Medication Review – Session Notes (Part 1)

Hydromorphone (Dilaudid)

• Class / Trade name
  • Class C opioid agonist; analgesic for moderate–severe pain
  • Trade & generic: Dilaudid = Hydromorphone
• Potency relationships
  • ≈ 7\times stronger than morphine
  • Fentanyl ≈ 10\times stronger than morphine (contextual comparison)
• Key adverse effects
  • Respiratory depression, nausea, sedation, constipation
• Nursing actions
  • If RR ≤ 10 breaths min⁻¹ → stop infusion, assess, apply O₂, call provider before giving naloxone
  • Keep O₂ and naloxone available
• Ethical / practical points
  • Autonomously stopping the infusion is correct; giving an antidote requires provider order on NCLEX, even if practice varies in real life

Insulin Detemir (Levemir)

• Long-acting basal insulin; replaces missing pancreatic hormone in Type 1 & 2 DM
• PK profile
  • Onset 1{-}2\text{ h}
  • Peak 6{-}8\text{ h}
  • Duration ≤ 24\text{ h}
• Not used to cover meals (no post-prandial control)
• Education → take at the same time daily; monitor for hypoglycemia

Tramadol

• Synthetic opioid (Schedule IV); centrally acting, PO only
• Uses – moderate–severe pain; low abuse potential
• Major cautions
  • ↓ Seizure threshold → avoid in epilepsy, head trauma, alcohol withdrawal, heavy lavender oil ingestion (also lowers threshold)
  • Do not combine with alcohol or other CNS depressants
• ADRs: sedation, dizziness, dry mouth, constipation

Methylergonovine (Methergine)

• Ergot alkaloid; post-partum hemorrhage / uterine atony
• Dose usually IM; causes sustained uterine contraction
• ADRs – nausea, hypertension, headache
• Risk factors for PPH (link‐in)
  • Macrosomia → overstretched uterus → atony
  • Lacerations, retained placenta (inspect: smooth vs tree side)
• Contraindication: uncontrolled HTN

Methotrexate

• DMARD & antineoplastic; folate antagonist
• Indications – RA, psoriasis, Crohn’s, ectopic pregnancy, several cancers
• Mechanism – immunosuppression → ↓ inflammation in autoimmune disease
• ADRs – N/V/D, stomatitis, hepatotoxic ↑ LFTs, renal failure, pulmonary fibrosis, fatigue
• Labs/monitor: CBC, LFTs, creatinine, CXR baseline

Gabapentin

• Anticonvulsant; partial seizures & neuropathic pain (off-label)
• Absorbed rapidly (onset 2{-}3\text{ h}) → effective q8h → tid dosing maximises analgesia
• ADRs – somnolence, dizziness, fatigue

Nitroglycerin

• Organic nitrate; SL, IV, transdermal
• Absolute contraindication with tadalafil / sildenafil / vardenafil (PDE-5 inhibitors) → profound hypotension
• ADRs – headache, flushing, reflex tachycardia
• Safety – orthostatic precautions, sit/lie when taking tablet

Oxytocin (Pitocin)

• Uterine stimulant: induce/augment labour, treat PPH
• ADRs – uterine tachysystole (> 5 Cx/10 min, > 2 min each, or < 1 min apart), rupture, ↑ BP, fetal hypoxia/late decels
• Management of tachysystole → stop oxytocin, give tocolytic (terbutaline, nifedipine), O₂, reposition, notify HCP
• Magnesium sulfate used primarily for pre-eclampsia but is also a tocolytic

Meloxicam

• 1st-generation NSAID; osteo- & rheumatoid arthritis
• Long-term ADR – GI bleed/ulcer
• Ulcer prophylaxis
  • Give with food/milk
  • Add PPI (omeprazole) or H₂ blocker (ranitidine)

Risperidone

• Atypical antipsychotic; schizophrenia, bipolar mania, autism-related irritability
• ADRs – weight gain, dyslipidemia, diabetes, orthostatic hypotension, sedation, EPS risk ↑ with long-acting injectable
• Monitoring
  • Fasting lipids & glucose (cholesterol < 200\ \text{mg·dL}^{-1})
  • Weight, A1c; assess for EPS (AIMS scale)

Methylprednisolone (Solu-Medrol)

• Glucocorticoid (IV/IM)
• Chronic use → Cushing’s syndrome (buffalo hump, moon face, truncal obesity, weakness, hyperglycemia, hypernatremia, hypokalemia)
• Immunosuppressive: ↑ infection risk; teach to report fever > 38\ ^\circ\text{C}

Budesonide + Formoterol (Symbicort)

• Inhaled steroid + LABA; maintenance therapy asthma/COPD (NOT rescue)
• ADRs – oral candidiasis, GI upset, infections
• Education
  • Rinse mouth after use
  • Do not stop abruptly → adrenal insufficiency

Allopurinol

• Xanthine oxidase inhibitor (uricostatic); chronic gout, tumor lysis hyperuricemia
• Not for acute attack (use colchicine, short-course NSAID)
• Diet: ↓ purines (aged cheese, organ meats, smoked meats)
• Give with food if nausea
• ADR: rash → Stevens–Johnson risk; stop drug & notify provider

Vancomycin

• Glycopeptide; MRSA, C. difficile (PO for C-diff)
• ADRs – nephrotoxicity, Red-Man syndrome (histamine mediated pruritic flushing w/o airway compromise)
• Monitoring
  • Trough 15 min pre-dose; Peak 30 min post-infusion
  • Renal labs: BUN 10{-}20\ \text{mg·dL}^{-1}, Creatinine 0.6{-}1.2\ \text{mg·dL}^{-1}
  • Hold dose until trough drawn

