Pharmacology Final Study Guide PDF

**Pharmacology Final Study Guide** -**Endocrine:** **Patient education for oral anti-diabetics** - - - - - - - - Used **only** for DM2 - **Withhold for IV contrast or surgery. Increases risk of lactic acidosis/risk of renal failure** **Types of insulin; onset, peak, du...

**Pharmacology Final Study Guide** -**Endocrine:** **Patient education for oral anti-diabetics** - - - - - - - - Used **only** for DM2 - **Withhold for IV contrast or surgery. Increases risk of lactic acidosis/risk of renal failure** **Types of insulin; onset, peak, duration, side effects** +-----------+-----------+-----------+-----------+-----------+-----------+ | **Insulin | **Example | **Onset** | **Peak** | **Duratio | **Adminis | | Type** | s** | | | n** | tration** | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Rapid | -Insulin | around 15 | -Lispro | Between | -10-15 | | Acting | lispro | minutes | and | 1-3 hours | minutes | | Insulin | (Humalog) | | aspart = | | before | | (clear)** | | | 40 | | meals | | | -Insulin | | minutes | | | | | aspart | | | | -Food | | | (NovoLog) | | -Glulisin | | should be | | | | | e | | present | | | -Insulin | | and | | | | | glulisine | | inhalatio | | | | | | | n | | | | | -Oral | | = 55 | | | | | inhalatio | | minutes | | | | | n | | | | | | | insulin | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Short | Regular | 30 | 1.5-3.5 | 4-12 | SubQ or | | Acting | Insulin | minutes | hours | hours | IV | | Insulin | | | | | | | (short)** | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Interme | Insulin | 1-2 hours | 4-12 | 14-24 | | | diate | Isophane | | hours | hours | | | Acting | NPH | | | | | | (cloudy)* | | | | | | | * | | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ | **Long | -Insulin | 1-1.5 | Does not | 24 hours | Once | | Acting** | glargine | hours | peak | | daily | | | (Lantus) | | | | before | | | | | | | bedtime | | | -Detemir | | | | | +-----------+-----------+-----------+-----------+-----------+-----------+ **Side effects and patient education for steroids** **Glucocorticoids** - **Side effects** - **Increased blood glucose (steroid induced DM), Moon face/buffalo hump from fat deposition, Growth retardation** - **MUST Taper off slowly to avoid adrenal insufficiency** **Mineralocorticoids** - Fludrocortisone - **Side effects** - **Monitor K+ for patients on fludrocortisone** - Fluid imbalance, fluid overload, HTN, hypokalemia, GI distress **Treatment for hypo and hyperparathyroidism** **HYPOparathyroidism** - Parathyroid hormone deficiency - **PTH replacement drug is Calcitrol** - Calcitrol is a Vitamin D analogue that promotes Ca absorption from GI tract and promotes secretion of Ca from bone to bloodstream **HYPERparathyroidism** - **Partial or full parathyroidectomy is most common treatment** - Excess parathyroid hormone secretion **Uses and side effects of Vasopressin** **Vasopressin** - Used to treat **diabetes insipidus (ADH deficiency)** - **Side effects** - **increased urine output, watered down urine (hypOosmolar). Electrolyte imbalances, fluid deficit** **Treatment for hypo and hyperthyroidism** - - - - Levothyroxine Sodium (Synthroid): - - - - Liothyronine: - - - - - - - Subtotal thyroidectomy, Radioactive iodine therapy, antithyroid drugs which inhibits synthesis or release of thyroid hormone - Beta blockers (propranolol) to manage tachycardia/palpitations from hyperthyroid - - **Thioamides:** - **Propylthiouracil (PTU) and methimazole** **Compare and contrast 1^st^ and 2^nd^ gen antidiabetic medications** **1^st^ generation** oral antidiabetics (Sulfonylureas) - **Stimulates pancreatic beta cells to secrete more insulin** (which is why its for T2DM, because they do still secrete some insulin on their own) - Drug Examples - Tolbutamide, Chlorpropamide, Tolazamide **2^nd^ generation** oral antidiabetics (sulfonylureas) - **Increases tissue response to insulin and decrease glucose production by liver.