CV:RENAL PART 1.docx

CV/RENAL PART 1 [DIURETICS] MOA: blockade of Na and chloride reabsorption Drugs that act early in the nephron greatest amount of solute reabsorption Can cause hypovolemia, acid-base imbalance, and E- loss +-----------------------------------+-----------------------------------+ | Loop: Furosemi...

CV/RENAL PART 1 [DIURETICS] MOA: blockade of Na and chloride reabsorption Drugs that act early in the nephron greatest amount of solute reabsorption Can cause hypovolemia, acid-base imbalance, and E- loss +-----------------------------------+-----------------------------------+ | Loop: Furosemide, Ethacrynic | \- Uses: pulm edema, edema, HTN, | | acid, Bumetide, Torsemide | good for renal impairment pts | | | | | \- acts on ascending loop of | \- AE: low Na/Cl, dehydration, | | Henle to block reabsorption | hypotension, low K, ototoxicity | | | | | | \- interactions: digoxin (inc K), | | | ototoxic drugs, | | | potassium-sparring diuretics, | | | lithium (accumulation), antiHTN, | | | NSAIDS (blunt effects) | +===================================+===================================+ | Thiazide: hydrochlorothiazide | \- uses: HTN, edema, DI | | | | | \- renal excretion of Na, Cl, K, | \- AE: low Na/Cl/K, dehydration, | | and water | hyperglycemia, hyperuricemia, | | | impact on lipids, Ca, and Mag | | Elevate uric acid and glucose | | | levels | \- interactions: same as above, | | | except NOT ototoxic | | **- unlike loop diuretics, it's | | | not effective in pts w/ renal | | | impairment** | | | | | | \- maximized diuresis is lower | | | than loop | | +-----------------------------------+-----------------------------------+ | Potassium-sparring Diuretics: | spironolactone: | | | | | Aldosterone antagonist | \- block aldosterone in the | | spironolactone | distal nephron | | | | | Nonaldosterone antagonist | \- retention of K, excretion of | | Triamterene, Amiloride | Na | | | | | -modest increase in urine | \- uses: HTN, edema, HF, | | production, decreases K excretion | hyperaldosteronism, premenstrual, | | | PCOS, acne | | -often combined w/loop and | | | thiazide to counteract K loss | \- AE: high K, tumors, | | | gynecomastia, menstrual | | | irregularities, deeper voice, | | | impotence | | | | | | \- interactions: thiazide/loop, | | | agents that raise K (ace, arbs, | | | and K supplements) | | | | | | Triamterene: | | | | | | \- direct inhibitor of exchange | | | mechanism | | | | | | \- uses: HTN, edema | | | | | | \- AE: high K, leg cramp, n/v, | | | blood dyscrasias | | | | | | Amiloride: | | | | | | \- similar to above | +-----------------------------------+-----------------------------------+ [DRUGS OF RAAS] +-----------------------------------+-----------------------------------+ | ACE Inhibitors (angiotensin | \- MOA: block production of | | converting enzyme) | angiotensin II (angiotensin III), | | | increase levels of bradykinin | | "prils) | | | | \- Inhibition of Angiotensin II: | | | Dilate blood vessels, reduce | | | blood volume, prevent/reverse | | | pathologic changes in the heart | | | and blood vessels, hyperkalemia, | | | fetal injury | | | | | | \- Bradykinin: Vasodilation, | | | cough, angioedema | | | | | | \- all excreted by the kidneys | | | | | | \- Admin orally w/food (captopril | | | and moexipril) | | | | | | - Enalapril IV | | | | | | - Captopril prolong halflife | | | | | | - All except lisinopril are | | | prodrugs that must undergo | | | conversion to active form in | | | the small intestines and | | | liver | | | | | | - Ramipril reduce risk of MI, | | | stroke, death from CV | | | | | | - Benazepril, perindopril, and | | | trandolapril available | | | combined w/ calcium channel | | | blockers | | | | | | - Dosages for all ACE (except | | | fosinopril) should be reduced | | | in renal pts | | | | | | \- Uses: HTN, HF, MI, dm/nondm | | | nephropathy, and dm retinopathy | | | | | | \- AE: first-dose hypotension, | | | cough, hyperkalemia, angioedema, | | | neutropenia, and renal failure in | | | pts w/ bilateral renal artery | | | stenosis | | | | | | \- Interactions: diuretics may | | | intensify first-dose hypotension, | | | caution w/ potassium sparing | | | drugs, can cause lithium to | | | accumulate to toxic levels, | | | NSAIDS may reduce antiHTN effects | +===================================+===================================+ | ARBs (angiotensin II receptor | \- Blocks ACTIONS (receptors) of | | blockers) | angiotensin II | | | | | "sartans" | \- Uses: HTN, HF, diabetic | | | nephropathy, prevention for | | | MI/stroke/ death from CV | | | | | | \- Much like ACE's but ARBs pose | | | lower risk for cough or | | | hyperkalemia | | | | | | \- ACEs are preferred for CV but | | | ARBs is second choice | | | | | | \- AE: angioedema, renal failure, | | | fetal injury | | | | | | \- ARBS do not promote | | | accumulation of bradykinin in the | | | lung lower instance of cough | +-----------------------------------+-----------------------------------+ | Direct Renin Inhibitors (DRIs) | \- Act on renin to inhibit the | | | conversion of angiotensinogen | | | into angiotensin I suppress the | | | entire RAAS | | | | | | - Aliskiren (only one | | | available) | | | | | | - Blood pressure reduction, | | | less | | | cough/angioedema/hyperkal | | | emia, | | | similar risk to | | | developing fetus | | | | | | - Approved only for HTN | | | | | | - s/e: diarrhea | +-----------------------------------+-----------------------------------+ | Aldosterone antagonist | Spironolactone (diuretic) | | | | | "one\'s" | - add-on therapy in HTN and | | | class III-IV HR, edema in | | | cirrhotic adults not | | | responsive to fluid and Na | | | restrictions, | | | hyperaldosteronism, and in | | | nephrotic syndrome | | | | | | - has antiandrogenic properties | | | off label use for hirsutism, | | | female pattern hair loss, and | | | acne | | | | | | Eplerenone (diuretic) | | | | | | - aldosterone receptor blockers | | | **K retention, Na/water | | | excretion (do not combine w/ | | | potassium or potassium | | | sparing drugs)** | | | | | | - uses: HTN, HF | | | | | | - s/e: hyperkalemia, diarrhea, | | | abd pain, cough, fatigue, | | | gynecomastia, flu-like symp | | | | | | - inhibitors of CYP can | | | increase levels of eplernone | | | toxicity | | | | | | - weak inhibitors | | | (erythromycin, | | | saquinavir, verapamil, | | | fluconazole)= eplernone | | | dosage should be reduced | | | | | | - strong inhibitors | | | (ketoconazole, | | | itraconazole)= do not | | | combine with | +-----------------------------------+-----------------------------------+ +-----------------------------------+-----------------------------------+ | Calcium Channel Blockers | \- uses: HTN, angina, | | | dysrhythmias | | Act on vascular smooth muscle and | | | the heart | \- block Ca contraction prevented | | | and vasodilation will result. | | | Work on arteries not veins. | | | | | | Verapamil: (nondihydropyridine) | | | | | | \- acts on arterioles and the | | | heart | | | | | | \- uses: angina, HTN, | | | dysrhythmias | | | | | | \- dilation, increases coronary | | | perfusion, reduces HR (block SA), | | | decreased conduction (block AV), | | | decreases force of contraction | | | (block myocardium) | | | | | | BUT because the baroreceptor | | | reflex causes release of NE inc | | | HR, av conduction, and force of | | | contraction, this all equals out | | | and effects of verapamil | | | neutralize so has little effect | | | on cardiac performance. | | | Pointless? | | | | | | \- so the only thing this | | | actually does is vasodilation and | | | increased coronary perfusion | | | | | | \- AE: constipation, LE edema, | | | gingival hyperplasia, flushing, | | | HA, bradycardia and partial or | | | complete AV block | | | | | | \- interactions: w/digoxin risk | | | for AV block, **w/ BB excessive | | | cardio suppression**, grapefruit | | | juice can increase levels also w/ | | | felodipine and nifedipine | | | | | | Diltiazem: (nondihydropyridine) | | | | | | \- same as verapamile | | | | | | \- less constipation | | | | | | Nifedipine: (dihydropyridine) | | | | | | \- works on vascular smooth | | | muscle vasodilation inc coronary | | | perfusion, less blockade of Ca | | | not used for dysrhythmias, does | | | not cause cardiac suppression and | | | less likely to exacerbate | | | preexisiting cardiac disorders | | | | | | \- because it lacks Ca blocking | | | HR and contractile force | | | increases | | | | | | \- reflex effects occur primarily | | | with immediate-release | | | formulation | | | | | | \- can cause reflex tachycardia | | | | | | \- AE: flushing, HA, edema, | | | gingival hyperplasia, eczematoush | | | rash in elderly | +===================================+===================================+ | Vasodilators | \- uses: HTN, HTN crisis, angina, | | | HF, MI | | Act directly on smooth muscle in | | | arterioles and veins to produce | AE: postural hypotension | | vessel relaxation | | | | Hydralazine: | | | | | | \- dilation of arterioles | | | peripheral resistance and | | | arterial bp fall HR and | | | myocardial contractility increase | | | | | | \- hydralazine induced | | | tachycardia give w/ BB | | | | | | \- hydralazine induced | | | hypotension Na/water retention | | | inc in blood volume, a diuretic | | | can help | | | | | | \- can cause acute rheumatoid | | | syndrome that resembles SLE | | | (lupus): muscle/joint pain, | | | fever, nephritis, pericarditis, | | | and presence of antinuclear | | | bodies, rare if dosages are kept | | | below 200mg/day dc if occurs. | | | Symp are reversible but take 6mo | | | or more | | | | | | Minoxidil: | | | | | | \- more intense vasodilation than | | | hydralazine and causes severe AE | | | reserved for pts w/ severe HTN | | | not responding to safer drugs. | | | | | | \- uses: HTN only, people say it | | | helps with hair growth | | | (hypertrichosis) | | | | | | \- the same as hydralazine | +-----------------------------------+-----------------------------------+ [DRUGS TO TREAT HTN] - Anti-hypertensives Dilation of arterioles AND veins - s/e hypotension, sedation, and all antihypertensives interfere w/ sexual dysfunction - Can give: diuretics ,calcium channel blockers, ACE and ARBS - For initial therapy w/ the absence of a compelling indication: thiazide diuretic. Other options are ACEs, ARBs, and CCB - Comorbid conditions that complicate tx: renal disease (nephrosclerosis) and DM - Nephrosclerosis: ACE and ARBS - DM: all work. w/ dm nephropathy ACE and ARBs can slow renal damage and reduce albuminuria - When needing to add combination therapy: - An ACE plus a thiazide diuretic - An ACE plus CCB - Or a BB plus thiazide - With pregnancy - w/ exception of ACE, ARBs, and DRIs, antiHTN drugs that were taken before pregnancy can be continued - when initiated during pregnancy: methyldopa and labetalol are of choice - preeclampsia and eclampsia: hydralazine and mag sulfate