Pharm/ drug need to know

Question 1

Epinephrine (Adrenalin)

Answer 1

Drug Class: Sympathomimetic: adrenergic agonist

Dosage: Anaphylaxis; Adult: subQ 0.3-0.5 mL of 1:1000 PRN

Contraindications: Cardiac tachydysrhythmias, cerebral arteriosclerosis, pregnancy, narrow-angle glaucoma, cardiogenic shock.
Caution: Hypertension, prostatic hypertrophy, hyperthyroidism, pregnancy, diabetes mellitus (hyperglycemia could result).

Drug-Lab-Food Interactions: Drug: Increased effects with tricyclic antidepressants and MAOIs. Methyldopa and beta-blockers antagonize epinephrine effects. Digoxin may cause dysrhythmias with epinephrine. Lab: Increases blood glucose and serum lactic acid.

Pharmacokinetics of Epinephrine: Used in emergency anaphylaxis because it can be administered via various routes: topically, subcutaneous injection, inhalation, instillation, and intracardiac. It cannot be given orally. Epinephrine is metabolized by the liver and excreted in the urine.
Pharmacodynamics of Epinephrine: The onset of action and peak concentration times are rapid.
Therapeutic Effects/Uses: To treat allergic reaction, anaphylaxis, asthma, bronchospasm, severe hypotension, cardiac arrest.
Mode of Action: Acts on alpha and beta-receptors. Promotes CNS and cardiac stimulation and bronchodilation. Strengthens cardiac contraction. Increases cardiac rate and cardiac output. Reduces mucosal congestion by inhibiting histamine release. Reverses anaphylactic reactions.

Question 2

Albuterol (Proventil, Ventolin)

Answer 2

Drug Class: Beta2-adrenergic agonist

Dosage: Adult PO: 2-4 mg. t.i.d./q.i.d; max: 32 mg/d in 4 divided doses
Inhalation: 1-2 puffs q 4-6 hrs. PRN

Contraindications: cardiac dysrhythmias, coronary artery disease.
Caution: Severe cardiac disease, hypertension, hyperthyroidism, diabetes mellitus, renal dysfunction, older adults, pregnancy.

Drug-Food-Interactions: Drug: Increased effect with other Sympathomimetics. May increase effect with MAOIs and tricyclic antidepressants. Antagonized effect with beta-blockers. Lab: May increase glucose level slightly. May decrease serum potassium level.

Pharmacokinetics of Albuterol: Albuterol is absorbed by the GI tract and metabolized by the liver. Half-life for oral route is 2.7 to 6 hours and half-life of inhalation route is 3.5 hours

Pharmacodynamics of Albuterol: The primary use of albuterol is to prevent and treat bronchospasm. Tremors, restlessness, and nervousness are common side effects or oral or inhalation albuterol. If albuterol is taken with MAOIs, hypertensive crisis can result.

Therapeutic Effect/Uses: To treat asthma and prophylaxis and treatment of bronchospasm
Mode of Action: Stimulates beta 2-adrenergic receptors in the lungs, which relaxes the bronchial smooth muscle causing bronchodilation.

Side effects: Tremor, dizziness, nervousness, restlessness, sweating, nausea, diarrhea, muscle cramps
Adverse reactions: Palpitations, tachycardia, HTN, infection, hyperglycemia. Life-threatening: cardiac dysrhythmias, Stevens-Johnson Syndrome, angioedema

Question 3

Atenolol

Answer 3

Drug Class: Beta1-adrenergic blocker

Dosage: Hypertension/angina: Adult PO: 25-50 mg/day; may increase to 100 mg/day

Contraindications: Sinus bradycardia, heart block, cardiogenic shock, pulmonary edema, acute bronchospasm, cardiac failure, pregnancy, lactation.

Caution: renal dysfunction, diabetes mellitus.

Drug-Lab-Food Interactions: Drug: Increased absorption with atropine and other anticholinergics. Decreased effects with NSAIDS, increased risk of hypoglycemia with insulin and sulfonylureas. Increased hypotension with prazosin and terazosin. Increased lidocaine and verapamil levels with toxicity.

Pharmacokinetics: Atenolol is 50% absorbed form the GI tract. It has a half-life of 3 to 6 days and is excreted in the urine and feces.

Pharmacodynamics: decreases the heart rate, peripheral vascular resistance, force of cardiac contractions, cardiac output, and blood pressure. It is available in tablets and IV. The drug is effective for dosing once a day.

Therapeutic Effects/Uses: To treat HTN, angina, and prophylaxis and treatment of acute MI.

Mode of Action: Selectively blocks beta1-adrenergic receptor sites, decreases sympathetic outflow to the periphery, suppresses renin-angiotensin-aldosterone system

Drug Interactions: NSAIDS decrease the effect of atenolol. Atropine increases the absorption of atenolol.

Side Effects: Drowsiness, dizziness, depression, weakness, nausea, diarrhea, cool extremities, ED

Adverse Reactions: bradycardia, hypotension, HF, dyspnea.
Life-threatening: bronchospasm, dysrhythmia, thrombocytopenia
** A selective beta 1 blocker that is one of the most frequently prescribed drugs in the United States. Atenolol decreases sympathetic outflow to the periphery and suppresses the renin-angiotensin-aldosterone system response. It is contraindicated in bradycardia, heart block, cardiogenic shock, pulmonary edema, acute bronchospasm, and pregnancy.
Patients should be taught to rise slowly d/t orthostatic hypotension.**

Question 4

Bethanechol Chloride

Answer 4

Drug Class: Cholinergic – parasympathomimetic

Dosage: PO:10-15 mg tid/qid; Max: 200 mg/day. Subcut: 5 mg tid/qid; max: 40 mg/d

Contraindications: Intestinal or urinary tract obstruction, IBS, severe bradycardia, hypotension, COPD, asthma, peptic ulcer, hyperthyroidism, seizure, parkinsonism.

Drug-Lab-Food Interactions: Drug: Decreases Bethanechol effect w/ antidysrhythmic; ganglionic blocking agents cause significant hypotension following severe abdominal symptoms.
Atropine counteracts Bethanechol action. Lab: False test results (amylase, lipase).

Pharmacokinetics: Absorption: Poorly absorbed PO

Pharmacodynamics: PO: Onset 0.5 – 1.5 hours. Peak: 1-2 hours. Duration: 4-6 hours.

Therapeutic Effects/Uses: To treat urinary retention and neurogenic bladder.
Mode of action: Stimulates the cholinergic (muscarinic) receptors; promotes contraction of the bladder; increases GI secretions and peristalsis, pupillary constriction, and bronchoconstriction.

Side Effects: N/V/D, abdominal cramps, hypersalivation, sweating, HA, dizziness, flushing, urinary urgency and frequency.

Adverse reactions: Tachycardia weakness. Life threatening: Bronchospasm

Question 5

Atropine

Answer 5

Drug Class: Anticholinergic: parasympatholytic

Dosage: Bradycardia: IV: 0.5-1 mg, repeat q 6 min., max: 2mg. Preoperative: PO: 2 mg, 20-30 min before anesthesia

Contraindications: Narrow angle glaucoma, obstructive GI disorders, paralytic ileus, ulcerative colitis, tachycardia, BPH, myasthenia gravis, MI.

Drug Label/Food Interactions: Increased effect with antihistamines, TCAs, amantadine, quinidine, and many more

Pharmacokinetics: Absorption: PO.IM well absorbed. Distribution: Crosses the placenta. Metabolism: t1/2: 2-3 hours. Excretion: 75% excreted in the urine

Pharmacodynamics: PO: onset O.5-1 hour. Duration: 4hours. IV: onset: immediate Peak: 5minutes

Therapeutic Effects/Uses: Preoperative medication to reduce salivation. Increase the heart rate in bradycardia (by blocking vagus stimulation). To dilate pupils for eye exams.

Side effects: Dry mouth, nausea, headache, amnesia, constipation, dry skin, urinary retention, mydriasis, photophobia, palpitation.

Adverse reactions: Tachycardia, hyper/hypotension, seizures. Life threatening: ventricular fibrillation, laryngospasm, Stevens-Johnson syndrome, coma

** Atropine is a classic anticholinergic –or muscarinic antagonist– medication. Atropine is primarily useful as a pre-op medication to decrease salivary secretions and as an agent to increase heart rate when bradycardia is present. It increases the heart rate by blocking vagus stimulation. Atropine can also be used as an antidote for Bethanechol.**

Question 6

Benztropine

Answer 6

Drug Class: Antiparkinsonism: anticholinergic agent

Dosage: Antiparkinsonism: Adult: PO/IM 0.5-0.6 mg/day at bedtime; max: 8 mg/day. Extrapyramidal symptoms (except tardive dyskinesia): PO/IM/IV: 1-4 mg q daily/bid; max: 8 g/day.

Contraindications: Closed-angle glaucoma, tardive dyskinesia, dementia, myasthenia gravis, contraindicated for children. Caution: Tachycardia, cardiac disease, autonomic neuropathy, prostatic hypertrophy, psychosis.

Drug-Lab-Food Interactions: Drug: increase anticholinergic effects with phenothiazines, tricyclic antidepressants, and other anticholinergics.

Pharmacokinetics: Absorption: PO, well-absorbed. Distribution: Protein binding unknown. Metabolism: t ½ unknown. Excretion: in urine.

Pharmacodynamics: PO: Onset 1 hr.

