last pharm

Myasthenia Gravis

• Acquired autoimmune disease

  • Impairs transmission of messages at the neuromuscular junction

    • Results in varying degrees of skeletal muscle weakness that incr w/ muscle use

• Chronic autoimmune neuromuscular disease that affects approximately 20 in 100,000 persons

  • Although not a genetic disorder, a familial tendency may be apparent

• Patho

  • Autoimmune disorder

  • Antibodies attack acetylcholine receptors, obstruct binding of acetylcholine, and destroy receptor sites

  • Lack of acetylcholine impairs transmission of messages at neuromuscular junctions

    • Leads to…

• Characteristics

  • skeletal muscle weakness

  • Fatigue, ptosis, diplopia

  • Dysphagia, dysarthria

    • Respiratory muscle weakness, paralysis, arrest

• Favored classification of drugs

  • AChE inhibitors

• Inhibit the action of the enzyme AChE. As a result of this action, more ACh is available to activate cholinergic receptors and promote muscle contraction

• Cholinergic crisis (Major signs)

  • Usually occurs w/n 30-60min after taking Acetylcholinergesterase Inhibitors medications

  • Triggered by overdosing

  • Sx

    • Severe muscle weakness

    • Can lead to respiratory paralysis and arrest

    • Abnormal pupil constriction (Mimosis)

    • Pallor, sweating, vertigo

    • Excess salivation/drooling, GI distress

    • Bradycardia, fasciculations (muscle …

Acetylcholinesterase Inhibitors

• Also called cholinesterase inhibitors

• Doses must be individualized

• Neostigmine methylsulfate

  • Short-acting

  • 1st drug used to manage MG

  • Drug of choice for diagnosing MG for rapid onset of action and reversibility of ptosis and diplopia

• Pyridostigmine

  • intermediate -acting

  • Promotes transmission of neuromuscular impulses across myoneural junction by preventing acetylcholine destruction

  • increases muscle strength in pts w/ MG

  • Poorly absorbed from the GI tract

  • Overdosing of pyridostigmine can result in cholinergic crisis

  • Atropine is the antidote for pyridostigmine overdose

• Side effects

  • Miosis, blurred vision, tearing, confusion, depression, 

    • Bradycardia, hypotension

  • Incr salivation

  • GI distress - nausea, vomiting, diarrhea, abdominal cramps

  • Fecal and urinary incontinence

• Pts not responsive to AChE inhibitors given:

  • Prednisone (drug of choice)

  • Plasma exchange

  • IV immune globulin

  • Immunosuppressive drugs

Myasthenic Crisis

• Can occur when muscular weakness becomes generalized

• Death can occur …

• Involves diaphragm and intercostal muscles

• Triggers:

  • Inadequate dosing of AChE inhibitors

  • Emotional stress, menses, pregnancy

  • Infection, surgery, trauma

  • Hypokalemia, alcohol intake

  • Temperature interactions

  • Medication interactions

  • Treat w/ Neostigmine Methylsulfate

Clinical Judgement: Pyridostigmine

• Concept

  • Sensory perception

• Recognize cues

  • Assess for evidence of overdosing/underdosing, such as muscle weakness w/ difficulty breathing and swallowing

• Analyze cues and prioritize hypothesis

  • Decr gas exchange, decr mobility

• Generate solutions

  • Pts muscle weakness …

• Take action

  • Monitor drug effectiveness

  • Observe pt for s/s of cholinergic crisis

  • Encourage pt to wear medical ID

  • Teach pt side effects and when to notify PCP

  • Advise pt to report recurrence of sx of MG to PCP

• Eval outcomes

Nursing Process: Acetylcholinesterase Inhibitors

• Assessment

  • Assess for s/s of myasthenic crisis, such as muscle weakness w/ difficulty  breathing and swallowing

• Nursing Dx

  • Breathing …

• Planning

• Nursing interventions/Pt teaching

  • Administer doses on time

  • Take drug before meals if possible

  • Monitor drug effectiveness

  • Have antidote available for cholinergic crisis

• Atropine …

Multiple Sclerosis

• Pathophysiology

  • Autoimmune disorder

  • Attacks myelin sheath of nerve fibers in brain and spinal cord

  • Causes lesions (plaques)

• Characteristics 

  • Remission and exacerbations

  • Weakness or paralysis of extremities, fatigue

  • Muscle spasticity, parasthesia

  • Dysarthria, dysphagia, ataxia, vertigo

  • Diplopia, blurred …

• Diagnosis

  • No specific diagnostic test

  • Indicators of diagnosis

    • Medical Hx

    • Neurologic exam

    • Test likely to be ordered to aid in diagnosis:

      • Multiple lesions observable through MRI

      • Immunoglobulin G in the cerebrospinal fluid will be elevated

• No known cure for MS

Classifications of MS

• Relapsing remitting MS (RRMS)

  • Complete recovery until relapse, may have residual deficits

• Primary progressive MS (PPMS)

  • Slowly worsening neurologic function s/ no relapses or remissions

• Secondary progressive MS (SPMS)

  • Initial corse is relapsing remitting, then progression w/ or w/o occasional relapses, minor remissions, and plateaus

  • Chronic phase

• Progressive relapsing MS (PRMS)

  • Progressive from onset w/ acute relapses w/ or w/o full recovery

• Clinically isolated syndrome

  • Pt has only one flareup of MS

MS Drug Treatment

• Immunomodulators

  • Interferon beta-1a

  • Interferon beta-1b

  • First line treatment

  • Slows disease progression and prevents relapses

  • Treats phase of remission and exacerbations of MS sx

    • Episodes of muscle spasticity and recurrence of muscle weakness and diplopia

  • Glatiramer Acetate —

    • Prescribed for relapsing remitting forms of MS

  • Immunosuppressants

    • Mitoxantrone — used when in Chronic (SPMS) to Progressive/Relapsing Worsening (RRMS) Phase of MS

Combined Hormonal Contraceptives

• One of the most commonly used methods of reversible contraception in the world

  • Ease of use

  • High degree of effectiveness

  • Relative safety

• Contain a synthetic version of estrogen and progestin

• Action

  • Inhibit ovulation by preventing formation of dominant follicle

  • Suppress luteinizing hormone surge

• Routes of delivery

  • Oral

  • Transdermal

  • Transvaginal

• Types of combined hormonal contraceptives

  • Monophasic

  • Multiphasic

    • Biphasic

    • Triphasic

    • Four-phasic

• Withdrawal bleeding

  • Pseudomenstruation occurring during monthly 7-day hormone-free period

  • Mimics normal 28-day menstrual cycle

• Extended-use combined hormonal contraceptives

  • 91-day continuous-dosing pill regimen

  • Causes withdrawal bleeding only 4 times/year

• Continuous-use combined hormonal contraceptives

  • Menses is completely eliminated

• Ethinyl estradiol and norelgestromin transdermal patch

  • Placed weekly for 3 weeks in a row

  • Fourth week is patch-free to allow for withdrawal bleeding.

  • Place on clean, dry skin; rotate placement.

  • Avoid placement near breast area.

  • Inhibits ovulation,

  • Thickens cervical mucus to prevent sperm penetration

  • Prevents fertilized egg implantation in uterus

• Ethinyl estradiol and etonogestrel transvaginal contraception

  • 2-inch-diameter flexible indwelling ring inserted into vagina

  • Inserted during first 5 days of menstrual cycle, removed after 3 weeks; then ring-free for 1 week

  • Back-up contraception is recommended during first 7 days after ring is placed.

  • May cause vaginal discharge, irritation, infection

Progestin Contraceptives

• Do not contain estrogen

  • Provides relative safety

  • Reduced risk of circulation disorders

• Higher incidence of:

  • Irregular bleeding and spotting

  • Depression, mood changes, fatigue

  • Decreased sexual desire, weight gain

• Progestin-only oral contraceptive pills

  • Called the minipill

  • Taken continuously without break for withdrawal bleeding

  • Action:

    • Alter cervical mucus, making it thick and viscous, which blocks sperm penetration

    • Interfere with endometrial lining, which makes implantation difficult

    • Decrease peristalsis in fallopian tubes, slowing transport of ovum

    • Interfere with luteinizing hormone surge and inhibits ovulation

• Depot medroxyprogesterone acetate

  • Highly effective, long-acting injectable progestin

  • Flexible dosing schedule every 11 to 13 weeks

  • Action:

    • Thickens cervical mucus

    • Thins uterine endometrium

    • Decreases fallopian tube motility

    • Inhibits FSH and LH, preventing the formation of a dominant follicle

  • Side effects

    • Anovulation, amenorrea

• Progestin implant

  • Implanted in inner side of upper nondominant arm

  • Removed no later than 3 years after insertion

  • May be replaced with new implant

  • Contains radiopaque barium for easy location

• Side effects/adverse reactions due to excess estrogen

  • Nausea, vomiting, dizziness, fluid retention

  • Edema, bloating, breast enlargement

  • Breast tenderness, chloasma, leg cramps

  • Decreased tearing, corneal curvature alteration, visual changes, vascular headache, hypertension

