Adv Pharmacology Exam #3
5 classes of lipoproteins
1. chylomicrons--> • Transport lipids from the intestinal cells --> the rest of the body 2. VLDL--> Very low density lipoproteins • Transports hepatic TGs --> peripheral tissue 3. IDL --> • Mainly composed of TG • Transport TG from the liver --> adipose tissue and muscle for fuel 4. LDL --> "Bad" cholesterol • 60-70% of cholesterol • Transport lipids from liver --> peripheral tissue 5. HDL--> "Good" cholesterol • 20-30% of cholesterol • Transport lipids from peripheral tissue--> liver
Sulfonylureas
2nd generation- glimepiride or glipizide usually preferred; alternative: glyburide Oldest class of oral hypoglycemic agents Still one of the most commonly prescribed Benefits: Good A1c lowering (~1-2%) One of the lowest cost options Oral Rapidly effective Extensive use for decades (though more safety studies ongoing)
The APRN needs to consider a 36 hr (~ 2 days) wash out period when switching from an ___________ to an ________ (and vice versa)?
ACEi; ARNI
Alpha-Glucosidase inhibitors (AGIs)
Acarbose (Precose) most common; Alternative: Miglitol (Glyset) AGis are NOT considered a first-line therapy Limited use d/t modest efficacy (~0.5% A1c lowering) and poorer tolerance overall Pros: • May be helpful in certain situations (ex: postprandial hyperglycemia) • Does not cause hypoglycemia as monotherapy Cons: • Main AE: GI (***flatulence [73%] and diarrhea), usually mild, slow dose titration to mitigate (maybe wait 1-2 months to increase dose) • Dosed TID with first bite of each meal • Mild A1c lowering effect • Can be more costly than others
Third Generation Beta Blockers?
Blocks alpha & Beta receptors- Labetalol & Carvedilol Used for the tx of: HTN, MI, HF Carvedilol (Coreg, Coreg CR) • Blocks catecholamine stimulation • suppresses O2 free radicals • Oral preparation only • Onset 90 minutes, ½ life 7-10 hours Labetalol • More Beta than Alpha • Available orally and IV • IV preparation with rapid onset (1-2 min), ½ life 5 min • First Line for HTN in pregnancy
GDMT for HF
Both cause of HF and co-morbidities guides choice of ACEi/ARB/ARNI in HF • Post MI Valsartan (VALIANT Trial) • LV dysfunction + CVD/DM Ramipril and Telmisartan (ONTARGET Trial) One of these agents should be considered is first line therapy in HF • For both symptomatic vs non-symptomatic • Suppression of RASS system (or RASS inhibition) is strongly correlated with improved clinical outcomes • Used for vasodilator effect • Angioedema = ABSOLUTE contraindication to using ACEi • With ARB < 10% incidence of cross-reactivity and subsequent angioedema
Pharm for HTN (Specialty populations)
CKD-ACE/ARB diabetes-ACE/ARB early HF-ACE/ARB early Pregnant-no ACE/start ARB or renin inhibitor
SGLT2 inhibitors
Canagliflozin (Invokana) Dapagliflozin (Farxiga) Empagliflozin (Jardiance)
Second Generation Beta Blockers?
Cardioselective (B1 only) - Atenolol, Metoprolol, Esmolol, Bisoprolol Second Generation BB have NO effect on bronchial Beta2= Safer in asthmatics, diabetics and PVD Used for tx of: HTN, HTN urgency, HF, Dysrhythmias, Angina, MI *Two Metoprolol formulations • Tartrate (HTN & Angina is tart!) • Metoprolol Succinate (It "succs" to have heart failure)
BB for HF
Carvedilol (Coreg), Metoprolol succinate (Toprol XL), bisoprolol (Zebeta)
If your patient has HTN & CKD which med is the best choice? which should patient not take?
