NR 565 - advanced pharmacology midterm - Chamberlain questions bank | 221 questions and answers

What is BEERS criteria?

Recommendations of medications inappropriate for elderly (65 and older), prescriber ultimately decides

What is the CYP450 (cytochrome P450)

liver enzyme system where medications are metabolized, can either be inducers or inhibitors and create drug-drug interactions

CYP450 inducers

Speed up metabolism of drugs (drug is cleared faster), drug has lesser effect (decrease blood levels of drug), elevate CYP450 enzymes

CYP450 inducer drug names

Barbituates, St John wort, Carbamazepine, rifampin, alcohol, phenytoin, griseofulvin, phenobarbital, sulfonylureas

CYP450 inhibitors

inhibit metabolism, increase blood levels of medications

CYP450 pneumonic

"VISA credit card debt INHIBITS spending on designers like CK to look GQ"

CYP450 inhibitors drug names

Valproate, isoniazid, sulfonamides, amiodarone, chloramphenicol, ketoconazole, grapefruit juice, quinidine

How is absorption of intramuscular medications different in neonates?

slow and erratic due to low blood flow in muscles first few days of life

Why is absorption of medication in the stomach increased in infancy?

delayed gastric emptying

Some medications that should be avoided in the pediatric patient?

glucocorticoids, discoloration of developing teeth with tetracyclines, and kernicterus with sulfonamides, levofloxacin (antibiotics)

aspirin (Severe intoxication from acute overdose)

what should be included in medication administration patient education?

dosage size and timing

route and technique of administration

duration of treatment

drug storage

nature and time course of desired responses

nature and time course of adverse responses

finish taking antibiotic

What are some things that put the elderly patient at higher risk for adverse drug reactions?

reduced renal function

polypharmacy (the use of five or more medications daily)

greater severity of illness

presence of comorbidities

use of drugs that have a low therapeutic index (e.g., digoxin)

increased individual variation secondary to altered pharmacokinetics

inadequate supervision of long-term therapy

poor patient adherence

How can healthcare providers decrease likelihood of an elderly patient experiencing an adverse drug reaction?

obtaining a thorough drug history that includes over-the-counter medications

considering pharmacokinetic and pharmacodynamics changes due to age

monitoring the patient's clinical response and plasma drug levels

using the simplest regimen possible

monitoring for drug-drug interactions and iatrogenic illness

periodically reviewing the need for continued drug therapy

encouraging the patient to dispose of old medications

taking steps to promote adherence and to avoid drugs on the Beers list

How can we promote medication adherence with elderly patients?

simplifying drug regimens

providing clear and concise verbal and written instructions

using an appropriate dosage form

clearly labeling and dispensing easy-to-open containers

developing daily reminders

monitoring frequently

affordability of drugs

support systems

Why do nitrates need to be taken no later than 4 PM?

Need nitrate free interval so tolerance doesn't develop

Nine factors that impact outcome of medication?

Gender and race

Genetics and pharmacogenomics

Variability in absorption

placebo effect

Tolerance

patho

age

bodyweight

Do you need informed consent for genetic testing?

yes

What is the purpose of the Genetic Information Non-Discriminatory Act?

Protects patients from discrimination by employers and insurance providers based on genetic information

Difference between practice authority and prescriptive authority?

Practice authority refers to the nurse practitioner's ability to practice without physician oversight, whereas prescriptive authority refers to the nurse practitioner's authority to prescribe medications independently and without limitations.

Who regulates prescriptive authority?

the jurisdiction of a health professional board. This may be the State Board of Nursing, the State Board of Medicine, or the State Board of Pharmacy, as determined by each state.

What is scope of practice determined by?

is determined by state practice and licensure laws.

What are components of Rx?

Prescriber Contact info

Prescribers name

NPI

DEA

Patient name

DOB

Date

Allergies

Medication name

Strength

Quantity

Indication for use

Direction for use

Refills

Signature

What are some potential problems that arise with written prescriptions?

