Pharmacology Final

Question 1

Minimum effective concentration

Answer 1

The minimum amount of drug required for drug effect.

Question 2

Nitrites

Answer 2

The first agents used to relieve angina.

Question 3

Finasteride

Answer 3

Used to treat BPH only in men without large postvoid residuals. Inhibits conversion of testosterone to DHT. Can treat male pattern baldness. Results require continued tx-reversal of effects within one year if discontinued. Follow the aptient every 1-3 months. Avoid drugs that can cause urinary retention such as anticholinergics, antihistamines, and decongestants. Women of childbearing age must not handle crushed or broken tablets due to possible absorption and risk to male fetuses.

Question 4

Drug Development

Answer 4

Drug discovery and manufacturing takes 10-12 years with a cost of more than $1 billion for each drug. Out of every 5000 to 10000 compounds that begin preclinical testing only one makes it through the FDA approval process.

Question 5

Drug Inclusion and Exclusion

Answer 5

Inclusion: persons between ages 18 and 65, 50-100 kg, stable dose of cardiac medications, and no-added-salt diet
Exclusion: pregnant/nursing, childbearing age, symptomatic cardiac disease, hepatic dysfunction, chronic kidney disease, neurologic disorders, musculoskeletal disorders. Persons with clinically significant abnormal laboratory values.

Question 6

Drug discover and development

Answer 6

Drug target - basic research, preclinical and animal assays, clinical development-phase 1 - 20-100 healthy volunteers, phase 2 100-300 patients - safety and efficacy - dose optimization, phase 3 - 1000-5000 patients-large scale studies-efficacy and side effects

Question 7

Pharmcokinetics

Answer 7

The process of drug movement throughout the body necessary to achieve drug action

Question 8

Pharmcodynamics

Answer 8

Mechanisms of action and effects of a drug on the body; includes onset, peak, and duration of effect on a drug

Question 9

Bioavailability

Answer 9

The percentage of administered drug available for activity

Question 10

Therapeutic index

Answer 10

The relationship between the therapeutic dose of a drug and the toxic dose of a drug

Question 11

Albuterol

Answer 11

High doses or overuse of beta 2 adrenergic agonists can cause some degree of beta 1 response such as nervousness, tremor, and increased pulse rate. Albuterol is one that has a rapid onset of action, longer duration and of action, and few side effects. Treatment of asthma with side effects such as ataxia, headache, nasopharyngitis, insomnia, weakness, dry mouth, nausea, diarrhea, edema, urinary retentions, muscle cramps, hyperhidrosis. Hyperglycemia, hypokalemia, infection, chest pain, dyspnea.

Question 12

Pediatric Drug Considerations

Answer 12

Family centered care, developmental and cognitive differences. Lack of maturation in GI tract in infancy. Gastric pH is alkaline at birth-favors alkaline drugs. Gastric emptying and GI motility are unpredictable in neonates and infants until 6-8 months of age. Reduced surface area of intestines. Increased amount of water which results in lower drug concentration. Decreased protein and fewer receptor sites.

Question 13

Geriatric Drug Considerations

Answer 13

Reduced total body water, lean body mass, reduction in kidney and liver mass, decline in physiologic processes. Adherence, polypharmacy.

Question 14

Hydrochlorathiazide

Answer 14

Thiazides are used to treat hypertension adn peripheral edema. Do not use if the patient has renal disorders. Promote loss of sodum, potassium, and magnesium. Hypercalcemia may result. Hyperglycemia can also occur. Hyperuricemia. Hyperlipidemia. Dizziness, headache, nausea, vomiting, constipation, and blood dyscrasias. Hypokalmiea which enhances the action of digoxin-toxicity include bradycardian, nausea, vomiting, and visual changes. Enhances the action of lithium.

Question 15

Insulin

Answer 15

Used to control type 1 diabetes mellitus to lower blood glucose and promotes use of glucose by body cells. Lispro 15-30 mins, peak: 30-90 mins, duration 3-5 hours, regular- onset 30 mins, peak: 1.5-3.5 hours, duration 4-12 hours, NPH: onset-1.5 h, peak 4-12 h, duration: 14-24 h, Glargice: onset: 1-1.5 h, peak: none, duration 24 h+

Question 16

Digoxin

Answer 16

Inhibits sodium ATPase, promoting increased force of contraciton, cardiac output, and tissue perfusion, decreases ventricular rate. Side effects: anorexia, nausea, vomiting, abdominal pain, headachea, blurred or yellow vision, dizziness, weakness, confusion, visual impairment, depression, anxiety. Bradycardia, bowel necrosis, palpitations, dysrhythmias, thrombocytopenia.

Question 17

Alpha blockers

Answer 17

Vasodilator, decreased blood pressure. Treat hypertension in patients with lipid abnormalities. Do not affect glucose metabolism. Ex: phenoxybenzamine and phentolamine. Selective: prazosin, terazosin, doxazosin - used to treat BPH. Side effects: dizzinesss, fainteness, lightheadedness, and increased heart rate with first dose, nausea, headache, drowsiness, nasal congestion caused by vasodilation, edema, and weight gain. Reflex tachycardia with phentolamine- decrease in BP, nasal congestion caused by vasodilation and GI distrubance.

Question 18

Atropine

Answer 18

Anticholinergic. Preoperative medication to reduce salivation, increase heart rate for bradycardia, neuromuscular blockade reversal, cholinergic crisis and dilate pupils for ocular diagnostic examinations. Inhibits acetylcholine by occupying the receptors; increased heart rate by blocking vagus stimulation; promotes pupil dilation by blocking iris sphincter muscle. Side effects: drowsiness, dizziness, nausea, dry mouth, headache, confusion, insomnia, amnesia, constipation, flushing, hypohydrosis, blurred vision, mydriasis, anxiety, photophobia, palpitations, urinary retention, hyperreflexia, ataxia, weakness, dehydration, injection site reaction. Tachycardia, paradoxical bradycardia, hypertension, hypotension, angina, dyspnea, pulmonary edema, respiratory depression, ileus, seizures, dysrhthmia, laryngospasm, coma.

Question 19

Benztropine

Answer 19

Anticholinergic. To decrease involuntary symptoms of parkinsonism or drug-induced parkinsonism. Blocks cholinergic receptors, thus decreasing acetylcholine to reduce excess cholinergic activity, also blocks dopamine reuptake to prolong dopamine effects and decrease involuntary movement. SE: nausea, vomiting, dry mouth, constipation, anhidrosis, dizziness, headache, drowsiness, blurred vision, confusion, depression, hallucination, weakness, hyperthermia, and paresthesia, mydriasis, urinary retention.

