902 Midterm Review PDF

902 MIDTERM REVIEW - HUY PHAN - I. ANTIBACTERIAL DRUGS A. Cell wall inhibitors (bind to penicillin-binding proteins and block cell wall formation) Penicillin Natural penicillins can...

902 MIDTERM REVIEW - HUY PHAN - I. ANTIBACTERIAL DRUGS A. Cell wall inhibitors (bind to penicillin-binding proteins and block cell wall formation) Penicillin Natural penicillins can active against gram+ cocci and gram+ rods, against Spirochetes (T Penicillin V palladium), against most anaerobes (except Prevotella/Bacteroides), NOT active against β- lactamase producing strains or those with highly altered PBPs (resistant pneumococci). Penicillin would NOT treat atypicals. Absorption impaired by food except amoxicillin. Elimination primarily through kidneys. Levels raised by probenecid which decreases excretion of penicillin by interfering with the kidney’s organic anion transporter - increased half-life of penicillins. Toxicities: Nausea, Vomiting and Diarrhea, Hypersensitivity reactions (type I reaction), Seizures (high doses can cause seizure in renal failure), Pseudomembranous colitis. Aminopenicillins Active against gram-positive and gram-negative organisms Amoxicillin β-Lactamase susceptible Action enhanced when combined with inhibitors of β-lactamase (ie, clavulanic acid and sulbactam). Toxicities: Hypersensitivity, Pseudomembranous colitis (esp Ampicillin), Diarrhea (Amoxicillin- clavulanate) Cephalosporins Spectrum of Activity: higher-number generations tend to decrease activity against gram (+) but st Cephalexin 1 increase in gram (-) activity. nd Cefuroxime 2 Cephalosporin would NOT treat atypicals and enterococcus. rd Cefdinir 3 DIs: can enhance aminoglycoside nephrotoxicity. Toxicities: allergy but different from penicillins - some cross reactivity (1st), local irritation (IM), renal toxicity, Disulfiram-like reactions. B. Protein Synthesis Inhibitors: Buy AT 30, CELL at 50 (“Buy at 30, Sell at 50.”) 30s ribosomal subunit inhibitors: Aminoglycosides, Tetracyclines. 50s ribosomal subunit inhibitors: Chloramphenicol, Macrolides (e.g., Erythromycin), Linezolid, CLindamycin. Aminoglycosides Bactericidal with prolonged post-antibiotic effect (PAE). Tobramycin Neomycin - mostly topical use Broad spectrum: against aerobic gram- rods (and gram + cocci with cell wall inhibitors) - Synergistic action Toxicities: Nephrotoxicity, Ototoxicity, Vestibular toxicity, Neuromuscular blockade CI: Myasthenia gravis Tetracyclines Broad-spectrum Bacteriostatic Doxycycline Minocycline Concentrated several folds in the gingival fluid; useful for periodontal disease. Absorption impaired by milk and milk products and divalent and trivalent cations. Toxicities: GI upset, Bone/Teeth: Binding to bone and teeth with permanent discoloration of teeth in children. Possible deformity- inhibit bone growth, Phototoxic dermatitis, Superinfections Contraindicated in pregnant and nursing women. Macrolides and related compounds Bacteriostatic or bactericidal depending on organism/conc. Erythromycin Azithromycin Gram + organisms especially in penicillin hypersensitivity. Greatest use in upper respiratory infections like CAP, MAC in AIDS patients. Inhibit CYP450 except azithromycin. Toxicities: Cholestatic hepatitis, Prolonged QT (torsade de pointes), GI toxicity, thrombophlebitis. CLindamycin Spectrum: gram + and anaerobes infections Streptococci, staphylococci. Alternative to penicillin for endocarditis prophylaxis. Toxicities: Nausea & Diarrhea, Pseudomembranous entercolitis BB Miscellaneous Bactericidal drugs that disrupt the outer cell membrane of gram-negative rods. Polymyxin B Toxicities: Nephrotoxicity, Neurotoxicity. C. Inhibitors of Nucleic Acid Synthesis and Metabolism Sulfonamides and Trimethoprim