Pharmacology Session 1 Study GuideModule 1 Pharmaceutics: Study of how the drug forms influence pharmacokinetics and pharmacodynamics

Pharmacokinetics: Drug movement throughout the body Absorption: Administration to blood stream Distribution: transportations through the body Metabolism: changes activity of drug to be excreted Excretion: kidneys, liver, bowel Ways to administer: (Fastest to Slowest) #1: IV, SL, Inhilation #2: PO, SQ, IM #3: Rectal, Extended Release, XL (extended release), coated Pharmacokinetic Curve: onset & duration Peak: highest point, most effective/therapeutic Trough: lowest level, excretion time

Pharmacodynamics: How drugs produce change in the patient MOA: Receptor/Enzyme/non-selective interactions Drug and receptor site

Six Rights Medication Dose Route Time Patient Documentation 3 More Rights Refuse Receive education Correct preparation

Module 2 Gram +/- Gram + has thick layer Gram has thin layer and outer membrane Antibiotic Coverage Narrow Spectrum: only covers + or (not both) Broad Spectrum: covers both + and Bacteriocidal: kills bacteria Bacteriostatic: slows growth and prevents further growth Drugs Used: Sulfonamides Betalactams Macrolides Tetracyclines Aminoglycosides Quinolones Miscellaneous

Sulfonamides: Alters growth so it cannot multiply (bacteriostatic) Prototype: trimethioprim-sulfamethoxazole (Bactrim/Septra) Others: Sulfamethoxazole Sulfazaxoline Sulfisoxazole Nursing Considerations: maintain fluids (these drugs can cause crystallization) Teach: Rashes, photosensitivity, bone marrow suppression (BMS). Monitor glucose (Increased hypoglycemic effects) Med Interactions: Coumadin will have increased effects

Penicillin: Kills cells so it wont grow (bacteriocidal) MC use: skin & staph infections Narrow Spectrum Prototype: penicillin G potassium Others Dicioxacillin Oxacillin Broad Spectrum (aminopenicillins G+) Prototype: ampicillin Others: Amoxicillin Penicillinase Inhibitors: Prototype: amipicillin w/sulbactim Others: Amipicillin clovadinate Extended Spectrum (G-) Prototype: piperacillin Others: Ticarcillin Nursing Considerations: adequate hydration, watch for superinfection, anaphylaxis, GI symptoms, candidiasis Teach: Avoid grapefruit juice

Cephalosporins Bacteriocidal 1st Gen: cephalexin (Keflex) G+ 2nd Gen: Cefuroxime, cefotetan 3rd Gen: cefotaxime/cefdinir 4th Gen: cefepime 5th Gen: CeftobiproleG- Nursing Considerations: Cross-sensitivity to penicillins Prolongs effects of anti-coagulants (Incr. bleeding) Teaching: Avoid alcohol Rash, anorexia, GI pain/upset may occur

Tetracyclines Broad Spectrum MC Use: skin, soft tissue, abd. cavity, pneumonia Prototype: tetracycline (Achromycin) Others: Democlocycline Doxycycline Minocycline Nursing Considerations: Stains teeth. Avoid milk/antacids/calcium. Passes in utero and breast milk Teaching: Can cause photosensitivity Use sunscreen Rinse mouth, avoid calcium products Contraindicated in pregnancy and breastfeeding Aminoglycosides Bacteriocidal/aerobic G- (Gram neg aerobic organisms need oxygen vs. anaerobic needs none) Prototype: gentamycin (Garamycin) Others: Amikacin Kanamycin Neomycin Streptomycin Tobramycin Nursing: nephro/ototoxicity (Look for vertigo and ringing) Peak/trough will be drawn BUN/Creatinine, F&E levels Hearing baseline! Teaching: Nephro/ototoxicity S/S. Rash, itching may occur

FYI: PEAK LEVEL: BLOOD WILL BE DRAWN ONCE TO CHECK LEVEL TROUGH LEVEL: BLOOD WILL BE DRAWN TWICE TO CHECK LEVEL

Macrolides: Bacteriostatic/bacteriocidal effects Prototype: erythromycin Others: Azithromycin (Z-Pak) Clarithromycin Nursing: liver toxicity CAM (Herbal) remedy interactions NVD, abd. pain, superinfection can occur Teaching: Talk to doctor about OTC meds/herbals Fluoroquinolones: Bacteriocidal 1st Gen: nalidixic acid 2nd Gen: ciprofloxacin (Avoid under 18 yrs) 3rd Gen: levofloxacin 4th Gen: pernifloxacin Nursing: Avoid during pregnancy 1-2x/day admin Maintain fluids ( as needed) Photosensitivity Avoid taking with iron and antacids Use caution in: CNS disorders Renal disorders Seizures Theophylline Teach: NVD Dyspepsia (indigestion) Constipation/gas

