NAPLEX Super Review: Key Concepts and
Medications Summary
PRESERVATIVES
Benzalkonium Chloride – topical antibiotic
FLUIDS AND ELECTROLYTES
Hyponatremia:
Medication causes:
Hypovolemic: diuretics
Isovolemic: [SIADH] chlorpropamide, carbamazepine, vincristine, cyclophosphamid, NSAIDs, SSRIs, Ecstasy
Hyperkalemia
Can be a symptom of Metabolic acidosis
Treatment:
If abnormal ECG Calcium Gluconate IV or Calcium Chloride
If hyperglycemic Insulin IV or SubQ
If not hyperglycemic and no ECG changes Insulin and glucose
Other alternatives:
Furosemide (Lasix®)
Sodium Polystyrene Sulfonate(SPS) (Kayexalate®) [longest onset]
Available: Oral 15-60g in 70% sorbitol suspension
Enema prepared by mixing 60 to 100g SPS in 100-200mL 30% sorbitol or 10% dextrose
warmed to body temperature
Sodium bicarbonate, albuterol, and hemodialysis
Hypokalemia
Look at the magnesium level before treating because hypomagnesemia can cause hypokalemia
Hyperkalemia and Hypermagnesemia
Treatment:
IV Calcium gluconate or Calcium chloride with repeated doses hourly to effect
If adequate renal function IV furosemide(Lasix®) 40mg can be used
If CKD long term loop diuretics
If ESRD hemodialysis with a magnesium-free dialysate
Hyperphosphatemia
Aluminum Hydroxide (Amphojel®, ALternaGel® [OTC])
Use: hyperphosphatemia, hyperacidity, skin protectant
Hypocalcemia
Causes: Hypoparathyroidism (↓ PTH), hypomagnesemia (↓ PTH), Vitamin D deficiency
Metabolic Acidosis
Sodium Citrate and Citric Acid (Bicitra®, Cytra-2®, Oracit®) – Modified Shohl’s Solution
Dosed QID: after meals and at bedtime
Sodium Acetate
ASTHMA
Rescue Medications:
Albuterol (Proventil®, Ventolin®) Inhalation, Nebulization
MOA: relaxes bronchial smooth muscle by action on beta-2 receptors with little effect on heart rate
ADRs: tremors, anxiety
Overdose: give a beta blocker such as Propranolol
Administration: Albuterol 0.5% is administered via nebulization
For prophylaxis of exercise-induced bronchospasm: 2 puffs 5-30 minutes prior to exercise
If the canister floats in water then it is empty (this could be wrong since water can damage the valve)
Treatments:
Leukotriene Receptor Antagonists:
Zafirlukast (Accolate®)
Use: prophylaxis and chronic treatment of asthma in adults and children ≥ 5 years of age
MOA: Selectively and competitively inhibits leukotriene-receptors
ADRs: Headache, Dizziness, Pain, Fever, N/V/D/abdominal pain/dyspepsia; ALT increase, back
pain/myalgia/weakness; infection
,DIs: Substrate for and inhibits 2C9, ASA increases concentration
1
, Dose: Available in 10 and 20mg tablets
Adults: 20mg BID on empty stomach
Children 5-11: 10mg BID
Montelukast (Singulair®)
Dosage Forms: granules, tablet, chewable tablet
Use: prophylaxis and chronic treatment of asthma and relief of seasonal allergic rhinitis and perennial
allergic rhinitis
MOA: leukotriene receptor antagonist that inhibits the cysteinyl leukotriene receptor
Administration: granules may be taken directly or mixed with applesauce, carrots, rice, ice cream, baby
formula, or breast milk, but no other liquids; take in the evening
ADRs: can cause flu-like symptoms
Anticholinergic Agents
Ipratropium (Atrovent®)
MOA: blocks the action of acetylcholine (ACH) at parasympathetic sites in bronchial smooth muscle
causing bronchodilation
Inhaled Corticosteroids
Triamcinolone (Azmacort®)
Administration: use spacer device provided
Budesonide (Pulmicort®)
Pulmicort Respules®)
Administration: shake well before using; Use Pulmicort
Respules® with jet nebulizer connected to an air compressor; administer with
mouthpiece or facemask; do not mix with other medications; rinse mouth following
treatments to decrease risk of oral candidiasis (wash face if using face mask)
Dosage: twice daily
Beclomethasone (QVAR®)
Flunisolide (AeroBid®)
Beta-2 Agonists
Salmeterol (Serevent®)
Dosing: scheduled basis 1 inhalation BID
Diskus should be kept dry, don’t use spacer, administer horizontally, rinse mouth after use
Formoterol (Foradil®)
Administration: Remove capsule form foil blister, place capsule in
the base of the Aerolizer inhaler; press both buttons once and then release. Keep inhaler horizontal and
inhale fully. If any powder remains in capsule, exhale and inhale again – repeat until empty. Do not use a
spacer.
