PharmacologyBy: Jan Michael Khalid L. Macarambon, RN

Definition of TermsPharmacology is the science of drugs and their effects on biological systems y Drug a chemical that can cause a change in a biological system y Medicine is a formulation of a drug (e.g., tablet, capsule, etc.)y

Drug ClassificationChemical according to structure y Pharmacologic according to physiologic activities and mechanisms of action y Therapeutic according to therapeutic indicationsy

Drug NamesChemical name chemical structure of the compound y Generic name name selected by the original manufacturer of the drug based on the chemical structure that is used worldwide as established through the committee on International Nonproprietary names of the WHO; AKA nonproprietary name. y Trade/Brand name proprietary name owned by the company that manufactures the drug. Example: Chemical name N-Acetyl-para-aminophenol Generic name Acetaminophen Trade/Brand name Acephen, Tynenoly

Drug SourcesPlants (morphine) y Animals (insulin) y Minerals (calcium)y y

Most modern drugs are synthetic chemical compounds

Pharmacodynamicsy

Is the process by which drugs influence the cell physiology to achieve the desired result

WHAT THE DRUG DOES TO THE BODY

PharmacodynamicsDrugs can: 1. Inhibit 2. Activate 3. Replace They interact with specific sites called receptors Receptors cellular proteins or nucleic acids that regulate the cellular activities

PharmacodynamicsReceptors are regulated in two ways: 1. Agonists (activators) bind to the receptor and act to produce a pharmacologic effect 2. Antagonists (blockers) bind to the receptor and prevent the cell from producing an effect

Pharmacokineticsy

Is the process by which the body absorbs the drug into the bloodstream, distributes it to its site of action, metabolizes it, and excretes it

WHAT THE BODY DOES TO THE DRUG

PharmacokineticsADME1. 2. 3. 4.

Absorption Distribution Metabolism/biotransformation Excretion

Pharmacokinetics

Factors Affecting PharmacokineticsAge y Diseases y Individual Differences y Psychological Factors y Type & Amount of Drug Prescribed y Social Factorsy

Routes of Administration

OralPills, capsules, tablets, liquids y SL, buccal, NG, gastrostomy, duodenostomy tubes are also included y Assess clients ability to take oral medicationsy

Intradermal Injection SitesVentral forearm y Upper chest y Shouldery

Subcutaneous Injection SitesOuter aspects of the arms & thighs y Hip and lower abdomen y Above the iliac cresty

IntramuscularVentrogluteal for 1 year and above y Preffered sitey

Intramusculary

Vastus lateralis below 1 year old

Intramusculary

Dorsogluteal clients w/ welldeveloped gluteal muscles

Intramusculary

Deltoid

Other RoutesIntravenous y Topical skin, ophthalmic, otic, nasal, vaginal, rectal y Respiratory inhalationy

InfectiousAntibacterials y Antivirals y Antifungals y Antiparasitics y Antihelminthicsy

Antibacterials4 Major Types: 1. Cell Wall Inhibitors a. Penicillins pen G, amoxicillin b. Cephalosporins cephalexin, cefuroxime c. Glycopeptides vancomycin 2. Protein Synthesis Inhibitors a. Aminoglycosides gentamycin, amikacin b. Macrolides erythromycin c. Lincosamides clindamycin d. Chloramphenicols, tetracyclines 3. Antimetabolites a. Sulfonamides cotrimoxazole 4. DNA Synthesis Inhibitors a. Quinolones ciprofloxacin b. Metronidazole

AntibacterialsAdverse effects : 1. Aminoglycoside - nephrotoxicity & ototoxicity 2. Sulfonamides - Steven-Johnsons syndrome, photosynsetivity 3. Quinolones insomnia 4. Tetracyclines - bone problems 5. Chloramphenicol - Gray syndrome, bone marrow depression 6. Erythromycin - hepatitis

AntibacterialsNursing considerations : 1. Collect appropriate specimen for C & S before starting antibiotics. 2. Check clients history of allergies. 3. Avoid administering erythromycin and quinolones with food. 4. Pregnant precautions. 5. Report for diarrhea - pseudomembranous colitis (clindamycin) 6. Monitor adverse effects.

