Carbamazepine (Tegretol) can sometimes show subtherapeutic range due to what?
Carbamazepine auto-induces metabolism, leading to lower levels despite good compliance
What are the black box warnings for Carbamazepine?
Dermatologic reactions
- Steven’s Johnson
- Toxic epidermal necrolysis
What lab test should be ordered for patients on Carbamazepine?
CBC every 3-4 months because it can cause decreased WBC, decreased platelets, and trouble with RBC
What kind of teaching needs to be done with families of patients who have seizure disorders?
Prevention is important, patient safety is important, Do NOT abruptly stop taking medication.
Ethosuximide (Zarontin), an anti-seizure medication can cause what?
Blood dyscrasias
Patients taking Topiramate need to be monitored for what electrolyte imbalance?
Decreased sodium bicarb leading to hyperchloremic metabolic acidosis
Topiramate treats seizures and what is one common side effect?
Normal side effect is weight loss, especially in higher dose patients
A child on Topiramate that wants to play sports should monitor what?
Don’t get overheated. Topiramate may affect his ability to sweat in the heat.
What should a pregnant patient be told about taking Valproate (Depakote)?
It is a known teratogen and category X medication. It should not be used in the first trimester, it may be restarted in second trimester.
What patient population should tricyclic antidepressants be used cautiously in?
Heart Disease patients
Phenelzine (Nardil) is a MAOI. What teaching needs to be done with this medication?
He should not use serotonergic drugs like Imitrex. Also, this class of medication interacts with yogurt, sour cream, soy sauce, etc.
Phenelzine (Nardil) may cause what if there is an interaction with known contraindicated foods?
Hypertensive crisis
What are the side effects of tricyclic antidepressants?
Anticholinergic type effects like dry mouth, sedation, constipation, increased appetite, blurred vision, tinnitus, euphoria, mania
How long does it take for SSRIs to take effect
2-6 weeks
SSRIs may cause what onset of action symptoms?
Nausea, but this will usually resolve in a week.
What is one thing you should not do with SSRIs?
Drink alcohol
What should happen when going off an SSRI?
Wean slowly, do not stop abruptly
What medications would a patient with depression and anxiety respond well to?
Buspar and an SSRI combined
Celexa (Citalopram)
Lexapro (Escitalopram)
Why should you combine an SSRI with Buspar?
Buspar augments the SSRI and is a good combo for anxiety and depression
What is a first line drug for mild to moderate generalized anxiety disorder?
Buspirone
How fast does Celexa start to demonstrate effects?
Improved appetitie and concentration in 1-2 weeks.
What is a major drug to treat bipolar disease?
Lithium
Blood levels need to be monitored with Lithium because why?
Lithium has a narrow therapeutic range so it is important to recognize toxicity
What are symptoms of lithium toxicity?
Drowsiness and Nausea
What dietary teaching needs to be done with patients taking lithium?
Salt intake needs to be consistent
What are the side effects of SSRIs (selective seratonin reuptake inhibitor)?
N/V, dizziness, light headedness, dry mouth, increased sweating, weight changes, agitation, sexual side effects.
What are the side effects of SNRIs (serotonin norepinephrine reuptake inhibitor)
Headache, somnolence, dizziness, insomnia, nervousness, dry mouth, constipation, abnormal ejaculation, anorexia/weight loss, elevated BP
What are the side effects of MAOIs?
Insomnia, anxiety, agitation, dizziness, headache, restlessness, hypotension, dry mouth, blurred vision, constipation
What Benzo has the greatest likelihood of dependence?
Xanax /alprazolam
What receptors do Benzos act on?
Enhances the neurotransmitter GABA (gamma-aminobutyric acid) receptors
What result do Benzos have on the body?
sedative
hypnotic
anxiolytic
anticonvulsant
muscle relaxer
What are long acting Benzos prescribed for?
Treatment of anxiety
What are short acting Benzos prescribed for?
Treatment of insomnia
What would be a good medication to prescribe for panic disorder?
Diazepam (Valium)
What is a anorexiant medication to treat obesity?
Phentermine
What is a precaution with Phentermine?
Anorexiants may cause tolerance and should only be used for 6 months
What medications or herbals should be avoided with Phentermine? Why?
SSRIs and St. Johns Wort…the combination may cause serotonin syndrome
Phentermine releases what two chemicals?
Epinephrine and norepinephrine
Epi and norepi causes what to break down?
Fat cells to break down stored fat
What are Signs and symptoms of seratonin syndrome?
Headache, agitation, mental confusion, hallucinations, coma
What are autonomic effects that you can get from seratonin syndrome?
Shivering, sweating, hyperthermia, vasoconstriction, tachycardia, nausea, diarrhea
What factors place a patient at risk for developing antimicrobial resistant organisms?
