Exam 3 Pharm Pt 1

Diuretics, blood pressure, and cardiac medications

Osmotic Diuretics indications

Acute situations such as intracranial pressure, acute renal failure from shock, drug overdose, or trauma.

Decrease intraocular pressure pre-op

How do osmotic diuretics work?

Increase osmotic pressure in glomerular filtrate

Inhibit the reabsorption of sodium and water

Draws fluid from intracellular to intravascular spaces to be excreted

Decrease water in body

How do osmotic diuretics work in the body?

IV admin only

Use filter needle because mannitol crystalizes

Contraindications/considerations for osmotic diuretics

Caution pts w/ renal disease, pulmonary congestions, intracranial bleeding, dehydrations, and HF.

Mannitol causes large fluids shifts, can exacerbate them.

Adverse effects of osmotic diuretics

N/V, hypotension, light headedness, confusion, headache, cardiac decompression, and shock

Carbonic Anhydrase Inhibitors indications

Used as adjunct w/ other diuretics

Tx glaucoma, decrease secretions in eye

How do carbonic anhydrase inhibitors work?

Block effects of carbonic anhydrase enzyme, slows movement of hydrogen ions, more sodium and bicarbonate lost in urine

How do carbonic anhydrase inhibitors work in the body?

PO and IV admin

Contraindications/considerations for carbonic anhydrase inhibitors

Pts w/ sulfonamide allergy and thiazine allergy

caution pts w/ non congestive closed angle glaucoma

caution pts w/ fluid/electrolyte imbalances, renal/hepatic disease, andrenocortical insufficiency, respiratory acidosis or COPD

Adverse effects for carbonic anhydrase inhibitors

Increase secretion of salicylates and lithium.

Monitor serum lithium levels

Loop diuretic indications

“High ceiling diuretics”

Used in heart failure, pulmonary edema, and HTN

How do loop diuretics work?

Blocks chloride pump in ascending loop of henle, descending loop of henle, and distal convoluted tubule.

Increase amounts of sodium rich urine

Effective in acid-based disturbances, renal failure, and electrolyte imbalances

How do loop diuretics work in the body?

PO and IV

Only furosemide can be admin IM (safest)

Contraindications/considerations for loop diuretics

Electrolyte imbalance, severe renal failure/anuria, and hepatic coma

Adverse effects of loop diuretics

Dizziness, vertigo, orthostatic hypotension, and nausea

Fluid imbalances of loop diuretics

Hypokalemia- K+ lost in attempt to save sodium

Alkalosis- bicarb lost in urine

Hypocalcemia- calcium/bicarbonate lost, causing low sugar and tetany

Hyperglycemia- long term use, hypokalemia stops pancreas from releasing insulin

Ototoxicity and deafness- reversable

Drug-drug interactions for loop diuretics

Aminoglycosides/ Cisplatin- increase risk of ototoxicity

Anticoagulants- increased blood thinning effects

NSAIDS- reduce effectiveness of loop on decrease BP

Thiazide diuretics indications

Tx edema and HTN

Mild diuretic

First tx for essential HTN

How do thiazide diuretics work?

Block chloride pump in ALH and distal tubule

Hold chloride and sodium

Not much increase in urine

Urine sodium rich

How do thiazide diuretic work in the body?

Oral and IV, absorbed well in GI tract

Contraindicaions/considerations for thiazide diuretics

Don’t use on thiazine or sulfonamide allergic pt

Don’t use in renal disease- either prevent urine to cause too much urine

Monitor electrolyte satus

Caution pts w/ lupus, can lead to renal failure

If electrolyte imbalance, caution pts w/ diabetes, gout, liver disease, hyperparathyroidism, and bipolar disorder

Adverse effects of thiazide diuretics

GI upset, fluid/electrolyte imbalance, and hypotension, hypokalemia, decrease Ca excretion, increase Ca in blood, decrease uric acid secretions, increase uric acid in blood

Alkaline urine, increase UTI

Potassium sparing diuretic indications

Used in conjunction with/ thiazide or loop diuretic

Used in pts avoiding hypokalemia

How to potassium sparing diuretic work?

Loss of sodium while retaining potassium

Aldosterone antagonist, blocks aldosterone in distal tubule and block potassium secretions

Urine production comes from losing sodium and retaining potassium

How do potassium sparing diuretic work in the body?

Oral ONLY

Contraindications/considerations for potassium sparing diuretics

Don’t use in pat with renal disease or anuria

Adverse effects of potassium sparing diuretics

Hyperkalemia, blocks androgen production, alters testosterone-estrogen ratio which causes s/s of hormonal changes, hirsutism, gynecomastia, and irregular menses

Drug-drug interactions for potassium sparing diuretics

Salicylates, decrease diuretic effect

Drug-food interactions for potassium sparing diuretics

Avoid high-potassium foods

Cardiac glycosides indications

Tx for heart failure, atrial flutter, and atrial fibrillation

Increase CO

How do cardiac glycosides work?

Increase intracellular calcium in myocardial cells during depolarization

Increase force of contraction

Slow down HR

Increase CO which increases renal perfusion

How do cardiac glycosides work in the body?

Narrow therapeutic margin of safety

Oral and IV admin

Contraindications/considerations for cardiac glycosides

V-tac, V-fib, heart block, sick sinus syndrome

Must check apical HR pre-admin

Hold med if HR is less than 60

Hypokalemia increase toxicity risk

Adverse effects for cardiac glycosides

Headache, weakness, drowsiness, arrhythmia, vision changes, GI upset, and anorexia

S/s toxicity for cardiac glycosides

Seeing halos around lights, hallucinations, irregular heartbeats, palpations

What is the antidote for Digoxin toxicity?

Digifab (Digoxin immune Fab IV)

Nursing implications for cardiac glycosides

Digoxin levels must be drawn on reg basis

Check for potential drug toxicity

Phosphodiesterase Inhibitors indications

Short term tx of HF that doesn’t respond for digoxin or diuretics

How do phosphodiesterase inhibitors work?

Block enzyme phosphodiesterase

Increase calcium levels in cell

Cause increase in contractibility

Vasodilate vascular muscle

How do phosphodiesterase inhibitors work in the body?

IV only, widely distributed after injection

Nursing implications for phosphodiesterase inhibitors

Protect drug from light

Ensure IV access

VS and I/O monitoring

Monitor platelet counts

Inspect the skin for bruising or petechiae

Adverse effects of phosphodiesterase inhibitors

Arrythmias, hypotension, chest pain, thrombocytopenia, hypersensitivity, may burn at IV site.

HCN Blockers indications

Tx for chronic heart failure

How do HCN blockers work?

Slow pacemaker of the heart (SA node)

Allows more time for ventricular filling

Improves CO

How HCN blockers work in the body?

Oral only, widely distributed throughout body

Contraindications for HCN blockers

Active decompensated HF, hypotension, SSS, heart block, HR under 50, patients who are pacemaker dependent.

ACE inhibitors indications

Tx of hypertension, treatment of HF when used w/ digoxin/diuretics

How do ACE inhibitors work?

Act on lungs, prevent ACE covering angiotensin I to angiotensin II

Decrease BP and aldosterone

Increase K+

Lose sodium and fluid

How do ACE inhibitors work in the body?

Oral, only enalapril can be given IV

Excreted stool and urine

Contraindications/considerations for ACE inhibitors

Don’t use w/ impaired renal function, med reduces BP to kidneys

Caution pts w/ HF due to fluid shifts

Med is teratogenic

Black pts have 3-5x increased risk of angioedema

Adverse effects of ACE Inhibitors

Hypotension, renal impairment, GI upset, hyperkalemia, and angioedema

Cam cause non-productive cough

Drug-drug and food interactions for ACE Inhibitors

Certain meds increase risk of angioedema

Risk for decreased antihypertensive effect it taken w/ NSAIDS

Don’t give in combination w/ other ACE inhibitors or ARBs

Absorption decreased if taken w/ food, fasted 1hr pre meal and 2hr post meal

Angiotensin II receptor blockers (ARBs) indications

Tx of hypertension

Tx of HF in ACE tolerant pts

Slow progression of renal disease in hypertensive and diabetic pts

How do angiotensin II receptor blockers work?

