Pharmacology Review

By

Mrs. McCann

Five Rights of Drug Administration THE RIGHT:

1. Patient

2. Drug

3. Dose The original Five Rights

4. Route

5. Time

6. Documentation

Miss any one or more of the above and you have

made a “medication error”

Vitamins

Characteristics of Vitamins

Fat-soluble vitamins are A, D, E, and K.

OR

Water-soluble vitamins are B vitamins, folic acid, and vitamin C.

Citrus fruits are rich in Vitamin C.

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Minerals

Iron Calcium and phosphorus

Potassium Extremely irritating to veins and fatal if given by

intravenous push method

Antimicrobials

Sulfonamide Drugs (Sulfa Drugs) Pre-date Pennicillins

Used to treat Urinary Tract Infections & Malaria

Bactrim or Bactrim DS

drink high volume of fluids to keep urine dilute. Sulfonamides crystallize in the urine and deposit in the kidneys causing pain.

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Antibiotic Agents

Broad-spectrum antibiotic agents are effective against many microorganisms.

Narrow-spectrum antibiotic agents are effective against only a few microorganisms.

Allergic reactions to antibiotic agents are common; repeated exposure may cause a mild rash or severe or even fatal reactions.

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Antibiotic Agents

Antibiotic agents are placed in broad groups:

penicillin agents (Allergic reactions are common)

cephalosporin agents

tetracycline agents

macrolide agents,

quinolone agents.

General toxicity and side effects are as follows:

Allergy

Abdominal cramping and diarrhea

Rashes

Monilia overgrowth; vaginal, perineal, or oral thrush infections result

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Antifungal Agents

Do not mix “p.o.” antifungal meds with alcohol = nausea vomiting.

Infections may be simple, as in athlete’s foot fungal rash or thrush.

In patients with impaired immune systems, fungal infections can be life threatening.

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Antiviral Agents Treats viral infections such as hepatitis, AIDS, Herpes, Flu

Interferon alfa-2b is used to treat hepatitis B, C, D, and West Nile virus

Herpes virus Drugs (topical or systemic)

Acycylovir

Famcylovir

Valacylovir

Pencylovir

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Antiparasitic Agents Lice

Lindane (Kwell) – for head lice or full body scabies

Scabies Permethrin – (Nix) for scabies

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Allergy/Anaphalaxis

&

Antihistamines

Allergic Reactions Anaphylaxis – Severe allergic reaction and is life

threatening.

Medical emergency (ABCs)

Administer epinephrine

In Hospital (epinephrine)

In field (FIRST LINE – EPIPEN)

Corticosteroid agents

Benadryl

Provide intravenous fluids.

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Treatment of Allergies

Sedating effect traditional antihistamine agents

SHORT ACTING:

Diphenhydramine hydrochloride (Benadryl)

Controls moderate to severe allergic reactions

Dimenhydrinate (Dramamine) Relieves motion sickness, nausea, and vomiting

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Treatment of Allergies

The Nonsedating antihistamines

Long Acting (examples): Cetirizine hydrochloride (Zyrtec)

Loratadine (Claritin) Adults and children older than 6 years

Loratadine plus pseudoephedrine (Claritin D)

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Respiratory Drugs

Mucous Membrane Lining of the Respiratory Tract

Expectorant agents

Liquefy mucus in the bronchi

Require sufficient fluid intake

Ex. Mucinex

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Administration of Drugs by Inhalation

Drug classes of drugs available by inhalation:

Bronchodilator agents Albuterol, Xopenex – for acute attack and prophylaxis

Combination bronchodilator agent and steroid agent inhaler Advair – for prophylaxis

Corticosteroid agents Azmacort – anti-inflammatory and for prophylaxis

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Circulatory Rx

Drugs That Affect the Heart Heart failure is treated with several classes of drugs:

Angiotensin-converting enzyme (ACE) Inhibiors (Capoten, Vasotec) Ace Inhibitors exact mode of action is debated. (annoying side effect “nonproductive cough”) Ace Inhibitors are the drug of choice (first line) for treating congestive heart failure. Suffix “pril” – e.g. Captopril (Capoten)

Beta blockers (Tenormin) Beta blockers are of greatest benefit to patients with reduced “ejection fraction”. Suffix “olol” – e.g. Atenolol (Tenormin)

Angiotensin II Receptor Blockers Used after MI; greatest benefit to patients who cannot tolerate the ACE inhibitors. Suffix “sartan” – e.g. Telmisartan (Micardis)

Inotropic drugs Inotropic drugs increase contractility of the heart muscle. (antidote = Digibind) -e.g. Digitalis (Digoxin)

Diuretic agents Diuretics promote the formation and excretion of urine. -e.g. Furosomide (Lasix)

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Diuretic Agents Used in combination with other drugs to treat

heart failure Reduces fluid volume

Reducing fluid in the lungs

Reduce s dyspnea

Examples: Furosemide (Lasix) Metolazone (Zaroxolyn) Hydrochlorothiazide (HydroDIURIL)

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Vasoconstricting Agents Epinephrine injection, (Adrenalin)

Prolongs the effectiveness of a local anesthetic:

Epinephrine (Adrenalin) is used in combination with the Novacaine. (e.g. dental anesthetic)

Frequently used in eyes to constrict blood vessels

Use during “codes”, resucitation

Markedly increases blood pressure

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Vasodilating Agents

Cause the blood vessels to relax or increase in diameter

Used to treat peripheral vascular diseases, heart conditions, hypertension

Nitrates

Chief use is to treat angina pectoris

Nitroglycerin (Nitrostat)

Topical nitroglycerin (Transderm-Nitro)

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Coagulant Agents Vitamin K

Fat-soluble vitamin needed for normal blood coagulation

Vitamin K is the antidote drug to warfarin (Coumadin) overdose Colloidal solution of vitamin K is AquaMEPHYTON

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Heparin Prevention and treatment of venous thrombosis

Heparin - Available as sodium heparin injection

Not active orally; must be given parenterally (intravenously or subcutaneously)

Heparin use is recommended when immediate effect is desired

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Coumarin (Coumadin) Anticoagulant Agents Uses:

treatment of thromboembolic disorders (DVT)

Treatment of atrial fribulation

Alters the synthesis of blood coagulation factors

Main advantage: May be taken orally

Main disadvantage: Do not take effect for 2 to 7 days

Coumarin agents are adjusted using PT/INR blood testing

Accepted theraputic PT Ratio is 1.5 to 2.5

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Thrombolytic Therapy for Myocardial Infarction

Uses:

Dissolves clots

Rescue the myocardium

Examples:

Streptokinase (Streptase)

Urokinase (Abbokinase)

Alteplase (Activase, rt-PA, t-PA)

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Anti-platelet Therapy in Cardiovascular Disease

Antiplatelet drugs Interfere with platelet aggregation on the surface of atherosclerotic plaques

Prevent the formation of thrombi and emboli

Drugs

Plavix

Inhibits platelet aggregation

Used for patients allergic to aspirin.

Aspirin

If myocardial infarction is suspected, 325 mg;

otherwise 81 mg daily

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Antilipidemic Drugs Antilipidemic Drugs are used to bring total cholesterol

level to ~ 160 mg/dL. Monitor Liver Functions Tests

Increase in LFTs, may indicate liver toxicity/impairment.

