NURSING>NR 565Pharm midterm study guide/Midterm Pharm study guide NR565NP., Exams of Health sciences

Download NURSING>NR 565Pharm midterm study guide/Midterm Pharm study guide NR565NP. and more Exams Health sciences in PDF only on Docsity! NR 565Pharm midterm study guide Chapter 2. Review of Basic Principles of Pharmacology 1. A patient’s nutritional intake and laboratory results reflect hypoalbuminemia. This is critical to prescribing because: Distribution of drugs to target tissue may be affected. 2. Drugs that have a significant first-pass effect: Are rapidly metabolized by the liver and may have little if any desired action 3.The route of excretion of a volatile drug will likely be the: Lungs 4. Medroxyprogesterone (Depo Provera) is prescribed intramuscularly (IM) to create a storage reservoir Increase the length of time a drug is available and active 5. The NP chooses to give cephalexin every 8 hours based on knowledge of the drug’s: Biological half-life 6. Azithromycin dosing requires that the first day’s dosage be twice those of the other 4 days of the prescription. This is considered a loading dose. A loading dose: Rapidly achieves drug levels in the therapeutic range 7. The point in time on the drug concentration curve that indicates the first sign of a therapeutic effect is the: Onset of action 8. Phenytoin requires that a trough level be drawn. Peak and trough levels are done: To determine if a drug is in the therapeutic range 9. A laboratory result indicates that the peak level for a drug is above the minimum toxic concentration. This means that the: Concentration will produce an adverse response 10. Drugs that are receptor agonists may demonstrate what property? Desensitization or downregulation with continuous use 11. Drugs that are receptor antagonists, such as beta blockers, may cause: An exaggerated response if abruptly discontinued 12. Factors that affect gastric drug absorption include: Lipid solubility of the drug NR 565Pharm midterm study guide 13. Drugs administered via IV: Begin distribution into the body immediately 14. When a medication is added to a regimen for a synergistic effect, the combined effect of the drugs is: Greater than the sum of the effects of each drug individually 15. Which of the following statements about bioavailability is true? Bioavailability issues are especially important for drugs with narrow therapeutic ranges or sustained-release mechanisms. 16.Which of the following statements about the major distribution barriers (blood-brain or fetal- placental) is true? The blood-brain barrier slows the entry of many drugs into and from brain cells. 17.Drugs are metabolized mainly by the liver via phase I or phase II reactions. The purpose of both of these types of reactions is to: Change drug molecules to a form that an excretory organ can excrete 18. Once they have been metabolized by the liver, the metabolites may be: More active than the parent drug Less active than the parent drug Totally “deactivated” so they are excreted without any effect 19. All drugs continue to act in the body until they are changed or excreted. The ability of the body to excrete drugs via the renal system would be increased by: Unbinding a nonvolatile drug from plasma proteins 20. Steady state is: When the amount of drug in the body remains constant 21. Two different pain medications are given together for pain relief. The drug—drug interaction Additive 22.Actions taken to reduce drug—drug interaction problems include all of the following EXCEPT: Prescribing a third drug to counteract the adverse reaction of the combination 23. Phase I oxidative-reductive processes of drug metabolism require certain nutritional elements. Which of the following would reduce or inhibit this process? Neither Protein malnutrition OR Iron-deficiency anemia NR 565Pharm midterm study guide 2. Up to 21% of Asians are ultra-rapid 2D6 metabolizers, leading to: Increased dosages needed of drugs metabolized by 2D6, such as the selective serotonin reuptake inhibitors 3.Rifampin is a nonspecific CYP450 inducer that may: Induce the metabolism of drugs, such as oral contraceptives, leading to therapeutic failure 4.Inhibition of P-glycoprotein by a drug such as quinidine may lead to: Increased levels of a coadministered drug, such as digoxin, that requires P-glycoprotein for absorption and elimination 5.Warfarin resistance may be seen in patients with VCORC1 mutation, leading to: Decreased response to warfarin 6.Genetic testing for VCORC1 mutation to assess potential warfarin resistance is required prior to prescribing warfarin. False 7.Pharmacogenetic testing is required by the U.S. Food and Drug Administration prior to prescribing: Cetuximab 8.Carbamazepine has a Black Box Warning recommending testing for the HLA-B*1502 allele in patients with Asian ancestry prior to starting therapy due to: Increased risk for Stevens-Johnson syndrome in Asian patients with HLA- B*1502 allele 9. A genetic variation in how the metabolite of the cancer drug irinotecan SN-38 is inactivated by the body may lead to: Increased adverse drug reactions, such as neutropenia 10. Patients who have a poor metabolism phenotype will have: Slowed metabolism of a prodrug into an active drug, leading to accumulation of prodrug 11.Ultra-rapid metabolizers of drugs may have: Active drug rapidly metabolized into inactive metabolites, leading to potential therapeutic failure NR 565Pharm midterm study guide 12. A provider may consider testing for CYP2D6 variants prior to starting tamoxifen for breast cancer to: Reduce the likelihood of therapeutic failure with tamoxifen treatment Chapter 1. The Role of the Nurse Practitioner 1.Nurse practitioner prescriptive authority is regulated by: The State Board of Nursing for each state 2. The benefits to the patient of having an Advanced Practice Registered Nurse (APRN) prescriber include: Nurses care for the patient from a holistic approach and include the patient in decision making regarding their care 3. Clinical judgment in prescribing includes: Factoring in the cost to the patient of the medication prescribed 4. Criteria for choosing an effective drug for a disorder include: Consulting nationally recognized guidelines for disease management 5. Nurse practitioner practice may thrive under health-care reform because of: The demonstrated ability of nurse practitioners to control costs and Improve patient outcomes Chapter 4. Legal and Professional Issues in Prescribing 1. The U.S. Food and Drug Administration regulates: The official labeling for all prescription and over-the-counter drugs 2. The U.S. Food and Drug Administration approval is required for: Medical devices, including artificial joints 3. An Investigational New Drug is filed with the U.S. Food and Drug Administration: Prior to human testing of any new drug entity 4. Phase IV clinical trials in the United States are also known as: Postmarketing research 5. Off-label prescribing is: Legal if there is scientific evidence for the use 6. The U.S. Drug Enforcement Administration: NR 565Pharm midterm study guide Registers manufacturers and prescribers of controlled substances 7. Drugs that are designated Schedule II by the U.S. Drug Enforcement Administration: May not be refilled; a new prescription must be written 8. Precautions that should be taken when prescribing controlled substances include: Using tamper-proof paper for all prescriptions written for controlled drugs 9. Strategies prescribers can use to prevent misuse of controlled prescription drugs include: Use of chemical dependency screening tools Firm limit-setting regarding prescribing controlled substances Practicing “just say no” to deal with patients who are pushing the provider to prescribe controlled substances 10. Behaviors predictive of addiction to controlled substances include: Stealing or borrowing another patient’s drugs 11. Medication agreements or “Pain Medication Contracts” are recommended to be used: Universally for all prescribing for chronic pain 12. A prescription needs to be written for: Legend drugs Most controlled drugs Medical devices Chapter 13. Over-the-Counter Medications 1. Michael asks you about why some drugs are over-the-counter and some are prescription. You explain that in order for a drug to be approved for over-the-counter use the drug must: Be safe and labeled for appropriate use Have a low potential for abuse or misuse Be taken for a condition the patient can reliably self-diagnose 2. In the United States, over-the-counter drugs are regulated by: The U.S. Food and Drug Administration Center for Drug Evaluation and Research 3. As drugs near the end of their patent, pharmaceutical companies may apply for the drug to change to over-the-counter status in order to: Continue to make large profits from their blockbuster brand-name drug NR 565Pharm midterm study guide 15.Henry is 82 years old and takes two aspirin every morning to treat the arthritis pain in his back. He states the aspirin helps him to “get going” each day. Lately he has had some heartburn from the aspirin. After ruling out an acute GI bleed, what would be an appropriate course of treatment for Henry? Add an H2 blocker such as ranitidine to his therapy. 16.The trial period to determine effective anti-inflammatory activity when starting a patient on aspirin for rheumatoid arthritis is: 4 to 6 days 17. Patients prescribed aspirin therapy require education regarding the signs of aspirin toxicity. An early sign of aspirin toxicity is: Tinnitus 18.Monitoring a patient on a high-dose aspirin level includes: Salicylate level Complete blood count Urine pH 19. Patients who are on long-term aspirin therapy should have annually. Complete blood count Chapter 52. Pain Management: Acute and Chronic Pain 1. Different areas of the brain are involved in specific aspects of pain. The reticular and limbic systems in the brain influence the: Motivational aspects of pain 2. Patients need to be questioned about all pain sites because: Patients tend to report the most severe or important in their perception. 3. The chemicals that promote the spread of pain locally include: Neurokinin A 4. Narcotics are exogenous opiates. They act by: Attaching to receptors in the afferent neuron to inhibit the release of substance P 5. Age is a factor in different responses to pain. Which of the following age-related statements about pain is NOT true? Preterm and newborn infants do not yet have functional pain pathways. NR 565Pharm midterm study guide 6.Which of the following statements is true about acute pain? Referred pain is present in a distant site for the pain source and is based on activation of the same spinal segment as the actual pain site. 7. One of the main drug classes used to treat acute pain is NSAIDs. They are used because: Inflammation is a common cause of acute pain. 8. Opiates are used mainly to treat moderate to severe pain. Which of the following is NOT true about these drugs? Opiates stimulate only mu receptors for the control of pain. 9.If interventions to resolve the cause of pain (e.g., rest, ice, compression, and elevation) are insufficient, pain medications are given based on the severity of pain. Drugs are given in which order of use? Non-opiate, increased dose of non-opiate, opiate 10. The goal of treatment of acute pain is: Reduction or elimination of pain with minimum adverse reactions 11. Which of the following statements is true about age and pain? Acetaminophen is especially useful in both children and adults because it has no effect on platelets and has fewer adverse effects than NSAIDs. 