NSG-533-H11 Advanced Pharmacology Exam Two Study Guide – Download For An A+

NSG-533-H11 Advanced Pharmacology Exam Two Study Guide – Download For An A+ What are the various Pain types of pain and how do they differ. Consider acute, chronic, nociceptive, neuropathic and malignant pain acute- sudden and usually subside when treated (ex: postop pain) chronic- persistent or recurring , lasting 3 -6months or longer, difficult to treat nociceptive-pain results from the stimulation of sensory nerve fibers. transmit pain signals from various body regions to the spinal cord and brain which creates the sensation of pain neuropathic- results from damage to peripheral or CNS nerve fibers by disease or injury but may be idiopathic (unexplained) malignant pain- associated with diminishing function due to disease progression. Emphasize non-pharmacological treatments What are some non-pharmacological approaches to pain • acupuncture, art therapy, behavior therapy, biofeedback, comfort measures, counseling, distraction, hypnosis, imagery, music/pet therapy, therapeutic communication, baths, touch, yoga, hot/cold packs The World Health Organization (WHO) has recommended a three- step ladder approach to pain management. What is this approach and provide examples of proper therapy at each step § Also see figure 34-1, 34-2 and table 34-1 NSAIDs mechanism: -inhibits the leukotriene pathway, the prostaglandin pathway or both. - relieves pain, headache, and inflammation by blocking the chemical activity called the cyclooxygenase (COX) enzyme *ALL NSAIDs can be ulcerogenic and induce gastrointestinal bleeding due to their activity against COX1 Aspirin – inhibits platelet aggregation. Has the ability to be an irreversible inhibitor of COX-1receptors within the platelets themselves. perfect for treatment in MI and other thromboembolic disorders. Other NSAIDs lack these antiplatelet effects. Indication : analgesic, anti-inflammatory, and antipyretic effects, and antiplatelet inhibition Contraindication; known drug allergy, conditions that place the patient at risk for bleeding, vitamin K deficiency and peptic ulcer disease. • Category C ( in first and second trimester) Category D (not recommended in 3rd trimester) - stop taking NSAIDs 1 week before surgery - not recommended for breastfeeding, secreted in breastmilk Adverse effect: gastrointestinal bleeding, risk of heart attack, stroke, death ***Ceiling effect- NSAIDs show ceiling effects that can limit their effectiveness. any further increase in the dosage beyond a certain level increases the risk of adverse effect without a corresponding increase in the therapeutic effect Celebrex- CO-2 inhibitor (arthritis and dysmenorrhea) A. Pain – 16% of exam Acetaminophen B. mechanism (works similar to salicylates) - it blocks peripheral pain impulses by inhibition of prostaglandin synthesis. - lowers febrile body temperatures by acting on the hypothalamus - lack anti-inflammatory effects, not associated with CV effects (edema) or platelet effect (bleeding) - analgesic and antipyretic C. 1. Know the normal maximum daily dose of Acetaminophen and the maximum daily dose of Acetaminophen in the elderly. Understand Acetaminophen is also in combination products. Acetaminophen APAP: The maximum recommended dose for patients with normal renal and hepatic function is 4000 mg/day. FDA limited the APAP component of narcotic analgesic combination to 325 mg per dosing unit. maximum dose should be reduced by 50% to 75% in patients with renal dysfunction or hepatic disease and in those who engage in excessive alcohol use. b. Know which medications are Cyclooxygenase inhibitors. COX 1: promotes the synthesis of prostaglandins that have beneficial effects on various bodily functions (ex: maintains intact gastrointestinal mucosa) NSAIDs: nonselective (they inhibit COX-1 and COX-2) Aspirin, ibuprofen, and naproxen Increased GI and renal toxicity ALL NSAIDs except aspirin increase cardiovascular risk!!!!! ALL NSAIDs cause adverse renal effects especially in patients with chronic renal insufficiency Use caution in patients with reduced cardiac output due to sodium retention and in patients receiving antihypertensives, warfarin, and