NAPLEX SECRET 2015 Choose calcium gluconate over chloride bc it dissociates

less and less chance of binding to phosphate and

Calculations: precipitating

ung-ointment WA-while awake mEq : Electrical charges provided per mole

PR-per rectum BM-bowel movement mOsmol/L = {(g/L)/(g/mole)} x ( # of particles it splits up into)

x 1000
1 pint= 473 ml 1 quart = 946 ml
Isotonicity (osmolarity in body fluids, when we want to make
1 gallon = 3785 ml 1 pound = 454 g
something isotonic to blood): E Value
Percentage Strength: g/100ml (w/v); ml/100ml (v/v) ;
First find out how much NaCl would make it isotonic.
g/100g (w/w)
0.9g/100ml = X g/X mL
Ratio Strength: (1:X) ex. 0.04% = 0.04g/100ml = 1g/2500ml E= sodium chloride equivalents of a drug = (58.5 x i) /
= 1:2500 **Put in grams (MW of drug x 1.8) *i = dissociation factor of drug
example: if calculated E value is 0.23 and you have 0.4g
PPM: (parts of drug/1,000,000) parts of whole ex.
of drug, this represents 0.4g x .23 = 0.092 g NaCl
0.00022g/100ml = 2.2g/1,000,000 = 2.2PPM
Then subtract them from each other.
BMI: (kg/m2) *2.54cm/inch <18.5 = Underweight, 18.5-24.9
Fahrenheit = (C x 1.8) +32
= normal 25-29.9=overweight >30 =obese
pH = pka + log (salt/acid) For Acids
IBW: Male: 50+2.3 (inches above 5 feet) Female: 45.5 +
2.3(inches > 5 feet) pH = 14 pKb + log (base/salt) For Bases
Adjusted BW: IBW + 0.4(TBW-IBW) eAG: (28.7 x A1C) 46.7
CrCl: { (140-age) x weight }/SCr x72 Multiply by 0.85 for Calcium Carbonate: 40% elemental calcium Calcium Citrate:
females 21% elemental calcium
Dilutions: (Changing a strength or quantity) Q1 * C1 = Q2 * C2 Absolute Neutrophil Count: WBC x ((%segs+%bands)/100)
Alligation: (Combining two strengths to get a strength in Anion Gap: Na+-Cl-HCO3- *>12 is high (gapped)
between) **Watch for ADD TO
Minimum Weighable Quantity (MWQ) : SR/error
2+
**Corrected Calcium: Ca (from lab) + {(4-albumin)
Absolute Bioavailability: F = (AUCextravascular x Doseintravenous)/
x(0.8)}
(AUCintravenous x Doseextravascular)
** Phenytoin correction= PHT measured/{(0.2x Alb) +
0.1} IV Bolus VD= Dose/Co or Co = Dose/VD
Oral VD= (Dose x F) /(ke xAUC) Cl=(Dose x F)/AUC
Cl=ke x VD
1
ke= {ln(Cmax/Cmin)}/ Time interval
Enteral/Parental Nutrition:
Carbs: Enteral (4kcal/gram) Parenteral (Dextrose 3.4
kcal/gram)
Protein: (4kcal/gram)
Fat: Enteral (9kcal/gram) Parenteral IVFE (10% - 1.1 kcal/ml,
20% - 2kcal/ml, 30% -3kcal/ml) *often weekly and might have
to divide by 7 for daily
TEE = BEE x activity factor x stress factor *usually doesnt
use protein calories
BEE estimate: 15-25kcal/kg (adults)
Daily Fluid Needs: 1500mL + (20mL)(Kg-20)
Nitrogen Intake: grams of protein intake/6.25
Compounding:
Emulsifiers/ Surfactants: Tween (polysorbate), Myrj, Arlacel,
Span, PEG, acacia, sodium laurel sulfate, glyceryl monostearate
Thickeners: Agar, carrageenan, gelatin, sorbitol
Suspending Agents: acacia, alginic acid, gelatin, gums,
methylcellulose, bentonite
Levigation/Wetting Agents for creams and ointments: *must
be compatible with base
Aqueous (O/W): glycerin, propylene glycol, PEG 80
Oleaginous (W/O): Mineral Oil, Castor Oil, Cottonseed Oil,
Tween
2
Collagenase Ointments are for debridement of skin wounds.
Benzyl Alcohol used as a solvent and antimicrobial.
Statistics:
Type 1 Error: Say theres a difference when there is not; The
null hypothesis is true, but is rejected in error. (P-value or alpha
is the chance of a type 1 error). P-value is the probability that
the result obtained was due to chance. P <0.05 = less than 5%
probability it was due to chance.
95% CI means there is a 95% chance that the interval contains
the true population mean.
Type 2 Error: Say theres no difference when there is; The null
hypothesis is false, but is accepted in error.
RR= risk in tx/risk in control
RRR = 1-RR
ARR= Risk in control Risk in tx
NNT (Number Needed to Treat): 1/ARR (decimal, not %)
Cost-Effectiveness analysis How effective the tx was for what
it was supposed to do
Cost-Minimization analysis two drugs health benefits are
equal, just want to find which is cheaper
Cost-Benefit Analysis Outcome in dollars (monetary)
Cost-Utility Analysis Includes Quality of Life variables
Case-Control: Have a disease and look back for risk factors
Cohort: Prospective or Retrospective. Starts with risk
factors to see if they get a disease.
Cross-Sectional: Looks at a specific point in time.
RCT: interventional
Meta-Analysis: Combining many RCTs and drawing a
conclusion
Pharmacogenomics:
- 2D6 ultra rapid metabolizers have increased risk of Codeine
Morphine toxicity
-HLA-B*1502 (mainly Asians) on carbamazepine: 5-10%
chance of SJS with carbamazepine
-SLCO1B1 Polymorphism - statin myopathy increased
-HER2/Neu Oncogene needed for Herceptin (trastuzumab)
and Kadcyla (ado-trastuzumab) to work
-Warfarin 2C9*2 and 2C9*3 and VKORC1 (A haplotype)
require lower doses or they will bleed (Homozygous for
*3 is has greatest risk of bleeding)
-HLA-B*5701: If positive for this, do not give Abacavir
(Ziagen)
-2C19: Clopidogrel is a prodrug and needs this enzyme
to convert to active form
-Selzentry (Maraviroc) must be CCR5 positive only to receive
drug
Drug Allergies/ADRs
-Naranjo scale is used to help pharmacists determine if the
drug caused the ADR.
3
-Severe Skin Rashes (SJS, TEN, DRESS, TTP) - Stop the offending
agent *corticosteroids CI in TEN
-Stomach upset/Nausea from a drug not a true allergy, it is an
intolerance
- Niacin and Statins taken together have an increased
risk of muscle toxicity.
-Photosensitivity: Sulfa Antibiotics, Tetracyclines,
Fluoroquinolones, Diuretics, Flagyl, Tacrolimus, Cyclosporine,
NSAIDs, voriconazole, methotrexate.
-Penicillins: Allergic to one presumes allergic to all. Small risk
for cephalosporin and carbapenem cross reaction but should
still avoid on the exam.
-Sulfa/Sulfonamides Mostly with sulfamethoxazole (Bactrim,
Septra) but should also avoid sulfapyridine, sulfadiazine, and
sulfisoxazole. **For exam also avoid loop diuretics,
thiazide diuretics, sulfonylureas, acetazolamide,
zonisamide, and celocoxib), darunavir (Prezista). There is
no cross-reactivity with sulfites or sulfates.
-Morphine type opioid allergies do not cross react with
Fentanyl (Duragesic), meperidine (Demerol), or methadone
(Dolophine).
-Peanuts and soy are in the same family and can have cross
reactivity. Soy is in some medications:
clevidipine (Cleviprex), propofol (Diprovan), and
progesterone in (Prometrium)
-If allergic to eggs avoid:
clevidipine (Cleviprex), propofol (Diprovan), Influenza
vaccine (**Flublok is ok)
-True Drug Allergies/Anaphylaxis (Mediated by IgE and
Histamine release):
 Swelling, possible hives, bronchoconstriction, low blood
pressure
Tx with epinephrine (Epipen, Epipen Jr., Adrenaclick,
Auvi-Q) and diphenhydramine (25mgx2) *rub the area
after injection *epinephrine is used when they have
trouble breathing
Medication Errors and Patient Safety
-Medication errors are preventable events that may cause or
lead to inappropriate medication use or patient harm. *It is not
an adverse drug reaction (ADR).
-The most common medication error is wrong drug or
dose to patient.
-Root-Cause Analysis (RCA) is done retrospectively to see
what led to a sentinel event. Failure Mode and Effects
Analysis (FMEA) is done prospectively to see what potential
could lead to a problem.
-Error of Omission is leaving something out that is needed for
safety. Error of Commission is when something was done
incorrectly.
-Medication reconciliation is updating the patients
medication list. It should be done at every transition of care.
4
-REMS is an FDA program that requires specific training and
requirements for certain meds ex: clozapine, isotretinoin
(iPLEDGE), erythropoietin in oncology (APPRISE). Goal is to
make sure the benefits of the drug outweigh the risks.
-Medication guides are FDA-approved printed handouts for
over 300 medications that that tell patients of important
adverse events and should be dispensed every time. Can
be part of REMS.
-Tall man letters can be used for look-alike sound-alike drugs.
ex. celeXA and celeBREX
-Use As Directed is not acceptable
- Alcohol has poor activity against spores like C. Difficile. Use
soap and water to wash hands when in contact.
-Contact precautions for patients colonized with MRSA and VRE.
Airborne precautions for patients with measles, varicella
(chickenpox), and Tuberculosis.
-Barcoding is great and helps prevent errors
FDA Drug Approval/Bioequivalence:
New Drug Approval:
1. Pre-Clinical Animal Research
2. IND-Investigational New Drug
Phase 1- Asses safety/PK/PD parameters with low
doses in 20-80 healthy people
Phase 2- Safety and Efficacy in 100-300 people
with indication
Phase 3- Confirm previous studies in 100s-
1000s of people with the indication at the
dose youre seeking approval.
 3. NDA Submitted Either Approved, Rejected, or further
studies requested
Phase 4 Post-marketing studies after NDA
approval
*For changes to an existing drug they can submit a
Supplemental New Drug Application (sNDA) ex. Label, Dose,
Strength, Manufacturing Process, and Indication Changes
* Abbreviated NDA for generic approval
Orange Book On Bioequivalence:
AB- Therapeutically equivalent and can be interchanged
(brand to generic)
Drugs with a 3-character code under a heading are
considered therapeutically equivalent only to other drugs
with the same 3-character code under that heading.
Example AB1, AB2, AB3
Natural Products/Vitamins:
(They do not have to prove to be safe and effective)
*Many natural products can be hepatotoxic and elevate
liver enzymes (ex. Kava Kava)
- Ginkgo can increase bleeding with no change in INR. Other
that can also do this are garlic, Vitamin E, fish oils, and
ginseng.
5
- St. Johns Wort for depression is an inducer, serotonergic,
and can cause photosensitivity.
- Saw Palmetto used for BPH
- Ginger for nausea/motion sickness
- Tea Tree Oil for acne
- Lysine for canker sores
- Melatonin for insomnia and jet lag
- Black Cohosh, Estroven (black cohosh + soy), and Red
Clover for menopausal symptoms
- Cranberry can be used for UTI prevention but can increase
risk of kidney stones.
- Folic Acid (B9) started 1 month before pregnancy. 400-
800mcg daily.
- Pyridoxime (B6) supplemented in Tuberculosis treatments
that have Isoniazid in them
- Thiamine(B1) deficiency can cause Wernickes
encephalopathy.
- Niacin (B3) deficiency causes pellagra
- Vitamin C deficiency can cause scurvy
-Vitamin E should not exceed 150 IU/day
- L-Arginine can have hypotensive effects, its a precursor
to NO.
- Iron: Breast-fed babies need 1mg/kg/day from 4-6 months old
and anemic patients may need supplementation too (ex. Renal
problems or menstruating females)
- Probiotics: If taking antibiotics, dont take the probiotic at
the same time of day as the antibiotic
- Echinacea, zinc, elderberry, garlic, vitamin C- used for
colds/flu. Zinc can cause loss of smell.
- Adequate Calcium and Vitamin D needed for low bone
density, pregnancy (fetus depletes stores), menopause,
children, and men who take steroids or androgen blockers.
Calcium absorption is saturable so doses should be
divided.
1000mg/day for women 19-50 and 1200mg/day
for>50
Citracal (calcium citrate) preferred in low acid
environments (ex. with H2 blocker and PPI use). Can be
taken with or without food. (21% Elemental)
Oscal, Tums (calcium carbonate) has acid-
dependent absorption, take with food. Smaller
pills than the Citracal and provide more elemental
calcium. (40% Elemental)
Vitamin D: 600IU daily for <70, 800IU daily for
>70 (cholecalciferol (D3) is the preferred source).
Poly Vi Sol multivitamin contains Vit D and is easy for
infants to take. Breast-fed babies or formula fed babies
who drink less than 1 liter/day need 400IUs Vit D.
Drug Interactions:
Inducers (slow to have this effect): carbamazepine
(Tegetrol), phenytoin (Dilantin), Oxcarbazepine
(Trileptal), smoking, rifampin, St. Johns Wort,
phenobarbital, efavirenz (3A4)
6
Inhibitors (fast to have this effect): Azole Antifungals,
Macrolides (clarithromycin and erythromycin), cimetidine,
amiodarone, valproate, non-DHP Ca2+ Blockers (diltiazem
and verapamil), protease inhibitors (lopinavir, ritonavir,
etc..), grapefruit, cyclosporine.
Fluoxetine (Prozac,Sarafem) , Duloxetine (Cymbalta),
and Paroxetine (Paxil) are 2D6 inhibitors. (Watch with
certain opioids like tramadol, hydrocodone, and
codeine(prodrug))
**SMX/TMP is a 2C9 inhibitor so caution with warfarin.
Oxycodone and Methadone are metabolized by 3A4 (watch
for inducer and inhibitors)
Amiodarone use Decrease Digoxin and Warfarin dose by
30-50%. Also use lower doses of Simvastatin, Atorvastatin, and
Lovastatin.
Digoxin: Watch for renal dysfunction, hypokalemia, and
additive heart rate lowering drugs such as Beta Blockers, non-
DHP calcium channel blockers, amiodarone, Precedex,
clonidine, and opioids.
Grapefruit: 3A4 inhibitor increased SAL statins (rhabdo),
increased bleeding risk with rivaroxaban and ticagrelor,
increased levels of calcineurin inhibitors (tacrolimus and
cyclosporine).
Valproate: used with lamotrigine (Lamictal) can increase
lamotrigine levels and cause a severe rash
MAOi: do not use with SSRI, SNRI, TCAs, bupropion,
buspirone, tramadol, muscle relaxants, triptans, St. Johns
Wort, ephedrine/pseudoephedrine, epi, norepi, dopamine,
meperidine (meperidine blocks serotonin reuptake), linezolid
(Zyvox) etc
Serotonin Syndrome: Tremor, Agitation, Confusion,
Hallucination, Diarrhea, Muscle rigidity, Shivering, Tachycardia,
Sweating, Hyperthermia
Chelation: Tetracyclines and quinolones can chelate so
separated from Al, Ca, Mg, Fe compounds, including dairy.
Bleeding Risk: SNRI, SSRI, NSAIDS, Ginkgo, fish oil,
garlic, grapefruit
*Wellbutrin (Bupropion) Doesnt affect 5HT so doesnt
increase bleeding risk
Hyperkalemia: ACEi, ARB, amiloride, triamterene,
epleronone (Inspra), spironolactone (Aldactone), KCl,
tacrolimus(Prograf), cyclosporine (Neoral), trimethoprim,
canagliflozin (Invokana), drospirenone (Yasmin)
Ototoxicity: salicylates, vancomycin, aminoglycosides,
cisplatin, loop diuretics
QT Prolongation: Quinolones, Macrolides, Methadone, -The level of Albumin in urine can gauge the severity of kidney
TCAs, Some SSRIs (Citalopram and Paroxetine), Azole damage. (Micro and Macroalbuminuria)
antifungals, SMX/TMP, some Protease Inhibitors
- Serum Creatinine (SCr) is used as a marker of renal function
Renal Disease and Dosing Considerations: - BUN increases in renal impairment but not used alone as a
marker b/c it can increase for other reasons such as
dehydration.
-Loop Diuretics inhibit Na+/K+ pump in ascending limb of loop of
Henle
-Thiazide Diuretics inhibit Na+/Cl- pump in the distal tubule
-Aldosterone antagonists/ Potassium Sparing Diuretics work in
the collecting duct
- The goal BP in CKD is <140/90
- ACEis and ARBs are reno-protective in that they slow
down the progression of nephropathy in diabetic and non-
diabetics with proteinuria.