Question 20

Bethanechol

Answer 20

Cholinergic. To treat urinary retention and neurogenic bladder. Stimulates the cholinergic (muscarinic) receptors; promotes contraction of the bladder; increases GI secretions and peristalsis, pupillary constriction, and bronchoconstriction. SE: nausea, vomiting, diarrhea, abdominal cramps, hypersalivation, diaphoresis, headache, dizziness, flushing, urinary urgency and frequency, weakness, miosis, lacrimation. Tachycardia and hypotension. Bronchospasm, wheezing, and seizures.

Question 21

Metoclopramide

Answer 21

Suppresses emesis by blocking the dopamine receptors in the CTZ. It is used in the treatment of postoperative emesis, cancer chemotherapy, and radiation therapy. High doses can cause sedation and fatigue. With this agent, the occurrence of extrapyramidal symptoms is more prevalent in children than in adults. Metoclopramide should not be given if the patient has GI obstruction, hemorrhage, or perforation.

Question 22

Neostigmine (short acting)

Answer 22

Acetylchoinesterase inhibitor. Used for treatment of myasthenia gravis and for neuromuscular blockade reversal and the diagnsosis of MG. May cause dizziness, headache, nausea, vomiting, bradycardia, hypotension, tachycardia, muscle cramps, seizures, and dyspnea.

Question 23

Edrophonium (short acting for diagnosis purposes)

Answer 23

Cholinesterase inhibitors. Neuromuscular blockade reversal and to diagnose myasthenia gravis. Monitor pulse, respiratory rate, BP, neurologica static, and ECG. May cause diplopia, hypersalivation, dysphonia, dysphagia, dysarthria, diaphoresis, bradycardia, hypotension, respiratory depression, and seizures.

Question 24

MAOIs

Answer 24

The enzyme monoamine oxidase inactivates norepinephrine, dopamine, epinephrine, and serotonin. By inhibiting MAO the levels rise. Inactivates dopamine in the brian. Tranylcypromae sulfate, isocarboxazid, selegiline HCl, and phenelzine sulfate. Used for depression. Hypertensive crisis can occur with CNS stimulants, sympathomimetics, vasocontrictors, cold medications, phenylephrine, psudoephedrine, tyrame: aged cheese, cream, yogurt, coffee, chocolate, bananas, raisins, italian green beans, liver, pickled foods, sausage, soy sauce, yeast, beer, and red wines. Monitor BP. SE: insomnia, orthostatic hypotension, and anticholinergic effects.

Question 25

MAOIs

Answer 25

The enzyme monoamine oxidase inactivates norepinephrine, dopamine, epinephrine, and serotonin. By inhibiting MAO the levels rise. Inactivates dopamine in the brian. Tranylcypromae sulfate, isocarboxazid, selegiline HCl, and phenelzine sulfate. Used for depression. Hypertensive crisis can occur with CNS stimulants, sympathomimetics, vasocontrictors, cold medications, phenylephrine, psudoephedrine, tyramine: aged cheese, cream, yogurt, coffee, chocolate, bananas, raisins, italian green beans, liver, pickled foods, sausage, soy sauce, yeast, beer, and red wines. Monitor BP. SE: insomnia, orthostatic hypotension, and anticholinergic effects.

Question 26

Aspirin

Answer 26

Salicylate. Prostaglandin inhibitor that decreases the inflammatory process. Blood clotting is decreased. Side effects: anorexia, dyspepsia, nausea, vomiting, diarrhea, constipation, abdominal pain, heartburn, and flatulence. Reye syndrome, Steven’s Johnson syndrome, blood dycrasias.

Question 27

Cephalosporins

Answer 27

Beta-lactam structure and act by inhibiting the bacterial enzyme necessary for cell-wall synthesis. A major antibiotic group used in hospitals and in health care offices. Effective against most gram-positive and some gram-negative bacteria. Examples: cefadroxil, cefaclor, cefixime, cefepime, ceftolozane and toazobactam.

Question 28

Alpha Agonist

Answer 28

Decrease the sympathetic response from the brainstem in the peripheral vessels. They stimulate the alpha receptors which in turn decreases sympathetic activity; increases vagus activity; decreases cardiac output; and decreases serum epinephrine, norepinephrine, and renin release. Methyldopa, clonidine, and guanfacine. Can cause sodium and water retention-administered with diuretics. Drowsiness, dry mouth, dizziness, and slow heart rate. Do not use with impaired liver function. Restlessness, tachycardia, tremors, headache, and increased BP.

Question 29

Celecoxib

Answer 29

COX-2 inhibitor

Question 30

Tetracyclines

Answer 30

First antibiotic effective against gram-positive and gram-negative bacteria. Inhibit bacterial protein synthesis and have a bacteriostatic effect. Treat H.pylori and acne. Take on an empty stomach 1 hour before or 2 hours after mealtime. Side effects: GI disturbances, photosensitivity, do not take during pregnancy, do not take if younger than 8 years of age - irreversibly discolors the permanent teeth. Minocycline can cause damage to the vestivular part of the inner ear, which may result in difficulty maintaining balance. Nephrotoxic when given in high doses. Superinfection. T

Question 31

TB treatment

Answer 31

Isoniazid is used to treat active tuberculosis and as a prophylactic measure against tuberculosis. SE: drowsiness, tremors, rash, blurred vision, photosensitivity, tinnitus, dizziness, nausea, vomiting, dry mouth, constipation, diarrhea with oral solution, injection site reaction. Blood dyscrasias. Pyridoxine may be prescriped to avoid vitamin B deficiency and to minimize peripheral neuropathy. Treatment lasts 6-9 months and can include rifampin, ethambutol, and pyrazinamide in combination to reduce the bacterial resistance. Hepatotoxicity! Hyperglycemia, ocular toxicity, hyperkalemia, hypophophatemia, hypocalcemia. Rifampin turns body fluids orange and soft contact lenses may be permanently discolored.

Question 32

Streptomycin

Answer 32

Antitubercular - aminoglycoside - ototoxic, hepatotoxic, and nephrotoxic. Test renal and liver failure. Baseline hearing assessment. Within 2-3 months of tx you want a negative sputum culture. TB can be passed to the fetus.