lithium. COX2: selective (inhibit only COX-2) -promotes the synthesis of prostaglandins that are involved in the inflammatory process • Preferred for patients with GI bleed and high-risk GI complication (hx of Peptic Ulcer Disease) • Selective: Celecoxib (Celebrex) is the only remaining drug in USA • Nabumetone (Relafen), Meloxicam (Mobic) slightly selective for COX2 COX-2 inhibition is responsible for anti-inflammatory effects, whereas COX-1 inhibition contributes to increased GI and renal toxicity associated with nonselective agents. Because the antiplatelet effect of nonselective NSAIDs is reversible, concurrent use might reduce the cardioprotective effect of aspirin due to competitive inhibition of COX- 1. A boxed warning highlighting the potential for increased risk of cardiovascular events and GI bleeding is now required for all prescription nonselective NSAIDs and celecoxib. Stronger warnings about these adverse events are also required on nonprescription NSAIDs. When an NSAID is needed in a patient with cardiovascular risk, the benefits of therapy must outweigh the risks, and the lowest effective dose of the NSAID is recommended. What is meant by an adjuvant analgesic and when would they be appropriate. Provide examples of medications in this class. Eg. DPN, PHN, fibromyalgia An analgesic adjuvant is a medication that is typically used for indications other than pain control but provides control of pain in some painful diseases. Ex: Antidepressants and anticonvulsants. They can work well for neuropathic pain and pain syndromes such as fibromyalgia. They also have a role in treating cancer pain. Opioids mechanism : agonist- binds to an opioid pain receptor in the brain and causes and analgesic response to reduce pain agonist-antagonist (mixed or partial)- bind to a pain receptor and cause weaker pain response than does a full agonist. Binds to different degrees of kappa and mu opioid receptors. Not use in first line analgesics, but useful in OB pts (to avoid over sedation of mom and baby) antagonist- binds to pai receptor but does reduce pain signals. It competes with and reverses the effects of agonist and agonist-antagonist drugs. Opioid Adverse effects: (strong abuse potential) histamine release - pruritus’, rash and hemodynamic changes, orthostatic hypotension, flushing, bradycardia, sedation, euphoria, n/v, constipation, respiratory depression Management of Toxicity: Naloxone used for opioid overdose Naltrexone used for alcohol and opioid addiction, can be used in small doses to relieve itching cause by taking opioid *opioids can cause abnormal increase in serum levels, check labs, follow recommended dosage § Tolerance can develop to adverse events, such as constipation c. Know the side effects of opioids. Most frequent: constipation, nausea, and sedation Meperidine can produce tremors, myoclonus, delirium, and seizures. Due to the potential for accumulation of normeperidine, meperidine should not be used in the elderly, those with renal impairment, in patients using patient-controlled analgesia (PCA) devices, or for more than 1 to 2 days of intermittent dosing Methadone: Another safety concern with methadone involves risk of arrhythmia secondary to QT prolongation. Tramadol is associated with an increased risk of seizures in patients with a seizure disorder, those at risk for seizures, and those taking medications that can lower the seizure threshold. The use of tramadol with other serotonergic drugs (eg, selective serotonin reuptake inhibitors Serotonin syndrome [SSRIs]) might precipitate Early warning signs for overdose risk such as confusion, sedation, or slurred speech. In these situations, the dose should be reduced by 10% per week to avoid withdrawal symptoms. d. Know which medications may be used for both pain and other diagnoses. (Example: some antidepressants may also be used for different types of pain). SNRI (Cymbalta) & Venlafaxine (Effexor) for diabetic peripheral neuropathy TCA (Amitriptyline) for fibromyalgia. Avoid in older adults (anticholinergic effects). Contraindicated in patients with heart disease. Cyclobenzaprine for fibromyalgia and short-term treatment of low back pain. Gabapentin (Neurontin) and Pregabalin (Lyrica) for diabetic neuropathy and fibromyalgia e. Understand how to do opioid conversions with reductions for incomplete cross tolerance. (You do not have to memorize the conversions). Page 525 textbook e. Understand the World Health Organization pain treatment guidelines. P 526 1. Mild pain: Non opioid first; acetaminophen (1000mg q 6 hours); 2. ibuprofen 600 mg q 6 hours 3. Moderate pain: Add an opioid; acetaminophen 325 mg + oxycodone 5 mg q 4 hours acetaminophen 325 mg + codeine 60 mg q 4 hours 4. Severe pain: High potency opioid; morphine 10 mg po every 4 hours g. Understand the role of Cyclooxygenase Inhibitors in patients with gastrointestinal problems. COX1 increases GI toxicity COX2 drugs do not inhibit COX1 and are developed for patients with GI with high risk of GI bleeding h. Understand structurally different opioids and how this would affect cross-sensitivity with allergies. True narcotic allergies are rare and should not be confused with pruritus associated with opiate use. Cross-sensitivity between morphine-like, meperidine-like, and methadone-like agents is unlikely. Therefore, when an individual is allergic to one drug in a chemical class of opioids, it is reasonable to select an agent in another chemical class. D. Headache – 14% of exam chapter 35 1.1 Migraine without aura is a clinical syndrome characterized by headache with specific features and associated symptoms - At least 5 attacks of recurrent headache lasting 4–72 hour. headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia. 1.2 Migraine with aura is primarily characterized by the transient focal neurological symptoms that usually precede or sometimes accompany the headache. Some patients also experience a prodromal phase, occurring hours or days before the headache, and/or a postdromal phase following headache resolution. - At least 2 attacks. Recurrent attacks, lasting minutes, of unilateral fully reversible visual, sensory or other central nervous system symptoms that usually develop gradually and are usually followed by headache and associated migraine symptom cluster headaches- Attacks of severe, strictly unilateral pain which is orbital, supraorbital, temporal or in any combination of these sites, lasting 15–180 minutes and occurring from once every other day to eight times a day. Provide a stepwise approach to the management of migraine and cluster headaches. Include abortive therapies and preventative strategies. ***Migraine treatment involves acute (abortive) and preventive (prophylactic) therapy. - Acute treatment aims to reverse, or at least stop, the progression of a headache that has started. Analgesics used in migraine include acetaminophen, NSAIDs, and narcotic analgesics (eg, oxycodone, morphine sulfate. prophylactic therapy: • Reduce attack frequency, severity, and/or duration • Improve responsiveness to acute attacks • Reduce disability • 5-HT2 antagonism – Methysergide, Calcium channel blockers, Beta blockers, tricyclic antidepressants 1. Know what symptoms of a migraine would require immediate medical attention. E. Table 35–1 E. Headache “Red Flags” Indicating Need for Urgent Medical Evaluation E. New-onset sudden and/or severe pain E. Stereotyped pain pattern worsens E. Systemic signs (eg, fever, weight loss, or accelerated hypertension) E. Focal neurologic symptoms (ie, other than typical visual or sensory aura) E. Papilledema E. Cough-, exertion-, or Valsalva-triggered headache E. Pregnancy or postpartum state E. Patients with cancer, human immunodeficiency virus (HIV), and other infectious and immunodeficiency disorders E. Seizures b. Know how habits or diet could trigger migraines. 1. Changes in behavior, environment, diet, and hormone levels. 2. Intake of tyramine, aspartame, monosodium glutamate, and nitrites 4. Migraine Triggers c. Understand how to treat acute symptoms of a migraine. 