51 entries across the Exam 3 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 |
|---|---|---|---|---|
| Loop diuretics | ||||
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Volume depletion through reflex mechanisms, with azotemia (a rise in blood urea nitrogen). Excess diuresis can cause hypotension and cardiovascular collapse. | Check weight, blood pressure and orthostatic symptoms; check blood urea nitrogen and creatinine. | Renal / Fluid | L9 slide 18 |
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acidBlack box | Volume depletion when given in excess. Added background: furosemide, bumetanide and ethacrynic acid carry an FDA boxed warning (black box) for profound diuresis with water and electrolyte depletion; torsemide carries none. | Start at the lowest effective amount and watch fluid status and electrolytes closely. | Renal / Fluid | L9 slide 18 |
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Hypokalemia (potassium loss) with the risk of cardiac arrhythmias. | Monitor serum potassium; a potassium-sparing partner or supplement may be added. Highest risk with digoxin. | Electrolytes / Cardiovascular | L9 slide 18 |
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Loss of calcium and magnesium in the urine (hypocalcemia and hypomagnesemia). | Monitor magnesium and calcium with long-term use. | Electrolytes | L9 slide 13 |
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Hyponatremia, which can lead to seizures. | Monitor serum sodium. | Electrolytes / Neurologic | L9 slide 18 |
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Hyperglycemia (a diabetogenic effect): low potassium impairs insulin release, catecholamines are released reflexively (alpha-2 decreases insulin release, beta-2 increases glycogenolysis) and peripheral glucose uptake is impaired. | Monitor blood glucose in patients with diabetes. | Metabolic | L9 slide 18 |
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Contraction alkalosis: mild metabolic alkalosis from volume depletion and, mainly, enhanced hydrogen ion secretion. | Watch serum bicarbonate. | Acid-base | L9 slide 18 |
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Hyperuricemia and gout: less uric acid is excreted and the plasma is concentrated by the lost volume. | Ask about a history of gout; a flare may follow starting the drug. | Metabolic / Musculoskeletal | L9 slide 18 |
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Ototoxicity: damages hair cells in the cochlea (hearing loss). Aminoglycosides potentiate it. | Ask about tinnitus or hearing change; avoid combining with other ear-toxic drugs. | Sensory | L9 slide 18 |
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Allergic reactions: rash and photosensitivity. | Counsel on sun protection and to report a rash. | Dermatologic | L9 slide 18 |
| Loop diuretics furosemide, bumetanide, torsemide, ethacrynic acid | Mild hyperlipidemia (sympathetic activity raises triglycerides) and reflex activation of renin-angiotensin, aldosterone and antidiuretic hormone. | Lipids are a minor concern; the reflex activation explains a weakened diuretic effect. | Metabolic / Endocrine | L9 slide 16 |
| Thiazide diuretics | ||||
| Thiazide diuretics chlorothiazide, hydrochlorothiazide, chlorthalidone, metolazone, indapamide | Volume depletion with reflex sympathetic activation and increased renin-angiotensin, aldosterone and antidiuretic hormone activity; an acute drop in glomerular filtration rate. | Check weight, blood pressure and kidney function. | Renal / Fluid | L9 slide 26 |
| Thiazide diuretics chlorothiazide, hydrochlorothiazide, chlorthalidone, metolazone, indapamide | Hypokalemia (and magnesium loss) and metabolic alkalosis from the contracted extracellular fluid. | Monitor potassium; keep it above 4.0 mEq per liter in anyone taking digoxin. | Electrolytes / Acid-base | L9 slide 26 |
| Thiazide diuretics chlorothiazide, hydrochlorothiazide, chlorthalidone, metolazone, indapamide | Hyperuricemia and gout. | Ask about a history of gout. | Metabolic / Musculoskeletal | L9 slide 26 |
| Thiazide diuretics chlorothiazide, hydrochlorothiazide, chlorthalidone, metolazone, indapamide | Hyperglycemia (lower glucose tolerance and decreased insulin secretion). | Monitor blood glucose in diabetes. | Metabolic | L9 slide 27 |
| Thiazide diuretics chlorothiazide, hydrochlorothiazide, chlorthalidone, metolazone, indapamide | Hypercalcemia: less calcium is excreted, so serum calcium can rise slightly. | Monitor calcium in patients with hypercalcemia or parathyroid disease. | Electrolytes | L9 slide 27 |
| Thiazide diuretics chlorothiazide, hydrochlorothiazide, chlorthalidone, metolazone, indapamide | Hyperlipidemia: low-density lipoprotein (LDL) cholesterol rises by roughly 5 to 15 percent. | Lipids may be checked during long-term use. | Metabolic | L9 slide 27 |
