L3 pharm

antiarrhythmics

Life-threatening ventricular arrhythmias unresponsive to less toxic agents

• *Inhibits adrenergic stimulation
• *Slows the sinus rate, increases PR and QT intervals, and decreases peripheral vascular resistance (vasodilation)

• Patients with cardiogenic shock• Severe sinus node dysfunction• 2nd- and 3rd-degree AV block• Bradycardia (has caused syncope unless a pacemaker is in place)• Hypersensitivity to amiodarone or iodine• OB: Can cause fetal hypo- or hyperthyroidism• Lactation: Enters breast milk and can cause harm to the neonate; use an alternative to breast milk

• ARDS
• pulm. fibrosis
• pulm. toxicity
• CHF
• worsening of arrhythmias
• Toxic epidermal necrolysis (rar)

ECG, pulm. toxicity, ARDS. liver and thyroid functions, AST, ALT, daily pulses

antipsychotics. mood stabilizers

Indications• Schizophrenia• Acute and maintenance therapy of manic and mixed episodes associated with bipolar disorder (as monotherapy or with lithium or valproate)• Adjunctive treatment of depression in adults• Agitation associated with schizophrenia or bipolar disorder• Irritability associated with autistic disorder in children

Action• Psychotropic activity may be due to agonist activity at dopamine D2 and serotonin 5-HT1A receptors and antagonist activity at the 5-HT2A receptor• Also has alpha1 adrenergic blocking activityTherapeutic Effect(s):• Decreased manifestations of schizophrenia• Decreased mania in bipolar patients• Decreased symptoms of depression• Decreased agitation associated with schizophrenia or bipolar disorder• Decreased emotional and behavioral symptoms of irritability

• suicidal thoughts
• agranulocytosis
• neuroleptic malignant syndrome

Assess mental status (orientation, mood, behavior) before and periodically during therapy. Assess for suicidal tendencies, especially during early therapy for depression. Restrict amount of drug available to patient. Risk may be increased in children, adolescents, and adults C24 yrs

• Ther. class.agents for attention deficit disorder
• Pharm. class.selective norepinephrine reuptake inhibitors

• Indications Attention-Deficit/Hyperactivity Disorder (ADHD)
• Action Selectively inhibits the presynaptic transporter of norepinephrine

Contraindicated in:• Concurrent or within 2 wk therapy with MAO inhibitors• Angle-closure glaucoma

• suicidal thoughts
• angioneurotic edema

Capsules should be swallowed whole; do not open, crush, or chew.

lipid-lowering

Indications• Management of primary hypercholesterolemia• Pruritus associated with elevated levels of bile acidsUnlabelled Use(s): Diarrhea associated with excess bile acids

Bind bile acids in the GI tract, forming an insoluble complex. Result is increased clearance of cholesterolTherapeutic Effect(s):• Decreased plasma cholesterol and low-density lipoproteins (LDLs)• Decreased pruritus

Contraindicated in:• Hypersensitivity• Complete biliary obstruction• Some products contain aspartame and should be avoided in patients with phenylketonuria Use Cautiously in:History of constipation

• Ther. class.antianginal santiarrhythmics(class IV) antihypertensives
• Pharm. class.calcium channel blockers

Indications• Hypertension• Angina pectoris and vasospastic (Prinzmetal's) angina• Supraventricular tachyarrhythmias and rapid ventricular rates in atrial flutter or fibrillation

Action Inhibits transport of calcium into myocardial and vascular smooth muscle cells, resulting in inhibition of excitation-contraction coupling and subsequent contractionTherapeutic Effect(s):• Systemic vasodilation resulting in decreased blood pressure• Coronary vasodilation resulting in decreased frequency and severity of attacks of angina• Reduction of ventricular rate in atrial fibrillation or flutter

Contraindicated in:• Hypersensitivity• Sick sinus syndrome• 2nd- or 3rd-degree AV block (unless an artificial pacemaker is in place)• Systolic blood pressure <90 mm Hg• Recent MI or pulmonary congestion• Concurrent use of rifampin

• arrhythmias
• CHF
• Stevens-Johnson syndrome

Drug-Drug• ↑ hypotension may occur when used with fentanyl , other antihypertensives , nitrates , acute ingestion of alcohol , or quinidine• Antihypertensive effects may be ↓ by NSAIDs• May ↑ digoxin levels• Concurrent use with beta blockers , digoxin , disopyramide , or phenytoin may result in bradycardia, conduction defects, or CHF• Phenobarbital and phenytoin may ↑ metabolism and ↓ effectiveness• May ↓metabolism of and ↑ risk of toxicity from cyclosporine , quinidine , or carbamazepine• Cimetidine and ranitidine ↑ levels and effects• May ↑ or ↓ the effects of lithium or theophyllineDrug-FoodGrapefruit juice ↑ levels and effect

• Assess for signs of CHF (peripheral edema, rales/crackles, dyspnea, weight gain, jugular venous distention).
• Monitor ECG continuously during administration.
• Do not open, crush, break, or chew sustained-release capsules or tablets.

