Pharm Exam 3

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Pharm Exam 3
2013-05-01 21:48:56
Nurse Anesthesia

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  1. What is the Methamphetamine Epidemic Act?
    • - Restricts the sale of cough and cold products that contain methamphetamine precursor chemical ephedrine, pseudoephedrine, or phenylpropanolamine.
    • - Daily limit 3.6 g & monthly limit 9 gram (retail store & internet purchases.)
    • - Retailers must ask for ID and keep log for purchases.
  2. To be classified as OTC?
    1.) safe

    2.)  Low potential for misuse or abuse

    3.) Can be labeled

    4.)  Pt must be able to self dx the condition the drug treats

    5.) Must be condition pt can manage without supervision of licensed health profession
  3. Tylenol:
    MOA, Drug interactions, side effects, safety
    • MOA- Central inhibition of prostaglandin
    • synthesis, ( no anti-inflammatory activity)

    • Drug interactions: ? anything metabolized by
    • liver

    Side effects: liver toxicity

    Safety: do not exceed 4g / day adults. 10-15mg/kg children
  4. Ibuprofen
    side effects
    • Uses: Analgesic, antipyrietic, antiplatelet,
    • anti-inflammatory

    MOA: Cox1, Cox2 inhibitors

    • Side effects: GI tract (heartburn, nausea, gi
    • bleeding).  Possible decrease renal blood
    • flow

    • Safety- b/c of decreased renal blood flow
    • cautions with renal impairment and CHF.
    • -bleeding

    Pregnancy category C and D
  5. Drug interactions with Ibuprofen
    Anticoagulants- may prolong prothrombin time

    Hydantoins- increase serum phenytoin levels (toxicity)

    Lithium- Increaed lithium levels

    Loop diuretics- decreased effect of loop diuretics

    Salicylates- decreased plasma concentration of nsaids

    Digoxin- May decrease Digoxin levels
  6. Diphenhydramine :
    Uses, MOA, S/E
    Uses: antihistamine,  first line agent for prophylaxis and treatment of allergic symptoms ( rhintits, uticartia)

    • MOA: first generation antihistamine,
    • lipohphyllic, crosses bbb

    •  S/E:
    • Drowsiness, sedation b/c crosses BBB
  7. apn role in use of herbal medications
    • o  educate
    • pt about the many different concepts and herbal traditions used and help guide
    • them to an appropriate resource

    o  be educated about herbs commonly used by pt’s and be aware of interactions
  8. Licorice route
    o  Use: GI health.

    o  MOA: Potentiates endogenous steroids, stiumltes gastric mucous synthesis

    o  Adverse effects:

    §  MANY drug interactions. ( antihtn, diurectis, digoxin, quinidine, spironolactone)

    • §  Minderal
    • corticoid effects of Headache, lethargy, sodium and water retention.
  9. Ginko: Uses? drug interactions?
    o  Use –Confusion and memory loss

    o  Drug interactions, SHOULD NOT be taken with anticoagulants or antiplatelets.

    o  (has s/e of diarrhea, h/a, nausea, BLEEDING, seizures. )

    • FYI moa of ginko-
    • Stimulates prostaglandin synthesis, stimulates vasodilation, increases cerebral blood flow
  10. St John's Wart:
    Drug interactions
    • o  Use: depression ( sometimes gastriticus,
    • hypothroyroid, HIV, antiviral)

    • o  Drug
    • interactions:  

    • -Tricylcic antidepressants, MAO inhbitors,
    • sympathomimetics( risk of SERATONIN SYNDROME)

    -  Sympathomimetics ( Serotonin syndrome)

    - OTC cold and flue medications, narcotics

    • o  FYI
    • MOA- serotonin reuptake inhibitor, antiviral.
  11. Ginseng
    Drug interactions
    o  Use: confusion memory loss

    • o  Drug interactions:
    •  - May potentiate insulin and oral hypoglycemic

    -MAO inhibitors

     Fyi moa is ? CNS stimulating
  12. Phenytoin:
    Adverse effects:
    Indications: first line treatment for tonic clonic & partial complex seizures

