herbals & OTC Flashcards
DHEA (dihydroepiandrosterone)
-naturally occurring steroid hormone
-promoted to slow the aging process, vaginal thinning (recommend vaginal suppositories), & depression
-make sure pt does NOT have breast cancer (fueled by estrogen) or prostate cancer (fueled by testosterone). DHEA increases risk of hormone-sensitive cancers
Lysine or L-lysine
-used for cold sores
-administer on an empty stomach + have low amounts of arginine (this competes w/ lysine for absorption)
-what naturally has lysine: food rich in PRT, meat, cheese (parmesan), yogurt, certain fish (cod, sardines), eggs
-our bodies don’t make it (essential amino acid)
FAV: famcyclovir, acyclovir valcyclovir –> all FDA approved to treat cold sores
Lutein
EYE HEALTH (Lut”eye”in)
St. Johns Wort
-used for depression
-effects 5-HT1 and 5-HT2
-increases serotonin (serotonergic agent)
-potent CYP450 inducer (DDI) –> decreases birth control (ethinyl estradiol), warfarin (increased clot risk), cyclosporine, non-DHPS, antifungal (keto, itraconazole), chemotherapy agents (etoposide - G2 phase; caps in the fridge, paclitaxel, vinblastine, vincristine)
dextromethorphan
INCREASES SEROTONIN
serotonin symptoms
-agitation or restlessness
-insomnia
-confusion
-rapid heart rate + high bp
-dilated pupils
-loss of muscle coordination OR twitching muscles (tremors)
-muscle rigidity
-diarrhea
-fever
TCA
Increases serotonin + norepinephrine
serotonin syndrome: what drugs to look out for DDI (can increase or decrease)
-SSRIs
-SNRIs
-TCAs
-cyclobenzaprine (remember: looks like TCAs)
-triptans
-ergots
-MAOI (phenelzine, tranylcypromine, isocarboxazid, safinamide, selegiline, rasagiline, linezolid, tedizolid, methylene blye, procarbazine)
-5-HT3 receptor antagonists (example: ondansetron –> decreases serotonin)
-tramadol
-meperidine
-methadone
-fentanyl
-dextromethorphan (delsym: long acting)
SAM-e (S-adenosyl-L-methionine)
-used for depression (can be rec’d instead of St. John’s Wort since it is NOT AN INDUCER)
-also used for osteoarthritis
-naturally occurring in the body; concentrations highest in childhood
[CAUTION]
-theoretically, SAM-e might increase serotonin levels i.e., pts with bipolar d/o should NOT take SAM-e for their depressive symptoms
-theoretically, SAM-e might increase chance of PCP infection in pts with AIDS
lithium orotate (symmetry, serenity)
promoted for addiction, insomnia, mood swings, stress
many SEs: cognitive, wt gain, risk for hypothyroidism. polyuria & DM can also occur
narrow therapeutic index drug
-early lithium toxicity < 2 mEq/L –> diarrhea, drowsiness, muscle weakness & vomiting
-blood levels > 2 mEq/L can cause ataxia, blurred vision, tinnitus, polyuria
-blood levels > 3 mEq/L can causes cardiac arrhythmias, kidney damage, and neurologic toxicity
always take w/ food
balance electrolytes
DDI
-NSAIDs increase lithium levels (but not ASA and sulindac)
-lithium goes in the opposite direction of sodium
-thiazides, ACEi both increase lithium toxicity
SE mnemonic = LITHIUM
L = leukocytosis, check Levels (maintenance levels 0.6 - 1 mEq/L; Max = 1.2)
I = Increase in polyuria & polydipsia
T = tremor, hypothyroidism (check TSH; can also cause hyperthyroidism)
H = hypercalcemia
I = increase in dermefex, increase in CNS effects
U = 100% through kidneys; bUn = remember renal
M = monitor the web (Wt, EKG, BetaHCG = don’t want to give in pregnancy)
*no proof that lithium orotate is effective
[ lithium carbonate / lithium citrate = rx for bipolar disorder ]
glucosamine sulfate
used for osteoarthritis (SAMY also used for osteoarthritis) [there IS evidence showing efficacy]
caution w/ DM pts
glucosamine is involved in building tendons, ligaments, cartilage, and the fluid that surrounds joints
some products made from the shells of shrimp = concern for shellfish allergy (but allergy is typically with the meat of the shellfish = allergy w/ glucosamine not actually seen)
chondroitin
used for osteoarthritis
normally found in cartilage around joints in the body
glucosamine / chondroitin
used for osteoarthritis (takes 2 - 3 months to work)
caution w/ DM pts (may increase blood sugar –> use under close medical supervision)
some reports, w/ blood-thinning meds, of increased INR and bleeding w/ Coumadin
kava (or kava-kava)
used for anxiety disorders, stress & insomnia (think alcohol –> sedating effect)
