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MN 553 Pharmacology Exam 1 2024
Prescriptive Authority - *States vary in their laws related to prescriptive authority for APRNs. *Scope of practice is determined by the individual NP's license under the nurse practice act of the licensing jurisdiction. Some have a graduated scope based on experience level. New prescribers need to understand that their employment sites may restrict this legal scope of practice but cannot extend it. Prescribing - •Ensure that prescribing practices meet current standards of medical care. •Maintain accurate and thorough documentation of prescribing practices. •Engage in informative and interactive informed consent discussions that allocate appropriate responsibility between physician and patient. •Evaluate split treatment arrangements and supervisory settings to ensure that your supervisees have the training, ability, and resources to provide high-quality medical care. •Your State Practice Act-What are your limits in prescribing? •Your State Board of Nursing •Your Role and Licensure •National Certification and Credentialing *Prescribing a drug results from clinical judgment based on a thorough assessment of the patient and the patient's environment, the determination of medical and nursing diagnoses, a review of potential alternative therapies, and specific knowledge about the drug chosen and the disease process it is designed to treat. In general, the best therapy is the least in Writing and Transmitting the Prescription - 1. Use preprinted prescription pads/electronic templates that contain the name, address, telephone number, and NPI number of the prescriber. This will allow the pharmacist to contact the prescriber if there are any questions about the prescription.
- Designate the complete drug name, strength, dosage, form and number to dispense.
- Indicate the date of the prescription.
- Use metric units of measure, such as milligrams and milliliters; avoid apothecary units of measure.
- Avoid abbreviations.
- Avoid the use of "as directed" or "as needed."
- Include the general indication, such as "for infection."
- Indicate "Dispense as Written" if generic substitution is not desired.
- Include the patient weight, especially if pediatric or geriatric.
- Indicate if a safety cap is not required, as medications will be dispensed with them by default. ETHICAL ASPECTS OF PRESCRIBING - Informed Consent
- The notion of informed consent is shorthand for the patient's right to make informed decisions about those things that will affect him or her. Prescribing for Self, Family, or Friends
- State law varies regarding whether an NP can prescribe for family or friends. For a prescription to be clinically legitimate, a patient must be assessed and there must be a record of his or her assessment. It is clearly unethical to prescribe for oneself, and many states punish this with significant fines or board action. Although it may be technically legal to
prescribe for family or friends, an NP needs to consider whether it is ethical. If the clinical circumstance requires a controlled substance, the judicious prescriber will refer a friend or family member to a colleague for confidential assessment and treatment. It is never considered ethical for a mental health provider to engage a family member or close friend in a clinically therapeutic relationship, whether or not prescribing First Pass effect - •Oral meds are generally absorbed by the GI tract and carried to the liver. Drug may undergo extensive metabolism leaving little for systemic use. This is called the first pass effect. Are rapidly metabolized by the liver & may have little if any desired action. Loading dose - - Rapidly achieves therapeutic levels
- Dose of medication, often larger than subsequent doses, administered for the purpose of establishing a therapeutic level of the medication. Peak drug level - *Time it takes a drug to demonstrate its full therapeutic effect. *The peak level is the highest concentration of a drug in the patient's bloodstream. **Note: Random drug levels may be ordered and are appropriate for monitoring drug usage if drug is being administered by continuous IV infusion. Investigating new drugs - *New drug investigation is filed with the USDA prior to human testing of any new drug entity. *An Investigational New Drug (IND) is a drug developed by a pharmaceutical or biotech company or other organization that is ready for clinical trials on humans. When a drug reaches this point, the pharma company submits an application to get the consent of the Food and Drug Administration (FDA) to begin these trials. Being an Interpreter - *Use reliable person at hospital (employee) *Use certified interpreters for language, hearing and speech impairments. Provider liable for poor outcomes if lay interpreter is used Nonadherence - Choose drugs with higher tolerability & fewer SE such as n/v, & dizziness. Contributing factors:
- poor communication
- forgetfulness (especially if it is a side effect of a drug), lack of knowledge, dementia, mental health problems, simple procrastination, or an overextended lifestyle.
- Adverse Drug Reactions.
- Cognitive Impairment and Psychiatric Illness.
- Complexity of Drug Regimen and Polypharmacy. Top 4 Reasons for Non-Adherence •Side Effects •Cost •Too Complex and/or Forgetfulness •"I'm Cured" Complex Poor health outcomes in vulnerable populations - - Discrimination, cultural barriers, and lack of health care.
