Final Safety Exam (Module 1-8) Flashcards
Grapefruit juice
-can inhibit metabolism in those drugs that use the same metabolic pathway
-this increases the levels of drugs which can potentially cause toxicity
-one cup can inhibit metabolism up to 72 hours!
If we INDUCE a substrate….
it leaves the system faster → not as effective
If we INHIBIT a substrate
increase exposure to that drug, takes more time to leave the body
Can schedule 2 drugs have refills?
No
How often can schedule III and IV have refills?
5x within 6 months
What are substrates?
drugs that are metabolized by P450 system. Can be both substrate and inducer/inhibitor.
Pathway Competition between drugs
If both drugs are metabolized in same pathway, it might slow the process down which would increase build up of these drugs and increase toxicity.
Type 1 allergic reaction
IgE mediated - particularly scary - reaction happens right away→ histamines, leaky blood vessels, itching, life-threatening
Type 4 allergic reaction
Derm reactions (SJS, TENS) - delayed reactions → skin blistering
How do we need to modify dosage if we know someone is an ultra-metabolizer?
ncreased dosage of the drug to be effective
How do we need to modify dosage if we know someone is a poor metabolizer?
Reduced dosage (they can easily accumulate)
What are agonists?
fully activates receptor site
Partial agonists
partially activates receptor site
What are Antagonists? What does this mean as far as affinity?
blocks receptors action (and has stronger affinity for a receptor site than an agonist, which is good in the case of narcan / heroin)
What do we mean when we say the “all or nothing” period?
Prior to implantation. Either going to implant and be fine or not implant.
When does Organogensis start?
3 weeks
When does the fetal period start and what impact do teratogens have in this stage?
11 weeks and will not cause any obvious malformations. May alter the growth and function of tissues and organs resulting in growth restriction, alternation in size and functional ability of specific organs, or developmental and behavioral abnormalities
When is PCN absolutely contraindicated?
Previous type 1 reactions
Safety with cephalasporins
-do not use if previous type 1 hypersensitivity reaction to Penicillins- cross reactivity higher with 1st gen but overall has very low likelihood of cross reactivity
-could potentially cause disulfiram reaction with concurrent alcohol use
-can increase bleeding by interfering with Vitamin K metabolism
Macrolides: Erythromycin, azithromycin
-many drug interactions
-Clarithromycin-many DIs, interacts with calcium channel blockers & can cause severe kidney damage
-avoid use with Statins—can increase Statins to dangerous levels
-prolong QT
-potential for ototoxicity esp when combined with other ototoxic
BBW for our aminoglycosides (gentamycin, tobramycin)
can cause severe nephrotoxicity and ototoxicity and neurotoxicity(flaccid paralysis neuromuscular block)
Safety aminoglycosides (gentamycin, tobramycin)
monitor drug levels closely
-caution with renal impairment
-pregnancy Cat D
Clindamycin BBW
fatal CDAD- high risk for C. Diff- report diarrhea immediately
Vancomycin: BBW
if used with severe renal impairment—increased risk of mortality
Safety vancomycin
monitor drug levels
-can cause red man syndrome if infused too rapidly
-reserve for serious infection
Fluoroquinolones: (ciprofloxacin) BBW
Can cause tendon rupture, tendinitis, tendon damage
Safety fluoroquinolones (Ciprofloxacin)
-avoid in pregnancy, lactation, children <18yo
-avoid in peripheral atherosclerotic vascular disease, hypertension, Marfan’s syndrome, elderly–increases risk of aortic aneurysm
-photosensitivity
Safety macrobid
avoid with renal impairment
avoid in 3rd trimester of pregnancy, breastfeeding infant less than 1 month old, G6PD deficiency—these can cause hemolytic anemia
Vaccine spacing for live vaccines
4 weeks
Safety with PREP
Negative HIV before starting
If pt becomes HIV positive on drug, they need to stop the drug immediately
Drug can cause resistance → education to take drug every single day (may not be a good candidate for med if they aren’t going to take every day)
Safety with oral antifungals (-AZOLES)
can cause inhibition of MANY drugs—increasing drug levels and potentially causing toxicity—Ex: Statins
-can cause QT prolongation, CNS effects, hepatotoxicity, hypersensitivity reactions, SJS, adrenal insufficiency, GI disturbances, gynecomastia, decreased blood counts
-monitor LFTs and blood counts in long term use
-ketoconazole has the least DIs
-avoid in pregnancy and lactation—can cause congenital or fetal malformations & can enter breast milk in similar concentration to maternal blood levels
-BBW—Ketoconazole—can potentiate QT prolongation & cause liver damage
What do you need to supplement when taking INH (Isoniazid)
B6
BBW INH
severe hepatitis, liver failure, & death
QT drugs (antibiotis, antifungals, antimalarial)
Azoles, specifically fluconazole
Azithromycin
Ciprofloxacin
Clarithromycin
Erythromycin
Levofloxacin
Moxifloxacin
Chloroquine - antimalarial
Safety with PPIs
decreases acidity which can cause decreased absorption of certain drugs and may cause vitamin deficiencies
-risk for C. Diff & Pneumonia, fractures, gastric malignancy—deprescribe whenever possible
-wean when discontinuing to avoid rebound hyperacidity
What causes superinfections?
