Cardiac Pharma
K sparing diuretics
Spironolactone
Dyazide
Maxide
K sparing diuretics target
Duct tubules and late distal tubules
Considerations for Loop Diuretics
Hyperglycemia,
do not give w/ digoxin, lithium (increases effects), antihypertensives, gout, nephrotoxicity
May be used for pulm. edema
Loop diuretics can cause ----toxicity
ototoxicity
Hypokalemia manifests as
leg cramps, fatigue, vomiting
Hypomagnesemia manifests as
muscle twitching, tremors
Loop diuretics hypo
natremia, KALEMIA, magnesimia
Loop Diuretics target
Loop of henle
Thiazide diuretic considerations
Give early in day, normal kidney function, photosensitivity
Thiazide diuretics can cause hyper
calcemia, glycemia, uricemia, LDL
Thiazide diuretics can cause hypo
KALEMIA, natrimia, magnesemia
Thiazide Diuretics target
Distal convoluted tubule
Spironolactone
K sparing diuretic
Dyazide
K sparing diuretic
Maxide
K sparing diuretic
5 antihypertensive classes (Sympatholytic)
Beta adrenergic blockers
centrally acting alpha-2 antagonists
Alpha adrenergic blockers
Alpha 1
Beta 1
Metaprolol
Beta Blocker only Beta 1
Propanolol
Beta Blockers BETA 1 and 2
Atenolol
Beta Blocker
Prazosin
Alpha-1 adrenergic blocker
Doxazosin
Alpha-1 adrenergic blocker
Clonidine
Centrally acting alpha-2 agonist
Methyldopa
Centrally acting alpha-2 agonist
Lisinopril
ACE inhibitor
Captopril
ACE inhibitor
Valsartan
ARBS (Angiotensin 2 receptor blocker)
Lorsartan
ARBS (Angiotensin 2 receptor blocker)
Verapamil
Calcium channel blocker
Nifipedine
Calcium channel blocker
Diltiazam
Calcium channel blocker
Metoclopramide
Cholinergic Agonists (Parasympathetic increase)
Bethanechol
Cholinergic Agonists (Parasympathetic increase)
Pilocarpine
Cholinergic Agonists (Parasympathetic increase)
Atropine
Anticholinergics (Antiparasympathetic)
Benzotropine
Anticholinergics (Antiparasympathetic)
**Antiparkinsonism
Scopolamine
Anticholinergics (Antiparasympathetic)
**Motion sickness
Alpha 1
Cardiac, pupils, increase BP, bladder&prostate
Alpha 2
Vasodilation, decrease BP, decrease motility, decreased insulin secretion
Beta 1
Heart contractility, increase BP/HR
Beta 2
Decrease motility, bronchodilation, relax uterus, increase CBG/glycogenolysis
Epi (catachol.)
Direct Adrenergic Agonist--Produce sympathetic response, A1,B1,B2
Norepi. (catechol.)
Direct Adrenergic Agonist--Produce sympathetic response
Dopamine (catechol)
Direct Adrenergic Agonist--Produce sympathetic response
Phenylepherine (Noncatechol)
Direct Adrenergic Agonist--Produce sympathetic response
Metaproterenol
Direct Adrenergic Agonist--Produce sympathetic response
Albuterol
Direct Adrenergic Agonist--Produce sympathetic response Beta 1 and 2
Amphetamines
Indirect Adrenergic Agonist--Produce sympathetic response
Adrenergic Antagonists
Blocks adrenergic neurotransmitter--beta blocker
ISA-- Intrinsic sympathomimetic activity
Ability to bind with beta receptor to prevent strong agonists from binding
Carvedilol
beta blocker
Hydrochlorothiazide
Thiazide diuretic
Furosemide
loop diuretic
Proximal tubules %%%
50-55%
Loop of henle %%%
35-40%
Distal tubules %%%
5-10%
Loop (high ceiling) details
Peripheral edema
Good for kidney insufficiency
Very effective, fast
digoxin toxicity
Loop (high ceiling) side effects
Ototoxicity
photosensitivity
Hypo-kal, nat, calc, chlor
hyperglycemia, uricemia
Thiazide details
no renal failure
admin early
no NSAIDS
NO DIGITALIS
risk digoxin
Herbal interactions- ginko, licorice
photosensitivity
Thiazide side effects
not immediate diuresis
GI distress
