Pharm 212 final

Nonsteroidal antiinflammatory drugs (NSAIDs) pain management

Indications

• primarily used for analgesic, anti-inflammatory, & antipyretic effects, platelet inhibition

• widely used for the treatment of rheumatoid arthritis

• ceiling effect that limits their effectiveness

Risks

• black box warning for CV(MI, stroke) and GI risk (bleeding, ulcers, perforation) except for aspirin

Nonsteroidal antiinflammatory drugs (NSAIDs) patient teaching pain management

CAUTION DRUMS

• Cardiovacular effects

  • monitor for chest pain, sob, sudden weakness

• Avoid alcohol

  • increases risk of gI bleed & liver damage

• Understand “ceiling effect”

  • more pills doesn’t = more relief, effect is capped

  • it just increases more side effects

• Tarry stools

  • report black tarry stools or emesis (bloody vomit)

• Interactions

  • Always check before mixing with blood thiners or BP meds

• On an empty stomach?

  • NO always take with food, milk, or antacids to protect lining

• Not for everyone

  • considerations for pregancny, kidney, or liver disease

• Don’t share

• Report side effects

  • watch fro tinnitus, swelling, or blurred vision

• Use for indication

  • treats pain, fever, inflammation

• Maximize safety (follow dosing)

  • don’t exceed prescribed dose

• Stomach irritation

  • can cause ulcers

Tylenol vs NSAIDS pain management

Acetaminophen (tylenol)

• analgesic choice for many

• consider hepatic risks before admin

• safer GI profile

• no anti-inflmmatory effect

NSAIDs

• examples; ibupuprofen, naproxen, keterolac

• risk factors for adversre effect in >60 years, hx of pepetic ulcer, or CV disease

• black box warning for risk of MI or stroke

• want to use lowest dose for shortest time

Can be given together

• Recommended for surgical patients

NSAID complications pain management

GI

• gi bleed

• melena or emesis

CV

• BLACK WARNING BOX

• MI or stoke

• HF

Renal

• acute renal failure

• overdose toxicity

  • CNS effects

  • treated with activated charcoal

Bleeding risk

• inhibit platelet aggregation (especially aspirin)

• pt should stop taking 1 week before surgery

High risk patients

• Age >60 years

• History of peptic ulcer disease

• History of cardiovascular disease

• Dehydrated patients

• Patients with vitamin K deficiency

Dehydration diagnoses and cues Fluid and electrolytes

“I Think High Water Often Helps During Dry Episodes, So Some People Take Water Low, Providing Help Correcting Cells” for S/S

Priority nursing actions

Monitor:

• Intake and output (I&O)

• Daily weights

• Vital signs with orthostatic measurements

• Urine characteristics

Safety:

• Fall precautions due to orthostatic hypotension and altered mental status

Fluid Replacement:

• Oral rehydration solutions (ORS) for mild-moderate dehydration

• IV crystalloids for severe dehydration or intolerance to oral fluids

Penicillin drug interactions FINISH Antibiotics

• classified as pregnancy category B drugs (very safe)

Nursing responsibilities when starting antibiotic therapy Antibiotics

• Antibiotics have 3 uses

  • empiric (can best kill the microorganisms known to be the most common causes of the infection)

  • definitive (tailored to treat the identified organism by using the most narrow-spectrum, least toxic drug based on sensitivity results.)

  • prophylactic therapy

    • used to prevent an infection

"A Professional Learns Many Core Safety Actions."

• A — Allergy History: Assess for hypersensitivity, ranging from mild rashes to severe anaphylaxis.

• P — Physical Assessment before and after: Document age, weight, vitals, and neurological, GI, and immune status.

• L — Laboratory/Diagnostic Studies: Review C&S, liver (AST/ALT), renal (BUN/Cr), cardiac, and blood counts.

• M — Medication Review: Document all OTCs, herbals, and supplements; check for drug interactions.

• C — Cultural Assessment: Consider ethnic responses to drugs and alternative healing practices.

• S — Superinfection: Monitor for secondary infections (like fungal) due to flora destruction.

• A — Antibiotic Resistance: Stay alert for resistance (like CRO), especially in pediatrics and facilities.

