patho & pharm exam 3 - PHARM CONTENT

Pantoprazole (Protonix) action

Blocks proton pump proteins (decreases gastric acid production)

Pantoprazole (Protonix) use

Prevents AND treats gastric/duodenal ulcers, and GERD

• Usually only used as treatment for 2-8 weeks; long-term use is not advised

Pantoprazole (Protonix) side effects

• Headache, N/V most common

• Diarrhea, stomach pains and gas

• C. Diff infection is a risk! (decreased acidity in stomach means spores can survive)

Long-term (>3 mo) use of this drug can lead to low Magnesium levels and Vit B12 deficiency

• Take supplements to offset the loss of absorption

Infliximab (Remicade): what is it used for?

• Crohn's disease

• ulcerative colitis

• rheumatoid arthritis

• psoriasis

• ankylosing spondylitis

• A monoclonal antibody that blocks TNF-alpha (an inflammatory cytokine).

Infliximab (Remicade): safety and monitoring

IV infusion: monitor for infusion reactions (fever, chills, hypotension, dyspnea, rash).

Immunosuppression: serious infections (TB reactivation, fungal), lymphoma/malignancy.

Can worsen heart failure.

Infliximab (Remicade): patient teaching

Report signs of infection (fever, cough, wounds); avoid sick contacts; no LIVE vaccines.

Infliximab (Remicade): labs

TB test and hepatitis B screening before starting; CBC and liver function.

Infliximab (Remicade): major side effects

• Infusion reaction

• infections (respiratory)

• headache

• abdominal pain

• rash.

Infliximab (Remicade): drug interactions

Live vaccines; other immunosuppressants/biologics increase infection risk.

Morphine: what is it used for?

Severe pain (acute, post-op, MI, cancer, end of life). Binds mu opioid receptors.

Morphine: safety and monitoring

• Respiratory depression (check respiratory rate BEFORE giving; hold and notify if low, often below 12)

• sedation

• hypotension

• urinary retention

• Assess pain and sedation level

• Keep naloxone available.

• Dependence/tolerance.

Morphine: patient teaching

Avoid alcohol and CNS depressants; rise slowly; don't drive; don't crush extended-release; take a bowel regimen.

Morphine: diet

Increase fluids and fiber for constipation (also stool softener/stimulant laxative).

Morphine: major side effects

• Constipation

• nausea/vomiting, sedation

• respiratory depression

• miosis (pinpoint pupils)

• itching

• urinary retention

• orthostatic hypotension.

Morphine: drug interactions

Benzodiazepines, alcohol, other CNS depressants (additive respiratory depression).

morphine is a type of

opioid agonist

Infliximab (Remicade) is a type of

TNF-alpha inhibitor

Pantoprazole (Protonix) is a type of

proton pump inhibitor (PPI)

Naloxone (Narcan) is a type of

opioid antagonist

Naloxone (Narcan): what is it used for?

Reverses opioid overdose/respiratory depression (competes for the opioid receptors).

Naloxone (Narcan): how to administer

• Call for help/911 and support airway and breathing first

• Routes: IV (fastest, hospital), IM, subcut, or intranasal (spray 1 dose in one nostril). Repeat in 2-3 minutes if no response (use the other nostril for intranasal)

• In the hospital, give small doses and titrate to respiratory rate and LOC, especially in opioid-dependent patients.

Naloxone (narcan): safety and monitoring

Short half-life, often shorter than the opioid, so the overdose can RETURN (renarcotization).

• Monitor respiratory rate, LOC, and pain for hours; more doses may be needed.

Naloxone (narcan): major adverse effects

• Acute opioid withdrawal (agitation, tachycardia, hypertension, nausea/vomiting, sweating)

• return of severe pain.