Question 33

Epinephrine

Answer 33

To treat nasal congestion, allergic reactions, anaphylaxis, asthma exacerbation, bronchospasm, angioedema, status asthmaticus, cardiac arrest. Acts on alpha nad beta receptors; promotion of CNS and cardiac stimulation and bronchodilation; strengthens cardiac contraciton, increases cardiac rate and cardiac output; reduces mucosal congestion by inhibiting histamine release, reverses anaphylactic reactions. NOT GIVEN ORALLY. Increases renal vasoconstriction, decreasing renal perfusion and urinary output. SE: hypertension, tachycardia, palpitations, restlessness, tremors, dysrhthmia, dizziness, urinary retention, nausea, vomiting, dyspnea, and pulmonary edema.

Question 34

Tiotropium

Answer 34

Anticholinergic drug used for maintenance treatment of bronchospasms associated with COPD. This drug is administered by inhalation only with the HandiHaler. Adverse effects: dry mouth, constipation, vomiting, dyspepsia, abdominal pain, depression, insomnia, headache, joint pain, and peripheral edema. Caution with use in those with narrow-angle glaucoma, bladder neck obstruction, renal impairment, cardiac dysrhythmias, breastfeeding, and older adults.

Question 35

Verapamil

Answer 35

Calcium channel blocker used to treat chronic hypertension, angina pectoris, and cardiac dysrhythmias. Act on the arterioles and the heart. Can cause dizziness, headache, confusion, fatigue, orthostatic hypotension, blurred vision, peripheral edema, erectile dysfunction, nausea, and constipation.

Question 36

Spirinolactone

Answer 36

Potassium sparing diuretics-weaker than other diuretics. Inhibits aldosterone effects on the distal renal tubules to promote sodium and water excretion and potassium retention. Can cause n/v/d, abdominal cramps, dizziness, headache, confusion, weakness, muscle spasms, paresthesia, dehydration, ataxia, erectile dysfunction. Hyperkalemia, hypomagnesemia, hyponatremia, hypocalcemia, hypovolemia, hyperglycemia, hyperuricemia, orthostatic hypotension, bradycardia, metabolic acidosis/alkalosis. The heart rate is more regular, and the possibility of myocardial fibrosis is decreased. Do not take with ARBs or ACE inhibitors because they will increase serum potassium levels. Pair with hydrochlorothiazide or a loop diuretic.

Question 37

Psyllium

Answer 37

Bulk forming laxative draws water into the intestine. Defecation takes 8-24 hours and may take up to 3 days. Insufficient fluid intake can cause the drug to solidify in the GI tract, which can result in intestinal obstruction. This group of laxatives does not cause dependence. Can cause anorexia, nausea, vomiting, abdominal cramps, flatulence, diarrhea.

Question 38

Peptic Ulcer Treatment

Answer 38

H2 blocker: cimetidine, famotidine, and nizatidine. Side effects and adverse reaction include headache, agitation, dizziness, nausea, vomiting, constipation, or diarrhea, pruritus, skin rash, vitamin B12 deficiency, erectile dysfunction, and blood dyscrasias.

PPI: Omeprazole-effective against suppressing gastric acid secretions. Can enhace digoxin, oral anticoagulants, benzodiazepines, and phenytoin because they interfere with liver metabolism.

Pepsin inhibitors: sucralfate - mucosal protective drug combines with protein to form a viscous substance that covers the ulcer and prtects it from acid and pepsin.

Misoprostol - prostaglandin analogue - used to prevent and treat peptic ulcer. Suppress gastric acid secretion and increase cytoprotective mucus in the GI tract. Gastric distress from NSAIDs such as aspirin or indomethacin can benefit.

Antacid- neutralize HCl and reduce pepsin activity. Magnesium can cause diarrhea and aluminum and calcium cause constipation. Sithethicone - an antigas agent is found in many antacids.

Two antibiotics, a PPI, and a bismuth or histamine blocker is recommended.

Question 39

Famotidine

Answer 39

H2 blocker: cimetidine, famotidine, and nizatidine. Side effects and adverse reaction include headache, agitation, dizziness, nausea, vomiting, constipation, or diarrhea, pruritus, skin rash, vitamin B12 deficiency, erectile dysfunction, and blood dyscrasias. Enhances the effects of oral anticoagulants, theophylline, caffeine, phenytoin, diazepam, propranolol, phenobarbial, and CCB. Do not take with iron.

Question 40

Lansoprazole

Answer 40

PPI: Omeprazole-effective against suppressing gastric acid secretions. Can enhace digoxin, oral anticoagulants, benzodiazepines, and phenytoin because they interfere with liver metabolism. Take before meals. Caution in hepatic impairment, monitor liver enzymes. Side effects include headache, dizziness, diarrhea, or constipation, abdominal pain, vitamin B12 deficiency, and hypomagnesemia.

Question 41

Glucocorticoids

Answer 41

Natural cortisol produced by the body and are influenced by ACTH. Cortisone drugs - used to treat inflammatory, allergic, and autoimmune disorders like rheumatoid arthritis, myasthenia gravis, etc. Pred

Question 42

Glucocorticoids

Answer 42

Natural cortisol produced by the body and are influenced by ACTH. Cortisone drugs - used to treat inflammatory, allergic, and autoimmune disorders like rheumatoid arthritis, myasthenia gravis, etc. Prednisone.
SE: prologned use include increased BGL, cushing’s, sodium and water retention, hypertension, euphora, increased intraocular pressure, peptic ulcers, and growth retardation. Should be tapered. Increase effect of NSAIDS and hypokalemia with diuretics. Barbiturates, phenytoin, and rifampin decrease the effects.

Question 43

Bethanechol chloride

Answer 43

Parasympathomimetic, stimulates the cholinergic receptors, promotes contraction of the bladder, increases GI secretions and peristalsis, pupillary constriction, and bronchoconstriction. Treats urinary retention and neurogenic bladder. Side effects: n/v/d, abdominal cramps, hypersalivation, diaphoresis, headache, dizziness, flushing, urinary urgency and frequency, weakness, miosis, and lacrimation.

Question 44

Tolterodine tartrate

Answer 44

Decrease urinary frequency, urgency, and incontinence. Anticholinergic. SE: drowsiness, dizziness, dry mouth, eyes, and skin; headache, blurred vision, confusion, diarrhea, abdominal pain, constipation, dyspepsia, dysuria, fatigue, weight gain, arthralgia, hallucinations, and urinary retention. Can cause tachycardia, chest pain, angioedema.