Piperacillin + Tazobactam (Zosyn)

• Extended-spectrum penicillin + β-lactamase inhibitor
• Loading dose 4.5\text{ g} (adult)
• Cross-reactivity: penicillin allergy
• Often paired with vancomycin for broad coverage

Clopidogrel (Plavix)

• Platelet aggregation inhibitor (P2Y₁₂ ADP antagonist)
• Prevents MI, ischemic CVA, post-stent thrombus
• ADR – bleeding, GI upset, rash
• D/C 5 days pre-elective surgery
• Assess for occult bleeding (H/H, melena vs iron-dark stool)

Lithium

• Mood stabiliser for bipolar mania/depression
• Therapeutic level 0.4{-}1.4\ \text{mEq·L}^{-1}
• Toxicity
  • Early: >!2.0 → N/V/D, tremor, ataxia, slurred speech
  • Severe: >!2.5 → seizures, coma, death
• Prevention
  • Consistent Na⁺ intake; avoid hyponatremia/dehydration
  • Avoid NSAIDs & caffeine (↑ levels)
• Pregnancy category D

Haloperidol (Haldol)

• High-potency typical antipsychotic; schizophrenia, psychosis, Tourette’s
• ADRs
  • EPS: dystonia, akathisia, tardive dyskinesia (lip smacking, tongue rolling)
  • Neuroleptic malignant syndrome: rigidity, sudden hyperthermia, autonomic instability, ↑ CK
  • Neutropenia

Zolpidem (Ambien)

• Sedative–hypnotic for short-term insomnia
• Rapid onset → take immediately before bed
• ADRs – dizziness, daytime drowsiness, sleep-walking/driving, agitation, depression
• Avoid alcohol, CNS depressants, operating machinery

Esomeprazole (Nexium)

• Proton-pump inhibitor; GERD, PUD
• Give \approx1\text{ h} before meals
• Long-term (> 1 yr) risks
  • ↓ Ca²⁺ & Mg²⁺ absorption → osteoporosis (hip fracture ↑ 44\%)
  • ↓ B₁₂ → macrocytic pernicious anemia
  • Rebound hypersecretion when abruptly stopped

Amiodarone

• Class III anti-dysrhythmic; FDA-approved for recurrent VF/unstable VT; common off-label for AF
• ADRs – pulmonary fibrosis, bradycardia/heart failure, liver & thyroid dysfunction, photosensitivity
• Very long half-life (weeks)
• Nursing
  • Baseline & periodic CXR/PFTs, LFTs, TSH
  • Report dyspnea, cough, weight gain, syncope
  • Avoid grapefruit juice (↑ levels)

Aripiprazole (Abilify)

• Atypical antipsychotic; schizophrenia, bipolar, MDD adjunct, autism irritability
• Low metabolic & EPS burden but
  • Risk of akathisia, insomnia, headache
  • Black-box: suicidal thoughts in young adults → monitor mood

Epoetin Alfa (Erythropoietin)

• Recombinant hormone; anemia of CKD, chemo, zidovudine, pre-op
• Hold if
  • Hgb > 11\ \text{g·dL}^{-1}
  • ↑ Hgb > 1\ \text{g·dL}^{-1} in ≤ 2 wk
• ADRs – HTN, thrombotic stroke, AV-fistula clot, tumor progression
• Monitor H/H, ferritin, transferrin saturation, K⁺, BP
• Physiologic note: endogenous EPO released by kidneys at low O₂; high altitude ↑ RBC mass

Risedronate (Actonel)

• Bisphosphonate; prevents/treats osteoporosis, glucocorticoid-induced bone loss
• Administration
  • AM, full glass H₂O, swallow whole
  • Remain upright ≥ 30\text{ min}, NPO other than water during that period
• ADRs – esophagitis, musculoskeletal pain, jaw osteonecrosis
• Ensure adequate Ca²⁺ + Vit D; evaluate lifestyle risks (sedentary, steroids, menopause)

Pregabalin (Lyrica)

• Anticonvulsant; neuropathic pain, fibromyalgia, partial seizures, alcohol detox (off-label)
• ADRs – dizziness, somnolence, peripheral edema, weight gain, blurred vision, ataxia
• Pain assessment in non-verbal pts → FACES scale, body posture, restlessness, vital signs

Insulin Aspart (NovoLog)

• Rapid-acting bolus insulin
• PK
  • Onset 10{-}20\text{ min}
  • Peak 40{-}50\text{ min}
  • Duration 3{-}5\text{ h}
• Give 5–10 min before meals; monitor for hypoglycemia at peak

Diltiazem (Cardizem)

• Non-DHP calcium-channel blocker; HTN, angina, AF/A-flutter, SVT rate control
• ADRs – bradycardia, heart block, heart failure, peripheral edema
• HF monitoring: dyspnea, orthopnea, > 2 lb weight gain day⁻¹, crackles, edema

General Cross-links & Exam Tips

• Peak/trough ABX (vanco, gentamicin) & lab values: BUN 10{-}20, Cr 0.6{-}1.2
• Glucocorticoids (prednisone, methyl-pred) + long-acting inhaled steroids (budesonide) → adrenal suppression & osteoporosis; taper slowly
• Caffeine acts as a mild diuretic/CNS stimulant → avoid with lithium & severe anxiety
• Grapefruit interactions: statins, amiodarone, nifedipine, buspirone
• Purine-rich foods mnemonic "SMASH PA" (Seafood, Meat-organs, Alcohol, Sardines, Herring, Poultry, Anchovies)