Coagulation Modifier Drugs - Cardiovascular II - 2020 PDF

Chapter 26 C O A G U L AT I O N M O D I F I E R DRUGS COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. Organization of Slides (Ch. 26) Definitions Pharmacology overview Anticoagulants Antiplatelets Antithrombotics Antifibrinolytics Nursing Implications Hemostasis Any process that stops bleeding C...

Chapter 26 C O A G U L AT I O N M O D I F I E R DRUGS COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. Organization of Slides (Ch. 26) Definitions Pharmacology overview Anticoagulants Antiplatelets Antithrombotics Antifibrinolytics Nursing Implications Hemostasis Any process that stops bleeding Coagulation: hemostasis that occurs because of the physiologic clotting of blood. Complex relationship between substances: that promote clot formation and either inhibit coagulation or dissolve a formed clot Thrombus: technical term for a blood clot Embolus: thrombus that moves through blood vessels Fibrin: a clot-forming substance COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 3 Fibrinolytic System Initiates the breakdown of clots and serves to balance the clotting process Fibrinolysis: mechanism by which formed thrombi are lysed to prevent excessive clot formation and blood vessel blockage COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 4 Fibrinolytic System (Cont.) Fibrin in the clot binds to a circulating protein known as plasminogen. This binding converts plasminogen to plasmin. Plasmin is the protein that eventually breaks down the fibrin thrombus. This keeps the thrombus localized to prevent it from becoming an embolus. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 5 Hemophilia ▪ Rare genetic disorder ▪ Natural coagulation and hemostasis factors are limited/absent. ▪ Patients with hemophilia can bleed to death if coagulation factors are not given. ▪ Two types: ◦ Factor VII deficiency ◦ Factor VIII and/or factor IX deficiency COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 6 Pharmacology Overview Drugs that affect coagulation are some of the most dangerous drugs used today. Why? Numerous factors can affect their action: ▪ ▪ ▪ COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 7 Coagulation Modifier Drugs 1. Anticoagulants ◦ Inhibit the action or formation of clotting factors ◦ Prevent clot formation 2. Antiplatelet drugs ◦ Inhibit platelet aggregation ◦ Prevent platelet plugs COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 8 Coagulation Modifier Drugs (Cont.) Hemorheologic drugs ◦ Alter platelet function without preventing the platelets from working (example: Pentoxifylline (Pentoxil, Trental)— improve circulation 3. Thrombolytic drugs ◦ Lyse (break down) existing clots 4. Antifibrinolytic or hemostatic ◦ Promote blood coagulation COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 9 Also known as antithrombotic drugs Have no direct effect on a blood clot that is already formed 1. Anticoagulants Prevent intravascular thrombosis by decreasing blood coagulability Used prophylactically to prevent ◦ _____________________ ◦ _____________________ COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 10 Thomboembolic Events Event Location of Embolus Myocardial infarction (MI) coronary artery Stroke brain vessel Pulmonary embolus pulmonary circulation Deep vein thrombosis (DVT): vein in the leg COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 11 Anticoagulants Heparins ◦ Action: inhibit clotting factors IIa (thrombin) and Xa ◦ Two types: ◦ Unfractionated heparin: “heparin” ◦ Low–molecular-weight heparins (LMWHs) ◦ Enoxaparin (Lovenox) ◦ Dalteparin (Fragmin) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 12 Anticoagulants (Cont.) Unfractionated Heparin (heparin) ◦ Relatively large molecule that is derived from animal sources ◦ Frequent laboratory monitoring for bleeding times such as aPTT ◦ Heparin for catheter flush (10 to 100 units/mL): no monitoring is needed COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 13 Heparin Natural anticoagulant obtained from the lungs or intestinal mucosa of pigs 10 to 40,000 units/mL DVT prophylaxis: 5000 units subcutaneously two or three times a day; does not need to be monitored when used for prophylaxis When heparin is used therapeutically (for treatment), continuous IV infusion. Measurement of aPTT (usually every 6 hours until therapeutic effects are seen) is necessary. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 14 Anticoagulants (Cont.) Low Molecular Weight Heparins (LMWH) ◦ Enoxaparin (Lovenox) and dalteparin (Fragmin) ◦ Synthetic smaller molecular structure ◦ More predictable anticoagulant response ◦ Frequent laboratory monitoring of bleeding times using tests such as aPTT not needed COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 15 Enoxaparin (Lovenox) Prototypical LMWH Greater affinity for factor Xa than for factor Iia Higher degree of bioavailability and longer elimination half-life Lab monitoring is not necessary. Injectable form Used for prophylaxis and treatment Pre-filled syringes ◦ Do not expel air bubble COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 16 Anticoagulants (Cont.) Coumarins ◦ Action: inhibit vitamin K–dependent clotting factors II, VII, IX, and X ◦ Warfarin (Coumadin) Warfarin (Coumadin) ◦ Inhibits vitamin K synthesis by bacteria in the gastrointestinal tract ◦ Inhibits production of vitamin K–dependent clotting factors II, VII, IX, and X, which are normally synthesized in the liver ◦ Final effect prevention of clot formation COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 17 Warfarin (Coumadin) Coumadin ◦ Most commonly prescribed oral anticoagulant ◦ Careful