Comprehensive Pharmacology Review – Analgesic, Neuropsychiatric, Pulmonary & Ophthalmic Agents

47 question-and-answer flashcards covering drug class, mechanism, indications, boxed warnings, maximum doses, key interactions, and essential counseling points for the analgesic, neuropsychiatric, pulmonary, and ophthalmic medications discussed in the lecture notes.

What drug class does diclofenac belong to and what is its primary mechanism of action?

Diclofenac is a non-selective NSAID that reversibly inhibits COX-1 and COX-2 enzymes, decreasing prostaglandin synthesis to reduce pain, inflammation, and fever.

List two boxed warnings associated with diclofenac (Voltaren).

1) Increased risk of serious cardiovascular thrombotic events (MI, stroke). 2) Increased risk of GI bleeding, ulceration, and perforation; contraindicated for peri-operative pain in CABG.

Meloxicam preferentially inhibits which cyclo-oxygenase isoenzyme at low doses?

COX-2 (it is a preferential COX-2 inhibitor at low doses).

What is the maximum recommended daily oral dose of meloxicam in adults?

15 mg once daily.

State the usual OTC adult naproxen dose and maximum daily OTC limit.

220 mg every 8–12 hours as needed; maximum 660 mg per day OTC.

What cardiovascular boxed warning applies to all non-selective NSAIDs such as naproxen?

They increase the risk of serious cardiovascular thrombotic events, including myocardial infarction and stroke.

How does celecoxib differ from traditional NSAIDs in its mechanism and GI risk profile?

Celecoxib selectively inhibits COX-2, providing similar analgesia with less GI ulcer risk than non-selective NSAIDs, although GI risk still exists.

Why should patients with a sulfonamide allergy avoid celecoxib?

Celecoxib contains a sulfonamide group that can trigger hypersensitivity reactions in sulfa-allergic patients.

Describe the black box warning related to codeine use in children.

Ultra-rapid metabolizers (CYP2D6) can convert codeine to morphine rapidly, leading to fatal respiratory depression—thus codeine is contraindicated post-tonsillectomy/adenoidectomy and generally avoided in children.

What is the absolute maximum daily acetaminophen dose (from all sources) when taking Tylenol #3 or #4?

4,000 mg of acetaminophen per 24 hours.

Hydrocodone ER products carry a boxed warning about interactions with which CYP enzyme?

CYP3A4—strong inhibitors can dramatically raise hydrocodone levels and precipitate fatal overdose.

List two key counseling points for patients taking hydrocodone/acetaminophen (Norco).

1) Do not exceed 4 g of total acetaminophen per day (check all OTC medications). 2) Avoid alcohol or CNS depressants and monitor for excessive sedation or slow breathing.

State the usual oral morphine immediate-release (IR) dose range for acute pain.

10–30 mg every 4 hours as needed.

Why must extended-release morphine tablets be swallowed whole?

Crushing, chewing, or dissolving ER morphine can cause rapid release and absorption of a potentially fatal dose (dose-dumping).

Give the starting adult dose for oxycodone ER (OxyContin).

10 mg orally every 12 hours; titrate cautiously based on response.

What is the primary boxed warning for all opioid analgesics such as oxycodone?

Risk of addiction, abuse, misuse, leading to overdose and death, plus life-threatening respiratory depression.

When dispensing Percocet, what maximum daily acetaminophen intake must the pharmacist emphasize?

No more than 4,000 mg acetaminophen from all products in 24 hours.

Explain acetaminophen’s boxed warning.

Severe hepatotoxicity may occur with doses >4 g/day, use of multiple acetaminophen-containing products, or excessive alcohol consumption.

What is the maximum OTC daily dose of ibuprofen for adults?

1,200 mg per day (equivalent to six 200 mg tablets/capsules).

All NSAIDs (except aspirin) share what peri-operative CABG contraindication?

They are contraindicated for treatment of peri-operative pain in the setting of coronary artery bypass graft (CABG) surgery.

Why must lamotrigine be titrated slowly?

Rapid dose escalation increases the risk of serious, potentially fatal skin rashes such as Stevens-Johnson syndrome (boxed warning).

Which antiepileptic markedly increases lamotrigine levels, and how should the lamotrigine dose be adjusted?

Valproic acid inhibits lamotrigine metabolism; lamotrigine doses should be reduced (usually by 50%).

Levetiracetam has minimal CYP interactions. Name one important neuropsychiatric adverse effect that still requires monitoring.

Behavioral or psychiatric changes such as irritability, aggression, or suicidality.

List three boxed warnings associated with valproic acid/divalproex.

1) Hepatotoxicity (especially in young children). 2) Life-threatening pancreatitis. 3) Major fetal risk/teratogenicity (neural tube defects, cognitive impairment).