can cause hepatotoxicity and liver failure
kava kava + alcohol –> CNS depression
valerian
ONLY INSOMNIA
chamomile
used for anxiety & as a bedtime tea
caution: anaphylaxis if the pt has a ragweed allergy or similar allergies
saw palmetto
used for bph
appears to non competitively inhibit 5 alpha-reductase
SEs: mild GI, HA
[ overall studies have not shown effectivity ]
Ma Huang (Ephedra)
used to increase energy levels, for wt loss (“fat burner”), and marked as a stimulant
as of 2004, dietary supplements containing ephedrine are illegal to sell in the US so wt loss products have used other stimulant substitutes instead (e.g., bitter orange - contains synephrine, synephrine, guarana - major stimulant, yerba mate, green tea)
ginseng
used for fatigue and stress
-increase athletic performance
-improve cognitive function
-stimulate immune function
-decrease blood glucose levels in pts with type 2 DM (hypoglycemia; especially w/ insulin or oral hypoglycemics i.e., an agent that secretes insulin)
SEs (think of it as a stimulant): insomnia, nervousness, tachycardia, HA, HTN (may worsen HTN w/ concomitant caffeine use), GI
Toxicity: “Ginseng Abuse Syndrome” aggressive behavior
*AMERICAN ginseng can decrease INR (cause induction of 2C9)
*ASIAN + SIBERIAN ginseng can increase INR
gingko
used for dementia, TO IMPROVE MEMORY, cerebral vascular insufficiency, Alzheimer’s, asthma
SEs: GI upset, dizziness, HA
inhibits platelet aggregation (increase INR) –> additive effect w/ warfarin, ASA, NSAIDs, heparin
because of potential bleeding risk, it should be discontinued at least 36 hours prior to a planned surgical procedure
might increase the risk of strokes in elderly patients who take it for > 6 years (don’t recommend for the long term)
[ no real proof that it is effective ]
prevagen
marketed to improve memory (this is a protein that comes from jellyfish)
SEs: CV events (e.g., stroke), may cause seizure in pts w/ predisposing conditions
[ no real proof that it is effective ]
Garlic (Allium sativum)
used for:
-prevention of atherosclerosis
-high blood pressure (weak evidence)
-immune system stimulation (weak evidence)
-hyperlipidemia (not recommended; literally no evidence)
SE: Mild GI Symptoms
DDI
-INCREASES INR (increased risk of bleeding)
-Inducer of CYP3A4 (similar to St. John’s Wort)
-Also reduces saquinavir
Echinacea (purple coneflower)
used for respiratory tract infections and general immune system stimulation (it can help prevent infections)
Possible MOA: May increase phagocytosis
SE: Mild GI
Toxicity: May include anaphylaxis
sometimes used w/ Goldenseal
Goldenseal
used as an
-antimicrobial (for colds and other RTI)
-anti-inflammatory
-laxative
-induce contract of greater tonicity of the uterus (never rec in pregnancy)
sometimes used w/ Echinacea
Feverfew
used for migraine prophylaxis
also has anti-inflammatory & anticoagulant effects
Butterbur
used for migraine prophylaxis
SE = GI upset (burping), possible hepatotoxicity
Soy
may decrease hot flashes and other postmenopausal symptoms; may have CV benefits
some evidence that is can lower risk of getting breast cancer
Yohimbe
used to treat:
-impotence
-aphrodisiac (stimulates sexual desire)
-body building (as a fat burner)
caution. associated w/:
-MI
-seizures
-GI problems
-tachycardia, anxiety, HTN (think of it as a stimulant)
tree native to western Africa
Evening Primrose Oil
used for [limited evidence]:
-eczema (think atopic dermatitis)
-inflammation such as RA
-breast pain associated w/ menstrual cycle, premenopausal & post menopausal syndrome
usually in capsule
may increase bleeding (such as when combined with Coumadin) (when hear that something is an oil –> think “this may increase INR”)
Borage Seed Oil
used for:
-skin conditions (e.g., atopic dermatitis - eczema)
-joint pain
-menopausal disorders
caution:
-liver damage
-increase bleeding (when hear that something is an oil –> think “this may increase INR”)
Cranberry
used for PREVENTION of UTI // reducing RECURRENT UTIs
caution:
-large doses may increase anticoagulant effect (limited evidence)
-drinking large amounts may increase the risk of kidney stones, calories, and glucose
what helps is increasing fluid intake. women w/ recurrent cystitis should increase fluid intake to 2-3 L daily (i.e., it might just be the fluid increase that is helping w/ the UTIs)
