PHARM: ER / CC / SURG / GERIACTRICS INDICATIONS

MS

What organization ultimately determines the efficacy and addictive qualities of Rx?

(1973) Drug Enforcement Agency (DEA) was created to regulate the manufacturing and dispensing of controlled substances

Which schedule for Rx has no acceptable medical use?

Schedule I (heroin, LSD, weed, MDMA, PCP)

What Schedule are the following Rx: hydromorphone, hydrocodone, oxycodone, fentanyl, cocaine, (meth)amphetamines, methylphenidate

Schedule II

PA / NP = only in-facility use; 90 days max + no re-fils

MD = 90 days max; no re-fills

What Schedule are the following Rx: codeine, ketamine, anabolic steroids

How many days supply can mid-levels / MD Rx?

Schedule III

PA / NP = 90 days max (includes refill amts)

MD = 5 refills worth

What Schedule are the following Rx: benzos, Z-drugs, tramadol, carisoprodol

Rx will be valid for 6 mos, how many days of supply can mid-levels / MD Rx?

Schedule IV

PA / NP = 90 days max (includes refill amts)

MD = 5 refills worth

What Schedule are the following Rx: diphenoxylate / atropine, pregablin (lyrica)

How many days supply can mid-levels / MD Rx?

schedule V

PA / NP = 90 days max (includes refill amts)

MD = 5 refills worth

How many days will the Rx be valid for if Rx by mid-levels / MD Rx for NON-controlled Rx?

PA / NP = 6 mos

MD = 12 mos

What are the essential pharmacologic points about Why Does Scheduling Matter??

• DEA sets limits on production of higher abuse potential drugs

• Strict regulations on how they are Rx

• Lesser prescription quantities for higher abuse drugs 

What is the acute MOA of EtOH like what NT incr. and inhibits?

• Enhances GABA receptors (dose dependent)

• Inhibits glutamate receptors (excitatory)

  • V, coma hypoTN, resp depression

  
  

• Activation of the reward circuit (dopamine)

Chronic EtOH users can be functional d/t the upregulation of what receptors?

NMDA (glutamate) + slight depression of GABA receptors

What is the physiology of EtOH withdrawals?

upregulated NMDA receptors = unopposed (excitatory → tremors, seizures, etc.) when EtOH no longer agonizes GABA receptors

What are some chronic complications of EtOH use?

• Wernicke’s encephalopathy → Korsakoff psychosis

What are 3 Rx that can help tx EtOH withdrawals acutely + Rx that can be used for long-term mgmt of alcoholism?

• Benzodiazepines: stabilize vitals, reduce risk for seizures

  • Scheduled vs PRN (based on CIWA assessment) regimen

  
  

• Clonidine ± BB: Reduce autonomic component of withdrawals

• Thiamine: prevent Wernicke’s encephalopathy

• Prevention: naltrexone, acamprosate, disulfiram

What is the best option for EtOH dependence PREVENTION ?

hint: interacts w/ opioids → MUST question pt for any recent consumption of any recreational drugs 

What is its MOA, PK, ADE?

Naltrexone

MOA: pure opioid antagonist → Decr craving and blocks reinforcing effects

PK: qd PO or 1 monthly IM

ADE: N

caution: will induce opioid withdrawals! AVOID if opioids!

What is the Rx for EtOH dependence PREVENTION in a mgmt program setting (after detox)?

What is its MOA, PK, ADE?

Acamprosate (Campral)

• MOA: possible restoration of GABA and glutamate balance

• rec for mgmt programs w/ psychosocial support

• PK: PO TID

• ADE: D

What option for EtOH dependence PREVENTION causes unpleasant effects if interacts w/ EtOH?

• Caution: MAY have to avoid all forms of alcohol (cough syrups, aftershave, cologne, etc.)

hint: similar to metronidazole

What is its MOA, PK, ADE?

Disulfiram (Anatabuse)

• MOA: inhibits aldehyde dehydrogenase (acetaldehyde s.) → disrupts EtOH metabolism → Causes unpleasant effects if taken w/ EtOH

• PK: PO qd → Effects last 2 weeks after the last dose

• ADE: minimal as long as NO EtOH

T/F: its ok to Rx disulfiram for a pt tapering off EtOH

F. ≠ Rx if alcoholics lack the determination to stop drinking

Serotonin Syndrome: ± Mild / life-threatening condition d/t serotonin toxicity; Dx via exclusion

• How fast does this develop?

• How does it present?

• How to tx?

