ADRENERGIC AGONISTS:
Can Catecholamines be given PO? - ANSWER-No, they are given parenterally.
Non-catecholamines can be given orally
ADRENERGIC
... [Show More] AGONISTS:
□ Oxidation of catecholamines over time causes color changes and these solutions should be DISCARDED, T/F? - ANSWER-true
ADRENERGIC AGONISTS:
□ Adrenergic agonists are also called (sympathomimetics or sympatholytics)? - ANSWER-Sympathomimetics
ADRENERGIC AGONISTS:
□ Activation of alpha_1 receptors located in the eye causes (miosis or mydriasis) - ANSWER-Mydriasis (wide-eyed with fear)
ADRENERGIC AGONISTS:
□ Alpha_1 agonists are used to (increase or decrease blood pressure) - ANSWER-Increase B/P
- Phenylepherine
- pseudoephedrine (Sudafed)
- activate alpha_1 receptors causes vasoconstriction of blood vessels
ADRENERGIC AGONISTS
□ Is activation of alpha_2 receptors in the periphery significant? - ANSWER-No, however activation of alpha_2 receptors in the CNS leads to anti-adrenergic responses:
- clonidine (Catapres) ---> decrease in
BP and heart rate)
ADRENERGIC AGONISTS
□ What can occur if an alpha_1 agonist that is given IV is given into SQ tissue such as with an infiltrated IV? - ANSWER-Vasoconstriction can lead to tissue necrosis (extravasation)
ADRENERGIC AGONISTS
□ What is the treatment for extravasation of an alpha_1 agonist? - ANSWER-Phentolamine (OraVerse; Rogitine), an alpha adrenergic antagonist
ADRENERGIC AGONISTS
□ Phenylephrine (Rectacain, Anu-Med)
given topically is an alpha_1 agonist that treats_______? - ANSWER-Nasal congestions
ADRENERGIC AGONISTS
□ Epinephrine is the drug of choice for treating anaphylaxis.
Stimulation of adrenergic receptors leads to (bronchoconstriction or bronchodilation) - ANSWER-Bronchodilation
- occurs with activation of beta_2 receptors S/P epinephrine
ADRENERGIC AGONISTS
□ What is the impact of activation of adrenergic receptors when epinephrine is given for anaphylaxis? - ANSWER-- Elevation on BP
- suppression of glottal edema
- counteraction of bronchoconstriction
ADRENERGIC AGONISTS
□ Why should patients who have used their Epi Pen be hospitalized for up to 6 hours? - ANSWER-There can be a biphasic and prolonged phase to an anaphylactic reaction
ADRENERGIC AGONISTS
□ Delayed and or persistent symptoms of anaphylaxis can be treated with_______? - ANSWER-Oral glucocorticoids
ADRENERGIC AGONISTS
□ When a patient with severe allergies reaches a weight of________lbs. - ANSWER-66 lbs, they can transition from the Epi Pen Jr. to the adult dose of 0.3 mg.
ADRENERGIC AGONISTS
□ A patient having an anaphylactic reaction would use an epinephrine solution concentration of__________% for IM injection. - ANSWER-0.1% or 1:000
- The adult dose is 0.3 mg and 0.150 mg for a pediatric dose (less than 66 lbs.)
ADRENERGIC AGONISTS:
□ What are the uses of the adrenergic agonist isoproterenol? - ANSWER-- AV block
- cardiac arrest
- shock
ADRENERGIC AGONISTS:
□ Which drug classes when can intensify the effects of alpha antagonists such as epinephrine - ANSWER-MAOI's, TCA's and general anesthetics
□ Beta_2 agonists are used for treatment for _______________ and in ___________________. - ANSWER-Asthma, preterm labor
□ What are the adverse effects of beta_2 agonists?
ie) albuterol - ANSWER-Tachycardia
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ A drug that blocks alpha_1 receptors (alpha-adrenergic antagonist) would be used to (increase or decrease) blood pressure? - ANSWER-Decrease
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ Are alpha blockers recommended for "first line" use in patients with HTN? - ANSWER-No, they are used more for BPH.
