Module 5 PPT - Pharm Updated 3.23 PDF

CH. 44 DIURETICS CH. 47 DRUGS ACTING ON THE RA AS CH. 48 CALCIUM CHANNEL BLOCKERS CH. 50 DRUGS FOR HTN CH. 51 DRUGS FOR HEART FAILURE CH. 52 ANTIDYSRHYTHMIC DRUGS  Recognize common medications used to treat clients with disorders related to the cardiovascular and renal syst...

CH. 44 DIURETICS CH. 47 DRUGS ACTING ON THE RA AS CH. 48 CALCIUM CHANNEL BLOCKERS CH. 50 DRUGS FOR HTN CH. 51 DRUGS FOR HEART FAILURE CH. 52 ANTIDYSRHYTHMIC DRUGS  Recognize common medications used to treat clients with disorders related to the cardiovascular and renal systems. Contrast the various classes of medications used to treat common disorders related to the cardiovascular and renal MODULE systems. Recognize the indications, pharmacokinetics, laboratory 5 monitoring, and side effects of medications that are commonly used to treat common disorders related to the cardiovascular and renal systems. LEARNIN Discuss accepted nursing practice for the care of clients taking medications that affect the cardiovascular and renal systems. G Explain the common adverse reactions and client education for frequently prescribed medications that affect the cardiovascular OBJECTIV and renal systems. ES  HYPERTENSION (HTN) An increase in the blood Primary/essential HTN is the most pressure such that the systolic common type with no identifiable pressure is >140mm/Hg and cause. (no cure, worse with age) the diastolic is >90mm/Hg. Secondary HTN is less than 10% of Contributing factors include: HTN cases and brought on by an family history of HTN, identifiable cause. (can be cured by hyperlipidemia, African treating the underlying cause) American heritage, diabetes,  Cushing’s  Tumor age, sex, stress, excess alcohol  Hormonal contraceptives intake, smoking & inactivity. Untreated HTN can lead to heart disease, kidney disease, stroke, etc. NONPHARMALOGIC CONTROL OF HYPERTENSION Stress reduction Alcohol restriction Aerobic exercise Smoking cessation Salt restriction www.bulletpr oofexec.com  HYPERTENSION Cardiac Output is influenced by: Consequences  Heart rate  Myocardial contractility (force of contraction) Myocardial ischemia & Infarction  Blood volume Heart Failure  Venous blood return Angina CVA (Stroke)/Brain hemorrhage Kidney damage, and more... 3 Regulatory Systems for BP: Sympathetic nervous system RAAS  PHARMALOGIC CONTROL OF HYPERTENSION Drugs for HTN: Additional classes:  Centrally Acting Alpha2 Agonists Diuretics  Alpha Adrenergic Blockers Beta Adrenergic Blockers Calcium Channel Blockers Blo cke Inhibitors of the RAAS System ACE rs &  Angiotensin Converting Enzyme (ACE) AR B s & Inhibitors s, O My. h  Angiotensin Receptor Blockers (ARBs)..  Direct Renin Inhibitor  Aldosterone Antagonists www.ondemandstr esssolutions.com CH. 44 DIURETICS  DIURETICS Produce increased urine outflow. Basic functions of the kidneys:  Cleansing and maintaining ECF volume and applications: composition  Treatment of HTN  Maintenance of acid-base balance  Mobilization of edematous fluid  Excretion of metabolic wastes and foreign associated with heart failure, cirrhosis, or substances kidney disease.  Also used to prevent renal failure Small particles such as electrolytes, amino acids, drugs, glucose & waste Every minute the kidney produces products are filtered in the glomeruli. 125mL of filtrate… about 180 L/day. Larger products such as protein and lipids remain in circulation. 