Tetracycline patient teaching Antibiotics

• end in “cycline.”

• choice of drugs to treat infections caused by Rickettsia, Chlamydia, and Mycoplasma

• used to treat acne in teens/adults

Contraindiccations

• known drug allergy, pregnancy, children younger than 8

“To Teach All Clients: Take Caution, Complete Daily Pills, Protect Personal Integument, Seek Speedy Vision Reports”)

Timing & Food

• T — Take on an empty stomach (1h before/2h after).

• T — Take with a full glass of water.

• A — Avoid dairy, antacids, and iron (within 2 hours).

Consistency

• C — Consistency: Take at evenly spaced intervals.

• T — Total: Complete the full course of therapy.

• C — Continuity: Do not skip doses.

Safety Information

• D — Discoloration: Permanent yellow-brown tooth staining risk.

• P — Pregnancy: Contraindicated (harms fetal bone/teeth).

• P — Photosensitivity: Increased sensitivity to sunlight.

What to Report

• I — Intracranial Pressure: Report severe headache or blurred vision.

• S — Stomach: Report severe diarrhea or cramping (C.diff).

• S — Superinfection: Report vaginal itching or discharge.

• V — Visual: Report vision changes immediately.

• R — Reaction: Report rash, hives, or difficulty breathing

Cephalosporin contraindications finish later Antibiotics

• penicillin allergies may have cross-sensitivity to cephalosporins

• 1-5 gens (cephalexin, cefoxitin, ceftriaxone, cefepime, ceftaroline)

Contraindications

• hypersensitivity to cephalosporin or PCN,

• jaundice

• premature neonates

Antiseptic vs Disinfectant Antibiotics

Antiseptic

• inhibits the growth and reproduction of microorganisms without killing them.

• called static agents.

Disinfectant

• applied to nonliving objects to kill microorganisms

• called cidal agents.

Healthcare associated infection facts Antibiotics

infections acquired in the hospital hat were not present at time of admission.

Sources

• Hands of healthcare workers

• Medical tubes

• Implants

• Medical devices

Prevalence & Impact

• Occur in 1 in 25 hospitalized patients

• Cause increased healthcare costs and many deaths

• preventable!!

Most Common Types

1. Urinary tract infections (UTIs)

2. Surgical site infections (SSIs)

3. Bloodstream infections - especially central-line-associated (CLABSIs)

4. Pneumonia - including hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP)

High-Risk Areas (immunocompromised)

• Critical care units

• Dialysis units

• Oncology units

• Transplant units

• Burn units

Common causes

• not following basic infection control

• organisms are now multidrug-resistant

Best prevention = Hand washing

Aminoglycoside adverse effects Antibiotics

Nephrotoxicity (Kidney Damage)

• Manifested by:

  • Urinary casts, Proteinuria, Increased BUN and CR

• Risk increased with concurrent nephrotoxic drugs (cyclosporine, IV contrast for CT scans)

Ototoxicity (Ear Damage)

• Often NOT reversible

• Results from injury to CN VIII

  • Cochlear damage → hearing loss

  • Vestibular damage → disrupted balance

• Symptoms include:

  • Dizziness

  • Tinnitus (ringing in ears)

  • Sense of fullness in the ears

  • Hearing loss

Other

• Headache

• Paresthesia

• Vertigo

• Skin rash

• Fever

• superinfection

• Neuromuscular paralysis

-Neomycin patient teaching Antibiotics

• ONLY oral aminoglycoside

• used for preoperative bowel cleansing

• other uses for for skin infections, bladder irrigation, and treatment of E. coli diarrhea, hepatic encephalopathy, and eye infections.

“Daily Hydration Can Tame Frequent Complications; Doctors Often Note Probiotics Yield Powerful Maintenance, Keeping Hearing Dependable”

Dosing

• D — Duration: Do not skip doses or stop early

Hydration

• H — Hydration: Drink plenty of fluids (up to 3000 mL/day).

What to Report Immediately

• C — Change in hearing

• T — Tinnitus: Ringing in the ears.

• F — Full feeling: Pressure in the ears.

• C — Changes in balance: Dizziness or vertigo.

• D — Decreased urination: Changes in urine output.

Serious Risks

• O — Ototoxicity: Permanent ear damage.