12. Pain assessment to determine adequacy of pain management is important for all patients. This assessment is done to: Determine if the diagnosis of source of pain is correct Determine if the current regimen is adequate or different combinations of drugs and non- drug therapy are required Determine if the patient is willing and able to be an active participant in his or her pain management 13. Pathological similarities and differences between acute pain and chronic pain include: Chronic pain has a predominance of C-neuron stimulation. 14. A treatment plan for management of chronic pain should include: Negotiation with the patient to set personal goals for pain management Discussion of ways to improve sleep and stress An exercise program to improve function and fitness NR 565Pharm midterm study guide 15.Chronic pain is a complex problem. Some specific strategies to deal with it include: Scheduling return visits on a regular basis rather than waiting for poor pain control to drive the need for an appointment 16. Chemical dependency assessment is integral to the initial assessment of chronic pain. Which of the following raises a “red flag” about potential chemical dependency? Multiple times when prescriptions are lost with requests to refill 17. The Pain Management Contract is appropriate for: Patients with chronic pain who will require long-term use of opiates Chapter 14. Drugs Affecting the Autonomic Nervous System 1.Charlie is a 65-year-old male who has been diagnosed with hypertension and benign prostatic hyperplasia. Doxazosin has been chosen to treat his hypertension because it: Relaxes smooth muscle in the bladder neck 2.To reduce potential adverse effects, patients taking a peripherally acting alpha1 antagonist should do all of the following EXCEPT: Monitor their blood pressure and skip a dose if the pressure is less than 120/80. Patients should Take the dose at bedtime, Sit up slowly and dangle their feet before standing, & Weigh daily and report weight gain of greater than 2 pounds in one day 3. John has clonidine, a centrally acting adrenergic blocker, prescribed for his hypertension. He should Not miss a dose or stop taking the drug because of potential rebound hypertension 4. Clonidine has several off-label uses, including: Alcohol and nicotine withdrawal Post-herpetic neuralgia 5. Jim is being treated for hypertension. Because he has a history of heart attack, the drug chosen is atenolol. Beta blockers treat hypertension by: Reducing vascular smooth muscle tone 6. Which of the following adverse effects are less likely in a beta1-selective blocker? Impaired insulin release NR 565Pharm midterm study guide 27. Nicotine gum products are: Bound to exchange resins so the nicotine is only released during chewing 28. Nicotine replacement therapy (NRT): Delays healing of esophagitis and peptic ulcers 29. Success rates for smoking cessation using NRT: Vary from 40% to 50% at 12 months 30. Cholinergic blockers are used to: Counteract the extrapyramidal symptoms (EPS) effects of phenothiazines Control tremors and relax smooth muscle in Parkinson’s disease Inhibit the muscarinic action of ACh on bladder muscle 31. Several classes of drugs have interactions with cholinergic blockers. Which of the following is true about these interactions? Drugs with a narrow therapeutic range given orally may not stay in the GI tract long enough to produce an action. 32. Scopolamine can be used to prevent the nausea and vomiting associated with motion sickness. The patient is taught to: Swallow the tablet 1 hour before traveling where motion sickness is possible 33.You are managing the care of a patient recently diagnosed with benign prostatic hyperplasia (BPH). He is taking tamsulosin but reports dizziness when standing abruptly. The best option for this patient is: Discontinue the tamsulosin and start doxazosin. 34. You are treating a patient with a diagnosis of Alzheimer’s disease. The patient’s wife mentions difficulty with transportation to the clinic. Which medication is the best choice? Donepezil 35. A patient presents with a complaint of dark stools and epigastric pain described as gnawing and burning. Which of the medications is the most likely cause? Bethanechol 36. Your patient calls for an appointment before going on vacation. Which medication should you ensure he has an adequate supply of before leaving to avoid life-threatening complications? Carvedilol NR 565Pharm midterm study guide 37. Activation of central alpha2 receptors results in inhibition of cardioacceleration and centers in the brain. Vasoconstriction Chapter 15. Drugs Affecting the Central Nervous System 1. Sarah, a 42-year-old female, requests a prescription for an anorexiant to treat her obesity. A trial of phentermine is prescribed. Prescribing precautions include: Anorexiants may cause tolerance and should only be prescribed for 6 months 2. Before prescribing phentermine to Sarah, a thorough drug history should be taken including assessing for the use of serotonergic agents such as selective serotonin reuptake inhibitors (SSRIs) and St John’s wort due to: The risk of serotonin syndrome 3.Antonia is a 3-year-old child who has a history of status epilepticus. Along with her routine antiseizure medication, she should also have a home prescription for to be used for an episode of status epilepticus. Rectal diazepam (Diastat) 4. Rabi is being prescribed phenytoin for seizures. Monitoring includes assessing: For phenytoin hypersensitivity syndrome 3 to 8 weeks after starting treatment 5. Dwayne has recently started on carbamazepine to treat seizures. He comes to see you and you note that while his carbamazepine levels had been in the therapeutic range, they are now low. The possible cause for the low carbamazepine levels include: Carbamazepine auto-induces metabolism, leading to lower levels in spite of good compliance. 