PHARM FINAL Flashcards
MORPHINE
Opioid agonist
- Binds with mu and kappa receptor sites.
- Analgesia, euphoria, pupil constriction, stimulation of cardiac muscle, peripheral vasodilation
- Pre-anesthesia
- Treatment of shortness of breath associated with heart failure/pulmonary edema
- Acute chest pain with MI
Check VS before admin/ do not give if RR 12
Morphine S/E + RISKS
- IV morphine should be given by slow IV push, (4-5 minutes). Must know where the naloxone and resuscitation equipment is located.
- Head of bed down, do not get out of bed by yourself, side rails up, call light in place
- Risk of orthostatic HTN do not get out of bed for 15 min
NALOXONE
Opioid antagonist -Opioid reversal agent
- Complete or partial reversal of opioid effects during emergency. (works within minutes)
- Post op opioid respiratory depression
Centrally acting pain medications
Tramadol
Weak opioid
Main action is to inhibit re-uptake of norepinephrine and serotonin in the spinal neurons.
Hypotension, dry mouth, constipation, drowsiness, sedation, dizziness.
- Helps with decreasing addiction
Centrally acting pain medications
Acetaminophen
-Centrally acting COX inhibitor (direct action to hypothalamus) and dilation of peripheral vessels.
minimal anti-inflammatory activity and no effect on platelets
-Adjunct to opioid use (synergistic drug + drug effect)
Main action is reduction of fever (allow for sweating and dissipation of heat)
Acetaminophen SE
Anaphylaxis with angioedema
Hepatic toxicity/ Liver tox
Antidote is acetylcysteine (Smells like rotting eggs)
Labs: ALT increase/ AST increase/ Bili increase
Anti-inflammatories
IBU
COX Inhibitor (1 and 2) with reversibility
Mild to moderate pain, inflammation and fever reduction
Anti-platelet effect is less significant
Anti-inflammatories
IBU SE
- Headache, drowsiness, dizziness, anorexia, dyspepsia, nausea, possible occult blood loss
- Peptic ulcer, GI bleed, aplastic anemia, agranulocytosis, laryngospasm/edema, anaphylaxis, renal failure, vomiting, constipation, diarrhea
- Serious increased risk of thrombotic events, MI and CVA
- HX of MI/ Stroke should not take
Anti-inflammatories
ASA
- COX Inhibitor (I and 2)
- Significant anti-platelet effect-IRREVERSIBLE
- Decreased inflammation/pain
- Mild to moderate decrease in fever
- Risk reduction for colorectal cancer (unknown mechanism)
- 7 days lie of platelet of schedule for SX must be off for 7 days prior sx
Anti-inflammatories
ASA SE
- Heartburn, stomach pain, ulceration
- Bronchospasm, anaphylaxis, hemolytic anemia
- Salicylism tinnitus, impaired hearing, sweating, HA, and dizziness.
- Toxicity: sweating, high fever, coma, respiratory depression
- Reye’s Syndrome (children with viral infection ASA is contraindicated. Can cause vomiting and mental status change. Elevated LFTs, elevated ammonia, possible serious brain injury
- children under 12 can not take
- contraindication c ppl peptic ulcers/ asthma
Steroids: prednisone
Blocks COX 1&2
Decrease synthesis of prostaglandins
Suppress histamine, phagocytes and lymphocytes
Larger side effect profile especially with prolonged use-adrenal insufficiency, hyperglycemia, mood changes, cataracts, PUD, electrolyte imbalance and osteoporosis. May suppress active infection.
Prednisone safety
If on steroids long term should carry medic alert bracelet or information in wallet. Periodic lab monitoring. Monitor BP, HR, and weight Report changes in mood. Report changes in vision Do not stop abruptly Weight bearing and calcium intake. Review signs of GI bleeding. Take with food.
Migraine: Sumatriptan
-Cranial artery vasoconstriction, can give via multiple routes. Can repeat dose, max 2 doses per day.
Serotonin receptor agonists
- Contraindicated in patients with CAD, HTN, liver disease
- Pregnancy category C
- Do not give with ergot alkaloids
Hydroxychloroquine For RA
- Take the same time everyday, with milk to decrease GI upset.
- Pregnancy category C
- Anorexia, GI disturbance, loss of hair, HA, mood/mental changes.
- Ocular side effects: blurred vision, diminished ability to read, blacked out areas, possible irreversible retinal changes.
