Pharmacology Exam I Review

Neuropathy and Neuropathic Pain Medications

• Tramadol     * Warnings:         * The drug carries a significant suicide risk in individuals presenting with suicidal ideation.         * Risk of Seizures.

• Gabapentin     * Teaching: Patients must be instructed to report rapid weight gain immediately.

• Pregabalin     * Adverse Drug Reactions (ADR):         * Dizziness.         * Suicidal ideation.     * Patient Teaching:         * The patient must consume NO alcohol or other CNS depressants.         * The patient must report any mood changes or occurrences of suicidal ideation.

Cardiovascular and Peripheral Vascular Conditions

• Chest Pain     * Sublingual (SL) Nitroglycerin is the standard medication used for chest pain.

• Intermittent Claudication     * Definition: Cramping that occurs during activity and is subsequently relieved by rest, caused by an artery narrowed by plaque.     * Pentoxifylline         * Mechanism of Action (MOA): Improves blood flow.         * Effectiveness/Monitoring: Observe and document the patient's pain level using a numerical scale to evaluate the drug's effect.

Chronic vs. Acute Gout Management

• Chronic Gout Management     * Mnemonic: "Probe All Chronic Gout"     * Allopurinol ("allow no more")         * MOA: Stops the production of uric acid.         * ADRs:             * Hypersensitivity reaction, specifically Stevens-Johnson Syndrome (SJS).             * Agranulocytosis, indicated by symptoms such as fever, sore throat, and signs of infection.     * Probenecid ("pro-excretion")         * MOA: Increases the excretion of uric acid.

• Acute Gout Management     * Treatment Overview: Acute gout can be treated on an as-needed (PRN) basis.     * Non-pharmacological intervention: Apply a cold compression to the affected area.     * Pharmacological Treatments:         * NSAIDS: Used as an analgesic.         * Glucocorticoids: Provide anti-inflammatory effects.         * Colchicine (Mnemonic: "A cute coal")             * MOA: Anti-inflammatory.             * Indications: Used specifically for acute flare-ups.             * Expected outcome: Pain is typically relieved within $1-2$ days.             * ADR: GI toxicity, characterized by nausea, vomiting, and diarrhea. If these occur, the patient must STOP the medication and notify the physician immediately.

Aspirin (Acetylsalicylic Acid): Pharmacology and Nursing Considerations

• Classification and MOA     * Class: First-generation Non-Steroidal Anti-Inflammatory Drug (NSAID).     * MOA: Irreversible blocking of Cyclooxygenase-1 (COX-1) enzymes.

• Uses     * Prevention of clotting; decreases risk of Myocardial Infarction (MI) and stroke.     * Analgesic (pain relief).     * Anti-inflammatory.     * Antipyretic (fever reduction).

• Nursing Considerations and Monitoring     * Monitor for bleeding and assess kidney function regularly.     * Surgery: Aspirin must be discontinued $5-7$ days before a procedure due to the high risk of bleeding.     * Administration:         * Take with food or milk to reduce Gastric irritation.         * Do NOT chew or crush the tablets.     * OTC Watch: Many over-the-counter drugs contain Aspirin or Salicylate. Caution is required with:         * Alka-Seltzer (e.g., Alka-Seltzer Plus Severe Cold).         * Pepto Bismol (e.g., Pepto Bismol Ultra).         * Excedrin (Excedrin Migraine Relief contains Acetaminophen $250\,mg$, Aspirin $250\,mg$, and Caffeine $65\,mg$).

• Interactions     * NSAIDS: Increases risk of GI bleeding.     * Corticosteroids: Increases risk of GI ulcers.     * Alcohol: Enhances bleeding risk.     * Anticoagulants: Significantly increases bleeding risk.

• Signs of Bleeding     * Melena (black, tarry stools).     * Severe abdominal pain.     * Coffee-ground emesis.     * Diagnostic Actions: Monitor CBC (Hemoglobin and Hematocrit) and perform a guaiac occult stool test.

• Reye's Syndrome     * Occurs when Aspirin is given to children $<12\text{ years}$ old who have recently been sick (e.g., VZV infection).     * Can occur up to $6\text{ weeks}$ after receiving the varicella vaccine.     * Precaution: Avoid Aspirin for several weeks ($\sim 3\text{ weeks}$) after viral illness or vaccination.     * Symptoms: Sudden swelling in the brain (Encephalopathy) and liver (Hepatomegaly), neurological deficit, confusion, lethargy, liver damage, and coma.

• Aspirin Toxicity (Salicylate Poisoning)     * Mnemonic: CRASHED         * C: Confusion.         * R: Renal failure.         * A: Antipyretics needed (for hyperthermia).         * S: Sound in ears (Tinnitus/R-I-N-G).         * H: Hemorrhage (GI ulcers/bleeding).         * E: Emesis (Nausea/vomiting).         * D: Dehydration.     * Additional symptom: Lethargy.

