23/06/2013

Disclaimer
Materialsnotmeanttocovereverythingbut
tofocusonthemoreimportantinformation
pertainingtoeachclass
Sources:Therapeuticchoice,CPS,RxFiles,and
Dipiro
Conflictinginformationwasfoundinmany
area.Practicenormswereconsidered.
ImportanttoUNDERSTANDhowtoUSEthe
knowledgeratherthanKNOWINGit.

Topics
Diuretics
Somedrugswillbecoveredin
ACEI
thetherapeuticsection
ARB
BetaBlockers
CalciumChannelBlockers
Nitrates
Digoxin
Miscellaneousantihypertensiveagents
Drugsaffectingbloodclotformation
Aldosteronereceptorblockers

Listofdrugsthatcauseorworsenhypertension
Drugs
NSAIDs +COX2I,steroids,
estrogen,salt

Mechanism
Promotewaterretention

Sympathomimeticdrugs,
stimulants(ex.Amphetamines) Sympatheticoutflow
,MAOI,SNRI
midodrine

1 agonist(vasopressor)

Erythropoietin analogues

Hgb is associatedwith BP

Licoriceroot

Pseudohyperaldosteronism

Calciunrine inhibitors

HTNisa reportedADR

23/06/2013

Diuretics

Diuretics
Thiazides

Loop

Initially: Na+ reabsorption Na+ reabsorptioninthe

atproximaltubules
ascendingloopofHenle
potentdiuresis
diuresis plasmavolume
Improvesrenalbloodflow
BP
andGF(usefulinpatients
Chronically: peripheral
withrenalfailure)
resistance

Diuretics
Whenapatientstartstakingdiuretics,Allofthe
followingshouldbemonitoredEXCEPT:
A) SrCr
B) BUN
C) Electrolytes
D) Bloodpressure
E) LFT
F) Noneoftheabove(allmonitored)

23/06/2013

Diuretics
Apatientwhoisallergictosulfaandneeda
diuretic.Whichofthefollowingisanoptionin
thiscase?
A. Indapamide
B. Ethacrynic acid
C. Chlorthalidone
D. Bumetanide
E. Noneoftheabove

ThiazideDiuretics

Thiazidediuretics
Thiazidediureticsareused inallofthefollowing
patientsEXCEPT:
A.
B.
C.
D.
E.
F.

Preventionofrenalcalculi
Hypertension
Edema
Ascitesduetolivercirrhosis
Preeclampsiaofpregnancy
Noneoftheabove(TDareusedinalloftheabove
conditions)

23/06/2013

Thiazidediuretics
Thiazidediureticsarecontraindicated inallof
thefollowingpatientsEXCEPT:
A.
B.
C.
D.
E.

Hypersensitivity
Anuria
Diabetesincipidus
Hepaticcoma
Noneoftheabove(Allofabovearecontraindications)

ThiazideDiuretics
Thiazidesdiureticscauseallofthefollowing
electrolyteabnormalitiesEXCEPT
A.
B.
C.
D.
E.
F.

Hypokalemia,
Hyponatremia
Hypochloremia
Hypomagnesemia
Hypocalcemia
Noneoftheabove(allabnormalities)

ThiazideDiuretics
Hypokalemia
Risk withtopiramate, steroidsandsalbutamol
Hypokalemia theriskofdigoxintoxicity,
arrhythmia andrespiratorydepressionwhenused
withcurari NMblockers
Management:(moreunderhypokalemia)
MonitorK+ level
Management:K+richfood(preventionforK+ 3
3.5mmol/L),K+ supplementorK+sparingdiuretic(ifK+ <
3mmol/L)andsaltrestriction(makesureMg+2 isnormal)

23/06/2013

ThiazideDiuretics
Hypotension
Orthostatic:Risk byalcohol,opioids,
barbiturates
Whenusedwithotherantihypertensiveagents
excessivehypotension
Management:Startnewagent(s)atlowdoseOR the
doseofcurrentagentbeforestartingnewone.

Whenusedwithrituximab(Rituxan
antineoplastic) excessivehypotension
Management:holdthiazide12hourspriortorituximab

ThiazideDiuretics
Hypercalcemia
mobilizationand excretionofcalcium
Risk byCa+2 supplement,vit.D,and
Hyperparathyroidism
Management:
MonitorCa+2
D/Csupplementsifnecessary

Thiazidediuretics
Thiazidediureticswouldworsenallofthe
followingmedicalconditionsEXCEPT:
A) Gout
B) Diabetes
C) Hyperlipidemia
D) Raynaudsphenomena
E) Noneoftheabove(allwillgetworse)

23/06/2013

ThiazideDiuretics
Drug DrugInteractions
Drugsthatcause/worsenHTN monitorBP
Cholestyramine: thiazideabsorption(give
thiazides2hoursbeforeor6hoursafter)
Li+:Thiazide Li+ toxicity
Management:
Li+ doseby50%
MonitorLi+serumconcentration
Monitorelectrolytes.

ThiazideDiuretics
Adversereactions:
CVS:arrhythmia,edema
CNS:Headache,dizziness,vertigo
Eye: glaucoma,conjunctivitisanditchyanddry
eye(avoidcontactlenses)
GIT:N/V,constipation,drymouth,abdominal
pain,pancreatitis
Skin:rash,urticaria,pruritus
Kidney:Acuteinterstitialnephritis
Notanallinclusivelevelbutlimitedtocommonones

ThiazideDiuretics
WhataretheadvantagesofHCTZover
Chlorthalidone inmanagementofHTN?
A.
B.
C.
D.
E.
F.

Betterevidence
lesseffectonelectrolytes
higherpotency
longerduration
lesseffectonlipids
Noneoftheabove(chlorthalidone issuperior)

23/06/2013

ThiazideDiuretics
PatientonHCTZexperiencereducedkidney
functionwithCrCl =25ml/min,whatshould
wedo?
A.
B.
C.
D.
E.

