PHARMACOLOGY

A.General Principles

B.Administration of:

1. Oral 2. Parenteral 3. Opthalmic 4. Otic 5. Topical 6. Vaginal

7. Rectal

NERVOUS SYSTEM

CNS PNS

BRAIN SPINAL CORD

SOMATIC AUTONOMIC

PARASYMPATHETIC (cholinergic)

ACH

SYMPATHETIC (adrenergic) NE

AUTONOMIC

adrenergic (sympathomimetic)

Cholinergic (parasympathomimetic)

Bethanecol, carbachol, methacoline,

neostigmine, physostigmine

=antimuscarinic drugs

*belladona alkaloids (atropine & scopolamine)

*Norepinephrine *Epinephrine *Dopamine

* Propranolol *catecholamines

Cholinergic blockers (parasympatholytic)

Adrenergic blockers (sympatholytics)

1. NARCOTIC AGONISTS

2. NARCOTIC PARTIAL AGONISTS; NARCOTIC ANTAGONISTS

3. NON-STEROIDAL ANTI-INFLAMMATORY

4. MISCELLANEOUS ANALGESIC AGENTS

Librium – watch for signs of leukopenia, hypotension

Equanil – metabolizes extensively in the liver &

interferes w/ liver function tests. - decreases PT if on coumadin

Atarax - does not cause tolerance & can be used

temporarily when other anti-anxiety agents have been abused

Serax – useful for treating elderly clients. Does not

rely on liver for metabolism

BARBITURATES*treat grandmal seizures ; tonic-clonic seizure

BENZODIAZEPINES*diazepam is DOC for Rx of STATUS

EPILIPTICUS*clorazepate is use w/ other antiepileptic

agents to control partial seizures

HYDANTOINS*Used to depress abnormal neuronal charges

& prevent spread of seizures*also used to treat dysrhythmias*A/R: gingival hyperplasia, alopecia,

hyperglycemia, blood dyscracias*Seizure precaution & dental hygiene*Give IV with normal saline & never with

dextrose

AMPHETAMINESincrease the release of catecholamines (NE from stored sites in nere terminals)Block the re-uptake of dopamine & NE following release into the synapse, & inhibit the action of MAOIncrease stimulating effect on cerebral cortex & RAS

DOXAPRAM (DOPRAM)

METHYLPHEMDATE Hcl (Ritalin)

PEMOLINE (Cylert)

CAFFEIN

DOPAMINERGIC MEDSamantidine (Symmetrel); bromocriptine (Parlodel); carbidopa-levodopa (Sinemet) ;trihexyphenidyl (artane)

*Increases the amount of dopamine in the brain

*A/R: involuntary body movements, urinary retention, constipation, dizziness,

*For levodopa avoid vitamin B6 & eat low-CHON food

*Not to take in ROH & never to discontinue meds abruptly

*Urine & perspiration may be discolored & stain clothing but this is harmless

*neostigmine bromide (Prostigmin), pyridostigmine bromid (Mestinon) are used to control myasthenic symptoms -take meds on time…MG impairs breathing & swallowing -take a.c. for best absorption -meds for life & wear Medic-Alert bracelet

*edrophonium chloride (Tensilon) is used to diagnose myasthenia gravis & differentiate cholinergic crisis

(drug overdose) -prepare resuscitative equipment & antidote: atropine SO4 -dx as M.G. if client shows marked improvement in muscle tone within 30-60 seconds after injection lasting 4-5 mins …positive Tensilon Test -dx as cholinergic crisis when muscle tone does not improve upon injection…negative Tensilon Test -S/Sx: muscle twitching around eyes & face

benztropine mesylate (Cogentin), biperiden HCl (Akineton) Trihexyphenidyl HCl (Artane), scopolamine, atropine

*Block cholinergic receptors in the CNS, thereby suppressing acetylcholine activity

*A/R: blurred vision, dry mouth & secretions, urinary retention, constipation, restlessness & confusion

*Client to have regular eye check up for increase in IOP

*Avoid aspirin, caffeine, smoking & ROH to decrease gastric acidity

Antianxiety or anxiolytic agents-zolam -zepam -zepate -zepoxide

Antidepressantsa. selective serotonin reuptake inhibitor

Fluoxetine (proxac), Paroxetine (Paxil),Sertraline hcl (Zoloft)

b. tricyclic Elavil, Vivactil, Sinequan, Aventyl, Tofranil,

Norpramin

c. MAOi Marplan, Nardil, Parnate

* watch out for strokes!

Neuroleptic (antipsychotic) agents* blocks dopamine receptors in basal ganglia of brain, inhibitiing transmission of nerve impulses

a. phenothiazines (zines)b. butyrophenones (peridol)c. thioxanthenia (trixene)

antimanic and mood-stabilizing agents (LITHIUM) *encourage diet containing normal amts of SALT & FLUID intake of 3L/day

sedative and hypnotic agents

MYDRIATICS & MYDRIATICS & CYCLOPLEGICSCYCLOPLEGICS

Atropine, Epinephrine, Cyclogyl, & Mydriacyl

*Used to facilitate eye exam & treat uveitis

*A/R: photophobia, impaired distant vision, increased IOP, blurred vision, reduced lacrimation

MIOTICSMIOTICS

CARpine, CARbachol, piloCARpine, demeCARium

*Cholinergic drug that causes miosis (contraction) of the pupil & contraction of the ciliary muscle of the eye

*Decreases IOP in glaucoma & achieves miosis in cataract surgery

*A/R low toxicity level: transient hypotension & decreased heart rate, blurred vision & focusing difficulty

*Inhibit response to beta-adrenergic stimulation *Inhibit response to beta-adrenergic stimulation

*Block release of epi & NE thus decreasing HR & BP*Block release of epi & NE thus decreasing HR & BP

*Used for angina, dysrhythmias, prevention of MI & *Used for angina, dysrhythmias, prevention of MI & glaucomaglaucoma

*A/R: bradycardia, hypotension, weakness & fatigue*A/R: bradycardia, hypotension, weakness & fatigue