Why should serum sodium be monitored in patients taking oxcarbazepine?

Oxcarbazepine can cause dose-dependent hyponatremia due to SIADH-like effects.

Identify the boxed warning on zolpidem products.

Complex sleep behaviors (sleepwalking, sleep-driving, etc.) that can lead to serious injury or death; discontinue if they occur.

What serious impulse-control adverse effect can occur with dopamine agonists like pramipexole?

Pathologic gambling, hypersexuality, or other compulsive behaviors (impulse-control disorders).

State the maximum total daily dose of ropinirole for Parkinson disease.

24 mg per day (IR or ER formulations).

What important drug interaction exists between rizatriptan and propranolol?

Propranolol approximately doubles rizatriptan exposure; therefore the maximum rizatriptan dose is reduced to 5 mg per dose and 15 mg per 24 hours.

Give the usual adult oral dosing limits for sumatriptan within 24 hours.

Maximum 200 mg orally per 24 hours (two 100 mg doses separated by ≥2 hours).

Albuterol provides rescue bronchodilation for about how many hours after an inhaled dose?

Approximately 4–6 hours of relief.

Why should patients rinse and spit after using Combivent Respimat?

To minimize dry mouth and bitter taste from ipratropium’s anticholinergic effect and reduce oral irritation.

What boxed warning was added to montelukast in 2020?

Serious neuropsychiatric events (e.g., agitation, depression, suicidal thoughts); benefits vs. risks must be evaluated, especially for mild symptoms like allergic rhinitis.

How often is Symbicort (budesonide/formoterol) usually taken for asthma maintenance?

Two inhalations twice daily (BID).

Explain why Advair Diskus (fluticasone/salmeterol) cannot be used for acute bronchospasm.

LABA onset is too slow for rescue, and the product is designed for maintenance; albuterol or another SABA is required for quick relief.

What is the dosing frequency for Breo Ellipta (fluticasone/ vilanterol)?

One inhalation once daily at the same time each day.

Trelegy Ellipta contains which three pharmacologic components?

Fluticasone furoate (ICS) + umeclidinium (LAMA) + vilanterol (LABA).

Describe the correct daily dosing of tiotropium HandiHaler.

Inhale the contents of one 18-mcg capsule once daily (two separate inhalations from the same capsule).

Why must benzonatate capsules be swallowed whole?

Chewing or dissolving can numb the mouth/throat, causing choking or aspiration; accidental chewing in children can cause fatal seizures/cardiac arrest.

After using an inhaled corticosteroid such as fluticasone, what counseling step prevents oral thrush?

Rinse the mouth with water and spit it out after each inhalation.

Restasis (cyclosporine ophthalmic) takes how long to show full benefit for dry eye?

Typically 3–6 months of twice-daily use are needed for maximal tear production improvement.

What permanent ocular cosmetic change can bimatoprost cause?

Increased brown iris pigmentation that may not reverse after discontinuation.

Why should brimonidine (Alphagan P) be avoided in infants and very young children?

Systemic absorption can cause profound CNS depression, apnea, hypotension, and coma in children <2 years old.

State the usual dosing schedule for timolol ophthalmic solution.

One drop in the affected eye(s) twice daily (or once daily if using the gel-forming Timoptic-XE).

What key storage instruction applies to unopened Xalatan (latanoprost) bottles?

Store refrigerated before opening; after opening, they may be kept at room temperature for up to 6 weeks.

What is a typical oral dosing regimen for diclofenac in adults?

For osteoarthritis, common doses are 50 mg TID or 75 mg BID; for rheumatoid arthritis, 50 mg TID or QID or 75 mg BID.

What is the usual adult oral dose for celecoxib for osteoarthritis?

For osteoarthritis, the usual dose is 200 mg once daily or 100 mg twice daily (BID).

What is the typical dosing frequency for hydrocodone extended-release (ER) products?

Hydrocodone ER is typically dosed once daily (QD) or twice daily (BID), with the initial dose individualized based on opioid history and titration for effect and tolerability.

What is the usual dosing frequency and starting dose for oral morphine extended-release (ER)?

Morphine extended-release (e.g., MS Contin) is usually taken every 8 or 12 hours, with the initial dose often beginning at 15-30 mg.

What is a common oral dose range and frequency for oxycodone immediate-release (IR) for acute pain?

For acute pain, oxycodone immediate-release (IR) is commonly dosed as 5-15 mg every 4-6 hours as needed.

How is lamotrigine typically initiated to prevent skin rash?

Lamotrigine initiation begins with a very low dose, typically 25 mg once daily for the first two weeks, followed by gradual increases over several weeks to minimize the risk of serious rash.

What is the usual initial adult oral dose for levetiracetam?

