1)   Uterine relaxation (tocolytic) is a _____effect

2)  T/F Sympathetic effects cause hyperkalcemia

   3)  phenoxybenzamine (Dibenzyline®) and phentolamine (Regitine®) are __ blockers

1)  ß2 (sympathetic)

2)  False Hypokalcemia

3) Alpha

•    Cardiac arrhythmias
•    Angina pectoris
•    Hypertension

These can all be treated with what?

• Migraine headache prophylaxis • Acute anxiety reaction • Prevent recurrent M.I. • Glaucoma (topically applied agents only) • Chronic (Congestive) heart failure

These can all be treated with what?

True

 The initial signs of hypoglycemia include tachycardia and tremors, which generally occur when the blood glucose is ~50-60.  ß-blockers slow heart rate and prevent tremors, so the person with diabetes will not notice the signs of hypoglycemia until they are lower, e.g., 40-50, thus delaying treatment which could lead to CNS effects.  

Direct-Acting—acts like acetylcholine...

1)Usually perscribed for Dry Mouth.

2)   for urinary retention

1)Cevimeline (Evoxac) 

2) Bethanechol (Urecholine®, Duvoid®)—

1)  Drugs that have ______ effects are derived from natural sources such as the belladonna plant (Atropa belladonna or “Deadly Night Shade”) or are manufactured synthetically.  They have similar effects.

2)  These alkaloids are tertiary amines, thus are absorbed into the ____.

1)  anticholinergic

2)  CNS

The following are all members of what group of pharmaceuticals?

•    Atropine
•    Scopolamine (Hyoscine®, Transderm-SCOP®) – used for motion sickness
•    Hyoscyamine (Levsin®, Cystospaz)

The following affects are ______ agents.

o    anti-nausea effect
o    to cause somnolence and “twilight sleep”

The following affects are ______ affects.

• To decrease gastrointestinal and genitourinary tract actions • To cause a bronchodilation effect in asthma and COPD • Antidote for cholinergic (some “nerve gas”) poisonings • To stimulate the heart to counteract bradyarrhythmias

1)    Less than __ of patients with hypertension are adequately controlled

 2)  JNC-7 found:  In persons >__ years, systolic pressure >140 is a much more important CVD risk factor than diastolic blood pressure.

3)    JNC-7 found: ____ diuretics should be used in drug treatment for most patients with uncomplicated hypertension, either alone or combined with drugs from other classes

1)  1/3 (it is usually a "silent" disease)

2)  50

3) Thiazide

1)  JNC-7 found:    Most patients will require ___ or more antihypertensive medications to achieve goal blood pressure.

2) (ALLHAT), one of the most important trials of antihypertensive therapy, studied chlorthalidone, amlodipine and lisinopril and concluded that _____ diuretics, specifically _______, should be the initial drug of choice for the treatment of hypertension. 

1) two

2)  Thiazide.....Chlorthalidone

ACCOMPLISH: 
1)   _____ is less potent and shorter-acting than chlorthalidone, the one (thiazide diuretic) with the most evidence of improved outcomes.

2)  These diuretics (thiazide)  work on which part of the renal system?

1)  HCTZ

2)  Distal Convoluted Tubule (DCT)

1)  T/F Thiazides decrease blood glucose?

2)  T/F Thiazides decrease blood potassium?

3)  T/F Thiazides decrease blood lipids?

1)  False they increase blood glucose

2)  True (hypokalcemia may occur)

3

)  False they may actually lead to Hyperlipidemia and hypercholesterolemia

 1)  These are all what? 

 bumetanide (Bumex®)
furosemide (Lasix®)
torsemide (Demadex®)
ethacrynic acid (Edecrin®)

 2)  They work on 

3)  They have the same side effects as _____  ____ except that they may also cause _____.