hypercalcemia
hyperglycemia, uricemia
hypo kal, mag, nat, chlor
K sparing details
ED
weaker
INTERFERE WITH ALDOSTERONE
caution kidney function
K sparing side effects
hyperkalemia, glycemia, uricemia
hyponat, calc, mag
GI distress
Photosensitivity
Osmotic Diuretics
Enhances concentration
Proximal tubule and loop of henle
ICP & IOP
Mannitol
Crystalization, osmotic diuretic
Triamterene and hydrochlorothiazide
K sparing and K wasting to enhance diuretic effect and retain K
Hyperkalemia w/ ACE inhibitor
Life threatening
Alcohol increases renin secretions T/F
T
Meds less effective for African American people
Beta blockers and ACE inhibitors
Low renin hypertension
Asian descent Beta blockers
Twice as effective
Six Classes Antihypertensives
-Diuretics
-Sympatholytics (sympathetic DEPRESSANTS)
-Direct acting arteriolar vasodilators
-ACE inhibitors
- ARBS
- Calcium Channel Blockers
5 groups of Sympatholytics
- Beta adrenergic blockers
- Centrally acting alpha-2 agonists
- alpha blockers
- Adrenergic neuron blockers
- Alpha1 and beta1 adrenergic blockers
Beta blocker action
Reduce HR, contractility and renin release
How to treat HTN in african americans
Beta blockers with diuretics
Nonselective beta blockers
Propranolol-- beta 1 (Heart) & beta 2 (lungs, constriction)
Cardioselective beta blockers
Atenolol & metoprolol-- Beta 1 only-- preferred
Beta blockers in asthma?
Caution
What is the real value in beta blocker selectivity?
Maintaining renal blood flow and minimizing hypoglycemia
Metoprolol Beta blocker info
better for high renin
risk of bradycardia, hypotension, acute HF, ED
Centrally acting alpha 2 AGONISTS
methyldopa and clonidine
--decrease epi, renin and norepi--
Centrally acting alpha 2 AGONISTS details
-minimal effect on cardiac output & renal blood flow
- NOT given w/ beta blockers (bradycardia)
May cause sodium retention
Centrally acting alpha 2 agonists
methyldopa, clonidine
Sympatholytic available in transdermal patch--7 days
methyldopa -- centrally acting alpha 2 agonist
Centrally acting alpha 2 agonist details
normal antihypertensive side effects
NOT for impaired hepatic function
Diuretic may be concurrent for retention
Centrally acting alpha2 agonist NOT used during pregnancy
Clonidine
Helps maintain renal blood flow and used for HTN in people with lipid imbalance
Alpha adrenergic blockers
Decrease VLDL and LDL, increase HDL
Alpha adrenergic blockers
Safe for diabetics
alpha or beta blockers?
Alpha
Prazosin details
Alpha 1 adrenergic blocker
HTN and BPH
May not work for 4 wks
Selective
sodium and water retention
Highly protein bound, may displace
Doxazosin details
Alpha 1 adrenergic blocker
Selective
may cause sodium and water retention
Selective vs nonselective Alpha blockers
Selective- HR only slightly increased-- DILATE VASCULATURE -- better for long term
Nonselective-- Tachycardia--good for acute HTN due to dramatic decrease in BP
Alpha blocker interactions
NSAIDS (edema) and Nitrates (Syncope)
Adrenergic neuron BLOCKERS (peripherally acting sympatholytics)
Block release of norepi @ nerve endings
HTN
Last line of defense for chronic HTN due to ortho HypoTN?
Adrenergic neuron blockers
Adrenergic neuron blocker details
Retention
Ortho HypoTN
LABETalol
Alpha 1 and beta 1 blockers
LABETalol
Alpha 1- vasodilation (STRONGER)
Beta 1 - HR moderately decreased, AV contractility
Alpha-beta blocker details
Too much can have an effect on beta 2 and cause AV block
Ortho. hypoTN
GI distress
dry mouth
Alpha adrenergic blockers contraindicated in..
