NRNP 6566> week 1 to 5 Exams Key Concepts 202
g g g g g g g g g
2 Version. g
Weekg1
1. DescribegthegcytochromegP450gsystem.g Describeghowginducersgandginhibitorsgaffectgth
egcytochromegsystemgandghowgthatgaffectsgtheghalf-lifegofgmedications.
a. Cytochromegp450gsystemgisgagseriesgofgenzymesgusedgtogmetabolizegmedications.
b. DrugsgthatgcausegCYP450gmetabolicgdrugginteractionsgaregreferredgtogasgeitherginhibitor
sgorginducers.gInducersgincreasegCYP450genzymegactivitygbygincreasinggenzymegsynth
esis
c. InhibitorsgblockgthegmetabolicgactivitygofgonegorgmoregCYP450genzymes
2. Describegthegaffectgonglowgandghighgalbuminglevelsgongactivegdrugglevelsgespeciallygforgdru
gsgthatgareghighlygproteingbound.
a. Albumingisgthegplasmagproteingwithgtheggreatestgcapacitygforgbindinggdrugs.
i. Bindinggtogplasmagproteinsgaffectsgdruggdistributiongintogtissues,gbecausegonlyg
druggthatgisgnotgboundgisgavailablegtogpenetrategtissues,gbindgtogreceptors,gandg
exertgactivity.gAsgfreegdruggleavesgthegbloodstream,gmoregboundgdruggisgrelease
dgfromgbindinggsites.
b. Highlygproteingboundgdrugs,glowgalbuminglevelsg(w/gmalnutrition,gorgchronicgillness)gm
aygleadgtogtoxicitygbecausegtheregaregfewergthangthegnormalgsitesgforgthegdruggtogbind
3. Describegwaysgtoglessengtheghepaticgfirstgpassgeffect:gmetabolismgduringgfirstgpassgthroughgth
egliver
a. Alternativegroutesg(suppository,gintravenous,gintramuscular,ginhalationalgaerosol,gtrans
dermal,gandgsublingual)gavoidgthegfirst-
passgeffectg gallowgdrugsgtogbegabsorbedgdirectlygintogthegsystemicgcirculation
4. BegablegtogcalculategcreatininegclearancegusinggthegCockgraftgGaultgequiation:
a. Maleg g =g([140-age]g×gweightgingkg)/(serumgcreatinineg×g72)
b. Femaleg g=gCrClg(male)g×g0.85
5. Describegwhatgdeterminesgthegfrequencygofgdruggadministration:
a. Drugghalf-life,gplasmagconcentration
6. BegfamiliargwithgthegBeersgcriteriagandghowgtogusegit:
a. PotentiallygInappropriategMedicationgUsegingOldergAdults
i. togcallgattentiongtogmedicationsgthatgaregcommonlygproblematic,gandgthusgshoul
dgbegavoidedgingmostgoldergadults
7. Describegfactorsgthatgaffectgabsorption,gdistribution,gmetabolismgandgexcretion:
a. Absorptiong glowgbloodgstateg(shockgorgarrest);gcontactgtimegwithgGIgtractgtoogfastg(diarr
heag=gcan’tgabsorb);gdelayedgstomachgemptyingg(largegmealg=gdelayedgabsorption);gdru
g-druggorgdrug-foodginteractions
b. Metabolismg ggenetics,gage,gorgangfunction
c. Distributiong glowgalbuminglevels,gbodygcomposition,gcardiacgdecompg(HF),gandgage
d. Excretiong gaffectedgbygabnormalgkidneygorglivergfunction;gage,gdrugginteractions
,NRNP 6566> week 1 to 5 Exams Key Concepts 202
g g g g g g g g g
2 Version. g
8. Definegnarrowgtherapeuticgindexg Howgwouldgyougmonitorgagpatientgwithgagnarrowgtherapeuti
cgindex?
,NRNP 6566> week 1 to 5 Exams Key Concepts 202
g g g g g g g g g
2 Version. g
a. Therapeuticgindex:gdosegrangegwheregefficacygofgmedgisgoptimizedgwhilegsidegeffect
sgminimized
b. Narrowgtherapeuticgindexg(NTI)gdrugsgaregdefinedgasgthosegdrugsgwheregsmallgdiff
erencesgingdosegorgbloodgconcentrationgmaygleadgtogdosegandgbloodgconcentrationgd
ependent,gseriousgtherapeuticgfailuresgorgadversegdruggreactions.
c. Bloodgtestsgtogmonitorgbloodgconcentrationsgandgdosegadjustmentsgaccordingly
9. Describeghowgaginggaffectgabsorption,gdistribution,gmetabolism,gandgexcretion
a. Decreasedgorgangfunction,gpoorlygtolerategdrugsgthatgrequiregmetabolism,glowergratesg
ofgexcretion
b. decreaseg ing small-
bowelg surfaceg area,g slowedg gastricg emptying,gandg ang increaseg inggastricgpH,gchan
gesgingdruggabsorption
c. Withg age,g bodyg fatg generallyg increasesgandg totalg bodyg watergdecreases.g Increasedg f
atgincreasesgthegvolumegofgdistributiongforghighlyglipophilicgdrugs
(eg,g diazepam,g chlordiazepoxide)g andg mayg increaseg theirg eliminationg half-lives.
