Drug Formulations Flashcards
Which drugs have a granule/capsule formulation that can be sprinkled on applesauce? What are other counseling points associated with this?
Drugs:
-Adderall XR
-Coreg CG (carvedilol)
-Dexilant (dexlansoprazole)
-Folacin XR (dexmethylphenidate)
-Namenda XR (memantine)
-Nexium (esomeprazole)
-Ritalin LA (methylphenidate)
Counseling:
-do NOT chew any long-acting pellets or beats emptied out from a capsule
-If capsule contents mixed in food or liquid, do NOT let sit long and use a small mount
-Entire mixture should be ingested to ensure full dose taken
-do NOT add anything warm or hot (contents can dissolve too quickly)
Cambia is the brand of _________ which is a powder that can be mixed in ______.
diclofenac; water
Creon (pancreatic enzymes) can be taken with soft food with low pH such as ____, ______, or ______.
Applesauce, banana, pureed pears
Potassium ER capsules can be sprinkled on _____ or _____.
Applesauce or pudding
Depakote sprinkles (valproic acid) can be taken with ______.
Soft food
Vyvanse (lisdexamphetamine) can be taken how?
In water, yogurt, or orange juice
Singluair (montelukast granules) can be taken how?
In 5mL of baby formula or breast milk OR spoonful of applesauce, carrots, rice, or ice cream
Questran/Questran light (cholestryamine) is a powder that should be taken how?
In 2-6 oz of water or non-carbonated liquid
What are some of the risks associated with adding sweeteners to medications?
Sorbitol: produces gas, cramping, and bloating in sensitive pts including IBS
Aspartame: contains phenyalanine which is dangerous in pts with phenylketonuria (PKU) where phenyalanine cannot be digested
Lactose: commonly used, may be an issue in lactose intolerant pts
Xylitol: poisonous to dogs
ODT and Oral Film Counseling
do NOT push tablet through foil backing (friable)
Using dry hands, peel back the foil of one blister and remove tablet. Place on tongue to let dissolve in seconds. Once dissolved, then can swallow with saliva. Administration with water NOT necessary.
Injectable Medication Counseling
Basics: wash hands –> prepare injection –> select and clean injection site –> inject – > discard syringes/pen needles in sharps container/thick container
Injection: at least one 1 inch away from previous site, do NOT inject in mole or scar tissue
-Intradermal: 15 degree angle on inner arm (tuberculosis skin test)
-Subcutaneous: outer upper thigh (45 degree), adomen (90 degree or 45 degree if not too much fat tissue), or back of arm halfway between shoulder and elbow(45 degree) –> pinch skin prior
-Intramuscular: deltoid muscle in arm, dorsal gluteal (upper outer quadrant of buttocks), thigh –> 90 degree angle for all, hold skin taut
Anticoagulant injections: do NOT rub skin near injection site as this can cause severe bruising
Biologics: often proteins –> do NOT shake as this can easily denature and avoid extreme temperatures
-Biosimilars: have a 4-letter code at end of name (ex. adaliumumab-bwwd); assume requires same special handing as biologic
Patches: administration sites and counseling
Sites: upper chest, upper and lower back, upper arm on the part facing out, flanks (sides of the body, abdomen level)
-Pain patches: can be applied to the area the pain is at
Counseling:
-Rotate the site where patch is placed with exception of pain patches
-Patches cannot be cut into pieces
-do NOT apply patches on irritated skin or skin shaved shortly before applying
-When discarding, remove the patch to press adhesive surfaces together
Explain where the following patch can be placed: Exelon (rivastigmine patch)
Typical sites, except cannot place on flanks
Explain where the following patch can be placed: Daytrana (methylphenidate patch)
Applied on hip, alternating between right and left
Explain where the following patch can be placed: Transderal-Scop (scopolamine patch)
Behind the ear at least 4 hours before needed, alternating ears Q72H
Explain where the following patch can be placed: Xulane (norelgestromin/EE patch)
Back, abdomen, arm, or buttock
Explain where the following patch can be placed: Oxytrol (oxybutynin patch)
Abdomen, hip, or buttock
Explain where the following patch can be placed: Vivelle-Dot (estradiol patch)
Lower abdomen or buttock
If a patch is irritating to the skin, what can a pt do?
Apply hydrocortisone after patch is removed
Majority of patches cannot be cut, except which ones?
Lidoderm (lidocaine patches) and Qutenza (capsaican patches)
Patches that contain metal must be removed prior to an MRI otherwise the metal can burn the skin. Which ones are these?
- Clonidine (Catapres-TTS)
- Rotigotine (Neupro)
- Scopolamine (Transderm-Scop)
- Testosterone (Androderm)
In general, always verify the contents of the patch or if the drug resembles metal in any sort (recommended to remove estradiol patches for this reason prior too).
Can a patch be covered with tape if it does not stick or falls off?