- They can be used first line for a "therapeutic twofer" such as in a patient that has HTN and BPH
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ Other than BPH what are some other less common indications for the use of alpha blockers? - ANSWER-- Pheochromocytoma
- Raynaud's disease
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ A consequence of using an alpha-adrenergic antagonist might have what effect on sexual function? - ANSWER-- Impotence failure to ejaculate
- erectile dysfunction
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ How do alpha-adrenergic antagonists lower blood pressure? - ANSWER-- Blocking of alpha_1 receptors on
blood vessels
- leads to DILATION ----> BP lowering.
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ Orthostatic hypotension, reflex tachycardia, inhibition of ejaculation and nasal congestion are adverse effects of which category of drugs? - ANSWER-Alpha-adrenergic antagonists such as:
- prazosin (Minipress)
- doxazosin (Cardura).
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ What type of drugs used to lower blood pressure also help men with benign prostatic hypertrophy (BPH)? - ANSWER-Alpha-adrenergic antagonists or alpha blockers such as:
- prazosin (Minipress)
- doxazosin (Cardura)
- alfuzosin (Uroxatral)
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ Do alpha-adrenergic antagonists differ in their specificity of receptor blockade and resultant impact on blood pressure? - ANSWER-Yes, (older agents are approved for HTN)
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ Which of the alpha-adrenergic antagonists can cause vasodilation in the blood vessels that contributes to hypotension as well as relaxation in the bladder neck and prostatic capsule? - ANSWER-Older alpha-adrenergic antagonists include -
- prazosin (Minipress)
- doxazosin (Cardura)
- terazosin (Hytrin)
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ Which of the alpha-adrenergic antagonists were developed as antihypertensive agents first and then later used for BPH? - ANSWER-- Prazosin (Minipress)
- doxazosin (Cardura)
- terazosin (Hytrin)
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ Which alpha-adrenergic antagonist would be appropriate for a normotensive male with BPH because the blockade of vascular alpha_1 receptors is weak? - ANSWER-- Silodosin (Rapaflo)
- tamsulosin (Flomax)
- alfuzosin (Uroxatral)
- are new agents that cause "selective" blockade of alpha_1 receptors in the prostate
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ A dangerous lowering of blood pressure can occur when alpha-adrenergic antagonists are used with______________? - ANSWER-Phosphdiesterase type 5 Inhibitor(PDE5) inhibitors such as:
- sildenafil (Viagra)
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ Floppy iris syndrome can occur with the use of__________? - ANSWER-Alpha-adrenergic antagonists
(alpha blockers)
- tamsulosin (Flomax)
- doxazosin (Cardura)
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ A patient is scheduled for cataract surgery and the surgeon wants to know it the patient is on an alpha blocker or has ever been on an alpha blocker. Why is this important to know? - ANSWER-Patients on that have been on alpha blockers require special equipment in the operating room during cataract surgery because alpha blockers can cause FLOPPY IRIS SYNDROME.
□ Older adults should avoid the older alpha blockers such as doxazosin, prazosin, and terazosin because of the risk of: - ANSWER-Orthostatic hypotension
ALPHA-ADRENERGIC ANTAGONISTS (ALPHA BLOCKERS):
□ Phentolamine is a non-selective alpha blocker that blocks alpha_1 and alpha_2 receptors. The most common use is: - ANSWER-Prevention of tissue necrosis following extravasation of drugs that produce vasoconstriction such as epinephrine
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Beta blockers also call beta adrenergic antagonists are considered to be (sympathomimetics or sympatholytics)? - ANSWER-Sympatholytics
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Beta_1 receptors are located in the: - ANSWER-- heart (incr HR, incr contraction)
- kidney (renin release)
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Blocking of beta_1 receptors in the heart leads to: - ANSWER-- Reduced heart rate
- reduced force of contraction
- reduced AV conduction
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Beta blockers are used for: - ANSWER-- Angina
- HTN, dysrhythmias
- MI
- reduction of perioperative mortality
- heart failure
- hyperthyroidism
- migraine prophylaxis
- stage fright,
- pheochromocytoma
- glaucoma
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ What are 3 categories of Beta Blockers? - ANSWER-1) First generation-nonselective:
- nadolol (Corgard)
- propanolol (Inderal)
2) Second generation-cardio-selective
- metoprolol (Lopressor, Toprol XL)
- atenolol (Tenormin)
- bisoprolol (Zebeta)
- esmolol (Brevibloc)
- acebutolol (Sectral)
3) Third-generation beta blockers with vasodilation actions
- Nebivolol (Bystolic)
- labetolol (Normodyne, Trandate)
- carvedilol (Coreg)
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Which of the beta blockers also block alpha receptors? - ANSWER-- carvedilol (Coreg)
- labetalol (Trandate)
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Should carvedilol (Coreg) or labetalol (Trandate) be given to patients with asthma? - ANSWER-No, because they are non cardio-selective and block the beta_1 receptors (heart) and beta_2 receptors (lung) that can lead to bronchodilation
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Which beta blocker would be appropriate for a patient with asthma? - ANSWER-- Metoprolol is a good choice because it is a cardio-selective BB.
