127 entries across the Exam 2 lectures, each citing its slide, with black box warnings shaded. Companion to the contraindications and indications charts.
| Drug or class | Side effects | Monitoring & what to watch | System | Source |
|---|---|---|---|---|
| Delivery routes and absorption | ||||
| Topical route drops, gels, ointments | Corneal and conjunctival toxicity, nasal mucosal toxicity and systemic side effects from nasolacrimal absorption. Adherence (compliance) is also a problem. | Watch for systemic effects from drug draining down the tear duct; block the duct after instilling. | Ocular / Systemic | L4 slide 5 |
| Injections around the eye subconjunctival, sub-Tenon's, retrobulbar | Local toxicity, tissue injury, globe perforation, optic nerve trauma, central retinal artery or vein occlusion, direct retinal toxicity with inadvertent globe perforation, ocular muscle trauma and prolonged drug effect. | Specialist procedure; any sudden vision loss needs urgent ophthalmology. | Ocular | L4 slide 5 |
| Intracameral injection | Corneal toxicity and intraocular toxicity, with a relatively short duration of action. | Specialist procedure. | Ocular | L4 slide 5 |
| Intravitreal injection or device | Retinal toxicity. | Specialist procedure. | Ocular (retina) | L4 slide 5 |
| Nasolacrimal drainage any topical eye drop | Systemic side effects, because drug draining down the tear duct is absorbed and avoids first-pass metabolism. | Pressing on the tear duct after instillation cuts down systemic absorption. | Systemic | L4 slide 8 |
| Chloroquine drug that accumulates in the eye | Some drugs accumulate in the eye: bull's eye lesion after chloroquine. | Report any change in vision. | Ocular (retina) | L4 slide 10 |
| Ocular antibiotics | ||||
| Macrolides erythromycin, azithromycin | Eye irritation and hypersensitivity. | Irritation is listed for essentially every ophthalmic antibiotic; hypersensitivity is listed only for the macrolides and sulfacetamide. No drug interactions with the topical forms. | Ocular / Allergy | L4 slide 15 |
| Trimethoprim with polymyxin B (Polytrim) | Ocular irritation. | No clinically important drug interactions. | Ocular | L4 slide 18 |
| Sulfacetamide ointment or solution | Ocular irritation and allergic reactions. | Avoid in a patient with a sulfonamide allergy; ask about drug allergies first. | Ocular / Allergy | L4 slide 19 |
| Bacitracin ointment | Ocular irritation. | No clinically important drug interactions. | Ocular | L4 slide 20 |
| Fluoroquinolones ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin, gatifloxacin | Ocular irritation, white precipitate (ciprofloxacin, about 17%) and unpleasant taste after instillation. | The taste comes from drainage down the tear duct. No clinically important interactions when given in the eye. | Ocular / Taste | L4 slide 21 |
| Fluoroquinolones treatment considerations | Emerging resistance and expense; dosing is frequent (up to every 2 to 4 hours). | A patient who is not improving may have a resistant organism. | Ocular | L4 slide 22 |
| Aminoglycosides gentamicin, tobramycin | Ocular irritation, corneal ulceration and reactive keratoconjunctivitis (with several days of use). | Watch for corneal changes when the drops are used for more than a few days. No clinically important interactions. | Ocular | L4 slide 23 |
| Ocular antivirals | ||||
| Trifluridine (Viroptic) | Ocular irritation and punctate keratopathy (small pinpoint corneal surface damage). | Punctate change is seen after fluorescein staining. No drug interactions. | Ocular | L4 slide 27 |
| Ganciclovir (Zirgan) | Ocular irritation and punctate keratitis. | No drug interactions. | Ocular | L4 slide 28 |
| Ocular antifungals | ||||
| Natamycin (Natacyn) | Ocular irritation. | No drug interactions. | Ocular | L4 slide 32 |
| Ocular allergy | ||||
| Ophthalmic antihistamines | Ocular irritation, headache and increased ocular dryness. | No significant drug interactions. | Ocular / Neurologic | L4 slide 44 |
| Mast cell stabilizers cromolyn, lodoxamide, nedocromil | Ocular irritation, unpleasant taste and headache. | Not useful for acute symptoms; allow 5 to 14 days for full effect. | Ocular / Taste / Neurologic | L4 slide 47 |
| Topical vasoconstrictors tetrahydrozoline, naphazoline, pheniramine with naphazoline | REBOUND HYPEREMIA after stopping, after prolonged use. | Use for less than 2 weeks. If no improvement in 72 hours, stop and see a provider. | Ocular (vascular) | L4 slide 48 |
| Imidazoline derivatives tetrahydrozoline, naphazoline | Accidental ingestion is dangerous: systemically these drugs target alpha 2 receptors (central nervous system depression, slow heart rate, low blood pressure in a small child). | Counsel to keep the bottle away from young children; a child who swallows it needs emergency care. | Central nervous system / Cardiovascular | L4 slide 49 |
| Ocular anti-inflammatories | ||||
| Ophthalmic nonsteroidal anti-inflammatory drugs (NSAIDs) bromfenac, diclofenac, flurbiprofen, ketorolac, nepafenac | Lacrimation, keratitis, raised eye pressure and ocular irritation. | Watch eye pressure, especially in a patient at risk for glaucoma. | Ocular | L4 slide 51 |
