Pharmacology Notes: Diuretics, Antilipemics, and Cardiovascular Drugs PDF

Diuretic Review - Mostly blocks Na+ and Cl- reabsorption - More water and solutes (Na+ and K+), stay in the nephrons - Use for edema: pulmonary, HF and HTN - Monitor for: - Dehydration / hypovolemia / hypotension - Electrolytes - Diabetes -- hyperglycemia - Go...

Diuretic Review - Mostly blocks Na+ and Cl- reabsorption - More water and solutes (Na+ and K+), stay in the nephrons - Use for edema: pulmonary, HF and HTN - Monitor for: - Dehydration / hypovolemia / hypotension - Electrolytes - Diabetes -- hyperglycemia - Gout -- hyperuricemia - Caution with digoxin, ototoxic drugs, NSAIDs (block effects of diuretics), lithium (can cause lithium levels to go up lithium toxicity) Loop (i.e. furosemide) -- cause reflex tachycardia and decrease BP w digoxin - Most effective; even w renal impairment - Watch for: Hypokalemia, ototoxicity, dehydration, hypotension Thiazide and Thiazide-like (i.e. HCTZ, chlorthalidone) - Most commonly prescribed - Watch for: Hypokalemia and Hypotension Potassium-sparing (i.e. spironolactone, triamterene) - Used to retain potassium: limited efficacy as a diuretic should be combined w loop or thiazide diuretic - Watch for: Hyperkalemia, endocrine effects - Salt substitutes Osmotic (i.e. mannitol) - Used to lower ICP, IOP, & renal failure - Used with filter needle and in line filter Antilipemic Agents HMG-CoA Reductase Inhibitors (Statins) (i.e Simvastatin, Lovastatin, Pravastatin, Rosuvastatin, Fluvastatin, Pitavastatin) **[FIRST LINE DRUG FOR CHOLESTEROL]** - Benefits: - **[Most Effective for lowering LDL --]** also lowers VLDL - **[Increases HDL]** - Lowers TG in some - [Non-lipid plaque stability, reduce CV events, increase bone formation] - Action - **[Liver makes less cholesterol and responds by making more LDL receptors to remove cholesterol from blood]** - Uses - Hypercholesterolemia - 1° & 2° prevention of CV Events - Post-MI therapy - Diabetes - Protect vs MI & stroke - Adverse Effects - **Common : HA, Rash, GI upset** - Rare: Myopathy */ **[rhabdomyolysis (breakdown of muscle tissue]**)*, hepatotoxicity (watch the liver), cataracts - Interactions - Other lipid-lowering drugs (fibrates, ezetimibe) - **[Grapefruit juice and other CYP3A4 inhibitors]** - Nursing 101 - **Pregnancy Cat X** - **[TAKE IN THE EVENING (because most cholesterol is produced at night)]** - Watch Lipids, LFTs, CK - Assess more muscle tenderness, pain, numbness, tingling [ ] Cholesterol absorption inhibitor -- Ezetimibe - Action: - Blocks cholesterol absorption - Lowers total cholesterol, LDL, and apolipoprotein B - Adverse Effects: - Myopathy / rhabdomyolysis, hepatitis, pancreatitis, thrombocytopenia - Monitor LFTs, CK - Interactions - Other lipid lowering drugs BAS, statins, fibrates - Nursing 101 - Monitor lipids, LFTs, CK Bile Acid Sequestrants (i.e. **colesevelam, cholestyramine, colestipol)** - Action - Lower LDL levels - Alone or with statin - **A Nonabsorbable resin that binds bile acids & other substances in GI tract** - **[Triggers the body to need bile acid for digestion (bile acids are made from cholesterol produced in the liver) the need for bile acid for digestion has the liver take cholesterol out of the blood]** - Adverse Effects - Constipation - Interactions - **[Can bind with other drugs (can inhibit thiazide diuretics, digoxin, warfarin)]** - **[Block absorption of MANY drugs: i.e. fat-soluble vitamins, levothyroxine, oral contraceptives]** - Nursing 101: - Tablet or powder -- drink at least 4 -- 8 oz fluid - **[Take other medications 1 hour