Medications Grouped Flashcards by Kelsea Pearson

Thiazide Diuretics

Hydrochlorothiazide - more common
Chlorthalidone - more common and more effective
Metolazone
Indapamide

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

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

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

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Loop Diuretics

Furosemide - 50% oral bioavailability
Toresemide - 100% oral bioavailability
Bumetanide 100% oral bioavailability
Ethacrynic Acid

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

Use IV in Acute Heart Failure

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Potassium Sparing Diuretics

Amiloride
Triamterene

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

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Beta Blockers: Non-selective without ISA

Nadolol
Propanolol
Timolol

Indication: Antihypertensive

MOA: 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

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Beta Blockers Non-selective with ISA

Pindolol
Carteolol
Penbutolol

Indication: Antihypertensive

MOA: Block B1 and B2

Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

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

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Beta Blockers Selective without ISA

Atanolol
Metoprolol - heart failure (good for patients with HF and hypotension)
Emolol
Betaxolol
Bisoprolol (HF, but not FDA approved)

Indication: Antihypertensive

Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

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

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Beta Blockers Selective with ISA

Acebutolol

Indication: Antihypertensive

Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

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

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Beta Blockers with Vasodilation Properties

Labetolol (block a1)
Carvedilol (block a1) (Heart Failure - not FDA approved)
Nebivolol (NO activity)

Indication: Antihypertensive

Class II Antiarrhythmics - Inhibit AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

MOA: Block B1 and B2

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

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Calcium Channel Blockers - Dihydropyridines

Nifedipine
Amlodipine
Felodipine

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 (amlodipine is okay)

Caution: contaminant use with Beta Blockers – can cause heart block

most have short half-lives, so extended release is preferred; amlodipine is the exception (long half-life)

will not hurt HF, but will not help

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Calcium Channel Blockers - Non-dyhydropyridines

Verapamil
Diltiazem

Class IV Antiarrhythmics - blocks calcium from entering cardiac cell; inhibits AV nodal conduction by slowing AV nodal conduction and prolonging AV nodal refractoriness

Hypertensives - 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 heart failure

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

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Angiotensin Converting Enzyme Inhibitors

Lisinopril - most common
Fosinopril - uncommon
Moexipril - uncommon
Trandolapril - uncommon
Benazepril
Captopril
Enalapril
Perindopril
Quinapril
Ramipril

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

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Direct Renin Inhibitor

Aliskren

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

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Alpha 1 Blockers

Doxazosin
Prazosin
Terazosin

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

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Alpha 2 Agonsists

Clonidine - common; patch or tablet
Methyldopa - common
Guanfacine
Guanabenz

Indication: resistant hypertension

AE: Clonidine - orthostatic hypotension, dry mouth, muscle weakness; Methyldopa - hepatotoxicity, peripheral edema, hemolytic anemia, orthostatic hypotension; all - transient sedation initially, vision disturbances, sedation (avoid other sedatives)

CI: Methyldopa - concurrent use of MAO inhibitor, hepatic disease, pheochromocytoma; all - hypersensitivity

Clonidine - 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

Methyldopa - first line hypertensive treatment in pregnancy; tolerance may occur after 2-3 mo; increase dose

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Peripheral Sympathetic Inhibitors

Reserpine

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

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Direct Vasodilators

Isosorbide Dinitrate/Hydralazine
Hydralazine
Minoxidil

Indication: resistant hypertension

MOA: relax smooth muscles in arterioles and activate baroreceptors

AE: tachycardia; hydralazine - lupus-like syndrome; Minoxidil - edema, hypertrichosis

CI: hypersensitivity; Minoxidil - pheochromocytoma; Isosorbide Dinitrate/Hydralazine - 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

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Aldosterone Antagonists

Spironolactone
Eplerenone

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

Eplerenone Interactions: CYP34A substrate – do not use eplerenone with strong 3A4 inhibitors (increase eplerenone plasma concentrations)

Monitor: check K at baseline and after week

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ARB/Neprilysin Inhibitor

Sacubitril/Valsartan

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

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Angiotensin Receptor Blockers

Azilsartan
Candesartan
Irbesartan
Losartan
Olmesartan
Telmisartan
Valsartan
Eprosartan

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

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Digoxin

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

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Vasodilators

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Nitroglycerin
Nitroprusside
Nesiritide

Indications: Acute Heart Failure (IV)

