Hospital Lab 2 Final - Pearls

Quizzes 1-6

amikacin sulfate

BBW: neprotoxicity, ototoxicity, neuromuscular blockade, and respiratory paralysis

avoid with other neurotoxic/ nephrotoxic drugs

tobramycin sulfate

BBW: neprotoxicity, ototoxicity, neuromuscular blockade, and respiratory paralysis

avoid with other neurotoxic/ nephrotoxic drugs

extended interval IV dosing- dosing intervals are determined by nomogram

gentamicin

BBW: neprotoxicity, ototoxicity, neuromuscular blockade, and respiratory paralysis

avoid with other neurotoxic/ nephrotoxic drugs

extended interval IV dosing- dosing intervals are determined by nomogram

erythrocin

CI: do not use with lovastatin or simvastatin (increased risk of muscle toxicity)

zithromax

Warnings: Qt prolongation, hepatotoxicity

ancef

commonly used for surgical prophylaxis

fortaz, tazicef

lacks gram positive activity, covers pseudomonas

Rocephin

CI: hyperbilirubineic neonates (causes biliary sludge and kernicterus), insoluble precipitates may form when administered with calcium products IV-do not use in neonates 0-28 days old, in adults flush IV line between

no renal dose adjustment

cefepime

active against pseudomonas

fetroja

approved for complicated UTI/ pyelonephritis

avycaz

active against some carbapenem resistant enterobacteriae

cipro

BBW: tendon inflammation and or rupture, peripheral neuropathy, CNS side effects, use caution in patients with CNS disorders or with drugs that cause seizures

levaquin

BBW: tendon inflammation and or rupture, peripheral neuropathy, CNS side effects, use caution in patients with CNS disorders or with drugs that cause seizures

dosed every 24 hours- dose interval

avelox

BBW: tendon inflammation and or rupture, peripheral neuropathy, CNS side effects, use caution in patients with CNS disorders or with drugs that cause seizures

no renal dose adjustment

nafcillin sodium

preferred for MSSA, no renal dose adjustments

vessicant- if extravasation occurs use cold packs and hyaluronidase injections

ampicillin

PO rarely used due to poor bioavailability, IV must be diluted in NS only

zosyn

extended infusions can be used (over four hours to maximize T>MIC)

only penicillin active against pseudomonas

unasyn

IV must be diluted in NS

SE: seizures (with accumulation in renal dysfunction)

vibramycin

Warnings: pregnancy and breastfeeding (suppresses bone growth and skeletal

development, and permanently discolors teeth)

No renal dose adjustments required.

Note(s): IV:PO ratio is 1:1;

Xerava

Warnings: pregnancy and breastfeeding (suppresses bone growth and skeletal

development, and permanently discolors teeth)

Only approved for complicated intra-abdominal infections.

Azactam

Can be used when beta-lactam or penicillin allergy is present

Cleocin

BBW: Risk of enterocolitis and C. diff are increased with administration. AVOID use if a history of C. diff exists

No renal dose adjustments required.

Positive induction D-test indicates clindamycin resistance and clindamycin should NOT be used.

Invanz

Warnings: Do not use in patients with PCN allergy (small risk of cross-reactivity);

CNS effects (seizures and

confusion)

No coverage against atypical pathogens, MRSA, VRE, C.diff , Stenotrophomonas, Pseudomonas , Acinetobacter , or Enterococcus.

Primaxin

Warnings: Do not use in patients with PCN allergy (small risk of cross-reactivity);

CNS effects (seizures and

confusion)

Merrem

Warnings: Do not use in patients with PCN allergy (small risk of cross-reactivity);

CNS effects (seizures and

confusion)

Recarbrio

Warnings: Do not use in patients with PCN allergy (small risk of cross-reactivity);

CNS effects (seizures and

confusion)

Vancocin

Only covers Gram-positive bacteria (Staphylococci (MRSA), Streptococci, Enterococci (not VRE), and C. difficile

(using PO route only)

First-line treatment for moderate-severe systemic MRSA infections

Vancomycin

infusion reaction from rapid infusion rate (formerl

Dalvance

Warnings: Can falsely raise PT/INR for up to 12 hours, and aPTT for up to 120 hours; ALT elevation >3 times the

upper limit of normal (ULN) during therapy

Side effects: Rapid infusion-related reactions (similar to vancomycin)

