Pharmacological Profiles Flashcards

(199 cards)

1
Q

Class of drugs that cause a dose-dependent depression of CNS function, inducing sedation, sleep, and unconsciousness with increasing dose.

A

Sedatives & Hypnotics

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2
Q

What are the agents in the Sedative and Hypnotic class?

A

Barbiturates, Benzodiazepine, and melatonin agonists

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3
Q

What drugs have anticonvulsant properties, depress the sensory cortex, decrease motor activity, altar cerebellar function, and produce drowsiness, sedation, and hypnosis, can be used as a sedative, can manage seizures?

A

Barbiturates

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4
Q
  • Phenobarbital
  • Thiopental

are examples of what?

A

Barbiturates

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5
Q

Antianxiety drugs can be subdivided into:

A

1) Benzodiazepines (short term use only)

2) Non-benzodiazepines

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6
Q

1) Alprazolam
2) Diazepam
3) Lorazepam

Are examples of what?

A

Benzodiazepines (PAM & LAM)

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7
Q

1) Buspirone hydrochloride
2) Hydroxyzine
3) Sertraline

Are examples of what?

A

Non-benzo antidepressants

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8
Q

What are the different classes of antidepressants?

A

1) TCAs: Tricyclic antidepressants
2) MAOI: Monoamine Oxidase Inhibitors
3) SSRI: Selective Serotonin Reuptake Inhibitors
4) SNRIs: Serotonin-norepinephrine reuptake inhibitors
5) Serotonin Reuptake inhibitor/antagonist
6) Dopamine/Norepinephrine-Reuptake Inhibitor

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9
Q

How many weeks can it take for antidepressants to be effective?

A

4-6 weeks

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10
Q

What’s the first line of medication for depression?

A

SSRI:

1) Citalopram
2) Fluoxetine
3) Sertraline
4) Paroxetine

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11
Q

Bupropion is commonly used for what?

A

Smoking cessation

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12
Q

What class of drugs blocks dopamine receptors in the brain; also alter dopamine release and turnover. Peripheral effects include anticholinergic properties and alpha-adrenergic blockade.

A

Antipsychotic

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13
Q

What drug is used in the treatment of intractable hiccups?

A

Chlorpromazine

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14
Q

Neuroleptic malignant syndrome is mainly seen in what drug?

A

Haloperidol

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15
Q

Haloperidol
Prochlorperazine
Quetiapine
Olanzapine

Are examples of what?

A

Antipsychotics

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16
Q

What are CNS stimulants subdivided into?

A

Amphetamines and Anorexiants

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17
Q

Produce respiratory stimulation, dilated pupils, increased motor activity and mental alertness, and a diminished sense of fatigue. Used in children with ADHD these agents decrease restlessness and increase attention span. Used in the treatment of narcolepsy.

A

CNS Stimulants (Amphetamines and anorexiants)

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18
Q

1) Methylphenidate HCL
2) Dextroamphetamine

Are examples of what?

A

Amphetamines

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19
Q

Phentermine

Is an example of what?

A

Anorexiants

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20
Q

What class reduces the excitability of neurons in the brain?

A

Anticonvulsant

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21
Q

Anticonvulsants treat seizures but can also be used in the treatment of what?

A

Neuropathic pain and Headache symptoms

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22
Q

What’s an adverse reaction in the eyes caused by taking anticonvulsants?

A

Nystagmus

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23
Q

Benzodiazepines are used to treat status epilepticus. What are some benzo’s that are used as anticonvulsants?

A

1) Diazepam
2) Lorazepam
3) Midazolam
4) Clonazepam

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24
Q

What class of drugs are Phenytoin, Ethosuximide, and Valproic acid?

