Pharmacology: Fast Facts
LEADERSHIP & MANAGEMENT
Pharmacokinetics
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Absorption (skipped with IV meds)
Distribution
Metabolism
Excretion
Pregnancy Classes
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A, B, C, D, X
Labs
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Peak/Trough
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Collect cultures prior to abx
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Pertinent labs vary by medication (e.g. renal labs, thyroid labs, INR, etc.)
Six Rights
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Client
Drug
Dose
Route
Time
Documentation
Antidotes and Common Levels
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Acetaminophen
(acetylcysteine)
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Benzodiazepines (flumazenil)
Digitalis (digoxin immune FAB)
Heparin (protamine sulfate)
Magnesium sulfate (calcium
gluconate)
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Opioids (naloxone)
Warfarin (phytonadioneVitamin K)
• Digoxin (0.8-2.0ng/mL)
• Lithium (0.4-1.4 mEq/L)
• Magnesium Sulfate (48mg/dL)
• Phenytoin (10-20
mcg/mL)
• Theophylline (10-20
mcg/mL)
• Warfarin INR 2.0-3.5
• Heparin aPTT 60-90
seconds
Cardiac Medications (antihypertensives)
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All antihypertensive meds can causes dizziness/falls
All antidysrhythmics can cause dysrhythmias
ACEs (prils) and ARBs (sartans)
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HTN, HF, diabetic nephropathy
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Can cause hyperkalemia
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ACEs can cause persistent cough
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Monitor BP, monitor for angioedema
Calcium Channel Blockers
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HTN, tachydysrhythmias (certain meds)
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Amlodipine (HTN only), verapamil/diltiazem (a-fib, a-flutter, SVT)
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All decrease BP, verapamil/diltiazem decrease HR
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Note VS hold parameters, Constipation common
Cardiac Medications (antihypertensives)
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Centrally Acting Alpha2 Agonists
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Clonidine
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HTN, Drug withdrawal
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Drowsiness, dry mouth side effects
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Never suddenly discontinue (rebound hypertension)
Beta blockers (olol’s)
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HTN, Angina, Tachydysrhythmias
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Use cardiac selective in patients with respiratory problems
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All decrease BP and HR, contraindicated in AV block/bradycardia
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Note VS hold parameters, check apical HR
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Can mask hypoglycemia symptoms
Cardiac Medications
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Vasodilators and Antianginal Meds
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Hydralazine/Nitroprusside (HTN emergency)
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Nitroglycerin (antianginal)
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Adverse effects HA, dizziness, profound hypotension
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Monitor BP, HR, cardiac rhythm
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SL NTG –must dispose when expired, keep in original dark bottle
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Take 1, if chest pain not relieved call 911, can repeat q 5 min x 3
Antidysrhythmics (all can cause dysrhythmias)
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Adenosine – SVT, causes flushing & period of asystole, RAPID IV push
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Amiodarone – V-fib, V-tach, can cause pulmonary toxicity
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Atropine – bradycardia, causes anticholinergic side effects
Cardiac Medications
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Digoxin
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HF, A-fib
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Thiazide/loop diuretics increase risk of toxicity (secondary to hypokalemia)
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Digoxin toxicity (GI upset, fatigue/weakness, blurred vision/yellow-green
halos)
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Check apical HR, hold < 60
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Monitor potassium
Antilipemic Medications (Statins)
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Pregnancy class X
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Adverse effects muscle aches, hepatotoxicity, rhabdomyolysis
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Monitor liver/renal function, evaluate effectiveness with lipid panel
Respiratory Medications
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Review inhaled medication administration
Bronchodilators before inhaled steroids
Rinse mouth after inhaled steroids
Beta2 Agonists – bronchodilators
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Albuterol (short acting)
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Salmeterol (long acting – ALWAYS combined with inhaled steroids)
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Caution with HTN, angina
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Adverse effects tachycardia, tremors, palpitations
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Monitor breath sounds/peak flow before and after
Respiratory Medications
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Methylxanthines (same class as CAFFEINE) - bronchodilator
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Aminophylline, Theophylline
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IV, PO
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Adverse effects restlessness, (toxicity: tachycardia, tachypnea,
seizures)
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Avoid caffeine intake
