3 P's Drug Cards- WK 4-Present

Class: Antihyperuricemics/Uricosurics/Urate Lowering Therapy

Prototype: Allopurinol

Treats gout which is caused by hyperuricemia.

Urate acid crystals get deposited in the joints causing inflammation.

Class: Antihyperuricemics/Uricosurics/Urate Lowering Therapy

Prototype: Allopurinol

Action

•Inhibits xanthin oxidase from converting to uric acid

•Decreases uric acid production

Class: Antihyperuricemics/Uricosurics/Urate Lowering Therapy

Prototype: Allopurinol

ADRs

•Hypersensitivity

•N/V/D

•Drowsiness, HA, vertigo

•Bone marrow suppression (rare)

•Metallic taste

•Cataracts

Rash with allopurinol is not a simple allergic rash. It can lead to liver and kidney damage – stop drug immediately if rash develops.

Class: Antihyperuricemics/Uricosurics/Urate Lowering Therapy

Prototype: Allopurinol

Interventions:

•Monitor for hypersensitivity

•Give after meals if N/V occur

•Fall risk if vertigo

•Monitor CBC

•Monitor uric acid levels

Class: Antihyperuricemics/Uricosurics/Urate Lowering Therapy

Prototype: Allopurinol

Client Instructions:

•↑ fluid intake – 3L/day

Safety Alert: Kidneys filtering uric acid can cause nephropathy/kidney damage if inadequate hydration

Drink at least 3 liters of fluid per day

•Report bleeding/bruising

•Wear sunglasses with UV protection

Class: Antihyperuricemics/Uricosurics/Urate Lowering Therapy

Prototype: Allopurinol

Contraindications and Precautions:

•Hypersensitivity

•Caution with bone marrow depression

•Caution with liver or renal dysfunction, PUD

Glucocorticoids
Prototype:

Prednisone

Other medications in this category include prednisolone, hydrocortisone, methylprednisolone, betamethasone, cortisone, dexamethasone, and triamcinolone.

Glucocorticoids
Prototype: Prednisone

IMPORTANT to memorize:

Increased cortisol or drugs acting like cortisol will increase glucose levels.

Diabetics need to be especially alert to glucose and may need a change in medication such as higher insulin doses while on prednisone

Causes suppression of the immune system, caution around crowds or sick people.

Increases risk of osteoporosis, increase Ca++ and Vit D consumption

Cushing’s syndrome characterized by weight gain.

Glucocorticoids
Prototype: Prednisone

Action:

•Mimic cortisol by suppressing inflammation

•↓ pain

•↓ capillary permeability

Glucocorticoids
Prototype: Prednisone

ADRs:

•Hyperglycemia

•↑ Na⁺ or ↓ K⁺

•Immuno-suppression

•Cushing’s syndrome

•Osteoporosis

•Cataracts

Glucocorticoids
Prototype: Prednisone

Interventions:

•Monitor for adrenal insuff.

•Monitor blood glucose

•Give with food

•Monitor for infection

•Monitor for Cushing’s effects

Glucocorticoids
Prototype: Prednisone

Client Instructions:

•Take as prescribed – each day may vary

•Requires tapering

•Consume adequate Ca⁺⁺ & vitamin D

Glucocorticoids
Prototype: Prednisone

Contraindications and Precautions:

•Systemic fungal infection

•Cataracts

•Caution with heart failure, DM, osteoporosis

Penicillin
Prototype: amoxicillin (Amoxil®)

broad spectrum antibiotic that treats ear and upper respiratory/throat infections as well as UTIs.

amoxicillin is beta-lactam

meaning it has beta-lactam in it’s molecular structure – why is this important??

Some bacteria produce an enzyme (beta-lactamase) that attaches to the antibiotic making it inactive.

If the bacteria causing the infection has this previously stated ability, then what?

adding clavulanic acid which binds to and inactivates the enzyme. Clavulanic acid is often added to PCNs like amoxicillin (Augmentin) that will then allow the penicillin to work.

Why not use the combo formula all the time?

