Pharmacology Exam 3

Question 1

Chapter 22 : Patients receiving lipid-lowering therapy : minimizing adverse effects

Answer 1

 Continue to monitor periodic liver function tests, and CPK levels
• Abnormal liver function tests and increased CPK levels may indicate drug-induced adverse hepatic effects or myopathy and should be reported
 Continue to assess for drug-related symptoms, which may indicate adverse effects are occurring
• Lipid-lowering drugs often adversely effect the liver but may also cause-drug specific adverse effects
 Assess for possibility of increased adverse effects when a combination of lipid-lowering agents are used
• Lipid-lowering agents may be combined for better effects but this increases the risk of adverse effects

Question 2

Prototype : Gemfibrozil (Lopid)

Class, Action& Use, Drug-Drug interaction, Herbal/Food/ administration alert !

Answer 2

 Antihyperlipidemic, Fibric acid agent
 Action :
• Effects include up to 50% reduction in VLDL with an increase in HDL
• Not the first drug of choice because it is less effective than statins in lowering LDL
 Drug-drug
• Concurrent use of gemfibrozil with oral anticoagulants may potentiate anticoagulant effects. Concurrent use with statins should be avoided because this increases risk of myopathy and rhabdomyolysis.
• Gemfibrozil may increase effects of certain antidiabetic agents, statins, sulfonylureas, and vitamin K antagonists.
 Herbal
• Fatty foods may decrease the efficacy of gemfibrozil
 Administration alert
• Administer with meals to reduce GI distress

Question 3

prototype : Cholistyramine (Questran) (Bile acid resin, antihyperlipidemic) Action&Uses

Answer 3

 Questran binds with bile acids (containing cholesterol) in an insoluble complex that is expected in the feces. Cholesterol levels decline due to fecal loss.
 Cholestyramine is a powder that is mixed with fluid before being taken once or twice daily. It is not absorbed or metabolized once it enters the intestine thus it does not produce any systemic effects.
 It may take 30 days or longer to produce maximum effects.

Question 4

prototype : Cholistyramine (Questran)

Lab tests

Answer 4

• AST, phosphorus, chloride, and alkaline phosphate (ALP) levels may increase
• Serum calcium, sodium, and potassium levels may decrease

Question 5

prototype : Cholistyramine (Questran)

Drug-drug interaction

Answer 5

• Cholestyramine can bind to other drugs such as digoxin, penicillins, thyroid hormone, and thiazide diuretics, and interfere with their absorption, it should NOT be taken at the same time as these other medications.
• Cholestyramine may increase the effects of anticoagulants by decreasing the levels of vitamin K in the body.

Question 6

prototype : Cholistyramine (Questran)

Herbal/food and admin. alert

Answer 6

• Taking cholestyramine with food may interfere with the absorption of essential nutrients: beta-carotene, calcium, folic acid, iron, magnesium, vitamin B₁₂ , vitamin D, vitamin E, vitamin K, and zinc.
• Manifestations of nutrient depletion may include weakened immune system, cardiovascular problems, and osteoporosis.
 Administration alert
• Give other drugs more than 2 hours before or 4 hours after the patient take cholestyramine

Question 7

o Prototype : Ranitidine (Zantac) H2 Receptor antagonist

10 bullets -_-

Answer 7

 Blocks H2 receptors in stomach = decreased acid production
 Adverse effects: decreased WBC’s, RBC’s, platelets, sexual side effects
 Lab: CBC, liver, renal function
• May increase serum levels of : AST, ALT, LDH, alkaline phosphatase, and bilirubin.
 May inhibit absorption of drugs/ substances requiring acid GI environment
 Rantidine may reduce absorption of cefpodoxime, ketoconazole, itraconazole
 Antacids should not be administered within 1 hour of H2 receptor antagonists
• Effectiveness may be decreased due to reduced absorption
 Smoking decreases effectiveness of rantidine
 Adequate healing of ulcer takes approx. 4-8 weeks
 Herbal/Food: absorption of vitamin B12 depends on acidic environment; thus, deficiency may occur. Iron is also better absorbed in an acidic environment

Question 8

Prototype drug : proton pump inhibitor Omeprazole (Prilosec)

Drug-drug interaction, Lab results, herbal/food

Answer 8

 Drug-drug interactions :
• Concurrent use with diazepam, phenytoin, and CNS depressants may cause increased blood levels of these drugs
• Concurrent use with warfarin may increase the likelihood of bleeding
• Alcohol can aggravate the stomach mucosa and decrease the effectiveness of Omeprazole
 LAB RESULTS that may increase :AST, ALT, alkaline phosphatase
 Herbal-food : st. wort’s decrease plasma level of omeprazole

Question 9

Prototype drug : proton pump inhibitor Omeprazole (Prilosec)

action & duration of therapy

Answer 9

 It reduces acid secretion in the stomach by binding irreversibly to the enzyme H+, K+-ATPase
 Prevent movement of H2 out of parietal cell
 Longer duration than H2 blockers, more effective
 Used short-term (4-8 weeks)

Question 10

adverse effects for proton pump inhibitors !