*Hold if BP & HR not within parameters prescribed by MD*Hold if BP & HR not within parameters prescribed by MD

*Not to D/C meds abruptly…rebound HPN, tachycardia, *Not to D/C meds abruptly…rebound HPN, tachycardia, anginaangina

*Early signs of hypoglycemia such as tachycardia & *Early signs of hypoglycemia such as tachycardia & nervousness can be masked by these drugs…monitor blood nervousness can be masked by these drugs…monitor blood sugarsugar

BETA1 ADRENERGIC ( CARDIO SELECTIVE) BETA1 ADRENERGIC ( CARDIO SELECTIVE) BLOCKING AGENTSBLOCKING AGENTS

-acebutolol (Sectral)-acebutolol (Sectral)-atenolol (Tenormin, Atenol, -atenolol (Tenormin, Atenol,

Premorphine)Premorphine)-metoprolol (apo-metoprolol, betaloc)-metoprolol (apo-metoprolol, betaloc)

BETA1 & 2 ADRENERGIC (nonselective) BETA1 & 2 ADRENERGIC (nonselective) BLOCKING AGENTSBLOCKING AGENTS

-nadolol (corgard)-nadolol (corgard)-pindolol (visken)-pindolol (visken)-propranolol( inderal, novopranol)-propranolol( inderal, novopranol)-timolol (blocadren, betin, temserin)-timolol (blocadren, betin, temserin)

BETA- BLOCKING AGENTS

verapamil (Calan, Isoptin), nifedipine (Procardia)verapamil (Calan, Isoptin), nifedipine (Procardia)felodipine (Plendil), diltiazem (Cardizem)felodipine (Plendil), diltiazem (Cardizem)

*Decrease cardiac contractility by relaxing smooth *Decrease cardiac contractility by relaxing smooth musclemuscle and the workload of the heart…thus decreasing need for and the workload of the heart…thus decreasing need for O2O2

*Promote vasodilation of coronary & peripheral vessels*Promote vasodilation of coronary & peripheral vessels

*A/R: bradycardia, hypotension, dizziness & *A/R: bradycardia, hypotension, dizziness & lightheadednesslightheadedness

*Instruct client how to take HR & to inform MD if *Instruct client how to take HR & to inform MD if dizzinessdizziness persistspersists

dobutamine (Dobutrex)dobutamine (Dobutrex)*Increases myocardial force & C.O. through beta *Increases myocardial force & C.O. through beta receptorsreceptors stimulationstimulation*Used in clients with CHF*Used in clients with CHF dopamine (Intropin)dopamine (Intropin)*Increases BP & C.O. & increases renal outflow through *Increases BP & C.O. & increases renal outflow through itsits action on alpha & beta receptorsaction on alpha & beta receptors*Treat mild renal failure due to decreased C.O.*Treat mild renal failure due to decreased C.O.epinephrine (adrenalin)epinephrine (adrenalin)*Cardiac stimulation during cardiac arrest, *Cardiac stimulation during cardiac arrest, bronchodilation bronchodilation asthma & allergy, mydriasisasthma & allergy, mydriasis*Promotes vasoconstriction when combined with local *Promotes vasoconstriction when combined with local anesthetics to promote prolonged anesthetic action by anesthetics to promote prolonged anesthetic action by decreased blood flow to areadecreased blood flow to area

isoproterenol (Isuprel)*Stimulates beta receptors & used for cardiac stimulation &

bronchodilation

norepinephrine (Levophed)

*Stimulates heart in cardiac arrest

*Vasoconstricts & increases BP during hypotension & shock

*A/R: tachycardia, angina, restlessness

*If extravasation occurs, infiltrate with normal saline &

phentolamine (Regitine)

Weight reduction, sodium restriction elimination or limited consumption of alcohol & tobacco, reduction of dietary saturated fats, regular exercise program, behavior modification to promote relaxation

GUANETHIDINE, MINOXIDIL, OR

ANGIOTENSIN INHIBITORS

VASODILATOR AGENT

ADRENERGIC BLOCKING AGENT

BETA-BLOCKING AGENT

BETA-BLOCKING AGENT

DIURETIC

STEP 2 ADRENERGIC BLOCKING DRUGS

CENTRALLY ACTING SYMPATHOLYTICS CENTRALLY ACTING SYMPATHOLYTICS

clonidine (Catapres), methyldopa (Aldomet)clonidine (Catapres), methyldopa (Aldomet)

*Stimulate alpha receptors in medulla causing *Stimulate alpha receptors in medulla causing reduction in sympathetic action in heart; decreases rate to reduction in sympathetic action in heart; decreases rate to inhibit vasoconstriction & reduce peripheral resistanceinhibit vasoconstriction & reduce peripheral resistance

*A/R: Na & H2O retention, edema & hypotension*A/R: Na & H2O retention, edema & hypotension

*Instruct client not to D/C meds rapidly because it will *Instruct client not to D/C meds rapidly because it will cause rebound HPNcause rebound HPN

PERIPHERALLY-ACTING ALPHA ADRENERGIC PERIPHERALLY-ACTING ALPHA ADRENERGIC BLOCKERSBLOCKERS

prazoline (Minipress), phentolamine prazoline (Minipress), phentolamine (Regitine)(Regitine)

*Decrease sympathetic vasoconstriction by reducing *Decrease sympathetic vasoconstriction by reducing thethe effects of NE at the peripheral nerve endings,effects of NE at the peripheral nerve endings, resulting to vasodilation & decreased BPresulting to vasodilation & decreased BP

*A/R: orthostatic hypotension, Na & H2O retention, *A/R: orthostatic hypotension, Na & H2O retention, edemaedema and weight gainand weight gain

*Client to rise slowly, decrease Na intake & monitor for*Client to rise slowly, decrease Na intake & monitor for fluid retention & edemafluid retention & edema

STEP 2 ADRENERGIC BLOCKING DRUGS

= exhibit direct action on the smooth muscle walls of = exhibit direct action on the smooth muscle walls of arterioles &/or veinsarterioles &/or veins

