COMBINED SET

Oxybutynin

(Oxytrol)

patch for women with overactive bladder

changed every 4 days

OTC dose (3.9 mg) a lot less than Rx (5-10 mg, max 30 mg)

Anticholinergic - AVOID IN myasthenia gravis, bladder neck obstruction, glaucoma!!

Sunscreen

Permethrin

Prethrin

Benzyl alcohol

Spinosad

Malathion

Ivermectin

Medication causes of constipation

Antacids with Aluminum and Calcium

Calcium and Iron Supplements

CCB (diltiazem and verapamil)

anticholinergics (remember dry things up, TCA, antihistamines, antipsychotics)

opioids

5-HT3 receptor antagonists (ondansetron)

Bulk Laxatives

Names

• Psyllium (Metamucil)

• Methylcellulose (Citrucel)

• Polycarbophil

MOA: adds bulk to stool

MUST be taken with lots and lots of water —> can worsen/cause constipation

do NOT use in severe diarrhea

taken 3 times a day, takes a day to work

Emollient (Surfactants)

Docusate (Colace)

Draws water/fats into stool

like bulk laxatives, takes awhile to work (2-3 days)

Most taken multiple times a day, EXCEPT docusate calcium (QD)

Osmotic Laxative

Magnesium citrate/sulfate

PEG

Lactulose

Sorbitol

Glycerin suppository

Sodium phosphate

Draws water from our body into the stool → may causes electrolyte abnormalities and fluid overload

Avoid magnesium products in renal insufficiency —> use lactulose or sorbitol instead

Glycerin suppository works the fastest (15 min) and then magnesium sulfate (30 min)

Stimulants

Senna (Senokot)

Bisacodyl (Dulcolax): taken QD, also has suppository form (works super fast)

Senna/Docusate (Senokot-S)

Caution with chronic use —> hypokalemia and salt overload

Lubricant Laxative

Mineral Oil
Taken over long period of time, can absorb fat-soluble vitamins from intestines
separate from medications
not used that often (aspiration risk)

not used in sensitive populations (kids <6 yo, preg, elderly, bedridden) or long term use

Enema

gives water from outside source instead of taking from within
other than suppositories, works the FASTEST

Bowel Preps

use osmotic laxatives to clear out the colon so people do colonoscopy

Sodium phosphate (OsmoPrep = Rx, Fleet Enema = OTC): tablets have risk of acute phosphate nephropathy

PEG + electrolyte (GoLYTELY = Rx): good for fluid loss and dehydration

PEG without electrolytes (Miralax): taste better but no electrolytes, not for bowel prep, dont taking anything that’s red (may look like blood) if used for bowel prep mixed with something else

Prepopik (Rx): stimulant + magnesium

Constipation in children

Start with osmotic laxatives (PEG, lactulose)

Avoid docusate —> takes too long to work

Avoid suppositories → children may be conditioned to depend on rectal stimulation to poop

Constipation in pregnancy

Can use bulk agents (psyllium) long term or magnesium osmotic laxatives (watch out for electrolyte abnormalities)

If not then short term use → bisacodyl

Docusate not as effective

Avoid castor oil —> causes uterine contraction/rupture

Loperamide (Imodium)

for diarrhea

works on the opioid receptors → think opioid cause constipation

available as 2 mg

max dose: Rx 16 mg/day, OTC 8 mg/day

start with 2 tablets, then 1 tablet every loose stool after

Simethicone

(Gas-X)

used for gas, makes big bubble into small bubble —> stops discomfort

can be used in infants

Octreotide

(Sandostatin) Rx

Off label for diarrhea associated with tumors

SC/IV/IM

Refrigerate

Bismuth Subsalicylate

Prescription Meds for Constipation

1st gen antihistamine

Names

Indications

Side effects

Very sedating

• Brompheniramine, Chlorpheniramine

• Diphenhydramine: exists Rx as IV and IM

• Doxylamine: part of Sleep Aid-OTC and Nyquil formulations

• Carbinoxamine (Karbinal ER): exists as prescriptions

Indications

• Diphenhydramine for parkinsons and drug induced EPS

• Doxylamine: insomnia (see formulations)

Side effects

• VERY sedating, does opposite for very young kids

• Anticholinergic —> avoid in BPH, glaucoma, bladder neck obstruction, myasthenia gravis

• Tachycardia → avoid in arrhythmias

2nd gen/3rd gen antihistamines

Desloratadine sold as Rx

Decongestants

Phenylephrine (Sudafed PE) not than effective as Sudafed, only use for 2-3 days —> rebound congestion