Naloxone (narcan): patient/family teaching

Keep it available if opioids are at home; teach family how to give it and always call 911 afterward.

phenytoin (Dilantin): Use

prevention; epilepsy

• Tonic-clonic and focal seizures; status epilepticus

phenytoin (Dilantin): action

Lengthening time stimulus can cause an effect

phenytoin (Dilantin): side effects

• Drowsiness, dizziness, weakness

• GI distress

• Gingival Hyperplasia

• Rash

phenytoin (Dilantin): safety and monitoring

Therapeutic range: 10-20mcg/ml

• Toxicity signs: nystagmus, ataxia, slurred speech, confusion, drowsiness

• IV: give slowly (max 50 mg/min), only in normal saline, with cardiac monitoring (hypotension, dysrhythmias); irritating to veins

phenytoin (Dilantin): safety and monitoring

Serum phenytoin level; CBC; liver function

Phenytoin: drug interactions

Many (induces liver enzymes): lowers effect of warfarin and oral contraceptives. Hold tube feeds around dosing (feeds reduce absorption).

levodopa (Dopar)/levodopa/carbidopa (Sinemet): use

Parkinson's disease

levodopa (Dopar)/levodopa/carbidopa (Sinemet): action

Increase dopamine levels

• Levodopa is converted to dopamine in the brain; carbidopa blocks its breakdown OUTSIDE the brain, so more reaches the brain and there is less nausea.

levodopa (Dopar)/levodopa/carbidopa (Sinemet): side effects

• N/V

• Movement disorders (dyskinesia)

• Dysrhythmias

• Postural Hypotension

• Psychologic disorders (night terrors/hallucinations)

levodopa (Dopar)/levodopa/carbidopa (Sinemet): safety and monitoring

• Orthostatic hypotension (rise slowly)

• Dyskinesias (involuntary movements)

• hallucinations/confusion

• "On-off" effect and wearing-off

• Don't stop abruptly.

levodopa (Dopar)/levodopa/carbidopa (Sinemet): patient teaching

Urine and sweat may turn dark (harmless). Take with food if nauseated. Report involuntary movements or hallucinations.

levodopa (Dopar)/levodopa/carbidopa (Sinemet): diet

High-protein meals compete with absorption of levodopa, so don't take with a high-protein meal.

levodopa (Dopar)/levodopa/carbidopa (Sinemet): drug interactions

MAOIs (hypertensive crisis). Antipsychotics such as haloperidol block dopamine and work against it.

Methylphenidate (Ritalin): action

blocks reuptake of dopamine and norepinephrine (more of it remains in brain)

Methylphenidate (Ritalin): use

ADHD and narcolepsy

Methylphenidate (Ritalin): side effects

• tachycardia, palpitations, HTN, dysrhythmias

• Restlessness

• irritability

• Euphoria

• confusion

• insomnia

• Anorexia a/o weight loss

Methylphenidate (Ritalin): patient teaching

• Take after eating

• Last dose of day should be taken no later than 4-5 pm

• Avoid caffeine (can increase its effects)

• Potential for abuse and dependence (drug holidays)

Methylphenidate (Ritalin): safety and monitoring

• Schedule II (high abuse/dependence potential)

• Monitor BP, heart rate

• weight,

• (in children) growth; sleep

• Give early in the day (insomnia)

• Don't crush extended-release forms.

Methylphenidate (ritalin): drug interactions

MAOIs (hypertensive crisis).

Haloperidol (Haldol): use

Schizophrenia, acute psychosis, Tourette’s Syndrome

• Blocks dopamine (D2) receptors

Haloperidol (Haldol): safety and monitoring

• EPS: acute dystonia (muscle spasms)

• akathisia (restlessness)

• pseudo-parkinsonism

• tardive dyskinesia (late, may be irreversible)

• NMS: high fever, rigid muscles, altered mental status, high CK (emergency)

• QT prolongation

• orthostatic hypotension

• sedation

• Increased death risk in elderly patients with dementia

Haloperidol (Haldol): patient teaching

• Rise slowly

• avoid alcohol

• sun protection

• don't stop abruptly

• report muscle stiffness

• abnormal movements

Haloperidol (Haldol): labs

ECG for QT; CBC.