    • Adverse effects: hypersensitivity reactions! : hepatitis, fever ;**rash; athralgias,
    • lymphandenopathy

    • ·  MANY drug interactions! (estrogens, acetaminophen, carbamazepine ,
    • corticosteroids, levodopa, sulfonylureas, cardiac glycocides (digoxin))
    • Phenytoin decreases the effect of those

    ·  Caution with patients with liver and renal disease

    • · Nystagmus, dizziness, h/a, somnolence, confusion, hypotension,
    • tachycardia, n/v, dry mouth , gingival
    • hyperplasia, urine discoloration

    · STEVEN JOHNSON’s syndrome ( rash like burn, d/c drug)
  13. phenytoin MOA
    type of Hydantoin

    • MOA- stabilizes neuronal membranes and decrease seizure activity by
    • increasing efflux of decreasing efflux of sodium ions across cell membranes in
    • motor cortex.
  14. education points Phenytoin
    • - report adr
    • - no driving till seizure free 1 YEAR
    • - oral hygiene
    • - avoid abrupt withdrawal- Rebound status epilepticus
    • -
  15. Carbazepine: ( Tegretol) 
    Type of Iminostilbene

    • Indications:
    • Tonic clonic seizures, partial seizures

    • Pharmackokinetics:
    •  - Absorbed through stomach, metabolized
    • by the liver
    • - Depresses neuron transmission in the
    • nucleus ventralis anterior
  16. Carbamazipine ( Tegretol)
     adverse effects
    -  *black box warning for blood descrasias

    - has ability to induce it’s own metabolism (auto induction)

    -  bone marrow depression

    -  liver damage, impairs thyroid

    -  drowsiness, dizziness, blurred vision, n/v, dry mouth, diplopia, h/a
  17. Carbazipine ( Tegretol) Long term monitoring
    • Monitoring:
    • Drug levels 3, 6, 9 weeks, goal 4-12 mcg/ml, then every 2 months there after,
    • cbc every 3-4 months- 
    • initial:  cbc, chem panel, hepatic pane, TSH level. IF pt has low wbc more risk for leukemia.-  

    EDUCATE pt s/s of bone marrow suppression ( petechia, sore throat)
  18. Ethosuximide (Zarontin)
    Adverse Effects

    Indications: tx of absence seizures

    • Adverse Effects:
    • - agranulocytosis , aplastic anemia,
    • granulocytopenia
    • ( pt should report fever, sore througat, petchia, get cvc at baseline and intermittently)
  19. Topiramate ( Topamax)
    indications and monitoring
    • o  Indications: adjuctive therapy for Partial seizures and primary
    • generalized tonic clonic seizures.

    · Monitoring: Get bicarb at baseline an 2-4 months
  20. Topiramate (Topamax)
    adverse reactions
    • · Adverse Reactions:
    • oWeight loss
    • oImpaired cognition (reversible)
    • o Parathesiaso Depression and mood problems
    • o Decreased sweating leading to heat intoleratnce and hyperthermia inchildreno
    • Serious:
    • - Metabolic acidosis
    • - Measure bicarb at baseline and 2-4 month.
    • - Myopia and secondary angle glaucoma
  21. Gabapentin
    Moa-bind to Ca+ channel which reduces the neurotransmitter release

    • - Indications:  add on therapy for
    • refractory partial seizures ( adults)

    • -   Monitoring: no routine drug levels, check CBC with diff for risk fo
    • leukopenia and thrombocytopenia

    • Side effects:
    • Serious: Leukopenia, thrombocytopenia
    • Common : dizziness, weight GAIN, somnulence

    * children BEHAVOIR, hostility etc, increased risk of suicide

    - avoid abrupt withdrawal
  22. Side effects Gabapentin
    Serious: Leukopenia, thrombocytopenia

