Exam 2 Prototype Drugs

Heparin

DRUG CLASS: Anticoagulant, intrinsic pathway

Heparin

USE: Prevent thromboembolism assoc. w/ PE, MI, unstable angina, prosthetic heart valves; treat DVT, DIC, a-fib, acute coronary syndrome

Heparin

MOA: Binds w/ antithrombin III → inactivates thrombin → prevents conversion of fibrinogen to fibrin → inhibits clot formation

Heparin

CLINICAL JUDGMENT: 

• Administer SubQ or IV.

• Monitor aPTT labs and platelet count

• Keep protamine sulfate available (antidote). 

• Advise pt to use soft toothbrush, avoid large amounts of green, leafy vegetables and inform dentist about coagulant.

Warfarin

DRUG CLASS: Anticoagulant, extrinsic pathway

Warfarin

USE: Prevent thromboembolic conditions assoc. w/ thrombophlebitis, PE, MI, unstable angina, prosthetic heart valves, DVT, cerebral venous thrombosis. Treat a-fib. 

Warfarin

MOA: Inhibits hepatic synthesis of vitamin K clotting factors + anticoagulant proteins (C and S)

Warfarin

CLINICAL JUDGMENT: 

• Administered PO.

• Monitor PT (1.25-2.5) and INR (2-3).

• Monitor platelet count and vitamin K intake.

• Keep vitamin K available (antidote).

• DO NOT take w/ aspirin.

• Acute bleeding calls for fresh, frozen plasma.

• Highly protein-bound → risk for toxicity

• Advise pt to use soft toothbrush, avoid large amounts of green, leafy vegetables and inform dentist about coagulant.

Clopidogrel bisulfate

DRUG CLASS: 

Antiplatelet

USE:

Prevent arterial thromboembolism assoc. w/ unstable angina, AMI, CVA, TIA

Clopidogrel bisulfate

MOA: 

• Inhibits platelet aggregation in the arteries.

• Prevents ADP from binding w/ ADP platelet receptor. 

CLINICAL JUDGMENT: 

• INTERACTIONS: Potentiation w/ St. John’s wort 

Alteplase

DRUG CLASS: 

Thrombolytic agent (clot specific)

USE:

Promote fibrinolysis assoc. w/ thrombosis in pts w/ AMI, PE, DVT, ischemic stroke, and occluded IV catheter

Alteplase

MOA: 

• Binds to fibrin surface of clot → promotes conversion of plasminogen → plasmin → digests the fibrin matrix in clot (initiates fibrinolysis)

Alteplase

CLINICAL JUDGMENT: 

• Examine the patient for active bleeding x 24 hrs after thrombolytic therapy has been discontinued 

• HIGH RISK: hemorrhage 

Epoetin Alfa

DRUG CLASS: Biologic response modifier

Epoetin Alfa

USE: Treats anemia to increase Hgb concentration to the lowest level sufficient to avoid the need for RBC transfusions

Epoetin Alfa

MOA: 

Regulates the production of RBCs → stimulates erythroid progenitor cells → divide and differentiate in the bone marrow → optimal RBC mass → enhance O2-carrying capacity  

Epoetin Alfa

CLINICAL JUDGMENT: 

• Administered via injection 

• Avoid aspirin and NSAIDs.

• Avoid venipuncture / arterial sticks. 

• Decreased immunity → advise pt to avoid large crows and people w/ infection

Filgrastim

DRUG CLASS: 

Granulocyte colony-stimulating factor (G-CSF)

USE: 

• Tx for pts w/ severe chronic neutropenia. 

• Decrease incidence of infection in pts w/ myelodysplastic syndrome, pts receiving myelosuppressive chemotherapeutic drugs, and pts w/ aplastic anemia. 

• Mobilization of progenitor stems cells used in bone marrow transplant.

Filgrastim

MOA: Increases production, maturation, and activation of neutrophils and enhances their migration and cytotoxicity

Sargramostim

DRUG CLASS: 

Granulocyte-macrophage colony-stimulating factor (GM-CSF)

USE: 

• Accelerate growth and development of myeloid cell lines to shorten neutropenic state 

• Mobilize peripheral blood progenitor cells for collections 

• Bone marrow graft failure or engraftment delay 

• Myelosuppressive chemotherapy 

Sargramostim

MOA: 

• Stimulates the proliferation and differentiation of myeloid cell lines → enhance immune defense mechanisms

• Enhances the function of mature granulocytes and monocytes

• Enhances bactericidal activity of neutrophils

CLINICAL JUDGMENT: 

• INTERACTIONS: Synergistic effects w/ lithium and steroids.

