Actual pharm final (copy) written

What are H2RA blockers for?

* Decreases amount of gastric juice
* Decreases H+ concentration

What type of drugs end with -tidine?

H2RA blockers

What is an important note about antacids?

Don’t take with other drugs

What is the tidine mnemonic?

take h2 blockers 30 mins before you go tidine. (take w food)

what is the dine mnemonic in tidine?

D: dont take with antacids

I: Inform HCP of bleeding

N: No nsaids/alcohol

E: Elevate HOB

What is the prototype drug for h2ra’s?

Cimetidine

What would food do to cimetidine?

Decrease rate of absorption

How does cimetidine move through the body?

* Can cross bbb
* Metabolized in liver
* Excreted through urine

What can cimetidine treat?

* Gastric and duodenal ulcers
* Zollinger-Ellison syndrome
* GERD
* Acid issues

what is zollinger-ellison syndrome?

Tumors on pancreas or duodenum that causes a lot of gastrin release → acid → ulcers

What are adverse effects of cimetidine?

* Gynecomastia
* CNS effects
* Pneumonia
* Drowsiness

What are drug interactions with cimetidine?

* Hepatic inhibitor (CYP450)
* Increased toxicity to warfarin, phenytoin, theophylline

What is ranitidine?

Recalled, stronger than cimetidine

what are differences between cimetidine and ranitidine?

* Ranitidine is more potent
* Given PO, IM, IV
* Food has no impact
* Fewer adverse effects (No antiandronergic)
* Does not cross BBB
* Weak hepatic inhibitor, fewer drug interactions
* Could cause cancer

What is famotidine compared to cimetidine?

* No antiandrogenic effects
* Does not inhibit liver (Safer)
* Lasts longer

What do proton pump inhibitors do?

* Inhibits the production of gastric juices

What drugs end with -prazole?

* Proton pump inhibitors

What is the prototype drug for Proton pump inhibitors?

* Omeprazole (Prilosec)

What are proton pump inhibitors used for?

* Gastric and duodenal ulcers
* GERD
* Erosive esophagitis
* Zollinger-Ellison Syndrome

When should you take PPIs? What should you tell the patient?

* Take before meals
* Don’t crush or chew bc they extended release

What are short term effects of proton pump inhibitors?

* Nausea and vomiting
* Headache
* Diarrhea

What are long term side effetcs of proton pump inhibitors?

* Pneumonia
* Fractures
* Rebound acid hypersecretion
* Hypomagnesemia
* C. Difficile

What drugs can Proton pump inhibitors interact with?

* Drugs that alter gastric PH
* Inhibit CYP2C19
* HIV drugs
* Antifungals
* Clopidogrel (Plavix) (Antiplatelet)

How to treat PUD caused by H. Pylori?

* Combination therapy: 2-3 antibiotics and PPI/H2RA

What antibiotics are used for H. Pylori?

* BATMC:
* Bismuth - black tongue/shit
* Amoxicillin - Best in neutral pH
* Tetracycline - Stains teeth
* Metronidazole - High Resistance
* Clarithromycin - Distortion of taste, nausea, diarrhea

What is selective toxicity?

* Ability of drug to harm pathogen without harming host cells

What is empiric therapy?

* Giving drugs without knowing the cause because of severe infection.
* Make sure to get cultures first.

What is the key thing that makes penicillin do its thing? What does it bind to?

* Beta-lactam ring in their structure
* Disrupts cell wall synthesis
* Binds to penicillin binding proteins

What type of bacteria is penicillin best against? What type of antibiotic is it?

* Gram positive bacteria
* Bactericidal

What do bacteria do to defend against penicillins?

* Create penicillinase, an enzyme that deactivates penicillin

What is the prototype penicillin?

* Penicillin G

What spectrum is penicillin G? What does it come in?

* Narrow Spectrum
* Forms in different salts

What can Penicillin G be used for?

* Prophylactically: Endocarditis, prosthetic heart valves, congential heart disease
* Meningitis, pneumonia, syphillis

How is penicillin G administered?

* IV and IM
* Potassium and sodium salts for IV only

How is penicillin distributed?

* Increased penetration into CSF, joints and eye in presence of inflammation

Where is Penicillin G elimated?

* Eliminated in the kidneys mostly intact, monitor kidney in high risk people

What are adverse effects of penicillin g?

* Allergic reaction
* Pain at IM injection site
* Neurotoxicity (hallucinations, confusions, seizures) with high blood levels
* Hyperkalemia with large IV doses

What not to mix penicillin G with?

* Do not mix PCN and aminoglycosides in the same IV
* PCN inactivates aminoglycoside

What is penicillin V?

* Oral form of penicillin

Do you take penicillin V w or w/o food?

* Take with meals

What are aminopenicillins?