• Develops w/n mins to hrs

• S/s:

  • AMS

  • autonomic instability: tachy, hyperthermia, diaphoresis, V, +

  • neuromuscular hyperactivity: clonus, hyperreflexia, tremors, + 

• Treatment: D/C agent(s), supportive care (IV hydration + O2 + cardiac monitoring ± sedation w/ benzos)

Which antimicrobials are serotonergic?

linezolid // ritonavir

what mood stabilizers are serotonergic?

lithium // valproate

List some Serotonergic Medications:

• Antidepressants

  • SSRi / SNRi / MAOi / TCA

• addictive drugs

  • cocaine, MDMA, LSD, Opioids (fentanyl / meperidine / tramadol / methadone), amphetamines, +

• Antiemetics

  • ondansetron / metoclopramide

• Migraine (triptans)

• mood stabilizers (lithium / valproate)

• Antimicrobials (linezolid / ritonavir)

Which opioid reversal agent has a short ½ life?

naloxone — may need multiple doses

What is the reversal agent for acetaminophen / paracetamol ?

NAC to prev hepatic failure

What is the reversal agent for BB / CCB via metabolic shift?

insulin → incr contractibility

What is the reversal agent for digoxin (GI, neuro (visual halos), cardiac (dangerous arrhythmias) s/e)?

digibind

What is the reversal agent for sulfonylureas?

octreotide → suppresses insulin → prev hypoglycemia

What is the reversal agent for benzos?

flumazenil

T/F: flumazenil is used if a chronic benzo user ODs on benzos

F. chronic users ≈ seizure prevention → reversal → ± seizures

What reversal agent converts cyanide into vit. B12?

hydroxocobalamin (renal excretion)

What is the reversal agent for methanol / ethylene glycol?

fomepizole or ethanol → inhibits alcohol dehydrogenase

What recreational schedule II Rx causes

• euphoria 

• C

• resp depression

• endocarditis

What is the acute tx?

heroin (opioid) → release S / NE / D

acute tx = naloxone

What recreational schedule II Rx causes

• HTN + tachycardia + vasoconstriction

• hyperthermia

• alertness

• nasal dmg

What is the acute tx?

cocaine (anesthetic) → dopamine reuptake inhibitor

acute tx = supportive care ± benzos (seizures) ± anti-HTN

What recreational schedule II Rx causes

• incr wakefullness

• HTN + tachycardia

• decr appetite

• violent behavior

meth-amphetamine (Stimulant) → crosses BBB → incr NE / D

acute tx = supportive care ± benzos ± anti-psychotics (agitation)

What recreational schedule I Rx causes

• loss of coordination

• altered sense

• relaxation

• hyperemesis

What is the acute tx?

marijuana (delta-9-THC) → cannaboids receptor activation → incr D

acute tx = supportive care (IV fluids (hypoTN) ± hot showers (hyperemesis))

What recreational schedule I Rx causes

• decr inibition

• enhanced sensations

• psychedelic effects

• a common party drug

• ± used for PTSD

MDMA / esctasy → blocks reuptake of S → incr S / NE / D

acute tx = supportive care (IV fluids ± rapid cooling (hyperthermia))

What Rx is 50-100x more potent than morphine and can easily become fatal?

fentanyl (≈ contaminant in illicit Rx: cocaine, heroin, weed, benzos, meth, etc.)

What is the PK of fentanyl that makes it so dangerous (harder to reverse → ± multiple does of Naloxone?

very lipophilic → rapid brain penetration → tight bind to mu-opioid → rapid onset → quick resp depression

Indications for medical maurijuana and what are the legalities?

• Must have a debilitating medical condition + documentation

• Uses: seizures, N (dronabinol), pain, PTSD, insomnia

• 24 states have legalized recreational use / the 47 states allow for medical use

What program in Texas allows for Rx of marijuana? What are some indications?

Texas’s Compassionate Use Program (CUP) allows certain physicians to Rx low THC (tetrahydrocannabinols) cannabis for medical purposes (PO form)

Limited to:

• epilepsy, seizures, MS, spasticity, ALS, autism, terminal cancer, incurable neurodegenerative dx

Activated Charcoal acts like a sponge to absorb toxins before they hit the bloodstream, what is the MOA, PK, and monitoring markers?

finely ground molecules traps chemicals d/t its highly porous surface

• aqueous slurry to protect airway

• Monitor:

  • sx improvement

  • C

  • electrolytes lvls

  • black discoloration of stools

When is activated charcoal most effective?

w/n 1hr of consumption of toxin

the usage of vasopressors / inotropes is guided by what measurement?

mean arterial pressure (MAP) = CO x SVR

vasopressor vs inotropes:

which impacts cardiac contractility → incr CO?

inotropes

T/F: vasopressors incr vasc tone / SVR

T

What is the common classification for the following Rx: Norepi, Epi, Dopamine, Phenylephrine, Vasopressin?

vasopressors (constricts blood vessels → incr. BP)

which vasopressor is mainly used for anaphylaxis + cardiac arrest?

epinephrine (acts on a1, b1, & b2 receptors)

which vasopressor is 1st-line for septic shock for resuscitation

norepinephrine (more a1 receptor act)

which vasopressor is dose-dependent?

