PHARM HESI PT 3

Rapid-acting (SQ)

• Insulin lispro, aspart, glulisine,

• Onset = 5-15 minutes; make sure to provide food at same time this insulin is given, take IMMEDIATELY before eating

• Peak = 1-2 hours

• Duration = 3.5-5 hours

Short-acting (regular) (SQ, IV, or IM)

• Regular Insulin (Humumlin R, Nocvolin R)

• Onset = 30-60 minutes; usually BEFORE a meal

• Peak = 2-4 hours

• Duration = 6-8 hours

Intermediate-acting (SQ; often with rapid-/short-acting insulin)

• NPH Insulin (Humulin N, Novolin N)

• Onset = 1-2 hours

• Peak = 4-8 hours

• Duration = 12-18 hours; may be given two times daily to provide glycemic control between meals and during the night

Long-acting (basal, background) (SQ; NOT be mixed in a single syringe with other insulins, should never be IV)

• Insulin glargine, Insulin degludec, Insulin detemir

• Onset = 1-2 hours

• Peak = no peak

• Duration = 24 hours

* release a constant steady level on insulin once a day

Oral anti-diabetic: metformin. Contraindications.

CONTRA: alcohol, renal disease (creatinine > 1.2)

Oral anti-diabetic: sulfonylureas (glimepiride, glipizide). Adverse effects and nursing.

• glimepiride, glipizide, glyburide

• ADR: hypoglycemia, disulfiram reaction if combined with alcohol

• NURSING: teach patient to avoid alcohol;inform about disulfiram reaction (nausea, headache, cramps, flushing, hypoglycemia)

  • persistent vomiting = high risk of hypoglycemia

  • take 30 minutes before breakfast

  • do NOT give if NPO

Oral anti-diabetic: acarbose. Nursing.

• acarbose & miglitol

• NURSING: take with first bite of each meal; 3x day, hold if meal is delayed

CONTRA: inflammatory bowel disease

Know exenatide and -TIDE drugs, route, side/adverse effects.

• non-insulin injectables

• ROUTE: SQ

• ADR/SE:

  • GI: nausea, diarrhea, anorexia

  • pancreatitis: persistent upper abdominal pain (pancreatitis) & increased serum amylase and lipase

  • risk of thyroid cancer

  • hypoglycemia when combined with other anti-diabetic meds

Know signs of hypoglycemia. Glucagon and when it is used.

• hypoglycemia <70 mg/dL

• diaphoresis/sweating, shakiness/tremor, persistent headache, tachycardia, anxiety, nervousness, irritability, dizziness, confusion, impaired vision

Glucagon

• IM or SQ

• USE: when hypoglycemia <70 mg/dL

• if conscious: administer oral form of glucose (tablets, gel, corn syrup, honey, fruit juice)

• if unconscious: administer glucagon or 50% Dextrose (D50W)

• turn the patient on the side until patient becomes alert to prevent aspiration; if no response after 15 minutes, another dose may be given

• IV 50% Dextrose (D50W) or IV dextrose

Levothyroxine adverse effects.

ADR: s/s of hyperthyroidism; nervous/restless, insomnia, tremor, tachycardia, palpitations, heat intolerance, weight loss, angina, dysrhythmias, MI

Know radioactive iodine.

• can take several months to see full effect

• USE: if patient has not responded to other anti-thyroid treatments

• CONTRA: pregnancy, lactation, children, iodine rich diet

• ISOLATION: maintain 6 feet away from others, sleep alone for 7 days, do not share food with anyone for the first week

Know methimazole and propylthiouracil (PTU) and how to take if Lugol’s solution is ordered

Propylthiouracil & Methimazole

• MOA: anti-thyroid therapy; blocks or interferes with thyroid hormone T3 & T4 synthesis; SLOW onset of action (3-4 weeks); take at same time everyday

SSKI & Lugol’s solution

NURSING: separate PTU/ methimazole and LUGOL’S by AT LEAST 1 HOUR for treatment of severe hyperthyroidism; give 7-10 days before a thyroidectomy surgery

Vasopressin/Desmopressin, use, monitoring, adverse effects.

