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 Pharm study guide 1:Concepts: Special population considerationsElderly - they can have multiple chronic conditions, polypharmacy, adherence issues, functional limitations, use 31% of the drugs even though they represent 12% of population. Issues in All parts of ADMEA: ↓ GI motility and gastric emptying, ↑ gastric pHD: ↑ body fat %, ↓ body H2O, Lean body mass, albuminM: ↓ hepatic (Liver) mass, blood flow, and metabolism.E: Renal issues will cause excretion issues and can lead to toxicity and negative drug effects African population responds poorly to ACE inhibitors, but responds better to calcium channel blockers and Diuretics. Kiddos, but I did not find information about this population in the slides except do not recommend over the counter cough meds to a child less than 6 yo. (per the American Academy of Pediatrics) Scheduled vs. legend drugsLook in davis/onlineHalf-life(t ? )The amount of time it takes for the body to eliminate half of the drug. Pregnancy categories (old and new) Davis Drug Guide for Nurses Appendix I.A: have not shown an increased risk of fetal abnormalitiesB: Studies in animals show no negative effects, but there are no studies in pregnant women, or there are animal studies that show adverse effects and studies in pregnant women are not adequate C: animals have shown adverse effect, and there are no adequate and well-controlled studies in pregnant women, OR no animal studies have been conducted and there are no adequate and well controlled studies in pregnant women D: studies, adequate well-controlled or observational, in pregnant women have demonstrated a risk to the fetus. however, the benefits of therapy may outweigh the potential risk. X: Studies, adequate well-controlled or observational, in animals or pregnant women have demonstrated positive evidence of fetal abnormalities. the use of the product is contradicated in women who are or may be pregnant. Concepts of potentiation and interference in CYP 450 systemSystem overview: 12 channels, 50 isoenzymes, 90% of drugs go through 6 channels. If 2 or more drugs need one channel there can be interference. Interference: one drug can increase or decrease the excretion or metabolism of another drug. ex. Erythromycin taken w/ increases serum digoxin levels, and increases action of Coumadin potentiation: when two similar drugs have an effect that adds on one another. ex. Coumadin + aspirin can = excessive bleedingex. sedatives + ETOH can = excessive sedation How other organ system issues impact drug dosing (i.e. renal)The renal system if not working well or in a disease state, will cause drug accumulation. this is an extremely important and common cause of toxicity and adverse med effects.Protein bindinga drug is competing to bind a protein in the blood and will end in a “drug reservoir” and allows accumulation to occur. the drug must be unbound to be useful or work.the most common protein that a drug binds to is albumintwo similar drug molecules will have compete for binding sites on serum proteins Therapeutic indexis a ratio between the lethal dose and the effective dose. TI=LD/EDTherapeutic range: the area between the ED and LD, so effective but not lethal or toxic. First pass effectfor most oral or enteral drugs will be metabolized by the liver on the first pass through the liver. Some drugs could be 90% metabolized on the first pass.Nursing interventions to reduce adverse effectsMonitor for drug interactions know pt allergies historymonitor patient for s/sDrug interactionsinterference - one drug stops or slows the action of a second drug. cyp450 systemcan be used on purposeHIV meds: ritonavir inhibits metabolism of lopinavir so the second drug can be effective. Potentiation: similar meds have effects that add to each otherdisplacement is when two drugs are fighting for the same binding sites and only one can win. this leads to a drug with a higher affinity for the site or higher serum levels to displace the lesser drug. Different forms of meds and how fast into the systemOral: swallowed, sublingual, buccal: 30 mins to and hour?enternal: NG, gastric tubes, rectal:Parental: SC, IM, IV, intrathecal, epidural:from slow to fast: ID, SC, IM, IV (IV is almost instantaneous in some cases) Pulmonary: gas, mist:fast due to the large amount of capillaries topical: local effect usually, must be lipid soluble. Loading dosesinitial dose that is larger than maintenance dose that brings the levels of the drug up to the desired range.Duration of action and minimal effective concentrationmeasurable action of the drug from the beginning to endlowest serum levels that produce the desired effect.BBB and drugsthe Blood-brain barrier is a barrier that is harder to pass through than normal endothelial cells. this is due to the fatty sheath that covers the endothelial columnsonly lipid soluble meds can pass through (also drugs that are compatible with specific active transport site but this was not covered in class soooo) What is ADME? Absorption, Distribution, Metabolism, Excretion This is all a part of pharmacokinetics What is included in patient education?How, when, why, how much, how long, for what reason, diet, when not to take it, side effects, adverse effects, s/s of toxicity, when to notify HCP---Emergency care (Appendix T) of Davis Drug Guide for Nurses Appendix T.Early management of anaphylactic reactionsStop the administration of the drugMaintain airway: bronchodilators and Aminophylline may be needed to keep the airways open in severe resp. distress.Administer epinephrine: IM, SubQ; adults 0.3-0.5 mg q5-15 mins, Kiddos 0.01mg/kg or 0.1 q5-15 minsIV: Adults 0.1mg over 5mins or 1-4 mcg/min infusion, Kiddos 0.01mg/kg or 0.1-0.2 mg over 5 mins q 30 mins, infusion 0.1-1.5 mcg max/ kg/min4. Administer antihistamines: diphenhydramine (Benadryl) IM, IV: 50-100 mg initial, kiddos 5mg/kg/day divided into doses q6-8hr do not exceed 300mg/day (so child >15kg should not get the maximum dose)5. Support BP w/ fluids and vasopressors 6. Administer corticosteroids: hydrocortisone (Sulo-cortef) IV 100-1000mg mg followed by 7mg/kg/day IV for 1-2 days 7. Document the reaction in medical reaction and have the pt/family to carry ID Side effects of anti-HTN meds and digoxin Thiazides cause a shift of K out of the body causing Digoxin toxicity Furosemide can cause ototoxicity Spironolactone (K sparing diuretic) will increase the half life of digoxin---Inotrope, chronotrope, dromotrope Cardiac drug effectsinotropic ↑ contractility Chronotropic ↑ HRdromotropic ↑ conduction velocity of the heartSelecting a BP medication Step I: A diuretic, calcium channel blocker, or ACE inhibitor Step II: increase dose of the first med, or ad anotherStep III: Pick another drug from a different classStep IV: Add another one or two meds, three or four total. ---Labs and HTN medsLabs:Urinalysis for kidney function, lipid panel, electrolytes, Basic metabolic panelMeds: Beta blockers, ACE inhibitors, Diuretics Bibliography Deglin, J., Vallerand, A., & Sanoski, C. (2015). Davis's drug guide for nurses (14th ed.). Philadelphia, Pennsylvania: F.A. Davis.Robinson PhD, FNP, M., & Gilbert DNP ARNP-BC, M. (2015, September 1). Pharmacokinetics & Pharmacodynamics. Lecture presented in Anschutz Medical campus, Aurora.Robinson PhD, FNP, M., & Gilbert DNP ARNP-BC, M. (2015, September 8). Antihypertensives and Diuretics. Lecture presented in