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From Flashcardlet > LEIK Pharmacology Review > Flashcards

LEIK Pharmacology Review Flashcards

0
Q

Drug Metabolism

A

The most active organ is the LIVER (Cytochrome P450 enzyme system)

Others are Kidneys, GI Tract, Lungs

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1
Q

First Pass Metabolism

A

GI Tract —> Portal Circulation —> Liver —>Metabolized —> Systemic Circulation

1st pass metabolism lowers the amount of drug available.

If high first-pass effect, mostly becomes inactivated and cannot be used, these meds cannot be given orally. Example: Insulin

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2
Q

Coumadin and Bactrim

A

Sulfa drugs will interact with warfarin (increases the blood level) which results in:

*Elevation of INR and Risk of Bleeding!

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3
Q

Potent Inhibitors of the cytochrome P450 (CYP450) System

*Responsible for a number of drug to drug interactions

A

■ Macrolides (erythromycin, clarithromycin, pediazole)

■ Antifungals (ketoconazole, fluconazole)

■ Cimetidine (Tagament)

■ Citaprolam (Celexa)

■ Cisapride (Propulsid). This drug has been pulled from the U.S. market.

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4
Q

Pharmacology terms

A

■ Half-life (t½): the amount of time in which drug concentration decreases by 50%.

■ Area under the curve (AUC): the average amount of a drug in the blood after a dose is given. It is a measure of the availability (bioavailability) of a drug after it is administered.

■ Minimum inhibitory concentration (MIC): the lowest concentration of an antibiotic
that will inhibit the growth of organisms (after overnight incubation).

■ Maximum concentration: the highest concentration of a drug after a dose.

■ Trough (minimum concentration): the lowest concentration of a drug after a dose.

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5
Q

Narrow Therapeutic Index Drugs*

A

■Warfarin sodium (Coumadin): monitor INR.

■ Digoxin (Lanoxin): monitor digoxin level, EKG, electrolytes (potassium, magnesium, calcium).

■ Theophylline: monitor blood levels.

■ Carbamezapine (Tegretol) and phenytoin (Dilantin): monitor blood levels.

■ Levothyroxine: monitor TSH.

■ Lithium: monitor blood levels, TSH (risk of HYPOthyroidism).

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6
Q

Safety Issues: Thiazolidinediones (TZDs)

Pioglitazone (Actos)

*Insulin Sensitizer

A

Can Cause or exacerbate CHF in some patients.

*Do not use if NYHA Class III or IV heart failure

STOP if: c/o dyspnea, weight gain, cough (HEART FAILURE)

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7
Q

Safety Issues: Atypical antipsychotics

Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quietipine (Seroquel)

A

High risk of WEIGHT GAIN, metabolic syndrome, and type 2 diabetes.

Monitor weight every 3 months. Black Box Warning: higher
mortality in elderly patients.

Monitor: TSH, lipids, weight/body mass index (BMI)

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8
Q

Safety Issues: Biphosphonates

Alendronate (Fosamax)
Risedronate (Actonel)

A

Jaw pain (JAW NECROSIS). Chest pain, difficulty swallowing, burning mid-back (perforation).

Take ALONE upon awakening with 8 oz glass water (NOT JUICE) before breakfast. Do not lie down x 30 minutes afterward. Do not mix with other drugs). Take FIRST thing in the morning before breakfast

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9
Q

Safety Issues: Statins

Atorvastatin (Lipitor)
Lovastatin (Mevacor)
Rosuvastatin (Crestor)
Simvastatin (Zocor)

A

Do NOT mix with GRAPEFRUIT juice

Drug-induced hepatitis or rhabdomyolysis higher if mixed with
AZOLE antifungals

High-dose Zocor (80 mg) has highest risk of rhabdomyolysis (muscle pain/tenderness)

CK (creatine kinase) level goes up.

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10
Q

Safety Issues: Lincosamides

Clindamycin (Cleocin)

A

Higher risk of Clostridium difficile-associated diarrhea (CDAD)

Metronidazole (Flagyl) PO TID × 10-14 days

Probiotics daily—BID × few weeks

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11
Q

Drugs used to treat heart disease

A

■ Cardiac Glycosides: Digoxin (Lanoxin)

■ Anticoagulants: Warfarin Sodium (Coumadin)

■ Thiazide Diuretics

■ Potassium-Sparing Diuretics

■ Loop Diuretics

■ Aldosterone Antagonists

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12
Q

Cardiac Glycosides: Digoxin (Lanoxin)

A

Treats atrial fibrillation.
- Digoxin has a narrow therapeutic range (0.5-2.0 ng/mL).

*NOT a first-line drug for heart rate control in atrial fibrillation.

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13
Q

Signs and symptoms of digoxin overdose:

A
  • Initial symptoms are GASTROINTESTINAL (anorexia, nausea/vomiting, abdominal pain). Others are arrhythmias, confusion, and VISUAL CHANGES (yellowish green tinged-color vision, scotomas).
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14
Q

Severe toxicity

A

Severe toxicity is treated with digoxin-binding antibodies (Digibind).

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15
Q

What laboratory test should be ordered if digoxin toxicity is suspected?

A

Order a digoxin level, electrolytes (potassium, magnesium, calcium), creatinine, and serial EKGs.

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16
Q

Anticoagulants: Warfarin Sodium (Coumadin)

A

■ Decreases emboli/thrombi formation (atrial fibrillation, stroke, pulmonary emboli).

■ For atrial fibrillation, the target INR is from 2.0 to 3.0.

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17
Q

A patient has an INR of 8.0. Physical examination is negative for petechiae, bleeding gums, bruising, or dark stools. What is the best treatment plan for this patient?

A
  • INR between 5.0 and 9.0 (without bleeding): Hold the warfarin for 1 to 2 doses. Recheck INR every 2 to 3 days until it is stable (INR between 2.0 and 3.0).

Another option is to hold the warfarin and add a small dose of oral vitamin K. Limit and/or avoid high vitamin K foods (green leafy vegetables, broccoli, brussels sprouts, cabbage). After the INR becomes stable, recheck it monthly.*

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18
Q

Clinical Tips

A

■ INR values BELOW 2.0 increase stroke risk SIXFOLD.

■ There is a higher risk of hemorrhage with high INRs in the elderly (age greater than 70 years).

■ Mayonnaise, canola oil, and soybean oil also have high levels of vitamin K.

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19
Q

Thiazide Diuretics

A

■ Uncomplicated hypertension (FIRST line), heart failure (FIRST line), edema.

■ Hypertension accompanied by OSTEOPOROSIS.

■ Hydrochlorothiazide (HCTZ) 12.5 to 25 mg PO daily.

■ Chlorthalidone 12.5 to 25 mg PO daily.

■ Indapamide (Lozol) PO daily.

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20
Q

Thiazide Diuretics: Adverse Effects

A

■ HYPERglycemia (careful with diabetics).

■ ELEVATES triglycerides and LDL (careful if preexisting
hypertriglyceremia).

■ ELEVATES uric acid (can precipitate a gout attack).

■ HYPOkalemia (muscle weakness, arrythymia).

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21
Q

Pharma Notes: Thiazide Diuretics

A

■ Patients with both HYPERTENSION and OSTEOPOROSIS have an extra benefit from thiazides.

