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  1. #11
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    I'm trying to paste it here.
    For last week revision for Naplex exam, I think this might be helpful. Questions:
    • Mother has gestational diabetes, what is likely to occur when the baby is born. Mother also has epilepsy & is taking tegretol.
    • I. high birth weight II. Baby may have congenital abnormalities III. Baby is likely to have diabetes
    • Answer: I & II Tegretol is a class D drug
    • What strength will Albuterol 0.5% end up based on an order to mix it with 2.5 mL normal saline? 0.083%
    • Isosorbide dinitrate is dosed BID, what regimen is best 7 am & 12 noon, 7 am & 7 pm, 9 am & 9 pm, 8 am & 5 pm? 8 am & 5 pm to allow nitrate free period (same as removing NTG patches at bedtime)
    • What substitute can you use for desitin ointment (Balmex, Boudreaux’s Butt Paste)? Zinc oxide
    • Precose counseling information:
    • I. Take 30 minutes before meal II. Causes gas III. Should not take if meal skipped Answer: II & III
    • What treatment would increase antibiotic compliance? Patient receiving zithromax 1 tsp QD x 5days
    • Augment, ceftriaxone, cefuroxime axetil, doxycycline Answer: the usual method to improve compliance for any type of drug is to reduce the number of doses that must be taken each day & to give a drug with the fewest uncomfortable or dangerous SE (I would chose ceftriaxone- IM single dose treatment)
    • Which of the following could you give a patient on NTG?
    • I. Cialis II. Muse (alprostadil) III. Caverject (alprostadil)
    • Answer: II & III- alprostadil is prostaglandin used for erectile dysfunction & patent ductus arteriosus Available as: intracavernosal Kit, intracavernosal powder for solution, intracavernosal solution, intraurethral Suppository, & intraurethral solution Alprostadil (Prostin VR)
    • Patient requesting antihistamine eye drop & having a dark spot in vision- refer to MD
    • Which of the following is available in a liquid formulation?
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  2. #12
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    1 out of 1 members found this post helpful. Good post? Yes | No
    Looks OK, so I will paste all of them below,thanks Divine06 for the useful summary to us. Appreciate.
    For last week revision for Naplex exam, I think this might be helpful. Questions:
    • Mother has gestational diabetes, what is likely to occur when the baby is born. Mother also has epilepsy & is taking tegretol.
    • I. high birth weight II. Baby may have congenital abnormalities III. Baby is likely to have diabetes
    • Answer: I & II Tegretol is a class D drug
    • What strength will Albuterol 0.5% end up based on an order to mix it with 2.5 mL normal saline? 0.083%
    • Isosorbide dinitrate is dosed BID, what regimen is best 7 am & 12 noon, 7 am & 7 pm, 9 am & 9 pm, 8 am & 5 pm? 8 am & 5 pm to allow nitrate free period (same as removing NTG patches at bedtime)
    • What substitute can you use for desitin ointment (Balmex, Boudreaux’s Butt Paste)? Zinc oxide
    • Precose counseling information:
    • I. Take 30 minutes before meal II. Causes gas III. Should not take if meal skipped Answer: II & III
    • What treatment would increase antibiotic compliance? Patient receiving zithromax 1 tsp QD x 5days
    • Augment, ceftriaxone, cefuroxime axetil, doxycycline Answer: the usual method to improve compliance for any type of drug is to reduce the number of doses that must be taken each day & to give a drug with the fewest uncomfortable or dangerous SE (I would chose ceftriaxone- IM single dose treatment)
    • Which of the following could you give a patient on NTG?
    • I. Cialis II. Muse (alprostadil) III. Caverject (alprostadil)
    • Answer: II & III- alprostadil is prostaglandin used for erectile dysfunction & patent ductus arteriosus Available as: intracavernosal Kit, intracavernosal powder for solution, intracavernosal solution, intraurethral Suppository, & intraurethral solution Alprostadil (Prostin VR)
    • Patient requesting antihistamine eye drop & having a dark spot in vision- refer to MD
    • Which of the following is available in a liquid formulation?
    • I. NTG II. Hydroxyzine III. Digoxin Answer: II & III
    • Which is the shortest acting insulin?
    • Humulin N, Humulin U, Humalog, or regular Answer: Humalog
    • Who should not get a flu shot? An infant in day care; 32 yo type II diabetic; 65 yo retired lady; 35 yo nurse working in hospital Answer: 32 yo type II diabetic
    • Which of the following cannot be self monitored?
    • Glucose level; K level; cholesterol levels; hormone used in pregnancy test Answer: K levels
    • Cytoxan is most similar to mechlorethamine, procarbazine, or 5-FU? Answer: mechlorethamine
    • A patient with Traveler’s diarrhea too PeptoBismol 4 tsp Q ½ hour. After 3 days he began experiencing ringing in the ears. What does he have? Bismuth toxicity or salicylate toxicity?
    • Answer: salicylate toxicity Bismuth toxicity would cause neurotoxicity
    • Which of the following are OTC hemorrhoid treatments:
    • I. TUCKs pads II. Nupercainal ointment III. Rowasa Answer: I & II
    • Which of the following is an ER Morphine?
    • A. MSIR B. MS Contin C. Diluadid D. Oxycontin Answer: B
    • Which of the following agents should be administered to a person exposed to Anthrax?
    • A. Flagyl B. Cipro C. Zovirax D. Valtrex Answer: B
    • Erythromycin exhibits its anti-infective properties by- blocking protein synthesis via binding & inhibition of the 50-S subunit of bacterial ribosomes
    • Patient has pseudomembranous colitis & allergy to metronidazole. Which of the patient’s medications could have caused the pseudomembrane colitis?
    • A. Ibuprofen B. Tylenol C. Flagyl D. Cleocin E. Zantac
    • Answer: D
    • This person could be treated with?
    • A. Flagyl B. Vancomycin C. Doxycycline D. Lincomycin E. Ampicillin Answer: B
    • The DOC for the treatment of pseudomembraneous colitis is: A. Metronidazole B. Erythromycin C. Clindamycin D. Ampicillin E. Lincomycin Answer: A
    • Which of the following NSAIDs has an ophthalmic preparation:
    • A. Ibuprofen B. Naproxen C. Diclofenac D. Ketoprofen Answer: C- Voltaren
    • Cedax acts by- inhibiting the use of pencillin binding proteins in bacterial cell wall synthesis
    • Acetylcysteine in the treatment of CF is best given:
    • A. IV B. By inhalation C. IM D. Orally Answer: B
    • A patient is given a rx for fentanyl 100 mcg/hr patch for 1 month. How many boxes should you dispense?
    • A. 1 B. 2 C. 3 D. 4 E. 5 Answer: 2; 1 patch= 3 days, so you need 10 patches; comes in boxes of 5 patches so you need 2
    • Which of the following is not an erythropoetin formulation?
    • A. Epogen B. Procrit C. Aranesp D. Neupogen Answer: Neupogen
    • Which of the following fluoroquinolones has an otic preparation?
    • Answer: ofloxacin (Floxin- also has an ophthalmic); Eye drops only: levofloxacin, gatifloxacin, moxifloxacin
    • The use of this agent is CI in children?
    • A. Erythromycin B. Bactrim C. Ciprofloxacin D. Cephalexin Answer: C
    • What is the recommended daily dosage of calcium for an adult?
    • A. 300-500 mg B. 600-800 mg C. 800-1000 mg D. 100-1500 mg Answer: D
    • Due to difficulty in coordinating their inhalations, older patients should use:
    • A. Nebulizer B. Peak flow meter C. Spacers D. Spirometer Answer: C Monitoring of asthma at home can be done with: A. Nebuli
    NAPLEX Review AIDS:
    • Initial treatment: NNRTI + 2 NRTIs or PI + 2 NRTIs
    • NRTIs:
    • MOA: interfere with HIV viral RNA-dependent DNA polymerase, resulting in chain termination & inhibition of viral replication
    • Class toxicities:
    • Lactic acidosis, sever hepatomegaly with steatosis Most require renal dosing (except abacavir)
    • Do not use lamivudine & emtricitabine together (chemically similar)
    • Do not use zidovudine with stavudine together (both require thymidine for activation)
    • Do not use didanosine with stavudine during pregnancy (increased risk of lactic acidosis & liver damage)
    • The “D” drugs cause pancreatitis & peripheral neuropathy & lactic acidosis ddI (didanosine), d4T (stavudine), ddC (zalcitabine)
    • Low pill burden
    • All are prodrugs requiring 2-3 phosphorylations for activation
    • Zidovudine (Retrovir):
    • AZT, ZDV
    • SE: bone marrow suppression, GI intolerance Dosage forms available: IV, 200 mg (10 mg/mL); syrup 50 mg/5 mL in 240 mL; capsule, 100 mg & tablet 300 mg
    • Lamivudine (Epivir):
    • 3TC Minimal toxicity
    • Abacavir (Ziagen):
    • ABC SE: hypersensitivity reaction that can be fatal with rechallenge
    • Didanosine (Videx, Videx EC):
    • ddI
    • Take ½ hour before or 2 hours after meals (empty stomach) SE: pancreatitis, peripheral neuropathy
    • Stavudine (Zerit):
    • D4T SE: pancreatitis, peripheral neuropathy
    • Zalcitabine (Hivid):
    • ddC SE: pancreatitis, peripheral neuropathy
    • Tenofovir (Viread):
    • TDF SE: renal insufficiency, Fanconi syndrome
    • Emtricitabine (Emtriva):
    • FTC Minimal toxicity
    • Combination products:
    • Zidovudine 300 mg + lamivudine 150 mg (Combivir)
    • Zidovudine 300 mg + lamivudine 150 mg + abacavir 300 mg (Trizivir) Tenofovir 300 mg + emtricitabine 200 mg (Truvada) Lamivudine 300 mg + abacavir 600 mg (Epzicom)
    • NNRTIs:
    • MOA: bind to reverse transcriptase at a different site than the NRTIs, resulting in inhibition of HIV replication
    • Class toxicities: rash & hepatoxicity
    • All should be dosed for hepatic impairment
    • Most are affected by food (except efavirenz)
    • Efavirenz is CI in pregnancy
    • Efavirenz (Sustiva):
    • EFV
    • Take on an empty stomach SE: CNS side effect; false + cannabinoid test
    • Nevirapine (Viramune):
    • NVP
    • Autoinducer SE: rash, symptomatic hepatitis, including fatal hepatic necrosis
    • Delavirdine (Rescriptor): DLV SE: rash, increased LFTs
    • PIs:
    • MOA: inhibit protease, which then prevents the cleavage of HIV polyproteins & subsequently induces the formation of immature noninfectious viral particles
    • All should be dosed for hepatic impairment
    • Most should be taken with food (except amprenavir & indinavir)
    • Amprenavir & fosamprenavir are chemically similar- avoid combination
    • Atazanavir & indinavir require normal acid levels in stomach for absorption
    • Ritonavir is the most potent
    • Lopinavir/ritonavir, ritonavir, & saquinavir gel caps require refrigeration
    • Class toxicities: lipodystrophy, hyperglycemia, hyperlipidemia, hypertriglyceridemia, bleeding in hemophiliace, osteonecrosis & avascular neocrosis of the hips, osteopenia & osteoporosis
    • All are CYP3A4 inhibitors
    • Lopinavir + ritonavir (Kaletra):
    • SE: GI intolerance
    • Refrigerate caps stable until date on label; stable for 2 months at room temperature Can cause hyperglycemia
    • Atazanavir (Reyataz):
    • ATV SE: increased indirect hyperbilirubinemia, prolonged Princeton Review interval
    • Fosamprenavir (Lexiva):
    • f-APV
    • SE: rash
    • Sulfonamide Oral solution contains propylene glycol
    • Amprenavir (Agenerase):
    • APV
    • SE: rash
    • Sulfonamide Avoid high fat meal
    • Saquinavir:
    • SQV-hard gel cap (HGC)- (Invirase):
    • SE: GI intolerance Room temperature
    • SQV- soft gel cap (SGC)- (Fortovase):
    • SE: GI intolerance Refrigerated caps stable until date on label; stable for 3 months at room temperature HGC & SGC are not bioequivalent & should not be interchanged
    • Nelfinavir (Viracept):
    • NFV
    • SE: diarrhea Needs 500 kCal of food for absorption; take after eating
    • Ritonavir (Norvir)
    • RTV
    • SE: GI intolerance Refrigerated caps stable for 1 month at room temp
    • Indinavir (Crixivan):
    • IDV SE: nephrolithiases- drink at least 48 oz. daily to prevent Take on an empty stomach
    • Fusion inhibitors:
    • MOA: binds to gp41 on HIV surface, which inhibits HIV binding to CD4 cell
    • Enfuvirtide (Fuzeon)
    • T20 Salvage regimens Reconstituted form should be stored in the refrigerator- stable for 24 hours Viracept, Norvir
    • Those available as suspensions: Nevirapine
    • Those available as a syrup or oral solution: Epivir, Ziagen, Videx, Kaletra, Agenerase,
    • Post-exposure Prophylaxis (PEP):
    • Start therapy within 1-2 hours of exposure
    • Length of therapy is 4 weeks
    • Treatment options: AZT 200 mg po Q8h or 300 mg po Q12h AND 3TC(lamivudine) 150 mg po Q12h AZT 200 mg po Q8h or 300 mg po Q12 + 3TC 150 mg po Q12h + Indinavir 800 mg Q8h OR Nelfinvir 750 mg po Q8h or 1250 mg Q12h
    • PCP treatment:
    • A protozoan, but may be more closely related to fungi
    • Treat when CD4+ cells fall below 200
    • DOC: trimethoprim-sulfamethoxazole (Bactrim DS) DS po QD
    • Alternatives:
    • TMP + dapsone
    • Atovaquone (Mepron)
    • Pentamidine (NebuPent; Pentam-300) Comes as injection & powder for nebulization
    • Clindamycin + primaquine Trimetrexate (NeuTrexin) + folinic acid Treatment for PCP also covers prophylaxis for: toxoplasmosis
    • Macobacterium avium complex (MAC):
    • Treat when CD4+ cells fall below 50/mm3 DOC is azithromycin 1200 mg po Q week
    • CMV: Cytomegalovirus
    • Ganciclovir (Cytovene, Vitrasert):
    • Use: treatment of CMV retinitis in immunocompromised individuals, including patients with AIDS
    • CI: ANC <500/mm3 or PLT <25,000/mm3
    • Dosage forms: Capsule (Cytovene) Implant, intravitreal (Vitrasert)- 4.5 mg released gradually over 5-8 months Injection, powder for reconstitution Should be prepared in a vertical flow hood Reconstitute powder with sterile water NOT bacteriostatic water because parabens may cause precipitation Alzheimer’s Disease:
    • Donepezil (Aricept):
    • Cholinesterase inhibitor
    • MOA: reversibly & noncompetitively inhibits centrally active acetylcholinesterase, the enzyme responsible for hydrolysis of acetylcholine
    • Available dosage forms: tablets, ODT Max dose: 10 mg QD
    • Galantamine (Razadyne, Razadyne ER, Reminyl-old name):
    • Acetylcholinesterase inhibitor
    • Max dose: IR tablet or solution: 24 mg/day (in 2 divided doses) ER capsule: 24 mg/day
    • Memantine (Namenda):
    • Low affinity, non-competitive, voltage dependent NMDA receptor antagonist
    • Neuroprotective
    • Less cognitive decline & improves cognition in impaired patients
    • After depolarization, Namenda leaves the site & allows sodium & calcium entry into the cell
    • Behaves like magnesium Approved for moderate to severe Alzheimer’s Disease
    • Rivastigmine (Exelon):
    • Acetylcholinesterase inhibitor (central)
    • MOA: increases acetylcholine in the CNS through reversible inhibition of its hydrolysis by cholinesterase SE: GI upset (titrate slowly to avoid) Dosage forms: capsules & solution Anemia:
    • Folic acid deficiency would also be called: macrocytic anemia, pernicious anemia
    • Macrocytic (large cell):
    • Megaloblastic:
    • Vitamin B12 deficiency Lack of intrinsic factor results in pernicious anemia Folic acid deficiency ↓Hct, Hgb, RBC, ↑ MCH
    • Normochromic, normocytic:
    • Aplastic anemia Anemia of chronic disease
    • Hypochromic (low hemoglobin content), microcytic (small cell):
    • Iron deficiency ↑ TIBC, ↓ MCV, MCH, MCHC, Hgb Genetic anomalies: Sickle cell anemia, thalassemia
    • Treatment:
    • Darbepoetin Alpha (Aranesp):
    • Recombinant human erythropoietin
    • Caution in patients with HTN or with a hx of seizures Can cause hypo- or hypertension Available as an injection
    • Epoetin Alpha (Epogen):
    • Colony stimulating factor
    • Onset of action: several days Peak effect: 2-3 weeks SQ 1-3X per week SE: HTN Antidotes:
    • Acetaminophen overdose:
    • Antidote: Acetylcysteine (Mucomyst, Acetadote): MOA: thought to reverse APAP toxicity by providing substrate for conjugation with the toxic metabolites Dose: oral- 140 mg/Kg followed by 17 doses of 70 mg/Kg Q4h; repeat dose if emesis occurs within 1 hour of administration
    • Albuterol overdose: Antidote: propranolol or beta blocker
    • Anticholinergic overdose: Antidote: Physostigmine (Antilirium): Do not use if solution is cloudy or dark brown
    • Arsenic overdose: Antidote: Succimer (Chemet) or dimercaprol (British anti-lewisite, BAL in oil)
    • Benzodiazepine overdose: Antidote: flumazenil (Romazicon)
    • β-blocker overdose: Antidote: glucagon (GlucaGen)
    • CCB overdose: Antidote: calcium chloride 10% or glucagon (GlucaGen)
    • Carbamates overdose: Antidote: atropine
    • Coumadin overdose:
    • Antidote: Vitamin K1 or phytonadione (Mephyton, AquaMEPHYTON); fresh frozen plasma Dosage forms available for phytonadione: injection & tablet
    • Digoxin overdose: Antidote: digoxin immune antibody fragment (Digibind, DigiFab)
    • Ethylene glycol (Antifreeze) overdose: Antidote: ethyl alcohol; fomepizole (Antizol); pyridoxine (Aminoxin-OTC); sodium bicarbonate
    • Heparin overdose: Antidote: protamine sulfate
    • Iron overdose:
    • Antidote: deferoxamine (Desferal)
    • Antidote: Polyethylene glycol (high molecular weight) Lethal dose of iron is 180-300 mg/Kg Isoniazid overdose: Antidote: pyridoxine (Vitamin B6)
    • Lead overdose:
    • Antidotes:
    • Succimer (Chemet) Dimercaprol; also called British anti-lewisite (only for lead encephalopathy) Calcium disodium EDTA (calcium disodium versenate)
    • Leucovorin:
    • Antidote for folic acid antagonists (methotrexate, trimethoprim, pyrimethamine) Water soluble vitamin
    • Magnesium overdose:
    • Death due to muscle relaxation (includes heart failure) Antidote: calcium
    • Methanol or Ethylene glycol overdose:
    • Antidote: Ethanol 10%
    • Antidote: Fomepizole (Antizol)
    • AKA: 4-methylpyrazole or 4-MP MOA: competitively inhibits alcohol dehydrogenase, an enzyme which catalyzes the metabolism of ethanol, ethylene glycol, & methanol to their toxic metabolites ?Decreases metabolism of methanol (prevents metabolism)
    • Methemoglobinemia overdose: Antidote: methylene blue
    • Opioid overdose:
    • Antidote: Naloxone (Narcan) MOA: opioid antagonist that competes at all three CNS opioid receptors (mu, kappa, & delta) Antidote: Nalmefene (Revex)
    • Organophosphates overdose: Antidote: atropine or pralidoxime (Protopam)
    • Salicylate overdose: Antidote: sodium bicarbonate
    • TCAs overdose: Antidote: sodium bicarbonate
    • Type Ia antiarrhythmics overdose: Antidote: sodium bicarbonate Vecuronium overdose: & other nondepolarizing neuromuscular blockers Antidote: edrophonium (Enlon, Reversol) Asthma:
    • Drugs available for nebulization:
    • Budesonide 0.25 & 0.5 mg (Pulmicort Respules®)
    • Shake well before using
    • Use with jet nebulizer connected to an air compressor
    • Administer with a mouthpiece or facemask
    • Do not use with an ultrasonic nebulizer
    • Do not mix with other medications Rinse mouth after use
    • Cromolyn (Intal®)
    • Mast cell stabilizer Use: adjunct in the prophylaxis of allergic disorders, including asthma; prevention of exercise-induced bronchospasm Nasal: for prevention & treatment of seasonal & perennial allergic rhinitis
    • Albuterol
    • Ipratropium Ipratropium & Albuterol
    • Drugs available as MDI:
    • Beclomethasone HFA 40 mcg/puff & 80 mcg/puff (QVAR®)
    • Flunisolide 250 mcg/puff (Aerobid®)
    • Fluticasone 44, 110, 220 mcg/puff (Flovent®)
    • Cromolyn (Intal®)
    • Nedocromil (Tilade®)
    • Albuterol (Proventil®, Ventolin®)
    • Pirbuterol (Maxair Autohaler®)
    • Ipratropium (Atrovent®) Ipratropium & Albuterol (Combivent®)
    • Drugs available as turbuhaler: Budesonide 200 mcg/inhalation (Pulmicort® Respules) Inhaler should be shaken well immediately prior to use
    • Drugs available for dry powder inhalation (DPI):
    • Fluticasone (Flovent Rotadisk®)
    • Fluticasone-salmeterol (Advair Diskus®)
    • Formoterol (Foradil Aerolizer®)
    • Salmeterol (Servent Diskus®) Stable for 6 weeks after removing foil 1 inhalation BID
    • Drugs available as MDI/spacer: Triamcinolone 100 mcg/puff (Azmacort®)
    • Class of drugs to use to prevent a child allergic to pollen from having an asthma attack- could use antihistamines, cromolyn or inhaled corticosteroids
    • A patient would monitor their asthma from home with a peak flow meter which measures the FEV1
    • Goal: 80% of personal best Green zone (80-100%), yellow zone (50-79%), & red zone (<50%)
    • Montelukast (Singulair):
    • MOA: selective leukotriene receptor antagonist that inhibits the cysteinyl leukotriene receptor
    • Use: asthma & allergies NOT for COPD
    • Dosing;
    • 6-23 months: 4 mg oral granules
    • 2-5 years: 4 mg chewable tablet or oral granules
    • 6-14 years: 5 mg chewable tablet
    • >15 years: 10 mg tablet Take in evening Granules must be used within 15 minutes of opening
    • Zafirlukast (Accolate):
    • MOA: selectively & competitive leukotriene-receptor antagonist of leukotriene D4 & E4
    • Use: prophylaxis & chronic treatment of asthma in adults & children >5 years old
    • Dose: 20 mg BID
    • Administer 1 hour before or 2 hours after meals
    • Monitor: LFTs
    • Extensively hepatically metabolized via CYP2C9 Tablets only
    • Theophylline:
    • 0.80 AT = T
    • SE:
    • 15-25 mcg/ML: GI upset, N/V/D, nervousness, headache, insomnia, agitation, dizziness, muscle cramp, tremor
    • 25-35 mcg/mL: tachycardia, occasional PVC > 35 mcg/mL: ventricular tachycardia, frequent PVC, seizure
    • Theophylline + erythromycinà increased levels of theophylline DI with cimetidine A patient who has had too much albuterol could be given a cardioselective beta blocker Bioterrism:
    • Ebola: virus; no cure Anthrax: bacteria (aerobic, gram + bacillus); ciprofloxacin or doxycycline for 60 days BPH:
    • Tamulosin (Flomax) & Alfuzosin (Uroxatrac):
    • Greater affinity to α-1 in prostate
    • Less SE Work quickly for instant relief
    • Finasteride (Proscar/Propecia) & Dutasteride (Avodart):
    • Great for a large prostate
    • Take longer to work Proscar MOA: a competitive inhibitor or both tissue & hepatic 5-alpha reductace; this results in the inhibition of the conversion of testosterone to dihydrotestosterone & markedly suppresses serum dihydrotestosterone levels
    • Doxazosin (Cardura) & terazosin (Hytrin) also used for BPH Saw palmetto Cancer:
    • Chemo drugs that should be refrigerated: cyclophosphamide (after reconstitution)
    • Should be heated prior to
    • Antimetabolites:
    • Pyrimidine analogs: interfere with the synthesis of pyrimidine bases & thus DNA synthesis
    • Can cause mucositis
    • Capecitabine (Xeloda)
    • Fluorouracil; 5-FU (Adrucil)
    • Cytarabine (Cytosar)
    • Gemcitabine (Gemzar) AE: mucositis
    • Folic acid analog: interferes with synthesis of pyrimidine bases & thus DNA synthesis
    • Methotrexate After reconstitution with preservative: may refrigerate AE: myleosuppression, N/V, mucositis
    • Purine analogs: interfere with synthesis of purine bases & thus DNA synthesis
    • Mercaptopurine (Purinethol) DI with allopurinol
    • Thioguanine (Tabloid)
    • Fludarabine (Fludara) Cladribine (Leustatin) Pentostatin (Nipent)
    • Plant alkaloids:
    • Vinca alkaloids: bind to tubulin to prevent formation of microtubules during mitosis
    • Fatal if administered intrathecally
    • Vincristine (Oncovin):
    • Neurotoxic Can cause a decrease in sensation reflexes
    • Vinblastine (Velban)
    • Vinorelbine (Navelbine) AE: neuropathy
    • Podophyllotoxins: bind to tubulin, inhibiting topoisomerase II to cause DNA strand breaks
    • Etoposide; VP-16 (VePesid)
    • Teniposide (Vumon) AE: myelosuppression, neuropathy
    • Taxanes: bind to tubulin, promotes synthesis of nonfunctional microtubules
    • Paclitaxel (Taxol) Use a in-line filter; non-PVC
    • Docetaxel (Taxotere) AE: myelosuppression, alopecia
    • Camptothecins: inhibits topoisomerase I, stabilizing single-strand breaks in DNA
    • Irinotecan (Camptosar)- *Diarrhea* Topotecan (Hycamtin) AE: myelosuppression, alopecia
    • Alkylating Agents: cross-link between DNA bases or between DNA strands to inhibit DNA replication
    • Nitrogen Mustard Derivative:
    • Mechlorethamine (Mustargen)
    • Melphalan (Alkeran)
    • Chlorambucil (Leukeran)
    • Cyclophosphamide (Cytoxan)
    • Ifosfamide (Ifex)
    • AE: myelosuppression Mesna is given with cyclophosphamide & ifosfamide to prevent hemorrhagic cystitis
    • Other:
    • Carmustine (BiCNU)
    • Lomustine (CeeNU)
    • Stretozocin (Zanosar)
    • Thiotepa (Thiopex) Busulfan (Myleran) Dacarbazine (DTIC)
    • Antitumor antibiotics:
    • Anthracycline:
    • Cardiotoxic: 450-550 mg/m2 cumulative lifetime dose
    • Doxorubicin (Adriamycin):
    • MOA: appears to directly bind to DNA & inhibit DNA repair (via topoisomerase II inhibition) resulting in the blockade of DNA & RNA synthesis & fragmentation of DNA
    • Turns urine & all other body fluids red
    • SE: myelosupression, cardiotoxicity, extravasation Decrease dose in renal impairment
    • Daunorubicin (Cerubidine)
    • Idarubicin (Idamycin)
    • Mitoxantrone (Novantrone) AE: myelosuppression
    • Other: Mitomycin C (Mutamycin) Bleomycin (Blenoxane)
    • Heavy Metals:
    • Cisplatin (Platinol)
    • Carboplatin (Paraplatin)
    • Oxaliplatin (Eloxatin) AE: myelosuppression, neuropathy
    • Antiandrogens: inhibit uptake & binding of testosterone & dihydrotestosterone in prostatic tissue
    • Flutamide (Eulexin)
    • Bicalutamide (Casodex)
    • Nilutamide (Nilandron) AE: diarrhea
    • Progestins: suppress release of LH & increase estrogen metabolism (decrease available estrogen for estrogen-dependent tumors)
    • Megestrol (Megase): also used to stimulate appetite Medroxyprogesterone (Provera)
    • Estrogens: estramustine is combination of estrogen plus nitrogen mustard; estrogen facilitates uptake, nitrogen mustard released to alkylate cancer cells Estramustine (Emcyt)
    • Antiestrogens: bind to estrogen receptor in breast tissue, preventing binding by estrogen & thereby reducing estrogen-stimulated tumor growth
    • Tamoxifen (Nolvadex) Toremifine (Fareston)
    • Gonadotropin-releasing hormone analogs: turn off negative-feedback release of FSH & LH, reducing testosterone & estrogen production in testes & ovaries
    • Leuprolide (Lupron (breast/prostate); Eligard (prostate); Viadur (prostate)) MOA: potent inhibitor of gonadotropin secretion; continuous daily administration results in suppression of ovarian & testicular steroidogenesis due to decreased levels of FSH & LH with subsequent decreases in testosterone & estrogen levels Goserelin (Zoladex)
    • Aromatase inhibitors: blocks enzyme responsible for conversion of circulating androgens to estrogens
    • Anastrazole (Arimidex):
    • For breast cancer
    • Can increase LDL
    • Cannot use with Tamoxifen AE: vasodilation, headache, pain, depression, hot flashes, HTN, osteoporosis
    • Letrozole (Femara) AE: diarrhea
    • Other miscellaneous agents for cancer:
    • Asparaginase (Elspar)
    • Hydroxyurea (Hydrea)
    • Tyrosine kinase inhibitors:
    • Imatinib mesylate (Gleevec)
    • Erlotinib (Tarceva) Gefitinib (Iressa)
    • 26S Proteasome inhibitor: Bortezomib (Velcade)
    • Biological Response Modifiers
    • Immune therapies:
    • Aldesleukin (Proleukin) Interferon-alpha 2b (Intron A) Levamisole (Ergamisol)
    • Monoclonal antibodies:
    • Rituximab (Rituxan)
    • Trastuzumab (Herceptin): works at HER-1 receptor
    • Gemtuzumab (Mylotarg)
    • Alemtuzumab (Campath)
    • Bevacizumab (Avastin)
    • Cetuximab (Erbitux)
    • Denileukin diftitox (Ontak) Ibritumomab tiuxetan (Zevalin) Tositumomab (Bexxar)
    • Colony Stimulating Factors:
    • Filgastrim (Neupogen):
    • MOA: granulocyte colony stimulating factor (G-CSF); stimulation of granulocyte production in patients with malignancies
    • Increases production of neutrophils
    • Does not cause agraulocytosis—used to treat it
    • SE: bone pain
    • Store in refrigerator Injection
    • Pegfilgrastim (Neulasta):
    • MOA: stimulates the production, maturation, & activation of neutrophils; activates neutrophils to increase both their migration & cytotoxicity
    • Prolonged duration of effect relative to filgastrim & reduced renal clearance
    • Store in refrigerator SE: bone pain Injection
    • Octreotide (Sandostatin):
    • Somatostatin analog
    • Use: antidarrheal agent for diarrhea secondary to cancer
    • MOA: mimics natural somatostatin by inhibiting serotonin release, & the secretion of gastrin, VIP, insulin, glucagons, secretin, motilin & pancreatic polypeptide Dosage forms available: injection only
    • High emetic potential: Cisplatin, cyclophosphamide, cytarabine, dacarbazine, ifosfamide, melphalan, mitomycin, mechlorethamine
    • Prevention of Acute Chemotherapy-Induced N/V:
    • 5-HT3 receptor antagonist:
    • Dolasetron (Anzemet)
    • Granisetron (Kytril)
    • Ondansetron (Zofran) Palonosetron (Aloxi)
    • Phenothiazines:
    • Prochlorperazine (Compazine)
    • Chlorpromazine (Thorazine) Promethazine (Phenergan)
    • Butyrophenones:
    • Droperidol (Inapsine) Haloperidol (Haldol)
    • Corticosteroids: Dexamethasone (Decadron)
    • Cannabinoids: Dronabinol (Marinol)
    • Benzodiazepines: Lorazepam (Ativan)
    • Benzamides: Metoclopramide (Reglan)
    • Neurokinin-1 Antagonist:
    • Aprepitant (Emend):
    • Substance P/neurokinin 1 receptor antagonist Uses: prevention of acute & delayed N/V associated with highly-emetogenic chemotherapy in combination with a corticosteroid (i.e. dexamethasone) & 5-HT3 (ondansetron) receptor antagonist Avoid with grapefruit juice (CYP3A4) MOA: prevents acute & delayed vomiting by selectively inhibiting the substance P/neurokinin 1 (NK1) receptor Dose: oral: 125 mg on day 1, followed by 80 mg on days 2 & 3 1st dose should be given 1 hour prior to chemotherapy Cardiology:
    • ACEI:
    • Benazepril (Lotensin)
    • Captopril (Capoten):
    • Used to decrease the progression of CHF
    • SE: rash, hyperkalemia, angioedema, cough
    • Strengths: Tablets: 12.5, 25, 50, & 100 mg Dosed BID-TID
    • Enalapril (Vasotec):
    • Enalaprilat (Vasotec): only ACEI available as IV 1.25 mg/dose given over 5 minutes Q6 hours 40 mg/day max dose
    • Fosinopril (Monopril)
    • Lisinopril (Prinvil, Zestril)
    • Moexipril (Univasc)
    • Perindopril (Aceon)
    • Quinapril (Accupril)
    • Ramipril (Altace)
    • Trandolapril (Mavik)
    • Proven to decrease mortality in CHF
    • Ineffective as monotherapy in African Americans
    • MOA: inhibit the conversion of angiotensin I to angiotensin II (a potent vasoconstrictor)
    • SE: increased SCr, cough, angioedema, sexual dysfunction, hyperkalemia, rash
    • CI: bilateral renal artery stenosis; pregnancy DI: aspirin (high doses); rifampin; antacids (more likely with captopril- separate administration by 1-2 hours); NSAIDS; probenecid (captopril); lithium; allopurinol
    • Alpha agonists:
    • MOA: causes decreased sympathetic outflow to the cardiovascular system by agonistic activity on central α-2 receptors
    • Clonidine (Catapres)
    • More withdrawal Unlabeled use: heroin or nicotine withdrawal
    • Guanabenz (Wytensin)
    • Guanfacine (Tenex) Less withdrawal
    • Methyldopa (Aldomet) SE: sedation, dry mouth, bradycardia, withdrawal HTN, orthostatic hypotension, depression, impotence, sleep disturbances
    • Alpha blockers:
    • MOA: blocks peripheral α-1 postsynaptic receptors, which causes vasodilation of both arteries & veins (indirect vasodilators)
    • Causes less reflex tachycardia than direct vasodilators (hydralazine/minoxidil)
    • Dosazosin (Cardura)
    • Prazosin (Minipress)
    • Terazosin (Hytrin)
    • Counseling: take 1st dose at bedtime, may cause dizziness SE: weight gain, peripheral edema, dry mouth, urinary urgency, constipation, priapism, postural hypotension No effects on glucose or cholesterol
    • Anti-arrhythmic Drugs:
    • Arrhythmias:
    • A. Fib or flutter: DOC- digitalis glycoside; alternative- verapamil or propranolol
    • Supraventricular tachycardia: DOC- verapamil or adenosine; alternative- diltiazam or procainamide
    • Ventricular premature complexes: DOC- beta blocker; alternative- beta blocker
    • Ventricular tachycardia: DOC- beta blocker; alternative- amiodarone
    • Ventricular fibrillation: DOC- amiodarone; alternative- beta blocker
    • Digoxin-induced tachyarrhythmia: DOC- lidocaine; alternative- phenytoin
    • Torsades de pointes: DOC- magnesium; alternative- beta blocker
    • Class IA: inhibit fast Na channels
    • Quinidine SE: Cinchonism
    • Procainamide (Pronestyl) SE: lupus-like syndrome Disopyramide (Norpace)
    • Class IB: inhibit fast Na channels
    • Lidocaine (Xylocaine):
    • Phenytoin (Dilantin) SE: nystagmus
    • Tocainide (Tonocard) Mexiletine (Mexitil)
    • Class IC: inhibit fast Na channels
    • Moricizine (Ethmozine)
    • Flecainide (Tambocor) Propafenone (Rhythmol)
    • Class II: beta-adrenergic agents
    • Propranolol (Inderal)
    • Esmolol (Brevibloc) Acebutolol (Sectral)
    • Class III: primarily block K channels
    • Bretylium (Bretylol)
    • Amiodarone (Cordarone®):
    • SE:
    • IV: phlebitis General: corneal microdeposits, photophobia, ↑LFTs, photosensitivity, blue-gray skin discoloration, pulmonary fibrosis (reduced at low doses- 300 mg/d; increases as dose increases), hyper- or hypothyroidism, polyneuropathy
    • Watch for iodine allergy
    • Avoid grapefruit juice Prior to use: check thyroid levels, eye exam
    • Ibutilide (Corvert) Sotalol (Betapace) Dofetilide (Tikosyn) SE: torsades de pointes Class IV: calcium channel antagonists Verapamil (Isoptin, Calan)
    • Anticoagulation:
    • Direct thrombin inhibitors:
    • Argatroban:
    • A synthetic molecule that reversibly binds to thrombin
    • Eliminated by the liver Use if renal impairment
    • Lepirudin (Refludan):
    • Recombinant DNA-derived polypeptide nearly identical to hirudin
    • Produces an anticoagulant effect by binding directly to thrombin & does not require AT to produce it effect
    • Does not bind to other proteins as heparin does Eliminated by the kidneys Use if liver impairment
    • Enoxaparin (Lovenox):
    • Low molecular weight heparin
    • MOA: inhibits factor Xa greater than IIa
    • Dosing:
    • DVT prophylaxis: 40 mg QD or 30 mg BID DVT treatment: 1 mg/Kg/dose Q12 hours or 1.5 mg/Kg/dose QD Monitor: anti-Xa, platelets
    • Heparin:
    • MOA: potentiates the action of antithrombin III & prevents the conversion of fibrinogen to fibrin
    • Dosing:
    • DVT prophylaxis: 5000 units SQ Q8-12 hours
    • IV infusion: 10-30 units/Kg/hr Line flushing: 10 units/mL for infants (<10 Kg); 100 units/mL for older infants, children & adults Monitor: PTT (1.5-2X the upper limit of control; 50-70 sec), platelets
    • Warfarin (Coumadin, Jantoven)
    • MOA: inhibits reduction of vitamin K to its active form; leads to depletion of vitamin K-dependent clotting factors II, Vii, IX, X & protein C & S
    • Requires 4-5 days before full anticoagulation effect is achieved
    • Recommended starting dose: 5 mg po QD
    • Strengths/Dosage forms:
    • Injection: 5 mg Tablets: 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg
    • Most indications want an INR in the 2.0-3.0 range Mechanical valves require a higher level of anticoagulation (INR 2.5-3.5)
    • Minor bleeding or elevated INR: hold warfarin dose or decrease dose until INR returns to appropriate range Purple Toe Syndrome may occur due to cholesterol microembolization
    • Acetaminophen is usually a good antipyretic & analgesic choice for patients taking oral anticoagulants Risk factors for DVTs: >40 years old; prolonged immobility; major surgery involving the abdomen, pelvis, & lower extremities; trauma, especially fractures of the hips, pelvis, & lower extremities; malignancy; pregnancy; previous venous thromboembolism; CHF or cardiomyopathy; stroke. Acute MI; indwelling central venous catheter; hypercoagulability; estrogen therapy; varicose veins; obesity; IBD; nephrotic syndrome; myeloproliferative disease; smoking
    • Antiplatelet Drugs:
    • Thienopyridines:
    • MOA: block adenosine diphosphate (ADP)-mediated activation of platelets by selectively & irreversibly blocking ADP activation of the glycoprotein IIb/IIIa complex
    • Clopidogrel (Plavix):
    • Use: reduce atherosclerotic events (MI, stroke, vascular deaths)
    • MOA: irreversibly blocks the ADP receptors, which prevents fibrinogen binding at that site & thereby reducing the possibility of platelet adhesion & aggregation AE: chest pain, headache, dizziness, abdominal pain, vomiting, diarrhea, arthralgia, back pain, upper respiratory infections
    • Ticlopidine (Ticlid):
    • Maintenance dose: 250 mg BID
    • DC if the ANC drops to <1200 or platelet count drops to <80,000
    • AE: rash, nausea, dyspepsia, diarrhea, neutropenia, thrombotic thrombocytopenic purpura Dosage form: 250 mg tablet CI: active bleed, severe liver disease, ticlopidine: neutropenia, thrombocytopenia
    • Glycoprotein IIb/IIIa inhibitors:
    • Abciximab (Reopro) No renal dosing adjustment required Eptifibatide (Integrillin) Tirofiban (Aggrastat) Storage: room temperature, protect from light
    • ARBs:
    • Candesartan (Atacand)
    • Eprosartan (Tevetan)
    • Irbesartan (Avapro)
    • Losartan (Cozaar)
    • Olmesartan (Benicar)
    • Telmisartan (Micardis) Valsartan (Diovan)
    • Beta Blockers:
    • Nonselective:
    • Nadolol (Corgard)
    • Penbutolol (Levatol) Has ISA
    • Pindolol (Visken) Has ISA
    • Propranolol (Inderal):
    • Nonselective beta blocker
    • Can increase cholesterol
    • Strengths available:
    • ER capsule (InnoPran XL): 80, 120 mg
    • SR capsule (Inderal LA): 60, 80, 120, 160 mg
    • Injection (Inderal): 1 mg/mL Solution: 4 mg/mL; 8 mg/mL Tablet (Inderal): 10, 20, 40, 60, 80 mg Timolol (Blockadren)
    • Cardioselective:
    • Acebutolol (Sectral) Has intrinsic sympathomimetic activity (ISA)
    • Betaxolol (Kerlone)
    • Bisoprolol (Zebeta)
    • Metoprolol (Lopressor, Toprol XL)
    • Strength/dosage forms:
    • Lopressor: Injection: 1 mg/mL Tablet: 25, 50, or 100 mg ER tablets: 50 & 100 mg Toprol XL: Tablets: 25, 50, 100, 200 mg
    • Mixed:
    • Labetalol (Trandate): Beta blocker (heart rate drop) with alpha-blocking (vasodilation & BP drop) activity
    • Carvedilol (Coreg):
    • MOA: blocks β-1, β-2, & α-1 receptors
    • Has had proven effects on patient survival in large clinical trials for HF
    • Take with food
    • Antioxidant effects Preferred in HF patients who BP is poorly controlled due to its greater hypertensive effect Increases stroke volume
    • MOA: competitively blocks response to beta-adrenergic stimulation: Blocked secretion of renin; decrease cardiac contractility, thereby decreasing CO; decreased central sympathetic output; decreased HR, thereby decreasing CO
    • Mask signs of hypoglycemia Can increase lipids
    • CCBs:
    • MOA: inhibit the influx of Ca ions through slow channels in vascular smooth muscle & cause relaxation of both coronary & peripheral arteries SA & AV nodal depression & decrease in myocardial contractility (nondihydropyridines)
    • Nondihydropyridines:
    • SE: conduction defects, worsening of systolic dysfunction, gingival hyperplasia
    • Diltiazem ( Cardizem , LA & CD, Dilacor XR, Tiaziac)
    • SE: nausea, headache
    • Cardizem: 30, 60, 90, 120 mg tablets
    • Cardizem LA: 120, 180, 240, 300, 360, 420 mg Cardizem CD: 120, 180, 240, 300, 360 mg capsules
    • Verapamil:
    • IR: (Calan, Isoptin)
    • LA: (Calan SR, Isoptin SR) Coer: (Covera HS, Verlan PM) SE: constipation
    • Dihydropyridines:
    • SE: edema of the ankle, flushing, headache, gingival hyperplasia
    • Amlodipine (Norvasc)
    • Felodipine (Plendil)
    • Isradipine (DynaCirc & CR)
    • Nicardipine (Cardene SR) Nifedipine (Procardia XL, Adalat CC) Nisoldipine (Sular)
    • Combination products:
    • Amlodipine & benazepril (Lotrel)
    • Bisoprolol & HCTZ (Ziac) Losartan & HCTZ (Hyzaar)
    • Direct vasodilators:
    • SE: headaches, fluid retention, tachycardia, peripheral neuropathy, postural hypotension
    • Hydralazine (Apresoline) Minoxidil (Loniten) Hirsutism
    • Diuretics:
    • Monitor: urine output, edema, weight
    • Can increase lipids
    • Loops:
    • MOA: reduction of total fluid volume through the inhibition of Na & Cl reabsorption in the ascending loop of Henle, which causes increased excretion of water, Na, Cl, Mg, & Ca
    • Are more effective that thiazides in patients with renal failure (SCr >2 mg/dL or GFR < 30 mL/min)
    • AE: ototoxicity at high doses; photosensitity; may increase blood glucose in diabetics; orthostatic hypotension; hypokalemia; gout
    • DI: aminoglycosides (increase risk of ototoxicity), NSAIDs (blunt diuretic response), Class Ia or III antiarrhythmics (may cause torsades de pointes with diuretic induced hypokalemic); probenecid (blocks loop effects by interfering with excretion into the urine)
    • Bumetanide (Bumex)
    • Furosemide (Lasix) Available dosage forms: injection, solution, tablet Torsemide (Demadex)
    • Thiazides:
    • MOA: direct arteriole dilation; reduction of total fluid volume through the inhibition of Na reabsorption in the distal tubules, which causes increased excretion of Na, water, K, & hydrogen; increase the effectiveness of other antihypertensive agents by preventing re-expansion of plasma volume
    • Significant decrease in efficacy in renal failure (SCr > 2 mg/dL or GFR < 30 mL/min)
