NR 508 MIDTERM QUIZ 1,2,3 REVIEW course outline; verified and correctly answered

NR 508 MIDTERM QUIZ REVIEW Quiz #1 1) When taking acyclovir, patients should be educated regarding the Need to drink lots of water during treatment 2) Precautions that should be taken when prescribing controlled substances include Using tamper-proof paper for all prescriptions written for controlled drugs 3) Medication agreements or “Pain medication Contracts” are recommended to be used: Universally for all prescribing for chronic pain 4) Clinical judgment in prescribing include Factoring the cost to the patient of the medication prescribed 5) Vitamin B12 deficiency may lead to: Numbness and tingling on the hands 6) Behaviors predictive of addiction to controlled substances include: Stealing or borrowing another patient’s drugs 7) Isoniazid (INH) may induce a deficiency of which vitamin: C 8) There is often cross-sensitivity and cross-resistance between penicillin and cephalosporins because: Both drugs contain a beta-lactam ring that is vulnerable to the beta-lactamase-producing organism 9) An 82 y/o pt who has herpes zoster (shingles)and would benefit from an anti-viral such as acyclovir. Prior to prescribing valacyclovir, she will need an assessment ofthe Renal function 10) According to the National Health and Nutrition Examination Survey study of dietary intake, the group at risk for inadequate calcium was: Teenage females Quiz #2 1) Pt with c/o vaginal discharge that when tested meets the criteria for bacteria vaginosis. Tx of bacterial vaginosis in nonpregnant symptomatic women would be: Metronidazole 500 mg PO bid x 7 days 2) If a woman presents with recurrent vulvovaginal candidiasis she may be treated with: Intravaginal tioconazole x 14 days 3) Besides prescribing microbial therapy, pts with bacterial vaginosis require education regarding the fact that: alcohol should not be consumed during and 1 day after metronidazole is taken 4) Tx for chancroid in a nonpregnant pt would be: Oral azithromycin; ceftriaxone; oral ciprofloxacin 5) Dysmenorrhea is one the most common gynecological complaints in young women. The first line drug for this disorder is: NSAIDS 6) Men who are prescribed an erectile dysfunction drug such as sildenafil (Viagra) should be warned about the risk for: fatal hypotension if combined with nitrates 7) The drug of choice for tx of primary or secondary syphyllis is: Benzathine penicciliin G IM 8) A contraindication to the use of combined contraceptives is: A hx of clotting factors 9) Patients who are prescribed exogenous androgens need to be warned that decreased libido: May occur with androgen therapy 10) Long-term use of androgens requires specific laboratory monitoring of: calcium, testosterone, PSA, liver function, glucose, and lipids Quiz #3 1) Pt teaching r/t amlodipine includes: Rise slowly from a supine position to reduce orthostatic hypotension 2) The NP orders a thyroid panel for a pt on amiodarone. The pt tells the NP that he does not have thyroid disease and wants to know why the test is ordered: Amiodarone inhibits an enzyme that is important in making thyroid hormone and can cause hypothyroidism 3) Which of the foll. AE may occur due to a dihydropyridine-type CCB? Edema of hands and feet 4) Rodrigo has been prescribed procainamide after a MI. He is monitored for dyspnea, jugular venous distention, and peripheral edema bcuz they may indicate: Onset of CHF 5) Patrick is 10 y/o pt who presents with uncomfortable constipation. Along with diet changes, a laxative is ordered to provide more rapid relief of constipation. An appropriate choice of medication for a 10 y/0 child would be: Bisacodyl (Dulcolax) suppository 6) All pts with HTN benefits from diuretic therapy, but those who benefit the most are: African Americans 7) Kelly has diarrhea and is wondering if she can take loperamide (Imodium) for diarrhea. Loperamide: Slows gastric motility and reduces fluid and electrolyte loss from diarrhea 8) Angiotensin-converting enzyme inhibitors are the drug of choice in treating htn in diabetic pts bcuz they: All of the above 9) Colestipol come in powder form. The pt is taught to: Mix the powder with 4-6 oz of milk or juice 10) Pts at high risk for developing significant coronary heart disease are those with: Class III angina Midterm Outline Chapter 1: The Role of the Advanced Practice Nurse as Prescriber Roles and responsibilities of APRN prescribers Clinical judgement in Prescribing: use tamper proof paper for all prescriptions written for controlled substance Collaboration with other providers Autonomy and Prescriptive authority Chapter 2: Review of Basic Principles of Pharmacology Metabolism: Metabolism & Half Life Metabolism is related to drug concentration so that a fixed fraction of the drug is metabolized per hour. This is called first-order metabolism