Glucocorticoids
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IV/PO for acute asthma/COPD exacerbation
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Inhaled for daily prophylaxis – this is NOT a rescue inhaler
Respiratory Medications
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Leukotriene Modifiers
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Montelukast
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Daily asthma prophylaxis, not a rescue drug
Antitussives/Expectorants
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Opioid (codeine), cause drowsiness, potential for abuse
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Guaifensin, makes it easier to clear mucous
Decongestants and Antihistamines
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Phenylnephrine, pseudoephedrine, can cause rebound congestion,
caution with HTN, short term use only
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Diphenhydramine, loratadine, fexofenadine
• Drowsiness with diphenhydramine, anticholinergic effects
Endocrine Medications
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Oral diabetic medications
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Alpha-glucosidase inhibitors (acarbose), slow carbohydrate absorption,
causes flatus, abdominal bloating
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Biguanides (metformin), makes muscle more sensitive to insulin, hold
for at least 48 hours after test with contrast media (lactic acidosis)
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Meglitinides (repaglinide), short acting – stimulates insulin release, take
with meals, risk for hypoglycemia
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Sulfonyureas (glipizide, glyburide), long acting- stimulates insulin
release, high risk for hypoglycemia
Endocrine Medications
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Insulins
Onset
Peak
Duration
Rapid acting (aspart/lispro)
15-30m
0.5-2.5hr
3 to 6 hr
Short-acting
0.5 to 1 hr
1 to 5 hr
6 to 10 hr
Intermediate (NPH)
1 to 2 hr
6 to 14 hr
16 to 22 hr
Long acting (glargine)
70 min
none
24 hr
(regular)
Hypoglycemia treat with juice (if awake able to swallow)
Dextrose solution IV
Glucagon IM
Endocrine Medications
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Thyroid Medications
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Levothyroxine/T4
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Overmedication causes hyperthyroidism symptoms
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Take in morning before breakfast and other medications
Methimazole and propylthiouracil (PTU)
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For hyperthyroidism, Thyroid crisis
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Adverse effects rashes, GI upset, agranulocytosis
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Report fever/sore throat to provider immediately
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Monitor for signs of hypothyroidism
Hematologic Meds
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Anticoagulants/Antiplatelets – Bleeding concern for all!
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Parenteral anticoagulants
• Heparin
– IV gtt keep aPTT 1.2-2x baseline (~60-90 seconds
therapeutic)
– Monitor platelets
– SC for DVT prophylaxis give in abd., no aPTT
monitoring required
• LMWH (enoxaparin)
– Weight-based, predictable
– Monitor platelets, given SC in abd., no aPTT
monitoring
Hematologic Meds
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Oral Anticoagulants – uses: DVT treatment, thrombus prevention
in afib, post-op, heart valve replacement
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Warfarin – interacts with many meds
• Vitamin K is antidote, patient can eat foods with Vitamin K,
but needs approx. same amount of it daily
• INR monitoring – goal 2-3.5 depending upon indication
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Newer Oral Anticoagulants
• Dabigatran, Rivaroxaban, Apixaban
• Less med/food interactions, standard dose, no INR
monitoring
Hematologic Meds
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Antiplatelets
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Aspirin = high dose ototoxicity, GI distress, ACS –chew tablets
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Clopidogrel – GI distress
Hematopoietic Factors – do not shake, agitate
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Epoetin alfa and Darbepoetin alfa (long acting) – treat anemia
• HTN, MI, Stroke, don’t use if Hgb over 11g/dL or >1g/dL
increase in 2 weeks
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Filgrastim and Pegfilgrastimi (long acting) – prevent infection
• Bone pain common! Treat with analgesic
Fluid/Electrolytes
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Loop- Furosemide
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Thiazides-Hydrochlorothiazide
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HF, liver and kidney disease
High risk for dehydration, ↓K+, ↓Na+, ototoxicity
Usually on K+ replacement
Monitor BP, Urine output, fall risks
Less profound than loops
For treating HTN, mild fluid overload
Increase K+ dietary intake
Monitor for fluid/electrolyte imbalance
Potassium-sparing- Spironolactone
• Cause least amount of diuresis
• Often used with other diuretics
• Risk for hyperkalemia, endocrine effects
Fluid/Electrolytes
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Potassium replacement
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IV give on pump, no faster than 10mEq/hr, NEVER RAPID IV
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PO, take with at least 8oz water or juice to reduce GI distress
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IV, burning at IV site common
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Monitor VS, cardiac rhythm with IV replacement
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HYPERKALEMIA – treat with IV insulin/dextrose, calcium gluconate,
sodium polystyrene sulfonate
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Magnesium replacement
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PO – diarrhea
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IV – slowly administer, monitor cardiac and neuromuscular status.
