Pharmacy Foundations 2 Flashcards
Root Cause Analysis (RCA)
-a retrospective investigation of an event that has already occurred. The information obtained in the analysis is used to design changes that will hopefully prevent future errors
At risk behaviors that can compromise patient safety: Drug and Patient - Related
-failure to check/reconcile home medications and doses
-dispensing medications without complete knowledge of the medication
-not questioning unusual doses
-not checking/verifying allergies
At risk behaviors that can compromise patient safety: Communication
-not addressing questions/concerns
-rushed communication
At risk behaviors that can compromise patient safety: Technology
-overriding computer alerts without proper consideration
-not using available technology
At risk behaviors that can compromise patient safety: Work environment
-trying to do multiple things vs focusing on a single complex task
-inadequate supervision of orientation/training
The Joint Commission
Independent, not for profit organization that accredits and certifies hospitals –> main focus = safety
TJC: National Patient Safety Goals
-label all medication on and off the sterile field
-reduce hard associated with anticoagulant therapy (bleeding risk)
-maintain and communicate accurate patient medical information
-report critical results (labs and diagnostic) on a timely basis
-comply with CDC hand hygiene guidelines
-reduce health-care associated infections
avoid “do not use” abbreviations
-U, u –> write units
-IU –> write international units.
-QD,qd, QOD,qod –> write daily or every other day
-trailing zero: X mg or 0.X mg
-MS,MO4 –> write morphine sulfate, magnesium sulfate
High alert medications
-anesthetics (propofol)
-antiarrhythmics (amiodarone)
-Anticoagulants/antithrombotics (heparin, warfarin)
-Chemo (methotrexate)
-Epidural/intrathecal
-hypertonic saline
-Immunosuppressants (cyclosporin)
-Ionotropics (digoxin)
-Insulins
-Magnesium sulfate
-Neuromuscular blocking agents (vecuronium)
-opioids
-oral hypoglycemics
-parenteral nutrition
-potassium chloride
-sterile water
what kind of pts have contact precautions?
–> intended to prevent transmission of infectious agents which are spread by direct and indirect contact with the patient and the patients environment
-MRSA
-VRE
-C. diff
Universal precautions to prevent droplet transmission
-B pertussis
-influenza
-RSV
-adenovirus
-rhinovirus
-N. meningitides
-group A strep
Airborne precautions
-isolation room
-KN95 mask
Safe injection practices for healthcare facilities
-never administer an oral solution/suspension IV, use oral syringes
-never reinsert used needles into a multiple dose vial or solution container, single dose vials are preferred over multiple dose vials
-use engineered sharp protection needles, drawing the needle into the syringe barrel after use
-never touch the tip or plunger os syringe
-throw the entire needle/syringe assembly (needle attached to the syringe) into the red plastic sharps container
Type A reactions
-most ADRs
-dose-dependent and are predictable based on the drugs pharmacology
Type B reactions
idiosyntric- not predictable from drugs pharmacology (hard to predict and bad)
-can be influenced by patient specific factors
Type 1 hypersensitivity reaction
Immediate (within 15-30 mins of drug exposure).
-severity ranges from minor inconvenience to death :)
Type 2 hypersensitivity reaction
-minutes to hours after drug exposure
-hemolytic anemia and thrombocytopenia
Type 3 hypersensitivity reactions
-immune complex reactions
-they occur 3-10 hours after drug exposure
ex) drug induced lupus and serum sickness
Type 4 hypersensitivity reactions
-delayed reactions, they can occur anywhere from 48hrs to several weeks after drug exposure.
ex: PPD skin test
iPLEDGE program
progran for isotretinoin, requires a monthly pregnancy test
-get 30 ds at a time
Where are drugs and vaccine adverse events reported to?
-FAERS (FDA adverse event reporting system)
-VAERS (Vaccine adverse event reporting system)
Allergies
due to immune system response and can affect multiple areas (bronchoconstruction and severe drop in BP from taking codeine)
Intolerence
less severe complaints, such as nausea or constipation. Since the drug bothers the patient, it should be avoided if possible
Histamine release & tx
Urticaria: erythematous swelling of the skin, with prutitis (itching)
Angioedema: swellings caused by edema in the deeper dermal, cutaneous and sub-mucosal tissue
–> Prutitus & hives only?