Anschutz Medical campus, Aurora.Robinson PhD, FNP, M., & Gilbert DNP ARNP-BC, M. Nino, T. (2015, September 15). Respretory Pharmacology Fall 2015 Updates. Lecture presented in Anschutz Medical campus, Aurora.Meds:Drugs listed in the test by Name/FamilyACE inhibitors, -pril, Angiotensin converting enzyme inhibitorscaptopril (Capoten) PO 12.5-25mg 2-3 times per dayActionDecrease BPDecrease vascular toneInhibit RAAS systemStops angiotensin I from converting to angiotensin II(a vasoconstrictor)reduces the amount of aldosterone in the bodyReport Chest pain to HCPTake BP before administration, Monitor I’s & O’s, look for signs of CHF and angioedema Acetylcysteine (mucomyst): Mucolytic PO 140mg/kg, then 70mg/kg q4hrAction: Decreases viscosity of mucus to expectorate inhaled through nebulizer DX that need this are COPD and cystic fibrosisOnset > 1 min Peak 5-10 min Bad odorside effects are runny nose, throat and lung irritation, rash and stomatitis Albuterol: Bronchodilator Beta2-AgonistAction: relaxes smooth muscle in the bronchioles by binding to the Beta2 adrenergic receptorsused in asthma or COPDside effects are not common but increase in sympathetic nervous system(nervous, tremors, hyperactivity, headache), and chest pn, palpitations, angina, arrhythmias, hypertension. Spacer doubles the effective doseThese are used before the steroid inhalers to increase the area that the second medication can affect. Wait one minute between doses, and rinse out mouth afterward to avoid THRUSHAnithistamines H1 antagonists Generations: Gen 1: Diphenhydramine (Benadryl)causes sedation and crosses the blood brain barrier Gen 2: Loratadine (Claritin) is non sedating Action: binds H1 sites and blocks the effects of histamines, Also binds Ach (muscarinic) receptors Routes: IV, PO, Nasal, Topicaleffects:peripheral: decreased itching, pain, flushing, mucus secretions CNS: depression is the therapeutic effect and excitement is the over dose effect.Caution: anti-cholinergic side effects, use with caution in patients with glaucoma, hyperthyroidism (tachycardia), HTN or BPH/urinary retention Sedation: do not take with ETOH, no driving Children: some become hyperactive—unpredictable Drug interactions: CNS effects with ETOH, hypnotics, antipsychotics, anxiolytics, narcotics Anticholinergic effects: antipsychotics, TCAsARBs Angiotensin II receptor blocker losartan (Cozaar)Management of HTN, and CHF in people that cannot take ACE inhibitorsDisables Raas system, by blocking the receptor for angiotensin IIAssess for signs of CHF and angioedema more specific than ACE inhibitors, Action - smooth muscle dilation to reduce BP, reduce salt and H2O in bodyRetains less K than ACEAtropine(Lomotil): antidiarrhealstreatment of chronic diarrhea often caused by inflammatory bowel disease Action: inhibits GI motility and peristalsis, by direct nerve effect on the muscle walldecrease the loss of fluid and electrolytes side effects: Anticholinergic effects Drowsiness, dizziness, nervousness, constipation, abdominal pain, distention, discomfort, dry mouth, nausea, vomiting, ileus “hot as a hare, dry as a bone,red as a beet, mad as a hatter, and blind as a bat”Beta 2 agonists (albuterol)Action: relaxes smooth muscle in the bronchioles by binding to the Beta2 adrenergic receptorsused in asthma or COPDside effects are not common but increase in sympathetic nervous system(nervous, tremors, hyperactivity, headache), and chest pn, palpitations, angina, arrhythmias, hypertension. Spacer doubles the effective doseThese are used before the steroid inhalers to increase the area that the second medication can affect. Wait one minute between doses, and rinse out mouth afterward to avoid THRUSHBeta blockers metoprolol (Lopressor) Antihypertensives, antiarrhythmicstreatment of HTN, prevention of MI and decrease of mortality in people that have had an MIBlocks the stimulation of beta1-adrenergic receptorsside effects: Bradycardia, CHF, pulmonary edemateach the pt to call HCP if slow HR or Dyspnea occurs Calcium Salts: Ca carbonate, Ca gluconate, Ca Citrate, Ca Acetateelectrolyte replacement supplement, Acid buffer/ electrolyte treat osteoporosis, antacid, treat electrolyte imbalance activates nerve impulses of muscle, buffers acid, essential for bone formationSide effects: cardiac arrest through IV therapy, arrhythmias, bradycardiamonitor BP pulse and ECG frequently Calcium channel blockers: verapamil (Calan)Antihypertensive agent, antiarrhythmic agent, treat HTN, angina, arrhythmias inhibits the transport of calcium into muscles (cardiac muscles are the most delicate/important) this makes the excitation of the muscle inhibited or blockedside effects: arrhythmias, CHF, peripheral edema, bradycardia, chest pain, hypotension, palpitations, syncope, tachycardia----------------Chlorpheniramine (Chlor-Trimeton)antihistamine, antitussiveLike benadryl but non drowsytreats s/s not the cause of the problem----------CodeineCorticosteroidsCromolyn sodium (Intal) ----------DextromethorphanDigoxin---------Digoxin Immune FabEnalaprilEpinephrine-Ethambutol-Furosemide (Lasix)Guiafenesen (Mucinex)Hydroclorothiazide (HCTZ)Ipratropium-Isoniazid-Lisinopril-Leukotriene inhibitors-Loratadine (Claritin)-----Mannitol------Methyldopa-Montelukast (Singulair)Order of giving inhalation medsOTC cold medsPotassiumPotassium supplements-------Propranolol (Inderal)--------Pseudoephedrine-Pyrazinamide-Rifampin-Salmeterol-Spironolactone (Aldactone)--------Steroids--------Zinc for coldsDeglin, J., Vallerand, A., & Sanoski, C. (2015). Davis's drug guide for nurses (14th ed.). Philadelphia, Pennsylvania: F.A. Davis.Robinson PhD, FNP, M., & Gilbert DNP ARNP-BC, M. (2015, September 1). Pharmacokinetics & Pharmacodynamics. Lecture presented in Anschutz Medical campus, Aurora.Robinson PhD, FNP, M., & Gilbert DNP ARNP-BC, M. (2015, September 8). Antihypertensives and Diuretics. Lecture presented in Anschutz Medical campus, Aurora.Robinson PhD, FNP, M., & Gilbert DNP ARNP-BC, M. Nino, T. (2015, September 15). Respretory Pharmacology Fall 2015 Updates. Lecture presented in Anschutz Medical campus, Aurora.ACE Inhibitor Angiotensin converting enzyme inhibitorsstops RAAS system stop hypertensionstep 1 for HTN medsAfrican population tend to respond poorly to ACE inhibitors adenosine (Adenocard) slows AV node conductionfor PSVT Paroxysmal supraventricular tachycardiarate of delivery is over 3 seconds by an MD, Very uniqueAlpha blocker Block the Alpha receptors which cause vessels to dilateLower BPalprazolam (Xanax) Anti anxiety schedule IV, pregnancy class DS/E: Dizzy, Lethargy, Drowsiness, CNS depressiongrapefruit increases increases effects and the measurable levels of the drugamiodarone (Cordarone) Group III K channel blockers: delay repolarization delays ventricular repol at qtprolongs action potentialincreases effective refractory periodPulmonary toxicitygrapefruit interactionSide effects: thyroid issues, blue grey skin, D/D interactions: increase effect Digoxin, anticoags, statins, dilantinlife threatening dysrhythmias Angiotensin Receptor Blocker for HTN blocks angiotensin II receptor from binding and causing vasoconstrictionex.Losartan (Cozaar)Actions - more specific than ACEAntacids Antacids that can be bought over the counter (the goal is to bring pH of the stomach to about 3.5): Tums, Caltrate, OsCal, Viactiv(not w/ coumadin), Citracal (not w/ KD)Action: increase stomach pHindications: Peptic