Interactions and Incompatibilites Flashcards
1
Q
- occurs inside the body
- cannot be seen
A
Interaction
2
Q
- problem which could arise when two or more substances interact during, before, or after drug administration
- occurs outside the body
- usually visible
A
Incompatibility
3
Q
Forms of Incompatibilities
A
- Pharmaceutical Incompatibilities
a. Physical Incompatibilities
b. Chemical Incompatibilities
c. Pharmaceutic - Therapeutic Incompatibilities
a. Drug Interactions
4
Q
interaction between two or more ingredients that leads to a visibly
recognizable change
- same drug is present
- state is altered
A
Physical Incompatibilities
5
Q
- insolubility
- immiscibility
Example:
• gum and alcohol
• pectin and alcohol
• resin and water
• oil and water
A
Incomplete Solution
6
Q
- salting-out process
- solute which is originally dissolved in the solvent is thrown out of solution
- factors affecting solubility: solvent, pH, temperature
Example:
• aromatic water and salt
• spirits and salt solution
• camphor solution and water
A
Precipitation
7
Q
Management of precipitation
A
- know the drug’s solubility
- use the salt or ester form
- know or calculate for the drug’s pH
- add solubilizers or co-solvents
8
Q
Four types of Liquefaction of a Solid Ingredient
A
- deliquescence
- efflorescence
- eutexia
- hygroscopicity
9
Q
A liquefaction of solid ingredient that absorbs moisture and dissolves.
A
deliquescence
10
Q
A liquefaction of solid ingredient that release of water of crystallization.
A
efflorescence
11
Q
A liquefaction of solid ingredient that lowering of melting point. Occurs at room temperature.
A
eutexia
12
Q
A liquefaction of solid ingredient that absorbs moisture but does not dissolve.
A
hygroscopicity
13
Q
Solid ingredients that can undergo deliquescence.
A
NaCl
14
Q
Solid ingredients that can undergo efflorescence.
A
- citric acid
- atropine sulfate
- ferric sulfate
- alum
15
Q
Solid ingredients that can undergo eutexia.
A
- menthol
- phenol
- thymol
- camphor
16
Q
Solid ingredients that can undergo hygroscopicity.
A
• silica gel
17
Q
Management of liquifaction.
A
- solvates and hydrates must be stored and dispensed in tight containers
- substitute anhydrous form
- add adsorbent
- place product in a low humidity environment
- separate and protect potential eutectic mixtures
18
Q
collective term for absorption and adsorption of drugs onto containers, IV tubing, devices,
closures
A
Sorption
19
Q
Management for sorption
A
- shorten contact time
20
Q
- liberation of the active ingredient
- compounds with high vapor pressure
A
Vaporization (or Volatilization)
21
Q
Another term for vaporization
A
Volatilization
22
Q
An example of a compound with high vapor pressure based on maam ka’s reviewer lols
A
nitroglycerin (Monday disease)
23
Q
Management for Vaporization
A
- store in tight containers
- reduce the vapor pressure
24
Q
existence of one or more crystalline and/or amorphous forms
A
Polymorphism
25
Examples of compounds are amorphous based on maam ka's reviewer lols
* aspirin
* Theobroma cacao
* chloramphenicol
* sulfanilamide
26
Cubic
NaCl
27
Monoclinic
sucrose, ritonavir (form I)
28
Tetragonal
urea
29
Hexagonal
iodoform
30
Triclinic
boric acid
31
Rhombic
iodine
32
Orthorhombic
ritonavir (form II)
33
- reverse of liquefaction
| - dehydration due to extreme conditions in the environment
Loss of Water
34
loss of water for emulsions
phase inversion in o/w emulsions; cracking
35
loss of water for suspensions and solutions
increased potency
36
loss of water for ointments
crumbling
37
loss of water for gels
syneresis
38
Management for Loss of water
- store in tight containers
- store in correct conditions
- add humectant
39
reaction between two or more ingredients that leads to a change in its
chemical properties
- a visible change is not necessarily observed
- original drug is no longer present
- may or may not retain form or state
Chemical Incompatibilities
40
- loss of electrons
- reducing agents
- dehydrogenation
- increase in oxidation state
- triggered by oxygen, light, metals
- manifests as change in color
Oxidation
41
Example of drugs that may undergo oxidation based on maam ka's reviewer
* ascorbic acid
| * epinephrine
42
Management of oxidation
- protect from oxygen and light
- add antioxidants
- keep oxidizing agents and reducing agents away from each other
43
- gain of electrons
- oxidizing agents
- hydrogenation