Overprescribing
Prescribing broad spectrum rather than narrow spectrum
Patients not taking drug as ordered, self treating, not taking full course
Prescribing when not indicated
Rifampin
powerful CYP inducer- can decrease OCPs—need to have back up methods
-always give in combo, not a monotherapy- lots of Resistance
-discolors urine
BBW Phenergen
respiratory depression - caution in children & elderly
BBW Zofran
QT prolong
BBW Lotronex
→Ischemic bowel
BBW cytotec
can cause miscarriage / induction of labor
What GI drugs do we want to avoid in pregnancy?
Pepto-Bismol, sodium bicarbonate antacids (Alka Seltzer), Cytotec, Castor oil, methotrexate
Tagamet (H2)
avoid whenever possible—potent CYP enzyme inhibitor—many drug interactions
What GI drugs can cause tardive dyskinesia?
Phenergen and Reglan (BBW)
Guanylate cyclase-C agonist (Linzess) BBW
Profound dehydration
Beta Blockers:
-Not first choice
-Contraindicated in heart block or bradycardia
-do not use non-selective beta blockers in patients with COPD or asthma due to bronchoconstriction
-also used for migraine prophylaxis (propranolol, etc) & HF
-can mask signs of hypoglycemia (Hide tachy)—caution use with diabetics
BBW betablockers
Do not stop abruptly—angina & risk for MI
ACE BBW
pregnancy (category X)—can cause fetal harm or congenital abnormalities
ACE
can cause hyperkalemia
Do not combine with ARBs
-can be renal protective however RF needs to be monitored—discontinue if function declines—they need angiotensin II vasoconstriction to maintain adequate vascular tone
-risk of angioedema
-may cause ACE cough (bradykinins)—switch to ARB if bothersome for patient
-CI in bilateral renal stenosis or hyperkalemia- monitor renal and potassium
ARBS BBW
Pregnancy/fetal abnormalities
ARBS
-do not combine with ACEs
-Hyperkalemia
-decreased risk of angioedema (but still has some) and bradykinin cough
-contraindicated in bilateral renal stenosis or hyperkalemia- monitor renal and potassium
Coumadin/Heparin D2D
Avoid NSAIDs
Warfarin: Many D2D
Warfarin BBW
can cause serious & fatal bleeding
Heparin BBW
increased risk of spinal or epidural hematoma
What is the preferred blood thinner in pregnancy?
Heparin (does not cross barrier)
Dosage safety with warfarin
use lower doses in elderly, CHG, malnourished, liver disease, recent surgery, fever, hyperthyroidism
Statins
-risk of myopathy and rhabdomyolysis
-can cause new onset diabetes, cataracts, hepatotoxicity
-CI in pregnancy—can cause birth defects
-CI in lactation, active liver disease, concurrent use of CYP inhibitors such as oral antifungals (can increase statin drug levels)
-important to obtain baseline muscle function prior to therapy
-if rhabdomyolysis is suspected immediately stop and obtain CK, LFTs, CBC, urinalysis
-if only mild symptoms and resolves—may resume at lower dose or a different statin
-low dose occasional statin is better than no statin
Digoxin
-risk of digoxin toxicity
-risk of dysrhythmia with hypokalemia
-increased risk: low body weight, advanced age, renal impaired, hypokalemia, hypercalcemia, hypomagnesemia, NSAID use, tetracycline use
Nitrates
-avoid concurrent use of PDE-5 inhibitors—can cause severe hypotension
-hypotension, HA, reflex tachycardia
-must taper to avoid vasospasm from abrupt discontinuation
Amioderone BBW
Fatal arrythmias
Plavix BBW
Poor metabolizers (can’t covert to active form)
What cardiac drugs are safe in pregnancy per ACOG?
