The adverse effects of the Exam 2 lectures sorted the way Dr. Wood sorts them. 117 entries.
Dangerous. Immediate discontinuation and evaluation. Not necessarily common: these are the ones you warn the patient about in advance.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Systemic beta blockade from beta blocker eye drops: worsening heart failure, bradycardia, heart block, increased airway resistance | timolol, carteolol, levobunolol (nonselective); betaxolol (beta-1 selective, less bronchial risk) | Drops drain down the tear duct and are absorbed. Ask about heart failure, heart block, slow pulse and asthma before starting; stop and evaluate if any appear. Warn the patient in advance. | L4 slide 67 |
| Central nervous system depression and apnea in children under 2 years | alpha-2 agonists (brimonidine, apraclonidine) | Contraindicated in children under 2 years. Never use in an infant. | L4 slide 69 |
| Accidental ingestion of imidazoline eye drops | tetrahydrozoline, naphazoline (redness-relief drops) | Systemically these target alpha 2 receptors, so a swallowed bottle is dangerous, especially in a small child. Keep the bottle out of reach; a child who swallows it needs emergency care. | L4 slide 49 |
| Worsening visual acuity during treatment | any ophthalmic medication | Measure visual acuity before starting and at every follow-up. If it gets worse, immediate ophthalmology consult (something more serious may be going on). | L4 slide 33 |
| Steroid-induced raised eye pressure and glaucoma, infection and corneal ulcer | ophthalmic glucocorticoids (dexamethasone, prednisolone, difluprednate and others) | Raised eye pressure (more likely with a family history), glaucoma, infection from reduced immune function and corneal ulcers, plus cataract and delayed wound healing. Limit to a pulse of less than 2 weeks; the soft steroids carry lower pressure risk. | L4 slide 54 |
| Loss of the blink reflex after anesthetic drops | tetracaine, proparacaine | The eyes stay numb for 10 to 20 minutes with no blink reflex, leaving the cornea unprotected. Do not write prescriptions or dispense for home use. | L4 slide 75 |
What actually happens, often. These belong to the class, not the drug, so they are listed by class.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Ocular irritation | all ophthalmic antibiotics: macrolides, trimethoprim with polymyxin B, sulfacetamide, bacitracin, fluoroquinolones, aminoglycosides | Ocular irritation is listed for essentially every eye antibiotic (macrolides, trimethoprim with polymyxin B, sulfacetamide, bacitracin, fluoroquinolones, aminoglycosides), so it belongs to the class and names no single drug. Hypersensitivity is listed only for the macrolides and sulfacetamide. | L4 slide 15 |
| Unpleasant taste after instillation | fluoroquinolones | Drug drains down the tear duct to the throat. Blocking the duct after the drop helps. | L4 slide 21 |
| Ocular irritation, headache and increased ocular dryness | ophthalmic antihistamines | Irritation can settle with time. Onset of benefit is within minutes, but allow two weeks of therapy to judge full efficacy. | L4 slide 44 |
| Ocular irritation, unpleasant taste and headache | mast cell stabilizers | Not useful for acute symptoms; full effect takes 5 to 14 days and four-times-daily dosing is often needed. | L4 slide 47 |
| Rebound hyperemia after stopping | topical vasoconstrictors (tetrahydrozoline, naphazoline, pheniramine with naphazoline) | Prolonged use leads to rebound hyperemia after discontinuation. Use for less than 2 weeks; if no improvement in 72 hours, stop and see a provider. A great counseling point. | L4 slide 48 |
| Lacrimation, keratitis, raised eye pressure and irritation | ophthalmic nonsteroidal anti-inflammatory drugs (bromfenac, diclofenac, flurbiprofen, ketorolac, nepafenac) | Why they are not routinely used for simple conjunctivitis. | L4 slide 51 |
| Conjunctival hyperemia and ocular irritation | prostaglandin analogs | Common with the class; systemic effects are limited. | L4 slide 65 |
