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Assessment 05
Pharm - Gout; Angina; Anti-Arrhythmics
40
Pharmacology
Professional
08/31/2010

Additional Pharmacology Flashcards

 


 

Cards

Term
Colchicine
Definition

Depolymerizes microtubules.

IV only

 

Tx acute gout attack, recurrence of gouty arthritis (not other types of arthritis) and Familial Mediterranean Fever

 

SE GI disturbance, blood dyscrasias

Term
Indomethacin
Definition

COX inhibitor

NSAID, analgesic, antipyretic (inhbits the release of PG and inflammatory cytokines), inhibits leukocyte motility

 

Tx: acute gout attacks

*Must give with an antacid (prevent peptic ulcers)

 

Dosing: 50 mg 3x/day

 

SE: GI (nausea, vomiting, ulcers), severe frontal HA, hematopoietic disorders, and Indomethacin antagonizes furosemide and HCTZ (pay attn to HTN meds the pt is on when perscribing).

Term
Allopurinol
Definition

Structurally similar to uric acid.

A competitive/suicide inhibitor of xanthine oxidase (binds active site). Metabolized to oxypurinol (non-competitive inhibitor of XO)

 

↓ plasma levels and ↓ urinary levels of UA;

↑ precursors of UA (xanthine & hypoxanthine);

Helps dissolve UA crystals & prevent UA kidney stones.

 

Tx: Primary Gout (↑ UA due to enzyme abnormalities) and Secondary gout (due to hematologic disorders like multiple myeloma or chemo)

 

SE: ↑ acute gout flares, hypersensitivity rxns (dermatitis)

 

CI: liver failure, renal failure,

 

Drug Interactions:

Antibiotics (Ampicillin and related abx) and 6-mercaptopurine (chemo drug, must ↓ 6-mercap dose when on allopurinol bc 6-mercap is metabolized by XO).

Term
Febuxostat
Definition

Mkt as Uloric

Structurally unrelated to Uric Acid (unlike allopurinol)

Inhibitor of oxidized & reduced forms of xanthine oxidase.

↓ uric acid levels.

More potent than allopurinol with less SE.

 

Tx: Gout, second line (pt who don't tolorate allopurinol); useful in renal insufficiency, in place of allopurinol (which is CI in renal failure pt).

 

SE: transaminase elevation (mild liver damage)

Term
Probenecid
Definition

Inhibits transport of organic anions across epithelia (blocks the Brush Border Transporter in the PCT) blocking UA reabsorption.

↑ UA excretion (Uricosuric); ↑ dissolution of UA crystals.

 

Tx: Hyperuricemia due to poor renal UA secretion (kidney is not screting enough UA daily, <1g/day)

 

Pt must maintain high urine volume (remain hydrated) and renal function must be normal to take this drug*

 

SE: Salicylates (asprin) inhibit the uricosuric actions of probenecid.

Term
Pegloticase
Definition

A bio-uricolytic: recombinant, PEGylated (↑ half life) analog of urate oxidase;

Urate oxidase is an enzyme humans lack that degrades UA to, easily excreted (more soluble) form: Allantoin.

 

Pegloticase ↓ serum UA AND ↓ urinary UA

 IV Only

Tx: Severe gout and when all other meds have failed (2nd/3rd line), dissolution of trophi, ↓ kidney stones (if pt remain well hydrated).

 

SE: Gout flares due to rapid ↓ in UA levels (tx w/ colchicine, NSAIDs prophylactically), antibodies can develop against PEG moiety.

Term
Recognize the following Beta-blockers (9)
Definition

Non-specific: Propranolol, Pindolol, Naldolol,

 

Cardioselctive (β1): Timolol, metoprolol, Atenolol, Esmolol, Acebutolol

 

Mixed (nonspecific β+α) : Labetolol

Term
Nitrostat
Definition

Nitroglycerine: sublingual, short acting

 

Causes venodilation (↓ preload),

coronary vasodilation (↓ afterload), ↓/reverses coronary vasospasm (tx variant angina), slight ↓ BP, slight ↑ HR,

↓ pulmonary vascular resistance

 

SE - hypotension (arterial vasodilation), reflex tachy, ↓ coronary perfusion, HA, rash.

CI - with Sildenifil (Viagra), profoundly potentiates its effects. Dangerous interaction.

