Drugs

Aminoglycosides Prototype: Gentamicin (Pregnancy Cat D)

Aminoglycosides Prototype: Gentamicin (Pregnancy Cat D) • Action: Interfere with protein synthesis by binding with ribosomes (often combined with PCNs that attack cell wall for even better cell wall penetration) • Use: Gm - bacilli (E. coli, Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, some aerobic gm +; used empirically in combination with other antibiotics until C&S results are available [not as effective used alone] • Contraindications: Hypersensitivity; • Caution: Renal impairment (dosage adjustment); • Administration: don't mix with PCNs in same IV (inactivates aminoglycosides); give 1 hour before or after • Multiple daily doses OR • Extended-interval -Once Daily Aminoglycosides (ODA) • Category D • There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Drug has a concentration-dependent bactericidal effect - high peak serum concentrations kill more micro-organisms. Postantibiotic effect - continue killing organsims even at lower concentrations Pre-dose (trough) gentamicin levels should be checked after 24 hours and then twice weekly (target <1mg/L). Peak gentamicin levels, taken one hour after administration, can also be measured (target 3-5mg/L). "Antennae Up" Drug! Aminoglycosides: Contraindications & Cautions • Hypersensitivity to aminoglycosides • Renal or hepatic disease • Preexisting hearing loss • Myasthenia gravis or parkinsons- may be exacerbated by the effects of aminoglycoside on the nervous system • Pregnancy or Lactation - aminoglycosides are excreted in breast milk and potentially could cause serious effects in the infant • Children and Older Adults: Low therapeutic index! Serum levels must be monitored carefully due to increased risk ototoxicity and nephrotoxicity • Accumulates in high concentrations in renal tubules - may lead to acute tubular necrosis • Accumulates in high concentrations in inner ear - may lead to hearing loss and disturbed balance or vertigo • Caution: Active infection with herpes or mycobacterial infections that could be worsened by the effects of an aminoglycoside on defense mechanisms • Narrow Therapeutic Window - Check blood levels • Multiple daily doses: Check Peak (1 hr. after dose) and trough (right before next dose) • ODA: Check 12 hours after daily dose • Adverse effects: • Hypersensitivity • Nephrotoxicity (ATN) • Ototoxicity (cochlear & vestibular • Neurotoxicity, neuromuscular blockade • Monitor renal function! • Monitor: dizziness, vertigo, hearing loss, vestibular symptoms • Monitor: numbness, tingling, muscle twitching • MANY DRUG INTERACTIONS (antibiotics, antivirals, salicylates - increase nephrotoxicity - look them up!) • Additive risk of ototoxicity with other ototoxic meds (e.g. loop diuretics) or nephrotoxicity with other nephrotoxic meds (e.g. vancomycin) • Vestibular toxicity - ataxia, vertigo; ototoxicity - hearing loss may be irreversible • Nephrotoxicity - cloudy urine, hematuria - prolonged aminoglycoside therapy (> 1 week) increases risk • Neuromuscular blockade - resp depression and muscle weakness • Neurotoxicity - peripheral neuritis; optic nerve dyfx; numbness, tingling;

Thiazolidinediones (TZD)

- PIOGLITIZONE (ACTOS) - Increases insulin sensitivity **powerful insulin sensitizer - Side effects: weight gain (increases circulating volume) - Black box warning: TZD's may cause or worsen heart failure, monitor for edema, weight gain. - Increased peripheral fracture risk, increased risk of bladder cancer - Lowers A1c 0.5-1%

Anti-Gout Medications

Allopurinol - Action: Inhibits the enzyme (xanthine oxidase) that converts purines to uric acid - Contraindicated: hypersensitivity; familial idiopathic hemochromatosis - Adverse effects: - CNS: drowsiness, headache, vertigo - Hematologic: agranulocytosis, aplastic anemia, bone marrow suppression - GI: nausea, vomiting, diarrhea, abdominal pain, indigestion - Probenecid - increases urinary excretion of uric acid; not effective in acute attacks; may be used to reduce hyperuricemia and tophi in chronic gout; (also used to increase blood levels of penicillin by decreasing urinary excretion of penicillin) - Thiazides - increased uricosuric toxicity; anticoagulants - increased risk of bleeding - What would signs of bone marrow suppression? Nursing Implications • Prevent • Prevent drug interactions: • thiazide diuretics (increased allopurinol toxicity) • anticoagulants (increased anticoagulant effects) • alcohol (decreased uricosuric effects) • Monitor • Monitor for therapeutic effects: • Decreased uric acid • Monitor • Monitor for adverse effects: • cloudy urine or decreased urine output - urine crystals or stones • GI effects • Signs of bone marrow suppression • Myeloma develops and grows in the bone marrow. The disease can suppress the bone marrow's ability to make new blood cells • Fatigue. • Paleness of skin, lips and nail beds. • Increased heart rate. • Easy tiring with exertion. • Dizziness. • Shortness of breath. Note: You will need to know these lab values for Unit Test 2 WBC - 4.5 - 10.0 x 103 (4500 - 10, 000) Platelets: 150,000 - 450,000 Neutrophils: 45 to 75% of all white blood cells <1500 cells/microliter (1.5 × 109 cells per liter) = neutropenia

