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MPJE + NAPLEX 2023 PREP > herbals & OTC > Flashcards

herbals & OTC Flashcards

1
Q

DHEA (dihydroepiandrosterone)

A

-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

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2
Q

Lysine or L-lysine

A

-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

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3
Q

Lutein

A

EYE HEALTH (Lut”eye”in)

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4
Q

St. Johns Wort

A

-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)

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5
Q

dextromethorphan

A

INCREASES SEROTONIN

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6
Q

serotonin symptoms

A

-agitation or restlessness
-insomnia
-confusion
-rapid heart rate + high bp
-dilated pupils
-loss of muscle coordination OR twitching muscles (tremors)
-muscle rigidity
-diarrhea
-fever

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7
Q

TCA

A

Increases serotonin + norepinephrine

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8
Q

serotonin syndrome: what drugs to look out for DDI (can increase or decrease)

A

-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)

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9
Q

SAM-e (S-adenosyl-L-methionine)

A

-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

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10
Q

lithium orotate (symmetry, serenity)

A

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 ]

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11
Q

glucosamine sulfate

A

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)

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12
Q

chondroitin

A

used for osteoarthritis

normally found in cartilage around joints in the body

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13
Q

glucosamine / chondroitin

A

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

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14
Q

kava (or kava-kava)

A

used for anxiety disorders, stress & insomnia (think alcohol –> sedating effect)

can cause hepatotoxicity and liver failure

kava kava + alcohol –> CNS depression

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15
Q

valerian

A

ONLY INSOMNIA

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16
Q

chamomile

A

used for anxiety & as a bedtime tea

caution: anaphylaxis if the pt has a ragweed allergy or similar allergies

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17
Q

saw palmetto

A

used for bph

appears to non competitively inhibit 5 alpha-reductase

SEs: mild GI, HA

[ overall studies have not shown effectivity ]

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18
Q

Ma Huang (Ephedra)

A

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)

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19
Q

ginseng

A

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

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20
Q

gingko

A

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 ]

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21
Q

prevagen

A

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 ]

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22
Q

Garlic (Allium sativum)

A

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

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23
Q

Echinacea (purple coneflower)

A

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

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24
Q

Goldenseal

A

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

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25
Q

Feverfew

A

used for migraine prophylaxis

also has anti-inflammatory & anticoagulant effects

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26
Q

Butterbur

A

used for migraine prophylaxis

SE = GI upset (burping), possible hepatotoxicity

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27
Q

Soy

A

may decrease hot flashes and other postmenopausal symptoms; may have CV benefits

some evidence that is can lower risk of getting breast cancer

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28
Q

Yohimbe

A

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

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29
Q

Evening Primrose Oil

A

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”)

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30
Q

Borage Seed Oil

A

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”)

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31
Q

Cranberry

A

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)

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32
Q

Dong Quai

A

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]

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33
Q

Black Cohosh

A

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

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34
Q

CoQ10

A

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

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35
Q

milk thistle

A

used for liver problems to support liver cirrhosis, hepatitis and gall bladder problems

may decrease glucose

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36
Q

red yeast rice supplements

A

used to lower cholesterol (think lovastatin = products may contain monacolin K which is chemically identical to lovastatin = think statin SEs)

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37
Q

what other meds can cause myopathy

A

daptomycin and zidovudine

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38
Q

honey

A

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)

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39
Q

cinnamon

A

beneficial for T2DM

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40
Q

Kratom

A

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

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41
Q

think what can cause bleeding

A

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)

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42
Q

herbs w/ clotting problems

A

AMERICAN ginseng

green tea

CoQ10

goldenseal (induces CYP3A4 and 2D6 –> not rec’d d/t lack of proof)

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43
Q

herbs drug interaction potential

A

st johns wort - inducer (depression, increases serotonin)

American ginseng - induces CYP2C9

5Gs/BCDEEFF

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44
Q

fat soluble vitamins

A

ADEK

(“that fat man named KADE”)

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45
Q

vitamin A

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)

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46
Q

vitamin D

A

is a prohormone for calcium regulation

deficiency may cause Rickets (softening of bones in children, due to prolonged Vitamin D deficiency)

