Final: HB/Dys, D/HI - Drug Info Flashcards
Insomnia: Exclusions
- <12 years of age
- ≥65 years of age
- Pregnancy or breastfeeding
- Frequent nocturnal awakenings or early morning awakenings
- Chronic insomnia (>3 months)
- Sleep disturbance secondary to psychiatric or medical disorders
Diphenhydramine: Onset, Half-life, Max Sed, Dosing
• Rapid onset (1-4 hrs) - T1/2: 2.4-9.3 hrs - (max sedation after 3-6 hrs) • Metabolized in liver (delayed half-life in liver dysfunction) • Transient and short-term use • Dose: 25-50 mg HS (Preg->PCP, Nursing->NO)
Diphenhydramine: Adverse Effects
- Sedation/hangover effect
- Anticholinergic symptoms (dry mouth, constipation, blurred vision, urinary retention, tinnitus)
- Inability to concentrate, cognitive impairment
- Tachycardia/QT prolongation
- Paradoxical CNS stimulation (excitation in children and elderly)
Diphenhydramine: Contraindications
- Men with BPH and difficulty urinating
- Angle-closure glaucoma
- Angina or arrhythmias
- Dementia
- Children <6 years old OR with family hx of SIDS or sleep apnea
Diphenhydramine: Interactions
- ↓ clearance of metoprolol especially in women
- May enhance CNS depression of alcohol and opioids
- May enhance adverse effects of glucagon
- Avoid with solid potassium supplements (may cause ulceration)
- Avoid driving, cooking, and operating machinery until response is known
Diphenhydramine: Patient Education
- Take diphenhydramine 30-60 min before sleep
- Do not take more than 50 mg/night
- After 3 consecutive nights, skip for 1 night to see if relieved
- Don’t use longer than 10 days
- Do not take with alcohol
- Do not take with prescription sleep aids
- Caution with children/teens in home
Drowsiness & Hyper-insomnia: Exclusions
- <12 years of age
- Pregnancy and breast-feeding
- Heart disease
- Anxiety disorders
- Medication-induced drowsiness (refer to PCP)
- Chronic fatigue (refer to provider to rule out hypothyroidism, sleep apnea, etc)
Caffeine: Dose, Peak, Half-life
- For occasional use for mental alertness or wakefulness
- Dose: 100-200 mg PO q3-4h PRN
- Peak concentration within 30-75 min, half-life of 3-6 hours
- Can accumulate causing decreased clearance
- Rapid tolerance is common
- HA, fatigue, decreased concentration, irritability within 12-24 hours after cessation persisting for 1-5 days
Caffeine-Containing Products
• Nonprescription caffeine-only
- NoDoz Maximum Strength® (200 mg)
- Vivarin® (200 mg)
• Nonprescription combination
- Excedrin Migraine® caplets (65 mg)
- Midol Complete® caplets (60 mg)
Caffeine powder NOT recommended
Caffeine: Adverse Effects
- CNS stimulation: insomnia, nervousness, restlessness, tinnitus, tremor, headache, irritability, anxiety, depression
- GI irritation (N/V/D, stomach pain)
- Cardiovascular (tachycardia, arrhythmias, increases in BP/HR)
- Renal (diuresis)
- Increased effects in caffeine-naive, elderly, females, non-smokers, anxiety/panic attack
Caffeine: Drug Interactions
- Reduce CL of theophylline (increased HR)
- Blocks clozapine at high doses
- HC and cipro inhibit caffeine abs.
- If on MAO-Is or HD/cardio., avoid non-rx caffeine preparations and moderate intake of dietary caffeine
- Cigarette smoking increases caffeine CL: if trying to quit smoking, decrease caffeine 50%
Antacids: MOA, FOR, Salts
- Neutralize gastric acid; act as buffering agents in GI tract
- FOR: Temporary and rapid relief of mild, infrequent heartburn
- Salts: all interchangeable
• Magnesium (hydroxide, carbonate, or trisilicate)
• Aluminum (hydroxide or phosphate)
• Calcium carbonate
• Sodium bicarbonate
Avoid Antacid If…
- ≥60 years old
- History of stomach ulcers or bleeding problems
- Using anticoagulants, systemic steroids, or NSAIDs
- Consume ≥3 alcoholic beverages daily
Antacids: Adverse Effects
• Mg2+ → diarrhea (avoid if CrCl <30 mL/min d/t toxicity)
• Al → constipation, hypophosphatemia (avoid if CrCl <30 mL/min)
• Ca2+ → belching and flatulence, constipation
• NaHCO3 → belching and flatulence
- Avoid in renal failure, HF, cirrhosis, pregnancy, and sodium-restricted diets
• If taking calcium supplement
- Avoid Ca2+ and NaHCO3 antacids
- Avoid Ca2+ antacid in renal failure
Antacids: Counseling
- Use product-specific doses, repeat in 1-2 hours PRN
- Food slows absorption (longer relief with food)
- Chew tablets well and drink 8 oz water
- Do not use >2x/week or >2 weeks
Antacids May IN/DEC Abs. of Other Meds.