Therapeutic Effects/Uses: To decrease involuntary symptoms of Parkinson’s or drug-induced Parkinson’s.

Mode of Action: Blocks cholinergic (muscarinic) receptors and decreases acetylcholine to reduce excess cholinergic activity (involuntary movements), also blocks dopamine reuptake to prolong dopamine effects and decrease involuntary movements.

Side Effects: N/V, dry mouth, constipation, anhidrosis, dizziness, HA, drowsiness, blurred vision, confusion, depression, hallucinations, hyphohidrosis, weakness, hyperthermia, paresthesia.

Adverse Reactions: Tachycardia, urinary retention, ocular hypertension. Life-threatening: Ileus.

Question 7

Tolterodine Tartrate

Answer 7

Drug Class: anticholinergic

Dosage: Immediate release; Adult: 1-2 mg bid; max: 4 mg/day. Extended release: Adult: PO: 2-4 mg/day; 4 mg/day

Contraindications: Hypersensitivity, urinary retention, gastric paresis, GI obstruction, glaucoma, lactation.
Caution: Alcoholism, cardiovascular disease, HTN, bradycardia, heart failure, GERD, paralytic ileus, ulcerative colitis, diabetes, myasthenia gravis, urinary tract obstruction, prostatic hypertrophy, renal or hepatic dysfunction.

Drug-Lab-Food-Interactions: Drug increased effect with amantadine, amoxapine, bupropion, clozapine, cyclobenzaprine, disopyramide, maprotiline, olanzapine, H1 blockers, phenothiazines, TCAs. Decreased effects with azole antifungals, macrolide antibiotics, cyclosporine, fluoxetine.

Pharmacokinetics: Absorption: GI absorption decreased with food intake. Distribution: Protein binding 96%. Metabolism: t1/2 2-4 hrs. Excretion: Urine and feces.

Pharmacodynamics: PO: Onset Unknown.

Therapeutic Effects/Uses: To decrease urinary frequency, urgency, incontinence. Mode of Action: Blocks cholinergic (muscarinic) receptors selectively in the urinary bladder.

Side Effects: Dry mouth, eyes, and skin; headache, drowsiness, dizziness, vertigo, blurred vision, confusion, diarrhea, abdominal pain, constipation, dyspepsia, dysuria, fatigue, weight gain, urinary retention .

Adverse Reactions: Angioedema, chest pain, tachycardia, peripheral edema. Life threatening: Stevens-Johnson syndrome.

Question 8

Methylphenidate

Answer 8

Drug Class: Amphetamine-like drug. CNS stimulant.

Dosage: ADHD: Children > 6 yrs.: PO 5-20mg before breakfast and lunch; may increase dosage weekly by 5-10mg. Max: 60mg/day. Adults: PO 20-30 mg in divided doses before breakfast and lunch. Max: 60 mg/day. Narcolepsy: PO 10-60 mg /day, divided doses 30 minutes before meal.

Contraindications: Hyperthyroidism, anxiety, history of seizures, coronary artery disease, hypertension, Tourrette’syndrome, glaucoma, psychosis, depression.
Caution: Not to be used in children < 6 yrs. of age.

Drug-Lab-Food Interactions: May increase effects of sympathomimetics, psychostimulants, may reduce effect of antihypertensives. Increases effects of oral anticoagulants, barbiturates, anticonvulsants, antidepressants. Food: Caffeine may increase effects. Give 30 to 45 minutes before meals.

Therapeutic Effects/Uses: To correct hyperactivity caused by ADHD, increase attention span, and control narcolepsy.

Side Effects: Anorexia, dry mouth, vomiting, dizziness, insomnia, irritability, tremors, blurred vision, headache, anemia.

Adverse Reactions: Tachycardia, HTN, growth suppression, palpitations, seizures, transient weight loss in children.
Life threatening: Exfoliative dermatitis, stroke, thrombocytopenia, hepatotoxicity

Question 9

Alprazolam (Xanax)

Answer 9

Drug Class: Sedative-hypnotic: benzodiazepine.

Dosage: Adult PO Initially 0.25-0.5 mg/day

Contraindications: Respiratory depression, acute alcohol intoxication, psychotic reactions, recent respiratory depressants, hypersensitivity. Caution: Older adults, sleep apnea, renal or liver dysfunction, depression, suicidal ideation, drug abuse.

Drug-lab-Food interactions: Drug Interactions: decreases respiration with alcohol, CNS depressants, azole antifungals (ketoconazole), antibiotics (erythromycin), cimetidine, diltiazem, verapamil increases blood levels of alprazolam, rifampin, phenytoin decrease blood levels of alprazolam, alprazolam increases digoxin and lithium levels. Food: Grapefruit juice increases alprazolam levels; green tea decreases alprazolam effects.

Therapeutic Effects/Uses: To treat anxiety and panic disorders.
Mode of Action: CNS depression, binds receptors in limbic system and reticular formation, increases GABA to GABA receptors, shifts chloride ions leading to less excitability and stabilizes neuronal membranes.

Side Effects: Lethargy, drowsiness, dizziness, HA, constipation, memory impairment, fatigue, agitation, ataxia, increases appetite, blurred vision, decreased libido, dry mouth, nausea, edema, weight gain/loss

Adverse reactions: Depression, tolerance, dependence, withdrawal, hypotension, tachycardia, seizures. Life-threatening: Hepatic failure, Stevens-Johnson Syndrome

Question 10

Zolpidem Tartrate

Answer 10

Drug Class: Sedative-hypnotic: nonbenzodiazepine.

Dosage: Adult PO: 5-10mg hs (at bedtime); max: 10 mg/day

Contraindications: Hypersensitivity to benzodiazepine, respiratory depression, lactation. Caution: renal or liver dysfunction, mental depression, suicidal ideation, pregnancy, children, older adults, and debilitated individuals.

Drug-Lab-Food Interactions: Drug: Decreases CNS function with alcohol, CNS depressants, anticonvulsants, and phenothiazines; increased levels with azole antifungals; decreased levels with rifampin. Food: Decreases absorption.

Therapeutic Effects/Uses: To treat insomnia.

Mode of Action: CNS depression, neurotransmitter inhibition.

Side Effects: Drowsiness, lethargy, headache, hot flashes, hangover (residual sedation), irritability, dizziness, ataxia (lack of coordination of voluntary muscle movements), visual disturbances, anxiety, mental depression, N/V, edema, anterograde amnesia, memory impairment, nightmares, binge eating, erectile dysfunction.

Adverse reactions: Tolerance, psychological or physical dependence, sleep-related behavior, hypotension, angioedema, dysrhythmias, suicidal ideation. Life-threatening: Pulmonary edema, renal failure

** Zolpidem (Ambien) is a nonbenzodiazepine that differs in chemical structure from benzodiazepines. It is used for short term treatment of insomnia (<10 days). When prescribed to older adults, the dose of zolpidem should be decreased.**

Question 11

Phenytoin (Dilantin)

Answer 11

Drug Class: Anticonvulsant: hydantoin. Trade name: Dilantin.

Dosage: Adult: PO 4-7 mg/kg/day. IV: Loading dose: 15-20 mg/kg/day; max: 30 mg/kg. Child: 5 mg/kg/day in 2-3 divided doses.
Therapeutic serum range: 10-20 mcg/mL. Toxic level: 30-50 mcg/mL

Contraindications: Hypersensitivity, heart block, bradycardia, Adams-Stokes syndrome.
Caution: Hyponatremia, hypotension, hypoglycemia, suicidal ideation, myasthenia gravis, thyroid disease, alcoholism, DM, renal and hepatic impairment, Asian.

Drug-Lab-Food Interactions: Drug: increases effects with cimetidine, isoniazid, and chloramphenicol, decrease effects with folic acid, calcium, antacids, sucralfate, vinblastine, and cisplatin. Decreases effects of: anticoagulants, oral contraceptives, antihistamines, corticosteroids, theophylline, cyclosporine, quinidine, dopamine, and rifampin. Food: Decreased effects of folic acid, calcium, and Vitamin D because absorption is decreased with phenytoin.

Therapeutic Effects/Uses: To prevent tonic-clonic seizures and complex partial seizures and status epilepticus.
Mode of Action: Reduces motor cortex activity by altering ion transport.

Side Effects: Headache, diplopia (double vision), confusion, dizziness, drowsiness, insomnia, fatigue, ataxia, tremor, rash, anorexia, N/V, gingival hyperplasia, pink-red/brown discoloration of urine.

Adverse reactions: Leukopenia, hepatic impairment, depression, hyperglycemia, bradycardia, peripheral neuropathy, purple glove syndrome.
Life threatening: Aplastic anemia, thrombocytopenia, agranulocytosis, Stevens-Johnson syndrome, hypotension, ventricular fibrillation, suicidal ideation.

Question 12

Carbidopa-Levodopa (Sinemet)

Answer 12

Drug Class: Antiparkinsonian: Dopamine replacement. Trade name: Sinemet.

Dosage: Adult: PO initially 1 tablet containing 25mg carbidopa/100mg levodopa t.i.d/q.i.d.; maintenance: 25/250 mg t.i.d./q.i.d.; max: 8 tablets per day. Extended release: 50mg carbidopa/200 mg levodopa b.i.d.

Contraindications: Narrow-angle glaucoma, severe cardiac, renal, hepatic disease; suspicious skin lesions (activates malignant melanoma), MAOI therapy. Caution: Peptic ulcer, impulse control syndrome, orthostatic hypotension, psychosis, seizure disorder, suicidal ideation.

