Medications

Question 1

Hydrochlorothiazide

Answer 1

Thiazide Diuretic

Indications: antihypertensives (reduce blood volume, cardiac output, and peripheral resistance)

AE: hypokalemia, hyperglycemia, hyperuricemia, diuresis, hyperlipidemia; AE increase with age

CI: GFR <30

Caution: renal function declines with age; diabetics (increased uric acid and insulin resistance)

Interactions: steroids, NSAIDs, class IA or III antiarrythmics that prolong QT interval (induce torsades de pointes with hypokalemia), probenecid and lithium, and digoxin

dose in morning to prevent nocturia

more common

monitor electrolytes

Question 2

Chlorthalamide

Answer 2

Thiazide Diuretic

Preferred! 1.5 - 2 times more effective than hydrochlorothiazide

Indications: antihypertensives (reduce blood volume, cardiac output, and peripheral resistance)

AE: hypokalemia, hyperglycemia, hyperuricemia, diuresis, hyperlipidemia; AE increase with age

CI: GFR <30

Caution: renal function declines with age; diabetics (increased uric acid and insulin resistance)

Interactions: steroids, NSAIDs, class IA or III antiarrythmics that prolong QT interval (induce torsades de pointes with hypokalemia), probenecid and lithium, and digoxin

dose in morning to prevent nocturia

more common and more effective

monitor electrolytes

Question 3

Metalozone

Answer 3

Thiazide Diuretic

Indications: antihypertensives (reduce blood volume, cardiac output, and peripheral resistance)

AE: hypokalemia, hyperglycemia, hyperuricemia, diuresis, hyperlipidemia; AE increase with age

CI: GFR <30

Caution: renal function declines with age; diabetics (increased uric acid and insulin resistance)

Interactions: steroids, NSAIDs, class IA or III antiarrythmics that prolong QT interval (induce torsades de pointes with hypokalemia), probenecid and lithium, and digoxin

dose in morning to prevent nocturia

monitor electrolytes

Question 4

Indapamide

Answer 4

Thiazide Diuretic

Indications: antihypertensives (reduce blood volume, cardiac output, and peripheral resistance)

AE: hypokalemia, hyperglycemia, hyperuricemia, diuresis, hyperlipidemia; AE increase with age

CI: GFR <30

Caution: renal function declines with age; diabetics (increased uric acid and insulin resistance)

Interactions: steroids, NSAIDs, class IA or III antiarrythmics that prolong QT interval (induce torsades de pointes with hypokalemia), probenecid and lithium, and digoxin

dose in morning to prevent nocturia

monitor electrolytes

Question 5

Furosemide

Answer 5

Loop Diuretic

50% bioavailability of oral medication; only give half of IV dose

Indications: antihypertensives and treat symptoms of heart failure and edema

MOA: prevent reabsorption of Na and Cl in the kidneys, reduce renal vascular resistance and increase renal flow

AE: hypokalemia, hypo Ca, hypo Mg (can cause arrhythmias), excessive diuresis (hyponatremia, hypotension, renal insufficiency), reflex activation of RAAS, hypouricemia

Caution: diuresis continues despite dehydration; watch for drugs that aggravate hyperglycemia, dyslipidemias, and hyperuricemia; watch kidney function with ARBs or ACE-I

Interactions: aminoglycosides, NSAIDs, class IA or III antiarrhythmics, probenacid

Monitor: electrolytes and renal function

IV used in Acute Heart Failure

Question 6

Torsemide

Answer 6

Loop Diuretic

100% oral bioavailability

Indications: antihypertensives and treat symptoms of heart failure and edema

MOA: prevent reabsorption of Na and Cl in the kidneys, reduce renal vascular resistance and increase renal flow

AE: hypokalemia, hypo Ca, hypo Mg (can cause arrhythmias), excessive diuresis (hyponatremia, hypotension, renal insufficiency), reflex activation of RAAS, hypouricemia

Caution: diuresis continues despite dehydration; watch for drugs that aggravate hyperglycemia, dyslipidemias, and hyperuricemia; watch kidney function with ARBs or ACE-I

Interactions: aminoglycosides, NSAIDs, class IA or III antiarrhythmics, probenacid

Monitor: electrolytes and renal function

IV used in Acute Heart Failure

Question 7

Bumetamide

Answer 7

Loop Diuretic

100% oral bioavailability

Indications: antihypertensives and treat symptoms of heart failure and edema

MOA: prevent reabsorption of Na and Cl in the kidneys, reduce renal vascular resistance and increase renal flow

AE: hypokalemia, hypo Ca, hypo Mg (can cause arrhythmias), excessive diuresis (hyponatremia, hypotension, renal insufficiency), reflex activation of RAAS, hypouricemia

Caution: diuresis continues despite dehydration; watch for drugs that aggravate hyperglycemia, dyslipidemias, and hyperuricemia; watch kidney function with ARBs or ACE-I

Interactions: aminoglycosides, NSAIDs, class IA or III antiarrhythmics, probenacid

Monitor: electrolytes and renal function

IV used in Acute Heart Failure

Question 8

Ethacrynic Acid

Answer 8

Loop Diuretic

Indications: antihypertensives and treat symptoms of heart failure and edema

MOA: prevent reabsorption of Na and Cl in the kidneys, reduce renal vascular resistance and increase renal flow

AE: hypokalemia, hypo Ca, hypo Mg (can cause arrhythmias), excessive diuresis (hyponatremia, hypotension, renal insufficiency), reflex activation of RAAS, hypouricemia

Caution: diuresis continues despite dehydration; watch for drugs that aggravate hyperglycemia, dyslipidemias, and hyperuricemia; watch kidney function with ARBs or ACE-I

Interactions: aminoglycosides, NSAIDs, class IA or III antiarrhythmics, probenacid

Monitor: electrolytes and renal function

IV used in Acute Heart Failure

Question 9

Amiloderone

Answer 9

Potassium Sparing Diuretic

Indications: antihypertensive

MOA: inhibits sodium transport at late distal and collecting ducts

AE: hyperERkalemia, especially in those with severe renal impairment, or those receiving potassium sparing drugs (ACE-I, ARBs, K supp, and NSAIDs

Interactions: ACE-I – may increase risk of hyperkalemia

Monitor: electrolytes and renal function

not very effective at diuresis; sometimes used with thiazides and loops to prevent K loss

Question 10

Triamterene

Answer 10

Potassium Sparing Diuretic

Indications: antihypertensive

MOA: inhibits sodium transport at late distal and collecting ducts

AE: hyperERkalemia, especially in those with severe renal impairment, or those receiving potassium sparing drugs (ACE-I, ARBs, K supp, and NSAIDs

Interactions: ACE-I – may increase risk of hyperkalemia; Indomethacin – decrease in renal function when combined with triamterene; Cimetidine: increases bioavailability and decreases clearance of triamterene

Monitor: electrolytes and renal function

not very effective at diuresis; sometimes used with thiazides and loops to prevent K loss

Question 11

Spironolactone

Answer 11

Aldosterone Antagonist/ Potassium Sparing Diuretic

better outcomes in patients with heart failure!