99% of water, electrolytes, and nutrients that are filtered are reabsorbed. Diuretics can cause: Hypovolemia Diuretics that promote potassium Acid-base imbalances excretion are called “potassium- Altered electrolyte levels wasting” diuretics. Diuretics can cause the loss of electrolytes Diuretics that promote potassium including: retention are called “potassium- Sodium sparing” diuretics. Potassium Magnesium Chloride Bicarbonate DIURETICS  Loop diuretics  (furosemide) Thiazide diuretics  (hydrochlorothiazide) Osmotic diuretics  (mannitol) Potassium-Sparing diuretics  Aldosterone antagonists (spironolactone, Eplerenone)  Nonaldosterone antagonists DIURETIC CLASSES (triamterene)  LOOP DIURETICS Act on the thick ascending loop of Henle to block furosemide (Lasix) reabsorption of sodium and Torsemide chloride preventing water reabsorption. bumetanide (Bumex) Ethacrynic Acid Sodium & water are lost along with potassium, calcium & Generally reserved for situations magnesium. that require rapid or massive mobilization of fluid. Most effective diuretics Useful in patients with severe renal available and are very potent; impairment (can promote diuresis can cause marked depletion of even when GFR and renal blood flow water and electrolytes. are low).  LOOP DIURETICS furosemide (Lasix) Side effects:  Dehydration bumetanide (Bumex)  Hypotension Should be taken in the morning  Electrolyte imbalances due to diuresis.  Hyponatremia  Hypokalemia used in IV form for emergent  Hyperglycemia treatment of pulmonary edema  Ototoxicity or acute heart failure. Assess vital signs, daily weights Drug Interactions: (report gain or loss >2lbs in 24  Digoxin-secondary to low potassium hours) & electrolytes.  Ototoxic drugs  Lithium-secondary to low sodium Caution patients about possible  Antihypertensive agents orthostatic hypotension.  NSAIDs-can counteract diuretic effect  WARNING: FUROSEMIDE (LASIX) When administering a dose into an IV, with a syringe, it must be pushed SLOWLY, not to exceed 20mg/min. Too rapid IV push is associated with ringing in the ears (tinnitus) and permanent hearing loss (ototoxicity), especially when combined with other ototoxic drugs like gentamicin or vancomycin. Best practice is to use an infusion pump with drug library. POTASSIUM SUPPLEMENT S Patients on potassium- wasting diuretics are usually on potassium supplements. Monitoring of serum potassium levels is essential. Normal serum potassium levels are 3.5-5.0 POTASSIUM RICH FOODS Good idea for people on potassium-wasting diuretics. Large quantities: Bad idea for people on potassium-sparing diuretics. www.projectnext.eu  DIURETICS: THIAZIDES hydrochlorothiazide (HCTZ), Side effects: Chlorthalidone  Electrolyte imbalances  Can cause hyperglycemia Acts on the distal convoluted  Dehydration tubule (not as effective). Promotes sodium, potassium, Use only in patients with normal chloride & water excretion. renal function  If BUN and/or Creatinine are elevated, or Used to treat hypertension & if GFR is Low- do not give this class peripheral edema.  First-line drugs for HTN Not effective for immediate, emergency diuresis.  Diuresis begins about 2 hours after oral administration www.canadianpharm acy365.net  DIURETICS: THIAZIDES First line drugs for the treatment of HCTZ is often prescribed in combination hypertension. with other antihypertensive agents because Many antihypertensive drugs HCTZ is the most frequently can cause fluid retention. prescribed diuretic for controlling mild hypertension, by decreasing excess fluid volume. Loop diuretics, like furosemide, are best in patients with decreased renal function because they do not cause decreased renal blood flow like thiazide diuretics. T Z c an HC s e rum e c re ase v els! d l e t a s siu m ls: po l e v e o rm al N t o 5.0 3.5  POTASSIUM-SPARING DIURETICS PG. 461 Spironolactone-Aldosterone If serum potassium is >5 mEq/L the antagonist potassium-sparing diuretic should be discontinued. Amiloride-Nonaldosterone antagonist Triamterene-Nonaldosterone antagonist Weaker than thiazides & loop diuretics. Used alone but mostly in conjunction with a potassium-wasting diuretic (HCTZ) to have better diuresis.  