Vancomycin Gram +; Generally MRSA IV over 1 hour (slower if having mild reaction) Monitor for REDMAN SYNDROME Decrease in BP, red flushing first signs Pretreat with Benadryl Nephro/ototoxicity Peak/trough level monitoring Others Clindamycin Aztreonam Primaxicin

Antivirals HSV, Influenza, RSV, HIV

HSV Infections: HSV1 & 2, EBV, Varicella (Pox/Shingles) Prototype:acyclovir (Zovirax) MOA: reduce viral shedding Others: Docosonal (Abreva) Famiciclovin Penciclovin Valacyclovir (Valtrex) Teach: oral is affected by foods. Get treated as soon as breakout occurs. Use separate fingers for application (topical) NVD, fever, HA, dizziness, nephrotoxicity

Anti-Influenza: Tx must be within 48 hours Prototype: amantadine (Symmetrel) Others: Oseltamavir (Tami-flu) Zanamavir Nursing/Teaching: Within 48 hours, PO, with food, during day (Can cause insomnia). CNS stimulation, anxiety

Anti-RSV Prototype: ribavirin (Virazole) Nursing: Avoid during pregnancy, be away from treatments Watch for pulmonary changes Mostly babies and geriatrics

Anti-retroviral (HIV) Prototype: nevirapine (Viramine) Other: Saquinavir (Fortovase) Nursing/Teaching: Hepato/ototoxicity (monitor lab values) Orange urine NVD Cocktail (3-4) drugs, to prevent resistance Assess for skin lesions/pain/itching Does not cure/expensive/lifelong Take at consistent times Avoid intercourse during breakout

Anti-Fungal Fungostatic/Fungocidal Prototype: amphotericin Fluconazole Metronidazole Other: Ketoconazole Nursing: Watch for IV incompatabilities Monitor for anaphylaxis, cardiac arrest, nephrotoxicity, fever, chills, rigor, HR/BP Tylenol, Benadryl, hydrocortisone, Demerol used for shaking Avoid alcohol and alcohol products SE: HA, dry mouth, fatigue, metallic/bitter taste, GI distressModule 3: Respiratory System Common Cold: Infection/inflammation of Upper Respiratory System (URS) S/S: congestion and drainage. Productive cough Asthma: Bronchospasm and inflammation TB: Persistent, productive cough, chills/fever, night sweats, +PPD, abnormal CXR, +sputum culture

Antihistamines: MOA: blocks effects of antigens on histamine by blocking receptor. Relieves symptoms of nasal allergies. Prototype: Benadryl Brompheniramine 2nd Gen: Fexofenadine Loratidine Certirizine SE: Dry eyes, mouth, vision changes, urinary retention, constipation

Nasal Decongestants: Constricts arterioles and reduces blood flow to nasal mucosa Prototype: naphozoline (Pivine) Other: Ephedrine sulfate Pseudoephedrine (Sudafed) Oxymetazoline (Afrin) Phenylephedrine Nursing: Nasal rebound and dependence may occur. Nervousness and palpitations may occur

Corticosteroids: Nasal: relieves nasal obstruction and discharge Prototype: fluticasone (Flonase) Nursing: Given as intranasal spray Wound healing is a problem (steroid) Glucose unstable (steroids increase glucose serum levels) ACCU-CHEK! Antitussive: Prevents cough; increases salivation, may contain anesthetics Narcotic: codeine Non-narcotic: dextromethorphan (Robitussin DM), benzonatate

Expectorants: To cough; stimulates cough activity Prototype: guaifenesin (Robitussin) Nursing: Increase fluids, will aid in thinning secretions

Mucolytics: Breaks up mucous Prototype: acetylcystine (Mucomyst) Nursing: Increase fluids, will aid in thinning secretions

Bronchodilators: Beta1/Beta2 Agonists Acute attacks/Short Acting: Prototype: albuterol (Proventil) Other: levalbuterol (Xopenex) Long-lasting: Prevent attacks Long lasting have increased side effects Beta 1 Agonist: Metaproterenol (Alupent) Beta 2 Agonist SE: tachycardia/dysrhythmias, palpitations, hyper/hypotension, restlessness/nervousness/agitation, insomnia, vascular headaches Agonist: fits perfectly and causes reaction

Bronchodilators: Anticholinergics Blocks PNS stimulation, allows SNS to take over Prototype: ipratropium (Atrovent)/ tioproprium (Spiriva) SE: dry eyes/mouth, constipatin, blurred vision, urinary retention