CCBs
Methyldopa
NSAIDs
GI bleed. Do not give NSAID!
Decrease prostaglandin.
Cardiac (previous MI → increases risk for another one)
Avoid in pregnancy
avoid with Hypertension (can increase BP)
Renal insufficiency and kidney disease.
Caution with asthma.
Celebrex- higher cardiac risk (cox 2)
Tylenol
-avoid alcohol with use—can increase risk of liver toxicity- not a hangover drug!!!
-CI liver disease, alcoholism, dehydration, concurrent use of other liver-toxic drugs
-maximum Tylenol dosage is 4g/day in healthy adults and 3g/day in those who use Tylenol often or at risk of liver toxicity
-increases warfarin levels
Opioids/benzos used together
avoid concurrent use with benzodiazepines or alcohol—can cause severe respiratory depression
Codeine
-pro-drug so avoid use with breastfeeding as it may cause overdose in the infant if mother is ultra-rapid metabolizer.
BBW- death in iBF infants or peds- avoid in peds also
Ergotamine BBW
avoid use with potent CYP inhibitors—can cause SEVERE peripheral vasospasm or cerebral ischemia
Botox BBW
Can spread to other parts of the body
Tramadol BBW and concerns
BBW: Resp. depression
Concern: Seizures
What opioid addiction treatment can we give prior to weaning?
Subutex
Nicotine Replacement Therapy:
Recent MI.
Increased BP, tachycardia
Oral corticosteroids
can cause hyperglycemia–try to avoid in diabetics
-can increase risk of infections or mask infections
-may worsen heart failure & cause arrhythmias in high doses
-can cause calcium resorption, HTN, Cushing’s, cataracts, exophthalmos, papilledema, protein wasting, lipid deposition, acne exacerbation, angle closure glaucoma, immunosuppression, HPA suppression
-can cause H/A, dizziness, sleep difficulty, inappropriate happiness, severe mood swings
-if used longer than 1-2 weeks—must taper to allow adrenal glands to resume endogenous steroid production
-long term use–monitor height, weight, BP, BMI, CBC, glucose, lipids, BMD, eyes
-may cause oral cleft defects, decreased birth weight, hypoadrenalism of newborn—if used during pregnancy
Theophylline
multiple drug interactions
-need near toxic doses for therapeutic effects/ narrow therapeutic window- monitor drug levels
-caution use with history of seizures, HTN, CVA
-try to avoid in breastfeeding—hyperstimulation & disrupted sleep of infant
Antihistamines:
Anticholinergic with elderly, glaucoma (increase ICP-worsen), BPH (decreases urine flow)
1st gen vs 2nd gen:
1st is more sedating
second selective and less sedating (Zyrtec is slightly sedating).
BBW promethazine-
Behavioral <2yo
Decongestants
-increases cardiac workload
-contraindicated for uncontrolled HTN, MAOIs, severe CAD, BPH, concurrent use of CNS stimulants like caffeine, Ritalin
-Nasal: No longer than 3 days (rebound)
Cough suppressants
Don’t use if productive cough (unless needed for sleep).
Don’t use in asthma and in COPD
LABAs BBW and QT
Prolong QT- serevent
-BBW- increased rate of asthma death- do not use as monotherapy
-BBW- increased rate hospitalization in peds
Chantix
Depression, suicide.
Increases alcohol’s effects
Wellbutrin
-can cause suicidal thoughts, HTN, weight loss, seizures
-contraindicated in history of seizures, anorexia, concurrent MAOI use, or during discontinuation of alcohol or sedatives (due to increased seizure risk)
Singulair BBW and D2D
BBW: Psych.
Increased risk of seizures with dilantin.
Zyban (Bupropion HCL): BBW and cautions
Hx of seizures, anorexia/bulimia.
BBW: Suicide in children.
MAOI
Many drug to drug interactions
Not first line in treating depression
Lots of side effects.