Inappropriate use of antibiotics
Children less than 2 years of age
Adults older than 65 yrs of age
Patients who do not finish their antibiotic regimen
What are appropriate antibiotics to prescribe to pregnant women and children?
PCN or Cephalosporins
(Amoxicillin, or Augmentin)
Which antibiotics inhibit cell wall synthesis?
Beta-lactam antibiotics
Vancomycin
Why is clavulanate added to Amoxicillin?
Clavulanate is a Beta-lactam inhibitor. This increases the spectrum of action and is effective at preventing amoxicillin-resistant bacteria that produce Beta-lactamase
What type of antibiotics should be avoided in children and pregnant women?
Tetracycline, fluoroquinolones
What is a normal side effect of amoxicillin?
Diarrhea and it is recommended to continue to take the medicine, drink lots of water, and take probiotics daily, eat yogurt
The American Heart Association recommedations for prophylaxis antibiotic use prior to dental care are…
- Prosthetic cardiac valve or prosthetic material used in valve repair
- Previous Endocarditis
- The following congenital diseases
I. Unrepaired cyanotic congenital heart disease including palliative shunts and conduits
II. Completely repaired congenital heart disease with prosthetic material device, whether placed surgically or with a catheter for 6 months following the procedure
III. Repaired congenital heart disease with residual effects at the site or adjacent to the site of a prosthetic patch or prosthetic device which inhibit endothelialization
IV. Cardiac transplantation recipients with cardiac valvular disease
What antibiotic is used for dental appointments?
Amoxicillin 2 gm for adults
50mg/kg in children
What should fluoroquinolones be reserved to treat?
Community acquired pneumonia in patients with comorbidities and Hospital acquired pneumonia
What is the black box warning for fluoroquinolones?
It may cause tendon ruptures. Specifically of the achilles tendon.
What medication can be affected with the use of fluoroquinolones?
Warfarin because fluoroquinolones displace the flora of the gut and displaces warfarin from albumin and interferes with metabolism by the P450 system.
Why are tetracyclines not recommended in pregnancy and in children less than 8 yrs of age?
They can cause staining of teeth, and cause problems with bone growth.
What population can tetracyclines like minocycline be used on? And patients who use it might develop what?
Adolescents. It may cause psuedotumor cerebri, drug-induced lupus and hepatitis, skin photosensitivity, tinnitus, fatty liver
Tetracycline should be avoided with what foods and medications?
Calcium ions
milk, yogurt, or other dairy products
Methotrexate
What drug interactions should be avoided when taking levaquin?
It is a fluoroquinolone, so do not take with coumadin or corticol steroid use.
Gentamycin is known to cause what?
Ototoxicity and hearing loss
Which medications interact with Linezolid?
Linezolid is a MAOI, so it should not be used with other MAOIs, pethidine, or demerol because of the risk of seratonin syndrome.
What are the food restrictions while taking linezolid?
Tyramine rich foods such as pork, aged cheese, alcohol, smoked or pickled foods.
What is the treatment for Lymes Disease?
Doxycycline 100mg PO BID x 21 days
What vitamin can prevent peripheral neuropathy from isoniazid?
Vitamin B 6 (Pyridoxine)
What should you monitor before prescribing valacyclovir?
Renal function. Patients should drink lots of water while on this medication.
Which medication would be appropriate for Influenza A?
Oseltamivir, if started within the first 48 hours
Name 3 things ta Rifampin is prescribed for?
TB, leprosy, legionella
What are the adverse effects for Isoniazid?
Hepatotoxicity and peripheral neuropathy
What are the main side effects of Doxycycline?
Mainly GI upset. Take with food. Can cause photosensitivity, Stephens Johnson syndrome, and toxic epidermal necrosis
What is the difference between oral and I.V. Vanco?
Oral is given for C-Diff as it goes right to the site of infection. I.V. vanco is given for MRSA infections and needs to be administered through a picc line or central line because it is toxic to veins.
What is the mechanism of action for Azithromycin?
It inhibits bacterial protein biosynthesis and prevents peptidyl transferase from adding to the growing peptide attached to the transfer RNA to the amino acid. It also inhibits ribosome ranslation.
Which class of antibiotics block bacterial protein production?
Bacteriostatic antibiotics: Tetracyclie, Sulfonamides, Macrolides, Clindamycin, Ethambutol, Nitrofuantoin, Novobiocin, tigecycline, oxazolidinone
What labs need to be monitored for long term antifungal therapy with ketoconazole?
AST, ALT, Phosphatase, bilirubin
What teaching should be done with Flagyl?
Do not consume alcohol in any form with this medication
Which antihelmintic is used to treat parasitic worms?
Mebendazole, and agromectin
and ivermectin to treat true parasites
What antifungal can be used topically?