| Ocular irritation, rebound hyperemia, pruritus and allergic conjunctivitis | alpha-2 agonists (apraclonidine, brimonidine) | Allergic conjunctivitis is less common with brimonidine. | L4 slide 69 |
| Bitter taste (25%) and burning or stinging (33%) | carbonic anhydrase inhibitors (dorzolamide, brinzolamide) | Both are frequent (about one in four and one in three patients), so warn them first. | L4 slide 70 |
| Fixed small pupils, myopia, visual disturbances and headaches | cholinergic agonists (pilocarpine, carbachol, acetylcholine) | Younger patients are usually intolerant because of visual blurring. | L4 slide 72 |
| Photosensitivity and blurred vision | antimuscarinic cycloplegics (atropine, cyclopentolate, tropicamide) | Expected with pupil dilation; warn the patient not to drive until it clears. | L4 slide 76 |
| Ocular burning (17%), foreign body sensation and blurred vision | cyclosporine drops (immunomodulator) | Warn patients up front. | L4 slide 58 |
Uncommon, but unique to one drug. Each is worth about one question, and with the killers they are where to look.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| White precipitate on the eye (about 17%) | ciprofloxacin | Unique to ciprofloxacin among the fluoroquinolone drops. Warn the patient so it is not mistaken for a worsening infection. | L4 slide 21 |
| Corneal ulceration and reactive keratoconjunctivitis with several days of use | aminoglycosides (gentamicin, tobramycin) | Specific to the aminoglycoside eye drops (gentamicin, tobramycin) among the antibiotics: watch for it when the drops are used beyond a few days. | L4 slide 23 |
| Punctate keratopathy | trifluridine | Pinpoint corneal surface damage, seen after fluorescein staining. | L4 slide 27 |
| Punctate keratitis | ganciclovir (Zirgan) | The ganciclovir eye preparation carries its own punctate keratitis. | L4 slide 28 |
| Changes in eyelash length and iris color | prostaglandin analogs (latanoprost, travoprost, bimatoprost, tafluprost) | Unique to the prostaglandin analogs. Warn the patient before starting. | L4 slide 65 |
| Bull's eye lesion | chloroquine | A drug that accumulates in the eye. | L4 slide 10 |
| Allergic reaction in a patient with a sulfonamide allergy | sulfacetamide | Allergic reactions are listed for sulfacetamide. Avoid it in a patient with a sulfonamide allergy and ask about drug reactions before using it. | L4 slide 19 |
Dangerous. Immediate discontinuation and evaluation. Not necessarily common: these are the ones you warn the patient about in advance.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Reye syndrome | aspirin (all salicylates) | Children under 15, mortality 50%: vomiting, progressive central nervous system damage, liver injury and hypoglycemia after influenza, chickenpox or an upper respiratory infection. Never give aspirin to a child with a viral fever; warn parents in advance. Stop and evaluate urgently. | L5 slide 18 |
| Salicylism (aspirin toxicity) | aspirin | Hyperventilation and alkalosis, then fever, dehydration and metabolic acidosis, then shock, coma, respiratory and renal failure and death. Ringing in the ears (tinnitus) is the early warning that exposure is too high. | L5 slide 16 |
| QTc (corrected QT interval) prolongation | ketoconazole | A life-threatening arrhythmia risk, made worse by any other QT-prolonging or cytochrome P450 3A4 (CYP3A4) interacting drug. Check the electrocardiogram and the medication list. | L5 slide 12 |
| Hepatitis, cirrhosis and hepatic failure | ketoconazole | Liver injury from a systemic antifungal. Stop the drug and evaluate the liver if liver function tests rise. | L5 slide 12 |
| Cochlear damage and hearing loss | polymyxin B (Cortisporin ear drops) | Permanent inner-ear injury when the drops pass a ruptured eardrum or tubes. Examine the eardrum first; do not use polymyxin B if it is perforated or tubes are in place. | L5 slide 10 |
| Gastric or duodenal ulcer, perforation and bleeding | ibuprofen (nonsteroidal anti-inflammatory drugs) | Bleeding ulcers and perforation, mainly with regular daily use. Warn patients about black stools and stomach pain; stop and evaluate. | L5 slide 21 |
