Unit 3 Pharmacology PDF

- In palliative medicine, they represent the first step of the LESSON 1: PAIN RELIEVER AND ANTI- WHO’s analgesic ladder used for mild pain INFLAMMATORY DRUGS - They are an important suppl...

- In palliative medicine, they represent the first step of the LESSON 1: PAIN RELIEVER AND ANTI- WHO’s analgesic ladder used for mild pain INFLAMMATORY DRUGS - They are an important supplement to opioids and adjuvant drugs at higher steps of the ladder. DRUGS USED TO MANAGE PAIN - Also associated with an increased risk of adverse gastrointestinal, renal and cardiovascular effects and PAIN hepatotoxicity can result from overdosing with paracetamol - a general term that describes uncomfortable sensations in the The disadvantages of non-opioid analgesics include a ceiling body. effect for pain relief and the risk of side effects. - It stems from activation of the nervous system - Can range from annoying to debilitating; can feel like a sharp Difference between Salicylates & Non-Salicylates stabbing or a dull ache - Can also be described as throbbing, stinging, sore and Salicylates Non-Salicylates pinching. - Useful in pain management because of - Used as aspirin substitute for Acute pain analgesic, antipyretics and anti- patients allergic to aspirin who - Can be mild and last just a moment inflammatory effects. experience gastric upset. - Might be severe and last for weeks or months Drug of choice in treating children with fever and flu-like Chronic pain symptoms. - Ongoing pain Mechanism of action: Mechanism of action: - Usually lasts longer than six months Lower body temperature by Doesn’t possess dilating peripheral blood anti-inflammatory Major Types of Pain vessels action 1. Nociceptive Pain Inhibit the production of Doesn’t inhibit - Typically the result of tissue injury. prostaglandins platelet aggregation Common types are arthritis pain, mechanical back pain or Makes pain receptors less o the analgesic of likely to send pain messages choice when post-surgical pain. Aspirin prolongs bleeding time bleeding tendencies 2. Inflammatory Pain by inhibiting aggregation of are issues - An abnormal inflammation caused by an inappropriate platelets response by the body’s immune system. Adverse reactions: Adverse reactions: Conditions include gout and rheumatoid arthritis. GI system: gastric upset, Skin eruptions, 3. Neuropathic Pain heartburn, nausea, vomiting, urticaria - Caused by nerve irritation anorexia, GI bleeding Hemolytic anemia Conditions include neuropathy, radicular pain and trigeminal Loss of blood through GI tract Pancytopenia Allergy may manifest in hives, Hypoglycemia neuralgia. rash, angioedema, jaundice 4. Functional Pain bronchospasm, anaphylactic - Without obvious origin, but can cause pain. shock Examples are fibromyalgia and irritable bowel syndrome. Used for: Used for: Relieving mild to moderate Treating mild to Pain Perception Pathway pain moderate pain - Essential to human well-being Reducing elevated body Reducing elevated and survival. temperature body temperature Treating inflammatory (fever) The sensation of pain conditions such as rheumatoid Managing pain and originates through complex arthritis, osteoarthritis, and discomfort signaling pathways which rheumatic fever associated with begins in the periphery, Decreasing the risk of arthritic disorders ascends in the spinal cord or myocardial infarction in those brainstem (cranial sensory with unstable angina or input), and is ultimately previous myocardial infarction (aspirin only) interpreted in the cortex of the Reducing the risk of transient brain. ischemic attacks or strokes in men who have had transient ischemia of the brain due to Characteristics of Pain fibrin platelet emboli (aspirin only). 1. Provocation and Palliation - This use have been found to What were you doing at the onset? What provokes it, what be effective in men (and women older than 65 years of alleviates it? age only) 2. Quality/Quantity Helping maintain pregnancy in What does the pain feel like and how often? Is it sharp, dull, special at-risk populations stabbing, crushing, throbbing and nauseating? (low-dose aspirin therapy). 3. Region/Radiation - It may be used to prevent or Where is the pain located? To be specific, point to the location of treat inadequate uterine- the pain or draw it on the diagram. Does it radiate anywhere? If so, placental blood flow where and to what side? Is it equal if both sides are involved? The Examples: Example: Aspirin (Acetylsalicylic acid) Acetaminophen more specific, you can be the better. Diflunisal 4. Severity Scale Magnesium salicylate How much does it hurt on a scale from 1-10? Salsalate 5. Timing Does the severity or character of the pain change based on time of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) day, activity, weather, year or position? - Are medicines that are widely used to relieve pain, reduce inflammation and bring down a high temperature. Pain Assessment - Often used to relieve symptoms of headaches, painful periods, - An overall appraisal of the factors that may influence a sprains and strains, colds and flu, arthritis, and other causes of patient’s experience and expression of pain (McCaffery and long-term pain. Pasero 1999) - A group of chemically dissimilar agents that differ in their - A comprehensive process of describing pain and its effect on antipyretic, analgesic, and anti-inflammatory activities function; - Act primarily by inhibiting the COX enzymes that catalyze the - An awareness of the barriers that may affect nurse’s first step in prostanoid biosynthesis assessment and management of pain. o Leads to decreased PG synthesis with both beneficial and unwanted effects Classification of NSAIDs Acetates Diclofenac, Indomethacin, Sulindac Fenamates Mefenamic acid Oxicams Piroxicam Propionates Ibuprofen, ketoprofen, naproxen Pyrazolones Phenylbutazone Salicylates Aspirin, diflunisal Nonopioid Analgesics - Encompass the non-steroidal anti-inflammatory drugs NSAIDs should usually be avoided by people with the following (NSAIDs) and paracetamol (acetaminophen) conditions: NSAIDs Peptic ulcer or stomach bleeding. - Have potent anti-inflammatory, analgesic and antipyretic Uncontrolled hypertension. activity, and are among the most widely used drugs worldwide. Kidney disease.  