before or 4 hours after the BAS]** - **[Safe during pregnancy]** Fibric Acid Derivatives (Fibrates) (i.e. gemfibrozil, fenofibrate, fenofibric acid) THIRD LINE - Action - **[Lower TG levels (VLDLs)]** - Adverse Effects: - GI, Gallstones, myopathy, hepatotoxicity - Can increase risk for rhabdomyolysis with statins - Interactions - Statins increased risk of myopathy / rhabdo - Warfarin increased risk of bleeding - Nursing 101 - LABS CK, LFTS, PT/INR if on warfarin - Take 30 min before breakfast or dinner Niacin (nicotinic acid) - Action - Reduces LDL and TG levels, [raises HDL (best)] - ***[Does little to improve CV outcomes]*** - More adverse effects than statins - Adverse Effects: - [***Intense Flushing***,] GI upset, liver injury - Muscle cramps, HA, rash, photosensitivity - Nursing 101: - **[To avoid flushing Take one adult strength ASA (325mg) tablet 30 minutes before the niacin dose ]** Monoclonal Antibodies (i.e. alirocumab, evolocumab) - Actions - [Lower LDL] - Adverse Effects: - Hypersensitivity Reaction, Injection Site Reaction The RAAS Drugs - Act on **R**enin-**A**ngiotensin-**A**ldosterone **S**ystem (Angiotensin-converting enzyme (ACE) inhibitors -- comes from the lungs and blocks bradykinin , Angiotensin II receptor blockers (ARBs), Aldosterone antagonists) A diagram of a blood vessel Description automatically generated Direct Renin Inhibitor (aliskiren) - Actions - HTN - Adverse effects - Fetal injury Cat X - Low risk: Angioedema, rash, cough - Low risk: Hyperkalemia - In high doses: Diarrhea - Hypotension - Interactions - High-fat meals block absorption - Atorvastatin, ketoconazole - Furosemide because of the K+ ACE inhibitors (ACEI) -- considered kidney protectors - Therapeutic Uses - HTN, Heart failure, MI, diabetic/nondiabetic nephropathy (Promotes vasodilation) - MI/stroke/death prevention in high CV risk patients - Adverse Effects - **[First -- dose orthostatic hypotension]** - **[Cough -- UNCOMMON dry consistent non productive]** - **[Angioedema]** - **[Fetal injury (Cat X)]** - Hyperkalemia (s/s numbness or tingling, no salt substitutes) - Rash/Dysgeusia - Contradictions - Pregnancy - Bilateral renal artery stenosis or a single kidney (blocks urine production and renal perfusion) - Interactions - diuretics, antihypertensives - K+ sparing diuretics & supplements - Lithium - NSAIDs  **[ACEI: -pril drugs: Captopril, Enapril, Enalaprilat, Ramipril]** Angiotensin II receptor blockers (ARBs) - Actions - HTN, Heart failure, MI, diabetic nephropathy/retinopathy - MI/stroke/death prevention in high CV risk patients - Adverse Effects - **[Angioedema ]** - **[Fetal injury (Cat X)]** - Orthostatic hypotension / lightheadedness / dizziness - No cough compared to ACEI and no hyperkalemia - Contraindications - Pregnancy, renal artery stenosis - Interactions - Antihypertensives, lithium ARBs: --sartan drugs: Losartan, Valsartan Aldosterone Antagonists (i.e. Eplerenone, Spironolactone) - Actions - HTN, Heart failure - PMS, PCOS, acne in young women, 1° hyperaldosteronism - Adverse Effects - **Hyperkalemia, hyponatremia (relisten to audio)** - Flu-like symptoms - Endocrine changes - Dizziness / fatigue - Contraindications: - Pregnancy/lactation - High K^+^, kidney/liver disease, T2DM with microalbuminuria - Interactions - Increase risk of hyperkalemia - Verapamil, ACEIs, ARBs, K^+^-sparing diuretics, NSAIDs, ketoconazole, erythromycin - Salt substitutes - Lithium - Diuretics -- hypotension - CYP3A4 inhibitors - Including grapefruit juice Calcium Channel Blockers Dihydropyridines (i.e. **nifedipine, amlodipine, felodipine, nicardipine, isradipine, nislodipine)** - Actions - Block Ca^2+^ channels - in blood vessels - Vasodilation - Peripheral arterioles - Arteries/arterioles of heart - Uses: - Angina pectoris, HTN - Adverse Effects - Vasodilation → Lowers BP - Reflex Cardiac Stimulation - Increases HR **Reflex Tachycardia** - **[Give with a beta blocker (i.e. metoprolol) to slow it down]** - Increases contractile force - Acute toxicity - Orthostatic hypotension and peripheral edema - Gingival hyperplasia - Interactions - Dihydropyridines - Cimetidine, famotidine, grapefruit juice    toxicity - Contraindications - Acute MI, unstable angina, aortic stenosis, SSS, 2^nd^/3^rd^ degree AV block Nondihydropyridines (Verapamil and Diltiazem) -- no beta blockers needed - Action - Block Ca^2+^ channels - in blood vessels - Vasodilation: Lowers BP reflex cardiac stimulation - Reflex Tachycardia & Increased contractile force - Peripheral arterioles - Arteries/arterioles of heart - In myocardium, SA & AV nodes - Decreased force of contraction - Decreased heart rate - Slowed conduction through AV node - Blocks cardiac conduction but relax cardiac stimulation - **[Net effect]** -- HR, AV conduction, & contractility ***not noticeably changed*** - Uses - Angina pectoris, HTN - Cardiac dysrhythmias - Afib, A flutter, SVT - Adverse Effects; - **CONSTIPATION**, flushing, dizziness, HA, peripheral edema - **Cardiac effects** -- bradycardia, AV block, decreased contractility - Caution in cardiac failure -- do NOT use in SSS, 2^nd^/3^rd^ degree heart block - gingival hyperplasia, chronic eczematous rash in older patients - Interactions - Digoxin, Beta Blockers, Grapefruit juice - Contraindications - Heart block, heart failure Vasodilators Selectivity: - Arterioles (i.e. hydralazine) - Decreases cardiac afterload: - Giving less cardiac work - Increase cardiac output - Increased tissue perfusion - Veins (i.e. nitroglycerin) - Decrease cardiac preload - Less cardiac work - Decreased cardiac output - Decrease tissue perfusion - Both (i.e. prazosin) - Actions - Severe HTN hypertensive crisis - angina pectoris, heart failure, MI - pheochromocytoma, PVD, pulmonary arterial HTN, controlled hypotension in surgery - Adverse Effects - Postural hypotension (venous only) - Reflex tachycardia - Expansion of blood volume (beta blockers and diuretics are needed w vasodilators) Hydralazine - Action - ARTERIAL DILATION - decrease cardiac afterload - less cardiac work - increased cardiac output - increased tissue perfusion - Adverse Effects - HA, dizziness, weakness, fatigue, SLE-like syndrome - Reflex tachycardia, ↑ blood volume - Combined with beta-blocker & diuretics - Postural hypotension is less common than venous dilators Minoxidil - Actions - Arteriole Dilation - decrease cardiac afterload - less cardiac work - increased cardiac output - increased tissue perfusion - Adverse Effects: - Hypertrichosis - Pericardial effusion - nausea, HA, fatigue, breast tenderness, glucose intolerance, thrombocytopenia, skin reactions - Reflex tachycardia, ↑ blood volume - Combined with beta-blocker & diuretics Sodium Nitroprusside: think hypertensive crisis - Action - Vein & Arteriole dilation - Decreased preload & afterload - ***Fastest Acting antihypertensive agent!