Clotrimazole
What medication treats scabies and lice?
Ivermectin and permethrin cream
Rifampin is used to treat what?
TB
Side effects of rifampin?
Joint pain because it can precipitate gout and it is hepatotoxic.
IF patients are hypersensitive to Sulfa, what other medications will they be sensitive to?
Loop Diuretics, thiazide diuretics, and sulfonylureas
Sulfa antibiotics can cause what?
Stephen Johnsons Syndrome and toxic epidermal necrolysis
Nurs 615 pharm exam 2 questions and answers
Nurs 615 pharm exam 2 questions
Nurs 615 pharm exam 2 pdf
Nurs 615 pharm exam 2 answers
Nurs 615 pharm exam 2 answer key
NURS 615 Pharm Exam 2 MegaReview Study Guide latestNURS 615 Pharm Exam 2 Mega Review Study GuideLaw-Ham Pharm Exam 2 ReviewKnow every drug that is on the PowerPoint – have a one-line mechanism of action on a table for each drug and understand it, as well as how and where it worksCarbamazepine (Tegretol) – is an anticonvulsant = thought to affect Na+ channels to slow spread of abnormal activity•SE = decreases body’s production of blood cells, rare reports of aplastic anemia and agranulocytosis, can cause Steven Johnson Syndrome and Toxic Epidermal Necrolysis•Should get a CBC Q3-4 months (watch for WBC count in particular)•Carbamazepine is a strong inducer of hepatic enzymes/metabolism and can lead to lower levels•Do NOT stop taking abruptly, has a shorter half-life w/repeated usesTopiramate (Topamax) – is for tx of epilepsy, seizures, migraine prophylaxis•Blocks sodium channels or potentiate GABA•Peaks 2 hours after oral admin, mostly eliminated via urine•Can cause ↓ Na bicarb levels which can lead to hyperchloremic metabolic acidosis•Serum bicarbonate should be monitored at baseline and periodically•Can cause ocular syndrome (acute myopia and glaucoma) – should inform provider immediately if pt experiences eye pain or blurred vision•Rare side effect is oligohidrosis (↓sweating) and hyperthermia•Can increase the risk of suicidal behavior/ideation, cause weight reduction•Should NOT be discontinued abruptly•Is a pregnancy category D and can increase risk of cleft lip/palate in infantsLevetiracetam (Keppra) – antiepileptic, does NOT affect GABA, does inhibit burst firing and spread of seizure activity•Mostly cleared through renal system, is not extensively metabolized•Absolute contraindication is sensitivity to the drug•At increased risk for suicidal thoughts and depression, behavioral changes, somnolence, fatigue, dizziness, muscle coordination difficulties•Potential for withdrawal seizures if keppra is stopped abruptly•Safer med for seizures in children and pregnancyValproate (Depakote) – is an anticonvulsant, for tx of bipolar disorder and mania also •Blocks GABA uptake into presynaptic neurons•SE = GI distress, heartburn, CNS depressant•Is a pregnancy category X, known teratogen, may only be taken after the 1st trimester if necessary, bur should recommend switching to different anticonvulsant like Keppra NURS 615 Pharm Exam 2 Mega Review Study GuideEthosuximide (Zarontin) – tx for seizuresNURS 615 Pharm Exam 2 Mega Review Study Guide•Should be monitored for blood dyscrasia (an abnormal condition or dx of the blood)Antiepileptics block transmission, raise the seizure threshold, so that the patient will not peak over the seizure threshold and have a seizure.Anticonvulsants in terms of monitoring (most common side effects, most serious side effects) – know that they are all monitored with blood work for their levels so that is a similarity amongst them•Carbamazepine – CBC – Causes agranulocytosis so be watching the white count in particular although there is other bone marrow suppression as well•What do you monitor? – TSH because the med can affect the thyroid•Never want anyone to d/c suddenly, must be weaned off•Talk to patients about safety – driving limitations, may have to report patient to DMV if they are having active seizures•Oral health can be affected by anti-seizure meds and extra trips to the dentist may be requiredNeurotransmitters•GABA – calming•Acetylcholine – muscle action, thought and learning*If a specific drug is listed on the PowerPoint, know all about it.•All these drugs are listed on the PowerPoint•SeizureoTopiramate – topamaxoCarbamazepine – TegretoloValproate – DepakoteoLevetiracetam – Keppra•MAOIo Phenelzine – Nardil•AnxiolyticsPhentermine (Adipex-P) – used for obesity, stimulating satiety centers•Should only be used short-term (6 months or less)•DO NOT mix w/ SSRIs or St. John’s Wart (Serotonin Syndrome), or w/ MAOIs (HTN crisis)Lithium— tx of choice for manic-depressive (bipolar) illness, ↓ severity/frequency of mania▪Replaces Na+ during depolarization in neurons = stops transmission of electrical impulses▪Inversely proportional to Na+ — ↓Na+ = ↑Lithium ↑Na+ = ↓Lithium▪Lithium Toxicity can occur = drowsiness, nausea, course tremors, diarrhea, confusion, stupor▪NOT to be used in renal pts, children under 12, or pregnant women▪Pt education = avoid dehydration, eat a diet with consistent Na+ levels