Dong Quai
herbal tonic for woman called the “female ginseng”
used to regulate menstrual cycle & help w/ painful menstruation/pelvic pain (female shouldn’t take it while she’s menstruating)
may help w/ menopausal difficulties (may affect estrogen)
stimulates CNS; acts as an energizer
also given to strengthen the blood
SE: bleeding, fever, photosensitivity (limit sun exposure), diarrhea
effects and safety concerns:
-should not be used if bleeding concerns (no use w/ warfarin)
-should not be taken by pregnant or nursing women, children, or patients with breast cancer
[head of the root has anticoagulant activity, and the end of the root eliminates blood stagnation]
Black Cohosh
used for menopausal symptoms (think VMS)
takes 4 - 5 weeks to see an effect
caution: causes liver failure // don’t use if have beast cancer, pregnant
CoQ10
used to reduce risk of heart damage, migraine prevention, decrease complications of heart surgery
potentially good for:
-migraine prevention (slight evidence here)
-heart failure
-statin myalgia
-HTN
-T2DM
doses up to 3,000 mg/day = safe
SE = nausea or diarrhea
milk thistle
used for liver problems to support liver cirrhosis, hepatitis and gall bladder problems
may decrease glucose
red yeast rice supplements
used to lower cholesterol (think lovastatin = products may contain monacolin K which is chemically identical to lovastatin = think statin SEs)
what other meds can cause myopathy
daptomycin and zidovudine
honey
used for wound healing (has antibacterial and antifungal activity); provides moisture barrier
medical honey = Medihoney
cough: children 1 - 5 years with cough (teaspoon and a half) (< 1 = NEVER GIVE TO CHILDREN D/T INFECTION RISK)
cinnamon
beneficial for T2DM
Kratom
opioid-like effects = low doses as a mild stimulant or in higher doses as a sedative
can be used for withdrawal effects
prohibited in some states
think what can cause bleeding
5Gs & BCCDEEFF
5Gs: garlic, Ginger, ginkgo, glucosamine, ginseng (non-American: panax // siberian)
BCCDEEFF:
borage seed oil
chondroitin, cranberry
dong quai (tell women stop during menstruation)
vitamin E, evening primrose oil [OILS]
feverfew, fish oil (high doses)
herbs w/ clotting problems
AMERICAN ginseng
green tea
CoQ10
goldenseal (induces CYP3A4 and 2D6 –> not rec’d d/t lack of proof)
herbs drug interaction potential
st johns wort - inducer (depression, increases serotonin)
American ginseng - induces CYP2C9
5Gs/BCDEEFF
fat soluble vitamins
ADEK
(“that fat man named KADE”)
vitamin A
retinol, beta-carotene
helps w/ vision, deficiency may cause night blindness
xerophthalmia (dry eyes) is a progressive eye disease caused by vitamin A deficiency
high doses may cause birth defects, increase the risk of osteoporosis, CV mortality, and lung cancer (smokers)
vitamin D
is a prohormone for calcium regulation
deficiency may cause Rickets (softening of bones in children, due to prolonged Vitamin D deficiency)
Vitamin E
(tocopherol)
is an antioxidant
[theoretically protects cells against free radicals which can damage cells & may contribute to CV dx & cancer but the use of vitamin E supplements is NOT recommended for primary prevention of CV disease and cancer since it may also increase the risk of strokes and HF in pts with DM or heart disease]
Vitamin K
is a clotting factor
Vitamin K foods include green leafy vegetables: spinach, kale, etc –> which decreases INR
what are the water soluble vitamins
Vitamins B1 - B12 (B1, 2, 3, 5, 6, 7, 9, 12), Vitamin C
vitamin B1
thiamine
deficiency causes wet beriberi (causes HF), and dry beriberi (causes peripheral neuropathy), Wernicke encephalopathy (caused by long term alcohol use)
vitamin B2
riboflavin
in many foods; deficiency is rare
vitamin B3
niacin (nicotinamide)
deficiency may cause Pellagra: marked by 3 D’s: dementia, diarrhea, and dermatitis. researchers say vitamin B3 may give skin cells an energy boost- “turns back on the immune system,” helping them repair the damage
vitamin B5
pantothenate
vitamin B6
pyridoxine
if a pt is on isoniazid, must add 25-50 mg pyridoxine to prevent peripheral neuropathy
vitamin B7
biotin
may help w/ hair, nail and skin (but no evidence)
FDA warns that increased doses may affect some lab tests (e.g., such as false LOW troponin, TSH, PSA)