| Acute renal failure | ibuprofen (nonsteroidal anti-inflammatory drugs) | Decreased creatinine clearance and acute renal failure; worst in patients who already have kidney disease or take diuretics. Stop and check kidney function. | L5 slide 21 |
| Liver damage from acetaminophen | acetaminophen | Chronic alcohol use increases the risk of liver damage; a fixed daily maximum applies and every acetaminophen-containing product counts toward it. Warn the patient in advance. | L5 slide 25 |
| Arrhythmia from hypokalemia | dexamethasone with digoxin or a diuretic | Potassium loss from the steroid, worsened by a diuretic, raises the arrhythmia risk with digoxin. Monitor potassium and the electrocardiogram. | L5 slide 45 |
| Serotonin syndrome | dextromethorphan | Risk with other pro-serotonergic drugs, and the drug is contraindicated with a monoamine oxidase inhibitor (MAOI) taken now or within 2 weeks. Stop and evaluate agitation, confusion or fever. | L5 slide 58 |
| Bronchospasm | N-acetylcysteine (inhaled) | Airway narrowing with the nebulized route. Stop and treat wheezing or breathlessness. | L5 slide 63 |
What actually happens, often. These belong to the class, not the drug, so they are listed by class.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Sedation | First-generation H1 antagonists (histamine-1 blockers) | The major side effect of the whole class and additive with alcohol and other depressants; second-generation agents cause much less. It is why doxylamine works as a sleep aid. | L5 slide 32 |
| Dry mouth, urinary retention, blurred vision | First-generation H1 antagonists (antimuscarinic effect) | The antimuscarinic set, plus gastrointestinal disturbances; with topical use, dermatitis and photosensitivity. | L5 slide 36 |
| Gastric and duodenal ulcer, edema and renal effects | Nonsteroidal anti-inflammatory drugs (ibuprofen) | Stomach, fluid and kidney effects are the class pattern for these drugs. | L5 slide 21 |
| Fluid retention, hypertension, potassium loss, glucose intolerance | Systemic corticosteroids (dexamethasone, prednisone) | Salt and water retention, raised blood pressure, low potassium and high glucose belong to the class, not the individual drug. | L5 slide 44 |
| Cataracts, glaucoma, increased intraocular pressure, infection risk | Systemic corticosteroids (dexamethasone, prednisone) | Eye effects and weakened immunity are shared by the class; risk rises with dose and duration. | L5 slide 47 |
| Epistaxis, septal perforation, unpleasant taste | Nasal corticosteroids | Mostly local effects at usual doses. The source gives no interaction information (that is not the same as no interactions); strong CYP3A4 inhibitors such as ketoconazole can raise systemic exposure to some nasal steroids. | L5 slide 43 |
| Tachycardia, hypertension, headache | Oral decongestants (pseudoephedrine) | Vasoconstriction spreads beyond the nose, and the oral agent also weakens antihypertensive treatment. | L5 slide 52 |
| Nausea, vomiting, diarrhea and stomach pain | Nonabsorbable antifungal (nystatin) | Expected, minor gastrointestinal upset; not a reason to stop. | L5 slide 13 |
Uncommon, but unique to one drug. Each is worth about one question, and with the killers they are where to look.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Rhinitis medicamentosa (rebound congestion) | oxymetazoline | Use beyond 3–5 days causes rebound congestion, and patients reuse the spray to treat it. Limit to 3–5 days. | L5 slide 50 |
| Tinnitus | aspirin | Ringing in the ears appears in the anti-inflammatory exposure range, before frank toxicity. | L5 slide 16 |
| Cytochrome P450 3A4 (CYP3A4) inhibition | ketoconazole | Raises levels of many drugs cleared by CYP3A4, so it interacts with many medicines. | L5 slide 12 |
| Hypersensitivity of the ear canal | neomycin (Cortisporin drops) | The component most likely to cause an allergic reaction in otic drops. | L5 slide 10 |
| Numbing of the mouth when the capsule is chewed | benzonatate | Local anesthesia from chewing; hence swallow whole. Cross-allergy is possible with related local anesthetics such as tetracaine. | L5 slide 57 |
