Pharm quiz 2 Flashcards
thyroid replacement contraindications
after acute MI, thyrotoxicosis
T3 vs. T4
both are iodine-contiaining derivatives of aa tyrosine
T3-much less produced but less protein bound and much more active
T4- much more produced, becomes T3 in tissues for activity; very protein bound, must measure free T4
inhibiting mechanism for coagulation cascade
antithrombin III (ATIII)
mimic endorphins
opiates
cholinergic medication considerations (3)
- don’t stop abruptly
- spread doses evenly, short half life
- beware of OD, can be lethal
pt on antipsychotics experienceing galactorrhea–must rule out
pituitary tumor; get pituitary MRI
DPP4 Inhibitors-action and what to watch
is like a PO GLP-1 inh (enzyme inactivates GLP-1 so this inhibits that enzyme); increases incretin hormone level
“gliptins”, Januvia
Caution in renal impairment, watch for pancreatitis
what to watch with ADHD Stimulant meds
methylphenidate (Ritalin) and
Amphetamines (Concerta, Adderall)
arrhythmias, tachycardia *get baseline EKG if any question of cardiac history
Hx sudden deaths
anxiety, weight loss, abuse, growth supression
Advantages (2) and Disadvantages (3) of metformin
rare hypoglycemia
wt loss, better lipid profile
GI side effects (often wane after a few weeks)
CI in renal insufficiency (Cr > 1.5)
can cause lactic acidosis
Foods to avoid with MAOIs
Tyramine-containing foods
anything fermented, aged cheeses, wine, chocolate
sulfonylureas-mechanism
2nd gen: glipizide, glyburide
Stimulate beta cells to release insulin
*effective monotherapy in lean pts/newer Dx bc they can still produce enough insulin
once beta cells are fatigues this isn’t as effective
AEs of MAOIs
The three Hs:
- hepatocellular jaundince
- hyperthermia
- hypertension
aspirin action and indications
binds COX enzyme on platelets and inhibits for life of plt, unable to produce thromboxane 2–can’t clot
stroke prevention, even better if used with plavix
lithium AEs
GI distress: anorexia, n/v/d
ADH antagonism->polyuria/polydipsia—>can cause renal fibrosis . *worry about kidneys with lithium
hair loss, acne, thyroid abn
CNS- reduced seizure threshold, slow cognition, intention tremor
baseline labs before starting lithium
BMP-creatinine, GFR
TSH
CBC (causes nonsignificant leukocytosis)
HCG- Pregnancy Category X
can count on these AEs with 2nd gen antipsychotics
stronger antiserotonergic effects–
weight gain
increased blood glucose
hyperlipidemia
phenobarbital-mechanism and effects
enhances GABA
sedating and addictive, multiple other AEs
major reason for lack of adherence with SSRIs
sexual dysfunction
this toxin is a nicotinic antagonist
botulinum toxin
danger with gabapentin, what to monitor for
depression, suicidal ideation
hydantoins (2)
antiseizure meds
phenytoin (Dilantin)
fosphenytoin (Cerebryx)
last ditch antipsychotic clozapine can cause
fatal agranulocytosis–freq monitoring of CBC
many other AEs
tricyclic AEs
anticholinergic AEs (block M1)
oHoTN (block alpha 1)
sedation (histaminergic)
weight gain
decreased libido
cardiac arrhythmia (block Na channels) –>
cardiotoxicity
enzyme that converts fibrinogen (loose, soft clot) to fibrin
thrombin
GLP-1 agonist-action and advantages/dis
mimic incretin GLP-1 (stimulates insulin and suppreses glucagon when glucose is high in GI tract)
Adv: no inc CV risk, and less risk of hoGly than SUs
Dis: injectible only; pancreatitis, endocrine tumor risk
propanolol mechanism and indications
nonselective (beta 1 and beta 2) blocker
HTN (poor for this)
arrhythmias, angina
migraine
stage fright/performance anxiety
increase insulin sensitivity in muscle and fat cells and liver by regulating gene expression
TZDs (Actos, Avandia)
many dangerous AEs: HF, liver, bladder ca
how to switch antidepressants
b/t SSRIs-just switch
one med class to another-taper first med over two weeks, then start low and taper next med up
some meds need washout period (MAOIs)
s/s serotonin syndrome
akathasia (movement disorders)
AMS
tremors, muscle hypertonicity
hyperthermia
Myasthnia gravis treatment med
AChEI
pyridostigmine
goal of Alzheimer’s treatment
to increase activity of ACh (opposite of Parkinson’s)
treated with cholinesterase inhibitors (rivastigmine, donepezil-CNS specific AChEI)
T/F norepi is cholinergic
FALSE
norepi does not affect the PNS
first line partial and absence seizures, fairly sage
lamotrigine (Lamictal)
bisphosponates AEs
GI, eso ulcers, pathological Fx
caution with renal, liver, heart disease, GI problems
benzodiazepine withdrawal s/s
anxiety, insomnia
—> convulsions, death
atypical antidepressant-SSRI and 5HT1 agonist (mimics serotonin)
vortioxetine (Trintellix)
SU lite
tissue selective secreation of insulin
take with meals, good at reducting postprandial BG
meglitinides (Prandin, Starlix)