d. Serumgalbuming decreasesg andg alphag 1-acidg glycoproteing increases
i. Phenytoing andg warfaring areg examplesgofg drugsg withg aghighergriskgofgtoxicgeffect
sgwhengthegserumgalbuminglevelgdecreases
e. hepaticgmetabolismg ofgmanygdrugsgthroughgthegcytochromeg P-
450genzymegsystemgdecreasesg withg age.g Forg drugsg withg decreasedg hepaticg metaboli
smg clearanceg typicallygdecreasesg30gtog40%.
i. Drugsg metabolizedg ing phaseg 1g reactionsg likelyg prolonged
ii. First-
passg metabolismg (metabolism,g typicallyg hepatic,g thatg occursg beforeg ag druggreac
hesgsystemicgcirculation)gdecreasinggbygaboutg1%/yrgaftergageg40.
1. Thus,gforgag giveng oralg dose,g oldergadultsg mayghaveghighergcirculatinggdru
ggconcentrations.
f. Decreasedg renalg elimination
Weekg2gandg3
1. Identifygandgdescribeg12gleadgEKGsgthatgdemonstrate:
a. 1st,g 2nd,g andg 3rdg degreegAVg blocks
i. 1stgdegreegHB cardsgconsult
ii. 2ndgdegreegHBg gtypeg1g&g2
1. Typeg1:gEchog(r/ogstructuralgdx),gThyroidglevels,gmeds,glytesgtogidentifygan
dgtreatgcause
2. Typeg2:gPPM,gcontinuousgtelegwithgtranscutaneousgpacinggifgneeded,gdet
erminegcause;gIVgatropinegifgpoorgperfusiongs/sgqg3-
5mgwithgmaxg3mggifgs/sgpoorgperfusion;
, NRNP 6566> week 1 to 5 Exams Key Concepts 202
g g g g g g g g g
2 Version. g
3. Ifgnogresponsegtogatropine gdopa,gepi,gisoproterenol
iii. 3rdgdegree/gcompletegHB:gPPM;gtelegandgtranscutaneousgpacegifgneded;gidentif
ygcause;gIVgatropinegifgs/sgpoorgperfusion;gIfgnogresponsegtogatropine gdopa,ge
pi,gisoproterenol
b. STEMIginganygleadg(knowgwhatgareagofgthegheartgisgaffectedgbasedgongleadglocation)
c. Atrialgfibrillation:
g g g g g g g g g
2 Version. g
Weekg1
1. DescribegthegcytochromegP450gsystem.g Describeghowginducersgandginhibitorsgaffectgth
egcytochromegsystemgandghowgthatgaffectsgtheghalf-lifegofgmedications.
a. Cytochromegp450gsystemgisgagseriesgofgenzymesgusedgtogmetabolizegmedications.
b. DrugsgthatgcausegCYP450gmetabolicgdrugginteractionsgaregreferredgtogasgeitherginhibitor
sgorginducers.gInducersgincreasegCYP450genzymegactivitygbygincreasinggenzymegsynth
esis
c. InhibitorsgblockgthegmetabolicgactivitygofgonegorgmoregCYP450genzymes
2. Describegthegaffectgonglowgandghighgalbuminglevelsgongactivegdrugglevelsgespeciallygforgdru
gsgthatgareghighlygproteingbound.
a. Albumingisgthegplasmagproteingwithgtheggreatestgcapacitygforgbindinggdrugs.
i. Bindinggtogplasmagproteinsgaffectsgdruggdistributiongintogtissues,gbecausegonlyg
druggthatgisgnotgboundgisgavailablegtogpenetrategtissues,gbindgtogreceptors,gandg
exertgactivity.gAsgfreegdruggleavesgthegbloodstream,gmoregboundgdruggisgrelease
dgfromgbindinggsites.
