Pharmacology Study Guide Summer 2023 PDF
Document Details
Uploaded by Deleted User
2023
Tags
Summary
This is a study guide for pharmacology, covering topics such as FDA regulation, nursing process, pharmacokinetics, pharmacodynamics, routes of administration, and adrenergic drugs. It was created for the summer of 2023.
Full Transcript
PHARMACOLOGY STUDY GUIDE SUMMER 2023 USE THE NURSING PROCESS. Remember, when you are offered a choice of things to DO in a situation, act like a nurse! Read the WHOLE label, every word, and process what you are reading befo...
PHARMACOLOGY STUDY GUIDE SUMMER 2023 USE THE NURSING PROCESS. Remember, when you are offered a choice of things to DO in a situation, act like a nurse! Read the WHOLE label, every word, and process what you are reading before answering the questions. ○ what is the FDA (est. 1938)? ⇢ an agency that regulates the manufacturing and marketing of drugs. ⇢ protects the american population from companies that only seek a profit. ⇢ claims about a drug cannot be made unless approved by the FDA. ⇢ why are some side/adverse effects not seen prior to drug release? ○ exclusion. ⇢ women and children were not included in former testing. ○ acceleration. ⇢ allowed drugs for serious conditions and unmet clinical need to be approved faster. ⇢ e.g. cancer drugs, vaccines, and the AIDS epidemic. ○ safety innovations act. ⇢ drugs are approved based on a benefit to risk ratio. ⇢ e.g. drug doesn’t cure cancer, but has shrunk tumors! ○ what is the nursing process and its steps? ⇢ the nursing process is a systematic problem-solving approach. ⇢ identifies, prevents, and treats actual or potential health problems and promotes wellness. ⇢ there are five steps (ADPIE). ○ assessment. ⇢ gather information about the patient’s condition. ○ diagnosis. ⇢ identify the patient’s problem(s). ○ planning. ⇢ set goals of care and desired outcomes. ⇢ identify appropriate nursing actions. ○ implementation. ⇢ perform the nursing actions identified in planning. ○ evaluation. ⇢ determine if the goals and expected outcomes have been achieved. ○ what factors influence how well or poorly a medication works on someone? 1 ⇢ genetics. ⇢ tolerance. ⇢ idiosyncrasy (the drug may work “funny” in someone for unknown reasons). ⇢ pharmacokinetics. ⇢ pharmacodynamics. ⇢ what is pharmacokinetics? ○ absorption (small intestine). ⇢ gastric acidity ⇢ surgical interventions (removed parts of certain organs). ⇢ blood circulation. ⇢ stomach contents (e.g. food may help/hurt absorption). ⇢ bioavailability. ⇢ lipid solubility. ○ distribution (circulatory system). ⇢ blood flow. ⇢ the drug’s affinity to the tissue. ⇢ the penetration of certain barriers (BBB/placenta). ○ metabolism (liver). ⇢ first pass effect. ○ when the liver is too efficient. ○ results in a significantly reduced drug concentration. ⇢ disease, affecting half-life. ○ elimination. ⇢ decreased kidney function. ⇢ pH of the urine. ⇢ what is pharmacodynamics (drug interactions)? 2 ○ additive (1 + 1 = 2). ⇢ when two drugs given equals the sum of their effects when given alone. ⇢ may be useful or harmful. ○ synergistic (1 + 1 = 3). ⇢ when two drugs given are greater than the sum of their effects when given separately. ⇢ can lead to toxicity. ○ antagonistic (1 + 1 = 0). ⇢ an interaction between drugs that have opposite effects on the body. ⇢ may block or reduce the effectiveness of one or more drugs. ⇢ considered at times an “antidote” (blocker). ○ what are the different routes of administration? ⇢ what are the discussed enteral routes? 3 ○ orally. ⇢ must dissolve in the stomach. ⇢ liquids/powder work the fastest. ⇢ there are three types: ○ tablets. ○ enteric coated. ○ sustained-release/extended-release. ○ sublingual. ⇢ the tablet is placed under the tongue. ⇢ medicine goes directly to the heart. ⇢ what are the discussed parenteral routes? ○ intravenous (IV). ⇢ immediate absorption. ⇢ can be harmful if the wrong drug was administered. ⇢ can result in disease transmission. ○ intramuscular (IM). ⇢ second quickest concerning absorption. ⇢ most painful. ○ subcutaneous (SQ). ⇢ slowest to absorb. ⇢ requires asepsis (absence of microorganisms). ○ what is understood from this graph? 4 ○ sub-therapeutic window. ⇢ the drug has been administered but hasn’t yet caused an effect. ○ onset (“desired response”). ⇢ a moment in time. ⇢ the patient has begun to experience the good effects of the drug. ⇢ e.g. the patient no longer feels intense pain after taking a tylenol. ○ duration of action. ⇢ the length of time that a drug exerts its effects. ○ peak of effect. ⇢ the highest blood concentration attained before it goes down with metabolism. ⇢ the most and best effects received from a drug. ⇢ the half-life of a drug (T½). ○ therapeutic window/index (TI). ⇢ the drug is producing therapeutic effects! ⇢ varies and depends on the drug that is administered. ⇢ what does it mean if a drug has a “narrow” TI? ○ DANGEROUS! ○ the margin in which the drug is therapeutic is very small. ○ a little more than is accepted can be harmful. ○ enhanced monitoring is required to avoid toxicity. ⇢ what nursing implications can be implemented? ○ read the medication order carefully. ○ verify the identity of the patient (minimum of two identifiers). ○ read the medication label carefully. 5 ○ verify dosage calculations. ○ implement any special handling the drug may require. ○ don’t administer any drug if the reason for its use isn’t understood. ○ “adverse response” window. ⇢ if a drug reaches this window, it can lead to… ✗ side effects. ✗ adverse reactions. ✗ toxicity. ○ what is drug tolerance and its signs? ⇢ the physical habituation to a drug’s effect. ⇢ to benefit from the therapeutic effects of a certain drug, a larger dose is required. ⇢ an increased amount of a drug can potentially lead to an overdose. ⇢ what is drug dependence? ○ physical dependence. ⇢ the body needs it. ⇢ there is a risk of withdrawal. ○ psychological dependence. ⇢ the mind needs it. ○ how can medical errors be prevented (generally and institutionally)? ⇢ the five “rights” of drug administration (as listed above). ⇢ orders are computerized rather than handwritten. ⇢ certain abbreviations are forbidden to prevent misunderstandings. ⇢ the implementation of “look alike/sound alike” drug posters. ⇢ unit dose vs. stock drugs. 