Pharmacology HESI

BASICS: Pharmacokinetics- the process by which a drug is absorbed, distributed, metabolized and eliminated in the body. Pharmacodynamics- the study of biochemical & physiological effects of drugs Generic name: The name for the drug when it is ready for commercial distribution used to describe the active drugs in the

product. Manufactures must each come up with their own generic name. Brand name: The name for the drug when it first becomes available it is patent gives the manufacturer exclusive use of the

name. Ex. Metform (Glucophage) → Metformin (generic) Glucophage (Brand) Absorption : When the drug passes from the site of administration into the fluids

◦ Slow absorption:▪ orally (swallowed)▪ MM (oral and nasal mucosa)▪ Topical/transdermal (through skin)▪ Rectally (suppository)

◦ Fast absorption:▪ Parenterally (injection- IV, IM, SC)▪ Inhaled through lungs

◦ General principle → The faster the absorption, the quicker the onset, the higher the addictiveness, but the shorter the duration.

Distribution: When the drug reaches the site of action the bloodstream to tissues Biotransformation : metabolism of the drug. Takes place in the liver. Elimination: Elimination can occur in many ways E.g. kidneys, sweat, feces, saliva, breast milk, or exhaled through the

respiratory tract ◦ Half Life - The amount of time for 50 % of serum concentration of the drug to be eliminated from the body

Synergistic effect: When the combined effects of 2 drugs taken simuulatenously produce an effect that is greater than that of each drug alone.

Antagonists: When the combined effects of 2 drugs taken simuulatenously produce an effect that is less than that of each drug alone.

Antiinfectives: Broad-spectrum vs. narrow-spectrum antibiotics Antimicrobials treat bacterial, viral, and fungal infections Culture and sensitivity specimens should be collected prior to initiation of therapy. Adverse effects: hypersensitivity & anaphylaxsis, nephrotoxicic, ototoxic, decrease efficacy of oral contraceptives, increase

warfarin activity, superinfection Pencillins: Med of choice for G+ cocci (Strep pneumoniae, S. viridans, S. pyogenes), Med of choice for syphilis, First choice

for meningitis, Prophylaxis against bacterial endocarditis, Extended spectrum against Pseudomonas, Proteus, Klebsiella◦ penicillin G, augumentin (amoxicillin-clavulanate)- broad spectrum, Nafcillin – antistaphylococcal, Carbenicillin –

antipseudomonas◦ Adverse effects: Anaphylaxis / Renal Impairment / Hyperkalemia (w doses)◦ contraindicated: Allergies to Penicillin, Cephalosporin, or Imipenem / Kidney Dysfunction

Cephalosporins: Broad spectrum with TI for postop infections, meningitis, pelvic infections◦ 1 degree → cephalexin (keflex) & Cephapirin (cefadyl) – 2 degree → cefaclor (Ceclor) & Cefotetan (Cefotan) – 3 degree

→ cefatrixaone (rocephin) & Cefotaxime (claforan) – 4 degree → cefepime (maxipime)◦ Adverse effects: Anaphylaxis◦ Contraindications: Allergies to Penicillin / Kidney Dysfunction, Caution with anticoagulants, antiplatelets, and

thrombolytics◦ interactions: ETOH intolerance (disulfiram reaction)◦ take w/ food

Carapenems: Broad spectrum effective for serious infections such as pneumonia, peritonitis, and UTIs. P. aeruginosa develops resistance (use combo) – [broadest spectrum available]◦ Imipenem (primaxin), meropenem (merrem IV)

monbactams: MRSA / Antibiotic-associated pseudomembranous colitis by C. difficile◦ Vancomycin (vancocin), Aztreonam (Azactam), Fosfomycin (monurol) ◦ adverse effects: Ototoxicity / Infusion Rxn (red man syndrome) / Thrombophlebitis◦ Caution with renal impairment, Infuse over 60 minutes, Very low therapeutic index

TCAs: Acne / rickettsia / Chlamydia / Helicobacter pylori / periodontal disease / typhus fever / Rocky Mountain spotted fever / Lyme disease / UTI & VI◦ Tetracycline hydrochloride (Sumycin), Doxycycline (Vibramycin), Minocycline◦ adverse effects: GI symptoms / tooth discoloration / hepatotoxicity / photosensitivity / superinfection of bowel◦ interactions: Milk / Ca2+, Fe3+ supplements / Mg2+ laxatives / antacids ◦ Give with water on an empty stomach (except doxycycline & minocycline)

bacteriostatic inhibitors (macrolides/ketolides): Use for pts with penicillin allergies / pertussis / diphtheria / Legionnaires’

◦ Azithromycin (Zithromax), Clarithromycin (Biaxin), Dirithromycin, Erythromycin, Clindamycin (Cleocin)◦ Toxic with: antihistamines, theophylline (asthma med), carbamazepine (anticonvulsant), warfarin◦ Administer on empty stomach with water – IV is rarely used

Aminoglycosides: Med of choice against aerobic G- bacilli (E. coli, K. pneumoniae, P. mirabilis, P. aeruginosa) Oral paromomycin use for amebiasis and tapeworm.◦ Gentamicin , tobramycin sulfate, streptomycin, amikacin, neomycin, kanamycin, paromomycin◦ Adverse effects: Ototoxicity /nephrotoxicity

Sulfonamides & Trimethoprim: Sulfamethoxazole–Trimethoprim (TMP-SMZ, Bactrim): Med of choice for UTI by E. coli and Pneumocystis carinii (Cotrim, Septra, Sulfadiazine, Sulfamethoxazole, Sulfisoxazole)

▪ take on empty stomach w/ full glass of water▪ Avoid in: folate deficiency / pregnancy / creatinine clearance < 15 mL/min & Reduce dosages with renal dysfunction

Fluoroquinolones◦ Ciprofloxacin

▪ Broad spectrum / prevention of inhaled anthrax▪ Adverse Rx: GI discomfort / Achilles tendon rupture / superinfection▪ infuse slowly for over 60min

Antimycobacterial◦ isoniazid (INH), streptomycin, ethambutol, pyrazinamide

▪ treats active and latent tuberculosis▪ adverse effects: Peripheral neuropathy (administer 50-200 mg of vitamin B6 daily) & hepatoticity

Antiviral◦ Acyclovir: Prevents reproduction of viral DNA

▪ Never give IV bolus, Infuse over 1 hour min Antiprotozoals

◦ Proto: Amphotericin Others: flucytosine, miconazole, nystatin, griseofulvin, ketoconazole▪ permeability leakage of intracellular cations (static or cidal)

◦ metronidazole (Flagyl)▪ Broad spectrum with anaerobic activity▪ Adverse rx: GI discomfort, metallic taste , darkening of urine, CNS symptoms

Pain & Inflammation Analgesics relieve pain

◦ Narcotics / NSAIDs / Antimigraine agents Anti-inflammatory medications relieve inflammation

◦ Salicylates / Glucocorticoids / Antigout / Disease-modifying antirheumatics drugs (DMARDs)◦ Some are antipyretic (salicylates, ibuprofen)

Salicylates and NSAIDs reduce platelet aggregation Salicylates, NSAIDs, and glucocorticoids pose risk for ulceration Acetaminophen has analgesic and antipyretic properties but not anti-inflammatory. It poses a risk for liver injury NSAIDs – Inflammation suppression / analgesia / fever, dysmenorrhea / suppression of platelet aggregation

◦ Aspirin, Celecoxib (Celebrex), Ibuprofen, Naproxen, Ketorolac (Toradol), Valdecoxib (Bextra), Indomethacin◦ adverse effects: GI discomfort, aspirin induced ulceration and bleeding, Renal dysfunction, Reye syndrome (in kids with

viral illnesses), Salicylism (tinnitus, resp. alkalosis, dizziness)◦ interactions: Warfarin (increase bleeding), Glucocorticoids (increase gastric bleeding) – use antiulcer prophylactic like

misoprostol (Cytotec) to prevent, Ibuprofen ( decrease antiplatelet effects of low-dose aspirin), EtOH (increase bleeding)◦ Give with food or milk to reduce GI discomfort. If can’t tolerate 1st generation, give 2nd generation (celecoxib).◦ ketorolac (Toradol) – 1st generation NSAID: Short-term treatment of moderate to severe pain (post-op). Enhances opioid

analgesia without opioid adverse effects▪ Give no more than 5 days▪ Usually started parenteral and then transition to oral dose

Acetaminophen: Analgesic and antipyretic Max 4 g daily, Antidote: acetylcysteine (Mucomyst), adverse effects: Acute liver toxicity interactions: EtOH risk to liver / Warfarin decrease levels of warfarin

Opioid Agonists: morphine, fentanyl, meperidine, methadone, codeine, oxycodone

1. Moderate to severe pain / Sedation / bowel motility / Cough suppression2. Adverse effects: Constipation, Respiratory depression, Urinary retention, Orthostatic Hypotension, Sedation3. contraindications: Increases cardiac workload, Meperidine metabolites are neurotoxic4. interactions: CNS depressants (barbiturates, phenobarbital, benzodiazepines, EtOH), Anticholinergics, antihistamines,

tricyclic antidepressant anticholinergic effects , MAOIs (hyperpyrexia, seizures), Antihypertensives5. Withhold if RR<12, Have naloxone (Narcan) and resuscitation equipment available., Infuse IV slowly over 4-5 minutes