Choose: ACEi or ARB (if can not tolerate ACEi) Avoid: HCTZ
Classes of Anti-dysrhythmic drugs
Class I Anti-dysrhythmic drugs: Sodium Channel Blockers - Class 1A (delays repolarization)-quinidine (Quinidex), procainamide (Procan), disopyramide (Norpace) - Class 1B (accelerate repolarization)- *lidocaine, phenytoin, mexiletine - Class 1C (pro-dysrhythmic actions)- flecainide, propafenone Class II Anti-dysrhythmic drugs: Beta Blockers 1st Generation = Propranolol & Sotalol 2nd Generation = Acebutolol (best for tx of PVC's) & Esmolol (Refractory SVT) Class III Anti-dysrhythmic drugs: K+ Channel Blockers Amiodarone, Dronedarone, *Sotalol, Dofetilide, Ibutilide **All effect repolarization of fast potentials --> cannot be used interchangeably • Useful in the tx of: • Afib/flutter • Paroxysmal afib (Amio and Dronedarone) • VT/SVT Class IV Anti-dysrhythmic drugs: Non dihydropyridines CCBs (Verapamil and Diltiazem only) Not effective in ventricular dysrhythmia CONTRAINDICATED in pt's with HF
Lidocaine Toxicity: signs and symptoms
Early Signs/Symptoms • Paresthesia's • Dizziness • Tinnitus • Blurred Vision • Sedation Late Signs/Symptoms • Hypotension • CNS Depression • Bradycardia • Seizures
Sulfonylureas MOA
Enhances insulin secretion, "secretagogue"
GLP-1 agonists
Exenatide (Byetta) Liraglutide (Victoza) Albiglutide (Tanzeum) Dulaglutide (Trulicity)
HTN in pregnancy
First Line TX: Labetalol (3rd gen Combined Alpha/Beta-blocker) • Pregnancy Class C Methyldopa - (alpha2 adrenergic agonist) • Pregnancy Class B Other Options: Nifedipine (long-acting CCB) • Pregnancy Class C Hydrochlorothiazide (Thiazide Diuretic) • Pregnancy Class C AVOID: ACEI/ARBs/ARNI/Renin Inhibitors (RAAS) • Teratogenic - Decreased placental blood flow Propranolol (non-selective beta blocker) • Associated with premature labor and neonatal apnea Atenolol/Esmolol/Metoprolol/Bisoprolol (2nd Gen/Cardio selective Beta-1) • Significant Effects on Fetal hemodynamics
HTN Guidelines Refresher
First Line Therapies - Diuretics (Thiazides first line; with HF may add AA or Loops, see HF guidelines) Angiotensin Converting Enzyme Inhibitors (ACE-I or ACEI) • Medication names end in "pril" Angiotensin II Receptor Blockers (ARBs) • Medication names end in "artan or sartan" Calcium Channel Blockers (CCB) • Medication names end in "pine" 2nd/3rd Line Treatment Options Aldosterone Antagonist (AA)/Mineralocorticoid Antagonist (MRA)/Potassium Sparing (Diuretic) Direct Renin Inhibitors Vasodilators • will be limited if HF is also present Alpha Blockers and Alpha Agonist • Blocker send in "zosin" Beta Blockers (BB) • Medication names end in "olol"
AGis: Key Monitoring
Glycemic control Maybe SMBG sometimes A1c can be checked q 3 months, maybe q 6 months if stable and no therapy change Renal function Baseline, then periodically as indicated; many need to avoid with impairment Serum creatinine, eGFR
SGLT2i: Key Monitoring
Glycemic control - A1c can be checked q 3 months, maybe q6 months if stable and no therapy change Renal function routinely- Baseline, then periodically as indicated; check renal dosing if impairment Serum creatinine, eGFR- Volume Status Baseline and ongoing Blood pressure
TZD (Pioglitazone): Monitoring
Glycemic control: A1c can be checked q 3 months, maybe q 6 months if stable and no therapy change Liver function: Baseline, periodic per clinical judgement Continue to monitor periodically if used with NASH/NAFLD
DPP4i monitoring
Glycemic control: A1c can be checked q 3 months, maybe q 6 months if stable and no therapy change Renal function: Baseline and routinely; check for dose adjustment, Serum creatinine, eGFR Liver function for some: With vildagliptin and alogliptin due to reports of liver toxicity
Meglitinides: Key Monitoring
Glycemic control: SMBG- has increased risk of hypoglycemia A1c can be checked q 3 months, maybe q 6 months if stable and no therapy change Renal function: Baseline, then periodically as indicated Serum creatinine, eGFR
Sulfonylureas Monitoring
Glycemic control: SMBG- has increased risk of hypoglycemia A1c can be checked q 3 months, maybe q6 months if stable and no therapy change Renal function: Baseline serum creatinine and periodically as indicated, more frequently if decreased (increased risk of hypoglycemia with renal impairment)
Beta Blockers are used for the TX of?