• Contraindications     * Same as general NSAIDs (GI ulcers, bleeding issues, late pregnancy).     * Salicylate hypersensitivity.     * History of Asthma (a "red flag" in some patients).     * Age under $12\text{ years}$ with recent viral illness.

Sucralfate

• Function and MOA     * Activation: Requires a stomach pH level of $<4$ to trigger the drug reaction.     * Action: Forms a sticky gel that adheres to the ulcer site, creating a physical barrier against hydrogen ions ($H+$), gastric acid, and other irritants.     * Purpose: Assists with healing irritated areas and protection of gastric ulcers.

• Administration Guidelines     * Administer on an EMPTY stomach.     * Timing: $1\text{ hour}$ before meals and at bedtime.     * Interactions: Other drugs should be administered either $2\text{ hours}$ before or $2\text{ hours}$ after Sucralfate.

Acetaminophen

• Classification and MOA     * Class: Nonopioid Analgesic.     * MOA: Operates in the hypothalamus to decrease body temperature and modulate pain perception.     * Distinct Lack of Effects: Unlike NSAIDs, Acetaminophen does NOT affect inflammation, platelet aggregation, gastric ulceration, or renal blood flow/function.

• Uses     * Mild-to-moderate pain.     * Antipyretic effects.     * Frequently combined with opioid analgesics (e.g., Tylenol #3 contains Acetaminophen $300\,mg$ and Codeine Phosphate $30 mg$).     * Treatment of headaches.

• Adverse Effects and Monitoring     * Overdose: Taking $>4\,g/day$ leads to overdose and severe liver damage.     * Half-life: Short half-life; can be administered every $4\text{ hours}$.     * Therapeutic Range: $5-25\,mcg/mL$ serum acetaminophen is considered normal.     * Liver Toxicity Signs: Jaundice, abdominal pain, dark urine, pale stool, and fatigue. Nurses must check ALT and AST levels.     * Nursing Actions: Frequent reassessment of vital signs, liver function tests (LFTs), and serum acetaminophen levels.     * Antidote: Acetylcysteine (Mucomyst).

• Contraindications and Precautions     * Hypersensitivity.     * Alcoholism.     * Hepatitis.

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

• First-Generation (Non-selective)     * MOA: Inhibit both COX-1 and COX-2.         * COX-1 Inhibition: Reduces platelet aggregation (increasing bleeding), weakens stomach lining, and alters renal blood flow.         * COX-2 Inhibition: Produces analgesic effects, decreases inflammation, and reduces fever.     * Generic Examples: Ibuprofen, Indomethacin, Diclofenac, Naproxen ($220\,mg$ units), and Ketorolac.

• Second-Generation (Selective COX-2 Inhibitors)     * MOA: Primarily target COX-2; less effect on platelet aggregation, renal function, and gastric mucosa.     * Examples: Celecoxib, Meloxicam.     * Uses: Acute pain, menstrual pain, osteoarthritis, rheumatoid arthritis, musculoskeletal pain.     * Administration: Give with food or milk to prevent GI upset.

• NSAID Patient Teaching     * Take with meals/milk.     * Do not exceed recommended daily dosage.     * Avoid concurrent use with Aspirin, Alcohol, or Corticosteroids due to GI distress risk.     * Ketorolac Limit: Do not take for more than $5\text{ days}$. Maximum dose is $40\,mg/day$.     * Discontinue NSAIDs $5\text{ days}$ before major surgery.     * Report black, tarry stools immediately.

• NSAID Side Effects and Monitoring     * Monitor: Renal function (Creatinine, BUN, urine output), Hematuria, Melena, CBC, Pain level, Blood Pressure, Cardiovascular status, and Weight Gain.     * SE/ADRs: Fluid retention, edema, Hypertension, GI ulceration, bleeding, nausea, vomiting, photosensitivity, and dyspepsia.     * Contraindications: Hypertension, Edema, Heart Failure (HF), Chronic Kidney Disease (CKD). High risk for patients prone to stroke or MI.     * Drug Interactions: Nephrotoxic meds (e.g., aminoglycosides), anticoagulants, antiplatelets, corticosteroids.

Opioid Analgesics

• Mechanism and Receptors     * Agonists to Mu and Kappa opioid receptors.     * Mu Receptor: Responsible for the majority of analgesia, but also causes most SE/ADRs.     * Kappa Receptor: Provides some analgesia and aids in sedation.