6 ADRENERGIC DRUGS ○ what is the sympathetic nervous system (SNS)? ⇢ the nervous system that activates our “fight or flight”. ⇢ activates as a response toward a challenge (can be life-threatening). ⇢ what drugs stimulate the SNS? ○ these are all the same, just synonyms! ⇢ adrenergics. adrenergic agonists. ⇢ sympathomimetics. ⇢ adrenomimetics. ⇢ what are the four different types of receptors for the SNS? ○ alpha–1. ⇢ located in the blood vessels of the muscles. ○ alpha–2. ⇢ acts the opposite as alpha-1 receptors (undoing effect). ⇢ inhibit the release of norepinephrine. ⇢ cannot be used with beta-blockers as it lowers HR. 7 ○ beta–1. ⇢ located primarily in the heart (“we only have 1 heart!”). ○ beta–2. ⇢ located primarily in the lungs (“we have 2 lungs!”). ⇢ how can the effects of alpha/beta receptors be inhibited? ○ alpha blockers (alpha-1 with suffix “–zosin/–losin”). ⇢ can be general or selective. ⇢ promotes the opposite effect of the expected reaction from the alpha-agonist(s). ⇢ see chart to determine such behaviour. ⇢ what are general SE of alpha-blockers? ○ orthostatic hypotension. ○ reflex tachycardia. ○ beta blockers (all with the suffix “–olol”). ⇢ can be general or selective. ⇢ promotes the opposite effect of the expected reaction from the beta-agonist(s). ⇢ do not use if the patient has COPD or asthma. ⇢ see chart to determine such behaviour. ⇢ what are general SE of beta-blockers (dangerous)? ○ bradycardia. ○ hypotension. ○ headaches. ○ dizziness. ○ hypoglycemia. ○ bronchospasm. 8 ⇢ what are SPECIFIC ADRENERGIC DRUGS? ○ epinephrine (non-selective). ⇢ given SC or IV. ⇢ bronchodilator. ⇢ can result in ↓ UO/renal perfusion and vasoconstriction. ○ midodrine (alpha-1 and 2). ⇢ treats orthostatic hypotension. ⇢ only given 4 hours before bed / when patient is upright. ○ dopamine (quick). ⇢ administered via IV infusion (central catheter). ⇢ dosage determines the receptors it affects. ○ low (dopamine-1 receptors). ⇢ causes vasodilation. ○ medium (beta-1 receptors). ⇢ increases cardiac output. ○ high (alpha-1 receptors). ⇢ vasoconstriction and hypertension. ○ albuterol (selective beta-2). ⇢ purely bronchodilation. ⇢ administered orally or via inhalation. ○ clonidine. ⇢ regulates norepinephrine release and treats HTN. ⇢ causes cardiovascular depression. ⇢ prevents sx of narcotic withdrawal. ○ tamsulosin. ⇢ increases urine flow. ⇢ relaxes urinary sphincter smooth muscle. ○ propranolol (nonselective). ⇢ for angina, HTN, heart failure, and dysrhythmias. ⇢ side effects? ○ drowsiness. ○ dizziness. ○ nausea/vomiting. ○ weakness. ○ bradycardia. ○ hypotension. ○ metoprolol (beta-1). ⇢ used for HTN, migraines, tremors, and MIs. ⇢ DO NOT STOP SUDDENLY (MI). 9 CHOLINERGIC DRUGS ○ what is the parasympathetic nervous system (PSNS)? ⇢ the nervous system that activates a state relaxation. ⇢ activates as a response to put things back to its resting rate. ⇢ what drugs stimulate the PSNS? ○ these are all the same, just synonyms (“–chol”)! ⇢ cholinergic agonists/stimulants. ⇢ cholinomimetics. ⇢ HOWEVER, THERE ARE TWO TYPES. ○ direct-acting drug. ⇢ plugs into parasympathetic receptors wherever they find them. ○ indirect acting. ⇢ promotes cholinergic action by allowing ACh to build up. ⇢ does so through: ○ reversible inhibitors. ⇢ inactivates ACh enzyme. ○ irreversible inhibitors. ⇢ destroys ACh enzyme. ⇢ what are the two different types of receptors for the PSNS? 10 ○ muscarinic. ⇢ stimulated by ACh and muscarine from mushrooms. ⇢ results in different organ effects. ⇢ what sx show muscarinic toxicity? ○ SLUDGE. ○ salivation, lacrimation, urination, defecation, GI cramping, and emesis. ○ nicotinic. ⇢ stimulated by ACh and nicotine. ⇢ results in different skeletal muscle effects. ⇢ what sx show nicotinic toxicity? ○ MTWTF (the weekdays). ○ muscle cramps, tachycardia, weakness, twitching, and fasciculations. ⇢ how can the effects of cholinergic receptors be inhibited? ○ anticholinergics (synonyms include…). ⇢ cholinergic blockers/antagonists. ⇢ muscarinic antagonists. ⇢ antispasmodics. ⇢ anti-parasympathetic or antimuscarinic agents. ⇢ what is imp. to know about anticholinergics? ○ blocks acetylcholine. ○ avoid acid causing foods/cigarettes. ○ antidote for cholinesterase toxicity. ○ anticholinergic effects ⋍ adrenergic effects. ⇢ what is a good analogy to remember antichol. effects? ○ can’t SEE. ○ can’t PEE. ○ can’t SPIT. ○ can’t SHIT! ⇢ what are some extra side effects of anticholinergics? ○ tachycardia. ○ drowsiness. ○ delirium in older adults. 11 ⇢ what are specific cholinergic drugs? ○ neostigmine/edrophonium Cl. ⇢ to increase muscle strength. ⇢ short or moderate acting. ○ neostigmine/edrophonium Cl. ⇢ to increase muscle strength. ⇢ moderate acting. ○ pilocarpine. ⇢ for glaucoma. ⇢ can be administered locally or systemically. ⇢ constricts pupils to allow drainage. ⇢ side effects? ○ stinging. ○ burning. ○ nicotine. ⇢ stimulates the CNS. ⇢ used with smoking cessation. ⇢ comes in a variety of forms (gum, patch, spray, etc.). ⇢ side effects? ○ constricts blood vessels. ○ headaches. ○ nervousness. ○ GI upset. ○ atropine. ⇢ classic anticholinergic. ⇢ used pre-operation. ⇢ decreases peristalsis and increases the heart rate. ⇢ side effects? ○ dry mouth. ○ decreased sweating. ○ blurred vision. ○ tachycardia. ○ drowsiness. ○ constipation/urinary retention. ○ delirium in older adults. 12 GLAUCOMA DRUGS ○ what is glaucoma? ⇢ occurs when fluid builds up in the front of the eye, damaging the optic nerve. ⇢ can lead to increased IOP, narrow visual field, and optic nerve atrophy. ⇢ what are the different types of anti-glaucoma agents? ○ beta blockers (“first line”). ⇢ decreases the production of fluid. ⇢ monitor VS and symptoms of systemic absorption. ⇢ e.g. TIMOLOL. ⇢ what are some side effects of this drug? ○ hypotension. ○ bradycardia. ○ bronchoconstriction. ○ alpha-2-adrenergic drugs. ⇢ increases the drainage of fluid. ⇢ can discolor contacts (orange), so wait 15 minutes. ⇢ e.g. BRIMONIDINE. ⇢ what are some side effects of this drug? ○ itching. ○ tearing. ○ ocular pain. ○ cholinergic agents (miotics). ⇢ constricts the pupils to enhance fluid drainage. ⇢ e.g. PILOCARPINE. ⇢ what are some side effects of this drug? ○ headache. ○ eye pain. ○ systemic effects, if absorbed. ○ carbonic anhydrase inhibitors (diuretics). ⇢ pulls fluid from the eye. ⇢ also used for altitude sickness. ⇢ can result in problems with hydration/electrolytes (e-). ⇢ e.g. DORZOLAMIDE and ACETAZOLAMIDE. ○ prostaglandins. ⇢ can result in darkened irises and strengthened eyelashes. ⇢ LATANOPROST (lowers IOP). ⇢ BIMATOPROST (increases drainage). 