Bind w/ angiotensin II in vascular smooth muscle and adrenal cortex

Blocks vasoconstriction, blocks aldosterone release

Lowers BP by blocking effects of RAAS

How do angiotensin II receptor blockers work in the body?

Oral, excreted stool and urine

Contraindications/considerations for angiotensin II receptor blockers

Caution w/ impaired renal/hepatic

Caution if pt hypovolemic, ARBs block compensatory for hypovolemia

Med is teratogenic

Adverse effects for angiotensin II receptor blockers

Dizziness, hypotension, renal impairment, GI upset, hyperkalemia, and angioedema

Drug-drug interactions for angiotensin II receptor blockers

NSAIDS blunt hypertensive effects, increase risk of renal dysfunction

Caution w/ potassium sparing diuretics, risk of hyperkalemia

Increase risk of lithium toxicity

Don’t use w/ ACE inhibitors

No food interactions

Give w/ food to minimize GI upset

Calcium channel blockers indications

Tx of HTN and angina

Decreases cardiac workload

Adjunct med to slow progression of renal disease in pts w/ HTN and diabetes

How do calcium channel blockers work?

Inhibit movement of calcium across myocardial cells

Alters action potential

Blocks muscle cell contraction

Relaxes and dilates arteries, decrease BP and venus return

How do calcium channel blockers work in the body?

Oral

Nicardipine and Diltiazem can be given IV

Contraindications/considerations of calcium channel blockers

Heart block and sinus syndrome

Caution renal and/or hepatic impairment

Considered low risk for HTN management in pregnancy

Must be taken on empty stomach, 1 hour pre, 2 hours post

Adverse effects of calcium channels blockers

Dizziness, head ache, fatigue, peripheral edema, hypotension, bradycardia, palpitations, skin flushing, and rash.

Nausea and hepatic injury related to toxic effects

Drug-drug/food interactions for calcium channels blockers

Bradycardia and heart block - beta blockers

Toxicity- digoxin

rhambdomylosis - statin

Steven Johnson syndrome - CCB use

Toxicity- grapefruit juice

Direct vasodilators indications

Only tx of severe HTN or HTN crisis when no other methods have worked

How do direct vasodilators work?

Act on vascular smooth muscles

Drop BP

Don’t block reflexive tachycardia

How do direct vasodilators work in the body?

Absored rapidly

Hydralazine: PO, IV, IM

Minoxidil: PO only

Nitroprusside: IV only

Contraindications/considerations for direct vasodilators

Don’t use w/ cerebral insufficiency

Caution pts w/ PVP, CAV, HF, and tachycardia

Caution in pregnancy

Adverse effects of direct vasodilatiors

Dizziness, orthostatic hypotension, reflex, tachycardia, edema, anxiety, headache, chest pain, skin rash, Gi upset

If nitroprusside toxic, cyanide toxicity

s/s of toxic include dyspnea, headache, vomiting, dizziness, loss of consciousness, absent reflexes, dilated pupils, shallow respirations

Beta blockers indications

Tx HTN, long-term angina, and refraction prevention in stable MI

Cardiac arrhythmia and HF

How do beta blockers work?

Block beta adrenergic receptors in heart

Decrease sympathetic NS response

Decreases excitability, CO, and O2 consumption in heart

How do beta blockers work in the body?

All PO expect Timolol and metoprolol

Timolol: eye drops

Metoprolol: IV

Adverse effects of beta blockers

Bradycardia, hypotension, bronchospasm, peripheral/pulmonary edema, arrythmias, erectile dysfunction, fatigue, dizziness, sleep disruption, and GI upset.

