Test 2 Flashcards
What is the mechanism of action of NSAIDs?
inhibit COX 1 and COX 2 to promote anti-inflammatory process
What are the side effects of NSAIDs?
GI upset, GI bleeds, renal impairments, salicylism
What are the symptoms of salicylism?
tinnitus, sweating, headache, dizziness
What NSAID is salicylism associated with?
aspirin
When are NSAIDs contraindicated?
- Children with fevers due to the possibility of Reyes Syndrome
- Celecoxib in pregnancy due to teratogenic effects
How do you select an opioid?
- Pain untreated with lesser medications
- Short duration of time and re-evaluated
What is the current prescribing guide for med-niave patients in regard to opioids?
They can only recieve a 72-hour prescription and need to be re-evaluated in 72-hours to see if medication can be titrated to a less strong medication
Is morphine or codeine a stronger opioid agonist?
morphine is stronger than codeine
What is codeine most commonly used for?
cough suppression
What substance class is morphine?
Schedule 2
What substance class is fentanyl?
Schedule 2
How long does it take for opioid tolerance to develop?
As few as 5 days
How long does opioid withdrawal take?
7-10 days
Is opioid withdrawal dangerous?
No, it is just unpleasant
What is the medication prescribing pathway for pain treatment?
- Non-pharm
- Acetaminophen and NSAIDS
- Opioids or tramadol
What are the side effects of opioids?
respiratory depression, sedation, increased ICP, orthostatic hypotension, constipation, urinary retention, cough suppression, miosis
What is the reversal agent for opioids?
Narcan (opioid antagonist)
What is the reversal agent for acetaminophen?
Acetylycysteine
What are “red flags” for opioid seeking behaviors?
Use more than prescribed, subjective does not match objective pain indicators, frequent requests for refills
How are opioids tirtrated?
Based on their morphine conversion
What medications are used for the treatment of CODP?
bronchodilators, LABAs, long-acting anticholinergics, inhaled corticosteroids
What medication is recommended for COPD patients with 0-1 moderate exacerbations with a CAT score < 10 and no hospitalizations?
a bronchodilator
What medication is recommended for COPD patients with 0-1 moderate exacerbations with a CAT score >10 and no hospitalizations?
a LABA or a LAMA
What medication is recommended for COPD patients with >/= 2 moderate exacerbations with a CAT score <10 and at least one hospitalization due to symptom exacerbation?
LAMA
What medication is recommended for COPD patients with >/= 2 moderate exacerbations with a CAT score >10 and at least one hospitalization due to symptom exacerbation?
LAMA
LAMA + LABA (CAT >20)
LABA + ICS (eos >300)
When can a LABA be used as monotherapy?
COPD only, can increase catastrophic events in asthma 2-fold (Black box warning)
What medications are used for asthma?
SABA, ICS, LABA, theophyline, omalizumab
What is the first line therapy that all asthmatics should be prescribed?
Short-acting bronchodilators (SABA)
What is the second line therapy for patients who progress past intermittent asthma?
inhaled corticosteroids
What is the meds are classified as the short-acting bronchodilators? (SABAs)
albuterol
What is the mechanism of action of SABAs and LABAs?
promote smooth muscle relaxation to help enhance breathing
What is the time frame of action of the SABAs?
almost immediate action, peak 30-60 minutes, duration 3-5 hours
What is the time frame of action of the LABAs?
onsets vary for the drug but will take a few hours for onset, do not help with short-term relief
What are the side effects of SABAs?
tachycardia, angina, tremors
What are the side effects of LABAs?
same as the SABAs, but they do carry a black box warning for increased risk of severe asthma and should not be used as a monotherapy for asthma patients
When are PO beta agonists used?
for long-term asthma control in patients who are unresponsive to other treatments, last line
When are inhaled corticosteroids (ICS) used?
When asthmatic patients are deemed to have persistent asthma symptoms or as a last line for patients with COPD with a CAT >20
What is the mechanism of actions of ICS?
help suppress inflammation, reduce bronchial reactivity, and decrease airway mucus production
What are side effects of ICS?
candidiasis (primarily of the tongue and throat), dysphonia, adrenal suppression (in high doses, long-term), stunted growth (in children), cataracts, and glaucoma
What is the mechanism of action of the long-acting anticholinergics (LAMAs)?