A

Anticonvulsant

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25
1) Phenothiazines 2) Metoclopramide 3) Odansetron 4) Prochlorperazine 5) Pomethazine Are all examples of what?
Antiemetics
26
What drugs are classified as antivertigo?
1) Meclizine 2) Diphenhydramine 3) Bezodiazepines
27
What class of drug produces a local anesthesia by inhibiting transport of ions across neuronal membranes, thereby preventing initiation and conduction of normal nerve impulses?
Local Anesthetic
28
What drug causes neuro inhibition and anesthesia, where the patient is dissociated from the surrounding?
Ketamine
29
Removes the feeling or sensation (chemical changes to the nerve impulse).
Anesthetic
30
Alleviates or relieves pain from a patient
Analgesic
31
What are utilized to produce a loss of sensation prior to minor painful procedures?
Local Anesthetics
32
What are the doses of Ketamine for: 1) Analgesia (IV) 2) Analgesia (IM) 3) Induction of anesthesia (IV) 4) Induction of anesthesia (IM)
1. 10-20mg IV (analgesia) 2. 20-40mg IM (analgesia) 3. 1-2mg/kg (anesthesia IV) 4. 4-6mg/kg (anesthesia IM)
33
What is the most hemodynamically neutral of the sedative-hypnotic agents use for the induction of general anesthesia?
Etomidate
34
What is the IV induction drug of choice for most non-trauma patients because of its rapid onset and recovery, antiemetic properties, and relatively no adverse side effects?
Propofol
35
The use of ketamine increases the risk of what?
Laryngospasm
36
What are the different classes of Analgesics?
1) Salicylate 2) Non-salicylate 3) Nonsteroidal Anti-Inflammatory Drug (NSAID) 4) Urinary analgesics
37
What class inhibits prostaglandins, dilates peripheral blood vessels (cools body), and prolong bleeding by inhibiting aggregation of platelets?
Salicylates
38
What class of drug's action is analgesic and antipyretic?
Non-salicylate
39
What drug is often associated with acute liver failure?
Acetaminophen
40
What class of drug is used to decrease risk of myocardial infarction and used in the prevention and treatment of blood clots?
Salicylates
41
What an example of salicylates?
Aspirin
42
What are examples of non-salicylates?
1) Acetaminophen | 2) Benzocaine-Menthol
43
What class of drugs inhibit the action of the enzyme cyclooxygenase (COX-1 & COX-2 Nonselective or COX-2 Selective)?
Nonsteroidal Anti-Inflammatory Drug (NSAIDS)
44
What drugs are used for dysmenorrhea (painful menstruation)?
NSAIDS
45
What are some examples of NSAIDS?
1) Ibuprofen 2) Indomethacin 3) Ketorolac 4) Naproxen 5) Celecoxib (selective COX 2 inhibitor) 6) Meloxicam (selective COX 2 inhibitor)
46
What is the first line treatment for Gout?
Indomethacin
47
What is a topical bladder, urethral anesthetic, and analgesic through an known mechanism?
Pyridium (100mg TID for 5 days as needed for dysuria)
48
What class of drug results in the alteration to the perception of and response to pain?
Narcotic Analgesics
49
What are contraindications for giving narcotic analgesics?
1) Head injury or Intra-Cranial Pressure 2) Hypoxia 3) Hepatic impairment
50
What are examples of narcotic analgesics?
1) Codeine 2) Fentanyl 3) Hydromorphone 4) Methadone 5) Morphine Sulfate 6) Oxycodone 7) Hydrocodone
51
What blocks the opioid receptors, preventing the body from responding to opiates and endorphins?
Naloxone
52
Histamines are found where?
Highest amount found in basophils (WBC) and mast cells
53
What type of antihistamines are used to treat allergic reactions, insomnia, motion sickness or vertigo?
H1
54
What type of antihistamines treat gastric acid conditions and relief of Parkinson-like reactions?
H2
55
What are some examples of antihistamines?
1) Diphenhydramine 2) Hydroxyzine 3) Promethazine 4) Cetirizine HCL 5) Fexofenadine 6) Loratadine
56
What class of drug reduces swelling of nasal passages and enhances drainage of sinuses?
Decongestant
57
What are some contraindications for decongestants?
1. Use with caution in hypertension 2. May worsen prostatic hyperplasia/urinary obstruction 3. Elderly may be more sensitive 4. Pregnancy C. Not recommended.
58
What are examples of decongestants?
1. Oxymetazoline 2. Pseudoephedrine 3. Phenylephrine (Nasal/Opthalmic decongestant)
59
What is drug is notorious for causing rebound congestion when used for more than 3 days consecutively?
