CPhT-Test 1-Complete/Long Review Material

Single-dose vial

NO PRESERVATIVE (one patient, one entry)
-use once, then discard
-sterility is not assured after puncture
-Never share across patients

Multi-dose vial

CONTAINS PRESERVATIVE
-May be entered more than once with a NEW sterile needle each time
-Once punctured: date it (BUD) and discard within 28 days
-Never past the manufacturer expiration date

Glass ampule

FILTER NEEDLE REQUIRED — NEVER INJECT THROUGH THE FILTER
-snapping the neck sheds glass into the solution
-withdraw through a 5-micron filter needle
-switch to a regular needle before injecting

Capsule sizes

000 to 5 — 000, 00, 0, 1, 2, 3, 4, 5
000 — Largest
5 — Smallest
Sizes run opposite to intuition

What must appear on a reconstituted product

-Final CONCENTRATION and total volume
-Beyond-use date and time (BUD)
-Storage requirements, such as refrigerate
-Date and time prepared, plus your initials
-Auxiliary label: shake well, etc

Freezer Storage Temperature Range

-25 to -10 C
-13 to 14 F

Refrigerated Storage Temperature Range

2 to 8 C
36 to 46 F

Cool Storage Temperature Range

8 to 15 C
46 to 59 F

Controlled room temperature range

20 to 25 C
68 to 77 F

Excessive heat Temperature Range

Above 40 C
Above 104 F

Insulin & GLP-1 (weight loss) injectables Storage Rules

-refrigerate until first use, then room temperature for a product-specific number of days
NEVER FREEZE

Multi-dose vial once punctured storage rules

date it and discard within 28 days
Aerosol canisters: keep away from heat, since the canister is pressurized

Levothyroxine storage rules (example in storage rules, I think)

-protect from light and moisture
-confirm every storage requirement against the specific product labeling

BUD

Beyond use date and time
A family with no discard date has no way to know when the bottle stopped being good

Enteral

Involves the GI tract
-Oral is the main one
-Sublingual, buccal, and rectal are grouped here by convention
-SL, buccal, and rectal wholly or partly bypass the liver

Parenteral

by injection
-IV, IM, and subcut
-outside of the digestive tract
-all must be sterile
-none can be retrieved once given

PO Abbreviation

by mouth (per os)

SL Abbreviation

Sublingual, under the tongue

PR Abbreviation

per rectum

IV Abbreviation

Intravenous, into the vein

IM Abbreviation

Intramuscular, into muscle

subcut Abbreviation

subcutaneous, into the fat under the skin
Write subcut, NOT SC or SQ. Both are on the ISMP error-prone abbreviation list

TD Abbreviation

Transdermal, through the skin

IVPB

IV piggyback, small-volume bag on a primary line

First-Pass Metabolism

-swallowed drug is absorbed from the gut
-travels the hepatic portal vein to the LIVER
-part of the dose is destroyed BEFORE it ever reaches systemic circulation

Does First-Pass Apply if it goes through the Liver?

Yes, FIRST PASS APPLIES
-oral
-bioavailability is reduced, sometimes drastically
-larger dose required

Does First-Pass apply if it bypasses the Liver?

NO FIRST PASS
-IV, IM, subcut
-sublingual and buccal
-transdermal and inhaled
-rectal bypasses only PARTLY
-faster and more complete

Classic Example of First-Pass Metabolism

NITROCLYCERIN
-swallowed: over 90% destroyed on first pass, oral bioavailability under 1%
-sublingual: thin, vascular mucosa straight to circulation
-onset in about 1 to 3 minutes

Are bypassing the liver and being 100% bioavailable the same thing?

No, only IV is 100% bioavailable; a patch bypasses the liver but absorbs incompletely.

IV Route — why it matters?

-Immediate Onset
-100% bioavailable, no absorption step, cannot be retrieved

Inhalation and sublingual Route — why it matters?

Seconds to minutes onset
Rescue inhalers and SL nitroglycerin

IM Route — why it matters?

Minutes onset
Muscle is highly vascular, so faster than subcut

Rectal Route — why it matters?

Minutes
Works when the patient is vomiting
partly bypasses the liver

Oral and subcutaneous Route — why it matters?

Minutes to hours onset
subcut fat is less vascular, giving slow steady absorption

Transdermal Route — why it matters?