7
- ACEis and ARBs can cause a 30% rise in SCr and is not
a reason to stop therapy. If >30% then it should be
discontinued. SCr and K+ should be monitored 1-2 weeks
after initiating.
-Hyperphosphatemia:
1. Restrict Dietary Phosphate
2. Phosphate Binders: Bind Meal-time phosphate in the gut
from the diet so only take them with meals. ****They dont
work if taken after a meal.
Aluminum based (Alternagel)- can accumulate and is
toxic so not used much
Calcium based First line therapy. Calcium acetate
**(Phoslo, Phoslyra) or Calcium carbonate (Tums)
*Can cause hypercalcemia
Aluminum Free, Calcium Free Expensive
o **lanthanum(Fosrenol) - must be chewed thoroughly.
o **sevelamer(Renvela/Renagel). added benefit of
lowering LDL
-Secondary Hyperparathyroidism: Calcitriol (Rocaltrol) is
given to CKD patients with secondary hyperparathyroidism
to inhibit PTH secretion . It is the active form of Vitamin D3.
doxercalciferol (Hectoral) and paricalcitol(Zemplar)
are newer active VitD drugs with less
hypercalcemia.
cinacalcet (Sensipar) calcimimetic to increase
sensitivity to calcium and decrease PTH.
-Vitamin D deficiency: Cholecalciferol (D3) and
Ergocalciferol (D2)
8
-Hyperkalemia: Usually from renal failure and/or drugs that
increase K+. Muscle weakness, bradycardia, chest pain,
paresthesias and fatal arrhythmias may occur.
Treatment:
IV Calcium to stabilize the cardiac tissue
Glucose and Insulin to drive K+ into cells
sodium polystyrene sulfonate (Kayexelate) is a
cation exchange resin given orally or rectally. Rectal
preferred in emergency situations. Side Effects: Nausea,
Vomiting, Constipation, Loss of Appetite.
Loop Diuretics
-Metabolic Acidosis: Tx with sodium bicarbonate or sodium
citrate (Bicitra)
Common: drugs that need dose adjustments in renally
impaired: acyclovir, valacyclovir, amphotericin, amantadine, ,
Allopurinol, aminiglycosides, azole antifungals, antiarrhythmics,
aztreonam, colchicine, dabigatran, LMWHs, macrolides,
quinolones, metoclopramide, penicillins, morphine/codeine,
Maraviroc, NRTIs, statins, SMT/TMP, tramadol, venlafaxine,
zolendronic acid.
Drugs not to use in severe renal impairment:
Bisphosphonates, dabigatran(Pradaxa), duloxetine,
fondaparinux (Arixtra), glyburide, Lithium, meperidine,
metformin, NSAIDs, nitrofurantoin, potassium sparing diuretics,
rivaroxaban (Xarelto), tadalafil, tenofovir, tramadol ER,
voriconazole IV.
Drugs in Pregnancy:
- As a general rule, try to avoid all drugs during the 1 st
trimester.
- Pregnancy exposure registries are designed to collect info
from women who take various meds during pregnancy and
breastfeeding.
- Well known teratogens: alcohol, ACEi/ARB, benzos,
carbamazepine, phenytoin, valproic acid, topiramate,
phenobarbital, isotretinoin, NSAIDs, methimazole, lithium,
paroxetine (Paxil), tetracyclines, quinolones, warfarin,
statins, methotrexate, dutaseride, finasteride.
- 2011 FDA issued a warning about SSRIs causing persistent
pulmonary HTN in newborns
- Women need 400-800mcg/day folic acid, 1,000mg/day
calcium, and 600IU/day Vit D
- Iron for anemic patients. Absorbs better on an empty
stomach. Vitamin C increases absorption.
- Folic acid >1mg is prescription only
- Nausea/Vomiting: First recommend easting smaller, more
frequent meals, avoid spicy/odorous foods, take naps, and
reduce stress. Then, 1st line OTC by ACOG is pyridoxine
(Vitamin B6).
- GERD/Heartburn/Gas Pains: First recommend easting
smaller, more frequent meals, avoid foods that worsen GERD,
elevate head of bed before sleep. Antacids like Tums are
first line OTC. Many PPIs/H2 blockers are category B
and pretty safe. For gas, simethicone (Gas-X, Mylicon)
are safe.
- Constipation: Increase fluids and physical activity. Fiber is
first line such as psyllium (Metamucil) is safe.
- Cough/Cold/Allergies: First generation antihistamines
are 1st line. Chlorpheniramine (Chlor-Timetron) is the
DOC. Diphenhydramine may also be safe. Non-sedating 2 nd
9
generations like loratidine and cetirizine are often
recommended by doctors during the 2nd and 3rd trimesters. If
nasal steroids are needed for chronic allergy symptoms,
budesonide (Rhinocort) and beclamethasone (Beconase
AQ) are considered safest.
- Pain: Only recommend acetaminophen (Tylenol) for pain in
pregnancy
-Anticoagulation: UFH is preferred in all stages
- Vaccines: Inactivated Influenza vaccine should be given
each fall whether pregnant or not and in all stages of
pregnancy. *No Live Vaccines one month before and during
pregnancy.
- Antibiotics: Penicillins, Cephalosporins, and
macrolides (except clarithromycin) are considered safe.
Fosfomycin for UTI is safe. Nitrofurantoin for UTI is safe
but at term is CI.**Do not use quinolones (cartilage
damage) or tetracyclines (teeth discoloration). SMX/TMP
can cause hyperbilirubinemia and kernicterus in the 3rd
trimester so do not use. Do not use Aminoglycosides (Category
D). Do not use flagyl in the 1st trimester.
Bacterial Vaginosis: Clindamycin oral or
metronidazole oral
Chlamydia: Azithromycin 1gm x 1 or Amoxicillin
500 TID x 7 days
Gonorrhea: Rocephin 250mg x 1 and/or
Azithromycin 2gm x 1 (Covers chlamydia too)
Trichmoniasis: metronidazole 2gm x 1 or 250
TID/500BID for 7 days
-Vaginal fungal infections: Use topical antifungals for 7
days (ex. clomitrazole)
-Asthma: Inhaled Corticosteroids are 1st line (budesonide
preferred). Albuterol inhaler is used for rescue.
- Hypothyroidism: use levothyroxine (Category A)
-Hyperthyroidism: PTU and Methimazole are pregnancy
D. PTU is used in the 1st trimester and Methimazole is
after that. Both can cause serious liver damage.
Drug References:
Average wholesale prices and suggested retail prices of
drugs: Red Book
Principles of Immunization: Pink Book from the CDC
Patents, Manufacturing, Industry issues: Pink Sheet
Travelers Health: Yellow Book
Therapeutic equivalence: Orange Book; published by the
FDAs CDER(Center for Drug Evaluation and Research)
Clinical Trials: Clinicaltrials.gov by the national institute of
health
Comprehensive Patient Information: MedlinePlus, FDA,
CDC
Natural Medicines: Natural Medicines Comprehensive
Database and Natural Standards
Pregnancy/Lactation: Breastfeeding: A guide for the medical
profession, Briggs, Lactmed, Micromedex, Hales, CDC
Pediatrics: AHFS, Micromedex, Harriet Lane, Pediatric Dosage
Handbook, Neofax, Nelson, CDC, Professional Colleagues
IV Drugs: Trissels, Kings, Package Insert, Micromedex, AHFS
Drug ID: Ident-A-Drug, Micromedex, Facts and Comparisons,
Clin Pharm etc..
Medication Safety: Medwatch (Adverse Reactions) and
Institute for Safe Medication Practices (ISMP)
Foreign Drug ID: Martindales, micromedex
10
Infectious Disease:
-Gram Positive Stain Purple/Blue, Gram Negative Stain Pink
-Breakpoint: level of MIC at which the bacteria is deemed
susceptible or resistant
-Beta Lactams (Time-Dependent) can be maximized by
extending the infusion time or giving a continuous infusion
Antibacterials:
-Aminoglycosides: (Bactericidal)
bind to 30S and 50s ribosome units and interfere with
protein synthesis
concentration dependent killing and post antibiotic
effect (PAE)
High dose extended interval dosing is less nephrotoxic
and more cost-effective
BBW for Neurotoxicity and Nephrotoxicity
Gent/Tobra: 4-7mg/kg (peak 5-10 trough <2) , for
synergy ex. with vanco peak (3-4)
Amikacin: 15-20 mg/kg (peak 20-30 trough <5)
(dose based on IBW)
-Penicillins: (Bactericidal except against Enterococci)
bind to PBP and inhibit cell wall synthesis
Time-Dependent Killing
amoxicillin (Amoxil) refrigerate suspension to improve
taste
amoxicillin + clavulanate (Augmentin) refrigerate
suspension
ampicillin + sulbactam (Unasyn)
penicillin VK (Oral) and Penicillin G (IV) take Pen VK on
an empty stomach
piperacillin + tazobactam (Zosyn) anaerobic
coverage and pseudomonas
 nafcillin, oxacillin, docloxacillin (PO) antistaph pcn
no renal dose adjusting, is a vesicant
bone marrow suppression with long-term use or
seizures with accumulation
-Cephalosporins: (bactericidal)
same mechanism as PCNs
activity against staph decrease with
generations but strep and gram neg.
increases
1st Gen: cefazolin (Kefzol,Ancef)(iv),
cephalexin (Keflex)(po) - covers PEK (proteus,
Ecoli, Klebsiella)
2nd Gen: cefuroxime (Ceftin,Zinacef)(iv/po),
cefotetan (avoid alcohol) or cefoxitin (cover some
anaerobes) more gram negative coverage than
1st gen. HNPEK (H.Flu, Neisseria, proteus, Ecoli,
Klebsiella)
3rd Gen: cefdinir(Omnicef)(po), ceftriaxone
(Rocephin)(iv), ceftazidime (Fortaz)
(iv),cefpodoxime (Vantin)(po) less staph and
more strep activity. More gram negative acitivity
covers serratia (HNPEKS). **Ceftazidime
covers Pseudomonas
4th Gen: cefepime (Maxipime)(iv) - best gram
negative activity, covers (HNPEKS) and
Serratia, Pseudomonas , Acinetobacter,
Citrobacter, Enterobacter (SPACE bugs)
5th Gen: ceftaroline (Teflaro)(iv) Best gram
positive activity covers MRSA, no Pseudomonal
coverage
**Ceftriaxone(Rocephin) is the only one that
can be dosed once daily. It should not be
used via Y-site or with calcium containing
stuff. DOC for primary peritonitis infections.
11
-Carpapenems: (bactericidal)
same mechanism as PCNs
Broad Spectrum against Gram +/-, Anaerobes,
Pseudomonas (except Ertapenem), AMPC
and ESBLS
imipenem/cilastatin (Primaxin), meropenem
(Merrem), ertapenem (Invanz), doripenem
(Doribax)
Side Effects: Can cause seizures
ertapenem (Invanz) can be dosed once daily
-Aztreonam(Azactam):
no Gram + activity but good for
Pseudomonas
can be used in PCN allergic patients
-Fluoroquinolones: (Bactericidal)
Inhibit DNA gyrase and topoisomerase IV
concentration dependent killing
ciprofloxacin (Cipro or ciprodex (otic)),
levofloxacin (Levaquin), moxifloxacin (Avelox
or Vigamox (eye)), ofloxacin (Floxin (otic))
Cipro and Levo have Pseudomonal coverage, not
Moxi
moxi covers some anaerobes
Atypical Coverage
Levo and Moxi referred to as the respiratory
FQs because they have more Strep. Pneumo
coverage
**BBW for Tendon Inflammation/Rupture and
may exacerbate muscle weakness in
Myasthenia Gravis. Pregnancy D for cartilage
damage.
QT prolongation, GI upset, Hepatotoxicity,
seizures, peripheral neuropathy,
 **hypoglycemia (sometimes fatal),
peripheral neuropathy, and photosensitivity.
Cipro Oral Suspension should not be given via
feeding tubes b/c it adheres to the tubing.
Chelation with cations so separate doses from
things like antacids, mutivaitmins etc..
Cipro CI with tizanidine (Zanaflex)
-Macrolides: (Bacteriostatic)
binds to 50S ribosome to inhibit protein synthesis
azithromycin (Z-Pak, Zithromax),
erythromycin (Erythrocin), clarithromycin
(Biaxin)
Atypical coverage
QT prolongation, GI upset, Hepatotoxicity
erythromycin and clarithromycin are
inhibitors of 3A4
azithromycin has less drug-drug interactions
-Tetracyclines: (Bacteriostatic)
bind to 30s ribosome to inhibit protein synthesis
tetracycline, doxycycline, minocycline
Photosensitivity
Pregnancy Category D (teeth discoloration
and skeletal growth suppression)
doxycycline IV to PO is 1:1
Chelation with cations
do not use in children < 8 yrs. old
doxy doesnt need renal dose adjusting
-Sulfonamides: (Bactericidal when SMX/TMP are used
together)
inhibit the folic acid pathway
MRSA coverage
Bactrim and Septra
Always in a 5:1 (SMX:TMP)
12
CI: Pregnancy, Sulfa Allergy, breastfeeding,
anemia due to folate deficiency, marked
renal/hepatic disease, infants <2 months
Side Effects: Photosensitivity, Skin
reactions, hyperkalemia, hypoglycemia,
crystalluria (take with 8oz) of water
IV to PO is 1:1
**Inhibitor of 2C9 so caution with warfarin
-Vancomycin (Vancocin): (Bactericidal)
blocks glycol-peptide polymerization of the cell
wall
can be used orally for C. Diff 125-500mg QID x
10-14 days
Side effects: Nephrotoxicity, Ototoxicity,
infusion rxn/redman syndrome(hypotension,
flushing, chills, etc..- so give 30 min infusion for
each 500mg)
Troughs: 15-20mcg/ml for pneumonia,
endocarditis, osteomyelitis, meningitis, and
bacteremia; 10-15 for others.
MRSA, PRSP, Enterococcus (Not VRE)
-Telavancin (Vibativ): (Bactericidal)
derivative of vancomycin
red man syndrome, nephrotoxicity, QT
prolongation
-Linezolid (Zyvox): (Bacteriostatic)
binds to 23S ribosomal RNA of the 50S subunit
CI with MAOI inhibitors or within 2 weeks
use of them
IV to PO 1:1 (600mg Q12)
MRSA, PRSP, VRE
 associated with bone marrow suppression and
peripheral neuropathy
-Daptomycin (Cubicin): (Bactericidal)
o depolarizes cell membrane
o MRSA, PRSP, VRE
o Side Effects: **Myopathy and increased CK
o **Do not use for pneumonia b/c its inactivated
by surfactant
o can cause false elevations in INR with no
increased bleeding
o compatible with NS but not D5W
-Tigacycline (Tygacil):
o related to tetracyclines
o BBW: increased risk of DEATH
o Lipophilic and distributes to tissues so not for
bloodstream infections
-Clindamycin (Cleocin):
binds 50s subunit
Covers gram + (not enterococcus) and most
anaerobes
BBW for severe or fatal colitis
D-test for macrolide-induced resistance
no renal adjustments
-Metronidazole (Flagyl) and Tinidazole (Tindamax):
DNA damage which blocks translation and protein
synthesis
Anaerobes and protozoal infections
BBW for possible carcinogenicity
**CI: Pregnancy(1st trimester), *Alcohol and
no alcohol for 3 days after discontinuing
Can increase INR if used with warfarin
IV to PO 1:1
Can cause metallic taste in mouth
13
Do not refrigerate b/c crystals can form
-Rifaximin(Xifaxan) : for travelers diarrhea and hepatic
encephalopathy
-Fosfomycin: single dose for UTI, ok for pregnancy
-Nitrofurantoin (Macrobid or Macrodantin): for
uncomplicated UTI, **CI with CrCl<60ml/min, rarely can
cause pulmonary toxicity.( Darkens urine rust colored.)
Refrigeration of antibiotics:
Refrigerate: Penicillins (amoxicillin just for taste),
Cephalosporins (except Cefdinir(Omnicef)), Erythomycin
Do Not Refrigerate: Cefdinir, Azithromycin, Clarithromycin,
Clindamycin, Ciprofloxacin, Levofloxacin, Doxycycline,
Fluconazole, Voriconazole, linezolid (Zyvox), SMT/TMP
Specific Disease Treatments with Antibiotics:
Surgery Prophylaxis:
Usually initiated within 60 minutes before the procedure
unless FQ or Vanco is used then its 120 min. before.
Second doses may need to be given for longer
procedures or if there is significant blood loss.
1st or 2nd Gen. Cephalosporins usually given unless
PCN allergy then Vanco is used.
If bowel parts are involved, need anaerobic
coverage such as cefotetan, ertapenem, or
Rocephin with Flagyl
Meningitis:
Most common pathogens: Strep.Pneumo, H.Flu,
Neisseria Meningitis, and Listeria
Tx with Ceftriaxone (Rocephin) + Vancomycin
usually for 7-14 days + dexamethasone
 For immunocompromised or >50, add Ampicillin
for Listeria coverage
If Beta Lactam Allergy: Chloramphenicol + Vanco +
Bactrim (Listeria)
Infective Endocarditis:
Usually from Staph, Strep, or Enterococcus
**Prosthetic valve IE usually from Staph and
requires addition of Rifampin
Gentamicin often used for synergy, peak 3-4
mcg/ml, trough <1, do not use extended-interval
dosing
usually 4-6 weeks of treatment with a PCN,
Cephalosporin (ceftriaxone), or Vanco
Prophylaxis from dental procedure: ** Amoxicillin,
clindamycin, or azithromycin 30-60 min before
procedure.
URTI:
Acute Otitis Media: Usually use **High dose
amoxicillin 90mg/kg/day or Augmentin
Most are caused by viruses
LRTI:
Acute Bronchitis: Usually Viral Antitussives and
Bronchodilators Used
CAP: usually causes by Strep. Pneumo, H.Flu, or M.
Catarrhalis. Usually use a macrolide, or beta-lactam
+ macrolide, or a FQ for 5-10 days
HAP:
Early Onset (<5days): Usually same bugs as
CAP
14
Late Onset (>5days): Usually MDR pathogens
(MRSA, Pseudomonas). Tx for 7-8 days unless
pseudomonas then its 14 days.
Tuberculosis:
caused by mycobacterium tuberculosis
high contagious
Diagnosed with Tuberculin skin test (aka PPD).
Look for raised area with 48-72 hrs.
Latent usually treated with rifampin and isoniazid
If active, Tx with RIPE regimen which is
Rifampin, Isoniazide (INH), Pyrazinamide,
and Ethambutol
Direct observed therapy (DOT) if possible to
make sure they take all the meds
Patients should be in isolated, negative
pressure rooms
Recommend pyridoxine (Vit B6) to prevent
neuropathy with isoniazid (INH)
Rifampin and INH taken on an empty stomach
Ethambutol can cause optic neuritis
pyrazinamide CI in acute gout and hepatic
damage
INH can cause hepatic damage too
rifampin can cause red-orange secretions
and stain contacts
RIPEM if resistant to others
(M=moxifloxacin)
Intra-Abdominal Infections:
Primary peritonitis: mostly from strep and enteric
gram negative rods (PEK). Tx with ceftriaxone
(Rocephin) for 5-7 days.
Secondary peritonitis from traumatic event (surgery,
ulceration, ischemia, obstruction) usually strep, gram
neg. rods and anaerobes
Skin and Soft Tissue Infections:
Cellulitis: Affects all layers of the skin and usually
caused by Staph. Aureus or Strep. Pyogenes
abscesses need incision and drainage (I&D)
Purulent(pus): requires MRSA coverage
non-purulent: (Keflex)
IV antibiotics may be necessary for severe infections
UTI:
more common in females b/c of shorter urethra
all male UTIs are considered complicated
Signs/Symptoms: dysuria, urgency, frequency, burning,
nocturia, suprapubic heaviness, hematuria , (fever is
uncommon)
Positive Urinalysis when there is pyuria/pus in urine
(positive leukocyte esterase, or >10 WBC/ml) and
bacteriuria >105 for uncomplicated or >103 for
complicated.
Phenazopyridine(Azo) often given for urinary pain
(dysuria) can cause red/orange urine. Max of 2
days b/c you dont want to cover symptoms that
can worsen.
Asymptomatic (no fever or urinary symptoms)
does not need to be treated unless pregnant then
you treat for 7 days
Nitrofurantoin (CI if CrCl < 60 ml/min) for
uncomplicated UTI or SMX/TMP
Can use FQ for complicated UTI or SMX/TMP
C.Difficile:
Usually from Antibiotic use especially Clindamycin,
Ampilcillin, Cephalosporins, and FQs.
Remove offending agent
15
avoid anti-motility agents due to risk of toxic
megacolon
wash hands with soap and water to prevent
transmission, alcohol does not kill the spores
Tx: Metronidazole 500mg TID (mild-mod) or Oral
Vanco 125mg QID (mod-severe) or both for severe
complicated 10-14 days with flagyl being IV.
fidaxomicin in clinical trials shows lower recurrence rates
Travelers Diarrhea