6. Carbamazepine has a Black Box Warning due to life-threatening: Dermatologic reaction, including Steven’s Johnson and toxic epidermal necrolysis 7. Long-term monitoring of patients who are taking carbamazepine includes: Complete blood count every 3 to 4 months 8. Six-year-old Lucy has recently been started on ethosuximide (Zarontin) for seizures. She should be monitored for: Blood dyscrasias, which are uncommon but possible 9.Sook has been prescribed gabapentin to treat neuropathic pain and is complaining of feeling depressed and having “strange” thoughts. The appropriate initial action would be: Assess for suicidal ideation NR 565Pharm midterm study guide 10. Selma, who is overweight, recently started taking topiramate for seizures and at her follow- up visit you note she has lost 3 kg. The appropriate action would be: Reassure her that this is a normal side effect of topiramate and continue to monitor her weight. 11. Monitoring of a patient on gabapentin to treat seizures includes: Recording seizure frequency, duration, and severity 12. Scott’s seizures are well controlled on topiramate and he wants to start playing baseball. Education for Scott regarding his topiramate includes: He should monitor his temperature and ability to sweat in the heat while playing 13. Cara is taking levetiracetam (Keppra) to treat seizures. Routine education for levetiracetam includes reminding her: To wear sunscreen due to photosensitivity from levetiracetam 14. Levetiracetam has known drug interactions with: Few, if any, drugs 15. Zainab is taking lamotrigine (Lamictal) and presents to the clinic with fever and lymphadenopathy. Initial evaluation and treatment includes: Ruling out a hypersensitivity reaction that may lead to multi-organ failure 16. Samantha is taking lamotrigine (Lamictal) for her seizures and requests a prescription for combined oral contraceptives (COCs), which interact with lamotrigine and may cause: Reduced lamotrigine levels, requiring doubling the dose of lamotrigine 17. The tricyclic antidepressants should be prescribed cautiously in patients with: Heart disease 18. A 66-year-old male was prescribed phenelzine (Nardil) while in an acute psychiatric unit for recalcitrant depression. The NP managing his primary health care needs to understand the following regarding phenelzine and other monoamine oxidase inhibitors (MAOIs): He should not be prescribed any serotonergic drug such as sumatriptan (Imitrex) MAOIs interact with many common foods, including yogurt, sour cream, and soy sauce Symptoms of hypertensive crisis (headache, tachycardia, sweating) require immediate treatment NR 565Pharm midterm study guide 38. When prescribing Adderall (amphetamine and dextroamphetamine) to adults with ADHD the nurse practitioner will need to monitor: Blood pressure Chapter 29. Anxiety and Depression 1. Common mistakes practitioners make in treating anxiety disorders include: Thinking a partial response to medication is acceptable 2.An appropriate first-line drug to try for mild to moderate generalized anxiety disorder would be: Buspirone (Buspar) 3.An appropriate drug to initially treat panic disorder is: Diazepam (Valium) 4.Prior to starting antidepressants, patients should have laboratory testing to rule out: Hypothyroidism 5. David is a 34-year-old patient who is starting on paroxetine (Paxil) for depression. David’s education regarding his medication would include: He may experience sexual dysfunction beginning a month after he starts therapy 6. Jamison has been prescribed citalopram (Celexa) to treat his depression. Education regarding how quickly selective serotonin reuptake inhibitor (SSRI) antidepressants work would be: Appetite and concentration improve in the first 1 to 2 weeks. 7. An appropriate drug for the treatment of depression with anxiety would be: Escitalopram (Lexapro) 8.An appropriate first-line drug for the treatment of depression with fatigue and low energy would be: Venlafaxine (Effexor) 9. The laboratory monitoring required when a patient is on a selective serotonin reuptake inhibitor is: There is no laboratory monitoring required 10.Jaycee has been on escitalopram (Lexapro) for a year and is willing to try tapering off of the selective serotonin reuptake inhibitor. What is the initial dosage adjustment when starting a taper off antidepressants? Reduce dose by 50% for 3 to 4 days NR 565Pharm midterm study guide 11. The longer-term Xanax patient comes in and states they need a higher dose of the medication. They deny any additional, new, or accelerating triggers of their anxiety. What is the probable reason? They have become tolerant of the medication, which is characterized by the need for higher and higher doses. 12. What “onset of action” symptoms should be reviewed with patients who have been newly prescribed a selective serotonin reuptake inhibitor? They can feel a bit of nausea, but this resolves in a week. 13. Which of the following should not be taken with a selective serotonin reuptake inhibitor? Alcohol 14. Why is the consistency of taking paroxetine (Paxil) and never running out of medication more important than with most other selective serotonin reuptake inhibitors (SSRIs)? It has a shorter half-life and withdrawal syndrome has a faster onset without taper. 