Hours to days onset
Steady delivery, so never the answer for acute pain

IM preferred site

Ventrogluteal is preferred over dorsogluteal
the dorsogluteal site carries sciatic nervew injury risk

Suppository counseling

-Remove wrapper first (this is a real world error)
-pointed end first, then lie down 15 to 20 minutes
-check whether the product needs refrigeration

Fat-soluble Vitamins

STORED IN THE FAT AND LIVER
A, D, E, K
-Excess ACCUMULATES, so toxicity is possible
-Absorbed better with a fat-containing meal
-Vitamin K opposes warfarin: keep intake consistent rather than avoiding greens

Water-soluble Vitamins

EXCESS IS EXCRETED
B complex & C
-toxicity is far less likely at usual doses
-Vitamin C increases absorption of non-heme iron
-B9 is folic acid & B12 is cyanocobalamin

Vitamin D2 vs D3

D2 is ergocalciferol (plant or fungal source)
D3 is cholecalciferol (animal source)

Vitamin D2

ergocalciferol (plant or fungal source)

Vitamin D3

cholecalciferol (animal source)

Folate vs B12

Both cause megaloblastic anemia
Only B12 deficiency causes neurologic findings, so folate alone can MASK it

B12 absorption

-pernicious anemia lacks intrinsic factor,
-so injection or high-dose oral is needed.
-Long-term metformin and PPIs lower B12

Folic acid dose

-400 mcg daily for anyone who could become pregnant
-started before conception (per CDC)

Salt Weight vs Elemental Weight

The number of the bottle is the weight of the WHOLE compound, not the weight of the mineral the body uses.

Ferrous sulfate elemental content

20% iron
worked example: 325mg x 0.2 = 65mg elemental iron

Ferrous gluconate elemental content

12% iron
worked example: 325mg x 0.12 = about 39 mg elemental iron

Ferrous fumarate elemental content

33% iron
The most concentrated of the three common salts

Calcium carbonate elemental content

40% calcium
1250mg x 0.4 = 500mg elemental calcium

Calcium citrate elemental content

21% calcium
Less calcium per tablet, but no stomach acid required

Carbonate vs citrate

-Carbonate NEEDS stomach acid, so take with food
-A patient on a PPI or H2 blocker has suppressed acid, so citrate is the better choice
-Split doses: no more than about 500 to 600mg elemental calcium at once, since body only absorbs this much max at a time.

Iron counseling

-Best absorbed on an empty stomach
-vitamin C or orange juice helps
-if it upsets the stomach, take with food and accept slower repletion
-dark or black stools are expected and harmless
-leading cause of fatal pediatric poisoning: KEEP OUT OF REACH OF CHILDREN

Iron and Calcium do what?

bind other drugs in the gut. Need to be separated in time from certain other drugs.

Separation Rule for Iron & Calcium with Antibiotics

-Separate by at least 2 hours
-Tetracyclines: doxycycline, tetracycline, minocyclin
-Fluoroquinolones: ciprofloxacin, levofloxacin, moxifloxacin
-Also separate iron from calcium by about 2 hours

Separation Rule for Iron & Calcium with levothyroxine (thyroid medication)

-FDA labeling directs at least 4 hours from calcium carbonate and ferrous sulfate
-Levothyroxine also needs an empty stomach, so 30 to 60 minutes before breakfast
-Bisophosphonates (osteoperosis drugs) need their own empty-stomach and upright rules

Things that reduce iron absorption

-antacids, PPIs, and H2 blockers (less acid)
-calcium and diary, coffee and tea (tannins)
-high fiber foods, eggs, taking iron with a meal

Things that help iron absorption

-Vitamin C or orange juices
-empty stomach

furosemide effect on Potassium

Loop diuretic
WASTES (lowers) potassiium

hydrochlorothiazide effect on Potassium

Thiazide diuretic
WASTES (lowers) potassium

chlorthalidone effect on Potassium

Thiazide-like diuretic
WASTES (lowers) potassium

lisinopril effect on Potassium

ACE Inhibitor
RAISES potassium

losartan effect on Potassium

ARB
RAISES potassium

spironolactone effect on Potassium

potassium-sparing diuretic
RAISES potassium

triamterene effect on Potassium

potassium-sparing diuretic
RAISES potassium

Potassium scenario question - A profile shows lisinopril, spironolactone, and a new potassium chloride prescription

DO NOT FILL IT AND DO NOT COUNSEL ON IT
Flag it for the pharmacist BEFORE processing
Stacking potassium-raising drugs risks hyperkalemia, which can be fatal.

salt substitiutes

-are potassium chloride
-Patients on ACE inhibitors, ARBs, or K-sparing diuretics should avoid them

potassium chloride important counseling point

Klor-Con, K-Tab, Micro-K
Take with food and a full glass of water
Do not crush or chew the ER tablet

ferrous sulfate important counseling point

Feosol, Slow Fe
Empty stomach with vitamin C
expect dark stools
KEEP AWAY FROM CHILDREN

calcium carbonate important counseling point

Tums, Os-Cal, Caltrate
Take WITH food, since it needs stomach acid
watch for duplicate therapy with OTC antacids

folic acid important counseling points

Folvite (brand discontinued); Rx 1mg
400 mcg daily before conception
do not treat suspected B12 deficiency with folate

cyanocobalamin important counseling points

Nascobal (nasal)
pernicious anemia needs injection or high-dose oral — problem is absorption

ergocalciferol important counseling points

Drisdol — Vitamin D2
The 50,000 unit capsule is WEEKLY, not daily.
Take with a fat containing meal.