NURS 615 Pharm Exam 2 Mega Review Study GuideAntidepressants – SSRIs (fluoxetine, paroxetine, sertraline, citalopram, escitalopram)
NURS 615 Pharm Exam 2 Mega Review Study Guide•SSRI blocks the reuptake of serotonin which keeps it present in the synapse for longer, so you get more effect from it•All of the antidepressants, whether a drug family or specific drug, you need to know and understand that drugand mechanism of action•Common side effects of SSRIs – weight gain, sometimes weight loss, anticholinergic effects like dry mouth and constipation, nausea, vomiting, sexual side effects – diminished, delayed or absent orgasm, premature ejaculation, decreased libido•Nausea can occur when first starting SSRI, but will resolve in a week or so•With citalopram, appetite and concentration improve in the first 1-2 weeks, works quickly•Interacts w/ MAOIs•SSRIs – serotonin syndrome – HA, hallucinations, shivering, agitation, sweating, high body temperature, tremor, hyperreflexia, dilated pupils, nausea, diarrhea•DO NOT stop abruptly or miss doses = serotonin withdrawal – can see this in shorter acting SSRI’s when peopleforget to take them (paroxetine is the shortest acting), sertraline and citalopram can also happen but not as quickly as paroxetine.•Serotonin withdrawal syndrome – tremulous, paresthesia’s, nausea, vomiting, sweatingSNRIs•Effect and block the reabsorption of norepinephrine – norepi effects specifically the sympathetic nervous system and also has serotonergic effects•Sevilla, Cymbalta, etc. names of drugs•An initial tx for depression w/ symptoms of fatigue, sleeping all the time, and lack of motivation•Side effects – headaches, nausea, somnolence, dry mouth, anticholinergic things, palpitations, hypertension, and hyperhidrosis (excessive sweating).TCAs (amitriptyline, nortriptyline, imipramine, trimipramine)•Effect brain chemicalsoSerotonin – 5htoNoradrenaline/norepinephrineoActs on Histamine and Acetylcholine•This group of medications has the highest anticholinergic effects – the highest amount of dry mouth and constipation•People who have BPH, glaucoma, urinary problems should not take this medication due to the degree ofanticholinergic effect•Should be prescribed cautiously in patients with heart disease•Can behave like class 1 antiarrhythmics = terminate Vfib, ↓ heart contractility, increase collateral blood flow to ischemic heart muscles•SE = anticholinergic, sedating, increased appetite, tinnitus, nausea, as well as cardiac conduction disordersincluding a prolonged QT interval with this drug – a baseline EKG is imperative before starting on this medication. Tardive dyskinesia (movement), neuroleptic malignant syndrome•If you ever put someone on this for their depression, understand that in the first few weeks they can have increased suicidal ideation•An overdose of TCAs is fatal; whereas, with the SSRIs it isn’t
NURS 615 Pharm Exam 2 Mega Review Study GuideBuspirone (full agonist, serotonin) but can also be an antagonist•Full agonist for the presynaptic 5ht1 receptor
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NURS 615 Pharm Exam 2 Mega Review Study Guide•If someone has too much serotonin, it will act as an antagonist•Or if they do not have enough serotonin, it will act as an agonist in the post synaptic•Structure similar to clozapine which is an atypical antipsychotic•Pt with anxiety and depression may respond to buspirone and an SSRI combined•Is an appropriate first-line drug for mild to moderate generalized anxiety disorder•Works well for anxiety and has a synergistic effect with SSRI for someone who has a resistant type of depression that needs an extra boost•Will compete for metabolism site w/ antipsychotics (Haldol)MAOI Inhibitors•Phenelzine (Nardil)•Parmate•Marplan•Not used often and are not popular due to the amount of adverse effects•MAO – irreversibly inactivates the enzymes that metabolize NE, serotonin, and dopamine therefore increasing bioavailability of each so you get a longer serotonin, norepi effect such as more energy as well as a better mood)•Adverse effects: tardive dyskinesia•Do not mix with other substances (other MAOI’s)•Do NOT eat foods containing tyramine (aged cheese/meats, alcohol) as these can cause symptoms of HTN crisis (increased BP, tachycardia, HA, dizziness, sweating, tremors) which requires immediate tx•Do not mix well with other things so they need to be two weeks separated from anything else (assuming this isspecifically referring to other antidepressants)•When starting new antidepressant, wean patient off this medication. Pt must be off of this medication at least two weeks before starting another antidepressantBenzodiazepines – binds to GABA receptors to inhibit the neurotransmitter release•Alprazolam, Chlordiazepoxide, Clonazepam, Diazepam, Lorazepam•Effect/binds to GABA receptors – which is sedating, acts as anticonvulsant, muscle relaxant, helps with alcohol withdrawal•Tend to be very habituating – be aware of this and limit prescribing, CNS depressant•If you have to put a patient on a benzo, try to choose something that is longer acting so that patient does not need to redose constantly. Longer acting benzo example is klonopin•Short and intermediate acting benzos to tx insomnia, long-acting benzos to tx anxiety•An appropriate drug to initially tx panic disorder is diazepam (Valium)•CAUTION IN PRESCRIBING, alprazolam (Xanax) has greatest likelihood of rapid dependenceInsomnia Meds•Familiarize yourself with what it means to utilize sleep hygiene and be sure your clients are using that.