Pharm #3 exam

Adrenal glands help..

• Increase BP (blood volume)

• slows protein production, increase protein breakdown

• Releases glucose

• Slows down  inflammatory/immune system

What med needs to be injected intra articular?

Triamcinolone

Addison’s disease is when you have an

Adrenal INSUFFICIENCY

Addison’s disease symptoms

• Hypoglycemia

• Postural Hypotension

• Weight Loss

• GI disturbance

• Weakness

• Change in body hair distribution

• Bronze Skin Pigmentation

Cushing Disease is when you have..

Adrenal EXCESS

Symptoms of Cushing disease

• Personality Changes

• Hyperglycemia

• Weight gain

• Moon Face

• Increase risk for fracture

• Gynocomastia (male breast)

• Na+/Fluid Retention

• Thin extremities

• Thin skin/purple striae/ bruises/ petechiae

• Fat deposits  on face/back/shoulders

Adrenocortical Agents

• Androgens (estrogen/testosterone)

• Glucocorticoids

• Mineralocorticoids

Types of glucocorticoids

Hydrocortisone, Cortisone, prednisone (oral only)

Glucocorticoids help

• reduce inflammation and suppress immune system

• Increase glucose

• Increase protein/fat breakdown

Caution w/ glucocorticoids

• Diabetes

• Infection

• Acute peptic ulcers

Adverse Effects of glucocorticoids

• stunt growth

• vertigo, headache, hypotension, sodium/fluid retention, immunosuppression 

• Adrenal insufficiency

• Roid rage

Interactions w/ glucocorticoids

• NSAIDs /  alcohol

• Potassium depleting agents

• Vaccines &  anticoagulants

Mineralcorticoids action

increase sodium reabsorption & potassium excretion

Mineralcorticoids medications

Cortisone, Fludrocortisone, Hydrocortisone

Mineralcorticoids help treat

• Replacement therapy in primary/secondary adrenal insufficiency

  • Ex: tumor, adrenal gland removed/partially functioning

• Salt-wasting adrenogenital syndrome

Cautions of Mineralcorticoids

• High sodium intake

• Severe hypertension, HF, CV disease (these pt already retain water)

Adverse effects of mineralcorticoids

• increased fluid volume (edema)

Drug interactions w/ Mineralcorticoids

• Antidiabetics

• Barbiturates, phenytoin, rifampin (breaks drug down too fast)

Salicylates medications

Aspirin, Balsalazide, Diflunisal

Salicylates help..

reduce inflammation

Salicylates help treat

• Rheumatoid arthritis, osteoarthritis, IBD

• Unique Effect: low dose aspirin = platelet aggregation inhibition

Salicylates properties are

• Anti-inflammatory, Antipyretic, analgesic

Adverse Effects of Salicylates

• GI discomfort (nausea, dyspepsia)

• Reye’s syndrome

• Bleeding

• Tinnitus

• Salicylism

  • Salicylate poisoning -> cardiopulmonary arrest due to pulmonary edema

Salicylates interactions

Anticoagulants, alcohol, NSAIDs

NSAIDs are used for

• Anti-inflammatory, analgesic, antipyretic effects

NSAIDs medication

Ibuprofen, Naproxen, Ketorolac, Celecoxib

NSAIDs help treat

• Arthritis, Dysmenorrhea, mild-moderate pain, fever

NSAIDs contraindications

• GI Bleeding

• Peptic ulcers

• CV Dysfunction

NSAIDs adverse effects

• GI Distress

• HTN & risk of CV events

• Renal dysfunction

NSAIDs interactions

• Reduce efficiency of diuretics & antihypertensives

• Higher risk of bleeding  w/ anticoagulants & glucocorticoids

• Ibuprofen = ^ risk of lithium toxicity

Acetaminophen treats

• Pain/fever, preferred for children over NSAIDs

Acetaminophen does not have

anti-inflammatory effects

Acetaminophen adverse effects

• hepatotoxicity with overdose or chronic use

Acetaminophen contraindications

Liver dysfunction (metabolizes in the liver) & chronic alcohol use

Acetaminophen antidote

Acetylcysteine

Antiarthritis agents help..