Oxymetazoline (Afrin): nasal formulation, only use for 2-3 days —> aggressive rebound

Pseudoephedrine

acts like stimulant —> ADE, caution in said population

Intranasal corticosteroids

Nasal steroids (QD) vs inhaled (BID)

All 3 for at least 2 years of age, except budesonide (6 years)

Fluticasone indicated for nasal and ocular symptoms

Neti Pot

Rinsing nose with salt water

only use distilled, boiled, or sterilized water —> tap water increase infection

keep mouth open

use neti pot before nasal steroids

Racepinephrine

(Asthmanefrin)

only for temporary chest tightness and wheezing

need to be cleaned out every time

kind of like epinephrine (stimulating): dont use in pregnant patients or children <4 yo

Cannot use within 14 days of MAOIs

Epinephrine

(Primatene Mist)

mild asthma for children at least 12 yo

must shake and prime every time

no more than once a day

OTC cough meds

Guaifenesin (mucinex) wet cough, break up mucus

Dextromethorphan (Delsym) dry cough, stop cough

Dextromethorphan increase serotonin —> DDI with MAOIs, VERY important for exam

Benzonate (Tessalon Perles) Rx: swallow whole (numbs mouth)

Narcotic Antitussives

Codeine Products

• Codeine: CII, for night-time cough

• Codeine-chlorpheniramine (Tuzistra XR): CIII, ER susp

• Codeine-guaifensin (Robitussin AC): CV, syrup

Hydrocodone Products

• Hydrocodone + guaifensin: CII, solution

• Hydrocodone + homatropin: CII, tap/syrup

• Hydrocodone + chlorpheniramine (Tussionex): CII, susp

Due to risk of ADE, FDA recommended against use of codeine/hydrocodone containing cough/cold products for patients <18 yo

If patient has resp infection and cough…(treatment)

agents that reduce postnasal drip that triggers coughs

Oral decongestant such as pseudoephrine, alone or in combo with 1st gen antihistamine

Carbamide peroxide

isopropyl alcohol and anhydrous glycerin

Ear drying drops after swimming

Counseling on Ear Drops

Acetaminophen

Toxicity

Max doses/tabs

Pediatric Dosing

(Tylenol), also in Vicodin and Norco

Dont give if have hepatotoxicity (max dose: outpatient 3000 mg, inpatient 4000 mg)

Max tabs: Regular strength (325 mg) 10 tabs, extra strength (500 mg) 6 tabs

Stages

• first day: asymptomatic

• 2nd day: LFT starts to rise

• 3rd day: jaundice (yellow skin, light stools, very dark urine), acute renal failure, metabolic acidosis

• after: death

N-acetylcysteine

Structure

MOA —> Indication

Formulation

tylenol toxicity: restore glutathione levels —> helps remove toxic metabolites of tylenol

sometimes used as mucolytic (free sulfhydryl groups open up disulfide bonds) and prevent contrast induced nephropathy (scavenges oxygen derived free radicals)

Formulations

inhalation

oral solution (unpleasant sulf odor, must readminister if throw up)

effervescent tablet

IV: incompatible with metals (cefepime, ceftazidime)

72 days of oral vs 21 days of IV → usu give IV

Aspirin

Indications

ADE

DDI

Hypersensitivity

Other Contraindications

DDI

Overdose

Indications

• Mainly used for antiplatelet

• Never give with stroke (could be hemorrhagic stroke, increased risk of bleeding, makes it worse)

• Always give with MI (feeling of elephant on chest)

• Maintenance: usual 81 mg (cant go above 100 mg with ticagrelor)

• Max dose: 4 grams

Safety

• ADE: GI bleeding, salicylism (ringing in the ear), increase uric acid (never add with gout)

• DDI (other meds that increase uric acid): Forteo (teriparatide), niacinamide, TB meds (ethambutol and pyrazinamide), thiazide and loops

• Hypersensitivity to NSAIDs, Sensitivity to tartrazine dye

• Other Contraindications: risk of Reye’s syndrome, pregnancy (fetal toxicity)

• Avoid ibuprofen or naproxen with aspirin (reduce effectiveness of antiplatelet effects for secondary prevention). If they have to take ibuprofen, taking aspirin first and ibuprofen 2 hours later

Overdose: sodium bicarb, activated charcoal, IV dextrose, dialysis

NSAIDs

MOA, ADE, BBW, Other

Work on afferent arterioles (ACE, ARBs etc work on efferent)

