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242 Cards in this Set
- Front
- Back
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What is the formula for determining blood pressure?
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BP = CO (cardiac output) x SVR (systemic vascular resistance)
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What are the four systems that regulate blood pressure?
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Sympathetic nervous system, Renin-Angiotensin-Aldosterone system, plasma volume, and others
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Why is it important to regulate BP?
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Essential hypertension is part of the aging process
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What occurs at the sympathetic synapses during an action potential?
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Preganglionic neurons release acetylcholine that binds to nicotinic receptors on postganglionic neurons. These postganglionic neurons release norepinephrine which binds to adrenergic receptors on the organ causing a sympathetic response
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What are the effects of a sympathetic response?
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Pupil dilation, sweating, increased HR, occs. vomiting, increased BP, and bronchodilation
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What is the baroreceptor reflex?
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Specialized neurons called baroreceptors are found in the aortic arch and carotid sinus and are sensitive to changes in BP. An elevated BP when sensed by these receptors causes a reflexive drop in BP whereas a low BP sensed by these receptors causes a reflexive increase in BP
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What nerve regulates the baroreceptors in the carotid arch?
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Glossopharyngeal nerve.
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What nerve regulates the baroreceptors in the aortic arch?
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Vagus nerve
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What neurotransmitters control SVR?
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Epinephrine, norepinephrine both increase SVR by binding to adrenergic receptors, particularly alpha.
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What factors affect HR?
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Beta receptor activation, Na/K/Ca channels, and vagus nere
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What types of drugs affect the SNS and BP?
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Alpha 2 agonists, Alpha 1 blockers, and beta blockers
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What are sympatholytics?
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Drugs that antagonize the effects of epinephrine
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What does stimulation of alpha 1 cause?
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Vasoconstriction w/ reflex bradycardia, bladder sphincter contraction, and decreased lipolysis
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What are some alpha 1 blockers?
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Prazosin (Minipress); Terazosin (Hytrin); and Doxazosin (Cardura)
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How do alpha 1 blockers work?
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They decrease BP, decrease bladder sphincter constriction, and increase lipolysis
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What are the major side effects of alpha 1 blockers?
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Reflex tachycardia and orthostatic hypotension,
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What is Flomax?
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A urologic agent that blocks alpha 1 receptors but is not indicated for the treatment of hypertension
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Why shouldn't alpha 1 blockers be used for monotherapy?
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They have an increased risk of heart failure and stroke because of increased lipolysis.
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What does stimulation of alpha 2 cause?
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A decrease in the pre-synaptic release of norepinephrine so a decreased HR and BP
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What are some alpha 2 agonists?
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Clonidine (Catapres)
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How does Clonidine work?
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It activates alpha 2 receptors which decrease sympathetic outflow. It also inhibits pain neurotransmission in the spinal cord
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What is clonidine used for?
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HTN, cancer pain unresponsive to opioids, and opioid withdrawal.
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What happens if you abruptly withdrawal clonidine?
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Rebound hypertension
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What are the two types of beta blockers?
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Selective and nonselective
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What is the benefit of giving a selective beta blocker?
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You avoid the respiratory bronchoconstriction
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What are some non-selective beta blockers?
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Propanolo (Inderal) and Timolol (Blocadren)
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How do the non-selective beta blockers work?
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If you block B1, you have decreased HR, contractility, renin, and lipolysis. If you block B2, you have bronchoconstriction, vasoconstriction, muscle relaxation, and decreased glycogenolysis and gluconeogenesis.
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What is propanolol used for?
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It is an antihypertensive that can be used in angina, post MI, cardiomyopathy, benign tumor, migraine prophylaxis, and thyrotoxicosis
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What are some selective beta 1 blockers?
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Metoprolol (Lopressor, Toprol XL) and Atenolol (Tenormin)
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How do selective beta 1 blockers work?
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They selectively block B1 receptors causing decreased HR, contractility, BP, renin, and lipolysis
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Do you get bronchospasm with a selective or nonselective Beta blocker?
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Nonselective
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Do you get hypoglycemia with nonselective or selective beta blockers?
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Nonselective
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Do you get increased triglycerides with selective or nonselective?
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Both
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What are some metabolic inhibitors?
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Methyldopa, Reserpine
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How does Methyldopa work?
