PHARM HESI PT 1

Epinephrine (Epi-pen)

• USE: treats anaphylaxis (wheezing, swollen tongue, trouble breathing)

  • administer into middle of the outer thigh, can be over clothing, hold pen in place after injecting

  • each pen CANNOT be reused

Penicillin/ “-cillin”

• INTERACT: cross sensitivity with cephalosporins

• ADR: hypersensitivity (RASH MOST COMMON), anaphylaxis, C. diff diarrhea

Cephalosporins/ “ceph- or cef-”

• INTERACT: cross sensitivity with penicillin

  • AVOID alcohol = disulfiram-like reaction, hypotension, tachycardia

  • antacids and iron = ↓ effectiveness of drug

  • may ↓ efficacy of oral contraceptives

• ADR: hypersensitivity and bleeding

Macrolides/ “-thromycin”/ ACE

• INTERACT: alternative option for patients with a penicillin allergy

  • may ↓ efficacy of oral contraceptives

• ADR: QT prolongation (cardiac dysrhythmias) and hepatotoxicity (↑ ALT/AST/LDH, jaundice, dark urine/pale stool)

Fluoroquinolones/ “-floxacin”

• INTERACT: take interacting drugs at least 2 hours before/after

  • AVOID dairy, antacids, iron, zinc, magnesium, aluminum, sucralfate

• ADR: photosensitivity, C. diff, hepatotoxicity, prolonged QT interval, confusion/neuropathy/depression

  • FDA BLACK BOX: tendonitis/tendon rupture

Tetracyclines/ “-cycline”

• CONTRA: pregnant/lactating women and children under 8yo (bone deformities & teeth discoloration)

• TEACH: take medication with 6-8oz of water

  • AVOID antacids, dairy, calcium, iron, magnesium, and sucralfate (↓ absorption)

• WARNING: can bind to calcium to form insoluble complexes → tooth discoloration and suppress long bone growth; superinfections may occur; photosensitivity (avoid sunlight)

Sulfonamides/ “sulfa-”

• USE: UTIs and Staph infections

• MONITOR: “sulfa allergy” (do not take celecoxib), photosensitivity, CBC for agranulocytosis and Stevens-Johnson Syndrome

Vancomycin, Aminoglycosides Peak & Trough

PEAK: highest concentration of drug in blood measured AFTER completion of infusion

TROUGH: lowest concentration of a drug in blood measured RIGHT BEFORE (within 30 mins) the next dose

• optimal vancomycin trough level = 10 to 20 mcg/mL

Vancomycin

• ADR: nephrotoxicity (hematuria and edema), ototoxicity, Red Man Syndrome (tachycardia, hypotension, flushing, pruritus, dyspnea, redness, chest pain), 

• NURSING: administer IV

  • must infuse IV slowly over 1 hour; if too quickly = RMS (not an allergic reaction - anaphylaxis)

  • if RMS, hold infusion and restart at a slower rate once symptoms resolve; monitor vitals and lung sounds, antihistamines and steroids may be ordered

Aminoglycosides/ “-micin or -mycin”/ amikacin / GNATS

• ADR: nephrotoxicity (↑ BUN/creatinine and ↓ urine) & ototoxicity

Metronidazole/ Flagyl

• ADR: metallic taste, dark/red urine, dry mouth

• NURSING: test all sexual partners at the same time

  • AVOID alcohol 24hrs before & 36hrs after (tachycardia/hypotension), sexual intercourse, OTC antitussives

  • harmless darkening of urine may occur

  • can take w/ food to minimize GI distress

  • ensure all sexual partners are treated at the same time

Nitrofurantoin/ Macrobid

• ADR: pulmonary toxicity and hepatotoxicity

• NURSING: harmless dark yellow/brown urine, increase fluid intake

Linezolid

• AVOID SSRIs (serotonin syndrome) and tyramine-containing foods (cheese, wine, cured meats → hypertension)

Superinfections.