and is characterized by a half-life, the time period over which the drug concentration will decrease by half. How Drugs are Developed: drugs were developed by accident, this involves designing and synthesizing compounds based on the known structure of a specific target molecule Drug Responses: Receptors: agonists cause an action; antagonists: opposes the action of the agonist Antagonists occupy a receptor site and prevent other molecules, such as agonists, from occupying the same site and producing a response. Antagonists produce no direct response Pharmacokinetics: The study of what happens to a drug from the time it is put into the body until the parent drug and all metabolites have left the body. Pharmacokinetics represent the drug absorption into, distribution and metabolism within, and excretion from the body. Absorption: is the movement of a drug from its site of administration into the bloodstream for distribution to the tissues. Distribution: refers to the transport of a drug by the bloodstream to its site of action, first to those areas with extensive blood supply. Areas of rapid distribution include the heart, liver, kidneys, and brain; while areas of slower distribution include muscle, skin, and fat Protein Binding: Protein binding may lead to an unpredictable drug response called a drug-drug interaction. A drug-drug interaction occurs when the presence of one drug decreases or increases the actions of another drug that is administered concurrently (i.e., given at the same time). Metabolism: Metabolism of drugs occurs mostly in the smooth endoplasmic reticulum of cells in the liver. A drug that is absorbed from the intestine must first pass through the liver before it reaches the systemic circulation. If a large proportion of a drug is chemically changed into inactive metabolites in the liver, then a much smaller amount of drug will pass into the circulation (i.e., will be bioavailable) thus creating a first-past effect that reduces drug bioavailability. Hepatic metabolism involves the activity of a very large class of enzymes known as cytochrome P-450 enzymes First Pass Routes: Hepatic, arterial, Oral, Portal, venous, Rectal Phase I: It begins with preclinical testing phases, which include in vitro studies (using tissue samples and cell cultures) and animal studies, healthy people without the disease. Phase I studies is to determine the optimal dosage range and the pharmacokinetics of the drug and to ascertain if further testing is needed. II: Clinical (human) studies follow the preclinical phase. This phase involves small numbers of volunteers who have the disease that the drug is designed to diagnose or treat and are closely monitored for the effectiveness of treatment Cytochrome P450 metabolism: the family of enzymes that metabolizes drugs; CYP P450 (mixed-function oxidase reaction) catalyzes the metabolism of a large number of diverse drugs and chemicals that are highly lipid soluble (lipophilic). Excretion: Renal excretion is accomplished through passive glomerular filtration, active tubular reabsorption, and active tubular secretion. Biliary: The excretion of drugs by the intestines is another route of elimination where drugs are taken up by the liver, released into the bile, and eliminated in the feces. Other (eg for volatile drugs) Chapter 3: Rational Drug Selection Process of rational drug prescribing: 6 Steps proposed by WHO Step 1 Define the patient’s problem. Step 2 Specify the therapeutic objective. Step 3 Choose the treatment. Step 4 Start the treatment. Step 5 Educate the patient. Step 6 Monitor effectiveness. Patient education: Monitor effectiveness: Passive monitoring occurs when the patient is educated on the expected outcome of the drug therapy and is instructed to contact the provider if the treatment is not effective or if adverse drug effects occur and is common in short term treatment such as antibiotic Active monitoring occurs when the provider schedules a follow-up examination to determine the effectiveness of the drug therapy; may also include adding are subtracting a medication from the treatment. Drug, Patient, and Provider factors that influence drug selection Drug factors: Drug must be specific and selective to the target tissues affected by the disease to have the greatest therapeutic effect with the least adverse effects; relationship between a drug’s desired therapeutic effects and its adverse effects is called its therapeutic index; narrow therapeutic index requires close monitoring for signs of toxicity, while wide therapeutic index is much safer. Pt factors: Previous Adverse Drug Reactions, health belief, current drug therapy, patient age, cost, pregnancy Provider factors: Ease of Prescribing or Monitoring, fomularies Influences on Rational Prescribing: Pharmaceutical Promotion: free gifts, free drug samples to