AntiviralsMechanism of action - inhibits virus specific enzymes involve in DNA synthesis. They only control the growth of virus but it does not cure y Prototype - acyclovir (Zovirax), ganciclovir (Cytovene), vidarabine (ViraA), amantidine (Symmetrel), ribavirin (Virazole), zidovidine (Retrovir)y

AntiviralsAdverse Effects - granulocytopenia, thrombocytopenia, nausea, nervousness, headache, nephrotoxicity Nursing consideration : 1. Pregnant and breastfeeding precautions. 2. Administer IV antivirals to avoid crystallization in renal tubules. 3. Give ribavirin only with aerosol generator. 4. Monitor CBC and creatinine level. 5. Refer for signs of bleeding. 6. Take amantidine after meals.y

AntifungalsMechanism of action - inhibit the synthesis of fungal sterol y Prototype - amphotericin B (Fungisone), nystatin, fluconazole (Diflucan), ketoconazole (Nizoral) y Adverse effects nephrotoxicity and neurotoxicity, bone marrow depression, chills, fever, joint pains, abdominal pain and headachey

AntifungalsNursing considerations : 1. Dilute amphotericin B with sterile water solution not with electrolyte solution. 2. Tell clients that fever, chills, GI upset, joint and muscle pain will subside as amphotericin B continues. 3. With oral candidiasis, let nystatin tablet dissolve in mouth rather than swallowing it. 4. Refrain ketoconazole with antacids. 5. Report for signs of bleeding, infection & fatigue

Antiparasitics2 Types: y Antimalarial chlroquine, mefloquine, primaquine, quinine, pyrimethamine y Antiamebiasis metronidazole (Flagyl), iodoquinol, furozolidone (Furoxone)

AntiparasiticsMechanisms of action: y Antimalarial alters protozoal DNA, depleting folates, & reducing nucleic acid production y Antiamoeba block protein synthesis

AntiparasiticsNursing considerations : 1. Administer anti-malarial drugs with food. 2. Take seizure precautions while administering antimalarial drugs. 3. Refer cinchonism during quinine treatment: - tinnitus, headache, vertigo, fever, and visual changes. 4. Inform clients that iodoquinol falsify thyroid function test for up to 6 months.

AntihelminthicsPrototype mebendazole (Vermox), thiabendazole, niclosamide (Niclocide), piperazine (Antepar), praziquantel (Biltricide) y Mechanism of action paralyze larva and adult helmints by acting on parasite microtubulesy

AntihelminthicsAdverse effects - GI upset, urinary odor (thiabendazole), headache, dizziness, fatigue Nursing considerations : 1. Treat all the family members for nematodes infection to prevent recurrence. 2. Praziquantel must swallowed rapidly because of its bitter taste to avoid gagging. 3. Other antihelmintics should be chewed.y

OncologicAlkylating Agents y Antitumor Antibiotic Agents y Antimetabolites y Mitotic Inhibitors y Hormonal Medicationsy

Alkylating Agentsinhibits cell production by causing cross linking of DNA Busulfan hyperuricemia Chlorambucil gonadal suppression Cisplatin ototoxicity and nephrotoxicity Cyclophosphamide hemorrhagic cystitis.y

Antitumor Antibiotic Agentsinterfere in DNA and RNA synthesis Plicamycin affects bleeding time Doxurubicin cardiotoxicity Bleomycin pulmonary toxicityy

Antimetabolitesy

replace normal proteins required for DNA synthesis by inhibiting the S phase Cytarabine hepatotoxicity 5-flourouracil phototoxicity reaction and cerebellar dysfunctions 6-marcaptopurine hyperuricemia Methotrexate photosensitivity, given with leucoverin to lessen its toxicity

Mitotic Inhibitorsy

prevent mitosis acting on the M phase causing cell death Vincristine sulfate neurotoxicity, numbness