= stimulation of calcium binding process= stimulation of calcium binding process

1)1) ARTERIOLAR DILATORS (selective effect on arteries)ARTERIOLAR DILATORS (selective effect on arteries)-diazoxide, hydralazine, minoxidil-diazoxide, hydralazine, minoxidil

2) ARTERIOLAR & VENOUS DILATORS2) ARTERIOLAR & VENOUS DILATORS-Na nitroprusside.. Acts on arteriolar resistance & -Na nitroprusside.. Acts on arteriolar resistance & venous capacitancevenous capacitance

STEP 3 VASODILATOR

STEP 4 ACE INHIBITORS

*Prevent peripheral vasoconstriction by blocking *Prevent peripheral vasoconstriction by blocking conversion of angiotensin 1 to angiotensin 2conversion of angiotensin 1 to angiotensin 2

*Instruct client to take Capoten 20 minutes to 1 *Instruct client to take Capoten 20 minutes to 1 hour a.c.hour a.c.

*Not to D/C meds abruptly because it causes *Not to D/C meds abruptly because it causes rebound HPNrebound HPN

*If dizziness persist, report to MD*If dizziness persist, report to MD

*Taste for food may be diminished during 1*Taste for food may be diminished during 1stst month of therapymonth of therapy

NITRATES NITRATES nitroglycerin (Nitrostat, Nitrolingual)nitroglycerin (Nitrostat, Nitrolingual)nitroglycerin ointment 2% (Nitrol, Transderm-Nitro)nitroglycerin ointment 2% (Nitrol, Transderm-Nitro)*Produce vasodilation & improved myocardial O2 *Produce vasodilation & improved myocardial O2 consumptionconsumption*C/I in client with severe hypotension*C/I in client with severe hypotension*A/R: H/A, orthostatic hypotension, dizziness, weakness & *A/R: H/A, orthostatic hypotension, dizziness, weakness & faintnessfaintness

SUBLINGUAL:SUBLINGUAL:*Offer sips of H2O since dryness may inhibit absorption*Offer sips of H2O since dryness may inhibit absorption*Leave under tongue until fully absorbed, not swallowed*Leave under tongue until fully absorbed, not swallowed*Take 1 tab for pain ff q5 mins for a total of 3 doses. If pain *Take 1 tab for pain ff q5 mins for a total of 3 doses. If pain not relieved in 15 minutes, seek MD help….. may indicate MInot relieved in 15 minutes, seek MD help….. may indicate MI*Stinging/burning feeling means tablet is fresh*Stinging/burning feeling means tablet is fresh

TOPICALTOPICAL*Remove ointment from previous dose, rotate sites & *Remove ointment from previous dose, rotate sites & avoidavoid touching ointment & hairy areastouching ointment & hairy areas*Squeeze ribbon into prescribed length on applicator *Squeeze ribbon into prescribed length on applicator paperpaper*Sites: chest, back, abdomen, upper arm & anterior *Sites: chest, back, abdomen, upper arm & anterior thighthigh

TRANSDERMAL PATCHTRANSDERMAL PATCH*Apply patch to hairless area, using new patch & *Apply patch to hairless area, using new patch & differentdifferent site every daysite every day*Remove patch after 12-14 hours, allowing 10-12 “patch-*Remove patch after 12-14 hours, allowing 10-12 “patch- free” hours daily to prevent tolerancefree” hours daily to prevent tolerance*Stand away from microwave ovens*Stand away from microwave ovens

generally inhibit the fast sodium channel in cardiac muscle resulting in an increased refractory period

a. Disopyramide phosphate (NORPACE) Procainimide hcl (PROCAN)Quinidine (QUINIDEX)

b. Lidocaine (XYLOCAINE)

b. Flecainide

GROUP 1

GROUP 2

BETA BLOCKERS THAT DECREASE STIMULATION OF THE HEART

Beta 1 selective antagonists=cardiogenic blockers; block Beta1 cardiac

receptors

=atelonol (ternonim), acebutolol sectral, metoprolol (betaloc)

Beta 2 Selective = mucolytics & bronchodilators

Nonseletive Beta Adrenergic = beta1 & beta2 blockers blocking agents = nadolol (corgard), oxyprenelol (trasicor), pindolol (visken) propranolol (inderal) , timolol

* generally do not affect depolarization but work by prolonging cardiac repolarization

• Anti adrenergic; positive inotropic action• Bretylium, amiodarone hcl (cordarone)

GROUP 3

GROUP 4

• Calcium antagonist action= depression of heart & smooth muscle contraction, decreased automaticity, & decreased conduction velocity

• verapamil

Effects of digitalis1. Positive inotrope2. Negative chrono & negative dromo

DIGITALIZATION*administration of layer dose of digitalis preparation for an initial 24-48 hours

COMMON S/E *weakness, fatigue, vomiting, diarrhea,

arrhythmia & PR < 60bts/min

DIGITALIS TOXICITY* loss of apetite, nausea, extreme fatigue, weakness of the arms & legs, psychiatric disturbances (nightmares, agitation, listlessness, or hallucination) or visual disturbances ( hazy, or blurred vision, difficulty reading & green color…)

N.I.

