Exam 3 Review SHeet Flashcards
(156 cards)
1
Q
Thiazide Diuretics
A
hydrocholorthiazide
P: Hydodiuril
other drugs end in “zide”
Used most for hypertension tx d/t low cost and short acting (half life: 1-2 hrs)
act on distal convoluted tubule in nephron
2
Q
Indication for use of hydrocholothiazide
A
Used in CHF, HTN & edema patients
3
Q
MOA for hydrocholothiazide
A
Inhibits Na/Cl pump = decrease Na/Cl absorption and increase excretion of Na/Cl and eventually H2O
Modest diuresis
Some K and Mg excreted also
Check electrolyte levels and BP before admin
4
Q
Cautions for hydrocholothiazide
A
Gout (Inhibits uric acid secretion)
Women have a greater decrease in K than men
Hypercalcemia
Do not give to severe renal impairement, diabetics (Increase blood sugar), hyperlipidemia, lupus & sulfa patients
5
Q
Adverse effects of hydrocholorthiazide
A
Orthostatic hypotension, dizziness Drowsiness N/GI upset - take with food if discomfort Electrolyte imbalance Increase blood glucose Headache Rash Hyperuricemia (Blocks uric acid secretion Hyperlipidemia
6
Q
Nursing implications for hydrocholothiazide
A
Take in the AM
Monitor I&O
Avoid high Na foods and increase K foods
Monitor electrolytes and blood sugars
Caution with position changes = orthostatic hypotension
Men can have possible ED
Be aware of hyponatremia s/s – craving salt, cramps, wt loss
7
Q
Drug Interactions with hydrocholorothiazide
A
Many
High Na foods decrease effectiveness
8
Q
Potassium sparing diuretics
A
Na channel blockers: triamterene (P) Dyrenium
Aldostersone antagosnists: spironolactone (P) Aldactone
9
Q
triamterene (Dryenium) and spironolactone (Aldactone) characteristics
A
Weaker diuresis and antihypertensive effects when used alone
Usually used with other K wasting diuretics to maintain K levels
10
Q
Indications for use of triamterene (Dryenium) and spironolactone (Aldactone)
A
HTN, edema, and cirrhosis
11
Q
MOA of spironolactone (Aldactone)
A
Works in the distal tuble
Increase Na and H2O loss while keeping K
Aldosterone antagonist
12
Q
MOA of triamterene (Dyrenium)
A
Works in distal tubule
Increase sodium, Cl, H20, Ca, and bicarb loss but keeps K and Mg (Watch for arrhythmia’s)
Inhibits uric acid secretion = increase uric acid levels
Independent of aldosterone
13
Q
Cautions with triamterene (Dyrenium) and sprironolactone (Alactone)
A
Renal insufficiency, pre existing hyperkalemia
Liver disease
Diabetes (Increase BS)
Pts on ACE inhibitors (Increase K), NSAIDS or K supplements (Increase K)
No Mrs. Dash (Increase K)
14
Q
Adverse effects of triamterene and spironolactone
A
Hyperkalemia (Muscle cramping, arrhythmias, tingling/numbness, confusion Electrolyte imbalance Hypotension N/V/D Weakness, fatigue Headache Gynecomastia Nephrotoxic – triamterene (rare)
15
Q
Nursing implications/education of triamterene and spironolactone
A
Take in the AM or early PM (if bid) to prevent nocturia
I&O
Monitor electrolytes and BS
Caution with position changes = orthostatic hypotension
Men can have possible ED
Be aware of hyponatremia s/s= craving salt, cramps, wt loss
16
Q
Loop diuretics
A
furosemide (Lasix)
other drugs end in “zide”
Cause a greater natriuresis than thiazides
PO and IV form - PUSH IV SLOW (tinnitus or CV collapse)
Short onset: 15-30 min, lasts 6-8 hours
Furosimide less bioavailablility than other d/t increase protein bound
Torsemide less renal cleared so easier on kidneys/renal patients
17
Q
MOA of furosemide (Lasix)
A
Act in loop of henle
Inhibit Na/K/Cl channel = prevents reabsorption of Na/Cl and eventually H2O
Increase K/Ca/Mg excretion
18
Q
Cautions with furosemide (Lasix)
A
Gout
Impaired glucose intolerance
Renal disease
Elderly and PG pts
19
Q
Adverse effects of furosemide (Lasix)
A
Hypokalemia Orthostatic Hypotension Dehydration Hypomagnesium Ototoxicity Hyperuricemia
20
Q
Drug interactions with furosemide (Lasix)
A
Other ototoxic drugs - amnioglycosides (abx), aspirin
Beta Blockers - increase level
Many others - see book
21
Q
Nursing implications/Education on furosemide (Lasix)