DMARDS: Methotrexate
-Given as a once weekly dose (IM, SQ, PO) Cannot touch the medication
-Is an anti-metabolite, it interferes with the production of immune cells. The end result is immunosuppression
-Must drink 8-12, 8oz glasses of water per day.
No alcohol
Cannot take with NSAIDS or ASA as will increase toxicity of both.
Methotrexate Side effects
DMARDS
Pregnancy Category X Can also pass through breast milk Hepatotoxic Bone marrow suppression GI ulceration (anywhere down the GI tract, including mouth) Pulmonary Fibrosis
(DMARDS) Enterecept
Local reaction at the injection site, HA, nasopharyngitis (runny nose)
Increased risk of infection
Severe skin reactions: SJS or TEN (toxic epidermal Necrosis)
Heart failure (even in patients without a history of heart failure)
Reactivation of latent TB
Osteoporosis
Raloxifene SE
- worse Hot flashes
- risk of clots (DVT/ PE) - so have pt walk/ no smoke/ move/ weight bearing exercise
- preg cat X
Osteoporosis
Alendronate ( FOSAMAX)
- Oral medication, daily
- Taken prior to breakfast with full glass of water.
- Cannot eat or drink anything after taking for the next 30 minutes
- Must be upright (sitting or standing) after taking
- No calcium supplements or dairy within 30 min pre and post taking this medication, will decrease absorption
- can get esophagitis unceration*
Osteoporosis
Alendronate ( FOSAMAX) SE
Nausea, vomiting, abd pain, muscle and joint pain
Esophagitis, eye pain, vision change
if GERD occurs pt must stop med
Osteoporosis
Calcitonin-Salmon
- Will treat post menopausal osteoporosis
- Also can treat increased calcium levels related to hyperparathyroidism
- allow CA to leave kidney and inhibits osteoclast
- pt should have fish allergy testing*
- Can decrease calcium
- Can lead to nasal irritation, dryness and ulceration
- After a year can stop working
Gout
Allopurinol
GI distress: nausea, vomiting, diarrhea Drowsiness, vertigo Headache Metallic Taste - Blocks uric acid production *Drink 3 L of water daily *Adverse effects: Cats/ Bone marrow supression/ Hypersensitivity
Chemotherapy
Anti-tumor AntibioticsAnthracyclines-Doxyrubicin
Intercalation of DNA, prevention of enzyme repair
Nadir 10-14 days
Alopecia
Red urine and tears for 1-2 days after infusion
Cardiac toxicity (even years later) Need prophylactic ACEi
Hepatotoxicity
Vesicant
Supra-infections
Gout
ProbenecidA
- *help with pt with kidney problems**
- Increase excretion of uric acid by blocking reabsorption in the kidney
- Probenecid
- No analgesia or anti-inflammatory properties
- Can precipitate gout in the beginning as increases mobilization in the tissues.
- Started low and then increased
- *Drink 3L of water per day!!**
Chemotherapy
Anti-MitoticsTaxanes-Paclitaxel
Stops mitosis, nonfunctional microtubules
Nadir 11 days
Allergy
Bradycardia during infusion
Neuropathy
IV, 3 hour infusion, special filter/tubing
Pretreat with anti-histamine and steroids
SE: Peripheral neuropathy /allergic rxn/ bone marrow supression/ dysrhythmia
Anti-hypertensives
Beta Blockers1 Metoprolol (Lopressor)
SIDE EFFECTS
orthostatic hypotension
Worsening heart block (HF) (contraindicated)
Higher doses cause beta 2 blockade (located on the lungs)
Male sexual dysfunction
Cannot abruptly discontinue
- Have to check apical pulse and id less than 60 need to hold.