Hormonal Medicationsblock the normal hormones in hormone sensitive tumors Tamoxifen citrate visual problems, elevate cholesterol & triglycerides level Diethylstilbestrol impotence and gynecomastia in meny

Side Effectsstomatitis y - bland diet, avoid strong mouthwash y - soft tooth brush, ice chips diarrhea, nausea and vomiting y - anti-emetic, replace fluids and electrolytes y - alopecia y - reassure that it is temporary y - encourage o wear wigs, hats and head scarf skin pigmentation y - inform that it is only temporary tumor lysis syndrome y - hyperuricemia & hyperkalemia y - force fluids infection y - notify physician if WBC is 1.5 mEq/L blood level may cause toxicity manifested by: confusion, lethargy, seizures, hyperreflexia, maintain salt and adequate fluid intake, tremors may occur but it is temporary, monitor white blood cell count (increase).

Antipsychotics2 Types: y Phenothiazines chlorpromazine (Thorazine), trifluoperazine (Stelazine), thioridazine (Mellaril) y Other Agents clozapine (Clozaril), haloperidol (Haldol)

AntipsychoticsMechanism of action block dopamine receptor in the limbic system, hypothalamus, and other regions of the brain y Adverse effects -Extra pyramidal symptoms such as dystonia, pseudoparkinsonism, and an irreversible tardive dyskinesia as manifested by : lip smacking, fine wormlike tongue movement, involuntary movements of arms and leg. -Neuroleptic malignant syndrome fever, tachycardia, tachypnea, diaphoresis, cardiovascular collapse, muscle rigidity, seizures. -Orthostatic hypotensiony

AntipsychoticsNursing considerations : 1. Teach family members the signs of EPS and NMS, and report to physician immediately. 2. Normalization of symptoms may not occur for several weeks after beginning of therapy. 3. Avoid administering haloperidol intravenously. 4. Watch out of neutropenia with clozapine. 5. Watch out for orthostatic hypotension and photosensitivity with phenothiazine. 6. Be sure that oral doses are swallowed, and not hoarded.

MusculoskeletalGeneral Anesthetics y Local & Topical Anesthetics y Analgesicsy

General Anesthetics2 Types: y Inhalation anesthetics enflurane (Ethrane), halothane, isoflurane (Forane), nitrous oxide y Injection anesthetics fentanyl (Sublimaze), ketamine (Ketalar), thiopental Na (Penthotal), etomidate (Amidate)

General Anestheticsy

Mechanism of action cause CNS depression, by producing loss of consciousness, unresponsiveness to pain stimuli, and muscle relaxation

General AnestheticsNursing considerations : 1. Instruct client NPO for 8 hours before administration. 2. Monitor cardio pulmonary depression and hypotension. 3. Monitor urinary retention. 4. Monitor body temperature malignant hyperthermic crisis : dantrolene (antidote) 5. Avoid alcohol or CNS depressants for 24 hours after anesthesia. 6. In patient who received halothane, monitor signs of hepatic fatal side effects : - rash, fever, nausea, vomiting, jaundice and altered liver function.

Local & Topical Anesthetics2 Types: y Local : bupivacaine, lidocaine, tetracaine, procaine, mepivacaine, prilocaine y Topical : benzocaine, butacaine, dibucaine,lignocainey

Mechanism of action block transmission of impulses across nerve cell membrane

Local & Topical AnestheticsAdverse effects cardiac dysrhythmias y Nursing considerations : 1. Lignocaine + prilocaine (EMLA cream) should be applied topically 60 minutes before procedure. 2. Administer cautiously to the areas of large broken skin. 3. Observe for fetal bradycardia in pregnant clients.y

Analgesics2 Types: y Narcotic analgesics codeine, meperidine (Demerol) morphine, butorphanol (Stadol), nalbuphine (Nubain) y Non narcotic analgesic NSAIDs aspirin (aminosalicylic acid), mefenamic acid (Ponstan), ibuprofen (Motrin), naproxen, ketoprofen (Orudis), ketorolac paracetamol and acetaminophen (Tylenol)

AnalgesicsMechanisms of action: y Narcotic analgesics alter pain perception by binding to opioid receptors in CNS. y Non-narcotic analgesic relieves pain and fever by inhibiting the prostaglandin pathway.