A
Take in the AM or early PM (if bid) to prevent nocturia
I&O
Increase K foods
Monitor electrolytes and blood sugars
Caution with position changes = orthostatic hypotension
Men can have possible ED
Be aware of hyponoctremia s/s = craving salt, cramps, and wt loss
22
Q
Beta Blockers
A
propranolol (Inderal)
Other drugs end in “olol”
Good absorption, onset 30 min, duration 6-12 hrs
Some large first pass effect: propranolol, labetalol
Some highly protein bound: propranolol, penbutolol, carvedilol
Takes 2-3 weeks for full effect of beta blockers to be achieved
Cardioprotective: BB occupy catecholemine receptors so they cant bind = Decrease sympathetic nervous system (HR/BP)
23
Q
Indications for use of propranolol (Inderal)
A
HTN, angina, MI, irregular cardiac rhythyms
Stable CHF
Migraines, anxiety, substance withdrawl
Tremors (Mask s/s of hypoglycemia)
24
Q
MOA of propranolol (Inderal)
A
Part of ANS - blocks beta 1 (Heart) and beta 2 (lungs) receptors
- Some are selective and others are non-selelctive
Vasodilation = decrease BP/HR
Decreased force of contractions (NOT good for Unstable CHF pts.)
Decreased renin secretion
Hard to increase HR with exercise/stress test
Bronchospastic disease (Never give COPD/asthma/resp pts)
Mask s/s of hypoglycemia
25
Adverse effects of propranolol (Inderal)
```
Hypotension
Arrythmias
Bronchospams
Hypoglycemia
Bradycardia, depression, ED, elevated liver enzymes, dizziness, fatigue, lethargy, hyperlipidemia
```
26
Nursing implications/Education for propranolol (Inderal)
Do not stop abruptly - can cause rebound HTN and MI
Check VS (esp HR) before administering
Change positions slowly (orthostatic hypotension)
Alert diabetics about hypoglycemia
Eat high fiber diet to avoid constipation
Lifestyle changes: Wacth Na intake, diet and exercise
Can cause sexual dysfunction (esp. in men)
27
Cautions and Contraindications Mnemonic for propranolol (Inderal)
```
A: Asthma
B: block (Heart block)
C: COPD
D: Diabetes mellitus
E: Electrolyte (Hyperkalemia)
```
28
Ace inhibitors
captopril (Capoten)
other drugs end in "pril" (A-pril)
Most are prodrugs = need good liver function to metab into active form
Takes up to 4 weeks to get full effect
29
Indications for use of captopril (Capoten)
HTN, CHF, DM neuropathy, L ventricular dysfunction, Acute MI
| Unlabeled uses: RA, dementia (Decrease inflammation in the brain)
30
MOA of captopril (Capoten)
Inhibit conversion of angiotensin I to angiotensin II = decrease aldosterone secretion
- leads to decrease Na and H2O rentention
Prevents breakdown of bradykinin (vasodilator) = Increase badykinin levels = Increase vasodilation
Decrease in K excretion (Know K levels before giving)
31
Effects of captopril (Capoten)
Decrease systemic vascular resistance
No change in HR
Increase renal perfusion/Decrease renal vascular resistance
- renal protective, give to DM pts to prevent nephropathy
Prevent ventricular remodeling
32
Cautions of captopril (Capoten)
Do not give to PG pts - Category D
33
Cautions of captopril (Capoten)
Do not give to PG pts - Category D
Renal insufficiency
Photosensitivity (Wear sunscreen to prevent burning)
Captopril and moexipril need to be taken on an empty stomach (Watch for proteinuria w/in first 2-4 wks)
34
Adverse effects of captopril (Capoten)
Cough
Orthostatic Hypotension
Hyperkalemia (Cramping, arrythmias)
Angioedema
ACE w/diuretic = 1st dose phenomenon (Decrease BP)
- Hold diuretic for a few days to get used to ACE then add diuretic again
Rach (rare), N/D/Constipation, leukopenia, myalgia, headache
35
Drug interactions of captopril (Capoten)
Increase levels of digoxin, lithium, and potassium
Decrease levels of ACE by antacids and indomethacin use
Potassium sparing diuretics
Potassium Supplements
36
Angiotensin II Receptor Blockers (ARBs)
losartan (Cozaar)
other drugs end in "sartan", they "sartanly" resemble ACE
High 1st pass effect, highly protein bound, renal/hepatic elimination
37
MOA of losartan (Cozaar)
Much like ACE, block binding of angiotensin II to receptors
