NURS 5334 - Final Exam Study Guide-latest-2023-2024, Study notes of Health sciences

Download NURS 5334 - Final Exam Study Guide-latest-2023-2024 and more Study notes Health sciences in PDF only on Docsity! 1 NURS 5334 - Final Exam Study Guide-latest-2023-2024 Final Exam Blueprint Prescribing Basics: 2 questions Prescriptive authority regulated by the state BON in each state. Tall man lettering to highlight dissimilaries with look-alike names *Prescription contains… Physicians Name, Address, and telephone number are required to be included in the prescription. DEA number (two letters, five numbers) if the prescription is for controlled substance, Patient name and DOB (also may include address and weight), Date Rx is written (expires 1 year after date issued), Name of drug and strength- avoid trailing zeroes, use leading zeroes, Directions with indications/route of administration and frequency, write out number of refills, quantity of drug, signature, NPI number (9 or 11 numbers), sign as A-PNP or role recognized by the BON Drug schedules – one is most addictive, up to schedule 5. 1) heroin, LSD, marijuana. 2) oxycodone, hydrocodone, methamphetamines. 3) codeine, ketamine, testosterone. 4) Xanax, valium, ambien, tramadol. 5) antidiarrheal, antitussives, Lomotil, lyrica. *calculation question Pharmacology Principles: 3 questions Pharmacodynamics – effect of drugs on body. Works by receptors. Usually proteins that interact with drugs. Agonist – produce receptor stimulation, conformational change every time they bind. Partial agonist – properties between agonists and antagonists. Submaximal effect. Stimulate only some of the receptors. Antagonist – affinity for receptor but NO intrinsic activity. Affinity allows antagonist to bind to receptors, but lack of intrinsic activity prevents receptor activation. Blocks action of drugs (example Narcan). Therapeutic range – between minimum effective concentration and toxic concentration. Working effectivity with no toxicity or adverse effects. Wider therapeutic range is better! Easiest to control. Bioavailability – percentage of dose of drug that survives first pass through liver and reaches blood 2 stream. Half life – time required for amount of drug to decline by 50%. Shorter half life admin more frequently. 4.5-5 half lives to get to steady state and to eliminate from body. 5 Extended- Spectrum- Ticarcillin, Piperacillin Beta Lactamase Inhibitors- Clavulanic Acid, Tazobactam, Sulbactam Cephalasporins- binds to penicillin binding proteins (PBPs), disrupts cell wall synthesis, causing cell to lyse. First generation cephalosporins – gram positive cocci. Second and third generation more broad spectrum – gram positive and gram negative. !st generation- prophylactic for surgery- never for active infection • Cephazolin (do not give with alcohol) • Cephalexin • Cefadroxil 2nd generation- works against URI- pneumonia from h. flu, klebsiella, pneumoniacocci, staphylococci • Cefotetan (do not give with alcohol or drugs that promote bleeding) • Cefprozil • Cefoxitin • Cefuroxime • Cefactor 3rd generation- preferred gram -, treats meningitis • Ceftriaxone (do not give with drugs that promote bleeding, or calcium) • Cefixime • Cefditoren • Cefotaxime 4th generation- Used to treat HAP, pseudomonas aeruginosa • Cefepime • Ceftolozone 5th generation- used to treat MRSA • Ceftaroline *which can cause bleeding, which contraindicated with alcohol? If have an anaphylactic reaction, do not give PCNs or Cephalosporins. If not anaphylactic, can give cephalosporins. Vancomycin – active against MRSA, bacteriocidal, red man syndrome. Bacteriostatic inhibitors of protein synthesis: 1 question Tetracyclines- non-lethal inhibitors of protein synthesis- Broad Spectrum 6 Used to treat: Infectious Disease, Acne, Peptic Ulcer disease, Periodontal disease, RA, Mycoplasma Pneumoniae, helicobacter Pylori, lyme disease, anthrax, RMSF Do not give with calcium, iron, mag, aluminum, zinc, laxatives, antacids- decreases absorption- wait a couple of hours between Adverse reactions- GI irritation, staining of bones and teeth in children less than 8 years (only exception is with the infection of RMSF and doxycycline), superinfection, renal toxicity, photo sensitivity, caution of women in childbearing age. -Diarrhea may indicate potential life-threatening superinfection - High dose may be associated with liver damage (tetracycline- Short acting, Doxycycline- long acting, Minocycline- long acting) Macrolides (Mycins)- Bacteriostatic or Bacteriocidal- inhibit protein synthesis, broad spectrum Used if: a patient is allergic to PCNs, whooping cough, active diptheria, coryne bacterium, diptheriae, chlamydia infections, m. pneumoniae, group A strep pyogens, may also be used as an alternative for PCN G if allergic. Drug interactions- CYP3A4, Cisapride, ergotamine or dihydroergotamine, terfenadine, astemizole, lovastatin, simvastatin Adverse Effects- GI, QT prolongation and sudden cardiac death, superinfection, thrombophlebitis, transient hearing loss Clindamycin- BBW- can cause C-diff. Example: Erythromycin, (Others: Clarithromycin, Azithromycin- prolong QT) Rifampin, Metronidazole, and Floroquinolones- inhibit synthesis of DNA or RNA by binding directly to nucleic acids or interacting with enzymes required for nucleic acid synthesis Aminoglycosides MOA – inhibit protein synthesis, can cause ototoxicity and nephrotoxicity. Gentamicin – continues to exert antibacterial effects even after plasma levels decrease below detectable levels – reaction will stay for a while. Erythromycin – can prolong QT interval, so pause simvastatin while taking erythromycin! Traveler’s diarrhea – ciprofloxacin for E.Coli (gram negative bacillus) Sulfonamides – most common SE is skin reactions. Allergy to sulfa – usually skin rx. Ciprofloxacin – tendonitis and tendon rupture may occur. Drugs used for UTIs: 2 question *Tx UTIs. 80% E.Coli, then Proteus and Klebsiella. Most UTI gram- d/t cause from intestinal bacteria. Prophylaxis -SMZ/TMP- 3x/wk for 6 months 7 Postcoital UTI- Nitrofurantoin 100mg after intercourse *Uncomplicated UTI- Book says TMP/SMZ, new guidelines nitrofurantoin x5days (only UTI and not kidney infection- excreted and metabolized rapidly so only in bladder), second line are ciprofloxacin and levofloxacinx 3d. Pyelonephritis- (fluoroquinolones) Levofloxacin x10-14 days Bacterial Prostatitis- (fluoroquinolones) Levofloxacin 2-4 weeks UTI in pregnancy- amoxicillin Urine growing E.Coli – less the MIC is, the more effective the antibiotic. TMP/SMZ SE- Blood disgrasias, SJS, Rash- common, renal damage Fluoroquinolones – not for children, do not give with antacids, have different therapeutic applications depending on the generation. Some for UTIs, some for URIs. Levaquin for both. Misc. antibiotics: 1 question Floroquinolones- can cause tendon rupture BBW Risk to all patients, but higher than age of 60 or glucocorticoids or has had transplant Do not prescribe under age of 18 SE- nerve damage, neuropathies, AMS in elderly, QT prolongation Cefepime eliminated by tubular secretion or glomerular filtration. Daptomycin- works well for MRSA- only IV Rifampin- used for meningitis, and prophylaxis of meningitis Rifaximin- traveler’s diarrhea, encephalopathy in liver disease Bacitracin and Polymyxin- topical antimicrobials TB: 1 question *INH SE- peripheral neuropathies- take folic acid as prevention, can be reversed by pyridoxine Anticoagulant tx, diagnosed with TB. Rifampin induces CYP450, so it decreases the efficacy of warfarin and oral contraceptives. TB – drug combinations to delay or prevent the emergence of resistance. 10 Cox 2- bad (increased risk for heart disease)- produced at sites of injury, and where mediates inflammation, and sensitizes to painful stimuli, and present in the brain so takes part in fever as well, in kidneys- supports renal function with renal vasodilation, and in colon- linked to colon cancer- blocking effects: suppression of inflammation, alleviation of pain, reduction of fever, protection again colorectal Ca. *NSAIDs – SE is GI ulcers/bleeds, prevent by giving PPIs (-prazole). Danger of PPIs include increased risk for fractures when given long term, increased risk for C.DIFF. ASA- nonselective inhibitor of cox- not recommended for primary prevention of MI and stroke, not worth the risk of GI bleed. Antipyretic, anti-inflammatory, decreases platelet aggregation, decreases risk for colon cancer, prevent Alzheimer’s. AE: GI (ulcers or GI bleed), can cause acute reversible impairment of renal function. Ductus arteriosus of fetus (do not give with pregnancy). Interaction with glucocorticoids, alcohol, warfarin, ibuprofen- reduces antiplatelet effects of asprin. ACEi, and ARBs- can increase risk for bleed 1st generation NSAIDS- prevent Cox1 and Cox2- Used to alleviate mild-moderate pain, suppress fever, alleviate dysmenorrhea. Supress inflammation but pose risk of serious harm. can cause GI bleed and renal impairment Ibuprofen- tx RA and OA, don’t protect against MI and Stroke. SE- GI bleed. Check RFP, Check CBC for H&H, check occult blood, watch for tarry stools. 2nd gen- only cox2 inhibitors- increase risk for heart problems. (Celebrex) Celebrex- decrease risk for GI bleed, but increased risk for MI and stroke. Drug interactions- can increase anticoag effects of warfarin, decrease diuretic effect of Lasix, can decrease the antihypertensive effect of ACEi, can increase levels of lithium, Celebrex levels can be increased with fluconazole. Acetaminophen- considered cox medication, but only has analgesic and antipyretic effects, doesn’t have any anti-inflammatory- works by inhibiting prostaglandin synthesis in the central nervous system AE: hepatotoxicity (alcoholics), if taking pain medication, some contain Tylenol- could overdose. Overdose: acetylcystine (mucomyst) Three main classes opioid receptors – mu, kappa, delta. Reverse effects caused by opioid agonists – naloxone (antagonist). Tolerance – increased doses needed to obtain same response. Opioid abuse – naltrexone. Naloxone for reversal. Euphoria induced by morphine – well-being exaggerated 11 *first line drug for 6 month old with fever- acetaminophen- know SE Non-Opioid Centrally acting analgesics- Tramadol (suicide risk), Clonidine, Ziconotide, Dexmedetomidine Tramadol ■ Mechanism of action- Combination of opioid and nonopioid mechanisms ■ Therapeutic use moderate to severe pain ■ Adverse effects and interactions: sedation, dizziness, headache, constipation, Seizures ■ Drug interactions – CNS depressants ■ Abuse liability ■ Suicide ■ Preparations, dosage, and administration – Immediate-release and extended-release Clonidine ■ Treatment of hypertension and relief of severe pain ■ Mechanism of pain relief – Alpha2-adrenergic agonist ■ Analgesic use – Used in combination with opioid analgesics ■ Adverse effects – Cardiovascular: Severe hypotension, rebound hypertension, and bradycardia ■ Contraindications: bradycardia, hypotension Ziconotide ■ Mechanism of action – Selective antagonist at N-type voltage-sensitive calcium channels on neurons – Blocks calcium channels on primary nociceptive afferent neurons in dorsal horn of the spinal cord ■ Pharmacokinetics – Distributed through cerebrospinal fluid and then transported to systemic circulation ■ Adverse effects – CNS and muscle injury ■ Drug interactions – Formal studies not done ■ Preparations, dosage, and administration – Intrathecal administration