They block the muscarinic cholinergic receptors promoting smooth muscle relaxation
What are the side effects of the LAMAs?
Cough, dry mouth, constipation, urinary retention
What is a cross sensitivity for LAMAs?
Soybean and legume allergies, can have similar allergic reactions to LAMAs
What is the SABA drug prototype?
albuterol
What is the LABA drug prototype?
Salmeterol
What are the ICS drugs?
Fluticasone, Budesonide (-sone/-ide)
What are the LAMA drugs?
Ipratropium bromide and Tiotropium bromide
What is Symbicort, Breo, and Advair?
Beta 2 agonist combined with glucocoriticoids
When are the B2/Glucocoricoid combination medications used?
When patients are not well controlled on an ICS alone, 3rd step in asthma treatment, last step in GOLD treatment of COPD
What are Combivent, Anoro, and Utibron neohaler?
Beta 2 agonist combined with long-acting anitcholinergics
When are the LABA/LAMA combination medications used?
When a patient needs optimal bronchodilation and have not achieved this goal on other medications alone, COPD last line only at present time
What are the leukotriene modifiers?
Montelukast (Singular)
What is the mechanism of action of the leukotriene modifiers?
play a significant role in the inflammation process to reduce inflammation and promote smooth muscle relaxation
What are the side effects of leukotriene modifiers?
headache, fever, GI upset, mylagias, infection, neuropsychiatric symptoms
When are leukotriene modifiers indicated for use?
When glucocorticoids are not well tolerated or in conjunction with glucocoriticoids, step 3 of the asthma step chart (moderate persistent asthma)
Who cannot take leukotriene modifiers?
Pregnant and breastfeeding women
What is the safest medication for pregnant women with asthma?
Beta 2 agonists (SABAs and LABAs)
What are some patient education points with inhaled medications?
Use as directed
SABAs should be carried at ALL times
Rinse mouth out after administration to prevent candidiasis especially in patients taking ICS
Spacers are helpful with MDIs to get the timing properly
Inhaler technique education
What is the mechanism of action of theophyline?
promotes bronchial smooth muscle relaxation, CNS stimulation, increased eGFR, increased gastric production
What are the side effects of theophyline?
irritability, restlessness, seizures, insomnia, GERD, tachycardia, palpitations, hypotension
What is the therapeutic window of theophyline?
less then 15
What is theophyline toxicity considered at?
a level of 20
S/S include seizures, N/V/D, insomnia, irritability, hyperglycemia, brain damage, death
When is theophyline indicated?
severe asthma unresponsive to conventional treatments, last line, fallen out of favor due to narrow therapeutic window and multiple side effects and drug/food interactions
What are the medications for TB?
INH-RIF-PZA-EMB
Isoniazid-rifampin-pyrazinamide-ethambutol
What medication class if used for decongestants?
alpha agonists
What is the mechanism of action of the alpha agonists in regards to decongestion?
they stimulate the alpha receptors of the respiratory tract to promote vasoconstriction
What effects do the oral decongestants have?
They promote temporary relief of nasal congestion, drainage of ear and sinus fluid, and relieve eustachian tube congestion
What effects do the topical decongestants have?
Direct stimulation of the alpha receptors
Relieve nasal congestion and ear pressure
What are phenlyepherine and afrin?
topical decongestants (nasal sprays)
What are phenlyepherine and pseudoephedrine?
oral decongestants
Who are decongestants contraindicated in?
Pts on MAOIs, severe HTN, or CAD
What decongestants can a patient with severe HTN or CAD take?
The coricidin brand the is specialized for pt with HTN and CAD (red heart on the box)
What are the side effects of decongestants?
dryness, tingling sensation (nasal), burning (nasal), HTN, tachycardia, restlessness, tremors, rebound congestion with continued use
Why does pseudoephedrine need ID verification for purchase?
It can be abused to make meth
How does a patient know if a medication contains pseudoephedrine on quick glance?
It is the ‘D’ in medications (ie Allegra-D, Claritin-D, etc)
What medications are the anithistamines?