    • DI: steroids (cause salt retention & antagonize thiazide action), NSAIDs (blunt thiazide response), Class Ia or III antiarrhythmics (may cause torsades de pointes with diuretic induced hypokalemic); probenecid & lithium(blocks thiazide effects by interfering with excretion into the urine), lithium (thiazides decrease lithium renal clearance & increase risk of lithium toxicity)
    • AE: increased cholesterol & glucose (short term); decreased: K, Na, Mg; increased: uric acid & Ca; photosensitivity; pancreatitis; impotence; sulfonamide-type reactions
    • Bendroflumethiazide (Naturetin)
    • Benzthiazide (Aquatag, Exna)
    • Chlorothiazide (Diuril)
    • Chlorthalidone (Hygroton, Hylidone)
    • Hydrochlorothiazide (HydroDIURIL, Microzide)
    • Hydroglumethiazide (Saluron, Diucardin)
    • Meethyclothiazide
    • Polythiazide (Renese) Trichlormethiazide (Metahydrin, Naqua)
    • Thiazide-like:
    • Less or no hypercholesterolemia compared to other thiazides; decreased microalbuminuria in DM
    • Metolazone (Mykrox, Zaroxolyn) Indapamide (Lozol)
    • Potassium-sparing:
    • MOA: interferes with K/Na exchange in the distal tubule; decreases Ca excretion, increases Mg loss
    • AE: hyperkalemia
    • Amiloride (Midamor) Triamterene (Dyrenium) Avoid with history of kidney stones or hepatic disease
    • Aldosterone Blocker:
    • Eplerenone (Inspra):
    • Selective
    • CI: DM type II; K > 5.5; ClCr < 30 mL/min PO- tablet 25 & 50 mg K sparing Spironolactone (Aldactone)
    • Epinephrine (Adrenalin):
    • MOA: stimulates α-, β-1, & β-2 adrenergic receptors resulting in relaxation of smooth muscle of the bronchial tree, cardiac stimulation, & dilation of skeletal muscle vasculature
    • Sensitive to light & air- protection is recommended
    • Oxidation turns drug pink, then a brown color Solutions should not be used if they are discolored or contain a precipitate Admixture is stable at room temperature for 24 hours
    • Heart failure:
    • Drugs that can worsen or precipitate:
    • Antiarrhythmics: disopyramide, flecainide, propafenone
    • Beta blockers
    • CCB: verapamil & diltiazem
    • Oral antifugals: itraconazole & terbinafine
    • Cardiotoxic drugs: doxorubicin, daunorubicin, cyclophosphamide, alcohol Na & water retention: NSAIDs, glucocorticoids, rosiglitazone, pioglitazone
    • Metoprolol, bisoprolol, & carvedilol (Starting dose: 3.125 mg BID for 2 weeks) have all shown to be effective in HF
    • Digoxin (Lanoxin):
    • Does not improve mortality, but does produce symptomatic benefits
    • MOA: inhibits Na-K-ATPase pump, which results in an increase in intracellular Ca, which causes a + inotropic effect Reduces sympathetic outflow from the CNS
    • AE: arrhythmias, bradycardia, heart block, anorexia, abdominal pain, N/V, visual disturbances, confusion, fatigue Toxicity is more commonly associated with serum concentrations > 2 ng/mL, but may occur at lower levels if patients have hypokalemia, hypomagnesemia, & in the elderly
    • Serum levels: 0.5-1.0 ng/mL 60-80% is eliminated renally- dosage requirement for renal insufficiency
    • ACEI & beta blockers improve mortality
    • Aldosterone antagonist reduce the risk of death & hospitalization Diuretics- symptomatic relief
    • Inotropes:
    • Dobutamine (Dobutrex):
    • MOA: stimulates β-1 receptors causing increased contractility & heart rate, with little effect on β-2 or alpha receptors
    • β-1 > β-2 > α Increases CO & vasodilates
    • Use: inotropic support for patients with shock & hypotension Dosage: start at 3 mcg/Kg/min & titrate to 20 mcg/Kg/min
    • Dopamine (Intropin):
    • MOA: depends on the given dose
    • 1-5 mcg/Kg/min: renal dose; increases urine output Stimulates dopamine receptors
    • 5-15 mcg/Kg/min: increases contractility, HR Stimulates β-1 & β-2 receptors >15 mcg/Kg/min: increases BP Stimulates α-1 receptors Extravasation: give phentolamine
    • Milrinone (Primacor):
    • MOA: inhibits phosphodiesterase III, increases cAMP, resulting in positive inotropic & vasodilating effects
    • Use: short-term IV therapy of CHF; calcium antagonist intoxification Dosage: 50 mcg/kg LD over 10 min; followed by 0.375 mg/Kg/min Preferred over amrinone because of decreased risk of thrombocytopenia
    • MONA-B for MI: Morphine, oxygen, NTG, Aspirin, beta blockers
    • Norepinephrine (Levophed):
    • MOA: stimulates β-1 adrenergic receptors & α-adrenergic receptors causing increased contractility & HR as well as vasoconstriction thereby increasing systemic BP & coronary blood flow Alpha effects > beta effects
    • Readily oxidized, protect from light
    • Do not use if brown coloration Admixture stable at room temperature for 24 hours
    • Postganglionic adrenergic neuron blockers:
    • Guanadrel (Hylorel)
    • Guanethidine (Ismelin) Reserpine (Serpasil) Can cause depression
    • Torsades de pointes: Common drugs that can cause it: quinidine, dofetilide (Tikosyn), sotalol (Betapace), thioridazine, ziprasidone (Geodon)
    • Thrombolytics:
    • Use:
    • ST-elevation > 1 mm in 2 or more contiguous leads or left bundle branch block
    • Presentation within 12 hours or less of symptoms onset
    • In patients >75 years old may be useful & appropriate
    • Can be used in STEMI when time to therapy is 12-24 hours if chest pain is ongoing
    • Should NOT be used if the time to therapy is >24 hours, & the pain is resolved CI in a patient with NSTEMI
    • Drugs:
    • Streptokinase (SK, Streptase)
    • Tissue plasminogen activator (tPA, Alteplase)
    • Tenecteplase (TNK, TNKase) AE: hemorrhage (cerebral)
    • Vasodilators:
    • Nitroprusside (Nitropress):
    • Vasodilator
    • Use: hypertensive crises; CHF
    • Watch for cyanide toxicity (especially with hepatic dysfunction)
    • Watch for thiocyanate toxicity (especially with renal dysfunction or prolonged infusions)
    • Highly sensitive to light Normally a brownish color A blue color indicates almost complete degradation & breakdown to cyanide
    • Nesirtide (Natrecor): B-type natriuretic peptide that increases diuresis & is an arterial & venous dilator
    • Nitroglycerin (NitroBid, Nitrostat):
    • Venous dilator but also an arterial dilator at higher doses
    • MOA: Nitroglycerin, an organic nitrate, is a vasodilating agent that relieves tension on vascular smooth muscle & dilates peripheral veins & arteries
    • It increases guanosine 3'5' monophosphate (cyclic GMP) in smooth muscle & other tissues by stimulating guanylate cyclase through formation of free radical nitric oxide This activity results in dephosphorylation of the light chain of myosin, which improves the contractile state in smooth muscle , and subsequent vasodilation
    • Dosage forms available: Spray (do not inhale), ER cap, infusion, injection, ointment (Nitro-Bid), buccal tab (Nitrogard), SL tab (NitroQuick, Nitrostat, Nitro-tab), patch (Minitran, Nitrek, Nitro-Dur) Isosorbide mononitrate (Imdur (ER), Ismo, Monoket): Long acting metabolite of the vasodilator isosorbide dinitrate used for the prophylactic treatment of angina Should be given at 8 AM & 3 PM (any combination that doses them within 7-8 hours of each other to allow for the nitrate-free period in the PM) Isosorbide dinitrate (Dilatrate-SR, Isochron, Isordil) Compatibility: Drugs that must be mixed with sterile water: Amphotericin B: no electrolytes, mix in D5W, & reconstitute with sterile water Conversions:
    • 1 lb = 454 gm
    • 1 in = 2.54 cm
    • 1 grain = 64.8 mg
    • 1 avoirdupois pound = 454 gm
    • 1 fluid ounce = 29.57 mL
    • 1 gallon = 128 fluid ounces Also 3785 mL, 4 quarts, 8 pints 1 pint = 473 mL (round to 480 mL) COPD: 1st line therapy: beta-2 agonist or ipatropium Counseling Points:
    • Calcitonin (Miacalcin):
    • For injection:
    • Keep vials in refrigerator
    • Stable for 2 weeks at room temperature Give injection in upper arm, thigh or buttock
    • Nasal spray:
    • Store unopened bottle in refrigerator
    • Once pump has been activated, store at room temperature Good for 30 days Must prime prior to first use or if it has been greater than 5 days
    • Adequate vitamin D & calcium intake is essential for osteoporosis May cause increased warmth & flushing (should last only about 1 hour after administration) Take in evening to minimize discomfort
    • Sulfa eye drops: burns Nicotine gum: chew until peppery taste appears, then park Cystic Fibrosis:
    • Autosomal recessive disease of exocrine gland function resulting in abnormal mucus production
    • Genetic mutation on the long arm of chromosome 7
    • The protein encoded by this gene, the cystic fibrosis transmembrane regulator (CFTR), is a channel involved in the transport of water & electrolytes Most common genetic mutation involves a 3-base-pair deletion at position ΔF508
    • Antibiotics for Cystic Fibrosis:
    • Cover for Staphylococcus aureus, H. flu, & pseudomonas
    • Double coverage of antibiotics when pseudomonas (most common) is suspected
    • Antipseudomonal PCN: piperacillin (Pipracil), mezlocillin (Mezlin), piperacillin-tazobactam (Zosyn), ticarcillin-clavulanate (Timentin), ticarcillin (Ticar), aztreonam (Azactam), meropenem (Merrem), or imipenem (Primaxin)
    • Or a cephalosporin: ceftazidime (Fortaz, Tazidime, Tazicef) AND an aminoglycoside: tobramycin
    • Vancomycin for MRSA Burkholderia & Stenotrophomonas species are commonly resistant Trimethoprim-sulfamethoxazole (Bactrim), chloramphenicol (Chloromycetin), ceftazidime, doxycycline, piperacillin Fluoroquinolones are the ONLY oral antibiotics with good coverage against pseudomonas
    • Pulmozyme (dornase alfa):
    • Recombinant human deoxyribonuclease
    • Use: for management of CF patient to reduce the frequency of respiratory infections that require parenteral antibiotics, & to improve pulmonary function
    • MOA: reduces mucous viscosity resulting in airflow improvement
    • Used with a nebulizer (jet nebulizer) Must be stored in the refrigerator & should be protected from light Should not be exposed to room temp for a total of 24 hours Should not be mixed with or diluted with other drugs in the nebulizer Devices:
    • Swan Ganz catheter:
    • Inserted into right side of heart into the pulmonary circulation
    • Measures pulmonary capillary wedge pressure Takes accurate measurement of BP
    • You must measure the scrotum to fit a swimmer’s athletic support
    • Crutches: Armpits should be 2 inches away from crutches PICC line: Peripherally inserted central catheter Diabetes:
    • Insulin:
    • Rapid-acting:
    • Lispro (Humalog)
    • Aspart (NovoLog)
    • Glulisine (Apidra)
    • Onset: <15 min
    • Peak: 30-90 min Duration: 3-5 hours
    • Short-acting:
    • Regular- human (Humulin R, Novolin, Velosulin BR)
    • Regular- purified (Regular Ilentin II-pork)
    • Onset: 30-60 min
    • Peak: 2-3 hours Duration: 3-6 hours
    • Intermediate-acting:
    • NPH- isophane insulin suspension (NPH Iletin II- pork)
    • Human (Humulin N, Novolin N)
    • Lente- insulin zinc suspension (Lente Iletin II- pork)
    • Human (Humulin L, Novolin L)
    • Onset: 2-4 hours
    • Peak: 6-12 hours Duration: 10-18 hours
    • Long-acting:
    • Ultralente- extended insulin zinc suspension; human (Humulin U, Ultralente)
    • Onset: 6-10 hours
    • Peak: 10-16 hours Duration: 18-20 hours
    • Insulin glargine (Lantus)
    • Onset: 5 hours
    • Peak: none Duration; 20-24 hours Cannot mix with any other insulin
    • Premixed products:
    • 50/50: 50% regular with 50% NPH Rapid acting for pre-meal & intermediate acting to control later hyperglycemia
    • 70/30: 30% regular with 70% NPH
    • 70/30 analogue: 30% aspart with 70% neutral protamine aspart insulin analogue 75/25: 25% lispro with 75% neutral protamine lispro insulin analogue
    • MOA: decreases blood glucose & assists with glucose control by:
    • Increasing glucose uptake & utilization by peripheral tissues (primarily in muscle)
    • Increasing glycogenesis (glucose à glycogen; primarily in liver)
    • Decreasing glycogenolysis (glycogen à glucose)
    • Decreasing gluconeogenesis (amino acids à glucose)
    • Decreasing lipolysis & ketogenesis (fats à ketone bodies)
    • Converting amino acids to increase protein Converting triglycerides & fatty acids to increase adipose tissue
    • Appearance:
    • Clear (solution): aspart, lispro, glulisine, glargine, regular Cloudy (suspension): NPH, lente, ultralente, all premixed insulin products
    • Sites of injection: abdomen > arm > hip > thigh > buttock In order of greater & more rapid absorption to lesser & slower absorption There’s 1000 units in a 10 mL bottle
    • Insulin secretagogues:
    • MOA: stimulates pancreatic β cells to secrete insulin
    • 1st generation sulfonylureas: can cause a disulfiram-like rxn
    • Acetohexamide (Dymelor)
    • Chlorpropamide (Diabinese)
    • Tolazamide (Tolinase) Tolbutamide (Orinase)
    • 2nd generation sulfonylureas
    • Glimepiride (Amaryl) Max dose: 8 mg/day
    • Glipizide (Glucotrol, Glucotrol XL)- use in renal impairment
    • Glyburide (Diabeta, Micronase)- safe in pregnancy Glyburide micronized (Glynase)
    • Regular meal times are necessary- must not skip SE: hypoglycemia & weight gain
    • Alpha-glucosidase Inhibitors:
    • Acarbose (Precose)
    • Miglitol (Glyset) Least likely to cause hypoglycemia even when fasting
    • Should be taken with the first bite of a meal
    • MOA: delays carbohydrate metabolism & absorption (due to competitive & reversible inhibition of intestinal alpha-glucoside hydrolase & pancreatic alpha-amylase)
    • SE: GI intolerance To treat a hypoglycemic attack: treat with oral glucose Sucrose or fructose would not work
    • Biguanide:
    • Metformin (Glucophage, Fortamet, Riomet):
    • MOA:↓ insulin resistance 1° in liver; 2° in periphery
    • Dosage: start with 500 mg po BID or 875 mg po QD Max: ~2500 mg QD (850 mg TID) When to hold: in patients undergoing diagnostic radiology procedures that use an iodinated contrast media; hold for 48 hours after the radiology drug is administered i.e. angiogram SE: GI, megaloblastic anemia, & lactic acidosis (Scr men <1,5, women <1.4- don’t use)
    • Thiazoladinediones (glitazones or TZDs):
    • Pioglitazone (Actos)
    • Rosiglitazone (Avandia): need AST prior to starting Wait 3 months before deciding on therapeutic failure
    • MOA: ↓ insulin resistance 1° in periphery; 2° in liver SE: edema, anemia, weight gain, exacerbation of CHF, URIs, resumption of ovulation
    • Meglitinides (nonsulfonylurea secretagogues):
    • Repaglinide (Prandin) Max daily dose: 16 mg/day
    • Nateglinide (Starlix)
    • MOA: stimulates pancreatic β cells to secrete insulin SE: hypoglycemia, weight gain, GI
    • Combination drugs:
    • Glyburide + Metformin (Glucovance)
    • Glipizide + Metformin (Metaglip) Rosiglitazone + Metformin (Avandamet)
    • Example of question: Diabeta is most like Prandin
    • Glyset will not cause hypoglycemia Only sulfonylureas & insulin will lower blood sugar in non-diabetics
    • Glucagon (GlucaGen):
    • Use: management of hypoglycemia Unlabeled use: beta blocker & CCB overdose
    • MOA: stimulates adenylate cyclase to produce increased cAMP, which promotes hepatic glycogenolysis & gluconeogenesis, causing a rise in blood glucose levels 1 unit = 1 mg
    • Diabetic nephropathy:
    • Microalbuminuria (30-300 mg albumin/24 hours) used to diagnosis Annual screening for DM type II measures microalbumin-creatinine ratio (normal <30)
    • Diabetic neuropathy:
    • Treat with TCA’s
    • Neurontin, carbazepine ACEI treat the decreased renal function, NOT the neuropathy itself
    • DKA:
    • A potentially fatal complication that occurs in up to 5% of patients with Type I annually
    • Seen less frequently in Type II
    • Precipitating factors: interruption of insulin therapy, sepsis, trauma, MI, pregnancy
    • Clinical features: N/V, vaguely localized abdominal pain; dehydration, respiratory distress, shock & coma can occur
    • Lab evulation: anion gap metabolic acidosis & positive serum ketones; plasma glucose is usually elevated Hyponatremia, hyperkalemia, azotemia, & hyperosmolality
    • Treatment:
    • Supportive measures
    • Fluids
    • Insulin therapy
    • Dextrose (5%)- once plasma glucose decreases to 250 mg/dL & the insulin infusion rate decreased to 0.05 U/Kg/hr Potassium Bicarbonate therapy Phosphate & magnesium Drug-Drug Interactions:
    • Sertraline (Zoloft) & diltiazem (Cardizem; Cartia XT; Dilacor XR; Diltia XT; Taztia XT; Tiazac) Hydroxyzine pamoate (Vistaril) & meperidine (Demerol) Both are CNS depressants Epilepsy:
    • Pharmacotherapy:
    • Carbamazepine (Tegretol):
    • Na channel blocker
    • An autoinducer
    • Tegretol XL: ghost tablets in stool
    • SE: rash (rarely causing DC), folate deficiency, hepatotoxicity, aplastic anemia
    • Teratogenic Cannot be given for status epilepticus
    • Felbamate (Felbatol):
    • Rarely used
    • MOA: blocks glycine on N-Methyl-D-Aspartate receptor (NMDA)
    • SE: hepatotoxicity, aplastic anemia 50% renal elimination
    • Gabapentin (Neurontin):
    • MOA: unknown; structurally related to GABA but does not interact with GABA receptors
    • Also used for peripheral neuropathies
    • 100% renal elimination- no DI that effect drug metabolism Al or Mg containing antacids may decrease absorption
    • Lamotrigine (Lamictal):
    • MOA: decrease glutamate & aspartate release, delays repetitive firing of neurons, blocks Na channels SE: life-threatening skin rash Titrate slowly to avoid
    • Levetiracetam (Keppra):
    • MOA: may prevent hypersynchronization of epileptiform burst firing & propagation of seizure activity Adjust in renal dysfunction
    • Oxycarbazepine (Trileptal):
    • MOA: Na channel blocker
    • PKS: active metabolite- 10-monohydroxycarbazepine (MHD) SE: hyponaturemia; blood dysrasias
    • Phenobarbital (Barbital, Luminal, Solfoton):
    • MOA: increases GABA-mediated Cl- influx
    • SE: drowsiness, dizziness, hyperactivity, folate deficiency, hepatic failure, SJS
    • Teratogenic Decreases effectiveness of BC pills
    • Phenytoin (Dilantin):
    • MOA: Na channel blocker
    • Can only prepare in NS @ 50 mg/mL
    • Highly protein bound
    • SE: peripheral neuropathy, hydantoin faces, acne, hirsutism, gingival hyperplasia, osteomalacia, vitamin K- deficient hemorrhagic disease, folate deficiency (megaloblastic anemia), hepatic failure, SJS Dose-related SE: nystagmus, ataxia, drowsiness, cognitive impairment
    • PKS: exhibits capacity-limited or saturable (Michaelis-Menton) PKS
    • Teratogenic
    • DC tube feedings 2 hours before & after a dose of phenytoin
    • Available dosage forms: suspension, chewable tablet, prompt-release capsule, ER capsule, injection Need albumin level to calculate phenytoin level
    • Primidone (Mysoline):
    • MOA: increase GABA-mediated Cl- influx
    • Metabolized to Phenobarbital & phenylethylmalonamide (PEMA) Primidone, Phenobarbital, & PEMA all have anti-epileptic activity
    • Tiagabine (Gabitril): MOA: blocks GABA reuptake in presynaptic neuron
    • Topiramate (Topamax):
    • MOA: blocks Na channels, enhances GABA activity, antagonizes AMPA/kainite activity Also a weak carbonic anhydrase inhibitor
    • Elimination: primarily renal
    • SE: drowsiness, dizziness, kidney stones, oligohidrosis (may not sweat)
    • Sprinkle capsules can be opened & sprinkled onto a small amount of cool, soft food (i.e. applesauce or yogurt)
    • Drink plenty of fluids Dosage forms available: sprinkle capsules & tablets
    • Valproic acid:
    • MOA: blocks T-type Ca currents, blocks Na channels, increases GABA production
    • SE: weight gain, alopecia, thrombocytopenia, increased LFTs, heptotoxicity (fatal), hemorrhagic pancreatitis (fatal), folic acid deficiency
    • Available dosage forms:
    • Sodium valproate (Depacon): injection
    • Divalproex sodium:
    • Depakene: syrup & gel capsule Depakote Sprinkles: capsules Depakote: delayed-release tablets Depakote ER: ER tablet
    • Zonisamide (Zonegran):
    • MOA: Na channel blocker, blocks T-type Ca channels (currents) Weak carbonic anhydrase inhibitor SE: kidney stones, weight loss, oligiohidrosis Sulfa drug
    • Nonpharmacologic therapy:
    • Ketogenic diet: devised in the 1920’s
    • High in fat & low in carbohydrates & protein
    • Leads to acidosis & ketosis
    • Most calories are provided in the form of cream & butter No sugar allowed Fluids are also controlled
    • Status epilepticus: seizure lasting longer than 5 minutes or ≥2 discrete seizures between which there is incomplete recovery of consciousness
    • Treatment:
    • ABC’s: airway, breathing, circulation
    • 1st line: benzodiazepines
    • Lorazepam (Ativan): rapid onset Diazepam (Valium)
    • IV phenytoin (Dilantin)
    • provided patient was not on phenytoin at home
    • Can only mix with NS
    • 15-20 mg/Kg
    • Contains propylene glycol- cardiotoxic therefore do not infuse faster than 50 mg/min
    • Fosphenytoin (Cerebyx):
    • Prodrug of phenytoin
    • Improves water solubility of phenytoin Can be admixed with any IV solution Dosed in PE (phenytoin equivalents): 1 mg of phenytoin = 1.5 mg of fosphenytoin Can be give at a rate of 150 mg/min IV Phenobarbital (20 mg/Kg)or begin a continuous infusion of midazolam Begin a medically-induced coma Must be on a vent Equations:
    • BMI: body mass index
    • Men = 66 + (13.7 X W) + (5 X H) – (6.8 X A)
    • Women = 665 + (9.6 X W) + (1.8 X H) – (4.7 X A)
    • Where W= adjusted body weight in Kg; H= height in centimeters; A= age in years 1 in = 2.54 cm CrCl = (140- age) (IBW) X 0.85 (if woman) (72) (SCr)
    • IBWman= 50 + 2.3 (inches over 5’)
    • IBWwoman= 45.5 + 2.3 (inches over 5’)
    • ABW = IBW + 0.4 (Actual – ideal)
    • Henderson Hasselbach:
    • pH= pka + log [base]/[acid]
    • log values:
    • log 100 = 2
    • log 10 = 1
    • log 1 = 0 log 0.1 = -1 log 0.001 = -2
    • Loading dose (LD) = Css X VD
    • Dose = Css X Cl or Css X VD X Cl T1/2 = 0.693 VD/Cl Fanconi’s Syndrome:
    • A congenital anemia due to low production of RBC’s
    • Can also be induced by anything that causes failure of the proximal renal tubules
    • Patients develop polyuria (cannot concentrate the urine), osteomalacia, & reduced growth size
    • At one time it was associated with the use of out-dated tetracycline but this is no longer a problem since the product has been reformulated The filler was the actual culprit Tenofovir (Viread) can cause this GERD:
    • H2RA:
    • Cimetidine (Tagamet)
    • Famotidine (Pepcid)
    • Nizatidine (Axid)
    • Ranitidine (Zantac)
    • Available dosage forms:
    • 150 & 300 mg capsules
    • 50 mg infusion for IV
    • 25 mg/mL injection 15 mg/mL syrup 75, 150, 300 mg tablet 75 mg effervescent tablet
    • PPIs:
    • MOA: suppresses gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump
    • Rabeprazole (AcipHex): Strength/dosage form: delayed-release EC 20 mg tablet
    • Esomeprazole (Nexium):
    • Strength/dosage form: Capsule: delayed release 20 & 40 mg Injection, powder for reconstitution: 20 & 40 mg
    • Lansoprazole (Prevacid):
    • Strength/dosage form:
    • Capsule: delayed release 15 & 30 mg
    • Granules, for oral suspension: 15 & 30 mg/packet Injection, powder for reconstitution: 30 mg ODT: 15 & 30 mg
    • Omeprazole (Prilosec):
    • Do not put in OJ- not stable in an acidic environment
    • Cannot sprinkle onto food
    • Strength/dosage form:
    • Capsule: delayed release 10 & 20 mg Oral suspension (Zegerid): 20 & 40 mg Tablet: delayed release 20 mg (OTC)
    • Pantoprazole (Protonix):
    • Strength/dosage form: Injection, powder for reconstitution: 40 mg Tablet: delayed release 20 & 40 mg Take 15-30 minutes before breakfast to maximize efficacy GERD can exacerbate asthma Glaucoma:
    • Increased intraocular pressure, which causes pathologic changes in the optic nerve & typical visual field defects
    • Open-angle glaucoma:
    • Primary glaucoma
    • The angle of the anterior chamber remains open in an eye, but filtration of aqueous humor is gradually diminished because of the tissues of the angle 80-90% of cases
    • Angle-closure (narrow angle) glaucoma:
    • Primary glaucoma Shallow anterior chamber & narrow angle; filtration of aqueous humor is compromised as a result of the iris blocking the angle
    • Therapy:
    • β-adrenergic antagonists:
    • MOA: decrease in aqueous humor formation with slight increase in outflow (beta selective)
    • Often DOC for open-angle glaucoma
    • AE: cardiac effects, worsening pulmonary effects, depression, dizziness
    • Nonselective:
    • Timolol (Timoptic)
    • Carteolol (Ocupress)
    • Levobunolol (Betagen) Metipranolol (OptiPranolol)
    • Selective: Betaxolol (Betoptic) Levobexaxolol (Betaxon)
    • Carbonic anhydrase inhibitors:
    • MOA: decrease in aqueous humor formation
    • AE: lethargy, decreased appetite, GI upset, urinary frequency
    • Do not use with sulfa allergy
    • Acetazolamide (Diamox) Tablets, capsules
    • Dorzolamide (Trusopt)
    • Brinzolamide (Azopt) Methazolamide (Neptazane) Tablets
    • Prostaglandin analogs:
    • MOA: increased uveoscleral outflow without effect on aqueous humor formation
    • Also used as 1st line agents or in combination with beta blockers
    • AE: iris pigmentation, eyelid darkening, macular edema
    • Latanoprost (Xalatan)
    • Administer 1 drop at bedtime
    • Refrigerate Can change blue eyes to brown
    • Bimatoprost (Lumigan) Can cause darkening of eyelids & eye lashes
    • Travoprost (Travatan) Frequent ocular hyperemia Unoprostone (Rescula)
    • α-2 adrenergic agonists:
    • MOA: decrease in aqueous humor formation
    • AE: tachycardia, dry mouth, eyelid elevation, CNS effects in the old & young Brimonidine (Alphagan) Wait at least 15 minutes after using before placing soft contacts
    • Other α-adrenergic agonists:
    • MOA: increase in aqueous humor outflow
    • AE: tachycardia, increased BP, allergic responses
    • Dipivefrin (Propine) Prodrug of epinephrine
    • Pilocarpine (Pilocar) Once weekly dose form called Ocuserts Miotic agent Combination: Timolol & dorzolamide (Cosopt) Hydroxypropyl methylcellulose added to decrease burning Gout:
    • Treatment of acute attack:
    • Colchicine:
    • MOA: inhibits phagocytosis of urate crystals by leukocytes; anti-inflammatory agent without analgesic activity Decrease leukocyte mobility thereby decreasing inflammation
    • Dosed until resolution of symptoms, severe GI symptoms occur, or max of 8 mg Available PO (0.6 mg) & IV (0.5 mg/mL)
    • Indomethacin
    • Corticosteroids Effective when given intra-articularly, IV, or PO Used when there is failure to colchine and NSAIDS
    • Prophylaxis:
    • Colchicine (low dose: 0.6-1.2 mg/d)
    • Colchicine + probenecid (ColBenemid)
    • Probenecid (Benemid):
    • MOA: uricosuric agent that promotes the excretion of UA by blocking its reuptake at the proximal convoluted tubule Inhibits renal absorption of UA from the urine into the blood
    • Should drink at least 2 L of water/day to decrease the risk of UA stone formation
    • Available as a 500 mg tablet Avoid use with aspirin
    • Sulfinpyrazone (Anturane):
    • MOA: uricosuric agent that promotes the excretion of UA by blocking its reuptake at the proximal convoluted tubule
    • Drink at least 2 L of water/day Do not use with CrCl < 50 mL/min
    • Allopurinol (Zyloprim):
    • MOA: allopurinol & its metabolite oxypurinol, inhibit xanthine oxides formation, which is the rate-limiting step in UA synthesis; this facilitates the clearance of the more water soluble precursors of UA, oxypurines Inhibits xanthine oxides which reduces UA formation from the metabolism of purine bases of DNA & RNA Take with food Watch for rash- SJS can occur DI: azathioprine, 6-mercaptopurine, ACEI Hemorrhoids:
    • Therapy:
    • Soap suds enema QD
    • Sitz bath QD
    • Fiber therapy
    • Sitting on a doughnut
    • Cleaning anal area with soap & water after each defecation Dibucaine (Nupercainal): OTC local anesthetic for fast temporary relief of pain & itching due to hemorrhoids Pramoxine (Anusol ointment, ProctoFoam NS , Tucks): OTC local anesthetic for fast temporary relief of pain & itching due to hemorrhoids Hepatic Encephalopathy:
    • Syndrome of disordered consciousness & altered neuromuscular activity seen in patients with acute or chronic hepatocellular failure or portosystemic shunting
    • Precipitating factors: azotemia; use of tranquilizer, opioid, or sedative-hypnotic medication; GI hemorrhage; hypokalemia & alkalosis; constipation; infection; high-protein diet
    • Monitor: ammonia levels
    • Treatment:
    • Fleet’s enema
    • Protein restriction; special diet (vegetable protein or branched-chain amino acid enriched)
    • Nonabsorbable disaccharides: lactulose (Cephulac, Constulose, Enulose, Generlac, Kristalose), lactitol, & lactose
    • Lactulose syrup 30 mL of 50% solution QID; diminish to BID when 3 or more bowel movements a day occur daily Lactulose dosage forms: powder for oral suspension, oral solution, oral syrup Neomycin Metronidazole Herbs:
    • Herbals that interfere with anticoagulation:
    • Ginkgo, Ginseng, Fish Oil, Garlic, Feverfew, & Ginger “All begin with F or G”
    • Chamomile:
    • Uses: dyspepsia, oral mucositis, dermatitis, ADHD
    • Might have anti-inflammatory effects; might bind to GABA receptors
    • DI: benzodiazepines, tamoxifen, CNS depressants, warfarin, estrogens, CYP1A2 & CYP3A4 substrates CROSS-ALLERGENICITY: German chamomile may cause an allergic reaction in individuals sensitive to the Asteraceae/Compositae family; members of this family include ragweed, chrysanthemums, marigolds, daisies, and many other herbs
    • Chasteberry:
    • Uses: PMS, BPH, menstrual irregularities, female infertility, insect repellant DI: antipsychotics, contraceptives, dopamine agonists, estrogens, metoclopramide
    • Cholesterol: garlic
    • Depression: St. John’s Wort, SAM-e (& Official Answer), DHEA, Kava-kava (anxiety, stress)
    • Dong quai:
    • Used for PMS & menopausal symptoms Interaction with warfarin- made up of several coumarin constitutes Increase INR
    • Feverfew:
    • Use: migraines, arthritis, allergies DI: anticoagulants, antiplatelets, CYP (1A2, 2C9, 2C19, 3A4)
    • Garlic:
    • Active compounds: alliin, allicin
    • Uses: hyperlipidemia, HTN, prevention of atherosclerosis
    • MOA: May act as an HMG-CoA reductase inhibitor; may vasodilate & relax smooth muscle, release NO; may also reduce oxidation of LDL & inhibit platelet formation
    • Generally safe with the exception of heartburn, N/V, body ordor, bad breath DI: CYP3A4, cyclosporine, saquinavir, OCs, anticoagulants
    • Ginkgo:
    • Uses: memory, Raynaud’s, glaucoma, diabetic retinopathy, intermittent claudication, PMS, vertigo
    • Can cause seizures at high doses DI: anticoagulants (warfarin), anticonvulsants, Buspar, CYP (1A2, 2C19, 2C9, 2D6, 3A4), ibuprofen, insulin, drugs that lower the seizure threshold (i.e. anesthetics (propofol, others), antiarrhythmics (mexiletine), antibiotics (amphotericin, penicillin, cephalosporins, imipenem), antidepressants (bupropion, others), antihistamines (cyproheptadine, others), immunosuppressants (cyclosporine), narcotics (fentanyl, others), stimulants (methylphenidate), theophylline)
    • Glucosamine:
    • Use: Official Answer, TMJ, glaucoma
    • Glucosamine is an amino sugar, which is a constituent of cartilage proteoglycans. It is derived from marine exoskeletons or produced synthetically DI: APAP, antidiabetic agents, warfarin
    • Hyperglycemia may be caused by: Black tea, coffee, cola nut, green tea, guarana, mate, N-acetyl glucosamine, niacin, oolong tea, shark cartilage
    • Kava Kava:
    • Uses: insomnia, anxiety, stress, benzodiazepine withdrawal
    • May adversely affect the liver- increase LFTs DI: xanax, CNS depressants CYP (1A2, 2C19, 2C9, 2D6, 2E1, 3A4), hepatotoxic drugs, levodopa
    • Licorice:
    • Uses: dyspepsia
    • has antispasmodic, anti-inflammatory, laxative, & soothing properties
    • The constituents glycyrrhizin & glycyrrhetinic acid inhibit 11-beta-hydroxysteroid dehydrogenase, an enzyme located in the aldosterone receptor cells of the cortical collecting duct
    • Glycyrrhizin may contribute to licorice-associated mineralocorticoid SE, including HTN & hypokalemia, by both binding directly to mineralocorticoid receptors & by decreasing the conversion of active cortisol to inactive cortisone DI: antihypertensives, corticosteroids, CYP3A4, digoxin
    • Milk thistle:
    • Used for liver disorders; dyspepsia
    • Interactions with CYP2C9 (warfarin, elavil, diazepam), CYP3A4 substrates, estrogens Avoid with hormone sensitive cancers
    • Hot flashes & menopausal symptoms: black cohosh
    • Passion Flower:
    • Used for anxiety, GAD, opioid withdrawal Interactions with CNS depressants
    • Podophyllin:
    • Uses: applied locally for wart removal; Can increase LFTs
    • SAM-e:
    • Uses: depression & Official Answer
    • S-adenosylmethionine (SAMe) is a naturally occurring molecule that is distributed throughout virtually all body tissues and fluids; concentrations are highest in childhood & decrease with age
    • Plays an essential role in >100 biochemical rxn involving enzymatic transmethylation
    • It contributes to the synthesis, activation &/or metabolism of hormones, neurotransmitters, nucleic acids, proteins, phospholipids, & some drugs DI: antidepressants, dextromethorphan, levodopa, meperidine
    • St. John’s Wort:
    • Uses: depression, anxiety
    • Two constituents that play a significant role are hypericin & hyperforin
    • MOA: believed to act as a serotonergic 5-HT3 and 5-HT4 receptor antagonist, & down-regulate beta-adrenergic, & serotonergic 5-HT1 & 5-HT2 receptors when used chronically in animals DI: triptans, xanax, elavil, antidepressants, barbiturates, plavix, OCs, cyclosporine, dextromethorphan, CYP (1A2, 2C9, 3A4), warfarin
    • Valerian:
    • Used for anxiety, stress, insomnia
    • A sedative; similar effects to Ambien Avoid with: etoh, benzadiazepines, CNS depressants, CYP3A4 substrates Some herbs that affect platelet aggregation: angelica, clove, danshen, dong quai, garlic, ginger, ginkgo, feverfew, Panax ginseng, horse chestnut, red clover, turmeric Hyperkalemia:
    • Sodium polystyrene disulfonate (Kayexalate): cation exchange resin- promotes the exchange of Na for K in GIT Can be administered as a retention enema or orally
    • IV insulin Causes K to shift into the cells & temporarily lowers the plasma K
    • Calcium gluconate
    • Decreases membrane excitability Administer 1st with hyperkalemia & EKG changes
    • Other: IV NaHCO3 (shifts K into cells); β-2 adrenergic agonists (promote the cellular uptake of K); Loop & thiazide diuretics (enhance K excretion if renal function is adequate); dialysis
    • If the patient also has EKG changes the usual treatment (in order) is:
    • IV calcium first
    • Then IV bolus of 10-20 units of regular insulin with 25 gm of glucose (prevents hypoglycemia)
    • 150 mEq of sodium bicarbonate is one liter of D5W forces K into cells
    • Beta-2 agonists (i.e. Albuterol) nebulized or SQ
    • Combination of loop & thiazide (i.e. Lasix + Diuril) if the renal function is adequate
    • Kayexalate (slow to work) Hemodialysis is best overall, if the time is available & K is severe Peritoneal dialysis is less effective Hyperlipidemia:
    • Bile Acid Sequestrants:
    • Effects on cholesterol:
    • TC: ↓
    • TG: ↑ or <-->
    • LDL: ↓ HDL: ↑
    • Cholestyramine Resin (Questran, Prevalite): MOA: forms a nonabsorable complex with bile acids in the intestine, releasing chloride ions in the process; inhibits enterohepatic reuptake of intestinal bile salts & thereby increases the fecal loss of bile salt-bound low density lipoprotein cholesterol
    • Colesevelam (WelChol) Strength/dosage forms: 625 mg tablet
    • Colestipol (Colestid) Not absorbed; safest for pregnant women
    • Fibrates:
    • Effects on cholesterol:
    • TC: ↓
    • TG: ↓
    • LDL: ↑ or <--> HDL: ↑
    • MOA: increase catabolism (breakdown) of triglycerides
    • Can cause pancreatitis & liver problems
    • Fenofibrate (Tricor) Changed from 160 mg (with meals) to 145 mg Made it nanocrystals for better bioavailability
    • Gemfibrozil (Lopid) Take 30 minutes before breakfast & dinner Clofibrate (Atromid-S)
    • Statins:
    • Effects on cholesterol:
    • TC: ↓
    • TG: ↓
    • LDL: ↓ HDL: ↑
    • MOA: HMG-CoA reductase inhibitors
    • Atorvastatin (Lipitor)
    • Fluvastatin (Lescol, Lescol XL) Shortest t1/2
    • Lovastatin (Mevacor, Altoprev- with niacin)
    • Strengths/Dosage forms:
    • Tablet: 10, 20, 40 mg
    • Mevacor: 20, 40 mg ER tablets Altoprev: 10, 20, 40, 60 mg tablets No grapefruit
    • Pravastatin (Pravachol)
    • Not metabolized in the liver- therefore statin with the least amount of DIs Max daily dose: 80 mg
    • Rosuvastatin (Crestor)
    • Simvastatin (Zocor)
    • No grapefruit Manufacturer recommends limiting simvastatin dose to 20 mg/day when used with amiodarone or verapamil, & 10 mg/day when used with cyclosporine, gemfibrozil, or fibric acid derivatives
    • All except for Lipitor & Crestor should be administered in the evening
    • Pregnancy category: X Monitor: LFTs, CK
    • Cholesterol Absorption Inhibitor:
    • Effects on cholesterol:
    • TC: ↓
    • TG: ↓
    • LDL: ↓ HDL: ↑ or <--> Ezetimibe (Zetia): Monitor for muscle pain & increased liver enzymes
    • Niacin (Niacor, Niaspan, Slo-Niacin: OTC):
    • Synonyms: Nicotinic acid; vitamin B3
    • Effects on cholesterol:
    • TC: ↓
    • TG: ↓
    • LDL: ↓ HDL: ↑
    • MOA: inhibits the synthesis of VLDL
    • Target dose: 1.5-6 g/day in 3 divided doses with or after meals
    • SE: flushing (pretreat by taking aspirin 30 minutes prior), dizziness, lightheadedness Caution in DM & gout
    • Combination products:
    • Niacin & lovastatin (Advicor)
    • Ezetimibe & simvastatin (Vytorin) Aspirin & pravastatin (Pravigard PAC)- aspirin tablets & pravastatin tablets are separate tablets within the PAC Exercise will help to raise HDL Hypermagnesemia: Treatment: 10% calcium gluconate (renal failure) or 0.9% saline with 2 g calcium gluconate per liter (absence of severe renal failure) Hyperthyroidism:
    • Thyrotoxicosis
    • Graves disease- most common cause
    • Thyroid storm is a life threatening, sudden exacerbation of all the symptoms of thyrotoxicosis characterized by fever, tachycardia, delirium, & coma
    • Can be caused by drugs such as amiodarone & iodine
    • S/Sx: heat intolerance, weight loss, weakness, palpitation, anxiety, tremor, tachycardia, eyelid sag, warm or moist skin
    • Diagnosis: ↑T4 or T3, ↓ TSH
    • Three modes of treatment:
    • Surgery
    • Radioactive iodine (RAI)
    • Antithyroid (thionamide) drugs:
    • Propylthiouracil (PTU):
    • MOA: inhibit the synthesis of thyroid hormones by preventing the incorporation of iodine into iodotyrosines & by inhibiting the coupling of monoiodotyrosine & diiodotyrosine to form T4 & T3; also inhibits the peripheral conversion of T4 to T3 Dosage form: tablets
    • Methimazole (Tapazole): MOA: inhibit the synthesis of thyroid hormones by preventing the incorporation of iodine into iodotyrosines & by inhibiting the coupling of monoiodotyrosine & diiodotyrosine to form T4 & T3 SE: fever, headache, paresthesias, rash, arthralgia, urticaria, jaundice, hepatitis, agranulocytosis, leucopenia, bleeding
    • Iodide drugs: Strong iodine solution (Lugol’s Solution): Dosage form: solution- 5% iodine & 10% K iodide; delivers 6.3 mg iodine per drop Saturated solution of potassium iodide (SSKI) Dosage form: solution- 1 g/mL; delivers 38 mg iodine per drop of saturated solution MOA: blocks hormone release, inhibits thyroid hormone synthesis Hypokalemia: Diarrhea is associated with liquid KCl Hyponatremia:
    • Drugs can cause by 1 of 3 mechanisms:
    • Stimulation of vasopressin release (i.e. nicotine, carbamazepine, Lithium, TCA’s, antipsychotic agents, antineoplastic drugs, narcotics) Potentiation of antidiuretic action of vasopressin (i.e. chlorpropamide, methylxanthines, NSAIDs) Vasopressin analogs (i.e. oxytocin, DDAVP) Hypothyroidism:
    • Deficient thyroid hormone production
    • Hashimoto’s disease is the cause of 90% of primary hypothyroidism Autoimmune resulting from cell- & antibody-mediated thyroid injury
    • S/Sx: cold intolerance, fatigue, somnolence, constipation, menorrhagia, myalgias, hoarseness, thyroid gland enlargement or atrophy, bradycardia, edema, dry skin, weight gain Body slows down
    • Thyroxine (T4) is the major hormone secreted by the thyroid, which is converted to the more potent triiodothyronine (T3) in tissues
    • Thyroxine secretion is stimulated by thyroid stimulating hormone (TSH) Diagnosis: ↑TSH, ↓T4
    • Drug therapy:
    • Levothyroxine sodium, T4 (Synthroid, Levothroid, Levoxyl, Unithroid, Thyro-Tabs):
    • Usually DOC
    • Typical dose is 100-125 mcg po QD; reduce dose to 50 mcg for elderly & 25 mcg in patients with CAD to reduce risk of precipitating angina Dose changes are made within a 6-8 week interval
    • Desiccated thyroid USP (Armour Thyroid, Nature-Throid, Westhroid)
    • Liothyronine, T3 (Cytomel, Triostat)
    • Liotrix, T4 & T3 in a 4:1 ratio (Thyrolar)
    • Take 30 minutes before breakfast Don’t take antacids, calcium, or iron supplements within 4 hours of levothyroxine SE: tachycardia, arrhythmia, angina, MI, tremor, headache, nervousness, insomnia, diarrhea, vomiting, weight loss, excessive sweating, hair loss Body speeds up ID:
    • Aminoglycosides:
    • MOA: bactericidal; interferes with bacterial protein synthesis by binding to 30S & 50S ribosomal subunits resulting in a defective bacterial cell membrane
    • For serious aerobic gram + infections
    • Poorly absorbed for GIT
    • Renally eliminated by glomerular filtration