AnalgesicsNursing considerations : 1. Monitor respiratory depression & hypotension in clients taking narcotic analgesic. 2. Injury and accident precautions in clients taking narcotic analgesic. 3. Warn clients about possibility of dependency, and do not discontinue narcotics abruptly in the narcotic-dependent clients. 4. Naloxone is antidote for narcotic overdose. 5. Advice clients to take NSAIDs with food and monitor bleeding complications. 6. Aspirin is contraindicated in clients below 18 years old with flulike symptoms. 7. Monitor hearing loss in clients taking aspirin. 8. Monitor liver function in clients taking acetaminophen. 9. N-acetylcysteine is antidote for paracetamol overdose.

Cardiovasculary y y y y y y y y y y y

Anticoagulants Thrombolytics Hemostatic Agents Antiplatelets Cardiac Glycosides Nitrates Anti-arrhythmics Antilipemics ACE Inhibitors Calcium-Channel Blockers Diuretics Vasodilating Agents

Anticoagulants2 Types: 1. Heparin SQ & IV 2. Warfarin Oral Mechanism of actions : y Heparin prevents thrombin from converting fibrinogen to fibrin. y Warfarin suppress coagulation by acting as an antagonist of vitamin K after 4-5 days

AnticoagulantsIndications thrombosis, pulmonary embolism, myocardial infarction y Adverse effect bleedingy

Nursing ConsiderationsHEPARIN sodium y if given SQ dont aspirate or rub the injection site (above the scapula - best site). y therapeutic level 1.5-2.5 times normal PTT; y normal PTT is 20-35 sec. = 50-85 sec. y antidote : (protamine sulfate)1.

Nursing Considerations2. y y y y y y y

WARFARIN sodium (coumadin) warfarin is used for long-term. onset of action is 4-5 days. therapeutic level is 1.5-2.5 times normal PT; normal PT = 9.6 -11.8 sec. = 25 - 30 sec. should be taken at the same time of the day to maintain at therapeutic level. reduce intake of green leafy vegetables. antidote : Vitamin K ( Aquamephyton)

ThrombolyticsMechanism of action activates plasminogen to generates plasmin (enzyme that dissolve clots) y Indication - use early in the course of MI (within 4-6 hours of the onset) y Prototype Streptokinase, Urokinase y Nursing considerations - monitor bleeding, antidote : Aminocaproic acidy

Hemostatic AgentsMechanism of action terminates/stops bleeding y Indications treatment of bleeding as a side effect for anticoagulant/thrombolytic therapy y Prototype Aminocaproic acid (Amicar), Tranexamic acid (Hemostan), Protamine sulfate,Vitamin K (aquaMEPHYTON, Konakion)y

AntiplateletsMechanism of action inhibit the aggregation of platelet thereby prolonging bleeding time y Indication - used in the prophylaxis of long-term complication following M.I, coronary revascularization, and thrombotic CVAy

AntiplateletsPrototypes - aspirin, Dipyridamole (Persantin), Clopidoigrel (Plavix), Ticlopidine y Nursing Considerations - Monitor bleeding time ( NV = 1-9 mins), take the medication with foody

Cardiac Glycosidesincrease intracellular calcium, which causes the heart muscle fibers to contract more efficiently, producing positive inotropic & negative chronotropic action y Indications use for CHF, atrial tachycardia and fibrillationy

Cardiac GlycosidesPrototype digoxin (Lanoxin) and digitoxin (Crystodigin) Nursing considerations : 1. Monitor for toxicity as evidence by : nausea, vomiting, anorexia, halo vision, confusion, bradycardia and heart blocks. 2. Do not administer if pulse is less than 60 bpm. 3. Should be caution in patient with hypothyroidism and hypokalemia. 4. Antidote : Digi-bind 5. Phenytoin is the drug of choice to manage digitalis-induced arrhythmiay