Diphenhydramine and the -dine family of medications
What is the mechanism of action of the antihistamines?
block the histamine receptor site to block the histamine response, decrease inflammation and itching
Which antihistamine does not produce the side effect of drowsiness?
The second generations (-dine and zyrtec)
Who are first generation (diphenhydramine) antihistamines contraindicated in?
Infants and Children due to the sedative properties
What is the pregnancy category for diphenhydramine?
Category B
Which second generation antihistamine is safest for children to use?
Cetrizine (zyrtec) and desloratadine syrup is safe for children 6 months and older
Which second generation antihistamine cannot be used in children until at least 6 years old?
Fenofexadine
What is an off-label use for diphenhydramine?
sleep aid due to it’s sedative properties
What are side effects of the antihistamines?
fatigue/drowsiness (1st gen)
dizziness, headache, urinary retention, N/V, blurred vision, tremors, dry mouth, constipation or diarrhea
When are antihistamines used?
Allergies (PO or topical), hypersensitivity reactions, rashes (topical), motion sickness/antiemetic, night time sleep aid (1st gen)
Which antihistamines require a prescription?
Anitvert (for vertigo)
Hydroxyzine (itch relief, anti-anxiety)
What medications are antitussives?
Dextromethropan, codeine, benzonatate
How would a patient recognize if there is dextromethropan in their antitussive?
It is the ‘DM’ in the medication (ie Mucinex-DM, Robitussin-DM, etc)
What is the mechanism of action of dextromethropan and codiene?
They increase the threshold for cough in the central medulla
What is the mechanism of action of benzonatate?
It interferes with the stretch receptors to decrease the responsiveness to need to cough
Who are antitussives contraindicated in?
Patients who cannot clear their secretions as they need the cough receptor to move secretions and prevent aspiration PNA
How long should a patient take an antitussive?
No more than 7 days, if cough lasts longer than 7 days, should seek out medical attention for possible underlying conditions
Should a patient with a chronic cough take an antitussive?
No, they should have the underlying condition that causes the cough treated prior to treating the cough itself
What should a patient with a post-nasal drip take as an antitussive?
Benzonatate as it numbs the stretch receptors and best responds to this medication
What is Mucinex considered?
An expectorant medication
What is the mechanism of action of an expectorant?
It thins the secretions by decreasing the adherence of the secretions through decreased surface tension and increase the water in the bronchi
What are the side effects of Mucinex?
N/V/D, GI upset, dizziness, rash, headache
What should a patient on Mucinex be educated on?
Staying hydrated as the medication depends on water to promote it’s mechanism of action causing drying effects
When is acytelcysteine (Mucomyst) used?
In CF or COPD pts or for acetaminophen overdose
What is the mechanism of action of Mucomyst?
It breaks the bonds of the secretions to thin secretions for the patient to clear them easier
What is the most common treatment for smoking cessation?
Nicotine replacement therapy
What is a patient education for nicotine gum and lozenges?
Do not eat or drink for 15 minutes before or while using the treatment
What is a patient education for nicotine patches?
Rotate sites, do no use the same site for 1 week, remove after 12 hours
Who are the nicotine inhalers contraindicated in?
Patients with asthma
What is a patient education point for patients using any type of nicotine replacement therapy?
They cannot smoke while using the therapy as it will increase their risk for nicotine toxicity
What are the 5 A’s of tobacco dependence?
Ask (screen all pts)
Advise to quit
Assess willingness to attempt quitting
Assist with quitting (replacement therapy or drug therapy)
Arrange follow up appointments (within 1st week beginning treatment)
Why is bupropion used for smoking cessation?
It reduces the urge to smoke and helps alleviate the anxiety and irritability feelings from nicotine withdrawal
What are side effects of bupropion?
dry mouth and insomnia
Why is chantix used for smoking cessation?
It is a partial agonist at the nicotine receptors to help promote smoking cessation
What are the side effects of chantix?
N/V, sleep disturbances, headaches, abnormal dreams, dry mouth, constipation, neuropsychiatric events
Who cannot be prescribed chantix per the US FDA?
truck drivers, bus drivers, pilots, airplane traffic controllers
What is the mechanism of action of antacids?
