Comprehensive NAPLEX Clinical Pharmacy & Pharmacotherapy Study Guide

Oncology Management: IV Administration and Extravasation

• Vesicants: Many chemotherapy agents are classified as vesicants, meaning they cause necrosis (tissue death) if the drug accidentally leaks from the vein into surrounding tissue, a process known as extravasation.
• Major Vesicants:     1. Anthracyclines     2. Vinca Alkaloids
• Extravasation Management:     * General Protocol: Apply cold compresses to the site.     * Exceptions: For vinca alkaloids and etoposide, use warm compresses instead of cold.
• Drug-Specific Antidotes:     * Anthracyclines: Treat with dextrazoxane (Totect) or dimethyl sulfoxide.     * Vinca alkaloids and etoposide: Treat with hyaluronidase.

Oncology Support: Anemia and Neutropenia

• Anemia Assessment: Hemoglobin (Hgb) levels are used to assess anemia. Anemia can recover spontaneously, via Red Blood Cell (RBC) transfusion, or rarely with Erythropoiesis-Stimulating Agents (ESAs).
• Erythropoiesis-Stimulating Agents (ESAs):     * Examples: Erythropoietin (epoetin alfa; Epogen, Procrit) and the longer-acting darbepoetin alfa (Aranesp).     * Risks: ESAs can shorten survival and increase tumor progression. They are not recommended for patients receiving chemotherapy with curative intent.     * Initiation Threshold: Initiate only when Hgb < 10\,g/dL. Use the lowest dose necessary to avoid RBC transfusions.
• Absolute Neutrophil Count (ANC): Use the following formula to calculate neutrophil counts:     * $ANC\,(cells/mm^3) = WBC \times [(\%segs + \%bands)/100]$

Chemotherapy-Induced Toxicities and Nausea

• Peripheral Neuropathy: Associated with the following classes:     1. Vinca alkaloids (vincristine, vinblastine, vinorelbine)     2. Platinums (cisplatin, oxaliplatin)     3. Taxanes (paclitaxel, docetaxel, cabazitaxel)
• Chemotherapy-Induced Nausea and Vomiting (CINV):     1. Acute CINV: Occurs within $24\,hours$ after chemotherapy. Treated with $5HT3$ receptor antagonists.     2. Delayed CINV: Occurs > 24\,hours after chemotherapy. Treated with NK1-RA, corticosteroids, palonosetron, or granisetron ER SC (the only $5HT3$-RAs with labeled indication for delayed emesis), and olanzapine.     3. Anticipatory CINV: Occurs before chemotherapy. Treated with Benzodiazepines.

IV Medication Management: Containers, Dilution, and Filtration

• Leaching/Absorption Issues with PVC Containers:     * Lorazepam     * Amiodarone     * Tacrolimus     * Taxanes (except paclitaxel-albumin bound, Abraxane)     * Insulin     * Nitroglycerin
• Dilution Requirements:     * Saline Only (No Dextrose): Ampicillin, Daptomycin (Cubicin), Infliximab (Remicade), Ampicillin/Sulbactam (Unasyn), Caspo fugin (Invanz), Phenytoin (Dilantin).     * Dextrose Only (No Saline): Bactrim (SMX/TMP), Oxaliplatin, Amphotericin B, Synercid (Quinupristin/Dalfopristin).
• Filter Requirements:     * Golimumab (Simponi)     * Amiodarone     * Lorazepam (for continuous infusion, not IV push)     * Phenytoin (for continuous infusion, not IV push)     * Lipids: Use a $1.2\,micron$ filter.     * Amphotericin B (lipid formulations): Prepare using a $5\,micron$ filter.     * Taxanes (except docetaxel).
• Refrigeration Warnings (Do Not Refrigerate):     * Dexmedetomidine (Precedex)     * SMX/TMP (Bactrim)     * Phenytoin (Crystallizes if refrigerated)     * Metronidazole     * Moxifloxacin (Avelox)     * Enoxaparin (Lovenox)
• Light Protection During Administration:     * Phytonadione (Vitamin K; Mephyton)     * Epoprostenol (Flolan)     * Nitroprusside (Nitropress)     * Micafungin (Mycamine)     * Doxycycline

