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Cardiovascular Drugs
ACE Inhibitor
• Generic ends in “pril”
• Works in the kidney (renin system) blocks
angiotension I from forming angiotension II
a strong vasoconstrictor
• Generic names/trade name:
quinapril (accupril), ramapril (altace),
benazepril (lotensin), captopril (capoten),
enalapril (vasotec), fosinopril (monopril),
lisinopril (prinivil), ramipril (altace)
This drug will:
Lower BP
Raise pulse
Side Effects
hypotension
hyperkalemia
AceInduced renal insufficience/failure
Angioedema
dry hacking cough
CAN CAUSE FETAL DEATH
Avoid if Hx of Renal artery stenosis
I teach my patient that the
benefit of this drug is:
Lowers BP
Strengthens a weak heart muscle
Slows the progression of renal disease
Prevents strokes
Improve survival after MI
I monitor the following
blood pressure
(what are my parameters)
Renal Function: BUN&Creatinine
Potassium level (K) =
Angiotension II Receptor
Antagonist
• Generic ends in “sartan”
• Works in the kidney – cousin to the ACE,
blocks the action of angiotension II, permits
relaxation and dilation of blood vessels.
• Generic names/trade name:
candesartan (atacand), irbesartan (avapro),
olmesartan (benicar),
losartan ( cozaar), valsartan (diovan),
telmisartan (micardis), eprosartan (teveten)
This drug will:
Lower BP
Raise pulse
Side Effects
hypotension
hyperkalemia
AceInduced renal insufficience/failure
Angioedema
CAN CAUSE FETAL DEATH
I teach my patient that the
benefit of this drug is:
Lowers BP
Strengthens a weak heart muscle
Slows the progression of renal disease
I monitor the following
blood pressure
(what are my parameters)
Renal Function: BUN&Creatinine
Potassium level (K) =
Beta Blockers
• Generic names end in “olol”
• Beta1 cells in heart, eyes and kidneys. Beta 2 cells in lungs, gi tract,
liver, uterus, blood vessels, and skeletal muscle.
• Block Beta cells by blocking effect of norepinephrine and
epinephrine.
• Generic/trade name:
Non-selective beta blockers affect B1 and B2 cells: propranolol
(Inderal) affects heart, blood vessels and air passages
Selective Beta blockers primarily block B1 cells:Atenolol (tenormin),
nebivolol (bystolic), metoprolol tartrate (lopressor), metoprolol
succinate (toprol xl), bisoprolol (zebeta),
Block beta and alpha-1 receptors which add to blood vessel dilating
effect: carvedilol, (coreg), Labetalol (Normodyne, Trandate).
This drug will:
Lower BP
Lowers pulse
I teach my patient
the benefit of this drug:
Lowers BP
Antiarrythmic
Strengthens weak heart muscle
Lowers risk of second MI
Angina
Reduce production of aqueous humor
Therefore reduce pressure for glaucoma
Side effects:
hypotension
bradycardia (heart block)
may worsen copd and DM
I will monitor the following:
BP
Pulse
Calcium Channel Blockers
• Generic/trade name: differ in their duration action,
elimination from body, and in their ability to affect heart
rate and contraction. They dilate areteries.
• Some have little affect on heart rate and contraction so
they are safer to use in people with heart failure and
bradycardia: felodipine (plendil), amlodipine (norvasc),
nifedipine (procardia)
These have greatest effect on heart and reduce the
strength and rate of contraction, therefore they are used
quite often for their antiarrythmic affect: diltiazem
(cardizem), verapamil (calan, isoptin),
This drug will:
Lower BP
Lower pulse
Side effects:
hypotension
bradycardia
ankle edema
constipation
I teach my patient
I will monitor
The benefit of this drug:
BP
Lowers BP
pulse
antiarrythmic
No grapefruit juice 2hours ac
Angina
or 4 hours after CCB cyp4503a4
Pulmonary HTN
LFT’s
Raynauds, subarachnoid hemorrhage
And prevention of migraines
Antiarrhythmics
• These can have mild antiarrhythmic effect to a
very strong effect.
