Cardiac Drugs PowerPoint PDF

NURSING 3314: Pharmacology Cardiac Drugs Juan Feng, PhD, RN, CNE Copyright 2018 University of Texas Medical Branch,  Cardiac Review Anatomy and Physiology of the heart; chambers of the heart and blood flow, electrical and mechanical pumping; la...

NURSING 3314: Pharmacology Cardiac Drugs Juan Feng, PhD, RN, CNE Copyright 2018 University of Texas Medical Branch,  Cardiac Review Anatomy and Physiology of the heart; chambers of the heart and blood flow, electrical and mechanical pumping; layers of the heart, valves, Arteries and blood vessels; hemodynamics Copyright 2018 University of Texas Medical Branch, Module 5: Diuretics and Potassium Copyright 2018 University of Texas Medical Branch, Types of Diuretics Loop Diuretics Diuretics increase Thiazide urine output (diuresis) Osmotic diuretics Normal urine output Potassium is considered to be sparing Diuretics 30 mL/hour or greater Diuretics work by blocking sodium and chloride reabsorption Copyright 2018 University of Texas Medical Branch, Kidney Tubule/Diuretic Sites of Action Copyright 2018 University of Texas Medical Branch, Diuretics: Types/Prototypes Loop: furosemide (Lasix) Thiazides: hydrochlorothiazide (Hydrodiuril) Osmotic: Mannitol (Osmitrol) Potassium Sparing: Spironolactone (Aldactone) Copyright 2018 University of Texas Medical Branch, Diuretics: Loop Prototype: furosemide (Lasix) Indications: Very powerful diuretic given for massive movement of fluids, usually in both acute and chronic heart failure; if a lesser diuretic such as a thiazide can be used, it is generally best to do so. Mechanism of Action: Rapid acting loop diuretic, inhibits Na and Cl reabsorption in ascending Loop of Henle Therapeutic Action: decreases edema, decreases BP Adverse Effects: postural hypotension, loss of K, Na, Mg, Cl; HYPOKALEMIA, HYPONATREMIA, HYPOCHLOREMIA, Nausea and vomiting, dehydration; tinnitus, circulatory collapse Copyright 2018 University of Texas Medical Branch, Furosemide (continued) Nursing Implications: check K level before giving(3.5- 5.0); check BP before giving; Weigh daily to evaluate its effectiveness; rapid IV use has caused cardiac arrest; monitor pts closely during high volume diuresis for hypotension, circulatory collapse. Dosage: Oral, IV, IM, 20 mg- 80 mg; IV action starts in 5 minutes and lasts for 2 hours. Oral action starts within 60 minutes and lasts for 8 hours. Drug Interactions: If low potassium, high risk for dig toxicity; Digoxin toxicity can cause dysrhythmias; hearing loss when combined with other ototoxic drugs such as aminoglycosides; monitor Lithium level; hypotension when combined with any other antihypertensive. Other Loop Diuretics: bumetanide, ethacrynic acid, torsemide Copyright 2018 University of Texas Medical Branch, Question: Which is a symptom of dehydration? A. Incontinence B. Oliguria C. Polyuria D. Diuresis Copyright 2018 University of Texas Medical Branch, Question Which nursing intervention is most important before giving oral furosemide (Lasix) each day? A. Weigh patient on bed scales. B. Check EKG strip for current dysrhythmia. C. Check for potassium level D. Monitor amount of urine excreted the prior 24 hours. Copyright 2018 University of Texas Medical Branch, Question The physician orders lasix (furosemide) 40 mg po daily. What time does the nurse schedule the medication and why? A. 8 AM, needs to be given with breakfast to avoid upsetting the stomach. B. 9 AM, needs to be given early so patient is not awakened at night by urination. C. 12 noon, needs to be given at the same time as the patient’s other medications. D. 9 pm, give at night so that diuresis will start in AM about 12 hours later. Copyright 2018 University of Texas Medical Branch, hydrochlorothiazide (Hydrodiuril) Prototype drug for thiazides MOA: Blocks reabsorption of Na and Cl in early segment of the distal convoluted tubule. Drug not effective if there is low GFR < 15-20 ml/min. Indication: Hypertension, frequently 1st choice drug especially in African Americans. Can also be used in mild to moderate heart failure, mobilize edema associated with hepatic or renal disease. Adverse Effects: Hyponatremia, hypochloremia, hypokalemia, dehydration; pregnancy category B. Also can enter breast milk; elevate glucose