GU/Men’s Health
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5-apha reductase inhibitors - BPH
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Finasteride (end in asteride)
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Oral preparation, may not improve symptoms for 6 months
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Side effects gynecomastia, decreased libido
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Class X, cannot donate blood, pregnant women would not handle broken or
crushed meds
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Alpha1- adrengeric antagonists – BPH, urinary hesitancy
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Tamsulosin (end in losin or zosin)
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Minimal side effects, some in class can drop BP
Phosphodiesterase-type 5 inhibitors -Sildenafil (afils) - ED
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Notify provider if erection last > 4 hrs or sudden vision/hearing change
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Cannot take nitrates within 24 hrs of an PDE5 inhibitor
GI
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Antacids
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Aluminum and Calcium can cause constipation
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Magnesium can cause diarrhea
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Don’t take with other PO meds, short term use only.
H2 antagonists – antisecretory effect, block h2 action on parietal cells
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Cimetidine – Ranitidine –Famotidine, can be PRN or routine
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Cimetidine avoid in older adults risk for confusion
Proton-pump inhibitors – antisecretory effect, directly blocks acid
production
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Omeprazole (end in prazole)
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Diarrhea common
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Once daily in morning, not usually for PRN use
GI
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Antiemetics
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Serotonin antagonists
• Ondansetron, IV, oral, no drowsiness, diarrhea possible
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Dopamine antagonists
• Promethazine, prochlorperazine, metoclopramide (also a
prokinetic), IV, PO, cause drowsiness, EPS (treat with
diphenhydramine)
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Anticholinergics
• Scopolamine, PO, IV, transdermal, anticholinergic SE, good for
motion sickness, end of life care
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Cannabinoids
• Dronabinal, PO, decreases nausea and increases appetite,
“munchies”, can cause confusion in older adults.
Neuro
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Cholinesterase inhibitors
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Neostigmine – increase muscle strength in myasthenia gravis
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Donepezil – used to treat Alzheimer’s disease
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Risk for cholinergic crisis (particularly if OD), treat OD with atropine
Dopamine replacement therapy
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Levodopa/carbidopa – use for PD
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Take with food to avoid nausea, but avoid high protein with intake, protein
intake spread throughout day
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Can cause dyskinesias, orthostatic hypotension, tachycardia, psychosis,
discoloration of sweat/urine (harmless)
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Take on time and avoid missed doses
Neuro- Antiepileptic Drugs
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General rule – All AEDs can cause some drowsiness
Some are used for bipolar disorder and neuralgias
Older AEDs- typically monitor levels, more adverse effects
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Phenytoin – gingival hyperplasia, cardiac (with IV)
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Carbamazepine - blood dyscrasias
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Valproic Acid – hepatoxicity
Newer AEDs- generally don’t monitor levels, less adverse effects
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Levetiracetam
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Gabapentin
Antibiotics
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General antibiotic rules
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Culture prior to starting antibiotics
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If organism is known generally narrow spectrum
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Empiric treatment generally start broad may change when C+S results
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Teach patient to take all doses as prescribed even if feeling better
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Allergic reactions common for many antibiotics
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No antibiotics for viral URIs
Antibiotics
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Those affecting cell wall – Humans don’t have a cell wall!
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Penicillins – allergic reactions greatest toxicity
• PCNs differ in terms of antimicrobial coverage
• Some combined with beta lactamase inhibitor
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Cephalosporins - most given IV/IM, some PO
• Low risk of cross sensitivity if allergic to PCNs
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Vancomycin
• Reserved for serious infections
• IV slowly, decrease risk of red man syndrome
• Ototoxic, Nephrotoxic
Antibiotics – affecting protein synthesis
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Tetracyclines – Doxycycline
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GI distress
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Cannot give to children under 8 – stains teeth
Lincomycins - Clindamycin
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IV slowly
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High risk for C. diff colitis
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Aminoglycosides – gentamicin
• Ototoxic, Nephrotoxic, Peaks/Troughs only absorbed IV
Sulfa antibiotics
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Limited use alone
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GI upset, photosensitivity, hypersensitivity reactions
Fluoroquinolones - Levofloxacin
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Dizziness, tendon rupture!
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Don’t take PO with calcium, magnesium, aluminum, Fe
Macrolides
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Azithromycin
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With or without food, can prolong QT interval
Antibiotics
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Urinary antiseptics
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Nitrofurantoin
• Only antimicrobial action is in bladder
• Risk for peripheral neuropathy
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Antibiotic General Concerns
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Pseudomembranous colitis!
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Resistance
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Antimicrobial stewardship