Drug-Lab-Food Interactions: Drug: Increases hypertensive crisis with MAOIs. Decreased levodopa effect with anticholinergics and antipsychotics. Lab: May increase BUN, AST, ALT, ALP, LDH. Food: High-protein foods decrease levodopa absorption

Therapeutic Effects/Uses: To treat parkinsonism; to relieve tremors and rigidity. Mode of Action: Transmission of levodopa to brain cells for conversion to dopamine; carbidopa blocks the conversion of levodopa to dopamine in the intestine and peripheral tissues.

Side Effects: Anorexia, N/V, dysphagia, dyskinesia, erythema, fatigue, dizziness, HA, dry mouth, constipation, bitter taste, twitching, blurred vision, insomnia, excess dark sweating, urine discoloration (red, brown, black).

Adverse reactions: Involuntary movements, angioedema, palpitations, orthostatic hypotension, urinary retention, priapism, psychosis, severe depression with suicidal ideation, hallucinations, sudden sleep onset, impulse control symptoms.
Life-threatening: agranulocytosis, hemolytic anemia, leucopenia, thrombocytopenia, cardiac dysrhythmias, neuroleptic malignant syndrome (w/ abrupt discontinuation).

Question 13

Rivastigmine

Answer 13

Drug Class: Acetylcholinesterase inhibitor. Trade Name: Exelon

Dosage: Adult: PO: Initially: 1.5 mg bid; increase gradually. Maintenance: 3-6 mg bid; max: 12 mg/day.

Caution: Liver and renal disease, urinary tract obstruction, orthostatic hypotension, bradycardia, asthma, COPD, seizures, peptic ulcer disease.

Drug-Lab-Food Interactions: Drug: Increased effect of theophylline, general anesthetics; TCAs decrease effect; Increased effect with cimetidine; NSAIDS increase GI effects. Tobacco increases clearance of rivastigmine.

Pharmacokinetics: Absorption: PO: Food decreases absorption rate.

Therapeutic effects/Uses: Improves memory loss in Alzheimer disease. Mode of Action: Elevates acetylcholine concentration.

Side Effects: Anorexia, N/V, diarrhea or constipation, abdominal pain, weight loss, dizziness, HA, depression, confusion, peripheral edema, dry mouth, dehydration, nystagmus.

Adverse reactions: Seizures, bradycardia, orthostatic hypotension, cataracts, MI, heart failure.

Life-threatening: Hepatotoxicity, dysrhythmias, suicidal ideation, Stevens-Johnson syndrome.

Question 14

Pyridostigmine

Answer 14

Drug Class: Acetylcholinesterase (AChE) inhibitor Trade name: Mestinon

Dosage: Adult: PO: 60-120 mg in 5 to 6 doses per day; max: 600 mg/day in divided doses. Sustained release (SR):180-540 mg daily/b.i.d, with at least 6 hours between doses; max: 1.5 g/day. Adult: IM/IV: 2 mg q 2-3 hours. Child: PO:1mg/kg/day every 4-6 h; max single dose:10 mg. Must be administered on time.

Contraindications: GI and GU obstruction, ileus, bladder obstruction Caution: Asthma, bradycardia, seizure disorder, peptic ulcer, cardiac arrhythmias, renal impairment, hyperthyroidism, pregnancy, breastfeeding.

Drug-Lab-Food Interactions: Drug: Corticosteroids, neuromuscular blockers, aminoglycosides, local anesthetics, magnesium salts; increased toxicity with AChE inhibitors, atropine, tetracyclines, polymyxin B, bacitracin, digoxin, quinidine, and insecticides containing malathion; atropine decreases the effect of pyridostigmine.

Therapeutic Effects/Uses: To control and treat MG, for neuromuscular blockade reversal, and for nerve gas (soman) exposure prophylaxis.
Mode of action: Transmission of neuromuscular impulses by preventing destruction of acetylcholine. Preserves muscle strength.

Side Effects: N/V/D, HA, blurred vision, dizziness, abdominal pain, excess saliva & sweating, rash, miosis (constricted pupils).

Adverse reactions: Hypotension, bradycardia. Life-threatening: Dyspnea, bronchospasm, cardiac dysrhythmias, seizures.

** Pyridostigmine increases muscle strength with muscular weakness resulting from MG.**

Question 15

Cyclobenzaprine (Flexeril)

Answer 15

Drug Class: Centrally acting muscle relaxant Trade name: Flexeril

Dosage: Adult: PO: 5-10 mg tid; max: 30mg/day. Treatment beyond 2-3 wk is not recommended

Contraindications: Acute MI, AV blocks, bradycardia, bundle branch block, cardiac arrhythmias, children, HF, hyperthyroidism, HTN, hypokalemia, paralytic ileus, concurrent use of MAOI therapy or within 14 days after discontinuation.
Caution: Seizure disorder, alcohol, CNS depressants, glaucoma, prostatic hypertrophy, urinary retention, hepatic dysfunction, breastfeeding, driving or operating machinery, morbidity in geriatric pts, sunlight UV exposure

Drug-lab-Food Interactions: Drug: Increased CNS depression with alcohol, kava, valerian, barbiturates, TCAs, and other CNS depressants. Food: Take with food or milk to decrease GI effects.

Therapeutic effects/Uses: For short-term treatment of muscle spasms.

Mode of Action: relieves muscle spasms through a central action, possibly at brain stem level.

Side Effects: Anticholinergic effects (blurred vision, constipation, dry mouth, tachycardia, urinary retention); arrhythmias, confusion, drowsiness, dizziness, headache, nausea, nervousness, unpleasant taste

Adverse reactions: Allergic reactions, angioedema, MI, seizures, ileus.

Question 16

Phenothiazine (Prolixin)

Answer 16

Drug Class: Antipsychotic: Neuroleptic Piperazine Phenothiazine Trade name: Prolixin

Dosage: Psychosis: Adult: PO 0.5-10 mg/day; max: 40mg/day.IM, subQ: 2.5-10mg/day; max:100 mg/day. Older adults: PO: 1-2.5 mg /day; max: 40mg/day. Decanoate: 12.5mg q3wk

Contraindications: Hypersensitivity, subcortical brain damage, severe CNS depression, coma.
Caution: Dysrhythmias, paralytic ileus, urinary retention, BPH, leukopenia, neutropenia, agranulocytosis, hepatic and renal damage, hypotension, dementia, glaucoma, parkinsonism, seizure disorder.

Drug-Lab-Food Interaction: Drug: Increases effects when taken with alcohol and other CNS depressants. Lithium and beta blockers increase effects. Herbal: kava kava may increase dystonia.

Therapeutic effects/Uses: To manage symptoms of psychosis including schizophrenia.
Mode of Action: Blocks dopamine receptors in the brain and controls psychotic symptoms.

Side Effects: Sedation, dizziness, headache, dry mouth, blurred vision, excess sweating, weight gain, constipation, urinary retention, peripheral edema, sexual dysfunction

Adverse reactions: Hypertension, hypotension, tachycardia, ileus, EPS (including TD), seizures, psychosis Life-threatening: agranulocytosis, leukopenia, neutropenia, hepatotoxicity, bronchospasm, dysrhythmias, NMS

Question 17

Haloperidol (Haldol)

Answer 17

Drug Class: Anti-psychotic: Neuroleptic (non-phenothiazine) Trade name: Haldol

Dosage: Adult PO: initially 0.5-5 mg bid/tid; maint: 10-15 mg/d; max: 100 mg/d. Deconate: Adult: IM: Max 100 mg 1st dose, 450 mg subsequent monthly doses

Contraindications: Narrow angle glaucoma, severe hepatic, renal, cardiovascular disease; bone marrow depression, Parkinsonism, blood dyscrasias, CNS depression, subcortical brain damage, coma.
Caution: Alcoholism, dementia, glaucoma, dehydration, CAD, liver and renal damage, neutropenia, leukopenia.
Drug-Lab-Food Interactions: Drug: Increases sedation with alcohol, CNS depressants; increase toxicity with anticholinergics, CNS depressants, lithium. Decreased effects with phenobarbital, carbamazepine, and decreased effects with caffeine.

Therapeutic Effects/Uses: To treat acute and chronic psychosis, ADHD, schizophrenia, Tourette syndrome.
Mode of Action: Alters the effect of dopamine on the CNS; mechanism for antipsychotic effects are unknown.

Side Effects: Drowsiness, orthostatic hypotension, HA, lethargy, tremor, dry mouth and eyes, blurred vision, insomnia, agitation, weight gain, sexual dysfunction.

Adverse Reactions: Tachycardia, seizures, urinary retention, EPS. Life-threatening: laryngospasm, bronchospasm, dysrhythmias, NMS, agranulocytosis, leukopenia, neutropenia.

Question 18

Aripiprazole (Abilify)

Answer 18

Drug Class: Non-phenothiazine: Atypical Antipsychotic Trade name: Abilify

Dosage: Psychosis: Adult PO: 10-15mg/daily; may increase dose q 2 weeks; max: 30mg/day. Adolescent: PO 2mg/day; may increase q 2 days to max:30 mg/day.

