PHARM HESI PT2

Bronchodilators: (ALBUTEROL acute only – SABA – know adverse/side effects

• ADR:

  • CNS: anxiety, restlessness, insomnia, tremors, headache

  • CV: palpitations & dysrhythmias (most common)

  • RESP: rebound bronchospasm

  • GU: urinary retention

  • GI: nausea, GE reflux

  • oral infections

  • SABA: albuterol, levalbuterol, pirbuterol, metaproterenol, terbutaline

    LABA: arformoterol, formoterol, salmetero

    
    

Anti-cholinergics like -ipraTROPIUM and long-acting tioTROPIUM)

• USE: COPD; Ach causes bronchial constriction and narrowing of the airways

• ADR: usually not absorbed systemically (locally in respiratory tract)

  • dry mouth or dry throat

  • GI distress, urinary retention, increased intraocular pressure

  • headaches, coughing, anxiety

INHALED: Fluticasone propionate

• LONG TERM control/prevention of asthma; 1-2 inhalations 2x day

SE: oral candidiasis, dry mouth, dysphonia/hoarseness, adrenal suppression if used long term

ORAL: Prednisone

• intended for SHORT TERM use

• ADR: ↑ risk of infections, ↓WBC, ↑ BP, ↑ blood glucose, weight gain, osteoporosis, cataracts, glaucoma, mood changes, insomnia, Cushing’s Syndrome, peptic ulcers, ↓ Hgb, impaired wound healing, hypokalemia

• NURSING: take exactly as prescribed (early in the morning; long term use must not be stopped abruptly)

  • report s/s of infection (fever); avoid sick people

  • monitor BP (may be elevated from fluid and Na retention)

  • monitor blood glucose (esp. in DM)

  • take w/ food to minimize GI upset

  • weight-bearing exercise & diet rich in vitamin D and calcium to prevent osteoporosis

  • eat diet high in protein and potassium, low in carbohydrates and Na

  • avoid ETOH and NSAIDs during therapy

  • report weight gain of 2lbs or more in a day or 5lbs or more in a week

  • if taking long term, watch for Cushing’s Syndrome

Fluticasone and salmeterol inhalers

• use only BID

Decongestants – rebound congestion.

• NURSING: rebound congestion if long term/excessive use in NASAL form

Know Montelukast and how to use it for asthma. When to administer the drug.

• USE: used for CHRONIC asthma management; NOT for acute asthma attacks nor COPD

ADR: headache, nausea, dizziness, insomnia, diarrhea

Know antihistamines and side effects.

ADR:

• anticholinergic (drying) effects are most common

  • dry mouth, urinary retention, constipation, changes in vision

• CNS

  • mild drowsiness-deep sleep

• cardiovascular

  • hypotension, palpitation, syncope (fainting/passing out)

Anti-tussive. Uses. Side effects. Nursing.

• USE: stop or reduce non productive coughs; may be used in cases when coughing is harmful

• ADR:

  • Benzonatate: dizziness, headache, sedation, nausea

  • Dextromethorphan: dizziness, drowsiness, nausea

  • Opioids: sedation, n/v, lightheadedness, constipation (codeine and hydrocodone)

• NURSING: respiratory/cough/allergy assessment, instruct patients to avoid driving or heavy equipment; report fever, persistent headache, and/or cough that lasts >1 week

Rifampin

• USE: treats M. tuberculosis and Neisseria meningitis

• ADR: hepatotoxicity, discoloration of bodily fluids (red-orange urine, sweat, saliva, tears)

TEACH: reduces efficacy of oral contraceptives (use non hormonal form of birth control), take on empty stomach or 1 hour before or 2 hours after meal

Isoniazid

MONITOR/ADR: hepatotoxicity and peripheral neuropathy (administer pyridoxine/Vitamin B6 if developed neuropathy)

Know theophylline – xanthine.