NitratesMechanism of action produce vasodilatation including coronary artery y Indication angina pectoris, MI, peripheral arterial occlusive disease y Prototype isosorbide dinitrate (Isordil), nitroglycerine (Deponit, Nitrostat) y Adverse effects headache orthostatic hypotensiony

NitratesNursing Considerations : 1. Transdermal patch y - apply the patch to a hairless area using a new patch and different site each day. y - remove the patch after 12-24 hours, allowing 10-12 hours patch free each day to prevent tolerance. 2. Sublingual medications y - note the BP before giving the medication. y - offer sips of water before giving because dryness may inhibit absorption. y - one tablet for pain and repeat every 5 mins. for a total of three doses; if not relieved after 15 mins., seek medical help. y - stinging or burning sensation indicates that the tablet is fresh. y - instruct patient not to swallow the pill y - sustained release medications should be swallowed and not to be crush. y - protect the pills from light.

AntiAnti-arrhythmicsClass I (block Na channels) IA - quinidine, procainamide IB - lidocaine IC - flecainamide y Class II (Beta-blockers) propanolol, esmolol y Class III (block K channels) amiodarone, bretylium y Class IV (block Ca channels) verapramil, diltiazemy

AntiAnti-arrhythmicsNursing considerations : 1. Watch out for signs of CHF. 2. Have client weigh themselves and report weight gain. 3. Watch out for signs of lidocaine toxicity : - confusion and restlessness

AntilipemicsMechanism of action interfere with cholesterol synthesis as well as decreasing lipoprotein & triglyceride synthesis Prototype : y cholesterol-lowering agents cholestyramine, colestipol, lovastatin, atorvastatin (Lipitor) y triglyceride-lowering agents gemfibrozil, clofibratey

AntilipemicsNursing considerations : y - monitor liver functions while using statins. y - prevent constipation, flatulence, cholelithiasis y - encourage increase fluid and fiber intake.

ACE InhibitorsMechanism of action prevent peripheral vasoconstriction by blocking conversion of angiotensin I to angiotensin II decreasing peripheral resistance y Prototype captopril (Capoten), enalapril (Vasotec), quinapril, lisinopril y Adverse effects it cause hyperkalemia, induce chronic coughy

ACE InhibitorsNursing considerations : y - not to discontinue medications because it can cause rebound hypertension. y - avoid using K+ sparing diuretics.

CalciumCalcium-Channel BlockersMechanism of action decrease cardiac contractility and the workload of the heart, thus decreasing the need for O2, it also promotes vasodilatation of the coronary and peripheral vessels y Indications hypertension, angina, arrhythmiay

CalciumCalcium-Channel BlockersPrototype Nifedipine (calcibloc, adalat), Amlodipine (norvasc), Felodipine (Plendil), Verapramil (Isoptin) y Adverse Effects bradycardia, hypotension, headache, reflex tachycardia, constipationy

CalciumCalcium-Channel BlockersNursing considerations : y - Administer between meals to enhance absorption. y - Take clients pulse rate before each dose, withhold if pulse is below 60 bpm. y - Refer for signs of congestive heart failure.

DiureticsCARBONIC ANHYDRASE INHIBITORS y - Acetazolimide (Diamox) y - increase Na+, K+, & HCO3 secretion, along with it is H2O y - metabolic acidosis OSMOTIC DIURETIC y - Mannitol y - Increase osmotic pressure of the glomerular filtrate. y - hypotension THIAZIDE DIURETICS y - hydrochlorothiazide - blocks Na and K reabsorption; reabsorb Ca y - hypercalcemia LOOP DIURETICS y - Furosemide (Lasix) y - blocks Na, K, and Ca reabsorption y - hypocalcemia POTASSIUM SPARING DIURETICS y - Spironolactone (Aldactone) y - excrete Na and water but it reabsorb K y - hyperkalemiay

RespiratoryBronchodilators y Glucocorticoids y Mast Cell Stabilizers y Antihistamines (H1) y Anti-TB y Decongestants, Antitussives, & Expectorantsy

Bronchodilators2 Types: 1. Symphatomimetic albuterol, salbutamol, isoproterenol, salmeterol, terbutaline 2. Xanthines aminophylline, theophylline

