WCU Pharmacology Quiz 5

Hyperlipidemia

High levels of lipids in the blood - major risk factor for cardiovascular disease

Most patients are asymptomatic until cardiovascular disease produces symptoms

Triglyceride

Neutral fat

3 fatty acids attached to glycerol

Energy source

Account for 90% of total lipids in the body

Can be saturated (bad) and unsaturated

Saturated = with hydrogen atoms

Phospholipids

Essential to building plasma membranes

Best-known phospholipids are lecithins (eggs, soy beans)

Steroids

Cholesterol is most widely known of the steroids

Natural and vital component of plasma membranes

Necessary for production of vitamin D, bile, acids, cortisol, estrogen, testosterone

Body makes a lot of cholesterol (liver), the rest comes from animal products

Lipoproteins

Consists of various amounts of cholesterol, triglycerides, and phosphlipids along with a protein carrier (apoprotein)

High Density Lipoprotein (HDL)

Contains the most protein

Least fat

Assist in transport of cholesterol away from the tissues and back to the liver where it can unite with bile and be excreted in the feces

"Good cholesterol" - leads to excretion of cholesterol

Low Density Lipoprotein (LDL)

Contains the most cholesterol

Transport cholesterol from the lover to the tissues and organs where it can be stored

In the vessels however, this storage is not desirable (plaque build up)

Lifestyle Changes

Should always be included in the treatment plan for lipid disorder

Maintain weight at optimal level

Exercise (30 minutes of cardio 5 times a week)

Reduce saturated fats, trans fats, and cholesterol

Increase fiber (oat bran, apples, beans, broccoli)

Eliminate tobacco use

Often, lifestyle changes may only minimally lower cholesterol

Drug therapy includes statins, bile-acid sequestrants, fibrates, nicotinic acid, and cholesterol absorption inhibitors

Cholesterol is synthesized when?

At night

atorvastatin

Statins (HMG-CoA Reductase Inhibitors)

MOA

Interfere with the synthesis of cholesterol

Increase HDL while decreasing LDL and VLDL

HMG-CoA Reductase inhibitors (an enzyme involved in cholesterol synthesis)

Therapeutic Use

Hypercholesterolemia

Prevention of coronary event

MI

Complications

Hepatotoxicity (increase AST, anorexia, N/V, jaundice)

Myopathy (check CK levels. monitor aches,/pains/weakness)

Contraindications/Precautions

Pregnancy category X

Breastfeeding

Liver disorders

Interactions

Grapefruit juice increase statin levels

Fibrates (also used for hyperlipidemia) increase risk of hepatotoxicity and myopathy

Nursing Considerations

Take in the evening with or without food

Monitor cholesterol throughout therapy, and prior to therapy

Monitor liver function (AST/ALT)

Watch for signs of GI upset (could indicate liver dysfunction)

Stop drug for high CK level

No grapefruit juice

Tell patients this is a lifetime commitment to the drug

Nonpharmacologic Treatment of Hypertension

Limit alcohol usage

Diet - restrict sodium consumption, reduce saturated fat and cholesterol, increase fresh fruit and veggies intake

Increase aerobic physical activity

Discontinue tobacco use

Reduce stress

Weight management

enalapril; captopril

MOA

Reduces the production of angiotensin II by blocking conversion of angiotensin II and increasing levels of bradykinin. This leads to: vasodilation of the small arteries, excretion of sodium and water

enalapril; captopril

Therapeutic Uses

Hypertension

Heart failure

MI (decrease risk of heart failure and left ventricular dysfunction after MI)

Diabetic and non-diabetic neuropathy

Reduce risk for a CV event

enalapril; captopril

Complications

First-dose orthostatic hypotension - start low and go slow; monitor for 2 hours after initial treatment

Cough - medication should be discontinued

Hyperkalemia - avoid use of salt substitutes; monitor for signs of hyperkalemia (muscle twitches, cramps, paresthesia, irritability, anxiety, decreased blood pressure, EKG changes, dysrhythmias, abdominal cramping, diarrhea)

Rash and dysgeusia (altered taste) - primarily with captopril (symptoms will stop with discontinuation)

Angioedema (swelling of the tongue and oral pharynx) - epinephrine; stop medication