Opioid Antagonists: OD treatment, Reversal of opioid effects1. naloxone (Narcan), naltrexone, nalmefene2. adverse effects: Tachycardia / Tachypnea, Abstinence syndrome (cramping, hypertension)

3. Naloxone has extensive first-pass modification, Observe for w/d symptoms or abrupt onset of pain Adjuvant Pain meds: Enhance opioid effects thereby permitting lower opioid doses, Alleviate other symptoms that aggravate

pain, Treat neuropathic pain1. TCAs, Anticonvulsants, CNS stimulants, Antihistamines, Glucocorticoids, Bisphosphonates2. Adverse effects:3. TCAs (neuropathic pain) → Orthostatic hypotension, sedation, anticholinergic effects4. CNS stimulants → Weight loss, insomnia5. Anticonvulsants (neuropathic pain) → Bone marrow suppression6. Antihistamines → sedation 7. Glucocorticoids (increase ICP, nerve compression) → Adrenal insufficiency, Hypokalemia, Glucose intolerance, GI

Ulcers, Osteoporosis8. Bisphosphonate (CA bone pain) → Flu-like symptoms, Injection site irritation

Migraine meds: Prevent inflammation and dilation of the intracranial blood vessels1. Ergot Alkaloids (Ergotamine, ergotamine + caffeine)

1. Adverse effects: GI discomfort administer metoclopramide (Reglan), Ergotism (muscle pain, paresthesia) stop medication, Physical dependence, abortion.

2. Contraindications: Renal or liver dysfunction / sepsis / CAD / pregnancy3. Interactions: Sumatriptan (Imitrex) can lead to spastic rxn of blood vessels

2. Serotonin receptor antagonists (Sumatriptan (Imitrex), almotriptan (Axert))1. adverse effects: Chest symptoms (not dangerous, self-resolving), Coronary vasospasm/angina, Teratogenic2. contraindications: Pregnancy, hypertension, cardiac disease, CAD3. interactions: Triptans & Ergot Alkaloids spastic reaction of blood vessels, MAOIs Concurrent use leads to MAOI

toxicity (space 2 weeks apart)3. Beta-blockers (Metoprolol, atenolol)

1. adverse effects: Tiredness, fatigue, Asthma exacerbation, depression, bradycardia, hypotension4. Anticonvulsant (Divalproex (Depakote))

1. Adverse effects: Neural tube defects5. TCAs (Amitriptyline (Elavil))

1. adverse effects: Anticholinergic effects: dry mouth, constipation, urinary retention, tachycardia6. Ca channel blocker (Verapamil)

1. Adverse effects: ortho hypotension, constipation Rheumatoid Arthritis meds:

1. Cytotoxic medications – methotrexate (Rheumatrex)2. Gold salts – aurothioglucose3. Antimalarial agents – hydroxychloroquine (plaquenil) 4. Biologic Response Modifiers – etanercept (Enbrel)5. Penicillamine –Cuprimine, Depen6. Immunosuppressants – Cyclosporine7. NSAIDs – Naproxen

Cardiovascular Meds ANS helps control pressure by adjusting cardiac output (HR x SV) and peripheral resistance. The renin-angiotensin-aldosterone system helps control arterial pressure by:

1. Releasing angiotensin II – potent vasoconstrictor of arterioles and veins2. Releasing aldosterone – promotes Na+ and H2O retention by kidneys

Vasopressin (ADH) is a potent vasoconstrictor and water reabsorption Atrial natriuretic peptide (ANP) is a vasodilator and causes excretion of Na+ and H2O by kidneys. It also inhibits renin

secretion. Decreasing blood volume and dilating arterioles and veins help control BP Epinephrine (Adrenaline) – Catecholamine Adrenergic Agonist

1. absorption of local anesthetics or extravasated meds, Manage superficial bleeding, congestion of nasal mucosa, BP, Treatment of AV block and cardiac arrest, congestion of nasal mucosa, Asthma

2. Adverse effects: Hypertensive crisis, Necrosis from extravasation, Dysrhythmias / myocardial O2 demand angina3. interactions: MAOIs effect and duration, General anesthetics lead heart to be hypersensitive to epi dysrhythmias, α-

adrenergic blockers (phentolamine), β-adrenergic blockers (propanolol)4. Stop infusion with evidence of extravasation; treat with α-blocker (phentolamine)

Dopamine (Intropin) – Catecholamine Adrenergic Agonist 1. used for shock & HF2. Adverse effects: Necrosis can occur from extravasation of high doses, Dysrhythmias / increase myocardial O2 demand

angina3. contraindicated: Pheochromocytoma4. Stop infusion with evidence of extravasation; treat with α-blocker (phentolamine)

Adrenergic Receptors1. α1 → Vasoconstriction of arterioles in skin, viscera, and mucous membranes, and veins

2. β1 → increase HR, increase contractility, increase AV conduction, Release of renin in kidneys3. β2 → Vasodilation of arterioles in heart, lungs, and skeletal muscle, Bronchodilation, Relaxation of uterine smooth muscle,

Glycogenolysis in liver, Skeletal muscle contraction4. Dopamine → Vasodilation of renal blood vessels

Dobutamine (Dobutrex) – Catecholamine1. HF2. Adverse effects: increased HR

α-Adrenergic Blockers: Selective α1 blockade resulting in venous and arterial dilation1. Proto: Prazosin (Minipress) – Others: doxazosin mesylate (Cardura), Phentolamine (Regitine), ergotamine tartra2. for HTN, Phentolamine: Extravasation of adrenergic agonists, Doxazosin mesylate: decrease symptoms of benign prostatic

hypertrophy3. adverse effects: First-dose orthostatic hypotension (monitor BP for 2 hrs post-treatment)

Centrally Acting α2 Agonists – decrease sympathetic outflow in CNS bradycardia, decrease CO, vasodilation, decrease BP1. Proto: clonidine (Catapres) – Others: guanfacine (Tenex), methyldopa (Aldomet)2. for HTN, Severe cancer pain (epidural), Investigational: Migraine, flushing from menopause, withdrawal management3. Adverse effects: Dry mouth (usually resolves in 2-4 weeks), Drowsiness & sedation, Rebound hypertension4. interactions: Antihypertensives: Additive hypotensive effect, Prazosin, MAOIs, TCAs: Counteract effects of clonidine.,

CNS Depressants: Additive CNS depressant effect5. Apply patch to hairless skin on torso or upper arm

Beta blockers – Decreases HR, contractility, AV conduction1. Cardioselective: metoprolol (Lopressor), Nonselective: propanolol (Inderal) - Others: Cardioselective: atenolol,

Nonselective: nadolol (Corgard)2. For HTN, Dysrhythmias (block SA/AV cond.), Angina/MI (decrease O2 demand – increase diastole time perfusion –

decrease BP decrease O2), Hyperthyroidism, migraines, stage fright, pheochromocytoma, glaucoma, HF3. adverse effects: B1 – bradycardia, decreased CO, AV block, ortho hypotension. B2 – bronchoconstriction, glycogenolysis

inhibited4. Contraindications: AV block, sinus bradycardia. Nonselective should not be used in p/ts w/ asthma, bronchospasms, HF5. interactions: β1: calcium-channel blockers verapamil (Calan) and diltiazem (Cardizem) intensify effects of β-blockers. β2:

Insulin – prevents glycogenolysis ACE inhibitors – Block production of angiotensin II arteriole vasodilation, excretion of Na+ and H2O, retention of K+, and

possible pathological changes to vessels and heart1. Proto: captopril (Capoten) — Others: enalapril (Vasotec), fosinopril (Monopril), lisinopril (Prinivil), ramipril (Altace)2. For HTN, HF, Peripheral neuropathy, MI (decrease risk of HF and mortality, Ramipril can prevent MI, stroke, or death in

high-risk patients3. Adverse effects: Hyperkalemia, Angioedema (swelling in tongue/oropharynx) – treat with epinephrine, Neutropenia,

Cough, First-dose orthostatic hypotension, Rash & dysgeusia, 4. interactions: Diuretics 1st-dose hypotension, NSAIDs decrease antihypertensive eff., K+ supplements/K+ sparing diuretics

hyperkalemia ARBs – Blocks action of angiotensin arteriole vasodilation, excretion of Na+ & H2O, retention of K+

1. Δ ACE and ARB is that cough and hyperkalemia are not side effects of ARB.2. For Stroke prevention (losartan), Mgt of heart failure / mortality prevention after MI (valsartan), Delay progression of

diabetic neuropathy (irbesartan, losartan), decrease hypertension (all)3. adverse effects: Angioedema, fetal injury4. ARBs can be taken with or without food

Ca Channel blockers 1. Proto: nifedipine (Adalat) — Others: amlodipine (Norvasc), felodipine (Plendil), nicardipine (Cardene), verapamil