- Bradicardia
Chemotherapy
Tamoxifen Estrogen receptor modulators
- Decrease growth of estrogen receptor positive breast cancer
- 1 x 2 per day orally
- GI/ hot flases
- retinopathy
- increased risk of uterine CA
- DVT/ PE
Anti-hypertensives
ACE Inhibitor
Lisinopril
Side Effects
Can have profound low blood pressure after first dose- Hypo- HTN
Dry cough
Angioedema
Rash/metallic taste
Hyperkalemia ** Salt substitute is K+ — So pt can not use**
Leukopenia
Anti-hypertensives/Diuretics
Lasix (Furosemide)
Oral and IV
Can be given even with decreased kidney function
Serious side effects: dehydration, electrolyte imbalance (hypokalemia), hypotension (orthostatic hypotension), ototoxicity
Contraindications: allergy, sulfa allergy, anuria, hepatic failure
NSAIDS decrease effectiveness
Anti-hypertensives/Diuretics
Spironolactone (Aldactone)
Oral Diuresis without losing potassium Blocks aldosterone Could cause hyperkalemia Other side effects similar to increased testosterone Cannot use in pregnancy
Anti-lipids
Cholestyramine
Not systemically absorbed, act in the intestine
Increased excretion of cholesterol in the stool
- drink with 8 oz of water/ juice - take 1 hour before other meds or 4 hours after- other wise will bind with other drugs
- no vitamins-Will decrease absorption of fat soluble vitamins
Anti-dysrhythmics
Lidocaine Na channel blocker
Can cause other dysrhythmias
Hypotension (can be severe), dizziness, and syncope
Increased PR interval, widening of QRS (cardiotoxicity)
High doses can lead to confusion
Lidocaine toxicity can cause central nervous depression, malignant hyperthermia
Anti-dysrhythmics
Amiodarone K+ channel blocker
Delay repolarization and increase the refractory period
Decreased HR and hypotension
Can cause blurred vision, photosensitivity, N/V
Pulmonary complications-pneumonia like syndrome with decreased lung function
Anti-dysrhythmics
Amiodarone K+ channel blocker
Delay repolarization and increase the refractory period
Decreased HR and hypotension
Can cause blurred vision, photosensitivity, N/V
Pulmonary complications-pneumonia like syndrome with decreased lung function
Anti-lipids
Atorvastatin
20-40% reduction in lipid levels
Decrease in cardiac events
Short acting statins must be taken at night
Long acting statins can be taken at any time
Cannot use in pregnancy (pregnancy category X)
No grapefruit juice
Mild side effects: HA, fatigue, muscle and joint pain (check CPK- which is an enzyme muscle produces)
Small percentage of patients with liver disease: monitor labs
Severe-myopathy that leads to kidney failure
If pt experience muscle breakdown - it will hurt the kidney in the long run so pt no longer can be on statin
CHF
Preload: Furosemide
Afterload: Lisinopril
Contractility: Digoxin
Heart Failure:
Can be caused by an increase in preload (too much fluid volume)
Can be caused by decreased contractility (unable to contract the heart muscle)
Can be caused by an increase in afterload (too much resistance)
S&S : Left Sided CHF: cough/ SOB/ secretions
Right sided CHF: peripheral edema
Cardiac Glycoside: DIgoxin
Digoxin (Lanoxin)
Positive Inotrope. Increases calcium inside the heart muscle cell, increasing strength of contraction.
Suppress SA note to slow conduction thru the AV node, decreasing heart rate.
Decreases release of renin and angiotensin II
DIG Side effects
Narrow therapeutic range, decreased potassium increases risk of toxicity- Hypokalemia
Risk of Toxicity
GI: nausea, vomiting, anorexia
Neuro: headaches, vision change
Heart: dysrhythmias (especially heart blocks)
IV digoxin immune Fab (Digibind) is reversal
-Oral can give with food, can crush
IV give slowly over 5 minutes, vesicant
Angina (decrease work of the heart)
A. Preload: Nitroglycerin
B. Afterload: Metoprolol or Nifedipine
C. No meds for contractility.
Angina (decrease work of the heart)
A. Preload: Nitroglycerin
B. Afterload: Metoprolol or Nifedipine
C. No meds for contractility.
Anti-Infectives
Anti-Protozoa Metronidazole (Flagyl)
Other protozoa infection
- Cryptosporidiosis- diarrhea/ cramping
- Giardiasis-drinking contaminated water-iarrhea alternating with greasy stools. Fatigue, cramps
- Trichomoniasis STD-> Red/ burning/ white and running discharge
Disulfram reaction with alcohol ** Cause severe N/V + abd pain*
Side effect: metallic taste
Adverse effect: seizures, peripheral neuropathy
Anti-Infectives
Vancomycin
Oral- no systemic absorption, treatment of Cdiff
IV must be given dilute over 60 minutes to prevent flushing (redman syndrome)
Adverse effects: nephrotoxicity, otoxicity
Peak/ Trough measurements needed.
