Pharm Final Study Guide

What medications are used to treat the different anemias?

• Ferrous Sulfate

• Vitamin B12 (Cyanocobalamin)

  • Pernicious Anemia — lifelong treatment

  • Megaloblastic Anemia

• Folic Acid

  • Megaloblastic Anemia

Ferrous Sulfate Administration Route

Taken PO or IV

Ferrous Sulfate Uses

• Treats iron-deficiency anemia

• Prevention of iron-deficiency

Ferrous Sulfate MOA

Replaces iron stores, allowing for hemoglobin and RBC production

Ferrous Sulfate CI/C

Think “PLC” = “Please Limit Children”

• PUD

• Liver disease

• Children

Ferrous Sulfate AE

Think “SHIAGM” - “Some Healthy Iron Absorbs Good Metal”

• Staining (teeth/skin)

• Hypotension

• Iron toxicity

• Anaplhylactic reaction

• GI upset / tarry/green stools

• Metallic taste (iron dextran)

Ferrous Sulfate DI

• Antacids

• antibiotics

• dextran

• ACE inhibitors

Ferrous Sulfate Labs

• Hgb

• Hct

Ferrous Sulfate NI

• Take on an empty stomach

• Take in equal doses if possible

• When taking PO, use a straw to avoid staining teeth.

• *Can take with vitamin C to enhance absorption if having GI upset

• Keep out of reach of children

Vitamin B12 Administration Routes

PO, intranasal, parenteral

Vitamin B12 Uses

• Treatment of B12 deficiency anemia

• Pernicious anemia (lifelong therapy)

Vitamin B12 MOA

Replaces vitamin B12, necessary for DNA synthesis and RBC maturation

Vitamin B12 AE

Hypokalemia

Vitamin B12 CI/C

• Caution w/ folic acid

  • can mask B12 deficiency

Vitamin B12 Labs

• CBC

• Vitamin B12 lvl ecery 3-6 months

• Potassium lvls

Vitamin B12 NI

• Give 1 hr before or after HOT foods

• If nasal route, recheck CBC and B12 lvls in 3-6 months

• Parenteral forms are typically once/month

• *To enhance absorption, give with food

• *Pernicious anemia — lifelong treatment

Folic acid should be combined with _____ and is used with __________ __________.

B12, alcohol disorder

Folic Acid Uses

• Tx of folate deficiency anemia

• prevention of neural tube defects in pregnancy

Folic Acid MOA

replaces folic acid necessary for DNA synthesis and cell production

Folic Acid AE

• Bronchospasms

Folic Acid DI

Large doses may decrease effects of anticonvulsants

Folic Acid NI

• Prevents neural tube defects during pregnancy

• often combined w/ vitamin B12 to prevent masking of deficiency

What patient populations are prescribed epoetin alfa and what is the goal of this therapy?

Pts with CKD, anemia caused by chemotherapy, increasing erythrocyte counts in pts having elective surgery, anemia caused by taking Zidovudine for HIV/AIDs.

Epoetin Alfa MOA

Stimulates the production of RBCs

(Therapeutic effects - increase in RBC)

Epoetin Alfa Administration Routes

SC/IV

Epoetin Alfa CI/C

Think “ULAN” = “U Love A Normal kidney”

• Uncontrolled HTN

• Lactation/pregnancy

• Allergy to human albumin

• Normal renal function

Epoetin Alfa AE

Think “CHT” - “Can’t Handle Thick-blood”

• CNS effects (HA)

• HTN

• Thrombotic events (MI, stroke)

Epoetin Alfa Labs

• CBC

• Hgb

• Hct

• Renal function tests

Epoetin Alfa NI

• Increased risk for venous thrombosis and rapid growth of cancer when hemoglobin becomes higher than 11

• Frequent BP checks

• Advise pt to report HA, sudden chest pain, unilateral weakness, numbness/paralysis, vision changes, n/v, seizures

Warfarin and Heparin Labs

• Normal range:

  • Heparin PTT: 45-80 seconds (1.5-2.5 times baseline)

  • Warfarin PT: 18-30 seconds

  • Warfarin INR: 2-3

• PTT calculation: give the patient baseline: 27 seconds

  • 1.5 x 27 = 40.5 seconds

  • 2.5 x 27 = 67.5 seconds

• PTT individual range: 40.5-67.5 seconds

Heparin MOA

Blocks conversion of prothrombin to thrombin, indirectly inactivates thrombin and Factor Xa

Heparin Uses

• prevents new clot formation and extension of existing clots

• used in DVT, PE, MI, unstable angina

Heparin CI/C

Think “BT BUGS”