Monitor Serum Creatine Kinase Increase in Serum CK, may indicate skeletal muscle damage

Atorvastatin calcium (Lipitor)

Lovastatin (Mevacor)

Pravastatin (Pravachol)

Rosuvastatin (Crestor)

Simvastatin (Zocor)

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Drugs that Affect

the

Central Nervous System

Central Nervous System Stimulant Agents Increase the activity of the brain and spinal

cord. Used to treat:

1. attention-deficit/hyperactivity disorders (ADHD) in children

2. Narcolepsy

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Drugs Used to Treat ADHD Amphetamine Agents stimulate the Central

Nervous System:

Ritalin

Dexedrine

Adderall

Strattera

Monitor growth & development in children

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Central Nervous System Depressants Anesthesia - May be general, systemic, or localized

Pharmacologic CNS depressant

Produces loss of sensation

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Hypnotic and Sedative Agents

Uses include the following:

Daytime sedation–smaller doses Sleep induction–larger doses Pentobarbital (Nembutal) Secobarbital (Seconal)

Benzodiazepines diazepam (Valium) Lorazepm (Ativan) Chlordiazepoxide (Librium) Alprazolam (Xanax)

Nonbenzodiazepine (sleeping pills) Eszopiclone (Lunesta) Zolpidem (Ambien)

Considerations for older adults:

Doses may need to be reduced because of slower metabolism and excretion. Overdose may occur at or below standard doses. Initiate medication with a lower dose and observe the effect, then increase the

dose as needed. 35

Barbiturate Agents Act by depressing the respiratory rate, blood pressure,

and temperature, as well as the CNS Do not relieve pain Response to barbiturate agents may be:

mild sedation hypnosis general anesthesia depending on the dose and the method of

administration Problems:

Tolerance Addiction

Treatment for barbiturate overdose poisoning Respiratory support Possible dialysis

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Opiate Agents Morphine

Demerol

Vicodin

Percocet

Drug effects

Potent pain reliever

Respiratory center depression

Cough center depression

Decreased peristalsis, nausea, constipation

Patients on opiate pain medication for an extended period of time need to take stool softeners to prevent the incidence of constipation.

Impaired motor coordination

Constricted pupils (pinpoint)

Treat overdose with antidote drug Narcan 37

Antimigraine Agents Triptan agents

Examples:

Sumatriptan succinate (Imitrex)

Causes vasospasm to relieve migraine.

Side effects include: angina, hypertension and Raynoud’s phenomenon.

Use with extreme caution in patients with heart disease

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Parkinson’s Disease May be associated with dopamine depletion in brain

Dopaminergic agents

Used only in adults

Examples:

Levodopa plus carbidopa (Sinemet)

Combination Drug

Levodopa (Larodopa)

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Pain Medications

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Mild Pain Relief Mild pain

Nonsteroidal antiinflammatory drugs (NSAIDs) or nonopioid analgesic agents Acetaminophen (Tylenol)

Aspirin

Celecoxib (Celebrex)

Ibuprofen (Motrin)

Indomethacin (Indocin)

Ketorolac tromethamine (Toradol)

Naproxen sodium (Naprosyn)

Sulindac (Clinoril)

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Progressive Levels of Pain Relief Moderate pain

Drugs for moderate pain include the following: Hydrocodone bitartrate (Vicodin)

Oxycodone hydrochloride, combined (Percocet)

Tramadol, hydrochloride (Ultram)

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Progressive Levels of Pain Relief Severe Pain

Fentanyl citrate (Duragesic)

Hydromorphone hydrochloride (Dilaudid)

Meperidine hydrochloride (Demerol)

Morphine sulfate (MS Contin)

Oxycodone (Oxycontin)

Nalbuphine (Nubain) – used for patient with a history of opiod addiction.

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Neuropathic Pain

Causes include diabetes, phantom pain after limb amputation

Pain can be progressive; begins in feet and legs, and produces numbness and disability

Drugs Gabapentin (Neurontin)

Pregabalin (Lyrica)

Lidocaine patches 5% (Lidoderm)

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AntiinflamatoryMedications

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NSAIDS Non-steroidal Anti-inflammatory Drugs

Aspirin, acetylsalicylic acid (Oldest and most common NSAID) Long used as an analgesic (pain reliever) and an anti-inflammatory

agent

Reduces fever

Inhibits the synthesis of prostaglandins

Used to relieve mild to moderate pain

Used to treat headaches

Anti-inflammatory medication in arthritic conditions

Decreases platelet aggregation to reduce risk of clot formation

Relationship established in children between taking aspirin and development of Reye’s syndrome

Do not give Aspirin to children under 18 years old.

