CV Agents - Revised

Cardiovascular Agents 1. Cardiac Glycosides: Action: inhibit Na-K ATPase ---> increase cardiac contraction Indic: CHF, atrial dysrhythmias LIZZY DIGGY digoxin (Lanoxin) digitoxin Therapeutic level of Digoxin: 0.5 - 2 ng/ ml Dig level 2 ng/ml or greater is toxic!!!! Increases myocardial contractility GI or CNS signs indicate adverse effects SE:  GI- nausea & anorexia, vomiting & diarrhea  CNS – vertigo , HA, drowsiness, confusion  bradycardia --> cardiac dysrhythmias, heartblock  photophobia, yellow-green halos around visual images, flashes of light 2. Nitrates: ANDY ANGINA nitroglycerin (Nitro-Bid, Nitrostat, Transderm- Nitro) isosorbide dinitrate (Isordil) isosorbide mononitrate (Imdur) Action Relaxes vascular smooth muscle venous return arterial BP left ventricular workload myocardial oxygen consumption Indic: Angina Pectoris SE: headache (MC), syncope, weakness, nausea & hypotension SL: burning & tingling sensation in mouth 3. Antiarrhythmic : Lidocaine Action: Decrease cardiac excitability, delayed cardiac conduction Indic: ventricular dysrhythmias (ie. PVCs, ventricular tachycardia & fibrillation) SE:  bradycardia/tachycardia  hypotension, confusion & drowsiness  dizziness, NV, seizures  cardiac arrest Liddy Lidocaine lidocaine (Xylocaine) 4. ACE Inhibitors: Action: supressess renin- angiotensin-aldosterones system (RAAS) (blocks conversion of angiotensin 1---> angio .2) Indic: HPN, adjunct in CHF, prevents kidney failurein DM PRIL Sisters captopril (Capoten) enalapril quinapril Cough ontraindicated in renal artery stenosis Hypotension yperkalemia First- dose syncope SVR PVR Tx of MI Relase of aldosterone Occult diabetic nephropathy LVD after MI SVR =systemic vascular resistance PVR = peripheral vascular resistance LVD = left ventricular dilation 5. Angiotensin II Receptor Blockers (ARBS): Action: blocks angio. II binding to receptor --> blocks VC & aldosterone release --> Indic: HPN SE: occasional – cough, URTI, dizziness, diarrhea Overdose – hypotension BP SARTAN Sisters candesartan telmisartan (Micardis)) valsartan (Diovan) Cande Telmi Val Administer without regard to meals Renal function tests - review Blocks VC effect of RAS Salt substitution or potassium supplements – do not use 6. Alpha 1- adrenergic Blockers: Action: blocks alpha 1 adrenergic receptor --> VD, Indic: HPN, BPH PVR, relaxes bladder sphincter & Prostate MINI’s SINS prazosin (Minipress) terazosin doxazosin SE: Syncope, sexual dysfunction Increased drowsiness, orthostatic hypotension, HR Need to be recumbent for 3 -4 hours after initial dose 7. Beta- adrenergic Blockers: Action: blocks beta 1 & 2 receptors Indic: HPN, angina, MI The “LOL” Team Action: metoprolol (Lopressor) atenolol (Tenormin) propanolol (Inderal)) carvedilol labetalol heart contractility, renin, sympathetic act. SE: Bradycardia Lipidemia , libido br Oronchospasm CHF, conduction abnormailities Kinks peripheral vessels Exhaustion, emotional depression Reduces recognition of hypoglycemia difficulty breathing heart failure fats in blood Low Bld sugar Little or no interest in sex 8. Calcium -channel Blockers: Action: blocks calcium access --> heart contraction, BP My rate is slower and my pressure is down. Indic: HPN, vasospastic & classic angina “DON’T GIVE A SHIT Pills” amlodipine (Norvasc) felodipine (Plendil) nifedipine verapamil diltiazem SE: headache (MC), hypotension, syncope, peripheral edema & bradycardia, constipation 9. Central Alpha2 adrenergic agonists: Action: decreases NE from brain --> PVR & blood pressure Indic: Hypertension (Stepped- care approach, step 2 drug) CATAPRES clonidine(Catapres) guanabenz guanfacine methyldopa (Aldomet) C is at the eyes --.