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Materialsnotmeanttocovereverythingbut
tofocusonthemoreimportantinformation
pertainingtoeachclass
Sources:Therapeuticchoice,CPS,RxFiles,and
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Conflictinginformationwasfoundinmany
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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
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
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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
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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.
ACEI
Druginteractions:
Combinationcausinghypotension:
1 blockers Excessivehypotension
Management:starttherapyatlowdoseandmonitorBP
Thiazidediuretics Excessivehypotension
Management:
ifpossibleD/Cthiazidediuretic 1weekbeforestartingACEI.If
not,then..
StartACEIatlowdose
Patienttoremainsupinefor3hoursafterfirstACEdose
ConsiderincreasingNa+ intake
MonitorBPwheninitiatingACEItherapy
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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
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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
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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)
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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)
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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
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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)
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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)
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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
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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)
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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
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
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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.
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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.
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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
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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)
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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:
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Central2Agonists
Clonidine
CanbeusedforacuteincreaseinBP(0.1mgx1
then0.1mgq1hprn)
Avoidindiabetes(autonomicneuropathy)
BloodCoagulation
Source:http://almostadoctor.co.uk
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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
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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
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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)
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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
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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
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)
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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
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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)
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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)
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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
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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)
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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
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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