Week 3 Meds, Antihypertensive, RAAS, Diuretic, & Heart Failure Agents

What is the trade name for Sodium Polystyrene Sulfonate

Kayexalate

a cation-exchange resin that binds to K+ in the large intestine and is excreted in feces

kayexalate / Sodium Polystyrene Sulfonate

what is Sodium Polystyrene Sulfonate used for

hyperkalemia often found in CKD patients

what are the adverse effects of Sodium Polystyrene Sulfonate / Kayexelate

gastric irritation, nausea/vomiting, constipation or diarrhea, hypokalemia, or hypernatremia

what are the nursing considerations for Sodium Polystyrene Sulfonate

administered PO or as an enema, should assess for bowel sounds and if they are hypoactive it is contraindicated.

monitor vitals

EKGs for signs of hypokalemia (wide QRS)

what are the diuretics

loop, thiazide, K+ sparing

what are the RAAS agents

ACEs, ARBs, DRNI, ARNis

what are the calcium channel blockers

non-dihydropyridine and dihydropyridine

what are the direct acting vasodilators

hydralazine/minoxidil, nipride

are osmotic diuretics indicated for HTN?

no

cleaves angiotensinogen into angiotensin I

renin

coverts angiotensin (1) into angiotensin II

ACE

causes vasoconstriction, release of aldosterone and ADH

angiotensin II

induces sodium and water reabsorption in the kidneys

aldosterone

what is the direct renin inhibitor (DRI)

aliskiren

what is the trade name for aliskiren

tekturna

binds with renin to prevent angiotensinogen into angiotensin I to reduce influence of RAAS

aliskeren

what is aliskeren used for

hypertension

what are the adverse effects of Aliskeren

well-tolerated in CKD or non-diabetic pts. but NOT a first line drug

Diarrhea

Fetal injury and death

what are the nursing considerations for Aliskeren

make sure they’re not pregnant

I/O, vitals, weight, electrolytes

not widely used given cost and limited benefit

only FDA approved DRI for HTN, combing with other RAAS inhibitors can lead to hypotension/hyperkalemia

Aliskeren

what is the ACE inhibitor

lisinipro

what is the trade name for lisinipro

zestril

reduces level of angiotensin II through inhibition of ACE

lisinipro

what does lisinipro do

increases levels of bradykinin to dilate blood vessels

reduces blood volume

prevents/reverts changes in heart and blood vessels mediated by angiotensin II and aldosterone

what are the indications/what is lisinipro used for

hypertension, HF, post-MI therapy

prevention of MI, CVA, and death in patients with high CV risk

diabetic neuropathy

what are the adverse affects of lisinipro

first dose hypotension,

dry cough (bradykinin)

angioedema

hyperkalemia

fetal injury

what are the nursing considerations for Lisinipro/Zestril

monitor BP/electrolytes closely

educate patients to contact provider if cough or angioedema occurs

what is the Angiotensin Receptor Blocker (ARB) that we are learning

Losartan

what is the trade name for Losartan

Cozar

block angiotensin II by blocking access to its receptors in blood vessels, adrenal glands, and other tissues to cause dilation of vessels and prevent release of aldosterone

losartan

what is losartan used for

hypertension,

thought to reduce risk of stroke in MI patients with high CV risk

thought to improve blood flow in patients with diabetic neuropathy and retinopathy

what are the adverse effects of Losartan

angioedema (lower risk though but contact provider)

fetal injury

what are the nursing considerations of Losartan

do not use with ACEIs

monitor BP

contact provider of angioedema

Angiotensin receptor Neprilysin inhibitor ARNI

Valsartan + Sacubitril

what is the trade name for Valsartan + Sacubitril

entresto

blocks angiotensin II by blocking access to its blood vessels but also blocks neprilysin to break down natriuretic peptides

simultaneously prevents vasoconstriction and fluid retention

entresto

what is entresto used for

hypertension and heart failure, shown to slow down progression of cardiac remodeling and reduce mortality

what are the adverse effects of entresto

angioedema, hypotension/hyperkalemia

what are the nursing considerations for Entresto,

when switching from and ACEI to an ARNI, there is a required wash-out period of 36 hours required between doses to prevent toxicity

BNP levels may increase after starting ARNI, but BNP is still reliable biometer in HF patients

special considerations for ARNI (valsartan + sacubitril)

cannot be combined with an ace inhibitor because it increases bradykinin levels - angioedema

who should avoid calcium channel blockers

patients with heart failure

what type of inotropic effect does calcium channel blockers have

negative, meaning decreased contractility

two types of calcium channel blockers

dihydropyridines, and nondihydropyridines

more effect on vasodilation than heart function

dihydropyridines

more effect on heart function less effect on vasodilation

non-hydropyridines

what are the dihydropyridines

the ones that end with -pine

what are the non-hydropyridines

Phenylalkylamine (verampil), and (benzothiazepine) diltiazem

what is the trade name for nifedipine

procardia

blocks calcium channels on vascular smooth muscle, specifically in arterioles. minimal activity on heart

nifedipine

is nifedipine short acting or long acting

short acting, quick drop in blood pressure

what is nifedipine used for

angina pectoris and hypertension

adverse effects of nifedipine

peripheral edema, flushing headache, dizziness, reflex tachycardia, orthostatic hypotension

what are the nursing considerations for nifedipine

assess bp and hr in pre-admin

reflex tachycardia suppressed with beta blocker

may need diuretic for peripheral edema, but not optimal due to further decrease in bp

what happens if adverse effects become a problem with nifedipine

may used an extended release, switch to a non-dihydropyridine, or combine with ACEi/ARB

