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Pharmacology Final Exam

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What are the three most important properties of an ideal drug?
safe, effective, selective
Define effective.
produces the anticipated response
Define safe.
can't produce harmful effects even in high doses
Define selective
only produces the desired effect
What are some important properties of an ideal drug other than safe, effective, and selective? (7)
reversible action, predictable, easy administration, free of interaction, affordable, chemically stable, simple generic name
What are the three names that every drug has?
chemical, generic, brand or trade
What is a chemical name?
precise description of the chemical composition and molecular structure of the drug
What is a generic name?
nonproprietary name assigned by the US Adopted Names Council
What is a trade name?
proprietary name selected and marketed by a pharmaceutical company
Are generic and brand name medications the same?
yes
What drugs would we be concerned about switching for a generic to a brand name?
low therapeutic indexes (warfarin)
What are the six rights of medication administration?
medication, patient, dose, route, time, documentation
What information should you give the patient about their prescription?
drug name, therapeutic category, dosage size, dosing schedule, route of adminisration, technique of administration, non-pharmacologic measures, expected response, duration of treatment, method of storage, major adverse side effects, drug-drug interaction, drug-food interaction, contact person
What is a randomized controlled trial?
RCTs are the most reliable way to objectively assess drug therapies. Subjects in an RCT are either given a experimental drug or a control (standard or placebo) for comparison.
Why is randomization important?
to prevent allocation bias which results when subjects in the experimental group are different from those in the control group
What is a blinded study?
one in which the people involved do not know to which group - control or experiment - individual subjects have been randomized
What is a double blind study?
the researchers as well as the subjects do not know to which group - control or experiment - subjects have been placed
What is the order of new drug development? (5)
preclinical testing, clinical testing phase I, II, III, and IV
Which phase of new drug development is drug metabolism, pharmacokinetics, and biologic effects assessed?
phase I
Which phase(s) of new drug development assess(es) therapeutic effects, dosage range, safety, and effectiveness?
phase II and III
Which stage of new drug development involves animals?
preclinical testing
Which phase of new drug development involves healthy subjects?
phase I
Which phase of new drug development is postmarketing surveillance?
phase IV
Drug development has historically excluded which groups of people?
women, children, those with co-morbidities
What are the three phases of drug activity?
pharmaceutical, pharmacokinetic, pharmacodynamic
What are the two main components of the pharmaceutical phase of drug activity?
disintegration of dosage form, dissolution of drug
What are the four main components of the the pharmacokinetic phase of drug activity?
absorption, distribution, metabolism, excretion
What is the pharmacodynamic phase of drug activity?
drug-receptor interaction
Arrange the following oral dosage forms from slowest to fastest absorbing. (powders, tablets/capsules, liquids/elixirs/syrups, EC tablets, suspension solutions, coated tablets)
EC tablets, coated tablets, tablets/capsules, powders, suspension solutions, liquids/elixirs/syrups
What is a p-glycoprotein?
transport system that moves drugs form one side of a cell membrane to another
Where are p-glycoproteins found? (4)
liver, kidney, placenta, intestine, brain
What kinds of drugs can directly penetrate cell membranes?
lipid soluble (lipophilic)
What drugs cannot directly penetrate cell membranes? (3)
polar molecules, ions, those that are too large to pass through channels or pores
What is absorption?
process involving the movement of drug molecules from the site of entry into the body to the circulating fluids
What is distribution?
the transport of drug from the bloodstream to various tissues
Distribution is most affected by this drug characteristic.
protein binding
Is a drug that is bound to protein pharmacologically active?
no
What is Vd?
volume of distribution; relates the amount of drug in the body to the concentration of drug in the blood
Where is most of a drug located when it has a high Vd?
extravascular tissue
Where is most of a drug located when it has a low Vd?
vascular compartment
What is metabolism?
the process of chemically inactivating a drug by converting it into a more water-soluble compound or metabolite that can be excreted from the body
Biotransformation is another term for _____.
metabolism
Where are a majority of drug metabolized?
liver
What is the cytochrome P450 system?
hepatic enzyme system responsible for drug metabolism
What is a CYP substrate?
a drug that is metabolized by P450
What is a CYP inducer?
a drug that induces the metabolism of another drug
What is a CYP inhibitor?
a drug that inhibits the metabolism of another drug
A CYP inhibitor does what to the inhibited drug's half-life?
increases it
What is a prodrug?
a compound that is pharmacologically inactive as administered and then undergoes conversion to its active form within the body
Describe the process of Tylenol poisoning.
Tylenol (acetaminophen) is converted into a hepatoxic metabolite following metabolism in the liver; it is this product of metabolism, and not acetaminophen itself, that causes toxicity
Would you except to see increased or decreased metabolism in a malnourished patient? Why?
decreased; not as many CYPs due to insufficient protein intake
What is excretion?
The process by which drugs and metabolites are eliminated from the body
What organ is most important in excretion?
kidneys
List common excretion sites. (6)
urine, bile - feces, expiration, sweat, saliva, lactation
What is the most convenient route of drug administration?
oral
What are the two major disadvantages of enteral drug administration?
variability, inactivation
Where are sublingual drugs administered?
under the tongue
Name a SL drug.
nitroglycerin
Where are buccal drugs administered?
between the gums and mucous membranes of the cheek
What drugs are administered in a buccal route?
hormone preparations
The following parenteral routes are ordered from fastest to slowest or from slowest to fastest absorptive rate? SC, IM, IV
slowest to fastest
Where is SC injection administered?
connective tissue or fat
What are the barrier(s) to absorption for IV administration?
none
What are the barrier(s) to absorption for IM administration?
capillary wall
Where are intrathecal drugs administered?
spinal subarachnoid space
Where are epidural drugs administered?
epidural space of spinal column
Why is the pulmonary route of drug administration great for absorption? (2)
large surface area, rich capillary network
Where are topical preparations used? (5)
eyes, ears, nasal mucosa, mouth, vagina
Do rectal preparations have local or systemic effects?
may be local or systemic
How are transdermal drugs prepared?
patches
What is the hepatic first-pass effect?
a significant amount of drug is metabolized by the liver before reaching systemic circulation
Why is the dosage of morphine PO so much higher than the dosage IV?
hepatic first-pass effect
What is half-life?
time for the amount of drug in the body to decrease by 50%
If the dosage of PO morphine was doubled, would its half-life increase, decrease, or stay the same?
stay the same
If a patient has hepatic or renal dysfunction, you should expect the half-life to be longer or shorter?
longer
How many half-lives does it take for a drug to reach plateau (a steady level)?
3-5
How many half-lives does it take for a drug to be eliminated?
3-5
What is the therapeutic index?
measure of the relative safety of a drug; LD50/ED50
What is the lethal dose (LD)?
dose that is lethal in 50% of lab animals tested
What is the effective dose (ED)?
dose required to produce therapeutic effect in 50% of a similar population
A safe drug would have a high or low therapeutic index?
high
What is a toxic adverse reaction?
adverse drug reaction by excessive dosing
What is an idiosyncratic effect?
uncommon drug response resulting from a genetic predisposition
What is physical dependence?
a stage in which the body has adapted to drug exposure in such a way that an abstinence syndrome will result if the drug use is discontinued
What drugs high physical dependence rates? (3)
opioids, barbiturates, amphetamines
What is iatrogenic disease?
disease produced by a health-care professional
Drug-induced PD is an example of what type of adverse reaction?
iatrogenic
What is a teratogenic effect?
drug-induced birth defect
What is tolerance?
educed physiological response occurring after repeated drug administration
What is tachyphylaxis?
developing tolerance quickly after repeated administration
What is the cumulative effect?
additive effect of repeated dosing that can cause harm
If a drug is supposed to be given "with food," when do you give it in relation to meal time?
with or shortly after meals
If a drug is supposed to be given "on an empty stomach," when do you given it in relation to meal time?
1 hour before or 2 hours after
Do drugs generally cause upset in conjunction with food?
no
What are the two components of the CNS?
brain, spinal cord
What are the two major components of the peripheral nervous system? Which is voluntary? Which is involuntary?
somatic (voluntary) and autonomic nervous system (involuntary)
What are the two divisions of the ANS?
parasympathetic nervous system (PNS) and sympathetic nervous system (SNS)
Which division of the ANS has cholinergic effects?
PNS
Which division of the ANS has adrenergic effects?
SNS
During parasympathetic activity, the heart rate is increased or decreased?
decreased
During parasympathetic activity, pupils should be constricted or dilated?
constricted
What is innervated by both the PNS and SNS and produces complementary effects?
male reproductive function; PNS erection, SNS ejaculation
What are the four subtypes of adrenergic receptors?
alpha1, alpha2, beta1, beta2, dopamine
What is the result of alpha2 activation?
in the CNS, reduced sympathetic outflow to heart and blood vessels and relief of severe pain
Blood vessels are innervated by what division of the ANS?
SNS
What is the most important feedback loop of the ANS?
baroreceptor reflex
What does the baroreceptor reflex regulate?
blood pressure
Where are baroreceptors located?
carotid sinus and aortic arch
Adrenergic receptors are mediated by what neurotransmitter(s)?
EPI, NE
Cholinergic receptors are mediated by what neurotransmitter(s)?
ACh
What is the response of alpha1 activation for the following? (eye, arterioles, veins, male sex organs, prostate capsule, bladder)
mydriasis (dilation), constriction, constriction, ejaculation, contraction, contraction (sphincter)
What are three clinically significant actions of alpha1 agonists?
mydriasis (dilation), increased BP, nasal decongestion
What are two clinically significant actions of alpha1 antagonists?
decreased BP, decreased urinary symptoms associated with enlarged prostate
Where to beta1 receptors act?
heart, kidney
What is the response of beta1 activation for the following? (heart, kidney)
increased HR, increased AV node conduction, increase force of contraction; renin release
What are three clinically significant actions of beta1 agonists?
increase HR, increase cardiac output; increased BP with renin release
What are two clinically significant actions of beta1 antagonists?
decreased HR, decreased BP
Where do beta2 receptors act? (4)
bronchi, uterus, liver, select arterioles (heart, lungs, skeletal muscle)
What is the response of beta2 activation for the following? (bronchi, uterus, liver, select arterioles)
dilation, relaxation (to avoid labor), glycogenolysis, dilation
What are two clinically signficant actions of beta2 agonists?
bronchial dilation; relaxation of uterine smooth muscle
What cholinergic receptor subtype is activated by the PNS?
muscarinic
Where do muscarinic receptors act? (6)
eye, heart, lung, bladder, GI tract, male sex organs, sweat glands
What is the response of muscarinic activation for the following? (eyes, heart, lung, bladder, GI tract, male sex organs)
miosis (near vision focus), decreased rate, bronchial constriction, voiding, salivation/increased motility/gastric secretions/defecation, erection
What does the ending "mimetic" mean? For example, sympathomimetic.
agonist; SNS agonist
What does the ending "lytic" mean? For example, parasympatholytic.
antagonist; PNS antagonist
Using the ending "mimetic" or "lytic" construct a term to describe beta-blockers.
sympatholytic
What drug would need to be avoided when using prazosin (Minipress), an alpha1 anatgonist?
PDE5 inhibitors like Viagra
Name a non-selective beta-blocker.
propranolol
What is a cardio-selective beta-blocker?
one that only acts on beta1 receptors
Name a cardio-selective beta-blocker.
metoprolol (Lopressor), atenolol (Tenormin)
What type of beta-blocker is carvedilol (Coreg) and labetalol (Trandate)?
beta1, beta2, and alpha1
What type of effects does atropine elicit?
anticholinergic
What are the adverse effects of atropine?
blurred vision, photophobia, urinary retention, xerostomia (dry mouth), constipation, elevation of intraocular pressure, anhidrosis (absence of sweat), tachycardia, asthma (plugging secretions)
Phenotalamine (Regitine) is an antagonist of what receptors of the ANS?
alpha1,2
What do laxatives do?
soften stool, increase stool volume, hasten fecal passage through the intestine, facilitate evacuation from the rectum
What are the actions of bulk-forming laxatives? What group are they? What is their response time?
swell in water to soften and increase the bulk of fecal mass; group III; 1-3 days
Which class of laxative(s) do you need to take with a full glass of water?
bulk-forming, surfactant
Name two examples of bulk-forming laxatives.
psyllium (Metamucil), methylcellulose (Citrucel)
What are the actions of surfactant laxatives? What group are they? What is their response time?
lower surface tension to facilitate the movement of water into the stool; group III; 1-3 days
Name an example of a surfactant laxative.
docusate sodium (Colace)
What are the actions of stimulant laxatives? What group are they? What is their response time?
stimulate intestinal motility and increase water and electrolytes within the intestine; group II; 6-12 hours
Name two examples of stimulant laxatives.
bisacodyl (Correctol, Dulcolax, Feen-a-mint), senna (Ex-Lax, Senokot)
What are the actions of osmotic laxatives? What group are they? What is their response time?
osmotic action draws water into the intestine to the poorly absorbed compounds; group I; 2-6 hours
Name three examples of osmotic laxatives.
milk of magnesia, polyethylene glycol (Miralax), sodium phosphate (Fleet Phospho-Soda)
What toxicities are observed with osmotic laxative use? (2)
K+, Mag
What class of drug can induce peptic ulcer disease?
non-steroidal anti-inflammatory drugs (NSAIDs)
Where are H2 receptors located? What is their function?
parietal cells; activation promotes gastric acid secretion
What is the function of H2 blockers?
suppress acid secretion by blocking the receptors that promote acid secretion
What is the common ending for H2 blocker drugs?
-tidine
What are the uses for cimetidine (Tagamet)?
PUD, GERD, Zollinger-Ellison syndrome, aspiration pneumonitis, heartburn
What two main side effects are expected with cimetidine (Tagamet) use?
anti-androgenic, pneumonia
What two drugs are preferred over cimetidine (Tagamet)? Why? (3)
ranitidine (Zantac), famotidine (Pepcid); more potent, fewer side effects, fewer interactions
What characteristic of cimetidine (Tagamet) causes other drug levels to rise? What drugs agents should not be used with cimetidine? (4)
inhibits metabolic enzymes; warfarin, phenytoin, theophylline, lidocaine
What is the action of a proton pump inhibitor?
suppresses gastric acid secretion by inhibiting the enzyme, H+, K+-ATPase, which makes gastric acid
Are PPIs or H2 blockers better at decreasing acid production?
PPIs
What is the common ending of PPIs?
-prazole
What PPI is a prodrug? Where is it converted to an active form?
omeprazole (Prilosec); parietal cells
What side effect can results with drugs that increase the pH levels of gastric acid?
pneumonia
What is rebound acid hypersecretion?
when symptoms of PUD, GERD, Zollinger-Ellison, etc. get worse when a PPI is stopped
How long can omeprazole (Prilosec) be used?
4-8 weeks
What is the action of antacids?
neutralize gastric acid
What is ANC?
acid-neutralizing capacity
How is antacid potency expressed?
ANC
What are antacids used for?
PUD, GERD, heartburn
Name four antacids.
aluminum hydroxide, magnesium hydroxide (Milk of Magnesia), calcium carbonate (TUMS), sodium bicarbonate (Baking Soda)
Which antacid(s) can cause constipation?
aluminum hydroxide, calcium carbonate
Which antacid(s) can cause diarrhea?
magnesium hydroxide (Milk of Magnesia)
Which antacid(s) should be avoided in HTN and HF?
sodium bicarbonate (baking soda)
Which antacid(s) should be used cautiously with renal impairment?
magnesium hydroxide (Milk of Magnesia)
What two characteristics of antacids make them prone to drug interactions?
raise gastric pH thereby influencing the dissolution and absorption of many other drugs; akalinizes urine thereby accelerating excretion of acidic drugs and delaying excretion of basic drugs
What should you do to minimize the interaction of antacids and other drugs?
administer drugs at least 1 hour apart
Name a serotonin antagonist.
ondansetron (Zofran)
Name a dopamine antagonist.