OTC: diphenhydramine
RX: hydroxyzine
–> more than that?
-get airway open with epinephrine
-reduce swelling with steroids
-give antihistamine
Photosensitivity & Type -IV Hypersensitivity (delayed)
P: sunlight + drug = severe sunburn on sun-exposed areas
T IV: sunlight + drug = red, itchy rash that can spread to areas that were not exposed to sun; occurs within days of the sun exposure
Drugs most associated with photosensitivity
-Aminodarone
-Diuretics (thiazide and loop)
-Methotrexate
-Oral and topical retinoids
-Quinolones
-St. John’s wort
-Sulfa drugs
-Tacrolimus
-Tetracyclines
-Voriconazole
Photosensitivity protection/counseling points
-stay out of the sun 10am-4pm, including on cloudy days
-wear sun-protective clothing
-recommend ~SPF 30, broad spectrum (UVA-aging and UVB-burning)
-apply liberally and at least Q2 hrs and reapply after swimming or sweating
-keep infants out of the sun
SPF calculation =
take the usual time the person would burn and multiply by SPF –> 20 SPF x 15 min = 300 min –> BUT reapply q 2 hrs
Different types of spots & rashes
-Papules: raised spots
-Macules: flat spots
-Purpura: red/purple skin spots (lesions) due to bleeding underneath the skin
–> Petechiae: smaller lesions, < 3 mm
–> Ecchymoses: larger lesions, > 5 mm
-Hematoma: due to trauma; a collection of blood under the skin, visible or not
Thrombotic Thrombocytopenia Purpura (TTP)
-a blood clotting disorder in which clots form throughout the body, the clotting process consumes platelets and leads to bleeding under the skin with purpura
–> TTP can be fatal and should be treated immediately with plasma exchange
*KEY drugs associated: clopidogrel, ticlopidine, acyclovir, famiciclovir, quinine, sulfamethoxozole, valcyclovir
Key drugs associated with severe skin reactions
-allopurinol
-lamotrigine
-penicillins
-phenytoin
-piroxicam
-sulfamethoxazole
Key drugs associated with SJS/TEN
-Abacavir
-Carbamazepine
-Caspofungin
-Clindamycin
-Clopidogrel
-Deferasinox
-Ethosuximide
-Fosphenytoin
-Hydroxychloroquine
-Isavucinazonium
-Letrozole
-Minocycline
-Nevirapine
-Oseltamivir
-Oxacarbazepine
-Peramivir
-Phenobarbital
-quinine
-Terbinafine
-Tiagabine
Drugs associated with DRESS
-Carbamazepine
-Celecoxib
-Doxycycline
-Ethosuximide
-Fosphenytoin
-Gabapentin
-Ibuprofen
-Lacosamide
-Minocycline
-Olanzapine
-Oxacarbozempine
-Sulfasalazine
-Terbinafine
-Valpraote
-Vancomycin
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TENS)
S&S: 1-3 weeks after start of the offending drug, symptoms develop: malaise, fever, headache, cough and keratoconjunctivitis
-macules then appear suddenly, usually on the face,neck and upper trunk and then spread elsewhere on the body, coalescing inot large flaccid bullae and slough over a period of 1-3 days
TX: supportive care, cyclosporine, plasma exchange or IVIG and steroids
SJS rash: < 10%
TENS rash: > 30%
Erythema Multiforme (ME)
–> causes: herpes simplex virus, hep C, SLE, drugs
-morbilliform rash (looks like measles), with 1-20 mm lesions - in between the lesions is healthy skin
Drug classes that are likely to cause drug allergies
–>beta lactam: penicillin’s
–> sulfa allergies: sulfamethoxazole
–> opioids, heparin, biologics
–> ASA/NSAIDs = breathing difficulty
Drugs likely to cause allergic reaction with peanut/soy allergy
-Clevidipine (Cleviprex)
-Propofol (Diprivan)
-Progesterone in Prometrium capsules
Drugs likely to cause allergy with egg allergy
-Clevidine (Cleviprex)
-Propofol (Diprivan)
-Influenza vaccine, ok if only hives but with severe allergies: use FLBLOK
-yellow fever
Penicillin skin testing
-skin test to identify pts who are at greatest risk of a type 1 hypersentitivity reaction if exposed to a systemic penicillin
-can also be used to desensitize pts who need to have tx for sephalysis