• USE: DI, primary nocturnal enuresis, shock

• ADR: water intoxication, worsening headache, drowsy, increased BP

• NURSING: monitor I&O, thirst, weight, BP

  • drink only enough water to satisfy

  • if being used for DI, dose will be adjusted based on urine output

  • therapeutic outcome: increased urine OSMOLALITY and urine specific gravity; decreased urine OUTPUT, decreased thirst

Glucocorticoids

“sone”

• if used long-term, do NOT stop drug suddenly to prevent steroid withdrawal syndrome; taper off slowly to prevent risk of adrenal suppression

Fluticasone

• inhaled

• ADR: oral candidiasis, dry mouth, dysphonia, adrenal suppression

Prednisone

• oral

ADR: ↑ risk of infections, raised BP, raised blood glucose, weight gain, osteoporosis, cataract, mood changes, insomnia, Cushing’s syndrome

Treatment for acute episode of multiple sclerosis and adverse effects

• high-dose IV methylprednisolone for 3-5 days, then taper

ADR: flu-like reaction, depression/suicidal ideation

Bisphosphonates – names of drugs, adverse effects, how to take medication

• “-dronate” & Zoledronic acid

• ADR: esophageal burns, hypocalcemia, osteonecrosis of the jaw, esophageal irritation, dysphagia, severe heartburn, and retrosternal pain

• NURSING: oral = sit upright, take on empty stomach w/ a glass of water ONLY first thing in the morning

  • do NOT lie down for 30-60 minutes after

Epoetin alfa. Nursing/Monitoring.

• THERAPEUTIC: Hgb level; do NOT exceed 12g/dL

  • normal in men: 14-18 g/dL

  • normal in women: 12-15 g/dL

  • in patients with CKD taking epoetin alfa, raising Hgb levels to “normal” may worse CV outcomes

NURSING: monitor Hgb levels and BP; goal of Hgb is 11-12 g/dL

Ferrous sulfate. Teaching. Side effects. What to expect. Monitoring

• EVALUATION: CBC; Hgb, Hct, iron levels

• SE: GI distress (nausea & constipation), harmless black/tarry stools

• NURSING: take iron on an empty stomach or with vitamin C (ascorbic acid), take with food only if GI distress occurs, liquid formulations stain teeth (drink through straw and rinse mouth after)

INTERACTIONS: antacids, tea, coffee, calcium reduce iron absorption (take at least 1 hour before or 2 hours after), do NOT take with multivitamin (calcium/magnesium), iron will decrease absorption of tetracycline and fluoroquinolones

Calcitriol. Vitamin D overdose.

• Calcitriol & Ergocalciferol

• vitamin D toxicity: hypercalcemia; confusion, polyuria, kidney stones, nausea, constipation, HTN, dysrhythmias

  • might progress to bone pain and kidney problems

Oral contraceptives. Adverse effects, contraindications.

• ADR: thromboembolism, MI, stroke, DVT, PE, HTN (abdominal/chest pain, sudden severe headache, speech disturbance, severe leg pain, swelling of leg, SOB, eye problems)

• CONTRA: drug allergy, CAT X, thromboembolic disorders (MI, DVT, PE, stroke)

  • smokers, liver disease, uncontrolled HTN, migraine with aura, estrogen related cancers, estrogen-only products are contraindicated in women with an intact uterus

Sodium polystyrene sulfonate – nursing, monitoring.

• USE: reduce serum potassium levels; treats hyperkalemia

• MONITOR: electrolytes K+ level, cardiac rhythm

NURSING: effective if serum potassium levels is in normal range (3.5-5)

Isotretinoin. Class. Nursing, monitoring, adverse effects (sun toxicity).

• CLASS: retinoid- vitamin A derivative

• ADR: severe birth defects, miscarriage, hepatotoxicity, photosensitivity, depression

• NURSING: before starting…obtain

  • lipid panel, especially triglycerides

  • LFTs, pregnancy tests, mental health history (thoughts of suicide)

• MONITOR: photosensitivity and signs of depression

• CONTRA: pregnancy CATEGORY X; must use 2 forms of birth control while taking

  • AVOID vitamin A

Know Filgrastim uses and monitoring.

