Pharm 210 Final PDF

Long-term treatment of corticosteroids corticosteroids are frequently used to - suppress the inflammatory process - decrease the immune process patients on long-term steroid therapy - leads to afrenal atrophy from lack of stimulation - avoid LIVE vaccines (attenuated) - report wt gain over 2lbs in...

Long-term treatment of corticosteroids corticosteroids are frequently used to - suppress the inflammatory process - decrease the immune process patients on long-term steroid therapy - leads to afrenal atrophy from lack of stimulation - avoid LIVE vaccines (attenuated) - report wt gain over 2lbs in ONE day - oral route best option for chronic vs acute higher doses = faster atrophy og adrenal (2-4 weeks) Adverse effects of chronic corticosteroids 1. suppression of immune system 2. decreased inflammatory responses 3. GI bleeds/peptic ulcers 4. osteoporosis 5. behavioural changes 6. metabolic changes/fat redistribution and fluid retention replacement therapy with glucocorticoids - drug interactions potassium-wasting drugs anticholinesterase agents no LIVE vaccines toxoids insulin and oral alow, senna, cascara, buckthorn Increases effect of: erythomycin, ketoconazole Decreases effectiveness of: salicyclates, barbiturates, phenytoin, rifampim Physiology of the thyroid gland low blood levels trigger negative feedback loop hypothalamus (TRH - thyrotropin-releasing hormone) Anterior pituitary (TSH - thyroid-stimulating hormone) Thyroid (T3 and T4) Diagnosis of thyroid disorders TSH is preffered lab value - low TSH = GOOD! Primary hypothyroidism - low serum T4 - elevated TSH Hashimoto thyroiditis - abnormal levels of antithyroid antibody Pharmacotherapy of hypothyroid disorders - drug interactions phenytoin - accelerates the metabolism of levo pharmacotherapy of hypothyroid disorders - food interactions soybean flour walnuts fiber dairy calcium iron supplements strawberries peaches pears cabbage/brussel sprouts cauliflower turnips/radishes spinach pharmacotherapy of hypothyroid disorders watch for S&S assess vital signs and cardiovascular status if catecholamines are used concurrently (think BEAR) monitor patients who are taking warfarin for bleeding monitor monthly height and weight, growth and development and intellectual function in infants treated for thyroid deficiency monitor blood glucose levels if the pt is diabetic Gingko Biloba Label flavones of gingko can be dangerous to patients on anticoagulants Natural does not alsways mean safer some active chemicals are the same strength as in prescription and OTC meds can allergic reactions occur with the use of natural products? they do not necessarily have fewer SE they are not alwasy less expensive they can reduce the need for prescriptive meds Herb-Drug Interactions - Ginseng Ginseng - decreased: BS, stress, BP, sexual dysfunction - increased: energy Insulin and Oral hypoglycemic agents - increased: CNS depressants, anticoagulants - decreased: morphine Herb-Drug Interactions- Ginkgo-biloba Ginkgo-biloba - antioxidant increased: blood flow, memory decreased: BP Tricyclic antidepressants - risk of Serotonin Syndrome increased: anticoagulants decreased insulin levels in diabetics Herb-Drug Interactions- black licorice regulates hormones - decreases: stress, fat large amounts (x 4 wks +) = HA, increased BP, decreased K (*Dangerous) Increased: dig, aspirin GI irritation, steroids, K loss with laxatives Herb-Drug Interactions- ginger decreased: nausea, IBS, stomach issues, inflammation increased: anticoagulants Herb-Drug Interactions- feverfew decreased: fever, inflammation, migraines/dizziness, N/V, tinnitus, BP increased: anticoagulants, NSAIDS Herb-Drug Interactions- garlic thins blood increases: immunity, anticoagulants decreases: Chol Herb-Drug Interactions- valerian sleep disorders decreases: anxiety, BP increases: CNS depressants (benzos, barb, anticonvulsants, sedatives) Herb-Drug Interactions- Kava Kava sleeping problems decreased: stress/anxiety, convulsions, relaxes muscles increased: CNS depressants, Adderall, 5-HTPs Herb-Drug Interactions- st john's wort decreased: depression and anxiety, insomnia increased: appetite, CNS depressants Herb-Drug Interactions- Melatonin decreased: insomnia, antidepressent effects of desipramine and fluoxetine (Prozac) CCB may decrease melatonin Herb-Drug Interactions- Saw Palmetto decreased: BPH, urinary retention, nocturia and assists in initiating urination* decreased: absorption of iron, oral contraceptives hormon like effect - avoid in pregnancy, lactation and hormone sensitive cancers Do not take with finasteride (proscar) - similar effect Herb-Drug Interactions- turmeric decreased: inflammation, tumors, infections, stomach problems * enhances anticoagulants decreased PPIs and H2 blockers = increased stomach acid Vitamin K (AquaMEPHYTON) helps produce RBC and synthesize clotting factors used to treat neonatal hemorrhagic disease drug of choice as antidote for warfarin overdose takes 3-8hrs to stop bleeding* Pyridoxine: Vitamin B6 caution with Parkinson's medications - decreases efficacy drug interactions - effects of levodopa Ascorbic Acid: Vitamin C enhances iron absorption - used to enhance wound