Cubicin

Warnings: Myopathy and rhabdomyolysis; can falsely elevate PT/INR

Monitor: CPK level weekly

Do NOT use to treat pneumonia; inactivated by surfactant in lungs

Zyvox

Indication: Can be used for MRSA, VRE, and other infections when vancomycin is not an option

No renal dose adjustments required

Flagyl

Contraindications: Pregnancy (1st trimester), use of alcohol or propylene glycol-containing products during

treatment or within 3 days of treatment discontinuation (disulfiram reaction)

IV:PO ratio is 1:1

Vfend

Voriconazole is the treatment of choice for Aspergillus

Warnings: Hepatotoxicity, visual disturbances (optic neuritis), phototoxicity, QT prolongation

IV:PO ratio for all azoles is 1:1

Amphotericin

BBW: Medication errors confusing the lipid-based forms of amphotericin (AmBisome and Abelcet) and

conventional amphotericin B have resulted in cardiopulmonary arrest and death; conventional amphotericin doses

should not exceed 1.5 mg/kg/day

nephrotoxicity (Hydration is important to reduce the risk of nephrotoxicity!)

Conventional formulation:

Amphotericin B deoxycholate (conventional formulation) requires premedication to reduce infusion-related

reactions

Liposomal formulation:

Lipid formulations must be filtered during preparation

Diflucan

Used for treatment of candidiasis (systemic candida

infections

All azoles are cleared hepatically except fluconazole which requires renal dose adjustment

Fluconazole and voriconazole penetrate the CNS adequately to treat fungal meningitis

Cancidas

Warning(s): histamine-mediated symptoms

All are given once daily and do not require dose adjustment for renal impairment

Mycamine

Effective against most Candida species

Warning(s): histamine-mediated symptoms (rash, pruritus, facial swelling) have occurred; anaphylaxis

All are given once daily and do not require dose adjustment for renal impairment.

Rifadin

Orange-red discoloration of body secretions (sputum, urine, sweat, tears, teeth); can stain contact lenses, clothing.

Many drug-drug interactions.

Zovirax

Dosing is based on IBW, including in obese patients

Foscavir

Used for Cytomegalovirus (CMV) retinitis and resistant Herpes Simplex Virus (HSV)

BBW: Renal impairment (prehydration recommended)

Veklury

Initiate as soon as possible after COVID-19 diagnosis and within 7 days of symptom onset

Ferrlecit

Side effect(s): Risk for anaphylactic-type reactions

INFeD

BBW: Anaphylactic-type reactions, administer a test dose of iron dextran prior to the first therapeutic dose.

Venofer

Side effect(s): Risk for anaphylactic-type reactions

Desferal

Indication(s): Acute iron toxicity, chronic iron overload

Epogen, Procrit, Retacrit

Used for anemia due to chronic kidney disease; chemotherapy-induced anemia

Store in refrigerator protect from light, do not shake

Neupogen

Used for neutropenia

Side effect(s): Bone pain

Store in refrigerator, protect from light, do not shake

Neulasta

once per chemo cycle (pegfilgrastim is pegylated, extending the half-life)

Side effects: Bone pain

Nplate

romiplostim is not indicated for thrombocytopenia due to any cause other than Immune

Thrombocytopenia (ITP)

Decadron

Higher doses increase blood pressure and blood glucose (especially in patients with diabetes)

Warnings for adrenal suppression, if taking longer than 14 days, must taper slowly

Short-term side effects: increased appetite/weight gain, fluid retention, emotional instability (euphoria, mood

swings, irritability), insomnia

Solu-cortef

Warning(s): Adrenal suppression; must taper slowly

Side effect(s): Increased appetite/ weight gain, emotional instability, insomnia

Solu-medrol

Warning(s): Adrenal suppression; must taper slowly

Side effect(s): Increased appetite/ weight gain, emotional instability, insomnia

Pepcid

Only H2RA available for IV administration

Adjust dose for renal insufficiency: CrCl < 60 mL/min

Protonix

Warning(s): C. difficile-associated diarrhea, hypomagnesemia, vitamin B12 deficiency with prolonged use

osteoporosis-related bone fractures with high dose or long-term use

Pantoprazole and esomeprazole only PPIs available IV

Nexium

Warning(s): C. difficile-associated diarrhea, hypomagnesemia, vitamin B12 deficiency with prolonged use

osteoporosis-related bone fractures with high dose or long-term use

Pantoprazole and esomeprazole only PPIs available IV

PPIs may diminish the therapeutic effects of clopidogrel, do not use omeprazole and esomeprazole while taking