• Side effects/adverse reaction due to estrogen deficiency

  • Vaginal bleeding that lasts several days

  • Oligomenorrhea especially after long-term use

  • Nervousness, dyspareunia

• Side effects/adverse reactions due to excess progestin

  • Increased appetite, weight gain, oily skin and scalp

  • Acne, depression, excess hair growth, decreased breast size

  • Vulvovaginal candidiasis, amenorrhea

• Side effects/adverse reactions due to progestin deficiency

  • Dysmenorrhea, bleeding late in the cycle, heavy menstrual flow with clots

  • Amenorrhea, changes in laboratory values

Clinical Judgment: Combined Hormonal Contraceptives

• Concept

  • Hormonal regulation

• Recognize cues

  • Obtain complete menstrual history

  • Determine pregnancy status

• Analyze cues and prioritize hypothesis

  • Need for patient teaching, discomfort

• Generate solutions

  • The patient will choose a contraceptive method suitable for her lifestyle and health status

• Take action

  • Address patient's misconceptions and provide factual, evidence-based information

  • Ensure that patient understands the start date, drug continuation, and appropriate follow-up

  • Advise patient that concurrent use of some drugs and herbal products decreases effectiveness of hormonal contraceptives

• Evaluate outcomes

Preventing Fertilization

• CHCs are used to prevent fertilization

  • After unprotected vaginal intercourse

  • After failure of a contraceptive method

  • Initiate within 72 hours after intercourse

  • 2 to 5 OC pills are taken at one time

  • Raises estrogen & progestin levels to delay or prevent ovulation

  • Interferes with tubal transport of embryo, egg, sperm

  • Reduces pregnancy risk by 75%

  • May cause nausea

Drugs Used to Treat Disorders in Women's Health

• Irregular or abnormal uterine bleeding

• Amenorrhea

  • Primary amenorrhea

  • Secondary amenorrhea

• Polycystic ovarian syndrome

  • Disorder in metabolism of androgens and estrogens

• Abnormal uterine bleeding patterns

  • Menorrhagia

  • Metrorrhagia

  • Menometrorrhagia

  • Intramenstrual bleeding

• Dysfunction uterine bleeding

  • Irregular bleeding with no organic pathology

• Pharmacologic management of irregular bleeding

  • NSAIDs

    • Block prostaglandin production

    • Decrease excess bleeding

    • Decrease uterine cramps

  • Combined hormonal contraceptives

  • Progestins

• Dysmenorrhea

  • Pelvic pain associated with menstrual cycle

  • Accompanying symptoms

    • Uterine cramping, abdominal cramps, lower back pain

    • Changes in bowel patterns, increased bowel movements

    • Nausea, vomiting

  • Pharmacologic management of dysmenorrhea

    • NSAIDS

    • Combined hormonal contraceptives

• Endometriosis

  • Abnormal location of endometrial tissue outside the uterus

  • Symptoms

    • Dysmenorrhea, pelvic pain, back pain

    • Painful, bloody bowel movements

    • Dyspareunia, infertility

• Pharmacologic management of endometriosis

  • Combined hormonal contraceptives

  • Progestin therapy

  • Gonadotropin-releasing-hormone agonists

• Premenstrual syndrome

  • Cyclic physical symptoms and perimenopausal mood alterations

  • Physical symptoms

    • Headache, irritability, hostility, anxiety

    • Mood swings, depression, trouble with concentration

    • Appetite changes, fatigue, edema, acne, backache

    • Lower abdomen bloating, constipation or diarrhea

    • Sleep pattern alterations, breast soreness

    • Decreased sexual desire

• Premenstrual syndrome

  • Nonpharmacologic treatment

    • Empathy and support from family and friends

    • Exercise, dietary changes

    • Stress-reduction exercises

  • Pharmacologic treatment

    • Antidepressant drugs

    • Hormonal therapy

Drugs Used in the Treatment of Menopause

• Menopause

  • Transitional process experienced by women as they move from reproductive years into nonreproductive stage of life

• Stages

  • Perimenopause

  • Menopause

  • Postmenopause

• Perimenopause stage

  • Ovarian follicles become depleted, causing estrogen to diminish.