1. Take APICAL PULSE 1 full minute*don’t give for Adult <60/min; child < 90

bts/min*monitor potassium level specially

diuretics

digoxin (Lanoxin)digoxin (Lanoxin)

*Inhibit sodium-potassium pump

*positive inotropic action

*negative chronotropic action

*A/R: anorexia, N/V, visual disturbances

*Monitor serum therapeutic level 0.5-2.0 ng/ml; increased risk of toxicity in clients with hypokalemia

*Used for CHF, atrial tachycardia, atrial fibrillation & flutter

digoxin (Lanoxin)digoxin (Lanoxin)

*Increase K+ rich food: fresh & dried fruits, fruit juices, vegetables & potatoes

*Monitor HR & hold if below 60 & above 100 (adults)

*Antidote: digoxin immune FAB (Digibind)

*Life threatening toxicity: ventricular tachycardia, fibrillation, severe sinus bradycardia

*80% DIGOXIN excreted by kidneys; half life is 36-120H

*90% DIGITOXIN metabolized by liver; half life is 120-210H

*Prevent the extension & formation of clots by inhibiting factors in the clotting cascade & decreasing blood coagulability

*Used for thrombosis, pulmonary embolism & MI

*C/I in active bleeding except in disseminated intravascular coagulation (DIC), bleeding disorders, ulcers

*A/R: hemorrhage, hematuria, epistaxis, ecchymosis, bleeding gums, thrombocytopenia

heparin Na (Liquaemin Na)

*Prevents thrombin from converting fibrinogen to fibrin

*Prevents thromboembolism

*Therapeutic dose does not dissolve clots, but prevents new thrombus formation

*Blood levels: normal APTT is 20-36 seconds; maintain APTT is 1.5-2.5 times normal; APTT therapy should be measured q 4-

6H during initial therapy & then daily

heparin Naheparin Na

*Monitor clotting time; normal is 8-15 minutes; maintain clotting time 15-20 minutes

*Observe for signs of bleeding

*Inject SQ into the abdomen with 25-28g at 90 degrees angle; don’t aspirate or rub injection site

*Antidote is protamine SO4

warfarin Na (Coumadin)warfarin Na (Coumadin)

*Decreases prothrombin activity & prevents the use of vitamin K by the liver

*Used for long-term anticoagulation

*Prolongs clotting time & monitor PT (prothrombin time)

*Used mainly to prevent thromboembolitic conditions such as thrombophlebitis, pulmonary embolism, embolism caused by heart valve damage, atrial fibrillation & MI

*Given 2-3 months after an MI to prevent DVT

warfarin Na (Coumadin)warfarin Na (Coumadin)

*Average PT is 9.6 to 11.8 seconds & normal INR is 1.3-2.0 Goal is to raise the INR to 2 to 3

*Observe for signs of bleeding

*Antidote: Vitamin K (AquaMEPHYTON)

THROMBOLYTIC MEDSTHROMBOLYTIC MEDS

*Activates plasminogen which generates plasmin

*Used 4-6 hrs after MI to restore blood flow, limit myocardial damage, preserve left ventricular function

*C/I: active bleeding, history of thoracic, pelvic or abdominal surgery within the last 10 days

*A/R: bleeding & allergy

*Check APTT, PT, fibrinogen, platelet count

THROMBOLYTIC MEDSTHROMBOLYTIC MEDS

*Monitor for bleeding, hypotension & tachycardia

*Avoid injections; apply pressure to puncture site for 20-30 minutes

*Handle clients minimally & let clients use electric razors & brush teeth gently

*Antidote: aminocaproic acid (Amicar)

•FACTOR VIII-replace the missing factor

*ANTIINHIBITOR COAGULANT COMPLEX-made from pooled human plasma-help correct clotting time in factor VIII

•FACTOR IX COMPLEX-contains factor II, VII, IX & X (vit K coagulant factor)-hemophilia

SYSTEMIC HEMOSTATICS aminocaproic acid (AMIKAR, EPSIKARON)- competetive antagonist of plasminogen- C/I in intravascular active clotting

TOPICAL HEMOSTATICS- absorbable gelatin sponge (Gelfoam)- absorbable gelatin film (Gelfilm)- absorbable gelatin powder- oxidized cellulose

*Reduce serum level of cholesterol, *Reduce serum level of cholesterol, triglycerides & low- density lipoprotein when triglycerides & low- density lipoprotein when diet alone is not enoughdiet alone is not enough

*Elevated levels of these will place client at *Elevated levels of these will place client at high risk for CADhigh risk for CAD

*Restrict fats, cholesterol, carbohydrates & *Restrict fats, cholesterol, carbohydrates & ROHROH

BILE ACID SEQUESTRANTS cholestyramine (Questran)*Mix powder thoroughly with juice & H2O*A/R: constipation & PUD

HMGCoA REDUCTASE INHIBITORSatorvastatin (Lipitor)simvastatin (Zocor)*Check serum liver enzymes & eye exam annually for cataractOTHERSclofibrate (Lopid)*Don’t take with anticoagulants

EXPECTORANT EXPECTORANT

ANTITUSSIVE ANTITUSSIVE

MUCOLYTICMUCOLYTIC

-liquify mucus by stimulating secretion of natural lubricant

*Ammonium chloride * KISS

*Gaifenesin (robitussin) * saline soltions

-cough suppresant

* Codeine * dyphenhydramine * benzonatate

Decrease thickness of pulmonary secretions by acting directly on mucus plugs

* Acetylcysteine (mucomyst)

* Used for allergic rhinitis, acute bronchospasm, acute & chronic asthma, bronchitis, COPD, emphysema

•Caution with clients with glaucoma & HPN

* A/R: palpitations, tachycardia, nervousness, tremors, restlessness & HA•Give RTC to maintain therapeutic blood level

* Avoid caffeine products

aminophylline (Truphylline)Theophylline

*Stimulate the CNS & respirations, dilate coronary & Stimulate the CNS & respirations, dilate coronary & pulmonary vessels, cause diuresis & relax smooth pulmonary vessels, cause diuresis & relax smooth musclemuscle

*Serum theophylline level is 10-20 ug/ml*Serum theophylline level is 10-20 ug/ml

*IV preparation of these drugs must be given slowly & *IV preparation of these drugs must be given slowly & with with infusion pumpsinfusion pumps

SYMPATHOMIMETICS

XANTHINE DERIVATIVES

albuterol (Ventolin)

*Dilate the airways of the respiratory tree making air *Dilate the airways of the respiratory tree making air exchange and respiration easier for client; relaxes exchange and respiration easier for client; relaxes bronchial smooth muscle bronchial smooth muscle

astemizole (Hismanal), diphenylhydramine (Benadryl)loratadine (Claritin)

