Level IV pharm test 1

• corticosteroids
• mineralocorticoid

• Sodium loss and hypotension associated with adrenocortical insufficiency (given with hydrocortisone or cortisone)• Management of sodium loss due to congenital adrenogenital syndrome (congenital adrenal hyperplasia)

Causes sodium reabsorption, hydrogen and potassium excretion, and water retention by its effects on the distal renal tubuleTherapeutic Effect(s): Maintenance of sodium balance and blood pressure in patients with adrenocortical insufficiency

Use Cautiously in:• CHF• Addison's disease (patients may have exaggerated response)• OB: Lactation: Pedi: Safety not established

CNS: dizziness, headache.CV: CHF, arrhythmias, edema, hypertension.GI: anorexia, nausea.Endo: adrenal suppression, weight gain.F and E: hypokalemia, hypokalemic alkalosis.MS: arthralgia, muscular weakness, tendon contractures.Neuro: ascending paralysis.Misc: hypersensitivity reactions.

• Monitor blood pressure
• • Monitor for fluid retention (weigh daily, assess for edema, and auscultate lungs for rales/crackles)
• Monitor patients with Addison's disease closely

Fludrocortisone causes ↓ serum potassium levels

Normalization of fluid and electrolyte balance without the development of hypokalemia or hypertension

• Ther. class.hormones
• Pharm. class.antidiuretic hormones

• PO, SC, IV, Intranasal: Treatment of central diabetes insipidus caused by a deficiency of vasopressin• IV, Intranasal: Controls bleeding in certain types of hemophilia and von Willebrand's disease• PO: Primary nocturnal enuresis

ActionAn analogue of naturally occurring vasopressin (antidiuretic hormone). Primary action is enhanced reabsorption of water in the kidneysTherapeutic Effect(s):• Prevention of nocturnal enuresis• Maintenance of appropriate body water content in diabetes insipidus• Control of bleeding in certain types of hemophilia or von Willebrand's disease

Contraindicated in:• Hypersensitivity• Hypersensitivity to chlorobutanol• Patients with type IIB or platelet-type (pseudo) von Willebrand's disease• HyponatremiaUse Cautiously in:• Angina pectoris• Hypertension• Patients at risk for hyponatremia• OB: Lactation: Safety not established

CNS: SEIZURES, drowsiness, headache, listlessness.EENT: intranasal—nasal congestion, rhinitis.Resp: dyspnea.CV: hypertension, hypotension, tachycardia (large IV doses only).GI: mild abdominal cramps, nausea.GU: vulval pain.Derm: flushing.F and E: water intoxication/hyponatremia.Local: phlebitis at IV site.

Diabetes Insipidus• Monitor urine and plasma osmolality and urine volume frequently.

Treatment of overdose includes decreasing dose and, if symptoms are severe, administration of furosemide

IV desmopressin has 10 times the antidiuretic effect of intranasaldesmopressin

• Decreased frequency of nocturnal enuresis• Decrease in urine volume» Relief of polydipsia» Increased urine osmolality• Control of bleeding in hemophilia

Ther. class.hormonesPharm. class.thyroid preparations

• Thyroid supplementation in hypothyroidism• Treatment or suppression of euthyroid goiters• Adjunctive treatment for thyrotropin-dependent thyroid cancer

Action• Replacement of or supplementation to endogenous thyroid hormones• Principal effect is increasing metabolic rate of body tissues» Promote gluconeogenesis» Increase utilization and mobilization of glycogen stores» Stimulate protein synthesis» Promote cell growth and differentiation» Aid in the development of the brain and CNSTherapeutic Effect(s):• Replacement in hypothyroidism to restore normal hormonal balance• Suppression of thyroid cancer

Contraindicated in:• Hypersensitivity• Recent MI• HyperthyroidismUse Cautiously in:• Cardiovascular disease (initiate therapy with lower doses)• Severe renal insufficiency• Uncorrected adrenocortical disorders• Pedi: Monitor neonates and infants for cardiac overload, arrhythmias, and aspiration during first 2 wk of therapy• Geri: Extremely sensitive to thyroid hormones; initial dose should be ↓

Usually only seen when excessive doses cause iatrogenic hyperthyroidismCNS: headache, insomnia, irritability.CV: angina pectoris, arrhythmias, tachycardia.GI: abdominal cramps, diarrhea, vomiting.Derm: sweating.Endo: hyperthyroidism, menstrual irregularities.Metabolic: heat intolerance, weight loss.MS: accelerated bone maturation in children.