Alosetron (Lotronex) "a-low-se-tron"

Alosetron (Lotronex) "a-low-se-tron" • 5-HT3 receptor antagonist • Increases firmness of stool, decreases urgency and frequency • Used for irritable bowel syndrome with diarrhea • Side effects: headache, constipation, abdominal distension, flatulence • SERIOUS RISKS: ischemic colitis, obstruction, impaction, perforation (BB WARNING) • REPORT: rectal bleeding or abdominal pain - D/C medication! • Contraindicated: Crohn's, ulcerative colitis, diverticulitis, chronic constipation • Interacts with CYP450 enzymes - several drug interactions Can only be prescribed by providers enrolled in prescribing program - Patient signs an agreement acknowledging risks

Antacids

Antacids ± Mechanism of Action: Neutralizes acid (raises pH of gastric secretion) ± Uses: Prevention or treatment of PUD, GERD, esophagitis, gastritis, stress ulcers ± Pharmacokinetics you should know ° Onset: 20-60 minutes ° Minimal systemic absorption unless taken in high doses or for prolonged period ± Raising pH to 3.5 neutralizes more than 90% of gastric acid; inhibits conversion of pepsinogen to pepsin ± Mg - high neutralizing action and rapid onset ± Al - less neutralizing action (would need larger doses) ± Need steady neutralization of acid to prevent stress ulcers Prototype ± Mylanta = aluminum hydroxide + magnesium hydroxide + simethicone ± Other popular OTC antacids: ° Gelusil ° Amphogel ° Alka-seltzer ° Maalox ° Rolaids ° Tums ± Simethicone - anti-gas; antiflatulence ± Alka-seltzer antacid = citric acid + potassium bicarbonate + sodium bicarbonate ± Amphogel = aluminum hydroxide and amphogel plus = aluminum hydroxide+ magnesium hydroxide + simethicone ± TUMS = Calcium Carbonate ± Rolaids = Calcium Carbonate + Magnesium hydroxide Caution ± Renal failure (CrCL < 30 mL/min) ° Should NOT take magnesium-based antacids - risk for hypermagnesemia ° May take aluminum-based antacids to decrease absorption of phosphates but caution re: too much aluminum - Administration Concerns: ° Antacids: prevent absorption of most other medications ° Do not give within 1-2 hours of other medications unless prescribed ° Shake liquids well ° Older adults - may need lower doses due to lower acid secretion Antacids: Administration & Side Effects • Dosing: • 1 & 3 hours after meals and at bedtime (PUD, GERD) or prn (prevent or treat heartburn) • Side Effects: • Aluminum - constipation • Magnesium - diarrhea • Calcium - constipation; if large doses, acid rebound due to gastrin secretion; (caution - hypercalcemia • Minimal systemic absorption; raising pH to 3.5 prevents conversion of pepsinogen to pepsin; • Mylanta = aluminum + magnesium + simethicone Nursing Implications ± Preventing interactions ± Monitoring for therapeutic effects ± Monitor for adverse effects ± Patient education: ° Do not use OTC medications for more than 2 weeks without consulting provider (may delay diagnosis and treatment of serious illness) ° If you have kidney disease, consult provider or pharmacist before choosing antacid ° Allow effervescent medications to completely dissolve and stop bubbling; chewables should be chewed thoroughly and followed by glass of water, shake liquids well ± Therapeutic: Reduced epigastric distress, heartburn; reduced GI bleeding ± Adverse: Diarrhea, constipation, hypernatremia, hypercalcemia, hypermagnesemia