*Histamine antagonists or H1 blockers; compete with histamine for receptor sites preventing histamine response thus constricting smooth muscles*Decrease nasopharyngeal secretions & decreases itching which causes sneezing*Used for common colds, rhinitis, urticaria, nausea & vomiting, motion sickness & sleep aid*CNS depressant with ROH, narcotics, barbiturates & sedatives*Caution with COPD clients & Benadryl C/I in clients with glaucoma*A/R: dizziness, dry mouth, blurred vision

*react with gastric acid to produce neutral salts or salts of low acidity

*inactivate pepsin and enhance mucosal protection but do not coal ulcer to protect from acid & pepsin

*used for patients with PUD & GRF (gastroesophageal reflex disease)

*antacid tablets should be chewed and followed with glass of H2O or milk

*administer 1 hour apart from other meds to minimize the chance of drug interactions

sucralfate (Carafate)*creates a protective barrier against acid & pepsin*given po & on an empty stomach*A/R: constipation, impede absorption of warfarin Na, phenytoin, theophylline, digoxin & some antibiotics… administer 2 hours apart from these meds

magnesium hydroxide (Milk of Magnesia)*rapid acting & A/R is diarrhea*usually combined with aluminum hydroxide to counter diarrhea (MAALOX)

aluminum hydroxide (Amphojel, Alu-cap)*slow acting & A/R: constipation*with significant Na content…caution in clients with HPN & heart failure; reduce effect of tetracyclines, warfarin Na & digoxin*reduce phosphate absorption

calcium carbonate (Tums)

*rapid acting & A/R: constipation

sodium bicarbonate

*rapid onset*A/R: liberates CO2 & increases intra-abdominal pressure causing flatulence, caution in clients with HPN & heart failure, systemic alkalosis in clients with renal failure

*suppress secretion of gastric acid

*indicated for PUD & heart burn & for GRF disease

cimetidine (Tagamet)

*taken on an empty stomach

*administered 1 hour apart from antacids

*crosses the blood-brain barrier & may cause mental confusion, agitation, anxiety & disorientation

*dosages of these meds are reduced when taken together: warfarin Na, phenytoin, theophyllin & lidocaine

ranitidine (Zantac)

*not affected by food*S/E are uncommon & does not cross blood-brain barrier

pancreatin (Creon), pancrelipase (Cotazym, Viokase & Pancrease)

*used to supplement pancreatic enzymes

*taken with meals or snacks

*interacts with calcium carbonate & magnesium hydroxide

lactulose (Cephulac)*reduces the ammonia level*given p.o. in the form of a syrup*improves CHON tolerance in clients with advanced liver cirrhosis*lowers colonic pH from 7 to 5; acidification pulls ammonia into the bowel to be excreted in the feces thus decreasing the ammonia level

Neomycin (Mycifradin)*reduces the number of colonic bacteria that normally convert urea & amino acids into ammonia*given p.o. or via NGT*used with caution in clients with kidney impairment

BULK FORMING LAXATIVESpsyllium hydrophillic mucilloid (Metamucil)*absorbs water into the feces & increase bulk to form large and soft stools*C/I bowel obstruction*A/R: dehydration, electrolyte imbalance & dependency

STOOL SOFTENERSdocusate calcium (Surfak), docusate sodium (Colace)*inhibit the absorption of H2O so fecal mass remains large & soft*used to avoid straining

LUBRICANTSmineral oil*soften stools, ease strain of passing stools; lessen the irritation of hemorrhoids*interferes with absorption of fat-soluble vitamins A, D, E, K

SALINE CATHARTICSglycerin suppositories (Senokot); Mg hydroxide*Attract H2O to large intestine to produce bulk, stimulate peristalsis & effect begins in 2-6 hours

STIMULANT CATHARTICSbiscodyl (Dulcolax): give 1 hour before/after antacids & milk cascara (Castor Oil): effect 2-6 hours; give with juice*stimulate motility of large intestine

PROXIMAL TUBULE DIURETICS

CARBONIC ANHYDRASE INHIBITORSCARBONIC ANHYDRASE INHIBITORS

acetazolamide (Diamox)acetazolamide (Diamox)

*Inhibits the enzyme carbonic anhydrase causing *Inhibits the enzyme carbonic anhydrase causing increasedincreased Na, K & bicarbonate excretionNa, K & bicarbonate excretion

*Used to produce diuresis & decrease IOP*Used to produce diuresis & decrease IOP

*A/R: hypokalemia, hyperglycemia & orthostatic *A/R: hypokalemia, hyperglycemia & orthostatic hypotensionhypotension

DILUTING SEGMENT DIURETICS

THIAZIDE DIURETICSTHIAZIDE DIURETICSChlorothiazide (Diuril)Chlorothiazide (Diuril)

*Increase Na & H2O excretion by inhibiting Na *Increase Na & H2O excretion by inhibiting Na reabsorptionreabsorption in the distal tubule of the kidneyin the distal tubule of the kidney

*Used for clients with HPN & peripheral edema*Used for clients with HPN & peripheral edema

*A/R: hypokalemia, hyponatremia, hypovolemia, *A/R: hypokalemia, hyponatremia, hypovolemia, hypotensionhypotension

*Monitor U/O, take meds in the morning, eat foods high in *Monitor U/O, take meds in the morning, eat foods high in potassium, change position slowly & use sunscreenpotassium, change position slowly & use sunscreen

*Clients with diabetes must monitor bld glucose level *Clients with diabetes must monitor bld glucose level periodicallyperiodically

LOOP DIRETICS

furosemide (Lasix)furosemide (Lasix)

*Inhibit Na & Cl reabsorption from the loop of Henle & *Inhibit Na & Cl reabsorption from the loop of Henle & thethe distal tubuledistal tubule

*Little effect on blood glucose level but causes marked *Little effect on blood glucose level but causes marked depletion of water & electrolytesdepletion of water & electrolytes

*More potent than the thiazides causing rapid diuresis,*More potent than the thiazides causing rapid diuresis, decreasing vascular volume, cardiac output & BPdecreasing vascular volume, cardiac output & BP