Contraindications: Hypersensitivity, dehydration, alcohol intoxication, hypovolemia, agranulocytosis, neutropenia, leukopenia, HF, suicidal ideation, MI, DM, hyperglycemia, hypotension, seizures, Parkinsonism.
Caution: dysrhythmias, dementia, CNS depression, hyperglycemia, hypotension, parkinsonism, seizures, agranulocytosis, neutropenia, leukopenia

Drug-Lab-Food Interactions: Drug: Antidiabetic agents decrease Abilify drug levels and increase risk of hyperglycemia. Alpha blockers and antihypertensives increase risk of hypotension; other antipsychotics increase risk of NMS, EPS, anticholinergic effects, hypotension, and seizures. SSRIs may increase risk of serotonin syndrome. Food: Grapefruit juice may increase blood levels. Herbal: St. John’s wort may decrease blood levels. Lab: Increased blood glucose.

Therapeutic Effects/Uses: To manage schizophrenia, bipolar disorder, autism, depression, Tourette syndrome.
Mode of Action: Interferes with the binding of dopamine to dopamine (D2) and serotonin receptors.

Side Effects: drowsiness, memory impairment, weight gain/loss, HA, fatigue, blurred vision, photosensitivity, peripheral edema, amenorrhea, hyperglycemia, hypoglycemia, insomnia, anxiety, agitation, dizziness, constipation, N/V, sexual dysfunction.

Adverse Reactions: Orthostatic hypotension, tachycardia, EPS, dysrhythmias, seizures. Life -threatening: Suicidal ideation, NMS, agranulocytosis, leukopenia, laryngospasm

Question 19

Lorazepam (Ativan)

Answer 19

Drug Class: Anxiolytic: Benzodiazepine Trade name: Ativan

Dosage: Anxiety: Adult PO: 2-6 mg/day; max: 10 mg/day. Older adults: PO 1-2mg/day; max:10mg/day.

Contraindications: Hypersensitivity, narrow-angle glaucoma.
Caution: Hepatic or renal dysfunction, alcohol intoxication, depression, seizures, CNS depression, pregnancy, suicidal ideation.

Drug-lab-Food Interactions: Drug: Increases CNS depression when taken with alcohol, CNS depressants and anticonvulsants; cimetidine increases lorazepam plasma levels, increases phenytoin levels, decreases levodopa levels; smoking and caffeine decreases antianxiety effects, oral contraceptives decrease effects

Therapeutic Effects/Uses: To control anxiety and to treat status ecliptics; for preoperative sedation, for insomnia, for substance withdrawal.
Mode of Action: Potentiates GABA effects by binding to specific benzodiazepine receptors and inhibiting GABA neurotransmission.

Side Effects: Drowsiness, dizziness, weakness, confusion, HA, blurred vision, N/V, anorexia, restlessness, hallucinations, anterograde amnesia, ataxia.

Adverse Reactions: HTN, hypotension, bradycardia, dependence, seizures. Life-threatening: Suicidal ideation, NMS, respiratory depression.

Question 20

Fluoxetine (Prozac)

Answer 20

Drug Class: Antidepressant, selective serotonin reuptake inhibitor Trade name: Prozac

Dosage: Adult PO: Initially 20 mg/day in AM; max: 80 mg/day. Child >7 yrs.: PO: Initially 10 mg/day; max: 40 mg/day.

Contraindications: Hypersensitivity Caution: MI, taking MAOIs, dehydration, breastfeeding, suicidal ideation, liver disease, osteoporosis, glaucoma, seizure disorder, DM, malnourished, anticoagulant therapy, diarrhea.

Drug-Lab-Food Interactions: Drug: Increased CNS effect and respiratory depression, and hypotensive effect with alcohol and CNS depressants. Increased bleeding with NSAIDs. Herb: St. John’s Wort increases risk for serotonin syndrome; increased effects of hypoglycemics.

Therapeutic Effects/Uses: To treat depression, bipolar disorder, bulimia nervosa; obsessive-compulsive disorder (OCD), panic disorder; premenstrual dysphoric disorder.
Mode of Action: Serotonin is increased in nerve cells because of blockage from nerve fibers.

Side Effects: HA, dizziness, drowsiness, insomnia, anxiety, asthenia, memory impairment, mydriasis (dilated pupils), tremors, dry mouth, akathisia, anorexia, nausea, diarrhea, weight loss, erectile dysfunction.

Adverse Reactions: Seizures, angioedema, hyponatremia, hypokalemia, hyperkalemia, hypoglycemia, dehydration, bleeding, osteoporosis.
Life-threatening: Stevens-Johnson syndrome, hepatic dysfunction, suicidal ideation.

Question 21

Venlafaxine (Effexor)

Answer 21

Drug Class: Antidepressant: serotonin and norepinephrine reuptake inhibitor (SNRI) Trade name: Effexor

Dosage: Immediate- release: Adult PO: 75mg/day in 2 -3 divided doses; max: 225 mg/day in 3 divided doses. Adult PO: Initially 75 mg daily or 37.5 once daily for 4-7 days to allow patient to adjust, then increase to 75 mg/day; max: 225 mg/day.

Contraindications: Hypersensitivity. Caution: taking MAOIs, CNS depressants, SIADH, anticoagulant therapy, pregnancy, breastfeeding, children, suicidal tendency, kidney dysfunction, hepatic disease, bleeding, narrow-angle glaucoma, seizures, underweight, hypovolemia, hypokalemia, hyponatremia, hyperthyroidism, recent MI, heart failure.

Drug-lab-Food Interactions: Drug: Increases effects of CNS, respiratory depression, and hypotensive effect with alcohol and CNS depressants. Hypertensive crisis and death may occur with concurrent of MAOIs. Increased drug levels and toxicity with: cimetidine, haloperidol. Increased bleeding with anticoagulants. Increased risk of serotonin syndrome and NMS with other SNRIs, SSRIs, triptans, and amphetamines. Herb interaction: St. John’s Wort may cause serotonin syndrome (potentially life-threatening state with tachycardia, hypertension, confusion, twitching, hyperreflexia, and hyperthermia).

Therapeutic Effects /Uses: To treat depression generalized anxiety disorder, social anxiety disorder, panic disorder.
Mode of Action: Serotonin and norepinephrine are increased in nerve cells because of blockage from nerve fibers.

Side Effects: Drowsiness, dizziness, insomnia, HA, euphoria, confusion, amnesia, blurred vision, mydriasis, dry mouth and eyes, sweating, weakness, diarrhea, weight loss, nausea, anorexia, constipation.

Adverse Reactions: Tachycardia, seizure, HTN, serotonin syndrome. Life threatening: Suicidal ideation, NMS, SIADH, renal failure, Stevens-Johnson syndrome.

Question 22

Lithium

Answer 22

Drug Class: Mood stabilizer Trade name: Eskalith, Lithane, Lithobid, Carbolith

Dosage: Adult: PO: initially 600 mg t.i.d.; maintenance dose; 300 mg t.i.d.; max: 2-4 grams/day. Child PO: 15 to 20 mg/kg/day in 3 to 4 divided doses. Therapeutic range: 0.8-1.2 mEq/L.

Contraindications: Hypersensitivity. Caution: Liver and renal disease, pregnancy, lactation, severe cardiovascular disease, severe dehydration, hyponatremia, older adults, HTN, bradycardia, infection, thyroid disease, seizure disorder, alcoholism.

Drug-Lab-Food Interactions: Multiple. See Drug Chart 23.3, p. 303.
Drug: With thiazide diuretics, methyldopa, haloperidol, NSAIDS, antidepressants, carbamazepine, calcium channel blockers, spironolactone, ACE inhibitors, sodium bicarbonate, Phenothiazines – lithium level will be increased. Risk of serotonin syndrome when combined with theophylline, aminophylline. Increases rick of hyperglycemia in antidiabetic medications.
Lab: Increased urine and blood glucose levels; decreased sodium level.
Food: Lithium may cause sodium depletion (patients should be advised to increase their sodium intake). Caffeine decreases lithium levels.
Herbs: Neurotoxicity when combined with kava kava, valerian, and St. John’s Wort.

Therapeutic Effects/Uses: To treat bipolar disorder, manic episodes.
Mode of Action: Alteration of ion transport in muscle and nerve cells; increased receptor sensitivity to serotonin.

Side effects: Headache, memory impairment, blurred vision, metallic taste, dental caries, lethargy, drowsiness, dizziness, tremors, slurred speech, dry mouth, anorexia, vomiting, diarrhea, polyuria, dehydration, hypotension, abdominal pain, muscle weakness, restlessness.

Adverse Reactions: Urinary and fecal incontinence, hyperglycemia, hyponatremia, proteinuria, leukocytosis, nephrotoxicity.
Life threatening: Cardiac dysrhythmias, seizures, cardiac arrest, angioedema, serotonin syndrome, neuroleptic malignant syndrome.

Question 23

Aspirin

Answer 23

Drug Class: Analgesic: anti-inflammatory
Trade Name: ASA, Bayer, Ecotrin, Actin

Dosage: Arthritis: Adult: PO: 3 grams/day in divided doses.

Contraindications: Hypersensitivity to salicylates or NSAIDs, flu or virus symptoms in children, GI bleeding.
Caution: Renal or hepatic disorders, gout, alcoholism, anticoagulant therapy, GI bleeding, bone marrow suppression, head trauma, immunosuppression, pregnancy.

Drug-Lab-Food-Interactions: Drug: Increased risk of bleeding with anticoagulants and other NSAIDs; increased risk of hypoglycemia with oral hypoglycemic drugs; increased ulcerogenic effect with glucocorticoids; decreased effects of ACE inhibitors; effects are decreased by corticosteroids. Lab: Decreases cholesterol, potassium, T3, and T4 levels; increased PT, bleeding time, and uric acid.