> NE released from the brain. A is at the nose --.> clear risk factors: hypotension, hepatotoxicity, hemolytic anemia T is at the chin --> drops with transient drowsiness A is “body-wide” --> arterial pressure all over body is P --> paradoxical hypertension with propranolol R is a her baseline feet --> get baseline VS E is on her belt---> expand with weight gain S is on her tapered dress --> must be slowly tapered down 10. Vasodilators: Action: direct relaxation of bld vessels --> arteriole vasodilation --> decrease afterload Indic: HPN DILLY DILATOR hydralazine (Apresoline), minoxidil Directly acts on vascular smooth muscle causing VD Increases blood flow to kidneys & brain Lupus- like reaction ( fever, facial rash, muscle & jt ache, splenomegaly Assess peripheral edema of hands & feet Take with food Other SE- headache, dizziness, anorexia, tachycardia, hypotension Review BP PRESSURE Pressure (blood) monitor Rise slowly Eat low Na & low fat food Stay on medications Skipping or stopping is a no- no Undesirable responses Remind to exercise, alcohol Eliminate smoking; educate Drugs for CHF 1. Cardiotonic drugs a. Cardiac Glycosides b. Phosphodiesterase inhibitors 2. Vasodilators 3. ACE inhibitors 4. Diuretics 5. Nonselective adrenergic blockers Antianginal Drugs 1. Nitrates 2. Beta blockers 3. Calcium channel blockers Antihypertensive Drugs 1. 2. 3. 4. 5. 6. 7. 8. ACE Inhibitors Angiotensin II Receptor blockers (ARBS) Alpha 1 Adrenergic Blockers Beta Adrenergic Blockers Calcium Channel Blockers Central Alpha 2 Agonists Vasodilators Diuretics DIURETICS Diet - K for all except Aldactone Intake & output, daily weight Undesirable effects: fluid & electrolyte imbalance Review HR, BP, & electrolytes Elderly – careful Take with or after meals and in AM Increase risk or orthostatic hypotension: move slowly Cancel alcohol Diuretics: 1. Loop Diuretics  furosemide (Lasix)  bumetanide  torsemide  ethacrynic acid 2. Thiazides  hydrochlorothiazide (HydroDiuril)  chlorothiazide  chlorthalidone 3. Potassium- Sparing Diuretics  spironolactone (Aldactone)  amiloride  triamterene 4. Osmotic diuretics  mannitol (Osmitrol)  urea  glycerin 5. Carbonic anhydrase inhibitors  acetazolamide (Diamox)  methazolamide I. Loop Diuretics: Action: increase UO -->Inhibit Na, Cl & water reabsorption in the proximal portion of ascending LOH. Indications: 1. edema in CHF, liver or kidney dses 2. HPN SE:  hyponatremia, hypokalemia, hypocalcemia,hypochloremic alkalosis  hyperglycemia, hyperuricemia  hypotension, HA, dizziness, lightheadedness  anorexia, nausea, diarrhea, dehydration  muscle cramp, ototoxicity  leucopenia & photosensitivity Drug interactions:  digitalis & lithium toxicity  K with steroids & some penicillins,  Avoid nephrotoxic & ototoxic drugs anticoagulant effect Lou La BELL furosemide (Lasix) bumetanide torsemide ethacrynic acid 2. Thiazides: Action: increase UO -->inhibit Na, Cl, & water reabsorption in the distal portion of the ascending LOH. Indic: same as Loop diuretics SE:  same electrolyte imbalance as loop diuretics except o hypercalcemia  same CNS & GI effects as Loop diuretics except no ototoxicity Drug interactions: same as above Lou La hydrochlorothiazide (Hydrodiuril) chlorothiazide chlorthalidone 3. Potassium-sparing Diuretics: Action: promotes excretion of Na & water but retains K in the distal tubule Indications: 1. same as Loop or thiazide 2. diuretic- induced hypokalemia 3. steroid- induced edema 4. hyperaldosteronism SE:  nausea, diarrhea, dry mouth  