Unit 2

sodium bicarbonate

IV med given as an infusion for the management of severe acidosis or as a bolus for cardiac arrest

in the morning

when should diuretics be taken?

proximal convoluted tubule

what is the site of action for osmotic diuretics?

loop of Henle

what is the site of action for loop diuretics?

distal convoluted tubule

what is the site of action for thiazide diuretics?

collecting duct

what is the site of action for potassium-sparing diuretics?

loop diuretics

most potent diuretics, used for rapid diuresis, effective even when GFR is low

MOA: block reabsorption of Na & Cl in loop of Henle

TEs: decreases fluid volume, vascular resistance, BP

AEs: oto/nephrotoxicity, possible reaction with sulfa allergy, hypokalemia, hyperglycemia, hypocalcemia, alkalosis, hypomagnesemia, hypotension

• furosemide

• bumetanide

furosemide (Lasix)

loop diuretic with rapid onset

monitor: cardiac status, potassium, digoxin levels, BP

avoid excessive sunlight (may → photosensitivity)

interactions: digoxin, lithium, NSAIDs

thiazide/thiazide-like diuretics

should not be given if creatinine clearance < 30-50 mL/min, excessive licorice consumption can → additive hypokalemia

MOA: block Na & H20 reabsorption in distal convoluted tubule

AEs: elevated uric acid & glucose, hypokalemia (w/ digoxin)

• hydrochlorothiazide

• metolazone (can be given to creatinine clearance of 10 mL/min)

thiazide

if you are administering a thiazide and loop diuretic, which one should be given 30 minutes before the other?

hydrochlorothiazide (HCTZ)

thiazide diuretic used as first choice for essential HTN

also reduces urine production in diabetes insipidus

AEs: HYPO -natremia,-kalemia,- chloremia,-magnesemia; HYPER-glycemia, -uricemia

caution in patients with gout

potassium-sparing diuretics

only modest diuresis, caution with ACE inhibitors

MOA: block Na/K exchange in distal convoluted tubule

TEs: used long-term in HF patients, cardioprotective factor

AEs: hyperkalemia

• spironolactone

osmotic diuretics

concentrations of 20% may crystallize when exposed to low temps, use filter

MOA: pull water into proximal tubule from surrounding tissues

TEs: reduce ICP, treat cerebral edema, treat early ARF, promote toxic substance excretion

AEs: HF, pulmonary edema, metabolic acidosis, increased lithium excretion, increased hypokalemia risk (w/ cardiac glycosides)

contras: active intracranial bleed, pulmonary edema, anuria, renal failure, pregnancy/lactation

• mannitol

carbonic anhydrase inhibitors (CAIs)

MOA: block action of carbonic anhydrase (prevent exchange of H+ ions w/ Na & H2O)

TEs: long-term adjunct for open-angle glaucoma tx, useful in tx of edema and high-altitude sickness

AEs: acidosis, hypokalemia, paresthesias, photosensitivity, melena

• acetazolamide

acetazolamide (Diamox)

most commonly given CAI

contras: hypokalemia/natremia, severe renal or hepatic dysfunction, adrenal gland insufficiency, cirrhosis

interactions: digoxin, corticosteroids

histamine

major inflammatory mediator in many allergic disorders

antihistamines

drugs that directly compete with histamine for specific receptor sites

uses: nasal/seasonal allergies, allergic reactions, motion sickness, Parkinson’s, sleep disorders

contras: narrow-angle glaucoma, COPD, bronchial asthma, HTN, cardiac/kidney disease, PUD, seizures, BPH

AEs: anticholinergic effects, drowsiness

• H1: sedative effects

• H2: GI effects

H1 antagonists

antihistamine

antihistamine, anticholinergic, & sedative effects

• fexofenadine (Allegra)

• loratadine (Claritin)

• cetirizine (Zyrtec)

• diphenhydramine (Benadryl)

H2 antagonists

antihistamine

effects: used to reduce gastric acid in PUD

• cimetidine (Tagamet)

• famotidine (Pepcid)

• ranitidine (Zantac)

• nizatidine (Axid)

false

TRUE OR FALSE: antihistamines can push histamine off the receptor if it is already bound

dilation & increased permeability of capillaries

what are 2 cardiovascular effects of histamine?

activated charcoal

what is the treatment for acute toxicity of H1 antagonists?

bronchodilators, anticholinergics, corticosteroids

list the main 3 drug classes used to manage COPD

-tropium

common ending of anticholinergic drugs for COPD

-sone/-solone

common ending of glucocorticoids for COPD

insulin lispro (Humalog) & insulin aspart (NovoLog)

give 2 examples of rapid acting insulin

regular insulin (Humulin R, Novolin R)

give an example of short acting insulin

NPH insulin

give an example of intermediate acting insulin

insulin glargine (Lantus) & insulin detemir (Levemir)

give 2 examples of long-acting insulin

rapid-acting insulin

onset: 5-15 minutes

peak: 1-2 hours

duration: 3-5 hours

routes: subq

short-acting insulin

onset: 30-60 minutes

peak: 1-5 hours

duration: up to 10 hours

routes: IV, IM, subq

clear solution

intermediate-acting insulin

onset: 1-2 hours

peak: 4-8 hours

duration: 10-18 hours

routes: subq

dose: 2-3xs/day

cloudy suspensions

long-acting insulin

onset: 1-2 hours

peak: none

duration: 24 hours

routes: subq, NOT IV!!!

