Pharmacology Study Guide Summer 2023 PDF

PHARMACOLOGY STUDY GUIDE SUMMER 2023 USE THE NURSING PROCESS. Remember, when you are offered a choice of things to DO in a situation, act like a nurse! Read the WHOLE label, every word, and process what you are reading befo...

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