1)  Loop Diuretics (IDES)

2)  Loop of Henle (do not cause vasoconstriction like Thiazides so they are not as effective)

3)  Thiazide Diuretics (DCT), ototoxicity (IV doses of Lasix)

1)  Results of the study showed that for each 0.5 MEq/L decrease in serum potassium, there was a ___ increased risk of diabetes.

 2)  Potassium-Sparing Diuretics work where?

3)  What 2 did we speak of??

4)  Which one is 1st to be designed for SARA?

5)  Which is helpful for which pt?

6)  What are some side effects ...especially for Spiralactone?

1)  45%..this is relevent with hypokalcemic causing diuretics like DCTs and Loops.

2)   Cortical Collecting Tube (CCT) USED ALONE THEY CAUSE HYPERKALCEMIA!!

3)   Spiralactone and Eplerenone (Inspra®)

4)  Ephlerenone (selective Aldosterone receptor antagonist)

5)  improving the survival of CHF pts.

6)   mastodynia (pain in the breasts), gynecomastia and menstrual abnormalities

Nonselective ß-Blockers

Nonselective ß-Blockers with ISA

ISA=(Intrinsic Sympathomimetic Activity) or partial agonist activity.... 

Selective ß-Blockers

 1)  acebutolol (Sectral®) is the only ?

2)  carvedilol (Coreg®) is the only?

3)  What else does Coreg do?

1)  Selective ß-Blocker with ISA

 2)  Nonselective ß-Blocker with Alpha-Blocking Effects without ISA

3) Carvedilol is marketed primarily for prevention of morbidity and mortality from
    congestive heart failure and  has significant antioxidant activity which may
    account for many of its cardioprotectant effects.
 

1)  Beta-blockers  reduce blood pressure not only by reducing adrenergic stimulation to the β-receptors, but also by decreasing ___ release from the kidney.

2)   Agents with _____ _____ _____may cause fewer side effects, particularly a decrease in heart rate at rest, and may be preferred for clients who develop symptomatic bradycardia with other ß-blockers. 

1)  Renin (Renin-Angiotensin system responsible for BP Increases)

2)  intrinsic sympathomimetic activity (ISA)=some speeding up of heart rate as well...more balanced

  Bradycardia
 

Mental dullness, fatigue and ↓exercise tolerance
   

↓ HDL cholesterol
   

Bronchospasms

What are the 2 MAJOR Contraimplications with Beta-Blockers?

 Asthma/COPD—prevents dilation of bronchials from ß2 stimulation.
  

Diabetes—prolongs hypoglycemia and masks the signs of hypoglycemia.
 

1)  What type of Sympatholytic is Clonidine?

2)  how do these work?

SYMPATHOLYTICS

 1)  Peripheral Adrenergic Neuron Antagonists:      These drugs are taken up by the adrenergic nerve ending and then ↓ the release of _______ ?

2) T/F Commonly used to treat HTN?

3)  Any satanic side effects?

1)  catecholamines

 2)  False,     These drugs are rarely used since they can cause troublesome adverse effects, including severe depression from reserpine and postural and exertional hypotension with guanadrel.  

 3)  Yes reserpine..an ingredient of rauwolfia alkaloids commonly leads to dreams of snakes...whoa man.

SYMPATHOLYTICS:

 1)  What are these?

prazosin (Minipress®) (in Minizide®)
terazosin (Hytrin®)
doxazosin (Cardura®)

2)  Commonly used for?

3)  Which populations are they dangerous for?

1)  Alpha-Adrenergic Blockers (end in OSIN)

 2)  Treating BPH

 3) Possibly the those with HTN/heart dz...   Patients on the α-blocker experienced 25% more cardiovascular events and were twice as likely to be hospitalized for CHF than those taking the diuretic.  

 1)  These are both...

hydralazine (Apresoline®)

minoxidil (Loniten®

2)  hydralazine —can cause a ____
    like reaction in doses > 200 mg/day.  Combined with isosorbide dinitrate in the product
    BiDil® for heart failure in ______(which ethnic group).... is no longer being marketed.