b. Highlygproteingboundgdrugs,glowgalbuminglevelsg(w/gmalnutrition,gorgchronicgillness)gm
aygleadgtogtoxicitygbecausegtheregaregfewergthangthegnormalgsitesgforgthegdruggtogbind
3. Describegwaysgtoglessengtheghepaticgfirstgpassgeffect:gmetabolismgduringgfirstgpassgthroughgth
egliver
a. Alternativegroutesg(suppository,gintravenous,gintramuscular,ginhalationalgaerosol,gtrans
dermal,gandgsublingual)gavoidgthegfirst-
passgeffectg gallowgdrugsgtogbegabsorbedgdirectlygintogthegsystemicgcirculation
4. BegablegtogcalculategcreatininegclearancegusinggthegCockgraftgGaultgequiation:
a. Maleg g =g([140-age]g×gweightgingkg)/(serumgcreatinineg×g72)
b. Femaleg g=gCrClg(male)g×g0.85
5. Describegwhatgdeterminesgthegfrequencygofgdruggadministration:
a. Drugghalf-life,gplasmagconcentration
6. BegfamiliargwithgthegBeersgcriteriagandghowgtogusegit:
a. PotentiallygInappropriategMedicationgUsegingOldergAdults
i. togcallgattentiongtogmedicationsgthatgaregcommonlygproblematic,gandgthusgshoul
dgbegavoidedgingmostgoldergadults
7. Describegfactorsgthatgaffectgabsorption,gdistribution,gmetabolismgandgexcretion:
a. Absorptiong glowgbloodgstateg(shockgorgarrest);gcontactgtimegwithgGIgtractgtoogfastg(diarr
heag=gcan’tgabsorb);gdelayedgstomachgemptyingg(largegmealg=gdelayedgabsorption);gdru
g-druggorgdrug-foodginteractions
b. Metabolismg ggenetics,gage,gorgangfunction
c. Distributiong glowgalbuminglevels,gbodygcomposition,gcardiacgdecompg(HF),gandgage
d. Excretiong gaffectedgbygabnormalgkidneygorglivergfunction;gage,gdrugginteractions
,NRNP 6566> week 1 to 5 Exams Key Concepts 202
g g g g g g g g g
2 Version. g
8. Definegnarrowgtherapeuticgindexg Howgwouldgyougmonitorgagpatientgwithgagnarrowgtherapeuti
cgindex?
,NRNP 6566> week 1 to 5 Exams Key Concepts 202
g g g g g g g g g
2 Version. g
a. Therapeuticgindex:gdosegrangegwheregefficacygofgmedgisgoptimizedgwhilegsidegeffect
sgminimized
b. Narrowgtherapeuticgindexg(NTI)gdrugsgaregdefinedgasgthosegdrugsgwheregsmallgdiff
erencesgingdosegorgbloodgconcentrationgmaygleadgtogdosegandgbloodgconcentrationgd
ependent,gseriousgtherapeuticgfailuresgorgadversegdruggreactions.
c. Bloodgtestsgtogmonitorgbloodgconcentrationsgandgdosegadjustmentsgaccordingly
9. Describeghowgaginggaffectgabsorption,gdistribution,gmetabolism,gandgexcretion
a. Decreasedgorgangfunction,gpoorlygtolerategdrugsgthatgrequiregmetabolism,glowergratesg
ofgexcretion
b. decreaseg ing small-
bowelg surfaceg area,g slowedg gastricg emptying,gandg ang increaseg inggastricgpH,gchan
gesgingdruggabsorption
c. Withg age,g bodyg fatg generallyg increasesgandg totalg bodyg watergdecreases.g Increasedg f
atgincreasesgthegvolumegofgdistributiongforghighlyglipophilicgdrugs
(eg,g diazepam,g chlordiazepoxide)g andg mayg increaseg theirg eliminationg half-lives.
d. Serumgalbuming decreasesg andg alphag 1-acidg glycoproteing increases
i. Phenytoing andg warfaring areg examplesgofg drugsg withg aghighergriskgofgtoxicgeffect
sgwhengthegserumgalbuminglevelgdecreases
e. hepaticgmetabolismg ofgmanygdrugsgthroughgthegcytochromeg P-
450genzymegsystemgdecreasesg withg age.g Forg drugsg withg decreasedg hepaticg metaboli
smg clearanceg typicallygdecreasesg30gtog40%.
i. Drugsg metabolizedg ing phaseg 1g reactionsg likelyg prolonged
ii. First-
passg metabolismg (metabolism,g typicallyg hepatic,g thatg occursg beforeg ag druggreac
hesgsystemicgcirculation)gdecreasinggbygaboutg1%/yrgaftergageg40.
1. Thus,gforgag giveng oralg dose,g oldergadultsg mayghaveghighergcirculatinggdru
ggconcentrations.
f. Decreasedg renalg elimination
Weekg2gandg3
1. Identifygandgdescribeg12gleadgEKGsgthatgdemonstrate:
a. 1st,g 2nd,g andg 3rdg degreegAVg blocks
i. 1stgdegreegHB cardsgconsult
ii. 2ndgdegreegHBg gtypeg1g&g2
1. Typeg1:gEchog(r/ogstructuralgdx),gThyroidglevels,gmeds,glytesgtogidentifygan
dgtreatgcause
2. Typeg2:gPPM,gcontinuousgtelegwithgtranscutaneousgpacinggifgneeded,gdet
erminegcause;gIVgatropinegifgpoorgperfusiongs/sgqg3-
5mgwithgmaxg3mggifgs/sgpoorgperfusion;
, NRNP 6566> week 1 to 5 Exams Key Concepts 202
g g g g g g g g g
2 Version. g
3. Ifgnogresponsegtogatropine gdopa,gepi,gisoproterenol
iii. 3rdgdegree/gcompletegHB:gPPM;gtelegandgtranscutaneousgpacegifgneded;gidentif
ygcause;gIVgatropinegifgs/sgpoorgperfusion;gIfgnogresponsegtogatropine gdopa,ge
pi,gisoproterenol
b. STEMIginganygleadg(knowgwhatgareagofgthegheartgisgaffectedgbasedgongleadglocation)
c. Atrialgfibrillation:
