NGR 6172 MIDTERM STUDY GUIDE

NGR 6172 MIDTERM STUDY GUIDE Week 1 Chapter 1: “Prescriptive Authority and Role Implementation” It is generally agreed that providing health care includes: assessing health status, promoting health lifestyles, identifying/diagnosing normal and abnormal conditions, providing referrals, selecting appropriate measures, implementing treatment, and supervising on an ongoing basis -prevention, diagnosis, prescription, and treatment Physicians were the first health care practitioners to gain legislative recognition -very broad scope of practice; exclusive right to practice; preeminent position in a hierarchy of health occupations; monopoly in healthcare The role of the physician changed dramatically and driven by new technology and medications, physicians have been attracted into specialty, leaving primary care -Medicare reimbursement has fueled the growth of tertiary care -emergence of nonphysicians; delivered high-quality and cost-effective care Physician Payment Review Commission recommended changes in Medicare and the shift directly increased financial reimbursement to clinicians who were providing primary care and thus increased more providers to primary care -increased access of care Physicians and dentists are the professionals who traditionally have been given right to prescribe -has been thoroughly documented by the pharmaceutical industry -types of medications prescribed are more closely monitored -less research has been conducted on the appropriateness of physician prescriptive practices, although the literature suggests that some physicians may write prescribes for problems that might well respond to nonpharmacologic therapy New drugs go through a trial: awareness, interest, evaluation, and trial It has been suggested that financial ties to drug companies may influence physicians’ prescribing practices Guidelines forbid pharmaceutical companies from giving to prescribers nonpatient care-related items exceeding $100 Problems in the Prescribing Practice of Physicians -Writing up-to-date prescriptions because of physician failure to keep abreast of changes -Pharmaceutical companies influence practice and providing drug samples -lack of time has become major; decreased patient encounters, inadequate history taking, failure to define problem, and an overreliance on drug therapy -consumers pressure to prescribe medications; overuse of antibiotics -illegibility of prescriptions; use of preprinter prescription pads, fax machines, and computer forms have helped -providers may fail to detect or anticipate drug interactions; herbal and OTC Chapter 2: “History Review of Prescriptive Authority” Research on the practices of nonphysician providers has demonstrated that they are qualified to provide primary care -some nonphysician providers have added diagnostic and assessment skills to their pharmacology knowledge Obtaining prescriptive authority was one of the major benchmarks achieved by these new provider groups as they developed their new roles The NP role and the physician assistant (PA) role paralleled each other -however, the PA role was defined under the guidance and advocacy of the medical profession Role of the federal government: the act of limited prescribing, dispensing, manufacturing, and distribution to those individuals registered with the DEA -narcotics and other drugs such as depressants and stimulants by their abuse potential, with differing levels of control assigned to each class -the DEA will register individuals who may prescribe narcotics and other controlled substances; registration, however, depends on state authority to prescribe controlled substances; other nurses working in states granting authority can apply for a DEA # -the role of who may prescribe, dispense, or administer belongs to the state Although the state may establish a list of minimum requirements that one must meet to be licensed, meeting them does not guarantee the provider is competent Two types of prescriptive authority are afforded to NPs: delegable authority and authority legislated by statutes -Delegable authority requires the nurse to perform under the direction of a physician -legislated by the state boards of nursing: dependent (physician has ultimate authority) and independent (allows NP to prescribe alone) Certified Nurse Specialists -Scope of practice: study and supervised clinical practice; serve as an expert in clinical practice, an educator, a consultant, a researcher, and an administrator -Status of prescriptive authority: who work in homes and the community; around 30 states give authority Certified Registered Nurse Anesthetist -Scope of practice: qualified to make independent judgements concerning all aspects of anesthesia care and recognized in all states; performing and documenting a preanesthetic assessment and evaluation; documenting and implementing an anesthetics plan; initiating technique; selecting, obtaining, and administering anesthetics; emergence anesthetics -status of prescriptive authority: the term prescription does not include dispensing for immediate administration; typically, do not need prescriptive authority; 5 states currently have independent prescriptive authority for CRNAs Certified Nurse-Midwives -scope of practice: primary health care services for women from adolescence to after menopause -statues of prescriptive authority: legislative authority in all 50 states Nurse Practitioner -scope of practice: provide a level of care commensurate with that of physicians, well accepted by their patients, and cost-effective; patients have similar or better outcomes with APRNs -statues of prescriptive authority: NPs have steadily granted authority; 19 states granted pull independent authority; 30 states allow NPs to prescribe controlled substances with physician involvement Issues Common to All Advanced Practice Nurse Prescribers -federal policy has established that only health care providers who are granted prescriptive authority to prescribe controlled substances by the state can be registered by the DEA -Definition and Registration of Mid-Level Practitioners: letter M precedes any DEA # -inappropriate use of DEA #: required for samples, sometimes required for billing/tracking Dispensing Privileges -federal law addresses the labeling and packaging requirements that must be followed; does not exclude specific prescribers from dispensing medication; all NPs can receive and/or dispense pharmaceutical samples but is limited to specific site or circumstances -question of whether a prescription written by an authorized prescriber can be filled by a central distribution pharmacy located in another state other than the one the NP is in (no laws address this issue) -even if NPs could prescribe in state and other state, the pharmacy has the right to reject the prescription Research of Prescriptive Practices -limitations on prescriptive practice can effectively restrict the public’s access to affordable and comprehensive primary care delivered by diagnosing and prescribing nurses -in 1981, California guided a study in effort to guide future legislative initiatives surrounding prescriptive authority for NPs and other midlevel providers -barriers to practice for nurses in prescribing role: regulatory irregularity among states; increased antagonism from organized medical groups competing with APNs for patients; growing number of NP graduates without prior nursing experience; inequity in data collection on physician prescribing patterns among pharmaceutical companies; difficulty in obtaining prescribing data from PDMA Prescriptive Authority and the Physician’s Assistant -PAs have some authority to prescribe -Practice medicine under the guidance of a physician; medical diagnostic, therapeutic, and preventative services -roles may include providing health care services that complement physician services, such as health promotion and disease prevention, and/or assuming educational, research, and/or administrative duties -prescriptive authority: state regulatory agencies now tend to recognize prescribing activities of PAs within circumscribed boundaries; constraints of prescribing (physician co-signature, limitations of types of drugs, schedule II agents) Chapter 9: “Establishing the Therapeutic Relationship” Patients may not take their medications as instructed: does not understand the seriousness of the condition, does not understand the instructions, forgot verbal instructions, difficulty taking the medication, angry or depressed, wants attention, no transportation Establishing trusting relationships: -patient and provider should establish a long-term relationship; compliance and adherence -time: a scarce commodity these days -attitude: who owns the problem? You or the patient? -information: most important is the history -communication: effective and two-way -positive feedback: be supportive Failure of the Therapeutic Relationship -drug noncompliance may be seen as the inappropriate self-administration of medications -problematic behavior can be exhibited as overutilization or underutilization of medication -risk factors include: increases with preventative therapy, duration of therapy, greatest for regimens that require significant behavioral change, poor understanding of instructions, complex treatment regimen, unpleasant side effects, increases in drug costs Chapter 10: “Practical Tips on Writing Prescriptions” Drug Schedules -drugs in schedule I have the highest potential for abuse, and their use is limited to research protocols, instructional purposes, or chemical analysis -schedule V drugs are available by prescription of OTC -Schedule II, III, IV must contain a symbol that designates the schedule to which it belongs and the following warning: “Caution” -internet and mail-order pharmacies may not fill prescriptions for controlled substances Components of the Traditional Prescription -most states insist that the hospital name or the imprinted name of the prescriber, along with credentials, address, and telephone number must be printed on the prescription pad for controlled substances -top portion: name and address of the patient, date that the prescription is written, age and weight of the patient -middle portion: superscription (Rx: “take”), inscription (ingredients and their quantities, strength, or concentration), drug, strength or concentration (dose taken), signature (directions for use) -having specific information about why the patient is taking the medication can help the pharmacist give instructions -bottom portion: refills (not permitted for Schedule II drugs, max 5 refills or a 6-month supply), provider signature, DEA number, generic substitutions (write DISPENSE AS WRITTEN) Electronic Drug Prescriptions or E-Sign -voids the requirements that prescriptions must be written on paper or printed as a hard copy -there are financial incentive and penalties via Medicare for prescribing (HCPs that do not participate will receive a percentage decrease in reimbursement) Drug Prescribing Etiquette -federal law stipulates that providers may not write prescriptions for narcotics for themselves or family members -there is no law against prescribing for friends, but pharmacist may call and discuss as a curtesy -HMOs have begun to watch prescribing practices -prescriptions refilled regularly, although the patient is not required to return to provider, may stimulate questions for pharmacists -drug sample trading between providers; they are responsible for adverse effects Avoiding Mistakes -write clearly, E-prescribe, with disclosed suicidal ideation: write for no more than a 7-day supply of a medication a patient can overdose on if taken all at once; discuss side effects; discontinue a medication when it causes a cautioned side effect; get informed consent when a drug can cause permanent side effects and a less risky alternative is available -if prescribing “off-label”: document the rationale for deviating from the package insert instructions, and be prepared to prove that the standard of care supports the alternative prescribing regimen -if a drug is known to cause adverse effects after long-term use, avoid using the drug for long- term therapy or monitor carefully for the onset of potential problems -ask, listen, and alter the plan Administrative Concerns -formularies: can be restrictive -Medicaid: must be an authorized provider -out-of-state prescriptions: mail order, internet prescriptions (may not allow script) -prescriptions by telephone policy: except Schedule I and II (Schedule II: 10hr supply in emergency but must have prescription in 72 hrs) -prescription refill policy: minimally need to be done annually -dispensing medications: emergency of 1 or 2 doses by pharmacies -drug substitution by the pharmacist: many states where generic substitution is automatically allowed; if brand name is required, hand write “Do Not Substitute” on script Preventing Problems in Drug Use -the abusing patient: asks of narcotics by name, carries copies of abnormal lab tests/ECGS, calls frequently seeking refills or larger amounts -attempts to refill prescriptions early, change prescriptions so that more drug will be dispensed, and use multiple providers -the abusing health care provider -the financially needy patient ( ; most pharmaceutical companies have assistance programs) Good Communication and a Developing a Positive Relationship with the Pharmacist -establish a personal relationship with the pharmacist to establish a team that seeks to eliminate errors and increase patient satisfaction with medications Chapter 11: “EBD Making and Treatment Guidelines” Critical Decision Making -the quality of healthcare is determined by two main factors: the quality of the decisions that determine what actions are taken and the quality of the way I which those actions are executed -if the wrong actions are taken or the correct action but wrong execution is taken, the quality of care will suffer; traditionally healthcare education was taught by actions of physicians highly dependent on influence of mentor; diagnostic reasoning is an important role of the provider -components: judging and evaluating (implies not just contemplation but also action based on choices; establishing goals and taking risks); beyond what is thought of as critical thinking Critical Thinking -knowledge (domain-specific content and critical appraising skills) attitude (inquiry, curiosity, and desire to explore) outcomes (empirical indicators) -critical thinking involves dimensions of logic, problem solving, and scientific inquiry -Distinguishes between: observations and inference; determine the reliability of a claim or source, accuracy of statements, and strength of an argument; differentiate between relevant and irrelevant data and warranted and unwarranted claims; recognize ambiguous or equivocal claims/arguments; discern inconsistencies in reasoning; draw inferences -process of critical thinking: synthesis of information, prediction of outcomes, examination of assumptions, generation of options, identification of patterns, choice of action Decision Making -knowledge/evidence judgements/critical analysis/benefits vs harm costs/marginal benefits estimate/outcomes patient and provider preferences/critical thinking/judgements/important patient outcomes/estimated patient outcome/patient preferencesdecision Critical Decision Making Regarding Pharmacologic Therapy -confirm the diagnosis; determine (if a medication or nonpharmacologic therapy is chosen, and then how aggressive the therapy will bemust be individualized); select the drug and start it; determine if drug effectiveness after start of treatment (continue med, modify regimen, or discontinue) -some research findings found some nurses are action oriented and too early on diagnosis, forming incomplete assessments -diagnostic failures: faulty hypothesis triggering, faulty context formulation, faulty info gathering and processing, faulty verification of diagnosis -Eddy: outcomes of the different options must be eliminated, then the desirability of the outcomes must be compared (benefits vs harm, compare costs) Evidence-Based Medicine -training for uncertainty (incomplete or imperfect mastery of available knowledge and limitations in current medical knowledge) -traditional decision-making paradigm (unsystematic observations from clinical experience are a valid way of building and maintaining ones knowledge about diagnosis/tests/efficacy of treatment; study and understanding of the basic mechanisms of disease and pathophysiologic principles; combination of traditional medical training and common sense is sufficient to allow one to evaluate new tests and treatment; context expertise and clinical experience form a sufficient base from which valid guidelines can be derived) -What is EBHC? Evolution of focus on critically appraising available evidence that has been in progress for years -Barriers: ignores (clinical experience and clinical intuition, basic investigation and pathophysiology, standard aspects of clinical training -Does EBM improve patient outcomes? -antipathy and skepticism toward EMB may result from doubt about whether it can be applied to day to day practice -some don’t like it because it implies what they did previously was not evidence based -emotional barriers: topic can be threatening, people like quick and easy answers, high quality evidence may be lacking in some clinical questions -understanding basic investigation and pathophysiology plays no part in EBM Clinical Guidelines -clinical guidelines are official statements that outline how to prevent, diagnose, and treat specific medication conditions or how to perform certain clinical procedures -issues by government agencies, medical specialty societies, and other health organizations -factors to consider: source, appropriateness of method, scientific rigor in evaluation, use of expert experience, decision making, public policy issue consideration, feasibility issues, peer review, congruence with other practice guidelines, timeliness, funding -process for guideline development: -informal consensus: experts meet to discuss and decide recommendations subjectively -formal consensus: systematic approach to formally assess -EBG development: expert panel follows systematic approach and recommendations made -explicit guideline development: clarifies recommendations by calculating potential benefits, harms, and cost -limitations: “cookbook”-guideline that describe treatment without linking it to valid scientific evidence or ignore individuality of patients (degree of precision: some are too vague and have lack of clarity) Week 2 Chapter 3: “General Pharmacokinetic and Pharmacodynamic Principles” A drug is a substance that is used in the diagnosis, cure, treatment, or prevention of a disease Pharmacokinetics: the study of the action of drugs in the body, including the processes of absorption, distribution, metabolism, and elimination -what the body does to the drug Pharmacodynamics: the study of the biochemical and physiologic effects of drugs on the function of living organisms and of their component parts -what the drug does to the body Drug Nomenclature -chemical: drug’s chemical composition and molecular structure -generic (or nonproprietary): official name assigned by the manufacturer with the approval of the U.S. Adopted Name Council -trade: patent name given to the medicine by the company marketing the drug -if 1 or more companies manufacture the drug, the drug will have more than 1 name -providers should refer to drugs by their generic name to patients because the contents of trade name products may vary Pharmacokinetics -Absorption: how much the drug leaves its site of administration -bioavailability: how much of the drug that is administered reaches its site of action; the fraction of the drug that reaches systemic circulation is called f value; when a solid has been ingested, the drug must break down (disintegrate) and become soluble in body fluid (dissolution) -bioequivalence: two drug products (1) contain the same active ingredients; (2) are identical in strength of concentration, dosage form, and route of administration; and (3) have essentially the same rate and extent of bioavailability; the drug must be 20% of the generic drug, which causes concern when the therapeutic window is narrow -factors that affect absorption: drug characteristics, routes of administration, cell membrane characteristics -drug characteristics: formulation (influences dissolution rate of solid form of drug), concentration (the higher the concentration, the more quickly the drug is absorbed), lipophilicity (nonionized drugs are more lipid soluble and may readily diffuse across membranes; ionized drugs are nondiffusible), pH (basic drugs tend to ionize; acidic drugs become nonionized in the acidity of the stomach and diffuse more readily) -Routes of administration: oral (most common and safest method; however poor GI absorption, irritation of the GI mucosa, destruction of the drugs may occur because of digestive enzymes and low gastric pH, interactions mar occur; fastest to slowest- liquids, elixirs, syrups, suspensions, solutions, powders, capsules, tablets, coated tablets, enteric-coated tablets, and slow-release formulations), sublingual (avoid the first pass phenomenon; there will reach site of action quickly), topical (does not absorb well, avoids first-pass effect; skin not intact are more readily), rectal (when the pt is vomiting or nauseous; less first-pass metabolism; less complete), inhalation (pulmonary absorption uses a larger surface area, making absorption rapid; goes directly to the site of action; avoids first pass affect), and ophthalmic -blood flow: decreased circulation will result in decrease absorption; vice versa -cell membrane characteristics: drugs absorbed pass through cells and not between them via passive diffusion or active transport; pH affects diffusion; passive diffusion (area of high to low concentrations) and active transport (low to high concentration, using an energy source) -distribution: transport of a drug in body fluids from the bloodstream to various tissues; consists of two phases (movement from the site of administration into the bloodstream and then the delivery into the tissue); volume of distribution (Vd) is the amount of space into which a drug can be spread or distributed; geriatric population has less muscle and more fat, placing them at risk for accumulation; drugs that are highly protein bound have a volume of distribution that is about the same as the amount of plasma (if two protein-bound drugs are used, the most tightly protein-bound drug will tend to displace the other; another common change that may affect distribution in older adults is a decrease in serum albumin -factors affecting distribution: plasma protein binding, obesity, edema, tissue binding -biotransformation (metabolism): chemical inactivation of a drug through conversion or a more water-soluble compound that can be excreted from the body; occurs in the liver, but may be found in the lungs and GI tract; if blood flow to the liver is decreased, drugs will metabolize more slowly, leading to a longer duration of action; lipophilic drugs pass easily through membranes -phase I: oxidation or reduction: makes drug more hydrophilic and involves cytochrome P450 enzyme; a drug can be a substrate (a drug affected by a change in its enzyme metabolism), a inducer (a drug that causes acceleration in the enzyme metabolization of another drug), or an inhibitor (a drug that causes inhibition in the enzyme metabolization of another drug) -phase II: biotransformation: conjugate reactions in which a compound is added to the drug; drugs become a highly water-soluble substance with little or no pharmacologic activity; first- pass effect; oral medications are extensively metabolized to inert compounds when they first pass through the liver; a prodrug is a chemical that is pharmacologically inactive and is biotransformed into a biologically active metabolite -Elimination: is the process by which drugs and their metabolites are removed from the body, primarily through liver and kidneys; in the kidney (glomerular filtration, tubular secretion, and partial reabsorption); steady state means that there is a stable