•Meds should only be for short term or occasional use because you want the patient to develop their own sleep patterns and not become dependent upon a pill to go to sleep at night.•Ambien – non-benzo type of sleep aid – works within the GABA receptors but non-benzo – considered to work ata benzo booster site.•Temazepam – benzodiazepine sleep aid – has same side effects as other benzos Anti-infective
NURS 615 Pharm Exam 2 Mega Review Study Guide•Antibiotics is a broad term for a lot of things including antibacterial, antifungals, antiprotozoal, anthelmintic, and antiviral
NURS 615 Pharm Exam 2 Mega Review Study Guide•Classified as gram positive or gram negativeoGram positive bacteria have no capsule – have a thick peptidoglycan wall which stains purpleoGram negative bacteria have a capsule that protects the cell peptidoglycan wall from staining so it will show as pink•Also classified by shape – i.e. flagellated, spirilla, cocci•Classified by oxygen useoAnaerobes – cannot grow in the presence of oxygenoAerotolerant – most bacteria that cause humans to be sick. They can survive for 72 hours in the presence of oxygen, even though they may not usually, and they may not grow in oxygenoMost human flora is anaerobic deep within our bodies.•Anti-infective work in the following waysoCell walls – anoFolic Acid metabolism –oProtein synthesis inhibitors at 30s and 50s ribosomal subunitoMUST KNOW EACH ANTIBIOTICS FAMILIES MECHANISM OF ACTION*•Bacteriostatic vs bactericidaloBacteriostatic – stop bacteria from reproducing but do not kill it = utilized in people who have an intact immune system that is able to go in and kill the bacteria as long as it is not reproducingoBactericidal – wipes out the bacteria = the bad and the good which is where C. Diff and other things come from•What effects antibiotic efficacy?oPeople’s immune function – people with poor immune function may need bactericidal or higher levels of antibiotics▪Diabetic▪Steroids▪Chemotherapy▪Asplenia (absence of normal spleen function)▪Hx. Of previous infections▪Elderly▪Foreign bodies – catheters, artificial joints, valves, and shunts = may need to be removed if possible, in order for patient to be properly treated▪Autoimmune disease – autoimmune drugs lower ability to fight infectionoAlteration in Distribution▪Not high enough albumin level▪Overweight▪Underweight – emaciated or cachectic (physical wasting)▪Renal function decreased▪Anything that can affect kinetics needs to be thought about in relation to antibiotic efficacy•Bacteria cause resistance byoBreaking down beta lactam ringoOr breaking down whatever the drug is consisting of and inactivating itoPenicillin has things added to prevent the bacteria from breaking down the beta lactam ringoReduce bacterial efflux pumps or change the influx of it so it cannot work as welloAlter the binding site so the medicine cannot exert its action•Every antibiotic drug class has resistant organisms that influence prescribing decisions•Common resistant organismsoMRSA
NURS 615 Pharm Exam 2 Mega Review Study Guide▪Community acquired•Acquired from locker rooms, jails, prisons, gymnasiums, livestock handlers who handle animals who handle antibiotics
NURS 615 Pharm Exam 2 Mega Review Study Guide•Outpatient treatment options can be trimethoprim sulfa or doxycycline▪Hospital acquired – much more difficult to treat•Requires extensive antibiotics that we do not use often such as vancomycin, linezolid, daptomycin, maybe even imipenem’s and combinations of these things▪These occur in sicker patients who already have some bacterial resistance issuesoVRE (Vancomycin-Resistant Enterococci)▪Natural enterococcus in GI tract and female genital tract▪In weakened immune systems it can cause infection▪Treatment is with penicillin-cephalosporin combos, aminoglycosides▪Very difficult to treat•Who is affected by antibiotic resistance?oDaycares – children are more likely to be exposed to pathogens from other childrenoReview the slide and be familiar•Mentioned being familiar with drugs on the slides again – understand broad vs. narrow spectrum, bactericidal vs. bacteriostatic, common indications for use, concern or contraindications, interactionsBoth