*Caution with clients on digoxin & lithium*Caution with clients on digoxin & lithium

LOOP DIRETICS

furosemide (Lasix) furosemide (Lasix)

*A/R: hypo- kalemia, natremia, calcemia & *A/R: hypo- kalemia, natremia, calcemia & magnesemia,magnesemia, orthostatic hypotension, ototoxicity & deafness orthostatic hypotension, ototoxicity & deafness esp. with rapid IV administration, dehydrationesp. with rapid IV administration, dehydration

*Monitor urine output & electrolytes, signs & *Monitor urine output & electrolytes, signs & symptomssymptoms of digitalis & lithium toxicityof digitalis & lithium toxicity

*Take in the morning & eat K+ rich food*Take in the morning & eat K+ rich food

DISTAL TUBULE DIURETIC/ K+ SPARING

AMILORIDE (MIDAMOR)AMILORIDE (MIDAMOR)SPIRONOLACTONE (ALDACTONE)SPIRONOLACTONE (ALDACTONE)TRIEAMTRENE TRIEAMTRENE

*Used for edema, hypertension, increase U/O to Rx fluid *Used for edema, hypertension, increase U/O to Rx fluid overload with CHF, nephrotic syndrome, hepatic cirrhosis, overload with CHF, nephrotic syndrome, hepatic cirrhosis, diuretic-induced hypokalemiadiuretic-induced hypokalemia

*Monitor for hyperkalemia…K+ level higher than 5.3 MEQ/L,*Monitor for hyperkalemia…K+ level higher than 5.3 MEQ/L,

S/Sx are nausea, diarrhea, abdominal cramps, oliguria,S/Sx are nausea, diarrhea, abdominal cramps, oliguria,

narrow & peaked T wave on ECGnarrow & peaked T wave on ECG

OSMOTIC DIURETICS

Mannitol (osmitrol)Mannitol (osmitrol)IsosorbideIsosorbideUrea (ureaphil)Urea (ureaphil)

URINARY TRACT ANTISEPTICSnitrofurantoin (Furadantin, Furalan, Macrobid)*Inhibits the growth of bacteria in the urine*Indicated for UTIs & do not achieve antibacterial effects in the blood or tissues*Given with milk or meals to prevent GI distress*A/R: pulmonary reactions like dspnea, chest pain, chills, fever, cough & will resolve 2-4 days after treatment*Imparts a harmless brown color to urine

URINARY ANALGESICSphenazopyridine HCl (Pyridium)*Used to treat pain from UTI or irritation*usually given together with antibiotics*A/R: nausea, headache, vertigo, urine will turn red or orange

CHOLINERGICbethanechol chloride (Duvoid, Urecholine)*Used to treat nonobstructive urinary retention *Used to increase bladder tone & function*A/R: hypotension, diarrhea, urinary urgency & broncho- constriction*antidote: atropine SO4

ANTISPASMODICSoxybutynin chloride (Ditropan) relaxes smooth muscles of urinary tract*A/R: leukopenia, bradycardia, anxietypropantheline bromide (Pro-banthine) decreases bladder muscle spasms*A/R: palpitations, blurred vision, urinary hesitancy & urgency, dry mouth & constipation*Never given in clients with glaucoma, obstructive uropathy & colitis

HEMATOPOIETIC GROWTH FACTOR

epoetin alfa (Epogen, Procrit)

*Used to stimulate RBC*Reverses anemia in chronic renal failure*Initial effects seen in 1-2 weeks and hematocrit level reaches normal (30-33%) in 2-3 months*Monitor CBC & BP for hypertensive S/E*Caution in clients with uncontrolled HPN,hypersensitivity to human albumin

PREVENTING ORGAN REJECTION

Immunosuppressantscyclosporine (Sandimmune)

*Used to prevent kidney transplant rejection by acting to suppress the action of T-lympocytes *Administered together with prednisone*A/R: nephrotoxicity, hirsutism (reversible) & infection*Take with milk or orange juice, grapefruit juice increases drug level

Cytotoxic Medsazathioprine (Imuran)

*suppresses immune response by inhibiting B & T lymphocytes*adjunct to cyclosporine*A/R: neutropenia & thrombocytopenia

ACYCLOVIR (ZOVIRAX)ACYCLOVIR (ZOVIRAX)

*Inhibits viral DNA replication. Does not cure *Inhibits viral DNA replication. Does not cure nor nor prevent transmission of herpes infections but prevent transmission of herpes infections but decreases the severity & duration of the decreases the severity & duration of the infectioninfection

*Indicated for herpes simplex 1 & 2, varicella *Indicated for herpes simplex 1 & 2, varicella and and herpes zooster infectionherpes zooster infection

*A/R crystalluria & phlebitis at injection site*A/R crystalluria & phlebitis at injection site

ZIDOVUDINE (AZT, RETROVIR)ZIDOVUDINE (AZT, RETROVIR)

*Developed to control AIDS or ARC (AIDS- Related *Developed to control AIDS or ARC (AIDS- Related Complex) Complex)

*A/R: Leukocytopenia & Anemia, hepatotoxic & *A/R: Leukocytopenia & Anemia, hepatotoxic & nephrotoxic, nephrotoxic, dizziness..crosses blood & brain barrierdizziness..crosses blood & brain barrier

*Safe for pregnant women*Safe for pregnant women

Related Drugs: didanosine (Videx), Lamivudine (Epivir) & Related Drugs: didanosine (Videx), Lamivudine (Epivir) & Zalcitabine (ddC)Zalcitabine (ddC)

***Nucleoside reverse transcriptase inhibitors indicated ***Nucleoside reverse transcriptase inhibitors indicated for for CD4 of 500 & lessCD4 of 500 & less