** - Avoid 2^nd^ gen with kidney or liver impairment. - Have more potential for hypoglycemia than 1^st^ gen, so their doses will be lower. - Drug examples - Glimepiride, Glipizide **Hypertension:** **Review antihypertensives used during pregnancy** - **Methyldopa is the first line drug for hypertension in pregnancy.** **Review benefits of alpha-adrenergic blockers for HTN** - **Alpha-adrenergic blockers** - Lowers blood pressure via vasodilation - **Beneficial for patients with lipid abnormalities, causes decrease in LDL and increase in HDL. Safe for patients with diabetes. Does not interfere with glucose metabolism.** - Safe for patients with diabetes. Does not interfere with glucose metabolism. - **Drugs end in -azosin** **Give examples of different antihypertensives and their drug classes (ex: beta blockers, calcium channel blockers, etc.)** **Alpha 1 & Beta 1 Blockers** - Drug examples - **Labetalol** **Direct-acting arteriolar vasodilators** - Drug examples - **Hydralazine and minoxidil** - Action - Promote vasodilation by relaxing smooth muscle of arteries. - These are reserved for moderate to severe HTN. **Angiotensin-converting enzyme inhibitors (ACE)** - Drug examples - **Benazepril, captopril, enalapril, lisinopril, quinapril, ramipril, trandolapril** - Action - Inhibit the enzyme that converts angiotensin 1 to angiotensin 2, and blocks the release of aldosterone, which causes Na+ and water to be excreted (instead of retained), decreasing BP **Diuretics** - **Thiazides** - **Hydrochlorothiazide** - **Loop diuretics** - **Furosemide** - Effective as first line treatment for mild hypertension but are avoided in patients with secondary HTN **Sympatholytics** - **Beta adrenergic blockers (Beta Blockers)** - **Nonselective: propranolol, nadolol, pindolol** - decrease HR **AND** cause bronchoconstriction - Avoided in asthma due to bronchoconstriction - **Selective (beta 1): atenolol, metoprolol** - Decreased HR **ONLY** - Preferred for controlling angina **Calcium channel blockers** - Examples of meds - **Verapamil, Nifedipine, Diltiazem, Nicardipine, Amlodipine** - Nifedipine can cause cardiac death in high doses of immediate release. Reserved for acute HTN **Centrally Acting Alpha 2 Agonists** - Drug examples - **Methyldopa, Clonidine, Guanfacine** - Methyldopa is first line for HTN in pregnancy **Alpha-adrenergic blockers** - Drug examples - **Doxazosin, prazosin, terazosin** **Angiotensin II receptor blockers (ARBs)** - Drug examples - **Losartan, valsartan, irbesartan, eprosartan, candesartan, olmesartan, telmisartan, azilsartan** - May be used as first line treatment for HTN **Side effects of ACE inhibitors** - Nonproductive cough, Fatigue, Insomnia, Headache, Dizziness, Nausea, Vomiting, Diarrhea, Hyperkalemia, Tachycardia, Hypotension, Angioedema - Examples: - **Benazepril, Captopril, Enalapril, Lisinopril, Quinapril, Ramipril, Trandolapril** **Describe the MOA of direct acting vasodilators** **Direct-acting arteriolar vasodilators** - Action - **Promote vasodilation by relaxing smooth muscle of arteries.** - Vasodilation = decreased BP and sodium and water retention= peripheral edema - These are reserved for moderate to severe HTN. **Diuretics:** **Compare potassium sparing versus potassium wasting diuretics** - **Potassium-sparing diuretics** - interfere with Na/K+ pump by blocking aldosterone, **the result is Na and water excretion and potassium retention.** - Used often for cardiac patients - **Often combined with potassium wasting diuretics to increase diuretic effect while maintaining normal potassium** - If only taking Potassium sparing diuretic, monitor for **hyperkalemia** and educated on avoiding foods high in K+, avoid supplementation - **Life threatening hyperkalemia if taking with ACE inhibitors** **Side effects and nursing considerations of Furosemide** - **Side effects** - electrolyte imbalances and hyperglycemia, orthostatic hypotension, hearing loss (in high doses/peaks in serum levels) and photosensitivity. - **Drug Interactions** - **If loop diuretics are taken with digoxin it can lead to digitalis toxicity** **Urinary:** **Antibiotics/meds for UTI and their side effects** - **Fluoroquinolones** - Cipro**floxacin**, Levo**floxacin** - **Black