Comprehensive Undergraduate Pharmacology Exam Prep

Drug Regulatory Principles and Foundations

• General Drug Law Purposes     * Ensure safety of the public.     * Prevent misuse of pharmaceutical substances.     * Regulate the distribution of medications.

• Regulatory Agencies     * FDA (Food and Drug Administration): Responsible for approving drugs based on safety and effectiveness.     * DEA (Drug Enforcement Administration): Responsible for regulating controlled substances.

• Principles of First Pass Metabolism     * Mechanism: Oral medications enter the Gastrointestinal (GI) system for absorption and are subsequently transported to the liver for metabolism.     * Effect: This process results in decreased bioavailability of the drug.     * Comparison: Intravenous (IV) administration bypasses the liver and GI tract, resulting in a faster and stronger effect.     * Dosing Implication: Because of the first-pass effect, oral doses are frequently higher than IV doses of the same medication.

• Black Box Warning (BBW)     * Defined as the FDA's strongest safety warning.     * This designation indicates a life-threatening risk associated with the medication.

Anticoagulants and Dyslipidemia Medications

• Heparin     * Class: Anticoagulant / Indirect thrombin inhibitor.     * Mechanism: Prevents the formation of new clots; strictly does NOT break down existing clots.     * Indications: Pulmonary Embolism (PE), Deep Vein Thrombosis (DVT), Open heart surgery, Post-surgery, Disseminated Intravascular Coagulation (DIC), and as an adjunct to thrombolytic therapy.     * Pregnancy: Preferred anticoagulant in pregnancy when rapid anticoagulation is necessary.     * Monitoring: Partial Thromboplastin Time (PTT).     * Antidote: Protamine sulfate.     * Administration: Must be injected slowly, over approximately $30$ seconds.     * Heparin-Induced Thrombocytopenia (HIT):         * Watch for a decrease in platelets by half within $24$ hours of initiating Heparin.         * Treatment: Discontinue Heparin immediately. High-risk patients will require an alternative anticoagulant such as Argatroban.

• Low Molecular Weight Heparin (Enoxaparin / Lovenox)     * Class: Anticoagulant / Indirect thrombin inhibitor.     * Advantages over Heparin: Easier to use because no PTT monitoring is required; less likely to develop HIT; higher bioavailability; longer duration of action (requires less frequent dosing).     * Mechanism: Prevents clots; does NOT break down existing clots.     * Uses: Prevention of DVT post-surgery, treatment of established DVT, and prevention of ischemic complications in STEMI and MI.

• Warfarin (Coumadin)     * Class: Anticoagulant / Vitamin K antagonist.     * Pharmacokinetics: Delayed onset; requires $3$ to $5$ days to become therapeutic.     * Indications: Long-term prophylaxis of thrombosis, prevention of PE/DVT, prevention of thromboembolism in prosthetic heart valves, and prevention of AFIB thrombus formation.     * Monitoring: International Normalized Ratio (INR), target range is $2$ to $3$.     * Antidote: Vitamin K.     * Dietary Education: Consistent intake of Vitamin K-containing foods (Spinach, Kale, collard greens) is required, as diet directly affects INR levels.     * Interactions: Decreases the effect of Oral Contraceptive Pills (OCPs). Avoid Alcohol, Grapefruit, Cranberries, and Aspirin due to increased bleeding effects.     * Black Box Warning: Pregnancy Category X (teratogenic), causes excessive bleeding. Keep Vitamin K available.

• Statins: Atorvastatin (Lipitor)     * Class: HMG-CoA reductase inhibitor; most powerful class to lower LDL cholesterol.     * Clinical Benefits: Decreases risk for MI and stroke; preferred single drug treatment for dyslipidemia.     * Adverse Effects: Myopathies (range from muscle pain to rhabdomyolysis), liver toxicity.     * Contraindications: Liver disease, persistent ALT/AST elevation, Pregnancy.     * Administration: Take at night. NO GRAPEFRUIT (can lead to toxicity).     * Monitoring Labs: LDL, HDL, Triglycerides, ALT/AST, Creatinine Kinase.     * Critical Warning: If patient experiences severe muscle pain, fatigue, or cola-colored urine, hold the medication and call the Healthcare Provider (HCP) immediately.