| Ophthalmic glucocorticoids dexamethasone, prednisolone, difluprednate | Cataract formation; raised eye pressure (more with a family history) and glaucoma; infection from decreased immune function; delayed wound healing; corneal ulcers. | Limit to a pulse of less than 2 weeks. Check eye pressure and watch for infection and corneal ulcer. | Ocular / Immune | L4 slide 54 |
| Soft steroids fluorometholone, loteprednol, rimexolone | The same class risks, but with lower risk of raised eye pressure. | Useful when raised pressure is the main worry. | Ocular | L4 slide 55 |
| Dry eye | ||||
| Cyclosporine (Restasis) | Ocular burning (17%), foreign body sensation and blurred vision. | Warn the patient before starting. No drug interactions. | Ocular | L4 slide 58 |
| Glaucoma | ||||
| Prostaglandin analogs latanoprost, travoprost, bimatoprost, tafluprost | Conjunctival hyperemia, ocular irritation and changes in eyelash length and iris color. | Limited systemic side effects. Tell the patient about lash growth and iris color change before starting. | Ocular | L4 slide 65 |
| Beta blockers betaxolol (beta-1 selective); carteolol, timolol, levobunolol (nonselective) | Worsening heart failure, bradycardia, heart block and increased airway resistance (asthma). | Nonselective agents cause more side effects. Check pulse and breathing; ask about heart failure, heart block and asthma. | Cardiovascular / Respiratory | L4 slide 67 |
| Alpha-2 agonists apraclonidine, brimonidine | Ocular irritation, hyperemia (rebound effect), pruritus and allergic conjunctivitis (less common with brimonidine). Central nervous system depression and apnea in children under 2 years. | Not for children under 2 years. | Ocular / Central nervous system | L4 slide 69 |
| Carbonic anhydrase inhibitors dorzolamide, brinzolamide | Bitter taste (25%) and burning or stinging after administration (33%), and allergic conjunctivitis. | Warn in advance; both effects are frequent (bitter taste 25%, burning or stinging 33%). | Ocular / Taste | L4 slide 70 |
| Cholinergic agonists acetylcholine, carbachol, pilocarpine | Fixed small pupils, myopia, visual disturbances and headaches. | Younger patients are usually intolerant because of visual blurring. | Ocular / Neurologic | L4 slide 72 |
| Diagnostic and procedural agents | ||||
| Ocular anesthetics tetracaine, proparacaine | Hypersensitivity and burning sensation. The eyes stay numb for 10 to 20 minutes with NO blink reflex. | Do not dispense for home use. Protect the eye until sensation returns. | Ocular / Allergy | L4 slide 75 |
| Antimuscarinic cycloplegics atropine, cyclopentolate, tropicamide | Photosensitivity and blurred vision. | Warn the patient not to drive until vision clears. | Ocular | L4 slide 76 |
| Phenylephrine (Neo-Synephrine) sympathomimetic mydriatic (grouped with cycloplegics) | Photosensitivity and conjunctival hyperemia. | The pupil stays more reactive to light than with an antimuscarinic. | Ocular | L4 slide 77 |
| Fluorescein | Hypersensitivity and burning sensation. | Ask about prior reactions to dyes. | Ocular / Allergy | L4 slide 78 |
| Drug or class | Side effects | Monitoring & what to watch | System | Source |
|---|---|---|---|---|
| Otic antibiotics | ||||
| Neomycin in Cortisporin drops | Chance of hypersensitivity (allergic reaction). | Watch for new itching or worsening inflammation of the ear after starting the drops. | Allergy / Skin | L5 slide 10 |
| Polymyxin B in Cortisporin drops | Cochlear damage and hearing loss when the drops reach the inner ear through a ruptured eardrum or tubes. | Examine the eardrum before every use; do not use with a perforation or tubes in place. | Ear (ototoxicity) | L5 slide 10 |
| Antifungals | ||||
| KetoconazoleBlack box | QTc (corrected QT interval) prolongation. Hepatitis, abnormal liver function tests, cirrhosis and hepatic failure. Hyperlipidemia and orthostatic hypotension. Cytochrome P450 3A4 (CYP3A4) inhibitor, so it raises levels of drugs cleared by that enzyme. Also an FDA (Food and Drug Administration) boxed warning for oral ketoconazole: liver injury, and QT prolongation with interacting drugs. | Review every other medication for CYP3A4 interactions; monitor the electrocardiogram (QTc), liver function tests and lipids, and watch for dizziness on standing. | Cardiovascular / Hepatic / Metabolic | L5 slide 12 |
| Nystatin oral suspension | Diarrhea, nausea, stomach pain and vomiting. | Little to monitor: it is a nonabsorbable antifungal, so effects stay in the gut. | Gastrointestinal | L5 slide 13 |
| Aspirin, nonsteroidal anti-inflammatory drugs and acetaminophen | ||||
| Aspirin — dose-related effects | Bleeding (antiplatelet range); bleeding, gastrointestinal upset, nausea and hypersensitivity (fever and pain range); tinnitus (anti-inflammatory range). | Ringing in the ears is the audible marker that exposure has climbed into the anti-inflammatory range; watch for bruising, black stools and stomach pain. | Hematologic / Gastrointestinal / Ear | L5 slide 16 |
