Exam 2 Flashcards
(199 cards)
1
Q
Intensive insulin regimens have proven their effectiveness with the greatest impact on lowering blood glucose. Which of these is an intensive insulin regimen?
A
When using the intensive insulin therapy approach, three to four injections are administered per day. This regimen involves 1:1 basal bolus dosing with long-acting insulin (LAI) or the new ultra long-acting insulin (ULAI) administered either at breakfast or bedtime with either rapid-acting insulin (RAI) or short-acting insulin (SAI) bolus doses before each meal. An intensive insulin therapy would include a basal/bolus insulin combination.
EX: Lantus and Lispro
2
Q
To monitor the effectiveness of insulin lispro, the APN will instruct the patient to closely monitor which of these?
A
Postprandial glucose would be used to monitor the effectiveness of rapid-acting insulin (RAI). The RAIs are used as bolus insulin doses to correct hyperglycemia or to affect food eaten at meals, specifically carbohydrates.
3
Q
Insulin
Caution, Contraindications, Pregnancy, Pediatrics
A
Caution: Hepatic dysfx, Renal Impairment, Hypo/Hyperthyroidism
Pregnancy & Pediatric approved
4
Q
Glucagon
Pharmacodynamics, Contraindication
A
MOA: liver glucogenolysis
Contraindication:
- hypersensitivity to glucagon or lactose
- pts w/insulinoma or pheochromocytoma
5
Q
Glucophage (Metformin)
drug class, MOA, Contraindications, Adverse Effects, Pregnancy/Breastfeeding, peds
A
Biguanides Insulin Sensitizer
- **Do not cause hypoglycemia
- **1st line treatment
MOA:
- ^Peripheral glucose uptake
- Decrease hepatic glucose production & intestinal absorption glucose
CONTRAINDICATIONS:
-Liver/Renal disease
ADVERSE EFFECTS:
- lactic acidosis (prevents lactate converted to glucose)
- GI upset: diarrhea/bloating/nausea/flatulence
- Vit B12 Deficiency
PREGNANCY & BREASTFEEDING: approved
PEDIATRICS: >10 years
Labs:
GFR
HbA1C
Ketones
6
Q
Pioglitazone (Actos) Rosiglitazone (Avandia) Drug Class MOA Contraindications Black Box Warning Adverse Effects Drug Interaction Pregnancy/Lactation/children
A
Thiazolidinediones TZD Insulin Sensitizer
***Do not cause hypoglycemia
MOA:
- ^insulin sensitivity
- Insulin utilization in muscles, liver and ADIPOSE.
- decreases hepatic glucose production
Contraindications:
- Heart failure (Class III & IV)
- Liver Disease (ALT >2.5x normal limit)
Black Box Warning
- Bladder Cancer
- Hepatoxicity
- Heart Failure
Adverse Effects:
- fluid retention/weight gain*** monitor for HF
- Bone Fracture**
- Myalgia**
- URI**
- htn
Drug Interaction:
CYP34A = Birth Control
Pregnancy/Lactation/children NO!
7
Q
How much can Pioglitazone lower A1C?
A
1.5 to 2%
8
Q
There is some debate about the use of metformin in patients with type 1 diabetes mellitus (DM) because metformin is more effective in patients with which characteristics?
A
Tissue insensitivity to insulin
“Metformin increases peripheral glucose uptake and utilization (insulin sensitivity), which is not a feature of type 1 DM.”
9
Q
Metformin should be discontinued and switched to a different medication for which reason?
A
Metformin is contraindicated with GFR below 30 mL/min.
10
Q
Glipizide, Glyburide, Glimepiride Drug Class MOA Caution Contraindications #3 Adverse Effects #3 Pregnancy/lactation/peds Drug Interactions #2 Labs
A
Sulfonylureas
- **Insulin Secretagogues
- **Type 2 diabetics only
- **Prandial coverage
MOA:
- increase endogenous insulin release from beta cells
- Reduce glucose released from liver
Contraindications:
- Elderly (hypoglycemia)
- Sulfa allergy
- G6PD
Adverse Effects:
- Hypoglycemia
- Weight gain (Potentiates Antidiuretic Hormone)
- Blood Dyscrasia
Drug Interaction:
- Thiazide
- Sulfas
Pregnancy/lactation/peds: NO!
Labs:
- GFR
- HbA1C
- CBC
11
Q
How. much do you expect A1C to be reduced using glipizide?
A
1-2%
12
Q
Repaglinide (Prandin)
nateglinide (Starlix)
Drug Class Most effective at?? Patient Education MOA Contraindication pregnancy/lactation/peds Side Effects #4
A
Meglitinides
Insulin Secretagogues-Most effective at reducing postprandial glucose ***Quicker on quicker off
Patient education: Take 30mins before a meal,
skip meal skip dose
MOA:
- Block ATP-dep channels»_space; INCREASES CALCIUM»_space;pancreas secretes insulin
- Stimulate insulin release from beta cells
Contraindication:
-Elderly
Pregnancy/lactation/peds NO!
Adverse Effects:
- Hypoglycemia & Weight gain
- H/A
- Diarrhea
- Chest & back pain
13
Q
Acarbose
Drug Class Patient education (3) MOA Adverse Effects (2) Caution Contraindication (2) preg/lact/peds
A
Alpha-Glucosidase Inhibitors
Patient Education: GI upset, “add on” therapy, take w/food, don’t give sucrose for hypoglycemia
MOA:
-inhibits absorption carbs in small bowel
Adverse Effects:
- GI upset
- Elevated serum transaminases (Monitor LFTs)
Caution:
Renal/Hepatic impairment
Contraindication:
-Bowel disease/predisposed to intestinal obstruction
PREGNANCY/LACTATION/peds NO!!
14
Q
“-flozins”
Canagliflozin (Invokana)
Dapagliflozin
Drug Class MOA Adverse Effects #6 Contraindication #1 Black Box Warning preg/lact/peds Patient education Labs
A
Selective Sodium-Glucose Cotransporter 2 Inhibitors
(SGLT-2 Inhibitors)
“Flowin’”
MOA:
-Inhibit SGLT-2 in proximal tubule = urinary excretion of glucose
Adverse Effects
- Hyperkalemia
- GU: fungal infect/UTI/urinary frequency
- Hyperlipidemia
- Bladder Cancer
- Bone fracture
- 2-3x risk BKA
Contraindication:
Renal Failure
Black Box:
-Fournier’s gangrene
preg/lact/peds NO!
Education:
Monitor for new pain or sores
Labs:
- Potassium &
- Lipids
15
Q
A 72 y/o male patient is taking an SGLT2 inhibitor for type 2 diabetes mellitus. The APN should be concerned if the patient reports which symptom?
A
Falls
A history of falls may suggest hypotension as a result of hypovolemia.
16
Q
“-gliptins”
MOA (2) Caution preg/lact/peds adverse effects #4 Patient Education Drug Interaction Labs
A
Dipeptidyl Peptidase-4 Inhibitors
DPP-4 Inhibitors
MOA:
- Inhibit DPP-4 enzyme = prolonged (GLP1) incretin in GI tract = increase insulin synthesis & shut off glucagon
- Effect Pre & post prandial Blood glucose
Caution:
-Renal Impairment
Preg/lact/ped NO!