• Opioid Potency (Strongest to Weakest)     1. Fentanyl     2. Heroin     3. Morphine     4. Hydromorphone     5. Oxycodone     6. Hydrocodone     7. Codeine     8. Tramadol

• Side Effects and Adverse Reactions (Opioids relax the body)     * Respiratory Depression: Muscles/neurons for breathing are suppressed. If Respiratory Rate (RR) is $<12$, withhold the medication. Have Naloxone on standby.     * Orthostatic Hypotension: Caused by vasodilation.     * Constipation and Urinary Retention: Inhibition of gastric emptying/peristalsis. (Note: The ureters use peristalsis to move urine).     * Other: Sedation, confusion, N/V, miosis (pinpoint pupils), and itching.

• Major Opioid Medications     * Pure Agonists: Morphine, Meperidine (Demerol), Oxycodone (Percocet), Tramadol (Ultram), Methadone, Hydromorphone (Dilaudid), Hydrocodone (Vicodin), Fentanyl (Sublimaxe, Duragesic), Codeine (Tylenol 3).     * Agonist-Antagonists: Buprenorphine, Pentazocine, Nalbuphine.

• Opioid Concepts and Toxicity     * Tolerance: Develops for euphoria, sedation, and analgesia. Higher doses required for the same effect.     * No Tolerance: No tolerance develops for Miosis or Constipation; these effects persist.     * Withdrawal Syndrome: Occurs $10\text{ hours}$ after the last dose. Symptoms include sweating, yawning, rhinorrhea, anorexia, irritability, tremor, "goosebumps", violent sneezing, weakness, N/V, diarrhea, cramps, and muscle/bone pain. Symptoms last $7-10\text{ days}$. Unlike alcohol withdrawal, opioid withdrawal is generally not life-threatening.     * Toxicity Triad: Coma, Respiratory Depression, and Pinpoint Pupils.     * Meperidine Note: Lower seizure threshold; higher risk for hallucinations and confusion. Avoid in older individuals.     * Patient Controlled Analgesia (PCA): Keeps drug concentration in the narrowest therapeutic range for consistent relief.

Opioid Reversal: Naloxone (Narcan)

• General Information     * Mechanism: Opioid antagonist that displaces opioid molecules from receptor sites, allowing rapid reversal of effects and respiratory depression.     * Half-life: Narcan has a shorter half-life ($1-1.5\text{ hours}$) than opioids like Morphine ($2-4\text{ hours}$); multiple doses may be necessary.     * Administration: IV is preferred; can be nasal ($4\,mg$ doses), IM, or SubQ.     * Patient Response: Reversal causes loss of euphoria and analgesia; the patient may wake up angry or in pain.

Pharmacology Mnemonics

• Photosensitivity ("Fun in The Sun")     * Fluoroquinolones     * Tetracyclines     * Sulfonamides

• Oral Contraceptive Efficacy Reduction ("MS. PCT works with kids")     * Macrolides     * Sulfonamides     * Penicillins     * Cephalosporins     * Tetracyclines

• No Dairy ("mooove The Food")     * Tetracyclines     * Fluoroquinolones

• Hepatotoxicity ("My Silly Funny (Liver) Is Always Taking Naps")     * Macrolides     * Sulfonamides     * Fluoroquinolones     * Interferons     * -Azoles     * Terbinafine     * Nitrofurantoin

• Nephrotoxicity ("VACAnt bike")     * Vancomycin     * Aminoglycosides     * Cyclosporine     * Amphotericin B

• No Alcohol ("No alc until done with MCAT")     * Metronidazole     * Cephalosporins     * -Azoles     * Terbinafine

Miscellaneous Supplements and Antivirals

• Vitamin C (Ascorbic Acid): Vital for wound healing, connective tissue maintenance, tissue repair, and enhancing iron (Fe) absorption.

• Echinacea: Used topically for wounds/canker sores; used orally for common colds to stimulate the immune system.

• Interferons (Immune Modifiers)     * Uses: Hepatitis C treatment.     * Monitor: Depression/suicidal ideation, Hepatotoxicity, Myelosuppression (Check CBCs and LFTs).     * Combination Therapy (Interferon Alpha + Ribavirin): Associated with anemia (fatigue) and decreased hemoglobin.

• Hepatitis C and HIV Therapy     * Hepatitis C Goal: Reduce viral load and liver inflammation. No vaccine exists.     * HIV Antiretroviral Therapy: Uses at least $3$ medications to decrease resistance. Goal is an undetectable viral load ($<50\text{ copies/mL}$). This does NOT cure HIV or completely prevent transmission.

• Antiviral Specifics     * Influenza: Oseltamivir (Tamflu), Zanamivir, Peramivir. Give within $2\text{ days}$ of onset.     * Herpes Simplex: Acyclovir is the drug of choice for HSV-1 and HSV-2.