,chest pain, fever, chills)
 \Nursing considerations:
may cause an asthma attack in
asthmatics
I&O\
Alert patient it may cause darkAlert patient it may cause dark
yellow or brown urineyellow or brown urine

Ciprofoxacin

Class: Antibacterial
Use/action: UTI, bactericidal
Side effects: nausea +
vomiting, photosensitivity,
tendon rupture

Phenazopyridine (Pyridium)

Class: Analgesic
Use/action:relieve pain d/t UTI
Side effects: turn urine orange
or red
Nursing considerations:
• only take for up to 2 days, take after
meals, ↑ hydration,
• inform patients this is NOT an
antibiotic

Oxybutynin: Ditropan

Why
Bladder spasmBladder spasm
 How it works
Blocking parasympatheticy- block acetylcholineactivity-
Blocks the spasm of urinaryBlocks the spasm of urinary
tract musclestract muscles
 SE: anticholinergic

5 ⍺-reductase: Finasteride (Proscar)

• shrinks the prostate to open up the urine flow
• SE: decreased libido, PSA, gynecomastia

⍺1-adrenergic: Tamsulosin (Flomax)

blocks alpha 1 receptors, releasing smooth muscles to
improve urine flow
• SE: hypoTN, HA, diahrrea, priapism