15. The patient shares with the provider that he is taking his Prozac at night before going to bed. What is the best response? Have you noticed that you are having more sleep issues since you started that? Chapter 35. Headaches 1. Paige has a history of chronic migraines and would benefit from preventative medication. Education regarding migraine preventive medication includes: The goal of treatment is to reduce migraine occurrence by 50%. 2. A first-line drug for abortive therapy in simple migraine is: Naproxen (Aleve) 3. Vicky, age 56 years, comes to the clinic requesting a refill of her Fiorinal (aspirin and butalbital) that she takes for migraines. She has been taking this medication for over 2 years for migraines and states one dose usually works to abort her migraine. What is the best care for her? Assess how often she is using Fiorinal and refill her medication. 4. When prescribing ergotamine suppositories (Wigraine) to treat acute migraine, patient education would include: They may need premedication with an antinausea medication. 5. Migraines in pregnancy may be safely treated with: NR 565Pharm midterm study guide Acetaminophen with codeine (Tylenol #3) 6. Xi, a 54-year-old female, has a history of migraines that do not respond well to OTC migraine medication. She is asking to try Maxalt (rizatriptan) because it works well for her friend. Appropriate decision making would be: Prescribe Maxalt and arrange to have her observed in the clinic or urgent care with the first dose. 7.Kelly is a 14-year-old patient who presents to the clinic with a classic migraine. She says she is having a headache two to three times a month. The initial plan would be: Prescribe NSAIDs as abortive therapy and have her keep a headache diary to identify her triggers 8. Jayla is a 9-year-old patient who has been diagnosed with migraines for almost 2 years. She is missing up to a week of school each month. Her headache diary confirms she averages four or five migraines per month. Which of the following would be appropriate? Prescribe propranolol (Inderal) to be taken daily for at least 3 months. 9.Amber is a 24-year-old patient who has had migraines for 10 years. She reports a migraine on average of once a month. The migraines are effectively aborted with naratriptan (Amerge). When refilling Amber’s naratriptan, education would include: Naratriptan will interact with antidepressants, including selective serotonin reuptake inhibitors (SSRIs) and St John’s wort, and she should inform any providers she sees that she has migraines. Continue to monitor her headaches, if the migraine is consistently happening around her menses there is preventive therapy available. Pregnancy is contraindicated when taking a triptan 10. When prescribing for migraines, patient education includes: Stress reduction and regular sleep are integral to migraine treatment. 11. Juanita presents to the clinic with a complaint of headaches off and on for months. She reports they feel like someone is “squeezing” her head. She occasionally takes Tylenol for the pain, but usually just “toughs it out.” Initial treatment for tension headache includes asking her to keep a headache diary and a prescription for: Naproxen (Aleve) 12. Nonpharmacologic therapy for tension headaches includes: Biofeedback Stress management Midterm Pharm study guide NR565NP. Substances in this schedule have a low potential for abuse relative to substances in Schedule III. Examples of Schedule IV substances include: alprazolam (Xanax®), carisoprodol (Soma®), clonazepam (Klonopin®), clorazepate (Tranxene®), diazepam (Valium®), lorazepam (Ativan®), midazolam (Versed®), temazepam (Restoril®), and triazolam (Halcion®). Schedule V Controlled Substances Substances in this schedule have a low potential for abuse relative to substances listed in Schedule IV and consist primarily of preparations containing limited quantities of certain narcotics. Examples of Schedule V substances include: cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams (Robitussin AC®, Phenergan with Codeine®), and ezogabine. • Which ones can and can not be prescribed by nurse practitioners ➢ They can prescribe all but schedule 1 because they are not legal. Varies by state • Prescriptive Authority • Understand what prescriptive authority is and who mandates it. ➢ State mandates it under the jurisdiction of the health professional board. (state board of nursing, board of medicine or board of pharmacy). Federal government controls drug regulations but has no control over prescriptive authority. Prescriptive authority is the legal right to prescribe drugs. Full authority is being able to prescribe independently without limitations. MDs and DOs have no limits. Limitations are tied to oversight of the doctor or DO. Being able to prescribe independently means is not subject to rules requiring physician supervision or collaboration. Florida III-V collaborative. • What problems arise when it is limited? ➢ Barriers include quality, affordable, and accessible patient care. Can increase patient waits • Know the responsibilities of prescribing ➢ Must consider cost, availability, interactions with either food or other medications, side effects, allergies, how the drug is metabolized (hepatic or renal), need for monitoring (labs, effectiveness, ect) special populations (pregnancy, nursing mothers, or older adults) • Know patient reasons for medication non-adherence ➢ Missed a dose, forgot to take a dose, did not refill medication in time, took lower than prescribed dose, did not refill medication, stopped taking medication. ➢ Reason why includes forgot a dose, ran out, was away from home, trying to save money, did not like the side effects, was too busy, the medication didn’t work, didn’t believe medication was necessary, didn’t like taking the medication. Failure to comprehend instructions for reasons such as visual, intellectual or auditory