Pharm Final Exam Part 1

Cholinesterase Inhibitors

Includes: Neostigmine & Donepezil

MOA: prevent the enzyme cholinesterase from inactivating acetylcholine which increases acetylcholine

- Complications: Excessive muscarinic stimulation (too much saliva, too much pee, too much poop(diarrhea) diaphoresis(sweating), ; cholinergic crisis (overdose of Neostigmine --> Increases muscle weakness, respiratory depression & bradycardia, urinary urgency, eye spasms; provide respiratory support & use atropine bc its the antidote)

Use cautiously in:

Clients who have asthma, seizure disorders, bradycardia, hypotension, hyperthyroidism, PUD

Neostigmine

Longterm treatment of Myasthenia Gravis (does NOT cure)

- also used to counteract anesthesia bc reverses neurological blocks

Symptoms of Myasthenia Gravis:

ptosis (drooping eyelids/mouth), muscle weakness, double vision, difficulty swallowing/breathing/chewing, fatigue

Donepezil

Treats Alzheimer's symptoms (does NOT cure just slows progression)

Anti-Parkinson's medications:

Levodopa/Carbidopa

#1 drug combo for Parkinson's disease; effects of meds decrease at the end of year 5; "on-off" and "wearing off" occurs

- Complications: dyskinesias (head bobbing --> ABNORMAL, need to decrease dose), Discoloration of sweat and urine (NORMAL/harmless), ACTIVATION OF MALIGNANT MELANOMA (avoid patients who have skin lesions)

eat protein in SMALL portions and avoid vitamins/foods with pyridoxine (bananas, whole-grain cereals, green veggies, liver, legumes ---> reduce the effects of Levodopa/Carbidopa)

- only treats, does NOT cure

- monitor BUN/CREAT & AST/ALT

Typical Appearance of Parkinson's Disease

Extrapyramidal Symptoms

- continuous spasms/muscle contractions

- rolling hand tremor

- rigidity (stiff/inflexible muscles)

- slow/jerky movements

- stooped posture

Sedative Hypnotics

CNS depressants that induce a sense of calmness, decrease anxiety, and induce sleep

- Benzodiazepines (enhances action of GABA)

Benzodiazepines (Seizures)

Includes: Clonazepam, diazepam, lorazepam ("LAMS" AND "PAMS"!!!)

Status epileptics: Treat active or acute seizures (only STOPS a seizure, does NOT prevent them from occuring)

- also used for anxiety, insomnia, alcohol withdrawal, & anesthesia (a sedative)

Complications: PO: dizziness, drowsiness, incoordination IV: respiratory depression ---> leads to (hypertension, low respiratory rate, and may need supplemental oxygen), over-sedation

- do not stop abruptly, and administer with meals

IV Antidote: Flumazenil

PO Antidote: Activated charcoal

What medications are given for the long-term treatment of seizures?

Anti-epileptics: Phenytoin

Phenytoin

CONTROLS/PREVENTS seizures (LONG TERM): Monitor cardiac effects before giving (history of bradycardia, heart block, history of syncope(fainting) do NOT give during ACTIVE seizure

Administer IV very slowly no faster than 50mg/min(if you push fast --> dysrhythmias, bradycardia, hypotension)

- Complications: CNS effects: double vision, nystagmus(uncontrolled movement of eyes, STOP if occurs) ataxia (spasm movements, STOP), SKIN RASH --> STOP, Gingival Hyperplasia (overgrowth of gum tissue - report bleeding/swelling gums)

Phenytoin Teaching

- Take with food to reduce GI symptoms (increase vit D and calcium)

- DO NOT STOP ABRUPTLY

- Folic Acid can decrease occurrence of Hyperplasia

- Floss daily, normal dental visits, massage of gums

- Avoid Pregnancy - Category D!!

Phenytoin Levels

10-20 is normal

Over 20 is toxic

Carbamazepine

Anticonvulsant - Prevents/reduces seizures

Complications: Blood dycrasias (leukopenia, anemia, thrombocytopenia ---> bone marrow suppression), Skin disorders (Stevens-Johnson syndrome, rash), Decrease in urine output

- observe for bruising/bleeding gums, sore throat, fever, pallor, weakness, infection(low WBC)

- can cause false negative pregnancy tests

- Pregnancy Category D

- do not stop abruptly --> can be life threatening

obtain CBC and PLT before administering!!