Advair® contains (100/50, 250/50, 500/50mcg)
Fluticasone (Flovent®) – inhaled corticosteroid
Salmeterol (Serevent®) – a beta 2 agonist
Administration: rinse mouth with water after use to reduce risk of oral candidiasis
Combivent® contains
Ipratropium - anticholinergic
Albuterol – beta2 agonist
Vaccinations: yearly Influenza vaccine
If an older patient is not getting good results with an inhaler use a spacer such as Aerochamber
Aerochamber® should be sterilized before the first use then once a week thereafter
Inspirease® is a spacer used with MDIs
Rotohaler or Rotocap is a dry powder inhaler
Pulmoaide® is a nebulizer
TruZone® is a peak flow meter used to monitor asthma
Peak Flow Measurements
Green Zone - ≥ 80% of personal best
Yellow Zone – 50-79% of personal best
Red Zone - < 50% of personal best
Counsel patient to exhale with force, hold horizontally, and record the highest of 3 readings when using a PFM
A 4-year old with pneumonia and asthma what would you counsel the patient on?
I would counsel on the use of peak flow meter and spacer of on inhalers
Patient is on Albuterol and Pulmacort® waking up 1-2 nights per week using rescue inhaler. How would you classify her asthma?
Moderate Persistent: Daily symptoms, Daily use if inhaled short-acting beta2 agonist, exacerbations may affect activity and
sleep, nocturnal >1time/week
What would you add to her regimen?
2
, A. Theophylline
B. Singulair and Theophylline
C. Serevent and QVAR
D. Caffeine
I would choose Serevent since it is a long acting Beta2 agonist, but the QVAR is an inhaled corticosteroid and would be
duplicate therapy with Pulmicort® so perhaps Theophylline would be the best choice?
Can albulterol and Primatene Mist be used together and if so how far apart must they be used?
I don’t think you would use albuterol with Primatene Mist becase Primatene is
epinephrine and is an alpha/beta agonist so it works in the same way albuterol does. If it is used together it should be
separated by at least 5 minutes if the first dose doesn’t work.
Thrush – Infection of the oral tissues with Candida albicans; often an opportunistic infection in patients with AIDS or other disorders
that depress the immune system.
COPD
Beta Agonists
Albuterol (Proventil®, Ventolin®)
Levalbuterol (Xopenex®)
Formoterol (Foradil®)
Pirbuterol (Maxair®)
Salmeterol (Serevent®)
Terbutaline (Bricanyl®)
Anticholinergics
Ipratropium bromide (Atrovent®)
Tiotropium bromide (Spiriva®)
Methylxanthines
Aminophylline is converted to theophylline by multiplying the aminophylline
dose by 0.8 because aminophylline is 80% theophylline.
Theophylline
ADRs: arrhythmia, seizure, N/V/D, tachycardia, insomnia
Drug Interactions: Erythromycin (EES – erythromycin ethyl stearate) and other macrolide antibiotics may decrease
the metabolism of theophylline
Corticosteroids
SILICOSIS
A form of pneumoconiosis resulting from inhalation of silica dust over a period of years leading to slowly progressive fibrosis of the
lungs which predisposes them to pulmonary tuberculosis.
CYSTIC FIBROSIS
Pathophysiology
Inherited as an autosomal recessive trait
Affects multiple organ systems (Pulmonary, GI, Pancreas, Hepatic, Reproductive)
Mutation in the cystic fibrosis transmembrane regulator (CFTR) leads to abnormal regulation of epithelial ion transport
leading to thick, dehydrated secretions. The cAMP-stimulated Chloride channel is the most effected.
Pulmonary
Thick mucus airway plugging makes good environment for Pseudomonas
aeruginosa, Staphylococcus aureaus, Haemophilus influenzae, and Aspergillus
Consequences: reduced gas exchange, barrel chest, pulmonary
hypertension, GERD, right sided heart failure (cor pulmonale), pneumothorax, digital clubbing, chronic
rhinitis, sinusitis, and/or nasal polyposis.
Pancreas
Secretion accumulate in pancreatic ducts leading to obstruction which leads to digestive enzyme deficiency. May
lead to insulin deficiency (Type II DM) in older CF patients
Hepatic
Decreased flow and volume of bile due to obstruction of biliary tree leads
to biliary cirrhosis of chronic obstruction and gall stones.