impairment, use of complex regimens (taking several drugs multiple times a day) Midterm Pharm study guide NR565NP. Most common is forgetfulness. Use medication organizers and incorporate meds into a daily routine like brushing teeth or eating breakfast. • Know how what type of evidence prescribers should use to make treatment recommendations ➢ ? • Be familiar with physiological changes of aging that impact pharmacological treatments ➢ Drug sensitivity varies with age. Infants and older adults are especially sensitive to drugs. In the very young patient, heightened drug sensitivity is the result of organ immaturity. In older adults, heightened sensitivity results largely from decline in organ function. Other factors that affect sensitivity in older adults are the presence of multiple comorbidities and treatment with multiple drugs. The drug-metabolizing capacity of infants is limited. The liver does not develop its full capacity to metabolize drugs until approximately 1 year after birth. During the time before hepatic maturation, infants are especially sensitive to drugs, and care must be taken to avoid injury. Similarly, the ability of older adults to metabolize drugs is commonly decreased. Drug dosages may need to be reduced to prevent drug toxicity. The kidneys of newborns are not fully developed. Until their kidneys reach full capacity (a few months after birth), infants have a limited capacity to excrete drugs. This must be accounted for when medicating an infant. In older adults, renal function often declines. Older adults have smaller kidneys and fewer nephrons. The loss of nephrons results in decreased blood filtration. In addition, vessel changes such as atherosclerosis reduce renal blood flow. As a result, renal excretion of drugs is decreased. • Be familiar with Beer’s Criteria ➢ List that identifies drugs with a high likelihood of causing adverse effects in older adults. Drugs on the list should be avoided in patients over 65 except when the benefits significantly outweigh the risks. • Know CYP450 inducers and inhibitors Most drug metabolism that takes place in the liver is performed by the hepatic microsomal enzyme system, also known as the P450 system. The term P450 refers to cytochrome P450, a key component of this enzyme system. It is important to appreciate that cytochrome P450 is not a single molecular entity but rather a group of 12 closely related enzyme families. Three of the cytochrome P450 (CYP) families— designated CYP1, CYP2, and CYP3—metabolize drugs. The other nine families metabolize endogenous compounds (e.g., steroids, fatty acids). Each of the three P450 families that metabolize drugs is composed of multiple forms, each of which metabolizes only certain drugs. To identify the individual forms of cytochrome P450, designations such as CYP1A2 (metabolizes AcetAminophen), CYP2D6 (Metabolize Cardiovascular drugs 2D echo) and CYP3A4 (most common) are used to indicate specific members of the CYP1, CYP2, and CYP3 families, respectively. Drugs that are metabolized by P450 hepatic enzymes are substrates. Drugs that increase the rate of drug metabolism are inducers. Drugs that decrease the rate of drug metabolism are called inhibitors. Inducers act on the liver to stimulate enzyme synthesis. This process is known as induction. By increasing the rate of drug metabolism, the amount of active drug is decreased and plasma drug levels fall. If dosage adjustments are not made to accommodate for this, a drug Midterm Pharm study guide NR565NP. may not achieve therapeutic levels. They are Carbamazepine, rifampin, alcohol, phenytoin, griseofulvin, phenobarbital, sulfonylureas. Pneumonic is CRAP GPS induces my rage to memorize. Inhibitors act on the liver through a process known as inhibition. By slowing the rate of metabolism, inhibition can cause an increase in active drug accumulation. This can lead to an increase in adverse effects and toxicity. They are Valproate, Ketoconazole, Isoniazid, Sulfonamides, Chloramphenicol, Amiodarone, Erythromycin, Quinidine, Grapefruit juice. https://youtu.be/OhIopfQm9_w Video helps the breakdown of how it works • Be familiar with opioid agonists ➢ Agonists are molecules that activate receptors. Because neurotransmitters, hormones, and other endogenous regulators activate the receptors to which they bind, all of these compounds are considered agonists. When drugs act as agonists, they simply bind to receptors and mimic the actions of the body's own regulatory molecules. For example, dobutamine is a drug that mimics the action of NE at receptors on the heart, thereby causing heart rate and force of contraction to increase. In terms of the modified occupancy theory, an agonist is a drug that has both affinity and high intrinsic activity. Affinity allows the agonist to bind to receptors, whereas intrinsic activity allows the bound agonist to activate or turn on receptor function. Full agonists bind tightly to the opioid receptors and undergo significant conformational change to produce maximal effect. Examples of full agonists include codeine, fentanyl, heroin, hydrocodone, methadone, morphine, and oxycodone. The pure opioid agonists activate µ receptors and κ receptors. By doing so, the pure agonists can produce analgesia, euphoria, sedation, respiratory depression, physical dependence, constipation, and other effects. The pure agonists can be subdivided into two groups: strong opioid agonists and moderate to strong opioid agonists. Morphine is the prototype of the strong agonists. Codeine is the prototype of the moderate to strong agonists. • Know the outcome of having a poor metabolism phenotype ➢ A poor-metabolizing enzyme has very low activity. It is possible to have side effects even