promethiazine (Phenergan)
What is the mechanism of action for ondansetron (Zofran)?
blocks 5-HT3 in the CTZ and on afferent vagal neurons in upper GI
What are the uses of ondansetron (Zofran)?
chemo-induced and post-operative nausea and vomiting; acute emesis
What is the mechanisms of action for promethazine (Phenergan)?
blocks dopamine in CTZ; also blocks ACh, histamine 1, NE
What are the uses of promethazine (Phenergan)?
chemo-induced, post-operative, toxin-induced nausea
What are the adverse side effects of promethazine (Phenergan)?
sedation, hypotension, anticholinergic, extrapyramidal (EPS)
Promethazine (Phenergan) is contraindicated in which population?
children < 2 years old
Increased drug sensitivity in infants is due to what five immature pharmacokinetic processes?
absorption (prolonged gastric emptying), protein binding of drugs (albumin levels low), blood-brain barrier (not fully developed), hepatic metabolism (not fully developed), renal drug excretion (not fully developed)
Why is topical drug absorption increased in neonates and infants?
thin skin
What age is maturation of hepatic metabolism complete?
1 year old
What age is adult renal excretion reached?
1 year old
Describe the variable course of drug metabolism with relation to age.
Drugs metabolism is markedly faster than adults until 2 years of age, then gradual declines until puberty
What adverse effect of glucocorticoids is seen in children?
growth suppression
What adverse effect of tetracyclines is seen in children?
discoloration of developing teeth
How is dosing of a drug determined in the pediatric patient?
most commonly based on body surface area; initial dosing is, at best, an approximation; subsequent doses need to be adjusted
Why are geriatric patients more sensitive to drugs than younger adults?
system degeneration; altered pharmacokinetics; multiple pathologies
The _____ of treatment is essential in geriatric patients.
individualization
How does absorption of drugs change with age?
delayed gastric emptying and reduce splanchnic blood flow slows absorption
How does distribution of drugs change with age? (3)
increased body fat allows for storage of lipid-soluble drugs; decreased total body water concentrates drugs and causes a more intense effect; reduced serum albumin causes increase in levels of free drugs
How does metabolism of drugs change with age?
hepatic metabolism declines thereby prolonging some drug effects
How is the half-life of drugs affected by age?
increased
How does excretion of drugs change with age?
renal function undergoes progressive decline beginning in early adulthood (reduced blood flow, GFR, active tubular secretion, number of nephrons)
What is the most common cause of adverse drug reactions in the elderly?
drug accumulation secondary to reduced renal excretion
How should nurses assess renal function in elderly patients?
creatinine clearance
What CV drug class is less effective in the elderly? Why?
beta blockers; reduced number of beta receptors; reduced receptor affinity
Nonspecific symptoms in the elderly, such as dizziness and cognitive impairment, can be indicative of what?
adverse drug reactions
Nonadherence of drug regimens is highest in which population?
elderly
What percent of nonadherence cases are intentional? Why?
75%; expense, side effects, patient's conviction that the drug is unnecessary or the dosage is too high
What is an opioid?
a drug that has actions similar to morphine
What are the three classes of opioid receptors?
Mu, Kappa, Delta
What response is expected when Mu opioid receptors are activated? (5)
analgesia, respiratory depression, euphoria, sedation, physical dependence
What response is expected when Kappa opioid receptors are activated? (2)
analgesia, sedation
What opioid receptors are activated with a pure opioid agonist?
Mu, Kappa
Name an opioid antagonist.
naloxone (Narcan)
Describe agonist-antagonist opioids.
when given alone produce analgesia (opioid naive patient); antagonist effect when already taking an opioid
Strong and moderate to strong opioid agonists activate which opioid receptors?
Mu, Kappa
Name the six strong opioid agonists.
morphine, fentanyl, meperidine, hydromorphone, methadone, heroin
Name the four moderate to strong opioid agonists.
codeine, oxycodone, hydrocodone, propoxyphene
Name the three opioid agonist-antagonists.
butorphanol, nalbuphine, pentazocine
Which opioid is used in heroin treatment programs?
methadone
What is the action of morphine sulfate?
mimics actions of various types of "endorphins" (endogenous morphine)
What are the adverse effects of morphine sulfate? (16)
respiratory depression, sedation, orthostatic hypotension, urinary retention, cough suppression, biliary colic, constipation, nausea, vomiting, increased ICP, euphoria, dysphoria, miosis, neurotoxicity, itching, flushing
What schedule drug class is morphine sulfate?
schedule II
What is the prototype by which all other analgesics are measured?
morphine sulfate
What two topics would you be sure to educate your patient about regarding the pharmacokinetics of morphine sulface?
avoid abrupt discontinuation (tapering required); first pass effect is large with oral route (explains difference between large oral dose and relatively small IV dose)
Precautions for opioid use should be taken with patients with what conditions? (7)
hypersensitivity, head injury, acute asthma, decreased respiratory reserve (sleep apnea), biliary tract disease, BPH, chronic opioid users
What six categories of drugs interact with opioids?