- Separate by 1 hour: isoniazid
- Separate by 2 hours: amphetamines, azithromycin, enteric-coated products, iron, itraconazole, ketoconazole
- Separate by 4 hours: tetracyclines and levothyroxine
- Take 2 hours before or 6 hrs after antacid: fluoroquinolones
H2RAs: MOA, FOR
- Decrease fasting / food-stimulated gastric acid secretion and gastric volume by inhibiting histamine on the histamine type 2 receptor of the parietal cell
- Effective in relieving fasting and nocturnal symptoms
• FOR: mild-moderate, infrequent, or episodic heartburn and for prevention of heartburn associated with acid indigestion and dyspepsia
H2RAs: Counseling
- Reduce dose if impaired RENAL function (half dose in CrCl <50 mL/min) and in elderly
- Take at onset of sx or 30-60 min prior to anticipated heartburn, no more than 2x/day
- Tolerance may develop if taken daily (vs PRN)
H2RAs: Brands
- Tagament HB, Cimetidine
- Pepcid AC/Zantac 360, Famotidine
- Pepcid MAX, Zantac MAX, Famotidine
^ ALL 1 tab with water, max 2 tabs - Pepcid Complete/Tums: Famotidine + Ca carb + mag OH (chew 1 tab, max 2)
H2RAs: Adverse Effects
- Headache, diarrhea, constipation, dizziness, drowsiness
- Thrombocytopenia is rare (and reversible)
- Cimetidine has weak anti-androgenic effects
H2RAs: Interactions
- Cimetidine has many! Increases concentration of nifedipine (CCB), monitor
- May decrease absorption of pH-dependent drugs: itraconazole, ketonazole, iron sulfate, calcium carbonate
PPIs: MOA, FOR
- Inhibit H+/K+ ATPase (proton pump)
- Irreversibly block the final step in gastric secretion, thus providing a greater prolonged and potent effect
• Indicated for frequent heartburn with symptoms ≥2 days/week or when not responding to non-rx H2RAs
PPIs: Counseling
- Onset: 2-3 hours, may take 1-4 days for complete relief
- Do not chew or crush tablets/capsules
- Most effective 30-60min before meal (preferably before breakfast)
- Limit to 14 days of use, no more than every 4 months
PPIs: Adverse Effects
- Uncommon but may include diarrhea, constipation, headache
- Rebound acid reflux upon abruptly discontinuing after long term use
- May increase risk of traveler’s diarrhea by altering gut flora
PPIs: Interactions
• Omeprazole/esomeprazole
- May inhibit metabolism of clopidogrel
- May inhibit metabolism -> increased concentration of cilostazol and diazepam (avoid concurrent use)
• Lansoprazole may be a safer alternative!
Bismuth Subsalicylate (BSS): NOT REC FOR WHO, AE
- Indicated for heartburn, dyspepsia, indigestion, nausea, and diarrhea
- FDA approved for upset stomach (belching, gas) due to overindulgence in food and drink
- Topical effect on stomach mucosa
• Adult dose: 262-525 mg every 30-60 minutes as needed
- Not recommended for children or patients with renal failure or salicylate sensitivities
- May turn stool and/or tongue black
Elderly
- Avoid cimetidine; avoid H2RAs in those with or at high risk for delirium
Renally-Impaired
- Avoid magnesium and aluminum antacids
- Avoid cimetidine; use low doses of other H2RAs
Pregnant/BF
• Pregnancy: Infrequent, mild heartburn: diet, lifestyle interventions
- Ca and Mg antacids ok (max 1000-1300 mg/day calcium)
- H2RAs are ok; PPIs likely ok but limited evidence (refer for moderate heartburn)
• Breast-feeding
- Aluminum, calcium, or magnesium antacids safe
- Famotidine>cimetidine
• Avoid PPIs
