NAPLEX Review

NAPLEX Review
Prepared by a 2006 graduate. A must study document. I have done light editing to add some new
drugs and correct a few misspellings.
AIDS:
Initial treatment: NNRTI + 2 NRTIs or PI + 2 NRTIs
NRTIs:
a. MOA: interfere with HIV viral RNA-dependent DNA polymerase, resulting in chain termination
& inhibition of viral replication
b. Class toxicities:
i. Lactic acidosis, severe hepatomegaly with steatosis
ii. Most require renal dosing (except abacavir)
c. Do not use lamivudine & emtricitabine together (chemically similar)
d. Do not use zidovudine with stavudine together (both require thymidine for activation)
e. Do not use didanosine with stavudine during pregnancy (increased risk of lactic acidosis & liver
damage)
f. The “D” drugs cause pancreatitis & peripheral neuropathy & lactic acidosis
i. ddI (didanosine), d4T (stavudine), ddC (zalcitabine)
g. Low pill burden
h. All are prodrugs requiring 2-3 phosphorylations for activation
i. Zidovudine (Retrovir):
i. AZT, ZDV
ii. SE: bone marrow suppression, GI intolerance
iii. Dosage forms available: IV, 200 mg (10 mg/mL); syrup 50 mg/5 mL in 240 mL; capsule,
100 mg & tablet 300 mg
j. Lamivudine (Epivir):
i. 3TC
ii. Minimal toxicity
k. Abacavir (Ziagen):
i. ABC
ii. SE: hypersensitivity reaction that can be fatal with rechallenge
l. Didanosine (Videx, Videx EC):
i. ddI
ii. Take ½ hour before or 2 hours after meals (empty stomach)
iii. SE: pancreatitis, peripheral neuropathy
m. Stavudine (Zerit):
i. D4T
ii. SE: pancreatitis, peripheral neuropathy
n. Zalcitabine (Hivid):
i. ddC
ii. SE: pancreatitis, peripheral neuropathy
o. Tenofovir (Viread):
i. TDF
ii. SE: renal insufficiency, Fanconi syndrome
p. Emtricitabine (Emtriva):
i. FTC
ii. Minimal toxicity
q. Combination products:
i. Zidovudine 300 mg + lamivudine 150 mg (Combivir)
ii. Zidovudine 300 mg + lamivudine 150 mg + abacavir 300 mg (Trizivir)
iii. Tenofovir 300 mg + emtricitabine 200 mg (Truvada)
iv. Lamivudine 300 mg + abacavir 600 mg (Epzicom)
2. NNRTIs:
a. MOA: bind to reverse transcriptase at a different site than the NRTIs, resulting in inhibition of
HIV replication
b. Class toxicities: rash & hepatoxicity
c. All should be dosed for hepatic impairment
d. Most are affected by food (except efavirenz)
e. Efavirenz is CI in pregnancy
f. Efavirenz (Sustiva):
i. EFV
ii. Take on an empty stomach
iii. SE: CNS side effect; false + cannabinoid test
g. Nevirapine (Viramune):
i. NVP
ii. Autoinducer
iii. SE: rash, symptomatic hepatitis, including fatal hepatic necrosis
h. Delavirdine (Rescriptor):
i. DLV
ii. SE: rash, increased LFTs
3. PIs:
a. MOA: inhibit protease, which then prevents the cleavage of HIV polyproteins & subsequently
induces the formation of immature noninfectious viral particles
b. All should be dosed for hepatic impairment
c. Most should be taken with food (except amprenavir & indinavir)
d. Amprenavir & fosamprenavir are chemically similar- avoid combination
e. Atazanavir & indinavir require normal acid levels in stomach for absorption
f. Ritonavir is the most potent
g. Lopinavir/ritonavir, ritonavir, & saquinavir gel caps require refrigeration
h. Class toxicities: lipodystrophy, hyperglycemia, hyperlipidemia, hypertriglyceridemia, bleeding
in hemophiliace, osteonecrosis & avascular neocrosis of the hips, osteopenia & osteoporosis
i. All are CYP3A4 inhibitors
j. Lopinavir + ritonavir (Kaletra):
i. SE: GI intolerance
ii. Refrigerate caps stable until date on label; stable for 2 months at room temperature
iii. Can cause hyperglycemia
k. Atazanavir (Reyataz):
i. ATV
ii. SE: increased indirect hyperbilirubinemia, prolonged PR interval
l. Fosamprenavir (Lexiva):
i. f-APV
ii. SE: rash
iii. Sulfonamide
iv. Oral solution contains propylene glycol
m. Amprenavir (Agenerase):
i. APV
ii. SE: rash
iii. Sulfonamide
iv. Avoid high fat meal
n. Saquinavir:
i. SQV-hard gel cap (HGC)- (Invirase):
(1) SE: GI intolerance
(2) Room temperature
ii. SQV- soft gel cap (SGC)- (Fortovase):
(1) SE: GI intolerance
(2) Refrigerated caps stable until date on label; stable for 3 months at room temperature
iii. HGC & SGC are not bioequivalent & should not be interchanged
o. Nelfinavir (Viracept):
i. NFV
ii. SE: diarrhea
iii. Needs 500 kCal of food for absorption; take after eating
p. Ritonavir (Norvir)
i. RTV
ii. SE: GI intolerance
iii. Refrigerated caps stable for 1 month at room temp
q. Indinavir (Crixivan):
i. IDV
ii. SE: nephrolithiases- drink at least 48 oz. daily to prevent
iii. Take on an empty stomach
4. Fusion inhibitors:
a. MOA: binds to gp41 on HIV surface, which inhibits HIV binding to CD4 cell
b. Enfuvirtide (Fuzeon)
i. T20
ii. Salvage regimens
iii. Reconstituted form should be stored in the refrigerator- stable for 24 hours
5. Those available as suspensions: Nevirapine
6. Those available as a syrup or oral solution: Epivir, Ziagen, Videx, Kaletra, Agenerase, Viracept,
Norvir
7. Post-exposure Prophylaxis (PEP):
a. Start therapy within 1-2 hours of exposure
b. Length of therapy is 4 weeks
c. Treatment options:
i. AZT 200 mg po Q8h or 300 mg po Q12h AND 3TC(lamivudine) 150 mg po Q12h
ii. AZT 200 mg po Q8h or 300 mg po Q12 + 3TC 150 mg po Q12h + Indinavir 800 mg Q8h
(1) OR Nelfinvir 750 mg po Q8h or 1250 mg Q12h
8. PCP treatment:
a. A protozoan, but may be more closely related to fungi
b. Treat when CD4+ cells fall below 200
c. DOC: trimethoprim-sulfamethoxazole (Bactrim DS) DS po QD
d. Alternatives:
i. TMP + dapsone
ii. Atovaquone (Mepron)
iii. Pentamidine (NebuPent; Pentam-300)
(1) Comes as injection & powder for nebulization
iv. Clindamycin + primaquine
v. Trimetrexate (NeuTrexin) + folinic acid
e. Treatment for PCP also covers prophylaxis for: toxoplasmosis
9. Macobacterium avium complex (MAC):
a. Treat when CD4+ cells fall below 50/mm3
b. DOC is azithromycin 1200 mg po Q week
10. CMV: Cytomegalovirus
a. Ganciclovir (Cytovene, Vitrasert):
i. Use: treatment of CMV retinitis in immunocompromised individuals, including patients
with AIDS
ii. CI: ANC <500/mm3 or PLT <25,000/mm3
iii. Dosage forms:
(1) Capsule (Cytovene)
(2) Implant, intravitreal (Vitrasert)- 4.5 mg released gradually over 5-8 months
(3) Injection, powder for reconstitution
(a) Should be prepared in a vertical flow hood
(b) Reconstitute powder with sterile water NOT bacteriostatic water because parabens
may cause precipitation
Alzheimer’s Disease:
1. Donepezil (Aricept):
a. Cholinesterase inhibitor
b. MOA: reversibly & noncompetitively inhibits centrally active acetylcholinesterase, the enzyme
responsible for hydrolysis of acetylcholine
c. Available dosage forms: tablets, ODT
d. Max dose: 10 mg QD
2. Galantamine (Razadyne, Razadyne ER, Reminyl-old name):
a. Acetylcholinesterase inhibitor
b. Max dose:
i. IR tablet or solution: 24 mg/day (in 2 divided doses)
ii. ER capsule: 24 mg/day
3. Memantine (Namenda):
a. Low affinity, non-competitive, voltage dependent NMDA receptor antagonist
b. Neuroprotective
c. Less cognitive decline & improves cognition in impaired patients
d. After depolarization, Namenda leaves the site & allows sodium & calcium entry into the cell
e. Behaves like magnesium
f. Approved for moderate to severe Alzheimer’s Disease
4. Rivastigmine (Exelon):
a. Acetylcholinesterase inhibitor (central)
b. MOA: increases acetylcholine in the CNS through reversible inhibition of its hydrolysis by
cholinesterase
c. SE: GI upset (titrate slowly to avoid)
d. Dosage forms: capsules & solution
Anemia:
Folic acid deficiency would also be called: macrocytic anemia or increased mean corpuscular volume
5. Macrocytic (large cell):
a. Megaloblastic:
12 i. Vitamin B deficiency
(1) Lack of intrinsic factor results in pernicious anemia
ii. Folic acid deficiency dec Hct, Hgb, RBC, inc MCH; Normochromic, normocytic
b. Aplastic anemia
c. Anemia of chronic disease
6. Hypochromic (low hemoglobin content), microcytic (small cell):
a. Iron deficiency
i. Inc TIBC, dec MCV, MCH, MCHC, Hgb
b. Genetic anomalies: Sickle cell anemia, thalassemia
7. Treatment:
a. Darbepoetin Alpha (Aranesp):
i. Recombinant human erythropoietin
ii. Caution in patients with HTN or with a hx of seizures
(1) Can cause hypo- or hypertension
iii. Available as an injection
b. Epoetin Alpha (Epogen, Procrit):
i. Colony stimulating factor
ii. Onset of action: several days
iii. Peak effect: 2-3 weeks
iv. SQ 1-3X per week
v. SE: HTN
Antidotes:
1. Acetaminophen overdose:
a. Antidote: Acetylcysteine (Mucomyst, Acetadote):
i. MOA: thought to reverse APAP toxicity by providing substrate for conjugation with the toxic
metabolites
ii. Dose: oral- 140 mg/Kg followed by 17 doses of 70 mg/Kg Q4h; repeat dose if emesis occurs
within 1 hour of administration
2. Albuterol overdose:
a. Antidote: propranolol or beta blocker
3. Anticholinergic overdose:
a. Antidote: Physostigmine (Antilirium):
i. Do not use if solution is cloudy or dark brown
4. Arsenic overdose:
a. Antidote: Succimer (Chemet) or dimercaprol (British anti-lewisite, BAL in oil)
5. Benzodiazepine overdose:
a. Antidote: flumazenil (Romazicon)
b. â -blocker overdose: beta-stimulant (Isoproterenol) and glucagon (GlucaGen)
6. CCB overdose:
a. Antidote: calcium chloride 10% or glucagon (GlucaGen)
7. Carbamates overdose:
a. Antidote: atropine
8. Coumadin overdose:
1 a. Antidote: Vitamin K or phytonadione (Mephyton, AquaMEPHYTON); fresh frozen plasma
b. Dosage forms available for phytonadione: injection & tablet
9. Digoxin overdose:
a. Antidote: digoxin immune antibody fragment (Digibind, DigiFab)
10. Ethylene glycol (Antifreeze) overdose:
a. Antidote: ethyl alcohol; fomepizole (Antizol); pyridoxine (Aminoxin-OTC); sodium bicarbonate
11. Heparin overdose:
a. Antidote: protamine sulfate
12. Iron overdose:
a. Antidote: deferoxamine (Desferal)
b. Antidote: Polyethylene glycol (high molecular weight)
c. Lethal dose of iron is 180-300 mg/Kg
13. Isoniazid overdose:
6 a. Antidote: pyridoxine (Vitamin B )
14. Lead overdose:
a. Antidotes:
i. Succimer (Chemet)
ii. Dimercaprol; also called British anti-lewisite (only for lead encephalopathy)
iii. Calcium disodium EDTA (calcium disodium versenate)
15. Leucovorin:
a. Antidote for folic acid antagonists (methotrexate, trimethoprim, pyrimethamine)
b. Water soluble vitamin
16. Magnesium overdose:
a. Death due to muscle relaxation (includes heart failure)
b. Antidote: calcium
17. Methanol or Ethylene glycol overdose:
a. Antidote: Ethanol 10%
b. Antidote: Fomepizole (Antizol)
i. AKA: 4-methylpyrazole or 4-MP
ii. MOA: competitively inhibits alcohol dehydrogenase, an enzyme which catalyzes the
metabolism of ethanol, ethylene glycol, & methanol to their toxic metabolites
iii. ?Decreases metabolism of methanol (prevents metabolism)
18. Methemoglobinemia overdose:
a. Antidote: methylene blue
19. Opioid overdose:
a. Antidote: Naloxone (Narcan)
i. MOA: opioid antagonist that competes at all three CNS opioid receptors (mu, kappa, delta)
b. Antidote: Nalmefene (Revex)
20. Organophosphates overdose:
a. Antidote: atropine or pralidoxime (Protopam)
21. Salicylate overdose:
a. Antidote: sodium bicarbonate
22. TCAs overdose:
a. Antidote: sodium bicarbonate
23. Type Ia antiarrhythmics overdose:
a. Antidote: sodium bicarbonate
24. Vecuronium overdose: and other nondepolarizing neuromuscular blockers
a. Antidote: edrophonium (Enlon, Reversol)
Asthma:
1. Drugs available for nebulization:
a. Budesonide 0.25 & 0.5 mg (Pulmicort Respules®)
i. Shake well before using
ii. Use with jet nebulizer connected to an air compressor
iii. Administer with a mouthpiece or facemask
iv. Do not use with an ultrasonic nebulizer
v. Do not mix with other medications
vi. Rinse mouth after use
b. Cromolyn (Intal®)
i. Mast cell stabilizer
ii. Use: adjunct in the prophylaxis of allergic disorders, including asthma; prevention of
exercise-induced bronchospasm
(1) Nasal: for prevention & treatment of seasonal & perennial allergic rhinitis
c. Albuterol
d. Ipratropium
e. Ipratropium & Albuterol
2. Drugs available as MDI:
a. Beclomethasone HFA 40 mcg/puff & 80 mcg/puff (QVAR®)
b. Flunisolide 250 mcg/puff (Aerobid®)
c. Fluticasone 44, 110, 220 mcg/puff (Flovent®)
d. Cromolyn (Intal®)
e. Nedocromil (Tilade®)
f. Albuterol (Proventil®, Ventolin®)
g. Pirbuterol (Maxair Autohaler®)
h. Ipratropium (Atrovent®)
i. Ipratropium & Albuterol (Combivent®)
3. Drugs available as turbuhaler:
a. Budesonide 200 mcg/inhalation (Pulmicort® Respules)
i. Inhaler should be shaken well immediately prior to use
4. Drugs available for dry powder inhalation (DPI):
a. Fluticasone (Flovent Rotadisk®)
b. Fluticasone-salmeterol (Advair Diskus®)
c. Formoterol (Foradil Aerolizer®)
d. Salmeterol (Servent Diskus®)
i. Stable for 6 weeks after removing foil
ii. 1 inhalation BID
5. Drugs available as MDI/spacer:
a. Triamcinolone 100 mcg/puff (Azmacort®)
6. Class of drugs to use to prevent a child allergic to pollen from having an asthma attack- could use
antihistamines, cromolyn or inhaled corticosteroids
1 7. A patient would monitor their asthma from home with a peak flow meter which measures the FEV
a. Goal: 80% of personal best
b. Green zone (80-100%), yellow zone (50-79%), & red zone (<50%)
8. Montelukast (Singulair):
a. MOA: selective leukotriene receptor antagonist that inhibits the cysteinyl leukotriene receptor
b. Use: asthma & allergies
i. NOT for COPD
c. Dosing;
i. 6-23 months: 4 mg oral granules
ii. 2-5 years: 4 mg chewable tablet or oral granules
iii. 6-14 years: 5 mg chewable tablet
iv. >15 years: 10 mg tablet
v. Take in evening
d. Granules must be used within 15 minutes of opening
9. Zafirlukast (Accolate):
a. MOA: selectively & competitive leukotriene-receptor antagonist of leukotriene D4 & E4
b. Use: prophylaxis & chronic treatment of asthma in adults & children >5 years old
c. Dose: 20 mg BID
d. Administer 1 hour before or 2 hours after meals
e. Monitor: LFTs
f. Extensively hepatically metabolized via CYP2C9
g. Tablets only
10. Theophylline:
a. 0.80 Aminophylline x 0.8 = Theophylline
b. SE:
i. 15-25 mcg/mL: GI upset, N/V/D, nervousness, headache, insomnia, agitation, dizziness,
muscle cramp, tremor
ii. 25-35 mcg/mL: tachycardia, occasional PVC
iii. > 35 mcg/mL: ventricular tachycardia, frequent PVC, seizure
c. Theophylline + erythromycinà increased levels of theophylline
d. DI with cimetidine
11. A patient who has had too much albuterol could be given a cardioselective beta blocker
Bioterrism:
1. Ebola: virus; no cure
2. Anthrax: bacteria (aerobic, gram + bacillus); ciprofloxacin or doxycycline for 60 days
Benign Prostatic Hypertrophy (BPH):
1. Tamulosin (Flomax) & Alfuzosin (Uroxatrac):
a. Greater affinity to alpha-1 in prostate
b. Less SE
c. Work quickly for instant relief
2. Finasteride (Proscar/Propecia) & Dutasteride (Avodart):
a. Great for a large prostate
b. Take longer to work
c. Proscar MOA: a competitive inhibitor or both tissue & hepatic 5-alpha reductace; this results
in the inhibition of the conversion of testosterone to dihydrotestosterone & markedly suppresses
serum dihydrotestosterone levels
3. Doxazosin (Cardura) & terazosin (Hytrin) also used for BPH
4. Saw palmetto – advertised but has failed in good clinical trials
Cancer:
1. Chemo drugs that should be refrigerated: cyclophosphamide (after reconstitution)
2. Antimetabolites:
a. Pyrimidine analogs: interfere with the synthesis of pyrimidine bases & thus DNA synthesis
i. Can cause mucositis
ii. Capecitabine (Xeloda)
iii. Fluorouracil; 5-FU (Adrucil)
iv. Cytarabine (Cytosar)
v. Gemcitabine (Gemzar)
vi. AE: mucositis
b. Folic acid analog: interferes with synthesis of pyrimidine bases & thus DNA synthesis
i. Methotrexate
(1) After reconstitution with preservative: may refrigerate
(2) AE: myleosuppression, N/V, mucositis
c. Purine analogs: interfere with synthesis of purine bases & thus DNA synthesis
i. Mercaptopurine (Purinethol)
(1) DI with allopurinol
ii. Thioguanine (Tabloid)
iii. Fludarabine (Fludara)
iv. Cladribine (Leustatin)
v. Pentostatin (Nipent)
3. Plant alkaloids:
a. Vinca alkaloids: bind to tubulin to prevent formation of microtubules during mitosis
i. Fatal if administered intrathecally
ii. Vincristine (Oncovin):
(1) Neurotoxic
(2) Can cause a decrease in sensation reflexes
iii. Vinblastine (Velban)
iv. Vinorelbine (Navelbine)
v. AE: neuropathy
b. Podophyllotoxins: bind to tubulin, inhibiting topoisomerase II to cause DNA strand breaks
i. Etoposide; VP-16 (VePesid)
ii. Teniposide (Vumon)
iii. AE: myelosuppression, neuropathy
c. Taxanes: bind to tubulin, promotes synthesis of nonfunctional microtubules
i. Paclitaxel (Taxol)
(1) Use a in-line filter; non-PVC
ii. Docetaxel (Taxotere)
iii. AE: myelosuppression, alopecia
d. Camptothecins: inhibits topoisomerase I, stabilizing single-strand breaks in DNA
i. Irinotecan (Camptosar)- *Diarrhea*
ii. Topotecan (Hycamtin)
iii. AE: myelosuppression, alopecia
4. Alkylating Agents: cross-link between DNA bases or between DNA strands to inhibit DNA replication
a. Nitrogen Mustard Derivative:
i. Mechlorethamine (Mustargen)
ii. Melphalan (Alkeran)
iii. Chlorambucil (Leukeran)
iv. Cyclophosphamide (Cytoxan)
v. Ifosfamide (Ifex)
vi. AE: myelosuppression
vii. Mesna is given with cyclophosphamide & ifosfamide to prevent hemorrhagic cystitis
b. Other:
i. Carmustine (BiCNU)
ii. Lomustine (CeeNU)
iii. Stretozocin (Zanosar)
iv. Thiotepa (Thiopex)
v. Busulfan (Myleran)
vi. Dacarbazine (DTIC)
5. Antitumor antibiotics:
a. Anthracycline:
i. Cardiotoxic: 450-550 mg/m2 cumulative lifetime dose
ii. Doxorubicin (Adriamycin):
(1) MOA: appears to directly bind to DNA & inhibit DNA repair (via topoisomerase II
inhibition) resulting in the blockade of DNA & RNA synthesis & fragmentation of DNA
(2) Turns urine & all other body fluids red
(3) SE: myelosupression, cardiotoxicity, extravasation
(4) Decrease dose in renal impairment
iii. Daunorubicin (Cerubidine)
iv. Idarubicin (Idamycin)
v. Mitoxantrone (Novantrone)
vi. AE: myelosuppression
b. Other:
i. Mitomycin C (Mutamycin)
ii. Bleomycin (Blenoxane)
6. Heavy Metals:
a. Cisplatin (Platinol)
b. Carboplatin (Paraplatin)
c. Oxaliplatin (Eloxatin)
d. AE: myelosuppression, neuropathy
7. Antiandrogens: inhibit uptake & binding of testosterone & dihydrotestosterone in prostatic tissue
a. Flutamide (Eulexin)
b. Bicalutamide (Casodex)
c. Nilutamide (Nilandron)
d. AE: diarrhea
8. Progestins: suppress release of LH & increase estrogen metabolism (decrease available estrogen for
estrogen-dependent tumors)
a. Megestrol (Megase): also used to stimulate appetite
b. Medroxyprogesterone (Provera)
9. Estrogens: estramustine is combination of estrogen plus nitrogen mustard; estrogen facilitates
uptake, nitrogen mustard released to alkylate cancer cells
a. Estramustine (Emcyt)
10. Antiestrogens: bind to estrogen receptor in breast tissue, preventing binding by estrogen & thereby
reducing estrogen-stimulated tumor growth
a. Tamoxifen (Nolvadex): can cause bone pain
b. Toremifine (Fareston)
11. Gonadotropin-releasing hormone analogs: turn off negative-feedback release of FSH & LH, reducing
testosterone & estrogen production in testes & ovaries
a. Leuprolide (Lupron (breast/prostate); Eligard (prostate); Viadur (prostate))
i. MOA: potent inhibitor of gonadotropin secretion; continuous daily administration results
in suppression of ovarian & testicular steroidogenesis due to decreased levels of FSH & LH
with subsequent decreases in testosterone & estrogen levels
b. Goserelin (Zoladex)
12. Aromatase inhibitors: blocks enzyme responsible for conversion of circulating androgens to
estrogens
a. Anastrazole (Arimidex):
i. For breast cancer
ii. Can increase LDL
iii. Cannot use with Tamoxifen
iv. AE: vasodilation, headache, pain, depression, hot flashes, HTN, osteoporosis
b. Letrozole (Femara)
c. AE: diarrhea
13. Other miscellaneous agents for cancer:
a. Asparaginase (Elspar)
b. Hydroxyurea (Hydrea)
c. Tyrosine kinase inhibitors:
i. Imatinib mesylate (Gleevec)
ii. Erlotinib (Tarceva)
iii. Gefitinib (Iressa)
d. 26S Proteasome inhibitor:
i. Bortezomib (Velcade)
e. Biological Response Modifiers
i. Immune therapies:
(1) Aldesleukin (Proleukin)
(2) Interferon-alpha 2b (Intron A)
(3) Levamisole (Ergamisol)
f. Monoclonal antibodies:
i. Rituximab (Rituxan)
ii. Trastuzumab (Herceptin): works at HER-2 receptor
iii. Gemtuzumab (Mylotarg)
iv. Alemtuzumab (Campath)
v. Bevacizumab (Avastin)
vi. Cetuximab (Erbitux)
vii. Denileukin diftitox (Ontak)
viii. Ibritumomab tiuxetan (Zevalin)
ix. Tositumomab (Bexxar)
14. Colony Stimulating Factors:
a. Filgastrim (Neupogen):
i. MOA: granulocyte colony stimulating factor (G-CSF); stimulation of granulocyte production
in patients with malignancies
ii. Increases production of neutrophils
iii. Does not cause agraulocytosis—used to treat it
iv. SE: bone pain
v. Store in refrigerator
vi. Injection
b. Pegfilgrastim (Neulasta):
i. MOA: stimulates the production, maturation, & activation of neutrophils; activates
neutrophils to increase both their migration & cytotoxicity
ii. Prolonged duration of effect relative to filgastrim & reduced renal clearance
iii. Store in refrigerator
iv. SE: bone pain
v. Injection
15. Octreotide (Sandostatin):
a. Somatostatin analog
b. Use: antidarrheal agent for diarrhea secondary to cancer
c. MOA: mimics natural somatostatin by inhibiting serotonin release, & the secretion of gastrin,
VIP, insulin, glucagons, secretin, motilin & pancreatic polypeptide
d. Dosage forms available: injection only
16. High emetic potential:
a. Cisplatin, cyclophosphamide, cytarabine, dacarbazine, ifosfamide, melphalan, mitomycin,
mechlorethamine
17. Prevention of Acute Chemotherapy-Induced N/V:
3 a. 5-HT receptor antagonist:
i. Dolasetron (Anzemet)
ii. Granisetron (Kytril)
iii. Ondansetron (Zofran)
iv. Palonosetron (Aloxi)
b. Phenothiazines:
i. Prochlorperazine (Compazine)
ii. Chlorpromazine (Thorazine)
iii. Promethazine (Phenergan)
c. Butyrophenones:
i. Droperidol (Inapsine)
ii. Haloperidol (Haldol)
d. Corticosteroids:
i. Dexamethasone (Decadron)
e. Cannabinoids:
i. Dronabinol (Marinol)
f. Benzodiazepines:
i. Lorazepam (Ativan)
g. Benzamides:
i. Metoclopramide (Reglan)
h. Neurokinin-1 Antagonist:
i. Aprepitant (Emend):
(1) Substance P/neurokinin 1 receptor antagonist
(2) Uses: prevention of acute & delayed N/V associated with highly-emetogenic
3 chemotherapy in combination with a corticosteroid (i.e. dexamethasone) & 5-HT