Question 45

Phenazopyridine HCl

Answer 45

An azo dye and dimethyl sulfoxide are urinary analgesics that are used to relieve the urinary pain, burning, sensation, frequency, and urgency of urination that are symptomatic of cystitis. Can cause hemolytic anemia, renal and hepatic dysfunction. Urine may become reddish orange because of the dye and can alter the glucose urine test. Use blood test to monitor glucose levels.

Question 46

Protein binding

Thiazide diuretics

Answer 46

Hydrochlorothiazide has moderate protein-binding power.

Question 47

Parenteral drugs

Answer 47

Administered via injection. Intradermal, subcutaneous, intramuscular, z-track technique, and intravenous.

Question 48

Enteral drugs

Answer 48

Most drugs are administered orally. Oral drugs are available in caplet, capsule, powder, and liquid forms. Oral medications are absorbed by the GI tract, mainly from the small intestine. The patient can take oral meds without assistance and the cost of oral medications is usually less than that of parenteral preparations and medications are easy to store. Disadvantages include variation in absorption because of food in the GI tract and pH variations of GI secretions, irritation of the gastric mucosa by certain drugs and destruction or partial inactivation of drugs be liver enzymes.

Question 49

Controlled substances

Answer 49

1 - substances in this schedule have no currently accepted medical use in the US, a lack of accepted safety for use under medical supervision, and a high potential for abuse.

2- Substances in this schedule have a high potential for abuse that may lead to severe psychological or physical dependence.

3. substances in this schedule have a potential for abuse less than subastances in schedule 1 or 2, and abuse may lead to moderate or low physical dependence or high psychological dependence.

4-Substances in this schedule have a low potential for abuse relative to substances in schedule 3.

5-substances in this schedule have a low potential for abuse relative to substances listed in schedule 4 and consist primarily of preparations containing limited quantities of certain narcotics.

Question 50

Opioids

Answer 50

Codeine, dephenoxylate with atropine slows gastric motility, difenoxin, loperamide, morphine, codeine. Prescribed for moderate to severe pain. High abuse potential. Work on the mu receptors but also exert a weak activation of the kappa receptors. Suppress respiration and coughing. Meperidine - does not have a cough suppression effect. Side effects: nausea, vomiting, constipation, moderate decrease in BP, and orthostatic hypotension. Miosis, weakness flushing, euphoria, peripheral edema, paresthesia, diaphoresis, pruritis, infection, back pain, insomnia, dry mouth.

Question 51

Gabapentin

Answer 51

Promotes GABA release. For partial seizures, restless leg syndrome, and neuropathic pain. May cause dizziness, drowsiness, headache, nystagmus, vision impairment, fatigue, peripheral edema, tremor, ataxia, weakness, hostility, nausea, vomiting, and diarrhea.

Question 52

Acetaminophen

Answer 52

Inhibition of prostaglandin synthesis, inhibition of hypothalamic heat-regulator center. Side effect: headache, insomnia, anxiety, fatigue, anorexia, nausea, vomiting, constipation, peripheral edema. Life threatening: hepatotoxicity, renal failure, hypokalemia, anemia, blood dyscrasias. Max dose of 4 g and 2 g if taken frequently. Therapeutic range is 10-20. Monitor hepatic enzyme levels. Acetylcysteine is the antidote.

Question 53

Phenobarbital

Answer 53

A long-acting barbiturate is prescribed to treat tonic-clonic, partial, and myoclonic seizures and status epilepticus. Reduce seizures by enhancing GABA. Therapeutic range is 15-40. Sedation tolerance to the drug, respiratory depression, coma. Gradual discontinuance. Tolerance can happen within 6 months of therapy then you have to increase the dose to get the same effect.

Question 54

Cyclobenzaprine

Answer 54

Centrally acting muscle relaxant. Relieves muscle spasms through a central action, possibly at the brainstem level, with no direct action on the neuromuscular junciton or the muscle involved. Anticholinergic effects: blurred vision, constipation, dry mouth, urinary retention, confusion, drowsiness, nausea, nervousness, tachycardia, arrhythmias, headache, unpleasant taste. No dependence. Do not take with alcohol.

Question 55

Phenytoin

Answer 55

Reduces motor cortex activity and alters ion transport by acting on sodium channels on neuronal cell membranes. To prevent tonic-clonic, partial, and status epilepticus. SE: headache, confusion, dizziness, drowsiness, insomnia, nervousness, mood changes, nystagmus, asthenia, slurred speech, ataxia, rash, paresthesia, hyperreflexia, tremor, gingival hyperplasia, abdominal pain, dysgeusia, n/v/c. TR: 10-20. Blood dyscrasias, purple glove syndrome, elevated BGL. Highly protein bound - displace anticoagulants, aspirin.

Switch medications before they become pregnant
Avoid alcohol and CNS depressants
Dental hygiene – oral hygiene
Adjustment in insulin regimen
Teratogenic
Dose is based on plasma drug levels: 10-20 serum level therapeutic range
Children metabolize this quickly.
Highly protein bound – increase in free drug with low albumin and drug toxicity
Side effects and adverse reaction – psychiatric effects – drowsy, suicidal ideations, nystagmus-involuntary movements. Can cause diplopia. Headache, dizziness, drowsiness. N/V, constipation, gingival hyperplasia – overgrowth of the gum tissue, bleed easily, normal and manageable – teach to be careful with oral hygiene, Stevens-Johnson syndrome, purple glove syndrome, can cause blood dyscrasias-imbalances in the blood, thrombocytopenia or leukopenia, can cause alopecia or hirsutism, excess or hair loss, can turn urine pink or red/brown color. Hyperglycemia inhibits the release of insulin. May cause toxicity if taking other highly protein bound drugs. Alcoholics need higher dose. May have increased seizures if taken with an antipsychotic. Know the drug history. Accurate list of over the counter medications – assess BUN, crt, and liver function. When the patient has been taking this and they have seizures, the first step is to assess medications and then take drug levels.

Question 56

Antiepileptic drugs

Answer 56

Diazepam IV followed by phenytoin or phenobarbital, lorazepam IV followed with phenytoin. For continuous seizures midazolam or propofol and then high-dose barbiturates are used.