(Calan), diltiazem (Cardizem)2. Nifedipine- vasodilation peripheral & ♥ arterioles3. erapamil, Diltiazem: Above + decrease contractility, decrease HR, decrease AV conduction4. for HTN All , All but Felodipine: Angina, Verapamil, Diltiazem: Hypertension, Angina, Dysrhythmias5. adverse effects: Nifedipine: Tachycardia, peripheral edema, acute toxicity. Verapamil, Diltiazem: Orthostatic hypotension,

peripheral edema, constipation, cardiac suppression, dysrhythmias, acute toxicity6. Contraindications: heart block, hypotension, bradycardia, aortic stenosis, severe heart failure7. interactions:

1. Verapamil, Diltiazem,Nifedipine: : grapefruit toxicity.2. Β-blockers: HF, AV block, bradycardia. 3. β-blockers: Used to decrease reflex tachycardia

HTN Crisis Meds: Direct vasodilation of veins and arteries causing rapid decrease BP (preload/afterload)1. Proto: nitroprusside — Others: labetalol (Trandate), diazoxide (Hyperstat), fenoldopam (Corlopam), trimethaphan

(Arfonad)2. For Hypertensive emergencies, decrease bleeding during surgery by producing controlled hypotension3. adverse effects: Excessive hypotension, Cyanide poisoning: increase risk ĉ liver dysfunction; Give slowly (5 mcg/kg/min)

along with thiosulfate to deactivate cyanide, Thiocyanate poisoning: Can manifest as altered mental state/psychosis. Avoid prolonged use (>3 d). Plasma thiocyanate should be <0.1 mg/mL

4. Discard solutions that are blue, red, or green. Protect solutions from light. Do not mix other meds ĉ nitroprusside.

Organic Nitrates – decrease cardiac O2 demand by dilating veins and decreasing venous return (preload). Relaxes or prevents spasms in coronary arteries thus increase O2 supply

1. Proto: nitroglycerine — Others: isosorbide dinitrate (Imdur)2. For treatment of angina (acute, variant, and prophylaxis), IV perioperative BP control, HF d/t acute MI3. Adverse effects: Headache, Tolerance, Orthostatic hypotension, Reflex tachycardia - give metoprolol (Lopressor)4. contraindications: Head trauma IICP5. Interactions: Sildenafil (Viagra) Acute or fatal hypotension, EtOH, β-blockers, Ca-blockers, diuretics – additive

hypotensive effects Cardiac Glycosides – (+) inotropic increase SV, CO & (-) chronotropic > fill time increase SV, CO

1. digoxin (lanoxin)2. For HF , Dysrhythmias, A-Fib3. Adverse effects: GI effects, CNS effects (fatigue, vision changes), Dysrhythmias, cardiotoxicity: increase risk from

decrease K+, increase [digoxin], ♥ disease4. Contraindications: v-fib, v-tach, 2/3º blocks5. Interactions: Quinidine increase dig toxicity, Verapamil increase [digoxin], Sympathomimetics add to inotropic effect,

Loop & thiazide diuretics decrease K+ increase risk of digoxin dysrhythmia, ACE inhibitors / ARBs increase risk increase K+ decrease therapeutic digoxin effects.

6. Check apical pulse: hold < 60 (adults), < 70 (kids), < 90 (infants), Therapeutic levels = 0.5-2 ng/mL, Treat bradycardia ĉ atropine, Treat dysrhythmias ĉ phenytoin or lidocaine, Activated charcoal or cholestyramine can bind digoxin to prevent absorption.

Antidysrhythmias1. Sodium channel blockers: lidocaine (Xylocaine) – Short-term use only for ventricular dysrhythmias

1. Never administer lidocaine that has epinephrine in it.2. Calcium-channel blockers: verapamil (Calan), diltiazem (Cardizem) – A-fib, SVT, A-flutter3. Potassium channel blockers: amiodarone (Cordarone), bretylium, sotalol, dofetilide – Conversion of A-fib (oral),

Recurrent V-tach & V-fib4. Endogenous Glucoside: adenosine (Adenocard), ibutilide (Corvert) – Paroxysmal SVT, Wolff-Parkinson Syndrome

1. Very short life (< 1 min), Administer by IV bolus, flushed with NS Antilipids/STATINS – Promote vasodilation / decrease plaque-site inflammation / decrease thromboembolism risk, decrease

LDL by increase LDL receptors in liver, increase HDL1. For 1º hypercholesterolemia, increase HDL, Prevention of stroke and coronary events.2. Adverse effects: Myopathy (monitor CK), Peripheral neuropathy, Hepatotoxicity evidenced by increase serum

transaminase3. Atorvastatin or fluvastatin should be used with renal insufficiency, Lovastatin ĉ evening meal

Respiratory Meds β2-Adrenergic Agonists – Selectively activate β2 receptors resulting in bronchodilation: bronchospasm is relieved, histamine

release is inhibited, and ciliary motility is increased 1. Proto: albuterol (Proventil) — Others: formoterol (Foradil), salmeterol (Serevent), terbutaline (Brethine)2. Albuterol: Inhaled, short-acting and oral, long-acting. Formoterol, salmeterol: Inhaled, long-acting. Terbutaline: Oral, L-A.3. Adverse effects: Inhaled: Minimal adverse effects, Oral: Tachycardia/angina d/t β1 in ♥ / tremors d/t β2 in skeletal muscle. 4. Contraindications: tachydysrhythmias5. Inhale 3-5 sec, hold 10 sec, wait 60 sec for next dose, Use inhaled β2-agonist before using inhaled glucocorticoid

Methylxanthines – Theophylline relaxes bronchial smooth muscle bronchodilation1. Theophylline (Theolair)2. Long-term control of asthma3. Adverse effects: Mild toxicity GI distress & restlessness. Severe reactions.

1. Severe reactions can occur at increase therapeutic levels and include dysrhythmias and seizures. Effects unlikely @ <20 mcg/mL. Activated charcoal decrease absorption, lidocaine for dysrhythmias and diazepam for seizures.

4. Interactions: Caffeine: increases CNS/♥ effects of theophylline. Also increases [theophylline], Cimetidine, ciprofloxacin: increase [theophylline], Phenobarbital, phenytoin: decrease [theophylline]

Inhaled Anticholinergics – Relief of bronchospasms associated with COPD, Relief of allergen-induced and exercise-induced asthma.

1. Proto: ipratropium (Atrovent) — Others: tiotropium (Spiriva)2. Adverse effects: Local anticholinergic effects3. Contraindicated: Peanut allergy4. Usual adult dose is 2 puffs (1 minute apart), If taking two inhaled medications, separate by at least 5 minutes.

Glucocorticoids – Prevent inflammation, suppress airway mucous production, and promote responsiveness of β2-receptors in bronchial tree.

1. Proto: beclomethasone (QVAR) — Others: budesonide (Pulmicort), fluticasone (Flovent), triamcinolone (Azmacort), prednisone (Deltasone

2. For:1. Inhaled: Long-term asthma prophylaxis2. S-T, oral: Treat symptoms following acute asthma.3. L-T, oral: Treat chronic asthma

4. Promote lung maturity and decrease RDS in fetuses at risk for preterm birth.5. 1º adrenocortical insufficiency

3. Adverse effects: Inhaled: Dysphasia, candidiasis, bone loss. Oral (≥10d): decrease adrenal gland function / bone loss / hyperglycemia / glucosuria / / infection / peptic ulcer disease / myopathy / fluid & electrolyte disturbances.

4. Interactions: Diuretics: increase hypokalemia, NSAIDs: increase GI ulceration, Glucocorticoids counteract effects of insulin and oral hypoglycemics.

5. Oral are for short-term use, 3-10 days following acute attack Mast Cell Stabilizers – Anti-inflammatory: Stabilize mast cells, inhibiting histamine release, Suppress inflammatory cells

(e.g. eosinophils, macrophages)1. Cromolyn (Intal) — Others: nedocromil (Tilade)2. For Management of chronic asthma, Prophylaxis of exercise-induced and allergen-induced asthma attacks, Allergic rhinitis

by intranasal route3. Safest of all asthma meds / safe for kids4. Contraindications: Propellant - CAD, dysrhythmias, and status asthmaticus5. Take 15 min before exercise , Long-term prophylaxis may take several weeks

Leukotriene Modifiers – Prevent effects of leukotrienes thus suppressing inflammation, airway edema, bronchoconstriction, and mucus production.

1. Proto: montelukast (Singulair) — Others: zileuton (Zyflo), zafirlukast (Accolate2. Long-term asthma therapy in folks ≥ 12 YO3. Adverse effects: Liver injury ĉ zileuton and zafirlukast. (nausea, anorexia, abdominal pain)4. Zileuton given without regard to food. Zafirlukast taken ŝ food

Antitussive – Opioids – Suppresses cough center in the medulla oblongata.1. Proto: codeine — Others: hydrocodone2. For Chronic, non-productive cough3. Adverse effects: GI distress (nausea, constipation) – take ĉ food, increase fluid/fiber, CNS sedation effects: Respiratory

depression (<12/min) – naloxone, Potential for abuse, schedule II.4. Contraindications: acute asthma, head trauma, liver/renal dysfunction, acute alcoholism

Mucolytics – Enhance flow of secretions in the respiratory passages1. Proto: acetylcysteine (Mucomyst) — Others: hypertonic saline2. For acute & chronic pulmonary disease ĉ increase secretions, Acetylcysteine is the antidote for acetaminophen poisoning,

cystic fibrosis 3. Adverse effects: Aspiration and bronchospasm4. Contrandications/precautions: GI bleeding, Peptic ulcers / esophageal varices / severe liver disease5. Has smell of rotten eggs, Dilute in fruit juice, IV: Loading dose, next dose over 4h, last dose over 16h.