- In higher dosages it can still cause problems in patients with asthma
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Which newer beta blocker is cardio-selective and has vasodilating properties? - ANSWER-Nebivolol (Bystolic)
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Are beta blockers consider "first line" agents for patients with HTN? - ANSWER-No.
- They used to be considered first line agents for HTN. Other agents such as ACEI, ARBS, diuretic and CCBs are better at reducing BP and have less adverse effects.
- Beta blockers are essential in patients with ASCVD and are sometimes used for HTN to treat co-morbid conditions such as migraines, heart failure, dysrhythmias.
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
- Why do beta blockers need to be tapered? - ANSWER-Rebound tachycardia:
- occurs and can be problematic in patients with heart disease
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ What is the problem with patients with diabetes and concurrent use of beta blockers? - ANSWER-Recognition of hypoglycemia:
- may be diminished in patients with beta blockade
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ How do beta blockers impact glycogenolysis?
Glycogenesis---->breakdown of glycogen stores to glucose - ANSWER-Beta blockers REDUCE glycogenolysis:
- making it more difficult for a patient with diabetes to recover from a low blood sugar
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Are there ever reasons for a patient with DM to be on a beta blocker? - ANSWER-Yes.
Patients with heart disease and diabetes often require beta blockers
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Which beta blockers are preferred in patients with asthma and or diabetes? - ANSWER-Cardio-selective beta blockers ONLY**
metoprolol (Lopressor, Toprol XL)
nebivolol (Bystolic)
Atenolol (Tenormin)
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ What are some of the major adverse effects of beta blockers? - ANSWER-- bradycardia
- reduced cardiac output
- AV block
- bronchoconstriction
- reduced glycogenolysis
- masking of tachycardia in the event of hypoglycemia in patients with DM
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Why are beta blockers problematic in patients with severe allergies? - ANSWER-- Epinephrine is the drug of choice
- effects can be DIMINISHED in the presence of beta blockers
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Which beta blocker has indications for migraine prophylaxis? - ANSWER-propranolol (Inderal)
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Which beta blocker would be beneficial in a patient with symptomatic hyperthyroidism? - ANSWER-give a non cardio-selective beta blocker
ie) propranolol (Inderal)
- can help manage the tachycardia as well as other symptoms such as tremor
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ What is the problem with using a beta blocker and a non dihydropyridine CCB concurrently? - ANSWER-- Excessive cardio suppression
- risk for bradycardia
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Generic forms of metoprolol are metoprolol succinate and metoprolol tartrate. Which of these is given BID? - ANSWER-- Metoprolol succinate is long acting.
- Metoprolol tartrate is on the $4 drug list and must be given every 12 hours
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Atenolol is classified as pregnancy category_____? - ANSWER-D (this classification is no longer used)
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Atenolol (Tenormin) has been shown to be less effective than other beta blockers (true or false) - ANSWER-True
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Are beta blockers approved for the treatment of heart failure? - ANSWER-Yes, however they need to be titrated slowly
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Which non selective beta blockers also selectively blocks alpha_1 receptors? - ANSWER-- labetalol (Trandate,Normodyne)
- carvedilol (Coreg)
BETA-ADRENERGIC ANTAGONISTS (BETA BLOCKERS)
□ Which newer beta blockers blocks beta_1 receptors and dilates arteries by promoting the synthesis and release of nitric acid? - ANSWER-nebivolol (Bystolic)
Match the following to the above categories. You may use the items more than once and in more than one category. Some of the items may not be used at all:
a) Nonselective Beta Blocker
b) Cardioselective Beta Blocker
c) Beta Blockers with Vasodilating Actions - ANSWER-________1. Propranolol
________2. InnoPran
________3. Atenolol
________4. Nebivolol (Bystolic)
________5. Metoprolol
________6. Atenolol (Tenormin)
________7. Labetalol (Trandate, Normodyne)
________8. Bisoprolol (Zebeta)
________9. Inderal.
________10. Lopressor
________11. May lead to bronchoconstriction
________12. Used for hypertension
________13. Block alpha1 receptors
________14. Block beta1 receptors
________15. Block beta1 and beta2 receptors
________16. Slow AV conduction
________17. Are problematic in asthmatics
________18. Mask the s/s of hyperglycemia
________19. Cause bradycardia
________20. Decrease risk of second MI
________21. Abrupt cessation can lead to rebound
tachycardia
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ How does clonidine (Catapres) decrease blood pressure? - ANSWER-- It activates the alpha_2 receptors in the CNS to decrease sympathetic nervous system outflow.
- When norepinephrine is decreased blood pressure falls.
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ Activation of alpha_2 receptors in the CNS (increase or decreases) sympathetic outflow to the blood vessels and the heart and (increases or decreases) B/P and HR? - ANSWER-Decreases; decreases
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ Clonidine (Catapres) activates the alpha_2 receptors in the CNS to decrease SNS outflow to blood vessels and the heart.
- The outcome is (increased or decreased) blood pressure? - ANSWER-Clonidine decreases blood pressure
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ Why is it important to taper clonidine (Catapres) gradually when discontinuing therapy? - ANSWER-Rebound hypertension can occur
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ Does clonidine (Catapres) slow the HR? - ANSWER-Yes
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ Why is it important to advise patients to avoid hazardous activities while taking clonidine (Catapres)? - ANSWER-this alpha_2 agonist can lead to:
- CNS depression
- drowsiness
- sedation
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ Is clonidine (Catapres) a good choice for a woman that has hypertension and is of child-bearing age? - ANSWER-No, it is embryotoxic in animals and is not recommended for pregnant women. Methyldopa or labetolol (Trandate) can be used.
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ What are the principle adverse effects of clonidine (Catapres) ? - ANSWER-- hypotension
- bradycardia
- sedation
- xerostomia (dry mouth) - hemolytic anemia
- rebound tachycardia
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ What are the endocrine effects of clonidine (Catapres)? - ANSWER-Gynecomastia and impotence
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ Is clonidine (Catapres) considered a first line drug for treatment of HTN? - ANSWER-No.
- this alpha_2 agonist has too many adverse effects to be considered as a first line agent
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ Why do think that clonidine (Catapres) might be a drug of abuse? - ANSWER-Because of the sedating effects
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ Which alpha_2 agonist can cause hepatotoxicity? - ANSWER-Methyldopa
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ Which anti-adrenergic agent can cause a positive Comb's test and hemolytic anemia and also hepatotoxicity? - ANSWER-Methyldopa (alpha2 agonist)
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ What is the significance of a positive Comb's test? - ANSWER-- It indicates that there are auto-antibodies that can attack the RBCs causing HEMOLYTIC ANEMIA .
- It is a rare event.
- ie) Methyldopa, PCN, cephalosporins and beta-lactamase inhibitors can cause hemolytic anemia.
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ When should a Comb's test be drawn in a patient who is taking methyldopa? - ANSWER-- Before treatment
- at 6 months
- at 12 months
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ Which alpha_2 agonist is the preferred agent for management of hypertension during pregnancy? - ANSWER-Methyldopa
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ In addition to a Comb's test which other lab testes need to be ordered when a patient is prescribed methyldopa? - ANSWER-- CBC to look for anemia/hemolysis
- CMP to assess liver function
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ Reserpine (adrenergic neuron blocker) decreases norepinephrine (NE) in order to decrease blood pressure.
The reduction of NE can lead to severe_____________? - ANSWER-- Depression
- Reserpine is rarely used.