• a new infection that occurs because of an antibiotic (destroys normal flora)

  • thrush (creamy white lesion & sore mouth)

  • vaginal yeast infection (perineal itching, thick, white vaginal discharge)

  • Pseudomembranous colitis (persistent or bloody diarrhea, fever, abdominal pain)

    • Clostridium difficile (may be fatal, collect stool specimen)

-AZOLE medications. Monitoring/adverse effects.

• Fluconazole

• ADR: hepatotoxicity

• MONITOR: elevated LFTs

  • avoid grapefruit, antacids, and alcohol

  • hypokalemia, rare nephrotoxicity

  • PREGNANCY CAT. D

Anti-fungal: Terbinafine. Uses, adverse effects/monitoring.

• USE: onychomycosis (PO), tinea pedis/cruris/corporis (TOPICAL)

• ADR: hepatotoxicity

• MONITOR: increased LFTs

Oseltamivir – uses, nursing. 

• USE: influenza virus & prophylaxis

• NURSING: take within 2 DAYS of symptom onset, hydration is important

Echinacea uses.

• topical for wounds and canker sores

Acyclovir – when it is used.

• USE: DOC for initial and recurrent episodes of HSV (suppresses replication of HSV 1,2, and Zoster)

Interferons, hepatitis C combination therapy. Monitoring.

• MONITOR: depression/suicidal thoughts, CBC w/ LFTs

Combination Therapy

• interferon alpha + ribavirin therapy = ↓ rate of drug resistance

• MONITOR: CBC

Antiretroviral therapy goals.

• GOAL: reduce the viral load to undetectable in blood <50 copies/mL in HIV

Cyclosporine. Adverse effects.

• ADR: nephrotoxicity, ↑ risk of infections, risk of malignancies, tremors

• NURSING: 

  • St. John’s Wort can lower cyclosporine levels in the blood = organ rejection

Opioids

• Morphine

• Fentanyl

• Meperidine

• Hydromorphone

• Oxycodone

• Hydrocodone

• Codeine

• SAFETY: change positions slowly; use side rails

• SE/ADR: constipation, urinary retention, pruritus, dizziness, headaches, sedation/confusion, n/v, respiratory depression, orthostatic hypotension

  • TOXICITY: miosis, respiratory depression, coma

• NURSING: increase fluid intake and fiber, may take Docusate sodium/Senna

  • morphine & NSAIDs can be used w/ opioids for an additive analgesic effect w/ a lower dose of morphine

  • fixed schedule dosing may be more efficient that PRN dosing

  • assess history alcohol or another CNS depressant uses

Naloxone

• USE: treats opioid overdose; reverses respiratory depression, coma, analgesia, and sedation

• DOSE: 0.4-2 mg IV; may need multiple doses every 2-3 minutes (no response after 10 mg, reconsider diagnosis)

Know non-opioid, analgesic. Acetaminophen.

• does NOT have anti-inflammatory properties

• ADR: hepatotoxicity (↑ LFTs, jaundice, dark urine/pale stools)

• DOSE: max daily dose of 4,000 mg/day; if > 4g → OD/hepatotoxicity and liver damage

Know Non-Aspirin NSAIDs like ketorolac, diclofenac, ibuprofen.

• USE: osteoarthritis, reduce inflammation, decrease fever, analgesic

ADR: GI irritation/ulcers/bleeding, n/v, dyspepsia, dizziness, kidney impairment, weight gain/edema

Know Aspirin/Salicylic acid

• CONTRA: hypersensitivity to salicylates, history of GI ulcers/PUD/hemophilia, thrombocytopenia, pregnancy (especially 3rd trimester)

  • children w/ recent viral illnesses (chickenpox or influenza) → Reye’s Syndrome (neurologic deficits can lead to liver damage and coma)

• TOXICITY: ototoxicity, nephrotoxicity, GI bleed/ulceration, n/v, hyperthermia/sweating, dehydration w/ electrolyte imbalance, confusion

• INTERACT:

  • + alcohol & anticoagulants → ↑ bleeding

  • + NSAIDs → ↑ risk of GI irritation and bleeding

  • + corticosteroids → ↑ risk of GI ulcers

  • OTC drugs with aspirin and or salicylates -> Alka-Seltzer, PeptoBismol, and Excedrin

    • bismuth subsalicylate should NOT be used with aspirin

Colchicine

• ACUTE gout treatment

• reduced inflammation caused by gout

Allopurinol

• CHRONIC gout treatment

• inhibits uric acid production and prevents future gout attacks

Probenecid

• CHRONIC gout treatment

• increases excretion of uric acid via the kidneys out of the body

Know gabapentin

• ADR: dizziness, drowsiness, mood changes

Know pregabalin

• USE: second option if patient cannot take gabapentin

• ADR: dizziness, drowsiness, and suicidal ideations

• NURSING: report any mood changes and suicidal ideations

Beta Blockers/ “-lol”

• ↓ BP & HR

• ADR:

  • B1: bradycardia & AV heart block; masks early s/s of hypoglycemia

  • B2: bronchoconstriction, wheezing (likely not used in Pt. with asthma and COPD)

  • A1: vasodilation

  • CNS: depression, fatigue, unusual dreams/nightmares, ED

Labetalol

can cause weight gain; monitor and assess I&O and daily weights associated with pulmonary edema

Anti-hypertensives

can be taken with thiazide diuretics to treat edema, HF , hypertension.

ACE inhibitors (-prils)

• ADR/SE: angioedema, first dose orthostatic hypotension, hyperkalemia, DRY COUGH

ARBs (-sartans) 

ADR/SE: angioedema, hypotension, hyperkalemia, CKD, PREGNANCY CAT. D, NO DRY COUGH

Calcium channel blockers (CCB)/ “-dipine”

• dilates arteries in vascular smooth muscle; ↓ BP & HR (Amlodipine)

• ADR: hypotension, reflex tachycardia, peripheral edema (report sudden weight gain), headache/dizzy/flushing, gingival hyperplasia/rash

Diltiazem & Verapamil

• ADR: hypotension, bradycardia, AV heart block (irregular HR and rhythm)

• SE: constipation (increase fiber intake)

Loop Diuretics/ Furosemide, Bumetanide, Torsemide/ “-ide”

• ADR: severe dehydration, hypovolemia, hyponatremia,orthostatic hypotension, fall risk, prolonged can lead to rare ototoxicity

  • hypokalemia (<3.5 mEq/L): muscle cramps, weakness, fatigue, dysrhythmias/palpitations (needs cardiac monitoring)

  • NORMAL K+ RANGE: 3.5-5 mEq/L

• K+ FOODS: green leafy vegetables, legumes, bananas, oranges, cantaloupe, dates, beans, lentils, dried fruits, potatoes, broccoli, green beans, squash and sweet potatoes, salt substitutes

Diuretics: thiazides: Hydrochlorothiazide

• ADR: hypokalemia

• hypotension, hyponatremia

• ↑ glucose, ↑ cholesterol, and ↑ uric acid

Diuretics: potassium sparing, know Spironolactone, Triamterene

• ADR: HYPERkalemia, avoid foods rich in potassium

  • n/v/d, chest pain, palpitations, cardiac dysrhythmias

• SE: menstrual irregularities, hirsutism, impotence, and gynecomastia

• TAKE IN THE MORNINGS

Know anti-hypertensive: Clonidine. Transdermal patch.

• ADR: orthostatic hypotension/dizzy, drowsy, xerostomia (dry mouth); 3 D’s

• change transdermal patch every 7 DAYS; place on hairless, intact skin (use only upper arms or torso), REMOVE OLD PATCH BEFORE APPLYING A NEW ONE

Review Mannitol and its uses. What to monitor.