Sulfonamides are synthetic analogs of PABA. Sulfamethoxazole (Sulfonamides) Sulfonamides inhibit dihydropteroate synthase - Pyrimidines inhibit dihydrofolate reductase. Sulfacetamide They inhibit folic acid synthesis and DNA synthesis. Trimethoprim (Pyrimidines) Bactericidal: Synergistic effect with trimethoprim and pyrimethamine. Trimethoprim-sulfamethoxazole: Drug of choice for urinary, respiratory tract infections and Sulfamethoxazole-trimethoprim* traveler’s diarrhea. Used for Pneumocystis jirovecii pneumonia. TMP- SMX: not affected by food. Urinary excretion Dose adjustment with creatinine clearance less than or = 30mL/min Toxicities: Most common: GI and skin-Hypersensitivity: rashes, fever; Stevens-Johnson syndrome; Hematological reactions: hemolytic aplastic anemia (Glucose-6-phosphate dehydrogenase deficiency), Hyperkalemia. Fluoroquinolones (-floxacin) Inhibit topoisomerase II and IV. Ciprofloxacin Levofloxacin Relax positive supercoils and interfere with chromosome separation. Moxifloxacin Bactericidal: gram (-) activity Ofloxacin Treat: Anthrax, UTIs and respiratory tract infections, MDR TB, anaerobes (moxifloxacin) Good oral bioavailability, Renal elimination. Theophylline interaction (with ciprofloxacin). Toxicities: Gastrointestinal (nausea, vomiting, pain), damage to growing cartilage (not recommended for use in children), tendon rupture (elderly) BB, QTc prolongation, peripheral neuropathy warning for class.  II. ANTIVIRAL DRUGS HSV/VZV Acyclovir Acyclovir Valacyclovir § MOA: Guanosine analogs which are phosphorylated by viral thymidine kinase, accumulate in infected cells and inhibit viral DNA polymerase, incorporation into DNA results in chain termination. § Acyclovir is used for mucocutaneous (including oral hairy leukoplakia related to EBV). Influenza Oseltamivir/Zanamivir Oseltamivir § Influenza A/B has a unique, highly conserved neuraminidase enzyme which catalyzes the removal of sialic acid from glycoproteins and glycolipids, facilitating virus release. § Oseltamivir and Zanamivir are analogs of sialic acid and inhibit viral neuraminidase. III. ANTIFUNGALS Azoles (-conazole) Inhibit a fungal P450 enzyme 14α- sterol demethylase for the synthesis of membrane ergosterol. Ketoconazole* Clotrimazole Used for systemic fungal infections (candida, aspergillus, cryptococcus, blastomyces). Systemic treatment for oral candidiasis in immuno- compromised patients. Allylamines Drug of choice for fungal nail infections and skin infections. Terbinafine Topical Indications—superficial local infections, drug of choice for oral candidiasis. Nystatin Clotrimazole IV. ANTIPROTOZOALS AND ANTIHELMITHICS Hydroxychloroquine Antimalarials: Inhibitors of Heme Metabolism Metronidazole Damage DNA, loss of helical structure and strand breakage. Active against Protozoa and used in oral infections. Avoid ETOH: has disulfiram-like properties. Can cause metallic taste. V. CNS DRUGS – ANXIETY Benzodiazepines (Acute) Site of action is the GABAA –receptor complex Diazepam Lorazepam Treat anxiety disorders of all types –acute attacks Clonazepam Lorazepam - phase II metabolism Alprazolam DIs: most via combined CNS depression or CYP450 interactions Toxicities: Memory impairment, Syncope (older patients), Physical and psychological dependence, GI- occasional dry mouth Major Drug Interactions: § Drugs that inhibit CYP450’s o Erythromycin, calcium channel blockers, Cimetidine. o Antifungals (itraconazole, ketoconazole) and antiretroviral drugs used for HIV infections and AIDS. § Drugs that induce CYP450’s o Phenobarbital, phenytoin, carbamazepine, rifampin, and St. John's wort SSRIs Selective serotonin reuptake inhibitors Paroxetine Fluoxetine Metabolized by CYP3A4 and CYP2D6 enzymes Sertraline Paroxetine and