| Rotten-egg smell | N-acetylcysteine (inhaled) | The high sulfur content gives inhaled N-acetylcysteine a rotten-egg smell, alongside nausea and vomiting. | L5 slide 63 |
| Bitter taste | azelastine nasal spray | The bitter taste is listed alongside nosebleed for this nasal spray. | L5 slide 38 |
| Confusion, excitement, agitation | dextromethorphan | The central nervous system effects listed for this antitussive. | L5 slide 58 |
| Papilledema and hirsutism | dexamethasone | Listed among dexamethasone's adverse effects, but not unique to it: prednisone and prednisolone share the same steroid side effects, so treat these as class effects. | L5 slide 44 |
| Pathologic fractures of long bones and raised liver enzymes | prednisone | Listed among prednisone's adverse effects, but not unique to it: dexamethasone and other glucocorticoids share the same bone and steroid effects, so treat these as class effects. | L5 slide 47 |
Dangerous. Immediate discontinuation and evaluation. Not necessarily common: these are the ones you warn the patient about in advance.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Hyperkalemia (raised potassium) | ACE (angiotensin-converting enzyme) inhibitors | Most often with kidney disease and with potassium-sparing diuretics, potassium supplements or salt substitutes. Check the potassium; stop the potassium source. Warn the patient in advance to avoid potassium supplements and salt substitutes. An easy question and a way to cause an arrhythmia. | L6 slide 20 |
| Angioedema | ACE (angiotensin-converting enzyme) inhibitors | Rapid swelling of the nose, throat, mouth, larynx, lips and tongue, usually in the first week; reversible if the drug is removed. Airway risk: stop the drug and evaluate. Tell the patient in advance to report swelling at once. | L6 slide 22 |
| Fetal morbidity and mortality (birth defects, fetal death) | ACE (angiotensin-converting enzyme) inhibitors | Contraindicated in the second and third trimesters. Confirm the patient is not pregnant before starting and stop as soon as pregnancy is found. | L6 slide 22 |
| Acute fall in glomerular filtration rate | ACE (angiotensin-converting enzyme) inhibitors | Where kidney blood flow depends on angiotensin II, the drug can dramatically decrease the glomerular filtration rate. Start low, go slow, and follow kidney function. | L6 slide 21 |
| Heart block and severe bradycardia; worsening heart failure | Non-dihydropyridine calcium channel blockers (diltiazem, verapamil) | First-degree atrioventricular block, bradycardia and exacerbation of congestive heart failure or pulmonary edema from the negative inotropic effect. Follow heart rate and watch for swelling or breathlessness; stop and evaluate. | L6 slide 45 |
| Bronchospasm (asthma exacerbation) | Beta blockers (less likely with beta-1 selective agents) | Blockade of airway beta-2 receptors can trigger bronchospasm; about one third of patients with chronic obstructive pulmonary disease have bronchospasm. Contraindicated in bronchospasm; beta-1 selective agents are less likely to cause it, so if a beta blocker is truly needed in lung disease they are the ones to choose, with caution. | L6 slide 71 |
| Heart block and severe bradycardia | Beta blockers | Negative chronotropy (heart rate below 60 beats per minute) and first-, second- or third-degree atrioventricular block. Check pulse; stop and evaluate for a slow or blocked rhythm. Stacking with verapamil or diltiazem multiplies the risk. | L6 slide 71 |
| Masked and prolonged hypoglycemia | Beta blockers (type 1 diabetes especially) | Beta blockers inhibit glycogenolysis, prolong hypoglycemia and hide its warning symptoms. Warn diabetic patients in advance that the usual warning signs may not appear. | L6 slide 72 |
| Sudden withdrawal syndrome (acute angina, myocardial infarction, marked rise in blood pressure) | Beta blockers | Blockade upregulates the receptors, so stopping abruptly exposes them to catecholamines. Never stop suddenly; withdraw slowly. Tell the patient in advance. | L6 slide 73 |
| Withdrawal reactions (rebound hypertension) | Clonidine | Withdrawal reactions may be severe. Taper; never stop abruptly. Tell the patient in advance. | L6 slide 94 |