AT1 receptors prevent vasoconstriction and aldosteron relsease
AT2 may have vasodilary effects
No effect on bradykinin pathway
38
Cautions of ARBs/losartan/Cozaar
Do not give pregnant women - Category D
39
Adverse effects of ARBs/losartan/Cozaar
```
Hypotension
Angioedema (rare)
Thrombocytopenia
Rhabdomyolysis
Diarrhea, Dizziness, fatigue
```
40
Drug interactions with ARBs/losartan/Cozaar
```
Termisartan with other hepatically cleared drugs
- increase digoxen and warfarin levels
Potassium sparing diuretics
Potassium supplements
Grapefruit (metab by CYP also)
```
41
Selective Aldosterone blockers
eplerenone (Inspra)
Less side effects than spironolactone because they are selective
Natuetic = Decrease Na and H2O retention
42
Indications for use of Selective Aldosterone Blockers/eplerenone/Inspra
HTN and Heart Failure after an MI
43
MOA for Selective Aldosterone Blockers/eplerenone/Inspra
Bind to mineralcorticoid receptors so aldosterone can't bind = Decrease Na and H20 retention
K not excreted - watch K levels
44
Contraindications of selective aldosterone blockers/eplerenone/Inspras
Hyperkalemia, Diabetics with microalbuminuria, renal pts.
45
Adverse effects selective aldosterone blockers/eplerenone/Inspras
Hyperkalemia, Hyponatremia, Increase Triglicerides, dizziness, angina, MI
46
Drug interactions with selective aldosterone blockers/eplerenone/Inspra
Potassium supplements/potassim sparing diuretics = Increase K levels/ret
ACE/ARB's = Increase K levels/ret
Grapefruit may increase effects of Inspra
47
Alpha 1 blockers
praxosin (Minipress) - given via patch, 1st dose effect
terazosin (Hytrin)
doxazosin (Cardura)
Indicated for HTN
48
Central ALpha 2 agonist
Not first line tx for HTN, usually added with other HTN meds
clonidine (Catapress)
methyldopa (Aldomet) - ok for pregnant patients, can darken urine
49
Alpha Beta blockers
Usually used in ICU via drip, lying flat
| labetolol
50
Direct acting vasodilators
hydralazine
side effects: palpatations, tachy, angina
Usually also on BB to stop tachy
51
Direct acting vasodilators
hydralazine
side effects: palpatations, tachy, angina
Usually also on BB to stop tachy
52
Cardiac Glycosides
```
digoxin
helps with a-fib/flutter/HR
60-80% oral absorp, 36 hour half life
Not recommended by dialysis
Give loading dose to speed up therapeutic effect
```
53
MOA for cardiac glycosides/digoxin
Inhibit Na-K-ATPase pump = Na & Ca can't leave cell = Increase in Ca = Increase force of contraction
54
Effects of cardiac glycosides/digoxin
Increase force of contraction - positive inotrope
Depress SA node = Decrease HR (negative chronotrope)
Prolongs refractory period of AV node (negative dromotrope)
55
Cautions for cardiac glycosides/digoxin
Renal insuff
Can cause electrolyte imbalance - hypokalemia, hypercalcemia, hypomagnesemia
Contraindicated for v-fib, v-tach, heart block patients
Thyroid patients - need to know thyroid levels before admin and adjust dose
High bran fiber diets reduce absorption
56
Monitoring for cardiac glycosides/digoxin
Dig levels: therapeutic 1-2 ng/mL
Electrolyte levels (K/Ca/Mg)
Heart rate
57
Signs of digoxin toxicity
```
N/V (extreme)
Arrythmias
Visual disturbances (Halos/yellow)
Fatigue, weakness, diarrhea
ANTIDOTE: digoxin immune fab (Digibind)
- IVP slow (15-30 min)
- does not change dig levels, can only tell if working by decrease s/s
```
58
Adverse effects of digoxin
Anorexia, N/V, abd discomfort
Headache, weakness, visual disurbances
Arrythmias, confusion, aggitation
Very similar to toxicity - get levels to determin dig tox
59
Drug interactions with digoxin
MANY, may increase digoxin levels
60
Patient education on digoxin
Take pulse before taking medication, Call MD if below 60 bpm
Do not d/c w/o approval from MD
NO OTC antacids, cough/cold, dietary supplements w/o approval from MD
Do not take with food - absorbes better on an empty stomach
Eat K rich foods, do not eat high fiber
Keep away from kids (Deadly)
Keep lab appointments
If missed dose, do not double up.
