When NOT to give each drug. 32 entries across the Exam 3 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 |
|---|---|---|---|
| Loop diuretics | |||
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Caution | Caution: history of gout. Loop diuretics raise plasma uric acid and can precipitate a gout attack. | L9 slide 18 |
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Caution | Caution: diabetes. Hyperglycemia (low potassium, impaired insulin release, insulin resistance) can worsen blood sugar control. | L9 slide 18 |
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Caution | Caution with other ear-toxic drugs (aminoglycosides), lithium, warfarin and digoxin: aminoglycosides add to ear toxicity, lithium clearance falls, warfarin competes for protein binding and low potassium and magnesium with digoxin cause arrhythmias; nonsteroidal anti-inflammatory drugs blunt the diuretic and blood pressure response. | L9 slide 19 |
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Caution | Caution: volume depletion, hypokalemia and hyponatremia. Existing volume depletion or electrolyte loss is worsened by a loop diuretic. | L9 slide 18 |
| Thiazide diuretics | |||
| Thiazide diuretics chlorothiazide, hydrochlorothiazide, chlorthalidone, metolazone, indapamide | Caution | Caution: gout and diabetes. Thiazides cause hyperuricemia and hyperglycemia. | L9 slide 26 |
| Thiazide diuretics chlorothiazide, hydrochlorothiazide, chlorthalidone, metolazone, indapamide | Caution | Caution: hypercalcemia. Thiazides decrease renal calcium excretion and can raise serum calcium. | L9 slide 27 |
| Thiazide diuretics chlorothiazide, hydrochlorothiazide, chlorthalidone, metolazone, indapamide | Caution | Poor effect at a low creatinine clearance (below about 30 to 40 milliliters per minute); a loop diuretic still works there, and metolazone remains effective. Added background: newer trial data show chlorthalidone can still work in advanced kidney disease, so the cutoff is not absolute. | L9 slide 28 |
| Thiazide diuretics chlorothiazide, hydrochlorothiazide, chlorthalidone, metolazone, indapamide | Caution | Caution with digoxin and nonsteroidal anti-inflammatory drugs: thiazides increase digoxin toxicity unless potassium stays above 4.0 mEq per liter, and nonsteroidal anti-inflammatory drugs weaken the diuretic effect. | L9 slide 29 |
| Potassium-sparing diuretics | |||
| Potassium-sparing diuretics amiloride, triamterene | Caution | Caution with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and potassium supplements because of hyperkalemia. Added background: these drugs should not be started when serum potassium is already high; salt substitutes (potassium chloride) count as potassium. | L9 slide 33 |
| Potassium-sparing diuretics amiloride, triamterene | Caution | Caution: diabetes (glucose intolerance). | L9 slide 33 |
| Triamterene and amiloride named reactions | Named reaction | Triamterene: megaloblastic anemia. Amiloride: azotemia. | L9 slide 33 |
| Aldosterone antagonists | |||
| Aldosterone antagonists spironolactone, eplerenone | Avoid | Not eligible if potassium is above 5 or serum creatinine is above 2.5: kidney dysfunction makes hyperkalemia and arrhythmias more likely. | L9 slide 73 |
| Spironolactone named reaction | Named reaction | Gynecomastia and testicular atrophy in men; menstrual irregularities in women (hirsutism is also listed, but spironolactone is used to treat it). Switch to eplerenone, which has less effect on androgen receptors. | L9 slide 38 |
| Carbonic anhydrase inhibitors | |||
| Carbonic anhydrase inhibitors acetazolamide, dichlorphenamide, methazolamide | Caution | Caution: metabolic acidosis and potassium depletion. These drugs cause both, so they add to an existing acidosis or low potassium. | L9 slide 43 |
| Heart failure: diuretics, ACE inhibitors and beta blockers | |||