The usual initial adult oral dose for levetiracetam (Keppra) is 500 mg twice daily (BID).

What is the usual adult oral dose for zolpidem (Ambien) for insomnia?

The usual adult dose of zolpidem tartrate (Ambien) for insomnia is 5 mg or 10 mg taken immediately before bedtime.

What is the typical dosing for albuterol using a metered-dose inhaler for acute bronchospasm?

For acute bronchospasm, albuterol is usually dosed as 1-2 inhalations every 4-6 hours as needed.

What is the typical daily dosing frequency for Advair Diskus for maintenance treatment?

Advair Diskus (fluticasone/salmeterol) is typically taken as one inhalation twice daily (BID) for maintenance treatment of asthma or COPD.

What is the usual adult oral dosing for benzonatate?

Benzonatate is typically dosed as 100-200 mg orally three times daily (TID) as needed for cough.

What is the usual dosing frequency for Restasis in dry eye syndrome?

Restasis (cyclosporine ophthalmic emulsion) is typically dosed as one drop in each affected eye twice daily (BID).

What is the usual dosing frequency for latanoprost (Xalatan) ophthalmic solution?

Latanoprost (Xalatan) ophthalmic solution is typically dosed as one drop in the affected eye(s) once daily (QD) in the evening.

What is a “must-know” black box warning for combination estrogen/progestin oral contraceptives?

Smoking cigarettes can increase risk of seriously increased cardiovascular events, especially for women ages 35 and over.

What is a “must-know” black box warning for Fluoroquinolone antibiotics?

Associated with disabling, potentially disabling tendinitis/tendon rupture, Patients > 60 are at higher risk.

What is a “must-know” black box warning for Clindamycin?

C. difficile-associated diarrhea. Reaction can range from mild to fatal and can occur during treatment or up to 2 months after discontinuation.

What is a “must-know” black box warning for Methadone?

Respiratory depression, addiction, and particularly life-threatening QT-prolongation.

What is a “must-know” black box warning for Acetometophin?

Hepatotoxicity w/ doses > 40,000 mg/d and w/ cocurrent use of an additional acetometphin-containing product

What is a “must-know” black box warning for ACE-inhibitors?

Fetal/neonatal morbidity & mortality when used in pregnancy by affecting the renin-angiotensinogen system

What is a “must-know” black box warning for long-acting Beta-2 agonists?

Asthma-related death when used as monotherapy.

What is a “must-know” black box warning for anti-depressants?

Increased risk of suicidality. Weigh risk vs. benefit and monitor closely when initiating therapy.

What is a “must-know” black box warning for Benzodiazepines?

Concomitant use with opioids may lead to profound sedation, respiratory depression, coma, and death.

What is a “must-know” black box warning for atypical Antipsychotics?

Increased risk of death for elderly patients with dementia-related psychosis.

What is a “must-know” black box warning for Carbamazepine?

Fatal dermatologicial reactions (Steven-Johnsons Syndrome), especially in patients with the HLA-B*1502 allele; aplastic anemia; agranulocytosis.

What is a “must-know” black box warning for Stimulants?

High potential for abuse and dependence.

What is a “must-know” black box warning for Divalproex?

Hepatotoxicity, fetal risk, tetratogeneicity, pancreatitis

What is a “must-know” black box warning for Lamotrigine?

Life-threatening serious rashes, toxic epidermal necrolysis, and/or rash-related death. Risk is greater in pediatric patients.

What is a “must-know” black box warning for Lunesta/Ambien?

Complex sleeping behaviors (sleep-walking, sleep-driving, etc.) that may result in serious injury. Patient must receive full 8 hours of sleep.

Voltaren

Diclofenac

Tylenol with Codeine

Acetaminophen with Codeine

Norco

Hydrocodone + Acetaminophen

OxyContin

Oxycodone

Percocet

Oxycodone + Acetaminophen

Ambien

Zolpidem

Combivent Respimat

Ipratropium + Albuterol

Symbicort

Budesonide + Formoterol

Advair Diskus

Fluticasone + Salmeterol

Breo Ellipta

Fluticasone + Vilanterol

Trelegy Ellipta

Fluticasone Furoate+ Umeclidinium + Vilanterol

Restasis

Cyclosporine

Alphagan P

Brimonidine

Timoptic-XE

Timolol

Xalatan

Latanoprost

Lunesta

Eszopiclone

Mobic

Meloxicam

Aleve

Naproxen

Celebrex

Celecoxib

Lamictal

Lamotrigine

Keppra

Levetiracetam

Depakote

Valproic Acid

Trileptal

Oxcarbazepine

Mirapex

Pramipexole

Requip

Ropinirole

Maxalt

Rizatriptan

Inderal

Propranolol