cardiovascular systme medications handouts

8/8/2019 Cardiovascular Systme Medications Handouts

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CARDIOVASCULAR SYSTME MEDICATIONS

INTRODUCTION- The carsoivascular system is responsible for delivering oxygen and nutrients

to all of the cells in the body and for removing waste products for excretion

- It consistes of the a pump, the heart and a series of interconnected tubes thatconsinually move the blood throughout the body

I. ANTIHYPERTENSIVE AGENTS

BLOOD PRESSURE CONTROL- Blood flows from areas with higher pressure to areas with lower

pressure- The area of highest pressure in the system is always the left ventricle

during the systole. The pressure from this area propels the blood out ofthe heart to the aorta and into the systmeic circulation

- The lowest pressure is in the right atrium, which collects deoxygenated

blood rfom the body- If the pressure bocomes too high, the perosn is said to become

hypertensive- If the pressure cannot be delivered effectively, the person is said to be

hypotensive- The pressure in the cardiovascular system is determined by 3 elements:

Heart rate

Stroke volume: amount of blood that is pump out of the ventriclewith each heartbeat

Total peripheral resistance: the resistance of the musculararteries to the blood being pumped through

- Arterioles determine peripheral resistance ; they are very

responsive to stimulation of the SNS and constrict whenstimulated increasing total prepheral resistance and bloodpressure

- Baroreceptors:

As the blood leaves the ventricle through the aorta, itinfluences speciallized cells in the aorta called baroreceptors

Similar cells are located in the carotid arteries, whichdeliver blood to the brain

If there is sufficient pressure in these vessles, thebaroreceptors are stimulated, sendnig information to thebrain

If the pressure falls, the stimulation if the baroreceptorsfall of and that information is sent to the brain The sensory input from the baroreceptors is received inthe medulla, in th earea called the cardiovascular center orvasomotor center

If the pressure is too high, the medulla stimulatesvasodilation and decrease cardiac rate and output, causingblood pressure systme to drop If the pressure is low, the medulla directly stimulates anincrease in cardiac rate and output and vasoconstriction; thisincreases peripheral resistance and raises the blood pressure

- Renin Angiotensin System:

Compensatory mechanism which is activated when the bloodpressure in the kidney falls = the system is called renin-angiotensin-aldosterone system

Release of renin is stimulated by:________________________________________________________________________________________________________________________________________

gats2010 Nursing Pharmacology: Cardiovascular System Medications| 1


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Renin is released into the blood stream and arrives in the liverto convert angiotensinogen to angiotensin I. Angiotensin Itravels the bloodstream and arrives in the lungs and it will beconverted Angiotensin II by Angiotensin Converting Enzyme(ACE). Angiotensin II reacts with angiotensin II receptor sitesin the blood vessels and causes vasoconstriction. This willraise total preipheral resistance leading to an increase inblood pressure. Angiotensin II also stimulates the adrenalcortex to release aldosterone. Aldosterone acts on thenephrons to cause sodium and water retention. This effect willincrease the blood volume, increasing the cardiac output andthen lead to an increase in blood pressure. The sodium richblood also stimulates the osmotic receptors in thehypothalamus to cuase the release of ADH which in turncauses water retnetion contributing to the further rise bloodvolume.

- Hypertension:

Is also known as high blood pressure

It is defined as persistent systolic pressure of >/= 140mmHg, diastolic pressure of >/= 90 mmHg or current useof antihypertensive medication

Epidemic rate world wide is upto 1 billion people

Causes: idiopathic (type 1), increased SNS activity,overproduction of sodium retaining hormones, increasedsodium intake, greater than ideal body weight, diabetesmellitus, excessive alcohol consumption, renal disorders,liver disorder, endocrine disorders, brain tumors,medications and cardiac disorders

- Hypotension:

Is low blood pressure It can progress to shock Can occur in the following situations:

a. ________________________________________________________b. ________________________________________________________c. When there is extreme stress and the bodys

borepinephrine is depleted leaving the body unabale torespond to stimuli to raise the blood pressure

- The Seventh Joint National Committee on Prevention,Detection, Evaluation and Treatment of Hypertension, from theNational Institute os Health has established a stepped careapproach to treating hypertension:

a. Step 1: Lifestyle ModificationsWeight reduction, reduction of sodium intake,moderation of alcohol intake, smokingceassation, increase physical activity

b. Step 2: Inadequate ResponseContinue lifestyle modificationsInitial drug selection:

1. Diuretic or beta blocker2. ACE inhibitor, calcium channelblocker, alpha blocker, alpha and betaadrenergic blocker

c. Step 3: Inadequate Response

Increase the dose orSubtitute another drug orAdd another drug from another classification

d. Step 4: Inadequate ResponseAdd a second or third agent or diuretic if notalready prescribed



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A. Angiotensin Converting Enzyme Inhibitor (ACEI)

Sample Medictions:Indicated for:

a. Hypertension onlybenazepril (Lotensin), moexipril (Univasc), perindopril (Aceon)

b. Hypertension and CHFramipril (Altace), fosinopril(Monopril), quinapril (Accupril)

c. Hypertension, CHF and Myocardial Infarctioncaptopril (Capoten) also used for Diabetic nephropathy,

enalapril (Vasotec), trandolapril (Mavik), lisinopril (Prinivil),Action: ACE inhibitors prevent angiotensin-converting enzyme from convertingangiotensin I toAngiotensin II, a powerful vasoconstrictor and stimulator of aldosterone release.This action leads toA decrease in blood pressure and in aldosterone secretion with a resultant slightincrease in serumPotassium and a loss in serum sodium and fluid.Contraindication and caution:

Allergy

Impaired renal function

Pregnancy and lactationCaution with:

CHF because a change in hemodynamics could be detrimental in somecases

Salt volume depletionAdverse effects:Common: those associated with vasodilations and alterations in blood flow suchas reflex tachycardia, chest pain, angina, CHF, cardiac arrhythmias

GI: irritation, ulcers, constipation, liver injury, renal insufficiency, rash alopecia,dermatitis, photosensitivityhypotension, dizziness, lightheadedness, cough, difficulty breathing, swelling ofthe feet, hands or face, palpitationsNursing Responsibilities:

______________________________________________________________________________

_________________________________________________________________________ (food decreases absorption of ACE inhibitors)

Alert the surgeon and mark the patients chart if he is about to undergosurgery to alert medical staff that the blockade of compensatoryangiotensin II could result in hypotension after surgery and that it couldbe reversed through voume expansion

Give parenteral forms only if an oral form is not feasible; transfer to anoral form as soon as possible to avert increased adverse reactions

Consult with prescriber to reduce dose if patient has renal damage, toaccount for their lower than normal production of renin and angiotensin II

Provide comfort measures to help patient tolerate drug effects. Theseinclude small frequent feeding, access to bathroom facilities, bowelprogram is needed, environmental controls, safety precautions

There is an increased risk of hypersensitivity reaction if these drugs aretaken with allopurinol.

Monitor the blood pressure before and after giving the drug.

Be alert for situations that might lead to a drop in blood pressure likeexcessive sweating, vomiting, diarrhea and dehydration.

Educate patients that they may experience dry cough that does notsubside until the drug therapy is discontinued.

B. _________________________________ (ARB)



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Sample Medications and their Indications:a. Hypertension

valsartan (Diovan) candesartan (Atacand), telmisartan (Micardis),eprosartan (Teveten)

b. Hypertension and diabetic nephropathy

Losartan (Cozaar), irbesartan (Avapro),Action:__________________________________________________________________________________Contraindications and cautions:

Allergy, pregnancy and lactation Caution: hepatic and reanl dysfunction and patients with hypovolemia

Adverse effects: headache, dizziness, syncope, and weakness which could beassociated with a drop in the blood pressure; abdominal pain, nausea, drymouth, tooth pain, symptoms of upper respiratory tract infection, cough, rashdry skin alopecia and preclinical trials have been associated with cancer

developmentNursing Responsibilities:

Encourage the patient to implement lifestyle changes including weightloss, smoking cessation, decreased alcohol and salt in the diet

Alert the surgeon and mark the patients chart if he is about to undergosurgery to alert medical staff that the blockade of compensatoryangiotensin II could result in hypotension after surgery and that it couldbe reversed through voume expansion

Provide comfort measures to help patient tolerate drug effects. Theseinclude small frequent feeding, access to bathroom facilities, bowelprogram is needed, environmental controls, safety precautions,appropriate skin care

Monitor the blood pressure before and after giving the drug. Administer without regards to meals.