Term
Nitrol Ointment
Definition

Nitroglycerine: slow onset, medium duration of action (4-6 hrs)

 

Causes venodilation (↓ preload),

coronary vasodilation (tx ischemia, vasospasm),

slight ↓ BP, slight ↑ HR,

↓ pulmonary vascular resistance

 

SE - hypotension (arterial vasodil), reflex tachy, ↓ coronary perfusion, headache, rash.

 

CI- with Sildenifil (Viagra)

Term
Isosorbide dinitrate
Definition

Nitroglycerine: Medium onset and duration of action (4-6 hrs) 

 

Causes venodilation (↓ preload),

coronary vasodilation (tx ischemia, vasospasm),

slight ↓ BP, slight ↑ HR,

↓ pulmonary vascular resistance

 

SE - hypotension (arterial vasodil), reflex tachy, dec coronary perfusion, headache, rash

 

CI- (potentiation) with Sildenifil (Viagra)

Term
Nitro-SR
Definition

Nitroglycerine: medium onset, long duration (8-12 hrs)

 

Causes venodilation (↓ preload),

coronary vasodilation (tx ischemia, vasospasm),

slight ↓ BP, slight ↑ HR,

↓ pulmonary vascular resistance

 

SE - hypotension (arterial vasodil), reflex tachy, dec coronary perfusion, headache, rash

 

CI- Interacts (potentiation) with Sildenifil (Viagra)

Term
Nifedipine
Definition

L-type Calcium Channel Blocker (CCB); dihydropyridine (DHP):selective for vascular SM, not cardiac;

Short Acting

 

↓ O2 demand of the heart by ↓ afterload*

 

Tx HTN (use w/ diuretic), angina, valvular insufficency

 

SE - Peripheral edema (precapillary arteriolar vasodilation), hypoT=reflex tachycardia (always use w a βB), HA, GI irritation, constipation.

Coronary Steal, a paradoxical worsening of angina DHP CCB.

 

*Beta blockers are better for angina* DHP CCB are used in pt unable to tolorate a BB or as an add-on*

Term
Amlodipine
Definition

L-type CCB; DHP: selective for vascular SM, not cardiac; short acting

 

↓ O2 demand of the heart by ↓ afterload*

Tx HTN (use w/ diuretic), angina, valvular insufficency

 

SE - Peripheral edema (precapillary arteriolar vasodilation), hypoT=reflex tachycardia (always use w a βB), HA, GI irritation, constipation.

Coronary Steal, a paradoxical worsening of angina DHP CCB.

 

*Beta blockers are better for angina* DHP CCB are used in pt unable to tolorate a BB or as an add-on*

 

Term
Felodipine
Definition

L-type CCB; DHP

↓ O2 demand of the heart by ↓ afterload*

 

Tx HTN (use w/ diuretic), angina, valvular insufficency

 

SE - Peripheral edema, hypoT=reflex tachycardia (always use w a βB), HA, GI irritation, constipation.

Coronary Steal, a paradoxical worsening of angina w use of DHP CCB.

 

*Beta blockers are better for angina* DHP CCB are used in pt unable to tolorate a BB or as an add-on*

Term
Nicardipine
Definition

L-type CCB; DHP

↓ O2 demand of the heart by ↓ afterload*

 

Tx HTN (use w/ diuretic), angina, valvular insufficency

 

SE - Peripheral edema (precapillary arteriolar vasodilation), hypoT=reflex tachycardia (always use w a βB), HA, GI irritation, constipation.

Coronary Steal, a paradoxical worsening of angina with use of DHP CCB.

 

*Beta blockers are better for angina* DHP CCB are used in pt unable to tolorate a BB or as an add-on*

Term
Isradipine
Definition

L-type Calcium Channel Blocker; dihydropyridine;

long 1/2 life

 

↓ O2 demand of the heart by ↓ afterload*

Tx HTN (use with diuretic), angina, arterial vasodilation,

 

Ok to use in pts with CHF, no neg inotropy;

selective for vascular SM, not cardiac.

 

SE - peripheral edema, reflex tachy (use w βB), hypotension, constipation

Term
Verapamil
Definition

Class IV AA; non-DHP CCB; phenylalkylamine

Works at slow conduction tissues: SA, AVN

 

 Arterial vasodiltior, - ionotrope, - chronotrope, ↓ contractility, ↓ AV conduction

(↓ HR, ↑ diastole=↑ coronary perfusion)

Reverses vasospasm (varient angina)

 

Tx: HTN w/angina (exertional, vasospastic), Afib, Aflutter, reentry arrhythmias, PSVT (↓ contractility/AV conduction);

Asthma, COPD and DM=OK!