• TOXICITY: due to theophylline levels (normal 10-20 mcg/mL)

  • mild toxicity: nausea, vomiting, diarrhea, insomnia, restlessness

  • serious (over 30 mcg/mL): severe dysrhythmias, convulsions

  • ADR:

  • CNS: tremors (later sign of toxicity), nervousness, insomnia, agitation, convulsions

  • CV: tachycardia, tachydysrhythmias, angina, hypotension, palpitations

  • GI: nausea (first sign of toxicity), vomiting, anorexia

• NURSING: 

  • AVOID caffeine (methylxanthine) and smoking

  • give in daytime to prevent insomnia

  • take on full stomach or with milk to prevent GI distress

  • MONITOR blood levels for drug toxicity (checked 1-2 times a year)

  • can interact with many other drugs

Lithium – therapeutic range. Patient teaching. Lithium toxicity. Drug interactions.

• THERAPEUTIC:

  • acute mania: 1-1.5 mEq/L

  • long term maintenance: 0.6-1.2 mEq/L

• TEACH:

  • take w/ 2-3 liters of water/day and after meals to minimize GI upset

  • expect nausea, polyuria, thirst, and discomfort the first few days

  • avoid activities that require alertness and good psychomotor coordination until CNS effects are known, don’t switch brands, wear or carry medical identification

  • blood level slightly high can be dangerous (narrow therapeutic margin of safety)

    • watch for s/s of toxicity (diarrhea, vomiting, tremor, drowsy, weak, ataxia)

    • withhold one dose and call HCP if toxic symptoms appear; NOT ABRUPTLY

  • while taking lithium, do not make sudden changes to your salt intake. a sudden DECREASE in Na intake may result in a higher lithium level while a sudden INCREASE in Na might prompt your lithium levels to fall

  • decreases in body fluid leading to dehydration can result in lithium toxicity

• TOXICITY: n/v/d, ataxia, confusion, agitation, tremor, slurred speech

• INTERACT: 

  • ↑ risk of lithium toxicity when taking NSAIDs

  • ↑ risk of neurotoxicity w/ haloperidol, phenothiazides, & carbamazepine

  • ↑ hypothyroid effects of potassium iodine

  • ↑ lithium excretion w/ sodium bicarbonate

  • SSRIs may induce mania

  • loss of Na+: kidneys retain Li to compensate → Li toxicity

    • when Li is taken w/ a thiazide or loop diuretic

Selective Serotonin Reuptake Inhibitors (SSRIs)

• fluoxetine

• ADR: n/v/d, headaches, insomnia, agitation, anxiety, allergic reaction, tremors, seizures, sexual dysfunction, rare EPS, bruxism, BLEEDING DISORDERS, teratogenic, weight loss (short term but weight gain if taken > 6 months)

  • LIFE THREATENING SEROTONIN SYNDROME: AMS, myoclonus, hyperreflexia, excessive sweating, tremor, fever; occurs 2-72 hours after treatment 

• MEDICATION HISTORY: MAOIs can  ↑ risk of serotonin syndrome; antiplatelet meds can ↑ bleeding

Know Succinylcholine.

• neuromuscular blocking agents

• patients will not be able to breathe on their own; paralyses skeletal muscles (intercostal and diaphragm)

• does not affect consciousness or pain perception

Anti-anxiety: (end in -LAM or -PAM, like clonazePAM)

Benzodiazepines

• USE: treat anxiety and some insomnia, induce generalized anesthesia, manage seizure disorders, muscle spasm & spasticity, panic disorder, alcohol withdrawal

• ADR: CNS depression, anterograde amnesia, respiratory depression, insomnia/excitation/euphoria/anxiety/rage, hypotension & cardiac arrest (IV), CAT. D & X

• ANTIDOTE: 

  • acute toxicity: gastric lavage & dialysis; monitor resp and BP

  • OD: flumazenil; lasts for 1 hour so repeat doses, may not reverse respiratory depression

Buspirone – given on a scheduled basis. Know onset of action timing.

• PROS: does NOT produce CNS depression

• given on a scheduled basis

• ACTION: 2-4 weeks

Anti-depressants: Tricyclics – names, CNS effect. Nursing.