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Non-steroidal Antiinflammatory Drugs

Diclofenac (Voltaren)

Diflunisal (Dolobid)

Etodolac (Lodine)

Ibuprofen (Motrin) Used as anti-inflammatory agent

Used to treat menstrual cramps and ovulation pain

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Psychiatric Medications

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Depression Selective Serotonin Reuptake Inhibitors

Other examples:

Citalopram (Celexa)

Escitalopram (Lexapro)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Sertraline (Zoloft)

Paroxetine (Paxil)

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Tricyclic Antidepressant Agents

Examples: Amitriptyline hydrochloride (Elavil)

Nortriptyline (Pamelor)

Desipramine hydrocholoride (Norpramin)

Desipramine (Norpramin)

Imipramine (Tofranil)

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Depression Monoamine Oxidase Inhibitors

MAOIs inhibit monoamine oxidase in the brain. Last drug choice for depression. Many drug-food interactions

Chianti wine, older cheeses, chicken liver, avocados, pickled herring, figs, alcoholic beverages

Severe increase in blood pressure occurs when these foods combined with MAOIs

Best results obtained when used for true depressive states Parnate Nardil

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Tranquilizing Agents

Benzodiazepine agents

Alprazolam (Xanax)

Chlordiazepoxide hydrochloride (Librium)

Diazepam (Valium)

Lorazepam (Ativan)

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Antipsychotic Agents Nonphenothiazine agents

Examples:

Aripiprazole (Abilify)

Haloperidol (Haldol)

Loxapine (Loxitane)

Olanzapine (Zyprexa)

Pimozide (Orap)

Quetiapine fumarate (Seroquel)

Risperidone (Risperdal)

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Digestive System Medications

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Treatment for Helicobacter H. Pylori

Prevpak

Prepackaged combination drug used twice a day for 10 to 14 days

Contains the following:

Amoxicillin (Amoxil) 1 g

Clarithromycin 500 mg

Lansoprazole 30 mg

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Antisecretory Agents Cimetidine (Tagamet)

Serious Side effects can occur with use in the elderly

Avoid using Tagamet in older patients, as they are more sensitive to medications. Increased susceptibility to mental confusion, agitation, psychosis, and hallucinations

Esomeprazole (Nexium) Lansoprazole (Prevacid) Omeprazole (Prilosec)

Pantoprazole (Protonix)

Used to treat erosive gastritis, erosive esophagitis, and gastroesophageal reflux disease

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Antacid Agents Tums (calcium carbonate)

Magnesium oxide (MOM)

Antacid in small doses

Laxative in larger doses

Sucralfate (Carafate) Provides a mechanical barrier to gastric ulcers.

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Digestant Agents

Pancrelipase (Viokase, Pancrease, Ku-Zyme, Creon, Ultrase)

Used in cystic fibrosis because of pancreatic dysfunction

Lactase enzyme (Lactaid)

Digests lactose or milk sugar;

Used in lactose intolerance.

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Emetic Agents Ipecac syrup

Induces vomiting for 30 minutes

Inhibited by milk

Dose should be followed by additional fluids

Should not be used in poisoning with caustic or corrosive substances

Produce vomiting. Never induce vomiting unless instructed to do so. Always call Poison Control first.

Largely replaced by gastric lavage with stomach tube.