*** - ***Drug of choice for hypertensive crisis*** - Adverse Effects - Excessive hypotension - Cyanide poisoning & Thiocyanate toxicity - Bradycardia, Tachycardia, ECG changes - Caution - HF with reduced peripheral vascular resistance, AV shunt - Liver/kidney disease, hypothyroid, hypovolemia, fluid/electrolyte imbalance, older Adrenergic Agonists (Alpha and Beta) -- also known as sympathomimetics Insert slides 50-55 - Action: induces flight-or-fight response Alpha 1 Adrenergic Agonist - Action: Vascular tissue & smooth muscle - ↑ Force of heart contraction - Vasoconstriction ↑ BP - Dilate pupils (mydriasis) - ↓ GI secretions - ↑ bladder & prostate contraction Alpha 2 Adrenergic Agonist - Action: Sympathetic nerve endings - ↓ Norepinephrine release - Vasodilation ↓ BP - ↓ GI motility Beta 1 Adrenergic Agonist - Action: Heart - ↑ Heart Rate - ↑ Force of heart contraction - ↑ BP - ↑ renin secretion Beta 2 Adrenergic Agonist - Action: Smooth muscle of lungs, Uterine muscles, Arterioles - skeletal muscles, heart, lungs - Dilates bronchioles - GI & Uterine relaxation - ↑ Blood sugar (glycogenolysis) Dopamine Agonist - Action - Renal vasodilation increase renal perfusion A diagram of a patient\'s heart Description automatically generated Centrally-acting Alpha 2 Agonists (i.e. Clonidine, Guanfacine, Methyldopa) - Uses - HTN, severe pain, ADHD - Action - Bradycardia, decreased cardiac output, vasodilation - Adverse Effects - **Drowsiness / sedation, xerostomia**, **rebound HTN** - constipation, impotence, gynecomastia, CNS effects - Cautions - Methyldopa is safe during pregnancy and lactation Antagonist - BLOCKERS Alpha Adrenergic Antagonist: - azosin (i.e. prazosin, doxazosin, terazosin, tamsulosin) - Uses -- blocks alpha 1 - selective α~1~ blockade - **HTN, BPH** - pheochromocytoma, Reynaud's disease - **Adverse Effects** - **[Orthostatic hypotension]** - **["First Dose" Effect]** - **[Severe postural hypotension - syncope]** - **[Prevention]** - **[Initial therapy begun with low doses]** - **[Initial dose given at bedtime ]** - Reflex tachycardia, nasal congestion Beta-adrenergic Antagonists: -olol - Cardioselective β~1~ - **metoprolol atenolol esmolol bisoprolol** - Nonselective β~1~ (heart) & β~2~ (lungs) can cause vasocontraction bad for asthmatics - **propranolol nadolol** - Alpha & Beta α & β - **carvedilol labetalol** - Beta - [Lower heart rate, myocardial contractility, cardiac output, AV node conduction] - Alpha - Vasodilation - Uses - HTN, Angina, Tachydysrhythmias, Heart Failure, MI - [Suppress reflex tachycardia] - **[Hyperthyroid]**, migraines, pheochromocytoma, glaucoma - Adverse Effects - Beta~1~ - Bradycardia -- it can work too well - Reduced cardiac output - AV Block - Orthostatic hypotension - Rebound myocardial excitation - Beta~2~ - Bronchoconstriction - Glycogenolysis inhibited - Cautions - Pregnancy/lactation - Neonate bradycardia, respiratory distress, hypoglycemia - Do not use - AV Block, sinus bradycardia -- HR under 50 HOLD - Nonselective - Asthma, diabetes (can mask hypoglycemia), bronchospasm, heart failure - Depression, hypotension, myasthenia gravis, PVD, older adults - Severe allergies (epinephrine is given for severe allergies and may block the effects of epinephrine) - Caution in asthma, diabetes, and allergies Etiologies and Pathogenesis of Hypertension  Management of Hypertensive Emergency: commonly caused by a sudden stop of htn meds A close-up of a medical chart Description automatically generated Pregnancy  Drugs for Heart Failure: Beta Blocker is first line Cardiac Glycoside: Digoxin - **[Second-line treatment for HF & dysrhythmias (A Fib)]** - **[Digoxin improves the efficiency of the heart and slows the SA node increasing filling time, stroke volume, and cardiac output]** - Actions - Positive inotropic - [Increased force & efficacy of myocardial contraction] - Negative chronotropic - Decreased HR - Adverse Effects: - Dysrhythmias / cardiotoxicity - **[NARROW Therapeutic Range (0.5 -- 2 ng/L)]** - GI - Anorexia, N/V, Abd pain - CNS - Fatigue, weakness, vision changes - Nursing - Give at the same time daily - **[Take apical pulse 1 minute before administration]** - [Withhold medication if apical pulse below parameters (usually below 60)] - Monitor lab values - Potassium - Digoxin level - Obtain drug levels 6 -- 8 hours after last dose - Caution/Contraindications - Do not use - **[V Fib, V Tach, 2^nd^ or 3^rd^ degree heart block]** - Caution - Hypokalemia, partial AV block, advanced HF, renal impairment - Thiazide/Loop diuretics, ACEI/ARB, sympathomimetics (i.e. dopamine), quinidine, verapamil - Digoxin Toxicity - Stop digoxin and potassium-wasting diuretics - Monitor K+ levels - Treat dysrhythmias - Phenytoin or lidocaine - Treat bradycardia - Atropine - **Toxic levels** - **Activated charcoal** - **Cholestyramine** - **Digoxin immune Fab** Adenosine - Adverse Effects - Sinus bradycardia, hypotension, dyspnea - Face flushing - 10-second ½ - life, so AEs self-limiting - **[Terminates tachycardia]** - Primary indication is **[PSVT]**. Angina: Organic Nitrates - Nitroglycerin (NTG) - Oral ER Capsules, SL Tablet, Translingual Spray, Topical ointment, Transdermal Patch, IV - Long term angina: Isosorbide dinitrate (SL) Isosorbide mononitrate (po) - Action: - **[Dilates veins ↓ venous return (preload) ↓ cardiac oxygen demand]** - Adverse Effects - **HEADACHE** - Orthostatic Hypotension - Reflex Tachycardia (need a beta blocker with use) - Tolerance - Precautions - **[Phosphodiesterase Type 5 meds (ED meds)]** - Not give in severe anemia, closed-angle glaucoma, traumatic head injury (↑ ICP) A list of medications with text Description automatically generated Antianginal: Ranolazine - Adverse Effects: - QT prolongation **[Initial MI Management ]** 1. **[ABCs]** 2. **[Cardiac & O2 monitors]** 3. **[ACLS as needed ]** 4. **[ASA 325mg - aspirin]** 5. **[Assess & Blood work]** 6. **[Give 3 SL NTG tabs or spray]** A. **[Treat LHF if present]** B. **[Beta blocker]** 7. **[Morphine]** 8. **[Statin]** Anti-Infective Pharmacotherapy Part I -- Concepts and Antibiotics Basic Principles: Antimicrobials -- used to treat infectious diseases - Any agent that can kill or suppress microorganisms (bacteria, virus, fungi) Antibiotics -- a chemical produced by one microbe that can harm other microbes - Selective Toxicity: harm to microbes but not the body - Disrupt the cell wall - Inhibit bacterial enzymes - Disrupt bacterial protein synthesis Bactericidal (weaken cell wall killing bacteria) vs Bacteriostatic (stopping growth & divide) Classification of antimicrobials: By susceptible organism - Narrow spectrum -- very specific - Broad spectrum -- attempts to affect a wider range By mechanism of action - Inhibit cell wall synthesis: weaken cell wall lysis - Disrupt cell membrane: leakage of cell wall - Inhibitor protein synthesis - Bactericidal - Bacteriostatic Interfere with synthesis or integrity of bacterial DNA or RNA Antimetabolites Viral enzyme inhibitors Describing Bacteria: Staining - Gram Postitive: thick cell wall that retains violet color - Gram Negative: pink and thin cell wall Shape: - \- Rod Bacilli - Sphere Cocci - Spiral Spirilla Oxygen or No Oxygen \- Aerobic require oxygen for growth Anaerobic do not require oxygen for growth Acquired Resistance - 4 Basic Actions - Decrease concentration of drug at site of action - Stop cellular uptake - Increase active transport out of cells - Inactivate drug (i.e. penicillinase) - Alter structure of drug target molecules (receptors) - Produce a drug antagonist - Mutations: single-drug resistance - Conjugation: multi-drug resistance; chromosomal transfer between DNAs Preventing Resistance - Prevent infections when possible - Diagnose and treat infection properly - Use antimicrobials ***appropriately*** - Promote appropriate prescribing - Reduce demand for antibiotics among healthy adults and parents of young children - Emphasize adherence to prescribed antibiotic regimens - Prevent transmission Drug -- Resistant Microbes - [Nosocomial Infections] - [Health care-associated infections (HAI)] - Urinary tract, surgical wounds, respiratory tract, bacteremia - General sources of HAIs - Patient flora normal bacteria that is usually around - Invasive devices urinary catheters, endotracheal tubes, central lines - Medical personnel infected health care workers - Medical environment contaminated instruments, air, food, or fluids Superinfections - Normal host flora - Produces natural antibacterial substances and Breaks down toxic agents - Antibiotics: kill all... pathogens room to grow - Superinfection = New infection that appears during course of treatment for a primary infection - S/S - diarrhea, bladder pain, dysuria, vaginal discharge - Ex: clostridium difficile, clostridium albicans How to Choose the right antibiotic - Empiric therapy: treating without knowing the organism - Identify the organism & drug sensitivity - Culture & Sensitivity (C&S) - 1 - Obtain a specimen - 2 - Isolate and identify the pathogen in the lab - 3 - Expose the identified microbe to different antibiotics - Host factors - Host defenses - immune system - Infection Site - Allergy? - Other Prophylactic Use of Antimicrobials = agents are given **[to prevent infection]** rather than to treat an established infection: - Surgery: - Cardiovascular (heart, peripheral vascular) - Orthopedic (bone hard to treat) - GI tract (Stomach, colon, duodenum, esophagus, appendix) - Hysterectomies and **[Emergency]** C-sections - Bacterial endocarditis: people with a bad heart valve - Suppressed immune system -- Severe Neutropenia - Other indication: - deep puncture wounds - mother w HIV/AIDS/Herpes - healthcare workers - STIs after exposure - Reoccurring UTIs Misuses of antibiotics: - Viral infections - Upper respiratory infections - Treating fever of unknown origin - Expect the severely immunosuppressed - Improper dosage - Treatment without bacteriologic information - Omission of surgical drainage Bacterial cell walls: - Cell walls protect bacterial cells from the environment - Main material is peptidoglycan - Chains are made of enzymes - Penicillin-binding proteins (PBP) -- gram-positive has more so penicillin is more effective then gram negative - PCNs and related antibiotics to them! Penicillin: [works because of the B-lactam ring Decreases the efficacy of Oral Contraceptives] - First mass-produced antibiotic - Destroys bacterial cell wall -- very effective on gram-positive - Antibacterial activity due to - **β-lactam ring** - Weakens cell wall - Bacteria take up excessive water & rupture (lyse) - **[Only active against bacteria undergoing growth & division!]