- The MOA of reserpine is important in order to understand the monoamine hypothesis of depression which links a deficiency of neurotransmitters with the cause of depression
INDIRECT-ACTING ANTIADRENERGIC AGENTS
- CENTRALLY ACTING ALPHA2 AGONISTS:
□ Why are alpha2 agonists such as clonidine on the Beer's list? - ANSWER-Their side effects that outweigh the benefits include:
- CNS effects
- bradycardia
- hypotension
DIURETICS
□ What are the therapeutic uses of high-ceiling (loop) diuretics? - ANSWER-Rapid mobilization of fluids to treat pulmonary edema, heart failure & HTN
DIURETICS
□ Describe the MOA of furosemide (Lasix) - ANSWER-Blocks reabsorption of sodium and chloride in the ascending loop of Henle
- Think: "L_asik = L_oop",
- In order of location of MOA think: "M_y F_ood T_astes S_poiled" ---> M_annitol (Osmotic/ lumen of nephron), F_urosemide (Loop of Henle), T_hiazides (Distal Tubule), S_pironaldactone ("distal sparing diuretic")
DIURETICS
□ Which class of diuretics is especially useful in patients with renal impairment? - ANSWER-Loop diuretics
DIURETICS
□ List the adverse effects of furosemide (Lasix) - ANSWER-- Decreases electrolytes (Na+, Cl-, K+ )
- Hypotension
- dehydration can also occur
DIURETICS
□ What is the potential problem when diuretics and digoxin are used together? - ANSWER-Low potassium can increase digoxin levels to toxic range
DIURETICS
□ What is the potential problem when lithium and diuretics are combined? - ANSWER-Low sodium can elevate lithium levels to toxic levels
DIURETICS
□ Which antibiotic when combined with furosemide (Lasix), can potentiate hearing loss? - ANSWER-Gentamycin (aminoglycoside antibiotic)
DIURETICS
□ How is intravenous furosemide (Lasix) administered? - ANSWER-Over 1-2 minutes.
DIURETICS
□ Describe the MOA of thiazide diuretics. - ANSWER-Block reabsorption of sodium and chloride in the distal convoluted tubule, Think: "T_hiazide = T_ubule"
DIURETICS
□ Diuretics should be given in the AM to avoid__________? - ANSWER-Nocturia
DIURETICS:
□ Why do patients with diabetes need to be concerned if they are being treated with diuretics? - ANSWER-Use of high doses of diuretics can elevate blood sugar levels
DIURETICS:
□ Are thiazide diuretics effective in patients with decreased glomerular filtration? - ANSWER-No, they are ineffective with kidney impairment (eGFR 15-20 mL/min): loop diuretics are needed
DIURETICS:
□ Which diuretic is used for heart failure, HTN, treatment of hyperaldosteronism, and is also used to counteract the loss of potassium with the use of other diuretics? - ANSWER-Spironolactone (Aldalctone) or other potassium sparing diuretics such as triamterene
DIURETICS:
□ What is the major indication for using a potassium-sparing diuretic such as spironolactone (Aldactone)? - ANSWER-Common use, to counteract loss of potassium with loop or thiazide diuretics,
In order of location of MOA think: "M_y F_ood T_astes S_poiled" ---> M_annitol, F_urosemide, T_hiazides, S_pironaldactone
DIURETICS:
□ Describe the MOA of spironolactone - ANSWER-Blocks aldosterone in distal nephron, potassium is retained, sodium is excreted. Aldosterone is essential for Na+ rentention, so a decre in B/P can occur.
DIURETICS:
□ Why are ACE inhibitors and potassium-sparing diuretics problematic? - ANSWER-Both can lead to hyperkalemia
DIURETICS:
□ Dehydration from diuretic use can promote thromboembolism.
- Describe the symptoms of thromboembolism. - ANSWER-- headache
- pain in chest
- pain calves
- pain in pelvis
- positive Homan's sign
- erythema
DIURETICS:
□ Give examples of foods high in potassium - ANSWER-- Nuts
- dried food
- spinach
- citrus fruits
- potatoes
- bananas
- salt substitute
DIURETICS:
□ Why are thiazide diuretics considered "first-line" for treatment of stage-one hypertension? - ANSWER-- Diuretics have been shown to be effective in
decreasing morbidity and mortality and they are
inexpensive.
JNC-8 lists 4 agents as first line, not just diuretics
as in the past:
1) ACEI - ramipril (Altace), enalapril (Vasotec)
2) ARB - losartan (Cozaar), valsartan (Diovan)
3) Thiazide Diuretic - HCTZ
4) CCB's - dilitalizem (Cardizem), verapamil (Calan)
DIURETICS:
□ Which thiazide diuretic was used in the ALLHAT study that demonstrated efficacy of thiazides? - ANSWER-Chlorthalidone, has a long 1/2 life (40hrs), inhibits distal convolute Na+ and Cl- reabsorption
DIURETICS:
□ How do chlorthalidone and HCTZ differ? - ANSWER-- Cholorthalidone is stronger, it also has a longer half life (40hrs).