Neutropenia (rare) - monitor WBC every 2 weeks for up to 3 months; reversibled when detected early; clients should notify provider of first sign of infection

enalapril; captopril

Interactions

Diuretics (hydrochlorothiazide) contribute to first-dose hypotension

Antihypertensive medications have an additive effect when used together

ACE inhibitors can increase levels of lithium carbonate

K supplements and K-sparing diuretic increase the risk of increased potassium, no added K

NSAIDS may decrease antihypertensive effect (decreased blood flow to the kidney)

enalapril; captopril

Contraindications

Avoid use in pregnancy

Those with kidney disease

History of angioedema

enalapril; captopril

Administration

Enalapril only ACE inhibitor for IV use

Monitor BP for a minimum of 2 hours after first dose

Can be taken with or without food

Notify provider - cough, rash, dysgeusia, s/s infection

enalapril; captopril

Expected Outcome

Decrease BP

Alleviate symptoms of CHF

losartan

Angiotensin II Receptor Blockers (ARBs)

MOA

Block the action of angiotensin II

Vasodilation of the small arteries

Excretion of sodium and water; retention of K (decrease release of aldosterone)

losartan

Therapeutic Use

Hypertension

HF and prevention of mortality following MI

Stroke prevention

Delay progression of diabetic nephropathy and retinopathy

losartan

Complications

Angioedema

Fetal injury during 2nd and 3rd trimester

Hypotension, dizziness, lightheadedness

losartan

Administration

May be taken with or without food

losartan

Precautions

Category D

use cautiously in those who experienced angioedema with ACE inhibitor

losartan

Interactions

Additive effect with other antihypertensives

Increase the risk for lithium toxicity

losartan

Evaluation

Monitor weight, edema, and BP

aliskiren

Direct Renin Inhibitor

MOA

Binds with renin to inhibit angiotensin and aldosterone activation

aliskiren

Therapeutic Use

Hypertension

May be combined with other antihypertensive medication

aliskiren

Complications

Angioedema

Rash

Cough

Hyperkalemia

Diarrhea (females/elderly)

Hypotension

aliskiren

Contrainidications/Precautions

Hyperkalemia

Pregnancy

Elderly

aliskiren

Drug/Food Interactions

Decreases blood levels of furosemide

Additive effect with other antihypertensives

High fat foods reduce absorption of aliskiren

Other medication that cause hyperkalemia: ACE inhibitors, K supplements, K-sparing diuretics

verapamil; nifedipine; diltiazem

Calcium Channel Blockers

MOA

Block calcium channels in the blood vessels leading to vasodilation in heart and peripheral vessels; veins not significantly affected

Verapamil/diltiazem block calcium channels in the conduction system of the heart

Therapeutic Uses

Angina pectoris and hypertension

Cardiac dysrhythmias (atrial fib/flutter and SVT) - verapamil and diltiazem

Complications

Reflex tachycardia (hypotension leads to tachycardia) - give beta blocker

Flushing

HEadache

Acute toxicity (arrhythmias, hypotension) - gastric lavage and drugs to increase BP/HR

Orthostatic hypotension - get up slowly

Peripheral edema - diuretic may be needed

Verapamil, diltiazem specific complications include: constipation, bradycardia, dysrhythmias

Contrainications/Precautions

Verapamil contraindicated: hypotension, heart block, heart failure (severe), lactation

Nifedipine is contraindicated in those who are in cardiogenic shock and used with caution in those who have MI, unstable angina, aortic stenosis, hypotension, AV block

Used with caution in older adult clients who have kidney/liver issues, mild to moderate heart failure or GERD

Drug/Food Interactions

Grapefruit juice can lead to toxicity

Concurrent use with beta blockers may increase risk for severe bradycardia

May increase levels of digoxin leading to digoxin toxicity

H2RA's such as cimetidine and ranitidine may lead to toxicity (decrease in BP, increase in HR, and flushing)

Monitoring/Administration

Do not crush or chew

Monitor HR & BP

Notify provider if symptoms worsen

Keep weight and BP records

Hold medication if patient is bradycardic (HR of 50 or below)

Obtain BP in lying, sitting, and standing positions

Assess for signs of heart failure and reflex tachycardia

Obtain daily weights

Assess bowel function (constipation)

If given IV - slow with continuous monitoring

doxazosin

Alpha Adrenergic Blockers

MOA

Selective alpha 1 blockade

Venous and arterial dilation

Smooth muscle relaxation of the prostatic capsule and bladder neck

doxazosin

Therapeutic Use

Hypertension

Doxazosin and terazosin can decrease manifestations of BPH (urgency, frequency, dysuria)

doxazosin

Complications

First dose orthostatic hypotension (often given at night)