aldosterone antagonist, diminish cardiac remodeling in HF

Indications: anithypertensives and prevent remodeling in patients with heart failure

MOA: modulate vascular tone and cause diuresis (increase NaCl excretion, decrease K+ excretion)

AE: hyperkalemia, especially with impaired renal function, ACE, ARBs, direct renin inhibitors, K sup, K salts subs, NSAIDs); gynecomastia or breast tenderness; menstrual irregularities, hirsutism

Caution: elderly, diabetics (increased risk of hyperkalemia), and patients with poor renal function

Interactions: ACE-I, ARBs, NSAIDs, Digoxin (increased plasma concentration of spironolactone), K supplements

Discontinue: K > 5.5 mEq/L, worsening renal function

Monitor: check K at baseline and after week

Question 12

Eplerenone

Answer 12

Aldosterone Antagonist/ Potassium Sparing Diuretic

aldosterone antagonist, diminish cardiac remodeling in HF

Indications: anithypertensives and prevent remodeling in patients with heart failure

MOA: modulate vascular tone and cause diuresis (increase NaCl excretion, decrease K+ excretion)

AE: hyperkalemia, especially with impaired renal function, ACE, ARBs, direct renin inhibitors, K sup, K salts subs, NSAIDs); gynecomastia or breast tenderness; menstrual irregularities, hirsutism

Caution: elderly, diabetics (increased risk of hyperkalemia), and patients with poor renal function

Interactions: ACE-I, ARBs, NSAIDs, Digoxin (increased plasma concentration of spironolactone), K supplements; CYP34A substrate – do not use eplerenone with strong 3A4 inhibitors (increase eplerenone plasma concentrations)

Monitor: check K at baseline and after week

Discontinue: K > 5.5 mEq/L, worsening renal function

Question 13

Nadolol

Answer 13

Beta Blockers: Non-selective without ISA

Indication: Antihypertensive- Block B1 and B2; Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics), hypokalemia, hyperlipidemia

Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use

CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure, asthma

Question 14

Propanolol

Answer 14

Beta Blockers: Non-selective without ISA

Indication: Antihypertensive- Block B1 and B2; Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

MOA: Block B1 and B2

AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics), hypokalemia, hyperlipidemia

Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use

CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure, asthma

Question 15

Timolol

Answer 15

Beta Blockers: Non-selective without ISA

Indication: Antihypertensive- Block B1 and B2; Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

MOA: Block B1 and B2

AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics), hypokalemia, hyperlipidemia

Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use

CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure, asthma

Question 16

Pindolol

Answer 16

Beta Blockers Non-selective with ISA

Indication: Antihypertensive- Block B1 and B2; Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

MOA: Block B1 and B2

AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics), hypokalemia, hyperlipidemia

Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use

CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure, asthma; not with ACS

Question 17

Carteolol

Answer 17

Beta Blockers Non-selective with ISA

Indication: Antihypertensive- Block B1 and B2; Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics), hypokalemia, hyperlipidemia

Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use

CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure, asthma; not with ACS

Question 18

Penbutolol

Answer 18

Beta Blockers Non-selective with ISA

Indication: Antihypertensive- Block B1 and B2; Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics), hypokalemia, hyperlipidemia

Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use

CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure, asthma; not with ACS

Question 19

Atanolol

Answer 19

Beta Blockers Selective without ISA

Indication: Antihypertensive - block B1, Heart Failure (good for patients with HF and hypotension);Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics), hypokalemia

Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use

CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure; Not with ACS

use low doses only; can use with asthma, COPD, peripheral vascular disease, but avoid non-selective with these patients

Question 20

Metoprolol

Answer 20

Beta Blockers Selective without ISA

Indication: Antihypertensive - block B1 only, Heart Failure (good for patients with HF and hypotension); Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics), hypokalemia

Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use

CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure; Not with ACS

use low doses only; can use with asthma, COPD, peripheral vascular disease, but avoid non-selective with these patients

Question 21

Emolol

Answer 21

Beta Blockers Selective without ISA

Indication: Antihypertensive - block B1 only; Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics), hypokalemia

Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use

CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure; Not with ACS

use low doses only; can use with asthma, COPD, peripheral vascular disease, but avoid non-selective with these patients

Question 22

Betaxolol

Answer 22

Beta Blockers Selective without ISA

Indication: Antihypertensive - block B1 only; Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics), hypokalemia

Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use

CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure; Not with ACS

use low doses only; can use with asthma, COPD, peripheral vascular disease, but avoid non-selective with these patients

Question 23

Bisoprolol

Answer 23

Beta Blockers Selective without ISA

Indication: Antihypertensive - block B1 only; Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness; Heart Failure (not FDA approved)

AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics), hypokalemia

Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use

CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure; Not with ACS

use low doses only; can use with asthma, COPD, peripheral vascular disease, but avoid non-selective with these patients

Question 24

Acebutolol

Answer 24

Beta-blocker: Selective with ISA

Indication: Antihypertensive - block B1 only; Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics), hypokalemia

Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use

CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure; Not with ACS

ISA beta blockers are not recommended for patients with previous acute coronary syndrome (ACS)

use low doses only; can use with asthma, COPD, peripheral vascular disease, but avoid non-selective with these patients

Question 25

Labetolol

Answer 25

Beta Blocker with Vasodilation Properties Indication: Antihypertensive; Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness MOA: Blocks a1, B1 and B2 AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics), hypokalemia Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure

Question 26

Carvedilol

Answer 26

Beta Blocker with Vasodilation Properties Indication: Antihypertensive, Heart Failure (most BP lowering HF BB; but more dizziness and hypotension); Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness MOA: Blocks a1, B1 and B2 AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics) Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure

Question 27

Nebivolol

Answer 27

Beta Blocker with Vasodilation Properties Indication: Antihypertensive; Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness MOA: Block B1 and B2, and has NO activity AE: bradycardia, heart block, heart failure, dyspnea, bronchospasm, fatigue, dizziness, lethargy, depression, decreased libido, erectile dysfunction, hyper/hypoglacemia (watch in diabetics) Caution: Heart Rate <60, respiratory disease, abrupt discontinuation – rebound hypertension or ischemic syndrome (taper), may mask signs of hypoglycemia, hypokalemia with diuretic use CI: hypersensitivity, sinus node dysfunction (okay with pacemaker), severe sinus bradycardia, heart block, cardiogenic shock, acute decompensated heart failure

Question 28

Nifedipine

Answer 28

Calcium Channel Blocker - Dihydropyridine MOA: dilate the arterioles by blocking the movement of calcium into smooth muscle cells preventing their contraction, and causing relaxation and dilation; greater affinity for vascular calcium channels than calcium channels in the heart AE: bradycardia, peripheral edema, headache, flushing, gingival hyperplasia, reflex tachycardia CI: Hypersensitivity, reduced ejection fraction Caution: contaminant use with Beta Blockers – can cause heart block most have short half-lives, so extended release is preferred will not help heart failure, but will not hurt

