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Pharmacological Agents and Their Clinical
Applications
Lipid-Lowering Agents
Gemfibrozil : A lipid-lowering agent that requires monitoring of liver panels, specifically AST and ALT.
Gastrointestinal Agents
Famotidine : An H2-histamine blocker used to treat gastric and duodenal ulcers. It should be taken before meals or at bedtime to relieve heartburn, difficulty swallowing, and GERD. Esomeprazole : A proton pump inhibitor (PPI) that reduces stomach acid and is indicated for GERD and peptic ulcer disease (PUD). Caution is needed to avoid interactions with other medications, and supplements may be required to address potential hypomagnesemia. Smoking and alcohol use should be avoided.
Antidiabetic Agents
Glipizide : A second-generation sulfonylurea used in patients with type 2 diabetes mellitus who produce minimal amounts of insulin. Its effects can be increased by medications such as aspirin, oral anticoagulants, MAOIs, sulfonamides, cimetidine, some NSAIDs, ginseng, and gemfibrozil.
Antiarrhythmic Agents
Procainamide : Used to treat premature ventricular contractions (PVCs) or atrial tachycardia. Potential side effects include hypotension and bradycardia. Lidocaine : Used to manage frequent PVCs (more than 6-10 per minute) and pulseless ventricular tachycardia. Atropine sulfate : An antidysrhythmic agent used to treat symptomatic bradycardia, as it increases heart rate and cardiac output.
Antiparkinson Agents
Benztropine : An anti-parkinsonian agent used to counteract extrapyramidal side effects of other medications.
Cardiovascular Agents
Verapamil : A calcium channel blocker used to treat supraventricular tachycardia. It is not recommended for patients with kidney issues. Dexamethasone : A corticosteroid that should be taken with breakfast to prevent ulcer formation.
Antimicrobial Agents
Amikacin : An aminoglycoside antibiotic with risks of ototoxicity and nephrotoxicity. It can also potentiate the action of warfarin, requiring caution.
Hormonal Agents
Estrogen : Initial adverse effects include nausea, which is common at breakfast time, so it should be taken after a meal. Alteplase : A thrombolytic agent used to dissolve existing or potential clots, indicated for sluggish blood return and acute ischemic stroke (within 4.5 hours of symptom onset). Oxytocin/Pitocin : Used to stimulate contractions, with the need to monitor maternal pulse, blood pressure, contractions, and fetal heart rate.
Anticoagulant and Antithrombotic Agents
Heparin : A fast-acting anticoagulant with protamine sulfate as the antidote. It is administered subcutaneously or intravenously, with specific needle size and volume requirements. It is safe for use during pregnancy. Enoxaparin : A low-molecular-weight heparin (LMWH) that reduces the risk of deep vein thrombosis (DVT). It is administered subcutaneously, and monitoring for signs of bleeding and thrombocytopenia is essential.
Diuretic Agents
Spironolactone : A potassium-sparing diuretic that requires a low- potassium diet. Lasix/Furosemide : A potassium-wasting diuretic that can cause depletion of sodium, potassium, calcium, and magnesium. It should be taken in the morning to avoid nocturia.
Antibiotic Agents
Ceftriaxone : A cephalosporin antibiotic that requires monitoring for Clostridium difficile infection, allergic reactions, and Stevens-Johnson syndrome.
Anticoagulant Agents
Warfarin/Coumadin : A long-term anticoagulant used in conditions like atrial fibrillation, thrombotic stroke, and mechanical heart valve replacement. It requires monitoring of prothrombin time (PT) and international normalized ratio (INR), with vitamin K as the antidote.
Dermatological Agents
Permethrin : Used to treat head lice. Depilatory : Removes hair from the skin. Scabicide lotion (permethrin) : Used for the treatment of scabies.
Immunosuppressant Agents
Common anti-rejection or immunosuppressants : Cyclosporine, prednisone, azathioprine, tacrolimus, mycophenolate, sirolimus, and mofetil.