People that suffer with inflammatory bowel disease (Crohn's oral/transdermal/rectal route not usable); Has incident pain or disease or ulcerative colitis) other pain patterns that are not predictable. Past transient ischemic attack (excluding aspirin) Past stroke (excluding aspirin) Opioid Analgesics - can be used for either short-term or long-term relief of severe pain. o In contrast, the anti-inflammatory compounds are used for short-term pain relief and for modest pain, such as that of headache, muscle strain, bruising, or arthritis. Analgesics – a class of medications designed to specifically relieve pain. They include acetaminophen (Tylenol), which is available over the counter (OTC) or by prescription when combined with another drug, and opioids (narcotics), which are only available by prescription. Types of Analgesia Paracetamol NSAIDS Opioids (Weak & Strong) Neurophatic Agents Paracetamol - also known as acetaminophen - a medication used to treat pain and fever. - is typically used for mild to moderate pain relief. - Good for mild to moderate pain. Use iv route in severe acute pain. - Contraindicated in severe hepatic impairment, dose reduce in mild impairment (e.g. 500mg QDS). - Generally safe (except in overdose) and can be used in pregnancy Prescribe: Paracetamol 1g four times a day orally Regular is better than PRN as paracetamol acts in conjunction with other analgesia (e.g. opiates) to increase efficacy How does paracetamol work? Paracetamol seems to work by blocking chemical messengers in the brain that tell us we have pain. Paracetamol also reduces fever by affecting the chemical messengers in an area of the brain that regulates body temperature. Opioid Antagonist - or opioid receptor antagonist - is a receptor antagonist that acts on one or more of the opioid receptors. The two most common opioid antagonist medications include: 1. Naloxone - comes in intravenous, intramuscular and intranasal formulations, and is FDA-approved for the use in an opioid overdose, and the reversal of respiratory depression associated with opioid use. - can find in Suboxone®, a medication used to treat opioid addiction as a measure to discourage misuse. - is also used as a rescue medicine for opioid overdose and is commonly known by the brand name Narcan. 2. Naltrexone - Some people in opioid addiction treatment take naltrexone to block the effects of opioids. - As a result, they don’t feel the effects of opioids if they relapse Anesthetic Drugs - also spelled anaesthetic, any agent that produces a local or general loss of sensation, including pain - achieve this effect by acting on the brain or peripheral nervous system to suppress responses to sensory stimulation. The unresponsive state thus induced is known as anesthesia. General anesthesia - involves loss of consciousness, usually for the purpose of relieving the pain of surgery. Regional anesthesia - is used to numb only the portion of the body that will undergo the surgery. Usually, an injection of local anesthetic is given in the area of nerves that provide feeling to that part of the body. Local anesthesia - involves loss of sensation in one area of the body by the blockage of conduction in nerves. Patient-Controlled Analgesia (PCA) - Any method of allowing a person in pain to administer their own pain relief. - is a computerized machine that gives you a drug for pain when you press a button. The infusion is programmable by the prescriber. If it is programmed and functioning as intended, the machine is unlikely to deliver an overdose of medication. In most cases, PCA pumps supply opioid pain-controlling drugs such as morphine, fentanyl, and hydromorphone The pump is attached to a thin, flexible tube (intravenous or I.V.) Indications: The primary indication for PCA is the patient who requires parenteral analgesia (e.g. severe pain and/or  fluid and electrolyte imbalance as well as “laxative habit”, that is LESSON 2: GASTROINTESTINAL AGENTS dependence on laxative to have bowel movement. Laxatives come in many different forms. Some are used by mouth and Antidiarrheals some are used in your rectum. - Any medication which provides symptomatic relief for diarrhea - Inhibits the release of acetylcholine and prostaglandins, Stool softeners are available as: Other laxatives come in these forms: thereby reducing peristalsis, and increasing intestinal transit oral soft gel capsules oral capsule time, which also favorably affects water and electrolyte oral liquids chewable tablet movement through the bowel rectal enema oral tablet - These drugs are contraindicated in patients whose diarrhea is oral granules (powder) associated with organism that can harm the intestinal mucosa oral gummy (Escherichia coli, Salmonella and Shigella). oral liquid - are contraindicated in children younger than 2 years of age oral wafer rectal suppository - are used cautiously in patients with severe hepatic impairment rectal enema or inflammatory bowel disease - are classified as pregnancy category C drugs and should be used cautiously during pregnancy and lactation. Antacids - a class of medicines that neutralize acid in the stomach. Patients with pseudomembranous colitis, abdominal pain of unknown origin, and obstructive jaundice also should not take - contain ingredients such as aluminum, calcium, magnesium, or antidiarrheals. sodium bicarbonate which act as bases (alkalis) to counteract stomach acid and make its pH more neutral. Loperamide is a pregnancy category B drug, yet is not recommended for use during pregnancy and lactation. - act by neutralizing the acid in the stomach and by inhibiting pepsin, which is a proteolytic enzyme. Adverse reactions in GI system: - a substance which neutralizes stomach acidity and is used to anorexia, nausea, vomiting, constipation, abdominal discomfort, pain, and relieve heartburn, indigestion or an upset stomach distention. Other system reactions: Drug interactions: Dizziness, drowsiness, and headache, sedation and euphoria, rash When antacids are taken with acidic drugs (for example, digoxin [Digitek], Drug interactions may occur when antidiarrheal drug is administered with phenytoin [Dilantin], chlorpromazine [Thorazine], [isoniazid]), they cause the another agent such as: absorption of the acidic drugs to be