• USE: treats low WBC count, especially low neutrophil counts (neutropenia)

MONITOR: normal WBC 4,500-11,000 mm3 for adults

Ustekinumab – adverse effect and monitoring– risk of infection.

ADR: increased risk of infection; avoid sick people (monitor signs of infection)

Know Scopolamine. Patient teaching. What is it used for?

Anticholinergics - Scopolamine

• USE: motion sickness

• 72 hour transdermal patch; apply behind ear 4 hours before travel

Know Docusate sodium, Senna or sennoside

Docusate sodium/Emollient/Stool Softeners

• USE: acute & chronic constipation, fecal impaction, facilitation of bowel movement in anorectal conditions

Senna/Stimulant

USE: acute constipation, diagnostic and surgical preps

Lactulose. Uses. Also to decrease ammonia levels when used for hepatic encephalopathy

• hyperosmotic

USE: chronic constipation, diagnostic and surgical preps; decrease ammonia levels when used for hepatic encephalopathy

Bulk forming laxatives – names, MOA and nursing.

• Psyllium & Methyacellulose

• MOA: absorbs water to increase bulk → distends bowel to initiate reflex bowel activity

• NURSING: encourage high fiber and fluid intake as alternative to laxative use

  • time drug administration so that bowel evacuation doesn’t interfere w/ scheduled activities or sleep

  • do not crush enteric coated tablets

  • do not use stimulant laxatives regularly (laxative dependency)

  • inform to contact HCP if they experience severe abdominal pain, muscle weakness, cramps, or dizziness, which may indicate possible fluid or electrolyte loss

Orlistat: MOA, side effects, nursing.

• MOA: alters fat digestion by inhibiting pancreatic lipases; increases fat excretion and decreases absorption of 25-30% calories ingested as fat

ADR: acute kidney injury, increased urinary oxalate (oxalate nephrolithiasis), decreased absorption of fat soluble vitamins (A, D, E, K), severe liver injury/hepatic failure, cramps/flatus/fecal incontinence/bowel urgency/steatorrhea

H2 blockers. Drug names, MOA, nursing, adverse effects.

• Cimetidine, Nizatidine, Famotidine, Ranitidine (“-tidine”)

• MOA: increases pH of stomach by reducing H2 from parietal cells; ↓ production of gastric acid

• ADR: elderly; CNS confusion and disorientation, impotence/gynecomastia in Cimetidine, thrombocytopenia in Famotidine

NURSING: take 1-2 hours before antacids

PPIs. Drug names (omeprazole, lansoprazole); their uses, Nursing.

• Lansoprazole, Omeprazole, Rabeprazole, Pantoprazole, Esomeprazole, Dexlansoprazole (“-prazole”)

• USE: GERD, erosive esophagitis, NSAID induced ulcers, stress ulcer prophylaxis, H. pylori induced ulcers, Zollinger-Ellison syndrome, active duodenal and benign gastric ulcers (short term)

NURSING: allergies, impaired renal or liver function, administer 30-60 minutes before breakfast for max inhibition

Sucralfate. Administration.

• NURSING: take on an empty stomach, typically 1 hour before meals and at bedtime. Teach to avoid foods that may cause an increase in GI irritation.

Ondansetron. Uses, nursing.

• antiemetic drug

USE: n/v in patients receiving chemotherapy and for postop n/v

Generic name for Benadryl is diphenhydramine

• antihistamine

USE: motion sickness, nonproductive cough, allergy symptoms, sedation

Know all antidotes

• warfarin = potassium/vitamin K - digoxin = digibind, digifab

• heparin = protamine sulfate - anticholinergics = physostigmine

• opioid OD = naloxone - magnesium sulfate = calcium gluconate

• acetaminophen = acetylcysteine - beta blockers = glucagon

• benzodiazepine = flumazenil - aspirin = sodium bicarbonate

• cholinergics = atropine and pralidoxime - tricyclic antidepressants = sodium bicarbonate

Know Pregnancy category X drugs (contraindicated in pregnancy, review misoprostol, isotretinoin, finasteride, -statins, testosterone)

• finasteride - estrogen therapy

• isotretinoin - hormonal contraception

• misoprostol - Raloxifene & Tamoxifen

• -statins - warfarin

• testosterone - methotrexate

Which patient populations should avoid attenuated immunizations.