HTN + HTN Urgency Arrhythmias Cardiomyopathies (HOCM) MI/Angina CHF Anxiety (anxiolytic) Migraines Glaucoma Tremor/Movement Disorders Hyperthyroidism/Thyrotoxicosis Pheochromocytoma Alcohol Withdraw Esophageal varical bleeding/Portal HTN
If your patient is one ACEi or ARB and presents with AKI, what actions should you take?
Hold the ACEi or ARB * contraindicated in AKI
Sulfonylureas Adverse Effects
Hypoglycemia: Increased risk of hypoglycemia (esp. in combo with other DM meds; consider MOA) • Glyburide has higher risk than others Weight gain: Can be mitigated with diet, exercise; some are more sensitive to this gain Weight gain and may need to DC CV Safety?: Some questions- Neutral? Possible risk? Risk with some? (Less study of CV effects than newer meds, but some in progress) Sulfonamide Allergy: Potential crossreactivity if allergic to sulfonamide antimicrobial; often listed as a caution; appears to be low risk
Beta Blocker Overdose TX
IV glucagon (Blocks Beta 2 on liver/muscles)
Hyperlipidemia "Influencers"
Medications: • Oral contraceptive pills • Corticosteroids • Cyclosporine • Progesterone or anabolic steroid treatment • Protesase inhibitors for tx of HIV • Beta-blockers • Thiazide diuretics Syndromes/Diseases: • Nephrotic syndrome, CKD • Hypothyroidism • Diabetes • Cholangiolithic hepatitis • Obesity • Pregnancy • Anorexia nervosa • Diet-related (excessive intake of dairy products or alcohol)
Biguanide
Metformin (Glucophage)
Which Vasodilator is for Acute Angina (intermittent)?
NGT Peripheral AND coronary vasodilator • MONA guidelines updated...avoid morphine and oxygen...keep ASA and NTG • Pt develop tolerance (to po, IV, SL, and topical formulations • To prevent this from developing, nitroglycerin-free intervals "washout periods" of 10-12 hours between doses are recommended.
Which hyperlipidemia medication may cause flushing?
Niacin
DPP4-I adverse effects
Pancreatitis: Avoid for patients with a h/o pancreatitis, stop if suspected, Pancreatitis do not restart if occurs Severe joint pain: Usually resolves within 1 month after stopping (associated with Sitagliptin, vildagliptin, saxagliptin) Heart failure risk: • Underlying mechanisms unknown, (Associated with for saxagliptin, alogliptin + Cautions listed for others)
TZDs (thiazolidinediones)
Pioglitazone (Actos)- most commonly prescribed in class Rosiglitazone (Avandia)- rarely used due to concern about adverse CV effects that resulted in significant restrictions 2010-2013 TZDs are not considered first-line agent for T2D ---> Because of adverse effect profile ---> Might be used 2nd /3rd line in certain situations Benefits: Can lower the A1c pretty well (~1%) Low risk of hypoglycemia Can be lower cost than some options (generic) Oral, dosed once daily
Class III antiarrhythmics
Potassium channel blockers (amiodarone, dronedarone, sotalol, ibutilide, dofetilide) **All effect repolarization of fast potentials --> cannot be used interchangeably • Useful in the tx of: • Afib/flutter • Paroxysmal afib (Amio and Dronedarone) • VT/SVT
SGLT2i adverse effects
Primary: Genitourinary infections • Ex: vaginal candidiasis, UTI; DC if frequent infections Serious Infection called Necrotizing Fasciitis of the perineum, or Fournier's gangrene--> rare but life threatening Volume loss/dehydration • Consider impact on renal function and other drugs that could potentiate (ex: ACEi or ARB, diuretics, NSAIDs) Hypotension starting • Consider adjusting other antihypertensives when Hypotension starting Small risk of lower extremity infection and amputation • FDA warning about canagliflozin, then boxed warning removed DKA (even in T2D) • May not present typically- BG may be only minimally elevated, work up needed to confirm
Apolipoproteins
Protein molecules responsible for the interaction of lipoproteins with cells and the transfer of lipid molecules between lipoproteins; also called apoproteins 6 subtypes; Lp(b) and Lp(a) • Lp(a) in lipid panels as risk factor for CVD
Meglitinides