Ensure that female patient is not pregnant before beginning of therapyand suggest use of barrire contraceptive while taking this drug

Find alternative method of feeding the baby if nursing

Provide thorough patient teaching, including the name of the drug,dosage prescribed, measures to avoid adverse reactoins, warning signsof problems and the need for periodic monitoring and evaluation

C. _________________________________ (CCB)

Amlodipine (Norvasc), diltiazem (Cardizem), felodipine (Plendil), nicardipine(Cardene), nifedipine (Procadia, Calcibloc), verapamil (Isupten)Action: Inhibit the movement of calcium ions across the membranes ofmyocardial and arterialMuscle cells, altering the action potential and blocking muscle cell contraction.This effect will depressMyocardial contractility, slow cardiac impulse formation and relax and dilatearteries.Indication:Contraindications and caution:

Presence of allergy, heart block, sick sinus syndrome, hepatic and renaldisorders and pregnancy and lactationAdverse effects:Relate to their effects on cardiac output and on smoth muscledizziness, lightheadedness, headache and fatigue, hypotension, bradycardia,peripheral edema, and heart block, skin flushing and rash

D. ____________________________



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Nitroprusside (Nitropress), diazoxide (Hyperstat), , hydralazine (Apresoline),minoxidil (Loniten),Action: Act directly on vascular smooth muscles to cause muscle relaxation,leading to vasodilation and aDrop in blood pressure.

Indication: severe hypertensionMinoxidil: severe hypertension that has not responded to other

therapyNitroprusside (Nitropress) __________________________

Contraindications and cautions:

Pregnancy, allergy and lactation

Caution: peripheral vascular disease, CAD CHF, tachycardiaAdverse effects:Changes in blood pressure: dizziness, anxiety, headache, reflex tachycardia,abnormal hair growth with minoxidil.GI: upset, nasusea and vomiting

Cyanide toxicity: dyspnea, headache, vomiting, dizziness, ataxia, loos ofconsciousness, dilated pupils, pink color, distant heart sounds, shallowbreathing, hypothyroidism associated with nitropussideNursing Responsibilities:

Be alert for signs of cyanide toxicity with intake of nitroprusside such asdyspnea, headache, vomiting, dizziness, dilated pupils, pink color, distantheart sounds (metabolized to cyanide

o And also suppresses iodine uptake and can cause hypothyroidism)

Monitor blood pressure closely during administration to evaluate foreffectiveness and to

o Ensure quick response if blood pressure falls rapidly or too low.

Minoxidil increases the heart rate, notify the physician if the HR is 20

beats above the normal. Nitroprusside and diazoxide are used to treat patients a hypertensive

emergency.

Nitroprusside infusion bottles are wrapped in aluminium foil or otheropaque material to protect the drug from light. If protected from light, itremains stable for up to 24 hours.

Encourage the patient to implement lifestyle changes including weightloss, smoking cessation, decreased alcohol and salt in the diet

Provide comfort measures to help patient tolerate drug effects. Theseinclude small frequent feeding, access to bathroom facilities, bowelprogram is needed, environmental controls, safety precautions,

appropriate skin care Monitor the blood pressure before and after giving the drug.


Monitor electrolyte levels


E. DIURETICS- Will be discussed in detail in drugs that affects that renal system- Increase the excretion of sodium and water

- Often the first agents given for mild hypertensionF. BETA BLOCKERS (-olols)

- Block vasoconstriction, increases the heart rate and cardiac muscle contractionwhich increases the blood flow to the kidney to decrease the release of renin.

- Atenolol, metoprolol, nadolol, propanololG. ALPHA ADRENERGIC BLOCKERS (-zosins)

- Decrease sympathetic tone in the vasculature and cause vasodilation leading to a



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decrease in the blood pressure- Prazosin, terazosin,

NURSING RESPONSIBILITIES FOR ANTIHYPERTENSIVE DRUGS:1. Before therapy with antihypertensive drugs, obtain blood pressure and pulse rate

on both arms with the patient standing, sitting and lying.2. The blood pressure and pulse rate must be obtained immediately before each drug

administration and compared with previous readings. If blood pressure issignificantly low from baseline values, the nurse should not give the drug butshould notify the physician.

3. Obtain daily weights because of sodium and water retention. Examine theextremities for edema. Report a weight gain of 2 lbs or more per day.