Catch for ergocalciferol that you are expected to find

Ergocalciferol 50,000 units with a sig of “daily” and a quantity of 12 is almost certainly a transcription error. The recognized course is one capsule WEEKLY for about 12 weeks. Do not fill and do not correct it yourself. Flag it so the pharmacist can contact the prescriber.

ACE Inhibitors and ARBs

same pathway, two classes — distinguishing detail is the cough

ACE Inhibitors uses?

-pril
LISINOPRIL, ENALAPRIL
hypertention, heart failure, post-MI, diabetic kidney protection

ACE Inhibitors signature adverse effects

-pril
LISINOPRIL, ENALAPRIL
-Dry hacking cough & angioedema (allergic reaction)
-raises potassium: avoid salt substitutes & K supplements
Fetal toxicity, stop if pregnancy occurs

ACE Inhibitors Class Boxed Warning

-pril
LISINOPRIL, ENALAPRIL
Fetal toxicity, stop if pregnancy occurs

ARBs Class Boxed Warning

-sartan
losartan, valsartan, telmisartan
Fetal toxicity, stop if pregnancy occurs

Zestoretic

lisinopril + HCTZ
ACE inhibitor plus a -thiazide

angioedema

Allergic reaction to ACE Inhibitor
swelling of face, lips, tongue, and throat

ARBs uses

-sartan
losartan, valsartan, telmisartan
hypertention, heart failure, post-MI, diabetic kidney protection
Used when ACE cough will not tolerate

ARB adverse effects

-sartan
losartan, valsartan, telmisartan
NO cough, but still RAISES potassium
Fetal toxicity, stop if pregnancy occurs
Valsartan products were recalled for nitrosamine (NDMA impurities)

Hyzaar

losartan + HCTZ
ARB plus a -thiazide

What happens if a patient has a new dry cough on lisinopril?

Technician refer to pharmaicist

LASA ARB alert

losartan and valsartan look and sound alike
Verify full generic name, not the first three letters

Beta blockers important info

-olol
metoprolol, carvedilol, atetnolol
-Never stop abruptly: rebound tachycardia, hypertension, and angina

metoprolol TARTRATE (Lopressor, immediate release, usually twice daily) and
metroprolol SUCCINATE (Toprol XL, once daily) are NOT interchangeable
-carvedilol: take with food, nonselective, so caution in asthma and COPD
-check pulse and blood pressure before dosing

Calcium channel blockers uses

-dipine — amlodipine
hypertension and angina

Calcium channel blockers side effects & counseling points

-dipine
amlodipine
-hallmark side effect: peripheral and ANKLE EDEMA (swelling in feet and ankles - not dangerous)
-avoid grapejuice
-Lotrel is amlodipine plus benazepril, so it carries the ACE warning too
-LASA: amlodipine and amiodarone

Can metroprolol be written with no salt named?

NO —not enough information.
Tartrate and succinate differ in release, frequency, and indication.
Verify against the original prescription rather than guessing from the profile

Loop Diuretic used to treat

furosemide (Lasix)
-Edema from heart failure, kidney or liver disease

Loopp diuretics important points

furosemide (Lasix)
-WASTES potassium, monitor K
-sulfonamide related: caution with sulfa allergy
-causes photosensitiity
-oxotoxicity

Thiazide Drug Class is used to treat

First line hypertention (hydrochlorothiazide, Chlorthalidone)

Thiazide Diuretic important points

hydrochlorothiazide, Chlorthalidone
-WASTES potassium
-also raises glucose and uric adid
-photosensitivity
-chlorthalidone is longer acting with more K loss
-do not abbreviate HCTZ

Potassium-sparing diuretic important points

spironolactone, triamterene
-RAISES potassium, avoid salt substitutes
-spironolactone causes gynecomastia in men
-triamterene can tur urine pale blue
-Dyazide and Maxzide are NOT interchangeable
-watch K with ACE inhibitors and ARBs

diuretic dosing — time of day

all dosed in morning to limit nighttime urination

LASA cluster worth drilling

hydrochlorothiazide, hydralazine, and hydroxyzine all start the same way and do completely different things. Tall Man lettering exists for exactly this

Lotrel

amilodipine plus benazepril
Calcium channel blocker plus ACE inhibitor
-carries the ACE and calcium channel blocker warnings

Class-wide effects or Statin, HMG-CoA reductase inhibitors

Report unexplained MUSCLE PAIN: myopathy and rhabdomyolysis.
Also liver enzyme elevation
Contraindicated in pregnancy

atorvastatin detail that gets tested

Lipitor
-Long half-life, so any time of the day
-Avoid grapefruit
-LASA: atorvastatin and atomoxetin