If sudden discontinuing, angina, hypertensions, arrhythmia, or acute MI

Drug-Drug interactions for beta blockers

Antacids: delay absorption

NSAIDS: decrease anti-hypertensive effects

Lidocaine: toxicity

Insulin/oral diabetic: Adjust, hypoglycemia

Albuterol/pseudoephedrine: counteract effect

Diuretics/CCB/Digoxin: decrease cardiac effects

Counterindications/considerations of beta blockers

Monitor HR, BP, fluid overload

Withhold if apical pulse less than 50 or arrythmia

Alpha blockers and alpha agonist indications

Tx of HTN, some meds tx BPH and ADHD

How do alpa blockers/agonist work?

Both alpha 1 and alpha 2 work in central vasomotor center

Inhibit SNS stimulation

Dilate peripheral BV or decrease CO to decrease BP

How to alpha blockers/agonist work in the body?

IV, IM, PO, and patches

Adverse effects of alpha blockers/agonist

Depression, drowsiness, edema, liver, dysfunction, numbness, tingling, vertigo

Contraindications/considerations of alpha blockers/agonist

Take at bedtime

Nitrate indications

Prevent/ tx angina

Decrease preload, decrease after load

How do nitrates work?

Relaxe smooth muscles, dilate BV

Increase blood flow, lower BP

How do nitrates work in the body?

Nitroglycerin: sublingual, spray, patch, topical ointment, paste IV fusion

Amyl nitrate: inhalation by fumes

Adverse effects of nitrates

headaches, dizziness, weakness, hypotension, reflex tachycardia, syncope, angina, nausea, vomiting, flushing, pallor, and increased perspiration..

Drug-drug interactions of nitrates

Heparin: decreases it’s effects

Contraindications/considerations for nitrates

Assess for Mi, head trauma, cerebral hemorrhage, hypotension, hypovolemia, anemia, low cardiac output

For patch, risk of contact dermatitis and hypersensitivity reaction

Lay pt down pre-admin

Abrupt withdrawal causes MI

Bile acid sequestrants indications

Decrease plasma cholesterol levels

How do Bile acid sequestrants work?

Bind w/ bile acids in intestine to form secretions that is excreted through feces

How do bile acid sequestrants work in the body?

Cholestyramine: power mixed w/ liquids, taken x6 a day

Colesevelam: tablet 1-2x a day

Contrainidcations/considerations of bile acid sequestrants

Don’t give if biliary obstruction or impaired intestinal function

Adverse effects of bile acid sequestrants

Headache, anxiety, fatigue, drowsiness, due to cholesterol levels

GI irritations, nausea, constipation, fecal impact, and aggravation of hemorrhoids.

Drug-drug interactions of bile acid sequestrants

Malabsorption of fat-soluble vitamins

Decreased/delayed absorption of thiazide, digoxin, warren, thyroid hormones, and corticosteroids

Take those meds 1 hr pre or 4-6 post taking bile acid sequestrants

Statins indications

Decrease plasma cholesterol and high-moderate-low intensity depend of the type of statin and dose

How do statins work?

Blocks HMG-CoA enzyme, decrease serum cholesterol and LDL due to absorption of LDL

HDL levels increase

How do statins work in the body?

Only PO

Taken at night

Contraindications/considerations of statins

Caution pts w/ active liver disease. hx of alcoholic liver disease

Caution pts w/ impaired endocrine function

Adverse effects of statins

Rhabdomyolysis in pts w/ renal impairment, cause acute renal failure

Flatulence, abd pain, cramps, n/v, constipation, headaches, dizziness, blurred vision, insomnia, fatigue

Increase concentrations of liver enzymes

Drug-drug/food interactions of statins

rhabdomyolysis if combined with/ certain vitamins, antibiotics, immunosuppressants, lipid lowering agents, and anti fungal drugs

Digoxin/warfarin: toxicity

Contraceptives: increased estrogen

Grapefruit juice: toxicity

Cholesterol absorption inhibitor indications

Can be used as adjunct w/ statin

Lower LDL cholesterol, decrease risk of cardiovascular events

How do cholesterol absorption inhibitor work?

In small intestine, decrease absorption of dietary cholesterol

Liver increases cholesterol by pulling from blood

Decrease total serum cholesterol