CNS depressants, anti-cholinergic, anti-hypertension, MAO-I, agonist antagonist opioid, opioid antagonist
Can you give naloxone (Narcan) to a patient that isn't on an opioid if you suspect opioid toxicity?
yes
You observe your patient on a opioid with pinpoint pupils of <2mm. What should you suspect?
morphine sulfate toxicity (overdose)
What routes can morphine be given?
oral, IV, IM, SC, rectal, SL, epidural, intrathecal
Can you crush or chew an extended or controlled release form of morphine?
no
Which is recommended for opioid dosing, scheduled or prn?
scheduled
What can be used to treat constipation that may result with opioid usage?
stool softeners, stimulant laxatives
What can be used to treat sedation that may result with opioid usage?
stimulants such as caffeine and amphetamines
What can be used to treat the nausea and vomiting that may result with opioid usage?
promethazine (Phenergen) or ondansetron (Zofran)
Does the sedation side effect of opioid usage get better? Does the constipation side effect?
yes (2-3 days); no
What drugs is 100 times more potent than morphine?
fentanyl (sublimaze IV)
What is fentanyl (sublimaze IV) used for?
conscious sedation, anesthesia
Describe the onset and duration of fentanyl (sublimaze IV).
rapid, short
What is Duragesic?
fentanyl patch
How long does it take for the first patch of Duragesic to be effective?
24 hours
What is Actiq? What question should we ask a patient who is using Actiq?
fentanyl lozenges on a stick; are their children in the home?
Why is meperidine (Demerol) use declining? (3)
frequent dosing, interactions, neurotoxic metabolite (confusion, seizure)
What is the major adverse side effect of methadone?
prolonged QT that may lead to fatal dysrhythmias
Which moderate to strong opioid was recently taken off the market?
propoxyphene (Darvon, Darvocet)
What are the two uses of codeine (Tylenol #3)?
pain, cough
What is oxycodone (OxyContin, Percocet) used for?
breakthrough pain
What are the two uses of hydrocodone (Vicodin)?
pain, cough
What is the difference between the OxyContin and Percocet preparation of oxycodone?
OxyContin is long acting, Percocet is short aciting
When should the nurse reevaluate pain addressed with pharmacologic agents?
1 hour after
What is drug abuse?
use that is inconsistent with medical or social norms (may vary in different cultures)
What is addiction?
behavior pattern characterized by continued use of a psychoactive drug despite harm to family, friends, career, etc.
What are PCA devices?
patient-controlled analgesia
Can a person with dementia press their PCA button?
no
Can a family member press the patient's PCA button?
no
Can a two year old press a PCA button?
no
In what specific settings are opioids commonly used? (6)
postoperative pain, obstetric analgesia, myocardial infarction, head injury (caution), cancer-related pain, chronic noncancer pain
What routes are available for naloxone (Narcan)?
IV (immediate effect), IM, SC (2-5 minutes)
How long can your administer meperidine (Demerol)?
up to 48 hours
What chemicals cause pain with inflammation?
prostaglandins
What is the action of NSAIDs?
blockade of the production of prostaglandins by inhibiting cyclooxygenase (COX) at the site of injury in the periphery, thus decreasing the formation of mediators of pain in the peripheral nervous system
Are NSAIDs opioids?
no
What are the three major uses of cyclooxygenase inhibitors?
suppress inflammation, relieve pain, reduce fever
What are the three major adverse effects of cyclooxygenase inhibitors?
gastric ulceration, bleeding, renal impairment
Ketoralac (Toradol) is given as an injection and is restricted to 5 days or less because of this risk.
GI ulceration
Which cyclooxygenase inhibitor does not have anti-inflammatory properties?
acetaminophen
Which NSAID(s) prevent(s) MI and stroke?
aspirin
Which pain reliever causes liver damage with overdose?
acetaminophen
Which NSAID(s) do not prevent fever?
second-generation (coxibs)
Which NSAID(s) cause renal impairment?
first-generation (aspirin, others), second-generation (coxibs)
What is the action of first-generation NSAIDs?
inhibit COX-1 and COX-2; nonselective
How is aspirin abbreviated?
ASA
What are the five major therapeutic uses of aspirin?
analgesic, antipyretic, anti-inflammatory, suppression of platelet aggregation (protects against MI and stroke), dysmenorrhea
What is Reye's syndrome?
toxic infiltration of aspirin into the brain of children
What is salicylism?
adverse effect of high dose of aspirin; ringing in the ears, sweating
What GI effects are common with aspirin?
bleeding, ulceration
Is inhibition of COX-1 and COX-2 reversible or irreversible with aspirin use?
irreversible
Is inhibition of COX-1 and COX-2 reversible or irreversible with first-generation NSAID use?
reversible
Compared to aspirin, first-generation NSAIDs have fewer _____? (3)
GI, renal, and hemorrhagic effects
Name three first-generation NSAIDs.
ibuprofen (Advil, Motrin), naproxen (Aleve), ketoralac (Toradol)
What is the drug of choice for children with mild to moderate pain?
acetaminophen (Tylenol)
What is the abbreviation for acetaminophen (Tylenol)?
APAP
Does acetaminophen (Tylenol) cause gastric ulceration?
no
Does acetaminophen (Tylenol) suppress platelet aggregation?
no
Why do most inadvertent overdoses of acetaminophen (Tylenol) occur?
OTC preparations contain APAP, prescription opioid combinations contain APAP
What drug is used to treat an overdose of acetaminophen (Tylenol)?
acetylcysteine (Mucomyst) PO or IV
What is the maximum about of grams of acetaminophen that can be given in 24 hours?