Adverse Effects:
- Pancreatitis (makes pancreas work harder)
- hypersensitivity
- Arthralgas
- hypoglycemia (when combined with secretagogue
Patient Education: Report abdominal pain (pancreatitis)
Drug Interaction:
-ACE = angioedema
Labs
- GFR
- HbA1C
17
Q
“-tides”
Exenatide (Byetta), Liraglutide (Victoza)
Dulaglutide (Trulicity)
Drug Class MOA Adverse Effects Contraindication #2 Black box warning preg/lact/peds
A
GLP-1 Agonist
MOA:
- injection!
- mimis incretin = increase insulin secretion & decrease glucagon, slows gastric emptying
- protein binding
Adverse Effects:
-N/V/D
Contraindication:
ESRD
GI disease
Black Box Warning:
Thyroid tumor
preg/lact/ped NO
18
Q
Levothyroxine
Patient Education
Caution (2) Contraindication (1) preg/lact/peds Adverse Effects Education
A
MOA:
Synthetic T4
Caution:
CVD
Adrenal insuff
Contraindications:
Recent MI
preg/lact/peds YES
Adverse Effects:
^HR ^BP insomnia etc etc
Education: Recheck 6-8 weeks
19
Q
Methimazole (Tapazole) Indication MOA Adverse Effects #2 Caution preg lact peds
A
Indication: Hyperthyroidism
MOA:
Prevents production of Thyroid Hormone
Adverse Effects:
- Urticaria
- Blood Dyscrasia,
- Bone marrow suppression
Caution:
Other medications that can suppress bone marrow
preg: Do NOT use in 1st trimester
lact: lowest dose
peds: YES!
20
Q
Propylthiouracil (PTU) Indication MOA Adverse Effects #2 Black Box warning preg lact peds caution #2
A
Indication: Hyperthyroidism
MOA:
- Prevents comversion of T4 to T3
- Highly protein-bound = more drug interactions
Adverse Effects:
- Urticaria
- Blood Dyscrasia
- GI upset
Black Box Warning:
Hepatotoxicity
preg: 1st trimester
lact: low dose
peds: No (undeveloped liver)
Caution:
- Increased bleeding risk
- Other meds that suppress bone marrow
21
Q
Which symptom should be reported to the health-care provider and may be a reason to discontinue an antithyroid medication?
A
The most common potential adverse reaction is agranulocytosis. Patients are taught to report sore throat, fever, chills, rash, and unusual bleeding or bruising.
22
Q
For the diabetic patient with hypothyroidism, the APN should expect to take which action?
A
Decrease Basal Insulin
Hypothyroidism may delay insulin turnover, requiring less insulin to treat diabetes mellitus.
23
Q
Alpha-glucosidase inhibitors function by which primary mechanism of action?
A
Alpha-glucosidase inhibitors delay the absorption of complex CHO from the small bowel.
24
Q
Canagliflozin should not be initiated in patients with which condition?
A
ESRD
25
Acarbose (Precose) has which feature?
Reduced postprandial peaks of plasma glucose
26
The APN would avoid use of saxagliptin (Onglyza) in which patient?
DPP-4 Inhibitor
Cases of acute pancreatitis have been reported with dipeptidyl peptidase-4 inhibitors (DPP-4) inhibitors such as saxagliptin.
It should be avoided in a patient with history of pancreatitis.
27
Which oral medication has the most potential for hypoglycemia?
Sulfonylurea (glipizide, glyburide, glimepiride)
| All sulfonylureas may produce severe hypoglycemia.
28
A patient with type 2 diabetes mellitus (DM) is taking a rapid-acting insulin before meals and an alpha-glucosidase inhibitor three times a day. Her blood glucose log reveals a fasting glucose of 50 on several occasions. The APN instructs the patient that which of these will increase glucose levels when the patient is experiencing hypoglycemia?
Treatment of hypoglycemia cannot be accomplished with the usual ingestion of sucrose, fructose, or starches because alpha-glucosidase inhibitors delay the absorption of these disaccharides.
SHE NEEDS GLUCAGON
29
```
"-prils"
3 highlights
racial consideration
Indication
MOA (3)
Contraindication (3)
preg/lact
peds
side effects
Monitoring Parameters
```
```
ACE inhibitor
***Renal protective for DM
***1st line Tx for HF (Cardioprotective)
***if bp goes up it's because kidneys are not working
Racial consideration:
More adverse reactions in Black/Asian
```
Indication: HTN, hypertensive proteinuric diabetes, IHD, post-MI, HF
MOA:
ACE inhibit...
-inhibit bradykinin degradation
-^^synthesis of vasodilating prostaglandins
Contraindication:
- bilateral renal artery stenosis******
- idiopathic angioedema
- Do NOT USE WITH ARBS
Side Effect:
- cough
- Angioedema
- ^^K+ (r/t shutting down RASS)
- rash (hypersensitivity), altered taste, hypotension
preg/lact NO!
peds >6yrs
Monitoring: If BP goes up its r/t renal stenosis
30
```
"-sartans"
Indication
MOA
Caution (2)
Contraindication (2)
preg/lact
peds
adverse effects
```
Angiotensin Receptor Blocker (ARB)
Indication: htn, hypertensive proteinuric diabetes, angina, IHD, post-MI, HF
MOA:
ARB
Shuts down RAS (holds onto K+ and excrete NA+
Caution:
- Other meds that cause ^^^K+ hyperkalemia
- renal/hepatic impairment
Contraindication:
- bilateral renal artery stenosis
- DO NOT USE WITH ACE
preg/lact NO!
peds >6yrs
adverse effects:
- dizzy, hypotension, fatigue
- ^^^K+ hyperkalemia
- URI
31
What are the calcium channel blockers?
Dihydropyridines
(Nifedipine, Amlodipine)
Non-dihydropyridines
(Verapamil, Diltiazem)
32
-pines
Nifedepine (Procardia)
Amlodipine (Norvasc)
Felodipine (Plendil)
```
Drug class
Highlights (2)
Indication (2)
MOA
Contraindication
Black Box
preg
peds
racial concerns
adverse reactions
```
Calcium Channel Blocker
dihydro (for BP or you will DI from htn)
**DO NOT DEPRESS SA/AV NODES
******no direct effect on heart, SMOOTH MUSCLE RELAXATION because you don’t have the calcium in your muscle…makes muscles more leaky = peripheral edema/increasing workload of heart = WHY WE DON’T USE IN HF
Indication: HTN & angina
MOA:
- inhibit calcium ion from crossing cell membrane = smooth muscle relaxation
- CYP450 system
CONTRAINDICATION:
- patients with peripheral edema (increases workload on heart)
- unstable angina/post MI/HF
BLACK BOX:
Nifedipine high mortality post-MI
PREG: Nifedipine only
peds: >6yrs
Racial concerns:
1st choice for blacks
Adverse Reactions:
flushing, dizzy, h/a, hypotension,
**Peripheral Edema**
33
Verapamil
Diltiazem (Cardizem)
```
Drug class
highlights (1)
Indication (3)
MOA
Contraindication (4)
preg/lact
Adverse Effects (4)
```
Non-dihydropyridines (Calcium channel blocker)
**Depresses SA/AV nodes
Indication:
angina
htn
afib/SVT
MOA:
inhibit Ca+ crossing cell membrane = smooth muscle relaxation & coronary vasodilation
-negative inotrope, negative chronotrope
```
Contraindication:
EF <40%
Ventricular dysfunction
SA/AV disturbances
SBP <90
```
preg/lact: NO!!