Oxymetazoline HCL (Afrin)
60
What class of drub releases stimulants and reuptake inhibitors that increase the levels of endogenous catecholamines? These are found in bronchial smooth muscle and when stimulated cause relaxation (dialation) of bronchioles.
Beta2 Agonists
61
What are some examples of Beta2 agonists?
1. Albuterol sulfate | 2. Levalbuterol HCL
62
What beta2 agonists should you use with caution in patients with diabetes mellitus since it can increase serum blood glucose?
Albuterol
63
What class of drug antagonizes acetylcholine receptors, producing bronchodilation? (anticholinergic)
Muscarinic Antagonists
64
What class of drug would you use for relief or prevention of bronchial asthma and the management of COPD?
Muscarinic Antogonists
65
What class of drug would you use for reversible airway obstruction caused by bronchospasm due to bronchial asthma, exercise-induce bronchospasm, bronchitis, emphysema, and other obstructive pulmonary disorders?
Beta2 Agonists
66
Xanthine Derivatives (-tropium) 1. Ipratropium 2. Tiotropium Are examples of what?
Muscarinic antagonist anticholinergics
67
What class of drug is broncho constrictive substance released by the body during inflammation. Antagonists results in bronchodilation.
Leukotriene
68
What class of drug inhibit the release of substances that cause bronchoconstriction and inflammation from the mast cells in the respiratory tract?
Mass Cell stabilizer
69
What are leukotriene Antagonists and Mast Cell Stabilizers used in the treatment of?
1. Asthma | 2. COPD
70
Aspirin-sensitive asthmatics should avoid what medication?
Montelukast
71
What are examples of a leukotriene receptor antagonist & a mast cell stabilizer?
Leukotriene receptor antagonist = Montelukast Mast cell stabilizer = Cromolyn
72
What class of drug produces profound and varied metabolic effects, in addition to modifying the normal immune response and suppressing inflammation, decrease inflammatory process in the airway through inhibiting multiple different inflammatory cytokines?
Inhale Corticosteroids
73
1. Budesonide 2. Fluticasone Are examples of what?
Inhalant Corticosteroids
74
What class of drug depresses the cough center and anesthetizes stretch receptors?
Antitussives
75
1. Codeine sulfate 2. Benzonatate 3. Dextromethorphan 4. Diphenhydramine Are examples of what?
Antitussives
76
What class of drug loosens and mobilizes thick mucus from respiratory system?
Expectorants & Mucolytics
77
What are examples of a mucolytic & a expectorant?
Mucolytic = Acetylcysteine Expectorant = Guaifenesin
78
Actions of this drug include: 1. Blockade of Na or K channels 2. Raise the potential threshold 3. Block beta receptor stimuli 4. Block calcium channels
Antiarrhythmics
79
What class of antiarrhythmics depresses myocardial excitability to electrical stimuli thus decreasing the pulse rate?
Class 1
80
What class of antiarrhythmics block stimulation of the beta receptors of the heart?
Class 2
81
What class of antiarrhythmics block potassium channels to the heart and are used for ventricular dysrhythmias and atrial fibrillation?
Class 3
82
What antiarrhythmic class blocks calcium channels which are critical in the production of muscle contraction and electrical conduction?
Class 4
83
Lidocaine HCL, Amiodarone, Metoprolol, Verapamil, and Diltiazem are all examples of what classification?
Cardiac antiarrhythmics
84
What class or drug has a direct effect on smooth muscle of blood vessels?
Nitrates
85
What is used in the treatment of angina pectoris?
Nitroglycerin
86
Do not give nitroglycerin if their BP is lower than what?
Systolic, lower than 100
87
What stage of hypertension is Systolic 130-139 or Diastolic 80-89 mm Hg?
Stage 1
88
What stage of hypertension is Systolic >140 or Diastolic >90 mm Hg?
Stage 2
89
What percentage of diuretics are used to control hypertensive patients?
80%
90
What are the different classes of antihypertension medications?
1. ACE inhibitors, Angiotensin II antagonists (ARBs) 2. Diuretics 3. Calcium channel blockers 4. Beta Blockers
91
What is the action of ACE inhibitors, ARBs?
Lower blood pressure by dilating or increasing the size of the arterial blood vessels
92
What converts angiotensin I to angiotensin II?
Angiotensin-Converting Enzyme (ACE)