concentration of the drug or the drug is being administered at the same rate at which it is being eliminated; other routes of elimination: Fecal (often clinically significant in patients with hepatic insufficiency or failure), respiratory (important in elimination of anesthetic gases), breast milk (effect of nursing infant), perspiration/saliva/tears/hair/skin (not significant) -cr. Clearance= weight(kg) * (140-age)/72 *serum cr. -clearance= rate of removal/plasma concentration -clearances is the volume of plasma from which all drug is removed within a given time; if stored in adipose tissue, it cannot be cleared from the body -First-order/linear kinetics: half-life is the length of time required for the amount of drug in the body to decrease by one half; significant factor in accumulation and elimination and depends on clearance and volume of distribution -steady state is achieved after 4-5 half lives -drugs with short-half-lives include ibuprofen and the benzodiazepine lorazepam; long half- lives include anticoagulants, diazepam, digoxin, and fluoxetine -when a patient is given a drug on a regular schedule, the drug will continue to accumulate until steady state is achieved -Nonlinear kinetics: when the amount of drug concentration exceeds the ability of the liver to metabolize the drug; half-life depends on the concentration of the drug; the amount of drug eliminated is constant; the drug is removed via saturation of a function, such as protein being, hepatic metabolism, and active renal transport; toxicity is a frequent problem -phenytoin is a nonkinetic because of both protein binding and hepatic metabolism (when the drug is first taken, the molecules bind to protein, when they become saturated, the more drug floating in the system); narrow therapeutic window, making toxicity a problem -theophylline is another nonkinetic Pharmacodynamics -Mechanism of action: most drugs act on the body via chemical reactions with some large molecular component of the organism -drug receptor: a receptor is the component of the organism that binds to a ligand and produces a change in function within the body; drugs cause effect by interacting with receptors, most drug receptors are proteins; the site where the drug acts depend on the location of the receptor -two types of drug-receptor interaction can occur: agonist (a drug with an affinity for and stimulates physiologic activity at cell receptors normally activated by naturally occurring substances) and antagonist (drug that inhibits or counteracts effects produced by other drugs or eliminates undesired physiologic effects caused by illness; inactivates the receptor) -some drugs are not mediated by receptors but by: interaction with small molecules or ions that are found in the body or have structures close enough to normal biologic chemicals that the body may incorporate them into cellular components -Adverse drug reactions and side effects: ADRs (a response to a drug that is noxious and unintended and occurs at doses normally used for man for prophylaxis, diagnosis, or therapy of disease; an undesired experience associated with the use of drug; unfavorable and unintended) side effects (additional effect, desirable or undesirable, of a drug that is not the primary purpose of the drug) -ex: adverse (development of pancytopenia from chloramphenicol) side effects (photosensitivity caused by tetracycline taken for acne) -risk factors: prescriber (duplication of meds, unclear directions, incomplete drug history, inappropriate dosing, and no follow up), pharmacist (automatic refills, prescription errors, failure to review medication profile, lack of appropriate education) patient (use of OTC, incomplete knowledge of drug history, use of alcohol, use of multiple pharmacies with no coordination of drugs, use of multiple providers, poor compliance -serious ADRs: events caused by a drug that results in a patient’s death, hospitalization, or disability, or that causes a congenital abnormality or life-threatening event, or that require an intervention to prevent permanent damage; if serious warnings to drug prescribers is required to ensure the continued safe use of a product, the FDA may require the drug manufacturer to print a warning “black box” -drug interactions: always evaluate the risk versus benefit; if the drug has a narrow therapeutic window, then the risk of drug-drug interaction is greater extreme of age is a greater disposition (others: seizure disorder, CVD, HIV); common drug interactions may be described as summative, synergistic, or potentiating -Many antibiotics. Erythomycin is a substrate and inhibitor; azole antifungals are inhibitors; warfarin is a substrate; caffeine is a substrate; grapefruit is an inhibitor -food and drug interactions: interactions occur as a result of activation of the P450 enzyme system or competition with receptor sites; MAOIs cannot be taken with aged cheese or processed foods; nicotine can diminish effectiveness of drugs; caffeine; penicillin should avoid fruits/juices/soda; cephalosporin should be taken on an empty stomach -alcohol-drug interactions: may be a factor in at least 25% of all emergency department admissions; geriatric population is at risk; an acute dose of alcohol may inhibit drug metabolism by competing with the drug metabolism by competing with the drug for the same set of metabolizing enzymes (prolongs and enhances the drugs availability); chronic alcohol ingestion may activate drug-metabolizing enzymes, decreasing the drug’s availability and diminishing its effects); alcohol can influence the effectiveness of a drug by altering its availability (enzymes activated by chronic alcohol consumption transform some drugs into toxic chemicals that can damage the liver or other organs; alcohol can magnify the inhibitory effects of sedative and narcotic drugs at their sites of action in the brain; some drugs affect the metabolism of alcohol, altering its potential for intoxication and the adverse effects associated with alcohol consumption) -other concerns: OTC interaction (read the attached warning label), herbal and CAM therapies (ginkgo, ginseng, and garlic are known to interact with anticoagulants and antiplatelets), genetic disorders (when LQTS is identified, immediate withdrawal of agent is crucial), drug effects on laboratory tests and blood substances, chronotherapy (secretion of catecholamines increases early in the morning which increases the HR, CO, contractile force, and systolic blood pressure  take antihypertensives in the AM -Toxicities and overdose: most frequent is accidental overdosage; other causes (repeated doses, confusion, failure to make adjustments in medication, unsupervised children) -Risk-benefit ratio: amount of “acceptable” risk of adverse reaction or treatment failure that a patient might experience when taking a drug vs the calculation of potential benefit; patient and provider together must determine the degree of risk that will be tolerated (dependent on the severity of the disease that is being treated) -Design and optimization of dosage regimens: calculate the therapeutic index (lethal dose/therapeutic dose); consider target level (steady-state concentration), maintenance levels (the rate of input equals the rate of output); loading (if target dose must be met rapidly), therapeutic drug monitoring (measuring serum drug levels in patients with narrow therapeutic window, to maximize efficacy and minimize toxicity) Practical Application to Drug Prescribing -always try nonpharmacologic therapy first, use a drug only when it is clearly indicated for a specific purpose, use only one drug when possible, use lowest effective dose, start low and go slow (no more than 50% and no more often then 3-4 half-lives; 1-2 weeks after dose is started), simply regimen whenever possible, use the side effect profile on one drug to treat other symptoms, monitor for therapeutic effects, keep good patient records, be particularly careful with drugs that are strongly associated with adverse effects, always keep drug interactions and adverse effects in mind when evaluating