```
Adverse Effects:
Edema
h/a
gingival hyperplasia
constipation (smooth muscle effects)
```
34
Which suffix is best associated with DPP-4 inhibitors?
-gliptin
35
What MOA best describes sitagliptin (januvia) ?
Increases Insulin release
36
What is a consideration when prescribing sitagliptin (januvia)
"add-on agent"
37
A new patient presents today for evaluation of hypertension. The patient states that he has been feeling weak and thinks that his heartbeat is irregular at times. The APN notes that the patient is being treated with lisinopril and spironolactone. Which condition would the APN most likely suspect?
Hyperkalemia
In this patient scenario, the patient is taking an angiotensin-converting enzyme inhibitor (ACEI) and a potassium-sparing diuretic. Concurrent administration of potassium-sparing diuretics and ACEIs may lead to significant hyperkalemia.
38
What kind of diet would you recommend to someone on a potassium sparing diuretic or ACE-inhibitor?
Low Potassium
39
All calcium channel blockers (CCBs) are in which pregnancy category?
Pregnancy Category C
CCBs are Pregnancy Category C. Female patients capable of childbearing should be made aware of the risks of these drugs, and contraception should be instituted before CCBs are prescribed. They should be used only when benefits clearly outweigh risks.
40
A patient with left ventricular dysfunction is taking a calcium channel blocker (CCB) and a beta blocker (BB). This combination may induce which condition?
Heart Failure & Bradycardia
Combinations of BBs and CCBs have been shown to be more effective than the individual drugs used alone. However, these combinations are questionable for patients with left ventricular dysfunction because together they may induce heart failure or bradycardia. Verapamil and diltiazem also should be avoided in these combinations.
41
Calcium channel blockers (CCBs) are indicated to treat which condition?
Chronic Angina
Both type 1 and type 2 CCBs are effective in the treatment of stable and exertional angina. They act on both sides of the supply–demand equation: peripheral vasodilation and negative inotropism reduce oxygen demand; dilation of coronary arteries increases oxygen supply.
42
The highest rate of adverse reactions is found in which calcium channel blocker (CCB)?
Nifedipine
43
Which action should be considered when planning the management of angiotensin II receptor blockers (ARBs) or ACE-I?
Stop diuretics 2-3 days to allow hydration before starting ARB or ACE-I to reduce risk of adverse effects
44
Which adverse reaction is uncommon with use of angiotensin-converting enzyme inhibitors (ACEIs)?
Blood Dyscrasia
45
Which medication sometimes induces a lupus-like syndrome that appears to be dose-related with an incidence highest in white women?
Hydralazine
46
Which calcium channel blocker (CCB) is the drug of choice during lactation if a CCB is required?
Nifedipine
47
First-generation antihistamines are contraindicated in patients with which condition
contraindicated in patients with narrow-angle glaucoma, lower-respiratory tract symptoms (they thicken secretions and impair expectoration), stenosing peptic ulcer, BPH, bladder neck obstruction, pyloroduodenal obstruction, and (MAOI) use.
48
Which medication is used to treat seasonal allergic rhinitis and vasomotor rhinitis?
Azelastine (Astelin, Astepro) and olopatadine (Patanase)
are the intranasal histamine (H1) blockers currently available in the United States. They are used for the treatment of seasonal allergic rhinitis and
vasomotor rhinitis. Afrin causes rebound decongestion.
49
Which statement about long-acting beta agonists (LABAs) is most accurate?
LABAs should be used for the shortest duration of time required to achieve control of asthma symptoms and discontinued, if possible, once asthma control is achieved. Patients should then be maintained on an asthma controller medication.
Pediatric and adolescent patients who require the addition of a LABA to an inhaled corticosteroid should use a combination product containing both an inhaled corticosteroid and a LABA to ensure compliance with both medications.
50
A patient who has been diagnosed with asthma presents today for follow-up. She states that she has been using a short-acting beta2 agonist (SABA) four times a week. Which action taken by the APN is most appropriate?
Add a low-dose inhaled corticosteroid.
51
In 2009, the U.S. Food and Drug Administration (FDA) established a recommendation that patients be informed of the potential for neuropsychiatric events associated with which drug?
Leukotriene modifiers
neuropsychiatric events include agitation, aggression, anxiousness, dream abnormalities and hallucinations, depression, insomnia, irritability, restlessness, suicidal thinking and behavior (including suicide), and tremor
52
A patient has just been prescribed azelastine for her allergic rhinitis. She asks about driving with this medication. Which response by the APN is most appropriate?
“You may feel sleepy with azelastine, so you should not drive when using it.”
Patients should not use alcohol or other central nervous system (CNS) depressants while using azelastine.
53
The nurse practitioner has prescribed zafirlukast (Accolate) to a 12-year-old for asthma control. Which is a common adverse effect of this medication?
The most common adverse effect of zafirlukast is headache.
54
What is a common side effect of zileuton?
Dyspepsia
55
Albuterol
"think of what stimulating the adrenergic system does"
```
Drug Class
Indication
MOA
Contraindication #2
Caution #4
Side Effects
peds
```
Short Acting Beta2 Agonist (SABA)
Indication: Asthma, COPD
MOA: activate beta2 by relaxing smooth muscle & increasing volume, capacity, and airflow
Contraindication:
- avoid in arrhythmia,
- pheochromocytoma (massive release of catecholamines (epi/norepi)=severe htn),
Caution:
- CVD (CHF, htn),
- DM (increases blood sugar = increase diabetic needs), -Glaucoma (increase in BP = increases eye pressure),
- Hyperthyroidism (stimulates thyroid)
Albuterol Safe in all ages
Used 3+ days per week = asthma not well controlled
56
What would you give to an asthmatic that could handle the side effects of albuterol? Why?
Levalbuterol (Zopenex)
more selective so less beta1 activation
57
Semeterol (Serevent)
```
Drug class
Indication
Caution
Block box warning
Age range
```
Long Acting Beta2 Agonist (LABA)
Indication: Asthma, COPD
Caution: Hyperglycemia
BLACK BOX: should not be used as monotherapy = 2x increase in catastrophic events
Contraindicated if there is not another controller medication like steroid
- Digitalis glycosides
- Beta Blockers
Peds >4yrs old
58
What asthma reliever medication would you give to pregnant person?