93
What antihypertension medication is the 1st line in the treatment for patients with Diabetes?
ACE inhibitors, ARBs
94
What adverse effect is often foundin 5-20% of patients treated with an ACE inhibitor?
Dry cough | begins 1-2 weeks; can be delayed up to 6 months
95
What is a contraindication for prescribing ACE inhibitors and ARBs?
1. Caution with renal or hepatic disease | 2. Electrolyte imbalance
96
What class of medication is: 1. Lisinopril 2. Captropril 3. Enalapril 4. Ramipril
ACE inhibitors (-pril)
97
What class of medication causes peripheral vasodilation by inhibiting calcium from getting into the muscle to cause contraction?
Calcium Channel Blocker
98
What are the two types of calcium channel blockers, and what do they do?
Dihydropyridines - potent vasodilators; no negative effect on cardiac system; primarily used for HTN Non-dihydropyridines - less potent vasodilators but have a greater effect on cardiac conduction and contractility. Used for stable angina, cardiac arrythmias, and for proteinuria reduction.
99
Calcium channel blockers are much more common in what types of patients?
Older and black patients with HTN
100
Nifedipine, Felodipine, Nicardipine, Almodipine are all examples of what?
Dihydropyridines (CCBs) DIPPING (dipine)
101
Verapamil and Diltiazem are examples of what?
Non-dihydropyridines (CCBs)
102
What class is used in the management of HTN, angina pectoris, tachyarrhythmia, hypertrophic subaortic stenosis, migraine headache, MI prevention, glaucoma, CHF, and hyperthyroidism symptoms?
Beta Blockers Metoprolol Propanolol *end in -olol*
103
What type of diuretic leads to the excretion of sodium, potassium, bicarbonate and water?
Carbonic Anhydrase Inhibitor
104
What type of drug is used to treat open angle glaucoma, Edema due to CHF, and HTN?
Diuretics
105
What cross-sensitivity are you worried about when prescribing diuretics?
Sulfonamides
106
HMG-CoA reductase inhibitors are also called what?
Statins
107
What inhibits an enzyme involved in cholesterol synthesis and is the most commonly prescribed anti-hyperlipidemic?
Statins (HMG-CoA reductase inhibitors)
108
Rhabdomyolysis, constipation, abd cramps, nausea, and liver dysfunction are adverse effects of what?
Anti-hyperlipidemics
109
What kind of labs do you need prior to prescribing anti-hyperlipidemics?
LFTs, Lipid panel, and Chemistry
110
How many weeks would you allow the patient to make lifestyle changes prior to starting anti-hyperlipidemics?
6-8 weeks
111
Cholestyramine, colestipol, and colesevelam are examples of what?
Bile acid sequestrants *Chole/cole*
112
What is used to treat heartburn, GERD relief, sour stomach, acid indigestion, and peptic ulcers?
Antacids
113
What type of antacids produce constipation?
Aluminum & calcium containing antacids
114
What are contraindications to prescribe antacids?
Unknown abdominal pain Sodium containing antacids: HTN/CHF Calcium containing antacids: Renal calculi or hypercalcemia
115
What do Histamine H2 antagonists do?
Inhibit actions of H2 receptor cells of the stomach which then reduces the secretion of gastric acid.
116
What is used to treat gastric or duodenal ulcers, gastric hyper secretory conditions, GERD, prevention of stress related ulcers, and acute upper GI tract bleed?
Histamine H2 Antagonists
117
Cimetidine, Famotidine, and ranitidine are all examples of?
Histamine H2 Antagonist | rantidine has been withdrawn by the FDA
118
What class's action suppresses gastric acid secretion by blocking the final step in the production of gastric acid in the gastric mucosa
Proton Pump Inhibitors
119
When pregnant and in need of treatment of GERD, what class of medication is recommended?
Proton Pump Inhibitors
120
High doses and chronic use of Proton Pump Inhibitors (PPIs) can lead to what?
Osteoporosis
121
Omeprazole, Esomeprazole, Pantoprazole, Lansoprazole, and Rabeprazole are examples of what?
Proton pump inhibitors (PPIs) *prazole*
122
What deceases intestinal peristalsis?
Antidiarrheal (loperamide)
123
What class of medication is simethicone?
Antiflatulant
124
Long term use of laxatives can result in a dependency called?
"Laxative Habit"
125
Hemorrhoid agents are used on what type of hemorrhoids?
Inflamed
126
Excessive or prolonged use of hemorrhoid agents may lead to what?