• Ther. class.anti-Alzheimers's agents
• Pharm. class.cholinergicscholinesterase inhibitors

Indications Mild to moderate dementia associated with Alzheimer's disease

Emphasize the importance of taking donepezil daily, as directed. Missed doses should be skipped and regular schedule returned to the following day. Do not take more than prescribed; higher doses do not increase effects but may increase side effects

Assessment• Assess cognitive function (memory, attention, reasoning, language, ability to perform simple tasks) periodically during therapy• Administer Mini-Mental Status Exam (MMSE) initially and periodically as a screening tool to rate cognitive functioning• Administer Clock Drawing Test initially and periodically as a screening tool to measure severity of dementia• Monitor heart rate periodically during therapy. May cause bradycardia

• Ther. class.inotropicsvasopressors
• Pharm. class.adrenergics

Indications• Adjunct to standard measures to improve» Blood pressure» Cardiac output» Urine output in treatment of shock unresponsive to fluid replacement• Increase renal perfusion (low doses)

Drug-Drug• Use with MAO inhibitors , ergot alkaloids ( ergotamine ), doxapram , guanadrel , or some antidepressants results in severe hypertension• Use with IV phenytoin may cause hypotension and bradycardia• Use with general anesthetics may result in arrhythmias• Beta blockers may antagonize cardiac effects

Extravasation may cause severe irritation, necrosis, and sloughing of tissue. Administer into a large vein and assess administration site frequently. If extravasation occurs, affected area should be infiltrated liberally with 10–15 mL of 0.9% NaCl containing 5–10 mg of phentolamine.

• Ther. class.antiasthmatics, bronchodilators vasopressors
• Pharm. class.adrenergics

Indications• SC, IV, Inhaln: Management of reversible airway disease due to asthma or COPD• SC, IM, IV: Management of severe allergic reactions• IV, Intracardiac, Intratracheal, Intraosseous (part of advanced cardiac life support [ACLS] and pediatric advanced life support [PALS] guidelines): Management of cardiac arrest (unlabeled)• Inhaln: Management of upper airway obstruction and croup (racemic epinephrine)• Local/Spinal: Adjunct in the localization/prolongation of anesthesia

Action• Produces bronchodilation• Also has alpha-adrenergic agonist properties, which result in vasoconstriction• Inhibits the release of mediators of immediate hypersensitivity reactions from mast cellsTherapeutic Effect(s):• Bronchodilation• Maintenance of heart rate and blood pressure• Localization/prolongation of local/spinal anesthetic

Contraindicated in:• Hypersensitivity to adrenergic amines• Cardiac arrhythmias• Some products may contain bisulfites or fluorocarbons (in some inhalers) and should be avoided in patients with known hypersensitivity or intolerance

Drug-Drug• Concurrent use with other adrenergic agents will have additive adrenergic side effects• Use with MAO inhibitors may lead to hypertensive crisis• Beta blockers: may negate therapeutic effect• Tricyclic antidepressants enhance pressor response to epinephrineDrug-Natural Products Use with caffeine-containing herbs ( cola nut , guarana , mate , tea, coffee) ↑ stimulant effect

• IM, SC: Medication can cause irritation of tissue. Rotate injection sites to prevent tissue necrosis. Massage injection sites well after administration to enhance absorption and to decrease local vasoconstriction. Avoid IM administration in gluteal muscle

• Ther. class.antidepressants
• Pharm. class.selective serotonin reuptake inhibitors ssris

Indications• Major depressive disorder• Obsessive compulsive disorder (OCD)• Bulimia nervosa• Panic disorder• Depressive episodes associated with bipolar I disorder (when used with olanzapine)• Treatment-resistant depression (when used with olanzapine)• Sarafem: Premenstrual dysphoric disorder (PMDD)

• Concurrent use or use within 14 days of discontinuing MAO inhibitors (fluoxetine should be discontinued at least 5 wk before MAO therapy is initiated)• Concurrent use of pimozide• Concurrent use of thioridazine (fluoxetine should be discontinued at least 5 wk before thioridazine therapy is initiated)