Calculating Bioavailability
F = 100 * (AUC ex/ AUC IV) * (Dose IV/ Dose EX)
AUC- represents total drug exposure
Properties of drug molecules and their effects on drug distribution
-lipophilicity (affinity for lipids) - increased
-molecular weight - small weight is better
-ionization status - uncharged
-protein binding - low = more free drug in blood
formula for corrected calcium
calcium (reported/serum) + [ (4.o - albumin) * 0.8]
*use when pt has low albumin
formula for corrected phenytoin
total phenytoin measured / (0.2 * albumin) + 0.1
*use when pt has low albumin
Volume of distribution (Vd)
-relates amount of drug un the body to the concentration measured in serum or plasma
Vd = amount of drug in body / concentration of drug in plasma
–> small Vd = confined to plasma or extracellular space
–> large Vd = wide distribution to all body tissues
Clearance equations
cl = rate of elimination / concentration
cl = f* x dose - AUC
*for IV, use F = 1
first order elimination
(most drugs)
-constant PERCENT of drug is removed per unit of time-
zero order elimination
-constant amount of drug is removed per unit of time - MG STAYS THE SAME
Michaelis- Menten Kinetics
-also called saturable or non-linear kinetics
-there is a maximal rate of metabolism (Vmax)
-MM constatnt (Km) is the concentration at 1/2 Vmax
-inc dose leads to a disproportionate inc in concentration
–> can lead to toxicity
–> phenytoin, theophylline and voriconazole
Michaelis-Menten Kinetics study tip girl*
-most drugs follow first order (linear) kinetics:
–> at steady state, doubling the dose ~ doubles the serum concentration
-some drugs (phenytoin (dose adjustments should be made within the 30-50 mg range), theophyline and voriconazole) follow MM kinetics:
–> using a proportion to calculate a new dose is not appropriate
–> dosing adjustments must be made cautiously to avoid toxicity
Elimination rate constant (Ke)
-the fraction of the drug eliminated (cleared) per unit of time
ke = CL/Vd
Half life and steady state
-half life can be used to estimate % of. drug remaining or % of steady-state achieved
–> > 95% of drug is eliminated after 5 half lives
–> 95% of steady state will be achieved after 5 half lives
t1/2 = 0.693/Ke
Loading dose
-necessary for some drugs to rapidly achieve therapeutic concentrations
-helpful when 1/2 life is long relative to the frequency of admin
LD = desired concentration * Vd / F
Required/strongly recommended genomic testing
-abacavir (Ziagen) and combination products (Triumeq) - HLAB5701
-Azathioprine - TPMT
-Carbamazepine (Tegretol) - HLAB*1502
-Cetuximab (Erbitux) and panitumumab (Vectibix) - KRAS (want -)
-Trastuzumab (Herceptin), ado-trastuzumab emtansine (Kadcyla), lapatinib (Tykerb) and pertuzumab (Perjeta) - HER2 (want +)
Genetic test drugs results and what to do
avoid the drug when these pharmacogenomic tests are POSITIVE:
–> HLA-B: a positive test indicates inc risk of hypersensitivity
–> KRAS mutation: a positive test (often called KRAS mutant) predicts a poor response
avoid the drug when this pharmacogeenomic test is NEGATIVE:
–> HER2 expression: a negative result indicates a poor response
Interactions with prescription drugs: The 5 Gs
-Ginkgo
-Garlic
-Ginger
-Glucosamine
-Ginseng
(others = fish oil, vitmain E, willow bark)
dec platelet aggregation and inc bleeding risk
Interactions with prescription drugs: St. John’s wort
1) Borad spectrum enzyme inducer (CYP 3A4, 2C19, 2C9, 1A2) –> dec drug levels
-oral contraceptives: increases risk of ovulation and breakthrough bleeding
-transplant drugs: drug failure, organ rejection
-warfarin
2) serotonin syndrome: MAOI, SSRI/SRI, triptans (neuromuscular excitation, AMS, autonomic dysfunction)
