When NOT to give each drug. 121 entries across the Exam 2 lectures, each citing its slide and tiered by the strength of the slide’s own wording.
| Drug or class | Tier | Do not use / caution | Source |
|---|---|---|---|
| Ocular antibiotics | |||
| Sulfacetamide ointment or solution | Avoid | AVOID in patients with a sulfonamide allergy (allergic reactions). | L4 slide 19 |
| Fluoroquinolones ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin, gatifloxacin | Caution | For a contact lens wearer with conjunctivitis, rule out keratitis first. Emerging resistance is a caution: a patient who does not improve may have a resistant organism. | L4 slide 22 |
| Aminoglycosides gentamicin, tobramycin | Caution | Corneal ulceration and reactive keratoconjunctivitis with several days of use: do not continue them casually. | L4 slide 23 |
| Ocular antivirals | |||
| Antivirals adenoviral conjunctivitis | Caution | There is no antiviral for viral conjunctivitis caused by adenoviruses; it is self-limited and treated with symptomatic relief only. | L4 slide 25 |
| Ocular antifungals | |||
| Topical glucocorticoids fungal infection risk | Caution | Topical steroid use counts as immunosuppression and is a risk factor for fungal eye infection, alongside trauma, chronic ocular surface disease and contact lens wear. | L4 slide 30 |
| Precautions and administration | |||
| Any patient with an eye complaint | Caution | If visual acuity gets worse during treatment, refer immediately to ophthalmology. | L4 slide 33 |
| Ophthalmic ointments and gels | Avoid | Vision blurs for about 20 minutes: do not drive until it clears. | L4 slide 37 |
| Contact lens wearers with conjunctivitis | Avoid | Should discontinue contact lens use; resume only when the eye is not inflamed and there has been no discharge for 24 hours, and discard or disinfect the lens first. | L4 slide 38 |
| Ocular allergy | |||
| Mast cell stabilizers cromolyn, lodoxamide, nedocromil | Caution | NOT useful for acute symptoms; full effect takes 5 to 14 days, so they are the wrong choice for a patient who is symptomatic right now. | L4 slide 47 |
| Topical vasoconstrictors tetrahydrozoline, naphazoline, pheniramine with naphazoline | Caution | Short-term use only (less than 2 weeks): prolonged use leads to rebound hyperemia after stopping. If no improvement in 72 hours, discontinue and see a provider (it could be something more serious). | L4 slide 48 |
| Imidazoline derivatives tetrahydrozoline, naphazoline | Caution | Accidental ingestion: systemically these target alpha 2 receptors, so a swallowed bottle is dangerous, especially in children. | L4 slide 49 |
| Ocular anti-inflammatories | |||
| Ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) bromfenac, diclofenac, flurbiprofen, ketorolac, nepafenac | Caution | Not routinely recommended for conjunctivitis, and they can raise eye pressure (a concern in glaucoma). | L4 slide 51 |
| Ophthalmic glucocorticoids dexamethasone, prednisolone, difluprednate and others | Caution | Generally reserved for refractory symptoms and limited to less than 2 weeks. Cautions: cataract, raised eye pressure (more with a family history) and glaucoma, infection, delayed wound healing and corneal ulcers. | L4 slide 54 |
| Glaucoma | |||
| Prostaglandin analogs latanoprost, travoprost, bimatoprost, tafluprost | Caution | Do not exceed once-daily dosing: more frequent dosing inhibits the pressure-lowering effect. | L4 slide 66 |
| Beta blockers timolol, carteolol, levobunolol, betaxolol | Caution | Worsening heart failure, bradycardia, heart block and increased airway resistance (asthma): avoid in these patients or use only with great caution (the drug labels list these as contraindications for the nonselective agents); a prostaglandin analog is the safer choice. | L4 slide 67 |
| Nonselective beta blockers carteolol, timolol, levobunolol | Caution | Nonselective agents block both beta-1 and beta-2 receptors, so use a beta-1 selective agent in a patient with an asthma history (less risk of bronchoconstriction). | L4 slide 68 |