Analgesic and Anti-inflammatory Agents
Acetaminophen/Tylenol : The maximum daily dose is 3,000 mg. NSAIDs : Used for conditions like gout and rheumatoid arthritis. They can have adverse effects on the gastrointestinal system, asthma, kidney function, and increase the risk of blood clots and bleeding. Aspirin : Should be stopped 5-7 days before surgery. Aspirin toxicity can lead to tinnitus, hyperventilation, vomiting, dehydration, fever, and metabolic acidosis.
Antibiotic Agents
Doxycycline : A tetracycline antibiotic with considerations for backup birth control, monitoring for glossitis, and the need to take it on an empty stomach.
Miscellaneous Agents
Niacin : Can cause facial flushing as a side effect and requires monitoring of liver function tests and HDL levels. Benzonatate : An antitussive that produces an anesthetic effect in the lungs, but should not be chewed as it can cause numbness of the throat and tongue. Buspirone : An anxiolytic agent with a slow onset of action and no sedative effects. Sertraline : An SSRI used for anxiety, depression, OCD, and PTSD. Sildenafil : Indicated for the treatment of erectile dysfunction and pulmonary hypertension, with a contraindication for use with nitrates. Antiparkinsonian Drugs : Biperiden, levodopa, and amantadine are used for the relief of extrapyramidal side effects.
Methylphenidate : Used in the treatment of ADHD, with the need to monitor height in pediatric patients and administer it in the morning due to its stimulant effects. Antipsychotics : First-generation (typical) antipsychotics like haloperidol, fluphenazine, and chlorpromazine have a risk of extrapyramidal side effects. Second-generation (atypical) antipsychotics like olanzapine, clozapine, and risperidone have a higher risk of metabolic syndrome. Propranolol : A beta-blocker that can be used to treat akathisia (motor restlessness), but is contraindicated in bronchospastic lung disorders, cardiogenic shock, sinus bradycardia, and heart blocks greater than first-degree. Lithium Toxicity : Drugs that increase the risk of lithium toxicity include dobutamine, diuretics, methyldopa, tetracyclines, and NSAIDs. Mirtazapine : A tetracyclic antidepressant with sedative effects, used in depression, anxiety, and insomnia related to depression. Levothyroxine : Should be taken before breakfast to prevent insomnia, as it replaces the T4 hormone and decreases TSH levels. ACE Inhibitors : Captopril and enalapril are examples of ACE inhibitors, which can cause angioedema, cough, hyperkalemia, and are contraindicated in pregnancy. Cimetidine : A histamine H2-receptor antagonist that decreases gastric secretions and can cause constipation and central nervous system adverse effects, especially in older adults. Dextrose 50 (D50) : Administered intravenously to treat hypoglycemia, with the need to monitor for hyperglycemia, osmotic diuresis, and hypotension. Intravenous Medication Administration : Ampicillin, digoxin, furosemide, and metoprolol can be given intravenously, while vancomycin and potassium chloride should not be given as intravenous push. Steroid Monitoring : When administering steroids, monitor white blood cell count (risk of infection), C-reactive protein, and lipid levels. Dopamine : A vasopressor used to treat hypotension and decreased cardiac output, with phentolamine as the antidote. Potassium Chloride (KCl) : Oral supplementation for the treatment of hypokalemia, which can be taken with food to reduce gastrointestinal side effects. Theophylline : An asthma medication with the potential for toxicity, including irregular pulse, seizures, palpitations, and arrhythmias. Febuxostat : Used in the management of gout, with potential side effects like splenomegaly, angina pectoris, and hyperglycemia. Zidovudine : An antiretroviral medication used in HIV/AIDS, with risks of anemia and infections. Atorvastatin : An HMG-CoA reductase inhibitor used to lower cholesterol, with the potential for rhabdomyolysis as an emergent side effect. Ephedrine : Should be avoided in patients with pheochromocytoma due to its potential to increase blood pressure. Beta-Blockers : Cause vasodilation, leading to decreased blood pressure, heart rate, afterload, contractility, cardiac output, and stroke volume.
Drugs that Decrease the Effectiveness of Oral
Contraceptives
Certain drugs can decrease the effectiveness of oral contraceptives, including:
Carbamazepine Phenytoin Penicillin Amoxicillin Ampicillin Doxycycline Metronidazole Tetracycline Benzodiazepines
Diltiazem
Diltiazem is a calcium channel blocker (CCB) that decreases cardiac output and acts as a vasodilator. It is used in the treatment of hypertension and stable angina.
Bumetanide
Bumetanide is a potassium-wasting diuretic that causes sodium loss in the urine.
Ciprofloxacin
Ciprofloxacin is a fluoroquinolone antibiotic used to treat a variety of infections, including those of the urinary tract, bones, joints, skin, respiratory tract, prostate, and sinuses. When administering ciprofloxacin, it is important to:
Increase fluid intake Avoid sunlight exposure Avoid dairy products and caffeine Take antacids or multivitamins 2 hours before or 6 hours after a dose
Atomoxetine
Atomoxetine is a medication used in the treatment of Attention Deficit Hyperactivity Disorder (ADHD). It has a low risk of dependence and is not a stimulant. Atomoxetine can be taken with or without food. Patients should have their weight monitored weekly, and healthcare providers should be aware of potential side effects, such as constipation (which can be managed by increasing fiber intake), suicidal ideation, and mood changes.
Cisplatin
Cisplatin is a chemotherapeutic drug used in the treatment of cancer. It can affect the patient's red blood cells, white blood cells, platelets, and kidney function. Healthcare providers should monitor for bone marrow suppression. Common side effects of cisplatin include nausea, vomiting, diarrhea, alopecia, loss or inability to taste food, hiccups, dry mouth, dark urine, decreased sweating, and dry skin.
Tenofovir-Emtricitabine
Tenofovir-emtricitabine is used as pre-exposure prophylaxis (PrEP) for individuals at high risk of HIV infection. When taken daily, it has an efficacy of 96% in preventing HIV transmission.
Kayexalate
Kayexalate is an enema used to excrete potassium and is indicated in the treatment of hyperkalemia.
Classic Side Effects of Antidysrhythmics
The classic side effects of antidysrhythmic medications include dizziness, hypotension, and weakness.
Sevelamer
Sevelamer is a phosphate binder used in chronic kidney disease (CKD) to inhibit phosphorus absorption and allow for an increase in calcium levels. The primary side effect is constipation, which can be managed by taking the medication with meals.
Rescue Medications in Acute Asthma Attacks
The rescue medications used in the management of acute asthma attacks are short-acting beta-2 agonists (e.g., albuterol, salbutamol) and anticholinergics (e.g., ipratropium, tiotropium).
Finasteride
Finasteride is used in the treatment of benign prostatic hyperplasia (BPH) as it reduces the size of the prostate and decreases the risk of urinary retention.
Tolterodine
Tolterodine is an anticholinergic medication used in the management of overactive bladder. It helps to reduce urgency and urinary frequency.
Phenazopyridine (Pyridium)
Phenazopyridine is used to relieve pain, irritation, discomfort, or urgency caused by urinary tract infections, surgery, or any injury to the urinary tract. It causes the urine to turn an orange color.
Midazolam (Versed)
Midazolam is a benzodiazepine used for conscious sedation. Healthcare providers should monitor for respiratory depression and hypotension.
Antabuse/Revia
Antabuse and Revia are aversion therapies used in the treatment of alcohol use disorder. The onset of action is 2 weeks, and patients must abstain from all forms of alcohol for 2 weeks after discontinuation.
Methylergonovine
Methylergonovine is an alkaloid medication used in the management of postpartum hemorrhage. It causes vasoconstriction, which helps to stop the bleeding.
Colfosceril Palmitate
Colfosceril palmitate is a pulmonary surfactant used to treat and prevent respiratory distress syndrome (RDS) in newborns. It is administered via an endotracheal tube in 2-4 doses during the first 1-2 days of life.
Morphine and Breastfeeding
Morphine should not be given to lactating women, as it can be excreted in breast milk.
Nalbuphine Hydrochloride
Nalbuphine hydrochloride is a pain medication used during labor. It crosses the placenta, so healthcare providers should monitor the fetal respiratory rate.
Hypertensive Mothers and Antihypertensive Medications in
Pregnancy
The antihypertensive medications considered safe for use in pregnancy are hydralazine, methyldopa, labetalol, and nifedipine. Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) should be avoided.
Terbutaline
Terbutaline is a tocolytic medication used to stop labor and uterine contractions. Potential side effects include pulmonary edema, so healthcare providers should monitor the patient's breath sounds and heart rate.
Nifedipine
Nifedipine is also a tocolytic medication used to stop labor. Potential side effects include headache and hypotension, but it is considered safe for use in patients with cardiac disease.
Methergine
Methergine is an obstetric medication used to promote vasoconstriction and uterine contraction. An increase in blood pressure is a potential side effect.
Antidotes
Beta-blocker overdose: Glucagon Calcium channel blocker overdose: Insulin, calcium chloride, glucagon Hyperkalemia: Kayexalate, insulin/dextrose, sodium bicarbonate Benzodiazepine overdose: Flumazenil (Romazicon) Cholinergic crisis: Atropine Cyanide poisoning: Hydroxocobalamin Tricyclic antidepressant overdose: Sodium bicarbonate Iron overdose: Deferoxamine Lead poisoning: Chelation agents/succimer
IV Solutions
Hypotonic: 0.45% normal saline, 2.5% dextrose, 1/2 normal saline Isotonic: Lactated Ringer's, 0.9% normal saline Hypertonic: 3% normal saline, 5% dextrose and 0.9% normal saline, 10% dextrose, albumin, dextran
Herbal Supplements
Avoid with CNS depressants: Kava, valerian root Chondroitin, garlic: Increase risk of bleeding with anticoagulants or antiplatelets Licorice: May decrease the effect of spironolactone and warfarin, and increase the effect of digoxin Valerian: May increase the effect of CNS depressants and antihistamines Capsicum: Decrease the effect of antihypertensives Echinacea: Decrease the effect of immunosuppressants Chamomile: Increase the effects of sedatives, risk of bleeding with anticoagulants Glucosamine: May interfere with insulin secretion or increase insulin resistance
Delusions of Reference
Delusions of reference are a false belief that public events or people are directly related to the patient themselves.
Miller-Abbott Tube
The Miller-Abbott tube is used to provide intestinal decompression, such as in cases of paralytic ileus, and removes fluids and gas from the small intestine.
Buerger's Disease
Buerger's disease is characterized by digital sensitivity to cold and intermittent claudication.
Continuous Bladder Irrigation (CBI)
Continuous bladder irrigation is used to prevent the formation of clots.
Meniere's Syndrome
Meniere's syndrome is characterized by vertigo attacks, which can be managed by decreasing head movements.
Hyperphosphatemia
Hyperphosphatemia can be treated with aluminum hydroxide, which binds to phosphates.
Hickman Catheter
A Hickman catheter is placed in the subclavian vein, extending to the superior vena cava and above the right atrium.
Parathyroid Hormone (PTH)
Parathyroid hormone (PTH) has the following effects: - Increases phosphate excretion - Increases catecholamine release, leading to PTH release - Accelerates bone breakdown, releasing calcium into the blood - Hypermagnesemia decreases PTH, and vice versa
Hypoparathyroidism
In hypoparathyroidism, seizure precautions are necessary, and patients should be monitored for tingling, numbness, tetany, and respiratory distress due to hypocalcemia.