- decrease in oxidation state
Reduction
44
Test for reducing sugars
Tollen's test
45
- neutralization
- evolution of gas
- changes in color
Acid-Base Reaction
46
An evolution of gas applied in drug dosage forms
effervescence
47
effervescent tablets composes of
NaHCO3 + tartaric acid/citric acid
48
Example of drugs with effervescence based on reviewer that starts with p
p-aminosalicylic acid
49
- involving water as solvent
- breaking-up of bonds with water
- most common type of incompatibility
- most common mechanism of drug degradation
Hydrolysis
50
Examples of drugs that involves degradation through hydrolysis based on reviewer
* lactams (penicillins, cephalosporins)
* esters (cocaine, physostigmine, aspirin, tetracaine, procaine, methyldopa)
* amides (dibucaine)
* imines (diazepam)
* glycosides
51
Management of hydrolysis
- store in tight containers
- add desiccants
- control pH
- refrigeration
52
- interaction of drug with solvent other than water
Solvolysis
53
- action or process of changing from an optically active compound into a racemic compound
or an optically inactive mixture
- racemic mixture: equal amounts of dextro- (+) and levo- (-) isomers
Racemization
54
Examples of drugs involved in racemization based on reviewer
* thalidomide
* catecholamines
* local anesthetics
55
- formation of epimers
| - interconversion of one epimer to another epimer
Epimerization
56
compounds with two or more chiral centers
Epimer
57
Examples of drugs that undergo interconversion of one epimer to another epimer
* tetracycline
| * pilocarpine
58
- salting-out process
| - two or more drugs interacting to form a new substance
Precipitation
59
Ca(OH)2 + CO2 → CaCO3↓ + H2O
Precipitation nani lols
60
-reducing agent (RA) + oxidizing agent (OA)
Explosive Mixture
61
Name two examples of an explosive mixture based on reviewer!!!!!!!!
• sugar + KMnO4 • glycerin + KMnO4
62
-cake formation
Cementation
63
An example of cementation
acacia + Bi salts
64
An example of gelatinization
acacia + Fe salts
65
-gel formation
Gelatinization
66
- formation of 5-hydroxymethylfurfural from dextrose
Polymerization
67
- degradation by light
- photooxidation
- photolysis
- remedy: protect from light; given at night; cover IV line with carbon paper
- manifests as change in color
Photochemical Degradation
68
Examples of drugs that can undergo photochemical degradation
* nifedipine
* nitroprusside
* riboflavin
* phenothiazines
* Adriamycin
* cisplatin
* amphotericin B
69
management of photchemical degradation
protect from light
70
- caused by a chemical or physical incompatibility when two or more drugs are mixed together
- occurs when drugs are mixed inappropriately in syringes or infusion fluids prior to administration
Pharmaceutic (in general najud ni sis. physicochemical instability najud)
71
phenytoin sodium will precipitate in an acidic pH. true or false?
true
72
aminophylline (basic pH) should be mixed with epinephrine which decomposes at
alkaline pH
false. it should not be mixed with epinephrine sis. daot jud na kay alkaline si aminophylline.
73
two or more drugs are administered, and response is different from
what is expected
- undesirable pharmacological interaction between two or more ingredients that leads to:
• potentiation of the therapeutic effects of the ingredients
• destruction of the effectiveness of one or more of the ingredients
• occurrence of a toxic manifestation within the patient
THERAPEUTIC INCOMPATIBILITIES
74
increase or decrease in pharmacological response due to the presence of another
drug, herbal medicine, food or drink, treatment, or environmental chemical agent
DRUG INTERACTIONS
75
drug, chemical, or food causing the interaction
Precipitant drug
76
drug affected by the interaction
Object drug
77
supported by well-proven clinical studies
Established
78
very likely but might not be proven clinically
Probable
79
might occur and some data might be available
Suspected
80
could occur and limited data are available
Possible
81
- doubtful
| - no good evidence of an altered clinical effects is available
Unlikely
82
Drug interactions include:
1. Drug-herbal
2. Drug-food
3. Drug-laboratory test
4. Drug-drug
• pharmacokinetic
• pharmacodynamic
83
(Drug+Herbal) What interaction will happen with digoxin and st. john's wort
decreased conc. of digoxin
84
(Drug+Herbal) What interaction will happen with warfarin, LMWH, heparin and garlic
bleeding or hemorrhage!!!!!!!!!!!