61
Natriuretic Peptides
nesiritides (Natrecor)
62
MOA of Natriuretic Peptides/nesiritides (Natrecor)
Promotes smooth muscle relaxation and dilation of vein and arteries
Decrease vascular resistance
Decrease fatigue and dyspnea
Decrease aldosterone levels = Decreased Na and H2O
Given by IV bolus and infusion
63
Cautions with Natriuretic Peptides/nesiritides (Natrecor)
Watch for hypotension
| Arrythmias and hypotension are #1 adverse effect
64
Phosphodiasterase inhibitor
inamrinone (Inocor)
| Peak 10-15 min
65
MOA for Phosphodiasterase inhibitor/inamrinone (Inocor)
Inhibit breakdown of CAMP = Increase Ca = Increase contraction of the heart
ST use for pats on diuretics, dig and vasodilators
Positive inotropic effect = Increase contraction
Vasodilation effect
Given by IV infusion
66
Adverse effects for Phosphodiasterase inhibitor/inamrinone (Inocor)
hypotension, nausea, thrombocytopenia (low platelets), hepatotoxicity (ICU/monitors)
67
Phospodiasterase inhibitor
inamrinone (Inocor)
| Peak 10-15 min
68
MOA for Phospodiasterase inhibitor/inamrinone (Inocor)
Inhibit breakdown of CAMP = Increase Ca = Increase contraction of the heart
ST use for pats on diuretics, dig and vasodilators
Positive inotropic effect = Increase contraction
Vasodilation effect
Given by IV infusion
69
Adverse effects for Phospodiasterase inhibitor/inamrinone (Inocor)
hypotension, nausea, thrombocytopenia (low platelets), hepatotoxicity (ICU/monitors)
70
Phospodiasterase inhibitor #2
milrinone (Primacor)
| Peak 10-15 min
71
MOA for Phospodiasterase inhibitor/milrinone (Primcor)
Inhibit breakdown of CAMP = Increase Ca = Increase contraction of the heart
ST use for patients on diuretics, dig, and vasodilators
Positive inotropic effect = Increase contraction
Vasodialtion effect
Propmt increase in CO
72
Adverse effects for Phospodiasterase inhibitor/milrinone (Primcor)
hypotension, headache, ventricular arrythmias, thrombocytopenia
73
Nitrates
```
nitroglycerin
Rapidly absorbed when SL or transdermal
Dry mouth will decrease absorption
Transdermal absorption increase with exercise, Increase body temp or applied to broken skin
Gradual release with transdermal
```
74
Indications for use of Nitrates/nitroglycerin
Angina
75
MOA for Nitrates/nitroglycerin
Dilate veins and arteries = decrease venous return = decrease myocardial tension = decrease O2 demand = arterial dialation
76
Cautions with Nitrates/nitroglycerin
Orthostatic hypotension
Caution with glaucoma pts = Increase introcular pressure
Caution with ED meds (Viagra, Cialis, Levitra) = Severe hypotension
77
Adverse effects of Nitrates/nitroglycerin
```
Headache (d/t vasodilation in brain, migraines)
Flushing
N/V
Tachycardia
Hypotension, Syncope
Rash
Blurred vision
Dizziness, vertigo
```
78
Education with Nitrates/nitroglycerin
Tolerance develops with continuous use = need nitrate free period of 8-12 hours/day
Trandermal patch: Nitro-Dur, Minitran
- apply to clean, dry, hairless skin; apply to chest, thigh or upper arm
- Do not cut or tear
Topical ointment (Nitro-bid)
- Apply to clean, dry, hairless skin, do not rub in
- avoid getting on hands
SL tablets: Nitrostat
- Do not chew or swallow
- Take one q5 min x3, if pain is unresolved go to ER
- Keep in cool, dry place
- Replace on a yearly basis
SL Spray
- Highly flammable, keep fire and cigarettes away
- Spray onto tongue or under tongue - do not inhale
79
Education with Nitrates/nitroglycerin
Tolerance develops with continuous use = need nitrate free period of 8-12 hours/day
Trandermal patch: Nitro-Dur, Minitran
- apply to clean, dry, hairless skin; apply to chest, thigh or upper arm
- Do not cut or tear
Topical ointment (Nitro-bid)
- Apply to clean, dry, hairless skin, do not rub in
- avoid getting on hands
SL tablets: Nitrostat
- Do not chew or swallow
- Take one q5 min x3, if pain is unresolved go to ER
- Keep in cool, dry place
- Replace on a yearly basis
SL Spray
- Highly flammable, keep fire and cigarettes away
- Spray onto tongue or under tongue - do not inhale
80
Nursing Implications with Nitrates/nitroglycerin
Always check BP before admin
Pts. should be sitting or lying when given
Watch for orthostatic hyptension
Treat headaches with aspirin or acetaminophen
Gradually wean/taper dose when d/c
Transdermal not used for acute angina.