• N — Nephrotoxicity: Kidney damage.

Preventing Superinfections

• P — Preventing superinfections: Protect natural flora.

• Y — Yogurt: Or buttermilk to maintain gut health.

• P — Probiotics: Essential to avoid secondary infections.

Monitoring

• M — Monitoring: Oversight of drug levels and health.

• K — Kidney function tests: BUN and Creatinine.

• H — Hearing tests: Needed for prolonged therapy.

• D — Drug level monitoring: Checking peak and trough levels.

Treatment of MRSA Antibiotics

Antibiotic options

• IV vancomycin

• IV or oral linezolid

• IV daptomycin

• IV ceftaroline (only cephalopsorin approved)

Prolonged therapy often needed - more than 3 months

Community-Associated MRSA (CA-MRSA) Antibiotic options:

• Minocycline (usually effective)

• Doxycycline (usually effective)

Infection Prevention Measures

• Nasal swabs and cultures for MRSA screening

• Contact Precautions required

• Bathing patients with chlorhexidine wipes

• Administering nasal mupirocin ointment

Vancomycin infusion precautions Antibiotics

contraindicated in patients with a known hypersensitivity to it. It should be used with caution in those with preexisting renal dysfunction or hearing loss, as well as in older adult patients and neonates.

VANCO-SLOW

V - Vital signs (monitor BP - rapid infusion causes hypotension)

A - At least 1 hour infusion time (NEVER IV push)

N - Nephrotoxicity risk (ensure hydration og 2L fluids/day, monitor BUN/creatinine)

C - Compatibility check (multiple drug/diluent incompatibilities)

O - Ototoxicity monitoring (assess hearing, report ringing/roaring in ears)

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S - Skin assessment (watch for red man syndrome - flushing of face, neck, upper trunk)

L - Levels - trough only (before 4th dose, within 30 min of next dose; goal 10-20 mcg/mL)

O - Over 1 hour minimum (slow infusion prevents red man syndrome)

W - Watch for reactions (if flushing occurs, SLOW the rate further)

Acyclovir indications/patient teaching Antiviral

• applied every 3 hours, or six times daily, for 1 week

• classified as a pregnancy category C drug

Indications

• HSV-1 and HSV-2 infection, including genital herpes, mucocutaneous herpes, herpes encephalitis; herpes zoster (shingles); higher-dose therapy for acute episodes; lower-dose therapy for viral suppression

Adverse effects

• Nausea, diarrhea, headache, burning when topically applied

Teaching

• don’t use in eyes or when there is no evidence of infection

• apply with glove to prevent further infection

• avoid use of OTC creams, ointments, lotions

• Advise hand washing before, after each application

• adhere strictly to regimen to maximize successful treatment

• Advise patient to begin taking product when symptoms arise

Oseltamivir indications/patient teaching Antiviral

Uses

• Prevention and treatment of influenza type A or B

Contraindications

• Hypersensitivity

• Precautions: Pregnancy, neonates, infants, children, geriatric patients, renal/hepatic/pulmonary/cardiac disease, psychosis, viral infection

Teaching

• About all aspects of product therapy

• To avoid hazardous activities if dizziness occurs

• take as soon as symptoms appear; ake full course even if feeling better

• To take missed dose as soon as remembered if within 2 hr of next dose

• To stop immediately; to report to prescriber skin rash, delirium, psychosis, hallucinations (child)

• should not be substituted for flu shot

• will not treat the common cold

• To avoid other products

Oral thrush treatment Antifungal

Oral Thrush aka (Candidiasis)

Primary Treatment: Systemic Fluconazole

Oral fluconazole:

• May be taken without regard to meals

• Clear solutions only

IV fluconazole:

• Use only if solution is clear

• Protect from light

• Diluted solutions stable for 24 hours only

• Stop infusion immediately if itching or rash occurs; take vital signs and contact prescriber

Alternative Treatment: Nystatin

Nystatin is another antifungal option, available as:

Lozenges/Troches

• Must be slowly and completely dissolved in mouth

• Do NOT chew or swallow whole

• Allows medication to coat affected areas

Oral Suspension

• Swish thoroughly in mouth for as long as possible before swallowing

• Maximizes contact with oral lesions

Miconazole schedule Antifungal

• topical antifungal drug

• inhibits the growth of several fungi, including dermatophytes and yeast, as well as gram-positive bacteria

For athlete’s foot, jock itch, ringworm, fungal infections are treated by

• applying to cleansed, dry, infected area twice daily, in the morning and evening.