providers to raise awareness of their products and to influence physicians to prescribe a company’s medicines even when evidence indicates another drug would be more beneficial” When Prescribing Recommendations Change: antibiotic resistance and overprescribing of antibiotics for URIs: The CDC developed the “Get Smart” campaign, and a similar STAR (Stemming the Tide of Antibiotic Resis - tance) campaign was conducted in the United Kingdom. Chapter 4: Legal and Professional Issues in Prescribing New Drug Approval process including Clinical Phases Preclinical Investigation (Stage 1) Range: 1–3 years; Clinical investigation phase: Range: 2–10 years Average: 5 years; Phase I – pharmacodynamics, Phase II -controlled studies performed on patients with the target disease or disorder to determine a compound’s potential usefulness and short-term risks; Phase III - trials are controlled and uncontrolled clinical trials of a drug’s safety and efficacy in hospital and outpatient settings. U.S. FDA Regulatory Jurisdiction: official labelling vs off-label use of drugs Controlled Substance Laws Controlled Drug DEA schedules (Table 4-1): Schedule III: Prescription must be rewritten after 6 mo or 5 refills; Telephone or fax prescription okay Controlled Substance Misuse: Prescriber Education - Behavioral Red Flags, Pressure to Prescribe, Enabling: refers to the powerful instinct in practitioners to do anything medically possible to enable patients with a present or potential disability to live at a higher level of function. When you suspect a Patient is Misusing Medications: Communication, Systemic Solutions, Prescribing Tips, Medication Agreements: universal precaution” model of care, meaning that the NP develops and uses agreements that are expected of all patients requiring ongoing use of medications with potential for misuse., Prescription Drug Monitoring Programs State Law: Writing and Transmitting the Prescription: Use preprinted prescription pads/electronic templates that contain the name, address, and telephone number and NPI number of the prescriber. This will allow the pharmacist to contact the prescriber if there are any questions about the prescription. Ethical Aspects of Prescribing: Chapter 5: Adverse Drug Reactions: an exaggerated physiological response related to the pharmacology of the drug eg. Hypotension from a beta-blocker, diarrhea from the fat-blocking drug orlistat, and insomnia from the stimulant methylphenidate that is either manage by drawing the medication or reducing the dose Mechanistic Classification of ADRs including Types of Immune-Mediated ADRs: Idiosyncratic reactions are unpredictable and may be more likely to result in mortality Type I - IgE-mediated, immediate-type hypersensitivity eg. angioedema and anaphylaxis Type II Antibody-dependent cytotoxicity Example: heparin-induced thrombocytopenia Type III Immune complex hypersensitivity Example: Arthus reaction to tetanus vaccine Type IV- Cell-mediated or delayed hypersensivity Example: Drug Rash, Eosinophilia and Systemic Syndrome Types A-F: Type A reactions are equivalent to pharmacological reactions, account for 85% to 90% of ADRs, are dose-dependent, and are predictable, whereas Type B reactions are idiosyncratic, account for 10% to 15% of ADRs, are not dose-dependent, and are not predictable, Type C reactions result from chronic medication use, Type D reactions are delayed, Type E reactions are from drug–drug interactions, and Type F reactions result from treatment failures. Common Causes of ADRs: Risk Factors, including common drugs involved and which cause skin reactions Time-Related Classification of ADRs including drugs associated with withdrawal symptoms: Late reaction (For example, rapid discontinuation of oxycodone can cause the patient to experience symptoms of withdrawal (i.e., anxiety, insomnia, rhinorrhea, diaphoresis, tremor, vomiting, diarrhea, and/or tachycardia). A patient who takes clonidine or propranolol may experience rebound hypertension following withdrawal of the medication). Dose-Related ADRs classification: administering an excessive dose or failing to adjust doses properly for age and organ function (i.e., renal insufficiency or liver failure). For example, a person with diabetes may become hypoglycemic after administering an excessive dose of insulin. An individual patient could experience lithium toxicity upon development of acute renal failure with no adjustment of the lithium dose. Severity of ADRs: Any ADR that meets FDA criteria should be reported to the FDA MedWatch program (death, are life-threatening, result in hospitalization (new or prolonged), are disabling or incapacitating, produce congenital abnormality or birth defect, or require an intervention to prevent one of these outcomes). Risk factors: genetic abnormalities, age, sex, polypharmacy (increasing the