- Chronically ill and disabled
Efficacy Safety Adverse drug reaction Drug-drug reaction Hospital admission, clinic visits Humanistic outcomes Patient satisfaction with care Quality of life measured by validated instrument Economic outcomes Cost associated with immunosuppressive therapy Cost to treat adverse drug reactions Cost to treat drug-drug interactions Cost to treat long-term toxicity (nephrotoxicity, hypertension) Cost of laboratory workups Commonly Used Pharmacoeconomic Research Methodologies - **Cost-minimization Outcome: Outcome must be clinically identical in similar patient population All social costs should be considered EX: Adalat CC vs Procardia XL. Generic azathioprine vs brand-name azathioprine. **Cost-effectiveness Different clinical outcome Justify the incremental cost increase for the therapeutic benefit from extra costs associated with treatment EX: antilymphocyte induction vs no induction. **Cost-benefit Expressing clinical outcome purely in monetary units Assigns a dollar value to specific disease state Unethical and should be avoided Ex: 10 mm Hg reduction in blood pressure worth $ Pharmacoeconomics - Pharmacoeconomics is the study of the appropriate utilization of drugs for the treatment of a specific disease. Pharmacoeconomic studies characterize the improved outcomes while justifying additional drug expenditures. Because the value and economics of many approved drugs are unknown at the time, the true impact of new drug substitution on the cost and care of most patients with complicated conditions is also unknown. In theory, if a therapeutically equivalent and less expensive product is available, it should be substituted. This may substantially affect the cost of drug therapy and overall health-care costs. Applying pharmacoeconomics to prescribing practice involves understanding the impact of drug costs on patients and making an educated prescribing decision to ensure the best outcome. Tetracycline Pharmacodynamics - Tetracyclines are bacteriostatic; they inhibit or retard the growth of bacteria but do not kill them. They retard bacterial growth by inhibiting protein synthesis in sensitive bacteria and by preventing cell division and replication. Like other antibiotics their effect on the body is indirect. Tetracycline Absorption - *Take tetracycline on an empty stomach or with foods that are not high in calcium, aluminum, iron, or magnesium because the drug chelates with these minerals, thereby decreasing absorption.
*When taken together (Tetracycline+quinolone antibiotic). Do not take antacids while on these medications as the antacid decreases absorption. Tetracycline Contraindications & Precautions - Tetracycline is contraindicated in patients with a known allergy to tetracyclines or to tartrazine (specific oral preparations contain tartrazine) and during pregnancy and lactation. Tetracycline should be used with caution in children younger than 8 years and in patients with hepatic and renal dysfunction. Tetracycline Adverse Effects: - N/V, diarrhea, abdominal or epigastric discomfort, HA, dizziness, photosensitivity. Tetracycline Drug Interactions: - *The effectiveness of penicillin G decreases if it is taken concurrently with tetracyclines. If this combination is used, the dosage of the penicillin will have to be increased. *Oral contraceptives may be less effective if taken with tetracycline. Patients taking oral contraceptives should be advised to use an additional form of birth control while receiving tetracycline. *Tetracycline forms an insoluble chelate with aluminum, bismuth, calcium, iron, magnesium, and zinc salts which are frequently an ingredient in anacids. This chelate decrease the absorption of either tetracyclines or the salt. Beta blockers - Tx: HTN by reducing vascular smooth muscle tone. First drug choice after MI. other tx for angina, dysrhythmias class 2, heart failure, tachycardia, anxiety, tremor. Action of Beta Blockers - Decrease HR & contractility which decreases cardiac output and decreases BP. Works by blocking sympathetic stimulation, epinephrine & norepinephrine but doesn't block completely because you wouldn't have a pulse or a BP. Beta blocker action and anti-dysrhythmic drugs - Slow HR & decrease conduction through the AV node, often used if arterial dysrhythmias accompanied by heart failure. BB effect on whole body - *Opposite of an adrenaline rush slows everything down. *Beta-1 receptors: Located primarily in the heart. *Beta-2 receptors-Located in the smooth muscle of lungs, uterus, and other organs. BB Precautions and Contraindications - *Contraindicated for patients with respiratory conditions that include a bronchospastic component. *contraindicated for patients with AV block because their actions to decrease heart rate and myocardial contractility result in an increased reduction in cardiac output and worsened failure. Decreased cardiac output and the initial vasoconstrictive action of these drugs may also worsen peripheral vascular diseases. *Beta blockers may precipitate or exacerbate type 2 diabetes. Because of their effects on carbohydrate metabolism and their ability to mask the common symptoms of hypoglycemia, beta blockers must be used cautiously in patients with diabetes. *Propranolol and metoprolol are excreted in breast milk and the manufacturer recommends using caution when administering to nursing mothers. BB Adverse Effects - Cardiovascular reactions: Bradycardia, CHF w/concomitant pulmonary edema, hypotension.