Switchtofurosemide
Switchtometolazone
Switchtochlaorthalidone
Alloftheabove
A&Bonly

ThiazideDiuretics
WhichofthefollowingisNOTtrueabout
indapamide?
A. indapamide issuperiortoHCTZinhyperlipidemia
anddiabetes
B. Indapamide +perindoprilcanreducetheriskof
stroke
C. Commonsideeffectswithindepamaide:
Headache/dizziness
D. Itiseliminatedbythekidney
E. Alloftheabove(noneistrue)

ThiazideDiuretics
Whencounselingthepatientsonthiazde diuretics,arethefollowing
statementstrueorfalse:
A. Takewithorwithoutfood
B. Avoidsunexposure,wearprotectivecloths,andusesunscreen
C. Avoidwhenbreastfeeding
D. Shouldexpecttheeffectin1 2hoursbutdropinbloodpressure
maytakefewdays
E. Swallowwhole,donotcheworcrush
F. Itcancausedryeye,becarefulifyouusecontactlenses
G. Eatabananaeveryday
H. Avoidafter4:00pm
I. NoteffectiveifCrCl <30ml/min

23/06/2013

LoopDiuretics

Loopdiuretics
Indications:
EdemainHF,livercirrhosis,renaldiseaseand
nephrotic syndrome(slidingscale)
MildmoderateHTN particularlyinpatientswith
HF orCKD(not1st line)
Oliguria
Treatmentofhypercalcemia

Loopdiuretics
Indicateifeachofthefollowingstatementsistrueorfalse
aboutloopdiuretics:
A. Theyarepotentdiuretic
B. Causehypercalcemia
C. uricacidand BGlevel
D. DoNOTrestrictsalt
E. Donotuseinjectionsifitturnsyellow
F. D/CIVfurosemide2dayspriortosurgery
G. WhenswitchingfromIVtooral,reducethedoseby
50%
H. Avoiddosesafter4:00pmtoavoidnighttimediuresis

23/06/2013

Loopdiuretics
WhichofthefollowingisNOTtrueabout
furosemidesolution?
A) Dispenseinoriginaltight,lightresistantglass
container
B) Storeatcontrolledroomtemperature
C) Discard120daysafteropeningthebottle
D) Itcontains11%alcohol
E) Noneoftheabove(Alltrue)

Loopdiuretics
FurosemidecancauseOTOTOXICITY.Arethe
followingstatementstrueorfalse?
Itcanbepermanentdeafness
Developslowlyin6years
Earlysymptomsmaybetinnitus
Risk withaminoglycosidesandcisplatin
Risk withslowIVadministration
Risk withsevererenalimpairment

ACEI

23/06/2013

UnderstandRAAS

http://www.cvphysiology.com/Blood%20Pressure/BP015.htm

ACEI
Pharmacology
InhibitionofAngiotensinIIformation
Hypertension: vascularresistance systolic
anddiastolicBP
HF: cardiacoutput( HRx SV= CO)

Accumulationofbradykinin (ACEisalsocalled
bradykininase)
Vasodilation

ACEI
Indications:Indicationmayverybyagent.Classeffectisassumed
1st lineforHTN andHF
Slowdownnephropathy
Indiabetics+/ proteinuria
Innondiabeticnephropathy

PostMI

LesseffectiveinAfrican

mortality
Americanunlessusedwith
thiazidediureticsbutcan
hospitalizations
complicationssuchasHF beusedinMI,HFandCKD

10

23/06/2013

ACEI
Contraindications:
Hypersensitivity(nocrosssensitivity)
Historyofangioedema
Pregnancy(malformationinthe1st and
complicationsinthe2nd and3rd trimesters)
Lactation

ACEI
Adverseeffects:
Angioedema:
0.5%
Risk inAfricanAmerican
Management:
Educatethepatient
Involvelarynxortongue(canbefatal) epinephrine
Lipsandface D/Ctherapy

ACEI
Adverseeffects:
Hypotension:
Risk byvolumedepletion,HF,diuretics,hyponatrmia
anddialysis
Management:
Ifondiuretic startACEattheusualdose
educatepatienttoconsultphysicianifvomitingordiarrhea
developor fluidintake
WheninitiatingACEItherapy:monitorBPx2hourspostfirst
dose

11

23/06/2013

ACEI
Adverseeffects:
Cough:

10%withundefinedonsetofuptomonths
Dry,nonreproductive
Accumulationofbradykinin
Risk bynonsmoking,eastAsians,female andHF
Management:
D/CACEI
switchingtoARB
Sodiumcromoglycate ??

ACEI
Adverseeffects:
Hyperkalemia:
Risk bydiabetes,renalfailure,HF and
concomitantusewithmedsthatK+ (amiloride,
trimetrene,spironolactone,K+supplements,
drospirenone)
Management:
MonitorK+ level
K+ >5.6mEq/Lmayrequirediscontinuationoftherapy

ACEI
Adverseeffects:
Neutropenia/Agranulocytosis:
Risk byimmunosuppressant andrenalfailure
Management:
Educatepatient:reportsymptomsofinfection(sorethroatandfever)
Monitor leukocytes

ImpairedRenalfunction:
Mayprogresstoacutefailureby renalbloodflow
Risk bydiuretics,renalarterystenosis,volumedepletion,
NSAIDs,andHF
Management:
D/Cdiureticor ACEIdose
Monitorkidneyfunction

12

23/06/2013

ACEI
Adverseeffects:
Rash
Morewithcaptoptil (containssulfa)
Onsetis1month.Mayspontaneouslydisappear
Management:AH, orD/CACEI

Hepatotoxicity: transaminases,bilirubin,jaundice
Reversiblelossoftaste=dysguesia (whichagent?)
Photosensitivity(whichagent?)
Blooddyscrasias
Pancreatitis

ACEI
Druginteractions:
Irondextran(IV) ACEI IVironsideeffects
particularlyanaphylacticreaction.
Allopurinol ACEI riskofhypersensitivityand
SJS.
Ifcombinationisrequired monitorfor
hypersensitivityforaminimumof5weeks.

Drugsthat K+ level monitorK+ level

ACEI Li+ level( renalclearance) monitorLi+

ACEI
Druginteractions:
Combinationcausinghypotension:
1 blockers Excessivehypotension
Management:starttherapyatlowdoseandmonitorBP

Thiazidediuretics Excessivehypotension
Management:
ifpossibleD/Cthiazidediuretic 1weekbeforestartingACEI.If
not,then..
StartACEIatlowdose
Patienttoremainsupinefor3hoursafterfirstACEdose
ConsiderincreasingNa+ intake
MonitorBPwheninitiatingACEItherapy

13

23/06/2013

ACEI
Monitoring
K+ levelandSCr atbaselineand1 2weeks
afterinitiationoftherapyordoseincrease
thenannually
IfSCr >30%ofthebaseline mayD/CACEI
K+>5.6mEq/ml mayD/CACEI
SamemonitoringforARB

ACEI
NOTESonACEI
WhichACEisavailableforIVadministration?
WhichACEIareapprovedinHTNinchildren?
WhichACEIdonotrequiredoseadjustmentin
patientswithrenalfailure?
WhichACEIdonothaveactivemetabolites?