  • Common symptoms

  • Short or long cycles, heavy or light bleeding, periods of longer or shorter duration

  • Skipped periods, abrupt stopping of periods, vaginal dryness, oligomenorrhea, menorrhagia, hot flashes

  • Insomnia, headaches, irritability, anxiety, mood variation, cognitive difficulties, memory lapses, joint aches, decreased libido

• Menopause stage

  • Permanent end of spontaneous menstruation caused by cessation of ovarian function

  • Menstruation has stopped for 1 year

  • Premature ovarian failure is menopause before age 40

  • May occur abruptly due to oophorectomy, ovarian function destroyed by radiologic procedures, severe infection, ovarian tumors, endometriosis

• Postmenopause

  • Stage when body adapts to a new hormonal environment

  • Production of estrogen and progesterone from ovaries decreases

  • Surge of luteinizing hormone causes hot flashes, tachycardia, sleep disruption

• Pharmacologic therapy for perimenopausal and menopausal symptoms

  • Hormone therapy-estrogen-progestin for females with an intact uterus

  • Hormone therapy-estrogen for females with a hysterectomy

  • Hormone therapy relieves hot flashes, vaginal dryness, and related sleep disorders.

  • Boxed warning—hormone therapy should be used only for the treatment of menopausal symptoms, at the lowest dose possible, for the shortest duration possible, usually less than 5 years.

• Other drugs for menopausal symptoms

  • SSRIs

    • Reduce vasomotor symptoms

    • Reduce depression, irritability, mood changes

  • Bremelanotide

    • Increase sexual desire

Osteoporosis Disease

• Osteoporosis

  • Progressive, debilitating skeletal disease that affects older men and women.

  • Monoclonal antibodies

  • Hormonal therapy is no longer recommended for treatment of osteoporosis but may be considered as a preventive measure in postmenopausal women at risk.

  • Bisphosphonates

  • Selective estrogen receptor modulators

  • An imbalance of osteoblasts and osteoclasts lead to bone reabsorption and bone density decrease

Clinical Judgment: Management of Symptomatic Menopausal Women

• Concept

  • Hormonal regulation

• Recognize cues

  • Obtain a complete menstrual history

  • Obtain a full gynecologic history

• Analyze cues and prioritize hypothesis

  • Need for patient teaching, discomfort

• Generate solutions

  • The patient will report abnormal uterine bleeding and other side effects associated with HT

• Take action

  • Teach patient about the nature of menopause

  • Advise patient to have breast and pelvic exams and Pap test before starting hormonal therapy

  • Suggest to the patient to use a water-soluble vaginal lubricant to reduce painful intercourse and prevent trauma

  • Monitor patient for side effects of nausea, difficulty swallowing, abdominal pain, esophageal inflammation, reflux, ulcers

A client with dysmenorrhea is looking for first-line treatment options. Which pharmacologic intervention would be most appropriate to recommend?

NSAIDS

What information will the nurse include when teaching a patient about hormonal methods of contraception?

"Call your health care provider immediately if you experience severe abdominal pain, chest pain or shortness of breath, headaches, eye disorders, or severe leg pain or swelling."

A nurse is caring for a menopausal client who is currently prescribed estrogen therapy and has an intact uterus. Which other action is most appropriate to ensure safe hormone replacement therapy?

Add a progestin medication to the regimen to reduce the risk of endometrial hyperplasia

Drugs Related to Male Reproductive Disorders

• Androgens

  • Testosterone

• Action

  • Controls development/maintenance of sexual processes, accessory sexual organs, cell metabolism, and bone/muscle growth

• Indications

  • Androgen deficiency, hypogonadism

• Administration

  • Buccal, nasal, transdermal, parenteral

Androgens

• Testosterone

  • Side effects/adverse reactions

  • Priapism, gynecomastia, urinary urgency, polyuria

  • Stops spermatogenesis, oligospermia, virilization

  • GI distress, increased salivation, mouth soreness

  • Insomnia, injection site reaction, impaired bone growth

  • Increased or decreased sexual desire, lethargy

  • Hypercalcemia, decreased muscle tone, edema

  • Muscle cramps, elevated cholesterol, bleeding

  • Menstrual irregularities, clitoris hypertrophy

  • Baldness or hirsutism, vocal changes, depression

  • Weakness, confusion, dizziness, paresthesia

  • Changes in skin color, headaches

• Testosterone

  • Drug interactions

    • Oral anticoagulants, calcitonin, parathyroid hormones

    • Antidiabetic agents, corticosteroids

    • Barbiturates, phenytoin, phenylbutazone

  • Caution

    • Hypertension, coronary artery disease, seizures

    • Hypercholesterolemia, renal disease

    • Infants, prepubertal children, older men

• Contraindications

  • Pregnancy

  • Nephrosis or nephrotic phase of nephritis

  • Hypercalcemia

  • Pituitary insufficiency

  • Hepatic dysfunction

  • BPH

  • Prostate cancer

  • History of myocardial infarction

  • Men with breast cancer

Anabolic Steroids

• Anabolic steroids

• Class of steroid hormones related to testosterone

• Action

  • Increase protein synthesis in cells resulting in anabolism, especially in muscles

  • Development and maintenance of masculine characteristics

• Testosterone precursors

• Available as nutritional supplements

• Adverse effects:

  • Increased weight and body size, acne

  • Mood and behavioral changes, aggression

  • Increases low-density lipoprotein cholesterol

  • Decreases high-density lipoprotein cholesterol

  • Hypertension, liver damage

  • Cardiac structural changes

Clinical Judgment: Androgens

• Take action

  • Advise patient that an intermittent approach to therapy allows for monitoring of endocrine status.