13 URINARY DRUGS ○ what is the urinary tract? ⇢ includes the kidneys (upper) and the bladder/urethra (lower). ⇢ treated well if relieved of frequency, urgency, nocturia, bladder pain/distension. ⇢ what are the types of drugs that can treat urinary infections? ○ urinary antiseptics/anti-infectives. ⇢ kills bacteria that causes infection. ⇢ patients should drink lots of fluids. ⇢ concentrates in the urine, not blood. ⇢ what are imp. instructions for NITROFURANTOIN? ○ MUST BE TAKEN WITH FOODS. ○ DO NOT TAKE WITH ANTACIDS. ⇢ what are imp. instructions for METHANAMINE? ○ urine must be acidic. ○ DRINK WITH CRANBERRY/OJ. ○ DO NOT GIVE WITH SULFA DRUGS. ○ urinary analgesics. ⇢ relieves burning, pain, and frequency. ⇢ urine can turn an orange color (harmless). ⇢ can result in… ✗ headaches. ✗ rashes. ✗ GI upset. ✗ nephrotoxicity/hepatotoxicity. ⇢ e.g. PHENAZOPYRIDINE. ○ urinary stimulants. ⇢ increases the detrusor muscle = prompts bladder to pee. ⇢ can cause GI distress. ⇢ e.g. BETHANECHOL. ○ anticholinergic drugs. ⇢ used if the bladder is overactive and results in irritation. ⇢ decrease in… ✗ dysuria/nocturia. ✗ abdominal pain. ✗ urge incontinence. ⇢ many uncomfortable SE, esp. with the elderly. ○ urinary antispasmodics/antimuscarinics. ⇢ has an anticholinergic action (+ SE). ⇢ e.g. OXYBUTYNIN and TOLTERODINE. 14 IV SOLUTIONS ○ what are IV FLUIDS? ⇢ specially formulated liquids that are injected into a vein to prevent or treat dehydration. ⇢ there are four types: crystalloids, colloids, blood and blood products, and lipids. ⇢ what are CRYSTALLOID IV SOLUTIONS? ○ used to replace fluids. ○ maintains (or alters) the electrolyte balance/tonicity of the blood. ○ basically, a solution of water + some combination of an e-: ⇢ glucose. ⇢ saline. ⇢ potassium. ⇢ calcium. ⇢ lactate. ○ what is an isotonic solution? ○ any external solution = same solute and water concentration compared to body fluids. ○ same concentration as the blood. ○ what are the three types? ○ dextrose. ⇢ ISOTONIC IN BAG, NOT BODY. ⇢ sugar and a few calories. ⇢ there are two… ✗ D5W (dextrose 5% in water). ✗ D10 (any concentration higher than 10% is dangerous). ○ normal saline (NS). ⇢ ISOTONIC IN BAG AND BODY. ⇢ salt solution at the same concentration as the blood (0.9%). ○ ringer's lactate/lactated ringers (RL/LR). ⇢ ISOTONIC IN BAG AND BODY. ⇢ interchangeable name. ⇢ solution of Na+, lactate, Ca++, and K+. ⇢ in specific concentrations to make it very similar to the bloodstream. 15 ⇢ what are COLLOID IV SOLUTIONS (“VOLUME EXPANDERS”)? ○ IV solutions with big, fat proteins/protein-like molecules. ⇢ dextran. ⇢ albumin (comes directly from human blood). ⇢ hetastarch (synthetic fluid like albumin). ○ used if there is not enough fluid in one’s intravascular space. ○ increases the oncotic pressure in the plasma. ⇢ pulls fluid into the intravascular space and holds it there. ⇢ controlled by the amount of protein in the blood. ○ USE CAREFULLY IF WITH HEART FAILURE. ⇢ what are BLOOD AND BLOOD PRODUCTS? ○ meant to replace blood loss (1 unit raises HCT by 3%). ○ donated blood is separated into three different components… ○ RBCs. ⇢ used to increase the blood count in the blood. ○ plasma. ⇢ has a lot of clotting factors. ⇢ useful in certain circumstances. ○ platelets. ⇢ for those who need it. ⇢ each donation has a few. ⇢ many are combined with that of other people. ⇢ what are LIPID (SOLUTIONS)? ○ fat emulsion solution. ○ meant for nutrition. ○ used as a base for toxic medications. ○ be careful as germs grow quickly. ○ what is TPN (TOTAL PARENTERAL NUTRITION)? ○ the feeding of required nutrients through the veins caused by fluid volume deficit. ○ VERY HYPERTONIC, leading to excessive urination. ○ a daily bag with all nutrients. ⇢ mixed in high glucose fluid (D20) ⇢ lots of electrolytes. 16 VITAMINS AND MINERALS. ○ what is SODIUM (mineral)? ○ regulates body water and aids in nerve transmission. ○ if high, give “free water” (plain water or D5W). ○ if low, give 0.9% SALINE IV FLUID or 3% SALINE (if really low). ○ what is POTASSIUM (mineral)? ○ needed for nerve impulse conduction, essentially muscle contraction. ○ can get depleted with some diuretics (loop). ○ give with lots of fluid and take with a meal. ○ administering too much at once can stop the heart. ○ what is MAGNESIUM (mineral)? ○ helps move Na+ and K+ move across cell membranes. ○ involved in neuromuscular activity. ○ high levels can cause weakness and potentially stop breathing. ○ to replace, use magnesium oxide (oral) or magnesium sulfate (IV). ○ what is CALCIUM (mineral)? ○ strengthens heart contractions and clotting. ○ can be elevated with cancers and low with kidney failure. ○ do not take with an iron supplement. ○ take with meals, vitamin D, and plenty of fluids to avoid kidney stones. ○ to replace, use… ⇢ calcium carbonate (oral). ⇢ calcium gluconate/chloride (IV). ⇢ calcitriol (highly active form of vit. D)… ○ increases absorption from the intestines. ○ reduces excretion by the kidneys. ○ to reduce = calcitonin-salmon (intranasal) or lots of saline IV (+ diuretic). ○ REMEMBER: THE CALCIUM/PHOSPHORUS SEE SAW. ○ what is PHOSPHORUS (mineral)? ○ important for cellular energy—structure, acid base, etc. ○ mostly eliminated by the kidneys (“PP” and also magnesium). ○ to raise, give an oral or IV supplement. ○ to reduce, give dialysis/calcium acetate or sevelamer (phosphorus binder). 17 ○ what is VITAMIN A? ○ helps with bone growth, skin, eyes, hair, and night vision. ○ excess results in teratogenicity and hepatotoxicity. ○ e.g. RETINOL (anti-aging/acne) and BETA-CAROTENE (PO). ○ what is VITAMIN K? ○ derived from diet and is produced by the gut flora. ○ synthesizes clotting factors, preventing hemorrhage. ○ given to newborns and certain over coagulation situations. ○ e.g. PHYTONADIONE (PO and SQ). ○ what is THIAMINE (vitamin)? ○ alcohol abusers may have a deficiency = wernicke-korsakoff syndrome. ○ use parenteral thiamine for treatment, but give BEFORE glucose. ○ what is NIACIN (VITAMIN B3, NICOTINIC ACID)? ○ used to reduce cholesterol and pellagra (B3 deficiency, “sour skin). ○ requires high doses to receive therapeutic effects. ○ causes vasodilation/flushing so PREMEDICATE WITH ASA (30 MIN.). ○ can result in elevated liver enzymes and hyperglycemia. ○ make sure to ADMINISTER WITH FOOD and AVOID ALCOHOL. ○ what is FOLATE (vitamin)? ○ absorbed from the small intestine and stored in the liver/tissues. ○ synthetic is more bioavailable and stable than food sourced. ○ important for body growth. ○ prevents colorectal cancer and neural tube defects in babies. ○ what is VITAMIN B12? ○ DNA synthesis, hematopoiesis, and maintains myelin sheaths on nerves. ○ e.g. COBALAMIN/CYANOCOBALAMIN (PO, IM, and SQ). ○ what is IRON (mineral)? ○ necessary for RBC formation. ○ insufficient = black stools, excessive = hepatotoxicity. ○ ↑ with supplements (ferrous sulfate/gluconate, fumarate) or iron dextran (IV). ○ onset of action is slow (days to weeks). ○ TAKE WITH VITAMIN C and ON AN EMPTY STOMACH. 