* Am---cillin
* Ampicillin/Amoxicillin
* Broad Spectrum
* Works on gram-negative and are penicillinase resistant

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Penicillin allergies:

* No direct relationship between size of dose and intensity of reaction
* Prior exposure required
* Be careful with cephalosporins (if mild give orally)

How to treat penicillin allergy?

1. Stop drug
2. Notify doctor
3. Benadryl
4. Epinephrine
5. Notify Pharmacy
6. Complete report

What are vancomycins used for?

* Only gram positive bacteria
* MRSA, C.Diff

Can people w pcn allergy get vancomycin?

* Yes

What is vancomycin often given with?

* Aminoglycosides

What are adverse effects of vancomycin?

* Hypersensitivity reactions like redman/redneck syndrome
* Nephrotoxic and ototoxic
* Thrombophlebitis at injection site
* Thrombocytopenia

What are nursing considerations for vancomycin?

* Caution w renal failure
* Hearing Loss and allergies
* Monitor peak and trough
* Infuse slowly (at least over an hour)

What is Amphotericin B? Spectrum? When is it used?

* Dangerous antifungal that is reserved for fatal infections
* Broad Spectrum

Why is amphotericin B called ampho terrible?

* It is highly toxic

What is the drug of choice for most systemic fungal infections?

* Amphotericin B

How would you administer Amphotericin B?

* IV route every other day for several months (3-4)
* With Normal saline

Is amphotericin B absorbed in the GI tract?

* Absorbs poorly

What are adverse effects of Amphotericin B?

* All patients will experience renal damage (nephrotoxic)
* Infusion reactions (Phlebitis → slow infusion)
* Hypokalemia
* Hematological effects

Why does amphotericin B cause severe side effects?

* It has minimal selectivity and binds to cholesterol in humans

Tell me more about infusion reactions of amphotericin B. When do they start? What are the s/s? What do do? What to avoid?

* Symptoms start 1-3 hours after infusion
* Fever, chills, rigors (dantrolene), nausea, headache
* Pretreat with Benadryl and Acetaminophen
* Avoid NSAIDS, aminoglycosides, aspirin r/t kidney damage
* Frequent monitoring by RN

What to monitor in patients taking amphotericin B?

* Nephrotoxicity
* BUN/CR, GFR, Hypokalemia
* Intake and output
* Hemoglobin/hematocrit CBC
* Anemia

What is ketoconazole (nizoral)? Why is it used

* Broad spectrum antifungal for systemic and superficial fungus
* Used as an alternative to amphotericin B
* Less toxic

What are drug interactions of ketoconazole?

* Inhibits cyp450
* Increase levels of other drugs

What is itraconazole (sporanox) used for?

* Systemic fungal infection
* Superficial mycoses

What are adverse effects of itraconazole?

* Nausea/vomiting, diarrhea
* Hepatotoxicity
* Effects on sex hormones
* Cardiac suppression (caution use in heart failure)

What are drug interactions of itraconazole?

* Azoles increase drugs of certain meds
* Drugs that raise gastric ph will block absorption
* Inhibit cyp450 → Quinidine, cyclosporine, digoxin, warfarin, sulfonylureas

What is zidovudine used for? Does it penetrate CSF?

* Anti HIV drug that is drug of choice in pregnancy
* Yes

What are the adverse effects of Zidovudine?

* Hematologic toxicity
* Lactic acidosis (potentially fatal)
* Myopathy
* GI effects
* CNS reactions

What are drug interactions of Zidovudine?

* Myelosuppressive drugs
* Nephrotoxic Drugs
* Drugs toxic to circulating blood cells can increase hematologic toxicity ex. ganciclovir

What to monitor with zidovudine?

* Hematologic toxicity:
* Hold for Hgb below 5gm/dL or 25% drop from baseline
* Hold for neutrophil count below 750 cells/mL

What is darunavir (prezista)?

* Protease inhibitor
* One of the best antiretroviral drugs

What are adverse effects of Darunavir?

* Hyperglycemia/diabetes
* Fat redistribution
* Hyperlipidemia
* Reduced bone density
* Increased bleeding in people w hemophilia
* Elevation of ALT

What are drug interactions of protease inhibitors?

* Do not administer with PPI
* Metabolized by CYP450
* Inhibitors: Grapefruit, ketoconazole
* Inducers: Benzodiazepine, midazolam, st. johns wort
* Garlic: decreases levels

What is isoniazid? (INH/Laniazid)

* Primary bactericidal drug for Tubeculosis

What are adverse effects of isoniazid? (INH/Laniazid)

* Peripheral neuropathy (pyridoxine vitamin B6)
* Hepatotoxicity
* CNS effects

What are drug interactions of isoniazid? (INH/Laniazid)

* Inhibitor of CYP450
* Increases levels of phenytoin, diazepam, carbamazepine
* Alcohol

What is rifampin (rifadin)?