■ Thiazide diuretics DECREASE CALCIUM EXCRETION by the kidneys and STIMULATE OSTEOCLAST formation.

■ Patients with serious SULFA allergies should AVOID thiazide diuretics. POTASSIUM-SPARING diuretics such as triamterene and amiloride (Midamor) are the ALTERNATIVE options for these patients.

■ Chlorthalidone is LONGER acting and more POTENT than HCTZ.

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22
Q

Potassium Sparing Diuretics

A

■ Hypertension, alternative diuretic for patients with severe SULFA allergy.

■ Triamterene (Dyrenium).

■ Amiloride (Midamor).

■ Combination: triamterene and HCTZ (Dyazide), amiloride and HCTZ (Moduretic).

■ Black Box Warning: HYPERKALEMIAS, which can be fatal. Higher risk with renal impairment, diabetes, elderly, severely ill.

■ Monitor serum potassium frequently (baseline, during, dose changes, illness).

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23
Q

Pharma Notes: Potassium Sparing Diuretics

A

■ Do NOT give potassium supplement. AVOID using salt SUBSTITUTES that contain potassium.

■ Be careful with combinations of ACEI/angiotensin-receptor
blockers (ARBs); INCREASES risk of HYPERKALEMIA.

■ AVOID with severe RENAL disease (increases risk of hyperkalemia).

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24
Q

Loop Diuretics

A

■ EDEMA from heart failure, cirrhosis, renal disease, hypertension.

■ Loop diuretics are excreted via the loop of Henle of the kidneys and are MORE POTENT than HCTZ.

■ More potent than thiazides, but with SHORTER DURATION of action (BID).

■ Black Box Warning: EXCESSIVE amounts of furosemide may lead to PROFOUND DIURESIS. Medical supervision required, individualized dose schedule.

■ Furosemide (Lasix) PO BID.
■ Bumetanide (Bumex).

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25
Q

Loop Diuretics: Adverse Effects

A

■ Electrolytes (HYPOkalemia, HYPOatremia/low sodium, low levels of chlorine).

■ HYPOvolemia and HYPOtension (dizziness,
lightheadedness).

■ Pancreatitis, jaundice, rash.

■ Ototoxicity (worsens aminoglycoside ototoxicity effect if combined).

■ Be careful with GOUT diuretics can cause HYPERuricemic states due to fluid loss.

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26
Q

Aldosterone Antagonists

A

■ Hirsuitism, hypertension, severe heart failure

■ Spironolactone (Aldactone)

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27
Q

Pharma Notes: Aldosterone Antagonists

A

Adverse effects are GALACTORRHEA and HYPERKALEMIA. Spironolactone is RARELY used to treat hypertension in primary care due to adverse effects and HIGHER risk of certain cancers.

■ Black Box Warning: INCREASES risk of both BENIGN and MALIGNANT TUMORS.

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28
Q

Drugs used to treat Hypertension

A

BETA-BLOCKERS (Beta Antagonists)
ACE INHIBITORS (ACEIs) AND ARBs
CALCIUM CHANNEL BLOCKERS
ALPHA-BLOCKERS

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29
Q

*ACE Inhibitors

A

Avoid potassium supplements. Check POTASSIUM about one month after starting or changing therapy.

Lisinopril (Zestril) Careful with potassium-sparing diuretics
Captoril (Capoten) ACE inhibitor cough—new onset of dry COUGH (not accompanied by URI symptoms)

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30
Q

*ARBs

A

Valsartan (Diovan)
Losartan (Cozaar)

FIRST-line choice for DIABETICS

FIRST-line choice for mild to moderate RENAL disease

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31
Q

*Potassium-sparing diuretics

A

Triamterene (Dyrenium)
Triamterene + HCTZ (Dyazide)
Amiloride (Midamor)

Higher risk of hyperkalemia if combined with ACEI or ARBs
and with severe RENAL disease

Diuretics may WORSEN URINARY incontinence

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32
Q

*Beta Blockers

A

Propranolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor), pindolol (Visken)

Contraindicated if patient has CHRONIC LUNG diseases (asthma, COPD, emphysema, chronic bronchitis)

Do NOT discontinue beta-blockers ABRUPTLY due to severe REBOUND (hypertensive crisis)

May MASK the signs and symptoms of HYPOGLYCEMIA!

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33
Q

*Sildenafil (Viagra)

A

Do NOT mix with NITRATES (nitroglycerine, isosorbide dinitrate) and some ALPHA-blockers.

Erection greater than 4 HOURS—REFER to ED

Tadalafil (Cialis) Do NOT give within 3 to 6 MONTHS of an MI, stroke

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34
Q

Pharma Notes: Beta Blockers

A

■ Hypertension, POST MI-myocardial infarction (FIRST LINE), angina, arrhythmias, MIGRAINE prophylaxis.

■ Adjunct treatment: HYPERthyroidism/thyrotoxicosis (DECREASES heart rate, anxiety).

■ Migraine prophylaxis.
- Non-cardioselective (blocks beta-1 and beta-2).

■ Propanolol immediate release (Inderal) or extended release (Inderal LA).

■ Timolol oral (Blocadren) or timolol ophthalmic drops (glaucoma).

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35
Q

Cardioselective (blocks BETA-1 ONLY)

A

■ Cardioselective (blocks beta-1 only).

  • ATENOLOL (Tenormin) daily.
  • METOPROLOL immediate release (Lopressor) or extended release (Toprol XL).
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36
Q

Beta-Blockers Side Effects

A

SE:
■ BRONCHOSPASM

■ Bradycardia

■ Depression, fatigue (careful with elderly)

■ Erectile dysfunction (ED)

■ Blunts hypoglycemic response (warn diabetic patients)

■ Contraindications:

  • ASTHMA (causes BRONCHOCONSTRICTION)
  • COPD (causes BRONCHOCONSTRICTION)
  • Chronic bronchitis (causes BRONCHOCONSTRICTION).
  • Emphysema (causes BRONCHOCONSTRICTION).
  • Bradycardia and AV-block (second- to third-degree block).
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37
Q

ACE Inhibitors: Contraindications

Lisinopril (Zestril)
Captoril (Capoten)

A
  • Avoid POTASSIUM supplements
  • Careful with POTASSIUM SPARING diuretics
  • ACE inhibitor COUGH—new onset of dry cough (not accompanied by URI symptoms)
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38
Q

ARBs: Contraindications

Valsartan (Diovan)
Losartan (Cozaar)

A
  • FIRST-line choice for DIABETICS

* FIRST-line choice for mild to moderate RENAL disease

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39
Q

Potassium-sparing diuretics: Contraindications

Triamterene (Dyrenium)
Triamterene + HCTZ (Dyazide)
Amiloride (Midamor)

A

Higher risk of HYPERkalemia if combined with ACEI or ARBs
and with severe RENAL disease

Diuretics may WORSEN URINARY incontinence

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40
Q

Beta-Blocker: Contraindications

Propranolol (Inderal), atenolol (Tenormin), metoprolol (Lopressor), pindolol (Visken)

A

Contraindicated if patient has CHRONIC LUNG diseases (asthma, COPD, emphysema, chronic bronchitis)

Do NOT discontinue beta-blockers abruptly due to severe
REBOUND (HYPERTENSIVE crisis)

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41
Q

Sildenafil (Viagra) and Tadalafil (Cialis): Contraindications

A

Do NOT mix with NITRATES (nitroglycerine, isosorbide dinitrate) and some ALPHA-blockers. Erection greater than 4 hours—REFER to ED

Do NOT give within 3 to 6 MONTHS of an MI, STROKE

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42
Q

Ace Inhibitors (ACEIs) and ARBS

A

*CANNOT be PREGNANT or LACTATING
■ Hypertension, DIABETES (RENAL), chronic kidney disease (CKD), others.