Bacterial (80%): enterotoxigenic E.Coli,
Campylobacter jejuni, shigella, salmonella
Viral sometimes
Protozoal sometimes
Tx: Fluoroquinolones are the the DOC plus
loperamide
Hydration is very important
prophylaxis is not recommended but can use
Pepto-Bismol to reduce incidence
No Fever and No blood in stool can use
loperamide: 4mg then 2mg, max 16mg/day
Fungal Infections:
Amphotericin B: (fungicidal)
binds to ergosterol, altering cell membrane
permeability, causing cell death
Comes in conventional and lipid formulation
(Abelcet, Ambisome)
BBW that medication errors occur due to the mix-
up between conventional and lipid formulation
dosing differences. Conventional has a max dose
of 1.5mg/kg/day.
 Side Effects: Fever, chills, headache, malaise, rigors,
hypokalemia, hypomagnesemia, **nephrotoxicity
Lipid formulation reduce the risk for infusion
reactions and **nephrotoxicity
If using conventional, pre-medicate for infusion
related reactions with:
acetaminophen or NSAID
Diphenhydramine and/or hydrocortisone
Meperidine to reduce duration of rigors
fluid boluses to reduce nephrotoxicity
Flucytosine (Ancobon): (fungicidal)
penetrates into fungal cells and is converted to fluorouracil
which competes with uracil, interfering with fungal RNA and
protein synthesis
BBW to use extreme caution in renal dysfunction and
closely monitor renal, hepatic, and hematologic
status
Side Effects: Bone marrow suppression, hepatitis,
nephrotoxic increase BUN and Scr
Azoles: (fungicidal and fungistatic)
decrease ergosterol synthesis and thus cell
membrane formation
Fluconazole is the DOC for thrush in HIV patients or
non-HIV with moderate-severe disease. Nystatin also
good for thrush.
Voriconazole is the DOC for Aspergillus
Itraconazole (Sporanox), fluconazole (Diflucan),
voriconazole (VFEND), posaconazole (Noxafil)
Ketoconazole (Nizoral topical, generic for tablets)
Fluconazole IV to PO is 1:1
Voriconazole should be taken on an empty
stomach, posaconazole with full meal
16
Voriconazole CI with many 3A4
substrates/inhibitors/inducers. It starts 1st order
then is 0 order PK so small dose increases can
have large affects (michaelis menton).
Only Fluconazole and Voriconazole penetrate the
CNS well enough to treat fungal meningitis
**All are 3A4 inhibitors
**Side Effects of all: Increase LFTs, QT
prolongation
Side effects of Voriconazole/Posaconazole: **Visual
changes, hallucination
Itraconazole is CI in heart failure
EchinoCANDIns:
o inhibit synthesis of B(1,3) D- Glucan of the cell wall.
o DOC for most systemic Candida
o Caspofungin (Cancidas), mycafungin (Mycamine),
anidulafungin (Eraxis)
o Side effects: Increased LFTs, hypotension, fever,
diarrhea, hypokalemia, hypomagnesemia, rash
o good for C. krusei and glabrata too
o all once daily and no renal adjustments
Terbinafine (Lamisil): Inhibits squalene epoxidase
Side effects: Increased LFTs,
headache
Nystatin: Griseofulvin (Grifulvin,Gris-PEG):
photosensitivity & pregn.cat X
Viral Infections:
Influenza:
Neuramidase Inhibitors
o decrease the release of viral particles
o should be used within 48 hours of illness
onset
 o Oseltamivir (Tamiflu) Tx: 75mg BID x 5
days Prevention: 75mg BID x 10 days
o Tamiflu can cause vomiting
o Zanamivir (Relenza Diskhaler) BBW
bronchospasm risk
o amanatadine
Antivirals for Herpes Simplex Virus (HSV), Varicella
Zoster Virus (VZV) and Cytomegalovirus (CMV):
o acyclovir (Zovirax), valacyclovir (Valtrex),
valganciclovir (Valcyte), famciclovir ( Famvir)
ganciclovir (Cytovene), cidofovir (Vistide), foscarnet
(Foscavir)
o **valganciclovir has a BBW for
myelosuppression and carcinogenic/teratogenic
effects. **Prepared in vertical air hood.
o cidofovir has a BBW for nephropathy
o valganciclovir is taken with food
o ganciclovir and valganciclovir are the DOC for
CMV
o if resistant to acyclovir you will be resistant to
valacyclovir and famciclovir
o Therapy for HSV should be within 24 hours of
symptoms and therapy for VZV should be
within 72 hours of rash.
West Nile Virus: Antivirals do not work well so just dont
get it. Use repellants and wear protective clothing.
Malaria:
Atovaquone/proquanil (Malarone)
17
Mefloquine (Lariam):CI with Hx of seizures or
psychiatric disorders
Doxycycline (Vibramycin)
Chloroquine (Aralen) QT prolonging, visual
disturbances, retinopathy
Quinine (Qualaquine) CI with prolonged QT and
G6PD deficiency
Primaquine CDC requires screening for G6PD
deficiency
Immunizations:
Federal law requires patients receive the most up to date
version of the Vaccine Information Statement (VIS)
BEFORE EACH vaccine is administered.
Active Immunity produced by the persons own
immune system (permanent). Get it from surviving and
infection or vaccination.
Passive Immunity products like Immunoglobulins are
transferred to a patient (wanes within weeks to months)
Usually 3 months spacing between anti-body
containing blood products and MMR or Varicella
vaccines. (Zoster is not affected by circulating
antibodies)
Pink Book for recommendations
 Simultaneous administration of all vaccines for 30 min after administration. Inactivated for
which they are eligible is fine and efforts should everyone > 6 months. Mild-illness is not a CI to
be made to do them at one visit on the same day influenza vaccine. LAIV only for healthy people 2-
If live parenteral vaccines (MMR, Varicella, Zoster, and 49 years old.
yellow fever,) or live intranasal influenza (LAIV) are not Varvax/Zostavax/MMRV (zoster and chickenpox)
administered at the same visit, then separate them by should not be given to anyone with a true gelatin
4 weeks. or neomycin allergy. Store vaccine in freezer and
Increasing the dosing interval between multi-dose diluent in fridge or room temp.
vaccines doesnt decrease effectiveness but may delay HPV vaccine (Gardasil, Cervarix) for males (to reduce
more complete protection. genital warts or anal cancers) or females 9-26 yrs old. (3
Decreasing the dosing interval between multi-dose Doses). Males only use Gardasil.
vaccines may interfere with antibody response and IM is given into the deltoid muscle with a 1
protection. needle (women >200lbs and men >260 lbs need 1
Side effects: and ). SC is given into the fatty tissue above
Local pain, swelling, redness at site the tricep with a 5/8 needle.. PPSV23 is SC or IM
Systemic fever, malaise, myalgia, headache, loss but PPSV13 is IM only.
of appetite (LAIV can cause runny nose) **LAIV , Varicella/Zoster and MMR are live
Allergic or Anaphylactic Hives, difficulty **SC is varicella, ZOSTER (Zostavax) and MMR
breathing, hypotension, swelling of mouth and **Varicella and Zoster are stored in the freezer
throat. Severe reactions CIs subsequent dose of Children get DTap and adults get Tdap
the vaccine. All providers must have emergency ***CDC does not recommend using acetaminophen
protocols and supplies to treat anaphylaxis. before a vaccine bc it can decrease immune
**Absolute CIs to live vaccines (ex. Zoster, response
Varicella, LAIV (Flumist), and MMR): Pregnancy Never mix vaccines together
and Immunosuppression In Florida, pharmacists give Influenza, Shingles,
Tdap: Pregnant women should receive Tdap with each and Pneumococcal Vaccines
pregnancy, most effective in weeks 27-36. Also, a one-
time dose for those <65 or >65 who have close contact
with children who are less than 6 months. Tdap is IM.
Pneumovax (PPSV23): All patients > 65 x 1 dose, 19-
64 who smoke or have asthma, 2-64 who have chronic Travelers Medicine:
illnesses.
Yellow Book for travel information
Flu: If a person can eat lightly cooked eggs or if
Malaria parasite protection is provided by oral meds
they only experience hives after eating egg-
prior to travel. Use DEET. Plasmodium Vivax causes 65%
containing products, then they can receive
of cases in India. Plasmodium falciparum is the most
inactivated flu vaccine but should be observed for
deadly.
18
 Treatment:
o Mefloquine (Larium): High resistance and
many psychiatric and neurologic side effects.
Once weekly. Started 1-2 weeks before and 4
weeks after
o Chloroquine: Once weekly. Started 1-2 weeks
before and 4 weeks after
o Atovaquone/Proguanil (Malarone): Started
1-2 days before travel and for 7 days post
travel. Well tolerated but CI in pregnancy.
Once Daily.
o Primaquine: Once daily. Started 1-2 days
before travel and for 7 days post travel. CI in
pregnancy. CDC requires screening for
G6PD deficiency before use.
Meningococcal vaccine: required for Saudi Arabia.
Also prevalent in the meningitis belt of Africa. Menactra (2
doses for 9-23 months, 1 for 2-55 yrs), Menveo (2-55 yrs.),
Menomume (56 and older). 7-10 days for protective
antibodies.
Yellow Fever Virus Vaccine: for certain parts in sub-
saharan Africa and South America. Watch for allergies to
eggs and gelatin. It is a live vaccine so dont use in
immunocompromised. ASA and NSAIDs should not be used
b/c of increased risk of bleeding.
Typhoid Fever: bacteria spread through consumption of
food/water contaminated with feces or sexual contact. Use
safe food and water precautions. Vaccine is Vivitof
Berna, 4 capsules, 1 every other day taken with cool
liquid or IM shot > 2 weeks before exposure.
Altitude Sickness: acetazolamide (Diamox Sequels).
CI in sulfa allergy.
International certificate of vaccination (Yellow Card)
HIV:
19
CD4+ counts are the major laboratory indicator of
immune function and need for prophylaxis against
opportunistic infections.
HIV-1 RNA (Viral Load): most important indicator of
response to anti-retroviral therapy (ART). Used to
help assess disease progression and possible drug
resistance. Measured at baseline and then on a
regular basis thereafter.
Spread through blood, semen, and vaginal secretions.
Also spread through vertical transmission during
pregnancy, at birth, or breastfeeding.
**ART is recommended in ALL HIV-infected patients
**Need adherence of 95% or greater to be effective
long-term
PIs and stavudine associated with
lipodystrophy/lipoatrophy and fat
redistribution/lipohypertrophy
Diarrhea is a common side effect of ART.
Crofelemer(Fulyzaq) is approved for non-infectious
diarrhea in adult patients on ART.
NRTIs: (Abacavir, lamivudine, emtricitabine,
tenofovir, didanosine, stavudine, zidovudine)
**All have BBW for lactic acidosis and
hepatomegaly with steatosis(fatty liver)
Suspend treatment if there is lactic acidosis
or hepatomegaly with steatosis.
abacavir: BBW for severe hypersensitivity
reaction. Must test for HLA-B*5701.
Ziagen (abacavir)
Epzicom (abacavir + lamivudine) Once Daily
emtricitabine: BBW for Hep B exacerbation once
discontinued or HBV resistance. Can cause
hyperpigmentation of soles and feet.
Emtriva (emtricitabine)
 **Truvada (emtricitabine + tenofovir): Once
Daily
**Atripla (emtricitabine + tenofovir + efavirenz):
Once Daily. Take on empty stomach.
lamivudine: BBW for Hep B exacerbation once
discontinued or HBV resistance. BBW to not use
Epivir-HBV for HIV(contains lower dose of
lamivudine). Preferred in Pregnancy
Epivir (lamivudine)
Epzicom (abacavir + lamivudine)
tenofovir: BBW for Hep B exacerbation once
discontinued or HBV resistance. Fanconi
syndrome, renal failure, osteomalacia, decreased
bone density.
Viread (tenofovir)
Truvada (tenofovir + emtricitabine)
Atripla (tenofovir + emtricitabine + efavirenz)
Zidovudine: BBW for hematologic toxicity
(neutropenia and anemia) and myopathy.
Preferred in pregnancy.
NNRTIs (Efavirenz, delavirdine, etravirine, nevirapine,
rilpivirine)
**All can cause SJS(rash) and Hepatotoxicity
**Inhibitor of 2C9, 2C19, and 3A4, and strong
INDUCER of 3A4 = many drug interactions
efavirenz (Sustiva):
600 mg daily on empty stomach. CNS side
effects (vivid dreams, drowsy, impaired
concentration) and psychiatric side effects
(depression, paranoia, mania, suicide). CNS
side effects usually resolve in 2-4 weeks.
Pregnancy D
Atripla ( tenofovir + emtricitabine + efavirenz
Protease Inhibitors: (atazanavir, darunavir, ritonavir,
lopinavir/ritonavir, fosamprenavir, indinavir, nelfinavir,
saquinavir, tipranivir)
20
**All strong INHIBITORS of 3A4 = many drug
Interactions
**Side Effects: Hyperglycemia, Insulin Resistance,
Diabetes, fat maldistribution, hepatitis, immune
reconstitution syndrome
atazanavir (Reyataz): PR interval prolonging,
hyperbilirubinemia (aka bananvir), rash, take
with 1.5 L of water to reduce nephrolithiasis.
Needs Acid,Avoid acid suppressants b/c they can
decrease levels, take with food and water. (1st line)
darunavir (Prezista): Rash, Sulfa Allergy (1st line)
ritonavir (Norvir): PR prolonging
lopinavir/ritonavir (Kaletra) : PR prolonging,
Preferred in Pregnancy
Integrase Inhibitors: (Raltegravir, dolutegravir, elvitegravir)
raltegravir (Isentress): 400mg BID
Fusion Inhibitor: enfurvitide (Fuzeon)
local injection site reactions in 100% of patients
CCR5 antagonist: maraviroc (Selzentry)
only works for CCR5 type HIV so must be screened
before using
BBW for hepatotoxicity
Side Effects: UTRI, fever, rash, musculoskeletal
symptoms, dizziness
Pregnancy: Combivir (lamivudine + zidovudine) +
Kaletra (lopinavir/ritonavir) OR atazanavir + ritonavir OR
nevirapine (NNTRI)
Pre-Exposure Prophylaxis: Truvada 1 tab PO QD
Occupational post-exposure prohylaxis - Truvada +
Raltegravir (Isentress) x 4 weeks
Opportunistic Infections:
PCP (CD4<200): Prophylaxis: SMX/TMP Tx:
SMX/TMP +/- corticosteroids
Toxoplasma gondii (CD4<100): Prophylaxis:
SMX/TMP Tx: Pyrimethamine + sulfadiazine
Mycobacterium Avum (CD4<50) Prophylaxis:
Azithromycin Tx: Azithromycin + Ethambutol
CMV Valganciclovir
Cryptococcal Meningitis: Liposomal Amphotericin
B + Flucytosine
Hepatitis/ Liver Disease:
Hepatic Encephalopathy: From Ammonia Buildup
Tx: Lactulose or rifaximin (Xifaxan) + **low protein
diet
Ascites: Furosemide and Spironolactone
Hepatitis B: Vaccine preventable. Usually treat for 1
year.
Tx: pegylated interferon (Pegasys) : BBW for
many things; exacerbate or cause autoimmune
disorders, infectious disorders, CVA, depression
(20%) **pegylation increases half-life for once
weekly dosing.
NRTIs tenofovir (Viread),* lamivudine (Epivir
HBV) entecavir(Baraclude)
Hepatitis C: Not Vaccine Preventable. 3 different types
(Genotype 1,2, and 3). 1 is the most difficult to treat and
treated for 48 weeks. Genotype 2 and 3 treated for 24
weeks.
Tx: pegylated interferon (Pegasys or Pegintron):
BBW for many things. (See above)
Ribavirin: BBW for teratogenic. SE: hemolytic
anemia
Protease Inhibitor: (ex. boceprivir): only for
genotype 1
Drugs:
21
sofosbuvir (Sovaldi): inhibits HCV NS5B RNA
polymerase
Diabetes:
Type 1: Autoimmune destruction of beta cells in the
pancreas
Type 2: Insulin resistance or relative deficiency
eAG: (28.7 x A1C) 46.7
Diagnosis: Classic signs
(Polyuria/polydipsia/polyphagia/weight loss) + A1C
> 6.5 % or FPG > 126 or Random >200 or 2hr.
glucose > 200 after 75 gram OGTT
Common drugs that alter glucose:
Hyperglycemina- Corticosteroids, Thiazide/Loop
Diuretics, Statins, FQs, Protease Inhibitors
Hypoglycemia: FQs, Lorcaserin (Belviq satiety
drug)
Treatment Goals: ADA: A1C < 7% Pre-Prandial
70-130 mg/dl Post-Prandial: <180 mg/dl
AACE: A1C < 6.5% Pre-Prandial
<110 mg/dl Post-Prandial: <140 mg/dl
Tx: Lifetstyle Modifations: Weight Loss, Diet, Exercise,
waist circumference <35 for females and < 40 for males
plus Drugs
Nephropathy Screenings: (Annually)
microalbuminuria: 30-299
macroalbuminuria: >300
Add ACEi or ARB
Retinopathy Screening: (Annually)
Foot Screening: (Annually)
All diabetics should inspect their feet daily
Type 2 Diabetes Treatment: Metformin is the initial
treatment. If not at goal in 3 months, add a
second oral agent. If not at goal 3 months from
then, add a 3rd, usually basal insulin.
Biguanides: (Metformin)
*decreased hepatic glucose production, *increase insulin
sensitivity, decrease absorption of glucose
metformin (Glucophage, Glumetza, Fortamet)
(Janumet has sitagliptin)
**BBW: Lactic Acidosis
CI: SCr >1.5 (males) and SCr>1.4 (females).
*Temporarily D/C in patients getting IV contrast
die, hold for 48 hours and once renal function is
normal
Weight Neutral and little to no risk of
hypoglycemia
SE: Diarrhea, Nausea, Vomiting, Flatulence, Vit B12
deficiency, ER tablet shows up in stool sometimes (ok)
Max daily dose: 2,550 mg
Take with food
Sulfonylureas: (Glipizide, Glimepiride, Glyburide)
stimulate insulin secretion (do not use with
meglitinides)
chlorpropamide (Diabinese), glipizide (Glucotrol,
Glucotrol XL, Glipizide XL), glimepiride (Amaryl),
glyburide (Diabeta)
SE: Hypoglycemia and Weight Gain
**glyburide (Diabeta) should not be used in renal
impairment, it has a renally cleared active
metabolite
Meglitinides: (baby sulfonylyureas)
stimulate insulin secretion (do not use with
sulfonylureas)
repaglinide (Prandin), nateglinide (Starlix)
SE: Hypoglycemia, weight gain, URTI
Thiazolidinediones (TZDs):
22
PPARy agonists that cause increased insulin
sensitivity
pioglitozone (Actos), rosiglitazone (Avandia)
BBW: do not use in NYHA Class III/IV heart failure
SE: Peripheral edema, URTI, Weight gain
Alpha-Glucosidase Inhibitors:
delay glucose absorption in intestines
acarbose(Precose)
*taken with first bite of each meal
*Flatulence and diarrhea are common
GLP-1 Agonists: (Incretin Mimics) SQ injections
increase insulin secretion, decrease glucagon
secretion, slow gastric emptying, improve satiety,
may cause weight loss
exenatide (Byetta), exenatide ER (Bydureon-Once
Weekly), liraglutide (Victoza)
BBW for Bydureon and Victoza only for Thyroid C-
Cell carcinoma
Warning for Pancreatitis
SE:* Nausea (Primary Side Effect), **Weight Loss
Byetta and Victoza 30 days, Bydureon 28 days
room temp
DPP4-Inhibitors:
prevent the breakdown of GLP-1 agonists
sitagliptin (Januvia), sitagliptin + metformin
(Janumet), saxagliptin (Onglyza)
Weight neutral
SE: Nasopharyngitis, URTI, UTI
SGLT2 Inhibitors:
canagliflozin (Invokana)
SE: Female genital mycotic infections, UTIs ,
hyperkalemia, increased urination
Pramlintide (Symlin): Amylin analogue that increases satiety,
prevents glucagon secretion after a meal, slows gastric
emptying. Taken with insulin at mealtime with separate
injections. Reduce mealtime insulin dose by 50%. Can be
for Type 1 or Type 2 diabetics.
Bromocriptine (Cycloset) : Dopamine agonist that works in
CNS to increase insulin sensitivity. Take with food to
decrease nausea.
coselevam (Welchol) bile acid sequestrant, unknown MOA