ulcer, GERD, herniaADME:onset: 20-40 min (give 1-3hr before meal + night)not meant to absorb, just buffer the acidexcreted in the fecesreduces Absorption of other drugs (chelation) due to the raise in stomach pHS/E: constipation, bone deg, increased acid secretion, Kidney failure, Diarrheaincreased Ca, K and NA, decreased MgKidney failure in chronic useAntibiotics used to treat H.pylori with bismuth and proton pump inhibitors lasts for 2, and then the Antibiotics and bismuth drop off and the PPI is prescribed for 4 more weeks, about 90% of people are recovered after this treatment.antibiotic- induced Diarrhea for the elimination of C. diff with the antibiotic fidaxomicin (Dificid)antidysrhythmic drugs Antidysrhythmic drug classes or group (listen to heart for 1 min)I – quck Na channel blockers (broken up into three classes, but do not need to know that for the testIa - quinidineprocainamide (more side effects)Ib - lidocaineIc - flecainide II – Beta BlockersPropanololmetoprololIII – K channel blockersAmiodaroneIV – Ca channel blockersVerapamil DilitiazemV - variable mechanism AdenosineDigoxinMagnesium sulfateAntiemetics Action: Block CTZ (chemoreceptor trigger zone)relieve nausea and vomitingAnticholinergic: Scopolamine (Transderm-Scop)for motion sicknessSide effects: Blurred vision, dry mouth and CNS depressionAntihistaminesDiphenhydramine (Benadryl)Dimenhydrinate (Dramamine)H1 blocker (antihistamine), CNS depressionPhenothiazine:Prochlorperazine (compazine)similar to atropineDopamine receptor blockerMetoclopramide (Reglan)Drousie, extrapyramidal effects, DiarrheaCannabinoidDronabinol (Marinol)Made from THCAnti-inflammatoryNSAID’sSteriodsC-reactive protein levels reflect inflammationhigh levels associated w/ increased risk of CV problemsAntiseasickness pills Antiemetics will help, but not all. Action: Block CTZ (chemoreceptor trigger zone)relieve nausea and vomitingAnticholinergic: Scopolamine (Transderm-Scop)for motion sicknessSide effects: Blurred vision, dry mouth and CNS depressionAntihistaminesDiphenhydramine (Benadryl)Dimenhydrinate (Dramamine)H1 blocker (antihistamine), CNS depressionAtorvastatin (Lipitor) Class: HMG-CoA reductase inhibitorsAction:block the synthesis of cholesterol inhibits HMG-CoA reductase: so the pathway for cholesterol synthesis is blocked.Indications: Hypercholesterolaemia, Coronary heart disease, Stroke, MI and chest painS/E: Rhabdomyolysis (ask about muscle pain and tell the patient to report any pain or weakness), Angioneurotic edemastronger than simvastatin, not as strong and RosuvastatinAtropine Anticholinergic/antiarrhythmic Action: blocks vagal stimulation, which increases (HR) SNSblocks Acetylcholine at prostaglandin sites Tachy arrhythmias, Pulmonary edema, physostigmine is the antidote for an ODside effects: red as a beet, mad as a hatter, hot as a hare, Benzodiazepine drugs for insomnia, anxiety, seizures, alcohol withdrawalsfor acute use not chronic (does not cure Dx, can develop tolerance and dependence)14 days topsschedule IV (most) may be related patho: increases the effect of GABA, calming, sedativeGABA receptors are dense in the limbic system, which messes with your emotions abnormal non-REM sleepBZ1 receptor: cerebellum: controls anxietyBZ2 receptor: basal ganglia, and hippocampus: MM relaxation side effects and interactions: Smoking decreases effectiveness, parental rout can cause cardiovascular issues and must adhere strictly to the rate, hypotension depression of RR(with IV), and CNS, Pregnancy risks. IV, give slowly, needs to be monitored make resp issues worse will not cure, or meant to cure the symptomsused for conscious sedation (colonoscopy)Withdrawal: starts in 1 to 3 days and peaks in 1 to 2 weeks (depends if short or long acting drug) weight loss, anxiety, weakness, insomnia, and tremorsex: diazepam (Valium), used for: Calms a person down so they don’t puke as much before chemo, alcohol withdrawalthe metabolites can collect over time and cause CNS depressionResp. ↓ and hypotensionwhen given IV the vessel gets irritated burns in IV so dilute or slow down the rate of admin#1 drug in the US ex: lorazepam (Ativan) similar to diazepamfor status epilepticusdosing too fast can lead to bradycardia, RR depression, and apnea about 2 mg/minBeta blockers reduces heart rate and force of contraction and therefore O2 demandlong term onlymakes vasospastic angina worse (prinzmetal)Non-selective – decrease Cardiac contractility, drops bp and renin releaseHTN, tachycardia, and anginaSome are more lipid soluble and more water solubleEducation – don’t change the regimenOTC cold meds with pseudoephedrine/ phenylephrineHR <45 don’t giveorthostatic hypotensiondon’t stop the regime or the opposite effects happen, HTN, rapid HRBile acid sequestrants Colesevelam (Welchol)binds bile acid so it cannot reabsorbdoes not decrease vitamin absorption and not many other medsNot absorbedfor hyperlipidemia and high LDLtake with lots of fluidscholestyramine (Questran)Binds bile so it cannot be reabsorbedused with statinstake with lots of fluidsBismuth subsalicylate (Pepto-Bismol) Antidiarrhealpromotes absorption in the intestines to decrease diarrhea bismuth is not absorbed, subsalicylate is S/E constipation, grey stool, OTCif taken with ASA increases toxicity riskBulk-laxatives psyllium (metamucil)encreases stool size and softens by absorbing water, this increases the size of the bolus and pushes against the wall of the intestine to stimulate peristalsistakes 12hr -3 days workexcreted in stoolNEED fluid for it to work!Calcium carbonate (TUMS) Action: increase stomach pHindications: Peptic ulcer, GERD, herniaADME:onset: 20-40 min (give 1-3hr before meal + night)not meant to absorb, just buffer the acidexcreted in the fecesreduces Absorption of other drugs (chelation) due to the raise in stomach pHS/E: constipation, bone deg, increased acid secretion, Kidney failure, Diarrheaincreased Ca, K and NA, decreased MgKidney failure in chronic useCCBs Diltiazem (Cardizem)Verapamil (Calan)Calcium channel blockersused in stable vasospastic angina, Arrhythmias, HTNSlows HRCimetidine (Tagamet) Peptic ulcer DrugAcid-Neutralizing DrugsH2 receptor blockerdigoxin – positive inotropic, negative chronotrope, neg dromotropeincreased cardiac contractilitydecreased conductionindications: CHF, AFIBuse loading dosesSE: bradycardia, av block, anorexia, vision issues, green- yellow tint, halo around lights, gynecomastia with long term use.dopamine (Intropin) catecholamine (sympathomimetic)increase BP, CO, vasoconstriction (B1, A2)Very toxic to tissuesneed large bore IVFor Cardiogenic shock primarily and vasoconstriction (neurogenic shock)epinephrine catecholamine (sympathomimetic)Bronchodilation, vasoconstrictionA1, vaso constrictionBeta1, increase BPcan have a paradoxical bronchospasm Eszopiclone (Lunesta) Benzo-like drugfor sleep only, not anxietyfor increasing the duration of sleep S/E sleepwalking, driving and suchBitter after taste Flumazenil Benzo antagonist no effect on a person not on a benzodiazepine antidote for benzo OD or excessive effectshort half life so it is given through a drip or multiple IVPS/E: hypotension, decreased respers, and cardiac arrestH2 Blockers Cimetidine (tagamet)ranitidine (Zantac) fewer side effects and strogerewBetter value to prevent ulcer than PPIAction: Lowers H2 secretion by stopping histamine from stimulating H2 receptorsPrevents PUD, acid reflux, hypersecretionIV fluids Lactulose Osmotic Laxativesand milk of magnesiasugar, and salt that don’t absorb well and then attract water to induce peristalsis.