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Antiemetic Agents Dimenhydrinate (Dramamine)

Used for vomiting sedates Relieves motion sickness

Ondansetron hydrochloride (Zofran) Administered intravenously or by mouth Used for severe nausea and vomiting Used postoperatively and with chemotherapy

Prochlororperazine maleate (Compazine) Also acts as tranquilizing agent Used postoperatively to control vomiting

Trimethobenzamide hydrochloride (Tigan) Related to antihistamine agents Acts on the vomiting center to decrease nausea

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Cathartic Agents Bulk-increasing laxatives

Examples: Psyllium seed (Metamucil) Methylcellulose (Citrucel)

Fecal softeners Surfactants or detergents Mix with fecal material, emulsifying and softening it for easier

elimination Docusate sodium (Colace)

Irritant cathartic agents Irritate intestinal mucosa and prompt contraction Examples:

Castor oil Senna (Senokot) Biscodyl (Dulcolax)

Saline cathartic agents Act in 1 to 4 hours Examples:

Magnesia magma (milk of magnesia) Magnesium citrate solution (citrate of magnesia)

Commonly used to evacuate bowels before surgery. Electrolytes for oral solution (GoLYTELY)

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Antidiarrheal Agents Diphenoxylate hydrochloride plus atropine sulfate

(Lomotil)

Inhibits gastrointestinal motility; acts similarly to morphine

Atropine is purposely added to Lomotil to decrease chances of overuse of the drug. Atropine causes unpleasement sideffects such as tachycardia, dry mouth.

Loperamide hydrochloride (Imodium)

Slows intestinal motility by acting directly on nerve endings in the intestinal wall.

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Endocrine

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Thyroid Preparations Synthetic thyroid preparations (provide greater

accuracy and predictability when treating thyroid dysfunction)

Synthroid

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Antithyroid Agents

Reduce thyroid hormones

Treat hyperthyroidism and Graves’ disease

Should not be taken by pregnant women Can induce goiter and hypothryoidism in the developing

fetus.

Tapazole and PTU are used to suppress the thyroid gland before)

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Cortisone and Hydrocortisone Potent antiinflammatory drugs

Suppress symptoms of arthritis, bursitis, and skin diseases

Used to treat multiple sclerosis

Side effects

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– Muscular weakness

– Acne

– Peptic ulcers

– “Moon face”

– Hirsutism

– Mental disturbances

– Fluid retention

Steroids Cortisone and Hydrocortisone

Synthetic compounds Prednisone (Deltasone)

Hydrocortisone (Solu-Cortef - IV)

Prednisolone (Cotolone)

*Patients that are on long-term steriod therapy are at risk for the unrecognized incidence and advancement of Tuberculosis or Perforated Ulcers.

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Insulin Therapy

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Oral Hypoglycemic Agents Used only by type 2 diabetics In order for Oral hypoglycemics to be effective the patient’s

pancreas MUST have the ability to release some residual insulin.

Drugs

Metformin hydrochloride (Glucophage) Glipizide (Glucotrol) Glyburide (Diabeta, Micronase) Glimepiride (Amaryl) Pioglitazone (Actos) Rosiglitazone maleate (Avandia)

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Hormone Replacement Therapy Estrogen replacement therapy (ERT)

Estrogens, conjugated (Premarin)

• Hormone replacement therapy, for women going through menopause, has been associated with Breast Cancer and Cardiovascular complications.

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Oral Contraceptives Side effects (High Risk – Smokers and Obese Patients)

Breast changes Loss of hair Dermatoses Headache Nervousness Thromboembolic disorders Emotional instability Accelerated growth of fibroids Less effective with antibiotic agents

Examples: Levonorgestrel plus ethinyl estradiol (Triphasil) Levonorgestrel plus ethinyl estradiol (Seasonale)

Emergency contraceptives Taken within 72 hours after intercourse Drugs

Levonorgestrel (Plan B)

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Agents to Promote Ovulation

Used as a last resort in an attempt to promote pregnancy in a women previously unable to conceive

Only one agent in United States

Clomiphene citrate (Clomid)

Multiple conceptions is a risk

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Oxytocic Agents Uterine stimulant, like hormone oxytocin

Used during pregnancy, delivery, and postpartum

Drugs Oxytocin injection (Pitocin, Syntocinon)

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Male Hormones

LH causes testosterone production Treatment of “low –T”, hypogonadism in adolescents Testosterone