• Drug will slow heart rate and hopefully keep the
heart in normal sinus rhythm
• Common ones you will see: Beta blockers/CCB
• Lanoxin, sotalol (betapace), flecainide,
• The most common and effective is:
amiodarone (cordarone, nexterone, pacerone)
• The newest one: Multaq may cause liver
failure if used long term
• This drug will:
slow the heart rate
is used to help maintain
sinus rhythm .
Side effects are drug specific
All can cause: bradycardia.
Used with caution in heart failure.
Caution with any 2nd or 3rd degree heart block if
no pacemaker present.
Amiodarone: causes hypothyroid, interstitial lung
changes, visual disturbances, and potentiates coumadin,
liver damage
I teach my patient
That the benefit of this drug is:
Helps rate control your heart
Helps to maintain sinus rhythm
I will closely monitor:
Heart rate
If on amiodarone
coumadin (INR) , TFT, LFT’s, CXR with PFT’s, eye exam along
fundoscopy exam, BP and ECG
****Amiodarone is very effective anti arrhythmic with many side effects will
see it often due to it is cheap
Multaq newer but more expensive used with extreme caution with any
one with hx of CHF you wont see this one as often due to cost and
concern over long term use due to liver failure.
Diuretics
•
•
•
Potassium wasting versus potassium sparing.
Thiazide (HCTZ) mild used genererally first for HTN treatment (minimal
effect on K but still check) Metazolone (zaroxolyn) boosts loop use with
caution will really make them increase urine output and waste K must
give 30 minutes prior to loop to work!!!!!!
Loop Furosemide, torsemide(demadex), Bumetanide(bumex) lowers bp and
decreases edema
• Potassium sparing: triamterene, Spironolactone
(aldactone) Aldactone used in CHF with
decreased EF < 35-40 patients it increases long
term survival used to decrease aldosterone
levels in CHFer’s
This drug will:
Increase urine output
Side effects:
hypokalemia
hyperkalemia w/k sparing
hypotension
dehydration
I teach my patient
That the benefit of this drug is:
Decrease blood pressure
Decrease edema (lungs and legs)
I will closely monitor:
BP
K
BUN
Creatinine
Antiplatelet aggregration
•
•
•
•
Aspirin (ASA) 81mg, 162mg or 325mg
Clopidogrel (plavix) 75mg
Prasugrel (effient) 10mg daily (5mg if wt<60kg)
If s/p PCI with Stent placement must remain on above
for at least 12 months minimum generally ASA325 +
plavix or effient x 90 days, then ASA 81mg + plavix or
effient. Do not stop unless you speak with cardiologist
and are told to do so. If they are stopped high risk for
restenosis of drug eluting stent
• Effient and plavix cost about $185 dollars for 30 day
supply very expensive.
Anti platelets
•
ASA reduces production of platelets
ASA: Bleeding/tinnitus
•
Effient/plavix prevents platelet aggregation
effient not advised if pateint is >75 years old,
actively bleeding, recent CVA/TIA, wt<60kg. For
Effients and Plavix bleeding and hemorrhage
•
Prevents MI’s and embolic CVA/TIA
S/P PCI with drug eluting stent:
these patient must remain on asa
plus one of the antiplatelets as previously
described for at least one year with
no interruption in therapy
monitor for bleeding
Actively Bleeding labs: H&H
Can the patient form a clot labs: Plt
Anticoagulants
• Warfarin (Coumadin)
afib, aflutter thromboembolism/stroke prophylaxis,
mechanical valve, DVT, VTE prophylaxis with hip/knee replacements QD dosing. Vit K reverses now given orally
not IM
• Dabigatran (Pradaxa)
•
afib/aflutter thromboembolism/stroke prophylaxis
When switching from coumadin to pradaxa INR has to be < 2 BID dosing No antidote
• Rivaroxaban (Xarelto)
afib, aflutter thromboembolism/stroke prophylaxis, DVT
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prophylaxis with hip/knee replacements when switching from coumadin to Xarelto INR has to be < 3.,
DVT prophylaxis post op hip start 6-10h post op once hemostasis is established X 35 days
DVT prophylaxis post op knee start 6-10h post op once hemostasis is established X 12 days No antidote
Anticoagulants
•
Coumadin: inhibits Vit K dependent
Bleeding
coagulation factor synthesis.
Pradaxa: reversibly inhibits thrombin
Xarelto: selectively blocks active site
of factor Xa, thus inhibiting blood
coagulation
Prevents Embolic events
Types of embolic events?