ACEI
NOTESonACEI
WhichACEIareNOTprodrugs?__________________
TheabsorptionofwhichACEIarenotaffectedbyfood?
_______________________________(otheraffected,
consequenceunclear)
WhenswitchingfromIVenalapril topo startwith
________
Alloncedaily(EXCEPT_______________________)
Captopril take_____________meals

14

23/06/2013

ACEI
NOTESonACEI
Usualdailydosescaptopril50 150mg,
enalapril 10 40mg
Captorpril hasshortduration canbeused
formanagementofacuteHTN
Perindopril+indapamide decreasestroke

ACEI
Apatientwhotakesramipril shouldcontacthis
physicianifheexperiencesallofthefollowing
adversereactionEXCEPT:
A. muscleweaknessandsloworirregularheart
rate
B. Swellingoftheface,lipstongueorthroat
C. Dryhackingandpersistentcough
D. Reducedurineoutput
E. Alloftheabove

ACEI
CounselingforACEI:
Takewithorwithoutfood(exceptcaptopril1hbefore
meals)
Cancrushorchewtablets(Ramipril capsulescanbe
opened)
Takeatthesametimeeveryday
Continuetakingthemedicationevenifyoudonotfeel
anybetter
Avoideatingtoomuchfoodrichinpotassium
Itmaycausedizziness,changeyourpositionslowly

15

23/06/2013

ARB

ARB
Mechanism:
BlockangiotensinIItype1receptors(AT1)
Indications:
1st lineagentinpatientsuncomplicatedHTNand
HTN+diabetes,ISH andLVH
InHF:asalternativetoorincombinationwithto
ACEI
Allotherindications:alternativetoACEI

ARB
SwitchingpatientsfromACEItoARBisachoicein
patientswhotakeACEIanddevelop:
A) Hyperkalemia
B) Cough
C) Angioedema
D) Renalfailure
E) A&B
F) B&C
G) B&D
H) Alloftheabove

16

23/06/2013

ARB
CombininganACEIandARBcancauseallofthe
followingEXCEPT:
A) BP
B) WorsenRF,
C) risk syncope,
D) WorsenHF
E) riskof stroke
F) riskofhyperkalemia

DirectReninInhibitor

DirectReninInhibitor
Aliskiren
Indications:HTN+/ diureticsandDHPCCB
CI:hypersensitivity,pregnancy,Hx of
angioedema,combinationwithACEI/ARB
ADR:K+,angioedema,cough(rare),
headache,diarrhea,rash,gout
DI:Avoidusewithcyclosporineandazoles.
Grapefruitjuice,

17

23/06/2013

BetaBlockers

Betablockers Effect
WhichofthefollowingisNOTaneffectofbeta
blockersonthecardiovascularsystem?
A. Decreaseheartrate
B. Decreasecardiacoutput
C. Decreasecardiaccontractility
D. Improvecoronarybloodsupply
E. Noneoftheabove(alloftheaboveare
effects)

Betablockers Indications
Allofthefollowingareindications ofbetablockers
EXCEPT
A. HTN
B. Angina
C. PostMI
D. Migraine
E. Heartfailure
F. Arrhythmia
G. Noneoftheabove(Allaboveareindications)

18

23/06/2013

Betablockers Contraindications
WhichofthefollowingisNOT acontraindicationfor
betablockers?
A. AsthmaandCOPD
B. Bradycardia
C. AVblock
D. Overtheartfailure
E. Tremors
F. Raynaud'sdisease
G. Noneoftheabove(alloftheaboveare
contraindications)

Betablockers Indications
Specificindicationsperagents
Propranolol

Tremors,
Alsousedfor:bleedingesophagealvarices,
thyrotoxicosis,anxiety

Sotalol

ONLYindicatedforarrhythmia

Carvedilol

ONLYindicated forstableHF

Propranolo &
Headache(otherscanalsobeused)
Timolol

Betablockers Classifications
Allofthefollowingbetablockershaveintrinsic
sympathomimeticeffectEXCEPT:
A. Pindolol
B. Metoprolol
C. Acebutolol
D. Oxprenolol
E. Noneoftheabove(AllhaveISA)

19

23/06/2013

Betablockers Classifications
Allofthefollowingbetablockersarecardio
selectiveExcept
A. Bisoprolol
B. Pindolol
C. Metoprolol
D. Acebutolol
E. Atenolol
F. Noneoftheabove(Allareselective)

Betablockers Classifications
Whichofthefollowingbetablockersblockboth
betaandalphareceptors?
A. Pindolol
B. Carvedilol
C. Sotalol
D. Timolol
E. Labetalol

Betablockers
Whenbetablockersisneededforapatientwith
highriskofstroke,whichbetablockershouldbe
used?
A.
B.
C.
D.
E.

Anonselectivebetablocker
AbetablockerwithhighCNSpenetration
Acardioselectivebetablocker
AbetablockerwithISA
Anyoftheabove

20

23/06/2013

Betablockers
Betablockerswouldworsenallofthefollowing
medicalconditionsEXCEPT
A.
B.
C.
D.
E.
F.
G.

Depression
Hyperlipidemia
Hyperthyroidism
Diabetes
Psoriasis
Erectiledysfunction
Patientswithanaphylacticreactionwhoneed
epinephrine
H. Noneoftheabove(alloftheabovemaygetworse)

Betablockers
Allofthefollowingpatientswillbenefitfroma
betablockerwithISAEXCEPT:
A. Apatientwithexcessivebradycardia whenusing
otherbetablockers
B. PatientpostMI
C. ApatientwithDiabetes
D. Patientswithcoldextremities
E. Apatientwithhyperlipidemia
F. Apatientwithasthmasymptoms

Betablockers
Whichofthefollowingbetablockershasan
activemetabolite?
A.
B.
C.
D.
E.

