pharm final

What type of coughs are Antitussives for?

-Dry hacking coughs
-Not one with mucus because you want secretions to come out

Antitussive Opioids

-Codein, hydrocodone

Antitussive Nonopioids

-Dextromethorphan (robitussin)
-Benzonatate (Tessalon): children were overdosing bc it look like candy.

antitussives Opioid addiction

-Risk for abuse when mixing antitussives esp. codeine.

What do antihistamines do?

-Reduces: Edema, flushing, itching, pain, rhinorrhea, sneezing
-Effective prophylactically

Do antihistamines reduce congestion?

They do not reduce congestion

Therepeutic uses for antihistamines

-Mild allergies
-Used with epinephrine during anaphylaxis
-Motion sickness
-Insomnia

Adverse effects of antihistamines

-Sedation
-Nonsedative CNS effects: Dizziness, lack of coordination, confusion, fatigue. Paradoxical excitation, esp in children
-GI effects: could upset stomach, give with food
-Anticholinergic effects: urinary hesitancy, constipation, palpitations

Antihistamine drug interactions

-Alcohol ETOH and CNS depressants
-Can cause more sedation

1st Generation Antihistamines are

-Diphenhydramine (Benadryl)
-Promethazine (Phenergan)

-Cross BBB
-Causes sedation

Administration of 1st Gen Antihistamines

-PO, slow IV
PROMETHAZINE NEVER IV BC NECROSIS, IM PREFERRED

Second Generation Antihistamines are

-Loratizine (Claritin)
-Cetirizine (Zyrtec)
-Fexofenadine (Allegra)

-Little to no sedation
-Minimal anticholinergic effects

Administration of 2nd Gen Antihistamines

-Oral, OTC and expensive

What do statins do?

-Increased HDL
-Decrease LDL, cholesterol, VDLL, and plasma triglycerides
-Inhibits HMG-CoA reductase (makes LDLs)

When should you take statins?

-AT NIGHT*

Pregnancy and statins

-hoes should not take STATIN bc baby finna get clapped

Main statins

-Lovastatin (Mevacor)
-Atorvastatin (Lipitor)

Adverse effects of Atorvastatin (Lipitor)

-Elevated liver enzymes
-Monitor Liver function tests
-Injury to muscle and tissue can occur
-Metabolized by hepatic enzyme CYP3A4 (no grapefruit)

-Look for tea color urine and weakness

Goals of drug therapy for angina

-Prevent MI, death, ischemia, pain

Factors that determine oxygen demand

-Heart rate
-Contractility
-Preload
-Afterload

What is nitroglycerin

-Drug for angina
-Relaxes vascular smooth muscle
-Dilate arteries and veins.
-Decreases systemic vascular resistance
-Decreases oxygen demand
-Increases flow to heart
-Decrease preload and afterload

Type of nitrates

-Nitroglycerin
-Isosorbide mononitrate
-Isosorbide dinitrate
-Sustained and immediate release

Nitroglycerin Metabolism

-First past effect (give sublingual)
-Short half life 5-7 minutes
-Pharmacodynamic tolerance

how to minimize tolerance to nitrates

-Tolerance happens in a day
-Take smallest does possible
-Remove patches for 8-10hrs at night
-Sustained release same time

What nitrates to use for acute angina

-Sublingual tablets or powder (burn feel)
-Translingual spray

What nitrates to use for chronic recurrent angina

-Topical - NTG paste
-Transdermal - NTG patch (rotate sites)
-Oral

Nitrates for hypertension

-IV
-Continuous infusion
-Monitor HR and BP
-Decrease BP

Adverse effects of nitrates

-Headaches
-Orthostatic hypotension
-Low BP
-Tachycardia (counteract with beta blocker to lower HR or calcium channel blocker to lower bp)
-We want to keep HR low

How do nitrates lose potency (storage)

-Light
-Humidity
-Heat
-Plastic IV/Tubing (use non pvc tubing)
-Replace sublingual NTG every 3 months

Nitrate drug interactions

-Sildenafil (viagra)
-Tadalafil (Cialis)
-Cause fatal drop in Blood pressure

What to do before administer nitrate

ASSESS BP AND PULSE BEFORE ADMINISTRATION
-Make sure IV Access
-have patient sit/lie down before NTG for angina pain

How much nitrate can patient get

-Patient can take 5 mins x 3 doses
-Call 911 if no relief after 1st dose

What to monitor in nitrate patient

-hypotension and reflex tachycardia
-PROB GET HEADACHE

List of beta blockers for angina

-Propanolol (Inderal) and Metoprolol (lopressor)

What are beta blockers (angina) ?

-Propanolol (Inderal) and Metoprolol (lopressor)
-First line drug for stable angina
-not for vasospastic angina
-Administerd on schedule to provide protection against angina from exercise

What do beta blockers do?