• USE:

  • edema to promote diuresis in cerebral edema

  • severe head injury to decrease intracranial pressure

  • induce renal excretion of toxic substances

  • glaucoma to decrease intraocular pressure

• MONITOR:

  • listen to lung sounds (dyspnea and crackles)

  • monitor urine output and renal function

Know alpha 1 stimulation (vasoconstriction); beta 1, beta 2.

STIMULATION

• B1: ↑ HR and force

• B2: bronchodilation

• A1: vasoconstriction

Alpha 1 adrenergic blockers – Tamsulosin – use and its side effects.

“-zosin” = A1 adrenergic blockers

• USE: promote vasodilation and ↓BP

• ADR: orthostatic hypotension

• TEACH: stand up slowly & administer once daily at BEDTIME to avoid daytime dizziness/falls

Adrenergic agonists – uses.

Dopamine, Dobutamine, Epinephrine

• USE: severe HF and emergency for cardiac arrest and/or hypotension

• INFILTRATION: pain, swelling, redness, and vesicles on the skin

  • immediately turn off the infusion and intervene to prevent further complications.

* when dopamine is given to treat shock, the drug also activates beta 1 receptors in the heart

* Catecholamines (epinephrine, norepinephrine, dopamine) must be watched carefully for extravasation

Digoxin

• NURSING: take apical pulse for a 1 minute before administering

  • if apical pulse >60, HOLD DOSE

  • if serum potassium <3.5, do NOT administer (can increase risk of digoxin toxicity)

• INTERACT: digoxin toxicity w/ furosemide due to hypokalemia

• THERAPEUTIC: 0.5-2 ng/mL

• TOXICITY:

  • early: anorexia, n/v, headache, bradycardia

  • late: blurred vision, yellow vision, visual halos around bright objects, muscle weakness, confusion

Sildenafil – contraindication, monitoring.

• CONTRA: nitrates → SEVERE HYPOTENSION

• MONITOR: BP

Anti-cholesterol meds: (end in -STATIN drugs (atorvastatin, simvastatin, etc)

• USE: ↓ LDL, ↑ HDL

• MONITOR: LFTs, CK levels, LDH

• ADR: 

• myalgias: generalized muscle pain; mild increase in CPK/CK levels

• myositis: muscle pain and inflammation; moderate increase in CPK/CK

• rhabdomyolysis: MOST SEVERE MYOPATHY (breakdown of muscle); very high CPK/CK levels, myoglobin, and dark urine; can be FATAL

• hepatotoxicity (↑LFTs); dark urine, vomiting, jaundice; ALT normal is 4-36 U/L

• CONTRA: pregnancy, breastfeeding, liver disorders (alcoholism), and drug allergy

Anti-anginals (have the word NITRATE or NITRO in it).

• MOA: ↓ preload & afterload; dilates (widens) veins & arteries causing smooth muscle relaxation

• SE: headaches (expected), can be managed with acetaminophen

• TRANSDERMAL PATCH: used to prevent anginal attacks, not to manage an acute attack

  • use a hairless area of upper arms or body; rotate sites

  • remove at night to allow 8-12 hours without patch → “nitrate free period” to prevent tolerance

  • apply once a day for 12 hours (wear gloves)

• SL NITRO: place 1 SL nitro under the tongue every 5 minutes for a maximum dose of 3 tablets

• IV GTTS: can be titrated based on BP

Know anti-platelets including -GREL drugs (clopidogrel, prasugrel). 

Aspirin, Clopidogrel, Prasugrel (“-grel”)

• NURSING: 

  • hold drug within 5-7 days before surgery

  • do not give if platelets are low or hemophilia

TEACH: notify HCP of drug regimen prior to surgery

Enoxaparin / Low Molecular Weight Heparin

• SQ ONLY

• NURSING: monitor for thrombocytopenia and if platelet count is ≤100,000/mm3 (CBC)

Know anti-coagulant Heparin

• MONITOR: requires FREQUENT monitoring of activated partial thromboplastin time (PTT) levels; measures how long it takes blood to clot