Most patches cannot be covered with tape - a few can be taped around the edges; when appling a patch, smooth out and press down for 10-30 seconds
Fentanyl (Duragesic) and buprenorphine (Butrans) can only be covered w/ permitted adhesive film dressings, Bioculsive or Tegaderm
Catapre-TTS: comes w/ own adhesive cover
What patches do the FDA/manufacturer may recommend to flush down the toilet?
Highly potent narcotic patches as they can be fatal if ingested aafter removal
Nasal Spray Counseling
Before use:
-Shake bottle gently and remove cap.
-Prime pump before use or if you haven’t used recently (usually 7-14 days).
-Blow your nose to clear your nostrils.
Using spray:
-Close one nostril using finger and insert nasal applicator into the other nostril.
-Start to breathe in through your nose and press firmly and quickly down once on the applicator to release spray.
-Breathe out through mouth.
-Repeat steps if a second spray needed.
-Wipe nasal applicator with clean tissue and replace cap.
Eye Drop Counseling
-Include timing of drops if pt is putting into drops drops of same med or drops of different med
-How long to wait to reinsert contacts
- Wash hands before use and after using eye drops.
- Shake bottle a few times (if gel, invert and shake once to help medication reach the tip).
- Bend neck back to look up. Use one finger to pull down lower eyelid.
- Without letting tip of bottle touch the eye, release on drop of the medication, going into the space between the eeye and lower eyelid.
- Close eye and press finger between your eye and top of your nose for at least one minute so more medication stays in the eye and to prevent side effects.
Timing:
-Two drops of same medication: wait 5 minutes between drops
-Two different eye medications: wait 5-10 minutes between drops (10 minutes between gel)
-Contacts: wait 15 minutes before reinserting
Ear Drop Counseling
- If cold, gently shake the bottle or roll into hands for 1-2 minutes to warm solution (this helps avoid dizziness or discomfort w/ cold drops).
- Lie down or tilt head so affected ear faces up
- Gently pull the earlobe up and back for adults to straighten ear canal (children: pull down and back).
- Administer number of drops into ear canal, and keep ear facing up for about 5 minutes to let medication coat ear canal.
- Wipe tip with a clean tissue. Do NOT touch tip to any surface.
Enema Counseling
- Empty bowel immediately before use.
- Shake bottle well and remove sheat from applicator tip. Hold bottle at neck to prevent any medication from being discharged.
- Best results from lying on the left side with the left leg extended and the right leg flexed forward for balance. Gently insert the tip into the rectum, pointing slightly toward navel to prevent damage to rectal wall.
- Grasp bottle firmyl and tilt slightly to aim towards back. Squeeze slowly to instill medication. After administering, withdarwl and discard bottle.
- Remain in position for at least 30 minutes or preferably all night for maximum benefit.
Suppository Counseling
- Empty bowel immediately before use.
- Detach one suppository from strip. Remove foil wrapper while holding suppository upright. Do NOT handle suppository much as heat from hand and body can melt.
- Insert suppository with the pointed end first completely into rectum. Lubricating gel can be put on suppository if needed.
- For best results, keep suppository in rectum for at least 1-3 hours.
Peripheral versus central catethers
Peripheral catheter: inserted into smaller veins typically in arm, metacarpal veins in hand, or saphenous vein near ankle
-Simpler and less expensive
-Can cause phlebitis (vein irritation), venous thrombosis, and interstitial fluid extravasation when dislodged from vein
Central catheter: inserted into larger vein (superior or inferior vena cava)and contents are quickly diluted allowing these types of drugs to be administered:
-Higher concentrations of drugs
-Long-term antibiotics
-Toxic drugs that would cause severe phlebitis or tissue damage, especially vesicants (vasopressors, anthracyclines, vinca alkaloids)
-Drugs with a pH not close to the blood’s pH
-Drugs with higher osmolarity (ex. parenteral nutrition)
Polyvinyl chloride (PVC) containers:
1. Majority of PVC containers have ______________ which can make the bag more flexible, but can leach and be toxic causing harm to the liver and possibly male infertility.
- What are non-PVC container alternatives?
- Diethylhexyl phosphate (DEHP)
- Polyolefin, polyprophylene, or glass containers
What medications require non-PVC containers since they absorb to PVC? (LATTIN)
LATTIN = “Leach Absorbs To Take In Nutrient”
L: Lorazepam
A: Amiodarone
T: Tacrolimus
T: Taxanes (xcept paclitaxel-albumin bound = Abraxane)
I: Insulin (reastically will see in practice since its very minimal absorption to bag and not much impacted)
N: Nitroglycerin
Drugs to mix in saline only
“A DIAbetic Can’t Eat Pie”
A: Ampicillin*
D: Daptomycin
I: Infliximab
A: Ampicillin/Sulbactam (Unasyn)*
C: Caspofungin
E: Ertapenem
P: Phenytoin
*Stability much shorter in dextrose
Drugs to mix in dextrose only
“Only Sugar Always”
O: Oxaliplatin
S: Sulfamethoxazole/trimethoprim
A: Amphotericin B - all versions
Ceftriaxone IV cannot be mixed with __________.