For treatment of yeast infections

• one 200mg suppository is inserted into vagina once daily, at bedtime for 3 consecutive days

• 100mg administered intravaginally once daily at bedtime for 7 days

adverse effects

• vulvovaginal burning and itching, pelvic cramps and rash, urticaria, stinging, and contact dermatitis.

• pregnancy category C drug.

Fat and water soluble vitamins Vitamins

Fat soluable vitamins

Benzoyl peroxide Skin, hair, and nails

• most common anti-acne drugs

• effective in combating such infections because it slowly and continuously liberates active oxygen in the skin, resulting in antibacterial, antiseptic, drying, and keratolytic actions.

• soften scales and loosen the outer horny layer of the skin are referred to as keratolytics.

• pregnancy category C drug

-Diverticulitis -S/S to report SAT ??? Inflammatory bowel disease

• represents inflammation of the diverticula and occurs in about 10% to 15% of cases of diverticulosis

• cramping pain of the lower abdomen can accompany constriction of the thickened colonic muscles.

• Diarrhea, constipation, distention, or flatulence may occur.

• diverticula become inflamed or abscesses form, the individual develops fever, leukocytosis, and tenderness in the lower left quadrant.

-Pathophysiology of paralytic ileus  redo Inflammatory bowel disease

cause of postoperative paralytic ileus remains unknown

-interaction between the autonomic and central nervous systems that disorganizes electrical activity and causes paralysis.

Antiemetics  GI Disorder and therapy 

• meds used to treat N/V

  • chemotherapy, postop, or radiation induced N/V

  • hyperremsis gravidrum (pregnancy-related)

• block receptors in the central nervous system (CNS), while some work directly in the gastrointestinal (GI) tract.

Different drug classes of antiemetics (7) GI Disorder and therapy 

"All Anxious Actors Need Proper Stage Time"

• All = Anticholinergics (scopolamine)

  • block receptors located in the reticular formation so that nausea-inducing signals can’t be trasnmitted

• Anxious = Antihistamines (dimenhydrinate, diphenhydramine, meclizine)

  • prevent cholinergic stimulation

• Actors = Antidopaminergics (prochlorperazine, promethazine, droperidol)

  • used for antipsychotic effects

• Need = Neurokinin antagonists (aprepitant, fosaprepitant, rolapitant)

  • inhibit acute and delayed phases of chemotherapy-induced emesis.

• Proper = Prokinetics (metoclopramide)

  • stimulate peristalsis in the GI tract. This enhances the emptying of stomach contents

• Stage = Serotonin blockers (ondansetron, granisetron, dolasetron, palonosetron)

• Time = Tetrahydrocannabinoids (dronabinol) THC

  • cause an alteration in mood and in the body’s perception of its surroundings,

Antiemetics and chemotherapy GI Disorder and therapy 

Antiemetics are used to treat chemotherapy-induced nausea

• give before chemo and neusea

• continue even if n/v appears controlled

“SAN"

1. Serotonin Blockers (5-HT₃ antagonists)

• Examples: Ondansetron, granisetron, dolasetron, palonosetron

• Timing: Give 30-60 minutes before chemotherapy

• Key role: First-line for CINV control

2. Adjunctive Agents

• Dexamethasone (corticosteroid)

• Lorazepam (anxiolytic) - Also blunts memory of the experience

• Dronabinol (tetrahydrocannabinoid) - Give 1-3 hours before chemotherapy

3. Neurokinin Antagonists (NK₁)

• Examples: Aprepitant, fosaprepitant, rolapitant

• Use: Added for moderately and highly emetogenic regimens

• Impact: Greatly improves CINV control

These work best in combination, especially for highly emetogenic chemotherapy.