3) photosensitivity
4) lowers seizure threshold
Dietary supp that induce liver toxicity
-kava
-chaparral
-comfrey
Dietary supps that induce cardiac toxicity
-Ephedra- removed from market
replaced by: bitter orange (synephrine) - reports of cardiac toxicity
-weight loss supplements
-pre-workout
-attention or focus supps
Commonly used natural medicine: anxiety
-valerian
-passoinflower
-kava
-st johns wort
Commonly used natural medicine: ADHD
omega -3 fatty acids
Commonly used natural medicine: cold sores
l lysine
Commonly used natural medicine: cold & flu
-echinacea
-zinc
-vitamin C
Commonly used natural medicine: dementia/memory
-ginko
-vitamin E
Commonly used natural medicine: depression
-st johns wort
-SAMe
-valerian
-5-HTP
-l tryptophan
Commonly used natural medicine: diabetes
-alpha lipoic acid
-chromium
-cinnamon
-bitter melon
-genseng
Commonly used natural medicine: hyperlipidemia
-fish oil
-garlic
-niacin
-fibers
Commonly used natural medicine: dyspepsia
-calcium
-magnesium
Commonly used natural medicine: energy/weight loss
- bitter oranges
-caffeine
-guaranta
Commonly used natural medicine:: erectile dysfunction
- ginseng
-l-arginine
-yohimbe
Commonly used natural medicine: HF
-co enzyme Q10
-hawthorn
-omega 3 fatty acids
Commonly used natural medicine: HTN
-omega 3 fatty acid
-l arginine
-coenzyme Q
-garlic
Commonly used natural medicine: GI health
-fibers
-chamomile
-probiotics
-peppermint
Commonly used natural medicine: inflammation
-omega 3 fatty acid
-flax seeds
-tumeric
Commonly used natural medicine: insomnia
-melatonin
-valerian
-chamomile
Commonly used natural medicine: liver disease
milk thisle
Commonly used natural medicine: menopause
-black cohosh
-dong qui
-primrose oil
-soy, red clover
Commonly used natural medicine: migraine
-feverfew
-butterbur
-magnesium
-riboflavin
Commonly used natural medicine: osteoarthritis
-glucosamine
-chondrotin
-SAMe
-tumeric
Commonly used natural medicine: osteroprosis
-calcium
-vitamin D
-soy
Iron need for children 4-6 months (breastfed)
need 1 mg/kg/day from 4-6 months old and until consuming iron rich foods
drugs that cause nutrient depletion
-loop diuretics: potassium
-Orlistat: beta-carotene, fat soluble vitamins
-PPIs: magnesium, vitamin B12
-Valproic acid: calcium
Conditions with recommended supplements
-alcoholism: vitamin B1/thiamine (wenickes), folate
-pregnancy: prenatal vitamin (calcium, folate)
common symptomatic treatments of overdose
-agitation: sedatives (benzos)
-bradycardia: atroptine, inotropes
-seizure: benzos
-hypertension: IV vasodilator
-hypoglycemia: dextrose
-hypotension: IV fluids, vasopressors
-QRS widening: sodium bicarbonate
-sedation: protection of airway with intubation
decontamination with activated charcoal
-non-absorbable adsorbent when indicated (within 1 hr of ingestion***)
-effective adsorbent of drugs/chemicals with a molecular weight of 100-1000 daltons
Dose = 1 g/kg
CI: hydrocarbon injection (gas) inc risk of aspiration,
phases of acetaminophen overdose
phase 1: 1-24 hrs, asymptomatic or non-specific (N/V)
phase 2: 24-48 hrs, inc INR, and AST/ALT
phase 3: 48-96 hrs, fulinanat hepatic failure (irreversible injury/ death)
phase 4: > 96 hrs, recovery or liver transplant
N-acetylcysteine tx
-Cetylev PO or IV Acetadote
-restores hepatic glutsthoine (acts as a glutathoine substrate)
Oral: 140 mg/kg x1, followed by 70 mg/kg every 4 hrs x 17 additional doses. repeat the dose if emesis occurs within 1 hr of admin
IV: 150 mg/kg IV over 60 mins, followed by 50 mg/kg IV over 4 hrs, followed by 100mg/kg IV over 16 hrs
Initial management of suspected opioid overdose
-call 911 if pt is unconscious, having difficulty breathing, agitated, or is having a seizure
-ensure pts airway, breathing and circulation is meintained