Hematology, Analgesics, and Steroids

• Epoetin alpha (Epogen)     * Class: Red cell stimulator.     * Action: Stimulates erythropoiesis and oxygen carrying capacity; maintains or increases RBC count.     * Uses: Chronic renal failure anemia, chemotherapy-associated anemia, acute hemorrhage, and pre-operative anemia (especially for Jehovah's Witnesses who refuse blood products).     * Nursing Considerations: Store in the fridge and warm to room temperature before admin. Do not use for bone marrow disorders.     * Administration: IV or SC. Monitor Blood Pressure (BP) and Apical pulse before dosing.     * Monitoring Labs: CBC (H&H). Goal is to keep hemoglobin less than or equal to $12\,g/dL$.     * Adverse Effects: Stroke, MI, DVT, HTN, severe bone pain.     * Black Box Warning: Can alter tumor progression and shorten life in cancer patients. Avoid use if Hg is greater than $12$ due to cardiovascular events.

• Acetaminophen (Tylenol)     * Use: Pain relief and fever reduction; limited anti-inflammatory properties.     * Antidote: Acetylcysteine (Mucomyst).     * Dosing Limits: Max dose for adults is $3,000\,mg/24\,hours$. Toxicity occurs at levels >4,000\,mg.     * Risks: Liver failure (monitor liver labs). Use caution with warfarin due to increased bleeding risk.

• Steroids (Cortisone, Prednisone, Dexamethasone)     * Use: Anti-inflammatory.     * Side Effects: High blood sugars (Diabetes), weight gain, "moon face," "buffalo hump," Peptic Ulcer Disease (PUD), delayed wound healing, insomnia, increased eye pressure (Glaucoma), and Cushing's syndrome.     * Addison's Crisis: A life-threatening event occurring when cortisol is abruptly stopped. Symptoms include shivering, confusion, decreased Level of Consciousness (LOC), high heart rate, low BP, high potassium, and low sodium.

NSAIDs and Pharmacokinetics

• NSAIDs (Non-Steroidal Anti-inflammatory Drugs)     * Mechanism: Inhibits COX-1 and COX-2 enzymes; decreases prostaglandins.     * Pharmacodynamics: Results in decreased pain, inflammation, and fever.     * Generations:         * 1st Generation: Aspirin, Ibuprofen, Toradol.         * 2nd Generation (Selective COX-2): Celebrex (used for juvenile arthritis, ankylosing spondylitis).     * Administration: Take with food to prevent GI upset.     * Dosing: Ibuprofen max per day is $3,200\,mg$.     * Safety: Discontinue $7$ days prior to elective surgery. Avoid "EGGOS" (Vitamin E, Garlic, Ginkgo) due to bleeding risk.     * Major Adverse Effects: GI bleeding, kidney damage, MI, Stevens-Johnson Syndrome (SJS).

• General Pharmacokinetics (ADME)     * Absorption: How the drug enters the bloodstream (route).     * Distribution: How it travels through the tissue.     * Metabolism: How it is broken down, primarily in the liver.     * Excretion: How it leaves the body, primarily via urine.

Endocrinology and Bone Health

• Insulin Table and Timing     * Rapid Acting (Humalog, Novolog): Onset <15\,min, Peak $60-90\,min$, Duration $3-5\,hours$. Inject $10-15\,minutes$ before a meal.     * Short Acting (Regular, Humulin R, Novolin R): Onset $30-60\,min$, Peak $2-5\,hours$, Duration $6-8\,hours$. Inject $20-30\,minutes$ before a meal. Note: Regular is the only insulin given IV.     * Intermediate (NPH): Onset $1-2\,hours$, Peak $1-2.5\,hours$, Duration $18-24\,hours$. Used $2\times/day$; often mixed with rapid/short.     * Long Acting (Lantus, Levemir): Onset $1-2\,hours$. Peak: Lantus has no peak; Levemir $6-8\,hours$. Duration $24\,hours$.     * Mixing Rules: Always draw "Clear to Cloudy" (Rapid/Short first, then NPH).