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It is an alpha 2 agonist so it decreases the synaptic release of norepinephrine
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What population is methyldopa used in?
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Pregnant women
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Why isn't Reserpine well tolerated?
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Causes depression
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What is the renin-angiotensin-aldosterone system (RAAS)?
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A hormone system that helps regulate long-term blood pressure and extracellular volume in the body
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What two occurrences activate the system?
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A loss in blood volume or a drop in blood pressure
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What happens if perfusion of the juxtaglomerular apparatus in the kidneys decreases?
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Juxtaglomerular cells release the enzyme renin
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What does renin do?
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It breaks down angiotensinogen and converts it to angiotensin I
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What happens to angiotensin I after it is converted by renin?
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It is converted to angiotensin II by angiotensin converting enzyme
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Where is ACE found?
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Lung capillaries
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What are the effects of Angiotensin II?
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Potent vasoconstrictor, releases aldosterone from the adrenal cortex which acts on the kidney tubules and causes them to reabsorb more sodium and water from the urine. Potassium is retained and secreted into the tubule. It also causes the release of ADH or vasopressin from pituitary gland.
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What factors stimulate the release of renin?
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Upright position, hypotension, low-salt diet, hemorrhage, dehydration
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How do ACE inhibitors work?
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If you block angiotensin converting enzyme, angiotensin I cannot be converted to angiotensin II.
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What are the effects of ACE inhibitors?
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Decreased vasoconstriction and increased diuresis because there is no release of aldosterone.
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What is an example of a sulfhydral containing ACE inhibitor?
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Captopril (Capoten)
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Enalapril (Vasotec) and Lisinopril (Zestril, Prinivil) belong to which group?
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Dicarboxyl
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What causes the cough and angioedema in ACE inhibitors?
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The inhibition of bradykinin degradation
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What are the adverse effects of ACE inhibitors?
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HA, dizziness, hypotension, ARF in renal artery stenosis or volume depletion, hyperkalemia, cough, rash, angioedema, teratogenic, and bone marrow suppression
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What causes the ARF in volume depletion or renal artery stenosis when you give an ACE inhibitor?
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Vasodilation causes decreased perfusion to area that is used to being vasoconstricted.
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What are the proven benefits of ACE inhibitors?
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Improvement in HF, particularly LV systolic dysfunction and diabetic nephropathy by decreasing proteinuria
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How do Angiotensin receptor blockers work?
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They specifically block receptors for angiotensin II to decrease vasoconstriction and decrease the release of aldosterone
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What are the two angiotensin receptor blockers to know?
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Losartan (Cozaar) and Valsartan (Diovan)
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What are renin inhibitors?
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They inhibit juxtaglomerular cells in kidneys from releasing renin
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What types of diuretics are most potent?
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Osmotic. They work in the proximal tubule
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How do loop diuretics work?
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They inhibit sodium and chloride reabsorption in the Loop of Henle
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What are the adverse effects of loop diuretics?
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Decreased BP, volume depletion, dehydration, hypokalemia, sulfonamide allergy, ototoxicity, hyperuricemia, hyperglycemia, and hypochloremic
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What are the two loop diuretics to know?
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Furosemide (Lasix) and Bumetanide (Bumex)
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How do thiazide diuretics work?
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They inhibit sodium and chloride reabsorption in distal tubule to promote excretion of Na, K, and Cl
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What is the daily dose range of hydrochlorothiazide (HCTZ)?
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12.5mg to 50mg once daily
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What happens beyond doses of 25mg of HCTZ?
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Clinical benefits plateau and you get less benefits but more adverse effects
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How do potassium sparing diuretics work?
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They block reabsorption of sodium in distal tubule and collecting duct
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What kind of drug is spironolactone (Aldactone)?
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Potassium sparing diuretic
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What other mechanisms does Aldactone have?
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It blocks aldosterone receptors in collecting duct which increases sodium excretion and decreases potassium excretion
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What are the adverse effects of spironolactone?
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Acne, hirsutism, and gynecomastia
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How do direct vasodilators work?
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They relax smooth muscle cells around venous and arteriole blood vessels.
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What are the direct vasodilators?
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Nitroprusside (Nitropress), Minoxidil (Loniten), and Hydralazine (Apresoline)
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How does Hydralazine work as a direct vasodilator?