- It can also cause more hypokalemia than HCTZ.
DIURETICS:
□ Why would a thiazide diuretic be helpful for a woman with HTN and osteoporosis? - ANSWER-Thiazides promote tubular reabsorption of calcium, helps decrease the risk of osteoporosis in postmenopausal woman
DIURETICS:
□ What are the possible consequences to the fetus if diuretics are taken during pregnancy? - ANSWER-- Decrease in placental perfusion
- nutrition and growth retardation
DIURETICS:
□ Should women who are breastfeeding take diuretics? - ANSWER-No.
- Diuretics enter breast milk and can be hazardous to the nursing infant
DIURETICS:
□ Why should patients with gout avoid diuretics? - ANSWER-Diuretics can increase uric acid levels to precipitate a gouty attack
DIURETICS:
□ What are the uses for osmotic diuretics such as mannitol? - ANSWER-- prophylaxis of renal failure
- reduction of intracranial pressure
- reduction of intraocular pressure
DIURETICS:
□ Why is it important to use lower doses of THIAZIDE diuretics in older adults? - ANSWER-- Lower doses such as 12.5 mg-25 mg seem as effective as higher doses with less S/E's
- can cause dehydration
DIURETICS:
□ Can diuretics effect lipid levels? - ANSWER-Yes, high doses of diuretics can elevate LDL and lower HDL
DIURETICS:
□ Why is it important to use lower doses of diuretics in older adults? - ANSWER-- They can cause lots of symptoms:
- Think "D_iurese E_veryone H_olding H_2O"
D_izziness
E_lectrolyte imbalances
H_ypovolemia
H_ypotension
AGENTS AFFECTING VOLUME AND ION CONTENT OF BODY FLUIDS:
□ Give examples of foods high in potassium - ANSWER-- Nuts
- dried food
- spinach
- citrus fruits
- potatoes
- bananas
- salt substitute
AGENTS AFFECTING VOLUME AND ION CONTENT OF BODY FLUIDS:
□ List the causes of hypokalemia - ANSWER-- Decreased diuretics
- excessive sweating
- increased insulin
- alkalosis
AGENTS AFFECTING VOLUME AND ION CONTENT OF BODY FLUIDS:
□ What is the recommended infusion rate of intravenous potassium replacement? - ANSWER-No more than 10 mEq/hour diluted for adults
AGENTS AFFECTING VOLUME AND ION CONTENT OF BODY FLUIDS:
□ List the causes of hyperkalemia - ANSWER-six "A's"
A_ccident/ Trauma
A_cute renal failure
A-cute acidosis
A_CE inhibitors
A_RBs
A_ddison's disease
AGENTS AFFECTING VOLUME AND ION CONTENT OF BODY FLUIDS:
□ What EKG changes occur with elevated potassium levels? - ANSWER-- T wave heightens.
- PR prolongation
AGENTS AFFECTING VOLUME AND ION CONTENT OF BODY FLUIDS:
□ How is hyperkalemia treated? - ANSWER-Stop infusion of potassium replacement or intake of foods high in potassium
AGENTS AFFECTING VOLUME AND ION CONTENT OF BODY FLUIDS:
□ Besides adjusting diet and meds, how is hyperkalemia treated? - ANSWER-Calcium gluconate, glucose & insulin are given to promote uptake into cells
REVIEW OF HEMODYNAMICS:
□ State the three factors that determine stroke volume. - ANSWER-Myocardial contractility, cardiac afterload and cardiac preload SV = EVD - ESV
REVIEW OF HEMODYNAMICS:
□ Define preload. - ANSWER-The amount of tension applied to a muscle before contraction. In the heart stretch is determined by ventricular filling pressure also known as the force of venous return. P_reload = P_re contraction
REVIEW OF HEMODYNAMICS:
□ Define afterload. - ANSWER-- The arterial pressure that the left heart must overcome to eject blood.