Decongestants – Stimulate α1-adrenergic receptors decreasing inflammation of nasal membranes1. For Allergic rhinitis, sinusitis, and common cold2. Adverse effects: Rebound congestion (Max 3-5 days, taper down use), CNS stimulation (rare ĉ topical), Vasoconstriction3. Contraindications: Chronic rhinitis, CAD and hypertension4. Oral do not lead to rebound congestion

Digestion & nutrition drugs GI tract is the route of administration and the target of action GI effects are common (abdominal pain, constipation, nausea) When peptic ulcers are caused by H. pylori, non-antibiotics promote healing but only antibiotics will cure the disease. Drug therapy for peptic ulcers is directed at controlling symptoms, facilitating healing, lowering risk for complications, and

preventing relapse Prevention of emesis is more effective than treating it. Histamine2 (H2) Receptor Agonists – Selectively block H2 receptors in parietal cells to suppress gastric acid secretion

1. Proto: ranitidine (Zantec) — Others: cimetidine (Tagamet), nizatidine (Axid), famotidine (Pepcid)2. For OTC for heartburn, sour stomach, and indigestion, Gastric/peptic ulcers / GERD / hypersecretory conditions (Zollinger

syndrome), In conjunction with antibiotics to treat ulcers caused by H. pylori3. Adverse effects: decreased libido / impotence, CNS effects (lethargy, depression, confusion) – increase frequent in elderly

ĉ renal or liver dysfunction.4. Contraindications: increased risk of bacterial colonization of stomach and respiratory tract5. Interactions: Warfarin, phenytoin – metabolizing enzymes inhibited by cimetidine increase levels, Concurrent use of

antacids decrease absorption H2-receptor antagonists6. Stop drinking, stop smoking, eat smaller, more frequent meals, Ranitidine can be taken without regard to food.

Proton Pump Inhibitor – decrease gastric acid secretion by irreversible inhibition of enzyme that produces it, Reduce basal and stimulated acid production

1. Proto: omeprazole (Prilosec) — Others: pantoprazole (Protonix), lansoprazole (Prevacid), esomeprazole (Nexium)2. Gastric/peptic ulcers / GERD / hypersecretory conditions (Zollinger syndrome)3. Adverse Effects: Insignificant ĉ short-term treatmenT4. Contraindications: increase risk pneumonia d/t increase pH promoting bacterial colonization5. Interactions: Delayed absorption of Ampicillin, digoxin, iron, ketoconazole if concurrent6. IV pantoprazole may cause thrombophlebitis, headache, or diarrhea.

Antacids – Neutralize gastric acid and inactivate pepsin, Mucosal protection through stimulation of prostaglandin production1. Proto: Al(OH)3 gel (Amphojel), Others: AlCO3, Mg(OH)2 (Milk of Magnesia), NaHCO3

2. For Peptic ulcer disease and GERD3. Adverse effects: Al/Ca compounds constipation, Mg compounds diarrhea, Na+-containing fluid retention, Al(OH)3

hypophosphatemia, Mg2+ compounds toxicity with renal impairment.4. Interactions: Aluminum-compounds bind to warfarin, tetracycline and decrease their absorption5. Chew tablets thoroughly then take with 8 oz water or milk, Frequency of administration makes compliance difficult

Antiemetics – 1. Ondansetron – Chemo, radiation, postop

1. Adverse effects: Headache, diarrhea, dizziness2. Prochlorperazine – Chemo, opioids, postop

1. Adverse effects: EPS (Tx ĉ Benadryl or Ativan), hypotension, sedation, and anticholinergic effects.3. Dexamethasone – Combo for chemotherapy4. Dronabinol – Chemotherapy (CINV)

1. Adverse effects: Dissociation, dysphoria, hypotension, tachycardia5. Scopolamine –Motion sickness6. Dimenhydrinate – Motion sickness7. Interactions: CNS depressants / Antihypertensives / Anticholinergics Additive Effects, Antagonists ĉ urinary retention,

asthma, and narrow-angle glaucoma, Combo therapy allows lower doses of each decreases side effects. Laxatives –

1. Bulk-forming {psyllium} – Soften mass, increase bulk – same as dietary fiber – diarrhea, control stool, promote defecation

2. Surfactant {docusate} – increase H2O content – Opioids, pain, straining, risk impaction, promote defecation3. Stimulant {bisacodyl} – increase peristalsis, H2O absorption (decrease colon, increase intestine) – Colonoscopy prep,

short-term Tx d/t increased opioid use4. Osmotic {Mg(OH) 3} – increase intestine H2O increase mass increase stretching increase peristalsis – Chemotherapy

(CINV)5. Adverse effects: (Mg2 salts) Accumulate toxic levels of magnesium ( in renal dysfunction), (Na Salts) Accumulation:

in heart disease and hypertension6. Interactions: Milk & antacids destroy enteric coating7. Promote increase fiber foods and > 1.5 L

Antidiarrheals – Activate opioid receptors in GI to decrease motility and increase absorption of water & Na+

1. Proto: diphenoxylate (Lomotil) Others: loperamide (Imodium), difenoxin (Motofen2. At recommended doses, diphenoxylate has no CNS effects, increased diphenoxylate doses typical opioid responses.3. Contraindications: increased risk of megacolon with inflammatory bowel disorders serious complications including

perforated bowel.4. Interactions: CNS depressants increase depressive effect5. Encourage use of electrolyte replacement drinks, Avoid plain water (no electrolytes) and caffeine (increases motility),

Manage dehydration (weight, VS, I&O) – 0.45% NS may be prescribed Prokinetic – Augments action of acetylcholine to increase upper GI motility

1. metoclopramide (Reglan)2. Postop and chemo-induced nausea and vomiting, Diabetic gastroparesis, GERD3. Adverse effects: EPS: Restlessness, spasms of face & neck. Minimize EPS with benzodiazepine like lorazepam (Ativan),

Diarrhea, Sedation4. Contraindications: Seizure disorder (increase seizure risk), GI perforation or bleeding, bowel obstruction, and hemorrhage,

Kids and older adults due to increased risk of EPS5. interactions: Concurrent EtOH or CNS depressant: increased seizure / sedation risks, Opioids and anticholinergics

decreases effects of metoclopramide.6. Dose ≥ 10 mg dilute in 50 mL D5W or Ringer’s; Infuse over 15m

Nervous System Meds Dopaminergics (Anti-Parkinsons) – Levodopa taken up and converted to dopamine. Carbidopa augments levodopa by

preventing conversion to dopamine in intestine and periphery 1. Levodopa, carbidopa, Sinemet2. Symptomatic relief from dyskinesias3. Adverse effects: Dyskinesias, Discoloration of sweat & urine, Nausea / drowsiness, ortho hypotension, psychosis

(clozapine), activiation of malignant melanoma4. Contraindications: 2 wks from MAOI5. Interactions: Proteins interfere with absorption and transport, Carbidopa, dopamine agonists, anticholinergics, COMT

inhibitors and dopamine releasers increase therapeutic effects. Centrally acting cholinergics (anti-Parkinsons) – Block ACh at muscarinic receptors which helps maintain ACh, dopamine

balance1. Benztropine (Cogentin), trihexyphenidyl (Artane)2. Adverse effects: Nausea (take ĉ food), Atropine-like effects (dry mouth, blurred vision, mydriasis, constipation),

Antihistamine effects (sedation, drowsiness)

Antiepileptic – 1. Barbiturates – Partial seizures and generalized tonic-clonic seizures, Not effective against absence seizures2. Phenobarbital (Luminal)

1. Adverse effects: CNS effects: Adults as sedation and anxiety, kids as irritability and hyperactivity, Toxicity: Nystagmus, ataxia, respiratory depression, pinpoint pupils

3. Hydantoins – Effective against all major forms except absence seizures1. Phenytoin (Dilantin)2. Adverse effects: CNS effects, skin rash, teratogenic, cardiovascular, endocrine, Vit D metabolism3. Contraindications: sinus bradycardia, SA blocks, 2nd & 3rd degree AV blocks4. Use IV route for status epilepticus, Antidysrhythmias Carbamazepine – Partial seizures, tonic-clonic seizures, bipolar disorder, trigeminal neuralgia

Tegretol Adverse effects: Cognitive function is minimally affected but CNS effects can occur, Hypo-osmolarity ( ADH

secretion), Blood dyscrasias Contraindications: marrow suppression / bleeding disorders Interactions: Grapefruit juice: inhibits metabolism [carbamazepine]

Valproic Acid – Partial, generalized, and absence seizures, bipolar disorder, and migraines Depakote Adverse effects: GI effects (take ĉ food), Hepatotoxicity, Thrombocytopenia, Pancreatitis as evidenced by

nausea, vomiting, and abdominal pain Contraindications/precautions: Avoid in children younger than 3 (hepatotoxicity), Liver disorders Interactions: Phenytoin and phenobarbital: Concurrent use increases these medications

