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PHARM FINAL REVIEW

NO DOSING
-H/A TX OF choice and SE. Adjunct therapy for migraines, desirable SE's
Migraine DOC: Triptans: serotonin agonists, keep vessels constricted
SEs: Tingling, warmth, flushing, chest discomfort, sensation of pressure, dizziness
Adjunct for migraines: TCAs, Antiepileptic drugs, BB, CCB, Antipsychotics, Botox
Desirable SEs: TCAs depression, Zonegran & Topamax wt loss
-ER lecture, when to use Narcan, when not to use. Asthma tx, narcotics
and heart meds out of ER Allergic reaction DOC.
Narcan (naloxone): Opiate OD tx, may repeat every 2-3 min
Contraindications: ?
Asthma tx: Albuterol, Ipatropium Bromide/Albuterol (Duo-Neb), Prednisone/ SoluMedrol, Epi if status
asmaticus
ER heart meds:
AMI ASA, NTG, BB, Morphine, Thrombolytics, O2, Integrelin, Plavix
CHF O2, NTG, Lasix, Morphine
Allergic Reaction: Benadryl (antihistamine H1 antagonist, prednisone, SoluMedrol, Pepcid
If anaphylaxis add Epi
-Prescriptions, what goes on and what doesn't, who can sign, drug codes, what do you need DEA
license for
Prescriptions:
Components:
Patients full name and address
Prescribers full name, address, telephone number, DEA # and license number
Supervising physicians name, and DEA #
Date of issuance
Signature of Prescriber
Drug name, dose, dosage form, amount
Route of administration
Length of therapy
Quantity of Drug
Refill Instructions
Who can sign???
Rx Codes:
A: Panic Disorder
B: Attention Deficit Disorder
C: Chronic debilitating neurological conditions characterized as a movement disorder or exhibiting
seizure, convulsive or spasm activity
D: Relief of pain in patients suffering from conditions or diseases known to be chronic or incurable
E: Narcolepsy
F: Hormone deficiency states in males; gynecologic conditions that are responsive with anabolic
steroids or chorionic gonadotropin; metastatic breast cancer in women; anemia and angioedema
Need a DEA license to prescribe controlled substances

-APAP vs. ASA vs. NSAID. Pros, cons, who should take what
ASA: gold standard NSAID
MOA: inhibits prostaglandin synthesis and platelet synthesis
Indication: pain, inflam, fever, cadioprotection
Contraindications: Children under 15 w/ viral infection (Reyes) preg/lactation, bleeding d/o
AEs: hemorrhage, anemia, kids, stomach damage, hepatotoxicity
Acetaminophen:
MOA: Inhibits prostaglandins
Indication: pain of non-visceral origin, fever
Contraindication: liver dz, alcohol use
AEs: hepatotoxicity
NSAIDS:
MOA: inhibits prostaglandin synthesis and platelet synthesis
Indication: pain of non-visceral origin, fever, inflam, dysmenorrhea
Contraindications: Heart failure, HTN, impaired renal or liver fxn, asthma
AEs: dyspepsia, anorexia, fluid retention
-PID outpatient drug choices, when do they have to be hospitalized?
Ceftriaxone 250mg IM x 1 + Doxycycline 100mg PO BID x 14 days +/- Metronidazole 500mg PO
BID x 14days (Treats BV which is frequently associated with PID)
Recheck patient in 24-48hrs, if no improvement, admit to hospital for inpt tx
Hospitalized:
Pts who do not respond clinically to oral antibiotics
Pts unable to follow oral regimen
Pt has severe illness, nausea, vomiting or with high fever
Surgical emergencies (ex: appendicitis) cannot be excluded
Pt has tubo ovarian abscess
-When do you use lomotil, colace
Lomotil antidiarrheal
Colace constipation (stool softener)
-Pt. having endoscopy what are you concerned about with non-esophageal varices
Esophageal varices can be treated with Nadolol & Octriotide
-Who gets drug holiday and why in peds.
ADHD tx of stimulants sometimes use holidays to catch up growth over summer vacation
-PPIs how do they work, who gets them, considerations if on blood thinners, SEs that we're
concerned about (long range issues)
MOA: inhibit final step of gastric secretion
Drug interaction with Plavix
Long term use linked with increased rick of bone fx and decreased vit B12 levels
-What drugs cause black tongue
Pepto Bismol (Bismuth Salicylate), antimuscarinics for urge incontinence