with a very low drug dose, because the enzyme is very slow to break down the drug • Know the role of the government agencies when it comes to prescription drugs Week 2 - Know black box warning for various pain medications. ➢ The boxed warning, also known as a black box warning, is the strongest safety warning a drug can carry and still remain on the market. Text for the warning is presented inside a box with a heavy black border. The FDA requires a boxed warning on drugs with serious or life-threatening risks. The purpose of the warning is to alert providers to (1) potentially severe side effects (e.g., life-threatening dysrhythmias, suicidality, major fetal harm) as well as (2) ways to prevent or reduce harm (e.g., avoiding a teratogenic drug during pregnancy). The boxed warning provides a concise summary of the adverse effects of concern. A boxed warning must appear prominently on the package insert, on the product label, and even in magazine advertising. Drugs that have a boxed warning must also have Midterm Pharm study guide NR565NP. ➢ Multiple prescribers given prescription drugs, refill requested early - When is it appropriate to prescribe naloxone? ➢ Naloxone (Narcan) is a structural analog of morphine that acts as a competitive antagonist at opioid receptors, thereby blocking opioid actions. Naloxone can reverse most effects of the opioid agonists, including respiratory depression, coma, and analgesia. Naloxone is the drug of choice for treating overdose with a pure opioid agonist. The drug reverses respiratory depression, coma, and other signs of opioid toxicity. Naloxone can also reverse toxicity from agonist-antagonist opioids (e.g., pentazocine, nalbuphine). However, the doses required may be higher than those needed to reverse poisoning by pure agonists. ➢ Dosage must be carefully titrated when treating toxicity in opioid addicts because the degree of physical dependence in these individuals is usually high and hence an excessive dose of naloxone can transport the patient from a state of poisoning to one of acute withdrawal. Accordingly, treatment should be initiated with a series of small doses rather than one large dose. Because the half-life of naloxone is shorter than that of most opioids, repeated dosing is required until the crisis has passed. If the patient received a dose of naloxone by a friend or family member for a suspected overdose, the patient should be transported by emergency providers to the nearest emergency department for further evaluation. ➢ In some cases of accidental poisoning, there may be uncertainty as to whether unconsciousness is due to opioid overdose or to overdose with a general CNS depressant (e.g., barbiturate, alcohol, benzodiazepine). When uncertainty exists, naloxone is nonetheless indicated. If the cause of poisoning is a barbiturate or another general CNS depressant, naloxone will be of no benefit—but neither will it cause any harm. ➢ Should be prescribe if patients are at risk for opioid use disorder, have a history of nonfatal overdose, higher dose opioids (>50 MME/day), concurrent benzo use You may want to consider prescribing naloxone for the following patients at risk: - Be familiar with drugs that are not safe to take with opioids. ➢ Benzos, other substances, alcohol, - Be familiar with the PEG Assessment Scale. ➢ PEG stands for Pain average, interference with Enjoyment of life, and interference with General activity Assessment scale. Helps track patient outcomes. Clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and Naloxone can cause acute withdrawal symptoms with adverse effects in patients physically dependent on opioids. Caution must be exercised with a review of needs, benefits, and risks. Patients taking benzodiazepines concurrently with opioids Patients receiving high opioid dosages (≥ 50 MME per day) Patients diagnosed or suspected of having OUD Patients with a history of nonfatal overdoses Patients who have concurrent alcohol or substance use Midterm Pharm study guide NR565NP. function. Monitoring progress toward patient centered function goals, such as walking the dog or walking around the block, returning to work part time, can also contribute to the assessment of functional improvement. 0-10 scale Midterm Pharm study guide NR565NP. ➢ Question 1. what number describes your pain on average in the past week 0 (no pain)- 10 (pain as bad as you can imagine) ➢ Question 2. What number best describes how, during the past week, pain has interfered with your enjoyment to life? 0 (does not interfere) -10 (completely interferes) ➢ Question 3. What number best describes how, during the past week, pain has interfered with your general activity 0 (does not interfere) – 10 (Completely interferes) - Patient and provider responsibilities in opioid drug therapy ➢ Risk vs benefits, policies of practice, follow up, ➢ Patient responsibilities ➢ Provider responsibilities - How to approach conversations about Opioid Use Disorder ➢ Open and honest discussion, non-confrontational - What types of pain can be treated by psychotropic medications? ➢ Neuropathic pain, postherpetic neuralgia, fibromyalgia, migraines, diabetic neuropathy. Examples are pregabalin, gabapentin, carbamazepine, TCA’s and SNRI’s o Taking all medications as prescribed o Keeping appointments with provider o Committing to all recommended therapies o Acknowledging risks and side effects o Communicating any questions or concerns o Participating in urine drug testing (UDT) o Disclosing the use of other medications, including OTC and illicit drugs o Keeping medication in a safe place, away from other people (including children) o Communicating expected benefits and risks throughout therapy, at least every three months