Pharm Exam 1

• Failure to stay up to date
• Pharmaceutical influences
• Lack of time
• Consumer pressure to prescribe
• Illegibility of prescriptions
• Failure to detect/anticipate drug interactions

• PA: PA educational program not tied to specific degree
• NP: Bachelor nurses must obtain Master's or post-master's certificate program

• PA: practice under physician supervision, complement physician services
• NP: May not require physician supervision, holistic

• PA: Co-signature requirements
• NP: 19 states have no MD supervision, in FL and AL NPs cannot prescribe controlled substances

• COST, Genereic much cheaper.
• Same efficacy, ingredients, MOA

• Fluctuating GI till 8 months affects enteral meds
• Neonate higher proportion of body weight in form of water than in the adult
• Reduced fat in premies
• Premies: incomplete glial development enhances permeability of BBB and permits drugs and bilirubin to enter CNS more readily
• Metabolism slower in infants than older children and adults
• Slow clearance rate and prolonged half lives
• Excretion: GFR at 50% of adult by 3rd week of life
• Consider: FORMULATION, VEHICLE OF DELIVERY, TASTE
• AVOID: Tetracycline, codeine, dextromethorphan, aspirin, and valproic acid

• Polypharmacy, multiple providers, OTC, vitamins, home remedies
• Risk for ADRs: limited knowledge of impact of specific drugs on older adults
• Disease processes
• Decline in total body water - Body mass: lean vs. fat
• Decrease in serum albumin
• Enhanced effect (toxicity)
• Altered hepatic reserve
• Declining mass
• Decreased hepatic flow
• Altered nutrition
• Drugs metabolized in liver: 30-40% lower dose
• Decreased # of nephrons
• Decreased renal blood flow, GFR, tubular secretion rate, creatinine clearance
• Inc # of sclerosed glomeruli
• CONSIDER: BARRIERS TO ADHERENCE (COST, COMPLICATED SCHEDULES, IMPAIRED COGNITION/JUDGMENT, SIDE EFFECTS, LACK OF KNOWLEDGE R/T PURPOSE OF MED, FEAR OF SIDE EFFECTS OR EXACERBATION OF OTHER PROBLEMS, NO PERCEIVED RESPONSE/EFFECT FROM MED

• MOST CRITICAL PERIOD TO AVOID 3-8 WEEKS
• Placental transfer
• Maternal-fetal genotype
• dose-response relationship
• Specificity of agent
• Polypharmacy
• AVOID: Isotretinoin, rubella vaccine, caffeine, alcohol, nicotine/smoking, illegal drugs
• CONSIDER: PREGNANCY RISK CATEGORIES, DRUGS USED DURING BREASTFEEDING, WHEN TO INTERPRET/WEAN DRUGS FOR BREASTFEEDING, LACTATION RISK CATEGORIES

Therapeutic range

steady state

4-5 half-lives

After 4-5 half-lives, 94-97% of drug is eliminated

• Perceived importance
• Duration of therapy
• Behavioral changed required
• Poor understanding of instructions
• Complexity of treatment regimen
• unpleasant side effects

• NOT-EVIDENCED BASED
• Assess appropriateness of drug
• High risk for producing ADRs and less likely to produce severe ADRs
• Used by clinicians to predict the occurence of ADRs, particularly when taking fewer than 5 drugs

• Patient's are becoming more informed of their health and OTC meds and often misdiagnose and treat with the wrong meds
• OTC meds can also have drug interactions with themselves and prescribed meds

• Drug type, necessity
• Patient current response to treatment
• If uncomfortable about increasing requests of meds, confront pt, offer support and assistance if pt inappropriately relies on meds, do not continue to provide prescription to pt, if PCP feels they cannot meet need of pt then refer out

• Oral candidiasis
• Irritation of throat
• Cough
• Possible bronchospasm

• Hyperglycemia (INC need for insulin in DM)
• Immunosuppression
• Cushing's syndrome
• Vit D deficiency
• Decreased Bone marrow density
• Edema, wt gain, neg nitrogen imbalance, electrolyte imbalance

• Mild: Antihistamine and Decongestant
• Moderate: Reg-High dose ICS, add oral/nasal antihistamine and decongestant if necessary
• Severe: Nonsedating antihistamine w/ or w/out decongestant and ICS, consider oral steroid and use of oxymetazoline

• Caffeine intake
• Alcohol
• Smoking

• MVP
• Cardiac Palpitations

• URI
• Allergic rhinitis
• Hay Fever
• Nasal congestion associated with sinusitis and eustachian tube congestion

Selectively acts on B2 receptors in the bronchial, uterine, and vascular smooth muscle causing bronchial dilation, artery dilation, relaxation of alveolar walls, vasodilation of blood vessels with various degrees of cardiac effects and muscle tremors