| Thiazide diuretics chlorothiazide, hydrochlorothiazide, chlorthalidone, metolazone, indapamide | Allergic skin rashes and photosensitivity. | Counsel on sun protection and to report a rash. | Dermatologic | L9 slide 27 |
| Thiazide diuretics chlorothiazide, hydrochlorothiazide, chlorthalidone, metolazone, indapamide | Dizziness, headaches, weakness and restlessness. | Ask about these symptoms; they are usually mild. | Neurologic | L9 slide 27 |
| Thiazide diuretics chlorothiazide, hydrochlorothiazide, chlorthalidone, metolazone, indapamide | Sexual dysfunction and constipation. | Ask directly; patients rarely volunteer sexual symptoms and may stop the drug. | Genitourinary / Gastrointestinal | L9 slide 28 |
| Potassium-sparing diuretics | ||||
| Potassium-sparing diuretics amiloride, triamterene | Hyperkalemia: the characteristic adverse effect, and the major difference from other diuretics. Use caution with angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and potassium supplements. | Monitor serum potassium and kidney function. Added background: warn about potassium-rich foods and salt substitutes, which are usually potassium chloride. | Electrolytes | L9 slide 33 |
| Potassium-sparing diuretics amiloride, triamtereneBlack box | Hyperkalemia, which can be fatal. Added background: FDA boxed warning (black box) for amiloride and triamterene. | Check potassium early and regularly; stop and treat a rising level. | Electrolytes / Cardiovascular | L9 slide 33 |
| Potassium-sparing diuretics amiloride, triamterene | Diabetes: glucose intolerance. | Monitor blood glucose in diabetes. | Metabolic | L9 slide 33 |
| Triamterene unique effect | Megaloblastic anemia. | Watch for fatigue and pallor; a blood count and folate level can be checked. | Hematologic | L9 slide 33 |
| Amiloride unique effect | Azotemia (a rise in blood urea nitrogen). | Monitor kidney function. | Renal | L9 slide 33 |
| Aldosterone antagonists | ||||
| Aldosterone antagonists spironolactone, eplerenone | Hyperkalemia and mild acidosis. | Monitor potassium, especially with kidney disease, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. | Electrolytes / Acid-base | L9 slide 38 |
| Aldosterone antagonists spironolactone, eplerenone | Nausea, vomiting and gastrointestinal upset. | Take with food if upset occurs. | Gastrointestinal | L9 slide 38 |
| Spironolactone androgen-receptor effects | Hormonal effects at the androgen (testosterone) receptor. Men: gynecomastia and testicular atrophy. Women: menstrual irregularities (hirsutism is also listed). Gynecomastia occurs in about 10 percent of men in heart failure. Added background (truth over the course wording): the course calls spironolactone a weak partial agonist at the androgen receptor, but in current pharmacology it blocks that receptor (and has some progesterone-like activity). That explains the breast and sexual effects in men and the menstrual changes; hirsutism is not a typical effect, because spironolactone is used to treat hirsutism and acne. | Ask about breast tenderness, breast enlargement and menstrual changes; switch to eplerenone if these occur, because it has less effect on androgen receptors. | Endocrine / Reproductive | L9 slide 38 |
| Carbonic anhydrase inhibitors | ||||
| Carbonic anhydrase inhibitors acetazolamide, dichlorphenamide, methazolamide | Metabolic acidosis (bicarbonate is lost in the urine), unlike the contraction alkalosis of other diuretics. | Monitor serum bicarbonate. | Acid-base | L9 slide 43 |
| Carbonic anhydrase inhibitors acetazolamide, dichlorphenamide, methazolamide | Potassium depletion. | Monitor serum potassium. | Electrolytes | L9 slide 43 |
| Carbonic anhydrase inhibitors acetazolamide, dichlorphenamide, methazolamide | Drowsiness. | Counsel about drowsiness before driving. | Neurologic | L9 slide 43 |
| Heart failure: diuretics, ACE inhibitors and beta blockers | ||||
| ACE (angiotensin-converting enzyme) inhibitors in heart failure | Impairment of renal function (an acute decrease in kidney function). | Check creatinine and potassium at the start and after dose changes. | Renal | L9 slide 56 |
| ACE (angiotensin-converting enzyme) inhibitors in heart failure | Hypotension, particularly with other blood-pressure-lowering drugs. | Check blood pressure; warn about dizziness on standing. | Cardiovascular | L9 slide 56 |
| ACE (angiotensin-converting enzyme) inhibitors in heart failure | Elevation of serum potassium. A loop diuretic lowers potassium while these raise it, so the balance must be checked. | Monitor potassium. | Electrolytes | L9 slide 56 |
| ACE (angiotensin-converting enzyme) inhibitors in heart failure | Cough (dry cough). | Ask about a persistent dry cough; an angiotensin receptor blocker avoids it. | Respiratory | L9 slide 56 |