Must contain all elements

May have pre-populated information

Write legibly

Avoid error prone abbreviations

Tamper resistant scripts are often required

Reasons for monitoring drug therapy

determining therapeutic dosage

evaluating medication adequacy

identifying adverse effects

serious or life-threatening risks.

Which schedules of drugs can APRNs prescribe?

depends on state - most II-V

How does limited prescriptive authority impact patients within the healthcare system?

longer wait times to sign a prescription

limits practitioners that are needed in rural areas

unequal relationships between providers. Ex. one has more power

high need for providers due to lack of providers and high amounts of patients.

Independent practitioners= more patients being seen= lessens the patient/provider load

Provider key responsibilities when prescribing?

safe and competent practice

understanding of the drugs, reactions, and pharmacology

Be aware of the age group you are prescribing to

Ex. Children vs older adults

What should be used to make prescribing decisions?

documented provider-patient relationship, not prescribing for family or friends, documenting a thorough H&P, including discussions with the patient, drug monitoring/titrating.

cost, guidelines, availability, interactions, side effects, allergies, hepatic and renal function, need for monitoring, and special populations

What happens when someone has a poor metabolism phenotype?

medications metabolized slower, medication might not work or put them at risk for side-effects

What does the US food and drug administration regulate when it comes to medications?

Whether the drug is safe, effective, and benefits of a drug outweigh the risks

reasons for medication non-adherence

patients never filling/refilling prescriptions (resulting in therapeutic failure)

multiple chronic disorders

multiple prescription medications

multiple doses per day for each medication

drug packaging that is difficult to open

multiple prescribers

changes in the regimen (adding meds, changes in dose or timing)

cognitive or physical impairment (reduction in memory, hearing, visual, color, or manual dexterity)

living alone

recent discharge from hospital

low literacy

inability to pay for meds

personal conviction that a drug is unnecessary or the dosage is too high

presence of side effects

Which statements are possible reasons for medication non-adherence?

"I tried to take for weeks and it just wasn't working"

"It was so expensive I only took it once a day instead of twice"

"I dropped the whole medication bottle on the floor"

"I was traveling and busy"

"I lost the medication level"

"I ran out"

"I couldn't remember if I took it this morning and sometimes I just forget"

What are black box warnings?

Is the strongest safety warning a drug can carry and still remain on the market. Usually presented on the label with a heavy black border.

Why are black box warnings issued?

Issued by the FDA due to having serious or life-threatening risks

What is neonate and infant drug dosing based on?

weight or body surface area (BSA)

After age one what happens to pharmacokinetic parameters, including drug sensitivity?

mirror adult parameters

Children under two have fast metabolism

true

How is absorption of transdermal medications different in neonates?

more rapid and complete in infants than in older children and adults. the skin is very thin and blood flow is great in infants

How is absorption of oral medications different in neonates?

absorption may be enhanced or impeded depending on the properties of the drug. gastric emptying is irregular, drugs absrobed in the intestine are absorbed slower.

Common fears with genetic testing

Lack of education - many health care providers do not possess the knowledge or comfort to interpret the tesgin

financial cost - many insurance plans do not cover this. cost can be from $100-2000.

discrimination from employers, insurance companies or providers

12 CDC guidelines for prescribing opioids

Opioids are not first line therapy

establish goals for pain and function

Discuss risks and benefits

Use immediate release opioids when starting

Use the lowest effective dose

Prescribe short durations for acute pain

Evaluate benefits and harms frequently

Use strategies to migrate risk

Review PDMP data

Use urine drug testing

Avoid concurrent opioid and benzo prescribing

Offer treatment for opioid use disorder

Pure opioid agonist

activate opioid receptors in brain resulting in opioid effect

examples of pure opioid agonist

morphine, methadone, fentanyl, heroin, oxycodone, hydrocodone, opium

pure opioids produce what effects?