18 CARDIAC GLYCOSIDES (CARDIOTONICS). ○ cardiotonics (alongside diuretics) were first in line for heart failure. ○ systemic congestion of fluid (RHF) or blood flow backing into the pulmonary circulation (LHF). ○ order is ACE inhibitors/ARBs, diuretics, beta blockers, CCBs, and then cardiotonics. ○ what is DIGOXIN? ○ used only if nothing else works. ○ used for persistent heart failures and certain arrhythmias. ○ causes calcium to move into the myocardial cell, ↑ the efficiency of muscles. ○ increases the output force of the heart and decreases its contraction rate. ○ monitor BP, HR, and check lungs for fluid. ○ HAS A VERY NARROW THERAPEUTIC INDEX (0.5 to 2.0 ng/mL). ○ what are the care considerations? ○ do not take with an antacid ( = poor absorption). ○ teach the patient to check their own pulse. ○ if the pulse is less than 60… ⇢ do not administer the next dose. ⇢ call the doctor. ○ BE CAREFUL OF ACE Is and ARBs (↑ K+, ↓ digoxin). ○ what are signs of toxicity? ○ GI (least). ⇢ diarrhea. ⇢ nausea/vomiting. ⇢ anorexia. ○ cardiac. ⇢ bradycardia. ⇢ PVCs, irregular heartbeats. ○ neurological (worst). ⇢ malaise. ⇢ yellow/blurred vision. ⇢ halos around lights. ⇢ confusion, delirium. ○ how can digoxin toxicity be prevented/fixed? ○ lower K+ levels. ⇢ certain diuretics. ⇢ diet/eat licorice. ⇢ cortisone. ⇢ remember the Na+/K+ exchange. ○ digoxin immune fab IV (the antidote). 19 DIURETICS ○ what are DIURETICS? ⇢ decreases HTN/edema and increases urine flow. ⇢ there are two types: potassium-wasting and potassium-sparing. ⇢ what are THIAZIDES? ○ a first-line hypertension (and peripheral edema) treatment drug. ○ causes vasodilation and promotes Na+/H2O excretion by the kidneys. ○ for patients with normal renal function, not severe renal dysfunction. ○ not for immediate diuresis as it takes hours to be therapeutic. ○ e.g. CHLORTHALIDONE and HYDROCHLOROTHIAZIDE. ○ what are the care implications? ○ DO NOT TAKE WITH DIGOXIN. ○ potassium-wasting, so be careful with hypokalemia. ○ what do thiazides make the body hold onto? ○ calcium (may affect electrolyte balance). ○ sugar (may affect diabetes mellitus). ○ uric acid (may affect gout). ⇢ what are LOOP (HIGH CEILING) DIURETICS? ○ calcium and potassium-wasting. ○ more effective diuresis than thiazides. ○ used when in need for rapid fluid mobilization (HF, not HTN). ○ e.g. FUROSEMIDE and BUMETANIDE. 20 ○ what is FUROSEMIDE? ○ a loop diuretic and potassium-wasting. ○ can cause OTOTOXICITY (w/ too rapid admin. IV). ○ BEWARE IF ALLERGIC TO SULFA DRUGS. ○ DO NOT TAKE WITH DIGOXIN. ○ what is ETHACRYNIC ACID? ○ not used as often as furosemide. ○ can be used to decrease ascites (related to cancer). ○ can cause IRREVERSIBLE OTOTOXICITY. ○ what are some side effects? ○ dehydration/e- disturbances. ○ transient deafness. ○ hypokalemia (arrhythmias, weakness, etc.). ○ hypocalcemia (tetany, chvostek/trousseau signs, etc.). ⇢ what are OSMOTICS DIURETICS? ○ raises serum osmolarity (water pulled from cells → bloodstream). ○ increases flow through the kidneys = preventing renal injury. ○ increases the excretion of Na+, H2O, and K+. ○ e.g. MANNITOL and UREA. ○ what is MANNITOL? ○ pulls fluid from the cells to reduce ICP/IOP. ○ what are some side effects? ○ fluid/e- imbalances. ○ can cause rapid fluid shifts. ○ nausea and vomiting. ○ what are the care implications? ○ check vial for mannitol crystals in the solution. ○ draw up using a filter needle. ⇢ filters invisible crystals. ⇢ then change needles. ⇢ NEVER STICK FILTER NEEDLE INTO THE PATIENT OR IV. 21 ⇢ what are CARBONIC ANHYDRASE INHIBITORS? ○ blocks the conversion of CO2 to bicarb. ○ increases excretion of bicarb, Na+, and K+ by the kidney. ○ helps with epilepsy/high altitude sickness, and decreases IOP. ○ e.g. ACETAZOLAMIDE. ○ what are some side effects? ○ drowsiness. ○ fatigue. ○ nervous system irritability. ⇢ what are POTASSIUM-SPARING DIURETICS? ○ weaker than thiazides and loop diuretics. ○ blocks aldosterone and promotes Na+/H2O excretion. ○ e.g. SPIRONOLACTONE and TRIAMTERENE. ○ what are some side effects? ○ nausea. ○ vomiting. ○ diarrhea. ○ anorexia. ○ numbness/tingling of the extremities. ○ what are the care implications? ○ client should NOT take K+ supplements. ○ teach patient to recognize/modulate foods high in K+. ○ DO NOT GIVE WITH ACE INHIBITORS. ⇢ what are the general care implications for diuretics? ○ take early in the day. ○ if BID, take the second dose no later than 1400. ○ track fluid loss or gain on the scale. ○ be careful with… ⇢ orthostatic hypotension (change positions carefully). ⇢ signs of fluid volume excess or deficit. 22 ANTI-ANGINALS. ○ heart pain caused by not enough blood flow (O2) to the heart. ○ includes stable (stress/exertion), unstable (unrelated to activity), and variant (uncommon). ○ non-pharmacological means of prevention include cessation of smoking and the avoidance of heavy meals, strenuous exercise, and emotional upset. ○ what are NITRATES? ○ first agents for angina. ○ results in coronary and general vasodilation. ○ reduces myocardial ischemia, resulting in hypotension. ○ what are the different types? ○ sublingual nitroglycerine. ⇢ onset is in minutes, with its peak at 5 minutes. ⇢ sometimes stings a little when fresh. ⇢ light and heat sensitive (so store well!). ⇢ can result in headache and dizziness. ⇢ EXPECT THE BP TO LOWER, BUT THE HR TO INCREASE. ○ nitro transdermal paste. ⇢ dosed by the inch. ⇢ lasts several hours (reapply every 6 hrs). ⇢ takes a while to absorb but lowers the BP quickly. ⇢ wear gloves to avoid personal absorption to apply. ⇢ requires a daily nitrate free period (8-12 hrs). ○ nitro transdermal patch. ⇢ on daily, off at night to prevent tolerance. ⇢ what are possible side effects? ○ orthostatic hypotension. ○ headache (use tylenol/habituation). ○ reflex tachycardia if not tapered. ○ may antagonize heparin. ○ nitroglycerine infusion. ⇢ used emergently for acute coronary syndrome. ⇢ requires constant monitoring (pain and blood pressure). ⇢ if with pain, increase dose. ⇢ if with hypotension, decrease the dose. ⇢ USE “LOW SORBING” TUBING. requires special IV tubing because the nitroglycerine absorbs into the plastic of the normal IV, so less drug gets to the patient. 23 ○ isosorbide dinitrate/isosorbide mononitrate ER. ⇢ forms include SL, chewable, or tablets. ⇢ used for prophylaxis and maintenance. ⇢ not for emergent therapy. ○ what are the care implications for at-home nitro? ○ often ordered in the hospital. ○ take the medication, but if it doesn’t work, call 911! ○ a second dose can lead to complications, so… ⇢ call for an ambulance first, then administer the second dose to ensure patient safety. ○ what are the possible drug interactions? ○ PDE-5 inhibitors (sildenafil, vardenafil, and tadalafil). ○ what are CALCIUM CHANNEL BLOCKERS (CCB)? ○ medication that causes vasodilation (lowering of the blood pressure). ○ aside from anginas, CCBs can also help treat hypertension. ○ blocks the amount of Ca+ available for contractions by… ⇢ relaxing coronary artery spasm and the peripheral arterioles. ⇢ decreases contractility, the heart’s need for O2, and its workload. ○ DO NOT TAKE WITH GRAPEFRUIT JUICE. ○ all end with the suffix “–dipine” (except for VERAPAMIL and DILTIAZEM). 