fluoxetine can inhibit CYP2D6 Escitalopram Citalopram Toxicities: Nausea, serotonin syndrome, sexual dysfunction, sedation, suicide risk: BB warning, xerostomia (paroxetine), QTc interval prolongation (Citalopram) SNRIs Block presynaptic reuptake by serotonin transporter (SERT) and norepinephrine transporter Duloxetine (NET) proteins. Venlafaxine Desvenlafaxine Duloxetine is a moderately potent inhibitor of hepatic CYP2D6 Atomoxetine Toxicities: Serotonin syndrome, sexual dysfunction, ­BP (monitor), Pseudoanti-cholinergic? Miscellaneous Buspirone Buspirone Promethazine § Partial agonist for 5-HT1A/2 receptors, action at DA2 receptors. § Not recommended for use with MAOIs - BP elevated § CNS side effects - dizziness, drowsiness, and dry mouth. VI. CNS DRUGS – MAJOR DEPRESSIVE DISORDER (MDD) TCAs Inhibits reuptake of both serotonin and norepinephrine. Amitriptyline Treatment - resistant depression. Nortriptyline Doxepin Toxicities: 3C’s: Cardiotoxicity, Coma, and Convulsions, anticholinergic and antihistaminergic effects. SSRIs and SNRIs Serotonin Syndrome § Clinical Features: tachycardia and hypertension, but severe cases may develop hyperthermia and dramatic swings in pulse and blood pressure - 3A’s o Agitation o Autonomic Stimulation (hyperthermia, diaphoresis, diarrhea) o Neuromuscular Activity (deep tendon hyperreflexia, bruxism, muscle and ocular clonus,) Neuroleptic Malignant Toxidrome has the same symptoms as Serotonin Syndrome except that Neuroleptic Malignant Toxidrome has no myoclonus. Atypical agents Bupropion Bupropion Mirtazapine § Weak inhibitor of DA & NE uptake § Treat tobacco dependence. § Weight loss and no sexual side effects. § Toxicities: CNS stimulation (tachycardia, insomnia), Xerostomia, BB: Suicidality Mirtazapine § Central presynaptic alpha 2-adrenergic antagonist - increased release of NE and SE. § Blocks 5-HT2, 5-HT3 receptors, histamine receptors. § Drowsiness, weight gain, xerostomia, increased appetite, constipation, BB: Suicidality. Serotonin modulators Antagonize postsynaptic serotonin receptors and inhibit reuptake of postsynaptic serotonin. Trazodone Toxicities: Sedation, Orthostatic hypotension, dry mouth, serotonin syndrome. BB: rare liver failure for nefazodone. VII. CNS DRUGS – BIPOLAR DEPRESSION Bipolar Lithium Lithium carbonate Valproate § Specific mechanism is unknown. Risperidone § Acute treatment of manic episodes and maintenance therapy for patients with a Quetiapine Aripiprazole diagnosis of bipolar disorder. § Ibuprofen (and other NSAIDs) can decrease lithium excretion. § Tremor, diarrhea, unsteady walking-, Hypothyroid goiter, Polyuria and thirst-, xerostomia, Complaints of metallic taste, Poor oral hygiene. Bipolar: Depressive episodes Bipolar: Maintenance Olanzapine/fluoxetine lithium carbonate Quetiapine lamotrigine olanzapine quetiapine aripiprazole VIII. CNS DRUGS – ANTIPSYCHOTICS Antipsychotics: 2nd gen or atypical Blockade of D2 and 5-HT2 receptors Olanzapine Risperidone Paliperidone - 80% renal excretion Quetiapine Toxicities: Metabolic: weight gain, diabetes, hyperlipidemia, hyperprolactinemia. Aripiprazole IX. CNS DRUGS – EPILEPSY Na+ channel blockers Lamotrigine Lamotrigine § Stevens-Johnson, serious skin rash (BB) GABA modulators (enhancers) Benzodiazepines diazepam clonazepam § Uncontrolled seizure disorders, status epilepticus (SE) lorazepam § 1st line: SE, breakthrough seizures-short-term. 2nd line: myoclonic, atonic, absence. Neuropathic pain Gabapentin Pregabalin  Disrupt vesicle storage Affects synaptic vesicle proteins, SV2A Levetiracetam Toxicities: Most common: somnolence, dizziness, fatigue and nausea, Psychiatric. Multiple MOAs Valproic acid Topiramate Valproate § Enhances GABA at several levels/ Blocks Na and Ca