levels; May precipitate gouty arthritis Drug Interactions: Promote digoxin toxicity due to promoting potassium loss; Increase effects of hypotension when combined with other anti- hypertensives. Dosage: given orally Copyright 2018 University of Texas Medical Branch, Osmotic Diuretics Copyright 2018 University of Texas Medical Branch, Mannitol (Osmitrol) Osmotic diuretic (only one at this time in USA) Mechanism of Action- In the proximal convoluted tubule, mannitol creates osmotic force that inhibits passive reabsorption of water. No significant effect on excretion of K. Indications : Can prevent or slow onset of renal failure in severe hypotension, hypovolemic shock; Reduction of ICP caused by cerebral edema; reduction of intraocular pressure. Adverse Effects: Headache, N&V, Electrolyte imbalance possible, pulmonary edema and congestive heart failure. Administration: Solutions are 5-25% and usually crystallized; warmed then cooled to body temp; Administer per IV infusion to obtain urine flow rate of 30- 50ml/hr. Copyright 2018 University of Texas Medical Branch, Potassium Sparing Diuretics Two categories: Aldosterone antagonists- spironolactone Nonaldosterone antagonists- Triamterine Amiloride INSTRUCTIONS to STUDENTS : Write up a drug card for triamterine and amiloride. Copyright 2018 University of Texas Medical Branch, spironolactone (Aldactone) Classification: Potassium Sparing Diuretic: Aldosterone antagonists- Prototype Drug: spironolactone (Aldactone) Mechanism of action: Blocks action of aldosterone in the distal nephron; Since aldosterone promotes Na reabsorption in exchange for K secretion, inhibition of aldosterone causes retention of K and excretion of Na and water. Indications: Hypertension and edema; Usually given in combo with a Loop or thiazide diuretic because of low diuresis Adverse Effects: Hyperkalemia >5.0 (injection of insulin can reverse this) resulting in fatal cardiac dysrhythmias such as VFib. Endocrine effects such as gynecomastia and menstrual irregularities since the drug is similar in chemical structure to steroid hormones. Nursing Implications: NEVER give Aldactone in conjunction with potassium, salt substitutes, or another potassium sparing drug. Copyright 2018 University of Texas Medical Branch, Potassium Sparing Diuretics Classification: Non-Aldosterone antagonist Prototype Drug: Triamterene (Dyrenium) MOA: Disrupts sodium-potassium exchange DIRECTLY in the distal nephron Indications: Hypertension and edema (scant diuresis); used mainly to counteract the potassium wasting effects of lasix etc. Adverse Effects: Commonly nausea and vomiting, leg cramps and dizziness; hyperkalemia, also use caution if combined with ACE inhibitors, ARBS, direct renin inhibitors. Copyright 2018 University of Texas Medical Branch, Potassium Supplementation Prototype: Potassium chloride Mechanism of Action: Replacement Transmission of nerve impulses especially in the heart, hypo or hyperkalemia will both cause cardiac dysrhythmias Potassium is lost in vomiting, diarrhea, prolonged diuresis; insufficient intake, alkalosis and excessive insulin Nursing Implications: IV, can only be given per IV drip NEVER push and no faster than 10 meq per hour; never add KCL to an existing IV; Dilute 40meq/L or less; check K level before infusion and periodically throughout the treatment; Mix K well in the IV solution. Oral: make sure to give pills with meals or a full glass of water; Liquid KCl : dilute in cold water or juice according to directions; Copyright 2018 University of Texas Medical Branch, Potassium Supplementation Adverse Effects: Oral KCl can irritate GI tract causing abdominal discomfort, N&V, diarrhea, SEVERE intestinal ulcers, bleeding, and perforation. Hyperkalemia can cause cardiac dysrhythmias- (mild, 5-7: Prolonged PR, Tented t waves); (severe >7: cardiac arrest due to V-tach or V-Fib). Final Warning: potassium given IV push OR more than 10 meq/hour will cause INSTANT DEATH!!!!! Copyright 2018 University of Texas Medical Branch, Removal of Excess Potassium Symptoms in addition to cardiac can include: confusion, anxiety, dyspnea, heaviness or tingling of legs, numbness/tingling of hands, lips, feet. Steps to control/remove: 1. Withhold potassium containing foods/meds, including potassium sparing diuretics. 