POTASSIUM-SPARING DIURETICS PG. 461 Spironolactone Triamterene Aldosterone antagonist Nonaldosterone antagonist Prescribed because of its potassium Inhibits sodium and potassium retaining effects. exchange in the distal nephron.  Because of this, it acts much faster than Effects take up to 48 hours to develop spironolactone (within hours) Adverse Effects: life-threatening hyperkalemia, especially if given with an ACE inhibitors, ARBs, or direct renin inhibitor.  POTASSIUM-SPARING DIURETICS... Your patient has hypertension and takes triamterene/HCTZ and tells you they have tried to reduce the sodium in their diet, by using a salt substitute instead. Is this a good idea, or not? www.walmart.com  OSMOTIC DIURETICS Inhibits passive reabsorption of water (causing diuresis) mannitol used frequently in emergency Has no significant effect on the situations to treat excess excretion of potassium or other intracranial pressure. electrolytes. Used to prevent kidney failure to decrease intracranial pressure and intraocular pressure. Side effects:  Edema-when the drug leaves the capillaries, it draws water long. www.mcfarlanemedical.co m.au CH. 47 DRUGS ACTING ON THE RAAS  BLOOD PRESSURE VIDEO Ted Ed Blood Pr essure Video (4 min)  REGULATION OF BLOOD Kidneys regulate blood PRESSURE pressure, blood volume, and fluid and electrolyte balance through the renin-angiotensin- aldosterone (RAAS) system. The RAAS raises blood pressure through vasoconstriction and water and sodium retention. www.cdc.gov RAAS SYSTEM medicalassessmentonline.com  ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACE INHIBITORS) ACE inhibitors block the production Used to treat: HTN, heart failure, of Angiotensin II: reduce levels of diabetic nephropathy, MI, and angiotensin II, increase levels of prevention of cardiovascular events. bradykinin (cause cough). Prevention of angiotensin I from  Can cause angioedema being converted to angiotensin II and prevent the release of aldosterone (a promoter of sodium Should not be used in pregnancy due and water retention) which leads to decreased placental blood flow. to diuretic-type effects.  The results are prevention of vasoconstriction and the excretion of Drug of choice for diabetics with sodium of and water; these promote HTN diuresis, improve circulation, and improve cardiac function.  ANGIOTENSIN CONVERTING ENZYME INHIBITORS (ACE INHIBITORS) Used primarily to treat HTN. Side Effects (for all ACE)  captopril  Dry, hacking cough (10%)  enalapril  NOT AN ALLERGY  lisinopril  ****If bothersome, drug can be  ramipril discontinued and replaced with  benazepril an ARB.***  First dose hypotension  Hyperkalemia  ***Angioedema  Tongue  Lips  Eyes  ANGIOTENSIN II RECEPTOR BLOCKERS (ARBS) treats  HTN losartan (Cozaar)  Heart failure  Diabetic nephropathy olmesartan (Benicar)  MI  Prevention of cardiovascular events valsartan (Diovan) Blocks the actions of angiotensin II from Adverse effects for all: receptors found at many tissue sites  Orthostatic Hypotension (very similar to ACE Inhibitors)  Hyperkalemia (lower risk)  Cause vasodilation & decrease peripheral  Angioedema vascular resistance.  Inhibits aldosterone, producing diuretic-type Do not cause the ACE cough. effects. Should not be taken in pregnancy. Can be taken alone or in combination with diuretics.  