24 ○ what are the care implications for CCBs? ○ calcium levels are unlikely to be affected by meds. ○ CCB and a beta blocker = excessive myocardial depression. ○ no fast movements (hypotension, headache, etc). ○ rebound angina may occur (taper medication). ○ what other drugs can help with angina? ○ beta blockers. ⇢ blocks beta-1 impulses. ⇢ slows the heart rate and reduces the blood pressure. ⇢ allows the heart muscles to… ✗ work less hard. ✗ use less O2. ✗ suck up more oxygen with each contraction. ⇢ e.g. METOPROLOL. ⇢ what are the care considerations? ○ reflex tachycardia can occur, so taper! ○ beware: ⇢ behavioural psychotic effects. ⇢ sexual dysfunction. ○ aspirin (ASA). 25 ANTICOAGULANTS, ANTIPLATELETS, AND THROMBOLYTICS. do not use the term “blood thinners” as it is not a medical term! ○ what are ANTICOAGULANTS? ⇢ prevents the formation of clots in the veins. ⇢ used for patients who are at a high risk for clot formation. ⇢ DOES NOT DISSOLVE CLOTS, BUT STABILIZES THEM. ⇢ what is HEPARIN (“UNFRACTIONATED HEPARIN”)? ○ given SQ or IV. ○ inhibits the clotting cascade. ○ used for immediate effect (dangerous thrombus). ○ may cause frank or occult bleeding. ○ requires frequent lab testing (PTT or aPTT). ○ reversed with PROTAMINE SULFATE. ○ all end with the suffix “–parin” (e.g. enoxaparin). ○ what are LOW-MOLECULAR WEIGHT HEPARINS? ○ derivatives of standard heparin. ○ inactivates Xa factor. ○ administered deep SQ. ○ has a less risk for bleeding and monitoring of labs. ○ what are the care implications? ○ has prefilled syringes. ○ keep the environment safe! ○ dose only once a day (long T½). ○ don’t aspirate during the injection. ○ don’t rub the site of administration. ○ avoid medication that causes bleeding. ⇢ aspirin. ⇢ vitamin E. ⇢ “G HERBS”. ○ ginger. ○ gingko. ○ ginseng. ○ garlic. 26 ○ what is HEPARIN-INDUCED THROMBOCYTOPENIA? ○ the body forms antibodies to heparin. ○ occurs usually a week after starting. ○ can result in… ⇢ new/worse thrombosis. ⇢ falling platelet levels. ○ how can HIT be treated? ○ an anticoagulant. ⇢ injected SQ, daily. ⇢ e.g. fondaparinux. ○ direct thrombin inhibitors. ⇢ given IV with close monitoring. ⇢ e.g. argatroban or lepirudin. ⇢ what is WARFARIN (VIT. K ANTAGONIST)? ○ an oral anticoagulant. ○ takes several days to get therapeutic. ○ affects certain clotting factors and is highly protein bound. ○ monitor PT/INR labs. ○ administered after heparin until clot resolution. ○ what are the three antidotes for warfarin? 1. vitamin K (requires 1-2 days, SQ). 2. fresh frozen plasma (immediate). 3. diet teaching (sources of vit. K, consistent). ⇢ what is DABIGATRAN? ○ an oral anticoagulant. ○ directly inhibits thrombin. ○ has no antidote if it becomes toxic. ○ does not require blood monitoring and has less drug interactions. ○ what are ANTIPLATELETS? ⇢ prevents platelet aggregation (thrombosis) in the arteries. ⇢ mainly prophylactic, preventing MI and stroke. 27 ⇢ what is ASPIRIN (ASA)? ○ long term, low dose (“baby aspirin”). ○ discontinue 7 days before an operation. ○ do not take with herbs and other antiplatelet medications. ○ BE CAREFUL, CAN BE OTOTOXIC. ⇢ what is CLOPIDOGREL? ○ an oral antiplatelet drug. ○ used after a heart attack or stroke alongside ASA. ○ some people are “non-responders”. ⇢ some do not have the ABCB1/CYP2C19 enzymes. ⇢ genetic testing is required. ⇢ what are some side effects? ○ GI distress. ○ bleeding. ○ similar to aspirin SE. ○ what are THROMBOLYTICS? ⇢ quickly dissolves a major clot to restart blood flow to the heart and prevent damage. ⇢ without medication, a thrombus can take 1 to 2 weeks to dissolve naturally. ⇢ used ASAP… ✗ 6 hours after a heart attack to minimize and prevent infarction. ✗ within 3-4 hours after the start of stroke symptoms. ⇢ CAN RESULT IN A HEMORRHAGE RISK. ⇢ all end with the suffix “–ase” (e.g. alteplase, urokinase, streptokinase, etc.). ⇢ what is AMINOCAPROIC ACID? ○ systemic means of preventing the breakdown of clots. ○ administer either PO or IV. ○ can result in seizures or renal failure. ○ do not give with estrogen/BC = clots. 28 ANTI-HYPERLIPIDEMICS/PERIPHERAL VASODILATORS. ○ non-drug therapy includes… ⇢ change in diet and inclusion of lean meats. ⇢ exercise, weight reduction (with obesity). ⇢ cessation of smoking (which would lower LDLs and raise HDLs). ○ what are STATINS (HMG-CoA reductase inhibitors)? ○ considered a “first-line” drug. ○ works in the liver to limit the production of cholesterol and LDL. ○ optimal therapy involves the drug and a heart healthy diet. ○ results in reduced CAD, MI, stroke risk, and mortality. ○ all end with the suffix “–statin” (e.g. lovastatin). ○ what are the expected therapeutic effects? ○ reduced risk of… ⇢ coronary artery disease (CAD). ⇢ myocardial infarction. ⇢ stroke. ⇢ mortality. ○ what are possible side effects/adverse reactions? ○ nausea. ○ vomiting. ○ tiredness. ○ headaches. ○ rhabdomyolysis. ○ cataracts. ○ what are the care implications with statin drugs? ○ it is lifetime therapy. ○ do not stop suddenly! ⇢ can result in a 3x rebound effect. ⇢ overall stopping can return cholesterol levels to how it was prior to treatment. ○ take it at bedtime (body makes cholesterol) / with food. ○ make sure to avoid alcohol → excess strain on the liver. ○ DO NOT TAKE WITH GRAPEFRUIT JUICE. 29 ○ what is BILE ACID SEQUESTRANTS? ○ can help with symptoms. ○ binds to bile acids in intestine = preventing fat-absorption/reduced LDLs. ○ can lead to excessive bile salts in the blood and pruritus. ○ may accumulate in the liver resulting in cholestasis and gallbladder disease. ○ what is CHOLESTYRAMINE? ○ first line (newer). ○ doesn’t affect fat soluble vitamins. ○ can result in constipation. ○ what is COLESEVELAM? ○ powder that is mixed into food. ○ does not have a good taste. ○ can result in N, bloating, and constipation. ○ what are FIBRIC ACID DERIVATIVES (FIBRATES)? ○ reduces TG and VLDL. ○ causes the liver to either break down lipids or not make more. ○ increases the excretion of cholesterol (which is made, not eaten). ○ highly protein bound = DO NOT TAKE WITH AN ANTICOAGULANT. ⇢ can result in more free anticoagulant in blood (bleeding). ○ what is GEMFIBROZIL? ○ take before breakfast and dinner, but NOT with other meds. ○ may cause gallstones, GI distress, rash, and headache. ○ what are possible ADJUNCTS that can help? ○ NICOTINIC ACID (NIACIN, VITAMIN B3). ⇢ reduces LDL/TG and increases HDL. ⇢ take with food and avoid alcohol. ⇢ requires large doses. ⇢ effective, but can lead to… ✗ elevated liver enzymes. ✗ flushing (aspirin 30 min. prior to administration). ✗ hyperglycemia. 