Haloperidol (Haldol): side effects

• Extrapyramidal reactions

• Tardive dyskinesia

• Prolonged QT

Haloperidol (Haldol): drug interactions

• Other QT-prolonging drugs

• CNS depressants and alcohol

• levodopa (opposing effects)

Fluoxetine (Prozac): use

Depression, OCD, bulimia, panic disorder

Fluoxetine (Prozac): safety and monitoring

• increased suicidal thoughts in children, adolescents, and young adults (watch closely at start and dose changes)

• takes 4-6 weeks for full effect

• Serotonin syndrome (agitation, tremor, sweating, hyperthermia, diarrhea, tachycardia)

• Hyponatremia/SIADH (especially elderly)

• Bleeding risk.

Fluoxetine (Prozac): action

blocks reuptake of serotonin

Fluoxetine (Prozac): patient teaching

• Don't stop abruptly

• take in the morning

• don't expect immediate relief

• report worsening mood or suicidal thoughts.

Fluoxetine (Prozac): side effects

• Suicidal thoughts/behaviors

• sexual dysfunction

• Nausea

• Headache

• CNS stimulation

• Weight gain

• Serotonin syndrome

Fluoxetine (prozac): drug interactions

• MAOIs (serotonin syndrome; needs a washout period)

• other serotonergic drugs (tramadol, triptans, St. John's wort)

• NSAIDs/anticoagulants (bleeding).

lorazepam (Ativan): action

Potentiates action of GABA (limited sedation

• Enhances GABA (the brain's main inhibitory neurotransmitter).

lorazepam (Ativan): use

Anxiety (short-term), insomnia, prolonged seizure

• Anxiety, status epilepticus, alcohol withdrawal, preoperative sedation, insomnia

Lorazepam (Ativan): safety and monitoring

• CNS and respiratory depression (check respiratory rate and sedation level)

• falls

• dependence/tolerance (Schedule IV)

• Don't stop abruptly after long-term use (withdrawal, seizures)

• IV: give slowly and have resuscitation equipment ready

• Reversal agent: flumazenil.

Lorazepam (Ativan): patient teaching

Avoid alcohol and other sedatives; don't drive until you know how it affects you; rise slowly; don't stop suddenly.

Lorazepam (Ativan): side effects

• Drowsiness

• dizziness

• confusion

• ataxia

• amnesia

• Paradoxical agitation can occur, especially in elderly patients.

Lorazepam (Ativan): drug interactions

Opioids, alcohol, and other CNS depressants (profound sedation, respiratory depression, death).

lithium (Lithobid): use

acute manic episodes/recurrence of mania and depression

• Decreases excitability without sedation

• Bipolar disorder (mania and prevention of mood swings)

• Takes 1-2 weeks or more to work.

lithium (Lithobid): action

unknown- some regulation with dopamine, glutamate, and GABA?

lithium (Lithobid): safety and monitoring

• NARROW therapeutic range, about 0.6-1.2 mEq/L

• Toxicity (above about 1.5): coarse tremor, vomiting, diarrhea, confusion, ataxia, seizures

• Dehydration and sweating raise levels.

lithium (Lithobid): patient teaching

• Keep fluid intake adequate (about 2-3 L/day) and salt intake consistent don't restrict sodium

• Hold and call if vomiting/diarrhea/fever

• Take with food

• Avoid dehydration (heat, exercise).

lithium (Lithobid): diet

Consistent sodium and fluid intake

• Low sodium makes the kidneys retain lithium, raising levels toward toxicity.

lithium (Lithobid): labs

• Serum lithium level (draw at trough, about 12 hours after the last dose)

• kidney function (BUN/creatinine)

• hyroid function; electrolytes.

lithium (Lithobid): side effects

• Therapeutic levels: N/V, diarrhea, polyuria, listlessness

• Toxic levels: Vomiting and weakness- early signs. Drowsiness- “intoxicated,” seizures and cardiac arrest