channels. § Sedation, GI upset, thrombocytopenia, weight gain, tremor, Hepatotoxicity (BB) idiosyncratic. § CI: women of childbearing potential (X) Topiramate § Blocks NaCh, AMPA/kainate, NMDA; enhances GABA effects § Toxicities: sedation, paresthesias. X. CNS DRUGS - PARKINSON DISEASE L-Dopa L-dopa + carbidopa Carbidopa/ Levodopa Anticholinergics Levophenidyl DA Receptor Agonists pramipexole  XI. CNS DRUGS - ALZHEIMER DISEASE/DEMENTIA Cholinesterase Inhibitors Toxicities: SLUDGE effects Donepezil XII. CNS DRUGS - SKELETAL MUSCLE RELAXANTS Centrally Acting Spasmolytics Baclofen Diazepam Tizanidine Cyclobenzaprine Methocarbamol XIII. CNS DRUGS – MIGRAINE Abortive Triptans acetaminophen and caffeine Sumatriptan Rizatriptan XIV. THYROID Hypothyroidism Levothyroxine Liothyronine Thyroid USP XV. ADRENAL Glucocorticoids MOA: Bind glucocorticoid receptor to regulate gene transcription. Hydrocortisone Prednisone Prednisolone Betamethasone Dexamethasone Triamcinolone XVI. ANTIDIABETIC DRUGS Rapid-acting Insulins Toxicities: Hypoglycemia, lipodystrophy, weight gain. Lispro-ultrashort Aspart Glulisine Short-Acting Insulins Regular insulin Intermediate Acting Insulins Insulin NPH Long-Acting Insulins Glargine Detemir Degludec Sulfonylureas/Sulfonamides: 2nd gen MOA: Stimulate insulin release by binding to a specific site on the β cell K ATP channel Glipizide Glimepiride complex (the sulfonylurea receptor, SUR) and inhibiting its activity. Toxicities: Hypoglycemia, weight gain. Biguanide MOA: Metformin Metformin + Glyburide § Increases the activity of the AMP-dependent protein kinase (AMPK). § Activated AMPK reduces lipogenesis and gluconeogenesis. § Lowers blood glucose by reducing hepatic glucose production and increasing peripheral glucose uptake. Besides treating Diabetes mellitus, it also treats the polycystic ovarian syndrome (PCOS) Toxicities: most common side effects: gastrointestinal- nausea, indigestion, abdominal cramps or bloating, diarrhea (dose-related). § BB: associated with lactic acidosis. § Vitamin B12 deficiency Glitazones/ Thiazolidinediones MOA: Ligands for the peroxisome proliferation activating receptor γ (PPARγ) receptors. Pioglitazone  Toxicities: Weight gain and edema, increased risk of bone fracture in women, monitor liver function. § BB: increased incidence of congestive heart failure (CHF) § CI: moderate to severe heart failure DPP4 Inhibitors MOA: increase insulin synthesis and release by inhibiting the inactivation of incretin hormones- Sitagliptin GLP-1 and GIP. Toxicities: headache, nausea, nasopharyngitis. GLP-1 Receptor agonists MOA: Synthetic GLP-1 receptor agonists. Liraglutide Dulaglutide Toxicities: predominantly gastrointestinal, particularly nausea, vomiting, and diarrhea. Semaglutide § Rare pancreatitis § CI: MEN2 SGLT2 inhibitors DIs: rifampin Dapagliflozin Empaglifozin Toxicities: Most common: genital mycotic infection, UTI and increased urination. § Special alerts: Bone fractures XVII. REPRODUCTIVE HORMONE Estrogens Clinical Applications: Contraception, Primary Hypogonadism, Postmenopausal Hormone Estradiol Ethinyl Estradiol replacement therapy (HRT). § DI: CYP450 Inducers § CIs: estrogen dependent cancers or high risk, liver disease, undiagnosed genital bleeding, thromboembolic disorders, pregnancy. Progestins Development and maintenance of endometrium for pregnancy. Progesterone Norethindrone Clinical applications: Hormone replacement, Contraception, Dysfunctional Uterine Bleeding. Norgestrel/ Norgestimate Levonorgestrel Medroxyprogesterone Etonogestrel Drospirenone  Androgens Clinical applications: Male hypogonadism Testosterone Toxicities: § In females, virilization. § In men, high doses can cause gynecomastia, testicular shrinkage, infertility. Antiandrogens