COX2 enzyme: anti-inflam, renal, and may prevent colon cancer

Worried about

• GI bleeding (less in COX2 selective),

• renal issues (watch out for ACEi/ARB and diuretics),

• hyperkalemia (look out for ACE/ARB, tekturna, aliskiren, K sparing, bactrim)

• headache (esp in indomethacin),

• edema (→ heart failure)

BBW:

• GI bleeding

• CV events (MI, stroke, heart failure. give naproxen if worried, never diclofenac or celecoxib)

With food - protect GI lining

Dont recommend in pregnancy

Pain Patches Duration

Lidocaine patch (4%): 12 hrs on, 12 hrs off

Diclofenac (Flector): every 12 hours on

Capsaicin patch: OTC 8 hrs on, Rx 1 hour on

Diclofenac formulations

Cambia (fast acting, packet for acute migraine attack)

Zipsor

Arthrotec (Diclofenac/misoprostel) - never give to pregnancy or child baring ages

3% gel used for actinic keratosis —> less irritation than Efudex (chemo agent)

Flector patch: apply every 12 hours

Indomethacin formulations

Comes as oral, rectal, IV

Sulindac

does NOT have lithium toxicity like the rest of NSAIDS

Ketorolac

IV, IM and PO should only take up for 5 day (after has higher chance of GI bleed)

Other formulations: eye drops, nasal spray (Sprix)

Celecoxib

(Celebrex)

COX2 selective (less GI side effects)

Avoid with sulfa allergy and CV events

Capsaicin

(Zostrix)

Very good for pain (used for post-herpetic neuralgia, muscle/joint pain etc), wash hands —> made out of chili peppers

Patches:

OTC version (0.025-0.05%): max for 8 hrs or 4 patches, dont use for more than 5 consective days

Rx version (8%): only applied by healthcare provider for 1 hour

May cut patch

Piroxicam

(Feldene)

long half life → QD

daily limit 20 mg —> risk of GI complications

prescribing limited to pain/inflammation specialist

Ibuprofen and Naproxen Dosing

Fat soluble

ADEK

Vitamin A

Too little: night blindness, xerophthalmia (dry eyes)

Too much: birth defects

Vitamin D

prohormone for calcium regulation

Too little: rickets (softening of bone in children)

Vitamin K

clotting factors (green leafy vegetables)

Vitamin E

theoretically: antioxidant

NOT recommended for primary prevention of cardiovascular disease and cancer (like prostate cancer)

Vitamin Bs Memory Tip

The Rabbi Needs Pray Because For Comfort

Vitamin B1 (Thiamine)

Vitamin B2 (Riboflavin)

Vitamin B3 (Niacin)

Vitamin B6 (Pyridoxine)

Vitamin B7 (Biotin)

Vitamin B9 (Folate)

Vitamin B12 (Cyanocobalamin)

Vitamin C

(asorbic acid)

deficiency causes scurvy

too much: kidney stones

Vitamin B7

(biotin)

may help with hair, skin, nails

false low levels of troponin, TSH or PSA

Vitamin B1

(thiamine)

deficiency: wet beriberi (causes HF) and dry beriberi (causes peripheral enuropathy), wernicke encephalopathy

Vitamin B2

(riboflavin)

deficiency rare

Vitamin B3

(niacin)

deficiency: Pellagra (marked by the 3 D’s: Dementia, Diarrhea, Dermatitis)

Vitamin B6

(pyridoxine)

used at 25-50 mg dose with isoniazid to prevent peripheral neuropathy

Vitamin B9

(folate)

deficiency: megaloblastic anemia

given to pregnancy to prevent neural tube defects

Vitamin B12

Calcium

Formulations

RDA

Drug Interactions

Calcium carbonate with food, derived from oyster shell

Calcium citrate with/without food

OsCal: Calcium carbonate + Vitamin D3

RDA (pay attention to gender)

Everyone under 50: 1000 mg elemental calcium daily

Females at least 51 and males at least 71: 1200 mg elemental calcium daily

Iron

Only worry about deficiency in
Increased iron requirements
Iron supplements (%)
Administration/Side Effects

Dosing based on Hgb

Only worry about deficiency in

• males and postmenopausal women

• colon cancer or GI bleed (check if they have bleeding there)

Increased iron requirements

• pregnancy

• children (start giving at 4 months)

Iron supplements

Ferrous fumarate (33%)

Ferrous sulfate (20%) → exception, slow Fe (32%)

Ferrous gluconate (12%), also has IV formulation

Administration/Side Effects

Give on empty stomach with vitamin c for acidic environment

Never give with antacids (remove acidic environment)