the patient, stay up-to-date Chapter 4: “Special Populations: Geriatrics” Older adults make up 14% of the population yet account for 30% of medication expenditures (12% take 10 medications daily and 23% take 5 medications daily) 82% of population is on at least 1 drug; most common classes are cardiovascular, analgesic, and CNS and will additionally add supplements, vitamins, and home remedies; more at risk for ADRS -warfarin, insulin, oral antiplatelet drugs, and oral hypoglycemic agents are responsible for 2/3 ER admissions ages 65 and older -evaluate medications for efficacy, ARDs, and functional status (weight, mobility, continence, and falls); assessment tools Katz’s Activities of Daily Living and Folstein Mini-Mental Status Examination -Absorption: some reduced absorption has been noted in older adults; physiologic changes affect the GI tract including a reduction in acid output and the subsequent alkaline environment (because the GI tract has such as large surface area, extent of absorption is not effected; nonionized forms of a drug are more readily absorbed than ionized forms); a change in absorption may also results of alterations in motility and in the rate of gastric emptying; food can delay or reduce the absorption of certain drugs, particularly antibiotics -Distribution: consider common age changes including decline of total body water, body mass (lean vs fat [increase fat= drug accumulation), decrease in serum albumin (most common protein that binds acidic drugs, creating greater free concertation of highly, protein-bound drugs); drug distribution dependent on any of these variables may be affected (enhanced effect and toxicity) -distribute into body water or lean body mass: digoxin, lithium, meperidine, theophylline, cimetidine, gentamicin, phenytoin -examples of lipid-soluble drugs: diazepam, chlordiazepoxide, flurazepam, thiopental, antipsychotics, antidepressants -sample of high-binding affinity to albumin (need reduced dose): phenytoin, warfarin, naproxen, theophylline, phenobarbital, antidepressants -Biotransformation (metabolism): aging influences loss of hepatic reserve: declining mass, decreased hepatic blood flow, altered nutritional status, other physiologic changes and disease -when flow is reduced, less drug is metabolized and increased amounts may be present in active form in the blood, when the drug with first-pass metabolism are prescribed lower doses may be necessary -first-pass effect meds: lidocaine, meperidine, morphine, propranolol, metoprolol, verapamil, estrogens, nitrates, barbiturates -Phase I metabolism is primarily affected; drugs complete with CYP450 pathway for metabolism; drugs that are metabolized and excreted by the liver should be started at 30-40% less than average dose -Ex of drugs of phase I: lidocaine, phenytoin, propranolol, and theophylline -Ex of drugs that depend on phase I: diazepam, flurazepam, chlordiazepoxide, piroxicam, quinidine, barbiturates -Excretion: age-related changes in renal function are most important physiologic factor that results in ADRs; changes include (decreased of nephrons, decreased renal blood flow, glomerular filtration rate, and tubular secretion, increased number of sclerosed glomeruli, decreased creatinine clearance) -chronic diseases also may affect renal function; this can further complicate required dosing -creatine clearance: 24-hr urine collection Pharmacodynamic Chances in the Elderly -change in receptor affinity or number or changes in hormonal levels; the impact of drugs that affect the CNS and the cardiovascular system changes -drugs with anticholinergic side effect profiles often cause central and peripheral adverse effects (sedation, confusion, orthostatic hypotension, constipation); high risk for falls Common Concerns Related to Medication use in Older Adults -Adverse drug reactions: higher in the older adult; increase exponentially with 4 or more drugs; reduction in number of medications may not be an option; the average older adult uses 4.5 prescription and 2 OTC daily -when treating depression with SSRIs, consider serotonin syndrome (most often occurs when 2 drugs that affect the body’s level of serotonin are taken together and too much serotonin is released or remains in the brain producing a life-threatening condition -Adherence: the extent to which a patient follows a planned medical regimen -barriers to adherence: cost, complicated/unrealistic schedules, impaired cognition/judgement, side effects, lack of knowledge related to need or purpose of medication, fear of side effect or exacerbation of other problems, no perceived response/effect from drug therapy -compliance decreases in: denial regarding their condition, meds prescribed for preventative reasons, when patient feels no benefit, patient does not believe the medication will help condition, when no immediate consequences result, and when they feel short term side effects outweigh benefits Chapter 5: “Special Populations: Pediatrics” Pharmacokinetics of Drug Therapy in Infants and Children -determining how to give medications to children involves an understanding of various physiologic factors that may be affected by these drugs -Information must be mastered for each age group that makes up the pediatric category -preterm (gestational age younger than 36 weeks), neonates (30 days old and younger), infant (1-12 months), toddler (1-4 years), children (5-12 years), adolescents (13 years and older) -Absorption: physiologic status affects blood flow, which affects absorption at the site of parenteral drug administration; fluctuating GI function from neonatal period to about 8 months affects enteral administration; transdermal permeability is enhanced in premature infants and newborns -factors that reduce blood flow to muscular or subcutaneous tissue include cardiovascular shock, vasoconstriction caused by sympathomimetic agents, and heart failure -in the first weeks of life, the intestine is highly permeable and premature babies may absorb substances that cannot penetrate the more mature intestine (presence of amniotic fluid in stomach ensures an alkaline pH) -drug absorption may be delayed or increased to a greater extent than anticipated because of the density of intestinal flora, reduced enzyme function, delays in gastric emptying, deficient transport mechanisms, or slow GI tract -normal levels of gastric acid is produced between 3-7 years -Distribution volumes of drugs in the child vary as body composition changes through growth and development; (1) the physiochemical properties of the drug itself (2) the physiologic factors specific for the patient including total body water, extra cellular water, protein binding, and pathological conditions that modify physiologic function. -the neonate has a higher proportion of its body weight in the form of water; body fat in premature is less than in full term infants (reduced % of fat in premature infants; plasma protein binding in neonates comparatively low; drug distributed in breast milk of breastfeeding mothers may pose problems for infants; in premature infants, incomplete glial development enhances the permeability of blood-brain barrier and permits drugs and bilirubin to enter the CNS more readily -plasma protein binding in neonates is comparatively low because of decreased plasma protein concentration, lower binding capacity of protein, decreased affinity of proteins for drug binding, and competition for binding sites (concentration of free drug in plasma is increased and exerts powerful pharmacologic effects and can increase toxicity -Metabolism: slower in infants than in older children and adults; slow clearance rates and prolonged half-lives (given neonates decreased ability to metabolize drugs, they may be at increased risk for adverse effects because of slow clearance rates and prolonged half-lives) -Excretion: glomerular filtration rate is at 50% of the adult value by about the 3rd week of life; GFR reaches adult value by about 6 months; changes in urinary pH affect excretion (increased duration of action); if a child is ill enough to require drugs