monitoring of the prothrombin time/international normalized ratio (PT/INR) ◦ A normal INR (without warfarin) is 1.0, but a therapeutic INR (with warfarin) ranges from 2 to 3.5, depending on the indication for use of the drug (e.g., atrial fibrillation, thromboprevention, prosthetic heart valve). ◦ Variations in certain genes, CYP2CP and VKORC1 ◦ Many drug interactions ◦ Dietary considerations COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 18 Video about warfarin Anticoagulants: Factor Xa Drugs Fondaparinux (Arixtra) Rivaroxaban (Xarelto) Apixaban (Eliquis) Edoxaban (Savaysa) Betrixaban (Bevyxxa) Inhibits thrombosis by its specific action against factor Xa COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 20 Anticoagulants: Indications Used to prevent clot formation in certain settings in which clot formation is likely ◦ MI ◦ Unstable angina ◦ Atrial fibrillation ◦ Indwelling devices, such as mechanical heart valves ◦ Major orthopedic surgery COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 21 Anticoagulants: Contraindications Drug allergy Any acute bleeding process or high risk for such an occurrence. Warfarin is strongly contraindicated in pregnancy. Other anticoagulants are rated in lower pregnancy categories (B or C). LMWHs are contraindicated in patients with an indwelling epidural catheter risk of epidural hematoma. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 22 Anticoagulants: Adverse Effects Bleeding ◦ Risk increases with increased ________ ◦ May be localized or systemic May also cause: ◦ Heparin-induced thrombocytopenia (may note petechiae) ◦ Nausea, vomiting, abdominal cramps, thrombocytopenia, others COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 23 Heparin-Induced Thrombocytopenia Type I ◦ Gradual reduction in platelets ◦ Heparin therapy can generally be continued. Type II ◦ Acute fall in the number of platelets (more than 50% reduction from baseline) ◦ Discontinue heparin. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 24 Treatment for Toxic Effects of Heparin Symptoms: hematuria, melena (blood in the stool), petechiae, ecchymoses, and gum or mucous membrane bleeding Stop drug immediately. Reversal agent: Intravenous (IV) protamine sulfate: 1 mg of protamine can reverse the effects of 100 units of heparin. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 25 Treatment for Toxic Effects of Warfarin Discontinue the warfarin. May take _______ hours before the liver can resynthesize enough clotting factors to reverse the warfarin effects Vitamin K1 (phytonadione) can hasten the return to normal coagulation. Reversal agent: High doses of vitamin K (10 mg) given IV will reverse the anticoagulation within 6 hours. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 26 Treatment for Toxic Effects of Warfarin Caution: when vitamin K is given, warfarin resistance will occur for up to 7 days. For severe bleeding: give transfusions of human plasma or clotting factor concentrates. Life-threatening bleeding from warfarin: Kcentra and Profiline IV vitamin K: risk of anaphylaxis. Risk is diminished by diluting it and giving it over 30 minutes. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 27 Dabigatran (Pradaxa) First oral direct thrombin inhibitor approved for prevention of strokes and thrombosis in patients with nonvalvular atrial fibrillation Prodrug that becomes activated in the liver ◦ Specifically and reversibly binds to both free and clotbound thrombin Dose dependent on renal function Adverse effects: bleeding, GI bleeding No coagulation monitoring is required. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 28 Idarucizumab (Praxbind) Antidote for dabigatran Reverses the anticoagulant effects for dabigatran for emergency surgery or in life-threatening or uncontrolled bleeding COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 29 Rivaroxaban (Xarelto) First oral factor Xa inhibitor Used for prevention of strokes in patients with a-fib; post-op thromboprophylaxis with ortho surgeries; treatment of DVT and PE Does not require routine lab monitoring Adverse reactions: Peripheral edema, dizziness, headache, bruising, diarrhea, hematuria, and bleeding COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 30 Work to prevent platelet adhesion at the site of blood vessel injury 2. Antiplatelet Drugs Platelets normally flow through blood vessels without adhering to their surfaces Collagen from damaged vessels stimulate platelet adhesion COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 31 Antiplatelet Drugs (Cont.) Prevent platelet adhesion and aggregation ◦ Aspirin ◦ Cilostazol (Pletal) ◦ Clopidogrel (Plavix) ◦ Prasugrel (Effient) ◦ Treprostinil (Remodulin) ◦ Abciximab (ReoPro) ◦ Eptifibatide (Integrilin) ◦ Tirofiban (Aggrastat) ◦ Anagrelide (Agrylin) ◦ Dipyridamole (Persantine) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 32 Antiplatelet Drugs: Indications and Adverse Effects Antithrombotic effects Adverse effects ◦ Vary according to drug COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 33 Aspirin Available in many combinations with other prescription and nonprescription drugs Contraindicated for flulike symptoms in children and teenagers ◦ Reye’s syndrome Aspirin and dipyridamole (Aggrenox) ◦ Used for antiplatelet purposes COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 34 Clopidogrel (Plavix) Most widely used Adenosine Diphosphate Receptor (ADP) Inhibitor Oral use Prasugrel (Effient), ticagrelor (Brilinta) ◦ Similar to clopidogrel Many drug interactions COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 35 Eptifibatide (Integrilin) GP Iib/IIIa inhibitor Usually administered in an