Question 57

Carbamazepine

Answer 57

Toxic when given with grapefruit juice. Tonic-clonic, partial seizures
Tx bipolar disorder, alcohol withdrawal, diabetic neuropathy
Signs and symptoms of toxicity 4-12 – TR
Side effects – dizziness, drowsiness, grapefruit juice inhibits the CYP enzymes that breakdown carbamazepine and decreases the drug levels. Ask about diet – what have you been eating? Ask specifically have you been eating grapefruit?

Question 58

Status epilepticus

Answer 58

A rapid succession of epileptic seizures.

Question 59

Succinimide

Answer 59

Ethosuximide 40-100 - used to treate absence seizures. Act by decreasing calcium influx through the T-type calcium channels.

Question 60

Clorazepate dipotassium

Answer 60

Treats partial seizures, anxiety and alcohol withdrawal.

Question 61

Diazepam-Valium

Answer 61

Status epilepticus
First line treatment for status epilepticus, then phenobarbital
Short acting, then follow it up with a longer acting drug such as phenytoin or phenobarbital

Question 62

Valproic Acid – Depakote

Answer 62

Tonic clonic and absence and mixed seizure
Not safe for children less than 2 because of the immature liver function
Toxic to the liver – monitor liver function carefully – do not give with someone who has decreased liver function.
Side effects – similar to other AED’s
Seizure activity increases in pregnant women, metabolic rates increase. Medications are teratogenic – control seizures without putting the fetus at risk. Hypoxia may occur.

Question 63

SSRIs

Answer 63

Block the reuptake of serotonin into the nerve terminal of the CNS, thereby enhancing its transmission at the serotonergic synapse. Do not block the uptake of dopamine or norepinephrine and they do not block cholinergic and alpha adrenergic receptors. Can treat anxiety, depression, panic disorders, phobias, posttraumatic stress disorder. Flovoxamine is useful for OCD in children and adults. Used to treat eating disorders and selected drug abuses. Fluoxetine, sertraline, paroxetine, citalopram, and escitalopram. Interact with grapefruit juice. Effects in 3-4 weeks. SE: dry mouth, blurred vision, insomnia, headache, anorexia, nausea, diarrhea, and suicidal ideation. Fewer side effects than amitriptyline. SE cease over the 1-4 week period of waiting for TE to emerge.

Question 64

Atropine sulfate

Answer 64

Anticholinergic; muscarinic antagonist drug. Useful primarily as a preoperative medication to decrease salivary secretions and as an agent to increase heart rate when bradycardia is present. Can be used as an antidote for bethanechol. Promotes pupil dilation. SE: drowsiness, dizziness, nausea, dry mouth, headache, confusion, insomnia, amnesia, constipation, flushing, hypohydrosis, blurred vision, mydriasis, anxiety, photophobia, palpitations, urinary retention, hyperreflexia, ataxia, weakness, dehydration, injection site reaction. Tachycardia, paradoxical bradycardia, hyper/hypotension, angina, dyspnea, pulmonary edema, respiratory depression. Treats cholinergic crisis and dilate pupils for ocular diagnostic examination.

Question 65

Oxybutynin

Answer 65

Antispasmodics-anticholinergic. For neurogenic and overactive bladder. May cause drowsiness, dizziness, headache, insomnia, blurred vision, dry mouth, n/v/d/c, urinary retention, erythema, dysuria, and edema. Contraindicated for use if urinary or GI obstruction is present or if the patient has glaucoma.

Question 66

ACE inhibitors

Answer 66

Inhibits the formation of angiotensin II and blocks the release of aldosterone. -PRIL. Used to treat hypertension and heart failure. African americans and older adults do not respond to ACE inhibitors. SE: cough, n/v/d, headache, dizziness, fatigue, insomnia, serum potassium excess, and tachycardia. Angioedema- epinephrine, hypotension, hypersensitivity.

Question 67

Nitroglycerin

Answer 67

SL tablet which is absorbed under the tongue. If pain has not subsided, then 911 should be called. The effects of SL nitro last 30-60 minutes. Acts directly on the smooth muscle of blood vessels, causing relaxation and ilation. It decreased preload and afterload, and reduces myocardial O2 demand. SE: headache, hypotension, dizziness, flushing, weakness, and faintness.

Question 68

Beta blockers

Answer 68

Antihypertensive, antianginal, antidysrhythmic. Reduce cardiac output by diminishing the sympathetic nervous system response to decrease basal sympathetic tone. Vascular resistance is diminished and BP is lowered. Reduce heart rate, contractility, and renin release. SE: decreased pulse rate, decreased BP, bronchospasm, rebound hypertension, angina, dysrhythmias, and MI. Cause dizziness, insomnia, depression, fatigue, nightmares, and erectile dysfunction.

Question 69

Digoxin

Answer 69

Inhibits sodium-potassium ATPase, promoting increased force of cardiac contraction, cardiac output, and tissue perfusion. Decreases ventricular rate. TD: 0.8-2 for dysrhythmias and 0.5-1 for HF. Overdose or accumulation: anorexia, n/v/d, cardiac dysrhythmias, premature ventricular contractions, headaches, malaise, blurred vision, visual illusions - white/green/yellow halos, confusion, and delirium. Lidocaine or phenytoin can treat digoxin-induced ventricular dysrhythmias or Digoxin-immune Fab. Interacts with diuretics that decrease potassium. Should consume foods rich in potassium.

Question 70

Cardiac glycosides

Answer 70

1- positive inotropic action increases myocardial contraction stroke volume
2- negative chronotropic action decreases heart rate
3-negative dromotropic action decreases conduction of heart cells.

Question 71

Warfarin

Answer 71

Inhibits the hepatic synthesis of vitamin K clotting factors and anticoagulant proteins. Prevents thrombosis associated with PE, MI, unstable angina, prosthetic heart valves, DVT, and PCI. Normal Icimetidine, NR is 2-3. Heart valve or embolism: 2.5-3.5. SE: petechiae, ecchymosis, tarry stools, and hematemesis. Antidote is vitamin K. Aspirin, NSAIDs, sulfonamides, phenytoin, cimetidine, allopurinol, and oral hypoglycemic drugs for diabetes can displace warfarin from the protein-bound site and can cause more free-circulating anticoagulant. Acetaminophen should be used instead of aspirin by patients taking warfarin.

Question 72

Heparin

Answer 72

Indicated for a rapid anticoagulant effect for DVT, PE, or an evolving stroke. Used to prevent venous thrombosis. Combines with antithrombin III, which accelerates the anticoagulant cascade of reactions that prevents thrombosis formation. By inhibiting the action of thrombin, conversion of fibrinogen to fibrin does not occur and the formation of a fibrin clot is prevented. ONLY GIVEN IV OR SUBQ. Protamin sulfate is the antidote. Can cause thrombocytopenia.

