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Pharm II N306 > Pharm II week 6: Antifungal and Antiviral I > Flashcards

Pharm II week 6: Antifungal and Antiviral I Flashcards

1
Q

What are the two types of antifungal agents?

A

Systemic mycoses

Superficial mycoses

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2
Q

System mycoses:
1. Occur more or less frequently (than superficial)?
2. More or less dangerous and why?
3 What are the 2 subdivisions?

A
  1. Occur less frequently (than superficial)
  2. More dangerous b/c they are difficult to treat due to resistance, treatment may be prolonged course so frequent issue with toxicity
  3. Subdivided into 2 categories
    Opportunistic and non-opportunistic
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3
Q

What is the difference b/w Opportunistic vs non-opportunistic systemc mycoses?

A
  • Opportunistic: candidiasis, aspergulosis; immnocompromised pts (HIV or transplant)
  • Non-opportunistic: can occur in any host
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4
Q

What are the two organisms of superficial mycoses?

A
  1. Candida

2. Dermatophyte

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5
Q

Where is Candida found with superficial mycoses?

A
  1. mucous membranes, oral, vaginitis, under breasts
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6
Q

What are types of dermatophytes?

A

ringworm

onichomcosis: toenail or fingernal fungus

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7
Q

What are the 4 classes of systemic antifungal drugs?

A
  1. Polyene Antibiotics
  2. Azoles
  3. Echinocandins
  4. Pyrimidine analogs
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8
Q

Amphotericin B is a ____ and works as a ___ spectrum agent. It is highly toxic. ____ reactions and ____ damage occur in all patients to some degree. Must be given via ____. Resistance is common or rare?

A
  1. Polyene Antibiotic
  2. Infusion reactions and renal damage
  3. IV
  4. resistance is rare
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9
Q

What is the MOA of Amphotericin B (3)?

A
  1. Binds to components (sterols) of the fungal cell membrane = increases permeability
  2. Resultant leakage of intracellular cations (especially K+) reduces viability
  3. Fungistatic or fungicidal depending on concentration of Amphotericin B and susceptibility of fungus
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10
Q

How is Amphotericin B toxic or dangerous to the host?

A

Binds to sterols which includes cholesterol in the host

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11
Q

What is the therapeutic use for Amphotericin B? treatment timeframe?

A

Use for potentially fatal systemic mycoses

Treatment is 6-8 weeks but may last up to 3-4 months.

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12
Q

Regargind the pharmacokinetics of Amphotericin B:

  1. How absorbed in GI tract?
  2. Parenteral or enteral?
  3. CSF?
  4. What is known about the elimination of Amphotericin B?
A
  1. Poorly absorbed from GI tract
  2. Must administer IV
  3. Does not readily enter CSF
  4. Little is known about elimination. The drug has been detected in tissues more than a year after treatment has ended
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13
Q

What are the 4 A/e associated with use of Amphotericin B?

A
  1. Infusion reactions
  2. Nephrotoxicity
  3. Hypokalemia
  4. Bone Marrow suppression
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14
Q

What are the signs of infusion reaction with Amphotericin B and how should each be avoided?

A
  1. Phlebitis:
    - monitor the IV site
    - infuse thru a large central vein
  2. Fever, chills, rigors, nausea and H/a
    - occur 1-3 hours after starting the infusion due to cytokine release
    - persist for about an hour
    - Pretreat with Tylenol and Benadryl
    - Use IV meperidine or dantrolene for rigors
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15
Q

Amphotericin B is toxic to the cell of the kidney:

  1. Renal impairment occurs in ____ patients.
  2. Extent related to ____ dose administered.
  3. If > __ g, ____impairment likely.
  4. Damage minimized by infusing 1 L of ____ on days of treatment.
  5. Avoid concurrent use of what?
  6. Monitor ______ every 3–4 days
  7. Monitor?
A
  1. Renal impairment occurs in MOST or ALL patients
  2. Extent related to TOTAL dose administered
  3. If >4 g, RESIDUAL impairment likely
  4. Damage minimized by infusing 1 L of SALINE on days of treatment
  5. Nephrotoxic drugs: Aminoglycosides, cyclosporines, NSAIDs
  6. Serum Creatinine and Reduce dosage if >3.5 mg/dL
  7. I/O
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16
Q

Hypokalemia is a A/e of Amphotericin B use. Why does this occur and what care should occur?