 Use in pts with normal LV fxn who can't tolerate BBs

 

SE - Peripheral edema, reflex tachy, hypoT, constipation, depression of SA/AV node+myocardial depression, nausea, HA.

 

CI: With BB (cardiac depression, asystole) and in pt with history of MI/CHF (causes ↑ mortality in these pt), CI with other CYP metabolized drugs*

Term
Diltiazem
Definition

Class IV AA, non-DHP CCB; benzothiazepine, intermediate between phenyl and DHPs

 

Tx angina (or HTN w angina)

(arterial vasodilator, - ionotrope, - chronotrope), Afib, Aflutter, reentry arrhythmias, PSVT.

 

Use in pts with normal LV function, but can't tolerate BBs

 

Ltd. reflex tachycardia (better at this than Verapamil but Verapamil has ↑ Ionotropic/Chronotropic effects)

 

SE - depression of SA/AV nodes, myocardial depression (↓ contractility), peripheral edema, hypoT, rashes, nausea, headache, bradycardia, CHF

 

CI- pt on BB and pt with CHF andwith other CYP metabolized drugs*

 

Term
Ranazoline
Definition

Metabolic Modulator

↑ glucose oxidation/efficiency of O2 use in heart

Does not effect HR/BP and does not relieve acute anginal attacks.

 

Tx:Chronic stable angina (w/ amlodapine, BB, nitrates);for pts refractory to revascularization (4th, 5th-line tx)

OK in pregnancy (Class C)

 

SE - Dizziness, syncope, HA, nausea, constapation, asthenia (weakness).

 

CI- w/ CYP3A4 inhibitors (nonDHP CCBs, some abx, grapefruit juice),

 Preexisting long QT or use of class 1A/III AAs, or Digoxin, use of TCA.

Liver or renal impairment.

Term
Quinidine
Definition

Class 1A - (intermed. dissociation rate) antiarrhythmic;

 

↓ membrane responsiveness by binding to Na channels (also has action as an alpha-blocker and a vagolytic)

 

↓ conduction velocity, ↓ effective refractory period

 

Tx atrial and ventricular arrhythmias

 

SE - hypoT Torsades, syncope, diarrhea, autoimmune thrombocytopenia

 

CI- Pt with A-fib (causes paradoxical acceleration of AV nodal conduction due to vagolytic activity)

Term
Procaineamide
Definition

Class 1A prototype- intermed. dissociation rate (2 sec);

 

↓ membrane responsiveness by binding to Na channels O and C states and preventing reversion to R, has some K+ blocking properties (see QT prologation below),

↓ conduction velocity, ↓ effective refractory period;

 

IV only

Tx-Short-term, acute control of atrial and ventricular arrhythmias (ex: post-op A-fib)

 

SE - High prevalence of SE incl (+)FANA, drug induced lupus, GI intolerance, bone marrow aplasia, QT prolongation, Torsades.

Watch dosing in slow acetylators*

Term
Disopyramide
Definition

Class 1A- intermed. dissociation rate;

Decreases membrane responsiveness by binding to Na channels, dec conduction velocity, dec effective refractory period

 

Tx atrial and ventricular arrhythmias (autonomic anticholinergic effects) and urinary retention

 

SE - Torsades

Term
Lidocaine
Definition

Class 1B prototype - rapid dissociation rate (< 1 sec);

↓ membrane responsivity by binding to Na channels, ↓ conduction velocity, ↓ ERP

 

Short half-life, extensive first pass metabolism, req loading IV bolus or 2.

 

Tx - Ventricular arrhythmias, short-term suppression of VPBs, V tach; suppression of automaticity, interruption of ventricular reentry.

Specifically able to ↓ membrane responsivity in ischemic and partially depolarized tissues=esp good at preventing V-fib*

 

SE - CNS, agitation, confusion, seizures

Often missed, these symptoms=those of CCU Psychosis

 

Elimination is by hepatic biotransformation which is altered in CHF pt who are prone to lidocaine toxicity.