    Common : dizziness, weight GAIN, somnoulence

    * children BEHAVOIR, hostility etc, increased risk of suicide

    avoid abrupt withdrawal
  23. Monitoring Gabapentin
    • No routine drug levels
    • get cbc with diff
  24. Levetiractam ( Kepra)
    pt education
    • Indication:
    • adjuctive therapy tx of partial onset seizures and myoclonic seizures,
    • generalized tonic clonic seizures

    •  Patient education
    • *withdrawal seizures if abruptly d/c

    may be some drowsiness in initial tx
  25. Lamotrigine (Lamictal) indications
    • Adjuctive treatment of primary generalized tonic-clonic
    • seizures and partial seizures in adults and children greater than 2 years
  26. Lamotrigine (Lamictal)
    o  GI mostly ( n/v, constipation) 

    o  Somnolence

    o  Fatigue, dizziness,

    o  Anxiety insomnia

    o  *** stevens Johnson

    o  suidciality

    o  blood dyscrasias

    o  mutliorgan failure, hepatic failure
  27. Lamotrigine (Lamictal)
    Drug interactions
    -  contraceptive decrease lamictal effectiveness by 50%

    • -  if pt on valproic acid and lamictal increased risk for steven johnson’s
    • syndrome
  28. Oral contraceptive combined
    MOA, Adverse effects
  29. MOA  Synthetic hormones       
    • Adverse effects:      
    • -  VTE
    • -  MI
    • -  CVA         
    • -  Benign liver tumor    
    • - Renal and mesenteric artery thrombosis
    • - Gallbladder disease
    •  Systemic effects of OC  
    • Increase lipids  
    • Increased insulin resistance & decrease
    • glucose tolerance    
    • Increase clotting
    • Raised bp
    • Smoking will increase effects
    • ◦ dvt/pe or Hx
    • ◦ CVA, CAD or hx
    • ◦ Structural heart disease or subacute bacterial
    • endocarditis
    • ◦ Diabetes with vascular disease or >20
    • yr hx of
    • ◦Breast CA
    • ◦pregnancy
  31. Unacceptable risk to use
    • Age >35 
    • smoker >15cig/day                            
    • Current or hx of ischemic heart disease
    • HTN not controlled                                             
    • Valvular heart disease
    • Current or hx of DVT/PE                             SLE w/positive or unknown        
    • antiphospholipid antibodies
    • Major surgery
    • w/immobilization              
    • Current Breast Cancer
  32. Progestin only pill
    MOA, Indication, education
    • MOA- thickens cx mucous, endometrial changes, ovulation
    • inhibition less predictable than combined                  
    • Indications:
    • Birth control; ok for smokers.
    • Thrombosis less of an issue, bp changes usually
    • not a problem.  No estrogen s/e
    • Education:                  
    • - no placebo pills, all active                  
    • - take at same time daily
  33. NuvaRing
    • Indication- birth control         
    • Adverse effects: increase vag. d/c. ;
    • feeling. Expulsion.