PCNs and Cephalosporins contain a beta-lactam ring that is vulnerable to beta-lactamase-producing organisms = why there is often cross-sensitivity and cross-resistance btw the two.PCNs and Cephalosporins are generally regarded as safe to prescribe to children, but Fluoroquinolones and Tetracyclines are to AVOIDED in childhood.The beta-lactam ABX (PCNs and Cephalosporins) and Vancomycin inhibit bacterial cell wall synthesis.Penicillins•Bactericidal•Inhibit cell wall synthesis•Usually used for strep throat and upper respiratory types of things – otitis media•Some pneumonias – amox-clavulanate used for this as it is a beta-lactamase inhibitor which increases its efficacy against amoxicillin-resistant bacteria – *Augmentin•Maybe meningitis•Valve infections•Blood infections•Abdominal•Sensitive infections – bacteria that are sensitive to it•SAFEST DRUG for pregnancy (UTI) and pediatrics – AUGMENTIN/AMOXICILLIN•Amoxicillin – risk for anaphylaxis – cross sensitivity with cephalosporin risk up to 25%oIf you cannot find something other than a cephalosporin to treat somebody with allergic reactions to penicillin’s, go with a higher generation cephalosporin. Higher generations have a little bit less crossover with penicillinoSome anaphylactic risk comes from previous exposure with mold spores•Remember that penicillin’s and cephalosporins can give you diarrhea, continue tx but recommend probiotics daily and yogurt helpso Kaopectate and some other things can be used after verifying that this is not a c. diff or bacterial overgrowth type of diarrheaCephalosporins NURS 615 Pharm Exam 2 Mega Review Study Guide•Note that the first generation usually has gram positive coverage•By the time you get to the fifth generation, there is a lot of gram-negative activity NURS 615 Pharm Exam 2 Mega Review Study Guide•If you are wanting gram negative activity, do not choose cephalexin or cefazolin, you need to go to a different drug group altogether or something in a higher generation•Widely distributed•Renally excreted as is penicillin – if you have a patient that does not have a renal system that is working well, you may need to adjust your dosing and monitor the renal functions•Generally a pretty safe drug•Same adverse effects of penicillins; however, very uncomfortable at injection siteo Rocephin – often mixed with lidocaine to ease discomfort•Mechanisms of resistance – also add a beta lactamase inhibitor type of medication to itoHas other mechanism of resistance such as▪Making bacterial cell wall impermeable to the antibiotic▪Effecting the upregulation and the pumping in of the antibiotic•If a client with strep pharyngitis is allergic to penicillin or cephalosporins then what do you use?o Macrolides – erythromycin or azithromycin – do not risk allergic reactionVancomycin•Very toxic to the ear and the kidney•Has gram positive coverage – particularly effective in IV form for staph aureus or MRSA infection•Bactericidal – widely distributed and renally excreted – watch the kidneys•Does not absorb well in GI tract so mostly given IV unless somebody has C. diff in which case we can give it PO because it will work topically•Can cause phlebitis at IV site as well as nephro and ototoxicity•Red Man syndrome if infused too rapidly – histamine type release and patient feels flushed, fever, chills, tachycardia, pruritis, paresthesia’s – does not mean this is an allergic response, means we need to slow it downBacteriostatic ABX limit bacterial growth by interfering w/bacterial protein production, DNA replication = Tetracyclines, Sulfonamides, Spectinomycin, Trimethoprim, Chloramphenicol, Macrolides, Lincosamides, Clindamycin, Ethambutol, Nitrofurantoin, Oxazolidinone.Tetracyclines•Doxycylcine 100 mg PO Q12H or BID for 14-28 days depending•If pt is on doxycycline for a chlamydia infection, recommend she use a back-up method of birth control (condom) since this med can ↓ effectiveness of oral contraception•Doxycycline can cause anorexia, N/V, diarrhea = should take w/food•Tetracyclines such as Minocycline are safe to use in adolescents for the tx of acne•If pt taking Minocycline complains of a HA, evaluate for pseudotremor cerebri•Do not give to children less than age 8 because it effects bone growth as well as causing stained teeth•Adverse effects = photosensitivity, lupus/hepatitis, fatty liver, tinnitus, SJS (serious), TEN•Can be inactivated by calcium ions, DO NOT give with an antacids or dairy (yogurt, milk) because that decreases the absorption•BacteriostaticMacrolides, Azalides•Bacteriostatic as a general rule, inhibits bacterial protein biosynthesis (peptidyl transferase), binds to the P site of the 50S ribosome subunit NURS 615 Pharm Exam 2 Mega Review Study Guide•Vary in excretion – stool and urine•Cover some of the unusual or uncommon respiratory problems such as mycoplasma pneumonia, chlamydia pneumonia, Bordetella pertussis NURS 615 Pharm