Naplex - Drug Interactions And Ade

Front 1

DI: Thiazide Diuretics

Back 1

Steroids: Salt retention and antagonize thiazides
NSAIDS: Blunt response
Antiarrythmics: Torsades
Probenicid.Lithium: Block effects
Lithium: Decreases lithium clearance

Front 2

ADE: Thiazide Diuretics

Back 2

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*

Front 3

ADE: Loop diuretics

Back 3

Electrolyte: Hypokalemia, hypomagnesia

Hypotension

Renal

Front 4

DI: Loop Diuretics

Back 4

AG: Increased ototoxicity

NSAIDs: Decreased effect

Antiarrythmics: Torsades

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

Ototoxicity at high doses

Front 5

DI: K-sparing diuretics

Back 5

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

Front 6

Adrenergic Neuron Blockers

Back 6

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.

Front 7

Drugs for Hypertensive Emergencies:
Encephalopathy
MI/Angina
CHG
SAH/ICH
Dissectin aortic aneuryism
pheochromocytoma/cocaine OD
Renal insufficiency
Post-OP HTN

Back 7

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

Front 8

Medications used for HTN urgencies

Back 8

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.

Front 9

Causes of Inadequate Response to HTN Therapy

Back 9

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.

Front 10

Which medications are compelling and favorable for which conditions?

Back 10

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

Front 11

DI: ACEI/ARBs

Back 11

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.

Front 12

ADE: ACEI/ARBs

Back 12

Hyperkalemia
Cough
Angioedema
Renal insufficiency
Taste disturbances
Rash
Hypotension
Dizziness

Front 13

Drugs that exacerbate HF

Back 13

Antiarrhythmics: Disopyramide, flecainide, propafenone
BB
CCB: Verapamil and diltiazem
Itraconazole and terbinafine

Cardiotoxic: Doxo/daunorubicin, cyclophosphamide, EtOH

Na/water: NSAIDs, COX2, glucocorticoids, rosi/pioglitazone

Front 14

Medications for HTN with unfoavorable conditions

Back 14

Liver = labetolol, methyldopa
Renal insufficiency = K-sparin diuretics
renovascular = ACEI/ARBs
Gout = diuretics

Front 15

BB in HF

Back 15

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.

Front 16

DI: BB

Back 16

Amiodarone/ nonDHP CCB/ opthalmic BB: bradycardia, heart block, hypotension

P450 inhibitors: hepatic metabolism of metoprolol and coreg.

Front 17

ADE: Digoxin

Back 17

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

Front 18

Drugs that increase digoxin levels

Back 18

Quinidine/verapamil/amiodarone: Decrease digoxin 50%

Propafenone
Flecainide
Macrolide ABX
Itraconazole/ketoconazole
K-sparing diuretics: Increases risk of toxicity

Front 19

Drugs that decrease digoxin levels

Back 19

Antacids
Bile acid sequestrants
Kaolin-pectin
Metoclopramide

Front 20

Bidil

Back 20

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

Front 21

Treatment of advanced/decompensated HF

Back 21

Warm/dry: No specific therapy

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

Cold/dry: Gradual BB

Cold/wet: Improve CO

Front 22

Vasodilators

Back 22

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

Front 23

Inotropes

Back 23

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.

Front 24

Nondrug therapy for HF

Back 24

Intra-aortic balloon pump
Left ventricular assist devices
Biventricular pacing
Implantable cardioverter-defibrillator
Cardiac transplantation

Front 25

CI: Hormone replacement therapy

Back 25

Abnormal, undiagnosed genital bleeding
Breast cancer
DVT/PE
Estrogen-dependent neoplasia
Pregnancy
Stroke/MI in last year
Thromboemolic disorder
Thrombophlebitis

Front 26

How does Progestin protect the uterus?

Back 26

Decrease nuclear estradiol receptor concentrations
Suppresses DNA synthesis
Decrease estrogen bioavailability

SE: Depression, HA, irritability

Front 27

Which disease states are exacerbated by estrogen?

Back 27

Depression
DM
Hypertriglceridemia
Hepatic adenoma
Thyroid disorder (may require supplement)
CVD
Impaired hepatic function

Front 28

Medications that decrease effects of estrogen

Back 28

P450 inducers (3A4): Barbituates, carbamazepine, rifampin, St. John’s wort
Hydantoins
Topiramate

Front 29

Medications that increase effects of drug used with estrogen

Back 29

Corticosteroids
TCA (increase toxicity of TCA)

Front 30

Medications that increase effects of estrogen

Back 30

P450 inhibitors (3A4): Azole antifungals, macrolide ABX, ritonavir etc.
Grapefruit juice

Front 31

CI: Progestin

Back 31

Aminoglutethimide: Increased metabolism of medroxyprogesterone
Rifampin: Increased metabolism of norethindrone

Front 32

Androgen

Back 32

Estrogen precursor

CI: Androgenic alopecia, hirsutism, moderate-severe acne

ADE: Fluid retention, lipid profile, virilization

Front 33

What patients should not used combinded oral contraceptives?

Back 33

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

Front 34

Medications the decrease the effectiveness of OCs

Back 34

ABX
Anticonvulsasnts: Barbituates, carbamazepine, felbamate, phenytoin, topiramate
NNRTI, protease inhibitors
Pioglitazone
Rifampin
Theophylline

Front 35

Medications that increase the effectiveness of OCs

Back 35

Atorvastatin
Vitamin C
Cyp 3A4 inhibitors

Front 36

Drugs that have decreased effect with concurrent use of OCs

Back 36

Anticoagulants
Lorazepam
Oxazepam
Temazapam
Hypoglycemics
Methyldopa
Phenytoin

Front 37

Drugs that have increased effect with concurrent use of OCs

Back 37

TCAs
BZDs BB
Theophylline
Cortisone: Increased risk of toxicity

Front 38

Risk factors for osteoporosis

Back 38

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

Front 39

Medical conditions associated with increased risk of osteoporosis

Back 39

AIDS
Cushing’s
Eating disorder
Hyperparathyroidism
IBD
DM (Insulin dependent)
Lymphoma/leukemia
Malabsorptio
Rheumatoid arthritis

Front 40

Drugs Associated with Increased Risk of Osteoporosis

Back 40

Anticonvulsants
Cytotoxic drugs
Glucocorticoids
Immunosuppressants
Lithium
Long-term heparin
Progesterone
Supraphysiologic thyorxine
Tamoxifen

Front 41

Medical conditions associated with increased risk of osteoporosis

Back 41

AIDS
Cushing’s
Eating disorder
Hyperparathyroidism
IBD
DM (Insulin dependent)
Lymphoma/leukemia
Malabsorption
Rheumatoid arthritis

Front 42

What are the recommendations for initial evaluation of osteoporosis?

Back 42

Screen all women > 65
< 65 with family history
Women with a fracture unrelated to trauma

Front 43

What is the least androgenic progestin?
Most androgenic?

Back 43

Least = Desogestrel

Most = Levonorgestrel

Front 44

Progestin only

Back 44

Ovrette
Ortho Micronor
Errin
Nor-QD
Camila