Bronchodilators: Xanthines: Dilates smooth muscle Prototype: theophylline (COPD, Asthma, CHF), Elixophilline (Short-acting), Theo-dur SE: tachycardia/dysrhythmias, CNS stimulation, insomnia, convulsions, palpitations Avoid caffeine Nursing/Teaching: Must receive around the clock, with water, food if upset occurs

Bronchodilators Summary Adrenergic Agonists: Beta1/2: SNS receptor stimulation Anticholinergics: Blocks PNS Xanthines Direct action on bronchial smooth muscle

Anti-Inflammatories: Corticosteroids Decrease inflammation in airways Prototype: beclomethlasone (inhalation) Others: budesonide, flunisolide, fluticasone, trriamcinolone, fluticasone w/salmeterol Prototype: prednisone (oral) Other: methylprednisolone (PO/IV) All preventative. Will NOT help in acute attack Decrease mucous, decrease airway edema, decrease reactivity (to environmental stimulants) Oral/IV SE: Incr. risk of infection Decr. Wound healing Multiple metabolic effects Inhaled SE: Hoarseness Cough Throat Irritation Fungal infection of mouth (RINSING) Teaching: Rinse after every dose, casting should be rinsed too Adm: dilator ( inc. expansion) then steroid (5 min. after)

Anti-Inflammatories: Leukotrine Receptor Antagonist Prevents acute asthma attack Prototype: montelukast (Singular) Inhibits leukotrine receptors SE: HA, systemic infections, nausea, muscle pain, Incr. liver function tests

Anti-Inflammatory: Summary Corticosteroids: Suppress inflammation Inhalation/PO/IV Leukotrine Receptor Antagonists: block chemical reaction of inflammation. Inhilation: causes bronchodilation Teaching: Dilators/Anti-Inflammatories Avoid allergens. Stop smoking Monitor resp. status Short term for acute symptoms Use even when symptom free Always shake/force out air in lungs PERF: Peak Expiratory Flow Rate (decr.= treatment, incr. = good)

Anti-tuburcular: Prototype: isoniazid (INH) Others: Rifampin Pyrazinamide Streptomycin (IM, painful) Ethambutol Anti-viral cocktain (resistance) Decreases warfarin and oral contraceptive effects 6-24 months treatment regimen Take at same time every day SE: NVD, peripheral neuritis (B12) ototoxicity, hepatotoxicity (no alcohol), Flu-like symptoms 2-3 week isolation until non-infectious 3 consecutive negative sputum culturesModule 4: GI System Sodium: do not use w/renal and cardiac patients, or liver patients (fluid retention) Aluminum: slower onset but better tolerance in renal patients SE is constipation Magnesium: is faster onset and NOT tolerated in RF patients Calcium: is tolerated in renal failure Decrease phosphorus Can have acid rebound Can also use with osteoporosis

Antacids: Used to neutralize stomach acid (decr. Pepsin activity) Aluminum hydroxide/carbonate Magnesium hydroxide Calcium carbonate Sodium bicarbonate Do not use with sensitivity or electrolyte imbalance or GI obstruction Follow with water, 1-3 hour after meal & HS (at bed) 1 hour before or after other meds, not with Monitor and fecal impaction, Gi obstruction, hypophosphatemia

PUD & Acid Reflux Diseases H2 Receptor Antagonist: (Competes for H2 Site):Decrease acid production Famotidine Cimetidine (Tagamet) Ranitidine (Zantac) nizatidine (Axid) SE: B12/iron deficiency(long-term), drowsiness/dizziness Considerations: Smoking decreases effectiveness Black/tarry stool may occur Should tolerate food and no burning May increase candida and bacteria in stomach Avoid irritating factors

PPI: Proton Pump Inhibitor:decreases gastric acid secretion Prototypes: Omeprazole (Prilosec) Panloprazole (Protonix) Lansoprasole (Prevacid) Esomeprazole (Nexium) Rabeprazole (Aciphex) Considerations: 30-60 minutes before breakfast. Give whole. SE: HA, nausea, diarrhea, abd. pain, toxicity, seizure, resp. depression, decr. LOC Med Interactions: valium (incr. serum), dilantin (incr. serum)

MISC. Anti-Ulcer Coats gastric lining Sucralfate (Carafate) Give 1 hour before meals & HS Antacids 30 mins before or after SE: constipation Anti-Flatulant Reduce eructation or flatus Proto: simethicone (Mylicon) Given orally and calcium antacid to decr. gas formation 1-2 tabs, 4-6x/day Antidiarrheals Adsorbents: Treats diarrhea Proto: bismuth subsalycilate (Pepto) SE: darkening of tongue and stool Increases effects of Coumadin and decreases effect of Digoxin

Anticholinergic: decreases peristalsis Proto: atropine SE: dry eyes/mouth, constipation, urinary retention, blurred vision