81
Nursing Implications with Nitrates/nitroglycerin
Always check BP before admin
Pts. should be sitting or lying when given
Watch for orthostatic hypotension
Treat headaches with aspirin or acetaminophen
Gradually wean/taper dose when d/c
Transdermal not used for acute angina.
82
Nursing Implications with Nitrates/nitroglycerin
Always check BP before admin
Pts. should be sitting or lying when given
Watch for orthostatic hypotension
Treat headaches with aspirin or acetaminophen
Gradually wean/taper dose when d/c
Transdermal not used for acute angina.
83
Beta adrenergic blockers
beta blockers, "olol" meds
Decrease HR/contractility/BP
All help reduce myocardial O2 demand
Extend release BB cause fatigue and lethargy
84
Calcium Channel Blockers
Dihydropyridines: nifedipine (Procardia), amlodipine (Norvasc), nicardipine (Cardene)
- Increase vasodilation in periphery = cause edema (caution with CHF patients)
- DOes not effect conduction = does not effect HR
Non-dihydropyridines: verapamil (Calan), dilitazem (Cardizem)
- Affect conduction = decreased HR
- Used for arrythmias (a-fib/flutter)
- Cause vasodilation in periphery and coronary arteries = Decreased BP
Immediate relsease, rapid onset (30-60 min for most)
Large first pass effect
Highly protein bound
85
MOA for Calcium Channel Blockers
Block slow Ca channels in cardiac and smooth muscles = decreased muscle contraction
Relaxes and dilated arteries
Slows cardiac impulse formation in conduction tissues
86
Effects of Calcium Channel Blockers
Decrease peripheral vascular resistance (Vasodilation) = Decreased BP
Negative inotropic effects = Decreased contraction d/t decreased Ca
Decreased automaticity in SA and AV nodes (Negative dromotrope/non-dihydropyridines)
Decreased cardiac workload and myocardial O2 consumption
Good for chronic stable angina and variant (Prinzmetal) angina patients
87
Cautions for Calcium Channel Blockers
Heart block and sick sinus syndrome (arrhythmias)
Renal and hepatic patients
PG women
TBI patient = Increase ICP
Do not give with dig and BB = Decrease CO
Do not give with grapefruit
88
Adverse effects of Calcium Channel Blockers
Constipation - slows peristalsis with smooth muscle dilation
AV block
Edema
Hypotension, bradycardia
Steven Johnson Syndrome (esp w/verampamil and dilitazem)
Rash, arthralgias, impotence, ecchymosis
89
Adverse effects of Calcium Channel Blockers
Constipation - slows peristalsis with smooth muscle dilation
AV block
Edema
Hypotension, bradycardia
Steven Johnson Syndrome (esp w/verampamil and dilitazem)
Rash, arthralgias, impotence, ecchymosis
90
HMG - CoA Reductase inhibitors
"statin" meds
lovastatin (Mevacor) and simvistatin (Zocor) both pro-drugs
atorvastatin (Lipitor) most used
Large first pass effect
Highly protein bound
Mostly excreted in feces
Onset of action: 2 weeks, Max effect 4-6 weeks
91
MOA of HMG-CoA Reductase Inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)
Inhibits HMG-CoA reductase enzyme responsible for biosynthesis of cholesterol in the liver
Liver will also make more HDL receptors on liver cells to remove more LDL cholesterol from bloodstream
92
Effects of HMG-CoA Reductase inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)
```
Decrease LDL (25-63%) and Decrease TGL
Increase HDL
```
93
Cautions with HMG-CoA Reductase inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)
PG category X, avoid if breastfeeding also
| Not for liver disease patients
94
Adverse effects of HMG-CoA Reductase Inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)
```
Rhabdomyolysis
Arthralgia, Myalgia
Progression of cataracts
Increased LFT's = hepatitis, jaundice
Fatigue, rash, cough, chest pain, N/V, abd pain, flatulance, dizziness, anemia, HA, gynecomastia, Sun sensitivity
```
95
Monitoring HMG-CoA Reductase Inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)
LFTs: baseline, 6 weeks, 12 weeks, q3months, then annually
- if LFT become 3x upper limit or greater, decrease or d/c dose
Fasting lipid profile
96
Drug interactions with HMG-CoA Reductase Inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)
Grapefruit juice
Digoxin
Warfarin
Antifungals, erythromycin, many others