Finasteride Finasteride § MOA: 5α-reductase inhibitors/ Inhibit conversion of testosterone to DHT § Clinical applications: Benign prostatic hyperplasia, Androgenetic alopecia. XVIII. BREAST CANCER Aromatase inhibitors Inhibition of estrogen production. Anastrozole Antimetabolites Folic acid analogue: Methotrexate Methotrexate Fluorouracil Pyrimidine analogues: 5-Fluorouracil (5-FU) XIX. ANTI-HEPERTENSIVE DRUGS Thiazide Diuretics Thiazide Diuretics __thiazide Hydrochlorothiazide § Target Na+/Cl– carrier (NCC) in the distal convoluted tubule (DCT). Chlorthalidone § Clinical applications: Hypertension, Nephrogenic diabetes insipidus § Toxicities: Hypokalemia, Hypercalcemia, Dehydration, Hyperglycemia, Dyslipidemia. Loop Diuretics __semide Loop Diuretics Torsemide § Target Na+/K+/2Cl– carrier (NKCC2 in the thick ascending limb (TAL) of the loop K+-sparing Diuretics of Henle. Na+-channel blocker Triamterene § Clinical applications: Severe Hypertension, Heart Failure, Edema: ascites, and acute pulmonary edema), Severe hypercalcemia. § Toxicities: Hypokalemia, Hypomagnesemia, Hypocalcemia, Hyperuricemia, Dehydration, Ototoxicity.  K+-sparing Diuretics § The aldosterone receptor and the sodium channels are sites of action of the potassium- sparing diuretics in cortical collecting tubule. § The potassium-sparing diuretics act by directly inhibiting the epithelial sodium channel. § Toxicities: Hyperkalemia RAAS Drugs Aldosterone antagonists Spironolactone ACE Inhibitors __pril Ramipril Enalapril Benazepril Lisinopril Angiotensin Receptor Blockers __sartan Losartan Valsartan Olmesartan Irbesartan Telmisartan Spironolactone acts by competing with aldosterone for binding to the mineralocorticoid receptor. ACE Inhibitors § Side effects: Bradykinin cough, Angioedema, Taste impairment. ***Contraindicated in pregnancy and bilateral renal artery stenosis to single kidney*** Angiotensin Receptor Blockers § Side effects: Hyperkalemia, Angioedema, Hypotension ***Contraindicated in pregnancy and bilateral renal artery stenosis to single kidney***  Sympatholytics Alpha1 Blockers (-zosin) § Side effect: Orthostatic hypotension Alpha-blockers __zosin § Treat BPH (Benign prostatic hyperplasia) Doxazosin Tamsulosin Nonselective beta-blockers side effects: § Bradycardia Beta-Blockers __olol § Heart block Nonselective § Bronchospasm Propranolol Timolol § Vasoconstriction § Mask symptoms of Hypoglycemia Cardioselective (β1) Atenolol Central Alpha2 Agonists side effects: Metoprolol § Hypotension Nebivolol Bisoprolol § Sedation § Dry mouth Alpha-Beta Blockers § Constipation i/a_lol § Urinary Retention Carvedilol Labetalol § Blurred Vision Review this chart: Central Alpha2 Agonists Clonidine Guanfacine  Vasodilators Dihydropyridine CCBs (Amlodipine) side effects: § Reflex tachycardia Direct Vasodilator NO-donating § Peripheral edema Sodium nitroprusside § Flushing Nitroglycerin Hydralazine § Gingival overgrowth Ranolazine Non-dihydropyridine CCBs (diltiazem and Verapamil) side effects: § Bradycardia (voltage-gated) Calcium Channel § Heart block Blockers § Peripheral edema Frequency-independent __dipine § Constipation Amlodipine Frequency dependent diltiazem verapamil Phosphosdiesterase Inhibitors Tadalafil XX. ANTIARRHYTHMICS DRUGS Class I: Sodium Channel Blockers Lidocaine Class II: Beta Adrenergic Adverse Effects Antagonists § Bronchospasm in asthmatic patients (β2-blocker) § Bradycardia/ AV heart block § Exercise intolerance, erectile dysfunction § May mask hypoglycemia in diabetics § Non-selective β-blockers and epinephrine can lead to hypertension and bradycardia Class III: K channel blockers Class IV: Calcium Channel Blockers XXI. ANTILIPIDEMICS DRUGS HMG-CoA Reductase Inhibitors Adverse effects of statin: __statins § Fatigue/reduced energy Lovastatin Simvastatin § Myopathy or severe rhabdomyolysis Rosuvastatin § Teratogenic, should be avoided during pregnancy, and breastfeeding Pravastatin § Metabolized by the CYP450 system, drugs or foods (eg, grapefruit juice) NPCL1 Inhibitor Inhibitor of Cholesterol Absorption. Ezetimibe Ezetimibe: a prodrug, converted in the liver to the active glucuronide form, inhibit a transporter NPC1L1 Fibrates Fibric Acid Derivatives (Fibrates): Gemfibrozil § Ligands for PPAR-α protein, a receptor that regulates transcription of genes involved in Fenofibrate lipid metabolism. Miscellaneous Icosapent ethyl XXII. COAGULATION DRUGS Antiplatelet Aspirin: Ticagrelor § Cyclooxygenase (COX) (irreversible) Anticlotting Drugs Rivaroxaban Warfarin (Coumadin) § Inhibits Factor Xa directly. Acetylsalicylic acid (Aspirin) Warfarin Adenosine diphosphate (ADP) § MOA: Inhibits Vitamin K epoxide reductase which is required for the carboxylation of receptor inhibitors Factors II (Thrombin), VII, IX, X and proteins S and C in the liver. -grel-, -grel Clopidogrel § Full anticoagulation after4-7days, heparin in parallel for immediate anticoagulation. § Anticoagulation level must be monitored regularly with PT/INR (should be 2-3). Newer oral anticoagulants (Factor Xa inhibitors)  Rivaroxaban Adenosine diphosphate (ADP) receptor inhibitors prevent ADP-mediated platelet aggregation Apixaban XXIII. GI DRUGS H2 Receptor Antagonists Absorption reduced by antacid but not food. Famotidine Toxicities: B12 deficiency with chronic use Proton Pump Inhibitors (PPIs) -prazole Inhibit active H+/K+ ATPase pumps. Omeprazole Treat Peptic Ulcer Disease Esomeprazole Lansoprazole Dexlansoprazole Pantoprazole Sucralfate MOA: not clear but appears to form a protective coating. XXIV. ANTIEMETICS Antihistamines MOA: Antagonize H1 receptors. May also affect M1 Diphenhydramine Prevention or treatment of motion sickness Meclizine Promethazine Serotonin Receptor Antagonists Primary agents for chemotherapy-induced nausea and vomiting (CINV) and prophylaxis Ondansetron N & V from GI disorders Postoperative or postradiation N & V Dopamine Receptor Antagonists Metoclopramide Promethazine XXV. PULMONARY DRUGS: ASTHMA & COPD Beta-Adrenergic Bronchodilators Corticosteroids, Inhaled Ultrashort-acting Fluticasone Epinephrine Budesonide Triamcinolone  Short-acting Albuterol Long acting Salmeterol/Formoterol Vilanterol Anticholinergic Bronchodilators Antileukotrienes Short-acting Montelukast Ipratropium/Ipratropium and albuterol Long acting Umeclidinium XXVI. CANCER CHEMOTHERAPY Antimetabolites Hormonal Agents Folic acid analogue Prednisone Methotrexate Antihormonal Agents Pyrimidine analogues Aromatase inhibitors 5-Fluorouracil Anastrazole XXVII. INFLAMMATORY DISEASES Antihistamines (H1) Decongestants First generation Pseudoephedrine Diphenhydramine (BENADRYL) Chlorpheniramine Hydroxyzine Meclizine Promethazine Second generation Cetirizine Loratadine Fexofenadine Olopatadine XXVIII. GOUT Microtubule assembly inhibitor Xanthine oxidase inhibitors Colchicine Allopurinol XXIX. NSAIDs Salicylates NSAIDs: inhibits the enzyme cyclooxygenase (COX 1/2), which is responsible for converting Aspirin arachidonic acid into prostaglandins, thromboxane, and prostacyclin. Acetic Acid derivatives Aspirin: irreversible inhibitor COX 1. Ketorolac Indomethacin Toxicities: effects on bone and teeth, platelet function, perfusion of kidneys, and mucous production Diclofenac of GI. Propionic Acid derivatives Notes: Acetaminophen acts as inhibition of prostaglandin synthesis in the CNS (not periphery), Ibuprofen suppresses pain and fever but not inflammation. It is NOT an NSAID. Acetaminophen can cause Naproxen hepatotoxicity. Fenamates Nabumetone Cox-2 