■ Category C (first trimester) and Category D (second to third trimesters).

■ ACE inhibition BLOCKS CONVERSION of angiotensin I to 
angiotensin II (potent VASOCONSTRICTOR).

■ ARBs block angiotensin II (less aldosterone). ACEI suffix of “PRIL.” ARB suffix of “SARTAN.”

■ Black Box Warning: ACEI can cause DEATH/INJURY to the developing FETUS during the second and third trimesters. STOP ACEIs and ARBs immediately if PREGNANT.

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43
Q

ACEIs

A

■ Lisinopril (Zestril, Prinivil)

■ Combination: lisinopril and HCTZ (Zestoretic)

■ Benazepril (Lotensin)

■ Captopril (Capoten)

■ Enalapril (Vasotec)

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44
Q

ARBs

A

■ Losartan (Cozaar)

■ Irbesartan (Avapro)

  • Contraindication: ACEI-/ARB-associated angioedema, hereditary angioedema
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45
Q

Adverse Effects: ACEI and ARBS

A

■ Angioedema and anaphylactoid reactions

■ ACEI cough

■ Hyperkalemia

■ ACE works in the KIDNEYS & IMPAIRS POTASSIUM EXCRETION with normal kidney function. Must monitor POTASSIUM, BUN, & CREATININE “1” WEEK after initiation and with each increase.

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46
Q

Pharma Notes: ACEI and ARBS

A

*ACEI COUGH occurs within the FIRST few months of treatment. It is a DRY and HACKING cough (without other symptoms of URI). STOP ACEI and SWITCH to an ARB.

■ ARBS are FIRST-line drug for hypertension in DIABETICS (diabetic nephropathy).

■ FIRST-line drug for patients with (proteinuric) CKD.

■ AVOID using SALT substitutes that contain POTASSIUM.

■ Captopril associated with agranulocytosis, neutropenia, leukopenia (rare). MONITOR CBC.

■ Both ACEIs and ARBs are EXCRETED in BREAST MILK (breastfeeding mothers should avoid them).

*Be careful prescribing ACEIs/ARBs to SEXUALLY ACTIVE, reproductive-aged females who are NOT consistently
using BIRTH CONTROL (Category C and Category D during the second and third trimester).

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47
Q

Calcium Channel Blockers

A

■ Hypertension, RAYNAUDS phenomenon (FIRST line)

■ Amlodipine (Norvasc)

■ Diltiazem (Cardizem)

■ Nifedipine (Procardia)

■ Verapamil (Calan): Do NOT mix with ERYTHROMYCIN and CLARITHROMYCIN (MACROLIDE drug interaction)

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48
Q

Calcium Channel Blockers: Contraindications

A
  • AV-BLOCK (second- to third-degree block)
  • BRADYCARDIA
  • Congestive heart failure (CHF)
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49
Q

Pharma Notes: Calcium Channel Blockers

A

■ Educate patients to AVOID GRAPEFRUIT JUICE (toxicity results as it will INCREASE drug level).

■ Possible drug interactions: intraconazole, MACROLIDES (EXCEPT AZITHROmycin).

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50
Q

Adverse Effects: Calcium Channel Blockers

A

■ HEADACHE (vasodilation)

■ Peripheral EDEMA (not due to fluid overload)

■ BRADYcardia

■ Heart failure and heart block

■ HYPOtension, QT prolongation

  • CONSTIPATION is the MOST COMMON side effect
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51
Q

Alpha Blockers

A

■ Hypertension with coexisting BPH.

■ Terazosin (Hytrin) 1 mg PO at bedtime (lowest dose).

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52
Q

Pharma Notes: Alpha Blockers

A

■ NOT a first-line choice

■ FIRST LINE for males with BOTH HYPERTENSION and BPH.

■ Potent VASODILATOR. Common side effects are DIZZINESS and HYPOTENSION. Give at BEDTIME at very LOW dose and SLOWLY TITRATE up. Careful with frail ELDERLY (risk of syncope and falls).

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53
Q

Antibiotic Allergies

A

If PENICILLIN allergic, may also be allergic to CEPHALOSPORINS

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54
Q

Gram Positive Infections

A

DOXYCYCLINE NOT effective for GRAM-POSITIVE infections.

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55
Q

Pharma Notes: Antibiotics

A

Become familiar with alternative antibiotics for penicillin-allergic patients.

A good alternative antibiotic for PCN-ALLERGIC patients with gram-positive bacterial infections are MACROLIDES such as azithromycin × 5 days (Z-Pack) or clarithromycin (Biaxin) PO BID.

■ CLINDAMYCIN (Cleocin) is also an ALTERNATIVE, but it is associated with slightly higher risk for C. difficile colitis.

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56
Q

Monospot and Group A Beta Hemolytic Strep Positive

A

AVOID using AMOXIcillin (high risk of DRUG RASH)

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57
Q

Pharma Notes: Mononucleosis

A

In the case of rash in mononucleosis patients, it is very hard to determine whether the rash is due to a true allergy or whether the patient has a benign nonallergic drug rash. About 70% to 90% of patients with MONO taking AMOXIcillin may break out with a “NONALLERGIC” generalized MACULOPAPULAR rash (mechanism is not well understood). If a patient has both mono and strep throat, AVOID using AMOXIcillin or AMPIcillin. Instead, use PENIcillin (if NOT allergic) or a MACROLIDE to treat the patient.

*Up to 10% of patients may report being allergic to penicillin. A very small percentage (0.17%-8.4%) will also react to a cephalosporin.

58
Q

Bactrim

A

Bactrim is NOT effective against MYCOPLASMA or CHLAMYDIA bacterial infections.

Bactrim IS EFFECTIVE against some gram-NEGATIVE infections.

59
Q

Pharma Notes: COPD

A

The INITIAL treatment of choice for chronic bronchitis/COPD is IPRATROPIUM BROMIDE or ATROVENT (an antiCHOLINERGIC). If the question is asking you for the nextstep (if symptoms are not better with Atrovent), then ADD a SHORT-acting BETA-2 AGONIST (ALBUTEROL) or both drugs COMBINED (COMBIVENT). PNEUMOVAX is recommended for ALL with COPD—it is considered a PRIMARY prevention measure.

60
Q

Antibiotics

A

BacterioCIDAL KILLS bacteria.

BacterioSTATIC limits growth and replication.