• Palpitations
• Tachycardia
• Inc BP
• Cough
• Tremors, nervousness
• heartburn
• nasal congestion

2-4 mg PO tid-qid, Max 32 mg/day

4-8 mg PO q 12 hours, max 32 mg/day

• 80-100% in urine,
• <20% in feces

Nonselective competitors of muscarinic receptors present in airways and other organs. Airway secretions and resistance reduced

COPD because of increased cholinergic tone in airways

• Dry mouth
• GI distress
• Constipation
• Urinary retention
• Eye pain

0.5 mg q 20 min x 3 doses and prn

feces primarily, urine (50% unchanged)

Reduce airflow obstruction by reducing airway inflammation in bronchioles, suppress cytokine, inflammatory mediators, and eosinophils in airway

• Hyperglycemia (inc insulin need in DM)
• Dec BMD
• Immunosuppresion
• Cushings
• edema, wt gain, htn
• Vit D defiency
• Neg nitrogen and electrolyte imbalance

• Acute: 40-80 mg/day PO qd-bid till peak flow 70%
• Severe, Persistent: 7.5-60 mg qd or qod

SAME AS PREDNISONE

Oral candidiasis, poss bronchospasm, RARE: HPA axis at high doses

1-4 puffs (40-80 mcg) BID

feces primary, <10% urine

Prevent and reduce infllamatory response in bronchial walls by inhibiting the secretion of mediators from mast cells

HA, Nausea, Cough, Wheeze, Sneeze

200 mg PO qid, Max 400 mg qid

feces, <1% urine

• Inhibit airway cysteinyl leukotriene inhibitors which are products of arachidonic acid metabolism released from mast cells ad eosinophils.
• CysTL type 1 found in airway smooth muscle, airway macrophages, and eosinophils

Abnormal hepatic function tests, HA, Abd pain with cramps, Infectious GI myopia

10 mg PO q afternoon/evening

86% bile, feces, <2% urine

Same as Albuterol

Same as Albuterol with the addition of joint, muscle pain

1 puff (50 mcg) or 2 puffs (21 mcg) q 12 hours

Feces

• Promote bronchodilation, act directly on CNS stimulants that produce vasoconstriction and stimulation of vagal center which causes bradycardia
• + ino and chronotropic effect on myorcardiu on SA node
• Diuresis from renal arteriole dilation
• < esophageal pressure and relaxed biliary contraction along with stimulation of gastric secretions

Tachycardia, palpitations, NVD, GI reflux, HA, Insomnia, irritability

300-600 mg qd or BID

Urine, 10% unchanged

Inhibitors

Inducers

Anti-convulsants

• 1 - SABA2
• 2 - LABA2, SABA2, Theophylline, Pulm rehab
• 3 - 2 + ICS
• 4 - 3 + O2, poss bullectomy, lung volume reduction, or lung transplant

Acute bronchospasm, prevention of exercise-induced bronchospasm

• >65 years
• RR >30
• SBP <90 or DBP <60
• Confusion
• Blood Urea Nitrogen <20

Amoxicillin

Augement

• Fluoroquinolones (Floxacin 750mg) or
• B-lactam plus a Macrolide (HD Amoxcillin 1g 3x daily or AMCT 2g 2x daily)

• Macrolide (romycin) or
• Doxycycline

H Influenzae and M catarrhalis

• Macrolides
• Fluoroquinolones

• black hair tongue
• RENAL: ELV BUN and Creatinine
• SERIOUS: serum sickness, colitis, BMS

• deposition of teeth
• Photosensativity
• Black hair tongue
• SERIOUS: Blue-grey pigmentation, exfoliative dematitis, colitis, BMS, hepatotoxicity, INC Bun and creatinine

• Azithromycin: photosensativity
• SERIOUS: SJS, Inc QT interval, Arrythmias, Hepatotoxic

• Phototoxcitiy, edema, palpitations
• SERIOUS: SJS, Prolonged QT interval, colitis, BMS, ACHILLES TENDON RUPTURE

• Tinnitus
• SERIOUS: Inc Ca, K, NA, MG, hypotension, BMS, Ecephalopathy, Neuromuscular blockade, hearing loss

• Photosensativity
• SERIOUS: Lupus, SJS, Periorbital edema, myocarditis, HEPATITIS

• Penicillin
• Cepahlosporins

• Tetracyclines
• Macrolides
• Aminoglycosides

Fluoroquinolones

Sulfonamides

• PCN
• Cephalosporin
• Macrolide
• Fluoroquinolones
• Aminoglycosides

• Tetracylcines
• Macrolides
• Sulfonamides

• Azithromycin 1 g x 1 dose or
• Doxycycline 100 mg BID x 7 days

• Tinidazole 2000 mg PO x 1 day or
• metronidazole

Fluorquinolones

• Usually virus, NO ABX
• AM/CL if sx >14 days, fever >102, unilateral pain, sinus tenderness, tooth pain, green discharge, pt condition improves than worsens
• Decongestants and mucolytics
• Shorter Tx times
• Drink hot fluids, apply moist heat, inhale steam, saltwater nasal spray rinses