| Alpha-2 agonists apraclonidine, brimonidine | Contraindicated | CONTRAINDICATED in children under 2 years (central nervous system depression and apnea). The label contraindication is for brimonidine; apraclonidine is likewise not recommended in small children. | L4 slide 69 |
| Cholinergic agonists acetylcholine, carbachol, pilocarpine | Caution | Younger patients are usually intolerant of miotic therapy because of visual blurring; poor compliance from side effects and frequent administration. | L4 slide 72 |
| Diagnostic and procedural agents | |||
| Ocular anesthetics tetracaine, proparacaine | Avoid | Do not write prescriptions for these: the eyes stay numb for 10 to 20 minutes with no blink reflex. | L4 slide 75 |
| Drug or class | Tier | Do not use / caution | Source |
|---|---|---|---|
| Otic antibiotics | |||
| Neomycin in Cortisporin drops | Caution | Chance of hypersensitivity: stop if itching or inflammation worsens. | L5 slide 10 |
| Polymyxin B in Cortisporin drops | Avoid | Not recommended with a ruptured eardrum (tympanic membrane) or tubes in place: the drug can reach the cochlea and cause damage and hearing loss. Choose a different drop in that patient. | L5 slide 10 |
| Antifungals | |||
| Ketoconazole | Caution | Cautions: QTc (corrected QT interval) prolongation, hepatic toxicity (hepatitis, cirrhosis, hepatic failure) and cytochrome P450 3A4 (CYP3A4) inhibition, which raises levels of drugs cleared by that enzyme. | L5 slide 12 |
| Aspirin, nonsteroidal anti-inflammatory drugs and acetaminophen | |||
| Aspirin — salicylism | Named reaction | Salicylism: the toxic syndrome of hyperventilation, alkalosis, metabolic acidosis, shock, coma and renal and respiratory failure at high exposure. | L5 slide 16 |
| Aspirin — bleeding disorders | Contraindicated | Contraindicated in bleeding disorders (irreversible platelet inhibition). | L5 slide 17 |
| Aspirin — pregnancy | Contraindicated | Contraindicated in pregnancy, although very low doses may be of benefit in hypertensive disorders of pregnancy (preeclampsia). | L5 slide 17 |
| Aspirin — children with viral fever | Contraindicated | Contraindicated in children with fever associated with viral disease (chickenpox, influenza): increased incidence of Reye syndrome. | L5 slide 17 |
| Aspirin — Reye syndrome fatty liver encephalopathy | Named reaction | Reye syndrome: children under 15, mortality 50%; vomiting, progressive central nervous system damage, liver injury and hypoglycemia after an upper respiratory infection, influenza or chickenpox. | L5 slide 18 |
| Aspirin — interactions | Caution | Do not combine with anticoagulants (aspirin inhibits platelet function) or with other nonsteroidal anti-inflammatory drugs (NSAIDs). | L5 slide 20 |
| Ibuprofen — allergy, ulcer, kidney disease | Avoid | Allergy to the product is a contraindication; avoid with a past history of stomach ulcers or perforation, or with renal dysfunction (listed as relative or absolute). | L5 slide 22 |
| Ibuprofen — asthma | Caution | May exacerbate asthma. | L5 slide 22 |
| Ibuprofen — young infants | Avoid | Avoid in children younger than 6 months. | L5 slide 22 |
| Ibuprofen — interactions | Caution | Decreases the effect of angiotensin-converting enzyme (ACE) inhibitors; with diuretics watch for renal failure; decreases lithium excretion (levels rise); decreases methotrexate excretion (toxic levels); increases bleeding risk with anticoagulants (serious gastrointestinal bleeds). | L5 slide 22 |
| Acetaminophen — allergy | Contraindicated | Contraindicated in allergy to the product (the only listed contraindication). | L5 slide 25 |
| Acetaminophen — alcohol | Caution | Alcohol increases the risk of liver damage (chronically). | L5 slide 25 |
| H1 antagonists (antihistamines) | |||
| First-generation H1 antagonists | Caution | Additive sedation with other central nervous system depressants or alcohol; excitation instead of sedation at higher doses, especially in children, and in overdose. | L5 slide 32 |