decreased, which causes low blood a. Antihistamine, Opioids, Sedatives, or Hypnotics concentrations of the drugs, which ultimately results in reduced effects of the b. Antihistamine and General Antidepressants drugs. c. Monoamine Oxidase Inhibitor Antidepressants Indications: Heartburn symptoms in GERD. Antiflatulents Duodenal and gastric ulcers. Stress gastritis. - or deflatulent Pancreatic insufficiency. - is a drug used for the alleviation or prevention of excessive Non-ulcer dyspepsia. intestinal gas Diarrhea caused by bile-acid. For the alleviation of flatulence, an antifoaming agent such as Biliary reflux. simethicone may be taken orally. This agent will coalesce the a. Administer the drug apart from any other oral medications smaller gas bubbles into larger bubbles, thereby easing the approximately1hourbefore or 2 hours after to ensure adequate absorption of the other medications. release of gas within the gastrointestinal tract via burping or b. Note number and consistency of stools. Constipation is common flatulence. and dose related. Intestinal obstruction from fecal concretions has o Simeticone or (simethicone) is a type of medicine called an been reported. antiflatulent. It is used to treat wind (flatulence). It is a mixture c. Lab tests: Monitor periodic serum calcium and phosphorus levels of silica gel and dimeticone (or dimethicone, a type of with prolonged high-dose therapy or impaired renal function. silicone)and is known as "activated dimeticone". It can help d. Antacids may cause stools to appear speckled or whitish. with trapped wind and bloating as well as colic in babies. e. Report epigastric or abdominal pain; it is a clinical guide for adjusting dosage. Keep physician informed. Pain that persists beyond 72h may signify serious complications. No adverse reactions have been reported with the use of antiflatulents f. Seek medical help if indigestion is accompanied by shortness of In terms of interactions, there may be a decreased effectiveness of other breath, sweating, or chest pain, if stools are dark or tarry, or if drugs because of absorption by charcoal, which can also absorb other drugs symptoms are recurrent when taking this medication. in the GI tract. There are no known interactions with Simethicone Antiflatulent are used to relieve painful symptoms of excess gas in the digestive tract that may be caused by the following: H2-Receptor Antagonist a. postoperative gaseous distention and air swallowing - are a group of medicines that reduce the amount of acid b. Dyspepsia (fullness or epigastric discomfort) produced by the cells in the lining of the stomach. c. Peptic ulcer - also called 'histamine H2-receptor antagonists' but are d. Irritable Bowel Syndrome or Diverticulosis commonly called H2 blockers - include cimetidine, famotidine, nizatidine and ranitidine, and In terms of interactions, there may be a decreased effectiveness of other drugs because of absorption by charcoal, which can also absorb other drugs have various different brand names in the GI tract. - also known as H2-blockers - are used to treat duodenal ulcers and prevent their return. Laxatives - also used to treat gastric ulcers and for some conditions, such - A substance that you use to help have a bowel movement as Zollinger-Ellison disease, in which the stomach produces - are a group of drugs that either accelerate fecal passage or too much acid. decrease fecal consistency. - are used primarily to treat constipation. Mechanism of action: H2RAs decrease gastric acid secretion by reversibly binding to histamine H2 Emollient laxative – a stool softener receptors located on gastric parietal cells, thereby inhibiting the binding and all stool softeners are laxatives, but not all laxatives are stool action of the endogenous ligand histamine. H2 blockers thus function as softeners. competitive antagonists. The term is often used interchangeably with cathartics, Nursing assessment for a patient using H2 antagonists include: purgatives or evacuants, but there are subtle differences in the Assess for possible contraindications and cautions: meaning especially between laxatives and cathartics. o history of allergy to any H2 antagonists to prevent o Cathartics decrease the absorption of substances by potential allergic reactions o impaired renal or hepatic function, which could affect accelerating their expulsion from the GI tract. Cathartics often the metabolism and excretion of the drug; are administered with charcoal to hasten toxin elimination from the GI tract before absorption. o a detailed description of the GI problem, including length of time of the disorder and medical evaluation Categories of Laxatives to evaluate the appropriate use of the drug and possibility of underlying medical problems; 1. Bulk forming laxatives o current status of pregnancy and lactation because of the potential for adverse effects on the fetus or - Are mild laxatives with little adverse effects. newborn 2. Osmotic laxatives Perform a physical examination to establish baseline data before - have strong laxative activity and can produce serious adverse beginning therapy, determine effectiveness of the therapy, and effects. evaluate for any adverse effects associated with drug therapy 3. Stimulant laxatives Assess cardiopulmonary status - work by stimulating intestinal motility and secretion of water o including pulse, blood pressure, and into the bowel. electrocardiogram (if IV use is needed), to evaluate the cardiac effects of the drug. - generally take 6 to 12 hours to take effect and may cause Perform abdominal examination, abdominal cramping and diarrhea. o including assessment of the liver, to establish a 4. Stool softeners or Surfactant laxatives baseline and rule out underlying medical problem. - little adverse effects and are usually safe but potentially can Monitor the results of laboratory tests, have serious problems. o including liver and renal function tests, to predict changes in metabolism or excretion of the drug that If laxatives of any type are heavily used, not necessarily to the point of might require dose adjustment. Inspect the skin abuse, diarrhea will be common, as well as a tendency to nausea and  o for evidence of lesions or rash to monitor for adverse reactions. Evaluate neurological status o