2. Infuse calcium gluconate to counteract cardiotoxicity 3. Infuse insulin and glucose to push potassium into cells 4. Infuse sodium bicarbonate to increase ph and increase cellular intake of potassium. 5. Give either oral or by enema Kayexalate (sodium polyesterene sulfonate) an exchange resin that removes K 6. Do peritoneal or hemodialysis to remove potassium. Copyright 2018 University of Texas Medical Branch, The effect of calcium gluconate Copyright 2018 University of Texas Medical Branch, Module 6: Cardiovascular Meds Copyright 2018 University of Texas Medical Branch, 2017 Hypertension Guidelines Copyright 2018 University of Texas Medical Branch, Cholinergic Drugs: Atropine (AtroPen) Atropine (Prototype) is the only drug in this category used for cardiovascular purposes Muscarinic antagonists: selectively block the effects of acetylcholine at the muscarinic receptors. Indications: Bradycardia (in ICU) since atropine increases heart rate, nursing gives per emergency protocols Adverse Effects: tachycardia, dry mouth, blurred vision and photophobia, elevation of intraocular pressure (avoid in glaucoma), urinary retention; anhidrosis (avoid working in hot weather) Interactions: with antihistamines, phenothiazine antipsychotics, tricyclic antidepressants. Dosage: 1 mg IV or IM Copyright 2018 University of Texas Medical Branch, Actions of Adrenergic Receptors (heart related only) Alpha 1- Arterioles and veins- constriction Alpha 2 – mainly in central nervous system Beta 1- heart and kidney; Heart- increase rate, force of contraction, AV conduction velocity; Kidney- release of renin Beta 2- bronchi- dilation; arterioles of heart , lung, and skeletal muscle-vasodilation Neuro transmitters (epinephrine, norepinephrine, and dopamine), see page 123 Table 15-4, Lehne, 11th ed., for specific adrenergic receptors. E.g. epinephrine stimulates alpha 1 and 2, beta 1 and 2, but not dopamine. Norepinephrine stimulates alpha 1 and 2, and beta 1; Dopamine stimulates alpha 1 and beta 1 and dopamine. Copyright 2018 University of Texas Medical Branch,  Alpha adrenergic antagonists (Sympatholytics) prazosin (Minipress)- Prototype Mechanism of action: Inhibits alpha 1 receptors, dilation of arterioles and veins, resulting in decreased BP, decreased CO Indications: Essential Hypertension, BPH, Raynaud’s Adverse effects: dizziness, Headaches, drowsiness, impotence (alpha 1 blockage inhibits ejaculation), reflex tachycardia, nasal congestion, edema, postural hypotension. WATCH for 1st dose effect. Nursing Implications: impotence is the major reason for nonadherence Other alpha adrenergic antagonists are: terazosin, doxasosin Copyright 2018 University of Texas Medical Branch, Beta Blockers: Therapeutic Effects -Reduced heart rate -Reduced peripheral vascular resistance with long term use -Reduced force of contraction -Reduced speed of AV conduction Multiple indications: Angina; hypertension, cardiac dysrhythmias (SA node, sinus tachy); MI; heart failure Adverse Effects of Beta blockers: Bradycardia, reduced CO, precipitation of heart failure, AV heart block, rapid withdrawal of drug will cause angina or ventricular dysrhythmias (need to taper withdrawal over several weeks). Copyright 2018 University of Texas Medical Branch, Beta Adrenergic Antagonists (Beta Blockers) Prototype: 1 Generation Nonselective beta 1 st and 2 adrenergic blocker (Propranolol: generic only) Mechanism of action: blocks adrenergic receptors in the cardiac (beta 1) and lungs (beta 2); renal (beta 1) suppresses renin secretion Therapeutic Action: Antihypertensive, reduces HR, CO, used in MI, angina, cardiac dysrhythmias. Adverse Effects: Hypotension, bradycardia, bronchoconstriction, may rarely cause depression. Nursing Implications: Non selective drugs are contraindicated in asthma, COPD; take HR and BP before giving; May mask signs & symptoms of hypoglycemia. Drug interactions : Calcium channel blockers (may cause cardiac suppression, very low heart rate and BP). Usually given po but occasionally IV Copyright 2018 University of Texas Medical Branch, Metoprolol (Lopressor, Toprol XL Prototype 2nd generation Selective B1 Blocker (cardiac) Mechanism of Action- blocks beta1 receptors in the heart Reduces heart rate, force of contraction, conduction