REVIEW
INTRODUCTION MODULE
• Drug class—identifies mechanism of action for the medication
• Indications—may be different than the class (ex. Benadryl for sleep)
• Absorption, distribution, metabolism, excretion—considerations
• Agonist—binds to a receptor (ex Morphine)
• Antagonist—blocks the receptor (ex Naloxone)
• Partial agonist/antagonist—less adverse effects (ex Tramadol)
• Anaphylaxis—low BP, wheezing, tachycardia, angioedema
• Side effects—common, often expected
• Adverse effects—not expected, can be life threatening
• Contraindications—do not give drug (includes allergies to)
DEFINITIONS
• Salicylism—toxicity caused by excessive intake of salicylic acid (ringing of the
ears, nausea, vomiting, respiratory alkalosis, organ failure)
• Reye’s disease—children with viral infection who take aspirin (develop swelling
of the liver and brain)
• Serotonin Syndrome—accumulation of serotonin from multiple medications
(diarrhea, muscle rigidity, hallucinations, fevers, seizures, death)
• Agranulocytosis—destruction of white blood cells that fight infection
(granulocytes)
• Extrapyramidal effects—drug induced movement disorders, primarily
antipsychotic drugs (akathisia, dystonia, tardive dyskinesia)
• Neuroleptic malignant syndrome—rare but serious muscle rigidity, fever,
drowsiness, confusion, seizures caused by antipsychotic drugs
AUTONOMIC NERVOUS SYSTEM
• Autonomic nervous system
• Adrenergic nervous system “fight or flight”
• Sympathetic nervous system
• Releases epinephrine and norepinephrine (vasopressors)
• Uses alpha and beta receptors
• Cholinergic nervous system “rest and digest”
• Parasympathetic nervous system
• Releases acetylcholine
• Uses nicotinic and muscarinic receptors
• Cholinergic symptoms: cramps, salivation, blurry vision, diarrhea, paralysis
• Anticholinergic symptoms: dry mouth, dry eyes, blurred vision, constipation
MATH CALCULATIONS
MUSCULOSKELETAL DRUGS
• NSAIDs—non steroidal anti inflammatory drugs. Can cause GI upset, increased
risk of ulceration/GI bleed, renal toxicity. Ketorolac has a black box warning—
GI perforation if used more than 5 days
• Corticosteroids—can increase infection, fluid retention, GI upset,
hyperglycemia, adrenal insufficiency, “Cushings” symptoms. Do not stop
suddently if on for more than 7 days
• Colchicine—given for an acute gout attack. Always causes diarrhea
• Gabapentin/pregabalin—used for fibromyalgia, nerve pain, seizures. Causes
sedation
• Methotrexate is a category X, inhibits folic acid, causes bone marrow
suppression
• Entercept requires TB test, causes bone marrow suppression
MUSCULOSKELETAL DRUGS
• Duloxetine—SSRI antidepressant, can lead to serotonin syndrome, used for
fibromyalgia, nerve pain, depression, can cause sexual side effects
• Amitriptyline—tricyclic antidepressant, used for insomnia, nerve pain,
migraines. Causes anticholinergic side effects, very sedating
• Bisphosphonates—used for osteoporosis, hypercalcemia. Can cause
osteonecrosis of the jaw, monitor for hypocalcemia
• Raloxifene—used for osteoporosis, decrease the risk of breast cancer. Is an
estrogen modulator. Can increase risk of DVT/PE. Teach smoking cessation
PAIN DRUGS
• Acetaminophen—antidote is acetylcysteine, use cautiously with liver disease,
max is 4 grams per day
• Tramadol is contraindicated in seizure disorders
• Opioids—antidote is naloxone, which has a shorter half life, so monitor closely
Common side effects are constipation, respiratory depression
• Remember patients can have abstinence syndrome, which is a sudden
withdrawal (DTs)
RESPIRATORY DRUGS
• Beta 2 adrenergic agonists—can affect the heart if non-selective (fight or flight)
• Anticholinergics—inhaled drugs, teach to rinse their mouth
• Inhaled corticosteroids—can cause thrush
• Acetylcysteine is a mucolytic
• Guaifenesin is an expectorant
• Antihistamines cause sedation
• Decongestants stimulate alpha 1 adrenergic receptors (increased CNS effects)
and can only be purchased in limited quantities
CARDIOVASCULAR DRUGS
• Chronotrope—rate
• Inotrope—contraction
• Domotrope—conduction
• Hypertensive crisis—give niprusside, nitroglycerine, beta blocker, calcium
channel blocker, ace inhibitor
• Hypotensive crisis—adrenergic agonists—epinephrine, dopamine, dobutamine,
ephedrine, albuterol
CARDIOVASCULAR DRUGS
• ACE-I—”pril”—cause dry cough, angioedema (give epinephrine)
• ARBs—”artan”—angioedema
• Aldosterone agonist—spironolactone—potassium sparing, avoid salt subsitutes