| Azelastine Astelin | Caution | Stop and follow up immediately if a nosebleed develops. Do not use with other nasal sprays. | L5 slide 39 |
| Systemic corticosteroids | |||
| Dexamethasone — interactions | Caution | With a diuretic, hypokalemia; with digoxin, increased risk of arrhythmia because of hypokalemia; macrolides decrease its clearance; it decreases the effect of antidiabetic drugs. | L5 slide 45 |
| Dexamethasone — systemic fungal infection | Contraindicated | Contraindicated in systemic fungal infections. | L5 slide 46 |
| Dexamethasone — abrupt withdrawal | Caution | Do not discontinue abruptly if taken for more than 1 week. | L5 slide 46 |
| Prednisone and prednisolone | Avoid | Contraindicated in allergy to the product; avoid in infections, especially fungal ones (listed as relative or absolute), because the steroid weakens immunity. | L5 slide 48 |
| Prednisone — withdrawal | Caution | Do not discontinue abruptly: rebound symptoms. | L5 slide 48 |
| Prednisone — infection exposure and vaccines | Avoid | Avoid exposure to chickenpox and measles, and avoid live vaccines: the patient is considered immunocompromised. | L5 slide 48 |
| Decongestants | |||
| Oxymetazoline Afrin | Named reaction | Rhinitis medicamentosa: rebound congestion when used for more than 3–5 days. | L5 slide 50 |
| Oxymetazoline — interactions | Caution | Interacts with monoamine oxidase inhibitors (MAOIs) and antidepressants. Do not use for more than 3–5 days. | L5 slide 51 |
| Pseudoephedrine Sudafed | Caution | Decreases the effect of antihypertensives, and causes tachycardia and hypertension. | L5 slide 52 |
| Antitussives | |||
| Benzonatate Tessalon | Contraindicated | Contraindicated in allergy to the product or related products (tetracaine). | L5 slide 57 |
| Dextromethorphan — monoamine oxidase inhibitors | Contraindicated | Contraindicated if taking, or within 2 weeks of taking, a monoamine oxidase inhibitor (MAOI). | L5 slide 58 |
| Dextromethorphan — serotonin syndrome | Named reaction | Serotonin syndrome risk with other pro-serotonergic drugs. | L5 slide 58 |
| Expectorants and mucolytics | |||
| Guaifenesin | Contraindicated | Contraindicated in allergy to the product. | L5 slide 59 |
| N-acetylcysteine inhaled | Caution | Bronchospasm is a listed adverse reaction of the inhaled route: use with care in patients with airway disease. | L5 slide 63 |
| Drug or class | Tier | Do not use / caution | Source |
|---|---|---|---|
| ACE inhibitors | |||
| ACE (angiotensin-converting enzyme) inhibitors -pril: captopril, lisinopril, enalapril, ramipril | Contraindicated | Contraindicated in the second and third trimesters: birth defects and fetal death. (In practice they are stopped as soon as pregnancy is found.) | L6 slide 22 |
| ACE (angiotensin-converting enzyme) inhibitors -pril: captopril, lisinopril, enalapril, ramipril | Caution | Use cautiously in kidney disease: low doses, moved upward slowly, because ACE inhibitors can dramatically decrease the glomerular filtration rate where kidney blood flow depends on angiotensin II. | L6 slide 21 |
| ACE (angiotensin-converting enzyme) inhibitors -pril: captopril, lisinopril, enalapril, ramipril | Caution | Hyperkalemia risk: kidney disease, potassium-sparing diuretics, potassium supplements and salt substitutes. | L6 slide 20 |
| ACE (angiotensin-converting enzyme) inhibitors -pril: captopril, lisinopril, enalapril, ramipril | Caution | First-dose hypotension is most likely in patients who are sodium depleted, have heart failure, or take multiple antihypertensive drugs. | L6 slide 20 |
| ACE (angiotensin-converting enzyme) inhibitors -pril: captopril, lisinopril, enalapril, ramipril | Caution | NSAIDs (nonsteroidal anti-inflammatory drugs) decrease the effect of ACE inhibitors (they block prostaglandin-dependent, bradykinin-mediated relaxation). | L6 slide 22 |
| ACE (angiotensin-converting enzyme) inhibitors -pril: captopril, lisinopril, enalapril, ramipril | Named reaction | Angioedema (rare, 0.1–0.5%) usually develops in the first week and is reversible if the drug is removed. Stop the drug. | L6 slide 22 |