4. Gabapentin – Single agent used for partial seizures, Neuropathic pain , Migraine prevention1. Neurontin2. Adverse effects: CNS effects (drowsiness, nystagmus)

5. Benzodiazepines – Used in status epilepticus1. Diazepam (Valium)2. Adverse effects: Respiratory depression, Anterograde amnesia, Teratogenic

Muscle relaxants/antispasmodics1. Diazepam – Acts in CNS to enhance GABA and produce sedation, Acts in CNS to depress spasticity of muscles

1. Diazepam (Valium)2. Relief of spasticity d/t Cerebral Palsy or MS, Anxiety & panic disorders, EtOH withdrawal, Relief of spasm d/t injury,

Insomnia, Status epilepticus, Anesthesia induction, Relief of spasm d/t injury3. adverse effects: CNS depression, Physical dependence from long-term use4. contraindications: Caution ĉ impaired liver or renal function5. interactions: CNS depressants (EtOH, opioids, antihistamines, barbiturates): Additive CNS depressive effects with

concurrent use. Local anesthetics – decrease pain by blocking local conduction of pain impulses\

1. Amide type: Lidocaine – Ester type: tetracaine, procaine2. Adverse effects: Hypotension, bradycardia, heart block, cardiac arrest, CNS excitation -- treat ĉ midazolam (Versed) or

diazepam, Allergic reactions (more likely ĉ esters), decrease uterine contractility., Freely cross placenta, Urinary retention (call after 8 hrs), Spinal headache (lay flat for 12 hrs)

3. Contraindications: CI in dysrhythmias and/or heart block, Caution with liver/kidney dysfunction, heart failure, myasthenia gravis

IV anesthetics – Adjunct to inhalation anesthesia, Induction & maintenance of anesthesia, Midazolam & an opioid result in conscious sedation, Ketamine can be used with children, Amnesia

1. Barbiturates: Thiopental (Pentothal), Ketamine (Ketalar), Benzodiazepines: Diazepam (Valium), midazolam (Versed), lorazepam (Ativan), Propofol (Diprivan)1. Adverse effects: Respiratory and cardiovascular depression, PropofolBacterial infection (use opened vial within 6

hrs), Ketamine: Psychologic reaction (premedicate with diazepam to decrease risk)2. Contraindications: Ketamine should be avoided with psychiatric disord: ers3. Interactions: CNS depressants and stimulants: Additive effects, Opioid analgesics: Constipation and urinary retention4. Midazolam (Versed): inject over >2 minutes, Propofol (Diprivan): inject into large vein; prep site with lidocaine.

Antipsychotics – conventional – Dopamine, acetylcholine, histamine, & norepinephrine receptors in brain and periphery are blocked. Symptom inhibition d/t dopamine2 blockade in brain.

1. chlorpromazine (Thorazine), : haloperidol (Haldol), Others: fluphenazine, molindone, perphenazine, thiothixene2. For Delusional disorder, Bipolar disorder, Schizoaffective disorder, Huntington’s chorea, Schizophrenia, Dementia,

Tourette’s Syndrome3. Adverse effects: Anticholinergic effects, Parkinsonism, Tardive dyskinesia, Akathisia, Dystonia, Neuroleptic malignant

syndrome4. Interactions: Levodopa: Counteracts antipsychotics by stimulating dopamine receptors, CNS depressants: Additive effects5. Consider depot preparations, Protect liquid prep from ☼, Early EPS symptoms with anticholinergics, β-blockers,

benzodiazepines Antipsychotics – atypical – Action results from blocking serotonin and dopamine receptors (block other receptors, too) –

decrease Pr developing EPS or tardive dyskinesia1. Proto: clozapine – Others: risperidone, olanzapine, quetiapine2. For Psychosis induced by levodopa therapy, Severe schizophrenia3. Adverse effects: Agranulocytosis (WBC<3000/cc, Neu<1500/cc), Wt. Gain, Myocarditis (dyspnea, increased RR, lethargy,

chest pain, palpitations), New onset diabetes, seizures 4. Immunosuppressive medications: Avoid

Antidepressants – TCAs – Block reuptake of norepinephrine and serotonin in synaptic space1. Proto: amitriptyline (Elavil) Others: imipramine (Tofranil), doxepin (Sinequan)2. Depression & bipolar disorders3. Adverse effects: Anticholinergic effects, Toxicity evidenced by dysrhythmias, confusion, & agitation followed by seizures,

Orthostatic hypotension, Cardiac toxicity @ increased doses4. Interactions: MAOIs hypertension, Antihistamine & anticholinergicsadditive effects, Epi/Norepi increase amounts of

adrenergics because reuptake is blocked by TCA, Ephedrine/amphetamine decrease responses to these d/t uptake inhibition keeps them from reaching site of action in nerve terminal, EtOH, benzodiazepines, opioids, antihistamines Additive CNS depression

SSRIs – Block reuptake of serotonin in synaptic space1. Proto: fluoxetine (Prozac) – Others: citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), sertraline (Zoloft)2. For Major depression, Panic disorders, PTSD, Bulimia, OCD3. Adverse effects: Sexual dysfunction, Weight gain, Serotonin syndrome 2-72 hrs (confusion, anxiety, agitation,

hallucinations), Withdrawal syndrome, Sleepiness, faintness, hyponatremia 4. Contraindciations: MAOI5. Intreractions: NSAIDs & anticoagulants fluoxetine suppresses platelets increase bleeding risk, MAOIs increase risk of

serotonin syndrome, TCA & Lithium increase levels of these MAOI – Block MAO in brain increase norepinephrine and serotonin available for impulses

1. Proto: phenelzine (Nardil) – Others: isocarboxazide2. For Atypical depression, OCD, Bulimia nervosa3. Adverse effects: Hypertensive crisis from dietary tyramine (increase HR, increase BP): Induce vasodilation with IV

phentolamine (α-blocker) or sublingual nifedipine., Orthostatic hypotension, CNS stimulation4. Contrandications: CI: SSRIs, pheochromocytoma, cardiovascular disease & renal insufficiency5. interactions: Indirect sympathomimetic release NE causing hypertensive crisis, TCA hypertensive crisis, SSRIs serotonin

syndrome, Meperidine hyperpyrexia, Tyramine-rich foods hypertensive crisis (aged cheese, salami, avocados, bananas, protein, & red wine), Vasopressors (phenylethylamine, caffeine) hypertension, Antihypertensives additive hypotensive effect

Mood stabilizers – Lithium causes serotonin receptor blockade, Lithium use will evidence decrease neuronal apathy and/or increase in neuronal growth.

1. Proto: Lithium, mood-stabilizing anticonvulsants: valproic acid (Depakote), carbamazepine (Tegretol)2. For Bipolar / alcoholism / bulimia / schizophrenia3. Adverse effects: GI effects, usually transient (give ĉ milk), Tremors (give β-blocker like propanolol), Polyuria ,Renal

toxicity, Goiter/hypothyroidism ,Teratogenic4. contraindications: Caution ĉ renal dysfunction, heart disease, Na+ depletion & dehydration5. Interactions: Diuretics decrease Na+ decrease lithium excretion toxicity, NSAIDs increase renal absorption lithium

toxicity (aspirin OK), Anticholinergics abdominal discomfort from urinary retention & polyuria6. Maintain adequate sodium intake and 8-12 glasses of H2O, Plasma lithium levels must be monitored (> 1.5 mEq/L is toxic)

Sedative hypnotics – benzodiazepines – Enhance the action of gamma-aminobutyric acid (GABA)1. Proto: diazepam (Valium) – Others: alprazolam (Xanax), lorazepam (Ativan), chlordiazepoxide (Librium)2. For Anxiety, Muscle spasms, Anesthesia, Seizures, Panic disorder, Insomnia, EtOH w/d3. Adverse effects: CNS depression, Respiratory depression, Anterograde amnesia, Paradoxical response, Acute toxicity

(treat oral ĉ charcoal, treat IV ĉ flumazenil)4. interactions: CNS depressants additive effects

Sedative hypnotics – non benzodiazepine – Enhance action of GABA in CNS leading to prolonged sleep duration. They do not function as antianxiety, muscle relaxant, or antiepileptic agents.