Atenolol
Metoprolol
Propranolol
Sotalol
Labetalol

21

23/06/2013

Betablockers AdverseReactions
CNS:depression,dizziness,fatigue,weakness,vivid
dreams,confusion,impairedconcentration/memory,
hallucination,insomnia,somnolence(propranololhas
mostCNSeffects)
CVS:hypotension,Orthostatichypotension(morewith
Carvedilol),bradycardia,coldextremities
Respiratory:dyspnea,bronchospasm,wheezing,
GIT:N/V,constipation,diarrhea,drymouth
Dermatology:rash,exacerbatepsoriasis,
photosensitivity
Sexualdysfunction

Betablockers
NOTES:
Betablockersmaybeineffectiveinpreventing
cardiovasculareventsinpeoplewhosmoke.
Avoidabruptwithdrawal severeHTNand
riskofangina.Taperover2 4weeksperiod

Betablockers Interactions
CYP2D6inhibitorsincreaselevelsof
propranololandmetoprolol andcarvedilol
Digoxin,amiodarone,diltiazem,verapamil:
bradycardia,additivecardiodepressant effect
Howtomanagethebradycardia causedby
Betablockers?Atropine

22

23/06/2013

Betablockers Monitoring
Patientswhotakebetablockersshouldbe
monitoredforallofthefollowingEXCEPT:
A. Heartrate
B. BP
C. Fatigue
D. Dyspnea
E. SOB
F. Erectiledysfunction

CCB

CCB
Dihydropyridine
relaxvascularsmooth
muscles vasodilatation
withminimaleffect(ifany)
onheartrate
Nifedipine,amlodipine,
andfelodipine

Nondihydropyridine
reduceheartrateand
contractilitywithless
vasodilatoreffect
Verapamilanddiltiazem

23

23/06/2013

CCB
CCBcanbeusedforallofthefollowingindications
EXCEPT:
A) HTN
B) Migraine
C) subarachnoidhemorrhage
D) A.Fib&A.flutter
E) Prinzmetal angina
F) Stableangina
G) Noneoftheabove(Allareindications)

CCB
WhichofthefollowingisNOTacontraindicationto
CCB?
A. Hypersensitivity
B. Patientatriskofseverehypotension
C. Severebradycardia
D. RecentIM
E. Severeheartfailure
F. PatientwithAVblock
G. Concomitantusewithcardiacdepressantdrugs
H. Noneoftheabove(allarecontraindications)

CCB
WhichofthefollowingCCBdoesNOTinteract
withgrapefruitjuice?
A. Amlodipine
B. Nifedipine
C. Felodipine
D. Diltiazem
E. Verapamil
F. None(allinteract)

24

23/06/2013

CCB
WhencombiningDHPCCBwithother
antihypertensivemedicationswhichofthe
followingisthebestcombination?
A. WithACEI
B. WithARB
C. Withdiuretic
D. WithBB
E. A&B

CCB
WhencounselingonCCB,thepatientshouldbe
educatedaboutallofthefollowingsideeffects
EXCEPT
A. Gingivalhyperplasia
B. Constipation
C. Swellingoftheankle
D. Flushing
E. Headache
F. Rash
G. Alloftheabove

CCB
WhichofthefollowingLACCBcanbecrushed?
A. Felodipine
B. Amlodipine
C. Verapamil
D. Adalat
E. Noneoftheabove(Allnoncrushable)

25

23/06/2013

Nitrates

Nitrates
Mechanism:
Allprodrugs liberatenitricoxide
(endotheliumderivedrelaxingfactor)
vasodilatation
Coronaryartery CardiacO2 delivery
Veins preload O2 consumption

Italsohassmoothmusclerelaxingeffect

Nitrates
Pharmacokinetics:
AbsorptionthroughGITandskin
Tolerancedevelopparticularlywithlongt
preparations keep1012hoursdrugfree
interval ( exercisetoleranceand frequency
andseverityofanginaattheendofdose
interval) keepdrugfreeperiodatnight
(lesslikelytoexperienceangina)

26

23/06/2013

Nitrates
WhichifthefollowingisNOT acontraindication
fornitrates?
A)
B)
C)
D)
E)

Severeanemia
Hypotension
Cranialhemorrhage
Uncontrolledhypovolemia
Noneoftheabove(allarecontraindications)

Nitrates
Adversereactions:
Themostfrequentisheadache(50%), in
fewdays(maytakeacetaminophen)
Dizziness,hypotension,flushing,reflex
tachycardia,rash,nausea,vomiting,
dermatitis(withtopical),muscletwitching,
blurryvision.

Nitrates
Druginteractions:
Excessivehypotensionwithalcohol,
antihypertensive drugsandPDE5inhibitors
Drugsthatmayprecipitateanginaex.Ergot
IVnitroglycerin heparinresistance
WhenPDE5inhibitorisgivenwithnitrate
separatebyatleast24hours(safetynot
established)

27

23/06/2013

Nitrates
WhichofthefollowingisTRUEaboutusing
sublingualNTG?
A. Patientshouldbeinstructedtositdownbefore
usingNTG
B. Acetaminophencanbeusedtotreatheadache
C. Storeatroomtemperature.
D. SLNTGcanbeused510minutesbeforeangina
provokingactivities
E. SLNTGhasa1 5minutesonset
F. Alloftheabovearetrue

Nitrates
WhichofthefollowingistrueabouttakingSLNTG
inpatientswhoexperiencechestpain?
A. Call911thenuse1sprayevery5minutesx3
B. Use1spraySLandthencall911andrepeatthe
doseevery5minutesx3ifneeded
C. Use1spraySL,waitfor5minutes,call911if
painpersistsandrepeatx2every5minutesif
needed
D. Use1spraySLevery5minutesx3dosesand
call911rightafterthe3rd dose(donotwait5
minutes)

Nitrates
WhichofthefollowingisNOTtrueaboutusingsublingualNTG
TABLETS:
A. IftabletsstingwhenplacedSL,thismeanstheyareno
longerpotent discard
B. Itisrecommendedtorenewthestockevery6months
C. Onceopened,removethecottonplugpermanently
D. Tabletcanbeplacedunderthetongueorinbuccal pouch
E. NITROSTATmaycauseafalsetestresultofdecreased
serumcholesterol.
F. Donotchew,crush,orswallowNITROSTATtablets.
G. Noneoftheabove(allofabovearetrue)

28

23/06/2013

Nitrates
WhichofthefollowingisNOTtrueaboutusingsublingualNTG
SPRAY:
A. Itshouldnotbeinhaled
B. Patientmustclosemouthimmediatelyafteruse
C. Itcansprayedonthetongue
D. Thedrugmaintainitspotencytilltheexpirydateoncanister
E. DoNOTshake
F. Prime,reprimeifnotusedfortwoweeks
G. Noneoftheabove(alltrue)

Nitrates
WhichofthefollowingisNOTtrueaboutNTGpatch?
A. Thebloodlevelbecomesunpredictable2hoursafter
removingthepatch
B. Onepatchcankeepsteadystatefor24hours
C. Patchmustberemovedbeforecardioversion
D. Avoidextremitiesbelowthekneeorelbow
E. Avoidskinfolds,scartissue,burnedorirritatedareas.
F. Washskinareawithsoapandwater
G. Useadifferentapplicationsiteeveryday.
H. Skinmayfeelwarmandappearredandwilldisappear
I. Iftheareafeelsdry,youmayapplyasoothinglotion.
J. Alloftheabove

Nitrates
WhichofthefollowingisNOTtrueaboutusingNTG
ointment?
A.
B.
C.
D.
E.
F.
G.