NEUROLEPTIC MALIGNANT SYNDROME, SEIZURES, SUICIDAL THOUGHTS

Drug-Drug• Discontinue use of MAO inhibitors for 14 days before fluoxetinetherapy; combined therapy may result in confusion, agitation, seizures, hypertension, and hyperpyrexia (serotonin syndrome).Fluoxetine should be discontinued for at least 5 wk before MAO inhibitor therapy is initiated• Concurrent use with pimozide may ↑ risk of QT interval prolongation

Advise patient, family and caregivers to look for suicidality, especially during early therapy or dose changes. Notify health care professional immediately if thoughts about suicide or dying, attempts to commit suicide, new or worse depression or anxiety, agitation or restlessness, panic attacks, insomnia, new or worse irritability, aggressiveness, acting on dangerous impulses, mania, or other changes in mood or behavior or if symptoms of serotonin syndrome occur

• Ther. class.anti inflammatories steroidal
• Pharm. class.corticosteroids

Indications• Maintenance and prophylactic treatment of asthma• May decrease requirement for or avoid use of systemic corticosteroids and delay pulmonary damage that occurs from chronic asthma

Potent, locally acting anti-inflammatory and immune modifier

Acute attack of asthma/status asthmaticus

CHURG-STRAUS SYNDROME

• Ther. class.bronchodilators
• Pharm. class.adrenergics

• Long-term control of reversible airway obstruction due to asthma and for maintenance treatment of asthma and prevention of bronchospasm• Prevention of exercise-induced asthma• Maintenance treatment to prevent bronchospasm in COPD including chronic bronchitis and emphysema

• Acute attack of asthma (onset of action is delayed)

Drug-Drug• Beta blockers may ↓ therapeutic effects of salmeterol• MAO inhibitors and tricyclic antidepressants potentiate cardiovascular effects

• Ther. class.laxatives
• Pharm. class.osmotics

• Treatment of chronic constipation• Adjunct in the management of portal-systemic (hepatic) encephalopathy (PSE)

• Increases water content and softens the stool• Lowers the pH of the colon, which inhibits the diffusion of ammonia from the colon into the blood, thereby reducing blood ammonia levelsTherapeutic Effect(s):• Relief of constipation• Decreased blood ammonia levels with improved mental status in PSE

Patients on low-galactose diets

Drug-Drug• Should not be used with other laxatives in the treatment of hepatic encephalopathy (leads to inability to determine optimal dose oflactulose)• Anti-infectives may ↓ effectiveness in treatment of hepatic encephalopathy

mood stabilizers

Manic episodes of manic depressive illness (treatment, maintenance, prophylaxis)

• Action• Alters cation transport in nerve and muscle• May also influence reuptake of neurotransmitters
• Therapeutic Effect(s): Prevents/decreases incidence of acute manic episodes

Contraindicated in:• Hypersensitivity• Severe cardiovascular or renal disease• Dehydrated or debilitated patients• Should be used only where therapy, including blood levels, may be closely monitored• Some products contain alcohol or tartrazine and should be avoided in patients with known hypersensitivity or intolerance

• SEIZURES
• ARRHYTHMIAS

Drug-Drug• May prolong the action of neuromuscular blocking agents• ↑ risk of neurologic toxicity with haloperidol or molindone• Diuretics , methyldopa , probenecid , fluoxetine , and NSAIDs may ↑ risk of toxicity• Blood levels may be ↑ by ACE inhibitors• Lithium may ↓effects of chlorpromazine• Chlorpromazine may mask early signs of lithium toxicity• Hypothyroid effects may be additive with potassium iodide or antithyroid agents• Aminophylline , phenothiazines , and drugs containing large amounts of sodium ↑ renal elimination and ↓ effectiveness• Psyllium can ↓ levels

Ther. class.antidiarrheals

• Adjunctive therapy of acute diarrhea• Chronic diarrhea associated with inflammatory bowel disease• Decreases the volume of ileostomy drainage

• Inhibits peristalsis and prolongs transit time by a direct effect on nerves in the intestinal muscle wall• Reduces fecal volume, increases fecal viscosity and bulk while diminishing loss of fluid and electrolytes

• Hypersensitivity• Patients in whom constipation must be avoided• Abdominal pain of unknown cause, especially if associated with fever• Alcohol intolerance (liquid only)

Ther. class.central nervous system stimulants

• Treatment of ADHD (adjunct)• Oral: Symptomatic treatment of narcolepsyUnlabelled Use(s): Management of some forms of refractory depression

Produces CNS and respiratory stimulation with weak sympathomimetic activityTherapeutic Effect(s):• Increased attention span in ADHD• Increased motor activity, mental alertness, and diminished fatigue in narcoleptic patients