healing Renal Physiology kidneys are major organs of excretion and homeostasis role of the kidney in homeostasis - fluid balance (think HR/BP) - electrolyte balance (think arrhythmias) - acid-base balance (think K+/H+) endocrine functions of the kidney - renin - erythropoietin - calcitrol (Vit D) Diuretic Therapy desirable for: edema hypertension heart failure renal failure liver failure or cirrhosis pulmonary edema Common adverse effects: - electrolyte imbalances (esp. K+) - dehydration - hypotension (monitor BP?HR) Loop (High Ceiling) Diuretics Block Na+ reabsorption at loop of Henle either oral or parenteral administration extensively bound to plasma proteins indications = edema Loop (High-Ceiling) Diurectics - considerations complete health history monitor VS (apical HR, rhythm, and BP) establish safety precautions observe older adults carefully ensure ready access to bathroom administer early in day watch K+ levels! Loop (High-Ceiling) Diurectics - drugs similar to furosemide (Lasix) Bumetanide (Bumex)* - ascites, peripheral edema Ethacrynic Acid (Edecrin) - can be used in pts allergic to sulfonamides - causes most severe hearing loss Torsemide (Demadex) - x2 as potent Thiazide and Thiazide-Like Diurectics - Considerations encourage water intake vs alcohol or caffeinated drinks caution with electrolyte drinks baseline and periodic determination of serum electrolytes measure BP before therapy and at regular intervals Monitors I&O Monitor for therapeutic effectiveness Monitor for adverse effects Potassium-Sparing Diurectics - drug interactions acidosis with ammonium chloride decreased diuretic effects with aspirin and other salicylates decreased effects of digoxin Can cause hyperkalemia with potassium supplements, ACE inhibitos, ARB Additive hypotensive results with other antihypertensives Principles of Fluid Imbalance 1. Body fluids continuously travel between intracellular and extracellular compartments via - water - intracellular fluid (ICF)- 2/3 water in body - extracellular fluid (ECF) -1/3 water in body 2. Balance problems between intake and output can lead to fluid imbalance disorders and cause shock and dehydration Principles of Fluid Imbalance - electrolytes electrolytes are cahrged substances (+/-), essential to homeostasis imbalance is a sign of a medical condition treatment = diagnosis and correct the underlying cause of the disorder Na2+, K+, Mag2+ and Ca2+ most important Know your lab levels for these 4 electrolytes Pharmacotherapy of Electrolyte Imbalances - adverse effects hypernatremia (watch neuro status/LOC) lethargy confusion muscle termor or rigidity hypotension restlessness pulmonary edema Pharmacotherapy of Electrolyte Imbalances - K+ most abundant intracellular cation insulin key hormone for maintaining potassium balance Hyperkalemia - serum level greater than 5 mEq/L - caused by excessive consumption or renal pathology Hypokalemia - serum level less than 3.5 mEq/L - usual cause is pharmacotherapy with loop and thiazide diurectics Pharmacotherapy of Electrolyte Imbalances - K+ indications for administration 1. preventing hypokalemia 2. treatment of hypokalemia 3. treatment of mild alkalosis Pharmacotherapy of Electrolyte Imbalances - Mag2+ second most abundant intracellular cation essentail for proper nneuromuscular function levels controlled by kidneys Hypomagnesemia - serum level below 0.65 mmol/L - caused by renal problems and loop diuretics Hypermagnesemia - serum level above 1.05 mmol/L - advanced renal failure is onlu major cause Pharmacotherapy of Electrolyte Imbalances - Mag2+ adverse effects Adverse effects: diarrhea magnesium overdose flushing of the skin sedation confusion intense thirst muscle weakness Serious adverse effects neuromuscular blockade respiratory paralysis (watch RR) heart block circulatory collapse Pharmacotherapy of Electrolyte Imbalances - Ca2+ the most abundant mineral in the body Hypercalcemia - serum level greater than 2.5 mmol/L - most commonly results from overactive parathyroid glands Hypocalcemia - serum level less than 2.1 mmol/L signs of underlying pathology caused by: - lack of calcium or vitamin D - hypothyroidism - drug therapy Pharmacotherapy of Electrolyte Imbalances - Ca2+ adverse effects Adverse effects constipation nausea vomiting metallic taste serious adverse effects hypercalcemia dysrhythmias cardiac arrest confusion delirium stupor coma Pharmacotherapy of Electrolyte Imbalances - Ca2+ contraindications/precautions hypercalcemia hyperparathyroidism digoxin toxicity renal or cardiac insufficiency dysrhymias dehydration diarrhea sarcoidosis (metastatic bone disease) renal calculi hyperphosphatemia Cardiac adnormalities cause by hypercalcemia degenerative diseases of the CNS AKA neurodegenerative diseases progressive, irriversible loss of neuron can affect any age group pharmacotherapy treats symptoms, as there is no cure depression is a common problem with these chronic and irreversible disorders Pharmacotherapy of Parkinson Disease goal is to blance dopamine and acetylcholine treatment may take 2-3 weeks to see benefits of drug Dopamine Agonists - increase the available dopamine by directly replacing dopamine, decreasing