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Pharmacology 2 Exam 2
Pharmacology II (NUR 354)
Arizona College of Nursing
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Pharmacology 2
Fredrick Linthicum
Exam 2
Loop Diuretics (K+ Wasting)
Ex. Furosemide (Lasix), Bumetanide (Bumex), Torsemide
Work on the loop of Henle, mainly used for heart failure. Prevent the reabsorption of sodium and chloride in the nephron loop.
Furosemide (Lasix)
Used for heart failure, edema, rapid weight gain Furosemide may increase values for the following: blood glucose, BUN, serum amylase, cholesterol, triglycerides, and serum electrolytes. Adverse effects of furosemide, like those of most diuretics, involve potential electrolyte imbalances, the most important of which is hypokalemia. Hypovolemia may cause orthostatic hypotension and syncope. Ototoxicity can develop from Lasix Because hypokalemia may cause dysrhythmias in patients taking digoxin, combination therapy must be carefully monitored. Furosemide should be used cautiously with aminoglycoside antibiotics due to the possibility of additive nephrotoxicity and ototoxicity. Monitor blood glucose. Medication held if K+ level is lower than 3 Low potassium can cause ST depression, U waves, or flat waves on telemetry. Given in the morning to prevent nocturia.
Thiazide Diuretics (K+ Wasting)
Ex. Hydrochlorothiazide (Microzide), Chlorothiazide (Diuril)
These drugs act on the DCT to block Na+ reabsorption and increase K+ and water excretion. Their primary use is for the treatment of mild to moderate HTN; however, they are also indicated for edema due to mild to moderate heart failure, liver failure, and CKD.
Hydrochlorothiazide (Microzide)
Hydrochlorothiazide is the most common medication found in fixed- dose combination drugs for HTN. It is approved to treat ascites, edema, heart failure, HTN, and nephrotic syndrome. Hydrochlorothiazide is the most widely prescribed diuretic for HTN. Hydrochlorothiazide acts on the kidney tubule to decrease the reabsorption of Na+. Normally, more than 99% of the sodium entering the kidney is reabsorbed by the body. When hydrochlorothiazide blocks this reabsorption, more Na+ is sent into the urine. Lab Tests: Hydrochlorothiazide may increase serum glucose, cholesterol, bilirubin, triglyceride, and calcium levels. The drug may decrease serum magnesium, potassium, and sodium levels. Adverse effects electrolyte imbalances due to loss of excessive K+ and Na+. Because hypokalemia may cause cardiac conduction abnormalities, patients are usually instructed to increase their potassium intake as a precaution. Take early in the morning to avoid nocturia. This medication can increase frequency of gout attacks. Avoid taking NSAIDS Digoxin toxicity risk Ginkgo biloba may produce a paradoxical increase in blood pressure. Hawthorn will decrease blood pressure.
Potassium Sparring Diuretics
Ex. Spironolactone (Aldactone), Eplerenone
Eplerenone and spironolactone act by blocking the actions of the hormone aldosterone; thus, they are some-times called aldosterone antagonists. Blocking aldosterone enhances the excretion of Na+ and the retention of K+. Like the other two drugs in this diuretic class, eplerenone and spironolactone produce only a weak diuresis.
Spironolactone (Aldactone)
Spironolactone, the most frequently prescribed potassium-sparing diuretic, is primarily used to treat mild HTN, often in combination with other antihypertensives. Can be used for CKD or Liver disease also. Spironolactone acts by inhibiting aldosterone, the hormone secreted by the adrenal cortex responsible for increasing the renal reabsorption of
inhibiting ACE and decreasing aldosterone secretion. Blood pressure is decreased, and cardiac output is increased. Common SE: Headache, dizziness, orthostatic hypotension, rash, cough Serious SE/Adverse effects: Angioedema, acute renal failure, first- dose phenomenon, fetal toxicity, hyperkalemia Captopril can cause neutropenia Can increase Lithium levels. Avoid NSAIDS. Assess patients’ blood pressure before administration
Enalapril
Addresses both vasoconstriction and fluid retention
ARB’s (Angiotensin II Receptor Blockers)
Ex. Losartan, Valsartan, Irbesartan
Angiotensin II stimulates the secretion of aldosterone, a hormone from the adrenal cortex. The primary action of aldosterone is to increase Na+ reabsorption in the kidney. The enhanced Na+ reabsorption causes the body to retain water, increasing blood volume and raising blood pressure. ARB’s block angiotensin II preventing this process.
Losartan (Cozaar)
It is approved for the treatment of HTN, the reduction of the risk for stroke in patients with both HTN and left ventricular hypertrophy, and the prevention of nephropathy in patients with type 2 diabetes and a history of HTN. Its actions include vasodilation and reduced blood volume, due to the drug’s blocking the release of aldosterone by angiotensin II. SE: Dizziness, fatigue, Orthostatic HTN, Pregnancy Cat D, Angioedema, Fetal injury, Hypoglycemia, and AKI Watch for orthostatic HTN
Lab Tests: May increase values of the following: blood urea nitrogen (BUN), serum potassium, serum creatinine, alanine aminotransferase (ALT), and aspartate aminotransferase (AST). Grapefruit juice may increase the antihypertensive action and adverse effects of losartan.