| Angiotensin receptor blockers | |||
| ARBs (angiotensin receptor blockers) -sartan: losartan, valsartan, candesartan | Avoid | Not given in the second and third trimesters (fetal morbidity and mortality). An angiotensin receptor blocker is therefore not a safe substitute for an ACE (angiotensin-converting enzyme) inhibitor in pregnancy. | L6 slide 29 |
| ARBs (angiotensin receptor blockers) -sartan: losartan, valsartan, candesartan | Caution | Hyperkalemia with kidney disease or potassium-sparing diuretics; first-dose hypotension; impaired kidney function. | L6 slide 29 |
| ARBs (angiotensin receptor blockers) -sartan: losartan, valsartan, candesartan | Caution | In heart failure, start with low doses and titrate upward. | L6 slide 30 |
| Calcium channel blockers: non-dihydropyridines | |||
| Non-dihydropyridine calcium channel blockers diltiazem, verapamil | Contraindicated | Contraindicated in advanced heart block and hypotension. | L6 slide 46 |
| Non-dihydropyridine calcium channel blockers diltiazem, verapamil | Caution | Relative contraindications: heart failure, liver disease and gastroesophageal reflux disease. Heart failure is the one to remember, because these drugs suppress contractility. | L6 slide 46 |
| Non-dihydropyridine calcium channel blockers diltiazem, verapamil | Caution | Pharmacodynamic interactions: amiodarone (slower sinus rate, worse atrioventricular block), digoxin and beta blockers. Cytochrome P450 3A4 (CYP3A4) and P-glycoprotein inhibition raises levels of statins, carbamazepine, propranolol, tacrolimus, cyclosporine and digoxin. | L6 slide 47 |
| Calcium channel blockers: dihydropyridines | |||
| Dihydropyridine calcium channel blockers -dipine: amlodipine, nifedipine, nicardipine | Contraindicated | Contraindicated in severe aortic stenosis, and in unstable angina or recent myocardial infarction (immediate-release formulation). | L6 slide 52 |
| Dihydropyridine calcium channel blockers -dipine: amlodipine, nifedipine, nicardipine | Avoid | Avoid short-acting formulations. | L6 slide 49 |
| Dihydropyridine calcium channel blockers -dipine: amlodipine, nifedipine, nicardipine | Caution | Pharmacodynamic interactions with amiodarone, digoxin and beta blockers; cytochrome P450 3A4 (CYP3A4) inhibitors increase the half-life. | L6 slide 54 |
| Beta blockers | |||
| Beta blockers -olol | Contraindicated | Contraindicated in bronchospasm: about one third of patients with chronic obstructive pulmonary disease have bronchospasm, and asthma can flare. Bronchoconstriction is less likely with beta-1 selective agents. | L6 slide 71 |
| Beta blockers -olol | Avoid | Avoid agents with intrinsic sympathomimetic activity after an acute myocardial infarction. | L6 slide 68 |
| Beta blockers -olol | Caution | Heart failure: beta blockers were originally contraindicated. They are now used in a failing ventricle (carvedilol, metoprolol succinate, bisoprolol) but initially worsen symptoms: start with a very low dose and increase slowly. | L6 slide 70 |
| Beta blockers -olol | Caution | Bradycardia (heart rate below 60 beats per minute) and heart block: first-, second- and third-degree atrioventricular block are listed adverse effects. | L6 slide 71 |
| Beta blockers -olol | Caution | Diabetes: prolong and mask hypoglycemia (type 1); raise glucose and make control hard (type 2). | L6 slide 72 |
| Beta blockers -olol | Named reaction | Sudden withdrawal syndrome: acute angina, myocardial infarction and marked rise in blood pressure; withdraw slowly. Also worsens peripheral artery disease (intermittent claudication) and Raynaud phenomenon. | L6 slide 73 |
| Beta blockers -olol | Caution | Verapamil or diltiazem together with a beta blocker (synergistic falls in pressure, rate and contractility): use lower doses of each. Abrupt clonidine withdrawal in a patient also on a beta blocker causes a marked rise in blood pressure. | L6 slide 75 |
| Alpha-1 blockers | |||