4. If postural hypotension occurs, the nurse advises the patient to rise slowly from asitting or lying position.

5. Advise pt. Not to discontinue the drug. These drugs control but do not curehypertension. Skipping doses of the drug or discontinuation may cause severe,rebound hypertension.

6. The nurse educates the patient about lifestyle modifications to managehypertension.

II. ANTIHYPOTENSIVE AGENTS- See entry on sympathomimetic (dobutamine, dopamine,

ephedrine, epinephrine, isoproterenol, midodrine)

III. CARDIOTONIC AGENTS- Affect the intracellular calcium levels in the heart muscles

leading to increased contractility- Increase in contraction leads to incareased cardiac output which

causes increased renal blood flowand increased urine production- Increased renal blood flow also decreases renin release leading

to decreased blood volume- This is generally indicated to patients with CHF, a disorder which

the heart fails to pump blood around the body effectively

A. _____________________________

Originally derived from the digitalis plant

Digoxin (Lanoxin), digitoxin (Crystodigin)Action: increase intracellular calcium and allow more calcium to entermyocardial cells during depolarization, causing the following effects:

1. Increased force of myocardial contraction (a positive inotrope effect)2. Increased cardiac output and renal perfusion (which has a diuretic effect,

increasing urine output and decreasing blood volume while decreasingthe activation of the RAA mechanism)3. Slowed heart rate by slowing the rate of cellular repolarization (a

negative chronotropic effect)4. Decreased conduction velocity through the AV node

The over-all effect is a decrease in myocardial workload and relief of CHF.Indications: treatment of CHF, atrial flutter, atrial fibrillation and paroxysmalatrial tachycardiaAdverse effects: headache, weakness, drowsiness and vision changes (a yellowhalo around objects is often reported with digoxin toxicity), bradycardia,anorexia. GI upset and anorexia also commonly occur.Contraindications and caution:

Allergy, ventricular tachycardia, fibrillation, idiopathic hypertrophicsubaortic stenosis, electrolyte abnormalities

Caution in pregnancy and lactation



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Nursing Responsibilities:

Consult with the prescriber about the need for a loading dose whenbeginning therapy.

Check the dosage and preparation carefully because it has a smallmargin of safety

Check pediatric dosage with extreme care

Follow dilution instructions carefully for intravenous route

Monitor apical pulse for 1 full minute before administering the drug. Holdthe dose if pulse is less than 60 in adults or less than 90 in infants; retakepulse in 1 hour.

Administer IV doses very slowly over at least 5 minutes. Avoid IMbecause it could be quite painful

Avoid administering the oral drug with food or antacids to avoid delays inabsorption.

Monitor the patient for therapeutic digoxin level 0.5-2 ng/ml.

Severe toxicity with digoxin is treated with digoxin immune fab(Digibind).

Avoid hypokalemia. Hypokalemia makes the heart muscle more sensitiveto digitalis, increasing the possibility of developing digitalis toxicity.

Arrange to weigh ddaily at the same time each day wearing the sameclothes

Maintain emergency equipment on standby: potassium salts, lidocaine,phenytoin, atropine and cardiac monitor


Provide thorough patient teaching, including the name of the drug,dosage prescribed, measures to avoid adverse reactoins, warning signs

of problems and the need for periodic monitoring and evaluation Offer support and encouragement

B. Phosphodiesterase Inhibitors

Sample Medications:Action: block the enzyme phosphodiesterase; this blocking effect lead to anincrease in myocardial cell cAMP, which increases calcium levels in the cell.Increased cellular calcium causes a stronger contraction and prolongs theeffects of sympathetic stimulation which leads to vasodilation, increasedoxygen consumption and arrhythmiasIndications: short-term treatment of CHFnot responsive to digoxin, diuretics, or

vasodilatorsContraindications and cautions:

Allergy to bisulfites Aortic or pulmonic valvular disease, acute MI, fluid volume deficit,

ventricular arrhthmias

Caution in elderly, pregnant and lactating womenAdverse effects:Ventricular arrhythmias (which can progress to fatal ventricularfibrillation)hypotension and chest pain, nausea, , vomiting, anorexia andabdominal pain, thrombocytopenia, hypersensitivity reactoins includingvasculitis, pericarditis, pleuritis, and ascitisNursing Responsibilities:

Protect the drug from light to prevent drug degradation.

Monitor pulse and blood pressure periodically during administration.