61
Q

Tetracyclines

A

CATEGORY D

Tetracyclines may cause PERMANENT DISCOLORATION of TEETH (Yellow-brown to gray) and SKELETAL DEFECTS if taken during LAST half of PREGNANCY, in infancy, or by children less than 8 years of age. Generally tetracycline is used to treat acne starting at age 13 to 14 years. By this age, all of the PERMANENT TEETH have erupted (except wisdom teeth).

62
Q

Antibiotics

A

BacterioCIDAL KILL bacteria.

BacterioSTATIC LIMIT bacterial GROWTH and REPLICATION.

63
Q

Tetracycline Medications

A
  • DOXYcycline PO BID (FIRST-line CHLAMYDIAL and ATYPICAL bacterial infections.
  • MINOcycline (has more side effects and adverse reactions)
  • TETRAcycline (FIRST-line moderate to severe ACNE, ROSACEA.
64
Q

Tetracycline Adverse Reactions

A
  • PHOTOSENSITIVITY reaction (severe sunburns from minimal sunlight exposure. AVOID or minimize SUNLIGHT exposure; use sunblock, wide-brim hats, and sunglasses.
  • ESOPHAGEAL ulcerations (rare). Swallow tablet completely using full glass of WATER.
  • Contraindications: AVOID use in PREGNancy, INFancy, and children aged 8 years or younger.
65
Q

Pharma Notes: Tetracycline

A

1) Do NOT use oral tetracycline for MILD ACNE (comedones). Use ONLY TOPICALS.
2) For mild acne NOT responding to OTCs, trial PRESCRIPTION TOPICALS (BENZAmycin, RETIN-A).
3) Consider ADDING TETRAcycline if a patient with moderate ACNE is NOT responding to TOPICAL prescriptions (Benzamyzin, Retin-A) AFTER 2 to 3 MONTHS.
4) TETRAcycline BINDS to some MINERALS (calcium, dairy products, iron, magnesium, zinc). It’s best to take it on an EMPTY STOMACH. Take 1 HOUR BEFORE or 2 HOURS AFTER a MEAL.
5) TETRAcyclines may DECREASE effectiveness of oral contraceptive pills OCPs.
6) DOXYcycline is FIRST line for CHLYMYDIAL infections (i.e., cervicitis, PID, atypical pneumonia) and other ATYPICAL bacteria like ureaplasma or mycoplasma (i.e., nongonococcal urethritis).

■ A COMMON side effect of MINOcycline (Minocin) is VERTIGO and DIZZINESS (vestibular dysfunction).

■ Advise patients to THROW away EXPIRED TETRAcycline pills (they degenerate and may cause NEPHROpathy or FANCONI syndrome.

66
Q

Macrolides

A

Category B

MACROLIDES and (QUINOLONES) are associated with more 
DRUG INTERACTIONS. Both ERYTHOmycin and CLARITHROmycin are potent CYP34A INHIBITORS, but NOT AZITHROmycine (which has FEWER drug INTERACTIONS).

All MACROLIDES are CATEGORY B except CLARITHOmycin and TELITHthromycin which are CATERGORY C and AVOID in PREGNANCY.

67
Q

Macrolide Medications

A

■ Erythromycin PO QID.
■ Azithromycin (Z-Pack).
■ Clarithromycin PO BID.

Many major drug interactions:

Careful with MYASTHENIA GRAVIS.

Anticoagulants: warfarin (COUMADIN)

QT PROLONGATION/bradyarrhythmias: verapamil (Calan), amlodipine (Norvasc), diltiazem (Cardizem), amiodarone, others

BENZODIAZEPINES: TRIAzolam (Halcion), MIDAzolam (Versed)

Asthma: SALMEterol (Serevent), THEOphylline

Others: anticonvulsants (carbamezapine (Tegretol), phenytoin), ergotamine, statins (rhabdomyolysis), and others

68
Q

KETOlide

TELITRHOmycin (Ketek) once a day

A

Treats mild to moderate CAP, do NOT use under 18 years.
Black Box Warning: MYASTHENIA GRAVIS patients—do NOT use on these patients
Same drug interactions as macrolides
Causes LIVER FAILURE

69
Q

TETRAcyclines

A

■ TETRAcycline QID
■ DOXYcycline BID
■ MINOcycline (Minocin) BID

PHOTOsensitivity reactions (use hat, SUNblock)
BINDS with iron, calcium, magnesium, zinc
Antacids, sucralfate, and bile-acid sequestrants markedly DECREASE ABSORPTION. Oral contraceptives (may DECREASE effectiveness OCP). Can cause pseudotumor cerebril.
70
Q

Macrolides: Adverse Effects

A

■ GI distress (especially erythromycin).
■ OTOtoxicity, CHOLESstatic jaundice.
■ QTc PROLONGation (risk of torsades de pointes, like VT).

71
Q

Pharma Notes: Macrolides

A

1) Erythromycin’s GI side effects are COMMON (nausea, vomiting, abdominal pain, diarrhea).

2) If a condition must be treated with a MACROLIDE (i.e., atypical bacteria) and the patient cannot tolerate erythromycin or Biaxin, switch the patient to
AZITHROmycin (Z-Pack).

3) Many DRUG INTERACTIONS (anticoagulants, digoxin, theophylline, astimizole, carbamazepine, cisapride, triazolam, terfenadine).

72
Q

Pharma Notes: Erythromycin

A

GI upset (N/V, abdominal pain) are COMMON side effects of erythromycin—it is NOT an allergic reaction (such as angioedema, hives, anaphylaxis). If a patient who needs a MACROLIDE is NOT allergic, AZITHROmycin (Z-Pack) is a good choice. It usually does not cause GI side effects, has FEWER drug interactions, and a BROADER spectrum of activity. If the patient is ALLERGIC to macrolides, an alternative is DOXYCYCLINE PO BID or the new generation QUINOLONES (Levaquin, Avelox).

  • Consider macrolide-RESISTANT Strep pneumoniae if the patient was on a macrolide the PREVIOUS 3 months.
    1) Erythromycin’s GI side effects are COMMON (nausea, vomiting, abdominal pain, diarrhea).
    2) If a condition must be treated with a macrolide (i.e., atypical bacteria) and the patient CANNOT tolerate erythromycin or Biaxin, SWITCH the patient to AZITHROmycin (Z-Pack).
    3) Many DRUG INTERACTIONS (anticoagulants, digoxin, theophylline, astimizole, carbamazepine, cisapride, triazolam, terfenadine).
73
Q

Clinical Pearls

A

1) Advise patients to use only ONE PHARMACY so that all the drugs they take are on one database. It makes it easier for the pharmacy to check for drug interactions (your back-up system).
2) May PROLONG INR and INCREASE risk of BLEEDING if Warfarin is mixed with ERYTHROmycin or CLARITHROmycin.
3) MACROlides (and QUINOlones) will PROLONG QT intervals (risk of torsade de pointes—variant type of VT).

74
Q

Cephalosporins

A

■ CEPHALOporins and PENIcillins belong to the BETA-LACTAM family of antibiotics.

■ BETA-LACTAMS are bacteriCIDAL and work by INTERFERING with the CELL WALL synthesis of actively growing bacteria.

75
Q

First-Generation Cephalosporins

A

■ Activity against gram-POSITIVE bacteria. Used to treat infections caused mainly by gram-POSITIVE bacteria (cellulitis, mastitis).

