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Med Type MOA SE/NOTES MILK/GRAPEFRUIT JUICE?RENAL dosing? CARDIAC MEDS ACE INHIBITORS 1st choice for inhibitors -“prils” prevent Na retention and vasodilation Category x Dry cough-> bradykinin ANGIOEDEMA Cannot be used w/ RF, but can prevent worsening rf in diabetic pts Amioderone (Coradarone)Amyl Nitrate Antidote for Nipride toxicity (CN)Anti-dysrythmics Class I: acts at Na+ channels, prevents influx of sodium, decreased excitability Ia: quinidine: prophylaxis of SVTNurs priorities: dig, QRS SE: decreased cardiac fx (HB), mental status 1b: lidocaine: VtachCNS/CV SE Propanolol and cimetidine incr toxicity 1c: fleccanide (ATOMIC BOMB) PVCs Class II: beta blockers (-olol) Make HF worse, MI, diabetics Decreases HR by neg chonotropes, neg dromotropes ClassIII: Amioderone: K+ channel blockers IND: cardiac conversion of afib; life threatening Vtach ELONGATES refractory periodBlue skin, pulmonary fibrosis, thyrotoxicosisdigoxin/anticoag toxicity Class IV: CCB’s (Verapamil) neg inotrope, neg dromotrope Kindey failure-> caution, pitting edema of LEAnti-hypertensives 1st line: CCB, dirutetic (loop/thiazide) or RAAS (ACE, RB, DRI’s); ACE 1st choice 2nd line: add another or change classes; BBlockers ASA81 mg for stroke/clot prevention Atorvastatin (Lipitor)Statin (HMGOA inhibitor) DECREASES TOTAL, triglycerides, LDL And increases HDL (35-40%) COQ10 enhances absorption RHABDO, HepatitisEnhanced with BAD W/ GRAPEFRUIT JUICE Atropine AnticholinergicIndication: Bradycardia SE: decreased U/O, constipation, drymouth, HR, mental status Beta blockers Calcium Channel BlockersDigoxinUsed for HFIncr refractoy period Negative chornotrope (decr HR) Negative dromotropeIncreased Fcontraction (positive inotrope) Narrow therapeutic range .125-.25 mg/day; serum levels btwn 0.5 to 0.8 ng/mL T1/2: 36 hr Toxicity: decreased effect, halo, GI CONSIDERATION: hypokalemia Direct Acting Vasodialator RASHOsmotic diureticsLoop diureticsFurosemide (Lasix) SULFA ALLERGY Orthostatics, increased UO, otoxicity/photosensitivity, hypokalemiaThiazide diureticsHCTZ (hydrochlorothiazide) SULFA allergy More distal loop: decreased UO than loop Decreased K+ Na+ Increased Ca2+, uric acid, glucose K+ sparing Spironolactone Supplement considerations Cant use Thiazides in low GFRDiureticsFurosemide (Lasix) Hydrochlorothyazide (HCTZ)Loop diuretics Niacin B vitamins RISK OF STROKEHot flushASANo evidence of effectiveness Omega 3 fatty acids Not effectiveIncreased LDL Potassium supplements (KCl) Not advised for ACE inhibitors or potassium sparing diuretics Propranolol (Inderal) Non selective betablocker Thiazide diuretics RESP MEDS ASTHMA SCHEDULE Mild: SABA for resuce, if >2x week consider next stepMild, persistent: low dose steroidal inhaler (Beclomethasone, fluticasone [flovent]) + a leukotriene inhibitor or methylxanthine. SABA Moderate: intermediate dose, LABA, tablets or theophylene Severe: High doses steroid inhaler, LABA, tablets, or theophylline, and oral steroid (Prednisone) SABA Albuterol (Proventil) Short acting beta 2 (non selective) adrenergic. RESCUE MED, not effective used regularly SNS stimulation causes relaxation of airways and bronchodilation. SE: paradoxical bronchospasm w/ excessive use, arrhythmias, hypertension, hypokalemia, hyperglycemia Propper MDI technique: breathe in slowly, hold breath for 10 s, wash mouth between uses, SPACER, Anti-histamine spray (Astelin) Decreases mucus, runny nose, itching, sneezing Given intranasally Beta 2 agonists Beclamethasone (QVAR)Glucocorticoid LOW DOSE STEROID INHALER USED FOR MILD, PERSISTENT MED Taper off; candiasis increase dose w/ stress Fluticasone FLONASE: REBOUND CONGESTION corticosteroid inhaled for congestion/sneezing FLOVENT; used as low dose steroid inhaler H1 blockers Rhitis/allergy Anticholinergic effectsParadoxical excitation in 50% of children Montelukast (Singulair)Leukotrine inhibitor: decreases eosinophil response