Dexmedetomidine ■ Selective alpha2-adrenergic agonist – Acts in the CNS to cause sedation and analgesia ■ Uses – Short-term sedation in critically ill patients who are initially intubated and undergoing mechanical ventilation – Sedation for nonintubated patients before or during surgical and other procedures ■ Adverse effects – Hypotension – Bradycardia 12 ■ Preparations, dosage, and administration Given IV infusion with loading dose Second generation Cox 2 inhibitors – suppress inflammation, less risk gastric ulceration, increase risk heart disease!!! Give for acetaminophen overdose – acetylcysteine. Antiinflammatory Drugs and Glucocorticoids: 5 questions *SEs of glucocorticoids – major SEs- GI bleeds, increased blood sugar, negative effect on protein metabolism, decrease muscle mass, decrease protein matrix of bone causing osteoporosis and thinning of skin. central adiposity, moon face, adiposity on cervical of the spine, psychosis. Can lead to Cushing’s syndrome. If diabetic, and on glucocorticoids, sugars can go up- may need to adjust diabetic meds. *steroids used to: suppress immune response and inflammation, reducing swelling, redness, warmth, and pain. Used to treat RA, SLE, Inflammatory Bowel Disease, misc inflammatory disorders (bursitis, tendonitis, synovitis, OA, gouty arthritis, disorders of the eye. Also used to treat allergic conditions, asthma, and dermatologic disorders. Used for neoplasms, suppression of allograft rejection, and Given to mother in preterm labor in maturation of the lungs of infant. If on long term, want to get to minimum dose= 5mg/day, Be aware of adrenal suppression, need to taper if over 7 days, except for asthmatic or COPD patients, can go up to 10 days without tapering. *Do not give glucocorticoids with ASA – BBW increased risk for GI bleeds. Nonendocrine uses for glucocorticoids – RA, SLE, IBS, OA, bursitis, gout, disorders of eye. Monitor adrenal glands and endocrine system. Prolonged use of glucocorticoids – adrenal insufficiency. Principles of Neuropharmacology/PNS Pathophysiology: 2 question PNS: Parasympathetic functions – constrict pupils and bronchial smooth muscle, decreases HR, increases gastric secretions, empties bladder and bowel, digestion of food, excretion of waste, control vision, conservation of energy – muscarinic agonists, cholinergic agonists, acetylcholine function Sympathetic functions – mostly acts on vascular- maintain blood flow to brain, redistribution of blood, and compensation for loss of blood (fight or flight)- increase HR and BP, shunting blood to vital organs, dilating bronchi and pupils, mobilizing stored energy. Agonist and antagonist 15 Propranolol: adrenergic blocker Dobutamine: sympathomimetic Acetylcholine binds to muscarinic and nicotinic receptors. Atropine antidote for muscarinic agonist toxicity. Sympathomimetic is a adrenergic agonist. Muscarinic antagonist is anticholinergic. Cholinergic is muscarinic agonist and parasympathomimetic Toxicity of cholinergic: bradycardia, bronchoconstriction, pupil constriction, urinary urgency. Muscarinic antagonist toxicity opposite symptoms. Alpha1 agonists increase blood pressure. Alpha 1 antagonists decrease blood pressure. Beta 1 activation will cause bronchodilation, nonselective beta blocker causes bronchoconstriction Alpha 2 agonist (clonidine) decreases blood pressure Epinephrine in cardiac arrest, anaphylaxis, hypotension Parkinson’s: 1 question Parkinson’s: caused by low dopamine, high acetylcholine- characterized by dyskinesias(tremmors at rest, rigidity, postural instability, bradykinesia) and akinesia, motor symptoms (autonomic disturbances, depression, psychosis and dementia)- early symptoms include loss of smell, excessive salivation, clumsiness in hands, worstening handwriting, bothersome tremor, slower gait, and reduced voice volume. Treatment to cure does not exist, goal is to improve patients ability to carry out activities of daily life. Mild symptoms: MAO-B inhibitor- Selegiline or Rasagiline If respond to Levodopa, diagnosis is sure. Levodopa can also make dyskinesias worse, especially as it is given longer. Usually only good for five years, so wait to start on levodopa for as long as you can. Initially when mild start on dopamine agonist. Start to have off periods when levodopa levels drop, so combine with *MAOB inhibitor (selegilene, rosagiline) or COMT inhibitor (entacapone)- add for off periods of disease. Amantadine can also help with off periods. Shorten dosage interveral, give another drug listed above, give dopamine agonist. *Give levodopa with carbidopa, they work better together. Levodopa replaces depleted stores of dopamine Alzheimer’s Disease/Spasticity: 2 questions 16 Alzheimer’s: Progressive degeneration of the neurons- early in hippocampus- short term memory loss, and later in cerebral cortex difficulty in language begins such as speech perception, reasoning, and other high functions. no drugs cure it or reverse. Treatment goal slow memory loss and cognition and prolong independent function. Only keep from progressing as fast. Weight risk and benefit with family. Deonepezil, can add memantine. 