76
Q

First-Generation Cephalosporins: Indications

A

CEPHAlexin (KEFLEX) PO QID

Pregnancy: UTI (If sensitive) Pregnancy
Skin: CELLULITIS (NOT caused by MRSA), IMPETIGO

77
Q

Second-Generation Cephalosporins

A

■ Considered as “BROAD-spectrum” antibiotics. Used to treat infections caused by both gram-POSITIVE and gram-NEGATIVE bacteria (i.e., sinusitis, otitis media).

78
Q

Second-Generation Cephalosporins: Indications

A 
Cefuroxime axetil (CEFTIN) PO BID 
ENT: SINUSitis, OTITIS Media

Cefprozil (CEFZIL) PO BID
RESPIRATORY: CAP, exacerbation chronic BRONCHITIS

Cefaclor (CECLOR) PO BID
OTHERS: AOM, SINUSitis, SKIN infections

79
Q

Third-Generation Cephalosporins

A

■ LESS activity against gram-POSITIVE infections compared to the FIRST-generation cephalosporins.

■ BETTER coverage for gram-NEGATIVE bacteria (i.e., Neisseria GONORRHEA infections) and against ENTERIC bacteria.

80
Q

Third-Generation Cephalosporins: Indications

A

Ceftriaxone (ROCEPHIN) IM
STDs: GONORRHEA cervicitis, URETHRitis, PID

Cefixime (SUPRAX) daily to BID
ENT: AOM in children, acute SINUSitis, OTitis media

Cefdinir (OMNICEF) daily to BID
GU: PYELOnephritis, CAP

81
Q

Pharma Notes: Cephalosporins

A

1) ROCEPHIN (ceftriaxone) IM is FIRST-line treatment for GONORRHEAL infections.
2) MRSA skin infections (boils, abscesses)—do NOT use cephalosporins. FIRST line is either trimethoprim-SULFA (BACTRIM DS) BID or CLINDAmycin TID. Treat for at least 5 to 10 DAYS.
3) Patients who have a TRUE ALLERGY to PENIcillin (history of ANAphylaxis, ANGIOedema) are MORE likely to have an ALLERGIC reaction to CEPHALOsporins (especially FIRST-generation).
4) ANAphylaxis and ANGIOedema are type 1 IgE-mediated reactions.

82
Q

PENIcillins

A

CATEGORY B

There is a chance of CROSS-reactivity, especially with FIRST-generation CEPHALOsporins. AMOXIcillin and AMPIcillin are EXTENDED-spectrum penicillins. They are EFFECTIVE
against gram-POSITIVE bacteria as well some gram-NEGATIVE bacteria (Haemophilus influenzae,
Escherichia coli, Proteus mirabilis).

83
Q

Pharma Notes: Penicillin

A

1) AVOID using AMOXIcillin for patients with MONOnucleosis (causes a generalized RASH NOT related to allergy). Use PENICILLIN VK instead (if NOT allergic).
2) DICLOXAcillin is for PENIcillinase-producing staph SKIN infections (MASTITIS and IMPETIGO).
3) Patients who have a TRUE allergy to penicillin (history of anaphylaxis, angioedema) are more likely to have an allergic reaction to CEPHALOsporins (especially, FIRST generation).
4) ANAphylaxis and ANGIOedema are type 1 IgE-mediated reactions.
5) Some women will complain of CANDIDA vaginitis with AMOXIcillin. Recommend PROBIOTIC capsules or eating YOGURT daily.

84
Q

PENIcillin V PO QID

A

STREP throat (FIRST line)

85
Q

AMOXIcillin BID to TID

A

OTITIS media (FIRST line)

86
Q

AMOXIcillin plus CLAVULANIC acid

AUGMENTIN PO BID

A

OTITIS media/SINUsitis (FIRST to SECOND line)

87
Q

BENZATHINE PENIcillin G IM

A

SYPHILLIS (FIRST)

88
Q

DICLOXAcillin PO QID

A

CELLULITIS (NON-MRSA), IMPETIGO, ERYSIPELAS

89
Q

Fluroquinolones (QUINOLONES)

A

Effective against gram-NEGATIVE bacteria and some ATYPICAL bacteria (Chlamydia, Mycoplasma, Legionella). NEWER-generation quinolones (LEVOfloxacin, MOXIfloxacin, GATIfloxacin) are also active against gram-POSITIVE bacteria. LEVOloxacin and MOXIfloxacin
are also known as the “RESPIRATORY quinolones” due to their excellent activity against STREP PNEUMONIA.

90
Q

Fluroquinolones: Medications (OXACIN)

A

■ Norfloxacin (Noroxin) BID.

■ Ciprofloxacin (Cipro) BID.

■ Ofloxacin (Floxin) BID.

Broad-spectrum quinolones.
■ Levofloxacin (Levaquin) daily. (RESP)
■ Moxifloxacin (Avelox) daily. (RESP)
■ Gemifloxacin (Factive) daily.

*Black Box Warning: INCREASED risk of ACHILLES TENDON rupture. AVOID STRENUOUS activity while on the drug. STOP drug if develops TENDON pain/swelling.

91
Q

CIPROfloxacin (Cipro) BID

A

ANTHRAX infection and prophylaxis (Cipro)
Traveler’s DIARRHEA (Cipro)
PSEUDOMONAS AERUGINOSA

*Black Box Warning: Risk of tendinitis and Achilles tendinopathy/rupture

92
Q

OFLOxacin (Floxin) BID

A

UTIs, CAP, PYELONEPHRitis, EPIDIDYMitis, PROSTATitis

*Black Box Warning: Risk of tendinitis and Achilles tendinopathy/rupture

93
Q

BROAD-SPECTRUM: Quinolones

A

■ LEVOfloxacin (Levaquin) daily
*LEVOfloxacin has INCREASED risk of HYPOglycemia
CAP, ACUTE EXACERBATION of chronic BRONCHITIS, PYELONEPHRitis, EPIDIDYMitis, PROSTATitis

■ MOXIfloxacin (Avelox) daily

■ GEMIfloxacin (Factive) daily

*OSTEOmyelitis, SINUSitis, AOM

94
Q

TOPICAL Forumlations: Quinolones

A 
FLOXIN Otic (gtts)
*OM with perforated TM, otitis EXTERNA
OCUFLOX ophthalmic (gtts)
*BACTERIAL CONJUNTIVitis
95
Q

Fluroquinolones: Drug Interactions

A

AVOID concomitant use of QUINOLONES with other QT-PROLONGING drugs (amiodarone, macrolides, TCAs, antipsychotics, others) or with ELECTROLYE IMBALANCE (hypomagnesemia, hypokalemia) since these will ELEVATE the RISK of sudden death from arrhythmias (torsades de pointes, LIKE VT).

COADMINISTRATION of ANTACIDS (aluminum/magnesium/calcium) or SUCRALFATE drastically REDUCES effectiveness of QUINOlones due to BINDING (inactivation).

Contraindications:
■ Children (LESS than 18 years of age).
■ MYASTHENIA GRAVIS.
■ PREGNANT women, BREASTfeeding

96
Q

Fluroquinolones: Adverse Effects

A

■ CNS (dizziness, headache, insomnia, mood changes).