that affect the kidneys, the FGR will not improve as predicted in the first few weeks and will require an adjustment in dose Consider a Drug Regimen -Consider: formulation (pull, liquid, suppository), vehicle of delivery (dropper, teaspoon), taste -Drugs to avoid in children: tetracycline (stains permanent teeth), codeine and dextromethorphan (poor antitussives vulnerable to respiratory depression), aspirin (reye’s syndrome), valproic acid (high incidence of liver toxicity) Adverse Drug Reactions in Children -children may be exposed to drugs likely to provide adverse reactions in three major ways: trasplacentally, by direct administration, by ingestion of drug through breast milk -the incidence of adverse reactions in pediatric patients is unknown; CNS depression in the newborn may result from analgesics or esthetics -excessive uterine stimulants are associated with anoxic encephalopathy and excessive IV fluids can cause convulsions or electrolyte disturbances -studies generally have found the rate of adverse reactions to equal that in adults; rate may be 5.8% of drugs administered in children, although the rate is higher if the child is hospitalized rather than ambulatory Calculation of Pediatric Dosages -package insert provided by the manufacturer is the best source for pediatric dose recommendations (if not available, proper dosage is calculated based on weight, age, or surface area -weight of child/weight of adult (70) *adult dose = child’s dose -topical is more likely to cause toxic effects because the child’s skin is thinner and more sensitive Status of Drug Dosing and Policy Regarding Children -research on drug dosing for children: in 1995, the American Academy of Pediatrics reported that only a small proportion of all drugs and biologic products marketed in the US had clinical trials performed in pediatric patients (most marketed drugs were not labeled for use in pediatric patients or for use in specific pediatric age groups) -variables attributed to adherence: patients’ conscientious effort to follow directions, measuring errors, spilling, spitting out -parent and child education Chapter 6: “Special Populations: Pregnant and Nursing Women” Incidence: 90% of pregnant women take 1 prescription drug during pregnancy; average patient uses 5-9 different drugs during pregnancy; 65% of women admit to self-administration of drugs during pregnancy Principles of Teratology: Incidence and Types of malformations -200,000 birth defects annually; 5% of birth defects attributed to drugs; only 19 drug groups identified as probably teratogenic agents in humans; almost 1000 known teratogens identified for laboratory animals -Drugs causing teratogenic effects: ACE inhibitors, antithyroid, antibiotics, aminoglycoside, tetracycline, cephalosporin, anticancer agents, methotrexate, androgenic hormones, isotretinoin, thalidomide, primidone, valproate acid, carbamazepine, coumadin, anticoagulants, alcohol, cocaine -Thalidomide: CNS depressant used in 1960s as sedative-hypnotic agent and to reduce nausea and vomiting of pregnancy birth defects worldwide and this forced the attention of scientific and lay community on the question of drug safety and pregnancy -drugs have pregnancy ratings: A (adequate, well controlled with no abnormalities) B (animal studies show no harm) C (animals show deformity, but not well controlled studies on humans; give only if the potential benefit justifies) D (well controlled demonstrating harm to fetus; benefits may outweigh risk) X (well controlled and positive for abnormalities, contraindicated) -preembryonic period is an all or none effect because there are no cells to create malformations, the ovum can just die -the most critical time in which drug exposure should be avoided is the embryonic period (week 3-8) due to the major organogenesis and risk of inducing major malformations -the placenta plays an important role in determining the teratogenic potential of a drug. The surface area increases with gestation while placental thickness decreases -Caution: maternal-fetal genotype, dose-reponse relationship, sepcificity of agent, and drug interactions or polypharmacy Common Conditions During Pregnancy -physiologic changes (maternal blood flow increaes, decreased protein building, increased renal function), N/V (start 2-3 weeks after missed menstrual cycle until 8-12th week; antihistamines, promethazine, doxylamine, dopamine antagonists) UTI (most common), asthma (becomes worse), infection, epilepsiy (anticonvulsants use is associated with hemorrhagic disease of the newborn [can be decreased with vitamin K, take after week 36th; give folic acid beforehand]), diabetes, HTN (second leading cause of maternal death; try nondrug; ACE inhibitors, ARBs, and statins are contraindicated in the first trimester), STIs, depression (sertaline or paroxetine) Hazards to Mothers and their Children -isotretinoin (used to treat severe recalcitrant consular acne, restricted med-must have pregnancy test in order to take); vaccinations (rubella); caffeine (2-4 caffeine-containing beverages per day); alcohol (down syndrome, spina bifida, growth retardation, neurologic defects); nicotine and smoking, illegal drugs Chapter 33: “Male Genitourinary Agents” Benign prostatic hyperplasia: A1-adrenergic antagonists: a1a-selective: tamsulosin (flomax), alfuzosin (uroxatral), siodosin (rapaflo) Long-acting a1: doxazosin (cardura), terazosin (hytrin) Short-acting a1: prazosin (minipress) 5a-reductase inhibitors: finasteride (proscar), dutasteride (avodart), dutasteride plus tamsulosin (jalyn) Erectile dysfunction: PDE5 inhibitors: sildenafil (viagra), tadalafil (cialis), vardenafil (levitra), avanafil (stendra) Other: alprostadil (caverject), yohimbine (yocon) Indications BPH: management of BPH, more commonly the a1-adrenergic receptor blockers such as doxazosin and terazosin, which can also be used for HTN; tadalafil has recently been approved for enlarged prostate Indications ED: unlabeled use include treatment of ED resulting from vascular or diabetic origins, or from the use of serotonin reuptake inhibitors; also used of rorthostatic hypotension; alprostadil is used in treatmetn of ED resulting from neurogenic, vasculogenic, or psychogenic Physical examination emphasizes the digital rectal examinatino and the neurologic system; lab tests required to assess renal function include urinalysis, serum creatinine, and BUN MOA BPH: -a1-adrenergic receptor blockers: reduce sympathetic tone and relax urethral stricture the causes BPH symptoms; prazosin has a shorter duration of action and is no the first line; lowering BP by blockign a1-adrenergic receptors on arterioles, causing vasodilation (short acting has minial BP effects) -5a-reductase inhibitors: reduces the size of the prostate gland, but 6-12 months may be required; blocks the conversion of testosterone Treatment Principles: -surgery is primary treatment; transurethral microwave thermotherapy -treatment is initiated when symptoms become problematic -all a-blockers are considered equally efficacious; first line; selective antagonist w/o HTN or long acting w/ HTN -a-blockers are the best for quick symptoms relief -5a-reductase inhibitors can prevent growth of the prostate over the long term -goals: alleviate symptoms and maintain kidney function -herbal treatments: B-sitosterol plant and saw palmetto plant are likely beneficial -the FDA issues a warning that there is an increase of being diagnoses with high-grade prostate cnacer while on 5a-reductase inhibitors Patient Variables -pregnancy: finasteride and dutasteride are category X (use condomes; do not touch) MOA for ED: Men who have ED are at an increased risk for cardiovascular disease, stroke, and death -PDE5 inhibitors: NO increases cGMP, producing muscle relaxation. PDE5 breaks down cGMP, so inhibitors inhibit cGMP breakdown allowing for increased bloodflow into the penis -maintains smooth muscle relaxation and promote inflow of bloodflow -Alprostadil relaxes the trabecular smooth muscle and by dilation of the cavernous always arteries causing expansion of the venules