A

Hypokalemia results from damage to the kidneys
Potassium supplements may be needed.
Monitor serum levels.

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17
Q

Hematologic effects occur as A/e of Amphotericin B use. Why? and what monitoring should occur?

A

Bone marrow suppression resulting in anemia. Monitor hematocrit levels.

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18
Q

Besides hypokalemia and hemotogic affects, what are the other 5 A/e?

A 
Delirium
hypotension
HTN
wheezing
hypoxia
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19
Q

What are the 4 nursing interventions for Amphotericin B use?

A
  1. Monitor/rotate peripheral IV sites
  2. Infuse through large central line
  3. Infuse slowly (over 2-4 hours): if do it rapidly, get cardiovascular reactions
  4. Monitor temp, HR, RR, BP every 30 minutes
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20
Q

Ketoconazole is an antifungal. What is the MOA and therapeutic use?

A

MOA:
- broad spectrum
- inhibits synthesis of ergosterol (disrupts the fungal cell membrane)
- fungistatic and funcicidal
Therapeutic use:
- Alternative to Amphotericin B for systemic mycoses
- slower response
- used for less severe infections and superficial mycoses

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21
Q

What are the A/e of ketoconazole? (3)

A
  1. N/V (reduce by giving with food)
  2. Hepatotoxicity (monitor LFTs)
  3. Inhibits sex hormones causing gynecomastia, decreased libido and menstrual irregularities
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22
Q

What are the D/i associated with ketoconazole? (3)

A

Any drug that raises gastric pH:

  1. Reduced absorption when used with Antacids, H2RA, PPIs (give 2 hours apart)
  2. Ketoconazole inhibits cytochrome P450 (so increased levels of other drugs using P450)
  3. Rifampin reduces plasma levels of ketoconazole
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23
Q

With dermatophytic infections, what type of ringworm is indicated:

  1. Tinea Pedis
  2. Tinea Corporis
  3. Tinea Crusis
  4. Tinea Capitis
A
  1. athletes foot
  2. body
  3. groin (jock itch)
  4. scalp
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24
Q

What patients are at risk for Candidiasis (a superficial mycoses)?

A

Predisposed and immunocompromised:
HIV, pregnant, hormonal differences, obesity, diabetic, glucocorticoid use, immunosuppresant use, oral contraceptives, systemic antibiotics

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25
Q

Name the 3 types of candidiasis syperficial mycoses.

A
  1. Vulvovaginal Candidiasis
  2. Oral candidiasis (thrush)
  3. Onychomycosis (nails)
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26
Q

What treatment is required for superficial mycoses? what are the associated A/e?

A

Azole antifungals

Burning, itching and rash

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27
Q

Which drug is used for dermatophytic infections? which body areas are indicated for Therapeutic use and how long is treatment?

A

Griseofulvin

  1. skin (3-8 weeks); palms (2-3 months)
  2. hair
  3. nails (one year or more)
28
Q

How does Griseofulvin work?

A
  1. inhibits fungal mitosis
  2. deposited in keratin precursor cells
  3. newly formed keratin is resistant to fungal infection
29
Q

Nystatin (Mycostatin, Nilstat) is what type of antibiotic? what is it’s limited use? and route of administration?

A

Polyene Antibiotic
Candidiasis
Oral and topical

30
Q

Allylamines are a new class of antifungals. What two drugs are included in this class?