Anasarca
Anasarca is a condition characterized by massive, generalized edema, which requires examination of all body surfaces.
Phobias
Ailurophobia: Fear of cats, treated with exposure therapy Social phobia: Fear of social interactions, treated with exposure therapy, antidepressants, and beta blockers Coulrophobia: Fear of clowns, treated with exposure therapy Enochlophobia: Fear of crowds, treated with exposure therapy
Battle Sign
The battle sign is a sign of basilar skull fracture, characterized by raccoon's eyes and hemotympanum.
Brown-Sequard Syndrome (BSS)
Brown-Sequard syndrome is characterized by weakness and loss of proprioception on one side of the body, and loss of temperature sensation on the opposite side. Causes include spinal cord tumor, trauma, tuberculosis, and multiple sclerosis.
Subarachnoid Hemorrhage (SAH)
Subarachnoid hemorrhage is characterized by severe headache, photophobia, nausea, vomiting, and vision changes.
Gastrointestinal X-ray
For a gastrointestinal X-ray, a small amount of contrast medium is used, and the patient must be NPO (nothing by mouth) for 8 hours prior to the procedure.
Gastrointestinal Conditions
Cholecystitis: Episodic, colicky pain in the epigastric area that radiates to the back and shoulder
Negative Pressure Wound Therapy (NPWT): Promotes wound closure and healing, but should not be used on eschar tissue Ante room: For patients with organism precautions Chemotherapy precautions for 48 hours after treatment: Special chemo gloves, gown, eye shield, mask, flush toilet twice, special containment for chemo linens Radiation exposure: Limit to 30 minutes per 8-hour period, visitors must remain 6 feet apart from patients Radioactive iodine precautions: Avoid airplane travel, sleep in separate beds 6 feet apart for 1-11 days, cannot go to work immediately, encourage fluids 2-3 days after treatment Rubeola/measles: Airborne precautions (N95, gown, gloves), door closed, negative pressure, no visitors Rubella: Droplet precautions (gown, gloves, eye shields if needed)
Central Venous Pressure (CVP) Measurement
CVP is measured at the 5th intercostal space in the mid-axillary line with the patient in a supine position no more than 45 degrees. Normal CVP is 2- mmHg. - Increased CVP: Fluid overload, heart failure, positive pressure breathing, straining - Decreased CVP: Hypovolemic shock, dehydration
Fundamental Needs Theory
The Fundamental Needs Theory, as described by Virginia Henderson, outlines the basic needs that must be met for an individual to achieve independence.
Dysphagia, Dysphasia, and Aphasia
Dysphagia: Difficulty swallowing Dysphasia: Difficulty in speech Expressive aphasia: Difficulty finding the right words to communicate
Agnosia and Hemianopsia
Agnosia: Inability to recognize familiar objects, people, or places, but can comprehend safety instructions Hemianopsia: Vision loss in one or both eyes, putting the individual at risk for falls
Intramuscular (IM) Injection in Infants
In infants under 12 months of age, IM injections are given in the vastus lateralis muscle.
Heroin or Narcotic Withdrawals
Heroin or narcotic withdrawals present with symptoms similar to the flu, including: - Runny nose - Yawning - Fever - Muscle/joint pain - Diarrhea
Lyme Disease
Lyme disease is caused by bacteria and presents with redness of the skin at the tick bite site. It is treated with antibiotics such as doxycycline or amoxicillin.
Cystic Fibrosis
Cystic fibrosis is characterized by the following signs and symptoms: - Steatorrhea (but not in newborns) - Meconium ileus - Salty sweat - Hyponatremia - Bilious vomiting - Barrel chest (related to hypoxemia) - Chronic cough - Stool: Large, bulky, greasy, and foul-smelling
The dietary recommendations for cystic fibrosis include a high-fat, high- protein, and water-soluble vitamin (ADEK) diet.