Appliedinthemorningandthenagain6hourslater
Wipeofftheointmentatbedtime
Doseismeasuredingramsofointment
Dosemustbeappliedtoanareaofminimumof5x7.5cm
Donotrubintotheskin
Applicatorcanbetapedinplacetocovertheointment
Itcanstainclothingsocompletelycoverthedose
measuringapplicatorwithaplastickitchenwrap
H. Thedose:arearatiomustbekeptconstant
I. Alloftheabovearetrue

29

23/06/2013

Digoxin

Digoxin
Indications:
HF (addontherapy, hospitalizationandimprove
symptomsexercisetolerance,noeffecton
mortality)
A.Fib (controlventricularrate)

Contraindications:
Ventriculartachycardia
Hypersensitivityreaction

Digoxin
WhichofthefollowingisNOTtrueaboutthe
effectofdigoxinontheheart?
A. HR
B. contractility
C. LVEF
D. Cardiacoutput
E. Noneoftheabove(allcorrect)

30

23/06/2013

Digoxin
Thedoseofdigoxindependsonallofthe
followingEXCEPT:
A. Age
B. Renalfunction
C. Leanbodyweight
D. Concomitantdiseasestates
E. Liverfunction
F. Noneoftheabove(Allareimportant)

Digoxin
Whatistheobjectiveofdigitalization?
A. Tobuildbodystoresof4to6g/kg
B. Tobuildbodystoresof8to12g/kg
C. Tobuildbodystoresof16to24g/kg
D. Tobuildbodystoresof24to36g/kg
E. Noneoftheabove

Digoxin
Digitalization:twoapproaches:
Gradualdigitalization:Givemaintenancedoseto
allowslowaccumulation(willtakeabout5half
lives1to3weeks)
RapidDigitalization:Giveasingleinitialdoseof
500to750g(0.5to0.75mg)followedby125
to375g(0.125to0.375mg)dosesgivenat6 to
8hourintervalsuntilclinicalevidenceofan
adequateeffectisnoted(monitoraftereach
dose)

31

23/06/2013

Digoxin
Drugs

Effect

Cholestyramine,antacid,adsorbent
antidirrhea,sulfasalazine,sucralfate,
metocloperamide,St.Johnswort

Digoxin level(take8hoursbefore
cholestyramine andadsorbentand2
hoursapartofantacids)

Omeprazole,cyclosporine,flecainide,
itraconazole,quinidine,
spironolactone, quinidine,NSAIDs
(particularlyindomethacin)

Digoxinlevel(differentmechanisms)
monitordigoxin level

Betablockers,verapamil,diltiazem,
nifedipine,

Furtherdepressionof HRmonitor
digoxinlevelandHR

Antibiotics

Digoxin inactivation effect

Thiazideandloop diuretics

K+ toxicity (monitordigoxinlevel)

Sympathomimeticagents

Riskofarrhythmia

Thyroidhormone

Responsetodigoxin

Digoxin
AllofthefollowingsymptomsdoesNOTsuggest
digoxintoxicity?
A.
B.
C.
D.
E.

Anorexia
Nausea
Vomiting
Fluidretention
Arrhythmia

Digoxin
Adversereaction:
nausea,vomiting,headache,diarrhea,mental
disturbances,dizziness

32

23/06/2013

Digoxin
WhichofthefollowingisNOTtrueconcerning
digoxintoxicity?
A. Therapeuticdigoxinlevelis0.8to2.0ng/mL
B. Hypokalemia riskofdigoxintoxicity
C. Digoxintoxicitymaydevelopevenwhenthe
serumconcentrationistherapeutic
D. Hypercalcemia riskofdigoxintoxicity
E. Noneoftheabove(ALLtrue)

Digoxin
WhichofthefollowingisNOTtrueabout
treatingbradycardia inpatientswithdigitalis
toxicity?
A. Treatbradycardia evenifasymptomatic
B. Digoxinimmunefabshouldbeusedtoreverse
digoxintoxicity
C. Atropinecanbeusedtoreversebradycardia
D. Temporarycardiacpacemakermayberequired
E. Noneoftheabove(alltrue)

Digoxin
Monitoring:

Digoxinserumlevel
BUNandSCr
Electrolytes
Weighpatientdaily.
Measureandmonitorurineoutputdaily
Monitorpulsedaily.

33

23/06/2013

MiscellaneousAgents

Vasodilators
Whichofthefollowingagentsisdirectacting
vasodilator?
A)
B)
C)
D)
E)

Methyldopa
Hydralazine
Guanethidine
Clonidine
Alloftheabove

Vasodilators
Notes:
Vasodilation compensatorystimulationofSNS
Reflextachycardia, reninrelease(Na/H2O
retention), incardiacoutputand HR
effect
Canprecipitateangina
Uses:
3rd lineagentagentsinHTN
Hydralazine+nitratesinHF
Inseverechronickidneydiseaseandinkidneyfailure.

34

23/06/2013

Vasodilators
Howtopreventthecompensatorymechanismand
anginaprecipitationinpatientswhoreceive
vasodilators?
A) Briefdrugholidaysshouldbescheduledtointerrupt
thecompensatorymechanism
B) PatientsshouldbestabilizedonACEorARBbefore
startinghydralazinetherapy
C) Patientsshouldbestabilizedonbetablockers+
thiazidediureticsbeforestartingvasodilators
D) Patientshouldadvisedtoavoidsuddenchangesin
positioninthefirsttwoweeksoftherapy

Vasodilators
Hydralazine:
UsedincombinationwithNitratesinHF
mortality,hospitalization, QOL(particularly
inAfricanAmerican).
Thecombination ADR(hypotension,
headache,flushing,dizziness,GIdistress)

Vasodilators
Hydralazine:
AdverseReactions:
Reversible,dosedependentlupuslikesyndrome
(keepdailydose<200mg)
Headache,flushing,hypotension,dermatitis,drug
fever,peripheralneuropathy,hepatitis
AvoidinLVH

ADRanddiminishingeffect usefulnessof
vasodilators

35

23/06/2013

Vasodilators
Minoxidil:
Morepotentvasodilator dramatic
compensatoryespeciallyNa/H2Oretention
precipitateHF
ADR:
Hypertrichosis (reversible,involveface,arms,
back,andchest)