Gastrointestinal
Obstruction and maldigestion leads to bilious vomiting, meconium ileus (infant can’t pass stool), abdominal
distention/pain, and fecal impaction
Sweat Glands
Dysfunctional ion channel leads to increased Chloride and Sodium excretion
Genitourinary – infertility
3
Medications Summary
PRESERVATIVES
Benzalkonium Chloride – topical antibiotic
FLUIDS AND ELECTROLYTES
Hyponatremia:
Medication causes:
Hypovolemic: diuretics
Isovolemic: [SIADH] chlorpropamide, carbamazepine, vincristine, cyclophosphamid, NSAIDs, SSRIs, Ecstasy
Hyperkalemia
Can be a symptom of Metabolic acidosis
Treatment:
If abnormal ECG Calcium Gluconate IV or Calcium Chloride
If hyperglycemic Insulin IV or SubQ
If not hyperglycemic and no ECG changes Insulin and glucose
Other alternatives:
Furosemide (Lasix®)
Sodium Polystyrene Sulfonate(SPS) (Kayexalate®) [longest onset]
Available: Oral 15-60g in 70% sorbitol suspension
Enema prepared by mixing 60 to 100g SPS in 100-200mL 30% sorbitol or 10% dextrose
warmed to body temperature
Sodium bicarbonate, albuterol, and hemodialysis
Hypokalemia
Look at the magnesium level before treating because hypomagnesemia can cause hypokalemia
Hyperkalemia and Hypermagnesemia
Treatment:
IV Calcium gluconate or Calcium chloride with repeated doses hourly to effect
If adequate renal function IV furosemide(Lasix®) 40mg can be used
If CKD long term loop diuretics
If ESRD hemodialysis with a magnesium-free dialysate
Hyperphosphatemia
Aluminum Hydroxide (Amphojel®, ALternaGel® [OTC])
Use: hyperphosphatemia, hyperacidity, skin protectant
Hypocalcemia
Causes: Hypoparathyroidism (↓ PTH), hypomagnesemia (↓ PTH), Vitamin D deficiency
Metabolic Acidosis
Sodium Citrate and Citric Acid (Bicitra®, Cytra-2®, Oracit®) – Modified Shohl’s Solution
Dosed QID: after meals and at bedtime
Sodium Acetate
ASTHMA
Rescue Medications:
Albuterol (Proventil®, Ventolin®) Inhalation, Nebulization
MOA: relaxes bronchial smooth muscle by action on beta-2 receptors with little effect on heart rate
ADRs: tremors, anxiety
Overdose: give a beta blocker such as Propranolol
Administration: Albuterol 0.5% is administered via nebulization
For prophylaxis of exercise-induced bronchospasm: 2 puffs 5-30 minutes prior to exercise
If the canister floats in water then it is empty (this could be wrong since water can damage the valve)
Treatments:
Leukotriene Receptor Antagonists:
Zafirlukast (Accolate®)
Use: prophylaxis and chronic treatment of asthma in adults and children ≥ 5 years of age
MOA: Selectively and competitively inhibits leukotriene-receptors
ADRs: Headache, Dizziness, Pain, Fever, N/V/D/abdominal pain/dyspepsia; ALT increase, back
pain/myalgia/weakness; infection
,DIs: Substrate for and inhibits 2C9, ASA increases concentration
1
, Dose: Available in 10 and 20mg tablets
Adults: 20mg BID on empty stomach
Children 5-11: 10mg BID
Montelukast (Singulair®)
Dosage Forms: granules, tablet, chewable tablet
Use: prophylaxis and chronic treatment of asthma and relief of seasonal allergic rhinitis and perennial
allergic rhinitis
MOA: leukotriene receptor antagonist that inhibits the cysteinyl leukotriene receptor
Administration: granules may be taken directly or mixed with applesauce, carrots, rice, ice cream, baby
formula, or breast milk, but no other liquids; take in the evening
ADRs: can cause flu-like symptoms
Anticholinergic Agents
Ipratropium (Atrovent®)
MOA: blocks the action of acetylcholine (ACH) at parasympathetic sites in bronchial smooth muscle
causing bronchodilation
Inhaled Corticosteroids
Triamcinolone (Azmacort®)
Administration: use spacer device provided
Budesonide (Pulmicort®)
Pulmicort Respules®)
Administration: shake well before using; Use Pulmicort
Respules® with jet nebulizer connected to an air compressor; administer with
mouthpiece or facemask; do not mix with other medications; rinse mouth following
treatments to decrease risk of oral candidiasis (wash face if using face mask)
Dosage: twice daily
Beclomethasone (QVAR®)
Flunisolide (AeroBid®)
Beta-2 Agonists
Salmeterol (Serevent®)
Dosing: scheduled basis 1 inhalation BID
Diskus should be kept dry, don’t use spacer, administer horizontally, rinse mouth after use
Formoterol (Foradil®)
Administration: Remove capsule form foil blister, place capsule in
the base of the Aerolizer inhaler; press both buttons once and then release. Keep inhaler horizontal and
inhale fully. If any powder remains in capsule, exhale and inhale again – repeat until empty. Do not use a
spacer.