Selective Meloxicam Celecoxib XXX. GLUCOCORTICOIDs Prednisone MOA: decreases transcription of pro-inflammatory cytokines and increases effects of anti- Prednisolone Dexamethasone inflammatory cytokines. Hydrocortisone MOA: binds glucocorticoid receptor to regulate gene transcription, inhibits phospholipase A to Fluocinonide (topical) prevent production of arachidonic acid pathway products, inhibits nuclear factor kapa-light-chain- enhancer of activated B cells (NF-kB). XXXI. OPIOIDs Phenanthrenes Codeine: a prodrug that is less efficacious than morphine. Morphine/ Hydromorphone Morphine, Hydromorphone, Oxycodone: mu receptor agonists (moderate to strong), schedule II. Codeine Phenanthrenes: Semi-synthetic derivatives Oxycodone Other Analgesics Tramadol: moderate mu agonist, moderate SERT inhibitor, weak NET inhibitor, schedule IV. Tramadol XXXII. MISCELLANOUS FROM DRUG LIST Antihistamine Azelastine (an intranasal spray for the treatment of allergic and vasomotor rhinitis) Ketotifen (treat allergic symptoms) Brompheniramine-dextromethorphan-pseudoephedrine (combination of an antihistamine, decongestant, and cough suppressant). Cyproheptadine (a combined serotonin and histamine antagonist used in the treatment of allergic symptoms) Antitussives (cough suppressants) Benzonatate Pseudoephedrin Glaucoma medications Bimatoprost Latanoprost Brimonidine Vitamins and Supplements Calcitriol Ergocalciferol Tretinoin (Vitamin A) Thiamine (Vitamin B1)  Ascorbic acid (Vitamin C) Cholecalciferol (Vitamin D3) Folic acid (Vitamin B9) Cyanocobalamin (Vitamin B12) Calcium Phosphate Ferrous sulfate (treat iron-deficiency anemia) Omega-3 acid ethyl esters Potassium chloride Magnesium Salts Sodium Salts CNS Stimulants Dexmethylphenidate (treat ADHD). Amphetamine and dextroamphetamine (treat narcolepsy and ADHD). Methylphenidate (treat narcolepsy and ADHD). Lisdexamfetamine (treat eating disorder) Irritable bowel syndrome (IBS) Drugs Linaclotide (increased levels of extracellular cGMP in submucosa inhibit colonic nociceptors and relieve abdominal pain). Dicyclomine Laxative Drugs Lactulose (Constipation Treatment) Polyethylene glycol Senna/Docusate/sennosides Immunosuppressive agents Mycophenolate Cyclosporine and cyclosporine Insomnia Medication Melatonin Zolpidem Anticholinergics/antimuscarinics Oxybutynin (relaxing the bladder muscles) Mirabegron (relaxing the bladder muscles) Solifenacin (relaxing the bladder muscles)  Atropine/diphenoxylate (antidiarrheal agents) Loperamide (antidiarrheal agents) Others Adalimumab: tumor necrosis factor (TNF) inhibitors. Adapalene: a topical retinoid for treating acne vulgaris. Benzoyl peroxide: a topical antibiotic that is an antibacterial and anti-inflammatory agent. Alendronate: a bisphosphonate that inhibits osteoclastic bone resorption. Azelate/Azelaic acid: a dicarboxylic acid that treats rosacea by decreasing the swelling and redness of the skin. Chlorhexidine: an antimicrobial biguanide. Ciclopirox: an antifungal. Guaifenesin: an expectorant that works by thinning the mucus in the air passages to make it easier to cough up the mucus and clear the airways. Dorzolamide: a topical carbonic anhydrase inhibitor. Timolol: a topical beta blocker. Dorzolamide and timolol lowers pressure in the eye by decreasing the production of natural fluids in the eye. Isosorbide: a nitrate that treats and prevents angina pectoris in patients with coronary heart disease. Pancrelipase: contains a mixture of digestive enzymes (eg, lipases, proteases, and amylases) needed for the digestion of proteins, starches, and fats. Silver sulfadiazine: a sulfa antibiotic. Hydroquinone: a topical depigmenting agent that used to correct skin discoloration associated with disorders of hyperpigmentation.