Pharmacology Unit 3 Exam Review

Unit 3 Exam Review: High-Yield Topics and Testable Concepts

• Testable Medication Categories:

  • Estrogens, Progesterone, and Birth Control.

  • Selective Estrogen Receptor Modulators (Raloxifene).

  • Androgens (Testosterone, Oxandrolone).

  • Phosphodiesterase-5 (PDE-5) Inhibitors (Sildenafil).

  • Prostaglandin Analogs (Misoprostol).

  • Thyroid Hormones and Antithyroid Agents (Levothyroxine, Radioactive Iodine).

  • Osteoporosis Agents (Alendronate, Calcium, Vitamin D).

  • Pituitary Hormones (Somatropin, Octreotide, Desmopressin).

  • Adrenal System Medications (Corticosteroids, Fludrocortisone).

  • Diabetes Medications (Insulin, Metformin, Semaglutide, Glyburide).

  • Calculations: Insulin, Heparin, and Pediatric dosages.

Estrogens and Oral Contraceptive Therapy

• Purpose and Indications:

  • Primarily used for managing menopause symptoms, low estrogen states, and hormone replacement therapy (HRT).

  • Natural Source: Primarily produced in the ovaries; smaller amounts from adrenal glands and fat tissue. The placenta produces estrogen during pregnancy.

  • Release Trigger: The brain sends Gonadotropin-Releasing Hormone (GnRH) $\rightarrow$ the anterior pituitary releases Follicle-Stimulating Hormone (FSH)/Luteinizing Hormone (LH) $\rightarrow$ the ovaries produce estrogen.

  • Normal Function: Builds the uterine lining, supports female secondary sex characteristics, and maintains bone density.

  • Mechanism of Action (MOA): Binds to estrogen receptors to activate estrogenic effects in target tissues (uterus, breasts, bones, brain, blood vessels).

• Formulations and Administration:

  • Tablets: Taken orally once daily as ordered.

  • Patches: Applied to the abdomen or shoulder. Patients must rotate the site daily and avoid placing it in the same spot twice in a row.

• Patient Education and Safety:

  • Stopping Therapy: Do not stop hormones suddenly, even if feeling better; they typically require a taper.

  • Alcohol Contradiction: Do not consume alcohol (e.g., wine) with estrogen/steroid hormone therapy. Alcohol suppresses the Central Nervous System (CNS) and impairs immune and gut function.

  • Smoking Contradiction: Smoking is strictly prohibited. It significantly increases the risk of thromboembolic events.

• Serious Risks and Adverse Reactions:

  • Thromboembolic Events: Estrogen and progesterone (alone or combined) carry a high risk for blood clots (DVT), Pulmonary Embolism (PE), stroke, and Myocardial Infarction (MI).

  • Contraindications/Focus Points: Risk is highest in patients over age $35$, smokers, those with a history of clots, hypertension, or migraines with aura.

  • Other Side Effects: Nausea, headache, breast tenderness, bloating/fluid retention, breakthrough bleeding, gallbladder/liver problems, and endometrial cancer risk if estrogen is used without progesterone in a patient with a uterus.

Progesterone and Norethindrone

• Norethindrone: A progesterone-only birth control pill.

• Mechanism of Action: Circulating estrogen/progesterone levels signal the brain that the body is "pregnant," suppressing FSH and LH from the anterior pituitary.

  • FSH Function: Creating and maturing the egg; supporting sperm production.

  • LH Function: Maturing the egg; supporting reproductive function.

• Main Effect: Prevents ovulation and thickens cervical mucus.

• Patient Teaching: Take every day at the same time. If a dose is missed, follow specific medication instructions immediately.

• Serious Reporting (ACHES):

  • A: Abdominal pain (severe).

  • C: Chest pain or Shortness of Breath (SOB).

  • H: Headache (severe).

  • E: Eye/vision changes.

  • S: Severe leg pain.

Raloxifene (Selective Estrogen Receptor Modulator)

• Purpose: Prevention and treatment of osteoporosis, typically in post-menopausal women.

• Mechanism: Acts as an estrogen agonist specifically in the bone. It stimulates estrogen receptors to put calcium into the bone and prevents bone breakdown by inhibiting osteoclast activity.

• Benefits: Prevents bones from becoming weak, brittle, or easily broken.

• Adverse Reactions:

  • Common: Hot flashes, leg cramps, sweating, joint pain, flu-like symptoms.

  • Serious: DVT/PE and stroke.