• Alendronate (Fosamax)     * Class: Bisphosphonate.     * Action: Inhibits osteoclast migration and bone reabsorption.     * Admin: Give $30\,minutes$ before breakfast with a full glass of water. Patient must stay upright for $30\,minutes$ to prevent ESOPHAGITIS.     * Adverse Effects: Osteonecrosis of the jaw, bone pain.

Neurological and Gastrointestinal Medications

• Carbidopa-levodopa (Sinemet)     * Use: Parkinson's first-line for tremors, restless legs; slows disease progression.     * Mechanism: Levodopa converts to dopamine in the brain; Carbidopa blocks levodopa's peripheral breakdown.     * Adverse Effects: Orthostatic hypotension (rise slowly), dark urine/sweat, increased ocular pressure, thrombocytopenia.     * Dietary Caution: Avoid high protein and Iron supplements. Take on time.     * Neuroleptic Malignant Syndrome: Caused by abrupt discontinuation; monitor for fever, rigidity, and altered LOC.

• Bulk Forming Laxatives: Psyllium (Metamucil)     * Action: Increases stool bulk and draws water into the lumen.     * Admin: Drink lots of water; will solidify if it sits. Take $1\,hour$ before or $2-4\,hours$ after other meds.

• Stool Softeners: Docusate (Colace)     * Action: Reduces surface tension; "surfactant acts as detergent to mix fat in stool."     * Use: Post-MI patients (avoid straining).

• Stimulant Cathartics: Bisacodyl (Dulcolax, Senna)     * Action: Irritates GI mucosa. Strongest constipation med; most abused for weight loss.     * Side Effects: Hypokalemia, dehydration.

• Osmotic Laxatives: (Magnesium citrate, Go-lightly, Miralax)     * Lactulose: Unique osmotic used to lower ammonia levels.     * Nursing Notes: Magnesium contraindicated in renal disease. Don't put meds in red/blue liquids.

• Omeprazole (Prislosec)     * Class: Proton Pump Inhibitor (PPI).     * Three P's: 1. Prevent holes (ulcers), 2. Porous bones (osteoporosis risk), 3. Possible infection (C. Diff).     * Admin: Take $30\,minutes$ before breakfast.

Hormone Therapy and Anti-emetics

• Desmopressin acetate (DDAVP)     * Use: Diabetes Insipidus, ADH deficiency, bleeding disorders.     * BBW: Hyponatremia (leads to seizures/death) and water intoxication. Monitor Sodium and LOC.     * Admin: Nasal route; discard after $50$ sprays. Empty bladder before bed.

• Levothyroxine (Synthroid)     * Action: Synthetic T4 converted to active T3.     * Onset: Takes $1\,month$ for lab improvement. Life-long treatment.     * Admin: Empty stomach $30-60\,minutes$ before breakfast. Separate from Ca/Fe/Mg by $4\,hours$.     * Hyperthyroid Symptoms (Overdose): Tachycardia, chest pain, insomnia, weight loss.     * Myxedema Crisis: Occurs if stopped abruptly (low HR, BP, and Temp).

• Ondansetron (Zofran)     * Mechanism: Blocks serotonin receptors.     * Adverse Effects: QT prolongation, diarrhea, Serotonin Syndrome (agitation, muscle rigidity).

Cardiovascular Medications

• Digoxin (Lanoxin)     * Therapeutic Range: $0.5-2.0$.     * Toxicity Signs: GI upset, yellow-green visual halos, bradycardia.     * Nursing: Check Apical pulse; hold if <60\,bpm. Maintain potassium (low K+ increases toxicity risk).     * Antidote: DigiFab.

• Nitrates (Nitroglycerin, Isosorbide)     * Action: Decreases preload and oxygen demand.     * Emergency Admin: $1$ sublingual tablet every $5\,minutes$ ($3$ max). Call $911$ if pain persists.     * Contraindication: Sildenafil (Viagra) within $24\,hours$ (leads to profound hypotension).

• Diuretics     * Potassium Sparing (Spironolactone): Blocks aldosterone. Risk for Hyperkalemia and gynecomastia.     * Potassium Wasting (Furosemide / Lasix, HCTZ): Loop diuretics are strong. Monitor for Hypokalemia (muscle cramps, weakness).