| ACE (angiotensin-converting enzyme) inhibitors in heart failure | Angioedema: swelling of the lips, tongue or throat. | Teach the patient to seek urgent help for swelling of the face or tongue; stop the drug. | Immunologic / Airway | L9 slide 56 |
| ACE (angiotensin-converting enzyme) inhibitors in heart failureBlack box | Added background: all angiotensin-converting enzyme inhibitors carry an FDA boxed warning (black box) for fetal toxicity (injury and death of the developing fetus). | Confirm the patient is not pregnant before starting; counsel on contraception. | Reproductive / Fetal | L9 slide 56 |
| Beta blockers in heart failure carvedilol, metoprolol succinate, bisoprolol | Worsening heart failure if started in an unstable patient or raised too fast: beta blockers lower heart rate and contractility, so the patient can decompensate. | Monitor for worsening heart failure signs and symptoms and for fluid accumulation (weight). | Cardiovascular | L9 slide 58 |
| Beta blockers in heart failure carvedilol, metoprolol succinate, bisoprololBlack box | Added background: beta blockers must not be stopped abruptly (rebound angina, arrhythmia, myocardial infarction). Metoprolol carries an FDA boxed warning (black box) for abrupt cessation; carvedilol and bisoprolol carry no boxed warning but give the same caution. | Never stop abruptly. Ask about missed doses and running out of medicine. | Cardiovascular | L9 slide 58 |
| Digoxin | ||||
| Digoxin cardiac glycoside | Gastrointestinal: anorexia and nausea. | Check a digoxin level and electrolytes when nausea or anorexia appears in a patient taking digoxin. | Gastrointestinal | L9 slide 68 |
| Digoxin cardiac glycoside | Visual disturbances: blurred vision, photophobia, xanthopsia (yellow-green tinge) and yellow-green halos or shining lights around objects. | Ask every patient on digoxin about visual change; yellow-green halos should prompt a drug level right away. | Sensory | L9 slide 68 |
| Digoxin cardiac glycoside | Central nervous system: delirium, fatigue, confusion, dizziness and abnormal dreams. | Suspect toxicity in an older patient with new confusion or fatigue; check the level. | Neurologic | L9 slide 69 |
| Digoxin cardiac glycoside | Cardiac: nodal slowing with a longer PR interval and shorter QT interval, ST-segment depression, bradycardia and digoxin-induced afterdepolarizations. Almost any arrhythmia can occur, including premature ventricular beats. | Monitor pulse and the electrocardiogram; bradycardia and heart block are classic toxic findings. | Cardiovascular | L9 slide 70 |
| Digoxin cardiac glycoside | Toxicity risk rises with low potassium, low magnesium and high calcium. Added background: digoxin has a narrow therapeutic window, and kidney impairment also raises toxicity risk because digoxin is cleared by the kidneys. | Drug levels are checked for digoxin; keep potassium and magnesium normal. | Toxicity | L9 slide 65 |
| Other heart failure drugs | ||||
| Phosphodiesterase (type III) inhibitors milrinone, inamrinone | Thrombocytopenia (less with milrinone) and ventricular arrhythmias. | Monitor platelet count and cardiac rhythm during infusion. | Hematologic / Cardiovascular | L9 slide 76 |
| Phosphodiesterase (type III) inhibitors milrinone, inamrinone | Long-term use raises mortality and morbidity compared with placebo. | Used only short term in hospital. | Cardiovascular | L9 slide 76 |
| Ivabradine hyperpolarization-activated channel blocker | Increased risk of atrial fibrillation and symptomatic bradycardia. | Monitor heart rate and rhythm; report palpitations or dizziness. | Cardiovascular | L9 slide 80 |
| Ivabradine hyperpolarization-activated channel blocker | Visual impairment (phosphenes): a transient brightness in a limited area of the visual field, halos or multiple images, from an effect on retinal photoreceptors (retinal persistency). It can resolve on its own. | Warn about driving at night or in changing light; usually resolves. | Sensory | L9 slide 80 |
| Sacubitril-valsartan neprilysin inhibitor with an angiotensin receptor blocker | The most common adverse effects: hypotension, hyperkalemia, cough and renal insufficiency. | Check blood pressure, potassium and kidney function. | Cardiovascular / Electrolytes / Renal | L9 slide 81 |
| Sacubitril-valsartan neprilysin inhibitor with an angiotensin receptor blockerBlack box | Added background: sacubitril-valsartan carries an FDA boxed warning (black box) for fetal toxicity. | Confirm the patient is not pregnant; counsel on contraception. | Reproductive / Fetal | L9 slide 81 |
| Sodium-glucose cotransporter 2 (SGLT2) inhibitors dapagliflozin, empagliflozin | Hypotension (blood volume falls as sugar and fluid are passed in the urine) and fungal infections of the genital and urinary tract. | Check blood pressure and volume status; ask about genital itching, discharge and urinary symptoms. | Cardiovascular / Genitourinary | L9 slide 82 |