(ondansetron) receptor antagonist
(3) Avoid with grapefruit juice (CYP3A4)
(4) MOA: prevents acute & delayed vomiting by selectively inhibiting the substance
1 P/neurokinin 1 (NK ) receptor
(5) Dose: oral: 125 mg on day 1, followed by 80 mg on days 2 & 3
(a) 1st dose should be given 1 hour prior to chemotherapy
Cardiology:
1. Angiotensin Converting Enzyme Inhibitors (ACEIs):
a. Benazepril (Lotensin)
b. Captopril (Capoten):
i. Used to decrease the progression of CHF
ii. SE: rash, hyperkalemia, angioedema, cough
iii. Strengths:
(1) Tablets: 12.5, 25, 50, & 100 mg
iv. Dosed BID-TID
c. Enalapril (Vasotec):
i. Enalaprilat (Vasotec): only ACEI available as IV
(1) 1.25 mg/dose given over 5 minutes Q6 hours
ii. 40 mg/day max dose
d. Fosinopril (Monopril)
e. Lisinopril (Prinvil, Zestril)
f. Moexipril (Univasc)
g. Perindopril (Aceon)
h. Quinapril (Accupril)
i. Ramipril (Altace)
j. Trandolapril (Mavik)
k. Proven to decrease mortality in CHF
l. Ineffective as monotherapy in African Americans
m. MOA: inhibit the conversion of angiotensin I to angiotensin II (a potent vasoconstrictor)
n. SE: increased SCr, cough, angioedema, sexual dysfunction, hyperkalemia, rash
o. CI: bilateral renal artery stenosis; pregnancy
p. DI: aspirin (high doses); rifampin; antacids (more likely with captopril- separate administration
by 1-2 hours); NSAIDS; probenecid (captopril); lithium; allopurinol
2. Alpha agonists:
a. MOA: causes decreased sympathetic outflow to the cardiovascular system by agonistic activity
on central á-2 receptors
b. Clonidine (Catapres)
i. More withdrawal
ii. Unlabeled use: heroin or nicotine withdrawal
c. Guanabenz (Wytensin)
d. Guanfacine (Tenex)
i. Less withdrawal
e. Methyldopa (Aldomet)
f. SE: sedation, dry mouth, bradycardia, withdrawal HTN, orthostatic hypotension, depression,
impotence, sleep disturbances
3. Alpha blockers:
a. MOA: blocks peripheral á-1 postsynaptic receptors, which causes vasodilation of both arteries
& veins (indirect vasodilators)
b. Causes less reflex tachycardia than direct vasodilators (hydralazine/minoxidil)
c. Dosazosin (Cardura)
d. Prazosin (Minipress)
e. Terazosin (Hytrin)
f. Counseling: take 1st dose at bedtime, may cause dizziness
g. SE: weight gain, peripheral edema, dry mouth, urinary urgency, constipation, priapism,
postural hypotension
i. No effects on glucose or cholesterol
4. Anti-arrhythmic Drugs:
a. Arrhythmias:
i. A. Fib or flutter: DOC- digitalis glycoside; alternative- verapamil or propranolol
ii. Supraventricular tachycardia: DOC- verapamil or adenosine; alternative- diltiazam or
procainamide
iii. Ventricular premature complexes: DOC- beta blocker; alternative- beta blocker
iv. Ventricular tachycardia: DOC- beta blocker; alternative- amiodarone
v. Ventricular fibrillation: DOC- amiodarone; alternative- beta blocker
vi. Digoxin-induced tachyarrhythmia: DOC- lidocaine; alternative- phenytoin
vii. Torsades de pointes: DOC- magnesium; alternative- beta blocker
viii. Class IA: inhibit fast Na channels
(1) Quinidine
(a) SE: Cinchonism
(2) Procainamide (Pronestyl)
(a) SE: lupus-like syndrome
(3) Disopyramide (Norpace)
ix. Class IB: inhibit fast Na channels
(1) Lidocaine (Xylocaine):
(2) Phenytoin (Dilantin)
(a) SE: nystagmus
(3) Tocainide (Tonocard)
(4) Mexiletine (Mexitil)
x. Class IC: inhibit fast Na channels
(1) Moricizine (Ethmozine)
(2) Flecainide (Tambocor)
(3) Propafenone (Rhythmol)
xi. Class II: beta-adrenergic agents
(1) Propranolol (Inderal)
(2) Esmolol (Brevibloc)
(3) Acebutolol (Sectral)
xii. Class III: primarily block K channels
(1) Bretylium (Bretylol)
(2) Amiodarone (Cordarone®):
(a) SE:
(i) IV: phlebitis
(ii) General: corneal microdeposits, photophobia, 8LFTs, photosensitivity, bluegray
skin discoloration, pulmonary fibrosis (reduced at low doses- 300 mg/d;
increases as dose increases), hyper- or hypothyroidism, polyneuropathy
(b) Watch for iodine allergy
(c) Avoid grapefruit juice
(d) Prior to use: check thyroid levels, eye exam
(3) Ibutilide (Corvert)
(4) Sotalol (Betapace)
(5) Dofetilide (Tikosyn)
(a) SE: torsades de pointes
xiii. Class IV: calcium channel antagonists
(1) Verapamil (Isoptin, Calan)
5. Anticoagulation:
a. Direct thrombin inhibitors:
i. Argatroban:
(1) A synthetic molecule that reversibly binds to thrombin
(2) Eliminated by the liver
(3) Use if renal impairment
ii. Lepirudin (Refludan):
(1) Recombinant DNA-derived polypeptide nearly identical to hirudin
(2) Produces an anticoagulant effect by binding directly to thrombin & does not require
AT to produce it effect
(3) Does not bind to other proteins as heparin does
(4) Eliminated by the kidneys
(5) Use if liver impairment
b. Enoxaparin (Lovenox):
i. Low molecular weight heparin
ii. MOA: inhibits factor Xa greater than IIa
iii. Dosing:
(1) DVT prophylaxis: 40 mg QD or 30 mg BID
(2) DVT treatment: 1 mg/Kg/dose Q12 hours or 1.5 mg/Kg/dose QD
iv. Monitor: anti-Xa, platelets
c. Heparin:
i. MOA: potentiates the action of antithrombin III & prevents the conversion of fibrinogen to
fibrin
ii. Dosing:
(1) DVT prophylaxis: 5000 units SQ Q8-12 hours
(2) IV infusion: 10-30 units/Kg/hr
(3) Line flushing: 10 units/mL for infants (<10 Kg); 100 units/mL for older infants,
children & adults
iii. Monitor: PTT (1.5-2X the upper limit of control; 50-70 sec), platelets
d. Warfarin (Coumadin, Jantoven)
i. MOA: inhibits reduction of vitamin K to its active form; leads to depletion of vitamin Kdependent
clotting factors II, Vii, IX, X & protein C & S
ii. Requires 4-5 days before full anticoagulation effect is achieved
iii. Recommended starting dose: 5 mg po QD
iv. Strengths/Dosage forms:
(1) Injection: 5 mg
(2) Tablets: 1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg
v. Most indications want an INR in the 2.0-3.0 range
(1) Mechanical valves require a higher level of anticoagulation (INR 2.5-3.5)
vi. Minor bleeding or elevated INR: hold warfarin dose or decrease dose until INR returns to
appropriate range
vii. Purple Toe Syndrome may occur due to cholesterol microembolization
e. Acetaminophen is usually a good antipyretic & analgesic choice for patients taking oral
anticoagulants
f. Risk factors for DVTs: >40 years old; prolonged immobility; major surgery involving the
abdomen, pelvis, & lower extremities; trauma, especially fractures of the hips, pelvis, & lower
extremities; malignancy; pregnancy; previous venous thromboembolism; CHF or
cardiomyopathy; stroke. Acute MI; indwelling central venous catheter; hypercoagulability;
estrogen therapy; varicose veins; obesity; IBD; nephrotic syndrome; myeloproliferative disease;
smoking
6. Antiplatelet Drugs:
a. Thienopyridines:
i. MOA: block adenosine diphosphate (ADP)-mediated activation of platelets by selectively &
irreversibly blocking ADP activation of the glycoprotein IIb/IIIa complex
ii. Clopidogrel (Plavix):
(1) Use: reduce atherosclerotic events (MI, stroke, vascular deaths)
(2) MOA: irreversibly blocks the ADP receptors, which prevents fibrinogen binding at that
site & thereby reducing the possibility of platelet adhesion & aggregation
(3) AE: chest pain, headache, dizziness, abdominal pain, vomiting, diarrhea, arthralgia,
back pain, upper respiratory infections
iii. Ticlopidine (Ticlid):
(1) Maintenance dose: 250 mg BID
(2) DC if the ANC drops to <1200 or platelet count drops to <80,000
(3) AE: rash, nausea, dyspepsia, diarrhea, neutropenia, thrombotic thrombocytopenic
purpura
(4) Dosage form: 250 mg tablet
iv. CI: active bleed, severe liver disease, ticlopidine: neutropenia, thrombocytopenia
b. Glycoprotein IIb/IIIa inhibitors:
i. Abciximab (Reopro)
(1) No renal dosing adjustment required
ii. Eptifibatide (Integrillin)
iii. Tirofiban (Aggrastat)
(1) Storage: room temperature, protect from light
7. Angiotensin Receptor Blockers (ARBs):
a. Candesartan (Atacand)
b. Eprosartan (Tevetan)
c. Irbesartan (Avapro)
d. Losartan (Cozaar)
e. Olmesartan (Benicar)
f. Telmisartan (Micardis)
g. Valsartan (Diovan)
8. Beta Blockers:
a. Nonselective:
i. Nadolol (Corgard)
ii. Penbutolol (Levatol)
(1) Has ISA
iii. Pindolol (Visken)
(1) Has ISA
iv. Propranolol (Inderal):
(1) Nonselective beta blocker
(2) Can increase cholesterol
(3) Strengths available:
(a) ER capsule (InnoPran XL): 80, 120 mg
(b) SR capsule (Inderal LA): 60, 80, 120, 160 mg
(c) Injection (Inderal): 1 mg/mL
(d) Solution: 4 mg/mL; 8 mg/mL
(e) Tablet (Inderal): 10, 20, 40, 60, 80 mg
v. Timolol (Blockadren)
b. Cardioselective:
i. Acebutolol (Sectral)
(1) Has intrinsic sympathomimetic activity (ISA)
ii. Betaxolol (Kerlone)
iii. Bisoprolol (Zebeta)
iv. Metoprolol (Lopressor, Toprol XL)
(1) Strength/dosage forms:
(a) Lopressor:
(i) Injection: 1 mg/mL
(ii) Tablet: 25, 50, or 100 mg
(iii) ER tablets: 50 & 100 mg
(b) Toprol XL:
(i) Tablets: 25, 50, 100, 200 mg
c. Mixed:
i. Labetalol (Trandate):
(1) Beta blocker (heart rate drop) with alpha-blocking (vasodilation & BP drop) activity
ii. Carvedilol (Coreg):
(1) MOA: blocks â-1, â-2, & á-1 receptors
(2) Has had proven effects on patient survival in large clinical trials for HF
(3) Take with food
(4) Antioxidant effects
(5) Preferred in HF patients who BP is poorly controlled due to its greater hypertensive
effect
(6) Increases stroke volume
d. MOA: competitively blocks response to beta-adrenergic stimulation:
i. Blocked secretion of renin; decrease cardiac contractility, thereby decreasing CO; decreased
central sympathetic output; decreased HR, thereby decreasing CO
e. Mask signs of hypoglycemia
f. Can increase lipids
9. Calcium Channel Blockers (CCBs):
a. MOA: inhibit the influx of Ca ions through slow channels in vascular smooth muscle & cause
relaxation of both coronary & peripheral arteries
i. SA & AV nodal depression & decrease in myocardial contractility (nondihydropyridines)
b. Nondihydropyridines:
c. SE: conduction defects, worsening of systolic dysfunction, gingival hyperplasia
i. Diltiazem (Cardizem, LA & CD, Dilacor XR, Tiaziac)
(1) SE: nausea, headache
(2) Cardizem: 30, 60, 90, 120 mg tablets
(3) Cardizem LA: 120, 180, 240, 300, 360, 420 mg
(4) Cardizem CD: 120, 180, 240, 300, 360 mg capsules
ii. Verapamil:
(1) IR: (Calan, Isoptin)
(2) LA: (Calan SR, Isoptin SR)
(3) Coer: (Covera HS, Verlan PM)
(4) SE: constipation
d. Dihydropyridines:
i. SE: edema of the ankle, flushing, headache, gingival hyperplasia
ii. Amlodipine (Norvasc)
iii. Felodipine (Plendil)
iv. Isradipine (DynaCirc & CR)
v. Nicardipine (Cardene SR)
vi. Nifedipine (Procardia XL, Adalat CC)
vii. Nisoldipine (Sular)
10. Combination products:
a. Amlodipine & benazepril (Lotrel)
b. Bisoprolol & HCTZ (Ziac)
c. Losartan & HCTZ (Hyzaar)
11. Direct vasodilators:
a. SE: headaches, fluid retention, tachycardia, peripheral neuropathy, postural hypotension
b. Hydralazine (Apresoline)
c. Minoxidil (Loniten)
i. Hirsutism
12. Diuretics:
a. Monitor: urine output, edema, weight
b. Can increase lipids
c. Loops:
i. MOA: reduction of total fluid volume through the inhibition of Na & Cl reabsorption in the
ascending loop of Henle, which causes increased excretion of water, Na, Cl, Mg, & Ca
ii. Are more effective that thiazides in patients with renal failure (SCr >2 mg/dL or GFR < 30
mL/min)
iii. AE: ototoxicity at high doses; photosensitity; may increase blood glucose in diabetics;
orthostatic hypotension; hypokalemia; gout
iv. DI: aminoglycosides (increase risk of ototoxicity), NSAIDs (blunt diuretic response), Class
Ia or III antiarrhythmics (may cause torsades de pointes with diuretic induced
hypokalemic); probenecid (blocks loop effects by interfering with excretion into the urine)
v. Bumetanide (Bumex)
vi. Furosemide (Lasix)
(1) Available dosage forms: injection, solution, tablet
vii. Torsemide (Demadex)
d. Thiazides:
i. MOA: direct arteriole dilation; reduction of total fluid volume through the inhibition of Na
reabsorption in the distal tubules, which causes increased excretion of Na, water, K, &
hydrogen; increase the effectiveness of other antihypertensive agents by preventing reexpansion
of plasma volume
ii. Significant decrease in efficacy in renal failure (SCr > 2 mg/dL or GFR < 30 mL/min)
iii. DI: steroids (cause salt retention & antagonize thiazide action), NSAIDs (blunt thiazide
response), Class Ia or III antiarrhythmics (may cause torsades de pointes with diuretic
induced hypokalemic); probenecid & lithium(blocks thiazide effects by interfering with
excretion into the urine), lithium (thiazides decrease lithium renal clearance & increase risk
of lithium toxicity)
iv. AE: increased cholesterol & glucose (short term); decreased: K, Na, Mg; increased: uric
acid & Ca; photosensitivity; pancreatitis; impotence; sulfonamide-type reactions
v. Bendroflumethiazide (Naturetin)
vi. Benzthiazide (Aquatag, Exna)
vii. Chlorothiazide (Diuril)
viii. Chlorthalidone (Hygroton, Hylidone)
ix. Hydrochlorothiazide (HydroDIURIL, Microzide)
x. Hydroglumethiazide (Saluron, Diucardin)
xi. Meethyclothiazide
xii. Polythiazide (Renese)
xiii. Trichlormethiazide (Metahydrin, Naqua)
e. Thiazide-like:
i. Less or no hypercholesterolemia compared to other thiazides; decreased microalbuminuria
in DM
ii. Metolazone (Mykrox, Zaroxolyn)
iii. Indapamide (Lozol)
f. Potassium-sparing:
i. MOA: interferes with K/Na exchange in the distal tubule; decreases Ca excretion, increases
Mg loss
ii. AE: hyperkalemia
iii. Amiloride (Midamor)
iv. Triamterene (Dyrenium)
(1) Avoid with history of kidney stones or hepatic disease
g. Aldosterone Blocker:
i. Eplerenone (Inspra):
(1) Selective
(2) CI: DM type II; K > 5.5; ClCr < 30 mL/minPO- tablet 25 & 50 mgK
sparingSpironolactone (Aldactone)
13. Epinephrine (Adrenalin):
a. MOA: stimulates á-, â-1, & â-2 adrenergic receptors resulting in relaxation of smooth muscle
of the bronchial tree, cardiac stimulation, & dilation of skeletal muscle vasculature
b. Sensitive to light & air- protection is recommended
i. Oxidation turns drug pink, then a brown color
ii. Solutions should not be used if they are discolored or contain a precipitate
iii. Admixture is stable at room temperature for 24 hours
14. Heart failure:
a. Drugs that can worsen or precipitate:
i. Antiarrhythmics: disopyramide, flecainide, propafenone
ii. Beta blockers
iii. CCB: verapamil & diltiazem
iv. Oral antifugals: itraconazole & terbinafine
v. Cardiotoxic drugs: doxorubicin, daunorubicin, cyclophosphamide, alcohol
vi. Na & water retention: NSAIDs, glucocorticoids, rosiglitazone, pioglitazone
b. Metoprolol, bisoprolol, & carvedilol (Starting dose: 3.125 mg BID for 2 weeks) have all shown
to be effective in HF
c. Digoxin (Lanoxin):
i. Does not improve mortality, but does produce symptomatic benefits
ii. MOA: inhibits Na-K-ATPase pump, which results in an increase in intracellular Ca, which
causes a + inotropic effect
(1) Reduces sympathetic outflow from the CNS
iii. AE: arrhythmias, bradycardia, heart block, anorexia, abdominal pain, N/V, visual
disturbances, confusion, fatigue
(1) Toxicity is more commonly associated with serum concentrations > 2 ng/mL, but may
occur at lower levels if patients have hypokalemia, hypomagnesemia, & in the elderly
iv. Serum levels: 0.5-1.0 ng/mL
v. 60-80% is eliminated renally- dosage requirement for renal insufficiency
d. ACEI & beta blockers improve mortality
e. Aldosterone antagonist reduce the risk of death & hospitalization
f. Diuretics- symptomatic relief
15. Inotropes:
a. Dobutamine (Dobutrex):
i. MOA: stimulates â-1 receptors causing increased contractility & heart rate, with little effect
on â-2 or alpha receptors
(1) â-1 > â-2 > á
(2) Increases CO & vasodilates
ii. Use: inotropic support for patients with shock & hypotension
iii. Dosage: start at 3 mcg/Kg/min & titrate to 20 mcg/Kg/min
b. Dopamine (Intropin):
i. MOA: depends on the given dose
(1) 1-5 mcg/Kg/min: renal dose; increases urine output
(a) Stimulates dopamine receptors
(2) 5-15 mcg/Kg/min: increases contractility, HR
(a) Stimulates â-1 & â-2 receptors
(3) >15 mcg/Kg/min: increases BP
(a) Stimulates á-1 receptors
ii. Extravasation: give phentolamine
c. Milrinone (Primacor):
i. MOA: inhibits phosphodiesterase III, increases cAMP, resulting in positive inotropic &
vasodilating effects
ii. Use: short-term IV therapy of CHF; calcium antagonist intoxication Dosage: 50 mcg/kg
LD over 10 min; followed by 0.375 mg/Kg/min
iii. Preferred over inamrinone because of decreased risk of thrombocytopenia
16. MONA-B for MI:
a. Morphine, oxygen, NTG, Aspirin, beta blockers
17. Norepinephrine (Levophed):
a. MOA: stimulates â-1 adrenergic receptors & á-adrenergic receptors causing increased
contractility & HR as well as vasoconstriction thereby increasing systemic BP & coronary blood
flow
i. Alpha effects > beta effects
b. Readily oxidized, protect from light
c. Do not use if brown coloration
d. Admixture stable at room temperature for 24 hours
18. Postganglionic adrenergic neuron blockers:
a. Guanadrel (Hylorel)
b. Guanethidine (Ismelin)
c. Reserpine (Serpasil)
i. Can cause depression
19. Torsades de pointes:
a. Common drugs that can cause it:
i. quinidine, dofetilide (Tikosyn), sotalol (Betapace), thioridazine, ziprasidone (Geodon)
20. Thrombolytics:
a. Use:
i. ST-elevation > 1 mm in 2 or more contiguous leads or left bundle branch block
ii. Presentation within 12 hours or less of symptoms onset
iii. In patients >75 years old may be useful & appropriate
iv. Can be used in STEMI when time to therapy is 12-24 hours if chest pain is ongoing
v. Should NOT be used if the time to therapy is >24 hours, & the pain is resolved
vi. CI in a patient with NSTEMI
b. Drugs:
i. Streptokinase (SK, Streptase)
ii. Tissue plasminogen activator (tPA, Alteplase)
iii. Tenecteplase (TNK, TNKase)
iv. AE: hemorrhage (cerebral)
21. Vasodilators:
a. Nitroprusside (Nitropress):
i. Vasodilator
ii. Use: hypertensive crises; CHF
iii. Watch for cyanide toxicity (especially with hepatic dysfunction)
iv. Watch for thiocyanate toxicity (especially with renal dysfunction or prolonged infusions)
v. Highly sensitive to light
(1) Normally a brownish color
(2) A blue color indicates almost complete degradation & breakdown to cyanide
b. Nesirtide (Natrecor):
i. B-type natriuretic peptide that increases diuresis & is an arterial & venous dilator
c. Nitroglycerin (NitroBid, Nitrostat):
i. Venous dilator but also an arterial dilator at higher doses
ii. MOA: Nitroglycerin, an organic nitrate, is a vasodilating agent that relieves tension on
vascular smooth muscle & dilates peripheral veins & arteries
(1) It increases guanosine 3'5' monophosphate (cyclic GMP) in smooth muscle & other
tissues by stimulating guanylate cyclase through formation of free radical nitric oxide
(2) This activity results in dephosphorylation of the light chain of myosin, which improves
the contractile state in smooth muscle , and subsequent vasodilation
iii. Dosage forms available:
(1) Spray (do not inhale), ER cap, infusion, injection, ointment (Nitro-Bid), buccal tab
(Nitrogard), SL tab (NitroQuick, Nitrostat, Nitro-tab), patch (Minitran, Nitrek, Nitro-Dur)
iv. Isosorbide mononitrate (Imdur (ER), Ismo, Monoket):
(1) Long acting metabolite of the vasodilator isosorbide dinitrate used for the prophylactic
treatment of angina
(2) Should be given at 8 AM & 3 PM (any combination that doses them within 7-8 hours
of each other to allow for the nitrate-free period in the PM)
v. Isosorbide dinitrate (Dilatrate-SR, Isochron, Isordil)
Compatibility:
Drugs that must be mixed with sterile water:
a. Amphotericin B: no electrolytes, mix in D5W, & reconstitute with sterile water
Conversions:
1 lb = 454 gm 1 in = 2.54 cm
1 grain = 64.8 mg 1 avoirdupois pound = 454 gm
1 fluid ounce = 29.57 mL 1 gallon = 128 fluid oz, 3785 mL, 4 quarts, 8 pints
1 pint = 473 mL (round to 480 mL)
COPD:
1 line therapy: st beta-2 agonist or ipatropium
Counseling Points:
1. Calcitonin (Miacalcin):
a. For injection:
i. Keep vials in refrigerator
ii. Stable for 2 weeks at room temperature
iii. Give injection in upper arm, thigh or buttock
b. Nasal spray:
i. Store unopened bottle in refrigerator
ii. Once pump has been activated, store at room temperature
(1) Good for 30 days
iii. Must prime prior to first use or if it has been greater than 5 days
c. Adequate vitamin D & calcium intake is essential for osteoporosis
d. May cause increased warmth & flushing (should last only about 1 hour after administration)
i. Take in evening to minimize discomfort
2. Sulfa eye drops: burns
3. Nicotine gum: chew until peppery taste appears, then park
Cystic Fibrosis:
1. Autosomal recessive disease of exocrine gland function resulting in abnormal mucus production
2. Genetic mutation on the long arm of chromosome 7
a. The protein encoded by this gene, the cystic fibrosis transmembrane regulator (CFTR), is a
channel involved in the transport of water & electrolytes
b. Most common genetic mutation involves a 3-base-pair deletion at position ÄF508
3. Antibiotics for Cystic Fibrosis:
a. Cover for Staphylococcus aureus, H. flu, & pseudomonas
i. Double coverage of antibiotics when pseudomonas (most common) is suspected
(1) Antipseudomonal PCN: piperacillin (Pipracil), mezlocillin (Mezlin), piperacillintazobactam
(Zosyn), ticarcillin-clavulanate (Timentin), ticarcillin (Ticar), aztreonam
(Azactam), meropenem (Merrem), or imipenem (Primaxin)
(2) Or a cephalosporin: ceftazidime (Fortaz, Tazidime, Tazicef)
(3) AND an aminoglycoside: tobramycin
ii. Vancomycin for MRSA
iii. Burkholderia & Stenotrophomonas species are commonly resistant
(1) Trimethoprim-sulfamethoxazole (Bactrim), chloramphenicol (Chloromycetin),
ceftazidime, doxycycline, piperacillin
b. Fluoroquinolones are the ONLY oral antibiotics with good coverage against pseudomonas
4. Pulmozyme (dornase alfa):
a. Recombinant human deoxyribonuclease
b. Use: for management of CF patient to reduce the frequency of respiratory infections that require
parenteral antibiotics, & to improve pulmonary function
c. MOA: reduces mucous viscosity resulting in airflow improvement
d. Used with a nebulizer (jet nebulizer)
e. Must be stored in the refrigerator & should be protected from light
i. Should not be exposed to room temp for a total of 24 hours
ii. Should not be mixed with or diluted with other drugs in the nebulizer
Devices:
1. Swan Ganz catheter:
a. Inserted into right side of heart into the pulmonary circulation
b. Measures pulmonary capillary wedge pressure
c. Takes accurate measurement of BP
2. You must measure the scrotum to fit a swimmer’s athletic support
3. Crutches:
a. Armpits should be 2 inches above top of crutches
4. PICC line:
a. Peripherally inserted central catheter
Diabetes:
1. Insulin:
a. Rapid-acting:
i. Lispro (Humalog)
ii. Aspart (NovoLog)
iii. Glulisine (Apidra)
iv. Onset: <15 min
v. Peak: 30-90 min
vi. Duration: 3-5 hours
b. Short-acting:
i. Regular- human (Humulin R, Novolin, Velosulin BR)
ii. Regular- purified (Regular Ilentin II-pork)
iii. Onset: 30-60 min
iv. Peak: 2-3 hours
v. Duration: 3-6 hours
c. Intermediate-acting:
i. NPH- isophane insulin suspension (NPH Iletin II- pork)
ii. Human (Humulin N, Novolin N)
iii. Lente- insulin zinc suspension (Lente Iletin II- pork)
iv. Human (Humulin L, Novolin L)
v. Onset: 2-4 hours
vi. Peak: 6-12 hours
vii. Duration: 10-18 hours
d. Long-acting:
i. Ultralente- extended insulin zinc suspension; human (Humulin U, Ultralente)
(1) Onset: 6-10 hours
(2) Peak: 10-16 hours
(3) Duration: 18-20 hours
ii. Insulin glargine (Lantus)
(1) Onset: 5 hours
(2) Peak: none
(3) Duration; 20-24 hours
(4) Cannot mix with any other insulin
e. Premixed products:
i. 50/50: 50% regular with 50% NPH
(1) Rapid acting for pre-meal & intermediate acting to control later hyperglycemia
ii. 70/30: 30% regular with 70% NPH
iii. 70/30 analogue: 30% aspart with 70% neutral protamine aspart insulin analogue
iv. 75/25: 25% lispro with 75% neutral protamine lispro insulin analogue
f. MOA: decreases blood glucose & assists with glucose control by:
i. Increasing glucose uptake & utilization by peripheral tissues (primarily in muscle)
ii. Increasing glycogenesis (glucose à glycogen; primarily in liver)
iii. Decreasing glycogenolysis (glycogen à glucose)
iv. Decreasing gluconeogenesis (amino acids à glucose)
v. Decreasing lipolysis & ketogenesis (fats à ketone bodies)
vi. Converting amino acids to increase protein
vii. Converting triglycerides & fatty acids to increase adipose tissue
g. Appearance:
i. Clear (solution): aspart, lispro, glulisine, glargine, regular
ii. Cloudy (suspension): NPH, lente, ultralente, all premixed insulin products
h. Sites of injection: abdomen > arm > hip > thigh > buttock
i. In order of greater & more rapid absorption to lesser & slower absorption
i. There’s 1000 units in a 10 mL bottle
2. Insulin secretagogues:
a. MOA: stimulates pancreatic â cells to secrete insulin
b. 1 generation st sulfonylureas: can cause a disulfiram-like rxn
i. Acetohexamide (Dymelor)
ii. Chlorpropamide (Diabinese)
iii. Tolazamide (Tolinase)
iv. Tolbutamide (Orinase)
c. 2nd generation sulfonylureas
i. Glimepiride (Amaryl)
(1) Max dose: 8 mg/day
ii. Glipizide (Glucotrol, Glucotrol XL)- use in renal impairment
iii. Glyburide (Diabeta, Micronase)- safe in pregnancy
iv. Glyburide micronized (Glynase)
d. Regular meal times are necessary- must not skip
e. SE: hypoglycemia & weight gain
3. Alpha-glucosidase Inhibitors:
a. Acarbose (Precose)
b. Miglitol (Glyset)
i. Least likely to cause hypoglycemia even when fasting
c. Should be taken with the first bite of a meal
d. MOA: delays carbohydrate metabolism & absorption (due to competitive & reversible inhibition
of intestinal alpha-glucoside hydrolase & pancreatic alpha-amylase)
e. SE: GI intolerance
f. To treat a hypoglycemic attack: treat with oral glucose
i. Sucrose or fructose would not work
4. Biguanide:
a. Metformin (Glucophage, Fortamet, Riomet):
i. MOA: 9 insulin resistance
(1) 1° in liver; 2° in periphery
ii. Dosage: start with 500 mg po BID or 875 mg po QD
(1) Max: ~2500 mg QD (850 mg TID)
iii. When to hold: in patients undergoing diagnostic radiology procedures that use an
iodinated contrast media; hold for 48 hours after the radiology drug is administered
(1) i.e. angiogram
iv. SE: GI, megaloblastic anemia, & lactic acidosis (Scr men >1,5, women >1.4- don’t use)
5. Thiazoladinediones (glitazones or TZDs):
a. Pioglitazone (Actos)
b. Rosiglitazone (Avandia): need AST prior to starting
i. Wait 3 months before deciding on therapeutic failure
c. MOA: 9 insulin resistance
i. 1° in periphery; 2° in liver
d. SE: edema, anemia, weight gain, exacerbation of CHF, URIs, resumption of ovulation
6. Meglitinides (nonsulfonylurea secretagogues):
a. Repaglinide (Prandin)
i. Max daily dose: 16 mg/day
b. Nateglinide (Starlix)
c. MOA: stimulates pancreatic â cells to secrete insulin
d. SE: hypoglycemia, weight gain, GI
7. Combination drugs:
a. Glyburide + Metformin (Glucovance)
b. Glipizide + Metformin (Metaglip)
c. Rosiglitazone + Metformin (Avandamet)
8. Example of question: Diabeta is most like Prandin
9. Glyset will not cause hypoglycemia
a. Only sulfonylureas & insulin will lower blood sugar in non-diabetics
10. Glucagon (GlucaGen):
a. Use: management of hypoglycemia
i. Unlabeled use: beta blocker & CCB overdose
b. MOA: stimulates adenylate cyclase to produce increased cAMP, which promotes hepatic
glycogenolysis & gluconeogenesis, causing a rise in blood glucose levels
c. 1 unit = 1 mg
11. Diabetic nephropathy:
a. Microalbuminuria (30-300 mg albumin/24 hours) used to diagnosis
b. Annual screening for DM type II measures microalbumin-creatinine ratio (normal <30)
12. Diabetic neuropathy:
a. Treat with TCA’s
b. Neurontin, carbazepine
c. ACEI treat the decreased renal function, NOT the neuropathy itself
13. DKA:
a. A potentially fatal complication that occurs in up to 5% of patients with Type I annually
b. Seen less frequently in Type II
c. Precipitating factors: interruption of insulin therapy, sepsis, trauma, MI, pregnancy
d. Clinical features: N/V, vaguely localized abdominal pain; dehydration, respiratory distress,
shock & coma can occur
e. Lab evulation: anion gap metabolic acidosis & positive serum ketones; plasma glucose is
usually elevated
i. Hyponatremia, hyperkalemia, azotemia, & hyperosmolality
f. Treatment:
i. Supportive measures
ii. Fluids
iii. Insulin therapy
iv. Dextrose (5%)- once plasma glucose decreases to 250 mg/dL & the insulin infusion rate
decreased to 0.05 U/Kg/hr
v. Potassium
vi. Bicarbonate therapy
vii. Phosphate & magnesium
Drug-Drug Interactions:
Sertraline (Zoloft) & diltiazem (Cardizem; Cartia XT; Dilacor XR; Diltia XT; Taztia XT; Tiazac)
Hydroxyzine pamoate (Vistaril) & meperidine (Demerol) – Both are CNS depressants
Epilepsy:
Pharmacotherapy:
a. Carbamazepine (Tegretol):
i. Na channel blocker
ii. An autoinducer
iii. Tegretol XL: ghost tablets in stool
iv. SE: rash (rarely causing DC), folate deficiency, hepatotoxicity, aplastic anemia
v. Teratogenic
vi. Cannot be given for status epilepticus
b. Felbamate (Felbatol):
viii. Rarely used
ix. MOA: blocks glycine on N-Methyl-D-Aspartate receptor (NMDA)
x. SE: hepatotoxicity, aplastic anemia
xi. 50% renal elimination
g. Gabapentin (Neurontin):
i. MOA: unknown; structurally related to GABA but does not interact with GABA receptors
ii. Also used for peripheral neuropathies
iii. 100% renal elimination- no DI that effect drug metabolism
iv. Al or Mg containing antacids may decrease absorption
h. Lamotrigine (Lamictal):
i. MOA: decrease glutamate & aspartate release, delays repetitive firing of neurons, blocks
Na channels
ii. SE: life-threatening skin rash
(1) Titrate slowly to avoid
i. Levetiracetam (Keppra):
i. MOA: may prevent hypersynchronization of epileptiform burst firing & propagation of
seizure activity
ii. Adjust in renal dysfunction
j. Oxycarbazepine (Trileptal):
i. MOA: Na channel blocker
ii. PKS: active metabolite- 10-monohydroxycarbazepine (MHD)
iii. SE: hyponaturemia; blood dysrasias
k. Phenobarbital (Barbital, Luminal, Solfoton):
i. MOA: increases GABA-mediated Cl- influx
ii. SE: drowsiness, dizziness, hyperactivity, folate deficiency, hepatic failure, SJS
iii. Teratogenic
iv. Decreases effectiveness of BC pills
l. Phenytoin (Dilantin):
i. MOA: Na channel blocker
ii. Can only prepare in NS @ 50 mg/mL
iii. Highly protein bound
iv. SE: peripheral neuropathy, hydantoin faces, acne, hirsutism, gingival hyperplasia,
osteomalacia, vitamin K- deficient hemorrhagic disease, folate deficiency (megaloblastic
anemia), hepatic failure, SJS
(1) Dose-related SE: nystagmus, ataxia, drowsiness, cognitive impairment
v. PKS: exhibits capacity-limited or saturable (Michaelis-Menton) PKS
vi. Teratogenic
vii. DC tube feedings 2 hours before & after a dose of phenytoin
viii. Available dosage forms: suspension, chewable tablet, prompt-release capsule, ER capsule,
injection
ix. Need albumin level to calculate phenytoin level
m. Primidone (Mysoline):
i. MOA: increase GABA-mediated Cl- influx
ii. Metabolized to Phenobarbital & phenylethylmalonamide (PEMA)
iii. Primidone, Phenobarbital, & PEMA all have anti-epileptic activity
n. Tiagabine (Gabitril):
i. MOA: blocks GABA reuptake in presynaptic neuron
o. Topiramate (Topamax):
i. MOA: blocks Na channels, enhances GABA activity, antagonizes AMPA/kainite activity
(1) Also a weak carbonic anhydrase inhibitor
ii. Elimination: primarily renal
iii. SE: drowsiness, dizziness, kidney stones, oligohidrosis (may not sweat)
iv. Sprinkle capsules can be opened & sprinkled onto a small amount of cool, soft food (i.e.
applesauce or yogurt)
v. Drink plenty of fluids
vi. Dosage forms available: sprinkle capsules & tablets
p. Valproic acid:
i. MOA: blocks T-type Ca currents, blocks Na channels, increases GABA production
ii. SE: weight gain, alopecia, thrombocytopenia, increased LFTs, heptotoxicity (fatal),
hemorrhagic pancreatitis (fatal), folic acid deficiency
iii. Available dosage forms:
(1) Sodium valproate (Depacon): injection
(2) Divalproex sodium:
(a) Depakene: syrup & gel capsule
(b) Depakote Sprinkles: capsules
(c) Depakote: delayed-release tablets
(d) Depakote ER: ER tablet
q. Zonisamide (Zonegran):
i. MOA: Na channel blocker, blocks T-type Ca channels (currents)
(1) Weak carbonic anhydrase inhibitor
ii. SE: kidney stones, weight loss, oligiohidrosis
iii. Sulfa drug
14. Nonpharmacologic therapy:
a. Ketogenic diet: devised in the 1920’s
i. High in fat & low in carbohydrates & protein
ii. Leads to acidosis & ketosis
iii. Most calories are provided in the form of cream & butter
iv. No sugar allowed
v. Fluids are also controlled
15. Status epilepticus: seizure lasting longer than 5 minutes or $2 discrete seizures between which
there is incomplete recovery of consciousness
a. Treatment:
i. ABC’s: airway, breathing, circulation
ii. 1st line: benzodiazepines
(1) Lorazepam (Ativan): rapid onset
(2) Diazepam (Valium)
iii. IV phenytoin (Dilantin)
(1) provided patient was not on phenytoin at home
(2) Can only mix with NS
(3) 15-20 mg/Kg
(4) Contains propylene glycol- cardiotoxic therefore do not infuse faster than 50 mg/min
(5) Fosphenytoin (Cerebyx):
(a) Prodrug of phenytoin
(b) Improves water solubility of phenytoin
(c) Can be admixed with any IV solution
(d) Dosed in PE (phenytoin equivalents): 1 mg of phenytoin = 1.5 mg of fosphenytoin
(e) Can be give at a rate of 150 mg/min
iv. IV Phenobarbital (20 mg/Kg)or begin a continuous infusion of midazolam
v. Begin a medically-induced coma
(1) Must be on a vent
Equations:
§ BMI: body mass index
o Men = 66 + (13.7 X W) + (5 X H) – (6.8 X A)
o Women = 665 + (9.6 X W) + (1.8 X H) – (4.7 X A)
o Where W= adjusted body weight in Kg; H= height in centimeters; A= age in years
o 1 in = 2.54 cm
§ CrCl = (140- age) (IBW) X 0.85 (if woman)
(72) (SCr)
man § IBW = 50 + 2.3 (inches over 5’)
woman § IBW = 45.5 + 2.3 (inches over 5’)
§ ABW = IBW + 0.4 (Actual – ideal)
§ Henderson Hasselbach:
o pH= pka + log [base]/[acid]
o log values:
§ log 100 = 2
§ log 10 = 1
§ log 1 = 0
§ log 0.1 = -1
§ log 0.01 = -2
ss D § Loading dose (LD) = C X V
ss ss D § Dose = C X Cl or C X V X Cl
1/2 D § T = 0.693 V /Cl
Fanconi’s Syndrome:
§ A congenital anemia due to low production of RBC’s
§ Can also be induced by anything that causes failure of the proximal renal tubules
§ Patients develop polyuria (cannot concentrate the urine), osteomalacia, & reduced growth size
§ At one time it was associated with the use of out-dated tetracycline but this is no longer a
problem since the product has been reformulated
o The filler was the actual culprit
§ Tenofovir (Viread) can cause this
GERD:
§ H2RA:
o Cimetidine (Tagamet)
o Famotidine (Pepcid)
o Nizatidine (Axid)
o Ranitidine (Zantac)
§ Available dosage forms:
· 150 & 300 mg capsules
· 50 mg infusion for IV
· 25 mg/mL injection
· 15 mg/mL syrup
· 75, 150, 300 mg tablet
· 75 mg effervescent tablet
§ PPIs:
o MOA: suppresses gastric acid secretion by inhibiting the parietal cell H+/K+ ATP
pump
o Rabeprazole (AcipHex):
§ Strength/dosage form: delayed-release EC 20 mg tablet
o Esomeprazole (Nexium):
§ Strength/dosage form:
· Capsule: delayed release 20 & 40 mg
· Injection, powder for reconstitution: 20 & 40 mg
o Lansoprazole (Prevacid):
§ Strength/dosage form:
· Capsule: delayed release 15 & 30 mg
· Granules, for oral suspension: 15 & 30 mg/packet
· Injection, powder for reconstitution: 30 mg
· ODT: 15 & 30 mg
o Omeprazole (Prilosec):
§ Do not put in OJ- not stable in an acidic environment
§ Can be opened & sprinkled onto applesauce
§ Strength/dosage form:
· Capsule: delayed release 10 & 20 mg
· Oral suspension (Zegerid): 20 & 40 mg
· Tablet: delayed release 20 mg (OTC)
o Pantoprazole (Protonix):
§ Strength/dosage form:
· Injection, powder for reconstitution: 40 mg
· Tablet: delayed release 20 & 40 mg
o Take 15-30 minutes before breakfast to maximize efficacy
§ GERD can exacerbate asthma
Glaucoma:
§ Increased intraocular pressure, which causes pathologic changes in the optic nerve & typical
visual field defects
§ Open-angle glaucoma:
o Primary glaucoma
o The angle of the anterior chamber remains open in an eye, but filtration of aqueous
humor is gradually diminished because of the tissues of the angle
o 80-90% of cases
§ Angle-closure (narrow angle) glaucoma:
o Primary glaucoma
o Shallow anterior chamber & narrow angle; filtration of aqueous humor is
compromised as a result of the iris blocking the angle
§ Therapy:
â-adrenergic antagonists:
§ MOA: decrease in aqueous humor formation with slight increase in outflow
(beta selective)
§ Often DOC for open-angle glaucoma
§ AE: cardiac effects, worsening pulmonary effects, depression, dizziness
§ Nonselective:
· Timolol (Timoptic)
· Carteolol (Ocupress)
· Levobunolol (Betagen)
· Metipranolol (OptiPranolol)
§ Selective:
· Betaxolol (Betoptic)
· Levobexaxolol (Betaxon)
o Carbonic anhydrase inhibitors:
§ MOA: decrease in aqueous humor formation
§ AE: lethargy, decreased appetite, GI upset, urinary frequency
§ Do not use with sulfa allergy
§ Acetazolamide (Diamox)
· Tablets, capsules
§ Dorzolamide (Trusopt)
§ Brinzolamide (Azopt)
§ Methazolamide (Neptazane)
· Tablets
o Prostaglandin analogs:
§ MOA: increased uveoscleral outflow without effect on aqueous humor
formation
§ Also used as 1st line agents or in combination with beta blockers
§ AE: iris pigmentation, eyelid darkening, macular edema
§ Latanoprost (Xalatan)
· Administer 1 drop at bedtime
· Refrigerate
· Can change blue eyes to brown
§ Bimatoprost (Lumigan)
· Can cause darkening of eyelids & eye lashes
§ Travoprost (Travatan)
· Frequent ocular hyperemia
§ Unoprostone (Rescula)
á-2 adrenergic agonists:
§ MOA: decrease in aqueous humor formation
§ AE: tachycardia, dry mouth, eyelid elevation, CNS effects in the old & young
§ Brimonidine (Alphagan)
· Wait at least 15 minutes after using before placing soft contacts
o Other á-adrenergic agonists:
§ MOA: increase in aqueous humor outflow
§ AE: tachycardia, increased BP, allergic responses
§ Dipivefrin (Propine)
· Prodrug of epinephrine
§ Pilocarpine (Pilocar)
· Once weekly dose form called Ocuserts
· Miotic agent
o Combination:
§ Timolol & dorzolamide (Cosopt)
o Hydroxypropyl methylcellulose added to decrease burning
Gout:
§ Treatment of acute attack:
o Colchicine:
§ MOA: inhibits phagocytosis of urate crystals by leukocytes; antiinflammatory
agent without analgesic activity
· Decrease leukocyte mobility thereby decreasing inflammation
§ Dosed until resolution of symptoms, severe GI symptoms occur, or max of 8
mg
§ Available PO (0.6 mg) & IV (0.5 mg/mL)
o Indomethacin
o Corticosteroids
§ Effective when given intra-articularly, IV, or PO
§ Used when there is failure to colchine and NSAIDS
§ Prophylaxis:
o Colchicine (low dose: 0.6-1.2 mg/d)
o Colchicine + probenecid (ColBenemid)
o Probenecid (Benemid):
§ MOA: uricosuric agent that promotes the excretion of UA by blocking its
reuptake at the proximal convoluted tubule
· Inhibits renal absorption of UA from the urine into the blood
§ Should drink at least 2 L of water/day to decrease the risk of UA stone
formation
§ Available as a 500 mg tablet
§ Avoid use with aspirin
o Sulfinpyrazone (Anturane):
§ MOA: uricosuric agent that promotes the excretion of UA by blocking its
reuptake at the proximal convoluted tubule
§ Drink at least 2 L of water/day
§ Do not use with CrCl < 50 mL/min
o Allopurinol (Zyloprim):
§ MOA: allopurinol & its metabolite oxypurinol, inhibit xanthine oxides
formation, which is the rate-limiting step in UA synthesis; this facilitates the
clearance of the more water soluble precursors of UA, oxypurines
· Inhibits xanthine oxides which reduces UA formation from the
metabolism of purine bases of DNA & RNA
§ Take with food
§ Watch for rash- SJS can occur
§ DI: azathioprine, 6-mercaptopurine, ACEI
Hemorrhoids:
§ Therapy:
o Soap suds enema QD
o Sitz bath QD
o Fiber therapy
o Sitting on a doughnut
o Cleaning anal area with soap & water after each defecation
o Dibucaine (Nupercainal): OTC local anesthetic for fast temporary relief of pain &
itching due to hemorrhoids
o Pramoxine (Anusol ointment, ProctoFoam NS, Tucks): OTC local anesthetic for fast
temporary relief of pain & itching due to hemorrhoids
Hepatic Encephalopathy:
§ Syndrome of disordered consciousness & altered neuromuscular activity seen in patients
with acute or chronic hepatocellular failure or portosystemic shunting
§ Precipitating factors: azotemia; use of tranquilizer, opioid, or sedative-hypnotic medication;
GI hemorrhage; hypokalemia & alkalosis; constipation; infection; high-protein diet
§ Monitor: ammonia levels
§ Treatment:
o Fleet’s enema
o Protein restriction; special diet (vegetable protein or branched-chain amino acid
enriched)
o Nonabsorbable disaccharides: lactulose (Cephulac, Constulose, Enulose, Generlac,
Kristalose), lactitol, & lactose
§ Lactulose syrup 30 mL of 50% solution QID; diminish to BID when 3 or more
bowel movements a day occur daily
§ Lactulose dosage forms: powder for oral suspension, oral solution, oral syrup
o Neomycin
o Metronidazole
Herbs:
§ Herbals that interfere with anticoagulation:
o Ginkgo, Ginseng, Fish Oil, Garlic, Feverfew, & Ginger
o “All begin with F or G”
§ Chamomile:
o Uses: dyspepsia, oral mucositis, dermatitis, ADHD
o Might have anti-inflammatory effects; might bind to GABA receptors
o DI: benzodiazepines, tamoxifen, CNS depressants, warfarin, estrogens, CYP1A2 &
CYP3A4 substrates
o CROSS-ALLERGENICITY: German chamomile may cause an allergic reaction in
individuals sensitive to the Asteraceae/Compositae family; members of this family include
ragweed, chrysanthemums, marigolds, daisies, and many other herbs
§ Chasteberry:
o Uses: PMS, BPH, menstrual irregularities, female infertility, insect repellant
o DI: antipsychotics, contraceptives, dopamine agonists, estrogens, metoclopramide
§ Cholesterol: garlic
§ Depression:
o St. John’s Wort, SAM-e (& OA), DHEA, Kava-kava (anxiety, stress)
§ Dong quai:
o Used for PMS & menopausal symptoms
o Interaction with warfarin- made up of several coumarin constitutes
§ Increase INR
§ Feverfew:
o Use: migraines, arthritis, allergies
o DI: anticoagulants, antiplatelets, CYP (1A2, 2C9, 2C19, 3A4)
§ Garlic:
o Active compounds: alliin, allicin
o Uses: hyperlipidemia, HTN, prevention of atherosclerosis
o MOA: May act as an HMG-CoA reductase inhibitor; may vasodilate & relax smooth
muscle, release NO; may also reduce oxidation of LDL & inhibit platelet formation
o Generally safe with the exception of heartburn, N/V, body ordor, bad breath
o DI: CYP3A4, cyclosporine, saquinavir, OCs, anticoagulants
§ Ginkgo:
o Uses: memory, Raynaud’s, glaucoma, diabetic retinopathy, intermittent claudication,
PMS, vertigo
o Can cause seizures at high doses
o DI: anticoagulants (warfarin), anticonvulsants, Buspar, CYP (1A2, 2C19, 2C9, 2D6,
3A4), ibuprofen, insulin, drugs that lower the seizure threshold (i.e. anesthetics (propofol,
others), antiarrhythmics (mexiletine), antibiotics (amphotericin, penicillin, cephalosporins,
imipenem), antidepressants (bupropion, others), antihistamines (cyproheptadine, others),
immunosuppressants (cyclosporine), narcotics (fentanyl, others), stimulants
(methylphenidate), theophylline)
§ Glucosamine:
o Use: OA, TMJ, glaucoma
o Glucosamine is an amino sugar, which is a constituent of cartilage proteoglycans. It
is derived from marine exoskeletons or produced synthetically
o DI: APAP, antidiabetic agents, warfarin
§ Hyperglycemia may be caused by:
o Black tea, coffee, cola nut, green tea, guarana, mate, N-acetyl glucosamine, niacin,
oolong tea, shark cartilage
§ Kava Kava:
o Uses: insomnia, anxiety, stress, benzodiazepine withdrawal
o May adversely affect the liver- increase LFTs
o DI: xanax, CNS depressants CYP (1A2, 2C19, 2C9, 2D6, 2E1, 3A4), hepatotoxic
drugs, levodopa
§ Licorice:
o Uses: dyspepsia
o has antispasmodic, anti-inflammatory, laxative, & soothing properties
o The constituents glycyrrhizin & glycyrrhetinic acid inhibit 11-beta-hydroxysteroid
dehydrogenase, an enzyme located in the aldosterone receptor cells of the cortical
collecting duct
o Glycyrrhizin may contribute to licorice-associated mineralocorticoid SE, including
HTN & hypokalemia, by both binding directly to mineralocorticoid receptors & by
decreasing the conversion of active cortisol to inactive cortisone
o DI: antihypertensives, corticosteroids, CYP3A4, digoxin
§ Milk thistle:
o Used for liver disorders; dyspepsia
o Interactions with CYP2C9 (warfarin, elavil, diazepam), CYP3A4 substrates, estrogens
o Avoid with hormone sensitive cancers
§ Hot flashes & menopausal symptoms: black cohosh