Terbutaline is safe in pregnancy
59
Steps to prescribing for asthma
Step 1: Always start with SABA, if 3+ days/wk…
Step 2: Maintenance: inhaled corticosteroids, still not managed
Step 3: LABA
**beta blockers MR BEAN is selective and has no Nads**
***If they have asthma and need to be on a beta blocker it NEEDS TO BE A MR BEAN (selective beta blockers)***
**including beta blocker eye drops**
60
Theophylline
```
Drug class
Indication
MOA #2
Patient Education
Toxicity s/s
Contraindications #4
```
"Theo shouldn't drink coffee"
Indication: Asthma, COPD
MOA: Relaxation of bronchial smooth muscle, general sympathomimetic agent (increasing SNS)
-CYP450 system and converted into caffeine
Patient Education:
* *inducers speed up metabolism into caffeine!
* *Smoking increases the excretion and increase BP and more blood through kidneys
* *Narrow therapeutic index
Over range: N/V/D
HIGHER toxic: seizure, cardiac, hypotension
Contraindication:
- hypersensitivity,
- SZ disorders,
- -PUD,
- decrease appetite (puts you in fight or flight)
61
Ipratropium bromide (Atrovent)
```
Drug Class
Indication
MOA
Contraindication (2)
Side Effects
```
Short-Acting Anticholinergics (SAMA)
Short acting muscarinic antagonist
-Ipratropium (I=immediate release)
Asthma Exacerbation (like Combivent/DuoNeb), >>>>COPD<<<<
MOA: Blocks muscarinic acetylcholine receptor
“blocks cholinergic receptors…(acetylcholine not absorbed (PNS-rest and digest) = Cholinergic Effects
Contraindication:
Legume allergy,
Cholinergic Effects
Side Effect: Cholinergic Effects
62
```
Tiotropium Bromide (Spiriva)
Aclidinium bromide (Tudorza Pressair)
```
```
Drug Class
Indication
MOA
Contraindications
Side Effects
```
Long-Acting Anticholinergic (LAMA)
Indication: COPD (Maintenance)
MOA: Muscarinic M3 antagonist
Contraindication: **anticholinergic Effects (not for glaucoma, BPH, urinary retention etc), not to be used for exacerbations
Side Effects: Anticholinergic Effects (dry mouth, cough, constipation)
63
What are the cholinergic Effects?
"can't think, see, spit, pee, poop"
```
Confusion/dizzy
Blurred Vision
Dry mouth
urinary retention
constipation
```
64
Steps to prescribing for COPD
Step 1: SABA, SAMA or Combination of both
Step 2: Maintenance LABA or LAMA or Combination of both
Step 3: if an increase in exacerbations: Corticosteroids to reduce # of exacerbations
65
Zafirlukast
Montelukast (Singulair)
```
Drug Class
Indication
MOA
Contraindication
Side Effects #2
Patient Education #2
Pregnancy
Peds
```
Leukotrine receptor Antagonists
Indication: Allergic Rhinitis, or someone’s allergies are causing asthma to worsen
MOA: Blocks cysteinyl leukotriene receptor (CysLT1)= prevents inflammatory processes from happening
Contraindication:
*If it starts w/ "Z"afirlukast/Zileuton can’t take with liver issues* monitor LFTs
Montelukast should not take if SEVERE LIVER DISEASE,
Side Effects: Headache, Neuropsychiatric symptoms
Patient Education:
Neuropsychiatric symptoms (AMS, depression, agitation),
Take at night
Pregnant: NO!
Peds: Montelukast preferred
66
Ages for prescribing Leukotrine Modifiers
Montelukast 1+ yrs
Zafirlukast 5+ yrs
Zileuton 12+ yrs
67
Zileuton
```
Drug class
Indication
MOA
Side Effects
Education
```
Leukotriene Modifier
Indication: Chronic Asthma/allergies
MOA: inhibits enzyme (5-liopoxygenase) that produces leukotrienes = reduce inflame, edema, mucus, bronchoconstriction
Side effects: headache, Neuropsych events
```
Patient Education
Monitor ALT (hard on liver)
```
68
Fluticasone (Flovent (inh)) or Flonase (nasal)) “-sone” Budesonide (Pulmicort)
```
Indication
MOA #3
Contraindication #2
preg
adverse #4
Education #2
```
Corticosteroids
Indication: Asthma, COPD, allergic rhinitis (intranasal)
MOA:
- Extremely vasoconstrictive and
- Anti-inflammatory activity,
- decreases airway responsiveness
Contraindication:
asthma exacerbation,
active infection (don’t want to suppress immune system),
Pregnancy NO!
Adverse: hoarse, oral candidiasis, irritation, urticaria
Education:
- Rinse mouth after!!!
- High dose for a long time watch HYPERGLYCEMIA and HYPOKALEMIA and WEIGHT GAIN
69
Cromolyn Sodium
```
Drug Class
Indication
MOA
Education
Contraindication
Peds
Inhaled & Intranasal side effects
```
Inhaled antiinflammatory agent
Indication: bronchospasm, exercise induced bronchospasm (people who need something for after soccer practice everyday)
MOA: Mast cell stabilizer/degranulation inhibitor
Education: take before soccer practice
Contraindication: not for exacerbation (prophylaxis only)
Peds >2yrs
Inhaled side effects: drowsy, bronchospasm, cough
Intranasal side effects: nasal irritation
70
Diphenyhydramine (Benadryl)
```
Drug Class
Indication
MOA
Contraindication
peds
```
First generation Antihistamine
Indication: allergic rhinitis, hypersensitivity reactions, insomnia, seasickness
MOA: Block H1 receptors ...crosses blood-brain barrier
Contraindication: Avoid in glaucoma, BPH, CNS depressants (related to anticholinergic effects)
Paradoxical effect with children
>2yrs
DON’T TAKE IN LACTATION
Adverse Effects: sedation, urinary retention, dry mouth, blurred vision “anticholinergic effects”
71
Certizine
Loratadine
"ine"
Drug class
Indication
MOA
Fun fact about certirizine
Second-Generation Antihistamine
Certizine, Loratadine, “-ine”
Indication: Respiratory allergies & urticaria
MOA: Block H1 receptor NO ANTICHOLINERGIC EFFECTS
Certirizine: fastest onset and least metabolized by CYP450, less drug interactions, kids 6 months+
Loratadine Age 2+
72
phenylephrine & Pseudoephedrine
```
Indication
MOA
Contraindication #4
peds
Side Effects
```
Decongestant
Systemic
MOA: sympathomimetic agent, Alpha1 agonist, potent vasoconstrictor
(alpha 1= “on” switch for fight or flight)
Contraindication:
- severe htn
- CAD,
- MAOI
- Beta-blockers (don’t increase SNS if you are on a drug that’s blocking it)
Peds >4yrs
Side Effects: “meth heads’
73
What decongestant is safe for cardiac patients?
phenylephrine (much less potent)
74
What is Verapamil? A unique side effect?