Therapeutic Effects/Uses: To reduce pain and inflammatory symptoms, decrease fever, and inhibit platelet aggregation; for osteoarthritis and rheumatoid arthritis.
Mode of Action: Inhibition of prostaglandin synthesis, inhibition of hypothalamic heat-regulator center.

Side Effects: Anorexia, N/V/D, dizziness, headache, heartburn, rash, abdominal pain, drowsiness.

Adverse Reactions: Tinnitus, hearing loss, GI ulceration and bleeding. Life threatening: Agranulocytosis, hemolytic anemia, bronchospasm, anaphylaxis, thrombocytopenia, Reye’s syndrome, hepatotoxicity, leukopenia.

Question 24

Ibuprofen

Answer 24

Drug Class: NSAID: Propionic acid derivative. Trade Name: Motrin, Advil

Dosage: Adult: PO: 200-800 mg tid/qid; max: 3200 mg/day.

Contraindications: Hypersensitivity, coronary artery bypass graft surgery.
Caution: Bleeding disorders, pregnancy, lactation, systemic lupus erythematosus, asthma, peptic ulcer, anticoagulant therapy, renal or hepatic disease.

Drug-Lab-Food-Interactions: Drug: Increases bleeding time with oral anticoagulants; increases effects of phenytoin, sulfonamides, warfarin; decreased effect with aspirin; may increase side effects of lithium.

Therapeutic Effects/Uses: To reduce inflammatory process; to relieve pain; anti-inflammatory effect for arthritic conditions; to reduce fever.
Mode of Action: Inhibition of prostaglandin synthesis, thus relieving pain and inflammation.

Side Effects: Headache, dizziness, anorexia, N/V/D, edema, rash, fluid retention

Adverse reactions: Hearing loss, tinnitus, bleeding. Life threatening: Anemia, neutropenia, thrombocytopenia, nephrotoxicity, anaphylaxis.

Question 25

Celecoxib (Celebrex)

Answer 25

Drug Class: NSAID: Cox-2 inhibitor. Trade Name: Celebrex

Dosage: Arthritis: Adult PO: 100-200 mg qd/bid; Max: 800 mg/d

Contraindications: Hypersensitivity, coronary artery bypass surgery. Caution: Renal or hepatic dysfunction, HTN, dysrhythmias, HF, anemia, dehydration, peptic ulcer disease, GI bleeding or perforation, concurrent anticoagulant therapy, steroids, alcoholism, immunosuppression.

Drug-Lab-Food-Interactions: Drug: decreases effect of ACE inhibitors, increased INR and GI bleeding with warfarin (Coumadin) and SNRIs, may increase toxicity with lithium, fluoroquinolones may increase the risk of seizures; fluconazole and ketoconazole increase celecoxib levels. Complementary & Alternative Therapies: Ginkgo biloba may increase bleeding risk.

Therapeutic effects/ Uses: To treat osteoarthritis and rheumatoid arthritis, to relieve dysmenorrhea and moderate to severe pain, for ankylosing spondylitis. Mode of Action: Inhibits COX-2 but does not inhibit COX-1.

Side Effects: Headache, dizziness, sinusitis, abdominal pain, nausea, flatulence, diarrhea, rash.
Adverse Reactions: Peripheral edema, bleeding, HTN. Life-threatening: Stroke

Question 26

Infliximab (Remicade)

Answer 26

Drug Class: Immunomodulator; Tumor necrosis factor blocker Trade name: Remicade

Dosage: Rheumatoid arthritis: Adult: IV: 3mg/kg over2 hours, then 3mg/kg on week 2 and 6, then q8 weeks. Max: 10 mg/kg/dose Crohn’s Disease: Adult: IV: 5mg/kg over 2 hours, initially and on week 2 and 6; Maint: 5-10 mg/kg q8wk

Contraindications: Hypersensitivity, heart failure. Caution: Renal or hepatic dysfunction, bone marrow suppression, DM, COPD, immunosuppression, multiple sclerosis, seizures, corticosteroid therapy, older adults.

Drug-lab-Food Interactions: Drug: May decrease effectiveness of vaccines; concurrent immunosuppressives may increase risk for infection or adverse effects.

Therapeutic Effects/Uses: To treat psoriasis, rheumatoid arthritis, psoriatic arthritis, spondylitis, ulcerative colitis, and Crohn disease.
Mode of Action: Binds to Tumor Necrosis factor (TNF) receptors on synovial cell surfaces. Reduces infiltration of inflammatory cells and delays inflammatory process.

Side Effects: Headache, dizziness, cough, fatigue, chills, flushing, fever, anxiety, N/V/D, constipation, flatulence, abdominal pain, weight loss, rash, alopecia, dry skin, pharyngitis.

Adverse Reactions: Severe infections, chest pain, hypotension/hypertension, seizures, arthralgia, bone fractures, increased hepatic enzymes, anemia, neutropenia, pancytopenia, Stevens-Jonson Syndrome.

Question 27

Acetaminophen (Tylenol)

Answer 27

Drug Class: Analgesic
Trade name: Tylenol

Dosage: Adult: PO: 325-650 mg q 4-6 hours PRN; max: 4000 mg/day; rectal sup: 650 mg q.i.d. Adult: IV: 1 g q 6 hours or 650 mg q 4 hors PRN; max: 4 g/day. Child > 2 yrs.: PO: 15 mg/kg q 6 hours; max: 75 mg/kg/day.

Contraindications: Acetaminophen hypersensitivity, severe hepatic disease.
Caution: Renal disease, alcoholism, severe hypovolemia, chronic malnutrition.

Drug-Lab-Food Interactions: Increase effect with caffeine. Decreased effect with oral contraceptives, antacids, anticholinergics, cholestyramine, charcoal, barbiturates, carbamazepine, and phenytoin.

Therapeutic effects/Uses: To decrease pain and fever.
Mode of Action: Inhibition (weak) of prostaglandin synthesis, inhibition of hypothalamic heat-regulator center.

Side Effects: Headache, anorexia, nausea, vomiting, constipation, insomnia.

Adverse reactions: Oliguria, elevated liver enzymes. Life threatening: Hepatotoxicity, hemolytic anemia, agranulocytosis, leukopenia, neutropenia, thrombocytopenia, renal failure.

Question 28

Morphine Sulfate

Answer 28

Drug Class: Opioid
Trade name: MS Contin, Roxanol

Dosage: Adult: PO: 10-30 mg q 4 hours PRN. Child >6 months: PO: 0.2-0.5 mg/kg q 4 hours PRN; Infants < 6 months/neonates: PO: 0.1 mg/kg q 3-4 hours. Adult: Sustained-Release: 15-30 mg q 12 hours PRN; Adult: IV/IM/subQ: 0.05 – 0.2 mg/kg q 2-4 hours PRM, max :< 15 mg/dose. Neonate: subQ/IM/IV: 0.05 mg/kg q 4-8 hours.

Contraindications: Hypersensitivity, CNS or respiratory depression, status asthmaticus, increased intracranial pressure, shock, alcoholism, ileus, hypovolemia.
Caution: Respiratory insufficiency, renal or hepatic diseases; urinary retention, sleep apnea, older adults and very young.

Drug-Lab-Food-Interactions: Drug: Increases effects of alcohol, sedative-hypnotics, antipsychotic drugs, muscle relaxants. Lab: Increases AST, ALT. Complementary &
Alternative Therapy: St. John’s Wort may decrease drug effect.

Therapeutic Effects/Uses: To relieve severe pain. Mode of
Action: Depression of CNS; depression of pain impulses by binding with the opiate receptor in the CNS.

Side Effects: Anorexia, N/V, abdominal pain, diarrhea/constipation, flatulence, fever, drowsiness, dizziness, agitation, anxiety, sedation, confusion, depression, urinary retention, rash, blurred vision, miosis, weakness, flushing, euphoria, pruritus.

Adverse reactions: Hypotension, urticaria, seizures, ileus, psychological dependence. Life threatening: Respiratory depression.

Question 29

Nalbuphine (Nubain)

Answer 29

Drug Class: Opioid agonist-antagonist
Trade name: Nubain

Dosage: Adult: IV/IM/subQ: 10-20 mg q3-6 hours; max: 160 mg/day.
Contraindications: Hypersensitivity. Caution: History of alcohol or drug abuse, impaired respirations, head injury, increased ICP, biliary tract surgery, renal or hepatic dysfunction.

Therapeutic Effects/Uses: To relieve moderate to severe pain and for anesthesia induction and maintenance.
Mode of Action: Inhibition of pain impulses transmitted in the CNS by binding with opiate receptor and increasing pain threshold.

Side Effects: Dizziness, drowsiness, headache, dry mouth, N/V, diaphoresis.

Adverse Reactions: Bradycardia, tachycardia, hypotension, hypertension, dyspnea. Life-threatening: Respiratory depression

Question 30

Sumatriptan (Imitrex)

Answer 30

Drug Class: 5-HT receptor agonist: antimigraine
Trade name: Imitrex

Dosage: Adult: PO: 25-50 mg for 1 dose, may repeat once after 2 hours; max: 200 mg/day. Adult: SubQ: 6 mg, may repeat with 6 mg at least 1 hour after the first injection; max: 12 mg/day. Adult: Intranasal: 5-20 mg in one nostril, may repeat after 2 hours; max: 40 mg/day.