They neutralize the pH of gastric acid
What are the types of antacids?
Calcium-based, Magnesium-based, Aluminum-based
What base is tums?
Calcium
What base is mylanta and maalox?
Aluminum
Which base-cation combination have the most neutralizing capacity for antacids?
sodium bicarb-calcium carbonate
When should antacids be administered?
1-3 hours after meals with gastric pH is highest
When should antacids be dosed as compared to other medications?
2 hours apart from other medications as lowering the gastric pH will cause alterations in absorption of the medications
Who should not take calcium based antacids?
Patients with renal stones or hypercalcemia
Who should not take magnesium based antacids?
Patients with renal failure or insufficiency
Who should not take aluminum based antacids?
Patients with ESRD on dialysis
What should patients be cautious of in regards to antacids if they have HTN, CHF, renal failure?
the cation in the antacid, especially if it is sodium bicarb as that will promote fluid retention and worsening of underlying conditions
What are the side effects of the magnesium based antacids?
diarrhea
What are the side effects of the calcium and aluminum based antacids?
constipation
How long should a patient be taking antacids?
No longer than 2 weeks, if taking for longer than 2 weeks contact PCP to treat underlying condition of the gastric acid elevation
What should patients be counseled on to help alleviate the symptoms of increased gastric pH to accompany the relief of symptoms?
Smoking cessation, decrease alcohol intake, avoid spicy and fatty foods, elevate HOB while sleeping, decrease caffeine intake
What is the first consideration when deciding on an antidiarrheal?
What is the cause (infectious, drug/food induced, IBS)
What do patients experiencing diarrhea need to be educated on?
Remaining hydrated as diarrhea can promote dehydration very quickly (children and elderly very susceptible to dehydration)
What is the mechanism of action of Kaolin?
It attracts the bacteria and holds it to promote excertion
What is the mechanism of action of pectin?
It thickens the stool
What is the mechanism of action of bismuth?
It helps promote antisecretory and antimicrobial effects
What is a common side effect of bismuth?
black tongue and black stools
What is the mechanism of action of loperamide?
It binds to the opioid receptors to slow gastric motility
What is the side effect of all the antidiarrheal medications?
Constipation
Who are antidiarrheals contraindicated in?
children
What is a dangerous side effect of loperamide?
It can decrease motility to the point that toxic megacolon develops
When are kaolin, pectin, or bismuth administered?
After each loose stool (binding effects)
What are the medication commonly used as prevention for travelers diarrhea?
Bismuth
What medication is most effective for patients with IBS-D?
Loperamide
Can any antidiarrheal be given for treatment of diarrhea?
Yes
What medications are used as antiemetics?
Antihistamines, phenthiozines, sedative hypnotics, cannabinoids, 5-HT3 receptor antagonists
What are the mechanism of action of the antihistamines?
They block histamine receptors and can have anticholinergic effects
What is the mechanism of action of the phenothiazines (pheregan, reglan)?
They block the dopamine receptors in the chemoreceptor trigger zone
What is the mechanism of action of the cannabinoids (dronabinol)?
they work in the CNS to prevent nausea and vomitting
What is the mechanism of action of the 5-HT3 receptor antagonists (zofran)?
the block serotonin and vagal nerve triggers in the chemoreceptor trigger zone
What antihistamines are used in the treatment of emesis?
Dimenhydrinate and meclizine for motion sickness
What medications are used for N/V related to gastroparesis?
5-HT3 antagonists (zofran), phenothiazines (phenergan, reglan), cannabinoids (dronabinol)
How often do patients on long-term pheregan and reglan need labs?
Week 4 and Week 10 of therapy
What labs are monitored in long-term pheregan and reglan use?
CBC to monitor for bone marrow suppression and dycrasias
When should patients take their antiemetics?
1-2 hours before movement for motion sickness
30-60 minutes before intended trigger (cancer treatment)
What education do patients taking antiemetics need?
Remain hydrated as many of the medications cause drying side effects
Consider electrolyte replacement if experience emesis to prevent dehydration and electrolyte abnormalities
What medications are used in the treatment of GERD?
