Antihyperlipidemic and Anticoagulants Overview

Antihyperlipidemic

• HMG-CoA reductase Inhibitors ("statins")
  • Atorvastatin: Used for primary prevention of cardiovascular disease, and risk of MI or stroke
    • Take in the evening
  • Important labs to monitor: Liver labs, AST, ALT
  • Absolute contraindication: Pregnancy
  • Diet recommendations: Avoid grapefruit juice, Avoid alcohol
  • Side Effects: Rash, Diarrhea, Abdominal cramps, Rhabdomyolysis
  • Most serious adverse effect: Rhabdomyolysis - muscle pain
  • What do statins treat? High cholesterol
• Bile Acid Resins
  • Cholestyramine:
    • Side effects: Constipation, Headache, Gall stones, GI upset, Dyspepsia
    • Drug of choice for pregnant women
    • Treatment: High cholesterol
    • Mechanism: Works in the intestines
    • Considerations: Drink fluids (constipation)

Anticoagulants

• Enoxaparin
  • Monitoring: APTT (45 to 90 degrees)
  • Administer: Subcutaneous tissue
  • Considerations: Do not administer IM, Rotate injection sites
  • Important to Know: Takes 2 to 3 weeks to work
• Warfarin
  • Mechanism: Interferes with hepatic synthesis of Vitamin K, Prolongs clotting time
  • Antidote: Vitamin K
  • Lab Monitoring: INR
• Rivaroxaban
  • Lab Monitoring: Not frequently needed
• SE: SYNCOPE
  • Lab Monitoring: ALT & AST

Antiplatelets

• Clopidogrel

  • Mechanism: Inhibits platelet aggregation
  • Caution: Bleeding risk, hepatic impairment, History of GI bleeding

• Aspirin

  • Mechanism: Antiplatelet

Anticoagulant Antagonists

• Phytonadione (Vitamin K)

  • Antidote: Warfarin

• Protamine Sulfate

  • Antidote: Heparin

Renal Medications

• Diuretics
• Loop - Furosemide (Loop diuretic): Potassium-Wasting diuretic
• Potassium-Sparing - Spironolactone: Potassium sparing diuretic, avoid potassium-rich foods
• Thiazides - Hydrochlorothiazide (HCTZ): Thiazide diuretic

Dietary Considerations for Potassium-Wasting vs. Potassium-Sparing Diuretics

• Potassium-Wasting: Encourage consistency of vitamin K intake
• Potassium-Sparing: Avoid vitamin K foods, Avoid salt substitutes (like Mrs.Dash)

Potassium-Rich Foods

• Leafy greens (spinach, cabbage, broccoli, squash)

Diuretic with Antiandrogenic Effects

• Spironolactone (can cause gynecomastia and irregular menses)

Hematopoietic Growth Factors

• Erythropoietin
  • Mechanism: Stimulates erythropoiesis (red blood cell production)

Ferrous Sulfate (Iron)

• Mechanism: Increases iron levels
• Administration: Administer 1 hour before or after meals
• Considerations: May cause constipation, May cause black/dark stools and stained teeth
• Importance: Oral hygiene is important
• Labs to monitor: Hematocrit, Hemoglobin

Role in RBC Formation

• Erythropoietin and iron play a role in red blood cell formation

Inhaler Information

• Theophylline
  • Factors that increase theophylline blood levels (require decreased dose): Chocolate and caffeine
  • Factors that decrease theophylline blood levels (require increased dose): Smoking

Inhaler Types and Instructions

• Ipratropium: Short-acting anti-cholinergic
• Tiotropium: Anti-cholinergic (long-acting)
• Metered Dose Inhaler (MDI) Instructions:
  • Exhale
  • Shake
  • Prime
  • Inhale with spacer
  • Hold breath for 10 seconds
  • Rinse mouth
• Dry Powder Inhaler (DPI) Instructions:
  • Do not exceed dosage recommendations
  • Wash mouth for thrush

Antiasthma/Anti-inflammatory Agents

• Fluticasone/Salmeterol
• Montelukast: Used when other options haven't been effective

Montelukast - Mechanism of Action, Nursing Considerations, and Teaching Reinforcement

• Mechanism of Action: Blocks leukotriene receptors, decreasing inflammation
• Nursing Considerations: Safe for 12 months, Can be chewable or granulated
• Teaching Reinforcement: Take two hours prior to exercise

Considerations when multiple inhaler classes are ordered:

• Check the order
• See what it is used for

Beta-Blockers

• Negative Inotropic: Force of contraction
• Negative chronotropic: Timing
• Negative Dromotropic: Electricity
• Metoprolol (Selective) - Hold dose if BP lower than 60 systolic and pulse < 60 bpm
• Propranolol (Non-Selective) - Monitor Blood Sugar because it masks signs & symptoms
• Important to know: Selective beta blocker works on certain receptors, whereas a non-selective one will not bind to certain ones & will mask other systems
• Carvedilol affects: Beta 1, Beta 2, and Alpha 1
• Heart Failure: Don't want patients taking beta-blockers if they have acute heart failure
• Important Teaching: Don't stop abruptly
• Off label uses: Migraines and tremors

Explain the RAAS system:

• Renin release: Triggers when blood pressure is low
• What does renin do? Catalyzes the conversion of angiotensinogen to angiotensin I
• What is ACE, where is it found, and what does it do?
  • Angiotensin-converting enzyme is found in the lungs and converts angiotensin I to angiotensin II
• Function of Angiotensin II: It vasoconstricts and increases aldosterone secretion
• Aldosterone: Comes from the adrenal gland and causes sodium retention (and water retention) and potassium excretion
• Angiotensin Converting Enzyme Inhibitors (ACE-I) "pril"
  • Lisinopril

Cardiac Glycosides

• Digoxin: No longer used as first-line therapy, Therapeutic range: 0.5-2.0 ng/mL
• Relationship with Potassium Levels: Low potassium levels increase the risk of digoxin toxicity
• Symptoms of Digoxin Toxicity: Bradycardia, Hypokalemia, Anorexia, Nausea/Vomiting (N/V), Yellow-green halos, Arrhythmias

Antiarrhythmic

• Amiodarone

Anticoagulants

• Heparin
  • Mechanism: Prolongs clotting time
  • Antidote: Protamine Sulfate
  • Lab Monitored: Activated Partial Thromboplastin Time (APTT)
  • APTT Interpretation:
    • ↑ APTT = Too long for clotting, risk for bleeding
    • ↓ APTT = Increase dosage because clotting is happening too fast
• Fibrates
  • Gemfibrozil: Decreases (↓) triglyceride production by the liver, ↑ good HDL levels
  • Labs to monitor: BUN, Creatinine, ALT, AST
  • Side effects: Abdominal pain, Nausea, Gall stones, Diarrhea, Epigastric pain, Renal/hepatic impairment, Gall bladder disease, Concurrent use of statins
• Other
  • Ezetimibe: Do not take if pregnant, Liver disease impairment
  • Niacin: Contraindication if pregnant
• Role in Cholesterol Management:
  • Ezetimibe: Ezetimibe inhibits the absorption of cholesterol in the small intestine
  • Niacin: Stops the removal of HDL- good cholesterol
  • Vitamin B3
• Common Side Effect of Niacin: Nausea, vomiting, dizziness
• How to Manage Side Effects of Niacin: Drink flat soda, eat crackers

Antihypertensive: Beta Blockers

• Metoprolol (selective): Beta 1 blocker
• Propranolol (Non-selective): Beta 1 and Beta 2 blocker
• Considerations: Monitor Blood Sugar because it masks signs & symptoms

What is a beta blocker blocking?

• Blocks the stimulation of beta-1 (myocardial (heart)) and beta-2 (lungs) adrenergic receptors

Calcium Channel Blockers (CCB)

• Side effects specific to CCB (calcium channel blockers) verapamil vs amlodipine:
  • Amlodipine: Pedal edema, gingival hyperplasia
  • Verapamil: Hypotension, palpitations, constipation
• Effectiveness: For African Americans, CCB's have greater effectiveness as compared to other antihypertensive classes.
• Dietary modifications: Drink fluids

Antianginal: Nitroglycerin (discuss forms)

• Mechanism of Action of NTG: Increases coronary (heart) blood flow
• Routes of administration: Patch (transdermal), IV solution, Pill (oral), Translingual sprays, Under the tongue (sublingual)
• Transdermal patch considerations: Remove patch at bedtime for 8-12 hours, so there is no tolerance development
• Sublingual NTG administration:
  • Drink water before administering tablet
  • Do not chew tablet
  • Give 1 tablet every 5 minutes (3 times), call 911 if pain isn't relieved or if it worsens after first dose
  • Store at room temperature, out of sun, remove cotton
• Important to know about sublingual NTG: No first-pass effect when taking properly
• Managing pain: Give acetaminophen for headache

Antititussives

• Codeine:
  • Mechanism: Relieves cough
  • Considerations: Important to drink fluids, Monitor cough for 1 week, Increase fiber intake
  • Important to know: Inhibits cough reflex and leads to respiratory depression if high doses are taken
• Dextromethorphan:
  • Mechanism: Depresses cough receptors in the throat, lungs, trachea
  • Considerations May cause hallucinations in high doses
  • Important to know: Encourage fluid intake, and monitor for dizziness
  • Important to know: Avoid driving

Expectorants

• Guaifenesin:
  • Mechanism: Loosens mucus from respiratory tract
  • Considerations: Avoid taking with CNS depressants or alcohol
  • Side Effects: May cause skin rash, headaches, or difficulty breathing (NIV)
  • Important to know: Safe in all ages, including pregnancy, and can be used during breastfeeding

Mucolytics

• Acetylcysteine (oral, IV, topically by nebulizer):
  • Considerations: Oral administration is better tolerated
  • Important to assess: Bilirubin levels
  • Indications: Overdose on acetaminophen, COPD, Asthma, cystic fibrosis

Antihistamines

• Diphenhydramine:
  • Side Effects: Dizziness, hypotension, dry mouth, nausea, photosensitivity, Paradoxical excitation in children, constipation
• Cetirizine:
  • Important to know: Anticholinergic effects minimal, and sedation is dose-related

Difference between Antihistamines:

• First-generation (Diphenhydramine): More side effects
• Second-generation (Cetirizine): Fewer side effects