Contraindications: Hypersensitivy, CAD, peripheral vascular disease, HTN, cerebrovascular disease. Caution: Renal or hepatic dysfunction, obesity, DM, smoking, seizures, older adults.

Drug-Lab-Food Interactions: Drug Risk of vasospasm and blood pressure elevation with Dihydroergotamine and other ergot alkaloids; increased levels and toxicity within 2 weeks of MAOIs; increased risk of serotonin syndrome or neuroleptic malignant syndrome with SSRIs.

Therapeutic effects/Uses: To treat migraine and cluster headaches.
Mode of Action: Causes vasoconstriction of cranial arteries to relieve migraine attacks.

Side Effects: Dizziness, vertigo, headache, paresthesia, fatigue, flushing, drowsiness, dysgeusia, N/V, injection site reaction, pruritis.

Adverse reactions: Hypotension, hypertension, AV heart block, angina, dysrhythmias, bradycardia, elevated hepatic enzymes, thromboembolism, seizures.
Life threatening: Coronary artery vasospasm, myocardial infarction, cardiac arrest, suicidal ideation.

Question 31

Digoxin

Answer 31

Drug Class: Cardiac Glycoside Trade Name: Lanoxin

Dosage: Adult PO: LD 10-15 mcg/kg in 3 divided doses; maint: 3.4-5.1 mcg/kg/d. Adult IV/IM: LD 8-12 mcg/kg/d in 3 divided doses; maint: 2.4-3.6 mcg/kg/d

Contraindications: Ventricular fibrillation. Caution: AMI, AV block, HTN, hypothyroidism, hyperthyroidism, renal and hepatic dysfunction, bradycardia, hypokalemia, electrolyte imbalance, older adults.

Drug-lab-Food Interactions: Drug: Increased digoxin serum level with quinidine, flecainide, verapamil, indomethacin; Decreased digoxin absorption with antacids, kaolin, pectin, psyllium, acarbose, colestipol; Increased risk for digoxin toxicity with thiazide diuretics (HCTZ) and loop diuretics (furosemide(Lasix), PPIs. Lab: Hypokalemia, hypomagnesemia, hypercalcemia can increase digitalis toxicity. Herb: See Box 37.1, p. 537)

Therapeutic Effects/Uses: To treat heart failure and atrial fibrillation.
Mode of Action: Promotes increased force of cardiac contraction, cardiac output, and tissue perfusion. Decreases ventricular rate.

Side Effects: Anorexia, N/V/D, abdominal pain, headache, blurred or yellow vision (yellow-green halos), dizziness, weakness, confusion.

Adverse Reactions: Bradycardia Life-threatening: Cardiac dysrhythmias, thrombocytopenia

**Asses apical pulse for a full 60 seconds before administering digoxin. Do NOT administer if pulse is less than 60 bpm.

Serum dig level should be 0.8-2 ng/ml. Serum dig level above 2 is indicative of digitalis toxicity.
Side effects to report: HR less than 60 bpm, N/V/D, HA, and visual disturbances. **

Question 32

Nitroglycerin (Nitro)

Answer 32

Drug Class: Antianginal
Trade name: Nitrostat, Nitro-Bid, Transderm Nitro Patch, NTG, Nitro Gard

Dosage: Adult SL: 1 tab of 0.3, 0.4, or 0.6 mg; repeat q5min x 3 as needed; or 5-10 min prior to angina-provoking activities

Contraindications: Increased intracranial pressure, severe anemia, cardiomyopathy, shock. Caution: Severe renal or hepatic disease, acute MI, severe hypotension, hypovolemia, head trauma, pregnancy, breastfeeding.

Drug-lab-Food Interactions: Drug: Increased effect with alcohol, beta blockers, calcium channel blockers, antihypertensives, aspirin, benzodiazepines, vasodilators. Decreased effects of heparin. Herbs: Hawthorne increases nitroglycerin levels.

Therapeutic Effects/Uses: To control angina, AMI, hypertensive emergency, pulmonary edema, and heart failure.
Mode of Action: Decreases myocardial demand for oxygen; decreases preload by dilating veins, indirectly decreases afterload.

Side Effects: Nausea, vomiting, headache, blurred vision, dizziness, syncope, weakness, diaphoresis, flushing, pallor, rash, dry mouth, palpitations, paresthesia, peripheral edema, tolerance.

Adverse Reactions: Orthostatic hypotension, reflex tachycardia, paradoxical bradycardia.
Life-threatening: Circulatory collapse.

Patient education for Nitroglycerin:
• If pain persists after 1st dose, the patient should take a 2nd dose and immediately call 911.
• SL tablets decompose when exposed to heat and light, so they must be kept in original, airtight glass container.
• If the patient is prescribed a transdermal patch, they should be instructed to remove at night for at least 8-12 hrs to avoid tolerance.
• Do NOT apply nitro ointment or patch in any area on the chest in the vicinity of defibrillator-cardioverter paddle placement. Explosion and skin burns may result.
• If ointment or transdermal patch is being discontinued, dose should be slowly tapered over several weeks to prevent rebound effect of severe pain caused by myocardial ischemia (lack of blood supply to the heart muscle).
• Reflex tachycardia may occur if nitrate is given too rapidly; the HR increases greatly because of overcompensation of the cardiovascular system.
• Place patient in a supine position with legs elevated if hypotension results from SL nitro

Question 33

Acebutolol Hydrochloride

Answer 33

Drug Class: Beta 1 blocker: cardio selective beta-adrenergic antagonist
Trade Name: Sectral

Dosage: Ventricular dysrhythmias: Adult PO: 200 mg q 12 hours. May increase dose to 600 -1200 mg in 2 divided doses; max: 1200 mg/day. Older adults: PO: 200-400 mg/Day; max: 800 mg/day. Not for children < 12 years of age.

Contraindications: AV heart block, bradycardia, heart failure, cardiogenic shock.
Caution: Major surgery, renal and hepatic impairment, DM, hyperthyroidism, asthma, bronchitis, COPD, pulmonary edema, MG, PVD.

Drug-Lab-Food Interactions: Drug: Increased effects with diuretics; prolongs hypoglycemic effects of insulin and oral antidiabetics; antagonist effect with albuterol, metaproterenol, terbutaline. Lab: May increase ALT, AST, ALP, ANA titer, BUN, lipoproteins, potassium levels.

Therapeutic Effects/Uses: To aid in the treatment of premature ventricular contractions and HTN.
Mode of Action: Blocks beta1 adrenergic receptors in cardiac tissues.

Side effects: Dizziness, nausea, vomiting, anorexia, edema, headache, visual impairment, hypotension, diaphoresis, fatigue, insomnia, nightmares, anxiety, constipation, diarrhea, impotence, depression.

Adverse reactions: Palpitations with abrupt withdrawal, bradycardia, chest pain, hyperglycemia, hypoglycemia, lupus-like syndrome, elevated hepatic enzymes.
Life-threatening: agranulocytosis, dyspnea, thrombocytopenia, bronchospasm (high doses).

Question 34

Hydrochlorothiazide (HCTZ)

Answer 34

Drug Class: Thiazide diuretic

Dosage: HTN Adult PO: 12.5-50 mg/day; max: 50 mg/day. Edema Adult PO: 25-100 mg/d in single or divided doses; max: 100 mg/d. Administer in the morning to avoid nocturia.

Contraindications: Renal failure, hypersensitivity. Caution: Hepatic and renal dysfunction, DM, gout, systemic lupus erythematosus (SLE), electrolyte imbalance, hypotension.

Drug-lab-Food Interactions: Drug: Increases digitalis toxicity if hypokalemia is present; Increases renal toxicity with aspirin. Increases potassium loss with steroids. Decreases diabetic medication effect; decreased thiazide absorption and effects with NSAIDS, cholestyramine, and colestipol. Lab: Increases serum calcium, glucose, uric acid; decreases serum potassium, sodium, magnesium.

Therapeutic Effects/Uses: To increase urine output and treat hypertension, edema, HF, nephrotic syndrome, and ascites.
Mode of Action: Action is on the renal distal tubules, promoting sodium, potassium and water excretion and decreasing preload and cardiac output; also decreases edema; acts on arterioles, causing vasodilation, thus decreasing BP.

Side Effects: Dizziness, HA, weakness, N/V/D, abdominal pain, hyperglycemia, constipation, rash, photosensitivity, blurred vision, paresthesia, hyperuricemia, muscle cramps.

Adverse Reactions: Severe dehydration, hyponatremia, orthostatic hypotension, gout.
Life threatening: Severe potassium depletion, marked hypotension, aplastic anemia, hemolytic anemia, thrombocytopenia, agranulocytosis, renal failure, Steven-Johnson syndrome.

Question 35

Furosemide (Lasix)

Answer 35

Dosage: Adult PO: 20-80 mg single dose/day. (given in the morning)

Contraindications: Presence of severe electrolyte imbalances, hypovolemia, anuria, hepatic coma, hypersensitivity to sulfonamides. Caution: Heart failure, diabetes, hypotension, SLE, gout, patients with hearing impairment, nephrotoxicity.