1. Proto: zolpidem (Ambien) – Others: zaleplon (Sonata), eszopiclone (Lunesta) , trazodone (Desyrel)2. for Management of insomnia3. adverse effects: Daytime sleepiness and light headedness4. Interactions: CNS depressants additive effects, decreases Food absorption when taken with food

Anxiolytic – non-barbiturate – Treatment of Generalized Anxiety Disorder1. Buspirone (BuSpar)2. adverse effects: CNS effects, No sedation3. contraindications: Erythromycin, ketoconazole, and grapefruit juice increases effects of buspirone, Does NOT potentate

CNS depressants4. Take with meals to prevent gastric irritation

CNS stimulants – Release norepinephrine and dopamine and prevent their reuptake in CNS.1. Proto: methylphenidate (Ritalin) – Others: amphetamine, dextroamphetamine (Dexedrine), Adderall, caffeine2. For ADHD, narcolepsy, obesity 3. Adverse effects: CNS stimulation, Cardiovascular effects (dysrhythmias, chest pain, BP), Weight loss

4. Contraindications/precautions: Caution: hyperthyroidism, heart disease, glaucoma, Hx of drug abuse, MAOIs5. interactions: MAOIs hypertensive crisis, Caffeine increases CNS stimulant effects, Phenytoin, warfarin, phenobarbital

Inhibited metabolism of these levels, OTC cold & decongestants increases CNS stimulant effects Drugs for ETOH abuse

1. Withdrawal Symptoms –-> Usually start within 12-72 hours / Persist 5-7 days – Can be mild: nausea, anxiety, tremors, – Can be life-threatening: hallucinations, cramps, tremors, seizures, Increased HR, BP, T

2. Support meds → Benzodiazepines (chlordiazepoxide, diazepam, lorazepam) decreases DT and risk of seizures, decreases intensity of symptoms ---- Adjuncts (carbamazepine, clonidine, propanolol) decreases seizure, decreases craving, depress autonomic response (decreases HR, BP, T)

3. Maintenece meds → Disulfiram (Antabuse) ĉ EtOH, aldehyde syndrome occurs (nausea, extreme vomiting, hypotension) Can progress to respiratory and cardiac depression, seizures, and death – Naltrexone (ReVia) decreases Opioid antagonist that decreases craving and pleasurable effects – Acamprosate (Campral) decreases unpleasant effects of abstinence (anxiety, etc)

Drugs for opioid abuse 1. Withdrawal symptoms → Self-limiting in 7-10 days – Begins with sweating and rhinorrhea, progressing from tremors and

irritability to weakness, nausea, vomiting, muscle/bone pain, and spasticity. – NOT life-threatening.2. Detox meds → Methadone substitution Prevents withdrawal syndrome.3. Matienence meds → Methadone Long-term maintenance. Dependence is transferred to methadone. – Clonidine (Catapres)

Control autonomic hyperactivity (nausea, vomiting) – Buprenorphine (Subutex) Opioid agonist/antagonist – Naloxone (Suboxone) Opioid agonist/antagonist

Drugs for nicotine abuse 1. withdrawal symptoms → Abstinence syndrome is evidenced by irritability, nervousness, restlessness2. support meds → Bupropion (Zyban) decreases craving and symptoms of withdrawal. – Nicotine Pharmaceutical � �

replacement to alleviate symptoms3. Chew gum over 30 minutes; avoid eating and drinking within 15 minutes of gum – Gum not recommended for use longer

than 6 months – Avoid use of all nicotine products while pregnant or breastfeeding.

Blood meds Anticoagulants (parenteral) – Intrinsic factors and thrombin conversion are inhibited by heparin

1. Proto: Heparin — Others: enoxaparin, tinzaparin (Innohep)2. For Evolving stroke, PE, MI, DVT, Adjunct during ♥ surgery, dialysis, abdominal surgery, or joint replacement, DIC3. adverse effects: Hypersensitivity reaction (chills, fever, urticaria), Hemorrhage 2º heparin OD (treat ĉ protamine sulfate),

Heparin-induced thrombocytopenia (stop if PLT < 100,000/cc)4. contraindications: low PLT or uncontrollable bleeding, Surgery of eye, brain, spinal cord; regional anesthesia; lumbar

puncture5. interactions: Anti-platelet agent additive risk of bleeding6. Monitor aPTT levels Q4-6h and then QD (60-80 sec)7. protamine sulfate for heparin OD --- Administer slowly (20 mg/min or 50 mg in 10 min)

Anticoagulant (oral) – Antagonizes vitamin K / prevents synthesis of 4 intrinsic factors & prothrombin1. warfarin (coumadin) 2. for Prevention of venous thrombosis, Prevention of thrombi in A-fib and with prosthetic heart valves3. Adverse effects: Hemorrhage (Tx with vitamin K)4. contraindications: Surgery of eye, brain, spinal cord; regional anesthesia; lumbar puncture, low PLT counts, uncontrolled

bleeding, vit. K δ, liver problems, alcoholism5. PT therapeutic level = 18-24 sec (normal = 11-12.5 sec), Onset takes 8-12 hrs, full effect takes 3-5 days6. Antidote : Vitamin K (Phytonadione)

Antiplatelets – Prevent platelet clumping by inhibiting arterial clotting enzymes and factors1. Proto: Aspirin — Others: ticlopidine (Ticlid), clopidogrel (Plavix), dipyridamole (Persantine), abciximab (Reo Pro)2. for Primary prevention of acute MI, Prevention of stroke, Prevention of reinfarction, Acute coronary syndromes

(abciximab and tirofiban {Aggrastat})3. adverse effects: GI effects (concurrent PPI / enteric-coated / take ĉ food), Hemorrhagic stroke4. ASA (81 mg) for prevention / ASA (325 mg) during initial acute MI episode

Thrombolytic – Clot dissolution by plasminogenplasmin which destroys fibrinogen1. Proto: streptokinase Others: alteplase (tPA), tenecteplase, reteplase2. for Acute MI / DVT / Massive PE / Ischemic stroke (alteplase)3. adverse effects: Serious risk of bleeding from different sites Streptokinase, Hypotension (infuse slowly), Allergic reaction

or anaphylaxis4. contraindications: Hx of intracranial hemorrhage. Brain tumors / pericarditis / Recent head or facial trauma / internal

bleeding5. Admin within 4-6 hours of onset, IV aminocaproic acid for excessive fibrinolysis, Administer H2 antagonists such as

ranitidine (Zantec) or PPI such as omeprazole (Prilosec) to prevent GI bleeding. Iron preparations – Increase iron level for RBC development and oxygen transport capacity

1. Proto: Ferrous sulfate — Others: Iron Dextran2. Treat and prevent iron-deficiency anemia

3. adverse effects: Teeth staining (liquid) {Dilute / Drink ĉ straw / Rinse}, GI distress: {take ĉ food if necessary but decreases absorption}, Anaphylaxis (parenteral): IV is safer / Deep IM ĉ Z-track / Infuse slowly

4. Vitamin C increase absorption but increases side effects, Antacids or tetracyclines decrease absorption5. Take on empty stomach to increase absorption, Anticipate dark green or black stool

Vitamin B12 (Cyanocobalamin) – Necessary to convert folate (required for DNA production) from inactive form1. for Treatment of B12 deficiency, Megaloblastic (macrocytic) anemia related to B12 deficiency2. adverse effects: Hypokalemia 2º increases RBC production3. interactions: Folic acid supplements mask signs of B12 deficiency4. Intranasal spray / oral / IM / SC, Injections are painful; reserved for reduced ability to absorb.

Folic Acid – Folic acid is essential in DNA production & erythropoiesis (RBC, WBC, PLT)1. Tx of macrocytic anemia, Prevention of neural tube defects in pregnancy

Hamatopoietic Growth factors – Act on bone marrow to increase RBC production1. Epoetin alfa (Epogen, Procrit) 2. For Anemia of chronic renal failure or chemotherapy, HIV patients taking zidovudine (Retrovir), Anemia in patients

schedule for elective surgery3. adverse effects: Hypertension 2º increased Hct, high risk for CV event (MI, stroke, arrest) ĉ high Hgb > 12 g/dL or > 1 g in

2 weeks4. contraindications: uncontrolled HTN5. RBC production requires iron, folate, and vitamin B12, Monitor Hgb and Hct 2x per week until target range is reached

Granulocyte colony stimulating factor – Medications stimulate bone marrow to increase production of neutrophils.1. filgrastim (Neupogen)2. decrease infection risk with neutropenia (e.g. cancer)3. adverse effects: Bone pain, Leukocytosis: decrease dose / interrupt treatment if WBC > 50,000/cc, ANC > 20,000/cc, or

platelets > 500,000/cc.4. Filgrastim should not be agitated nor mixed, Monitor CBC 2x per week

Whole blood – Increases circulating blood volume1. For Acute blood loss, extensive burns, dehydration, shock2. adverse effects: Sepsis (culture, antibiotics, IV fluids, vasopressors, steroids), Acute hemolytic rxn (fever, tachycardia,

hypotension): VS Q5m for 15m, Febrile nonhemolytic rxn (most common) (fever, headache): VS Q5m for 15m, Anaphylaxis: VS Q5m for 15m – IM or IV epinephrine, Mild allergy: If respiration uncompromised, antihistamines and restart, Circulatory overload: Place upright / O2 and diuretics / slower rate

3. Requires countersign, Assess site & patency, Use ≥19 ga, filter, Y-tubing, Assess before, during, & after, increase Hgb 1-2 g/dL per unit, Complete in 2-4 hours, no mix

Packed RBCs – # of RBCs1. For Erythroblastosis fetalis, Hemoglobinopathies, Severe symptomatic anemia (Hgb<6 g/dL), Med-induced hemolytic

anemia2. Adverse effects: Sepsis (culture, antibiotics, IV fluids, vasopressors, steroids), Acute hemolytic rxn (fever, tachycardia,

hypotension): VS Q5m for 15m, Febrile nonhemolytic rxn (most common) (fever, headache): VS Q5m for 15m, Anaphylaxis: VS Q5m for 15m – IM or IV epinephrine, Mild allergy: If respiration uncompromised, antihistamines and restart