 Proton pump inhibitors (omeprazole, lansoprazole, etc. zole*)

Answer 10

 Serious adverse effects are rare

 Headache, diarrhea, nausea, rash, dizziness are side effects

Question 11

o Cimetidine (Tagamet) : adverse effects and class

Answer 11

 H2 receptor antagonist
 Adverse effects
 Rare : hepatitis, blood dyscrasias, anaphylaxis, dysrhythmias, skin reactions, galactorrhea, confusion, psychoses

Question 12

o Prototype : Antacid : Aluminum hydroxide (alternaGEL, others)
Action & uses , drug-drug interaction

Answer 12

• Inorganic agents used alone or in combo with other antacids
• In combo with magnesium increase the effectiveness
• Aluminum compounds are minimally absorbed
• Primary action is to neutralize stomach acid by raising pH of the stomach contents
• Aluminum antacids do not reduce the volume of acid secretion
 Drug drug interaction
• Should not be administered with other medications, as they may interfere with their absorption.
• Use with sodium polystyrene sulfonate may cause systemic alkalosis

Question 13

Prototype : Antacid : Aluminum hydroxide (alternaGEL, others) Herbal/food, lab tests, and adverse effects / side effects

Answer 13

 Lab tests
• Values for serum gastrin and urinary pH may increase
• Serum phosphate values may DECREASE
 Hearbal/food
• May inhibit the absorption of dietary iron
 2 hours before or after medication to be administered because absorption could be affected
 Adverse effects:
• Fecal impaction, hypophosphatemia
• Side effects : constipation , nausea, stomach cramps

Question 14

o	Sucralfate(Carafate) Cytoprotective agents
Action

Answer 14

 This drug produces a thick, gel-like substance that coats the ulcer, protecting it against further erosion and promoting healing

Question 15

o	Misoprstol (Cytotec)
What it causes, inhibits, and prevents

Answer 15

 Inhibits gastric acid secretion and stimulates the production of protective mucus
 Causes uterine contractions : pregnancy Cat. C
 Prevents ulcers when taking antiprostaglandins (NSAIDS, ASA, glucocorticoids)

Question 16

questions to ask for PUD and assessment ?

Answer 16

 If you have pain after eating food, gastric
 If you have pain, and goes away after eating, duodenal
 Assessment ? Tarry stool : upper GI Bleeding
• Lower GI bleeding : reddish stool, bloody stool

Question 17

o Prototype drug : psyllium mucilloid (Metamucil) adverse effect, class, action, administration alert

Answer 17

 Bulk forming laxative
 Esophageal or GI obstruction if taken with insufficient fluid
 Action : Bulk forming laxative
• When taken with a sufficient quantity of water, psyllium swells and increases the size of fecal mass
• The larger the size of fecal mass, the more defecation reflex will be stimulated, thus promoting the passage of stool
 Administration alerts :
• Mix with at least 8 oz of water, fruit juice, or milk, and administer immedaitley. Follow each dose with an additional 8 oz of fluid

Question 18

 Saline and osmotic drugs (Milk of magnesia, Miralax, Fleet phospho-soda)
Adverse effects

Answer 18

• Hypermagnesemia with magnesium hydroxide (dysrhythmias, respiratory failure

Question 19

 Stimulant (correctol, dulcolax, emulsoil, neoloid, purge)

Adverse effects

Answer 19

• Fluid and electrolyte loss

Question 20

 Stool softeners, surfactant (docusate (Colace)

adverse effects

Answer 20

• No serious adverse effects

* Abdominal cramping , diarrhea

Question 21

 Herbal agent (Ex-lax, senokot)

Adverse effects

Answer 21

• No serious adverse effects

* Abdominal cramping, diarrhea

Question 22

 Misc. agents (amitiza, mineral oil)

Adverse effects

Answer 22

• Nutritional deficiencies, aspiration pneumonia

Question 23

o Nursing implications in power point

Answer 23

Assess EACH PATIENT EACH DAY re: bowel movements
 Use non-pharmacological approaches first (be able to list some), establish bowel patterns
 DON’T wait until constipation is severe to intervene
 Use most gentle laxatives first
 Avoid laxative dependence
 Must re-establish a “fecal column” to have BM

Question 24

o What is diarrhea ?