Atrophy of the affected tissues
127
Increase excretion of sodium and chloride by inhibiting the reabsorption of these ions in the distal proximal tubules and the loop of Henle
Loop Diuretics
128
Increase the density of the filtrate in the glomerulus; prevents reabsorption of water; salt and chloride follow water
Osmotic Diuretics
129
Decreases the reabsorption of sodium and water in the kidney and increases potassium retention
Potassium Sparing diuretics
130
Inhibit reabsorption of sodium and chloride ions in the kidney
Thiazide diuretics
131
Diuretics used in the management of idiopathic intracranial hypertension and elevated pressure (glaucoma)
Acetazolamide (Carbonic Anhydrase Inhibitor)
132
Diuretics used to treat edema associated to CHF, cirrhosis of liver, renal disease, or acute pulmonary edmea
Furosemide (Loop diuretic)
133
Diuretic used for the management of elevated intracranial pressure and cerebral edema
Mannitol (Osmotic diuretics)
134
Diuretic that maybe by used as additional therapy for HTN; can treat ascites due to cirrhosis, heart failure
Spironolactone (potassium sparing diuretics)
135
What type of diuretic is the first line indication for managing hypertension in the absence of any contraindication?
Thiazide diuretics (Chlorthalidone (preferred) or Hydrochlorothiazide (HCTZ))
136
Oral antidiabetics are used to treat what?
Type 2 diabetes not controlled with diet and exercise
137
Lowers blood glucose by stimulating beta cells of panaceas to make more insulin
Sulfonylureas
138
Reduces hepatic glucose production and increases insulin sensitivity
Biguanides
139
Lower blood sugar by delaying digestion of carbs and absorption
Glucosidase inhibitors
140
Antidiabetic that stimulates release of insulin
Meglitinides
141
Decrease insulin resistance and increase insulin sensitivity
Thiazolidinediones
142
Glyburide is what type of antidiabetic?
Sulfonylureas
143
Metformin is what type of antidiabetic?
Biguanides
144
Pioglitazone is what type of antidiabetic?
Thiazolidinediones
145
What antidiabetic can result in lactic acidosis, especially in patients with renal impairment?
Biguanides (Metformin)
146
What antidiabetic can cause or exacerbate CHF in some patients?
Thiazolidinediones (Pioglitazone)
147
Thyroid hormones can take up to how many weeks to see effects?
6 weeks; can been as soon as 48 hours
148
Example of a drug used in replacement therapy when a patient is hypothyroid?
Levothyroxine
149
What are the contraindications for Levothyroxine?
1. Myocardial infarction | 2. Thyrotoxicosis
150
What are contraindications for Methyltestosterone?
1. Liver disorders 2. Serious cardiac disease 3. Prostate gland disorders 4. Breast cancer in males; prostate cancer
151
Protein anabolism, thinning of the cervical mucus, inhibitions of ovulation
Estrogen
152
Prevents maturation of the ovarian follicle and ovulation; secreted by the corpus luteum, the placenta, and adrenal cortex
Progestin
153
Norethindrone, Drospirenone, and Levonorgestrel are examples of what?
Progestin only pills (POPs)
154
1.5mg as soon as possible within 72 hours of unprotected sex or 0.75mg as soon as possible and a second dose of 0.75 within 12 hours after first dose
Levonorgestrel
155
What is used in Combined estrogen-progestin oral contraceptives (COCs)?
Ethinyl estradiol (combined with progestin only pill)
156
Fixed dose of estrogen and progestin
Monophasic (COC)
157
Deliver hormones similar to the levels naturally produced by the body to provide lower doses with the same degree of effectiveness
Biphasic and Triphasic (COC)
158
What is increased risk of females 35 and older that use tobacco and on COCs?
Thromboembolic
159
Acyclovir, Vancyclovir, Penciclovir, Oseltamivir are all examples of what?
Antivirals
160
Antivirals are contraindicated in patients with:
CHF, seizures, or renal disease
161
What can you use to treat superficial infections, tinea pedis, tinea cruris, tinea corporis, onychomycosis, cutaneous GI and vaginal yeast infections, Deep mycotic infections (lungs)
Antifungals
162
Antifungal that can cause hepatic toxicity, in which case the drug must be discontinued immediately
Oral ketoconazole
163
Clotrimazole and tolnaftate are what?
Topical antifungals
164
Ketoconazole, fluconazole, and terbinafine
Systemic antifungals
165