clopidogrel

Reglan

BBW: Tardive dyskinesia that can be irreversible

Adjust dose for renal insufficiency

Aloxi

Warning(s): Dose-dependent increase in QT interval (Torsades de Pointes) - common with IV formulation,

serotonin syndrome when used in combination with other serotonergic agents

Zofran

Warning(s): Dose-dependent increase in QT interval (Torsades de Pointes) - common with IV formulation,

serotonin syndrome when used in combination with other serotonergic agents

Granisetron

Warning(s): Dose-dependent increase in QT interval (Torsades de Pointes) - common with IV formulation,

serotonin syndrome when used in combination with other serotonergic agents

Compazine

BBW: Increased risk of mortality in elderly patients with dementia-related psychosis

Phenergan

BBW: Avoid use in children <2 years old due to risk of respiratory depression

Can cause severe tissue injury - Avoid intravenous or subcutaneous route, when possible. IM preferred.

Cinvanti

Substance P/NK1-RA antagonists inhibit substance P/neurokinin 1 receptor, therefore augmenting the antiemetic

activity of 5HT-3 receptor antagonists and corticosteroids to inhibit acute and delayed phases of chemotherapy-

induced emesis.

Emend

Substance P/NK1-RA antagonists inhibit substance P/neurokinin 1 receptor, therefore augmenting the antiemetic

activity of 5HT-3 receptor antagonists and corticosteroids to inhibit acute and delayed phases of chemotherapy-

induced emesis.

Vidaza

Confirm route of administration; SUBQ and IV require different instructions for reconstitution

Notes: Solutions for IV administration have very limited stability and must be prepared immediately prior to each

dose.

Administration must be completed within 1 hour of (vial) reconstitution.

Paraplatin

BBW: Anaphylactic-like reactions, myelosuppression, vomiting

Calvert Formula used to dose carboplatin

Platinol

Notes: Amifostine (Ethyol) can be given prophylactically to help reduce the risk of nephrotoxicity.

IV hydration required before and after administration.

Both nephrotoxicity and ototoxicity are cumulative, do not exceed 100 mg/m2/cycle.

Oxaliplatin

Acute sensory neuropathy: occurs 1-7 days after administration and can be exacerbated by exposure to cold,

including drinking cold beverages

Cyclophosphamide

Warning(s): Hemorrhagic cystitis- ensure adequate hydration, give Mesna prophylactically with high doses

Ifex

BBW: Hemorrhagic cystitis

Notes: Mesna must be given prophylactically

Xeloda

Oral prodrug of fluorouracil

PGx: Dihydropyrimidine dehydrogenase (DPD) deficiency can increase risk of toxicity

Side effects: Hand-foot syndrome, diarrhea, mucositis

fluorouracil

Leucovorin given in combination increases the efficacy by helping 5-FU bind more tightly to its target enzyme

(thymidylate synthetase)

Side effects: Hand-foot syndrome, diarrhea, mucositis

Camptosar

BBW: Diarrhea (acute or delayed)

*Acute diarrhea is best treated or prevented with atropine; delayed diarrhea is managed with antimotility agents

(loperamide)

Daunorubicin

BBW: Myocardial (CV) toxicity, vesicant, myelosuppression,

Drug is red, and causes red discoloration of urine, tears, sweat, and saliva

Adriamycin

BW: Myocardial (CV) toxicity, vesicant, myelosuppression, secondary malignancy

Do not exceed 450-550 mg/m2 (total lifetime cumulative dose)

Drug is red, and causes red discoloration of urine, tears, sweat, and saliva

Doxil

BBW: Myocardial (CV) toxicity, myelosuppression, infusion-related reactions

Notes: Liposomal formulations of doxorubicin should NOT be substituted for conventional doxorubicin

hydrochloride on a mg-per-mg basis.