Question 29

Amlodipine

Answer 29

Calcium Channel Blocker - Dihydropyridine MOA: dilate the arterioles by blocking the movement of calcium into smooth muscle cells preventing their contraction, and causing relaxation and dilation; greater affinity for vascular calcium channels than calcium channels in the heart AE: bradycardia, peripheral edema, headache, flushing, gingival hyperplasia, reflex tachycardia CI: Hypersensitivity Caution: contaminant use with Beta Blockers – can cause heart block Safe to use in patients with heart failure/reduced ejection fraction Long-half life; no extended release

Question 30

Verapamil

Answer 30

Calcium Channel Blocker - Non - dihydropyridine MOA: dilate the arterioles by blocking the movement of calcium into smooth muscle cells preventing their contraction, and causing relaxation and dilation; affects both vascular and heart calcium channels AE: bradycardia, heart block, constipation, peripheral edema, headache, flushing, may worsen HF CI: sinus node dysfunction, severe sinus bradycardia (pacemaker okay), heart block, afib/flutter associated with accessory bypass tract Caution: heart rate <60, contaminant use with Beta Blockers – can cause heart block hypersensitivity, reduced ejection fraction most have short half-lives, so extended release is preferred

Question 31

Diltiazem

Answer 31

Calcium Channel Blocker - Non - dihydropyridine MOA: dilate the arterioles by blocking the movement of calcium into smooth muscle cells preventing their contraction, and causing relaxation and dilation; affects both vascular and heart calcium channels AE: bradycardia, heart block, constipation, peripheral edema, headache, flushing, may worsen HF CI: sinus node dysfunction, severe sinus bradycardia (pacemaker okay), heart block, afib/flutter associated with accessory bypass tract Caution: heart rate <60, contaminant use with Beta Blockers – can cause heart block hypersensitivity, reduced ejection fraction most have short half-lives, so extended release is preferred

Question 32

Linsinopril

Answer 32

ACE-I most common Indication: antihypertensive MOA: inhibit conversion of angiotensin I to angiotensin II; lowers output of SNS, increases vasodilation of smooth muscle, and lowers retention of sodium and water AE: hyperkalemia, especially when starting or increasing dose and with NSAID use; persistent dry cough; reduced GFR and serum creatine (monitor); acute renal failure; angioedema Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Caution: baseline hyperkalemia, NSAIDs, can potentially cause declined renal function Dosage Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 33

Fosinopril

Answer 33

ACE-I uncommon Indication: antihypertensive MOA: inhibit conversion of angiotensin I to angiotensin II; lowers output of SNS, increases vasodilation of smooth muscle, and lowers retention of sodium and water AE: hyperkalemia, especially when starting or increasing dose and with NSAID use; persistent dry cough; reduced GFR and serum creatine (monitor); acute renal failure; angioedema Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Caution: baseline hyperkalemia, NSAIDs, can potentially cause declined renal function Dosage Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 34

Moexipril

Answer 34

ACE-I uncommon Indication: antihypertensive MOA: inhibit conversion of angiotensin I to angiotensin II; lowers output of SNS, increases vasodilation of smooth muscle, and lowers retention of sodium and water AE: hyperkalemia, especially when starting or increasing dose and with NSAID use; persistent dry cough; reduced GFR and serum creatine (monitor); acute renal failure; angioedema Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Caution: baseline hyperkalemia, NSAIDs, can potentially cause declined renal function Dosage Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 35

Trandolapril

Answer 35

ACE-I uncommon Indication: antihypertensive MOA: inhibit conversion of angiotensin I to angiotensin II; lowers output of SNS, increases vasodilation of smooth muscle, and lowers retention of sodium and water AE: hyperkalemia, especially when starting or increasing dose and with NSAID use; persistent dry cough; reduced GFR and serum creatine (monitor); acute renal failure; angioedema Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Caution: baseline hyperkalemia, NSAIDs, can potentially cause declined renal function Dosage Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 36

Benazepril

Answer 36

ACE-I Indication: antihypertensive MOA: inhibit conversion of angiotensin I to angiotensin II; lowers output of SNS, increases vasodilation of smooth muscle, and lowers retention of sodium and water AE: hyperkalemia, especially when starting or increasing dose and with NSAID use; persistent dry cough; reduced GFR and serum creatine (monitor); acute renal failure; angioedema Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Caution: baseline hyperkalemia, NSAIDs, can potentially cause declined renal function Dosage Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 37

Captopril

Answer 37

ACE-I Indication: antihypertensive MOA: inhibit conversion of angiotensin I to angiotensin II; lowers output of SNS, increases vasodilation of smooth muscle, and lowers retention of sodium and water AE: hyperkalemia, especially when starting or increasing dose and with NSAID use; persistent dry cough; reduced GFR and serum creatine (monitor); acute renal failure; angioedema Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Caution: baseline hyperkalemia, NSAIDs, can potentially cause declined renal function Dosage Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 38

Enalapril

Answer 38

ACE-I Indication: antihypertensive MOA: inhibit conversion of angiotensin I to angiotensin II; lowers output of SNS, increases vasodilation of smooth muscle, and lowers retention of sodium and water AE: hyperkalemia, especially when starting or increasing dose and with NSAID use; persistent dry cough; reduced GFR and serum creatine (monitor); acute renal failure; angioedema Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Caution: baseline hyperkalemia, NSAIDs, can potentially cause declined renal function Dosage Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 39

Perindopril

Answer 39

ACE-I Indication: antihypertensive MOA: inhibit conversion of angiotensin I to angiotensin II; lowers output of SNS, increases vasodilation of smooth muscle, and lowers retention of sodium and water AE: hyperkalemia, especially when starting or increasing dose and with NSAID use; persistent dry cough; reduced GFR and serum creatine (monitor); acute renal failure; angioedema Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Caution: baseline hyperkalemia, NSAIDs, can potentially cause declined renal function Dosage Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 40

Quinapril

Answer 40

ACE-I Indication: antihypertensive MOA: inhibit conversion of angiotensin I to angiotensin II; lowers output of SNS, increases vasodilation of smooth muscle, and lowers retention of sodium and water AE: hyperkalemia, especially when starting or increasing dose and with NSAID use; persistent dry cough; reduced GFR and serum creatine (monitor); acute renal failure; angioedema Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Caution: baseline hyperkalemia, NSAIDs, can potentially cause declined renal function Dosage Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 41

Ramipril

Answer 41

ACE-I Indication: antihypertensive MOA: inhibit conversion of angiotensin I to angiotensin II; lowers output of SNS, increases vasodilation of smooth muscle, and lowers retention of sodium and water AE: hyperkalemia, especially when starting or increasing dose and with NSAID use; persistent dry cough; reduced GFR and serum creatine (monitor); acute renal failure; angioedema Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Caution: baseline hyperkalemia, NSAIDs, can potentially cause declined renal function Dosage Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 42

Aliskren

Answer 42

Direct Renin Inhibitor Indication: Antihypertensive MOA: directly inhibits Renin AE: hyperkalemia, hypotension CI:with ACE-I or ARB in diabetics, pregnancy Caution: severe renal impairment, deteriorating renal function, renal artery stenosis Monitor: K+, GFR and serum creatine Interactions: ACE-I, ARB, cyclosporine, any potassium supplements, furosemide concentration decreased, ketoconazole increases aliskirin levels