Alpha 1 Adrenergic Blockers
Ex. Doxazosin, Terazosin, Tamsulosin
The alpha1-adrenergic antagonists lower blood pressure directly by blocking sympathetic receptors in arterioles, causing the vessels to dilate.
Doxazosin (Cardura)
Doxazosin and several other alpha1-adrenergic blockers also relax smooth muscle around the prostate gland. Patients who have benign prostatic hyperplasia (BPH) sometimes receive this drug to relieve symptoms of dysuria. Orthostatic hypotension, dizziness, headache, fatigue Check HR & BP NSAIDs can decrease the antihypertensive action of doxazosin. When given concurrently, other antihypertensives have additive effects with doxazosin on blood pressure. Concurrent administration of doxazosin with phosphodiesterase- inhibitors, such as sildenafil (Viagra), can result in additive blood pressure lowering effects and symptomatic hypotension.
Beta Blockers (Beta-Adrenergic Blockers)
Ex. Metoprolol, Propranolol, Atenolol
Beta-adrenergic antagonists or blockers reduce the cardiac workload by slowing the heart rate and reducing contractility. These drugs are as effective as the organic nitrates in decreasing the frequency and severity of angina episodes caused by exertion.
Metoprolol (Lopressor, Toprol XL)
Selective beta1-adrenergic blocker (Beta Blocker)
The drug acts by reducing sympathetic stimulation of the heart, thus decreasing cardiac workload. Metoprolol slows the progression of HF and reduces the long-term consequences of the disease. Assess the pulse and blood pressure before oral administration. Hold if the pulse is below 60 beats per minute or if the patient is hypotensive. Lab Tests: Metoprolol may increase values for the following: uric acid, lipids, potassium, bilirubin, alkaline phosphatase, creatinine, and ANA. Hawthorn should be avoided because it may increase the actions of beta-adrenergic blockers. Monitor blood glucose for hypoglycemia Rescue Drugs: Atropine or isoproterenol can be used to reverse bradycardia caused by metoprolol overdose.
Propranolol (Inderal)
Non-Selective Beta Adrenergic Antagonist (Beta Blocker)
Propranolol is a nonselective beta-adrenergic antagonist that affects beta1 receptors in the heart and beta2 receptors in pulmonary and vascular smooth muscle.
Selective ( Blood Vessels )
Nifedipine is a CCB prescribed for HTN and variant or vasospastic angina. It is occasionally used to treat Raynaud’s phenomenon (off-label). Nifedipine acts by selectively blocking calcium channels in myocardial and vascular smooth muscle, including those in the coronary arteries. This results in coronary artery dilation, less oxygen utilization by the heart, an increase in cardiac output, and a fall in blood pressure. Lab Tests: May increase values for the following: alkaline phosphatase, lactate dehydrogenase, ALT, creatine phosphokinase (CPK), and AST. SE: headache, dizziness, peripheral edema, heartburn, nausea, and flushing. Do not stop any blood pressure medications abruptly. Monitor Digoxin levels. Melatonin may increase BP and HR with this med. Do not take with alcohol. Grapefruit may enhance absorption.
Diltiazem (Cardizem, Cartia XT, Dilacor XR)
Non-Selective (Blood Vessels & Heart)
Drug for angina, hypertension, and dysrhythmias Check HR & BP every 5 mins. Headache, dizziness, peripheral edema, Like other CCBs, diltiazem inhibits the transport of calcium into myocardial cells. It has the ability to relax both coronary and peripheral blood vessels, bringing more oxygen to the myocardium and reducing cardiac workload Diltiazem is contraindicated in patients with acute MI, AV heart block, sick sinus syndrome, severe hypotension, bleeding aneurysm, or those undergoing intracranial surgery. This drug should be used with caution in patients with chronic kidney disease or hepatic impairment. Do not stop abruptly. Atropine or isoproterenol may be used to reverse bradycardia caused by diltiazem overdose. St. John’s wort and ginseng may decrease the effectiveness of diltiazem. Garlic, hawthorn, and goldenseal may increase the antihypertensive effect of diltiazem.