BronchodilatorsMechanism of actions: y - sympathomimetic (b-receptor agonist) bronchodilators dilate airways y - xanthine bronchodilators stimulate CNS for respiration Indications bronchospasm, asthma, bronchitis, COPD

BronchodilatorsAdverse effects palpitations and tachycardia, restlessness, nervousness, tremors, anorexia, nausea and vomiting, headache, dizziness Nursing considerations : y - Contraindicated hyperthyroidism, cardiac dysrhythmia, or uncontrolled seizure disorder y - Should be used with caution in patient with HPN and narrow-angle glaucomay

GlucocorticoidsMechanism of action act as antiinflammatory agents and reduce edema of the airways, as well as pulmonary edema y Prototype dexamethasone, budesonide, fluticasone, prednisone, beclomethasone y Adverse effects Cushings syndrome, neutropenia, osteoporosisy

GlucocorticoidsNursing considerations : y - Take drugs at meal time or with food. y - Eat foods high in potassium, low in sodium. y - Instruct client to avoid individuals with RTI. y - Instruct client not to stop medication abruptly, it should be tapered to prevent adrenal insufficiency y - Avoid taking NSAID while taking steroids. y - Take inhaled bronchodilators first before taking inhaled steroids, and rinse mouth after using.

Mast Cell StabilizersMechanism of action stabilize mast cells that release histamine triggering asthmatic attacks y Prototype cromolyn sodium (Intal) Nursing Consideration: y - Should be given before asthmatic attacks. y - Administer oral capsule at least 30 mins before meals for better absorption. y - Drink a few sips of water before & after inhalation to prevent cough & unpleasant taste y - Assess for lactose-intolerancey

H1 BlockersMechanism of action decrease nasopharyngeal secretions and decrease nasal itching by blocking histamine in H1receptor y Indications common colds, rhinitis, nausea and vomiting, urticaria, allergies and as sleep aidy

H1 BlockersPrototype - Astemizole (Hismanal), Loratidine (Claritin), Brompheniramine (Dimetapp), Diphenhydramine (Benadryl), Cetirizine (Iterax), Celestamine (Tavist) Nursing Considerations : y - Administer with food and drink. y - Given IM via Z-track method or orally. y - Precautions in handling machine and driving while taking these drugs. y - Ice chips or candy for dry mouthy

AntiAnti-TBFirst Line: y Rifampicin y Isoniazid y Pyrazinamide y Ethambutol y Streptomyciny

Second Line: y Cycloserine y Kanamycin y Ethonamide y Para-aminosalicylic Acidy

AntiAnti-TB- active tuberculosis are treated with drug combination for 6-9 mos. y - multidrug-resistant strain (MDR-TB) are medicated for 1 year up to 2 years y - given before mealsy

Rifampicin- given on an empty stomach with 8 0z. of water, 1 hour before or 2 hours after meals and avoid taking antacids with medications. y - hepatotoxic thus avoid alcohol. y - instruct the client that urine, feces, sweat, and tears will be redorange in color.y

Isoniazidy y y

y y

- should be given 1 hr before or 2 hrs after meals because food may delay absorption. - should be given at least 1 hr before antacids. - instruct to notify physician for signs of hepatoxicity (jaundice), and neurotoxicity, numbness of extremities. - administer with Vitamin B6 to counteract the neurotoxic side effects. - avoid alcohol.