Question 43

Doxazosin

Answer 43

Alpha 1 Blocker Indication: hypertension MOA: block alpha 1 receptors AE: first dose – syncope, dizziness, palpitations; orthostatic hypertension CI: hypersensitivity not for monotherapy for hypertension may cause increase in cardiovascular events used in really resistant patients as a back-up

Question 44

Prazosin

Answer 44

Alpha 1 Blocker Indication: hypertension MOA: block alpha 1 receptors AE: first dose – syncope, dizziness, palpitations; orthostatic hypertension CI: hypersensitivity not for monotherapy for hypertension may cause increase in cardiovascular events used in really resistant patients as a back-up

Question 45

Terazosin

Answer 45

Alpha 1 Blocker Indication: hypertension MOA: block alpha 1 receptors AE: first dose – syncope, dizziness, palpitations; orthostatic hypertension CI: hypersensitivity not for monotherapy for hypertension may cause increase in cardiovascular events used in really resistant patients as a back-up

Question 46

Clonidine

Answer 46

Alpha 2 Agonist common; tablet and patch Indication: occasionally used for resistant hypertension MOA: reduce sympathetic outflow (NE); enhance parasympathetic activity, reducing heart rate, cardiac output, and total peripheral resistance AE: transient sedation initially, vision disturbances, sedation (avoid other sedatives), orthostatic hypotension, dry mouth, muscle weakness CI: hypersensitivity discontinuation results in severe rebound hypertension, so it much be tapered if on a beta blocker, taper it before starting clonidine – too much PNS activity clonidine withdrawal – too much SNS activity

Question 47

Methyldopa

Answer 47

Alpha 2 Agonist Indication: occasionally used for resistant hypertension MOA: reduce sympathetic outflow (NE); enhance parasympathetic activity, reducing heart rate, cardiac output, and total peripheral resistance AE: transient sedation initially, vision disturbances, sedation (avoid other sedatives), hepatotoxicity, peripheral edema, hemolytic anemia, orthostatic hypotension CI: hypersensitivity, concurrent use of MAO inhibitor, hepatic disease, pheochromocytoma first line hypertensive treatment in pregnancy tolerance may occur after 2-3 mo; increase dose

Question 48

Guanfacine

Answer 48

Alpha 2 Agonist Indication: occasionally used for resistant hypertension MOA: reduce sympathetic outflow (NE); enhance parasympathetic activity, reducing heart rate, cardiac output, and total peripheral resistance AE: transient sedation initially, vision disturbances, sedation (avoid other sedatives) CI: hypersensitivity

Question 49

Gaunabenz

Answer 49

Alpha 2 Agonist Indication: occasionally used for resistant hypertension MOA: reduce sympathetic outflow (NE); enhance parasympathetic activity, reducing heart rate, cardiac output, and total peripheral resistance AE: transient sedation initially, vision disturbances, sedation (avoid other sedatives) CI: hypersensitivity

Question 50

Resperpine

Answer 50

Peripheral Sympathetic Inhibitor Indication: hypertension MOA: reduces sympathetic tone and peripheral resistance; depletes NE from nerve endings AE: gastric ulceration, depression, sexual side effects, orthostatic hypotension, nasal congestion, fluid retention, peripheral edema, diarrhea, increased gastric secretion CI: hypersensitivity, peptic ulcer disease, ulcerative colitis, history of depression, history of ECT

Question 51

Isosorbide Nitrate/Hydralazine

Answer 51

Direct Vasodilators Indication: resistant hypertension MOA: relax smooth muscles in arterioles and activate baroreceptors AE: tachycardia CI: hypersensitivity, increased cranial pressure cause reflex tachycardia and fluid retention; use beta blockers and diuretics too use caution and review use and monitoring before prescribing for hypertension

Question 52

Hydralazine

Answer 52

Direct Vasodilators Indication: resistant hypertension MOA: relax smooth muscles in arterioles and activate baroreceptors AE: tachycardia, lupus-like syndrome CI: hypersensitivity cause reflex tachycardia and fluid retention; use beta blockers and diuretics too use caution and review use and monitoring before prescribing for hypertension

Question 53

Minoxidil

Answer 53

Direct Vasodilators Indication: resistant hypertension MOA: relax smooth muscles in arterioles and activate baroreceptors AE: tachycardia, edema, hypertrichosis CI: hypersensitivity, pheochromocytoma cause reflex tachycardia and fluid retention; use beta blockers and diuretics too use caution and review use and monitoring before prescribing for hypertension

Question 54

Sacubitril/Valsartan

Answer 54

ARB/Neprilysin Inhibitor Indication: Heart Failure MOA: ACE-I/ARB Combo; Sacubitril increases natriuretic peptides (involved in diuresis) by preventing their breakdown, but causes increase in AT II; Valsartan blocks AT II’s receptor AE: new; theoretical risk of increasing peptides associated with Alzheimer’s NEW - don't be the first, don't be the last! may improve HF outcomes

Question 55

Hydralazine + Isosorbide Dinitrate

Answer 55

Heart Failure – for patients intolerant to ACE-I or ARBs; or African Americans MOA: Nitrates – venous vasodilation, reducing preload; Hydralazine – direct arterial smooth muscle relaxation, reducing afterload AE: hypotension, headache, tachycardia, lupus; often poorly tolerated CI: concomitant use of sildenafil, tadalalfil, vardenafil (increase risk of hypotension)

Question 56

Azilsartan

Answer 56

Angiotensin Receptor Blockers Indications: hypertension; heart failure (improves symptoms and outcomes/heals the heart) MOA: block angiotensin II from binding to angiotensin receptor AE: hyperkalemia, renal function deterioration, angioedema, hypotension/syncope Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Dose Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 57

Candesartan

Answer 57

Angiotensin Receptor Blockers Indications: hypertension; heart failure (improves symptoms and outcomes/heals the heart) MOA: block angiotensin II from binding to angiotensin receptor AE: hyperkalemia, renal function deterioration, angioedema, hypotension/syncope Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Dose Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 58

Irbesartan

Answer 58

Angiotensin Receptor Blockers Indications: hypertension; heart failure (improves symptoms and outcomes/heals the heart) MOA: block angiotensin II from binding to angiotensin receptor AE: hyperkalemia, renal function deterioration, angioedema, hypotension/syncope Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Dose Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 59

Losartan

Answer 59

Angiotensin Receptor Blockers Indications: hypertension; heart failure (improves symptoms and outcomes/heals the heart) MOA: block angiotensin II from binding to angiotensin receptor AE: hyperkalemia, renal function deterioration, angioedema, hypotension/syncope Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Dose Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 60

Olmesartan

Answer 60

Angiotensin Receptor Blockers Indications: hypertension; heart failure (improves symptoms and outcomes/heals the heart) MOA: block angiotensin II from binding to angiotensin receptor AE: hyperkalemia, renal function deterioration, angioedema, hypotension/syncope Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Dose Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 61