Modulate immune response and reduce inflammation

Antiarthritis agents treats

joint inflammation and slow disease progression

Types of antiarthritis agents medications

Nonbiologic: Methotrexate, abatacept

Biologic: TNF blockers (etanercept)

Adverse effects of antiarthritis agents

• Serious infections

•  Lymphoma

•  demyelinating diseases

  • MS

Boxed warning of antiarthritis agents

Increased risk of fatal infections and cancer

Antiarthritis Agents Interactions

Live vaccines contraindicated due to infection risk

Antigout Agents actions

Target inflammation and uric acid levels

Types of Antigouts Agents medication

Colchicine, allopurinol, febuxostat, probenecid

Antigout medications treat

• Colchicine: Reduces neutrophil-mediated inflammation.

• Allopurinol, febuxostat: Inhibit uric acid production.

•  Probenecid: Increases uric acid excretion.

• Pregloticase: used IV for refractory gout

Pegloticase can cause

risk for anaphylaxis, premedication required

Antigout agent adverse effects

• GI distress

• Renal calculi risk

• Rhabdomyolysis with colchicine

• cardiovascular events with febuxostat

Antigout Agent interactions

• CYP3A4 inhibitors increase colchicine toxicity

• Allopurinol:Increases bleeding risk with anticoagulants.

Generalized seizures

• Both hemisphere

• Results in  LOC due to massive electrical  activity

• Motor vs nonmotor

Focal seizures

• One area of the brain (partial seizure), usually stay on one side

• Classification: retaining awareness/impaired awareness (motor/nonmotor)

Febrile seizures

• Due to very high fever

• Usually tonic-clonic seizures

• Antiseizure meds req. (doesn't reappear once temp reduces)

Febrile seizures are common between the ages of

3m-6yr

Myoclonic seizures

• Motor or nonmotor

• Short, sporadic periods of muscle contractions (face, trunk, one or bilateral extremity)

• Cause: cerebral stimuli (rare/often secondary)

Absent seizures

• Nonmotor: Blank stare, motionless, unresponsive, no muscle contractions

• Abrupt 3-5 sec LOC (staring/blinking)

• Atypical 

  • Difficult to dx w/o EEG

  • Prolonged symptoms w/ muscle tone alterations

Absent seizures are common in the age of

3yr

Hydantoins meds

• phenytoin (Dilantin), fosphenytoin

Hydantoins are known to be

• Cost effective

• less sedating & less dependent (addictive) than benzos/barbilurates

Hydantoin medication actions

• Decreases excitability/hyperexcitability

• reduce tonic-clonic, muscular, and emotional responses

Hydantoins cautions

• Pregnancy/Lactation 

  • congenital abnormalities

  • D/C can cause status epilepticus

• Hepatic impairment = ^  risk of toxicity

• Older adults = FALL RISK (low & slow)

• Coma, depression, psychosis (CNS Depressants)

• IV w/ fosphenytoin (CV Monitoring & name confusion)

Hydantoins treat

Generalized seizures

Hydantoins adverse effects

• SLOWS EVERYTHING DOWN

• bone marrow suppression, gingival hyperplasia, serious dermatological reactions (hirsutism, Steven Johnson’s Syndrome), Frank malignant lymphoma

Interactions with hydantoins

• Alcohol/CNS depressants

• primrose (increase seizure risk)

• Ginkgo (lowers effectiveness)

Barbiturates medications

• phenobarbital (solfoton, luminal), primidone (mysoline)

Barbiturates treat/action

• Seizures

• Inhibit impulse conduction in RAS (CNS Depression) & stabilize nerve membranes (stopping one neuron from firing w/ another)

Barbiturates pharmacological effects

• Phenobarbital: 

  • Route: Oral or Injection

  • Lipid solubility (slow onset, long duration)

  • Therapeutic range: 10-40, adverse effects seen at 30+

• Primidone:

  • Route: Oral ONLY

  • Therapeutic Range: 5-12

Patients with status epilpticus you would want to have a..

Higher loading dose

Adverse effects are the same as..