USED in mild,persistent for long term asthma control Suicidal thoughts Prednisone PO: glucocorticoid for SEVERE asthma Pseudoephedrine SympathomimeticUsed for decongestionREBOUND DECONGESTION Often combined w/ guaifenesinDO NOT USE W/ HBP (coricedin hbp) Rifampin Inhibits RNA synthesis of TB ORANGE/RED discoloration of bodily fluidsStains contact lenses Decreases effectiveness of hormonal b/c, hiv meds HEPATOTOXICITY Empty stomach SalmeterolLong acting beta agonist for mgmt. of MODERATE asthma symptomsMDIWASH MOUTHADHERENCE NOT RESUCE Steroid inhalersWash mouth between uses to prevent candiasisMedications for HA, Insomnia, Parkinson’s Disease, Alzheimer’s, Antieleptics, and Anxiolytics (NEURO) Anti-depressant principlesBenzodiazepines Diazepam (valium) Flumazenil Why did we give it? Headache Meds Preventative or abortive Start w/ OTC Then w/ ergotamine and triptans MAOI’s Thiamine: HTN crisis Phenytoin (Dilantin) Partial tonic/clonic szsT1/2: 8-60 hrsTI: 10-20 mcg/mL SE: gingival hyperplasia , SJS Pregnancy: folic acid/defects, SJS Decreses effects of hormonal bc/warfarin/glucoIncreases [serum]: benzos, ETOH, cimetatdine NO ANTIDOTE Triptans Serotonin agonistvasodilation Heavy arm and chest Zolpidem (Ambien) Benzo like drugs Better to stay asleep Rebound insomniasleep behaviors GI MEDS Antacids Reduces absorption of many other drugs through chelation: timing is critical -Aluminum SE: constipation, bone demineral-Calcium: gastric acid hypersecretion, constipation, renal failure, hypercalcemia -magnesium: diarrhea, hyperkalemia, and hypomagnamesia-Hypernatremia (cardiac overload) Long term use can result in CKI Anti-emetics Block receptors of chemorecptor trigger zone SE: drowsiness, tardive dyskinesia -anticholinergic: scopolamine-antihistamines-phenothiazine -dopamine receptor blocker :metoclopramide (Reglan) -cannaboid -bismuth salts (pepto bismol) Bulk forming laxatives Calcium Carbonate (TUMS)Advise pts that amount of calcium in Tums is not sufficient to achieve DRA (would have to take 10-15). Discourage “popping” Cimetidine (Tagamet)Acts at Histamine-2 receptors of gastric parietal cells to prevent secretion of gastric acidINDICATED IN PUD, reflux diseases Reduces heaptic metabolism of MANY drugs (resulting in toxicity)Reduced effect w/ antacidsToxicity: tachycardia, changes in mental status CNS confusion, dizziness/drowsinessANTICHOLINERGIC SECheaper than PPI and just as effective w/ ulcer prophylaxis H2 Blockers (like Zantac)Magnesium salts in meds NEED TO MONITOR FOR IN PT CONDITION, esp cardiac as can result in hypomagnamemesia (HTN, tachycardia) and in hyperkalemia (arrhythmias, muscle weakness) Psyllium (Metamucil )Bulk forming laxative Absorbs water and forms mass to stimulate peristalsisW/OUT WATER: can lead to obstruction GI SE (cramps, intestinal/esophageal)Metoclopramide (Reglan) Dopamine (inhibitory) receptor blocker . Used for anti-emetic. Accelerates gastric emptyingSE: Extrapyramidal side effects. Can cause arrhythmias, hypo/hypertension, drowsinessOsmotic laxatives Draw water from capillaries of gut and stimulate gut LYTE! Usually loose/watery stoolsUsed for rapid, complete evacuation of stools Pancreatic enzymesPancrelipase (Pancrease): promotes process of digestion Nausea, abd cramps, loose stools, obstructionHold if NPO, take immediately prior to meals Can produce statoreas Scopolamine Anticholinergic Used for motion sicknessATROPINE LIKE EFFECTS Blurred visionSerotonin Receptor Agonists (Zofran) Commonly used in hosptials for chemo. Serotonin antagonist at chemoreceptor trigger zoneSE: CNS depression and potentiation of other narcotics, can cause QT INTERVAL ELONGATION Sodium Bicarb Stimulant laxatives Biacodyl (Dulcolax)Stimulates peristalsis and impacts fluid/electrolyte balance in gut Abd cramps, nausea, diarrhea, rectal burning, hypokalemia, muscle weakness Surfactant laxatives Antimicrobials Amoxicillin/clavulantic acid (Augmentin) Broad spectrum Indicated: penicillin resistant bact. Lyses cell wall <6 mo OM: amoxicillin>2 yo, wait to seenon-resolve: amoxicillinDR OM: augmentin Bactericidal MACULAR RASH: not allergy diarrhea Probenecid decreases excretion Avoid high fat meals Nephrotoxic: Fluroquinolones Cephalosporins GentamycinFlagyl Chelation agents: Cipro (floroquinolone) Tetracycline/doxycylcine Anti-fungals Examples: Amphotericin B, nystatin mycotic=fungal Disrupts cell wall permeability Bind ergosterol (cholesterol component of fungal membrane) Systemic (opportunisitic/nonopportunistic) NephrotoxicitySuperficial Take a long time to work WKS Not DAYS Hepatotoxic Anti-virals (-vir) Inhibition of nucleic acid synthesisStops viruses from reproducing Cephalosporins Bind to penicillin binding proteins 1st/2nd gen: narrow spectrum3rd/4th: broad4th: can cross BBB Seizures Given preoperative prophylaxis Good for use w/ kidneys, however in kidney failure (decreased excretion) incr risk of seziures -use w/ loop diuretics and aminoglycosides: nephrotoxicity Ciprofloxacin Doxycycline TetracylineBacterostatic inhibitor of prn synthesis Used for “weird diseases” lyme, anthrax, h pylori, acne, etc POchelating agent: binds to milk, minerals, AND OTHER DRUGS SE: photosensitivity, brown teeth, suppresses long bone (<8 yo)Use back up B/C, potentiates warfarin Chelation Avoid mealsDrink w/ waterFluroquinolones Broad spectrum; inhibits DNA gyrase Pseudomonas/anthrax SE: Tendon rupture (NOT GIVE TO CHILDREN <18yo)Risk of torsades du pointes Pharynx and Vagina candiasis [bile/urine/stool/prostate] CHELATION AGENT: avoid antacids, iron, mag, milk Renal adjustment dosing Gentamycin Aerobic gram negativeInhibits 30s ribosmome P. aergenosa, ecoli, klibsiella, serratia, proteus mirabellus Nephro/ototoxicity Peak: 30 min-1 hr after IV Trough: 1 hr before give you next dose Inactivd by penecillins/cephalopsorins Hard on kidneys and earMetronidazole (Flagyl)Protozoal infections/parasiets/ and obligate anaerobes Trichomonoiasis and Giardia SE: nephrotroxicity DISULFIRAM RXN Durg interaction w/ ETOH and anti-coags Nephorotoxicty Penicillin Narrow spectrum Mainly gram +, some gram-Least toxic, glossitis/stomatitis; Most incidences of anaphylaxis: could be immediate/accelerated (1-72)/late (days-wks)IM or IV recommended lasts 24-4 wks Probenecid Potentiates warfarinBack up form of BC Analgesics Acetaminophen (Tylenol)Antipyretic, analgesic Inhibits synthesis of prostaglandins in central NS3 mg/day MAX ASA1st generation NSAID (cox-1 inhibitor and cox 2-inhibitor) REYE’s SYNDROME CATEGORY XANTAGONIZE DIURETIC EFFECTS Can cause renal failure Ibuprofen 1st generation NSAID (cox-1 inhibitor and cox 2-inhibitor)Kidneys and Liver Renal failure N-acetycystine MUCOMYSTantidotePO/IVcharcoal may decrease effectivenss must give w/in 10-12 hrs Narcan (Naloxone) Narcotics NSAIDs-may be beneficial to promote mobility in ligament pain, not effective for muscle pain, result in malformation/malhealing delayed healing COX-1: GI bleeding, renal failure, clotting issuesCOX-2: decreasd inflammation, sensitivity to pain, risk for colon CA Synthetic Opioids Tramadol (Ultram) acts on the mu receptorAnalgesic w/ less resp depressionDecreased chance of dependence CONTRAINDICATED in opioid dependence Drugs Affecting Blood, Coagulation, and Clotting Agatroban Direct thrombin inhibitor, Utilized when a person w/ Heparin Induced thrombocytopenia (HIT) needs anticoagulation no reversal agent known Monitored via aPTT (12-24 s normal; measures extrinsic pathway) Protamine sulfate Antidote for heparin overdose Base that forms w/ acidic heparin to prevent absorption and promote excretion Initial loading dose given IV and then adjusted via lab monitoring. HYPERSENSITIVITY RXNS, PE, hyper/hypotensionIf initated in pt w/ hypovolemia can result in cardiovascular complex Pt may need FFP TpA Clot buster Less allergic rxns than streptokinase Vitamin K Antidote for warfarin IMPORTANT to teach pt to keep