85
(Drug+Herbal) What interaction will happen with warfarin and asian ginseng?
decreased conc. of warfarin
86
(Drug+Herbal) What interaction will happen with barbiturates, BZDs and valerian
"double sedation"
87
(Drug+Herbal) What interaction will happen with hypoglycemic agents and ginseng
increased hypoglycemic effect
88
(Drug+Herbal) What interaction will happen with anti-HTN and licorice
antagonism
89
(Drug+Herbal) What interaction will happen with MAOIs, PPA, epinephrine,
caffeine and ma huang
increased blood pressure; irregular heart rate
90
(Drug+food) CNS depressants and caffeine
antagonism
91
warfarin and green leafy veggies
antagonism
92
tetracycline,
| quinolone + dairy products
chelation/complexation causing decreased
| tetracycline absorption
93
MAOIs + tyramine-rich food (beer,
cheese, wine, chicken
liver)
decreased metabolism of norepinephrine causing
| hypertensive crisis
94
INH + histamine-rich food
(cheese, tropical fish,
tuna)
flushing reaction with headache, difficulty of
| breathing, nausea, tachycardia
95
bisacodyl + milk
alteration of pH causing premature liberation of
| bisacodyl
96
ASA + caffeine
alteration of pH causing increased ASA
| absorption
97
metronidazole + alcohol (wine, beer)
disulfiram-like effect
98
spironolactone + banana
hyperkalemia
99
digoxin + oatmeal
decreased A of digoxin
100
bisphosphonates + any food
decreased BA
101
drugs increased by food
```
acarbose
griseofulvin
itraconazole
metoprolol
theophylline
phenytoin
metolazone
```
102
drugs decreased by food
```
alendronate
captopril
erythromycin stearate
isoniazid
penicillamine
penicillins
tetracycline
quinolones
```
103
drugs that absorption can be increased by high fat-containing food
griseofulvin, theophylline, phenytoin, and metolazone
104
___ and ___are affected only to a lesser extent
doxycycline and minocycline
105
```
(Drug + Lab) penicillin,
chloramphenicol,
vitamin C,
INH,
streptomycin and glucose in urine (Benedict's test)
```
false positive result
106
(Drug + Lab) chlordiazepoxide and thyroid function test (I131)
false negative result
107
(Drug + Lab) rifampicin
vitamin B2
chloroquine
metronidazole and urinalysis
```
change in color:
red-orange
intense yellow
brown
ash gray
```
108
(Drug + Lab) allopurinol and blood cholesterol levels
false positive result
109
- processes of ADME of drugs
| - “what the body does to the drugs”
Pharmacokinetics
110
Alterations in Absorption (A)
- Alteration of pH
- Complex Formation
- Decreased Gastric Emptying Time
- Increased Gastric Emptying Time
- Increased GI Motility
- Adsorption of Drug
- Interruption of Enterohepatic Circulation
- Inhibition of GI Microbial Flora
111
(Alteration of pH) antacid + bisacodyl
premature liberation of bisacodyl
112
(Alteration of pH)antacid + ketoconazole
decreased ketoconazole A
113
(Alteration of pH) antacid + salicylates
decreased salicylate A
114
(Complex Formation) tetracycline + metal-containing drugs
decreased tetracycline A
115
(Complex Formation) fluoroquinolones + metal-containing drugs
decreased fluoroquinolone A
116
(Complex Formation) cholestyramine + digoxin
decreased digoxin A
117
(Complex Formation) cholestyramine + warfarin
decreased warfarin A
118
(Complex Formation) penicillamine + metal-containing drugs
decreased penicillamine A
119
(Complex Formation) sucralfate + levothyroxine
decreased thyroxine A
120
(Decreased Gastric Emptying Time) atropine + antacid
increased antacid A
121
(Decreased Gastric Emptying Time) atropine +amphetamine
decreased amphetamine A
122
(Increased Gastric Emptying Time)
| nicotine + antacid
decreased antacid A
123
(Increased GI Motility) laxative or cathartic + any drug
decreased drug A
124
(Adsorption of Drug) adsorbent + any drug
decreased drug A
125
(Interruption of Enterohepatic Circulation) antibiotics + OCP
decreased OCP A
126
(Inhibition of GI Microbial Flora) antibiotics + digoxin
increased digoxin A
127
erythromycin decreases bacterial inactivation of digoxin. true or false.
