Pharmacy Foundations Flashcards
Muscarinic receptor
Substrate acetylcholine
Agonist: paraympathetic ANS (wet) (pilocarpine, bethanechol)
Antagonist: sympathetic (dry) (atropine, oxybutynin)
Nicotinic receptor
Substrate: acetylcholine
Agonist: increase HR and BP (nicotine)
Antagonists: neuromuscular blockade (rocuronium etc)
Alpha-1 receptor
Substrate; epinephrine, norepinephrine
Mainly peripheral
Agonist: vasoconstriciton of smooth muscles and increased BP (phenylephrine, dopamine)
Antagonist: vasodilation of smooth muscles and decreased BP (doxazosin, carvedilol, phentolamine)
Alpha-2 receptor
Substrate; epinephrine, norepinephrine
Mainly central and brain
Agonist: inhibits release of Epi and NE, decreased BP and HR (clonidine, brimonidine)
Antagonist: increased BP and HR (ergot alkaloids, yohimbine)
Beta-1 receptor
Substrate; epinephrine, norepinephrine
Mainly heart
Agonist: increased contractility, CO, HR (dobutamine, isoproterenol, dopamine)
Antagonist: decreased CO and HR (metoprolol, propranolol, carvedilol)
Beta-2 receptor
Substrate: epinephrine
Mainly in lungs
Agonist: bronchodilator (albuterol, terbutaline, isoproterenol)
Antagonist: bronchoconstriction (propranolol, carvedilol)
Dopamine receptor
Substrate: dopamine
Agonist: renal, cardiac, and CNS effects (levodopa, pramipexole)
Antagonist: renal, cardiac, and CNS effects (haloperidol, metoclopermide)
Serotonin receptor
Substrate: serotonin
Agonist: platelet, GI, psychiatric (triptans)
Antagonist: platelet, GI, psychiatric (ondansetron, quetiapine)
Acetylcholinesterase
Breaks down acetylcholine
Inhibitors: donepezil, rivastigmine, galantamine
Results in increased ACh to treat Alzheimer’s
Angiotensin-converting enzyme
Converts angiotensin I to II that controls vasoconstriction
Inhibitors: lisinopril, ramipril
Resulting in decreased vasoconstriction and aldosterone secretion to treat hypertension, HF, and kidney disease
Catechol-O-methyltransferase
Breaks down levodopa
Inhibitor: entacapone
Blocks peripheral breakdown resulting in better duraiton of levodopa to treat Parkinson’s
Cyclooxygenase
Converst arachidonic acid to prostaglandins to cause inflammation, and thromboxane A2 to cause platelet aggregation
Inhibitors: aspirin, ibuprofen
Results in decreased inflammation, and platelet aggregation
Monoamine oxidase
Breaks down catecholamines (DA, NE, 5-HT)
Inhibitors: phenelzine, tranylcypromine, isocarboxazid, selegiline, rasagiline, methylene blue, linezolid
Results in increased catecholamine levels to treat depression
Overdose: hypertensive crisis, serotonin syndrome
Phosphodiesterase
Breaks down cGMP, which is a smooth muscle relaxant
Inhibitors (5): sildenafil, tadalafil
Competitively binds to cGMP active site on the PDE-5 enzyme resulting in smooth muscle relaxation to treat erectile dysfunction
Vitamin K epoxide reductase
Converts vitK to the active form to create clotting factors
Inhibitor: warfarin
Results in less clotting factors being produced such as II, VII, IX, X for blood clot prevention
Xanthine oxidase
Breaks down hypoxanthine and xanthine to uric acid
Inhibitor: allopurinol
Results in decreased uric acid production to treat gout
Neutral functional groups
Alcohol primary group, ketone, aldehyde, amide, nitrate, nitro, aromatic benzene ring, urea, carbonate, carbamate, ether, thioether
Acidic functional groups
Carboxyl, phenol, imide, sulfonamide
Basic functional groups
Amine primary group, amine tertiary group, imine, amidine
Essential drug structures