| Aspirin — salicylism (toxicity) | Salicylism: hyperventilation and alkalosis; then fever, dehydration and metabolic acidosis; then shock, coma, respiratory and renal failure, and death. | Treat any suspected overdose as an emergency; hyperventilation and ringing in the ears are early warnings. | Metabolic / Respiratory / Renal / Neurologic | L5 slide 16 |
| Aspirin — Reye syndrome fatty liver encephalopathy | Reye syndrome: vomiting, progressive central nervous system damage, hepatic injury and hypoglycemia. Fatty change of the liver and kidney tubules, cerebral edema and mitochondrial dysfunction. Children under 15; mortality 50%. | Occurs after an upper respiratory infection, influenza or chickenpox: never give aspirin to a child with a fever from a viral illness; vomiting and a change in behavior after aspirin need urgent evaluation. | Neurologic / Hepatic / Metabolic | L5 slide 18 |
| Aspirin — the five stages of Reye syndrome | I rash on hands and feet, vomiting, high fever, lethargy; II encephalitis, hyperventilation, fatty liver; III coma, cerebral edema; IV deeper coma, fixed dilated pupils, hepatic dysfunction; V seizures, multiple organ failure, death. | The early stage looks like the viral illness it follows, so vomiting plus lethargy in a child who took aspirin is the trigger to act. | Neurologic / Hepatic | L5 slide 19 |
| IbuprofenBlack box | Gastric or duodenal ulcers, perforation and bleeding. Edema and fluid retention. Acute renal failure and decreased creatinine clearance. Prescription nonsteroidal anti-inflammatory drugs also carry an FDA (Food and Drug Administration) boxed warning for cardiovascular events and gastrointestinal bleeding. | Monitor kidney function (creatinine clearance) and watch for signs of stomach bleeding and swelling; risk climbs with regular daily use. | Gastrointestinal / Renal | L5 slide 21 |
| Acetaminophen | No notable side effects at therapeutic doses; very well tolerated. | Stay within the fixed daily maximum, counting every product that contains it; too much damages the liver. | Hepatic (overdose) | L5 slide 24 |
| Acetaminophen — with alcohol | Alcohol plus acetaminophen increases the risk of liver damage (chronically). | Ask about regular alcohol use and pre-existing liver disease before recommending it. | Hepatic | L5 slide 25 |
| H1 antagonists (antihistamines) | ||||
| First-generation H1 antagonists — central effects | Sedation is the major side effect and is additive with other central nervous system depressants or alcohol. Restlessness and excitation at higher doses (especially in children); excitation is seen in overdose. | Warn about driving and alcohol. Second-generation agents cause much less sedation. | Neurologic | L5 slide 32 |
| First-generation H1 antagonists — class adverse effects | Sedation; gastrointestinal disturbances; antimuscarinic effects: dry mouth, urinary retention, blurred vision; with topical use, hypersensitivity (dermatitis, photosensitivity). | Ask about difficulty urinating and vision change; advise sun protection with topical use. | Neurologic / Anticholinergic / Skin | L5 slide 36 |
| Azelastine Astelin | Bitter taste and epistaxis (nosebleed). | If a nosebleed develops, stop the spray and follow up. | Ear, nose and throat / Local | L5 slide 38 |
| Nasal corticosteroids | ||||
| Nasal corticosteroids beclomethasone, budesonide, flunisolide, fluticasone, mometasone, triamcinolone | Epistaxis (nosebleed), septal perforation and an unpleasant taste. | Effects are mostly local at usual doses; check the septum if nosebleeds recur. | Ear, nose and throat / Local | L5 slide 43 |
| Systemic corticosteroids | ||||
| Dexamethasone | Congestive heart failure, hypertension and fluid retention; glucose intolerance; hirsutism, cushingoid features, potassium loss, sodium retention, tendon rupture; papilledema, glaucoma, increased intraocular pressure, cataracts, exophthalmos; decreased resistance to infections. | Watch blood pressure, weight and swelling, glucose, potassium, eye pressure and signs of infection; time and dose drive the risk, so keep courses short. | Cardiovascular / Metabolic / Eye / Immune | L5 slide 44 |
| Prednisone and prednisolone | Sodium and fluid retention, congestive heart failure, hypertension, low potassium; tendon rupture and pathologic fractures of long bones; increased liver function tests, cushingoid features, glucose intolerance; cataracts, increased intraocular pressure, glaucoma, exophthalmos; compromised immune system. | Watch blood pressure, fluid status, potassium, glucose, liver function tests, eye pressure and signs of infection. | Cardiovascular / Metabolic / Musculoskeletal / Eye / Immune | L5 slide 47 |
| Decongestants | ||||
| Oxymetazoline Afrin | Rebound rhinitis (rhinitis medicamentosa) if used for more than 3–5 days. Hypertension. | Count the days of use; a patient stuck in rebound needs to taper off, not simply reuse the spray. | Ear, nose and throat / Cardiovascular | L5 slide 50 |