Opiate-Related: reduces peristalsis Protos: diphenoxylate w/atropine (Lomotil) Loperamide (Imodium) OTC SE: constipation and dizziness Major SE: sedation, tachycardia, fatigue, depression, GI discomfort, constipation Flora Modifiers: Restores flora after antibiotic therapy Proto: lactobacillus acidophilus (Bacid) Live culture must be obtained Prevent diarrhea, F&E imbalances, clear liquids or IVF. Good skin care Build to normal diet

Constipation: Regulation= fluid and food intake and peristalsis Laxatives: Bulk Forming Promotes bowel elimination (stretches bowels) Psyllium hydrophilic muciloid (Metamucil) Methylcellulose (Citrucel) Calcium polycarbophil (FiberCon) Must mix with 8 oz. and follow with water. SE: impaction or obstruction, NVD

Laxatives: Stool Softeners Prevents constipation and straining at stools Docusate sodium (Colase) Mineral oil (OTC) Do not give if GI obstruction is present SE: Diarrhea Laxatives: Hyperosmotics Treats constipation and impaction, test-prep Lactulose Polyethylene glycol-electrolyte soln Sodium (bi)phosphate Stimulates for peristalsis: semi-liquid stools Laxatives: Saline Draws in F&Es. (usually test prep) Magnesium citrate/hydroxide/sulfate Do not use in renal disease or heart disease SE: abd. cramping, diarrhea, dehydration Laxative: Stimulant: Bowel Cleanse Bisacodyl (Dulcolax) OTC Senna (senakot) SE: diarrhea Give at night Stimulant Cathartics Oral: dont chew, 1 hour before or after antacids, not with Rectal: 1 finger length against bowel wall mucous membranes SE: diarrhea Give at night Establish bowel elimination routine Short term use only

Antiemetics

Antiemetic: Anticholinergics Reduce motion sickness Prototype: scopolamine (Trans-derm Scop) Do not use in glaucoma SE: dry eyes/ mouth, burred vision, constipation, u. retention

Antiemetic: Antihistamines Controls N,V, pre-op, Labor & Delivery Prototype: meclizine (Antivert) Other:dimenhydrate (Dramamine) SE: drowsiness, dry mouth

Antiemetic: Antidopaminergics Controls chemo induced N &V IV irritation can occur Prototype: prochlorperazine/promethazine SE: dry mouth, sedation, orthostatic hypotension, tachycardia, extrapyramidal symptoms Extrapyramidal Effects: Dyskinesia: impaired ability to do voluntary movement Dystonia: very strong spasms Akathisia: flaccid/floppy Parkinsonian Symptoms: pill rolling, shuffling, ataxic gait

Antiemetics: Prokinetic Agent: (emptying, peristalsis) Treat/prevent NV; GERD Prototype: metoclopramide (Reglan) SE: Sedation, fatigue, restlessness, extrapyramidal effects, diarrhea

Antiemetics: 5-HT (Serotonin) Receptor Antagonist Prototype: odansetron (Zofran) Others: Granisetron Dolasetron SE: headache, dizziness, diarrhea, constipation

Antiemetics: Tetrahydrocannabinoids Reduce N, V, increase appetite Prototype: dronabinol (Marinol) Derivative of marijuana Monitor F/E imbalances. 30-60 minutes before procedure Monitor safety for drowsiness Do not give food or drink during acute episodeModule 5: Neurologic Drugs CNS Depressants Benzodiazepines: Decrease anxiety, treat insomnia, treat seizures and withdrawal discomforts Long Lasting: pam Diazepam (Valium)/lorazepam (Ativan) Short Acting: lam Midazolam (Versed)/Alprazolam (Xanax) Monitor: respiratory depression, dysrhythmias, hypotension, decreased LOC, agitation, confusion Use caution: COPD, heart/renal failure Avoid sudden withdrawal (rebound) Use caution with other CNS depressants SE: sedation, increased intraocular pressure, respiratory depression, overdose

Insomnia: Hypnotic Effects Benzo: temazepam (Restoril) Others: zolpidem (Ambien), zalesplon (Sonata), eszoplican (Lunesta), ramelteon (Rozerem) SE: respiratory depression, daytime drowsiness, dizziness, sleepwalking, eating Use caution in the elderly Teach: 30-60min before bed. Morning grogginess, short-term use, additive effects, keep away from children.