4
What are the two most common drugs that interact with acetaminophen (Tylenol)?
alcohol (increases risk of liver damage), warfarin (increases risk of bleeding by inhibiting the metabolism of warfarin)
How do antibiotics promote resistance?
the weakest microorganisms are killed and the stronger ones survive, reproduce and cause greater harm
What are nosocomial infections?
healthcare acquired infection presented 48 hours after admission
What is a suprainfection or superinfection?
a new infection that appears during the course of treatment for a primary infection
What organisms are known to have drug resistance?
enterococcus faecalis, enterococcus faecium, staphylococcus aureus, staphylococcus epidermidis, streptococcus pneumonia, klebsiella pneumonia, HIV, TB, MRSA (HA and CA), VRE
What are two common suprainfections?
clostridium difficile (diarrhea), yeast (oral and vaginal)
What are the common side effects of antimicrobials? (7)
diarrhea, allergic reactions, phlebitis with IV, pain with IM; renal, liver, and bone marrow toxicity
Why are women who use OCP advised to use "back up" methods for up to 2 weeks after discontinuing antimicrobial therapies?
antimicrobials can inactivate OCPs
What are two classes of beta-lactam antibiotics?
penicillins, cephalosporins (4 generations)
Which penicillin is commonly used for strep. throat and sinus infections?
amoxicillin
What ending is common for all penicillins?
-cillin
What is the most common side effect of penicillins?
allergic reaction (rash, hives, anaphylaxis)
Which class of antibiotic is the least toxic?
penicillins
What is the action of penicillin+beta-lactamase inhibitors?
inhibit bacterial beta-lactamases to extend the antimicrobial activity of the penicillin
What is an example of a penicillin+beta-lactamase?
amoxicillin/clavulanic acid (Augmentin)
How should the nurse administer oral penicillin?
oral doses should be taken with a full glass of water 1 hour before or 2 hours after meals
What should the nurse avoid when administering IV penicillin?
mixing aminoglycosides (gentamicin) in the same IV; running two different antibiotics at the same time
Which class of antibiotic is the most widely used?
cephalosporins
Do cephalosporins have a high or low therapeutic index?
high
Which class of antibiotic has a cross allergy with penicillin?
cephalosporins
Cephalosporins have four generations with increasing activity against microorganisms. Which is the preferred generation for therapy?
third
What prefix do all cephalosporins have?
ceph or cef
What four adverse effects are expected with cephalosporin use?
allergic reaction, thrombophlebitis with IV, pain with IM, bleeding
What should be avoided with ceftriaxone (Rocephin) use?
calcium
Are tetracyclines broad or narrow spectrum?
broad
How do tetracyclines work?
inhibit protein synthesis
What is use of tetracyclines declining?
increasing resistance, other agents that are less toxic
Yellow discoloration of teeth is an adverse side effect in children <8 years old seen with this drug.
tetracycline
What is the common ending for tetracyclines?
-cycline
What are the six major adverse effects of tetracyclines?
GI (burning, nausea, vomiting, diarrhea, cramps), yellow discoloration of teeth, photosensitivity, clostridium dfficile or candida infection, hepatotoxicity (high IV doses), renal toxicity
What common tetracycline adverse effect does doxycycline not exhibit?
renal toxicity
How should the nurse administer tetracyclines?
1 hour before or 2 hours after a meal; not with calcium, iron, magnesium, aluminum, or zinc
Erythromycin is the prototype of which class of antibiotics?
macrolides
A patient with an atypical respiratory pneumonia or anaerobic agent will be treated with which class of antibiotics?
macrolides
Are macrolides broad or narrow spectrum?
broad
Which two classes of antibiotics are bacteriostatic?
tetracyclines, macrolides
Vancomycin is most commonly used to treat which resistance organism?
MRSA
What adverse effects are expected with vancomycin? (5)
ototoxicity (tinnitus, decreased hearing), red man syndrome (flushed color - not true allergy), thrombophlebitis, thrombocytopenia, allergy
Which antibiotic is used for patients with a serious infection and a penicillin allergy?
vancomycin
What are the two most common adverse effects seen with macrolide use?
intense nausea, prolong QT
Should you give macrolides with food?
no
Name two macrolides.
clarithromycin (Biaxin), azithromycin (Zithromax)
What is the common ending of macrolides?
-thromycin
What does the use of clindamycin (Cleocin) put a patient at risk for?
CA-MRSA
Clindamycin (Cleocin) is a relative of which class of antibiotics?
macrolides
Name three common aminoglycosides.
gentamicin, tobramycin, amikacin
Aminoglycosides are most common used for what type of infection?
serious gram negative
What are the two major adverse effects of aminoglycosides?
ototoxicity (cochlear and vestibular), nephrotoxicity
Which class of drug requires peak and tough levels to be drawn 30 minutes and 1 hour, respectively, after dosage?
aminoglycosides
Neosporin contains which antibiotic class?
aminoglycosides
Which antibiotic class is the first choice for UTIs?
sulfonamides
What is kernicterus?
bilirubin build up in infants that causes brain damage and a yellow appearance
Which class of antibiotics is contraindicated in infants <2 months old?
sulfonamides (kernicterus)
Which class of antibiotic should be avoided in patients under 18 years of age?
fluoroquinolones
Which class of antibiotics can result in tendon rupture, especially in the Achilles tendon?
fluoroquinolones
What is the most common fluoroquinolone?
ciprofloxacin (Cipro)
What are two adverse effects of fluoroquinolones?