Calcium-containing solutions (Lactated Ringers) - can be lethal in neonates from precipitation
Calcium IV cannot be mixed with __________ due to precipitation.
Phosphate
If a filter is needed, majority of drugs require _______micron filters which another common one being _____micron used for parenteral nutrition to catch calcium-phosphate particulartes and injection emulsions.
Large molecules, including many liposomal formulations of __________drugs must not be filtered due to particle size.
If compounding IV medications packaged in glass ampules, ________ are used to withdrawl the solution from ampule to prevent glass particulates from entering the IV bag.
0.22 micron; 1.2 micron; chemotherapy; filter needles
Common Drugs with Filter Requirements
“my GAL Is PAT who has a MaP”
G: Golimumab
A: Amphotericin B (lipid formulations)*
L: Lipids-1.2 micron
I: Isavuconazonium
P: Phenytoin**
A: Amiodarone
T: Taxanes (cabazitaxel, paclitaxel conventional)
M: Mannitol
P: Parenteral nutrition-1.2 micron
*Larger pore size filter required (5 micron)
**Phenytoin requires a filter when administered as CIV, but NOT for IV push
Drugs that should NOT be refrigerated
“Dear Sweet Pharmacist Freezing Makes Me Edgy”
D: Dexmedetomidine*
S: Sulfamethoxazole/trimethoprim
P: Phenytoin (crystallizes)
F: Furosemide (crystallizes)*
M: Metronidazole
M: Moxifloxacin
E: Enoxaparin
*Optional: diluted dexmedetomidine and furosemide can be kept cold
Others: APAP, acyclovir (crystallizes), deferoxamine (precipitates), levetiracetam, pentamidine (crystallizes), valproate
Drugs to keep away from light during administration
“Protect Every Necessary Med from Daylight”
P: Phytonadione (vitamin K)
E: Epoprostenol
N: Nitroprusside
M: Micafungin
D: Doxycycline
Others: amphotericin B, deoxycholate, anthracyclines, dacarbazine (if extravasates, protect exposed tissues from light), pentamidine
What drugs should not be shaken or agitated that can be easily destroyed/damaged?
- Vaccines that have been reconstituted
- Emulsions (ex. propofol, injectable lipid emulsions
- Products that foam (ex. alteplase, etanercept, rasburicase, or capsofungin) –> only swirl when reconstituting
- Protein/blood products (ex. albumin, immune globulins, monoclonal antibodies, insulins)
Others: hormones or other proteins
In general, if a medication changes color, then avoid using as this indicates oxidation or some type of decomposition. However, certain changes to what color on the following medications is okay to still use:
1. Chlorpomazine
- Dobutamine
- Dopamine
Chlorpromazine and dopamine: slight yellow - potency still retained and okay to use
Dobutamine: oxidation turns slightly pink, but potency NOT lost
IV drugs - what color is the solution and do they cause skin/secretion discolorations? –> Anthracyclines
Red –> yes, causes sweat and urine discoloration
IV drugs - what color is the solution and do they cause skin/secretion discolorations? –> Rifampin
Red –> yes, causes saliva, sweat, and tears discoloration
IV drugs - what color is the solution and do they cause skin/secretion discolorations? –> Mitoxantrone
Blue –> yes, causes skin, eyes, and urine discoloration
IV drugs - what color is the solution and do they cause skin/secretion discolorations? –> Methotrexate
Yellow –> NO discolorations occur
IV drugs - what color is the solution and do they cause skin/secretion discolorations? –>Tigecycline
Yellow/orange –> yes, causes teeth discoloration IF USED during development
IV drugs - what color is the solution and do they cause skin/secretion discolorations? –> iron
Brown –> yes, causes urine discoloration
What is unique about epinephrine injection?
THIGH ONLY administration and RUB area (helps medication reach lungs quicker)
Patch application frequency for: Diclofenac
BID
Patch application frequency for: Daytrana (methylphenidate)
QD, but only in morning (2 hours prior to school) –> may cause insomnia at night
Patch application frequency for: Nicoderm
QD - may be stimulating at night
Patch application frequency for: Androderm (testosterone)
Nightly
Patch application frequency for: Lidoderm (lidocaine)
1-3 patches PRN ON for 12 hours and OFF for 12 hours to prevent arrhythmias
Patch application frequency for: Nitroglycerin
On for 12-14 hours, off for 10-12 hours
Patch application frequency for: Duragesic (fentanyl)
Q72H –> IF wears off within 48 hours, Q48H
Patch application frequency for: Transdermal Scop (scopolamine)
Q72H PRN
Patch application frequency for: Alora and Vivelle-Dot (estradiol)
Twice weekly
Patch application frequency for: Oxytrol (oxybutynin)
Twice weekly
Patch application frequency for: Catapres-TTS (clonidine)
Weekly
Patch application frequency for: estradiol-containing patches (Xulane, Twirla, can be Climara)
Weekly for 3 weeks then off for one week
Amphotericin B is incompatible with ______ in IV administration.
Sodium bicarbonate