4 drugs approved for treatment- Donepezil, Galantamine, Rivestigmone, and Memantine Muscle spasm: all meds can cause physical dependence. Can give benzodiazepines if also having insomnia, or give metaxalone or chlorzoxazone (no sedation). *treatment for alzheimer’s Epilepsy: 2 questions SZ meds: many side effects and drug interactions Carbamazepine: use in SZ, BPD. Can cause bone marrow suppression, aplastic anemia BBW. Ethosuximate: can cause blood dysgracias Lamotrigine: oral contraceptives lower effectiveness of lamotrigine, need increased dose. Lamotrigine for SZ: if starting on oral contraceptive, increase dose lamotrigine Gabapentin monitoring: record SZ frequency, duration, severity always *Phenytoin: side effect of gingival hyperplasia- give folic acid, good hygiene. Decreases effects of oral contraceptives, warfarin, glucocorticoids. Antipsychotic drugs/Schizophrenia: 1 question Psych drugs: Refer BPD, Schizo patients to psychiatrist. Antipsychotic drugs: first generation (haloperidol, fluphenazine) side effect of tardive dyskinesia, weight gain. Used for schizo, major depression, mania. Schizo: first generation APS, second generation, benzodiazepine, antidepressants *know difference in 1st gen and 2nd gen antipsychotic Tailor to person, if sexual dysfx from SSRI give bupropion. If fatigue during day, give bupropion. *Serotonin syndrome: altered mental status, myoclonus, hyperreflexia, fever, tremor, can cause death St.John’s wort: many drug interactions. 17 Depression: 4 questions Antidepressants: first line are SSRI, SNRI, bupropion SSRI: fluoxetine, sertraline, paroxetine, fluvoxamine, escitalopram *Side effects of SSRI: sexual dysfx, nausea and vomiting in first few weeks, but resolves SNRI: venlafaxine, desvenlafaxine, duloxetine (given for neuropathies). Can give patient more energy than SSRIs. Bupropion: CNS stimulant, can help with ADHD and sexual dysfunction associated with SSRI as well. Increased risk SZ. Before starting antidepressants, check for hypothyroidism Ethosuximide: monitor for blood dysgracias TCAs: not in CAD *SSRI for children are the safest option Bipolar disorder: 2 question Lithium: mood stabilizer for BPD, Schizo…, excreted by kidneys (less excretion when sodium is low), narrow therapeutic index, monitor closely. Side effects N/V/D, thirst, ataxia, polyuria, can develop clonic movement and SZ when levels are toxic. Can use valproate, carbamazepine, lamotrigine in BPD Can use olanzapine, queitapine, aripirazole, risperidone, ziprasidone. Can cause weight gain. BPD: lithium toxicity: drowsiness and nausea Anxiety: 1 question Anxiety: benzodiazepines (alprazolam, lorazepam, diazepam, chlordiapoxide, oxazepam, chorazepate) work immediately. Can develop dependence. Buspirone: no abuse potential. Use for anxiety, and ED due to SSRI SE. Can use SSRIs when pt is anxious and depressed (escitalopram, citalopram, fluoxetine, fluvoxamine, paroxamine, sertraline). Also venlafaxine SNRI. *Buproprion SE and what it is used for? ADHD:1 question 20 Antiarrhythmics:1 question Antidysrhythmics: classifications Afib: BB, diltiazem, amiodarone if others don’t work. Aflutter: same as Afib. Easy to tx. SVT: diltiazem, BB, adenosine VT and Vfib: amiodarone, lidocaine, procainamide. Long term amiodarone and setolol. Nifedipine: HTN, migraines, angina BBs decrease adverse effects of nifedipine, but increase effects of verapamil and diltiazem. Hydralazine: can cause lupus like syndrome, check ANA if arthralgias or other symptoms. Untreated HTN leads to angina, CHF, MI, kidney disease, stroke. Treat HTN!!! Treat digoxin induced dysrhythmias: phenytoin *Amiodarone for Afib: check TSH and CXR Q6months because can cause pulmonary fibrosis!! ACE inhibit effect on failing heart: reduce preload ACE inhib can cause hyperkalemia Selective BB: atenolol, bezoprolol, esmolol, acebutalol, metoprolol – can use in diabetic and asthmatic (ABEAM) *Why do we give BB after MI?- Prevention CAD: 3 questions Risk factors include smoking, high blood pressure, high blood sugar, family history and ethnicity and certain health conditions such as metabolic syndrome, chronic kidney disease, chronic inflammatory conditions, premature menopause or pre-eclampsia and high lipid biomarkers. High LDL- tx with smoking cessation, TLC diet, and exercise- second line therapy are drugs only if TLC fails, such as HMG-CoA reductase inhibitors (Statins- Atorvastatin, Fluvastatin, Lovastatin, Pravastatin, etc), Bile sequestrants (Colesevelam), Nicotinic acid (Niacin), and Fibrates (reduce levels of TGs, not LDLs) Secondary Treatment Targets ▪ Metabolic syndrome High TG levels—150 mg/dL or higher (or undergoing drug therapy for high TGs) Low HDL cholesterol—below 40 mg/dL for men or below 50 mg/dL for women (or undergoing drug therapy for reduced HDL) 21 Hyperglycemia—fasting blood glucose 100 mg/dL or higher (or undergoing drug therapy for hyperglycemia/diabetes mellitus) High blood pressure—systolic 130 mm Hg or higher and/or diastolic 85 mm Hg or higher (or undergoing drug therapy for hypertension) Waist circumference 40 inches or more for most men or 35 inches or more for most women ▪ High blood glucose ▪ High triglycerides ▪ High apolipoprotein B ▪ Low-HDL cholesterol ▪ Small LDL particles ▪ Prothrombotic state ▪ Proinflammatory state ▪ Hypertension ▪ High triglycerides ▪ Levels above 150 mg/dL HMG-CoA Reductase Inhibitors (Statins)- Reduce LDL, Elevate HDL, reduce Triglyceride Levels, promote plaque stability, reduce CV events, increase bone formation - Administer at night - Common SE- Headache, Rash, GI disturbances - Drug interactions- other lipid lowering drugs, CYP3A4, teratogenic Nicotinic Acid (Niacin)- - Common SE- flushing (intense flushing initially, can pre-treat with asprin, or can prevent with sustained release version of niacin), itching, GI upset, hepatotoxicity, hyperglycemia, gout arthritis, can raise blood levels of uric acid Bile Acid Sequestrants (colesevelam)- Reduces LDL, Increases VLDL levels in some patients by inceasing LDL receptors on hepatocytes, and preventing reabsorbtion of bile acids. - SE- Constipation Fibric Acid Derivatives (Fibrates)- most effective drug available at lowering TG levels, Can raise HDL cholesterol, but little to no effect on LDL - Side Effects- increased risk for bleeding in patients