PROTEASE INHIBITORSPROTEASE INHIBITORS

saquinavir (Invirase)saquinavir (Invirase)*A/R: photosensitivity*A/R: photosensitivity

ritonavir (Norvir)ritonavir (Norvir)*A/R: increase triglyceride levels*A/R: increase triglyceride levels

stavudine (d4T, Zerit)stavudine (d4T, Zerit)*for those who do not respond to conventional *for those who do not respond to conventional therapytherapy*A/R: peripheral neuropathy, unsteady gait*A/R: peripheral neuropathy, unsteady gait

SULFONAMIDES- SULFISOXAZOLE (GANTRISIN)SULFONAMIDES- SULFISOXAZOLE (GANTRISIN)

*Prevents conversion of (PABA) to folic acid which is *Prevents conversion of (PABA) to folic acid which is needed for bacterial growth; bacteriostatic & needed for bacterial growth; bacteriostatic & bactericidalbactericidal*Used for UTIs, eye infections, otitis media, vaginitis*Used for UTIs, eye infections, otitis media, vaginitis*A/R: Steven-Johnson syndrome (acute onset of fever, *A/R: Steven-Johnson syndrome (acute onset of fever, bullae on bullae on skin & ulcers on mucus membranes of lips, eyes, mouth, skin & ulcers on mucus membranes of lips, eyes, mouth, nasal nasal passages & genitalia. Pneumonia & joint pains may passages & genitalia. Pneumonia & joint pains may occur; fever occur; fever after 7-10 days after onset of therapy indicates after 7-10 days after onset of therapy indicates hypersensitivity hypersensitivity or hemolytic anemiaor hemolytic anemia*Caution diabetics that drug may cause hypoglycemia; *Caution diabetics that drug may cause hypoglycemia; women women on oral contraceptives need an alternative method of on oral contraceptives need an alternative method of contraceptioncontraception

PENICILLINSPENICILLINSPENICILLIN G POTASSIUM PENICILLIN G POTASSIUM

(PENTIDS)(PENTIDS)*Inhibits cell wall synthesis of *Inhibits cell wall synthesis of microorganisms; microorganisms; bactericidalbactericidal

*Systemic infections of gram-positive cocci; *Systemic infections of gram-positive cocci; syphilis, prophylaxis for rheumatic fever & syphilis, prophylaxis for rheumatic fever & bacterial endocarditisbacterial endocarditis

*A/R: hypersensitivity; GI upset, nephritis, *A/R: hypersensitivity; GI upset, nephritis, anemia, leukopenia & thrombocytopeniaanemia, leukopenia & thrombocytopenia

PENICILLIN G POTASSIUM (PENTIDS)PENICILLIN G POTASSIUM (PENTIDS)

Probenecid (Benemid) may be given to increase blood levels of penicillins

RELATED DRUGS:

A. PENICILLINASE-RESISTANT PENICILLINS

METHICIN Na (STAPHCILLIN) & NAFCILLIN Na (NAFCIN, UNIPEN)

*Used to treat penicillinase-producing organisms

B. AMINOPENICILLINS

AMPICILLIN(AMCILL, POLYCILLIN) & AMOXICILLIN TRIHYDRATE (AMOXIL)

*Increased effectiveness against gram-negative organisms

FIRST-GENERATION – CEFAZOLIN Na (ANCEF)

*Inhibits bacterial cell wall synthesis; bactericidal (same action for all generations)

*Against gram-positive cocci

*A/R: hypersensitivity; nephrotoxicity & hepato- toxicity; bone marrow depression

*Cross-allergy with penicillin

*Probenecid therapy

SECOND GENERATION – CEFOXITIN Na SECOND GENERATION – CEFOXITIN Na (MEFOXIN)(MEFOXIN)

*Used against gram-negative & gram-positive bacteria*A/R is the same for all generations*Lidocaine used as diluent for IM injection to reduce the pain

THIRD GENERATION – CEFOTAXIME (CLAFORAN)THIRD GENERATION – CEFOTAXIME (CLAFORAN)

*Used in serious gram-negative & gram-positive infections such as neonatal meningitis & gonorrhea*A/R is the same for all generations *Protect IV solutions from light & do not mix with amino- glycosies---nephrotoxic

CHLORAMPENICOL (CHLOROMYCETIN)CHLORAMPENICOL (CHLOROMYCETIN)

*Inhibits CHON synthesis; bacteriostatic & *Inhibits CHON synthesis; bacteriostatic & bactericidalbactericidal

*Used against Haemophilus influenzae meningitis, *Used against Haemophilus influenzae meningitis, salmonella typhi- used only in severe infections salmonella typhi- used only in severe infections where other antibiotics can’t be used because where other antibiotics can’t be used because A/R are A/R are aplastic anemia & gray baby syndromeaplastic anemia & gray baby syndrome (seen in premature infant & children below 2 (seen in premature infant & children below 2 years…experiences vomiting, abdominal years…experiences vomiting, abdominal distention, irregular respirations & circulatory distention, irregular respirations & circulatory collapse)collapse)

*referred to as 4 quinolone or fluroqinolone

CIPROFLOXACIN (CIPROBAY)

S/E =N/V, diarrhea, discomfort, dizziness, lightheadednessS/E TO REPORT = rash = neurologic effects: H/A, mental depressionDRUG INTERACTION = antacids = probenecid = theophylline

TETRACYCLINE HCl (ACHROMYCIN V)TETRACYCLINE HCl (ACHROMYCIN V)

*Inhibits bacterial cell wall synthesis; bacteriostatic & bactericidal; reduces fatty acids from triglycerides

*Used for acne vulgaris, gonorrhea & spirochetes

*A/R: photosensitivity, hepatotoxicity; chelating to teeth and new bones..avoid giving to pregnant & nursing women, children under 8 as drug binds to Ca in teeth & new bones causing permanently discolored teeth & retarded bone growth

General Information on all agents

GENTAMICIN (GARAMYCIN) GENTAMICIN (GARAMYCIN) “Mycins”“Mycins”

*Suppresses protein synthesis in bacterial cell; bactericidal

*Against gram-negative bacterial infections; eye infections

*A/R: ototoxicity; nephrotoxicity & neuromuscular blockage

VANCOMYCIN HCl (VANCOCIN)