Salmeterol (BRONCHODILATOR) - Beta2-receptor agonist (B2RA) bronchodilator agents are widely used for patients of all ages to treat reversible bronchoconstriction caused by asthma, reactive airway disease (RAD), or COPD. A variety of beta-agonist bronchodilators are available, and the medications come in multiple forms and delivery systems. Bronchodilators act on the smooth muscle of the bronchial tree to reverse bronchospasm, thereby decreasing airway resistance and residual volume and increasing vital capacity and airflow. Long-acting bronchodilator. Use cautiously in African Americans. Not prescribed as monotherapy for persistent asthma. Salmeterol is excreted in breast milk in small amounts. Salmeterol Precautions and Contraindications - Sympathomimetic bronchodilators have relatively few contraindications to their use. Cardiac arrhythmias associated with tachycardia or heart block caused by digitalis intoxication, angina, narrow-angle glaucoma, organic brain damage (epinephrine only), and shock during general anesthesia with halogenated agents are all contraindications to beta2 agonists. Because of these drugs' effects on the cardiovascular system, patients with hypertension, ischemic heart disease, coronary insufficiency, congestive heart failure, and a history of stroke and/or cardiac arrhythmias should be monitored closely for adverse effects during administration of any of the sympathomimetic bronchodilators. For patients with diabetes mellitus, there is a potential drug-induced hyperglycemia that may result in loss of diabetic control when using any of the beta2 agonists, and their insulin dosage may need to be increased. For patients with hyperthyroidism. Salmeterol should not be prescribed to children youn Salmeterol Adverse Drug Reactions - The beta-agonist bronchodilators exhibit some CNS excitation effects, with tremors, dizziness, shakiness, nervousness, and restlessness reported in some patients. Headaches may occur with bronchodilator use in 2% to 28% of patients. Insomnia is rare, reported in 1% to 3% of patients. Patients (up to 26%) may exhibit a post- inhalation cough after using indacaterol. Salmeterol and the other LABAs have a documented increased risk of exacerbation of severe asthma symptoms if the patient is deteriorating. To avoid this risk, none of the LABAs should be started in patients with acutely deteriorating asthma and are best used in combination with an inhaled steroid. Salmerterol Drug Interactions - If any of the beta agonists are prescribed with digitalis glycosides, caution and careful monitoring of the patient's electrocardiogram (ECG) is necessary because there is an increased risk of cardiac arrhythmia. Beta agonists used with beta-adrenergic blocking agents (including ophthalmic preparations) may result in mutual inhibition of therapeutic effects.
Tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) used with albuterol, metaproterenol, or terbutaline may potentiate the effects of the bronchodilator on the vascular system. Hypokalemia or ECG changes may be seen with coadministration of the beta agonists with drugs that lower the potassium level such as diuretics. Diphenhydramine - - Benadryl, anti-histamine.