including orientation and affect, to assess CNS effects of the drug and to plan for protective measures. Administer a once-daily dose at bedtime to promote compliance. o Twice daily dose should be administered in the morning and evening; multiple doses, with meals and at bedtime. Ensure therapeutic levels. o Administer drug with or before meals and at bedtime (exact timing varies with product) to ensure therapeutic levels when the drug is most needed. Prevent serious toxicity. o Arrange for decreased dose in cases of hepatic or renal dysfunction to prevent serious toxicity. Monitor IV doses carefully. o Monitor the patient continually if giving IV doses to allow early detection of potentially serious adverse effects, including cardiac arrythmias Assess for potential drug-drug interactions. o Assess the patient carefully for any potential drug- drug interactions if given in combination with other drugs because of the drugs’ effects on liver enzyme systems. Provide patient’s comfort. o Provide comfort, including analgesics, ready to access bathroom facilities, and assistance with ambulation, to minimize possible adverse effects. Reorient patient thoroughly. o Periodically reorient the patient and institute safety measures if CNS effects occur to ensure patient safety and improve and improve patient tolerance of the drug and drug effects. Proton Pump Inhibitors - are members of a class of medications whose main action is a profound and prolonged reduction of stomach acid production. - interact with few drugs. The absorption into the body of some drugs is affected by the presence of acid in the stomach, and because PPIs reduce acid in the stomach, they may affect the absorption of these drugs. Within the class of medications, there is no clear evidence that one agent works better than another. They are the most potent inhibitors of acid secretion available. The most common side effects reported include: headache, diarrhea, nausea, and vomiting. Reports of more serious side effects include kidney disease, fractures, infections and vitamin deficiencies, but these are very rare and are generally associated with long-term use (using these products for more than a year). Nursing considerations In combination with antibiotics, proton pump inhibitors are used to eradicate H.pylori infection, one of the main causes of recurring stomach ulcers. The differences between proton pump inhibitors in clinical efficacy and safety are considered to be minimal. Patients who require long-term symptom management should reduce their use of prescribed medication stepwise: o using the lowest effective dose, then as required before returning to self-treatment with antacid and/or alginate therapy. Medically used proton pump inhibitors: Omeprazole Lansoprazole Dexlansoprazole Esomeprazole Pantoprazole Rabeprazole Ilaprazole  The uses of the bile acid resins are hyperlipidemia and pruritus LESSON 3: CARDIOVASCULAR DRUGS associated with partial biliary obstruction. Adverse reactions: ANTI-ARRHYTHMIC DRUGS o Constipation, abdominal cramps, flatulence, nausea, increased bleeding tendencies - are drugs that are used to treat abnormal heart rhythms resulting from irregular electrical activity of the heart. Example of bile acid resins drugs: o Cholestyramine - prevent and treat abnormal heartbeats (arrhythmias). o Colestipol o Problems with your heart's rhythm are caused by a o Colesevelam disruption in the heart's electrical system. A drug called atropine may be prescribed if your heart beats FIBRIC ACIDS DERIVATIVES too slowly (bradycardia) - also known as fibrates CARDIAC ILLNESSES - are the third group of antihyperlipidemic drugs and work in a variety of ways. CARDIAC STIMULANTS - are contraindicated in patients with hypersensitivity to the - is a substance which acts as a stimulant of the heart – e.g., via drugs and in those with significant hepatic or renal dysfunction positive chronotropic or inotropic action because these drugs may increase the already elevated o examples are cocaine and methamphetamine. cholesterol. The heart really takes a beating when stimulants are abused. Clofibrate acts to stimulate the liver to increase breakdown of A stimulant forces the heart to work harder, creating a strain on very low-density lipoproteins (VLDLs) to LDLs, decreasing liver the whole cardiovascular system. The blood pressure goes up. synthesis of VLDLs and inhibiting cholesterol formation and One's heart rhythm may become irregular and a person may lowering triglycerides suffer chest pain. Fenofibrate acts by reducing VLDL and stimulating the catabolism of triglyceride-rich lipoproteins, resulting in a CARDIAC DEPRESSANT decrease in plasma triglycerides and cholesterol. - an agent that depresses the rate or force of contractions of the Gemfibrozil increases the excretion of cholesterol in the feces heart and reduces the production of triglycerides by the liver, thus Cardio-inhibitory drugs depress cardiac function by decreasing lowering serum lipids levels and triglycerides. heart rate (chronotropy), myocardial contractility (inotropy), or Adverse reactions: both, which decreases cardiac output and arterial pressure o Nausea, vomiting, GI upset, diarrhea, cholelithiasis These cardiac changes reduce the work of the heart and (stone in gallbladder), and cholecystitis myocardial oxygen consumption. (inflammation of the gallbladder). The drugs are used cautiously during pregnancy(category c)and not during lactation or in patients with peptic ulcer or CORONARY VASODILATORS DRUGS diabetes. - are mainly represented by nitroglycerin-derived nitrates, which are potent vasodilators and may also decrease blood pressure MISCELLANEOUS ANTIHYPERLIPIDEMIC DRUGS (nitroprusside). - include niacin and ezetimibe. Antihyperlipidemic drugs for - Drugs that dilate large coronary arteries, such as nitroglycerin information on combinations of more than one class of and the calcium channel-blocking agents, can dilate these antihyperlipidemic drugs in one tablet. stenotic segments. This dilation may contribute to the relief of The mechanism of action by which Niacin (nicotinic acid) myocardial ischemia by increasing coronary blood flow. lowers blood lipids. Ezetimibe inhibits the absorption of - medications that open (dilate) blood vessels. They affect