Monitor input and output and record daily weights to evaluate resolutionof CHF.

Monitor platelet counts prior to and regularly during therapy.

Monitor injection sites and provide comfort measures. Infusions are



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painful

Provide life support equipment on standyb in case of severe reaction



Offer support and encouragement

IV. ANTIARRHYTHMIC AGENTS / Antiarrhythmics

Automaticity of the Heart- All cardiac cells poses some sort of automaticity- These cels undergo spontaneous depolarization during diastole or rest

because they decrease the flow of potassium ions out of the cells andprobable leak of sodium into the cell causing action potential

- 5 phases of action potential:1. Phase 0: occurs whne the cell reaches a point of stimulation.The sodium gates open and sodium rushes into the cell. This positiveflow of electrons into the cells results in an electrical potential. Thisis called depolarization

2. Phase 1: is a very short period where in the sodium ions equalizes inand ouside of the cell

3. Phase 2: or plateau stage, occurs as the cell membranes becomeless permeable to sodium and calcium slowly enters and potassiumbegins to leave the cell.

4. Phase 3: is a time of rapid repolarization as sodium gates are closedand potassium leaves the cell

5. Phase 4: occursr when the cell comes to rest, the sodium potassiumpump returns the membrane into its resting membrane potentialand spontaneous depolarization begins

- Arrhythmias or dyrrhthmias are alterations in the cardiac rhythmpossibly due to electrolyte imbalances, decrease oxygen delivery tocells, structural damage, acidosisA. Class I Antiarrhythmics

Class Ia drugs:- ____________, _______________, disopyramide, moricizine

Class Ib drugs:- lidocaine (Xylocaine), mexilitine

Class Ic drugs- flecainide (Tambocor), propafenone (Rythmol)

Action: Stabilize the cell membrane of cardiac muscles by binding to sodiumchannels, depressing phase 0 of the action potential. They have a localanesthetic effect.Indications: ventricular arrhythmiasContraindications and cautions:Allergy, bradycardia, heartblock, CHF, hypotension, shock, electrolyteimbalancesCaution: renal and hepatic dysfunctionAdverse effects: dizziness, drowsiness, twitching, mouth numbness, slurredspeech and tremors leading to seizures, Change in taste, hypotension and

vasodilation, respiratory arrestNursing Responsibilities:

Continually monitor cardiac rhythm when initiating or changing dose.

Maintain life support on standby.give parenteral forms only if oraladministration is not possible

Titrate the dose to the smallest amount needed to achieve control of thearrhythmia.



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Consult the prescriber to reduce the dosage in patients with renal orhepatic dysfunction



Arrange periodic monitoring of cardiac rhythm when patient is receivinglong term therapy

B. Class II Antiarrhythmics

Acetabutolol (Sectral) also used as antihypertensive,

esmolol (Breviloc) used short term for SVT and ventriculartachycardia adn tachycardia when unresponsive for other methods,

propanolol (Inderal)use as antihypertensive, anti migraine

Action: Block beta receptor sites in the heart and kidneys, thereby decreasingheart rate, cardiac excitability, and cardiac output and slowing conductionthrough the AV node and decreasing the release of rennin. These effectsstabilize excitable cardiac tissue and decrease blood pressure.Indications:Contraindications:Sinus bradycardia, AV block, cardiogenic shick, CHF, asthma, respiratorydepression, pregnancy and lactationCaution:Diabetes and thyroid dysfunction, renal and hepatic disordersAdverse effects: dizziness, insomnia, hypotension, BRADYCARDIA,bronchospasm and dyspnea, alterations in blood glucose level, AV block,

arrhythmias, nausea, vomiting, anorexia, diarrhea, constipation, decreaedlibido, decreased exercise tolerance

C. Class III Antiarrythmics

Amiodarone (Cordarone), bretylium, dofetilide, ibutilideAction: Block potassium channels and slow the outward movement ofpotassium during phase 3 of the action potentialIndication: life threatening ventricular arrhythmias; atrial fibrillation and atrialflutter (dofetilide)Contraindications:

When used in life threatennig situations, there are no contraindications; but tilides should not be used with AV block if used as part of regular treatmentregimenCaution:Shock, hypotension, respiratory depression, prolonged QT interval, renal andhepatic diseaseAdverse effects: nausea, vomiting, GI distress, weakness and dizziness,hypotension, CHF arryhtmias are commonAmiodarone: _____________________________________________