vitamin B9
folate
deficiency causes megaloblastic anemia; given in pregnancy to prevent neural tube defects
vitamin B12
cyanocobalamin
deficiency causes megaloblastic anemia (pernicious anemia - in which the body isn’t able to absorb B12 due to lack of intrinsic factor), with neurologic symptoms
metformin & vegan diet can also cause B12 deficiency
vitamin C
ascorbic acid
an antioxidant; helps with collagen synthesis; deficiency causes scurvy (fatigue, weakness, bruising, bleeding gums). Vitamin C increases urinary oxalate excretion and may increase risk of kidney stones
calcium misc
calcium carbonate (with food)(OTC)
calcium citrate w/ or w/out food (OTC)
both males and females
19 to 50 –> 1000 mg QD
females
>/= 51 –> 1200 mg QD
males
51 to 70 –> 1000 mg QD
>70 –> 1200 mg QD
give in divided doses to increase absorption
only calcium products that come in IV:
-calcium chloride
-calcium gluconate
Os-Cal
calcium carbonate + vitamin D3
take w/ food
D3 is up to 3x more effective than D2
iron misc
iron deficiency = microcytic anemia (for review, macrocytic anemia = B12 + folic acid deficiency)
increased iron requirements:
-pregnancy (Category A)
-childhood
take on an empty stomach BUT need an acidic environment to be absorbed –> can take w/ vitamin C to increase absorption
SEs = constipation (but if take too much = diarrhea), heartburn, GI, black stools, oral solution can temporarily stain teeth
when pts have ESRD –> may need to give erythropoietin
ferrous gluconate
(12% elemental)
has the lowest amount of elemental iron
brands: ferate, generic of fergon
ferrous gluconate complex = (IV)
brand: ferrlecit
ferrous sulfate
(20% elemental)
think sulfate = SECOND i.e., has the SECOND highest amount of elemental iron
brands:
-fer-in-sol, fer-iron
-slow Fe (exsiccated) = 32% elemental iron
dosing: 325 mg PO TID [usually max]
iron deficiency anemia
-hgb 7-9 –> 325 mg PO TID
-hgb 9-10 –> 325 mg PO BID
-hgb >10 –> 325 mg PO QD
ferrous fumarate
(33% elemental)
think fumarate = FIRST i.e., has the highest amount of elemental iron
brand: ferretts
ferric carboxymaltose
(IV)
injectable (IV) iron formulation for iron deficiency
-each mL contains 50 mg of elemental iron
iron for pediatrics
apap misc
used for pain, to decrease fever, antipyretic of choice during pregnancy
risk of hepatotoxicity w/ chronic use; rare, potentially fatal skin reactions such as SJS and TEN
apap dose for children
well-hydrated: 15 mg/kg every 4 - 6 hr
dehydration risk: 10 mg/kg every 4 - 6 hr
maximum: 75 mg/kg/day
for infants –> available as 160 mg/5 mL
apap dose for adults
reg strength (325 mg) max 10 tabs QD –> 3,250 mg QD
extra strength (500 mg) max 6 tabs –> 3 g QD
tylenol 8 hr arthritis pain ER (650 mg) 6 c QD –> 3,900 mg QD
never exceed maximum daily dosage (hepatotoxicity)
apap overdose stages + antidote info
antidote = N-Acetylcysteine (NAC)
dosage forms:
-inhalation: incompatible w/ rubber & metals
-oral 5% solution: use w/in 1 hr; bad odor
-effervescent tabs (Cetylev): used w/ apap overdoses
-IV (Acetadote): incompatible w/ metals, cefepime, ceftazidime
thiol (sulfhydryl) group has the antioxidant effects and is able to reduce free radicals. the “sulfa” group is the part with the pharmacologic effect i.e., PHARMACOPHORE
NAC uses // MOA:
apap toxicity: antidote IV / PO
-works by restoring glutathione (hepatoprotective agent) levels to inactivate toxic metabolite of apap
adjuvant in respiratory conditions/mucolytic action (inhalation)
-sulfyl group opens up the disulfide bonds in the mucoproteins to decrease mucous viscosity
preventing contrast-induced nephropathy: PO BID x2 days -beginning day before procedure, may be able to scavenge oxygen-derived free radicals and improve endothelium-dependent vasodilation
N-acetylcysteine (NAC) DOSING
tx should begin w/in 8 hrs or ASAP
oral protocol: 72 hr*
-loading: 140 mg/kg then 70 mg/kg Q4H x 17 doses
-may mix w/ water or soft drink
IV protocol: 21 hr*
-loading: 150 mg/kg IV 60 minutes
-second dose: 50 mg/kg over 4 hours
-third dose: 100 mg/kg over 16 hours
aspirin general info
MOA: irreversibly inhibits COX 1 & 2 enzymes which causes:
anti-inflammatory effect
-inhibits prostaglandin biosynthesis
analgesic effect
-relieves mild to moderate pain
antipyretic
-lowers temperature
*antiplatelet effect
-inhibits thromboxane synthesis