  • Encourage patient to monitor muscle strength.

  • Urge men undergoing androgen therapy to report priapism promptly.

  • Instruct men to report decreased urinary stream promptly.

  • Counsel patient to record body weight several times per week.

Antiandrogens

• Antiandrogens

• Action

  • Block synthesis/action of androgens

• Use

  • Benign prostatic hypertrophy

  • Advanced prostatic cancer

  • Endometriosis, male baldness pattern

  • Acne, hirsutism, precocious puberty in boys

  • Virilization syndrome in women

Drugs Used in Other Male Reproductive Disorders

• Delayed puberty

  • Testicular enlargement, penile growth, pubic hair development has not begun by age 14

  • Treat with testosterone cypionate

• Pituitary, thyroid, adrenal inadequate function

  • Menotropins, hCG, hormonal replacement

• Sexual dysfunction

  • Treat with phosphodiesterase-5 inhibitors:

    • Vardenafil, tadalafil, sildenafil

Benign Prostatic Hyperplasia

• Benign prostatic hyperplasia

  • Glandular units in prostate gland undergo tissue hyperplasia with aging

  • Symptoms:

    • Bladder fullness sensation, frequency, nocturia

    • Hesitation, dribbling, erectile dysfunction

  • Treatment:

    • Alpha-adrenergic antagonists

    • 5-Alpha-reductase inhibitors

    • Anticholinergics

    • Phosphodiesterase-5 inhibitors

The nurse teaches a patient that sildenafil is contraindicated for patients taking which category of medications?

Nitrates

Which medications should be avoided in clients with BPH due to their potential to cause urinary retention? (Select all that apply)

• Cetirizine

• Pseudoephedrine

• Diphenhydramine

• Scopolamine

Sexually Transmitted Infections

• Risk factors

• Transmission

  • Sexual contact

  • Blood or blood products

  • Mother-to-child during pregnancy or childbirth

• Common symptoms

  • Vaginal discharge

  • Male urethral discharge or burning

  • Genital ulcers

  • Abdominal pain

Sexually Transmitted Pathogens

• Bacterial pathogens

  • Bacterial vaginosis

  • Chlamydia

  • Gonorrhea

  • Syphilis:

    • Primary

    • Secondary

    • Tertiary

Bacterial Pathogens

• Bacterial vaginosis

  • Healthy bacteria in vagina replaced with anaerobic bacterla

• Symptoms

  • Thin white discharge with strong fishy odor

• Treatment

  • Metronidazole

  • Clindamycın

  • Tinidazole

Chlamydia

• Chlamydia

  • Most common STI in the United States in young adults

• Symptoms

  • Usually asymptomatic

• Complications

  • Pelvic inflammatory disease

  • Ectopic pregnancies, infertility

• Treatment

  • Azithromycin, levofloxacin, ofloxacin

  • Erythromycin base and erythromycin ethylsuccinate

  • Doxycycline, amoxicillin

Gonorrhea

• Gonorrhea

  • Second most common STI in the United States

• Symptoms

  • Males—greenish-yellow or white discharge from penis, burning upon urination

  • Females-frequently asymptomatic

• Oral infections:

  • Sore throat, difficulty swallowing

• Treatment

  • Ceftriaxone, doxycycline

Syphilis

• Syphilis

  • Primary:

    • Painless chancre at entrance site

  • Secondary:

    • Skin rash, mucocutaneous lesions, fever

    • Fatigue, sore throat, lymphadenopathy

    • Latent stage-asymptomatic, lasts 1 to 20 years

  • Tertiary:

    • Large sores on skin or inside body

    • Cardiovascular and ocular syphilis, neurosyphilis

• Treatment

  • Benzathine penicillin

Viral Pathogens

• Infection caused by viral pathogens is not curable, although medication therapy is palliative