*Interferes with cell membrane activities; bacteriostatic & bactericidal

*Effective against gram(+) cocci like staphylococcus

*A/R: ototoxicity, nephrotoxicity, thrombophlebitis, Red-neck syndrome (flushing & hypotension from rapid IV infusion)

*Clindamycin hcl capsules (cleocin, dalacin C)

*lincomycin hcl (lincocin)- semisynthetic derivative of lincomycin, is

more effective & causes fewer untoward effects

ERYTHROMYCINS – ERYTHROMYCIN BASE (E-MYCIN)

*Inhibits protein synthesis in bacterial cell; bacteriostatic

*Used in persons with allergy to penicillins; indicated for acne, streptococcal & staphylococcal infections

*A/R: GI irritation, allergic reactions, hepatitis, reversible hearing loss

*Do not give with acids e.g. orange juice

Amphoterizin B (fun gizone)* shld be mixed only w/ water & slowly infuse* BUN, liver enzymes, u/a shld be checked

Butoconazole nitrate (femstat)

Ketonazole (nizoral)

Miconazole (monistat)

Nystatin (mycostatin)

General Considerations

ISONIAZID (INH)ISONIAZID (INH)

*Initial TTT against PTB; prophylaxis for high-risk groups*A/R: peripheral neuritis)…give vitamin B6 (pyridoxine); hepatitis…check liver enzymes frequently; hyperexcitability*Taken on empty stomach, avoid alcohol & interferes with Phenytoin (Dilantin) requiring lowering of INH dose

ETHAMBUTOL (MYAMBUTOL)

*A/R: optic neuritis & loss of red-green color discrimination but it’s reversible

RIFAMPICINRIFAMPICIN

*A/R: hepatitis, flu-like syndrome, may turn body fluids (urine, tears, saliva etc. ) orange*Interacts with anticoagulants, oral contraceptives, oral hypoglycemics, methadone & corticosteroids

STREPTOMYCINSTREPTOMYCIN

*A/R: cranial nerve 8 damage (roaring, ringing & feeling of fullness in the ear); vestibular damage (dizziness & vertigo)

PYRAZINAMIDEPYRAZINAMIDE

*A/R: increased uric acid causing gout or hepatitis

ACNE PRODUCTS

Isotretinoin (Accutane)

*metabolite of vitamin A*treatment for severe cystic acne *C/I: sun exposure, ROH & pregnancy

BURNS PRODUCT

Mafenide (Sulfamylon)

*bacteriostatic against gram-negative & gram-positive org.*apply 1/6 inch film directly to burn*A/R diffuses via devascularized areas; may precipitate metabolic acidosis manifested by hyperventilation; bone marrow depression & hemolytic anemia

Burns Products

nitrofurazone (Furacin)

*bactericidal*apply 1/16 inch film directly to burn*A/R: contact dermatitis & rash

silver sulfadiazine (Silvadene, Flint SSD)

*bactericidal against gm-positive, gm-negative org. & yeast*apply 1/16 inch film to burn*A/R: leukopenia

silver nitrate

*antiseptic against gm-negative org.*apply to dressing & not to wound or broken skin*A/R: stains anything it comes into contact with but discoloration is not permanent

ALKYLATING MEDICATIONS

*Affects by crosslinking DNA to inhibit cell productionEg: chlorambucil (Leukeran), mechlorethamine HCl (Mustargen) *A/R gonadal suppression & hyperuricemia

cisplatin (Platinol) *A/R: ototoxicity, tinnitus, hypokalemia, hypocalcemia, hypomagnesemia & nephrotoxicity *assess for dizziness, tinnitus, hearing loss, incoordination, numbness & tingling extremities

cyclophosphamide (Cytoxan)*A/R: gonadal suppression, hemorrhagic cystitis..hematuria & dysuria…encourage 2-3 liters of fluids/day unless C/I*Encourage diet low in purine to alkalinize urine & lower blood uric acid level purine food: organ meats

ANTITUMOR ANTIBIOTIC MEDS

*Interfere with DNA & ribonucleic acid synthesis

plicamycin (Mithracin) *A/R: prolongs bleeding time…avoid aspirin, anticoagulants & antithrombolytics

daunorubicin (Cerubidine) *A/R: CHF & dysrhythmias

bleomycin SO4 (Blenoxane)*A/R: pulmonary toxicity

doxorubicin (Adriamycin) & idarubicin (Idamycin) *A/R: cardiotoxicity, dyspnea, hypotension, ECG changes & weight gain* Hydration to prevent hyperuricemia

ANTIMETABOLITE MEDSANTIMETABOLITE MEDS

*Halt the synthesis of cell CHON; replaces CHON needed for DNA synthesis

Cytarabine HCl (ara-C, Cytosar-U)*A/R: hepatotoxicity

5-Fluorouracil (5-FU; Adrucil)*A/R: phototoxicity & cerebellar dysfunction (dizziness/ weakness)

6-mercatopurine (Purinethol)*A/R: hepatotoxicity

Methotrexate (Folex)…given with leukovorin (folinic acid)*A/R: photosensitivity, hepatotoxicity, hematologic, GI &

skin toxicity

VINCA (PLANT) ALKALOIDS

*Prevents mitosis causing cell death

vincristine SO4 (Oncovin)*A/R: neurotoxic…tingling & numbness of extremities

HORMONAL MEDS & ENZYMES

*suppress the immune system & block normal hormones in hormone-sensitive tumors; change hormonal balance & slows growth of certain tumors

aspariginase (Elspar)*A/R: impaired pancreatic function

HORMONAL MEDS & ENZYMES

mitotane (Lysodren)*A/R: hemorrhagic cystitis & hypercholesterolemia

tamoxifen citrate (Nolvadex)*A/R: edema. Hypercalcemia, elevated cholesterol & triglyceride levels; decreases estrogen effect

Diethylstilbestrol (DES, Stilphostrol)*A/R: impotence & gynecomastia in men; alter effects of anti-coagulants, oral hypoglycemic agents & insulin