taking warfarin, increased risk for rhabdomyolysis in patients taking statins - 3 available drugs: Gemfibrozil, Fenofibrate, Fenofibric acid Angina:1 question *Chronic Stable( exertional angina- brought on by emotional excitement, large meals, cold exposure, CAD): nitrates, can develop tolerance so use lowest dose and have eight hours drug free during each day. Variant (Prinzmetal or vasospastic) angina: ranolazine (new drug, good in HF), CCBs, nitrates (Beta blockers are not effective with vasospastic angina) Unstable:symptoms of angina at rest, new-onset exertional angina, intensification of existing angina= Treatment strategy is to maintain oxygen supply, and decrease oxygen demand. EKG changes. (if also 22 cardiac enzymes elevated, troponin, non-STEMI). Nitroglycerin (sublingual X3, then IV), BB, oxygen, morphine, ACE inhib and statin. Clopidogrel, others if go to cath lab. Reduction of risk factors includes: smoking, high cholesterol, Hypertension, diabetes, and physical inactivity. *How to treat Angina Unstable angina: ASA, morphine, BB, statin, ACE, Plavix all on long term BB during angina- decreases cardiac oxygen demand Antiplatelets/anticoagulants: 1 question Anticoag used for Afib: chads (congestive heart failure, HTN, diabetes, previous stroke) vascular (VD, PVS, age 75 or older, gender: female higher risk) scoring system (two or above need anticoagulant). Afib is a/w mitral regurgitation. High risk for stroke! Consider fall risk, intracranial bleed risk. Warfarin (insurance often only pays for this one) – sensitive to diet and other meds, narrow therapeutic level, hard to follow levels. Diet needs to be consistent (greens every day or never). INR levels. Reversal vitamin K. Use lovenox until INR therapeutic. LMWH only anticoag used in pregnancy! DTI (direct thrombin inhibitors): pridaxa, dabigatran. Praxibind (idaruzicumab) antidote. Direct factor Xa inhib: rivaroxaban, apixaban, (those two can be reversed with indexa). All used for Afib. Not for artificial heart valves (not really tested yet). Only coumadin used for now for artificial heart valves. Antiplatelets: ASA, clopidogrel, others… increase risk bleeding. Clopidogrel: put on PPI to decrease risk for GI bleed. PPIs can also decrease effects of clopidogrel but still recommended. Gemfibrozil and warfarin: INR might be elevated (metabolized by same liver enzymes!) Clopidogrel with PPI: antiplatelet effect decreased Heparin binds to antithrombin III Digoxin: decreases AV node conduction, increases vagal tone *which anticoagulants have reversals: Warfarin, reversed with Vitamin K; Dabigatran Etexilate , reversed with Praxabind STEMI: 1 question STEMI: oxygen, ASA (decreased mortality), morphine (promotes venodilation, reduces preload), nitro (reduce preload, reduce oxygen demand), BB (*reduce cardiac pain, infarct size, and short-term mortality), recurrent ischemia and reinfarction are also decreased Diabetes: 5 questions 25 Cholesterol levels checked Q5years after age 20. Fibrates: fenofibrate, for TG only Hyperlipidemia: statin inhibits biosynthesis of cholesterol Metabolic syndrome: elevated TG, LDL, HTN, diabetes, central adiposity (waist circumference). High risk CAD. Cholesterol at age 10, 20, then Q5years or earlier if high risk family, even age two! TSH reassess after levothyroxine used for 6-8 weeks. Amiodarone can induce thyroid dysfunction – check TSH and CXR Q6months 80year old with hyperthyroid – 12.5-25mcg because she is elderly and has CAD Normal 1.6-1.8mcg/kg/hr Hyperthyroid in pregnancy – PTU Monitor with a TZD – liver enzymes Levothyroxine to elderly – dose is 75% less of what is needed by young adult Methimazole excreted via urine Antithyroid drugs – avoid seafood because of iodine (no extra iodine when on meds for thyroid) Take thyroid medicine an hour before eating, no supplements especially calcium a couple hours before and after Drugs for Women’s Health: 4 questions *Estrogen – MOA blocks bone resorption, strengthens bone (prevents osteoporosis), lowers LDL, raises HDL. Can raise risk blood clots. *Never give estrogen alone to postmenopausal woman with uterus. Add progesterone so no increased uterine cancer. If no uterus, estrogen only post menopause. Give for first five years post-menopause and then remove. The older they are, the greater the risk for clots. Major substrates of CYP so watch for drug interactions, ie antiSZ, warfarin Oral contraceptives and combination birth control – help control irregular bleeding, heavy bleeding, acne, PCOS, do not ovulate (increased risk cancer). Interact with antiepileptics, rifampin, rifonamir, St.Johns wort. Also warfarin, insulin, hypoglycemics increase dose of these. Decrease dose of antidepressants, diazepam, chlordizapoxide… B Yaz and Safyral – also contain folate, good choices for women that want to stop pill and get pregnant in the future. 26 oral contraceptives or estrogen pills – can cause stroke. Estrogen increases clotting risk more. *Migraine with aura, she wants contraceptive – mirena IUD only (has progesterone only), do NOT give SSRIs can also treat vasomotor S/S of menopause. SERMs worsen vasomotor S/S but help with osteoarthritis and prevent cancer. Postmenopausal vasomotor S/S with uterus – estrogen and progesterone. SERMs (tamoxifen) used for preventing osteoporosis and breast cancer, make vasomotor S/S worse If miss a pill of contraceptive, take pill asap and continue pack, use another form of contraception for 7 days B yaz includes folic acid, good if wanting to stop OC soon to get pregnant Progestin alone can cause break through bleeding! Postmenopause and frequent UTIs – give vaginal estrace vaginally weekly. Due to atrophy and drying of vagina. Goal of HRT – to reduce vasomotor