Non-dihydro Ca++ Channel blocker
Antiarrythmic
Lowers sphincter tone = ^^GERD s/s
75
HCTZ
```
Drug Class
Indication
MOA #2
Location
Fun fact
Side Effects #3
Special Patient Considerations
```
Diuretic
Indication: htn, mild fluid retention
*Hardest on Kidneys*
MOA: Blocks reabsorption of sodium and Cl- = keeping Na+ in urine and H2O stays in urine
CYP450 metabolizer
Location: distal convoluted tubule
Fun Fact: Maintenance, long-lasting effect not brisk
```
Important Side Effects:
hypokalemia,
hyperglycemia (DM),
hyperuricemia (gout)
Hyperlipidemia
```
Special patient considerations: Hyperlipidemia
76
Furosemide
```
Drug class
Indication
MOA
Location
Side effect #3
Contraindication #2
```
Loop diuretic
Indication: Acute exacerbation
*best option for renal dysfx
MOA: Blocks reabsorption of Na+ & Cl-
Location: LOOP OF HENLE (most water is absorbed here = shut down = profound effect)
Side effect:
hypokalemia,
hyperuricemia (gout),
ototoxicity
Contraindication:
- anuric
- Sulfa allergy
77
Aldactone (Spironolactone)
```
Indication
MOA
Location
Fun Fact
Side Effects #3
```
Indication: edema r/t HF
MOA: inhibits reabsorption of Na+ & excretion of K+
Location: early collecting duct
Fun fact: aldosterone antagonist (anti androgen effects)
Side effects:
- Hyperkalemia,
- Gynecomastia/menstrual irregularities (anti androgen effects),
- hyperuricemia
78
Ranexa
Caution
MOA
Drug Interaction
anti anginal/refractory angina
-last resort
Caution: QT interval
MOA: restrict late sodium flow in the myocytes
- improve O2 demand
- no effect on BP
Drug Interaction: Do not use with CYP450 inducers
79
Hydralazine
Indication #2
MOA
Side Effects #3
Contraindication
Vasodilator
Indication:
hypertensive crisis,
HF (need to be on BB and diuretic (to prevent peripheral edema))
MOA: dilate smooth muscles & vasculature
Adverse Effects:
- Reflex tachycardia (therefore could cause angina)
- Lupus syndrome,
- fluid retention/peripheral edema
Contraindicated:
-CAD
80
Older adults taking ranitidine should be monitored carefully for which of these?
Mental Status Changes/confusion
81
Which is the standard first-line therapy for the treatment of gastroesophageal reflux disease (GERD)?
Proton pump inhibitors (PPIs)
82
Many patients are prescribed opioid analgesics for the amelioration of chronic pain. Chronic constipation often results from taking these medications long term. Which medication is the best choice for the APN to prescribe to help with the constipation?
Methylnaltrexone
an antagonist to the mu-receptor in the gastrointestinal (GI) tract. It is used for treating constipation from chronic opioid use.
83
What would you prescribe for a women with constipation from IBS?
Lubiprostone (Amitiza)
84
Patients with uncomplicated peptic ulcer disease or mild gastroesophageal reflux disease (GERD) may benefit from taking antacids daily. Which instruction should the APN give the patient regarding an antacid suspension?
Taking the antacid 1 to 3 hours after eating will prolong the antacid effect.
85
A patient with gastroesophageal reflux disease (GERD) has been self-medicating with various antacids at home. The APN is reviewing the patient’s prescription medications with him. Which medication decreases lower esophageal sphincter (LES) tone and could potentially exacerbate GERD?
Verapamil
86
The APN is caring for a patient who will be receiving epoetin alfa preoperatively to reduce the need for blood transfusion during the surgery. Which prescriptions will the patient need in addition to the one for the epoetin alfa?
Both—a prophylactic anticoagulant and an iron supplement are recommended in this situation.
87
Which of these would be first-line therapy for mild acne vulgaris with closed comedones?
Benzoyl Peroxide
Acne is classified as mild, moderate, or severe, and pharmacological intervention is based on the severity of acne. Benzoyl peroxide has antibacterial activity against P. acnes, the predominant organism in sebaceous follicles and comedones of acne vulgaris.
88
A 60-year-old female patient is being treated for pernicious anemia. In addition to anemia, she has neurologic symptoms associated with vitamin B12 deficiency. Which regimen is recommended for treatment in this situation?
Vitamin B12 1,000 mcg weekly for 1 month, then twice monthly for 6 months, and then monthly for life
Increased doses are required to treat neurologic symptoms at the onset of treatment. After improvement in neurologic symptoms, monthly treatment with injectable vitamin B12 is adequate.
89
A patient taking warfarin is having pain associated with an acute musculoskeletal injury. He asks the APN if he can take acetaminophen because he knows he should not take an NSAID for pain while on warfarin. Which response by the APN is most appropriate?
“You can take the acetaminophen as needed, and then I will check your [international normalized ratio] INR in a few days to see if there is a change.”
Close monitoring of INR is needed to identify a possible drug-drug interaction.
90
Most common side effect of Metformin?
Diarrhea
91
Rare but serious side effect of Metformin?
Lactic Acidosis
Increased risk with liver damage, alcohol, and dehydration
92
What is the one true contraindication of Metformin?
Renal Impairment
93
What is the first line therapy for gestational diabetes?
Insulin
94
Biggest side effect of medications that increase insulin?
hypoglycemia
| weight gain
95
Lispro & Aspart - Rapid Acting
onset
peak
duration
onset 5 mins
Peak: 1 hour
Duration: 4 hours
96
Short Acting - Regular Humulin
Directions
Onset
Peak
Duration
Directions: 30mins prior to eating
Onset: 30 mins
Peak 1-2 hours
Duration: 3-7 hours
97
Intermediate - NPH
Onset
peak
duration
directions
Onset 1.5 hours
Peak: 4-12 hours
Duration: 10-16 hours
Directions: Draw clear than cloudy
98
Long Acting - Glargine & Detemir
onset
Duration
Onset 2-4 hours
Duration 24 hours
99
What sulfonylurea can you take concurrently with insulin?
Glimepiride
100
Noninflammatory comedonal acne drug selection
Topical retinoid or benzoyl peroxide
101
Inflammatory papularpustular acne drug selection
Topical Combination therapy:
topical antibiotic
Benzoyl peroxide
topical retinol
102
Severe inflammatory acne drug selection
Oral antibiotics w/topical combination therapy
103
Last resort drug choice for acne
Accutane - Isotretinoin
104
Benzoyl Peroxide
MOA
Side Effects
Patient Education
MOA: comedeolytic/desquamation & slightly antibacterial
Side Effects:
Photosensitivity, Irritating
Education:
Bleaches clothes
Inactivates retinol
105
Erythromycin
| Drug interaction
Topical Antibiotic
| Do not use concurrently with Clindamycin
106
```
Clindamycin
Drug Interaction
Side Effects
Contraindication
Patient Education
```
Topical Antibiotic
Don’t use with erythromycin
Contraindication: crohn’s, ulcerative colitis, etc
Monitor for diarrhea/colitis and stop medication
Side Effects: burning, peeling
107
Azelaic Acid
Drug class
Caution
Topical Antibiotic
*mostly antibacterial*
Caution: Dark skin pigmentation
108
Tertinoin (Retin-A)
Drug Class
MOA
Patient Education
Retinoid
MoA: reduces cohesion between keratanized cells
Pt Education:
6-8 weeks to see improvement
109
Tetracycline
Drug Class
Education
Pregnancy
Pediatric
Oral Antibiotic
Pt Education:
Photosensitivity
Take on empty stomach
Pregnancy: NO!