Cardiovascular Medications: Carvedilol and Hypertensive Crises

• Carvedilol (Coreg, Coreg CR):     * Classification: Nonselective Beta-Blocker and Alpha1 Blocker.     * Counseling: Take all forms with food to decrease the rate of absorption and the risk of orthostatic hypotension.     * CR vs. IR Dosing: Carvedilol CR has less bioavailability; dosing is not $1:1$. (Example: Coreg $3.125\,mg$ BID equals Coreg CR $10\,mg$ daily).
• Hypertensive Crises (BP $\ge 180/130\,mmHg$):     * Emergency: Acute target organ damage (stroke, AKI, encephalopathy). Treat with IV medications. Decrease BP by no more than $25\%$ within the first hour.     * Urgency: No acute organ damage. Treat with oral medications and decrease BP gradually over $24-48\,hours$.     * Key IV Hypertension Meds: Chlorothiazide, Clevidipine, Diltiazem, Enalaprilat, Esmolol, Hydralazine, Labetalol, Metoprolol tartrate, Nicardipine, Nitroglycerin, Nitroprusside, Propranolol, Verapamil.

Clinical Reference Guides ("Color Books")

1. Orange Book (FDA): Approved drugs and therapeutic equivalence (generics).
2. Pink Book (CDC): Epidemiology and vaccine-preventable diseases.
3. Pink Sheet (Pharma Intelligence): Regulatory, legislative, and business news.
4. Purple Book (FDA): Biological products and biosimilars.
5. Red Book (Pharmacy): Drug pricing.
6. Red Book (Pediatrics/AAP): Summaries of pediatric infectious diseases and antimicrobial treatment.
7. Yellow Book (CDC): Health risks of international travel and travel vaccines.
8. Green Book (FDA): Approved animal drug products.

Infectious Disease: Oxazolidinones and Specific Antibacterials

• Linezolid (Zyvox):     * Gram-Positive Coverage: Includes Vancomycin-Resistant Enterococcus (VRE).     * Dosing: No adjustment for renal impairment. IV to PO ratio is $1:1$.     * Contraindications: Use with or within $14\,days$ of MAO inhibitors.     * Warnings: Duration-related myelosuppression ($thrombocytopenia$, anemia, leukopenia), peripheral/optic neuropathy if used > 28\,days, serotonin syndrome, and hypoglycemia.     * Side Effects: Decreased platelets.     * Note: Do not shake Linezolid.
• Alvimopan (Entereg): Used for hospitalized surgery patients to reduce post-operative ileus. Max $15\,doses$. Boxed warning for MI with long-term use. Contraindicated if opioids used for > 7\,consecutive\,days.
• Daptomycin (Cubicin, Cubicin RF):     * Prohibited Use: Do not use for pneumonia (inactivated by surfactants).     * Warnings: Myopathy, rhabdomyolysis. Can falsely increase PT/INR.     * Monitoring: Weekly CPK levels.     * Dilution: Cubicin compatible with NS only; Cubicin RF compatible with NS.

Pathogen-Specific Drug of Choice

• MSSA: Dicloxacillin, Nafcillin, Oxacillin, 1st/2nd gen cephalosporins (Cefazolin, cephalexin), Amoxicillin/clavulanate.
• CA-MRSA (SSTIs): SMX/TMP, Clindamycin, Linezolid.
• Severe MRSA SSTIs (IV): Vancomycin, Linezolid, Daptomycin, Ceftaroline.
• Nosocomial MRSA: Vancomycin, Linezolid, Daptomycin (except pneumonia).
• VRE (E. faecalis): Pen G/ampicillin, Linezolid, Daptomycin. (Cystitis only: nitrofurantoin, fosfomycin, doxycycline).
• VRE (E. faecium): Daptomycin, Linezolid. (Cystitis only: nitrofurantoin, fosfomycin, doxycycline).
• Pseudomonas aeruginosa: Piperacillin/Tazobactam, Cefepime, Ceftazidime, Ceftazidime/Avibactam, Carbapenems (except ertapenem), Ciprofloxacin, Levofloxacin, Aztreonam, Aminoglycosides.
• ESBL GNRs: Carbapenems, Ceftolozane/Tazobactam.
• CRE: Ceftazidime/Avibactam, Polymyxin B, Colistimethate.
• Bacteroides fragilis: Metronidazole, Carbapenems, Cefotetan, Cefoxitin.
• C. difficile: Oral Vancomycin, Fidaxomicin.
• Atypical Organisms: Azithromycin, Doxycycline, Quinolones.

