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44 Cards in this Set

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DI: Thiazide Diuretics
Steroids: Salt retention and antagonize thiazides
NSAIDS: Blunt response
Antiarrythmics: Torsades
Probenicid.Lithium: Block effects
Lithium: Decreases lithium clearance
ADE: Thiazide Diuretics
Short term: Increased cholesterol and glucose.

Biochemical: Hypokalemia, hyponatremia, hypomagnesia,
Hypercalcima, increased uric acid.

Rare: Blood dyscrasias, photosensitiviey, pancreatitis,
hyponatremia, sulfa-like reaction.

Other: Impotence, fatigue, HA, rash, vertigo

•Thiazide-like = less or no hypercholesteremia*
ADE: Loop diuretics
Electrolyte: Hypokalemia, hypomagnesia

Hypotension

Renal
DI: Loop Diuretics
AG: Increased ototoxicity

NSAIDs: Decreased effect

Antiarrythmics: Torsades

Probenecid: Blocks loop diuretic effect by interfering with excretion into the urine.

Ototoxicity at high doses
DI: K-sparing diuretics
ACEI/ARBS/NSAIDs/DM: Increased hyperkalemia

Indomethacin: With triamterene, can decrease renal function.

Cimetidine: Increased bioavailability and decreased clearance of triamterene.

Digoxin: Increased levels

P450 inhibitors: Increased levels of eplerenone
Adrenergic Neuron Blockers
Guanadrel, Guanethidine
ADE: Postural hypotension, diarrhea

Reserpine
ADE: Nasal congestions etc.

OTC sympathimimetics: Acute hypertension
TCA/Chlorpromazine: Antagonizes guanethidine
Pheochromocytoma: Absolute contraindication

Avoid in HTN unless refractory to other agents.
Drugs for Hypertensive Emergencies:
Encephalopathy
MI/Angina
CHG
SAH/ICH
Dissectin aortic aneuryism
pheochromocytoma/cocaine OD
Renal insufficiency
Post-OP HTN
Encephalopathy: Labetolol, nicardipine, nitroprusside
MI/Angina: NTG, esmolol
CHF: Nitroprusside, NTG, Enaliprat
SAH/ICH: Nitroprusside
Dissecting Aortic Aneuryism: Trimethaphan, esmolol, nitroprusside
Pheochromocytoma/Cocaine OD: Phentolamine, labetolol
Renal insufficiency: Nitroprusside, CCB, labetolol
Postoperative HTN: Nitroprusside, nicardipine, labetolol
Medications used for HTN urgencies
Captopril: 25mg, repeat in 1-2 hours
Clonidine: 0.1-0.2mg, repeat in 1-2 hours
Labetolol: 100-400mg, repeat in 3-4 hours.
Causes of Inadequate Response to HTN Therapy
1. Psuedoresistance
a. White-coat HTN, cuff size
2. Non-adherence
3. Volume Overload
a. Salt, renal damage, fluid retention, diuretic
4. Drug-related
a. Licorice, CSA, Tacrolimus, OC, caffeine, cocaine, NSAIDs, Steroids, Erythropoeitin, nasal decongestants, OTC sympathomimtics.
5. Associated conditions.
Which medications are compelling and favorable for which conditions?
Most all are BB except:
Diabetes = ACEI, diuretics
HF = same + carvedilol, losartan
Prostatism (BPH) and dyslipidemia = Alpha-blockers
Isolated systolic HTN = Diuretics, CCB
Cyclosporine-induced HTN = CCB
Osteoporosis = Thiazides
Renal insufficiency = ACEI
DI: ACEI/ARBs
NSAIDs: Increaes risk of renal insufficiency and attenuate the beneficial effects of ACEIs.

* Candesartan and valsartan are only ARBs with proven efficacy for HF.

K-supplements or K-sparing diuretics: Use with caution.

Cyclosporine/Tacrolimus: Nephrotoxicity and hyperkalemia

Diuretics: General increase risk of hypotension.
ADE: ACEI/ARBs
Hyperkalemia
Cough
Angioedema
Renal insufficiency
Taste disturbances
Rash
Hypotension
Dizziness
Drugs that exacerbate HF
Antiarrhythmics: Disopyramide, flecainide, propafenone
BB
CCB: Verapamil and diltiazem
Itraconazole and terbinafine

Cardiotoxic: Doxo/daunorubicin, cyclophosphamide, EtOH

Na/water: NSAIDs, COX2, glucocorticoids, rosi/pioglitazone
Medications for HTN with unfoavorable conditions
Liver = labetolol, methyldopa
Renal insufficiency = K-sparin diuretics
renovascular = ACEI/ARBs
Gout = diuretics
BB in HF
Metoprolol, bisoprolol, coreg

Indication: Stable HF due to LV systolic dysfunction.

In combo w/ ACEI and diuretics

CI: Asthma, COPD, symptomatic bradycardia or heart block and mask hypoglycemia

Bisoprolol renally eliminated. Dose adjust.
DI: BB
Amiodarone/ nonDHP CCB/ opthalmic BB: bradycardia, heart block, hypotension

P450 inhibitors: hepatic metabolism of metoprolol and coreg.
ADE: Digoxin
CV: Arrythmias, bradycardia, heart block.

GI: Anorexia, abdominal pain, N&V

Neurological: Visual, disorientation, confusion, fatigue

Toxicity is associated with serum levels > 2 ng/mL.
nl = 0.5 - 1
Drugs that increase digoxin levels
Quinidine/verapamil/amiodarone: Decrease digoxin 50%

Propafenone
Flecainide
Macrolide ABX
Itraconazole/ketoconazole
K-sparing diuretics: Increases risk of toxicity
Drugs that decrease digoxin levels
Antacids
Bile acid sequestrants
Kaolin-pectin
Metoclopramide
Bidil
Hydralazine/isosorbide dinitrate

For patients who cannot take ACEI or ARBs b/c of drug intolerance, hypotension or renal insufficiency.