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It alters calcium metabolism within the cell
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How does Minoxidil work as a vasodilator?
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It opens potassium channels in vascular smooth muscle causing hyperpolarization with resultant muscle relaxation and vasodilation
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What is the most common side effect of Apresoline and Loniten?
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Reflex tachycardia
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What is coronary "steal"?
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If you vasodilate someone with a blockage, blood will go to areas that are vasodilated and be shunted away from an area that is already compromised
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What direct vasodilator cause lupus-like syndrome?
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Hydralazine
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What direct vasodilator causes hirsutism/hypertrichosis?
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Minoxidil
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What are the adverse effects of Nitroprusside?
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Hypotension and toxic accumulation of cyanide
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What can cyanide do to the body?
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Lactic acidosis
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How do Calcium channel blockers work?
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Block entry of calcium into myocytes and other vascular cells to alter contraction
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What are the three groups of calcium channel blockers?
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Dyhydropyridine, benzothiapine, and phenylalkylamine
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What two calcium channel blockers have similar side effects?
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Diliazem and Verapamil
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Which group of calcium channel blockers promote the most vasodilation?
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Dyhydropyridine
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Which group has the least suppression of contractility and AV/SA nodes?
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Dihydropyradine
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What are the two side effects that are common to Diltizem and Verapamil?
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Constipation and gingival hyperplasia
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What juice should be avoided when taking a calcium channel blocker?
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Grapefruit juice
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What are the general side effects of calcium channel blockers?
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Headache, dizziness, hypotension, peripheral edema
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What fraction of diabetics are poorly controlled?
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2/3
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What is an A1c?
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A measure of the average blood sugar over 2-3 months
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What is the ideal A1c?
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Less than 7%
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What are the three factors that cause hyperglycemia in Type II diabetes?
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Impaired insulin secretion from the pancreas, peripheral insulin resistance, and increased hepatic glucose production
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Which insulin can be given IV?
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Regular and fast-acting
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What is the mechanism of action of insulin?
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It replaces endogenous insulin in diabetics
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What factors can alter the absorption of insulin?
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Injection site, exercise, accuracy of dose adjustment, depth of injection, and environmental temperature
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What is short-acting insulin called and when is it given?
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Regular insulin or Humalin-R and it is given in emergent situations
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What is an ultra short-acting insulin?
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Lispro (Humalog)
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What is an intermediate-acting insulin?
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NPH (Humalin-N)
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What is intermediate insulin used for?
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Used for control between meals
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What is a long-acting insulin?
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Glargine (Lantus)
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What is the onset, peak, and duration of regular insulin?
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30-60", 2-3 hours, 4-6 hours
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What is the onset, peak, and duration of Lispro?
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Less than 30", 30-90", and less than 5 hours
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What is the onset, peak, and duration of NPH?
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2-4 hours, 4-10 hours, and 14-18 hours
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What is the onset, peak, and duration of Lantus?
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2-6 hours, Minimal, and 24 hours
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What did the Diabetes Control and Complications Trial (DCCT) show?
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People with DM underwent intensive vs. standard care. Initially, no reduction in macrovascular events. A follow-up study did show that though
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What are the 2nd generation sulfonylureas?
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Glyburide (DiaBeta and Micronase)
Glipizide (Glucotrol, Glucotrol XL) Glimepiride (Amaryl) |
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What is the clinical use of Glyburide?
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Type II DM
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What is the mechanism of action of Glyburide (DiaBeta and Micronase)?
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It causes the influx of Ca2+ and the release of insulin. You must have a functioning pancreas.
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What are the side effects of sulfonylureas?
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Allergic rx, photosensitivity, nausea, diarrhea
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What study led to a major bias in relation to sulfonylurea use, particularly Tolbutamide?
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University Group Diabetes Program
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What factors determine whether or not a sulfonylurea can be used?
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Age, hepatic function, and renal function
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If a patient is a diabetic and allergic to sulfa, what drugs can you give?
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Non-sulfonylurea secretatogues
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How do non-sulfonylurea secretatogues work?
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They promote the release of insulin from the pancreas w/o sulfa. They also reduce postprandial blood glucose and glycosylated hemoglobin concentrations.
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Besides allergies, why else is Prandin ideal?
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It is ideal for patients who are susceptible to hypoglycemia because it only works while they are eating.