• Beef/pork allergies

• Thrombocytopenia

• Bleeding disorders

• Uncontrolled HTN

• GI ulcers

• Surgery

Heparin Routes

SQ/IV

Heparin AE

Think “HB” - “Heparin Bleeds”

• Heparin induced thrombocytopenia

• Bleeding

Heparin Labs

• PTT:

  • 45-80 sec (1.5-2.5x baseline)

• CBC

  • STOP if platelets < 100,000 and change to another agent

Heparin DI

• Other anticoagulants

• antihistamines

• Digoxin

• Nitoglycerin

• nicotine

Heparin NI

• monitor for signs of bleeding

Heparin Antidote

Protamine Sulfate

Low Molecular Weight Heparin Prototype

Enoxaparin (Lovenox)

Low Molecular Weight Heparin MOA

Inactivate Factor Xa

Low Molecular Weight Heparin Route

SQ/weight based

Low Molecular Weight Heparin CI/C

Spinal block/epidural

Low Molecular Weight Heparin AE

Think “TNT” - “Tiny Nerve Toxins”

• Thrombocytopenia

• Neurological damage

• Toxicity

Low Molecular Weight Heparin DI

Antiplatelets

Low Molecular Weight Heparin Therapeutic Effects

No further development of clots

Low Molecular Weight Heparin NI

• No required monitoring

• Instruct pt on self-admin

• Monitor for bleeding

Heparin and LMW Heparin Patient Education

• Use electric razor for shaving

• Use soft toothbrush

• Avoid use of OTC NSAIDs

• Do not expel air bubble in LMWH unless adjustments must be made to the dose — helps trap the medication in the SQ layer preventing it from leaking out into the epidermis

• Monitor for signs of bleeding

Warfarin MOA

Blocks Vitamin K at sites of action

Warfarin Uses

• prevent venous thrombosis and PE

• prevents clot formation

Warfarin Route

PO (Given at night)

Warfarin CI/C

Think “BHG MAP”

• Blood disorders / hemophilia

• Hepatic disease

• GI ulceration

• Major bleeding

• Alcohol use disorder

• Pregnancy (Cat X)

Warfarin AE

Think “GB” - “Guts Bleed”

• GI upset

• Bleeding

Warfarin DI

• Bactrim

• NSAIDs

• PPIs

• BC

• Spironolactone

• Haldol

• H2 Blockers

• Apreitant

Warfarin Labs

• CBC

• Liver enzymes

• PT:

  • 18-30 sec

• INR:

  • 2-3

Warfarin NI

• Diet: Green leafy vegetables

  • Food may delay absorption (eat same amount each day for consistency)

• Emaciated pts

• Wear medical ID

• May be used with children/decrease dose with elderly

Alternative Therapies that Interact with Warfarin

• Saw palmetto

• Coenzyme Q-10

• feverfew

• garlic

• ginger

• glucosamine

• gingko balboa

Warfarin Antidote

Vitamin K

Thrombolytics Prototype

Alteplase

Alteplase MOA

Dissolves clots that have already formed by conversion of plaminogen to plasmin

Alteplase Uses

• Acute MI (within 2 hrs)

• Massive PE

• acute ischemic stroke (within 3-4.5 hrs)

• CVL patency

Alteplase Route

IV only

Alteplase CI/C

Think “PH CASe”

• Pregnancy cat C

• Hemorrhage (intracranial prior)

• Cerebral lesion

• Active internal bleeding

• Stroke (recent)

Alteplase Labs

• PTT

• PT

• Hgb

• Hct

Alteplase NI

• Monitor changes in VS, LOC, weakness, neurological status

• Monitor neurological status q30 min for 8hrs

  • due to risk for intracerebral hemorrhage

• Pts should be on bed rest and lie flat or w/ the HOB elevated

  • prevent increased pressure in the cerebral vessels

Alteplase Antidote

Aminocaproic Acid

S/S of Bleeding

• Hypotension

• tachycardia

• bruising

• epistaxis

• hemoptysis

• gum bleeding

• melena

• abdominal pain

• coffee-ground emesis

• petechiae

What common OTC medications increase the risk of bleeding in patients taking anticoagulants and antiplatelets?

Avoid NSAIDs (ibuprofen, celecoxib, aspirin)

Which anticoagulation medication is safest for use in pregnancy?

Heparin is the safest for pregnancy and lactation

What surgical procedures typically use enoxaparin post-op?

taken 3-5 days following Orthopedic surgery

Can you explain why a patient newly diagnosed with blood clots might be taking heparin and warfarin before discharge?