-ED who gets what and who cannot get that med
Dx made by H&P, rule out reversible causes (meds), evaluate psych/emotional
PDE5 inhibitors inhibit PDE5 leads to smooth muscle relaxation and inflow into corpus cavernosum
Viagra, Cialis, Levitra
NITRATES = NO!!!
-Urine dip and there's blood, what does that tell you about a UTI? Any meds that affect color of
urine
Blood alone is not specific for UTI
Nitrofurantoin (Macrobid, Macrodantin) cause very yellow to orange tinge
-Which POs cover MRSA
Bactrim, Clindamycin, Tetracyclines
-Contraceptives most/least reliable, what to do if you miss a pill
Least reliable OTCs like male/female condoms, diaphragms, caps, etc.
Most reliable IUDs (being promoted first line), COCs
1 Pill : Take as soon as remembered, take next at regularly scheduled time
No back up
2 pills in a row
( week 1 or 2): take 2 on day remembered
Take 2 at regularly scheduled time next day
Back up x 1 week
2 pills in a row wk 3 or three pills in a row at any time : discard pack, start new pack same day
Back up x 1 week

-What OTCs do you worry about in elderly. What drugs are behind counter due to abuse?
Worry about anticholinergics, certain antihistamines (Benadryl, Tylenol PM), PSE
PSE now behind counter due to abuse (YAY FOR METH)
-What covers gonorrhea, chylmadia
Chlamydia Azithro or Doxy (Erythro if preggo)
Gonorrhea Ceftriaxone IM + Azithro OR Doxy alone (remember to always treat for chlamydia too)
-Barriers to pain management in elderly and standard of care. Use of topical compound for pain
Blunted response, cognition, communication, cultural & social, co-morbidities/multiple meds, lack of
provider training and access to tools, misdiagnosis, fear
Topicals great for pain, localized response (NO systemic), no affect on renal/liver, very low abuse
potential. EX: Voltaren, Lidoderm
-HRT greatest reasons for it and risks. Why do people stop taking it?
For moderate-severe menopausal symptoms (vasomotor sx, hot flashes, atrophic vaginitis). Reevaluate
every 3-6 months. Lowest dose for shortest time. Also good for osteoporosis proph. ONLY in women
who cant take bisphosphonates.
Risk of DVT, endometrial/ breast cancer.
Greatest reason for discontinuation is withdrawal bleeding
-Ulcerative colitis and Chrons take heavier drugs to surpress whats the screening
Common drugs are Aminosalicylates (Mesalamine, Asacol, Pentasa, Colazol)
Heavier are Immunomodulators & Thiopurines (Imuran Azothiopurine) Need routine CBC and CMP
due to myelosuppresion, mainly neutropenia. Also monitor metabolite levels of drug and LFTs.
Can also use Anti-TNF (Remicade, Humira, Cimizia) Prior to starting treatment, must place a PPD, and
rule out exposure to TB that could be reactivated with treatment