-Peptic ulcer disease interaction warning GI Disorder and therapy 

• B = Bismuth + aspirin = salicylate overdose risk

  • black stools//tomhue are normal w bismuth

• A = Alcohol - stimulates gastric acid secretion

• N = NSAIDs - major contributor to ulcer formation

• S = Smoking/tobacco - stimulates gastric acid secretion

• P = PPI abrupt stop - causes rebound acid (step-down needed)

• U = Uncrushable tablets (rabeprazole, pantoprazole - enteric-coated)

• D = Don't forget corticosteroids increase ulcer risk

WARNING

"If you're taking bismuth (like Pepto-Bismol) for your ulcer treatment, NO ASPIRIN - it can cause a dangerous overdose!"

GERD treatment GI Disorder and therapy 

• Abnormalities in LES function, esophageal motility, and gastric motility or emptying can cause GERD

Nutrition Management

Foods to AVOID:

• Decrease LES pressure: Peppermint, chocolate, fatty/fried foods, caffeine, carbonated beverages

• Irritate inflamed tissue: Spicy foods, acidic foods (orange juice, tomatoes)

Eating Pattern Changes:

✓ Eat 4-6 small meals daily (not 3 large ones)
✓ Eat slowly and chew thoroughly
✓ Large meals increase stomach volume/pressure and delay emptying

Helpful apps: MyFitnessPal, MyPlate

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Lifestyle Modifications

✓ Weight reduction
✓ Smoking cessation
✓ Elevate head of bed 6 inches
✓ Avoid tight clothing
✓ Eliminate drugs causing reflux (if possible):

• Oral contraceptives

• Anticholinergics

• NSAIDs (ibuprofen)

• Nitrates

• Calcium channel blockers

• Sedatives

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Drug Therapy (Three Major Types)

1. Antacids

• Neutralize stomach acid

2. H₂-Receptor Antagonists (Histamine Blockers)

• Reduce acid production

3. Proton Pump Inhibitors (PPIs) ⭐ Agents of choice

• Examples: Esomeprazole, pantoprazole, omeprazole

• Benefits: Promote rapid tissue healing

• IV form available for short-term use (stress ulcer prevention)

⚠ PPI Long-Term Use Risks:

• Kidney, liver, cardiovascular disease

• Dementia

• GI tumors

• Nutrient absorption difficulties

• Increased susceptibility to respiratory/GI infections

• Monitoring required during extended use

• Recurrence common when stopped

4. Prokinetics

• Example: Metoclopramide

• Improves gastric emptying

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Surgical Option

Laparoscopic fundoplication - Most common surgical treatment for severe cases

Use of bismuth subsalicylate GI Disorder and therapy 

FOR Diarrhea management

• an activated charcoal that coats walls of GI tract

  • Binds toxins and bacteria

  • Promotes elimination

• will turn the stool black or gray.

Adverse effects

• Increased bleeding time when combine with warfarin, aspirin, NSAIDs

• constipation, dark stools, confusion, tinnitus, metallic taste, blue gums

• risk for Reye’s syndrome, use cautiously in children & teenagers who are recovering from chickenpox or influenza

• salicylate-based product, avoid other salicylates due to risk for toxicity

Asthma

• chronic airway inflammation. It is

• defined by hx of respiratory symptoms

  • wheeze, SOB, chest tightness, and cough that vary over time and in intensity, together with variable expiratory airflow limitation.”

• Risk factors associated with adult-onset asthma prevalence include heredity factors, allergen exposure, changes in the microbiome, exposure to tobacco smoke and air pollution, occupational exposure, socioeconomic factors, diet, obesity, and certain medications.

Status asthmaticus s/s and treatment

Status asthmaticus is a severe, life-threatening acute episode of airway obstruction that intensifies once it begins and often doesn't respond to usual therapy.

Key clinical findings:

• Extremely labored breathing

• Wheezing

• Use of accessory muscles for breathing

• Distention of neck veins

• Patient may be unable to speak more than a few words between breaths

  Potential complications if not reversed:

  • Pneumothorax

  • Cardiac arrest

  • Respiratory arrest

• Immediate Medications:

  • IV fluids

  • Potent systemic bronchodilators

  • Steroids

  • Epinephrine

  • Oxygen

Emergency Procedures:

• emergency intubation

• tracheotomy may be required

Once breathing improves

• Control therapy drugs

• Reliever drugs/rescue drugs

COPD

• progressive respiratory disease characterized by airway obstruction that is not fully reversible

  • chronic bronchitis and emphysema.