Amoxicillin, ceftriaxone, ertapenem, aztreonam, gentamicin, sulfamethoxazole, aspirin, ibuprofen, amphetamine, levothyroxine, amiodarone, fenofibrate, amitriptyline, chlorpromazine
Common prodrugs
Capecitabine; fluorouracil
Clopidogrel; metabolites active
Codeine; morphine
Colistimethate; colistin
Famciclovir; penciclovir
Fosphenytoin; phenytoin
Isavuconazonium sulfate; isavuconazole
Levodopa; dopamine
Lisdexamfetamine; dextroamphetamine
Prednisone; prednisolone
Primidone; phenobarbital
Tramadol; metabolites active
Valacyclovir; acyclovir
Valganciclovir; ganciclovir
Common CYP inhibitors
GPACMAN
Grapefruit juice
Protease inhibitors, especially ritonavir
Azole antifungals
Cyclosporine, cobiscistat
Macrolides, except azithromycin
Amiodarone, dronedarone
Non-DHP CCB
Common CYP inducers
PS PORCS
Phenytoin
Smoking
Phenobarbital
Oxcarbazepine
Rifampin, rifabutin, rifapentine
Carbamazepine
St. John’s Wort
Common p-gp substrates, inhibitors, inducers
Substrates: anticoagulants (esp riva and api), cardiovascular (esp digoxin, verapamil, diltiazem), immunosuppressants (esp cyclosporine, tacrolimus), HCV drugs, and colchicine
Inducers: same as CYP inducers plus dexamethasone, and tipranavir
Inhibitors: Anti-infectives, cardiovascular drugs (esp amiodarone, diltiazem, verapamil), HIV drugs (esp cobiscistat, ritonavir), cyclosporine
Common CYP substrates
3A4: Analgesics, anticoagulants, immunosuppressants, statins, HIV (esp NNRTI), PDE-5 inhibitors, ethinyl estradiol
1A2: theophylline, warfarin
2C8: amiodarone, pioglitazone, repaglinide
2C9: warfarin
2C19; clopidegrel
2D6: analgesics, antipsychotics, antidepressants, tamoxifen
Normal BMP
Na: 135-145mEq/mL
K: 3.5-5mEq/mL
Cl: 95-106mEq/mL
Ca: 8.5-10.5mg/dL
Ca, ion: 4.5-5.1mg/dL
Mg: 1.3-2.1mEq/mL
PO4: 2.3-4.7mg/dL
HCO3 venous: 24-30mEq/mL
HCO3 arterial: 22-26mEq/mL
BUN: 7-20mg/dL
SCr: 0.6-1.3mg/dL
Glu: 70-110mg/dL
AG: 5-12mEq/mL
Normal CBC
WBC: 4-11 thousand cells/mm3
Neut: 45-73%
Bands: 3-5%
Eos: 0-5%
Baso: 0-1%
Lymph: 20-40%
Mono: 2-8%
RBCm: 4.5-5.5 thousand cells/mcL
RBCfe: 4.1-4.9 thousand cells/mcL
HGBm: 13.5-18g/dL
HGBfe: 12-16g/dL
HCTm: 38-50%
HCTfe: 36-46%
MCV: 80-100fL
Folate: 5-25mcg/L
B12: >200pg/mL
Reticulocyte: 0.5-2.5%
G6PD: 5-14Units/g
Normal anticoagulants
Anti-XaLMWH: 1-2IU/mL peak
Anti-XaHep: 0.3-0.7IU/mL peak
PT: 10-13sec
INR: <1.2
aPTT: 22-38sec
PLT: 150-450 thousand cells/mm3
Normal liver and GI tests
Alb: 3.5-5g/dL
AST: 10-40units/L
ALT: 10-40units/L
TBili: 0.1-1.2mg/dL
Amylase: 60-180units/L
Lipase: 5-160units/L
Normal cardiovascular
CK/CPKm: 55-170IU/L
CK/CPKfe: 30-135IU/L
TnT: <0.1ng/mL
TnI: <0.5ng/mL
BNP: <100pg/mL
NT-proBNPm: <61pg/mL
NT-proBNPfe: 12-151pg/mL
LDL: <100mg/dL
HDL: >60mg/dL
TG: <150mg/dL
TChol: <200mg/dL
CRP: <0.5mg/dL
Normal diabetes
FPG: <100mg/dL, >126mg/dL diabetic
A1c: <7%
C-peptide fasting: 0.78-1.89ng/mL
UAE: <30mg/d
Normal thyroid, gout, and inflammation
TSH: 0.3-3mIU/L
Uric acidM: 3.5-7.2mg/dL
Uric acidFe: 2-6.5mg/dL
RF: <20IU/L
ESRm: <20mm/H
ESRfe: <30mm/H
Normal HIV
CD4: >200cells/mm3
HIV RNA: 0copies/mL
Normal acid-base
pH: 7.35-7.45
Normal hormones
PSA: <4ng/mL
Normal other;
Lactic acid: 0.5-2.2mEq/L
TPMT: >15units/mL
VitD: >30ng/mL
Common therapeutic drug levels
Carbamazepine: 4-12mcg/mL
Digoxin AF: 0.8-2ng/mL
Digoxin HF: 0.5-0.9ng/mL
Genta/Tobra P: 5-10mcg/mL
Genta/Tobra Tr: <2mcg/mL
Li: 0.6-1.2mEq/L
Phenytoin: 10-20mcg/mL
Free phenytoin: 1-2.5mcg/mL
Procainamide: 4-10mcg/mL
NAPA (metabolites): 15-25mcg/mL
Both: 10-30mcg/mL