- Urinary retentions (Black Box warning for elderly) Action/kinectics: H1-receptor antagonist in the respiratory tract, blood vessels, and GI smooth muscle; blocks release of histamine. Blocks cellular histamine receptors, decreases vasodilation, decreases motion sickness. Prevents but does not reverse, histamine mediated responses. Reverses extrapyramidal reactions from phenothiazine does that result in dystonic reactions. Indications: allergic reaction, urticatia, acute dystonic reactions, peds sedation, motion sicknes. Side effect: sedation, blurry vision, anticholinergic effects, tachycardia, PVCs. Caution in serotonin syndrome b/c diphenhydramine can cause increase serotonin activity and inhibit reuptake. Caution with pt. w/asthma, COPD, increased intraocular pressure, hyperthyroidism, CV disease, drug & ETOH use increases CNS assoc. depression. Contraindications: hypersensitivity, acute angle glaucoma, pt taking MAOI, not recommended in breast feedin Aspirin toxicity - Aspirin can produce gastric erosions that increase the risk of serious upper GI bleeding. This adverse effect is more likely when it is used in combination with other anticoagulants such as warfarin. In addition to tinnitus, indications of aspirin toxicity are headache, hyperventilation, agitation, mental confusion, lethargy, diarrhea, and sweating. *tinnitus Severe aspirin toxicity - *Fever, AMS, seizures, noncardiogenic pulmonary edema, GI bleed, liver failure, renal failure, hemodialysis. *ABG will show high anion gap metabolic acidosis & resp. alkalosis. TX for ASA toxicity (mild to moderate): supportive care (ABCs), if recent ingestion- activated charcoal/gastric lavage, dextrose to avoid CSF hypoglycemia, IVF, bicarb. Why are OD of ASA harmful? They interfere with KREBS cycle & cause UNCOUPLING of oxidative phosphorylation >>>accumulation lactate and ketoacids (anion gap) Iron replacements - - Best taken on empty stomach with juice
- Dietary sources of iron: red meat, iron enriched breads/cereals, raisins, dark green leafy vegetables, fish, poultry & eggs. AE: N/V constipation, turns stool dark green/black. Calcium decrease absorption, increase fluids+ fiber/stool softner.
· In times of mumps outbreak, a third dose of MMR has been administered with minimal adverse effects, including injection site pain, redness and swelling, muscle or joint aches and dizziness or light-headedness. MMR · Drug Interactions - · MMR should not be administered to patients receiving immunosuppressants, including high-dose corticosteroids, interferon, and antineoplastic drugs, because they may have insufficient response to immunization. Inhaled corticosteroids are not a contraindication to MMR vaccine. · The MMR vaccine may be inactivated by IG. To avoid inactivation of the attenuated virus, administer the MMR vaccine at least 14 to 30 days before or 6 months after the IG. If IG is being given in preparation for international travel, the MMR vaccine should be administered at least 2 weeks before IG. · MMR is not contraindicated if a PPD was done recently. PPD should be delayed for 4 to 6 weeks after an MMR has been given because it may interfere with the tuberculin skin test, causing a temporary decrease in tuberculin skin sensitivity. Chronic PPI - Chronic use of PPI, pt may have Iron deficiency, anemia, B12 & Calcium def. · PPIs are antisecretory drugs used to treat gastric conditions characterized by hyperacidity. They are used for erosive gastritis, GERD, and Zollinger-Ellison syndrome and as part of a multidrug regimen for short-term treatment of active PUD, especially duodenal ulcers caused by H. pylori. PPI Pharmacodynamics - · PPIs do not exhibit anticholinergic or histamine2-blockade properties but suppress gastric acid secretion. These drugs reduce H+ secretion by inhibition of the H+/K+-ATPase enzyme system at the secretory surface of the parietal cell itself to block the final step in H+ secretion. The effect is dose-related and inhibits basal and stimulated acid secretion regardless of the stimulus. They reduce gastric acid by more than 90% and frequently produce achlorhydria. Increases in serum gastrin levels parallel inhibition of the acid secretion. The decrease in acid secretion lasts for up to 72 hours after each dose. · Normal physiological effects related to suppression of gastric acid secretion result in decreased blood flow to the antrum, pylorus, and duodenal bulb. Increased serum pepsinogen levels and decreased pepsin activity also occur. As with other drugs that increase gastric pH, related increases in nitrate-reducing bacteria and elevation of nitrate concentration in gastric juice oc PPI Pharmacokinetics - Absorption and Distribution · All PPIs are acid-labile and so most are formulated as enteric-coated tablets or granules. Absorption is rapid and begins after the granules leave the stomach and reach the less acidic duodenum. · The peak and AUC of lansoprazole are diminished by 50% to 70% if the drug is given after food as opposed to the fasting state. It should be given on an empty stomach. When pantoprazole is given with food, absorption may be delayed by 2 hours or longer. Taking rabeprazole (Aciphex) with a high-fat meal may delay its absorption by up to 4 hours. In each case, the peak and AUC are not altered.