** - Generalizations - Bactericidal - Mainly active ***against gram-positive*** bacteria - Widely distributed to tissues - Small amount into CSF - Nearly all excreted by kidneys - Short ½ lives - Most common cause of drug allergy - Bacterial resistance: - Inability to reach target - Inactivation by bacterial enzymes - **Penicillinases *or* Beta-lactamases (-asas=enzyme)** - Altered - Beta-lactamase inhibitors taken with an antibiotic to inactivate **Beta-lactamases to expand the efficiency of the antibiotic against the bacteria** - **Clavulanic Acid** - **Tazobactam** - **Sulbactam** - Classifications - Penicillinase sensitive -- narrow-spectrum, broad-spectrum, and antistaphylococcal - Extended Spectrum - Antipseudomonal PCNs - Adverse Effects: - **[Allergy/Anaphylaxis: understand the type of allergy and a cross-sensitivity to cefa]** - **[Types: Immediate (30 min), Accelerated (1-72 hr), Delayed ]** - **[Epinephrine and respiratory support]** - **[Renal Impairment (older pt and children)]** - Hyperkalemia, dysthymias, hypernatremia - High dose PCN G potassium or PCN sodium - Interactions - Do not mix aminoglycosides in the same IV - Probenecid -- delays excretion of some drugs more time to kill the bug - Nursing - Watch for allergic reaction - Take with meals - PenV, Amoxicillin, Amoxicillin/clavulanate - Others -- 8 oz water before/after meals - Use additional contraceptive method - TAKE THE WHOLE PRESCRIPTION! - Pregnancy / Lactation generally safe Cephalosporins -- Most widely used group of antibiotics (Cefa -- drugs) - Beta-lactam antibiotics is similar to penicillin - Beta-lactamase (cephalosporinases) can affect the drug - Bactericidal - Affective against gram-positive and more - *Usually* given parenterally - Low toxicity - Adverse Effects - Allergy / Anaphylaxis / Cross-sensitivity - OK with *mild* PCN allergy - Bleeding - With Cefotetan, Ceftriaxone - Thrombophlebitis IM and IV - **[Renal insufficiency -- poor kidney function then a lower dose is needed ]** - Pain - Pseudomembranous colitis (broader spectrum) - **[Interactions]** - **[Disulfiram (a drug prescribed to alcoholics) reaction]** - **[Flushing, N/V, HA, sweating, lightheadedness, vertigo]** - **[Ceftriacxone and Calcium]** - **[Preovencid]** - Nursing - Pregnancy / Lactation - Take the whole course - Take with food - Store po suspension in refrigerator Carbapenems -- used for serious infections (-penem) - Adverse Effects - Allergy / hypersensitivity / cross-sensitivity - GI - Superinfection - colitis - oral thrush - black, furry tongue - vaginal yeast - Cautions - Pregnancy / Lactation - Renal impairment - Reduces valproic acid levels - breakthrough seizures Other cell Wall inhibitors Vancomycin -- commonly used in hospitals (given by mouth for C-diff pts, IV for systemic) - Adverse effects - Ototoxicity: trough levels to ensure it is staying in therapeutic range and (assess hearing) - Not recommended to give to other drugs causing ototoxicity loop diuretics - Renal toxicity: trough levels - Trough levels -- monitored in IV infusion - Rate dependent infusion reaction - Infusion reactions: Red man syndrome is an infusion reactive bc it is too fast - Administer slowly 60+ minutes - If they develop Red man syndrome stop the infusion and give - IV histamine blockers - i.e. diphenhydramine, cimetidine - Restart - At ½ original rate or 10 mg/min - over 4+ hours - Nursing Considerations: - IV Infusions - Monitor BP & HR - At least 60 minutes - Monitor for red man syndrome - Monitor urinalysis and renal & hepatic functions - Monitor blood levels - Vancomycin trough before the next dose - Assess hearing / tinnitus - Monitor fluid balance - report changes in intake and output ratio and pattern - Note oliguria or cloudy or pink urine - Caution -- renal impairment and/or hearing loss **[Aztreonam -- only used for C-diff but not as much as vancomycin ]** **[Telavancin -- for those allergic to vancomycin still has red man syndrome]** **[Fosfomycin -- single dose therapy of uncomplicated UTI]** Inhibitors of Protein Synthesis -- suppress the replication and