• Assess apical pulse and blood pressure prior to and periodically during therapy. Assess for tachyarrhythmias and chest pain
• Children• Monitor height, weight, and psychomotor developmentLab Test Considerations• Monitor thyroid function studies prior to and during therapy. Monitor thyroid-stimulating hormone serum levels in adults 8–12 wks after changing from one brand to another» Monitor blood and urine glucose in diabetic patients. Insulin or oral hypoglycemic dose may need to be increasedToxicity and Overdose• Overdose is manifested as hyperthyroidism

Administer as a single dose with a full glass of water, preferably before breakfast to prevent insomnia

• Therapy is lifelong
• Advise patient to notify health care professional if headache, nervousness, diarrhea, excessive sweating, heat intolerance, chest pain, increased pulse rate, palpitations, weight loss >2 lb/wk, or any unusual symptoms occur

Ther. class.hypocalcemicsPharm. class.hormones

• IM, SC: Treatment of Paget's disease of bone• Adjunctive therapy for hypercalcemia• IM, SC, Intranasal: Management of postmenopausal osteoporosis

Inhibits osteoclastic bone resorption and promotes renal excretion of calciumTherapeutic Effect(s):• Decreased rate of bone turnover• Lowering of serum calcium

Observe patient for signs of hypersensitivity (skin rash, fever, hives, anaphylaxis, serum sickness). Keep epinephrine, antihistamines, and oxygen nearby in the event of a reaction

In patients with suspected sensitivity to calcitonin, skin test should be considered before starting therapy. Test dose is prepared in a dilution of 10 IU/mL by withdrawing 0.05 mL in a tuberculin syringe and filling to 1 mL with 0.9% NaCl for injection. Mix well and discard 0.9 mL. Administer 0.1 mL intradermally on inner aspect on forearm and observe site for 15 min. More than mild erythema or wheal constitutes positive response

» Advise patient to report signs of hypercalcemic relapse (deep bone or flank pain, renal calculi, anorexia, nausea, vomiting, thirst, lethargy) or allergic response promptly» Reassure patient that flushing and warmth following injection are transient and usually last about 1 hr

• Lowered serum calcium levels• Decreased bone pain• Slowed progression of postmenopausal osteoporosis. Significant increases in bone marrow density may be seen as early as 6 months after initiation of therapy

Ther. class.antithyroid agents

• Palliative treatment of hyperthyroidism• Used as an adjunct to control hyperthyroidism in preparation for thyroidectomy or radioactive iodine therapy

Inhibits the synthesis of thyroid hormonesTherapeutic Effect(s): Decreased signs and symptoms of hyperthyroidism

CNS: drowsiness, headache, vertigo.GI: diarrhea, hepatotoxicity, loss of taste, nausea, parotitis, vomiting.Derm: rash, skin discoloration, urticaria.Hemat: AGRANULOCYTOSIS, anemia, leukopenia, thrombocytopenia.MS: arthralgia.Misc: fever, lymphadenopathy.

• Monitor response for symptoms of hyperthyroidism or thyrotoxicosis (tachycardia, palpitations, nervousness, insomnia, fever, diaphoresis, heat intolerance, tremors, weight loss, diarrhea)• Assess patient for development of hypothyroidism (intolerance to cold, constipation, dry skin, headache, listlessness, tiredness, or weakness). Dose adjustment may be required• Assess patient for skin rash or swelling of cervical lymph nodes. Treatment may be discontinued if this occurs

Monitor WBC and differential counts periodically during therapy. Agranulocytosis may develop rapidly; usually occurs during the first 2 mo and is more common in patients over 40 yr and those receiving >40 mg/day. This necessitates discontinuation of therapy

Take missed doses as soon as remembered; take both doses together if almost time for next dose

• Decrease in severity of symptoms of hyperthyroidism (lowered pulse rate and weight gain)• Return of thyroid function studies to normal• May be used as short-term adjunctive therapy to prepare patient for thyroidectomy or radiation therapy or may be used in treatment of hyperthyroidism. Treatment from 6 mo to several yr may be necessary, usually averaging 1 yr