Exam 2 Mega Review Study Guide•There is a molecule with a macrolide ring on this drug•Have been around a really long time so we are starting to appreciate problems with resistance now•Azithromycin for sinus infection is not really used much more because of problems with resistance – gets to the ears and throat better as they are deeper in the body•Azithromycin is a good abx for strep throat especially if pt has developed a rash/rxn to PCN•Besides causing significant GI upset, can cause acute hepatitis, rash, prolonged QT and malignant arrhythmias – serious side effects that need to be monitoring•Given for upper and lower respiratory infections, uncomplicated skin infections•STIsLincosamides•Clindamycin – relative of erythromycin – binds like they do to the bacterial 50s ribosomes•Bacteriostatic for certain bugs•Works deep within the body•Bactericidal for certain bugs•If a bacteria is resistant to macrolides, it will be resistant to clindamycin as well•If pt begins to have frequent diarrhea w/blood in it, assess pt for pseudomembranous colitis•Adverse effects: nausea, vomiting, diarrhea – can cause c. diff diarrhea, metallic taste in mouth, dizziness,vertigo, hypotension, arrhythmias – if patient is having bad c. diff diarrhea from this med, that could bethe reason the patient offloads their metabolism and has arrythmiasOxazolidinones•Linezolid –oBacteriostatic although can be cidal against a few gram positivesoUtilized for the big bads – pneumonias and more complicated infections, VREs – not first drug of choiceoSHOULD NEVER BE USED within two weeks or concurrently with maoi d.t drug interactionsocauses BONE MARROW SUPPRESSION – MONITOR CBC can cause lactic acidosis so be concerned with acid base balances, optic and peripheral neuropathies▪Especially if used greater than 28 daysoHeadache and nausea also ADRsoOriginally developed as an MAOI, indirect acting sympathomimetic – giving an SSRI with this would cause serotonin syndrome and also interactions with tyramine rich foods (aged cheese, wines, etc.)Sulfonamides•Sulfamethoxazole – often utilized with trimethoprim (Bactrim)•Silver sulfadiazine – cream used in burns•Bacteriostatic, highly protein bound and well distributed•Effect folic acid so never use in somebody who has a folic acid deficit•If pt has sulfonamide allergy, then they are cross-sensitive to loop/thiazide diuretics and sulfonylureas•Excreted via the kidneys so make sure this is prescribed in somebody with good kidney function•Used to treat E. coli UTIs and occasionally strep pneumonia and pyrogens – used to be used for c. trachomatous•Adverse effects – folate deficiency because it disrupts folic acid synthesis. Can also cause SJS or TEN so systemic reaction can occur (esp. w/large doses). Glossitis, stomatitis, hepatitis – can cause transient jaundice, CNS effects– can suppress bone marrow, renal impairment NURS 615 Pharm Exam 2 Mega Review Study Guide•Contraindicated in people that are folate deficient or G6PD deficient (condition causing RBCs to break down in response to certain meds, infections, stressors) NURS 615 Pharm Exam 2 Mega Review Study Guideo People with G6PD deficiency are missing an enzyme needed for cellular processes – what happens is that you give a sulfonamide and the persons RBCs will hemolyze and they will develop an anemia and so forth•Avoid in lactation and infants under 2 months because they are G6PD deficient just by being too new, also avoid in sulfa allergiesMacrobids•Nitrofurantoin (Macrodantin)•Used for urinary tract infections, also works well with kidney infections (basically goes directly to the kidneys) so it would be contraindicated in somebody with kidney disease•Renally excreted•Crosses the placenta•Same effect as sulfa in terms of g6pd thoughFluoroquinolones•One of the latest and greatest medications•End in floxacin•Bactericidal working on the bacterial DNA replication•Work very well on inner anaerobe type of bacteria that live deep within us – Haemophilus, enterococcus, pseudomonas•Save for the ‘big bads’ – pneumonias, things that could really hurt us, things that are resistant to all other typesof medications•Fluoroquinolones should be reserved for tx of community-acquired PNA in pts w/ comorbidities•Can go where many other antibiotics cannot•Avoid antacids, dairy, and iron within a few hours of taking this medication•Understand that it does concentrate in the prostate and the kidneys – it is a good prostatitis medication for this reason•Is renally excreted – alter dose and monitor functions with patients that have renal disease•Not recommended in pregnancy or children under 18o Damage to cartilage – black box warning for tendon rupture even months after tx– elderly are the most susceptible•Can prolong the QT intervaloKnow the patient’s cardiac statusoKnow other medications that patient is on that also prolong the QT•Know drug to drug interactions with fluoroquinolonesoWhat