box warning** for peripheral neuropathy and **spontaneous tendon rupture**, can also cause elevated triglycerides - **Side effects** - Photosensitivity, eye damage, visual disturbances - **Urinary Analgesics** - **Phenazopyridine** (Pyridium, Azo Standard) - Side effects - **Pyridium turns urine reddish orange due to the dye** - **Urinary antispasmodics** - Mirabegron, Oxybutynin, Flavoxate - Side effects - **Blurred vision, GI distress, constipation, drowsiness, dry mouth (anticholinergic side effects)** **Describe contraindications for urinary antispasmodics** - Due to anticholinergic like side effects **avoid in glaucoma** or if patient wears contact lenses. - **Avoid in GI or urinary obstruction**, side effects could worsen. **Describe medications used for urinary retention** **Urinary Stimulants** - Drug example - **Bethanechol** - Action - Increase bladder tone of detrusor muscle which produces a contraction strong enough to stimulate urination. **Neuro:** **Review meds used for cerebral edema** **Describe medications used for myasthenia gravis** - Myasthenic Crisis - Severe generalized muscle weakness that involves diaphragm and intercostal muscles - Left untreated it may cause death from paralysis of respiratory muscles - Treatment - **Neostigmine** - acetylcholinesterase inhibitor - inhibits the enzyme that breaks down acetylcholine and allows for more acetylcholine in the blood. **Side effects and patient education for antispasmodic drugs** **Understand the relationship for carbidopa and levodopa** - Dopaminergics - **Levodopa** - Converted into dopamine in brain and PNS by nerve cells. Very little makes it to brain since most is converted in the PNS so larger doses are needed to achieve the wanted response. - **Carbidopa-levodopa** - Inhibits the enzyme that converts levodopa into dopamine in the PNS to allow for increased mobility - Doing this allows for more dopamine to reach the brain in smaller doses **Side effects and patient education for MAOI's** - Monoamine Oxidase B Inhibitors - **Selegiline** - Action - **Inhibits MAO-B enzyme** and **prevents break down of levodopa/dopamine** - Inhibiting MAO-B prolongs the action of levodopa/dopamine since it is not being broken down - Side effects - **Depression, insomnia, orthostatic hypotension** - Food interactions - **Foods high in tyramine can cause hypertensive crisis** - **Smoked/aged cheeses, red wine, bananas** **Review MOA for drugs for Alzheimer's disease** - Acetylcholinesterase/Cholinesterase Inhibitors (Alzheimer's drug) - **Rivastigmine** - **Used for management of Alzheimer's disease** - Actions - **Increases cognitive function and slows disease process by stopping breakdown of acetylcholine** **Heart Failure:** **MOA and side effects of Digoxin and Nitroglycerine** - **MOA of Digoxin** - Increase myocardial contraction, increasing cardiac output and improving circulation. Digoxin decreased HR and conduction through AV node. - Inhibits Na/K+ pump shifting sodium into cell (Intracellular), allowing for influx of calcium into cardiac myocytes (allows heart to contract more easily) - **Second-line drug for HF** - **Side effects** - Bradycardia, **dysrhythmias**, anorexia, blurred/yellow vision, confusion - Dysrhythmias are caused due to narrow therapeutic range and must be administered carefully - **Digitalis Toxicity** - Causes - Overdose of digoxin, drug interaction, and hypokalemia (often underlying cause of dysrhythmias) - Signs & Symptoms - **White/yellow/green halos around objects**, nausea, anorexia, confusion, PVCs, HR less than 60, delirium, can lead to cardiotoxicity and death - **Nitroglycerine** - Causes vasodilation which **reduces preload and afterload** and improves blood flow through the coronary arteries. - Used to treat **angina pectoris, HTN, HF** - Side effects such as headache, flushing, orthostatic hypotension **Medications used for angina** - **Nitrates** - Cause vasodilation and decrease preload and afterload (can cause hypotension) - Act on vascular smooth muscle to decrease venous tone which promotes vasodilation and decreased cardiac workload - **Examples of nitrate meds** - **Nitroglycerin, isosorbide dinitrate, isosorbide mononitrate** - **Side Effects** - Hypotension, orthostatic hypotension dizziness, headache, syncope (orthostatic) - Routes of administration - Sublingual - Avoids first pass effect - Absorbed more quickly - Breaks down if exposed to heat or light - **Beta Blockers** - **Work as antianginal drugs by reducing hearts oxygen demand and slowing the heart rate.