Nausea, HA, drowsiness, congestion, edema/weight gain

doxazosin

Precautions

Use cautiously in patients with angina, renal insufficiency, and in the elderly

doxazosin

Food/Drug Interations

Can have additive effect with other antihypertensives

doxazosin

Nursing Care

Can be taken with food

Take initial dose at bedtime due to first dose effect

Ensure safety measures to ensure safety and orthostatic hypotension

clonidine (guanfacine; methyldopa)

Centrally Acting Alpha-2 Agents

MOA

Decrease sympathetic outlaw flow from the brainstem to the peripheral vessels

Decrease in sympathetic outflow to the peripheral vascular results in vasodilation which leads to decreased BP

clonidine

Therapeutic Uses

Hypertension (often combined with other drugs)

Additive use - severe cancer pain

Multiple investigational uses (migraines, ADD, withdrawal from opiates, alcohol, tobacco)

clonidine

Complications

Drowsiness and sedation (will diminish with use)

Dry mouth (resolves in 2-4 weeks)

Rebound congestion if discontinued abruptly

Not prescribed often for treating HTN - serious side effects

clonidine

Precautions/Contraindications

Pregnancy and lactation

Avoid use of transdermal patch on patients with skin issues

Bleeding disorders, anticoagulant usage

Cautious use with recent stroke, MI, DM, depression, asthma, and CRF

clonidine

Medication/Food Interactions

Antihypertensives may have additive effects

Concurrent use of MAOI's, tricyclics, and prazosin can counteract effect of clonidine

Additive CNS depression with other depressants (alcohol)

clonidine

Administration

Oral

Epidural

Transdermal

Twice daily - larger dose in evening

Transdermal patch replaced every 7 days (apply to hairless area of intact skin)

metoprolol; propranolol

Beta Adrenergic Blockers

Selective vs. non-selective vs. alpha/beta blockers

Some types can affect both alpha and beta receptors

Nonselective beta 1 and beta 2 (affecting both heart and lungs - propranolol)

MOA

Decrease heart rate

Decrease myocardial contractility and cardiac output

Decrease rate of conduction through the AV node

Alpha blockade adds vasodilation in medications such as carvedilol and labetalol

Can be combined with diuretic like diuril for additive effect on BP; additional benefit of fewer adverse effects.

Therapeutic Uses

Hypertension

Angina, tachydysrhythmias, heart failure, MI

Suppress reflex tachycardia due to other vasodilators

Hyperthyroidism, migraine headaches, stage fright, pheochromocytoma, and glaucoma

Complications

Bradycardia; AV block; decreased cardiac output (start low, go slow, hold HR <50)

Fatigue; drowsiness; insomnia

Orthostatic hypotension

Rebound myocardium excitation (discontinue use slowly)

Bronchoconstriction (question use in asthma)

Inhibition of glycogen breakdown in hypoglycemia (careful use with DM)

Contraindications/Precautions

Contraindicated in AV block and sinus bradycardia

Asthma, bronchospasm, and heart failure (nonselective)

DM (masks hypoglycemia), older adults

Drug/Food Interactions

Calcium channel blockers: intensify the effects of beta blockers (decrease HR, myocardial contractility, rate of conduction through the AV node)

Beta-2 Blockade: can mask the hypoglycemia and prevent the breakdown of fat in response to hypoglycemia; bronchoconstriction - contraindicated in patients with asthma

Administration

Give orally 1-2 times daily

Do not discontinue abruptly or without consulting provider

Do not crush or chew extended release tablets

Take with food to increase absorption

Expected Outcome

Absence of chest pain and cardiac dysrhythmias

Normotensive

Control of HF symptoms

hydralazine

Direct Vasodilators

MOA

Direct vasodilation of arterial smooth muscle

Therapeutic Uses

Hypertension (rarely used due to potential of tolerance and safety concerns)

Complications

Headache

Reflex tachycardia

Palpitations

Flushing

Nausea

Diarrhea

Sodium and fluid retention

May need beta blocker to combat reflex tachycardia

Contraindicated with angina, rheumatic heart disease, MI, tachycardia, lupus

Interactions

Additive effect with other antihypertensives

NSAIDS may inhibit the action of hydralazine

Administration

IV administration used for hypertensive emergencies

Start low and go slow dosing

Treat overdose with vasopressors and IVF

digoxin

Cardiac Glycosides and Heart Failure

MOA

Increase force and efficiency of myocardial contraction

Decreased heart rate, more forceful contraction

digoxin

Therapeutic Use

Treatment of heart failure (advanced stages)