Barbituates: seizures, sedation Prototype: Phenobarbital: Potentiate GABA Others: pentobarbital, thiopental, methoexital SE: sedation, respiratory depression, paradoxal excitement

Muscle Relaxants Central Acting: Cyclobenzaprine (Flexeril) Baclofen (Lioresal) SE: drowsiness, sedation, muscle weakness Give with food or milk Do not stop intrathecal dose abruptly Direct Acting: Dantrolene (Dantrium) SE: N, V, drowsiness, sedation, muscle weakness

CNS Stimulants ADHD Drugs Prototype: methylphenidate (Ritalin, Concerta) Others: atomoxetine (Strattera) Non-stimulant SE: nervousness, insomnia, dysrhythmias, CAD, HTN Give with meals, give last dose before 6 PM Drug holidays to increase effectiveness

Antinarcolepsy & Anorexient Narcolepsy, decreased appetite, decreased fat absorption Adderall Phentermine (Ionamin Orlistat (Xenical( (Alli)

Antimigraine Drugs Serotonin Receptor Agonist Prototype: sumatriptan (Imitrex) Eletriptan (Replax) Ergot Alkaloids Prototype: ergotamine w/caffeine (Cafergot) Do not use in CAD, HTN SE: Increased BP, chest pain, paresthesias Analeptics: post-pone need for sleep Xanthenes: Do not use in PUD, CAD Proto: caffeine SE: sleep deprivation Can potentiate analgesics

Antiepileptic Drugs Seizures: barbiturates, hydantoins, benzodiazepines, iminostilbenes, misc., succinimides, unspecified Hydantoins: PO/IV Proto: phenytoin (Dilantin) Do not give w/antacids Do not mix phenytoin with any other drug. Administer slowly SE: ataxia, drowsiness, lethargy, N, V, bradycardia, gingival hyperplasia Barbituates: PO/IV/IM Proto: phenobarbital SE: drowsiness, addiction Iminostilbenes: PO (taper) SE: allergy to sulfonamides, dizziness, headache, drowsiness Nursing process with Antiepileptic Drugs Monitor for seizure Teach to monitor for aura Teach consistent dosing Safety measures Treatment is lifelong-wear medic alert bracelet Common Interactions Avoid alcohol, smoking, caffeine Avoid milk, juices and carbonated beverages Avoid antacids Common Side Effects Photosensitive: sunscreen Drowsiness: safety If SE occur notify, do not abruptly withdrawal seizures can occur Carbamazepine (Tegretol): Visual problems, ataxia, vertigo Valporic Acid (Depakote): GI upset, hepatotoxicity

Anti-Parkinsonian Dopamine Receptor Agonists: Allow dopamine to be used at receptor sites Indirect Acting: Selegilline Amatadine Entacopone Direct Acting: Bromocriptine Ropinirole

Dopamine Replacements Proto: carbidopa-levodopa (Sinemet) SE: Anorexia, N, V, orthostatic hypotension, tachycardia, preventricular contractions, dyskinesias, agitation, confusion On/Off phenomenon (med break to incr. effectiveness)

Anticholinergics: Decrease muscle tremors/rigidity Proto: benztropine mesylate (Cogentin): PO/IM/IV PO with food to decr. irritation SE: SLUDGE

Antihistamines: Reduce Acetylcholine(Ach) effects Proto: diphenhydramine (Benadryl) Acetylcholine: organic, polyatomic cation that acts as a neurotransmitter in PNS and CNS.

Parkinsons Considerations Safety Measures Avoid hazardous activities Position changes slowly Monitor effect on gait Oral hygiene, constipation, monitor I/O

Anemia Drugs B12 & Folic Acid: Pernicious Anemia (PA) Proto: cyanocobalamin (Cyanabin): PO/IM/SL/SQ Folic Acid (Folvite)-Do not use in PA-PO/IV

Iron Preparations: microcytic-anemias MOA: aids in RBC formation Foods high in iron:Gr. Leafy veggies, veal, fish, OJ Protos: ferrous sulfate/fumarate/gluconate (PO) Others: iron dextran/sucrose (IV/IM) Avoid milk, eggs, corn, cereals Use z-track method Stains teeth, vit. C increases absorption, keep away from children SE: GI upset, dark/tarry stools, constipation, heartburn

Coagulation Modifiers Anticoagulants: Prevents formation of clots and extension of clots present Thrombocytopenia: low platelet count Hemophelia: missing factor + FFP H-A: Factor VIII H-B: Factor IX (Christmas Disase) VonWillebrands Disease: Factor VIII + DDAVD

Heparin: Prevents clotting Proto: Heparin Other: enoxaparin (Lovenox) =LMWH Lovenox absorbed more consistently. LMWH is more stable Given SQ-abd. fat pad, avoid umbilicus and bruises Do not absorb will in muscle Not a thrombolytic Monitor PTT. IV:2-6 hour, SQ:8-12 hours Antidote: protamine sulfate Drug Interactions: antiplatelet, NSAIDs, Coumadin, feverfew, gingko, ginger, valerian root- all increased effects (Incr. risk of bleeding) Protamine sulfate, nitroglycerin, digitalis, nicotine, tetracyclines, antihistamines (Decr. risk of bleed, decr. effects)