velocity through AV node, reduces secretion of renin Indications: hypertension; also approved for angina, MI, heart failure Adverse effects: bradycardia, reduced cardiac output, AV heart block; Also can CAUSE heart failure Dosage: IR tablets and ER tablets, dosage varies depending on why it is being given; also there is an IV formulation 16 beta blockers approved for usage in USA. Write drug cards for atenolol and labetol Copyright 2018 University of Texas Medical Branch, Central Acting Alpha 2 agonists Prototype drug: clonidine (Catapres) Mechanism of action: activates the alpha 2 receptors in the brainstem and thus reduces sympathetic outflow to blood vessels and the heart. Indications: Treatment of hypertension and in some cases treatment of pain. Adverse effects: Drowsiness and sedation; xerostomia; constipation, impotence, rebound hypertension in response to abrupt withdrawal; can cause fetal harm; can cause euphoria, hallucinations if abused. Dosage: Oral, transdermal (1 patch q 7 days). Others- Methyldopa and reserpine Copyright 2018 University of Texas Medical Branch, Drugs working on Renin Angiotensin System Copyright 2018 University of Texas Medical Branch, Ace (Angiotensin Converting enzyme) Inhibitors Prototype: captopril (generic only) Mechanism of Action: Lowers BP by inhibition of ACE; this disrupts conversion of angiotensin I to II in the kidneys; since angiotensin II is a powerful vasoconstrictor, vasodilatation occurs and BP is lowered. Indications: Hypertension, heart failure, MI, BP med of choice for DM since it slows progression of kidney disease Adverse Effects: 1st dose hypotension, cough (increase in bradykinin), angioedema, neutropenia (may progress to agranulocytosis), fetal injury, hyperkalemia Interactions: Other antihypertensives enhance hypotensive effect Nursing Implications: Take BP before giving; report unexplained fever; may cause hypoglycemia in DM, check BG Dosage: give orally Drug cards on lisinopril and enalapril (Vasotec) given IV for severe hypertension Copyright 2018 University of Texas Medical Branch, Angiotensin II Receptor Blockers (ARBs) Prototype: Losartan (Cozaar) MOA: Block access of angiotensin II to its receptors in blood vessels, the adrenals, and other tissues. Thus causes dilatation of arteries and veins; Indications: Hypertension, diabetic retinopathy (slows development) in Type I without established retinopathy. ARBs: They have a lower risk of cough; can cause angioedema Interactions: with other antihypertensives For pt with diabetes, preferred antihypertensives are: ACEI, ARBs, CCBs, and diuretics Copyright 2018 University of Texas Medical Branch, Calcium Channel Blockers 3 chemical families which have somewhat different actions Prototype: Verapamil (calan); Mechanism of action: inhibits calcium ion influx across cardiac and smooth-muscle cells, thus decreasing myocardial contractility and oxygen demand; it also dilates coronary arteries and arterioles. Therapeutic Action: antihypertensive, reduces heart rate, anti arrhythmic for SVT (IV), anti- anginal, decreases force of contraction. Adverse Effects: Dizziness, headache, fatigue, sleep disturbances, hypotension, bradycardia, constipation (does not occur in nifedipine), nausea, edema in legs, severe CHF Interactions: Grapefruit juice may increase drug levels, increases plasma level of digoxin, potentiates effects of other antihypertensives Nursing Implications: Take BP and HR before giving; teach pt to monitor use of grapefruit juice and avoid large amts; report gradual weight gain Copyright 2018 University of Texas Medical Branch, CCB’s Diltiazem (Cardizem) is very similar to verapamil Nifedipine (procardia)- also prevents calcium influx into the calcium channels, however it works only on the arteries not the heart itself. Indications: hypertension and angina Adverse effects: edema, flushing, HA, dizziness, reflex tachycardia (does not occur in verapamil or diltiazem), hypotension. Maternal side effects are rare: tachy, facial flushing, HA, dizzi, nausea. Drug cards should be written on all the calcium channel blockers. Copyright 2018 University of Texas Medical Branch, Vasodilators Prototype drug: hydralazine (apresoline) MOA: Selective dilation of arterioles, no effect on veins. HR increases