level of vitamin k intake (leafy vegetables) constant when on Coumadin Warfarin Modifies intrinsic pathwayOral anticoagulant Measured via PT and INR (normal 2-3) *VALVES need higher INR than arrhythmia care (4-5) Once pt is on warfarin, anticipate switching for Coumadin for home use stress importance of follow up visits PREGNANCY CATEGORY X!!!!!!!!!!!! Chemotherapy Drugs Cisplatin (Platinol) Alkylator like agentNonspecific disruptor of DNA synthesis in bladder, ovarian, and testicular cancerHIGH ALERTDoes not cross BBB in significant amount: excreted 5 daysNephrotoxicity/ototoxicity, sterility, hypocalcemia, hypoklameia, hypomagnemesia, hyperuricemia, leukopenia/thrombocytopenia/anemiaNephrotoxicCytotoxic chemo Act on similar metabolic pathways in both normal and CA cells Lack tumor specificity Toxicity divided into common SE, adverse rxns, dose limited Common SE: n/v, alopecia, bone marrow suppressionTypesAntimetabolite: interfere w/ normal DNA production Alkylating: Prevent cell division Antibiotic: block transcriptionMitotic inhibitorsOthers: hormones, antihormones, steroids Herceptin HIGH ALERT monoclonal antibodies Tx of metastatic br ca displaying human epidermal growth factor receptor 2 (HER2)SE: LOTS OF PULOMNARY SE (Pneumonitis, edema, fibrosis), bone marrow suppression, hypersensitivity rxns MegaceProgestin-Used in prostate CA to suppress androgens -Used in oncology to promote weight gainBelieved to derive benefit from suppression of pituitaryThrombocytopenia, edema,Use w/ caution in thrombophlebitis, vaginal bleedingMethotrexate Antimetabolite: inhibits synthesis of DNA/RNA Indications: head, neck, lung, renal, ovary, bladder, testicle, leukemia, lymphomaAlso used as a DMARD Cell phase specific BIG SE: pulmonary fibrosis Bone marrow suppression, blurred vision, SJS/TENS, n/v, acute renal failure GIVEN W/ LEUCOVORIN TO REDUCE TOXICITY Tamoxifen Anti-estrogens Estrogen receptor + breast cancers; breast cancer prevention FULL ANTINEOPLASTIC EFFECT MAY TAKE MONTHS TO OBSERVE KNOWN TO CAUSE BIRTH DEFECTSMAY CAUSE S/SX such as hotflashes MSK Bisphoshonates Osteoperosis Inhibits osteoclasts 90 degrees for 30min-1hrOsteonecrosis of the jaw (ONJ) Renal failure Colchicine HIGH ALERT Gout Agranulocytosis Rhabdo w/ statins GI bleed w/ NSAIDS Use w/ caution in renal pts Cyclobenzaprine (Flexeril) Central acting muscle relaxant (spasm) ; local Not indicated w/ hyperthyroidism, MI, HF Anticholinergic Methocarbamol (robaxin) Central acting muscle relaxant (Spasm) ;local CNS depressionBest in acute injury black/brown/green urineBoth: intensified w/ ETOH SHORT TERM ONLY: mood alterin, tolerance, potential for abuse SE: increased muscle tone, loss of dexterity SERMsOsteoperosis Contraindications “men” MUST Take w/ calcium Postmenopausal Succinylcholine Spasticity (systemic) Malignant hypertension Endocrine/Diabetes Biguanides (metformin) GOLD STANDARD OF ORAL TII DM meds Promotes peripheral uptake of glucose and decreased gluconeogenesis by liverWILL NOT cause hypoglycemia BIGGEST SE: LIFE THREATENING lactic acidosis w/ IV contrast dye Decreased vitamin B12 levels Unpleasent metallic taste Administered w/ meals LIFE THREATENING LACTIC ACIDOSIS W/ DYE Liothyronine (Cytomel) T3 preperation indicated for hypothyroidism; T3 has shorter half-life, more rapid onset than pro-hormone T4 SE: excessive dosing results in hyperthyroidism Single dose before breakfast, can be crushed and suspended in waterBile acid sequestrants impact absorption, alters effectiveness of warfarin, diabetes agents, and estrogen therapy DDAVP[desmopressn acetate] Vasopressin analog given to treat Diabetes Inseppidus (retains water) -Intranasal/PO also indicated for nocturnal enuresis Given PO, Sub Q, IV, and Intranasal HTN, flushing, water retention (water intoxication; drowsy/listless, HA, convulsions), vasoconstriction, rhinitis, nausea Assess constantly for fluid retention Intranasal administration: tolerance can develop, 