ICU or cardiac catheterization lab setting IV use Others: ◦ Tirofiban (Aggrastat) ◦ Abciximab (ReoPro) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 36 Drugs that break down, or lyse, preformed clots Older drugs 3.Thrombolytic Drugs ◦ Streptokinase and urokinase Current drugs ◦ Alteplase (Activase, Cathflo Activase) ◦ Reteplase (Retavase) ◦ Tenecteplase (TNKase) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 37 Thrombolytic Drugs: Mechanism of Action Activate the fibrinolytic system to break down the clot in the blood vessel quickly Activate plasminogen and convert it to plasmin, which can digest fibrin Reestablish blood flow to the heart muscle via coronary arteries, preventing tissue destruction COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 38 Thrombolytic Drugs: Indications Acute MI Arterial thrombolysis DVT Occlusion of shunts or catheters Pulmonary embolus Acute ischemic stroke COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 39 Thrombolytic Drugs: Adverse Effects Bleeding ◦ Internal ◦ Intracranial ◦ Superficial Other effects ◦ Nausea, vomiting, hypotension, anaphylactoid reactions ◦ Cardiac dysrhythmias; can be dangerous COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 40 Alteplase (Activase) t-PA made through recombinant DNA techniques Fibrin specific so does not produce a systemic lytic state Present in the body in a natural state Very short half-life (5 minutes) Indications: MI, strokes Smaller doses to flush clogged IV or arterial lines—used often in home care COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 41 4. Antifibrinolytic Drugs Prevent the lysis of fibrin Result in promoting clot formation Used for prevention and treatment of excessive bleeding resulting from hyperfibrinolysis or surgical complications Treatment of hemophilia or von Willebrand’s disease Examples: ✓ Aminocaproic acid (Amicar) ✓ Tranexamic acid (Cyklokapron) ✓ Desmopressin COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 42 Antifibrinolytic Drugs: Adverse Effects Uncommon and mild Rare reports of thrombotic events Others include ◦ Dysrhythmia, orthostatic hypotension, bradycardia, headache, dizziness, fatigue, nausea, vomiting, abdominal cramps, diarrhea, others COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 43 ✓ Aminocaproic Acid (Amicar) Synthetic antifibrinolytic drug Prevents and controls excessive bleeding that result from surgery or overactivity of fibrinolytic system Oral or parenteral COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 44 ✓ Desmopressin (DDAVP) Synthetic polypeptide Similar to vasopressin, which is an antidiuretic hormone Indications: diabetes insipidus; hemophilia Nasal spray: used for nocturnal enuresis COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 45 Nursing Implications Assess ◦ Patient history, medication history, allergies ◦ Contraindications ◦ Baseline vital signs, laboratory values ◦ Potential drug interactions ◦ History of abnormal bleeding conditions COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 46 Heparin: Nursing Implications IV doses are usually double checked with another nurse. Ensure that subcutaneous doses are given subcutaneously, not intramuscularly. Subcutaneous doses should be given in areas of deep subcutaneous fat and sites rotated. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 47 Heparin: Nursing Implications (Cont.) Do not give subcutaneous doses within 2 inches of: ◦ The umbilicus, abdominal incisions, open wounds, scars, drainage tubes, or stomas Do not aspirate subcutaneous injections or massage the injection site—why? COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 48 Heparin: Nursing Implications (Cont.) IV doses may be given by bolus or IV infusions. Anticoagulant effects are seen immediately. Laboratory values are done daily to monitor coagulation effects (aPTT). Protamine sulfate can be given as an antidote in case of excessive anticoagulation. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 49 LWMHs: Nursing Implications Given subcutaneously in the abdomen Rotate injection sites. Protamine sulfate can be given as an antidote in case of excessive anticoagulation. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 50 Warfarin (Coumadin): Nursing Implications May be started while the patient is still on heparin until PT/INR levels indicate adequate anticoagulation Full therapeutic effect takes several days. Monitor PT/INR regularly; keep follow-up appointments. Antidote is vitamin K. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 51 Warfarin (Coumadin): Nursing Implications Many herbal products have potential interactions; increased bleeding may occur ◦ Capsicum pepper ◦ Garlic ◦ Ginger ◦ Ginkgo ◦ St. John’s wort ◦ Feverfew COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 52 Anticoagulants: Patient Education Education should include: ◦ Importance of regular laboratory testing ◦ Signs of abnormal bleeding ◦ Measures to prevent bruising, bleeding, and tissue injury ◦ Wearing a medical alert bracelet ◦ Avoiding foods high in vitamin K (broccoli, dark leafy green vegetables) ◦ Consulting physician before taking other drugs or overthe-counter products, including herbals COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 53 Antiplatelet Drugs: Nursing Implications Concerns and teaching tips same as for anticoagulants Drug-drug interactions Adverse reactions to report Monitoring for abnormal bleeding COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 54 Thrombolytic Drugs: Nursing Implications Follow strict manufacturer’s guidelines for preparation and administration. Monitor IV sites for bleeding, redness, and pain. Monitor