S/S. Maximum time for HRT is five years. Drugs for Men’s Health: 3 questions *Testosterone – monitor liver enzymes (LFT), cholesterol, prostate levels- yearly Controlled substance, abuse potential Always give instructions, especially if gels and patches, wash hands, do not transfer to any female in house. PDE5 inhibitors – (-nafil) for ED. SEs are hypotension (only with nitrates), priapism, hearing loss, optic neuropathy (regular eye exams needed). Relaxes arterial and trabecular smooth muscle in the penis. Take one hour before sexual activity. BPH – 5alpha reductive inhibitors (-steride) and *alpha antagonists (-zosin). Give if HTN and BPH. Watch for orthostatic hypotension. *Sildenafil for ED – SEs of optic neuropathy, priapism, hearing loss, hypotension- *Avoid nitro/nitrates when taking this med. SEs of testosterone – liver D/O, prostate cancer, edema, abuse potential, elevates LDL Alpha adrenergic agents – relaxes smooth muscle in bladder neck, BPH and HTN Enlarged prostate, HTN: terazosin (alpha 1 antagonist) (-osin) will treat both 27 Antihistamines/coughs/colds: 3 questions Bronchitis – almost always viral. Lasts long time (minimum three months), bad cough, feel awful. Do not need an antibiotic. Give something for cough (cough syrup with codeine, Tessalon purls). Allergic rhinitis – H1 antagonists for mild allergy, insomnia, motion sickness, decreases rhinorrhea 1st generation – most side effects, including anticholinergic dryness and sedation 2nd generation – low affinity for receptor in brain so do not cause sedation Some OTC, some prescription only. Nasal sprays – good for nose bleeds, do have anticholinergic effects and rebound rhinorrhea. Nasal corticosteroids can work well for allergies, but they take a couple weeks to be symptomatic. Good for maintenance to prevent allergy exacerbations. *Montelukast SE- anti-inflammatory - can cause psychiatric SEs, monitor when giving to children. Warn parents about depression, suicide SEs. Antitussives – nonopioid dextromethorphan (high potential for abuse, causes euphoria when taken in high doses), benzonatate (Tessalon purls) Expectorants – thin secretions, guaifenesin Oral decongestants should be discouraged in pt with cardiovascular disease because they increase HR and BP. Dextromethorphan suppresses cough reflex by direct action on cough center Tessalon works by decreasing sensitivity of respiratory tract stretch receptors OTC cold remedies avoided in under six years old AAPs – restrict use of cough and cold medicine in children younger than six years old Asthma: 3 questions *Asthma: stepwise approach Mild intermittent: symptoms less than twice per week or less than two nights per month Mild persistent: symptoms between twice per week and daily Moderate persistent: daily symptoms, more than 3-4 nights per month Severe persistent: symptoms daily, many nights Start with SABA always. Then add low dose ICS. Then increase dose ICS or add LABA. Then increase dose and LABA. Then high dose ICS and LABA and oral prednisone if needed. Also give singulair when moderate persistent. (these steps associated with classifications above) 30 Dry ARMD tx with vitamins, zinc, antioxidants *AOM organisms – strep pneumonia, H flu, M catarralis Recurrent otitis media – 3 or more X in 6 months, need tympanostomy tubes *1st line treatment for Acute Otitis Media and causative organism *1st line treatment for bacterial rhino-sinusitis and causative organism *1st line treatment for pneumonia and causative organism Antibiotics NOT used when otitis media with effusion Acute otitis externa – pseudomonas and staph aureus – use cipro drops. Fungal EOM – aspergillus and candida – tx with acidifying drops, clotrimazole 1%, then PO Diflucan or itraconazole if drops ineffective. PUD/GERD: 7 questions PUD – multiple agents used due to risk of resistance. Antibiotics always used for H. pylori. Dx H. pylori with breath test, serologic test, stool test. Endoscopy. Two to three abx: clarithromycin (inhibits protein synthesis, about 20% resistance, can cause N/V/D, metallic taste), amoxicillin (resistance 3%), arithromycin, bismuth (act topically to disrupt cell wall, causing lysis and death, can cause neuro injury if used long term), tetracycline (1% resistance, careful in children), metronidazole (40% resistant, SE of disulfiram like rx if pt takes alcohol, do not give during pregnancy), tinidazole (expensive). Goal to minimize resistance. Use antisecretory agent as well. Use 10-14 day courses. * Treatment- Know regimens listed! 1. Clarithromycin, amoxicillin and PPI. 2. Clarithromycin, metronidazole, and PPI. 3. Metronidazole, bismuth, tetracycline, and PPI or ranitidine. 4. PPI plus amoxicillin 5 days, then PPI plus clarithromycin and tinidazole 5 days. NSAID induced ulcers – be on PPIs prophylactically. H2 blockers not as effective as PPIs. Avoid smoking, alcohol, NSAIDs, stress. *GERD Stepwise Treatment – start with antacids, then H2 blockers, then PPIs, then increase PPIs to BID, then refer out. GERD can cause berretts esophagitis (cancer). PPIs long term increase risk of fractures. Antiulcer drugs – eradicate h. pylori (antibiotics), reduce gastric acidity (antisecretory agents, misoprostol), enhance mucosa defenses (sucralate, misoprostol) Chronic long term PPI – iron deficiency anemia, vitamin B12 and calcium deficiency, at risk for fractures and c.diff GERD – aggravated by estrogen, and caffeine Metoclopramide improves GERD S/S by increasing esophageal tone Antacids treat GERD by increasing gastric PH 31 “Step-Down approach” on GERD – start with antacids, H2, PPIs, PPIs BID, referral. Step up and down. GERD on PPI daily – next step take PPI BID and refer to GI doc. PUD with positive H.pylori – PPI