-inhibits platelet aggregation
-effects last 8 days (until new platelets formed)
AE // Precautions: GI bleed, CNS: tinnitus - ringing in the ear/vertigo, serum uric acid changes (low dose aspirin increases uric acid), don’t give if have NSAID allergy
*pts with sensitivity to tartrazine dyes, nasal polyps and asthma may have an increased risk of salicylate sensitivity
contra: don’t give to kids (concern for Reyes syndrome), gout pts, active PUD, aspirin-induced fetal toxicity (it can cross placenta and cause bleeding; it might be used to prevent preeclampsia but the RPh would never recommend this)
ASA CAUSES GI BLEED
DDI:
-ibuprofen inactivates ASA’s anticoagulation effect
-ibuprofen and naproxen may decrease ASA’s CV benefit
-tell pts to take ibuprofen 2 hrs after OR 8 hrs before taking ASA (TRY TO GIVE ASA FIRST)
-does not interact w/ topical NSAIDs or celebrex (this is COX 2 selective)
aspirin dosing
anticoagulation (antiplatelet action) dose - acute MI:
-initial: 162 - 325 mg given on presentation (patient SHOULD CHEW nonenteric-coated asa)
-maintenance (secondary prevention): 81 - 325 mg QD
-when ASA is used w/ ticagrelor, rec’d ASA dose = 81 mg QD
antipyretic or analgesic dose - adult dose:
-325 - 650 mg orally every 4 hrs PRN or
-500 - 1000 mg every 4-6 hrs PRN
anti-inflammatory
-recommend non-ASA NSAID for osteoarthritis, RA, and other inflammatory arthritides
*adults: 4 grams maximum per day
ASA overdose: WHAT ANTIDOTE
toxicity is managed with:
-activated charcoal (binds to ASA)
-IV dextrose in pts w/ altered mental status
*sodium bicarbonate
-dialysis in patients w/ renal failure (ASA eliminated almost completely via the kidneys)
sodium bicarbonate (increasing pH) can facilitate the elimination of acetylsalicilic acid (ASA). the mechanism is known as “ion trapping”
NSAIDs: COX1
MOA: block cox 1 & cox 2
THINK KIDNEYS
work on afferent arteriole (ACEi, ARBS, tekturna all work on efferent arterioles;if take NSAID, diuretic and RAAS med = “Triple Whammy” effect aka drop in plasma volume)
picture of kidney
[NSAID location of action]
NSAIDs: COX2
MOA: block cox 1 & cox 2
anti-inflammatory action; analgesic action
renal: predisposes pts to renal injury in hypovolemic pts
colorectal adenomas: decrease in malignant potential of colonic polyps; may prevent colon cancer
NSAID AEs
renal
bleeding risk
-COX2 specific have less bleeing
HA / CNS effects
-especially indomethacin (up to 16%)
hyperkalemia
interfere w/ aspirin anti-PLATELET effects
-diclofenac may have least impact
-take asa 2 hrs before or 8 hrs after ibuprofen (GIVE ASA 1ST)
-take asa 36 hours after last naproxen
NSAID US BOXED WARNING
GI events –> avoid in pts w/ active bleeding
CV events –> (edema and increased BP- d/t Na retention) increased risk of serious cardiovascular thrombotic events (e.g., MI, stroke)
-risk CAN occur early
-if NSAID needed, recommend naproxen
-do NOT recommend diclofenac or celecoxib
NSAID contraindications
PUD - ADMINISTER W/ FOOD (H2 blocker)
bleeding risk
renal insufficiency (eGFR <30)
avoid in the 1st and 3rd trimester (rec apap)
the risk of MI or stroke can occur as early as the 1st week (risk increases w/ longer use)
increased risk of heart failure(d/t water retention, incr BP)
contra to use to treat pain after CABG surgery
asthma (if have ASA sensitivity asthma)
diclofenac
Cambia: packets, for acute migraine attack (fastest acting)
zipsor: diclofenac, potassium, QID capsules
zorvolex: caps TID
arthrotec: diclofenac + misoprostil (decrease GI irritation)
topical: cream, gel (voltaren - 1%; 3% used for actinic keratosis), solution, PATCH (flector patch - apply Q12H)
longer half life NSAIDs
meloxicam: long duration of effect; slow offset
piroxicam (Feldene): 20 mg QD (max dose)(long half-life)
ibuprofen
motrin, advil
Q4-6H
caldor: IV
OTC max = 1200 mg/day; Rx max = 3,200 mg/day
duexis (ibuprofen 800 mg + famotidine 26.6 mg) TID
naproxen
naprosyn-rx
Q12H
Aleve, OTC max = 600 mg/day; Rx max = 1500 mg/day
vimovo (naproxen + esomeprazole magnesium)
naproxen sodium = Anaprox = 550 mg Q12H
lowest CV risk –> rec’d in CV pts
fenoprofen
nalfon
200 mg Q4-6H
avoid in renal pts
*wasn’t emphasized in vid
ketoprofen
orudis
25-75 mg Q6-8H
*wasn’t emphasized in vid
Oxaprozin
daypro
1200 mg QD
*wasn’t emphasized in vid
partially COX2 selective –> less GI AEs (4)