■ QT prolongation and others.

97
Q

Pharma Notes: Quinolones

A

1) ACHILLES tendon rupture is a serious complication of quinolone therapy.
2) Do NOT use quinolones on children (LESS than 18 years) due to adverse effects on growing CARTILAGE.
3) If a patient on quinolone reports a new onset of DIFFICULTY in WALKING, order an ULTRASOUND to rule out Achilles tendon rupture and DISCONTINUE the medicine.
4) Bioterrorism-related INHALATION of ANTHRAX s treated with CIPROfloxacin 500 mg BID × 60 DAYS.
5) CUTANEOUS ANTHRAX is treated with CIPROfloxacin 500 mg BID × 7-10 DAYS
6) Traveler’s DIARRHEA is treated with Cipro 500 mg BID × 3 DAYS.
7) CIPROfloxacin has the BEST activity against PSEUDOMONAS AERUGINOSA (gram-NEGATIVE) and is the FIRST-line drug for treating PSEUDALmonal pneumonia.
8) Per the CDC (2009), STOP using quinolones to treat gonorrheal infections.

*Quinolones have THREE to FOUR times the risk of TENDON rupture (especially the Achilles tendon).
Patients with the HIGHEST risk for tendon rupture are those on STEROIDS and OLDER patients (older than 60 years).

98
Q

Sulfonamides

A

CATEGORY C

■ Active against gram-NEGATIVE bacteria (E. coli, Klebsiella, H. influenzae).
- BacterioSTATIC.

■ Trimethoprim-sulfamethoxazole (TMP-SMX) Bactrim DS BID.

99
Q

Other SULFA-type drugs:

A
  • DIURETICS (furosemide, HCTZ).
  • SULFOnylureas (glyburide, glipizide, etc.).
  • COX-2 inhibitor (CELEcoxib or CELEbrex).
  • DAPSONE (for HIV).
100
Q

Sulfonamides: Contraindications

A

■ Contraindications:

  • G6PD anemia (a GENETIC hemolytic anemia) causes HEMOLYSIS
  • Newborns and infants LESS than 2 months of age.
  • PREGNANCY in late THIRD trimester (increased risk of hyperbilirubinemia/kernicterus).
  • Hypersensitivity to sulfa drugs.

■ Drug interactions:
- Warfarin (INCREASES INR).

101
Q

Sulfonamides: Adverse Reactions

A

Skin RASH, STEVENS-JOHNSON syndrome, and others.

102
Q

Trimethoprim-sulfamethoxazole

(TMP-SMX) Bactrim DS BID

A

Indications:

■ PROPHYLAXIS/ treatment of PCP (HIV-patients)
■ MRSA cellulitis
■ UTIs, pyelonephritis

103
Q 
Topical sulfas 
Silver sulfadiazine (Silvadene)
A

■ Burns

104
Q

Pharma Notes: Sulfa

A

1) Patients with a UTI who are on warfarin (COUMADIN) should NOT be given TMP-SMX (increased RISK of BLEEDING). Monitor INR closely.
2) PREGNANT woman (or suspected pregnancy) with a UTI can be treated with AMOXIcillin or CEPHALOsporins (CATEGORY B)

105
Q

Clinical Pearls

A

1) HIV patients are at high risk (25%-50%) for sulfa-related STEVENS-JOHNSON syndrome.
2) The typical G6PD patient in the United States is a BLACK MALE (10%) who presents with HEMOLYSIS/JAUNDICE secondary to being TREATED with a SULFA drug. Look for a LOW H&H and JAUNDICE.
3) Sulfonamide antibiotics are the SECOND most frequent CAUSE of allergic drug reactions (PENIcillins and CEPHALOsporins are the FIRST.

106
Q

Topical Nasal Decongestants

A

Oxymetazoline Nasal Spray (AFRIN), Phenylephrine (NEO-SYNEPHRINE).

■ SHORT-term use of topical nasal DECONGESTANTS (BID PRN × 3 DAYS) is considered safe treatment for nasal congestion (common cold, allergic rhinitis).

■ RHINITIS MEDICAMENTOSA is due to CHRONIC use (GREATER than 3 DAYS) of nasal decongestants.

107
Q

Antihistamines

A

Diphenhydramine (BENADRYL)

Loratadine (CLARITIN)

Cetrizine (ZYRTEC)

■ AVOID using diphenhydramine (BENADRYL) with the ELDERLY.

■ For ELDERLY patients, USE loratadine (CLARITIN) since it has a LOWER incidence of SEDATION.

■ ZYRTEC is more POTENT and LONG acting. It is very EFFECTIVE for acute and chronic URTICARIA.

108
Q

Cold, Cough, and/or Sinus Medicines

A

DECONGESTANTS: Pseudoephedrine (SUDAFED), Phenylephrine

ANTITUSSIVES: Dextromethorphan (ROBITUSSIN, DELSYM), benzonatate (TESSALON).

MUCOLYTICS: GUAIFENESIN.

■ DECONGESTANTS CONTRAindicated with HYPERTENSION, CAD (angina, MI).

■ AVOID MIXING decongestants with other STIMULANTS (caffeine, Ritalin) since they can ELEVATE blood PRESSURE and CAUSE palpitations, arrythymias, tremors, and anxiety.

■ DEXTROMETHORPHAN is CONTRAindicated within 14 DAYS of a MAOI and seligiline (Eldepryl).

109
Q

NSAIDs

A

■ Ibuprofen (Advil, Motrin), naproxen sodium (ALEVE).

110
Q

Prescription NSAIDs

A

■ Naproxen (Naprosyn, Anaprox), diclofenac (Voltaren) oral and topical gel

■ Indomethacin (Indocin), ketoprofen (Orudis), ketorolac (Toradol)

■ COX-2 inhibitors: Celecoxib (Celebrex)

111
Q

NSAID Warnings

A

■ NSAIDs should be AVOIDED in HEART failure, severe heart disease, GI BLEEDING, severe RENAL DISEASE.

■ Ketorolac (TORADOL) IM, IV, or tablets is for SHORT-term use only (up to 5 DAYS).

■ Contraindications: Ketorolac should NOT be used BEFORE SURGERY with concurrent ASA, PEDIATRIC patients, active or recent GI BLEED, STROKE, labor/delivery, and others.

■ For LONG-term use, document INFORMED CONSENT such as the higher risk of serious MI, STROKE, emboli, GI BLEEDS, acute RENAL failure.

■ COX-2 inhibitors (celecoxib) have LOWER risk of GI bleeding compared with the other NSAIDs. They are NOT a FIRST-line NSAID EXCEPT for patients at HIGH risk for GI BLEEDING.

■ INCREASED risk of bleeding if NSAIDs are COMBINED with: warfarin, STEROIDS, aspirin, ALOCHOL. For LONG-term use, consider prescribing concurrent PPIs, H2-receptor ANTAGONISTS, or misoprostol (CYTOTEC). Cytotec is a SYNTHETIC PROSTAGLANDIN.

■ Avoid LONG-term use of NSAIDs if patient is on ASPIRIN prophylaxis (INTERFERES with aspirin’s CARDIOprotective effect).