• MONO/HERPES: Acylovir
• RMSF: 1st: Doxycycline 100 mg PO bid x 7 days, 2nd: Chloramphenicol 50 mg/kg/day IV q 6 hrs x 7 days

0.1 mL ID, read 48-72 hours, induration >2mm considered +

• HIV
• Lymphoma
• Recent live vaccinations

• ISAOLATE
• CXR
• Sputum AF stainn (4-6 hours)
• Culture (6 weeks)
• Biopsy (caseation granulomas)
• Report to state HD, test and tx close contacts, monitor compliance (DOT)

Isoniazid & Rifapentine x 3 months, add 2 more drugs if failure suspected (rifampin, ethambutol, pyrazinamide)

• XRAY OR CLINICAL EVIDENCE OF TB
• Close contact of person with active disease
• evidence of old, healed TB lesions
• Recipients of organ transplant
• Person's with immunosuppression

• Children <4 years
• Foreign born
• HIV, drug users
• Employee's long-term/health care facilities

ALL OTHER

• Avoid sex when lesions present
• Blurred vision/impaired mental acuity
• avoid excessive alcohol
• stop Zanamivir if bronchospasm
• Monitor pts with renal impairments

• Transient burning, stinging, sneezing, discharge
• Rebound congestion, rhinitis
• Sympathomimetic response
• Spistaxis, bad taste
• Bronchospasm
• Dryness, pharyngitis, cough, nasal ulcer

• Brimonidine
• Dec aqueous humor, Inc outflow of aqueous humor

• MAOI
• CV disease
• Dec hepatic or renal function

• Systemic antihistamines, INS
• 1st line: Topical antihistamine, NSAID, MCS for long-term control, possible corticosteroids

• Wash hands
• Tilt head back or lie down and gaze up
• pull eyelid away from pouch
• place dropper directly over eye and look up
• look down for several sec after drop
• release lid, close eyes gently
• apply gentle pressure to inside eye corner for 3-5 min
• do not rub eye or squeeze life
• minimize blinking

• 0.25-0.5 inch ointment sweeping motion inside lower eyelid by squeezing tube gently and releasing eyelid slowly
• Close eyes 1-2 min and role eyeball in all directions
• Temporary blurring may occur
• use at night

erythromycin

• 1st: Dicloxacillin
• 2nd: mupirocin, azithromycin, cephalexin

• 1st: amoxicillin, AM/CL (if vomiting or cannot tolerate oral med give 1 dose ceftriaxone
• 2nd: azithromycin, Doxycycline

AM/CL or fluoroquinolones (adults) x 10 days

• M-M: AM/CL + extra amoxicillin or cefdinir
• Severe: Levofloxacin

• 1st: PCN V x po x 10 days or Amoxicillin
• 2nd: Cephalexin, azithromycin (if allergic)

OTC meds >6 years

nasal suctioning

TMP/SMX, AM/CL, cephalexin (2-24 months) for 7-14 days

• 1st: ciprofloxcain 750 mg x 1 dose (mild), Fluoroquinolones bid x 3 days (severe)
• 2nd: azithromycin usual or 1000 mg x 1 dose

Tindazole 2000 mg po x 3 days

corticosteroids: dexamethasone 0.15-0.6 mg/kx x 1 dose

• Antihistamines
• Intranasal Mast cell stabilizers
• Leukotreine Receptor antagonists
• INS

• 1st: Sulfacetamide sodium 3-4x/day
• 2nd: erythromycin

Topical Corticosteroids

• Moderate: Benzoyl Peroxide
• Mild-severe: Topical clindamycin or erythromycin (inflammatory lesions)
• Mild-moderate: Topical Tretinoin or Azelaic acid for inflammatory and non-inflammatory
• SALICYCLIC ACID, BENZOYL PEROXIDE, ORAL/TOPICAL ABX, TOPICAL RETINOIDS, ISOTRETINOIN

• Amantadine, Rimantidine
• Oseltamivir, Zanamivir

Erythromycin

Acyclovir

• SABA2: albuterol, AC, ICS
• Step 1: SABA2 prn
• Step 2: Low dose ICS (preferred), cromolyn, LTRA, Theophylline (alternative)
• Step 3: Low dose ICS + LABA or medium dose
• ICS (preferred) OR Low dose ICS + LTRA, Theophylline, or Zileuton (alternative)
• Step 4: Medium dose ICS + LABA (preferred) or Medium dose ICS + either LTRA, Theophylline, or Zileuton (alternative)
• Step 5: High dose ICS, LABA, Omalizumab
• Step 6: High dose ICS, LABA, oral corticosteroid, and omalizumab