Theophylline: 5-15mcg/mL
Valproic acid: 50-100mcg/mL
Vanco Bad: 15-20mcg/mL
Vanco Fine: 10-15mcg/mL
Warfarin: 2-3 INR
Warfarin mechanical: 2.5-3.5 INR
FDA colored books
Orange: interchangeable Brand/generic
Pink: epidemiology and vaccine preventable diseases
Pink Sheet: news reports on regulatory, legislature, legal, and business development
Purple: Biologics and biosimilars
Red Phar: pricing
Red Peds: peds ID’s, tx, and vaccines
Yellow: international traveler’s
Green: animal drugs
Common drugs with diluent requirements; NS or dextrose only
NS only, no dextrose: A DIAbetic Can’t Eat Pie
Ampicillin, daptomycin, infliximab, ampicillin/sulbactam, caspofungin, ertapenem, phenytoin
Dextrose only, no NS: Outrageous Bakers Avoid Salt
Oxaliplatin, Bactrim, Amphotericin B, Synercid
Common drugs with leaking in PVC and filters
Issues with PVC: Leach Absorbs To Take In Nutrients
Lorazepam, amiodarone, tacrolimus, taxanes, insulin, nitroglycerin
Filter requirements (5 microns): GAL Is PAT who has a MaP
Golimumab, Amphotericin B lipid, Lipids (1.2 microns), Isavuconazonium, pheytoin, amiodarone, taxanes, Mannitol, parenteral nutrition (1.2 micron)
Common drugs that cannot be refrigerated
Dear Sweet Pharmacist Freezing Makes Me Edgy
Dexedetomidine
Sulfamethoxazole/trimethoprim
Phenytoin
Furosemide
Metronidazole
Moxifloxacin
Enoxaparin
Common drugs that must be protected from light
Protect Every Necessary Med from Daylight
Phytonadione (vitK)
Epoprostenol
Nitroprusside
Micafungin
Doxycycline
Colored IV solutions
Red: anthracyclines, rifampin
Blue: mitoxantrone
Yellow: methotrexate, multivitamins
Orange: tigecycline
Brown: IV iron
Medication problems
Untreated medical treatment
No indications
Improper drug selection for indication
Dose is too high or low
Therapeutic duplication
Patient does not know about it
Drug allergies
Drug interactions
Improper use
Failure to receive meds
Adverse drug reactions
Nonadherence
High alert medications
IV or inhaled anesthesias, IV antiarrythmias, anticoagulants, antiplatelets, chemotherapeutics, epidurals or intrathecal, hypertonic saline, immunosuppressants, inotropics, insulins, magnesium sulfate inj, neuromuscular blockers, opioids, hypoglycemic, parenteral nutrition, KCl and PO4 inj, sterile water.
Types of drug allergies
Type I: IgE mediated immediate reaction; urticaria, bronchospasms, angioedema, anaphylaxis
Type II: antibody mediated delayed 5-8 days after; hemolytic anemia, thrombocytopenia
Type III: immune complex delayed 7 day reaction; serum sickness
Type IV: T cell mediated delayed 2-7 days after; Stevens-Johnson syndrome
Meds associated with phototoxicity
Amiodarone, thiazide and loop diuretics, methotrexate, retinoids, quinolones, St. John’s Wort, sulfa drugs, tacrolimus, tetracyclines, voriconazole
Meds associated with severe cutaneous side effects
Allopurinol, amoxicillin, ampicillin, carbamazepine, ethosuximide, lamotrigine, nevirapine, phenytoin, sulfamethoxazole, sulfasalazine, vancomycin
Meds that follow Michaelis-Menten kinetics
Phenytoin, theophylline, voriconazole
Do not double dose to adjust, use smaller increments and based on levels or toxicity
HLA pharmacogenomics
HLA-B5701 positive should avoid abacavir due to hypersensitivity risk.
HLA-B5801 positive should avoid allopurinol due to SJS.
HLA-B*1502 positive should avoid carbamazepine, oxcarbazepine, phenytoin, and fosphenytoin due to SJS and TEN. Testing is needed for carbamazepine in Asian patients and is recommended for all others.