does fluoroquinolones and warfarin do? Enhances the effect of warfarinoWhat does fluoroquinolones and NSAIDs do?Aminoglycosides•Gentamicin •Amikacin •Tobramycin •Neomycin •Things mostly systemically given – eye drops and ear drops most frequentoPoor GI absorption so IV drugoRenally excreted and concentrates in the kidneys as well as the inner ear which is why the issue with NURS 615 Pharm Exam 2 Mega Review Study Guidegentamicin and ototoxicity and hearing lossoAlso can cause renal problems (nephrotoxicity) so monitoring of hearing and renal functions incredibly necessary NURS 615 Pharm Exam 2 Mega Review Study Guide•Topically administered medications have different side effectsMetronidazole (Flagyl)•Bacterial vaginosis, h. pylori, diverticulitis, etc. used for•Great for anaerobic coverage – things found deep within the body•Bactericidal•Works on nucleic acid synthesis•Can be IV or PO•Metabolized in the liver•*Biggest take away from this is to tell patients they can have nothing with alcohol (not even cough medicine) because they will vomit profusely (disulfiram like reaction) – tachycardia, nausea, vomitingAntimycobacterial and meds (TB)•Know what TB looks like – clinical manifestations – weight loss, night sweats, hemoptysis, fatigue•Rifampin used to tx TB, leprosy, and legionella•Isoniazid (INH) – used as 1st line agent for prevention and tx of both waiting and active TB•Rifampin – causes red orange secretions and urine if someone is wearing contacts, they should be taken out because this med will ruin their contactso Often see this given to people exposed to meningococcus as a preventative•Isoniazid – peripheral neuritis or neuropathy can occur so recommend Pyridoxine (vitamin B6) be taken while on INH•Pyrazinamide – increases uric acid (Gout flare-ups) but can also decrease liver functions and cause someone tobecome hepatotoxic (most dangerous side effect)•Ethambutol – can cause optic neuritis leading to visual problems such as green red color blindness, tell pt to report these symptoms immediately as it can be permanentLyme disease medications – Doxycycline 100 mg Q12H for 21 daysA pt with a small ventricle septal defect (VSD) that was repaired some years ago with no residual cardiac problems DOES NOT need ABX before dental procedures.A pt who is experiencing non-infectious diarrhea related to ABX administration will need to be assessed for C. diff colitis,so advise pt to increase probiotic intake w/yogurt to repopulate the gut flora.If a child comes to the clinic with a cough, low-grade fever, rhinorrhea, and the mucous is greenish-yellow then NO ABX should be prescribed because this is a virus.Antivirals•Make sure you know what the names are for influenza drugs and simplex and zoster drugs•Influenza – oseltamivir (Tamiflu) or zanamivir (Relenza) – start within 48 hours of influenza symptoms in order to successfully treato Prophylactic treatment will occur in places such as nursing homes to prevent death•Acyclovir, famciclovir, valacyclovir – antivirals of choice for herpes simplex 1 and 2 as well as zosteroStart as soon as symptoms begin – numbness or tingling feelingoDrink lots of fluids when taking acyclovir (to help prevent nephrotoxicity)•Zoster
NURS 615 Pharm Exam 2 Mega Review Study GuideoFor herpes zoster (shingles) – asses renal function prior to taking valacyclovir
NURS 615 Pharm Exam 2 Mega Review Study GuideoUnilateral rash along nerve root – will also be put on gabapentin or possible tricyclic to help with the painoPeople who are on antivirals for any length of time need monitoring for their liver functionAntifungals•Organized according to polyenes, azoles, allyamines•Can be systemic or topical depending on the infection•Some require system – example is griseofulvin for ringworm (often seen on client’s head)•Ketonazole – can cause hepatoxicity (need to monitor AST/ALT, alkaline phosphatase, and bilirubin)•Amphotericin B is systemic and for serious type of fungal infection•Candidiasis – topical tx (clotrimazole) = yeast, thrush, commonly used things are nystatin, mycostatin, itraconazole, fluconazole (big treatment for oral, oropharyngeal, or esophageal yeast, as well as vaginal yeast infection).•Take note that these drugs can be hepatotoxic (need baseline LFTs) and nephrotoxic so good follow up is required for useAntihelminetics•Lice and scabies = use permethrin cream and Ivermectin•Mebendazole and agromectin used to tx intestinal parasitic worms•Elimite cream – apply from head to toe, leave on for 8 hours before rinsing offHow do we know what we use?•Lexicomp – expensive program but most hospitals have this•Uptodate online – also expensive for individuals – most practices have one or the other•Harriet lane is a good book – also online and is a good reference for pediatrics•Consult infectious disease society of America•American college of physicians•Sanford guide – can place as download on phone