10x less potent than IV, blow nose before use DPP-4 inhibitors (Januvia)PO given to prevent breakdown of insulin by inhibiting DPP-4 enzyme ; incretin enhancer DOES NOT cause hypoglycemia Can cause acute renal failure, other few se: HA, pancreatitis, n/d, URI, allergic rxnRenal adjustment Glucocorticoids Given topically, PO (prednisone), for systemic anti-inflammatory effectsAlters glucose metabolism Toxicities are duration/dose dependent BIGGEST SE: adrenal suppression (immunosuppression (except neutrophilia), altered glucose metabolism) Withdrawal can be life threatening, MUST TAPER OFF and must increase doses in times of stressLong term dosing Cushingoid appearance Incretin mimetics (exentide: Byetta)Stimulates release of insulin to: -decr glucagon production-incr satiety -decrease gastric emptyingMAY promote wt loss Sub Q injectionCAN cause hypoglycemia N/v, pancreatitis, diarrhea, thyroid t cell tumors, acute renal failrues Insulin IV drips Varies based on hyperglycemia protocol Only lispro (short acting) indicated for IV use according to Davis Levothyroxine (Synthroid)T4 preperation Given PO before breakfast Takes about 4 half lives (1 mo) to achieve therapeutic effect Dif []’s in dif colors SE: hyperthyroidism NPH insulin (HUMALIN N) Intermediate acting insulin Protamine retards absorption and prolongs effects Administer 30-60 min before mealonset takes 1-2 hrsPeak is 6-14 hr and duration is 6-24 hr Given w/ short acting @ breakfast to cover breakfast, peak is 4-8 hrs later, so main concern is late afternoon (3-4 pm) May be mixed w/ regular, short acting Can be kept at room temp for 28 daysRadioactive Iodine I133 Emits γ and β rays to kill thyroid cells, block thyroid hormone synthesisIndicated for hyperthyroidism Monitor/assess for development of hypothyroidism and complications (myxedema) Must sleep alone, can’t share utensils/drinking glasses for few days following treatment; half life of 8 days thyroid labs Regular insulin 30-60 minPeak: 2-4 hr Duration: 5-7 hr Give w/in 15-30 min before a meal Can be kept @ room temp for 28 days after opened CAN BE drawn w/ NPH; NOT MIXED w/ lispro Sulfonylureas (Glipizide)PO, stimulates release of insulin from pancereas (requires pancreatic function) -increases sensitivity of receptors -may decr hepatic glu producHIGH ALERT CAN cause hypoglycemia ASSESS FOR SULFA ALLERGY Aplastic anemia Do not administer micronized sulfonylureas w/ high fat meals Herbals/Toxins Anaphylaxis intervention D/c suspected drug Maintain airway (bronchodialators may be required) Adminsiter epiAdults: IM, Sub Q: 0.3-0.5 mg q 5-15 min IV: 0.1 mg over 5 min OR 1-4 mcg/min infusion Children IM, Sub Q: 0.01 mg/kg or 0.1 mg q 5-15 min IV: 0.1 -0.2 mg over 5 min, repeat q 30 min OR 0.1-1.5 mcg/kg/min infusion Diphenhydramine Adult: IM, IV: 500-100 mg single dose, may follow w/ 50 mg q 6 hr for 1-2 days Children: 5mg/kg/day in divided doses q 6-8 hrs; may follow w/ oral therapy for 1-2 days Support BP Administer corticosteroids Documentation CalciumStored in liver and fatty tissues (linked to coronary artery plaques?) Constipation, bone pain, kidney stones Best taken w/ food Can cause Mg toxicity if taken simultaneously Binds to chelating drugs Charcoal Slurried solution to bind w/ drug and prevent absorption when drugs/poisons can’t be vomitied (esophageal irritants resulting in Mallory Weiss tear) Herbal supplement oversight DO NOT UNDERGO FDA review and approval Sales surged in 1990s; in 2009: $33.9 billion dollar industryFederal Trade Commission (FTC): has oversight/responsibility of Monitor advertising, reports of SE, can stop sale of product MEDWATCH program tracks reports of SE Poisoning approaches Principles revolve around stopping absorption, removing or reversing toxin, and providing supportive careIpecac IS NOT go to; should call poison control w/ specific insturctons If can’t vomit med, use activated charcoal Some meds/toxins have specific reversal agents (when in doubt use Narcan) Vitamins Two categories Fat soluble : risk of toxicity Vitamin D (calcium deposition in bones), Vit K, A (adaptation to light, role in growth/immunity)Water soluble: need more frequent replacement Vitamin B 12 (pernicious anemia or IF deficiency from gastrectomy)Topical medications Atropine eye drops Anticholinergic drug used for mydriasis (pupil dilation) and cycloplegia (paralysis of cilliary muscle of eye) for ophthalmic surgery or tx of uveitis (infection) SE: biggest is systemic anticholinergic effects (parasympatholytic): tachycardia, decreased salivation, constipation, increased RR, addative CNS depression. Also, blurred vision, photophobia (may last ~6 days) Cycloplegic eye drops Drugs that paralyze ciliary muscles Administered by creating lower lid pocket, administering , applying pressure for 1-2 min, leaving in for 5 minAVOID touching tip to cap that has touched pt, or pt’s eye Ear drop meds Should be WARMED prior to administration to prevent dizziness/confusion For children <3 yr, pull outer ear downward; children >3 pull outer ear out and up Keep child on side and instill cotton ball for 2 min Avoid touching dropper to ear Antibiotics given to children <6 mo, after 2 yr observation therapy applied Floxin Otic Drugs Floroquinolone otic drop administered in treatment of Necrotizing Otitis Externa; DAVIS says for OM as well Floroquinolone, but very few systemic SE have been reported from otic concentration (); can cause local irritation/rxns, or overgrowth of resistant bacteria Similarly, few drug-drug interactions Isoretinoin (Accutane) Retinoid: reduces sebaceous gland size and differentiationPREGNANCY CATEGORY X: Pt must read drug information sheet for each refill, must register w/ IPLEDGE, have at minimum 2 pregnancy tests, and agree to use of 2 bc methods -Regimen is 15-20 wk, may be resumed if acne relapses SE: suicidal thoughts/behavioral changes, blurred vision, chelitis, dry mouth, n/v, abd pain, anorexia, SJS, TENS, photosensitivity, skin infections, hypertriglyceridemia, hyperuicemia-Addative toxicity easily possible (fat soluble vitamin A derivative) -addative anticholinergic effects, drying effects-ETOH: hypertriglyceridemia Administered w/ meals to reduce GI upset Latanprost (Xalatan) eye drops Prostaglandin analog Used for open angle glaucoma (characterized by increased intraocular pressure) and ocular hypertension Relaxes ciliary muscle to promote outflow of aqueous humor -1st Line Therapy for Open Angle Glaucoma: AS effective as beta blockers w/ less systemic SECharacterized by progressive pigmentation (harmless but generally irreversible) Phyenylephrine Alpha adrenergic agonist (sympathomimetic) Mydriatic agent;Stimulates adrenergic receptor of pupil -b/c shorter acting preferential for exams whereas atropine used for surgeryAgain, SE are systemic sympathetic related: tachycardia, hypertension, hyperhidrosis, trembling, paleness Addative cardio effects w/ MAOIs Pilocarpine Direct acting cholinergic 2nd line drug of open angle glaucoma (facilitates outflow of aqueous humor) Also given to counteract mydriatics following surgeryParasympathomimetic: stimulates constriction of pupils and contraction of ciliary muscle CONTRAINDICATIONS: conditions where pupil constriction should be avoided Ranibizumab (Lucentis)Angiogenesis inhibitor used w/ wet (neurovascular) ARMD (age related macular degeneration) Can improve visual acuity, and prevent futher damage from progression of wet ARMD. SE: Inflamation/enopthamlitis (infection) Timolol eye drops NON selective beta blocker (-olol); 1 of five approved for reduction of aqueous humor in open angle glaucoma and ophthalmic hypertension -decreases production of aqueous humor Minimal local effects, but riskof systemic absorption resulting in bradycardia, bronchospasm, AV heart block ABSOLUTE CONTRAINDICATION: hx of AV heartblock, not recommended for asthma pts Applying pressure reduces systemic