Verampil, Diliatazem

what is the class and trade name

CCB - non class, trade name Calan

blocks calcium channels on both heart and blood vessels

angina pectoris, hypertension, and dysrhythmias

what are the adverse effects of verampil

constipation, orthostatic hypotension, cardiosuppresion with bradycardia, AV block and decreased contracility with possible cardiotoxicity.

slows AV nodal conduction

what are some interactions to look out for with verampil

and some nursing considerations

digoxin and beta blockers because it will decrease HR completely, grapefruit increased effort

assess BP and HR pre-admin

what happens if you overdose on verampil

gastric lavage, activated charcoal, IVF/IV calcium gluconate

how to verampil interact with digoxin

it increases its levels

what are the vasodilators

hydralazine, nitroprusside

selective dilation of arterioles through actions on vascular smooth muscle to reduce peripheral resistance and blood pressure

hydralazine

trade name for hydralazine

apresoline

what us hydralazine used for

essential htn, hypertensive crisis, heart failure

what are the adverse effects of hydralazine

reflex tachycardia, increased blood flow, SLE - like syndrome (muscle/joint pain, serositus)

when used for heart failure what should you combine hydralazine with

dinitrate

what should you combine hydralazine with for tachycardia and to reduce risk of sodium or water retention

beta blocker and diuretic

nursing considerations for hydralazine

monitor vitals closely, especially excessive hypotension

if you give hydralazine PO whats the onset and duration

45 min and 6 hour

if you give hydralazine IV what is the onset and the duration

10 min and 2-4 hours

whats the trade name for hydralazine

apresoline

vasodilator that causes both venous and arterial dilation to decrease blood pressure

nitroprusside

nitroprusside aka

nipride/nitropress

drug of choice for hypertensive emergencies where SBP >180 and DBP >120

nitropress

adverse effects of nitropress

cyanide and thiocyanate toxicity (weakness or delirium) in patients receiving prolonged infusion and/or those with hepatic or renal impairments

if you have a cyanide and thiocyanate toxicity with nitropress what do you give

hydroxocobalmin because it binds with cyanide to form cyancobalmin (vit b12) which is excreted

nursing considerations of nitropress

tachycardia minimal, monitor vitals, monitor EKG and reassess for s/s that reflect dramatic changed in blood pressure

what are the IV infusion ranges for nitropress

0.3-0.5 mcg/kg/min

whats the titration rule for nitropress sl

done slowly to bring down BP (map should be lowered no faster than 10-20% in the first hours and a further 5-15% in the next 23 hours)

nitroprusside released what ions which must be detoxified

cyanide ions

cyanide is normally converted to thiocyanate in the

liver

thiocyanate is excreted how

renally

meds for heart failure - diuretics

furosemide (lasiks), Hydrochlorothiazide (HCTZ), and spirolactone (aldactone)

part of first line treatment of heart failure

utilized for severe heart failure

monitor closely for digitalis toxicity

effective even with low GFR

monitor electrolyte levels

furosemide

produces modest diuresis

NOT effective with low GFR, why loops are preferred

monitor electrolyte levels

thiazide diuretics

produces little diuresis

these agents are used to provide further diuresis without further potassium loss

spironolactone

in addition to diuretics, other drugs are used in treatment of patients with an EF less than 40% - which has moved to the top as being most effective in their category for HF

ARNI

what are the 3 beta blockers for HF

carvedilol (coreg), metoproplol succinate (toprol-XL), and bisoprolol (zebeta)

what are the aldosterone antagonist/MRA for HF

spironolactone (aldactone) and eplerenone (inspra)

what are the SGLT2 inhibitors

dapafliflozin (farxiga), empafliflozin (jardiance), Canagliflozin (invokana)

whats the med for HF for african americans

hydralazine + nitrate (isosrbide dinatrate)

SGLT2 inhibitors end in

-zin

can be used in both HFpEF and HFrEF patients

moa: blocks the SGLT2 protein in the proximal tubule of the nephron, reducing the amount of reabsorbed glucose and sodium into the blood

blocks glucose reabsorption leading to glucosuria

SGLT2 inhibitors

causes lower blood glucose levels, osmotic diuresis, natriuresis, and cardiovascular protection

SGLT2 inhibitors

first line therapy for HFrEF patients

beta blockers

meds for heart failure

Oral vasodilator

BiDil (20 mig isosorbide dinitrate/37.5 hydralazine)

first med approved for specific ethinic group (african americans - 2005) improves survial and heart failure symptoms

BiDil (20 mig isosorbide dinitrate/37.5 hydralazine)

meds for heart failure

IV vasodilator

Nitroglycerin (NTG), and Sodium Nitroprusside (nipride), and nesirtide (natrecor)

powerful decreased pulmonary edema, and angina

adverse effects, hypotension, reflex tachycardia, headaches are the most common

NTG