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44 Cards in this Set
- Front
- Back
DI: Thiazide Diuretics
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Steroids: Salt retention and antagonize thiazides
NSAIDS: Blunt response Antiarrythmics: Torsades Probenicid.Lithium: Block effects Lithium: Decreases lithium clearance |
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ADE: Thiazide Diuretics
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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* |
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ADE: Loop diuretics
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Electrolyte: Hypokalemia, hypomagnesia
Hypotension Renal |
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DI: Loop Diuretics
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AG: Increased ototoxicity
NSAIDs: Decreased effect Antiarrythmics: Torsades Probenecid: Blocks loop diuretic effect by interfering with excretion into the urine. Ototoxicity at high doses |
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DI: K-sparing diuretics
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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 |
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Adrenergic Neuron Blockers
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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. |
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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 |
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Medications used for HTN urgencies
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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. |
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Causes of Inadequate Response to HTN Therapy
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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. |
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Which medications are compelling and favorable for which conditions?
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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 |
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DI: ACEI/ARBs
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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. |
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ADE: ACEI/ARBs
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Hyperkalemia
Cough Angioedema Renal insufficiency Taste disturbances Rash Hypotension Dizziness |
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Drugs that exacerbate HF
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Antiarrhythmics: Disopyramide, flecainide, propafenone
BB CCB: Verapamil and diltiazem Itraconazole and terbinafine Cardiotoxic: Doxo/daunorubicin, cyclophosphamide, EtOH Na/water: NSAIDs, COX2, glucocorticoids, rosi/pioglitazone |
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Medications for HTN with unfoavorable conditions
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Liver = labetolol, methyldopa
Renal insufficiency = K-sparin diuretics renovascular = ACEI/ARBs Gout = diuretics |
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BB in HF
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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. |
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DI: BB
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Amiodarone/ nonDHP CCB/ opthalmic BB: bradycardia, heart block, hypotension
P450 inhibitors: hepatic metabolism of metoprolol and coreg. |
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ADE: Digoxin
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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 |
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Drugs that increase digoxin levels
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Quinidine/verapamil/amiodarone: Decrease digoxin 50%
Propafenone Flecainide Macrolide ABX Itraconazole/ketoconazole K-sparing diuretics: Increases risk of toxicity |
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Drugs that decrease digoxin levels
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Antacids
Bile acid sequestrants Kaolin-pectin Metoclopramide |
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Bidil
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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 |
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Treatment of advanced/decompensated HF
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Warm/dry: No specific therapy
Warm/wet: IV loop, thiazide (metolazone) as supplement. IV vasodilators helpful. Cold/dry: Gradual BB Cold/wet: Improve CO |
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Vasodilators
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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 |
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Inotropes
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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. |
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Nondrug therapy for HF
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Intra-aortic balloon pump
Left ventricular assist devices Biventricular pacing Implantable cardioverter-defibrillator Cardiac transplantation |
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CI: Hormone replacement therapy
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Abnormal, undiagnosed genital bleeding
Breast cancer DVT/PE Estrogen-dependent neoplasia Pregnancy Stroke/MI in last year Thromboemolic disorder Thrombophlebitis |
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How does Progestin protect the uterus?
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Decrease nuclear estradiol receptor concentrations
Suppresses DNA synthesis Decrease estrogen bioavailability SE: Depression, HA, irritability |
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Which disease states are exacerbated by estrogen?
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Depression
DM Hypertriglceridemia Hepatic adenoma Thyroid disorder (may require supplement) CVD Impaired hepatic function |
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Medications that decrease effects of estrogen
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P450 inducers (3A4): Barbituates, carbamazepine, rifampin, St. John’s wort
Hydantoins Topiramate |
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Medications that increase effects of drug used with estrogen
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Corticosteroids
TCA (increase toxicity of TCA) |
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Medications that increase effects of estrogen
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P450 inhibitors (3A4): Azole antifungals, macrolide ABX, ritonavir etc.
Grapefruit juice |
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CI: Progestin
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Aminoglutethimide: Increased metabolism of medroxyprogesterone
Rifampin: Increased metabolism of norethindrone |
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Androgen
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Estrogen precursor
CI: Androgenic alopecia, hirsutism, moderate-severe acne ADE: Fluid retention, lipid profile, virilization |
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What patients should not used combinded oral contraceptives?
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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 |
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Medications the decrease the effectiveness of OCs
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ABX
Anticonvulsasnts: Barbituates, carbamazepine, felbamate, phenytoin, topiramate NNRTI, protease inhibitors Pioglitazone Rifampin Theophylline |
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Medications that increase the effectiveness of OCs
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Atorvastatin
Vitamin C Cyp 3A4 inhibitors |
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Drugs that have decreased effect with concurrent use of OCs
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Anticoagulants
Lorazepam Oxazepam Temazapam Hypoglycemics Methyldopa Phenytoin |
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Drugs that have increased effect with concurrent use of OCs
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TCAs
BZDs BB Theophylline Cortisone: Increased risk of toxicity |
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Risk factors for osteoporosis
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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 |
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Medical conditions associated with increased risk of osteoporosis
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AIDS
Cushing’s Eating disorder Hyperparathyroidism IBD DM (Insulin dependent) Lymphoma/leukemia Malabsorptio Rheumatoid arthritis |
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Drugs Associated with Increased Risk of Osteoporosis
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Anticonvulsants
Cytotoxic drugs Glucocorticoids Immunosuppressants Lithium Long-term heparin Progesterone Supraphysiologic thyorxine Tamoxifen |
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Medical conditions associated with increased risk of osteoporosis
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AIDS
Cushing’s Eating disorder Hyperparathyroidism IBD DM (Insulin dependent) Lymphoma/leukemia Malabsorption Rheumatoid arthritis |
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What are the recommendations for initial evaluation of osteoporosis?
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Screen all women > 65
< 65 with family history Women with a fracture unrelated to trauma |
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What is the least androgenic progestin?
Most androgenic? |
Least = Desogestrel
Most = Levonorgestrel |
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Progestin only
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Ovrette
Ortho Micronor Errin Nor-QD Camila |