Can be added to therapy if refractory to ACEI/BB
Treatment of advanced/decompensated HF
Warm/dry: No specific therapy

Warm/wet: IV loop, thiazide (metolazone) as supplement. IV vasodilators helpful.

Cold/dry: Gradual BB

Cold/wet: Improve CO
Vasodilators
Nitroprusside(Nipride) 0.1-.25 mg/kg/min
•Cyanide and thicyanate toxicity, MI
•Arterial/venous dilatro

Nitroglycerine(Nitrobid/stat)5-10 mcg/min
•Venous dilator, arterial at high doses

Nesiratide (Natrecor) 2mcg/kg bolus
•BNP peptide increases diuresis and dilates A/V

Hypotension, HA, tachy
Inotropes
Dopamine(Inotropin) - Dose dependent elevations
•Use in systemic hypotension, cardiogenic shock

Dobutamine (Dobutrex) - B1/2, weak A1.
Increases CO & vasodilates
•Does not increase BP in hypotensive pts.

Milrinone (Primacor) Phosphdiesterase inhibitor
•Patients unresponsive to dopamine/dobutamine
•Useful in patients receiving BB
•Adjust in renal insufficiency
•Preferred over milrinone b/c less thrombocytopenia.
Nondrug therapy for HF
Intra-aortic balloon pump
Left ventricular assist devices
Biventricular pacing
Implantable cardioverter-defibrillator
Cardiac transplantation
CI: Hormone replacement therapy
Abnormal, undiagnosed genital bleeding
Breast cancer
DVT/PE
Estrogen-dependent neoplasia
Pregnancy
Stroke/MI in last year
Thromboemolic disorder
Thrombophlebitis
How does Progestin protect the uterus?
Decrease nuclear estradiol receptor concentrations
Suppresses DNA synthesis
Decrease estrogen bioavailability

SE: Depression, HA, irritability
Which disease states are exacerbated by estrogen?
Depression
DM
Hypertriglceridemia
Hepatic adenoma
Thyroid disorder (may require supplement)
CVD
Impaired hepatic function
Medications that decrease effects of estrogen
P450 inducers (3A4): Barbituates, carbamazepine, rifampin, St. John’s wort
Hydantoins
Topiramate
Medications that increase effects of drug used with estrogen
Corticosteroids
TCA (increase toxicity of TCA)
Medications that increase effects of estrogen
P450 inhibitors (3A4): Azole antifungals, macrolide ABX, ritonavir etc.
Grapefruit juice
CI: Progestin
Aminoglutethimide: Increased metabolism of medroxyprogesterone
Rifampin: Increased metabolism of norethindrone
Androgen
Estrogen precursor

CI: Androgenic alopecia, hirsutism, moderate-severe acne

ADE: Fluid retention, lipid profile, virilization
What patients should not used combinded oral contraceptives?
Breast CA
DVT/PE
CVA/CAD/IHD
DM
HA
HTN
Lactation (<6 wks postpartum)
Liver disease
Pregnancy
Surgury with prolonged immobilization
Smoker (> 20/day or > 35yo)
HD + pulmonary HTN, atrial fibrillation, hx of acute bacterial endocarditis
Medications the decrease the effectiveness of OCs
ABX
Anticonvulsasnts: Barbituates, carbamazepine, felbamate, phenytoin, topiramate
NNRTI, protease inhibitors
Pioglitazone
Rifampin
Theophylline
Medications that increase the effectiveness of OCs
Atorvastatin
Vitamin C
Cyp 3A4 inhibitors
Drugs that have decreased effect with concurrent use of OCs
Anticoagulants
Lorazepam
Oxazepam
Temazapam
Hypoglycemics
Methyldopa
Phenytoin
Drugs that have increased effect with concurrent use of OCs
TCAs
BZDs BB
Theophylline
Cortisone: Increased risk of toxicity
Risk factors for osteoporosis
Advanced age
Amenorrhea
Anorexia
Smoking
Current low bone mass
Estrogen deficiency
Ethnicity (caucasion/asian)
Excessive EtOH
Family hx
Female
Fracture > 50yo
Long-term corticosteroids/ anticonvulsants
Low life-time calcium intake
Low testosterone levels in men
Thin/small frame
Medical conditions associated with increased risk of osteoporosis
AIDS
Cushing’s
Eating disorder
Hyperparathyroidism
IBD
DM (Insulin dependent)
Lymphoma/leukemia
Malabsorptio
Rheumatoid arthritis
Drugs Associated with Increased Risk of Osteoporosis
Anticonvulsants
Cytotoxic drugs
Glucocorticoids
Immunosuppressants
Lithium
Long-term heparin
Progesterone
Supraphysiologic thyorxine
Tamoxifen
Medical conditions associated with increased risk of osteoporosis
AIDS
Cushing’s
Eating disorder
Hyperparathyroidism
IBD
DM (Insulin dependent)
Lymphoma/leukemia
Malabsorption
Rheumatoid arthritis
What are the recommendations for initial evaluation of osteoporosis?
Screen all women > 65
< 65 with family history
Women with a fracture unrelated to trauma
What is the least androgenic progestin?
Most androgenic?
Least = Desogestrel

Most = Levonorgestrel
Progestin only
Ovrette
Ortho Micronor
Errin
Nor-QD
Camila