3)   minoxidil (Loniten®)—common side effect of hirsutism (excessive hair growth) and fluid retention.  Topically applied, it becomes _____.

1)  Direct Vasodilators

2)  Lupus, African-Americans

3)  Rogaine

Renin-Angiotensin System (RAS) Agents

 It's long been known that use of a RAAS antagonist (ACEIs, ARBs, or DRIs) slows the progression of kidney disease and specifically slows progression of advanced kidney disease, primarily in patients with _____ who have greater than ______(amount) and have lost at least ____(degree) of their kidney function.

proteinuria

 300 mg/day

half

 In addition to lowering blood pressure, the ACE inhibitors have become standard, first-line therapy for what 3 things?

Prevention of Diabetic Nephropathy (manifested by proteinuria)

Congestive Heart Failure
 

Post-Myocardial Infarction Prevention of 2nd Attacks
 

1)  T/F?   ACE inhibitors have large effects on plasma lipids or on glucose tolerance 

2)  Since the cough is thought to be due to an accumulation of _____ and substance P, some clinicians have had success in controlling the cough with _____ or a ____.  

1) False....they have no effect on plasma lipids or glucose

2)  bradykinin, aspirin, NSAID (particularly sulindac (Clinoril®)

1)  T/F....   (CHARM)-supported the concept that ACE inhibitors and the ARB Atacand®,  complemented each other when used together to further improve outcomes in patients with DM.

 2)  T/F.... In general, combo therapy improves outcomes more than an ACE inhibitor alone in patients with vascular disease, diabetes, or after a heart attack, despite additional blood pressure lowering.

1)  False...they helped in patients with HF

2) FALSE ...Combo does not improve

 1)  Direct Renin Inhibitor (DRI): Aliskiren (Tekturna®)
  Side effects are?

 2)  What are the 2 major groups of Calcium Channel Blockers (CCBs)?

 3)  Which group all end in "-ipine"

4)  T/F ...The two groups of CCBs are dissimliar in their effects?

1)     It can cause diarrhea, especially at the higher dose.

 2) Dihydropyridines
Nondihydropyridines
3)  Dihydropyridines

4)  True

 1)  How do both groups of CCBs work? 

2)  Which group Generally increases HR and CO?

3)  Which group lowers PR?

4)  Name the Dihydrophyrimidine found in Caduet (1/2 of the drug) 

1)      Blockage of the voltage-dependent calcium channels on cell membranes.

 2) Dihydropyrimidines

 3)  They both do  (nondihydropyrimidines and dihydropyrimidines )

 4)  Amlodipine..other half is atorvastatin (for hyperlipidemia)

1)  CCB's:    The primary “class” side effect is?

2) Verapamil also causes?  

3)  (JNC-VI) long-acting CCBs are the drug of choice for which group?

1)   peripheral edema, which occurs with verapamil, diltiazem, and, most frequently, nifedipine. 

2)  GERD and CONSTIPATION

3) OLDER CLINTS WITH ISH..isolated systolic hypertension 

JNC-7 Guidlines for HTN Tx:

1)  Type 1 diabetes with proteinuria: 
2)   Heart failure: 
3)   Isolated systolic hypertension (ISH) in older clients: 
4)  Myocardial infarction (MI):  

1)  ACEIs

2) ACEIs, diuretics

3)  diuretics, CCBs

4)  ß-blockers (non ISA), ACEIs
 

Favorable (Good) Effects on Comorbid Conditions:
1)  Angina pectoris: 
 

2)  Atrial tachycardia and fibrillation: 

3)   Dyslipidemia: 

4)   Essential tremor:

1) ß-blockers, CCBs

2) ß-blockers, Nondihydropyridine CCBs

3) α-blockers

4) Nonselective ß-blockers 

Favorable (Good) Effects on Comorbid Conditions:

1)   Heart failure:

2)  Hyperthyroidism:

3)  Migraine: 

4)  Prostatism (BPH):

1)  Some ß-blockers (carvedilol),ACEIs

2)  ß-blockers

3)   Nonselective ß-blockers, Nondihydropyridine CCBs

4) α-blockers

Contraindicative Effect on Comorbid Conditions:

1)  Bronchospastic disease:

2)  Depression: 

3)   Diabetes (type 1 and 2): 

4)  Dyslipidemia: 

1)   ß-blockers

2)  ß-blockers, central alpha-antagonists, reserpine

3) ß-blockers, high-dose diuretics

4) Non-ISA ß-blockers, high-dose diuretics

Contraindicative Effect on Comorbid Conditions:

 1) Gout: 
 

2)  Second or third degree heart block: 

3)  Peripheral vascular disease: 
4)  Pregnancy: 
 

1)  Diuretics

2)   ß-blockers, Nondihydropyridine CCBs

3)  ß-blockers

4)  ACEIs, ARBs, DRIs
  Use Beta blockers instead

1)  Generally considered the drug of choice for most hypertensive emergencies since it is a arteriolar and venous dilator.  

2)  May cause _____ if improperly stored prior to injection

 3)  Another used is _____, a peripheral dopamine-α (DA1) agonist given I.V. infusion with an onset of 4-5 minutes

1)   Nitroprusside (Nipride)

2)  Cyanide toxicity

3)  Fenoldopam (Corlopam®)

1)  Name it...a nitrate given IV, it is the preferred drug for hypertensive emergencies in patients with cardiac ischemia or angina, or after coronary artery bypass surgery.

 2)  Name it.... —an α-blocker used primarily in patients with catecholamine-related hypertensive emergencies, including cocaine or amphetamine intoxication, and pheochromocytoma.

1)  Nitroglycerin

2)  Phentolamine (Regitine®)

1)  Statins inhibit ______ to keep Acetyl CoA from eventually becoming _______.

2)  The term "Metabolic Syndrome"  is used to describe pts who have 3/4 of what 4 common health problems?

1)  HMG-CoA Reductase, Cholesterol

2)  •    Obesity:

•    Dyslipidemia:
 Hypertension:  Blood pressure >135/85 mm Hg
Diabetes:  Fasting blood glucose > 110 mg/dL
 

1)  Given that cholesterol is biosynthesized in the early morning hours, the FDA has recommended ______administration for statins with shorter half-lives:

2)  T/F....Statins are Pregnancy Category D...They may be used in some situations

3)  What are the 2 major side effects of Statins?

4)  What blood level might we monitor for those on Statins?

1)  evening (morning for those with long half-lives.

2)  False...they are Category X...absolutely contraindicative.

3)   Hepatotoxicity (↑ in plasma aminotransferase)
   Myalgia and Muscle Toxicity (Myopathy)

4)  CP or CPK to detect breakdown of muscle
 

1)    _______ is the only statin that is totally hydrophilic—not lipophilic

 2)   In patients of Asian descent, there tends to be up to a two-fold increase in serum concentrations of _____, thus it should not be used or used in a lower dose in Asians (start at 5 mg and titrate slowly).

1)   Pravastatin (Pravachol®)

2)   rosuvastatin (Crestor®)

1)  Multiple trials with the major statins have shown a ___% (roughly) decrease in the liklihood of CHD if preventative tx with a statin is undertaken

 2)  (JUPITER study): Rosuvastatin(Crestor) studied which group? 
3)  the found those who took Crestor® had a ___ reduction in the combined risk of stroke, heart attack or cardiovascular death compared with those who took placebo and a __% reduced mortality

1)  30%  (Lovastatin, Prevastatin, Simvastatin)

2)  low to normal LDL, but elevated C-reactive-protein (CRP) levels

3)   47%, 20%

1)  Another metaanalysis found that in those without heart disease statins were found to reduce heart attacks by___  and strokes by __.