• low dose = dopamine receptors

• med dose = beta receptors

• high dose = alpha receptors

dopamine

which vasopressor causes reflex bradycardia

phenylephrine (pure a1 receptors) → good for tachycardic hypoTN

which vasopressor is an adjuct to reduce the norepinephrine dose (short ½ life)

vasopressin (V1 receptor)

Which inotrope acts on beta receptors?

dobutamine (cardiogenic shock)

which inotrope inhibits PDE-3 receptors

milrinone (cardiogenic shock, HF, on BB)

What are the typical ADE of vasopressors / inotropes that require monitoring EKG and MAP?

• Dysrhythmias (d/t beta-agonist effects)

• Myocardial ischemia (d/t increased myocardial O2 consumption)

• Hypoperfusion (d/t excessive/prolonged vasoconstriction)     

What is common about the following RFs:

• infxn

• 75+ y/o

• cancer

• hx of VTE

• Virchow’s triad

  • stasis (immobility, bed rest, obesity)

  • vasc inj. (trauma, surg, catheters, smoking)

  • hypercoagulability (trauma, cancer, pregnancy, factor V leiden, oral contraceptives)

risk of VTE!

What scoring chart helps determine the usage of thromboprophylaxis?

Padua Score!

What does a Padua score of <4 suggest?

low risk of VTE

What does a Padua score of 4+ suggest?

high risk of VTE → pharmacological thromboprophylaxis

What scoring chart provides suggestions on NON-pharm + thromboprophylactic MEDs?

Caprini Score

What does a Caprini Score of 0 rec for the pt to do?

early ambulation

What does a Caprini Score of 1-2 rec for the pt to do?

low — Sequential Compression Device

What does a Caprini Score of 3 rec for the pt to do?

mod - SCD / heparin / enoxaparin

What does a Caprini Score of 5+ rec for the pt to do?

high - SCD + heparin / enoxaparin

What dose of Enoxaparin (LMWH) = prophylaxis ?

40 mg qd

Why is LMWH preferred vs heparin for acute prophylactic tx?

convenience (1-2/day vs q8-12hrs)

UFH  (IV / SQ) inhibits factor 2a and used for VTE prev. & tx // ACS // A-fib.

What labs need to be monitored, what aversion do you need to be aware of, and what capabilities do nurses have w/ this Rx?

What organ-dysfct makes this rx preferred?

monitor: aPTT, Hg / Hct / plt

pork-derivative → avoid pork allergy / religious rzns

nurse-driven dosing to help avoid HIT

used if pt has kidney dx

EnoXaparin (SQ) inhibits factor X and used for VTE prev. & tx // ACS // A-fib.

What labs need to be monitored?

This Rx is ≈ used to bridge pt until what Rx is effective?

monitor: SCr (caution in kidney dx), Hg / Hct / plt, ± anti-Xa if renal dx, extreme habitus, pregnant, prior bleeds / failures

used to bridge for warfarin

FondaparinuX (SQ) inhibits factor X and used for VTE prev. & tx // ACS // HIT

What labs need to be monitored?

monitor: SCr (caution in kidney dx), Hg / Hct / plt

Bivalirudin (IV) is used for ACS (w/ PCI) // HIT

What labs need to be monitored?

monitor: SCr , Hg / Hct / plt

directly inhibits thrombin

What are the time goals for STEMI tx? If PCI-incapable, what rx is given?

• cath lab w/n 90 mins since 1st medical contact (EMTs, etc.)

  • if PCI unable to w/n 120 minutes → fibrinolytic (HIGH risk of bleeding) IF sx w/n last 12 hrs

What does MONA stand for in ACS management? When are each used and what is PK?

• Morphine (2nd-line if SL NTG x 3 ≠ effective)

• oxygen (if <90%)

• nitroglycerin

  • 0.4 mg SL q5mins PRN x 3 max (1st line)

  • IV (3rd-line)

• aspirin (1 tab 325mg chewed)

  • alt: P2Y12i if allergic

Prior to the PCI, what 2 anti-thrombotic Rx are ≈ given and what can be added on? What are their purposes?