Levetiracetam

NEWER anticonvulsant - Prevents/reduces seizures

Complications: suicidal ideation, anxiety, depression, dizziness, agitation, asthenia (loss of strength/weakness)

Discontinue slowly --> Abruptly can cause rebound DEADLY seizure

Succinylcholine

MOA: Neuromuscular blocking agents resulting in muscle paralysis (paralytic)

Complications: Hyperkalemia, malignant hyperthermia (temp higher than 109.4), hypertension, respiratory arrest (give neostigmine)

- GIVE SEDATIVE FIRST

Labs: Potassium (K+)

A sedative and a paralytic are ordered... What do you administer first?

Sedatives (Benzos --> "Pams" and "Lams") then Paralytic (Succinylcholine)

- rescue equipment and antidotes (Flumazenil) need to be available for over-sedation

What medication is given to treat Malignant Hyperthermia?

Dantrolene

Dantrolene

Peripherally acting (ACTS DIRECTLY ON MUSCLES)

- muscle relaxant that treats Malignant Hyperthermia and provides relief of cerebral palsy, spinal cord injury, and multiple sclerosis

Baclofen

Centrally acting (CNS - works on the spinal cord, brain and nerves)

- muscle relaxant that produces sedative effects and provides relief of cerebral palsy, spinal cord injury, and multiple sclerosis

Dantrolene and Baclofen Adverse Effects and Teaching

CNS depression: sleepiness, lightheadedness, fatigue, HEPATOTOXICITY (AST, ALT)

Avoid driving, alcohol and DONT stop abruptly

Oxybutynin

treats urinary frequency (overactive bladder) by decreasing the urge to void

- Complications: Constipation, dry mouth, blurred vision, can't pee, tachycardia, anhidrosis (little to no sweat)

- contraindicated with clients who have myasthenia gravis

Bethanechol

Treats urinary retention by increasing the urge to void

- can cause cholinergic crisis (bradycardia, hypotension, urinary urgency, sweating, etc)

Benzodiazepines (Anxiety/Trauma)

Includes: Alprazolam (Xanax) and Diazepam (Valium)

"-lams and -pams"; used for generalized anxiety disorder and panic disorder; short term therapy bc potential for DEPENDENCE

Complications: PO: dizziness, drowsiness, incoordination IV: respiratory depression ---> leads to (hypertension, low respiratory rate, and may need supplemental oxygen), over-sedation

- administer with meals and do not stop abruptly

IV Antidote: Flumazenil

PO Antidote: Activated charcoal

Selective Serotonin Reuptake Inhibitors (SSRIs)

Includes: Fluoxetine, Paroxetine, and Sertraline

- #1 med choice for depression, 4 weeks to produce therapeutic levels

- Complications: sexual dysfunction, weight gain (long term), insomnia, SEROTONIN SYNDROME - (hallucinations/confusion w/in 2 to 72 hrs of starting and can be lethal), bruxism (teeth grinding)

Serotonin Syndrome

can begin 2 to 72 hrs after starting treatment of a SSRI

can be lethal

- Manifestations: hallucinations, confusion, agitation, diaphoresis, fever, incoordination, tremors, poor concentration, disorientation, delirium, seizures, tachycardia leading to cardiovascular shock, labile blood pressure, incoordination, nausea, vomiting, coma leading to apnea and death

- This resolves when the medication is discontinued

Lithium Carbonate

Treats bipolar disorder

Complications: fine hand tremors, polyuria and mild thirst, weight gain, renal toxicity, hypothyroidism (long-term), hypotension & bradycardia, electrolyte imbalances, and LITHIUM TOXICITY

- maintenance level of lithium: less than 1.5

- toxicity = 1.5 mEq/L

- stress the importance of fluids and sodium intake

- take with meals

Early Indications of Lithium Toxicity

Lithium level: 1.5 to 2.0 mEq/L

- Symptoms: nausea, vomiting, diarrhea, mental confusion, poor coordination, coarse tremors, and sedation

- withhold med

Advanced Indications of Lithium Toxicity

Lithium level: 2.0 to 2.5 mEq/L

- Symptoms: extreme polyuria, tinnitus, blurred vision, ataxia, seizures, severe hypotension leading to coma/death

- whole bowl irrigation may be prescribed (make them throw up)

Severe Indications of Lithium Toxicity

Lithium level: greater than 2.5 mEq/L

- Symptoms: oliguria, seizures, rapid progression of manifestations leading to coma and death

- put patient on hemodialysis

Methylphenidate

end in "-phenidate" or "-amphetamine"

treats ADHD (causes focus) and conduct disorder

- Complications: cardiovascular effects (dysrhythmias, hypertension and angina(chest pain)

- NO caffeine or OTC decongestants --> NO pseudoephedrine(increases stimulant effects)

- do not stop abruptly (will cause depression & severe fatigue)

Nicotine Replacement

Patches/gum used for nicotine replacement in cigarettes and tobacco

DO NOT CONTINUE TAKING NICOTINE WHILE USING NICOTINE REPLACEMENT!!!! (Use one or the other)

Medications affecting the Reproductive Tract....