-Decrease oxygen demand
-Decrease HR and contractility
-Increase oxygen supply

Adverse effects of beta blocker for angina

-Decrease contractility
-Decrease Heart rate
-AV block

When do you hold beta blockers?

-Less than 60bpm

List of calcium channel blockers

-Diltiazem (cardezem), verapamil, nifedipine

What do calcium channel blockers do?

-Arteriole dilation
-Reduction of resistance (afterload)
-Relaxes coronary spasm
-Slow HR, decrease oxygen demand

When to give Calcium channel blockers for stable angina?

-Given when patient cannot tolerate beta blockers or nitrates or if symptoms.

What is drug of choice for prinzmetal (variant) angina?

-Calcium channel blockers
-Increases cardiac oxygen supply

Adjunct drug therapy for angina

-Oxygen
-Aspirine
-Morphine
-Nitroglycerin
-MONA

-Don't decrease oxygen demand
-Slows down progression of complications and CAD

What do anticoagulants do?

-Prevent blood clots from forming or extending
-Do not break down clots-

When to give anticoagulants?

-To prevent thrombosis in the veins
-DVT
-Atherosclosis
-Acute coronary syndrome
-PVD
-Oncologic processes
-Genetic predisposition

How can anticoagulants be given?

-IV, SQ, PO

Lab values to monitor for anticoagulants

-Complete blood count
-PT prothrombin time
-aPTT
-INR

What does warfarin (coumadin) do?

-Blocks vitamin K and prevents activation of prothrombin and other factors
-Prevent clots

-Administer PO

What to monitor in Warfarin (Coumadin)

-Monitored by prothrombin time (PT) and international normalized ratio (INR)

-PT should be 1.5-2x control
-INR should be 2-3x

-ANTITODE is VITAMIN K
-Adverse effect is bleeding

Absorption of warfarin

-Initial response seen in 8-12 hrs
-Half life 1.5-2 days

Adverse effects of warfarin

-Hemorrhage
-Lots of drug interactions

What does heparin do?

-Is an anticoagulant
-Short half life 1.5 days
-Requires continuous monitoring

Antidote for heparin

-Protamine sulfate
-1mg/100u of heparin

How to monitor heparin

-Monitor aPTT during IV therapy
-Levels are 15-2x.
-Normal is 40 seconds; therapeutic is 60-80 seconds
-Antifactor Xa

Adverse effects of Heparin

-Hemorrhage
-Spinal/epidural hematoma
-Thrombocytopenia
-Chills, fever, urticaria

Heparin administration

-IV heparin is HIGH ALERT
-Have colleague double check

-Subq for low dose
-Do not massage
-Does not require monitoring
-Q12 or Q8

What is enoxaparin (lovenox) used for?

-Prevention and treatment of DVT
-Prevent ischemic complications of MI

How to administer enoxaparin (lovenox)

-Administer SQ
-Anterior or posterolateral sites (love handles)

Antitode for enoxaparin (lovenox)

- Protamin sulfate

Advantages for enoxaparin (lovenox)

-Fixed dose
-Longer half life
-Does not require PTT monitoring
-Plasma predictable
-Less bleeding, thrombocytopenia
-Longer half life
-Predictable

enoxaparin (lovenox) Administration

-Subq
-Do not expel air bubble
-Do not massage/avoid umbilicus
-Daily or Q12h dosing

What is rivaroxaban (Xarelto)?

-It is an anticoagulant
-Prevents DVT and embolism following surgery
-Prevent stroke in patients with atrial fib
-No monitoring
-Less drug interactions

Adverse effects rivaroxaban (Xarelto)

-Use with caution w renal impairment and hepatic impairment
-No antidote
-No pregnanct
-Bleeding

What is clopidogrel (plavix)

-Is a prodrug
-Irreversible antiplatelet effects
-Return to normal after 7-10 days

Therapeutic uses for clopidogrel (plavix)

-Prevent blockage of coronary artery stents
-PRevention of thrombotic events (stroke, mi) in patients with ACS

Administration Clopidogrel (Plavix)

-PO
-Some are poor metabolizers

Adverse effects of clopidogrel (plavix)

-Bleeding
-Thrombotic Thrombocytopenia Purpura

What do thrombolytic drugs do?

-Breaks down formed clots
-Used in acute mi, embolism
-Lower doses used to open occluded arteriovenous catheters

Thrombolytics administration

-Administered IV
-Timely interventions is priority

When not to use thrombolytics?

-Active bleeding
-Uncontrolled hypertension
-Intercranial hemorrhage or trauma
-History of cerebrovascular accident

Side effects of thrombolytics

-Bleeding ofc

List of thrombolytics

-Shit with ase
-Alteplase
-Reteplase
-Tenecteplase

What to monitor or mfs with blood drugs

-Vital sign changes
-Bleeding
-Blood work abnormalities
-Arrhythmias
-Respiratory difficulties

Management of bleeding

-Minimize physical manipulations
-Avoid injections
-Manual BP, no automated
-Minimize concurrent use of anticoagulants and antiplatelet drugs
-Electric razors
-Vitamin K during coumadin.