[NSAIDs]
etodolac (Lodine) 200 - 400 mg PO Q6-8hrs
etodolac XL 400 - 1200 mg QD
nabumetone 1000 mg PO as a single dose
meloxicam (Mobic - suspension, tab; Vivlodex - cap) QD
[can rec these if don’t want to give celebrex]
indoles (3)
[NSAIDs]
indomethacin: can cause HAs (CNS), used in gout pts
25 - 50 mg PO/PR BID - TID
Tivorbex - cap, 20, 40 mg
IV
sulindac (Clinoril): NSAIDs increase Li EXCEPT sulindac + ASA
150 - 200 mg PO BID
tolmetin sodium (wasn’t emphasized in vid)
400 mg PO TID
when DO NOT rec/give celebrex
SULFA ALLERGY + @ INCREASED RISK OF CV EVENTS
ketorolac
toradol (only Rx)
IV, IM, PO: indicated for the short-term (up to 5 days) in adults d/t increase risk of GI bleed [can be used longer if eye drops or nasal spray]
Eye gtts
-Aculair, Acuvail = postoperative ocular inflammation following cataract extraction
-0.5% solution = continue for 2 weeks, also used for allergic conjunctivitis
nasal spray (Sprix)
-2 sprays Q6-8H (max = 8 sprays)
cox2 selective
celecoxib (celebrex)
amlodipine/celecoxib (Consensi)
still worry about cox1 selective AEs
capsaicin (general)
Zostrix
there is proof that it is effective
capsaicin dosing
[thinking of patches–> lidocaine patches –> can also be cut to desired size –> but its 12 hours on, 12 hours off]
1st gen antihistamines
very sedating (in general, rec 2nd or 3rd FIRST, then rec 1st)
brompheniramine
chlorpheniramine
-chlor-trimeton allergy
-dose: 4 mg PO Q4-6H
diphenhydramine
-adult: 25 to 50 mg PO Q4-8hrs
-IM/IV 10 to 50 mg per dose
-child: 5 mg/kg/day divided Q6-8H (12.5 mg/5 ml)
doxylamine (sleep aid OTC)(in Nyquil formulations)
carbinoxamine (Karbinal ER)(Rx) - ER suspension
-indicated for allergies Q12H for children >2
-option for pts who dont respond to 2nd gen. antihistamines
1st gen antihistamine indications + SEs
[General]
allergic symptoms, allergic rhinitis, urticaria (hives), and pruritis (itching of the skin) in pregnant women (but 2nd gen preferred)
also anticholinergic: hallucinations, blurred vision, agitation
-sedation or paradoxic excitability (4 kids - test kid response)
-worsening of BPH, glaucoma
-dizziness
-respiratory depression
-tachycardia, torsade de points
-seizures
-short term memory loss
doxylamine indication
insomnia
diphenhydramine indications
diphenhydramine: allergic symptoms
-adjunct to epi in the tx of anaphylaxis
-insomnia
-motion sickness
-management of parkinsonian syndrome and drug induced EPSE (dystonic reactions)[1st is Cogentin - benztropine, 2nd is diphenhydramine]
2nd/*3rd gen antihistamines examples
*fexofenadine (Allegra)(OTC) [180 mg max]
-for kids as young as 6 months
loratadine (Claritin, Alavert)(OTC) [10 mg max]
*desloratadine (Clarinex)(Rx) [5 mg max]
-for kids as young as 6 months
cetirizine (Zyrtec)(OTC) [10 mg max]
-sedating even at normal doses
-Zzzzzzyrtec
*levocetirizine (Xyzal)(OTC) [5 mg max]
[cetirizine & fexofenadine are most effective agents]
[3rd are metabolized –> tech should cause less CNS effects]
fexofenadine general
(Allegra)
EMPTY STOMACH
least sedating, even at higher doses
orange, apple, grapefruit juice, green tea can decrease levels (juices inhibit OATP - organic anion transporting polypeptide; separate by 4 hours)
loratadine general
(Claritin)
sedating at higher doses
less potent than allegra and zyrtec
decongestant examples + MOA
narrow blood vessels in the nose lining. swollen nose tissue inside the nose shrinks and allows air to pass through more easily
all pregnancy category C
all nasal formulations –> worry about severe rebound
pseudoephedrine
-sudafed
phenylephrine (nasal/oral)
-sudafed PE
oxymetazoline (nasal ONLY)
-afrin, dristan 12-hr
pseudoephedrine general
DON’T TAKE AT NIGHT
phenylephrine general
oxymetazoline general
Insect repellent DEET
(N,N-diethyl-meta-toluamide)
used to repel biting pests such as mosquitos (to help prevent encephalitis) & ticks (to help prevent lyme disease from deer ticks - DOA: ~3 - 8 hrs)
% indicates how long med will be effective for
usually recommend 30%
rec’d in kids over 2 months
put on sunscreen THEN put on DEET
never put on underneath the clothes
don’t spray directly on face
what // how treat head lice
lice likes warm areas
use of OTC product pediculicide is the first step. permethrin or pyrethrins are first line. both OTC:
-permethrin >/= 2 months (1%; 5% for scabies)