the cholesterol in the small intestine, leading to a decrease in muscles in the walls of your arteries and veins, preventing the cholesterol in the liver. muscles from tightening and the walls from narrowing. As a Niacin is used as adjunctive therapy for lowering very high result, blood flows more easily through your vessels. serum triglyceride levels in patients who are at risk for pancreatitis and whose response to dietary control is ANTIHYPERLIPIDEMIC DRUGS inadequate. It is also used in combinations with other Hyperlipidemia is an increase in the lipids, which area group antihyperlipidemics in lipid lowering treatment. of fats or fat-like substances in the blood. Cholesterol and triglycerides are the 2 lipids in the blood. ANTIHYPERTENSIVE DRUGS Elevation of one or both of these lipids occurs in - are a class of drugs that are used to treat hypertension (high hyperlipidemia. blood pressure). Serum cholesterol levels above 250 mg/dl and the triglyceride Antihypertensive therapy seeks to prevent the complications of levels above 150 mg/dl are associated with Atherosclerosis high blood pressure, such as stroke and myocardial infarction. which is considered to be a major contributor in the development of heart disease. CLASSES OF BLOOD PRESSURE MEDICATIONS Low-density lipoprotein (LDL) transport cholesterol to the peripheral cells. a. Angiotensin-converting enzyme (ACE) inhibitors High-density lipoprotein (HDL) take cholesterol from the - are a class of medication used primarily for the treatment of peripheral cells and transport it to the liver, where it is high blood pressure and heart failure. metabolized and excreted. - They work by causing relaxation of blood vessels as well as a decrease in blood volume, which leads to lower blood pressure HMG-COA REDUCTASE INHIBITORS and decreased oxygen demand from the heart. - (3-hydroxy-3-methyglutaryl coenzyme A) Mechanism of action: ACE inhibitors produce vasodilation by - are typically referred to as Statins inhibiting the formation of angiotensin II. - These drugs appear to have one of two activities, namely, - This vasoconstrictor is formed by the proteolytic action of renin inhibiting the manufacturer of cholesterol or promoting the (released by the kidneys) acting on circulating angiotensinogen breakdown of cholesterol to form angiotensin I. Angiotensin I is then converted to angiotensin II by angiotensin converting enzyme - along with diet restricted in saturated fat and cholesterol are the treatment of hyperlipidemia. ACE inhibitors are contraindicated in patients with a history of angioedema or hypersensitivity related to treatment with an Adverse reactions: ACE inhibitor and those with hereditary or idiopathic o the statins are usually well tolerated when adverse angioedema. Should not be given to patients that are already reactions occur. Often mild and transient and do not taking a direct renin inhibitor such as aliskiren. required is continuing the therapy. These includes: headache, dizziness, insomnia, flatulence, Block box warning: Captopril, this medication may cause abdominal pain, cramping, constipation and nausea. fetal/neonatal morbidity/mortality if used in pregnancy HMG-CoA Reductase Inhibitors (STATINS) drugs: Give potassium supplements and potassium-sparing diuretics o Atorvastatin cautiously because ACE inhibitors can cause potassium o Fluvastatin retention and hyperkalemia. o Lovastatin Warn the patient to avoid potassium-containing salt o Pravastatin substitutes. Give captopril and moexipril 1 hour before meals. o Rosuvastatin withhold the dose and notify the prescriber if the patient o Simvastatin develops fever, sore throat, leukopenia, hypotension or tachycardia. BILE ACID RESINS Captopril may cause protein in the urine, reduced neutrophils Bile, which is manufactured and secreted by the liver and and granulocytes, rash, loss of taste, hypotension or a severe stored in the gallbladder, emulsifies fat and lipids as these allergic reaction. products pass through the intestines. Examples of ACE inhibitors include: Once emulsified, fats and lipids are readily absorbed in the o Benazepril intestine. o Captopril The bile acid resins bind to bile acids to form insoluble o Enalapril substances that cannot be absorbed by the intestine, so it is o Fosinopril secreted in the feces. With increased loss of bile acids, the o Lisinopril liver uses cholesterol to manufacture more bile. o Moexipril o Perindopril  o Quinapril o Nebivolol o Penbutolol b. Angiotensin II Receptor Blocking Agents o Pindolol Angiotensin II receptor blockers help relax your veins and o Propanolol arteries to lower your blood pressure and make it easier for o Sotalol your heart to pump blood. o Timolo Angiotensin is a chemical in your body that narrows your blood vessels. This narrowing can increase your blood pressure and d. Calcium Channel Blockers force your heart to work harder. Calcium-channel blockers as antihypertensive agents Indications: Like ACE inhibitors, they can also be used alone decrease blood pressure, cardiac workload, and myocardial for treatment of hypertension or in combination with other consumption of oxygen antihypertensive agents. Since these drugs can significantly decrease cardiac workload, Utilized in treatment of heart failure for patients who do not they are effective in treatment of angina. respond to ACE inhibitors. These drugs inhibit the movement of calcium ions across Assess for the mentioned contraindications to this drug (e.g. myocardia land arterial muscle cell membranes. As a result, drug allergy, hypovolemia, renal impairment, etc.) to prevent action potential of these cells are altered and cell contractions potential adverse effects. are blocked. Resultant effects include: depressed myocardial Obtain baseline status for weight, vital signs, overall skin contractility, slow cardiac impulse in conductive tissues, and condition, and laboratory tests like renal and hepatic function arterial dilation and relaxation tests, and serum electrolyte to assess patient’s response to Like ACE inhibitors and ARBs, they can also be used alone for therapy. treatment of hypertension or in combination with other By blocking the effects of angiotensin receptors in vascular antihypertensive agents endothelium, these drugs are able to