■ NSAIDs may WORSEN HYPERTENSION in patients who were previously well controlled.

112
Q

Salicylates

A

■ Aspirin (BAYER), magnesium salicylate (DOAN’s Pills).

■ Topical: Methyl salicylate and menthol (BENGAY gel/cream).

■ Nonacetylated salicylates: Salsalate (DISALCID), namebutone (RELAFEN).

113
Q

Exam Tips

A

1) Aspirin IRREVERSABLY SUPPRESSES PLATELET function for up to 7 DAYS (due to irreversible ACETYLATION).
2) DISCONTINUE ASA if patient complains of TINNITUS (possible aspirin TOXICITY). OTOTOXIC
3) For CHRONIC use, the recommended dose is 81 mg/DAY (some exceptions exist).
4) Aspirin given POST-MI or AFTER a stroke/TIA is considered TERTIARY prevention.
5) Avoid using in CHILDREN with VIRAL infections who are LESS than 16 years of age (Reye’s syndrome).

114
Q

Acetaminophen (Tylenol)

A

MAXIMUM dose up to 4 g/day (or 1,000 mg QID or 650 mg every 4 hours).

■ AVOID if: chronic HEPATITIS B/C/D, DEHYdration, LIVER disease, CIRRHOSIS, heavy drinker (ALCOHOLIC).

■ Considered FIRST-line drug for pain from OSTEOARTHRITIS.

■ The ANTIDOTE for acetaminophen overdose is ACETYLCYSTEINE.

115
Q

Immune System: Glucocorticoids (Steroids)

A

■ RHEUMATOID arthritis and other AUTOIMMUNE disorders.

■ POLYMYALGIA RHEUMATICA (dramatic relief of symptoms).

■ ASTHMA or acute asthmatic exacerbations.

■ TEMPORAL ARTERITIS (HIGH doses × several WEEKS to MONTHS) and UVEITIS.

■ SKIN (ECZEMA, PSORIASIS, CONTACT DERMATITIS.

116
Q

Oral Steroids

A

■ PREDNISONE 40 to 60 mg/day (HIGH-dosed) for 3-4 days. Can be used for SHORT-term treatment (i.e., ASTHMA EXACERBATION). There is NO need to TAPER if patient is NOT on CHRONIC steroids.

■ METHYLpredniSOLONE (MEDROL DOSE Pack) × 7 DAYS. Does NOT need to be weaned.

117
Q

Topical Steroids

A

■ Classification: (Class 1 SUPERPOTENT to Class 7 (LEAST POTENT)

  • Superpotent (Class 1) —CLOBETASOL (TEMOVATE)
  • Potent—HALOCINONIDE (HAlog)
  • Moderate—TRIMACINOLONE (KENAlog)
  • LEAST potent (Class 7)—HYDOCORTISONE
118
Q

Pharma Notes: Topical Steroids

A

■ Use LOW potency steroid for CHILDREN, and on the FACE intertriginous areas, and the GENITALS.
- Example: Use hydrocortisone 1% cream (OTC) to treat RASHES on the FACE. May need to use ophthalmic-grade ointments for rashes around the eyes/eyelids.

■ Use MODERATE to HIGH potency steroids for THICKER skin (scalp, soles of feet, palms of the hands) or for PLAQUES (psoriasis). TAPER topical steroids (or WILL REBOUND).

■ What is “OCCLUSION”?
THICK resistant PSORIATIC PLAQUES are sometimes TREATED by using OCCLUSION (INCREASES absorption). The topical steroid is APPLIED to the plaque and is COVERED with PLASTIC wrap. ULTRAPOTENT steroids (TEMOVATE, etc.) should NOT be OCCLUDED for MORE than 2 WEEKS (risk of hypothalamicpituitary-axis [HPA] SUPPRESSION).

119
Q

Acutely inflamed joints (knees/hips/shoulders/elbows)

A

Treated with INTRAarticular TRIAMCINOLONE (Kenalog) INJECTIONS up to 3 TIMES per YEAR.

*SEPTIC joint—do NOT INJECT steroids.

120
Q

Side Effects of Glucocorticoids/Steroids (Chronic Use)

A

■ HPA SUPPRESSION.

■ CUSHING’S disease (dorsal hump, rounded face, etc.).

■ OSTEOPOROSIS (advise weight-bearing exercises, vitamin
D, calcium 1,200 mg/day, bisphosphonates).

■ IMMUNOSUPRESSION (INCREASED risk of INFECTION).

■ SKIN changes from LONG-term topical therapy (skin ATROPHY, STRIAE, TELANGEICTASIA, ACNE).

121
Q

Clinical Pearl

A

A severe case of poison IVY or poison OAK rash may require 14 to 21 DAYS of an ORAL steroid to clear.

122
Q

Drugs That Require Eye Examination

A

■ Digoxin (yellow to green vision, blurred vision, halos if blood level too high).

■ Ethambutal and linezolid (optic neuropathy).

■ Corticosteroids (cataracts, glaucoma, optic neuritis).

■ Fluoroquinolones (retinal detachment).

■ Viagra, Cialis, Levitra (cataracts, blurred vision, ischemic
optic neuropathy, others).

■ Accutane (cataracts, decreased night vision, others).

■ Topamax (acute angle-closure glaucoma, increased ICP, mydriasis).

■ Plaquenil (neuropathy and permanent loss of vision). Treats or prevent malaria.

123
Q

Theophylline drug interactions:

A

■ Theophylline level (adults): 5-15 mcg/mL.

■ Drug interactions (cimetidine, alprazolam, macrolides, fluvoxamine, others).

■ AVOID combining with other stimulants (theophylline, pseudoephedrine, caffeine, Ritalin).

■ Disorders WORSENED by STIMULANTS: hypertension, arrhythmias, stroke, seizures.

■ BPH: causes urinary retention, worsening of symptoms.

■ Suspect TOXICITY if: PERSISTENT VOMITING.

124
Q

Cisapride (Propulsid):

A

■ Available only by limited-access protocol in the United States.

■ Block Box Warning: Serious cardiac arrhythmias (ventricular fibrillation/tachycardia, torsades de pointes, prolongation of QT interval). Check: 12-lead EKG at BASELINE.

■ Check serum electrolytes and creatinine.

■ Numerous drug contraindications (macrolides, antifunglas, TCAs, etc.).

125
Q

Tapering (weaning) drugs

A

■ Certain drugs that are used long term need to be tapered. ABRUPT discontinuation will cause the treated condition to FLARE up (exacerbation), REBOUND, and/or have adverse effects:

  • Beta-blockers (rebound hypertension or hypertensive crisis).
  • Benzodiazepines (severe anxiety, insomnia, seizures, tremors).
  • Oral steroids.
  • Anticonvulsants (seizures).
  • Paroxetine or Paxil.
  • Antiarrythmics (refer to cardiologists).
  • Antipsychotics and many others.
126
Q

Illegal Drug Overdose

A

All of these drugs will cause euphoria, sociability, talkativeness, more energy, need for less sleep or no sleep, anorexia, others. The most common cause of DEATH (COCAINE, ECSTASY, AMPHETAMINES) is CARDIAC-related (hypertension, MI, sudden death, arrhythymias,
seizures resulting in respiratory arrest, stroke, others).