* Broad spectrum drug for tuberculosis and others

What are adverse effects of Rifampin?

* Hepatitis
* Discoloration of body fluids (red/orang)
* Tears, urine, sweat, saliva
* Can stain contact lenses

What are drug interactions of rifampin?

* CYP450 enzymes
* Coumadin, oral contraceptives, HIV drugs, NNRTIs

What not to mix rifampin with?

* Don’t mix with INH and pyrazinamide bc severely hepatotoxic

What is rifabutin?

* Better alterantive than Rifampin in HIV patients for Tuberculosis

What are adverse effects of rifabutin?

* GI upset
* Rash
* Neutropenia
* Uveitis

What are drug interactions of rifabutin?

* CYP450 enzymes
* Oral contraceptives
* NNRTIs (1)

What is metronidazole (flagyl)?

* Used for anaerobic bacteria and for protozoa
* Bactericidal

What are side effects of metronidazole (flagyl)?

* Causes disulfiram like reactions (flushing, severe, nausea, and vomiting) when taken w alcohol
* Nausea, Headache, dark urine, metallic taste, hypersensitivity risk, neurological effects

What should women know about metronidazole (flagyl)?

* Crosses BBB avoid in FIRST trimester of pregnancy (others ok)
* Ok for breastfeeding after 12-24 hours
* All sex partners need to be treated
* Use barrier contraceptives

What is chloroquine used for?

* Drug of choice for malaria
* Prophylaxis

What are adverse effects of Chloroquine?

* GI effects: N/V/D abdominal pain
* Visual disturbance
* Hepatotoxicity
* Pruritus (itching)
* Headache

What is primaquine uses?

* Used for hepatic malaria and relapse prevention

What are adverse effects of primaquine?

* Hemolysis: monitor CBC
* Mostly blacks, middle eastern, southeast Asians, Mediterranean

What is Epoetin Alfa (erythropoietin)?

* Stimulates stem cells in bone marrow to make RBCs in response to anemia/hypoxia
* Must have enough iron, folic acid, B12 to work
* Increased hematocrit (may take up to 3 months) transfusion

When is Epoetin Alfa (erythropoietin) used?

* Chronic renal failure
* Anemia from chemotherapy (non bone cancer)
* HIV patients taking zidovudine
* Elevate anemia patients before surgery

What are adverse effects of Epoetin Alfa (erythropoietin)?

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* Autoimmune pure red-cell aplasia (rare)
* Cardiovascular events:
* Cardiac arrest
* Hypertension
* Heart failure
* Stroke/MI
* Increased risk if
* HGB > 11gm
* Rise exceeds 1gm/ dL in two weeks

What are warnings of Epoetin Alfa (erythropoietin)?

* Excessive dosage
* Renal failure patients
* Preop patients
* Cancer patients

What to monitor in patients taking Epoetin Alfa (erythropoietin)?

* CBC with differential
* HGB level (twice weekly)
* Increased risk if HGB >11 gm/dL
* BUN, uric acid, Creatinine, K+, PO4
* Iron

What is filgrastim (neupogen)? Uses?

* Increases neutrophils in bone marrow
* Used in chemo patients to reduce infection and chance of neutropenia
* Patients undergoing bone marrow transplant
* Patients with chronic neutropenia
* Before harvesting stem cells

What are adverse effects of filgrastim (neupogen)?

* Bone pain (25% of patients)
* Leukocytosis (too many wbcs)

What to monitor in patients with Filgrastim?

* CBC prior to starting and twice weekly during treatment

What is cyclosporine? Uses?

* Immunosuppressant drug that suppresses t cells
* Prevent organ rejections
* Psoriasis, rheumatoid arthritis

What are adverse effects of cyclosporine?

* Nephrotoxicity
* Infection
* Hepatotoxicity
* Lymphomas
* Hypertension
* Gingival Hyperplasia
* Tremor
* Hirsutism
* Hyperkalemia
* Leukopenia
* Avoid in pregnancy

What are interactions with cyclosporine?

* CYP450
* Drugs that increase cyclosporine:
* Inhibitors: ketoconazole, erythromycin, amphotericin B
* Drugs that decrease cyclosporine:
* Inducers: phenytoin. rifampin, bactrim
* Nephrotoxic
* Grapefruit juice
* Repaglinide

What is tacrolimus (prograf)?

* Alternative to cyclosporine for preventing allograft rejection
* More effective than cyclosporine but more toxic
* Narrow therapeutic index

What are uses for tacrolimus (prograf)?

* Organ rejection of those receiving liver, kidney, and heart transplant

What are adverse effects of tacrolimus?

* Similar to cyclosporine
* Nephrotoxicity
* Neurotoxicity
* GI effects, HTN, Hyperkalemia, infections, lymphomas