97
Education with HMG-CoA Reductase Inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)
Report brown, orange, red urine = proteinuria
Take at bedtime (liver works hardest making cholesterol at night)
Report muscle pain, tenderness or weakness
Teach about low saturated fat/low cholesterol diet
Keep lab appointments
Stay away from grapefruit juice
Monitor ETOH use d/t liver tox
Be aware of photosensitivity
98
Mnemonic for HMG-CoA Reductase Inhibitors/lovastatin (Mevacor)/atorvastatin (Lipitor)
H: Hepatotoxicity (Side effect)
M: Myositis (rhabdo - side effect)
G: Girl, PG
C: Coumadin/cyclosporine (Interactions)
99
Fibric Acid Derivative
fenofibrate (Tricor, Lipofen), gemfribrozil (Lopid)
100
MOA for Fibric Acid Derivative/gemfibrozil (Lopid)
Increase lipoprotein lipase activity = catabolism of VLDL
101
MOA for Fibric Acid Derivative/fenofibrate (Tricor, Lipofen)
pro-drug, inhibits TGL synthesis and accelerated removal of lipoproteins
102
Adverse effects of Fibric Acid Derivatives/fenofibrate (Tricor, Lipofen), gemfibrozil (Lopid)
```
Hepatotoxicity
Cholelithiasis (gall stones)
Anemia (watch CBC)
Increase glucose
Rhabdo
Fatigue, rash, a-fib, abd pain, n/v, decreased renal function
```
103
Monitoring of Fibric Acid Derivatives/fenofibrate (Tricor, Lipofen), gemfibrozil (Lopid)
Lipid profile
Gemfibrozil:
- CBC q 3 mo for 12 mo d/t anemia
- LFT's: Baseline, 6 weeks, 12 weeks, and then twice yearly
104
Drug interactions with Fibric Acid Derivatives/fenofibrate (Tricor, Lipofen), gemfibrozil (Lopid)
Statins - increase risk of rhabdo
Warfarin - Increase anticoagulation response
Bile acid sequestrants = Decrease absorption of fibric acid derivatives
105
Drug interactions with Fibric Acid Derivatives/fenofibrate (Tricor, Lipofen), gemfibrozil (Lopid)
Statins - increase risk of rhabdo
Warfarin - Increase anticoagulation response
Bile acid sequestrants = Decrease absorption of fibric acid derivatives
106
Bile Acid Sequestrants
cholestyramine (Questran): powder, mix with 8oz of water and drink, 4-6x per day
colesevelam (WelChol): tabs/chew, most rx, least side effects, 2-3 times per day
colestipol (Colestid): 3-4x/day
Not absorbed orally, no metabolism
Completely excreted in feces
Max effect in 1 month
107
MOA of Bile Acid Sequestrants/cholestyramine (Questran)/colesevelam (WelChol), colestipol (Colestid)
Bind to bile acids and increase their excretion = conversion of cholesterol into bile acid synthesis
Leads liver to increase catabolism of LDL
No breakdown of cholesterol so it gets excreted and not absorbed
108
Cautions with Bile Acid Sequestrants/cholestyramine (Questran)/colesevelam (WelChol), colestipol (Colestid)
```
Biliary Obstruction
Interferes with absorption of fat soluble vitamins (A,D,E,K)
Pts with hemorrhoids
PG Women
GI pts: Chrohns, IBS, diverticulitis
```
109
Adverse effects with Bile Acid Sequestrants/cholestyramine (Questran)/colesevelam (WelChol), colestipol (Colestid)
Malabsorption of nutrients and meds
Hematuria
Constipation (esp. w/powder form)
Abd pain, cramping and distention (Increase fluids, stool softener)
110
Drug interactions with Bile Acid Sequestrants/cholestyramine (Questran)/colesevelam (WelChol), colestipol (Colestid)
Decreased absorption of most meds
- take other meds one hour before or 4 hours after
- Separate from other oral meds
111
Drug interactions with Bile Acid Sequestrants/cholestyramine (Questran)/colesevelam (WelChol), colestipol (Colestid)
Decreased absorption of most meds
- take other meds one hour before or 4 hours after
- Separate from other oral meds
112
Nicotinic Acids
```
Niacin
Well absorbed
Hepatically/renally cleared
Give at night
Max effect in 3-5 weeks
```
113
MOA of Nicotinic Acids/Niacin
Inhibition of release of fatty acids from adipose tissues
| Leads to decrease free fatty acids xport to liver and decrease synthesis of VLDL = Decrease LDL
114
Effects of Nicotinic Acids/Niacin
Decrease TGL's
Increase HDL's
Similar to bile acid sequestrants in lowering LDL (10-15%)
When combines with other meds = 50-60% decreased LDL
When combines with 2+ other meds = 70-80% decrease LDL's
Drug of choice for very high TGL pts.