**Do not give with an SU!
inducer for intrinsic and extrinsic pathways
intrinsic induced by blood vessel injury
extrinsic induced by tissue injury
with antiseizure meds you need to monitor drug levels, even without dosage changes, because
many use the CYP 450 pathway and can have increased plasma levels (inducers)
metoprolol mechanism and indications
selective beta 1 blocker
HTN
second line for anxiety
buspirone
no QTc prolongation–can use for cardiac pts when want to avoid SSRI
minimal abuse potential
1-2 weeks for effect
sulfonylureas-considerations (5)
- risk of hypoglycemia, esp with EtOH/illness
- fatigues beta cells over time
- assoc with inc CV disease and mortality
- Cross allergy with sulfa drugs (Bactrim, thiazides)
- teratogenic (not glyburide)
first line mood stabilizer in bipolar disorder
mechanism
lithium
pre synapse-enables more serotonin to be released
post synapse- enables cells to take up serotonin
apixaban (Eliquis)
direct Xa inhibitor; Better outcomes than warfarin, can renally dose, fast onset (hours); no antidote, $$, AEs unknown-new
two common and dangerous AEs of antiseizure meds
Cardiac effects and skin reactions
1st line therapy DM
mechanism
metformin (Glucophage)
inhibits glucose production by the liver, decreases absorption of glucose by GI tract, and increases insulin sensitivity
1st line med for partial and generalized seizures (block Na movement) but not myoclonic; 2 black box warnings, and what you must monitor (2)
carbamazepine (Tegretol)
- Serious Derm reactions (asians at inc risk–polymorphism)
- aplastic anemia
- CBC
- drug levels-CYP 450 inducer
preterm labor can be slowed bu use of this beta 2 agonist
terbutaline-relaxes smooth muscle in uteral, GI, bladder, and bronchioles
uterus has smooth muscle with Beta 2 receptors not no ACh receptors
AEs: tachycardia, anxiety
tolerance vs. dependence
tolerance-you need to take more of the drug to get the same effect
dependence–physiological state in which you need to take the drug to prevent withdrawal
levothyroxine directions/education
take with full glass of water at same time each day, preferably 1 hour before breakfast, 3 hrs after last meal
teach how to measure HR
don’t stop taking if feel better
serotonin syndrome results from
toxic increase in serotonin often caused by taking two meds that increase serotonin at the same time (ex SSRIs and MAOIs)
dopamine is used as adrenergic agonist-mechanism and used in treatment of
alpha and beta agonist
low BP:
hypovolemia
cardiogenic shock
failing to taper SSRIs when discontinuing can cause
“withdrawal” of flu-like and/or GI symptoms
Taper over 2 weeks
of the multiple AEs with hydantoins, these are the most concerning…(1)
and these should also be watched for…(3)
Cardiac (bradycardia, heart block)
skin rashes
gingival hyperplasia
CNS-nystagmus, cognitive slowing, lethargy
adjunct seizure and neuropathic pain med without risk of SI; blocks Ca++ in CNS and blocks glutamate release
pregabalin (Lyrica)
atypical antidepressants, no effect on serotonin
less weight gain and sexual AEs, no effect on serotonin
NDRIs
Wellbutrin
Zyban-smoking cessation
not good with comorbid anxiety
indirect cholinergic agonists
AChEIs
two cholinergic agonists used to treat glaucoma
pilocarpine (muscarinic agonist)
carbachol (nicotinic agonist)
urinary retention is treated with
cholinergics
bethanechol-relaxes urinary sphincter and causes bladder contraction
MAOIs
meds than inhibit MAO enzymes that break down neurotransmitters
Isoniazid
phenelzine (Nardil)
selegiline
rasagiline
irreversible ACh inhibition is caused by these toxins
Sarin
Malathion
causes muscle weakness –> respiratory depression –> death
how to beta one antagonists cause exercise intolerance ?