Vasodilators
Minoxidil shouldbereservedfor:
A) PatientswithHTNandalopecia
B) PatientswithHTNwhocannottolerateACEI
C) Patientswithdifficulttocontrolhypertension
D) Patientswhoexperiencelupuslikesymptoms
whileonhydralazine

1ReceptorBlockers
Mechanism:Blocking1receptor
vasodilatation
DoNOT CVAsonotusedas1st linetherapy
UsefulinmaleswithHTNandBPH(butmustbe
usedincombinationwithotheragents)

36

23/06/2013

1ReceptorBlockers
ADR:
1st doseeffect:orthostatichypotension,dizziness,
fainting,palpitations,andsyncope(1 3hoursofthe
firstdoseordoseincrease).Take1st dose(and1st
doseafterincreasedose)atbedtime.Ifinterrupted
forfewdays startatinitialdose
OtherADR:nasalcongestion,palipitation,
hypotension,orthostaticdizziness,Na/H2Oretention
(optimaleffectand edemawhengivenwith
diuretic)
Prazosin maybeassociatedwithstillbirths

Central2Agonists
Mechanism:stimulatecentral2receptors
sympathetictone HR,cardiacoutput,PR,
plasmareninactivity BP
ADR:
Chronicuse Na/H2Oretention(avoidinHF)
Depression,sexualdysfunction, orthostatichypotension,
dizziness,andanticholinergiceffects (drowsiness,dry
mouth,constipation,etc.)nasalcongestion,palpitations,

Abruptwithdrawal reboundHTN(taper)

Central2Agonists
Methyldopa:1st choiceinpregnancy
ADR:
Drugfever+/ influenzalikesymptoms;
Hepatitis(transientLFT,ifpersist D/C)
Hemolyticanemia

Interactions:

Ironsaltsabsorp on(separateadministra on).

LDopa hypotension
TCAD BP
Li+ADR(withoutincreasingthelevel)

37

23/06/2013

Central2Agonists
Clonidine
CanbeusedforacuteincreaseinBP(0.1mgx1
then0.1mgq1hprn)
Avoidindiabetes(autonomicneuropathy)

BloodCoagulation

Source:http://almostadoctor.co.uk

38

23/06/2013

Plateletaggregationinhibitors

Plateletaggregationinhibitors
Threeclasses:
ASA
Dipyridamole
ADPreceptorblockers:
Clopidogrel
Prasugrel (Effient)
Ticagrelor (Brilinta)
Ticlopidine (Ticlid)

ASA
Indications&doses
AcuteMI( mortality) Chew/crush160162mg
ASAPthensamedoseqd x30daysthenreassess
1ryand2ry preventionofMI andstroke in
patientsatrisk80325mgpo daily
Unstableangina( mortality)
riskofTIA80325mgpo daily
PreventionofVTEaftertotalhipreplacement
650mgpo BID1daybeforesurgeryandcontinue
for14days

39

23/06/2013

ASA
Mechanism
InhibitsCOX1 inhibitsTXA2synthesis
irreversible inhibitionofplateletaggregation
Contraindications:

Hypersensitive
Historyofsalicylates/NSAIDinducedasthma
PatientsonMTXdose15mg/week
3rd trimesterofpregnancy
Activebleeding
Reyessyndrome
Severerenalandhepaticimpairment

ASA
DrugInteractions
Drugsinhibitingclotformation: effectandriskof
bleeding
Glucocorticoids/SSRI: riskofbleeding
NSAIDS riskofulcersandGIbleed
Ibuprofen plateletaggregationinhibitionbyASA
ASA effectofhypoglycemicagent(dosedependent)
ASA levelofvalproic acidanddigoxin
ASA effectofuricosuric agents(atlargedose)and
antihypertensivedrugs(dosedependent)

ASA
Adverseeffect(mostlydoserelated)
GI:upset(5%)bleed(2.7%)
Tinnitus,vertigo,hearingloss
Rash,fatigue,muscleweakness,gout,
leukocyte/platelets

Notes:
ASAshouldbediscontinued7 10dayspriorto
surgery(except CABGormoderatetohighCVrisk)
FreshplateletsareusedasantidoteforASA
5 10%maydevelopplateletresistance
Takewithfood

40

23/06/2013

ASA+Dipyridamole
Mechanism
ASA+Dipyridamole inhibitsplateletaggregation
andhasvasodilation effect.

Indication
2rypreventionofTIAandstroke

Contraindications
SimilartoASA+fructose/galactose intolerance
(capscontainlactose)

ASA+Dipyridamole
Adverseeffects
SimilartoASA+
Headache(atbeginning,common30%) donotuseNSAID
Dizziness(10%)diarrhea(13%)

Notes:
Avoidinpatientswithunstableangina(canworsen
Sxs duetoDipyridamole)
DoseforTIApreventiondoesnotofferMIprotection
(containonly25mgofASA/cap)
PreferredoverASAbuthigherD/Crate

ADPreceptorblockers
Clopidogrel

Prasugrel

Ticagrelor

Ticlopidine

Effect

Irreversible

Irreversible

Reversible

Irreversible

Prodrug?

Yes

Yes

No

Yes

+ASAin2ry
preventionof
MIinACS
withPCI

1ryand2rystroke
+ASAin2ry
preventionof prevention
MIinACS
withPCI
and/or CABG

Cancer
(lung/colon),
bleeding (
age>75and
weight<60Kg)

Bleeding(GI,
urinary tract)
Dyspnea,
cough,
headache,
arryhtemia
(A.fib/
bradycardia)

2rypreventionof
MI/stroke
+ASAto prevent
Indication strokeduetoA.fib
+ASAinunstable
angina/acuteMI

ADR

GIbleed,GIupset,
headache,rash,
dizziness,
thrombocytopenia
( 1st year,
monitorCBC
everyweekx4)

Rarely useddueto
ADR:diarrhea(Take
withFOOD),rash,
dizziness,
neutropenia
(monitorCBCevery
2weeksx3
months)

41

23/06/2013

ADPreceptorblockers
GHwillstartclopidogrel followingstent
placement.GHiscurrentlytakingPPIfor
preventionofGIbleed.Whichofthefollowing
PPIwillleastlikelyinteractwithclopidogre?
A)
B)
C)
D)
E)

Omeprazole
Lansoprazole
Pantoprazole
Rabeprazole
Allareequal

ADPreceptorblockers
Whatadvantagedoesclopidogrel offeroverASA
A)
B)
C)
D)
E)
F)

Lowercost
Moreeffective
LessADR
Longerduration
Higherpotency
Alloftheabove

ADPreceptorblockers
Clopidogrel
PPI(EXCEPT
pantoprazole)
activation &
effect
Azolesantifungal
activation &
Interaction effect