Dysrhythmias (AF)

digoxin

Complications

Dysrhythmias (keep potassium between 3.5-5 to avoid)

GI - anorexia, N/V, abdominal pain

CNS effects - fatigue, weakness, vision changes (blurred vision, yellow-green or white halos around objects)

Risk of toxicity increases as potassium decreases

digoxin

Contraindications/Precautions

Ventricular dysrhythmias

AV block

Hypokalemia (increases risk of dysrhythmias)

Advanced heart failure

Renal insufficiency

Aging

digoxin

Medication/Food Interactions

Thiazide diuertucs and loop diuretics may lead to hypolalemia which increases the risk of dysrhythmias

ACE inhibitors and ARBs, spironolactone, KCL supplements - all increase the risk of hyperkalemia which can lea to decreased therapeutic effects of digoxin

Verapamil, quinidine, amiodarone, and alprazolam and increase plasma levels of digoxin

Sympathomimetic medications such as dopamine complement digoxin and increase the rate and force of heart muscle contractions

Antacids decrease absorption of digoxin and can decrease effectiveness

Use with caution in those with renal impairment, hypokalemia, dysrhythmias

Administration

Take medications as prescribed; do NOT double up

Check apical pulse (1 full minute) prior to administration - notify provider of < 60 in adults, < 70 in children, < 90 in infants

Administer at the same time everyday

Therapeutic levels between patients may vary - pay attention to s/s of toxicity

Avoid OTC with consulting PCP

Observe for s/s of digoxin toxicity (hypokalemia increases risk) - GI symptoms (anorexia); faigue; weakness; vision changes (halos)

If given IV, give over 5 minutes

Expected Outcome

Control of HF

Absence of cardiac dysrhythmias

digoxin

Managing Toxicity

Stop drug immediately and any other potassium wasting medication

Monitor potassium levels (give potassium PO or IV) - avoid potassium levels exceeding 5

Treat dysrhythmias with phenytoin or lidocaine

Treat bradycardia with atropine (expected outcome normal pulse rate > 60 in adults)

For excessive OD - activated charcoal; cholestyramine; digoxin immune Fab

nitroglycerin

Organic Nitrates

Treatment of acute angina attacks

nitroglycerin

MOA

Relax both arterial and venous smooth muscle; dilate coronary arteries

Short acting - Terminate acute angina episode (SL, Buccal)

Long acting - Decrease severity and frequency of episodes (Oral, Dermal)

Reduce heart workload, lower myocardial oxygen demand

nitroglycerin

Complications

Headache - occurs often, expected (dilation of cerebral vessels - may be severe)

Hypotension

Dizziness

Flushing of face

Rash

Reflex tachycardia - give beta blocker

Tolerance - use lowest dose, long-acting forms should have a medication free period every day

nitroglycerin

Administration

Stop activity, sit/lie down

One SL tab, wait 5 minutes

Unrelieved pain - call 911, take second tab

Unrelieved pain - take 3rd tab

Note and record pain intensity, duration, location, frequency and notify MD for changes

Do not crush or chew tablets

nitroglycerin

Contraindications/Precautions

Hypersensitivity

Severe asthma

Head injury

Glaucoma

Kidney/liver dysfunction

Hyperthyroidism

nitroglycerin

Interactions

Sildenafil (increases risk of hypotension)

Alcohol (hypotension)

Antihypertensives

heparin; enoxaparin

Parenteral Anticoagulants

Prevent clotting by activating antithrombin, thus inactivation both thrombin and factor Xa and thereby inhibiting fibrin formation and preventing clot formation

Does not dissolve existing clots - only prevents clot formation

heparin; enoxaparin

Therapeutic Uses

Heparin: prompt anticoagulants activity (stroke, PE, DVT), open heart surgery, renal dialysis, treatment of DIC

Enoxaparin: prevent DVT in post-op client, treat DVT and PE, prevent complications in angina and MI

heparin; enoxaparin

Complications/Precautions/Interactions

Hemorrhage - watch for tachycardia, hypotension, bruising, petechiae, hematomas, dark stools

Heparin - induced thrombocytopenia - low platelet count and increased thrombi (stop heparin for platelet count below 100,000)