H2RAs, PPIs, antacids
What medication is safer from long term GERD treatment?
H2RA
What is the mechanism of action of the H2RAs (-tidine)?
block the histamine receptors to prevent binding, thus reducing the proton pump action and decreasing gastric acid secretion
What is the side effects of the H2RAs (-tidine)?
gynecomastia, impotence, confusion, agitation, psychosis, depression, agranulocytosis
What labs should be monitored with patients on an H2RA?
LFTs with long-term, high-dose therapy, CBC if suspected anemia
Which H2RAs can be prescribed to children?
Ranitidine and famotidine
What is the pregnancy category of H2RAs?
Category B
Which patient population do H2RAs need to be cautioned with?
renal and liver impairment
When should H2RAs be administered?
with meals
What are some patient education points for patients taking H2RAs?
Take with meals, do not take with an antacid, smoking cessation is important as smoking will decrease the absorption, alcohol should be reduced as it will increase gastric irritation
What is the mechanism of action of the PPIs (-prazole)
block the proton pump itself from secreting gastric acid (90% secretion reduction)
How long can PPIs be used for?
8 weeks and then should be tapered off
Why should PPIs not be used for long-term therapy?
They carry increased risk of osteoporosis and fracture due to the decrease in absorption of iron, Vit B12 and calcium
Why is there an increased risk for pneumonia with PPIs?
The decrease in the gastric pH
When weaning a PPI, can a patient also be taking an H2RA?
Yes, starting an H2RA when weaning a patient off of a PPI can help alleviate the symptoms of GERD that can begin with the weaning process and can be used to transition the patient to an H2RA for longer term use if they need if for symptom management
What is the pregnancy category for PPIs?
Category B or C depending on the medication
Can children take PPIs?
Yes, they can take esomeprazole, omeprazole, and lansoprazole can be used short term for children 1 year or older
Pantoprazole and rabeprazole are not for children until the age of 12 or older
What patient population are PPIs greatly cautioned with?
Liver failure and elderly do to the extensive liver metabolism required
Who would be considered for prescribing a weight loss medication to?
- BMI of 30 or greater
- BMI of 25-29.5 plus two risk factors
- Waist circumference of 40 (men) or 35 (women) plus two risk factors
What is the only OTC treatment approved for long-term use for weight loss?
Orlistat
What are the side effects of Orlistat?
GI upset, liver damage, kidney stones, pancreatitis, loose stools, GI leaking
What is the mechanism of action of Belviq?
It promotes the feeling of fullness, thus decreasing appetite
What is the mechanism of action of Adipex?
It is a CNS stimulant so it promotes an increase in norepinephrine thus decreasing appetite
Who cannot be prescribed Adipex?
Cardiac patients as this is a CNS stimulant and will exacerbate their condition
What medications are effected by Orlistat?
Warfarin (decreased Vit K can increase warfarin levels), levothyroxine (decreased absorption), and fat-soluble vitamins (decreased absorption, can take supplements 2 hours before or after to prevent this issue)
What is the goal of weight loss treatment?
5% weight loss in 12 weeks
If a patient does not achieve a 5% weight loss in 12 weeks, what is the next step?
Stop the medication and consider other treatment pathways
What is a side effect that can occur with weight loss treatment and diabetic patients?
As the patient loses weight, they have an increased sensitivity to their insulin needs, their diabetic medications will need to be adjusted to help prevent hypoglycemic episodes
What is an education point for a patient receiving Contrave for weight-loss?
Report suicidal thoughts and depression to provider as there is an increased risk as a side effect of the medication
When is thyroid replacement therapy indicated?
In patients with an elevated TSH
What is the common lab to monitor for hypothyroidism?
TSH with reflex T4
What is a normal TSH?
0.4-4.0
What is hypothyroidism marked by?
An elevated TSH to compensate for the low T4/3
What is the first line therapy for hypothyroidism?
Levothyroxine (T4)
What other medication can be given for hypothyroidism?
Livothyronine or Liotrix
What is the characteristic signs for hyperthyroidism?
elevated T3 levels and low TSH
What are the drug therapies for hyperthyroidism?
PTU and methimazole
What is the mechanism of action of PTU and methimazole?