↓serum Ammonia in people with chronic liver diseaseworks in 1-3 days and not much is absorbed into the bodyLidocaine (Xylocaine)Group IB Na channel blockers↓ depol of mm contraction (decreases the time of action potential)monitor on EKGworks first on the tissues with the issuesfor Ventricular dysrhythmias acutely narrow therapeutic rangethe maximum dose is 3mg/kgSide effects – CARDIAC ARREST, confusion, tremors, twitching, blurry vision, tinnitus, dizziness, fainting, BradycardiaD/D interactions with propranolol and cimetidine increase the drug levelsLovastatin (Mevacor) HMG-CoA reductase inhibitorsStops the pathway for the synthesis of cholesterolfor hyperlipidemia when diet is not enoughSide effects: MYALGIA, can lead to mm damage, Kidney injurymore risky when taken w/ niacin or gemfibrozilGrapefruit interaction, increase the level of the medMelatonin remelton (Rozerem)activates melatonin receptors hypnotic, for falling asleepeffect in 30mins, ok for chronic useno dependence symptoms when stoppedsafe for long term useMetoclopramide ( Reglan)Dopamine receptor blockergastric stimulant Drousie, extrapyramidal effects, DiarrheaS/E: Gynecomastia, bone marrow suppression Misoprostol (Cytotec)Prostaglandincytoprotective agent PG E1 analog – ↓Acid secretion, ↑ Bicarb (HCO3) and mucus secretionCategory X, miscarriagePrevents NSAID ulcersMylanta or Maalox liquidsAluminum and magnesium antacid neutralizes acid in the stomach increasing pHmay affect absorption of some drugs and foodsNarcanOpiate AntagonistAntidote for opiatesreverses the CNS and Respiratory effects of opioids S/E V. fibNiacinnicotinic agent, lipid lowering agentcoenzymes for lipid metabolismincreased risk of myopathy with Statins Flushing occursVitamin B 3NitratesNitroglycerin SL, ointment, patch (NTG)Organic Nitrate Vasodilatorsnitroglycerinboth short and long termvasodilates peripheral and coronary arteriesdoes not dilate the atherosclerotic vessels (so the elderly may not respond well)Hypotension Fall riskwill get a headache and that’s OKtaken sublingual(minutes), ointment (half hour to hour and can cause tolerance)wear gloves when applying the patch to avoid headacheUse for chest pain emergencyone SL wait 5minsif after second dose pain is still happening call 911take no more than 3 dosesCapsulessustained releaseOintmentapply to hairless chest wall and cover with plastictransdermal patchdon’t soak in waterrotate placement of patch10-12 hr time w/out patchD/D interactions: any hypertension medsnicotinePhosphodiesteraseLight and heat will break down the drug and make it ineffectiveOthers for chronic anginaBeta blockersreduces heart rate and force of contraction and therefore O2 demandlong term onlymakes vasospastic angina worse (prinzmetal)Calcium channel blockersused in stable vasospastic anginaNSAIDsNon steroidal anti inflammatory Ibuprofen, ASA, acetaminophen can cause ulcersmisoprostol and sucralfate can prevent these ulcersOmega 3 fatty acids fish oilRX is Lovazanot complete evidence in: dementia, DiabetesOmeprasole (Prilosec)Proton pump inhibitorbetter at repairing ulcers than H2 blockerBlocks acid secretionBlocks ATPase at the parietal cells that would produce H2treats: esophagitis from GERD, Duodenal ulcer, long term HTNquick onset, 2h to peak, and ends effectiveness at 3-4 daysSide effects are: Heartburn, weakness, dizziness, C.diff risk increases, also cannot absorb Ca as efficientlyUlcers can heal in a matter of weeksOndansteron (Zofran)Block serotonin 5 HT3 receptors, antiemeticD-D interaction with apomorphine causing hypotensionmonitor EKG in patients with hypoK and Mg, HF, brady arrhythmiascan be hepatotoxic over 8mg for day Osmotic laxativeslactulose and milk of magnesiasugar, and salt that don’t absorb well and then attract water to induce peristalsis.↓serum Ammonia in people with chronic liver diseaseworks in 1-3 days and not much is absorbed into the bodypolyethylene glycol (Golytely) (Glycerin sup in children)draws water into intestine (sugar, salt, and PEG)Cleansing before colonoscopy(Other) metoclopramide (Reglan)↑ ACH, stim PSNS↑secretions, and motilityfor GERD, risk of ileus, and to eliminate bariumContra indicated in patient with intestinal blockageOxygenPancreatic enzymes (Prancrelipase)ind: Pancreas insufficiency (pancreatitis, cystic fibrosis, Pancreatectomy)Act: increased digestion in GI (enzymatic)Enteric coatedS/E all abdominal, Fibrosinghold if NPO, give before meals (dose based on calories)PhenobarbitalBarbituratepatho: increases the effect of GABA, calming, sedativeused in addition to anesthesiafor insomnia, seizures, anxiety (acutely) develop tolerance to the therapeutic effect, but not to the side effectsliver makes more enzymes to break down the drug, and lowers the therapeutic half life. used to treat neonatal kiddos to use this increased metabolic effect w/ hyperbilirubinemia. S/E: ↓ CNS, cardiovascular function, and RR. hangover, porphyria (werewolf?), suicidewithdrawal: seizures (if they have epilepsy), anorexia, weakness, chills, poor sleepThis is called abstinence syndrome Phenothiazine antiemetics Prochlorperazine (compazine)antiemeticmanagement of nausea and vom. depresses the CTZ, changes the effect of dopamine S/E: Neuroleptic malignant syndrome, and med leads to Reye’s syndrome in kids younger than 16dry eyes and mouth, pink or reddish brown urine, agranulocytosis similar to atropinePhenytoin (Dylantin)For tonic clonic seizuresblocks Na channels selectivelytake often (tid)low therapeutic index half life is variable even in the same patient: 8-60 hrS/E: gingival hyperplasia, CV effects, cognition issues, steven johnson syndrome and toxic epidermal necrolysis (like being burned inside out)screws up Vitamins: deficiencies Folic acid, D and kPravastatin (Pravachol)HMG-CoA reductase inhibitor, lipid lowering agent Blocks synthesis of cholesterol additive med for the prevention of CV disease in people that already have CHDS/E: Rhabdomyolysis, least impactful to most impactfulLova-, Prava-, Simva-, Atorva-, Rosuva-rosuvastatin newest, strongest, most side effectsHDL changes start at simvastatinPromethazine (Phenergan)AntiemeticCTZ depression, changes the effect of dopamine S/E: agranulocytosis, neuroleptic malignant syndrome dry eyes and mouth, blurry vision, and constipation Propranololpropranolol(only one that is not beta 1 selective), acebutolol, esmolol, sotalolDecreases contractility, automaticity in SA, and slows conductioncardioprotective for post MI and HF? this is now uncertain, and may not be trueslows conduction, HR, renin, BP,increases cardiac outputProton Pump Inhibitors (PPIs)omeprazole (Prilosec) -prazolebetter at repairing ulcers than H2 blockerBlocks acid secretionBlocks ATPase at the parietal cells that would produce H2treats: esophagitis from GERD, Duodenal ulcer, long term HTNquick onset, 2h to peak, and ends effectiveness at 3-4 daysSide effects are: Heartburn, weakness, dizziness, C.diff risk increases, also cannot absorb Ca as efficientlyUlcers can heal in a matter of weeksRamelteon (Rozerem)Hypnoticmelatonin agonist (activates receptors)for insomnia, works in 30mins more selective and effective than supplement of melatoninD/D interactions: Fluvoxamine, Liver Dx’s, and alcoholS/E: basically getting too sleepy, also amenorrhea Ranitidine (Zantac)ranitidine (Zantac) fewer side effects and strogerewH2 receptor blockerBetter value to prevent ulcer than PPIAction: Lowers H2 secretion by stopping histamine from stimulating H2 receptorsPrevents PUD, acid reflux, hypersecretionRosuvastatin (Crestor)Strongest Statinthis means that it also has the most severe side effects HMG-CoA reductase inhibitors Sildenafil (Viagra)erectile dysfunction and vasodilationcan treat pulmonary artery HTNcontraindicated use with Nitrates (nitroglycerin)causes hypotension S/E: MI, hepatic toxicitySodium Nitroprusside (Nipride)vasodilationbreaks down into Nitrous oxide StatinsHMG-CoA reductase inhibitorsNot all statins are alikeleast impactful to most impactfulLova-, Prava-, Simva-, Atorva-, Rosuva-rosuvastatin newest, strongest, most side effectsHDL changes start at simvastatinStimulant laxativesbisacodyl (Dulcolax)stimulate peristalsis by affecting the muscle and mucus secreting cellsworks in 6-8hrcan cause fluid loss (watery discharge), cramping, and dependenceStool softenersDocusate sodium absorbent, water is pulled into fecal mattercauses the retention of water and electrolytes not letting them be absorbed into the bodytakes 12 hours to 3 daysSucralfate (Carafate)anti ulceral, GI protectant Protects ulcer by forming a barrier with the ulcer cells from acid in the stomach.For PUD, and protect other ulcers from forming. (NSAID’s)TetanusCaused muscle spasms including high HR and HTNvaccination is TdapZaleplon (Sonata)Benzo-like drugfor sleep only, not anxietyfor falling asleepS/E: sleepwalking, driving and suchrebound insomnia after tolerance is built over a time of longer than a weekMotor Paralysis “locked in”Zolpidem (Ambien)Benzo-like drugfor sleep only, not anxietyfor falling asleep and asleep and staying asleep S/E: sleepwalking, driving and suchrebound insomnia after tolerance is built over a time of longer than a weekHints Sheet Exam #3 – NURS 3150 PharmacologyAnesthesia and analgesia Acetaminophen (Tylenol)anti-prostaglandinmetabolized in liver (watch out for this)3 g per day is the most dose per dayworks in CNSlow GI irritationcan be used with kidss/e: liver damage with ETOH is a high risk,toxicity: 25 grams for adulttop cause of acute liver failurethe OD patient will die in 3-5 days from the liver damageAcetylsalicylic acid Aspirin (ASA) – COX 1gen 1 NSAIDinhibits platelet aggregation until there is a reproduction of more plateletsirreversible in the platelets that it affectsanti prostaglandin (inflammation)do not use in kiddoss/e: salicylism (ringing in ears points towards OD), reye’s syndrome, Renal impairmentToo Much? Tinnitus, respiratory depression, HypERthermia, can cause metabolic acidosis, then resp alkalosis to compensate.COX inhibitorsCOX 1: promotes Platelet aggregation, GI protection, renal fxn, (GOOD)COX 2: promote inflammation (bad)AnticholinergicsCan be used in pre anesthesia to reduce secretions“Caine” drugs for numbinglocal anesthesia for: fingers, ears, nose, toes, and thoseCodeineNarcotic*1/10th power of morphine5x power of aspirin, or acetaminophenEpinephrine with Lidocainekeeps the lidocaine local due to the vasoconstrictive properties of epiCelecoxib (Celebrex) – COX 2 similar strength to ibuprofenless stomach ulcers than other NSAIDs (some evidence)Fentanylnarcotic**one hundred times stronger than morphineLollipop form in some cases for chronic pain (cancer)will kill a kiddo!-fluranesIsofluraneStrong anesthetic weak analgesic Volatile liquids mixes with O2 and inhaledResp depression, HYPOtension, arrhythmias, Hyperthermia***can be mixed with Nitrous oxidefor the strong analgesic properties allows for a lower amount of each inhalant to get the desired effect, which lowers the risk for depression of resp. and the heartIbuprofen (Motrin, Advil) – COX 1S/E: can cause renal damage, and GI bleeding, Retention of NA and H2O (watch out for HF patients)Inhaled anesthetic agentsWorks very quicklyIV anesthesia agents lasts longer than inhaled Methadonenarcoticlongest duration of actionlong QT intervalfor coming off of narcotics and given in clinicsMeperidine (Demerol)narcoticsame action as morphine with a shorter actiontreats post anesthesia shivers or rigors that can occurno cough suppression effectMorphinenarcoticmoderate to severe paincan be given through almost all routescross BBBS/E: resp depression, constipation, nausea, Miosis(pinpoint pupils)morpheus god of sleepgive before the pain occurs if possiblePCA pump allows for the patient to not fall out of the TPRis better than PRN, or fixed scheduledecreases overdosecan use smaller dosesempowers patientcross tolerance to other opiatesNaloxone (Narcan)opiate antidotealso given when there is an OD of unknown causeNSAIDSgen 1: inhibit COX one and twoinhibit inflammationinhibits prostaglandins in the stomach, so there is a higher chance for ulcersGen 2:some studies show slowed healing of muscle, bone and ligament injuries.PropofolAnestheticrapid onset and short durationno analgesic effects/e: resp depression, rhabdoTramadol (Ultram)Non opiate CNS acting analgesicschedule 4not an opiate but binds to the receptorPyridium (Phenazopyridine)Treats pain from lower UTI’sdo not take if the pt has DM, or liver Dxcan cause a bright red or orange urine,take with food or there may be a Headache after doseOTC HA and migrainesAll of these drugs vaso constrict except the beta blockers and CCB. OTC is the most effective, and Ergot is not prescribed oftenBeta-blockers and Calcium Channel Blockersare prophylactic and chronically dilate and cause the vessels to be less spasticErgot AlkaloidErgotaminefor prophylaxis of migraines, Alpha blocker vasoCONstriction Rebound HAS/E: HTN, MI triggerincreased risk of stillborn pregnancy increased uterine stim, and decreases the blood flow to the placentaseparate 24hrs between the use of ergotamine and sumatriptan.related to ACIDExcedrin Migraine OTCone of the best if not the best remedy for HA and migrainesformulation: ASA, ibuprofen, and some caffeine basic and effectiveTriptansSerotonergic sumatriptan and zolmitriptanstim 5 – HT in the brainit vasoconstricts and inhibits inflammationnot for prophylaxis of migraines only treat S/E: stroke, MI, cerebral hemorrhageWAIT 2 weeks to use a MAO-I medDON’T take within 24 hours of ergotaminetoxicity w/ other 5-ht blockers, prozac,paxil, zoloftParkinson'stoo much ACH and not enough DA causing dyskinesia and Akinesia. Drugs do not cure but only slow the decline of symptoms, and treat the Bradykinesia, Gait, and improve daily activities. Comes from the degeneration in the extrapyramidal system which controls posture and gait (and others) Anticholinergicreduce ACH to bring balance to the Dopamine/ACH teeter totterBenzotropine (Cogentin) and trihexyphenidyl (Artane)similar to atropine, antimuscarinic DopaminergicMAO-B inhibitors are used in patients with mild symptomsSelegiline and rasagilineinhibit DA breakdown when the symptoms are increased, given meds change to levodopa and Dopamine agonistS/E: drooling, constipationLevodopaDA prodrug best effect in the first two yearstake time off the drug “holiday”many d/d interactionsvitamin B6 allows less levodopa to get to the CNSCarbidopano bad effects on its ownincrease usable levels of levodopa in the CNSIs the CAR that drives levodopa to the CNSCOMT inhibitors: blocks breakdown of LevodopaEntacapone, and Tolcapone CAPONE “protects” levodopa, like the mobLevodopa/Carbidopa (Sinemet)Levodopa/Carbidopa/Entacapone (Stalevo)increase TP effects by stopping the breakdown of Levodopa more convenient than taking 3 pillsPramipexole (Mirapex)dopamine agonistfirst given alone in early parkinson’s then added to Levodopa in late. S/E: sexy grandpa/grandmaMAO Inhibitors 2 kindsMAOA helps metabolize norepinephrine and serotoninMAOB metabolizes dopamineSelegiline (Eldepryl) inhibits this so DA is not metabolized. food interactions: aged cheeses and meats, yeast, bread, BEERstop antidepressants 2-7 weeks befor usingSelegilineMAOIlook MAOI’smany s/e and dd interactions Tricyclic antidepressants (Amitriptyline) Are the only antidepressants that should be used in PADo not use is ALZblocks ACHAlzheimers progression can only be slowed not cured. Medicine is creating new treatments, and there is a link to chromosome 21 (like in down’s). Tangles in the brain may be related to cholesterol so statins may be useful for prophylaxis. Know the lifestyle risk factors: low activity and education, smoking, DM, HTN, depression. Memantine (Namenda) NMDA antagonistRegulates calcium influx into the neuronIndication is moderate to severe AD, but some neurologists start it early with AriceptSE: dizzy, HA, confusion, constipation, hallucination donepezil (Aricept) Acetylcholinesterase inhibitors stop ACHesterase, increasing ACHtreatment of early dementiaAntimicrobialsAntivirals Acyclovir (Zocirax)similar to a purine nucleoside, and suppresses protein synthesisS/E: phlebitis, nephrotoxic, stinging sensations.Flu drugs:AmantadineOseltamivir (Tamiflu)Interferon alpha-2bFor hep B, also C if combined with Ribavirin and a PI causes flu like symptoms, and Hep causes flu like symptoms….RibavirinTreats hep C with pegylated interferon-Alpha and a PIHIV drugsReverse transcriptase, protease, and integrase are main targets of treatment to disrupt the virus.HAART therapy – highly active antiretroviral therapy. two nucleoside reverse transcriptase inhibitors, and a protease inhibitor.six classes of drugs to treat HIVNon-nucleoside reverse transcriptase inhibitors (NNRTIs) Nucleoside reverse transcriptase inhibitors (NRTIs) Protease inhibitors (PIs) Fusion inhibitors, CCR5 antagonists or entry inhibitors (CCR5s) Integrase strand transfer inhibitors (INSTIs)focus on the first three plus the fusion inhibitorsexamplesNRTI: Zidovudine (Retrovir)stops replication, slows the Dx, and increases the white blood cell (CD4) levelsTwo of these are in the First set of Meds given along with on of the following: INSTI, NNRTI, or PINNRTI: Nevirapine (Viramune) Efavirenz (sustiva)binds reverse transcriptase and stops the transcriptionCan be a part of the first line of meds along with two NRTI’sPI: Indinavir (Crixivan)very effectiveCan be a part of the first line of meds along with two NRTI’sFI: Fuzeon, T-20fusion inhibitors stops HIV envelope from fusing with a CD4 cell membrane. INSTI (HIV)- Integrase strand transfer inhibitorsCan be a part of the first line of meds along with two NRTI’sCCR5 Antagonist (HIV) - Maraviroc (selzentry)Entry inhibitorsBlocks HIV from binding to the CD4 cell (similar to the FI) Can have an allergic rxn, cough, nausea, dizzy Antibiotics AminoglycosidesInhibit protein synthesis and are bactericidal Causes injury to the inner ear and Kidneys Nephro, and Ototoxic that is permanent Narrow spectrum draw drug levelsPeak thirty minutes after IVTrough an hour before the next dosegiven once a dayAmoxicillin Broad spectrum Aminopenicillins disrupt cell wall with beta lactam ringAmoxicillin and Clavulanic acid is AugmentinThis increases the effectiveness by breaking down the PenASE enzymeAntibiotic resistance Bacteria can adapt to a drug and create defences from a drug such as the PenicillinASE enzyme. Carbapenems:Imipenem (primaxin)broad spectrumresistant to beta lactam break down (penASE resistant)used in Pseudomonas aeruginosaSuperinfections are an adverse effect as well and an allergic RXNCephalosporins break down cell wall, for G+ and an increasing effectiveness with G-bactericidal, and more resistant to PenASE than penicillinspectrum broadens from gen 1 and 2 (narrow) to gen 3 and 4 are broadADME: poorly absorbed through PO route, no metabolism, excreted in kidneys and stoolallergy in 10% of people w/ the pen allergyfour generations: they all have the Cef- or Ceph- prefix.Clindamycininhibits protein synthesis, Bacteriostatic Narrow spectrumGiven with Tetracycline and Bactrim in MRSA only for anaerobic infections such as in the gums, colon, sepsisnot effective in the CNSCan give orally (IM,IV as well)S/E: pseudomembranous colitis severe bloody diarrhea, Hepatic and renal toxicity, hypersensitivityErythromycin (macrolides)Broad spectruminhibits bacterial protein synthesisuse is allergic to penicillinfor G+long QT intervalS/E: GI upset, cholestatic hepatitis, superinfectionD/D: interacts with CCB, HIV protease inhibitors, and antifungal increase the serum levels of erythromycinSo HIV drugs and antifungals.Fluoroquinolones (Ciprofloxacin) Metronidazole (Flagyl)Broad spectruminhibits DNA gyrase in bacteriaTendon rupture!!! do not give to kiddos under 18undergo chelation just like tetracycline Gentamycin Aminoglycoside, Inhibits protein synthesis for G- serious (aerobic) infections nephro and ototoxicitydraw peak and trough levels to avoid toxicity Penicillinsbactericidal in gram positive bacteriasafe to humans b/c we do not have cell wallsD/D interactions with anticoags increase bleeding, contraceptives with estrogen can cause PEN to no be effectivebeta lactam ring weakens the cell wallbeta lactamASE is used by some bacteria, breaks up the ring in the drug to make the drug ineffectiveunstable absorption when taken orallyvery thick and viscous IM needs to be givin Z track. it is thick and a lot of pressure is needed to administer.few side effects, but 5% of the population has an allergic reactionPenASE (beta lactamase) makes bacteria resistant to PenicillinsClasses of Pen. - Maybe just skim this, the individual drugs are not on the review list. Pen GBenzylpenicillinnarrow specturom, and sensitive to penASEBac-cidal to G+prophylaxis in dental/invasive procedures for endocarditis and syphilisDicloxacillinNarrow, PenASE resistantTreat staphAminopenicillinsAmpicillin, Amoxicillin (broad spectrum)G+ and some G- are treatedS/E: rash and DiarrheaExtended spectrum PenicillinsTicarcillinPiperacillinless important Carbenicillin indanyl, and mezlocillinAmpicillin and sulbactam is UnasynAmoxicillin and Clavulanic acid is AugmentinSulfa drugs (sulfonamides)- Trimethoprim-Sulfamethoxazole (Bactrim)Broad spectruminhibits folic acid to slow down growth folic acid is used in the synthesis of Nucleic acid (DNA RNA and other nucleic acid strands) (this is also why pregnant women should take folic acid supplements) collect urine sample before giving any antibioticused in UTI G+ or G-UTI is usually caused by e. colisome elderly pts can have bacteria in the bladder and be asymptomatic and done not necessarily need to be treated.Hypersensitivity reaction results in stevens- johnson syndromeBc it is a sulfa drugTetracyclines Broad spectrumInhibit protein synthesis Effective through PO routefor acne, lyme Dx, H. pylori, Cholera, Riskettsia, choleraCan treat MRSA with Clindamycin, and Bactrim chelation occurs when calcium, Iron, and magnesium containing supplements and foods inactivate the tetracycline and cause it to be inactivedo not take with