| Myocardial ischemia and arrhythmias | Minoxidil | Reflex sympathetic activation with a 2–3 times rise in cardiac output causes myocardial ischemia, and its potassium channel action causes arrhythmias. Report chest pain or palpitations. | L6 slide 104 |
| Hyperkalemia (raised potassium) | Angiotensin receptor blockers | With kidney disease or potassium-sparing diuretics. Check the potassium, especially when a potassium-sparing diuretic is added. | L6 slide 29 |
| Fetal morbidity and mortality | Angiotensin receptor blockers | Not given in the second and third trimesters. Confirm the patient is not pregnant; stop as soon as pregnancy is found. | L6 slide 29 |
| Impairment of kidney function | Angiotensin receptor blockers | Angiotensin II is important for kidney function; follow kidney function, and in heart failure start low and titrate upward. | L6 slide 29 |
| Cyanide toxicity and thiocyanate toxicity | Nitroprusside | Cyanide toxicity (trembling, vomiting, convulsions) is limited by sodium thiosulfate. Thiocyanate toxicity (weakness, anoxia, tinnitus, muscle spasms, toxic psychosis) follows long infusions or kidney failure. Stop the infusion and treat. | L6 slide 107 |
What actually happens, often. These belong to the class, not the drug, so they are listed by class.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Dry cough (5–15%) | ACE (angiotensin-converting enzyme) inhibitors (class effect) | Bradykinin and substance P accumulate in the lungs; appears from 1 week to 6 months; not related to dose or specific agent; more frequent in women. If bothersome, remove the ACE inhibitor; an angiotensin receptor blocker does not cause cough. | L6 slide 19 |
| First-dose hypotension | ACE (angiotensin-converting enzyme) inhibitors (class effect) | At the first dose or on upward titration; most common in sodium-depleted patients, heart failure, or multiple antihypertensive drugs. Warn about dizziness on standing. | L6 slide 20 |
| First-dose hypotension | Angiotensin receptor blockers (class effect) | A first-dose effect; warn about dizziness on standing after the first dose. | L6 slide 29 |
| Peripheral vasodilation: flushing, headache, peripheral edema, dizziness | Non-dihydropyridine calcium channel blockers (class effect) | Flushing, headache, hypotension, peripheral edema and dizziness follow directly from relaxing vascular smooth muscle. | L6 slide 45 |
| Constipation and other gastrointestinal effects | Non-dihydropyridine calcium channel blockers (class effect) | Nausea, vomiting, diarrhea, anorexia and constipation; ask about bowel habits. | L6 slide 45 |
| Peripheral edema and rebound tachycardia | Dihydropyridine calcium channel blockers (class effect) | Vasodilation with reflex tachycardia after the fall in resistance; also dyspnea and wheezing. Gingival hyperplasia can also occur. | L6 slide 51 |
| Fatigue and limited exercise tolerance | Beta blockers (class effect) | The common complaint when a beta blocker is used for hypertension. | L6 slide 63 |
| Cold extremities and muscle fatigue | Beta blockers (class effect) | Block beta-2 receptors in blood vessels: cold extremities (Raynaud phenomenon), skeletal muscle fatigue and worse claudication. | L6 slide 73 |
| Depression, nightmares and vivid dreams | Highly lipid-soluble beta blockers (class effect) | Central effects of agents that enter the brain easily; the more lipid-soluble the drug, the more these symptoms. | L6 slide 74 |
| Orthostatic hypotension and dizziness | Alpha-1 blockers (class effect) | Postural dizziness, headache, drowsiness and lack of energy; counsel to stand slowly. | L6 slide 79 |
| Reflex tachycardia, fluid retention and impotence | Alpha-1 blockers (class effect) | Mild reflex tachycardia, raised renin with sodium and water retention, and impotence. | L6 slide 80 |
| Drowsiness, dry mouth and sexual dysfunction | Central sympatholytics (class effect) | Central effects; the class also has a narrow therapeutic range. | L6 slide 91 |