analgesia, euphoria, sedation, respiratory depression, physical dependence, constipation

prototype for strong opioid agonist

morphine

moderate to strong opioid agonist prototype

codeine

A person who is depend on a pure opioid agonist should NEVER receive an opioid agonist antagonist

true

opioid agonist-antagonist

used to treat opioid dependence and pain. They work by reducing the affects of withdrawal symptoms and affecting pain sensors.

examples of opioid agonist-antagonist

Buprenorphine, Pentazocine, Butorphanol, Nalbuphine

pure opioid antagonist

reverse and blocks opioid effects

example opioid antagonist

naloxone

When to refer a patient to a pain specialist?

required for patients who take 120 mme per day of morphine milligram equivalents

What is used to calculate pt's overdose risk?

total morphine milligram equivalent (MME) per day to help assess the patient's overdose risk. If it is high (≥50 MME/day and especially ≥90 MME/day)

Calculate total daily dose: 1. daily amount of each opioid that patient takes 2. convert to MME, multiply dose for each opioid by conversion factor 3. add them together

What is MME and when to use?

morphine milligram equivalent, represents the potency of an opioid in comparison to morphine, used to identify opioid prescription burden of a person

What is the prescription drug monitoring program?

electronic databases enable providers to access information regarding a patient's prescription history of controlled substances. Nearly all states have implemented PDMPs, and some states require providers to check the PDMP before prescribing controlled substances.

When should PDMP be used?

anytime a controlled substance is prescribed, refilled, or filled

Why is PDMP important?

identify those at risk for overdose

Assess someone for possible drug diversion?

Urine test at least yearly

PDMP routinely

How does renal and hepatic function impact medication levels in body?

Patients with renal or hepatic insufficiency can experience greater peak effect and longer duration of action for medications, thereby reducing the dose at which respiratory depression and overdose may occur. Similarly, for patients ages 65 years and older, reduced renal function and medication clearance due to age can result in a smaller therapeutic window between safe dosages and dosages associated with respiratory depression and overdose.

How do elderly metabolize differently than younger people?

Older adults metabolize opioids slowly and therefore require lower doses than younger adults.

When should naloxone be prescribed?

with every opioid prescription

What is the typical dose of naloxone and how is it administered?

4 mg, nasal spray- one spray to one nostril

If no response, additional doses can be given every 2 to 3 minutes until emergency services arrive

In regards to dosage, why do we need to be cautious when giving naloxone?

Dosage must be titrated carefully bc if too much is given the patient will swing from a state of intoxication to withdrawal

What is the half-life of naloxone?

Short- naloxone must be administered every few hours until opioid concentrations have dropped to nontoxic levels

US Drug Enforcement Administration description of the scheduled drugs

The DEA enacted the Controlled Substances Act (CSA) in 1970 to regulate drugs and other substances based on their potential for abuse and dependency. Five schedules of controlled substances were created that are updated annually. Classes of scheduled substances include narcotics, depressants, stimulants, hallucinogens, and anabolic steroids. The DEA issues eligible providers with a registration number to write prescriptions for controlled substances.

Schedule I

high potential for abuse and no current accepted medical use

example of schedule I

Heroin, Lysergic Acid Diethylamide (LSD), Marijuana (cannabis), 3,4-Methylenedioxymethamphetamine (ecstasy), Methaqualone, and Peyote

Schedule II

substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence

Examples of schedule II

Combination products with less than 15 milligrams of Hydrocodone per dosage unit (Vicodin), Cocaine, Methamphetamine, Methadone, Hydromorphone (Dilaudid), Meperidine (Demerol), Oxycodone (OxyContin), Fentanyl, Dexedrine, Adderall, and Ritalin

Schedule III

substances, or chemicals are defined as drugs with a moderate to low potential for physical and psychological dependence. Abuse potential is less than schedule I and II drugs, but more than schedule IV

examples of schedule III

Products containing less than 90 milligrams of Codeine per dosage unit (Tylenol with codeine), Ketamine, Anabolic steroids, Testosterone

