NR 508 Advanced Pharmacology Final Exam study guide. CHAMBERLAIN

Final study guide Cardiovascular management: 1. Know Initial treatment choices for HTN AceI- sartans Arbs- ipine, verapamil & diltazem Thiazide- iaside, chlorthalidone, imdapamide, metolazone calcium channel blocke ...

Final study guide Cardiovascular management: 1. Know Initial treatment choices for HTN AceI- sartans Arbs- ipine, verapamil & diltazem Thiazide- iaside, chlorthalidone, imdapamide, metolazone calcium channel blocker 2. Know first line treatment options for HTN for African Americans without renal impairment. Calcium channel blockers Thiazide 3. First line option for HTN for anyone with chronic kidney disease Ace inhibitors ARB’s Diuretics: 4. Types, Uses, Side effects Thiazides (HCTZ) Uses- HTN, CHF, edema, useful in decreases calcium stone formation Off label HCTZ- osteoporosis and diabetes AE- hypokalemia, hyperglycemia, arrhythmias, metabolic alkalosis, fatigue, postural Hypotension Loop diuretics (furosemide, torsemide, ethacrynic acid) *preferred diuretics for renal Impairment Uses- CFH, HTN, nephrotic syndrome, cirrhosis, pulmonary edema AE-hypocalcemia, hyponatremia, hypokalemia, ototoxicity Carbonic anhydrase inhibitors (acetazolamide) *weak diuretic Uses- edema, epilepsy, glaucoma, mountain sickeness AE- toxic epidermal necrolysis, agranulocytosis, aplastic anemia, thrombocytopenia, metabolic acidosis Potassium-sparing (spironolactone, eplerenone) Uses- CHF (in combo with thiazides or ACE and loop), HTN AE-gynomastia, n/v, erectile dysfuction, electrolyte imbalance, metabolic acidosis **postdiuretic sodium retention- It is important for pts to adhere to a low sodium diet. As drug concentrations fall, there is a period of positive sodium balance ** If a pt has a sulfa allergy= take ethacrynic acid 5. Preferred diuretic with renal impairment-  Loop diuretics because they retain efficacy even with moderate renal insufficiency: such as furosemide, buetanide, torsemide, ethacrynic acid.  Uses: Edematous states (HF, cirrhosis, pulmonary edema, nephrotic syndrome), hypercalcemia 6. Side effect of post diuretic sodium retention pg 374 As drug concentrations decrease, period of Na balance, this is the post diuretic sodium retention If there is a high Na intake then Na lost with diuresis is offset.. diuretic resistance 7. Recognition that some diuretics are sulfa derivatives (carbonic anhydrase inhibitors, loop diuretics, thiazides, but NOT ethacrynic acid)  Loops- Examples: furosemide, bumetanide, torsemide, ethacrynic acid "The Loop FURiously BUMmed my TORSo like ACID" Common side effects: orthostatic hypotension, excessive diuresis, tinnitus, vertigo, hyperuricemia note all these are precursors to toxicity  Thiazides Hydrochlorothiazide, Chlorothoazide, , Chlorthalidone, Indapamide, Metolazone 1st line for HTN, Chronic Calcium Kidney Stones, HF, Idiopathic hypercalciuria, Nephrogenic diabetes 2 insipidus, Osteoporosis. Other common side effects: orthostatic hypotension, dizzy, drowsy, syncope, weakness, nausea, GI irritation, elevated BUN, depressed respirations lethargy  Carbonic anhydrase inhibitors- Acetazolamide N/V/D, Drowsy, Parathesis, confusion, tinnitus, myopia, anorexia, change in taste; polyuria, mild electrolyte changes Uses: Edematous states ( HF, cirrhosis, pulmonary edema, nephrotic syndrome), hypercalcemia  Ethacrynic Acid Note it's the only diuretic with "acid" in its name 8. Management of edema  Loops for volume excess 9. CHF drugs including diuretic choices 1- Loops -fluid 2- ACEIs or ARBs 3-BB - Diastolic after stable (B-Day) 4- Digoxin - Systolic , AFib, (Dig A Syst) 5- Spironolactone - if above not effective 6- Nitrates & Hydralazine *AA only* Think Michael Jordan goes Hy in his NIkes CCBs ( Amlodipine/Felodipine) only for angina or HTN if EF is preserved 2- Clinical pearls for CHF- Improve SX: ACEIs, ARBs, BBs (metoprolol, Bisoprolol, Carvedilol) , Dig ( only after diuretics & ACEIs) Prolong survival: ACEIs, ARBS, BB, Hydralazine/Nitrates(AA only) Aldosterone Antagonists BB NEVER IN ACTIVE FAILURE Dig does not improve mortality but improves SX decreases Hospitalization.. CAUTION:: Loops without Spironolactone **with hyperkalemia DIG CAN BECOME TOXIC" Neuro/Psych: 10. Know migraine management and prophylactics (see migraine lecture) dark, quiet room *NSAIDS or APAP *Triptans (sumatriptan/imitrex, zolmatriptan/zomig, rizatriptan/maxalt) -nasal, oral, subq -use no more than 2d/wk -CI-recent use of MAOIs, ergots, or SSRIs, CVD, CAD, TIA, HTN, pregnancy *Ergots (ergotamine tartrate/cafergot) not used often, expensive -nasal, oral, rectal, IM, IV, siblingual -CI-recent use of triptans, CVD, CAD, TIA, HTN, pregnancy *Caffeine (Excedrin) *antiemetics Migraine prevention *beta blockers (metoprolol, propranolol, timolol) -takes 2-3 months for full benefit- can decrease frequency and severity by 50% -AE- drowsiness, exercise intolerance, depression -CI-CHF, asthma *anticonvulsants (valproate, topiramate) effective but both have major AE -valproate AE- dizziness, platelet dysfunction, hair loss, hepatotoxic, teratogenic -topiramate AE- cognitive dysfunction, weight loss, renal stones *butterbur- PA free only, otherwise can cause liver damage and severe illness 11. Herbal migraine management Butter bur root. It should be PA free or could result in liver damage. Feverfew (Tanacetum parthenium) - Action: Antiinflammatory effects Uses: migraine prevention Interactions: Anticoagulants, antiplatelet drugs, aspirin