dizziness, HA, photosensitivity  peak T waves on ECG Drug- interactions: digitalis & lithium toxicity , anticoagulant effects K levels with ACE inhibitors Alan Aldactone spirinolactone (Aldactone) amiloride triamterene Low Na Elevated T waves from K Agranulocytosis with triamterene K level must be monitored 4. Osmotic Diuretics: Action: increase in osmotic pressure, preventing reabsorption of water --> increase UO Buster Brain Man mannitol (Osmitrol) glycerin urea Oliguria, edema, ICP & IOP, drug toxicities. – indic. Stops reabsorption of water Mannitol Output of urine, electrolytes – monitor Tissue dehydration – SE Increased freq & vol of urination Circulatory overload –SE ANTIPLATELETS, ANTICOAGULANTS, THROMBOLYTICS  Process of blood coagulation & thrombus formation: Blood vessel injury Vasoconstriction Blood loss into tissues Intrinsic pathway to clot formation Extrinsic pathway to clot formation Platelet adhesion to injured wall of bv & platelet aggregation decrease blood flow at site of injury compression of injured bv platelet plug thrombus blood clot Decrease blood loss at site of injury  Final step of clot formation: Prothrombin Fibrinogen thrombin Fibrin clot  Clot dissolution: Plasminogen Fibrin clot plasmin (fibrinolysin) dissolution of clot Drugs for Coagulation Disorders: I. Anticoagulants: 1. warfarin (Coumadin) 2. heparin a. heparin sodium b. Low- Molecular-Weight Heparins (LMWH)  enoxaparin  dalteparin II. Antiplatelets: 1. aspirin 2. clopidrogel 3. ticlopidine 4. dipyridamole III. Thrombolytics: 1. altepase (tPA) 2. streptokinase 3. urokinase I. ANTICOAGULANTS: prevent clot formation 1. warfarin (Coumadin) Action: interferes with liver synthesis of vitamin K –clotting factors (II, VII,IX,& X) Indic: prevents or slows down clot formation SE:  GI – anorexia, nausea, diarrhea  bleeding, thrombocytopenia Drug interactions: effects with Vit k –rich foods, & with rifampin. OCP, phenytoin, estrogen (ROPE) risk of bleeding – chamomile, garlic, ginger, ginkgo, & ginseng tx with glucocorticoids, alcohol, salicylate (GAS) CORA Coumadin warfarin (Coumadin) PT/INR PT therapeutic range 1.5- 2.5 X control INR = 2- 3 3- 4.5 = prosthetic valves Coumadin -------------> vitamin K Check VS, platelet count, PT Observe for bleeding Review bleeding protocol Avoid ASA 2. Heparin Sodium: Action: combines with antithrombin III --> to stop thrombin activity. LMWH --> blocks factor Xa & IIa Indic: 1. thrombosis 2. reduces risk of MI, CVA 3. clots associated with atrial fibrillation & pulmonary embolism SE: bleeding tendencies Drug interactions: effects with digoxin, antihistamine, nitroglycerin (DAN) risk of bleeding (same with warfarin) effects with aspirin, alcohol & antibiotics (3A) Harry HEPARIN heparin sodium (Heparin) enoxaparin , dalteparin ---------------> PTT Therapeutic range 1.5 – 2.5 x control Heparin -------------------------------> Protamine sulfate II. ANTIPLATELETS: Aspirin, ticlodipine (Ticlid), dipyridamole,clopidogrel (Plavix) Action: inhibit platelet aggregation Indic: 1. Transient ischemic attacks (TIA) 2. CVA with hx of embolic TIA 3. reduces risk of death from MI SE: GI discomfort, bleeding, dizziness, tinnitus Drug interactions: risk of bleeding with anticoagulants, thrombolytics risk of GI ulcers with alcohol, NSAIDS Annie ASPIRIN Fever Inflammation Reduces TIAs due to fibrin platelet embolus Eliminates (reduces) death with hx of MI III. THROMBOLYTICS: Action: bind with plasminogen causing conversion to plasmin which dissolves clots. Indic: dissolves existing clots in pxs with CAD, CVA, DVT, pulmonary embolism SE: HA, nausea, rash, bleeding, fever, allergic rxn, hypotension, cardiac dysrhythmias ADAM “ASE” urokinase, streptokinase, altepase (tPA) CBC, hgb, hct, - monitor Look for dysrhythmias Observe for bleeding, antidote: aminocaproic acid The vital signs must be monitored. LIPID LOWERING DRUGS I. HMG- CoA reductase inhibitors / Statins: Action: inhibits HMG- CoA reductase  inhib. Cholesterol synthesis Indic: hypercholesterolemia SE: 1. GI distress 2. HA, BOV with lovastatin 3. rare: liver dysfunction, myalgia, myositis LDL L.L. STATIN atorvastatin (Lipitor) simvastatin (Zocor) lovastatin II. Bile Acid sequestrants: Action: binds bile acids in SI & promote increase disposal of cholesterol Indic: hypercholesterolemia if diet does not work SE: 1. 2. 3. 4. GI effects: constipation, indigestion, NV, GI bleeding CNS: HA, syncope increased bleeding tendencies rash, muscle pains BILE - ACiD SEQUESTRANT cholestyramine colestipol + LDL is 15 -30% Increase fluids & fiber PT monitoring Increase GI distress – constipation Decrease absorption of many meds III. Fibrates/ Fibric Acid: Action: increase activity of lipase --> breakdown of VLDL & TG ---> Indic: hyperlipidemia SE: 1. same GI effects + cholelithiasis 2. HA, muscle pains TG & HDL FIBRATES gemfibrozil clofibrate Liver or renal dse – WARNING Increases effect of warfarin & sulfonylureas VLDL, LDL, TG & cholesterol –monitor Encourage diet in fat, cholesterol & sugars Restrict alcohol IV. Nicotinic Acid / Vitamin B3 / Niacin Action: 1. inhib. release of fatty acids from adipose tissue 2. increase TG removal from plasma Indic: hyperlipidemia SE: 1. 2. 3. 4. intense flushing & itching with raised rash dizziness, fainting GI : nausea, abdominal pain hyperglycemia, hyperuricemia, cardiac dysrhythmias in CAD  TG & LDL, HDL NIACIN Note liver function tests – regular intervals Itching & flushing – SE Aspirin before Niacin may SE of VD CI: liver dse, pregnancy Instruct to take with food & at hs No high cholesterol foods DIABETES Diet , weight loss, exercise Identification – medic-alert bracelet Avoid alcohol & other meds Blood sugar, urine sugar, HbA1c Educ. - antidiabetic agents Therapy decrease signs, not a cure Educ. - foot care, no smoking, stressors S/sxs of hyper/hypoglycemia show to do self-monitoring skin care ANTIDIABETIC DRUGS: I. Oral Hypoglycemic Agents (OHA) A. Sulfonylureas 1. 1st generation:  chlorpropramide  tolbutamide (Orinase)  acetohexamide  tolazamide 2. 2nd generation:  glipizide  glyburide  glimepiride II. Insulin: A. Rapid –acting insulin:  Lispro (Humalog)  Insulin aspart (Novolog) B. Short-acting insulin:  Regular (Humulin R, Novolin R) C. Intermediate-Acting insulin:  NPH (Humulin N, Novolin N)  Lente (Humulin L, Novolin L) D. Long-acting insulin:  Ultralente (Humulin U)  Insulin glargine (Lantus) E. Premixed insulin:  70% NPH/ 30% regular (Humulin 70/30)  50% NPH/ 50% regular (HUmulin 50/50)  75% LIspro protamine/ 25%lispro B. Nonsulfonylureas: 1. Biguanides  metformin (Glucophage) 2. Alpha-glucosidase inhibitor  acarbose 3. Thiazolenidiones (Insulin sensitizer)  rosiglitazone (Avandia) 4. Meglitinides:  repaglinide (Prandin) Glucose Elevating Drugs: 1. glucagon (IV) 2. diazoxide (oral) Alpha- glucosidase Inhibitor works here Sulfonylureas & Meglitinides work here Biguanides, Diazoxide & glucagons work here Insulin replacement works here Thiazolinediones work here ANTIDIABETIC AGENTS: I. A. OHA - Sulfonylureas: Action:  stimulates insulin release from pancreas  reduce glucose output by liver  increase peripheral sensitivity to insulin Indic: NIDDM -Type 2 SE: GI: NV, diarrhea rash, pruritus, HA hypoglycemia Drug interactions: hypoglycemic effect with:  aspirin, alcohol, anticoagulant, anticonvulsants,beta-blockers  MAOIs, TCA, sulfonamides,  celery, coriander, dandelion roots, garlic, ginseng hypoglycemic effect with:  cortisone, thiazide diuretics, CCB  estrogen, OCPs, phenytoin, thyroid drugs Glimepride are better for Grandmother Glipizide Sulfonylureas 1. 