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Where is alpha-glucosidase and what does it do?
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It is found in the GI tract and it is responsible for breaking down complex sugars into simple sugars for bodily use
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What happens if you inhibit alpha-glucosidase?
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You slow the absorption of sugar
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What are the side effects of an alpha-glucosidase inhibitor?
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Flatulence and diarrhea
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What are the two alpha-glucosidase inhibitors?
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Acarbose (Precose) and Miglitol (Glyset)
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Alpha-glucosidase inhibitors cause hypoglycemia and weight gain. True or false?
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False
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What is the major biguanide for the management of DM?
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Metformin (Glucophage)
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What is the mechanism of action of Metformin (Glucophage)?
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It increases the number and affinity of insulin receptors in peripheral tissues, decreases hepatic glucose production, decreases GI glucose absorption, and increases glucose uptake and utilization in skeletal muscle and adipose tissue
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What toxicity can occur with Metformin if renal function is impaired?
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Lactic acidosis
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What agent can interact with Metformin and cause acute lactic acidosis?
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Contrast agent
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What study showed a significant reduction in macrovascular complications with the use of Metformin?
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United Kingdom Prospective Diabetes Study
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What is syndrome X?
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Impaired glucose tolerance, increased lipid profile (increased total cholesterol, increased LDL, increased triglycerides, decreased HDL)
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What patients should avoid Metformin?
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CHF, COPD, Liver disease, ETOH
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What are the symptoms of lactic acidosis?
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Malaise, myalgias, respiratory distress, somnolence, hypothermia, hypotension, bradyarrhythmias
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How is lactic acid produced?
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Anaerobic metabolism of glucose
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How do thiazolidinediones work?
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They improve the insulin receptors sensitivity to insulin
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What are the two thiazolidinediones available?
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Rosiglitazone (Avandia) and Pioglitazone (Actos)
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What are the adverse effects of thiazolidinediones?
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Extensive hepatic metabolism and fluid retention
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Thiazolidinediones are hard to use in diabetic patients with comorbidities. True or false?
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True
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What are the incretins?
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The family of hormones in the GI tract that tell the pancreas what to do in response to nutrients
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What do incretins do?
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They slow GI transit, suppress glucagon release from the pancreas, and promote the release of insulin
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What are the incretin modulators?
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Exenatide (Byetta) and Pramlitide (Symlin)
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Which modulator is a Glp-1 analog for Type II DM?
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Exenatide (Byetta)
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What do parietal cells do?
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They produce acid
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Where are parietal cells found?
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In the body and fundus of the stomach
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What four products influence the action of the H+/K+ ATPase pump?
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Acetylcholine, histamine, gastrin, and prostaglandins
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In what state is the pH the lowest in the GI tract?
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Preprandial or fasting state
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In what state is acid production the highest?
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Postprandial state
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What protects the cell from acid in the stomach?
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A mucosal barrier made up of bicarbonate ions, prostaglandins, and tight junctions
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How does gastrin work in the parietal cell?
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It stimulates cholecystokinin receptors
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How does acetylcholine work in the parietal cell?
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It stimulates muscarinic receptors and enterochromaffin like cells (ECL) which release histamine to H2 receptors.
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How does prostaglandin work in the parietal cells?
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It negatively stimulates EP3 receptors
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What are the four components of antacids?
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Aluminum hydroxide, magnesium hydroxide, calcium carbonate, and sodium bicarbonate
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What is the mechanism of action for antacids?
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They locally neutralize acid
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What components of antacids are constipating?
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Aluminum and calcium
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What is the risk of administering antacids to someone with renal insufficiency?
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Whatever is absorbed can accumulate and cause CNS toxicity
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What are the major drug interactions of antacids?
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Kinetic because they affect absorption
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How do you overcome the absorption problems associated with antacids?
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Change the administration times
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What happens in milk-alkali syndrome?
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Hypercalcemia, decreased PTH, phosphate retention, calcium precipitation in kidney
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What are the three cytoprotectants?
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Sucralfate (Carafate), Misoprostol (Cytotec), Bismuth compounds
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How do cytoprotectants work?
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They provide a physical barrier
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What class of GI drugs have no effect on pH?
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Cytoprotectants
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What is the most common adverse effect of Carafate and why?
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Constipation because of aluminum
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What group is at risk when given Carafate?