slow down the progress Extended-release preparations are usually indicated for of renal disease in patients with type 2 diabetes and hypertensions in adults. hypertension. Children: calcium-channel blockers is the drug group that is Children: safety and efficacy of ARBs has not been established first considered in cases of hypertension in this age group that in this age group. needs drug therapy. Adults: ARBs are not allowed during pregnancy. Adults: these drugs are not allowed during pregnancy. Older adults: are more susceptible to drug toxicity because of Older adults: are more susceptible to drug toxicity because of underlying conditions that would interfere with metabolism and underlying conditions that would interfere with metabolism and excretion of drug. Renal and hepatic function should always be excretion of drug. Renal and hepatic function should always be monitored monitored. Examples of Angiotensin II Receptor Blocking Agents Nursing considerations: o azilsartan o Assess for the mentioned contraindications to this o candesartan drug (e.g. headache, rash, bradycardia, etc.) to o eprosartan prevent potential adverse effects. o irbesartan o Monitor cardiopulmonary status closely as the drug o telmisartan can cause severe effects on these two body o valsartan systems. o losartan o Monitor the ECG when therapy starts and when the o olmesartan dosage is adjusted. o If the patient's systolic pressure is below 90 mmHg c. Beta blockers or the heart rate drops below 60 beats/minute, - also known as beta-adrenergic blocking agents withhold the dose and notify the prescriber or follow - are medications that reduce your blood pressure. the ordered parameters for withholding the - work by blocking the effects of the hormone epinephrine, also medication. known as adrenaline o Advise the patient that fluid and sodium intake may - cause your heart to beat more slowly and with less force, need to be restricted to minimize edema. which lowers blood pressure. Examples of calcium channel blockers Nursing considerations: o Amlodipine o Safety measures to prevent orthostatic hypotension such o Felodipine. as changing positions slowly, hold onto railings when o Isradipine. using stairs o Nicardipine. o To check pulse rate and when to call HCP o Nifedipine o Common side effects as well as potential long term o Nisoldipine effects such as sexual dysfunction and depression. If any issues arise, discuss with HCP. e. Diuretics Drugs o Do not stop taking drug suddenly. Doing so may cause - any substance that promotes diuresis, the increased tachycardia, dysrhythmias, elevated BP, angina and MI. production of urine. o Always inform HCP before surgery or dental work they - includes forced diuresis. There are several categories of are on a beta-blocker diuretics. All diuretics increase the excretion of water from o Any chest pain experienced during activity should be bodies, although each class does so in a distinct way. discussed with the HCP so that safe activity levels can be - sometimes called water pills, help rid your body of salt discussed. (If they exercise regularly, their target heart (sodium) and water. Most of them help your kidneys release rate may need to be lowered) more sodium into your urine. The sodium takes with it water o Extended release forms of the drug should never be from your blood, decreasing the amount of fluid flowing crushed and taken. through your veins and arteries. o Obtain current BP and apical pulse rate; if below 90 - This reduces blood pressure. systolic or 60 beats per minute (BPM) hold the drug and notify the healthcare provider (HCP). Check your There are three types of Diuretics: institution’s policy, some say hold below 50BPM 1. Thiazide Monitor for side effects, especially orthostatic hypotension 2. Loop Monitor older pts for mental confusion or changes in LOC 3. Potassium sparing which may indicate an overdose o Each type affects a different part of your kidneys. Some Diabetics are not usually given beta-blockers because they pills combine more than one type of diuretic or combine a can effect the blood glucose level and because the drugs will diuretic with another blood pressure medication. mask the cardiovascular effects of hypoglycemia such as o Which diuretic is best for you depends on your health and tachycardia, mild tremors and diaphoresis. If your patient is a the condition being treated diabetic and on a beta-blocker monitor closely for signs of hypoglycemia unique to the patient and monitor blood glucose Increased Intraocular Pressure: Monitor for persistent or frequently increased eye pain or decreased visual acuity. Patients with COPD (including asthma) should be monitored Lab Test Considerations: Monitor electrolytes (especially closely for respiratory issues such as wheezing and difficulty potassium), blood glucose, BUN, and serum uric acid levels breathing (remember what beta- blockers block– before and periodically throughout course of therapy. bronchodilation) They should not be given nonselective beta- When administering Furosemide: Assess fluid status. Monitor blockers. daily weight, intake and output ratios, amount and location of Drug Names of Beta-blockers include: edema, lung sounds, skin turgor, and mucous membranes. o Acebutolol Notify health care professional if thirst, dry mouth, lethargy, o Atenolol weakness, hypotension, or oliguria occurs. Monitor BP and o Betaxolol pulse before and during administration o Bisoprolol Examples of oral thiazide diuretics include: o Carteolol o Chlorothiazide (Diuril) o Carvedilol o Chlorthalidone o Labetalol o Hydrochlorothiazide (Microzide) o Metoprolol o Indapamide o Nadolol o Metolazone - are recommended as one of the first drug treatments for high blood pressure. Examples of loop diuretics include: o Bumetanide (Bumex) o Ethacrynic acid (Edecrin) o Furosemide (Lasix) o Torsemide (Demadex) Examples of potassium-sparing diuretics include: o Amiloride o Eplerenone (Inspra) o Spironolactone (Aldactone, Carospir) o Triamterene (Dyrenium) If diuretics aren't enough to lower your blood pressure, your doctor might add other blood pressure medications to your treatment plan. Diuretics are also used to prevent, treat or improve symptoms in people who have: o Heart failure o Liver failure o Tissue swelling (edema) o