• Beta Blockers (-olol)     * Action: Decreases HR and BP.     * Cardio-selective (Beta 1): Metoprolol, Atenolol (safe for COPD).     * Non-selective (Beta 2): Propranolol, Carvedilol (avoid in COPD/Asthma).     * Side Effects: Can mask hypoglycemia; bradycardia. Hold if HR <60 or SBP <90.

• Calcium Channel Blockers (CCB)     * Non-dihydropyridines (Heart acting): Verapamil, Diltiazem. Lower HR; Verapamil causes constipation.     * Dihydropyridines (Vessel acting): Amlodipine, Nifedipine. Cause peripheral edema and flushing.

• ACE Inhibitors (-pril)     * Side Effects: dry cough (bradykinin build-up), Angioedema (emergency), hyperkalemia.

• ARBs (-sartan)     * Difference: No cough side effect. Contraindicated in Pregnancy.

Respiratory Medications

• Albuterol (Proventil)     * Class: Short-acting beta-2 agonist (SABA).     * Use: Rescue inhaler for acute symptoms. Can cause tremors and tachycardia.

• Ipratropium (Atrovent)     * Class: Anticholinergic bronchodilator.     * Side Effects: Dry mouth, urinary retention.

• Inhaled Steroids (Fluticasone, Budesonide)     * Use: Long-term control; not for rescue. Rinse mouth to prevent oral thrush.

• Guaifenesin (Mucinex)     * Use: Expectorant; thins mucus. Encourage high fluid intake.

Anti-Infective Medications

• Tetracycline: Causes tooth discoloration (avoid in kids <8); no dairy/antacids/iron.

• Sulfonamides (Bactrim): Causes SJS and crystals in urine. Drink $2-3\,L$ fluids/day.

• Metronidazole (Flagyl): Antiprotozoal. No alcohol (disulfiram-like reaction: flushing, vomiting). Metallic taste.

• Macrolides (Erythromycin): "CLOG" (Cardiac QT, Liver, Ototoxicity, GI). Grapefruit avoidance.

• Aminoglycosides (Gentamicin): "EEKK" (Ears and Kidneys - toxic to both). Monitor peak and trough.     * Kidney Signs: BUN >20, Creatinine >1.3, Urine output <30\,ml/hr.

• Ciprofloxacin: "AAA" (Avoid food/dairy, Avoid sun, Achilles tendon rupture). BBW for tendonitis.

• Penicillin: Beta-lactam. Interaction with anticoagulants (bleeding). Do not take with acidic beverages (orange juice).

• Amphotericin B: Antifungal for severe infections. Highly nephrotoxic; causes fever/chills.

Psychopharmacology and Analgesics

• Lithium (Lithobid)     * Therapeutic Level: $0.6-1.2\,mEq/L$.     * Toxicity (>1.5): Confusion, tremors, vomiting. Keep sodium intake consistent.

• SSRIs (Fluoxetine/Prozac): 1st line for depression. Takes $2-4\,weeks$. BBW for suicidal ideation. Risk of Serotonin Syndrome if mixed with MAOIs/Triptans.

• MAOIs (Phenelzine): Prevent breakdown of monoamines. HTN Crisis risk with Tyramine foods (Aged cheese, wine).

• Opioids (Morphine, Fentanyl, Hydromorphone): Bind CNS receptors. Adverse effects: respiratory depression, constipation, sedation. Antidote: Narcan. Fentanyl patches changed every $72\,hours$.

Miscellaneous Nursing and Diagnostics

• Antidotes Summary     * Heparin: Protamine sulfate     * Warfarin: Vitamin K     * Opioids: Naloxone     * Benzodiazepines: Flumazenil     * Acetaminophen: Acetylcysteine     * Digoxin: Digifab

• Lab Review     * Low WBC: Infection risk     * Low Platelets: Bleeding risk     * Low RBC: Anemia     * Serum Peaks: Highest concentration (tox risk)     * Serum Troughs: Lowest concentration (draw before next dose)     * Liver Labs: ALT, AST     * Renal Labs: eGFR, Creatinine, BUN, Urine Output