Pediatric: Teeth staining
110
What is the first line treatment for oral antibiotics for acne?
Tetracycline
Unless contraindicated
111
What oral antibiotic for acne would you recommend for a pregnant person?
Azithromycin or Erythromycin
112
Minocycline
Drug class
Education
pregnancy
pediatrics
Oral antibiotic
Pt Education: Empty stomach
Pregnancy: NO!
Pediatrics: teeth staining
113
Doxycycline
Drug class
Education
Pregnancy
Oral antibiotic:Tetracycline
Education:
Take with meal & water
Pregnancy NO!
114
Isotretinoin (Accutane)
Drug class
MOA
Side Effect #4
3 labs to draw
Systemic Retinoid "IPledge"
MOA:
- reduces sebum production, -reduces hyperkeratinized follicle
- *prodrug*
Side Effect:
- Chelitis (sore around mouth),
- hypertriglyceridemia,
- hyperglycemia
- bone fracture
3 labs to draw and monitor:
- lipid (hard on liver),
- serum HcG (tetragenic),
- hyperglycemia
115
LDL Goal vs Guidelines
HDL Goal
Triglycerides Goal
LDL <100 OR <190 GUIDELINES
HDL >40
Triglycerides <150
116
```
"-statins"
MOA #3
Side Effect #3
Labs to check #3
Contraindications #3
Patient Education #2
```
MOA:
- metabolized by CYP34A
- HMG CoA Reductase Inhibitors (inhibits the enzyme to mevalonate) rate limiting step in production of cholesterol
- Increases LDL receptors on liver
Side Effect:
- myalgia,
- rhabdo,
- liver
Labs to check:
- creatine kinase &
- LFTs before therapy,
- lipids 4-6 wks
CONTRAINDICATION: PREGNANCY, liver disease, no grapefruit juice
Education:
- new onset myopathy,
- abdominal pain (liver)
117
What are the 4 statin benefit groups
Group 1:
CAD <75 yrs old = high intensity statin
>75 yrs old = mod intensity
Group 2:
LDL >190
Group 3:
Diabetes = moderate statin
Group 4:
ASCVD risk >7.5%
118
Niacin
"think 5 hour energy shot"
```
Indication
MOA #3
Side Effect
Fun Fact
Education
Contraindication #5
Lab Monitoring
```
Indication: hyperlipidemia
MOA:
- Naturally occurring B3 vitamin,
- Reduces VLDL synthesis
- Increases HDL
Side Effect:
-Flushing/pruritus (from increasing prostaglandin activity “energy shot”)
Education:
-NSAID 30 mins prior admin to stop flushing
Contraindication:
- hepatic dysfx,
- diabetes (vasodilating drops blood sugar),
- gout (vasodilation uric acid forced into joints),
- reflex tachycardia/afib (vasodilating),
- peptic ulcers,
Labs:
Creatinine
119
Gemfibrozil, Fenofibrate
```
Class
Indication
MOA
Side Effect
Drug Interaction
Lab Monitoring
Contraindication
```
Class: Fibrates
Indication:
-Triglycerides >400
MOA: increase lipolysis of triglycerides via lipoprotein lipase = DECREASE IN TRIGLYCERIDES
Side Effects:
- Gall stones/abdominal pain/dyspepsia (hard on GI),
- hard on liver
- Phototoxicity
Drug interactions:
-increased risk hepatotoxicity & myalgias if on -statins OR niacin
Lab Monitoring:
-Check LFTs
Contraindication:
- Liver disease
- Gall bladder disease
- Elevated ALT/AST
120
What drug class for lipids has no effect on pregnancy?
Bile Acid Sequestrants
121
What drug class for lipids has no effect on liver?
Bile Acid Sequestrants
122
Cholestyramine
Colestipol
Colesevelam
MOA
Side Effect #3
Patient Education
Pregnancy
Bile Acid Sequestrant
MOA:
-exchanges chloride ions for negatively charged acids in bowel
forms nonabsorbable complex w/bile acid in intestines >> bile salts can no longer be reabsorbed & stay in small intestine & fecally removed LDL
Side Effect:
- All fat stays in intestines >>> flatulence, bloating, abdominal pain, constipation
- Increased Triglycerides
- biliary obstruction,
OKAY FOR PREGNANCY AND LIVER DISEASE
Patient Education: Take 1 hour before, 4 hrs after
123
Ezetimibe (Zetia)
Drug Class
MOA
Side Effect #4
Prescribing information #2
Cholesterol Absorption Inhibitor
MOA: blocks absorption of cholesterol across intestinal border (keeps in GI tract)
Side Effect:
- Fatigue,
- Diarrhea,
- LFT
- Arthralgia
Adjunctive w/ statin
NO EFFECT ON LIVER
124
CYP3A inhibitors ____ stain concentrations
increase
Verapamil, Diltiazem, -azole, antifungals, erythromycin, fluoxetine, nefazodone, protease inhibitors
125
CYP3A inducers ____ stain concentrations
decrease
Rifampin, phenytoin, phenobarbital
126
What hyperlipidemia drug is most effective in combination with a statin?
Ezetimibe (Zetia)
127
Evolocumab (Repatha)
Indication
MOA
Side Effect
PCSK9 Inhibitor
SQ & expensive
Indication:
-genetic cases (familial homozygous
MOA:
-monoclonal antibody binds to PCSK9 so it doesn’t bind and destroy LDL receptors
Side Effects:
- pain at injection
- hypersensitivity
128
```
Pyrethrins (RID)
Indication
MOA
Allergy caution
Side Effect
Preg/lact
Peds
Education
```
Indication:
*prescription strength
MOA:
- absorbed through exoskeleton causing paralysis & death,
- no residual activity
Caution: Chrysanthemum or ragweed allergy
Side Effect:
localized
Prep/lact OK
Peds >2yrs
Education: works best on dry hair, active only when applied then rinses off
129
Permethrin
```
Indication
MOA
preg/lact
Peds
Education
```
Permethrin
Indication:
-1st line head lice and scabies
MOA: Absorbed through exoskeleton = paralysis & death
-Residual activity for 10 days
Preg/lact OK
Education: Treat whole family
Contraindication: eyes
Peds >2months
130
Malathione (Ovide)
```
Indication
MOA/residual effects
Education #2
Preg/lact
peds
Side Effects #2
```
*2nd line lice*
MOA:
-inhibits cholinesterace activity and residual 7 days.
Education:
- do not use hair dryer (Flammable)
- Rinse Ovide off & shampoo hair 8-12 hrs after
Preg/lact: NO!
Peds: >6yrs
Side Effects:
- organophosphate poisoning
- respiratory distress if ingested
131
Benzyl Alcohol (Ulesfia)
Indication
MOA
Peds
Indication: Live head lice
MOA: non-neurotoxin, stuns lice and leads to asphyxiation
Peds >6months
132
Ivermectin (Sklice)
MOA
Preg
Peds
MOA: Nerve Agent, Paralysis & Death,
*Single application effective to eradicate head lice*
Preg: NO
Peds >6yrs
133
What factors does warfarin act on?