** - Nonselective: propran**olol**, nad**olol**, pind**olol** - decrease HR **AND** cause bronchoconstriction - Selective (beta 1): aten**olol**, metopr**olol** - Decreased HR **ONLY** - Preferred for controlling angina - Action - Block beta 1 (selective) OR **both** beta 1 & beta 2 (nonselective) receptor sites which blocks action of norepi and epi decreased HR and BP - **Decrease workload of heart and oxygen demands** - Uses - Stable angina, HTN, dysrhythmias - **Calcium channel blockers** - Calcium activates myocardial contractions increased cardiac workload and oxygen consumption. By blocking calcium channels, it prevents this. - Examples of meds - **Verapamil, Nifedipine, Diltiazem, Nicardipine, Amlodipine** - Uses - **Stable and variant angina**, HTN, dysrhythmias - Side effects - Bradycardia, hypotension which leads to reflex tachycardia due to prolonged hypotension, peripheral edema **Compare and contrast symptoms left and right sided heart failure** - Right-sided heart failure - Right ventricle unable to efficiently pump blood through pulmonary artery - Causes blood to get backed up in periphery which causes peripheral edema - Left-sided heart failure - Left ventricle unable to efficiently pump blood though aorta to periphery - Causes blood to back up in lungs which can lead to shortness of breath and dyspnea **Review MOA and side effects of Milrinone** - **Phosphodiesterase inhibitors** - **Milrinone** lactate - **1st line drug for HF** - Action - Increases cAMP & causes bronchodilation - Inhibits enzyme phosphodiesterase - Promotes + inotropic effects & vasodilation (increasing contractility) - With increased contractility, stroke volume is increased and so is cardiac output - Caution - Should **not** be given IV longer than **48 to 72 hours** to **avoid severe cardiac dysrhythmias** - Requires close cardiac monitoring with EKG and/or telemetry **Anticoagulants:** **Describe the antidote for heparin overdose** - **Antidote** - **Protamine Sulfate**. - In case of uncontrolled bleeding or overdose, protamine sulfate can be given. It is also an anticoagulant but when combined with heparin it antagonizes its effects and reverses its action **Compare and contrast heparin and LMWH** Low Molecular Weight Heparin Heparin ------------------------------------------------------------------------ ----------------------------------------------------------------------------------------------------- Lower risk of bleeding and can be given at home, longer half life High risk of bleeding and must be monitored, immediate/short term. Doesn't cross placental barrier. Inactivates the Xa factor, but it is less able to inactivate thrombin. Prevents coagulation by combining with antithrombin III to inactivate factor Xa and thrombin **Describe side effects of anticoagulants** - **Oral Anticoagulants: Warfarin** - Side effects - **Prolonged bleeding**, petechiae, ecchymosis, tarry stools, hematemesis, hemorrhage, dermatitis (hypersensitivity), nausea, GI upset, potentially fatal bleeding **Medications used for ischemic stroke** - **Thrombolytics** - Attack & dissolve blood clots that have already formed to minimize tissue necrosis, improve blood flow, and potentially prevent thromboembolic effect - Actions - **Alteplase** (tPA -- tissue plasminogen activator) binds with plasminogen and forms complex that activates plasmin. Also decreases action of fibrinogen and clotting factors which increases risk of bleeding. - **MI Treatment** -- administration of thrombolytic (alteplase) **within 30 minutes of arrival to hospital** or **3-4 hours from onset of symptoms** or **within 3 hours of thrombotic