    • Benefits of this tx vs other forms: ease of
    • use ; limited remembering
    • Education- if out more than 2 hours
    • discard.
    • Contraindicated in women with cystocele,
    • rectocele or uterine prolapse
  34. Plan B
    • Indications:  emergency contraception, not
    • abortificant used to prevent ovulation or implantation. May be taken up to
    • 120 hrs PC act,         
    • Adverse effects:  same as OC, n/v, BTB
    • effectiveness: 75-89% oral; IUD/IUS 99%
    • Plan B is progestin only
  35. HRT goals of therapy
    • To treat symptoms,( mod-severe vasomotor
    • symptoms, vaginal atrophy, prevention of osteoporosis)     
    • short term only (no more than two years)             
    • - Make sure to document risk/benefits explained to patient and importance of follow up
  36. How long should HRT therapy be?
    short term, no more than 2 years
  37. Estrogen and Progestin VS estrogen
    only for  HRT therapy, which one should you prescribe , tx decision
    • If uterus intact use estrogen and progestin       
    • ·↑ risk of Endometrial Cancer (in those
    • w/uterus who are treated with unopposed ERT)
    • To ↓ this risk, progestin
    • was added to HRT for those w/uterus to help prevent endometrial hyperplasia & cancer
  38. Is hrt safe for someone with hx of
    breast ca ?
    • NO!
    • ERT/HRT is CONTRAINDICATED in women with HISTORY of breast cancer or gynecological cancers and those with FIRST DEGREE
    • family members w/breast cancer
  39. HRT drugs 
    Oral estrogen
    Oral combined
  40. Estrogen only:        
    • Equine (Premarin)        
    • Estradiol (estrace)
    • Combined:        
    • Estrogen/Prgestin combo-->
    • estradiol/norgestimate; conjugated estrogens + medroxyprogesterone acetate
  41. Vaginal estrogen preparations
    • Conjugated estrogens, estropipate, estradiol ,
    • premarine, estrace , ogen
    • Adverse effects
    •       LESS risk for endometrial hyperplasia compared to oral forms         
    • Body is exposed to less estrogen which may be
    • considered for women who have risk factors concern with ERT
  42. HRT drug uterus intact
    • Combo therapy                  
    • prempro, Activella, ClimaraPro
  43. HRT uterus not intact
    Estrogen alone: Climara, Premarin
  44. Osteoporosis risk factors
    • Family hx, age> 70, slight build, fair
    • complexsion, age, low calsium and or vit D diet, minimal sun exposure, weith
    • <70, sedentary lifestyle
  45. Ethnic differences osteoporosis
    • African American (AA) women have higher bone density but risk increases with age
    • AA women have lower calcium intake
    • Asians are at high risk 
    • Asians consume inadequate calcium
    • Hispanic women have similar risk as white women
  46. Drugs that increase risk for osteoporosis
    • Glucocorticoid use >5mg/day for >3 monty
    • Anticonvulsants ( phenobarbiol, pheyntoin,
    • carbamazepine)
    • Long term PPI
    • Tobacco or alchohol
  47. black box warning for HRT
    Not used for cardiac dz and prevention

    • Unopposed estrogen use in women with uterus
    • increases risk for endometrial CA
    • -No estrogen use with pregnancy

    ◦  Increase risk of developing dementia
  48. Buspirone (Buspar)
    • Indications: generalized anxiety disorder, social phobia
    • Non benzo, doesn’t cause CNS depression, doesn’t produce tolerance used for
    • pt’s with substance abuse problems
    • -Downside: takes a long time to get effect
    • Contraindicated :        
    • •   Metabolic acidosis, as in
    • diabete       
    • •   Should not be used with MAO
    • inhibitors       
    • caution compromised liver and/or renal function
  49. Escitalopram: (Lexapro)
    • SSRI          
    • Indications: Depression, ocd,
    • panic disorder, anxiety, ptsd, bulimia,
    • premenstrual dysphoric disorder
    • Adverse effects:         
    • Increased bleeding         
    • Monitor LFT’s        
    • Orthostadic hypotension  
    • Watch for hypomania
    • sedation
  50. Anti depressant tapering
    • Withdrawal or discontinue syndrome associated
    • mostly with SSRI

    ◦ (lexapro, paxil, celexa, zoloft, prozac etc)

    • ◦ Physical symptoms:dizziness, lethargy, diarrhea, flulike symptom
    • anxiety, agitation, confusion
    •  Taper by 50% every 3-4 days
  51. Phenelzine(Nardil)
    Principles of managing pt on MAO I
    Dietary restrictions- tyramine- yeast, yogurt, most cheeses, aged fish or meat, figs, bananas, raisins, avacados, wine, soy saulce