  • Nursing Pearl: Notify the provider and stop the medication before long periods of immobility to minimize clot risk.

Testosterone and Oxandrolone (Anabolic Steroids)

• Indicatons: Male hypogonadism (failure of testes to produce enough testosterone), muscle loss from severe burns/injury, and rebuilding muscle mass.

• Natural Release: Hypothalamus (GnRH) $\rightarrow$ Pituitary (LH) $\rightarrow$ Testes (Testosterone).

• Effects: Increased muscle mass, fat redistribution, male sexual development, sperm maturation, and strength.

• Safety and Warnings:

  • Organ Toxicity: Highly stressful to the liver and kidneys.

  • Abuse Potential: Unexpected increases in muscle mass may indicate overuse or abuse.

  • Contraindications: Older patients ($69-70$ years old) with cirrhosis, liver inflammation, or kidney disease should not receive Oxandrolone.

  • Pediatric Warning: Can cause early epiphyseal closure (closing growth plates too early), limiting final adult height.

  • Side Effects: Acne, oily skin, mood changes/aggression, fluid retention, hypertension, increased cholesterol, polycythemia (clot risk), and virilization in females.

Sildenafil (Viagra)

• Indicatons: Erectile dysfunction (ED) and pulmonary hypertension.

• Dangerous Interaction: Do NOT take with Nitroglycerin or other nitrates. Nitroglycerin is a vasodilator used for angina. Combining them leads to severe hypotension, dangerous BP drops, and possible coma. Take at least $1$ full day apart.

• Adverse Effects:

  • Priapism: An erection lasting longer than $4$ hours. This is a medical emergency that can cause permanent damage and future inability to maintain erections.

  • Other: Headache, flushing, dizziness, nasal congestion, and sudden vision or hearing loss.

Misoprostol (Cytotec)

• Indicatons:

  • Reproductive: Labor induction, uterine contractions, medication abortion.

  • GI: Treatment and prevention of peptic ulcer disease by coating and protecting the ulcer from stomach acid.

• Uterine Effects: Causes powerful contractions. It may be inserted vaginally or taken orally.

• Pregnancy Warning: This is a major contraindication for GI use. If a patient taking it for ulcers discovers they are pregnant, they must stop the medication and contact the provider immediately due to the risk of miscarriage/abortion.

• Memory Tip: "Misoprostol/Cytotec cannot get pregnant."

Thyroid Disorders and Levothyroxine

• Hypothyroidism Management (Levothyroxine):

  • Synthetic $T_4$ that converts to $T_3$ in the body to control metabolism, heart rate, and energy.

  • Administration: Take in the morning on an empty stomach with a full glass of water, $30-60$ minutes before eating.

  • Interactions: Binds with vitamins, calcium, and Vitamin D. These must be separated from levothyroxine by at least $30-60$ minutes (though $4$ hours is the preferred test answer for safety).

  • Adverse Effects (Toxicity): Nervousness, tremors, insomnia, tachycardia, palpitations, heat intolerance, and weight loss (resembles hyperthyroidism).

• Hyperthyroidism (Graves Disease):

  • Symptoms: Heat intolerance, exophthalmos (bulging eyes), hypertension, tachycardia, weight loss, and goiter.

  • Radioactive Iodine Treatment: Used to destroy overactive thyroid tissue.

  • Post-Treatment Risks: Can cause permanent hypothyroidism. If the nearby parathyroid glands are damaged, it can lead to hypocalcemia.

Bone Health: Alendronate and Calcium

• Alendronate (Bisphosphonate):

  • Used for osteoporosis.

  • Administration: Take with a full glass of water and remain upright (sitting or standing) for at least $30$ minutes. This prevents severe esophagitis and esophageal ulcers.

  • Spacing: Separate from calcium and other medications by $30$ minutes to $2$ hours (preferably $4$ hours on exams).

• Calcium Citrate / Vitamin D:

  • Promotes bone growth and prevents hypocalcemia. Vitamin D is required for calcium absorption and is activated by the kidneys.

  • Side Effects: Kidney stones, hypercalcemia (confusion/weakness), and constipation.

Growth Hormone: Somatropin and Octreotide

• Somatropin:

  • Used for growth hormone deficiency. Stimulates bone and muscle growth.

  • Administration: Subcutaneous injection (abdomen or arm).

  • Nursing Practice: The best way to verify understanding is for the patient to perform a teach-back demonstration of the injection.

  • Adverse Effects: Hyperglycemia, intracranial hypertension, and slipped capital femoral epiphysis (report hip/knee pain).