1st generation:  chlorpropramide  tolbutamide (Orinase)  acetohexamide  tolazamide 2. 2nd generation:  glipizide  glyburide  glimepiride  VS, BUN, Crea, liver function test  Bld & urine glucose  HbA1c B. OHA- Nonsulfonylureas: 1. Metformin (Glucophage) Action:  decreases hepatic glucose production  decreases intestinal glucose absorption  increases peripheral insulin uptake Indic: Type 2- NIDDM SE: GI: VAN, abdominal gas or pain, metallic taste, hypoglycemia Toxic: lactic acidosis (unexplained hyperventilation, muscle aches, & fatigue) METFORMIN HOME (N-range) HbA1c 6% VISITORS High HbA1c 12% 2.Insulin sensitizer: Rosiglitazone (Avandia) Action: decrease insulin resisitance Indic: monotherapy for type 2 DM combination with metformin AVANDIA Signs of anemia, hepatotoxicity, HA, hypoglycemia- SE Use barrier contraceptives --> lessen OCP effect Glucose urine & blood- monitor Administer with meals Rosiglitazone (Avandia) II. Insulin: Action:  increase glucose transport across muscle & fat cell  promote conversion of glucose to glycogen Indic: type 1 & 2 DM, DKA, SE: 1. 2. 3. 4. 5. 6. decrease blood glucose local allergic reaction insulin lipodystrophy insulin resistance Dawn Phenomenon Somogyi phenomenon Insulin waning Hypoglycemic Reaction: Tremors & tachycardia Irritability Restlessness Excessive hunger Diaphoresis & depression Hyperglycemic Reaction: DKA  polyuria, polydipsia,  VAN, abdo. pain  headache, hypotension, weak & rapid pulse  acetone breath, kussmaul’s respirations  weakness, mental status changes PEAK TIMES FOR INSULIN SHORT COMBINATION INTERMEDIATE LONG Humalog Regular Reg/NPH NPH Lente Ultralente Hoppy Humalog Reggie Regular Nanny NPH Lazy Lente THE Contestants A. Rapid –acting insulin:  Lispro (Humalog)  Insulin aspart (Novolog) B. Short-acting insulin:  Regular (Humulin R, Novolin R) C. Intermediate-Acting insulin:  NPH (Humulin N, Novolin N)  Lente (Humulin L, Novolin L) D. Long-acting insulin:  Ultralente (Humulin U)  Insulin glargine (Lantus) <15min 5-10 min 30-60 min 1hr 30- 60 min 2- 4 hr 4- 5 3- 5 6- 8 1-2 hrs 1- 2.5 hrs 6 hrs 30- 60 min 6-12hr 6-12 hr 18-24hr 18- 24 18-24 >36 24 E, Premixed insulin:  70% NPH/ 30% regular (Humulin 70/30)  50% NPH/ 50% regular (Humulin 50/50)  75% LIspro protamine/ 25%lispro ½-1 hr ½ hr 10-15 min 2-12 3- 5 1- 6 18-24 24 24 Mixing insulin FOOD- DRUG interactions Antacids calcium carbonate (TUMS) Bran & whole grain breads Antibiotics erythromycin, penicillin citrus fruits, cola & any food tetracycline dairy products Anticoagulants Warfarin (Coumadin) Vitamin K MAO inhibitors tyramine Drugs that can cause NEPHROTOXICITY acetaminophen acyclovir aminoglycosides amphotericin B ciprofloxaxin cisplatin methotrexate NSAIDs rifampin sulfonamides tetracyclines vancomycin Drugs that can cause HEPATOTOXICITY ACE inhibitors acetaminophen alcohol iron overdose erythromycin estrogens fluconazole isoniazid itraconazole NSAIDs phenothiazines phenytoin rifampin sulfamethoxazole & trimethoprin Drugs that can cause OTOTOXICTY aminoglycosides bumetanide cisplatin erythromycin ethacrynic acid furosemide hydroxychloroquine NSAIDs salicylates (chronic high dose) vancomycin Patient: Well, doc, what does the X-ray of my head show? Doctor: Nothing.