• Avoid sustained release decongestants
• AH may diminish mental alertness or Paradoxical effect
• Seizure risk high doses
• Use of INS in prepubescent children poses risk of growth retardation
• Codeine contraindicated in infants
• Caution recommended when expectorants are administered to children up to 12 years of age with persistent or chronic cough, asthma, or cough accompanied by mucus
• No OTC meds <6 years
• Low dose inhaled corticosteroids and pral prednisolone do not improve outcomes in children with asthma
• NO ABX for bronchiolitis, no racemic epinephrine when not hospitalized
• No evidence of routine deep suctioning
• No role for corticosteroids, ribavirin, or CPT in management of bronchiolitis
• Asymptomatic tx of bacteriuria not recommended
• Febrile infants with UTIs should undergo renal and bladder US during 1st UTI

• Children absorb >3x more than adults
• <12 years not treated with group I/II topical steroids
• Larger skin surface are-to-body ratio, more susceptible to topical corticosteroid-induced HPA axis suppression and cushings (HPA causes linear growth retardation, weight gain, and low cortisol levels)
• Potent corticosteroids not used for diaper rashes

• Blocks protein synthesis of bacteria by binding with transfer ribonucleic acid synthetase
• EFFECTIVENESS: VERY EFFECTIVE

Effective >1 day to >2 weeks

moderate

Mild

• Start with retinoid
• Consider adding topical antibacterials: benzoyl peroxide or topical antibiotic + inc strength of retinoid

• Retinoid w/ or w/out topical antibiotic or benzoyl peroxide
• Add later oral antibiotic (3 month trial)

Moderate

• Topical antibiotic (drying therapy)
• Sulfacetamide + sulfur or other topical antibiotic with Benzoyl peroxide w/ or w/out oral antibiotics
• Maximum effect of 8 weeks then add retinoid if not controlled

Severe

• minimal scarring: conventional tx and oral Rx
• Scarring, long history of acne tx, failed other rx: Isotretinoin

• oral contraceptives
• spironolactone

excessive drying, peeling, inflammation, swelling

Dried mucus membranes, nose bleeds, cheilitis, GI effects, SERIOUS: CNS, teratogenic, Hepatitis. pancreatitis

Skin irritation

Hypersensaitivity and cross-sensativity to bezoic derivatives (cinnamon and certain topical anesthetics)

• Sunburn
• Hypersensativity

Pregnancy

• I - most potent
• VII: least potent

• 1st: permethrin 1-5% 10 min
• 2nd: malathion (8-12 hours)
• 3rd: Lindane (NEUROTOXCICITY RISK)
• 4th: Ivermectin

• 1st: Permethrin 5% cream neck down, rinse 8-14 hours or
• Ivermectin 150-200 mcg/kg orally x 1 dose

Subtype 1: Erythematotelangiectatic

• Topical: metronidazole, azelaic acid, or sulfacetamide/sulfur
• Oral tetracyclines
• Vascular laser therapy
• 2nd: Oral doxycycline, topical clindamycin, pimercrolimus, tacrolimus, or other tetracyclines

Subtype II: Papulipustular

• Topical metronidazole and oral tetracycline or doxycycline
• 2nd: topical benzoyl peroxide/erythromycin or clindamycin
• Oral azithromycin
• Topical tretinoin
• Benzoyl peroxide
• Consider Isotretinoin

Subtype III: Phymatous

• Oral tetracyclines
• Referral for Isotretinoin

Subtype IV: Ocular

• Topical or oral tetracyclines
• Eyelid hygeine (artificial tears, lid cleaning)
• Referral to opthamologist

hypersensativity to pyrethrin, chrysantyemums. INFANTS <2 months

• Photophobia
• GI upset
• BMS
• CNS effects
• HEPATOTOXIC
• SJS
• Taste perversion

• Fatigue
• Photosensativity
• Erythema multiforme
• Thrush
• Proteinuria, Nephrosis
• Hepatotoxic

• Don't take ketoconazole or itraconazole within 2 hours of antacids
• Take fluconazole w/ or w/out food
• Women use contraception or abstain from sex during azole therapy
• Take Griseofulvin with food
• HAs occur with Griseofulvin and disappear with continued therapy or taken with food
• Notify PCP if skin rash or sore throat appear with Griseofulvin
• Griseofulvin may potentiate SE of alcohol

• Tinea everything
• Onychomycosis nail infection
• Candidiasis Albicans (yeast in skin folds, groin)