  • Herpes simplex virus

  • Human immunodeficiency virus

  • Human papillomavirus

Herpes Simplex Virus

• Herpes simplex virus

  • Genital herpes is a lifelong infection

• Types

  • HSV-1

  • HSV-2

• Symptoms

  • Lesions crusted over with scab, headache

  • Fever, lymphadenopathy, painful urination

• Treatment

  • Acyclovir, valacyclovir, famciclovir

Human Immunodeficiency Virus

• Human immunodeficiency virus

  • Chronic illness that progressively depletes CD4 T lymphocytes developing into AIDS

• Symptoms

  • Fever, fatigue, rash, pharyngitis, lymphadenopathy

• Treatment

  • Antiretroviral therapy

Human Papillomavirus

• Human papillomavirus

• Symptoms

  • Self-limited, asymptomatic

• Complications

  • Cervical cancer, genital warts, recurrent respiratory papillomatosis

• Prevention

  • Bivalent vaccine

• Treatment

  • Removal of genital warts and precancerous lesions, cryotherapy, loop electrosurgical excision procedure

Other Pathogens

• Pediculosis pubis

  • Parasitic infection caused by Phthirus pubis

• Scabies

  • Infection with Sarcoptes scabiei causes pruritus, taking several weeks to develop

• Trichomoniasis

  • Protozoan parasite Trichomonas vaginalis is the most common curable STI in the US

• Vulvovaginal candidiasis

  • Usually caused by Candida albicans but may also be caused by other Candida species

Scabies

• Transmission

  • Frequently by sexual contact in adults

• Symptoms

  • Pruritus

• Treatment

  • Permethrin

  • Ivermectin

  • Lindane

Trichomoniasis

• Trichomoniasis

  • Most common curable STI in the United States

• Symptoms

  • Males-urethritis, epididymitis, prostatitis

  • Females-yellow-green vaginal discharge, may have vulvar irritation

• Treatment

  • Metronidazole, tinidazole

Vulvovaginal Candidiasis

• Vulvovaginal candidiasis

• Symptoms

  • Pruritus, vaginal soreness, dyspareunia

  • External dysuria, thick curdy vaginal discharge

  • Vulvar edema, fissures, excoriations

• Treatment

  • Clotrimazole, miconazole, tioconazole

  • Butoconazole, terconazole, fluconazole

Clinical Judgment: Sexually Transmitted Infections

• Concept

  • safety

• Recognize cues

  • assess use of barrier methods

  • assess Hx of STIs

• Analyze cues and prioritize hypothesis

  • need for health teaching

• Generate solutions

  • The pt will identify S/S of STIs

• Take action

  • review modes of STI transmission, relationship of STIs to HIV infections, and how HIV risk is avoided

  • Ensure understanding of appropriate

  • Counsel pts on effective use of both male and female condoms

Which of the following is the term for a yeast infection of the vulva or vaginal area?

Vulvovaginal candidiasis

Which medication is indicated in the treatment of vulvovaginal candidiasis?

Fluconazole

GERD Overview

Definition

• inflammation of the esophageal mucosa from acid reflux

Sx

• heartburn

• regurgitation

• chest pain

Treatment

• Similar to peptic ulcers - H2 blocker and PPIs

Treatment Ex.

• H2 blockers:

  • famotidine (Pepcid)

  • Ranitidine (Zantac)

• PPIs

  • Omeprazole (Prilosec)

  • Esomeprazole (Nexium)

• Antacids:

  • Calcium carbonate (Tums)

  • Aluminum hydroxide (Amphojel)

• Lifestyle:

  • avoid food triggers

  • elevate head during sleep

GERD Treatment Approaches

First-Line Medications

• H2 blockers reduce acid production, providing Sx relief. PPIs offer stronger acid suppression for healing damaged esophageal tissue

Lifestyle Modification

• Elevate head during sleep.

• Avoid trigger foods like caffeine, chocolate, and fatty meals.

• Eat smaller portions and maintain healthy weight

Treatment Goals

• Control Sx

• heal inflammation

• prevent complications like Barrett’s esophagus

• Regular monitoring essential for chronic management

Antiulcer Drugs: H2 Blockers and PPIs

two primary medication classes that target acid production through different mechanisms

H2 Blockers

• Block histamine receptors on parietal cells, reducing acid secretion

• Examples:

  • rantidine (Zantac)

  • famotidine (Pepcid)

  • cimetidine (Tagamet)

• Faster onset by shorter duration than PPIs

• Used for mild-to-moderate GERD and prevention

PPIs

• irreversibly block hydrogen-potassium pumps in parietal cells

• Ex:

  • omeprazole (Prilosec)

  • esomeprazole (Nexium)

  • pantoprazole (Protonix)

• More potent acid suppression than H2 blockers

• First-line for severe GERD and healing esophagitis

What are Peptic Ulcers?