| Pseudoephedrine Sudafed | Tachycardia, hypertension and headache. Decreases the effect of blood pressure medicines. | Check blood pressure and heart rate; ask about antihypertensive use. | Cardiovascular / Neurologic | L5 slide 52 |
| Antitussives | ||||
| Benzonatate Tessalon | Local anesthesia of the mouth from chewing the capsule. | Ensure the capsule is swallowed whole. | Local / Mouth | L5 slide 57 |
| Dextromethorphan Robitussin, Delsym | Confusion, excitement and agitation. Risk for serotonin syndrome with other pro-serotonergic drugs. | Review the medication list for antidepressants and other serotonin-raising drugs. | Neurologic | L5 slide 58 |
| Expectorants and mucolytics | ||||
| Guaifenesin | Nausea and vomiting. | No interaction information is available. | Gastrointestinal | L5 slide 59 |
| N-acetylcysteine inhaled | Rotten-egg smell (high sulfur content), nausea and vomiting, and bronchospasm with the inhaled route. | Watch the breathing of any patient who wheezes, especially after nebulization. | Respiratory / Gastrointestinal | L5 slide 63 |
| Drug or class | Side effects | Monitoring & what to watch | System | Source |
|---|---|---|---|---|
| ACE inhibitors | ||||
| ACE (angiotensin-converting enzyme) inhibitors -pril: captopril, lisinopril, enalapril, ramipril | Dry cough in 5–15% of patients (bradykinin and substance P accumulate in the lungs), appearing from 1 week to 6 months; not related to dose or specific agent; more frequent in women. | Ask about a persistent dry cough. If bothersome, the ACE inhibitor may need to be removed; changing the dose does not help. | Respiratory | L6 slide 19 |
| ACE (angiotensin-converting enzyme) inhibitors -pril: captopril, lisinopril, enalapril, ramipril | Hyperkalemia (raised potassium). Most often seen with kidney disease and in those taking potassium-sparing diuretics, potassium supplements or salt substitutes. | Check potassium. Tell the patient to avoid potassium supplements and salt substitutes unless told to use them. | Metabolic / Cardiovascular | L6 slide 20 |
| ACE (angiotensin-converting enzyme) inhibitors -pril: captopril, lisinopril, enalapril, ramipril | First-dose hypotension, at the first dose or on upward titration. Most common in patients who are sodium depleted, have heart failure, or take multiple antihypertensive medicines. | Watch blood pressure after the first dose and after each increase; ask about dizziness on standing. | Cardiovascular | L6 slide 20 |
| ACE (angiotensin-converting enzyme) inhibitors -pril: captopril, lisinopril, enalapril, ramipril | Renal function impairment: where renal blood flow is highly dependent on angiotensin II, ACE inhibitors dramatically decrease the glomerular filtration rate. | Use cautiously: low doses, moved upward slowly; follow kidney function. | Renal | L6 slide 21 |
| ACE (angiotensin-converting enzyme) inhibitors -pril: captopril, lisinopril, enalapril, ramipril | Angioedema (rare, 0.1–0.5%): rapid swelling of the nose, throat, mouth, larynx, lips and tongue. Usually develops in the first week; reversible if the drug is removed; thought to be due to bradykinin accumulation. | Teach the patient to report lip, tongue or throat swelling immediately. Stop the drug. | Allergic / Airway | L6 slide 22 |
| ACE (angiotensin-converting enzyme) inhibitors -pril: captopril, lisinopril, enalapril, ramiprilBlack box | Fetal morbidity and mortality: birth defects and fetal death. Contraindicated in the second and third trimesters. This is also an FDA boxed warning (black box). | Confirm the patient is not pregnant before starting; counsel on contraception and to report a missed period. In practice the drug is stopped as soon as pregnancy is found. | Reproductive / Fetal | L6 slide 22 |
| ACE (angiotensin-converting enzyme) inhibitors -pril: captopril, lisinopril, enalapril, ramipril | Interaction with NSAIDs (nonsteroidal anti-inflammatory drugs): they decrease the effect of ACE inhibitors by blocking the bradykinin-mediated relaxation that depends on prostaglandins. | Watch for blood pressure rising when a nonsteroidal pain reliever is started. | Drug interaction | L6 slide 22 |
| Angiotensin receptor blockers | ||||
| ARBs (angiotensin receptor blockers) -sartan: losartan, valsartan, candesartan | Hyperkalemia with kidney disease or potassium-sparing diuretics. | Check potassium, especially when a potassium-sparing diuretic is added. | Metabolic / Cardiovascular | L6 slide 29 |
| ARBs (angiotensin receptor blockers) -sartan: losartan, valsartan, candesartan | First-dose hypotension, and impairment of kidney function (angiotensin II is important for kidney function). | Watch blood pressure after the first dose; follow kidney function. In heart failure start low and titrate upward. | Cardiovascular / Renal | L6 slide 29 |
| ARBs (angiotensin receptor blockers) -sartan: losartan, valsartan, candesartanBlack box | Fetal morbidity and mortality: not given in the second and third trimesters. This is also an FDA boxed warning (black box). | Confirm the patient is not pregnant before starting; report pregnancy right away. In practice the drug is stopped as soon as pregnancy is found. | Reproductive / Fetal | L6 slide 29 |