2, 7, 9, 10
134
Warfarin
```
Indication
MOA
Antidote
Caution
Side Effect #2
Black Box Warning
Contraindication #2
Monitoring Parameters & labs
Half life
Pregnancy
Lactation
```
Warfarin
Indication: DVT & PE & -Mechanical Heart Valve (INR 2.5-3.5)**
MOA:
-inhibits VKORC1 complex depletes Vitamin K = can’t produce clotting factors 2, 7, 9, 10 ……Vitamin K antagonist -CYP2C9, highly protein bound
“shot gun effect”
2+7 = 9 & 10
Antidote: Vitamin K
Caution: Hepatic impairment
Side Effect:
- Skin necrosis,
- rare macularpapular rash
Black Box Warning:
Fatal bleeding
Contraindication:
- hypermetabolic state,
- blood dyscrasias
```
Monitor:
-INR daily until therapeutic
2 days > 3x weekly 2 weeks > Q6 weeks,
-LFTs,
-TSH
```
Half-Life 3-4 days
Pregnancy: NO
Lactation: OK
135
If someone on an "-azole" antifungal on warfarin, the INR would ____
"-azole" is an inhibitor so INR increases
136
If a person on warfarin is prescribed rifampin, the INR would ____
Rifampin is an inducer so INR decreases
Antiseizure medications are inducers
137
Heparing
```
Indication
MOA #2
Pregnancy
Side Effect
Caution
Contraindication #2
Drug interactions #3
Monitor
Antidote
```
Indication: Postoperative thromboembolism
MOA:
- Increasing antithrombin III which inactivates thrombin to prevent conversion to fibrinogen to fibrin
- Highly Protein bound
Pregnancy: OK
Side Effect:
-Hyperkalemia
Caution:
-combining drugs that predispose to hyperkalemia****
Contraindication:
Liver & renal disease
Drug interaction:
- cephalosporin,
- PCN,
- Valproic Acid
Monitor: aPTT, PLT, Hct
Antidote: Protamine Sulfate
138
What is the anticoagulation of choice in pregnancy?
Lovenox
139
Low molecular weight heparin
```
Indication
MOA
Pregnancy
Contraindication #3
Side Effect #1
Monitor
```
Indication: DVT, PE, bridging
MOA:
-Activates antithrombin III and inactivates Xa and IIa (thrombin)
Pregnancy *Drug of Choice*
Contraindication:
allergies to pork, sulfites, or benzyl alcohol
Side effect: Peripheral Edema
Monitor: PLT and Hct
140
Dabigatran (Pradaxa)
```
MOA
Black Box Warning #2
Pregnancy
Side Effect
Antidote
```
MOA: Direct thrombin (factor II) inhibitor
Black Box Warning:
- Discontinuation = increased risk thrombolytic events,
- Epidural/Spinal hematomas
Pregnancy: NO!
Side Effect: Dyspepsia, gastritis
Antidote:
idarucizumab (Praxbind)
141
Factor Xa Inhibitors
Rivaroxaban, Apixaban, Edoxaban Betrixaban
```
"put a band around your Xa"
MOA
Caution
Antidote
Black Box #2
Pregnancy
Side Effect
```
MOA: direct Xa inhibitor
Caution: Liver and renal impairment
Antidote: Andexxa
Black Box:
- Discontinuation and increase of thrombotic evens,
- epidural/spinal hematoma
Pregnancy: NO!
Side Effect
Hemorrhage
142
Absolute contraindication in Rivaroxaband
Do not use in liver disease or GFR less than 30
143
Side Effects specific to Apixaban
Nausea
144
Endoxaban specific side effects
Rash
| GI bleed
145
What is the safest anticoagulation drug in kidney dysfunction?
Warfarin
146
Aspirin
```
Indication #3
MOA
Contraindication #4
Used to prevent..?
Drug Interaction #4
Side Effect #3
```
Indication: MI & Stroke prevention & ACS
MOA: Cyclooxygenase pathway antagonist
Contraindication:
- Flu,
- Chickenpox,
- Liver disease,
- Reye’s syndrome
*used to prevent preeclampsia*
Drug Interaction:
NSAIDs,
gingko, garlic, ginseng
Side Effect:
- GI ulcer,
- Tinnitus,
- Steven Johnson syndrome
147
Clopidrogel (Plavix)
MOA
How is it different from aspirin?
Metabolized by what system?
MOA:
-ADP receptor antagonist,
* no effect on prostaglandins*
* Prodrug metabolized by CYP2C19*
PPI, Psychotropics, anticonvulsants are 2C19 Inhibitor = Plavix ineffective
148
If you take PPI with Plavix are you more likely to clot?
True
PPI are 2C19 inhibitors and Plavix is a prodrug
149
Vitamin B12 Deficiency
Cause
anemia type
Side Effect
Monitoring Parameters
Lack of intrinsic factor from gastric bypass
Macrocytic Anemia
Side Effect:
Hypokalemia
Anaphylaxis
Monitor:
Potassium
150
What is Oxymetazoline
Afrin
| Intranasal Decongestant
151
Aluminum hydroxide, magnesium hydroxide, calcium carbonate
```
Indication
MOA
Contraindication
Caution
Patient Education
Drug Interaction
```
*Postively charged ions*
Indication:
acute hyperacidity,
GERD
MOA:
antacids are weak bases to neutralize gastric acidity and increase pH
Contraindication: abdominal pain
Caution:
HF r/t hypernatremia
Patient Education:
2 hours before/after any meds
Drug Interaction:
- Do not take with Iron (will not be absorbed)
- Increased absorption of enteric coated tablets
152
Aluminum and calcium based antacid side effect education
Constipation
153
Magnesium based antacid side effect education
Diarrhea
154
Ranitidine (Zantac) & Famotidine (Pepcid) & cimetidine
```
Drug Class
Indication
MOA
Best > worse
Side Effects
Lab monitoring
```
Histamine Receptor 2 Antagonist
Indication: mild intermittent GERD (maintenance)
MOA:
-blocks the histamine receptor = no activation of proton pump reduced stomach acid to 35-50%
Famotidine > ranitidine > cimetidine
Cimetidine side effects:
anti androgen & crosses blood-brain barrier (CNS)
preg/lact/kids not safe WITH cimetidine
Side effects:
- anti androgen (gynecomastia and impotence and menstrual cycle effected),
- CNS effects (confusion, agitation, psychosis ESPECIALLY IN ELDERLY), blood dyscrasias
Monitor:
LFTs
155
Cimetidine Side Effects
Anti Androgen
| CNS
156
Omeprazole, Pantoprazole, Esomeprazole “-prazole”
```
MOA
Indication
Drug Interaction
Caution
how long does one dose last?
preg/peds
Side Effects #3
```
Proton Pump Inhibitor
MOA: shut downs proton pump. Reduce stomach acid >90%
“H+/K+ ATPase pump inhibitor”
```
Indication:
GERD,
erosive gastritis,
ulcers,
multi drug regimen for H. pylori infection
```
Education: 30-60mins to work and before breakfast
Drug interactions:
- metabolized by CYP450 system
- Omeprazole reduces effectiveness of Plavix…Pantoprazole is better agent to use
Caution:
- elderly,
- hepatic dysfx/renal dysfx
One dose lasts 72 hours
Safe kids & pregnancy Omeprazole, Esomeprazole
PANTOPRAZOLE NOT SAFE IN KIDS OR PREGNANCY
Side Effects:
- Bone fractures/Osteoporosis,
- increased risk GI infection,
- Vit B12 deficiency (pernicious anemia)
157
What are the DPP-4 Inhibitors?