    • Watch for oto- & nephrotoxicity
    • Target serum concentrations:
    • Amikacin peak: 15-30 mcg/mL
    • Amikacin trough: <5 mcg/mL
    • Gentamicin & tobramycin peak: 4-10 mcg/mL Gentamicin & tobramycin trough: <2 mcg/mL
    • Amikacin (Amikin)
    • Least susceptible to resistance Rule of nines (see gentamicin)
    • Gentamicin (Garamycin):
    • Rule of eights to determine dosing interval SCr X 8 i.e. 2 X 8 = 16- - dose Q16 hours
    • Netilmicin (Netromycin) Tobramycin: Should be given after dialysis and be a routine loading dose
    • ANC: absolute neutrophil count
    • Neutrophils = bands + segs
    • i.e. 5 + 65 = 70
    • This means that 70% of the WBCs are neutrophils
    • If WBC= 14000 cells per cubic millimeter X 0.70 = 9800 neutrophil cells
    • Neutrophils are elevated with bacterial infections
    • Lymphocytes are elevated with viral infections Not much elevation with fungal infections Granulocytes= bands + segs + basophils + eosinophils
    • Anti-fungal agents:
    • Amphotericin B:
    • Amphotericin B-conventional (Amphocin; Fungizone)
    • Premedicate 30-60 minutes prior with NSAID or APAP with or without diphenhydramine Or hydrocortisone
    • Reconstitute ONLY with sterile water without preservatives, not bacteriostatic water Can add D5W
    • Amphotericin B- lipid complex (Abelcet) May also need to premedicate
    • Amphotericin B-liposomal (AmBisome) May also need to premedicate
    • Amphotericin B Cholesteryl Sulfate Complex (Amphotec) May also need to premedicate
    • Itraconazole (Sporanox):
    • MOA: interferes with cytochrome P450 activity, decreasing ergosterol synthesis (principle sterol in fungal cell membrane) & inhibiting cell membrane function
    • CI: CHF
    • Dosing:
    • Onychomycosis, Fingernail: ORAL, 200 mg BID X1 wk, off drug for 3 wk, repeat 200 mg BID X 1 wk Onychomycosis, Toenail: ORAL, 200 mg QD X 12 wk Aspergillosis, Blastomycosis, Histoplasmosis: ORAL, 200 mg QD, MAX 200 mg BID Dosage forms available: 100 mg capsule; injection; oral solution
    • Anti-influenza drugs:
    • Amantadine (Symmetrel)
    • Blocks influenza A; no activity against influenza B
    • Effective when initiated within 48 hours of initial symptoms & continued for 7-10 days
    • SE: GI disturbances & CNS dysfunction, including dizziness, nervousness, confusion, slurred speech, blurred vision, & sleep disturbances May lower seizure threshold- avoid with seizure history
    • Rimantadine (Flumadine)
    • Blocks influenza A; no activity against influenza B
    • Effective when initiated within 48 hours of initial symptoms & continued for 7-10 days SE: GI disturbances & CNS dysfunction, including dizziness, nervousness, confusion, slurred speech, blurred vision, & sleep disturbances Fewer SE than with amantadine
    • Zanamivir (Relenza)
    • Blocks influenza A & B neuraminidases
    • Powder for inhalation (rotadisk with Diskhaler)
    • 1-2 day improvement in symptoms in patients who are symptomatic for no longer than 48 hours SE: headache, GI disturbances, dizziness, upper respiratory symptoms
    • Oseltamivir (Tamiflu)
    • Block influenza A & B neuraminidases
    • 1-2 day improvement in symptoms in patients who are symptomatic for no longer than 48 hours
    • Dosing:
    • Prophylaxis: 75 mg po QD X at least 7 days; should begin within 2 days of contact with infected individual Treatment: 75 mg po BID initiated within 2 days of onset of symptoms; duration of treatment is 5 days SE: N/V/D Oral capsules & suspension
    • Anti-viral agents:
    • Acyclovir (Zovirax): Counseling: avoid sexual intercourse when lesions are present; this is not a cure for herpes; can take with food; maintain adequate hydration (2-3 L/day); may cause lightheadedness or dizziness
    • Famciclovir (Famvir):
    • Uses: genital herpes, herpes zoster
    • Biotransformed to the active metabolite: penciclovir
    • Need dose adjustment for renal impairment Tablet only
    • Valacyclovir (Valtrex):
    • Uses: treatment of herpes zoster (shingles), herpes labialis (cold sores) & genital herpes MOA: rapidly & nearly completely converted to acyclovir by intestinal & hepatic metabolism; inhibits DNA synthesis & viral replication by competing with deoxyguanosine triphosphate for viral DNA polymerase & being incorporated into viral DNA Reduce dose with renal dysfunction
    • Aspergillus:
    • Fungus
    • Amphotericin B (Amphotec, Abelcet, AmBisome), itraconazole (Sporanox), voriconazole (VFEND), caspofungin (Cancidas) Spells out CAVI NOT ketoconazole
    • Cephalosporins: 3rd generation: Cefpodoxime (Vantin) Refrigerate
    • Chlamydia:
    • STD
    • S/SX:
    • Males: urethritis, epdidymitis, proctitis, reiter syndrome, testicular pain Females: cervictis, urethral syndrome, endometritis, PID, urethral or cervical discharge, pelvic pain
    • If left untreated can lead to infertility Treatment: doxycycline, azithromycin, erythromycin (pregnant) Tetracyclines & quinolones CI in children & pregnant women
    • Clostridium difficile:
    • Gram +, anaerobic rod
    • Treatment: DOC: metronidazole Vancomycin
    • Enterococcus faecalis: penicillin, ampicillin, vancomycin, linezolid, aminoglycosides, quinupristin & dalfopristin (Synercid)- for vanco resistant enterococcus (VRE)
    • Chloramphenicol, streptomycin, bactrim
    • Gram + Clindamycin or cefazolin (cephalosporins ) will not treat
    • Escherichia coli: DOC: cefazolin (Ancef), cephalixin (Keflex, Biocef), cefotaxime (Claforan), gentamicin (Gentak)
    • Fluoroquinolones:
    • MOA: bactericidal; inhibit bacterial DNA topoisomemrase & disrupt bacterial DNA replication
    • Can cause QT prolongation
    • AE: crystalluria, tendon rupture
    • Avoid PO in children under 18 years old- may cause cartilage growth suppression
    • 2nd generation:
    • Ciprofloxacin (Cipro):
    • MOA: inhibits DNA-gyrase in suspectible organisms; inhibits relaxation of supercoiled DNA & promotes breakage of double-stranded DNA
    • Dosage forms: infusion, injection, microcapsules for oral suspension, ophthalmic ointment (Ciloxan) & solution (Ciloxan), tablet, ER tablet
    • Cipro ear drops: Ciprofloxacin & dexamethasone (Ciprodex): Antibiotic/corticosteroid Treatment of acute otitis media in peds with tympanostomy tubes or acute otitis externa in children & adults Ciprofloxacin & hydrocortisone (Cipro HC): Antibiotic/corticosteroid Treatment of acute otitis externa (swimmer’s ear)
    • Gonorrhea:
    • Neisseria gonorrhoeae
    • Gram – Cefixime, ceftriaxone, ciprofloxacin, ofloxacin
    • Inhibit cell wall synthesis: Vancomycin, PCNs, cephalosporins
    • Legionella pneumophilia:
    • DOC: azithromycin, clarithromycin, erythromycin Alternative: Rifampin, ciprofloxacin, levofloxacin
    • Lincosamides:
    • Treat gram +, gram - & anaerobic infections
    • Lincomycin (Lincocin) Clindamycin (Cleocin)
    • Lyme’s Disease:
    • Lyme borrelliosis
    • Caused by spirochete Borrelia burgdorferi
    • Tick-borne illness
    • Symptoms:
    • Stage 1 (early disease): erythemia migrans- a slowly expanding macular rash > 5 cm in diameter, often with a central clearing & mild constitutional symptoms
    • Stage 2 (early disseminated): occurs within several weeks to months & includes multiple erythema migrans lesions, neurologic symptoms (7th cranial nerve palsy, meningoencephalitis), cardiac symptoms (AV block, myopericarditis), & asymmetric olioarticular arthritis Stage 3 (Late disease): occurs after months to years & includes chronic dermatitis, neurologic disease, & asymmetric monoarticular or oligoarticular arthritis
    • Treatment:
    • Doxycucline 100 mg BID Amoxicillin 500 mg TID Cefuroxime axetil 500 mg BID for 14-21 days
    • Macrolides:
    • Bacteriostatic
    • Clarithromycin (Biaxin): Should not be stored in the refrigerator
    • Erythromycin:
    • Oral products:
    • Erythromycin base (E-Mycin, Ery-Tab, PCE (polymer coated ery), Eryc)
    • Sensitive to acid
    • Coating on most products Administer on an empty stomach
    • Erythromycin stearate (Erythrocin stearate, Wyamycin S) Properties similar to ery base but better absorbed
    • Erythromycin estolate (Ilosone)
    • Most hepatotoxic Better absorbed than ery base
    • Erythromycin ethylsuccinate (Eryped, EES)
    • Best absorbed form from GIT Available in liquid formulation 400 mg of EES = 250 mg erythromycin base
    • Parenteral products:
    • Erythromycin lactobionate Erythromycin gluceptate
    • Topical products:
    • Erythromycin (Staticin, Emgel)- for acne (colorless) Erythromycin (Ilotycin)- ophthalmic use
    • MOA:bacteriostatic macrolide antibiotic; may be bactericidal in high concentrations or when used against highly susceptible organisms. It penetrates the bacterial cell membrane & reversibly binds to the 50 S subunit of bacterial ribosomes Reacts with theophylline by altering hepatic metabolism Also increases levels of carbamazepine, cyclosporine, triazolam, lovastatin, simvastatin, valproate
    • Azithromycin (Zithromax):
    • More gram – activity than erythromycin or clarithromycin
    • Suspension & capsules: take on an empty stomach
    • Tablet: with or without food Not for children < 6 months old Dosage forms available: injection, oral suspension, tablet, Tri-PAK (3, 500 mg tabs), Z-PAK (6, 250 mg tabs)
    • Meningitis:
    • Inflammation of the meninges that is identified by an abnormal number of WBC in the CSF
    • Causative organisms: many gram + & - species Bacterial agents are associated with a large increase in WBCs, increased CSF protein, & decreased CSF glucose Fungal & viral agents exhibit smaller increases in CSF WBCs, smaller increases in CSF protein, & limited decreases in CSF glucose
    • Mycoplasma pneumoniae: Erythromycin, tetracycline, doxycycline, fluoroquinolones, azithromycin, clarithromycin
    • Onychomycosis:
    • Infection of the nail by fungi (dermatophytes, Candida, molds)
    • Treatment:
    • Fluconazole (Diflucan): 300 mg po weekly X 6 months (pulse therapy) Itraconazole (Sporanox): 200 mg po BID X 1 week per month for 2 months for fingernails & 3-4 months for toenails (pulse therapy) Terbinafine (Lamisil): 250 mg po QD X 3 months
    • Other:
    • Daptomycin (Cubicin):
    • Used for resistant gram + infections
    • MOA:binds to bacterial membrane causing rapid depolarization of membrane potential which leads to inhibition of protein, DNA & RNA synthesis, resulting in bacterial cell death Dosing: 4-6 mg/Kg QD
    • Linezolid (Zyvox):
    • Available dosage forms: IV, powder for oral suspension, tablet
    • For resistant gram + skin infections, vancomycin-resistant E. faecium
    • Monitor for myelosuppression, thrombocytopenia, & HTN (especially if used with tyramine-containing foods)
    • Do not combine with SSRIs because of potential for serotonin syndrome
    • Bacteriostatic/bactericidal agent Adjustment with renal dysfunction
    • Metronidazole (Flagyl):
    • Use: treatment of bacterial vaginosis & trichomonias
    • MOA: after diffusing into the organism, interacts with DNA to cause a loss of helical DNA structure & strand breakage resulting in inhibition of protein synthesis & cell death in susceptible organisms Avoid with etoh
    • Mupirocin (Bactroban):
    • Intranasal: eradication of nasal colonization with MRSA in adult patients & healthcare workers BID Topical treatment of impetigo due to Staphylococcus aureaus, beta hemolytic Streptococcus, & S. pyogenes Apply 2-5 times/day for 5-14 days
    • Nystatin:
    • Brand names: Bio-Statin; Mycostatin; Nystat; Nystop; Pedi-Dri
    • Antifungal agent for the treatment of susceptible cutaneous, mucocutaneous, & oral cavity fungal infections caused by the Candida species
    • MOA: binds to sterols in fungal cell membrane, changing the cell wall permeability allowing for leakage of cellular contents
    • Systemic relief in 24-72 hours from candidiasis
    • Oral: poorly absorbed
    • Available dosage forms: cream, lozenge (DSC), ointment, powder for compounding, suspension, tablet, vaginal tablet
    • Mycolog cream contains a corticosteroid (triamcinolone) as well as an antifungal (nystatin) Could be used for a patient with an ileostomy pouch Would also treat the inflammation that can occur from what are basically “tape burns”
    • Quinupristin/dalfopristin (Syncerid):
    • Indicated for vancomycin-resistant Enterococcus faecium & serious bacterial skin infections
    • MOA: inhibits bacterial protein synthesis by binding to different sites on the 50S bacterial ribosomal subunit thereby inhibiting protein synthesis
    • Strengths/dosage forms: Injection, powder for reconstitution: 500 mg: quinupristin 150 mg & dalfopristin 350 mg 600 mg: quinupristin 180 mg & dalfopristin 420 mg
    • Vancomycin (Vanocin, Vancole):
    • MOA: inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization through binding tightly to D-alanyl-D-alanine portion of cell wall precursor
    • Alternative to other antimicrobials, including penicillins & cephalosporins for serious gram + infections (resistant strains of strep, MRSA)
    • Watch for ototoxicity
    • Red man’s syndrome: rapid drop in BP accompanied by maculopapular rash in neck or chest area often associated with rapid IV infusion Should be infused slowly >60 mins
    • Draw peak 1 hour after infusion has completed; draw trough just before next dose Therapeutic peak: 25-40 mcg/mL (>80 toxic) Therapeutic trough: 5-12 mcg/mL
    • Otitis media:
    • 1st line drugs: ampicillin, amoxicillin, bacampicillin
    • Augmentin: (> 3 months & < 40 kg) 90 mg/Kg/day divided Q12 hours X 10 days
    • 2nd generation cephalosporin (cefaclor- Ceclor, cefuroxime- Ceftin, cefprozil-Cefzil, loracarbef-Lorabid)
    • Zithromax (treat recurrent OM ), Biaxin, Bactrim
    • Most common causative organisms: Streptococcus pneumoniae (pneumococcus), H. flu, moraxella catarrhalis, pseudomonas, klebsiella Rocephin can be used to treat: 50 mg/Kg in a single dose or for relapsing: 50 mg/Kg QD X 3 days
    • P. acne:
    • Clindamycin, erythromycin, & tetracycline are effective
    • Erythromycin & benzoyl peroxide (Benzamycin):
    • Apply BID This product contains benzoyl peroxide which may bleach or stain clothing Available as a topical gel or Benzamycin Pak (supplied with diluent containing alcohol
    • Penicillins: Resistance to PCN is caused by beta lactamase enzyme production & alteration of PCN-binding proteins
    • Pseudomembranous enterocolitis (PE): Clostridium difficile overgrowth
    • Caused by clindamycin & lincomycin Treat PE with fluid & electrolyte replenishment, oral metronidazole (IV if patient cannot take po), &/or vancomycin (oral only)
    • Pseudomonas:
    • Aerobic, gram – bacillus
    • Treatment:
    • Antipseudomonal PCN (mezlocillin, piperacillin, carbenicillin, ticarcillin) Ceftazidime (Fortaz, Tazidime, Tazicef), Cefepime (Maxipime) + aminoglycoside Quinolone + imipenem
    • Sulfonamide derivates:
    • SJS
    • The only sodium sulfa salt suitable for ophthalmic use is sulfacetamide sodium (Sodium Sulamyd, Bleph-10)
    • Metabolized via acetylation
    • Eliminated renally- good for UTIs
    • Can result in crystalluria- drink sufficient amounts of water to prevent (2-3 L/day)
    • Sulfamethoxazole & trimethoprim (Bactrim, Septra): MOA: Sulfamethoxazole interferes with bacterial folic acid synthesis & growth via inhibition of dihydrogolic acid formation form paraaminobenzoic acid (PABA) Trimethoprim inhibits dihydrofolic acid reduction to tetrahydrofolate resulting in sequential inhibition of enzymes of the folic acid pathway
    • Staphylococcus aureus:
    • DOC: dicloxacillin, nafcillin, oxacillin, PCN allergy: erythromycin, clindamycin, TCN, linezolid, synercid, vancomycin
    • Systemic fungal infection:
    • Would NOT use nystatin Fluconazole (Diflucan)
    • TB:
    • Initial therapy involves RIPE:
    • As therapy continues, therapy may go to RIP & then RI
    • May continue for 6-18 months
    • Rifampin (Rifadin, Rimactane):
    • Potent enzyme inducer
    • Orange discoloration of all bodily fluids- stains contacts Also used for elimination of meningococci from the nasopharynx in asymptomatic carriers
    • Isoniazid (Nydrazid):
    • AKA: INH
    • MOA: inhibits the bacterial cell wall of susceptible isolates & is therefore active against actively dividing cells only Bacteriocidal or bacteriostatic depending on tissue concentration of the agent
    • May cause vitamin B6 deficiency- give B6 (pyridoxine) with use SE: peripheral neuropathy
    • Pyrazinamide: MOA: Mycobacterium tuberculosis converts pyrazinamide to pyrazinoic acid which possesses antitubercular activity Ethambutol (Myambutol)
    • Monitor TB drugs with:
    • LFTs AST Or other transferases
    • Tetracyclines:
    • Broad spectrum
    • Doxycycline (Atridox, Doryx, Periostat, Vibra-Tabs, Vibramycin):
    • MOA:bacteriostatic effects by blocking the synthesis of bacterial proteins
    • Long-acting (BID) TCN Eliminated via non-renal routes- good choice for renal impairment DI with trivalent cations- Al (compatible with divalent cations)
    • Thrush:
    • Normally found in the mouth It is a fungal infection of the mouth consisting of white spots
    • UTI- pyelonephritis:
    • E. coli Bactrim, fluoroquinolones. Ampicillin + gentamicin UTI & sulfa allergy- treat with a FQ Do not give FQ to children Inflammatory Bowel Disease:
    • Ulcerative colitis: an idiopathic chronic inflammatory disease of the colon & rectum
    • Crohn’s disease: can affect any part of the tubular GIT & is characterized by transmural inflammation of the gut wall
    • Treat with:
    • Sulfasalazine (Azulfidine, Sulfazine)
    • Mesalamine (Asacol, Canasa, Pentasa, Rowasa)
    • Olsalazine (Dipentum)
    • Glucocorticords
    • Immunosuppressive agents (6-mercaptopurine, azathioprine, methotrexate, cyclosporine)
    • Antibiotics (metronidazole) Infliximab (Remicade)
    • Sulfasalazine (Azulfidine®):
    • Used in the treatment of inflammatory bowel disease (ulcerative colitis) & RA
    • Watch for sulfa allergy, salicylate allergy, & urinary discoloration Sulfasalazine à sulfapyridine + mesalamine (5-aminosalicyclic acid; 5-ASA) 5-ASA is more active If patient cannot tolerate sulfasalazine because of a sulfa hypersensitivity, mesalamine (Asacol, Pentasa, Rowasa) may be used Asacol Delayed released, EC coated tablet- do not crush or chew Immunosuppressive Therapy:
    • Calcineurin inhibitors:
    • Cyclosporine (Sandimmune, Neoral) Tacrolimus (Prograf)
    • mTOR inhibitors: Sirolimus (Rapamune)
    • Antiproliferative agents:
    • Azathioprine (Imuran)
    • Mycophenolate mofetil (CellCept)
    • Mycophenolate sodium (Myfortic) Leflunomide (Arava)
    • Monoclonal antibodies:
    • Muromonab-CD3 (Orthoclone OKT 3)
    • Basliximab (Simulect) Daclizumab (Zenepax)
    • Polyclonal antibodies: Anti-thymocyte globulin (Atgam): equine Anti-thymocyte globulin (Thymoglobulin): rabbit Insomnia, Anxiety, or both:
    • Benzodiazepines:
    • Most undergo oxidation to active metabolites in liver
    • Lorazepam (Ativan), oxazepam (Serax), & temazepam (Restoril) undergo glucuronidation to inactive metabolites Useful in elderly & those with liver disease
    • Can experience seizures & delirium with sudden discontinuation
    • Hypnotic agents:
    • Estazolam (ProSom)
    • Flurazepam (Dalmane)
    • Quazepam (Doral) Temazepam (Restoril) Triazolam (Halcion)
    • Trazodone (Desyrel):
    • Antidepressant that is useful for severe anxiety or insomnia
    • Highly sedating, causing postural hypotension & is associated with priapism
    • Doses: Sedation: 25-50 mg Depression: 150 mg divided into 3 daily doses; max 600 mg/day
    • Zolpidem (Ambien):
    • An imidazopyridine hypnotic agent
    • MOA: has much or all of its actions explained by its effects on benzodiazepine receptors, especially the omega-1 receptor binds the benzodiazepine (BZ) receptor subunit of the GABA-A receptor complex
    • No withdrawal symptoms, rebound insomnia or tolerance
    • Rapid onset good for initiating & maintaining sleep
    • SE: headache, daytime somnolence, GI upset Avoided in patients with obstructive sleep apnea
    • Zaleplon (Sonata)
    • Nonbenzodiazepine hypnotic
    • MOA: interacts with benzodiazepine GABA receptor complex
    • T1/2 is ~1 hour & has no active metabolites
    • SE: drowsiness, dizziness, & impaired coordination Caution in those with compromised respiratory function
    • Eszopiclone (Lunesta): MOA: may interact with GABA-receptor complexes
    • OTC sleep aids:
    • Doxylamine (Unisom)
    • Diphenhydramine (Nytol, Sominex) Diphenhydramine + APAP (Tylenol PM, Unisom Pain Relief) Diphenhydramine + ASA (Bayer PM) Lupus:
    • Autoimmune inflammatory condition
    • Systemic Lupus Erythematosus (SLE)
    • Drugs that can contribute: procainamide**, phenytoin, chlorpromazine, hydralazine*, quinidine, methyldopa, & isoniazid
    • Therapy:
    • Arthritis: NSAIDs or glucocorticoids
    • Dermatologic complications: hydroxychloroquine (Plaquenil) Thrombocytopenia: glucocorticoid therapy Refractory cases: cyclophosphamide Metabolic acidosis:
    • Give sodium acetate- acetate ion converts to bicarbonate
    • Bicitra:
    • Sodium citrate & citric acid
    • Other brand names: Cytra-2 & Oracit
    • AKA: Modified Shohl’s solution
    • Use: treatment of metabolic acidosis; alkalinizing agent in conditions where long-term maintenance of an alkaline urine is desirable Also solution antacid pre-op if patient has eaten just before emergency surgery or delivery of child Dosing: oral- 10-30 mL with water after meals (to avoid laxative effect) & at bedtime SE: N/V/D, hyperkalemia, tetany Migraines:
    • Triptans:
    • Selective serotonin receptor agonists that activate 5-HT1B/5-HT1D & to a lesser extent 5-HT1A/5-HT1F
    • Agents:
    • Almotriptan (Axert): 6.25 & 12.5 mg tablets; CYP450 & MAO metabolism NMT 2 doses in 24 hours
    • Sumatriptan (Imitrex): 25, 50, & 100 mg tablets, 5 & 20 mg nasal spray, 12 mg/mL injection; MAO metabolism
    • Can re-dose oral tablets & nasal spray if no response after 2 hours Can re-dose injection if no response after 1 hour
    • Eletriptam (Relpax): 20 & 40 mg tablets; CYP 3A4 metabolism
    • Can re-dose after 2 hours 80 mg/day max
    • Frovatriptan (Frova): 2.5 mg tablet; renal 50%
    • Can re-dose after 2 hours 7.5 mg/day max
    • Rizatriptan (Maxalt): 5 & 10 mg tablet/wafer; MAO metabolism
    • Can re-dose after 2 hours
    • 30 mg/day max 15 mg max if also taking propranolol
    • Zolmitriptan (Zomig): 2.5 mg tablet/wafer, nasal spray 5 mg, ODT; CYP450 & MAO metabolism
    • Can re-dose after 2 hours NMT 10 mg per 24 hours
    • Naratriptan (Amerge): 1 & 2.5 mg tablets; renal 70% & CYP450 Dose may be repeated after 4 hours NMT 5 mg in 24 hours
    • SQ sumatriptan has the fastest onset followed by sumatriptan nasal spray
    • Rizatriptan may have a slightly faster onset of action than the others
    • Migraine recurrence rates may be lower with long half-life triptans such as naratriptan & frovatriptan
    • SE: tingling & paresthesias; sensations of warmth in the head, neck, chest, & limbs; dizziness; flushing; neck pain or stiffness
    • Do not give sumatriptan to patients who have risk factors for CAD
    • CI: in patients with hx of ischemic heart disease, MI, uncontrolled HTN, or other heart disease; pregnancy Should not be taken within 24 hours of other triptans, isometheptene, or ergot derivatives
    • Combination:
    • Midrin:
    • Oral Capsule: (Acetaminophen - Dichloralphenazone - Isometheptene Mucate) 325 MG-100 MG-65 MG
    • Isometheptene: is an indirect-acting sympathomimetic agent with vasoconstricting activity
    • Dichloralphenazone: a mild sedative & relaxant Acetaminophen: may act predominantly by inhibiting prostaglandin synthesis in the CNS &, to a lesser extent, through a peripheral action by blocking pain-impulse generation The peripheral action may also be due to inhibition of prostaglandin synthesis or to inhibition of the synthesis or actions of other substances that sensitize pain receptors to mechanical or chemical stimulation
    • Butalbital 50 mg, aspirin 325 mg, & caffeine 40 mg (Fiorinal): Capsules Butalbital, acetaminophen, & caffeine (Anolor 300; Dolgic; Esgic; Fioricet; Medigesic; Repan; Zebutal): Butalbital 50 mg, APAP 325 mg & caffeine 40 mg (Fioricet) Tablet
    • Ergot derivatives:
    • CI: pregnancy, peripheral vascular disease, CAD, sepsis, hepatic or renal impairment
    • Dihydroergotamine (DHE 45, Migranal):
    • Migraines: with or without aura
    • MOA: ergot alkaloid alpha-adrenergic blocker directly stimulates vascular smooth muscle to vasoconstrict peripheral & cerebral vessels; also has effects on serotonin receptors 5-HT1D receptor agonist
    • Max: 6 mg/week
    • Patient takes too much: N/V/D, dizziness, paresthesia, peripheral ischemia, peripheral vasoconstriction Available dosage forms: injection & intranasal spray DHE 45 NS: 1 spray in each nostril; can repeat in 15 minutes; max is 4 sprays/day Discard open ampules after 8 hours
    • Ergotamine tartrate & caffeine (Cafergot):
    • Available dosage forms: tablets & suppositories Max: 6 mg/day or 10 mg/week
    • SE: nausea & vomiting (resulting from stimulation of the CTZ)
    • Ergotism: severe peripheral ischemia Sx: cold, numb, painful extremities, continuous paresthesias, diminished peripheral pulses & claudication may result from the vasoconstrictor effects of the ergot alkaloids Gangrenous extremities, MI, hepatic necrosis, & bowel & brain ischemia are rare, but have been reported
    • Propylactic therapy:
    • DOC:
    • Propranolol (Inderal): use if patient also has HTN Lipid soluble
    • Amitriptyline (Elavil): concomitant depression
    • Valproate (Depakote): concomitant seizures
    • Cyproheptadine (Periactin): useful for migraines in children
    • Feverfew: herbal with some benefits shown
    • Ergonovine maleate: effective for menstrual migraines
    • Methysergide (Sansert): Dose: 2 mg BID up to 8 mg X 6 months Then stop for 1 month If you don’t stop- get SE of retroperitoneal fibrosis: organs in abdominal cavity become fibrotic & can die This can occur as the result of constant vasoconstriction- which provides less blood flow to organs You must stop to allow blood flow to return Miscellaneous Drugs:
    • Acetylcysteine (Mucomyst, Acetadote): MOA: exerts mucolytic action through its free sulfhydryl group which opens up the disulfide bonds in the mucoproteins thus lowering mucous viscosity; thought to reverse APAP toxicity by providing substrate for conjugation with the toxic metabolites
    • Adalimumab (Humira):
    • Tumor necrosis factor (TNF) blocking agent
    • MOA: binds to human tumor necrosis factor alpha (TNF-alpha) receptor sites Elevated TNF levels in the synovial fluid are involved in pathologic pain
    • Use: treatment of active RA in patients with inadequate response to one or more DMARDs; psoriasis
    • Dose: 40 mg SQ EOW Before starting therapy: TB test, measure rheumatoid factor, PT
    • Adefovir (Hepsera):
    • Antiretroviral agent; reverse transcriptase inhibitor (nucleoside)
    • MOA: acyclic nucleotide reverse transcriptase inhibitor (adenosine analog) which interferes with HBV viral RNA dependent DNA polymerase resulting in inhibition of viral replication Use: treatment of chronic hepatitis B
    • Aspirin & dipyridamole (Aggrenox):
    • Use: reduction in the risk of stroke in patients who have had transient ischemia of the brain or completed ischemic stroke due to thrombosis
    • MOA:
    • Dipryidamole: inhibits the uptake of adenosine into platelets, endothelial cells & erythrocytes Aspirin: inhibits platelet aggregation by irreversible inhibition of platelet cyclooxygenase & thus inhibits the generation of thromboxane A2 Dosing: 1 capsule BID
    • Atropine (AtroPen; Atropine-Care; Isopto; Sal-Tropine):
    • AtroPen formulation is available for use primarily by the department of defense MOA: blocks the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands & the CNS; increases CO, dries secretions, antaonizes histamine & serotonin
    • Bismuth subsalicylate, metronidazole, tetracycline (Helidac): If patient has + urea breath test indicating H. pylori present
    • Chlorhexidine (Periogard):
    • Antibacterial agent for oral rinse
    • Bactericidal Uses: disinfectant; gingivitis; periodonitis; inhibits plaque formation
    • Cromolyn (NasalCrom): Dose: use 1 spray in each nostril 3-4 times per day
    • Cyclosporin (Gengraf, Neoral, Restasis, Sandimmune):
    • Neoral & Sandimmune are NOT therapeutically equivalent
    • Immunosuppressant agent MOA: inhibition of production & release of interleukin II & inhibits interleukin II-induced activation or resting T-lymphocytes
    • Danazol (Danocrine):
    • Use: treatment of endometriosis, fibrocystic breast disease & hereditary angioedema
    • Androgen
    • MOA: suppresses pituitary output of FSH & LH that causes regression & atrophy of normal & ectopic endometrial tissue; decreases rate of growth of abnormal breast tissue CI: markedly impaired hepatic, renal, or cardiac function
    • Desmopressin (DDAVP, Stimate):
    • Vasopressin analog
    • Uses: diabetes insipidus; control bleeding in hemophilia A & van Willebrand disease; primary noctural enuresis
    • Strengths/dosage forms:
    • Injection (IV): 4 mcg/mL Solution, intranasal: 100 mcg/mL Tablets
    • Desoximetasone (Topicort):
    • Intermediate to high potency topical corticosteriod Available as a cream & ointment
    • Dicyclomine (Bentyl);
    • MOA: anticholinergic agent
    • Uses: treatment of functional disturbances of GI motility such as irritable bowel syndrome NOT used for GERD
    • Diphenhydramine (Benadryl):
    • Analgesic, antihistamine, antipruritic, sleep aid, antitussive, antiemetic
    • Class: Ethanolamine
    • Dosing adjustments in renal impairment
    • MOA: Diphenhydramine hydrochloride acts as an antihistamine by competing with histamine for receptor sites on effector cells Precautions: bladder neck obstruction; concurrent MAOI therapy; concurrent use of CNS depressants; decreases mental alertness & psychomotor performance; do not use topical form on eyes or eye lids; elderly are more susceptible to the SE of diphenhydramine; history of bronchial asthma, increased intraocular pressure, hyperthyroidism, cardiovascular disease or HTN; may cause excitation in young children; narrow angle glaucoma; pyloroduodenal obstruction; stenosing peptic ulcer; symptomatic prostatic hypertrophy
    • Diphenoxylate & Atropine (Lomitol; Lonox):
    • Antidiarrheal
    • CI: severe liver disease; jaundice; narrow angle glaucoma; children < 2 years old
    • MOA: diphenoxylate inhibits excessive GI motility & GI propulsion
    • Commercial preparations contain a subtherapeutic amount of atropine to discourage abuse
    • Dosing: 15-20 mg/day of diphenoxylate in 3-4 divided doses Maintenance: 5-15 mg/day in 2-3 divided doses May cause drowsiness
    • Etancercept (Enbrel):
    • Disease modifying agent
    • MOA: binds to TNF & blocks its interaction with cell surface receptors TNF blocker
    • Use: moderate-severe RA; chronic plaque psoriases
    • Dose: 25 mg injection SQ twice weekly or 50 mg injection SQ once weekly
    • Initial storage of drug: in refrigerator (not frozen)
    • Stability of vials after reconstitution: 14 days in refrigerator
    • Allow prefilled syringes 15-30 minutes at room temperature prior to injection
    • Some foaming is normal
    • No DI with methotrexate Stop using when patient has a serious infection
    • Guaifensin: MOA: expectorant which acts by irritating the gastric mucosa & stimulating respiratory tract secretions, thereby increasing respiratory fluid volumes & decreasing mucus viscosity
    • Hyaluronate (Hyalgan, Biolon, Healon, Hylaform, Orthovisc, Provisc, Restylane, Supartz, Synvisc, Vitax):
    • MOA: sodium hyaluronate is a polysaccharide which is distributed widely in the extracellular matrix of connective tissue in man. It forms a viscoelastic solution in water (at physiological pH & ionic strength) which makes it suitable for aqueous & vitreous humor in ophthalmic surgery & functions as a tissue &/or joint lubricant
    • Use:
    • intra-articular injection (Synvisc)- treatment of pain in Official Answer in knee in patients who have failed nonpharmacologic treatment & simple analgesics No weight bearing exercise for 48 hours
    • Intradermal- correction of moderate to severe facial wrinkles Ophthalmic- surgical aid in cataract extraction, intraocular implantation, corneal transplant, glaucoma filtration, & retinal attachment surgery Topical- management of skin ulcers & wounds
    • Hydroxyzine (Atarax, Vistaril):
    • MOA: competes with histamine for H1 receptor sites on effector cells in the GIT, blood vessels, & respiratory tract; possesses skeletal muscle relaxing, bronchodilator, antihistamine, antiemetic, & analgesic properties
    • Use: treatment of anxiety; preoperative sedative; antipruritic; antiemetic
    • Causes sedation
    • Hydroxyzine pamoate (Vistaril)
    • Hydroxyzine HCl (Atarax) Not to be confused with Hydralazine
    • Interferon beta 1b (Betseron):
    • Use: treatment of MS Can cause hepatotoxicity- monitor LFTs
    • Isotretinoin (Accutane, Amnesteem, Clarais, Sotret):
    • Retinoic acid derivative
    • MOA: reduces sebaceous gland size & reduces sebum production; regulates cell proliferation & differentiation
    • Use: treatment of sever recalcitrant nodular acne unresponsive to conventional therapy
    • RiskMAP, S.M.A.R.T., S.P.R.I.T., I.M.P.A.R.T. programs
    • Cannot be dispensed unless the rx is affixed with a yellow, self-adhesive qualification sticker filled out by the prescriber
    • Telephone, fax, or computer-generated rxs are no longer valid
    • Rx cannot be written for more than a 1-month supply, must be dispensed with a patient education guide Females must have their rxs filled within 7 days of the qualification date- considered expired if > 7days
    • Pregnancy risk factor: X
    • Females must have 2 methods of contraception; 1 month prior to starting therapy & 1 month after discontinuation of therapy Therapy is begun after 2 negative pregnancy tests
    • SE: increased triglycerides, elevated blood glucose, photosensivitivity, seizure, cataracts
    • Avoid additional vitamin A supplements
    • Dose: 0.5-2 mg/Kg/day in 2 divided doses
    • Take with food; limit exercise while on therapy; capsules can be swallowed, or chewed & swallowed; capsule may be opened with a large needle & contents placed on applesauce or ice cream
    • Excerbation of acne may occur during the 1st weeks of therapy Accutane, Amnesteem, & Sotret contains soybean oil (Claravis does not)
    • Lansoprazole (30 mg), amoxicillin (1 g), clarithromycin (500 mg) (Prevpac):
    • For H. pylori Taken together BID for 10-14 days
    • Leflunomide (Arava):
    • Disease modifying agent
    • MOA: inhibits pyrimidine synthesis, resulting in antiproliferative & anti-inflammatory effects Use: treatment of active RA; indicated to reduce signs & symptoms, & to retard structural damage & improve physical function
    • Luride: source of fluoride to prevent dental caries
    • Supplied as sodium fluoride in chewable tablets that provide 0.25 mg, 0.5 mg, & 1 mg of fluoride ion per tab Prolonged ingestion with excessive doses may result in dental fluorosis (staining or hypoplasia of the enamel of the teeth) & osseous changes
    • Malathion (Ovide):
    • Class: organophosphate; pediculicide
    • Uses: pediculosis capitis; lice
    • MOA:acts via cholinesterase inhibition. It exerts both lousicidal & ovicidal actions in vitro.
    • Safety not established in children under 6 years old Lotion
    • Mannitol (Osmitrol, Resectisol):
    • Osmotic diuretic MOA: increases osmotic pressure of glomerular filtrate, which inhibits tubular reabsorption of water & electrolytes & increases urinary output
    • Mebendazole (Vermox):
    • Anthelmintic agent
    • MOA: selectively & irreversibly blocks glucose uptake & other nutrients in susceptible adult intestine-dwelling helminthes
    • Dosing:
    • Pinworms: 100 mg po ASD; may need to repeat after 2 weeks; treatment should include family members in close contact with patient
    • Whipworms, roundworms, hookworms: 1 tablet BID, morning & evening on 3 consecutive days; if patient is not cured within 3-4 weeks, a 2nd course of treatment may be administered Capillariasis: 200 mg BID for 20 days Strengths/dosage forms: Tablet, chewable: 100 mg
    • Methotrexate (Rheumatrex; Trexall):
    • MOA: inhibits dihydrofolate reductase causing interference with DNA synthesis, repair, & cellular replication
    • Juvenile RA: oral, IM: 10 mg/m2 once weekly
    • Does cause alopecia
    • Causes myelosuppression & thrombocytopenia NOT thrombocytosis (increased PLT)
    • BBW for hepatotoxicity Can cause megalobastic anemia
    • Misoprostol (Cytotec):
    • MOA: synthetic prostaglandin E1 analog that replaces the protective prostaglandins consumed with prostaglandin-inhibiting therapies (i.e. NSAIDs); has been shown to induce uterine contractions
    • Dosing:
    • Prevention of NSAID-induced ulcers: 200 mcg po QID with food (to decrease diarrhea)
    • Labor induction or cervical ripening: intravaginal- 25 mcg (1/4 of a 100 mcg tablet) Do not use in patients with previous cesarean delivery or prior major uterine surgery Fat absorption in CF (unlabeled use): 100 mcg QID (ages 8-16) Tablets only (no IV)
    • Nimodipine (Nimotop):
    • MOA: calcium channel blocker
    • Use: spasm following subarachnoid hemorrhage from ruptured intracranial aneurysms
    • Has a greater effect on cerebral arteries- may be due to the drug’s increased lipophilicity
    • Dosing: 60 mg po Q4h x 21 days; start 96 hours after subarachnoid hemorrhage If the capsules cannot be swallowed, the liquid may be removed by making a hole in each end of the capsule with an 18-guage needle & extracting the contents via syringe
    • Oxybutynin (Ditropan):
    • Urinary antispasmodic agent
    • MOA:Non-selective muscarinic receptor antagonist with a higher affinity for M1 & M3 receptors Increases bladder capacity, decreases uninhibited contractions, & delays desire to void Dosage forms available: syrup, tablet (IR, XR), patch (Oxytrol)
    • Palivilizumab (Synagis):
    • Use: monoclonal antibody used for prevention of serious lower respiratory tract disease caused by respiratory syncytial virus (RSV) in infants & children < 2 years MOA: exhibits neutralizing & fusion-inhibitory activity against RSV Ribavirin (Copegus, Rebetol, Ribasphere, Virazole) also used to treat RSV Available as: capsule; powder for aerosol; oral solution; tablet
    • Pancuronium:
    • Nondepolarizing neuromuscular blocking agent
    • MOA: blocks neural transmission at the myoneural junction by binding with cholinergic receptor sites
    • Onset: 2-4 minutes
    • Duration after single dose: 40-60 minutes
    • Use: adjunct to general anesthesia to facilitate endotracheal intubation & to relax skeletal muscles during surgery; does not relieve pain or produce sedation
    • DOC for neuromuscular blockade EXCEPT in patients with renal failure, hepatic failure, or cardiovascular instability AE: increased pulse rate, elevated BP & CO, edema, flushing, rash, bronchospasm, hypersensitivity rxn
    • Peginterferon Alfa-2a (Pegasys):
    • Use: hepatitis C Refrigerate; protect from light
    • Permethrin(Acticin, Elimite, Nix Creme Rinse, Pronto, Rid, A200 Lice Control) OTC available with same ingredient: Nix
    • PhosLo:
    • Calcium acetate
    • Use:
    • Oral: control of hyperphosphatemia in end-stage renal failure; does not promote aluminum absorption IV: calcium supplementation in parenteral nutrition therapy MOA: combines with dietary phosphate to form insoluble calcium phosphate which is excreted in the feces
    • Physostigmine (Antilirium):
    • Prednisone (Deltasone, Sterapred):
    • MOA: an adrenocortical steroid with salt-retaining properties; it is a synthetic glucocorticoid analog, which is mainly used for anti-inflammatory effects in different disorders of many organ systems; causes profound & varied metabolic effects, modifies the immune response of the body to diverse stimuli, & is also used as replacement therapy for adrenocortical deficient patients Cortiosteriods should be used with caution in patients with DM, HTN, osteoporosis, glaucoma, cataracts, TB, hepatic impairment, elderly
    • Propofol (Diprivan):
    • General anesthetic; no analgesic properties
    • Avoid abrupt discontinuation- titrate slowly
    • Propofol emulsion contains soybean oil, egg phosphatide & glycerol
    • “Propofol infusion syndrome”: symptoms include sever, sporadic metabolic acidosis &/or lactic acidosis which may be associated with tachycardia, myocardial dysfunction, &/or rhabdomyolysis
    • Short duration of action: 3-10 minutes
    • If on concurrent parenteral nutrition, may need to adjust the amount of lipid infused Provides 1.1 kCal/mL
    • Riopan:
    • Magaldrate (antacid) & simethicone (antiflatulent) combination Substitutes can be found in the Non-Prescription Handbook & Facts & Comparisons
    • Robitussin:
    • Robitussin: guaifenesin 100 mg/5 mL-OTC Alcohol free
    • Robitussin PE: guaifenesin 200 mg & pseudoephedrine 30 mg/5mL –OTC Alcohol free
    • Robitussin CF: guaifenesin 100 mg, pseudoephedrine 30 mg, & dextromethorphan 10 mg/5 mL -OTC Alcohol free Robitussin DM: guaifenesin 100 mg & dextromethorphan 10 mg/5 mL –OTC Alcohol free
    • Ursodiol (Actigall, Urso 250, Urso Forte):
    • Use: prevention of gallstones in obese patients experiencing rapid weight loss
    • AKA: ursodeoxycholic acid
    • MOA: decreases cholesterol content of bile & bile stones by reducing the secretion of cholesterol from the liver & the fractional reabsorption of cholesterol by the intestines