| ARBs (angiotensin receptor blockers) -sartan: losartan, valsartan, candesartan | Do not cause cough (they do not affect bradykinin metabolism) and have a lower incidence of angioedema; a patient may be switched from an ACE (angiotensin-converting enzyme) inhibitor. | A dry cough on an ACE inhibitor is the reason to switch. In heart failure, start with low doses and titrate upward. | Respiratory / Allergic | L6 slide 30 |
| Calcium channel blockers: non-dihydropyridines | ||||
| Non-dihydropyridine calcium channel blockers diltiazem, verapamil | Peripheral vasodilation: flushing, headache, hypotension, peripheral edema, dizziness. Negative inotropic effects: first-degree atrioventricular block, bradycardia, and exacerbation of congestive heart failure or pulmonary edema. | Watch heart rate, blood pressure and signs of heart failure (swelling, breathlessness). | Cardiovascular | L6 slide 45 |
| Non-dihydropyridine calcium channel blockers diltiazem, verapamil | Gastrointestinal effects: nausea and vomiting, diarrhea, anorexia and constipation. Elevations in liver-function tests. | Ask about bowel habits; follow liver function tests. | Gastrointestinal / Hepatic | L6 slide 45 |
| Non-dihydropyridine calcium channel blockers diltiazem, verapamil | Central nervous system effects: fatigue, nervousness, drowsiness, dizziness, depression, insomnia, confusion. Gynecomastia or sexual dysfunction, gingival hyperplasia and skin reactions. | Ask about mood, sleep and sexual side effects; good dental hygiene for the gums. | Neurologic / Endocrine / Dermatologic | L6 slide 45 |
| Non-dihydropyridine calcium channel blockers diltiazem, verapamil | They inhibit cytochrome P450 3A4 (CYP3A4), raising levels of the statins atorvastatin, lovastatin and simvastatin, carbamazepine, propranolol, tacrolimus and cyclosporine. They also inhibit P-glycoprotein, raising tacrolimus, cyclosporine, carbamazepine and digoxin. | Review every medicine on the list when one of these is started; watch for toxicity of the other drug. | Drug interaction | L6 slide 47 |
| Non-dihydropyridine calcium channel blockers diltiazem, verapamil | Pharmacodynamic interactions: with amiodarone (slows the sinus rate or worsens atrioventricular block), digoxin and beta blockers. | Monitor heart rate, rhythm and blood pressure whenever another drug that slows the heart is combined. | Cardiovascular / Drug interaction | L6 slide 47 |
| Non-dihydropyridine calcium channel blockers diltiazem, verapamil | Because these drugs are also substrates of cytochrome P450 3A4 (CYP3A4), CYP3A4 inhibitors increase their half-life. | Watch for more side effects when a CYP3A4 inhibitor is added. | Drug interaction | L6 slide 48 |
| Calcium channel blockers: dihydropyridines | ||||
| Dihydropyridine calcium channel blockers -dipine: amlodipine, nifedipine, nicardipine | Peripheral vasodilation: peripheral edema, dyspnea, wheezing and rebound tachycardia. | Ask about ankle swelling and a racing heart. | Cardiovascular / Respiratory | L6 slide 51 |
| Dihydropyridine calcium channel blockers -dipine: amlodipine, nifedipine, nicardipine | Gastrointestinal, central nervous system and skin effects. Gynecomastia (reported more with nifedipine than with diltiazem, a non-dihydropyridine) and gingival hyperplasia. | Good dental hygiene for the gums. | Gastrointestinal / Endocrine / Dermatologic | L6 slide 51 |
| Dihydropyridine calcium channel blockers -dipine: amlodipine, nifedipine, nicardipine | Pharmacodynamic interactions with amiodarone, digoxin and beta blockers. | Monitor blood pressure and heart rate when combined. | Drug interaction | L6 slide 53 |
| Dihydropyridine calcium channel blockers -dipine: amlodipine, nifedipine, nicardipine | cytochrome P450 3A4 (CYP3A4) inhibitors increase the half-life of dihydropyridines. | Watch for more side effects when a CYP3A4 inhibitor is added. | Drug interaction | L6 slide 54 |
| Beta blockers | ||||
| Beta blockers -olol | Bronchoconstriction: asthma exacerbation. About one third of patients with chronic obstructive pulmonary disease have bronchospasm. Less likely with beta-1 selective agents. | Ask about wheezing; prefer a beta-1 selective agent in patients with lung disease. | Respiratory | L6 slide 71 |
| Beta blockers -olol | Cardiodepressive actions: negative inotropy (fatigue, heart failure); negative chronotropy (bradycardia, heart rate below 60 beats per minute); atrioventricular block: first-, second- and third-degree heart block. | Check pulse and blood pressure; report fainting, marked fatigue or swelling. | Cardiovascular | L6 slide 71 |
| Beta blockers -olol | Disturbed glucose metabolism: they inhibit glycogenolysis, prolonging hypoglycemia and masking its symptoms (type 1 diabetes); in type 2 they lower insulin release and raise glucose, which is hard to control. | Monitor blood glucose; warn diabetic patients that warning signs of low blood sugar may be hidden. | Metabolic / Endocrine | L6 slide 72 |