S/S “COPD BREATH”

C - Cough (productive in chronic bronchitis, only with exacerbations in emphysema)

O - Orthopneic/tripod position (leaning forward, arms braced on knees)

P - Pursed-lip breathing (prevents airway collapse)

D - Dyspnea (on exertion → at rest as disease progresses)

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B - Barrel chest (increased anteroposterior diameter)

R - Respiratory rate increased (tachypnea with prolonged expiration)

E - Enlarged neck muscles (from accessory muscle use)

A - Accessory muscles (used for ventilation)

T - Thin (muscle wasting in extremities, weight loss)

H - Hyperresonant chest (on percussion)

Genetic mutation for emphysema

• involves alpha-1 antitrypsin (α₁-antitrypsin) deficiency.

  • enzyme that inhibits proteases—enzymes that break down lung tissue

• suspected in individuals who:

  • Develop emphysema before age 40

  • Have never smoked but still develop emphysema

  • Have a family hx of early-onset lung disease

• may also develop hepatic fibrosis (liver scarring)

• smoking accelerates lung damage.

• treatment: IV augmentation therapy using plasma-purified α₁-antitrypsin

Characteristic feature of emphysema

protease activity is increased and antiprotease activity is decreased

TRAPPED AIR

T - Tissue destruction (alveolar walls break down)
R - Recoil lost (elastic tissue can't spring back)
A - Alveoli enlarge (form bullae - big air spaces)
P - Proteases damage elastin
P - PaO₂ decreases (low oxygen in late stage)
E - Expiration difficult (air gets stuck)
D - Diaphragm flattens (hyperinflation pushes it down)

A - Accessory muscles needed (neck, chest, abdomen work hard)
I - Increased work of breathing
R - Respiratory acidosis (CO₂ retention in advanced disease)

"CUP" for emphysema types:

• Centriacinar = Upper lungs

• Panacinar = lower lungs (think "P" for "Pottom")

Cause of chronic bronchitis

SMOKER'S COUGH

S - Smoke (cigarette smoke is #1 cause!)
M - Mucus hypersecretion (thick, tenacious)
O - Obstruction of airways (especially on expiration)
K - Kick-starts inflammation (irritants trigger cascade)
E - Edema (mucosal swelling)
R - Respiratory acidosis (↑ PaCO₂)
S - Sputum production (productive cough)

C - Chronic cough (≥3 months/year for ≥2 years)
O - Organisms breed (mucus = infection risk)
U - Upregulation of mucus glands (↑ number and size)
G - Goblet cells increase
H - Hypoxemia (↓ PaO₂)

3 months of productive cough
2 consecutive years
= Chronic bronchitis diagnosis

Arterial blood gasses

Normal Values

• pH: 7.35–7.45

• PaCO₂: 35–45 mm Hg

• PaO₂: 80–100 mm Hg

• HCO₃⁻: 22–26 mEq/L

Respiratory = Opposite
Metabolic = Equal

• Respiratory: pH and PaCO₂ move in opposite directions

  • ↑ CO₂ = ↓ pH (acidosis)

  • ↓ CO₂ = ↑ pH (alkalosis)

• Metabolic: pH and HCO₃⁻ move in the same direction

  • ↑ HCO₃⁻ = ↑ pH (alkalosis)

  • ↓ HCO₃⁻ = ↓ pH (acidosis)

• SaO₂: 95–100%

Tuberculosis cause

• Mycobacterium tuberculosis (MTB)

• charcterized by granulomas in the lungs

Tuberculosis-Related Injections

Purified protein derivative (PPD):

• diagnostic injection given intradermally in doses of 5 tuberculin units (0.1 mL) to detect exposure to the tuberculosis

Bacille Calmette-Guérin (BCG):

• vaccine injection from an inactivated strain of Mycobacterium bovis.

• not normally used in US because the risk is not as high, is used in much of the world to vaccinate young children against tuberculosis.