• Hypersensitivity• Hyperexcitable states• Hyperthyroidism• Patients with psychotic personalities or suicidal or homicidal tendencies• Personal or family history of Tourette's syndrome• Glaucoma• Motor tics• Concurrent use or use within 14 days of MAO inhibitors• Fructose intolerance, glucose-galactose malabsorption, or sucrose-isomaltase insufficiency• Surgery

• ↑ sympathomimetic effects with other adrenergics , including vasoconstrictors , decongestants , and halogenated anesthetics• Use with MAO inhibitors or vasopressors may result in hypertensive crisis (concurrent use or use within 14 days of MAO inhibitors is contraindicated)• Metabolism of warfarin , phenytoin , phenobarbital, primidone, phenylbutazone, selective serotonin reuptake inhibitors, and tricyclic antidepressants may be ↓ and effects ↑

Ther. class.antiemetics

• Prevention of chemotherapy-induced emesis• Treatment of postsurgical and diabetic gastric stasis• Facilitation of small bowel intubation in radiographic procedures• Management of gastroesophageal reflux• Treatment and prevention of postoperative nausea and vomiting when nasogastric suctioning is undesirable

Blocks dopamine receptors in chemoreceptor trigger zone of the CNS• Stimulates motility of the upper GI tract and accelerates gastric emptying

• Hypersensitivity• Possible GI obstruction or hemorrhage• History of seizure disorders• Pheochromocytoma• Parkinson's disease

Additive CNS depression with other CNS depressants , including alcohol ,

Monitor for neuroleptic malignant syndrome (hyperthermia, muscle rigidity, altered consciousness, irregular pulse or blood pressure, tachycardia, and diaphoresis)

Ther. class.anti-infectives antiprotozoalsantiulcer agents

Indications• PO, IV: Treatment of the following anaerobic infections» Intra-abdominal infections (may be used with a cephalosporin)» Gynecologic infections» Skin and skin structure infections» Lower respiratory tract infections» Bone and joint infections» CNS infections» Septicemia» Endocarditis• IV: Perioperative prophylactic agent in colorectal surgery• PO: Amebicide in the management of amebic dysentery, amebic liver abscess, and trichomoniasis» Treatment of peptic ulcer disease caused by Helicobacter pylori• Topical: Treatment of acne rosacea• Vag: Management of bacterial vaginosis

Action Disrupts DNA and protein synthesis in susceptible organismsTherapeutic Effect(s): Bactericidal, trichomonacidal, or amebicidal actionSpectrum:• Most notable for activity against anaerobic bacteria, including» Bacteroides» Clostridium• In addition, is active against» Trichomonas vaginalis» Entamoeba histolytica» Giardia lamblia» H. pylori» Clostridium difficile

• SEIZURES
• STEVENS-JOHNSON SYNDROME

• Cimetidine may ↓ metabolism• Phenobarbital and rifampin ↑ metabolism and may ↓ effectiveness• Metronidazole ↑ the effects of phenytoin, lithium, and warfarin• Disulfiram-like reaction may occur with alcohol ingestion• May cause acute psychosis and confusion with disulfiram• ↑ risk of leukopenia with fluorouracil or azathioprine

• Ther. class.antianginals antihypertensives
• Pharm. class.beta blockers

• Hypertension• Angina pectoris• Prevention of MI and decreased mortality in patients with recent MI• Management of stable, symptomatic (class II or III) heart failure due to ischemic, hypertensive or cardiomyopathc origin (may be used with ACE inhibitors, diuretics and/or digoxin; Toprol XL only)

Therapeutic Effect(s):• Decreased blood pressure and heart rate• Decreased frequency of attacks of angina pectoris• Decreased rate of cardiovascular mortality and hospitalization in patients with heart failure

• Uncompensated CHF• Pulmonary edema• Cardiogenic shock• Bradycardia or heart block

BRADYCARDIA, CHF, PULMONARY EDEMA

General anesthesia , IV phenytoin , and verapamil may cause ↑ myocardial depression• ↑ bradycardia may occur with digoxin• ↑ hypotension may occur with other antihypertensives , acute ingestion of alcohol , or nitrates• Concurrent use with amphetamines , cocaine , ephedrine , epinephrine , norepinephrine , phenylephrine , or pseudoephedrine may result in unopposed alpha-adrenergic stimulation (excessive hypertension, bradycardia)• Concurrent administration of thyroid administration may ↓ effectiveness• May alter the effectiveness of insulins or oral hypoglycemic agents (dosage adjustments may be necessary)• May ↓ the effectiveness of theophylline• May ↓ the beneficial beta1-cardiovascular effects of dopamine or dobutamine• Use cautiously within 14 days of MAO inhibitor therapy (may result in hypertension)