true
128
Alterations in Distribution (D)
-Displacement from Protein Binding Sites
129
warfarin + phenylbutazone
hemorrhage
130
glibenclamide + phenylbutazone
hypoglycemia
131
OHA + ASA
hypoglycemia
132
bilirubin + salicylates
kernicterus
133
phenytoin + warfarin
gingival hyperplasia
134
tolbutamide + sulfonamide
hypoglycemia
135
epinephrine + lidocaine
restricted blood flow
136
Alterations in Metabolism (M)
Enzyme INDUCERS and Enzyme INHIBITORS
137
Enzyme INDUCERS
```
(GSMPRC)
Griseofulvin
St. John’s Wort
Meprobamate
Phenytoin
Phenobarbital
Rifampicin
Carbamazepine
Chronic
Alcoholism
Cigarette
Smoking
```
```
or
(BS CRAP GPS)
Barbiturates
St. John’s Wort
Carbamazepine
Rifampicin
Alcoholism (chronic)
Phenytoin
Griseofulvin
Phenobarbital
Sulfonylureas
```
138
Enzyme INHIBITORS
```
(MEDVICKSGAO)
Metronidazole
Erythromycin
Disulfiram, Diltiazem
Valproic acid,
Verapamil
Isoniazid, Indinavir
Cimetidine
Chloramphenicol
Ciprofloxacin
Clarithromycin
Ketoconazole
Saquinavir
Grapefruit juice
Acute Alcoholism
Omeprazole
```
or
```
(SICKFACES.COM)
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Acute Alcoholism
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole
Grapefruit juice
```
139
potent enzyme inhibitor
Grapefruit
140
- regular beer =
12 fl. oz.
141
- malt liquor =
8-9 fl. oz.
142
- table wine =
5 fl. oz.
143
Alterations in Excretion (E)
- Alteration of Urinary pH
| - Alteration of Active Transport
144
(Alteration of Urinary pH) salicylates + NaHCO3 →
increased renal E of salicylates
145
(Alteration of Urinary pH) amphetamine + NH4Cl →
increased renal E of amphetamine
146
(Alteration of Active Transport) probenecid + penicillin
decreased renal E of penicillin
147
(Alteration of Active Transport) probenecid + indomethacin
decreased renal E of indomethacin
148
(Alteration of Active Transport) NSAIDs + lithium salts
decreased renal E of lithium salts
149
(Alteration of Active Transport) NSAIDs + methotrexate
decreased renal E of methotrexate
150
(Alteration of Active Transport) quinidine + digoxin
decreased renal and non-renal E of digoxin
151
(Alteration of Active Transport) amiodarone + digoxin
decreased renal and non-renal E of digoxin
152
(Alteration of Active Transport) corticosteroids + ASA
increased renal E of ASA
153
– the MOA and pharmacologic effects of drugs
| - “what the drug does to the body”
Pharmacodynamics
154
- 1 + 1 = 2
| - response is equal to the combined effects of individual drugs
Additive Effects
155
- 1 + 1 = 3 or > 2
| - response is greater than the combined effects of the individual drugs
Synergistic Effects
156
- 1 + 0 = 2
| - a drug with no inherent activity will enhance the effect of another drug
Potentiation
157
- 1 + 1 = 0
| - a drug inhibits the effect of the other
Antagonism
158
* alcohol + barbiturates →
* alcohol + antihistamines →
* alcohol + CNS depressants →
* alcohol + chloral hydrate →
* benzodiazepine + antihistamine →
increased sedation
159
alcohol + chlorpropamide
increased hypoglycemic effects
160
flecainide + verapamil
increased negative inotropic and chronotropic effects
161
prazosin + beta-blocker
orthostatic hypotension
162
beta-blockers + non-DHP CCBs
heart block
163
antidepressants + azithromycin
QT interval prolongation
164
sulfamethoxazole + trimethoprim
co-trimoxazole
165
sulfadoxine + pyrimethamine
Fansidar
166
amoxicillin + clavulanic acid
increased amoxicillin’s antibiotic effect
167
ampicillin + sulbactam
increased ampicillin’s antibiotic effect
168
piperacillin + tazobactam
increased piperacillin’s antibiotic effect
169
levodopa + carbidopa
increased levodopa’s effect
170
(antagonism) phenoxybenzamine +
catecholamines
171
(antagonism) warfarin +
vitamin K
172
(antagonism) heparin +
protamine sulfate
173
(antagonism) opioids +
naloxone
174
(antagonism) benzodiazepine +
flumazenil
175
(antagonism) atropine +
physostigmine
176
(antagonism) procaine +
sulfonamides
177
(antagonism) epinephrine +
acetylcholine
178
(antagonism) propranolol +
albuterol
179
(antagonism) OHAs +
glucocorticoids
180
(antagonism) levodopa +
antipsychotics or neuroleptics
181
(antagonism) tetracycline +
penicillin
182