§ Passion Flower:
o Used for anxiety, GAD, opioid withdrawal
o Interactions with CNS depressants
§ Podophyllin:
o Uses: applied locally for wart removal;
o Can increase LFTs
§ SAM-e:
o Uses: depression & OA
o S-adenosylmethionine (SAMe) is a naturally occurring molecule that is distributed
throughout virtually all body tissues and fluids; concentrations are highest in childhood
& decrease with age
o Plays an essential role in >100 biochemical rxn involving enzymatic transmethylation
o It contributes to the synthesis, activation &/or metabolism of hormones,
neurotransmitters, nucleic acids, proteins, phospholipids, & some drugs
o DI: antidepressants, dextromethorphan, levodopa, meperidine
§ St. John’s Wort:
o Uses: depression, anxiety
o Two constituents that play a significant role are hypericin & hyperforin
3 4 o MOA: believed to act as a serotonergic 5-HT and 5-HT receptor antagonist, & down-
1 2 regulate beta-adrenergic, & serotonergic 5-HT & 5-HT receptors when used chronically
in animals
o DI: triptans, xanax, elavil, antidepressants, barbiturates, plavix, OCs, cyclosporine,
dextromethorphan, CYP (1A2, 2C9, 3A4), warfarin
§ Valerian:
o Used for anxiety, stress, insomnia
o A sedative; similar effects to Ambien
o Avoid with: etoh, benzadiazepines, CNS depressants, CYP3A4 substrates
§ Some herbs that affect platelet aggregation: angelica, clove, danshen, dong quai, garlic,
ginger, ginkgo, feverfew, Panax ginseng, horse chestnut, red clover, turmeric
Hyperkalemia:
§ Sodium polystyrene disulfonate (Kayexalate): cation exchange resin- promotes the exchange
of Na for K in GIT
o Can be administered as a retention enema or orally
§ IV insulin
o Causes K to shift into the cells & temporarily lowers the plasma K
§ Calcium gluconate
o Decreases membrane excitability
o Administer 1st with hyperkalemia & EKG changes
3 § Other: IV NaHCO (shifts K into cells); â-2 adrenergic agonists (promote the cellular uptake
of K); Loop & thiazide diuretics (enhance K excretion if renal function is adequate); dialysis
§ If the patient also has EKG changes the usual treatment (in order) is:
o IV calcium first
o Then IV bolus of 10-20 units of regular insulin with 25 gm of glucose (prevents
hypoglycemia)
o 150 mEq of sodium bicarbonate is one liter of D5W forces K into cells
o Beta-2 agonists (i.e. Albuterol) nebulized or SQ
o Combination of loop & thiazide (i.e. Lasix + Diuril) if the renal function is adequate
o Kayexalate (slow to work)
o Hemodialysis is best overall, if the time is available & K is severe
o Peritoneal dialysis is less effective
Hyperlipidemia:
§ Bile Acid Sequestrants:
o Effects on cholesterol:
§ TC: 9
§ TG: 8 or <-->
§ LDL: 9
§ HDL: 8
o Cholestyramine Resin (Questran, Prevalite):
§ MOA: forms a nonabsorable complex with bile acids in the intestine,
releasing chloride ions in the process; inhibits enterohepatic reuptake of intestinal
bile salts & thereby increases the fecal loss of bile salt-bound low density
lipoprotein cholesterol
o Colesevelam (WelChol)
§ Strength/dosage forms: 625 mg tablet
o Colestipol (Colestid)
o Not absorbed; safest for pregnant women
§ Fibrates:
o Effects on cholesterol:
§ TC: 9
§ TG: 9
§ LDL: 8 or <-->
§ HDL: 8
o MOA: increase catabolism (breakdown) of triglycerides
o Can cause pancreatitis & liver problems
o Fenofibrate (Tricor)
§ Changed from 160 mg (with meals) to 145 mg
· Made it nanocrystals for better bioavailability
o Gemfibrozil (Lopid)
§ Take 30 minutes before breakfast & dinner
o Clofibrate (Atromid-S)
§ Statins:
o Effects on cholesterol:
§ TC: 9
§ TG: 9
§ LDL: 9
§ HDL: 8
o MOA: HMG-CoA reductase inhibitors
o Atorvastatin (Lipitor)
o Fluvastatin (Lescol, Lescol XL)
1/2 § Shortest t
o Lovastatin (Mevacor, Altoprev- with niacin)
§ Strengths/Dosage forms:
· Tablet: 10, 20, 40 mg
· Mevacor: 20, 40 mg ER tablets
· Altoprev: 10, 20, 40, 60 mg tablets
§ No grapefruit
o Pravastatin (Pravachol)
§ Not metabolized in the liver- therefore statin with the least amount of DIs
§ Max daily dose: 80 mg
o Rosuvastatin (Crestor)
o Simvastatin (Zocor)
§ No grapefruit
§ Manufacturer recommends limiting simvastatin dose to 20 mg/day when
used with amiodarone or verapamil, & 10 mg/day when used with cyclosporine,
gemfibrozil, or fibric acid derivatives
o All except for Lipitor & Crestor should be administered in the evening
o Pregnancy category: X
o Monitor: LFTs, CK
§ Cholesterol Absorption Inhibitor:
o Effects on cholesterol:
§ TC: 9
§ TG: 9
§ LDL: 9
§ HDL: 8 or <-->
o Ezetimibe (Zetia):
§ Monitor for muscle pain & increased liver enzymes
§ Niacin (Niacor, Niaspan, Slo-Niacin: OTC):
3 o Synonyms: Nicotinic acid; vitamin B
o Effects on cholesterol:
§ TC: 9
§ TG: 9
§ LDL: 9
§ HDL: 8
o MOA: inhibits the synthesis of VLDL
o Target dose: 1.5-6 g/day in 3 divided doses with or after meals
o SE: flushing (pretreat by taking aspirin 30 minutes prior), dizziness, lightheadedness
o Caution in DM & gout
§ Combination products:
o Niacin & lovastatin (Advicor)
o Ezetimibe & simvastatin (Vytorin)
o Aspirin & pravastatin (Pravigard PAC)- aspirin tablets & pravastatin tablets are
separate tablets within the PAC
§ Exercise will help to raise HDL
Hypermagnesemia:
§ Treatment: 10% calcium gluconate (renal failure) or 0.9% saline with 2 g calcium gluconate
per liter (absence of severe renal failure)
Hyperthyroidism:
§ Thyrotoxicosis
§ Graves disease- most common cause
§ Thyroid storm is a life threatening, sudden exacerbation of all the symptoms of thyrotoxicosis
characterized by fever, tachycardia, delirium, & coma
§ Can be caused by drugs such as amiodarone & iodine
§ S/Sx: heat intolerance, weight loss, weakness, palpitation, anxiety, tremor, tachycardia,
eyelid sag, warm or moist skin
4 3 § Diagnosis: 8T or T , 9 TSH
§ Three modes of treatment:
o Surgery
o Radioactive iodine (RAI)
o Antithyroid (thionamide) drugs:
§ Propylthiouracil (PTU):
· MOA: inhibit the synthesis of thyroid hormones by preventing the
incorporation of iodine into iodotyrosines & by inhibiting the coupling of
4 3 monoiodotyrosine & diiodotyrosine to form T & T ; also inhibits the
4 3 peripheral conversion of T to T
· Dosage form: tablets
§ Methimazole (Tapazole):
· MOA: inhibit the synthesis of thyroid hormones by preventing the
incorporation of iodine into iodotyrosines & by inhibiting the coupling of
4 3 monoiodotyrosine & diiodotyrosine to form T & T
§ SE: fever, headache, paresthesias, rash, arthralgia, urticaria, jaundice,
hepatitis, agranulocytosis, leucopenia, bleeding
o Iodide drugs:
§ Strong iodine solution (Lugol’s Solution):
· Dosage form: solution- 5% iodine & 10% K iodide; delivers 6.3 mg
iodine per drop
§ Saturated solution of potassium iodide (SSKI)
· Dosage form: solution- 1 g/mL; delivers 38 mg iodine per drop of
saturated solution
§ MOA: blocks hormone release, inhibits thyroid hormone synthesis
Hypokalemia:
§ Diarrhea is associated with liquid KCl
Hyponatremia:
§ Drugs can cause by 1 of 3 mechanisms:
o Stimulation of vasopressin release (i.e. nicotine, carbamazepine, Lithium, TCA’s,
antipsychotic agents, antineoplastic drugs, narcotics)
o Potentiation of antidiuretic action of vasopressin (i.e. chlorpropamide,
methylxanthines, NSAIDs)
o Vasopressin analogs (i.e. oxytocin, DDAVP)
Hypothyroidism:
§ Deficient thyroid hormone production
§ Hashimoto’s disease is the cause of 90% of primary hypothyroidism
o Autoimmune resulting from cell- & antibody-mediated thyroid injury
§ S/Sx: cold intolerance, fatigue, somnolence, constipation, menorrhagia, myalgias,
hoarseness, thyroid gland enlargement or atrophy, bradycardia, edema, dry skin, weight gain
o Body slows down
4 § Thyroxine (T ) is the major hormone secreted by the thyroid, which is converted to the more
3 potent triiodothyronine (T ) in tissues
o Thyroxine secretion is stimulated by thyroid stimulating hormone (TSH)
4 o Diagnosis: 8TSH, 9T
§ Drug therapy:
4 o Levothyroxine sodium, T (Synthroid, Levothroid, Levoxyl, Unithroid, Thyro-Tabs):
§ Usually DOC
§ Typical dose is 100-125 mcg po QD; reduce dose to 50 mcg for elderly & 25
mcg in patients with CAD to reduce risk of precipitating angina
Dose changes are made within a 6-8 week interval
o Desiccated thyroid USP (Armour Thyroid, Nature-Throid, Westhroid)
3 o Liothyronine, T (Cytomel, Triostat)
4 3 o Liotrix, T & T in a 4:1 ratio (Thyrolar)
o Take 30 minutes before breakfast
o Don’t take antacids, calcium, or iron supplements within 4 hours of levothyroxine
o SE: tachycardia, arrhythmia, angina, MI, tremor, headache, nervousness, insomnia,
diarrhea, vomiting, weight loss, excessive sweating, hair loss
§ Body speeds up
ID:
§ Aminoglycosides:
o MOA: bactericidal; interferes with bacterial protein synthesis by binding to 30S &
50S ribosomal subunits resulting in a defective bacterial cell membrane
o For serious aerobic gram - infections
o Poorly absorbed for GIT
o Renally eliminated by glomerular filtration
o Watch for oto- & nephrotoxicity
o Target serum concentrations:
§ Amikacin peak: 15-30 mcg/mL
§ Amikacin trough: <5 mcg/mL
§ Gentamicin & tobramycin peak: 4-10 mcg/mL
§ Gentamicin & tobramycin trough: <2 mcg/mL
o Amikacin (Amikin)
§ Least susceptible to resistance
§ Rule of nines (see gentamicin)
o Gentamicin (Garamycin):
§ Rule of eights to determine dosing interval
· SCr X 8
· i.e. 2 X 8 = 16- - dose Q16 hours
o Netilmicin (Netromycin)
o Tobramycin:
§ Should be given after dialysis and be a routine loading dose
§ ANC: absolute neutrophil count
o Neutrophils = bands + segs
§ i.e. 5 + 65 = 70
§ This means that 70% of the WBCs are neutrophils
§ If WBC= 14000 cells per cubic millimeter X 0.70 = 9800 neutrophil cells
§ Neutrophils are elevated with bacterial infections
§ Lymphocytes are elevated with viral infections
§ Not much elevation with fungal infections
o Granulocytes= bands + segs + basophils + eosinophils
§ Anti-fungal agents:
o Amphotericin B:
§ Amphotericin B-conventional (Amphocin; Fungizone)
· Premedicate 30-60 minutes prior with NSAID or APAP with or without
diphenhydramine
o Or hydrocortisone
· Reconstitute ONLY with sterile water without preservatives, not
bacteriostatic water
· Can add D5W
§ Amphotericin B- lipid complex (Abelcet)
· May also need to premedicate
§ Amphotericin B-liposomal (AmBisome)
· May also need to premedicate
§ Amphotericin B Cholesteryl Sulfate Complex (Amphotec)
§ May also need to premedicate
o Itraconazole (Sporanox):
§ MOA: interferes with cytochrome P450 activity, decreasing ergosterol
synthesis (principle sterol in fungal cell membrane) & inhibiting cell membrane
function
§ CI: CHF
§ Dosing:
· Onychomycosis, Fingernail: ORAL, 200 mg BID X1 wk, off drug for 3
wk, repeat 200 mg BID X 1 wk
· Onychomycosis, Toenail: ORAL, 200 mg QD X 12 wk
· Aspergillosis, Blastomycosis, Histoplasmosis: ORAL, 200 mg QD, MAX
200 mg BID
§ Dosage forms available: 100 mg capsule; injection; oral solution
§ Anti-influenza drugs:
o Amantadine (Symmetrel)
§ Blocks influenza A; no activity against influenza B
§ Effective when initiated within 48 hours of initial symptoms & continued for
7-10 days
§ SE: GI disturbances & CNS dysfunction, including dizziness, nervousness,
confusion, slurred speech, blurred vision, & sleep disturbances
§ May lower seizure threshold- avoid with seizure history
o Rimantadine (Flumadine)
§ Blocks influenza A; no activity against influenza B
§ Effective when initiated within 48 hours of initial symptoms & continued for
7-10 days
§ SE: GI disturbances & CNS dysfunction, including dizziness, nervousness,
confusion, slurred speech, blurred vision, & sleep disturbances
· Fewer SE than with amantadine
o Zanamivir (Relenza)
§ Blocks influenza A & B neuraminidases
§ Powder for inhalation (rotadisk with Diskhaler)
§ 1-2 day improvement in symptoms in patients who are symptomatic for no
longer than 48 hours
§ SE: headache, GI disturbances, dizziness, upper respiratory symptoms
o Oseltamivir (Tamiflu)
§ Block influenza A & B neuraminidases
§ 1-2 day improvement in symptoms in patients who are symptomatic for no
longer than 48 hours
§ Dosing:
· Prophylaxis: 75 mg po QD X at least 7 days; should begin within 2
days of contact with infected individual
· Treatment: 75 mg po BID initiated within 2 days of onset of
symptoms; duration of treatment is 5 days
§ SE: N/V/D
§ Oral capsules & suspension
§ Anti-viral agents:
o Acyclovir (Zovirax):
§ Counseling: avoid sexual intercourse when lesions are present; this is not a
cure for herpes; can take with food; maintain adequate hydration (2-3 L/day); may
cause lightheadedness or dizziness
o Famciclovir (Famvir):
§ Uses: genital herpes, herpes zoster
§ Biotransformed to the active metabolite: penciclovir
§ Need dose adjustment for renal impairment
§ Tablet only
o Valacyclovir (Valtrex):
§ Uses: treatment of herpes zoster (shingles), herpes labialis (cold sores) &
genital herpes
§ MOA: rapidly & nearly completely converted to acyclovir by intestinal &
hepatic metabolism; inhibits DNA synthesis & viral replication by competing with
deoxyguanosine triphosphate for viral DNA polymerase & being incorporated into
viral DNA
§ Reduce dose with renal dysfunction
§ Aspergillus:
o Fungus
o Amphotericin B (Amphotec, Abelcet, AmBisome), itraconazole (Sporanox),
voriconazole (VFEND), caspofungin (Cancidas)
§ Spells out CAVI
§ NOT ketoconazole
§ Cephalosporins:
o 3rd generation:
§ Cefpodoxime (Vantin)
· Refrigerate
§ Chlamydia:
o STD
o S/SX:
§ Males: urethritis, epdidymitis, proctitis, reiter syndrome, testicular pain
§ Females: cervictis, urethral syndrome, endometritis, PID, urethral or cervical
discharge, pelvic pain
o If left untreated can lead to infertility
o Treatment: doxycycline, azithromycin, erythromycin (pregnant)
§ Tetracyclines & quinolones CI in children & pregnant women
§ Clostridium difficile:
o Gram +, anaerobic rod
o Treatment:
§ DOC: metronidazole
§ Vancomycin
§ Enterococcus faecalis: penicillin, ampicillin, vancomycin, linezolid, aminoglycosides
o Chloramphenicol, streptomycin, bactrim
o Gram +
o Clindamycin or cefazolin (cephalosporins) will not treat
§ Escherichia coli:
o DOC: cefazolin (Ancef), cephalixin (Keflex, Biocef), cefotaxime (Claforan), gentamicin
(Gentak)
§ Fluoroquinolones:
o MOA: bactericidal; inhibit bacterial DNA topoisomemrase & disrupt bacterial DNA
replication
o Can cause QT prolongation
o AE: crystalluria, tendon rupture
o Avoid PO in children under 18 years old- may cause cartilage growth suppression
o 2nd generation:
§ Ciprofloxacin (Cipro):
· MOA: inhibits DNA-gyrase in suspectible organisms; inhibits
relaxation of supercoiled DNA & promotes breakage of double-stranded
DNA
· Dosage forms: infusion, injection, microcapsules for oral suspension,
ophthalmic ointment (Ciloxan) & solution (Ciloxan), tablet, ER tablet
· Cipro ear drops:
o Ciprofloxacin & dexamethasone (Ciprodex):
§ Antibiotic/corticosteroid
§ Treatment of acute otitis media in peds with
tympanostomy tubes or acute otitis externa in children &
adults
o Ciprofloxacin & hydrocortisone (Cipro HC):
§ Antibiotic/corticosteroid
§ Treatment of acute otitis externa (swimmer’s ear)
§ Gonorrhea:
o Neisseria gonorrhoeae
o Gram –
o Cefixime, ceftriaxone, ciprofloxacin, ofloxacin
§ Inhibit cell wall synthesis:
o Vancomycin, PCNs, cephalosporins
§ Legionella pneumophilia:
o DOC: azithromycin, clarithromycin, erythromycin
o Alternative: Rifampin, ciprofloxacin, levofloxacin
§ Lincosamides:
o Treat gram +, gram - & anaerobic infections
o Lincomycin (Lincocin)
o Clindamycin (Cleocin)
§ Lyme’s Disease:
o Lyme borrelliosis
o Caused by spirochete Borrelia burgdorferi
o Tick-borne illness
o Symptoms:
§ Stage 1 (early disease): erythemia migrans- a slowly expanding macular rash
> 5 cm in diameter, often with a central clearing & mild constitutional symptoms
§ Stage 2 (early disseminated): occurs within several weeks to months &
includes multiple erythema migrans lesions, neurologic symptoms (7th cranial
nerve palsy, meningoencephalitis), cardiac symptoms (AV block, myopericarditis),
& asymmetric olioarticular arthritis
§ Stage 3 (Late disease): occurs after months to years & includes chronic
dermatitis, neurologic disease, & asymmetric monoarticular or oligoarticular
arthritis
o Treatment:
§ Doxycucline 100 mg BID
§ Amoxicillin 500 mg TID
§ Cefuroxime axetil 500 mg BID for 14-21 days
§ Macrolides:
o Bacteriostatic
o Clarithromycin (Biaxin):
§ Should not be stored in the refrigerator
o Erythromycin:
§ Oral products:
· Erythromycin base (E-Mycin, Ery-Tab, PCE (polymer coated ery), Eryc)
o Sensitive to acid
o Coating on most products
o Administer on an empty stomach
· Erythromycin stearate (Erythrocin stearate, Wyamycin S)
o Properties similar to ery base but better absorbed
· Erythromycin estolate (Ilosone)
o Most hepatotoxic
o Better absorbed than ery base
· Erythromycin ethylsuccinate (Eryped, EES)
o Best absorbed form from GIT
o Available in liquid formulation
o 400 mg of EES = 250 mg erythromycin base
§ Parenteral products:
· Erythromycin lactobionate
· Erythromycin gluceptate
§ Topical products:
· Erythromycin (Staticin, Emgel)- for acne (colorless)
· Erythromycin (Ilotycin)- ophthalmic use
§ MOA: bacteriostatic macrolide antibiotic; may be bactericidal in high
concentrations or when used against highly susceptible organisms. It penetrates
the bacterial cell membrane & reversibly binds to the 50 S subunit of bacterial
ribosomes
§ Reacts with theophylline by altering hepatic metabolism
· Also increases levels of carbamazepine, cyclosporine, triazolam,
lovastatin, simvastatin, valproate
o Azithromycin (Zithromax):
§ More gram – activity than erythromycin or clarithromycin
§ Suspension & capsules: take on an empty stomach
§ Tablet: with or without food
§ Not for children < 6 months old
§ Dosage forms available: injection, oral suspension, tablet, Tri-PAK (3, 500 mg
tabs), Z-PAK (6, 250 mg tabs)
§ Meningitis:
o Inflammation of the meninges that is identified by an abnormal number of WBC in
the CSF
o Causative organisms: many gram + & - species
§ Bacterial agents are associated with a large increase in WBCs, increased CSF
protein, & decreased CSF glucose
§ Fungal & viral agents exhibit smaller increases in CSF WBCs, smaller
increases in CSF protein, & limited decreases in CSF glucose
§ Mycoplasma pneumoniae:
o Erythromycin, tetracycline, doxycycline, fluoroquinolones, azithromycin,
clarithromycin
§ Onychomycosis:
o Infection of the nail by fungi (dermatophytes, Candida, molds)
o Treatment:
§ Fluconazole (Diflucan):
· 300 mg po weekly X 6 months (pulse therapy)
§ Itraconazole (Sporanox):
· 200 mg po BID X 1 week per month for 2 months for fingernails & 3-4
months for toenails (pulse therapy)
§ Terbinafine (Lamisil):
· 250 mg po QD X 3 months
§ Other:
o Daptomycin (Cubicin):
§ Used for resistant gram + infections
§ MOA: binds to bacterial membrane causing rapid depolarization of membrane
potential which leads to inhibition of protein, DNA & RNA synthesis, resulting in
bacterial cell death
§ Dosing: 4-6 mg/Kg QD
o Linezolid (Zyvox):
§ Available dosage forms: IV, powder for oral suspension, tablet
§ For resistant gram + skin infections, vancomycin-resistant E. faecium
§ Monitor for myelosuppression, thrombocytopenia, & HTN (especially if used
with tyramine-containing foods)
§ Do not combine with SSRIs because of potential for serotonin syndrome
§ Bacteriostatic/bactericidal agent
§ Adjustment with renal dysfunction
o Metronidazole (Flagyl):
§ Use: treatment of bacterial vaginosis & trichomonias
§ MOA: after diffusing into the organism, interacts with DNA to cause a loss
of helical DNA structure & strand breakage resulting in inhibition of protein
synthesis & cell death in susceptible organisms
§ Avoid with etoh
o Mupirocin (Bactroban):
§ Intranasal: eradication of nasal colonization with MRSA in adult patients &
healthcare workers
· BID
§ Topical treatment of impetigo due to Staphylococcus aureaus, beta hemolytic
Streptococcus, & S. pyogenes
· Apply 2-5 times/day for 5-14 days
o Nystatin:
§ Brand names: Bio-Statin; Mycostatin; Nystat; Nystop; Pedi-Dri
§ Antifungal agent for the treatment of susceptible cutaneous, mucocutaneous,
& oral cavity fungal infections caused by the Candida species
§ MOA: binds to sterols in fungal cell membrane, changing the cell wall
permeability allowing for leakage of cellular contents
§ Systemic relief in 24-72 hours from candidiasis
§ Oral: poorly absorbed
§ Available dosage forms: cream, lozenge (DSC), ointment, powder for
compounding, suspension, tablet, vaginal tablet
§ Mycolog cream contains a corticosteroid (triamcinolone) as well as an
antifungal (nystatin)
· Could be used for a patient with an ileostomy pouch
· Would also treat the inflammation that can occur from what are
basically “tape burns”
o Quinupristin/dalfopristin (Syncerid):
§ Indicated for vancomycin-resistant Enterococcus faecium & serious bacterial
skin infections
§ MOA: inhibits bacterial protein synthesis by binding to different sites on the
50S bacterial ribosomal subunit thereby inhibiting protein synthesis
§ Strengths/dosage forms:
· Injection, powder for reconstitution:
o 500 mg: quinupristin 150 mg & dalfopristin 350 mg
o 600 mg: quinupristin 180 mg & dalfopristin 420 mg
o Vancomycin (Vanocin, Vancole):
§ MOA: inhibits bacterial cell wall synthesis by blocking glycopeptide
polymerization through binding tightly to D-alanyl-D-alanine portion of cell wall
precursor
§ Alternative to other antimicrobials, including penicillins & cephalosporins for
serious gram + infections (resistant strains of strep, MRSA)
§ Watch for ototoxicity
§ Red man’s syndrome: rapid drop in BP accompanied by maculopapular rash
in neck or chest area often associated with rapid IV infusion
· Should be infused slowly >60 mins
§ Draw peak 1 hour after infusion has completed; draw trough just before next
dose
§ Therapeutic peak: 25-40 mcg/mL (>80 toxic)
§ Therapeutic trough: 5-12 mcg/mL
§ Otitis media:
o 1 line drugs: a st mpicillin, amoxicillin, bacampicillin
o Augmentin: (> 3 months & < 40 kg) 90 mg/Kg/day divided Q12 hours X 10 days
o 2nd generation cephalosporin (cefaclor- Ceclor, cefuroxime- Ceftin, cefprozil-Cefzil,
loracarbef-Lorabid)
o Zithromax (treat recurrent OM), Biaxin, Bactrim
o Most common causative organisms: Streptococcus pneumoniae (pneumococcus), H.