Estrogens

Includes: Conjugated Equine Estrogen

reduces menopausal symptoms (hot flashes, mood changes, osteoporosis); & most commonly found in combined oral contraceptives

- Complications: increases risk for endometrial and ovarian cancers when used alone, promotes growth of estrogen dependent breast cancer, and increases risk for clots/emboli(PE,DVT)(decreases effects of anticoagulants)

- Contraindications: Atypical vaginal bleeding, heart disease, breast or other estrogen dependent cancer, myocardial infarction, thromboembolic events (PE,DVT, coagulation disorder), prepubertal children/breast feeding women

- Women over 60 are at risk for MI and CAD

- Take @ same time everyday and report menstrual/breast changes

- Discontinue before any surgery requiring extensive immobilization

Progestin

synthetic hormone that can be combined with estrogen (PO, Subq, IM, transdermal, intravaginal)

- Complications: breast cancer, thromboembolic events (MI, pulmonary embolism, stroke), breakthrough bleeding, edema(weight gain), jaundice (AST/ALT)

- perform regular self-breast exams and mammograms

- Pregnancy Cat X!!!!!! (notify provider if you plan to become pregnant)

- once discontinued anticipate withdrawal bleeding 3-7 days after

- Contraindicated: undiagnosed vaginal bleeding, history of thromboembolic disease, cardiovascular disease, breast/genital cancers, cerebrovascular disease

- Avoid cortiocosteroids and anticoagulants

- Mini-pills (progestin only) is safe for breastfeeding

Ethinyl estradiol and drospirenone

Hormonal Contraceptive

prevents ovulation which prevents pregnancy

- helps w iron deficiency anemia, menstrual cramping, acne, and protects against endometrial/ovarian cancer

- Complications: thromboembolic events, breast cancer, hypertension, breakthrough bleeding, hyperglycemia, hyperkalemia(indicates renal problems)

- Contraindications: smokers and women over 35yrs old, abnormal vaginal bleeding, and family history for breast cancer

- NO antibiotics(cephalexin) and phenytoin (reduce the effects of BC)

- Pregnancy Cat X!!!!!!

- take pills at the same time each day

- HCG (pregnancy test that is the most accurate) and BUN/creatinine

Finasteride

decrease testosterone and treats BPH --> benign prostatic hyperplasia(enlargement of prostate) & male hair loss (androgenetic alopecia)

- Complications: decreased libido(sexual desire) and ejaculate volume, gynecomastia (MAN BOOBS!)

- therapeutic effects may take up to 6 months

- do not donate blood unless prescription has been discontinued for at least 1 month

- pregnant women should NOT handle crushed or broken meds (like don't touch it) PREG X!

- AST/ALT(jaundice, vomiting, nausea)

Sildenafil

(Viagra) enhances blood flow into the penis; used for erectile dysfunction

- Complications: MI, sudden death, priapism (erections lasting more than 4hrs)

- DO NOT USE WITH ORGANIC NITRATES(Nitroglycerin)!!!! FATAL HYPOTENSION!!

- use cautiously in pt with cardiovascular disease such as QT prolongation

- do not exceed more than one dose in 24hrs

- take 1 hr before sexual activity

Medication affecting Labor and Delivery

Magnesium Sulfate

Complications of Labor and Delivery

Preterm Labor - labor after 20 weeks but before 37 weeks

Gestational Hypertension - (mildest HTN) pt BP is elevated at 140/90 or greater ---> needs to be recordered on 2 separate occasions @ least 4 hrs apart & no protein in the urine

Pre Eclampsia - gestational HTN + proteinuria (protein in urine)

- headaches are COMMON, edema, severe = BP 160/110 or greater --> blurred vision, hyper-reflexia

GIVE MAGNESIUM SULFATE

Magnesium Sulfate

a CNS depressant that relaxes smooth muscle; prevents seizures in clients who have pre-eclampsia

-helps relax uterine contractions during preterm labor & provides neurological protection for the fetus

Life Threatening Complications: loss of deep tendon reflexes, urine output less than 25 ml/hr, respiratory rate less than 12/min, pulmonary edema, severe hypotension, altered LOC, decreased fetal HR (STOP infusion if any of these occur and give antidote)

Magnesium level of 10 or greater = toxicity

IV needs to infuse @ a rate to not exceed 125 ml/hr

(Ex: if magnesium rate is at 10ml per hr, max is 115 bc 10+115=125)