2)  Patients given a statin drug within __ hours of a heart attack increase their chances of survival by more than 50%.

1)  29% ...14% "these should be in teh water"

2)  24 hours (This effect is thought to be due to stabilization of arterial plaque. )

1)  T/F...statins are therapeutic for Diabetics

2)  T/F.., switching to a more potent statin is no safer than increasing to the maximum dose of simvastatin.

3)  What are the 2 most potent statins?

4)  T/F...a generic statin will work for most people who are hyperlipidemic and have a target LDL of 130 or lower. 

1)  True ...   The American College of Physicians (ACP) stated that all type 2 diabetes mellitus and coronary artery disease patients, and all patients with diabetes and any other risk for cardiovascular disease, should take a statin.

2)  May be safer...

3)  Atorvastatin (Lipitor®) 10-80 mg
Rosuvastatin (Crestor®) 10-40 mg

4)  True

THe ENHANCE study found

1)  T/F...a significant difference in the carotid artery thickness between teh statin group and Vitoryrin

2)  T/F.... a significant difference in LDL cholesterol lowering abilities with Vytorin lowering levels by  58% compared with 41% in the group that only received simvastatin.
 

1)  False...there was no difference in carotid artery thickness levels.

2)  True...Vitoryin was shown to be more effective

SEAS study:

1)  T/F...patients with aortic stenosis found some reduction after >4 years follow-up in the primary endpoint of “major cardiovascular events” with Vytorin® compared to placebo

2)  T/F....the cancer rates for those receiving Vytorin were slightly higher than the placebo group

1)  False, it showed no difference in this group

2)   True

1)  Nicotinic acid or niacin (Nicolar®, Niacor®, Niaspan®) is a naturally occurring B-vitamin (Vitamin B-3) that, at doses 100 to 300 times greater than the recommended daily allowance (RDA) as a vitamin, increases ___ and lowers ____ and triglycerides.

2)   What are  2 major side effects we discussed?

3)  Others include?

1)  HDL, LDL

2)   Flushing (avoidance of alcohol/hot bev can alleviate)

 Pruritus

3)  •    Nausea and GI distress
•    Glucose intolerance
•    Hyperuricemia
•    Hepatic toxicity (seen primarily with sustained-release preparations)

•    Increases plasma homocysteine levels.
•    Liver damage
 

1) T/F... Fibrates are similiar to Niacin in their end effects

2)  Name the only Fibrate approved by the FDA

3)  Name some other LDL lowering therapies

1)  False (they both raise HDL..but Fibrates lower TRIGLYCERIDES)

2)   TriLipix® (fenofibric acid)

3)  Omega-3

phytosterols 2000 mg/day can lower by 15%

Garlic

Red Yeast Rice

1)  How do nitrate vasodilators work?

2)  Primary Side effects are?

1)  NO relaxes vascular smooth muscle.  Nitrate-induced venodilation causes a decrease in venous return to the heart, thereby reducing left ventricular wall stress, which leads to a decrease in myocardial oxygen demand.

2)  •    Flushing
•    Headache
•    Hypotension—monitor blood pressure...don't take other vasodilators...like Cialis...Viagra..or WAIT AT LEAST 24 hrs...48 hrs with Cialis.

1)  How many doses of Nitrate should one take before calling 911?

2)    In November 2008, FDA approved_____as a first-line treatment for chronic angina and expanded the drug's label to include treatment for abnormal heart rhythms, including arrhythmias in the lower chambers of the heart, new onset atrial fibrillation and dangerously slow heartbeats.
 

1)  Just 1..call if no relief in 5 minutes.

2)   Ranexa®(works by prolonging QT interval)

Summary of Hyperlipidemia Tx Chart:

1)  Which group is most effective at lowering LDL?

2)  Which is best at raising HDL?

3)  Which group(s) are best at lowering Triglycerides?

1)  Statins

2)  Niacin

3) Niacin and Fibrates