Pyrazinamide- given for 2 months. y - increase serum uric acid and cause photosensitivity.y

Ethambutol- contraindicated in children under 13 years old. y - obtain a baseline visual acuity because it can cause optic neuritis. y - Instruct the client to notify the physician immediately if any visual problems occurs.y

Streptomycin- aminoglycoside antibiotic given IM. y - nephrotoxic and ototoxic. y - obtain baseline audiometric test and repeat every 1-2 months because the medications impairs the CN VIII.y

Cough & Cold Remedies3 Types: 1. Decongestants 2. Antitussives 3. Expectorants

DecongestantsMechanism of action acts through sympathomimetic action, usually by constricting arterioles & reducing blood flow to the area y Prototype phenylephriney

AntitussivesMechanism of action suppresses the cough center in the medulla y Prototype dextromethorpany

ExpectorantMechanism of action facilitate the secretion of fluid in the respiratory tract, thus liquefying secretions and allowing for easier expectoration during a cough y Prototype guaifenesin (Robitussin)y

GastrointestinalAntacids y H2 Blockers y Proton-Pump Inhibitors y Mucosal Barriers y Anti-diarrheals y Laxatives y Emetics y Antiemeticsy

AntacidsMechanism of action neutralize the stomach acidity y Prototype aluminum/magnesium compounds (Maalox), sodium bicarbonate (Alka-Seltzer), calcium carbonate (Tums), magnesium hydroxide (Milk of Magnesia)y

Antacidsy

Adverse effects - metabolic alkalosis, stone formation, electrolyte imbalance, diarrhea (magnesium), constipation (aluminum)

AntacidsNursing considerations : y - Give 1 hr after meals. y - Avoid giving medications within 1-2 hrs of antacid administration (decreases absorption). y - Take fluids to flush after intake of antacid suspensions. y - Monitor for changes of bowel patterns.

H2 BlockersMechanism of action - blocks H2 receptors in the stomach, reducing acid secretions y Prototype cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid)y

H2 BlockersNursing considerations : y - Given before or with meals y - Avoid giving other drugs with cimetidine y - Gynecomastia may develop with chronic use of cimetidine

ProtonProton-Pump InhibitorsMechanism of action inhibit the proton H+ to combine with Cl- to form hydrochloric acid y Prototype omeprazole (Losec), Lansoprazole (Lanz), pantoprazole (Pantoloc) Nursing considerations : y - Given before meals preferably at morning.y

Mucosal BarriersMechanism of action - coats the mucosa to prevent ulcerations y Prototype - sucralfate (Carafate), misoprostol (Cytotec) Nursing consideration : y - Given before meals. y - Misoprostol is contraindicated for pregnants. y - Sucralfate cause constipation.y

AntiAnti-diarrhealsMechanism of action decreases stomach motility and peristalsis y Prototype diphenoxylate (Lomotil), loperamide (Imodium), kaolin/pectin mixture (Kaopectate)y

AntiAnti-diarrhealsNursing considerations : y - Monitor for rebound constipation. y - Be cautious taking if with infectious diarrhea. y - Monitor atropine toxicity with diphenoxylate. y - Clay, white or pale stool is common with kaopectate.

Laxativesa.

lactulose (Cephulac), Na biphosphate (Fleet enema) & magnesium salt (Milk of Magnesia)x - retain fluid and distend intestine

b. c.

ducosate (Dialose)x - emulsify fecal fat and water

bisacodyl (Dulcolax) & senna (X-prep)x - irritates intestinal mucosa and stimulate intestinal smooth muscles

d. e.

bulk-forming laxative (Metamucil)x - increase fecal bulk and water content

mineral oilx - lubricates & prevent colon absorption

EmeticsMechanism of action induce vomiting through stimulation of vomiting center of medulla y Indications ingestion of poisonous or toxic substances y Prototype - ipecac syrup, apomorphiney

EmeticsNursing considerations : y - Consult poison control center before induction of vomiting. y - Administer ipecac syrup with large amount of fluid.

AntiemeticsMechanism of action inhibit the vomiting reflex y Prototype metoclopramide (Plasil)y

EndocrineThyroid Agents y Parathyroid Agents y Oral Hypoglycemic Agents y Insulin y Estrogen/Progesteroney

Thyroid AgentsMechanism of action function as natural or synthetic hormones y Prototype Proloid (thryroglobulin ), Synthroid (levothyroxine), Cytomel ( liothyronine)y

Thyroid AgentsNursing considerations : y - Taken in the morning. y - Caution with coronary artery disease. y - Monitor for signs of hyperthyroidism and refer for decreasing the dose.

Parathyroid AgentsMechanism of action reduce bone resorption, promotes calcium absorption y Prototype calcitonin (Calcimar), etidronate (Didronel), calcitrol (Rocaltrol), calcifediol (Calcedrol) Nursing considerations : y - Monitor signs of calcium imbalance y - Report for bone pains. y - Remain sitting upright after taking etidronatey

Oral HypoglycemicsSulfonylureas y Biguanides y Alpha-glucosidase Inhibitors y Thiazolinidine y Meglitinidinesy

Sulfonylureas- stimulate insulin secretions and increase tissue sensitivity to insulin. First Generation : y Chlorpropamide (Diabenese) disulfiram precautions y Tolbutamide (Orinase) congenital defect Second Generation : y Glypizide, Glymepiridey

Biguanidesy

- facilitates insulin action on the peripheral receptor site. Metformin and Glucophage (Glucovance) side effect is lactic acidosis

AlphaAlpha-glucosidase Inhibitorsy

- delay carbohydrate absorption in the intestinal system. Acarbose (Precose) side effect is diarrhea

Thiazolinidiney

- increase tissue sensitivity of insulin. Rosiglitazone (Avandia)

Meglitinidinesy

- stimulate insulin release in pancreatic Bcells. Repaglinide (Prandin)

InsulinInsulin Immediate-acting (lispro) Short-acting (regular, semilente) Intermediateacting (NPH, Lente) Long-acting (ultralente) Mixed (reg. 30%, NPH 70%) Onset - -1 Peak -1 24 Duration 3 68

12

6 12

18 24

24

10 30 48

24 36 25

InsulinNursing considerations : y - Usually given before meals. y - Roll the bottle in palm of hands, dont shake. y - Inject amount of air that is equal to each dose into the bottle short acting last (clear). y - Aspirate short acting first, then long or intermediate (cloudy). y - Alcohol is recommended for cleansing bottle but not with skin. y - Pinch skin, avoid I.M, dont aspirate. y - Rotate the injection site an inch a part. y - Prefilled syringes are stored vertically, needle-up. y - May increase dose during illnesses. y - Used bottles stored in room temperature, unused bottle stored in refrigerator. y - Monitor for acute hypoglycemia : a. 3-4 commercially prepared glucose tablet b. 4-6 ounce of fruit juice or regular soda c. 2-3 teaspoon or honey d. Glucagon 1 gm SQ or IM e. D50-50 IV.

Estrogens & ProgesteronesPrototype conjugated estrogen (Premarin), estrone (Bestrone), estradiol (Estrace), diethylstilbestrol (DES) y Indications prostate cancer, contraceptions, estrogen replacement Adverse effects : estrogen - endometrial CA, gallbladder disease, HPN, migraine, breast tenderness progesterone - altered menstrual flow, risk of thrombo embolismy

Estrogens & ProgesteronesNursing considerations : 1. Mix estrogen or progestins prior to IM administration by rolling vials between palms. 2. Monitor blood pressure. 3. Teach patient how to perform BSE. 4. Regular follow-up examination is required to detect associated risk of acquiring CA.

GynecologicUterine Stimulating Agents y Uterine Inhibiting Agents y Lactation Suppressantsy

Uterine Stimulating AgentsMechanism of action stimulates uterine smooth muscles, ripening of cervix y Prototype Oxytocin (Pitocin), ergonovine (Ergotrate), methylergonovine (methergine), carbopost (Prostin), dinoprostone (Prostin E2) Adverse reactions : y - fetal bradycardia (oxytocin), y - hypertension (ergonovine), palpitations y - allergic reactions (Prostaglandins)y

Uterine Inhibiting Agents (Tocolytics) Tocolytics)Mechanism of action relaxes the uterus by stimulating the B2- adrenergic receptors y Prototype ritodrine (Yutopar), terbutaline (Brethine) y Adverse effects tremors, nausea, vomiting and tachycardiay

Lactation SuppressantsMechanism of action decrease serum prolactin levels y Prototype bromocriptine (Parlodel) y Adverse effects drowsiness, headache, nausea, palpitationsy