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72 Cards in this Set

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Diuretic MOA
Acutely cause diuresis, chronic use associated w/ decreased peripheral vascular resistance
Thiazide and thiazide-like diuretics pros
*decreased morbidity and mortaility, effective, low-cost

*may be of benefit in salt-sensitive patients, including African-Americans
Thiazide and thiazide-like adverse effects
*frequent urination
*increase in uric acid levels
*increase calcium levels
*glucose intolerance/lipid changes
*photosensitivity/rash
Indication for thiazide diuretics
Diuretic of choice for HTN w/ normal renal function
How long may it take for thiazides to reduce blood pressure?
3-4 weeks
Hydrochlorothiazide dose
12.5-50mg QD (Esidrix, Microzide)
Metolazone dose
2.5mg QD (Zaroxolyn)
Hydrochlorothiazide dose
12.5-50mg QD (Esidrix, Microzide)
Metolazone dose
2.5mg QD (Zaroxolyn)
Hydrochlorothiazide dose
12.5-50mg QD (Esidrix, Microzide)
Metolazone dose
2.5mg QD (Zaroxolyn)
Hydrochlorothiazide dose
12.5-50mg QD (Esidrix, Microzide)
Metolazone dose
2.5mg QD (Zaroxolyn)
Loop diuretics pros
*useful in patients w/ CrCl<30 ml/min

*decreased morbidity and mortality, low-cost

*may be of benefit in salt-sensitive patients, including Arican-Americans
Loop diuretics adverse effects
*frequent urination
*increase uric acid levels
*decrease calcium levels
*metabolic effects (less common than w/ thiazides)
*photosensitivity/rash
*tinnitus/loss of hearing
What loop diuretic does not have a sulfa group?
Ethacrynic acid (phenoxyacetic acid derivative)
Potassium-sparing diuretics pros
effective in combination to prevent hypokalemia
Potassium-sparing diuretics adverse effects
*increase K+
*increase uric acid levels
*gynecomastia
*irregular menses
Diuretic drug interactions
NSAIDs and steroids
Diuretic monitoring parameters
BP, SCr, electrolytes, uric acid, weight
Diuretic patient education
*thirst and dry mouth -> try sugarless hard candy or sugarless gum

*sodium restriction important

*notify of s/sx of gout and electrolyte abnormalities (leg cramps, muscle weakness)
Furosemide dose
10-40mg BID
Beta-blockers MOA
*decrease in CO due to decrease in HR and contractility (decrease SV)

*reduction in plasma renin activity; inhibition of NE release via presynaptic beta-blockade
Beta-blocker pros
*decreased morbidity and mortality

*Good choice post-MI; also effective for angina

*Beneficial for patients w/ migraine, essential tremor, anxiety
BB adverse effects
*bradycardia
*exercise intolerance
*bronchospasm
*glucose intolerance
*masks symptoms of hypoglycemia
Caution/relative contraindications for BB
asthma, COPD, diabetes, peripheral vascular disease, sleep apnea
Cardioselective BB's to be used in aforementioned patients
low-dose:
*Bisoprolol
*metoprolol
*atenolol
*acebutolol
CNS adverse effects (depression) seen with what lipid soluble BB's?
Propanolol
ISA/partial Beta-receptor agonist agents
*pindolol
*penbutolol
*carteolol
*acebutolol
Combined alpha/beta-blocker
labetalol
What beta-blocker undergo extensive first-pass metabolism?

What beta-blockers are excreted renally?
propanolol and metoprolol

atenolol and nadolol
Beta-blocker drug interactions
*concomitant non-dihydropyridine calcium channel blockers may lead to heart block

*Unopposed alpha vasoconstriction with sympathomimetics (cocaine, amphetamines)
Beta-blocker monitoring parameters
BP, HR
Beta-blocker patient education
*do not discontinue abruptly (may cause tachycardia, aggravation of angina, or death)

*educate patients w/ diabetes of effect on masking hypoglycemia (except sweating)
ACE-Inhibitors pros
*documented to slow progression of diabetic nephropathy

*decreased morbidity and mortality in heart failure and acute-MI
ACE-Inhibitors adverse effects
*non-productive, dry cough
*Hyperkalemia
*Angioedema
Contraindications of ACE-Inhibitors
*Bilateral renal artery stenosis (cause renal failure)