what other complication can they cause?
can’t inc HR and CO to meet demands
can also mask s/s of hypoglycemia–pt won’t know
third line anxiety med
benzodiazepines-mimic GABA
okay short term, avoid long term
can cause daytime sedation
high abuse potential
choose based on onset and duration of action
why use an SNRI instead of an SSRI
to treat more cognitive slowing and dec concentration
actually have a few more AEs than SSRIs
alpha-glucosidase inhibitors-action and considerations
inhibits enzyme that breaks down starches; minimizes postprandial BG
take with meal; do not use dissacharides for hypoglycemia, monitor liver function
three types of mood stabilizers
- lithium
- anticonvulsants
- antipsychotics
AE cholinergics and anticholinergics have in common
erectile disfunction
PNS causes erection (pleasure)
SNS causes ejaculation (survival)
if hyperlipidemia exists with hypothyroidism
treat thyroid first; dec thyroid activity will cause inc lipids
First line in all seizure types, thought to increase GABA effects
valproic acid
with an alpha 1 blocker like doxazosin, what education does the patient need?
rise from supine position slowly (compensatory mechanisms used in position change are inhibited)
first line for anxiety
antidepressants
(takes weeks for effect, can use benzo short term)
First line in partial and generalized seizures, blocks Na movement
hydantoins
first line for absence seizures, a little safer than valproic acid but still many AEs, ex. SLE
ethosuximide (Zarontin)
cholinergic crisis antidote
atropine
muscarinic antagonist
also used for bradycardia
how long to use antidpressents before you see effects
4-6 weeks
dobutamine-mechanism and indication
beta one agonist
cardiac stimulation in cardiogenic shock
advantages of LMW heparins (Fragmin, Lovenox) over unfractionated
more predictibe pharmokinetics, less monitoring needed, lower incidence of HIT
Monitor with renal/hepatic disease
doxazosin and silodosin- mechanism and indication
alpha one blockers-vasodilators
last ditch treatment for HTN
BPH-relaxes smooth muscles to decrease size of prostate
SGLT-2 Inhibitors-action
Pros and Cons
sodium glucose transport inhibitors (Invokana)
increase excretion of glucose in urine by inhibiting resorption
Better reduction in HgA1C than others
lower CV mortality, BP, low risk of HoGly
Cons: UTIs/pyelo, candida, need good renal function
antipsychotic AEs Summary (6)
- EPS, tardive dyskinesia can be permanent
- hyperprolactinemia (dec inh of prolactin) gynecomastia, galactorrhea, *osteoporosis
- Sexual dysfunction, priapism
- Cardiac arrhythmia, prol QTc–>torsades; sudden cardia death risk inc 2x
- Seizures-all lower threshold
- Metabolic syndrome-weight gain, bad glycemic control, hyperlipidemia
aspirin AEs
GI bleed/ulcer
bronchospasm
renal damage
reye’s syndrome
dangerous OD
2nd line seizures and commonly used for status epilepticus, febrile seizures
phenobarbital
donepezil and rivastigmine are used in AD treatment because
they are cholinergic (AChEIs)
increase ACh in brain which supports memory
affects are temporary and take six weeks for effect
albuterol mecahnism and indications
beta 2 agonist-cause bronchodilation in asthma, allergy
AE: tachycardia
MAOS Alzheimer’s adjunct
selegiline
also used for smoking cessation, ADHD
muscarinic antagonists have a similar effect as
beta agonists
anti-thyroid meds
block incorporation of iodine into hormone
methimazole, PTU
*do not miss dose, don’t make up if you do; teach hypothyroid symptoms, reduce dietary iodine
adrenergic agonists that are not broken down by MAOx, can be taken PO and are nonpolar-cross BBB
non-catecholamines
rivoraxaban (Xarelto)
action and considerations
direct factor Xa inhibitor-prevents conversion of prothrombin to thrombin
similar to warfarin in effects, less ICH
fast onset (2-4h) and can renally dose
no antidote, $$, unknown AEs-new
intrinsic and extrinsic pathways both lead to
activated factor X= Xa
converts prothrombin to thrombin
(the common pathway from then on)
use this in valvular AFib
warfarin
Do not use dabigatran (Pradaxa)
black box warning on many antidepressants
4% inc risk of SI <25 years old
Pt education-bisphosphonates
take with full glass of water in am
remain upright for 30 minutes after dose
good dietary Ca and Vit D
avoid use with antacids, EtOH
1st gen antipsychotics vs 2nd