Answer 24

	Abnormal frequency and fluid
	Symptoms: Cramping, urgency
	Dehydration ( Fluid volume deficit)
	Loss of Na, K, Bicarbonate
	Colon fails to reabsorb enough water
	Increase in peristalsis

Question 25

o Antidiarrheals, Opiods

5 different class : what they do ?

Answer 25

	Adsorbents  -  COAT WALLS
	Anticholinergics -  REDUCE PERISTALSIS
	Intestinal flora modifiers – RESTORE FLORA
	Opiates  -  REDUCE PERISTALSIS & PAIN
	Other: Psyllium – absorbs fluid

Question 26

 Diphenoxylate with atropine (Lomotil ) Opioid antidiarrheals
Adverse effects

Answer 26

• Paralytic illeus with toxic megacolon, respiratory depression, CNS depression

Question 27

 Bismuth salts (Pepto-Bismol)

adverse effects

Answer 27

• Changes in serum glucose, gallstones, cholestatic hepatitis

Question 28

Prototype drug : diphenoxylate with atropine

drug-drug interaction , action, lab tests ?

Answer 28

 Drug-drug interaction
• Interacts with other CNS depressants including alcohol, to produce additive sedation. When taken with MAO inhibitors, diphenoxylate may cause hypertensive crisis
 LAB TESTS: may increase serum amylase
 Action :
• Slows peristalsis, allowing time for additional water reabsorption from the colon and more solid stools
• Acts within 45-60 minutes

Question 29

o	Anticholinergics (in power point)  Belladonna-alkaloid  (Donnatal)
Side effect ? what drug is associated , action

Answer 29

 Slow GI motility (use for spasms)
 Atropine
 Side effect - urinary retention, hypotension
 Ingredient in diphenoxylate with atropine (Lomotil)

Question 30

Prototype drug : sulfasalzine (Azulfidine)
 Drugs for inflammatory bowel disease, 5-aminosalycitate, sulfonamide
drug-drug interaction, action &uses, herbal/food

Answer 30

 Drug-drug Interaction
• May worsen bone marrow suppression caused by methotrexate and also results in additive hepatoxicity
• Absorption of digoxin may be decreased
• Can displace warfarin from its protein binding site causing increased anticoagulant effects
 Action
• Used to treat mild to moderate sumptoms of ulcerative colitis
• Used off-label to treat Crohn’s disease
• Inhibits mediators of inflammation in the colon such as prostaglandins and leuotrienes
• Colon bacteria metabolize sulfasalazine to active metabolites
 Herbal /food
• Sulfasalazine may decrease the absorption of iron and folic acid

Question 31

Treatment of IBS

Answer 31

	Supportive, symptomatic treatment
	Bulk laxatives 
	Psyllium 
	Anticholinergic medications
	Reduce bowel spasms
	Dicyclomine (Bentyl)

Question 32

o Tegaserod
Serotonin agonist :
action/what it causes
adverse effects ?

Answer 32

 Serotonin agonist: stimulates peristaltic reflex
 One of few drugs approved for IBS with constipation
 causes increase stool formation and number of bowel movements
 Adverse effects:
• diarrhea, which usually occurs as single episode
 Resolves as therapy progresses

Question 33

o Prototype drug : Antiemetics, Phenothiazines
 Raglan, phenazine, trilafon, compazine, phenergan
 Prototype drug : prochloperazine (Compazine)
adverse effects ?
what it inhibits, mec. of action, primary use ?

Answer 33

 Mechanism of action: blocks dopamine receptors in brain
 Inhibits signals to vomiting center in medulla
 Primary use: for severe nausea and vomiting
 Adverse effects
• Extrapyramidal symptoms, neuroleptic malignant syndrome, agranulocytosis
 Side effects : dry mouth, constipation, sedation, orthostatic hypotension, tachycardia

Question 34

Prototype drug : prochloperazine (Compazine)

drug-drug interaction

Answer 34

• Interacts with alcohol and other CNS depressants to cause additive sedation
• Antacids and antidiarrheals inhibit the absorption of prochlorperazine
• When taken with Phenobarbital, metabolism of prochlorperazine is increased
• Use with tricyclic antidepressants may produce increased anticholinergic and hypotensive effects

Question 35

 Benzodiazepine (Prototype) lorazepam (Ativan)

adverse effects ?