flu, moraxella catarrhalis, pseudomonas, klebsiella
o Rocephin can be used to treat: 50 mg/Kg in a single dose or for relapsing: 50 mg/Kg
QD X 3 days
§ P. acne:
o Clindamycin, erythromycin, & tetracycline are effective
o Erythromycin & benzoyl peroxide (Benzamycin):
§ Apply BID
§ This product contains benzoyl peroxide which may bleach or stain clothing
§ Available as a topical gel or Benzamycin Pak (supplied with diluent containing
alcohol
§ Penicillins:
o Resistance to PCN is caused by beta lactamase enzyme production & alteration of
PCN-binding proteins
§ Pseudomembranous enterocolitis (PE): Clostridium difficile overgrowth
o Caused by clindamycin & lincomycin
o Treat PE with fluid & electrolyte replenishment, oral metronidazole (IV if patient
cannot take po), &/or vancomycin (oral only)
§ Pseudomonas:
o Aerobic, gram – bacillus
o Treatment:
§ Antipseudomonal PCN (mezlocillin, piperacillin, carbenicillin, ticarcillin)
§ Ceftazidime (Fortaz, Tazidime, Tazicef), Cefepime (Maxipime) + aminoglycoside
§ Quinolone + imipenem
§ Sulfonamide derivates:
o SJS
o The only sodium sulfa salt suitable for ophthalmic use is sulfacetamide sodium
(Sodium Sulamyd, Bleph-10)
o Metabolized via acetylation
o Eliminated renally- good for UTIs
o Can result in crystalluria- drink sufficient amounts of water to prevent (2-3 L/day)
o Sulfamethoxazole & trimethoprim (Bactrim, Septra):
§ MOA:
· Sulfamethoxazole interferes with bacterial folic acid synthesis &
growth via inhibition of dihydrogolic acid formation form
paraaminobenzoic acid (PABA)
· Trimethoprim inhibits dihydrofolic acid reduction to tetrahydrofolate
resulting in sequential inhibition of enzymes of the folic acid pathway
§ Staphylococcus aureus:
o DOC: dicloxacillin, nafcillin, oxacillin,
o PCN allergy: erythromycin, clindamycin, TCN, linezolid, synercid, vancomycin
§ Systemic fungal infection:
o Would NOT use nystatin
o Fluconazole (Diflucan)
§ TB:
o Initial therapy involves RIPE:
§ As therapy continues, therapy may go to RIP & then RI
§ May continue for 6-18 months
§ Rifampin (Rifadin, Rimactane):
· Potent enzyme inducer
· Orange discoloration of all bodily fluids- stains contacts
· Also used for elimination of meningococci from the nasopharynx in
asymptomatic carriers
§ Isoniazid (Nydrazid):
· AKA: INH
· MOA: inhibits the bacterial cell wall of susceptible isolates & is
therefore active against actively dividing cells only
o Bacteriocidal or bacteriostatic depending on tissue
concentration of the agent
6 6 · May cause vitamin B deficiency- give B (pyridoxine) with use
· SE: peripheral neuropathy
§ Pyrazinamide:
· MOA: Mycobacterium tuberculosis converts pyrazinamide to
pyrazinoic acid which possesses antitubercular activity
§ Ethambutol (Myambutol)
o Monitor TB drugs with:
§ LFTs
§ AST
§ Or other transferases
§ Tetracyclines:
o Broad spectrum
o Doxycycline (Atridox, Doryx, Periostat, Vibra-Tabs, Vibramycin):
§ MOA: bacteriostatic effects by blocking the synthesis of bacterial proteins
§ Long-acting (BID) TCN
§ Eliminated via non-renal routes- good choice for renal impairment
§ DI with trivalent cations- Al (compatible with divalent cations)
§ Thrush:
o Normally found in the mouth
o It is a fungal infection of the mouth consisting of white spots
§ UTI- pyelonephritis:
o E. coli
o Bactrim, fluoroquinolones. Ampicillin + gentamicin
o UTI & sulfa allergy- treat with a FQ
§ Do not give FQ to children
Inflammatory Bowel Disease:
§ Ulcerative colitis: an idiopathic chronic inflammatory disease of the colon & rectum
§ Crohn’s disease: can affect any part of the tubular GIT & is characterized by transmural
inflammation of the gut wall
§ Treat with:
o Sulfasalazine (Azulfidine, Sulfazine)
o Mesalamine (Asacol, Canasa, Pentasa, Rowasa)
o Olsalazine (Dipentum)
o Glucocorticords
o Immunosuppressive agents (6-mercaptopurine, azathioprine, methotrexate,
cyclosporine)
o Antibiotics (metronidazole)
o Infliximab (Remicade)
§ Sulfasalazine (Azulfidine®):
o Used in the treatment of inflammatory bowel disease (ulcerative colitis) & RA
o Watch for sulfa allergy, salicylate allergy, & urinary discoloration
o Sulfasalazine à sulfapyridine + mesalamine (5-aminosalicyclic acid; 5-ASA)
§ 5-ASA is more active
§ If patient cannot tolerate sulfasalazine because of a sulfa hypersensitivity,
mesalamine (Asacol, Pentasa, Rowasa) may be used
· Asacol
o Delayed released, EC coated tablet- do not crush or chew
Immunosuppressive Therapy:
§ Calcineurin inhibitors:
o Cyclosporine (Sandimmune, Neoral)
o Tacrolimus (Prograf)
§ mTOR inhibitors:
o Sirolimus (Rapamune)
§ Antiproliferative agents:
o Azathioprine (Imuran)
o Mycophenolate mofetil (CellCept)
o Mycophenolate sodium (Myfortic)
o Leflunomide (Arava)
§ Monoclonal antibodies:
o Muromonab-CD3 (Orthoclone OKT 3)
o Basliximab (Simulect)
o Daclizumab (Zenepax)
§ Polyclonal antibodies:
o Anti-thymocyte globulin (Atgam): equine
o Anti-thymocyte globulin (Thymoglobulin): rabbit
Insomnia, Anxiety, or both:
§ Benzodiazepines:
o Most undergo oxidation to active metabolites in liver
o Lorazepam (Ativan), oxazepam (Serax), & temazepam (Restoril) undergo
glucuronidation to inactive metabolites
§ Useful in elderly & those with liver disease
o Can experience seizures & delirium with sudden discontinuation
o Hypnotic agents:
§ Estazolam (ProSom)
§ Flurazepam (Dalmane)
§ Quazepam (Doral)
§ Temazepam (Restoril)
§ Triazolam (Halcion)
§ Trazodone (Desyrel):
o Antidepressant that is useful for severe anxiety or insomnia
o Highly sedating, causing postural hypotension & is associated with priapism
o Doses:
§ Sedation: 25-50 mg
§ Depression: 150 mg divided into 3 daily doses; max 600 mg/day
§ Zolpidem (Ambien):
o An imidazopyridine hypnotic agent
o MOA: has much or all of its actions explained by its effects on benzodiazepine
receptors, especially the omega-1 receptor
§ binds the benzodiazepine (BZ) receptor subunit of the GABA-A receptor
complex
o No withdrawal symptoms, rebound insomnia or tolerance
o Rapid onset good for initiating & maintaining sleep
o SE: headache, daytime somnolence, GI upset
o Avoided in patients with obstructive sleep apnea
§ Zaleplon (Sonata)
o Nonbenzodiazepine hypnotic
o MOA: interacts with benzodiazepine GABA receptor complex
o T1/2 is ~1 hour & has no active metabolites
o SE: drowsiness, dizziness, & impaired coordination
o Caution in those with compromised respiratory function
§ Eszopiclone (Lunesta):
o MOA: may interact with GABA-receptor complexes
§ OTC sleep aids:
o Doxylamine (Unisom)
o Diphenhydramine (Nytol, Sominex)
o Diphenhydramine + APAP (Tylenol PM, Unisom Pain Relief)
o Diphenhydramine + ASA (Bayer PM)
Lupus:
§ Autoimmune inflammatory condition
§ Systemic Lupus Erythematosus (SLE)
§ Drugs that can contribute: procainamide**, phenytoin, chlorpromazine, hydralazine*,
quinidine, methyldopa, & isoniazid
§ Therapy:
o Arthritis: NSAIDs or glucocorticoids
o Dermatologic complications: hydroxychloroquine (Plaquenil)
o Thrombocytopenia: glucocorticoid therapy
o Refractory cases: cyclophosphamide
Metabolic acidosis:
§ Give sodium acetate- acetate ion converts to bicarbonate
§ Bicitra:
o Sodium citrate & citric acid
o Other brand names: Cytra-2 & Oracit
o AKA: Modified Shohl’s solution
o Use: treatment of metabolic acidosis; alkalinizing agent in conditions where longterm
maintenance of an alkaline urine is desirable
§ Also solution antacid pre-op if patient has eaten just before emergency
surgery or delivery of child
o Dosing: oral- 10-30 mL with water after meals (to avoid laxative effect) & at bedtime
o SE: N/V/D, hyperkalemia, tetany
Migraines:
§ Triptans:
1B 1D o Selective serotonin receptor agonists that activate 5-HT /5-HT & to a lesser extent
1A 1F 5-HT /5-HT
o Agents:
§ Almotriptan (Axert): 6.25 & 12.5 mg tablets; CYP450 & MAO metabolism
· NMT 2 doses in 24 hours
§ Sumatriptan (Imitrex): 25, 50, & 100 mg tablets, 5 & 20 mg nasal spray, 12
mg/mL injection; MAO metabolism
· Can re-dose oral tablets & nasal spray if no response after 2 hours
· Can re-dose injection if no response after 1 hour
§ Eletriptam (Relpax): 20 & 40 mg tablets; CYP 3A4 metabolism
· Can re-dose after 2 hours
· 80 mg/day max
§ Frovatriptan (Frova): 2.5 mg tablet; renal 50%
· Can re-dose after 2 hours
· 7.5 mg/day max
§ Rizatriptan (Maxalt): 5 & 10 mg tablet/wafer; MAO metabolism
· Can re-dose after 2 hours
· 30 mg/day max
· 15 mg max if also taking propranolol
§ Zolmitriptan (Zomig): 2.5 mg tablet/wafer, nasal spray 5 mg, ODT; CYP450
& MAO metabolism
· Can re-dose after 2 hours
· NMT 10 mg per 24 hours
§ Naratriptan (Amerge): 1 & 2.5 mg tablets; renal 70% & CYP450
· Dose may be repeated after 4 hours
· NMT 5 mg in 24 hours
o SQ sumatriptan has the fastest onset followed by sumatriptan nasal spray
o Rizatriptan may have a slightly faster onset of action than the others
o Migraine recurrence rates may be lower with long half-life triptans such as
naratriptan & frovatriptan
o SE: tingling & paresthesias; sensations of warmth in the head, neck, chest, & limbs;
dizziness; flushing; neck pain or stiffness
o Do not give sumatriptan to patients who have risk factors for CAD
o CI: in patients with hx of ischemic heart disease, MI, uncontrolled HTN, or other
heart disease; pregnancy
o Should not be taken within 24 hours of other triptans, isometheptene, or ergot
derivatives
§ Combination:
o Midrin:
§ Oral Capsule: (Acetaminophen - Dichloralphenazone - Isometheptene Mucate)
325 MG-100 MG-65 MG
§ Isometheptene: is an indirect-acting sympathomimetic agent with
vasoconstricting activity
§ Dichloralphenazone: a mild sedative & relaxant
§ Acetaminophen: may act predominantly by inhibiting prostaglandin synthesis
in the CNS &, to a lesser extent, through a peripheral action by blocking painimpulse
generation
· The peripheral action may also be due to inhibition of prostaglandin
synthesis or to inhibition of the synthesis or actions of other substances
that sensitize pain receptors to mechanical or chemical stimulation
o Butalbital 50 mg, aspirin 325 mg, & caffeine 40 mg (Fiorinal):
§ Capsules
o Butalbital, acetaminophen, & caffeine (Anolor 300; Dolgic; Esgic; Fioricet; Medigesic;
Repan; Zebutal):
§ Butalbital 50 mg, APAP 325 mg & caffeine 40 mg (Fioricet)
· Tablet
§ Ergot derivatives:
o CI: pregnancy, peripheral vascular disease, CAD, sepsis, hepatic or renal impairment
o Dihydroergotamine (DHE 45, Migranal):
§ Migraines: with or without aura
§ MOA: ergot alkaloid alpha-adrenergic blocker directly stimulates vascular
smooth muscle to vasoconstrict peripheral & cerebral vessels; also has effects on
serotonin receptors
1D · 5-HT receptor agonist
§ Max: 6 mg/week
§ Patient takes too much: N/V/D, dizziness, paresthesia, peripheral ischemia,
peripheral vasoconstriction
§ Available dosage forms: injection (DHE 45) & intranasal spray (Migranal)
· Migranal: 1 spray in each nostril; can repeat in 15 minutes; max is
4 sprays/day
o Discard open ampules after 8 hours
o Ergotamine tartrate & caffeine (Cafergot):
§ Available dosage forms: tablets & suppositories
§ Max: 6 mg/day or 10 mg/week
o SE: nausea & vomiting (resulting from stimulation of the CTZ)
o Ergotism: severe peripheral ischemia
§ Sx: cold, numb, painful extremities, continuous paresthesias, diminished
peripheral pulses & claudication may result from the vasoconstrictor effects of the
ergot alkaloids
§ Gangrenous extremities, MI, hepatic necrosis, & bowel & brain ischemia are
rare, but have been reported
§ Propylactic therapy:
o DOC:
§ Propranolol (Inderal): use if patient also has HTN
· Lipid soluble
§ Amitriptyline (Elavil): concomitant depression
§ Valproate (Depakote): concomitant seizures
§ Cyproheptadine (Periactin): useful for migraines in children
§ Feverfew: herbal with some benefits shown
§ Ergonovine maleate: effective for menstrual migraines
§ Methysergide (Sansert):
· Dose: 2 mg BID up to 8 mg X 6 months
o Then stop for 1 month
o If you don’t stop- get SE of retroperitoneal fibrosis: organs in
abdominal cavity become fibrotic & can die
o This can occur as the result of constant vasoconstrictionwhich
provides less blood flow to organs
o You must stop to allow blood flow to return
Miscellaneous Drugs:
§ Acetylcysteine (Mucomyst, Acetadote):
o MOA: exerts mucolytic action through its free sulfhydryl group which opens up the
disulfide bonds in the mucoproteins thus lowering mucous viscosity; thought to reverse
APAP toxicity by providing substrate for conjugation with the toxic metabolites
o Also used for prevention of radiocontract-induced renal dysfunction
§ Adalimumab (Humira):
o Tumor necrosis factor (TNF) blocking agent
o MOA: binds to human tumor necrosis factor alpha (TNF-alpha) receptor sites
§ Elevated TNF levels in the synovial fluid are involved in pathologic pain
o Use: treatment of active RA in patients with inadequate response to one or more
DMARDs; psoriasis
o Dose: 40 mg SQ EOW
o Before starting therapy: TB test, measure rheumatoid factor, PT
§ Adefovir (Hepsera):
o Antiretroviral agent; reverse transcriptase inhibitor (nucleoside)
o MOA: acyclic nucleotide reverse transcriptase inhibitor (adenosine analog) which
interferes with HBV viral RNA dependent DNA polymerase resulting in inhibition of viral
replication
o Use: treatment of chronic hepatitis B
§ Aspirin & dipyridamole (Aggrenox):
o Use: reduction in the risk of stroke in patients who have had transient ischemia of
the brain or completed ischemic stroke due to thrombosis
o MOA:
§ Dipryidamole: inhibits the uptake of adenosine into platelets, endothelial
cells & erythrocytes
§ Aspirin: inhibits platelet aggregation by irreversible inhibition of platelet
cyclooxygenase & thus inhibits the generation of thromboxane A2
o Dosing: 1 capsule BID
§ Atropine (AtroPen; Atropine-Care; Isopto; Sal-Tropine):
o AtroPen formulation is available for use primarily by the department of defense
o MOA: blocks the action of acetylcholine at parasympathetic sites in smooth muscle,
secretory glands & the CNS; increases CO, dries secretions, antaonizes histamine &
serotonin
§ Bismuth subsalicylate, metronidazole, tetracycline (Helidac):
o If patient has + urea breath test indicating H. pylori present
§ Chlorhexidine (Periogard):
o Antibacterial agent for oral rinse
o Bactericidal
o Uses: disinfectant; gingivitis; periodonitis; inhibits plaque formation
§ Cromolyn (NasalCrom):
o Dose: use 1 spray in each nostril 3-4 times per day
§ Cyclosporin (Gengraf, Neoral, Restasis, Sandimmune):
o Neoral & Sandimmune are NOT therapeutically equivalent
o Immunosuppressant agent
o MOA: inhibition of production & release of interleukin II & inhibits interleukin IIinduced
activation or resting T-lymphocytes
§ Danazol (Danocrine):
o Use: treatment of endometriosis, fibrocystic breast disease & hereditary angioedema
o Androgen
o MOA: suppresses pituitary output of FSH & LH that causes regression & atrophy of
normal & ectopic endometrial tissue; decreases rate of growth of abnormal breast tissue
o CI: markedly impaired hepatic, renal, or cardiac function
§ Desmopressin (DDAVP, Stimate):
o Vasopressin analog
o Uses: diabetes insipidus; control bleeding in hemophilia A & van Willebrand disease;
primary noctural enuresis
o Strengths/dosage forms:
§ Injection (IV): 4 mcg/mL
§ Solution, intranasal: 100 mcg/mL
§ Tablets
§ Desoximetasone (Topicort):
o Intermediate to high potency topical corticosteriod
o Available as a cream & ointment
§ Dicyclomine (Bentyl);
o MOA: anticholinergic agent
o Uses: treatment of functional disturbances of GI motility such as irritable bowel
syndrome
o NOT used for GERD
§ Diphenhydramine (Benadryl):
o Analgesic, antihistamine, antipruritic, sleep aid, antitussive, antiemetic
o Class: Ethanolamine
o Dosing adjustments in renal impairment
o MOA: Diphenhydramine hydrochloride acts as an antihistamine by competing with
histamine for receptor sites on effector cells
o Precautions: bladder neck obstruction; concurrent MAOI therapy; concurrent use
of CNS depressants; decreases mental alertness & psychomotor performance; do not use
topical form on eyes or eye lids; elderly are more susceptible to the SE of
diphenhydramine; history of bronchial asthma, increased intraocular pressure,
hyperthyroidism, cardiovascular disease or HTN; may cause excitation in young children;
narrow angle glaucoma; pyloroduodenal obstruction; stenosing peptic ulcer; symptomatic
prostatic hypertrophy
§ Diphenoxylate & Atropine (Lomitol; Lonox):
o Antidiarrheal
o CI: severe liver disease; jaundice; narrow angle glaucoma; children < 2 years old
o MOA: diphenoxylate inhibits excessive GI motility & GI propulsion
o Commercial preparations contain a subtherapeutic amount of atropine to discourage
abuse
o Dosing: 15-20 mg/day of diphenoxylate in 3-4 divided doses
§ Maintenance: 5-15 mg/day in 2-3 divided doses
o May cause drowsiness
§ Etancercept (Enbrel):
o Disease modifying agent
o MOA: binds to TNF & blocks its interaction with cell surface receptors
§ TNF blocker
o Use: moderate-severe RA; chronic plaque psoriases
o Dose: 25 mg injection SQ twice weekly or 50 mg injection SQ once weekly
o Initial storage of drug: in refrigerator (not frozen)
o Stability of vials after reconstitution: 14 days in refrigerator
o Allow prefilled syringes 15-30 minutes at room temperature prior to injection
o Some foaming is normal
o No DI with methotrexate
o Stop using when patient has a serious infection
§ Guaifensin:
o MOA: expectorant which acts by irritating the gastric mucosa & stimulating
respiratory tract secretions, thereby increasing respiratory fluid volumes & decreasing
mucus viscosity
§ Hyaluronate (Hyalgan, Biolon, Healon, Hylaform, Orthovisc, Provisc, Restylane, Supartz,
Synvisc, Vitax):
o MOA: sodium hyaluronate is a polysaccharide which is distributed widely in the
extracellular matrix of connective tissue in man. It forms a viscoelastic solution in water
(at physiological pH & ionic strength) which makes it suitable for aqueous & vitreous
humor in ophthalmic surgery & functions as a tissue &/or joint lubricant
o Use:
§ intra-articular injection (Synvisc)- treatment of pain in OA in knee in patients
who have failed nonpharmacologic treatment & simple analgesics
· No weight bearing exercise for 48 hours
§ Intradermal- correction of moderate to severe facial wrinkles
§ Ophthalmic- surgical aid in cataract extraction, intraocular implantation,
corneal transplant, glaucoma filtration, & retinal attachment surgery
§ Topical- management of skin ulcers & wounds
§ Hydroxyzine (Atarax, Vistaril):
1 o MOA: competes with histamine for H receptor sites on effector cells in the GIT, blood
vessels, & respiratory tract; possesses skeletal muscle relaxing, bronchodilator,
antihistamine, antiemetic, & analgesic properties
o Use: treatment of anxiety; preoperative sedative; antipruritic; antiemetic
o Causes sedation
o Hydroxyzine pamoate (Vistaril)
o Hydroxyzine HCl (Atarax)
o Not to be confused with Hydralazine
§ Interferon beta 1b (Betseron):
o Use: treatment of MS
o Can cause hepatotoxicity- monitor LFTs
§ Isotretinoin (Accutane, Amnesteem, Clarais, Sotret):
o Retinoic acid derivative
o MOA: reduces sebaceous gland size & reduces sebum production; regulates cell
proliferation & differentiation
o Use: treatment of sever recalcitrant nodular acne unresponsive to conventional
therapy
o RiskMAP, S.M.A.R.T., S.P.R.I.T., I.M.P.A.R.T. programs
§ Cannot be dispensed unless the rx is affixed with a yellow, self-adhesive
qualification sticker filled out by the prescriber
§ Telephone, fax, or computer-generated rxs are no longer valid
§ Rx cannot be written for more than a 1-month supply, must be dispensed
with a patient education guide
§ Females must have their rxs filled within 7 days of the qualification dateconsidered
expired if > 7days
o Pregnancy risk factor: X
§ Females must have 2 methods of contraception; 1 month prior to starting
therapy & 1 month after discontinuation of therapy
§ Therapy is begun after 2 negative pregnancy tests
o SE: increased triglycerides, elevated blood glucose, photosensivitivity, seizure,
cataracts
o Avoid additional vitamin A supplements
o Dose: 0.5-2 mg/Kg/day in 2 divided doses
o Take with food; limit exercise while on therapy; capsules can be swallowed, or chewed
& swallowed; capsule may be opened with a large needle & contents placed on applesauce
or ice cream
o Excerbation of acne may occur during the 1st weeks of therapy
o Accutane, Amnesteem, & Sotret contains soybean oil (Claravis does not)
§ Lansoprazole (30 mg), amoxicillin (1 g), clarithromycin (500 mg) (Prevpac):
o For H. pylori
o Taken together BID for 10-14 days
§ Leflunomide (Arava):
o Disease modifying agent
o MOA: inhibits pyrimidine synthesis, resulting in antiproliferative & antiinflammatory
effects
o Use: treatment of active RA; indicated to reduce signs & symptoms, & to retard
structural damage & improve physical function
§ Luride: source of fluoride to prevent dental caries
o Supplied as sodium fluoride in chewable tablets that provide 0.25 mg, 0.5 mg, & 1
mg of fluoride ion per tab
o Prolonged ingestion with excessive doses may result in dental fluorosis (staining or
hypoplasia of the enamel of the teeth) & osseous changes
§ Malathion (Ovide):
o Class: organophosphate; pediculicide
o Uses: pediculosis capitis; lice
o MOA: acts via cholinesterase inhibition. It exerts both lousicidal & ovicidal actions
in vitro.