• “-tyline/-tiline and -pramine”/ doxepin

• ADR: cardiac toxicity (lethal w/ OD), sedation, orthostatic hypotension, anticholinergic effects, diaphoresis, dysrhythmias, seizures, hypomania

• NURSING: initial doses should be low and give at bedtime PO; monitor for orthostatic hypotension regularly; may increase risk of suicide early in treatment

Know MAOIs. Avoid other CNS depressants. Foods rich in tyramine.

• isocarboxazid, phenelzine, tranylcypromine, selegiline

• ADR: hypertensive crisis, orthostatic hypotension, anxiety/insomnia/agitation/hypomania and mania

• AVOID: tyramine rich foods may trigger hypertensive crisis (aged cheese, cured meats, fermented)

  • CNS depressants: TCAs cause hypertensive episode; SSRIs cause serotonin syndrome/crisis

Know CNS depressants

• Opioids: Morphine, Fentanyl, Meperidine, Hydromorphone, Oxycodone, Hydrocodone, and Codeine

• Barbiturates

• Benzodiazepines: "-lam" or "-pam"

• Muscle Relaxants: Carisoprodol, Cyclobenzaprine, Baclofen, Tizanidine, Chlorzoxazone, Metaxalone, Methocarbamol, Orphendrine

• Antiepileptics: IPhenytoin, Carbamazepine, Valproic Acid, Gabapentin, Lamotrigine, Levetiracetam, Topiramate

• Alcohol/Ethanol

Names of antipsychotics and antinausea drugs (metoclopramide)– risk of EPS

• First-Generation Antipsychotics (FGAs): “-azine” like Phenothiazines; risk of EPS

• Second-Generation Antipsychotics (SGAs): Clozapine; less risk of EPS

• Antinausea Drugs: Metoclopramide; high risk for irreversible tardive dyskinesia.

What drugs can be used to treat EPS?

• acute dystonia: tx w/ diphenhydramine(BENADRYL) and benztropine

• parkinsonism: tx w/ anti-ACh drugs

• akathisia: tx w/ anti-ChE drugs

Benztropine use.

• USE: tremors, cogwheel rigidity, control sialorrhea (excessive flow of saliva/drooling), about 20% effective in reducing the incidence & severity of akinesia and rigidity

  • parkinsonism & acute dystonia in EPS

Phenytoin therapeutic range, toxicity, side effects.

• THERAPEUTIC RANGES: 10-20 mcg/mL; take at same time and do not miss doses

• TOXICITY: elevated blood levels

  • 20-30: nystagmus

  • 30-40: ataxia, slurred speech, hand tremors

  • >40: decreased LOC

• ADR: nystagmus, diplopia, sedation, cognitive impairment, hirsutism, gingival hyperplasia w/ possible bleeding, suicidal ideation, rash/Stevens-Johnson, toxic epidermal necrolysis (TEN; higher in asians), hypotension, dysrhythmias, thrombocytopenia and/or leukopenia, chemical hepatitis

• PREGNANCY CAT. D

Carbamazepine – therapeutic ranges. Adverse effects include risk of myelosuppression.

• THERAPEUTIC: 8-12 mcg/mL

• ADR: diplopia, blurred vision, n/v, leukopenia, SIADH (monitor Na), depress bone marrow, photosensitivity, low sodium (headache, confusion, slurred speech, severe weakness, unsteadiness), risk of myelosuppression

• PREGNANCY CAT. D

Levodopa-carbidopa Adverse effects. Diet teaching.

• ADR: reduced in combination but may not be completely eliminated

  • n/v, especially early in treatment

  • CV effects: postural hypotension & arrhythmias

  • psychosis and dyskinesias (more intense in combo than levodopa alone)

  • NORMAL red/brown urine, sweat, saliva

• DIET: high protein meals → slow absorption → reduce therapeutic effect

  • vitamin B6 (fish, beef liver, etc.) 

Know Baclofen – use, effect on CNS, adverse effects, teaching – do not stop taking abruptly.