in diabetes, CI with TG>500. Some meds that need to be
taken 4 hours before administration of this: Sulfonylureas,
Phenytoin, levothyroxine, oral contraceptives
Insulin:
***All insulins have a concentration of 100 units/ml
except Humulin R U-500 which is 500 units/ml
**Consider starting Type 2 with insulin if A1C>10%
or BG>300
Rapid-Acting: aspart (Novolog/Novolog Flexpen),
lispro (Humalog/Humalog Kwikpen ), glulisine
(Apidra/ Apidra Solostar) : 28 days
Regular/Short Acting: (Humulin R, Novolin R): 31
days(H) and 42 days(N)
NPH or Intermediate: Humulin N, Novolin N. This is
cloudy and can be mixed with Rapid and Short acting
insulins. Always mix clear before cloudy. 28(H) and
42(N), pens 14
Long Acting: glargine (Lantus) 28 days, detemir
(Levemir) 42 days
NPH to glargine: If NPH is once daily, 1:1 TDD. If
NPH is BID, then reduce daily dose 20%
NPH to detemir: 1:1 TDD
For Type 1: 0.6 units/kg/day (Total Daily Dose)
Basal-Bolus: 50% TDD basal, 50% TDD bolus (divided
evenly for 3 meals)
23
NPH-regular: 2/3 TDD NPH, 1/3 TDD regular (both
divided BID)
For counting carbs: Insulin to carbohydrate ratio:
500/TDD = grams of carb covered by 1 unit
rapid-acting
450/TDD = grams of carb covered by 1 unit
regular-acting
** Correction factor: (Blood Glucose Now - Blood Glucose
Target)/ Correction factor
Correction factor is rule of 1800 for rapid-acting insulin (CF=
1800/TDD) or rule of 1500 for regular-acting Insulin (CF =
1500/TDD)
For Type 2: 0.2 units/kg/day usually long-acting in the
morning
Hypoglycemia: (BG <70 mg/dl)
o Symptoms: Confusion, sweating, tachycardia,
hunger, blurred vision. **Beta blockers can mask
the symptoms except sweating and hunger.
o Treatment: 15-20 grams of glucose ( 3-4 glucose
tabs, 1 serving glucose gel, 4 oz orange juice, 8 oz
milk, 4 oz non-diet soda)
***Glucagon only used if patient is
unconscious or not conscious enough to self-treat
Side Note: NPH and Regular do not require a
prescription.
Autoimmune Disorders:
Immunocompromised: Steroids (oral and injectable only)
at 2mg/kg/day or 20mg prednisone or prednisone
equivalent for 14 days, Diseases (HIV, Diabetes), Transplant
Drugs, Oncology Drugs, Asplenia Drugs, and
immunosuppressant drugs.
Biologic Immune Suppressants: Strong immune depression
Rheumatoid Arthritis: Chronic, Symmetrical,
Polyarticular, Systemic, and Progressive inflammation of joints
and organs.
Symptoms: joint swelling, morning stiffness, pain,
and eventually bone deformity
Goal is to have them on a DMARD within 3 months of
diagnosis. May also need NSAIDs and steroids.
some people with milder symptoms may be ok with just
non-biologic DMARDs
Treatments:
Pain and Inflammation:
ibuprofen 800mg Q6-8hrs. (Max 3200
mg/day) ; OTC max 1200 mg/day
celocoxib (Celebrex) 100-200 mg BID
Non-Biologic DMARDs:
methotrexate (Rheumatrex, Trexall): Low WEEKLY
doses used, not daily. Pregnacy Category X. SE:
stomatitis (inflamed gums and mouth), alopecia,
photosensitivity, increase LFTs. DO NOT take with
alcohol.
hydroxychloroquine (Plaquenil): SE: pigmentation
of skin and hair, rashes. Requires eye exams every
3 months.
sulfasalazine: CI with sulfa allergy and GI obstruction. SE:
anorexia, oligospermia, rash, folate deficiency, yellow-
orange colored urine, impaired folate absorption.
24
minocycline: SE: photosensitivity
leflunomide (Arava): Hepatotoxic, Pregnancy Category
X.
tofactinib (Xeljanz): BBW for increased infections,
lymphomas and other malignancies, risk for developing
active TB.
Biologics: (TNFa Inhibitors and Non-TNF)
**Can all increase risk of infections, screen for
latent TB in all
Require Refrigeration (except etanercept can be
at room temp. for 14 days). Wait until drug is at
room temperature before injecting.
Do not use more than 1 biologic at a time and do
not give live vaccines
TNFa Inhibitors DMARDs:
**BBW for SERIOUS INFECTIONS, lymphomas and
other malignancies, risk for developing active TB.
**Can cause heart failure and hepatotoxicity
etanercept (Enbrel): Sub Q
adalimumab (Humira): Sub Q
infliximab (Remicade): (IV)Infusion reactions and
delayed hypersensitivity reactions. Given only in
combo with methotrexate.
golimumab (Simponi): Sub Q. Given only in combo
with methotrexate.
Biologic non-TNF DMARDs:
rituximab (Rituxan): Depletes CD20 B Cells. BBW
for severe/fatal infusion reactions, rashes etc.
Given in combo with methotrexate.
abatacept (Orencia)
tocilizumab (Actemra): BBW for serious infections.
Can cause hepatotoxicity.
Systemic Lupus Erythematous (SLE):
Auto-antibodies form that damage tissue. There is flare-
ups with periods of remission.
Butterfly rash on face typical
renal (Nephritis in > 50% of patients, hematologic,
and neurologic manifestations)
Hydralazine can cause drug-induced SLE, ***found
by ANA test
Treatment:
o Anti-malarials: hydroxychloroquine (Plaquenil) or
chloroquine; may take 6 months to work
o Prednisone
o mycophenolate mofetil (CellCept): BBW for
increased risk of infection, skin cancers,
congenital malformations. SE: pain, tachycardia,
electrolyte abnormalities (hyperkalemia,
hypomagnesemia, hypocalcemia), hypotension,
hypertension, hypercholesterolemia, diarrhea,
edema,vomiting, tremor, acne etc..
o belimumab (Benlysta) : IgG1-labmda antibody that
prevents survival of B cells by blocking the binding of B
lymphocyte stimulator protein (BlyS)
Multiple Sclerosis:
Immune system attacks myelin sheaths on
neurons in the brain and spinal cord
unknown cause
Most patients experience periods of disease
with intervals of remission
Treatment:
interferon beta drugs
glatiramer acetate (Copaxone)
25
natalizumab (Tysabri): given every 4 weeks, can
cause progressive multifocal leukoencephalopathy
Many drugs used for symptom control can worsen other
symptoms
Celiac Disease:
Immune response to gluten. Diarrhea,
abdominal pain, bloating, weight loss.
gluten is in wheat, barley, and rye
In many foods and many drug excipients.
The actual drug doesnt contain gluten.
Check for excipients on package insert and look
for the word starch. The starch will either be
corn, potato, tapioca, or wheat. If it doesnt say
which starch then call the manufacturer to find
out if the starch is wheat. You can also try the
website Gluten Free Drugs and the journal
Hospital Pharmacy.
Thyroid Disorders:
Thyroid hormone productions regulated by Thyroid
Stimulating Hormone (TSH)
Elevations in T4 will inhibit secretion of TSH via negative
feedback loop
T3 is more potent than T4
Its important to measure free T4 levels since it is the
active form
Hypothyroidism:
will have high TSH and low T4 (Hashimotos is
the most common cause)
 Tx: levothyroxine (Synthroid, Levothroid, Levoxyl) Many BBWs: Infections, Cancer etc.
Pregnancy Safe Do not use NSAIDs (nephrotoxic) and do not
liothyronine (T3,Cytomel), natural thyroid (porcine get live vaccines
T3 and T4, Armour Thyroid) If you miss a dose and its been less than 4 hours
Drug Causes: Amiodarone, Interferon take it. If more than 4 hours, skip it.
Take on an empty stomach 30 min. before Maintenance Immunosuppressant Therapy:
breakfast with a full glass of water o Calcineurin inhibitors: tacrolimus (Prograf) 1st
IV to PO is 1:2 line or cyclosporine (Neoral, SandIMMUNE) .
Symptoms: Weight Gain, Slow HR, Fatigue,
Constipation, Weak ** Interact with many drugs (3A4 and
PGP substrates). Avoid grapefruit and
Hyperthyroidism: St. Johns Wort.
will have low TSH and high T4 (Graves is the
SE: Nephrotoxic, worsen diabetes,
most common cause)
Tx for Graves: RAI-131 or surgery increase BP
Tx Drugs:
o mTor Inhibitors: everolimus and sirolimus SE:
propylthiouracil (PTU, Propyl-Thyracil):
worsen lipids
used in 1st trimester, preferred in thyroid
o Antiproliferative: myophenolate mofetil
storm
(CellCept) or mycophenolic acid (Myfortic) are
methimazole (Tapazole): used in 2nd and
1st line. They are not interchangeable.
3rd trimesters of pregnancy.
o +/- Prednisone
Beta Blockers for symptoms: palpitations,
tremors, tachycardia
Drug Causes: Amiodarone, Interferon Osteoporosis and Hormone Therapy:
Osteoporosis:
Transplant/Immunosuppression: Osteoporosis: T score <-2.5
Prior to transplant donor-recipient compatibility is Osteopenia: T score between -1 and -2.5
PPIs can increase fracture risk
done for Human Leukocyte Antigen (HLA) and
Ensure adequate Calcium and Vitamin D with any
ABO blood group.
Allograft: transplant from one individual to another treatment
o calcium citrate (Citracal): 315mg elemental, larger
that have different genotypes
pill
Isograft: transplant from a genetically identical
o calcium carbonate (Oscal, Tums): acid dependent,
donor
500mg elemental
Autologous Transplant: same patient, tissue
moved to a different site
26
 o cholecalciferol (Vit D3) preferred. 600IU for <70,
800IU for 71+
Treatment:
Bisphosphonates (1st line): alendronate
(Fosamax) 70 mg weekly, risendronate
(Actonel,Atelvia), ibandronate (Boniva),
zoledronic acid (Reclast)-yearly infusion. FDA
warning to stop after 3-5 years due to
esophageal cancer, osteonecrosis of jaw, and
atypical femur fracture. Take first thing in the
morning before eating or drinking anything with
6-8 ounces of water. Stay upright for at least 30
minutes, 60 min. for Boniva.
raloxifene (Evista): SERM, often used in women at
risk of breast CA. SE: Hot flashes, vaginal
bleeding, amenorrhea etc..
teriparatide (Forteo): Human PTH, for high risk
fractures, Sub Q daily, max: 2 years
denosumab (Prolia): antibody to RANKL
Hormone Therapy:
For women: (Hormone Replacement)
Decreased estrogen at menopause causes high LH which
can result in hot flashes and night sweats. Also can
cause vaginal dryness, painful sex, mood changes etc..
Use the lowest possible dose for the shortest
amount of time
Estrogen can be used to prevent post-menopausal
osteoporosis but not treat it.
Women with a uterus shouldnt use estrogen alone
b/c of endometrial cancer risk. Estrogen +
Progesterone increases breast cancer risk and use
should be limited to 3-5 years.
Topical Vaginal products are best for vaginal
dryness and painful intercourse
27
Estrogen SE: nausea, bloating, dizziness, breast
tenderness
Vivelle-Dot: estradiol transdermal, applied to lower
abdomen below waistline
Provera: medroxyprogesterone
Premarin, Premarin Vaginal Cream, or Prempro
(with progesterone) : Conjugated Estrogens
paroxetine (Brisdelle) Pregnancy Category X, 2D6
inhibitor
For Men: (Testosterone Replacement)
replacement is controversial
may increase risk for prostate cancer, increase
cholesterol, liver damage, and worsen BPH
Androgel, Axiron, Depo-Testosterone etc..
Gels are flammable until dry
BBW for secondary exposure to women and
children that could cause virilization (male
characteristics)
Contraception and Infertility:
Pregnancy/Infertility:
There are ovulation kits that test to see if LH is
present, first 3 days from a positive result are the
best chances.
Pregnancy test kits are positive if hCG is present
Should be taking 400-800 mcg/day folic acid at
least one month before pregnancy
Infertility Tx: clomiphene (Clomid): SERM that
increases ovulation
Contraception: Higher than normal doses of regular
daily oral contraceptives can be used
Progestin-Only Pills (POPs)
Estrogen and Progestin Pills (COCs)
SE: Nausea, breast tenderness/fullness, bloating,
weight gain, elevated BP. Can take at night or Pain The fifth vital sign
bedtime to reduce nausea.
Addition of a non-opioid can often reduce the
Serious adverse effects: **Clotting; Increased
amount of opioid needed and provide superior
risk from smoking, age, HTN, diabetes, long
analgesia
bedrest, overweight, and any that contain
It is important to distinguish between
drospirenone (Ortho-Evra Patch, YAZ,
physiological adaptation(Tolerance) and
Yazmin, Beyaz, Ocella, etc..). Best to avoid
addiction
these.
Addiction has strong compulsion and desire
Drospirenone acts as a potassium sparing
to take drug, despite harm along with drug-
diuretic. This is why women like it because it
seeking behavior.
decreases bloating and weight gain but high
Pseudo-addiction: Looks like addiction but could
risk for clotting.
be from uncontrolled pain
Drugs that decrease effectiveness
Chronic opioid use needs constipation
(Inducers): Rifampin, Anticonvulsants, St.
prophylaxis
Johns Wort, PIs and NNRTIs, Cellcept, Sedation should be monitored b/c it is the
Smoking)
most important predictor of respiratory
Depo-Porvera shot (medroxyprogesterone):
depression, the usual cause of fatality in
No drug interactions but it does lower bone
overdose.
density.
Nuvaring: If out greater than 3 hours in Acetaminophen:
weeks 2 or 3, need backup for a week Tylenol, hydrocodone+APAP (Vicodin, Lortab, Norco,
Ortho Evra Patch: if off greater than 24
Lorcet), oxycodone+APAP (Percocet, Endocet,
hours, need backup for a week Roxicet), codeine+APAP (Tylenol #2,3,4),
nonoxynol-9 is a common spermicide
tramadol+APAP (Ultracet)
Emergency Contraception: **BBW for Hepatotoxic: overdose can be fatal,
Plan B (levonorgestrel): good for 3 days
(Max: 4000mg/day). Overdose Tx: N-Acetylcysteine
(72 hours) after sex, OTC now for all ages. If
to restore Glutathione
you vomit within 2 hours of taking, may DOC for pain in pregnancy
want to take another dose. **Avoid in heavy drinkers or known hepatitis
Ella: Good for 5 days after sex, prescription
(<2gm /day)
only
Paragard Copper IUD
28
 meperidine (Demerol): serotonergic
hydrocodone (Lortab, Lorcet, Norco, Vicodin)
Aspirin/NSAIDs:
codeine (Tylenol #2,3,4)
ASA irreversibly inhibits while other NSAIDs reversibly tramadol (Ultram, Ultracet): serotonin syndrome
inhibit COX risk, increased seizure risk
ASA: Bayer, Bufferin, + caffeine/APAP (Excedrin), tapentadol (Nucynta)
salsalate
Allergic to morphine, hydrocodone etc.. : Can use
ibuprofen (Motrin, Advil), naproxen (Aleve, Naprosyn,
fentanyl, morphine, meperidine
Anaprox), naproxen + esomeprazole (Vimovo),
diclofenac (Voltaren), indomethacin (Indocin), Muscle Relaxants:
piroxicam (Feldene), ketorolac (Toradol), sulindac o baclofen (Lioresal), cyclobenzaprine (Flexeril,
(Clinoril) preferred with reduced renal function
Fexmif), tizanidine (Zanaflex), carisoprodol
Selective COX-2 Inhibitors: celecoxib (Celebrex) -
(Soma), metaxalone (Skelaxin), methocarbamol
most selective, meloxicam (Mobic), etodolac
(Robaxin)
(Lodine), nabumetone (Relafen) o cyclobenzaprine and tizanidine can cause
NSAID BBW: CV risks (thrombotic events), GI
xerostomia (dry mouth)
(bleeding), CABG contraindicated o tizanidine CI with Ciprofloxacin
naproxen has a lower CV risk
indomethacin (Indocin) has more CNS side effects so Neuropathic Pain Agents:
avoid in psych conditions pregabalin (Lyrica) max: 600mg/day
ketorolac (Toradol) can only be used for 5 days max
duloxetine (Cymbalta)
Celebrex CI with sulfa allergy
gabapentin (Neurontin) max: 3,600 mg/day
Photosensitivity
amitriptyline (Elavil) - anticholinergic
Take with food
milnacipran (Savella) - for fibromyalgia
Opioids:
Topical for Localized Pain :
BBW for respiratory depression
lidocaine (Lidoderm 5%) can cut into smaller pieces,
No tolerance to constipation so need a laxative with all
12 hours on 12 hours off, approved for post-herpetic
morphine (MS Contin, Avinza, Kadian, Oramorph
neuralgia.
SR, Roxanol) *Avinza and Kadian can be opened and
Capsaicin
sprinkled on applesauce *PO to IV is 3:1 diclofenac (Voltaren Gel)
fentanyl (Duragesic, Abstral, Fentora SL)
hydromorphone (Dilaudid)
oxycodone, Oxycontin, Endocet, Percocet, Roxicet, Migraine:
Roxicodone: Avoid with 3A4 inhibitors
oxymorphone (Opana): take on empty stomach Good to try and identify any triggers of
methadone (Dolophine): BBW for QT prolongation, migraine.
serotonergic
29
 Triptan drugs are serotonin-receptor agonists
and constrict cranial blood vessels used to
treat acute migraine.
sumatriptan (Imitrex): PO, Nasal spray, Sub
Q
rizatriptan (Maxalt) - eletriptan (Relpax)
Prophylaxis: Beta blockers like metoprol and propanolol
Gout:
Over-produce or under-excrete uric acid
Purines Xanthine Oxidase Uric Acid
People can be hyperuricemic and never get a gout attack
Drugs that increase uric acid: Diuretics, Niacin, ASA
(High dose), Pyrazinamide, Cyclosporine, Tacrolimus
Tx: Acute attack:
colchicine (Colcrys) 1.2mg orally then 0.6mg
one hour later (do not exceed 1.8mg). N/V/D
in 80% of patients. Only good within the
first 36 hours of onset
NSAIDs: Indomethacin, naproxen,
sulindac, celebrex (off-label)
Systemic Corticosteroids: prednisone,
methylprednisolone
Urate Lowering Therapy: When initiating therapy,
there is in increased risk of gout attacks so make
sure to give colchicine or NSAIDs prophylactically for
6 months.
allopurinol (Zyloprim): can cause
hypersensitivity reactions
febuxostat (Uloric)
probenecid: requires adequate renal function
pegloticase (Kystexxa) Uricase that turns uric
acid into allantoin
30
Hypertension
Diuretics:
Thiazides: Work on the distal convoluted tubule to
inhibit Na+. Sulfa Allergy. Can cause hypokalemia,
HYPERcalcemia, elevated lipids, hyperuricemia (gout),
hyperglycemia, photosensititivity, rash.
Chlorthalidone (Thalitone)
Hydrochlorothiazide
Metolazone (Zaroxolyn): may work in reduced
renal function more than others.
Loops: work in the ascending loop of Henle to inhibit
Na+. Sulfa Allergy except ethacrynic acid.
Ototoxic. Can cause hypokalemia, HYPOcalcemia,
hyperuricemia (gout), elevated lipids, hyperglycemia,
photosensititivity.
furosemide (Lasix): Oral Loop Dose Equivalency
= 40mg
bumetanide = 1mg
Torsemide (Demadex) = 20mg
ethacrynic acid (Edecrin) = 50mg
Potassium-Sparing: Work in the DCT and collecting
ducts. CI in CrCl <30 ml/min and hyperkalemia.
triamterene (Dyrenium)
triamterene + HCTZ (Maxzide, Dyazide)
amiloride(Midamor)
spironolactone (Aldactone): Can cause
gynecomastia and breast tenderness. BBW
for tumor risk.
epleronone (Inspra): for Heart Failure and HTN
RAAS Inhibitors:
***All have a BBW to discontinue if pregnant. CI in
renal artery stenosis, angioedema, and pregnancy. All
can cause hyperkalemia too.
 Angioedema (swelling of lips, mouth, tongue, face, 3.125 BID Coreg10mg Coreg CR Daily,
neck) more common in blacks. If they get 6.25BID20mg, 12.5mg BID40mg, 25mg BID80mg
angioedema, all others in the class including ARBs labetalol (Trandate): Alpha and Beta Blocker. 1st
and Aliskiren are CI. It can be fatal. line often in HTN in pregnancy.