Drug-Lab-Food Interactions: Drug: Increased digitalis toxicity and cardiac dysrhythmias with digoxin and hypokalemia; Increases orthostatic hypotension with alcohol, increases ototoxicity with aminoglycosides; increases bleeding with anticoagulants; increases potassium loss with steroids, Amphotericin B, amiodarone; increases digitalis toxicity. increases lithium toxicity. Food: Licorice may increase potassium loss. Lab: Increases BUN, blood/urine glucose, serum uric acid level, ammonia; decreases potassium, sodium, calcium, magnesium, chloride serum levels. Herbs: Hawthorn may potentiate hypotension. Ginseng may decease action of loop diuretics.

Therapeutic Uses/Effects: To treat fluid retention/fluid overload caused by heart Failure, renal dysfunction, hypertension, nephrotic syndrome, acute pulmonary and peripheral edema.
Mode of Action: Inhibition of sodium and water reabsorption from loop of Henle and distal renal tubules; potassium, magnesium, and calcium also may be excreted.

Side Effects: Nausea, diarrhea, electrolyte imbalances, dizziness, abdominal cramping, constipation, rash, headache, weakness, blurred vision, photosensitivity, muscle cramping, hyperuricemia.

Adverse reactions: Hypokalemia, hyponatremia, hypomagnesemia, severe dehydration; orthostatic hypotension, hyperglycemia, gout, hearing loss, hypercholesterolemia.
Life threatening: Renal failure, aplastic anemia, thrombocytopenia, agranulocytosis.

Question 36

Spironolactone (Aldactone)

Answer 36

Drug Class: Potassium-sparing diuretic

Dosage: Edema: Adult PO 25-200 mg/day in divided doses; mas: 400 mg/day.

Contraindications: Renal failure, hyperkalemia. Caution: renal or hepatic dysfunction, diabetes, HF.

Drug-Lab-Food Interactions: Drug: Increases serum potassium level with potassium supplement; increases effects of antihypertensives and lithium.
Life threatening: hyperkalemia if given with ACE inhibitor. Lab: Increases serum potassium level; may increase BUN, AST, alkaline phosphatase levels; decreases serum sodium, chloride levels.

Therapeutic Effects/Uses: For peripheral and pulmonary edema, circulatory overload, HTN, HF, ascites, hypokalemia.
Mode of Action: Acts on distal renal tubules to promote sodium and water excretion and potassium retention.

Side Effects: Nausea, vomiting, diarrhea, dizziness, headache, weakness, muscle cramps.

Adverse Reactions: Life-threatening: Severe hyperkalemia, thrombocytopenia, agranulocytosis, hepatotoxicity, Stevens-Johnson syndrome

** Spironolactone is an aldosterone antagonist. Remember, aldosterone is a mineralocorticoid that promotes sodium retention and potassium excretion. **

Question 37

Metoprolol (Lopressor)

Answer 37

Drug Class: Beta1 blocker Trade Name: Lopressor, Toprol

Dosage: Adult PO: 100 mg/day in 1 to 2 divided doses; maint: 100-450 mg in divided doses
Contraindications: Hypersensitivity, second and third-degree heart block, cardiogenic shock, hypotension, acute HF, bradycardia.
Caution: Hepatic, renal, or thyroid dysfunction, asthma, peripheral vascular disease, diabetes mellitus , COPD, cerebrovascular disease, depression.

Drug-Lab-Food Interactions: Drug: Increases bradycardia and heart block with digitalis, clonidine, SSRIs, MAOIs, cimetidine; increases hypotensive effect with other antihypertensives, alcohol, anesthetics; NSAIDS decreases effect of beta blockers. Lab: Increase in hepatic enzymes.

Therapeutic Effects/Uses: To control hypertension, acute MI, angina, and HF.
Mode of Action: Promotes blood pressure reduction via beta 1 blocking effect.

Side Effects: Fatigue, weakness, dizziness, dry mouth, N/V/D, drowsiness, headache, blurred vision, insomnia, short-term memory loss, peripheral edema, tinnitus, erectile dysfunction, depression.

Adverse Reactions: Bradycardia, hypotension, stroke, thrombocytopenia, hypoglycemia, diabetes mellitus. Life threatening: Complete heart block, bronchospasm, agranulocytosis, HF.

Question 38

Prazosin (Minipress)

Answer 38

Drug Class: Antihypertensive: Alpha-adrenergic blocker Trade Name: Minipress

Dosage: Adult PO: initially 1 mg bid/tid; maint: 6-15 mg/d; Max: 20 mg/d in divided doses

Contraindications: Hypersensitivity. Caution: Angina, orthostatic hypotension, syncope, ocular surgery, priapism, pregnancy, breastfeeding.

Drug-Lab-Food Interactions: Drug: Increased hypotensive effect with other antihypertensives, nitrates, diuretics, alcohol; decreased effects with NSAIDs. Lab: Increased hepatic enzyme.

Therapeutic Effect/Uses: To control hypertension; to treat benign prostatic hypertrophy (BPH).
Mode of Action: Dilates peripheral blood vessels by blocking alpha-adrenergic receptors.

Side Effects: Dizziness, drowsiness, nervousness, blurred vision, tinnitus, fatigue, weakness, headache, depression, nasal congestion, dry mouth, depression, N/V/D/C, abdominal pain, peripheral edema, erectile dysfunction, urinary incontinence.

Adverse Reactions: Orthostatic hypotension, palpitations, tachycardia, pancreatitis, elevated liver enzymes.

Question 39

Valsartan (Diovan)

Answer 39

Drug Class: Angiotensin II Receptor Blocker (ARB) Trade Name: Diovan

Dosage: Adult PO: initially 80-160 mg/day; Maint: 80-320 mg/d

Contraindications: Hypersensitivity. Caution: Renal and hepatic impairment, hypotension, HF, hypovolemia, hyperkalemia, pregnancy, breastfeeding.

Drug-Lab-Food Interactions: Drug: Antihypertensives, diuretics, MAOIs, and alcohol may increase hypotensive effects; ACE inhibitors and aspirin may increase hyperkalemia and renal dysfunction; Digoxin and NSAIDS may increase renal dysfunction; lithium may increase lithium toxicity. Lab: May increase AST, ALT, bilirubin, BUN, creatinine, Hct, Hgb.

Therapeutic Effects/Uses: To treat hypertension and HF.
Mode of Action: Potent vasodilator that inhibits binding of angiotensin II.

Side Effects: Dizziness, drowsiness, cough (rare), palpitations, blurred vision, headache, diarrhea, abdominal and back pain, arthralgia, fatigue, erectile dysfunction.

Adverse Reactions: Orthostatic hypotension, hyperkalemia, rhabdomyolysis, elevated hepatic enzymes.
Life-threatening: Renal dysfunction, neutropenia.

Question 40

Heparin

Answer 40

Dosage: A:Subcut: 8000-10,000 units q 4-6h based on aPTT q12h

Contraindications: Bleeding disorder, hypersensitivity.

Caution: Peptic ulcer, hepatic or renal disease, hemophilia, DIC, diverticulitis, head trauma, HIT, thrombocytopenia.

Drug-Lab-Food Interactions: Drug: Increased effect with aspirin, NSAIDs, thrombolytics, probenecid, antibiotics, SSRIs; decreased effect with nitroglycerin, protamine sulfate. Lab: May increase AST, ALT. Food: Decrease diet rich in vitamin K.

Therapeutic effects/uses: To prevent thrombosis associated with PE, MI, unstable angina, prosthetic heart valves, DVT, and PCI; to treat DIC.

Mode of Action: Inhibits thrombin, which prevents conversion of fibrinogen to fibrin

Side effects: Itching, chills, injection-site reaction, priapism

Adverse reactions: Hypersensitivity, bleeding, anemia, elevated hepatic enzymes, osteoporosis, stroke.
Life-threatening: Hemorrhage, HIT (heparin-induced thrombocytopenia)

Question 41

Warfarin (Coumadin)

Answer 41

Drug Class: anticoagulant

Dosage: Adult PO: 0.5-7 mg/d based on INR; target INR 2-3.5

Contraindications: Hematologic disorders, eclampsia, alcoholism, bleeding, head trauma, psychosis. Caution: DM, leukemia, anemia, hepatic and renal impairment, peptic ulcer, atrial fibrillation.

Drug-Lab-Food Interactions: Drug: Increased effect with amiodarone, aspirin, NSAIDs, sulfonamides, thyroid drugs, allopurinol, histamine 2 blockers, oral hypoglycemics, metronidazole, miconazole, methyldopa, diuretics, oral antibiotics, vitamin E; decreased effect with barbiturates, laxatives, phenytoin, estrogens, vitamins C and K, oral contraceptives, rifampin. Lab: May increase AST, ALT. Food: Decrease diet rich in vitamin K.

Therapeutic Effect/Uses: To treat atrial fibrillation.

Mode of Action: Depresses hepatic synthesis of vitamin K clotting factors

Side effects: HA, GI distress, alopecia, fever, weakness, priapism

Adverse Reactions: Purple-toe syndrome, bone fracture, hypotension, chest pain, elevated hepatic enzymes. Life-threatening: Hemorrhage.

Question 42

Clopidogrel Bisulfate (Plavix)

Answer 42

Drug Class: Antiplatelet Trade Name: Plavix

Dosage: Adult PO: 75 mg/day

Contraindications: Intracranial hemorrhage, peptic ulcer, GI bleeding.
Caution: Hepatic and renal disease, surgery, MI, stroke, bleeding from trauma, purpura.