A

Butenafine (Lotrimin)

Terbinafine (Lamasil)

31
Q

What superficial mycoses is Butenaine (Lotrimin) indicated for? S/e?

A

Topical: tineas (ringworm -all)

No systemic effects

32
Q

What superficial mycoses is Terinafine (Lamasil) indicated for? A/e?

A

Topical- ringworm
Oral- ringworm and onychomycosis
LIVER FAILURE (oral form)

33
Q

With oral Candidiasis, topical agents are usually used with the exception of what patient population?

A

Immunocompromised: use oral therapy -azole

34
Q

Why is treatment of viral infections limited?

A

Viruses use host cell enzymes and substrates to reproduce making suppression of viral replication difficult w/o significant harm to the host.

35
Q

How do antiviral drugs work?

A

suppress biochemical processing unique to viral reproduction.

36
Q

Acyclovir (Zovirax) is used to treat what 3 infections? MOA? Resistance?

A
  1. HSV (most sensitive), VZV (moderately sensitive), CMV (resistant)
  2. inhibits viral replication by suppressing synthesis of viral DNA
  3. Resistance is rare in immunocompetent patients and mostly seen in immunocompromised patients (Ie transplant or AIDs pts).
37
Q

Can Acyclovir eliminate HSVII (Herpes simplex genitalis)?

What patient Ed should be given?

A

No, reduces symptoms, shortens the duration of pain and viral shedding
Pt education: use condoms and abstain from sex during active infection

38
Q

What are the therapeutic uses for Acyclovir?

A

HSVII
Mucocutaneous herpes simplex infections
Varicella-Zoster infection (shingles)

39
Q

oral or IV? acyclovir is the treatment of choice in the immunocompromised host while
IV ____ is drug of choice for resistant strains of Herpes Zoster

A
  1. IV acyclovir

2. IV foscarnet is drug of choice for resistant strains of Herpes Zoster

40
Q

Acyclovir:

  1. ___ elimination
  2. Reduce dosages in patients with ____ disease
A

Renal

kidney

41
Q

What are the A/e of Acyclovir?

  1. Topical
  2. Oral
  3. IV
  4. Renal
  5. Neuro?
A

Acyclovir is safe during pregnancy

  1. Occasional stinging and burning
  2. Nausea, vomiting, headache, and vertigo
  3. Phlebitis
  4. Reversible nephrotoxicity: deposits in renal tubules
  5. rare with IV treatment
42
Q

What are the nursing implications for IV Acyclovir?

A

Infuse slowly: over one hour or more

Ensure adequate patient hydration during infusion and for 2 hours after infusion

43
Q

Ganciclovir (Cytovene and Vitrasert) are used to treat what viruses?
What is the MOA?
Pharmacokinetics?

A
  1. herpes viruses including CMV
  2. Inhibits DNA replication
  3. renal elimination
44
Q

What are the Therapeutic uses for Ganciclovir?

A
  1. Active against CMV retinitis in immunocompromised patients
  2. Prevention of CMV retintis in transplant patients
45
Q

What are the A/e of Ganciclovir use?

A
  1. Bone marrow suppresant
  2. Granulocytopenia: stop using if ANC <25000
  3. Teratogenic and embryotoxic: avoid pregnancy during treatment and 90 days after
  4. Possible infertility for both genders
46
Q

Is drug treatment indicated for Hepatitis B acute, chronic or both? Which drugs are used in treatment?

A

chronic

Interferon alfa, lamivudine, and adefovir

47
Q

To decrease unnecessary drug exposure and expense, current guidelines recommend treatment of Hepatitis B only for patients at highest risk, indicated by elevated _____ levels, or histologic evidence of moderate or severe ___ inflammation or advanced ____.

A

aminotransferase
hepatic
fibrosis

48
Q

What drugs are used for the treatment of chronic HCV?