risk for drug–drug interactions), and concomitant medical conditions (increasing the chance for drug–disease interactions) Chapter 6: Factors that Foster Positive Outcomes Overview of nonadherence Keys to effective patient education Health and Cultural beliefs Health Literacy Complexity of Drug Regimen and Polypharmacy Simplifying the Regimen Communication Difficulties Chapter 7: Cultural and Ethnic Influences in Pharmacotherapeutics Cultural Influences on Care Ethnopharmacology: —the study of racial differences in drug metabolism and response; a drug that is eliminated entirely by the kidney through filtration and reabsorption and is not highly protein bound is very unlikely to exhibit racial differences Chapter 9: Nutrition and Nutraceuticals Nutrient-Drug Interactions (eg warfarin and vit K): Patients who are taking warfarin should not ingest foods high in vitamin K (spinach, kale, turnip, swiss chard, parsley, mustard greens) as the combination may lead to therapeutic failure. Influence of Diet on Pharmacokinetics of Drugs: Drug absorption, Drug Metabolism, Grapefruit juice and CYP3A4: Grapefruit juice influences the metabolism of many drugs because it contains components that inhibit CYP3A4, leading to alterations in the metabolism of drugs; foods and CYP1A2: Cruciferous vegetables induce CYP1A2, an enzyme responsible for the metabolism of drugs including theophylline and may have therapeutic failure if they are being treated with drugs that are metabolized by CYP1A2 Drug Excretion, Drug -Induced Nutrient Depletion (eg folate and B12): changes in the pH from antacid therapy or potassium therapy can reduce the absorption of folic acid, iron, and vitamin B12 Outcomes of Nutrient-Drug Interactions Nutritional Management: Recommended vitamins for the following special populations: infants and: 400 IU of vitamin D daily children; women of child bearing age: 400 mcg/day of folic acid; pregnant women vegans: d 600 mcg/day of folic acid, a multivitamin/mineral supplement, 27 mg/day of iron (60 mg/d if patient is anemic), and vitamin B 12 if the patient is vegan or lacto-ovo-vegetarian; older adults: B12 2.4 mcg/day and need to ensure adequate intake of vitamin D and calcium.; those not exposed to sunlight or with dark skin: should consume vitamin D–fortified foods and/or supplements; alcoholics: Vit A; patients taking isoniazid (INH): Vit B6 Nutraceuticals: foods that claim to have a medicinal effect on health. Fiber intake: Male 14-50 y/o – 38 g/d, Female 51 yr or older 21, Male 51 yr or older 30 Table 9-2, Vitamins and Minerals (including Box 9-1): Vit A is labeled category X; Fatty Acids, Deficiency of thiamine can lead to beriberi or Wernicke’s encephalopathy, alcoholics are at risk; inadequate vitamin C intake may develop scurvy (smokers); Vitamin B 6 deficiency may be drug-induced by use of isoniazid (INH); Vitamin B12 is essential for red blood cell formation and neurological function. Older adults and patients with reduced stomach acid levels, gastric bypass surgery, or intestinal disorders are at risk for deficiency. Plant Sterols: plant sterols compete with cholesterol in the intestine, reducing the amount of cholesterol that is absorbed. Pre-, Pro- and Symbiotics; Vitamin that is teratogenic in excessive amounts, Vitamin that is useful for migraine prophylaxis: Vit B2 Chapter 12: Pharmacoeconomics Impact of Generic Drugs on Drug Therapy Generic Substitution Prescribing Generic vs Brand-Name Medications: signing “generic substitution permitted vs “dispense as written” Chapter 13: Over-the-counter Medications OTC Medication characteristics and regulation OTC Medication Sales Hazards of OTC Self-Medication Adverse Effects of OTC Self-Medication Drug Interactions: antacids: Most interactions can be avoided by separating the dosing of antacids by at least 2 hours apart. Anticholinergics: primary adverse effects of diphenhydramine and dox - ylamine are anticholinergic, such as dry mouth, constipation, blurred vision, and tinnitus. CNS Depressants: OTC drugs may all cause additive sedation when taken with CNS-sedating medications. NSAIDS: and ASA Abuse of OTC Medications: Combat Methamphetamine Epidemic Act: Law requires ID to track the sales, which is limited to daily or 30 days (ephedrine, pseudophedrine). Patient Education Regarding OTC Medications Chapter 14 Drugs Affecting the Autonomic Nervous System Pharmacodynamics of Alpha2 Agonists: 2nd/3rd line drug; results in inhibition of cardioacceleration and vasoconstriction centers in the brain that causes a decrease in the peripheral outflow of norepinephrine, leading to decreases in peripheral resistance, renal vascular resistance, heart rate, and blood pressure. (Clonidine use to tx withdrawal symptoms from opioids, is used in this class activate alpha 2 receptors in the medulla of the brain, reducing