Drug-Lab-Food Interactions: Drug: may increase bleeding when taken with NSAIDS, anticoagulants, antineoplastic, azole antifungals, barbiturates, and SSRIs; interferes with metabolism of phenytoin, warfarin, fluvastatin,tamoxifen, tolbutamide, NSAIDS, torsemide. Lab: prolongs bleeding time. Herb: May increase bleeding when taken with ginger, garlic, ginkgo, feverfew, green tea.

Therapeutic Effects/Uses: To prevent thrombosis associated with unstable angina, AMI, stroke, TIA.
Mode of Action: Inhibits platelet aggregation. Prevents ADP from binding with ADP platelet receptor.

Side Effects: Abdominal pain, flulike symptoms, dizziness, confusion, epistaxis, headaches, GI distress, bleeding, rash, pruritus.

Adverse Reactions: Hypotension or hypertension, bronchospasm, elevated hepatic enzymes, peptic ulcer.

Life-threatening: Agranulocytosis, aplastic anemia, thrombocytopenia, pancytopenia, Stevens-Johnson syndrome.

Question 43

Alteplase

Answer 43

Drug Class: Thrombolytic agent

Dosage: Adult: IV: 100 mg infusion over 2 h

Contraindications: Internal bleeding, bleeding disorders, aneurysm, recent CVA, surgery or trauma, bacterial endocarditis, severe liver dysfunction, severe uncontrolled hypertension, brain tumor, head trauma.
Caution: Cardiac dysrhythmias, hepatic or renal disease, CABG, peptic ulcer disease, diabetic retinopathy, older adults, pregnancy.

Drug-Lab-Food Interactions: Drug: Increase bleeding when taken with oral anticoagulants, NSAIDS, cefotetan, plicamycin; decrease effect when taken with aminocaproic acid, aprotinin. Lab: Decrease in plasminogen, fibrinogen, hematocrit, and hemoglobin. Herbs: Increased bleeding with ginkgo biloba, feverfew, ginger, green tea, omega-3 fatty acids.

Therapeutic Effects/Uses: To dissolve clot following acute MI, PE, acute ischemic stroke, occluded IV catheter.
Mode of Action: Alteplase promotes conversion pf plasminogen to plasmin. Plasmin, an enzyme, digests fibrin matrix of clots. Alteplase initiates fibrinolysis.

Side Effects: Bleeding, epistaxis, hypotension, infection, GI distress, rash.

Adverse Effects: Anaphylactoid reactions, laryngeal edema, angioedema, cholesterol micro embolization hypertension, MI, cerebral edema, rhabdomyolysis, bleeding, bradycardia, tachycardia, HF, seizures. Life threatening: Stroke; dysrhythmias, pulmonary edema

Question 44

Rosuvastatin (Crestor)

Answer 44

Drug Class: Antihyperlipidemic (Hmg-CoA reductase inhibitor) Trade Name: Crestor

Dosage: Adult PO: 5-40 mg/day.

Contraindications: Acute liver disease, pregnancy, breastfeeding.
Caution: History of liver disease, alcoholism, DM, seizures, renal impairment, Asian population, older adults.

Drug-Lab-Food Interactions: Drug: Decreased effect with antacids, phenytoin, and propranolol; may increase digoxin level, oral contraceptive efficacy; increased drug effects with macrolide antibiotics and antifungals.

Therapeutic Effects/Uses: To decrease cholesterol levels and serum lipids, especially LDL and triglycerides. For treatment of atherosclerosis, hypercholesterolemia, hyperlipoproteinemia, and hypertriglyceridemia.
Mode of Action: Inhibits Hmg-CoA reductase, the enzyme necessary for hepatic production of cholesterol.

Side Effects: Headache, flushing, dizziness, weakness, myalgia, arthralgia, abdominal pain, constipation, peripheral neuropathy, photosensitivity.

Adverse Reactions: Rhabdomyolysis (rare), myopathy, hyperglycemia, elevated liver enzymes, renal failure, hepatotoxicity, leukopenia, thrombocytopenia.

Blood lipid levels should be monitored q6-8wks for the first 6 months, then every 3-6 months. Cholesterol should be less than 200 mg/dL. Triglycerides < 150, LDL <100; HDL > 60

Question 45

Cilostazol

Answer 45

Drug Class: Direct-acting vasodilator

Dose: Adult PO: 50-100mg q 12 hours, 30 min before or 2 h after meals. Administer with full glass of water. Do not administer with grapefruit juice.

Contraindications: Congestive heart failure, hypersensitivity, bleeding disorders, thrombocytopenia.
Caution: Hepatic and renal disease, tobacco smokers, pregnancy, older adults.

Drug-Lab-Food Interactions: Drug: Increased effects with aspirin, cimetidine, clarithromycin, erythromycin, enoxaparin, ticlopidine, warfarin. Food: Grapefruit and green tea will increase levels; ginger and Ginkgo biloba may prolong bleeding time; St. John’s wort will decrease effect.

Therapeutic Effects/Uses: To treat peripheral vascular disease and intermittent claudication. Mode of Action: Acts directly to inhibit platelet aggregation and cause vasodilation.

Side Effects: Dizziness, HA, nasopharyngitis, N/V/D, flatulence, melena, back and abdominal pain, peripheral edema, increased susceptibility to infection, cough

Adverse Reactions: Tachycardia, palpitations, thrombocytopenia, leucopenia, aplastic anemia, agranulocytosis, elevated hepatic enzymes, dysrhythmias.

Question 46

Lidocaine

Answer 46

Drug Class: Antidysrhythmic, Class IB

Dosage: 1-1.5 mg/kg

Contraindications: Hypersensitivity, advanced atrioventricular block. Caution: Liver disease, heart failure, older adults

Drug-Lab-Food Interactions: Drug: Increased effects with phenytoin, quinidine, procainamide, propranolol. Increased risk for toxicity with cimetidine, beta-adrenergic blockers.

Therapeutic Effects/Uses: Antiarrhythmics drug to treat ventricular dysrhythmias such as premature ventricular contractions (PVCs), ventricular tachycardia, and ventricular fibrillation.
Mode of Action: Decreases automaticity and increases electrical threshold of ventricle.

Side Effects: Drowsiness, confusion, dyspnea, lethargy, hypotension, nausea, vomiting.

Adverse Reactions: Life-threatening: seizures, cardiac arrest.

**Treats significant ventricular dysrhythmias **

Question 47

Mannitol

Answer 47

Drug Class: Osmotic diuretic

Dosage: IV: Initially1-2 g/kg, followed by 0.25-1 g/kg q 4 hours

Contraindications: Hypersensitivity, severe dehydration.

Caution: Pregnancy, breastfeeding, current intracranial bleeding.

Drug-Lab-Food Interactions: Decreased effectiveness with lithium.

Therapeutic Effects/Uses: To treat cerebral edema and increased intracranial pressure.

Side effects: hyponatremia/hypernatremia, hypokalemia/hyperkalemia, dehydration, blurred vision, dry mouth.

Adverse Reactions: Pulmonary congestion, fluid/electrolyte imbalances. Life threatening: convulsions.

Question 48

Dopamine

Answer 48

Drug Class: Adrenergic agonist

Dosage drip: 5-10 mcg/kg/minute

Contraindications: Hypersensitivity, ventricular fibrillation, pheochromocytoma.

Drug-Lab-Food Interactions: May result in hypertensive crisis when used within 2 wk of MAOIs; sodium bicarbonate solutions inactivate dopamine

Therapeutic Effects/Uses: To treat hypotension in shock states. And to increase heart rate in atropine refractory bradycardia.
Mode of Action: Stimulates receptors to cause cardiac stimulation; increases systemic vascular resistance.

Side Effects: Palpitations, tachycardia, HTN, angina, IV-line irritation, nausea, vomiting.

Adverse Reactions: Cardiac dysrhythmias, azotemia, tissue sloughing (from extravasation.
Life threatening: MI, gangrene in extremities due to vasoconstriction.

Treats hypotensive shock states, increases heart rate in bradycardia when unresponsive to atropine In the emergency setting, dopamine is used for severe hypotension after IV fluids failed to increase the BP.**

Question 49

Nitroprusside

Answer 49

Drug Class: Vasodilator

Dosage: IV drip: Initially 0.25 -0.3 mcg/kg/min, then titrated to desired response.

Contraindications: Hypersensitivity, HTN (compensatory), decreased cerebral perfusion, coarctation of the aorta. C

Caution: Increased ICP

Drug-Lab-Food Interactions: Do not mix with any other drug syringe or solution.

Therapeutic Effects/Uses: To treat hypertensive crisis and to decrease systemic vascular resistance to improve cardiac performance.
Mode of Action: Stimulates smooth muscle of veins and arteries; produces peripheral vasodilation

Side Effects: Dizziness, HA, N/V, abdominal pain, sweating, palpitations, weakness.

Adverse Reactions: Hypotension, tinnitus, dyspnea, blurred vision. Life threatening: Severe hypotension, loss of consciousness, profound cardiovascular depression.

Therapeutic range of drugs requiring lab monitoring:
Heparin: PTT (60-70) aPTT (30-40) and per hospital protocol
Phenytoin: 10-20 mcg/mL
Warfarin: PT/INR 2-3 (Watch out for bleeding)
Lithium: 0.5-1.5 mEq/L (Watch out for dehydration)
Digoxin: 0.5-2 ng/mL
Medications with a narrow therapeutic range require lab monitoring. Too much of a drug with a narrow therapeutic range causes toxicity.