  • does not prevent infection, but reduces

 Tuberculosis treatment(1st and 2nd lines)

RIPE

• First line drugs

  • Rifapentine

  • Isoniazid (INH): primary drug used

  • Pyrazinamide (PZA)

  • Ethambutol

  • Rifabutin

  • Rifampin

  • Streptomycin

• "The fruit is RIPE for TB treatment"

  INH is #1:

  • Think: Isoniazid = Important = Initial choice

  • Used alone for prophylaxis OR combined for active TB

  All the "Rif-" drugs:

  • Rifampin, Rifabutin, Rifapentine = all rifamycins

  • They all turn body fluids orange-red

  • They're all enzyme inducers (drug interactions!)

  Ethambutol = Eyes:

  • Ethambutol affects Eyes (optic neuritis)

  • Monitor vision regularly

  PZA = Problem for liver:

  • Contraindicated in severe hepatic disease

BLOCK

• 2nd line drugs for (MDR-TB/XDR-TB)

  • B - Bedaquiline

    • For multidrug-resistant TB

    • Black box warning: QT prolongation, increased mortality

    • Must take with food

    • Avoid alcohol and QT-prolonging drugs

  • L - Levofloxacin

  • O - Ofloxacin

  • C - Cycloserine

  • K - Kanamycin

  • P - Para-aminosalicylic acid (PAS)

  • E - Ethionamide

  • K - Kapreomycin (Capreomycin)

Drug-Resistant TB

MDR-TB (Multidrug-Resistant):

• Resistant to isoniazid AND rifampin

• Requires second-line drugs

XDR-TB (Extensively Drug-Resistant):

• Resistant to first-line AND best second-line drugs

• Much less effective treatment options

Duration of TB treatment

Traditional Regimen: 6-9 months

• RIPE: rifampin, Isoniazid, pyrazinamide, and ethambutol

• Most common duration: 6 months

• May extend to 9-12 months depending on severity and response

Typical schedule:

• First 2 months: All 4 drugs (RIPE)

• Next 4 months: Rifampin + isoniazid only

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New Shortened Regimen: 4 months (2022)

• rifapentine, Isoniazid, pyrazinamide, and moxifloxacin

• Approved for drug-susceptible TB

• Significantly reduces treatment burden

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Drug-Resistant TB: Much Longer

MDR-TB and XDR-TB:

• Requires higher doses for longer periods

• Often 18-24 months or more

• Uses second-line drugs with more side effects

• Lower cure rates

Drug combinations purpose

1. Kill organisms as quickly as possible

• Multiple drugs attack bacteria through different mechanisms

• Faster bacterial elimination = faster symptom relief

2. Prevent drug resistance

• Using multiple drugs simultaneously reduces the chance resistant strains will emerge

3. Most effective treatment method

TB antimicrobial medications

Antitubercular combination therapy priority teaching

Medication Adherence:

• Take medications exactly as prescribed for the full duration

• Don't stop early, even if you feel better

• Skipping doses reduces effectiveness

Monitoring:

• Attend all follow-up appointments to monitor progress

• Report any concerning symptoms immediately

Drug Interactions:

• Avoid antacids, phenytoin, carbamazepine, beta blockers, benzodiazepines, anticoagulants, antidiabetics, oral contraceptives, and theophylline

• Get a complete interaction list before starting

Isoniazid Side Effects to Report:

• Numbness/tingling in extremities

• Abdominal pain, jaundice, vision changes

• May need vitamin B6 supplementation

Rifampin Side Effects to Report:

• Fever, nausea, vomiting, loss of appetite

• Jaundice or unusual bleeding

General Tips:

• Use sunscreen (photosensitivity risk)

• Women on oral contraceptives need alternative birth control with rifampin

• Practice good hygiene (hand washing, cover cough/sneeze)

• Maintain rest, nutrition, and general health

• Keep medications away from children

• Wear medical alert identification

Isoniazid labs to be monitored

Isoniazid patient teaching

Bedaquiline indications and side effects

TB patient teaching

Antitussives Indications and mechanisms of action

Antitussives potential complications

What are 1st line drugs for nasal congestion

Patient teaching of an adrenergic decongestant 

Antihistamines

Non-sedating histamines patient teaching 

Antishitamine contrainidncations

Diphenhydramine patient teaching