    • Low safety margin
    • Not a first line drug
    • ADR-    
    • orthostadic hypotension, HA, insominia, diarrhea, htn crisis when used with other antidepressants or sympathomimetic drugs or
    • with food containing tyramine
  52. Fluoexetine(Prozac)
    • - Pharmacokinetics- SSRI, half life 2-7
    • days, steady state
    • -  Indications- major depression,
    • bulimia, PMDD        
    • - Adverse effects- CNS, GI , Sexual dysfunction
    •  Risk of serotonin syndrome
  53. Serotonin Syndrome
    More likely in pt/s with 2 or more SSRI

    • ◦ wait 2 weeks after D/C MAO-I before starting
    •  SSRI
    • ◦ Rapid onset- can be fatal

    • ◦ agitation, myoclonus, hyperreflexia, mental
    • status chagne, fever, shivering, diaphoresis, ataxia, and diarrhea
  54. Alpraxolam (Xanax)
    • Indications: anxiety disorders, panic disorder,       
    • performance anxiety, social phobia (NOT for OCD)
    • Adverse effects: Sedation, memory impairment,       
    • withdrawal symptoms. 
    • Overdose potential
    • Risk of developing dependence.
  55. Antimicrobial resistance causes
  56. Causes-
    • recent use of antibiotics, over use of broad spectrum antibiotics      
    • age younger than 2 or older than 65-    
    • day care attendance 
    • exposure to young children
    • multiple medical conditions    immunosuppression
  57. Antibiogram purpose:
    result of lab test for sensitivity of an isolated bacterial strain todifferent antibiotics
  58. Fluoroquiniolones
    Ciprofloxaxin (cipro); Levofloxacin ( Levaquin); Ofloxaxin (Floxin); Lomefloxaxin (Maxquin) 

    • ·Indications:
    • o  Complicated uti, Pyelonephritis infections ,
    • chronic bacterial prostatitis
    • o  Pnuemonia/ chronic bronchitis exacerbation
    • o  PCN resistant S. pnuemoniae, skin infections,
    • bone/joint infections, complicated intra-abdominal , infections Diarrhea

    · Adverse Effects:

    • oBLACK BOX WARNING - tendonitis/ tendon rupture ( d/c drug and rest if s/s )
    • o  Pseudomembranous colitis
    • o  Sleep disorders, dizziness, acidosis
    • o  Renal/ hepatic failures
    • o  Angina, atrial flutter
    • o  Do not prescribe for <18 yr
  59. Penicillin:
    Allergies: common cause of drug allergies, can be fatal

    Cross sensitivities to other antibiotics:  B/W Pcn and cephalosporin occurs b/w 5-16% of patients

    • Indications:
    • Commonly prescribed for infections seen in pcp

    Amoxicilin is the first line drug for AOM and sinusitis

    PCN for streptococcal pharyngitis

                Amoxicillin/ clavulante first line drug for infection following bites

      MIC- minium inhibitory concentration is the concentration required to kill an organism.
  60. Erythromycins:
    (Type of Macrolide)


    o Active against most gram + and gram -

    • o Drug of choice for community acquired pneumonia
    • (mycoplasma)

    o  Chlamydia

    o  Pertussis

    o H Pyloria infections (clarithromycin)

    o Chronic Bronchitis

    • o Use often for PCN allergies however there is
    • increasing resistance

    • o ( Have high cross resistance for highly
    • resistant staph pneumonia, if pt isn’t getting better in 24-48 hr change drug
    • ).  Effective in COPD pt’s with sputum.


    • ·     
    • Adverse Effects:
    • o  Dose related GI nausea, vomiting, abd pain,
    • cramping, and diarrhea ( erythromycin)

    • o Skin- uticaria, bullous eruptions, exzema, and
    • Steven Johnson’s syndrome
  61. Sulfonamides:
    • ( ex Trimethoprim/
    • sulfamethoxazole (Bactrim); Nitrofurantoin ( Macrobid)
    • Indications:

    o  Most commonly used with UTI infections

    o  MRSA is susceptible in some areas

    o  No longer primary agent for infections but low cost alternative in children > 2 months and pcn allergies.