Ther. class.mineral electrolyte replacements supplements

• PO, IV: Treatment and prevention of hypocalcemia• PO: Adjunct in the prevention of postmenopausal osteoporosis• IV: Emergency treatment of hyperkalemia and hypermagnesemia and adjunct in cardiac arrest or calcium channel blocking agent toxicity (calcium chloride, calcium gluconate)

• Essential for nervous, muscular, and skeletal systems• Maintain cell membrane and capillary permeability• Act as an activator in the transmission of nerve impulses and contraction of cardiac, skeletal, and smooth muscle• Essential for bone formation and blood coagulationTherapeutic Effect(s): Replacement of calcium in deficiency states

Contraindicated in:• Hypercalcemia• Renal calculi• Ventricular fibrillationUse Cautiously in:• Patients receiving digitalis glycosides• Severe respiratory insufficiency• Renal disease• Cardiac disease

CNS: headche, tingling.CV: syncope, CARDIAC ARREST, arrhythmias, bradycardia.GI: constipation, nausea, vomiting.GU: calculi, hypercalciuria.Local: phlebitis.

Drug-Food• Cereals, spinach, or rhubarb may decrease the absorption of calciumsupplements• Calcium acetate should not be given concurrently with other calciumsupplements

Monitor blood pressure, pulse, and ECG frequently throughout parenteral therapy. May cause vasodilation with resulting hypotension, bradycardia, arrhythmias, and cardiac arrest. Transient increases in blood pressure may occur during IV administration, especially in geriatric patients or in patients with hypertension

High Alert: Errors with IV calcium gluconate and chloride have occurred secondary to confusion over which salt is ordered. Clarify incomplete orders. Confusion has occurred with milligram doses ofcalcium chloride and calcium gluconate, which are not equal. Chloride and gluconate forms are routinely available on most hospital crash carts; physician should specify form of calcium desired. Doses should be expressed in mEq

High Alert: Administer slowly. High concentrations may cause cardiac arrest

• Increase in serum calcium levels• Decrease in the signs and symptoms of hypocalcemia

Ther. class.allergy, cold and cough remedies(antitussive) opioid analgesicsPharm. class.opioid agonists nonopioid analgesic combinations

• Used mainly in combination with nonopioid analgesics (acetaminophen/ibuprofen) in the management of moderate to severe pain• Antitussive (usually in combination products with decongestants)

Head trauma• ↑ intracranial pressure• Severe renal, hepatic, or pulmonary disease• Cardiovascular disease (ibuprofen-containing products only)• History of peptic ulcer disease (ibuprofen-containing products only)• Alcoholism• Geri: Geriatric or debilitated patients (initial dosage ↓ required; more prone to CNS depression, constipation)• Patients with undiagnosed abdominal pain• Prostatic hyperplasia

CNS: confusion, dizziness, sedation, euphoria, hallucinations, headache, unusual dreams.EENT: blurred vision, diplopia, miosis.Resp: respiratory depression.CV: hypotension, bradycardia.GI: constipation, dyspepsia, nausea, vomiting.GU: urinary retention.Derm: sweating.Misc: physical dependence, psychological dependence, tolerance.

Use with extreme caution in patients receiving MAO inhibitors (may produce severe, unpredictable reactions—do not use within 14 days of each other)

Assess blood pressure, pulse, and respirations before and periodically during administration.

• Decrease in severity of pain without a significant alteration in level of consciousness or respiratory status• Suppression of nonproductive cough

• Ther. class.nonopioid analgesics
• nonsteroidal anti inflammatory agentsantipyretics

• Mild to moderate pain• Dysmenorrhea• Fever• Inflammatory disorders, including» Rheumatoid arthritis (adults and children)» Osteoarthritis

Inhibits prostaglandin synthesisTherapeutic Effect(s):• Decreased pain• Reduction of fever• Suppression of inflammation

• Hypersensitivity• Cross-sensitivity may occur with other NSAIDs, including aspirin• Active GI bleeding• Ulcer disease• Lactation: Passes into breast milk and should not be used by nursing mothers