| Beta blockers -olol | Impaired peripheral circulation: block beta-2 receptors in blood vessels, causing cold extremities (Raynaud phenomenon), skeletal muscle fatigue, and worsened intermittent claudication in peripheral artery disease. | Ask about cold hands and feet and leg pain on walking. | Vascular | L6 slide 73 |
| Beta blockers -ololBlack box | Sudden withdrawal syndrome: acute angina, myocardial infarction and a marked rise in blood pressure, because blockade upregulates the receptors. This is also an FDA boxed warning (black box). | Never stop abruptly; withdraw slowly. Ask about missed doses and travel. | Cardiovascular | L6 slide 73 |
| Beta blockers -olol | Central nervous system effects of highly lipid-soluble agents: depression, nightmares, vivid dreams, hallucinations, fatigue. Beta blockers in general can also elevate triglycerides, a separate effect. | Ask about mood and sleep; a less lipid-soluble agent may be substituted. Follow triglycerides. | Neurologic / Metabolic | L6 slide 74 |
| Beta blockers -olol | With verapamil or diltiazem: synergistic falls in blood pressure, heart rate and contractility. Use lower doses of each in combination. | Monitor pulse and blood pressure; the combination risks heart block and bradycardia. | Cardiovascular / Drug interaction | L6 slide 75 |
| Beta blockers -olol | With clonidine: further lowering of blood pressure; abrupt clonidine withdrawal produces a marked rise in blood pressure. | Never stop clonidine suddenly in a patient also taking a beta blocker. | Cardiovascular / Drug interaction | L6 slide 75 |
| Alpha-1 blockers | ||||
| Alpha-1 blockers -zosin: prazosin, terazosin, doxazosin | Orthostatic hypotension, postural dizziness, headache, drowsiness and lack of energy (prazosin). | Counsel on rising slowly; first doses at bedtime are commonly used. | Cardiovascular / Neurologic | L6 slide 79 |
| Alpha-1 blockers -zosin: prazosin, terazosin, doxazosin | Mild reflex tachycardia (perhaps limited by some central sympatholytic activity and by dilation of both arteries and veins); increased renin, and sodium and water retention; impotence. | Watch heart rate, fluid retention and sexual function. | Cardiovascular / Renal / Sexual | L6 slide 80 |
| Alpha-1 blockers -zosin: prazosin, terazosin, doxazosin | NSAIDs (nonsteroidal anti-inflammatory drugs) attenuate the response; beta blockers may enhance postural hypotension. | Use caution in cardiac and renal failure. | Drug interaction | L6 slide 81 |
| Tamsulosin Flomax | Hypotension, dizziness and diarrhea. | Less vascular effect than the other alpha-1 blockers, but still check for dizziness. | Cardiovascular / Gastrointestinal | L6 slide 84 |
| Central sympatholytics | ||||
| Central sympatholytics clonidine, guanfacine | General class effects: drowsiness and sedation, dry mouth (both central), sexual dysfunction, narrow therapeutic range and abrupt withdrawal hypertension. | Counsel to expect drowsiness and dry mouth; never stop suddenly. | Neurologic / Cardiovascular | L6 slide 91 |
| Clonidine Catapres | Increases blood glucose (inhibits insulin secretion). An initial acute pressor response (a brief rise in pressure) can occur. | Follow blood glucose in diabetic patients. | Metabolic / Cardiovascular | L6 slide 92 |
| Clonidine Catapres | Sodium retention (so it is often given with a diuretic), dry mouth and sedation (central effects); decreases antidiuretic hormone secretion. | Watch for fluid retention and swelling; counsel about drowsiness. | Renal / Neurologic | L6 slide 93 |
| Clonidine Catapres | Withdrawal reactions (may be severe), orthostatic hypotension, impotence and bradycardia. | Never stop abruptly; taper. Check pulse and standing blood pressure. | Cardiovascular | L6 slide 94 |
| Guanfacine Tenex | Less sedation than clonidine and only an occasional withdrawal syndrome. | Still avoid stopping suddenly. | Neurologic | L6 slide 95 |
| Direct vasodilators | ||||
| Direct vasodilators hydralazine, minoxidil, nitroprusside | Reflex effects of arteriolar dilation: tachycardia, increased cardiac output, fluid retention and increased renin, then tachyphylaxis. | Watch heart rate, weight and swelling; hydralazine and minoxidil are paired with a diuretic and a beta blocker. | Cardiovascular / Renal | L6 slide 97 |
| Hydralazine Apresoline | Headache, dizziness, flushing. Reflex increase in cardiac output and fluid volume. | Watch for swelling and a fast pulse. | Cardiovascular / Dermatologic | L6 slide 101 |
| Hydralazine Apresoline | Hydralazine “lupus syndrome”: more likely with high dose, long-term use, women, slow acetylators and Caucasians. Hydralazine is acetylated in the liver by fast or slow acetylators. | Ask about joint pain, fever and rash with long-term use. | Immunologic | L6 slide 101 |
| Minoxidil LonitenBlack box | More severe hemodynamic actions than hydralazine: cardiac output rises 2–3 times and renin release is stimulated. Myocardial ischemia from the reflexes and sympathetic activity; arrhythmias from action on the potassium channel. Minoxidil also carries an FDA boxed warning (black box) for pericardial effusion and worsening angina; it must be given with a beta blocker and a diuretic. | Report chest pain or palpitations; usually given with a beta blocker and a diuretic. | Cardiovascular | L6 slide 104 |