Hydantoins

barbiturates interactions

• Warfarin (decrease effectiveness)

• Vitamin K/D (decrease synthesis)

benzo meds

clobazam, clonazepam (Klonopin), diazepam (Valium)

Benzos treat

Seizures & anixety (works at neurotransmitters)

Benzos actions

• Mimics effects of GABA to make it stronger

• Muscle relaxation, decrease spasms

• Limited toxicity/most respond well

Benzo routes

• Diazepam: Oral and rectal

• Clonazepam: Orally disintegrating tab (dissolves)

• Clobazam: Oral form only

Benzo cautions

• Hepatic impairment = ^  risk of toxicity

• Older adults = FALL RISK (low & slow)

• Coma, depression, psychosis (CNS Depressants)

Benzo adverse effects

• CNS Depression, withdrawal w/ rapid d/c (pt dependent on this)

Blackbox warning with Benzos

sedative effects w/ Benzo’s & Opioids

• Profound sedation, respiratory depression, coma, death

Seizure meds that

that modulate the inhibitory neurotransmitter GABA

Migraine PREVENTION/seizure meds (gaba)

acetazolamide, divalproex, valproic acid, zonisamide

Valproic Acid treats

• Migraine prevention & BPD

Pharmacokinetics of GABA modulating meds

• Valproic Acid: oral, peak 1-4hrs

• Acetazolamide: oral/IM/IV

• Divalproex: oral

• Zonisamide: oral, peak 2-6hrs

Pharmacokinetics of GABA modulating meds

• Valproic Acid: oral, peak 1-4hrs

• Acetazolamide: oral/IM/IV

• Divalproex: oral

• Zonisamide: oral, peak 2-6hrs

GABA modulating meds C/C

• sulfonamides

• diuretics (High/Low Na+ or hypoglycemia cause seizures)

• zonsiamide (cause renal calculi/bone marrow suppression/seizures, taper off for 2weeks)

• pregnancy/lactation (teratogenic risk)

GABA modulating meds interactions

• Valproic acid increase salicylate toxicity

• Diavalproex (^ serum toxicity)

• Valproic acid + phenytoin = breakthrough seizure

• Zonisamide & carbazepine = ^ risk of toxicity

OTHER seizure medications

carbamazepine, lamotrigine (Lamictal), levetiracetam (Keppra) and topiramate (Topamax)

“other” seizure meds C/C

• Black box warning = Serious dermatologic reactions

• Aplastic anemia, Agranulocytosis

• Pregnancy: 

  • Congenital anomalies, Spina bifida, Cleft lip/palate, Low birth weight

  • Decreases serum levels

• Coadministration w/ valproate (kids)

Adverse effects of “other” seizure meds

Nystagmus (Eye wiggling), Glaucoma

Topiramate w/ birth control

Reduces birth control effects

Meds for nerve issues

• clorazepate (tranxene, Gen-Xene), gabapentin (Neurontin), pregabalin (Lyrica)

Nerve issue meds can help treat

• Gabapentin: Postherpetic neuralgia, restless leg syndrome

  • Many off label uses (Polypharmacy is a concern)

• Perampanel: Red Box Warning: Life threatening psychiatric behavioral adverse effects

  • Aggression, hostility, irritability, anger, homicidal ideation and threat

• Pregabalin: Postherpetic neuralgia (shingles), neuropathic pain, fibromyalgia (pain w/ no source)

C/C of nerve issues meds

decrease fertility, severe hepatic dysfunction, renal dysfunction

Adverse effects of nerve issue meds

• CNS depression: Pregabalin aka Lyrica (Schedule V)

  • Can cause euphoria

  • Limit in pts with substance disorders

• Increased Suicidal idiation…slowly d/c

  • Precipitate a seizure

• Severe liver failure, Aplastic Anemia, Dermatitis, Vision loss

Nerve issue meds interactions

Hormonal contraceptives (lose effectiveness & barrier needed)

Types of movement

• Simple = sensory neuron → motor neuron

• Complex: = sensory neuron → interneuron(s) → motor neuron

Pyramidal tract

controls intentional movement

Extrapyramidal tract

• moderates unconsciously controlled muscle activity

  • Allows body to posture/position & balance

Muscle spasms

injury causes too many signals from the injured area → temporary muscle tightening

Muscle spacisity

• brain/spinal cord damage disrupts muscle control → ongoing stiffness and tightness

Central muscle relaxants

• baclofen, carisoprodol, cyclobenzaprine, methocarbamol

Central Muscle relaxant actions

• interferes w/ reflexes, spasmolytics (destroy spasm), alter spinal/subcortical neuron

Central Muscle relaxants treat

• Acute discomfort, painful musculoskeletal conditions

Contraindications of central muscle relaxants

spasms resulting from rheumatic disorders

Cautions with central muscle relaxants

• epilepsy (might have a med prescribed), cardiac dysfunction, conditions w/ muscle weakness (worsens it)