Also must check for hepatitis B


-H. Pylori what drugs help in mono/double therapy
Try PPI trial first
Triple therapy- 2 abx + PPI (7-14 days, but 14 is recommended)
Claritho + Amox (Flagyl if pen allergic) + Omeprazole/Lansoprazole/Pantoprazole
Quadruple therapy- 2 abx + PPI + bismuth (14 days)
Flagyl + Tetra/Amox/Claritho + Omeprazole/Lansoprazole/Pantoprazole + Bismuth subsalicylate
AntacidsRapid onset but short acting (neutralize acid)
Ca2+ carbonate (Tums/Rolaids)
Maalox/Mylanta
Milk of Magnesia
Sodium bicarbonate (baking soda)
PPIsMost effective tx for short & long term tx of GERD
Long term use increased risk of bone fx and decreased vitamin B12 levels
Omeprazole (Prilosec)- purple pill
Lansoprazole (Prevacid)- good for peds (solu-tab)
Pantoprazole (Protonix)- safe choice for pts on Plavix
H2RAsCimetidine (Tagamet)- less effective for healing erosive gastric ulcers
Famotidine (Pepcid)- no drug interactions
Ranitidine (Zantac)- can be used with a PPI
Metclopramide (Reglan)Indicated for gastroparesis (this drug increases gastric motility)
***BBW- tardive dyskinesia

-Prostate cancer what drug can you give for BPH. Dosing at certain times, why?

Overflow incontinence leak urine all day long; patient may need a catheter due to
urinary retention
Bethanechol (Urecholine)Only med for chronic urinary retention; increases bladder tone
Alpha blockers***1st line for BPH
Dosed qhs due to postural HoTN
Terazosin (Hytrin)>Doxazosin (Cardura)
Selective alpha blockers- (less HoTN)
Fosamax (Tamsulosin)
Uroxatral (Afluzosin)
5-alpha reductase inhibitorsFinasteride (Proscar)- can actually modify BPH; preg cat X
Avodart (Dutasteride)- more potent and more selective; preg cat X

Non-steroidal anti androgen- Flutamide (Eulexin)- for prostate cancer; blocks


uptake/binding of DHT
-Who gets topical estrogen and why

Give topical estrogen to patients with atrophic vaginitis. Less systemic effects, helps
with vaginal dryness and itching.
Also for stress incontinence, boosts urethral mucosa
- ADHD what drugs 1st line, SE's, cautions
Combination therapy is best (behavioral and medicinal)

Stimulants- gold standard***; controlled substances; stimulate release of dopamine


and norepi; take prn; avoid in pts with underlying cardiac issues
S/Es: Insomnia, decreased appetite and weight loss, growth suppression, increased BP,
tachycardia, sudden unexplained death, depressed mood, agitation, and moodiness
Methylphenidate HCL
Ritalin
Daytrana- transdermal patch
Adderall- longer acting
Metadate CD- capsule that can be opened and sprinkled on food
Vyanase- smoother delivery system, no crashing
-Overactive bladder, what meds?

Urge incontinence strong and sudden desire to void due to detrusor hyperreflexia
Antimuscarinics- ***1st line, smooth muscle relaxants
S/Es: dry mouth, urinary retention, and black tongue
Caution: glaucoma, BPH
Non-selective Oxybutnin (Ditropan)- prescribe this 1st, Detrol LA (Tolterodine)
Selective (less s/es) Enablex, Sanctura, Vesicare, Toviaz
Beta-3 adrenergic agonist- Mybetriq (Mirabegron)
Relaxes bladder; no anticholinergic effects; can give to glaucoma patients
-Asymptomatic bacturia whats the approach? What if pregnant?

Large numbers of bacteria present in the urine, but the patient has no symptoms; does
not usually require treatment
Exception: ALWAYS treat pregnant women due to increased risk premature delivery
Nitrofurantoin (Macrobid, Macrodantin)Preg cat B
Orange discoloration of urine
-How to write a medication, when to put 0's etc.

Components:
a. Patients full name and address
b. Prescribers full name, address, telephone #, DEA #, and license #

c.
d.
e.
f.
g.
h.
i.
j.