D. Class IV Antiarrythmics

Sample Medcations:

Action: Block the movement of calcium ions across the cell membrane,depressing depolarization and prolonging repolarization, which slowsautomaticity and conductionIndications: hypertension, angina, supraventricular tachycardiaContraindications:Allergy, sick sinus syndrome, heart block, pregnancy, lactation, CHF,



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hypotension,Caution: idiopathic hypertrophic subaortic stenosis, renal and liver dysfunctionAdverse effects: vasodilation, dizziness, weakness, fatigue, headache,hypotension, edema, GI upset, nausea and vomiting

Note: adenosine and digoxin can also manage arrythmias

Nursing Responsibilties (ANTIARRHYTHMICS):

Take and record the BP, apical and radial pulses and respiratory ratebefore giving the drug.

Notify physician if the pulse rate is above 120 bpm or below 60 bpm.

Continual cardiac monitoring assists the nurse in assessing the patientfor adverse drug reactions.

Lidocaine is an emergency drug for ventricular arrhythmias. Constantcardiac monitoring is needed. Observe closely for signs of respiratorydepression, bradycardia, change in mental status, and hypotension.Airway and suction equipment are kept at bedside. Atropine is given IV

for pronounced bradycardia.*other nursing considerations for class II, II and IV are the same with class I

V. ANTIANGINAL MEDICATIONS- In early cases of angina, avoidance of exertion or stressful

situations maybe sufficient- The drugs are used to help restore the supply demand ration in

oxygen delivery of the myocardium if rest and oxygen is notenough

- The drugs work to improve blood delivery by one or two ways:a. Dilating the blood vesselsb. Decreasing work of the heart

A. Beta BlockersB. Calcium Channel BlockersC. Nitrates

Nitroglycerin (Nitrobid, Nitrostat), isosorbide dinitrate (Isordil) Sublingual, transmucosal, translingual, inhalation)

Action: Act directly on smooth muscles of the heart to cause relaxation and todepress muscle tone. Relax and dilate veins, arteries, and capillaries, allowingincreased blood flow through these vessels and lowering systemic bloodpressure because of a drop in resistance. Increases blood flow in coronaryarteries.Indications: prevention and treatment of angina pectoris

Adverse effects: headache, dizziness and weakness; nausea, vomiting andincontinence; hypotension; flushing, pallor, sweating, reflex tachy cardia,syncope, fluching, pallor, diaphoresisContraindication: allergy, anemia, head trauma, cerebral hemorrhage,pregnancy and lactationCaution: hypotension, hypovolemia



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Nursing Responsibilities:

Give SL preparations under the tongue or in the buccal puch.

Protect the medication from heat and light.

Rotate the sites of topical forms and monitor for skin breakdown.

The dose of sublingual nitroglycerin may be repeated every 5 minutes until

pain is relieved after three doses in a 15 minute period. The dose of topical nitroglycerin is measured in inches, 1 inch of ointmentequals 15 mg of nitroglycerin. Before the durg is applied, BP needs to bechecked. Areas that may be used for application include the chest,abdomen, upper arms and legs.

The nurse must not rub the nitroglycerin ointment into the patients skinbecause this will immediately deliver a large amount of the drug through theskin.

The nurse should wear disposable gloves (drug may be absorbed by thenurse)

Transdermal nitroglycerin is applied to the skin once a day for 10 to 12hours.

When applying the transdermal patch, the nurse inspects the skin to be sureit is dry, free of hair and not subject to excessive rubbing or movement.

VI. LIPID LOWERING AGENTS- Cholesterol

- Is the base unit for formation of steroid hormones and the basicunit for maintenance of cell membranes

- Provided through diet and fat metabolism- The enzyme hydroxymethylglutaryl-coenzyme A recuctase

regulates early, rate limiting step in the synthesis of cholesterol- Hyperlipidemias:

- Increase in lipid level in the blood

- Increases the person to develop CAD- Can result from excessive intake of cholesterol, genetic

alterations in fat metabolism- Diet is often successful in its therapy.