127
Q

Cocaine

A

■ Euphoria, sociability, more energy, decreased appetite, insomnia.

■ Pupils appear CONSTRICTED and are very small in size. Nasal cartilage ulcers/NOSEBLEEDS.

128
Q

Ecstasy (MDMA)

A

■ A powerful STIMULANT. Colors look BRIGHTER. VIVID dreams and hallucinations.

■ ENLARGED pupils. May cause DEHYDRATION (due to low sodium) if poor fluid intake.

129
Q

Methamphetamines (“Crystal Meth”)

A

■ Chronic use results in severe DENTAL CARRIES with LOSS of FRONT teeth on the upper jaw and DRASTIC WEIGHT LOSS. Pupils appear CONSTRICTED.

130
Q

Controlled Substances Act

A

■ Schedule I drugs (heroin, Ecstasy/MDMA, PCP, etc.).
- ILLEGAL to prescribe. No currently accepted medical use. HIGH ABUSE potential.

■ Schedule II drugs (Demerol, Dilaudid, OxyContin, cocaine, amphetamines, etc.).

  • Only the ORIGINAL prescription with the physician’s SIGNATURE (NOT stamped) is acceptable.
  • The TOTAL number of pills must be indicated. NO REFILLS are allowed.

■ Schedule III drugs (Tylenol with codeine, Vicodin, anabolic steroids, testosterone, etc.).

■ Schedule IV drugs (benzodiazepines, Ambien, Lunesta, Soma, etc.).

■ Schedule V drugs (cough medicines with less than 200 mg of codeine, Lomotil, Lyrica).

■ Schedule IV, V: can be MAILED to the patient. Some states allow NPs to prescribe lower-level controlled substances.

■ For ALL controlled substances: Must have the prescriber’s and the supervising physician’s NAME/DEA NUMBER with the CLINIC ADDRESS on the pad. CANNOT be PRE-DATED
or POST-DATED. Some states do not require a supervising physician’s signature.

131
Q

List of FDA Category X Drugs

A

■ FINASTERIDE (Proscar, Propecia): REPRODUCTIVE-aged or PREGNANT women should NOT HANDLE CRUSHED/BROKEN FINASTERIDE tablets

■ Isotretinoin (ACCUTANE)

■ Warfarin sodium (COUMADIN)

■ Misoprostol (CYTOTEC) “Synthetic Prostaglandin”

■ ANDROGENIC hormones: Birth control pills, HRT, testosterone

■ LIVE VIRUS VACCINES (measles, mumps, rubella, varicella, rotavirus, FluMist)

  • MMR
  • VARICELLA
  • ROTAVIRUS
  • FluMIST

■ THALIDOMIDE (Treats and Prevents LEPROSY), DES, methimazole, and so on

132
Q

LIVE VIRUS VACCINES

A

■ MMR
■ VARICELLA
■ ROTAVIRUS
■ FluMIST

133
Q

Pharma Notes: Category X Drugs

A

In general, FDA category X drugs are those that:

■ INTERFERE WITH or BLOCK HORMONES (finasteride, misoprostol, Lupron)

■ CONTAIN ESTROGEN (birth control pills, HRT)

■ LIVE VIRUS VACCINES

■ INTERFERE with CELL GROWTH (methotrexate, chemo, radiation)

■ DERIVATIVES of VITAMIN A (e.g., Accutane, high-dosed Vitamin A supplements).

134
Q

Exam Tips

A

1) Memorize the FDA category and DOSE of FINASTERIDE (Proscar 5 mg PO once a day).

2) ACCUTANE is a POTENT TERATOGEN. Reproductive-aged females must use 2 RELIABLE FORMS of BIRTH CONTROL and must have a NEGATIVE pregnancy test 1 month BEFORE, DURING and 1 month
AFTER ACCUTANE

3) HIGH-dose vitamin A is TERATOGENIC in animal studies—avoid “MEGA DOSES” of VITAMINS in PREGNANCY.
4) Avoid MIXING WARFARIN with SULFA drugs—can INCREASE INR and BLEEDING risk.

135
Q

Prescription Example

A

■ Date and name of the patient. The name of the drug, dose, frequency, and the quantity. If a refill, indicate how many times. Avoid using initials/shortcuts (i.e., daily
instead of QD).

■ If a controlled substance, the quantity of the drug is written
in both number and
written word form:
- Example:
Lunesta tablets 3 mg by mouth at bedtime as needed.
Dispense: #20 (twenty). Refills: 1 (one).
Bactrim DS 1 (one) tablet by mouth twice a day for 10 (ten) days. Dispense: #20 (twenty). Refills: 0 (none).

136
Q

The “Five Rights”

A

■ There are “Five Rights” that help to prevent or decrease the chances of a medical error:

1) Right patient
2) Right drug
3) Right dose
4) Right time
5) Right route

137
Q

What is “e-prescribing”?

A

The process of sending and receiving prescriptions by
electronic means. Clinicians write the prescription in their offices on the computer or by personal digital assistant (PDA) using e-prescribing software. PREFERRED METHOD method for drug prescriptions by MEDICARE.

138
Q

COMPLEMENTARY AND ALTERNATIVE MEDICINE

A 
Conventional medicine (or allopathic medicine) is also known as modern medicine or "Western" medicine. Alternative medicine is the treatments and substances that are not
part of standard medicine.

■ Examples: Herbal supplements, probiotics, chiropractic, homeopathy, meditation, yoga, massage therapy.
Complementary and alternative medicine (CAM) is the term used when Western medicine is combined with alternative medicine or “medical products and practices that are not part of standard care” (NIH, 2010). CAM is using both Western medicine with alternative medicines (herbs) or with another healing system such as homeopathy, AYURVEDA (from India), or traditional Chinese medicine (or TCM).

139
Q

Herbal Supplements

A

■ Glucosamine (with/without chondroitin): osteoarthritis.

■ Natural progesterone cream (from wild yam root extract): PMS symptoms (hot flashes)

■ Isoflavones (from soy beans): Estrogen-like effects

■ Saw palmetto: Urinary symptoms of BPH

■ Kava kava, Valerian Root: Anxiety and insomnia

■ St. John’s wort: For mild depression. Do not use with SSRIs, MAOIs, sumatriptan, HIV protease inhibitors (indinavir), others.

140
Q

St. John’s wort Contraindications

A

Do NOT use with:

■ SSRIs
■ MAOIs
■ sumatriptan
■ HIV protease inhibitors (indinavir)

141
Q

Homeopathy

A

Founder: physician Samuel Hahnemann (1755-1843). This healing system is based on the “Law of Similars” or “Let likes be cured by likes.”

■ What is the Homeopathic Pharmacopoeia of the United States (HPUS)? The HPUS is a list of approved homeopathic substances used in this country.

■ How are homeopathic substances made? Extremely SMALL amounts of a substance are DILUTED (ultradilution). For example, the herb Arnica montana, which is used to
prevent or treat bruises, can be diluted by 30X (e.g., Arnica montana 30X dilution).

142
Q

Ayurveda

A

An ANCIENT HEALING SYSTEM that is based on HINDU beliefs of the people from INDIA.

From Flashcardlet (14 decks)

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