Monitor vital signs and ECG every 5–15 min during and for several hours after parenteral administration. If heart rate <40 bpm, especially if cardiac output is also decreased, administer atropine 0.25–0.5 mg IV• Monitor intake and output ratios and daily weights. Assess routinely for signs and symptoms of CHF (dyspnea, rales/crackles, weight gain, peripheral edema, jugular venous distention)

• Ther. class.antiulcer agents
• Pharm. class.proton pump inhibitors

GERD/maintenance of healing in erosive esophagitis• Duodenal ulcers (with or without anti-infectives for Helicobacter pylori )• Short-term treatment of active benign gastric ulcer• Pathologic hypersecretory conditions, including Zollinger-Ellison syndrome• Reduction of risk of GI bleeding in critically ill patients• OTC: Heartburn occurring Btwice/wk

Binds to an enzyme on gastric parietal cells in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumenTherapeutic Effect(s):• Diminished accumulation of acid in the gastric lumen with lessened gastroesophageal reflux• Healing of duodenal ulcers

• Ther. class.antiulcer agents
• Pharm. class.proton pump inhibitors

Indications• Erosive esophagitis associated with GERD• Decrease relapse rates of daytime and nighttime heartburn symptoms on patients with GERD• Pathologic gastric hypersecretory conditionsUnlabelled Use(s): Adjunctive treatment of duodenal ulcers associated with Helicobacter pylori

cleanses the bowel by causing diarrhea

• An 8-ounce (240-milliliter) glass of solution should be rapidly swallowed every 10 minutes until the prescribed amount of liquid has been taken or your stool is watery, clear, and free of solid matter.
• You should not eat for at least 3 to 4 hours before you are told to begin drinking PEG-ES. You should not take any oral medications within 1 hour of starting PEG-ES. You should begin having bowel movements within 1 hour of beginning PEG-ES.

• nausea
• stomach pain
• bloatin
• gvomiting
• rectal irritation

Ther. class.anti inflammatories steroidal(intermediate acting) immune modifiers

• Used systemically and locally in a wide variety of chronic diseases including» Inflammatory» Allergic» Hematologic» Neoplastic» Autoimmune disorders• Suitable for alternate-day dosing in the management of chronic illness

• In pharmacologic doses, suppresses inflammation and the normal immune response• Has numerous intense metabolic effects (see Adverse Reactions and Side Effects)• Suppresses adrenal function at chronic doses of 5 mg/day• Replaces endogenous cortisol in deficiency states• Has minimal mineralocorticoid activity

• Active untreated infections (may be used in patients being treated for tuberculous meningitis)• Some products contain alcohol and should be avoided in patients with known intolerance

• PEPTIC ULCERATION
• THROMBOEMBOLISM

Drug-Drug• Additive hypokalemia with thiazide and loop diuretics , amphotericin B , piperacillin , or ticarcillin• Hypokalemia may ↑ risk of digoxin toxicity• May ↑ requirement for insulins or oral hypoglycemic agents• Phenytoin , phenobarbital , and rifampin stimulate metabolism; may ↓ effectiveness• Oral contraceptives may ↓ metabolism• ↑ risk of adverse GI effects with NSAIDs (including aspirin)• At chronic doses that suppress adrenal function, may ↓ antibody response to and ↑ the risk of adverse reactions from live virus vaccines• May ↑ risk of tendon rupture from fluoroquinolones

Guaiac-test stools. Promptly report presence of guaiac-positive stools

• Stopping the medication suddenly may result in adrenal insufficiency (anorexia, nausea, weakness, fatigue, dyspnea, hypotension, hypoglycemia). If these signs appear, notify health care professional immediately. This can be life-threatening.
• Instruct patient to inform health care professional promptly if severe abdominal pain or tarry stools occur

• Ther. class.antidepressants
• Pharm. class.selective serotonin reuptake inhibitors ssris

• Major depressive disorder• Panic disorder• Obsessive-compulsive disorder (OCD)• Post-traumatic stress disorder (PTSD)• Social anxiety disorder (social phobia)• Premenstrual dysphoric disorder (PMDD)

Inhibits neuronal uptake of serotonin in the CNS, thus potentiating the activity of serotonin. Has little effect on norepinephrine or dopamineTherapeutic Effect(s):• Antidepressant action• Decreased incidence of panic attacks• Decreased obsessive and compulsive behavior• Decreased feelings of intense fear, helplessness, or horror• Decreased social anxiety• Decrease in premenstrual dysphoriaPharmacokinetics