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  1. NSAID's
    • acetylsalicylic acid
    • 1st generation
    • ibuprofen
    • naproxen
    • indomethacin
    • ketorolac
    • 2nd generation
    • celecoxib
    • meloxicam
  2. NSAID's
    COX 1
    • bleeding/clotting disorder
    • peptic ulcer disease
    • use of anticoagulants or steroids (risk of bleeding)
    • viral disease in children
    • liver/kidney disease
    • avoid in pregnancy
  3. NSAID's
    COX 2
    • history of cardiovascular disease
    • liver/kidney disease, seizure disorders

    avoid in pregnancy
  4. NSAID's
    adverse effects
    • toxic additive effect:
    • taking ASA with another NSAID
    • ASA associated with Reye's in children
    • tinnitus in adults
    • impairment of renal perfusion
    • (risk increases in long-term use)
    • peptic ulcers, dyspepsia
  5. Acetaminophen
    • WATCH OUT !! Black Box Warning
    • liver disease

    don't drink
  6. Acetaminophen

    caution
    • when pt takes seizure meds, anticoags
    • (increase prothrombin time, slows metabolism of warfarin)
  7. Acetaminophen

    dosage
    do not exceed 4000 mg in 24 hours
  8. Acetaminophen

    antidote
    mucomyst
  9. Opioid Agonist
    • morphine sulfate (morphine)
    • fentanyl
    • meperidine
    • methadone
    • codeine
  10. Opioid agonists

    Watch out !!
    alcohol + opioid = dead
  11. Opioid agonists
    first pass drug = extensive liver metabolism with oral route availability (oral doses tend to be larger than IM or IV doses to accommodate the first pass metabolism)
  12. Opioid agonists

    things to avoid
    • use with MAOI's - increase BP, hyperpyretic coma
    • giving with sedative effect drugs - increases sedation
    • anticholinergics - used with benedryl will increase sedation
  13. Opioid agonists

    do not use
    • head injury or any condition where increased ICP could be problematic
    • will increase intracranial pressure

    reduced doses in elderly or with liver disease

    avoid in pregnancy - result may be fetal addiction
  14. Opioid agonists

    adverse effects
    • respiratory depression
    • sedation
    • decreases GI motility
    • vomiting
    • hypotension
    • urinary retention
    • euphoria
    • seizure
    • allergic reactions (causes histamine release - be alert to itching
  15. Opioid agonists

    a few notes
    • do not use for premies
    • caution: pt with COPD, asthma, head injury, extremely obese
    • very young or very old pt have increased adverse effects
    • Meperidine (Demerol) do not use for more than 48 hrs and never in kids
    • limit 600 mg/24 hours
  16. Opioid agonist - antagonist
    • butorphanol (stadol)
    • nalbuphine (nubain)
  17. Opioid agonist - antagonist

    Watch out !!
    • CNS depressants increase sedation
    • dose reduction needed with liver/renal disease
    • cardiovascular disease - increase cardiac workload
  18. Opioid agonist - antagonist

    adverse effects
    the type of side effects are the same as commonly observed with opioid analgesics

    somnolence, dizzyness, nausea/vomiting are the most common

    hypotension within first hour after administration
  19. Opioid antagonist
    naloxone (narcan)
  20. Opioid antagonist

    purpose
    interfere with action of opioids by competing with opioid receptors
  21. Opioid antagonist

    Watch out !!
    • dose adjustment needed if there is brain tumor or head injury, seizures, heart disease or a heart rhythm disorder, or a history of durg or alcohol addiction.
    • Possible hypersensitivity reactions may occur as well

    • works quick
    • wears off so additional doses may be needed
  22. Opioid antagonist

    adverse effects
    • dizzyness
    • fainting
    • dyspnea
    • chest pain
    • tachycardia
    • dysrhythmias
    • seizures
  23. Anti Gout medication
    • colchicine
    • indomethacine - also an NSAID - really does nothing to relieve uric acid crystals
  24. Anti Gout

    Watch out !!
    • colchine should not be used by a person with a known hypersensitivity to the drug or by a pt with serious GI, renal, hepatic, or cardiac disorders
    • also pt with blood disorders, should not use colchine
  25. Anti Gout

    adverse effects
    • GI effects most common: N/V/D
    • bone marrow depression with long-term therapy
    • peripheral neuritis, purpura, myopathy, allopecia, reversible azoospermia
  26. Anti Gout