30 ○ EZETIMIBE. ⇢ cholesterol absorption inhibitor from liver and food. ⇢ works in the small intestine. slightly increasing HDLs. ⇢ administered one a day and have lifestyle changes. ⇢ optimal therapy involves the drug and a statin drug. ○ FISH OIL (OMEGA-3 FATTY ACIDS). ⇢ not the same as fish oil supplements. ⇢ reduces LDLs and increases HDLs. ⇢ can be found in salmon, sardines, herring, anchovy, etc. ○ what are VASODILATORS? ○ used for peripheral artery disease (PAD) / intermittent claudication (IC). ○ both result in reduced flow of arterial blood, meaning less O2 to the tissues. ○ improvement is slow as it takes up to 2 to 12 weeks. ○ may cause hypotension, tachycardia, skin flushing. ○ DO NOT SMOKE WHILE ON THIS MEDICATION. ○ what is CILOSTAZOL? ○ vasodilates and reduces platelet aggregation in the arteries. ○ approved for intermittent claudication. ○ DO NOT TAKE WITH GRAPEFRUIT JUICE. ○ what is PENTOXIFYLLINE? ○ decreases the thickness of blood so BCs don’t get stuck. ○ a xanthine derivative (similar to asthma drugs/caffeine). 31 ANTIHYPERTENSIVE DRUGS. ○ AAs have a higher incidence of HTN. ○ AAPI are 2x sensitive to beta blockers and indigenous americans have lower response. ○ increased Na+, obesity, stress, alcohol, and smoking can increase the likelihood of HTN. ○ becomes increasingly common after the age of 65 (cardiovascular disease/death). ○ with drug therapy, start with a singular drug, max out the dose, then add if needed. ○ what is DIURETICS? ○ first line for mild HTN by helping the body reduce fluid level. ○ often combined with other drugs. ○ what is SYMPATHOLYTICS? ○ drugs that interfere with the sympathetic system. ○ what are BETA BLOCKERS? ○ reduces CO2, HR, BP, vascular resistance, and renin release. ○ selective beta-1 blockers are cardioselective. ○ e.g. METOPROLOL and ATENOLOL. ⇢ only atenolol truly protects from bronchospasm. ○ what are CENTRALLY ACTING ALPHA-2 AGONISTS? ○ causes vasodilation. ○ lowers CO2 and peripheral vascular resistance. ○ not used with beta blockers (slows HR too much). ○ can result in dry mouth, bradycardia, and dizziness. ○ can cause edema and rebound HTN if not tapered. ○ e.g. METHYLDOPA and CLONIDINE. ○ what is the CLONIDINE PATCH? ○ a 7-day patch. ○ place on the skin without hair/rotate sites. ○ monitor for skin irritation. ○ what are ALPHA-1 BLOCKERS? ○ vasodilation, decreased BP, renal blood flow, and cholesterol. ○ also helps treat prostate enlargement. ○ doesn’t affect airways and glucose metabolism. ○ all end with the suffix “–zosin”. ○ e.g. PRAZOSIN and DOXAZOSIN. 32 ○ what are the care implications? ○ hypotensive effect → additive w/ other drugs. ○ DO NOT GIVE PRAZOSIN IF P/T HAS RENAL DISEASE. ○ what are ALPHA-1/BETA-1 ADRENERGIC BLOCKERS? ○ results in vasodilation and decreased BP. ○ in large doses, can block beta-2 (bronchospasm). ○ typically end with the suffix “–olol” but can with “–alol”. ○ e.g. LABETALOL and CARTEOLOL. ○ what is DIRECT-ACTING ARTERIOLAR VASODILATORS? ○ relaxes the smooth muscles of arteries and leads to vasodilation. ○ reduces BP and increases flow to the brain/kidneys. ○ e.g. HYDRALAZINE. ⇢ often causes a lupus-like syndrome (DIL). ⇢ resolves when the drug is discontinued. ○ what is ACE INHIBITORS? ○ stops the conversion of angiotensin-1 → 2 ( powerful vasoconstrictor). ○ promotes the excretion of Na+ and H2O, so it is a potassium sparing drug. ○ do not administer with a potassium sparing diuretic. ○ all end with the suffix “–pril”. ○ what are some side/adverse effects? ○ N/V/D. ○ headaches. ○ hyperkalemia. ○ tachycardia. ○ angioedema. ○ dry cough (not dangerous, but unproductive). ⇢ affects 10% of those taking it. ⇢ more common in women, older adults, and AAPI. ⇢ do not confuse with the wheezing from beta blockers. ○ what are some care implications? ○ take on an EMPTY stomach. ○ not safe during pregnancy (affects the kidneys). 33 ○ what is ANGIOTENSIN-2 RECEPTOR BLOCKERS (ARBs)? ○ acts on the RAAS to block aldosterone (vasodilation, decrease PVR). ○ does not cause a chronic cough, but may cause angioedema. ○ ACE Is and ARBs may be substituted for each other. ⇢ both are combined to treat diabetic nephropathy ⇢ preserves kidney and left ventricular function. ○ e.g. LOSARTAN and VALSARTAN. ○ what are CALCIUM CHANNEL BLOCKERS (CCBs)? ○ promotes vasodilation. ○ more info. in the anti-anginals section. ○ treats hypertension, angina, and dysrhythmias. ○ affects the cardiac/cerebral arteries (not large central) and peripheral vessels. ○ e.g. VERAPAMIL, DILTIAZEM, and AMLODIPINE. ○ what are some side effects? ○ related to… ⇢ vasodilation (edema, bradycardia, palpitations, etc.). ⇢ relaxing smooth muscles (GI distress, constipation). ○ DO NOT TAKE WITH GRAPEFRUIT JUICE. ○ what can be used when in a HYPERTENSIVE EMERGENCY? ○ NITROPRUSSIDE. ⇢ can cause profound hypotension. ⇢ infused on the IV pump and titrate the dose carefully. ⇢ T½ is 2 minutes. ⇢ what are some important notes? ○ protect the drug from the light. ○ only used short term and emergently. ○ BBW: breakdown products include cyanide. 34 DRUGS FOR URC. ○ what are ANTIHISTAMINES? ⇢ H1 blockers (causes localized vasodilation and inflammation in the resp. tract). ⇢ there are two generations: first and second generation. ⇢ what can antihistamines be used for? ○ colds. ○ allergic rhinitis. ○ anti-itch. ○ antiemetic (nausea). ○ sedation. ⇢ how do 1st and 2nd generation antihistamines differ? ○ first generation (suffix “–amine”). ⇢ older. ⇢ used for rhinitis, sleep, and motion sickness. ⇢ anticholinergic effects. ⇢ what are the side effects of 1st generation? ○ sedating (no driving!). ○ may cause urinary retention. ○ GI distress if administered without food. ○ “super infection” may develop afterward. ⇢ what is DIPHENHYDRAMINE? ○ sleep aid or motion sickness preventative. ○ do not administer if with… ⇢ glaucoma. ⇢ urinary retention. ⇢ severe liver disease. ○ second generation (suffix “–adine”). ⇢ newer, but less potent. ⇢ over the counter (OTC). ⇢ non-sedating. ⇢ cholinergic. ⇢ what is LORATADINE? ○ used for upper respiratory infections. ○ a 24-hour tablet, therefore it doesn’t matter if it is administered with food or not. 35 ○ what are DECONGESTANTS? ⇢ promotes vasoconstriction (shrinks nasal blood vessels). ⇢ can be administered either locally or systemically. ⇢ what are nasal (local) decongestant sprays? ○ drug that remains in the nasal cavity. ○ fewer side effects but may have a nasal sting/burn. ○ do not touch the tip to the nose or share. ○ why is it dangerous to overuse nasal sprays? ○ dependency can occur if used for more than 3-5 days. ○ overuse = rebound congestion / systemic SEs. ⇢ what are oral (systemic) decongestants? ○ alpha-1 agonist decongestants that are systemic. ○ may have additive sympathetic effects. ○ who should avoid oral decongestants? ○ hypertensive patients. ○ patients with glaucoma. ○ individuals suffering with urinary retention. ○ what are INTRANASAL GLUCOCORTICOIDS? ⇢ steroid (“–one”) that is meant for a short term use. ⇢ decreases inflammation but may cause dryness. ⇢ e.g. BECLOMETHASONE or FLUTICASONE. ○ what are ANTITUSSIVES? ⇢ acts on the medulla (the cough center). ⇢ is usually used for non-productive coughs as it has an anesthetic effect. ⇢ reserved for when the patient is to sleep. ⇢ e.g. BENZONATATE. ○ what are EXPECTORANTS? ⇢ acts locally. ⇢ helps to loosen secretions and expel mucus. ⇢ e.g. GUAIFENESIN or HYDRATION (H2O). ○ what is ACETYLCYSTEINE? ○ a mucolytic drug. ○ liquefies and loosens mucus to be coughed out. ○ used as an antidote for tylenol toxicity. 