stroke** - Uses - **PE (pulmonary embolism), acute MI, acute ischemic stroke, DVT, thromboembolism, or CVAD** (central venous access device) occlusion - Side effects - **Anaphylaxis, dysrhythmias, hemorrhage/bleeding, low BP, allergic reactions, stroke** **Dyslipidemia:** **MOA, side effects, and patient education for statins** - **Statins** - First line drug for hyperlipidemia - **Med examples:** - Atorva**statin (Lipitor)**, simva**statin**, rosuva**statin (Crestor)**, lova**statin** - **Action** - **Inhibits the enzyme** **HMG-CoA reductase decrease in production of cholesterol, lowering the overall lipid levels and increasing HDL levels** - **Side effects** - **GI distress, cataracts, hyperglycemia, elevated hepatic enzymes, rhabdomyolysis,** cramps, myalgias, rash, headache - **Monitor liver enzymes with lipid panel** - **Yearly eye exams needed to evaluate for cataracts** - **Patient education** - **Report any muscle cramping/aches or dark urine (concern for rhabdo),** - Avoid grapefruit and grapefruit juice and limit alcohol - Increase complex carbohydrates and fiber intake and lower saturated fat intake - **Abrupt discontinuation can cause rebound effect that may result in MI and death** **Review cholesterol absorption inhibitors** - **Cholesterol Absorption Inhibitor** - Med examples: - Ezetimibe, acts in the small intestine to **inhibit dietary cholesterol absorption** - Actions - Reduces dietary absorption of cholesterol, LDL, and triglycerides - **Must be combined with a statin for optimum effect** - **Side effects** - **Myalgia, arthralgia, cholelithiasis, elevated hepatic enzymes, myopathy, rhabdomyolysis, dizziness, fatigue** **Utilization of Niacin therapy** - **Niacin (vit B3)** - Action - Reduces VLDL & LDL, but require large doses and has many side effects so is not tolerated by many - **Candidates** - Reserved for patients with **triglycerides over 500** or patients that have **failed other therapy** - **Side effects** - **Hypotension, edema, liver damage, cholelithiasis, hyperglycemia, hyperuricemia, flushing, hepatotoxicity, blurred vision** - **Arrhythmias are adverse effect** **Antibiotics:** **Describe varying generations and side effects of cephalosporins** - **cephalosporins** - Action - inhibit bacterial cell-wall synthesis - **5 generations** and with each, **coverage becomes broader with each generation** with increased ability to penetrate CSF (cerebrospinal fluid) - **Side effects** - **Increased bleeding**, elevated hepatic enzymes, and ABX side effects - **First-generation** - Effective against **most gram+** and **only some gram--** - **Destroyed by** beta lactamase (so **many** pathogens have resistance to first gen. cephalosporins). - **Cefazolin, cephalexin** - **Second-generation** - Effective against **gram+ and gram--** - **Only some affected** by beta lactamase (so **few** pathogens have resistance to second gen) - **Cefoxitin** - **Third generation** - **Broader than second** and **include coverage for pseudomonas** (remember this causes infections after surgery, so think immunocompromised, post op, ventilated) - **Resistant** to beta-lactamases (pathogens not resistant to 3^rd^ gen) - **Ceftriaxone (Rocephin), Cefotaxime, Cefdinir, Cefixime** - **Fourth generation** - **Very broad coverage** - **Highly resistant** to destruction of beta lactamase - **Penetrates CSF** (good for immunocompromised patients) - **Cefepime** - **Fifth generation** - **Most broad** out of all generations - **Highly resistant** to destruction by beta-lactamases**.** - **ONLY** cephalosporin effective at **covering MRSA** - **Ceftaroline** - **Patient Education** - **Avoid alcohol**, it can cause **disulfiram like effects** (flushing, dizziness, headache, nausea, vomiting, and muscular cramps) and it should be avoided **even** **3 days after** stopping medication - **Be cautious** **if taking** **anticoagulants** due to an increased risk of bleeding **Give examples of Macrolides** - **Macrolides** - **Inhibits protein synthesis** - **Used to treat mild to moderate respiratory (community acquired pneumonia in children \> 5), STIs (Chlamydia)**, sinuses, skin, soft tissue, GI tract infections, diphtheria - Ery**thromycin**, Azi**thromycin**, Clari**thromycin** - End in -thromycin - **Drug interactions** - **Do not give erythromycin with other macrolides (hepatoxicity concern)** - Macrolides can increase levels of theophylline, carbamazepine, and warfarin **Describe topical antibiotics used for burns and skin breakdown** **Sulfonamides** - **Silver Sulfadiazine used topically for burns to prevent infection from skin breakdown.