| Reflex tachycardia, fluid retention, tachyphylaxis | Direct vasodilators (class effect) | Reflex sympathetic activation, increased cardiac output, fluid retention and raised renin; the effect fades. Hydralazine and minoxidil are given with a diuretic and a beta blocker. | L6 slide 97 |
Uncommon, but unique to one drug. Each is worth about one question, and with the killers they are where to look.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Hydralazine “lupus syndrome” | Hydralazine | High dose, long-term use, women, slow acetylators, Caucasians. | L6 slide 101 |
| Black stools | Hydralazine | Warn the patient ahead of time that stools may turn black, so it is not mistaken for bleeding. | L6 slide 102 |
| Hypertrichosis (unwanted hair growth) | Minoxidil | Hair growth on the face, back, arms and legs; the topical form (Rogaine) is used for hair growth. | L6 slide 105 |
| Raised blood glucose | Clonidine | Inhibits insulin secretion; watch blood glucose in diabetic patients. | L6 slide 92 |
| Acute pressor response | Clonidine | A brief rise in pressure can occur before the fall. | L6 slide 92 |
| Diarrhea | Tamsulosin | Hypotension, dizziness and diarrhea, with limited vascular effect. | L6 slide 84 |
Dangerous. Immediate discontinuation and evaluation. Not necessarily common: these are the ones you warn the patient about in advance.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Rhabdomyolysis and other muscle toxicity | Statins | Myalgia and myopathy occur in 0.2 to 0.4% of patients, and rare cases progress to rhabdomyolysis. Muscle toxicity requires stopping the statin. Warn every patient in advance to report muscle symptoms; risk rises with kidney impairment, fibrate combinations and other interacting drugs. | L7 slide 22 |
| Serious liver injury | Statins | A rise in liver enzymes occurs in 0.5 to 2.5% of cases in a dose-dependent manner, and serious liver problems are exceedingly rare. Reduce the dose or stop until levels return to normal. | L7 slide 21 |
| Hypersensitivity reaction | PCSK9 inhibitors (alirocumab, evolocumab) | The most serious adverse reaction of this proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor class. Injectable monoclonal antibodies; stop and evaluate if an allergic reaction follows an injection. | L7 slide 60 |
| Bleeding from a warfarin interaction | Fibrates (gemfibrozil, fenofibrate, bezafibrate) | Increased anticoagulant effect of warfarin. Warn the patient to watch for bruising and bleeding, and monitor anticoagulation when a fibrate is started. | L7 slide 38 |
What actually happens, often. These belong to the class, not the drug, so they are listed by class.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Headache, sleep disturbance, fatigue, gastrointestinal intolerance and flu-like symptoms | Statins (class) | The common effects of the class, with liver enzyme rises in 0.5 to 2.5% of cases; listed once for the whole class. | L7 slide 21 |
| Myalgia and myopathy | Statins (class) | Class effect seen with every statin (0.2 to 0.4% of patients); ask about muscle aches at every visit because the severe end of this spectrum is rhabdomyolysis, and muscle toxicity requires stopping the statin. | L7 slide 22 |
| Gastrointestinal effects | Ezetimibe | The main adverse effect; liver transaminases can also rise when it is combined with a statin. | L7 slide 30 |
| Nausea, abdominal pain and diarrhea | Fibrates (class) | The common gastrointestinal effects of the fibrates (gemfibrozil, fenofibrate, bezafibrate). | L7 slide 36 |
| Bloating, flatulence, fullness, constipation and nausea | Bile acid sequestrants (class) | Local gastrointestinal effects only, because the drugs are not absorbed; the reason they are poorly tolerated. | L7 slide 46 |
| Cutaneous flushing with nausea and abdominal discomfort | Niacin | Flushing is prostaglandin mediated and is minimized by premedication with aspirin. Warn the patient in advance so it is not mistaken for an allergy. | L7 slide 55 |
Uncommon, but unique to one drug. Each is worth about one question, and with the killers they are where to look.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Cholelithiasis (gallstones) | Fibrates (and fibrate plus ezetimibe) | Uncommon but distinctive of the fibrates; existing gallbladder disease is also a contraindication. | L7 slide 36 |