 

CI- as MI prophylaxis, shows ↑ mortality

Term
Mexilitine
Definition

Class 1B - rapid dissociation rate;

↓ membrane responsiveness by binding to Na channels, ↓ conduction velocity, ↓ effective refractory period

 

 Orally-effective analog of Lidocaine

Tx- Vent arrhythmias, suppression of VPBs, V tach; suppresses automaticity, interrupts ventricular reentry;

 

SE - CNS, agitation, confusion, seizures, GI distress- (limiting factor to the use of this drug)

 

Note that in general the use of class IB agents is ↓ in favor of using class III agents

Term
Flecainide
Definition

Class 1C prototype - SLOW dissociation rate (>10 sec);

 

Prolongs QRS; ↓ membrane responsiveness by binding to Na channels with high affinity, ↓ conduction velocity, dec effective refractory period; ↓ automaticity, ↑ ERP in atria, vent, AVN

 

Tx: supraventricular arrhythmias, WPW, A fib, A flutter;

 

SE - pro-arrhythmic effect; contraindicated in pts with structural heart disease (incl. necrotic infarcts) - inc mortality post-MI;

Term
Propafenone
Definition

Class 1C - SLOW dissocaition rate;

 

↓ membrane responsiveness by binding to Na channels, has some B-blocker activity, ↓ conduction velocity, ↓ effective refractory period

 

Tx supraventricular arrhythmias, WPW, A fib, A flutter;

 

SE - Pro-arrhythmic effect (strictly CI in pt w/ structural heart disease, incl. necrotic infarcts),

↑ mortality post-MI

Term
Class II Anti-Arrhythmics - a.k.a. what functional category?
Definition

Beta-blockers, know them

  • ↓ automaticity related to catecholamine acvitity and ischemia (effective anti-anginals).
  • ↓ AVN conduction velocity.
  • ↓ atrial and ventricular arrhythmias post-MI and ↑ survival in these pt.
  • Interrupts reentry in the AV node to halt PVST
  • ↓ AV nodal conuction in supraventricular arrhythmias.
  • Prevents EAD and Toursades in pt with prolonged QT intervals.
  • Blocks the symptoms mediated by hyperadrenergic states (chest pain, arrhythmias etc...)
  • Tx HTN, angina, acute and prophylactic MI, CHF (off label for arrhythmias).
  • IV or PO
Term
Amiodarone
Definition

Class III - K+ channel blocker;

also blocks Na (class I), Ca (IV), and BB (class II);

Interacts with TH (thyroid) receptors; prolongs AP, ↑ effective refractory period*; inhibits abnormal automaticity, ↑ fibrillation threshold, prevents cell-cell coupling (key in preventing fibrillation).

 

Tx: Vtach, Vfib, A-fib, IV for cardiac rescuscitation, PO for chronic atrial, vent, AVN arrhythmias (Most effective drug at preventing Afib and Vent tachycardia).

Effective: See prolonged PR, QRS and QT intervals + bradycardia (unique EKG)

PO or IV, slow elimination (req loading dose)

 

SE - pulmonary fibrosis, hypo- hyper-thyroid, blindness, hepatitis, corneal microdeposits, photosensitivity dermatitis(grey-blue skin), muscle weakness

(Torsades is rare!)

CI- Metabolized by/inhibits CYP3A4 (CI with other drugs that use or block 3A4).

Term
Sotolol
Definition

Class III - K channel blocker (D and L isomers, prolongs AP); non-selective beta-blocker (L-isomer only, 1/3 the potency of propanolol)

 

Tx - Atrial, Vent, AVN reentrant arrhythmias incl V-tach

 

CI - long QT, COPD/Asthma, CHF, AV block, sinus bradycardia, as MI prophylaxis (↑ mortality), excreted in kidney, adjust dosing for renal failure pt.

 

SE - Torsades

Term
Ibutilide
Definition

Class III prototype - K channel blocker;

Prolong repolarization therefore ↑ effective refractory period; interrupts reentry, 

↑ fibrillation threshold (↓ fib's)

 

Tx: IV for acute atrial arrhythmias (Afib, Aflutter)

 

SE - Torsades

Term
Dofetilide
Definition

Class III - K channel blocker;

Prolong repolarization therefore ↑ effective refractory period and ↑ duration of the AP

 

Has significant pro-arrhythmic SE and is rarely used.