A. ____________________________

Cholestyramine (Questran) also used in patients with pruritusassociated with partial biliary obstruction

colestipol (Colestid)

colesevelam: can be used in combination with HMG COA RI and

adjunct to diet and exercise to patients with hereditaryhypercholesterolemiaAction: Bile acid sequestrants bind with bile acids in the intestine to form acomplex that is excreted in the feces. As a result, the liver must use cholesterolto make more bile acids, so the serum levels of cholesterol and LDL decrease toprovide the cholesterol for the liver.Indications: _____________________________Contraindications and caution:Allergy, complete biliary obstruction, abnormal intestinal function, pregnancyand lactationAdverse effects: headache, anxiety, fatigue, nausea, constipation and fecalimpaction, decreased absorption of vitamin K, vitamin A and D deficiencies,

muscle aches and painsNursing Responsbilities:

Do not administer powder in dry form; the drug must be mixed in fluidsto be effective. Stir and swallow all of the dose. They maybe mixed withfruit juices, soups, liquids and cereals or pulpy friuts. Colestipol maybemixed with carbonated beverages.

If taking tablets, make sure that tablets are not cut, crushed or chewed.



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They should be swallowed whole with plenty of fluid

Give the drug before meals to ensure that the drug is in the GI tract withfood.

Arrange bowel program as appropriate to effectively deal withconstipation

Administer OTHER oral medications 1 hour before or 4 to 6 hours afterthe bile sequestrant.



B. Hydroxymethylglutaryl Coenzyme A Reductase Inhibitor (HMG CoARI)

Atorvastatin (Lipitor), simvastatin (Zocor), lovastatin (Mevacor)Action: Block the formation of cellular cholesterol, leading to a decrease inserum cholesterol and a decrease in serum LDLs, with a slight increase or nochange in the levels of HDLs.Indications:

1. adjunct with diet and exercise for the treatment of elevated cholesteroland LDL levels in patients unresponsive to dietary restrictions alone

2. slow the progression of CAD3. prevent first MI in patients who are at risk for MI development

Contraindications and cautions:Allergy, liver disease, history of alcoholic or liver disease, pregnancy and

lactationCaution: impaired endocrine functionAdverse effects: flatulence, abdominal pain, cramps, nausea and vomiting;headache, dizziness, blurred vision, cataract development, elevated liverenzymesNursing Responsibilities:

Administer the drug at BEDTIME because the highest rates ofcholesterol synthesis occur between midnight and 5am.

Monitor serum cholesterol and LDL levels prior to and periodicallyduring therapy.

Arrange for periodic OPHTHALMIC examinations to monitor for cataractdevelopment.

Monitor liver function tests prior to and periodically during therapy tomonitor for liver damage.

Ensure that the patient has attempted a cholesterol-lowering diet andexercise program for at least 3 to 6 months before beginning therapy.

Encourage patient to make lifestyle changes.

Withhold lovastatatin, atorvastatin, or fluvastatin in any acute orserious conditoins

Suggest barrier contraceptive for women



C. Cholesterol Absorption Inhibitors

Ezetimibe (Zetia): adjunct to diet and exercise to reduce



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cholesterol as monotherapy or combined with statins; adjunct todiet to reduce elevated sitosterol and campesterol levels inhomozygous sitosterolemia

Action: works in the brush border of the small intestine to decrease absorptionof dietary cholesterol leading to a drop in serum cholesterol levelsContraindications and caution:Allergy, liver disease, pregnancy and lactationAdverse effects: abdominal pain and diarrhea and NOT associated withflatulence and bloating that are associate with sequestrants and fibrates; othereffects are: dizziness, fatigue, upper respiratory tract infectionsNursing Responsbilities:

Monitor serum cholesterol, triglyceride and LDL levels and liver functiontests periodically during the therapy

Ensure that the patient has attempted cholesterol lowering diet andexercise programs

Encourage lifestyle changes

Provide comfort measures to help patient tolerate drug effects. These

include small frequent feeding, access to bathroom facilities, bowelprogram is needed, environmental controls, safety precautions


D. Other Drugs Used to Affect Lipid Levels

1. Clofibrate (Atromid S), inhibits synthesis of LDL and cholesterol, lowersserum lipids and has an ANTIPLATELET EFFECT.

2. Fenofibrate (Tricor), inhibits triglyceride synthesis in the liver, resulting inreducation of LDLs; increase uric acid secretion.

3. Gemfibrozil (Lopid), inhibits peripheral breakdown of lipids, reducestriglyceride production and LDL production, and increases HDLconcentrations.


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