1. Aspirin, (NSAIDs), acetaminophen 2. Combination products containing caffeine, with or without an opioid, are the initial pharmacologic option for the acute management of migraine headache especially when severity is mild to moderate (Acetaminophen alone or in proprietary combinations with aspirin, opioids, caffeine, or butalbital is also effective) 3. Triptans: ineffective analgesics and severe headaches Pharmacologic treatment of acute headache should be started early to abort the intensification of pain and to improve response to therapy. d. Understand which medications would be used for migraine prophylaxis versus acute symptoms of a migraine. e. Understand the contraindications for Triptan medications. 1. Triptans are avoided in patients with migraine associated with neurologic focality, a history of previous stroke, poorly controlled hypertension (HTN), or unstable angina. 2. Triptans are relatively contraindicated for routine use in pregnancy. 3. Triptans should not be used with concurrent ergotamine administration with the wait time at least 24 hours between use depending on the half-life of the triptan 4- What "triptan" is most effective? f. Antidepressants: amitriptyline, venlafaxine f. β-Blockers: atenolol, nadolol f. Triptans: naratriptan, zolmitriptan for short-term MAMs prevention f. Know which medications can be used for cluster headache prevention and chronic cluster headache prophylaxis. 1. The calcium channel blocker verapamil 240 to 360 mg/day is the mainstay of cluster attack prevention and chronic prophylaxis. 2-A therapy specific to cluster headaches is the administration of high- flow-rate oxygen: 100% at 12 to 15 L/min by nonrebreather face mask for approximately 15 minutes. j. Know the first line treatments for mild to moderate and moderate to severe migraines. 1. Mild to moderate: Aspirin, acetaminophen, NSAIDs. 2. Moderate to severe: migraine-specific medications, such as triptans C. Osteoarthritis – 8% of exam chapter 58 1. Know the initial treatments of osteoarthritis. Nonpharmacologic therapy: education, exercise, weight loss, and cognitive behavioral intervention. Lifestyle modification should be encouraged for all patients at risk for, or with established OA. 1- Acetaminophen: Mild to moderate pain 2- NSAIDs: Moderate to severe: b. Be able to analyze a case for a patient and pick the best treatment for her osteoarthritis. 1. COX-2 inhibitors: Celecoxib Used for patients at high risk for GI complications and If previous history of NSAID-induced GI bleed combined with a proton pump inhibitor 2. Topical NSAIDs (Diclofenac) First-line treatment for patients with OA in a superficial joint, including hands, wrists, elbows, knees, ankles, and feet. Less systemic toxicity 3. Oral NSAIDs for deeper joints (hips, elbow, spine) 3. NSAIDs and selective COX-2 inhibitors should be used with caution in patients with hypertension, heart failure, or chronic renal insufficiency 3. COX-2 inhibitors.: High cardiovascular risk c. Know which herbal products can be used to help treat osteoarthritis. Glucosamine and Chondroitin Capsaicin d. Know the mechanism of action of tramadol and its side effects. 1- inhibits serotonin and norepinephrine reuptake. 3. Adverse events include dizziness, vertigo, nausea, vomiting, constipation, and lethargy. 3. Seizures with concomitant use of antidepressants (Tricyclic or SSRI) 3. Avoid with MAOIs (Serotonin syndrome) D. Osteoporosis – 10% of exam chapter 56 1. Know the recommended daily intake of Calcium and Vitamin D. 1. Calcium intake of 1000 mg for men between the ages of 51 to 70 and a higher intake of 1200 mg for women older than 51 and men older than 71. (Supplement doses 500 to 600 mg daily limit) 2. Vitamin D intake of 800 to 1000 IU daily for all adults age 50 and older. Maximum recommended dose 4000 IU/day. 3. Ergocalciferol 50,000 IU Q week (Vit D2) followed by Cholecalciferol (vitamin D3) daily Severe vitamin D deficiency b. Know the first-line treatment options for osteoporosis. 1. Bisphosphonates should be used as first-line pharmacologic treatment for osteoporosis. 1. Alendronate (Fosamax) 10 mg po daily or 70mg po Q week 2. Ibandronate (Boniva): 150 mg po Q month or 3 mg iv Q 3 months (only approved for postmenopausal osteoporosis). 