| Minoxidil Loniten; topical Rogaine | Hypertrichosis (hair growth) on the face, back, arms and legs. Topical Rogaine may have cardiovascular effects. | Warn the patient before starting. | Dermatologic | L6 slide 105 |
| Nitroprusside NitropressBlack box | Cyanide toxicity (a toxic metabolite): trembling, vomiting, convulsions. Sodium thiosulfate is given to limit cyanide toxicity. This is also an FDA boxed warning (black box). | Watch for the signs during infusion; give sodium thiosulfate. | Toxicologic / Neurologic | L6 slide 107 |
| Nitroprusside Nitropress | Thiocyanate toxicity: weakness, anoxia, tinnitus, muscle spasms and toxic psychosis, seen with long-term infusions or kidney failure. | Limit duration; follow kidney function. | Toxicologic / Neurologic | L6 slide 107 |
| Drug or class | Side effects | Monitoring & what to watch | System | Source |
|---|---|---|---|---|
| Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) | ||||
| Statins atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin | Common: headache, sleep disturbance, fatigue, gastrointestinal intolerance and flu-like symptoms. Increase in liver enzymes occurs in 0.5 to 2.5% of cases in a dose-dependent manner; serious liver problems are exceedingly rare. | Monitor liver enzymes. Manage a rise by reducing the dose, or stop the drug until levels return to normal. | Neurologic / Gastrointestinal / Hepatic | L7 slide 21 |
| Statins atorvastatin, fluvastatin, lovastatin, pitavastatin, pravastatin, rosuvastatin, simvastatin | Myalgia and myopathy (0.2 to 0.4% of patients) and rare rhabdomyolysis. | Reduce the risk with caution in impaired kidney function, the lowest effective dose, cautious combination with fibrates, avoiding other drug interactions, and careful monitoring of symptoms and laboratory values. Muscle toxicity requires stopping the statin. | Musculoskeletal / Renal | L7 slide 22 |
| Cholesterol absorption inhibitor | ||||
| Ezetimibe Zetia | Gastrointestinal effects and elevations in liver transaminases when combined with a statin. | Monitor liver function when it is used with a statin. | Gastrointestinal / Hepatic | L7 slide 30 |
| Ezetimibe Zetia | Combined with a fibrate, hepatobiliary side effects increase, leading to cholelithiasis (gallstones) and myopathies. | Watch for abdominal pain and for muscle symptoms if a fibrate is added. | Hepatobiliary / Musculoskeletal | L7 slide 31 |
| Fibrates (fibric acid derivatives) | ||||
| Fibrates gemfibrozil, fenofibrate, bezafibrate | Gastrointestinal: nausea, abdominal pain and diarrhea. Cholelithiasis (gallstones) and myopathy. | Ask about abdominal pain and muscle symptoms; use extra caution when a fibrate is combined with a statin. | Gastrointestinal / Hepatobiliary / Musculoskeletal | L7 slide 36 |
| Fibrates gemfibrozil, fenofibrate, bezafibrate | Increased anticoagulant effect of warfarin, so bleeding and bruising risk rises. Fibrates also interact with statins, ezetimibe and bile acid sequestrants. | Watch for bruising and bleeding and monitor anticoagulation when a fibrate is started in a patient on warfarin. | Hematologic | L7 slide 38 |
| Bile acid sequestrants (resins) | ||||
| Bile acid sequestrants cholestyramine, colestipol, colesevelam | Not absorbed from the gastrointestinal tract. Gastrointestinal effects: bloating, flatulence, fullness, constipation and nausea. Malabsorption of vitamins A, D, E and K and folic acid. May increase very low-density lipoprotein production and so raise triglycerides. The resin also increases calcium excretion. | Watch fat-soluble vitamin and folic acid status with long-term use and check triglycerides, since they can rise. | Gastrointestinal / Nutritional / Metabolic | L7 slide 46 |
| Niacin (nicotinic acid) | ||||
| Niacin nicotinic acid, vitamin B3 | Cutaneous flushing (prostaglandin mediated), nausea and abdominal discomfort. With larger doses, raised liver function tests, glucose and uric acid and decreased glucose tolerance. Immediate release and extended release forms differ in their adverse effects. | Premedicate with aspirin to minimize flushing. Monitor liver function tests, glucose (diabetes) and uric acid (gout); extended release is the usual form because it causes less flushing. | Dermatologic / Gastrointestinal / Metabolic / Hepatic | L7 slide 55 |
| Statin plus niacin combination | ||||
| Lovastatin plus extended release niacin Advicor | Hepatotoxicity, myopathy and flushing. | Monitor liver function and muscle symptoms, and warn about flushing. | Hepatic / Musculoskeletal / Dermatologic | L7 slide 59 |
| PCSK9 inhibitors | ||||
| PCSK9 inhibitors alirocumab, evolocumab | Hypersensitivity reactions are the most serious adverse reaction of the proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. | Watch for allergic reactions after injection; stop and evaluate if one occurs. | Immune / Allergic | L7 slide 60 |
| Drug or class | Side effects | Monitoring & what to watch | System | Source |
|---|---|---|---|---|