aminoglycoside + loop diuretic
increased nephrotoxicity and ototoxicity
183
aminoglycoside + neuromuscular blocker
increased muscle relaxation or paralysis
184
diuretic + neuromuscular blocker
increased hypokalemia causing increased muscle
| relaxation or paralysis
185
diuretic + digitalis
increased hypokalemia causing digitalis toxicity
186
diuretic + tetracycline
increased BUN levels
187
Risk for drug interactions:
1. Multiple drugs – more drugs, more potential for drug interactions
2. Multiple prescribers
3. Patient risk factors – elderly, predisposing illness (diabetes, asthma, alcoholism)
188
Prevention:
1. Review drug history and patient risk factors
| 2. Avoid complex therapeutic drug regimens
189
Management:
1. Be knowledgeable on the MOA of the drugs being used
2. Suggest a different drug for significant drug interactions or consider therapeutic alternatives
3. Instruct patient as to timing of the medication
4. Educate the patient
5. Monitor the patient for response, adverse events, and drug levels
190
Alcohol + sedative-hypnotics,
opioid analgesics,
TCAs,
antihistamines
- additive CNS
- depression
- sedation
- ataxia
- increased risk of accidents
191
aminoglycosides + loop diuretics
enhanced ototoxicity
192
antacids + iron supplements,
fluoroquinolones,
ketoconazole,
tetracyclines
decreased gut absorption
193
antibiotics + estrogens, including oral
| contraceptives
many antibiotics lower estrogen levels
| and reduce contraceptive effectiveness
194
antihistamines (H1-blockers) + antimuscarinics,
| sedatives
additive effects with the drugs involved
195
antimuscarinic drugs + drugs absorbed from small intestine
slower onset of effect
196
```
barbiturates (esp.
phenobarbital) + azoles,
CCBs,
propranolol,
quinidine,
steroids,
warfarin,
and many other drugs metabolized in
the liver
```
increased clearance of the affected
| drugs
197
beta-blockers + insulin
masking of symptoms of hypoglycemia
198
beta-blockers + prazosin
increased “first-dose” syncope
199
bile acid-binding resins + acetaminophen,
digitalis,
thiazides,
thyroxine
reduced absorption of the affected
| drugs
200
```
carbamazepine + doxycycline,
estrogen,
haloperidol,
theophylline,
warfarin
```
reduced effect of the affected drugs
201
```
cimetidine + benzodiazepines,
lidocaine,
phenytoin,
quinidine,
theophylline,
warfarin
```
increased effect
202
disulfiram,
metronidazole,
certain cephalosporins + ethanol
increased hangover effect
203
erythromycin + cisapride,
quinidine,
sildenafil,
theophylline
risk of toxicity
204
```
ketoconazole and other
azoles + benzodiazepines,
cisapride,
cyclosporine,
fluoxetine,
lovastatin,
omeprazole,
quinidine,
tolbutamide,
warfarin
```
risk of toxicity
205
MAOIs + catecholamine releasers
| amphetamine, ephedrine
increased NE in the sympathetic nerve
| endings
206
MAOIs + tyramine-containing food and
| beverages
hypertensive crisis
207
NSAIDs + anticoagulants
increased bleeding tendency
208
NSAIDs + ACE inhibitors
decreased antihypertensive efficacy
209
NSAIDs + loop diuretics,
| thiazides
reduced diuretic efficacy
210
```
phenytoin + doxycycline,
methadone,
quinidine,
steroids,
verapamil
```
increased metabolism of drugs involved
211
quinidine + digoxin
increased digoxin levels
212
```
rifampicin + azole antifungals,
corticosteroids,
methadone,
theophylline,
tolbutamide
```
decreased efficacy of the drugs involved
213
salicylates + corticosteroids
additive toxicity to gastric mucosa
214
salicylates + heparin,
| warfarin
increased bleeding tendency
215
salicylates + methotrexate
decreased clearance of drug involved
216
salicylates + sulfinpyrazone
decreased uricosuric effect
217
SSRIs + MAOIs,
meperidine,
TCAs
Serotonin syndrome
218
thiazides + digitalis
increased risk of digitalis toxicity
219
thiazides + lithium
increased plasma levels of lithium
220
warfarin + cimetidine,
erythromycin,
lovastatin,
metronidazole
increased anticoagulant activity
221
```
warfarin + anabolic steroids,
aspirin,
NSAIDs,
quinidine,
thyroxine
```
increased anticoagulant effect
222
warfarin + barbiturates,
carbamazepine,
phenytoin,
rifampicin
decreased anticoagulant effect