-gliptins
Sitagliptin (Januvia)
Linaglipton (Tradjenta)
158
CYP3A4 & CYP2C9 Inducers ___ meglitinide metabolism
Increase
159
What are common CYP inducers?
Phenobarbital
phenytoin
Rifampicin
Glucocorticoids
160
What are common CYP inhibitors
- Clarithromycin, erythromycin
- CCB non-dihydro (Diltiazem, Verapamil)
- Grapefruit juice!
- "-azoles"/antifungals
161
What are Constipation stimulants?
Castor Oil
Senna
Bisacodyl (dulcolax)
162
What are constipation bulk laxatives?
Psyllium
Methylcellulose
Polycarbophil
163
What is the safest laxative?
Bulk Laxatives
Psyllium
methylcellulose
polycarbophil
164
What are osmotic laxatives?
Magnesium hydroxide
lactulose
polyethylene glycol
165
What category is polythylene glycol?
osmotic laxative
166
What are the constipation lubricants?
Mineral oil
| Glycerin
167
Steps to treating constipation
Step 1: Bulk Laxatives, Sool softeners
Step 2: Saline, osmotic and lubricating laxatives
Step 3: Stimulants
168
What do you need to monitor for with lactulose?
Dehydration
Electrolytes
Hyperglycemia in DM
169
Senna, Bisacodyl, Castor Oil
```
MOA
Side Effects
Contraindication
Pregnancy
Peds
```
Stimulant, short term only
MOA: stimulates myenteric plexus >> prostaglandin release (increases motility)
Side Effects:
abdominal cramping
Contraindication:
-bowel obstruction
Pregnancy SAFE
**castor oil cannot be used in pregnancy may stim. contractions**
Peds >2yrs (Senna weaker and ok)
Peds >6yrs (bisacodyl)
170
Which stimulant is not safe for pregnancy?
Castor Oil
May stimulate contractions
171
Which stimulants are safe for Children 2+ years?
Senna weakest
172
Psyllium, methylcellulose, polycarbophil
MOA
Contraindication
Adverse Effects
Bulk Laxatives *Safest laxative*
MOA: Soluble fiber absorbs water into the intestine that promotes peristalsis and reduces transit time
Contraindication:
-narrowed GI tract/obstruction,
Adverse Effects:
- abdominal pain/bloat,
- intestinal obstruction**
173
Magnesium hydroxide, Lactulose, polyethylene glycol
MOA
Adverse Effects
Caution #2
Peds
Osmotic Laxative
*Safer for Acute Effects*
MOA: pulls water into intestine to distend colon and increase peristalsis
Adverse Effects:
-Abdominal cramping/diarrhea/bloating
Caution:
- Lactulose (a sugar) hyperglycemia in diabetic patients*
- Magnesium in renal impairment*
Peds >2yrs
174
What osmotic laxative is contraindicated in renal impairment?
Magnesium hydroxide
175
Docusate Sodium
MOA
preg/lact
peds
side effect
Stool Softener
MOA: Turns stool into emollient by mixing oil & water
Preg/lact safe
Peds >2yrs
Side Effect: diarrhea
176
Mineral Oil, glycerin
Indication
MOA
Contraindication
Side Effect
Lubricants
Indication: Usually given PR, fecal impaction
MOA: Lubricates stool
*lubricant and osmotic can be used together*
Contraindication:
-Elderly (beers criteria) r/t aspiration from oil going down throat
Preg NO!
Side Effect:
- abdominal cramp,
- oily rectal leakage
177
What laxatives can be used together?
Lubricants and osmotics
178
Lubiprostone (Amitiza)
Indication
MOA
Contraindication
Preg/peds
Chloride Channel Activator
Indication: idiopathic constipation
MOA:
-“hyperosmotic” produces chloride rich secretions that soften stool & increase motility
Contraindication:
-Bowel obstruction,
Preg/peds NO!
179
Methylnaltrexone
Indication
MOA
Contraindication
How is this given?
Opioid-receptor Antagonist
MOA:
-antagonist at peripheral mu receptors in the GI tract
Contraindication:
-bowel obstruction
**Weight based injection
180
PPIs have would make Plavix more or less effect?
PPI are 2C19 Inhibitor
Plavix is a Prodrug
Plavix would be ineffective
181
For patients taking warfarin, INRs are best drawn
In the morning if the patient takes their warfarin at night
182
Patients receiving heparin therapy require monitoring of
Platelets every 3 days for thrombocytopenia that may occur on day 4
Hyperkalemia starts as early as day 4
183
Routine monitoring of LMWH is?
Factor Xa
184
The first lab value indication that vitamin B12 therapy is adequately treating pernicious anemia is...
Hemoglobin levels return to normal
185
Patients who are beginning therapy with vitamin B12 need to be monitored for
Leukopenia that occurs at 1-3 weeks of therapy
186
A 17 y/o competitive runner presents w/ complaint of hip pain that occur after he fell after running. His only medical problem is severe acne for which he takes Accutane. What are you concerned for?
Bone fractures
187
Scabies Treatment for a 4 year old child includes a prescription for
Permethrin 5% cream applied from the neck down
188
What lab values should be monitored before beginning vitamin B12 therapy
```
Potassium
Vitamin B12
Iron
Reticulocyte count
Hemoglobin
Hematocrit
```
189
What drug class are the "-tides"
GLP-1 Agonist
Exenatide (Byetta), Liraglutide (Victoza)
Dulaglutide (Trulicity)
190
What drug class are the "-gliptins"
DPP-4
191
What drug class are the "-flozins"
Selective Sodium-Glucose Cotransporter 2 Inhibitors
| SGLT-2 Inhibitors
192
How long until NPH insulin begins to take effect? "onset of action"
60-90 mins
193
What is a fasting glucose target for type 1 diabetics?
120-150
194
What is a third generation sulfonylurea?
glimepiride
195
Symptoms of diabetic autonomic neuropathy
resting tachycardia
exercise intolerance
orthostatic hypotension
196
After administering PTU, what effect would the nurse anticipate the drug will have in the patient's body
inhibit production of TH in thyroid gland
197
What are the highest to lowest strength statins?
atorvastatin, rosuvastatin, simvastatin, lovastatin
198
Pregnant people with asthma can safely use what during their pregnancy?
inhaled corticosteroids (budesonide)
199
What are the histamine 2 receptor antagonists?
Ranitidine (Zantac) & Famotidine (Pepcid) & cimetidine