• P2Y12i: inhibits plt aggregation → reduce risk of stent thrombosis

• anti-coag: inhibits coag cascade → prev procedural thrombosis

• ± GP2b3ai: more anti-plt coverage for high thrombus burden

For PCI pharmacology, what anti-thrombotic needs a loading dose prior to Sx?

P2Y12i

What class of Rx are these: clopidogrel // prasugrel // ticagrelor

P2Y12i

What class of Rx are these: heparin // LMWH // Bivalirudin

anti-coags

What class of Rx are these: abciximab // eptifibatide // tirofiban

GP2b3ai

How is ischemic stroke treated if sx are w/n 4.5 hours?

Fibrinolytic (C/I in any bleeding risk)

What are absolute C/I to fibrinolytics?

• Previous hemorrhagic stroke  //  stroke w/n the last yr

• intracranial neoplasm

• recent head trauma  //  active internal bleeding  //  aortic dissection

Aspirin prevents secondary ischemic stroke, when can you give it?

after clear CT scan + 24-48 hrs since a fibrinolytic

If it was a minor stroke / TIA, how it aspirin given?

in the form of DAPT x 21 days (wait for clearance 1st)

what Rx is given in addition to aspirin if a fibrin-rich clot was of cardioembolic source (A-Fib, valvular dx, recent MI)?

anticoags (ck CHAD-VASC score 1st)

why are anti-PLTs given for NON-cardioembolic strokes?

clot = PLT-rich d/t PLT aggregation @ plaque rupture / vasc inj

What anti-thrombotics can be reversed w/ andeXanet alfa // 4F-PCC // FFP?

DOACs (apiXaban, RivaroXaban, EdoXaban)

What anti-thrombotics can be reversed w/ idarucizumab  //  4-PCC  //  FFP?

dabigatran

What anti-thrombotics can be reversed w/ vit K  //  4F-PCC (preferred for severe bleeding)  // FFP?

• What coag assay can be monitored?

warfarin → INR / PT decr

What anti-thrombotics can be reversed w/ protamine sulfate?

• What coag assay can be monitored?

• UFH: aPTT

• Enoxaparin IF w/n 12hrs of last dose

  • aPTT  //  anti-FXa

What distinguishes hypertensive EMR from urgency?

target organ damage → ADMIT

• neuro: stroke, ICH, AMS

• cardio: MI, unstable angina, aortic dissection

• renal: hematuria, AKI

What is the BP goal in hypertensive emergency management? PO or IV?

Reduce BP by 25% in first hour via IV anti-HTN

• then 160/100-110 in next 2-6 hours

• normal w/n 24 to 48 hours

What is the ≈ 1st-line anti-HTN for HTN EMR?

CCBs - nicardipine // clevidipine

which anti-HTN can be used in a HTN EMR but is unpredictable and SA?

hydraliazine (direct vasodialator)

Which anti-HTN is good during preg, but C/I in pulm dx (COPD, asthma) and HF?

BB - labetalol // esmolol

Which anti-HTN has a cyanide toxicity risk (renal / hepatic impairment?

nitroprusside

Which anti-HTN should not be used if pregnant, acute MI, or b/l renal a. stenosis?

ACEi enalaprilat

Which antibiotics cover MRSA (list 7)

• BCD²-C²L

• Very Large Cats Do Take Big Craps?

• Vancomycin

• daptomycin

• linezolid

• clindamycin

• bactrim

• doxycycline

• ceftaroline

Which antibiotics cover Pseudomonas?

• Pip-tazo

• carbapenems (err ertapenem)

• cefepime // cetazidime

• ciprofloxacin // levofloxacin

• aminoglycosides

What is the mainstay of COPD exacerbation treatment?

hint: PDA

• Systemic corticosteroids (any)

  • prednisone 40mg x 5 day

• Duoneb (SABA / SAMA)

• ± Abx if purulent sputum +

  • dyspnea / more sputum

What empiric antibiotics treat COPD exacerbation?

• Amoxi-clav

• azithromycin

• doxycycline

• FQ for severe or freq exacerbations

What is the mainstay of asthma exacerbation management?

• Systemic corticosteroids x 5-10 days

• Duoneb (SABA / SAMA)

• discharge with maintenance therapy

Where do stress ulcers develop and what are the RFs?

• ICU

• Mechanical ventilation 48+ hours

• coagulopathy (low PLT, high INR)

• steroid

• NSAID

• H pylori

What are options to prev stress ulcers?

• Proton pump inhibitor (pantoprazole)

• H2 receptor antagonist

discontinue when risk factors resolve

when are pre-op abx given, what form, and when to d/c?

give IV abx 30-60min prior → d/c 24hrs after sx