plus clarithromycin plus amoxicillin for 14 days PUD tx failure – antimicrobial resistance Antiemetics/antidiarrheals/ IBS/IBD: 1 question Antiemetics – ondansetron (Zofran) safe to use in children. Also used in CINV. Benzodiazepines can be used as antiemetics. Treat OIC (constipation) – naloxegol, methylinaltrexone, lubiprostone. Metoclopramide can cause TD CINV – can be given IV- Zofran- given with corticosteroids NVP – pregnancy, very common, HEG – end up in hospital dehydrated, loss of body weight – manage without drugs if possible – eat small meals, avoid triggers, ginger. Then doxylamine and vitamin B6 – diclectin an declegis. Also can use Zofran and methylprednisolone. Motion sickness – scopolamine, antihistamine anticholinergics Diarrhea – opioids can be used. Habit forming, addictive. Even Lomotil has risk for abuse. IBD – seen by GI doc. Not curable, manage symptoms and keep out of hospital. Sulfasalazine, glucocorticoids, immunosuppressants, immunomodulators, antibiotics: metronidazole, ciprofloxacin, ipronidazole. Loperamide (Imodium) – slows gastric motility and reduces fluid loss from diarrhea Bismuth subsalicylate – contains ASA, contraindicated in children, antimicrobial effects against enteropathogens, SE darkens stool! Travelers diarrhea – preventive take bismuth with meals and at bedtime or can give ciprofloxacin to take if you get it. Child with N/V/D, give ondansetron. Infants with reflux – first anti-reflux maneuvers, elevate HOB Opioid induced constipation meds – four of them. Stimulant laxatives – Bisacodyl, senna, castor oil. Drugs Used to Treat Anemia: 3 questions Iron deficiency anemia – determine source of bleeding. Females on period, GI bleeding. TX - ferrous sulfate 15mg/kg/day in 3-4 divided doses. Usually 325mg TID. Can cause constipation, nausea, staining 32 teeth. Check H&H and ferritin four weeks after starting ferrous sulfate. Antacids decrease absorption. Ascorbic acid increases absorption and adverse effects of iron. B12 deficiency – caused by lack of B12 in diet (vegans, alcoholics), pernicious anemia (lack of intrinsic factor). B12 levels less than 150. Levels between 150 and 400 deficiency possible. Above 400 no deficiency. TX – cyanocobalamin PO. 1000-2000mg/day for mild to moderate symptoms and maintenance dose as well. Vit B12 deficiency an cause paresthesias, glossitis of tongue, mouth ulcers if untreated. *Folic acid deficiency – deficiency give PO 1-2mg/day. Know recommendation for pregnant… 400mcg for adult. Pregnancy 600mcg. Lactation 500mcg. Women of childbearing age should consume even more 400 to 800mcg of supplemental folate. Pernicious anemia – vitamin B12 Premature infants iron supplementation – 2mg/kg per day until age 12 months Breastfed infants iron supplementation of 1mg/kg/day Iron education – increase fluid and fiber because can cause constipation Folic acid requirement in pregnancy is 800mcg/day Folate deficiency tx monitor H&H at one and eight weeks. Vitamin B12 therapy, get H&H, iron, and vitamin B12 labs before IM therapy Anemia due to CKD tx with erythropoietin, epoetin alfa Drugs Used for Dermatologic Disorders: 5 questions Glucocorticoids – ointments used frequently. Note low dose steroid creams – use most in primary care. Higher doses in derm clinic. Main SE – thinning of skin (if use over and over, educate to use sparingly, thin layer), stretch marks, purpura, hypertrichosis, possible systemic toxicity if absorbed if high dose given. Can cause growth retardation in children, adrenal suppression. Topicals for acne – benzoyl peroxide – mild to moderate acne. Keratolytic and antibiotics, often in combo with other antibiotic. Use topical first, before oral antibiotics. Retinoids – topical, when first start using may cause worse breakout at first that will improve. Also peeling skin, redness in beginning. Sunburn easily, use sun screen. Start with lowest dose and work up as needed. Start with .025% and increase as needed. Oral – doxycycline, tetracycline, erythromycin. Accutane is for severe nodular acne – is teratogenic. Monitor closely, on birth control. Can cause depression as well. OCs can be given, spironolactone as well. Sunscreens – UVA into dermis and epidermis, UVB into epidermis, both injure DNA synthesis. Can cause cancer. Sunscreen protects against damage, cancer, photosensitivity rx. Educate to use! After SPF 15, up 35 Vitamins, Herbal Remedies, and Drugs for Weight loss: 4 questions Vitamin C – required for production of collagen and other compounds that bind cells together. Sources are citrus fruits, juices, strawberries, tomatoes, potatoes, spinach, broccoli. Antioxidant properties facilitates iron absorption. Deficiency leads to scurvy Vitamin B complex – includes thiamin, riboflavin, B12, pyridoxine, cobalamin, niacin, folic acid… Niacin in large doses helps to raise HDL- given to decrease cholesterol. Deficiency can cause pellagra (scaling and cracking of the skin in areas exposed to the sun), GI and CNS disturbances (irritability, insomnia, memory loss). Toxicity causes vasodilation, flushing, nausea. Most people are not going to be deficient in niacin unless alcoholic Nicotinic acid, niacin causes skin flushing (give with ASA). Increases HDL, lowers LDL. B2 Riboflavin – enzymatic reactions. Adverse effects – dose. Use for migraine prevention, give 400mg daily doses, takes 3 months before works. B1 Thiamin– carbohydrate metabolism. Dose needs to be increased in pregnant and breastfeeding. Deficiency causes beriberi (impairment of the nerves and heart- decreased appetite, numbness, weakness of limbs) and Wernicke-Korsakoff syndrome (encephalopathy and psychosis). *Alcoholism causes deficiency of all B vitamins. Pyridoxine – B6 – coenzyme in the