- Antidote: Calcium gluconate

Medications for Gout

- Allopurinol (chronic)

- Colchicine (acute)

Reduces inflammation or decreases uric acid levels

Gout

Painful type of arthritis

- Primarily in the joints of the hands and feet

- result of elevated uric acid levels causing inflammation

Colchicine

Drug of choice for ACUTE gout attacks (anti-inflammatory drug)

- Complications: GI distress leading to toxicity(stop and notify doctor)(take with food), Thrombocytopenia (bone suppression, decreased platelets, bleeding, sore throat(WBC), anemia--> pale, fatigue(RBC) Rhabdomyolysis (sudden onset of muscle pain)

- no grapefruit juice

- Labs before giving med: CBC/BUN/Creat/AST/ALT

- Contraindicated: patients taking -STATINS

Allopurinol

for clients who have chronic gout or frequent gout attacks(will not stop, just prevents)

- for hyperuricemia (build up of uric acid)

- Complications: hypersensitivity syndrome(fever, rash--> STOP if IV infusion) and kidney injury (drink 2-3L of fluids/day) Hepatitis (jaundice, nausea, vomiting, anorexia, clay colored stools) increase in gout attacks (Colchicine or NSAID may need to be prescribed)

Bone Disorder Medications

Alendronate/Risedronate

Calcium CItrate/Calcium Gluconate

Raloxifene

Alendronate/Risedronate

decreases bone breakdown which leads to improved bone density

- Treatment For: postmenopausal osteoporosis, males with osteoporosis produced by long term glucocorticoid use, Paget's disease, hypercalcemia due to malignancy

Complications: Esophagitis/esophageal ulceration, blurred vision, atypical femoral fractures(when taking for 5 years), Muskuloskeletal pain, Osteonecrosis of the jaw (w IV infusion -- see dentist prior to treatment), renal toxicity with IV(BUN/Creatinine),

Teaching for Alendronate/Risedronate

- sit upright after taking because it can cause esophagitis

- take first thing in the morning on empty stomach

- if you miss a dose, wait til the next day

- take TABLETS with 8oz/240mL and liquid formulation with 2oz/60ml

- Discontinue and notify provider if swallowing issues or new heartburn

- do not take with other foods containing calcium or antacids (for 2 hr after)

- weight bearing exercises (walking 30-40 min a day)

- Increase Vitamin D bc it helps med absorb

Calcium Citrate/Calcium Gluconate

used for clients who have hypocalcemia or deficiencies of parathyroid hormone or vitamin D

IV: used for patients who have VERY LOW calcium levels: less than or equal to 6.5

Normal calcium levels: 9-10.5

Complications:

- Initially: tachycardia, hypertension then progresses to bradycardia

- GI Symptoms: nausea, vomiting, constipation

- Neuro: Lethargy, confusion

- Musculoskeletal: Muscle aches and weakness, hypotonia (decrease muscle tone and soft/floppy muscles)

Reverse hypercalcemia: IV furosemide

Prevent hypercalcemia: Bisphosphonates (Alendronate)

Raloxifene

- Prevent and treat postmenopausal osteoporosis to prevent spinal fractures in female clients

- Complications: PE/DVT(Red/swollen extremity) and hot flashes

- Pregnancy category X!!!

- prolonged immobility or travel = stop 72hrs before and resume once fully mobile

- weight bearing exercises (don't let them sit for long periods of time)

- adequate amount of calcium (from dairy products

and vitamin D such as egg yolks)

AST/ALT/Calcium Levels ---> 9-10.5

Raloxifene Therapeutic Effects?

Increase in bone density and no fractures

Adjuvants

medications for pain that are given with a primary pain medication (opioids) to increase pain relief while reducing the dosage and adverse effects of the opioid(NARCSU)

- adjuvants are not given alone and not used as a substitute for opioids (bc they are given w the opioid)

EX: NSAIDs (Ibuprofen) given to treat inflammation and decrease opioid dependence

- bleeding, GI effects, Kidney dysfunction

Local Anesthetics (Lidocaine)

used for pain management for minor surgical procedures(giving staples)

- Monitor for degree of numbness to area of pain relief before stapling (keep reassessing during procedure)

- lasts 1-3 hrs

- can cause CNS excitation (sedation, seizure, decreased LOC), hypotension/cardiosupression, burning/stinging/swelling /tenderness of site)

- do not give if client has supra-ventricular dysrhythmias or heart block

- teach client to be cautious against self inflicted injury (biting their tongue and they don't realize they are hurting themselves bc its numb) and with NSAIDS

- do not mix with Epinephrine in the fingers, nose, and other parts with end arteries bc = gangrene (loss of limbs)