Indications: Essential hypertension, Hypertensive crisis (IV), Heart failure Adverse effects: reflex tachycardia, increased blood volume, lupus like syndrome Interactions: combine with beta blocker to avoid reflex tachycardia; excessive hypotension if combined with other antihypertensive. Dosing: Oral and IV Copyright 2018 University of Texas Medical Branch, Vasodilators (Anti- anginal) Prototype: Nitroglycerine (Nitrol) Mechanism of action: Relaxes vascular smooth muscle; reduces preload, afterload, and myocardial O2 demand Therapeutic Action: reduces BP, chest pain Indications: Chest pain (angina) Copyright 2018 University of Texas Medical Branch, Nitroglycerine Sublingual tablet: Give one q5minutes up to three Sublingual Spray May take before known chest pain producing activity Nitrocream(topical) measure in increments Transdermal Patch: apply to hairless area Capsule SR: taken to prevent CP IV (Tridil): Titrate IV drip according to BP (only in ICU) Copyright 2018 University of Texas Medical Branch, Nitroglycerine Side Effects: Headache, postural hypotension, facial flushing Drug Interactions: Alcohol can worsen hypotension; IV nitro may antagonize heparin Nursing Implications: Give analgesics for headache; take BP before administering Unrelieved pain after 15 minutes after SL is usually indicative of an MI Clean area after removing patch; Swimming and bathing with patch okay Other antianginal drugs: isordil; isosorbide; Drug cards should be made Copyright 2018 University of Texas Medical Branch, Cardiac Glycosides Prototype: Digoxin (digitalis), digitoxin, etc.; also acts as an antiarrhythmic Mechanism of Action: Increases force of myocardial contraction; positive inotropic action on the heart Therapeutic Action: increases diuresis; used in atrial fibrillation, CHF Indications: heart failure (now 2nd line drug); Adverse Effects: Bradycardia, heart blocks, other dysrhythmias, visual disturbances, N&V, agitation, Interactions: Multiple; anti-acids, antibiotics, amiodarone, verapamil, quinidine, etc. Nursing Implications: take apical pulse one full minute before giving, must be above ordered parameter, usually 60 in adults Digoxin levels should be checked daily when first started and periodically later; hypokalemia increases risk of dig toxicity and is the most common reason for toxicity. Digibind can be used to reverse effects of high levels (therapeutic range is 0.5-0.8 ng/mL) NOTE : Read section on digoxin very carefully; one of the most common drugs tested on in all venues. Lehne, 12th ed, pp 558- 563 Copyright 2018 University of Texas Medical Branch, New York Association class The New York Heart Association (NYHA) functional class helps to classify heart failure patients based on their symptoms. Class I: No symptoms of heart failure. Class II: Symptoms of heart failure with moderate exertion, such as ambulating two blocks or two flights of stairs. Class III: Symptoms of heart failure with minimal exertion, such as ambulating one block or one flight of stairs, but no symptoms at rest. Class IV: Symptoms of heart failure at rest. Copyright 2018 University of Texas Medical Branch, ACC/AHA Heart Failure Class Stage A: Patients at risk for heart failure who have not yet developed structural heart changes (i.e. those with diabetes or coronary artery disease) Stage B: Patients with structural heart disease (i.e. reduced ejection fraction, left ventricular hypertrophy, chamber enlargement) who have not yet developed symptoms of heart failure Stage C: Patients who have developed clinical heart failure Stage D: Patients with refractory heart failure requiring advanced intervention (i.e. biventricular pacemakers, left ventricular assist device, transplantation) Copyright 2018 University of Texas Medical Branch, Meds for Heart Failure Diuretics- Furosemide Beta Blockers- Metoprolol RAAS Inhibitors captopril (ACE inhibitor), losartan (angiotensin II receptor blocker) spironolactone (aldosterone antagonist) Inotropics- Digoxin, Dopamine (Dopastat), dobutamine (Dobutrex) Copyright 2018 University of Texas Medical Branch, Meds for Heart Failure Dopamine is a catecholamine low dose (1-5 mcg/kg/min): dopamine receptors only, vasodilation; moderate dose (5-10 mcg/kg/min): beta1 & dopamine receptors, increase