Anti-Infectives
Augmentin AMOX + Clavulanate
PCN-> prototype AMOX
**Resistance to PCN develops when bacteria secrete betalacamase which destroys the beta lactam ring.
-Some drugs inhibit bacterial betalactamase and can be combined with penicillin (clavulanate, sulbactam, tazobactam)
Kills Bactalactamase
Anti-Infectives
Augmentin AMOX + Clavulanate SE
- Diarrhea, nausea and vomiting
- Supra-infections (pseudo-colitis - blood in stool)
- Allergy is the most common adverse event
- Decrease effectiveness of oral contraceptives
- Cannot be used with aminoglycosides
Tetracycline: Doxycycline
Doxycycline*
Give with full glass of water - try to take it sc food if you can - avoid GERD
-Inhibit bacterial protein synthesis, bacteriostatic
-Lipid soluble and can cross the blood brain barrier
Wide spread resistance
-Should take with food but not metal ions like calcium of iron. ( will bind + make med unuseful)
Tetracycline: Doxycycline Side Effects
Effect fetal bone growth and teeth development should not be given to pregnant women or children (8 or younger) ** DISCOLORATION of TEETH Grey/ Brown
GERD, irritation of the esophagus
Supra-infection
HIV: Zidovudine NRTI
If mom has HIV will used mets when prego and IV in labor to prevent transfer from mother to baby
Oral or IV
Bone marrow suppression (may need therapy interruption)
Fever/muscle aches
GI side effects
CNS side effects
Influenza (Tamaflu)
*Oseltamivir
Prophylaxis or treatment
Must be given within 48 hours (24-48 hours trying to tshorten 7 days - 5days)
Adverse effects: neuro-psychosis, SJS
Influenza (Tamaflu)
*Oseltamivir
Prophylaxis or treatment
Must be given within 48 hours (24-48 hours trying to tshorten 7 days - 5days)
Adverse effects: neuro-psychosis, SJS
Types of Insulin
Regular Insulin: Onset 30 minutes, peak in 2 hours, lasts 5 hours GIVE 30 MINUTES PRIOR TO MEAL.
NPH: Onset 1 hours, peak 4 hours, lasts 18 hours GIVE 30 MINUTES BEFORE FIRST MEAL OF DAY, SOMETIMES 30 MINUTES BEFORE SUPPER TOO.
Can mix in same syringe. R first than N
Glargine Lantus injection
Glargine: gradual onset, begins in 1 hour, no peak, lasts up to 24 hours. CANNOT BE MIXED WITH OTHER INSULINS
Lispro: Onset 5-10 minutes, peak 30 minutes to an hour, duration 3-4 hours. Given 5-10 minutes before a meal.
*Lispro give at the time of meal- give it with tray infront of them**
Oral
Biguanide: Metformin
Increase insulin sensitivity / decrease absorption in intestine
SE: abd cramping dirrhea- but will go away
-Nausea, vomiting, diarrhea, anorexia, headache, dizziness, agitation, fatigue.
**Does not cause hypoglycemia **
** has to be help pre procedures (SX or Scans with IV dyes)-> poss. Lactic acidosis
- eats BID- do not take when you are sick / dehydrated
Diabetes insipidus
When body hypo-secretion
S&S: alot of pee/ excessive urnation
ADH: Desmopressin (Synethic ADH) (DDAVP)
Produced by hypothalamus and stored in posterior pituitary
-Produces effects on kidneys *Works on renal collecting tubules to increase reabsorption of water *
-Short half life, need to give 4-5x per day.
Formulated with peanut oil
-Increases reabsorption of water
-Decreases urine volume
ADH: Desmopressin Side effects
Admin: Spray latteraly
Side effects: drying/ irritation/ bloody nose
fluid retention- low NA+
Follow up: Labs: renal fx, UA, specific gravity, NA+ (135-145 me 2/L)
Contraindications: Peanut allergy
Oral
Sulfonylurea: Glipizide
Stim pancreas to release insulin
*biggest worry= hypoglycemia
Persistent hypoglycemia, GI distress, hepatotoxicity
- decreased BS + take 30 min pre breakfast
ETOH= Disulfran- N/V + Flushing
Propylthiouracil PTU
-When there are too much Thyroid Hormone and this med will Interferes with synthesis of T3 and T4 in the thyroid gland as well as conversion of T4 to T3 in the peripheral tissues.