Certain kidney disorders, such as kidney stones ANTICOAGULANT DRUGS - are medicines that prevent the blood from clotting as quickly or as effectively as normal. - Some people call anticoagulants blood thinners. - are used to treat and prevent blood clots that may occur in your blood vessels. Blood clots can block blood vessels (an artery or a vein). - are medicines that help prevent blood clots. They're given to people at a high risk of getting clots, to reduce their chances of developing serious conditions such as strokes and heart attacks. A blood clot is a seal created by the blood to stop bleeding from wounds. Patients on anticoagulant therapy must be educated about their increased risk for bleeding, monitoring for bleeding, managing bleeding if it occurs, and drug-specific information. Sometimes it clots too much, putting the patient at risk of complications such as strokes or heart attacks. Anticoagulant drugs are used to reduce the ability of the blood to clot Examples of anticoagulants include: o aspirin, heparin and warfarin. ANTIPLATELET DRUGS - also known as a platelet agglutination inhibitor or platelet aggregation inhibitor, - is a member of a class of pharmaceuticals that decrease platelet aggregation and inhibit thrombus formation - are effective in the arterial circulation, where anticoagulants have little effect. - are medicines that stop cells in the blood (platelets) from sticking together and forming a clot. A blood clot can lead to a heart attack or stroke Aspirin is the most common antiplatelet. At a low dose, aspirin reduces inflammation in the arteries Nursing interventions: o Obtain baseline status for complete blood count and clotting studies to determine any potential adverse effects. Administer drug with meals to relieve GI upset. o Provide comfort measures for headache because pain due to headache may decrease patient compliance to treatment regimen. o Educate patient on ways to promote safety like using electric razor, soft-bristled toothbrush, and cautious movement because any injury at this point can precipitate bleeding. o Educate patient on drug therapy including drug name, its indication, and adverse effects to watch out for to enhance patient understanding on drug therapy and thereby promote adherence to drug regimen. o It is also important that adults are educated on what to do should bleeding occurs (e.g. applying firm pressure) as well as what signs of bleeding should be watched out for. o Other drugs taken should be documented because there are a lot of drug interactions with these drug class. It should also be emphasized that periodic blood tests is expected to monitor the effect of therapy. Antiplatelets drugs: o ASA, also called acetylsalicylic acid (Aspirin, Asaphen,Entrophen, Novasen) o Clopidogrel o Prasugrel o Ticagrelo  bronchitis, influenza, sinusitis, bronchial LESSON 4: RESPIRATORY AGENTS asthma and emphysema. ANTITUSSIVE INDICATIONS Symptomatic relief of respiratory conditions characterized by a dry, nonproductive cough - A drug used to relieve coughing CONTRAINDICATIONS Allergy - A medication often recommended for the treatment of cough Pregnancy or lactation and associated respiratory tract disorders Cough - Act on the cough-control center in the medulla to suppress the ADVERSE EFFECTS GI: Nausea, vomiting, anorexia. cough reflex; CNS: Headache, dizziness. - May be taken if cough is non-productive and irritating Underlying cough: The most important consideration in the use of these drugs is DESIRED ACTIONS Acts directly on the medullary cough center discovering the cause of the underlying of the brain to depress the cough reflex. cough; prolonged use of the OTC Because they are centrally acting, they are preparations could result in the masking of not the drugs of choice for anyone who has important symptoms of a serious underlying a head injury or could be impaired by disorder. central nervous system depression Respiratory: Rhinorrhea, bronchospasm. INDICATIONS Local anesthetic on the respiratory Skin: Rash. passages, lungs, and pleurae, blocking the o Guaifenesin isn't known to have effectiveness of the stretch receptors that specific drug interactions. stimulate a cough reflex. Adverse reactions include: vomiting, For relief of moderate to moderately severe diarrhea, drowsiness, nausea, abdominal pain. pain, headache, and hives or skin rash. For the treatment of dry cough, drug NURSING Proper administration withdrawal syndrome, opioid type drug CONSIDERATIONS Prevent GI upset dependence, and pain. Ensure safety ADVERSE EFFECTS CNS: Drowsiness and sedation. Avoid overdosage GI: Nausea, constipation, dry mouth, GI Provide health education upset Offer support CONTRAINDICATIONS Patent airways AND CAUTIONS Asthma and emphysema ANTIHISTAMINES Addiction - drugs which treat allergic rhinitis and other allergies Sedation Typically, people take antihistamines as an inexpensive, Pregnancy generic, over-the counter drug that can provide relief from INTERACTIONS Monoamine oxidase inhibitors (MAOI). INVOLVED Dextromethorphan should not be used with nasal congestion, sneezing, or hives caused by pollen, dust MAOIs because hypotension, fever, mites, or animal allergy with few side effects. nausea, myoclonic jerks, and coma could Antihistamines are divided into two major subtypes: occur օ H-1 receptor antagonists or H-1 blockers. ASSESSMENT AND Assess for possible contraindications and օ H-2 receptor antagonists or H-2 blockers HISTORY TAKING cautions (e.g., history of allergy to the drug, cough for more than 1 week, and H-1 ANTIHISTAMINES TREAT: H-2 ANTIHISTAMINES TREAT: pregnancy and lactation). Allergic rhinitis/hay fever. Heartburn. Perform a physical examination to Allergic conjunctivitis. Gastroesophageal reflux establish baseline data. Hives and other skin disease (GERD). Monitor the temperature to evaluate for rashes. Duodenal and gastric possible underlying infection. Colds. ulcers. Assess respirations and adventitious Food allergies. Zollinger-Ellison syndrome sounds. Hypersensitivity to certain Evaluate orientation and effect drugs. Insect bites and stings. MUCOLYTIC First-generation H-1 antihistamines - is a drug that breaks down thick, tenacious mucus in the lower also treat: portions of the lungs Insomnia. - are medicines that thin