Verapamil
Non-Selective (Blood Vessels & Heart)
Vasodilators
Ex. Hydralazine
It acts through a direct vasodilation of arterial smooth muscle; it has no effect on veins. Therapy is begun with low doses, which are gradually increased until the desired therapeutic response is obtained. Hydralazine was one of the first oral antihypertensive drugs marketed in the United States. It acts through a direct vasodilation of arterial smooth muscle; it has no effect on veins. Given in the hospital to correct high blood pressure quickly. Side effects: Headache, reflex tachycardia, palpitations, flushing, nausea, and diarrhea are common but may resolve as therapy progresses. NSAIDs may decrease the antihypertensive action of hydralazine. Patients with lupus should not receive hydralazine because the drug may worsen symptoms. Stopping abruptly may cause rebound hypertension. Sodium and fluid retention is a potentially serious adverse effect. Hawthorn should be avoided because it may cause additive hypotensive effects
Hypertension
Hypertension is a common and manageable chronic condition that is a major risk factor for atherosclerotic cardiovascular disease, heart failure (HF), stroke, kidney failure, vision loss, dementia, and circulation problems such as peripheral artery disease. Hypertension carries the risk for premature morbidity or mortality, which increases as systolic and diastolic pressures rise. Lifestyle changes are an important component of hypertension management. These lifestyle changes include weight control, diet modification including reduced salt intake, lowering alcohol use, and regular exercise and relaxation. Hypertension first line drugs - Diuretics, Calcium Channel Blockers, ARB’s, ACE Inhibitors, Beta Blockers, Vasodilators, Central Agonists, Combined Alpha, and Beta Blockers
DASH Diet
A 1,600-mg sodium DASH eating plan has effects similar to those of antihypertensive single-medication therapy. 2000 calories a day
Stable angina is defined as episodes of intermittent chest pain present when the artery is narrowed 60% to 70%. It is typically associated with activity or exercise and is relieved by rest. Stable angina is not associated with damage to the heart muscle but is a warning sign for potential heart muscle damage. Unstable angina is pain that is not associated with exercise and is not relieved by rest. It may present with ECG changes but no elevation in cardiac markers. It is an emergency requiring immediate treatment. Clinical manifestations of MI can vary significantly from person to person, with gender one prominent distinction. Women are more likely to present with atypical MI symptoms including neck, shoulder blade, and jaw pain, as well as abdominal pain. The geriatric population may not exhibit classic angina symptoms or may have coexisting conditions which mimic angina. They may experience dyspnea, syncope, weakness, or confusion. Many patients, especially patients with diabetes, never have the typical symptoms but may present with symptoms of shortness of breath or fatigue. Cardiovascular etiologies should be considered for patients exhibiting these atypical symptoms. Laboratory tests used to diagnose an MI include troponin, creatine kinase (CK), and CK-MB. Creatine kinase is a general marker of cellular injury. It is released from cells in the brain, skeletal muscle, and cardiac tissue after muscle damage has occurred. Creatine kinase–MB is the CK isoenzyme marker specific to cardiac tissue. When myocardial damage occurs, CK-MB is released from the cells. Increased levels can be seen at 3 hours and remain elevated for up to 36 hours before returning to normal. Cardiac troponin (I and T) are proteins expressed almost exclusively in the heart and are a specific marker of cardiac muscle damage. Troponin levels can elevate within 4 hours of injury and can stay elevated for as long as 10 days.
Chest pain Diaphoretic Get EKG done in less than 5 mins Troponin releases in 3 hrs. and becomes elevated, it is a cardiac enzyme. Monitor troponin and do EKG every 3 hrs.
Thrombolytics
Ex. Reteplase
Reteplase
Reteplase acts by cleaving plasminogen to form plasmin. Plasmin then degrades the fibrin matrix of thrombi. Like other drugs in this class, Reteplase should be given as soon as possible after the onset of MI symptoms. Administered by IV bolus, it usually acts within 20 minutes. A second bolus may be injected 30 minutes after the first, if needed to clear the thrombus. After the clot has been dissolved, therapy with heparin or an alternative anticoagulant is started to prevent additional clots from forming. Reteplase is contraindicated in patients with active bleeding or history of stroke or who have had recent surgical procedures. Reconstitute the drug immediately prior to use with diluent provided by the manufacturer; swirl to mix—do not shake. Do not mix with other medications, needs it's own line. Plasminogen & Fibrinogen levels will be off
Organic Nitrates
established by the healthcare provider (usually 60 beats per minute), withhold the dose and notify the provider The most serious adverse effect of digoxin is its ability to create dysrhythmias, particularly in patients who have hypokalemia or CKD. Because diuretics can cause hypokalemia and are often used to treat HF, concurrent use of digoxin and diuretics must be carefully monitored. Adverse effects of digoxin therapy include nausea, vomiting, fatigue,
anorexia, and visual disturbances such as seeing halos, a yellow-green tinge, or blurring. Potassium supplements or potassium salt substitute should
not be taken unless approved by the healthcare provider. Use with ACE inhibitors, spironolactone, or potassium supplements can lead to hyperkalemia and reduce the therapeutic action of digoxin. Check for recent serum digoxin level results before administering. If the level is higher than the parameter established by the healthcare provider (usually 1 ng/mL), withhold the dose and notify the provider.
Pharmacology 2 Exam 2
Course: Pharmacology II (NUR 354)
University: Arizona College of Nursing
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