| Alpha-1 blockers -zosin: prazosin, terazosin, doxazosin | Caution | Use caution in cardiac and renal failure. NSAIDs (nonsteroidal anti-inflammatory drugs) attenuate the response; beta blockers may enhance postural hypotension. | L6 slide 81 |
| Prazosin Minipress | Caution | Orthostatic hypotension is the main hazard, particularly at the start and with other blood pressure drugs. | L6 slide 79 |
| Central sympatholytics | |||
| Central sympatholytics clonidine, guanfacine | Named reaction | Abrupt withdrawal hypertension: do not stop suddenly. Narrow therapeutic range. | L6 slide 91 |
| Clonidine Catapres | Named reaction | Withdrawal reactions (may be severe); orthostatic hypotension and bradycardia. | L6 slide 94 |
| Direct vasodilators | |||
| Hydralazine Apresoline | Contraindicated | Contraindicated in coronary artery disease and ischemia, because vasodilation with sympathetic activation raises the workload of the heart. Use caution in the elderly. | L6 slide 102 |
| Hydralazine Apresoline | Named reaction | Hydralazine “lupus syndrome”: high dose, long-term use, women, slow acetylators, Caucasians. | L6 slide 101 |
| Minoxidil Loniten | Caution | Myocardial ischemia (reflexes and sympathetics) and arrhythmias (action on the potassium channel); cardiac output rises 2–3 times. | L6 slide 104 |
| Nitroprusside Nitropress | Named reaction | Cyanide toxicity (trembling, vomiting, convulsions): give sodium thiosulfate. Thiocyanate toxicity with long infusions or kidney failure. | L6 slide 107 |
| Drug or class | Tier | Do not use / caution | Source |
|---|---|---|---|
| Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) | |||
| Statins atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin | Contraindicated | Contraindicated in active hepatic disease and in pregnancy (the same no-go group as angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers). Newer labeling has relaxed the absolute ban, but statins are still stopped when pregnancy is recognized. | L7 slide 23 |
| Statins atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin | Caution | Relative contraindication: concomitant use of cyclosporine or other immunosuppressants, gemfibrozil, niacin and erythromycin. | L7 slide 23 |
| Statins atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin | Caution | Interactions: cytochrome P450 mediated, especially CYP3A4 (cytochrome P450 3A4) inhibitors and substrates. Verapamil, amiodarone and grapefruit juice raise statin levels this way; niacin and fibric acid derivatives are also listed because they add to the risk of muscle toxicity. | L7 slide 24 |
| Statins atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin | Caution | Caution in patients with impaired renal function and when combining a statin with a fibrate, because muscle toxicity risk rises; muscle toxicity requires discontinuing the statin. | L7 slide 22 |
| Cholesterol absorption inhibitor | |||
| Ezetimibe Zetia | Caution | No contraindication is listed. Interactions: fibrates increase hepatobiliary side effects (cholelithiasis, myopathies); bile acid sequestrants may decrease its concentrations; antacids decrease them; cyclosporine increases them. When it is combined with a statin, the statin contraindications (active liver disease, pregnancy) apply. | L7 slide 31 |
| Fibrates (fibric acid derivatives) | |||
| Fibrates gemfibrozil, fenofibrate, bezafibrate | Contraindicated | Contraindicated in pregnancy, severe hepatic or renal dysfunction, and existing gallbladder disease. | L7 slide 37 |
| Fibrates gemfibrozil, fenofibrate, bezafibrate | Caution | Interactions: increased anticoagulant effect of warfarin; also statins, ezetimibe and bile acid sequestrants. | L7 slide 38 |
| Bile acid sequestrants (resins) | |||
| Bile acid sequestrants cholestyramine, colestipol, colesevelam | Contraindicated | Absolute contraindications: familial dysbetalipoproteinemia (increased triglycerides) and triglycerides above 400 mg/dL. Resins can raise triglycerides, so they must not be used when triglycerides are already high. | L7 slide 48 |
| Bile acid sequestrants cholestyramine, colestipol, colesevelam | Caution | Relative contraindication: triglycerides above 200 mg/dL. | L7 slide 48 |