Telmisartan

Answer 61

Angiotensin Receptor Blockers Indications: hypertension; heart failure (improves symptoms and outcomes/heals the heart) MOA: block angiotensin II from binding to angiotensin receptor AE: hyperkalemia, renal function deterioration, angioedema, hypotension/syncope Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Dose Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 62

Valsartan

Answer 62

Angiotensin Receptor Blockers Indications: hypertension; heart failure (improves symptoms and outcomes/heals the heart) MOA: block angiotensin II from binding to angiotensin receptor AE: hyperkalemia, renal function deterioration, angioedema, hypotension/syncope Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Dose Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 63

Eprosartan

Answer 63

Angiotensin Receptor Blockers Indications: hypertension; heart failure (improves symptoms and outcomes/heals the heart) MOA: block angiotensin II from binding to angiotensin receptor AE: hyperkalemia, renal function deterioration, angioedema, hypotension/syncope Absolute CI: pregnancy, bilateral renal artery stenosis, history of angioedema Relative CI: unilateral renal artery stenosis, renal insufficiency, hypotension (go slow), hyperkalemia (greater than 5 mEq/L) Dose Adjustments: renal impairment, elderly, volume depleted, diuretic therapy Monitor: electrolytes (K+), GFR and serum creatine

Question 64

Felodipine

Answer 64

Calcium Channel Blocker - Dihydropyridine MOA: dilate the arterioles by blocking the movement of calcium into smooth muscle cells preventing their contraction, and causing relaxation and dilation; greater affinity for vascular calcium channels than calcium channels in the heart AE: bradycardia, peripheral edema, headache, flushing, gingival hyperplasia, reflex tachycardia CI: Hypersensitivity, reduced ejection fraction Caution: contaminant use with Beta Blockers – can cause heart block most have short half-lives, so extended release is preferred will not help heart failure, but will not hurt

Question 65

Digoxin

Answer 65

Indications: heart failure; add digoxin for patients who are symptomatic despite optimized ACE I and Beta Blocker and Diuretic, or if concomitant Afib – digoxin slows rate (beta blockers are better) MOA: binds to Na+ and K+ ATP pumps, leading to incrased intracellular Na concetnrations; more intracellular Ca is then available during systole; regulates heart rate (slows); Neurohormonal (RAAS, SNS) modulation – may be related to restoration of baroreceptor Antiarrhythmic - vagal stimulation (PNS), direct AV nodal inhibition, prolongs AV node refractoriness Digoxin Toxicity: fatigue, weakness, CNS effects (confusion, delirium, psychosis), GI effects (nausea, vomiting, anorexia), visual disturbances (halos, photophobia, color perception problems – red-green or yellow-green vision), cardiac effects (arrhythmias, ventricular tachycardia and fibrillation, AV node block, and sinus bradycardia) – increased with electrolyte disturbances (hypo K, hyper Ca, hypo Mg) Many Interactions digoxin conc <1.2 ng/mL – no adverse effect on survival digoxin conc >1.2 ng/mL – increased relative risk of mortality desired concentration range = 0.5 - 0.9 ng/mL; preferably at or less than 0.8 ng/mL slow onset of action – need loading dose in emergent situations Adjust Dose: age, renal function, weight, risk for toxicity, indication (HF vs arrhythmia) routine monitoring of serum drug concentrations not required, but recommended if there are changes in renal function, there is suspected toxicity, or after addition or

Question 66

Nitroglycerin

Answer 66

Vasodilator Indication: Acute Heart Failure (IV) MOA: acts as source of NO (induces smooth muscle relaxation in arterial and venous system) AE: hypotension (especially Nesiritide – long half-life) CI: if cardiac filling depends on venous return, shock

Question 67

Nitroprusside

Answer 67

Vasodilator Indication: Acute Heart Failure (IV) MOA: venous and arterial dilator AE: hypotension (especially Nesiritide – long half-life) CI: if cardiac filling depends on venous return, shock

Question 68

Nesiritide

Answer 68

Vasodilator Indication: Acute Heart Failure (IV) MOA: venous and arterial dilation, antagonizes RAAS AE: hypotension (especially Nesiritide – long half-life) CI: if cardiac filling depends on venous return, shock

Question 69

Dobutamine

Answer 69

Inotropic Agent adrenergic receptor agonist, drug of choice, not as effective if on BB, causes vasodilation

Question 70

Dopamine

Answer 70

adrenergic receptor agonist; use: low systolic BP, cardiogenic shock; dose dependent effects

Question 71

Milrinone

Answer 71

phosphodiesterase III inhibitor, vasodilation, limited use

Question 72

Atrovastatin

Answer 72

High Intensity Statin Indication: Hypercholesterolemia; reduces risk of ASCVD MOA: inhibit HMG-CoA, a rate-limiting enzyme in cholesterol biosynthesis, reducing LDL Common AE: constipation, abdominal pain, diarrhea, dyspepsia, nausea - but mostly well-tolerated Serious AE: elevations in liver function (monitor LFTs) and liver toxicity (LFT elevations > 3X upper limit of normal), myopathy, rhabdomyolysis may increase risk of getting diabetes mellitus CI: NEVER in pregnant women Discontinue: serum transaminase levels (liver function) rise to 3X upper limit of normal; signs or symptoms of myopathy check dosage if patients have renal function issues Interactions: drugs that inhibit metabolism: cyclosporine and gemfibrozil (statins metabolized by cytochrome p-450s) maximum effect on lipids at 4-6 weeks - follow-up and check cholesterol levels/adherence at this time Monitor: liver enzymes (LFTs) at baseline and as clinically indicated after; Creatinine Kinase in patients at risk for myopathy or complaining of muscle pain, weakness, tenderness, or brown urine; check for symptoms of myopathy at 6-12 weeks Re-challenge intolerance after 2-4 weeks except in patients with Rhabdomyolysis

Question 73

Fluvastatin

Answer 73

Statin fewer interactions; consider in re-challenges Indication: Hypercholesterolemia; reduces risk of ASCVD MOA: inhibit HMG-CoA, a rate-limiting enzyme in cholesterol biosynthesis, reducing LDL Common AE: constipation, abdominal pain, diarrhea, dyspepsia, nausea - but mostly well-tolerated Serious AE: elevations in liver function (monitor LFTs) and liver toxicity (LFT elevations > 3X upper limit of normal), myopathy, rhabdomyolysis may increase risk of getting diabetes mellitus CI: NEVER in pregnant women Discontinue: serum transaminase levels (liver function) rise to 3X upper limit of normal; signs or symptoms of myopathy check dosage if patients have renal function issues Interactions: drugs that inhibit metabolism: cyclosporine and gemfibrozil (statins metabolized by cytochrome p-450s) maximum effect on lipids at 4-6 weeks - follow-up and check cholesterol levels/adherence at this time Monitor: liver enzymes (LFTs) at baseline and as clinically indicated after; Creatinine Kinase in patients at risk for myopathy or complaining of muscle pain, weakness, tenderness, or brown urine; check for symptoms of myopathy at 6-12 weeks Re-challenge intolerance after 2-4 weeks except in patients with Rhabdomyolysis

