Advanced Pharm for Nursing Practice
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| JNC recommendations for HTN treatment Step 1 | Lifestyle changes: stop smoking, lose wt, exercise, control other diseases
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| JNC recommendations for HTN treatment Step 2 | Drugs
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| The most effective & best tolerated anti-HTN drugs | Thiazides, ACEIs, ARBs, CCBs
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| General rule about Thiazides | in general you start with thiazide diuretics unless you have reason to start with another; they tend to be the cheapest; only lower BP by a few mmHg, but they work very well.
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| Considerations for diabetics /c Diuretics | start wth ACEI b/c they protect kidneys from problems cause by the DM; AVOID beta-blockers b/c beta-blockers may decrease effectiveness of drugs and block hyperglycemia and DM symptoms
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| Diuretics are essential for HTN, but they DO NOT improve ______ | diuretics don’t improve mortality; neither does Digozin
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| Considerations for pts with bronchospastic dz | avoid beta-blockers
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| Considerations for pts /c DM | use ACEI; AVOID beta-blockers
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| Considerations for pts /c Hyperlipidemia | use CCB
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| Considerations for pts /c Heart Failure | use ACEI
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| Considerations for pts /c Bronchospastic Dz | avoid beta-blockers
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| Thiazides are considered __________ diuretics | moderate
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| How do Thiazide diuretics work? | Thiazide diuretics block Na+ and Cl- absorption form the renal tubules; they work as antihypertensives, and OVER TIME, they decrease vascular resistance
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| Pt considerations when on thiazides | follow-up labs in a few wks bc it takes time for solid lowering of BP. If not seeing desired decr in BP /p a few wks, add an ACEI or Ca+ channel blocker
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| Thiazides may not work well in pts with this chronic condition | poor renal function
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| Thiazide prototype | hydrochlorothiazide, hyrdoDIURIL
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| Thiazide diuretics can cause this kind of toxicity | Lithium toxicity
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| Clinical indications for thiazide diuretics | HTN & Edema
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| Thiazide diuretics are in what pregnancy category? Why? | category b or c because they may cause some fetal changes.
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| Thiazides may not work well in pts with these chronic conditions | poor renal function, gout, or DM II
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| Do not change or modify your salt intake if you’re on a Thiazide diuretic and this drug | Lithium
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| This group of drugs diminish the antihypertensive effectiveness of Thiazide diuretics bc they cause Na+ & H2O retention, increasing blood pressure | NSAIDs
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| Which dose of Thiazides do you take for HTN? Which dose for a diuretic? | HTN: 25mg; Diuretic:200mg
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| What time of day is best to take a diuretic? | morning
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| The prototype for Thiazide diuretics | hydrocholorothiazide (Hydro-Diuril); chlorthalidone (Hygroton) is the thiazide-like drug
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| How do Thiazides work in the kidneys | Thiazides work in the early distal convulated tubule. They inhibit the tubular reabsorption of Na+ and Cl- ions; as a result, water, Na- and Cl- are excreted.
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| High-ceiling diuretic means what? Ex? | the more Lasix you give, the more diuresis you’ll see, Ex. Lasix, a furosemide diuretic
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| This group of people already at risk, should be very careful taking Lasix because of the risk of what, especially if combined with other dugs of similar effects? | those at risk are: those on drugs of similar effect ototoxicity.
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| This group of diuretics is the most efficacious—they do the BEST job of getting rid of fluid, but they’re not as effective at lowering blood pressure unless its cause is poor renal function | loop (high ceiling) diuretics
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| Loop diuretics don’t reabsorb Calcium and Magnesium, and that can cause what problem? | Increase in Ca+ & Mg EXCRETION can cause cardiac arrhythmias
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| The prototype for loop (high ceiling) diuretics is what? | furosemide (Lasix)
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| Both Lasix and thiazides can cause hyponatremia & hypokalemia; but which drug is more prone to cause hypovolemia? | thiazides
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| Why is DOSE SEQUENCING so important when it comes to ACEIs? | ACEIs may result in profound hypotension and fainting if given to pts /c hypovolemia (like one on a diuretic)
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| The major side effect of loop diuretics is what? | electrolyte imbalances
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| There is a notion of cross allergy with sulfonamides and what diuretic? Why | furosemide is derived from sulfonamide type structure and there’s a notion of cross allergy /c sulfonamides.