• Alpha 1 blockers—promotes venous dilation, decreasing heart rate. Improves
prostate size
• Beta blockers—slows everything, can cause bradycardia, bronchoconstriction
• Thiazide diuretics—HCTZ—1st choice, monitor electrolytes, hydration
• Loop diuretics—furosemide—monitor K+ depletion, renal toxicity, tinnitus
CARDIOVASCULAR DRUGS
• Statins—for cholesterol, can cause myalgias, liver toxicity
• Gemfibrozil—given twice daily, monitor for myalgias, liver toxicity
• Nitrates—given for angina, causes major dilation (avoid ED drugs)
• Calcium channel blockers—monitor rhythm, cause peripheral edema
• Digoxin—increased inotrope, decrease chomotrope, monitor K+, lots of drug
interactions, narrow therapeutic range, “halo” often first sign of toxicity,
antidote is “antigen binding fragments”
IMMUNIZATIONS
• Tetanus—give booster every 10 years, for pregnancy and for traumas
• Don’t give vaccines if recently had Guillain Barre
• Polio—don’t give if pregnant
• Varicella—don’t give if pregnant….give Zoster vaccine at age 60
• Pneumovac—give to high risk, immunocompromised, chronic disease, smokers,
long-term care patients, patients greater than 65 years old
• Influenza—less than 2 years old, age 50-65; give inactivated
ages 2-50; give live attenuated, greater than 65; highest dose
• Do not give nasal dose if pregnant, on antivirals, age 2-17 taking aspirin, 2-4 with
asthma
• Menningial—give if college aged, due to increased risk living in dorms
• HPV—give between 11 and 12 years old
CHEMOTHERAPY
• Cytotoxic chemotherapy kills everything—hair, nails, stomach (nausea,
vomiting), mouth sores, diarrhea, low white blood cells, red blood cells,
platelets
• Biotherapy is more targeted to the specific tumor subtype, less side effects
• Often biotherapy causes a rash
• Avoid pregnancy
• Androgens—block testosterone
• Estrogen blocking agents—block estrogen
• Tamoxifen increases risk of DVT/PE, endometrial cancer
• Trastuzumab, Adriamycin cause cardiotoxicities
INFECTION DRUGS
• Monitor for allergies, take the whole course
• Get cultures prior to giving the first dose
• Watch for superinfections (c. diff, colitis, yeast infections)
• Cephalosporins, Flagyl cause disulfiram reactions
• Most interfere with OCPs
• Vancomycin causes “redman syndrome”
• Tetracyclines can discolor teach, avoid sun, milk, pregnancy
• Flouroquinones (Levaquin) can cause tendon rupture, do not give < 18 years
• Rifampin discolors body fluids
HEMATOLOGY
• Heparin antidote is protamine
• Watch for HIT (heparin induced thrombocytopenia)
• Do not use for surgery of the eyes, brain, spinal cord or lumbar puncture
• Warfarin antidote is vitamin K
• Foods high in vitamin K—green leafy veggies, broccoli, cauliflower, fish, liver
• Aspirin—hold for surgery, watch for gastric ulcers, salicysm
• Alteplase (TPA)—antidote is aminocaproic acid, FFP
• Epoetin—black box warning of DVT/PE/CVA, don’t give if hgb> 10
• Filgrastim can cause bone pain, enlarged or ruptured spleen
• Blood products can cause hemolytic reactions—know the protocol
GI
• H2 blockers—famitodine, cimetidine (causes CNS effects in elderly) and
ranitidine (taken off market for cancer) can increase bacterial growth, use
cautiously with COPD, pneumonia risk
• Antacids—take separately from other meds
• PPI—omeprazole, long term use leads to bone loss, increased pneumonia
• Misoprostal—protect mucus, causes cervical ripening—avoid in pregnancy
• Metroclopramide—can cause EPS with long term use
• IBS-D—alosetron—sign consent, use only 6 months, can cause life threatening
constipation
GI
• Iron—stains teeth, constipating, black stools, give vitamin C
• Iron chelating agent—deferoxamine
• Potassium—never give rapidly, monitor closely
• Magnesium—muscle relaxer, diarrhea, monitor deep tendon reflexes
• St. Johns Wart—multiple drug-drug effects, causes serotonin syndrome, has
anticholinergic side effects
ENDOCRINE
• Insulin antidote is glucagon
• Beta blockers mask hypoglycemia
• Metformin—hold for 48 hours after contrast IV dye is given, check creatinine
• Hypothyroid symptoms—weight gain, dry hair, constipation, tired
• Hyperthyroid symptoms—weight loss, diarrhea, insomnia
• Synthroid—hold POST MI
• Propylthiouracil—avoid iodine containing products, including seafood
• Radioactive iodine—radiation effects
• Vasopressin—give for either hemophilia or diabetes insipidus—monitor fluid
retention