    • Dosing:
    • Gallstone dissolution: 8-10 mg/Kg/day in 2-3 divided doses Gallstone prevention: 300 mg BID Use beyond 24 months is not established
    • Vecuronium:
    • Nondepolarizing neuromuscular blocker agent
    • MOA: blocks acetylcholine from binding to receptors on motor endplate by inhibiting depolarization
    • Onset: 2-4 minutes
    • DOA: 30-45 minutes Use: adjunct to general anesthesia to facilitate endotracheal intubation & to relax skeletal muscles during surgery; does not relieve pain or produce sedation AE: bradycardia, edema, flushing, hypersensitivity rxn, hypotension, tachycardia, rash Miscellaneous Facts:
    • Danger of decreasing DKA too fast: cerebral edema
    • Genetic polymorphism exists as acetylation
    • Albumin is important for measuring calcium levels Corrected calcium = serum calcium + 0.8(4 – patient’s albumin)
    • Caffeine treats respiratory distress in neonates
    • Emergency bee sting kit:
    • Epinephrine & APAP EpiPen auto-Injector 0.3 mg SQ dose of 1:1000 epinephrine in a 2 mL disposable prefilled injector
    • Liposyn III (fat emulsion) is stored at room temperature
    • MedWatch: a list of reported side effect Completely voluntarily reported
    • Stain dermatologists use for fungus identification: KOH
    • Kayexlate + sorbitol use: to prevent constipation Store at room temperature
    • Hypercalcemia: almost always caused by increased entry of Ca into the extracellular fluid & decreased renal Ca clearance More that 90% of cases are due to primary hyperparathyroidism or malignancy
    • Hypocalcemia in renal impairment:
    • Phosphorus & calcium levels are altered due to:
    • Phosphorus retention, resulting in a rise in serum phosphorus levels & a reciprocal fall in calcium levels, with resultant stimulation of parathyroid hormone (PTH) secretion Decreased generation of 1,25-dihyroxyvitamin D3, further contributing to low serum calcium levels & decreasing suppression of PTH
    • Addition of a phosphate binder prevent GI phosphate absorption: Calcium carbonate 500-1000 mg po with meals Sevelamer (Renagel): lacks aluminum & calcium
    • Cheilitis: inflammation of the lips
    • Herpes simplex I (cold sore): avoid the sunlight
    • Goodpasture’s syndrome: glomerulonephritis associated with pulmonary hermorrhage & circulating antibodies against basement membrane antigens Autoimmune disease
    • Resorcinol/ASA/LCD needs to be packaged in what container LCD is coal tar- brown glass container
    • Medrol dose pack: decremental dosing
    • Polydipsia: excessive thirst Patients with phenylketonuria (PKU) must avoid aspartame Myasthenia Gravis:
    • An autoimmune disorder that involve antibody-mediated disruption of postsynaptic nicotinic acetylcholine receptors at the neuromuscular junction & is often associated with thymus tumors
    • Treatment:
    • Anticholinesterase drugs:
    • Pyridostigmine Neostigmine
    • Thymectomy
    • Immunosuppressive drugs
    • High-dose prednisone Azathioprine Cyclosporine Cyclophosphamide Orange Book:
    • AKA: Approved Drug Products with Therapeutic Equivalence Evaluations
    • Codes:
    • A: Drug products that FDA considers to be therapeutically equivalent to other pharmaceutically equivalent products, i.e., drug products for which: there are no known or suspected bioequivalence problems. These are designated AA, AN, AO, AP, or AT, depending on the dosage form; or actual or potential bioequivalence problems have been resolved with adequate in vivo and/or in vitro evidence supporting bioequivalence. These are designated AB AA Products in conventional dosage forms not presenting bioequivalence problems § AB, AB1, AB2, AB3... Products meeting necessary bioequivalence requirements
    • AN Solutions and powders for aerosolization
    • AO Injectable oil solutions
    • AP Injectable aqueous solutions &, in certain instances, intravenous non-aqueous solutions AT Topical products
    • B: Drug products that FDA at this time, considers NOT to be therapeutically equivalent to other pharmaceutically equivalent products, i.e.,
    • drug products for which actual or potential bioequivalence problems have not been resolved by adequate evidence of bioequivalence. Often the problem is with specific dosage forms rather than with the active ingredients. These are designated BC, BD, BE, BN, BP, BR, BS, BT, BX, or B*.
    • B* Drug products requiring further FDA investigation & review to determine therapeutic equivalence
    • BC Extended-release dosage forms (capsules, injectables & tablets)
    • BD Active ingredients & dosage forms with documented bioequivalence problems
    • BE Delayed-release oral dosage forms
    • BN Products in aerosol-nebulizer drug delivery systems
    • BP Active ingredients & dosage forms with potential bioequivalence problems
    • BR Suppositories or enemas that deliver drugs for systemic absorption
    • BS Products having drug standard deficiencies BT Topical products with bioequivalence issues BX Drug products for which the data are insufficient to determine therapeutic equivalence Osteopenia/Ostoporosis:
    • T scores are used for diagnosis:
    • Osteopenia: T score -1 to -2.5 SD below the young adult mean Osteoporosis: T score ≤ -2.5 SD below the young adult mean
    • Bisphosphonates:
    • Could worsen esophagitis
    • Take with a full glass of water fir thing in the AM & at least 30 minutes before the 1st food or beverage of the day
    • Maximize therapy by taking calcium + vitamin D
    • Alendronate (Fosmax):
    • Prevention dose: 5 mg QD or 35 mg Q week
    • Treatment dose: 10 mg QD or 70 mg Q week Dosage forms: solution & tablet
    • Ibandronate (Boniva):
    • Prevention dose: 2.5 mg QD; 150 mg Q month may be considered Treatment dose: 2.5 mg QD or 150 mg Q month
    • Risedronate (Actonel): Prevention dose: 5 mg QD or 35 mg Q week may be considered Treatment dose: 5 mg QD or 35 mg Q week
    • Selective Estrogen Receptor Modulator:
    • Raloxifene (Evista):
    • MOA: estrogen receptor agonist at the skeleton decreases resorption of bone & overall bone turnover 60 mg QD for treatment & prevention of osteoporosis SE: increased risk of thromboembolism, hot flashes, nausea, dyspepsia, weight gain
    • Teriparatide (Forteo):
    • Parathyroid hormone (PTH) analog for osteoporosis
    • MOA: stimulates osteoblast function, increases GI calcium absorption, increases renal tubular reabsorption of calcium Dosage: injection Storage: refrigerate; discard pen 28 days after 1st injection OTC:
    • Aluminum hydroxide (ALternaGel, Amphojel):
    • Use: for treatment of hyperacidity & hyperphosphatemia
    • MOA: neutralizes hydrochloride in stomach to form Al(Cl)3 salt + H2O
    • Dose:
    • Hyperphosphatemia: 300-600 mg TID with meals (within 20 minutes of meal) Hyperacidity: 600-1200 mg between meals & at bedtime
    • Aluminum may accumulate in renal impairment Dose should be followed with water
    • Antidiarrheal agents: Bismuth subsalicylate (Kaopectate) Has both antisecretory & antimicrobial actions while possibly providing anti-inflammatory action as well
    • Atopic dermatisis: Hydrocortisone
    • Capsacin (Zostrix, Capzasin):
    • MOA: induces the release of substance P, the principle chemomediator of pain impulses from the periphery to the CNS; after repeated application, the neuron is depleted of substance P
    • Apply to the affected area at least 3-4 times/day If applied less than this, decreased efficacy Strength: 0.025%, 0.075%
    • Delsyn
    • Dextromethorphan Contains 0.26% alcohol
    • Diaper rash:
    • Breast-fed infants have less diaper rash than do bottle-fed infants
    • Skin protectants to treat: Allantoin, calamine, cod liver oil (in combination), dimethicone, kaolin, lanolin (in combination), mineral oil, petrolatum, talc, topical cornstarch, white petrolatum, zinc oxide, zinc oxide ointment
    • Can use Mycolog cream (triamcinalone & nystatin) Candidiasis (?)
    • Fleet’s Phospho-Soda (Sodium Phosphate):
    • CI: CHF, ascites, patients on a Na restricted diet Saline laxative
    • Gaviscon:
    • Aluminum hydroxide & magnesium trisilicate
    • Use: temporary relief of hyperacidity
    • Dose: chew 2-4 tablets QID
    • Aluminum &/or magnesium may accumulate in renal impairment Do not swallow tablets whole
    • Loratidine (Claritin, Alavert):
    • Nonsedating antihistamine
    • Patients with liver or renal impairment should start with a lower dose (10 mg QOD)
    • Do not use in children <2
    • Dosing:
    • 2-5 years old: 5 mg QD >6: 10 mg QD
    • Take on an empty stomach Available as: syrup, tablet, rapidly disintegrating tablets
    • Magnesium citrate (Citro-Mag):
    • Saline laxative
    • Use: evacuation of bowel prior to surgery & diagnostic procedures or overdose situations CI: renal failure, DM, GI complications
    • Milk of magnesia:
    • Magnesium hydroxide Short-term treatment of occasional constipation
    • Nicotine Replacement therapy: Products: patch, gum, lozenge, inhaler (Nicotrol Inhaler- Rx only), nasal spray (Nicotrol NS- Rx only)
    • Ostomy care:
    • Three basic types of ostomies:
    • Ileostomy
    • Colostomy (most common) Urinary diversion
    • Effect of food on stoma output:
    • Foods that thicken: Applesauce, bananas, bread, buttermilk, cheese, pasta, potatoes, pretzels, rice yogurt
    • Foods that loosen: Alcohol, chocolate, beans, fried or greasy foods, spicy foods, leafy veg
    • Foods that cause stool odor: Asparagus, beans, cheese, eggs, fish, garlic
    • Foods that cause urine odor: Asparagus, seafood, spices Foods that combat urine odor: Buttermilk, cranberry juice, yogurt
    • Local complications:
    • Local irritation: can occur because the output from the intestines or kidneys can irritate the skin around the stoma Patient can use: karaya powder, pectin base powder, ostomy creams, or barriers to protect the skin
    • Alakaline dermatitis: occurs in patients with urinary diversions because of the alkaline nature of the output
    • Major cause of blood in the pouch because it renders the stoma extremely friable Treatment is acidification of the urine (cranberry juice 2-3 quarts daily)
    • Excoriation: caused by erosion of the epidermis by digestive enzymes
    • The eroded or denuded epidermis may bleed, & is painful when touched when applying the appliance Treatment: karaya or pectin-based powder may be applied to the peristomal skin prior to application of the pouch, more frequent changing of the pouch Infection: candida species 2% miconzaole powder or nystatin powder
    • Fitting an ostomy:
    • Pouch opening may be cut to fit or presized If they are cut to fit, the stoma pattern is traced onto the skin barrier-wafer surface of the pouch & then cut out before being applied
    • The diameter of the round stoma is measured at the base, where the mucosa meets the skin, which is considered the widest measurement
    • Oval stomas should be measured at both their widest & narrowest diameters
    • A stoma may swell if the appliance fits too tightly or slips, or if the patient falls or experiences a hard blow to the stoma
    • Other consideration include: body contour, stoma location, skin creases & scars, & type of ostomy
    • To prevent leakage, the pouch should be emptied when it is 1/3 – 1/2 full The flange & skin barrier may be left in place for 3-7 days, depending on the condition of the skin & skin barrier Water will not enter the stoma so it is not necessary to cover it while swimming, bathing, or showering
    • Oxymetazoline (Afrin):
    • Adrenergic agonist; vasoconstrictor
    • Rebound congestion may occur with extended use (>3 days)
    • Caution in the presence of HTN, DM, hyperthyroidism, CAD, asthma
    • Increased toxicity with MAOI
    • Do not use if it changes color or becomes cloudy
    • MOA: stimulates alpha-adrenergic receptors in the arterioles of the nasal mucosa to produce vasoconstriction Approved for >6 years old
    • Poison ivy:
    • Urushiol plant
    • Urushiol can spread quickly over body
    • Vesiclar fluid cannot further spread Or not spread from the exudates of the blisters
    • Topical anesthetics: benzocaine & pramoxine
    • Hydrocortisone
    • Astringents: Aluminum acetate (Burrow’s solution, Domeboro Powder), zince oxide, zinc acetate, sodium bicarbonate, calamine, witch hazel (hamamelis waters)
    • Colloidal oatmeal baths to help to provide skin hydration, to aide in cleansing or removing skin debris, & to allay the drying & tightening symptoms Antihistamines
    • Robitussin: Guaifenesin: an expectorant used to help loosen phlegm & thin bronchial secretions to make coughs more productive
    • Warts:
    • Plantar warts: Clear Away Wart Remover: Salicyclic acid 40% Wart off Dr. Scholls Clear Away Pain:
    • Pure Mu Agonists: strong opioids for severe pain
    • Fentyl:
    • Sublimaze: injection
    • Duragesic: transdermal patch (change Q 3 days) 5 patches per box Actiq: lozenge
    • Hydromorphone (Dilaudid):
    • Can cause seizures Dosage forms: tablet, liquid, suppository, injection (a slight yellowish discoloration has not been associated with loss of potency
    • Levoophanol (Levo-Dromoran) Dosage forms: tablet & injection
    • Meperidine (Demerol, Meperitab):
    • MOA: binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways, altering the perception of & response of pain
    • Dosed Q 3-4 hours
    • Hepatic metabolite, normeperidine, can buildup & cause seizures Do not use in patients with seizure disorders
    • Avoid use with MAOIs
    • Isocarboxazid (Marplan)
    • Selegiline (Eldepryl, Deprenyl)- Parkinson’s Phenelzine (Nardil) Tranylcypromine (Parnate)
    • Methadone (Dolophine, Methdose): Dosage forms: tablet, liquid, injection
    • Morphine (Astramorph/PF, Avinza (ER cap), DepoDur, Duramorph, Infumorph, Kadian (SR), MS Contin (ER or SR), MSIR (IR), Oramorph SR, RMS, Roxanol):
    • MOA: binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways, altering the perception of & response of pain
    • Can cause: hypotension, bradycardia, respiratory depression
    • Vasodilatory properties
    • Dosage forms:
    • Capsules (ER, SR)
    • Infusion
    • Injection (ER liposomal suspension for lumbar epidural injection)
    • Injection, solution
    • Solution Suppository Tablet (CR, ER, SR)
    • Oxycodone (OxyIR, Roxicodone, Percocet, OxyContin (CR)): Oxymorphone (Numorphan-suppository) Dosage forms: injection & suppository
    • Pure mu agonists: mild to moderate pain
    • Codeine (Tylenol #3)
    • Hydrocodone:
    • With APAP: Vicoden 5/500; Vicoden ES 7.5/750; Lorcet or Vicodin HP 10/650; Lortab 2.5/500, 5/500, 7.5/500, 10/500; Norco 5/325, 7.5/325, 10/325 With IBU: Vicoprofen 7.5/200
    • Propoxyphene: Propoxyphene/APAP: Darvocet-N-50 (50/325); Darvocet-N-100 (100/650) Darvon 32, 65 mg
    • Agonists-antagonists:
    • Buprenorphine (Buprenex)
    • Butorphanol (Stadol) Available as: injection & nasal spray
    • Dezocine (Dalgan)
    • Nalbuphine (Nubain) Injection only
    • Pentazocine:
    • 50 mg tablet: Talwin 50 mg/naloxone 0.5 mg tablet: Talwin NX 12.5/ASA 325 tablet: Talwin Compound
    • Miscellaneous:
    • Tramadol (Ultram) 400 mg max Ultracet (Tramadol/APAP 37.5/325)
    • NSAIDS:
    • Indomethacin (Indocin):
    • Dosage: Inflammatory/RA: 25-50 mg/day 2-3 times/day; max 200 mg/day Dosage forms: IR & SR capsule, injection & suspension
    • Ketorolac (Toradol):
    • Do NOT use for more than 5 days
    • NMT 40 mg/day po Acular: ophthalmic dosage form
    • Nabumetone (Relafen):
    • For Official Answer & RA
    • Dosing: 1000 mg/day; an additional 500-1000 mg may be needed in some patients; may be administered QD or BID; NMT 2000 mg/day Take with food or milk to decrease GI upset
    • Diclofenac (Voltaren)
    • Etodolac (Lodine)
    • Tolmetin (Tolectin)
    • Sulindac (Clinoril)
    • Fenoprofen (Nalfon)
    • Flurbiprofen (Ansaid)
    • Ibuprofen (Motrin)
    • Ketoprofen (Orudis, Oruvail-SR)
    • Naproxen (Naprosyn)
    • Oxaprozin (Daypro)
    • Meclofenamate (Meclomen)
    • Piroxicam (Feldene)
    • Celecoxib (Celebrex) Interferes with ACEIs, ARBs, & diuretics
    • Conversions: Usual ratio is Morphine 8 to dilaudid 1 Methadone 10 mg = hydromorphone 7.5 mg (po) & 1.5 mg (IM) Parkinson’s:
    • A chronic progressive neurologic disorder with symptoms that present as a variable combination of rigidity, tremor, bradykinesia, & changes in posture & ambulation
    • Primary Parkinson’s- no identified cause
    • Secondary Parkinson’s- may be the result of drug use (i.e. reserpine, metoclopramide, antipsychotics), infections, trauma, or toxins
    • Progressive degeneration of the substantia nigra in the brain with a decrease in dopaminergic cells
    • Drug therapy:
    • Want medications that will increase dopamine or dopamine activity by directly stimulating dopamine receptors or by blocking acetylcholine activity, which results in increased dopamine effects
    • Carbidopa-levodopa (Sinemet):
    • MOA; levodopa increases DA; carbidopa prevents metabolism of levodopa allowing more to enter the blood brain barrier Take on an empty stomach & eat shortly after to prevent N/V
    • Direct stimulation of DA receptors:
    • Bromocriptine (Parlodel)
    • Pergolide (Permax)
    • Pramipexole (Mirapex) Ropinirole (Requip)
    • Selegiline (Eldepryl, Carbex, Atapryl, Selpak): MOA: inhibits MAOB; increases DA & 5-HT
    • Inhibits COMT; increases DA:
    • Entacapone (Comtan) Tolcapone (Tasmar)
    • Amantadine (Symmetrel): MOA: may increase presynaptic release of DA, blocks reuptake
    • Blocks acetylcholine, may balance DA: Benztropine (Cogentin) Trihexyphenidyl (Artane) Vitamin E- antioxidant; mixed results Pediatrics:
    • EES ointment given in neonate to prevent gonorrhea infection in the eyes
    • Vitamin K is given to babies until they can produce their own
    • Beractant (Survanta):
    • Lung surfactant
    • Prevention & treatment of respiratory distress syndrome in premature infants
    • If <1250 g: at risk for developing or with evidence of surfactant deficiency Given within 15 minutes of birth
    • Colfosceril (Exosurf): respiratory surfactant
    • Administered intrathecheally
    • Respiratory distress syndrome in the newborn: 5 mL (67.5 mg) per kg birthweight INTRATRACHEALLY Q 12 hr for 3 doses MOA: colfosceril, cetyl alcohol, & tyloxapol combination, when used as a replacement for deficient endogenous lung surfactant, is effective in reducing the surface tension of pulmonary fluids, thereby increasing lung compliance properties in RDS to prevent alveolar collapse & decrease work in breathing The possibility exists that it may also improve ventilation/perfusion matching, independent of its direct effect on lung compliance
    • Neural tube defects are a result of a decrease in folic acid (while pregnant)
    • Acetaminophen: <12 years: 10-15 mg/Kg/dose Q 4-6 hours prn (NMT 5 doses: 2.6 g in 24 hours)
    • Ibuprofen:
    • 6 months – 12 years
    • Temperature <102.5°F: 5 mg/Kg/dose Temperature >102.5°F: 10 mg/Kg/dose Q 6-8 hours; max daily dose: 40 mg/Kg/day Theophylline can be used as a respiratory stimulant in babies Pharmaceutics:
    • Bioavailability: refers to the rate & extent of absorption
    • Absolute bioavailability: the fraction (or %) of a dose administered non-IV (or extravascularly) that is systemically available (compared to an IV dose) If given orally, absolute bioavailability (F) is: F = (DIV/DPO) X (AUCPO/AUCIV) Relative bioavailability: the fraction of a dose administered as a test formulation that is systemically available as compared to a reference formulation: F = (AUCtest formulation/AUCreference) X ( Dreference/Dtest formulation)
    • Compounding:
    • Glycerin, talc, starch, witch hazel = suspension
    • Talc is not soluble Starch is not very soluble
    • To make a oleaginuous base use: white petrolatum Trituration: the process of grinding a drug in a mortar to reduce its particle size
    • Drug color change due to: oxidation
    • Filters: 0.22 micron filter does NOT remove pyrogens
    • Methylcellulose: a suspending agent (semisynthetic hydrocolloids)
    • Selected dosage forms:
    • Butorphanol (Stadol) Injection, intranasal spray
    • Calcitonin (Miacaclin)
    • Injection, intranasal spray Stored in refrigerator
    • Desmopressin (DDAVP, Stimate) Injection, intranasal spray, tablets
    • All three above come in a nasal inhaler
    • Budesonide: Capsules (Entocort), nasal suspension, powder for oral inhalation, suspension for oral inhalation Fluticasone: Aerosol for oral inhalation, cream (Cutivate), ointment, powder for oral inhalation, suspension intranasal spray
    • Rizatriptan (Maxalt), loratadine (Claritin), ondansetron (Zofran) are all available as an orally disintegrating tablet (ODT)
    • Mg sterate: lubricant in tablet Excess will cause alteration in tablet dissolution due to decreased rate of tablet break down (would slow down)
    • Incompatibility: Pick pair of drugs with one acid & one base
    • Storage:
    • Liposyn-II
    • Fat emulsion
    • May be stored at room temperature
    • Do not store partly used bottle for later use Do not use if emulsion appears to be oiling out Room temperature antibiotic suspensions: Clarithromycin (Biaxin); sulfamethoxazole-trimethoprim (Bactrim); azithromycin (Zithromax); cefdinir (Omnicef)
    • Furosemide has a pka of 3.7 at physiologic pH will it be 25% ionized, 75% ionized, all ionized, all ionized or can’t determine?
    • Furosemide (one word generic name) is an acid; acids are all non-ionized at acidic pH but are ionized at basic pH; physiologic pH is 7.4 which is quite alkaline compared to 3.7; means furosemide ionized to non-ionized ratio would be > 1:1000, so totally ionized Naproxen pka = 4.2 what would happen at plasma pH? Same as above because naproxen is also an acid
    • Typical pharmaceutical ingredients:
    • Antifungal preservative: used in liquid & semisolid formulations to prevent growth of fungi Ex: benzoic acid, butylparaben, ethylparaben, sodium benzoate, sodium propionate
    • Antimicrobial preservative: used in liquid & semisold formulations to prevent growth of microorganisms Ex: benzalkonium chloride, benzyl alcohol, cetylpyridinium chloride, phenyl ethyl alcohol
    • Antioxidant: used to prevent oxidation Ex: ascorbic acid, ascorbyl palmitate, sodium ascorbate, sodium bisulfate, sodium metabisulfite
    • Emulsifying agent: used to promote & maintain dispersion of finely divided droplets of a liquid in a vehicle in which it is immiscible Ex: acacia, cetyl alcohol, glyceryl monostearate, sorbitan monostearate
    • Surfactant: used to reduce surface or interfacial tension Ex: polysorbate 80, sodium lauryl sulfate, sorbitan monopalmitate
    • Plasticizer: used to enhance coat spread over tablets, beads, & granules Ex: glycerin, diethyl palmitate
    • Suspending agent: used to reduce sedimentation rate of drug particles dispersed throughout a vehicle in which they are not soluble Ex: Carbopol, hydroxymethylcellulose, hydroxypropyl cellulose, methylcellulose, tragacanth
    • Binder: used to cause adhesion of powder particles in tablet granulations Ex: acacia, alginic acid, ethylcellulose, starch, povidone
    • Diluent: used as fillers to create desired bulk, flow properties, & compression characteristics in tablet & capsule preparations Ex: kaolin, lactose, mannitol, cellulose, sorbitol, starch
    • Disintegrant: used to promote disruption of solid mass into small particles Ex: microcrystalline cellulose, carboxymethylcellulose calcium, sodium alginate, sodium starch, glycolate, alginic acid
    • Glidant: used to improve flow properties of powder mixture Ex: colloidal silica, cornstarch, talc Lubricant: used to reduce friction during tablet compression & facilitate ejection of tablets from the die cavity Ex: calcium stearate, magnesium stearate, mineral oil, stearic acid, zinc stearate Humectant: used for prevention of dryness of ointment & creams Ex: glycerin, propylene glycol, sorbitol Pharmacokinetics:
    • Tests used to test for drug absorption in GI:
    • Dissolution
    • Disintegration: must occur before dissolution can occur Hardness: hardness of a tablet influences its ability to break apart in the stomach All can be tested in vitro Pregnancy:
    • Tocolytics (stops labor): Magnesium is a tocolytic
    • Labor inducers:
    • Prostaglandins and oxytocin both cause labor to start or proceed
    • Oxytocin (Pitocin) is parenteral only (usually IV) PGE-2 does come in a gel that is applied to ripen the cervix prior to induction of labor & in suppositories (still technically topical) to induce labor
    • Fetal alcohol syndrome: facial deformities (low nasal bridge, flat midface), postnatal growth retardation, or mental retardation
    • Treatment of patent ductus arteriosus:
    • *Indocin injection* IV indomethacin
    • Ibuprofen
    • Oxygen
    • Diuretics Purpose of the ductus arteriosus in utero: to shunt blood from the pulmonary artery to the aorta Hydroxyurea (Droxia, Hydrea): use to increase fetal hemoglobin in sickle cell patients Priaprism:
    • Causative agents: chlorpromazine, prazosin, trazodone, other phenothiazines, antihypertensives, anticoagulants, corticosteroids, & any drug used to produce an erection
    • PDE-5 inhibitors: Sildenafil (Viagra) Vardenafil (Levitra) Tadalafil (Cialis) Can last up to 36 hours Psoriasis:
    • Chronic, epidermal proliferative disease characterized by erythematous, dry scaling patches, recurring remissions & exacerbations
    • Treatment:
    • Mild to moderate disease:
    • Emollients BID: soft yellow paraffin or aqueous cream; petrolatum or Aquaphor cream (greasier & more effective)
    • Topical, low potency corticosteroids on delicate skin (face, genitals): alclometasone dipropionate, triamcinolone acetonide 0.025%, hydrocortisone 2.5%
    • Topical, medium potency cortisteroids: fluticasone propionate, triamcinolone acetonide 0.1%, hydrocortisone valerate, mometasone furoate
    • Topical, strong potency: betamethasone dipropionate, halcinonide, fluocinonide, desoximetasone
    • Topical, super potency: augmented betamethasone dipropionate, diflorasone diacetate, clobetasol propionate, halobetasol propionate
    • Limit use to 2 weeks Avoid occlusive dressings
    • Intralesional corticosteroid: 2-5 mg/mL triamcinolone acetonide
    • Coal tar (Estar, PsoriGel) as an alterative to topical steroids
    • Keratolytic agents to decrease scales: salicyclic acid 6% gel UV lamps & sunlight are effective- best option for pregnancy or young children Anthralin ointment 1% or higher prior to light
    • Severe disease:
    • Triamcinolone, intralesional mix
    • Vitamin D analogs (calcipotriene ointment 0.05%- not on face)
    • Acitretin (Soriatane) Tazarotene (Tazorac) Methotrexate, hydroxyurea, azathioprine, or cyclosporine Triamcinolone (Aristocort A; Aristocort Forte; Aristospan; Azmacort; Kenalog; Nasacort AQ; Nasacort HFA; Tri-Nasal; Triderm) Psychriatric Disorders:
    • ADHD:
    • Methylphenidate (Concerta, Methadate, Methylin, Ritalin)
    • MOA: reuptake blockade of catecholamine (NE & DA) in presynaptic nerve endings Dosage form of Concerta: 18, 27, 36, 54 mg ER tablets NOT SR
    • Atomoxetine (Strattera):
    • BBW for suicide ideation in children MOA: NE reuptake inhibitor Dosed once daily (advantage over Concerta)
    • Antidepressants:
    • SSRIs:
    • MOA: selectively inhibit the reuptake of 5-HT
    • Citalopram (Celexa)
    • Escitalopram (Lexapro)
    • Fluvoxamine (Luvox)
    • Sertraline (Zoloft)
    • Auxiliary labeling:
    • No etoh
    • May cause drowsiness or dizziness May cause sexual dysfunction Take in AM to prevent insomnia in PM
    • Fluoxetine (Prozac):
    • Does not require tapering because of its long half life Take in AM
    • Paroxetine (Paxil):
    • Take in AM to reduce chances of insomnia Paxil CR incorporates a degradable polymeric matrix (Geomatrix) to control dissolution rate over a period of 4-5 hours EC delays the start of drug release until tablets have left the stomach May take 4 weeks to see effects
    • Miscellaneous:
    • Bupropion (Wellbutrin, Zyban):
    • MOA: dopamine reuptake inhibitor CI with history of seizure disorder
    • Venlafaxine (Effexor):
    • MOA: inhibits the reuptake of 5-HT & NE (& DA at higher doses)
    • Referred to as a serotonin-norepinephrine reuptake inhibitor (SNRI)
    • XR formulation is available to decrease GI upset Not recommended in patients with uncontrolled HTN, recent MI, or CV disorders
    • Duloxetine (Cymbalta):
    • MOA: potent inhibitor of 5-HT & NE (no DA activity)
    • Indicated for both major depression & diabetic peripheral neuropathic pain CI: uncontrolled narrow-angle glaucoma
    • Trazodone (Desyrel): MOA: inhibits 5-HT reuptake & blocks 5-HT2A receptors
    • Nefazodone (Serzone): MOA: inhibits 5-HT & NE uptake & blocks 5-HT2A receptors Mirtazapine (Remeron): MOA: antagonizes presynaptic α-2 autoreceptors & heteroreceptors that prevent the release of 5-HT & NE (resulting in increased 5-HT & NE in the synapses); antagonizes 5-HT2A & 5-HT3 receptors, resulting in less GI upset & less anxiety
    • Combinations:
    • Olanzapine & fluoxetine (Symbax): Atypical antipsychotic agent/SSRI Use: treatment of depressive episodes associated with bipolar disorder
    • MAOIs:
    • MOA: increase the synaptic concentration of NE, 5-HT, & DA by inhibiting the breakdown enzyme, monoamine oxidase
    • Isocarboxazid (Marplan)
    • Phenelzine (Nardil)
    • Tranylcypromine (Parnate)
    • Medications to avoid on MAOIs:
    • Compazine
    • Phenylpropanolamine: tyramine-like reaction
    • Pseudoephedrine: tyramine-like reaction
    • Meperidine (Demerol): life-threatening serotonin syndrome-like reaction
    • Methyldopa (Aldomet): hypertensive crisis
    • Morphine (Roxanol, MS Contin): CNS depression Reserpine (Ser-Ap-Es): increased catecholamines Serotonergic agents (i.e. fluoxetine): serotonin syndrome
    • TCAs:
    • MOA: increase the synaptic concentration of 5-HT &/or NE in the CNS by inhibiting the presynaptic neuronal membrane’s reuptake of 5-HT or NE
    • Amitriptyline (Elavil) Off label use: neuropathic pain
    • Nortriptyline (Pamelor, Aventyl)
    • Imipramine (Tofranil)
    • Doxepin (Sinequan) Clomipramine (Anafranil) Desipramine (Norpramin)
    • Antipsychotics:
    • Atypical:
    • Arpiprazole (Abilify):
    • AE: insomnia, +/- weight gain
    • Once daily dosing benefit Partial dopamine agonist
    • Clozapine (Clozaril, FazaClo-ODT:
    • For refractory schizophrenia only
    • A Dibenzodiazepine
    • AE: sedation, weight gain, hypersalivation, seizure risk Weekly CBC with diff required WBC <3500 or ANC <1500 MUST discontinue
    • Olanzapine (Zyprexa, Zydis-ODT):
    • MOA: a thienobenzodiazepine antipsychotic that is believed to work by antagonizing dopamine & serotonin activities
    • It is a selective monoaminergic antagonist with high affinity binding to 5-HT2A & 5-HT2C, dopamine D1-4, muscarinic M1-5, histamine H1 & α-1 receptor sites Binds weakly to GABA-A, BZD, & beta-adrenergic receptors AE: sedation, orthostasis
    • Quetiapine (Seroquel):
    • A dibenzothiazepine Low EPS risk
    • Risperidone (Resperdal):
    • Benzisoxazole
    • Use: schizophrenia, bipolar Dosage forms: injection, solution, tablet, ODT
    • Ziprasidone (Geodon) Benzisothiazoyl AE: +/- sedation, +/- weight gain, QT prolongation
    • Typical:
    • Chlorpromazine (Thorazine)
    • Fluphenzaine (Prolixin)
    • Haloperidol (Haldol) SE: Hyper-, hypotension, tachycardia, arrhythmias, torsade de points, EPS, anxiety, alopecia, rash, gynecomastia, jaundice, blurred vision
    • Thioridazine (Mellaril) BBW: QT prolongation Thiothixene (Navane) a psychotropic agent derived from thioxanthene & clinically useful in the tx of schizophrenia Similarities in chemical & pharmacological properties exist between this agent & piperazine phenothiazines
    • Anxiolytic agents:
    • Benzodiazepines:
    • MOA: potentiate the actions of GABA by increasing the influx of Cl ions into neurons
    • Alprazolam (Xanax, Niravam-ODT)
    • Chlordiazepoxide (Librium)
    • Available as injection Prior to reconstitution, keep refrigerated & protected from light Should be used immediately following reconstitution
    • Clonazepam (Klonopin) Available as an orally disintegrating wafer
    • Clorazepate (Tranxene)
    • Diazepam (Valium) Available as injection Potency is retained for up to 3 months when kept at room temp
    • Estazolam (Prosam)
    • Flurazepam (Dalmane)
    • Halazepam (Paxipam)
    • Lorazepam (Ativan)
    • Available as an injection
    • Intact vials should be refrigerated & protected from light
    • Do not use if discolored
    • Injectable vials may be stored at room temperature for up to 60 days Parenteral admixture is stable at room temperature for 24 hours
    • Oxazepam (Serax)
    • Prazepam (Centrax)
    • Quazepam (Doral)
    • Temazepam (Restoril)
    • Trazolam (Halcion)
    • Lorazepam, oxazepam, & temazepam ( LOT ) are conjugated & preferred in patients with hepatic dysfunction & elderly patients
    • Chlordiazepoxide, diazepam, & lorazepam available for IV use
    • Never abruptly discontinue Avoid in pregnancy- cause cleft palate
    • Buspirone (BuSpar):
    • MOA: unknown. It exhibits high affinity for serotonin (5-HT1A) receptors, moderate affinity for brain D2-dopamine receptors & no significant affinity for benzodiazepine receptors. It has no effect on GABA binding.
    • Non-FDA labeled indication: depression
    • Non-sedating No grapefruit Take consistently either with or without food
    • EPS treatment:
    • Dystonia: state of abnormal tonicity, sometimes described simplistically as a severe “muscle spasm”
    • Benzotropine mesylate 2 mg
    • Diphenhydramine 50 mg IV or IM
    • Diazepam 5-10 mg by slow IV push Lorazepam 1-2 mg IM
    • Akathisia: inability to sit still & being functionally mortor restless
    • Diazepam 5 mg TID
    • Propanolol 10 mg QD Nadolol 80 mg QD Beta 2 selective are less effective
    • Pseudoparkinsonism: an AP-induced extrapyramidal side effect, resembles idiopathic Parkinson’s Disease
    • Patient may have slurred speech & a drooping face
    • Trihexyphenidyl 2-5 mg TID
    • Diphenhydramine 25-50 mg TID
    • Biperiden (Akineton) 2 mg TID Amantadine
    • Tardive dyskinesia: syndrome characterized by abnormal involuntary movements occurring late in onset in relation to initiation or AP therapy No FDA approved agents α-tocopherol (vitamin E) 1200-1600 IU has been tried
    • Mood stabilizers:
    • Bipolar
    • Lithium (Eskalith CR, Lithobid, Eskalith, Cibalith-S--syrup):
    • Use: bipolar disorder
    • CI: renal disease, severe CVD, pregnancy
    • SE: hyponatremia
    • Monitor thyroid function
    • “Lithium does everything that sodium will do”
    • Reaches steady state in 4-5 days
    • Obtain level 2-8 hours post-dose
    • Toxicity:
    • Mild (serum levels 1.5-2): GI upset (N/V/D), muscle weakness, fatigue, fine hand tremor, difficulty with concentration & memory Moderate (2-2.5): Ataxia, lethargy, nystagmus, worsening confusion, severe GI upset, coarse tremors, increased deep tendon reflexes Severe (>3): Severely impaired consciousness, coma, seizures, respiratory complications, death
    • Dosage forms: capsules, syrup, tablet (IR, CR, slow release)
    • DI:
    • Increase Li levels:
    • NSAIDS
    • ACEI
    • Fluoxetine
    • Metronidazole
    • Diuretics Sodium depletion: low sodium diet, excessive sweating, vomiting/diarrhea, salt deficiency
    • Decrease Li levels:
    • Theophylline
    • Caffeine Pregnancy Osmotic diuretics (mannitol, urea) Pregnancy category: D
    • Divalproex sodium (Depakote) Carbamazepine (Tegretol)
    • Tourette’s Syndrome:
    • Simple tics & 1st line of therapy is short acting benzodiazepines
    • Next is clonidine which does not cause tardive dyskinesia in these patients
    • Intermediate acting benzodiazepines (Ativan) are also useful For severe cases, the choice is an antipsychotic such as haloperidol (Haldol) or pimozide (Orap) but these can cause tardive dyskinesia, dysphoria, & pseudoparkinson’s
    • Anon-sedating anxiolytic for the elderly: buspirone (Buspar) Has a high affinity for 5-HT & dopamine receptors Does not affect benzodiazepine GABA receptors Questions:
    • Mother has gestational diabetes, what is likely to occur when the baby is born. Mother also has epilepsy & is taking tegretol.
    • I. high birth weight II. Baby may have congenital abnormalities III. Baby is likely to have diabetes
    • Answer: I & II Tegretol is a class D drug
    • What strength will Albuterol 0.5% end up based on an order to mix it with 2.5 mL normal saline? 0.083%
    • Isosorbide dinitrate is dosed BID, what regimen is best 7 am & 12 noon, 7 am & 7 pm, 9 am & 9 pm, 8 am & 5 pm? 8 am & 5 pm to allow nitrate free period (same as removing NTG patches at bedtime)
    • What substitute can you use for desitin ointment (Balmex, Boudreaux’s Butt Paste)? Zinc oxide
    • Precose counseling information:
    • I. Take 30 minutes before meal II. Causes gas III. Should not take if meal skipped Answer: II & III
    • What treatment would increase antibiotic compliance? Patient receiving zithromax 1 tsp QD x 5days
    • Augment, ceftriaxone, cefuroxime axetil, doxycycline Answer: the usual method to improve compliance for any type of drug is to reduce the number of doses that must be taken each day & to give a drug with the fewest uncomfortable or dangerous SE (I would chose ceftriaxone- IM single dose treatment)
    • Which of the following could you give a patient on NTG?
    • I. Cialis II. Muse (alprostadil) III. Caverject (alprostadil)
    • Answer: II & III- alprostadil is prostaglandin used for erectile dysfunction & patent ductus arteriosus Available as: intracavernosal Kit, intracavernosal powder for solution, intracavernosal solution, intraurethral Suppository, & intraurethral solution Alprostadil (Prostin VR)
    • Patient requesting antihistamine eye drop & having a dark spot in vision- refer to MD
    • Which of the following is available in a liquid formulation?
    • I. NTG II. Hydroxyzine III. Digoxin Answer: II & III
    • Which is the shortest acting insulin?
    • Humulin N, Humulin U, Humalog, or regular Answer: Humalog
    • Who should not get a flu shot? An infant in day care; 32 yo type II diabetic; 65 yo retired lady; 35 yo nurse working in hospital Answer: 32 yo type II diabetic
    • Which of the following cannot be self monitored?
    • Glucose level; K level; cholesterol levels; hormone used in pregnancy test Answer: K levels
    • Cytoxan is most similar to mechlorethamine, procarbazine, or 5-FU? Answer: mechlorethamine
    • A patient with Traveler’s diarrhea too PeptoBismol 4 tsp Q ½ hour. After 3 days he began experiencing ringing in the ears. What does he have? Bismuth toxicity or salicylate toxicity?
    • Answer: salicylate toxicity Bismuth toxicity would cause neurotoxicity
    • Which of the following are OTC hemorrhoid treatments:
    • I. TUCKs pads II. Nupercainal ointment III. Rowasa Answer: I & II
    • Which of the following is an ER Morphine?
    • A. MSIR B. MS Contin C. Diluadid D. Oxycontin Answer: B
    • Which of the following agents should be administered to a person exposed to Anthrax?
    • A. Flagyl B. Cipro C. Zovirax D. Valtrex Answer: B
    • Erythromycin exhibits its anti-infective properties by- blocking protein synthesis via binding & inhibition of the 50-S subunit of bacterial ribosomes
    • Patient has pseudomembranous colitis & allergy to metronidazole. Which of the patient’s medications could have caused the pseudomembrane colitis?
    • A. Ibuprofen B. Tylenol C. Flagyl D. Cleocin E. Zantac
    • Answer: D
    • This person could be treated with?
    • A. Flagyl B. Vancomycin C. Doxycycline D. Lincomycin E. Ampicillin Answer: B
    • The DOC for the treatment of pseudomembraneous colitis is: A. Metronidazole B. Erythromycin C. Clindamycin D. Ampicillin E. Lincomycin Answer: A
    • Which of the following NSAIDs has an ophthalmic preparation:
    • A. Ibuprofen B. Naproxen C. Diclofenac D. Ketoprofen Answer: C- Voltaren
    • Cedax acts by- inhibiting the use of pencillin binding proteins in bacterial cell wall synthesis
    • Acetylcysteine in the treatment of CF is best given:
    • A. IV B. By inhalation C. IM D. Orally Answer: B
    • A patient is given a rx for fentanyl 100 mcg/hr patch for 1 month. How many boxes should you dispense?
    • A. 1 B. 2 C. 3 D. 4 E. 5 Answer: 2; 1 patch= 3 days, so you need 10 patches; comes in boxes of 5 patches so you need 2
    • Which of the following is not an erythropoetin formulation?
    • A. Epogen B. Procrit C. Aranesp D. Neupogen Answer: Neupogen
    • Which of the following fluoroquinolones has an otic preparation?
    • Answer: ofloxacin (Floxin- also has an ophthalmic); Eye drops only: levofloxacin, gatifloxacin, moxifloxacin
    • The use of this agent is CI in children?
    • A. Erythromycin B. Bactrim C. Ciprofloxacin D. Cephalexin Answer: C
    • What is the recommended daily dosage of calcium for an adult?
    • A. 300-500 mg B. 600-800 mg C. 800-1000 mg D. 100-1500 mg Answer: D
    • Due to difficulty in coordinating their inhalations, older patients should use:
    • A. Nebulizer B. Peak flow meter C. Spacers D. Spirometer Answer: C Monit
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  3. #13
    Trying to make mom and pop proud
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    Side effect: hypersensitivity reaction that can be fatal with rechallenge
    Didanosine (Videx, Videx EC):
    ddI
    Take Ω hour before or 2 hours after meals (empty stomach) SE: pancreatitis, peripheral neuropathy