Diphenhydramine

DRUG CLASS: 

First-generation antihistamine

USE: 

• Insomnia 

• Allergic reactions (allergic rhinitis) 

• Common cold, cough, sneezing, pruritus, urticaria 

• Prevent motion sickness 

Diphenhydramine

MOA: Competes w/ histamine for binding at H1-receptor sites → antagonize histamine effects

Diphenhydramine

CLINICAL JUDGMENT: 

• Avoid alcohol and CNS depressants 

• Educate older adults to avoid driving due to drowsiness 

• Common in OTC sleep aids 

Phenylephrine

DRUG CLASS: 

Alpha-1 agonist

USE:

• Allergic rhinits

• Inflammation 

• Infection 

Phenylephrine

MOA: Stimulate alpha-adrenergic receptors → nasal vascular constriction → shrinks nasal mucous membranes → reduces nasal secretions 

Phenylephrine

CLINICAL JUDGMENT: 

• ONLY use x 3 days (prolonged used may lead to rebound nasal congestion) 

• INTERACTIONS: caffeine, MAOIs, beta blockers

• Teach how to use properly (i.e. direct into nasal mucosa by pointing to eyes) 

• Assess for Hx of HTN 

Fluticasone

DRUG CLASS: Intranasal glucocorticoid

USE: Asthma and seasonal allergies 

MOA: Anti-inflammatory 

CLINICAL JUDGMENT: Administer MDI, tablet (e.g. prednisone, dexamethasone, methylprednisone), or IV. 

Dextromethorphan hydrobromide

DRUG CLASS: Antitussive (opioid)

USE: Temporary cough relief (nonproductive cough due to sore throat, irritation, common cold, inhaled irritants, chronic bronchitis)

Dextromethorphan hydrobromide

MOA: 

Decreases excitability of cough center in the medulla

CLINICAL JUDGMENT: 

Advise pts to read OTC labels and check w/ HCP before taking OTC cold remedies.

Albuterol

DRUG CLASS: 

Beta-2 adrenergic agonist

USE:

• Asthma exacerbation 

• Prophylaxis and Tx of bronchospasm 

MOA: 

Stimulates beta-2 adrenergic receptors in the lungs → relaxes bronchial smooth muscle → bronchodilation

Albuterol

CLINICAL JUDGMENT: 

• Use BEFORE administering other medications 

• Repeat PRN 

• Can be used w/ spacer to help w/ coordination 

Metaproterenol

DRUG CLASS: 

Beta-2 adrenergic agonist

USE:

• Inhalation administration preferred for long-term asthma Tx

• Acute bronchospasm

• COPD

MOA: 

Stimulates beta-2 adrenergic receptors in the lungs → relaxes bronchial smooth muscle → bronchodilation

Tiotropium

DRUG CLASS: Anticholinergic

USE: Maintenance Tx of bronchospasms assoc. w/ asthma and COPD

Tiotropium

MOA: Blocks muscarinic cholinergic receptors → inhibits M3 receptor response to ACh → antagonizes ACh action → relaxes bronchial smooth muscle → bronchodilation

Tiotropium

CLINICAL JUDGMENT: Administer by inhalation ONLY w/ a HandiHaler device

Guaifenesin

DRUG CLASS: Expectorant

USE: Common cold

MOA: Loosens bronchial secretions → coughing → elimination

CLINICAL JUDGMENT: Drink w/ water

Therophylline; Aminophylline

DRUG CLASS: Methylxanthine derivatives

USE: Asthma

Therophylline; Aminophylline

MOA: 

• Promotes bronchodilation

• Stimulates CNS + respiration

• Dilates coronary and pulmonary vessels

• Causes diuresis

Therophylline; Aminophylline

CLINICAL JUDGMENT: 

• Monitor levels

  • Therapeutic range: 5-15 mcg/mL

  • Toxicity: >20 mcg/mL

Cromolyn

DRUG CLASS: Mast cell stabilizer

USE: Bronchial asthma prophylaxis (NOT for acute asthma attacks)

Cromolyn

MOA: Inhibits histamine + inflammatory mediators from releasing mast cells to prevent asthmatic attacks

CLINICAL JUDGMENT: Administer MDI or nasal spray.

Montelukast

DRUG CLASS: 

Bronchodilator — leukotriene receptor antagonist

USE:

• Tx for allergic rhinitis 

• Asthma maintenance 

• Exercise-induced bronchospasm prophylaxis 

Montelukast

MOA: 

• Binds w/ leukotriene receptors → inhibit smooth muscle contraction and bronchoconstriction

• Reduce inflammatory response

Montelukast

CLINICAL JUDGMENT: 

• St. John’s wort may decrease concentration, so advise pt to check w/ HCP

• Encourage pts to inform a HCP if short-acting inhaled bronchodilators are needed more often than usual 

• Monitor for depression 

Insulin

DRUG CLASS: Antidiabetic

USE: To control T1DM and T2DM and lower blood glucose

MOA: Promotes use of glucose by body cells

CLINICAL JUDGMENT: Teach pts to recognize and report hypoglycemia and hyperglycemia Sx. Advise pts to wear MedicAlert tag, card or bracelet. 