Repaglinide (Prandin)- most common; Alternative: Nateglinide (Starlix) Short-acting secretagogue Pros • May be helpful in certain situations • Ex: unpredictable mealtimes or patients who have substantial postprandial hyperglycemia with large meals, but do not need additional medication the rest of the day, patients with allergy to sulfonylurea • Rapidly effective • Expected to lowers A1c ~0.5-1% Cons • Dosed TID, up to 30 min before meals • Hypoglycemia (but less than sulfonylureas) • Weight gain • Can be more costly than others
DPP-4 inhibitors
Sitagliptin (Januvia), Saxagliptin (Onglyza), Linagliptin (Tradjenta) Might be a 2nd line option Relatively weaker A1C-lowering effects compared to some others (~0.5-0.8%) Benefits: Oral Overall well tolerated, Low risk hypoglycemia Weight neutral May be less expensive than some
Class I antiarrhythmics
Sodium channel blockers, slows conduction - Class 1A (delays repolarization)-quinidine (Quinidex), procainamide (Procan), disopyramide (Norpace) - Class 1B (accelerate repolarization)- *lidocaine, phenytoin, mexiletine - Class 1C (pro-dysrhythmic actions)- flecainide, propafenone
Second Line for HTN?
Spironolactone, direct renin inhibitors, vasodilators (if HF or angina for afterload reduction), alpha blockers, non-selective beta blockers
First Line for HTN?
Start with thiazide diuretics unless CKD, then ACEI or ARBs, then CCB With any CKD, consider ACEI or ARBs regardless of ethnicity
Meglitinides MOA
Structurally different from sulfonylureas, but they act similarly by regulating KATP channels in pancreatic beta cells, thereby increasing insulin secretion
Calculating total cholesterol
Total Cholesterol = HDL + LDL + (*Triglycerides/5 or 20%) *As long as TG are < 400mg/dL Not a sum of HDL + LDL + TG
Vasodilators for chronic Angina?
Vasodilators & Nitrates- Isosorbide mononitrate (Imdur, Imdur ER) & Isosorbide dinitrate (Isordil) & Combo (Hydralazine & Isosorbide Dinitrate (Bidil)) Cardio-selective Beta Blockers (Metoprolol Tartrate, Atenolol (Tenormin), Bisoprolol (Cardicor)) Calcium Channel Blockers (Nifedipine long-acting is the only dihydropyridine used in angina BECAUSE it comes in long acting formulation) --> Chronic angina +HF = Amlodipine (Norvasc) ACEi- Ramipril (Altace)- *If stable angina AND other CAD (post MI with HFrEF), DMII, CKD, or LVEF < 40% Ranolazine (Ranexa)- **Can be used in conjunction with nitrates, or BB, or CCB
TZDs Adverse Effects
Weight gain: Often related to dose, can increase over time, partially related to edema Edema: *Black box warning: HF Skeletal fractures: Avoid if low bone density or other risk factors Hepatotoxicity (rare): Avoid active liver disease (unless NASH is cause) Bladder cancer (pioglitazone)?: Avoid if active or hx of bladder cancer
Which is true about SGLT2 inhibitors: (SATA) a. Lower blood pressure b. Cause hypoglycemia c. Frequently cause GI side effects d. Often result in some weight loss
a, d
A patient has unfortunately developed a veno-thromboembolism (VTE) of their extremity. The patient is on several medications which are metabolized in the CYP2C system. Which of the following medications is the most appropriate to chronically treat a VTE? a. Apixaban (Eliquis) b. Ticagrelor (Brilinta) c. tissue plasminogen activator (tPA) d. Warfarin (Coumadin)
a. Apixaban (Eliquis)
You are caring for a patient with know cirrhosis and elevated liver function test. Which of the following medications is safe to manage the patient's hyperlipidemia? a. Colesevelam (Welchol) b. Simvastatin (Zocor) c. Ezetimibe (Zetia) d. Bempedoic Acid (Nexletol)
a. Colesevelam (Welchol)
Class IV (four) antiarrhythmics (verapamil and diltiazem) are contraindicated in which of the following diagnosis? a. Heart Failure b. Hyperlipidemia c. Angina d. Atrial Fibrillation
a. Heart Failure
Which of the following medications would be contraindicated in the pregnant patient or the patient who is considering pregnancy? a. Lisinopril b. Labetolol c. Methyldopa d. Prazosin
a. Lisinopril