| ACE (angiotensin-converting enzyme) inhibitors in heart failure | Caution | Caution: impaired renal function, hypotension and high potassium. | L9 slide 56 |
| ACE (angiotensin-converting enzyme) inhibitors in heart failure | Avoid | History of angioedema. Angioedema is a listed problem. Added background: an angiotensin receptor blocker is the usual substitute if it occurs. | L9 slide 56 |
| ACE (angiotensin-converting enzyme) inhibitors in heart failure | Avoid | Pregnancy. Added background: FDA boxed warning (black box) for fetal toxicity with angiotensin-converting enzyme inhibitors; stop as soon as pregnancy is found. | L9 slide 56 |
| Beta blockers in heart failure carvedilol, metoprolol succinate, bisoprolol | Caution | Beta blockers were classically considered contraindicated in heart failure; they are now first-line in class II to IV heart failure when started carefully (stable patient, very low dose, slow titration). | L9 slide 57 |
| Beta blockers in heart failure carvedilol, metoprolol succinate, bisoprolol | Avoid | Do not start in an unstable or decompensated patient. The patient should be stable before initiation; start with very low doses and titrate up slowly. | L9 slide 58 |
| Thiazide diuretics in heart failure | Caution | Not potent enough for most patients with heart failure; a loop diuretic is the mainstay. | L9 slide 52 |
| Digoxin | |||
| Digoxin cardiac glycoside | Contraindicated | Advanced atrioventricular block. | L9 slide 71 |
| Digoxin cardiac glycoside | Contraindicated | Severe bradycardia or sick sinus syndrome. | L9 slide 71 |
| Digoxin cardiac glycoside | Contraindicated | Premature ventricular contractions and ventricular tachycardia (digoxin makes the ventricle more irritable). | L9 slide 71 |
| Digoxin cardiac glycoside | Contraindicated | Wolff-Parkinson-White syndrome. | L9 slide 71 |
| Digoxin cardiac glycoside | Caution | Electrolyte disturbances that raise the risk of toxicity: low potassium, low magnesium and high calcium. It is low potassium (hypokalemia), not high potassium, that increases digoxin toxicity. Loop diuretics and thiazides lower potassium and magnesium, so keep potassium above 4.0 mEq per liter and correct low potassium and magnesium before and during treatment. | L9 slide 71 |
| Digoxin cardiac glycoside | Caution | Caution: higher drug concentrations may be associated with worse outcomes in heart failure. Added background: digoxin has a narrow therapeutic index, so levels are monitored. | L9 slide 65 |
| Other heart failure drugs | |||
| Phosphodiesterase (type III) inhibitors milrinone, inamrinone | Avoid | Avoid long-term use: it is associated with higher mortality and morbidity than placebo; ventricular arrhythmias and thrombocytopenia are risks. | L9 slide 76 |
| Ivabradine hyperpolarization-activated channel blocker | Avoid | Similar contraindications to beta blockers: hypotension, heart block, pacemaker dependence. | L9 slide 80 |
| Ivabradine hyperpolarization-activated channel blocker | Caution | Not for patients without sinus rhythm or with a slow resting heart rate: it is used in normal sinus rhythm with a heart rate above about 70 beats per minute, and it increases the risk of atrial fibrillation. | L9 slide 79 |
| Sacubitril-valsartan neprilysin inhibitor with an angiotensin receptor blocker | Avoid | Do not use with an angiotensin-converting enzyme inhibitor; allow a 36-hour washout. | L9 slide 81 |
| Sacubitril-valsartan neprilysin inhibitor with an angiotensin receptor blocker | Avoid | Pregnancy. Added background: FDA boxed warning (black box) for fetal toxicity. | L9 slide 81 |
| Sodium-glucose cotransporter 2 (SGLT2) inhibitors dapagliflozin, empagliflozin | Caution | Caution: hypotension (volume depletion) and risk of fungal urinary infection. Added background: genital yeast infections are the typical form. | L9 slide 82 |