Anti-Gout Medications

Anti-Gout Medications • Anti -Inflammatory: Colchicine • Inhibits migration of WBC's into body tissues containing urate crystals • Reduces inflammation • Used in gout, familial Mediterranean fever • Other: Allopurinol • Inhibits enzyme that converts purines to uric acid • Used in gout and certain types of cancers that result in elevated uric acid levels due to tumor lysis (e.g. leukemia, lymphomas) [no anti-inflammatory action] • Others: Probenecid (uricosuric) Colchicine • Children: Over 4 years of age (used for familial Mediterranean fever) • Older adults: Reduced dosages necessary to prevent adverse effects • Renal or Hepatic Impairment: Reduced frequency of dosing • Contraindicated: Hypersensitivity • Administration: Give with food to ¯ GI distress (but not grapefruit juice) - Adverse Effects: - GI: Nausea, vomiting, abdominal pain, dyspepsia - Hematologic: bone marrow depression, aplastic anemia - Hepatotoxicity - Peripheral Neuropathy - Interactions: - Many antifungals - Many HIV meds - Macrolide antibiotics - Alcohol - Grapefruit juice

Antihistamine - Prototype: Hydroxyzine (Vistaril)

Antihistamine - Prototype: Hydroxyzine (Vistaril) o Others: o Dimenhydrate (Dramamine) o Meclizine (Antivert) - Action: Block histamine-1 and acetylcholine in the brain - Uses: Used to prevent and treat motion sickness, nausea & vomiting; hydroxyzine is also used pre-operatively and for itching - Contraindication: Hypersensitivity - Cautions: o Older Adults - Potentially inappropriate medication (Beer's Criteria) o Renal impairment - Dosage reduction may be needed o Hepatic impairment - More intensive monitoring needed o Home care patients - Potential for excessive sedation o Diagnoses - glaucoma, BPH - Adverse Effects: o CNS: drowsiness, dizziness o Anticholinergic effects § dry mouth § tachycardia § Mental _____ § Urinary retention Antihistamines: Nursing Implications - Prevent interactions: CNS depressants (sedatives, alcohol, muscle relaxants, some antidepressants) - Administer: May be given rectally or intramuscularly; do NOT give subcutaneously - Monitor: Therapeutic and Adverse Effects - Educate: o Do not take with alcohol or other sedating medications o Do not drive or operate heavy machinery if drowsy o If used for motion sickness, give 1-hour prior to travel

Antiviral Therapies Used for Respiratory Syncytial Virus

Antiviral Therapies Used for Respiratory Syncytial Virus ¡ Ribavarin - synthetic nucleoside antiviral ¡ Inhaled for treatment of RSV in infants/children ¡ Inhibits replication of RNA polymerase which stops viral protein synthesis ¡ CONTRAINDICATIONS: hypersensitivity, pregnancy - SIGNIFICANT TERATOGENIC EFFECTS ¡ Adverse Effects: ¡ General: fatigue, insomnia, headache ¡ Eye: conjunctivitis ¡ GI: nausea, anorexia ¡ Heme: anemia ¡ Rare but serious: hypotension, cardiac arrest, apnea, bronchospasm, decline in respiratory function - CAREFULLY MONITOR BP, CARDIAC & RESPIRATORY STATUS ¡ Administration: well-ventilated room

Antivirals Used for CMV

Antivirals Used for CMV ¡ Ganciclovir ¡ 20-40% of patients experience granulocytopenia and thrombocytopenia ¡ Dosage must be reduced with renal failure; need to monitor CBC and renal function ¡ Adverse effects: ¡ General: pruritis ¡ Eye: retinal detachment ¡ GI: anorexia, nausea, vomiting ¡ Heme: anemia, leukopenia, neutropenia, thrombocytopenia ¡ GU: hematuria, elevated BUN/Creat ¡ Neuro: neuropathy ¡ Do not allow powder or reconstituted medicine to touch skin ¡ Used for organ transplant patients and AIDS patients with CMV infections