Clavulanic acid worsens many of the ADRs. For example, instead of mild diarrhea, it may be profuse diarrhea. If the Clavulanic acid is not needed, we shouldn’t include it.

Because amoxicillin is broad spectrum it can and often does cause a ______________

superinfection

Most commonly yeast infections which can be oral (thrush or vaginal) Make sure to instruct the client to report difficulty swallowing or eating or vaginal itching or discharge.

many people have a penicillin ________

allergy

Be sure to monitor for anaphylaxis and stop the drug immediately.

This is a common drug for people to take at home, so be sure to tell them to call 911 if they begin having difficulty breathing.

Penicillin can reduce the effects of ____ ____________.

oral contraceptives

Advise the client to use alternative birth control while on abx. So as not to alter hormone levels, it is best to use alternative birth control along with the oral contraceptive. Just know the effectiveness can be reduced causing unplanned pregnancy.

Penicillin
Prototype: amoxicillin (Amoxil®)

Actions:

•Broad spectrum

•Weaken & destroy cell wall

•Beta-lactam antibiotic

•Adding clavulanic acid ↑ spectrum

•Treats ear & throat infections, UTIs

Penicillin
Prototype: amoxicillin (Amoxil®)

ADRs:

•Allergy- Hives, Anaphylaxis

•GI distress- Diarrhea, Nausea/Vomiting

•Superinfection- Candidiasis, Clostridium difficile

Penicillin
Prototype: amoxicillin (Amoxil®)

Interventions:

•Monitor GI symptoms

•Administer with food

•Report watery diarrhea

•Report candida of mouth or vagina

•Monitor for hives or difficulty breathing

Penicillin
Prototype: amoxicillin (Amoxil®)

Client Instructions:

•Take at start of meal for best absorption

•Notify provider for vaginal itching, burning or discharge

•If having difficulty breathing, call 911

Penicillin
Prototype: amoxicillin (Amoxil®)

Contraindications and precautions:

•Allergy to PCN, procaine or benzathine

•Caution with severe renal impairment

•PCN reduces effectiveness of oral contraceptives

Cephalosporins
Prototype: cephalexin (Keflex®)

IMPORTANT REMEMBER

Similar structure, action, ADR as PCN

Cross-allergy to PCN, important to assess allergies.

One cephalosporin (cefotetan) can cause increased risk of bleeding or hemorrhage – assess for easy bruising

Advise client not to drink alcohol. May cause disulfiram-like reaction (Antabuse): N/V, HA, hypotension

Multiple generations of cephalosporins. Higher (more recent) generations are more narrow spectrum.

Cephalosporins
Prototype: cephalexin (Keflex®)

Action:

•Broad spectrum

•Weaken & destroy cell wall

•Beta-lactam antibiotic

•Treats ear & throat infections, UTIs

•Uses and effects similar to PCN

Cephalosporins
Prototype: cephalexin (Keflex®)

ADRs:

•Allergy

•GI distress

•Superinfection

•Cross sensitivity with PCN allergy

Cephalosporins
Prototype: cephalexin (Keflex®)

Interventions:

•Assess for PCN allergy

•Monitor GI symptoms

•Administer with food

•Report watery diarrhea

•Report candida of mouth or vagina

•Monitor for hives or difficulty breathing

Cephalosporins
Prototype: cephalexin (Keflex®)

Client Instructions:

•Do not take with alcohol – N/V, HA, Hypotension

•Notify provider for vaginal itching, burning or discharge

•If having difficulty breathing, call 911

Cephalosporins
Prototype: cephalexin (Keflex®)

Contraindications and Precautions:

•Allergy to PCN

•Milk-protein allergy

•Caution with renal failure or GI disease

Vancomycin
Prototype: vancomycin (vancocin®)

Treats serious infections such as MRSA and C. diff

Vancomycin- nephrotoxic

can cause renal failure. Need to monitor trough levels for dosing to reduce risk of kidney injury/failure. May need renal dosing which is collaboration between provider and pharmacist. Nurse should advocate if decreased urine output or change in renal labs

Vancomycin- ototoxic

can cause tinnitus, vertigo, hearing loss

vanc- IV caution

When given IV, don’t give too quickly, can cause Vancomycin Flushing Syndrome (Red Man Syndrome) – flushing, feeling faint, pruritis, urticaria, tachycardia, low blood pressure.

