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Advanced Pharmacology Midterm
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- USMLE Step 1 Pharm
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- USMLE Step 1 Pharm
Advanced Pharmacology Midterm
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Advanced Pharmacology MidtermChapter 28
Additional patient variables: Angina and Concomitant Diseases and drugs to treat them
- ANS-Angina and Myocardial Infarction
aspirin and beta blockers
*ACE inhibitors are the drug of choice to treat angina in patients with diabetes or left
ventricular dysfunction.
Angina and Heart Failure
ACE inhibitors are first line
patients who cannot tolerate ACE inhibitors are being prescribed ARBs
Hypertension and Angina
lifestyle modifications are the first approach to treatment for patients with emphasis
placed on weight control, reduction of sodium, saturated fat, cholesterol, and alcohol
and increased physical activity. All drug classes used to treat angina are helpful in the
treatment of hypertension.
ACE inhibitors and direct renin inhibitors are useful in blood pressure control based on
their vasodilating effects
Beta blockers are no longer first line therapy in hypertension and CCBs are acceptable
for patients with HTN especially African Americans
Hypercholesterolemia
Patients should strive for LDL levels less than 100mg and less than 70mg in the very
high risk patients (diabetic, smoker, etc) lifestyle modifications are the first line
approach.
Beta blockers can negatively affect triglyceride and LDL levels
Peripheral Vascular Disease
BB's are contraindicated in patients with severe PVD. CCB's are the drug of choice for
patients with angina and PVD
Diabetes Mellitus
Diabetic patients with angina should make every attempt to have a near normal A1C
ACE inhibitors are drug of choice
,CCBs are also useful because of their lower effects on glucose metabolism, and they
also may have some degree of renal protection
BB's may mask the signs of hypoglycemia
Asthma and COPD
BBs may exacerbate disease but should only be avoided if the patient has severe or
uncontrolled disease
Erectile Dysfunction
related to endothelial dysfunction and vascular damage similar to HTN and angina
*treatment of HTN has also been asso
Chapter 28
Beta Blockers and Diabetes Mellitus - ANS-beta blockers decrease insulin secretion
and may mask the signs of hypoglycemia.
The one sign that is not masked is diaphoresis, and patients with diabetes who are
taking these drugs should be taught to test their blood glucose levels in the event of a
diaphoretic episode.
Chapter 36
Treatment for Stage A Heart Failure - ANS-initial focus is on reversing underlying
pathologies.
-lifestyle modification and avoidance of behaviors that may increase risk: smoking, poor
diet, obesity, sedentary lifestyle, alcohol or drugs
Drug therapy: ACE inhibitors recommended for patients with a history of atherosclerotic
vascular disease, diabetes mellitus, HTN. Definitely start ACE inhibitor and possibly add
a BB
BB are also recommended to control HTN and prevent HF
Treatment of Stage B heart failure - ANS-Drug therapy is ACE inhibitor and beta
blocker.
If patient was already on a BB for HTN or angina, provider can leave them on the same
med or switch it to a diff one
Treatment of Stage C heart failure - ANS-This is the first stage to be symptomatic
, *most of HF patients are at this stage
* all of the Class I recommendations for stage A and B are appropriate here ** in
addition moderate sodium restriction along with daily weight monitoring are indicated to
facilitate the most effective use of drugs
-Combination of 3 to 4 types of drugs: ACE inhibitors, BB's, cardiac glycosides (digoxin),
and a diuretic
Stage C patients who remain symptomatic despite optimal treatment therapy -
ANS-patients who remain symptomatic despite therapy with ACE inhibitors and beta
blockers it is recommended to start aldosterone antagonists (spironolactone) per the
NICE guidelines
Dosing of diuretics - ANS-goal with dosing is to increase the urine output and promote
weight loss of 0.5 to 1 kg daily
concurrent administration of NSAIDs can affect absorption of diuretics
**is symptoms seem resistant to to standard doses of diuretic check creatinine
clearance
Digoxin indications - ANS-used in patients with reduced systolic dysfunction (ejection
fraction <40%) while receiving standard therapy with a BB and ACE inhibitor.
The decision to begin patient on digoxin should only be made when there is clear
evidence of systolic dysfunction
Treatment for Stage D Heart failure - ANS-these are patients with refractory end-stage
HF
-marked symptoms even at rest despite maximal medical therapy
-ACE inhibitors and BB's in small doses
these drugs are contraindicated if systolic BP is <80 or who show signs of peripheral
hypoperfusion
-referral to cardiac transplantation and heart failure program
-infusions of vasoactive and positive inotropic agents are not recommended for these
patients
Patients with HF with preserved Ejection Fraction (HF-pEF) - ANS--half of the
population have HF-pEF
limited evidence to show benefit of ACE inhibitors and BB's
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