meals!one hour before or two hours after meals to avoid chelationS/E: photosensitivity, brown teeth, not ok for mothers pregnant and breastfeeding moms, do not give to kiddos.Vancomycin***inhibit Cell wall synthesismost used antibiotic in the USfor severe G+ infections: MRSA, C diff, prophylaxis endocarditisADME: PO is ok with this drug, S/E:**altered taste, OTOTOXICITY**, redneck syndrome if given to quick IVAntifungals Amphotericin BBroad spectrum Cell wall/membrane permeability is disrupted humans have cell membranes… binds -sterols which are also found in the human body (cholesterol) which causes the renal damage.it is very toxicused for SYSTEMIC mycoses that are potentially fatal, admin parentera/E: infusion reaction fever and chills, nephrotoxicADME: can be found up to a year later in the pt bodyGriseofulvinstill in the -azole classjust for SUPERFICIAL (skin infections), not systemicinhibits fungal mitosiss/e: Insomnia, Rash and headacheKetoconazole used in less severe fungal reactions (fungistatic) MOA is it inhibits the synthesis of ergosterol which is a part of the fungal cell membranethis also affects the body’s sterols (sex hormones)-conazols are all less toxicMycostatin (Nystatin)Candidiasis onlyIt is in the form of a mouth washalters the permeability of the membraneused for infant thrush often due to the low side effects. Extras:alprazolam (Xanax)Anti anxietyschedule IV, pregnancy class DS/E: Dizzy, Lethargy, Drowsiness, CNS depressiongrapefruit increases increases effects and the measurable levels of the drugEstrogensmay increase risk of ALZinactivated with Gentamicin contraceptives with estrogen can cause penicillin to be ineffective Food and meds Antacids, Fe, Ca, and Mg Causes chelation in tetracyclines and Fluoroquinolones all the previous + Alu, Zn, and sucralfate Pre-op medication reduce the bad effects of anesthesia AtropineLomotil treats diarrhea from the use of anestheticsalso decreases secretions BaclofenAnti-spastictreats MM spasms from cerebral palsy, or Multiple sclerosisCan cause seizures!Increase CNS depression with opiates and MAO’sMAO’s with this can also cause HYPOtensionPreg category CNarcotics (pain), Benzos and barbs (anxiety), phenothiazines (nausea), MM relaxers OD Reversal DrugsNARCANOpiate antidotegiven even if there is an OD of unknown causeFlumazenilAntidote for benzosAmyl NitrateFor Chest paincyanide antidote IpecacTo Pukemallory weiss tear from violent pukingvomiting like the exorcistAtropineto stop cholinergic effects It is an anticholinergicCharcoal Binds med in the gut so it cannot be absorbed then is passed in the stool. Powder form mixed in water and sucked through a straw to prevent reddining of the teeth. Vitamin KAntidote for Warfarin Protamine SulfateAntidote for heparin CancerAntimetabolite5FU (fluorouracil)Pyrimidine analog (disrupts nucleic acid fxn)IV or topical admin (topical for skin cancer and we may not need to know this)Cell cycle S-phase specific, prevents thymidine productionbone marrow depressionHigh alert medicationMTX methotrexate Folic acid analog (prevents folic acid conversion)Sphase specificPREG category XHigh alert meddose limiting bone marrow suppressionKills rapidly dividing cells, and causes immunosuppressionSE: Pulmonary fibrosis, Hepatotoxicity, nephrotoxic, Steven-Johnson’s syndrome, and aplastic anemiafor the pulmonary toxicity, early signs are a dry nonproductive cough for SJS, assess for rash as an early signfor nephrotoxicity low back and flank pain is an early sign as well as changes in urination patterns or pain. Alkylating agentsalkylates DNA and binds 2 guanines together to prevent the helix from becoming unbound, therefore inhibiting replication. The dose is limited by bone marrow suppression, but can be given in a bolus. Mustargen (mechlorethamine) inhibits DNA and RNA protein synthesisfor hodgkin’s disease and malignant lymphomas. Cell cycle phase nonspecificContraindicated in pregnancySE: thrombocytopenia, Leukocytopenia, Seizuresmonitor for bleeding and bone marrow suppressionnotify provider for sore throat, neph-toxic s/s, bruising, bleeding, red stoolsDO not drink alcohol, or take NSAIDs, or ASPIRIN, this will increase bleeding riskMustard Gassimilar to the nitrogen mustards, but for warfare. Cytoxan (cyclophosphamide)High alert medmost common alkylating agent cell cycle phase nonspecificSE: Pulmonary fibrosis, myocardial fibrosis, hemorrhagic cystitis(increase fluid intake to 3000ml/day), leukopenia(monitor for , thrombocytopenia(monitor for bleeding), anemia. increases effects of warfarin, phenobarb and rifampin increase toxicity of this drug. Prolongs the effects of cocaine. monitor for edema, crackles, cardio/resp distress, HF s/s. crosses BBBAntibody Anti-tumorDoxorubicin (Adriamycin)antitumor antibiotic binds directly to DNA and stops replicationHigh alert meddose limiting heart failure, and bone cell cycle S phase specificSE: CARDIO TOXIC, dark urine stools, palms and nails, alopecia, leukopenia, monitor uric acid levels, bleeding and CBC, I’s and O’sPlatinumCisplatinproduces crosslinks in DNA and is cell cycle nonspecificdose limiting kidney failuremetastatic, head and neck, testicular, ovarian, bladder ,lung, and colon cancertubular necrosis in the kidney, ototoxic, bone marrow suppression, severe nausea and vomiting in the first hour after administration. MOA similar to alkylating agents Kidney Failure is a dose limiting factor. Mitotic InhibitorsVincristineprevents cell division (m-phase specific)SE: peripheral neuropathy (Neurotoxic), barely and bone suppression!!vinblastine causes bone marrow suppression and not peripheral neuropathy, so when used together there is not stacking of those side effects. AntiHormonesTamoxifenantiestrogenfor treatment and PREVENTION of estrogen related cancers ie. breast SE: causes CANCER, birth defects, vaginal discharge w/ bleeding. DD: carbamazepine = rapid metabolism. and erythromycin = slowed metabolism. prednisoneuse in high dosesglucocorticoidstoxic to lymphocytes and lymph tissuesprogestin (megace) used in AIDS pt for anorexia, weight gain and stim of appetiteAnticoagulantsAspirinsuppress platelet aggregation for the platelet’s life span through cyclooxygenase inhibition. doubles bleeding time for up to seven dayscan be used for prophylaxis of MI in men and questionable in women. risk of GI hemorrhageHeparin Interrupt coag pathway in factor X and thrombin prevents thrombosis, post op thrombus, and more clots formingSE: HEMORRHAGE, HIT, Sensitivity reaction bc it is animal product, All kinds of bleeding (gums, bruises, petechiae, hematoma, red or black stool)HIT heparin induced thrombocytopenia - antibodies develop against Heparin, and the person can NEVER GET THE DRUG AGAIN, there will also be long term bleeding issues associated with thisRAPID acting, and only given IV never PO or IMMade from animalsnormal aPTT is 40 secondstherapeutic aPTT with heparin is 60-80 secondsPROTAMINE SULFATE is the antidoteLovenoxLMW Heparin - low molecular weight heparinonly stops factor X not thrombin for prevention and treatment of DVT, prevents complications with unstable anginado not need to check aPTTnever givin IM Argatrobandirect thrombin inhibitorUse this drug if the patient is experiencing HITalso bivalirudin does this (monitor with ACT test) monitor with aPTTno reversal agent expensiveStreptokinaseThrombolytic: Dissolves clot after formationstick all IV’s before