Can lead to hypothyroidism symptoms
-Given orally several times per day (one tablet q 8 hours) TID
Follow up: Labs; CBC/ TSH
Pregnancy Category D
during pregnacy hyper-thyroid can clear up and then come back
Short acting beta agonists
Albuterol
Rescue- fast acting
Last only 2-6 hours
Prn no more than 12 inhalations per day
Headache, dizziness, tremor, nervousness, throat irritation, tolerance
Tachycardia, dysrhythmia, hypokalemia, hyperglycemia, paradoxical bronchoconstriction, increased risk for asthma related death.
do not use with a Beta blocker
-wait 1 min between puffs & hold in puff for 5-10 sec
- can take 15-30 before exercise
Inhaled Corticosteroids: Betamethasone (Qvar)
Hoarseness, dry mouth, cough, sore throat
Candida- fungal infection in mouth - pt must rinse and spit
Systemic absorption (risks
** IF TAKEN WITH Abuterol**
Abuterol goes first THEN THE SEROID**
Inhaled Corticosteroids: Betamethasone (Qvar)
Hoarseness, dry mouth, cough, sore throat
Candida- fungal infection in mouth - pt must rinse and spit
Systemic absorption (risks
** IF TAKEN WITH Abuterol**
Abuterol goes first THEN THE SEROID**
Levadopa-Carbidopa
too much ACH, too little dopamine
-Levodopa crosses the blood brain barrier and becomes dopamine
Carbidopa prevents the metabolism of Levodopa allowing more to cross the blood brain barrier.
Levadopa-Carbidopa Side effects & cautions
Main side effects are orthostatic hypotension and dizziness **so if pt has HTN –> pt is at risk for falls **
- Can also cause tardive dyskinesia (uncontrolled involuntary movements) - tongue movements . blinking MUST LET MD KNOW AND FIND ALTERNATIVE OTHERWISE MAY BECOME PERMANENT
- Med can take up to 3 weeks to work
Should be stopped gradually, to abrupt could lead to increase in Parkinson’s symptoms.
Caution when used with antihypertensive medications. Antacids increase absorption and increase risk of toxicity
Monitor Liver Function
*can not be taken with High protein diet will decrease med absorption / can not be taken with MAOI can cause HTN crisis
Myasthenia Gravis meds
- Medications block acetocholinesterase so ACH is in the synapse longer and can produce a better, stronger muscle contraction
- Cholinestraise Inhibitor ** increase strength less fatigue
- Fast acting for diagnosis: endonorphium* (TESTER & will make muscle stronger if they have Myasthenia Gravis)
- Long acting for treatment: pyridostigmine*
Pyridostigmine
(SLUDGE)- cholinergics
PO medication
-Used to effect activity at the nicotinic (skeletal muscle) but could effect the muscarinic (smooth muscle) leading to parasympathetic side effects.
-Contraindicated in intestinal and urinary obstruction.
Reversal is atropine. for muscle weakness respiratory paralysis that occurs within 1 hr of admin = serum level too high.
Serotonin Reuptake Inhibitors
Depression Med
Focus on seratonin
Sertraline (SSRI)
-Oral
-As pill or liquid
-If liquid must be mixed with another liquid like water, white soda, or OJ
-Takes 2-4 weeks for onset of action (difficult to predict half life because is highly protein bound)
-Agitation, insomnia, headache, dizziness, somulene
Increased risk of suicide ideation
*risk of increased Weight- instruct healthy food for pt
risk of sexual dysfunction
Depression- Imiprimide (TCA)
Blocks reuptake of serotonin and norepinephrine
(Happy/ motivation/ increased mood but decreased in ACH and anticholinergic)
Takes at least 2 weeks to work
*Can also cause anticholinergic side effects : HTN/increased HR/ dry mouth -urniation hesitation
-Can cause diaphoresis (diabetics)
Increased risk of suicidal ideation (when you first start med)
Contraindicated in MI, bundle branch block, glaucoma, kidney or liver impairement
**causes dangerous heart failure/ Cardiac SE)
Depression Med
Phenelzine (MAOi)
Phenelzine (Nardil)
Inhibits MAO leaving norepinephrine in the synapse
*Keeping NE & Seratonin & Dopamine linger in the synapse *
- Cannot be used in cardiovascular, cerebrovascular, -hepatic/renal impairment, or pheochromocytoma.
- Cannot use with TCA or SSRI as will cause severe temperature elevations and seizures.