Side note: Beta Blockers with ISA: (acebutolol, carteolol,

ACE Inhibitors:
***Can cause dry cough. If so, switch to ARB. penbutolol, pindolol)- They dont decrease HR as much.
benazepril (Lotensin)
enalapril (Vasotec)
Calcium Channel Blockers:
lisinopril (Prinvil, Zestril)
quinapril (Accupril) ***Can cause peripheral edema and gingival
ramipril (Altace) hyperplasia.
ARBs:
Non-DHP: (Work in the heart, mainly for arrhythmias)
valsartan (Diovan)
losartan (Cozaar) 3A4 substrates and inhibitors
olmesartan (Benicar): ***Can cause Sprue-like diltiazem (Cardizem)
enteropathy (severe diarrhea) verapamil (Calan, Verelan): Can be constipating
telmesartan (Micardis)
irbesartan (Avapro)
DHP: (For HTN and Angina)
Direct Renin Inhibitor:
aliskiren (Tekturna) amlodipine (Norvasc)
Do not use with with ACEi or ARB in patients nifedipine (Adalat CC, Procardia XL, Procardia)
with diabetes nicardipine (Cardene): Comes IV also
clevidipine (Cleviprex): Do no use with soy or egg allergy

Beta Blockers:
***NOT FIRST LINE FOR HYPERTENSION ANYMORE
Can alter blood glucose levels
propranolol (Inderal): Non-selective
atenolol (Tenormin)
metoprolol tartrate (Lopressor): Take with food
metoprolol succinate (Toprol XL): Used in heart
failure too. Max in HF is titrating to 200mg/day.
nebivolol (Bystolic): Also releases Nitric Oxide
carvedilol (Coreg): Used in heart failure too. Alpha
and Beta Blocker. Take with food.
Dosing conversions between Coreg and Coreg CR:
31
Centrally acting alpha 2 agonists:
clonidine (Catapres, Catapres-TTS patch): Patch is
applied weekly. Do not stop abruptly or it can cause
severe hypertension. Has many off-label uses (opioid
withdrawal, anxiety, sleep etc.) Has many side effects
(bradycardia, drowsiness, sexual dysfunction,
depression, nasal stuffiness)
gaunfacine (Tenex): Intuniv is for ADHD
Direct Vasodilators:
Hydralazine
 directly vasodilates arteries, litte effect on veins initiation or titration then every 3-12 months
Hydralazine: can cause a rare lupus-like syndrome thereafter.
fibrates (when TG are high) and fish oil can
increase LDL
Alpha Blockers: (Used mostly for BPH, not first line for HTN)
bile acid sequestrant can increase TGs
terazosin (Hytrin)
doxazosin (Cardura, Cardura XL) 4 groups should be initiated on statin therapy:
Clinical ASCVD including coronary heart
Combo Products:
disease (ACS, S/P MI, stable or unstable
amlodipine + benazepril (Lotrel) angina, coronary or arterial
amlodipine + valsartan (Exforge) revascularization), stroke, TIA, or PAD.
lisinopril + HCTZ (Prinzide, Zestoretic) LDL > 190
losartan + HCTZ (Hyzaar) Diabetes and 40-75 yrs. old with LDL
valsartan + HCTZ (Diovan HCT) between 70-189
olmesartan + HCTZ (Benicar HCT) 40-75 yrs. old with LDL between 70-189 with
bisoprolol + HCTZ (Ziac) estimated 10-year ASCVD risk > 7.5%
triamterene + HCTZ (Dyazide, Maxide)
The appropriate statin intensity is based on the
patients level of risk:
JNC 8 (Joint National Committee): High Intensity Statins: (decreases LDL > 50%)
> 60 yrs. old (<150/90) o Atorvastatin 40-80mg/day
< 60 yrs. old (<140/90) o Rosuvastatin 20-40mg/day
>18 yrs. old with CKD or Diabetes (<140/90) Moderate Intensity: (decreases LDL 30-49%)
Non-Blacks Initial Tx (including Diabetes): ACEi, o Atorvastatin 10-20mg/day
o Rosuvastatin 5-10mg/day
ARB, CCB, or Thiazide o Simvastatin 20-40mg/day
Blacks Initial Tx (including Diabetes): CCB or Thiazide o Pravastatin 40-80mg/day
If CKD, must have ACEi or ARB regardless of race o Lovastatin 40mg/day
o Pitavastatin 2-4mg/day
Low Intensity: (Decreases LDL <30%)
Dyslipidemia: o Simvastatin 10 mg/day
o Pravastatin 10-20mg/day
LDL = TC HDL (TG/5) o Lovastatin 20mg/day
Non-statin therapies are not recommended unless o Pitavastatin 1mg/day
statins are not tolerated
Statins, fibrate, and niacin require LFT check at
Statins:
baseline. For statins, recheck in 4-12 weeks after HMG-CoA reductase inhibitors