-pyrethrins >/= 2 years old
also use fine tooth comb. leave OTC on for 10 min
rx products:
-benzyl alcohol (ulesfia) >/= 6 mon (suffocates lice)
-spinosad (natroba) >/= 6 mon (suspension = shake)
-malathion lotion (ovide) >/= 6 yrs (flammable, leave on 8 - 12 hrs)
-ivermectim (sklice) >/= 6 mon (use only once)
-ivermectin (stromectrol) weigh at least 15 kg (oral)
all lice products
oxybutynin
OTC = Oxytrol
overactive bladder
patch changed every 4 days
patch only delivers 3.9 mg/day [4 patches/box = 16 DS]
ANTICHOLINERGIC
[Rx - Ditropan: 5 - 10 mg QD, Max = 30 mg QD]
sunscreen general
UVB causes sunburns
UVA causes skin damage (wrinkles, sagging)
reapply sunscreen every 2 hours regardless of SPF
best rec for seasonal allergic rhinitis, for the relief of nasal congestion, itchy, watery eyes, runny nose and sneezing
intranasal corticosteroids
ex: fluticasone (Flonase), triamcinolone (Nasacort), Budesonide (Rhinocort)
don’t work right away, may take 7 - 14 days to see full effect
triamcinolone (Nasacort)
indication: allergic rhinitis for >/= 2 years old
1-2 sprays per nostril once per day
fluticasone (flonase)
indication: allergic rhinitis AND ocular symptoms for >/= 2 years old
do not use under 2 years
1-2 sprays per nostril once per day
budesonide (rhinocort)
indication: upper respiratory symptoms
dose: QD
6 - 12 yo: once spray per nostril once per day
> 12 yo: 2 sprays into each nostril once a per day (once symptoms improve, then 1 spray in each nostril once per day)
saline nasal spray
for nasal dryness, washing sinuses. works by moisturizing and loosening secretions
very safe, good for pregnancy
directions: 1 - 3 sprays in each nostril as needed
neti pot // “nasal irrigation”
rinsing out the nose with salt water
note: only use distilled, boiled or sterilized water
do NOT recommend tap water
do NOT use table salt
would use this first and then use other nasal meds (if they’re being used)
how to use: saline water in one nostril, comes out the other, KEEP MOUTH OPEN, over the sink
racepinephrine (asthmanefrin)
indication: for temporary relief of SOB, tightness of chest, and wheezing; this is a batter-powered atomizer
not for <4 yo, not for pregnant women, must clean device daily
contraindications: use within 14 days of MAOIs
SE: nervousness, tachycardia
epinephrine (primatene MIST)
MDI, for temporary relief of symptoms
for >/= 12 yo
EACH time, shake, spray into the air 1x, and wash
contact MD if use more than 2x per week
expectorant / antitussive examples
expectorant: thins mucus to help cough it out
guafenesin (Mucinex) [preg cat C]: used for wet cough to clear secretions
dextromethorphan (Delsym) [preg cat C]: for dry cough, blocks the cough reflex
rx antitussive: benzonotate, codeine, hydrocodone + chlorpheniramine (Tussionex), hydrocodone
cough suppressants rx & OTC non-narcotic antitussive points to remember
for dry, nonproductive cough
Delsym (REMEMBER THIS INCREASES SEROTONIN) is ER every 12 hours
Benzonatate 100 to 200 mg PO TID PRN cough (swallow whole, do not chew)
narcotic antitussives
codeine products are NOT CII
hydrocodone products are CII
none of these rec’d for pts <18
what to recommend for cough
want agents that reduce the post nasal drip that triggers coughs
oral decongestant (e.g., pseudoephedrine) alone or in combination with a 1st generation antihistamine
carbamide peroxide (Debrox, Murine Ear)
isopropyl alcohol + anhydrous glycerin (Swimmers’ Ears)
indications: Ear drying drops
dries and clears trapped ear-water due to bathing, showering, swimming, hair washing, jacuzzi, etc
instill 4 - 5 drops in ear after swimming, showering, or bathing
counseling on ear drops
underlying causes of constipation
antacids w/ Al or Ca (can rec a magnesium based antacid)
anticholinergics (e.g., TCAs, antihistamines, antipsychotics)
CCBs
calcium supplements
Fe supplements
opioids
5-HT3 receptor antagonists (ondansetron)
bulk laxatives
what do
examples
dietary fiber improves stool bulk and transit time
dietary fiber lowers serum cholesterol
if pt is severely constipated in the moment –> don’t rec bulk because it’ll add to the bulk d/t 12 ~72 hr onset (can rec if mild-moderate constipation)
always take w/ lots of water
SEs: gas, flatulence and bloating
examples:
-psyllium (e.g., metamucil)
-methylcellulose (e.g., citrucel)