• USE: DOC for spasticity associated w/ spinal cord injury (paraplegic or quadriplegic), MS, trauma

• ADR: Baclofen withdrawal; sudden increase or return of your spasticity or tone, profuse sweating and itching w/o rash, fever, high heart or respiratory rate, high or low BP, confusion, hallucinations, delirium, seizures, rhabdomyolysis, organ failure, death

• do not stop taking abruptly

Know Dantrolene and its use.

• USE: spasticity associated w/ spinal cord injury, MS, cerebral palsy; antidote for succinylcholine, TREATMENT FOR MALIGNANT HYPERTHERMIA

Know migraine medications triptans and contraindications.

CONTRA: HTN, dyslipidemia, peripheral arterial disease, seizure disorder, Hx of heart-related problems (Prinzmetal angina), stroke, hepatitis, cirrhosis, and/or liver failure

Know ADHD medications. Amphetamine and dextroamphetamine.

• Methylphenidate is DOC; reduces negative behavior (inattention, etc.)

• MONITOR: glucose levels in DM patients

  • BP in adult patients when first starting, then periodically

  • height/weight especially in children (can stunt growth)

• ADR: ACUTE REBOUND DEPRESSION, excessive stimulation, tolerance to effect/decrease effectiveness to the HCP

• NURSING: give drug 4-6 hours BEFORE bedtime to avoid sleep interference, AVOID hazardous activities until the drug’s CNS effects are known, AVOID caffeine (increases effect of amphetamines); after prolonged use reduce, reduce dosage gradually to prevent acute rebound depression

Know cholinergic/anticholinesterase/cholinesterase inhibitors.

• NMDA antagonist: Memantine

  • MOA: NMDA receptor antagonist

  • NMDA antagonists are generally well tolerated

• cholinesterase inhibitors: Donepezil, Rivastigmine, Galantamine

  • MOA: prevents breakdown of Ach by acetylcholinesterase and thus ↑ availability of Ach at the cholinergic synapses; CNS 

  • cholinesterase inhibitors are modest and short lasting

• take in the evening before bedtime

Know atropine.

• USE: bradycardia, preop reduction of secretions & blockage of cardiac vagal reflexes, peptic ulcer disease, GI disorders, muscarinic agonist poisoning (mushrooms), organophosphate poisoning, ophthalmic preparations to produce mydriasis and cycloplegia-pupillary dilation in acute inflammation of iris and uveal tract

• CONTRA: glaucoma (↑ IOP), asthma (↑ thick secretions in airway), intestinal atony, urinary obstruction, tachycardia

• ADR: blurred vision, mydriasis, cycloplegia, photophobia, ↑ IOP, flushing, nervous, weak/dizzy, insomnia, mental confusion, excitement, nasal congestion, palpitations, tachycardia, dry mouth, altered taste, n/v, dysphagia, heartburn, constipation, bloated, paralytic ileus, gastroesophageal reflux, urinary hesitancy & retention, impotence, ↓ sweating & predisposition to heat prostration, lactation suppression

ANTIDOTE: physostigmine

Know Bethanechol. Uses, MOA.

• USE: relieving urinary retention, especially in post op and postpartum patients

MOA: binds reversibly to the muscarinic receptor; no impact on the nicotine receptors

Know Oxybutynin – use and side/adverse effects.

• USE: overactive bladder; urgency incontinence where detrusor contracts when it should not

ADR: dry mouth, constipation, tachycardia

Know STIGMINE drugs. Uses, MOA, when to administer, adverse/side effects.

• USE: myasthenia gravis, reversal of competitive neuromuscular blockade

ADR: sialorrhea, ↑ gastric secretions, ↑ tone/motility of GI (diarrhea), urinary urgency, bradycardia, sweating, miosis, spasm

Know Alzheimer’s. Donepezil

• approved for severe AD

• cholinesterase inhibitor

Pilocarpine – effect on pupil size and result when in dark.

• causes pupils to CONSTRICT and manage glaucoma by reducing IOP

• the smaller pupil size limits the amount of light entering the eye, making it difficult to see in the dark