-attempt to identify substance/s of OD:
–> opioid overdose can present as slowed breathing, pinpoint pupils, AMS, and/or unconsciousness
–> adminster naloxone if any potential for opioid overdose
–> Naloxone is not harmful if opioids are not present
–> when in dount, just give it
Anticholinergic antidotes
ex: diphenhydramine, scopolamine, atropa belladonna (deadly nightshade)
–> antidote = physostigmine (only in severe cases)
Symptoms:
-hot as a hare (fever)
-dry as a bone (mucous mems)
-blind as a bat (large pupils)
-red as a beet (flushing)
-mad as a hatter (delirium)
Organophosphate antidote
ex: industrial insecticides, nerse gases,
–> antidote: atropine and pralidoxime (DuoDote, ATNAA)
Symptoms: SLUDD
Salivation
Lacrimation
Urination
Diarrhea
Defecation
Cardio med antidotes (digoxin, BBs, CCBs)
-Digoxin, plants contianing digitalis –> DigiFab
-BBs –> glucagon
-CCBs –> IV calcium
Anticoagulants antidotes
- Warfarin –> phytonadione (vit K), prothrombin complex concentrates (Kcentra)
-Heparin, LMWH –> protamine
-factor Xa inhibitors: Kcentra,
–> for apixaban and rivaroxaban: coagulant factor Xa recombinant (Adexxa)
-direct thrombin inhibitors: idarucizumab (Praxbind)
Additional antidotes to know
- bezos: flumazenil
-cyanide: hydroxocobalamin
-hydrocarbons: keep NPO
-sulfonylureas: octreotide
-Isoniazid: pyridoxine (B6)
-Iron: deferoxamine
-methotrexate: (leucovorin)
-paralytics: neostigmine, suggamadexx (roc or vec)
-salicylates: sodium bicarb
-stimulants: supportive care
-antifreeze: fomepizole
rabies antidote
-virus transmitted through contanct with salivia or fluid from an infected animal
Antidote: human rabies immune globulin (HyperRAB S/A)
–> provides immediate antibodies - given at the same time as the rabies vaccine
Snake bites
rattlesnakes and copperheads
antidote: crotalidae polyvalent immune Fab (CroFab)
genetic testing for abavacir
-HLA-B*5701
+ ptd are at inc risk for a hypersensitivity reaction; test all pts prior to starting
genetic testing for allopurinol (Zyloprim, Aloprim)
-HLA-B*5801
+ pts are at inc risk of SJS
genetic testing for carbamezepine, oxacarbazepine, phenytoin, fosphenytoin
-HLA-B 1502
*ocarbazepine: required for all asian pts
+ pts at risk for SJS and TEN
select drugs with CYP450 polymorphisms: Clopidogrel (Plavix)
CYP2C19
-pro drug, poor metabolizers are at inc risk of cardiovascular events
select drugs with CYP450 polymorphisms: codeine
CYP2D6
-prodrug, ultra metabolizers are at inc risk of opioid overdose due to extensive conversion to morphine
–> infant deaths have occurred when nursing mothers who were ultra-rapid metabolizers took codeine for pain
select drugs with CYP450 polymorphisms: Warfarin (Jantoven)
CYP2C9*2 and *3, VKORCL
-increased bleeding risk (start at a lower dose)
Pharmacogenomic testing for: Trastuzumab (herceptin)
HER2 gene
-requires over expression of HER2 for efficacy
Pharmacogenomic testing for: Cetumimab (Erbitux)
KRAS mutation
-do NOT use w/ KRAS mutation
Pharmacogenomic testing for: Azathioprine (Azason, Imuran)
Thiopurine methyltransfrase (TPMT)
-low/absent TPMT activity can inc the risk of severe, life threatening myelosuppression
Pharmacogenomic testing for: Capecitabine (Xeloda)
DPD deficiency
-deficiency can inc risk of severe toxicity
genetic testing: what does a + or - test require action? *
AVOID these drugs when tests are POSITIVE:
–> HLA-B (inc risk of hypersensitivity)
–> KRAS mutation (predicts poor outcome)
AVOID these drugs when tests are NEGATIVE:
–> HER2: indicates a poor outcome
Key drugs that genetic testing is required or strongly recommended*
-Abacavir & combo products
-Axathioprine
-Carbamazepine
-Cetuximab & other EGFR inhibitors
-Trastuzumab and other HER2 inhibitors