• Fine hand tremor, thirst and polyuria, nausea, weight gain, hypothyroidism.

lithium (Lithobid): drug interactions

NSAIDs (including ketorolac), ACE inhibitors, and thiazide diuretics raise lithium levels.

lithium (Lithobid) is a

mood stabilizer

Lorazepam (Ativan) is a

benzodiazepine

Fluoxetine (Prozac) is a

SSRI antidepressant

Haloperidol (Haldol) is a

typical antipsychotic

Methylphenidate (Ritalin) is a

CNS stimulant

Levodopa-Carbidopa (Sinemet) is a

anti-Parkinsons

Phenytoin (Dilantin) is a

anticonvulsant

Bethanechol (Urecholine) is a

cholinergic (muscarinic) agonist

Bethanechol (Urecholine): use

Urinary retention (not related to an obstruction

• Urinary retention (postoperative or neurogenic bladder, no obstruction). It stimulates bladder contraction (detrusor) and relaxes the sphincter.

Bethanechol (Urecholine): safety and monitoring

• Contraindicated with mechanical obstruction of the urinary or GI tract

• use caution in asthma, bradycardia, hypotension, peptic ulcer, hyperthyroidism, seizures, Parkinson's

• Monitor HR, BP, breath sounds, urine output.

Bethanechol (Urecholine): patient teaching

Take on an EMPTY stomach (nausea/vomiting); rise slowly

Bethanechol (Urecholine): side effects

• Mostly well-tolerated

• No longer give IV push- serious S/E

• Cholinergic effects (SLUDGE/DUMBELS)

• salivation

• lacrimation

• urination

• diarrhea/cramping, GI upset, emesis

• miosis

• bradycardia, hypotension, bronchospasm

• sweating.

Bethanechol (Urecholine): reversal agent for overdose

ATROPINE (a muscarinic antagonist).

Bethanechol (Urecholine): drug interactions

Anticholinergics (e.g., atropine) oppose its effect.

Ketorolac (Toradol) is a

NSAID

Ketorolac (Toradol): what is it used for

Short-term treatment of moderate-to-severe pain (limit to 5 days total, all routes)

Ketorolac (Toradol): safety and monitoring

• Bleeding (inhibits platelets)

• GI ulcers/bleeding

• kidney injury

• cardiovascular events (MI/stroke), hypertension

• fluid retention

• Contraindicated with active bleeding

• renal impairment

• aspirin/NSAID allergy

Ketorolac (Toradol): patient teaching

take oral doses with food; stay hydrated; report black/bloody stools, vomiting blood, decreased urination

Ketorolac (Toradol): labs

Kidney function (BUN/creatinine); CBC/bleeding signs.

Ketorolac (Toradol): side effects

• GI upset/dyspepsia

• nausea

• edema

• headache.

Ketorolac (Toradol): drug interactions

• Other NSAIDs/aspirin

• anticoagulants (bleeding)

• lithium (raises level)

• ACE inhibitors/diuretics (kidney risk).

Parasympathetic (cholinergic) rest and digest: effect on heart

Slows heart rate (bradycardia)

Parasympathetic (cholinergic) rest and digest: effect on lungs

Bronchoconstriction, more secretions

Parasympathetic (cholinergic) rest and digest: effect on eyes

Miosis (small pupils)

Parasympathetic (cholinergic) rest and digest: effect on gi tract

Increases motility and secretions (salivation, diarrhea)

Parasympathetic (cholinergic) rest and digest: effect on bladder

Contracts bladder, relaxes sphincter (urination)

Parasympathetic (cholinergic) rest and digest: effect on blood vessels

Mild vasodilation, lowers BP

Parasympathetic (cholinergic) rest and digest: effect on glands

Increased salivation, tears

Parasympathetic (cholinergic) rest and digest: effect on liver/energy

Rest and store

Sympathetic (adrenergic): fight or flight: effect on heart

Increases heart rate and contractility

Sympathetic (adrenergic): fight or flight: effect on lungs

Bronchodilation