    Allopurinal
    Probenacid

    Watch out !!
    cautious use when pt have renal disorders
  27. Anti Gout

    Allopurinal
    Probenacid

    Adverse effects
    • expected = increase in gouty pain which is transient
    • most frequent adverse event is skin rash which may result in discontinuation of the drug

    most serious is renal failure
  28. Anti Gout

    Probenacid
    • increase uric acid of kidney
    • drink 6-8 glasses of h2o per day

    prolongs antibiotic effects - penicillin or cephalosporin
  29. Anti Gout

    Glucocorticoids
    Used for anti-inflammatory effects
  30. Migraine Medications

    Purpose
    to prevent inflammation and dilation of intracranial blood vessels = decrease in pain
  31. Migraine Medications

    Prototypes
    • ergot alkaloids - ergotamine, ergotamine/caffeine
    • serotonin receptor agonists - triptans
    • beta-blockers - propranolol
    • anticonvulsants - divalproex ( depakote ER)
    • tricylics - amitriptyline
    • calcium channel blockers - verapamil
    • estrogen - gel & patches
  32. Migraine Medications

    Ergotamine

    Watch out !!
    • Pregnancy category X ( stimulates uterine contractions)
    • peripheral vascular disease
    • ateriosclerosis
    • heart/liver/kidney disease
    • high BP
  33. Migraine Medication

    Ergotamine

    DDI
    • SSRIs (prozac, paxil)
    • beta blockers
    • HIV meds
    • erythromycin
    • ketoconazole
    • tagamet
  34. Migraine Medication

    Ergotamine

    Adverse effects
    Ergotism =numbness or tingling in the fingers or toes, chest pain, weakness of the legs, muscle pain in the arms or legs, pain in the chest, changes in heart rate, swelling or itching
  35. Migraine Medication

    Ergotamine

    extra notes
    • a systemic drug- not just in the head
    • causes abortions
    • strong vasocontrictor, so = peripheral vascular - makes it worse
    • arteriosclerosis/heart/liver/angina
  36. Migraine Medication

    sumatriptan

    "triptan's"

    Watch out !!
    "sulfa" drug - hypersensitivity
  37. Migraine Medication

    sumatriptan

    DDI's
    • life-threatening serotonin syndrome when combined with MAOIs, SSRIs, SNRIs and triptans
    • liver disease = reduce dose
    • documented heard disease- don't use
    • elderly/peds - don't use
  38. Migraine Medication

    sumatriptan

    adverse effects
    • nausea
    • vomiting
    • dizzyness
    • burning sensation
    • numbness of digits
    • sinusitis
    • tinnitus
    • myalgia
    • phonophobia
    • photophobia
    • hypertensive events due to systemic vasoconstriction
    • serious cardiac events
  39. Migraine medications

    the others
    • propranolol - beta blocker
    • prevention of migraines
    • causes hypotension
    • divalproex - antiepileptic
    • stablize vessels in CNS
    • amitriptyline - tricyclic antidepressant
    • influences how body uses serotonin/norepinephine
    • verapamil - calcium channel blocker
    • stablize the vessels - preventive
    • estrogen - hormonal agent
    • stablize and prevent highs and lows
  40. RA meds

    methotrexate

    Watch out!!
    • caution with renal/liver disease or decreased lung function
    • pregnancy X - causes fetal defects/miscarriage
    • discontinue several months if conception is planned (either partner)
  41. RA meds

    methotrexate

    Adverse events
    • stomatitis
    • GI upset
    • WBC counts
    • hair loss
    • skin rash/itching
    • headache
    • drowsiness
    • severe toxicity of liver (cirrohosis)
    • kidneys (proteinuria)
    • bone marrow (WBC/platelets)
    • Chemo drug
  42. RA med

    aurothioglucose

    Watch out !!
    • avoid in pt with blood, liver or kidney disease
    • recent radiation treatment
    • uncontrolled diabetes
  43. RA med

    aurothioglucose

    Adverse effects
    • rash/inflammed skin (most common, itching is a first sign)
    • stomatits
    • indigestion
    • a metallic taste in your mouth
    • renal toxicity
    • blood dyscrasia (severe or bloody diarrhea, easy bruising or a nosebleed)
    • in rare cases - exposure to sunlight may cause areas of the skin to turn a bluish-gray color
  44. RA med

    aurothioglucose

    extra notes
    • a form of gold works against inflammation after other agents have failed or with something else
    • flushing, dizziness, fainting - have to sit/laydown when administering
    • given once a week and than back off once a month
  45. RA med