Definition:

• ulcers in esophagus, stomach, duodenum

Cause:

• hypersecretion of hydrochloric acid and pepsin

pH factor:

• Pepsin activated at pH2, inactive at pH 5

Types of Ulcers

Esophageal:

• Acid reflux into esophagus

Gastric

• breakdown of gastric mucosal barrier

Duodenal

• Acid hypersecretion passing into duodenum

Predisposing Factors

understanding risk factors helps pts take preventative action against peptic ulcers

Smoking

• increases acid secretion and damages protective stomach lining

NSAIDs

• regular use inhibits prostaglandins that protect stomach mucosa

H. pylori infection

• Bacterial infection that weakens stomach’s defense mechanisms

Stress

• Chronic stress increases gastric acid production and mucosal vulnerability

Non-Pharmacologic Measures

lifestyle modifications complement medical therapy for ulcer healing and prevention

Dietary Modifications

• avoid irritants life spicy foods, caffeine, and alcohol.

• Small, frequent meals reduce acid load

Stress Management

• Mindfulness, medication, and therapy help reduce harmful stress responses affecting gastric function

Smoking Cessation

• quitting smoking accelerates healing and prevents recurrence by improving mucosal blood flow

Medication Management

• Avoid NSAIDs when possible, Use COX-2 selective agents if anti-inflammatory therapy needed

Antiulcer Drug Categories

Prostaglandin Analogues

• Misoprostol (Cytotec)

Pepsin Inhibitors

• sucralfate (Carafate)

Antacids, Anticholinergics, Tranquilizers

• Aluminum/Magnesium hydroxide (Maalox, Mylanta), Dicyclomine (Bentyl), Diazepam (Valium)

Ulcer Complications

When left untreated, peptic ulcers can lead to serious and potentially life-threatening conditions

Hemorrhage

• bleeding occurs when ulcers erode blood vessels. May present as vomiting blood or black stools

Perforation

• complete erosion through stomach or intestinal wall creates a hole, causing severe abdominal pain

Obstruction

• Inflammation and scarring can block food passage, resulting in vomiting and weight loss

Malignancy

• Long-standing ulcers increase risk of gastric cancer, regular monitoring is essential

Antacids

Mechanism

• Neutralize acid, reduce pepsin activity

Systemic Types

• Sodium bicarbonate, calcium carbonate

Nonsystemic Types

• Aluminum and magnesium salts

Combination Benefits

• mg + Al balances constipation/diarrhea effects

Antacid Considerations in Geriatric Use

Special attention needed when prescribing antacids to elderly patients

Reduced Dosing

• elderly may require lower doses due to decreased renal function and metabolism

Electrolyte Monitoring

• Regular monitoring prevents imbalances. Magnesium antacids pose higher risk in overall impairment

Drug Interactions

• Antacids may affect absorption of medications commonly used by elderly patients

Cognitive Awareness

• Clear instructions needed. Timing between antacids and other medications is crucial

Antacid Considerations

Sodium Bicarbonate (Alka-Seltzer, Brioschi)

• causes sodium excess, water retention, acid rebound

Calcium Carbonate (Tums, Rolaids)

• Risk of hypercalcemia, Burnett syndrome

Magnesium Salts (Milk of Magnesia, Phillips’)

• contraindicated in renal impairment

Aluminum Hydroxides (Amphojel, Alternagel)

• Long-term use: hypophosphatemia, osteoporosis

Antacid Examples

Commercial products combine different ingredients to balance efficacy with reduced side effects

Calcium-Based

• Generic: Calcium carbonate

• Brands: Tums, Rolaids, Caltrate

• Fast-acting relief

• May cause constipation

Magnesium-Based

• generic: Magnesium hydroxide,

• Magnesium oxide

• Brands: Milk of magnesia, Phillips’ Gentler action.

• May cause diarrhea

Aluminum-Based

• Generic: Aluminum hydroxide

• Brands: Amphojel, Alternagel

• Slow-acting but long-lasting

• May cause constipation

Combined Products

• Generic: Aluminum hydroxide + magnesium hydroxide

• Brands: Maalox, Mylanta, Gaviscon

• Balance efficacy with minimized side effects

H2 Blockers

• 90% acid reduction

  • significant decrease in gastric acid

• 2-3 dosing

  • times per day typical dosing

• 4 common drugs

  • Cimetidine (Tagamet)

  • ranitidine (Zantac)

  • famotidine (Pepcid)

  • nizatidine (Axid)