They block the synthesis of thyronine to help reduce the T3 levels
What is the length of time that PTU and methimazole need to be used for?
18-24 months to achieve euthyroidism, if you take a patient off too soon their hyperthyroid state will return
What is the length of time that hypothyroidism need to be treated for?
Life-long treatment
What is the pregnancy category for levothyroxine?
Category A
What is the pregnancy category for PTU and methimazole?
Category D (crosses placenta, cannot take while breastfeeding)
What labs need to be monitored with PTU and methimazole?
CBC, thyroid panel, LFTs, kidney functions
How often are labs indicated with PTU and methimazole?
1-2 weeks after starting the drug initially
What is the mechanism of action of allopurinol?
blocks purine metabolism to reduce the production of uric acid
What are the side effects of allopurinol?
First dose gout flare, GI upset, diarrhea
What is the mechanism of action of colchicine?
inhibits migrations of the uric crystals and reduces the inflammation
What are the side effects of colchicine?
GI toxcity, N/V/D, abdominal pain, decreased bone marrow function, rhabdo
When are allopurinol or colchicine used?
For acute flare maintenance or prophylaxis
What are probenecid and sulfinpyrazone used for?
Acute gout flare prophylaxis
What is the mechanism of action of probenecid?
Inhibits the renal tubular reabsorption of uric acid
What is the mechanism of action of sulfinpyrazone?
Inhibits renal tubular reabsorption of urate and it inhbitis platelet prostagladin synthesis
When would probenecid and sulfinpyrazone be started?
After an acute flare attack, they cannot be started during an attack
What do you want to monitor with antigout medications?
BUN/Cr as they all have significant effect on the kidneys
What is the pregnancy category of probenecid?
Category B
What is the pregnancy category for sulfinpyrazone?
Category D
What is the pregnancy category for allopurinol and colchicine?
Category C
Who should not be given probenecid or sulfinpyrazone?
Patients with a sulfa drug allergy as there is cross-sensitivity with these medications
What medication is best for an acute gout flare?
Colchicine
What medication is best for patients with an overproduction of uric acid and renal dysfunction?
Allopurinol
What medication is best for secondary gout?
Allopurinol
What medication is best for a patient that under-secretes uric acid and has proper kidney functions?
Probenecid
What medication is the last line for acute gout treatment?
Sulfinpyrazone
What medications are used for dermatitis?
Topical corticosteroids, antipyretics, emollients, antibiotics (if infected)
What medications are used for acne?
Topical retinoids (Differin, Retin A, Epiduo), topical antibiotics, oral antibiotics (long-term tetracyclines), Accutane (iPLEDGE promise needed), oral contraceptives (estrogen based, women only)
What medications are used for psoarsis?
Topical corticosteroids (high potency), coal tar, anthralin (rarely used), Vitamin D3 derivatives, phototherapy and PO drugs (under specialist only)
What are the treatments for rosacea?
topical metronidazole, oral tetracyclines, avoiding triggers
What is the treatment of skin infestations?
Permetherin 5% (whole family treated, on for 8-14 hours, repeat in 2 weeks), Lindane
What is the treatment for lice?
Permetherin 1% shampoo (leave on for 10 minutes, repeat in 1 week), Pytherins (leave on for 10-20 minutes, repeat in 1 week), Ivermectin (resistant lice)
What it the treatment for alopecia androgenetica (male patterned baldness)?
Topical minoxidil or finasteride
What is the treatment for burns?
Silver sulfadiazine (falling out of favor for bacitracin instead)
What are silver nitrate and Podocon-25 used for?
They are cauterizing agents most commonly used for “freezing warts”
What is drysol used for?
It is an astringent used to prevent excessive sweating
What is the iPLEDGE with Accutane?
Accutane is highly tertatogenic, the patient, provider and pharmacist must adhere to the pledge. Patient needs 2 negative pregnancy tests prior to starting medication, 1 negative every month for continuation of medication, and must be on 2 forms of birth control
What is a consideration with PO finasteride for male patterned baldness?
The patient/partner need to used pregnancy prevention as a pregnancy while the patient or partner is taking the medication can cause fetal deformities or demise