- Medications that lower blood pressure can lower preload and afterload
REVIEW OF HEMODYNAMICS:
□ Does HTN increase or decrease afterload? - ANSWER-Increase
REVIEW OF HEMODYNAMICS:
□ Describe Starling's law of the heart. - ANSWER-When more blood enters the heart, more blood is pumped out in a healthy heart
REVIEW OF HEMODYNAMICS:
□ When venous return increases does cardiac output increase or decrease? - ANSWER-Increase
REVIEW OF HEMODYNAMICS:
□ State the four systems that regulate arterial pressure. - ANSWER-- The autonomic nervous system
- RAAS
- the kidneys
- Natriuretic peptides
REVIEW OF HEMODYNAMICS:
□ When the baroreceptor reflex is activated in response to low blood pressure the arterioles (dilate or constrict) and the heart rate (increases or decreases)? - ANSWER-Constrict; increases
REVIEW OF HEMODYNAMICS:
□ What is reflex tachycardia? - ANSWER-A response that occurs with the use of drugs that dilate arterioles (alpha anatagonist)
Examples:
- Hydralyzine
- nitroprusside (Nipride)
REVIEW OF HEMODYNAMICS:
□ Can the baroreceptor response temporarily negate the effect of drugs used to lower blood pressure? - ANSWER-Yes
REVIEW OF HEMODYNAMICS:
□ What causes postural (orthostatic) hypotension? - ANSWER-Pooling of blood in veins that decreases venous return and decreases cardiac output
REVIEW OF HEMODYNAMICS:
□ Drugs that dilate veins intensify and prolong postural hypotension. True or False? - ANSWER-True
REVIEW OF HEMODYNAMICS:
□ Brain natriuretic peptide (BNP) and is produced in the ventricles of the heart and is stimulated in response to fluid overload. What is the impact of these naturally occurring peptides? - ANSWER-- These peptides reduce blood volume
- They promote DILATION of arterioles and veins to lower
arterial blood pressure.
- BNP levels are measured in the serum and serve
as a marker for heart failure (HF)
RAAS BLOCKERS:
□ Where is renin produced? - ANSWER-The juxtaglomerular cells of the kidneys.
RAAS BLOCKERS:□ Which situations cause renin to be released for the kidneys? - ANSWER-___________________is released when there is a DECREASE in:
1) BP
2) blood volume
3) plasma sodium content 4) renal perfusion pressure
RAAS BLOCKERS:
□ What does renin do to angiotensinogen? - ANSWER-Helps convert angiotensinogen into angiotensin I.
RAAS BLOCKERS:
□ Vasoconstriction and stimulation of aldosterone release as well as pathologic structural changes in the heart and blood vessels (hypertrophy and remodeling) are the prominent actions of__________? - ANSWER-Angiotensin II.
RAAS BLOCKERS:
□ What effect does angiotensin II have on aldosterone? - ANSWER-Acts on the adrenal glands to STIMULATES release of aldosterone, to retain Na+.
RAAS BLOCKERS:
□ Where does aldosterone come from? - ANSWER-The adrenal cortex.
RAAS BLOCKERS:
□ Aldosterone leads to retention of sodium and excretion of potassium and hydrogen. Retention of sodium causes water to be retained which (elevates or lowers) the blood pressure? - ANSWER-Elevates, incr Na+ ----> incr B/P
RAAS BLOCKERS:
□ What effect does aldosterone have on plasma volume and blood pressure? - ANSWER-Increases blood volume and blood pressure.
RAAS BLOCKERS:
□ Which class of drugs blocks the conversion of angiotensin I into angiotensin II.
Med class is know to:
1) increase levels of bradykinin 2) dilates blood vessels
3) reduces blood volume
4) prevents cardiac remodeling - ANSWER-Angiotensin converting enzyme (ACE) inhibitors: Examples:
- lisinopril (Zestril)
- captopril (Capoten)
- benazepril (Lotensin)
- enalapril (Vasotec)
- quinapril (Accupril)
RAAS BLOCKERS:
□ ACEIs contribute to blood pressure lowering by dilation of veins or arterioles? - ANSWER-Both....in contrast, CCBs dilate only the arterioles.
RAAS BLOCKERS:
□ When ACE is blocked Kinase II is also blocked. Kinase breaks down bradykinins. When Kinase II is blocked, bradykinins build up and lead to edema.
Bradykinins promote dilation and its buildup is thought to cause a dry_______ in patients taking ACE inhibitors? - ANSWER-Cough
RAAS BLOCKERS:
□ HTN heart failure, MI, diabetic and nondiabetic nephropathy, prevention of MI, stroke, and death in high risk patients are some of the uses for ACEI's, True/false? - ANSWER-true, {ACEI's are first on JNC8 list for HTN}
RAAS BLOCKERS:
□ Why are ACE inhibitors considered first line treatment of hypertension for patients with diabetes? - ANSWER-They reduce glomerular filtration pressure and slow development of renal injury.