    hydroxycholorquine


    Watch out !!
    • few DDI known
    • typically well tolerated

    • pharmacogenetics:
    • use cautiously in pts of African descent (development of severe anemia) due to cycle cell anemia
    • worsens psoriasis
  46. RA med

    hydroxycholorquine

    Adverse Events !!
    • nausea and diarrhea, skin rashes or hair changes (bleaching or thinning of hair)
    • weakness
    • ocular toxicity - retina
    • get baseline eye exam to watch eye there after - visual changes - call us
    • autoimmune process is affected
    • prevents inflammatory process from starting
  47. RA med

    sulfasalazine

    Watch out !!
    • hypersensitivity (think "sulpha drug"
    • DDI - digoxin, warfarin, liver/kidney disease = reduced doses needed
  48. RA med

    sulfasalazine

    Adverse events
    • nausea/abdominal discomfort
    • stomach ulcers
    • skin rash
    • headache
    • photosensitivity = common for sulfa drugs = long sleeves =) sunburn
    • discoloration of urine/skin are most common
    • less common = reduced WBC/RBC counts
  49. RA med

    etanercept

    Watch out !!
    • not to be used with existing CNS disorders
    • multiple sclerosis
    • myelitis
    • optic neuritis
    • drug interaction studies have not been conducted
    • may reduce the response of the immune system (caution if pt has condition that suppresses the immune system OR when an immune response is desired such as a vaccination and DO NOT USE if there is an active infection)
  50. RA med

    etanercept

    Adverse Events !!
    most common = redness, itching, pain, or swelling at the site of injection
  51. RA med

    etanercept

    Extra notes
    • reverses response of immune system
    • "biologic response modifier"
    • depressing immune system
    • knock out ability of immune system to respond to inflammation
  52. RA med

    penicillamine

    Watch out !!
    • do not use if pt taking "gold salts"
    • antimalarial (plaquenil)
    • cytotoxic drugs (rheumatrex)
    • because of similar bone marrow and kidney risks
    • weakens collagen therefore reduce the dose when surgery is considered/resume after the wound has healed
  53. RA med

    penicillamine

    Adverse events
    • rash (itching may be pretreated with antihistamines to decrease)
    • if rash is accompanied by fever/joint pain = discontinue
    • anorexia
    • nausea
    • abdominal pain
    • loss of the tense of taste
    • bone marrow suppression serious kidney disease
  54. RA med

    penicillamine

    need compliant pt
    • all pts who take penicillamine require regular blood and urine testing for monitoring
    • may induce immune-mediated diseases
  55. Immune Basics

    passive
    • innate
    • you're born with it
  56. Immune basics

    active
    • acquired or adaptive
    • you develop it
  57. Purpose of vaccines
    • trick the body into producing antibodies against a harmless imposter
    • then, if the real microbe turns up, the body's defenses are primed to foil infection and disease
  58. Why are vaccines administered ??
    not to cure or manage disease but to prevent it
  59. Immunoglobulins

    gamma globulin
    imunoglobulin G

    Why do we use it ?
    to create rapid but temporary immunity because pt was exposed to something

    made up of pooled protein from 100's of people so like giving wrong blood
  60. Immunoglobulins

    assess for:
    • prior allergic reaction
    • recent or proposed live virus vaccination
    • recent or proposed allergy testing (may create false positive)
    • pregnancy & lactation (weigh risk vs. benefit)
  61. Immunoglobulins

    adverse reactions
    • local pain/tenderness at the injection site
    • urticaria
    • angioedema
    • anaphylactic reactions, although rare, have been reported-keep epinephrine on hand and observe pt closely after injection
  62. Immunoglogulins

    extra notes
    gives passive immunity - so chicken pox vaccine will not work

    • stay with pt for 20-30 minutes after given
    • any vaccines processed or planned - re-vaccinate or postpone vaccine
  63. Immunostimulants

    interferon alfa
    aldesleukin

    purpose
    • to enhance immune response
    • generally to reduce proliferation of cancer cells
  64. Immunostimulants

    interferon alfa
    aldesleukin

    Assess for:
    • underlying heart/kidney/liver/CNS disease
    • pregnancy
    • prior hypersensitivity
    • "dose limiting conditions"
  65. Immunostimulants

    interferon alfa
    aldesleukin

    adverse effects
    • rash
    • alopecia
    • N/V/D
    • dry mouth
    • "aftertaste"
    • flu-like syndrome
  66. Immunostimulants

    interferon alfa
    aldesleukin

    DDI
    hypotension (beware of pts on anti-HTN drugs)
  67. Immunosuppressants: overview

    calcineurin inhibitors: cyclosporin (Sandimmune)
    glucocorticoids: prednisone
    cytotoxics: asathioprine (immuran)