Development of male reproductive tract Maintains secondary sex characteristics Assists in developing penis, seminal vesicles, prostate gland,

and descent of testes Restores well-being Resists fatigue

Examples Testosterone gel (Angrogel)

Testosterone transdermal system (Androderm)

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Diuretics

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Thiazide (Benzothiadiazine) Diuretic Agents Side effects are as follows:

Decreased blood pressure

Tachycardia, jaundice, anemia, alkalosis, hypotension

Used with caution with patients who have the following: Gout

Liver or kidney disorders

Chlorothiazide (Diuril) Used in heart failure, pregnancy, and premenstrual fluid

retention

Hydrochlorothiazide (HydroDIURIL) More potent that chlorothiazide

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Diuretic Agents Furosemide (Lasix)

Loop diuretic

Acts on the collecting tubules of the nephron

Used in congestive heart failure (CHF) associated with liver or kidney disease

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Antineoplastic Drugs

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Cancer Treatments Act by interfering in a specific phase of cell

metabolism

In theory, should cause only a minimal interruption in the metabolism of normal cells

SIDE EFFECTS OF CHEMOTHERAPY; Often cause severe bone marrow suppression, requiring

withdrawal of the drug.

Significant decrease in WBCs Nadir – lowest point of WBCs, platelets, & RBC. ~ 10 day post-

chemo

Rx: epoetin alfa (Epogen, Procrit), or filgrastim (Neupogen)

Other side effects: loss of gastrointestinal epithelium, nausea, diarrhea, ulcers of the oral mucosa

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Immunizing Agents and Immunosuppressives

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Immunizations Vaccines

Diphtheria and tetanus toxoids, adsorbed (DT, Td) For boosting immunity when pertussis immunization is

unnecessary

Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) (Tripedia, Infanrix)

Measles, mumps, and rubella virus vaccine, live, (MMR) (M-M-R II) This vaccine is shown to confer immunity as effectively as single

vaccines.

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Agents That Provide Active Immunity Hib Vaccine - Haemophilus b conjugate vaccine

H. influenzae infections in infants and young children.

Hepatitis B vaccine (Recombivax HB)

Flu vaccine – injectable

Flumist vaccine - Influenza virus vaccine live, intranasal Intranasal form compares favorably with other injectable forms

Human papillomavirus vaccine – HPV - (Gardasil)

Intended for females between 11 and 26 years old

Protects against four types of HPV

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Agents That Provide Active Immunity

Tetanus toxoid, tetanus vaccine Often chosen for periodic tetanus boosters after childhood

Varicella virus vaccine, live (Varivax) For prevention of varicella virus (chickenpox)

Development of antibodies does not always occur

Zoster vaccine live (Zostavax) For prevention of herpes zoster in individuals 60 years and older

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Herbal Therapies and Drug-Herb Interactions

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Cayenne (Capsicum) Taken orally, cayenne is a digestive aid.

It stimulates the production of gastric juices and helps relieve gas.

Cayenne pepper’s active ingredient, capsaicin, can be applied topically for pain relief.

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Echinacea Extracts made from this root were favorite cold

remedies before antibiotic agents.

May be taken prophylactically to prevent colds or taken early in the infection.

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Garlic Garlic was used in ancient times in poultices as an

effective antibacterial agent.

Some effectiveness is noted in the lowering of cholesterol and triglyceride levels.

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Ginkgo biloba Studies have shown that seeds and leaves of ginkgo

tree do the following:

Relieve symptoms of intermittent claudication

Increase walking performance

Somewhat diminish lower extremity pain

An increase in bleeding time and subdural hematomas is observed with prolonged use.

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St. John’s Wort The medicinal parts of St. John’s wort plant.

It is used effectively to treat mild depression.

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Valerian Used as a sedative to treat insomnia

CNS depressant – caution with the use of other CNS depressants (alcohol, sedatives, opioids)

Disagreeable smell may be main disadvantage

Often combined with hops or St. John’s wort in commercial products

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