Question 73

Thrombolytic therapy

Answer 73

Alteplase - administered within 3-4 hours or within 30 minutes after arriving at the hospital. Side effects: epistaxis, hypotension, infection, ecchymosis, nausea, vomiting, rash. Alteplase promotes conversion of plasminogen to plasmin, an enzyme that digests the fibrin matrix of clots. Alteplase initiates fibrinolysis. Plasmin, an enzyme, digests the fibrin in the clot. Plasmin degrades fibrinogen, prothrombin, and other clotting factors. Aminocaproic acid is used to stop bleeding by inhibiting plasminogen activation.

Question 74

Nicotinic acid

Answer 74

reduces VLDL and LDL. Niacin is very effective at lowering cholesterol levels, and its effect on the lipid profile is highly desirable. 20% can tolerate niacin. With use of aspirin the number of 60-70% . Recommended in clinical situations such as triglyceride levels over 500 mg/dL or if intolerant to other treatment.

Question 75

Ezetimibe

Answer 75

For hypercholesterolemia. May cause diarrhea, arthralgia, abdominal and back pain, fatigue, infection, cholelithiasis, and myalgia. It is a cholesterol absorption inhibitor that acts on the cells in the small intestine to inhibit cholesterol absorption. It decreases cholesterol from dietary absorption, reducing serum cholesterol, LDL, triglycerids, and apoB levels. Only a small increase in HDL. It must be combined with a statin for optimum effect.

Question 76

HMG-CoA reductase inhibitors

Answer 76

inhibit the enzyme reducatese in cholesterol biosynthesis. Inhibiting cholesterol synthesis in the liver, antihyperlipidemics decrease the concentration of cholesterol, decreases LDL, and slightly increases HDL cholesterol. May be seen as early as 2 weeks after thereapy. Monitor liver enzymes, annual eye examination. Report immediatley any muscle aches or weakness, rhabdomyolysis, muscle disintegration is fatal. Decrease BP, blood clotting, and enhance hyperlipidemic effects. Abruptly stopping the med can cause AMI.

Question 77

Homocysteine

Answer 77

by-product of protein, found in eggs, chicken, beef, and cheddar cheese.

Question 78

Antilipemic therapy

Answer 78

Bile-acid sequestrants: bile-acid dequestrant that reduces LDL cholesterol levels by binding with bile acids in the intestine. Fibrates: gemfibrozil - effective for reducing triglycerides and VLDL levels than LDL. Highly protein bound and should not be taken with anticoagulants because they copete for protein sites. If taken with warfarin bleeding may occur.

Question 79

Furosemide

Answer 79

Inhibits transport of sodium into circulation and inhibit passive reabsorption of sodium. Sodium, water, potassium, calcium and magnesium are lost. Can affect BGL and increase uric acid levels. Can increase renal blood flow. Nausea, anorexia, diarrhea, dizziness, tinnitus, abdominal cramps, constipation, rash, headache, weakness, blurred vision, muscle cramps, photosensitivity, paresthesias, injection site reaction.

Question 80

Loop diuretics

Answer 80

Inhibits transport of sodium into circulation and inhibit passive reabsorption of sodium. Sodium, water, potassium, calcium and magnesium are lost. Can affect BGL and increase uric acid levels. Can increase renal blood flow. Nausea, anorexia, diarrhea, dizziness, tinnitus, abdominal cramps, constipation, rash, headache, weakness, blurred vision, muscle cramps, photosensitivity, paresthesias, injection site reaction.

Question 81

Osmotic diuretics

Answer 81

Increase the osmolality and sodium reabsorption in the proximal tubule and loop of Henle. Sodium, chloride, potassium, and water are excreted. Used to decrease ICP and IOP. Mannitol - potent, potassium-wasting diuretic used in ER situations. Fluid and electrolyte imbalance, pulmonary edema from rapid shift of fluids, n/v, tachycardia from rapid fluid loss, and acidosis. Caution in patients with HF.

Question 82

Thiazide diuretics

Answer 82

Promote water, sodium, magnesium, potassium, and chloride excretion. Treat hypertension and peripheral edema. No fluid loss in patients with severe renal dysfunction. Not effective for immediate diuresis. Must have normal renal function. Hypercalcemia may result and the condition can be hazardous to the patient who is digitalized. Hyperglycemia, hyperuricemia, hyperlipidemia. SE: dizziness, headache, nausea, vomiting, constipation, and blood dyscrasias. Enhance the action of lithium. Enhance the action of digoxin.

Question 83

Vasodilators

Answer 83

Cilostazol - antiplatelet inhibitor causing vasodilation to treat intermittent claudication. Headache, diarrhea, and abnormal stools. Dizziness, tachycardia, palpitations, orthostatic hypotension, n/v/d.

Pentoxifylline- blood viscosity reducer agent - improved microcirculation and tissue perfusion by decreasing blood viscosity and improving the flexibility of erythrocytes.

Nitrates - coronary arteries and blood vessels in the venous circulation.

BB and CCBS decrease the workload of the heart and decrease oxygen demands.

Question 84

Desmopressin

Answer 84

Given for DI and managing patients with bleeding disorders due to hemophilia A or von Willebrand disease. Does not induce the release of ACTH nor does it increase serum cortisol levels. Contraindicated in patients with moderate to severe renal disease and in patients with hyponatremia or hx of such. SE: hyponatremia, cephalgia, dyspepsia, n/v/d. Seizures with hyponatremia. Hypotension and tachycardia can occur.

Question 85

Cosyntropin

Answer 85

Synthetic ACTH approved for diagnostic purposes and is less potent and less allergenic than corticotropin. Stimulates the production and release of cortisol, corticosterone, and androgens from the adrenal cortex. Increase of electrolyte loss. SE: bradycardia, hypertension, sinus tachycardia, and peripheral edema. Primary vs secondary pituitary and adrenal insufficiency. Obtain plasma cortisol level before and after administration.

Question 86

Propylthiouracil

Answer 86

antithyroid drug used to control overactive thyroid due to graves disease, toxic nodular goiter, or multinodular goiter; used before radioiodine tx or thyroid surgery. Inhibits the conversion of T4 to T3. Do not take with soy products, cruciferous vegetables, iodized salt, shellfish, and coffee.