3. Risedronate (Actonel) 35 mg po Q week 4. Zoledronic acid (Reclast): 5 mg IVQ 12 months (Risk for renal failure) (Denosumab: 60 mg SC Q 6 months is for patients unable to tolerate bisphosphonates due to GI contraindications or side effects and for patients with malabsorption or adherence issues. c. Be able to recognize when a medication which is not safe for use in pregnancy. Bisphosphonates are contraindicated in pregnancy Raloxifene d. Know when and why you would choose the different Calciums (Calcium Carbonate vs. Calcium Gluconate vs. Calcium Citrate, etc.) Elderly patients or patients receiving proton pump inhibitors or H2- receptor antagonists may have difficulty absorbing calcium supplements due to reduced stomach acidity. Calcium citrate may be better absorbed in these situations because an acid environment is not needed for absorption; it may be taken with or without food. e. Understand how renal impairment would affect your choice in which medication you would choose to treat osteoporosis. Patients with moderate to severe renal impairment, severe dehydration, or taking concomitant diuretics or nephrotoxic drugs may be at higher risk of developing acute renal failure with zoledronic acid (Reclast) E. Gout – 10% of Exam Chapter 59 1. Know how to treat hyperuricemia and hypouricemia. Hyperuricemia: 1. Monotherapy: NSAIDs, colchicine, and corticosteroids (Etodolac, ibuprofen, ketoprofen, fenoprofen, sulindac, indomethacin, colchicine) Mild to moderate pain (pain score 6 or less) or limited joint involvement 2. Combination therapy: colchicine + NSAID or corticosteroid (Severe pain 7 or more) b. Know how lifestyle can affect gout. 1. Ingestion of animal purines, fructose, and alcohol (especially beer) 2. male sex. Avoid sweetbreads (organ meats such as thymus and pancreas), liver, and kidney meat; high-fructose corn syrup; and alcohol use b. Know how to treat a patient’s gout if they have renal impairment. 1. uric acid lowering therapy 2. Allopurinol 100 mg daily then reduce to 50mg if CR/CL les than 30 3. Febuxostat 40 mg daily then increase to 80mg daily for CR/CL 30- 89 with prophylaxis colchicine or NSAID (liver function tests) 4. Lesinurad, probenecid, and/or pegloticase to lower SUA level 5. Tapering dose of NSAIDs 6. Repeat dose of colchicine only every two weeks (Risk for Colchicine toxicity) d. Know when a patient would and would not require uric acid lowering therapy. 1. Asymptomatic hyperuricemia generally does not require treatment. 2. Patients with recurrent attacks (2 or more per year), evidence of tophus or tophi, CKD stage 2 or worse, or past urolithiasis are candidates for prophylactic therapy 3. Patients younger than 40 years, those with comorbidities, or SUA levels above 8 mg/dL F. Antibiotic Selection – 6% of Exam d. Understand what a gram stain is. A Gram stain may identify whether bacteria are present and determine bacterial morphologic characteristics b. Know which organisms are within the normal flora of the GI tract. Lactobacillus, streptococcus, c. Know what a virulent pathogen is. Causes diseases G. Lower Respiratory Tract Infections – 6% of Exam chapter 71 1. Know the organisms which may cause pneumonia. 1-S. pneumoniae (CAP), H. influenza in smokers 2- Mycoplasma pneumoniae (atypical) b. Know the risk factors for aspiration pneumonia. Dysphagia, change in oropharyngeal colonization, gastroesophageal reflux (GER), and decreased host defenses. c. Know the regimens used to treat community acquired pneumonia. Healthy outpatient adults without comorbidities: 1- Amoxicillin 1 g three times daily or 2-doxycycline 100 mg twice daily or 3-A macrolide (Azithromycin, clarithromycin) Outpatient adults with comorbidities: Combination therapy: 1-(amoxicillin/clavulanate 500 mg/125 mg three times daily, or amoxicillin/clavulanate 875 mg/125 mg twice daily, or 2,000 mg/125 mg twice daily) or a cephalosporin (cefpodoxime 200 mg twice daily or cefuroxime 500 mg twice daily); AND 2- macrolide a. (azithromycin 500 mg on first day then 250 mg daily, clarithromycin [500 mg twice daily or extended release 1,000 mg once daily or b. doxycycline 100 mg twice daily OR Monotherapy: Respiratory fluoroquinolone (levofloxacin 750 mg daily, moxifloxacin 400 mg daily, or gemifloxacin 320 mg daily) H. Upper Respiratory Tract Infections – 14% of Exam chapter 72 1. Know the risk factors for rhinosinusitis. b. Know how to treat acute bacterial rhinosinusitis. 