** - Inhibit bacterial synthesis of folic acid, which some bacteria need to survive/replicate **Describe antimicrobial coverage for immunocompromised patients** - **Broad-spectrum antibiotics** - Fourth generation cephalosporins - **Penetrates CSF** (good for immunocompromised patients) - **Cefepime** is drug example **Describe when to draw peaks and troughs** - A trough level is **drawn immediately before the next dose** of the drug is administered.  - A peak level is drawn **1 or more hours after the drug is administered** **Respiratory:** **Describe difference between 1^st^ and 2^nd^ generation antihistamines** - **Antihistamines** - By taking an H1 blocker **it decreases nasopharyngeal secretions** by **blocking the H1 receptor sites** - **1^st^ generation antihistamines** typically **cause drowsiness, dry mouth** and **more anticholinergic symptoms** - Diphenhydramine (Benadryl) would be an example of a 1^st^ gen - The anticholinergic effects of 1^st^ gen are often beneficial to someone with a cold because it helps dry up/decrease secretions and reduce nasal itching/congestion. - **2^nd^ generation antihistamines** cause **less drowsiness and less anticholinergic symptoms** compared to gen 1. - Cetirizine (Zyrtec), Loratadine (Claritin), and Fexofenadine (Allegra) are all examples of 2^nd^ gen **MOA of pseudoephedrine and epinephrine** - **Sympathomimetics** - **Epinephrine** - **Increases cAMP which increases bronchodilation**. It also **restores** **circulation** (increases HR and BP) which is useful in codes/cardiovascular collapse - **Nasal Decongestants** - Work by **stimulating alpha adrenergic receptors** (sympathetic nervous system) leading to **vasoconstriction of capillaries** in nasal mucosa causing **shrinking of nasal mucous membranes** and a **reduction in fluid secretion** - Dayquil, Tylenol, DM, phenylephrine, **pseudoephedrine,** tetrahydrozoline **Benefits and contraindications for dextromethorphan** - **Antitussives** - **Medications that suppress/reduce cough** by acting on cough control center in the medulla to supress cough - Antitussive come in non-opioid or opioid - **Dextromethorphan** is an example of an opioid antitussive; it does not provide analgesia but rather antitussive properties - Side effects include **dependence** (why some adolescents abuse "cough syrups") - **Can cause respiratory depression in children less than 6** **Provide examples of expectorants** - **Expectorants** - **Medications used to help us cough** (opposite of antitussives) loosen bronchial secretions allowing them to be eliminated - **Guaifenesin** is an example of an expectorant - **Educate patients to drink plenty of fluids when taking these to help loosen secretions.** **Drugs used for asthma exacerbation and status asthmatics** - **Anticholinergics** - Ipra**tropium** bromide (Atrovent), tio**tropium** (Spiriva) - Ipratropium bromide is often given in conjunction with **albuterol** if there is asthma exacerbation - Used in **treatment of asthma exacerbation** and **maintenance in treatment of bronchospasms** associated with COPD - **Side effects** - **Dry mouth, constipation**, GI distress, headache - **Sympathomimetics** - **Epinephrine** - **Increases cAMP which increases bronchodilation**. It also **restores** **circulation** (increases HR and BP) which is useful in codes/cardiovascular collapse - Used for acute bronchospasm, asthma, anaphylaxis, angioedema, nasal congestion, **status asthmaticus** - **Side effects** - **Tachycardia, HTN, tremors, palpitations, angina**, dizziness, dysrhythmias, restlessness **-GI:** **Give examples of dopamine antagonists** - Dopamine antagonists - Block dopamine receptors in CTZ - Useful in postoperative N/V, and chemo/radiation sickness - Side effects - **EPS** (lip smacking, gate shuffling, etc), photosensitivity, and hypotension (with droperidol) - **Examples** - Phenothiazines (promethazine (Phenergan), chlorpromazine (Thorazine)), Butyrophenones (Droperidol (Inapsine)), Benzodiazepines (Lorazepam (Ativan)) **Describe side effects of Ondansetron** - Ondansetron is a serotonin antagonist - **Side effects** - **Prolonged QT interval,** hypotension, headaches, edema, headache**.