*pregnancy
ACE-Inhibitors comments
*hyperkalemia in patients w/ renal disease or diabetes or in patients w/ concomitant NSAIDs, potassium supplements or potassium sparing diuretics

*Rash and taste disturbances may occur especially w/ captopril due to sulfhydryl group
ACE-Inhibitors drug interactions
*NSAIDs decrease efficacy of ACE-I

*May increase serum lithium levels

*caution with concomitant use of potassium supplements
ACE-Inhibitors monitoring parameters
BP, K, SCr, Cough, Angioedema
ACE-Inhibitors patient education
*seek medical attention if facial swelling occurs

*Use salt-substitutes sparingly

*If c/o cough: use sugar-free gum/candy to help reduce cough
Angiotensin-II Receptor Blockers (ARBs) Pros
*evidence of slowing of progression of diabeteic nephropathy

*Heart failure
Calcium Channel Blockers (CCBs) Non-dihydropyridine Pros
*useful in patients w/ tachyarrhythmias and/or atrial fibrillation

*delay onset of diabetic nephropathy

*no change in lipid profiles
CCCs Non-dihydropyridine adverse effects
*bradycardia
*1st-degree heart block
*negative inotropic effects
*constipation (V > D)
CCBs Non-dihydropyridine monitoring parameters
BP, HR, constipation
CCBs Non-dihydropyridine patient education
*constipation management
*do not crush or chew sustained-released product
CCBs Dihydropyridine pros
efficacious and no changes in lipid profiles
CCBs Dihydropyridine adverse effects
*HA
*Peripheral edema
*Reflex tachycardia (especially nifedipine)
CCBs Dihydropyridine comments
*long-acting preferred over short-acting products

*short-acting dihydropyridines, such as sublingual nifedipine, may increase morbidity/mortality

*Avoid in systolic heart failure (except amlodipine or felodipine)
CCBs Dihydropyridine monitoring parameters
BP, HR, peripheral edema, reflex tachycardia
CCBs Dihydropyridine patient education
*educate about possibility of peripheral edema

*do not crush or chew SR products
Diltiazem SR dose
90-180mg BID
Verapamil SR dose
QD or BID - dose range =180-480mg/day
Amlodipine dose
2.5-10mg QD (Norvasc)
Nifedipine long-acting dose
30-90mg QD (Adalat CC, Procardia XL)
Felodipine dose
5-20mg QD (Plendil)
Losartan dose
50-100mg QD or divide BID
Valsartan dose
80-320mg QD (Diovan)
Alpha blockers Pros
*improved lipid profile
*beneficial effects in patients w/ BPH
Alpha blockers adverse effects
*first-dose syncope (use 1mg hs)
*tachycardia
*edema
Alpha-blocker place in therapy
*Do not use as initial first-line therapy or as monotherapy

*Reasonable to consider in patients w/ HTN and BPH, if added to diuretic, beta-blocker, or ACE

*Use other agents for BPH before trying this

*If used, must use in combo w/ diuretic to limit fluid retention
Alpha-blocker monitoring parameters
BP, orthostatics
Alpha-blocker patient education
*take HS
*Rise slowly from seated/supine position
Central alpha2-agonists pros
*no effects on lipids

*Clonidine in patch form may improve compliance

*methyldopa is DOC in pregnancy
Central alpha2-agonists adverse effects
*anticholinergic
*bradycardia
*sexual dysfunction
*skin rash
*depression

RARE:
*hemolytic anemia and hepatic dysfunction (methyldopa)
Central alpha2-agonists comments
*significant rebound HTN upon withdrawal

*best in combination w/ diuretic therapy to minimize fluid retention
Central alpha2-agonists monitoring parameters
BP, adverse effects
Central alpha2-agonists patient education
Change patch every week
Direct vasodilators pros
effective for refractory HTN
Direct vasodilators adverse effects
Both: tachycardia, fluid retention, worsening angina,

Minoxidil: tachycardia, fluid retention, worsening angina, hypertrichosis

Hydralazine: HA, drug-induced lupus, peripheral neuropathy
Direct vasodilators comments
*need diuretic and beta-blocker used in combination to counteract reflex increase in sympathetic outflow to compensate for profound vasodilation

*Last-line therapy
Direct vasodilators monitoring parameters
BP, HR, edema, adverse effects