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Those with renal insufficiency because of accumulation of aluminum leading to CNS toxicity
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How does misoprostol work?
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It is a prostaglandin E1 analog that stimulates the secretion of mucin and bicarbonate. It increases mucosal blood flow and suppresses acid production in parietal cells by binding to EP3 receptor
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What drug class in GI causes darkening of tongue and stool and should be avoided in those with an aspirin allergy?
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Bismuth compounds
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What is the mechanism of H2 receptor antagonists?
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They compete with histamine for binding on H2 receptors on parietal cells
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How is Tagamet different from other H2 receptor antagonists?
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It actually blocks histamine so it can be used for allergic reactions
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What product is released with Tagamet?
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Prolactin which can cause sexual dysfunction and gynomastia
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What are the two types of drug interactions seen in H2 receptor antagonists?
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Absorption-drugs requiring an acidic environment; Hepatic-Inhibitor of CYP-450
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Omeprazole, lanzoprazole, rabeprazole, pantoprazole, and esmoprazole belong to which GI class?
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Proton pump inhibitors
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How do proton pump inhibitors work and how long do they last?
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They irreversibly shut down ATPase pumps and they last 60 hours.
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What is a prodrug?
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A drug that requires activation in an acidic environment
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What is the absorption problem with proton drug inhibitors?
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The parent compound is unstable in acid. You need an enteric coating.
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What is PPI withdrawal syndrome?
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Proton pumps become hypersensitive, so they oversecrete acid.
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Why does changing the pH set you up for infection?
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You are allowing the growth of new bacteria
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What cholinergic agent improves gut motility?
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Bethenechol
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What are the serotonin receptor modulators?
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Cisapride and Metoclopramide
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What is the mechanism of Cisapride and Metoclopramide?
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Agonist activity at 5-HT4 receptors
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Why was Cisapride taken off the market?
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QT prolongation
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What is a motilin-like antimicrobial?
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Erthromycin
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How do you treat H. pylori?
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Antibiotics and suppress acidic environment
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How do you diagnose H. pylori?
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Serology antibody or direct endoscopy
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How do you test for eradication of H. pylori?
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Breath test 1 month after completion of antibiotics because urease is converted to carbon dioxide
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What are the 3 groupings of bacteria?
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Aerobic, anaerobic, and others
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What are the two classifications of aerobes and what bacteria are included?
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Gram Positive/Negative; cocci and bacilli
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What are the two classifications of anaerobes?
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Gram Positive/Negative
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What bacteria is associated with TB?
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Mycobacterium
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What classifies an atypical bacteria?
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They lack a cell wall
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What are two examples of atypical bacteria?
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Mycoplasma, chlymadia
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What bacteria is associated with MRSA and what is its classification?
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Staph aureus, gram + cocci
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What gram negative cocci is responsible for bacterial meningitis?
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Neisseria meningitidis
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What gram negative cocci is responsible for community acquired pna?
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Moraxella catarrhalis
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What drug therapy do the other bacteria respond well to?
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Tetracyclines
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What are the adverse reactions of antibiotics?
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Allergies (Acute and delayed); GI upset
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Can you give a antibiotic within the same family to a patient with a delayed allergic reaction?
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Yes
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What is the most common biologic response to antibiotics?
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Thrush
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What are the 4 groups of beta-lactams?
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Penicillins, Cephalosporins, Carbapenems, and Monobactams
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How would you dose the beta-lactams for renal doses?
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Decrease the frequency or change the dose
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What group of beta-lactams have the broadest coverage?
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Carbapenems
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What group of beta lactams have the narrowest spectrum of coverage?
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Monobactams
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What are the sources of beta-lactams?
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Molds/fungi, bacteria, synthetic/semisynthetic
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What is the mechanism of action of beta-lactams?
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They inhibit bacterial cell wall synthesis
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What was the first antibiotic to be used IV and what was it for?
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Penicillin G for syphilus
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What drug remains the drug of choice for strep throat?
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Penicillin V
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If you have an infection that is resistant to methicillin, nafcillin, oxacillin, what is it called?
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MRSA
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What is the treatment for MRSA?
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Vancomycin
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What drugs do you give for MRSA in place of Vancomycin?
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Cubicin, Daptomycin, Linezolid
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What generation of cephalosporins is Ancef and Keflex?