metabolism of amino acids and proteins- Sources: breakfast cereals meats, poltry, potatoes, noncitrus fruits… Deficiency from poor diet, isoniazid (INH) use. S/S of deficiency – anemia, peripheral neuritis, convulsions. Alcoholics. Herbals Black cohosh – treat S/S of menopause. MOA not known, but some studies show just as effective as estrogen for vasomotor symptoms. Do not give with SERMs. Coenzyme 10 (CoQ10) – is an antioxidant in the body. Participates in production of adenosine triphosphate. Use for mitochondrial encephalomyopathy, CHF, muscle aches from statins (really helps, give to those who cannot tolerate statins). Cranberry juice – prevent UTIs. Works well for young and elderly females. Take daily to work. Can take tablets daily. CAUTION if on warfarin. Echinacea – antiviral, anti-inflammatory effects. Prevent colds. CAUTION if taking immunosuppressants. Febrifuge – prevent migraines. MOA is not known. No serious SE. Interacts with antiplatelets, anticoags, increase risk bleeding. Flaxseed – for constipation, high triglycerides. Just a soluble plant fiber. Garlic – decrease triglycerides, Decrease LDL, raise HDL. Can decrease BP, but must be eaten raw, one or two cloves daily. Most cannot tolerate taste raw. Antiplatelet effects! 36 *Ginger root – tx vertigo, N/V, arthritis, inflamm conditions. Antiplatelet effects! Can cause hypoglycemia in diabetes! *Ginko biloba – can increase pain free walking in PAD. Generally well tolerated Interactions! *Glucosamine – used to tx osteoarthritis of knee and hip, use in caution if shellfish allergy, increase risk bleeding, GI disurbances and bronchospasms!- look for drug interactions if taking this. Green tea – used to lose weight, improved mental clarity, prevent and treat cancer of stomach, skin, bladder, breast(data limited). Probiotics – take with antibiotics, to prevent diarrhea by preventing abx from killing all good bacteria in the gut. Sol palmetto – use in BPH, no evidence actually. Antiplatelet effects. Soy protein – prevent breast cancer, vasomotor S/S in menopause, prevent osteoporosis. Saint John’s wort – widely used for depression. CYP450 metabolism, many drug interactions. Must take high doses, 300mg TID for tx depression. Harmful substances – comfrey causes veno-occlusive disease. Kava causes liver damage. Ama haung (ephedra) band for elevated BP and stimulation of HR. 38% patients using herbal and supplement products. Ask about them to check for interactions! Tell patient to bring all they take with them. – NOT ON THE TEST Harmful effect of herbal medication – many cause lead poisoning, and hepatotoxicity. FDA does not regulate herbal meds. Black cohosh used for menopause! Works very well. Herbs ad Supplements are Not regulated by US food and drug admin. Melatonin – do not take more than three nights a week. Take 30 minutes before bedtime. Comfey on danger list – it causes veno-occlusive disease The role of the NP is to Educate and guide to appropriate sources to make decisions on supplements/herbs. Standard dose of St.Johns wort for depression – 300mg TID. Interacts with SSRIs, MAO inhibitors, OTC cough and cold meds because interacts with CYP450 system. Ginseng – assist with memory. Can potentiate insulin and cause hypoglycemia. Immunologic Drugs: 6 questions Vaccines – check CDC website often, schedules change frequently. Know which ones contain LIVE viruses. Do not give to immunocompromised patients. 37 *who should avoid live vaccines- immunocompromised children such as congenital immunodeficiency, HIV infection, leukemia, Lymphoma, Generalized malignancy, therapy with radiation, cytotoxic anticancer drugs, high dose glucocorticoids. *Killed vaccines- composed of whole, killed microbes or isolated components. Live (attenuated) vaccines are composed of live microbes that have been weakened or rendered completely avirulent. *Flu vaccine – everyone should get it, over 6 months old. Unless anaphylactic rx to eggs. *Pregnant females get TDAP every pregnancy! Between 27 and 36 weeks. *Gardasil – one of three HPV vaccines protects against cervical, vulvar, and vaginal cancer, – protects against anal cancer and genital warts in females and men. *Cervarix only against cervical cancer, not warts, lasts longer protection. Other is Gardasil 9. Adult vaccines – TDAP booster every 10 years, MMR doses 1 or 2, annual flu, HPV in men and women, *Shingrix for shingles – recombinant two doses, 6 months apart. Given between the ages of 50 and 65. Painful vaccine- can cause pain in arm and flulike symptoms. Live attenuated influenza vaccine (FluMist) – all patients over 6 months 2 MMR vaccines one month apart because only 95% patient fully immunized for measles after first dose. 99% after two doses. MMR vaccine NOT in pregnancy because live vaccine. Risk fetus developing congenital rubella syndrome. Rotavirus vaccine – live vaccine that replicates in small intestine providing active immunity against rotovirus, NOT to infants potentially immunocompromised or infant who is febrile DTaP Tdap vaccine – only contraindication is anaphylactic rx. Can die from tetanus. Hep B immune globulin provides passive immunity to infants born to HBsAG positive moms. To prevent passing to infant. Recognition phase of immune response – when a mature lymphocyte encounters its matching antigen. Activation phase- when the lymphocyte undergoes proliferation and differentiation Elimination Phase- elimination of the antigen NO LINK between MMR and autism. HPV vaccines – Gardasil, Cervarix, Gardasil 9 Gardsil protects cervical, vulvar, and vaginal cancer in females, and anal caner and warts in males and females. First vaccine to prevent cancer. Cervaris protects against cervical cancer only, lasts longer.