sympathetic tone and increasing parasympathetic tone, due to down regulation of alpha2 receptors after chronic use. This results in a decrease in peripheral resistance, reduced heart rate, reduced blood pressure, and reduced renal vascular resistance. SHOULD NOT STOP ABRUPTLY bcuz the relative lack will impair the homeostasis that regulates the SNS. Pharmacodynamics of Beta Blockers: used in the treatment of cardiac disorders such as heart failure, asymptomatic left ventricular dysfunction, and after acute myocardial infarction. When B-1 is bound to norepinephrine and epinephrine they influence heart rate and myocardial contraction. The blockade of beta-adrenergic receptors produces clinically significant action on the cardiovascular that acts as the SA node thus decreasing HR in atria and ventricles, renal by reducing the release of renin, and respiratory systems and on the eye. For patients with hyperlipidemia, beta2 blockade may worsen the condition. metabolized extensively by the liver and eliminated via the bile and feces. adverse effects: what happens with the abrupt withdrawal of Beta Blockers: withdrawal can result in MI, ventricular arrhythmias, and death. Pharmacokinetics: Beta blockers: Phamacotherapeutics: precautions and Contraindications of beta blockers Adverse Drug Reactions: Any unexpected, unintended, undesired, or excessive response to a medication given at therapeutic dosages (as opposed to overdose). Clinical Uses and Dosing of Beta Blockers Muscarinic Agonists: muscarinic receptors are located in the eye, heart, blood vessels, lung, GI tract, urinary bladder, and sweat glands. Muscarinic agonists are used clinically to treat glaucoma and to improve GI and urinary bladder tone. Stimulation of these receptors activates by muscarinic agonists that modify organ function by releasing ACh from PNS nerves: (1) to activate muscarinic receptors on target organs to alter organ function and (2) to activate muscarinic receptors on nerve terminals to inhibit the release of their neurotransmitters Pharmacodynamics, MOA, treatment uses, Chapter 15 Drugs Affecting the Central Nervous System Anorexiiants: Precautions and Contraindications Iminostilbenes: (antiepileptics: Carbamazepine (Tegretol) & Oxcarbazepine (Trileptal, Oxtellar XR)) Metabolism: Carbamazepine is metabolized in the liver and has the unique ability to induce its own metabolism, and excretion is through urine and feces; Oxcarbazepine has metabolized into an active metabolite 10-monohydroxy metabolite, which is responsible for the pharmacologic effect of the drug, 95% is excreted in the urine, 4% in the feces, and 1% as unmetabolized oxcarbazepine MOAs: slow the influx of sodium in the cortical neurons and slowing the spread of abnormal activity; indications: use to tx epilepsy, bipolar affective disorder, aggressive and assaultive behavior, and some neuralgias. Absolute contraindications, precautions, monitoring, adverse drug reactions, drug interactions: ones that raise the plasma level of the drug including grapefruit (the concurrent administration of propoxyphene, hydantoins, cimetidine, some antibiotics (erythromycin, clarithromycin), isoniazid, and verapamil such as tetracycline; interactions that cause hepatic damage (anesthetics, INH); and interactions that decrease the plasma levels o other drugs (beta blockers, succinimides, valproic acid, warfarin, haloperidol, doxycycline, and nondepolarizing muscle relaxants). Black Box warnings: regarding the development of Stevens-Johnson Syndrome (SJS) and toxic epidermal necrolysis (TEN) in patients of Chinese ethnicity; blood dyscrasia, thrombocytopenia, aplastic anemia… baseline CBC is required, TSH monitoring What does Long Term monitoring consist of Iminostilbenes: Carba - seizure activity, severity, and duration, CNS depression, and suicidality or behavioral changes. Range 4-12 mcg/ml Succinimides: used to tx absent seizures in children and adult. MOA: decreasing nerve impulses and transmission in the motor cortex. Monitoring: Plasma, renal, CBC levels should be monitored. The normal therapeutic range of ethosuximide is 40 to 100 mcg/mL; levels over 150 mcg/mL are considered toxic. The therapeutic range for methsuximide is 10 to 40 mcg/mL, with levels greater than 40 mcg/mL considered toxic. Drugs That Affect GABA: benzodiazepines, gabapentin (Neurontin), topiramate (Topamax), and tiagabine (Gabitril). The AEDs that affect the inhibitory neurotransmitter GABA are also used for pain, including neuropathic pain (gabapentin) and migraine (topiramate). Monitoring: Patients taking topiramate should have serum electrolytes, including sodium bicarbonate, monitored at baseline and periodically. Weight is monitored in all patients on topiramate as are body temperature and the ability to sweat, especially in warm weather. Serum ammonia levels should be