ALDOSTERONE ANTAGONIST (DIURETIC) FOR HTN: Eplerenone  Can be used alone or in combination with other antiHTN Side effects:  Reserved for patients who have not  Hyperkalemia-avoid salt substitutes responded to traditional antiHTN drugs FOR heart failure:  Can reduce hospitalizations and prolong life  DIRECT RENIN INHIBITOR aliskiren Inhibit the conversion of Side effects: antiotensinogen into angiotensin I,  Less likely to cause hyperkalemia, angioedema, or cough thereby suppressing the entire RAAS. Treatment for HTN only Can be used alone or in combination with other antiHTN.  CH. 48 CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS CALCIUM CHANNEL BLOCKERS Relax and widen blood vessels by blocking calcium channels in arterial smooth muscle, which leads to improved blood flow to the heart and can lead to a reduction in chest pain. Treatment of simmaronresearch. com choice for Angina with Cau ti HTN Wid on: e Vess ned Blo e o to P ls can l d o ead Hyp stural oten sion shriver.umassmed.edu CALCIUM CHANNEL BLOCKERS (CCB) Prevent calcium ions from entering In the heart, beta adrenergic cells…promotes vasodilation. receptors are coupled with Calcium channels Used to treat:  HTN Beta blockers and CCBs have  Angina the same effects on the  Cardiac dysrhythmias heart.  Reduce force of contraction  Slow heart rate  Suppress conduction of AV node Also called:  Slow channel blockers  Calcium antagonists CALCIUM CHANNEL BLOCKERS VERY = Verapamil NICE = nifedipine Drugs = diltiazem  CALCIUM CHANNEL BLOCKERS (CCB) Phenylalkylamines Each group has slightly different uses and considerations. verapamil Benzothiazepines diltiazem Dihydropyridines amlodipine nifedipine nicardipine  CCB-AGENTS THAT ACT MAINLY ON VASCULAR SMOOTH MUSCLE & THE HEART Blocks calcium channels in blood verapamil vessels and in the heart. Side effects: Causes:  Constipation  Dilation → reduces arterial pressure  Bradycardia  Increase in coronary perfusion  Facial flushing/redness  Reduction in heart rate (countered by  Headache release of NE)  Decrease in AV nodal conduction  Dizziness  Decrease in force of contraction  Peripheral edema  Decrease in BP  Hypotension ta ke Indications for use: Diltiazem N OT  Angina DO  Essential HTN Same as verapamil with efruit  Cardiac dysrhythmias grap ! e j uic  CCB-AGENTS THAT ACT MAINLY ON VASCULAR SMOOTH MUSCLE Promotes Nifedipine (table 45.2, pg. vasodilation by 501) Side Effects: blocking vascular  Constipation-increase fiber and fluid intake smooth muscle, ↓  Facial flushing  Headache BP and ↓ angina.  Dizziness  Peripheral edema  Hypotension  Gingival hyperplasia  Reflex tachycardia (sympathetic stimulation)  Give beta blocker CH. 50 DRUGS FOR HTN  BETA ADRENERGIC BLOCKERS Prevent sympathetic stimulation of the heart: Do not stop  Heart rate decreases  Myocardial contractility decreases abruptly! Can  Suppress renin release (↓ Angiotensin II)  Peripheral vasodilation cause rebound  Renal vasodilation  Suppression of aldosterone HTN!! Decreases cardiac output by decreasing HR and contractility. Suppress reflex tachycardia. This Photo by Unknown Author is Decrease peripheral vascular resistance. licensed under CC BY-SA Decrease the release of renin.. BETA ADRENERGIC BLOCKERS SELECTIVE NON-SELECTIVE atenolol propanolol metoprolol Inhibit beta1 (heart) and beta2 (lung) Act Mainly on beta1 (heart) receptors. receptors. Blood pressure decreases secondary Adverse Effects: to decreases in heart rate. Bradycardia Bronchoconstriction occurs (not the drug of choice for asthmatics). Hypotension Inhibit the liver’s ability to convert Reduced contractility stored glycogen to glucose in response to hypoglycemia (not the Decreased AV conduction drug of choice for diabetics). Masks hypoglycemia  Masks hypoglycemia BETA ADRENERGIC BLOCKERS metoprolol, Block epinephrine from beta atenolol, receptors. labetolol, Decrease heart rate and force. carvedilol, propanolol... m m ters on : o... Co a m e Par if a 60 p ld is < ! i c al S Check HR and BP before H o e