32
 **Liver enzymes need to be monitored. Stop drug if
ALT or AST > 3 times upper limit of normal
Obviously they can cause rhabdomyolysis .
Increased risk with Niacin or gemfibrozil (Lopid)
use
CI in Pregnancy
SAL are 3A4 substrates
simvastatin (Zocor), simvastatin + ezetimibe
(Vytorin) 20mg, **take in the evening.
Do not exceed 10mg/day with verapamil, diltiazem, or
dronedarone
Do not exceed 20mg/day with amiodarone, amlodipine,
or ranolazine
atorvastatin (Lipitor): equivalent dose: 10mg
Do not use with cyclosporine
Do not exceed 20mg/day with clarithromycin or
lopinavir/ritonavir
Do not exceed 40mg/day with nelfinavir and boceprevir
(Hep C)
lovastatin (Mevacor, Altoprev) 40mg,
**Mevacor with evening meal, Altoprev
bedtime.
Do not exceed 20mg/day with verapamil,
diltiazem, or dronedarone
Do not exceed 40mg/day with amiodarone
rosuvastatin(Crestor) 5mg
pravastatin (Pravachol) 40mg
pitavastatin (Livalo): most potent, 2mg
Cholesterol absorption inhibitor:
ezetimibe (Zetia)
simvastatin + ezetimibe (Vytorin)
Bile Acid sequestrant:
33
colesevelam (Welchol): also approved for Type 2 DM
to decrease A1C. Take with meals and liquid. Can cause
constipation, bloating, gas, cramping, increased
triglycerides or neutral, sipping or holding in mouth
can lead to tooth decay.
Many meds need to be taken 4 hours before or 4-6
hours after or it can bind them.
ex. Oral Contraceptives, phenytoin, levothyroxine,
olmesartan, sulfonylureas, tetracyclines and many
others.
Fibrates: PPARa Activators
fenofibrate, fenofibric acid (Tricor, Trilipix) **Only
Trilipix has indication for use with a statin
gemfibrozil (Lopid): avoid if on a statin
Can increase LDL if triglycerides are high
Can cause myopathy and hepatoxicity
Niacin: (nicotinic acid or Vit B3)
ER Niacin (Niaspan 500, 750, or 1,000 mg):***
Less flushing and Less Hepatotoxic
Hepatotoxic (monitor LFTs) and causes
Flushing/Itching. Can cause hyperuricemia
(gout) and orthostatic hypotension.
Slo-Niacin: Highest risk of hepatotoxicity
IR Max: 6 gm/day ER/CR Max: 2gm/day
Flush-free doesnt work for cholesterol
Fish Oils:
Not completely understood
Omega-3 acid (Lovaza) or Vascepa
Indicated as an adjunct in patients with TGs >500
Can increase LDL up to 44% (Only Lovaza).
Vascepa can cause joint pain (arthralgia)
Can prolong bleeding time
 Heart Failure:
Most commonly caused by ischemic heart disease
(MI) and HTN
Non-Pharmacologic Therapy:
monitor body weight daily
notify provider if symptoms worsen or weight
increases
sodium restriction to 1500 mg/day
weight reduction
exercise as tolerated
omega-3 fats are good
Avoid NSAIDs including COX-2 inhibitors
Pharmacotherapy:
**ACEi/ARB and Beta Blockers improve
survival and should be used in ALL heart
failure patients (Except when CI). Titrate
drug to target doses (from clinical trials).
Diuretics (Usually Loop)should be used to
control fluid volume (not shown to alter
survival)
Aldosterone Receptor Antagonist: Reduce
morbidity and mortality and should be added
to those who progress to NYHA Class III/IV.
**Amlodipine has a neutral effect on heart
failure. Good for further BP control.
It is a class effect with ACEi/ARBs but not
with Beta-Blockers. Only certain Beta-
Blockers are used.
Beta Blockers for HF:
Metoprolol succinate (Toprol XL): Target
dose is 200mg daily
Carvedilol (Coreg, Coreg CR): Target dose
for IR is 25mg BID (Unless >85kg then its
50mg BID) and for Coreg CR is 80mg daily.
Bisoprolol (Zebeta): Target Dose: 10mg daily
34
Beta blockers are only stopped if hypotension
or hypoperfusion is present.
Aldosterone Antagonists:
spironolactone (Aldactone) : Target
dose 25mg/day
epleronone (Inspra): Target dose 50mg/day
Hydralazine/Nitrate:
Hydralazine is a direct arterial dilator
that decreases afterload. Nitrates are
venous vasodilators that reduce
preload.
Indicated for Black people with NYHA
Class III/IV heart failure who are
symptomatic despite optimal therapy.
can be used in patients who cannot
tolerate ACEi/ARBs
isosorbide dinitrate/Hydralazine
(BiDil): CI with PDE-5 inhibitors
isosorbide mononitrate (Monoket): CI
with PDE-5 inhibitors
Digoxin (Lanoxin):
Inhibits the Na+/K+ ATP pump resulting in
positive inotropic (force) and negative
chronotropic (rate)
Does not improve survival but can decrease
hospitalizations
Improves symptoms, exercise tolerance, and
QOL
Antidote: DigiFab
Lower doses for renal insufficiency, smaller,
older, female
 Therapeutic range for HF: 0.5-0.9 ng/ml
(Higher for Afib)
Signs of toxicity: 1st signs are nausea,
vomiting, loss of appetite, bradycardia.
Blurred Vision, altered color perception,
greenish-yellow halos, confusion, delirium.
Hypokalemia, hypomagnesemia, and
hypercalcemia increase the risk of toxicity
Acute Decompensated Heart Failure:
Congestion: Diuretics and/or IV vasodilators
Hypoperfusion or Cardiogenic Shock: Milrinone or
Dobutamine
Vasodilators used in ADHF:
o Nitroglycerin: Venous at low dose, Arterial at higher
doses, effectiveness limited to 2-3 days.
o Nitroprusside (Nitropress): equal arterial and
venous, protect from light by covering with foil or
opaque material, blue solution indicates
degradation to cyanide.
o nesiritide (Natrecor): B-type natriuretic peptide,
arterial and venous dilation.
Anticoagulation:
Some risk factors for VTE: Surgery, Major Trauma,
Immobility, Cancer, previous VTE, Pregnancy, estrogen or
SERM use etc..
Heparin and LMWH can cause HIT: Body forms
antibodies to heparin which leads to further platelet
activation and pro-thrombotic state. Diagnosed by a
profound drop in platelets >50% from baseline.
**Argatroban is the DOC if this happens. DTIs do
not cross react with heparin induced antibodies.
Unfractionated Heparin:
o binds to antithrombin and inactivates Factor Xa and IIa.
35
o VTE prophylaxis: 5,000 units SC Q8-12hrs
o Also used for VTE treatment and ACS/STEMI treatment
VTE: 80 units/kg IV bolus then 18 units/kg/hr infusion
ACS/STEMI: 60 units/kg IV bolus then 12 units/kg/hr
inusion
o Do not mix-up the heparin injection with the HepFlush
heparin line flushes
o monitor aPTT and want to be 1.5-2.5 x control
o Antidote: Protamine; 1mg will reverse 100 units;
max 50mg.
o unpredictable anticoagulant response
o IV and SC
o osteoporosis with long term use
LMWH:
o binds to antithrombin and inactivates Factor Xa mostly
and some Factor IIa.
o BBW for hematomas and subsequent paralysis
with spinal punctures.(Bleeds then pushes on the
spine)
o enoxaparin (Lovenox)
**VTE prophylaxis: 30mg SC BID CrCl<
30ml/min, 30mg SC daily.
**Tx of VTE and UA/NSTEMI: 1mg/kg SC BID
CrCl< 30ml/min, 1mg/kg SC daily
**Tx for STEMI (<75): 30mg IV bolus plus
1mg/kg SC followed by 1mg/kg Q12 (Max
100mg for 1st two doses)
STEMI (>75) No bolus, just 0.75mg/kg SC Q12
(Max 75mg for 1st two doses)
o dalteparin (Fragmin)
o Anti-Xa levels can be monitored but not done
routinely unless Pregnant or Mechanical heart
valve, severe renal impairment, extreme weights.
o no antidote but protamine can help some
Factor Xa inhibitors:
Fondaparinux (Arixtra):
INJECTABLE SubQ indirect factor Xa inhibitor.
Works via antithrombin like heparins.
CI in severe renal impairment (CrCl <30
ml/min)
no antidote
Rivaroxaban (Xarelto):
o ORAL direct factor Xa inhibitor.
o A fib: 20mg PO QD (CrCl > 50); 15 mg PO QD (CrCl
15-50) with evening meal
o DVT prophylaxis (after knee/hip replacements): 10mg
PO QD without regards to meals
o DVT/PE Tx: 15 mg PO BID x 21 days then 20mg PO QD
with food
o **Can start when INR is < 3.0
o 3A4 substrate
o Do not use with CrCl< 15 ml/min
o no antidote
Apixaban (Eliquis): Similar to Xarelto
Direct Thrombin Inhibitors: (factor IIa)
directly inhibit Factor IIa (Thrombin)
Argatroban: Used in patients with HIT, no antidote
bivalrudin (Angiomax)
dabigatran (Pradaxa) :
o **ORAL
o For non-valvular A-Fib
o 150 BID; 75 BID if CrCl 15-30 ml/min
o **Can start when INR is < 2.0
o Swallow whole, do not put in NG tube.
o 50% have dyspepsia
o **Keep in original container and keep lid tightly
closed to protect from moisture. Discard after 4
months of opening bottle.
o Store in cool, dry place. Not in a bathroom
36
o no monitoring or antidote
Warfarin (Coumadin, Jantoven):
Inhibits Vit K epoxide reductase which depletes Factors
2,7,9,10, and protein C and S.
When starting, it is pro-thrombotic so use
parenteral anticoagulation for a minimum of 5 day
and until INR is therapeutic for 24 hours
INR usually 2-3
For mechanical heart valves in the mitral or aorta
and mitral often 2.5-3.5 is wanted
Pregnancy Category X
Antidote: Vitamin K; Oral is preferred when INR > 10
without bleeding. If major bleeding then IV Vit K infused
slowly and four factor PCC (Kcentra) for urgent warfarin
reversal (can cause anaphylaxis-like reaction).
Kcentra has heparin in it, so dont use with HIT.
Avoid SC Vit K b/c of variable absorption and avoid IM
due to hematoma.
Side Effects: Bleeding, Skin Necrosis, Purple Toe
Syndrome
S-enantiomer more potent
Pharmacogenomincs: 2C9*2 and *3 require lower
doses
VKOR polymorphisms require
lower doses
Chronic Stable Angina:
plaque buildup in coronary arteries reduces blood flow to
heart
Could be from Prinzmetals angina which is vasospasm of
coronary arteries, not plaque. Calcium channel blockers
preferred for this type.
Predictable chest pain
Treatment:
 Beta blockers are 1st line
ASA or Clopidogrel (for ASA allergy)
SL or spray nitroglycerin for immediate relief.
Long acting nitrates can be used for chronic therapy as
an add-on but require nitrate-free intervals.
o nitroglycerin SL tabs (Nitrostat 0.3, 0.4,
0.6mg)
o nitroglycerin SL 0.4mg (400mcg) spray
(Nitromist, Nitrolingual pump spray): do
not shake, prime it
o isosorbide mononitrate IR/ER (Monoket)
take when you wake up and then 2nd dose 5
hours later
o SE: HEADACHE (gets less bothersome),
dizziness
Moderate to high dose statin if not CI
Annual Influenza
Ranolazine (Renexa) also an option for angina. QT
prolongation, no effect on HR or BP. (anti-anginal)
Acute Coronary Syndromes: (UA/NSTEMI/STEMI):
UA: chest pain, enzyme negative, no or transient EKG
changes
NSTEMI: chest pain, cardiac enzymes (troponins, CK-MB),
no or transient EKG changes
STEMI: chest pain, cardiac enzymes (troponins, CK-MB),
ST Elevation
Initial Treatment: (MONA)
Morphine, Oxygen, Nitrates, Aspirin (162-325mg, then 81mg
daily)
Then, other therapies added based on what is
planned for the patient (GAP-BA)
GP 11b/IIIa anatagonist (abciximab (ReoPro),
eptifibatide (Integrelin), tirofiban): Abciximab
37
irreversibly blocks. Can cause bleeding,
thrombocytopenia, hypotension.
Anticoagulants (Heparin, LMWH, fondaparinux, bivalrudin):
P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor): Prasugrel
not for CABG. Clopidogrel requires 2C19 for activation.
Beta Blocker: within 24 hours without CI
ACE inhibitor: within 24 hours without CI
PCI is usually preferred if facilities are available.
Fibrinolytics used when facilities for PCI are not available or
when PCI cannot be done within 90 min. Fibrinolytics should be
started within 30 min. of arrival to hospital.
Fibrinolytics: alteplase, tenecteplase
NSAIDs not recommended post-MI due to risk of re-
infarction. (Use ASA or Tylenol)
Antiarrhythmics:
Usually from myocardial ischemia or infarction. Also
from things that damage the heart like HTN, heart
failure, hyperthyroidism, infection etc..
Electrolyte imbalances can cause arrhythmias
(potassium, sodium, magnesium, calcium)
Drugs, including drugs to treat arrhythmias can
cause it.
Afib is the most common supraventricular
arrhythmia and usually results in a rapid
ventricular response.
QT prolongation is a risk factor for Tosades de
Pointes, usually drug-induced and can lead to
sudden cardiac death.
Additive QT Prolongation: Class 1a and Class III
antiarthymics, quinolones, macrolides, SMX/TMP,
azole antifungals, TCAs, some SSRIs (Citalopram,
 paroxetine, fluoxetine, escitalopram),
antipsychotics, methadone, 5HT3 anatagonists
(ondansetron), PIs, anti-cancer drugs etc..
Class Ia: (quinidine and procainamide) block sodium
and potassium channels. Additive QT
prolongation.
Class Ib: (lidocaine) pure sodium channel blockers.
Only for ventricular arrhythmias. Cross BBB and
so can have CNS effects.
Class Ic: (flecainide, propafenone) sodium channel
Group 2 is PH, which is pulmonary venous HTN form left-sided
blocker. CI in heart failure and acute MI.
heart failure.
Class II: Beta Blockers (esmolol, propranolol) used
to slow ventricular rate.
Class III: (amiodarone (Cordarone, Pacerone,
Nexterone), dofetilide (Tikosyn, has REMS
program calls TIPS), dronedarone, ibutilide, sotalol)
mainly block potassium channels. Amiodarone is
the DOC if they have concomitant Heart Failure.
It can cause Corneal deposits, photosensitivity,
neuropathy, increased LFTs and blue-grayish
skin, pulmonary fibrosis. All have Additive QT
prolongation.
Class IV: Calcium Channel Blockers (diltiazem,
verapamil)
Others: Digoxin (Lanoxin): Hypokalemia,
hypomagnesemia, and hypercalcemia increase
risk of digoxin toxicity. **Therapeutic range for
Afib: 0.8-2 ng/ml. Enhances vagal tone.
SABA: (For Rescue PRN)
Pulmonary Arterial Hypertension:
Group 1 is PAH: can be idiopathic, genetic, liver disease, HIV
etc.
Warfarin titrated to INR of 1.5-2.5
prostacyclin analogues
38
endothelin receptor antagonists
soluble guanylate cyclase stimulator: riociguat
(Adempas): CI with PDE-5
PDE-5 inhibitors: sildenafil (Revalo) or Tadalafil
(Adcirca) : Different Brands and doses than used in ED.
CI with nitrates. If a patient is taking a PDE-5 inhibitor
and has chest pain, hold nitrates for 24 hours with
sildenafil and vardenafil and 48 hours for tadalafil
(tadalafil has longer half-life).
Asthma:
bronchial hyper-responsiveness and underlying
inflammation
chronic inflammatory disorder of the airways
Having patients demonstrate correct technique is often a
good idea
Wheezing, breathlessness, chest tightness,
coughing; often at night or early in the morning
Common Triggers: Allergens, Drugs (NSAIDs, ASA,
non-selective BBs), Cold air or humid hot air, smoke,
chemicals, Respiratory Infections.
Inhaled steroids are the preferred controller
(sometimes with LABA). Inhaled rapid-acting beta
agonist preferred reliever for acute bronchospasm and
prevention of EIB (Exercise-Induced Bronchospasm).
albuterol (ProAir, Proventil, Ventolin)
levalbuterol (Xopenex)
If using SABA > 2 days/week then increase
maintenance therapy
LABA: (***BBW to only used with steroids, not
monotherapy b/c increased risk of death)
Once asthma is controlled, assess for stepdown
therapy (removal of LABA) without loss of asthma
control.
salmeterol + fluticasone (Advair Diskus or HFA)
fomoterol + budesonide (Symbicort)
Inhaled Corticosteroids: (1st line therapy)
beclamethasone (QVAR): ** preferred in pregnancy
budesonide (Pulmicort)
fluticasone (Flovent)
mometasone (Asmanex)
SE: Oral Candidiasis (Thrush), dysphonia, cough.
**Prevent thrush with spacer or rinsing mouth with
warm water and spit after use
Oral Steroids: (for severely uncontrolled asthma)
Cortisone, hydrocortisone (Solu-Cortef),
methylprednisolone (Medrol, Medrol Dosepak, Solu-
Medrol), Prednisone, Prednisolone (Millipred,
Orapred, Prelone), triamcinolone (Kenalog),
dexamethasone (Decadron), betamethasone
If on it more than 10-14 days, requires a taper
Long-Term SE: Cushing Syndrome, Immunosuppression,
Acne, Insomnia/Nervousness, Hypokalemia, Amenorrhea,
Osteoporosis, Weight Gain, Diabetes, GI Bleed etc..
Methylprednisolone 4mg = Prednisone/Prednisolone
5mg = 0.75mg Dexamethasone
Leukotriene Receptor Antagonist:
montelukast (Singulair):
10mg QD, 1-5 yrs. old (4mg), 5-14yrs. old
(5mg)
can cause headache and neuropsychiatric
behavior
39
For EIB, only works in 50% of patients, take
2 hours before exercise
has phenyalanine in it for a sweetener so dont
use in PKU
Theophylline:
not the most effective and has many drug
interactions/side effects
Therapeutic range: 5-15 mcg/ml
SE: nausea, loose stools
Aminophylline to Theophylline multiple by 0.8
Theophylline to Aminophylline divide by 0.8
Omalizumab (Xolair):
For severe, allergic asthma. Inhibits IgE binding on
mast cells and basophils
Should always be given in the doctors office
can cause Anaphylaxis
COPD:
causes by cigarette smoke and other noxious chemicals
dyspnea, chronic cough/sputum production
smoking cessation is the only thing that slows the
progression
SABA and SAMA: Ipratropium (Atrovent),
ipratropium + albuterol (Combivent Respimat)
LABA and LAMA: tiotropium (Spiriva Handihaler) or
aclidinium (Tudorza) More effective and more
convenient. SE: Dry mouth.
PDE-4 inhibitor: roflumilast (Daliresp): increases CAMP
and decreases lung inflammation
Steroids: long term monotherapy are not recommended
in COPD, not very effective. Used in combo with LABA.
(Advair and Symbicort)
Get Vaccines
Smoking Cessation:
 Counseling and medication are more effective used
together than either alone. Strong correlation
between counseling intensity and quitting
success.
5 As: Ask, Advise, Assess, Assist, Arrange
(Follow Up)
Allergic Rhinitis Hay Fever:
Patients often fail when they do not use enough
NRT for a clinical effect.
Gum, Lozenge, and Patch are OTC only to 18 yrs.
and older
Nicotine Gum (Nicorette 2mg or 4mg) max: 24
pieces/day. Tapered dose. One Q1-2hrs. x 6weeks,
then Q2-4 hrs. x 3 weeks, then Q4-8 hrs. x 3 weeks.
Avoid acidic beverages (15 min. before or during Tx,
water is ok.) <25 cigs/day = 2mg >25 cigs/day =4mg
Nicotine Lozenges (Commit 2mg or 4mg) max: 20
lozenges/day. <30min to smoke in the AM =4mg;
>30min to smoke =2mg
Nicotine Patches (Nicoderm CQ 7mg, 14mg, 21mg): Can
remove to avoid insomnia. Local skin reaction
common. <10 cigs/day = 14mg >10cigs/day=21 mg.
6 weeks (21mg), then 2 weeks (14mg), then 2 weeks
(7mg) or 6 weeks (14mg), then 2 weeks (7mg)
Nicotine Inhaler: Frequent, continuous puffing for 20 min.
Clean mouthpiece. In cold temps, keep in warm area like
pocket. Once a cartridge is open, only good for 1 day.
e-cigarettes: not FDA approved, but popular
Buproprion SR (Zyban, Buproban): Start 1 week
before quitting, max: 450mg/day bc of seizures. SE:
Dry mouth/insomnia. BBW for neuropsychiatric events.
Varenicline (Chantix): Nicotine agonist/ antagonist;
Start 1 week before quitting. Do not use with nicotine
products. BBW for neuropsychiatric events.
Insomnia and Vivid Dreams.
Get Vaccines: Smokers 19-64 should get the
Pneumovax
40
Only gum and lozenge nicotine are pregnancy C,
others are D.
Allergic Rhinitis, Cough and Cold:
Avoid exposure to allergens
Moderate to severe: Intranasal Steroids 1st line :
fluticasone (Flonase or Vermyst), mometasone
(Nasonex), triamcinolone (Nasacort),
beclamethasone (Qnasl or Beconase), budesonide
(Rhinacort)
Mild to Moderate: Oral antihistamines (Usually 2nd
Gen): Good for sneezing, itching, rhinorrhea, but has
**minimal effect on congestion.
diphenhydramine (Benadryl): 1st gen, 25-
50mg PO Q4-6 hrs. Sedating.
chlorpheniramine (Chlor-Trimeton): 1st gen
preferred in pregnancy
cetirizine (Zyrtec)
levocetirizine (Xyzal)
loratidine (Claritin)
desloratidine (Clarinex)
fexofenadine (Allegra)
azelastine (Astelin): Intranasal
Decongestants: alpha agonists that cause
vasoconstriction to reduce congestion:
Oral: phenylephrine (Sudafed PE) : low
bioavailability
pseudoephedrine (Sudafed): Max able
to buy: 3.6 g/day or 9 g/month, Max intake is
240mg/day.
Nasal: Oxymetazoline (Afrin) or
phenylephrine (Neo-Synephrine). Limit use
to < 3days to prevent rebound congestion
 Others: cromolyn (Nasalcrom), Intranasal ipratropium
(for rhinorrhea to dry mucus), Singulair, Nasal irrigation
Cold/Cough:
Zinc: can decrease duration of a cold
Vitamin C: may help prevent a cold
Usually a Viral Infection (ex. Rhinovirus)
Advise patients to stay well hydrated
Humidifiers and Vaporizers can be useful. Do not use
topical menthol or camphor in children less than 2
yrs. old.
Children: OTC cough/cold/pain or aches products
should not be used in children < 4 yrs. old. Combo
cough/cold products should not be used in children <2
per FDA or <6 per American Academy of
Pediatrics. Do not use ASA due to risk of Reyes
syndrome.
ibuprofen (5-10 mg/kg Q 6-8 hrs.)
Formulation 50 mg/1.25mL or 100mg/5ml
APAP (10-15 mg/kg Q4-6 hrs.)
Formulation 160 mg/5mL
Use calibrated syringe for measuring if its
an oral liquid dispensed
Decongestant: Do not use in children < 6 yrs. old
except PSE (not < 4 yrs.). If pregnant, use
intranasal spray like Oxymetazoline or
phenylephrine b/c oral PSE can decrease blood
flow to infant.
Cough:
Dextromethorphan (Delsym or DM in the name):
Many mechanisms but is also a serotonin reuptake
inhibitor. Often abused by people when taken in larger
doses due to its ketamine/PCP like hallucinagenic affects.
Probably safe during pregnancy.
41
Antihistamines: dont work for cold symptoms. May
help cough.
Codeine: Never dispense codeine to a
breastfeeding woman; can cause fatal respiratory
depression in an infant.
Gauifenasin (Mucinex): decrease phlegm viscosity,
unclear benefit.
Cystic Fibrosis:
genetic disorder that disrupts CFTR protein causing
abnormal transport of sodium and chloride across cells
leads to thick, viscous lung secretions, difficulty
breathing, infections, and digestive complication (Kills
the pancreas).
Infections usually intermittent at first and
eventually become chronic where they may need
inhaled antibiotics.
If intermittent pseudomonas, treat with two IV anti-
pseudomonal agents.
Most common bugs: Staph. Aureus, H. Flu, Pseudomonas.
Treatment:
Bronchodilators: Use before giving inhaled
antibiotics to help antibiotic get in.
Hypertonic Saline (Hypersal): hyrdrates airway
mucus to thin secretions
DNAse enzyme: dornase alfa (Pulmozyme) to
thin mucous
Inhaled antibiotics: Tobramycin Inhaled
Solution (TOBI) or TOBI Podhaler or Aztreonam
Lysine Inhalation (Cayston) to prevent and treat
lung and sinus infections with chronic infections. Take
doses TOBI 6 hours apart and Cayston 4 hours apart.
Solutions stored in fridge, Podhaler xcapsules at room
 temp. in a dry place. 28 days on, 28 days off
cycle.
Oral Azithromycin: to reduce airway inflammation
and disrupt Pseudomonas biofilm
High Fat, calorie-dense diet
Pancreatic Enzymes: Peancrealipase
(Creon,Pancreaze, Zenpep, Viokase): contains
lipase, amylase, and protease. Dose adjusted
based on lipase component until stools are
normalized. Given before meals and snacks.
Snacks get 50% of the dose. They are not
interchangeable. Viokase is taken with a PPI b/c its
not enteric coated.
Vitamin ADEK
Insulin
Ivacaftor (Kalydeco): used for G551D mutations (4-5%
of population have this type). Taken with high-fat
meal.
Oncology:
Treated with surgical, radiation, chemotherapy, hormone
therapy, biological therapy, targeted therapy,
immunotherapy and/or vaccines.
Majority of adverse effects are due to damaging non-
cancerous cells that divide rapidly. Thus, nausea,
vomiting, alopecia, and myelosuppression are common.
Myelosuppression: All except asparaginase,
bleomycin, and vincristine. Cells generally recover
after 3-4 weeks post-treatment.
o Anemia: Serum Ferritin, transferrin saturation (TSAT),
and total iron binding capacity may be ordered b/c
ESAs like (epoeitin (Epogen) and darbopoetin
(Aranesp) will not work well unless iron levels are
adequate. ESAs can shorten survival and increase
risk for tumor progression in some cancers. Must
42
enroll in and comply with the ESA APPRISE Oncology
Program REMS to use these agents with cancer. Also
only used if HgB < 10. Not used when anticipation is
cure b/c they can cause thrombosis and tumor
progression. SC and IV
o Neutropenia: Colony stimulating factors (CSFs)
can be given prophylactically to patients at high-risk for
febrile neutropenia. Sargramostim (Leukine),
Filgrastim (Neupogen), and Pegfilgrastim
(Neulasta). They can cause bone pain.
o Thrombocytopenia: Chemo might get placed on hold,
dose reduction, or a transfusion(<10,000 or <20,000
with active bleed)
Hepatotoxic: Many
Nephrotoxic/ Bladder Toxic: Many; Hydration helps flush
drug out. Amifostene used to reduce risk of cisplatin
renal toxicity. Mesna(Mesnex) given with ifosfamide to
prevent hemorrhagic cystitis.
Mucositis: high risk with 5-FU, capecitabine, irinotecan,
and methotrexate. Use saline rinses daily.
Hand-Foot Syndrome: 5-FU, and capecitabine
Clotting: Often from SERMS
Alopecia: Taxanes and anthracyclines
Cardiotoxicity: Anthracyclines
Nausea/Vomiting: Most Chemo Drugs especially
cisplatin, doxorubicin, epirubicin, cyclophosphamide,
isofosfamide. CTZ receptors are 5HT, Dopamine, Ach,
Histamine, Opioid, and Substance P.
o usually uses a combination of anti-emetic drugs
o Ondansetron (Zofran, Zuplez film), granisetron
(Granisol), dolasetron (Anzemet), palonosetron
(Aloxi): 5-HT3 antagonists, risk of QT prolongation
o prochlorperazine (Compro) and promethazine
(Phenergan): block dopamine receptors in CNS. SE:
sedation, lethargy, acute EPS
o dexamethasone (Decadron)
 o aprepitant(Emend) and fosaprepitant (Emend Phase with single strand breaks. SE: Acute Diarrhea
IV): substance P/Neurokinin-1 receptor antagonist (treat with atropine), Delayed Diarrhea (treat with
o dronabinol (Marinol): Cannabinoid. SE: drowsy, loperamide)
euphoria, increased appetite
Topoisomerase 2 inhibitors: etoposide(VePesid).
Blocks coiling and uncoiling of DNA in G2 Phase with
Some Chemo drugs used in many cancers: single strand breaks. SE: Hypotension
Alkylators: Cyclophosphamide (Cytoxan) and
Taxanes: paclitaxel (Taxol) and docetaxel
ifosfamide (Ifex). They cross-link DNA preventing
(Taxotere): Inhibit microtubule function in M-Phase.
replication. SE: Bladder Toxicity/BBW
Must use non-pvc IV bag and tubing. SE: peripheral
***Hemorrhagic Cystitis so give Mesnex to prevent.
neuropathy. BBW for neutropenia. Always give
before platins.
Anthracyclines: DOXOrubicin(Adriamycin) and
DAUNOrubicin (Cerubidine). Intercalate into DNA. SE: Vinca Alkaloids: vincristine (Vincasar) and
BBW ***Cardiotoxicity, Vesicant/Extravasation, red
vinblastine (Velban): Inhibit microtubule function in M-
urine/body secretions. Do not exceed lifetime dose
Phase. SE: Vesicants, nerve damage/neuropathy
of 450-550 mg/m2 with DOXOrubicin and 400-550
(mostly vincristine). BBW: Intrathecal injections
with DAUNOrubicin. Extravasation is treated with
are fatal. Use hyaluronidase for extravasation.
dexrazoxane (Totect) or DMSO.