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1st generation
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What generation is Cefuroxime?
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2nd generation
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What generation of cephalosporins are Ceftriaxone, Ceftazidime, and Cefepime?
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3rd generation
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What bacteria does Ceftriaxone not cover?
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Pseudomonas
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What two cephalosporins do cover Pseudomonas
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Ceftazidime and Cefepime
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What serious side effect is associated with renal toxicity of Meropenem?
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Seizures
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What beta-lactam is the safest antibiotic to give if there is an allergy to PCN?
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Aztreonam
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What classification do erythromycin, clarithromycin, azithromycin, and dithromycin belong to?
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Macrolides
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What is the mechanism of action of macrolide antibiotics?
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Protein synthesis inhibitor that binds to 50s ribosome
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What are the common side effects associated with macrolides?
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GI upset, diarrhea
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What two macrolide antibiotics are potent inhibitors of CYP-450?
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Erythromycin and clarithromycin
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What macrolide is prescribed frequently because of its avoidance of inhibiting CYP-450?
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Azithromycin
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What are ketolides?
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Macrolide derivatives
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When do we use ketolides?
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We reserve their use for immunocompromised patients with infections unresponsive to treatment
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What is the controversy associated with ketolide use?
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Liver toxicity
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Why are ketolides more effective than macrolides?
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They have two binding sites vs. one
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What are the adverse effects of tetracyclines?
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GI (N/V, cramps), Deposition in calcified tissues (teeth discoloration), Vestibular (dizziness, nausea, vertigo), Photosensitivity, Liver (hepatotoxicity), Renal (Doxycycline is the only one that does not need renal adjustment)
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What group of antibiotics does not require dose adjustment for renal insufficiency?
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Macrolides
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What is the mechanism of action of fluoroquinolones?
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They inhibit bacterial DNA topoisomerase type II to prevent DNA replication
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Name 3 fluoroquinolones?
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Ciprofloxicin, Levofloxacin, Moxifloxacin
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Adverse side effects of fluoroquinolones are similar to tetracyclines. What other side effects are seen?
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QT prolongation, hypo/hyperglycemia, cartilage damage
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Fluoroquinolones have major drug interactions with methylxanthines, warfarin, and cimetidine. True or False?
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True
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What is Flagyl used for?
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C. Difficile
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What antibiotic has major drug interactions with ETOH?
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Flagyl
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What drug can cause ulcerations and require an upright position for 15-20"?
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Doxycycline
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What is an aminoglycoside and how does it work?
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Gentamicin. It is a protein synthesis inhibitor on 30s ribosome
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What toxicities occur with aminoglycosides?
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Ototoxicity and renal toxicity
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What is the mechanism of action for Vancomycin?
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It is a cell wall synthesis inhibitor
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What is the mechanism of action of Rifampin?
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Inhibition of DNA-dependent RNA polymerase of mycobacteria
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What kind of antiemetic do we give for Cisplatin?
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NK1 inhibitor
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What drug will add to the efficacy of antiemetics?
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Decadron
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At what ANC do we see an increase in infection rates?
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1000
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How does one calculate an ANC?
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WBC x (%bands + %neutrophils)/100
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What is acrolein?
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A metabolite of cytoxan that causes hemorrhagic cystitis
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What two drugs are associated with hemorrhagic cystitis?
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Cyclophosphamide and Ifosphamide
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What drug binds to acrolein to prevent hemorrhagic cystitis?
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Mesna
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What chemotherapy is the worst offender for acute/delayed N/V and nephrotoxicity?
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Cisplatin
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What cousin of Cisplatin can cause neurotoxicity w/sensation of not breathing and magnesium wasting?
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Oxaliplatin
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Why do you get prolonged toxicity of MTX if effusions or 3rd spacing is present?
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MTX is hydrophilic and when the water is gone, MTX redistributes
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What drug is taken to rescue normal cells from dihydrofolate reductase during MTX use
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Leucovorin rescue
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What drug potentiates the activity of 5FU?
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Leuocovorin rescue
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What toxicities are associated with high-dose Ara-C?
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Cerebellar toxicity and conjunctivitis
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What is the major side effect of anthracyclines?
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Cardiotoxicity
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What is the major side effect of Irinotecan and what is used to treat it?
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Diarrhea and it is treated with Loperamide ATC until resolved
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