Antivirals Used for Herpes Simplex Virus Infections

Antivirals Used for Herpes Simplex Virus Infections ¡ Acyclovir (Zovirax) - used orally, parenterally or topically for HSV and VSV ¡ ACTION: interferes with viral DNA replication; decreases viral shedding ¡ USES: herpes infections, shingles - decreases duration of skin lesions and pain ¡ CONTRAINDICATION: Hypersensitivity, heart failure, renal failure ¡ CAUTION: need reduced dosage in patients with ¯ CrCl ¡ ADVERSE EFFECTS: ¡ General: Malaise, headache ¡ GI: nausea, vomiting, diarrhea ¡ Organ-specific: liver enzymes; acute renal failure; hemolytic uremic syndrome ¡ Heme: thrombocytopenia purpura ¡ Administration: wash hands; wear gloves before applying topical preparation; IV - must be infused slowly and patient should be well hydrated ¡ Monitor: liver enzymes, BUN/Creat, confusion, coma, tremors ¡ Herpesviruses include: herpes simplex virus (HSV), varicella-zoster virus (VZV) ¡ HSV-1 - fever blisters, cold sores ¡ HSV-2 - genital herpes

Beta-lactamase Inhibitor Combinations Prototype: Amoxicillin + Clavulanate (Augmentin)

Beta-lactamase Inhibitor Combinations Prototype: Amoxicillin + Clavulanate (Augmentin) ◦ Clavulanate is a beta-lactamase inhibitor ◦ When combined with penicillins, beta-lactamase inhibitors protect the penicillin from enzymes (beta-lactamases) that break it down ◦ Amoxicillin + clavulanate = Augmentin ◦ Note: available in differing strengths of amoxicillin but ALL contain SAME dose of clavulanate (So...two 250 mg tabs of Augmentin ≠ one 500 mg tab) ◦ Others : ◦ Ampicillin + sulbactam = Unasyn ◦ Piperacillin + tazobactam = Zosyn ◦ Ticarcillin + clavulanate = Timentin Clavulanic acid protects certain beta-lactam antibiotics from breakdown in the presence of penicillinase enzymes.

Biguanides

Biguanides - METFORMIN (Glucophage) - control blood glucose - Decreases hepatic (liver) glucose output (gluconeogenesis) - First line med at diagnosis of Type 2 Diabetes o Benefits: lowers cholesterol, no hypo or weight gain, cheap o Side effects: nausea, bloating, diarrhea o Use XR to minimize GI side effects o GI intolerance or renal impairment cannot use o Lactic Acidosis precaution (avoid in patients with elevated creatinine, during illness, low perfusion state (heart failure), or surgery o Blocks intestinal B12 absorption o Lowers A1c 1.0-2.0%

Carbapenems (Prototype: Imipenem-cilastatin (Primaxin)

Carbapenems (Prototype: Imipenem-cilastatin (Primaxin) ◦ Action: Interferes with CELL WALL synthesis ◦ Use: Very broad spectrum, aerobes, anaerobes, many resistant organisms; Critical illnesses ◦ Administration: ◦ Usually given IV for severe infections and/or polymicrobial infections ◦ Contraindications: Hypersensitivity; prior anaphylactic reaction to PCN (cross-sensitivity) ◦ Caution: Renal impairment (dosage adjustment); History of seizure disorder • Adverse effects: • Hypersensitivity, rash • GI - nausea, vomiting, diarrhea, anorexia, abdominal pain; elevated liver enzymes • CNS - toxicity, including seizures (inc. risk with high doses or prior seizures) • Superinfections including C. Diff; yeast infections • Monitor renal function! • Imipenem/cilastatin (Primaxin); Others: Doripenem (Doribax); Ertapenem (Invanz); Meropenem (Merrem) • They are indicated for treating serious intra-abdominal, urinary tract, skin and skin structure, bone and joint, and gynecological infections. • Contra: known allergy to any of the carbanems or beta-lactams; seizure disorders, which could be exacerbated by the drug; meningitis, because safety in patients with meningitis has not been established; lactation, because it is not known whether these drugs enter breast milk, but potentially, they could cause serious effects in the infant. • Caution: check kidney function!

Cephalosporins (Prototype: Cefazolin)