Question 74

Lovastatin

Answer 74

Low Intensity Statin Indication: Hypercholesterolemia; reduces risk of ASCVD MOA: inhibit HMG-CoA, a rate-limiting enzyme in cholesterol biosynthesis, reducing LDL Common AE: constipation, abdominal pain, diarrhea, dyspepsia, nausea - but mostly well-tolerated Serious AE: elevations in liver function (monitor LFTs) and liver toxicity (LFT elevations > 3X upper limit of normal), myopathy, rhabdomyolysis may increase risk of getting diabetes mellitus CI: NEVER in pregnant women Discontinue: serum transaminase levels (liver function) rise to 3X upper limit of normal; signs or symptoms of myopathy check dosage if patients have renal function issues Interactions: drugs that inhibit metabolism: cyclosporine and gemfibrozil (statins metabolized by cytochrome p-450s) maximum effect on lipids at 4-6 weeks - follow-up and check cholesterol levels/adherence at this time Monitor: liver enzymes (LFTs) at baseline and as clinically indicated after; Creatinine Kinase in patients at risk for myopathy or complaining of muscle pain, weakness, tenderness, or brown urine; check for symptoms of myopathy at 6-12 weeks Re-challenge intolerance after 2-4 weeks except in patients with Rhabdomyolysis

Question 75

Pravastatin

Answer 75

Low Intensity Statin not metabolized by cytochrome 450 fewer interactions; consider in re-challenges Indication: Hypercholesterolemia; reduces risk of ASCVD MOA: inhibit HMG-CoA, a rate-limiting enzyme in cholesterol biosynthesis, reducing LDL Common AE: constipation, abdominal pain, diarrhea, dyspepsia, nausea - but mostly well-tolerated Serious AE: elevations in liver function (monitor LFTs) and liver toxicity (LFT elevations > 3X upper limit of normal), myopathy, rhabdomyolysis may increase risk of getting diabetes mellitus CI: NEVER in pregnant women Discontinue: serum transaminase levels (liver function) rise to 3X upper limit of normal; signs or symptoms of myopathy check dosage if patients have renal function issues Interactions: drugs that inhibit metabolism: cyclosporine and gemfibrozil (statins metabolized by cytochrome p-450s) maximum effect on lipids at 4-6 weeks - follow-up and check cholesterol levels/adherence at this time Monitor: liver enzymes (LFTs) at baseline and as clinically indicated after; Creatinine Kinase in patients at risk for myopathy or complaining of muscle pain, weakness, tenderness, or brown urine; check for symptoms of myopathy at 6-12 weeks Re-challenge intolerance after 2-4 weeks except in patients with Rhabdomyolysis

Question 76

Pitavastatin

Answer 76

Statin not metabolized by cytochrome 450 Indication: Hypercholesterolemia; reduces risk of ASCVD MOA: inhibit HMG-CoA, a rate-limiting enzyme in cholesterol biosynthesis, reducing LDL Common AE: constipation, abdominal pain, diarrhea, dyspepsia, nausea - but mostly well-tolerated Serious AE: elevations in liver function (monitor LFTs) and liver toxicity (LFT elevations > 3X upper limit of normal), myopathy, rhabdomyolysis may increase risk of getting diabetes mellitus CI: NEVER in pregnant women Discontinue: serum transaminase levels (liver function) rise to 3X upper limit of normal; signs or symptoms of myopathy check dosage if patients have renal function issues Interactions: drugs that inhibit metabolism: cyclosporine and gemfibrozil (statins metabolized by cytochrome p-450s) maximum effect on lipids at 4-6 weeks - follow-up and check cholesterol levels/adherence at this time Monitor: liver enzymes (LFTs) at baseline and as clinically indicated after; Creatinine Kinase in patients at risk for myopathy or complaining of muscle pain, weakness, tenderness, or brown urine; check for symptoms of myopathy at 6-12 weeks Re-challenge intolerance after 2-4 weeks except in patients with Rhabdomyolysis

Question 77

Rosuvastatin

Answer 77

High Intensity Statin fewer interactions; consider in re-challenges Indication: Hypercholesterolemia; reduces risk of ASCVD MOA: inhibit HMG-CoA, a rate-limiting enzyme in cholesterol biosynthesis, reducing LDL Common AE: constipation, abdominal pain, diarrhea, dyspepsia, nausea - but mostly well-tolerated Serious AE: elevations in liver function (monitor LFTs) and liver toxicity (LFT elevations > 3X upper limit of normal), myopathy, rhabdomyolysis may increase risk of getting diabetes mellitus CI: NEVER in pregnant women Discontinue: serum transaminase levels (liver function) rise to 3X upper limit of normal; signs or symptoms of myopathy check dosage if patients have renal function issues Interactions: drugs that inhibit metabolism: cyclosporine and gemfibrozil (statins metabolized by cytochrome p-450s) maximum effect on lipids at 4-6 weeks - follow-up and check cholesterol levels/adherence at this time Monitor: liver enzymes (LFTs) at baseline and as clinically indicated after; Creatinine Kinase in patients at risk for myopathy or complaining of muscle pain, weakness, tenderness, or brown urine; check for symptoms of myopathy at 6-12 weeks Re-challenge intolerance after 2-4 weeks except in patients with Rhabdomyolysis

Question 78

Sivastatin

Answer 78

Statin not metabolized by cytochrome 450 fewer interactions; consider in re-challenges Indication: Hypercholesterolemia; reduces risk of ASCVD MOA: inhibit HMG-CoA, a rate-limiting enzyme in cholesterol biosynthesis, reducing LDL Common AE: constipation, abdominal pain, diarrhea, dyspepsia, nausea - but mostly well-tolerated Serious AE: elevations in liver function (monitor LFTs) and liver toxicity (LFT elevations > 3X upper limit of normal), myopathy, rhabdomyolysis may increase risk of getting diabetes mellitus CI: NEVER in pregnant women Discontinue: serum transaminase levels (liver function) rise to 3X upper limit of normal; signs or symptoms of myopathy check dosage if patients have renal function issues Interactions: drugs that inhibit metabolism: cyclosporine and gemfibrozil (statins metabolized by cytochrome p-450s) maximum effect on lipids at 4-6 weeks - follow-up and check cholesterol levels/adherence at this time Monitor: liver enzymes (LFTs) at baseline and as clinically indicated after; Creatinine Kinase in patients at risk for myopathy or complaining of muscle pain, weakness, tenderness, or brown urine; check for symptoms of myopathy at 6-12 weeks Re-challenge intolerance after 2-4 weeks except in patients with Rhabdomyolysis

Question 79

Ezetimibe

Answer 79

Cholesterol Absorption Inhibitor Indication: sometimes recommended for hypercholesterolemia MOA: inhibits cholesterol absorption in the small intestine, preventing delivery to liver, causing an increase in cholesterol clearance from the blood AE: similar to placebo, possible increase in transaminases CI: similar to placebo, possible increase in transaminases primary used in combination with a statin when adequate reductions in cholesterol is not achieved, in patients that are intolerant to statins, or when patients can only tolerate moderate intensity statins