against the tunica albuginea; injection -Yohimbine stimulates presynaptic norepinephrine release in lower nerve centers Treatment Principles -oral PDE5 inhibitors should be first line unless contraindicated -pharmacologic treatment: hormone replacement, PDE5 inhibitrs (careful in cardiac pts.), intraurethral prostaglandin, yohimbine -nonpharmacologic treatment: vascular reconstruction, vacuum constrictio device, implanted penile prostheses Patient Variables -geriatric: sildenafil, vardenafil: reduce dose -pregnancy: alprostadil do not have sex w/pregnant woman unless using a condom; yohimbine do not use Sildenafil is linked to serious cardiovascular events, including MI, sudden cardiac death, ventricular arrhythmia, cerebrovascular hemorrhage, TIA, and HRT Chapter 34: “Agents for Urinary Incontinence and Urinary Analgesia” Anticholinergics: oxybutynin chloride (ditropan, oxytrol), fesoterodine (toviaz), tolterodine (detrol), trospium (sanctura), onabotulinumtoxinA (botox) Bladder-targets anticholinergics: darifenacin (enablex), solifenacin (vesicare) Antispasmodics: flavoxate (urispas), propantheline (pro-banthine) Cholinergic agonists: bethanechol chloride (urecholine) Posterior pituitary hormones: desmopressin (DDVAP) Urinary Tract Analgesia phenazopyridine (pyridium) Indications: oxybutynin: dysuria, neurogenic bladder, overactive bladder, urge continence/frequency/urgency; tolterodine: overactive bladder, urge incontinence, trospium: overactive bladder; darifenacin and solifenacin: overactive bladder; flavoxate: dysuria adjunt in UTI; propantheline: adjunctive therapy for peptic ulcer; desmopressin: primary nocturnal enuresis; bethanechol: urinary retention; phenazopyridine: dysuria; botox: bladder control -unlabeled: propantheline: urinary urge incontinence; desmopressin; overactive bladder MOA: -anticholinergic: blockade of muscarinic actions; inhibits action of acetylcholine on bladder smooth muscle; blocks contraction and decrease the urodynamic response; increase bladder capacity, delayed desire to void, and diminished frequency of involentary bladder -adverse effects: blurred vision, urinary retention, constipation, dry mouth, tachycardia, and confusion -cholinergic: stimulaton of parasympathetic system; release of acetycholine, increasing detrusor muscle tone; increased tone causes a contraction that initiates voiding and bladder emptying -Antispasmodic: smooth muscle relaxant thereby producing increased bladder capacity -Desmopression: can be used for child nocturia; strong antidiuretic; decreases urine output for 6 hours -Urinary tract analgesia: an azo dye that is excreted in the urine; exerts a topical analgesic effect on urinary tract mucosa Treatment Principles -Stress incontinence: beneficial is SNRIs, estrogen cream, ring, imipramine, pseudoephedrine; likely to be beneficial is pelvic floor electrical stimulation, pelvic flood muscle exercises, vaginal cones -urge incontinence: first line: oxybutynin, darifenacin, solifenacin, tolterodine, trospium; second line: TCAs; third line: flacoxate, propantheline, dicyclomine -nonpharmacologic: mainstay of treatment: fluid managemnet, bladder traiing, bladder retraiing, pelvic floor rehabilitation Patient Variables -geriatrics: sensitive to anticholinergics, both confusion and cardiac effects are commonly seen -pediatrics: oxybutynin is not indication as it causes hallucinatios and agitation; cholinergics are not inficated; primary nocturnal enuresis is common in children (desmopressin 6 years and older) Patient Education -avoid hot environments due to risk of heatstroke; take bethanechol on an empty stomach Week 3 Chapter 15: “Upper Respiratory Agents” Decongestants: Oral: pseudophedrine/phenylephrine (Sudafed) Topical: phenylephrine (neo-synephrine), oxymetazoline (afrin, neo-synephrine) Antihistamines: sedating: ethanolamine: diphenhydramine (benadryl), clemastine fumarate (tavist) Alkylamine: chlorpheniramine maleate Piperazine: cetirizine (zyrtec) Nonsedating: fexofenadine (allegra) Miscellaneous: loratadine (claritin), desloratadine (clarinex) Intranasal: axelastine (astelin) Intranasal corticosteroids: trimcinolone acetonide (nasacort), beclomethasone dipropionate (beconase), fluticasone propionate (flonase) Intranasal mast cell stabilizers: cromolyn sodium (nasalcrom) Leukotriene receptor antagonists: montelukast sodium (singulair) Antitussives: narcotic antitussives: codeine phosphate Nonnarcotic antitussives: dextromethorphan (robitussin), benzonatate (tessalon) Expectorants: guaifenesin (robitussin) Indications: Decongestants: oral (nasal congestion caused by the common cold, hey fever, or URI; sinusititis and eustachian tube congestion; unlabeled: treatment for mild to moderate urinary stress incontinence); nasal (symptomatic relief of nasal and nasopharyngeal mucosal congestion caused by the common cold, sinusitis, hay fever, or other URIs; adjunctaive therapy for middle ear infection by decreasing congestions; relief of ear block), antihistamines (relief of seasonal or perennial allergies; allergic and nonallergic pruritic symptoms; amelioration of allergic reactions to blood or plasma) -intranasal corticosteroids: vasomotor rhinitis and relief of symptoms of seasonal or perennial rhinitis -intranasal mast cell stabilizers: prevention and treatment of allergic rhinitis -Leukotreiene receptor antagonists: treatment of allergic rhinitis -antitussives: narcotic (suppression of cough); nonnarcotic (supression of nonproductive cough and symptomatic relief) -expectorants: symptomatic relief of respiratory conditions characterized by productive or nonproductive cough MOA: -Decongestants: sympathomimetic amines that act to stimulate a-adrenergic receptors of vascular smooth muscle and cause vasoconstriction; resultss in nasal decongestion, contraction of GI and urinary spincters, pupil dilation, and decreased pancreatic B-cell secretion -psudoephedine causes relaxation of bronchi -mimic norepinephrine on sympathetic effector organs, affecting the adrenergic receptors; a- adrenergic (vasoconstriction of arteriolesincreased blood pressure; dilation of the pupils; intestinal relaxation; bladder sphincter contraction) b-adrenergic (b1: cardioaccerleration and increased myocardial contractility; b2: vasodilation of skeletaal muscle, bronchodilation, uterine relaxation, and bladder relaxation) -Pseudoephedrine/phenylephrine is an a-adrenergic receptro agonist that produces vasoconstriction by stimulating a-receptors in the mucosa of the respiratory tract; reduces edema and nasal congestion, increases nasal airway patency, promotes drainage of sinus secretions, and opens obstructed eustachian ostia; pseudoephedrine also is used in illegal manufactoring of methamphetamine which led to the state and federal regulations restriction on sale -phenylephrine acts on a-adrenergic receptors and can be administered orally or topically to relieve nasal congestion in URI, sinusitis, and allergic rhinitis -nasal sprays or inhaled decongestants to the masal mucous membranes cause vasoconstrction, resulting in shrinkage, which helps to promote drainage and improved breathing through the nasal passages; inhaled produce reduced systemic effects -Antihistamines: compete for histamine at H1 receptor sites and are used to treat igE- mediated allergy (allergic rhinitis and urticaria); antagonize histamine; have anticholinergic, antipruritic, and sedative effects to varying degrees -first generation causes sedatino; second-generation do not have sedative effect and a rapid onset of relief from sneezing, pruritis, and rhinorrhea -Intranasal corticosteroids: potent glucocorticoids and weak mineralcorticoid activity; direct local antiinflammatory effects (minimal systemic effects); control the four main symptoms of allergic rhinitis (rhinorrhea, congestion, sneezing, nasal itch); moderate to severe disease; seasonal and perennial allergic rhinitis; must be used consistently on a daily basis for effectiveness; maximum effects may not be noted for several days to weeks -intranasal mast cell cell stabilizers: cromolyn is an