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| How do loop (high ceiling) diuretics work? | act directly on ascending loop of Henle to inhibit Na+ & Cl- resorption. Also inhibit electrolyte resorption in proximal renal tubule &, incr concentrations of renal prostaglandins-->bld vessel dilation in kidney, lungs, & whole body. NSAIDs reverse this.
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| How does Triamterene (Dyrenium) work? | acts directly on distal renal tubule to block Na+ resorption in exchange for K+ & hydrogen ions--> diuresis of H20 & Na+ and retention of K+
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| Why does Triamterene (a K+ sparing diuretic) work well /c thiazides? | by blocking the Na+/K+ mechanism, K+ sparing diuretic prevent thiazide-induced hypokalemia; thiazide diuretics cause loss of K+, Mg+, and Cl-, & K+ sparing diuretics like Triamterene counteract t/ loss by elevating K+ & Cl- levels
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| Explain the Na+/K+ mechanism, what drug blocks that? | when giving thiazides decr bld Na+ bc when Na+ gets out @ end of collecting tubules, XS Na+ stimulates Na+/K+ mechanism to work & reabsorb Na+ & discard K+ (tubular fluid acts as garbage gate); thiazides decr bld Na+. TRIAMTERNE blocks this mechanism.
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| How does Spironolactone work? | Spironolactone is a competitive agonist of aldosterone (*aldosterone, when triggered by decr in Na+, acts on aldosterone-receptors in the tubules and causes Na+ & H2O retention.) and causes Na+ and H2O to be excreted and K+ to be retained.
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| What endogenous hormone causes heart remodeling in CHF? What drug prevents that? | aldosterone causes heart remodeling, and spironolactone (Aldactone) blocks some of those changes.
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| SE/ADRs of Spironolactone? | b/c it has a steroid structure (coming from the adrenal medulla), it can cause impotency, gynomastia, decr libido, and menstrual abnormalities
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| Why can thiazides cause hyperglycemia? | t/ pancreas depends on a K+-Ca+ mechanism enzyme to release insulin, therefore, no K+ = lack of K+-Ca+ mechanism which = Ca+ can’t cause insulin release to outer cell, & therefore…no available insulin release from pancreas. (This is ONLY a prob for DM II)
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| Pt teaching for pts on diuretics? | eat K+ rich foods while on thiazides and loops (it may decr risk of hypokalemia, but it WON’T CURE hypokalemia; decr Na+ intake; use Na+ substitutes; use K+ sparing diuretics, use K+ salts
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| The concept of bld pressure is a combination of what 2 functions? | cardiac output (heart function) & peripheral resistance
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| Although this drug is the prototype for centrally acting sympatholytics (alpha-2 agonists), what drug is used most commonly? | Methyldopa (Aldomet) is the prototype, but Clonidine (Catapres) is primarily used
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| How do centrally acting sympatholitics work? | they decr bld pressure by stimulating t/ alpha2-adrenergic receptors in t/ brain, which results in decr sympathetic outflow of neurons from the CNS to the heart (slows heart) & decr sympathetic outflow to cause vasoconstriction and --> LOWERED BP and HR
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| What centrally acting sympatholytic (alpha 2-agonist) is primarily used in pregnant women? | methyldopa (Aldomet) bc it’s Category B
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| What are indications for centrally acting sympatholytics (alpha 2- agonists)? | mainly for HTN as a tablet or patch (2nd step); for severe pain: a clonidine epidural; ADHD
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| What are the SE/ADR of centrally acting sympatholytics (alpha 2-agonists)? | most common: SEDATION (esp with Clonidine); others are dry mouth, constipation, edema & ortho hypotension; methyldopa may cause a pos. Coombsâ test or rarely, hemolytic anemia
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| What are contraindications for pts /c centrally acting sympatholytics (alpha 2 – agonists)? | active liver (hepatic) dz, DON’T STOP CLONIDINE ABRUPTLY BC OF REBOUND HTN. If rebound HTN occurs, resume Clonidine and taper off more slowly
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