o Safety not established in children under 6 years old
o Lotion
§ Mannitol (Osmitrol, Resectisol):
o Osmotic diuretic
o MOA: increases osmotic pressure of glomerular filtrate, which inhibits tubular
reabsorption of water & electrolytes & increases urinary output
§ Mebendazole (Vermox):
o Anthelmintic agent
o MOA: selectively & irreversibly blocks glucose uptake & other nutrients in
susceptible adult intestine-dwelling helminthes
o Dosing:
§ Pinworms: 100 mg po ASD; may need to repeat after 2 weeks; treatment
should include family members in close contact with patient
§ Whipworms, roundworms, hookworms: 1 tablet BID, morning & evening on
3 consecutive days; if patient is not cured within 3-4 weeks, a 2nd course of
treatment may be administered
§ Capillariasis: 200 mg BID for 20 days
o Strengths/dosage forms:
§ Tablet, chewable: 100 mg
§ Methotrexate (Rheumatrex; Trexall):
o MOA: inhibits dihydrofolate reductase causing interference with DNA synthesis,
repair, & cellular replication
o Juvenile RA: oral, IM: 10 mg/m2 once weekly
o Does cause alopecia
o Causes myelosuppression & thrombocytopenia
§ NOT thrombocytosis (increased PLT)
o BBW for hepatotoxicity
o Can cause megalobastic anemia
§ Misoprostol (Cytotec):
o MOA: synthetic prostaglandin E1 analog that replaces the protective prostaglandins
consumed with prostaglandin-inhibiting therapies (i.e. NSAIDs); has been shown to
induce uterine contractions
o Dosing:
§ Prevention of NSAID-induced ulcers: 200 mcg po QID with food (to decrease
diarrhea)
§ Labor induction or cervical ripening: intravaginal- 25 mcg (1/4 of a 100 mcg
tablet)
· Do not use in patients with previous cesarean delivery or prior major
uterine surgery
§ Fat absorption in CF (unlabeled use): 100 mcg QID (ages 8-16)
o Tablets only (no IV)
§ Nimodipine (Nimotop):
o MOA: calcium channel blocker
o Use: spasm following subarachnoid hemorrhage from ruptured intracranial
aneurysms
o Has a greater effect on cerebral arteries- may be due to the drug’s increased
lipophilicity
o Dosing: 60 mg po Q4h x 21 days; start 96 hours after subarachnoid hemorrhage
o If the capsules cannot be swallowed, the liquid may be removed by making a hole in
each end of the capsule with an 18-guage needle & extracting the contents via syringe
§ Oxybutynin (Ditropan):
o Urinary antispasmodic agent
o MOA: Non-selective muscarinic receptor antagonist with a higher affinity for M1 &
M3 receptors
§ Increases bladder capacity, decreases uninhibited contractions, & delays
desire to void
o Dosage forms available: syrup, tablet (IR, XR), patch (Oxytrol)
§ Palivilizumab (Synagis):
o Use: monoclonal antibody used for prevention of serious lower respiratory tract
disease caused by respiratory syncytial virus (RSV) in infants & children < 2 years
o MOA: exhibits neutralizing & fusion-inhibitory activity against RSV
§ Ribavirin (Copegus, Rebetol, Ribasphere, Virazole) also used to treat RSV
· Available as: capsule; powder for aerosol; oral solution; tablet
§ Pancuronium:
o Nondepolarizing neuromuscular blocking agent
o MOA: blocks neural transmission at the myoneural junction by binding with
cholinergic receptor sites
o Onset: 2-4 minutes
o Duration after single dose: 40-60 minutes
o Use: adjunct to general anesthesia to facilitate endotracheal intubation & to relax
skeletal muscles during surgery; does not relieve pain or produce sedation
o DOC for neuromuscular blockade EXCEPT in patients with renal failure, hepatic
failure, or cardiovascular instability
o AE: increased pulse rate, elevated BP & CO, edema, flushing, rash, bronchospasm,
hypersensitivity rxn
§ Peginterferon Alfa-2a (Pegasys):
o Use: hepatitis C
o Refrigerate; protect from light
§ Permethrin(Acticin, Elimite, Nix Creme Rinse, Pronto, Rid, A200 Lice Control)
o OTC available with same ingredient: Nix
§ PhosLo:
o Calcium acetate
o Use:
§ Oral: control of hyperphosphatemia in end-stage renal failure; does not
promote aluminum absorption
§ IV: calcium supplementation in parenteral nutrition therapy
o MOA: combines with dietary phosphate to form insoluble calcium phosphate which
is excreted in the feces
§ Physostigmine (Antilirium):
§ Prednisone (Deltasone, Sterapred):
o MOA: an adrenocortical steroid with salt-retaining properties; it is a synthetic
glucocorticoid analog, which is mainly used for anti-inflammatory effects in different
disorders of many organ systems; causes profound & varied metabolic effects, modifies
the immune response of the body to diverse stimuli, & is also used as replacement
therapy for adrenocortical deficient patients
o Cortiosteriods should be used with caution in patients with DM, HTN, osteoporosis,
glaucoma, cataracts, TB, hepatic impairment, elderly
§ Propofol (Diprivan):
o General anesthetic; no analgesic properties
o Avoid abrupt discontinuation- titrate slowly
o Propofol emulsion contains soybean oil, egg phosphatide & glycerol
o “Propofol infusion syndrome”: symptoms include sever, sporadic metabolic acidosis
&/or lactic acidosis which may be associated with tachycardia, myocardial dysfunction,
&/or rhabdomyolysis
o Short duration of action: 3-10 minutes
o If on concurrent parenteral nutrition, may need to adjust the amount of lipid infused
o Provides 1.1 kCal/mL
§ Riopan:
o Magaldrate (antacid) & simethicone (antiflatulent) combination
o Substitutes can be found in the Non-Prescription Handbook & Facts & Comparisons
§ Robitussin:
o Robitussin: guaifenesin 100 mg/5 mL-OTC
§ Alcohol free
o Robitussin PE: guaifenesin 200 mg & pseudoephedrine 30 mg/5mL –OTC
§ Alcohol free
o Robitussin CF: guaifenesin 100 mg, pseudoephedrine 30 mg, & dextromethorphan
10 mg/5 mL -OTC
§ Alcohol free
o Robitussin DM: guaifenesin 100 mg & dextromethorphan 10 mg/5 mL –OTC
§ Alcohol free
§ Ursodiol (Actigall, Urso 250, Urso Forte):
o Use: prevention of gallstones in obese patients experiencing rapid weight loss
o AKA: ursodeoxycholic acid
o MOA: decreases cholesterol content of bile & bile stones by reducing the secretion
of cholesterol from the liver & the fractional reabsorption of cholesterol by the intestines
o Dosing:
§ Gallstone dissolution: 8-10 mg/Kg/day in 2-3 divided doses
§ Gallstone prevention: 300 mg BID
o Use beyond 24 months is not established
§ Vecuronium:
o Nondepolarizing neuromuscular blocker agent
o MOA: blocks acetylcholine from binding to receptors on motor endplate by inhibiting
depolarization
o Onset: 2-4 minutes
o DOA: 30-45 minutes
o Use: adjunct to general anesthesia to facilitate endotracheal intubation & to relax
skeletal muscles during surgery; does not relieve pain or produce sedation
o AE: bradycardia, edema, flushing, hypersensitivity rxn, hypotension, tachycardia,
rash
Miscellaneous Facts:
§ Danger of decreasing DKA too fast: cerebral edema
§ Genetic polymorphism exists as acetylation
§ Albumin is important for measuring calcium levels
o Corrected calcium = serum calcium + 0.8(4 – patient’s albumin)
§ Caffeine treats respiratory distress in neonates
§ Emergency bee sting kit:
o Epinephrine & APAP
o EpiPen auto-Injector
§ 0.3 mg SQ dose of 1:1000 epinephrine in a 2 mL disposable prefilled injector
§ Liposyn III (fat emulsion) is stored at room temperature
§ MedWatch: a list of reported side effect
o Completely voluntarily reported
§ Stain dermatologists use for fungus identification: KOH
§ Kayexlate + sorbitol use: to prevent constipation
o Store at room temperature
§ Hypercalcemia: almost always caused by increased entry of Ca into the extracellular fluid
& decreased renal Ca clearance
o More that 90% of cases are due to primary hyperparathyroidism or malignancy
§ Hypocalcemia in renal impairment:
o Phosphorus & calcium levels are altered due to:
§ Phosphorus retention, resulting in a rise in serum phosphorus levels & a
reciprocal fall in calcium levels, with resultant stimulation of parathyroid hormone
(PTH) secretion
3 § Decreased generation of 1,25-dihyroxyvitamin D , further contributing to low
serum calcium levels & decreasing suppression of PTH
o Addition of a phosphate binder prevent GI phosphate absorption:
§ Calcium carbonate 500-1000 mg po with meals
§ Sevelamer (Renagel): lacks aluminum & calcium
§ Cheilitis: inflammation of the lips
§ Herpes simplex I (cold sore): avoid the sunlight
§ Goodpasture’s syndrome: glomerulonephritis associated with pulmonary hermorrhage &
circulating antibodies against basement membrane antigens
o Autoimmune disease
§ Resorcinol/ASA/LCD needs to be packaged in what container
o LCD is coal tar- brown glass container
§ Medrol dose pack: decremental dosing
§ Polydipsia: excessive thirst
§ Patients with phenylketonuria (PKU) must avoid aspartame
Myasthenia Gravis:
§ An autoimmune disorder that involve antibody-mediated disruption of postsynaptic nicotinic
acetylcholine receptors at the neuromuscular junction & is often associated with thymus tumors
§ Treatment:
o Anticholinesterase drugs:
§ Pyridostigmine
§ Neostigmine
o Thymectomy
o Immunosuppressive drugs
§ High-dose prednisone
§ Azathioprine
§ Cyclosporine
§ Cyclophosphamide
Orange Book:
§ AKA: Approved Drug Products with Therapeutic Equivalence Evaluations
§ Codes:
o A: Drug products that FDA considers to be therapeutically equivalent to other
pharmaceutically equivalent products, i.e., drug products for which:
§ there are no known or suspected bioequivalence problems. These are
designated AA, AN, AO, AP, or AT, depending on the dosage form; or
§ actual or potential bioequivalence problems have been resolved with adequate
in vivo and/or in vitro evidence supporting bioequivalence. These are designated
AB
§ AA Products in conventional dosage forms not presenting bioequivalence
problems
§ AB, AB1, AB2, AB3... Products meeting necessary bioequivalence
requirements
§ AN Solutions and powders for aerosolization
§ AO Injectable oil solutions
§ AP Injectable aqueous solutions &, in certain instances, intravenous nonaqueous
solutions
§ AT Topical products
o B: Drug products that FDA at this time, considers NOT to be therapeutically
equivalent to other pharmaceutically equivalent products, i.e.,
§ drug products for which actual or potential bioequivalence problems have not
been resolved by adequate evidence of bioequivalence. Often the problem is with
specific dosage forms rather than with the active ingredients. These are
designated BC, BD, BE, BN, BP, BR, BS, BT, BX, or B*.
§ B* Drug products requiring further FDA investigation & review to determine
therapeutic equivalence
§ BC Extended-release dosage forms (capsules, injectables & tablets)
§ BD Active ingredients & dosage forms with documented bioequivalence
problems
§ BE Delayed-release oral dosage forms
§ BN Products in aerosol-nebulizer drug delivery systems
§ BP Active ingredients & dosage forms with potential bioequivalence problems
§ BR Suppositories or enemas that deliver drugs for systemic absorption
§ BS Products having drug standard deficiencies
§ BT Topical products with bioequivalence issues
§ BX Drug products for which the data are insufficient to determine
therapeutic equivalence
Osteopenia/Ostoporosis:
§ T scores are used for diagnosis:
o Osteopenia: T score -1 to -2.5 SD below the young adult mean
o Osteoporosis: T score # -2.5 SD below the young adult mean
§ Bisphosphonates:
o Could worsen esophagitis
o Take with a full glass of water fir thing in the AM & at least 30 minutes before the 1st
food or beverage of the day
o Maximize therapy by taking calcium + vitamin D
o Alendronate (Fosmax):
§ Prevention dose: 5 mg QD or 35 mg Q week
§ Treatment dose: 10 mg QD or 70 mg Q week
§ Dosage forms: solution & tablet
o Ibandronate (Boniva):
§ Prevention dose: 2.5 mg QD; 150 mg Q month may be considered
§ Treatment dose: 2.5 mg QD or 150 mg Q month
o Risedronate (Actonel):
§ Prevention dose: 5 mg QD or 35 mg Q week may be considered
§ Treatment dose: 5 mg QD or 35 mg Q week
§ Selective Estrogen Receptor Modulator:
o Raloxifene (Evista):
§ MOA: estrogen receptor agonist at the skeleton decreases resorption of bone
& overall bone turnover
§ 60 mg QD for treatment & prevention of osteoporosis
§ SE: increased risk of thromboembolism, hot flashes, nausea, dyspepsia,
weight gain
§ Teriparatide (Forteo):
o Parathyroid hormone (PTH) analog for osteoporosis
o MOA: stimulates osteoblast function, increases GI calcium absorption, increases
renal tubular reabsorption of calcium
o Dosage: injection
o Storage: refrigerate; discard pen 28 days after 1st injection
OTC:
§ Aluminum hydroxide (ALternaGel, Amphojel):
o Use: for treatment of hyperacidity & hyperphosphatemia
3 2 o MOA: neutralizes hydrochloride in stomach to form Al(Cl) salt + H O
o Dose:
§ Hyperphosphatemia: 300-600 mg TID with meals (within 20 minutes of meal)
§ Hyperacidity: 600-1200 mg between meals & at bedtime
o Aluminum may accumulate in renal impairment
o Dose should be followed with water
§ Antidiarrheal agents:
o Bismuth subsalicylate (Kaopectate)
§ Has both antisecretory & antimicrobial actions while possibly providing antiinflammatory
action as well
§ Atopic dermatisis:
o Hydrocortisone
§ Capsacin (Zostrix, Capzasin):
o MOA: induces the release of substance P, the principle chemomediator of pain
impulses from the periphery to the CNS; after repeated application, the neuron is depleted
of substance P
o Apply to the affected area at least 3-4 times/day
§ If applied less than this, decreased efficacy
o Strength: 0.025%, 0.075%
§ Delsyn
o Dextromethorphan
o Contains 0.26% alcohol
§ Diaper rash:
o Breast-fed infants have less diaper rash than do bottle-fed infants
o Skin protectants to treat:
§ Allantoin, calamine, cod liver oil (in combination), dimethicone, kaolin, lanolin
(in combination), mineral oil, petrolatum, talc, topical cornstarch, white
petrolatum, zinc oxide, zinc oxide ointment
o Can use Mycolog cream (triamcinalone & nystatin)
o Candidiasis (?)