for bleeding from gums, mucous membranes, nose, and injection sites. Observe for signs of internal bleeding (decreased blood pressure, restlessness, increased pulse). COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 55 Group Activity Case Study B. is a 41-year-old male landscaper who has been admitted with leg pain and swelling He experienced increasing pain and swelling of the right calf over several days He was diagnosed with deep vein thrombosis (DVT) and was started on heparin therapy as follows: 6000 units intravenous (IV) bolus followed by a continuous infusion of heparin (20,000 units/day). Questions? Break Chapter 27 ANTILIPIDEMIC DRUGS COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. This Photo by Unknown Author is licensed under CC BY Overview Key to understanding use of antilipemic drugs is a working knowledge of the pathology of lipid abnormalities and their contributions to CHD Important to understand, at the cellular level, the transporting and use of cholesterol and triglycerides Lipoproteins, apolipoproteins, receptors, and enzyme systems are integral parts of these processes. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 59 Triglycerides and Cholesterol Two primary forms of lipids in the blood Water-insoluble fats that must be bound to apolipoproteins, specialized lipid-carrying proteins Lipoprotein is the combination of triglyceride or cholesterol with apolipoprotein. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 60 Lipoproteins Very-low-density lipoprotein (VLDL) ◦ Produced by the liver ◦ Transports endogenous lipids to the cells Low-density lipoprotein (LDL) High-density lipoprotein (HDL) ◦ Responsible for “recycling” of cholesterol ◦ Also known as “good cholesterol” COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 61 Atherosclerotic Plaque Formation Lipids and lipoproteins form atherosclerotic plaque leading to development of CHD. When serum cholesterol levels are elevated, monocytes adhere to surfaces of coronary vessels. Macrophage cells are formed and fill with fat. Foam cells develop. ◦ Precursor lesion of atherosclerosis COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 62 Cholesterol and Coronary Heart Disease The risk of coronary heart disease in patients with cholesterol levels of 300 mg/dL is ____ times greater than that in patients with levels less than 200 mg/dL. Benefits of cholesterol reduction are well documented. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 63 Hyperlipidemias and Treatment Guidelines National Cholesterol Education Program Adult Treatment Panel III of the National Institutes of Health Antilipemic drugs ◦ Drugs used to lower lipid levels ◦ Used as an adjunct to diet therapy Drug choice based on the specific lipid profile of the patient (phenotyping) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 64 Hyperlipidemias Treatment and Guidelines (Cont.) All reasonable nondrug means of controlling blood cholesterol levels (e.g., diet, exercise) should be tried for at least 6 months and found to fail before drug therapy is considered. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 65 Antilipemics ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults (2013) 1. Hydroxymethylglutaryl–coenzyme A (HMG–CoA) reductase inhibitors (HMGs, or statins) 2. Bile acid sequestrants 3. B vitamin niacin (vitamin B3, nicotinic acid) 4. Fibric acid derivatives (fibrates) 5. Cholesterol absorption inhibitor (Zetia) Combination drugs (Vytorin) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 66 Statins 1. Antilipemics: HMG-CoA Reductase Inhibitors (Statins) ◦ Patients with clinical atherosclerotic cardiovascular disease (CVD) ◦ Patients with LDL cholesterol levels >190 mg/dL ◦ Patients with diabetes age 40 to 75 years with LDL levels of 70 to 189 mg/dL and without evidence of CVD ◦ Patients with LDL levels 70 to 189 mg/dL and a 10-year risk of CVD > 7.5% and without evidence of CVD or diabetes COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 67 Antilipemics: HMG-CoA Reductase Inhibitors (Statins) (Cont.) Most potent LDL reducers ◦ Lovastatin (Mevacor) ◦ Pravastatin (Pravachol) ◦ Simvastatin (Zocor) ◦ Atorvastatin (Lipitor) ◦ Fluvastatin (Lescol) ◦ Rosuvastatin (Crestor) ◦ Pitavastatin (Livalo) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 68 HMG-CoA Reductase Inhibitors: Mechanism of Action Inhibit HMG-CoA reductase, which is used by the liver to produce cholesterol Lower the rate of cholesterol production COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 69 HMG-CoA Reductase Inhibitors: Indications First-line drug therapy for hypercholesterolemia ◦ Reduces LDL levels by up to 50% ◦ Increases HDL levels by 2% to 15% ◦ Reduces triglycerides by 10% to 30% COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 70 HMG-CoA Reductase Inhibitors: Adverse Effects Mild, transient gastrointestinal (GI) disturbances Rash Headache Myopathy (muscle pain), possibly leading to the serious condition rhabdomyolysis Elevations in liver enzymes or liver disease COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 71 Rhabdomyloysis Breakdown of muscle protein Myoglobinuria: urinary elimination of the muscle protein myoglobin Can lead to acute renal failure and even death When recognized reasonably early, rhabdomyolysis is usually reversible with discontinuation of the statin drug. Instruct patients to immediately report any signs of toxicity, including muscle soreness or changes in urine color. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 72 HMG-CoA Reductase Inhibitors: Interactions Oral anticoagulants Drugs metabolized by CYP3A4 ◦ Erythromycin ◦ Azole antifungals ◦ Verapamil ◦ Diltiazem ◦ Human immunodeficiency virus protease inhibitors ◦ Amiodarone ◦ Grapefruit juice COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 73 Simvastatin (Zocor) One of the first statins to become generic and one of the most commonly used drugs in this class Used to primarily lower total and LDL cholesterol levels as well as triglyceride levels Can moderately raise levels of HDL Give at bedtime Monitor patient for muscle pain (myopathy) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 74 Cholestyramine (Questran) Colestipol (Colestid) ◦ Tablet form Colesevelam (Welchol) 2. Bile Acid Sequestrants Also called bile acid–binding resins and ion-exchange resins Powdered form must be mixed with liquid before administering Powdered form may not be convenient or well tolerated COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 75 Bile Acid Sequestrants: Mechanism of Action Considered second line choice after statins Prevent resorption of bile acids from small intestine Bile acids are necessary for absorption of cholesterol. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 76 Bile Acid Sequestrants: Indications Type II hyperlipoproteinemia Relief of pruritus associated with partial biliary obstruction (cholestyramine) May be used along with statins COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 77 Bile Acid Sequestrants: Adverse Effects Constipation Heartburn, nausea, belching, bloating ◦ These adverse effects tend to disappear over time. ◦ Increasing dietary fiber intake or taking a fiber supplement such as psyllium (Metamucil and others), as well as increasing fluid intake, may relieve constipation and bloating. ◦ May also cause mild increases in triglyceride levels COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 78 Bile Acid Sequestrants: Considerations Used in treatment of diarrhea Treatment of overdose includes restoring gut motility. Drug interactions ◦ All drugs must be taken at least 1 hour before or 4 to 6 hours after the administration of bile acid sequestrants. ◦ High doses of a bile acid sequestrant decrease the absorption of fat-soluble vitamins (A, D, E, and K). COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 79 Vitamin B3 3. Niacin (Nicotinic Acid) Lipid-lowering properties require much higher doses than when used as a vitamin. Effective, inexpensive, often used in combination with other lipid-lowering drugs COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 80 Niacin: Mechanism of Action Thought to increase activity of lipase, which breaks down lipids Reduces the metabolism or catabolism of cholesterol and triglycerides COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 81 Niacin: Indications Effective in lowering triglyceride, total serum cholesterol, and LDL levels Increases HDL levels Effective in the treatment of types IIa, IIb, III, IV, and V hyperlipidemias COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 82 Niacin: Adverse Effects Flushing (caused by histamine release) ◦ Small dose aspirin or NSAIDS 30 minutes before Niacin may help cutaneous flushing Pruritus GI distress COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 83 4. Fibric Acid Derivatives Primarily affect the triglyceride levels but may also lower the total cholesterol and LDL levels and raise the HDL Also known as fibrates ◦ Gemfibrozil (Lopid) ◦ Fenofibrate (Tricor) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 84 Fibric Acid Derivatives: Mechanism of Action Believed to work by activating lipase, which breaks down cholesterol Also suppress the release of free fatty acid from adipose tissue, inhibit synthesis of triglycerides in the liver, and increase secretion of cholesterol in the bile COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 85 Fibric Acid Derivatives: Indications Treatment of type III, IV, and V hyperlipidemias The fibric acid derivatives gemfibrozil and fenofibrate decrease the triglyceride level and increase the HDL cholesterol level by as much as 25%. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 86 Fibric Acid Derivatives: Contraindications Known drug allergy Severe liver or kidney disease Cirrhosis Gallbladder disease COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 87 Fibric Acid Derivatives: Adverse Effects Abdominal discomfort, diarrhea, nausea Blurred vision, headache Increased risk of gallstones Prolonged prothrombin time Liver studies may show increased enzyme levels. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 88 Fibric Acid Derivatives: Interactions Oral anticoagulants Statins ◦ Risk of myositis, myalgias, and rhabdomyolysis is increased. Laboratory test reactions ◦ Decreased hemoglobin level, hematocrit value, and white blood cell count ◦ Increased activated clotting time, lactate dehydrogenase level, and bilirubin level COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 89 5. Miscellaneous Antilipemic Drugs: Cholesterol Absorption Inhibitor Ezetimibe (Zetia) ◦ Inhibits absorption of cholesterol and related sterols from the small intestine ◦ Results in reduced total cholesterol, LDL, and triglyceride levels ◦ Also increases HDL levels ◦ Often combined with a statin drug ◦ Can be used as monotherapy COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 90 PSCK-9 Inhibitors Proprotein convertase subtilisin kein (PCSK9) ◦ Serine protease produced in the liver that leads to an increased low-density lipoprotein cholesterol level Shown to significantly lower LDL-C levels Alirocumab (Praluent) Evolocumab (Repatha) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 91 Alirocumab (Praluent) Approved in 2015 Given subcutaneously every 2 to 4 weeks Very expensive Adverse