· All drugs are distributed to the parietal cells of the stomach. They all cross the placenta. Omeprazole has been measured in human breast milk; the other PPIs have been found in breast milk in animal studies. PPI Metabolism and Excretion - · These drugs are extensively metabolized by CYP450 2C and CYP450 3A4, and several metabolites have been identified that appear to have little or no antisecretory activity. Omeprazole is metabolized by the CYP450 system and may interact with other drugs also metabolized by this system. Lansoprazole and dexlansoprazole are metabolized by the CYP450 3A4 and CYP450 2C19 isoenzyme systems; however, they do not have clinically significant drug interactions related to this metabolic site. · In patients with varying degrees of hepatic disease, the mean plasma half-life of each of these drugs increases from a low of 3 hours with omeprazole to a high of 9 hours for pantoprazole. The plasma elimination half-life of these drugs does not reflect the duration of suppression of gastric acid secretion, apparently because of prolonged binding to the parietal H+/K+-ATPase enzyme. · Little unchanged drug is excreted in the urine, but 33% to 90% of the metabolites is excreted in the urine. The res PPI Precautions and Contraindications - · The only true contraindication to PPIs is hypersensitivity to the ingredients. The PPIs are extensively metabolized in the liver; therefore, they should be used cautiously in patients with hepatic dysfunction and in older adults. No dosage adjustments are recommended for these patients, however. · Omeprazole is Pregnancy Category C. Multiple studies have followed women exposed to omeprazole during pregnancy and found no increase in congenital malformations, perinatal mortality, or morbidity. Guidelines for treatment of GERD state, "PPIs are safe in pregnant patients if clinically indicated". Use in pregnancy only if the potential benefits outweigh the potential risks to the fetus. · Omeprazole (20 mg/day), esomeprazole (20 mg/day), or pantoprazole (40 mg/day) do not cause any adverse effects in breastfed infants. There is little information on the use of lansoprazole, dexlansoprazole, or rabeprazole during lactation, although both lansoprazole and dexlansoprazole are used in new PPI · Adverse Drug Reactions - · These drugs are generally well-tolerated when used for short-term treatment, and the adverse reactions that did occur in more than 1% of patients in clinical trials included dizziness, drowsiness, abdominal pain, constipation, diarrhea, and flatulence. It is difficult to determine if the GI-related symptoms were associated with the disease or the drug. · Two recent large studies have indicated PPI use is associated with an increased risk of chronic kidney disease. · Stomach acid provides a natural defense against microbial pathogens. Patients on long-term PPI therapy have an increased risk of infections from Clostridium difficile, Salmonella, and Campylobacter. Short-term use of PPIs increases the risk of pneumonia.
Leaking stool Recurrent bleeding from the rectum See a doctor immediately if you notice: Vomiting occurs and the vomitus has a bright yellow or green coloration (bile) Vomiting and swelling or unusual abdominal distention Severe pain in the rectum Melena or black/tarry stool There are no bowel movements at all Gliptins - Act on the incretin system to indirectly increase insulin production. Gliptins are indicated as monotherapy and in combination with or added to other antidiabetic drugs for the treatment of patients with type 2 DM who cannot achieve adequate BG control with diet, exercise, weight control, metformin, and other drugs. This class is not for use in type 1 DM or DKA. They are especially useful for obese patients because they are not associated with weight gain. They can be given with or without food. The current guidelines typically use these drugs as adjunctive therapy. Gliptin Precautions and Contraindications - Because of their high dependence on the renal system for elimination, these drugs should be used cautiously in those with impaired renal function. A risk for toxicity exists for patients with end-stage renal disease and for those with moderate to severe renal impairment. Long-term exposure to the pregnant population with DM. Therefore, the risk to the mother and fetus or mother and infant must be considered before prescribing these drugs. The safety and efficacy in children (younger than 18 years of age) have not been established Gliptin Adverse Drug Reactions - Hypoglycemia, arthralgias, urinary tract infections, and upper respiratory tract infections. Serious adverse drug reactions include heart failure, bullous pemphigoid, Stevens-Johnson syndrome, rhabdomyolysis, acute renal failure, abnormal renal function, pancreatitis or pancreatic cancer, and hypersensitivity reaction Hypoglycemia can occur when used in combination with insulin, sulfonylureas, or the meglitinides Gliptin Drug