§ Fleet’s Phospho-Soda (Sodium Phosphate):
o CI: CHF, ascites, patients on a Na restricted diet
o Saline laxative
§ Gaviscon:
o Aluminum hydroxide & magnesium trisilicate
o Use: temporary relief of hyperacidity
o Dose: chew 2-4 tablets QID
o Aluminum &/or magnesium may accumulate in renal impairment
o Do not swallow tablets whole
§ Loratidine (Claritin, Alavert):
o Nonsedating antihistamine
o Patients with liver or renal impairment should start with a lower dose (10 mg QOD)
o Do not use in children <2
o Dosing:
§ 2-5 years old: 5 mg QD
§ >6: 10 mg QD
o Take on an empty stomach
o Available as: syrup, tablet, rapidly disintegrating tablets
§ Magnesium citrate (Citro-Mag):
o Saline laxative
o Use: evacuation of bowel prior to surgery & diagnostic procedures or overdose
situations
o CI: renal failure, DM, GI complications
§ Milk of magnesia:
o Magnesium hydroxide
o Short-term treatment of occasional constipation
§ Nicotine Replacement therapy:
o Products: patch, gum, lozenge, inhaler (Nicotrol Inhaler- Rx only), nasal spray
(Nicotrol NS- Rx only)
§ Ostomy care:
o Three basic types of ostomies:
§ Ileostomy
§ Colostomy (most common)
§ Urinary diversion
o Effect of food on stoma output:
§ Foods that thicken:
· Applesauce, bananas, bread, buttermilk, cheese, pasta, potatoes,
pretzels, rice yogurt
§ Foods that loosen:
· Alcohol, chocolate, beans, fried or greasy foods, spicy foods, leafy veg
§ Foods that cause stool odor:
· Asparagus, beans, cheese, eggs, fish, garlic
§ Foods that cause urine odor:
· Asparagus, seafood, spices
§ Foods that combat urine odor:
· Buttermilk, cranberry juice, yogurt
o Local complications:
§ Local irritation: can occur because the output from the intestines or kidneys
can irritate the skin around the stoma
· Patient can use: karaya powder, pectin base powder, ostomy creams,
or barriers to protect the skin
§ Alakaline dermatitis: occurs in patients with urinary diversions because of
the alkaline nature of the output
· Major cause of blood in the pouch because it renders the stoma
extremely friable
· Treatment is acidification of the urine (cranberry juice 2-3 quarts
daily)
§ Excoriation: caused by erosion of the epidermis by digestive enzymes
· The eroded or denuded epidermis may bleed, & is painful when
touched when applying the appliance
· Treatment: karaya or pectin-based powder may be applied to the
peristomal skin prior to application of the pouch, more frequent changing
of the pouch
§ Infection: candida species
· 2% miconzaole powder or nystatin powder
o Fitting an ostomy:
§ Pouch opening may be cut to fit or presized
· If they are cut to fit, the stoma pattern is traced onto the skin barrierwafer
surface of the pouch & then cut out before being applied
§ The diameter of the round stoma is measured at the base, where the mucosa
meets the skin, which is considered the widest measurement
§ Oval stomas should be measured at both their widest & narrowest diameters
§ A stoma may swell if the appliance fits too tightly or slips, or if the patient
falls or experiences a hard blow to the stoma
§ Other consideration include: body contour, stoma location, skin creases &
scars, & type of ostomy
§ To prevent leakage, the pouch should be emptied when it is 1/3 – 1/2 full
§ The flange & skin barrier may be left in place for 3-7 days, depending on the
condition of the skin & skin barrier
§ Water will not enter the stoma so it is not necessary to cover it while
swimming, bathing, or showering
§ Oxymetazoline (Afrin):
o Adrenergic agonist; vasoconstrictor
o Rebound congestion may occur with extended use (>3 days)
o Caution in the presence of HTN, DM, hyperthyroidism, CAD, asthma
o Increased toxicity with MAOI
o Do not use if it changes color or becomes cloudy
o MOA: stimulates alpha-adrenergic receptors in the arterioles of the nasal mucosa to
produce vasoconstriction
o Approved for >6 years old
§ Poison ivy:
o Urushiol plant
o Urushiol can spread quickly over body
o Vesiclar fluid cannot further spread
§ Or not spread from the exudates of the blisters
o Topical anesthetics: benzocaine & pramoxine
o Hydrocortisone
o Astringents:
§ Aluminum acetate (Burrow’s solution, Domeboro Powder), zince oxide, zinc
acetate, sodium bicarbonate, calamine, witch hazel (hamamelis waters)
o Colloidal oatmeal baths to help to provide skin hydration, to aide in cleansing or
removing skin debris, & to allay the drying & tightening symptoms
o Antihistamines
§ Robitussin:
o Guaifenesin: an expectorant used to help loosen phlegm & thin bronchial secretions
to make coughs more productive
§ Warts:
o Plantar warts:
§ Clear Away Wart Remover: Salicyclic acid 40%
§ Wart off
§ Dr. Scholls Clear Away
Pain:
§ Pure Mu Agonists: strong opioids for severe pain
o Fentyl:
§ Sublimaze: injection
§ Duragesic: transdermal patch (change Q 3 days)
· 5 patches per box
§ Actiq: lozenge
o Hydromorphone (Dilaudid):
§ Can cause seizures
§ Dosage forms: tablet, liquid, suppository, injection (a slight yellowish
discoloration has not been associated with loss of potency
o Levoophanol (Levo-Dromoran)
§ Dosage forms: tablet & injection
o Meperidine (Demerol, Meperitab):
§ MOA: binds to opiate receptors in the CNS, causing inhibition of ascending
pain pathways, altering the perception of & response of pain
§ Dosed Q 3-4 hours
§ Hepatic metabolite, normeperidine, can buildup & cause seizures
· Do not use in patients with seizure disorders
§ Avoid use with MAOIs
· Isocarboxazid (Marplan)
· Selegiline (Eldepryl, Deprenyl)- Parkinson’s
· Phenelzine (Nardil)
· Tranylcypromine (Parnate)
o Methadone (Dolophine, Methdose):
§ Dosage forms: tablet, liquid, injection
o Morphine (Astramorph/PF, Avinza (ER cap), DepoDur, Duramorph, Infumorph,
Kadian (SR), MS Contin (ER or SR), MSIR (IR), Oramorph SR, RMS, Roxanol):
§ MOA: binds to opiate receptors in the CNS, causing inhibition of ascending
pain pathways, altering the perception of & response of pain
§ Can cause: hypotension, bradycardia, respiratory depression
§ Vasodilatory properties
§ Dosage forms:
· Capsules (ER, SR)
· Infusion
· Injection (ER liposomal suspension for lumbar epidural injection)
· Injection, solution
· Solution
· Suppository
· Tablet (CR, ER, SR)
o Oxycodone (OxyIR, Roxicodone, Percocet, OxyContin (CR)):
o Oxymorphone (Numorphan-suppository)
§ Dosage forms: injection & suppository
§ Pure mu agonists: mild to moderate pain
o Codeine (Tylenol #3)
o Hydrocodone:
§ With APAP:
· Vicoden 5/500; Vicoden ES 7.5/750; Lorcet or Vicodin HP 10/650;
Lortab 2.5/500, 5/500, 7.5/500, 10/500; Norco 5/325, 7.5/325, 10/325
§ With IBU:
· Vicoprofen 7.5/200
o Propoxyphene:
§ Propoxyphene/APAP:
· Darvocet-N-50 (50/325); Darvocet-N-100 (100/650)
· Darvon 32, 65 mg
§ Agonists-antagonists:
o Buprenorphine (Buprenex, Subutex)
o Butorphanol (Stadol)
§ Available as: injection & nasal spray
o Dezocine (Dalgan)
o Nalbuphine (Nubain)
§ Injection only
o Pentazocine:
§ 50 mg tablet: Talwin
§ 50 mg/naloxone 0.5 mg tablet: Talwin NX
§ 12.5/ASA 325 tablet: Talwin Compound
§ Miscellaneous:
o Tramadol (Ultram)
§ 400 mg max
o Ultracet (Tramadol/APAP 37.5/325)
§ NSAIDS:
o Indomethacin (Indocin):
§ Dosage:
· Inflammatory/RA: 25-50 mg/day 2-3 times/day; max 200 mg/day
§ Dosage forms: IR & SR capsule, injection & suspension
o Ketorolac (Toradol):
§ Do NOT use for more than 5 days
§ NMT 40 mg/day po
§ Acular: ophthalmic dosage form
o Nabumetone (Relafen):
§ For OA & RA
§ Dosing: 1000 mg/day; an additional 500-1000 mg may be needed in some
patients; may be administered QD or BID; NMT 2000 mg/day
§ Take with food or milk to decrease GI upset
o Diclofenac (Voltaren)
o Etodolac (Lodine)
o Tolmetin (Tolectin)
o Sulindac (Clinoril)
o Fenoprofen (Nalfon)
o Flurbiprofen (Ansaid)
o Ibuprofen (Motrin)
o Ketoprofen (Orudis, Oruvail-SR)
o Naproxen (Naprosyn)
o Oxaprozin (Daypro)
o Meclofenamate (Meclomen)
o Piroxicam (Feldene)
o Celecoxib (Celebrex)
o Interferes with ACEIs, ARBs, & diuretics
§ Conversions:
o Usual ratio is Morphine 8 to dilaudid 1
o Methadone 10 mg = hydromorphone 7.5 mg (po) & 1.5 mg (IM)
Parkinson’s:
§ A chronic progressive neurologic disorder with symptoms that present as a variable
combination of rigidity, tremor, bradykinesia, & changes in posture & ambulation
§ Primary Parkinson’s- no identified cause
§ Secondary Parkinson’s- may be the result of drug use (i.e. reserpine, metoclopramide,
antipsychotics), infections, trauma, or toxins
§ Progressive degeneration of the substantia nigra in the brain with a decrease in dopaminergic
cells
§ Drug therapy:
o Want medications that will increase dopamine or dopamine activity by directly
stimulating dopamine receptors or by blocking acetylcholine activity, which results in
increased dopamine effects
o Carbidopa-levodopa (Sinemet):
§ MOA; levodopa increases DA; carbidopa prevents metabolism of levodopa
allowing more to enter the blood brain barrier
§ Take on an empty stomach & eat shortly after to prevent N/V
o Direct stimulation of DA receptors:
§ Bromocriptine (Parlodel)
§ Pergolide (Permax)
§ Pramipexole (Mirapex)
§ Ropinirole (Requip)
o Selegiline (Eldepryl, Carbex, Atapryl, Selpak):
§ MOA: inhibits MAOB; increases DA & 5-HT
o Inhibits COMT; increases DA:
§ Entacapone (Comtan)
§ Tolcapone (Tasmar)
o Amantadine (Symmetrel):
§ MOA: may increase presynaptic release of DA, blocks reuptake
o Blocks acetylcholine, may balance DA:
§ Benztropine (Cogentin)
§ Trihexyphenidyl (Artane)
o Vitamin E- antioxidant; mixed results
Pediatrics:
§ EES ointment given in neonate to prevent gonorrhea infection in the eyes
§ Vitamin K is given to babies until they can produce their own
§ Beractant (Survanta):
o Lung surfactant
o Prevention & treatment of respiratory distress syndrome in premature infants
o If <1250 g: at risk for developing or with evidence of surfactant deficiency
o Given within 15 minutes of birth
§ Colfosceril (Exosurf): respiratory surfactant
o Administered intrathecheally
o Respiratory distress syndrome in the newborn: 5 mL (67.5 mg) per kg birthweight
INTRATRACHEALLY Q 12 hr for 3 doses
o MOA: colfosceril, cetyl alcohol, & tyloxapol combination, when used as a replacement
for deficient endogenous lung surfactant, is effective in reducing the surface tension of
pulmonary fluids, thereby increasing lung compliance properties in RDS to prevent
alveolar collapse & decrease work in breathing
§ The possibility exists that it may also improve ventilation/perfusion matching,
independent of its direct effect on lung compliance
§ Neural tube defects are a result of a decrease in folic acid (while pregnant)
§ Acetaminophen:
o <12 years: 10-15 mg/Kg/dose Q 4-6 hours prn (NMT 5 doses: 2.6 g in 24 hours)
§ Ibuprofen:
o 6 months – 12 years
§ Temperature <102.5°F: 5 mg/Kg/dose
§ Temperature >102.5°F: 10 mg/Kg/dose
§ Q 6-8 hours; max daily dose: 40 mg/Kg/day
§ Theophylline can be used as a respiratory stimulant in babies
Pharmaceutics:
§ Bioavailability: refers to the rate & extent of absorption
o Absolute bioavailability: the fraction (or %) of a dose administered non-IV (or
extravascularly) that is systemically available (compared to an IV dose)
§ If given orally, absolute bioavailability (F) is:
IV PO PO IV · F = (D /D ) X (AUC /AUC )
o Relative bioavailability: the fraction of a dose administered as a test formulation that
is systemically available as compared to a reference formulation:
test formulation reference reference test formulation § F = (AUC /AUC ) X ( D /D )
§ Compounding:
o Glycerin, talc, starch, witch hazel = suspension
§ Talc is not soluble
§ Starch is not very soluble
o To make a oleaginuous base use: white petrolatum
o Trituration: the process of grinding a drug in a mortar to reduce its particle size
§ Drug color change due to: oxidation
§ Filters:
o 0.22 micron filter does NOT remove pyrogens
§ Methylcellulose: a suspending agent (semisynthetic hydrocolloids)
§ Selected dosage forms:
o Butorphanol (Stadol)
§ Injection, intranasal spray
o Calcitonin (Miacaclin)
§ Injection, intranasal spray
§ Stored in refrigerator
o Desmopressin (DDAVP, Stimate)
§ Injection, intranasal spray, tablets
o All three above come in a nasal inhaler
o Budesonide:
§ Capsules (Entocort), nasal suspension, powder for oral inhalation, suspension
for oral inhalation
o Fluticasone:
§ Aerosol for oral inhalation, cream (Cutivate), ointment, powder for oral
inhalation, suspension intranasal spray
§ Rizatriptan (Maxalt), loratadine (Claritin), ondansetron (Zofran) are all available as an orally
disintegrating tablet (ODT)
§ Mg sterate: lubricant in tablet
o Excess will cause alteration in tablet dissolution due to decreased rate of tablet break
down (would slow down)
§ Incompatibility:
o Pick pair of drugs with one acid & one base
§ Storage:
o Liposyn-II
§ Fat emulsion
§ May be stored at room temperature
§ Do not store partly used bottle for later use
§ Do not use if emulsion appears to be oiling out
o Room temperature antibiotic suspensions:
§ Clarithromycin (Biaxin); sulfamethoxazole-trimethoprim (Bactrim);
azithromycin (Zithromax); cefdinir (Omnicef)
§ Furosemide has a pka of 3.7 at physiologic pH will it be 25% ionized, 75% ionized, all ionized,
all ionized or can’t determine?
o Furosemide (one word generic name) is an acid; acids are all non-ionized at acidic pH
but are ionized at basic pH; physiologic pH is 7.4 which is quite alkaline compared to 3.7;
means furosemide ionized to non-ionized ratio would be > 1:1000, so totally ionized
o Naproxen pka = 4.2 what would happen at plasma pH?
§ Same as above because naproxen is also an acid
§ Typical pharmaceutical ingredients:
o Antifungal preservative: used in liquid & semisolid formulations to prevent growth
of fungi
§ Ex: benzoic acid, butylparaben, ethylparaben, sodium benzoate, sodium
propionate
o Antimicrobial preservative: used in liquid & semisold formulations to prevent growth
of microorganisms
§ Ex: benzalkonium chloride, benzyl alcohol, cetylpyridinium chloride, phenyl
ethyl alcohol
o Antioxidant: used to prevent oxidation
§ Ex: ascorbic acid, ascorbyl palmitate, sodium ascorbate, sodium bisulfate,
sodium metabisulfite
o Emulsifying agent: used to promote & maintain dispersion of finely divided droplets
of a liquid in a vehicle in which it is immiscible
§ Ex: acacia, cetyl alcohol, glyceryl monostearate, sorbitan monostearate
o Surfactant: used to reduce surface or interfacial tension
§ Ex: polysorbate 80, sodium lauryl sulfate, sorbitan monopalmitate
o Plasticizer: used to enhance coat spread over tablets, beads, & granules
§ Ex: glycerin, diethyl palmitate
o Suspending agent: used to reduce sedimentation rate of drug particles dispersed
throughout a vehicle in which they are not soluble
§ Ex: Carbopol, hydroxymethylcellulose, hydroxypropyl cellulose,
methylcellulose, tragacanth
o Binder: used to cause adhesion of powder particles in tablet granulations
§ Ex: acacia, alginic acid, ethylcellulose, starch, povidone
o Diluent: used as fillers to create desired bulk, flow properties, & compression
characteristics in tablet & capsule preparations
§ Ex: kaolin, lactose, mannitol, cellulose, sorbitol, starch
o Disintegrant: used to promote disruption of solid mass into small particles
§ Ex: microcrystalline cellulose, carboxymethylcellulose calcium, sodium
alginate, sodium starch, glycolate, alginic acid
o Glidant: used to improve flow properties of powder mixture
§ Ex: colloidal silica, cornstarch, talc
o Lubricant: used to reduce friction during tablet compression & facilitate ejection of
tablets from the die cavity
§ Ex: calcium stearate, magnesium stearate, mineral oil, stearic acid, zinc
stearate
o Humectant: used for prevention of dryness of ointment & creams
§ Ex: glycerin, propylene glycol, sorbitol
Pharmacokinetics:
§ Tests used to test for drug absorption in GI:
o Dissolution
o Disintegration: must occur before dissolution can occur
o Hardness: hardness of a tablet influences its ability to break apart in the stomach
o All can be tested in vitro
Pregnancy:
§ Tocolytics (stops labor):
o Magnesium is a tocolytic
§ Labor inducers:
o Prostaglandins and oxytocin both cause labor to start or proceed
o Oxytocin (Pitocin) is parenteral only (usually IV)
o PGE-2 does come in a gel that is applied to ripen the cervix prior to induction of labor
& in suppositories (still technically topical) to induce labor
§ Fetal alcohol syndrome: facial deformities (low nasal bridge, flat midface), postnatal growth
retardation, or mental retardation
§ Treatment of patent ductus arteriosus:
o *Indocin injection*
§ IV indomethacin
o Ibuprofen
o Oxygen
o Diuretics
o Purpose of the ductus arteriosus in utero: to shunt blood from the pulmonary artery
to the aorta
§ Hydroxyurea (Droxia, Hydrea): use to increase fetal hemoglobin in sickle cell patients
Priaprism:
§ Causative agents: chlorpromazine, prazosin, trazodone, other phenothiazines,
antihypertensives, anticoagulants, corticosteroids, & any drug used to produce an erection
o PDE-5 inhibitors:
§ Sildenafil (Viagra)
§ Vardenafil (Levitra)
§ Tadalafil (Cialis)
· Can last up to 36 hours
Psoriasis:
§ Chronic, epidermal proliferative disease characterized by erythematous, dry scaling patches,
recurring remissions & exacerbations
§ Treatment:
o Mild to moderate disease:
§ Emollients BID: soft yellow paraffin or aqueous cream; petrolatum or
Aquaphor cream (greasier & more effective)
§ Topical, low potency corticosteroids on delicate skin (face, genitals):
alclometasone dipropionate, triamcinolone acetonide 0.025%, hydrocortisone 2.5%
§ Topical, medium potency cortisteroids: fluticasone propionate, triamcinolone
acetonide 0.1%, hydrocortisone valerate, mometasone furoate
§ Topical, strong potency: betamethasone dipropionate, halcinonide,
fluocinonide, desoximetasone
§ Topical, super potency: augmented betamethasone dipropionate, diflorasone
diacetate, clobetasol propionate, halobetasol propionate
· Limit use to 2 weeks
· Avoid occlusive dressings
§ Intralesional corticosteroid: 2-5 mg/mL triamcinolone acetonide
§ Coal tar (Estar, PsoriGel) as an alterative to topical steroids
§ Keratolytic agents to decrease scales: salicyclic acid 6% gel
§ UV lamps & sunlight are effective- best option for pregnancy or young
children
· Anthralin ointment 1% or higher prior to light
o Severe disease:
§ Triamcinolone, intralesional mix
§ Vitamin D analogs (calcipotriene ointment 0.05%- not on face)
§ Acitretin (Soriatane)
§ Tazarotene (Tazorac)
§ Methotrexate, hydroxyurea, azathioprine, or cyclosporine
o Triamcinolone (Aristocort A; Aristocort Forte; Aristospan; Azmacort; Kenalog;
Nasacort AQ; Nasacort HFA; Tri-Nasal; Triderm)
Psychriatric Disorders:
§ ADHD:
o Methylphenidate (Concerta, Methadate, Methylin, Ritalin)
§ MOA: reuptake blockade of catecholamine (NE & DA) in presynaptic nerve
endings
§ Dosage form of Concerta: 18, 27, 36, 54 mg ER tablets
· NOT SR
o Atomoxetine (Strattera):
§ BBW for suicide ideation in children
§ MOA: NE reuptake inhibitor
§ Dosed once daily (advantage over Concerta)
§ Antidepressants:
o SSRIs:
§ MOA: selectively inhibit the reuptake of 5-HT
§ Citalopram (Celexa)
§ Escitalopram (Lexapro)
§ Fluvoxamine (Luvox)
§ Sertraline (Zoloft)
· Auxiliary labeling:
o No etoh
o May cause drowsiness or dizziness
o May cause sexual dysfunction
o Take in AM to prevent insomnia in PM
§ Fluoxetine (Prozac):
· Does not require tapering because of its long half life
· Take in AM
§ Paroxetine (Paxil):
· Take in AM to reduce chances of insomnia
· Paxil CR incorporates a degradable polymeric matrix (Geomatrix) to
control dissolution rate over a period of 4-5 hours
o EC delays the start of drug release until tablets have left the
stomach
§ May take 4 weeks to see effects
o Miscellaneous:
§ Bupropion (Wellbutrin, Zyban):
· MOA: dopamine reuptake inhibitor
· CI with history of seizure disorder
§ Venlafaxine (Effexor):
· MOA: inhibits the reuptake of 5-HT & NE (& DA at higher doses)
· Referred to as a serotonin-norepinephrine reuptake inhibitor (SNRI)
· XR formulation is available to decrease GI upset
· Not recommended in patients with uncontrolled HTN, recent MI, or CV
disorders
§ Duloxetine (Cymbalta):
· MOA: potent inhibitor of 5-HT & NE (no DA activity)
· Indicated for both major depression & diabetic peripheral neuropathic
pain
· CI: uncontrolled narrow-angle glaucoma
§ Trazodone (Desyrel):
2A · MOA: inhibits 5-HT reuptake & blocks 5-HT receptors
§ Nefazodone (Serzone):
2A · MOA: inhibits 5-HT & NE uptake & blocks 5-HT receptors
§ Mirtazapine (Remeron):
· MOA: antagonizes presynaptic á-2 autoreceptors & heteroreceptors
that prevent the release of 5-HT & NE (resulting in increased 5-HT & NE
2A 3 in the synapses); antagonizes 5-HT & 5-HT receptors, resulting in less
GI upset & less anxiety
o Combinations:
§ Olanzapine & fluoxetine (Symbax):
· Atypical antipsychotic agent/SSRI
· Use: treatment of depressive episodes associated with bipolar disorder
o MAOIs:
§ MOA: increase the synaptic concentration of NE, 5-HT, & DA by inhibiting
the breakdown enzyme, monoamine oxidase
§ Isocarboxazid (Marplan)
§ Phenelzine (Nardil)
§ Tranylcypromine (Parnate)
§ Medications to avoid on MAOIs:
· Compazine
· Phenylpropanolamine: tyramine-like reaction
· Pseudoephedrine: tyramine-like reaction
· Meperidine (Demerol): life-threatening serotonin syndrome-like
reaction
· Methyldopa (Aldomet): hypertensive crisis
· Morphine (Roxanol, MS Contin): CNS depression
· Reserpine (Ser-Ap-Es): increased catecholamines
· Serotonergic agents (i.e. fluoxetine): serotonin syndrome
o TCAs:
§ MOA: increase the synaptic concentration of 5-HT &/or NE in the CNS by
inhibiting the presynaptic neuronal membrane’s reuptake of 5-HT or NE
§ Amitriptyline (Elavil)
· Off label use: neuropathic pain
§ Nortriptyline (Pamelor, Aventyl)
§ Imipramine (Tofranil)
§ Doxepin (Sinequan)
§ Clomipramine (Anafranil)
§ Desipramine (Norpramin)
§ Antipsychotics:
o Atypical:
§ Arpiprazole (Abilify):
· AE: insomnia, +/- weight gain
· Once daily dosing benefit
· Partial dopamine agonist
§ Clozapine (Clozaril, FazaClo-ODT:
· For refractory schizophrenia only
· A Dibenzodiazepine
· AE: sedation, weight gain, hypersalivation, seizure risk
· Weekly CBC with diff required
o WBC <3500 or ANC <1500 MUST discontinue
§ Olanzapine (Zyprexa, Zydis-ODT):
· MOA: a thienobenzodiazepine antipsychotic that is believed to work
by antagonizing dopamine & serotonin activities
o It is a selective monoaminergic antagonist with high affinity
2A 2C 1-4 1-5 binding to 5-HT & 5-HT , dopamine D , muscarinic M ,
1 histamine H & á-1 receptor sites
o Binds weakly to GABA-A, BZD, & beta-adrenergic receptors
· AE: sedation, orthostasis
§ Quetiapine (Seroquel):
· A dibenzothiazepine
· Low EPS risk
§ Risperidone (Resperdal):
· Benzisoxazole
· Use: schizophrenia, bipolar
· Dosage forms: injection, solution, tablet, ODT
§ Ziprasidone (Geodon)
· Benzisothiazoyl
· AE: +/- sedation, +/- weight gain, QT prolongation
o Typical:
§ Chlorpromazine (Thorazine)
§ Fluphenzaine (Prolixin)
§ Haloperidol (Haldol)
· SE: Hyper-, hypotension, tachycardia, arrhythmias, torsade de
points, EPS, anxiety, alopecia, rash, gynecomastia, jaundice, blurred
vision
§ Thioridazine (Mellaril)
· BBW: QT prolongation
§ Thiothixene (Navane)
· a psychotropic agent derived from thioxanthene & clinically useful in
the tx of schizophrenia
· Similarities in chemical & pharmacological properties exist between
this agent & piperazine phenothiazines
§ Anxiolytic agents:
o Benzodiazepines:
§ MOA: potentiate the actions of GABA by increasing the influx of Cl ions into
neurons
§ Alprazolam (Xanax, Niravam-ODT)
§ Chlordiazepoxide (Librium)
· Available as injection
o Prior to reconstitution, keep refrigerated & protected from light
o Should be used immediately following reconstitution
§ Clonazepam (Klonopin)
· Available as an orally disintegrating wafer
§ Clorazepate (Tranxene)
§ Diazepam (Valium)
· Available as injection
o Potency is retained for up to 3 months when kept at room
temp
§ Estazolam (Prosam)
§ Flurazepam (Dalmane)
§ Halazepam (Paxipam)
§ Lorazepam (Ativan)
· Available as an injection
· Intact vials should be refrigerated & protected from light
· Do not use if discolored
· Injectable vials may be stored at room temperature for up to 60 days
· Parenteral admixture is stable at room temperature for 24 hours
§ Oxazepam (Serax)
§ Prazepam (Centrax)
§ Quazepam (Doral)
§ Temazepam (Restoril)
§ Trazolam (Halcion)
§ Lorazepam, oxazepam, & temazepam (LOT) are conjugated & preferred in
patients with hepatic dysfunction & elderly patients
§ Chlordiazepoxide, diazepam, & lorazepam available for IV use
§ Never abruptly discontinue
§ Avoid in pregnancy- cause cleft palate
o Buspirone (BuSpar):
1A § MOA: unknown. It exhibits high affinity for serotonin (5-HT ) receptors,
moderate affinity for brain D2-dopamine receptors & no significant affinity for
benzodiazepine receptors. It has no effect on GABA binding.