Cephalosporins (Prototype: Cefazolin) ◦ Action: Interferes with CELL WALL synthesis ◦ Use: Surgical prophylaxis; gram + bacteria ◦ Contraindications: Hypersensitivity; prior anaphylactic reaction to penicillin (cross-sensitivity) ◦ Caution: Renal impairment (dosage adjustment) ◦ Administration: ◦ PO: Give with food or milk ◦ Administer for full course of treatment ◦ IV - Meds - Preop: Give within 60 minutes prior to incision to reach effective serum/tissue concentrations ◦ Cefazolin = Kefzol or Ancef ◦ SBE = bacterial endocarditits ◦ Increasing resistance - staph, strep ◦ CAUTION - renal impairment ◦ Adverse effects: ◦ GI - nausea, vomiting, diarrhea, anorexia, abdominal pain ◦ CNS - HA, dizziness, lethargy ◦ Nephrotoxicity (if combined with aminoglycosides) ◦ Bleeding (cefotetan and ceftriaxone) - may deplete Vitamin K - caution in patients on anticoagulants ◦ Superinfections ◦ Interactions: ◦ Aminoglycosides - increased nephrotoxicity ◦ Probenecid (delays excretion) ◦ Anticoagulants - decrease prothrombin activity; depletion of Vit K - increased risk for bleeding ◦ Monitor: BUN/Creatinine; check for rash ◦ Teach patient: ◦ Inform provider if you have had previous severe reaction to PCN (difficulty breathing, swelling, skin rash) or reaction to cephalosporin ◦ Complete full course of treatment ◦ Follow instructions for dosing frequency to assure adequate blood levels ◦ Take oral drugs with food or milk ◦ Do not take oral drugs with antacids, H2RAs or PPIs ◦ Shake liquids well ◦ Report any rash ◦ Report any diarrhea (especially with blood, mucus, pus)

Incretin-Based Therapies DPP-4 Inhibitors

DPP-4 Inhibitors - "INCRETIN ENHANCERS" inhibit enzyme that breakdown incretins o Prolongs action of the gut hormones o Increases insulin secretion with meals o Delays gastric emptying - JANUVIA (sitagliptin) - ONGLYZA (saxagliptin) - TRADJENTA (linagliptin) *eliminated via feces DPP-4 Inhibitors • Side effects: headache, flu-like symptoms, joint pain. Report signs of pancreatitis. • Generally well tolerated. Low risk of hypoglycemia. • Dose adjustment in renal impairment (Januvia, Onglyza). • Advantage over GLP-1 agonists = oral formulation however, no weight loss • Commonly combination with Metformin (i.e. Janumet, Jentadueto)

Drugs for Hepatitis B

Drugs for Hepatitis B ¡ Lamivudine ¡ ACTION: Inhibits transcription of viral RNA ¡ USES: - to reduce risk of transmission; to prevent long-term complications such as cirrhosis and hepatocellular (liver) cancer ¡ ADVERSE EFFECTS: headache, myalgia, musculoskeletal pain; SERIOUS - Pancreatits (monitor for abdominal pain) ¡ Black Box Warning: lactic acidosis, hepatomegaly (enlarged liver) with steatosis (fatty liver) ¡ NURSING IMPLICATIONS: ¡ Assess for headache, myalgia, musculoskeletal pain ¡ Assess for abdominal pain, jaundice, elevated AST/ALT, enlarged liver ¡ Note: numerous treatments for Hepatitis C ;

Fluoroquinolones Prototype: Ciprofloxacin (Pregnancy Cat C)

Fluoroquinolones Prototype: Ciprofloxacin (Pregnancy Cat C) • Action: Interfere with bacterial synthesis of DNA necessary for reproduction • Uses: Broad spectrum: Urinary, respiratory, GI tract infections; anthrax • Contraindications/Cautions: Decreased renal function (dose adjustment); Lactation; Not recommended as first-line treatment of UTI for persons < 18 years of age (concern re: developing erosion of developing cartilage based on animal studies) • Administration: PO: Give with adequate fluids to prevent crystalluria; NG: not give suspension (crush IR tablets and hold feeding for 1 hour prior and 2 hours after drug); IV: give over 60 min. • Category C • Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. • Adverse Effects: • Hypersenstivity • GI : nausea, vomiting, abdominal discomfort • MS: Tendonitis; Achilles tendon rupture (higher risk: transplant patients, older adults, patients taking steroids); muscle weakness in myasthenia gravis • Derm: Photosensitivity reaction • Renal: crystalluria, hematuria, interstitial nephritis, nephropathy, renal failure • Heme: bone marrow depression • Superinfection • CNS : peripheral neuropathy, dizziness, HA,restlessness, agitation, insomnia, nightmares, confusion, depression • Cardiac: Increase QT interval (levo, moxi, gemifloxacin) • Endocrine: hypoglycemia or hyperglycemia Interactions • ¯ effect of quinolones: antacids, iron, dairy products • risk of QT interval prolongation: quinidine, amiodarone, procainamide, tricyclics, phenothiazines, others • risk toxicity - theophylline, warfarin • ACEI, ARB , spironolactone (dysrhythmias)