    Stavudine (Zerit):
    D4T SE: pancreatitis, peripheral neuropathy

    Zalcitabine (Hivid):
    ddC SE: pancreatitis, peripheral neuropathy

    Tenofovir (Viread):
    TDF SE: renal insufficiency, Fanconi syndrome

    Emtricitabine (Emtriva):
    FTC Minimal toxicity

    Combination products:
    Zidovudine 300 mg + lamivudine 150 mg (Combivir)

    Zidovudine 300 mg + lamivudine 150 mg + abacavir 300 mg (Trizivir) Tenofovir 300 mg + emtricitabine 200 mg (Truvada) Lamivudine 300 mg + abacavir 600 mg (Epzicom)

    NNRTIs:

    MOA: bind to reverse transcriptase at a different site than the NRTIs, resulting in inhibition of HIV replication

    Class toxicities: rash & hepatoxicity

    All should be dosed for hepatic impairment

    Most are affected by food (except efavirenz)

    Efavirenz is CI in pregnancy

    Efavirenz (Sustiva):

    EFV

    Take on an empty stomach SE: CNS side effect; false + cannabinoid test

    Nevirapine (Viramune):

    NVP

    Autoinducer SE: rash, symptomatic hepatitis, including fatal hepatic necrosis

    Delavirdine (Rescriptor): DLV SE: rash, increased LFTs

    PIs:

    MOA: inhibit protease, which then prevents the cleavage of HIV polyproteins & subsequently induces the formation of immature noninfectious viral particles

    All should be dosed for hepatic impairment

    Most should be taken with food (except amprenavir & indinavir)

    Amprenavir & fosamprenavir are chemically similar- avoid combination

    Atazanavir & indinavir require normal acid levels in stomach for absorption

    Ritonavir is the most potent

    Lopinavir/ritonavir, ritonavir, & saquinavir gel caps require refrigeration

    Class toxicities: lipodystrophy, hyperglycemia, hyperlipidemia, hypertriglyceridemia, bleeding in hemophiliace, osteonecrosis & avascular neocrosis of the hips, osteopenia & osteoporosis

    All are CYP3A4 inhibitors

    Lopinavir + ritonavir (Kaletra):

    SE: GI intolerance

    Refrigerate caps stable until date on label; stable for 2 months at room temperature Can cause hyperglycemia

    Atazanavir (Reyataz):

    ATV SE: increased indirect hyperbilirubinemia, prolonged Princeton Review interval

    Fosamprenavir (Lexiva):

    f-APV

    SE: rash

    Sulfonamide Oral solution contains propylene glycol

    Amprenavir (Agenerase):

    APV

    SE: rash

    Sulfonamide Avoid high fat meal

    Saquinavir:

    SQV-hard gel cap (HGC)- (Invirase):

    SE: GI intolerance Room temperature

    SQV- soft gel cap (SGC)- (Fortovase):

    SE: GI intolerance Refrigerated caps stable until date on label; stable for 3 months at room temperature HGC & SGC are not bioequivalent & should not be interchanged

    Nelfinavir (Viracept):

    NFV

    SE: diarrhea Needs 500 kCal of food for absorption; take after eating

    Ritonavir (Norvir)

    RTV

    SE: GI intolerance Refrigerated caps stable for 1 month at room temp

    Indinavir (Crixivan):

    IDV SE: nephrolithiases- drink at least 48 oz. daily to prevent Take on an empty stomach

    Fusion inhibitors:

    MOA: binds to gp41 on HIV surface, which inhibits HIV binding to CD4 cell

    Enfuvirtide (Fuzeon)

    T20 Salvage regimens Reconstituted form should be stored in the refrigerator- stable for 24 hours Viracept, Norvir

    Those available as suspensions: Nevirapine

    Those available as a syrup or oral solution: Epivir, Ziagen, Videx, Kaletra, Agenerase,

    Post-exposure Prophylaxis (PEP):

    Start therapy within 1-2 hours of exposure

    Length of therapy is 4 weeks

    Treatment options: AZT 200 mg po Q8h or 300 mg po Q12h AND 3TC(lamivudine) 150 mg po Q12h AZT 200 mg po Q8h or 300 mg po Q12 + 3TC 150 mg po Q12h + Indinavir 800 mg Q8h OR Nelfinvir 750 mg po Q8h or 1250 mg Q12h

    PCP treatment:

    A protozoan, but may be more closely related to fungi

    Treat when CD4+ cells fall below 200

    DOC: trimethoprim-sulfamethoxazole (Bactrim DS) DS po QD

    Alternatives:

    TMP + dapsone

    Atovaquone (Mepron)

    Pentamidine (NebuPent; Pentam-300) Comes as injection & powder for nebulization

    Clindamycin + primaquine Trimetrexate (NeuTrexin) + folinic acid Treatment for PCP also covers prophylaxis for: toxoplasmosis

    Macobacterium avium complex (MAC):

    Treat when CD4+ cells fall below 50/mm3 DOC is azithromycin 1200 mg po Q week

    CMV: Cytomegalovirus

    Ganciclovir (Cytovene, Vitrasert):

    Use: treatment of CMV retinitis in immunocompromised individuals, including patients with AIDS

    CI: ANC <500/mm3 or PLT <25,000/mm3

    Dosage forms: Capsule (Cytovene) Implant, intravitreal (Vitrasert)- 4.5 mg released gradually over 5-8 months Injection, powder for reconstitution Should be prepared in a vertical flow hood Reconstitute powder with sterile water NOT bacteriostatic water because parabens may cause precipitation Alzheimerís Disease:

    Donepezil (Aricept):

    Cholinesterase inhibitor

    MOA: reversibly & noncompetitively inhibits centrally active acetylcholinesterase, the enzyme responsible for hydrolysis of acetylcholine

    Available dosage forms: tablets, ODT Max dose: 10 mg QD

    Galantamine (Razadyne, Razadyne ER, Reminyl-old name):

    Acetylcholinesterase inhibitor

    Max dose: IR tablet or solution: 24 mg/day (in 2 divided doses) ER capsule: 24 mg/day

    Memantine (Namenda):

    Low affinity, non-competitive, voltage dependent NMDA receptor antagonist

    Neuroprotective

    Less cognitive decline & improves cognition in impaired patients

    After depolarization, Namenda leaves the site & allows sodium & calcium entry into the cell

    Behaves like magnesium Approved for moderate to severe Alzheimerís Disease

    Rivastigmine (Exelon):

    Acetylcholinesterase inhibitor (central)

    MOA: increases acetylcholine in the CNS through reversible inhibition of its hydrolysis by cholinesterase SE: GI upset (titrate slowly to avoid) Dosage forms: capsules & solution Anemia:

    Folic acid deficiency would also be called: macrocytic anemia, pernicious anemia

    Macrocytic (large cell):

    Megaloblastic:

    Vitamin B12 deficiency Lack of intrinsic factor results in pernicious anemia Folic acid deficiency ?Hct, Hgb, RBC, ? MCH

    Normochromic, normocytic:

    Aplastic anemia Anemia of chronic disease

    Hypochromic (low hemoglobin content), microcytic (small cell):

    Iron deficiency ? TIBC, ? MCV, MCH, MCHC, Hgb Genetic anomalies: Sickle cell anemia, thalassemia

    Treatment:

    Darbepoetin Alpha (Aranesp):

    Recombinant human erythropoietin

    Caution in patients with HTN or with a hx of seizures Can cause hypo- or hypertension Available as an injection

    Epoetin Alpha (Epogen):

    Colony stimulating factor

    Onset of action: several days Peak effect: 2-3 weeks SQ 1-3X per week SE: HTN Antidotes:

    Acetaminophen overdose:

    Antidote: Acetylcysteine (Mucomyst, Acetadote): MOA: thought to reverse APAP toxicity by providing substrate for conjugation with the toxic metabolites Dose: oral- 140 mg/Kg followed by 17 doses of 70 mg/Kg Q4h; repeat dose if emesis occurs within 1 hour of administration

    Albuterol overdose: Antidote: propranolol or beta blocker

    Anticholinergic overdose: Antidote: Physostigmine (Antilirium): Do not use if solution is cloudy or dark brown

    Arsenic overdose: Antidote: Succimer (Chemet) or dimercaprol (British anti-lewisite, BAL in oil)

    Benzodiazepine overdose: Antidote: flumazenil (Romazicon)

    fl-blocker overdose: Antidote: glucagon (GlucaGen)

    CCB overdose: Antidote: calcium chloride 10% or glucagon (GlucaGen)

    Carbamates overdose: Antidote: atropine

    Coumadin overdose:

    Antidote: Vitamin K1 or phytonadione (Mephyton, AquaMEPHYTON); fresh frozen plasma Dosage forms available for phytonadione: injection & tablet

    Digoxin overdose: Antidote: digoxin immune antibody fragment (Digibind, DigiFab)

    Ethylene glycol (Antifreeze) overdose: Antidote: ethyl alcohol; fomepizole (Antizol); pyridoxine (Aminoxin-OTC); sodium bicarbonate

    Heparin overdose: Antidote: protamine sulfate

    Iron overdose:

    Antidote: deferoxamine (Desferal)

    Antidote: Polyethylene glycol (high molecular weight) Lethal dose of iron is 180-300 mg/Kg Isoniazid overdose: Antidote: pyridoxine (Vitamin B6)

    Lead overdose:

    Antidotes:

    Succimer (Chemet) Dimercaprol; also called British anti-lewisite (only for lead encephalopathy) Calcium disodium EDTA (calcium disodium versenate)

    Leucovorin:

    Antidote for folic acid antagonists (methotrexate, trimethoprim, pyrimethamine) Water soluble vitamin

    Magnesium overdose:

    Death due to muscle relaxation (includes heart failure) Antidote: calcium

    Methanol or Ethylene glycol overdose:

    Antidote: Ethanol 10%

    Antidote: Fomepizole (Antizol)

    AKA: 4-methylpyrazole or 4-MP MOA: competitively inhibits alcohol dehydrogenase, an enzyme which catalyzes the metabolism of ethanol, ethylene glycol, & methanol to their toxic metabolites ?Decreases metabolism of methanol (prevents metabolism)

    Methemoglobinemia overdose: Antidote: methylene blue

    Opioid overdose:

    Antidote: Naloxone (Narcan) MOA: opioid antagonist that competes at all three CNS opioid receptors (mu, kappa, & delta) Antidote: Nalmefene (Revex)

    Organophosphates overdose: Antidote: atropine or pralidoxime (Protopam)

    Salicylate overdose: Antidote: sodium bicarbonate

    TCAs overdose: Antidote: sodium bicarbonate

    Type Ia antiarrhythmics overdose: Antidote: sodium bicarbonate Vecuronium overdose: & other nondepolarizing neuromuscular blockers Antidote: edrophonium (Enlon, Reversol) Asthma:

    Drugs available for nebulization:

    Budesonide 0.25 & 0.5 mg (Pulmicort RespulesÆ)

    Shake well before using

    Use with jet nebulizer connected to an air compressor

    Administer with a mouthpiece or facemask

    Do not use with an ultrasonic nebulizer

    Do not mix with other medications Rinse mouth after use

    Cromolyn (IntalÆ)

    Mast cell stabilizer Use: adjunct in the prophylaxis of allergic disorders, including asthma; prevention of exercise-induced bronchospasm Nasal: for prevention & treatment of seasonal & perennial allergic rhinitis

    Albuterol

    Ipratropium Ipratropium & Albuterol

    Drugs available as MDI:

    Beclomethasone HFA 40 mcg/puff & 80 mcg/puff (QVARÆ)

    Flunisolide 250 mcg/puff (AerobidÆ)

    Fluticasone 44, 110, 220 mcg/puff (FloventÆ)

    Cromolyn (IntalÆ)

    Nedocromil (TiladeÆ)

    Albuterol (ProventilÆ, VentolinÆ)

    Pirbuterol (Maxair AutohalerÆ)

    Ipratropium (AtroventÆ) Ipratropium & Albuterol (CombiventÆ)

    Drugs available as turbuhaler: Budesonide 200 mcg/inhalation (PulmicortÆ Respules) Inhaler should be shaken well immediately prior to use

    Drugs available for dry powder inhalation (DPI):

    Fluticasone (Flovent RotadiskÆ)

    Fluticasone-salmeterol (Advair DiskusÆ)

    Formoterol (Foradil AerolizerÆ)

    Salmeterol (Servent DiskusÆ) Stable for 6 weeks after removing foil 1 inhalation BID

    Drugs available as MDI/spacer: Triamcinolone 100 mcg/puff (AzmacortÆ)

    Class of drugs to use to prevent a child allergic to pollen from having an asthma attack- could use antihistamines, cromolyn or inhaled corticosteroids

    A patient would monitor their asthma from home with a peak flow meter which measures the FEV1

    Goal: 80% of personal best Green zone (80-100%), yellow zone (50-79%), & red zone (<50%)

    Montelukast (Singulair):

    MOA: selective leukotriene receptor antagonist that inhibits the cysteinyl leukotriene receptor

    Use: asthma & allergies NOT for COPD

    Dosing;

    6-23 months: 4 mg oral granules

    2-5 years: 4 mg chewable tablet or oral granules

    6-14 years: 5 mg chewable tablet

    >15 years: 10 mg tablet Take in evening Granules must be used within 15 minutes of opening

    Zafirlukast (Accolate):

    MOA: selectively & competitive leukotriene-receptor antagonist of leukotriene D4 & E4

    Use: prophylaxis & chronic treatment of asthma in adults & children >5 years old

    Dose: 20 mg BID

    Administer 1 hour before or 2 hours after meals

    Monitor: LFTs

    Extensively hepatically metabolized via CYP2C9 Tablets only

    Theophylline:

    0.80 AT = T

    SE:

    15-25 mcg/ML: GI upset, N/V/D, nervousness, headache, insomnia, agitation, dizziness, muscle cramp, tremor

    25-35 mcg/mL: tachycardia, occasional PVC > 35 mcg/mL: ventricular tachycardia, frequent PVC, seizure

    Theophylline + erythromycin‡ increased levels of theophylline DI with cimetidine A patient who has had too much albuterol could be given a cardioselective beta blocker Bioterrism:

    Ebola: virus; no cure Anthrax: bacteria (aerobic, gram + bacillus); ciprofloxacin or doxycycline for 60 days BPH:

    Tamulosin (Flomax) & Alfuzosin (Uroxatrac):

    Greater affinity to a-1 in prostate

    Less SE Work quickly for instant relief

    Finasteride (Proscar/Propecia) & Dutasteride (Avodart):

    Great for a large prostate

    Take longer to work Proscar MOA: a competitive inhibitor or both tissue & hepatic 5-alpha reductace; this results in the inhibition of the conversion of testosterone to dihydrotestosterone & markedly suppresses serum dihydrotestosterone levels

    Doxazosin (Cardura) & terazosin (Hytrin) also used for BPH Saw palmetto Cancer:

    Chemo drugs that should be refrigerated: cyclophosphamide (after reconstitution)

    Should be heated prior to

    Antimetabolites:

    Pyrimidine analogs: interfere with the synthesis of pyrimidine bases & thus DNA synthesis

    Can cause mucositis

    Capecitabine (Xeloda)

    Fluorouracil; 5-FU (Adrucil)

    Cytarabine (Cytosar)

    Gemcitabine (Gemzar) AE: mucositis

    Folic acid analog: interferes with synthesis of pyrimidine bases & thus DNA synthesis

    Methotrexate After reconstitution with preservative: may refrigerate AE: myleosuppression, N/V, mucositis

    Purine analogs: interfere with synthesis of purine bases & thus DNA synthesis

    Mercaptopurine (Purinethol) DI with allopurinol

    Thioguanine (Tabloid)

    Fludarabine (Fludara) Cladribine (Leustatin) Pentostatin (Nipent)

    Plant alkaloids:

    Vinca alkaloids: bind to tubulin to prevent formation of microtubules during mitosis

    Fatal if administered intrathecally

    Vincristine (Oncovin):

    Neurotoxic Can cause a decrease in sensation reflexes

    Vinblastine (Velban)

    Vinorelbine (Navelbine) AE: neuropathy

    Podophyllotoxins: bind to tubulin, inhibiting topoisomerase II to cause DNA strand breaks

    Etoposide; VP-16 (VePesid)

    Teniposide (Vumon) AE: myelosuppression, neuropathy

    Taxanes: bind to tubulin, promotes synthesis of nonfunctional microtubules

    Paclitaxel (Taxol) Use a in-line filter; non-PVC

    Docetaxel (Taxotere) AE: myelosuppression, alopecia

    Camptothecins: inhibits topoisomerase I, stabilizing single-strand breaks in DNA

    Irinotecan (Camptosar)- *Diarrhea* Topotecan (Hycamtin) AE: myelosuppression, alopecia

    Alkylating Agents: cross-link between DNA bases or between DNA strands to inhibit DNA replication

    Nitrogen Mustard Derivative:

    Mechlorethamine (Mustargen)

    Melphalan (Alkeran)

    Chlorambucil (Leukeran)

    Cyclophosphamide (Cytoxan)

    Ifosfamide (Ifex)

    AE: myelosuppression Mesna is given with cyclophosphamide & ifosfamide to prevent hemorrhagic cystitis

    Other:

    Carmustine (BiCNU)

    Lomustine (CeeNU)

    Stretozocin (Zanosar)

    Thiotepa (Thiopex) Busulfan (Myleran) Dacarbazine (DTIC)

    Antitumor antibiotics:

    Anthracycline:

    Cardiotoxic: 450-550 mg/m2 cumulative lifetime dose

    Doxorubicin (Adriamycin):

    MOA: appears to directly bind to DNA & inhibit DNA repair (via topoisomerase II inhibition) resulting in the blockade of DNA & RNA synthesis & fragmentation of DNA

    Turns urine & all other body fluids red

    SE: myelosupression, cardiotoxicity, extravasation Decrease dose in renal impairment

    Daunorubicin (Cerubidine)

    Idarubicin (Idamycin)

    Mitoxantrone (Novantrone) AE: myelosuppression

    Other: Mitomycin C (Mutamycin) Bleomycin (Blenoxane)

    Heavy Metals:

    Cisplatin (Platinol)

    Carboplatin (Paraplatin)

    Oxaliplatin (Eloxatin) AE: myelosuppression, neuropathy

    Antiandrogens: inhibit uptake & binding of testosterone & dihydrotestosterone in prostatic tissue

    Flutamide (Eulexin)

    Bicalutamide (Casodex)

    Nilutamide (Nilandron) AE: diarrhea

    Progestins: suppress release of LH & increase estrogen metabolism (decrease available estrogen for estrogen-dependent tumors)

    Megestrol (Megase): also used to stimulate appetite Medroxyprogesterone (Provera)

    Estrogens: estramustine is combination of estrogen plus nitrogen mustard; estrogen facilitates uptake, nitrogen mustard released to alkylate cancer cells Estramustine (Emcyt)

    Antiestrogens: bind to estrogen receptor in breast tissue, preventing binding by estrogen & thereby reducing estrogen-stimulated tumor growth

    Tamoxifen (Nolvadex) Toremifine (Fareston)

    Gonadotropin-releasing hormone analogs: turn off negative-feedback release of FSH & LH, reducing testosterone & estrogen production in testes & ovaries

    Leuprolide (Lupron (breast/prostate); Eligard (prostate); Viadur (prostate)) MOA: potent inhibitor of gonadotropin secretion; continuous daily administration results in suppression of ovarian & testicular steroidogenesis due to decreased levels of FSH & LH with subsequent decreases in testosterone & estrogen levels Goserelin (Zoladex)

    Aromatase inhibitors: blocks enzyme responsible for conversion of circulating androgens to estrogens

    Anastrazole (Arimidex):

    For breast cancer

    Can increase LDL

    Cannot use with Tamoxifen AE: vasodilation, headache, pain, depression, hot flashes, HTN, osteoporosis

    Letrozole (Femara) AE: diarrhea

    Other miscellaneous agents for cancer:

    Asparaginase (Elspar)

    Hydroxyurea (Hydrea)

    Tyrosine kinase inhibitors:

    Imatinib mesylate (Gleevec)

    Erlotinib (Tarceva) Gefitinib (Iressa)

    26S Proteasome inhibitor: Bortezomib (Velcade)

    Biological Response Modifiers

    Immune therapies:

    Aldesleukin (Proleukin) Interferon-alpha 2b (Intron A) Levamisole (Ergamisol)

    Monoclonal antibodies:

    Rituximab (Rituxan)

    Trastuzumab (Herceptin): works at HER-1 receptor

    Gemtuzumab (Mylotarg)

    Alemtuzumab (Campath)

    Bevacizumab (Avastin)

    Cetuximab (Erbitux)

    Denileukin diftitox (Ontak) Ibritumomab tiuxetan (Zevalin) Tositumomab (Bexxar)

    Colony Stimulating Factors:

    Filgastrim (Neupogen):

    MOA: granulocyte colony stimulating factor (G-CSF); stimulation of granulocyte production in patients with malignancies

    Increases production of neutrophils

    Does not cause agraulocytosisóused to treat it

    SE: bone pain

    Store in refrigerator Injection

    Pegfilgrastim (Neulasta):

    MOA: stimulates the production, maturation, & activation of neutrophils; activates neutrophils to increase both their migration & cytotoxicity

    Prolonged duration of effect relative to filgastrim & reduced renal clearance

    Store in refrigerator SE: bone pain Injection

    Octreotide (Sandostatin):

    Somatostatin analog

    Use: antidarrheal agent for diarrhea secondary to cancer

    MOA: mimics natural somatostatin by inhibiting serotonin release, & the secretion of gastrin, VIP, insulin, glucagons, secretin, motilin & pancreatic polypeptide Dosage forms available: injection only

    High emetic potential: Cisplatin, cyclophosphamide, cytarabine, dacarbazine, ifosfamide, melphalan, mitomycin, mechlorethamine

    Prevention of Acute Chemotherapy-Induced N/V:

    5-HT3 receptor antagonist:

    Dolasetron (Anzemet)

    Granisetron (Kytril)

    Ondansetron (Zofran) Palonosetron (Aloxi)

    Phenothiazines:

    Prochlorperazine (Compazine)

    Chlorpromazine (Thorazine) Promethazine (Phenergan)

    Butyrophenones:

    Droperidol (Inapsine) Haloperidol (Haldol)

    Corticosteroids: Dexamethasone (Decadron)

    Cannabinoids: Dronabinol (Marinol)

    Benzodiazepines: Lorazepam (Ativan)

    Benzamides: Metoclopramide (Reglan)

    Neurokinin-1 Antagonist:

    Aprepitant (Emend):

    Substance P/neurokinin 1 receptor antagonist Uses: prevention of acute & delayed N/V associated with highly-emetogenic chemotherapy in combination with a corticosteroid (i.e. dexamethasone) & 5-HT3 (ondansetron) receptor antagonist Avoid with grapefruit juice (CYP3A4) MOA: prevents acute & delayed vomiting by selectively inhibiting the substance P/neurokinin 1 (NK1) receptor Dose: oral: 125 mg on day 1, followed by 80 mg on days 2 & 3 1st dose should be given 1 hour prior to chemotherapy Cardiology:

    ACEI:

    Benazepril (Lotensin)

    Captopril (Capoten):

    Used to decrease the progression of CHF

    SE: rash, hyperkalemia, angioedema, cough

    Strengths: Tablets: 12.5, 25, 50, & 100 mg Dosed BID-TID

    Enalapril (Vasotec):

    Enalaprilat (Vasotec): only ACEI available as IV 1.25 mg/dose given over 5 minutes Q6 hours 40 mg/day max dose

    Fosinopril (Monopril)

    Lisinopril (Prinvil, Zestril)

    Moexipril (Univasc)

    Perindopril (Aceon)

    Quinapril (Accupril)

    Ramipril (Altace)

    Trandolapril (Mavik)

    Proven to decrease mortality in CHF

    Ineffective as monotherapy in African Americans

    MOA: inhibit the conversion of angiotensin I to angiotensin II (a potent vasoconstrictor)

    SE: increased SCr, cough, angioedema, sexual dysfunction, hyperkalemia, rash

    CI: bilateral renal artery stenosis; pregnancy DI: aspirin (high doses); rifampin; antacids (more likely with captopril- separate administration by 1-2 hours); NSAIDS; probenecid (captopril); lithium; allopurinol

    Alpha agonists:

    MOA: causes decreased sympathetic outflow to the cardiovascular system by agonistic activity on central a-2 receptors

    Clonidine (Catapres)

    More withdrawal Unlabeled use: heroin or nicotine withdrawal

    Guanabenz (Wytensin)

    Guanfacine (Tenex) Less withdrawal

    Methyldopa (Aldomet) SE: sedation, dry mouth, bradycardia, withdrawal HTN, orthostatic hypotension, depression, impotence, sleep disturbances

    Alpha blockers:

    MOA: blocks peripheral a-1 postsynaptic receptors, which causes vasodilation of both arteries & veins (indirect vasodilators)

    Causes less reflex tachycardia than direct vasodilators (hydralazine/minoxidil)

    Dosazosin (Cardura)

    Prazosin (Minipress)

    Terazosin (Hytrin)

    Counseling: take 1st dose at bedtime, may cause dizziness SE: weight gain, peripheral edema, dry mouth, urinary urgency, constipation, priapism, postural hypotension No effects on glucose or cholesterol

    Anti-arrhythmic Drugs:

    Arrhythmias:

    A. Fib or flutter: DOC- digitalis glycoside; alternative- verapamil or propranolol

    Supraventricular tachycardia: DOC- verapamil or adenosine; alternative- diltiazam or procainamide

    Ventricular premature complexes: DOC- beta blocker; alternative- beta blocker

    Ventricular tachycardia: DOC- beta blocker; alternative- amiodarone

    Ventricular fibrillation: DOC- amiodarone; alternative- beta blocker

    Digoxin-induced tachyarrhythmia: DOC- lidocaine; alternative- phenytoin

    Torsades de pointes: DOC- magnesium; alternative- beta blocker

    Class IA: inhibit fast Na channels

    Quinidine SE: Cinchonism

    Procainamide (Pronestyl) SE: lupus-like syndrome Disopyramide (Norpace)

    Class IB: inhibit fast Na channels

    Lidocaine (Xylocaine):

    Phenytoin (Dilantin) SE: nystagmus

    Tocainide (Tonocard) Mexiletine (Mexitil)

    Class IC: inhibit fast Na channels

    Moricizine (Ethmozine)

    Flecainide (Tambocor) Propafenone (Rhythmol)

    Class II: beta-adrenergic agents

    Propranolol (Inderal)

    Esmolol (Brevibloc) Acebutolol (Sectral)

    Class III: primarily block K channels

    Bretylium (Bretylol)

    Amiodarone (CordaroneÆ):

    SE:

    IV: phlebitis General: corneal microdeposits, photophobia, ?LFTs, photosensitivity, blue-gray skin discoloration, pulmonary fibrosis (reduced at low doses- 300 mg/d; increases as dose increases), hyper- or hypothyroidism, polyneuropathy

    Watch for iodine allergy

    Avoid grapefruit juice Prior to use: check thyroid levels, eye exam

    Ibutilide (Corvert) Sotalol (Betapace) Dofetilide (Tikosyn) SE: torsades de pointes Class IV: calcium channel antagonists Verapamil (Isoptin, Calan)

    Anticoagulation:

    Direct thrombin inhibitors:

    Argatroban:

    A synthetic molecule that reversibly binds to thrombin

    Eliminated by the liver Use if renal impairment

    Lepirudin (Refludan):

    Recombinant DNA-derived polypeptide nearly identical to hirudin

    Produces an anticoagulant effect by binding directly to thrombin & does not require AT to produce it effect

    Does not bind to other proteins as heparin does Eliminated by the kidneys Use if liver impairment

    Enoxaparin (Lovenox):

    Low molecular weight heparin

    MOA: inhibits factor Xa greater than IIa

    Dosing:

    DVT prophylaxis: 40 mg QD or 30 mg BID DVT treatment: 1 mg/Kg/dose Q12 hours or 1.5 mg/Kg/dose QD Monitor: anti-Xa, platelets

    Heparin:

    MOA: potentiates the action of antithrombin III & prevents the conversion of fibrinogen to fibrin

    Dosing:

    DVT prophylaxis: 5000 units SQ Q8-12 hours

    IV infusion: 10-30 units/Kg/hr Line flushing: 10 units/mL for infants (<10 Kg); 100 units/mL for older infants, children & adults Monitor: PTT (1.5-2X the upper limit of control; 50-70 sec), platelets

    Warfarin (Coumadin, Jantoven)

    MOA: inhibits reduction of vitamin K to its active form; leads to depletion of vitamin K-dependent clotting factors II, Vii, IX, X & protein C & S

    Requires 4-5 days before full anticoagulation effect is achieved

    Recommended starting dose: 5 mg po QD

    Strengths/Dosage forms:

    Injection: 5 mg Tablets: 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg

    Most indications want an INR in the 2.0-3.0 range Mechanical valves require a higher level of anticoagulation (INR 2.5-3.5)

    Minor bleeding or elevated INR: hold warfarin dose or decrease dose until INR returns to appropriate range Purple Toe Syndrome may occur due to cholesterol microembolization

    Acetaminophen is usually a good antipyretic & analgesic choice for patients taking oral anticoagulants Risk factors for DVTs: >40 years old; prolonged immobility; major surgery involving the abdomen, pelvis, & lower extremities; trauma, especially fractures of the hips, pelvis, & lower extremities; malignancy; pregnancy; previous venous thromboembolism; CHF or cardiomyopathy; stroke. Acute MI; indwelling central venous catheter; hypercoagulability; estrogen therapy; varicose veins; obesity; IBD; nephrotic syndrome; myeloproliferative disease; smoking

    Antiplatelet Drugs:

    Thienopyridines:

    MOA: block adenosine diphosphate (ADP)-mediated activation of platelets by selectively & irreversibly blocking ADP activation of the glycoprotein IIb/IIIa complex

    Clopidogrel (Plavix):

    Use: reduce atherosclerotic events (MI, stroke, vascular deaths)

    MOA: irreversibly blocks the ADP receptors, which prevents fibrinogen binding at that site & thereby reducing the possibility of platelet adhesion & aggregation AE: chest pain, headache, dizziness, abdominal pain, vomiting, diarrhea, arthralgia, back pain, upper respiratory infections

    Ticlopidine (Ticlid):

    Maintenance dose: 250 mg BID

    DC if the ANC drops to <1200 or platelet count drops to <80,000

    AE: rash, nausea, dyspepsia, diarrhea, neutropenia, thrombotic thrombocytopenic purpura Dosage form: 250 mg tablet CI: active bleed, severe liver disease, ticlopidine: neutropenia, thrombocytopenia

    Glycoprotein IIb/IIIa inhibitors:

    Abciximab (Reopro) No renal dosing adjustment required Eptifibatide (Integrillin) Tirofiban (Aggrastat) Storage: room temperature, protect from light

    ARBs:

    Candesartan (Atacand)

    Eprosartan (Tevetan)

    Irbesartan (Avapro)

    Losartan (Cozaar)

    Olmesartan (Benicar)

    Telmisartan (Micardis) Valsartan (Diovan)

    Beta Blockers:

    Nonselective:

    Nadolol (Corgard)

    Penbutolol (Levatol) Has ISA

    Pindolol (Visken) Has ISA

    Propranolol (Inderal):

    Nonselective beta blocker

    Can increase cholesterol

    Strengths available:

    ER capsule (InnoPran XL): 80, 120 mg

    SR capsule (Inderal LA): 60, 80, 120, 160 mg

    Injection (Inderal): 1 mg/mL Solution: 4 mg/mL; 8 mg/mL Tablet (Inderal): 10, 20, 40, 60, 80 mg Timolol (Blockadren)

    Cardioselective:

    Acebutolol (Sectral) Has intrinsic sympathomimetic activity (ISA)

    Betaxolol (Kerlone)

    Bisoprolol (Zebeta)

    Metoprolol (Lopressor, Toprol XL)

    Strength/dosage forms:

    Lopressor: Injection: 1 mg/mL Tablet: 25, 50, or 100 mg ER tablets: 50 & 100 mg Toprol XL: Tablets: 25, 50, 100, 200 mg

    Mixed:

    Labetalol (Trandate): Beta blocker (heart rate drop) with alpha-blocking (vasodilation & BP drop) activity

    Carvedilol (Coreg):

    MOA: blocks fl-1, fl-2, & a-1 receptors

    Has had proven effects on patient survival in large clinical trials for HF

    Take with food

    Antioxidant effects Preferred in HF patients who BP is poorly controlled due to its greater hypertensive effect Increases stroke volume

    MOA: competitively blocks response to beta-adrenergic stimulation: Blocked secretion of renin; decrease cardiac contractility, thereby decreasing CO; decreased central sympathetic output; decreased HR, thereby decreasing CO

    Mask signs of hypoglycemia Can increase lipids

    CCBs:

    MOA: inhibit the influx of Ca ions through slow channels in vascular smooth muscle & cause relaxation of both coronary & peripheral arteries SA & AV nodal depression & decrease in myocardial contractility (nondihydropyridines)

    Nondihydropyridines:

    SE: conduction defects, worsening of systolic dysfunction, gingival hyperplasia

    Diltiazem ( Cardizem , LA & CD, Dilacor XR, Tiaziac)

    SE: nausea, headache

    Cardizem: 30, 60, 90, 120 mg tablets

    Cardizem LA: 120, 180, 240, 300, 360, 420 mg Cardizem CD: 120, 180, 240, 300, 360 mg capsules

    Verapamil:

    IR: (Calan, Isoptin)

    LA: (Calan SR, Isoptin SR) Coer: (Covera HS, Verlan PM) SE: constipation

    Dihydropyridines:

    SE: edema of the ankle, flushing, headache, gingival hyperplasia

    Amlodipine (Norvasc)

    Felodipine (Plendil)

    Isradipine (DynaCirc & CR)

    Nicardipine (Cardene SR) Nifedipine (Procardia XL, Adalat CC) Nisoldipine (Sular)

    Combination products:

    Amlodipine & benazepril (Lotrel)

    Bisoprolol & HCTZ (Ziac) Losartan & HCTZ (Hyzaar)

    Direct vasodilators:

    SE: headaches, fluid retention, tachycardia, peripheral neuropathy, postural hypotension

    Hydralazine (Apresoline) Minoxidil (Loniten) Hirsutism

    Diuretics:

    Monitor: urine output, edema, weight

    Can increase lipids

    Loops:

    MOA: reduction of total fluid volume through the inhibition of Na & Cl reabsorption in the ascending loop of Henle, which causes increased excretion of water, Na, Cl, Mg, & Ca

    Are more effective that thiazides in patients with renal failure (SCr >2 mg/dL or GFR < 30 mL/min)

    AE: ototoxicity at high doses; photosensitity; may increase blood glucose in diabetics; orthostatic hypotension; hypokalemia; gout

    DI: aminoglycosides (increase risk of ototoxicity), NSAIDs (blunt diuretic response), Class Ia or III antiarrhythmics (may cause torsades de pointes with diuretic induced hypokalemic); probenecid (blocks loop effects by interfering with excretion into the urine)

    Bumetanide (Bumex)

    Furosemide (Lasix) Available dosage forms: injection, solution, tablet Torsemide (Demadex)

    Thiazides:

    MOA: direct arteriole dilation; reduction of total fluid volume through the inhibition of Na reabsorption in the distal tubules, which causes increased excretion of Na, water, K, & hydrogen; increase the effectiveness of other antihypertensive agents by preventing re-expansion of plasma volume

    Significant decrease in efficacy in renal failure (SCr > 2 mg/dL or GFR < 30 mL/min)

    DI: steroids (cause salt retention & antagonize thiazide action), NSAIDs (blunt thiazide response), Class Ia or III antiarrhythmics (may cause torsades de pointes with diuretic induced hypokalemic); probenecid & lithium(blocks thiazide effects by interfering with excretion into the urine), lithium (thiazides decrease lithium renal clearance & increase risk of lithium toxicity)

    AE: increased cholesterol & glucose (short term); decreased: K, Na, Mg; increased: uric acid & Ca; photosensitivity; pancreatitis; impotence; sulfonamide-type reactions

    Bendroflumethiazide (Naturetin)

    Benzthiazide (Aquatag, Exna)

    Chlorothiazide (Diuril)