drawn in any patient taking topiramate who exhibits any change in the level of consciousness, unexplained lethargy, or vomiting. ADR’s, Pharmacotherapeutics: Precautions and Contraindications: contraindicated in patients with multiorgan failure, hypersensitivity to the drug, DIC; Black-Box Warning regarding lifethreatening rashes, Stevens– Johnson syndrome, toxic epidermal necrolysis, and rash-related death. Patient Education: Drug interactions: Oral estrogen-containing contraceptives decrease lamotrigine levels by approximately 50% and Rifampin by 40% (Lamotrigine) Tricyclic Antidepressants (TCA): Precautions and Contradictions: with cardiovascular disorder due to their direct alpha-adrenergic blocking effect and quinidine-like effect on the myocardium, glaucoma due to their acetylcholine blocking effect, prostatic hypertrophy, or urinary incontinence. Must not prescribe for patients on MAOIs. Monoamine Oxidase Inhibitors(MAOIs - phenelzine (Nardil), isocarboxazid (Marplan), tranylcypromine (Parnate), and selegiline (Emsam), a transdermal): drug interactions Table15-13- avoid SSRIs, Food and drug interations. SSRIs (Prozac): Adverse Drug Reactions: With MAOIs, there needs to be at least a 14-day washout period before initiating an SSRI and at least a 21 day washout of fluoxetine before initiating an MAOI, management in children: , Drug interactions (including herbals & supplement): Concomitant use of St. John’s wort and/or SAMe (S-adenosylmethionine) may contribute to serotonin syndrome., Patient Education - 3 – 4 weeks before full therapeutic benefits Chapter 16: Drugs Affecting the Cardiovascular and Renal Systems ACEIs: increases oxygenation to heart muscles and decrease inappropriate remodeling of heart muscles after MI/HF, ARBs: blocks ATII receptors, does not affect ACEIs; Direct Renin Inhibitors: direct blocking of renin, decrease ATI & II, suppression of ATII triggers a mechanism that increases renin production, DO NOT USE IN DM. MOAs, indications, absolute contraindications, precautions, monitoring, adverse drug reactions, drug interactions CCBs: MOA, indications, precautions, contraindications, adverse drug reactions, drug interactions, differences between dihydropyridines and dihydropyridines, patient education, short acting vs long acting CCB side effects - bradycardia Cardiac Glycosides: indications, MOA, adverse drug reactions, contraindications, cautions, toxicity, drug and potassium, calcium and Mg interactions, monitoring, patient education, clinical pearls Antiarrhythmics- Procainamide monitoring and dosing: can cause long QT-syndrome; Amiodarone indications, patient education, monitoring; indications: onset of CHF; contraindications, and MOA: inhibits an enzyme that is important in making thyroid hormone and can cause hypothyroidism; BBs; Class IV CCBs that are indicated for arrhythmias Nitrates: MOA, patient education, precautions and contraindications, adverse drug reactions, tolerance, drug interactions, indications Peripheral Vasodilators: indications, adverse drug reactions, drug interactions Antilipidemics: MOAs, adverse drug reactions with each class, drug interactions, rational drug selection, monitoring, patient education, administration Diuretics: African American benefits the most. MOA, indications, precautions and contraindications, adverse drug reactions, drug interactions, rational drug selection, patient education, lifestyle management, lab monitoring patient education; Aldactone indication, MOA, side effects Chapter 20: Drugs Affecting the Gastrointestinal System Antacids: indications, precautions/contraindications, MOA; adverse drug reactions, drug interactions Antidiarrheals: MOA classes and MOAs; contraindications, adverse drug reactions, drug interactions, prevention and management of traveler’s diarrhea; rational drug selection : indications – bisacodyl suppository for a 10 y/o Cytoprotective agents: MOAs of misoprostol and sucralfate: decrease the exposure of the gastric mucosa to acid. Sucralfate acts largely as a Band-Aid to cover erosive ulcers and should be taken 2 hrs after an H2RA, while misoprostol acts by increasing the production of cytoprotective mucus. Antiemetics: classes and indications, precautions, adverse drug reactions H2Ras (ranitidine, famotidine, cimetidine): indications: tx duodenal ulcers, MOA: inhibit acid secretion by gastric parietal cells through a reversible blockade of histamine at histamine 2 receptors; metabolism, precautions, adverse drug reactions, drug interactions Prokinetic: MOA of metoclopramide: stimulates motility in the upper GI tract, precautions: Black box warning for tardive dyskinesia, adverse drug reactions, indications PPIs: Indications, MOA, adverse drug reactions, and monitoring; approach to GERD Laxatives: classes of drugs and their MOAs, indications for methylnaltrexone, those