Bipolar-Lithium
Mood Stabilizer: Lithium
- Narrow therapeutic range: 0.6-1.5 mEq/ml REMEMBER
- Relationship with sodium
- Low sodium can cause lithium toxicity (can cause profound hypo htn & causes cardiac arrest)
- Toxicity: hypotension, circulatory collapse
- Also treats Bipolar: Anti-seizure medications: tegretol, lamictal, and valproic acid & Atypical antipsychotics
Drugs that make the cell less positive (decrease sodium in the cell)
Phenytoin- (Dilantin)
IV : When someone comes in seizure
- Mixed with saline only. If mixes with dextrose will precipitate which can lead to embolus (always flush extra)
- -** Start a new line other arm or Start a new IV line**
- Use large vein or central line
- Can cause tissue necrosis
Can also be given PO
Pregnancy category D
ONLY GIVE WITH SALINE
Drugs that make the cell less positive (decrease sodium in the cell)
Phenytoin- (Dilantin)
Side Effects
*Narrow therapeutic window, requires close monitoring of phenytoin blood levels. Therapeutic Range: 10-20 microgram/mL** If test comes back @ 20micro/ml- leave it it is in good range- do not call MD JUST KEEP MONITORING
- Multiple side effects: dysrhythmia, hypotension(brady), hyperglycemia, confusion, slurred speech, agranulocytosis(low WBC), anemia
- Severe skin reactions like SJS
- Connective tissue disorders: lupus
- Gingival Hyperplasia
- Blood test*: CBC/ electrolyte/ BMP/ BS/ phenytoin
DO not stop med abruptly- even though pt has not have seizure for a long time - meds are usually used forever
Drugs that make the cell less positive (decrease sodium in the cell)
Valproic Acid
Drugs that make the cell less positive (decrease sodium in the cell)
Valproic Acid
Drugs that make the cell less positive (decrease sodium in the cell)
Valproic Acid
Drugs that make the cell less positive (decrease sodium in the cell)
Valproic Acid
Drugs that make the cell less positive (decrease sodium in the cell)
Valproic Acid
SIDE EFFECTS
- Sedation
- Drowsy- no driving
- Prolonged bleeding times- use soft tooth brush/ no razor
- Bone marrow suppression- platelets/ INR/ Infection
- Photosensitivity- sun burn wear long sleeves/ sun block
- Fatal Liver Toxicity- should not drink alcohol only water/ avoid Tylenol
- Have labs: Liver pannel/ PTT/ INR/ CBC/ Platelets
- Preg Cat D (DONT DO IT)*
Medications Affecting Platelets
Blocking ADP receptors
Clopidogrel (Plavix)
- Stops platelets from binding sites from binding for 7 days*
- Given to prevent clots in patient with recent MI, CVA, or PAD.
- Prevention in unstable angina, those receiving PCI or stent
- Irreversibly binding the receptor for ADP, lasts the life of the platelet
Do not crush or split
Flulike syndrome, HA, dizziness, bruising, rash , prurutis
Bleeding
- when treatment is effective: no more CVA/ MI
- Eat with food/ milk
- Ideally hold Plavix for 7 days before SX
- AVOID Other NSAIDS*
Medications Affecting Clotting Factors
Heparin
Hold 12 hrs before SX/ works around factor Xa
- Binds to anti-thrombin III inactivating several clotting factors
- Works immediately when given IV. Works in an hour when given SQ.
- Weight based monogram based on use
- With SQ do not draw back on syringe or massage area
- Bleeding
- Heparin induced Thrombocytopenia (if platelets are already low- heparin will lower it even more)
- Epidurals
- Overdose: Protamine Sulfate, given IV, 1mg for every 100u of heparin
- Give deep into fat tissue SQ - put pressure for 1-2 min to decrease bruising *
Heparin will also treat evolving clot - IV will prevent clot from getting bigger & body will try to get rid of clot
Medications Affecting Clotting Factors
Heparin
Hold 12 hrs before SX/ works around factor Xa
- Binds to anti-thrombin III inactivating several clotting factors
- Works immediately when given IV. Works in an hour when given SQ.
- Weight based monogram based on use
- With SQ do not draw back on syringe or massage area
- Bleeding
- Heparin induced Thrombocytopenia (if platelets are already low- heparin will lower it even more)
- Epidurals
- Overdose: Protamine Sulfate, given IV, 1mg for every 100u of heparin
- Give deep into fat tissue SQ - put pressure for 1-2 min to decrease bruising *
Heparin will also treat evolving clot - IV will prevent clot from getting bigger & body will try to get rid of clot
Warfarin (Coumadin)
- works around factor Xa*
- √ PT / INR
- Vitamin K antagonist, cannot synthesize several clotting factors
- Can take up to a week to work. Protein bound, clotting factors that are already produced need to be used up.