Insulin

DRUG INTERACTIONS:

• Increased glucose w/ thiaizides, glucocorticoids, estrogen, thyroid drugs

• Decreased glucose w/ aspirin, oral anticoagulants

• GI secretions destroy structure → NO oral insulin

Insulin regular

INSULIN TYPE: 

Short-acting, clear

CLINICAL JUDGMENT: 

• Administer 30 mins before meals

• RISK for hypoglycemia 

• Only type that can be given through IV

• Check glucose before every meal 

Insulin regular

ONSET: SubQ 30 mins

PEAK: SubQ 1.5-3.5 hrs 

DURATION: SubQ 4-12 hrs 

Insulin lispro (Humalog)

DRUG CLASS: 

Rapid-acting, clear 

CLINICAL JUDGMENT: 

• Administer 10-15 mins before meals

  • Food should already be present when administering

Insulin lispro (Humalog)

ONSET: 15-30 mins

PEAK: 30-90 mins 

DURATION: 3-5 hrs 

Insulin NPH (isophane)

INSULIN TYPE: 

Intermediate-acting, cloudy

CLINICAL JUDGMENT: 

• Helps manage glucose b/t meals and overnight

Insulin NPH (isophane)

ONSET: 90 mins

PEAK: 4-12 hrs

DURATION: 14-24 hrs

Insulin glargine (Lantus)

INSULIN TYPE: 

Long-acting, cloudy 

CLINICAL JUDGMENT: 

• All day / night coverage 

• Administered at bedtime 

Insulin glargine (Lantus)

ONSET: 60-90 mins

PEAK: N/A

DURATION: 24 hrs (evenly distributed)

Glipizide

DRUG CLASS: Second-generation sulfonylurea

USE: Control hyperglycemia in T2DM

Glipizide

MOA: 

Directly stimulates beta cells in the pancreas → secrete insulin → indirectly alters sensitivity of peripheral insulin receptors → increased insulin binding

CLINICAL JUDGMENT: 

• Administer at mealtime

• Avoid use in the elderly 

• Usually not the first choice due to side effects 

Metformin

DRUG CLASS: Biguanide

USE: Control hyperglycemia in T2DM

Metformin

MOA: 

• Increases binding of insulin to receptors → improves tissues sensitivity to insulin → increases glucose transport to skeletal muscles and fatty tissues 

• Decreases glucose production in the liver by reducing gluconeogenesis

• Decreases absorption of glucose from the small intestine

Metformin

CLINICAL JUDGMENT: 

• STOP 48 hrs before and after administration of IV contrast

  • Can lead to lactic acidosis or acute renal failure

• Monitor renal function. STOP if GFR < 45.

• When combined w/ a sulfonylurea (e.g. glipizide), it is useful in cases that are resistant to oral antidiabetics (hypoglycemics) 

Hydrochlorothiaizide (HCTZ)

DRUG CLASS: 

Thiazide diuretic

USE: 

• Increase urine output

• Long-term management of HTN and peripheral edema due to HF, nephrotic syndrome and ascites

Hydrochlorothiaizide (HCTZ)

MOA: 

• Acts on distal renal tubules → promote Na+, K+ and H2O excretion → decreases preload and cardiac output → decreases edema

• Acts on arterioles → vasodilation → decreases BP

CLINICAL JUDGMENT: 

• Instruct pts to slowly rise from lying position due to risk for orthostatic hypotension

• Advise prediabetic pts to check glucose periodically due to risk for hyperglycemia

• Monitor fluid and electrolytes

Hydrochlorothiaizide (HCTZ)

DRUG INTERACTIONS:

• Antihypertensives

• Antidiabetics (risk for hyperglycemia)

• Herbal preparations → electrolyte imbalances

Furosemide

DRUG CLASS: 

Loop diuretic

USE:

• Treat edema due to HF, renal dysfunction, hepatic cirrhosis and nephrotic syndrome 

• Treat HTN 

Furosemide

MOA: 

Inhibits Na+ and H2O reabsorption from ascending loop of Henle and distal renal tubules → increases excretion of K+, Cl-, Mg+, NH4+, PO4, and Ca2+

Furosemide

CLINICAL JUDGMENT: 

• Observe for hypokalemia (muscle weakness, abdominal distention, leg cramps, cardiac dysrhythmias) 

• Administer IV slowly (over at least 3 mins) 

  • May cause hearing loss if given too fast 

• Highly protein-bound → displace other drugs (e.g. warfarin)

• Administer in the morning to avoid nocturia / sleep disturbance

Spironolactone

DRUG CLASS: Potassium-sparing diuretic

USE: Edema, HTN, HF, hyperaldosteronism

Spironolactone

MOA: Inhibits aldosterone effects on distal renal tubules to promote Na+ and H2O excretion and K+ retention

Spironolactone

CLINICAL JUDGMENT: 

• Observe for hyperkalemia 

• Avoid direct exposure to sunlight (photosensitivity) 

• Monitor urinary output (at least 600 mL/day) 

• Administer in the morning to avoid nocturia / sleep disturbance