Prasugrel
Nothing
significant

Ticagrelor
3A4 inhibitors
(azoles,macrolides,
diltiazem,PI)
effect(CI)
3A4 inducers
(rifampin,
phenytoin,
carbamazepine)
effect
Ticagrerol
simvastatin/
digoxinlevel
(monitordigoxin)

Ticlopidine
phenytoin,
and
theophylline
level
cyclosporine
level
Antacids
ticlopidine
level

Allinteractwithdrugsaffectingbloodclotformation

42

23/06/2013

UFHandLMWH

UFHandLMWH
Mechanism:
BindtoandenhancetheeffectofAntithrombin
ACCELERATE theinactivateactivecoagulation
factors(Mainlythrombin(IIa)andfactorXa)
slowdownthecoagulationprocesswithout
breakingdown(lysis)theexistingclot(i.e.not
thrombolytic)

UF

LMWH

Largemolecule

Smaller(enz. degradationofUH)

Accelerateinactivationoffactors
IIa (thrombin)andfactorXa

AccelerateinactivationoffactorXa
2 4times>factorIIa

Highly boundtoplasmaprotein

Insignificantbinding

Removedbyendothelialsystem
(saturable) atlowdoseandrenally
(nonsaturable)athighdose

Removed renally (nonsaturable)

only.EliminationisNOTdose
dependent

T of0.5 2h(Dosedependent)

T of2 4h(Notdosedependent)

VariableSC bioavailability: 10
30%(lowdose)and>90%(high
dose)

Consistentbioavailability(>90%)

Unpredictabledoseresponse
(MONITORusingaPTT)

Predictabledoseresponse(No
needtomonitor)

43

23/06/2013

UFHandLMWH
Indications
UHandLMWH
TreatmentofDVT
Prevention(ex.Followingorthopedicandhighrisk
abdominalsurgery)

Heparin:
Preventclottingduringdialysis
MaintainIVlineopen(usedasaflush)

LMWH:
TreatmentofunstableanginaandSTsegment
elevationMI

UFHandLMWH
Contraindications
Hypersensitivity
ConfirmedTypeIIHIT
Activebleeding(ex.ulcer,hemorrhagicstroke)

riskofbleeding:

Patientswithclottingdisorderssuchashemophilia
Severeliverdamage
Patientswhohadarecentsurgery
Severehypertension

UFHandLMWH
WhichofthefollowingisanNOTanadverse
reactionofHeparin/LMWH?
A.
B.
C.
D.
E.

Allergicreaction(chills,fever,rash)
Hematomaatinjectionsite
HIT
Hypokalemia
Osteoporosis

44

23/06/2013

UFHandLMWH
WhichofthefollowingisNOTtrueaboutTypeII
HIT?
A.
B.
C.
D.

Immunemediated
plateletcountdropsbelow100x109/L
Onsetis2 5daysofinitiatingheparintherapy
Complicationsincludetheformationofwhite
thrombosis
E. Requirediscontinuationoftherapy

UFHandLMWH
WhichoftheisNOTtrueabouttreatmentof
TypeIIHIT?
A. D/Cheparintherapy
B. Freshplatelettransfusiontoplateletcount>
100x109/L
C. Plateletcountwillstarttorisewithin3 5days
D. Riskofthrombosisremainshighfor30days
E. Danaparoid,lepirudin,andargatroban canbe
usedasalternatives.

UFHandLMWH
Druginteractions:
Drugsaffectingbloodclot(oralanticoagulant,
ASA,thrombolyticagents) monitorfor
increasedriskofbleeding
Heparin:
IVnitroglycerin heparineffect(monitor)

45

23/06/2013

UFHandLMWH
Monitoring
Heparin:
Platelet: q23days,
aPTT : 6hoursafterinitiatingtherapy(4hinchildren)
x4thendaily(monitorq4hafterdosechange)
AntiXa levelcanbealsomonitored

LMWH:
Monitoringgenerallynotrecommended(butfollow
theheparinmonitoringabove)
Antifactos Xa levelcanbeusedinsomecases
(pregnant,obese,underweight)

UFHandLMWH
Notes:
Pregnancyandbreastfeeding
Heparin:
Safeinpregnancyandbreastfeeding
Alteredpharmacokinetics monitor
riskofbleedinginlasttrimesterandpostpartum
period monitor

LMWH:
1st choice(asperTC)
Safeinbreastfeeding

UFHandLMWH
Overdose
Heparin:
ElevatedaPTT butNO bleeding:
Holdheparin,monitor patient,mayrestarttherapyasneeded

Bleeding(especiallyaPTT >3xcontrol)
Protaminesulfate
Completereversal,doserequiredtoneutralize1000unitsvaries
(seelabel)
DoNOTexceed20mg/min (or50mgin10minutes) severe
hypotensionandanaphylacticreaction
Freshfrozenplasmacanbeused

LMWH:
Followsameprotocol
Protamine incompletereversal(doesnotreverseAntiIIa effect)

46

23/06/2013

HIT
Type1(nonimmunemediated directeffect)
Common,mild inplateletcount(remain>
100x109/L)inthefirstfewdays
Nothrombosis,maycontinueheparintherapy

UFHandLMWH
WhichofthefollowingisNOTtrueconcerning
theSCselfadministrationofLMWH?
A. ShouldbeinjectedinUshapedarea
surroundingnavel
B. Injectionsiteshouldvarydaily
C. Needlemustbeinsertedat45 90degreeangle
D. Thepatientmustsitorlyedownduringinjection
E. Noneoftheabove(alltrue)

UFHandLMWH
NOTES:
LMWH
SCisthepreferredrouteofadministration
Avoidinischemicstrokeuntilhemorrhageisruledout
Multidosevialsoftinzaparin containsodium
metabisulfite cancauseanaphylacticreactionin
certainpeople(ex.Asthmatic)
MultidosevialsofallLMWH(EXCEPTNadroparin)
containbenzylalcohol fetaltoxicsyndrome(avoid
inpregnancy)

47

23/06/2013

UFHandLMWH
NOTES:
Heparin
UsedIV(immediateonset)anddeepSC(<1hour
delayedonset)
Linearkinetics
Noactivemetabolite
Heparinresistancemaydevelopinpatientswithlow
ATlevel
Avoidinischemicstrokeuntilhemorrhageisruledout
Avoiduseinpregnantwithprostheticvalve

UFHandLMWH
NOTES:
Heparin
Treatmentdose
ContinuousIVinfusion:Tworegimens
5000IUbolusthen1300units/hourOR
80IU/Kgbolusthen18/Kg/h

SC:Tworegimens
Monitored:17500IUor250IU/Kgq12h
Unmonitored(Home):333units/Kgfirstthen250IU/Kgq12h

Prophylaxis:5000IUq812hSC(notnecessaryto
monitoraPTT withthisdose)

Warfarin

48

23/06/2013

Warfarin
Mechanism:
InhibitvitaminKdependentclottingfactorby
inhibitingvit.Kepoxidereductase (VKOR) 30
50%reductioninfactorsII,VII,IXandX)
Onset:24hourswithpeakanticoagulationin3 4
days
Durationofsingledoseis2 5days
Metabolism:MultipleCYP450enzymesbut2C9is
themainone.