    Adverse Effects

    • o  GI- anorexia, N/V, diarrhea, stomatitis, rashes,
    • increased hypersensitivity reactions ( Steven Johnsons)

    • o  CNS- h/a, dizziness, drug interactions,
    • peripheral neuropathy

    • o  Avoid in G6PD deficiency (inherited disorder RBC
    • break down causing anemia, 10 % black males, and small % from mediteranian
    • decent)

    o Avoid sun , can cause photosensitivity warning

    • Peripheral neuropathy- can be severe and
    • irreversible.  ( Renal impairment, diabetes, electrolyte imbalance,
    • debilitating disease predispose, this is more for nitrofurantoin rather than
    • sulfonamides)

    · Cross sensitivity to other drug categories:

    o  Loop diuretics/ Thiazide diuretics

    o Sulfonylureas

    o Sunscreens with PAVA
  62. Most common allergenic drug group?
    • Sulfonamides
    • Avoid in pt’s with allergy to Sulfonylurea (anti diabetic
    • agent); loop and thiazide diuretics. 
    • Caution in pt’s with severe allergies and bronchial asthma.
  63. Clindamycin ( Cleocin)
    -   (Lincosamide)

    •    Indications:
    •  1st line therapy for MRSA in someareas ( use antibiogram )
    • o  Infections in PCN allergy pt’so  1st line therapy for dentalinfectionso  (NOT recommended to tx pneumonia, sinusitis, andotitis media if there are other effective agents that can be used)-      
    • Adverse Effects:
    • o  BLACK BOX WARNING for severe colitis ( can happen during tx or 2 months after) stopmedication if sig. diarrhea occurs
    • o  Derm- rash, burning, itching , erythemao  Transient eosinophilia, neutropenia,thrombocytopenia
    • o  Caution with liver failureo  Caution if pt develops vertigo, could beindicator of QT prolongation- puts them at risk for Torsades de Point  ( more so azithromycin)
  64. Tetracyclines (Tetracycline; Doxycylcine; Minocycline)
    • ·     Indications:
    • o  Mainly used for uncommon infections b/c newerantibiotics have fewer interactions. However doxycycline is one of the most common drugs for std’s .
    • Tetracycline is used to tx acneo 
    •  Doxycyline- 1st line drug forgenuitourinary infections: C trachmotis and ureaplsam urealyticumo 
    •  Tetracycline and minocycline used to treat Pacneso  PUD ( one of 4 drugs used to tx h pylori withPUD), Lyme Disease  ( doxycycline)o  1st line drug for many diseases notseen often in North America like malariao  
    •   ·     Adverse Effects: 
    • o  many drug interactions
    • o  Cannot be given 
    • o  Causes stained teeth
    • o  Photosensativityo  Minocycline- vertigoo  Hepatotoxicity ( upper abd pain, dark urine,jaundice) or superinfection ( s/s puritis, hoarseness, vaginal itching anddischarge)o  Dirreah, antibiotic pseudomembrane colitis
  65. Oseltamivir:
    • Antiviral ·     
    • Clinical Use:
    • o  Are used to treat influenza A ( prophylaxis andtx of)
    • o  Reserved for pt’s who are at high risk forcomplications, not a substitute for vaccinationo   
    • ·     Adverse drug reactions:
    • o  GI – n/v , constipationo  Cns – vertigo , blurred vision( more common inamantadine)
    • o  Heart failure and peripheral edema ( more commonin amantadine)
    • o  With older pt’s evaluate for confusion
  66. Metronidazole:
    • ·     antifungal·     
    • Indications: Treats both parasitcal andbacterial infecitonso  
    • Active againt trichomonas vaginalis, entamoebahistolytica, H. Pylori, Clostridium, C diffo  T. VAginalis, G Lamblia, E histolyticao  Used for anaerobic bacterial infections,  bacterial vaginosis and is on e of the drugs in the H. pyloris T·     
    • ADR
    • o  Anorexia, nausea, abd pain, dizziness, vertigo,metallic tasteo  Rare seizure, leukopenia Avoid alcohol