Platinums: cisplatin (Platinol), carboplatin

Monoclonal antibodies: (Inhibit growth factors that
(Paraplatin), oxaliplatin (Eloxatin). Cross link DNA
promote cancer cell growth)
causing apoptosis. SE: Nephrotoxic, Ototoxic, Traztuzumab (Herceptin): HER2/Neu over-
neuropathy. Cisplatin has severe N/V.
expression required for use. Cardiotoxicity
Amifostene to reduce cisplatin nephrotoxicity.
Cetuximab (Erbitux): EGFR positive = good
Methotrexate: folate antimetabolite that prevents DNA response, K-ras mutation = poor
Rituximab (Rituxan): Targets CD-20, also
synthesis in the S-Phase. Leucovorin rescue to
used in RA
decrease toxicity. SE: Hand-foot syndrome
Prostate Cancer:
Pyrimidine Analogues: capecitabine (Xeloda) and
Antiandrogens: bicalutamide (Casodex) and
Fluorouracil (5-FU). Inhibits pyrimidine synthesis in the
flutamide (Eulexin)
S-Phase. SE: Hand Foot syndrome. CI with DPD
LHRH agonists: goserelin (Zoladex) and leuprolide
deficiency. Leucovorin increases efficacy of 5-FU.
(Lupron): start antiandrogen 1 week before to prevent
Topoisomerase 1 inhibitors: ironotecan tumor flare.
(Camptosar). Block coiling and uncoiling of DNA in S-
43
Breast Cancer: (hormonal therapy to prevent recurrence, not
the actual conventional chemo treatment)
Must have ER/PR+ cancer for these to work
Aromatase Inhibitors: anastrozole (Arimidex),
letrozole (Femara), exemestane (Aromasin). Inhibit
conversion of androgens to estrogen. SE:
Osteoporosis, menopausal symptoms.
SERMs: tamoxifen (Soltamox), fulvestrant
(Faslodex), raloxifene (Evista)- Also for
osteoporosis. Estrogen antagonists in breast but
agonists in other tissues. SE: DVT/PE, menopausal
symptoms. Tamoxifen increases risk of endometrial
cancer.
Chronic Myeloid Leukemia:
imatinib (Gleevec) : Tyrosine Kinase Inhibitor (TKI).
Requires testing for bcr-abl fusion gene.
Non-small cell lung cancer:
erlotinib (Tarceva): TKI targeting EGFR
Multiple Myeloma:
Signs of myeloma (CRAB): Calcium elevated, renal
failure, anemia, bone lesions
cancer of plasma cells in bone marrow
Thalidomide (Thalomid) and its derivatives. Do not
get pregnant while using, very teratogenic.
Anemia:
Decrease in RBCs and/or Hgb and Hct.
Mainly caused by impaired production, increased
destruction, or blood loss.
Iron is essential for Hgb formation. If iron is low, ESAs
will not work so correct iron first.
44
Most people can use oral supplementation for iron. Iron
IV is often used for hemodialysis.
Iron Deficiency Anemia: MCV (<80) and MCH Low
(Microcytic)
Oral Ferrous Sulfate is 1st line (not SR or
Enteric Coated). Absorption is enhanced by
acidic gastric environment. Take 1 hour before
meals b/c food will decrease absorption.
325 mg PO TID
SE: Nausea/Constipation. May want to use
docusate stool softener.
Separate from chelators: FQ, tetracyclines,
bisphosphonates etc..
Iron overdose is the leading cause of poisoning
deaths in young children. Antidote for overdose
is deferoxamine.
IV iron: sodium ferric gluconate (Ferrlecit) or
Iron sucrose (Venofer). Usually used for
hemodialysis. Iron dextran has a BBW for
anaphylaxis.
Folate or B12 Deficiency Anemia: MCV (>100) and
MCH High (Macrocytic)
can lead to neurological consequences
Pernicious anemia is when there is a lack of
intrinsic factor required for gut absorption of
B12 and folate. The Schilling test can diagnose
this. They will require lifelong B12 replacement,
usually by B12 injection.
cyanocobalamin (B12) and folic acid
(folate/vitamin B9)
metformin may decrease B12 absorption
Anemia of Chronic Disease: MCV and MCH normal
Chronic Kidney Disease: causes anemia via
deficiency in erythropoietin. May need ESAs
at the lowest possible dose started when
 Hgb is < 10. Transferrin should be at least
20% and ferritin should be at least 100 ng/ml
prior to starting ESA.
Sickle Cell Disease:
genetic disorder that causes shape of Hgb and RBC to
change. They cannot transport oxygen properly and get
stick in smaller blood vessels.
This can deprive tissues of oxygen leading to
ischemia and pain (sickle cell crisis or vaso-
occlusive crisis)
ACS is the leading cause of death in SCD. 35% of infants
die from infections. Chronic anemia is likely.
Treatment: Vaccines, Antibiotics, Analgesics, Folic
Acid, and Hydroxyurea (stimulates fetal Hgb)
IV Drugs, Fluids, and Antidotes:
Peripheral IV: placed in a small vein
Central IV: placed in a large vein. Example is a
peripherally inserted central catheter (PICC). Can give
meds that would be overly irritating to peripheral veins
like higher doses or greater volumes. Disadvantages:
higher bleeding risk, infection, thromboembolism,
and more difficult to insert.
Concern with PVC:
Leaching: Drugs pull out DEHP from bag:
tacrolimus, temsirolimus, teniposide,
cabazitaxel, docetaxel, ixacabepilone, and
paclitaxel.
Sorption: PVC bag pulls in drug: Amiodarone,
carmustine, lorazepam, sufentanil,
thiopental, insulin, nitroglycerin.
45
Colloids and Crystalloids: Colloids do not readily cross
capillaries (stay in veins) and may provide more
intravascular volume expansion than equal volumes of
crystalloids, but they are expensive. Crystalloids are
less costly and safer.
Shock: (Hypovelemic, Cardiogenic, Distribuitive,
Obstructive, Neurogenic)
Fluid Resuscitation is 1st line
Vasopressors: not effective without adequate fluid.
o Dobutamine: B1 Inotrope that increases HR,
Contractility, and CO.
o Dopamine: At medium doses B1 (SV/CO), at
higher doses a1 (vasoconstriction)
o Epinephrine (Adrenaline): alpha and beta.
o Norepinephrine(Levophed): a1 (mostly) and
beta
o Phenylephrine (Neo-Synephrine): all a1
(vasoconstriction)
o Vasopressin: V1 and V2 agonist
(vasoconstriction)
***The vasoconstrictors can cause peripheral
ischemia and necrosis (gangrene)
***If extravasation, treat with phentolamine (alpha
blocker)
ICU sedation, analgesia, and delirium:
Optimize analgesia first, usually fentanyl,
morphine, hydromorphone
Sedation usually with benzos (midazolam),
propofol, or dexmedetomidine (Precedex). Propofol
can cause infusion reactions that result in cardiac
arrhythmias and death.
Patients should frequently be assessed with
a validated sedation scale to adjust
therapies.
 The ACCM recommends using Precedex to Patients without risk factors should not receive
sedate patients with delirium. prophylaxis (Mechanical Vent, Coagulopathy, Sepsis,
Brain Injury, Burns, Renal Failure, High Dose Steroids)
H2 blockers
Commonly used agents for agitation and VTE prevention:
sedation:
High Risk: Surgery, trauma, immobility, cancer,
lorazepam (Ativan) previous VTE, pregnancy, estrogen etc..
midazolam UFH: 5,000 units SC BID-TID
propolol (Diprivan): propofol infusion related LMWH: Enoxapin 30mg SC BID or 40mg SC Daily. If
syndrome(PRIS), rare but can be fatal. CrCl<30, use 30mg SQ Daily
Hypertriglycerides
dexmedetomidine (Precedex): **Sedation without Anesthesia:
Respiratory Depression must be closely monitored
morphine: has active metabolite M6G, hypotension Inhaled anesthetics can cause malignant
from histamine release hyperthermia and should be given dantrolene.
fentanyl: less hypotension than morphine b/c no Neuromuscular blockers: cisatracurium (Nimbex)
histamine release and Vecuronium . Do not provide sedation or
hydromorphone (Dilaudid)
analgesia.
haloperidol (Haldol): QT prolongation, EPS
IV compatibility resources:
Acid-Base Homeostasis:
Trissels
pH < 7.35 is acidosis, pH > 7.45 is alkalosis
King Guide
Metabolic or Respiratory
Anion gap: Na+ - (Cl- + HCO3-) > 12 is gapped Poison Management:

Electrolyte Disorders: Insecticide Poisoning/Nerve Agents:

Organophosphates that inhibit acetlycholinesterase,
Sodium: Dont correct more than 12mEq/L in 24
leads to increase Ach. MUDDLES: miosis (pinpoint
hours to prevent central pontine myelinosis which is a
pupils), urination, diarrhea, diaphoresis, lacrimation,
devastating neurological complication.
excitation, salivation
Potassium: IV potassium should not be faster than
10-20 mEq/hr.
Antidotes for select toxicities:
Stress Ulcer Prophylaxis:
APAP: N-acetylcysteine
Critical illness leads to reduced blood flow to gut which Anticholinesterase: Atropine
results in breakdown of gastric mucosal defense Benzos: Flumazenil (Romazicon)
mechanisms Beta Blockers: Glucagon
46
 Digoxin: Digoxin Immune Fab (Digifab)
Heparin: Protamine
Iron: deferoxamine (Desferal)
Isoniazid: (Pyridoxine Vit B6)
Opioids: Naloxone
Warfarin: phytonadione (Mephyton) = Vitamin K
Depression:
Inform patients that physical symptoms such a slow
energy improve within a few weeks but psychological
symptoms may take a month or longer.
All drug therapies should be given with competent,
concurrent psychotherapy. (rarely done)
To avoid withdrawal when discontinuing, the drug
should be tapered.
Withdrawal symptoms: anxiety, agitation,
insomnia, dizziness, flu-like symptoms.
(Paroxetine and some others carry a high-risk)
Should do a 6-8 week trial at an adequate dose before
concluding its not working well.
Going to or from an MAOi requires 2 week washout
period except fluoxetine requires 5 weeks because
of its long half-life. MAO interaction can be lethal
if taken with other serotonergics.
Pregnancy:
FDA warning that SSRIs can cause
persistent pulmonary hypertension in the
newborn (PPHN).
Paroxteine (Paxil) is category D, paroxetine
(Brisdelle) is category X. Brisdelle is for
menopausal symptoms.
PTSD:
After a life-threatening experience or an event
that involves a threat to life or serious injury.
47
Many physical, cognitive, emotional, and
behavioral symptoms.
Sertraline and Paroxetine are FDA approved
for this
SSRIs:
BBW for increased risk of suicidal thinking in
children, adolescents, and young adults (18-24)
can cause persistent pulmonary hypertension in
the newborn (PPHN)
SE: increased bleeding risk, sexual dysfunction (not
erection), insomnia, somnolence, SIADH (hyponatremia)
Fluoxetine (Prozac): Can take 90mg/week, 2D6
inhibitor, most activating so take in the morning if
you have insomnia with it. Sarafem is used for
pre-menstrual dysphoric disorder.
Paroxetine (Paxil): 2D6 inhibitor
Sertraline (Zoloft)
Citalopram (Celexa): **QT prolongation risk with
>40mg/day, or >20mg/day and over 60, or liver
disease, or 2C19 poor metabolizers.
Escitalopram (Lexapro): Can also cause QT
prolongation
DNRI: (DA and NE reuptake inhibitor)
bupropion (Wellbutrin); Zyban or Buproban for
smoking cessation
CI: do not use in seizure disorder, do not exceed
450mg/day (seizures), do not use in bipolar, do not
use in anorexic
No effects on 5HT so no sexual dysfunction or
bleeding
SE: insomnia and dry mouth
SNRIs: deispramine
nortriptyline (Pamelor)
SE: same as SSRI plus Increased BP, urethral
resistance, MAOi:
venlafaxine (Effexor)
Inhibit monoamine oxidase which normally breaks down
desvenlafaxine (Pristiq)
catecholamines 5HT, DA, NE, EPI.
duloxetine (Cymbalta): CYP2D6 inhibitor
Not commonly used but watch for drug-drug and
levomilnacipran (Fetzima)
drug-food interactions
Can lead to hypertensive crisis, serotonin
Mixed SSRI and 5HT-1A partial agonists: syndrome, and psychosis if combined with other
drugs.
vilazodone (Viibryd) isocarboxazid (Marplan)
vortioxetine (Brintellex) phenelzine (Nardil)
Other: tranylcypromine (Parnate)
selegiline
mirtazapine (Remeron): inhibits 5HT reuptake and
Treatment resistant depression:
a1-blocker and antihistamine
SE: sedation and weight gain from increased aripiprazole (Abilify)
appetite olanzapine/fluoxetine (Symbyax)
used in oncology and skilled nursing homes quetiapine (Seroquel)
to help with sleep and weight gain in elderly
trazodone: inhibits 5HT reuptake and a1-blocker and
5HT2A/C blocker. Mainly used for sedation, rarely as
antidepressant.
Schizophrenia/Psychosis:
SE: sedation and priapism ***BBW for all anti-psychotics is increased death in
Tricyclics: elderly with dementia-related psychosis, primarily
due to increase strokes and infection.
NE and 5HT reuptake inhibitors primarily but also chronic relapsing, remitting episodes that are a result of
anticholinergic and antihistamine excess dopamine
more side effects than others Has positive and negative signs
Tertiary or Secondary amines: Secondary are more Positive Signs: Hallucinations, delusions (false
selective for NE but might not be as effective beliefs)
QT prolonging, Orthostasis, Anticholinergic (Dry Negative Signs: Anhedonia (loss of interest), lack of
mouth, blurred vision, urinary retention, emotion, poor hygiene, social withdrawal
constipation), sedation, weight gain etc.. Treatment adherence can be difficult to obtain
Amitriptyline (Elavil) One of the highest suicide rate
Doxepin
48
 1st Gens (more EPS and sedation, less weight
gain/metabolic SE), 2nd Gens (Less EPS, more
weight gain/metabolic SE)
Neuroleptic Malignant Syndrome: Extreme Muscle
Rigidity and Hyperthermia (rare and mainly with 1st
gens.)
Clozapine has high efficacy but has many BBWs and
side effects. It should be considered for those who have
failed with trying two others.
ODTs useful for cheeking where patients will cheek
the medicine and then spit it in the toilet.
Quetiapine has a low risk for movement disorders
and is recommended for psychosis with
parkinsons disease.
CV risk: Ziprasidone and Thioridazine have highest
QT prolonging risk
Weight Gain/Metabolic Effects: Clozapine,
Olanzapine, Quetiapine, Risperidone, and
Paliperidone.
Prolactin: Inhibiting dopamine can increase milk
production and lead to osteoporosis. Highest risk
with Risperidone and Paliperidone.
1st Gens:
Block D2 and 5HT2A
Thioridazine, Haloperidol (Haldol),
Chlorpromazine, Loxapine, Perphenazine,
Fluphenazine, Thiothixene
All cause EPS (Dystonia, Akathisia, Parkinsonism,
TD, Dyskinesia etc..) and are sedating. Tardive
Dyskinesia (TD) can be irreversible (higher in
elderly females).
2nd Gens:
49
Block D2 and 5HT2A (except Abilify, it blocks 5HT2A
but is a partial agonist at D2 and 5HT1A)
**Weight gain/metabolic side effects.
Clozapine (Clozaril): most effective but can
cause agranulocytosis ,*seizures, and
myocarditis. REMS- Patients must register with
the Clozaril registry. Only pharmacies
registered for this can dispense it.
Olanzapine (Zyprexa):
Quetiapine (Seroquel): least movement issues
Ziprasidone (Geodon): High QT prolongation
risk
Aripiprazole (Abilify)
Paliperidone (Invega): increased Prolactin
Risperidone (Risperdal): increased Prolactin
Lurasidone (Latuga)
Bipolar Disorder:
Show periods of mania and depression. Bipolar I is more
severe. Bipolar II has less severe mania (Hypomania)
that does not have psychotic features or need
hospitalization.
Mood Stabilizer (lithium, valproate,
carbamazepine (Equetro), lamotrgine) are defined
as drugs that can treat mania or depression without
inducing either.
1st gen antipsychotics can push them to
depressive state but 2nd gens do not and some 2nd
gens have antidepressant effects.
Antidepressants can push them to mania so only
use them if there is a mood stabilizer also.
Treatment: Mood Stabilizer, 2nd Gen Antipsychotic,
or Combo of both.
Mood Stabilizers:
 valproate/valproic acid (Depakene, Depacon,
Stavzor): BBW teratogenic, hepatic failure,
pancreatitis; inhibits 2C9
Divalproex (Depakote): BBW teratogenic, hepatic
failure, pancreatitis
lamotrigine (Lamictal): BBW skin reactions (SJS
and TEN), not used in mania.
Lithium (Lithobid): DO NOT USE IN RENAL
IMPAIRMENT (100% renally cleared); Therapeutic
range is 0.6-1.2 mEq/L trough. SE: GI, Cognitive,
cogwheel rigidity, hand tremor, weight gain,
polyuria,polydipsia, serotonergic. Maintain
adequate fluid intake and keep salt constant.
2nd Gen Antipsychotics used:
Aripiprazole (Abilify), quetiapine (Seroquel),
risperidone (Risperdal), ziprasidone (Geodon),
lurasidone (Latuda), olanzapine (Zyprexa)
Parkinson Disease:
Substantia nigra part of brain has cells that make
dopamine. When they are damaged and stop making
dopamine. This is what causes the disease.
Tremor, bradykinesia (slow movements), rigidity
(stiffness), postural instability
Most have depression from it and tricyclics
(nortriptyline) seem to work best
Psychosis can happen in later stages and
*quetiapine (Seroquel) is preferred.
***Drug induced (Dopamine Blockers):
prochlorperazine (D2 blocker for nausea),
antipsychotics, metoclopramide (Reglan: D2
blocker and prokinetic from muscarinic activity).
Treatment:
50
carbidopa/levodopa (Sinemet): 70-100 mg of
carbidopa is needed to prevent the peripheral
conversion of Levodopa to DA by dopa
decarboxylase. Can cause brown, black or dark urine.
Can cause unusual sexual urges and priapism.
entacapone (Comtan): inhibits COMT to prevent
peripheral breakdown of levodopa.
pramipexole (Mirapex) and ropinirole (Requip):
Dopamine agonists. Also bromocriptine.
amantadine (Symmetrel): blocks dopamine
reuptake and increases release. SE: Toxic delirium
and livedo reticularis (redish skin mottling). Also
used in Flu as a neuramidase inhibitor.
benztropine (Cogentin) and trihexphenidyl:
anticholinergics so mainly used in younger patients
MAO-B inhibitors: selegiline, zeleplar, rasagiline (Azilect).
Azilect can be used as initial monotherapy.
Alzheimers
most common type of dementia
memory loss, irritability, difficulty planning and
organizing, personality changes
Pathophysiology: Amyloid plaques and neurofibrillary
tangles Decreased Ach
Drugs that can worse dementia: Anticholinergics,
Antipsychotics, Anithistamines, Barbiturates, Benzos,
Skeletal Muscle relaxants, and other CNS depressants.
Treatment:
Acetlycholinesterase Inhibitors are the mainstay
of treatment.
Some improve a little and some dont. Even without
showing clinical improvement, they may have slower
progression vs if they didnt take the medication.
Gingko Biloba is used by some, studies are unclear but
it can increase bleeding
Achesterase Inhibitors: Anxiety:
donepezil (Aricept, Aricept ODT) Fear and worry are the primary symptoms along with
rivastigmine (Exelon, Exelon patch): take with
tachycardia, SOB, insomnia, fatigue.
food Anxiety disorders interfere with the ability to lead a
galantamine (Razadyne, Razadyne ER)
normal life.
SE: GI (N/V/loose stools), bradycardia, insomnia,
SSRIs and SNRIs are primarily used
fainting
Buspirone (Buspar) is a 2nd line option, 5HT1 partial
NMDA receptor antagonist: agonist, pregnancy B
Benzodiazepines:
memantine (Namenda): only for mod-
lorazepam (Ativan)
severe disease with or w/o Aricept alprazolam (Xanax)
ADHD: clonazepam (Klonopin)
diazepam (Valium)
Inattention, hyperactivity, impulsivity chlordiazepoxide (Librium)
1st line therapy is stimulants; atomoxetine temazepam (Restoril)
(Strattera) is a non-stimulant that can be tried midazolam (Versed)
afterwards or 1st line if the prescriber is concerned estazolam
of abuse. triazolam (Helcion)
clorazepate (Tranzene)
Stimulants: oxazepam (Serax)
Methyphenidate: Ritalin XR/SR/LA, Concerta (IR/ER ** LOT (Lorazepam, Oxazepam, Temazepam): less
combined from OROS system), Metadate CD (IR/ER harmful in elderly and hepatic impairment bc they are
beads), Daytrana (patch) metabolized to inactive compounds.
Dexmethylphenidate (Focalin, Focalin XR)
**Benzos Pregnancy D: Due to cleft palate and lip
Dextroamphetamine and amphetamine (Adderall,
Adderall XR) Insomnia:
Dextroamphetamine IR (Dexedrine, Dextrostat)
Lisdexamfetamine (Vyvanse): can mix capsule Lifestyle changes are the preferred treatment
contents with water and take stat. Hypnotics are over-prescribed
Focalin XR, Adderall XR, Metadate CD, and Ritalin LA can Sleep Drugs:
be taken whole or sprinkled on applesauce.
zolpidem (Ambien, Ambien CR)
Non-stimulants: zaleplon (Sonata)
eszopiclone (Lunesta)
Gaunfacine (Intuniv) or clonidine ER (Kapvay) are most
temazepam (Restoril)
often adjuncts
lorazepam (Ativan)
atomoxetine (Strattera): NE reuptake inhibitor
Other: Ramelteon (Rozerem): melatonin receptor agonist
51
 trazodone
diphenyhydramine(Benadryl): antihistamine, DO
NOT USE IN ELDERLY
Epilepsy/Seizures:
Unprovoked seizures or abnormal electrical storm in the
brain
Partial or Generalized. Partials can spread and become
secondarily generalized.
Status Epilepticus: seizure lasting more than 5
minutes or 2 or more seizures between where there is
incomplete recover of consciousness. Its a medical
emergency. (Lorazepam is the DOC)
Pregnancy: Carbemazepine, clonazepam,
phenobarbital/primidone, phenytoin/phosphenytoin,
topiramate, and valproate are Pregnancy Category D.
Valproate for migraine prophylaxis is Category X.
All other are category C.
**All require MedGuide for risk of suicidality
Most AEDs can lower Vit D so all patients on these
should supplement with Vit D and Calcium.
Discontinuing always requires a taper to prevent
seizures
Many Drug Interactions:
Inducers: carbamazepine, oxcarbazepine,
phenytoin, fosphenytoin, phenobarbital,
primidone, topiramate.
Inhibitors: Valproate
Treatment:
Benzos: clonazepam
Carbamazepine (Tegetrol, Carbatrol, Epitol): Fast
sodium channel blocker and also stimulates release of
ADH.
Therapeutic range: 4-12 mcg/mL
52
BBW: Skin reactions (SJS and TEN) usually 2-8
weeks after initiation. If Asian, must test for
HLA-B*1502. Can cause aplastic anemia and
agranulocytosis.
SE: SIADH, hepatotoxic.
Phenobarbital (Luminal) and primidone: Enhance
GABA mediated chloride influx. Primidone is a
prodrug of phenobarbital.
Phenytoin (Dilantin,Phenytek) and Fosphenytoin:
Fast sodium channel blockers. Has saturable
michaelis-menton kinetics.
Therapeutic range: 10-20 mcg/ml
BBW: Phenytoin max rate: 50mg/min IV and
Fosphenytoin max rate: 150mg PE/min IV
SE: Dose-related toxicity (ataxia, slurred speech,
nystagmus), skin thickening, gingival hyperplasia,
hirsutism, connective tissue changes, coarsening
of facial features, folate deficiency, hepatoxic.
Supplementation with B12, folate, calcium
and Vit D recommended
If the albumin is low, the true phenytoin
level will be higher than it appears.
PHT correction= PHT measured/(0.2x Alb) +
0.1
Valproate/Valproic Acid (Depakene, Stavzor,
Depacon) and Divalproez (Depakote):
Therapeutic range: 50-100 mcg/mL
BBW: Hepatic Failure, **Teratogenic (neural
tube defects, spina bifida) and Pancreatitis
SE: Dose-related thrombocytopenia, alopecia,
low IQ in children if exposed in utero, pancreatitis,
tremor.
If the albumin is low, the true valproate level
will be higher than it appears, use phenytoin
formula.