Answer 35

• Paradoxical excitation (more common in children), seizures, (if abruptly discontinued, coma)

Question 36

: prototype drug : sibutramine (Meridia)
 Anorexiant, SSRI, antiobesity agent, appetite suppressant
drug-drug interaction, action & use, administration alert

Answer 36

 Drug – drug interaction
• Use with decongestants, cough, and allergy medications may cause elevated blood pressure
• Ketoconazole and erythromycin may inhibit the metabolism of subutramine
• Concurrent use with a MAOI or SSRI may cause serotonin syndrome
 Action and use
• Only approved treatment for obesity when combined with a reduced-calorie diet and increased physical activity
• Able to produce 5%-10% loss of body weight within 6-12 months of treatment
 Administration alert
• Allow at least two weeks between discontinuing MAOIs and starting sibutramine
• This drug is not approved for use in patient under age 16

Question 37

: prototype drug: pancrelipase (Cotazym, Pancrease)
 Pancreatic enzyme
Lab tests, action & use

Answer 37

 Lab tests
• May increase serum or urinary levels of uric acid
 Action & Use
• Used as a replacement therapy for patients with insufficient pancreatic, exocrine, secretions, including those with pancreatitis and cystic fibrosis
• contains lipase, protease, and amylase of pork origin
• Facilitate conversion of lipids into glycerol and fatty acids
• Convert starches into dextrin and sugars
• Convert proteins into peptides

Question 38

Normal values : total cholesterol, LDL, HDL , etc

Answer 38

• Total cholesterol : 60 md/dL

* Triglycerides : <150 md/dL

Question 39

 Atorvastin (Lipitor)
Class : HMG-CoA reductase inhibitor (any drug with –statin)
adverse effect ?

Answer 39

o Rhabdomylosis, severe myositis

Question 40

 Class : Bile Acid binding agents
 Cholestyramine (Questran)
Adverse effects?

Answer 40

o GI tract obstruction, vitamin deficiencies due to absorption

Question 41

 Class : Fibric acid agents
 Gemfibrozil (Lopid)
Adverse effects?

Answer 41

o Cholelithiasis, pancreatitis

Question 42

 Class : Other agents
 Niacin (Niac, Nicobid, others)
Adverse effects

Answer 42

o Dysrhythmias

Question 43

o Prototype drug : Atorvastatin (Lipitor)
 Antihyperlipidemic , HMG-CoA reductase inhibitor, statin
Action & use

Answer 43

• Primary indication for Lipitor is hypercholesterolemia
• Acts by inhibiting HMG-CoA reductase
• As the liver makes less cholesterol, it responds by making more LDL receptors on surface of liver cells
• The greater the number of LDL receptors in liver results in increased removal of LDL from the blood thus reducing blood levels of LDL and cholesterol
• 2 weeks of therapy is required before these effects are realized
• The patient on atorvastatin should be placed on cholesterol-lowering diet to enhance therapeutic effects
• Primary goal of atorvastatin is to reduce risk of stroke and MI.

Question 44

o Prototype drug : Atorvastatin (Lipitor)
 Antihyperlipidemic , HMG-CoA reductase inhibitor, statin
Herbal/food

Answer 44

• Grapefruit juice inhibits metabolism of statins, allowing them to reach toxic levels.
• Red yeast rice contains small amounts of natural statins and may increase the effects of atorvastatin.
• Statins also decrease synthesis of coenzyme Q10 (CoQ10), patients may benefit from CoQ10 supplements
o Manifestations of CoQ10 deficiency include high BP, CHF, and low energy

Question 45

Prototype drug : Atorvastatin (Lipitor)
 Antihyperlipidemic , HMG-CoA reductase inhibitor, statin
drug-drug interaction, administration alert

Answer 45

• Atorvastatin may increase digoxin levels by 20% as well as increase levels of norethindrone and ethinyl estradiol (oral contraceptives)
• Erythromycin may increase atorvastatin levels 40%
• Risk of rhadomylosis increases with concurrent administration of atorvastatin with macrolide antibiotics, cyclosporine, azole antifungals, and niacin.
• Ethanol should be avoided during therapy because of its effects of hepatic function
 Administration alert
• Administer with food to decrease GI discomfort
• May be taken at any time of day