115
Cautions for Nicotinic Acids/Niacin
Gout (Increase uric acid levels)
Diabetes (Increase BS)
Liver disease (hard on liver)
Gallbladder disease
116
Adverse effects of Nicotinic Acids/Niacin
```
Hyperglycemia
Hyperuricemia
Rhabdo
Flushing - treat with aspirin
Arrhythmias, GI upset, n/v, HA, hepatotoxicity, vision disturbances
```
117
Monitoring of Nicotinic Acids/Niacin
LFT's: baseline, 6 weeks, 12 weeks, then 2x yearly
118
Drug interactions with Nicotinic Acids/Niacin
HMG-CoA reductase inhibitors (statins) and gemfibrozil = increase risk of rhabdo
119
Misc Anti-lipid Meds
Ezetimbe (Zetia): Selective cholesterol absorption inhibitor
Combo drug: simvastatin/ezetimbe (Vytorin): excretes excess cholesterol that liver relseases
- #1 side effect: diarrhea and fatty stools
- Start low cholesterol diet 2 weeks before starting drug
Omega 3 Acid Ethyl Ester (Fish Oil)
- Unknown MOA
- Decrease TGL's, antiplatelet effect
120
Misc Anti-lipid Meds
Ezetimbe (Zetia): Selective cholesterol absorption inhibitor
Combo drug: simvastatin/ezetimbe (Vytorin): excretes excess cholesterol that liver relseases
- #1 side effect: diarrhea and fatty stools
- Start low cholesterol diet 2 weeks before starting drug
Omega 3 Acid Ethyl Ester (Fish Oil)
- Unknown MOA
- Decrease TGL's, antiplatelet effect
121
Heparin UF
```
High Risk Drug
Not consistent sizes/shapes
Always monitor PTT
Not absorbed orally
Shart Half life (Usually give loading dose or IV Bolus
IV onset: Immediate, continous infusion needed for full effect
SubQ onset: 20-60 min
Hepatic metabolism, renal clearance
```
122
Indications for Heparin UF
Prevent extension of a blood clot (DVT/PE)
Prophylaxis (Surgical patients, clot risk patients)
Maintain patency of IV's
Off label tx: ACS, acute MI
123
MOA for Heparin UF
Inactive factor X which prevents the conversion of prothrombin to thrombin
Inhibits conversion of fibrinogen to firbin
HAS NO EFFECT ON EXISTING CLOT
124
Cautions for Heparin UF
Other anti-coag meds
Pts at risk for hemorrhage (peptic ulcers, liver disease, etc)
Allergies to beef or pork
Patients with recent epidural = Increase risk for bleeding
125
Adverse effects of Heparin UF
Bleeding
Thrombocytopenia
Clotting, fever, chills, pruritis, anaphylaxis, osteoporosis (LT use >6mo)
126
Monitoring Heparin UF
PTT
| CBC (Platelets, H&H)
127
Antidote for Heparin UF
protamine sulfate
128
Heparin Protocol
```
Draw baseline PT, PTT, CBC
Initial heparin bolus 60-80 units/kg
Begin heparin gtt at 7-18 units/kg
PTT q6h until 2 consecutive PTT are within 60-90 sec
CBC q3 days
```
129
Nursing implications with Heparin UF
Always be on a pump
Patients on fall precautions
Frequent blood draws
Report any blood in urine, stools, gums, nose, wounds, etc.
Teach pts to use soft toothbrush and electric razor
130
Nursing implications with Heparin UF
Always be on a pump
Patients on fall precautions
Frequent blood draws
Report any blood in urine, stools, gums, nose, wounds, etc.