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47
Q

Vitamin E

A

(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]

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48
Q

Vitamin K

A

is a clotting factor

Vitamin K foods include green leafy vegetables: spinach, kale, etc –> which decreases INR

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49
Q

what are the water soluble vitamins

A

Vitamins B1 - B12 (B1, 2, 3, 5, 6, 7, 9, 12), Vitamin C

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50
Q

vitamin B1

A

thiamine

deficiency causes wet beriberi (causes HF), and dry beriberi (causes peripheral neuropathy), Wernicke encephalopathy (caused by long term alcohol use)

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51
Q

vitamin B2

A

riboflavin

in many foods; deficiency is rare

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52
Q

vitamin B3

A

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

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53
Q

vitamin B5

A

pantothenate

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54
Q

vitamin B6

A

pyridoxine

if a pt is on isoniazid, must add 25-50 mg pyridoxine to prevent peripheral neuropathy

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55
Q

vitamin B7

A

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)

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56
Q

vitamin B9

A

folate

deficiency causes megaloblastic anemia; given in pregnancy to prevent neural tube defects

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57
Q

vitamin B12

A

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

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58
Q

vitamin C

A

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

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59
Q

calcium misc

A

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

60
Q

Os-Cal

A

calcium carbonate + vitamin D3

take w/ food

D3 is up to 3x more effective than D2

61
Q

iron misc

A

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

62
Q

ferrous gluconate

A

(12% elemental)

has the lowest amount of elemental iron

brands: ferate, generic of fergon

ferrous gluconate complex = (IV)

brand: ferrlecit

63
Q

ferrous sulfate

A

(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

64
Q

ferrous fumarate

A

(33% elemental)

think fumarate = FIRST i.e., has the highest amount of elemental iron

brand: ferretts

65
Q

ferric carboxymaltose

A

(IV)

injectable (IV) iron formulation for iron deficiency
-each mL contains 50 mg of elemental iron

66
Q

iron for pediatrics

A
67
Q

apap misc

A

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

68
Q

apap dose for children

A

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

69
Q

apap dose for adults

A

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)

70
Q

apap overdose stages + antidote info

A

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

71
Q

N-acetylcysteine (NAC) DOSING

A

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

72
Q

aspirin general info

A

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)

73
Q

aspirin dosing

A

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

74
Q

ASA overdose: WHAT ANTIDOTE

A

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”

75
Q

NSAIDs: COX1

A

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)

76
Q

picture of kidney

[NSAID location of action]

A
77
Q

NSAIDs: COX2

A

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

78
Q

NSAID AEs

A

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

79
Q

NSAID US BOXED WARNING

A

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

80
Q

NSAID contraindications

A

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)

81
Q

diclofenac

A

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)

82
Q

longer half life NSAIDs

A

meloxicam: long duration of effect; slow offset

piroxicam (Feldene): 20 mg QD (max dose)(long half-life)

83
Q

ibuprofen

A

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

84
Q

naproxen

A

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

85
Q

fenoprofen

A

nalfon

200 mg Q4-6H

avoid in renal pts

*wasn’t emphasized in vid

86
Q

ketoprofen

A

orudis

25-75 mg Q6-8H

*wasn’t emphasized in vid

87
Q

Oxaprozin

A

daypro

1200 mg QD

*wasn’t emphasized in vid

88
Q

partially COX2 selective –> less GI AEs (4)

[NSAIDs]

A

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]

89
Q

indoles (3)

[NSAIDs]

A

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

90
Q

when DO NOT rec/give celebrex

A

SULFA ALLERGY + @ INCREASED RISK OF CV EVENTS

91
Q

ketorolac

A

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)

92
Q

cox2 selective

A

celecoxib (celebrex)

amlodipine/celecoxib (Consensi)

still worry about cox1 selective AEs

93
Q

capsaicin (general)

A

Zostrix

there is proof that it is effective

94
Q

capsaicin dosing

A

[thinking of patches–> lidocaine patches –> can also be cut to desired size –> but its 12 hours on, 12 hours off]

95
Q

1st gen antihistamines

A

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

96
Q

1st gen antihistamine indications + SEs

[General]