Lamotrigine (Lamictal):
BBW: Skin reactions (SJS and TEN). Titration
schedule depends on if currently taking
another AED (inducer or inhibitor).
Pregancy C
Levetiracetam (Keppra): ** No significant drug
interactions, Pregnancy C
Oxcarbazepine (Trileptal, Oxtellar XR): Skin
Reactions SJS and TEN, Hyponatremia
Pregabalin (Lyrica): SE: peripheral edema, weight
gain
Gabapentin (Neurontin) SE: edema, weight gain
Topiramate (Topamax): SE: metabolic acidosis,
oligohydrosis/hyperthermia, nephrolithiasis
zonisamide (Zonegran): Sulfa Moiety. Skin Reactions (SJS
and TEN)
felbamate (Felbatol): BBW for Aplastic Anemia and
Hepatic Failure
lacosamide (Vimpat): No significant drug interactions
Stroke:
Ischemic or Hemorrhagic
Hemorrhagic Treatment:
compression stocking to prevent VTE, no
anticoagulants
Intracerebral Hemorrhage: Mannitol (Osmitrol):
Increases the osmotic pressure to reduce the
intracranial pressure.
Subarachnoid Hemorrhage: nifedipine (Nymalize)
Ischemic Stroke Prevention:
53
Correct modifiable risk factors: HTN, Diabetes,
Dyslipidemia, Weight, Smoking etc..
Primary prevention: Recommended for Afib
Secondary Prevention: Previous Cardioembolic
Strokeantiacoags
Previous Non-Cardioembolic
antiplatelets (ASA, Clopidogrel)
Ischemic Treatment:
TPA: alteplase (Activase); treatment must be
initiated within 3 hours of symptom onset.
Must confirm clot with head CT before use.
Max dose: 90mg IV over 60 min.
SE: Major Bleeding
Additional: ASA (not within 24 hours of TPA), HTN
management, Hyperglycemia Management (140-
180)
GERD:
LES muscle tone is reduced and allows for backflow of
stomach contents
Avoid: Nicotine, caffeine, spicy foods, alcohol, fatty
foods, citrus, chocolate, spearmint.
Weight loss shows the best evidence for improvement
**can exacerbate asthma
Treatment:
Antacids:
calcium (Tums), magnesium (Milk of Magnesia),
magnesium + aluminum or calcium (Maalox,
Mylanta), Mag-Al-Simethicone (Maalox Max,
Mylanta Max), Gaviscon.
Neutralizes acid within minutes and lasts 1-2
hours.
 SE: Magnesium can make you poop,
Aluminum can cause constipation.
H2 Blockers:
famotidine (Pepcid AC, Pepcid AC Max),
ranitidine (Zantac), cimetidine (Tagamet),
nizatidine (Axid).
Avoid cimetidine due to drug interactions
(3A4 inhibitor).
All must be renally adjusted.
Can worsen dementia/delirium/confusion.
May increase GI infections and risk of
pneumonia.
PPIs: block the final step in acid production (H +/K+)
ATPase pump.
omeprazole (Prilosec), omeprazole/sodium
bicarb (Zegerid), pantoprazole (Protonix),
lanzoprazole (Prevacid), esomeprazole
(Nexium), rabeprazole (Aciphex),
esomeprazole + naproxen (Vimovo),
dexlanzoprazole (Dexilant)
not indicated for PRN use
May increase risk of C. Difficile,
**Osteoporosis, pneumonia in hospitalized
patients.
pantoprazole and esomeprazole are the only
IV PPIs
PPIs inhibit 2C19
Avoid omeprazole and esomeprazole with
Clopidogrel (Plavix)
Cytoprotective Agents: Misoprostol (Cytotec) and
Sucralfate (Carafate)
Metoclopramide (Reglan): dopamine antagonist, at
higher doses it also blocks 5HT in CTZ, enhanced
54
response to Ach in GI which accelerates gastric
emptying and increases LES tone.
Peptic Ulcer Disease:
from mucosal erosion in the GI tract
Three most common causes: H. Pylori, NSAIDs,
Stress in critical illness/mechanical ventilation.
H.Pylori:
spiral gram negative bacteria that like acid
environments
eating usually lessens the ulcer pain
Diagnosis: Urea Breath Test and Fecal Antigen
Test. PPI, H2 blockers, bismuth, and antibiotics
should be discontinued 4 weeks before tests to
avoid false negative.
Treatment: ** Do not make drug substitutions, use
these drugs.
Triple Therapy: PPI + Clarithromycin +
Amoxicillin x 14 days
Quadruple Therapy: PPI + metronidazole +
tetracycline + bismuth x 10-14 days
NSAID-Induced Ulcer:
direct irritation and inhibition of prostaglandin synthesis
messes up GI mucosal barrier
Selective COX-2 inhibitors have less ulcer risk but more
CV risks.
PPI decreases the ulcer risk
Constipation/Diarrhea/and Bowel Prep:
Constipation:
 OTC laxatives should be limited to 7 days unless
under medical supervision
Stool softener (Docusate) is good for iron-induced
constipation
Opioids are the worse drug offenders for
Diarrhea:
constipation. Others are anticholinergics, Iron, and
Verapamil.
Opioids usually require a stimulant laxative
(Senna or Bisacodyl) +/- Docusate
Bowel Prep:
o colonoscopy requires bowel prep
o Sodium phosphate can cause fluid and electrolyte
abnormalities, risky in renal or cardiac disease.
o Ok to consume clear liquid diet (Water, broths, juices,
coffee, tea, etc.
o Do not consume anything with red, blue, or purple food
coloring. No alcohol. No solids or Semi-Solids.
o PEGs usually used (Golytely, Miralax, Carbowax)
Drugs for constipation:
Bulk-Producers: psyllium (Metamucil), calcium
polycarbophil (FiberCon), methylcellulose (Citrucel). DOC
in pregnancy and 1st line for constipation.
Emollients, Lubricants (Stool Softener): docusate
sodium (Colace), mineral oil
Stimulant: Senna (Ex-Lax), bisacodly (Dulcolax).
Caution that brand names can refer to multiple products.
Osmotics: PEG, Lactulose, Gycerin, Sorbitol, Salines
(various ions)
Rx Agents: Lubiprostone (Amitiza) Nausea (30%),
alvimopan (Entereg) blocks opioid
receptors in the gut
55
For STAT treatments and Bowel Preps: bisacodyl
rectal, magnesium salts (MOM), lactulose, sorbitol,
sodium phosphate (Osmoprep), polyethylene glycol
(Golytely, Miralax, Carbowax).
Most cases are viral, some bacterial (E.Coli), some drugs
(antibiotics, Mg), some diseases.
Antidiarrheals: Bismuth Subsalicylate (Pepto-
Bismol), loperamide (Immodium), diphenoxylate +
atropine (Lomotil)
Treatment should include fluids and electrolytes,
especially in children.
Not used with C. Difficile infections, body needs to
clear the toxin, not retain it.
Rule out lactose intolerance by avoiding dairy.
Inflammatory Bowel Disease:
Ulcerative Colitis and Crohns Disease: Idiopathic Bowel
Inflammation
Treatment:
Anti-diarrheals: Immodium, Lomitil
Anti-spasmodics: dicyclomine(Bentyl)
Short courses of oral or IV steroids: Prednisone or
budesonide (Entocort). Budesonide preferred
for ileum or colon problems, it has extensive first
pass so lower systemic exposure.
Maintenance therapy to reduce inflammation
and flare-ups.
mesalamine (Asacol, Pentasa, Canasa,
Rowasa)
methotrexate
TNF Inhibitors: adalimumbad (Humira),
infliximab (Remicade), golimumab (Simponi),
natalizumab (Tysabri): for refractory diseases.

Erectile Dysfunction:
Reduced blood flow to the penis. Often caused by
diabetes, HTN, heart disease, nerve damage, drugs
(antidepressants, blood pressure meds, antipsychotics,
finasteride, dutaseride, cimetidine, opioids, chemo,
nictotine), hormone imbalances (testosterone), stress
etc..
PDE5 inhibitors:
***CI with nitrates
Do not confuse with PAH/BPH drugs/doses:
sildenafil (Revatio): 20mg TID
tadalafil (Adcirca): 40mg QD for PAH or tadalafil
(Cialis): 5mg QD for BPH
sildenafil (Viagra): 1 hour before sex, start at
50mg unless >65 use 25mg
vardenafil (Levitra, Staxyn ODT): 1 hour before
sex. ,start at 10mg unless > 65 use 5mg
tadalafil (Cialis): 1 hour before sex: start with
10mg or 2.5-5mg if using more than twice a
week.
avanfil (Stendra): 30 min before sex
Glaucoma/Conjuctivitis/Opthalmics and
BPH:
Otics:
The patients perception of severity of BPH symptoms
Glaucoma: Increase IOP
guides the selection of treatment.
Treatment: Watchful waiting, Surgery, or Drugs
Alpha Blockers: terazosin (Hytrin), doxazosin
(Cardura), tamsulosin (Flomax), silodosin (Rapaflo).
SE: abnormal ejaculation, orthostatic hypotension,
floppy iris syndrome during cataract surgery,
priapism
56
5 Alpha-Reductase Inhibitors: dutaseride (Avodart) or
finasteride (Proscar) **Only used if the prostate is
enlarged.
PDE-5 Inhibitor: tadalafil (Cialis) 5mg QD
Overactive Bladder:
overactive detrusor muscle acted on by M3 receptor
Behavioral treatments are 1st line
Anticholingerics are 2nd line: Extended-Release
preferred due to lower rate of dry mouth.
oxybutynin, oxybutynin XL (Ditropan XL),
Oxybutynin patch (Oxytrol)
**Oxytrol patch is available OTC for women
>18 yrs. old
tolterodine (Detrol)
fesoterodine (Toviaz)
solifenasin (Vesicare)
darifenesin (Enablex)
trospium (Sanctura)
SE: Dry mouth, constipation, dizziness (mainly
with older agents like oxybutynin)
Beta Blockers: decrease aqueous humor production.
Timolol (Timoptic)
CAI: decrease aqueous humor production. dorzolamide
(Trusopt), dorzolamide + timolol (Cosopt)
Prostglandin Analougues: Increase outflow.
travoprost (Travatan Z), bimatoprost (Lumigan),
latanoprost (Xalatan). **Store latanoprost in
 fridge. SE: brown pigment in iris or eyelash
growth.
Alpha-2 agonist: increase outflow and reduce
production. brimonidine (Alphagan P), brimonidine
+ timolol (Combigan)
Conjuctivitis: (bacterial, viral, allergens)
Allergic: OTC naphazoline/pheniramine (Visine) or
ketotifen (Zaditor, Alaway)
Bacterial: azithromycin (Azasite), moxifloxacin
(Vigamox), besifloxacin (Besivance),
tobramysin/dexamethasone (Tobradex) + many
others.
Otic:
Eye drops can be used in the ears but never use
eardrops in the eyes
Common Skin Conditions:
Acne: From Androgens and bacteria (P.acnes) and fatty
acids in oil glands
Benzoyl Peroxide is the most effective OTC
treatment. Salicylic Acid is mildly useful.
Rx: tretinoin topical (Retin A, Avita) or
Adapalene (Differin). Pea sized amount spread
over entire face. May take 4-12 weeks to see
response and initially may worsen. Limit sun
exposure.
57
Rx: Oral Isotretinoin: ***Only for very severe
acne, Pregnancy X (Severe birth defects), must
be on 2 forms of birth control, must have 2
negative pregnancy tests, only filled by a
pharmacy that is registered and activated with
the IPLEDGE program. **Do not use with
Vitamin A supplements, or tetracyclines,
steroid, progestin only pills contraceptives, or
St.Johns Wort.
Rx: Antibiotics: minocycline ER (Solodyn) Oral,
or topical antibiotics like Clindamycin (Cleocin,
Clindamax, Clindagel, Evoclin) or clindamycin +
benzoyl peroxide (Duac)
Dandruff: eczema or fungal
First try dandruff shampoos daily with selenium
sulfide (Selsun). Leave in for 5 min. then wash out.
Then try Rx ketoconazole shampoo (Nizoral A-D).
Apply twice weekly.
Skin Fungal Infections:
athletes foot, jock itch, ringworm, candida etc.
Terbinafine (Lamisil AT) and butenafine
(Lotrimin Ultra) are highly effective.
Clomitrazole (Lotrimin), miconazole (Monistat,
Lotrimin), tolnaftate (Tinactin).
***Different brands have different active
ingredients. Check labels.
Toenail or Fingernail fungal infection
(Onychomycosis):
topical usually not potent enough
potassium hydroxide (KOH) smear needed
for diagnosis
Oral itraconazole (Sporanox) or Oral
Terbinafine (Lamisil, Terbinex) used most
often.
 **itraconazole BBW to not use in heart Lice:
failure. Permethrin: OTC drug of choice for lice. Must
Vaginal Fungal Yeast Infection: also remove the live lice and nits inspecting
cottage cheese discharge, itching, burning, carefully with a comb. Also used for scabies
pain during urination (mites)
miconazole (Monistat), Tioconazole Lindane not used much anymore due to
(Vagistat) etc.. neurotoxicity.
1 or 3 day treatment (unless pregnant then Genital Warts:
7-10) Imiquimod cream (Aldara)
Insert at night before bed when laying down Alopecia:
so medicine stays in. finasteride (Propecia): pregnancy category X
Eczema: so women shouldnt handle.
inflammation linked to allergies/allergens minoxidil (Rogaine) topical OTC
itchy, red, dry, scaly, skin rashes
Treatment: Topical Steroids, Moisturizers,
and Hydration
If topical steroids fail: tacrolimus (Protopic)
or pimecrolimus (Elidel)

58