effects: diarrhea, increased liver function tests, influenza, hypersensitivity reactions, injection site reaction, myalgia, cough COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 92 Herbal Product: Garlic Used as an antispasmodic, antihypertensive, antiplatelet, lipid reducer Adverse effects: dermatitis, vomiting, diarrhea, flatulence, antiplatelet activity Possible interactions with warfarin, diazepam May enhance bleeding when taken with nonsteroidal antiinflammatory drugs (NSAIDs) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 93 Herbal Product: Omega-3 Fatty Acids Fish oil products Used to reduce cholesterol May cause rash, belching, allergic reactions Potential interactions with anticoagulant drugs COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 94 Nursing Implications Before beginning therapy, obtain a thorough health and medication history. Assess dietary patterns, exercise level, weight, height, vital signs, tobacco and alcohol use, and family history. Assess for contraindications, conditions that require cautious use, and drug interactions. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 95 Nursing Implications Contraindications include biliary obstruction, liver dysfunction, and active liver disease. Obtain baseline liver function studies. Patients on long-term therapy may need supplemental fat-soluble vitamins (A, D, E, K). Refer to guidelines regarding administration times and meals. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 96 Nursing Implications Counsel patient concerning diet and nutrition on an ongoing basis. Instruct patient on proper procedure for taking the medications. Powder forms must be taken with a liquid, mixed thoroughly, and never taken dry. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 97 Nursing Implications Other medications should be taken 1 hour before or 4 to 6 hours after meals to avoid interference with absorption. To minimize adverse effects of niacin, start on low initial dose and gradually increase it, and take with meals. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 98 Nursing Implications Small doses of aspirin or NSAIDs may be taken 30 minutes before niacin to minimize cutaneous flushing. Provide teaching regarding use of NSAIDs and aspirin. Inform patients that these drugs may take several weeks to show effectiveness. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 99 Nursing Implications Instruct patients to report persistent GI upset, constipation, abnormal or unusual bleeding, and yellow discoloration of the skin. Monitor for adverse effects, including increased liver enzyme studies. Monitor for therapeutic effects: ◦ Reduced cholesterol and triglyceride levels COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 100 Case Study Questions? Break Chapter 28 DIURETIC DRUGS COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. Diuretic Drugs Drugs that accelerate the rate of urine formation Result in the removal of sodium and water Used in the treatment of ________, ________, and _________. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 104 Role of Kidneys Play an important role in the day-to-day functioning of the body Filters toxic waste products Conserves essential substances This balance is maintained by the nephron. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 105 Kidney Structure __________ is main structural unit of the kidney. ◦ Diuretics exert their effect in this main structure. Initial filtering of blood takes place in the glomerulus. ◦ Glomerular filtration rate (GFR) ◦ Afferent arterioles ◦ Efferent arterioles COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 106 Kidney Structure (Cont.) Proximal convoluted tubule (proximal tubule) Returns 60% to 70% of sodium and water from the filtered fluid back to the bloodstream Passive reabsorption of chloride and water Loop of Henle (ascending) ◦ 20% to 25% of sodium is reabsorbed here through active chloride reabsorption. Distal convoluted tubule (distal tubule) ◦ Remaining 5% to 10% of sodium is reabsorbed here. ◦ Regulated by aldosterone Collecting duct ◦ Final pathway COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 107 Pharmacology Overview Diuretics classified according to their: ✓ sites of action within the nephron, ✓ chemical structure, and ✓ diuretic potency COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 108 Types of Diuretic Drugs 1. Carbonic anhydrase inhibitors (CAIs) 2. Loop diuretics 3. Osmotic diuretics 4. Potassium-sparing diuretics 5. Thiazide and thiazide-like diuretics COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 109 Chemical derivative of sulfonamide antibiotics 1. Carbonic Anhydrase Inhibitors (CAIs) Inhibit the activity of the enzyme carbonic anhydrase ◦Found in kidneys, eyes, and other parts of the body Acetazolamide (Diamox) ◦Most commonly used CAI COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 110 Carbonic Anhydrase Inhibitors: Mechanism of Action The enzyme carbonic anhydrase helps to make H+ ions available for exchange with sodium and water in the proximal tubules. CAIs block the action of carbonic anhydrase, thus preventing the exchange of H+ ions with sodium and water. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 111 Carbonic Anhydrase Inhibitors: Mechanism of Action (Cont.) Inhibition of carbonic anhydrase reduces H+ ion concentration in renal tubules. As a result, there is increased excretion of bicarbonate, sodium, water, and potassium. Resorption of water is decreased, and urine volume is increased. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 112 Carbonic Anhydrase Inhibitors: Indications Adjunct drugs in the long-term management of open-angle glaucoma Used with miotics to lower intraocular pressure before ocular surgery in certain cases Also useful in the treatment of ◦ Edema ◦ High-altitude sickness COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 113 Carbonic Anhydrase Inhibitors: Contraindications Known drug allergy Hyponatremia Hypokalemia Severe renal or hepatic dysfunction Adrenal gland insufficiency Cirrhosis COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 114 Carbonic Anhydrase Inhibitors: Adverse Effects Acidosis Hypokalemia Drowsiness Anorexia Paresthesias Hematuria Urticaria Photosensitivity Melena (blood in the stool) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 115 Carbonic Anhydrase Inhibitors: Interactions Because CAIs can cause hypokalemia, an increase in digoxin toxicity may occur when they are combined with digoxin. Use with corticosteroids may also cause hypokalemia. Increased effects of amphetamines, carbamazepine, cyclosporine, phenytoin, and quinidine with concurrent use of CAIs COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 116 Bumetanide (Bumex) Ethacrynic acid (Edecrin) Furosemide (Lasix) Torsemide (Demadex) 2. Loop Diuretics COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 117 Loop Diuretics: Mechanism of Action Possess renal, cardiovascular, and metabolic effects Act directly on the ascending limb of the loop of Henle to inhibit chloride and sodium resorption Increase renal prostaglandins, resulting in the dilation of blood vessels and reduced peripheral vascular resistance Useful in treatment of edema Has the greatest impact on PRELOAD COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 118 Loop Diuretics: Drug Effects Potent diuresis and subsequent loss of fluid Decreased fluid volume causes a reduction in ◦ Blood pressure ◦ Pulmonary vascular resistance ◦ Systemic vascular resistance ◦ Central venous pressure ◦ Left ventricular end-diastolic pressure Potassium and sodium depletion COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 119 Loop Diuretics: Indications Edema associated with HF or hepatic or renal disease To control hypertension To increase renal excretion of calcium in patients with hypercalcemia In cases of HF resulting from diastolic dysfunction COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 120 Loop Diuretics: Adverse Effects Body system Adverse effects Central nervous system (CNS) Dizziness, headache, tinnitus, blurred vision Gastrointestinal (GI) Nausea, vomiting, diarrhea Integumentary Stevens-Johnson (torsemide) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 121 Loop Diuretics: Adverse Effects Body system Adverse effects Hematologic Agranulocytosis, neutropenia, thrombocytopenia Metabolic Hypokalemia, hyperglycemia, hyperuricemia COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 122 Loop Diuretics: Interactions Neurotoxic Nephrotoxic Increase serum levels of uric acid, glucose, alanine aminotransferase, and aspartate aminotransferase. Thiazide (metolazone): sequential nephron blockade Nonsteroidal antiinflammatory drugs (NSAIDs) ◦ Decrease effect of NSAIDs if taken at same time COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 123 Loop Diuretics: Furosemide (Lasix) Most commonly used loop diuretic Uses: pulmonary edema and the edema associated with HF, liver disease, nephrotic syndrome, ascites, hypertension COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 124 Mannitol (Osmitrol) ◦ Most used osmotic diuretic 3. Osmotic Diuretics Urea Organic acids Glucose COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 125 Osmotic Diuretics: Mechanism of Action Work mostly in the proximal tubule. Nonabsorbable, producing an osmotic effect Pull water into the renal tubules from the surrounding tissues Increase osmotic pressure in the renal tubules Inhibit tubular resorption of water and solutes, thus producing rapid diuresis. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 126 Osmotic Diuretics: Drug Effects Increases glomerular filtration rate and renal plasma flow; helps to prevent kidney damage during ARF Reduces intracranial pressure or cerebral edema associated with head trauma Reduces excessive intraocular pressure COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 127 Osmotic Diuretics: Indications Treatment of patients in the early, oliguric phase of acute renal failure (ARF) To promote excretion of toxic substances To reduce intracranial pressure Treatment of cerebral edema COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 128 Osmotic Diuretics: Adverse Effects Convulsions Thrombophlebitis Pulmonary congestion COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 129 Osmotic Diuretics: Mannitol (Osmitrol) Intravenous (IV) infusion only May crystallize when exposed to low temperatures Use of a filter is required. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 130 Amiloride (Midamor) 4. PotassiumSparing Diuretics Spironolactone (Aldactone) Triamterene (Dyrenium) Also known as aldosteroneinhibiting diuretics COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 131 Potassium-Sparing Diuretics: Mechanism of Action Work in collecting ducts and distal convoluted tubules. Interfere with sodium-potassium exchange. Competitively bind to aldosterone receptors. Block resorption of sodium and water usually induced by aldosterone. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 132 Potassium-Sparing Diuretics: Drug Effects Prevent potassium from being pumped into the tubule, thus preventing its secretion. Competitively block aldosterone receptors and inhibit their action. Promote the excretion of sodium and water. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 133 Potassium-Sparing Diuretics: Indications Spironolactone and triamterene ◦ Hyperaldosteronism ◦ Hypertension ◦ Reversing potassium loss caused by potassium-losing drugs ◦ Certain cases of HF: prevention of remodeling Amiloride ◦ Similar as spironolactone and triamterene, but amiloride is less effective in the long term COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 134 Potassium-Sparing Diuretics: Adverse Effects Body system Adverse effects CNS Dizziness, headache GI Cramps, nausea, vomiting, diarrhea Urinary frequency, weakness, hyperkalemia Other COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 135 Potassium-Sparing Diuretics: Adverse Effects Spironolactone (Aldactone) ◦ Gynecomastia ◦ Amenorrhea ◦ Irregular menses ◦ Postmenopausal bleeding COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 136 Potassium-Sparing Diuretics: Interactions Lithium Angiotensin-converting enzyme inhibitors Potassium supplements NSAIDs COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 137 5. Thiazide and ThiazideLike Diuretics Thiazide diuretics ◦ Hydrochlorothiazide (Esidrix, HydroDIURIL) ◦ Chlorothiazide (Diuril) Thiazide-like diuretics ◦ Metolazone (Mykrox, Zaroxolyn) ◦ Chlorthalidone (Hydone, Thalitone) ◦ Indapamide (Lozol) COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 138 Thiazide and Thiazide-Like Diuretics: Mechanism of Action Inhibit tubular resorption of sodium, chloride, and potassium ions Action primarily in the distal convoluted tubule Result: water, sodium, and chloride are excreted Potassium is also excreted to a lesser extent. Dilate the arterioles by direct relaxation COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 139 Thiazide and Thiazide-Like Diuretics: Drug Effects Lowered peripheral vascular resistance Depletion of sodium and water (and potassium) Thiazides should not be used if creatinine clearance is less than 30 to 50 mL/min (normal is 125 mL/min). Metolazone remains effective to a creatinine clearance of 10 mL/min. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 140 Thiazide and Thiazide-Like Diuretics: Indications Hypertension (one of the most prescribed group of drugs for this) Edematous states Idiopathic hypercalciuria Diabetes insipidus HF caused by diastolic dysfunction Adjunct drugs in treatment of edema related to HF, hepatic cirrhosis, or corticosteroid or estrogen therapy COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 141 Thiazide and Thiazide-Like Diuretics: Adverse Effects Body system Adverse effects CNS Dizziness, headache, blurred vision GI Anorexia, nausea, vomiting, diarrhea Genitourinary Impotence Hematologic Jaundice, leukopenia Integumentary Dizziness, headache, blurred vision Integumentary Metabolic Hypokalemia, hyperglycemia, hyperuricemia, hypochloremic alkalosis COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. Metabolic 142 Nursing Implications Perform a thorough patient history and physical examination. Assess baseline fluid volume status, intake and output, serum electrolyte values, weight, and vital signs (especially postural blood pressure). Assess for disorders that may contraindicate or necessitate cautious use of these drugs. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 143 Nursing Implications (Cont.) Instruct patients to take the medication _________(when?) to avoid interference with sleep patterns. Monitor serum __________ levels during therapy. Teach patients to maintain proper nutritional and fluid volume status. Teach patients to eat more potassium-rich foods when taking any diuretics (other than potassium-sparing drugs). Foods high in potassium include: ________________________ COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 144 Nursing Implications (Cont.) Patients taking diuretics along with a digitalis preparation should be taught to monitor for digitalis toxicity. Patients with diabetes mellitus who are taking thiazide or loop diuretics should be told to monitor blood glucose and watch for elevated levels. Teach patients to ________________prevent dizziness and fainting related to _________________. Encourage patients to keep a log of their ___________. Remind patients to return for follow-up visits and lab work. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 145 Nursing Implications (Cont.) Patients who have been ill with nausea, vomiting, or diarrhea should notify their primary care providers because fluid and electrolyte imbalances can result. Signs and symptoms of hypokalemia include muscle weakness, constipation, irregular pulse rate, and overall feeling of lethargy. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 146 Nursing Implications (Cont.) Instruct patients to notify their primary care providers immediately if they experience rapid heart rates or syncope (reflects hypotension or fluid loss). Excessive consumption of licorice can lead to additive hypokalemia in patients taking thiazides. Monitor for adverse effects: ◦ Metabolic alkalosis, drowsiness, lethargy, hypokalemia, tachycardia, hypotension, leg cramps, restlessness, decreased mental alertness Monitor for hyperkalemia with potassium-sparing diuretics. COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 147 Nursing Implications (Cont.) Monitor for therapeutic effects: ◦ Reduction of _______ ◦ Reduction of fluid volume _______ ◦ Improvement in symptoms of ____ ◦ Reduction of _____________ ◦ Return to normal intraocular pressures COPYRIGHT © 2020 ELSEVIER INC. ALL RIGHTS RESERVED. 148 Questions? ▪Please contact Dr. Smalley or Dr. Scott with questions, or visit during office hours to review information ▪You may also make an appointment to review information Thank you!