OTC preventative agent of allergen exposure; inhibits sensitized and mast cell degranulation that occurs after exposure to specific antigens; inhibits release of mediatros, histamine, and SRS-A from mast cell; inhibits calcium from entering mast cell, resulting in prevention of mediator release -reduce rhinnorrhea, sneezing, nasal itching; minimal effect on nasal congestion; should start 3-4 weeks before allergy season; nebulized aresol; inhaled through the mouth; swallowed orally 4-6 times a day; effects may not be seen for 4-6 weeks to months -anti-inflammatory with no intrinsic broncodilator, antihistamines, vascontstrictor, or glucocorticoid activity -leukotriene receptor antagonists: causes inhibition of airway cysteinyl leukotriene receptors, which are release from mast cells and eosinophils; CysTL type 1 receptor is found in airway smooth muscle cells, airway macrophages, and proinflammatory cells such as eosinohils and myeloind stem cells; cysTL are released from the nasal mucosa after allergen exposure and are released from the nasal mucosa after allergen exposure and are associated with symptoms of allergic rhinitis -antitussives: codeine and dextromethorphan act centrally on the medulla to suppress cough; dextromethorphan is the d-isomer of codeine- it lacks analgesic and addictive properties of coedine (but not as effective); benzonatate anesthetizes stretch receptors in the respiratory passages, reducing the cough reflex at its source (N/V, sedation, dizziness, and constipation are the most common side effects) -it is important to first find out the cause of the cough before giving narcotics -expectorants: increase respiratory tract fluid secretions; lossen bronchial secretions by reducing adhesiveness and tissue surface tension; increase efficacy of the mucociliary mechanism in removing accumulated secretions from the upper and lower airways -nonproductive coughs become more productive, less frequent, less irritating; used for the symptomatic relief of dry, nonproductive cough associated with respiratory tract infection Treatment Principles -nonpharmacologic treatment: rest, increase fluids (helps to decreae cough, thin secretions, and hydrate tissues), identification of environmental precipitants, implement strategies designed to reduce these factors, normal saline nasal sprays/nasal irrigation -tsp of honey in children for reducing cough; avoid outdoor allergens, use air conditioning, exercise outdoors in the afternoon, use high-efficiency particulate air filters, and use a dryer for clothes -pharmacologic: mild, intermittent symptoms (nonsedating antihistamines/decongestants; consider nasal antihistamine, intranasla cromolyn, or leukotreine receptor antagonist if the patient is unable to take oral); moderate, frequent symptoms (regular- to high-dose intranasal coarticosteroid and add antihismine and decongestant if necessary), moderate, persistent symptoms (combination regimen consisting of intranasal corticosteroids plus a nonsedating or intranasal antihistamine and decongestant if necessary), severe (combination regimen, nonsedating antihistamine with/without decongestant and intranasal corticosteroid; consider oral steroid and use of oxymetazoline) -decongestants: very effective in nasal congestion, use with caution in patients with HTN, CVD, and PVD, hyperthyroidism, DM, prostatic hyperplasia, urinary retention, and increased intraocular pressure; contraindicated in MVP and cardiac palpitations -many side effects that can limit their use, particularly in the elderly (do not cause sedation but may cause nervousness, dizziness, and difficulty sleeping; others: tachycardia, nervousness, insomnia, palpitations, headache, and irritability) -antihistamines: contraindicated in nursing mothers, avoid during 3rd trimester; used alone or in combination with decongestants; effective in allergic and nonallergic pruritic symptoms; mild uticaria and angioedema; prophylaxis against allergic reactions to blood or plasma products; adjunctive therapy in prophylactic reactions; certain antihistamines also have antiemetic effects (used for nausea, vomiting, vertigo, motion sickness) -sedating antihistmines are sometimes preferred to who have symptoms preventing them from sleeping and is used with analgesics as a pain reliever and sleep aid -in children, antihistamines may produce paradoxical excitation in a syndrome that may include excitement, hallucinations, ataxia, incoordination, muscle twitching, athetosis, hyperthermia, cyanosis, tremot, and hyperreflexia -intranasal steroid: most effective agents for managemnet of allergic rhinitis; use for at least 1 month before determining efficacy; can be used in asthmatic patients and patients who have comorbid nasal polyposis (intranasal steroids may help shrink nasal polyps) -some patients don’t like the taste or odor; must take everyday; does not begin to start working until 1-2 weeks after therapy starts; potential risk of growth suppression -decrease WBC, increase glucose, check height; may cause osteoporosis -mast cell stabilizers: particularly effective in seasonal allergies; start 3-4 weeks before peak season; frequent dosing affect compliance; intraocular agents also are very effective; continue treatment throughout exposure -leukotreiene receptor antagonists: used to treat symptoms of allergic rhinitis (adults, pediatric patients 2, adults and pediatric patients 6 months old with perennial allergic rhinitis); used in combination with other therapies, especially when nasal congestion is not ameliorated by other modalities -antitussives: used in control or suppress cough caused by respiratory tract irritation, colds, or allergies; determine the underlying disorder; do not give in conditions in which retention of respiratory secretions may be harmful; in general, a cough should not be suppressed (if a patient is having a nonproductive cough that is causing muscle pain or is interfering with sleep, then it should be suppressed) -most effective in suppressing cough is narcotic; N/V, sedation, dizziness, and constipation are the most common side effects of narcotic antitussives; do not give to premature infants and caution with infants and small children 6 yrs. -expectorants: symptomatic relief of a dry, nonproductive cough associated with repiratory tract infection; expectorants often are used when the patient insists on a cough rememdy when cough suppression is not indicated or because the patietn believes the effect to be beneficial; fluid intake up to 1 gallon of water a day in patients who do not have a fluid restiriction is important -increase renal clearance by lowering uric acid levels; caution for children up to 12 years Patient Variables -geriatrics: decrease dosage of antihistamine (if causing excessive sedation, syncope, dizziness, confusion, hypotension); prescribe antitussive codeine with caution -pediatrics: do nto give coedine to premature infants; avoid sustained-release decongestants; antihistamines may diminish mental alertness or paradoxical excitation (do not use in third trimester); seizure risk in high doses; do not give cold or cough suppressants to children 6; use of intranasal contricosteroids in prebubescent children poses a potential risk of growth suppression (studies have beclomethasone dipropionate used twice daily have shown a significant decrease in growth velocity; this has not been shown with other intranasal steroids [mometasone furoate monohydrate, budesonide, or fluticasone propionate]) -pregnancy: do not use antihistamines in the third trimester of pregnancy; newborn and premature infants may have severe reactions; antihistamine is generally contraindicated in pregnancy; do not give decongestant products Chapter 16: “Asthma and COPD Medications” SABA: aerosol: albuterol (proventil, ventolin), levalbuterol (xonepex) Oral: pirbuterol (maxair), albuterol LABA: salmeterol xinafoate (severent diskus), formoterol fumarate (foradil), indacaterol (arcapta) Methylxanthines: theophylline (theo-dur) Anticholinergics: ipratropium bromite (atrovent), tiotropium (spiriva) Mast cell stab