3. Requires countersign, Assess site & patency, Use ≥19 ga, filter, Y-tubing, Assess before, during, & after, increase Hgb 1-2 g/dL per unit, Complete in 2-4 hours, no mix

Platelet concentrate – increase platelet count1. For Thrombocytopenia (< 20,000/cc), Active bleeding (platelets < 80,000/cc)2. Adverse effects: Sepsis (culture, antibiotics, IV fluids, vasopressors, steroids), Febrile nonhemolytic rxn (most common)

(fever, headache): VS Q5m for 15m, Mild allergy: If respiration uncompromised, antihistamines and restart3. Requires countersign, Assess before, during, & after, Assess site & patency, Use special platelet kit (smaller filter, shorter

tube Fresh Frozen Plasma – Replaces coagulation factors

1. For DIC, Massive hemorrhage, Extensive burns, shock, Antithrombin III deficiency, Thrombotic thrombocytopenic purpura, Reverse warfarin effects, Replacement therapy for factors II, V, VII, IX, X, & XI

2. Adverse effects: Sepsis (culture, antibiotics, IV fluids, vasopressors, steroids), Acute hemolytic rxn (fever, tachycardia, hypotension): VS Q5m for 15m, Febrile nonhemolytic rxn (most common) (fever, headache): VS Q5m for 15m, Anaphylaxis: VS Q5m for 15m – IM or IV epinephrine, Mild allergy: If respiration uncompromised, antihistamines and restart, Circulatory overload: Place upright / O2 and diuretics / slower rate

3. Requires countersign, Assess before, during & after, Assess site & patency, no mix Albumin – Expands circulating blood volume by oncotic pressure

1. For Hypovolemia, burns, Adult respiratory distress, Hemolytic disease of the newborn, Cardiopulmonary bypass surgery, Hypoalbuminemia

2. adverse effects: Risk for fluid volume excess such as pulmonary edema3. Contraindications: CHF, Renal insufficiency 4. Must administer IV: Slowly using an infusion pump, Can be administered ĉ whole blood, plasma, saline, or glucose.

Endocrine Meds Carbohydrate, fat, and protein metabolism are all affected by diabetes

All people with type 1 diabetes require insulin for management of blood glucose People with type 2 diabetes require insulin when undergoing surgery, experiencing high levels of physiologic stress (e.g.

infection), and during pregnancy. Insulin is classified two ways:

1. Type – How it’s made1. Natural or regular2. Addition of protein to prolong duration (NPH)

Insulin analogs1. Lispro and Aspart insulins have shorter durations than Regular insulin2. Glargine insulin has a longer duration than Regular insulin.

Oral hypoglycemics used for type 2 diabetes when diet/exercise are not enough Types of insulin: onset – how soon the insulin starts to lower the BG peak- time the insulin is working the hardest to lower the BG duration- how long the insulin lasts – the length of time it keeps lowering the BG

1. Rapid acting- Lispro (Humalog), Aspart (Novolog) , Glulisine (Apidra) 1. 10-30 min onset – 30min-3hr peak – 3-4hr duration

1. Warning- due to it's rapid onset, have food ready or ingested when using Humalog or Humulin ® 2. Lispro can only mix w/ NPH, Lenter, Ultralente

2. Short- acting – Regular ® (Humulin, Novolin ), Velosulin (use in insulin pump)1. 30 min-1hr onset – 2-5hr peak – 5-7hr duration

1. regular insulin is the ONLY insulin that can be given IV2. regular insulin can mix with ALL insulins.

3. intermediate- acting – NPH (N) 1. 1.5-4hr onset – 4-12hrs peak – 18-24hrs duration

4. long-acting – Insulin glargine (Lantus), Insulin detemir (Levemir)0.8-4hr onset – minimal peak – 10.4-24hrs duration

Biguanides – decrease HEPATIC (liver) glucose formation. 1. "Metformin (Glucophage)"◦ It increases peripheral glucose uptake & decreases both basal & postmeal BG◦ Take it w/ food ◦ mointor LL & KK◦ LACTIC ACIDOSIS -adverse reaction◦ hold 24-48 hrs before & after ivy dye

Sulfonylurea agents – inhibit K+ channels in BETA CELLS which increases insulin release (3 main drugs)◦ "Glipizide (Glucotrol)"

▪ take 30 min before meals▪ KK function ▪ Adverse effects --> HYPOGLYCEMIA, disulfram like effects (GI disturbances)▪ Avoid NSAIDs (pg 1428 -- all the meds that interact w/ Sulgonylurea agents)

◦ "Glimepiride (Amaryl)"▪ used as single therapy or in combo w/ Metformin

longer acting◦ "Micronase (Glyburide)"

Thiazolidinediones – Bind to PPAR-Y receptor which eventually increases glucose transport into cell by working on the cell membrane & improving tissue sensitivity to insulin (2 main drugs)◦ "Pioglitazone (Actos)"

▪ monitor weight, assess for edema & SOB▪ full therapeutic response may not be evident for 8-12 wks after therapy

◦ “Rosiglitazone (Avandia)"▪ LL function tests▪ SERIOUS se of HEART problems (black box warning)▪ same as above

Alpha- Glucosidase inhibitors – stops/delays the breakdown of DISACCHARIDES (disaccharides are normally broken down to monosccharides so they can be absorbed by the small intestine --> less carbs absorbed means less glucose) (2 main drugs)◦ "Acarbose (precose)"

▪ Farting (flatulence) ▪ other GI disturbances▪ take w/ 1st bite of each meal ▪ Acarbose works ONLY when taken at beginning of meal, if not taken, it should not betaken until next meal. ▪ avoid foods that increase GI discomfort ▪ associated w/ elevation in serum transaminease levels (monitor LL function)

◦ "Miglitol (Glyset)" -- same as above Miglitinide Analogs – similar action & adverse effect to Sulfonylureas.

◦ "Nateglinide (Starlix)"▪ rapidly absorbed & stimulates insulin secretion within 20 min▪ taken just before meals to control mealtime hyperglycemia & improves overall glycemic control ▪ adverse effect – HYPOGLYCEMIA▪ if skipping meal, also skip dose to reduce risk of hypoglycemia

Incretin Memetics (GLP-1 agonist) ◦ “Exenatide (Byetta)”

▪ increases insulin secretion by increasing CAMP levels within the cell▪ decreases glucagon release ▪ Adverse effects – PANCREATITIS, GI disturbances

Antithyroid – Block thyroid hormone synthesis // Prevent oxidation of Iodine // T4 T3

◦ propylthiouracil◦ For Graves disease, Adjunct to thyroid irradiation, Produce euthyroid state prior to thyroid removal, Emergency

thyrotoxicosis treatment◦ adverse effects: Overmedication hypothyroidism (drowsiness, weight gain, edema, bradycardia, cold intolerance, dry

skin), Agranulocytosis Monitor for early signs (fever, pharyngitis) Tx: Neupogen◦ contraindications: Marrow depression or immunosuppression◦ interactions: increases anticoagulant effects◦ Take at consistent time and with meals (decreases GI distress), Hyperthyroidism may get β-adrenergic blocker

(propranolol) to decrease tremors Radioactive iodine – Destroys thyroid cells at high doses

1. For Hyperthyroidism (high dose), Thyroid cancer (high dose), low doses: Thyroid function studies2. Adverse effects: Marrow suppression (anemia, leukopenia, thrombocytopenia), Radiation sickness: Hematemesis,

epistaxis, intense nausea, vomiting3. Take on empty stomach, Void frequently // Limit contact to ½ hr/day/person // increase fluids, Dispose of body wastes per

protocol, Avoid coughing and expectorating Anti-diuretic hormone – Promote H2O reabsorption in kidneys (desmopressin preferred), Vasoconstriction due to smooth

muscle contraction (vasopressin)1. vasopressin (Pitressin) — desmopressin (DDAVP)2. For Diabetes insipidus, cardiac arrest 3. adverse effects: Overhydration (sleepiness, pounding headache)4. contraindications: CAD or decreased peripheral circulation (risk for gangrene)5. Monitor site carefully; extravasation can cause gangrene.

SE of Cancer meds: Bone marrow suppression → Avoid crowds, check for bleeding gums GI discomfort → Give antiemetic (ondansetron) with dexamethasone, metoclopramide or granisetron at outset Alopecia → Occur 7-10 days after, persist max of 2 months after Mucositis → Frequent oral care, soft toothbrush, EtOH mouthwash Reproductive toxicity → Sperm banking, Avoid gravid on meds. Hyperuricemia or high uric acid → increase fluids, I&O, Give allopurinol if high uric acid Extravasation of vesicants such as carmustine, dactinomycin, daunorubicin, and vincristine

Fluid & Electrolyte Meds High ceiling loop diuretics – In upper Loop of Henle to block reabsorption of Na+/Cl-/H2O Extensive diuresis.