Candida infections (pharynx and vagina), phototoxcity
What reduces the absorption of fluoroquinolones?
aluminum, magnesium, iron, zinc, milk and diary products
Which type of drug is used for prophylaxis of asthma attacks?
inhaled glucocorticoids
Are inhaled glucocorticoids administered on a fixed schedule or prn?
fixed schedule
What is the main action of glucocorticoids?
suppress inflammation
What is dysphonia?
changes in voice
What are five major adverse effects of glucocorticoids?
oralpharyngeal candidiasis, dysphonia, adrenal suppression, bone loss, slowed growth in children
What are the principal bronchodilators?
beta2 agonists
Do bronchodilators act on the underlying disease process of asthma or its symptoms?
symptoms
What are the two actions of beta2-adrenergic agonists?
promote bronchodilation, suppress histamine release
Name two SABAs.
albuterol (Proventil), levalbuterol (Xopenex)
Are SABAs used prophylactically?
no
Can SABAs be used alone?
yes
Can LABAs be used alone? Why not?
no; increases asthma-related death
Name two LABAs.
salmeterol (Serevent), formoterol (Foradil)
LABAs should be used with what type of drug?
inhaled glucocorticoid
Name two common glucocorticoid/LABA combinations.
fluticasone/salmeterol (Advair), budesonide/formoterol (Symbicort)
How is asthma drug management determined?
stepwise approach
What occurs when histamine 1 receptors are activated?
vasodilation, increased capillary permeability, bronchoconstriction, itching, pain, secretion of mucus
What drug therapy should be used with a mild allergic response?
antihistamine
If a patient presents with bronchoconstriction, hypotension, and edema of the glottis, should an antihistamine be used for drug therapy?
no
What is the drug of choice for severe allergic responses?
EPI
What is the main difference between the 1st generation and 2nd generation antihistamines?
the 1st generation is highly sedating and the 2nd generation is not
Name two common 1st generation antihistamines.
diphenhydramine (Benadryl), promethazine (Phenergan)
Name three common 2nd generation antihistamines.
fexofenadine (Allegra), cetririzine (Zyrtec), loratadine (Claritin)
You are having trouble sleeping, should you take Tylenol PM or Benadryl?
Benadryl (save your liver)
What is the action of antihistamines?
block H1 receptors
Do antihistamines block H2 receptors?
no
What are the adverse effects of an overdose of antihistamine?
CNS stimulation, convulsions
What are the adverse effects of a therapeutic dose of antihistamine?
CNS depression (negligible in second-generation), anticholinergic
Should the nurse administer an antihistamine to a patient with a cold?
no (may provide minimal relief with anticholinergic property)
What patients should not use antihistamines?
infants, young children, elderly
What should we teach patients to do once they have inhaled a glucocorticoid?
rinse mouth
A patient with thin skin, alopecia, muscle wasting, and fragile bones may be on what drug regimen?
glucocorticoids
Iatrogenic hyperglycemia or glucose intolerance may be caused by which drug therapy?
glucocorticoids
What are some examples of short acting GCs?
cortisone, hydrocortisone
What are some examples of intermediate acting GCs?
prednisone, prednisolone, methylprednisolone, triamicinolone
What is the common ending for GCs?
-one
What is insulin?
a hormone secreted by the beta cells in the pancreas that works like a key to unlock cells so that blood glucose can enter and be used as fuel
What is a normal fasting blood sugar? What about diabetic?
70-110; >126
What is a normal 2 hour post-prandial blood sugar? What about diabetic?
140; >200
What is a normal random blood sugar?What about diabetic?
125; >200
Which test is used to measure long-term control of blood sugar?
hemoglobin A1c
Each percent above 5% hemoglobin A1c increases the average glucose reading by how much?
30mg/dL
What is a normal hemoglobin A1c? What about diabetic?
5.7%; >6.5%
What is the A1c goal for people with diabetes?
<7%
Which drug class stimulates the pancreas to make more insulin?
sulfonylureas (SFUs)
Which drug classes sensitize the body to insulin and/or control hepatic glucose production?
thiazolidinediones (TZDs), biguanides
Which generation of sulfonylureas (SFUs) should be used in the eldelry?
second generation
Can you give sulfonylureas (SFUs) to a type II diabetic? What about a type I? Why or why not?
yes, no (must have ability to secrete insulin)
What are the two major adverse effects of sulfonylureas (SFUs)?
hypoglycemia, weight gain
What is the common ending of sulfonylureas (SFUs)?
-ide
Name three second generation sulfonylureas (SFUs).
glyburide (Micronase, Glynase, and DiaBeta), glimepiride (Amaryl), glipizide (Glucotrol, Glucotrol XL)
What is the target population for the thiazolidinediones (TZDs)?
insulin resistant
What are the two major adverse effects of thiazolidinediones (TZDs)?
hypoglycemia, weight gain
Which class of oral diabetic agent promotes symptoms of heart failure?
thiazolidinediones (TZDs)
What is the target population for biguanides?
overweight patient with insulin resistance
Name the most common biguanide.
metformin (Glucophage)
What are the two major adverse effects of biguanides?
diarrhea, lactic acidosis
Who is at risk for lactic acidosis? (4)
patients with impaired liver function, severe infection, excessive alcohol use, heart failure
What should the nurse explain to a patient complaining that he wants to stop taking his metformin because if gives him diarrhea?
diarrhea tends to resolve over and week; improves if taken with food
Your patient has just come back from a CT scan procedure using IV contrast. Which postoperative drug should you hold?
metformin (Glucophage)
Your patient is preparing for a CT scan. Which medication should you hold?
metformin (Glucophage)
Which oral diabetic agent does not have hypoglycemia or weight gain side effects?
metformin (Glucophage)
Most diabetic patients will require multiple medications to achieve control. Which oral agents can be used in combination?
sulfonylureas (SFUs), thiazolidinediones (TZDs), biguanides
Name the three most common rapid acting insulins.
lispro (Humalog), aspart (Novolog), glulisine (Apidra)
Name the most common short acting insulin.
regular (Novolin R, Humulin R, Reli-On R)
Name the most common intermediate acting insulin.
