Pharm: Diuretics, Hyperkalemia, Electrolytes, ...

Week 4

Diuretics

From strongest to weakest:

• Loop

• Thiazide

• Potassium-sparing

• Osmotic

LOOP Diuretics:

• Furosemide

• Bumetanide

• Ethacrynic Acid

A/E: dehydration, drop BP, hyponatremia, hypokalemia, hypocalcemia, … EVERYTHING goes down except for HYPERGLYCEMIA and HYPERURICEMIA

A/E: ototoxicity/tinnitus

CI: gouty

RN:

• don’t give med in the evening

• daily weights same time, same amt of clothing

• Potassium supplement (K+ 3.5-5.0)

• Labs: CMP, uric acid (bad for kidneys)

• watch for OH - fall risk

Precautions for LOOP diuretics

• Low K+ makes Digoxin more toxic

• Low Na+ makes Lithium more toxic (136-145 mEq)

• Low Ca2+ → check for Trousseau (carpopedal spasm)/Chvosteks (ipsilateral facial muscle contraction)

Measure for OH

• lying down

• standing up 1 min

• standing up 3 min

OH = more than 20 mmHg systolic change/report dizziness

Thiazide Diuretics:

• Hydrochlorothiazide, Metolazone, …

1st line treatment for HTN

A/E: same as loop except for hypercalcemia

***Good for patients with Tinnitus, Osteoporosis

Potassium-Sparing

• Spironolactone

• Triamterene

A/E: hyperkalemia

A/E: endocrine effects - deep voice, hirutism/hirsute, irregular menstrual cycle, gynecomastia, impotence (unable to erect)

CI: kidney failure

***RN:

• do not use with RAAS meds: ACE, ARBs, Aliskiren - increase risk of hyperkalemia

Tx for Hyperkalemia

• FIRST: IVP Ca Chloride - to stabilize the heart (crash cart)

• IV Sodium Bicarbonate - decrease acidity → drive K+ into cells

• IV insulin + D50W - drives K+ into cell

• Albuterol - shifts K+ into cell

• Loop diuretics

• Kayexalate (K-exit)

Osmotic Diuretics

• Mannitol

Tx: cerebral edema & closed-angle glaucoma

• reduces intracranial and intraocular pressure

A/E: HF, rebound ICP

RN: due to crystals, ALWAYS use a filter, warm up solution

Iron Supplements

• Ferrous Sulfate PO

• Iron Dextran IV

A/E: GI distress, teeth staining, anaphylaxis (IM Epi 1:1000)

Antidote: Deferoxamine

Pt: take with Vit C

Vitamin B12 - Cyanocobalamin IM

Tx: pernicious anemia (B12 deficiency)

A/E: diarrhea → hypokalemia

S/S B12 deficiency: red beefy tongue, pallor, neuropathy

RN: take with folic acid

Vit B9 - Folic Acid

Tx: supplement for ETOH DO - poor dietary intake and liver injury

MTX decreases folic acid

Banana bag: for ETOH DO patients

Potassium Supplements

• Potassium Chloride, K-Dur (ER) - do not chew

Tx: hypokalemia due to diuretics or steroids, prolonged diarrhea

CI: renal disease, K+ sparing, ACE, ARBs (RAAS drugs cause HYPERKALEMIA)

Pt: sit up for 30 min to prevent esophagitis (is a vesicant)

RN: never IVP, infusion rate peripheral 10 mEq/hr, central 20 mEq/hr

• Check kidney functions:

  • BUN 6-20

  • Cr 0.6-1.5

IV Extravasation

Vesicant drugs: epinephrine, Potassium Chloride, Dopamine

RN:

• stop and leave bad IV in for antidote, then notify MD and assess patient

IV Magnesium

First line Tx for Torsade de Pointes (polymorphic ventricular tachycardia)

PRBC

• A/E: HTN, TACO, hypocalcemia (citrate in PRBC to prevent clots binds with Ca2+ → hypocalcemia)

• RN: start within 30 after leaving the blood bank, finish within 4 hours, 2 filters, NS only

Blood Transfusion Rxn:

• Temp increases > 1.8 deg F or 1 deg C

• Fever with chills, SOB, drop SBP, hives, lightheadedness

• → stop, infuse NS to maintain patency, notify MD, return blood bag for testing

Male HRT:

• Testosterone

• Oxandrolone

Tx: AIDS, cachexia, muscle-wasting conditions

***Skin-to-skin transfer

BPH - the looooong “rides”:

• Finasteride, Dutasteride, …

Tx: treat BPH by reducing the size of the prostate

A/E: decreased libido, gynecomastia

LOOOONG ride - takes 6 months or longer - SLOOW

RN: need to wear gloves, avoid sem*n (category X)

BPH - the sins:

• Tamsulosin, Doxazosin, …

Tx: BPH, help pt go pee

A/E: hypotension, dizziness, retrograde ejaculation

CI: Sildenafil or NTG, Hx of syncope

RN:

• Take for the rest of their life

• 30 mins AFTER MEAL

ED:

• Sildenafil, Tadalafil, Vardenafil

WORK FAST

CI: NTG within 46 hours, or nitrate (Isosorbide Dinitrate)

A/E: MI, OH, priapism, hearing loss/visual changes

Pt: avoid hot shower

Female HRT

• Estradiol, Ethyl Estradiol

vs. SERMs (Estrogen modulators)

• A/E: endometrial, breast, ovarian cancer, hypercoagulability

• DO NOT place near breast/waistline

• AVOID cigarette smoking/nicotine → increase clotting risks

Progesterones

• Drospirenone (synthetic)

• depot injection: releases slowly

• IUDs: last 3-10 years