Lower elemental iron —> less GI upset

Black stools

Oral solution stains teeth

Erythropoietin

SAM-e (S-adenosyl-L-methionine)

used for depression and osteoarthritis

can give SAM-e for depression instead of St John Wort’s if worried about drug interactions

Lithium orotate

Same issues as prescription lithium (like lithium carbonate and citrate for bipolar disorder)

L- levels

T - hypo/hyper-THYROIDISM

H- hypercalcemia

I - increase derm, alopecia

U - bUn, rena

M - monitor weight, pregnancy etc

Glucosamine sulfate

osteoarthritis (also SAM-e)

made from shell of shrimp, dont use in shellfish allergy

Gluco - caution with diabetic patients

Kava kava

used for anxiety, stress, insomnia

Think alcohol (alcohol also bad for liver)

Causes hepatotoxicity

DDI with alcohol → CNS depression

Chamomile

Used for anxiety, bedtime tea

Caution in ragweed allergies

Saw Palmetto

Indicated for BPH

Ma Huang (Ephedra)

Stimulant used for weight loss

All removed from the market —> replaced with bitter orange (contains synephrine), guarana (caffeine), yerba mate, green tea

Ginseng

Different than other countries:

American ginseng —> decrease INR, warfarin DDI

Asian and Siberian ginseng —> increase INR

Used for fatigue, increase athletic performance, cog function, immune function, decrease glucose in T2DM

ADE: Hypoglycemia

Kind of like a stimulant —> tachy, nervousness etc

Ginkgo

Used for dementia (not FDA approved but many ADE)

Increase INR, discontinue 36 hrs before procedure —> DDI with warfarin, ASA, NSAID, heparin

Increase stroke in elderly

Prevagen

Improve memory

Dont recommend actually because cause stroke

DHEA

not the same as DHA (omega 3)

steroid hormone, helps synthesize raw materials for estrogen, progesterone, testosterone, and cortisol

Increase risk of hormone sensitive cancer

Lysine

used for cold sores

essential amino acid

Patients with herpes may benefit from high lysine, low arginine diet

Lutein

eye health

Lut “eye” in

St John’s Wort

used for depression, works on serotonin, CYP inducer

Valerian

used for insomnia

Garlic (Allium sativum)

Used for atherosclerosis, high BP, immune system, hyperlipidemia???

DONT use for hypercholesterolemia

May cause increased risk of bleeding

Echinacea

immune stimulant —> help fight infections

sometimes given with goldenseal (antimicrobial)

Goldensesal

Used as antimicrobial, anti-inflam, laxative

Never use with pregnancy (induce contraction of uterus)

Migraine prophylaxis

Use feverfew (increase INR) and butterbur (hepatotoxicity)

SOY

Used for decrease hot flashes and other postmenopausal ssymptoms → estrogen like effects

Pending safety and use in breast cancer

Yohimbe

Used for impotence, aphrodisiac, body building (as fat burner)

Act like stimulant —> associated with heart attack, seizure, tachy, anxiety, HTN

Evening Primrose Oil

used for eczema, inflammation, breast pain (pre/post menopausal syndromes)

like other oils —> increase INR with warfarin

Borage seed oil

Used for skin conditions, joint pain, menopausal disorder

just like other oils (evening primrose oil) —> increase INR

also watch for hepatotoxicity (like kava kava)

Cranberry

Prevention of UTI

too much —> increase INR and kidney stones

Dong Quai

“female ginseng” - for menstrual cycle and menopausal difficulties

Head of root —> increase bleeding with warfarin, stopped taking during menstruation

dOng —> photosensitivity

Black Cohosh

Used for menopausal symptoms, instead of hormone replacement therapy

Liver failure (just like kava kava, borage seed oil and butterbur)

Dont recommend in pregnancy —> can induce labor and miscarriage

CoQ10

lowers as we age

used for migraine prevention (like butterbur, feverfew), HF, statin myalgia, HTN, T2DM

Milk Thistle

HELPS liver

caution in diabetic patients (lower BG)

Red yeast rice supplements

acts like OTC Lovastatin (Lovastatin are produced when rice is fermented with yeast)

Biggest ADE: myopathy —> avoid with Zidovudine and daptomycin

Honey

Antibacterial and antifungal activity —> wound healing, cough

never give to kids <1 yo

Cinnamon

cinnamon balances sugar in cinnamon rolls —> for T2DM

Kratom

Opioid like effects —> used for opioid withdrawals, many places dont have bc of abuse potential

lower doses as mild stimulant or higher doses as sedative

Herbals that increase INR