Schedule IV

substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence

example schedule IV

Xanax, Soma, Darvon, Valium, Ativan, Talwin, Ambien, Tramadol

Schedule V

substances or chemicals are defined as drugs with lower potential for abuse than schedule IV and consist of preparations containing limited quantities of certain narcotics. Are generally used for antidiarrheal, antitussive, and analgesic purposes

example schedule V drugs

Cough preparations with less than 200 milligrams of Codeine or per 100 milliliters (Robitussin AC), Lomotil, Motofen, Lyrica, Parepectolin

What type of analgesic for mild to moderate pain?

tylenol, NSAID (Advil/motrin), COX2 inhibitors (like NSAIDS)

What type of analgesic for moderate to severe pain?

opioids

When to start using short acting opioids?

Should be used exclusively for acute pain in opioid naïve (never had before) patients as opposed to opioid tolerant patients

Adverse effects of opioids

constipation

urinary retention

orthostatic hypotension

emesis

neurotoxicity (delirium, agitation)

tolerance and physical dependence

respiratory depression

What are strong opioids analgesics usually reserved for?

moderate to severe pain, postoperative pain, labor and delivery, cancer, chronic pain, hospice/palliative care, end of life, acute traumatic events, burns

Use of opioids and these other medications should be avoided and why?

respiratory depression with other drugs with CNS depressant action

CNS depressants

barbiturates

benzo

alcohol

general aesthetics

anti-histamines

phenothiazine

anticholinergic drugs

atropine

tricyclic antidepressants (constipation and urinary retention)

what is the classic triad of symptoms for an opioid overdose?

MAOI (hyperpyrexia coma)

coma, resp depression, pinpoint pupuls

How does strength of fentanyl compare to morphine

high milligram potency (about 100 times that of morphine)

through what system is fentanyl metabolized?

CYP34A (isoenzyme of CYP450), levels of fentanyl can be increased by CYP34A inhibitors

What is methadone used to treat?

relieve pain and treat opioid addiction

For what level of pain is codeine prescribed?

mild to moderate

What does 10% of codeine convert to/black box warning

10% of each dose of codeine undergoes conversion to morphine, the active form of codeine (led to death in children and toxicity in infants through breast milk)

Black box warning for hydrocodone

products that contain Tylenol are associated with hepatotoxicity

Black box warning opioids, fentanyl, oxycodone, hydromorphone, oxymorphone

respiratory depression

black box warning for methadone

prolong QT interval, fatal dysrhythmias

Do opioid agonist-antagonist have high or low potential for abuse?

low - when compared with opioid agonists

If you switch a patient from oxycodone to buprenorphine quickly what may we expect to see?

If given to a patient who is physically dependent on a pure agonist, there drugs can precipitate withdrawal

What level of pain is tramadol approved for

moderate to moderately severe

What schedule is tramadol classified as?

schedule IV

What population should tramadol be AVOIDED in?

pt's with epilepsy, neurologic disorders, elderly

What drugs should be avoided for patients taking tramadol?

CNS depressants (benzo, alcohol), MAOI, SSRI, serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants, triptans

What government branch declared the opioid crisis a public health emergency?

Health and Human Services (HHS)

what are the top 5 priorities of HHS?

Improving access to treatment and recovery services

Promoting use of overdose-reversing drugs

Strengthening our understanding of the epidemic through better public health surveillance

Providing support for cutting edge research on pain and addiction

Advancing better practices for pain management

What were provisions made to the guidelines for prescribing opioids to non-cancer patients?

Using opioids only after non-opioid analgesics or more conservative methods have failed

Discussing the benefits and risks for long term opioids with patient

When possible, one prescriber, one pharmacy

Ensuring comprehensive follow up to assess efficacy and side effects of treatment and monitor for signs of opioid abuse

Stopping opioids after an attempt at opioid rotation had produced inadequate benefits

Fully documenting the entire process

When prescribing opioids should patient be initially started on IR or ER?

IR- lowest dose for shortest amount of time