§ Non-FDA labeled indication: depression
§ Non-sedating
§ No grapefruit
§ Take consistently either with or without food
§ EPS treatment:
o Dystonia: state of abnormal tonicity, sometimes described simplistically as a severe
“muscle spasm”
§ Benzotropine mesylate 2 mg
§ Diphenhydramine 50 mg IV or IM
§ Diazepam 5-10 mg by slow IV push
§ Lorazepam 1-2 mg IM
o Akathisia: inability to sit still & being functionally mortor restless
§ Diazepam 5 mg TID
§ Propanolol 10 mg QD
§ Nadolol 80 mg QD
· Beta 2 selective are less effective
o Pseudoparkinsonism: an AP-induced extrapyramidal side effect, resembles idiopathic
Parkinson’s Disease
§ Patient may have slurred speech & a drooping face
§ Trihexyphenidyl 2-5 mg TID
§ Diphenhydramine 25-50 mg TID
§ Biperiden (Akineton) 2 mg TID
§ Amantadine
o Tardive dyskinesia: syndrome characterized by abnormal involuntary movements
occurring late in onset in relation to initiation or AP therapy
§ No FDA approved agents
§ á-tocopherol (vitamin E) 1200-1600 IU has been tried
§ Mood stabilizers:
o Bipolar
o Lithium (Eskalith CR, Lithobid, Eskalith, Cibalith-S--syrup):
§ Use: bipolar disorder
§ CI: renal disease, severe CVD, pregnancy
§ SE: hyponatremia
§ Monitor thyroid function
§ “Lithium does everything that sodium will do”
§ Reaches steady state in 4-5 days
· Obtain level 2-8 hours post-dose
· Toxicity:
o Mild (serum levels 1.5-2):
§ GI upset (N/V/D), muscle weakness, fatigue, fine hand
tremor, difficulty with concentration & memory
o Moderate (2-2.5):
§ Ataxia, lethargy, nystagmus, worsening confusion,
severe GI upset, coarse tremors, increased deep tendon
reflexes
o Severe (>3):
§ Severely impaired consciousness, coma, seizures,
respiratory complications, death
§ Dosage forms: capsules, syrup, tablet (IR, CR, slow release)
§ DI:
· Increase Li levels:
o NSAIDS
o ACEI
o Fluoxetine
o Metronidazole
o Diuretics
o Sodium depletion: low sodium diet, excessive sweating,
vomiting/diarrhea, salt deficiency
· Decrease Li levels:
o Theophylline
o Caffeine
o Pregnancy
o Osmotic diuretics (mannitol, urea)
§ Pregnancy category: D
o Divalproex sodium (Depakote)
o Carbamazepine (Tegretol)
§ Tourette’s Syndrome:
o Simple tics & 1st line of therapy is short acting benzodiazepines
o Next is clonidine which does not cause tardive dyskinesia in these patients
o Intermediate acting benzodiazepines (Ativan) are also useful
o For severe cases, the choice is an antipsychotic such as haloperidol (Haldol) or
pimozide (Orap) but these can cause tardive dyskinesia, dysphoria, & pseudoparkinson’s
§ Anon-sedating anxiolytic for the elderly: buspirone (Buspar)
o Has a high affinity for 5-HT & dopamine receptors
o Does not affect benzodiazepine GABA receptors
Questions:
§ Mother has gestational diabetes, what is likely to occur when the baby is born. Mother also
has epilepsy & is taking tegretol.
o I. high birth weight II. Baby may have congenital abnormalities III. Baby is
likely to have diabetes
o Answer: I & II
o Tegretol is a class D drug
§ What strength will Albuterol 0.5% end up based on an order to mix it with 2.5 mL normal
saline?
o 0.083%
§ Isosorbide dinitrate is dosed BID, what regimen is best 7 am & 12 noon, 7 am & 7 pm, 9 am
& 9 pm, 8 am & 5 pm?
o 8 am & 5 pm to allow nitrate free period (same as removing NTG patches at bedtime)
§ What substitute can you use for desitin ointment (Balmex, Boudreaux’s Butt Paste)?
o Zinc oxide
§ Precose counseling information:
o I. Take 30 minutes before meal II. Causes gas III. Should not take if
meal skipped
o Answer: II & III
§ What treatment would increase antibiotic compliance? Patient receiving zithromax 1 tsp QD
x 5days
o Augment, ceftriaxone, cefuroxime axetil, doxycycline
o Answer: the usual method to improve compliance for any type of drug is to reduce
the number of doses that must be taken each day & to give a drug with the fewest
uncomfortable or dangerous SE (I would chose ceftriaxone- IM single dose treatment)
§ Which of the following could you give a patient on NTG?
o I. Cialis II. Muse (alprostadil) III. Caverject (alprostadil)
o Answer: II & III- alprostadil is prostaglandin used for erectile dysfunction & patent
ductus arteriosus
§ Available as: intracavernosal Kit, intracavernosal powder for solution,
intracavernosal solution, intraurethral Suppository, & intraurethral solution
§ Alprostadil (Prostin VR)
§ Patient requesting antihistamine eye drop & having a dark spot in vision- refer to MD
§ Which of the following is available in a liquid formulation?
o I. NTG II. Hydroxyzine III. Digoxin
o Answer: II & III
§ Which is the shortest acting insulin?
o Humulin N, Humulin U, Humalog, or regular
o Answer: Humalog
§ Who should not get a flu shot?
o An infant in day care; 32 yo type II diabetic; 65 yo retired lady; 35 yo nurse working
in hospital
§ Answer: 32 yo type II diabetic
§ Which of the following cannot be self monitored?
o Glucose level; K level; cholesterol levels; hormone used in pregnancy test
o Answer: K levels
§ Cytoxan is most similar to mechlorethamine, procarbazine, or 5-FU?
o Answer: mechlorethamine
§ A patient with Traveler’s diarrhea too PeptoBismol 4 tsp Q ½ hour. After 3 days he began
experiencing ringing in the ears. What does he have? Bismuth toxicity or salicylate toxicity?
o Answer: salicylate toxicity
o Bismuth toxicity would cause neurotoxicity
§ Which of the following are OTC hemorrhoid treatments:
o I. TUCKs pads II. Nupercainal ointment III. Rowasa
o Answer: I & II
§ Which of the following is an ER Morphine?
o A. MSIRB. MS Contin C. Diluadid D. Oxycontin
o Answer: B
§ Which of the following agents should be administered to a person exposed to Anthrax?
o A. Flagyl B. Cipro C. Zovirax D. Valtrex
o Answer: B
§ Erythromycin exhibits its anti-infective properties by- blocking protein synthesis via binding
& inhibition of the 50-S subunit of bacterial ribosomes
§ Patient has pseudomembranous colitis & allergy to metronidazole. Which of the patient’s
medications could have caused the pseudomembrane colitis?
o A. IbuprofenB. Tylenol C. Flagyl D. Cleocin E. Zantac
o Answer: D
o This person could be treated with?
§ A. Flagyl B. Vancomycin C. Doxycycline D. Lincomycin E .
Ampicillin
§ Answer: B
o The DOC for the treatment of pseudomembraneous colitis is:
§ A. Metronidazole B. Erythromycin C. Clindamycin D. Ampicillin E .
Lincomycin
§ Answer: A
§ Which of the following NSAIDs has an ophthalmic preparation:
o A. IbuprofenB. Naproxen C. Diclofenac D. Ketoprofen
o Answer: C- Voltaren
§ Cedax acts by- inhibiting the use of pencillin binding proteins in bacterial cell wall synthesis
§ Acetylcysteine in the treatment of CF is best given:
o A. IV B. By inhalation C. IM D. Orally
o Answer: B
§ A patient is given a rx for fentanyl 100 mcg/hr patch for 1 month. How many boxes should
you dispense?
o A. 1 B. 2 C. 3 D. 4 E. 5
o Answer: 2; 1 patch= 3 days, so you need 10 patches; comes in boxes of 5 patches so
you need 2
§ Which of the following is not an erythropoetin formulation?
o A. Epogen B. Procrit C. Aranesp D. Neupogen
o Answer: Neupogen
§ Which of the following fluoroquinolones has an otic preparation?
o Answer: ofloxacin (Floxin- also has an ophthalmic);
o Eye drops only: levofloxacin, gatifloxacin, moxifloxacin
§ The use of this agent is CI in children?
o A. Erythromycin B. Bactrim C. Ciprofloxacin D. Cephalexin
o Answer: C
§ What is the recommended daily dosage of calcium for an adult?
o A. 300-500 mg B. 600-800 mg C. 800-1000 mg D. 100-1500 mg
o Answer: D
§ Due to difficulty in coordinating their inhalations, older patients should use:
o A. Nebulizer B. Peak flow meter C. Spacers D. Spirometer
o Answer: C
§ Monitoring of asthma at home can be done with:
o A. Nebulizer B. Peak flow meter C. Spacers D. Spirometer
o Answer: B
§ A patient using a One-Touch machine will also need:
o A. Ketostix B. Cuff C. Lancing device D. Sphygmomanometer
o Answer: C
§ Which drug does not have immunomodulating effects?
o A. Prednisone B. Cyclosporin C. 5-FU D. Interferon alpha E. Infliximab
o Answer: 5-FU
§ Which of the following is used in the treatment of RA?
o I. Gold II. NSAID III. Immunosuppressant
o Answer: all of the above
§ Patient received a Z-pack on 11/25, what day will the patient finish the pack?
o A. 11/29 B. 11/30 C. 11/28
o Answer: A
§ A hypertensive patient that has a cold can be treated with:
o I. guaifenesin II. Dextromethorphan III. Diphenhydramine
o Answer: I & II
§ What would you give for an H. pylori infection?
o A. Amphotericin B B. Cipro C. Clarithromycin D. Levaquin
o Answer: C
§ Cyclosporine is available as:
o I. Rapamune II. Sandimune III. Neoral
o Answer: II & III (Rapamune is Sirolimus)
§ Which smoking cessation products are available OTC?
o I. Patch II. Nasal Spray III. Nasal Inhaler
o Answer: I only
§ Have a patient profile, patient is allergic to PCN & sulfa, they give you the option to treat with
bactrim, augmentin, 2 cephalosporings, or biaxin
o Answer: Biaxin
§ A person with Aspergillus could be treated with:
o I. Ampho B II. Itraconazole III. Ketoconazole
o Answer: I & II
§ Given patient profile; patient is on vicoden ES & taking acetaminophen what else can the
patient take?
o I. APAP II. ASA III. IBU
o Answer: II & III
§ Which of the following would be used to treat poison ivy?
o I. calamine II. Hydrocortisone III. Aluminum acetate (Domboro’s solution)
o Answer: I, II, III
§ Vitamin K is available as:
o I. injection II. Tablet III. Solution
o Answer: I & II
Raynaud’s Phenomenon:
§ Reversible vasospasm of the digital arteries that can result in ischemia of the digits
§ Avoid exposure to cold
§ CCB’s (i.e. nifedipine) are the preferred initial agents
§ Alternative vasodilators, such as prazosin (Minipress), may be helpful
§ Aggregated by beta blockers
References:
§ USP-NF:
o Officially recognized by the Federal Government in establishing standards for drugs
o Official monographs that describe drug structure, solubities, assays, & therapeutic
category with limited information of dosage, dosage forms, etc.
o Official tests (dissolution, disintegration) & definition of dosage forms
o No dosing or pharmacology
§ USP DI (Micromedex):
o Volume I: DI for the health care professional
§ Extensive information on about over 11,000 drug products available in the US
§ Includes pharmacology, AE, CI
o Volume II: advice for the patient
§ Easy to understand information to assist health professionals in providing
comprehensive patient education
o Volume III: approved drug products & legal requirements
§ Addresses regulatory information for prescribing & dispensing drugs in the
US
§ Also includes the complete FDA orange book
§ Orange Book Companion:
o Contains extensive patent & market exclusivity information for FDA-approved drugs
& national drug code classifications
§ Remington’s Pharmaceutical Sciences:
o An encyclopedia of pharmacy with information of pharmacology of drugs, theoretical
science, sterilization, isotonicity, healthcare products, practical pharmacy practice, etc
o Probably the best source of information not readily available in other references
o E-values
§ Facts & Comparisons:
o Looseleaf publication with monthly updates
o Lists both rx & OTC drugs by therapeutic categories with concise information
concerning pharmacology, dispensing information, ingredients
o Has a list of drugs from Canada
§ AHFS Drug Information:
o In-depth drug information addressing pharmacology & use of drugs
o Intended mainly for use by institutional RPhs
o Updates available regularly online
o Hass off-label use
§ American Druggist Blue Book & Drug Topics Red Book:
o Both consist of alphabetical listing of drugs, OTCs, cosmetics, & other items sold in
pharmacies
o Wholesale prices, AWPs, some suggested retail prices, NDC #’s & package sizes are
included
o Other sections list manufacturer address, product IDs, & pharmacy organizations
§ Physician’s Desk Reference (PDR):
o Yearly publication:
§ White pages: manufacturer’s index of products
§ Pink pages: product names listed by trade name
§ Blue pages: products listed by therapeutic categories
§ Yellow pages: generic names with trade names; colored product
identifications
o Remaining bulk of PDR contains drug descriptions listed by companies (often consists
of PI information, but not always)
§ Listing in this section is voluntary
§ Martindale’s Extra Pharmacopeia:
o Very comprehensive listing of information concerning drugs, especially those from
Europe
§ Handbook of Nonprescription Drugs (APhA):
o OTC products by category
o Extensive list of commercial products with manufacturer & ingredients
o PDR Nonprescription Drugs Book is not as complete
§ Merck Manual:
o Describes diseases by diagnostic symptoms & suggested therapy
§ Merck Index:
o Alphabetical listing of chemicals with data concerning solubility, structures, etc.
Sepsis:
§ Hypotension
§ Drotrecogin alpha (Xigris):
o Recombinant human activated protein C
o Has antithrombic, anti-inflammatory, & profibrinolytic properties
o Dosed 24 mcg/kg body weight/hr
o CI: increased risk of hemorrhage
o MOA: inhibits factors Va & VIIIa, limiting thrombotic effects
Shingles (Herpes Zoster):
§ Wet dressings with tap water or 5% aluminum acetate (Burrow’s) applied 30-60 minutes 4-6
times per day
§ Lotions such as calamine
Treatment of complications:
o 2nd bacterial skin infections:
§ Silver sulfadiazine
o Postherpetic neuralgia & zoster-associated pain:
§ Amitriptyline 25 mg QHS
§ Lidocaine (Lidoderm) patch 5% applied after skin rash closure over painful
areas (limit 3 patches simultaneously) for up to 12 hours
§ Gabapentin 100-600 mg TID
§ Pregabalin 50-100 mg TID
· Limited by AE
§ Capsaicin (Zostrix) cream
Silicosis:
§ A form of pneumoconiosis resulting from occupational exposure to & inhalation of silica dust
over a period of years
§ Characterized by a slowly progressive fibrosis of the lungs, which may result in impairment
of lung function
§ Predisposes person to pulmonary tuberculosis
Statistics:
§ Mean: the average of a set of values
§ Median: the middle value in a set of measurement
§ Mode: the value that appears most frequently
§ Statistically significant: the likelihood (probability) of obtaining a given result by chance
o p < 0.05
§ Standard deviation: statistical index of the degree of deviation from central tendency,
namely, of the variability within a distribution
§ T Test: used to compare two groups
Tests:
§ Blood glucose kits:
o Testing without pricking finger: Clinitest Tabs & TesTap- used to test urine sugar
then correlate to blood sugar
§ Cholesterol Kits
o Advanced cholesterol test kit
§ Need to avoid for at least 4 hours prior to testing: iron, prozac, vitamin c,
APAP
§ Heme guaiac exam:
o Vitamin C (antioxidant) can interfere with test
o Visual limitations can limit test
o Hemorrhoids (blood would cause a false +)
o Example test: EZ detector
§ Patient with a high PTT & receiving heparin:
o Could hold it then restart it at a lower dose
§ Patient on lovenox & warfarin:
o Appropriate to monitor:
§ APTT (no)
§ PT (yes for warfarin)
§ INR (yes for warfarin)
§ Ovulation tests:
o Test a rise in leutinizing hormone (LH) as an indicator for ovulation
o Examples include: First Response, Ovutime, Q-Test
§ Pregnancy tests:
o Measure a rise in the level of chorionic gonadotropin (HCG, CG) that begins the 2nd
week of pregnancy & peeks at about 8 weeks
§ Detect contraception 2 weeks after last missed period
§ Take first thing in the AM
§ Taking BP:
o Patients should refrain from smoking or caffeine ingestion for 30 min
o Measurement should begin after being seating at least 5-min
o Proper size cuff should be used
§ The bladder should encircle at least 80% of the arm & the width of the cuff
should be at least 2/3 the length of the upper arm
o Position cuff 1 inch above antecubital crease
o Ask patient about previous readings
o Inflate cuff rapidly to approximately 30 mm Hg above previous readings
o Deflate slowly & listen for Korotkoff sounds
o Wait 1-2 minutes before repeating
o Fluctuation of BP by 10 mm Hg from morning to night is normal
§ Urine glucose test kits:
o Clinitest tabs
§ Test method: copper sulfate
§ Urine & water mix in test tube, add reduction method tablet, wait for reaction
end, see resulting color on chart
o Chemstrip-uG
§ Test method: glucose oxidase
§ Dip stick into urine and wait for color to develop, then read on chart
o Clinistix, Diastix, TesTape
§ Test method: glucose oxidase
§ Dip stick in urine read color change on chart; dextrose only
o The copper sulfate method is better quantitatively but is subject to more interferences
(false +)
o The glucose oxidase method is less subject to interferences but is less accurate
Vaccines:
§ Active immunity: protection produced by an individual’s own immune system
o Vaccination: process of producing active immunity via use of vaccines
§ Passive immunity: protection produced by an animal or human & transferred to another
o Ex: immunity infants receive from mother
o One source of passive immunity is antitoxins, which contain antibodies against a
known toxin
o Immunoglobins (hep A)
§ Live vaccines:
o Influenza (live-attenuated), measles, mumps, rubella, typhoid oral, *varicella*,
vaccinia (small pox), yellow fever
§ Avoid with AIDS
§ Inactivated vaccines: anthrax, diphtheria, H. flu type b, hepatitis A & B, influenza, Japanese
encephalitis, meningococcal, pertassis (acellular), pneumococcal (polysaccharide & conjugate),
rabies, tetanus, typhoid (injectable)
§ Vaccine ok for pregnancy: flu (2nd or 3rd trimester) & tetanus
o AVOID MMR for the rubella part & varicella
o AVOID live viruses
o Do not give till 2nd trimester
o Hepatitis B, inactivated polio, & pneumococcal are all recommended if indicated
§ Vaccine needed in asthma patients: influenza
§ Vaccines that come PO & IV:
o Polio
§ IPOL: inactivated, trivalent injectable vaccine
§ OPV: oral- discontinued in US because of elimination of wild-type disease
§ Vaccines that need to be reconstituted:
o Hib
o Meningococcal (Menomune)
o MMR (MMR II)
o Varicella (Varivax)- for chickenpox
§ Prevnar: vaccine against a collection of bacteria that cause pneumonia
o Used in children up to 5 years old & usually delayed until child is 2
§ Pneumovax 23 cannot
§ Patients with spleenectomy:
o Pneumococcal vaccine is most essential
o Can also give: Hep A & B, MMR, varicella, flu
§ Vaccines grown in eggs: influenza (CI), measles (“should receive it”), mumps (not a CI)
§ Vaccines that can be given around 2 months of age: hepB, DTaP (diphtheria, tetanus,
pertussis), Hib (haemophilus influenza type b), IPV (polio), PCV (pneumococcal)
§ Diphtheria & tetanus: give Q 10 years
§ Hepatitis is given: 0, 1, then at 6 months
Vitamins/Minerals/Elements:
§ Elemental calcium:
o Calcium carbonate: 40%
§ Tums contains 500 mg of calcium carbonate, therefore 200 mg of element
calcium is provided
o Calcium phosphate tribasic: 39%
o Calcium citrate: 24%
§ Elemental Iron:
o Ferrous fumarate (Femiron, Fumerin, Feostat): 33%
o Ferrous sulfate (Feosol, Fer-in-Sol): 20%
o Ferrous gluconate (Fergon): 12%
o IV iron:
§ Iron dextran (InFeD)
· Risk of anaphylaxis: must receive a test dose
§ Sodium ferric gluconate (Ferrlecit)
§ Iron sucrose (Venofer)
§ Can cause hypotension
o Patient instructions:
§ Take on an empty stomach
· If unable to tolerate: administer with a small snack
· Avoid dairy products or tea
· Take with OJ if possible
§ Take 1 hour before or 3 hours after any antacids
§ May darken stools
§ May cause: constipation or diarrhea, N/V
§ Water soluble vitamins:
o Vitamin C (ascorbic acid)
§ Deficiency: Scurvy
1 o Thiamine (B ):
§ Sulfur
§ Deficiency: Beriberi; Wernicke-Korsakoff syndrome
2 o Riboflavin (B ):
§ Will impart a red-green-orange fluorescence to urine
3 o Niacin (B )
§ Nicotinic acid
§ Niacinamide (micotinamide)
· No hypolipidemic or vasodilating effect
6 o Pryidoxine (B ):
§ Deficiency: convulsions
§ Higher requirements for patients on isoniazid, oral contraceptive, or
hydralazine therapy
o Folic acid:
§ Deficiency: megaloblastic anemia
§ Dietary sources: leafy green vegetables, beef liver & citrus fruits
12 o Cyanocobalamin (B ):
§ Has cobalt
§ Deficiency: pernicious anemia, macrocytic anemia
§ Fat soluble vitamins:
o Vitamin A:
§ Reinoids, Retinol, Retinoic acid, Cartenoids, Beta carotene
§ Deficiency: dry eye (Xerophthalmia), night blindness, nyctalopia
§ Neomycin, mineral oil, cholestyramine administration may also cause vitamin
A malabsorption
o Vitamin D:
3 § Cholecalciferol (D ); ergocalciferol
§ Deficiency: Rickets
o Vitamin E:
§ Tocopherols; alpha-tocopherol; tocotrienol
§ Prevents hemolytic anemia
o Vitamin K:
1 2 3 § Phytonadione (K ), Menaquinone (K ), Menadione (K )
Weight Loss:
§ Noradrenergic Agents:
o Methamphetamine
o Amphetamine
o Dextroamphetamine (Dexedrine)
o Benzphetamine (Didrex)
o Amphetamine/dextroamphetamine mixture (Adderall)
o Phendimetrazine (Prelu-2, Bontril, Plegine, X-Trazine)
o Phentermine (Fastin, Oby-trim, Adipex-P, Ionamin)
o Diethylpropion (Tenuate)
o Mazindol (Mazanor, Sanorex)
§ Serotonergic Agents:
o Fluoxetine (Prozac) & Sertraline (Zoloft)- unlabeled uses
§ Noradrenergic/Serotonergic Agents:
o Sibutramine (Meridia)
§ CYP3A4
§ Strength: 5, 10 & 15 mg capsules
§ Gastrointestinal Lipase Inhibitor:
o Orlistat (Xenical)
§ Oily spotting; fecal incontinence
§ Absorption of fat soluble vitamins may be decreased
§ Strength: 120 mg capsule
Wilson’s Disease:
§ An autosomal recessive disorder that results in progressive copper overload
§ The average age at presentation of liver dysfunction is 10-15 years
§ Neuropsychiatric disorders can manifest later
§ Treatment:
o Copper-chelating agents:
§ Penicillamine (Cuprimine, Depen)
· MOA: chelates with lead, copper, mercury, & other heavy metals to
form stable, soluble complexes that are excreted in urine
§ Trientine (Syprine):
· MOA: an oral chelating agent structurally dissimilar from
penicillamine & other available chelating agents
§ Zinc salts
Women’s Health:
§ Birth Control:
o Sunday start for BC pills means: start the pack on the Sunday after the period starts
o Estrogen:’
§ Prevent development of a dominant follicle by suppression of FSH; does not
block ovulation
· SE: breast tenderness, heavy bleeding, headache
o Progestin:
§ Blocks ovulation; contributes to production of thick & impermeable cervical
mucus; contributes to involution & atrophy of endometrium
· SE: depression, headache, irritability
o Progesterone: decreases the risk of endometrial cancer
o Progestin-only (minipill):
§ Appropriate for use in breastfeeding women
§ Efficacy is less than that of combined oral contraceptives
§ Free of cardiovascular risks associated with estrogen-containing products
§ Ortho Micronor, Errin, Nor-QD, Nora-BE, Camila, Ovrette
o Biphasic oral contraceptives: Ortho-Novum 10/11, Necon 10/11
o Yasmin:
§ Ethinyl estradiol & drospirenone
· Drospirenone is a spironolactone analogue with antimineralocorticoid
& antiandrogenic activity
§ PMS:
o Symptoms: depressed mood, mood swings, irritability, difficulty concentrating,
fatigue, edema, breast tenderness, headaches, sleep disturbances
§ Postmenopausal hormone replacement therapy:
o Women with an intact uterus must be treated with estrogen + progestin
o Women with out a uterus- estrogen only
o Ingredients in PremPro or Premphase: conjugated estrogen & medroxyprogesterone
o Medroxyprogesterone (Provera) is with ERT to decrease the risk of endometrial cancer
§ Levonorgestrel (Plan B, Mirena-intrauterine system):
o For emergency contraception: 1 tablet (0.75 mg) asap within 72 hours of unprotected
sexual intercourse; a 2 tablet (0.75 mg) nd should be taken 12 hours after the 1st dose; can
be used at any time during the menstrual cycle
Zollinger-Ellison Syndrome:
§ A triad of:
o Markedly elevate gastric acid secretion
o Peptic ulcer disease
o A gastrinoma or non-beta islet cell tumor of the pancreas or duodenal wall which
produces gastrin
§ DOC:
o PPIs:
§ Omeprazole 60-120 mg/day
§ Lansoprazole 60-180 mg/day
§ Rabeprazole 60-100 mg/day
§ Pantoprazole 40-240 mg/day
o H2 blockers:
§ Cimetidine 300 mg Q6h; up to 1.25-5 gm/day
§ Ranitidine 150 mg Q12h; up to 6 gm/day
§ Famotidine 20 mg at bedtime; up to 800 mg QD