A

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

97
Q

doxylamine indication

A

insomnia

98
Q

diphenhydramine indications

A

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]

99
Q

2nd/*3rd gen antihistamines examples

A

*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]

100
Q

fexofenadine general

A

(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)

101
Q

loratadine general

A

(Claritin)

sedating at higher doses

less potent than allegra and zyrtec

102
Q

decongestant examples + MOA

A

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

103
Q

pseudoephedrine general

A

DON’T TAKE AT NIGHT

104
Q

phenylephrine general

A
105
Q

oxymetazoline general

A
106
Q

Insect repellent DEET

A

(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

107
Q

what // how treat head lice

A

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)

108
Q

all lice products

A
109
Q

oxybutynin

A

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]

110
Q

sunscreen general

A

UVB causes sunburns

UVA causes skin damage (wrinkles, sagging)

reapply sunscreen every 2 hours regardless of SPF

111
Q

best rec for seasonal allergic rhinitis, for the relief of nasal congestion, itchy, watery eyes, runny nose and sneezing

A

intranasal corticosteroids

ex: fluticasone (Flonase), triamcinolone (Nasacort), Budesonide (Rhinocort)

don’t work right away, may take 7 - 14 days to see full effect

112
Q

triamcinolone (Nasacort)

A

indication: allergic rhinitis for >/= 2 years old

1-2 sprays per nostril once per day

113
Q

fluticasone (flonase)

A

indication: allergic rhinitis AND ocular symptoms for >/= 2 years old

do not use under 2 years

1-2 sprays per nostril once per day

114
Q

budesonide (rhinocort)

A

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)

115
Q

saline nasal spray

A

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

116
Q

neti pot // “nasal irrigation”

A

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

117
Q

racepinephrine (asthmanefrin)

A

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

118
Q

epinephrine (primatene MIST)

A

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

119
Q

expectorant / antitussive examples

A

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

120
Q

cough suppressants rx & OTC non-narcotic antitussive points to remember

A

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)

121
Q

narcotic antitussives

A

codeine products are NOT CII

hydrocodone products are CII

none of these rec’d for pts <18

122
Q

what to recommend for cough

A

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

123
Q

carbamide peroxide (Debrox, Murine Ear)

A
124
Q

isopropyl alcohol + anhydrous glycerin (Swimmers’ Ears)

A

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

125
Q

counseling on ear drops

A
126
Q

underlying causes of constipation

A

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)

127
Q

bulk laxatives

what do

examples

A

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)

128
Q

emollient (surfactants), stool softeners

what do

examples

A

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

129
Q

osmotic laxatives

what do

examples

A

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)

130
Q

laxatives given to renal failure pts

A

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

131
Q

stimulant laxatives

what do

examples

A

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)

132
Q

lubricant laxatives

what do

examples

A

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

133
Q

enema and suppository examples

A

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)

134
Q

rx constipation meds

A
135
Q

bowel prep

[ what type is used ]

examples of what used

A

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

136
Q

bowel prep: sodium phosphate

examples

what to know

A

MOA: draws water into the intestinal lumen

OsmoPrep:
-oral tablets
-Rx

Fleet Enema:
-OTC

boxed warning for tabs = phosphate nephropathy

137
Q

bowel prep:
-PEGs
-Combo of laxative + Mg

examples

what to know

A

PEG
-w/out electrolytes = Miralax
-w/ electrolytes = GoLYTELY

Miralax is indicated for constipation NOT for bowel cleaning

138
Q

additional PEG info

A

tell pts not to drink anything red = otherwise could cause concern for a possible bleed

139
Q

prepopik info

A

this is rx

140
Q

constipation for kids

A

order of recs:
1. fruit
2. PEG
3. lactulose (safe for all ages)
4. docusate (long onset of action)

141
Q

constipation and pregnancy

A

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

142
Q

bismuth subsalicylate

what need to know

A

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

143
Q

loperamide

what need to know

A

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

144
Q

octreotide

what need to know

A

Brand = Sandostatin

rx

subQ // IV

in fridge

145
Q

simethicone

what need to know

A

MOA: decreases size of gas bubble –> makes life easier for stomach

can be used in infants

MPJE + NAPLEX 2023 PREP (16 decks)

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