Question 87

Corticosteroids

Answer 87

Glucocorticoids - Dexamethasone used for inflammatory responses. Cortisone for adrenocortical insufficiency. Hydrocortisone for adrenocortical insufficiency for crisis prophlaxis in ill patients. Can cause cushings syndrome, peptic ulcers, and growth retardation. Interactis with phenytoin, theophylline, rifampin, barbiturates, and antacids.

Mineralocorticoids - promotes sodium retention and potassium excretion in the renal tubules. Fludrocortisone is an oral mineralocorticoid that mimics aldosterone . Monitor serum potassium levels - fluid imbalance, fluid overload, and hypertension. Hypokalemia may cause metabolic alkalosis that can cause GI symptoms, orthostatic hypotension, cardiac rhythm changes, weakness, anorexia, and myalgia.

Question 88

Metformin

Answer 88

Biguanide that decreases hepatic production of glucose from stored glycogen. Decreases the absorption of glucose from the small intestine and increases insulin receptor sensitivity as well as peripheral glucose uptake at the cellular level. Not effective if combined with sulfonylurea. Lactic acidosis or acute renal failure may develop. Monotherapy with metformin is effective.

Question 89

Guaifenesin

Answer 89

A nonnarcotic antitussive used in OTC cold remedies. Reduces viscosity and adhesiveness of tenacious secretions. SE: dizziness, drowsiness, confusion, fatigue, ataxia, nausea, vomiting, restlessness. Ease secretions from the lower respiratory tract and to produce a productive, less frequent cough.

Question 90

Benzonatate

Answer 90

act on the cough-control center in the medulla to suppress the cough reflex. tessalon pearls - for cough. May cause drowsiness, dizziness, headache, confusion, nausea, constipation, and ocular irritation.

Question 91

Diphenhydramine

Answer 91

To treat allergic rhinitis, the common cold, cough, sneezing, pruritus, and urticaria, and to prevent motion sickness. Blocks the effects of histamine by competing for and occupying H1 receptor sites. It has anticholinergic effects and should not be used by patients with narrow-angle glaucoma. Drowsiness is a major side effect, can cause cough, headache, dizziness, weakness, agitation, insomina, fatigue, ataxia, urinary retention, blurred vision, dry mouth, rash , hypotension, abdominal pain, restlessness, confusion, diarrhea, constipation.

Question 92

Dextromethorphan

Answer 92

Expectorant- to ease expelling secretions from the lower respiratory tract and to produce a productive, less frequent cough. Reduces viscosity and adhesiveness of tenacious secretions. SE: dizziness, drowsiness, confusion, fatigue, ataxia, nausea, vomiting, restlessness. Hydration is the best expectorant - increase fluid intake to at least 8 glasses per day.

Question 93

Aminophylline

Answer 93

Relaxes the smooth muscles of the bronchi, bronchioles, and pulmonary blood vessels by inhibiting the enzyme phosphodiesterase- resulting in cAMP which promotes bronchodilation. Narrow TI or 5-15. SE: dysrhythmias, seizures, and cardiac arrest. For asthma exacerbations SE: restlessness, headache, insomnia, GERD, dizziness, n/v/d, hypokalemia, hypercalcemia, palpitations, and tachycardia. Patients should avoid caffeinated products such as coffee, tea, cola, chocolate, and increase fluid intake. Beta blockers, cimetidine, propranolol, and erythromycin decrease the liver metabolism rate and increase the half-life. Smoking increases the excretion via the kidneys. Barbiturates and carbamazepine decrease the effects. Increase the risk of digitalis toxicity and decrease the effects of lithium. Phenytoin decreases theophylline levels. Can be taken with a beta-adrenergic agonist for a synergistic result in cardiac dysrhythmias.

Question 94

Xanthine derivative

Answer 94

aminophylline, theophylline, and caffeine. Stimulate the CNS and respiration, dilate coronary and pulmonary vessels, and cuase diuresis. Treat asthma.

Question 95

Ipratropium

Answer 95

Blocks muscarinic cholinergic receptors and antagonizes acetylcholine action by inhibiting M3 receptor response to acetylcholine, thereby relaxing smooth muscle of bronchi; dilates bronchi. SE: insomnia, dizziness, headache, sinusitis, nasopharyngitis, cough, dry mouth, nausea, vomiting, abdominal pain, insomnia, constipation, urinary retention, arthralgia, myalgia, peripheral edema, blurred vision, oral ulceration, infection. Anticholinergic.

Question 96

Salmeterol

Answer 96

For asthma, COPD, and exercise-induced bronchospasm prophylaxis. May cause headache, pharyngitis, nasal congestion, palpitations, tachycardia, hypokalemia, hyperglycemia, arthralgia, and myalgia. Stimulate the beta 2 receptors in the lungs which relaxes the bronchial smooth muscle, thus causing bronchodilation.

Question 97

Fluticasone

Answer 97

Intranasal glucocorticoids antiinlammatory action, decrease the allergic rhinitis symptoms of rhinorrhea, sneezing, and congestion. Should be directed away from the nasal septum and the patient should sniff gently. Dryness may occur. SE: headache, nasal irritation, pharyngitis, fatigue, insomnia, and candidiasis. No longer than 3 days.

Question 98

Inhaled bronchodilators

Answer 98

Sympathomimetics, methylxanthines, leukotriene antagonists, glucocorticoids, cromolyn, and anticholinergics.

Glucocorticoids - treat respiratory disorders -asthma - indicated if unresponsive to bronchodilator therapy or if the pt has an asthmatic attack. May take 1-4 weeks for inhaled steroid to reach its full effect. Prednisone, prednisolone, dexamethasone, or methylprednisolone - moderate to severe asthma exacerbations. SE: coughing, dry mouth, hoarseness, throat irritation, headache, euphoria, confusion, diaphoresis, hyperglycemia, insomnia, nausea, vomiting, weakness, menstrual irregularities. Wash mouth after each dose.

Cromolyn- prophylactic treatment of bronchial asthma. Inhibit release of histamine and other inflammatory mediators from mast cells to prevent an asthma attack. Postnasal drip, irritation of the nose and throat, and a cough. Decreased by drinking water before and after use. Administered oral inhalation. REbound bronchospasm.