absorptionVaccinations/Immunomodulators Cyclosporine (Neoral) Immunosuppressant/DMARD: inhibits IL 2Indicated for renal/heaptic/cardiac transplant Dose is adjusted based on serum levelLIFELONG Therapy SE are typically dose dependent: post. reversible encephalopathy syndrome, renal toxicity, HEPATOTOXICITY, severe HTNMix w/ juice or milk to administerGRAPEFRUIT JUICE INCR ABSORPTION May need to adjust based on monitoring of renal lab tests Hep B vaccineINACTIVATED vaccine, Given in 3 doses at childhood (birth, 1-2 mo, 6-18 mo) , catch up in childhood or at risk adult population Give IM Unkown duration , 90% efficacy Adult high risk populations incl: immunocompromised and health care workers Mild SE related to injection (sl fever, irriation) Tacrolimus (Progaf)Prevention of organ rejection (used w/ corticosteroids) in liver, kidney, or heart transplant Inhibits T lymphocytes Alternative to Cyclosporine, MORE TOXIC -SZ, changes in sight/hearing, hypertension, QT elongation, GI bleeding, gi irritation, nephrotoxicity, hyper/hypokalemia, hyperlipidemia, hypophosphatemia, hypocalcemia, hyponatremia, lymphoma, metabolic acidosis/alkalosis AND A WHOLE LOT MORE GRAPEFRUIT JUINCE INCREASES ABSORPTION (TOXICITY)REPEATED LABS TO DETERMINE IF DOSES MUST BE ADJUSTED Tetanus vaccines/dose DTaP given IM in 5 doses to children <7 yo >7 yo and adults: doses of Tdap; should be fully immunized by 16 yo (using catch up schedule) Tdap preferred <65 yo Td booster should be given q 10 years Transplant therapies Results in immunocompromised state Monitor for s/sx of opportunistic infections Medical asepsis priority Almost all are toxic Typically, solu-mederol (glucocorticoid) administered w/ first dose of cyclosporine to prevent adverse rxnVaccine considerationsType of vaccine Live vaccine: contraindicated for most immunocompromised states Inactivated : short acting, need multiple doses Toxoid Killed Virus Gamma globulin (not true vaccine) Spacing issues Killed and live: can be administered simultaneously or at any interval between doses 2 or more killed antigens: “ “2 or more live antigens: 4 wk interval if not given simultaneously Adverse rxnsMust be prepared w/ epi and diphenhydramine TRUE contraindications Hx of anaphylactic rxn to specific vaccine OR to a vaccine component (ie. Latex, soy,e gss) Moderate or severe illness w/ or w/out fever Contraindicated in pregnancyPPV, MMR, Varicella, Meningococcal, Shingles Contraindicated in immunocompromised Varicella, shingles SPECIFIC VACCINES HIB contraindicated in children w/ active infection or febrile illness PPV contraindicated w/in 10 days of chemotherapy IPV: ALLERGY ALLERT: streptomycin, neomycin, bacitracin Influenza: contraindication w/ allergy to eggs MMR: neomycinHep A: bleeding disorder or febrile Small pox (Variola): can’t have direct pt contact until lesions healed Repro/renal medsFinasteride (Proscar)5 alpha reductase inhibitors; prevents conversion of T DHTIndications: BPH Decreased libido, impotency, decreased amount of ejaculate Women w/ male fetus shouldn’t handleWho can get preg shouldn’t handle w/out gloves Administered PO w/ or w/out consideration to meals Amyl nitrate “Poppers” Aphrodisiac that has been tried, but not proven to enhance libido/sexual gratification Systemic vasodilator in brain results in altered sensation ContraceptivesEFFECTIVENESS MAY BE DECREASED BY: CARBAMEZAPINE, PHENOBARBITOL, PHENYTOIN, RIFAMPIN,Typically combination of estrogen w/ synthetic progestin (10,000’s of combinations) Inhibits secretion of FSH and LH from ant. Pituitary; changes endometrium and thickens cervical mucusOC TYPICALLY 21 days w/ 1 week for period Lo dose: for skinny teens, Lower risk for adverse SE and ectopic pregnancy THAN TRADITIONAL ORAL CONTRACPETIVES Monophasic: estrogen/progestin taken for 21 days Biphasic: 2 different amounts of progestin, taken during ovulatory and menstrual phases Triphasic: Porgestin progressively increased for 21 days