mucus, making it less thick and sticky Motion sickness. and easier to cough up Anxiety. - used to treat respiratory conditions characterized by excessive or thickened mucus, such as a chesty (productive) cough OTC antihistamines include: Brompheniramine (Dimetane) ACTIONS a drug with mucolytic activity appears to reduce the Cetirizine (Zyrtec) viscosity(thickness) of respiratory secretions by direct Chlorpheniramine (Chlor-Trimeton) action on the mucus Clemastine (Tavist) ADVERSE headache, nausea, vomiting, gastric discomfort and EFFECTS bleeding, diarrhea, and rash. Diphenhydramine (Benadryl) It has, however, been shown to be an effective mucolytic Fexofenadine (Allegra) which is generally well tolerated with few adverse effects Loratadine (Alavert, Claritin) MORE COMMON Mucinex (guaifenesin) TYPES Carbocisteine DECONGESTANTS Pulmozyme (dornase alfa) - decrease the overproduction of secretions by causing local Erdosteine vasoconstriction to the upper respiratory tract Mecysteine o This vasoconstriction leads to a shrinking of swollen Bromhexine mucous membranes and tends to open clogged Hyperosmolar saline nasal passages, providing relief from the discomfort Mannitol powder of a blocked nose and promoting drainage of VARIOUS TYPES Expectorants AND ITS - increase airway water to help with mucus secretions and improved air DIFFERENT clearing. - are a type of medicine that can provide short-term relief for a ACTIONS Mucoregulators blocked or stuffy nose (nasal congestion). - increase the movement of mucus via cough. - can help ease the symptoms of conditions such as colds and Mucokinetics flu, hay fever and other allergic reactions, catarrh and sinusitis - suppress the mechanisms causing excess mucus secretions. CLASSIFICATIONS NURSING Ensure drug effectiveness. INTERVENTIONS Prevent skin breakdown. TOPICAL NASAL ORAL TOPICAL STEROID Proper use of nebulizer. Indications: Indications: Indications: Proper storage. Relieves discomfort of Decreases nasal Treatment of seasonal Provide health education. nasal congestion congestion associated allergic rhinitis in Provide support. associated with the with the common cold, patients who are not common cold, sinusitis, allergic rhinitis. obtaining a response EXPECTORANTS allergic rhinitis. Relief of pain and with other - a drug that thins respiratory secretions to remove them more Relieves pressure of congestion of otitis decongestants or easily from the respiratory system otitis media media. preparations. Relieves inflammation The most commonly used expectorant is Guaifenesin, a following removal of common component of OTC for cold and flu medications. nasal polyps. օ Guaifenesin ▪ is absorbed through the GI tract, ADVERSE EFFECTS Rebound congestion metabolized by the liver, and excreted Topical nasal decongestants primarily by the kidneys. Oral decongestants ▪ helps make mucus easier to cough up and Topical nasal steroids decongestant is used for the relief of symptoms caused CONTRAINDICATIONS Caution must be used when there is by productive cough from many disorders AND CAUTIONS lesion or erosion in the mucous such as colds, minor bronchial irritation, membrane that could lead to systemic  absorption. Use of inhalator Caution should also be used in Educate the patient patients with any condition that might Provide patient support be exacerbated by sympathetic activity. If used during pregnancy or lactation, caution is advised. Caution should be used in any patient who has an active infection, including tuberculosis because systemic absorption would interfere with the inflammatory and immune response HISTORY TAKING Assess for possible cautions and AND EXAMINATION contraindications Perform a physical examination Assess skin color and temperature Evaluate orientation and reflexes Monitor pulse, blood pressure, and cardiac auscultation Evaluate respirations and adventitious breath sounds Evaluate nasal mucous membrane Monitor urinary output Monitor temperature NURSING Proper administration INTERVENTIONS Proper technique Duration of intake Avoid overdosage Safety measures Comfort measures Patient teaching Provide support Ensure compliance Monitor for infection BRONCHODILATORS - are a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways (bronchi) - often used to treat long-term conditions where the airways may become narrow and inflamed, such as: asthma – a common lung condition caused by inflammation of the airways Bronchodilators may be either: o short-acting o long-acting The 3 most widely used bronchodilators are: o Beta-2 agonists, such as salbutamol, salmeterol, formoterol and vilanterol o Anticholinergics, such as ipratropium, tiotropium, aclidinium and glycopyrronium o Theophylline ANTIASTHMATIC DRUGS - are medicines that treat or prevent asthma attacks Three types of drugs are used in treating and preventing asthma attacks: o Bronchodilators relax the smooth muscles that line the airway. o Corticosteroids block the inflammation that narrows the airways. o Cromolyn also is taken regularly to prevent asthma attacks and may be used alone or with other asthma medicines PRECAUTIONS Using antiasthmatic drugs properly is important. Parents whose children are using their antiasthmatic drugs correctly but feel their asthma is not under control should see consult their child's physicians. Corticosteroids are powerful drugs that may cause serious side effects when used over the long term. When used to prevent asthma attacks, cromolyn must be taken as directed everyday. HISTORY TAKING Assess for possible contraindications or AND ASSESSMENT cautions Perform a physical examination Perform a skin examination, including color and the presence of lesions Monitor blood pressure, pulse, cardiac auscultation, peripheral perfusion, and baseline electrocardiogram Assess bowel sounds and do a liver evaluation and monitor liver and renal function tests Evaluate serum theophylline levels Evaluate urinary output and prostate palpation as appropriate Evaluate orientation, affect, and reflexes NURSING Relieve GI upset INTERVENTIONS Monitor drug response Provide comfort Provide follow-ups Individual drug response Proper administration and dosage Proper use of sympathomimetics Use of adrenergic blockers Increase oral fluid intake Encourage voiding Small, frequent meals