Renal insufficiency
Water retention is a problem with
Alpha blockers
Hydralazine
Alpha-beta blocker
Direct acting arteriolar vasodilators
POTENT antihypertensives
Increase blood flow to brain and kidneys
Hydralazine
Direct acting arteriolar vasodilator
Moderate HTN crisis
Tachycardia
Beta blockers concurrent
Nitroprusside
Direct acting vasodilator
EMERGENCY
Arterial and venous
Direct acting vasodilator details
GI Bleeding, reflex tachycardia, edema, congestion, tingling, numbness, excess hair growth
Nitroprusside details
Tachy, palpitations, restlessness, nausea, confusion
ACE inhibitor details
nausea, vomiting, dizziness, diarrhea, headache, fatigue
Ortho hypoTN
Captopril details
Dizziness & lightheadedness
NOT FOR PREGNANT WOMEN
Treats post MI, diabetic neuropathy, HTN, HF
Cough?
ACE inhibitors
ACE details
Hyperkalemia
Tachycardia
ANGIOEDEMA
NOT TAKE WITH K SPARING DIURETICS
ARBS
Block angiotensin II from receptors, cause vasodilation and decrease peripheral resistance
Lorsartan
ARBS
Valsartan
ARBS
Not safe during pregnancy?
ARBS
Lisinopril details
Treats AMI, HTN, HF
Lisinopril electrolyte imbalance
Hyperkalemia
Losartan details
HTN, diabetic neuropathy, prevents stroke, proteinuria,
Lorsartan (ARBS) may cause
typical antihypertensive SE, edema, nasal congestion, pharyngitis, nausea
Valsartan cautioned in
HF, renal/hepatic, hyperkalemia, pregnancy
ARBS are potent...
Vasodilators
Calcium channels...
increase contractility
increase peripheral resistance
increase BP
Verapimil and diltiazam (calcium blockers) act on
arterioles and heart
Nilfiedipine
Calcium channel blocker
Amlodipine
Calcium channel blocker
Nifedipine details (Calcium channel blocker)
used for HTN
decreases BP in older adults w/ low renin
POTENT
Associated with death and profound hypoTN, extended release unless ACUTE
Verapimil (calcium channel blocker) details
POTENT
used for HTN
ED, nausea, constipation
Vasodilation may cause
peripheral edema
Better for lowering BP in african americans..
Calcium blockers
Calcium blocker details
flushing
ankle edema
antihypertensive side effects
AV block
Amlopidine (calcium channel blocker) details
NSAIDS may increase renal disfunction
drowsiness, anxiety, flushing, fatigue, dizziness, weakeness,
WHich diuretic is most potent?
Loop
Adrenergic blockers are also called
Sympatholytics
Adrenergic agonists are also called
Sympathomimetics
Adrenergic meds are
high alert because they can cause harm
Alpha 1 adrenergic
peripheral vasoconstriction
Alpha 2 adrenergic
vasodilation
Beta 1 adrenergic
Myocardial contractility
Beta 2 adrenergic
bronchodilation, decrease in motility, increased glycogenolysis/CBG, decreased uterine contraction
3 ways neurotransmitters inactivated
Reuptake (Most important)
Enzymatic transformation/degradation
Diffusion away from receptor
Types of sympathomimetics
Direct
Indirect
mixed
Pseudoephedrine
Mixed adrenergic agonist- stimulates release of epi, but acts directly on beta and alpha 1 receptors
vasoconstriction
Epi acts on
Alpha 1, beta 1 and beta 2
Epi selective or nonselective?
Nonselective
Noncatecholamines
Phenylephrine, metaproterenol, ALBUTEROL
Albuterol is selective for..
beta 2
Epi can increase OR decrease blood
glucose
Epi contraindications
TCAs
MAOIs
Beta blockers
adrenergic agonists contraindicated in
closed angle glaucoma,
cardiac dysrhythmia
Cardiogenic shock
Norepi and dopamine IV considerations
Infiltration can cause necrosis
Continuous use of adrenergic agonists may cause
rebound congestion
Alpha 2 central agonist, methyldopa, due to new meds
Not used
Side effects of central acting alpha agonists
drowsiness, headache, nasal congestion, nightmares, constipation, ED, hepatic enzymes
Types of adrenergic antagonists
Indirect
Selective
Nonselective
Direct
Alpha antagonists
Vasodilation
Beta blockers
Decrease heartrate, and therefore, BP
Propanolol is
Nonselective, beta 1 and 2-- can be used for migraines
Atenolol suppresses
RAAS
Atenolol contraindicated in
Sick sinus, asthma, bradycardia, heart block, AHF
NSAIDS
Beta blockers should be tapered for..
1-2 weeks
Adrenergic neuron antagonists/blockers
HTN
Decreases epi/norepi and may cause depression