o Recommending a multimodal therapy approach, combining nonopioid and nonpharmacologic therapies with opioid therapy to improve effectiveness o Reviewing the PDMP and UDT o Reviewing refill requests carefully to ensure opioid medication is used appropriately o Identifying the need for early intervention to mitigate risks Midterm Pharm study guide NR565NP. • - Mechanism of action and related physiological outcomes Midterm Pharm study guide NR565NP. • o Cardiac glycosides (Digoxin) known for positive inotropic actions. Increase myocardial contractile force by inhibiting the enzyme known as sodium-potassium adenosine triphosphatase (Na+,K+-ATPase) and increase cardiac output. As a result of increased cardiac output, three major secondary responses occur: (1) sympathetic tone declines, (2) urine production increases, and (3) renin release declines. These responses can reverse virtually all signs and symptoms of HF. However, they do not correct the underlying problem of cardiac remodeling. Potassium competes with digoxin so if potassium levels are low digoxin levels increase and cause toxicity and if potassium levels are high digoxin level is reduced and impaired therapeutic response. It is imperative to keep potassium levels WNL while on dig. Used in Heart failure and a fib but is not shown to prolong life in HF. Second line agent now for HF. It has a profound neurohormonal effect. Can cause severe dysrhythmias and has a small window for a therapeutic dose. May shorten life in women. Patient education should include to monitor their heart rate and signs and symptoms of dig toxicity which include altered heart rate or rhythm, visual or gastrointestinal disturbances. o Verapamil -calcium channel blocker indicated for HTN, Angina, Dysrhythmias, and migraine and work on the arterioles and the heart. Can have toxic doses that produce dangerous cardiac suppression. By blocking calcium channels in the heart and blood vessels, verapamil has five direct effects: • • Blockade at peripheral arterioles causes dilation and thereby reduces arterial pressure. • • Blockade at arteries and arterioles of the heart increases coronary perfusion. • • Blockade at the SA node reduces heart rate. • • Blockade at the AV node decreases AV nodal conduction. Most important • • Blockade in the myocardium decreases force of contraction • SE include constipation, dizziness, facial flushing, headache, edema in feet or ankles. Can increase dig toxicity and interact with grapefruit juice • o Organic nitrates ➢ nitroglycerin is first choice. It is a vasodilator. Decrease oxygen demand by dilating veins and decreases preload, increases oxygen supply by relaxing coronary vasospasm. Fast acting and inexpensive. Acts directly on vascular smooth muscle to promote vasodilation and converts to its active form nitric oxide but requires the sulfhydryl enzyme. Nitro does not affect coronary blood flow. Highly lipid soluble and half-life is 5-7 minutes. Can cause orthostatic hypotension, reflex tachycardiac. • o Calcium channel blockers ➢ Used to treat HTN, angina, and dysrhythmias. Effects are on the blood vessels and the heart. They prevent calcium ions from entering the cell. Controversy in patients with diabetes and hypertension. Calcium entry plays a critical role in the function of vascular smooth muscle and the heart. Calcium channels regulate contraction and when channels Preventive Services Task Force (USPSTF) Guidelines 2016, the US Preventive Services Task Force (USPSTF) made similar but slightly different recommendations for adults without a history of cardiovascular disease (CVD) to use a low- to moderate-dose statin for the prevention of CVD events and mortality when all of the following criteria are met: 1. Age 40 to 75 years 2. 1 or more CVD risk factors (ie, dyslipidemia, diabetes, hypertension, or smoking) 3. Calculated 10-year risk of a cardiovascular event of 10% or greater (B recommendation) The USPSTF gave a B recommendation—indicating high certainty that the benefit is moderate or moderate certainty that the benefit is moderate to substantial—for starting low- to moderate-dose statins in adults ages 40 to 75 years without a history of cardiovascular disease (CVD) who have one or more CVD risk factors and a 10-year CVD risk of 10% or greater. The USPSTF dropped its level of endorsement to C for adults with a lower 1-year risk (7.5%-10%) and made no recommendations for adults 76 years of age and older, explaining that there was insufficient evidence for this age group. *Thanks to Vijay Shetty, MBBS, for this summary of the 2016 USPSTF guidelines. Intensity of Statin Therapy Midterm Pharm study guide NR565NP. are blocked contraction will be prevented and vasodilation will result and are selective on peripheral arterioles and arteries and the arterioles of the heart. They have no significant effect on the veins. SA node activity declines and reduces the HR. Discharge of the AV node is suppressed and decreases velocity of conduction through the AV node. • - Contraindications • o Beta-blockers • should not be used in sick sinus syndrome, HF, second degree or third-degree AV blocks and used with caution in patients with Asthma and diabetes. Beta blockers have decreased effects on Africain Americans. • o ACE Inhibitors ➢ Hyperkalemia, renal artery stenosis, pregnancy, or prior adverse reaction to ACEI such as angioedema • o Ranolazine ➢ hepatic cirrhosis • - Be familiar with clinical tools used to determine how to treat hyperlipidemia ➢ Assess ASCVD risk and calculating 10-year atherosclerotic cardiovascular disease risk. Type of Statin Taken Daily, Average LDL Lowering Effect Types of Medication High-Intensity Statin Therapy Approximately ≥50% Atorvastatin 40–80 mg