What antifungal is impaired when the drug is taken with histamine antagonist and antacids
Ketoconazole
166
Used as a muscle relaxer and an antianxiety drug
Diazepam
167
Muscle relaxer that has an effect on muscle tone, thus reducing muscle spasms
Cyclobenzaprine
168
Cyclobenzaprine, methocarbamol, metaxalone, diazepam, baclofen are all examples of what?
Muscle relaxers
169
Hormones secreted from the adrenal cortex made from the crystalline steroid alcohol cholesterol
Corticosteroids
170
Contraindications for corticosteroids include:
Serious infections such as tuberculosis and fungal infections
171
Hydrocortisone, prednisone, triamcinolone, methylprednisolone, dexamethasone are all examples of what
Corticosteroids
172
What can be used for allergic reactions, COPD and asthma exacerbations, SLE or other autoimmune disorders
Corticosteroids
173
Acts on intracranial blood vessels and sensory nerves of the trigeminal system; causes vasoconstriction and reduces neurogenic inflammation associated with antidromic neuronal transmission
Antimigraine (-TRIPTAN) - Rizatriptan - Sumatriptan
174
Adverse reactions include tingling sensation, dizziness, vertigo, chest tightness, chest pain
Antimigraine (-TRIPTAN) - Rizatriptan - Sumatriptan
175
Contraindications include peripheral vascular disease, controlled HTN, Coronary vasospasm, ischemic heart disease
Antimigraine (-TRIPTAN) - Rizatriptan - Sumatriptan
176
What specifically can not be prescribed to a patient diagnosed with Wolff-Parkinson-White syndrome?
-Rizatriptan
177
Inhibits sodium ion influx through nerve cell membrane channels in parasites resulting in delayed repolarization and thus paralysis and death of the pest
Scabicide -Permethrin
178
Bacitracin and mupirocin are examples of:
Topical antibiotic
179
Clotrimazole, ketoconazole, and miconazole are examples of what?
Antifungals
180
Acyclovir & Penciclovir are examples of:
Topical antivirals (used on cold sores)
181
Don't use topical anti-infectives on what?
Extensive burns or tropic ulceration when extensive absorption can occur
182
A drug that removes excess growth of the epidermis in disorders
Keratolytic - Podofilox (0.5%) - Salicylic acid (gel 17%)
183
How many categories are there for drugs that treat Otic disorders?
Three 1) Antibiotic 2) Antibiotic & Steroid combination 3) Miscellaneous
184
What would you use to treat otitis externa?
- Ciprofloxacin - 1% Hydrocortisone, 3.3mg neomycin sulfate - Aluminum acetate/acetic acid
185
What type of antibiotics are used to treat conjunctivitis, corneal ulcer, and other superficial infections of the eye?
Sulfonamides
186
What is used to treat Herpes simplex of the eye?
Acyclovir (ophthalmic)
187
What is used to prevent cytomegalovirus?
Ganciclovir (ophthalmic)
188
Contraindications are hypersensitivity, epithelial herpes simplex, varicella, mycobacterial, fungal disorders
Antibiotic ointments
189
Nicotine Replacement Therapy (NRT) is contraindicated in patients with:
- Allergies to soya | - Cardiovascular disease
190
Enhances central nervous system noradrenergic and dopaminergic release
Antidepressant (smoking cessation) -Bupropion
191
What smoking cessation drug can be used in patients with stable Cardiovascular disease or COPD?
Bupropion
192
Bupropion is contraindicated with patients who have:
Seizure disorder
193
What is more effective in producing six months of tobacco abstinence than other agents and is safe in patients with COPD?
Varenicline
194
What blocks nicotine from binding to the receptor interrupting the reinforcing effects of nicotine that lead to nicotine dependence?
Varenicline
195
What smoking cessation drug can have adverse effects including nausea and disordered sleep, including insomnia and abnormal or vivid dreams?
Varenicline
196
When prescribing patients varenicline what should you warn them about?
May cause CNS depression, cautioned before performing tasks that require mental alertness (heavy machinery, driving)
197
What class of drug acts on the brain's dopamine receptors?
Non-benzo
198
What class of drug binds to specific receptors in the GABA receptor complex, which enhances the binding of the inhibitory neurotransmitter?
Benzodiapines
199
What is used in the treatment of schizophrenia when conventional therapy dose not work?
Clozapine