MOA: cause rapid decrease in arterial tone, relieving symptoms of congestion

AE: hypotension (especially Nesiritide – long half-life)

CI: if cardiac filling depends on venous return, shock

Inotropic Agents

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Dobutamine - adrenergic receptor agonist, drug of choice, not as effective if on BB, causes vasodilation

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

Milrinone - phosphodiesterase III inhibitor, vasodilation, limited use

Statins

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Atrovastain - high intensity

Fluvastatin - less interactions

Lovastatin - low intensity

Pravastatin - low intensity, fewer interactions, not metabolized by cytochrome 450s

Pitavastatin - not metabolized by cytochrome 450s

Rosuvastatin - high intensity, fewer interactions

Simvastatin

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); exception pravastatin and pitavastatin

fewer interactions: rosuvastatin, pravastatin, fluvastatin

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

Cholesterol Absorption Inhibitor

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Ezetimibe

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

PCSK9 Inhibitors

Alirocumab Evolocumab 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

BIle Acid Sequestrants (Resins)

Cholestyramine Colesevelam (less SE) Colestipol 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

Nicotinic Acid

Niacin ER, IR, SR 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

Fibric Acid Derivatives

Fenofibrate Gemfibrozil 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

Omega 3 Fatty Acids

Lovaza; AE: eructation (burping), dyspepsia, taste perversion Vascepa; AE: arthralgia Epanova; AE: diarrhea, nausea, abdominal pain or discomfort Omtryg; 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)

Microsomal Transfer Protein Inhibitor

Lomitapide 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

Antisense Oligonucleotide

Mipmersen Indication: generally not recommended for hypercholesterolemia MOA: once-weekly subcutaneous injectable antisense inhibitor of Apo B synthesis; prevent synthesis of apoB, ultimately decreases LDL AE: injection site reactions, flu-like symptoms, hepatic fat, and liver enzyme elevation, hepatotoxic available only through the Risk Evaluation and Mitigation Strategy program (REMS) - Hepatotoxic

Sodium Channel Blockers

Class I Antiarrhythmics ``` Class IA: Quinidine (IV) Procainamide (IV) Disopyramide (IV) - intermediate potency ``` Class IB: Lidocaine (IV) Mexiletine (IV) - lowest potency; minimal effect on conduction velocity at normal heart rates Class IC: Flecainide (oral) Propafenone (oral) MOA: blocks sodium from entering cardiac cell, making it harder to depolarize General AE: pro-arrhythmic, increased risk of death (consult)

Potassium Channel Blockers

Class III Antiarrhythmics ``` Amiodarone - can work as all classes Dofetilide Dronedarone Ibutilide Soltolol (NOT BB) ``` Conversion to sinus rhythm MOA: blocks potassium from leaving cardiac cell, slowing repolarization

Adenosine

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

Warfarin

Anticoagulant

Indirect Xa Inhibitor

Anticoagulant | Fondaparinux

Direct Xa Inhibitors

Anticoagulant Rivaroxaban Apixaban

Direct Thrombin Inhibitors

Anticoagulant ``` Lepirudin (no longer used) Bivalirudin (IV) Desirudin (SubQ) Aragatroban (IV) Dabigatrin (PO) ```

Unfractionated Heparin

Anticoagulant

Low Molecular Weight Heparins

Anticoagulant Dalteparin Enoxaparin

Ventricular Rate Control

Amiodarone BB CCB (Dilt or Verap) Digoxin

Conversion to Sinus Rhythm

``` Amiodarone Ibutilide Dofetilide Flecainide Propafenone ```

Maintenance of Sinus Rhythm/Reduction of Episodes of Afib

``` Amiodarone Dofetilide Dronedarone Propafenone Flecainaide Sotolol ```

Antiplatelet

Apsirin

P2Y12 Inhibitors

Clopidogrel Prasugrel Ticagrelor Congrelor

Glycoprotein IIb/IIIc Receptor Inhibitors

Abciximab Eptifbatide Tirofiban

Fribrinolytics

``` Alteplase Reteplase Tenecteplase Streptokinase Urokinase ```

Short-Acting Nitrate

Nitroglycerin

Long-Acting Nitrates

Nitroglycerin ER Isosorbide dinitrate Isosorbide mononitrate

Non-nitrate Angina Treatment

Ranolazine

Medications Grouped Flashcards

(50 cards)