Interactions - Coadministration of gliptins with ACEIs, antidiabetic agents, protease inhibitors, quinolones, and somatostatin analogs have been associated with increased risk of hypoglycemia. Gliptin Monitoring - Before initiating therapy and at least annually thereafter, assess renal function. Gliptin Patient Education/Adverse Reactions - All gliptins are taken once daily in the morning. If the dose is missed, it should be taken as soon as remembered. If the dose is missed for the entire day, it should not be doubled the next day. It would be prudent to complete SMBG in the case of missed doses. Gliptins are generally well-tolerated and adverse reactions occur in only a small percentage of those taking the drugs. Hypoglycemia is not anticipated with monotherapy but may occur
when these drugs are combined with another glucose-lowering agent. The usual treatment for hypoglycemia is recommended. Instruct patients to report any symptoms of pancreatitis, heart failure, bullous pemphigoid, or severe joint pain. Ringworm - Fungal infections of the skin are common in all age groups. These infections, which occur in both healthy and immunocompromised persons, are caused by dermatophytes and yeasts. Dermatophyte infections are classified according to the anatomic location. Infants and immunocompromised patients may have thrush and Candida infections in the diaper area. Tinea corporis, also known as ringworm, can be found in patients of all ages. Tinea capitis is most common in children. Tinea pedis, also known as athlete's foot, can be found at any age but generally in postpubertal patients. Tinea cruris, also known as jock itch, is more common in men than women and is caused most commonly by T. rubrium. Fungal overgrowth occurs in immunocompromised patients or patients on antibiotics. Antifungal medications are used to treat superficial fungal infections caused by dermatophytic fungi and yeast. Oral agents must be used in the treatment of disease that is extensive, affects hair and nails, or does not respo Ringworm Treatment - (Tinea Corporis) miconazole, Nystatin or clotrimazole. Absorption and Distribution Topical Antifungals Topical antifungals are poorly absorbed from intact skin. Nystatin is not absorbed from intact skin or mucous membranes. Systemic Antifungals Griseofulvin and terbinafine are the two systemic antifungals that are primarily used in dermatological diseases. Griseofulvin is poorly absorbed; therefore, oral formulations have been developed in an attempt to increase bioavailability. Terbinafine, when administered orally, is well absorbed from the gut. It is unknown whether terbinafine crosses the placenta, but it is excreted in the breast milk of nursing mothers with a milk/plasma ratio of 7:1. Ringworm Treatment Precautions and Contraindications - Topical Antifungals There are few contraindications to the topical antifungal medications. Hypersensitivity to the antifungal agent or any of the components of the formulation is a contraindication. Patients with azole hypersensitivity are often sensitive to all azole derivatives. The antifungal agent should be discontinued if sensitization occurs. The use of antifungals around the eyes should be avoided. Ketoconazole cream contains sulfites that may cause allergic types of reactions, including anaphylactic symptoms and life-threatening or less severe asthmatic episodes in susceptible persons. Ciclopirox topical nail lacquer (Penlac) should not be used in immunocompromised or diabetic patients with onychomycosis. There are no contraindications to efinaconazole or tavaborole. The topical antifungals that are classified Pregnancy Category B are clotrimazole, oxiconazole, ciclopirox olamine, naftifine, and butenafine. The topical antifungals classified as Pregnancy Category C are nystatin Ringworm Treatment Adverse Drug Reactions - Topical Antifungals
PCN and Cephalosporins - Food in the stomach does not significantly alter absorption of penicillin V, so it should be taken after meals. Amoxicillins are penicillins that are unaffected by food. Other beta-lactam antibiotics should be used with caution in people with penicillin allergy as there is a risk, albeit slight, of a cross-reactive allergy. This includes cephalosporin antibiotics like Keflex (cephalexin), Maxipime (cefepime), Rocephin (ceftriaxone), and Suprax (cefixime). PCN side effects - Diarrhea Headache Stomach upset Nausea or vomiting Rash or hives (usually mild to moderate) Injection site pain (with penicillin G) Black hairy tongue Muscle twitches Oral thrush Vaginal yeast infection Fever and angioedema (tissue swelling) can also occur but are less common. Penicillins are generally considered safe during pregnancy and breastfeeding. With that said, the drugs are classified as Pregnancy Category B drugs. PCN drug interactions - Anticoagulants (blood thinners) like Coumadin (warfarin) Diuretics (water pills) like Lasix (furosemide) and Edecrin (ethacrynic