mechanism of both and AEs
1st gen treats positive but not negative symptoms, 2nd treats both; less AEs with 2nd, varies
Block dopamine receptors–>cause extrapyrimidal side effects
parkisonian syndrome, tardive dyskinesia, neuroleptic malignant syndrome (can start any time during treatment)
mimic GABA
benzodiazepines
antiplatelet agents, can use with ASA in ACS and post MI but not preventative for stroke
clopidrogel (Plavix)
ticlodipine (Ticlid)
block platelet activation
warfarin-action and indications
antagonizes vitamin K
PO
prophylaxis/Tx of DVT, PE, Afib clot, post MI, hypercoagubility disorders
long term use of levothyroxine associated with
dec bone density in hip/spine in post-menopausal women–monitor
common AEs SSRIs
sexual dysfunction (dec libido)
weight gain
insomnia/sedation
GI effects
prolonged QTc
bladder spasms are due to overactive PNS activity so treat with
anticholinergics
adjunct antiseizure med often also commonly used for neuropathic pain; mimics GABA
gabapentin (Neurontin)–
works like a benzo without the addiction risk
AChEIs used to treat MG
edrophonium- short acting, used for Dx
neostigmine and physostigmine (also used for AD and delayed gastric emptying)
succinylcholine mechanism for skeletal muscle paralysis
anticholinergic
nicotinic antagonist
warfarin-considerations
highly protein bound
metabolized in liver using CYP450 pathway
many drug interactions (any broad spectrum abx can dec absorption)
AEs: bleeding; teratogenic; warfarin-induced skin necrosis
Food interations: inh by Vit K and EtOH
and herbal interactions
mechanism of action of ipratropium (Atrovent) and tiotropium (Spiriva)
anticholinergic muscarinic antagonists that block PNS bronchoconstriction
1st line for COPD
if you need cardiac stimulation with vasoconstriction, use …
if you don’t need vasoconstriction, use …
dopamine
dobutamine
considerations-metformin (3)
- decrease/hold in dehydration
- hold 48 hrs before and after radiocontrast
- discourage EtOH
…is the precursor of norepi
norepi is the precursor of …
dopamine
epinephrine
dangers
opiates vs. benzos
opiate withdrawal is not fatal, benzo withdrawal can be
easier to OK with opiates, need 2nd depressant to OK with benzos.
adrenergic agonists that are destroyed by MAO; can’t take PO, don’t cross BBB
catecholamines (epi and norepi)
anticholinergic used for bowel spasm treatment to relax smooth muscle and dec GI motility
dicyclomine
better than warfarin in prevention of CVAs with reduced risk of bleeding; pros and cons
direct thrombin inhibitors (pradaxa)
Pros: no lab monitoring, no drug/food interactions
Cons: no antidote, $$
atypical antidepressants given for sleep
mirtazapine (Remeron)
trazadone (Desryel)
prazosin, mechanism and indications
alpha one antagonist/blocker
antihypertensive
goal of Parkinson’s disease treatment
increase effect of dopamine
dopamine agonists (Ex Requip) + Levodopa/Carbidopa
cholinergic medications that inhibit ACh breakdown
Acetylcholinesterase inhibitors (AChEIs)
baseline labs before starting metformin and to monitor during use
CMP (renal and hepatic function)
HgA1C
INR management
therapeutic 2-3
<8 no significant bleeding: hold dose(s) until <5 then resume doses
>8 no bleeding; hold until <5, maybe hospitalize
Any inc INR with serious bleeding–>hospitalize
MAOI used for Parkinson’s treatment
rasagiline (Azilect)
this med (type/name) is used to constrict the pupil in glaucoma treatment
cholinergic
carbachol
do not use propanolol in patients with
asthma, COPD
nonselective–will block beta 2
phenylephrine-mechanism and indications
alpha one agonist–vasoconstrictor
decongestant and hypotension
heparin action
increase the action of antithrombin III up to 1000x
inc inh of Xa on factor II-dec formation of fibrin
benzodiazepine reversal agent
flumazenil
heparin indications and AEs
immediate anticoagulation in which quick reversal may be needed-DVT, PE, ACS, can be used in pregnancy
AEs: bleeding, HIT, osteoporosis long term high dose use
*requires regular monitoring of aPTT
why are beta blockers useful in patients post MI?
decrease myocardial oxygen consumption and cardiac workload
muscarinic antagonist used to treat parkinson’s dyskinesia
benztropine
what type of med is contraindicated in a patient with bowel obstruction
an anticholinergic medication like hyoscimine