Chest Tube Management
Continuous bubbling in the water seal chamber indicates a leak, which requires checking the location, clamping, and checking for bubbling in the chamber. Tidaling in the water seal chamber is normal, indicating re-expansion of the lungs or obstruction/kink of the chest tube. Gentle/continuous bubbling in the suction control chamber is normal, and the water should be replaced with sterile water. Intermittent bubbling is abnormal. No bubbling in the chest tube drainage collection chamber is normal, as it is connected to the patient.
Rotavirus Transmission and Calf Pain
Rotavirus is transmitted via the fecal-oral route, and contact precautions are used. Calf pain with dorsiflexion of the ankle suggests a deep vein thrombosis (DVT), but it is not a confirmative sign. A Doppler study should be performed to follow up.
Pain Types
Cutaneous or Superficial Pain: Skin or subcutaneous tissue pain, described as "sharp, aching, gnawing, cramping" Visceral Pain: Pain originating from internal organs, described as "tight, pressure, aching, squeezing"
Tyramine-Containing Foods
Foods high in tyramine that should be avoided when taking monoamine oxidase inhibitors (MAOIs) include bananas, sour cream, yogurt, and Italian green beans.
Bulimia Nervosa
Individuals with bulimia nervosa view themselves as overweight, but they are in a healthy weight range. They engage in binge eating and then attempt to remove the calories, leading to erosion of tooth enamel.
Anorexia Nervosa
Anorexia nervosa is characterized by the following signs and symptoms: - Amenorrhea - Bradycardia - Hypotension - Constipation - Muscle weakness - Cold intolerance
Psychologically, individuals with anorexia nervosa are obsessed with what, how much, and when they eat, as well as food and exercise. Binge eating may also occur.
Nitrogen Balance
A negative nitrogen balance indicates the need for more protein intake.
Gastrointestinal Effects of Macronutrients
Protein slows the gastrointestinal tract. Fiber fastens the gastrointestinal tract.
Fat Embolism Syndrome (FES)
Fat embolism syndrome presents with the following signs and symptoms within the first 24-72 hours: - Dyspnea - Tachypnea - Hypoxemia - Altered mental status - Chest pain - Petechial rash of the thorax or mouth
Caution is necessary in pelvic and long bone fractures, and pelvic immobilization is the recommended action.
Vaccinations for Middle-Aged and Elderly
Adults
Influenza and pneumococcal vaccines are recommended for adults aged 50 and older.
Vision Changes
Macular degeneration: Loss of central vision Glaucoma: Peripheral vision loss, better vision in the center
Cardiac Arrhythmia Management
Ventricular fibrillation or ventricular tachycardia without a pulse: Assess ABC's, perform CPR and defibrillation Ventricular fibrillation or ventricular tachycardia with a pulse: Attach EKG or defibrillator, evaluate the rhythm
Antidiuretic Hormone (ADH)
Antidiuretic hormone (ADH) is stored and released by the pituitary gland, and it causes water retention. It plays a role in diabetes insipidus, where low ADH leads to dilute urine.
Syndrome of Inappropriate Antidiuretic
Hormone (SIADH)
SIADH is characterized by the following: - Water retention - Low sodium - Low urine output - Increased urine osmolality - Increased urine specific gravity - Normal or slightly increased blood pressure - Weight gain without peripheral edema
SIADH is diagnosed by the ACTH stimulation test, and the treatment includes adding salt, as well as using glucocorticoids and mineralocorticoids. SIADH is sensitive to stress and infection.
Adrenal Crisis/Insufficiency
Adrenal crisis or insufficiency can occur with trauma, surgery, systemic illness, or abrupt withdrawal of steroid medications. It is characterized by: - Loss of sodium with increased potassium - Reduced blood volume resulting in hypotension, hypoglycemia, tachycardia, dehydration, fever, weakness, and confusion
Streptococcal Pharyngitis
After 24 hours of antibiotic treatment, streptococcal pharyngitis is no longer contagious.