Which of the following medications would be contraindicated in the pregnant patient or the patient who is considering pregnancy? a. Lisinopril b. Labetolol c. Methyldopa d. Prazosin
a. Lisinopril Any med that acts on the RAAS system in contraindicated in pregnancy
Which of the following medications mechanism of action is to selectively block cardiac beta stimulation? a. Metoprolol b. Propranolol c. Timolol d. Labetalol
a. Metoprolol
What prescribing tip may help mitigate GI side effects of an AGI? a. Taking with food b. Taking every other day c. Slowly titrating the dose d. Slowly eating
a. Taking with food
Which is true regarding GLP-1 receptor agonists? a. The oral version is known by the brand name, Rybelsus b. Has a high risk of hypoglycemia as monotherapy c. Liragultide (Victoza) is dose once weekly d. Typically causes weight gain due to its mechanism of action
a. The oral version is known by the brand name, Rybelsus
TZDs MOA
agonists that cause increase in peripheral insulin sensitivity (Same as biguanides) • *Increase insulin receptor sensitivity • Decreases hepatic glucose production • Enhance glucose uptake in muscle cells
Reversal agent for Xa inhibitors?
andexanet alfa
Which is true about SGLT-2 inhibitor associated DKA? (SATA) a. It only occurs in those with T1DM b. A SGLT2 inhibitor should be held for at least a few days prior to surgery c. It is associated with excess carbohydrate intake d. It is best prevented by gradually titrating the dose when starting the drug
b, c, d
Which is true about SGLT-2 inhibitor associated DKA? (SATA) a. It only occurs in those with T1DM b. A SGLT2 inhibitor should be held for at least a few days prior to surgery c. It is associated with excess carbohydrate intake d. It is best prevented by gradually titrating the dose when starting the drug
b, d
The provider is caring for the patient with a history of hyperlipidemia and diabetes mellitus type II (two). The patient has been on atorvastatin (Lipitor) 80mg po daily for the past year. The patient's most recent LDL is 135mg/dL from 184mg/dL which remains above the goal of 100gm/dL. Other than ongoing lifestyle modifications, which pharmacologic intervention is the most appropriate option to assist the patient if further LDL reduction? a. Discontinue the atorvastatin (Lipitor) and add Aliroc
b. Add ezetimibe (Zetia) in addition to the atorvastatin (Lipitor) to the patient's current regimen
All diuretics share the same overall mechanism of action by causing which of the following? a. Inhibiting sodium and chloride reabsorption in the Loop of Henle b. Blocking sodium and chloride reabsorption in the nephron c. Excreting potassium from the distal convoluted tubule d. Inhibiting sodium and potassium reabsorption in the Loop of Henle
b. Blocking sodium and chloride reabsorption in the nephron
Which is true regarding sulfonylureas? a. Are typically very expensive b. Cause hypoglycemia c. Frequently cause GI side effects d. Commonly result in weight loss
b. Cause hypoglycemia
The AGACNP is caring for a patient with hypertension. Which of the following is the most appropriate medication for the initial treatment of hypertension. a. Metoprolol Tartrate (Lopressor) b. Hydrochlorothiazide (HCTZ) c. Furosemide (Lasix) d. Clonidine (Catapress)
b. Hydrochlorothiazide (HCTZ)
A patient with heart failure is on spironolactone (Aldactone). Which of the following is a side effect of spironolactone? a. Hypertension b. Hyperkalemia c. Hypotension d. Hypokalemia
b. Hyperkalemia
You are the provider caring for a patient with known heart failure Stage C and hypertension. Below is a list of their current medications. Current Medication List Hydrochlorothiazide (HCTZ) 25mg po BID Furosemide (Lasix) 80mg po BID Losartan (Cozaar) 25 mg po daily Spironolactone (Aldactone) 50mg po daily Labetalol (Normodyne) 100mg po BID Which of the following medications is not part of guideline directed medical therapy for heart failure? a. Furosemide (Lasix) b. Labetalol (Normodyne) c. Los
b. Labetalol (Normodyne)