• immunocompromised patients

• patients on cyclosporine or corticosteroids (-sone)

• “-mab”s

• pregnant women

Know these laboratory values:

• Normal BUN: 7 to 20 mg/dL If high, abnormal

• Creatinine: 0.6 to 1.2 mg/dL If high, abnormal

• ALT: 4 to 36 U/L If high, abnormal

• Glucose: 70 to 100 mg/dL

• Serum sodium: 135 – 145 mEq/L

• Serum potassium: 3.5 – 5.0 mEq/L

• Serum calcium: 8.5 – 10.5 mg/dL

Therapeutic Drug Ranges

• Digoxin: 0.5-2 ng

• Phenytoin: 10-20 mcg

• Vancomycin: 10-20 mcg

• Theophylline: 10-20 mcg

• Lithium:

  • acute = 1-1.5 mEq

  • long term = 0.6-1.2 mEq

• Carbamazepine: 4-12 mcg

• Ethosuximide: 30-100 mcg

• Acetaminophen: 5-25 mcg

Drugs to Avoid with Alcohol

• Antibiotics: Metronidazole (Flagyl) (Avoid for 24 hours before and 36 hours after therapy), Cephalosporins (e.g., Cefazolin, Ceftriaxone), Isoniazid (INH).

• Antifungals: Fluconazole, Terbinafine.

• Pain & Inflammation: Acetaminophen, NSAIDs (e.g., Ibuprofen, Naproxen), Aspirin, Opioids (e.g., Morphine, Fentanyl, Oxycodone).

• Mental Health: Lithium, Benzodiazepines (e.g., Alprazolam, Lorazepam), Antipsychotics, Anticonvulsants (e.g., Phenytoin, Carbamazepine).

• Nitroglycerin, Metformin, Gabapentin and Pregabalin.

Drugs to Avoid with Grapefruit

• Cholesterol-Lowering Statins: Specifically Atorvastatin and Simvastatin (increases risk of rhabdomyolysis/muscle breakdown)

• Calcium Channel Blockers: Nifedipine, Amlodipine, Verapamil, and Diltiazem

• Immunosuppressants: Cyclosporine

• Antidysrhythmics: Amiodarone and Quinidine

• Antifungals: Azole medications (e.g., Fluconazole)

• Anti-Anxiety: Buspirone.

Medical Alert Bracelet

High-Risk Medical Conditions

• Seizure Disorders: To alert emergency responders to the condition and typical seizure management

• Diabetes Mellitus: Necessary due to the risk of severe hypoglycemia (blood glucose < 70 mg/dL), which can cause confusion or loss of consciousness

• Asthma & COPD: Especially for clients with a history of severe or acute attacks

• Severe Allergies: For those at risk of anaphylaxis (e.g., allergies to penicillin, sulfa drugs, or specific foods)

• Adrenal Insufficiency: Clients on long-term glucocorticoid therapy (like Prednisone) who are at risk for adrenal suppression if the medication is stopped or if they face physiological stress

High-Alert Medications

• Anticoagulants (Blood Thinners): Warfarin, Heparin, Enoxaparin. Newer agents (e.g., Rivaroxaban, Apixaban, Dabigatran)

• Antiplatelet Agents: Medications like Aspirin or Clopidogrel (Plavix), which also increase bleeding potential

• Anticonvulsants: Such as Phenytoin (Dilantin), Carbamazepine, or Valproic Acid

• Lithium: Used for Bipolar Disorder; it has a narrow therapeutic index, and toxicity can cause severe neurological symptoms.