Supervising physicians name, and DEA #


Date of issuance
Signature of provider
Drug name, dose, dosage form, amount
Route of administration
Length of therapy
Quantity of drug
Refill instructions

Zero rules:
Never use trailing zeros: 5 ml not 5.0 ml
Always use a zero prefix: 0.5 ml not .5 ml
Always use ml, not cc
Codes that allow you to prescribe controlled substances for more than 30 days:

ABCDEF-

Panic disorder
Attention deficit disorder
Chronic neurological conditions (movement disorders, seizures)
Relief of chronic/incurable pain
Narcolepsy
Hormone deficiency, metastatic breast cancer, anemia, angioedema

-Tx for herpes. Suppression therapy?

Acyclovir***, Famciclovir, or Valacylovir


MOA: stops replication of herpes viral DNA
Suppressive tx: if patient has > 6 episodes/year; take antiviral everyday for 1 year,
d/c, then reassess
-Pertussis DOC and recommendation for quarantine
Macrolides (1st line)- azithromycin, clarithromycin, and erythromycin

Treat persons >1 y/o within 3 weeks of cough onset


Treat infants <1 y/o and pregnant women within 6 weeks of cough onset
Administer a course of abx to close contacts within 3 weeks of exposure
Isolation for 5 days from start of abx due to contagiousness
-H/A in ER, how to treat cluster HA
O2 for cluster HA
-OTC, what's biggest issue from provider perspective when patients buy, consult pt.
Potential drug-drug or drug-disease interactions with OTC meds. Side effects. Getting a thorough
Hx of OTC use (meds may be the reason for the chief complaint). Knowing what OTC meds will
help the specific symptom being described

-Dysmenorrhea 1st and 2nd line tx


1st line: NSAIDS (ibuprofen). 2nd line: Oral contraceptives
-Prostatitis, S/S and tx

Dysuria, hematuria, urinary incontinence (frequency), bladder pressure, fever, chills, fatigue. Tx:
Flouroquiolones (Cipro, Levo) for 21 days.

-Dif. types of pain, what are they, how do they present, and tx
Acute: <3-6 months (trauma, surgery), chronic: persisting longer than the normal course of time
associated with a particular injury (MS, neuropathy, vascular, cancer). Nociceptive pain: from nerves
that respond to damage. Well localized, constant, throbbing, time limited, responds well to opioids.
Neuropathic pain: from injury in PNS or CNS. May or may not involve actual damage. Burning,
lancinating, electric shock qualities. Allodynia (pain out of proportion), more often chronic. Less
responsive to opioids.
-Tx of gout thats not OTC
Indomethacin, colchicine, steroids. Preventative: Allopurinol (limits uric acid prod.), Probenecid
(helps kidney remove uric acid).
-Drugs to tx diarrhea
Lomotil (diphenoxylate + Atropine sulfate) is an (opioid + anticholinergic), TCA antidepressants.
-Opioids, who gets, how to prescribe, SEs from mild to bad
given to pts with acute moderate/severe to chronic pain. Prescribing opioids requires a DEA
license and consistent updating of opioid prescriptions on the Prescription Monitoring Program
(PMS) as a part of the I-STOP program. This controls the amount of over-prescribing to
patients and limits the amount addicts can acquire. SE: drowsiness, sedation, nausea. Pupil
constriction, constipation, urinary retention. Most deadly SE is respiratory depression, which
can be counteracted with naloxone (opioid antagonist).
-Nicotine replacement, whats available, how does it work, does it work?
Works by decreasing withdrawal symptoms (anxiety, irritability, depression etc.) Available in patches,
gum, lozenge OTC. / Patches, nasal spray, inhaler by Rx only. NRT is only affective if the smoker
truly wants to quit. It is a slow step-down approach when quitting with NRT, dedication is essential.
-1st line for Parkinsons and what meds work together in Parkinsons
-Gold Standard Levodopa, combined with Carbidopa for Sinemet (First line)
-COMT inhibitors also combined (Entacapone (Comtan), Tolcapone (Tasmar)
Stelevo: Carbidopa/Levodopa/Entacapone
-Selegiline (MAOB-I) can delay need for L-dopa by 9 months
-Dopamine agonists (Mirapex, Requip) Mono or add on
(FYI: Greys anatomy says these are first line too)
-Peds: AOM, strep, recurrent AOM
- AOM: 1st line- Amoxicillin (A Mac or sulfa if allergic), 2nd line-Augmentin
-Chronic AOM (3 or more in 6 months, 4 in 1 yr.) prophylactic
amoxicillin or Bactrim, ENT for possible BMT
- Strep: 1st line: Amoxicillin (Azithromycin or 1st gen. ceph. if allergic)
-AVOID flouroquinolones (<18 y/o) and Tetracyclines (<8)
-Who gets Rocephin and why
Rocephin (3rd den cephalosporin)-Typically given IM (Cat. B)
-Used for Gonorrhea, PID, and bacterial meningitis
-Used in peds if oral abx cant be taken or in cases of epiglottitis

-Whats abuse? Polypharmacy? Formulary


Overuse (Polypharmacy)- many pts > 65 (40% 5 to 9 meds and 18% take > 10)
-Formulary- a list of prescription drugs, both generic and brand name, used by
practitioners to identify drugs that offer the greatest overall value.
-1st line for memory loss
1st line: Acetylcholinesterase Inhibitors
-Aricept (tablet), Exelon (capsule or patch), Razadyne (capsule)
-SLUDGE S/Es (Sialorrhea, Lacrimation, Urination, Defecation, GI, Emesis)
-NMDA receptor antagonists 2nd line (Namenda/Memantine)
- Tx of ADHD, what meds are available that are non-controlled
Gold Standard is stimulant meds (release dopamine and norepinephrine)
-Adderall, Ritalin, Daytrana (patch), Concerta, Vyvanse (New, smoother)
-Non-stimulants (not controlled):
Straterra (SNRI): take daily, no holidays, dosed by weight
Intuniv S/Es of fatigue and HA at the start of taking med
Kapvay if also a sleep disorder
- Why do you use gardasil
if youre a male or female age 9-26, why not? Ya know?
- Against HPV types 6, 11, 16, and 18
- 6, 11: cause genital warts
- 16, 18 cause cervical cancer
-Abx that aren't appropriate for peds
AVOID flouroquinolones (<18 y/o) and Tetracyclines (<8)
-BBW for non abx
Metclopramide (Reglan) prokinetic for Gastroparesis, GERD, N/V
BBW: Tardive Dyskinesia
- Antipsychotics in elderly BBW for increased risk of death
- NSAIDs in eldery BBW for cardiovascular risk
-What causes tardive dyskinesia
Reglan, Compazine; anti-emetics
-Tx non obstructive urinary retention
OVERFLOW
-Bethanechol (only med for chronic urinary retention)
-Milk of Mg, whats it for who doesnt get it
-An antacid; reduces acidity of gastric juices; useful for GERD
-caution in pts with renal dz (cant clear Mg)
-Meds for overactive bladder, new unique drug class
Antimuscarinics (Oxybutinin black tongue!!)
-NEW class: Beta 3 adrenergic agonist (Myrbetriq- safe for glaucoma, no anti cholinergic
effects)

-Tx uncomplicated UTIs, time frame?


1st line = Bactrim (3 days)
((DOC for pregnancy= Nitrofurantoin (Macrobid/Macrodantin) 7 days but female pregnant pts
are complicated))
-In elderly, med for sleep with caution for use
Ambien ->lower recommended dose due to next morning impairment (ie driving)
-falls, fxs and delirium too
-Syphilis, DOC, possible reaction
-Benzathine PCN G
-rxn = Jarisch Herxheimer rxn (acute, febrile rxn) HA, myalgias 1st 24hrs after txt (usually
early syph)
-Antifreeze antidote
Fomepizole or ethanol
-Benzo antagonist in ER
-Flumazenil
-In elderly whats up with gastric issues? Faster,slower, etc
-delayed gastric emptying
-decreased GI motility
-decreased gastric acid production (relative achlorhydria)