Which of the following medications would be the most useful in a patient with cerebral edema and increased intracranial pressure? a. Loop diuretic b. Osmotic diuretic c. Thiazide diuretic d. Carbonic anhydrase inhibitor diuretic
b. Osmotic diuretic
Which is true about monitoring for a patient taking Metformin? a. Vitamin D deficiency is a frequent adverse effect, so patients should be advised to supplement throughout treatment b. Renal function should be routinely monitored due to risk for lactic acidosis c. Patients should monitor urine ketones when feeling ill due to the risk of diabetic ketoacidosis with this medication d. Bone density should be completed annually due to risk of osteoporosis
b. Renal function should be routinely monitored due to risk for lactic acidosis
Which is true regarding SGLT2 inhibitors? a. A major limitation of use for this medication is increased risk of adverse cardiovascular effects b. Routinely monitor blood pressure due to potential for hypotension related to the medication's mechanism of action c. Educate patients that this medication often causes hypoglycemia, so frequent blood glucose monitoring is needed d. Closely monitor weight, as weight gain is a common adverse effect of this medication
b. Routinely monitor blood pressure due to potential for hypotension related to the medication's mechanism of action
Which best describes the primary mechanism of action of a sulfonylurea? a. decrease hepatic glucose output b. increase insulin secretion c. increase insulin sensitivity d. increase urinary glucose excretion
b. increase insulin secretion
Class II antidysrhythmics
beta blockers decrease HR (by decreasing automaticity in SA node), AV conduction & myocardial contraction 1st Generation = Propranolol & Sotalol 2nd Generation = Acebutolol (best for tx of PVC's) & Esmolol (Refractory SVT)
Which hyperlipidemia medication is safe in pregnancy?
bile acid sequestrants
Which hyperlipidemia medication is the safest in a patient with Chronic liver disease or elevated LFTs?
bile acid sequestrants
When are meglitinides dosed? a. QD, Bedtime b. QD, fasting in the morning c. 30 minutes prior to meals TID d. 2 hours after meals BID
c. 30 minutes prior to meals TID
Which of the following medications mechanism of action is to block peripheral vascular smooth muscle a. Lisinopril (Zestril) b. Valsartan (Diovan) c. Amlodipine (Norvasc) d. Chlorothiazide (Diuril)
c. Amlodipine (Norvasc)
Which is true regarding DPP-4 inhibitors? a. Injectable b. Cause hypoglycemia c. Avoid if history of pancreatitis d. Limited use due to extensive adverse effect profile
c. Avoid if history of pancreatitis
Class I (one) anti-arrhythmic (dysrhythmics) mechanism of action is to inhibit cardiac sodium channels. Which of the following is an example of a class I (one) anti-arrhythmic? a. Verapamil b. Sotolol c. Lidocaine d. Amiodarone
c. Lidocaine
Which of the following is an important side effect of chronic loop diuretic therapy? a. Hyperkalemia b. Hypercalcemia c. Ototoxicity d. Chronic cough
c. Ototoxicity
Which is true regarding TZDs? a. They promote weight loss b. They cause hypoglycemia c. They are contraindicated in heart failure d. Do not expect results unless the patient is taking a high dose
c. They are contraindicated in heart failure
Class IV antiarrhythmics
calcium channel blockers: verapamil and Diltiazem slows AV firing, delays AV conduction, reduces contractility for SVT, a flutter, a. fib Not effective in ventricular dysrhythmia CONTRAINDICATED in pt's with HF
Which of the following medications mechanism of action is to block the reabsorption of sodium and chloride from the loop of Henle? a. Mannitol (Osmitrol) b. Spironolactone (Aldactone) c. Hydrochlorothiazide (HCTZ) d. Bumetanide (Bumex)
d. Bumetanide (Bumex)
All of the following nutrients are required for hematopoiesis and DNA synthesis except: a. Iron b. Folate c. Vitamin B12 d. Calcium
d. Calcium
A 55 y/o patient is started on a thiazide diuretic for hypertension. Two days later the patient has a seizure. Which of the following is an adverse effect of this medication and probable cause of the seizure? a. Hypernatremia b. Hyperkalemia c. Hypokalemia d. Hyponatremia