** **Treatment and monitoring for infectious diarrhea** - **Opiates and opiate-related agents** - **Decreases GI motility** and **decreases intestinal motility** and **slows peristalsis** - **atropine contraindicated in glaucoma** (anticholinergic) - Contraindicated in severe hepatic impairment (metabolized by the liver) - Can cause dehydration and fluid/electrolyte imbalances. Can be life threatening in children and older adults if unable to replace fluids (dehydration) **Medications utilized for GERD and their MOA** - **Inflammation or erosion of the esophageal mucosa caused by reflux of gastric acid content into the esophagus** - Occurs due to **incompetent lower esophageal sphincter** - Smoking accelerates progression - **Treated with antiulcer dugs, H2 blockers, PPI's** - **Antiulcer Drugs** - Tranquilizers - **Decrease vagal nerve activity, decreases anxiety** - Have minimal effect in preventing and treating ulcers - Side effects -- edema, ataxia, confusion, agranulocytosis - Anticholinergics - **Decrease acetylcholine by blocking the cholinergic receptors** and blocking histamine and HCI - Side effects -- dry mouth, decreased secretions, headache, dizziness, drowsiness, palpitations, urinary retention, constipation - Antacids - **Neutralizes gastric acid HCI and reduces pepsin activity** - Side effects/adverse reactions in specific drugs - Sodium bicarbonate - rarely used because systemically absorbed and many side effects - Calcium carbonate - most effective, but also can be systemically absorbed, can cause acid rebound, Burnett Syndrome (excessive calcium intake, blood level very high, but urine and bone level is low/normal, can lead to renal failure) - Magnesium and aluminium hydroxide - neutralizes gastric acid; Mylanta (one causes diarrhea and other causes constipation, so typically found together) - H2 blockers - **Blocks H2 receptor of parietal cells in stomach to reduce gastric acid secretion** - Promotes healing of ulcer by eliminating cause - Example -- **Famotidine (Pepcid)** - Side effects -- erectile dysfunction, vitamin B12 deficiency, headaches, agitation, dizziness - PPI - **Reduces gastric acid secretion** by inhibiting hydrogen/potassium ATPase enzyme located in parietal cells - Better than H2 blockers - Side effects -- Vit B12 deficiency, hypomagnesemia, headache, diarrhea, abdominal pain - Examples - Ome**prazole**, panto**prazole**, esome**prazole** **Patient education for laxatives and stool softeners** - **Types of laxatives** - **Osmotic (saline)** - **Hyperosmolar salts pull water into colon and increase water in feces to increase bulk which stimulates peristalsis and defecation.** - Used for bowel prep for diagnostics or surgery - **Stimulant (irritants)** - **Increase peristalsis by irritating sensory nerve endings in intestinal mucosa** - Used for bowel prep for diagnostics or surgery - Examples - bisacodyl (most commonly) (Dulcolax, fleets enema), castor oil (bowel prep) - Prolonged use can decrease muscle tone - **Avoid castor oil in pregnancy (stimulates contractions)** - **Bulk-forming** - **Absorb water into intestine, increase bulk and peristalsis** - Administer in glass of water or juice, stir, drink immediately, follow with glass of water - **Side effects -- insufficient fluid intake** can cause laxative to harden in GI tract and **leads to intestinal obstruction** - **Emollient (stool softeners)** - **Lower surface tension and promotes water accumulation in intestine and stool** - Prevents