CNS: dizziness, drowsiness, headache.EENT: tinnitus, visual disturbances.Resp: dyspnea.CV: edema, palpitations, tachycardia.GI: DRUG-INDUCED HEPATITIS, GI BLEEDING, constipation, dyspepsia,nausea, anorexia, diarrhea, discomfort, flatulence, vomiting.GU: cystitis, hematuria, renal failure.Derm: photosensitivity, rashes, sweating, pseudoporphyria (12% incidence in children with juvenile rheumatoid arthritis—discontinue therapy if this occurs).Hemat: blood dyscrasias, prolonged bleeding time.Misc: ALLERGIC REACTIONS INCLUDING ANAPHYLAXIS AND STEVENS-JOHNSON SYNDROME .

Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria

• Evaluate BUN, serum creatinine, CBC, and liver function tests periodically in patients receiving prolonged therapy

• Caution patient to avoid the concurrent use of alcohol, aspirin, acetaminophen, or other OTC medications without consulting health care professional. Use of naproxen with 3 or more glasses of alcohol per day may increase risk of GI bleeding

• Ther. class.bone resorption inhibitors
• Pharm. class.biphosphonates

• Treatment and prevention of postmenopausal osteoporosis• Treatment of osteoporosis in men• Treatment of Paget's disease of the bone• Treatment of corticosteroid-induced osteoporosis in patients (men and women) who are receiving B7.5 mg of prednisone/day (or equivalent) with evidence of decreased bone mineral density

Inhibits resorption of bone by inhibiting osteoclast activityTherapeutic Effect(s):• Reversal of the progression of osteoporosis with decreased fractures• Decreased progression of Paget's disease

• Renal insufficiency (CCr <35 mL/min)• OB: Lactation: Safety not establishedUse Cautiously in:• Patients with active GI pathology (dysphagia, esophageal disease, gastritis, duodenitis, ulcers)• Pre-existing hypocalcemia or vitamin D deficiency• Concurrent dental surgery (may ↑ risk of jaw osteonecrosis)

CNS: headache.EENT: blurred vision, conjunctivitis, eye pain/inflammation.CV: atrial fibrillation.GI: abdominal distention, abdominal pain, acid regurgitation, constipation, diarrhea, dyspepsia, dysphagia, esophageal cancer, esophageal ulcer, flatulence, gastritis, nausea, taste perversion, vomiting.Derm: erythema, photosensitivity, rash.MS: musculoskeletal pain, osteonecrosis (primarily of jaw).

Osteoporosis• Assess patients for low bone mass before and periodically during therapyPaget's Disease• Assess for symptoms of Paget's disease (bone pain, headache, decreased visual and auditory acuity, increased skull size)Lab Test Considerations• Osteoporosis: Assess serum calcium before and periodically during therapy. Hypocalcemia and vitamin D deficiency should be treated before initiating alendronate therapy. May cause mild, transient elevations of calcium and phosphate» Paget's Disease: Monitor alkaline phosphatase before and periodically during therapy. Alendronate is indicated for patients with alkaline phosphatase twice the upper limit of normal

Instruct patient on the importance of taking exactly as directed, first thing in the morning, 30 min before other medications, beverages, or food. Waiting longer than 30 min will improve absorption.Alendronate should be taken with 6–8 oz plain water (mineral water, orange juice, coffee, and other beverages decrease absorption).

• Prevention of or decrease in the progression of osteoporosis in postmenopausal women• Treatment of osteoporosis in men• Decrease in the progression of Paget's disease• Treatment of corticosteroid-induced osteoporosis

• Ther. class.antirheumatics
• nonsteroidal anti inflammatory agentsPharm. class.cox 2 inhibitors

• Relief of signs and symptoms of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis and juvenile rheumatoid arthritis• Reduction of the number of adenomatous colorectal polyps in familial adenomatous polyposis (FAP), as an adjunct to usual care (endoscopic surveillance, surgery)• Management of acute pain including primary dysmenorrhea

• Inhibits the enzyme COX-2. This enzyme is required for the synthesis of prostaglandins• Has analgesic, anti-inflammatory, and antipyretic propertiesTherapeutic Effect(s):• Decreased pain and inflammation caused by arthritis or spondylitis• Decreased number of colorectal polyps• Decreased pai