d. Hyponatremia
You are caring for a patient who would benefit from the use of sildenafil (Revatio) for their pulmonary hypertension. Prior to prescribing this medication, the provider who ensure the patient is not also prescribed or taking which of the following medications? a. Metoprolol Tartrate (Lopressor) b. Methyldopa (Aldomet) c. Lisinopril (Prinvil) d. Nitroglycerin (NTG)
d. Nitroglycerin (NTG)
You are caring for a patient on a lidocaine infusion. The patient was drowsy, confused and complaining of numbness and tingling in their extremities this morning on assessment. When you return to reassess the patient, you find the patient is seizing. Which of the following is the most likely cause of their symptoms? a. The patient is experiencing normal side effects from the lidocaine infusion b. The patient is likely sleeping and just needs to be awakened. c. The patient is hallucinating and i
d. The patient is experiencing lidocaine toxicity
Utilizing your knowledge of mechanism of action, if you were transitioning this patient from lisinopril (Prinvil) to Sacubitril/Valsartan (Entresto), which of the following statements is correct? a. The patient should take the lisinopril (Prinvil) in the morning and the sacubitril/valsartan (Entresto) in the evening. b. There is no need to adjust the timing between transitioning from lisinopril (Prinvil) and sacubitril/valsartan (Entresto), c. The patient should wait 36 hours after their first
d. The patient should wait 36 hours between their last dose of lisinopril (Prinvil) and their first dose of acubitril/Valsartan (Entresto)
What is the MOA of vasodilators?
direct vasodilation of arteries and veins, resutling in reduction of BP Act directly on smooth muscles of arterioles via Nitric Oxide (NO) Act on K+ channels --> Vessel relaxation --> decreased afterload
Which Vasodilators act on only arteries?
hydralazine and minoxidil
DPP-4 inhibitors MOA
inhibits the intestinal enzyme, DPP-4 --> increases endogenous incretins --> glucose-dependent release of insulin; suppression of glucagon
Which Vasodilators act on arteries AND veins?
nitropresside and nitroglycerin (both start with 'n' --> think artery 'N' veins)
First Generation Beta Blockers?
non-selective- Propanolol, Sotalol, Timolol, Nadolol Used for tx of: HTN, pheochromocytoma, atrial fibrillation Off label uses include: anxiety, performance induced anxiety (stage fright), angina (If concern for overdose, give glucagon = Reversal)
reversal agent for heparin
protamine sulfate
AGIs MOA
slows the absorption of dietary carbohydrate --> reduces PP BG inhibits enzymes- pancreatic alpha-amylase and GI brush border alpha-glucosidases, delays hydrolysis of ingested carbs, reduces postprandial insulin and glucose peaks
Sulfonylureas: Prescribing Notes
• Consider risk of hypoglycemia when selecting a dose • Typically dosed QD, sometimes BID • Take with a meal, usually breakfast • Usually DC'd if insulin is started
TZDs: Prescribing Notes
• Consider starting at lowest dose (15mg), titrate slowly if needed (q 2-3 months?) • Many adverse effects are dose-related • Dose changes can take several weeks to have full effect • Usually DC'd if insulin started
Life Cycle of Cholesterol
• Endogenous- manufactured by cells • Exogenous- dietary intake • Cholesterol- Synthesized in the liver by 3- hydroxy-3-methylglutaryl coenzyme A reductase (HMG-CoA reductase)
SGLT2 inhibitors: Prescribing Notes
• Include patient education about risk factors for DKA • Hold if acute illness, prolonged fasting, prior to surgery or invasive procedures • Diuretics and BP medications may require dose adjustment prior to starting a SGLT2i. • Decision to escalate the dose (typically after 1-3 months) should be based on tolerance and glucose response.
Treatment for lidocaine toxicity?
• Lipid Emulsion (20%) Therapy • AVOID vasopressin, calcium channel blockers, beta-blockers, or local anesthetic