1. First line treatment; Amoxicillin 5-7 days is effective for most infections and is less expensive 2. Doxycycline if allergic to penicillin or fluoroquinolone (levofloxacin or moxifloxacin) 3. Macrolides not recommended due to high level of resistance c. Know different drug-drug interactions with antibiotics. 1. There is limited cross-reactivity between penicillin and newer cephalosporins, use cephalosporins in penicillin-allergic patients because they are more effective than alternatives d. Know side effects of antibiotics in children. 1. Rash, nausea, vomiting e. Know which antibiotics may actually cause infections. Fluoroquinolone TMZ f. Know the treatment of choice for acute otitis media in children. 1. Acetaminophen and ibuprofen are commonly used for mild to moderate pain. 2. Amoxicillin is the drug of choice in most patients g. Know what pathogens may cause acute bacterial rhinosinusitis. Streptococcus pneumonia and H. influenzae cause more than half of ABRS. 8% to 16% of cases are caused by M. catarrhalis. I. Skin and Soft Tissue Infections – 10% of Exam CHAPTER 73 1. Know the risk factors for cellulitis Immunocompromised, diabetes or vascular insufficiency, or use injection drugs are at risk for polymicrobial cellulitis b. Know pathogens which may cause cellulitis. Streptococci (mainly group A) c. Know different treatments for community acquired MRSA versus hospital acquired MRSA. 1. trimethoprim-sulfamethoxazole 2. clindamycin, or doxycycline 3. Linezolid (Zyvox 4. Rifampin (Rifadin) Hospital acquired: Empiric broad-spectrum antimicrobial coverage (Vancomycin with beta-lactam (ie, piperacillin-tazobactam, cefepime, meropenem). d. Know the treatments for MSSA. Oral penicillin (such as dicloxacillin) or first-generation cephalosporins (such as cephalexin) are preferred J. Urinary Tract Infections – 6% of Exam chapter 79 Describe the clinical presentation of a UTI noting if the presentation is complicated or uncomplicated. Are there differences in presentation in the older population vs the general population? Will any of the presenting characteristic (or lack thereof) influence your approach to treatment (table 79-1 and highlighted box on pg 1170) • uncomplicated: an otherwise healthy patient with a structurally and functionally normal urinary tract • complicated: factors are present that decrease the likelihood of therapy being effective • urinary tract is structurally or functionally abnormal • immunocompromised status • especially virulent pathogens factors that may make a patient complicated 1 • male, childhood UTIs, immunocompromised, pregnancy, elderly, diabetes mellitus, failed antibiotic course, extended symptoms before presentation 1. Know the symptoms and lab results that would suggest a patient has a UTI. Signs and symptoms 1. Dysuria, gross hematuria, suprapubic heaviness, nocturia, increased urinary frequency, and urgency 2. Older adults: altered mental status, poor appetite, and incontinence. Lab results: Pyuria typically greater than 10 white blood cells/mm3 urine (10 × 106/L) • Bacteriuria, usually greater than 105 CFU organisms/mL (108 CFU/L) • Presence of nitrites • Presence of leukocyte esterase • Bacterial urine culture (E-coli) b. Know how to treat acute pyelonephritis. • Oral fluoroquinolones as a 5- or 7-day regimen if local E. coli resistance is less than 10% plus one-time initial dose of IV ciprofloxacin (400 mg) • If area of resistance 10% gibe initial dose of ceftriaxone 1 gm IV plus Oral fluoroquinolones • TMP/SMX as a 14-day treatment if susceptibility is confirmed. If not, initial dose of ceftriaxone 1 gm IV plus TMP/SMX • Oral beta-lactam for 10 to 14 days given with the initial IV dose of ceftriaxone or an aminoglycoside c. Know how to treat a patient who is pregnant with a UTI. • Nitrofurantoin is category B and can be safely used during pregnancy except in the last 30 days, due to an increased risk of neonatal jaundice. • Most β-lactams are pregnancy category B and can be safely used and are historically considered first-line options for pregnant patients. • Less clinical experience with Fosfomycin (NO) • follow-up: urine culture 1 to 2 weeks after completion of therapy then monthly until birth.