| Bile acid sequestrants cholestyramine, colestipol, colesevelam | Caution | Bind and block absorption of other drugs: digoxin, warfarin, thyroxine, beta blockers and thiazide diuretics. Give the other drug 1 hour before or 4 hours after the resin. | L7 slide 47 |
| Niacin (nicotinic acid) | |||
| Niacin nicotinic acid, vitamin B3 | Contraindicated | Absolute contraindication: chronic liver disease. | L7 slide 56 |
| Niacin nicotinic acid, vitamin B3 | Caution | Relative contraindications: peptic ulcer disease, history of symptomatic gout, significant hyperuricemia and diabetes (glucose intolerance). | L7 slide 56 |
| Niacin nicotinic acid, vitamin B3 | Caution | Interactions: statins, bile acid sequestrants and alcohol (ethanol). | L7 slide 57 |
| PCSK9 inhibitors | |||
| PCSK9 inhibitors alirocumab, evolocumab | Caution | No contraindication is listed for proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Hypersensitivity reactions are the most serious adverse reaction, and the product labeling contraindicates further use after a prior serious allergic reaction to the drug. | L7 slide 60 |
| Drug or class | Tier | Do not use / caution | Source |
|---|---|---|---|
| Beta blockers | |||
| Beta blockers metoprolol, atenolol (beta-1 selective); propranolol, nadolol (non-selective); carvedilol, labetalol (third generation) | Contraindicated | Contraindicated with heart rate below 60 beats per minute and with atrioventricular block. | L8 slide 18 |
| Beta blockers metoprolol, atenolol (beta-1 selective); propranolol, nadolol (non-selective); carvedilol, labetalol (third generation) | Contraindicated | Contraindicated with systolic blood pressure below 100 mmHg and in acute decompensated heart failure. | L8 slide 18 |
| Beta blockers metoprolol, atenolol (beta-1 selective); propranolol, nadolol (non-selective); carvedilol, labetalol (third generation) | Caution | Precautions: reactive airway disease, systolic heart failure, diabetes and peripheral vascular disease. | L8 slide 18 |
| Beta blockers metoprolol, atenolol (beta-1 selective); propranolol, nadolol (non-selective); carvedilol, labetalol (third generation) | Avoid | Avoid non-cardioselective beta blockers in asthma; avoid beta blockers in bradycardia or atrioventricular block (a dihydropyridine is first line there). | L8 slide 34 |
| Beta blockers metoprolol, atenolol (beta-1 selective); propranolol, nadolol (non-selective); carvedilol, labetalol (third generation) | Avoid | Diabetes: avoid non-cardioselective beta blockers; a cardioselective beta blocker is a listed alternative (beta blockers can raise blood sugar and mask hypoglycemia). | L8 slide 34 |
| Beta blockers metoprolol, atenolol (beta-1 selective); propranolol, nadolol (non-selective); carvedilol, labetalol (third generation) | Avoid | Avoid in variant (vasospastic) angina: beta blockers may lead to worsened symptoms. | L8 slide 39 |
| Beta blockers in acute coronary syndrome | Caution | Caution with bradycardia or hypotension, heart block and severe reactive airway disease. | L8 slide 55 |
| Calcium channel blockers | |||
| Calcium channel blockers dihydropyridine and non-dihydropyridine | Contraindicated | Contraindicated with systolic blood pressure below 100 mmHg. | L8 slide 23 |
| Non-dihydropyridine calcium channel blockers diltiazem, verapamil | Contraindicated | Contraindicated with heart rate below 60, acute heart failure and ejection fraction below 40 percent. Atrioventricular block is also listed; it is the non-dihydropyridines that slow atrioventricular conduction. | L8 slide 23 |
| Calcium channel blockers dihydropyridine and non-dihydropyridine | Caution | Precautions: concurrent beta blocker use (non-dihydropyridines) and cytochrome P450 3A4 (CYP3A4) interactions. | L8 slide 23 |
| Dihydropyridine calcium channel blockers nifedipine, amlodipine, felodipine | Avoid | Avoid short-acting agents, nifedipine being the named example. | L8 slide 22 |