YAZ: spironolactone cousin (monitor for hyperkalemia) OCP: water retention Extended cycle (Seasonale): theoretically only 4 periods a month, but breakthrough bleeding Rings (Nuva Ring) and Patch: 3 weeks than removed; HIGHER RISK OF CLOTS Mini-pill: progestin only, less effective BUT can be given during breastfeeding Long acting progestin: Implanon, Depo, IUD (Merena), Education regarding contraceptives 1 dose missed: take asap2 doses missed: take 2 pills/day for 2 days then resume 3 missed: stop taking, use another BC method until pregnancy R/O Estrogen (Premarin)Incr. activity of estrogen sensitive tissues, NA and water retention, cholesterol lowering Stomach cramps or gas, HA, n/v, decreased libido, edema, GALLSTONES, WT GAIN -RISK OF ENDOMETRIAL CA: should be combined w/ progestin to reduce risk -SHOULD NOT BE GIVEN TO BREASTFEEDING WOMEN-#1 KILLER OF WOMEN <35; STROKESContraindications: abnormal bleeding, br ca, hx of VTE, hypercalcemia, endometreois, uterine fibroids Estrogen-progestin comboNotable SE: wt gain (manufacturer says 5 lbs), edema, mood, gall stones, INCR clotting, breast pain, incr risk of STI w/out barrier method of contraception, hyperglycemia Notable benefits: pregnancy prevention (70% protection typical use ), ovarian cyst suppression (less ovulation/formation of corpus luteum/scarring), resolution of iron anemia (control for bleeding), reduced RA and increased bone density (HOWEVER, Lehne (2013): Benefits of HT for bone <risksHRTIndication: estrogen deficiency esp. in post menopausal women Use w/ extreme caution and careful monitoring; can provide relief of hot flashes, but benefits in ostesoperosis < risks w/ HRTIUD2 main types: Merena: 5 yr, progestin (hormonal) Tricks body into thinking it is pregnant to prevent implantation of fertilized ovum Paragaurd: Copper: ~10 yr, copper only Creates inflammation in endometrium to prevent implantationPrevious: Dykon Shiled (YIKES), copper cross, Skyla (available outside of US/UK for ~3 yr) MedroxyprogesteronePorgestin analog used for -prevention of pregnancy-decreased endometrial hyperplasia (in estrogen use) -restoration of hormonal balance SE: mood changes, retinal thrombosis, PE, drug induced hepatitis, cervical erosisons, amenorrhea, breakthrough bleeding, breast tenderness, edema, allergic rxns-part of combined oral contraceptives Sildenafil (Viagra) Phosphodiesterase 5 inhibitors: Enhances NO producing more cGMPpromotes smooth muscle relaxationpromotes filling and erection -SE: HA, nausea, flushin, back pain, allergic rxn, visual changes, HEARING LOSS, at higher doses (color: pilots) ABSOLUTE CONTRAINDICATION: USE W/ NITRATES FOR CHEST PAIN -Levitra: lasts longer -Cialis: provides coverage for 36 hrs but most men use it w/in 4 hrs ($$) -1 shot wonder Fatty meal delays absorption, slows effect -Incr fluid to 2000 mL to prevent UTI TestosteroneIndication: androgen deficiency, hypogonadism, delayed male puberty, treatment of anemia, illegal use for muscle gain PO, IM, SQ -SE: abd pain, insomnia, dizziness, red skin, HA, depression, jaundice, change in libidoIn females: secondary sex characeteristics (incl acne) In males: gyencomastia, urgency, impotenceUse w/ caution in cardiac patients: hypercholesterolemia and fluid retention May worsen BPHHypercalcemia secondary to metastic cancer worse Pharmacokinetics and Pharmacodynamics ADME issues with age First pass effect Half life Ionized v non-ionized drugsLoading doses Medication safety Meds and the placenta Plasma drug levels Prn binding Theraputic index Medications w/ renal considerations Immunosuppressents Biguanides (Metformin) Incretin enhancers (Januvia) Antacids CCBs Thiazide diuretics ACE inhibitors ASAIbuprofenCisplatin Cephalosporins Floroquinolones Gentamycin (aminogylcosides) Flagyl Colchicine Meds and Milk Cipro Tetracycline Meds and Grapefruit Juice Immunosuppressents DigoxinCCBsStatins ................
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