giving drugconverts plasminogen to plasminfor acute MI, pulmonary emboli, to break up a clot in a central linecan cause bleeding, Allergic RXN, tPA alteplasethrombolytic: Dissolves clot after formationstick all IV’s before giving drugmajor bleeding issues. but not as much of an allergy riskvery similar to streptokinaseDabigatran (Pradaxa)direct thrombin inhibitorfor HITORAL anti coag for stroke PT’s w/ non valvular Afibvery expensive, bleeding problems as wellclopidogrel (Plavix)ADP receptor antagonistgiven with ASA sometimes, but do not take ASAfor PAD and CVAthese are contraindicated with HERBALS proton pump inhibitors makes plavix not effectiveWarfarin (coumadin)indirectly decreases many clotting factorsworks in the LIVER not the bloodnormal tests while on warfarin are INR(2-3sec) and PT (12sec)Pregnancy category Xdecreases production of factors IIV, IX, X and prothrombinfor long term treatment of thrombosis, or pulmonary embolism, also prophylaxis of clot formation(TIA, Prosthetic valve, Afib)Lasts much longer than heparinSE: bleeding like the restkeep Vit K levels consistent throughout treatmentVit K is the antidoted/d interactions increase clotting: quinidine, antibiotics, NSAIDs, cimetidine, thyroid hormones, ASA, Tylenol even Musculoskeletal chapter 25Diazepam (Valium)Centrally acting MM relaxants flumazenil is the antidote for thisused to treat spasticityCNS depression, sedationbenzoSelegiline (Eldepryl)for parkinson's and for pt’s taking levodopa spasticity as wellBaclofenfor spasticityanalog for GABASE: sedation and HA, dizziness, diplopia and weaknessdo not stop the administration of this drug suddenlytaper over 2 weeks or: hallucinations, fever rigidity, paranoia, seizuresDO NOT mix with ALCOHOL given 2-3 times/day herbal interactions: kava-kava, valerian root, or chamomile these can cause CNS depressionno antidoteCarbamazepine (tegretol)SZ mednerve pain and bipolar disordergrapefruit interactionsteven johnson’s syndromesuicidal thoughtsdo not take with warfarin cyclobenzaprine (Flexeril)Centrally acting MM relaxants do not use in:hyperthyroidism, heart conduction difficulties, heart failure, recent MI.serotonin syndrome - agitation, tachy, hyperthermia, (madams TIPS) urine color changedo not use with other SSRI’sMetaxalone (Skelaxin)Centrally acting MM relaxants Can cause liver damagetest liver function before and throughoutACH effects, caution in sedation w/ elderly methocarbamol (Robaxin)Central acting MM relaxantunknown MOAfor acute injuriesgive ? x/day, urine color change, dizzy, drowsy, metallic taste. intensifies with ETOHchemically similar to tricyclic antidepressants Tizanidine (Zanaflex)Centrally acting MM relaxantsacts at presynaptic A-2 ACH effects, caution in sedation w/ elderly do not take with alcohol NM Blocker in generalBisphosphonates (alendronate)decrease bone resorptionSE: esophageal irritation, Heartburn, osteonecrosis of the jaw, atypical femur fractureSEVERE esophagitis, stand for 30 MINUTES after swallowing with water onlydo not take with other drugs TeriparatideSTIMULATES bone formationSQ injectioncan be taken for up to 2 yearsNSAIDs (COX 1 and 2)used in RA until the DMARDS kick in, (this is changing from NSAIDS to glucocorticoids though)1st line treatment for gout DMARDs (MTX, Arava, Plaquenil)Disease-modifying anti-rheumatic drugsgiven first for RAtake glucocorticoids until DMARD’s take effectsuppress autoimmune inflammatory process TNF is a part of the inflammatory process...Synviscinjectable directly into the jointcartilage and synovial fluid synthesisIndomethacinNSAID for goutinhibits prostaglandinsonly give for 3-6 dayscolchicineolder gout drugstops inflammation cycle, by decreasing mobility of granulocytes treats acute gout attackAllopurinolfebuxostat (Uloric)Xanthine oxidase inhibitor, stops production of uric acidfor chronic goutDrink 3 liters of water per dayDiabetes Mellitus Proinsulin is the prohormone to insulin, and is bound to a C-peptide. The peptide will be found in T2DM, but not T1DM.type 1 can have Ketoacidosis (DKA), and type 2 can have Hyperosmolar hyperglycemic non ketotic state (HHNK)incretins stimulate insulin release, suppresses glucagon, slows GI emptying, as well as suppress appetite. prediabetesImpaired fasting glucose (IFG) 100-125impaired glucose tolerance (IGT) 140 - 199 two hours after the oral glucose tolerance test6.5% > HgA1c > 5.7%Diabetes DiagnosisHgA1c > 6.5%FBG > 126glucose tolerance > 200Insulin(also promotes K uptake by the cells, so can also be given for hyperK)Lantusno peak, duration of 24 hoursDetemirno peak, duration of 24 hoursNPHO: 60-120 P: 6-14 D: 16-24cloudy solution70/3070% NPH, 30% Regularroll gently to mix RegularO: 30-60 min P: 1-5hr D: 6-10hrLisproO: 5-10 min P: 30min-2.5hr D: 3-6.5hrOralsBiguanide (Metformin)stops liver glucose production in liver, increases glucose uptake in the periphery skeletal muscles.Will NOT cause insulin production. this means that this drug does NOT put a person at risk for hypoglycemia. Can be used with regular insulin and sulfonylureas SE: Renal issues from LACTIC ACIDOSIS. If a person has renal insufficiency they are put at a much higher mortality rate. MONITOR renal fxn. Sulfonylureas (glipizide, Amaryl)First line, promotes insulin secretion, SE: HYPOGLYCEMIAsimilar structure to a sulfonamide antibiotic these are 2nd gen. and have longer durations than the 1st gen and fewer d/d interactions. D/D: all cause HypoGLY: ETOH, sulfonamides, Cimetidine, NSAIDs, beta blockersGlitazones (pioglitazone)decrease insulin resistance, and decreases liver glucose productionSE: HYPOGLYCEMIANot a first line medD/D interactions: CIMETIDINE, ketoconazole, rifampin, Atorvastatin Glinidesstimulates pancreatic secretion of insulin SE: HYPOGLYCEMIACan be used with metforminDD: Gemfibrozil A-Glucosidase inhibitors (acarbose, miglitol)Delays carb absorption 2% of drug is absorbed orally SE: abb cramps, borborygmus bowel sounds, flatulenceDPP-4 inhibitors (Sitagliptin)Stops DPP-4 from breaking down incretin the hormone Incretin increases insulin release, decreases hepatic glu production and release. Few SE and DDInjectable noninsulinINcretin mimetics (exenatide - Byetta)increase release of insulin, decrease glucagon secretion, makes you feel full, and slows GI emptyingSQ INJECTION at breakfast and supperfrom Gila monster spitNausea and vomitingHypoglycemia possible WITH sulfonylureas a new formulation is once a week SQ injection!SE: weight lossAmylin mimetics (pramlintide - Symlin)Slows GI emptying, decrease glucagon release, pt will feel more full, decrease postprandial glucose levelsSE: HYPOGLYCEMIA Antianemics (heme)Iron sulfateuse a strawtoxic in kidsMakes RA worse for iron deficiency anemia B12treats b12 or pernicious anemiab12 is needed to synthesize folic acid for cell growth and developmentcan cause hypoK CyanocobalaminFolic Acid (folate)for folic acid anemiaessential for cell replicationanemia can be from alcoholism, liver damage. Deferoxaminehigh affinity for ferric irondo not take with ojErythropoietin stimulates RBC productionmimics a natural hormone produced in the kidneyneeds the supplies to make RBC’s: iron, folate, and B12indications: chronic renal failure, anemia from chemo, or a chronic anemic patient having surgery. can cause HTNif HGB increases above 11 MI, CVA, and HF chances are increased dt increased clotting ................
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