appropriate for pediatric use; Loperamide MOA: slows gastric motility and reduces fluid and electrolyte loss from diarrhea; precautions, special indications Chapter 22: Drugs Affecting the Reproductive System Androgens and Antiandrogens: uses, effects, side effects and monitoring: DECREASE LIDIBO WITH ANDROGEN THERAPY Estrogens and Antiestrogens: uses, effects, contraindications, side effects, monitoring Progesterones and Progesterone antagonists: uses, precautions, side effects, monitoring Drugs used for erectile dysfunction: MOA, monitoring, risks, drug interactions, and screening required for PDE5 inhibitors such as sildenafil/Viagra: fatal hypotension if combined with nitrates Chapter 24: Drugs Used in Treating Infectious Diseases Antimicrobial Resistance Antibiotics: Beta-Lactams: Penicillins and cephalosporins (uses, MOA, mechanisms of resistance, pregnancy category, ADRs including diarrhea management, Drug interactions, Cross- reactivity of PCNS and cephalosporins Acute Bronchitis and URI, Sinusitis (guidelines for antibiotic use) Pharyngitis: recommendation for GABHS; alternative for PCN allergic UTIS Skin and Tissue Infections H. pylori eradications: PPI, amoxicillin, and metronidazole for 14 days. Age, Pregnancy and Genetic Factors Fluoroquinolones Precautions and Contraindications Macrolides: drugs in this class, precautions and contraindications, Patients with renal and hepatic impairment, Adverse drug reactions, Drug interactions Systemic Azoles and other Antifungals: Precautions and Contraindications, Monitoring Sulfonamides, Trimethoprim, Nitrofurantoin and Fosfomycin: Spectrum of Activity and Resistance, Precautions and Contraindications, Blood Dyscrasias or G6PD deficiency, Pregnancy, Clinical Use, Adverse Drug reactions including cross-hypersensitivity Tetracyclines: Precautions and Contraindications, Pregnancy and Children, Adverse Drug reactions including dermatologic and pseudotumor cerebri (etext has typo and names it “pseudotremor”) Antimycobacterials: Isoniazid (INH) Precautions and Contraindications and Adverse Drug Reactions and Drug interactionsIdentify drugs that interact with Isoniazid (INH) Nucleoside Analogues: Drugs in this class, Spectrum of activity, adverse drug reactions, clinical use and dosing, Rational Drug Selection, Patient Education: adverse drug reactions Antivirals for Influenza: Drugs in this class, Clinical Use and Dosing You may find this concise overview of antibiotic classes helpful: Chapter 28: Chronic Stable Angina and low-risk Unstable Angina Classes of drugs used and their MOAs: Nitrates, BBs, CCBs: Verapamil HCL (Calan) in pt with stable angina, ACEIs, DRIs, Ranolazine, ASA, statins Causes of angina What drugs increase myocardial oxygen supply Classification/Grading of angina, goals of treatment Rational drug selection Risk factors for CAD: Class III angina Noncardiac causes of chest pain Initial therapy for angina: Morphine, oxygen, nitro, ASA (MONA) Indication for ASA use in patients with angina Which agents decrease mortality for patients with angina Lifestyle modifications Table 28-4 Drug choice based on concomitant diseases Table 28-5 BB contraindications Special considerations for women Cost consideration for antianginal drugs Chapter 29: Anxiety & Depression Evidence based treatments Classes of medications ADRs & Rationale Drug Selection Monitoring and Patient Education Special Evaluation Chapter 31: Contraception Advantages and Disadvantages of the Contraceptive Options Pharmacodynamics of estrogen: improves efficacy by suppressing FSH release, and therefore development of a dominant follicle. and progestins: exhibit a negative effect in the hypothalamic- pituitary-ovarian axis, essentially suppressing the LH surge necessary for ovulation; progestins cause atrophy of the endometrium, preventing implantation. MOA of pregnancy prevention: Safety concerns and contraindications to combined oral contraceptive use Rational Drug Selection Guidelines including Patient variables and Drug variables Adverse effects of contraceptive methods Patient education for patients taking hormonal contraception including starting methods and Instructions for missing doses Alternative hormonal methods including Patch, Rings: placed in vagina and left in place for 3 wks Progesterone Only contraceptives: indications, formulations (POP: use when estrogen is contraindicated, Injections, IUD, Implants) Emergency contraception Interaction between hormonal contraceptives and antibiotics Unique properties of, and monitoring for the progesterone drospirenone: Drospirenone may cause hyperkalemia and should be used cautiously with women who are using drugs that cause a potassium-sparing effect, such as ACE inhibitors, or have underlying renal disease. Implications of obesity on efficacy of contraception: absorption and bioavailability