| Beta blockers | ||||
| Beta blockers metoprolol, atenolol (beta-1 selective); propranolol, nadolol (non-selective); carvedilol, labetalol (third generation) | Hypotension and bradycardia (slowed pulse) are the listed cardiovascular adverse reactions. | Monitor heart rate. Warn about dizziness. | Cardiovascular | L8 slide 19 |
| Beta blockers metoprolol, atenolol (beta-1 selective); propranolol, nadolol (non-selective); carvedilol, labetalol (third generation) | Hyperglycemia and dyslipidemia (altered lipids). | Monitor blood sugar and lipids. | Metabolic | L8 slide 19 |
| Beta blockers metoprolol, atenolol (beta-1 selective); propranolol, nadolol (non-selective); carvedilol, labetalol (third generation) | Fatigue, sexual dysfunction, nightmares and worsened claudication (leg pain on walking from peripheral vascular disease). | Ask about tiredness, sleep and sexual function; patients with peripheral vascular disease may notice more leg pain. | Neurologic / Vascular | L8 slide 19 |
| Beta blockers metoprolol, atenolol (beta-1 selective); propranolol, nadolol (non-selective); carvedilol, labetalol (third generation)Black box | Rapid discontinuation must be avoided; stop gradually. (Added background: abrupt cessation can cause rebound angina and myocardial infarction.) Added background: several beta blockers (for example metoprolol, atenolol and nadolol) carry a Food and Drug Administration (FDA) boxed warning (black box) for abrupt cessation; carvedilol and labetalol carry no boxed warning. | Never stop abruptly; stop gradually. Ask about missed doses, running out of medicine and travel. | Cardiovascular | L8 slide 19 |
| Calcium channel blockers | ||||
| Calcium channel blockers dihydropyridine and non-dihydropyridine | Hypotension is the adverse reaction listed for the whole class. | Monitor for relief of symptoms; ask about dizziness on standing. | Cardiovascular | L8 slide 24 |
| Dihydropyridine calcium channel blockers nifedipine, amlodipine, felodipine | Headache, flushing and peripheral edema (ankle swelling). | Ask about headache and ankle swelling; these come from the vasodilation. | Vascular / Neurologic | L8 slide 24 |
| Non-dihydropyridine calcium channel blockers diltiazem, verapamil | Slow the heart rate and atrioventricular conduction (verapamil the most), and lower contractility; dihydropyridines leave conduction unchanged. | Monitor heart rate. Watch for heart block, especially when combined with a beta blocker. | Cardiovascular | L8 slide 21 |
| Calcium channel blockers dihydropyridine and non-dihydropyridine | Dizziness and constipation are the counseling points for the class; constipation is mainly a verapamil effect. | Ask about bowel habits and dizziness. | Gastrointestinal / Neurologic | L8 slide 24 |
| Nitrates | ||||
| Long-acting nitrates isosorbide mononitrate (Imdur), isosorbide dinitrate; nitroglycerin ointment (Nitro-Bid) and transdermal patch | Headache, flushing, postural hypotension and reflex tachycardia (a fast pulse as the body answers the fall in pressure). | Ask about headache and dizziness on standing; orthostatic hypotension is the warning for every nitrate user. | Cardiovascular / Neurologic | L8 slide 31 |
| Short-acting nitrates nitroglycerin: sublingual tablet (Nitrostat), lingual spray (Nitrolingual Pumpspray) | Orthostatic hypotension is the warning given for the short-acting forms. | Ask about dizziness on standing after a dose. | Cardiovascular | L8 slide 28 |
| Nitrates nitroglycerin, isosorbide | Tachyphylaxis (loss of effect with continuous use). | Use a nitrate-free interval, timed to when symptoms are least frequent. | Drug tolerance | L8 slide 32 |
| Nitrates nitroglycerin, isosorbide | Hypotension and myocardial infarction or stroke when taken with a phosphodiesterase type 5 inhibitor (sildenafil, tadalafil, vardenafil). | Screen for erectile dysfunction drugs before starting or dosing a nitrate. | Cardiovascular / Neurologic | L8 slide 33 |
| Morphine | ||||
| Morphine opioid analgesic | Hypotension and allergy. It may also increase mortality in unstable angina and non-ST-elevation myocardial infarction. | Monitor blood pressure after a dose. | Cardiovascular / Immune | L8 slide 56 |
| Fibrinolytics | ||||
| Fibrinolytics streptokinase; alteplase (Activase), reteplase (Retavase), tenecteplase (TNKase) | Bleeding is the main adverse effect of every agent, and includes intracranial hemorrhage. | Watch for new neurologic signs and any bleeding; screen carefully against the contraindication list before giving. | Hematologic / Neurologic | L8 slide 62 |
| Streptokinase | Allergic reactions, with fever, chills and skin rash, occur mainly with streptokinase. Anaphylactic reactions can occur with the class. | A prior streptokinase exposure or reaction is a contraindication; choose a different agent next time. | Immune | L8 slide 62 |
| Fibrinolytics streptokinase; alteplase (Activase), reteplase (Retavase), tenecteplase (TNKase) | Ventricular arrhythmias are a listed adverse effect of the class. | Watch the heart rhythm after treatment. | Cardiovascular | L8 slide 62 |