NPH (Novolin N, Humulin N, Reli-On N)
Name the most common long acting insulin.
glargine (Lantus)
What is a bolus of insulin?
rapid and short-acting insulin that targets post-prandial glucose levels and bring elevated glucose down
What is basal insulin?
intermediate and long-acting insulin that targets between meals and fasting glucose levels
What are the two main side effects of insulin?
hypoglycemia, weight gain
Do all type 1 diabetics require insulin?
yes
What is the onset, peak, and duration of rapid acting insulin?
5-15 minutes, 30-90 minutes, 5 hours
Should you administer a rapid acting insulin when the patient skips a meal?
no
What is the onset, peak, and duration of short acting insulin?
30-60 minutes, 2-3 hours, 5-8 hours
What is the onset, peak, and duration of NPH?
2-4 hours, 4-10 hours, 10-16 hours
What insulin(s) can be mixed in a syringe with NPH?
rapid, short
How does NPH appear?
cloudy
What should you do before administering intermediate insulin?
roll vial in hands to mix the suspension prior to injection
What is premixed insulin?
preparations containing basal and bolus insulin (Novolin 70/30, Humulin 70/30, Novolog 70/30, Humalog 75/25)
When is most premixed insulin taken?
5-13 minutes before breakfast and supper
What is the onset, peak, and duration of long acting insulin?
2-4 hours, none, 18-24 hours
What adverse effect is common with IV insulin administration?
hypokalemia
What is the order to draw up rapid or short acting insulin with NPH?
insert air into cloudy then clear, draw up clear then cloudy; "cloudy, clear, clear, cloudy"
How should the nurse prepare for IV insulin administration?
prepare the bag and tubing 30 minutes prior to administration to allow binding to plastic
How often should blood glucose be monitored in a patient receiving IV insulin?
every hour
What is IV insulin used to treat?
diabetic ketoacidosis (DKA), hyperosmolar hyperglycemic state (HHS)
Why is the advantage of IV insulin?
tighter glucose control
Name a centrally acting alpha2 agonist.
clonidine (Catapress)
What is clonidine (Catapress) used for?
HTN
What are the adverse side effects of clonidine (Catapress)? (4)
sedation, dry mouth, rebound HTN if abrupt withdrawal, fetal harm
What is used instead of clonidine (Catapress) in pregnancy?
methyldopa
What is the most common preparation of clonidine (Catapress)?
patch (highly lipid soluble)
What is the action of calcium channel blockers (CCBs)?
prevent calcium ions from entering cells; inhibits the contractile process of peripheral arterioles/arteries and cardiac arterioles
CCBs are treat to treat which three conditions?
HTN, angina pectoris, dysrhythmias
What do nondihydrophyridines, such as verampil (Calan) and diltiazem (Cardizem), act on?
vascular smooth muscle (VSM), heart
What do dihydropyridines act on?
vascular smooth muscle (VSM)
What is the common ending of dihydropyridines?
dipine
Name the two nondihydropyridines.
verapamil (Calan), diltiazem (Cardizem)
What are the three most common adverse effects of verapamil (Calan) and diltiazem (Cardizem)?
constipation, lower extremity edema, gingival hyperplasia
What should the nurse teach a patient who is taking nondihydropyridines?
diet for constipation side effect
What food do nondihydropyridines interact with?
grapefruit juice
Are dihydropyridines used to treat dysrhythmias?
no (little effect on SA node, AV node)
What are the three most common adverse side effects of dihydropyridines?
reflex tachycarida, lower extremity edema, gingival hyperplasia
What food do dihydropyridines interact with?
grapefruit juice
What is the mechanism of action for beta antagonists?
prevent the binding of endogenous catecholamines (EPI and NE) to beta adrenergic receptors
What are the five conditions that beta blockers are commonly used to treat?
HTN, angina pectoris, dysrhythmias (tachycardias), MI (post-MI), heart failure
What is the mechanism of action for ACE-inhibitors?
decreases levels of angiotensin II and increase bradykinin by blocking ACE; vasodilation, reduced blood volume
What class of drugs are usually used first to treat HTN?
ACE-inhibitors
What is the common ending of beta antagonists (blockers)?
-lol
What is the common ending of ACE-inhibitors?
-pril
What are the five most common adverse effects of ACE-inhibitors?
cough, angioedema, 1st dose hypotensions, hyperkalemia, fetal injury
What is the mechanisms of action for angiotensin receptor blockers?
block receptors for angiotensin II on blood vessels, the adrenals, arterioles, and veins
What effect do ARBs have on bradykinin?
none (do not increase like ACE-inhibitors); vasodilation
What is the common ending of ARBs?
-sartan
What are the three most common adverse effects of ARBs?
angioedema, hyperkalemia, fetal injury
Can ARBs cause an uncontrollable, dry cough?
no
Which CV medications are contraindicated in pregnancy?
ACE-inhibitors, ARBs