acid) Nonsteroidal anti-inflammatory drugs like aspirin, Tivorbex (indomethacin), and phenylbutazone Sulfanomides like Bactrim (sulfamethoxazole/trimethoprim), Azulfidine (sulfasalazine), and Truxazole (sulfisoxazole) Long term antifungals - **Monitor pts on ketoconazole for long-term, AST/ALT, alk phos and bili. Pregnancy category for fluconazole indications (other than vaginal candidiasis) has been changed from category C to category D. The pregnancy category for a single dose of fluconazole 150 mg to treat vaginal candidiasis has not changed and remains category C. Pregnancy category D means there is positive evidence of human fetal risk based on human data but the potential benefits from use of the drug in pregnant women with serious or life- threatening conditions may be acceptable despite its risks. Long term antifungals Monitoring - The patient being treated for oral candidiasis should be monitored for efficacy of treatment, with no laboratory monitoring necessary. The patient being treated for tinea capitis will need monitoring for adverse effects from the systemic antifungals. All of the systemic antifungal agents can possibly cause some alteration in hepatic function. If the patient is to be on continuous therapy, then baseline and ongoing monitoring of liver function is necessary. If liver enzymes become elevated, the medication
should be discontinued. The patient being prescribed griseofulvin will require renal, liver, and hematopoietic function measurements every 8 weeks during therapy. Patients receiving ketoconazole require liver function tests prior to beginning therapy and monthly for the whole course of their treatment. Patients on itraconazole need liver enzyme and renal studies if the medication is prescribed for longer than 8 consecutive weeks. In that case, liver function and electrolytes should be Allopurinol - For gout. Labs to check are BUN/Create & Create clearance Antigout drugs reduce the inflammatory process or prevent synthesis of uric acid. Allopurinol and febuxostat inhibit xanthine oxidase, the enzyme responsible for the conversion of hypoxanthine and xanthine to uric acid. Allopurinol has a metabolite (alloxanthine) that is also an inhibitor of xanthine oxidase. Both decrease the production of uric acid without disrupting the biosynthesis of vital purines. Allopurinol - Allopurinol and colchicine are associated with hepatotoxicity. Allopurinol has been found in breast milk. It is not known whether the other drugs are excreted in breast milk. Patients should avoid taking aspirin or salicylates while taking probenecid or lesinurad. Patients should alert the health-care provider if they are started on another medication that may also affect uric acid levels, such as diuretics, cyclosporine, or nicotinic acid. Allopurinol Adverse Reactions/Lifestyle Management - GI distress. Taking these drugs with food or milk may minimize gastric irritation. maculopapular rash that sometimes is scaly or exfoliative. Drowsiness and dizziness Recommendations include an alkaline diet (urate-lowering) that includes reductions in sodium, refined sugars, oxalate-rich foods (e.g., liver, kidney, anchovies, sardines, herring, mussels, bacon, codfish, scallops, trout, haddock, veal, venison, turkey), and high-dose calcium supplement intake, as well as increases in oral fluids and dietary fiber. Fluid intake in excess of 3,000 mL/d also reduces the risk for renal calculi. Because large amounts of alcohol increase uric acid concentrations and may decrease the effectiveness of medications, alcohol should be avoided or consumed in very small amounts. T Otis media - In children, High dose Amoxicillin Caused by eustachian tube dysfunction **Negative pressure causes reflux of bacteria into middle ear. Pathogens **S. pneumoniae **Nontypeable H. influenzae **M. catarrhalis
Vit B12 - The underlying problem in PA is vitamin B12 deficiency. Patients should be taught to eat foods high in this vitamin, such as mollusks (e.g., clams), fortified breakfast cereals, liver, trout, salmon, milk, and eggs. These foods are listed in the order of highest to lowest amount of vitamin B12 (ODS, 2018c). One serving of fortified breakfast cereal provides 100% of the daily requirement for vitamin B12, Vitamin B12 is required for proper red blood cell formation, neurological function, and DNA synthesis Vit B12 - Vitamin B12, in the form of cyanocobalamin and occasionally hydroxocobalamin, can be administered parenterally as a prescription medication, usually by intramuscular injection [12]. Parenteral administration is typically used to treat vitamin B12 deficiency caused by pernicious anemia and other conditions that result in vitamin B12 malabsorption and severe vitamin B12 deficiency. Vit B12 Interactions with Medications - Proton pump inhibitors-interfere with vitamin B absorption. H2 receptor antagonists-interfere with vitamin B12 absorption. Metformin-might reduce the absorption of vitamin B Angina -