Teach pts to use soft toothbrush and electric razor
131
Low Molecular Weight Heparin
```
Smaller, consistent size = stable drug
enoxaparin (lovenox)
dalteparin (Fragmin)
tinzaparin (Innohep)
Not absorbed orally, give SubQ
Relatively long half life
Extensive renal clearance
Weight based, protein bound
```
132
MOA for Low Molecular weight Heparin/enoxaparin (Lovenox)
Inhibit clot formation higher up in the clotting cascade than heparin
Prevent intrinsic and extrinsic pathways from coming together
133
Cautions for Low Molecular Weight Heparin/enoxaparin (lovenox)
Other anticoagulant meds
| Epidural/Spinal patients (Black Box Warning)
134
Adverse effects of Low Molecular Weight Heparin/enoxaparin (Lovenox)
Bleeding
Thrombocytopenia
Pulmonary edema, fever, peripheral edema
135
Antidote for Low Molecular Weight Heparin/enoxaparin (Lovenox)
protamine sulfate
136
Teaching for Low Molecular Weight Heparin/enoxaparin (Lovenox)
Rotate injection sites (Stay away from belly button)
Teach good subQ techniques
Teach fall precautions at home
No need to follow PTT, still follow platelet counts
dalteparin (Fragmin) CANNOT be used in infants and women.
137
Warfarin (Coumadin)
Well absorbed orally
Half life = 40 hours
Bound to albumin in plasma
Max effect in 3-4 days, effects 4-5 days after drug is d/c'd
138
MOA of warfarin (Coumadin)
Blocks vitamin K at binding site
| Inhibits clotting factors VII, IX, X, & II which are dependent on vitamin K
139
Cautions of warfarin (Coumadin)
Other anticoagulant meds
Pts. w/active bleeding, open wounds, ulcers or bleeding disorders
Severe HTN, severe renal disease or hepatic dysfunction
Fall risk patients
PG women: category X
D/C 1 weeks prior to surgery
140
Antidote for warfarin (Coumadin)
Vitamin K injection (push slow)
141
Adverse effects of warfarin (Coumadin)
Hemorrhage
| Rash, gangrene, skin ulcers, myalgia, n/v
142
Monitoring PTT and INR with warfarin (Coumadin)
Therapeutic level is 1.5-4
143
Drug interactions with warfarin (Coumadin)
Interacts with almost everything
Drugs that increase effects: Acetaminophen, NSAIDs, statins, quinolones, etc
Drugs that decrease effects: Oral contraceptives, corticosteroids, some PCNs, diuretics, etc
144
Education for warfarin (Coumadin)
Teach s/s of bleeding
Take drug at same time and do not skip a dose
Do not take acetaminophen or aspirin - can affects action of warfarin
Be consistent with vitamin K foods
Inform health care providers, wear med ID bracelet
145
Education for warfarin (Coumadin)
Teach s/s of bleeding
Take drug at same time and do not skip a dose
Do not take acetaminophen or aspirin - can affects action of warfarin
Be consistent with vitamin K foods
Inform health care providers, wear med ID bracelet
146
Antiplatelet drugs
Aspirin and ADP inhibitors
147
Aspirin MOA
Irreversibe inhibition of thromboxane A2 which induces platelet aggregation and vasoconstriction
Antipyretic, anti-inflammatory and analgesic effects
148
Cautions with Aspirin
Other anticoag meds
Peptic ulcer disease
Bleeding disorders
149
Adverse effects of Aspirin
GI upset
Thrombocytopenia
Bleeding
150
Education with Aspirin
LT aspirin users will need blood work to monitor renal. hepatic and clotting functions
Read OTC labels to avoid products with aspirin or ibuprofen
If taking for CV reasons, avoid enteric coated
Take with food, milk or antacids to avoid GI upset
151
ADP inhibitors
```
clopidogrel (Plavix - to prevent MI)
ticlopidine (Ticlid - CVA pts)
50% absorbed, rapidly in GI tract
Metabolized in liver to active form
Eliminated by GI and kidneys
```
152
Indications for ADP inhibitors
Reduces the occurence of artherosclerotic events (MI, CVA)
Peripheral artery disease
Pts. w/recent stent or CABG
153
MOA for ADP inhibitors
Inhibits binding of adenosine diphosphate and activation of glycoprotein IIb/IIIa complex
Inhibits platelet aggregation
154
Cautions for ADP inhibitors
Liver disease
Other anticoagulant/antiplatelet drugs
Active bleeding disorders
155
Adverse effects of ADP inhibitors
Bleeding
Thrombocytopenia purpura
N/D, rash, fatigue, palpations, chest pain
156
Education of ADP inhibitors
Do not stop abruptly, can cause rebound clotting = massive MI/CVA
Apply pressure to wounds to stop bleeding
Inform health care providers that pt is on drug
Fall precautions
Take with food to avoid GI upset
d/c 1 week prior to surgery