breakdown, increasing release, or activating dopamine receptors Anticholinergic Drugs - bloc the excitatory action of acetylcholine in the striatum, reducing stimulation of abnormal muscle movements Levodopa - consideration take on empty stomach - avoid multivitamins/B6 - avoid high-protein diets watch for safety with ambulation d/t dizziness, assists with ADLs monitor liver and kidney function avoid alcohol watch for mood chanegs or behavioural changes (aggression/confusion) Pramipexole- considerations assess baseline VS and symptoms of PD monitor for orthostatic hypotension monitor for tardive dyskinesia assess mental status alert pt and family about sleep attacks ensure family understands that PD treatment is NOT a cure but might help with symtpoms for a period of time Benztropine - adverse effects adverse effects sedation constipation blurred vision dry mouth decreased sweating urinary retention confusion serious adverse effects paralytic ileus Benztropine - contraindications/precautions closed-angle glaucoma myasthenia gravis tardive dyskinesia GI/urinary obstruction prostatic hypertrophy peptic ulcers tachycardia alchol* Benztropine - drug interactions Additive toxicity - antihistamines, tricyclic antidepressants, phenothiazines, MAOIs, quinidine Additive sedative effect - alcohol, CNS depressants Slow GI motility/decreased absorption - antidiarrheals Pregnancy category C treatment of overdose - physostigmine, 1-2 mg subcutaneous or IV to reverse symptoms of anticholinergic intoxication Pharmacotherapy of Alzheimers Disease produces only modest results and is ineffective at stopping the progress of the disorder Cholinesterase inhibitors tacrine (Cognex) Cholinesterase breaks down acetylcholine goal is to improve function in ADLs, behaviour and cognition all drugs in this classification have equal efficacy GI system most adversely affected including liver - nausea, vomiting, diarrhea nursing considerations: - cognition, safety, independence, symptoms, baseline labs, VS, vision, weight, liver and kidney function Cholinesterase inhibitors - reversible raise acetylcholine concentrations in the brain fewer side effects than tacrine (Cognex) side effects are typically GI-related serious side effects include atrial fibrillation, sinus bradycardia and seizures nursing considerations: - cognition, safety, independence, symptoms, baseline labs, VS, vision, weight and kidney function Donepezil - adverse effects Adverse effects N/V/D & anorexia muscle cramps syncope ecchymosis fatigue arthralgia abnormal dreams/hallucinations/confusion/depressions headache serious adverse effects life-threatening dysrhythmias - atrial fibrillation - sinus bradycardia seizures renal failure or hepatotoxicity - watch the liver enzymes Donepezil - treatment and considerations treatment of overdose - anticholinergic drugs to reverse symptoms of cholinergic crisis Considerations determine cognitive functioning and safety issues obtain baseline lab tests - esp liver and renal determine symptoms of Alzheimer disease - determine degree of depression, agitation, axiety, aggression or confusion ensure family knows to monitor pt for irregular heart beat or if patient feels 'butterflies' in their chest evaluate need for alternative living arrangements encourage participation in support group (incl family) avoid alcohol Multiple Sclerosis exact cause unknown characterized by demyelination secondary to inflammatory response - considered autoimmune disease leading cause of neurologic disability in 20-40 age group pattern of symptom exacerbation alternating with periods of remission symptoms include: - difficulty maintaining balance, muscle weakness Muscle Spasms NSAIDs and skeletal muscke relaxants are used to treat muscle spasms Clyclobenzaprine - considerations Hx & Px (incl VS) baseline neurologic status assess for pain protect from injury related to falls from drowsiness assess for urticaria, rash, pruritis inform pt not to drive Clyclobenzaprine - drugs that are similar Methocarbamol (Relaxin, Robaxin) - ajunct to physical therapy interventions - don't drive Metaxalone (skelaxin) - ineffective in treatment of spasticity-related neurologfic disorders Orphenadrine (Banflex, Myophen, Norflex) - anticholinergic drug of the antihistamines class; it is closely related to diphenhydramine Tizanidine (Zanaflex) - spasticity related to brain or spinal cord injury of MS Muscle Spasticity continuous state of contraction pain is more intense than spasms and cause greater impairment irritable deep tendon reflexes scissoring movements lower extremities fixed joint movement not a disorder itself but rather caused by neuromuscular diseases Dantrolene- Considerations Hx & Px - baseline neurologic and pain status assess VS during IV administration assess for cardiopulmonary cahnges - monitor breath and heart sounds Watch liver - liver function tests - report signs of jaundice - avoid alcohol teach not to drive nonpharmacologic therapies Physical therapy - increases movement - prevents contractures Herbal Remedies - black cohosh, topical - castor oil packs, topical - capsaicin, topical (active chili peppers - wear gloves) B complex vitamins, specifically B6