• Hydrocortisone—Addison’s disease, increase dose in times of stress
NEURO DRUGS
• Benzodiazapines—antidote if flumazenil
• Can have withdrawals from it, but it treats withdrawals from ETOH
• Buspirone is less addicting, takes up to 4 weeks to work
• SSRIs—4-6 weeks to work, sexual side effects, can withdraw, monitor for suicidal
ideation and serotonin syndrome
• MAOIs—avoid tyramine rich foods
• Lithium—tremors, sweating are common side effects. Small range of lithium toxicity,
hold for exercise, heat, monitor kidney function
• 1st generation antipsychotics—cause EPS
• If acute dystonia or Parkinson’s symptoms—give Benadryl
• 2nd generation antipsychotics—less, but some EPS, sexual dysfunction, acute
diabetes or weight gain possible
NEURO DRUGS
• Stimulants—for ADHD, weight loss, narcolepsy. Can cause weight loss,
paranoia, restlessness. Avoid caffeine
• Methadone—given for heroin or opioid addition. Less addicting, less high
• Varenicline—can cause unpreditbile behavior, suicidal thoughts
• Naloxone—can be given IM for long-term use
• Disulfiram—given for ETOH to cause unpleasant side effects. Avoid all
products with alcohol, avoid alcohol for 14 days following last dose
PARKINSON’S DISEASE
• Levodopa/carbidopa—the carbidopa just makes the levodopa work better. Can
cause discoloration of the sweat or urine. Can have “off” times, lots of daytime
sleepiness
• Other Parkinson’s drugs are dopamine agonists/dopamine releaser
• This causes cholinergic effects, cause sleepiness
• Monitor kidney function
• Pramipexole—can cause impulse control disorder (sex, gambling, shopping)
• Amantadine—can discolor the skin
ANTIEPILEPTICS
• Phenobarbitol and phenytoin interfere with vitamin D and vitamin K
• Phenytoin causes gingival hyperplasia—overgrowth of the gums
• Valproic acid—watch for thrombocytopenia
• Lamotrigine can cause septic meningitis—monitor for stiff neck
• Levetiracetam can cause suicidal ideation
• Topiramate can cause reduced sweating and increased body temperature
• Gabapentin/pregabalin causes sedation, weight gain, edema
GLAUCOMA
• Open-angle = gradual, can be treated
• Closure or narrow = fast, can be irreversible
• Eye drop beta blockers can still cause systemic effects
• Latanoprost can increase the pigmentation of the irises, lids, lashes
• Pilocarpine is a cholinergic agonist
• All tend to cause stinging
MISCELLANEOUS DRUGS
• Succinylcholine—doesn’t cross the blood brain barrier
• Can cause respiratory arrest, hypotension, prolonged apnea
• Monitor for malignant hyperthermia, muscle pain
• Ketamine can cause hallucinations, confusion
• Zolpidem can cause daytime sleepiness, sleep related complex behaviors
(cooking, eating, walking, driving)
• Ramelteon can cause hormonal effects of decreased libido, infertility,
gallactorrhea
HORMONE REPLACEMENT THERAPY
• Estrogen and Testosterone
• Can be oral, transdermal, intravaginal, IM
• Given for growth and maturation, development of sexual characteristics,
increase bone resorption, treat abnormal vaginal bleeding or help with
menopausal symptoms
• Estrogen decreases the risk of ovarian cancer but increases the risk of breast
cancer
• Increases the risk of DVT/PE, stroke
• Encourage smoking cessation
• Testosterone causes polycythemia
• Testosterone causes premature closure of the epiphysis
ORAL CONTRACEPTIVE PILLS
• Increases the risk of DVT/PE
• Causes hypertension-check BP often
• If a patient is on antibiotics, they need a backup method
• Encourage smoking cessation
BPH AND ED
• Finasteride may take 6 months to work, cannot donate blood while on it, can
cause breast enlargement, must avoid touching if pregnant
• Tamsulosin can cause floppy iris syndrome, hold for cataract surgery
• Sildenafil should never be used with nitrates, can cause MI, sudden death
LABOR AND DELIVERY
• Oxytocin can cause hypertensive crisis. Use the IV pump, monitor fetal HR
• Terbutaline slows preterm labor by 24 hours
• Magnesium drips can cause too much muscle relaxation, check DTR
• Magnesium sulftate’s antidote is calcium gluconate
• Misoprostal ripens the cervix. Do not give if scarring or PID
• Clomid causes rapid weight gain, edema
• Cabergoline corrects prolactin levels
CHECK YOUR KNOWLEDGE
• https://www.colorado.gov/pacific/sites/default/files/10-1-20%20PDL%20v3.pdf
• This is the Colorado Medicaid preferred drug list. It has them separated into
drug categories. Pull it up and see how many drugs you know!