| Non-dihydropyridine calcium channel blockers diltiazem, verapamil | Avoid | Avoid in bradycardia or atrioventricular block (a dihydropyridine is first line). | L8 slide 34 |
| Calcium channel blockers dihydropyridine and non-dihydropyridine | Avoid | Decreased left ventricular function: amlodipine is the calcium channel blocker alternative; other calcium channel blockers are avoided. | L8 slide 34 |
| Calcium channel blockers dihydropyridine and non-dihydropyridine | Avoid | Prior myocardial infarction: a beta blocker is first line and, in the course table, calcium channel blockers are avoided (current practice allows a non-dihydropyridine when a beta blocker cannot be used). | L8 slide 34 |
| Nitrates | |||
| Nitrates nitroglycerin, isosorbide | Avoid | Avoid in severe aortic valve stenosis and obstructive cardiomyopathy (older lists call these contraindications; the risk is hypotension). | L8 slide 33 |
| Nitrates nitroglycerin, isosorbide | Contraindicated | Contraindicated with phosphodiesterase type 5 inhibitors (sildenafil, tadalafil, vardenafil): concurrent use may lead to hypotension, myocardial infarction or stroke. | L8 slide 33 |
| Nitrates in acute coronary syndrome | Contraindicated | Contraindicated with hypotension and with phosphodiesterase inhibitors. No mortality benefit, only pain relief. | L8 slide 54 |
| Aspirin | |||
| Aspirin in acute coronary syndrome | Contraindicated | Contraindications: allergy, recent gastrointestinal bleeding, recent intracranial hemorrhage. (Clopidogrel is the alternative for aspirin allergy in stable disease.) | L8 slide 53 |
| Fibrinolytics | |||
| Fibrinolytics streptokinase; alteplase (Activase), reteplase (Retavase), tenecteplase (TNKase) | Contraindicated | Active bleeding or a hemorrhagic disorder. | L8 slide 63 |
| Fibrinolytics streptokinase; alteplase (Activase), reteplase (Retavase), tenecteplase (TNKase) | Caution | Recent surgery, procedures and bleeding: surgery within 10 days (including organ biopsy, puncture of non-compressible vessels and cardiopulmonary resuscitation); serious gastrointestinal bleeding within 3 months. These are older cut-offs: current guidelines treat recent major surgery, prolonged resuscitation, non-compressible punctures and recent internal bleeding as relative contraindications with different time limits. | L8 slide 63 |
| Fibrinolytics streptokinase; alteplase (Activase), reteplase (Retavase), tenecteplase (TNKase) | Contraindicated | Serious head or facial trauma (current guidelines: significant head or facial trauma within 3 months is absolute). | L8 slide 63 |
| Fibrinolytics streptokinase; alteplase (Activase), reteplase (Retavase), tenecteplase (TNKase) | Contraindicated | Brain, aorta and pericardium: previous cerebrovascular accident or an active intracranial process (tumors); aortic dissection; acute pericarditis. Current guidelines are more specific: any prior intracranial hemorrhage, ischemic stroke within 3 months and intracranial tumors are absolute; an older ischemic stroke is only relative, and acute pericarditis is an older-list item. | L8 slide 63 |
| Fibrinolytics streptokinase; alteplase (Activase), reteplase (Retavase), tenecteplase (TNKase) | Caution | Severe uncontrolled hypertension (diastolic pressure above 110 mmHg). A history of hypertension alone is not a contraindication. | L8 slide 63 |
| Streptokinase fibrinolytic | Contraindicated | Prior streptokinase exposure or allergic reaction bars giving streptokinase again (not the recombinant agents). | L8 slide 63 |
| Fibrinolytics streptokinase; alteplase (Activase), reteplase (Retavase), tenecteplase (TNKase) | Caution | Pregnancy (a relative contraindication in current guidelines). | L8 slide 63 |
| Fibrinolytics in non-ST-elevation acute coronary syndrome | Avoid | Not recommended: the bleeding risk is greater than the benefit. | L8 slide 68 |
| Morphine and other acute agents | |||
| Morphine opioid analgesic | Caution | May increase mortality in unstable angina and non-ST-elevation myocardial infarction; its use is controversial. Adverse reactions: hypotension and allergy. | L8 slide 56 |