Human Immunodeficiency Virus (HIV) Therapy

• Initial One-Pill, Once-Daily Regimens:     1. Biktarvy (Bictegravir / Emtricitabine / Tenofovir alafenamide)     2. Triumeq (Dolutegravir / Abacavir / Lamivudine)     3. Dovato (Dolutegravir / Lamivudine) - The only preferred regimen with only 1 NRTI.
• Two-Pill Regimens: Usually an INSTI + a combo NRTI tablet (Truvada or Descovy).
• NRTI Key Pointers: Require dose reduction in renal impairment (except abacavir). Zidovudine is used IV during labor. Avoid older NRTIs due to lactic acidosis/hepatomegaly risk. Abacavir requires hypersensitivity testing.
• INSTIs (-tegravir): Block integrase. Separate from Al/Mg products (2 hours before or 6 hours after). Dolutegravir has neural tube defect risks and hepatotoxicity.
• NNRTIs:     * Rilpivirine (Edurant): Take with a meal and water; requires acidic environment (avoid PPIs).     * Efavirenz (Sustiva): Take on an empty stomach at bedtime (QHS) due to CNS effects.     * Atripla: Efavirenz / Emtricitabine / Tenofovir DF; no longer 1st line due to psych issues.
• Tenofovir Forms: Tenofovir DF has more renal and bone issues than the newer Tenofovir AF form.

Neurology: Parkinson Disease and Urinary Incontinence

• Dopamine Blockers (Worsen PD): Prochlorperazine, Haloperidol, Droperidol, Risperidone, Metoclopramide.
• Dopamine Agonists: Pramipexole (Mirapex), Ropinirole (Requip). SE: sudden daytime sleep attacks, hallucinations.
• Quetiapine (Seroquel): Lowest EPS risk; used for psychosis in PD. Take XR at night without food.
• Urinary Incontinence (Anticholinergics):     * Block Acetylcholine. ER is preferred over IR for lower dry mouth risk.     * M3 Selective (Fever CNS SE): Solifenacin, Darifenacin, Fesoterodine.     * Oxybutynin: Ditropan XL (OROS shell), patch/gel (lower dry mouth risk).     * Alternative: Mirabegron (lower dry mouth incidence).

Transdermal Patch Sites and Frequencies

• Locations:     * Xulane: Back, abdomen, buttock.     * Daytrana: Hip.     * Vivelle-Dot: Lower abdomen.     * Transderm-Scop: Behind the ear.
• Frequencies:     * Daily: Methylphenidate (Daytrana - 2hrs before school), Nicotine, Rivastigmine, Rotigotine.     * Daily (Special): Lidocaine (12 on / 12 off), Nitroglycerin (12-14 on / 10-12 off).     * Twice Weekly: Alora, Vivelle-Dot, Oxytrol (Oxybutynin).     * Weekly: Buprenorphine (Butrans), Clonidine (Catapres-TTS), Climara (Estradiol).     * Every 72 Hours: Fentanyl (can change to Q48H if worn off), Scopolamine.

Bone Health and Pain Management

• Osteoporosis:     * Bisphosphonates: 1st line. Must stay upright and drink $8\,oz$ water. Duration restricted to $3-5\,years$.     * Denosumab (Prolia): Alternative; SC every $6\,months$. Lowers calcium.     * Teriparatide (Forteo): PTH analog. Increases formation. High risk patients. Lifetime limit of $2\,years$. Side effect: hypercalcemia.
• Opioid Conversions:     * Morphine PO to Inj: $3 : 1$     * Dilaudid PO to Inj: $5 : 1$     * Morphine PO to Oxycodone: $1.5 : 1$     * Fentanyl Patch Conversion: Fentanyl $100\,mcg/hr \div 1.8 = 180\,mg\,MS/day$.
• Centrally Acting Analgesics: Tramadol (C-IV) and Tapentadol (C-II). Both mu-agonists and NE reuptake inhibitors. Tramadol inhibits serotonin and requires CYP2D6 activation.

Seizures, Asthma, and Hazardous Drugs

• Phenytoin: Therapeutic range $10-20\,mcg/mL$ (total); $1-2.5\,mcg/mL$ (free). IV max rate $50\,mg/min$ (Phenytoin) and $150\,mg\,PE/min$ (Fosphenytoin). Chronic SE: Gingival hyperplasia, hair growth.
• Asthma Steps:     * Step 1: PRN low-dose ICS + formoterol.     * Step 3: Low-dose ICS + LABA.
• Nutrient Depletion: Antiepileptics ($\downarrow$ Calcium), Metformin ($\downarrow$ B12), Methotrexate ($\downarrow$ Folate), PPIs ($\downarrow$ Magnesium, B12).
• Teratogens (Pregnancy Dangers): Isotretinoin, Quinolones, Tetracyclines, Warfarin, Statins, ACE inhibitors/ARBs, Valproic Acid, Topiramate, Lithium.
• Lamotrigine Starter Kits:     * Orange: Standard dosing.     * Blue: Lower dose (use with Valproic Acid).     * Green: Higher dose (use with enzyme inducers like Phenytoin).