-calcium polycarbophil (fibercon)
-dietary fiber (prunes, dates, bran, rolled oats)
emollient (surfactants), stool softeners
what do
examples
MOA: allow water and fat to penetrate the fecal mass
slow onset of action (24 to 72 hours)
ensure adequate fluid intake; overall well-tolerated
these meds often given w/ opioid rxs
stool softener examples:
-docusate sodium (Colace) = QD OR in divided doses
-docusate calcium = QD
*there are rectal emollients
osmotic laxatives
what do
examples
MOA: promote bowel evacuation by causing osmotic retention of fluid (excessive use may result in electrolyte and volume overload); take water from body and PUT INTO STOOL
complications: hypermagnesemia in Mg containing osmotics; DO NOT give to renal failure pts
use if need something fast d/t quick onsets
examples:
-Mg sulfate (onset = 30 min to 3 hrs)
-Mg citrate (onset = works w/in 3 hrs)
-PEG (onset = 1 to 4 days)
-lactulose (onset = 1 - 2 days)
-sorbitol (onset = 1 - 2 days)
-glycerin (glycerol)(onset = 15 min to 1 hr)
laxatives given to renal failure pts
lactulose or sorbitol –> these are poorly absorbed sugars and they are osmotic laxatives
remember, Mg (and Al) should be used cautiously in renal failure pts
stimulant laxatives
what do
examples
continuous daily ingestion of these agents may be associated w/ hypokalemia and salt overload –> should be used w/ caution if taken chronically
examples:
-senna (senokot)
-bisacodyl (dulcolax; correct) = tabs are QD, comes in a suppository that is also QD
-Senokot-S (senna + docusate)
lubricant laxatives
what do
examples
MOA: makes stools slippery. when taken over a long period –> can absorb fat-soluble vitamins from the intestine; separate this med from other meds
in general not rec’d d/t aspiration concerns
contraindications:
-oral forms –> children <6 years
-pregnancy
-bedridden pts
-elderly
-use longer than 1 week
-difficulty swallowing
examples:
-mineral oil (fleet oil - rectal)
-Goodsense mineral oil
enema and suppository examples
never use hot water, soap, or hydrogen peroxide enema
these are the fastest since inserting fluid from the outside
examples:
-tap water enema or saline enema (safest)
-glycerine suppository (works in ~15-60 minutes)
-bisacodyl suppository and enema
-mineral oil enema
-sodium phosphate enema (fleet enema)
rx constipation meds
bowel prep
[ what type is used ]
examples of what used
needed to clean out colon for colonoscopy –> rec’d have colonoscopy at 50 years
osmotic laxatives (putting body’s fluid into stool) used:
-sodium phosphate
-polyethylene glycol (PEG) electrolyte solution
-mg citrate (not used as monotherapy)
-combination: Na, K, Mg and sulfate oral solution, and PEG-3350
bowel prep: sodium phosphate
examples
what to know
MOA: draws water into the intestinal lumen
OsmoPrep:
-oral tablets
-Rx
Fleet Enema:
-OTC
boxed warning for tabs = phosphate nephropathy
bowel prep:
-PEGs
-Combo of laxative + Mg
examples
what to know
PEG
-w/out electrolytes = Miralax
-w/ electrolytes = GoLYTELY
Miralax is indicated for constipation NOT for bowel cleaning
additional PEG info
tell pts not to drink anything red = otherwise could cause concern for a possible bleed
prepopik info
this is rx
constipation for kids
order of recs:
1. fruit
2. PEG
3. lactulose (safe for all ages)
4. docusate (long onset of action)
constipation and pregnancy
good recs:
-bulk agents (e.g., psyllium)
-osmotic agents (e.g., Mg - Cat B)
-docusate stool softener
-SHORT TERM stimulant agent (e.g., bisacodyl)
DO NOT REC:
-castor oil d/t preg category X
-LONG TERM use of bisacodyl
bismuth subsalicylate
what need to know
Pepto-Bismol!
indications:
-traveler’s diarrhea
-H. pylori management
AEs:
-turns tongue and stool BLACK
-mild tinnitus (EAR RINGING)
contraindications:
-avoid in salicylate allergy
-avoid if pt on salicylates
-avoid if pt on warfarin
-DO NOT EXCEED 3WKS OF USE
loperamide
what need to know
Immodium~!
FOR DIARRHEA –> works by sitting on opioid receptors to cause constipation
available in 2 mg
initial: 4 mg PO for single 1st dose
titrate: 2 mg PO after each loose stool
MAX:
-OTC = 8 mg/day
-Rx = 16 mg/day
octreotide
what need to know
Brand = Sandostatin
rx
subQ // IV
in fridge
simethicone
what need to know
MOA: decreases size of gas bubble –> makes life easier for stomach
can be used in infants