Warfarin (Coumadin) Prevent/manage DVT, PE Used after MI Therapeutic effect occurs 3-5 days after oral use Antidote: Vitamin K Educate on diet Drug Interactions Incr. Effects: NSAID, steroids, bacteria, fungus, depression, CV/GI drugs Decr. Effects: antacids, carbamazepine, cholestyramine Maintain consistent level of intake Monitor vitamins C/E Monitor PT/INR Overdose: hemorrhage, HA, bruising, back pain, incr. pulse, incr. BP

Anticoagulant Evaluation: Heparin: (PTT): 1-2x control (NL=25-40 sec) Warfarin: (PT): 1-2x control (NL=12-15 sec) INR: 2-3.5 Adverse Effects: Bruising/bleeding-into mucous membranes (nose, gums, lungs, GI, GU, vagina) Nursing: Same time QD, contact HCP w/bleeding, safety measures

Platelet Anti-Aggregants Prevent platelet aggregation, prevent thromboembolism Proto: acetylsalicylic acid (Aspirin) Others: Dipyridomole (Persantine) Clopidogrel (Plavix) ASA SE:tinnitus, gastric ulceration and GI bleeding (give with food) Clopid SE: BMS, hypersensitivity Use caution in hepatic/renal problems and history of bleeding

Glycoprotein IIb/IIIa Receptor Blockers Used to prevent thrombosis after recent MI/CVA or PCTA Proto: eptifibatide (Integrillin) Others: Abciximab (ReoPro) Tirofiban (Aggrastat) Given IV SE: bleeding Give with food, safety measures, giving with anticholinergics increases risk for bleeding, BMS Antacids decr. absorption Garlic has antiplatelet effects, may decr. risk of HD or stroke Thrombolytics: ase Dissolves clots (inc. vasc. Catheters) Ex: Altepase (Activase) Reteplase (Retevase) Tenecteplase (TNKase) Anistreplase (Eminase) Streptokinase (Streptase) Given fast to prevent ischemia Must be administered 3-4.5 hours of acute event to prevent tissue infarction Peak effect 5-10 min SE: bleeding, monitor frequently, bedrest, safety measuresModule 6: Heart Failure & HTN Heart Failure Drugs Human Natriuretic Peptid B-Type Decrease preload and afterload Nesiritide (Natrecor) IV dedicated line SE: hypotension

Positive Inotropic Agents: Increase Contractility Glycosides, Beta Adrenergics, PDIs Cardiac Glycosides:strengthen contractility Digoxin (Lanoxin) Given PO/IV Serum levels stabilize after 1 week Antidote: Digibind SE: anorexia, NVD, vision changes (Yellow halo) Use caution in clients w/ acute MI, heart block, electrolyte (K) imbalances, renals Apical >60 HR: 60-120 NL level: 0.5-0.8ng/mL Hold if >1.0ng/mL

Phosphodiesterase Inhibitors Increase contractility, decrease afterload Milrinone (IV) Short-term use and rapid onset Bolus-continuous SE: ventricular dysrhythmias, tachycardia, hypotension, thrombocytopenia

Beta Adrenergic Agonist Increases contractility Dobutamine (Dobutrex) IV SE: tachycardia Diuretics Thiazide Diuretics Increase urine volume Reduce preload/afterload by decr. BP in HF and HTN EX: Hydrocholorthiazide (HCTZ) Metalozone (Zaroxolyn) Chlorthalidone (Hygroton) Sulfa allergy is contraindicated Onset: 2 hr Peak: 4-6 hr D: 6-24 hr SE: hypokalemia, hypovolemia, and dehydration

Loop Diuretics: Increase urine volume Reduces preload/afterload (BP), reduces pulmonary and peripheral edema EX: furosemide (Lasix) Bumetanide (Bumex) Tosemide (Demedex)\ MOA: inhibit Na & Cl reabsorption in ascending limb of loop of Henle Na restriction! SE: hypokalemia, hypovolemia, ototoxicity, muscle cramps

Potassium-sparing Diuretics: Increase urine volume Reduce preload/afterload sparing potassium EX: spironolactone/triamterene Do not use in renal failure, oliguria SE: hyperkalemia, HA, NVD, Fatigue, GI upset

Combination: Nondiuretic antihypertensive + potassium sparing diuretics EX: Maxide

Osmotic & Others Osmotic: maintain urine flow w/ARF and prolonged surgery. Reduces ICP EX: mannitol (Osmitrol) Carbonic Anhydrase Inhibitors: decrease intraocular pressure EX: acetaxolamide (Diamox)