    Chlorthalidone (Hygroton, Hylidone)

    Hydrochlorothiazide (HydroDIURIL, Microzide)

    Hydroglumethiazide (Saluron, Diucardin)

    Meethyclothiazide

    Polythiazide (Renese) Trichlormethiazide (Metahydrin, Naqua)

    Thiazide-like:

    Less or no hypercholesterolemia compared to other thiazides; decreased microalbuminuria in DM

    Metolazone (Mykrox, Zaroxolyn) Indapamide (Lozol)

    Potassium-sparing:

    MOA: interferes with K/Na exchange in the distal tubule; decreases Ca excretion, increases Mg loss

    AE: hyperkalemia

    Amiloride (Midamor) Triamterene (Dyrenium) Avoid with history of kidney stones or hepatic disease

    Aldosterone Blocker:

    Eplerenone (Inspra):

    Selective

    CI: DM type II; K > 5.5; ClCr < 30 mL/min PO- tablet 25 & 50 mg K sparing Spironolactone (Aldactone)

    Epinephrine (Adrenalin):

    MOA: stimulates a-, fl-1, & fl-2 adrenergic receptors resulting in relaxation of smooth muscle of the bronchial tree, cardiac stimulation, & dilation of skeletal muscle vasculature

    Sensitive to light & air- protection is recommended

    Oxidation turns drug pink, then a brown color Solutions should not be used if they are discolored or contain a precipitate Admixture is stable at room temperature for 24 hours

    Heart failure:

    Drugs that can worsen or precipitate:

    Antiarrhythmics: disopyramide, flecainide, propafenone

    Beta blockers

    CCB: verapamil & diltiazem

    Oral antifugals: itraconazole & terbinafine

    Cardiotoxic drugs: doxorubicin, daunorubicin, cyclophosphamide, alcohol Na & water retention: NSAIDs, glucocorticoids, rosiglitazone, pioglitazone

    Metoprolol, bisoprolol, & carvedilol (Starting dose: 3.125 mg BID for 2 weeks) have all shown to be effective in HF

    Digoxin (Lanoxin):

    Does not improve mortality, but does produce symptomatic benefits

    MOA: inhibits Na-K-ATPase pump, which results in an increase in intracellular Ca, which causes a + inotropic effect Reduces sympathetic outflow from the CNS

    AE: arrhythmias, bradycardia, heart block, anorexia, abdominal pain, N/V, visual disturbances, confusion, fatigue Toxicity is more commonly associated with serum concentrations > 2 ng/mL, but may occur at lower levels if patients have hypokalemia, hypomagnesemia, & in the elderly

    Serum levels: 0.5-1.0 ng/mL 60-80% is eliminated renally- dosage requirement for renal insufficiency

    ACEI & beta blockers improve mortality

    Aldosterone antagonist reduce the risk of death & hospitalization Diuretics- symptomatic relief

    Inotropes:

    Dobutamine (Dobutrex):

    MOA: stimulates fl-1 receptors causing increased contractility & heart rate, with little effect on fl-2 or alpha receptors

    fl-1 > fl-2 > a Increases CO & vasodilates

    Use: inotropic support for patients with shock & hypotension Dosage: start at 3 mcg/Kg/min & titrate to 20 mcg/Kg/min

    Dopamine (Intropin):

    MOA: depends on the given dose

    1-5 mcg/Kg/min: renal dose; increases urine output Stimulates dopamine receptors

    5-15 mcg/Kg/min: increases contractility, HR Stimulates fl-1 & fl-2 receptors >15 mcg/Kg/min: increases BP Stimulates a-1 receptors Extravasation: give phentolamine

    Milrinone (Primacor):

    MOA: inhibits phosphodiesterase III, increases cAMP, resulting in positive inotropic & vasodilating effects

    Use: short-term IV therapy of CHF; calcium antagonist intoxification Dosage: 50 mcg/kg LD over 10 min; followed by 0.375 mg/Kg/min Preferred over amrinone because of decreased risk of thrombocytopenia

    MONA-B for MI: Morphine, oxygen, NTG, Aspirin, beta blockers

    Norepinephrine (Levophed):

    MOA: stimulates fl-1 adrenergic receptors & a-adrenergic receptors causing increased contractility & HR as well as vasoconstriction thereby increasing systemic BP & coronary blood flow Alpha effects > beta effects

    Readily oxidized, protect from light

    Do not use if brown coloration Admixture stable at room temperature for 24 hours

    Postganglionic adrenergic neuron blockers:

    Guanadrel (Hylorel)

    Guanethidine (Ismelin) Reserpine (Serpasil) Can cause depression

    Torsades de pointes: Common drugs that can cause it: quinidine, dofetilide (Tikosyn), sotalol (Betapace), thioridazine, ziprasidone (Geodon)

    Thrombolytics:

    Use:

    ST-elevation > 1 mm in 2 or more contiguous leads or left bundle branch block

    Presentation within 12 hours or less of symptoms onset

    In patients >75 years old may be useful & appropriate

    Can be used in STEMI when time to therapy is 12-24 hours if chest pain is ongoing

    Should NOT be used if the time to therapy is >24 hours, & the pain is resolved CI in a patient with NSTEMI

    Drugs:

    Streptokinase (SK, Streptase)

    Tissue plasminogen activator (tPA, Alteplase)

    Tenecteplase (TNK, TNKase) AE: hemorrhage (cerebral)

    Vasodilators:

    Nitroprusside (Nitropress):

    Vasodilator

    Use: hypertensive crises; CHF

    Watch for cyanide toxicity (especially with hepatic dysfunction)

    Watch for thiocyanate toxicity (especially with renal dysfunction or prolonged infusions)

    Highly sensitive to light Normally a brownish color A blue color indicates almost complete degradation & breakdown to cyanide

    Nesirtide (Natrecor): B-type natriuretic peptide that increases diuresis & is an arterial & venous dilator

    Nitroglycerin (NitroBid, Nitrostat):

    Venous dilator but also an arterial dilator at higher doses

    MOA: Nitroglycerin, an organic nitrate, is a vasodilating agent that relieves tension on vascular smooth muscle & dilates peripheral veins & arteries

    It increases guanosine 3'5' monophosphate (cyclic GMP) in smooth muscle & other tissues by stimulating guanylate cyclase through formation of free radical nitric oxide This activity results in dephosphorylation of the light chain of myosin, which improves the contractile state in smooth muscle , and subsequent vasodilation

    Dosage forms available: Spray (do not inhale), ER cap, infusion, injection, ointment (Nitro-Bid), buccal tab (Nitrogard), SL tab (NitroQuick, Nitrostat, Nitro-tab), patch (Minitran, Nitrek, Nitro-Dur) Isosorbide mononitrate (Imdur (ER), Ismo, Monoket): Long acting metabolite of the vasodilator isosorbide dinitrate used for the prophylactic treatment of angina Should be given at 8 AM & 3 PM (any combination that doses them within 7-8 hours of each other to allow for the nitrate-free period in the PM) Isosorbide dinitrate (Dilatrate-SR, Isochron, Isordil) Compatibility: Drugs that must be mixed with sterile water: Amphotericin B: no electrolytes, mix in D5W, & reconstitute with sterile water Conversions:

    1 lb = 454 gm

    1 in = 2.54 cm

    1 grain = 64.8 mg

    1 avoirdupois pound = 454 gm

    1 fluid ounce = 29.57 mL

    1 gallon = 128 fluid ounces Also 3785 mL, 4 quarts, 8 pints 1 pint = 473 mL (round to 480 mL) COPD: 1st line therapy: beta-2 agonist or ipatropium Counseling Points:

    Calcitonin (Miacalcin):

    For injection:

    Keep vials in refrigerator

    Stable for 2 weeks at room temperature Give injection in upper arm, thigh or buttock

    Nasal spray:

    Store unopened bottle in refrigerator

    Once pump has been activated, store at room temperature Good for 30 days Must prime prior to first use or if it has been greater than 5 days

    Adequate vitamin D & calcium intake is essential for osteoporosis May cause increased warmth & flushing (should last only about 1 hour after administration) Take in evening to minimize discomfort

    Sulfa eye drops: burns Nicotine gum: chew until peppery taste appears, then park Cystic Fibrosis:

    Autosomal recessive disease of exocrine gland function resulting in abnormal mucus production

    Genetic mutation on the long arm of chromosome 7

    The protein encoded by this gene, the cystic fibrosis transmembrane regulator (CFTR), is a channel involved in the transport of water & electrolytes Most common genetic mutation involves a 3-base-pair deletion at position ?F508

    Antibiotics for Cystic Fibrosis:

    Cover for Staphylococcus aureus, H. flu, & pseudomonas

    Double coverage of antibiotics when pseudomonas (most common) is suspected

    Antipseudomonal PCN: piperacillin (Pipracil), mezlocillin (Mezlin), piperacillin-tazobactam (Zosyn), ticarcillin-clavulanate (Timentin), ticarcillin (Ticar), aztreonam (Azactam), meropenem (Merrem), or imipenem (Primaxin)

    Or a cephalosporin: ceftazidime (Fortaz, Tazidime, Tazicef) AND an aminoglycoside: tobramycin

    Vancomycin for MRSA Burkholderia & Stenotrophomonas species are commonly resistant Trimethoprim-sulfamethoxazole (Bactrim), chloramphenicol (Chloromycetin), ceftazidime, doxycycline, piperacillin Fluoroquinolones are the ONLY oral antibiotics with good coverage against pseudomonas

    Pulmozyme (dornase alfa):

    Recombinant human deoxyribonuclease

    Use: for management of CF patient to reduce the frequency of respiratory infections that require parenteral antibiotics, & to improve pulmonary function

    MOA: reduces mucous viscosity resulting in airflow improvement

    Used with a nebulizer (jet nebulizer) Must be stored in the refrigerator & should be protected from light Should not be exposed to room temp for a total of 24 hours Should not be mixed with or diluted with other drugs in the nebulizer Devices:

    Swan Ganz catheter:

    Inserted into right side of heart into the pulmonary circulation

    Measures pulmonary capillary wedge pressure Takes accurate measurement of BP

    You must measure the scrotum to fit a swimmerís athletic support

    Crutches: Armpits should be 2 inches away from crutches PICC line: Peripherally inserted central catheter Diabetes:

    Insulin:

    Rapid-acting:

    Lispro (Humalog)

    Aspart (NovoLog)

    Glulisine (Apidra)

    Onset: <15 min

    Peak: 30-90 min Duration: 3-5 hours

    Short-acting:

    Regular- human (Humulin R, Novolin, Velosulin BR)

    Regular- purified (Regular Ilentin II-pork)

    Onset: 30-60 min

    Peak: 2-3 hours Duration: 3-6 hours

    Intermediate-acting:

    NPH- isophane insulin suspension (NPH Iletin II- pork)

    Human (Humulin N, Novolin N)

    Lente- insulin zinc suspension (Lente Iletin II- pork)

    Human (Humulin L, Novolin L)

    Onset: 2-4 hours

    Peak: 6-12 hours Duration: 10-18 hours

    Long-acting:

    Ultralente- extended insulin zinc suspension; human (Humulin U, Ultralente)

    Onset: 6-10 hours

    Peak: 10-16 hours Duration: 18-20 hours

    Insulin glargine (Lantus)

    Onset: 5 hours

    Peak: none Duration; 20-24 hours Cannot mix with any other insulin

    Premixed products:

    50/50: 50% regular with 50% NPH Rapid acting for pre-meal & intermediate acting to control later hyperglycemia

    70/30: 30% regular with 70% NPH

    70/30 analogue: 30% aspart with 70% neutral protamine aspart insulin analogue 75/25: 25% lispro with 75% neutral protamine lispro insulin analogue

    MOA: decreases blood glucose & assists with glucose control by:

    Increasing glucose uptake & utilization by peripheral tissues (primarily in muscle)

    Increasing glycogenesis (glucose ‡ glycogen; primarily in liver)

    Decreasing glycogenolysis (glycogen ‡ glucose)

    Decreasing gluconeogenesis (amino acids ‡ glucose)

    Decreasing lipolysis & ketogenesis (fats ‡ ketone bodies)

    Converting amino acids to increase protein Converting triglycerides & fatty acids to increase adipose tissue

    Appearance:

    Clear (solution): aspart, lispro, glulisine, glargine, regular Cloudy (suspension): NPH, lente, ultralente, all premixed insulin products

    Sites of injection: abdomen > arm > hip > thigh > buttock In order of greater & more rapid absorption to lesser & slower absorption Thereís 1000 units in a 10 mL bottle

    Insulin secretagogues:

    MOA: stimulates pancreatic fl cells to secrete insulin

    1st generation sulfonylureas: can cause a disulfiram-like rxn

    Acetohexamide (Dymelor)

    Chlorpropamide (Diabinese)

    Tolazamide (Tolinase) Tolbutamide (Orinase)

    2nd generation sulfonylureas

    Glimepiride (Amaryl) Max dose: 8 mg/day

    Glipizide (Glucotrol, Glucotrol XL)- use in renal impairment

    Glyburide (Diabeta, Micronase)- safe in pregnancy Glyburide micronized (Glynase)

    Regular meal times are necessary- must not skip SE: hypoglycemia & weight gain

    Alpha-glucosidase Inhibitors:

    Acarbose (Precose)

    Miglitol (Glyset) Least likely to cause hypoglycemia even when fasting

    Should be taken with the first bite of a meal

    MOA: delays carbohydrate metabolism & absorption (due to competitive & reversible inhibition of intestinal alpha-glucoside hydrolase & pancreatic alpha-amylase)

    SE: GI intolerance To treat a hypoglycemic attack: treat with oral glucose Sucrose or fructose would not work

    Biguanide:

    Metformin (Glucophage, Fortamet, Riomet):

    MOA:? insulin resistance 1∞ in liver; 2∞ in periphery

    Dosage: start with 500 mg po BID or 875 mg po QD Max: ~2500 mg QD (850 mg TID) When to hold: in patients undergoing diagnostic radiology procedures that use an iodinated contrast media; hold for 48 hours after the radiology drug is administered i.e. angiogram SE: GI, megaloblastic anemia, & lactic acidosis (Scr men <1,5, women <1.4- donít use)

    Thiazoladinediones (glitazones or TZDs):

    Pioglitazone (Actos)

    Rosiglitazone (Avandia): need AST prior to starting Wait 3 months before deciding on therapeutic failure

    MOA: ? insulin resistance 1∞ in periphery; 2∞ in liver SE: edema, anemia, weight gain, exacerbation of CHF, URIs, resumption of ovulation

    Meglitinides (nonsulfonylurea secretagogues):

    Repaglinide (Prandin) Max daily dose: 16 mg/day

    Nateglinide (Starlix)

    MOA: stimulates pancreatic fl cells to secrete insulin SE: hypoglycemia, weight gain, GI

    Combination drugs:

    Glyburide + Metformin (Glucovance)

    Glipizide + Metformin (Metaglip) Rosiglitazone + Metformin (Avandamet)

    Example of question: Diabeta is most like Prandin

    Glyset will not cause hypoglycemia Only sulfonylureas & insulin will lower blood sugar in non-diabetics

    Glucagon (GlucaGen):

    Use: management of hypoglycemia Unlabeled use: beta blocker & CCB overdose

    MOA: stimulates adenylate cyclase to produce increased cAMP, which promotes hepatic glycogenolysis & gluconeogenesis, causing a rise in blood glucose levels 1 unit = 1 mg

    Diabetic nephropathy:

    Microalbuminuria (30-300 mg albumin/24 hours) used to diagnosis Annual screening for DM type II measures microalbumin-creatinine ratio (normal <30)

    Diabetic neuropathy:

    Treat with TCAís

    Neurontin, carbazepine ACEI treat the decreased renal function, NOT the neuropathy itself

    DKA:

    A potentially fatal complication that occurs in up to 5% of patients with Type I annually

    Seen less frequently in Type II

    Precipitating factors: interruption of insulin therapy, sepsis, trauma, MI, pregnancy

    Clinical features: N/V, vaguely localized abdominal pain; dehydration, respiratory distress, shock & coma can occur

    Lab evulation: anion gap metabolic acidosis & positive serum ketones; plasma glucose is usually elevated Hyponatremia, hyperkalemia, azotemia, & hyperosmolality

    Treatment:

    Supportive measures

    Fluids

    Insulin therapy

    Dextrose (5%)- once plasma glucose decreases to 250 mg/dL & the insulin infusion rate decreased to 0.05 U/Kg/hr Potassium Bicarbonate therapy Phosphate & magnesium Drug-Drug Interactions:

    Sertraline (Zoloft) & diltiazem (Cardizem; Cartia XT; Dilacor XR; Diltia XT; Taztia XT; Tiazac) Hydroxyzine pamoate (Vistaril) & meperidine (Demerol) Both are CNS depressants Epilepsy:

    Pharmacotherapy:

    Carbamazepine (Tegretol):

    Na channel blocker

    An autoinducer

    Tegretol XL: ghost tablets in stool

    SE: rash (rarely causing DC), folate deficiency, hepatotoxicity, aplastic anemia

    Teratogenic Cannot be given for status epilepticus

    Felbamate (Felbatol):

    Rarely used

    MOA: blocks glycine on N-Methyl-D-Aspartate receptor (NMDA)

    SE: hepatotoxicity, aplastic anemia 50% renal elimination

    Gabapentin (Neurontin):

    MOA: unknown; structurally related to GABA but does not interact with GABA receptors

    Also used for peripheral neuropathies

    100% renal elimination- no DI that effect drug metabolism Al or Mg containing antacids may decrease absorption

    Lamotrigine (Lamictal):

    MOA: decrease glutamate & aspartate release, delays repetitive firing of neurons, blocks Na channels SE: life-threatening skin rash Titrate slowly to avoid

    Levetiracetam (Keppra):

    MOA: may prevent hypersynchronization of epileptiform burst firing & propagation of seizure activity Adjust in renal dysfunction

    Oxycarbazepine (Trileptal):

    MOA: Na channel blocker

    PKS: active metabolite- 10-monohydroxycarbazepine (MHD) SE: hyponaturemia; blood dysrasias

    Phenobarbital (Barbital, Luminal, Solfoton):

    MOA: increases GABA-mediated Cl- influx

    SE: drowsiness, dizziness, hyperactivity, folate deficiency, hepatic failure, SJS

    Teratogenic Decreases effectiveness of BC pills

    Phenytoin (Dilantin):

    MOA: Na channel blocker

    Can only prepare in NS @ 50 mg/mL

    Highly protein bound

    SE: peripheral neuropathy, hydantoin faces, acne, hirsutism, gingival hyperplasia, osteomalacia, vitamin K- deficient hemorrhagic disease, folate deficiency (megaloblastic anemia), hepatic failure, SJS Dose-related SE: nystagmus, ataxia, drowsiness, cognitive impairment

    PKS: exhibits capacity-limited or saturable (Michaelis-Menton) PKS

    Teratogenic

    DC tube feedings 2 hours before & after a dose of phenytoin

    Available dosage forms: suspension, chewable tablet, prompt-release capsule, ER capsule, injection Need albumin level to calculate phenytoin level

    Primidone (Mysoline):

    MOA: increase GABA-mediated Cl- influx

    Metabolized to Phenobarbital & phenylethylmalonamide (PEMA) Primidone, Phenobarbital, & PEMA all have anti-epileptic activity

    Tiagabine (Gabitril): MOA: blocks GABA reuptake in presynaptic neuron

    Topiramate (Topamax):

    MOA: blocks Na channels, enhances GABA activity, antagonizes AMPA/kainite activity Also a weak carbonic anhydrase inhibitor

    Elimination: primarily renal

    SE: drowsiness, dizziness, kidney stones, oligohidrosis (may not sweat)

    Sprinkle capsules can be opened & sprinkled onto a small amount of cool, soft food (i.e. applesauce or yogurt)

    Drink plenty of fluids Dosage forms available: sprinkle capsules & tablets

    Valproic acid:

    MOA: blocks T-type Ca currents, blocks Na channels, increases GABA production

    SE: weight gain, alopecia, thrombocytopenia, increased LFTs, heptotoxicity (fatal), hemorrhagic pancreatitis (fatal), folic acid deficiency

    Available dosage forms:

    Sodium valproate (Depacon): injection

    Divalproex sodium:

    Depakene: syrup & gel capsule Depakote Sprinkles: capsules Depakote: delayed-release tablets Depakote ER: ER tablet

    Zonisamide (Zonegran):

    MOA: Na channel blocker, blocks T-type Ca channels (currents) Weak carbonic anhydrase inhibitor SE: kidney stones, weight loss, oligiohidrosis Sulfa drug

    Nonpharmacologic therapy:

    Ketogenic diet: devised in the 1920ís

    High in fat & low in carbohydrates & protein

    Leads to acidosis & ketosis

    Most calories are provided in the form of cream & butter No sugar allowed Fluids are also controlled

    Status epilepticus: seizure lasting longer than 5 minutes or =2 discrete seizures between which there is incomplete recovery of consciousness

    Treatment:

    ABCís: airway, breathing, circulation

    1st line: benzodiazepines

    Lorazepam (Ativan): rapid onset Diazepam (Valium)

    IV phenytoin (Dilantin)

    provided patient was not on phenytoin at home

    Can only mix with NS

    15-20 mg/Kg

    Contains propylene glycol- cardiotoxic therefore do not infuse faster than 50 mg/min

    Fosphenytoin (Cerebyx):

    Prodrug of phenytoin

    Improves water solubility of phenytoin Can be admixed with any IV solution Dosed in PE (phenytoin equivalents): 1 mg of phenytoin = 1.5 mg of fosphenytoin Can be give at a rate of 150 mg/min IV Phenobarbital (20 mg/Kg)or begin a continuous infusion of midazolam Begin a medically-induced coma Must be on a vent Equations:

    BMI: body mass index

    Men = 66 + (13.7 X W) + (5 X H) ñ (6.8 X A)

    Women = 665 + (9.6 X W) + (1.8 X H) ñ (4.7 X A)

    Where W= adjusted body weight in Kg; H= height in centimeters; A= age in years 1 in = 2.54 cm CrCl = (140- age) (IBW) X 0.85 (if woman) (72) (SCr)

    IBWman= 50 + 2.3 (inches over 5í)

    IBWwoman= 45.5 + 2.3 (inches over 5í)

    ABW = IBW + 0.4 (Actual ñ ideal)

    Henderson Hasselbach:

    pH= pka + log [base]/[acid]

    log values:

    log 100 = 2

    log 10 = 1

    log 1 = 0 log 0.1 = -1 log 0.001 = -2

    Loading dose (LD) = Css X VD

    Dose = Css X Cl or Css X VD X Cl T1/2 = 0.693 VD/Cl Fanconiís Syndrome:

    A congenital anemia due to low production of RBCís

    Can also be induced by anything that causes failure of the proximal renal tubules

    Patients develop polyuria (cannot concentrate the urine), osteomalacia, & reduced growth size

    At one time it was associated with the use of out-dated tetracycline but this is no longer a problem since the product has been reformulated The filler was the actual culprit Tenofovir (Viread) can cause this GERD:

    H2RA:

    Cimetidine (Tagamet)

    Famotidine (Pepcid)

    Nizatidine (Axid)

    Ranitidine (Zantac)

    Available dosage forms:

    150 & 300 mg capsules

    50 mg infusion for IV

    25 mg/mL injection 15 mg/mL syrup 75, 150, 300 mg tablet 75 mg effervescent tablet

    PPIs:

    MOA: suppresses gastric acid secretion by inhibiting the parietal cell H+/K+ ATP pump

    Rabeprazole (AcipHex): Strength/dosage form: delayed-release EC 20 mg tablet

    Esomeprazole (Nexium):

    Strength/dosage form: Capsule: delayed release 20 & 40 mg Injection, powder for reconstitution: 20 & 40 mg

    Lansoprazole (Prevacid):

    Strength/dosage form:

    Capsule: delayed release 15 & 30 mg

    Granules, for oral suspension: 15 & 30 mg/packet Injection, powder for reconstitution: 30 mg ODT: 15 & 30 mg

    Omeprazole (Prilosec):

    Do not put in OJ- not stable in an acidic environment

    Cannot sprinkle onto food

    Strength/dosage form:

    Capsule: delayed release 10 & 20 mg Oral suspension (Zegerid): 20 & 40 mg Tablet: delayed release 20 mg (OTC)

    Pantoprazole (Protonix):

    Strength/dosage form: Injection, powder for reconstitution: 40 mg Tablet: delayed release 20 & 40 mg Take 15-30 minutes before breakfast to maximize efficacy GERD can exacerbate asthma Glaucoma:

    Increased intraocular pressure, which causes pathologic changes in the optic nerve & typical visual field defects

    Open-angle glaucoma:

    Primary glaucoma

    The angle of the anterior chamber remains open in an eye, but filtration of aqueous humor is gradually diminished because of the tissues of the angle 80-90% of cases

    Angle-closure (narrow angle) glaucoma:

    Primary glaucoma Shallow anterior chamber & narrow angle; filtration of aqueous humor is compromised as a result of the iris blocking the angle

    Therapy:

    fl-adrenergic antagonists:

    MOA: decrease in aqueous humor formation with slight increase in outflow (beta selective)

    Often DOC for open-angle glaucoma

    AE: cardiac effects, worsening pulmonary effects, depression, dizziness

    Nonselective:

    Timolol (Timoptic)

    Carteolol (Ocupress)

    Levobunolol (Betagen) Metipranolol (OptiPranolol)

    Selective: Betaxolol (Betoptic) Levobexaxolol (Betaxon)

    Carbonic anhydrase inhibitors:

    MOA: decrease in aqueous humor formation

    AE: lethargy, decreased appetite, GI upset, urinary frequency

    Do not use with sulfa allergy

    Acetazolamide (Diamox) Tablets, capsules

    Dorzolamide (Trusopt)

    Brinzolamide (Azopt) Methazolamide (Neptazane) Tablets

    Prostaglandin analogs:

    MOA: increased uveoscleral outflow without effect on aqueous humor formation

    Also used as 1st line agents or in combination with beta blockers

    AE: iris pigmentation, eyelid darkening, macular edema

    Latanoprost (Xalatan)

    Administer 1 drop at bedtime

    Refrigerate Can change blue eyes to brown

    Bimatoprost (Lumigan) Can cause darkening of eyelids & eye lashes

    Travoprost (Travatan) Frequent ocular hyperemia Unoprostone (Rescula)

    a-2 adrenergic agonists:

    MOA: decrease in aqueous humor formation

    AE: tachycardia, dry mouth, eyelid elevation, CNS effects in the old & young Brimonidine (Alphagan) Wait at least 15 minutes after using before placing soft contacts

    Other a-adrenergic agonists:

    MOA: increase in aqueous humor outflow

    AE: tachycardia, increased BP, allergic responses

    Dipivefrin (Propine) Prodrug of epinephrine

    Pilocarpine (Pilocar) Once weekly dose form called Ocuserts Miotic agent Combination: Timolol & dorzolamide (Cosopt) Hydroxypropyl methylcellulose added to decrease burning Gout:

    Treatment of acute attack:

    Colchicine:

    MOA: inhibits phagocytosis of urate crystals by leukocytes; anti-inflammatory agent without analgesic activity Decrease leukocyte mobility thereby decreasing inflammation

    Dosed until resolution of symptoms, severe GI symptoms occur, or max of 8 mg Available PO (0.6 mg) & IV (0.5 mg/mL)

    Indomethacin

    Corticosteroids Effective when given intra-articularly, IV, or PO Used when there is failure to colchine and NSAIDS

    Prophylaxis:

    Colchicine (low dose: 0.6-1.2 mg/d)

    Colchicine + probenecid (ColBenemid)

    Probenecid (Benemid):

    MOA: uricosuric agent that promotes the excretion of UA by blocking its reuptake at the proximal convoluted tubule Inhibits renal absorption of UA from the urine into the blood

    Should drink at least 2 L of water/day to decrease the risk of UA stone formation

    Available as a 500 mg tablet Avoid use with aspirin

    Sulfinpyrazone (Anturane):

    MOA: uricosuric agent that promotes the excretion of UA by blocking its reuptake at the proximal convoluted tubule

    Drink at least 2 L of water/day Do not use with CrCl < 50 mL/min

    Allopurinol (Zyloprim):

    MOA: allopurinol & its metabolite oxypurinol, inhibit xanthine oxides formation, which is the rate-limiting step in UA synthesis; this facilitates the clearance of the more water soluble precursors of UA, oxypurines Inhibits xanthine oxides which reduces UA formation from the metabolism of purine bases of DNA & RNA Take with food Watch for rash- SJS can occur DI: azathioprine, 6-mercaptopurine, ACEI Hemorrhoids:

    Therapy:

    Soap suds enema QD

    Sitz bath QD

    Fiber therapy

    Sitting on a doughnut

    Cleaning anal area with soap & water after each defecation Dibucaine (Nupercainal): OTC local anesthetic for fast temporary relief of pain & itching due to hemorrhoids Pramoxine (Anusol ointment, ProctoFoam NS , Tucks): OTC local anesthetic for fast temporary relief of pain & itching due to hemorrhoids Hepatic Encephalopathy:

    Syndrome of disordered consciousness & altered neuromuscular activity seen in patients with acute or chronic hepatocellular failure or portosystemic shunting

    Precipitating factors: azotemia; use of tranquilizer, opioid, or sedative-hypnotic medication; GI hemorrhage; hypokalemia & alkalosis; constipation; infection; high-protein diet

    Monitor: ammonia levels

    Treatment:

    Fleetís enema

    Protein restriction; special diet (vegetable protein or branched-chain amino acid enriched)

    Nonabsorbable disaccharides: lactulose (Cephulac, Constulose, Enulose, Generlac, Kristalose), lactitol, & lactose

    Lactulose syrup 30 mL of 50% solution QID; diminish to BID when 3 or more bowel movements a day occur daily Lactulose dosage forms: powder for oral suspension, oral solution, oral syrup Neomycin Metronidazole Herbs:

    Herbals that interfere with anticoagulation:

    Ginkgo, Ginseng, Fish Oil, Garlic, Feverfew, & Ginger ìAll begin with F or Gî

    Chamomile:

    Uses: dyspepsia, oral mucositis, dermatitis, ADHD

    Might have anti-inflammatory effects; might bind to GABA receptors

    DI: benzodiazepines, tamoxifen, CNS depressants, warfarin, estrogens, CYP1A2 & CYP3A4 substrates CROSS-ALLERGENICITY: German chamomile may cause an allergic reaction in individuals sensitive to the Asteraceae/Compositae family; members of this family include ragweed, chrysanthemums, marigolds, daisies, and many other herbs

    Chasteberry:

    Uses: PMS, BPH, menstrual irregularities, female infertility, insect repellant DI: antipsychotics, contraceptives, dopamine agonists, estrogens, metoclopramide

    Cholesterol: garlic

    Depression: St. Johnís Wort, SAM-e (& Official Answer), DHEA, Kava-kava (anxiety, stress)

    Dong quai:

    Used for PMS & menopausal symptoms Interaction with warfarin- made up of several coumarin constitutes Increase INR

    Feverfew:

    Use: migraines, arthritis, allergies DI: anticoagulants, antiplatelets, CYP (1A2, 2C9, 2C19, 3A4)

    Garlic:

    Active compounds: alliin, allicin

    Uses: hyperlipidemia, HTN, prevention of atherosclerosis

    MOA: May act as an HMG-CoA reductase inhibitor; may vasodilate & relax smooth muscle, release NO; may also reduce oxidation of LDL & inhibit platelet formation

    Generally safe with the exception of heartburn, N/V, body ordor, bad breath DI: CYP3A4, cyclosporine, saquinavir, OCs, anticoagulants

    Ginkgo:

    Uses: memory, Raynaudís, glaucoma, diabetic retinopathy, intermittent claudication, PMS, vertigo

    Can cause seizures at high doses DI: anticoagulants (warfarin), anticonvulsants, Buspar, CYP (1A2, 2C19, 2C9, 2D6, 3A4), ibuprofen, insulin, drugs that lower the seizure threshold (i.e. anesthetics (propofol, others), antiarrhythmics (mexiletine), antibiotics (amphotericin, penicillin, cephalosporins, imipenem), antidepressants (bupropion, others), antihistamines (cyproheptadine, others), immunosuppressants (cyclosporine), narcotics (fentanyl, others), stimulants (methylphenidate), theophylline)

    Glucosamine:

    Use: Official Answer, TMJ, glaucoma

    Glucosamine is an amino sugar, which is a constituent of cartilage proteoglycans. It is derived from marine exoskeletons or produced synthetically DI: APAP, antidiabetic agents, warfarin

    Hyperglycemia may be caused by: Black tea, coffee, cola nut, green tea, guarana, mate, N-acetyl glucosamine, niacin, oolong tea, shark cartilage

    Kava Kava:

    Uses: insomnia, anxiety, stress, benzodiazepine withdrawal

    May adversely affect the liver- increase LFTs DI: xanax, CNS depressants CYP (1A2, 2C19, 2C9, 2D6, 2E1, 3A4), hepatotoxic drugs, levodopa

    Licorice:

    Uses: dyspepsia

    has antispasmodic, anti-inflammatory, laxative, & soothing properties

    The constituents glycyrrhizin & glycyrrhetinic acid inhibit 11-beta-hydroxysteroid dehydrogenase, an enzyme located in the aldosterone receptor cells of the cortical collecting duct

    Glycyrrhizin may contribute to licorice-associated mineralocorticoid SE, including HTN & hypokalemia, by both binding directly to mineralocorticoid receptors & by decreasing the conversion of active cortisol to inactive cortisone DI: antihypertensives, corticosteroids, CYP3A4, digoxin

    Milk thistle:

    Used for liver disorders; dyspepsia

    Interactions with CYP2C9 (warfarin, elavil, diazepam), CYP3A4 substrates, estrogens Avoid with hormone sensitive cancers

    Hot flashes & menopausal symptoms: black cohosh

    Passion Flower:

    Used for anxiety, GAD, opioid withdrawal Interactions with CNS depressants

    Podophyllin:

    Uses: applied locally for wart removal; Can increase LFTs

    SAM-e:

    Uses: depression & Official Answer

    S-adenosylmethionine (SAMe) is a naturally occurring molecule that is distributed throughout virtually all body tissues and fluids; concentrations are highest in childhood & decrease with age

    Plays an essential role in >100 biochemical rxn involving enzymatic transmethylation

    It contributes to the synthesis, activation &/or metabolism of hormones, neurotransmitters, nucleic acids, proteins, phospholipids, & some drugs DI: antidepressants, dextromethorphan, levodopa, meperidine

    St. Johnís Wort:

    Uses: depression, anxiety

    Two constituents that play a significant role are hypericin & hyperforin

    MOA: believed to act as a serotonergic 5-HT3 and 5-HT4 receptor antagonist, & down-regulate beta-adrenergic, & serotonergic 5-HT1 & 5-HT2 receptors when used chronically in animals DI: triptans, xanax, elavil, antidepressants, barbiturates, plavix, OCs, cyclosporine, dextromethorphan, CYP (1A2, 2C9, 3A4), warfarin

    Valerian:

    Used for anxiety, stress, insomnia

    A sedative; similar effects to Ambien Avoid with: etoh, benzadiazepines, CNS depressants, CYP3A4 substrates Some herbs that affect platelet aggregation: angelica, clove, danshen, dong quai, garlic, ginger, ginkgo, feverfew, Panax ginseng, horse chestnut, red clover, turmeric Hyperkalemia:

    Sodium polystyrene disulfonate (Kayexalate): cation exchange resin- promotes the exchange of Na for K in GIT Can be administered as a retention enema or orally

    IV insulin Causes K to shift into the cells & temporarily lowers the plasma K

    Calcium gluconate

    Decreases membrane excitability Administer 1st with hyperkalemia & EKG changes

    Other: IV NaHCO3 (shifts K into cells); fl-2 adrenergic agonists (promote the cellular uptake of K); Loop & thiazide diuretics (enhance K excretion if renal function is adequate); dialysis

    If the patient also has EKG changes the usual treatment (in order) is:

    IV calcium first

    Then IV bolus of 10-20 units of regular insulin with 25 gm of glucose (prevents hypoglycemia)

    150 mEq of sodium bicarbonate is one liter of D5W forces K into cells

    Beta-2 agonists (i.e. Albuterol) nebulized or SQ

    Combination of loop & thiazide (i.e. Lasix + Diuril) if the renal function is adequate

    Kayexalate (slow to work) Hemodialysis is best overall, if the time is available & K is severe Peritoneal dialysis is less effective Hyperlipidemia:

    Bile Acid Sequestrants:

    Effects on cholesterol:

    TC: ?

    TG: ? or <-->

    LDL: ? HDL: ?

    Cholestyramine Resin (Questran, Prevalite): MOA: forms a nonabsorable complex with bile acids in the intestine, releasing chloride ions in the process; inhibits enterohepatic reuptake of intestinal bile salts & thereby increases the fecal loss of bile salt-bound low density lipoprotein cholesterol

    Colesevelam (WelChol) Strength/dosage forms: 625 mg tablet

    Colestipol (Colestid) Not absorbed; safest for pregnant women

    Fibrates:

    Effects on cholesterol:

    TC: ?

    TG: ?

    LDL: ? or <--> HDL: ?

    MOA: increase catabolism (breakdown) of triglycerides

    Can cause pancreatitis & liver problems

    Fenofibrate (Tricor) Changed from 160 mg (with meals) to 145 mg Made it nanocrystals for better bioavailability

    Gemfibrozil (Lopid) Take 30 minutes before breakfast & dinner Clofibrate (Atromid-S)

    Statins:

    Effects on cholesterol:

    TC: ?

    TG: ?

    LDL: ? HDL: ?

    MOA: HMG-CoA reductase inhibitors

    Atorvastatin (Lipitor)

    Fluvastatin (Lescol, Lescol XL) Shortest t1/2

    Lovastatin (Mevacor, Altoprev- with niacin)

    Strengths/Dosage forms:

    Tablet: 10, 20, 40 mg

    Mevacor: 20, 40 mg ER tablets Altoprev: 10, 20, 40, 60 mg tablets No grapefruit

    Pravastatin (Pravachol)

    Not metabolized in the liver- therefore statin with the least amount of DIs Max daily dose: 80 mg

    Rosuvastatin (Crestor)

    Simvastatin (Zocor)

    No grapefruit Manufacturer recommends limiting simvastatin dose to 20 mg/day when used with amiodarone or verapamil, & 10 mg/day when used with cyclosporine, gemfibrozil, or fibric acid derivatives

    All except for Lipitor & Crestor should be administered in the evening

    Pregnancy category: X Monitor: LFTs, CK

    Cholesterol Absorption Inhibitor:

    Effects on cholesterol:

    TC: ?

    TG: ?

    LDL: ? HDL: ? or <--> Ezetimibe (Zetia): Monitor for muscle pain & increased liver enzymes

    Niacin (Niacor, Niaspan, Slo-Niacin: OTC):

    Synonyms: Nicotinic acid; vitamin B3

    Effects on cholesterol:

    TC: ?

    TG: ?

    LDL: ? HDL: ?