RAAS BLOCKERS:
□ Are ACEIs and ARBs recommended for primary prevention of diabetic nephropathy? - ANSWER-No. They should be initiated in the presence of HTN or in a normotensive patient with diabetes and evidence of microalbuminuria. They should not be prescribed to normotensive patients with DM unless there are signs of renal impairment (microalbuminuria).
RAAS BLOCKERS:
□ State the adverse effects of ACE inhibitors. - ANSWER-- first dose hypertension
- ace induced cough
- hyperkalemia
- angioedema.
Renin-Angiotension-Aldosterone System Blockers (RAAS BLOCKERS::
□ ACE inhibitors are contraindicated in patients with renal artery _________? - ANSWER-Stenosis
RAAS BLOCKERS:
□ Why is it important to check renal function after initiating an ACE inhibitor? - ANSWER-GFR can decrease in the presence of renal artery stenosis.
RAAS BLOCKERS:
□ What electrolyte abnormality is associated with the use of ACE inhibitors? - ANSWER-Hyperkalemia. When aldosterone is blocked potassium is retained.
□ Can ACE inhibitors be used in pregnancy? - ANSWER-NO. ARBs are also contraindicated.
RAAS BLOCKERS:
□ Explain how ACE inhibitors can lead to angioedema in rare instances. - ANSWER-Accumulation of bradykinins leads to edema.
RAAS BLOCKERS:
□ What is the treatment of angioedema? - ANSWER-Administer epinephrine and discontinue ACEI or ARB.
RAAS BLOCKERS:
□ What is the potential problem of using diuretics along with ACE inhibitors? - ANSWER-- May intensify first dose hypotension.
- If a patient is on a diuretic and an ACEI or ARB is added it is sometimes a good idea to suspend the diuretic to avoid excessive blood pressure lowering (it depends on the level of the BP)
RAAS BLOCKERS:
□ Why are ACE inhibitors and potassium sparing diuretics such as spironolactone used together with caution? - ANSWER-Using both can lead to hyperkalemia.
RAAS BLOCKERS:
□ ACEIs used along with lithium can lead to (increased or decreased) lithium levels? - ANSWER-Increased lithium levels
RAAS BLOCKERS:
□ Is there a problem with the combination of ACEIs and lithium? - ANSWER-Yes, concurrent use can cause lithium levels to rise to toxic levels
RAAS BLOCKERS:
□ Captopril was the first ACEI on the market. Why are other ACEIs favored? - ANSWER-- Captopril is short acting and requires multiple
daily doses and this is not convenient for long
term use.
- The risk of neutropenia, rash and dysguesia (foul taste in mouth) is greater with captopril.
Lisinopril is long acting and free at Publix..
RAAS BLOCKERS:
□ Which ACEI is available in an IV formulation? - ANSWER-Enalaprilat (Vasotec)
RAAS BLOCKERS:
□ Which drug category can decrease the antihypertensive effects of ACEIs? - ANSWER-NSAIDs
RAAS BLOCKERS:
□ What is the difference between ACE inhibitors (ACEI's) and Angiotensin II Receptor Blockers (ARBs)? - ANSWER-- ARB's blocks angiotensin (Ang I)at receptor sites and does not cause cough with few exceptions. ACEI's keep Ang I from becoming Ang II
RAAS BLOCKERS:
□ Are ARBs considered "first line" agents for the treatment of HTN? - ANSWER-Yes, however, it is recommended to start with an ACEI due to cost and use an ARB if the patient develops a cough
□ Do Angiotension II Receptor Blockers (ARBs) lead to hyperkalemia or cough? - ANSWER-No.
There is LESS hyperkalemia or build-up of bradykinin that leads to cough.
Do Angiotension II Receptor Blockers (ARBs):
□ Can use of ARBs cause angioedema? - ANSWER-ARBs can cause angioedema. About 8% will get angioedema with an ACEI and an ARB. In some situations the benefit may outweigh the risk.
Angiotension II Receptor Blockers (ARBs):
□ Which ARB is considered uricosuric (able to lower serum uric acid levels). - ANSWER-Losartan (Cozaar) may be helpful in patients with HTN and gout
Do Angiotension II Receptor Blockers (ARBs): [Show Less]