may be less effective due to lower serum levels Chapter 34: Gastroesophageal Reflux and Peptic Ulcer Disease Management of GERD: metoclopramide Management of H.pylori infection Chapter 36: Heart Failure Pathophysiology of heart failure Types of heart failure Classification of heart failure Symptoms of heart failure Indications for heart failure drugs by stage First line drugs of choice for heart failure: ACEIs, MOA of ACEIs that benefit heart failure Indications for use of BBs in patients with heart failure Diagnostic tests for heart failure Drugs that increase life expectancy in patients with heart failure Digoxin indications Drugs contraindicated in heart failure Drugs for managing heart failure during pregnancy Patient monitoring of HF Indications to use anticoagulant therapy Patient education Chapter 39: Hyperlipidemia Goals of treatment Rational drug selection Risk stratification Groups who benefit from statins (Table 39-5) First line drug therapy Statin: monitoring, patient education, contraindications Management of hyperlipidemia in those who do not tolerate or are not responding to statins Niacin: adverse effects; drug interactions, effect on reducing CV events Bile acid-binding resins indications Fibric acid derivative (eg Gemfibrozil) indications: lower triglycerides and raise good cholesterol (HDL) in the blood contraindications, including drug interactions: Risk of combining statins and fibrates: decrease fibric acid efficacy/ increase levels of statin Bild Acid sequestering resins – indications (eg colestipol: binds intestinal bile acids, increasing bile acid fecal elimination and preventing reabsorption, cholestyramine, colesevelam) Role of alternative therapy: Special considerations for treating patients with DM Chapter 40: Hypertension Rationale Drug Selection – Algorithm for management Lifestyle modifications Stepped therapy Initial Drug therapy - 1st line drug is thiazide Compelling indications-Table 40-3 and Table 40-5 Stepping up to multiple drugs – thiazide then diuretic Special considerations for older adults, African American patients, and concomitant diseases and therapies Patient education Ch. 43: Smoking Cessation Tobacco cessation therapies Goals of treatment for tobacco cessation treatment is the complete discontinuation of tobacco by going cold turkey or nicotine replacement therapy. Initial intervention for the treatment of tobacco use includes the Advise, Assess, and Refer (AAR) approach. Rationale drug selection Monitoring & outcome evaluation Patient education Chapter 44: Sexually Transmitted Infections and Vaginitis Differential diagnosis of vaginal discharge Management of syphilis: PCN G IM, All patients with syphilis should be tested for HIV; gonorrhea: Ceftriaxone 250 mg intramuscular single-dose injection plus azithromycin 1 g orally in a single dose or doxycycline 100mg; chlamydia: Azithromycin 1 g orally in a single dose or doxycycline 100 mg twice daily for 7 days, If pregnant Azithromycin 1 g orally in a single dose or amoxicillin 500 mg orally 3× daily for 7 days; bacterial vaginosis: Alcohol should be consumed during and 1 month after metronidazole 500 mg PO BID X 7 DAYS, is taken, use if pt is non-pregnant; Vulvovaginal candidiasis: OTC, intravaginal fluconazole 150mg if recurrent; HPV (genital warts): ; trichomonas: ; chanchroids: Azithro, cipro, erythro; cipro not recommended if under 18, Pregnant women are treated with azithromycin, ceftriaxone, or erythromycin; HSV: Acyclovir, drink lots of water; public lice, scabies Recommended follow-up (test-of-cure) for patients who have chlamydia: 3-4 wks after tx; gonorrhea 14 days after tx if it’s pharyngeal, retesting is recommended 3 to six months after tx to detect reinfection, or syphilis within six months after tx of primary and within 12-24 mnths after tx for latent phase Treating infections during pregnancy – choice of drugs (azithro/amoxicillin) PCN allergy and syphilis considerations - desensitize Chapter 48: Women as Patients Pharmacokinetic and Pharmacodynamic gender: Puberty: adolescent females may display female athlete triad (amenorrhea, eating disorder, osteoporosis) due to inadequate nutritional intake & disruption in normal growth. Also over exercising leads to syppression of the hypothalamic-pituitary ovarian axis that decreases estrogen levels, amenorrhea and decreases bone mineralization; Pregnancy: drug absorption increases due to increase cardic output that peaks at 20-24 wks Menopause: decrease in endonenous estrogen removes ptotective physiological mechanisms that support increase HDL and decrease LDL. DECREASE ESTROGEN LEVEL INCREASE THE risk of CAD, HTN, and stroke. and Older age considerations Pregnancy risk categories: Management of dysmenorrhea and PMDD - NSAIDs HIV and women – triple combined anti-retroviral decrease risk of passing to baby