    MOA: inhibits the synthesis of VLDL

    Target dose: 1.5-6 g/day in 3 divided doses with or after meals

    SE: flushing (pretreat by taking aspirin 30 minutes prior), dizziness, lightheadedness Caution in DM & gout

    Combination products:

    Niacin & lovastatin (Advicor)

    Ezetimibe & simvastatin (Vytorin) Aspirin & pravastatin (Pravigard PAC)- aspirin tablets & pravastatin tablets are separate tablets within the PAC Exercise will help to raise HDL Hypermagnesemia: Treatment: 10% calcium gluconate (renal failure) or 0.9% saline with 2 g calcium gluconate per liter (absence of severe renal failure) Hyperthyroidism:

    Thyrotoxicosis

    Graves disease- most common cause

    Thyroid storm is a life threatening, sudden exacerbation of all the symptoms of thyrotoxicosis characterized by fever, tachycardia, delirium, & coma

    Can be caused by drugs such as amiodarone & iodine

    S/Sx: heat intolerance, weight loss, weakness, palpitation, anxiety, tremor, tachycardia, eyelid sag, warm or moist skin

    Diagnosis: ?T4 or T3, ? TSH

    Three modes of treatment:

    Surgery

    Radioactive iodine (RAI)

    Antithyroid (thionamide) drugs:

    Propylthiouracil (PTU):

    MOA: inhibit the synthesis of thyroid hormones by preventing the incorporation of iodine into iodotyrosines & by inhibiting the coupling of monoiodotyrosine & diiodotyrosine to form T4 & T3; also inhibits the peripheral conversion of T4 to T3 Dosage form: tablets

    Methimazole (Tapazole): MOA: inhibit the synthesis of thyroid hormones by preventing the incorporation of iodine into iodotyrosines & by inhibiting the coupling of monoiodotyrosine & diiodotyrosine to form T4 & T3 SE: fever, headache, paresthesias, rash, arthralgia, urticaria, jaundice, hepatitis, agranulocytosis, leucopenia, bleeding

    Iodide drugs: Strong iodine solution (Lugolís Solution): Dosage form: solution- 5% iodine & 10% K iodide; delivers 6.3 mg iodine per drop Saturated solution of potassium iodide (SSKI) Dosage form: solution- 1 g/mL; delivers 38 mg iodine per drop of saturated solution MOA: blocks hormone release, inhibits thyroid hormone synthesis Hypokalemia: Diarrhea is associated with liquid KCl Hyponatremia:

    Drugs can cause by 1 of 3 mechanisms:

    Stimulation of vasopressin release (i.e. nicotine, carbamazepine, Lithium, TCAís, antipsychotic agents, antineoplastic drugs, narcotics) Potentiation of antidiuretic action of vasopressin (i.e. chlorpropamide, methylxanthines, NSAIDs) Vasopressin analogs (i.e. oxytocin, DDAVP) Hypothyroidism:

    Deficient thyroid hormone production

    Hashimotoís disease is the cause of 90% of primary hypothyroidism Autoimmune resulting from cell- & antibody-mediated thyroid injury

    S/Sx: cold intolerance, fatigue, somnolence, constipation, menorrhagia, myalgias, hoarseness, thyroid gland enlargement or atrophy, bradycardia, edema, dry skin, weight gain Body slows down

    Thyroxine (T4) is the major hormone secreted by the thyroid, which is converted to the more potent triiodothyronine (T3) in tissues

    Thyroxine secretion is stimulated by thyroid stimulating hormone (TSH) Diagnosis: ?TSH, ?T4

    Drug therapy:

    Levothyroxine sodium, T4 (Synthroid, Levothroid, Levoxyl, Unithroid, Thyro-Tabs):

    Usually DOC

    Typical dose is 100-125 mcg po QD; reduce dose to 50 mcg for elderly & 25 mcg in patients with CAD to reduce risk of precipitating angina Dose changes are made within a 6-8 week interval

    Desiccated thyroid USP (Armour Thyroid, Nature-Throid, Westhroid)

    Liothyronine, T3 (Cytomel, Triostat)

    Liotrix, T4 & T3 in a 4:1 ratio (Thyrolar)

    Take 30 minutes before breakfast Donít take antacids, calcium, or iron supplements within 4 hours of levothyroxine SE: tachycardia, arrhythmia, angina, MI, tremor, headache, nervousness, insomnia, diarrhea, vomiting, weight loss, excessive sweating, hair loss Body speeds up ID:

    Aminoglycosides:

    MOA: bactericidal; interferes with bacterial protein synthesis by binding to 30S & 50S ribosomal subunits resulting in a defective bacterial cell membrane

    For serious aerobic gram + infections

    Poorly absorbed for GIT

    Renally eliminated by glomerular filtration

    Watch for oto- & nephrotoxicity

    Target serum concentrations:

    Amikacin peak: 15-30 mcg/mL

    Amikacin trough: <5 mcg/mL

    Gentamicin & tobramycin peak: 4-10 mcg/mL Gentamicin & tobramycin trough: <2 mcg/mL

    Amikacin (Amikin)

    Least susceptible to resistance Rule of nines (see gentamicin)

    Gentamicin (Garamycin):

    Rule of eights to determine dosing interval SCr X 8 i.e. 2 X 8 = 16- - dose Q16 hours

    Netilmicin (Netromycin) Tobramycin: Should be given after dialysis and be a routine loading dose

    ANC: absolute neutrophil count

    Neutrophils = bands + segs

    i.e. 5 + 65 = 70

    This means that 70% of the WBCs are neutrophils

    If WBC= 14000 cells per cubic millimeter X 0.70 = 9800 neutrophil cells

    Neutrophils are elevated with bacterial infections

    Lymphocytes are elevated with viral infections Not much elevation with fungal infections Granulocytes= bands + segs + basophils + eosinophils

    Anti-fungal agents:

    Amphotericin B:

    Amphotericin B-conventional (Amphocin; Fungizone)

    Premedicate 30-60 minutes prior with NSAID or APAP with or without diphenhydramine Or hydrocortisone

    Reconstitute ONLY with sterile water without preservatives, not bacteriostatic water Can add D5W

    Amphotericin B- lipid complex (Abelcet) May also need to premedicate

    Amphotericin B-liposomal (AmBisome) May also need to premedicate

    Amphotericin B Cholesteryl Sulfate Complex (Amphotec) May also need to premedicate

    Itraconazole (Sporanox):

    MOA: interferes with cytochrome P450 activity, decreasing ergosterol synthesis (principle sterol in fungal cell membrane) & inhibiting cell membrane function

    CI: CHF

    Dosing:

    Onychomycosis, Fingernail: ORAL, 200 mg BID X1 wk, off drug for 3 wk, repeat 200 mg BID X 1 wk Onychomycosis, Toenail: ORAL, 200 mg QD X 12 wk Aspergillosis, Blastomycosis, Histoplasmosis: ORAL, 200 mg QD, MAX 200 mg BID Dosage forms available: 100 mg capsule; injection; oral solution

    Anti-influenza drugs:

    Amantadine (Symmetrel)

    Blocks influenza A; no activity against influenza B

    Effective when initiated within 48 hours of initial symptoms & continued for 7-10 days

    SE: GI disturbances & CNS dysfunction, including dizziness, nervousness, confusion, slurred speech, blurred vision, & sleep disturbances May lower seizure threshold- avoid with seizure history

    Rimantadine (Flumadine)

    Blocks influenza A; no activity against influenza B

    Effective when initiated within 48 hours of initial symptoms & continued for 7-10 days SE: GI disturbances & CNS dysfunction, including dizziness, nervousness, confusion, slurred speech, blurred vision, & sleep disturbances Fewer SE than with amantadine

    Zanamivir (Relenza)

    Blocks influenza A & B neuraminidases

    Powder for inhalation (rotadisk with Diskhaler)

    1-2 day improvement in symptoms in patients who are symptomatic for no longer than 48 hours SE: headache, GI disturbances, dizziness, upper respiratory symptoms

    Oseltamivir (Tamiflu)

    Block influenza A & B neuraminidases

    1-2 day improvement in symptoms in patients who are symptomatic for no longer than 48 hours

    Dosing:

    Prophylaxis: 75 mg po QD X at least 7 days; should begin within 2 days of contact with infected individual Treatment: 75 mg po BID initiated within 2 days of onset of symptoms; duration of treatment is 5 days SE: N/V/D Oral capsules & suspension

    Anti-viral agents:

    Acyclovir (Zovirax): Counseling: avoid sexual intercourse when lesions are present; this is not a cure for herpes; can take with food; maintain adequate hydration (2-3 L/day); may cause lightheadedness or dizziness

    Famciclovir (Famvir):

    Uses: genital herpes, herpes zoster

    Biotransformed to the active metabolite: penciclovir

    Need dose adjustment for renal impairment Tablet only

    Valacyclovir (Valtrex):

    Uses: treatment of herpes zoster (shingles), herpes labialis (cold sores) & genital herpes MOA: rapidly & nearly completely converted to acyclovir by intestinal & hepatic metabolism; inhibits DNA synthesis & viral replication by competing with deoxyguanosine triphosphate for viral DNA polymerase & being incorporated into viral DNA Reduce dose with renal dysfunction

    Aspergillus:

    Fungus

    Amphotericin B (Amphotec, Abelcet, AmBisome), itraconazole (Sporanox), voriconazole (VFEND), caspofungin (Cancidas) Spells out CAVI NOT ketoconazole

    Cephalosporins: 3rd generation: Cefpodoxime (Vantin) Refrigerate

    Chlamydia:

    STD

    S/SX:

    Males: urethritis, epdidymitis, proctitis, reiter syndrome, testicular pain Females: cervictis, urethral syndrome, endometritis, PID, urethral or cervical discharge, pelvic pain

    If left untreated can lead to infertility Treatment: doxycycline, azithromycin, erythromycin (pregnant) Tetracyclines & quinolones CI in children & pregnant women

    Clostridium difficile:

    Gram +, anaerobic rod

    Treatment: DOC: metronidazole Vancomycin

    Enterococcus faecalis: penicillin, ampicillin, vancomycin, linezolid, aminoglycosides, quinupristin & dalfopristin (Synercid)- for vanco resistant enterococcus (VRE)

    Chloramphenicol, streptomycin, bactrim

    Gram + Clindamycin or cefazolin (cephalosporins ) will not treat

    Escherichia coli: DOC: cefazolin (Ancef), cephalixin (Keflex, Biocef), cefotaxime (Claforan), gentamicin (Gentak)

    Fluoroquinolones:

    MOA: bactericidal; inhibit bacterial DNA topoisomemrase & disrupt bacterial DNA replication

    Can cause QT prolongation

    AE: crystalluria, tendon rupture

    Avoid PO in children under 18 years old- may cause cartilage growth suppression

    2nd generation:

    Ciprofloxacin (Cipro):

    MOA: inhibits DNA-gyrase in suspectible organisms; inhibits relaxation of supercoiled DNA & promotes breakage of double-stranded DNA

    Dosage forms: infusion, injection, microcapsules for oral suspension, ophthalmic ointment (Ciloxan) & solution (Ciloxan), tablet, ER tablet

    Cipro ear drops: Ciprofloxacin & dexamethasone (Ciprodex): Antibiotic/corticosteroid Treatment of acute otitis media in peds with tympanostomy tubes or acute otitis externa in children & adults Ciprofloxacin & hydrocortisone (Cipro HC): Antibiotic/corticosteroid Treatment of acute otitis externa (swimmerís ear)

    Gonorrhea:

    Neisseria gonorrhoeae

    Gram ñ Cefixime, ceftriaxone, ciprofloxacin, ofloxacin

    Inhibit cell wall synthesis: Vancomycin, PCNs, cephalosporins

    Legionella pneumophilia:

    DOC: azithromycin, clarithromycin, erythromycin Alternative: Rifampin, ciprofloxacin, levofloxacin

    Lincosamides:

    Treat gram +, gram - & anaerobic infections

    Lincomycin (Lincocin) Clindamycin (Cleocin)

    Lymeís Disease:

    Lyme borrelliosis

    Caused by spirochete Borrelia burgdorferi

    Tick-borne illness

    Symptoms:

    Stage 1 (early disease): erythemia migrans- a slowly expanding macular rash > 5 cm in diameter, often with a central clearing & mild constitutional symptoms

    Stage 2 (early disseminated): occurs within several weeks to months & includes multiple erythema migrans lesions, neurologic symptoms (7th cranial nerve palsy, meningoencephalitis), cardiac symptoms (AV block, myopericarditis), & asymmetric olioarticular arthritis Stage 3 (Late disease): occurs after months to years & includes chronic dermatitis, neurologic disease, & asymmetric monoarticular or oligoarticular arthritis

    Treatment:

    Doxycucline 100 mg BID Amoxicillin 500 mg TID Cefuroxime axetil 500 mg BID for 14-21 days

    Macrolides:

    Bacteriostatic

    Clarithromycin (Biaxin): Should not be stored in the refrigerator

    Erythromycin:

    Oral products:

    Erythromycin base (E-Mycin, Ery-Tab, PCE (polymer coated ery), Eryc)

    Sensitive to acid

    Coating on most products Administer on an empty stomach

    Erythromycin stearate (Erythrocin stearate, Wyamycin S) Properties similar to ery base but better absorbed

    Erythromycin estolate (Ilosone)

    Most hepatotoxic Better absorbed than ery base

    Erythromycin ethylsuccinate (Eryped, EES)

    Best absorbed form from GIT Available in liquid formulation 400 mg of EES = 250 mg erythromycin base

    Parenteral products:

    Erythromycin lactobionate Erythromycin gluceptate

    Topical products:

    Erythromycin (Staticin, Emgel)- for acne (colorless) Erythromycin (Ilotycin)- ophthalmic use

    MOA:bacteriostatic macrolide antibiotic; may be bactericidal in high concentrations or when used against highly susceptible organisms. It penetrates the bacterial cell membrane & reversibly binds to the 50 S subunit of bacterial ribosomes Reacts with theophylline by altering hepatic metabolism Also increases levels of carbamazepine, cyclosporine, triazolam, lovastatin, simvastatin, valproate

    Azithromycin (Zithromax):

    More gram ñ activity than erythromycin or clarithromycin

    Suspension & capsules: take on an empty stomach

    Tablet: with or without food Not for children < 6 months old Dosage forms available: injection, oral suspension, tablet, Tri-PAK (3, 500 mg tabs), Z-PAK (6, 250 mg tabs)

    Meningitis:

    Inflammation of the meninges that is identified by an abnormal number of WBC in the CSF

    Causative organisms: many gram + & - species Bacterial agents are associated with a large increase in WBCs, increased CSF protein, & decreased CSF glucose Fungal & viral agents exhibit smaller increases in CSF WBCs, smaller increases in CSF protein, & limited decreases in CSF glucose

    Mycoplasma pneumoniae: Erythromycin, tetracycline, doxycycline, fluoroquinolones, azithromycin, clarithromycin

    Onychomycosis:

    Infection of the nail by fungi (dermatophytes, Candida, molds)

    Treatment:

    Fluconazole (Diflucan): 300 mg po weekly X 6 months (pulse therapy) Itraconazole (Sporanox): 200 mg po BID X 1 week per month for 2 months for fingernails & 3-4 months for toenails (pulse therapy) Terbinafine (Lamisil): 250 mg po QD X 3 months

    Other:

    Daptomycin (Cubicin):

    Used for resistant gram + infections

    MOA:binds to bacterial membrane causing rapid depolarization of membrane potential which leads to inhibition of protein, DNA & RNA synthesis, resulting in bacterial cell death Dosing: 4-6 mg/Kg QD

    Linezolid (Zyvox):

    Available dosage forms: IV, powder for oral suspension, tablet

    For resistant gram + skin infections, vancomycin-resistant E. faecium

    Monitor for myelosuppression, thrombocytopenia, & HTN (especially if used with tyramine-containing foods)

    Do not combine with SSRIs because of potential for serotonin syndrome

    Bacteriostatic/bactericidal agent Adjustment with renal dysfunction

    Metronidazole (Flagyl):

    Use: treatment of bacterial vaginosis & trichomonias

    MOA: after diffusing into the organism, interacts with DNA to cause a loss of helical DNA structure & strand breakage resulting in inhibition of protein synthesis & cell death in susceptible organisms Avoid with etoh

    Mupirocin (Bactroban):

    Intranasal: eradication of nasal colonization with MRSA in adult patients & healthcare workers BID Topical treatment of impetigo due to Staphylococcus aureaus, beta hemolytic Streptococcus, & S. pyogenes Apply 2-5 times/day for 5-14 days

    Nystatin:

    Brand names: Bio-Statin; Mycostatin; Nystat; Nystop; Pedi-Dri

    Antifungal agent for the treatment of susceptible cutaneous, mucocutaneous, & oral cavity fungal infections caused by the Candida species

    MOA: binds to sterols in fungal cell membrane, changing the cell wall permeability allowing for leakage of cellular contents

    Systemic relief in 24-72 hours from candidiasis

    Oral: poorly absorbed

    Available dosage forms: cream, lozenge (DSC), ointment, powder for compounding, suspension, tablet, vaginal tablet

    Mycolog cream contains a corticosteroid (triamcinolone) as well as an antifungal (nystatin) Could be used for a patient with an ileostomy pouch Would also treat the inflammation that can occur from what are basically ìtape burnsî

    Quinupristin/dalfopristin (Syncerid):

    Indicated for vancomycin-resistant Enterococcus faecium & serious bacterial skin infections

    MOA: inhibits bacterial protein synthesis by binding to different sites on the 50S bacterial ribosomal subunit thereby inhibiting protein synthesis

    Strengths/dosage forms: Injection, powder for reconstitution: 500 mg: quinupristin 150 mg & dalfopristin 350 mg 600 mg: quinupristin 180 mg & dalfopristin 420 mg

    Vancomycin (Vanocin, Vancole):

    MOA: inhibits bacterial cell wall synthesis by blocking glycopeptide polymerization through binding tightly to D-alanyl-D-alanine portion of cell wall precursor

    Alternative to other antimicrobials, including penicillins & cephalosporins for serious gram + infections (resistant strains of strep, MRSA)

    Watch for ototoxicity

    Red manís syndrome: rapid drop in BP accompanied by maculopapular rash in neck or chest area often associated with rapid IV infusion Should be infused slowly >60 mins

    Draw peak 1 hour after infusion has completed; draw trough just before next dose Therapeutic peak: 25-40 mcg/mL (>80 toxic) Therapeutic trough: 5-12 mcg/mL

    Otitis media:

    1st line drugs: ampicillin, amoxicillin, bacampicillin

    Augmentin: (> 3 months & < 40 kg) 90 mg/Kg/day divided Q12 hours X 10 days

    2nd generation cephalosporin (cefaclor- Ceclor, cefuroxime- Ceftin, cefprozil-Cefzil, loracarbef-Lorabid)

    Zithromax (treat recurrent OM ), Biaxin, Bactrim

    Most common causative organisms: Streptococcus pneumoniae (pneumococcus), H. flu, moraxella catarrhalis, pseudomonas, klebsiella Rocephin can be used to treat: 50 mg/Kg in a single dose or for relapsing: 50 mg/Kg QD X 3 days

    P. acne:

    Clindamycin, erythromycin, & tetracycline are effective

    Erythromycin & benzoyl peroxide (Benzamycin):

    Apply BID This product contains benzoyl peroxide which may bleach or stain clothing Available as a topical gel or Benzamycin Pak (supplied with diluent containing alcohol

    Penicillins: Resistance to PCN is caused by beta lactamase enzyme production & alteration of PCN-binding proteins

    Pseudomembranous enterocolitis (PE): Clostridium difficile overgrowth

    Caused by clindamycin & lincomycin Treat PE with fluid & electrolyte replenishment, oral metronidazole (IV if patient cannot take po), &/or vancomycin (oral only)

    Pseudomonas:

    Aerobic, gram ñ bacillus

    Treatment:

    Antipseudomonal PCN (mezlocillin, piperacillin, carbenicillin, ticarcillin) Ceftazidime (Fortaz, Tazidime, Tazicef), Cefepime (Maxipime) + aminoglycoside Quinolone + imipenem

    Sulfonamide derivates:

    SJS

    The only sodium sulfa salt suitable for ophthalmic use is sulfacetamide sodium (Sodium Sulamyd, Bleph-10)

    Metabolized via acetylation

    Eliminated renally- good for UTIs

    Can result in crystalluria- drink sufficient amounts of water to prevent (2-3 L/day)

    Sulfamethoxazole & trimethoprim (Bactrim, Septra): MOA: Sulfamethoxazole interferes with bacterial folic acid synthesis & growth via inhibition of dihydrogolic acid formation form paraaminobenzoic acid (PABA) Trimethoprim inhibits dihydrofolic acid reduction to tetrahydrofolate resulting in sequential inhibition of enzymes of the folic acid pathway

    Staphylococcus aureus:

    DOC: dicloxacillin, nafcillin, oxacillin, PCN allergy: erythromycin, clindamycin, TCN, linezolid, synercid, vancomycin

    Systemic fungal infection:

    Would NOT use nystatin Fluconazole (Diflucan)

    TB:

    Initial therapy involves RIPE:

    As therapy continues, therapy may go to RIP & then RI

    May continue for 6-18 months

    Rifampin (Rifadin, Rimactane):

    Potent enzyme inducer

    Orange discoloration of all bodily fluids- stains contacts Also used for elimination of meningococci from the nasopharynx in asymptomatic carriers

    Isoniazid (Nydrazid):

    AKA: INH

    MOA: inhibits the bacterial cell wall of susceptible isolates & is therefore active against actively dividing cells only Bacteriocidal or bacteriostatic depending on tissue concentration of the agent

    May cause vitamin B6 deficiency- give B6 (pyridoxine) with use SE: peripheral neuropathy

    Pyrazinamide: MOA: Mycobacterium tuberculosis converts pyrazinamide to pyrazinoic acid which possesses antitubercular activity Ethambutol (Myambutol)

    Monitor TB drugs with:

    LFTs AST Or other transferases

    Tetracyclines:

    Broad spectrum

    Doxycycline (Atridox, Doryx, Periostat, Vibra-Tabs, Vibramycin):

    MOA:bacteriostatic effects by blocking the synthesis of bacterial proteins

    Long-acting (BID) TCN Eliminated via non-renal routes- good choice for renal impairment DI with trivalent cations- Al (compatible with divalent cations)

    Thrush:

    Normally found in the mouth It is a fungal infection of the mouth consisting of white spots

    UTI- pyelonephritis:

    E. coli Bactrim, fluoroquinolones. Ampicillin + gentamicin UTI & sulfa allergy- treat with a FQ Do not give FQ to children Inflammatory Bowel Disease:

    Ulcerative colitis: an idiopathic chronic inflammatory disease of the colon & rectum

    Crohnís disease: can affect any part of the tubular GIT & is characterized by transmural inflammation of the gut wall

    Treat with:

    Sulfasalazine (Azulfidine, Sulfazine)

    Mesalamine (Asacol, Canasa, Pentasa, Rowasa)

    Olsalazine (Dipentum)

    Glucocorticords

    Immunosuppressive agents (6-mercaptopurine, azathioprine, methotrexate, cyclosporine)

    Antibiotics (metronidazole) Infliximab (Remicade)

    Sulfasalazine (AzulfidineÆ):

    Used in the treatment of inflammatory bowel disease (ulcerative colitis) & RA

    Watch for sulfa allergy, salicylate allergy, & urinary discoloration Sulfasalazine ‡ sulfapyridine + mesalamine (5-aminosalicyclic acid; 5-ASA) 5-ASA is more active If patient cannot tolerate sulfasalazine because of a sulfa hypersensitivity, mesalamine (Asacol, Pentasa, Rowasa) may be used Asacol Delayed released, EC coated tablet- do not crush or chew Immunosuppressive Therapy:

    Calcineurin inhibitors:

    Cyclosporine (Sandimmune, Neoral) Tacrolimus (Prograf)

    mTOR inhibitors: Sirolimus (Rapamune)

    Antiproliferative agents:

    Azathioprine (Imuran)

    Mycophenolate mofetil (CellCept)

    Mycophenolate sodium (Myfortic) Leflunomide (Arava)

    Monoclonal antibodies:

    Muromonab-CD3 (Orthoclone OKT 3)

    Basliximab (Simulect) Daclizumab (Zenepax)

    Polyclonal antibodies: Anti-thymocyte globulin (Atgam): equine Anti-thymocyte globulin (Thymoglobulin): rabbit Insomnia, Anxiety, or both:

    Benzodiazepines:

    Most undergo oxidation to active metabolites in liver

    Lorazepam (Ativan), oxazepam (Serax), & temazepam (Restoril) undergo glucuronidation to inactive metabolites Useful in elderly & those with liver disease

    Can experience seizures & delirium with sudden discontinuation

    Hypnotic agents:

    Estazolam (ProSom)

    Flurazepam (Dalmane)

    Quazepam (Doral) Temazepam (Restoril) Triazolam (Halcion)

    Trazodone (Desyrel):

    Antidepressant that is useful for severe anxiety or insomnia

    Highly sedating, causing postural hypotension & is associated with priapism

    Doses: Sedation: 25-50 mg Depression: 150 mg divided into 3 daily doses; max 600 mg/day

    Zolpidem (Ambien):

    An imidazopyridine hypnotic agent

    MOA: has much or all of its actions explained by its effects on benzodiazepine receptors, especially the omega-1 receptor binds the benzodiazepine (BZ) receptor subunit of the GABA-A receptor complex

    No withdrawal symptoms, rebound insomnia or tolerance

    Rapid onset good for initiating & maintaining sleep

    SE: headache, daytime somnolence, GI upset Avoided in patients with obstructive sleep apnea

    Zaleplon (Sonata)

    Nonbenzodiazepine hypnotic

    MOA: interacts with benzodiazepine GABA receptor complex

    T1/2 is ~1 hour & has no active metabolites

    SE: drowsiness, dizziness, & impaired coordination Caution in those with compromised respiratory function

    Eszopiclone (Lunesta): MOA: may interact with GABA-receptor complexes

    OTC sleep aids:

    Doxylamine (Unisom)

    Diphenhydramine (Nytol, Sominex) Diphenhydramine + APAP (Tylenol PM, Unisom Pain Relief) Diphenhydramine + ASA (Bayer PM) Lupus:

    Autoimmune inflammatory condition

    Systemic Lupus Erythematosus (SLE)

    Drugs that can contribute: procainamide**, phenytoin, chlorpromazine, hydralazine*, quinidine, methyldopa, & isoniazid

    Therapy:

    Arthritis: NSAIDs or glucocorticoids

    Dermatologic complications: hydroxychloroquine (Plaquenil) Thrombocytopenia: glucocorticoid therapy Refractory cases: cyclophosphamide Metabolic acidosis:

    Give sodium acetate- acetate ion converts to bicarbonate

    Bicitra:

    Sodium citrate & citric acid

    Other brand names: Cytra-2 & Oracit

    AKA: Modified Shohlís solution

    Use: treatment of metabolic acidosis; alkalinizing agent in conditions where long-term maintenance of an alkaline urine is desirable Also solution antacid pre-op if patient has eaten just before emergency surgery or delivery of child Dosing: oral- 10-30 mL with water after meals (to avoid laxative effect) & at bedtime SE: N/V/D, hyperkalemia, tetany Migraines:

    Triptans:

    Selective serotonin receptor agonists that activate 5-HT1B/5-HT1D & to a lesser extent 5-HT1A/5-HT1F

    Agents:

    Almotriptan (Axert): 6.25 & 12.5 mg tablets; CYP450 & MAO metabolism NMT 2 doses in 24 hours

    Sumatriptan (Imitrex): 25, 50, & 100 mg tablets, 5 & 20 mg nasal spray, 12 mg/mL injection; MAO metabolism

    Can re-dose oral tablets & nasal spray if no response after 2 hours Can re-dose injection if no response after 1 hour

    Eletriptam (Relpax): 20 & 40 mg tablets; CYP 3A4 metabolism

    Can re-dose after 2 hours 80 mg/day max

    Frovatriptan (Frova): 2.5 mg tablet; renal 50%

    Can re-dose after 2 hours 7.5 mg/day max

    Rizatriptan (Maxalt): 5 & 10 mg tablet/wafer; MAO metabolism

    Can re-dose after 2 hours

    30 mg/day max 15 mg max if also taking propranolol

    Zolmitriptan (Zomig): 2.5 mg tablet/wafer, nasal spray 5 mg, ODT; CYP450 & MAO metabolism

    Can re-dose after 2 hours NMT 10 mg per 24 hours

    Naratriptan (Amerge): 1 & 2.5 mg tablets; renal 70% & CYP450 Dose may be repeated after 4 hours NMT 5 mg in 24 hours

    SQ sumatriptan has the fastest onset followed by sumatriptan nasal spray

    Rizatriptan may have a slightly faster onset of action than the others

    Migraine recurrence rates may be lower with long half-life triptans such as naratriptan & frovatriptan

    SE: tingling & paresthesias; sensations of warmth in the head, neck, chest, & limbs; dizziness; flushing; neck pain or stiffness

    Do not give sumatriptan to patients who have risk factors for CAD

    CI: in patients with hx of ischemic heart disease, MI, uncontrolled HTN, or other heart disease; pregnancy Should not be taken within 24 hours of other triptans, isometheptene, or ergot derivatives

    Combination:

    Midrin:

    Oral Capsule: (Acetaminophen - Dichloralphenazone - Isometheptene Mucate) 325 MG-100 MG-65 MG

    Isometheptene: is an indirect-acting sympathomimetic agent with vasoconstricting activity

    Dichloralphenazone: a mild sedative & relaxant Acetaminophen: may act predominantly by inhibiting prostaglandin synthesis in the CNS &, to a lesser extent, through a peripheral action by blocking pain-impulse generation The peripheral action may also be due to inhibition of prostaglandin synthesis or to inhibition of the synthesis or actions of other substances that sensitize pain receptors to mechanical or chemical stimulation

    Butalbital 50 mg, aspirin 325 mg, & caffeine 40 mg (Fiorinal): Capsules Butalbital, acetaminophen, & caffeine (Anolor 300; Dolgic; Esgic; Fioricet; Medigesic; Repan; Zebutal): Butalbital 50 mg, APAP 325 mg & caffeine 40 mg (Fioricet) Tablet

    Ergot derivatives:

    CI: pregnancy, peripheral vascular disease, CAD, sepsis, hepatic or renal impairment

    Dihydroergotamine (DHE 45, Migranal):

    Migraines: with or without aura

    MOA: ergot alkaloid alpha-adrenergic blocker directly stimulates vascular smooth muscle to vasoconstrict peripheral & cerebral vessels; also has effects on serotonin receptors 5-HT1D receptor agonist

    Max: 6 mg/week

    Patient takes too much: N/V/D, dizziness, paresthesia, peripheral ischemia, peripheral vasoconstriction Available dosage forms: injection & intranasal spray DHE 45 NS: 1 spray in each nostril; can repeat in 15 minutes; max is 4 sprays/day Discard open ampules after 8 hours

    Ergotamine tartrate & caffeine (Cafergot):

    Available dosage forms: tablets & suppositories Max: 6 mg/day or 10 mg/week

    SE: nausea & vomiting (resulting from stimulation of the CTZ)

    Ergotism: severe peripheral ischemia Sx: cold, numb, painful extremities, continuous paresthesias, diminished peripheral pulses & claudication may result from the vasoconstrictor effects of the ergot alkaloids Gangrenous extremities, MI, hepatic necrosis, & bowel & brain ischemia are rare, but have been reported

    Propylactic therapy:

    DOC:

    Propranolol (Inderal): use if patient also has HTN Lipid soluble

    Amitriptyline (Elavil): concomitant depression

    Valproate (Depakote): concomitant seizures

    Cyproheptadine (Periactin): useful for migraines in children

    Feverfew: herbal with some benefits shown

    Ergonovine maleate: effective for menstrual migraines

    Methysergide (Sansert): Dose: 2 mg BID up to 8 mg X 6 months Then stop for 1 month If you donít stop- get SE of retroperitoneal fibrosis: organs in abdominal cavity become fibrotic & can die This can occur as the result of constant vasoconstriction- which provides less blood flow to organs You must stop to allow blood flow to return Miscellaneous Drugs:

    Acetylcysteine (Mucomyst, Acetadote): MOA: exerts mucolytic action through its free sulfhydryl group which opens up the disulfide bonds in the mucoproteins thus lowering mucous viscosity; thought to reverse APAP toxicity by providing substrate for conjugation with the toxic metabolites

    Adalimumab (Humira):

    Tumor necrosis factor (TNF) blocking agent

    MOA: binds to human tumor necrosis factor alpha (TNF-alpha) receptor sites Elevated TNF levels in the synovial fluid are involved in pathologic pain

    Use: treatment of active RA in patients with inadequate response to one or more DMARDs; psoriasis

    Dose: 40 mg SQ EOW Before starting therapy: TB test, measure rheumatoid factor, PT

    Adefovir (Hepsera):

    Antiretroviral agent; reverse transcriptase inhibitor (nucleoside)

    MOA: acyclic nucleotide reverse transcriptase inhibitor (adenosine analog) which interferes with HBV viral RNA dependent DNA polymerase resulting in inhibition of viral replication Use: treatment of chronic hepatitis B

    Aspirin & dipyridamole (Aggrenox):

    Use: reduction in the risk of stroke in patients who have had transient ischemia of the brain or completed ischemic stroke due to thrombosis

    MOA:

    Dipryidamole: inhibits the uptake of adenosine into platelets, endothelial cells & erythrocytes Aspirin: inhibits platelet aggregation by irreversible inhibition of platelet cyclooxygenase & thus inhibits the generation of thromboxane A2 Dosing: 1 capsule BID

    Atropine (AtroPen; Atropine-Care; Isopto; Sal-Tropine):

    AtroPen formulation is available for use primarily by the department of defense MOA: blocks the action of acetylcholine at parasympathetic sites in smooth muscle, secretory glands & the CNS; increases CO, dries secretions, antaonizes histamine & serotonin

    Bismuth subsalicylate, metronidazole, tetracycline (Helidac): If patient has + urea breath test indicating H. pylori present

    Chlorhexidine (Periogard):

    Antibacterial agent for oral rinse

    Bactericidal Uses: disinfectant; gingivitis; periodonitis; inhibits plaque formation

    Cromolyn (NasalCrom): Dose: use 1 spray in each nostril 3-4 times per day

    Cyclosporin (Gengraf, Neoral, Restasis, Sandimmune):

    Neoral & Sandimmune are NOT therapeutically equivalent

    Immunosuppressant agent MOA: inhibition of production & release of interleukin II & inhibits interleukin II-induced activation or resting T-lymphocytes

    Danazol (Danocrine):

    Use: treatment of endometriosis, fibrocystic breast disease & hereditary angioedema

    Androgen

    MOA: suppresses pituitary output of FSH & LH that causes regression & atrophy of normal & ectopic endometrial tissue; decreases rate of growth of abnormal breast tissue CI: markedly impaired hepatic, renal, or cardiac function

    Desmopressin (DDAVP, Stimate):

    Vasopressin analog

    Uses: diabetes insipidus; control bleeding in hemophilia A & van Willebrand disease; primary noctural enuresis

    Strengths/dosage forms:

    Injection (IV): 4 mcg/mL Solution, intranasal: 100 mcg/mL Tablets

    Desoximetasone (Topicort):

    Intermediate to high potency topical corticosteriod Available as a cream & ointment

    Dicyclomine (Bentyl);

    MOA: anticholinergic agent

    Uses: treatment of functional disturbances of GI motility such as irritable bowel syndrome NOT used for GERD

    Diphenhydramine (Benadryl):

    Analgesic, antihistamine, antipruritic, sleep aid, antitussive, antiemetic

    Class: Ethanolamine

    Dosing adjustments in renal impairment

    MOA: Diphenhydramine hydrochloride acts as an antihistamine by competing with histamine for receptor sites on effector cells Precautions: bladder neck obstruction; concurrent MAOI therapy; concurrent use of CNS depressants; decreases mental alertness & psychomotor performance; do not use topical form on eyes or eye lids; elderly are more susceptible to the SE of diphenhydramine; history of bronchial asthma, increased intraocular pressure, hyperthyroidism, cardiovascular disease or HTN; may cause excitation in young children; narrow angle glaucoma; pyloroduodenal obstruction; stenosing peptic ulcer; symptomatic prostatic hypertrophy

    Diphenoxylate & Atropine (Lomitol; Lonox):

    Antidiarrheal

    CI: severe liver disease; jaundice; narrow angle glaucoma; children < 2 years old

    MOA: diphenoxylate inhibits excessive GI motility & GI propulsion

    Commercial preparations contain a subtherapeutic amount of atropine to discourage abuse

    Dosing: 15-20 mg/day of diphenoxylate in 3-4 divided doses Maintenance: 5-15 mg/day in 2-3 divided doses May cause drowsiness

    Etancercept (Enbrel):

    Disease modifying agent

    MOA: binds to TNF & blocks its interaction with cell surface receptors TNF blocker

    Use: moderate-severe RA; chronic plaque psoriases

    Dose: 25 mg injection SQ twice weekly or 50 mg injection SQ once weekly

    Initial storage of drug: in refrigerator (not frozen)

    Stability of vials after reconstitution: 14 days in refrigerator

    Allow prefilled syringes 15-30 minutes at room temperature prior to injection

    Some foaming is normal

    No DI with methotrexate Stop using when patient has a serious infection

    Guaifensin: MOA: expectorant which acts by irritating the gastric mucosa & stimulating respiratory tract secretions, thereby increasing respiratory fluid volumes & decreasing mucus viscosity

    Hyaluronate (Hyalgan, Biolon, Healon, Hylaform, Orthovisc, Provisc, Restylane, Supartz, Synvisc, Vitax):

    MOA: sodium hyaluronate is a polysaccharide which is distributed widely in the extracellular matrix of connective tissue in man. It forms a viscoelastic solution in water (at physiological pH & ionic strength) which makes it suitable for aqueous & vitreous humor in ophthalmic surgery & functions as a tissue &/or joint lubricant

    Use:

    intra-articular injection (Synvisc)- treatment of pain in Official Answer in knee in patients who have failed nonpharmacologic treatment & simple analgesics No weight bearing exercise for 48 hours

    Intradermal- correction of moderate to severe facial wrinkles Ophthalmic- surgical aid in cataract extraction, intraocular implantation, corneal transplant, glaucoma filtration, & retinal attachment surgery Topical- management of skin ulcers & wounds

    Hydroxyzine (Atarax, Vistaril):

    MOA: competes with histamine for H1 receptor sites on effector cells in the GIT, blood vessels, & respiratory tract; possesses skeletal muscle relaxing, bronchodilator, antihistamine, antiemetic, & analgesic properties

    Use: treatment of anxiety; preoperative sedative; antipruritic; antiemetic

    Causes sedation

    Hydroxyzine pamoate (Vistaril)

    Hydroxyzine HCl (Atarax) Not to be confused with Hydralazine

    Interferon beta 1b (Betseron):

    Use: treatment of MS Can cause hepatotoxicity- monitor LFTs

    Isotretinoin (Accutane, Amnesteem, Clarais, Sotret):

    Retinoic acid derivative

    MOA: reduces sebaceous gland size & reduces sebum production; regulates cell proliferation & differentiation

    Use: treatment of sever recalcitrant nodular acne unresponsive to conventional therapy

    RiskMAP, S.M.A.R.T., S.P.R.I.T., I.M.P.A.R.T. programs

    Cannot be dispensed unless the rx is affixed with a yellow, self-adhesive qualification sticker filled out by the prescriber

    Telephone, fax, or computer-generated rxs are no longer valid

    Rx cannot be written for more than a 1-month supply, must be dispensed with a patient education guide Females must have their rxs filled within 7 days of the qualification date- considered expired if > 7days

    Pregnancy risk factor: X

    Females must have 2 methods of contraception; 1 month prior to starting therapy & 1 month after discontinuation of therapy Therapy is begun after 2 negative pregnancy tests

    SE: increased triglycerides, elevated blood glucose, photosensivitivity, seizure, cataracts

    Avoid additional vitamin A supplements

    Dose: 0.5-2 mg/Kg/day in 2 divided doses

    Take with food; limit exercise while on therapy; capsules can be swallowed, or chewed & swallowed; capsule may be opened with a large needle & contents placed on applesauce or ice cream

    Excerbation of acne may occur during the 1st weeks of therapy Accutane, Amnesteem, & Sotret contains soybean oil (Claravis does not)

    Lansoprazole (30 mg), amoxicillin (1 g), clarithromycin (500 mg) (Prevpac):

    For H. pylori Taken together BID for 10-14 days

    Leflunomide (Arava):

    Disease modifying agent

    MOA: inhibits pyrimidine synthesis, resulting in antiproliferative & anti-inflammatory effects Use: treatment of active RA; indicated to reduce signs & symptoms, & to retard structural damage & improve physical function

    Luride: source of fluoride to prevent dental caries

    Supplied as sodium fluoride in chewable tablets that provide 0.25 mg, 0.5 mg, & 1 mg of fluoride ion per tab Prolonged ingestion with excessive doses may result in dental fluorosis (staining or hypoplasia of the enamel of the teeth) & osseous changes

    Malathion (Ovide):

    Class: organophosphate; pediculicide

    Uses: pediculosis capitis; lice

    MOA:acts via cholinesterase inhibition. It exerts both lousicidal & ovicidal actions in vitro.

    Safety not established in children under 6 years old Lotion

    Mannitol (Osmitrol, Resectisol):

    Osmotic diuretic MOA: increases osmotic pressure of glomerular filtrate, which inhibits tubular reabsorption of water & electrolytes & increases urinary output

    Mebendazole (Vermox):

    Anthelmintic agent

    MOA: selectively & irreversibly blocks glucose uptake & other nutrients in susceptible adult intestine-dwelling helminthes

    Dosing:

    Pinworms: 100 mg po ASD; may need to repeat after 2 weeks; treatment should include family members in close contact with patient

    Whipworms, roundworms, hookworms: 1 tablet BID, morning & evening on 3 consecutive days; if patient is not cured within 3-4 weeks, a 2nd course of treatment may be administered Capillariasis: 200 mg BID for 20 days Strengths/dosage forms: Tablet, chewable: 100 mg

    Methotrexate (Rheumatrex; Trexall):

    MOA: inhibits dihydrofolate reductase causing interference with DNA synthesis, repair, & cellular replication

    Juvenile RA: oral, IM: 10 mg/m2 once weekly

    Does cause alopecia

    Causes myelosuppression & thrombocytopenia NOT thrombocytosis (increased PLT)

    BBW for hepatotoxicity Can cause megalobastic anemia

    Misoprostol (Cytotec):

    MOA: synthetic prostaglandin E1 analog that replaces the protective prostaglandins consumed with prostaglandin-inhibiting therapies (i.e. NSAIDs); has been shown to induce uterine contractions

    Dosing:

    Prevention of NSAID-induced ulcers: 200 mcg po QID with food (to decrease diarrhea)

    Labor induction or cervical ripening: intravaginal- 25 mcg (1/4 of a 100 mcg tablet) Do not use in patients with previous cesarean delivery or prior major uterine surgery Fat absorption in CF (unlabeled use): 100 mcg QID (ages 8-16) Tablets only (no IV)

    Nimodipine (Nimotop):

    MOA: calcium channel blocker

    Use: spasm following subarachnoid hemorrhage from ruptured intracranial aneurysms

    Has a greater effect on cerebral arteries- may be due to the drugís increased lipophilicity

    Dosing: 60 mg po Q4h x 21 days; start 96 hours after subarachnoid hemorrhage If the capsules cannot be swallowed, the liquid may be removed by making a hole in each end of the capsule with an 18-guage needle & extracting the contents via syringe

    Oxybutynin (Ditropan):

    Urinary antispasmodic agent

    MOA:Non-selective muscarinic receptor antagonist with a higher affinity for M1 & M3 receptors Increases bladder capacity, decreases uninhibited contractions, & delays desire to void Dosage forms available: syrup, tablet (IR, XR), patch (Oxytrol)

    Palivilizumab (Synagis):

    Use: monoclonal antibody used for prevention of serious lower respiratory tract disease caused by respiratory syncytial virus (RSV) in infants & children < 2 years MOA: exhibits neutralizing & fusion-inhibitory activity against RSV Ribavirin (Copegus, Rebetol, Ribasphere, Virazole) also used to treat RSV Available as: capsule; powder for aerosol; oral solution; tablet

    Pancuronium:

    Nondepolarizing neuromuscular blocking agent

    MOA: blocks neural transmission at the myoneural junction by binding with cholinergic receptor sites

    Onset: 2-4 minutes

    Duration after single dose: 40-60 minutes

    Use: adjunct to general anesthesia to facilitate endotracheal intubation & to relax skeletal muscles during surgery; does not relieve pain or produce sedation

    DOC for neuromuscular blockade EXCEPT in patients with renal failure, hepatic failure, or cardiovascular instability AE: increased pulse rate, elevated BP & CO, edema, flushing, rash, bronchospasm, hypersensitivity rxn

    Peginterferon Alfa-2a (Pegasys):

    Use: hepatitis C Refrigerate; protect from light

    Permethrin(Acticin, Elimite, Nix Creme Rinse, Pronto, Rid, A200 Lice Control) OTC available with same ingredient: Nix

    PhosLo:

    Calcium acetate

    Use:

    Oral: control of hyperphosphatemia in end-stage renal failure; does not promote aluminum absorption IV: calcium supplementation in parenteral nutrition therapy MOA: combines with dietary phosphate to form insoluble calcium phosphate which is excreted in the feces

    Physostigmine (Antilirium):

    Prednisone (Deltasone, Sterapred):

    MOA: an adrenocortical steroid with salt-retaining properties; it is a synthetic glucocorticoid analog, which is mainly used for anti-inflammatory effects in different disorders of many organ systems; causes profound & varied metabolic effects, modifies the immune response of the body to diverse stimuli, & is also used as replacement therapy for adrenocortical deficient patients Cortiosteriods should be used with caution in patients with DM, HTN, osteoporosis, glaucoma, cataracts, TB, hepatic impairment, elderly

    Propofol (Diprivan):

    General anesthetic; no analgesic properties

    Avoid abrupt discontinuation- titrate slowly

    Propofol emulsion contains soybean oil, egg phosphatide & glycerol

    ìPropofol infusion syndromeî: symptoms include sever, sporadic metabolic acidosis &/or lactic acidosis which may be associated with tachycardia, myocardial dysfunction, &/or rhabdomyolysis

    Short duration of action: 3-10 minutes

    If on concurrent parenteral nutrition, may need to adjust the amount of lipid infused Provides 1.1 kCal/mL

    Riopan:

    Magaldrate (antacid) & simethicone (antiflatulent) combination Substitutes can be found in the Non-Prescription Handbook & Facts & Comparisons

    Robitussin:

    Robitussin: guaifenesin 100 mg/5 mL-OTC Alcohol free

    Robitussin PE: guaifenesin 200 mg & pseudoephedrine 30 mg/5mL ñOTC Alcohol free

    Robitussin CF: guaifenesin 100 mg, pseudoephedrine 30 mg, & dextromethorphan 10 mg/5 mL -OTC Alcohol free Robitussin DM: guaifenesin 100 mg & dextromethorphan 10 mg/5 mL ñOTC Alcohol free

    Ursodiol (Actigall, Urso 250, Urso Forte):

    Use: prevention of gallstones in obese patients experiencing rapid weight loss

    AKA: ursodeoxycholic acid

    MOA: decreases cholesterol content of bile & bile stones by reducing the secretion of cholesterol from the liver & the fractional reabsorption of cholesterol by the intestines

    Dosing:

    Gallstone dissolution: 8-10 mg/Kg/day in 2-3 divided doses Gallstone prevention: 300 mg BID Use beyond 24 months is not established

    Vecuronium:

    Nondepolarizing neuromuscular blocker agent

    MOA: blocks acetylcholine from binding to receptors on motor endplate by inhibiting depolarization

    Onset: 2-4 minutes

    DOA: 30-45 minutes Use: adjunct to general anesthesia to facilitate endotracheal intubation & to relax skeletal muscles during surgery; does not relieve pain or produce sedation AE: bradycardia, edema, flushing, hypersensitivity rxn, hypotension, tachycardia, rash Miscellaneous Facts:

    Danger of decreasing DKA too fast: cerebral edema

    Genetic polymorphism exists as acetylation

    Albumin is important for measuring calcium levels Corrected calcium = serum calcium + 0.8(4 ñ patientís albumin)

    Caffeine treats respiratory distress in neonates

    Emergency bee sting kit:

    Epinephrine & APAP EpiPen auto-Injector 0.3 mg SQ dose of 1:1000 epinephrine in a 2 mL disposable prefilled injector

    Liposyn III (fat emulsion) is stored at room temperature

    MedWatch: a list of reported side effect Completely voluntarily reported

    Stain dermatologists use for fungus identification: KOH

    Kayexlate + sorbitol use: to prevent constipation Store at room temperature

    Hypercalcemia: almost always caused by increased entry of Ca into the extracellular fluid & decreased renal Ca clearance More that 90% of cases are due to primary hyperparathyroidism or malignancy

    Hypocalcemia in renal impairment:

    Phosphorus & calcium levels are altered due to:

    Phosphorus retention, resulting in a rise in serum phosphorus levels & a reciprocal fall in calcium levels, with resultant stimulation of parathyroid hormone (PTH) secretion Decreased generation of 1,25-dihyroxyvitamin D3, further contributing to low serum calcium levels & decreasing suppression of PTH

    Addition of a phosphate binder prevent GI phosphate absorption: Calcium carbonate 500-1000 mg po with meals Sevelamer (Renagel): lacks aluminum & calcium

    Cheilitis: inflammation of the lips

    Herpes simplex I (cold sore): avoid the sunlight

    Goodpastureís syndrome: glomerulonephritis associated with pulmonary hermorrhage & circulating antibodies against basement membrane antigens Autoimmune disease

    Resorcinol/ASA/LCD needs to be packaged in what container LCD is coal tar- brown glass container

    Medrol dose pack: decremental dosing

    Polydipsia: excessive thirst Patients with phenylketonuria (PKU) must avoid aspartame Myasthenia Gravis:

    An autoimmune disorder that involve antibody-mediated disruption of postsynaptic nicotinic acetylcholine receptors at the neuromuscular junction & is often associated with thymus tumors

    Treatment:

    Anticholinesterase drugs:

    Pyridostigmine Neostigmine

    Thymectomy

    Immunosuppressive drugs

    High-dose prednisone Azathioprine Cyclosporine Cyclophosphamide Orange Book:

    AKA: Approved Drug Products with Therapeutic Equivalence Evaluations

    Codes:

    A: Drug products that FDA considers to be therapeutically equivalent to other pharmaceutically equivalent products, i.e., drug products for which: there are no known or suspected bioequivalence problems. These are designated AA, AN, AO, AP, or AT, depending on the dosage form; or actual or potential bioequivalence problems have been resolved with adequate in vivo and/or in vitro evidence supporting bioequivalence. These are designated AB AA Products in conventional dosage forms not presenting bioequivalence problems ß AB, AB1, AB2, AB3... Products meeting necessary bioequivalence requirements

    AN Solutions and powders for aerosolization

    AO Injectable oil solutions

    AP Injectable aqueous solutions &, in certain instances, intravenous non-aqueous solutions AT Topical products

    B: Drug products that FDA at this time, considers NOT to be therapeutically equivalent to other pharmaceutically equivalent products, i.e.,

    drug products for which actual or potential bioequivalence problems have not been resolved by adequate evidence of bioequivalence. Often the problem is with specific dosage forms rather than with the active ingredients. These are designated BC, BD, BE, BN, BP, BR, BS, BT, BX, or B*.