A

Interferon alfa and ribavirin

49
Q

Interferon alfa is used to treat HBV and HCV, what is the route of admin?
What is the MOA of Interferon alfa?

A

Parenteral- mostly SubQ

Effects the viral replication cycle

50
Q

What are the A/e of Interferon alfa use?

A
  1. flu-like syndrome
  2. Neuropsychiatric effects: severe depression and suicidal ideation
  3. GI disturbance
  4. Alopecia
  5. Injection site reactions
51
Q

Ribavirin (Rebetol, Copegus) has ___ spectrum antiviral activity. With unknown MOA. It must be combined with ____.

A

Broad

interferon alfa

52
Q

What are the A/e of Ribavirin use with hepatitis treatment?

A
  1. flu-like syndromes
  2. depression
  3. hemolytic anemia (use caution with cardiac pts, can worsen angina and increase chance of MI)
  4. birth defects
  5. Pregnancy cat X
53
Q

Pregnancy is contraindicated in Ribavirin use for chronic hepatitis, what nursing indications should be used?

A

R/o pregnancy prior to treatment; pregnancy test before treatment and every month for 6 months after treatment is stopped.
Patient education: use two reliable forms of birth control.

54
Q

Lamivudine (Epivir HBV) is a _____ ___. It suppressess HBV replication by inhibiting viral DNA ____. Lamivudine is used to treat infections caused by ___ and ___.

A

Nucleoside Analog
synthesis
HBV and HIV

55
Q

What are the A/e of Lamivudine?

A

Hepatomegaly and lactic acidosis

56
Q

Adefovir (Hespera) inhibits viral DNA synthesis and is used to treat chronic ___. ___ is an A/e of Adefovir use.

A

HBV

nephrotoxicity

57
Q

With Adefovir, to reduce risk, what should be assessed and which patients are at high risk?

A 
kidney function 
high risk (ie, patients with pre-existing renal impairment and those taking nephrotoxic drugs
58
Q

Which drugs are considered “nephrotoxic”?

A 
cyclosporine
tacrolimus
aminoglycosides
vancomycin
aspirin and other nonsteroidal anti-inflammatory drugs
59
Q

Why should HIV infection be ruled out before adefovir is used?

A

Because adefovir is related to the nucleoside analogs used against HIV, there is a concern that, if the patient were infected with HIV, giving adefovir in the low doses employed against HBV could allow emergence of HIV viruses resistant to nucleoside analogs.

60
Q

What are the most common A/e of influenza vaccine?

A
  • soreness at the injection site
  • flu like symptoms
  • GBS
  • possible anaphylaxis or Bells Palsy with LAIV
61
Q

Influenza vaccines consist of intranasal and IM or intradermal routes. Which is inactivated and which is live attenuated influenza virus (LAIV)?

A

Intranasal= FluMist, LAIV

IM or intradermal= inactivated influenza

62
Q

What age group does influenza vaccine start and what timeframe (months)?

A

6 months or older

Vaccinate b/w October- November (takes 1-2 weeks for protection and lasts 6 months or more)

63
Q

What are precautions and contraindications for influenza vaccination?

A
  • Acute febrile illness
  • Egg allergy
  • No LAIV in high risk patients
  • No Guillen Barre pts
64
Q

What are 1st and 2nd generations of Influenza drugs?

A

1st: Adamantanes
2nd: Neuraminidase inhibitors

65
Q

Amantadine (Symmetrel) and Rimantidine (Flumadine) are both 1st generation Adamantanes. Which type of flu is indicated? and describe resistance.

A

Influenza Type A

Develop resistance easily

66
Q

Oseltamivir (Tamiflu) and Zanamivir (Relenza) are both 2nd generation Neuraminadase inhibitors. Which type of flu is indicated? and describe resistance.

A

Type A and B.

Nearly all strains of influenza are resistant to the adamantanes, but remain sensitive to the neuraminidase inhibitors.

Pharm II N306 (2 decks)

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