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Pharmacology > TEST 2 > Flashcards

TEST 2 Flashcards

1
Q

African American patient

A

-thiazides are preferred over ACE for HTN
-HTN + DM = CCB, diuretic
-HF = ACE, BB -> stage C -> hydralazine/isosorbide

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2
Q

CCB

A

-indication- HTN, angina, atrial arrhythmias (non-DHP), migraine, raynauds disease
-precautions- peripheral edema, reflex tachycardia, non-DHP with BB
-Non-DHP CI- hypotension, cardiogenic shock, SSS, 2/3 heart block
-ADR: constipation, bradycardia, flushing, reflex tachycardia
-ADR for non-DHP- heart block, CHF, hypotension

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3
Q

beta blockers

A

-Indications: HTN, angina, post MI, specific agents for arrhythmias, migraine, glaucoma, CHF (specifically carvedilol and metoprolol succinate XL)
-Contraindications: bradycardia, > 1st degree heart block, uncompensated cardiac failure, cardiogenic shock, SSS, severe PAD, Asthma
-ADRs- bradycardia, CHF, hypotension, bronchoconstriction, sexual dysfunction, fatigue, dizziness, cold extremities (reflex peripheral vasoconstriction), hypercholesterolemia, CNS side effects like confusion, nightmares (w/ lipid soluble BB)

-titrate HR to 50-60 in angina

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4
Q

which drugs can you not take with PDE-5

A

-nitroglycerin
-alpha 1
-side note- alpha 1 can cause fluid retention so its usually given with diuretic

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5
Q

alpha 2: centrally acting agents

A

-ADR- bradycardia, heart block, impotence, dry mouth, sedation
-clonidine
-methyldopa- coombs + hemolytic anemia
-guanethidine and reserpine

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6
Q

HTN emergency

A

-BB- esmolol and labetalol
-sodium nitroprusside (SNP) - PVR
-nitroglycerin (NTG) - AMI or HF
-Hydralazine
-dopamine receptor agonist- Fenoldopam- good for renal dysfunction
-CCB- nicardipine (encephalopathy and stroke) and clevidipine (before CABG)
-ACE- enalaprilat -> HTN with HF

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7
Q

causes of HF

A

-MC cause of systolic HF -> MI
-non-cardiac causes:
-diet- low K and Ca
-anemia
-drugs- chemo agents (doxorubicin), COX-2, NSAIDs, thiazolidinediones (for DM)

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8
Q

HF med process

A

-1ST LINE- ACEi/ARB
-Add beta blocker -> pref carvedilol (once it HF is more advanced - caution bc it decreases contractility)

STAGE C CONSIDERATIONS:
-diuretics- sx of volume overload
-aldosterone antagonist
-d/c ACE or ARB and start ARNI
-hydralazine/isos- first line in AA
-ICD
-ivatradine
-HCN channel blocker- HR must be < 70 and EF < 35%
-digoxin

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9
Q

ARNI

A

-valsartan/sacubitril
-decrease fibrosis
-decrease morbidity and mortality
-SE- hypotension, hyperkalemia, cough, dizzy, acute renal failure

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10
Q

hyrdalazine/isosorbide

A

-hydralazine- arterial relax
-isosorbide dinitrate- venous relax
-preferred for AA in stage C
-reduce morbidity and mortality
-can be used for pts with ACE/ARB intolerance

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11
Q

HCN blocker

A

-Ivabradine
-reduces rate
-reduces hospitalizations in symptomatic HF with LVEF < 35% and HR >= 70
-must be on max BB or contraindicated
-ADR- bradycardia, HTN, afib, luminous phenomena (phosphenes) or brightness
-CI- acute decompensated HF, BP < 90/50, SSS, SA block, 3rd degree AV block, resting heart rate < 60, hepatic impairment, pacemaker dependence,

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12
Q

digoxin

A

-0.5-2 ng/mL - must monitor!!!!
-positive iontrope
-indications- CHF, atrial arrythmias, shock
-IV dose is 20-25% less than PO
-if CrCl <50 -> reduce dose by 50%
-digitoxin- metabolized in liver, excreted in feces
-ADR- GI, brady, arrythmias, AV block, weakness, fatigue, dizzy, AMS, visual disturbance
-precaution in hypomagnesaemia, hypercalcemia*, hypokalemia

-overdose- K, lidocaine, digibind

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13
Q

IV inotropes for acute decompensated HF

A

-adrenergic agonist- dobutamine
-selective beta agonist for contractility
-mild vasodilative effect

-phosphodiesterase (PDE) inhibitor- amrinone and milrinone
-long term use -> thrombocytopenia and ventricular arrythmias
-increase mortality

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14
Q

IV vasodilators for acute decompensated HF

A

-nesiritide- B-type human natriuretic peptide
-give to pts with dyspnea at rest
-CI in pts with shock or hypotension

-nitroprusside- arterial and venous dilation via nitric oxide

-nitroglycerin- venous dilation > arterial

-used in the ABSCENCE of hypotension

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15
Q

angina tx

A

-1st line for typical angina -> beta blocker- beta 1 selective
-add DHP CCB for further treatment -> NOT NON-DHP CCB
-if BB is contraindicated (asthma, DM) -> non-DHP CCB
-if bradycardia/heart block- DHP CCB
-nitrates- nitroglycerin, amyl nitrate, isosorbide
-ranolazine

-1st line for variant angina -> non-DHP CCB

-occasional episodes- SL nitroglycerin

ADJUNCT:
-antiplatelet- aspirin, clopidogrel, prasugral (UA), ticagrelor (UA) -> slow progression to acute coronary syndrome
-ACE- in all CAD pts to slow progression

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16
Q

specific CCB used for angina

A

-Non-DHPs
-Verapamil (Calan, Isoptin)
-Diltiazem (Cardizem, Tiazac)

-DHPs
-Amlodipine (Norvasc)
-Felodipine (Plendil)
-Nifedipine (Procardia XL) – avoid IR formulation

17
Q

nitrites and nitrates

A

-venous dilation (arterial at higher doses)
-contraindications- aortic valve stenosis, cerebral hemorrhage, anemia, hypotension <90, PDE-5, angle-closure glaucoma
-reflex tachy
-long term use in addition to BB and CCBs
-Amyl nitrate (INH) (X)
-nitroglycerin
-isosorbide

18
Q

nitroglycerin

A

-IV, PO, SL, buccal, topical, transdermal
-SL and buccal form- Deteriorates in sunlight -> Replace every 3-6 months after open
-Ointment- messy only inpatient
-Patch -> 12 hr intervals to prevent tolerance
-PO– must be QD or BID to minimize tolerance
-IV– contains propylene glycol, need special tubing
-cool dry place, fridge, keep in container
-0.4mg every 5mins (3 doses max) - sublingual
-if no relief after first dose -> call 911

19
Q

isosorbide: angina

A

-dinitrate form- PO or SL, give TID (8, 1, 6)
-mononitrate form- PO only -> BID or QD

20
Q

ranolazine

A

-used for chronic stable angina in combo with CCB, BB, or nitrates
-CI- QT prolongation, hypokalemia, hepatic failure
-torsades

21
Q

acute STEMI tx

A

-aspirin- 162-325 STAT, then 81-325
-nitroglycerin- for first 24-48 hrs -> do NOT give if hypotension <90 or HR <50
-analgesics- morphine every 5 mins
-beta blockers- ASAP and continue after
-ACE- post MI for pts with LV dysfunction and/or HF
-CCB- for pts intolerant to BB
-weight based unfractionated heparin
-LMWH (enozaparin/dalteparin)
-bivalrudin
-fondaparinux
-P2Y-12 inhibitors- clopidogrel, prasugrel or ticagrelor
-fibrinolytics
-statins- post MI

22
Q

fibrinolytics: contraindications and examples

A

-Absolute Contraindications in pts with MI*:
-Previous hemorrhagic stroke
-Other strokes or CVA within 1 year
-Intracranial neoplasm
-Suspected aortic dissection

-relative contraindications in pts with MI*:
-Severe uncontrolled HTN (> 180/110)
-Recent trauma, head trauma or major surgery
-Recent internal bleeding
-Pregnancy
-Active peptic ulcer
-History of chronic severe HTN

-Streptokinase – 1.5 million units over 30-60 minutes
-Alteplase (TPA) – 100 mg over 90 minutes total
-Reteplase (Retavase) – 10 units x 2 doses over 30 minutes total
-Anistreplase (Eminase) – 30 mg over 5 minutes total
-Tenecteplase (TNKase) - 30-50 mg (based on pt weight) over 5 seconds* -> time is tissue

23
Q

NSTEMI/UA

A

-PCI– stent placement
-some pts require CABG -> antiplatelets should be held for 5-7 days if possible*
-ASA
-BBs
-Nitrates
-Antithrombotic regimens

-Anticoagulants - Options include:
-Weight-based unfractionated heparin
-LMWH
-Bivalrudin
-fondaparinux

-Antiplatelets
-ASA
-P2Y12 inhibitor (Clopidogrel, Prasugrel or Ticagrelor)
-IV Glycoprotein IIb/IIIa inhibitors (not used much bc of P2Y 12 inhibitors + anticoagulants*)
-On discharge: Dual oral antiplatelet therapy with aspirin and a P2Y12 inhibitor depending on type of stent placed

-Statins – long term to delay progression, improve mortality
-ACE inhibitors – long term to delay progression, improve mortality
-A major difference in therapy between STEMI and NSTEMI is that fibrinolytics are NOT used in NSTEMI patients

24
Q

good fat

A

-Monounsaturated fatty acids (MUFA)
-Aka oleic acid
-found in olive oil, canola oil, safflower oil and sunflower oil
-Also found in walnuts, almonds, peanuts and sesame seeds and olives and avocados

-Polyunsaturated fatty acids (PUFA)
-Linoleic acid (omega-6) – found in vegetable oils (soybean, safflower, sunflower and corn)
-alpha-linoleic acid (omega-3) – found in certain fish, marine oils, flaxseed and linseed oils

25
Q

HTN and CHD age risk

A

-HTN- men > 55; women > 65
-CHD- men > 45; women > 55
-family hx of early CHD- male < 55; female <65

26
Q

risk factors for myopathy: statins

A

PATIENT FACTORS
-Age > 80
-Female gender
-Small body frame
-↓ hepatic/renal Fn
-Hypothyroidism
-Diet (grapefruit juice)
-polypharmacy

DRUG PROPERTIES
-Lipophilicity (pravastatin and rosuvastatin least likely)
-High F
-Limited protein binding
-CYP substrate

27
Q

statins dosing

A

-rule of 6- initial dose is most powerful -> every increase after is only 6% reduction of LDL
-high dose= >=50% decrease in LDL
-moderate dose= 50-30%
-low dose= <30%

28
Q

PCSK9 Mab/siRNAi

A

-alirocumab
-evolocumab
-every 2-4 weeks
-reduce degradation of LDLR -> more breakdown of LDL
-ADR- injection site rxn, nasopharyngitis, flu, allergic

-siRNAi:
-inclinsiran
-increase receptors too
-2x year

29
Q

bile sequestering

A

-decrease LDL
-INCREASE TG
-CI- TG > 400
-steatorrhea
-cholestyramine
-colestipol
-colesevelam
-need to take for a couple weeks for max effects

30
Q

fibric acid derivatives

A

-decrease TG
-increase HDL
-LDL variable
-CI- in severe renal/hepatic failure, biliary and gallbladder disease
-ADRs - GI, dyspepsia, rash, urticaria, alopecia, fatigue, headache, impotence, increase LFT, myopathy and rhabdomyolosis, gallstones

-gemfibrozil
-fenofibrate

31
Q

nicotinic acid

A

-decrease LDL
-decrease TG
-increase HDL
-vasodilation, flushing, pruritis -> take with ASA to prevent
-GI, PUD, increase LFT, hepatic dysfunction, hyperuricemia, hyperglycemia

32
Q

ezetimibe

A

-decrease TC, LDL, TG
-increase HDL (small)
-ADRs - Chest pain, dizziness, fatigue,
headache, GI effects – diarrhea and
abdominal pain, arthralgia

33
Q

probuchol

A

-lowers LDL AND HDL
-not really used
-last resort

34
Q

alternative lipid lowering

A

-Vitamin E
-Garlic
-HDL infusions
-artichoke extract
-fiber
-plant stanol/sterols
-soy
-walnuts

35
Q

fish oils

A

-PUFAs- EPA and DHA
-2g 2x day
-decrease TG
-decrease mortality
-decrease CVD
-decrease death due to MI
-Lovaza- Rx
-can have anticoagulant effect- monitor bleeding

-if getting from diet- fatty fish -> beware of mercury, PCB, dioxin -> tremor, numbness, tingling, difficulty concentrating, vision problems

36
Q

statin DDI

A

-things that increase statin: grapefruit juice, amiodarone, antifungals and macrolides
-dose adjustment of statin based on DDI -> this is a precaution NOT a CI
-CYP 450 3A4 substrates: Lovastatin & Simvastatin > Atorvastatin
-Significant 3A4 inhibitors: grapefruit juice, amiodarone, azole antifungal, macrolides
-Significant 2C9 inhibitors: amiodarone, cimetidine, azole antifungals, SSRIs, zafirlukast
-Fluvastatin is a CYP2C9 substrate.
-Pravastatin and Rosuvastatin have least DDIs

Pharmacology (16 decks)

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