Question 80

Alirocumab

Answer 80

PCSK9 Inhibitor Indications: sometimes recommended for hypercholesterolemia MOA: inhibits binding of PCSK9 to LDL receptors on hepatocytes; LDL receptors are not degraded and stay to clear LDL from circulation AE: well tolerated, injection site reactions, flu, common cold, itching, serious allergic reaction new; don’t know long-term effects expensive ($14,000/year) consider as add-on for familial hypercholesterolemia

Question 81

Evolocumab

Answer 81

PCSK9 Inhibitor Indications: sometimes recommended for hypercholesterolemia MOA: inhibits binding of PCSK9 to LDL receptors on hepatocytes; LDL receptors are not degraded and stay to clear LDL from circulation AE: well tolerated, injection site reactions, flu, common cold, itching, serious allergic reaction new; don’t know long-term effects expensive ($14,000/year) consider as add-on for familial hypercholesterolemia

Question 82

Cholestyramine

Answer 82

Bile Acid Sequesterants (Resins) Indications: not generally recommended for hypercholesterolemia MOA: bind to bile acids I the gut, which are then excreted; hepatic cholesterol converts to bile, more LDL receptors are made to make-up for loss of cholesterol inside of the liver, cholesterol is removed from the blood AE: nausea, constipation, bloating, flatulence, may worsen elevated triglycerides, impair absorption of fat soluble vitamins (remains in GI tract, so AE remain here) Interactions: may prevent absorption of other drugs; take 1 hour before or 4 hours after other medications Dosing: start low and go slow only hypercholesterolemia treatment recommended for pregnant women usually with a statin reduce CHD events in patients with CHD

Question 83

Colesevelam

Answer 83

Bile Acid Sequesterants (Resins) less likely to cause AE Indications: not generally recommended for hypercholesterolemia MOA: bind to bile acids I the gut, which are then excreted; hepatic cholesterol converts to bile, more LDL receptors are made to make-up for loss of cholesterol inside of the liver, cholesterol is removed from the blood AE: nausea, constipation, bloating, flatulence, may worsen elevated triglycerides, impair absorption of fat soluble vitamins (remains in GI tract, so AE remain here) Interactions: may prevent absorption of other drugs; take 1 hour before or 4 hours after other medications Dosing: start low and go slow only hypercholesterolemia treatment recommended for pregnant women usually with a statin reduce CHD events in patients with CHD

Question 84

Colestipol

Answer 84

Bile Acid Sequesterants (Resins) Indications: not generally recommended for hypercholesterolemia MOA: bind to bile acids I the gut, which are then excreted; hepatic cholesterol converts to bile, more LDL receptors are made to make-up for loss of cholesterol inside of the liver, cholesterol is removed from the blood AE: nausea, constipation, bloating, flatulence, may worsen elevated triglycerides, impair absorption of fat soluble vitamins (remains in GI tract, so AE remain here) Interactions: may prevent absorption of other drugs; take 1 hour before or 4 hours after other medications Dosing: start low and go slow only hypercholesterolemia treatment recommended for pregnant women usually with a statin reduce CHD events in patients with CHD

Question 85

Niacin ER, IR, or SR

Answer 85

Nicotinic Acid Indication: generally not recommended for Hypercholesterolemia MOA: inhibits fatty acid release from adipose tissue and inhibits fatty acid and triglyceride production in liver cells AE: flushing (IR), itching, gastric distress, headache, hepatotoxicity (SR), hyperglycemia, hyperuremia reduce flushing by taking aspirin or NSAID 30 min prior; take with food; start at low dose also known as vitamin B3, but the lipid treatment is a higher dose than the nutritional supplement

Question 86

Fenofibrate

Answer 86

Fibric Acid Derivatives Indications: generally not recommended for Hypercholesterolemia MOA: work by activating PPAR-alpha, which leads to destruction and removal of triglycerides and causes an increase in HDL production AE: nausea, diarrhea, flatulence, fatigue, gallstones, myositis, hepatitis CI: gallbladder disease, liver dysfunction, or severe kidney dysfunction Interactions: increase risk of rhabdomyolysis with statin, increase risk of bleeding with warfarin most effective triglyceride lowering drug; decrease by 20-50% max effect 2 weeks for Fenofibrate and 3-4 weeks for gemfibrozil

Question 87

Gemfibrozil

Answer 87

Fibric Acid Derivatives Indications: generally not recommended for Hypercholesterolemia MOA: work by activating PPAR-alpha, which leads to destruction and removal of triglycerides and causes an increase in HDL production AE: nausea, diarrhea, flatulence, fatigue, gallstones, myositis, hepatitis CI: gallbladder disease, liver dysfunction, or severe kidney dysfunction Interactions: increase risk of rhabdomyolysis with statin, increase risk of bleeding with warfarin most effective triglyceride lowering drug; decrease by 20-50% max effect 2 weeks for Fenofibrate and 3-4 weeks for gemfibrozil

Question 88

Lovaza

Answer 88

Omega 3 Fatty Acid AE: eructation (burping), dyspepsia, taste perversion Indication: generally not recommended for hypercholesterolemia MOA: reduced synthesis and increased clearance of triglycerides Caution: hypersensitivity to fish/shellfish Interactions; anticoagulant or antiplatelet agents (may increase risk of bleeding and hemorrhagic stroke)

Question 89

Vascepa

Answer 89

Omega 3 Fatty Acid AE: arthralgia Indication: generally not recommended for hypercholesterolemia MOA: reduced synthesis and increased clearance of triglycerides Caution: hypersensitivity to fish/shellfish Interactions; anticoagulant or antiplatelet agents (may increase risk of bleeding and hemorrhagic stroke)

Question 90

Epanova

Answer 90

Omega 3 Fatty Acid AE: diarrhea, nausea, abdominal pain or discomfort Indication: generally not recommended for hypercholesterolemia MOA: reduced synthesis and increased clearance of triglycerides Caution: hypersensitivity to fish/shellfish Interactions; anticoagulant or antiplatelet agents (may increase risk of bleeding and hemorrhagic stroke)

Question 91

Omtrya

Answer 91

Omega 3 Fatty Acid AE: eructation (burping), dyspepsia, taste perversion Indication: generally not recommended for hypercholesterolemia MOA: reduced synthesis and increased clearance of triglycerides Caution: hypersensitivity to fish/shellfish Interactions; anticoagulant or antiplatelet agents (may increase risk of bleeding and hemorrhagic stroke)

Question 92

Lomitapide

Answer 92

Microsomal Transfer Protein Inhibitor Indication: generally not recommended for hypercholesterolemia MOA: oral inhibitor of microsomal triglyceride transfer protein; prevents assembly of Apo-B lipoproteins, ultimately reducing LDL AE: GI side effects (low fat diet may reduce), elevation in liver enzymes and hepatic fat, hepatotoxicity CI: NEVER in pregnancy Interactions: strong and moderate cytochrome P-450 3A4 inhibitors, warfarin, lovastatin, simvastatin available only through the Risk Evaluation and Mitigation Strategy program (REMS) metabolized extensively by CYP450