| Malabsorption of vitamins A, D, E and K and folic acid | Bile acid sequestrants | Unique to the resins because they bind bile acids and other substances in the gut; supplement or space the vitamins. | L7 slide 46 |
| Rise in triglycerides | Bile acid sequestrants | The resins may increase very low-density lipoprotein production and raise triglycerides, the only lipid class to do so, which is why high triglycerides is a contraindication. | L7 slide 46 |
| Raised glucose and uric acid, decreased glucose tolerance | Niacin | At larger doses; the reason gout, hyperuricemia and diabetes are relative contraindications. | L7 slide 55 |
Dangerous. Immediate discontinuation and evaluation. Not necessarily common: these are the ones you warn the patient about in advance.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Abrupt beta blocker withdrawal (rebound angina, myocardial infarction) | Beta blockers | Avoid rapid discontinuation; stop gradually. Warn the patient in advance never to stop suddenly. (Added background: rebound angina and myocardial infarction; several beta blockers, for example metoprolol, atenolol and nadolol, carry a Food and Drug Administration (FDA) boxed warning.) | L8 slide 19 |
| Severe hypotension, myocardial infarction, stroke | Nitrates with phosphodiesterase type 5 inhibitors (sildenafil, tadalafil, vardenafil) | Contraindicated combination. Ask every nitrate patient about erectile dysfunction medicines before prescribing. | L8 slide 33 |
| Bleeding, including intracranial hemorrhage | Fibrinolytics (all agents) | The main risk of the class. Screen against the contraindication list before giving; watch for new neurologic signs. | L8 slide 62 |
| Anaphylaxis | Fibrinolytics (class list) | An anaphylactic reaction is listed for the class; a prior streptokinase exposure or allergic reaction bars giving streptokinase again (not the recombinant agents). | L8 slide 62 |
| Ventricular arrhythmias | Fibrinolytics (class) | Listed adverse effect of the class: monitor the rhythm after treatment. | L8 slide 62 |
What actually happens, often. These belong to the class, not the drug, so they are listed by class.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Bradycardia, hypotension, fatigue, dizziness | Beta blockers (class effect) | Heart rate is the monitoring parameter; counsel about dizziness and fatigue. | L8 slide 19 |
| Hyperglycemia and dyslipidemia | Beta blockers (class effect) | Follow blood sugar and lipids. | L8 slide 19 |
| Headache, flushing, peripheral edema | Dihydropyridine calcium channel blockers (class effect) | Vasodilation effects; hypotension is listed for the whole calcium channel blocker class. | L8 slide 24 |
| Dizziness and constipation | Calcium channel blockers (class counseling points) | The two education points listed for the class; constipation is mainly a verapamil effect. | L8 slide 24 |
| Headache, flushing, postural hypotension, reflex tachycardia | Nitrates (class effect) | Warn about orthostatic hypotension. | L8 slide 31 |
| Tolerance (tachyphylaxis) | Nitrates (class effect) | Managed with a daily nitrate-free interval. | L8 slide 32 |
Uncommon, but unique to one drug. Each is worth about one question, and with the killers they are where to look.
| Effect | Drug or class | What it means / what to do | Source |
|---|---|---|---|
| Allergic reaction, fever, chills, skin rash | Streptokinase | Mainly with streptokinase among the fibrinolytics; prior streptokinase exposure or allergic reaction is a contraindication. | L8 slide 62 |
| Possible increase in mortality | Morphine | In unstable angina and non-ST-elevation myocardial infarction; its use is controversial. | L8 slide 56 |
| Aspirin allergy | Aspirin | Allergy is a contraindication; clopidogrel is the substitute recommended for patients allergic to aspirin. | L8 slide 37 |
| Short-acting formulation problem | Nifedipine | Avoid short-acting agents (nifedipine is the named example). | L8 slide 22 |