CYP pharmacogenomics
2C19: *1 fully functional. *2 and *3 are poor metabolizers and should not use clopidogrel due to lack of conversion to active prodrug.
2D6: ultra-rapid metabolizers should avoid codeine due to increased conversion to morphine. Nursing mothers should also avoid due to infant deaths. Poor metabolizers should also not be used.
2C9: *2 and *3 should start at a lower dose of warfarin due to increased risk for bleeding.
VKORC1 G>A variant: start at a lower dose of warfarin.
Other pharmacokinetics
HER2 negative cannot use HER2 inhibitors (trastuzumab) due to lack of efficacy.
KRAS positive (aka wild type) should avoid EGFR inhibitors (cetuximab) due to lack of efficacy
Low TPMT activity should start at a low dose of azathioprine due to the risk of myelosuppression.
DPD deficiency do not use fluorouracil or capecitabine due to high risk for severity.
Avoid drugs in these positive screenings
HLA and KRAS
Avoid drugs in these negative screenings
HER2
Testing recommended or strongly encouraged for these drugs
Abacavir and combinations, azathioprine, carbamazepine, EGFR inhibitors (cetuximab), and HER2 inhibitors (trastuzumab).
May consider also testing for allopurinol, capecitabine, fluorouracil, clopidogrel, codeine, phenytoin, fosphenytoin, and warfarin.
Commonly used supplements in disease states: Anxiety, ADHD, cold sores, cold and flu, dementia, depression, diabetes, dyslipidemia, dyspepsia, energy/weight loss, heart health, erectile dysfunction, hypertension, GI health, inflammation, insomnia, liver disease, menopause, migraine, motion sickness, osteoarthritis, osteoporosis, prostate health, skin conditions, UTI, and weight loss.
Anxiety: valerian, passionflower, kava, St. Johns Wort, chamomile, 5-HTP (hydroxytryptophan).
ADHD: omega-3 fatty acids.
Cold sores: L-lysine.
Cold/flu: echinacea, zinc, vitamin C, eucalyptus oil, probiotics.
Dementia: ginkgo, vitamin E, vitamin D, acetyl-L-carnitine, vinpocetine.
Depression: St. John’s Wort, SAMe, valerian, 5-HTP.
Diabetes: Alpha lipoic acid, chromium, cassia cinnamon, magnesium, American ginseng, Panax ginseng.
Dyslipidemia: Red yeast rice, omega-3 fatty acids, garlic, plant sterol, fibers, artichoke extract.
Dyspepsia: calcium, magnesium, peppermint, chamomile.
Energy: bitter orange, caffeine, guarana.
Erectile dysfunction: ginseng, L-arginine, yohimbine.
Heart health: Coenzyme Q10, hawthorn, omega-3 fatty acids.
Hypertension: omega-3 fatty acids, L-arginine, coenzyme Q10, garlic, fiber, potassium.
GI health: fibers, chamomile, probiotics, peppermint, horehound, wheatgrass.
Inflammation: omega-3 fatty acids, flax seeds, turmeric.
Insomnia: melatonin, valerian, chamomile, lemon balm, passionflower, coenzyme Q10, 5-HTP, L-tryptophan.
Liver disease: milk thistle.
Menopause: black cohosh, dong quai, evening primrose oil, red clover, soy, Panas ginseng.
Migraine: feverfew, butterbur, magnesium, vitamin B2 (riboflavin), coenzyme Q10, guarana, caffeine.
Motion sickness: ginger, peppermint.
Osteoarthritis: glucosamine, chondroitin, SAMe, turmeric.
Osteoporosis: calcium, vitamin D, soy, ipriflavone.
Prostate: saw palmetto, lycopene, pygeum, pumpkin seed.
Skin: tea tree oil, aloe vera, vitamin D, biotin.
UTI: cranberry, yogurt, probiotics.
Weight loss: garvinia cambogia.
Safety issues with common supplements
St. John’s Wort: induces CYP 3A4, 2C19, 2C9, 1A2, is serotonergic, photosensitivity, and lowers the seizure threshold.
Increased bleeding risk: 5 G’s; garlic, ginger, ginkgo, ginseng, glucosamine, fish oils, vitamin E, dong quai, willow bark, feverfew,
Liver toxicity; black cohosh, kava, chaparral, comfrey, green tea extracts.
Cardiac toxicity; bitter orange, DMAAlicorice, yohimbe.
Serotonergic; 5-HTP, SAMe.