    KEY CONCEPT
    • any time immunosuppressants are used:
    • Pt is at risk for infection because their immune system is blocked from working appropriately !!
    • (that is what these drugs do)
  68. Immunosuppressants:

    calcineurin inhibitors:
    cyclosporin (Sandimmune, gengraf, neoral)

    assess for:
    • pre-existing renal/liver disease
    • hypersensitivity
    • pregnancy (embryo toxic)/lactation
    • presence of known neoplasms (risk to spread the cancer)
    • concurrent use of other immunosuppressants
  69. Immunosuppressants:

    calcineurin inhibitors

    adverse reactions
    • tremor
    • hypertension
    • hyperplasia of gums
    • renal dysfunction
    • diarrhea
    • hirsuitism
    • acne
    • bone marrow suppression
  70. Immunosuppressants:

    calcineurin inhibitors

    DDI
    • NSAIDS (aleve, naprosyn)
    • many antibiotics, especially aminoglycosides
    • many seizure drugs-VERY long list

    and pt needs to forget their grapefruit
  71. Immunosuppressants:

    cytotoxics

    assess for:
    • concurrent use of allopurinal (gout med)
    • ACE inhibitors
    • inhibits warfarin action
    • history of use of immunosuppressants previously (this is a 2nd line drug)
    • pregnancy category D (for don't use)
  72. Immunosuppressants:

    cytotoxics
    • Adverse reactions:
    • primarily hematologic (leucopenia/thrombocytopenia)
    • gastrointestinal (nausea/vomiting)
    • skin rashes and alopecia also seen
  73. Immunosuppressants:

    cytotoxics

    special note
    chronic immunosuppression increases risk of neoplasia & hematologic toxicities
  74. Immunosuppressants

    Glucocorticoids

    Hydrocortisone
    prednisone
    methylprednisolone

    indicated for:
    • acute/chronic anti-inflammatory
    • anti-immune needs
  75. Immunosuppressants

    glucocorticoids

    Assess for:
    • infectious disease (especially fungal)
    • diabetes
    • osteoporosis
    • liver or thyroid disease
    • psychoses ("roid rage" can occur)

    adverse effects: LOTS !!
  76. Corticosteroids:
    Short-term Vs. long-term therapy
    SHORT TERM:

    • moderate doses used
    • tapered over 1 to 2 weeks

    LONG TERM:

    • reserved for severe illnesses
    • often uses smaller doses
  77. Corticosteroids

    PRACTICE PEARL
    To reduce potential side effects, the lowest dose of corticosteroid possible, still yielding a positive impact, should be given.
  78. Chemo drugs

    side effects
    • bone marrow suppression
    • GI upset: nausea/vomiting which can be severe
    • alopecia
    • mucositis
    • sterility in males/reproductive toxicity
    • hyperuricemia - use allopurinal right away - no lobster/shrimp
  79. Adjuvants

    tricyclic antidepressant
    amitriptyline
    • orthostatic hypotension
    • sedation
    • anticholinergic effects such as dry mouth, urinary retention, constipation, blurred vision
  80. Adjuvants

    anticonvulsants
    carbamazepine, gabapentin
    • bone marrow suppression
    • gastrointestinal distress (nausea, vomiting and diarrhea)
  81. Adjuvants

    CNS stimulants
    methylphenidate
    • weight loss
    • insomnia
  82. Adjuvants

    antihistamine
    hydroxyzine
    • sedation
    • dry mouth
  83. Adjuvants

    glucocorticoids
    dexamethasone
    • adrenal insufficency (hypotension, dehydration, weakness, lethargy, vomiting, diarrhea associated with prolonged use)
    • osteoporosis
    • hypokalemia
    • glucose intolerance
    • peptic ulcer disease
  84. Adjuvants

    bisphosphonate
    etidronate
    • transient flu-like symptoms
    • venous irritation at injection site
    • renal failure, UTI
  85. Adjuvants

    NSAIDs
    ibuprofen
    • bone marrow suppression
    • gastrointestinal distress, such as nausea, vomiting and diarrhea, or ulceration

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