Question 99

Inhaled corticosteroids

Answer 99

Glucocorticoids - treat respiratory disorders -asthma - indicated if unresponsive to bronchodilator therapy or if the pt has an asthmatic attack. May take 1-4 weeks for inhaled steroid to reach its full effect. Prednisone, prednisolone, dexamethasone, or methylprednisolone - moderate to severe asthma exacerbations. SE: coughing, dry mouth, hoarseness, throat irritation, headache, euphoria, confusion, diaphoresis, hyperglycemia, insomnia, nausea, vomiting, weakness, menstrual irregularities. Wash mouth after each dose.

Question 100

Metered dose inhaler use

Answer 100

Get up to 12-14% of the drug deep into the lungs with each puff. Act faster than drugs taken by mouth and fewer side effects occur because the drug goes right to the lungs and not to other parts of the body.

Question 101

Penicillin

Answer 101

Interferes with the bacterial cell-wall synthesis by inhibiting the bacterial enzyme necessary for cell division and cellular synthesis. The bacteria diet of cell lysis. Primarily bactericidal. Amoxicillin inhibits the enzyme in cell-wall synthesis and has a bactericidal effect. For rheumatic fever prophylaxis, otitis media, tonsillitis, h. pylori, UTI, staphylococci, and streptococci. SE: n/v/d, abdominal pain, dysphagia, rash, pruiritus, stomatitis, glossitis, dysgeusia, tonge and tooth discoloration, headache, dizziness, anxiety, confusion edema, insomnia, crystalluria, and dermatitis. Clavulinic acid, probenecid, sulbactam, and tazobactam increase the effects.

Question 102

Cephalosporins

Answer 102

Five groups of cephalosporins have been developed, each generation is effective against a broader spectrum of bacteria, an increased resistance to destruciton by beta-lactamases and an increased ability to reach cerebrospinal fluid.

Question 103

Tetracyclines

Answer 103

Effective against MRSA, treats h. pylori, acne, avoid milk products, iron, and antacids. Take 1 hour beofre or 2 hours after meals. Can cause GI disturbances such as n/v/d, photosensitivity, not recommended for pregnancy or children under 8 years, can cause damage to the vestibular part of the inner ear, nephrotoxicity results when given in high doses, superinfection. SE: dry mouth, tooth/nail discoloration, diplopia, blurred vision, rash, cough, inejction site reaction, nasophayngitis, skin hyperpigmentation.

Question 104

Sulfonamides

Answer 104

Bacteriostatic because they inhibits bacterial synthesis of folic acid, which is essential for bacterial growth. Tx TUI and ear infection and new-born eye prophylaxis. E. coli. Sulfadiazine is used in prophylactic tx of streptococcal infections in pts with rheumatic fever who are hypersensitive to penicillin. SE: rash, itching, blood disorders, GI disturbances, crystalluria, hematuria, increase fluid intake dilutes the drug and prevents crystalluria, photosensitivity, cross-sensitivity. Avoid during pregnancy.

Question 105

Superinfection

Answer 105

The occurrence of a secondary infection when the flora of the body are disturbed. Anorexia, nausea, vomiting, diarrhea are common GI disturbances. Take penicillin with food. Rash is an indicator of a mild to moderate allergic reaction.

Question 106

Aminoglycosides

Answer 106

Inhibit bacterial protein synthesis. Streptomycin-ototoxic-tx tularemia and plague. Cannot be absorbed from the GI tract, nor can they cross cerebrospinal fluid. Neomycin is given as a preoperative bowel antiseptic. Gentamicin, tobramycin, and amikacin. Bactericidal effect. Draw blood levels periodically. SE: ototoxicity, nephrotoxicity, n/v, tremors, tinnitus, pruritus, and muscle cramps.

Question 107

Influenza antivirals

Answer 107

Oseltamivir or zanamivir. Neuraminidase inhibitors that decrease the release of the virus from infected cells by inhibiting the activity of neuraminidase, a viral glycoprotein, thus decreasing virla spread and shortening the duration of flu symptoms. Should be taken within 48 hours of the flu symptoms, they are not substitutes for the vaccine. SE: dizziness, headache, insomnia, vertigo, fatigue, n/v/d. Monitor closely for abnormal behavior, self-injury and delirium.

Question 108

Isoniazid

Answer 108

Contraindicated in persons with liver disease may cause liver damage. Bactericidal or bacteriostatic, depending on the drug concentration, inhibits bacterial cell-wall synthesis and MAO without affecting mitochondrial MAO, which interferes with the metabolism of tyramine and histamine. Pyridoxine supplementation reduces neurotoxic side effects. SE: drowsiness, tremors, rash, blurred vision, photosensitivty, tinnitus, dizziness, n/v, dry mouth, constipation, diarrhea with oral solution, injection site reaction. Peripheral neuropathy, vitamin B6 deficiency, hyperglycemia, metabolic acidosis, optic neuritis. Tyramine increase the effects.

Question 109

Allopurinol

Answer 109

Inhibits the final steps of uric acid biosynthesis and lowers serum uric acid levels preventing gout attack. Can be used with renal impairment. Useful for pts who have renal obstructions caused by uric acid stones and for pts with blood disorders such as leukemia and polycythemia vera. Increase fluid intake to promote diuresis and alkalinization of the urine. Monitor renal and liver labs. Record urine output. Report GI symptoms such as n/v/d and GI bleeding/obstruction. Prolonged use can cause vision changes.

Question 110

Antacids

Answer 110

Neturalize HCL and pepsin activity. Sodium bicarbonate - systemically absorbed - causes hypernatremia and water retention, metabolic alkalosis, and acid rebound- used les.s Calcium carbonate is most effective - 1/3 to 1/2 can be systemically absorbed and cause acid rebound. Hypercalcemia can cause Burnett syndrome - intensified if milk products are ingested. Identified by alkalosis, hypercalcemia, and crystalluria, and renal failure.
Alkaline salts - aluminum and magnesium - neutralizing power. Mg can cause diarrhea. Al and CA cause constipation. Simethicone can be given for gas. Take with 4 ounces of water to quicken gastric emptying. Contraindicated in renal failure.

Question 111

COPD vs. heart failure

Answer 111

COPD- chronic, dry cough, wheezing, rhonchi, barrel chest, tri-pod position,

HF: peripheral edema, ascites, JVD, rales, increased BP, S3 gallop, murmur, orthopnea,

Question 112

First pass effect

Answer 112

When drugs are metabolized in the liver to an inactive form and are excreted, thus reducing the amount of active drug available to exert a pharmacologic effect.