Warfarin
WhichofthefollowingisNOTanindicationfor
warfarin?
A) TopreventtheformationofDVTandPE
B) Topreventtheextensionofvenousthrombosis
C) Toreverseischemiainpatientswithacutestroke
D) InpatientswithA.fib topreventstroke
E) None(Alloftheaboveareindications)

Warfarin
Contraindications:
Pregnancy
Active/uncontrolledbleeding
Hx ofwarfarininducedskinnecrosis
Hemorrhagictendency

RecentorcontemplatedCNSoreyesurgery
Surgeryinvolvinglargeopenspace

CautioninpatientswithHIT(reportedlimb
necrosis)

49

23/06/2013

Warfarin
Monitoring:
WhendoweneedtomonitorINR?
inthefollowingsituations:
Initiationofwarfarintherapy
Increasingwarfarindose
Startinganewinteractingdrug

Warfarin
Monitoring:
Newpatient:

MonitorPTdailyuntilINRis

stabilizedinrange
Week1:Day3and5
Week2:checkINRtwice
Startingweek3:weeklytillINRwithinrangex2weeks
thenevery2weekstillwithinrangex1monththen
monthlytillstablex3monthsthenevery12weeks

Warfarin:weeklytillstablethenasabove
Newinteractingdrug:INRin5daysthenweekly
asabove

Warfarin
AllofthefollowingfactorswouldaffectINR
EXCEPT:
A.
B.
C.
D.
E.
F.

Comorbidities
Genetics
Diet.
Socialhistory
Environment
Alloftheabove

50

23/06/2013

Warfarin
VBcallsthepharmacytodayinpanic.Heindicates
thathemadeamistakeandhasbeendoublethe
warfarindosebyaccident.Whatisthebest
response?
A. Holdwarfarinandcontactphysicianfordose
adjustment
B. ContactthephysicianASAPtogettheINRchecked
C. May intakeofgreenleafyvegetabletodecrease
theeffectofhighdose
D. Inquireaboutsymptomsofbleedingandadvisethe
patienttoseethephysicianforINR

Warfarin
VBdeniesanysignsorsymptomssuggesting
bleeding.Intheabsenceofsignificantbleeding,
whenshouldyouvitaminK?
A.
B.
C.
D.

WhenINRis>3and<4.5
WhenINRis>4.5and<10
WhenINRis>10
VitaminKisreservedforpatientswithserious
bleedingonly

Warfarin
IfVPhasseriousbleeding,whichofthe
followingisNOTtrue?
A.
B.
C.
D.
E.

VitaminKshouldbegivenonceINR>6
Shouldget510mgofIVvit.K
VPmustholdwarfarin
FactorIVprothrombin concentrateisrequired
Noneoftheabove(alltrue)

51

23/06/2013

Warfarin
VPisgoingforaminordentalsurgeryandthe
dentistandphysicianagreedtocontinuewarfarin
therapy.Whichofthefollowingcanbeusedto
reducebleeding?
A.
B.
C.
D.

VitaminK2.5mgpo 1 2hoursbeforesurgery
VitaminK2.5mgIV30minutesbeforesurgery
Tranexamic acidmouthwashpresurgery
Reducewarfarindoseby15%3 5daysbefore
surgery
E. Minordentalsurgeriesaresafetohavewhileon
warfarin

Warfarin
Whichofthefollowingantidotescanbeusedto
reversetheeffectofwarfarininpatientswith
bleeding?
A. FactorIVprothrombin complex
B. Freshfrozenplasma
C. RecombinantfactorVIIa
D. VitaminK
E. Alloftheabove

Warfarin
Seriousadversereactions:
Bleeding:10%(serious1%)
Whatfactors theriskofbleeding?

INR>4 orhighlyvariableINR
Age>65
Uncontrolledhypertension
Hx ofGIbleeding
Longdurationoftherapy
Cancer
Interactingdrugs
Liverdiseases

52

23/06/2013

Warfarin
Seriousadversereactions:
Skinnecrosisduetomobilizationofplaque
emboli.Ex.Purpletoesyndrome(reversible,
appear3 10weeksmayprogressto
gangreneandrequireamputation)
OtherADR:
N/V,diarrhea,abdominalcramps,alopecia,
dermatitis

Warfarin
PatientsTAKINGALLmedsthatinhibitbloodclot
shouldbeeducatedtomonitorincreased
bleeding:
Unexplainedbruising
Nosebleed (epistaxis)
Gumbleed
Bloodinurineorinstool
Blacktarrystool

Aldosteroneantagonists

53

23/06/2013

Spironolactone
Mechanism:Aldosteronereceptorblocker
Indications:1ryHyperaldosteronism,CHF,
edema/ascitesinlivercirrhosis,HTN (mild
effect,usedwithotheragents)Hypokalemia
(treatmentandprevention)
CI:hypersensitivity,anuria,hyperkalemia(donot
startifK+ >5mmol/L),renalimpairment(donotstart
inCrCl <30ml/min),concomitantusewith
eplerenone,UF&LMWH(K)

Spironolactone
Druginteractions:
Similartothiazides.
Spironolactone digoxinlevel monitordigoxin

AdverseReactions:
hyperkalemia,gynecomastia,diarrhea,headache,
dizziness,legcramps.

Spironolactone
Notes:
D/CK+supplementoncestartspironolactone
Advisepatienttoholdspironolactoneifdevelop
diarrhea
Takewithfood

Monitoring:
SrCr andK+ 3daysand1weekafterinitiatingor
doseincrease.Repeatevery13monthsonce
stable.D/CifK+>5

54

23/06/2013

Eplerenone
WhichofthefollowingisNOTtrueabout
eplerenone?
A) Itismorepotent
B) IndicatedonlyforHFandpostMI
C) Itcauselessgynecomastia
D) Itcauseslessimpotence
E) Noneoftheabove(alltrue)

55