• Octreotide:

  • The "OFF switch" for growth hormone. Used for gigantism (children) and acromegaly (adults).

  • Suppresses growth hormone and GI hormones.

  • Serious Risks: Gallstones, bradycardia, and pancreatitis.

Diabetes Insipidus (DI) and Desmopressin

• Condition: DI is a water problem involving Antidiuretic Hormone (ADH), not a blood sugar problem.

• Symptoms: Excessive urination, excessive thirst, dehydration, poor skin turgor (tents and stays up), and low blood pressure.

• Potassium ($K^+$) Concern: Monitor $K^+$ levels as abnormalities affect heart rhythm.

• Desmopressin (DDAVP):

  • Acts as synthetic ADH to retain water.

  • Administration: Often IV or Subcutaneous in hospital settings.

  • Monitoring: Check daily weights and Intake/Output (I&O).

  • Laboratory Focus: Sodium ($Na^+$). Excessive water retention can lead to dilutional hyponatremia. Low sodium leads to cerebral swelling, altered level of consciousness, and seizures.

  • Emergency: If the patient is not urinating while on desmopressin, it is an emergency indicative of water intoxication.

Adrenal Disorders and Corticosteroids

• Adrenal Insufficiency (Addison's Disease):

  • A medical emergency. Symptoms include hypotension, bradycardia, and altered level of consciousness (coma).

  • Fludrocortisone: Synthetic aldosterone (mineralocorticoid). It retains sodium and water and excretes potassium.

  • Memory Tip: "Addison has the FLU" (Fludrocortisone).

• Cushing’s Syndrome:

  • Excessive steroid levels. Symptoms include moon face, buffalo hump, truncal obesity, weight gain, hypertension, and hyperglycemia.

• General Steroid Teaching (Prednisone/Hydrocortisone):

  • Tapering: Never stop abruptly; this can trigger a rebound adrenal crisis.

  • Long-term Risks: Osteoporosis, infection risk, hyperglycemia, and poor wound healing.

Diabetes Mellitus Medications

• Metformin:

  • Used for Type $2$ Diabetes.

  • Metabolic Risk: Lactic acidosis.

  • Contrast Dye Rule: Must be held for $24$ hours before and $48$ hours after procedures using contrast dye to protect the kidneys.

• Semaglutide (Ozempic):

  • GLP-1 agonist. Slows gastric emptying.

  • Side Effects: Nausea/vomiting (common, may improve). Serious risks include pancreatitis and gallbladder disease.

• Glyburide (Sulfonylurea):

  • Stimulates insulin release.

  • Contraindication: Do not give if the patient has a Sulfa allergy.

Insulin Therapy and Administration

• Types and Timing:

  • Rapid-Acting: Give within $15-30$ minutes of eating. Ensure food is present.

  • Regular: Give within $30$ minutes of eating.

  • NPH (Intermediate): Cloudy appearance is normal. Peaks at approximately $6$ hours; this is the highest risk time for hypoglycemia (provide a snack).

  • Lantus (Glargine): Long-acting ($24$ hours). Do not mix with other insulins in the same syringe.

• Mixing Rule: Draw up Clear (Regular) before Cloudy (NPH).

• Storage: Store in the refrigerator. Before giving, warm by rolling gently in hands; never microwave.

Hypoglycemia Management

• Signs: Shaky, weak, moody/angry, lightheaded, dizzy, nauseous, or "don't feel good."

• Treatment (Awake/Alert): Treat a blood sugar of $69$ or lower with fast carbohydrates (orange juice) followed by a protein/carb snack (crackers, peanut butter).

• Treatment (Unresponsive): Administer Glucagon. Once awake, provide a long-acting snack to prevent rebound hypoglycemia.

Quantitative and High-Yield Reminders

• Math Focal Points:

  • Insulin dosage and IV rates.

  • Heparin calculations.

  • Pediatric weight-based dosages.

• Test Tip - Most Serious Reactions: When asked for the "most serious" effect to report, prioritize: Clots, Priapism, Hyponatremia (seizure), Hypoglycemia (unresponsive), Lactic Acidosis, or Adrenal Crisis.

• Hormone Pattern Summary:

  • Thyroid: Speeds metabolism.

  • Insulin: Feeds cells (lowers glucose).

  • ADH: Holds water.

  • Aldosterone: Holds salt ($Na^+$) and water.

  • Cortisol: Handles stress and raises glucose.