If on Coumadin watch INR
Assess for bleeding: H&H
Oral Antidiabetic Medications
• Can insulin be given via oral route?
• Remember that people with type 2 diabetes tend to have two
problems that lead to increased sugar (glucose) in the bloodstream:
• They don't make enough insulin to move glucose into cells
where it belongs.
• The body's cells become "resistant" to insulin (insulin
resistance), meaning they don't take in glucose as well as they
should.
•
•
•
•
Oral antidiabetic medications work three different ways
Stimulates pancrease to produce insulin
Makes cells more sensitive to insulin
Decreases the GI tract’s absorption of glucose.
Sulfonylureas.
Increase insulin production
• These diabetes pills lower blood sugar by
stimulating the pancreas to release more
insulin.
• They include: Glucotrol (glipizide), Glucotrol
XL (extended release), DiaBeta (glyburide),
Micronase (glyburide), Glynase PresTab
(glyburide), and Amaryl (glimepiride). These
drugs can cause a decrease in the
hemoglobin A1c (HbA1c) of up to 1%-2%.
Sulfonylureas Side effects
•
•
•
•
Hypoglycemia (low blood sugar)
Upset stomach
Skin rash or itching
Weight gain
Biguanides.
Make cells more receptive
• These diabetes pills improve insulin's ability to move
sugar into cells especially into the muscle cells. They
also prevent the liver from releasing stored sugar.
• Used along with diet and exercise.
• Biguanides should not be used in people who have
kidney damage or heart failure because of the risk of
precipitating a severe build up of lactic acid (called
lactic acidosis) in these patients. Biguanides can
decrease the HbA1c 1%-2%.
• An example includes: metformin (Glucophage,
Glucophage XR, Riomet, Fortamet, and Glumetza).
Side effects:
•
•
•
•
Upset stomach (nausea, diarrhea)
Metallic taste in mouth
Vit B12 deficiency
Lactic Acidosis
Thiazolidinediones
Makes the cells use insulin better
• Actos (pioglitazone)
• Avandia (rosiglitazone) can only be used if
client has already been on it and has had
risks and benefits reviewed and they
decide to stay on it. Due to increased risk
of heart failure and CVS events
•
Typical reductions in glycolated hemoglobin (A1C) values are 1.5–2.0%.
Alpha-glucosidase inhibitors
• Precose (acarbose) and Glyset (miglitol).
• These drugs block enzymes that help
digest starches, slowing the rise in blood
sugar.
• They can lower hemoglobin A1c by 0.5%1%.
Side effects of Alpha-glucosidase
inhibitors
• Diarrhea, nausea, cramps or gas
Meglitinides,
stimulate release of insulin
• Prandin (repaglinide) and Starlix (nateglinide).
• The effects of these diabetes pills depend on the
level of glucose. They are said to be glucose
dependent.
• High sugars make this class of diabetes
medicines release insulin.
• This is unlike the sulfonylureas that cause an
increase in insulin release, regardless of glucose
levels, and can lead to hypoglycemia
Side effects of meglitinides include:
• Hypoglycemia (low blood sugar)
• Stomach upset
Dipeptidyl peptidase IV (DPP-IV) inhibitors
increasing insulin secretion from the pancreas and reducing sugar
production (great for lowering postprandial blood sugar)
• Januvia (sitagliptin), Onglyza
(saxagliptin), and Tradjenta (linagliptin),
Galvus (Vildagliptin) .
•
DPP-4 (dipeptidyl peptidase IV) is an enzyme that's responsible for
inactivating hormones in your gut called incretins (glp-1). These
helpful incretin hormones cause your pancreas to produce more
insulin and your liver to stop producing glucose. By depressing or
inhibiting the DPP-4 enzyme that inactivates incretins, DPP-4
inhibitors promote higher levels of incretins (glp-1) to keep your blood
glucose in the normal range, especially after meals.
• DPP-IV inhibitors control sugar without causing weight gain.
The medication may be taken alone or with other medications
such as metformin.
DPP-4 inhibitor Side effects
• During the clinical studies, the most
common side effects were:
• cold like symptoms, stuffy nose, sore
throat, coughing, high cholesterol, high
triglycerides and weight gain.
• Hypoglycemia when used with metformin.