Hypersensitivity

Overdose - antidote is protamine sulfate

Used cautiously in patient with hemophilia, PUD, severe HTN, liver/kidney disease

Antiplatelet agents like aspirin/NSAIDS may increase bleeding risk - avoid concurrent use if possible, avoid injury if necessary

heparin; enoxaparin

Nursing Implications & Teaching

Heparin and enoxaparin cannot be administered orally and must be given SQ or via IV - SQ: 90 degree angle, acceptable injection site, do not massage/aspirate, pressure may be needed 1-2 minutes

Monitor VS. CBC, aPTT levels (should be 1.5-2 times above normal)

Monitor for bleeding: bruising, bleeding gums, abdominal pain, nose bleeds, coffee-ground emesis, tarry stools

Avoid OTC NSAIDS, aspirin, or medications containing salicylates

Use and electric razor and a soft toothbrush

Laboratory values are done daily to monitor coagulation effects (aPTT)

Antidote - protamine sulfate

Ginger, garlic, green tea, feverfew, and ginkgo increase risk of bleeding

Heparin is measured in units - not ml's

LMWH - enoxaparin: more stable and thus less lab testing s/p discharge;

decreased incidence of thrombocytopenia; more frequently used to prevent DVT and therapy can be done t home; teach SQ administration and monitoring for bleeding; soft toothbrush/electric razor only; do not expel air bubble in pre-filled syringes

warfarin

Oral Anticoagulants

MOA

antagonize vitamin K, thereby preventing synthesis of four coagulation factors

warfarin

Therapeutic Uses

Treatment of venous thrombosis, thrombus formation in clients who have atrial fibrillation and heart valves, and prevention of recurrent MI, TIA, PE, DVT

warfarin

Complications

Hemorrhage: monitor VS, observe for bleeding, monitor PT and INR periodically

Overdose: antidote is vitamin K (phytonadione), FFP, whole blood transfusion

Hepatitis: monitor liver enzymes, jaundice

warfarin

Precautions

Category X due to high risk for fetal hemorrhage, death, and CNS defects (use heparin instead), passes through breast milk

warfarin

Interactions

Heparin, aspirin, acetaminophen, steroids, sulfonamides, cephalosporins - increase risk of bleeding

Phenobarbital, carbamazepine, phenytoin, oral contraceptives, and vitamin K decrease anticoagulant effects

Multiple herbals/OTC/prescription medications

warfarin

Nursing Considerations

Taken orally, once daily at the same time

Monitor PT (18-24) and INR (2-3), CBC, platelets

Effects may talke 8-12 hours Clients may need continued heparin until full effect is reached

Avoid alcohol and TOC medications to reduce risk of bleeding

Do not sit for long periods, wear restrictive clothing, elevate and move legs when sitting to prevent clot formation

Medical alert bracelet is needed

Monitor labs for frequently of using drugs that interact with warfarin

Use soft toothbrush and electric razor

Monitor for signs of clot formation (HA, chest pain, SOB, swelling/redness in the legs)

clopidogrel

Antiplatelet Agents

MOA

Prolongs bleeding time by preventing platelet aggregation

clopidogrel

Therapeutic Uses

Prevention of MI and recurrent MI, stroke, TIA

clopidogrel

Complications

Bleeding (particularly GI - watch for coffee-ground emesis and tarry stools), bruising, petechiae, bleeding gums

GI distress: diarrhea, dyspepsia, pain

clopidogrel

Precautions

Bleeding disorders, thrombocytopenia, PUD, intracranial bleeds, lactation

clopidogrel

Interactions

NSAIDS, heparin, warfarin, thrombolytics, antiplatelets increase risk of bleeding

PPI's decrease effectiveness of these drugs

clopidogrel

Administration

Clopidogrel should be stopped 5-7 days prior to elective surgeries

Should see absence of clot formation with no abnormal bleeding

Anticoagulants

Client Education

Importance of regular lab tests

Signs of abnormal bleeding

Measures to prevent bruising, bleeding, or tissue injury

Wear a medical alert bracelet

Avoid foods high in vitamin K (tomatoes, dark leafy green veggies, bananas, fish)

Consulting physician before taking other meds or OTC products, including natural health/herbal products

Report bleeding of gums while brushing teeth ,unexpected nosebleeds, heavier menstrual bleeding, blood or tarry stools, bloody urine or sputum, abdominal pain, vomiting blood