dose: usually once per day

clear colorless solution

adverse effects of insulin

hypoglycemia, lipohypertrophy, allergic reactions, hypokalemia

biguanides

first line tx for T2DM

MOA: decrease glucose production, increase insulin sensitivity

AEs: anorexia, GI upset, lactic acidosis (rare)

interactions: IV radiologic contrast

• metformin

sulfonylureas

used in early stages of T2DM

MOA: stimulates beta cells to release more insulin

AEs: hypoglycemia, weight gain

• glipizide

• glyburide

thiazolidinediones (glitazones)

slow onset (weeks-months)

MOA: increase insulin sensitivity in receptors, decrease glucose production

AEs: weight gain, water retention, do not use in pt w/ HF

• pioglitazone (Actos)

glinides

MOA: + pancreas to make insulin

AEs: hypoglycemia, weight gain

must eat w/n 30 minutes

• repaglinide (Prandin)

alpha-glucosidase inhibitors

MOA: delay carbohydrate absorption in intestines

AEs: hypoglycemia, liver dysfunction, GI upset

take with first bite of each meal

• acarbose

SGLT inhibitors

MOA: block reabsorption of filtered glucose in the kidney

AEs: fungal infections, UTIs, increased urination

• canagliflozin

• dapagliflozin

DPP-4 inhibitors

MOA: enhances incretin actions

AEs: hypoglycemia, pancreatitis

• sitagliptin [Januvia]

• saxagliptin [Onglyza]

• linagliptin [Tradjenta]

• alogliptin [Nesina]

GLP1-receptor agonists

MOA: slows gastric emptying, suppresses appetite

AEs: hypoglycemia, GI effects (+ pancreatitis)

routes: subq

• liraglutide (Victoza)

amylin mimetics

MOA: reduces postprandial glucose levels through delayed gastric emptying & suppression of glucagon secretion

AEs: hypoglycemia, nausea, injection site reactions

routes: subq

• pramlintide (Symlin)

somatropin & octreotide

name 2 growth hormone medications

somatropin

MOA: + skeletal growth in GH deficiency

routes: IM, subq

octreotide

MOA: GH antagonist

uses: carcinoid tumors that secrete VIP, acromegaly, esophageal varices

AEs: gallbladder dysfunction, hypoglycemia

routes: IV, IM, subq

vasopressin & desmopressin

name 2 pituitary gland hormones

ADH agonists

MOA: increase water resorption in distal tubules, concentrate urine

uses: ADH deficiency, DI

AEs: water intoxication, excessive vasoconstriction

• vasopressin

• desmopressin

desmopressin

which ADH agonist is also used to increase plasma levels of factor VIII, von Willebrand factor, and tissue plasminogen activator, OR for nocturnal enuresis (bed wetting)

vasopressin

which ADH agonist is used in hypotensive emergencies (ex: septic shock) OR to stop bleeding of esophageal varices

T4

levothyroxine is a synthetic form of which thyroid hormone?

T3

liothyronine is a synthetic form of which thyroid hormone?

T3 & T4

liotrix is a synthetic form of which thyroid hormone?

thyroid replacement drugs

MOA: synthetic forms of thyroid hormone

AEs: cardiac dysrhythmias, HTN, insomnia, tremors, N/D, weight loss, heat intolerance, etc.

interactions: catecholamine, warfarin

• levothyroxine

• liothyronine

• liotrix

antithyroid drugs

MOA: inhibits iodine + tyrosine (impedes thyroid hormone formation)

AEs: liver & bone marrow toxicity, agranulocytosis, hypothyroidism

interactions: warfarin, bone marrow suppressants

• propylthiouracil (PTU) 2+ weeks for TEs !! liver damage !!

• methimazole 3-12 weeks for TEs

PTU

which antithyroid drug may be taken during the first trimester of pregnancy?

methimazole

which antithyroid drug may be taken during the second & third trimesters of pregnancy?

glucocorticoids

corticosteroids involved in metabolism and stress response

• cortisol

• cortisone

mineralocorticoids

corticosteroids involved in maintaining fluid-electrolyte balance and BP regulation

• aldosterone

hydrocortisone

MOA: synthetic cortisol steroid

uses: adrenal insufficiency, allergic reactions to inflammation, cancer

AEs: PUD, glucose intolerance

routes: PO, IM, IV

do NOT abruptly stop

fludrocortisone

uses: Addison’s disease, primary hypoaldosteronism, congenital adrenal hyperplasia

AEs: water retention, heart failure, HTN, skin rash, menstrual irregularities, peptic ulcers, hyperglycemia, hypokalemia, compression bone fxs