Allergic reactions: artichoke extract, chamomile, echinacea.
Other heart: Qt prolongation with passionflower, positive inotrope with hawthorn (interacts with digoxin).
Iron recommendations and levels
0-4 months: not required
4-6 months: 1mg/kg/d
6-12 months: 11mg/d
12-36 months: 7mg/d
Meds that cause nutrient depletions
Acetazolamide: Ca, K
Antiepileptics: Ca
Amphotericin B: Mg, K
Isoniazid: B6
Loops: K
Metformin: B12
Methotrexate: B9
Orlistat: B-carotene, fat soluble vitamins
PPI: Mg, B12
Sulfamethoxazole: B9
Vitamin names
A; retinol
B1; thiamine
B2; riboflavin
B3; niacin
B6; pyridoxine
B9; folic acid
B12; cobalamin
C; ascorbic acid
D2; ergocalciferol
D3; cholecalciferol
E; alpha-tocopherol
Diseases with recommended supplements
Alcohol use disorder; B1, B9
Goiter; iodine
Microcytic anemia; ferrous sulfate
Macrocytic anemia; B12, B9
Pregnancy; B6, B9, Ca, D
Osteopenia; Ca, D
CKD; D
Scurvy; C
Crohn’s; iron, zinc, B, D, Ca
Bariatric surgery; patient-specific
Drug overdose symptoms and management
Acetaminophen: N/V, hepatotoxicity 24-48h, hepatic failure 48-96h. NAC using Rumack-Matthew monogram.
Anticholinergics (atropine, Benadryl, dimenhydrinate, belladonna, jimson weed): Dry as a bone, red as a beet, blind as a bat etc. Physostigmine rarely.
Anticoagulants: bleeding. Andexanet alfa for apixaban/rivaroxaban, idarucizumab for dabigatran, phytonadione or Kcentra for warfarin, protamine for LMWH or heparin, Kcentra for Xa inhibitors.
Antipsychotics; benztropine or bicarbonate.
Benzos; flumazenil. BB; glucagon, insulin, lipi emulsion.
CCB: glucagon, insulin, lipid emulsion, Ca.
Cyanide (nitroprusside); hydroxocobalamin (Cyanokit, Na thiosulfate with Na nitrite (Nithiodote).
Digoxin, oleander, foxglove; digoxin immune Fab. 40mg vials bind 0.5mg digoxin.
Heavy metals: dimercaprol for arsenic, gold, Hg, penicillamine for copper, ferric hexacyanoferrate (Prussian blue) for thallium, and for lead either dimercaprol with Ca Na2 EDTA edetate, or succimer with DMSA dimercaptosuccinic acid.
Hydrocarbons; do not induce vomiting.
Insulin; dextrose, glucagon, and octreotide for sulfonylureas.
isoniazid; vitamin B6, benzos, barbiturates.
Iron, Al: deferoxamine. Iron overload: deferiprone, deferasirox.
Local anesthetics: IV lipid emulsion 20%
Methotrexate; leucovorin (folinic acid), levoleucovorin (Fusilev), glucarpidase (Voraxaze)
Methemoglobinemia (benzocaine, dapsone, nitrates, sulfonamide); methylene blue except in G6PD, SSRI, and SNRI.
Amatoxin mushrooms; atropine.
Naphthalene mothballs; methylene blue.
Neostigmine, pyridostigmine; pralidoxime, atropine, glycopyrrolate.
Nicotine; early sx abdominal pain and nausea, late sx bradycardia. Atropine and benzos.
Paralytics; neostigmine methylsulfate for Roc, Vec, and Pan, or sugammadex for Roc or Vec.
Salicylates; bicarb.
Stimulants; benzos.
Alcohols; fomepizole or ethanol.
TCA: bicarb, benzos, vasopressors.
Valproate (hyperammonia); levocarnitine.
Organophosphate overdose and treatment
SLUDD: salivation, lacrimation, urination, diarrhea, defecation.
Atropine blocks ACh. Pralidoxime reactivates cholinesterase.
Combo is called DuoDote.
Usually caused by pesticides.
Antidotes to bites and stings
Animal bites generally: Rabies vaccine (RabAvert, Imovax) or human immune globulin (HyperRAB S/D, Imogam Rabies HT).
Black widow spider: Antivenin for Latrodectus mactans.
Scorpion stings: Antivenin immune FAB Centruroides (Anascorp).
Snake bites: Crotalidae polyvalent immune FAB (CroFab) for copperheads and rattlesnakes, and Crotalidae immune Fab2 (Anavip) for rattlesnakes.