H2RAs

H2RAs ± Action: inhibits the action of histamine at the H2 receptor to inhibit secretions stimulated by acetylcholine, histamine & gastrin --- decreases gastric acid ± Uses: ° OTC: symptomatic treatment of heartburn ° Rx: prevention & treatment: PUD, GERD, esophagitis, stress ulcers, ZES 2 Prototypes: Cimetidine (Tagamet) & Famotidine (Pepcid AC) - available OTC - 1st H2RA on market: cimetidine - Other drugs in class (do not affect CYP450 system) - Ranitidine (Zantac) - more potent; may be given at smaller dose, less frequently than cimetidine - Nizatidine (Axid) CAUTION • Older adults: Increased risk of CNS effects from cimetidine; delirium, agitation, disorientation (higher dose = higher risk) • Renal impairment: • Increased risk toxicity with cimetidine - needs dose reduction • Reduces creatinine clearance • Increased risk CNS effects, mental confusion • Hepatic impairment: Cimetidine inhibits liver's ability to metabolize other drugs • Do not give to persons with hypersensitivity Adverse Effects ± Cimetidine (adverse effects are more common with higher doses and longer duration of treatment): ° CNS: dizziness, drowsiness, headache, confusion ° GI: diarrhea ° Anti-androgenic effects: gynecomastia (enlargement or swelling of breast tissue in males) ± Famotidine and others: ° Less CNS effects ° Less anti-androgenic effects ± Less common SE - cimetidine: rash, arthralgia, or myalgia Nursing Implications ± Administration: Do not take at same time as antacids ± Preventing interactions: ° Cimetidine affects CYP450 system - interferes with metabolism of MANY, MANY other drugs and herbals (e.g. increased risk warfarin toxicity; reduced effectiveness of antifungal) ° Famotidine and others - Do not interfere with metabolism of other drugs ± Monitoring therapeutic effects ± Monitor for adverse effects ± Sample drug interactions: warfarin, anti-arrythmics, anticonvulsants, beta blockers, calcium channel blockers, tricyclic antidepressants, antidiabetic drugs (sulfonylureas), antibiotics, anti-inflammatories, antihistamines Patient Education • Do not take OTC medications for > 2 weeks without consulting provider • Take as prescribed (underdosing reduces effectiveness; overdosing increases side effects) • Discuss drug interactions with provider or pharmacist before taking cimetidine if you take other medications; do not combine with herbals

GLP-1 Agonists

Injectables that Lower Glucose GLP-1 Agonists • Increases insulin response with food • Slows gastric emptying • Inhibits hepatic glucose production • Promotes satiety • Exenatide XR (Bydureon) 2 mg SC weekly • Liraglutide (Victoza) 1.2-1.8 mg SC daily • Dulaglutide (Trulicity) 0.75 or 1.5 mg SC weekly • NEW Semaglutide (Ozempic) 0.5-1 mg SC weekly - Typically associated with weight loss - Side effects commonly include nausea, abdominal discomfort and possibly vomiting - BLACK BOX WARNING Thyroid C cell tumor warning increased risk of Medullary Thyroid CA and MEN syndrome (mice and rats). - Do not use if patient has PMHx pancreatitis, personal or family hx of Medullary Thyroid CA or MEN 2(Multiple Endocrine Neoplasia). - **advise patient to report signs of pancreatitis - (persistent severe abdominal pain, vomiting STOP MED) - Do not use in patients with renal impairment (eGFR < 30)

Lincosamides: Clindamycin (Cleocin)

Lincosamides: Clindamycin (Cleocin) • Pharmacodynamics: inhibits protein synthesis • No gram-negative activity • Gram-positive activity: corynebacterium acnes, gardnarella vaginalis, some methicillin-resistant Staphylococcus aureus (MRSA) • Pharmacokinetics: oral dosing completely absorbed, not affected by gastric acid • ADRs: boxed warning for severe colitis; dermatological: rash, burning, itching, erythema; transient eosinophelia, neutropenia, thrombocytopenia • Clinical use and dosing • First-line therapy for MRSA in some areas • Infections in PCN-allergic patients • Drug-resistant Streptococcus Pneumoniae infections • Dental infections • Rational drug selection • Considered second-line therapy, narrow spectrum of aerobic activity • First-line therapy in special populations (pregnancy and children) Lincosamides: Clindamycin (Cleocin) • Monitoring • Stop medication if significant diarrhea occurs. • Patient education • Finishing therapy • ADRs: diarrhea