• Exercise Extreme Caution in:History of ulcer disease or GI bleeding
• • Cross-sensitivity may exist with other NSAIDs, including aspirin• History of allergic-type reactions to sulfonamides• History of asthma, urticaria, or allergic-type reactions to aspirin or other NSAIDs, including the aspirin triad (asthma, nasal polyps, and severe hypersensitivity reactions to aspirin)• Advanced renal disease• Severe hepatic dysfunction• Peri-operative pain from coronary artery bypass graft (CABG) surgery

CNS: dizziness, headache, insomnia.CV: MYOCARDIAL INFARCTION, STROKE, THROMBOSIS, edema.GI: GI BLEEDING, abdominal pain, diarrhea, dyspepsia, flatulence, nausea.Derm: EXFOLIATIVE DERMATITIS, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, rash.

• • Monitor patient for signs of Stevens-Johnson syndrome and toxic epidermal necrolysis. Discontinue celecoxib at first sign of rash
• • Advise patient to notify health care professional promptly if sign or symptom of GI toxicity (abdominal pain, black stools), skin rash, unexplained weight gain, edema, or chest pain occurs

• Reduction in joint pain in patients with osteoarthritis• Reduction in joint tenderness, pain, and joint swelling in patients with rheumatoid arthritis and juvenile rheumatoid arthritis• Decreased number of colonic polyps in patients with FAP

Ther. class.skeletal muscle relaxants(centrally acting)

Muscle spasm associated with acute painful musculoskeletal conditions (with rest and physical therapy)

CNS: drowsiness, dizziness, confusion, headache, irritability, nervousness.GI: nausea, anorexia, dry mouth, GI upset, vomiting.GU: urinary retention.

Assess patient for pain, muscle stiffness, and range of motion before and periodically during therapy• Geri: Assess geriatric patients for anticholinergic effects (sedation and weakness)Lab Test Considerations• Monitor hepatic function tests closely in patients with pre-existing liver damage» May cause false-positive Benedict's tests

Decreased musculoskeletal pain and muscle spasticity» Increased range of motion

• Ther. class.erectile dysfunction agentsvasodilators
• Pharm. class.phosphodiesterase type 5 inhibitors

• Cialis: Erectile dysfunction• Adcirca: Pulmonary arterial hypertension

• Cialis: Enhanced blood flow to the corpus cavernosum and erection sufficient to allow sexual intercourse• Requires sexual stimulation

• Concurrent use of nitrates• Unstable angina, recent history of stroke, life-threatening heart failure within 6 months, uncontrolled hypertension, arrhythmias, stroke within 6 months or MI within 90 days• Any other cardiovascular pathology precluding sexual activity• Known hereditary degenerative retinal disorders• Severe hepatic impairment

CNS: headache.EENT: HEARING LOSS, VISION LOSS, nasal congestion.CV: hypotension.GI: dyspepsia.GU: priapism.Derm: flushing.MS: back pain, limb pain, myalgia.

Concurrent use of nitrates may cause serious, life threatening hypotension and is contraindicated

• Instruct patient to take tadalafil at least 30 min before sexual activity and not more than once per day.

• Ther. class.benign prostatic hyperplasia bph agents
• Pharm. class.androgen inhibitors

Management of the symptoms of benign prostatic hyperplasia (BPH) in men with an enlarged prostate gland (alone or with tamsulosin)

Therapeutic Effect(s): Reduced prostate size with associated decrease in urinary symptoms

GU: decreased libido, ejaculation disorders, erectile dysfunction.Endo: gynecomastia.Derm: rash, urticaria.Misc: ALLERGIC REACTIONS, ANGIOEDEMA.

• Assess patient for symptoms of prostatic hyperplasia (urinary hesitancy, feeling of incomplete bladder emptying, interruption of urinary stream, impairment of size and force of urinary stream, terminal urinary dribbling, straining to start flow, dysuria, urgency) before and periodically during therapy• Digital rectal examinations should be performed before and periodically during therapy for BPH

• • Inform patient that the volume of ejaculate may be decreased during therapy but that this will not interfere with normal sexual function
• Advise patient to avoid donating blood for at least 6 mo after last dose of dutasteride to prevent a pregnant female from receivingdutasteride through a blood transfusion