    B* Drug products requiring further FDA investigation & review to determine therapeutic equivalence

    BC Extended-release dosage forms (capsules, injectables & tablets)

    BD Active ingredients & dosage forms with documented bioequivalence problems

    BE Delayed-release oral dosage forms

    BN Products in aerosol-nebulizer drug delivery systems

    BP Active ingredients & dosage forms with potential bioequivalence problems

    BR Suppositories or enemas that deliver drugs for systemic absorption

    BS Products having drug standard deficiencies BT Topical products with bioequivalence issues BX Drug products for which the data are insufficient to determine therapeutic equivalence Osteopenia/Ostoporosis:

    T scores are used for diagnosis:

    Osteopenia: T score -1 to -2.5 SD below the young adult mean Osteoporosis: T score = -2.5 SD below the young adult mean

    Bisphosphonates:

    Could worsen esophagitis

    Take with a full glass of water fir thing in the AM & at least 30 minutes before the 1st food or beverage of the day

    Maximize therapy by taking calcium + vitamin D

    Alendronate (Fosmax):

    Prevention dose: 5 mg QD or 35 mg Q week

    Treatment dose: 10 mg QD or 70 mg Q week Dosage forms: solution & tablet

    Ibandronate (Boniva):

    Prevention dose: 2.5 mg QD; 150 mg Q month may be considered Treatment dose: 2.5 mg QD or 150 mg Q month

    Risedronate (Actonel): Prevention dose: 5 mg QD or 35 mg Q week may be considered Treatment dose: 5 mg QD or 35 mg Q week

    Selective Estrogen Receptor Modulator:

    Raloxifene (Evista):

    MOA: estrogen receptor agonist at the skeleton decreases resorption of bone & overall bone turnover 60 mg QD for treatment & prevention of osteoporosis SE: increased risk of thromboembolism, hot flashes, nausea, dyspepsia, weight gain

    Teriparatide (Forteo):

    Parathyroid hormone (PTH) analog for osteoporosis

    MOA: stimulates osteoblast function, increases GI calcium absorption, increases renal tubular reabsorption of calcium Dosage: injection Storage: refrigerate; discard pen 28 days after 1st injection OTC:

    Aluminum hydroxide (ALternaGel, Amphojel):

    Use: for treatment of hyperacidity & hyperphosphatemia

    MOA: neutralizes hydrochloride in stomach to form Al(Cl)3 salt + H2O

    Dose:

    Hyperphosphatemia: 300-600 mg TID with meals (within 20 minutes of meal) Hyperacidity: 600-1200 mg between meals & at bedtime

    Aluminum may accumulate in renal impairment Dose should be followed with water

    Antidiarrheal agents: Bismuth subsalicylate (Kaopectate) Has both antisecretory & antimicrobial actions while possibly providing anti-inflammatory action as well

    Atopic dermatisis: Hydrocortisone

    Capsacin (Zostrix, Capzasin):

    MOA: induces the release of substance P, the principle chemomediator of pain impulses from the periphery to the CNS; after repeated application, the neuron is depleted of substance P

    Apply to the affected area at least 3-4 times/day If applied less than this, decreased efficacy Strength: 0.025%, 0.075%

    Delsyn

    Dextromethorphan Contains 0.26% alcohol

    Diaper rash:

    Breast-fed infants have less diaper rash than do bottle-fed infants

    Skin protectants to treat: Allantoin, calamine, cod liver oil (in combination), dimethicone, kaolin, lanolin (in combination), mineral oil, petrolatum, talc, topical cornstarch, white petrolatum, zinc oxide, zinc oxide ointment

    Can use Mycolog cream (triamcinalone & nystatin) Candidiasis (?)

    Fleetís Phospho-Soda (Sodium Phosphate):

    CI: CHF, ascites, patients on a Na restricted diet Saline laxative

    Gaviscon:

    Aluminum hydroxide & magnesium trisilicate

    Use: temporary relief of hyperacidity

    Dose: chew 2-4 tablets QID

    Aluminum &/or magnesium may accumulate in renal impairment Do not swallow tablets whole

    Loratidine (Claritin, Alavert):

    Nonsedating antihistamine

    Patients with liver or renal impairment should start with a lower dose (10 mg QOD)

    Do not use in children <2

    Dosing:

    2-5 years old: 5 mg QD >6: 10 mg QD

    Take on an empty stomach Available as: syrup, tablet, rapidly disintegrating tablets

    Magnesium citrate (Citro-Mag):

    Saline laxative

    Use: evacuation of bowel prior to surgery & diagnostic procedures or overdose situations CI: renal failure, DM, GI complications

    Milk of magnesia:

    Magnesium hydroxide Short-term treatment of occasional constipation

    Nicotine Replacement therapy: Products: patch, gum, lozenge, inhaler (Nicotrol Inhaler- Rx only), nasal spray (Nicotrol NS- Rx only)

    Ostomy care:

    Three basic types of ostomies:

    Ileostomy

    Colostomy (most common) Urinary diversion

    Effect of food on stoma output:

    Foods that thicken: Applesauce, bananas, bread, buttermilk, cheese, pasta, potatoes, pretzels, rice yogurt

    Foods that loosen: Alcohol, chocolate, beans, fried or greasy foods, spicy foods, leafy veg

    Foods that cause stool odor: Asparagus, beans, cheese, eggs, fish, garlic

    Foods that cause urine odor: Asparagus, seafood, spices Foods that combat urine odor: Buttermilk, cranberry juice, yogurt

    Local complications:

    Local irritation: can occur because the output from the intestines or kidneys can irritate the skin around the stoma Patient can use: karaya powder, pectin base powder, ostomy creams, or barriers to protect the skin

    Alakaline dermatitis: occurs in patients with urinary diversions because of the alkaline nature of the output

    Major cause of blood in the pouch because it renders the stoma extremely friable Treatment is acidification of the urine (cranberry juice 2-3 quarts daily)

    Excoriation: caused by erosion of the epidermis by digestive enzymes

    The eroded or denuded epidermis may bleed, & is painful when touched when applying the appliance Treatment: karaya or pectin-based powder may be applied to the peristomal skin prior to application of the pouch, more frequent changing of the pouch Infection: candida species 2% miconzaole powder or nystatin powder

    Fitting an ostomy:

    Pouch opening may be cut to fit or presized If they are cut to fit, the stoma pattern is traced onto the skin barrier-wafer surface of the pouch & then cut out before being applied

    The diameter of the round stoma is measured at the base, where the mucosa meets the skin, which is considered the widest measurement

    Oval stomas should be measured at both their widest & narrowest diameters

    A stoma may swell if the appliance fits too tightly or slips, or if the patient falls or experiences a hard blow to the stoma

    Other consideration include: body contour, stoma location, skin creases & scars, & type of ostomy

    To prevent leakage, the pouch should be emptied when it is 1/3 ñ 1/2 full The flange & skin barrier may be left in place for 3-7 days, depending on the condition of the skin & skin barrier Water will not enter the stoma so it is not necessary to cover it while swimming, bathing, or showering

    Oxymetazoline (Afrin):

    Adrenergic agonist; vasoconstrictor

    Rebound congestion may occur with extended use (>3 days)

    Caution in the presence of HTN, DM, hyperthyroidism, CAD, asthma

    Increased toxicity with MAOI

    Do not use if it changes color or becomes cloudy

    MOA: stimulates alpha-adrenergic receptors in the arterioles of the nasal mucosa to produce vasoconstriction Approved for >6 years old

    Poison ivy:

    Urushiol plant

    Urushiol can spread quickly over body

    Vesiclar fluid cannot further spread Or not spread from the exudates of the blisters

    Topical anesthetics: benzocaine & pramoxine

    Hydrocortisone

    Astringents: Aluminum acetate (Burrowís solution, Domeboro Powder), zince oxide, zinc acetate, sodium bicarbonate, calamine, witch hazel (hamamelis waters)

    Colloidal oatmeal baths to help to provide skin hydration, to aide in cleansing or removing skin debris, & to allay the drying & tightening symptoms Antihistamines

    Robitussin: Guaifenesin: an expectorant used to help loosen phlegm & thin bronchial secretions to make coughs more productive

    Warts:

    Plantar warts: Clear Away Wart Remover: Salicyclic acid 40% Wart off Dr. Scholls Clear Away Pain:

    Pure Mu Agonists: strong opioids for severe pain

    Fentyl:

    Sublimaze: injection

    Duragesic: transdermal patch (change Q 3 days) 5 patches per box Actiq: lozenge

    Hydromorphone (Dilaudid):

    Can cause seizures Dosage forms: tablet, liquid, suppository, injection (a slight yellowish discoloration has not been associated with loss of potency

    Levoophanol (Levo-Dromoran) Dosage forms: tablet & injection

    Meperidine (Demerol, Meperitab):

    MOA: binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways, altering the perception of & response of pain

    Dosed Q 3-4 hours

    Hepatic metabolite, normeperidine, can buildup & cause seizures Do not use in patients with seizure disorders

    Avoid use with MAOIs

    Isocarboxazid (Marplan)

    Selegiline (Eldepryl, Deprenyl)- Parkinsonís Phenelzine (Nardil) Tranylcypromine (Parnate)

    Methadone (Dolophine, Methdose): Dosage forms: tablet, liquid, injection

    Morphine (Astramorph/PF, Avinza (ER cap), DepoDur, Duramorph, Infumorph, Kadian (SR), MS Contin (ER or SR), MSIR (IR), Oramorph SR, RMS, Roxanol):

    MOA: binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways, altering the perception of & response of pain

    Can cause: hypotension, bradycardia, respiratory depression

    Vasodilatory properties

    Dosage forms:

    Capsules (ER, SR)

    Infusion

    Injection (ER liposomal suspension for lumbar epidural injection)

    Injection, solution

    Solution Suppository Tablet (CR, ER, SR)

    Oxycodone (OxyIR, Roxicodone, Percocet, OxyContin (CR)): Oxymorphone (Numorphan-suppository) Dosage forms: injection & suppository

    Pure mu agonists: mild to moderate pain

    Codeine (Tylenol #3)

    Hydrocodone:

    With APAP: Vicoden 5/500; Vicoden ES 7.5/750; Lorcet or Vicodin HP 10/650; Lortab 2.5/500, 5/500, 7.5/500, 10/500; Norco 5/325, 7.5/325, 10/325 With IBU: Vicoprofen 7.5/200

    Propoxyphene: Propoxyphene/APAP: Darvocet-N-50 (50/325); Darvocet-N-100 (100/650) Darvon 32, 65 mg

    Agonists-antagonists:

    Buprenorphine (Buprenex)

    Butorphanol (Stadol) Available as: injection & nasal spray

    Dezocine (Dalgan)

    Nalbuphine (Nubain) Injection only

    Pentazocine:

    50 mg tablet: Talwin 50 mg/naloxone 0.5 mg tablet: Talwin NX 12.5/ASA 325 tablet: Talwin Compound

    Miscellaneous:

    Tramadol (Ultram) 400 mg max Ultracet (Tramadol/APAP 37.5/325)

    NSAIDS:

    Indomethacin (Indocin):

    Dosage: Inflammatory/RA: 25-50 mg/day 2-3 times/day; max 200 mg/day Dosage forms: IR & SR capsule, injection & suspension

    Ketorolac (Toradol):

    Do NOT use for more than 5 days

    NMT 40 mg/day po Acular: ophthalmic dosage form

    Nabumetone (Relafen):

    For Official Answer & RA

    Dosing: 1000 mg/day; an additional 500-1000 mg may be needed in some patients; may be administered QD or BID; NMT 2000 mg/day Take with food or milk to decrease GI upset

    Diclofenac (Voltaren)

    Etodolac (Lodine)

    Tolmetin (Tolectin)

    Sulindac (Clinoril)

    Fenoprofen (Nalfon)

    Flurbiprofen (Ansaid)

    Ibuprofen (Motrin)

    Ketoprofen (Orudis, Oruvail-SR)

    Naproxen (Naprosyn)

    Oxaprozin (Daypro)

    Meclofenamate (Meclomen)

    Piroxicam (Feldene)

    Celecoxib (Celebrex) Interferes with ACEIs, ARBs, & diuretics

    Conversions: Usual ratio is Morphine 8 to dilaudid 1 Methadone 10 mg = hydromorphone 7.5 mg (po) & 1.5 mg (IM) Parkinsonís:

    A chronic progressive neurologic disorder with symptoms that present as a variable combination of rigidity, tremor, bradykinesia, & changes in posture & ambulation

    Primary Parkinsonís- no identified cause

    Secondary Parkinsonís- may be the result of drug use (i.e. reserpine, metoclopramide, antipsychotics), infections, trauma, or toxins

    Progressive degeneration of the substantia nigra in the brain with a decrease in dopaminergic cells

    Drug therapy:

    Want medications that will increase dopamine or dopamine activity by directly stimulating dopamine receptors or by blocking acetylcholine activity, which results in increased dopamine effects

    Carbidopa-levodopa (Sinemet):

    MOA; levodopa increases DA; carbidopa prevents metabolism of levodopa allowing more to enter the blood brain barrier Take on an empty stomach & eat shortly after to prevent N/V

    Direct stimulation of DA receptors:

    Bromocriptine (Parlodel)

    Pergolide (Permax)

    Pramipexole (Mirapex) Ropinirole (Requip)

    Selegiline (Eldepryl, Carbex, Atapryl, Selpak): MOA: inhibits MAOB; increases DA & 5-HT

    Inhibits COMT; increases DA:

    Entacapone (Comtan) Tolcapone (Tasmar)

    Amantadine (Symmetrel): MOA: may increase presynaptic release of DA, blocks reuptake

    Blocks acetylcholine, may balance DA: Benztropine (Cogentin) Trihexyphenidyl (Artane) Vitamin E- antioxidant; mixed results Pediatrics:

    EES ointment given in neonate to prevent gonorrhea infection in the eyes

    Vitamin K is given to babies until they can produce their own

    Beractant (Survanta):

    Lung surfactant

    Prevention & treatment of respiratory distress syndrome in premature infants

    If <1250 g: at risk for developing or with evidence of surfactant deficiency Given within 15 minutes of birth

    Colfosceril (Exosurf): respiratory surfactant

    Administered intrathecheally

    Respiratory distress syndrome in the newborn: 5 mL (67.5 mg) per kg birthweight INTRATRACHEALLY Q 12 hr for 3 doses MOA: colfosceril, cetyl alcohol, & tyloxapol combination, when used as a replacement for deficient endogenous lung surfactant, is effective in reducing the surface tension of pulmonary fluids, thereby increasing lung compliance properties in RDS to prevent alveolar collapse & decrease work in breathing The possibility exists that it may also improve ventilation/perfusion matching, independent of its direct effect on lung compliance

    Neural tube defects are a result of a decrease in folic acid (while pregnant)

    Acetaminophen: <12 years: 10-15 mg/Kg/dose Q 4-6 hours prn (NMT 5 doses: 2.6 g in 24 hours)

    Ibuprofen:

    6 months ñ 12 years

    Temperature <102.5∞F: 5 mg/Kg/dose Temperature >102.5∞F: 10 mg/Kg/dose Q 6-8 hours; max daily dose: 40 mg/Kg/day Theophylline can be used as a respiratory stimulant in babies Pharmaceutics:

    Bioavailability: refers to the rate & extent of absorption

    Absolute bioavailability: the fraction (or %) of a dose administered non-IV (or extravascularly) that is systemically available (compared to an IV dose) If given orally, absolute bioavailability (F) is: F = (DIV/DPO) X (AUCPO/AUCIV) Relative bioavailability: the fraction of a dose administered as a test formulation that is systemically available as compared to a reference formulation: F = (AUCtest formulation/AUCreference) X ( Dreference/Dtest formulation)

    Compounding:

    Glycerin, talc, starch, witch hazel = suspension

    Talc is not soluble Starch is not very soluble

    To make a oleaginuous base use: white petrolatum Trituration: the process of grinding a drug in a mortar to reduce its particle size

    Drug color change due to: oxidation

    Filters: 0.22 micron filter does NOT remove pyrogens

    Methylcellulose: a suspending agent (semisynthetic hydrocolloids)

    Selected dosage forms:

    Butorphanol (Stadol) Injection, intranasal spray

    Calcitonin (Miacaclin)

    Injection, intranasal spray Stored in refrigerator

    Desmopressin (DDAVP, Stimate) Injection, intranasal spray, tablets

    All three above come in a nasal inhaler

    Budesonide: Capsules (Entocort), nasal suspension, powder for oral inhalation, suspension for oral inhalation Fluticasone: Aerosol for oral inhalation, cream (Cutivate), ointment, powder for oral inhalation, suspension intranasal spray

    Rizatriptan (Maxalt), loratadine (Claritin), ondansetron (Zofran) are all available as an orally disintegrating tablet (ODT)

    Mg sterate: lubricant in tablet Excess will cause alteration in tablet dissolution due to decreased rate of tablet break down (would slow down)

    Incompatibility: Pick pair of drugs with one acid & one base

    Storage:

    Liposyn-II

    Fat emulsion

    May be stored at room temperature

    Do not store partly used bottle for later use Do not use if emulsion appears to be oiling out Room temperature antibiotic suspensions: Clarithromycin (Biaxin); sulfamethoxazole-trimethoprim (Bactrim); azithromycin (Zithromax); cefdinir (Omnicef)

    Furosemide has a pka of 3.7 at physiologic pH will it be 25% ionized, 75% ionized, all ionized, all ionized or canít determine?

    Furosemide (one word generic name) is an acid; acids are all non-ionized at acidic pH but are ionized at basic pH; physiologic pH is 7.4 which is quite alkaline compared to 3.7; means furosemide ionized to non-ionized ratio would be > 1:1000, so totally ionized Naproxen pka = 4.2 what would happen at plasma pH? Same as above because naproxen is also an acid

    Typical pharmaceutical ingredients:

    Antifungal preservative: used in liquid & semisolid formulations to prevent growth of fungi Ex: benzoic acid, butylparaben, ethylparaben, sodium benzoate, sodium propionate

    Antimicrobial preservative: used in liquid & semisold formulations to prevent growth of microorganisms Ex: benzalkonium chloride, benzyl alcohol, cetylpyridinium chloride, phenyl ethyl alcohol

    Antioxidant: used to prevent oxidation Ex: ascorbic acid, ascorbyl palmitate, sodium ascorbate, sodium bisulfate, sodium metabisulfite

    Emulsifying agent: used to promote & maintain dispersion of finely divided droplets of a liquid in a vehicle in which it is immiscible Ex: acacia, cetyl alcohol, glyceryl monostearate, sorbitan monostearate

    Surfactant: used to reduce surface or interfacial tension Ex: polysorbate 80, sodium lauryl sulfate, sorbitan monopalmitate

    Plasticizer: used to enhance coat spread over tablets, beads, & granules Ex: glycerin, diethyl palmitate

    Suspending agent: used to reduce sedimentation rate of drug particles dispersed throughout a vehicle in which they are not soluble Ex: Carbopol, hydroxymethylcellulose, hydroxypropyl cellulose, methylcellulose, tragacanth

    Binder: used to cause adhesion of powder particles in tablet granulations Ex: acacia, alginic acid, ethylcellulose, starch, povidone

    Diluent: used as fillers to create desired bulk, flow properties, & compression characteristics in tablet & capsule preparations Ex: kaolin, lactose, mannitol, cellulose, sorbitol, starch

    Disintegrant: used to promote disruption of solid mass into small particles Ex: microcrystalline cellulose, carboxymethylcellulose calcium, sodium alginate, sodium starch, glycolate, alginic acid

    Glidant: used to improve flow properties of powder mixture Ex: colloidal silica, cornstarch, talc Lubricant: used to reduce friction during tablet compression & facilitate ejection of tablets from the die cavity Ex: calcium stearate, magnesium stearate, mineral oil, stearic acid, zinc stearate Humectant: used for prevention of dryness of ointment & creams Ex: glycerin, propylene glycol, sorbitol Pharmacokinetics:

    Tests used to test for drug absorption in GI:

    Dissolution

    Disintegration: must occur before dissolution can occur Hardness: hardness of a tablet influences its ability to break apart in the stomach All can be tested in vitro Pregnancy:

    Tocolytics (stops labor): Magnesium is a tocolytic

    Labor inducers:

    Prostaglandins and oxytocin both cause labor to start or proceed

    Oxytocin (Pitocin) is parenteral only (usually IV) PGE-2 does come in a gel that is applied to ripen the cervix prior to induction of labor & in suppositories (still technically topical) to induce labor

    Fetal alcohol syndrome: facial deformities (low nasal bridge, flat midface), postnatal growth retardation, or mental retardation

    Treatment of patent ductus arteriosus:

    *Indocin injection* IV indomethacin

    Ibuprofen

    Oxygen

    Diuretics Purpose of the ductus arteriosus in utero: to shunt blood from the pulmonary artery to the aorta Hydroxyurea (Droxia, Hydrea): use to increase fetal hemoglobin in sickle cell patients Priaprism:

    Causative agents: chlorpromazine, prazosin, trazodone, other phenothiazines, antihypertensives, anticoagulants, corticosteroids, & any drug used to produce an erection

    PDE-5 inhibitors: Sildenafil (Viagra) Vardenafil (Levitra) Tadalafil (Cialis) Can last up to 36 hours Psoriasis:

    Chronic, epidermal proliferative disease characterized by erythematous, dry scaling patches, recurring remissions & exacerbations

    Treatment:

    Mild to moderate disease:

    Emollients BID: soft yellow paraffin or aqueous cream; petrolatum or Aquaphor cream (greasier & more effective)

    Topical, low potency corticosteroids on delicate skin (face, genitals): alclometasone dipropionate, triamcinolone acetonide 0.025%, hydrocortisone 2.5%

    Topical, medium potency cortisteroids: fluticasone propionate, triamcinolone acetonide 0.1%, hydrocortisone valerate, mometasone furoate

    Topical, strong potency: betamethasone dipropionate, halcinonide, fluocinonide, desoximetasone

    Topical, super potency: augmented betamethasone dipropionate, diflorasone diacetate, clobetasol propionate, halobetasol propionate

    Limit use to 2 weeks Avoid occlusive dressings

    Intralesional corticosteroid: 2-5 mg/mL triamcinolone acetonide

    Coal tar (Estar, PsoriGel) as an alterative to topical steroids

    Keratolytic agents to decrease scales: salicyclic acid 6% gel UV lamps & sunlight are effective- best option for pregnancy or young children Anthralin ointment 1% or higher prior to light

    Severe disease:

    Triamcinolone, intralesional mix

    Vitamin D analogs (calcipotriene ointment 0.05%- not on face)

    Acitretin (Soriatane) Tazarotene (Tazorac) Methotrexate, hydroxyurea, azathioprine, or cyclosporine Triamcinolone (Aristocort A; Aristocort Forte; Aristospan; Azmacort; Kenalog; Nasacort AQ; Nasacort HFA; Tri-Nasal; Triderm) Psychriatric Disorders:

    ADHD:

    Methylphenidate (Concerta, Methadate, Methylin, Ritalin)

    MOA: reuptake blockade of catecholamine (NE & DA) in presynaptic nerve endings Dosage form of Concerta: 18, 27, 36, 54 mg ER tablets NOT SR

    Atomoxetine (Strattera):

    BBW for suicide ideation in children MOA: NE reuptake inhibitor Dosed once daily (advantage over Concerta)

    Antidepressants:

    SSRIs:

    MOA: selectively inhibit the reuptake of 5-HT

    Citalopram (Celexa)

    Escitalopram (Lexapro)

    Fluvoxamine (Luvox)

    Sertraline (Zoloft)

    Auxiliary labeling:

    No etoh

    May cause drowsiness or dizziness May cause sexual dysfunction Take in AM to prevent insomnia in PM

    Fluoxetine (Prozac):

    Does not require tapering because of its long half life Take in AM

    Paroxetine (Paxil):

    Take in AM to reduce chances of insomnia Paxil CR incorporates a degradable polymeric matrix (Geomatrix) to control dissolution rate over a period of 4-5 hours EC delays the start of drug release until tablets have left the stomach May take 4 weeks to see effects

    Miscellaneous:

    Bupropion (Wellbutrin, Zyban):

    MOA: dopamine reuptake inhibitor CI with history of seizure disorder

    Venlafaxine (Effexor):

    MOA: inhibits the reuptake of 5-HT & NE (& DA at higher doses)

    Referred to as a serotonin-norepinephrine reuptake inhibitor (SNRI)

    XR formulation is available to decrease GI upset Not recommended in patients with uncontrolled HTN, recent MI, or CV disorders

    Duloxetine (Cymbalta):

    MOA: potent inhibitor of 5-HT & NE (no DA activity)

    Indicated for both major depression & diabetic peripheral neuropathic pain CI: uncontrolled narrow-angle glaucoma

    Trazodone (Desyrel): MOA: inhibits 5-HT reuptake & blocks 5-HT2A receptors

    Nefazodone (Serzone): MOA: inhibits 5-HT & NE uptake & blocks 5-HT2A receptors Mirtazapine (Remeron): MOA: antagonizes presynaptic a-2 autoreceptors & heteroreceptors that prevent the release of 5-HT & NE (resulting in increased 5-HT & NE in the synapses); antagonizes 5-HT2A & 5-HT3 receptors, resulting in less GI upset & less anxiety

    Combinations:

    Olanzapine & fluoxetine (Symbax): Atypical antipsychotic agent/SSRI Use: treatment of depressive episodes associated with bipolar disorder

    MAOIs:

    MOA: increase the synaptic concentration of NE, 5-HT, & DA by inhibiting the breakdown enzyme, monoamine oxidase

    Isocarboxazid (Marplan)

    Phenelzine (Nardil)

    Tranylcypromine (Parnate)

    Medications to avoid on MAOIs:

    Compazine

    Phenylpropanolamine: tyramine-like reaction

    Pseudoephedrine: tyramine-like reaction

    Meperidine (Demerol): life-threatening serotonin syndrome-like reaction

    Methyldopa (Aldomet): hypertensive crisis

    Morphine (Roxanol, MS Contin): CNS depression Reserpine (Ser-Ap-Es): increased catecholamines Serotonergic agents (i.e. fluoxetine): serotonin syndrome

    TCAs:

    MOA: increase the synaptic concentration of 5-HT &/or NE in the CNS by inhibiting the presynaptic neuronal membraneís reuptake of 5-HT or NE

    Amitriptyline (Elavil) Off label use: neuropathic pain

    Nortriptyline (Pamelor, Aventyl)

    Imipramine (Tofranil)

    Doxepin (Sinequan) Clomipramine (Anafranil) Desipramine (Norpramin)

    Antipsychotics:

    Atypical:

    Arpiprazole (Abilify):

    AE: insomnia, +/- weight gain

    Once daily dosing benefit Partial dopamine agonist

    Clozapine (Clozaril, FazaClo-ODT:

    For refractory schizophrenia only

    A Dibenzodiazepine

    AE: sedation, weight gain, hypersalivation, seizure risk Weekly CBC with diff required WBC <3500 or ANC <1500 MUST discontinue

    Olanzapine (Zyprexa, Zydis-ODT):

    MOA: a thienobenzodiazepine antipsychotic that is believed to work by antagonizing dopamine & serotonin activities

    It is a selective monoaminergic antagonist with high affinity binding to 5-HT2A & 5-HT2C, dopamine D1-4, muscarinic M1-5, histamine H1 & a-1 receptor sites Binds weakly to GABA-A, BZD, & beta-adrenergic receptors AE: sedation, orthostasis

    Quetiapine (Seroquel):

    A dibenzothiazepine Low EPS risk

    Risperidone (Resperdal):

    Benzisoxazole

    Use: schizophrenia, bipolar Dosage forms: injection, solution, tablet, ODT

    Ziprasidone (Geodon) Benzisothiazoyl AE: +/- sedation, +/- weight gain, QT prolongation

    Typical:

    Chlorpromazine (Thorazine)

    Fluphenzaine (Prolixin)

    Haloperidol (Haldol) SE: Hyper-, hypotension, tachycardia, arrhythmias, torsade de points, EPS, anxiety, alopecia, rash, gynecomastia, jaundice, blurred vision

    Thioridazine (Mellaril) BBW: QT prolongation Thiothixene (Navane) a psychotropic agent derived from thioxanthene & clinically useful in the tx of schizophrenia Similarities in chemical & pharmacological properties exist between this agent & piperazine phenothiazines

    Anxiolytic agents:

    Benzodiazepines:

    MOA: potentiate the actions of GABA by increasing the influx of Cl ions into neurons

    Alprazolam (Xanax, Niravam-ODT)

    Chlordiazepoxide (Librium)

    Available as injection Prior to reconstitution, keep refrigerated & protected from light Should be used immediately following reconstitution

    Clonazepam (Klonopin) Available as an orally disintegrating wafer

    Clorazepate (Tranxene)

    Diazepam (Valium) Available as injection Potency is retained for up to 3 months when kept at room temp

    Estazolam (Prosam)

    Flurazepam (Dalmane)

    Halazepam (Paxipam)

    Lorazepam (Ativan)

    Available as an injection

    Intact vials should be refrigerated & protected from light

    Do not use if discolored

    Injectable vials may be stored at room temperature for up to 60 days Parenteral admixture is stable at room temperature for 24 hours

    Oxazepam (Serax)

    Prazepam (Centrax)

    Quazepam (Doral)

    Temazepam (Restoril)

    Trazolam (Halcion)

    Lorazepam, oxazepam, & temazepam ( LOT ) are conjugated & preferred in patients with hepatic dysfunction & elderly patients

    Chlordiazepoxide, diazepam, & lorazepam available for IV use

    Never abruptly discontinue Avoid in pregnancy- cause cleft palate

    Buspirone (BuSpar):

    MOA: unknown. It exhibits high affinity for serotonin (5-HT1A) receptors, moderate affinity for brain D2-dopamine receptors & no significant affinity for benzodiazepine receptors. It has no effect on GABA binding.

    Non-FDA labeled indication: depression

    Non-sedating No grapefruit Take consistently either with or without food

    EPS treatment:

    Dystonia: state of abnormal tonicity, sometimes described simplistically as a severe ìmuscle spasmî

    Benzotropine mesylate 2 mg

    Diphenhydramine 50 mg IV or IM

    Diazepam 5-10 mg by slow IV push Lorazepam 1-2 mg IM

    Akathisia: inability to sit still & being functionally mortor restless

    Diazepam 5 mg TID

    Propanolol 10 mg QD Nadolol 80 mg QD Beta 2 selective are less effective

    Pseudoparkinsonism: an AP-induced extrapyramidal side effect, resembles idiopathic Parkinsonís Disease

    Patient may have slurred speech & a drooping face

    Trihexyphenidyl 2-5 mg TID

    Diphenhydramine 25-50 mg TID

    Biperiden (Akineton) 2 mg TID Amantadine

    Tardive dyskinesia: syndrome characterized by abnormal involuntary movements occurring late in onset in relation to initiation or AP therapy No FDA approved agents a-tocopherol (vitamin E) 1200-1600 IU has been tried

    Mood stabilizers:

    Bipolar

    Lithium (Eskalith CR, Lithobid, Eskalith, Cibalith-S--syrup):

    Use: bipolar disorder

    CI: renal disease, severe CVD, pregnancy

    SE: hyponatremia

    Monitor thyroid function

    ìLithium does everything that sodium will doî

    Reaches steady state in 4-5 days

    Obtain level 2-8 hours post-dose

    Toxicity:

    Mild (serum levels 1.5-2): GI upset (N/V/D), muscle weakness, fatigue, fine hand tremor, difficulty with concentration & memory Moderate (2-2.5): Ataxia, lethargy, nystagmus, worsening confusion, severe GI upset, coarse tremors, increased deep tendon reflexes Severe (>3): Severely impaired consciousness, coma, seizures, respiratory complications, death

    Dosage forms: capsules, syrup, tablet (IR, CR, slow release)

    DI:

    Increase Li levels:

    NSAIDS

    ACEI

    Fluoxetine

    Metronidazole

    Diuretics Sodium depletion: low sodium diet, excessive sweating, vomiting/diarrhea, salt deficiency

    Decrease Li levels:

    Theophylline

    Caffeine Pregnancy Osmotic diuretics (mannitol, urea) Pregnancy category: D

    Divalproex sodium (Depakote) Carbamazepine (Tegretol)

    Touretteís Syndrome:

    Simple tics & 1st line of therapy is short acting benzodiazepines

    Next is clonidine which does not cause tardive dyskinesia in these patients

    Intermediate acting benzodiazepines (Ativan) are also useful For severe cases, the choice is an antipsychotic such as haloperidol (Haldol) or pimozide (Orap) but these can cause tardive dyskinesia, dysphoria, & pseudoparkinsonís

    Anon-sedating anxiolytic for the elderly: buspirone (Buspar) Has a high affinity for 5-HT & dopamine receptors Does not affect benzodiazepine GABA receptors Questions:

    Mother has gestational diabetes, what is likely to occur when the baby is born. Mother also has epilepsy & is taking tegretol.

    I. high birth weight II. Baby may have congenital abnormalities III. Baby is likely to have diabetes

    Answer: I & II Tegretol is a class D drug

    What strength will Albuterol 0.5% end up based on an order to mix it with 2.5 mL normal saline? 0.083%

    Isosorbide dinitrate is dosed BID, what regimen is best 7 am & 12 noon, 7 am & 7 pm, 9 am & 9 pm, 8 am & 5 pm? 8 am & 5 pm to allow nitrate free period (same as removing NTG patches at bedtime)

    What substitute can you use for desitin ointment (Balmex, Boudreauxís Butt Paste)? Zinc oxide

    Precose counseling information:

    I. Take 30 minutes before meal II. Causes gas III. Should not take if meal skipped Answer: II & III

    What treatment would increase antibiotic compliance? Patient receiving zithromax 1 tsp QD x 5days

    Augment, ceftriaxone, cefuroxime axetil, doxycycline Answer: the usual method to improve compliance for any type of drug is to reduce the number of doses that must be taken each day & to give a drug with the fewest uncomfortable or dangerous SE (I would chose ceftriaxone- IM single dose treatment)

    Which of the following could you give a patient on NTG?

    I. Cialis II. Muse (alprostadil) III. Caverject (alprostadil)

    Answer: II & III- alprostadil is prostaglandin used for erectile dysfunction & patent ductus arteriosus Available as: intracavernosal Kit, intracavernosal powder for solution, intracavernosal solution, intraurethral Suppository, & intraurethral solution Alprostadil (Prostin VR)

    Patient requesting antihistamine eye drop & having a dark spot in vision- refer to MD

    Which of the following is available in a liquid formulation?

    I. NTG II. Hydroxyzine III. Digoxin Answer: II & III

    Which is the shortest acting insulin?

    Humulin N, Humulin U, Humalog, or regular Answer: Humalog

    Who should not get a flu shot? An infant in day care; 32 yo type II diabetic; 65 yo retired lady; 35 yo nurse working in hospital Answer: 32 yo type II diabetic

    Which of the following cannot be self monitored?

    Glucose level; K level; cholesterol levels; hormone used in pregnancy test Answer: K levels

    Cytoxan is most similar to mechlorethamine, procarbazine, or 5-FU? Answer: mechlorethamine

    A patient with Travelerís diarrhea too PeptoBismol 4 tsp Q Ω hour. After 3 days he began experiencing ringing in the ears. What does he have? Bismuth toxicity or salicylate toxicity?

    Answer: salicylate toxicity Bismuth toxicity would cause neurotoxicity

    Which of the following are OTC hemorrhoid treatments:

    I. TUCKs pads II. Nupercainal ointment III. Rowasa Answer: I & II

    Which of the following is an ER Morphine?

    A. MSIR B. MS Contin C. Diluadid D. Oxycontin Answer: B

    Which of the following agents should be administered to a person exposed to Anthrax?

    A. Flagyl B. Cipro C. Zovirax D. Valtrex Answer: B

    Erythromycin exhibits its anti-infective properties by- blocking protein synthesis via binding & inhibition of the 50-S subunit of bacterial ribosomes

    Patient has pseudomembranous colitis & allergy to metronidazole. Which of the patientís medications could have caused the pseudomembrane colitis?

    A. Ibuprofen B. Tylenol C. Flagyl D. Cleocin E. Zantac

    Answer: D

    This person could be treated with?

    A. Flagyl B. Vancomycin C. Doxycycline D. Lincomycin E. Ampicillin Answer: B

    The DOC for the treatment of pseudomembraneous colitis is: A. Metronidazole B. Erythromycin C. Clindamycin D. Ampicillin E. Lincomycin Answer: A

    Which of the following NSAIDs has an ophthalmic preparation:

    A. Ibuprofen B. Naproxen C. Diclofenac D. Ketoprofen Answer: C- Voltaren

    Cedax acts by- inhibiting the use of pencillin binding proteins in bacterial cell wall synthesis

    Acetylcysteine in the treatment of CF is best given:

    A. IV B. By inhalation C. IM D. Orally Answer: B

    A patient is given a rx for fentanyl 100 mcg/hr patch for 1 month. How many boxes should you dispense?

    A. 1 B. 2 C. 3 D. 4 E. 5 Answer: 2; 1 patch= 3 days, so you need 10 patches; comes in boxes of 5 patches so you need 2

    Which of the following is not an erythropoetin formulation?

    A. Epogen B. Procrit C. Aranesp D. Neupogen Answer: Neupogen

    Which of the following fluoroquinolones has an otic preparation?

    Answer: ofloxacin (Floxin- also has an ophthalmic); Eye drops only: levofloxacin, gatifloxacin, moxifloxacin

    The use of this agent is CI in children?

    A. Erythromycin B. Bactrim C. Ciprofloxacin D. Cephalexin Answer: C

    What is the recommended daily dosage of calcium for an adult?

    A. 300-500 mg B. 600-800 mg C. 800-1000 mg D. 100-1500 mg Answer: D

    Due to difficulty in coordinating their inhalations, older patients should use:

    A. Nebulizer B. Peak flow meter C. Spacers D. Spirometer Answer: C Monitoring of asthma at home can be done with: A. Nebuli
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    Trying to make mom and pop proud oranges's Avatar
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    Hi Guys
    thank you very much for the hard work but I have tried to do the notepad thing but it didnt work. Any suggestions.

    Thanks again
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    This thread is incredibly long. I'm going to close it to prevent replies, as the replies were causing the thread to load slowly. If you have any questions, I'd be more than happy to answer them. Just head over to the Feedback Forum to post your question.

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