Bleeding
Avoid in HTN, endocarditis, hepatic/renal impairment
Dietary interactions
Overdose: PO or IV administration of vitamin K. (salads/ Spinach - watch diet)
- √ freq- INR NL: 1-2
- 2-3–> Needs to be on forever therapeutic range
- > 4 : risk of spontaneous bleeding
Colony Stimulating Factors
Epoetin Alfa
- Stimulates production of RBC
- Chronic anemia, kidney failure
- Given SQ three times per week
- Do not shake vial, will inactivate medication
*Side effects: elevated blood pressure, HA, fever, nausea, diarrhea, and edema
Risk of clot
Colony Stimulating Factors
Filgrastim (Neupogen)
- Increase number of neutropils, make the circulating neutrophils work better.
- Often used during chemotherapy
- Do not given within 24 hours before or after chemotherapy as this will decrease effectiveness
*Side effects: fatigue, rash, epistaxis, decreased platelets, fever, nausea and vomiting. Most common is bone pain
If WBC gets too high then can lead to serious adverse events respiratory failure, MI, intracranial hemorrhage, splenic rupture
Colony Stimulating Factors
Filgrastim (Neupogen)
- Increase number of neutropils, make the circulating neutrophils work better.
- Often used during chemotherapy
- Do not given within 24 hours before or after chemotherapy as this will decrease effectiveness
*Side effects: fatigue, rash, epistaxis, decreased platelets, fever, nausea and vomiting. Most common is bone pain
If WBC gets too high then can lead to serious adverse events respiratory failure, MI, intracranial hemorrhage, splenic rupture
Proton Pump Inhibitors
Omeprazole (Prilosec)*
FOR GERD/PUD
Omeprazole (Prilosec)*
Irreversibly binding to proton pumps
Give before breakfast on an empty stomach. Do not open capsules, no chewing or crushing
irreversible for 7 days
Proton Pump Inhibitors
Omeprazole (Prilosec)* SIDE EFFECTS
FOR GERD/PUD
HA, diarrhea, nausea, rash, dizziness
Increased risk of osteoporosis, hypomagnesium, C.diff
Rare blood disorders with fatigue and weakness
Antacids: Aluminum hydroxide
FOR GERD/PUD
Aluminum hydroxide (minimal absorption, aluminum reduces constipation) Calcium carbonate (more systemic absorption) *coat the stomach to protect the stomach *
Antacids: Aluminum hydroxide
SIDE EFFECTS
FOR GERD/PUD
SE: constipation, nausea, stomach cramps,
Adverse: fecal impaction, electrolyte imbalance
Oral Contraception
Prevent Ovulation
Combination (Estrogen and Progesterone)
Contain Estrogen and progestin
Ethinyl estradiol and drospirenone (Yasmin)-monophasic
- 21 days same dose daily & then the last 7 days are sugar pills
Ethinyl estradiol and norethindrone (Ortho-Novum)-triphasic
- First 7 days are the higest dose of Hormones
- second 7 days middle dose
- Third 7 days low dose
- Last 7 days are sugar pills
Progesterone only:
Norethindrone (Micronor)
OC Contraindications/ Serious Contraindications
- h/o DVT or thromboembolic disorders
- Cerebral vascular or coronary artery disease
- Smokers >35 yo
- Use cautiously in patients who are obese, diabetic, hyperlipidemic (clot)
- Presence or h/o breast or genital cancer (not absolute)
- Family history or risk factors for breast cancer
- Estrogen dependent tumors
- Uncontrolled hypertension
- Pregnancy category X
- *HTN/ Liver disease/ CLOTS**
OC Drug Interactions
- Antibiotics
- Decreased efficacy of oral contraceptives
- Antiepileptics
- Carbamazepine, phenobarbital, phenytoin, and topiramate will increase metabolism of oral contraceptive (decreasing its effect)
- Decreased effect of warfarin
- ACE inhibitors can cause hyperkalemia
MISSED PILLS
One missed pill?
-Take the pill as soon as remember and take the next pill at the regular time or
Take 2 pills at the next regularly scheduled dose
No need for alternative birth control (BC)
2 missed pills?