Term
Bretylium
Definition

Class III - K channel blocker;

inhibits NE release from presynaptic neurons

 

Tx - IV for emergency Vfib or Vtach

 

SE - orthostatic Hypotension

Term
Adenosine
Definition

AA (no class)

Terminates acute PSVT by blocking the AV node;

short half-life, IV only

 

Tx: PVST*

 

SE - tight chest, flushing, bronchospasm, transient asystole, and recurrence of PSVT (*Must follow with another antiarrhythmic to prevent this).

 

Contraindications - methylxanthines (think Dr. Nelson), Dypyridamole (potentiation), WPW

Term
Digoxin
Definition

AA (no class), Digitalis glycoside;

↑ intracell [Ca] by blocking the Na/K-ATPase, ↑ intracellular Na, ↑ activity Na/Ca exchanger;

↑ Ca = ↑ contractility;

AA - vagal nerve activity, ↓ SA automaticity, ↓ AVN conduction

Arrhythmogenic - direct effect due to Na/K ATPase activity (source of most SE).

 

Paradoxical effect, ↑ normal automaticity; ↓ in AV conduction velocity (↑ PR interval);

 

SE: ↑ automaticity causing DAD leading to premature atrial and vent contractions and v tach.

 

CI: interactions with diuretics, warfarin

Term
Why do you never want to interrupt an IV nitroglycerin drip in a pt with angina?
Definition

Anginal Rebound

 

If the angina in the pt is unstable interruption of the dose can cause vasospasm which can worsen angin or result in MI.

Term
Rationale behind the use of beta blockers in tx angina.
Definition

DO: blunt/↓ HR, ↓ contractility, ↓ afterload (CNS effects)

 

Tx: Unstable angina (with nitrates, asprin, and heparin) Exertional angina (↓ HR and contractility) Very good*

MI; acute and prophylaxis:↓ chest pain/angina, ↓ ST elevation, ↓ cardiac enzymes, ↓ ventricular ectopy/fibrillation, ↓ reinfarction and ischemic episodes, ↓ mortality!

 

BB do NOT: ↓ preload, or prevent coronary vasospasm.

 

CI: Sinus bradycardia, SA/AV block, decompensated CHF, asthma (bronchospasm), DM (hypoglycemia), or with non-DHP CCB.

 

Do not withdraw BB abruptly in an angina/MI pt = Severe reflex tachycardia.

Term
What are some popular combinations of BB with other drugs and what condition(s) are these combinations used to treat?
Definition

BB+Nitrates: ↓ LVEDP, LV volume, dilates coronary arteries. Tx angina (unstable and exertional).

 

BB+DHP-CCB: prevents coronary vasospasm, ↓ systemic vascular resistance. Tx angina (vasospastic and unstable)

Term
50% of the population are poor acetylators imparing their metabolism of which drug?
Definition

Procanamide (Class IA antiarrhythmic)

 

Is metabolized by the liver: Acetylated so it can be excreted by the kidneys.

 

Half of thepopulation are slow acetylators and these individuals have a higher incidence of +FANA and other SE of this drug.

Also, in renal failure pt who are also poor acetylators, the metabolites of this drug accumulate in the body.

Term

Distinguish structural from non-structural heart disease.

Why is this significant in tx arrhythmias?

Definition

Structural Heart Dz: Coronary Dz w/ ischemia, LV dysfunction, CHF, sustained ventricular tachycardia.

 

Non-Structural Heart Dz: Supraventricular arrhythmias incl atrial flutter, A-fib, and SVT.

 

Important because Class IC agents (Flecainide, Propfenone) are strictly CI in pt with structural heart dz but ok to use in those with non-structural heart dz*

Term
Amniodarone Pulmonary Toxicity
Definition

An important SE of Amniodarone (Class III AA) use.

Helpful to do a baseline CXR to detect, esp if pt has preexisting pulm dz (higher incidence in this group)

 

2 types of toxicity:

Interstitial pneumonitis is slow onset with intersitial shadows on CXR.

Acute Respiratory Distress Syndrome (ARDS) is rapid onset and CXR shows alveolar shadows.

 

Presents with dyspnea, a non-productive cough, pleuritic chest pain, weight loss and crepitations*

 

CXR shows bilateral diffuse changes + ↓ pulmonary fxn.

 

Stop the drug if this happens.

If you must continue the drug ↓ dosage bc risk is dose-related.

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