H2 Blocker Consideration

Side Effects

• HA

• GI issues

• skin reactions often occur due to the meds’ effect on the histamine receptors throughout the body, not just the stomach

Drug Interactions

• Cimetidine inhibits hepatic metabolism of many drugs because it competes for the same liver enzymes (CYP450) that metabolize other meds, potentially increasing their blood levels

Monitoring

• BUN, creatinine, alkaline phosphatase tests are necessary because H2 blockers can occasionally affect kidney function and liver enzyme levels, especially with long-term use

Sucralfate (Carafate) & Misoprostol (Cytotec)

These medications offer complementary approaches to ulcer management —- Sucralfate provides mechanical protection while Misoprostol enhances physiological mucosal defense. Selection depends on pregnancy status, concurrent medications, and ulcer etiology.

Sucralfate (Carafate)

• pepsin inhibitor with aluminum salt structure

  • forms protective barrier over ulcer site

  • Non-absorbable, acts locally w/ minimal systemic effects

  • Dosing: 1g QID before meals

  • Binds to proteins in ulcer exudates

  • Side effects: constipation, reduced phosphate absorption

  • Caution: reduces absorption of concurrent medications

Misoprostol (Cytotec)

• Prostaglandin E1 analogue

  • suppresses acid secretions and increases protective mucus

  • Primarily prevents NSAID-induced ulcers

  • Dosing: 200mcg QID w/ food

  • Enhances bicarbonate secretions and mucosal blood flow

  • Contraindicated in pregnancy (Category X)

  • Common side effects: diarrhea, abdominal pain

Special Considerations

Pregnancy

• Misoprostol (Cytotec) contraindicated in pregnancy

Drug Interactions

• PPIs (Omeprazole/Prilosec, Esopmeprazole/Nexium) affect metabolism of many drugs

Administration

• timing with meals affects drug efficacy (e.g. Pantoprazole/Protonix, Famotidine/Pepcid)

Drug Interactions

Understanding potential conflicts between antiulcer medications and other drugs is crucial for safe treatment

• Altered Absorption

  • antacids (aluminum/magnesium hydroxide: Maalox, calcium carbonate: Tums) can reduce absorption of antibiotics, iron supplements, and thyroid medications

• metabolism changes

  • PPIs inhibit CYP2C19 enzymes, affecting metabolism of clopidogrel and diazepam

• Timing Matters

  • space antacids 2 hours from other medications to prevent interactions

• Special Alerts

  • H2 blockers may increase toxicity of methotrexate and warfarin

Dietary Changes

dietary modifications complement pharmacological treatment by reducing gastric avid and supporting mucosal repair

• Beneficial Foods

  • high-fiber foods, probiotics, and antioxidant-rich produce

• hydration

  • adequate water intake between meals aids healing

Understanding Nausea and Vomiting

Cerebral Control Centers

• Two major cerebral centers control vomiting:

  • the chemoreceptor trigger zone (CTZ)

  • vomiting center in medulla

Importance of Diagnosis

• underlying cause must be identified before treatment. Antiemetics can mask Sx of serious conditions

Dehydration Risk

• Severe vomiting can lead to significant fluid and electrolyte imbalances requiring IV fluids

Non-Pharmacologic Management of Nausea and Vomiting

Dietary Approaches

• weak tea, flat soda, gelatin, sports drinks help manage mild nausea

• bland foods like crackers may settle the stomach.

Hydration Strategies

• small, frequent sips of clear fluids help prevent dehydration

• IV fluids may be needed when oral intake is insufficient

Environmental Modifications

• Create a calm environment with fresh air

• Avoid strong odors and use relaxation techniques

Herbal Remedies for Nausea and Vomiting

Advise patients to consult healthcare providers before using herbal remedies. These may interact with medications

Ginger

• Contains gingerols that reduce nausea intensity. Availability as tea, capsules, or candles

Peppermint

• relaxes stomach muscles and reduces spasms. Use as tea or aromatherapy

Fennel

• Relieves gas and bloating that can trigger nausea. Often used as seeds or tea

Chamomile

• Calms digestive tract and reduces anxiety-related nausea. Best consumed as tea

OTC Antiemetics

Antihistamine Antiemetics

• Drug class

  • H1 Receptor Antagonists

• Generic/Brand:

  • dimenhydrinate/Dramamine, Meclizine/Bonine

• Mechanism

  • Inhibit H1 receptors in vestibular apparatus and CTZ

• Nursing Considerations:

  • assess fall risk; contraindicated in glaucoma, prostatic hypertrophy

• Adverse Effects:

  • drowsiness, dry mouth, blurred vision, urinary retention