◦ Proto: furosemide (Lasix) — Others: ethacrynic acid (Edcrin), bumetanide (Bumex), Torsemide (Demadex)◦ Reserved for conditions unresponsive to other diuretics (e.g. edema d/t liver, cardiac or renal disease; hypertension),

Works well with renal impairment◦ adverse effects: Dehydration (output < 30 mL/hr), Hypotension,, hypokalemia, Hyperglycemia, hyperuricemia, ◦ interactions: Digoxin toxicity r/t increase K+, , NSAIDs blunt diuretic effect, Antihypertensives – Additive hypotensive

effect◦ Daily weights, Infuse slowly (20 mg/min), increase K+ foods (avocado, strawberry, banana, potato, spinach, tomato, meat,

carrots), decreased Mg2+ signs: muscle twitch and tremor Thiazide Diuretics – In early DCT to block Na+/Cl-/H2O reabsorption – promote diuresis when renal function is not impaired.

1. hydrochlorothiazide (HydroDIURIL) — chlorothiazide (Diuril), indapamide2. For 1st choice essential hypertension, Edema of mild-to-moderate heart failure and liver/kidney disease.3. Adverse effects: Dehydration, hypokalemia, hyperglycemia4. same as above

K+ sparing diuretics – Block aldosterone action resulting in K+ retention and Na+/H2O excretion.1. spironolactone (Aldactone) — triamterene (Dyrenium), amiloride (Midamore)2. Combined with other diuretics for K+-sparing effect, HF, Blocks aldosterone in hyperaldosteronism3. adverse effects: Hyperkalemia (insulin injection drives K+ back into cell), Endocrine effects: Irregular menses or

impotence4. interactions: ACE inhibitors (lisinopril) hyperkalemia,

5. Triamterene may color urine blue Osmotic diuresis – increase blood osmolality thus attracting fluid (e.g. 3rd spacing, CSF, intraocular)

1. mannitol (Osmitrol) — urea, glycerin, isosorbide2. For decreased ICP, Prevent renal failure in hypovolemic shock or severe hypotension., Promote Na+ retention and H2O

excretion in hyponatremia and fluid V excess3. Adverse effects: Heart failure / pulmonary edema, Renal failure (urine < 30 mL/hr, creatinine > 1.2 mg/dL, BUN > 20

mg/dL4. contraindications: Lasix complements through renal excretion of fluid drawn by osmotics.5. Most effective given as a bolus, Use filter to prevent crystals, Monitor serum osmolarity and every 6 hours / urine

osmolarity daily Sodium Polystyrene (Kayexalate) – Promotes K+ excretion and Na+ absorption, primarily in large intestine

1. Treat hyperkalemia2. adverse effects: Electrolyte (Ca2+, K+, Na+, Mg2+) imbalance3. interactions: Ca2+- or Mg2+-containing antacids or laxatives may decrease efficacy, Digoxin and K+-sparing diuretics

should undergo frequent K+ monitoring4. Given orally or rectally, Mix with juice, Retain enema for 30-60 minutes; irrigate ĉ non-Na+-containing solution

Sodium bicarbonate – Systemic alkalinizer used to correct metabolic acidosis (pH < 7.35) K+ supplements –

1. Potassium Chloride (K-Dur) — K+ gluconate, K+ phosphate, K+ bicarbonate2. Never give IV push, Use infusion pump, Assess site for irritation, phlebitis, infiltration – d/c immediately if present, Dilute

to no more than 40 mEq/L || give no faster than 10 mEq/hr.

Reproductive System Drugs3. Oxytocics – increase strength, frequency, and duration of uterine contractions

1. oxytocin (Pitocin), methylergonovine (Methergine)2. For: Methergine: Emergency intervention for serious postpartum hemorrhage, Oxytocin: Labor induction or

enhancement // Delivery of afterbirth // Control of postpartum bleeding // Fetal stress testing // Milk letdown (intranasal)

3. Adverse effects: Methergine: Hypertensive crisis (IV): Headache, nausea, BP, Oxytocin: Uterine rupture {Relax myometrium ĉ Mg(SO4)}

4. Contraindications: Methergine: Hypertension, Cardiovascular, renal, or hepatic failure. Oxytocin: unripened cervix, Hx of multiples, uterine surgery // immature lungs, cephalopelvic disproportion, prolapsed umbilical cord, fetal distress.

5. Use infusion pump and gradually increase rate, contractions longer than 60 sec, freq > q 2-3 min STOP infusion4. Tocolytic – Selectively activates β2-adrenergic receptors uterine smooth muscle relaxation

1. Terbutaline sulfate (Brethine), magnesium sulfate, ritodrine2. For: Delay of preterm labor3. adverse effects: Tremors, anxiety, headache (β2 skeletal muscle side effects), Tachycardia, palpitations, chest pain (β1

side effects)5. Oral contraceptives – decrease fertility by inhibiting ovulation, thickening cervical mucous, and making lining of

endometrium less favorable to implantation.1. Ovcon 35 —Necon, ortho-novum2. Prevent pregnancy3. adverse effects: Hypertension, Thromboembolic events, Breakthrough or abnormal uterine bleeding, Cervical cancer4. Take for 21 days followed by 7 days with no drug, 1 missed dose: Take 2 next time / 2 missed doses: double-up x 2

days

Maternity meds Rh (D) immune Globulin (RhoGAM)

1. prevention of anti-RH (D) antibody formation is most successful if the med is adminsitred 2x at 28 wks of gestation & again within 72hrs after delivery

2. Use : to prevent isoimmunization in RH-negative p/ts who are exposed or potentially exposed to Rh-positive red blood cells by transfusion, termination of pregnancy, amniocentesis, chorionic villus sampling, abdominal trauma, or bleeding during pregnancy or bith process

3. adverse effects/contranindications: elevated temp, tenderness at injection site, contraindicated for Rh-positive p/ts, contraindicated in p/ts w/ hx of systemic allergic rxs to preparationscontaining human immunioglobulins, not adminstered to a newborn.

4. Adminster via IM never IV – monitor injection site for tenderness & elevated temp. 5. this drug does not benefit if p/t has already develiped a positive antibody titer to the Rh antigen

Tocolytics “Anti-contraction” “labor repressants” 1. they produce uterine relaxation & suppress uterine activity in an attempt to halt uterine contractions & prevent preterm

birth 2. adverse effects/contraindications: (maternal contraindications) severe preeclampsia & eclampsia, active vaginal bleeding,

intrauterine infection, cardiac disease, & medical or obstetric condition that contraindicates continuation of pregnancy. (fetal contraindications) estimated gestational age greater than 37 wks, cervical dilation greater than 4 cm, fetal demise,

lethal fetal anomaly, chorioamnionitis, acute fetal distress. 3. Interventions – position p/t on side, monitor daily wt & I & O4. Indomethacin (indocin): prostglandin inhibitor, relaxes uterine smooth MM.

1. Adverse effects – N/V, dyspepsia, dizziness2. used when other methods fail only if gestational age is <32 wk

5. Magnesium Sulfate: CNS depressant; relaxes smooth MM. Used for preeclamptic p/ts to prevent seizures.1. Adverse effects- depressed respirations & DTRs, hypotension, extreme MM weakness, flushing, low UOP,

pulmonary edema2. use IV controller pump for adminstration

6. Nifedipine (procardia, adalat, Nifedical): Ca channel blocker; relaxes smooth MM by blocking Ca entry.1. Adverse effects– tachycardia, hypotension, dizziness, headache , nervousness, facial flushing, fatigue, nausea2. follow agency protocol for admin.

7. Terbutaline (brethine): B-adrenergic agonist; relaxes smooth MM by inhibiting uterine acticity & causing bronchodilation. 1. Adverse effects – tachycardia, palpitations, pulmonary edema, chest pain, myocardial ischemia, hypotension, termors,

hypokalemia, hyperglycemia2. monitor & report adverse rx

Betamethasone & Dexamethasone1. corticosteroids that increase the production of surfactant to accelerate fetal lung maturity & reduce the incidence or

severity of respiratory distress syndrome. Uterine stimulants (oxytocics): Ocytocin (Pitocin)

1. oxytocin stimulates the smooth MM of the uterus & increases the force, frequency, & duration of uterine contractions. Used to induce labor.

Ergot alkaloids:1. ergonvoine maleate or ergometrine (ergotrate Maleate) & methylergonovine maleate (methergine)2. Directly stimulate uterine MM, increase force & frequency of contractions, & produce a firm tetanic contraction of the

uterus.3. Can produce arterial vasoconstriction & vasospasm of the coronary arteries; not admin before the delivery of the placenta,;

check BP before admin an ergot alkaloid – can cause sever hypertension Rubella vaccine:

1. sub Q before hospital discharge to a nonimmune pospartum p/t 2. admin if rubella titer is less than 1:83. contraindicated in a p/t w/ an allergy to duck eggs4. don't get pregnant 1-3 months after immunization

PEDIATRICS Most oral ped meds are in liquid or suspension form b/c usually they are unable to swallow a tab Conversion by body wt:

1. 1 lb = 16oz2. I kg = 2.2 lb

Respiratory meds (PEDS) Quick relief (Rescue meds)

1. Short acting B2 agonists (for bronchodilation)2. Anticholinergics (for relief of acute bronchospasm)3. Systemic corticosteriods (for anti-inflammatory action to treat reversible airflow obstruction)

Long term control (preventer meds)1. corticosteroids2. antiallergic meds3. NSAIDs4. long acting B2 agonists5. leukotriene modifers

monoclonal antibody