• Heparin:

  • therapeutic effect is no further development of clots

• Warfarin:

  • prevents venous thrombosis and pulmonary embolism, used in Afib and patients with mechanical hear valves to prevents clots, reduces risks of recurrent MI or TIA

Why are anticoagulants contraindicated for long-term use in patients with alcohol use disorder?

May increase the risk of stomach ulcers and bleeds

Why is aspirin contraindicated in children?

Aspirin can cause Reyes syndrome in children

• Reyes syndrome: causes swelling in the liver and the brain

When considering alteplase therapy what are the time limits for drug administration?

Start drug within limited timeframe for best results

• 2 hrs for MI

• 3 - 4.5 hours for ischemic CVA

What is the only medication used for emergency use in acute bronchospasm?

Beta2-Adrenergic Agonist: Short-Acting Beta2 Agonist

• Albuterol: Can be used in emergent situations to open the airway!

Beta2-Adrenergic Agonist: Short-Acting Beta2 Agonist Prototype

Albuterol

Albuterol MOA

• mimic the effects of the SNS

• relaxes bronchial smooth muscle → bronchodilation

• decreases wheezing

• helps airways stay open!

Albuterol Uses

• acute bronchospasm in asthma or COPD

• First-line rescue med for acute symptoms

Albuterol CI/C

Think “CDHP” = “Cats Don’t Have Patience”

• Cardiac disease

• Diabetes

• Hyperthyroidism

• Pregnancy/lactation (risk v. reward)

Albuterol AE

Think “ID STIH” - “Inhaled Drugs, Start The Instant Hype”

• Increased BP / tachycardia

• Decreased renal/GI blood flow

• Sweating, pallor, flushing

• Tremors

• Increased blood glucose

• Hypokalemia

Albuterol DI

Avoid the use of other stimulants

Albuterol Labs

• BP

• HR

• Potassium

• Blood glucose

Albuterol NI

• Educate on proper delivery of inhaled medications

• Avoid caffeine

• Can be used in emergent situations to open the airway

Review how to educate the patient on proper inhaler technique.

1. Remove cap and shake inhaler

2. Breathe out all the way

3. Breathe in and press down on the inhaler

4. Hold your breath for a count of 10 seconds

5. Slowly breath out

What medication should the patient use first if they use both a steroid and SABA inhaler?

Inhale the short-acting beta2 agonist (SABA) before inhaling the glucocorticoid. The beta2 agonist promotes bronchodilation and enhances the absorption of the glucocorticoid

How long should the patient wait between inhalations via a metered dose inhaler of the same medication?

Wait at least 1 minute between inhalations of the same medications

How long should they wait between inhalations of different medications?

if 2 inhaled medications are prescribed, wait at least 5 minutes between medications

What is the purpose of using a spacer with medications taken via inhaler?

Increases the amount of med that reaches the lungs

Inhaled Steroids Prototype

Beclomethasone

Beclomethasone Uses

• long-term management of asthma/COPD

• prevention of exacerbations

Inhaled Steroids MOA

• suppress inflammation

  • prevent release of leukotrienes, prostaglandins, histamine

• decrease infiltration of inflammatory cells

  • eosinophils, leukocytes

• decreased edema of airways

Inhaled Steroids CI/C

• caution in active respiratory infection

Inhaled Steroids AE

Think “OD SHC” - “Often Dread Sore Hoarse Coughs”

• Oral thrush (pharyngeal/laryngeal fungal infections)

• Dry mouth

• Sore throat

• Hoarseness

• Cough

Inhaled Steroids NI

• Inhaled steroids have fewer systemic effects than oral steroids

• Contact the provider if there are S/S of respiratory infection

• May take 2-3 wks to reach effective lvls

• To prevent thrush pt needs to wash out mouth well after use

What is a common contraindication for the upper respiratory medications?

• found in various OTC cough and allergy preparations

  • pts need to be advised to always read the labels carefully to avoid inadvertent overdose and toxicity

What are the time limits of use for oxymetazoline? Why do we encourage patients not to take this medication past this timeframe?

Use for 3-5 days before risking rebound congestion

Topical Nasal Decongestants Prototype

Oxymetazoline (Afrin)

Oxymetazoline (Afrin) Uses

• Short-term relief of nasal congestion

Oxymetazoline (Afrin) MOA

• Local vasoconstriction → reduced nasal mucosa swelling

• This works FAST (within minutes)

Oxymetazoline (Afrin) CI/C

Must check nares to make sure no lesions or erosion exist before administering