Drug is red, and causes red discoloration of urine, tears, sweat, and saliva

Toposar

Infusion rate-related hypotension: Infuse over at least 30-60 mins

Docetaxel

BBW: Severe hypersensitivity reactions (HSR), fluid retention,

Hypersensitivity reactions (HSR): Premedicate with steroids for 3 days, starting 1 day prior to docetaxel

Causes severe fluid retention (pleural effusions, cardiac tamponade, edema)

Paclitaxel

BBW: Severe hypersensitivity reactions, myelosuppression

Use non-PVC bag and tubing and 0.22-micron filter

Fludara

BBW: Myelosuppression, neurotoxicity (blindness, coma, death) for high dose treatment, autoimmune effects (e.g.

hemolytic anemia), not recommended for combo treatment with pentostatin for chronic lymphocytic leukemia due

to fatal pulmonary toxicity

Otrexup, trexall

BBW: Hepatotoxicity, nephrotoxicity, myelosuppression, mucositis/stomatitis, pregnancy (teratogenic)

High-doses (>500 mg/m2) require leucovorin (folic acid) rescue

MOA: Irreversibly binds and inhibits dihydrofolate reductase, inhibiting folate formation

Alimta

Side effects: nephrotoxicity, hepatotoxicity, dermatologic toxicity (premedicate with dexamethasone)

*Administer folic acid, B12 and dexamethasone to decrease side effects

Vincasar

BBW:FATAL if given intrathecally- give IV

only

*To avoid accidental intrathecal administration: prepare in small IV bag (a piggyback)

Oncaspar

Notes: The pegylated form (pegasparaginase) allows for less frequent dosing (every 2 weeks) and less allergic

reactions than asparaginase

Lupron Depot

Side effects: Hot flashes, impotence, gynecomastia, bone pain, QT prolongation

Zoladex

Side effects: Hot flashes, impotence, gynecomastia, bone pain, QT prolongation

Cytotec

Indications: Nonsteroidal anti-inflammatory drug–induced gastric ulcers, prevention, termination of intrauterine pregnancy

BBW: Abortifacient, do not use to decrease NSAID-induced ulcers in females of childbearing potential unless capable of complying with effective contraceptive measures; warn patients not to give this drug to others

Imuran

Drug interactions: Azathioprine is metabolized by xanthine oxidase - avoid concurrent use with xanthine oxidase inhibitors (allopurinol or febuxostat).

Cellcept

Used for prophylaxis of organ rejection

CellCept (oral, injection) and Myfortic (oral) are not interchangeable

Sandimmune/ neoral, gengraf

BBW: cyclosporine (non-modified - Sandimmune) cannot be used interchangeably with cyclosporine

(modified - Gengraf/Neoral),

Notes: Numerous drug interactions - CYP3A4 inhibitor, CYP3A4 and P-gp substrate

Prograf

Indication: Organ rejection prophylaxis

Monitor: Specific trough level goal

Notes: IV is administered as a continuous infusion, must use non-PVC bag and tubing; numerous drug

interactions: CYP450 3A4 and P-gp substrate; avoid alcohol

Tracleer

Used for treatment of pulmonary artery hypertension (PAH)

Hydrea, Droxia, Siklos

Indications: Sickle cell anemia (Droxia, Siklos) ,

Chronic myeloid leukemia, resistant (Hydrea) ,

Head and neck cancer (Hydrea)

Sickle Cell MOA: Stimulates production of HgbF (fetal hemoglobin)

BBW: Myelosuppression, secondary malignancies (leukemia, skin cancer)

Warnings: Fetal toxicity, avoid live vaccines

Thalomid

BBW: Teratogenic, increased risk of thromboembolic events (DVT/PE)

Notes: severe birth defects- patient, prescriber, and pharmacist must be enrolled in Thalomid REMS program;

consider prophylactic anticoagulation due to increased VTE risk

Retrovir

Indication: HIV (human immunodeficiency virus)

BBW: Myopathy, hematologic toxicity- neutropenia and anemia (elevated MCV is a sign of adherence), lactic

acidosis/severe hepatomegaly

Administered IV during labor and deliver in patients with HIV RNA > 1,000 copies/mL to protect the baby

Vectibix

BBW: Dermatologic toxicity, EGFR → epidermis → skin toxicity (acneiform rash), development of rash is correlated with response to therapy

Rituxan, Truxima

BBW: Hepatitis B reactivation, progressive multifocal leukoencephalopathy (PML), mucocutaneous reactions

(SJS/TEN), severe/fatal infusion-related reactions

Premedicate with diphenhydramine, acetaminophen, and steroid

Avastin

Impairs wound healing, do not administer for 28 days before or after surgery

Remicade

BBW: Serious infections, malignancies

stable in NS only

Humira

BBW: Increased risk of developing serious infections and malignancies

Darzalex

Must be CD38 antigen positive to use

Keytruda

Immune-mediated toxicities