Advair® contains (100/50, 250/50, 500/50mcg)
Fluticasone (Flovent®) – inhaled corticosteroid
Salmeterol (Serevent®) – a beta 2 agonist
Administration: rinse mouth with water after use to reduce risk of oral candidiasis
Combivent® contains
Ipratropium - anticholinergic
Albuterol – beta2 agonist
Vaccinations: yearly Influenza vaccine
If an older patient is not getting good results with an inhaler use a spacer such as Aerochamber
Aerochamber® should be sterilized before the first use then once a week thereafter
Inspirease® is a spacer used with MDIs
Rotohaler or Rotocap is a dry powder inhaler
Pulmoaide® is a nebulizer
TruZone® is a peak flow meter used to monitor asthma
Peak Flow Measurements
Green Zone - ≥ 80% of personal best
Yellow Zone – 50-79% of personal best
Red Zone - < 50% of personal best
Counsel patient to exhale with force, hold horizontally, and record the highest of 3 readings when using a PFM
A 4-year old with pneumonia and asthma what would you counsel the patient on?
I would counsel on the use of peak flow meter and spacer of on inhalers
Patient is on Albuterol and Pulmacort® waking up 1-2 nights per week using rescue inhaler. How would you classify her asthma?
Moderate Persistent: Daily symptoms, Daily use if inhaled short-acting beta2 agonist, exacerbations may affect activity and
sleep, nocturnal >1time/week
What would you add to her regimen?
2
, A. Theophylline
B. Singulair and Theophylline
C. Serevent and QVAR
D. Caffeine
I would choose Serevent since it is a long acting Beta2 agonist, but the QVAR is an inhaled corticosteroid and would be
duplicate therapy with Pulmicort® so perhaps Theophylline would be the best choice?
Can albulterol and Primatene Mist be used together and if so how far apart must they be used?
I don’t think you would use albuterol with Primatene Mist becase Primatene is
epinephrine and is an alpha/beta agonist so it works in the same way albuterol does. If it is used together it should be
separated by at least 5 minutes if the first dose doesn’t work.
Thrush – Infection of the oral tissues with Candida albicans; often an opportunistic infection in patients with AIDS or other disorders
that depress the immune system.
COPD
Beta Agonists
Albuterol (Proventil®, Ventolin®)
Levalbuterol (Xopenex®)
Formoterol (Foradil®)
Pirbuterol (Maxair®)
Salmeterol (Serevent®)
Terbutaline (Bricanyl®)
Anticholinergics
Ipratropium bromide (Atrovent®)
Tiotropium bromide (Spiriva®)
Methylxanthines
Aminophylline is converted to theophylline by multiplying the aminophylline
dose by 0.8 because aminophylline is 80% theophylline.
Theophylline
ADRs: arrhythmia, seizure, N/V/D, tachycardia, insomnia
Drug Interactions: Erythromycin (EES – erythromycin ethyl stearate) and other macrolide antibiotics may decrease
the metabolism of theophylline
Corticosteroids
SILICOSIS
A form of pneumoconiosis resulting from inhalation of silica dust over a period of years leading to slowly progressive fibrosis of the
lungs which predisposes them to pulmonary tuberculosis.
CYSTIC FIBROSIS
Pathophysiology
Inherited as an autosomal recessive trait
Affects multiple organ systems (Pulmonary, GI, Pancreas, Hepatic, Reproductive)
Mutation in the cystic fibrosis transmembrane regulator (CFTR) leads to abnormal regulation of epithelial ion transport
leading to thick, dehydrated secretions. The cAMP-stimulated Chloride channel is the most effected.
Pulmonary
Thick mucus airway plugging makes good environment for Pseudomonas
aeruginosa, Staphylococcus aureaus, Haemophilus influenzae, and Aspergillus
Consequences: reduced gas exchange, barrel chest, pulmonary
hypertension, GERD, right sided heart failure (cor pulmonale), pneumothorax, digital clubbing, chronic
rhinitis, sinusitis, and/or nasal polyposis.
Pancreas
Secretion accumulate in pancreatic ducts leading to obstruction which leads to digestive enzyme deficiency. May
lead to insulin deficiency (Type II DM) in older CF patients
Hepatic
Decreased flow and volume of bile due to obstruction of biliary tree leads
to biliary cirrhosis of chronic obstruction and gall stones.
Gastrointestinal
Obstruction and maldigestion leads to bilious vomiting, meconium ileus (infant can’t pass stool), abdominal
distention/pain, and fecal impaction
Sweat Glands
Dysfunctional ion channel leads to increased Chloride and Sodium excretion
Genitourinary – infertility
3