36 NICOTINE AND SMOKING ADDICTION. ○ what is NICOTINE? ⇢ used with smoking cessation. ⇢ has many administration forms (gum, patch, and spray). ⇢ stimulates the CNS by dilating the blood vessels in the skeletal muscle. ⇢ use with caution with cardiac patients and pregnant women. ⇢ what are the different nicotine replacement agents? ○ nicorette gum. ⇢ doubles cessation success rate. ⇢ do not eat 15 minutes before use. ⇢ chew slowly and hold gum in cheek. ⇢ local irritation. ○ nicoderm CQ patch. ⇢ doubles cessation success rate. ⇢ helps prevent craving. ⇢ skin hypersensitivities. ○ nicotrol nasal spray. ⇢ not used with asthma and sinus allergies. ○ nicotrol (inhaler). ⇢ simulates smoking. ⇢ not used with asthma and pulmonary diagnosis. ○ commit lozenge. ⇢ DO NOT SWALLOW. ⇢ what are the non-nicotine drug therapy? ○ bupropion. ⇢ an antidepressant. ⇢ reduces the urge and some symptoms of withdrawal. ○ varenicline. ⇢ use for 12 to 24 weeks. ⇢ most effective aid for smoking cessation. ⇢ reduces cravings and the pleasurable effects of smoking. ⇢ causes HA, GI symptoms, and taste perception. ○ clonidine. ⇢ an antihypertensive drug. ⇢ prevents autonomic symptoms (N/V, etc.). 37 DRUGS FOR LRD. ○ contributes to the inflammation of airways and excessive mucus production. ○ meant to treat COPD (chronic asthma, bronchitis, emphysema) and acute asthma. ○ what are SYMPATHOMIMETICS? ○ a bronchodilator. ○ short or long acting beta-2 agonists. ○ all end with the suffix “–erol/–enol” (but look at context). ○ what is ALBUTEROL (first line)? ○ administered PO or via inhalation. ○ short acting with rapid onset. ○ if the dose is high enough, beta-1 receptors can be stimulated. ○ what is SALMETEROL? ○ long acting. ○ decreases inflammation, but not for an acute attack. ○ should be used in conjunction with an inhaled steroid. ○ what are some side effects? ○ hypertension. ○ tachycardia. ○ insomnia. ○ arrhythmias and anginas. ○ nervousness and restlessness. ○ shakiness and tremors. ○ what are INHALED GLUCOCORTICOIDS? ○ we all have fungi alongside our normal flora within the mouth. ○ oral, laryngeal, pharyngeal fungal infection is more likely to occur. ○ there is an oral form of steroids → acute asthma and for 3-10 days. ○ what are important care considerations? ○ THRUSH is likely to occur. ○ so, it is important to… ⇢ RINSE MOUTH WITH EACH DOSE. ⇢ WASH THE INHALER W/ WARM H2O (DAILY). 38 ○ what are the two different types of INHALERS? ○ METERED DOSE INHALER (MDI). ⇢ delivers the drug dose to the lower airways. ⇢ technique is important (spacer promotes correct delivery)! ⇢ how is an MDI used correctly? ○ remove the cap and SHAKE. ○ inhale slowly (for at least 3 seconds). ○ hold the medicine for 10 seconds. ○ wait one minute before the next puff. ○ rinse the inhaler. ○ DRY POWDERED INHALER. ⇢ there are several types, but each dose crushes a pill. ⇢ the patient must exhale away from the device, then inhales fully. ⇢ what are important care considerations? ○ keep the cap on between uses. ○ DO NOT IMMERSE. ○ what are LT RECEPTOR ANTAGONISTS & SYNTHESIS INHIBITORS? ○ prevents LT formation (i.e. prevents bronchoconstriction). ○ effective for exercise-induced asthma. ○ used only for maintenance and prevention, NOT for acute attacks. ○ all end with the suffix “–lukast”. ○ e.g. ZAFIRLUKAST and MONTELUKAST. ○ what are important care considerations? ○ give once at bedtime and safe for kids > 2 years. ○ serious behaviour or mood changes are possible. ○ can cause GI symptoms, N/V/D, headaches, and dizziness. ○ what are MAST CELL STABILIZERS? ○ prevents mast cells from releasing inflammatory substances. ○ prevents the release of histamine to prevent airway. ○ takes 2 to 4 weeks to work. ○ what is CROMOLYN? ○ inhaled (oral or nasal, not a bronchodilator). ○ prophylaxis use for bronchial asthma. ○ taper, if not could result in bronchospasm. 39 ○ what are ANTICHOLINERGICS? ○ a bronchodilator. ○ given by aerosol and has few side effects. ○ e.g. IPRATROPIUM (with albuterol = COMBIVENT). ○ what is TIOTROPIUM? ○ used as maintenance therapy for asthma/COPD. ○ administered w/ a dry powder inhaler using an intact capsule. ○ what are XANTHINE DERIVATIVES? ○ can result in diuresis and the dilation of coronary/pulmonary vessels. ○ stimulates CNS and respiration. ○ all end with the suffix “–phylline”. ○ e.g. THEOPHYLLINE, AMINOPHYLLINE, and CAFFEINE. ○ what is THEOPHYLLINE? ○ formerly first line for bronchospasms but dangerous SEs. ○ relaxes the smooth muscles in the airways. ○ has a narrow therapeutic index (frequent serum levels)! ○ can result in heartburn, N/V, palpitations, EKG changes, etc. GEN. CHART CATEGORIZING THE DRUGS. PREVENT BRONCHOSPASM. TREAT BRONCHOSPASM. cromolyn. albuterol. montelukast. theophylline. zafirlukast. tiotropium. ipratropium. beclomethasone. advair diskus (salmeterol + combivent (albuterol + fluticasone). ipratropium). salmeterol. epinephrine (emergency, acute). oral prednisone. 40 ANTITUBERCULARS/ANTIFUNGALS. ○ what needs to be known about TUBERCULOSIS? ⇢ transmission is through person to person and aerosolized droplets. ⇢ caused by mycobacterium tuberculosis (an acid-fast bacillus). ⇢ multidrug therapy is used to avoid drug resistance. ⇢ there are two types: latent (been exposed but not infectious) and active (infectious). ⇢ what is ISONIAZID (INH)? ○ first PO anti tubercular drug. ○ watch out for hepatitis and neuropathy. ○ blocks bacterial vitamin vitamin B6 synthesis (needs supplement). ○ TAKE ON AN EMPTY STOMACH. ⇢ what is RIFAMPIN (RIF)? ○ turns body fluid orange and may stain contact lenses. ○ watch out for N/V, jaundice, and bruising. ○ can result in hepatotoxicity. ○ TAKE ON AN EMPTY STOMACH. ⇢ what is ETHAMBUTOL? ○ can result in ocular toxicity/red-green color blindness. ⇢ get a baseline visual acuity test. ⇢ visual changes are reversible. ○ TAKE WITH FOOD. ⇢ what is PYRAZINAMIDE? ○ can result in hepatotoxicity, arthralgia, and myalgia. ○ watch out for N/V, jaundice, and bruising. ○ TAKE EITHER WITH OR WITHOUT FOOD. 41 ○ what needs to be known about MYCOSIS? ⇢ fungal infection. ⇢ either superficial/systemic or opportunistic/non-opportunistic. ⇢ what is NYSTATIN? ○ not well absorbed from the GI tract. ○ acts by contact with the infected area. ○ available as cream, oral suspension, and vaginal tablet. ○ give last, swish, swallow, spit, and don’t rinse after (if oral). ○ what are possible adverse effects? ○ skin irritation or itching. ○ hyperglycemia, angioedema, or bronchospasm. ⇢ what is AMPHOTERICIN B? ○ administer only via IV. ○ highly toxic (‘shake and bake’). ○ can result in severe systemic fungal infections. ○ what are possible adverse effects? ○ infusion reactions (less intense with lipid solution). ○ nephrotoxicity, hypokalemia, and BM suppression. ⇢ what are AZOLE GROUP? ○ powerful antimycotics. ○ can be absorbed PO, IV, vaginally, and topically. ○ used with tinea and candidiasis. ○ all end with the suffix “–azole”. ○ what is FLUCONAZOLE? ○ may cause N/V. ○ many drug interactions (+ sulfa = hypoglycemia). ○ can result in hepatotoxicity. ○ what are the care considerations? ○ good handwashing/separate towels (contagious). ○ avoid light exposure. ○ report skin irritation. ○ monitor renal and hepatic function labs. ○ take the entire course of meds. ○ AVOID ALCOHOL. 42 ANTIEMETICS (GI DRUGS). ○ what are DOPAMINE ANTAGONISTS (“–azine”)? ○ can result in extrapyramidal symptoms (EPS). ○ long term = tardive dyskinesia which can be treated but is incurable. ○ e.g. PROCHLORPERAZINE and PROMETHAZINE. ○ what are SEROTONIN ANTAGONISTS (“–setron”)? ○ most effective for chemotherapy-induced nausea. ○ can cause headaches, diarrhea, and dizziness. ○ e.g. ONDANSETRON, GRANISETRON, and DOLASETRON. ○ what are GLUCOCORTICOIDS? ○ very effective for nausea caused by chemotherapy. ○ mechanism is not well understood (increased appetite/well being). ○ e.g. DEXAMETHASONE and METHYLPREDNISOLONE. ○ what are CANNABINOIDS? ○ active ingredient in marijuana. ○ illegal in some areas as some tend to abuse the drug. ○ approved for… ⇢ clinical use for cancer treatment. ⇢ appetite stimulant for AIDS wasting syndrome. ○ e.g. DRONABINOL. ○ what is LORAZEPAM (benzodiazepine)? ○ used prior to an operation and with cancer therapy. ○ used with an antiemetic such as metoclopramide (antiemetic cocktail). ○ what are DIMENHYDRINATE? ○ an antihistamine. ○ inhibits vestibular stimulation in the ear. ○ should be used prior to nausea. ○ what are GASTRIC STIMULANTS? ○ increases gastric emptying by blocking dopamine. ○ increases peristalsis after abdominal surgery. ○ can cause drowsiness, EPS, tardive dyskinesia, and anticholinergic sx. ○ e.g. METOCLOPRAMIDE. 43 CONSTIPATION and DIARRHEA (GI DRUGS). ○ what is used for CONSTIPATION? ⇢ medication that often is given after loose stools (watch for drowsiness). ⇢ non-pharmacologic management includes push fluids and ointment on perianal skin. ⇢ avoid CNS depressants, complex activities, and fried food/milk products. ⇢ prolonged use can lead to dependence = loss of natural colon function/abuse. ⇢ what are LAXATIVES? ○ promotes soft stool. ○ can affect the absorption of other drugs. ○ four types: osmotic, stimulant, bulk-forming, and emollient. ○ what are OSMOTIC (SALINE) LAXATIVES? ○ hyperosmolar. ○ draws water into the colon and contains e- salts. ○ can result in cramps, flatulence, and diarrhea. ○ be careful of excessive dehydration/e- disturbances. ○ e.g. MAGNESIUM HYDROXIDE. ○ what are STIMULANT (CONTACT/IRRITANTS)? ○ produces a watery stool. ○ increases peristalsis via irritation of the mucosa. ○ can cause N, cramps, and fluid/e- imbalances. ○ has an immediate effect. ⇢ 6-8 hours orally (overnight). ⇢ 15-60 minutes rectally. ○ e.g. BISACODYL. ○ what are BULK FORMING LAXATIVES? ○ ↑ fecal bulk by absorbing extra H2O into the colon. ○ must take with a large glass of fluids or can obstruct. ○ e.g. methylcellulose/psyllium hydrophilic mucilloid. ○ what are EMOLLIENTS/STOOL SOFTENERS? ○ lubricants that decrease straining. ○ the stool just sliiiides out, but can cause cramping. ○ e.g. DOCUSATE. 44 ⇢ what are BOWEL EVACUANTS? ○ as the phrase states, literally cleans the colon. ○ what is GOLYTELY? ○ an isotonic solution that doesn’t get absorbed (safer). ○ used as bowel prep. for surgery and procedures. ○ patient must drink 3-4 L, but it is a miserable process. ○ what are LACTULOSE? ○ pulls water into the intestines. ○ decreases ammonia level affected by cirrhosis. ⇢ this is good. ⇢ excess ammonia = encephalopathy. ○ what is used for DIARRHEA? ⇢ medication that often is given after loose stools (watch for drowsiness). ⇢ avoid CNS depressants, complex activities, and fried food/milk products. ⇢ non-pharmacologic management includes… ✗ being alert for fluid depletion = electrolyte disarray. ✗ the drinking of push fluids (weak tea, water, and broth). ✗ the cleaning of the perianal skin and application of ointment. ⇢ what are FLUOROQUINOLONE ANTIBIOTICS? ○ used for traveler’s diarrhea (acute, e.coli, and can last 2 days). ○ helps to get the toxins out. ⇢ what are OPIATE ANTIDIARRHEALS? ○ decreases intestinal motility. ○ may cause constipation. ○ can lead to physical dependence and anticholinergic SEs. ○ e.g. DIPHENOXYLATE/ATROPINE and LOPERAMIDE. ⇢ what are ABSORBENTS? ○ coats the wall of the gut and absorbs bacteria/toxins. ○ acts on the gastric mucosa, suppressing emesis. ○ not for children and those with an ASA allergy. ○ e.g. KAOPECTATE and BISMUTH SUBSALICYLATE. 45 BIOLOGIC RESPONSE MODIFIERS. ○ mimics proteins that are usually produced by the body. ○ helps the body… ⇢ produce new cells. ⇢ inhibit normal cells from changing into cancer cells. ⇢ enhances the immune system’s ability to kill abnormal cells ○ what are INTERFERONS? ○ a normal part of the immune system. ○ slows the growth of cancer cells and causes them to act more normal. ○ some stimulate certain WBCs to fight cancer. ○ what is INTERFERON ALPHA 2B? ○ antiviral, antiproliferative, and immunomodulatory. ○ treats some cancers. ○ helps with AIDS, hepatitis B/C, and HPV. ○ what are INTERFERON B? ○ treats multiple sclerosis. ○ inhibits proinflammatory cytokines. ○ reduces t-cell migration across the BBB. ○ SC, every other day (ice packs before/after to ↓ pain). ○ NO ALCOHOL/MANY DRUG INTERACTIONS. ○ can result in… ⇢ flu-like symptoms. ⇢ hepatotoxicity. ⇢ depression/suicidal thoughts. ⇢ neutralizing antibodies. ○ what drugs are ANTI-ANEMIA? ○ EPOETIN ALFA (SQ). ⇢ made by bacteria in a petri dish. ⇢ used for… ✗ HIV patients. ✗ chronic kidney failure. ✗ aftercare of chemotherapy. ✗ if hemoglobin levels are below 12. ⇢ what are some care implications? ○ watch for HTN, headaches, and joint pain. ○ must consume enough Fe+, folate, and B12. 46 ⇢ what is the BB warning for epoetin? ○ cancer pt + hemoglobin (Hgb) > 12 g/dL = increased risk of death. ○ DARBEPOETIN (SQ). ⇢ made by bacteria in a petri dish. ⇢ reproduces erythropoietin. ○ what drugs help with NEUTROPENIA (