Diuretic Considerations Give early during day Give with food, easy method for voiding Monitor BP, I/O, weight Monitor electrolytes, CO2, BUN, uric acid Position changes slowly

Heart Failure and Hypertension ACE Inhibitors: pril decrease preload and afterload EX: Lisinopril Enalapril Fosinopril Ramipril Captopril Benazopril MOA: blocks RAAS SE: persistent, dry cough, Orthostatic hypotension, hyperkalemia, angioedema, neutropenia

Angiotensin II Receptor Blockers (ARBS) Decrease preload and afterload, decrease BP EX: losartan (Cozaar) valsartan (Diovan) olmesartan (Benicar) SE: less likely to cause hyperkalemia than ACE inhibitors Persistent coughs are rare

Direct Vasodilators (Misc) Reduce preload/afterload (nitrates) Reduce afterload (Direct acting vasodilators) EX: Isosorbide dinitrate Hydralazine (Apresoline) Combo (BiDil)

Beta Blockers: olol MOA: block the effect of norepinephrine and epinephrine, beta blockers reduce heart rate; reduce BP by dilating vessels. EX: Propranolol Atenolol Metoprolol Nadolol Nebivilol SE: HF, bradycardia, respiratory distress, masks signs of hypoglycemia, postural hypotension

Alpha & Beta Blockers Reduce afterload EX: carvedilol (Coreg) labetalol (Trandate) SE: HA, dizziness, masks hypoglycemia, postural hypotension, GI, CHF

Anti-Hypertensives Non-pharmaceutical modifications Decrease weight, no smoking, no salt, incr. K & Mg, no alcohol, exercise, decr. stress Diuretics NA & H2O depletion, HCTZ & loops used together

Adrenergics: Alpha2 Agonist, Alpha1 Blockers, Beta1 Blockers, Alpha1/Beta1 blockers Alpha2 Receptor Agonist Clonidine/ethyldopa Withdrawal gradually SE: orthostatic hypotension, dry mouth, constipation, drowsiness

Alpha1 Blocker EX: Doxazosin Prazosin Terazosin 4-6 weeks for therapeutic effect, avoid OTC cough/cold/allergy SE: otherostatic hypotension, HA, dizziness, tachycardia, vertigo, sexual dysfunction

Calcium Channel Blockers: Decrease BP EX: Nifedipine Amlodipine Diltiazem SE: vasodilation, peripheral edema, rebound HTN

Direct Acting Decrease BP EX: Hydralazine Minoxidil Do not discontinue abruptly

Direct Renin Inhibitor: Decrease BP EX: Aliskiren (up to 2 weeks for TE) SE: cough, abd. pain, diarrhea, dizziness