CO, HR, cardiac contractility; high dose (>10 mcg/kg/min): alpha1, beta1 & dopamine receptors, vasoconstriction, mainly used to increase low BP Dobutamine is a catecholamine, can increase myocardial contractility; does not activate alpha 1 receptors and is generally preferred to dopamine. IV infusion. Copyright 2018 University of Texas Medical Branch, Anti-Arrhythmics (Dysrhythmics) Dysrhythmias occur with increasing age, heart surgery, MI, HF, etc. Most can be given IV in the ICU or po for long term control of dysrhythmias. Side effects vary but many times can cause another fatal dysrhythmia. Class I: sodium channel blockers: lidocaine Class II: beta blockers Class III: potassium channel blockers: amiodarone Class IV: calcium channel blockers Other: adenosine, digoxin Copyright 2018 University of Texas Medical Branch, Anti-Arrhythmics drugs Prototype drug: Adenosine (Adenocard) MOA- decreases automaticity in the SA node and slows conduction through AV node. Inhibits cyclic AMP-induced calcium influx Indications: Terminating SVT including Wolff- Parkinson White Syndrome Adverse effects: last briefly, sinus bradycardia, dyspnea from bronchoconstriction. Short half life 1.5 to 10 seconds, give IV bolus as close to the heart as possible. Copyright 2018 University of Texas Medical Branch, Amiodarone Class III: Potassium Channel Blockers (delay repolarization) 6 drugs in class Amiodarone (Codarone) MOA: Slows AV conduction and prolongs AV refractoriness. Indications: IV for initial treatment of recurrent Vfib and unstable Vtach. Adverse effects: Severe hypotension, Bradycardia, may require pacemaker Copyright 2018 University of Texas Medical Branch, Calcium Gluconate/ Calcium Chloride (chapter Calcium chloride 78) is a 10% IV solution, can be given undiluted but preferably give diluted CaCl is 3x more powerful than calcium gluconate Indications: Given based on serum calcium levels in hypocalcemia, magnesium toxicity (antidote for magnesium sulfate), hyperkalemia (titrate dosage according to EKG changes), cardiac resuscitation (use AHA guidelines): calcium channel blocker toxicity. Contra-Indications: hypercalcemia, pt taking digoxin, ventricular fibrillation. Copyright 2018 University of Texas Medical Branch, Lipid lowering medications HMG-CoA reductase inhibitors (statins) Table 53-8 LEHNE Most effective for lowering LDL’s and total cholesterol; Improve clinical outcomes: lower risk of HF, MI, and sudden cardiac death, very commonly prescribed Prototype drugs are atorvastatin (lipitor) and lovastatin (mevacor) Indication: MI, adult DM pt, adolescents with familial hyperlipidemia Actions: Reduce LDL-C, Elevate HDL, may lower triglycerides S.E.- dyspepsia, cramps, flatulence, constipation and abdominal pain, usually mild and transient Adverse effects are myopathy/rhabdomyolysis (rosuvastatin (Crestor) has highest risk), results in renal damage. Watch for high CK levels; hepatotoxicity; Risk rises if combined with other lipid lowering agents. Dosage of crestor must be reduced in Asians Statin users must not eat grapefruit, since the juice inhibits CYP3A4 isoenzyme (macrolide antibiotics, anti-fungals, HIV protease inhibitors, amiodorane, cyclosporin) Prohibited in pregnancy- Category X Current LDL goal is 100 and 70 for very high risk pt (such as diabetes) Copyright 2018 University of Texas Medical Branch, Lipid lowering medications Ezetimibe (Zetia) Prototype drug- Cholesterol blocker MOA- inhibits dietary absorption of cholesterol. Treatment reduces total cholesterol, LDL- C, triglycerides, slight rise in HDLs. Adverse effects- generally well tolerated but some reports of rhabdomyolysis, hepatitis, and pancreatitis. Increase risk of liver damage when combined with a statin Copyright 2018 University of Texas Medical Branch, Fibric Acid Derivatives (Fibrates) Prototype Drug: Gemfibrozil (Lopid) (also fenofibrate, fenofibric acid) Decreases triglycerides. Increases HDL’s, reduce LDL-C slightly. Treatment usually limited to those who have not responded to weight control and diet modification Adverse Effects: Gall stones, myopathy, hepatotoxicity Interactions: displaces warfarin from plasma albumin, increasing anti-coagulation; should not be given with a statin. Copyright 2018 University of Texas Medical Branch,