-Take 2 pills that day and 2 pills the next day
3 missed pills?
-use additional birth control and start new cycle of medications after 7 days of waiting
Increased risk of ovulation and resulting pregnancy
Hormone Replacement Therapy
Oral: conjugated equine estrogen (Premarin)
SIDE EFFECTS: RISK CLOT
-Nausea (common, but decreases with use)
-Hypertension (increase in angiotensin and aldosterone)
hromboembolism events
DVT, PE, MI, CVA
-Breast tenderness, cancer in high risk family or personal history (avoid ppl with hx of Breast CA)
Endometrial cancer
If intact uterus and unopposed estrogen
(build up of tissue that lines the uterus from estrogen puts them at risk)
If med is working pt will feel better decreased in menopause symptoms (hot flashes/ insomia/ Bone loss/ Altered metabolism lipids/ Vaginal atrophy)
HRT Contraindications
Pregnancy Unexplained vaginal bleeding h/o thromboembolic disease Patient or family h/o heart disease Active or chronic liver disease Current or h/o breast or endometrial cancer Recent vascular thrombosis Smoking
** HRT also **
Decreased effect of warfarin
Increased effect of phenytoin
Uterine Stimulants
-increase stimulation of contraction for those who are overdue
Uterine Stimulants
Oxytocin
- Monitoring of mother (HR/ BP) & infant (HR)
- Continuous monitoring of maternal blood pressure, heart rate, and uterine contractions
*Uses: Must be on IV pump * Induction of labor (postterm, premature rupture of membranes, preeclampsia) -Enhance labor -Delivery of placenta -Control of postpartum bleeding -Fetal stress testing
Intranasal: promotion of milk letdown
Every time there is a contraction baby gets less blood - prolong contraction = danger for baby
Oxytocin- Adverse Events
-Antidiuretic effect (water intoxication)
uterine hyperstimulation could lead to uterine rupture
- Contractions > 60 seconds
- Contractions more frequently than every 2-3 minutes
- First thing you want to do in Emergency -Turn patient on LEFT side, stop infusion and administer oxygen.** (decrease pressure on baby )
- contractions less than 1 min and
- Administer a uterine relaxant like Terbutaline
premature ventricular contractions
hypotension mild and transient hypertension
Terbutaline
Tocolytics are medications used to suppress premature labor.
Goal: postpone delivery long enough to reduce incidence of problems associated w/prematurity.
The therapy buys time for the administration of steroids to accelerate fetal lung maturity and/or transport mom to high risk facility. Tocolytic therapy is less likely to be effective if cervical dilation is > 6 cm
**Uterine Relaxant: Smooth muscle relaxation uterus- Decrease in BP + reflux tachy + Vasodilation **
** Mom would be on monitor for HR for mom + infant**
Terbutaline
Adverse Effects
Adverse effects
Tachycardia, palpitations, chest pain, arrhythmias
Tremors, anxiety, headache
Pulmonary edema, dyspnea, cough, tachypnea
Terbutaline
Administration
Administration
Confirm preterm labor and gestation between 20 and 35 weeks
Usually given SQ: every 20 minutes, up to 3 hours: NO LONGER THAN 48 HOURS
Monitor FHR and rhythm
Report signs of maternal and fetal distress
If FHR >180 stop administration, call MD
Androgen Replacement Therapy
Testosterone (Delatestryl, Depo Testosterone) deep IM every 2-4 weeks
Androgel, Testoderm- topical
Halotestin- po
Striant-buccal tablets (apply to gums above an upper incisor/rotate sides
Testopel- SQ implants (every 3-4 months)
ART uses
*Hypogonadism in androgen deficient men
*Delayed puberty
Palliative treatment of androgen responsive breast cancer
Androgen replacement in testicular failure
ART SE
Hypogonadism in androgen deficient men
Delayed puberty *short stature
Palliative treatment of androgen responsive breast cancer
Androgen replacement in testicular failure
Medications for Erectile Dysfunction
Sildenafil (Viagra)
- Take 30 min prior planned sex
- Increase Venous dilation - penis enlargement
- No nitro - could cause profound drop in BP
Side effects:
Priapism
Flushing
Headache
MI
Drug interactions: Drug-drug interactions
Nitrates
Hypotension, syncope, fainting
Ketoconazole, erythromycin, cimetidine, ritonavir, grapefruit juice
Increase concentration of sildenafil