growth of bacteria - Bacteriostatic - Tetracyclines - Macrolides - Bactericidal - Aminoglycosides - Treat various infections - respiratory - GI - Urinary - Reproductive tract Tetracycline (-cycline): broad spectrum and Bacteriostatic (stopping growth) - Uses - Acne - GI - Adverse Effects: - GI: cramping, N/V/D, esophageal ulceration - Tooth discoloration - Hepatotoxicity (LFT, liver pain, jaundice) - Photosensitivity - Superinfection - pseudomembranous colitis - yeast - Cautions - No Pregnancy/Postpartum/Lactation - Reproductive: decreased efficiency of oral contraceptives - Liver / kidney disease - **[Children \ - Used for: - PCN allergies - Legionnaire's, *Bordetella pertussis*, acute diphtheria - Chlamydial infections, Pneumonia, Strep infections - Adverse Effects - GI - Prolonged QT interval - Ototoxicity - high doses - Cautions - Pregnancy / Lactation - Liver disease or pre-existing QT prolongation - Drug interactions - CYP450 inhibitors - antihistamines, theophylline, carbamazepine, warfarin, digoxin - Use backup contraception Aminoglycosides (Gentamicin -micin or -mycin no thro) - Action: inhibit protein synthesis -- bactericidal of gram-negative - Adverse Effects - **Ototoxicity** - Nephrotoxicity (for prolonged high doeses) - I&O, BUN, Cr, hematuria, cloudy urine - Intense neuromuscular blockade (blocks mg) - respiratory depression & muscle weakness - Streptomycin -- neurologic disorder - Cautions - Pregnancy / Lactation -- fetal harm and hearing loss - Kidney impairment: kidney damage - Also with amphotericin B or cephalosporins can worsen damage - Hearing loss - loop diuretics, ethacrynic acid - Myasthenia gravis - neuromuscular blocking agents (tubocurarine), skeletal muscle relaxants - PCN inactivates aminoglycosides in same IV solution - Don't mix in same IV bag - Monitor Peaks and Troughs - Once daily dosing -- only trough - Divided dosing -- Peak & trough - **Peak** - **30 min after IM or 30 min after IV [complete]** - **Trough** - **Take Right before next dose** Miscellaneous Bacteriostatic Inhibitors Protein Systhesis Clindamycin - Uses - PCN alternative - Some severe infections - Caution - SEVERE *C. dificile* associated diarrhea (CDAD) - What do pt with clindamycin need to watch for C-diff Linezolid - multidrug resistant Gram+ Retapamulin -- a topical used for impetigo and AE local irritation Mupirocin -- a topical used for impetigo or nasal MRSA AE local irritation and pharyngitis UTI's \- Treatments Sulfonamides and Trimethoprim - **Trimethoprim -- Sulfamethoxazole a combined drug** - Adverse Effects: - Hypersensitivity - Stevens-Johnson syndrome - burns - Allergies: - To Sulfa, Thiazide and Loop diuretics, Sulfonylurea oral hypoglycemics - Adverse Effects - Blood dyscrasias - Hemolytic anemia, Agranulocytosis, Leukopenia, Thrombocytopenia, Aplastic anemia - Crystalluria -- drink lots of water and UO should be at least 1200mL - Kernicterus -- no for pregnancy - Hyperkalemia - Cautions - Pregnancy / Lactation - Impaired kidney function can cause crystalluria - Older adults -- ACE/ARB hyperkalemia - Warfarin, Phenytoin, Sulfonylureas - Backup contraception Urinary Tract Antiseptics - Nitrofurantoin - Methenamine - Adverse effects - GI: N/V/D, anorexia - Hypersensitivity - **[Peripheral neuropathy]** - Hypersensitivity Fluoroquinolones (-floxacin) \- Many uses risk of superinfections Broad spectrum: Gram-positive and negative For - Adverse Effects - Achilles Tendon Rupture (leg pain, heel pain) Myasthenia Gravis - GI -- N/V/D - Superinfection - Phototoxicity - CNS -- older adults - Cautions - Pregnancy / Lactation - \