Tyramine foods can cause hypertensive crisis
BBW: INcreased risk of suicide (espeically children).
14 Day wash out period.
TCA
Anticholinergic effects
Do not combine with MAOI due to serotonin syndrome.
-lethal in overdose—cardiotoxicity
-anticholinergic side effects
-avoid in elderly due to anticholinergic side effects
Can be used for fibromyalgia
SSRIs/SNRIs
avoid concurrent use with other serotonin agents—increases risk of serotonin syndrome
Screen for bipolar.
-BBW–increased risk of suicidal ideations
-Prozac is the only SSRI approved for children 12 and older
-Prozac in breastfeeding can cause growth restriction in the infant
-Paxil is contraindicated in pregnancy—can cause congenital cardiac malformations, prematurity, newborn persistent pulmonary HTN, neonatal discontinuation syndrome
-Zoloft is safest for both lactation and pregnancy
-risk of discontinuation syndrome
SNRIs: Diastolic BP increase
Lithium
Considered gold standard for bipolar disorder
Lab monitoring: LIthium levels
Can cause hypothyroidism
Narrow therapeutic range
Tegretol BBW
It may cause SJS and TEN. Aplastic anemia and agranulocytosis.
Depakote BBW
fatal hepatic failure risk.
Fatal and rapidly progressing pancreatitis.
Valproate is highly teratogenic
BBW antipsychotoics (Haldol, etc)
Mortality in elderly
BBW prozac (SSRI)
Suicide risk, especially early on, may increase. Antidepressant-induced suicide applies mainly to children, adolescents, and adults younger than 25.
Lamotrigine (Lamictal) BBW
Serious Rash/SJS
Methylphenidate BBW
Dependence and addiction
QT drugs (AEDs, Anti-depressants, mood stabilizers, etc)
Haldol
Mellaril / Thioridazine
Thorazine
Celexa
What insomnia medication can be used long term?
Lunesta or Melatonin
BBW Remicade
Fatal infections. Used with methotrexate.
BBW methotrexate
Fetal
Liraglutide BBW
Thyroid C cell tumors. Contraindications in MENs2
Contrave (antiobesity) BBW
Neuropsych, homicidal, etc.
Metformin
-BBW—can cause lactic acidosis (worse risk if CHF, alcohol use, cimetidine, renal impairment
-hypoglycemia is NOT a risk
-hold 48 after IV contrast to avoid renal toxicity
-can deplete vitamin B12 & folic acid levels—check B12 levels prior if a patient has peripheral neuropathy or anemia- check after long term use
-can lower folic acid levels
-monitor LFTs
-contraindications—severe renal disease, acute or chronic metabolic acidosis, hypersensitivity reactions
Synthroid
dose should be reduced in the elderly—increased CV risk- increased myocardial demand
-pt education so important:
-long half-life—so levels won’t be accurate until about 6-8 weeks
-take first thing in AM on empty stomach with full glass of water and wait 1 hour before eating- many foods & drugs affect absorption
-take at the same time each day
-take same brand, do not switch around
-can increase warfarin effects (increases breakdown of vitamin K dependent factors)- decrease warfarin dose
-may need increased dose of insulin or digoxin while taking synthroid
-over thyroid replacement—hyperthyroidism symptoms, risk of bone loss & a-fib
-needs lab monitoring
- pregnancy usually needs more- fetus doesn’t make its own until after 1st trim
Synthroid BBW
do not use for weight loss
Who should not take inhaled insulin?
COPD and asthma
Thiazolidinediones (“glitazones”)
BBW–may exacerbate heart failure
Renal retention
-rare liver injury—monitor LFTs
-contraindicated in symptomatic heart failure or 2nd or 3rd stage CHF
- bladder cancer or increased risk fx (long-term)
Leflunomide (RA Drug)
Fetal toxicity & hepatotoxicity
SERMS (Evista) (HRT) and BBW
-can decrease risk of endometrial or breast cancer risk
-can cause hot flashes, weight gain, flu-like symptoms, arthralgias, infections
-BBW—risk of DVT, PE, retinal vein thrombosis—especially in the first 4 months of treatment
HRT (estrogen and progestin)
increases risk of heart disease, DVT, breast and endometrial cancer
Anti-obesity drugs are contraindicated in those with _____
malabsorption issues