constipation and **decreases straining during defecation** **-Stimulants** **Side effects and patient education for Antabuse (Disulfiram)** - **Disulfiram (Antabuse)** - inhibits enzyme needed to metabolize alcohol - Contraindicated in an intoxicated person and **should not be taken within 12 hours of alcohol consumption** (including alcohol mouthwash or other alcohol containing products/foods). - Side effects if taken with alcohol - **Difficulty breathing, chest pain, psychosis, hepatotoxicity**, vomiting, peripheral neuropathy **Medically approved uses of stimulants** - Are **used to treat ADHD, narcolepsy and reversal of respiratory distress** if other medications (amphetamine LIKE drugs) have failed **MOA of amphetamines** - Stimulates **release of norepi and dopamine and block the reuptake of them** resulting in CNS stimulation and increased serotonin, which can increase alertness, but also have adverse side effects. **Uses of caffeine in neonates** - **Analeptics** - **Used often in premature infants to stimulate respirations** **-Substance abuse:** **Review controlled substance schedule** - **Controlled Substance, Schedule Categories** - Understand **lower schedules have** **higher abuse potential** and some general drug categories that fall into each of them. **Review MOA and side effects of Methadone** - **Methadone** - Long-acting opioid drug that can be safe if administered as prescribed and combined with counseling and behavior therapy - Opioid receptor agonist that **alters brains perception of pain**, if taken daily it **blocks the euphoria and tranquility caused by opioids and prevents withdrawal and cravings** - **Black box warning for prolonged QT and cardiac arrythmias** - Teratogenicity does cross into breast milk so either discontinue breastfeeding or discontinue methadone. **-Pain, sedation, and psych drugs:** **Advantages and disadvantages of Lithium** - **Mood stabilizers (Lithium)** - First drug used to treat bipolar disorder - Works by **altering ion transport into muscle and nerve cells and increases receptor sensitivity to serotonin**. - Has calming effect but may cause memory loss/confusion - Have VERY narrow therapeutic window and levels greater than 1.5 may produce signs of toxicity - Due to this **must monitor serum sodium levels** (lithium depletes sodium) **Patient education for insomnia** - Arise at specific hour in morning - Limit daytime naps - Avoid caffeine, alcohol, and nicotine 6 hr before bedtime - Avoid heavy meals, strenuous exercise, and drinking large amounts of fluids before bedtime - Take warm bath, listen to quiet music, or perform other soothing activities like reading a book before bedtime - Decrease exposure to loud noises **Review inhaled anesthesia** - **Inhalation** - Haloth**ane**, enflur**ane** Isoflur**ane**, desflur**ane**, sevoflur**ane** - Mechanism of inhaled anesthetics on CNS depression is not fully understood, but theories include - Altering cell membranes and impairing physiologic function - Activating GABA, pushing chloride into neurons and decreasing their action potentials - **Adverse effects** - Respiratory depression - Malignant hyperthermia (hereditary disorder of skeletal muscle that classically presents as a hypermetabolic response to halogenated anesthetic gasses) - **Consciousness usually reoccurs minutes to an hour upon discontinuation** **Provide examples of appetite suppressants** - **Anorexiants** - Cause stimulant effect on hypothalamic and limbic areas of brain **to supress appetite** - Drug examples - Benz**phetamine**, Diethylpropion, **Phentermine** **Review uses of sedatives in the older adult population** - **Sedatives and Hypnotics for Older Adults** - **Avoid barbiturates** cause too much CNS depression/side effects, long-acting benzos should be avoided - **Short to intermediate acting benzos are acceptable** but encourage use **4x per week or less** **Compare and contrast general and local anesthesia** - **General causes depression of CNS, alleviation of pain, and loss of consciousness** - **Local cause only pain relief in a limited area**