What is morphine?

-Strong opioid analgesic
-moderate to high abuse potential
-Blocks Mu receptors

Uses for morphine

-Analgesia: more effective against dull than sharp intermittent pain
-Post operative pain, cancer, labor
-Can be used for MI, dyspnea with heart failure,
-Reduces air hunger in COPD

Morphine adverse effects

-Respiratory depression
-Constipation
-Orthostatic hypotension
-Urinary retention
-Cough suppression
-Biliary colic
-Emesis
-Elevated intracranial pressure
-Euphoria
-Sedation
-Miosis
-Birth defects
-Neurotoxicity

Morphine Administration

-IV, IM, SubQ, Epidural, intrathecal
-PO: can be short or long acting
-Does not cross BBB easily
-Metabolized by liver
-Excreted by the kidneys

-Fixed Schedule
-Monitor vitals, esp respiratory rate

Morphine Tolerance

-Tolerance develops to Analgesia, euphoria, sedation, respiratory depression
-Does not develop tolerance to constipation or miosis
-Cross tolerance exists w other opioids
-When switching opioids, make sure equinalgesic

Morphine dependence

-Abstinence syndrome when withdrawn
-Intensity of withdrawal parallels the degree of physical dependence
-NO ABRUPT WITHDRAWALS

Morphine Precautions

-Decreased respiratory reserve
-Labor and delivery
-Head injury
-Old and young
-Liver impairment

Morphine Interactions

-CNS depressants, anticholinergic drugs, hypotensive drugs, mao inhibitors, opioids

What is fentanyl and what are the routes

-Strong opioid analgesic
-Parenteral preferred for surgical anesthesia (conscious sedation) due to rapid onset and short duration
-Transdermal patch
-Transmucosal: lozenge on a stick
-Intranasal

When to asses pain for opioids?

-Prior to administration and 1 hour after

Preferred dosing for opioids

-Fixed dosing is recommended

What is naloxone (narcan)

-Blocks opioid actions
-Reverse effects of opioids: analgesia, respiratory depression, sedation, euphoria

Routes for naloxone

-IV, IM, subQ
-Can cause withdrawal
-Dilute it
-Administer 1mL every 30sec-1min

what are Neuromuscular blocking agents (NMB)

-Paralyse muscles by blocking neurotransmitter
-No oral forms
-Cannot cross the BBB. No central nervous system effects**
-Minimal effect of fetus
-NO analgesia or sedation

Uses for neuromuscular agents

-Facilitate endotracheal intubation
-Mechanical ventilation
-Patients undergoing surgery or procedures

What are non-depolarizing agents (competitive NMBS)

-Relax muscles, flaccid paralysis
-Hypotension
-No CNS effect
-Rapid onset
-Peaks 20-45 mins then decline
-Recovery in 1 hr

Adverse effects:
-Respiratory arrest
-Cardiovascular effects

What is pancuronium?

-Nondepolarizing NMB
-Approved for muscle relax during general anesthesia, intubation, ventilation
-Reduce agitation in ICU
-ECT therapy
-Caution with liver disease

What is succinylcholine

-Only depolarizing neuromuscular blocker
-Ultra short acting, Flaccid paralysis
-No CNS effect
-Peaks at 1 min, fade after 4-10min

succinylcholine uses

-Endoscopy, intubation
-muscle relaxation during procedure
-Not good for Long ass procedures
-Caution with hyperkalemia and glaucoma

succinylcholine adverse effects

-Prolonged apnea
-Can cause hours long paralysis
-Causes hyperkalemia
-No antidote

-Malignant hyperthermia.***
-Cool them and discontinue
-Administer dantrolene

Local anesthetics and blood flow

-High blood flow shortens effects.
-Low blood flow prolong anesthesia
-Combine with epinephrine to vasoconstrict and decrease toxicity risk of anesthesia (can increase toxicity of epinephrine)

Adverse effects of local anesthetics

-CNS agitation followed by depression
-Cardiovascular system:
-Heart causes suppression of excitability
-Vasodilation
-Allergic reactions
-Prolong labor

What is lidocaine?

-Local anesthetic
-Administered topically or injection
-Also used as an antidysrhythmic
-addition of epinephrine
-Risk of systemic toxicity

What is tetracaine?

-Local anesthetic
-Surface anesthesia
-Pain, itching, soreness
-Used in mucous membranes

Topical local anesthetic considerations

-Use smallest amount
-Avoid large areas
-Avoid broken skin
-Avoid hard exercise
-Avoid wrapping
-Avoid heating

Topical local anesthetic considerations

-Have resuscitation equipment ready
-Maintain IV line
-monitor cv, respiratory, loc
-Aspirate to ensure not administer in a vessel