Misc. Severely high BP, imprending CVA EX: Sodium nitro prusside (Nipride)-IV SE: hypotension, palpitations, HA, dizziness BP before and after each dose, position changes slowly, drowsinessModule 7: Antilipemic/Antianginal/Antidysrhythmics HDL= Happy/Good Cholesterol LDL=Loser/Bad Cholesterol VDL=Total cholesterol & Triglycerides Soluble Fiber=beans/legumes, potatoes, carrots, apples Lipid Lowering Drugs/Antilipemics Work in intestinal tract. Bind with cholesterol to rid before digestion. Niacins work with liver and lipase HMG-CoA Reductase Inhibitors: statins EX: Atorvastatin Lovastatin Pravastatin Rosuvastatin Simvastatin Pitavastatin SE: Gi cramping, diarrhea, constipation, myopathy, rhabdomylysis Lower LDL/raise HDLs Interferes with enzymes in liver Teach: Take at night. (Peak effect at peak cholesterol times) Weeks to achieve results Do not use in liver disease Erythromycin, grapefruit juice, digoxin and OC increase effect No alcohol Bile-Acid Sequestrates Used to lower serum lipid levels by directly binding with the bile in GI tract EX: Cholestyramine Colesevelam SE: constipation, impaction, abd. pain, bloating, NV, steatorrhea Not absorbed systemically Limits absorption of Vitamins A&D, and Folic Acid Dissolve in AT LEAST 120 mL Niacin: Decreases VLDL and LDL levels are decreased EX: Nicobid Niaspan SE: flushing, pruritis, N, D High doses are required. May cause hepatotoxicity Niacin= B Complex! Aspirin 30 mins prior for flush/pruritis effects Fibrates Lower lipid levels (LDL/HDL) Gemfibrozile Febofibrate Coumadin dose must be reduced SE: ND, may cause gallstones Cholesterol Absorption Inhibitor Reduce serum cholesterol (stop absorption all together) EX: Ezetimibe Vytorin CAM: Garlic, Flax, Omega-3 MOA: unknown AntiAnginal Our heart muscle never rests. There is no reserve, so it will die quickly without oxygen. It can never full heal. Angina: Transient chest pain (Pain w/exertion) Accompanied by: Pallor, dyspnea, cyanosis, diaphoresis, tachycardia Nonpharmacologic management No tobacco, limit sodium and fat intake, increase potassium/magnesium foods, no alcohol, exercise, weight management, HTN management PCTA: Percutaneous Transluminal Angioplasty Opening heart and using stent to hold open CABG: Coronary Artery Bypass Graft Vessel from leg is used to replace vessel in heart Nitrates/Nitrites Used to treat/prevent pain of angina EX: Nitroglycerin Isosorbide dinitrate Isosorbide mononitrate Relax arteriole and venous smooth muscle Decreases preload and afterload Coronary artery dilation IV/SL are fast acting (Monitor BP) PO is long-acting Tolerance develops, may need to remove at night (Transdermal) SE: HA, orthostatic hypotension, dizziness, interacts with alcohol & ED drugs Gloves prevent spreading! (Cream) Teach: NTG prior to activities, keep tabs cool, close by. 1 x 5min apart up to 3. Replace every 6 months (Look for tingleno tingle =no effectiveness). Oral on empty stomach w/full glass of water Beta Blockers Prevent pain of angina, HTN, dysrhythmias EX: Atenolol Metoprolol Propranolol Reduce HR-neg. chromotrophic Slow contractions Decreases myocardial workload These are Beta 1 Blockers, Beta 2 is lungs (1 heart/2 lungs) SE: fatigue, weakness, dizziness, hypotension, bradycardia Has beta 2 effects (incr. respiratory distress) Taper off (rebound effect) Monitor apical and BP before dose and after dose Change positions slowly. Monitor for HF and Resp. distress Calcium Channel Blockers Prevent pain of angina EX: Diltiazem Verapamil Nifedepin Amiodipine Nicardipine Calcium=contractility. Blocking decreases contractility. Decreases need for oxygen. Monitor HR/BP before dose. Change positions slowly Grapefruit juice increases toxicity (can have 2 hrs before or 5 hrs after) SE: HA, dizziness, peripheral edema Antidysrhythmics SA node is primary conductor, P wave Supraventricular=tachycardia above ventricles PSVT: paroximal (comes/goes) Atrial Flutter: antigoagulant (blood may settle) Nodal Tachy: AV node in charge, not SA VTach: QRS waves, no P waves PAC: premature atrial contractions PNC: premature nodal contractions VFib: rhythm before asystole (asystole=no rhythm) Goal of treatment is to prevent dysthrythmias, relieve symptoms, prolong life Class 1: membrane stabilizing (Na channel blockers) Class 2: Beta blockers: PSVT Class 3: K+ channel blockers Class 4: Ca+ channel blockers Misc: PSVT Class 1a: Membrane Stabilizing AFib, PACs, PVCs, VT EX: procainamide SE: orthostatic hypotension, rash, diarrhea, agranulocytosis CBC: decreased values Class 1b: Membrane Stabilizing PVCs, VT, VF EX: Lidocaine Phenytoin (Dilantin) (watch for digoxin toxicity) Given IV, rapid onset SE: neurotoxicity, hypersensitivity, cardiac arrest, seizures Class 1c: Membrane Stabilizing VT, PSVT, AFib, Aflutter EX: Flecainide (PO) SE: dizziness, vision changes, nausea, VT/VF Class 2: Beta Adrenergic Blockers Treat PSVT EX: propanolol esmolol: rapid onset/short duration SE: orthostatic hypotension, bradycardia, HF, bronchospasm Class 3: Potassium-Channel Blockers EX: Amiodarone Sotalol (Beta Bl./K+ CB) SE: pulmonary toxicity, muscle weakness, fatigue, dizziness, orthostatic hypotension, photosensitivity, thyroid changes, liver toxicity Digoxin/warfarin increase toxicity Class 4: Calcium Channel Blocker EX: Diltiazem Nifedipine Verapamil SE: HA, orthostatic hypotension, constipation, bradycardia, severe brady w/digoxin, peripheral edema Causes decreased contractility and decreased conductivity Misc. Antidysrhythmics Digoxin (Lanoxin): used to reduce ventricular rate with AFib/flutter Adenosine & ibutilide: used to restore NSR in clients with PSVT; given IV; short half-life. Allows SA node to restart Atropine: given IV or PO for severe sinus bradycardia. Drying agent, speeds up rate Nursing Considerations Monitor HR/BP before dose, 1 hour after dose. Dizziness! Monitor serum levels. Apical vs. radial pulses