Question 93

Quinidine

Answer 93

Class IA Antiarrhythmic intermediate potency IV MOA: blocks sodium from entering cardiac cell, making it harder to depolarize AE: proarrhythmic, increased risk of death (consult)

Question 94

Procainamide

Answer 94

Class IA Antiarrhythmic intermediate potency IV MOA: blocks sodium from entering cardiac cell, making it harder to depolarize AE: hypotension, torsades due pointes, proarrhythmic, increased risk of death (consult)

Question 95

Disopyramide

Answer 95

Class IA Antiarrhythmic intermediate potency IV MOA: blocks sodium from entering cardiac cell, making it harder to depolarize AE: proarrhythmic, increased risk of death (consult)

Question 96

Lidocaine

Answer 96

Class IB Antiarrhythmics - lowest potency, minimal effect on conduction velocity at normal heart rates IV MOA: blocks sodium from entering cardiac cell, making it harder to depolarize AE: proarrhythmic, increased risk of death (consult)

Question 97

Mexiletine

Answer 97

Class IB Antiarrhythmics - lowest potency, minimal effect on conduction velocity at normal heart rates IV MOA: blocks sodium from entering cardiac cell, making it harder to depolarize AE: GI distress, tremor, dizziness, fatigue, seizures (if dose too high)

Question 98

Flecainide

Answer 98

Class IC Antiarrhythmics - greatest potential for slowing ventricular conduction Conversion to Sinus Rhythm, Maintenance of Sinus Rhythm oral MOA: blocks sodium from entering cardiac cell, making it harder to depolarize AE: dizziness, blurred vision, HF exacerbation, proarrhythmic, increased risk of death (consult)

Question 99

Propafenone

Answer 99

Class IC Antiarrhythmics - greatest potential for slowing ventricular conduction oral Conversion to Sinus Rhythm, Maintenance of Sinus Rhythm MOA: blocks sodium from entering cardiac cell, making it harder to depolarize AE: dizziness, blurred vision, proarrhythmic, increased risk of death (consult)

Question 100

Amiodarone

Answer 100

Potassium Channel Blockers (also has CCB and BB activity) Class III Antiarrhythmic (technically can work as all four classes); Ventricular Rate Control (second-line) Conversion to Sinus Rhythm, Maintenance of Sinus Rhythm MOA: blocks potassium from leaving cardiac cell, slowing repolarization AE: IV: hypotension, sinus bradycardia Oral: blue-gray skin, photosensitivity, corneal microdeposits, pulmonary fibrosis, pulmonary toxicity, hepatotoxicity, sinus bradycardia, hypo or hyperthyroidism, peripheral neuropathy, weakness, AV block, exacerbated arrhythmias

Question 101

Dafetilide

Answer 101

Potassium Channel Blockers Class III Antiarrhythmic Conversion to Sinus Rhythm and Maintenance of Sinus Rhythm MOA: blocks potassium from leaving cardiac cell, slowing repolarization AE: torsades de pointes, hospitalize for initiation, correct potassium first, proarrhythmic, death

Question 102

Dronedarone

Answer 102

Potassium Channel Blockers Class III Antiarrhythmic Maintenance of Sinus Rhythm MOA: blocks potassium from leaving cardiac cell, slowing repolarization AE: diarrhea, asthenia, n/v abdominal pain, bradycardia, GI distress, hepatotoxicity, worsening HF, increased risk of stroke, arrhythmias, death CI: do not use in severe HF-increase death by 2X!

Question 103

Ibutilide

Answer 103

Potassium Channel Blockers Class III Antiarrhythmic Conversion to Sinus Rhythm MOA: blocks potassium from leaving cardiac cell, slowing repolarization

Question 104

Soltolol

Answer 104

DOES NOT WORK AS BB - FOR ARRHYTHMIAS Potassium Channel Blockers Class III Antiarrhythmic Maintenance of Sinus Rhythm MOA: blocks potassium from leaving cardiac cell, slowing repolarization AE: sinus bradycardia, AV block, fatigue, torsades de pointes, hospitalize for initiation, do not abruptly discontinue, monitor QT, proarrhythmic, death

Question 105

Adenosine

Answer 105

Non-class Antiarrhythmic - drug of choice for PVST IV Push MOA: causes direct AV node inhibition AE: chest pain (not ischemia), flushing, shortness of breath (bronchospasm possible), sinus bradycardia, AV block Interactions: dipyridamole and carbamazepine = increase response to adenosine successful in 90-95% of patients extremely short half-life: 10 seconds must administer very quickly

Question 106

Warfarin

Answer 106

Anticoagulant

Question 107

Fondaparinux

Answer 107

Indirect Xa Inhibitor | Anticoagulant

Question 108

Rivaroxaban

Answer 108

Direct Xa Inhibitor | Anticoagulant

Question 109

Apixaban

Answer 109

Direct Xa Inhibitor | Anticoagulant

Question 110

Lepiruidin

Answer 110

Direct Thrombin Inhibitor Anticoagulant IV No longer in use

Question 111

Bivalirudin

Answer 111

Direct Thrombin Inhibitor Anticoagulant IV

Question 112

Desirudin

Answer 112

Direct Thrombin Inhibitor Anticoagulant SubQ

Question 113

Aragatroban

Answer 113

Direct Thrombin Inhibitor Anticoagulant IV

Question 114

Unfractionated Heparin

Answer 114

Anticoagulant

Question 115

Dalteparin

Answer 115

Low Molecular Weight Heparin

Question 116

Enoxaparin

Answer 116

Low Molecular Weight Heparin

Question 117

Asprin

Answer 117

Antiplatelet

Question 118

Dipyridamole

Answer 118

antiplatelet that is expensive, but sometimes added to aspirin

Question 119

Clopidogrel

Answer 119

P2Y12 Inhibitor

Question 120

Prasugrel

Answer 120

P2Y12 Inhibitor

Question 121

Ticagrelor

Answer 121

P2Y12 Inhibitor

Question 122

Congrelor

Answer 122

P2Y12 Inhibitor

Question 123

Abciximab

Answer 123

Glycoprotein IIb/IIIc Receptor Inhibitors

Question 124

Eptifbatide

Answer 124

Glycoprotein IIb/IIIc Receptor Inhibitors

Question 125

Tirofiban

Answer 125

Glycoprotein IIb/IIIc Receptor Inhibitors

Question 126

Alteplase

Answer 126

Fibrin Specific Fibrinolytic

Question 127

Reteplase

Answer 127

Fibrin Specific Fibrinolytic

Question 128

Tenecteplase

Answer 128

Fibrin Specific Fibrinolytic

Question 129

Streptokinase

Answer 129

Fibrin Non-Specific Fibrinolytic

Question 130

Urokinase

Answer 130

Fibrin Non-Specific Fibrinolytic

Question 131

Nitroglycerin

Answer 131

Short-Acting Nitrates

Question 132

Nitroglycerin ER

Answer 132

Long-Acting Nitrates

Question 133

Isosorbide dinitrate

Answer 133

Long-Acting Nitrates

Question 134

Isosorbide Mononitrate

Answer 134

Long-Acting Nitrates

Question 135

Ranolazine

Answer 135

Treats Angina