  • NORMAL: 30-40 seconds

  • GOAL: PTT between 1.5-2.5x normal level (~60-80 seconds while on heparin)

• ANTIDOTE: effects reversed by IV protamine sulfate if PTT gets too long (>80 seconds)

• NURSING: review coagulation lab values (aPTT/PTT)

  • avoid other medications that promote bleeding (NSAIDs/aspirin, ginkgo biloba, garlic, feverfew)

  • use soft bristle toothbrush and electric razor

  • report any bleeding to HCP

  • avoid IM injections and unnecessary venipuncture

  • place patients on fall precautions; avoid going barefoot

  • instruct patient to avoid straining

  • wear medical alert bracelets

  • avoid injuries and high-risk activities

Know anti-coagulant warfarin

• NURSING: monitor PT/INR regularly

• take exactly as prescribed at the same time everyday

• avoid aspirin, NSAIDs, ginkgo, feverfew, garlic

• warfarin interacts w/ many antibiotics & antifungal medications and increase risk of bleeding

• PREGNANCY CAT. D

• ADR: bleeding, hematemesis, hemorrhage, melena

• ANTIDOTE: vitamin K can be given if overdose/hemorrhage occurs (if INR too long)

• PT/INR: prothrombin time/international normalized ratio

  • PT normal: 1.5x reference value

  • INR normal: 2-3

  • if PT is >2.5x the reference value or there is a high INR, the person will have bleeding tendencies

Ribaroxaban & Apixaban

• ADR: bleeding hematemesis, hemorrhage, melena

  • BLACK BOX: spinal hematomas if patient has an epidural catheter; avoid if recent spinal puncture

• does NOT require specific blood coagulation monitoring but still MONITOR CBC

• AVOID NSAIDs

• do not give for at least 6 hours after surgery

Dabigitran

• ADR: bleeding, GI hemorrhage, GI ulcers

• does NOT require specific blood coagulation monitoring but still MONITOR CBC

• AVOID NSAIDs

• DO NOT GIVE if renal impaired

Know thrombolytics – alteplase

“-ase”

• USE: dissolves clots in stroke, MI, PE, DVT

• NURSING: monitor vital signs and signs of bleeding (↓ BP, ↑ HR, ↑RR, ↓ Hemoglobin)

  • assess/report evidence of bleeding (insertion site, urinary catheter, incision) or hidden bleeding (altered mental status)

  • monitor blood tests (hemoglobin, hematocrit, platelets)

  • avoid aspirin, NSAIDs, ginkgo, feverfew, garlic

  • labs; ↑ clotting times, may ↓ Hgb & Hct

Amiodarone

• ADR:

  • pulmonary toxicity: dyspnea - SOB, cough, fibrosis

    • requires baseline chest x-ray and pulmonary function tests before administration

  • thyroid toxicity: hypothyroidism or hyperthyroidism

    • need baseline thyroid panels before administration

  • corneal deposits: visual halos, photosensitivity, photophobia, vision changes

    • need eye exams; report vision changes

    • photosensitivity (wear protective clothing)

  • hepatotoxicity: increased liver function tests

    • avoid alcohol, monitor LFTs, liver failure

  • dysrhythmias: monitor ECG, QT prolongation, and electrolyte levels

  • hypotension & bradycardia: monitor BP and pulse closely

  • neurologic: abnormal gait and coordination problems

• PATIENT TEACHING:

  • wear dark glasses, protective clothing, and sunscreen

  • follow recommendation for regular ophthalmic exams

  • AVOID grapefruit

  • report bradycardia, hypotension, ADR, and respiratory symptoms

  • monitor LFTs, thyroid function, ECG, BP, and pulse

Quinidine

• ADR: 

  • cinchonism (tinnitus, headache, nausea vertigo), thrombocytopenia

  • hypotension in high doses, QT prolongation, heart block

  • diarrhea (common)

• NURSING: dose every 6 hours around the clock so that stable blood level is maintained

• AVOID grapefruit