Give over at least 60 minutes to reduce risk.

Can be caustic to veins causing thrombophlebitis. Assess IV site frequently.

Oral vanc treats

C. diff or bacteria in colon only. Not well absorbed in GI tract so not useful for infection outside GI tract.

Vancomycin
Prototype: vancomycin (vancocin®)

Action:

•Broad spectrum for serious infections

•Effective against gram⁺ bacteria

•Effective against MRSA (IV) & C. diff (po)

•Alternative when PCN allergy present

Vancomycin
Prototype: vancomycin (vancocin®)

ADRs:

•Renal failure

•Red Man Syndrome

•Ototoxicity

•Thrombophlebitis at IV site

•Anaphylaxis

Vancomycin
Prototype: vancomycin (vancocin®)

Interventions:

•Monitor IV site for pain, redness, swelling

•Monitor renal function, BUN, Cr

•Administer over 60 min to prevent Red Man Syndrome

•Monitor labs – Trough level

Vancomycin
Prototype: vancomycin (vancocin®)

Client Instructions:

•Report facial flushing & feeling faint

•Report pain, swelling, redness at IV site

•Report tinnitus, vertigo, or hearing loss

Vancomycin
Prototype: vancomycin (vancocin®)

Contraindications and Precautions:

•Caution with renal insufficiency – may need reduced dose

•Caution with colitis or inflammation of colon

Antibacterials: Protein Synthesis Inhibitors

tetracyclines and macrolides

-Protein synthesis inhibitors generally interrupt the replication of the pathogen.

Tetracyclines
Prototype: tetracycline

Action:

•Broad spectrum & bacteriostatic

•Treats chlamydia &  mycoplasma

•Treats Ricketts, cholera, & anthrax

•For syphilis when PCN allergy

•Treats acne

**For chlamydia/syphilis and mycoplasma (usually respiratory infection in older children/young adults)

Also, nontypical infections like cholera, Ricketts, anthrax

Tetracyclines
Prototype: tetracycline

ADRs:

•GI symptoms

•Teeth discoloration if < 8 y/o or in utero

•Hepatotoxicity

•Superinfection

•Photosensitivity

***Interesting ADR, can cause teeth discoloration in teeth in the gums. This can be in fetus and affecting baby teeth or in children affecting permanent teeth.

Do not give to pregnant women or children < 8

Photosensitivity – can cause sunburn reaction with minimal sun exposure. Advise to wear sunscreen and/or protective clothing outside.

Tetracyclines
Prototype: tetracycline

Interventions:

•Monitor for GI discomfort

•Assess for potential pregnancy

•Monitor liver function tests

•Monitor for superinfections

Tetracyclines
Prototype: tetracycline

Client Instructions:

•Take 1 hr before or 2 hrs after meals

If GI upset is unbearable, take with non-dairy foods.

•Do NOT take with calcium products

•Do not take with any antacids – reacts with magnesium and aluminum like calcium

•Report pregnancy

•Use sunscreen

Tetracyclines
Prototype: tetracycline

Contraindications and Precautions:

•Pregnancy and children < 8

•Ultraviolet light

•Caution with liver or kidney impairment

Macrolides
Prototype: erythromycin

Action:

•Broad spectrum

•Treats Legionnaires’ disease, pertussis, & diphtheria

•Treats common infections when PCN allergy

Macrolides
Prototype: erythromycin

ADRs:

•GI symptoms

Fairly unique ADR is prolongation of QT interval of cardiac electricity. Can be seen on ECG. This can lead to deadly ventricular dysrhythmia called Torsades de Pointes

Ototoxic – hearing/balance problems

•Superinfection C. diff not uncommon – report bloody/watery diarrhea

Macrolides
Prototype: erythromycin

Interventions:

•Monitor for GI discomfort

•Assess for cardiac dysrhythmias

•Monitor liver function tests

•Monitor for superinfections

CYP3A4 inhibitors (some cancer drugs, HIV drugs, CCB verapamil and diltiazem) increase blood levels of erythromycin, very similar molecular structure)

Macrolides
Prototype: erythromycin

Client Instructions:

•Take 1 hr before or 2 hrs after meals

Best on empty stomach and drink 8 oz fluid after taking

•If GI upset, may take with food

•Report palpitations or syncope

•Report hearing loss, vertigo, tinnitus

•Report bloody or watery diarrhea

Macrolides
Prototype: erythromycin

Contraindications and Precautions:

•History of QT Syndrome

•Caution with GI or liver disorders

•Caution with hypokalemia & hypomagnesemia

Antibacterials that Inhibit Folic Acid Synthesis

Sulfonamides and Urinary Tract Antiseptics

-Folic acid is necessary for reproduction

Sulfonamides
Prototype: trimethoprim & sulfamethoxazole (Bactrim®)

Action:

•Broad spectrum against gram⁺ cocci, gram^- bacilli, & some protozoa & fungi

•Treats UTIs, Pneumocystis pneumonia, Shigella, bronchitis, otitis media

Commonly given for bronchitis or otitis media as well as pneumocystis pneumonia and shigella

Sulfonamides
Prototype: trimethoprim & sulfamethoxazole (Bactrim®)

ADRs:

•GI symptoms

Serious ADR – Stevens Johnson Syndrome – sloughing of skin from previous slide – early presentation is red/purple rash that progresses to blisters then sloughing

•Blood dyscrasias

•Urinary crystals

•Superinfection

Sulfonamides
Prototype: trimethoprim & sulfamethoxazole (Bactrim®)

Interventions:

•Monitor GI symptoms

monitor CBC, report fatigue (RBC), pallor (anemia), new infection (WBC)

•Monitor for skin rashes – esp blisters

monitor I&O for potential obstruction – increase fluid intake

Sulfonamides
Prototype: trimethoprim & sulfamethoxazole (Bactrim®)

Client Instructions:

•Drink 1.2-1.5 L H₂O/day

•Report fatigue, pallor, bruising, new infections

•Report signs of superinfection

•↓ oral contraceptive efficacy

Sulfonamides
Prototype: trimethoprim & sulfamethoxazole (Bactrim®)

Contraindications and Precautions:

•Pregnancy

Do not take if allergic to COX-2 inhibitor (celecoxib) – potential cross-allergy

Do not take if megaloblastic anemia from folic acid deficiency

•Pharyngitis d/t β-hemolytic strep

•Caution in renal or liver dysfunction

Urinary Tract Antiseptics
Prototype: nitrofurantoin (Macrodantin®)

Action:

•Broad spectrum

•ONLY Treats UTIs

•NO action outside of urinary tract

Urinary Tract Antiseptics
Prototype: nitrofurantoin (Macrodantin®)

ADRs:

•GI symptoms

Can cause lung damage leading to pulmonary fibrosis – respiratory distress, chest pain with breathing, chills, cough

Can cause permanent peripheral neuropathy – esp in renal dysfunction; manifestations – weakness, numbness, tingling from damage to myelin sheaths

•Blood dyscrasias

Liquid suspensions may stain teeth – dilute and rinse mouth after taking

Can cause brown discoloring of urine – harmless

CNS effects – dizziness, drowsiness, HA, photosensitivity

Urinary Tract Antiseptics
Prototype: nitrofurantoin (Macrodantin®)

Interventions:

•Monitor GI symptoms

•Monitor respiratory status

•Monitor for neuropathy

•Monitor CBC

Urinary Tract Antiseptics
Prototype: nitrofurantoin (Macrodantin®)

Client Instructions:

•Report respiratory symptoms

•Report numbness, tingling, weakness

•Report fatigue, easy bruising, new infection

•With suspension, dilute & rinse mouth after

Urinary Tract Antiseptics
Prototype: nitrofurantoin (Macrodantin®)

Contraindications and Precautions:

•Renal impairment

•Jaundice from gallbladder disease

•Caution in asthma, liver disorders, vit B12 deficiency