Little TV Addict

BNF CSM and Warnings

• Adenosine (supraventricular arrythmias)- heart transplant individuals require reduction dose of adenosine
• Beta-blocker and asthma – bronchospasm
• Labetalol – Liver damage irrespective of short or long term use
• Sotalol – limited for ventriclr arryth/prophylaxis of supravtclr arryth, not for angina, hypertension, thyrotoxicosis anymore
• Lisinopril – should not start after MI if BP < 100 mmHg
• GTN - must be kept in glass, not > 100 tabs, no cotton wool wadding, foil lined cap, discard after 8 weeks
• Diltiazem – standard formulation – no need brandspecific -tds, longer acting – must be brand specific i.e. XL, LA, SR, CR, retard (XL and LA are Once daily) , applies to Nifedipine as well
• Verapamil and BB used together can be hazardous
• Heparin – thrombocytopenia, does not develop until after 5-10days, monitoring of platelet counts recommended if given more than 4 days
• Heparin - inhibition of aldosterone secretion causes hyperkalaemia
• Statins – rhabdomyolysis rare but increase with renal impairment, hypothyroidism, or concomitant fibrate and statin use
• Bile acid sequestrant interferes with absorption of fat soluble vit A,D,E,K, require supplements
• Bezafibrate used in renal impairment –> myotoxicity
• Nicotinic acid – prostaglandin mediated symptom – flushing, reduce this by using initial low dose with meal, if takes aspirin, must be taken 30 mins before nicotinic acid

Extra bits

Diuretics

• gravitational oedema – not long term use
• thiazide – hypo K, hypo Na, hypo Mg, hyper Ca, hyperglycaemia, hyperuricaemia, gout
• loop        – hypo K, hypo Na, hypo Mg, hypo Ca, hyperglycaemia, hyperuricaemia, gout, deafness.
• hypo K –> precipitate encephalopathy in hepatic failure
• thiazide – act in 1-2 hours, duration of action 12-24 hours, loop act in 1 hour, complete in 6 hours
• metolazone – used with loop, ok in renal failure
• indapamide – less metabolic disturbance, ok in diabetes mellitus
• aldosterone antagonist – useful in ascites – liver cirrhosis
• eplerenone – suitable for use after MI

Beta Blocker

• BB not contraindicated in diabetes, but deteriorate glucose intolerance, may mask symptoms of hypo
• intrinsic sympathomimetic activity(less bradycardia and cold extremities, - oxprenolol, pindolol, acebutolol, celiprolol
• water soluble (less sleep disturbnc) – atenolol celiprolol, sotalol, nadolol
• cardioselective – atenolol, bisoprolol, metoprolol, nebivolol, acebutolol
• Labetolol – suitable for pregnancy, following MI, hypertensive crisis
• Avoid use of BB(mask symptoms of hypo) and thiazide(hyperglyc) in diabetics

ACE inhibitor

• Young Caucasians and below 55 - ACE i 1st line, over 55, afro carribean – CCB or Thiazide 1st line
• Pregnancy – contraindicated, suitable – methyldopa, hydralazine, labetalol, nifedipine
• Ace i can be used in renal impairment, but cautiously, avoid in renovascular disease
• Interactions – +NSAIDS – renal damage, +Diuretics – 1st dose postural hypo, +K-sparing diuretic – hyperK

Heart Failure

1. ACE i
2. Beta- Blocker
3. Diuretic (for fluid retention)- loop for poor renal function, thiazide for good renal function
4. Digoxin – where AF is present
5. Spironolactone can be added

Nitrates

• attack > twice a week require regular meds
• GTN subl – 20-30 min effect, 300mcg
• ISB MN – prophylaxis of angina
• ISB DN – sublingual
• GTN & ISB DN – IV injection

Calcium-channel Blocker

• Rate-limiting CCB – Verapamil and diltiazem – negative inotropic, constipation common
• CCB doesnt reduce risk of MI in unstable angina
• Nifedipine, nicardipine, amlodipine, felodipine – angina and hypertension
• Isradipin, lacidipine, lercanidipine – hypertension only
• Short acting nifedipine – not for angina or long term hypertension

Anticoagulant

• Heparin carry on for 5 days until INR stable for 2 days
• Start warfarin at the same time, it take 48-72 hours to work
• pregnancy – LMWH ok, does not cross placenta
• Heparin – side effect- osteoporosis, blood disorders, hyperK
• Warfarin – contraindicated in pregnancy – teratogenic, especially 1st and 3rd trimester
• Warfarin – avoid cranberry juice, avoid in hepatic impairment

MI

1. ACE i
2. Beta- Blocker
3. Aspirin (use with clopidogrel for 4 weeks)
4. Statin

Stroke – aspirin + dipyridamole for 2 years? to reduce risk of recurrent stroke.