Linezolid (Zyvox)

Linezolid (Zyvox) • Linezolid is used to treat infections, including pneumonia, and infections of the skin . • Used for the treatment of infections caused by multi-resistant bacteria including streptococcus and methicillin-resistant Staphylococcus aureus (MRSA) • Patients avoid dietary tyramine while taking linezolid. Foods and beverages that have been pickled, smoked, or fermented usually contain tyramine. • Must monitor CBC as myelosuppression may occur especially with treatment courses lasting more than 2 weeks. • May perpetuate serotonin syndrome. • Available in oral and IV forms

Lipoglycopeptides: Vancomycin

Lipoglycopeptides: Vancomycin • Pharmacodynamics • Used for severe gram-positive infections, such as MRSA-resistant to first-line antibiotics • Inhibits cell wall synthesis • Pharmacokinetics • Poor oral absorption, given IV • ADRs • Ototoxicity (transient or permanent) • Nephrotocity • "Red Man" syndrome if infused too fast • Vancomycin should be infused slowly in a dilute solution (2.5 to 5.0 mg/ml) at a rateno greater than 10 mg/min and over a period not less than 60 minutes to avoid rapidinfusion-related reactions. Stopping the infusion usually results in a prompt cessation of these reactions. • Clinical use and dosing • Serious gram-positive infections resistant to other medications • Monitoring • Hearing and renal function • Patient education • Administration • ADRs • Trough levels are collected just prior to a person's next vancomycin dose. Peak levels are collected 1 to 2 hours after the completion of the intravenous vancomycin dose. • lowest concentration reached by a drug before the next dose is administered,

Lubricants & stool softeners

Lubricants & stool softeners • Mineral oil enema • works in 6-8 hours • Mineral oil should not be taken orally (risk of aspiration & malabsorption of fat-soluble vitamins) • Surfactants: Prototype: docusate sodium (Colace) • Decreases surface tension, allowing water to penetrate stool • No laxative effect • Reduces straining (used post-MI or cardiovascular procedures, hemorrhoids, etc.) Sodium phosphate enemas should be avoided in older adults or patients at risk for electrolyte disturbances because they have been associated with complications : hypotension and volume depletion, hyperphosphatemia, hypo- or hyperkalemia, metabolic acidosis, severe hypocalcemia, renal failure, and electrocardiogram changes (prolonged QT interval)

Macrolides

Macrolides Azithromycin. Clarithromycin. Erythromycin. Fidaxomicin. Considered to be a broad-spectrum class of abx. Azalide contain nitrogen in the macrolide ring Macrolides • Pharmacodynamics: Erythromycin • Inhibits ribonucleic acid (RNA)-dependent protein synthesis; Usually bacteriostatic but can be bactericidal • Active against most gram-positive and some gram-negative bacteria • Atypical and intracellular organisms commonly resistant to beta-lactam antibiotics are often susceptible. • Cross-resistance seen to all in class • Pharmacokinetics: well-absorbed from duodenum • Potent inhibitors of CYP 450 3A4 • Combination with statins may increase risk for myopathy. • Exhibit enterohepatic recycling, which can lead to buildup in the system and can cause n/v; tissue levels are higher than serum levels • Bind to site of cell growth, in high doses, bacetericidal • Precautions and contraindications • Most are safe in pregnancy and children • ADRs • Dose-related GI: n/v, abdominal pain, cramping, diarrhea • Skin: urticaria, bullous eruptions, eczema, Stevens-Johnson syndrome • Drug interactions • Inhibitors of CYP 3A4 • Clinical use and dosing • Drug of choice for community-acquired pneumonia (mycoplasma) • Chlamydia • Pertussis (whooping cough) • H. Pylori infections (clarithromycin) • Chronic bronchitis infections • Rational drug selection • Often used as alternatives for PCN allergies • Increasing resistance • Not appropriate for treating sinusitis • Monitoring • For altered response to concurrent medications metabolized by CYP 450 3A4 or 2C9 • Hepatic/renal impairment • Hearing loss • Patient education • ADRs • Drug interactions

Metronidazole (Flagyl)

Metronidazole (Flagyl) • Pharmacodynamics • Metronidazole treats both parasitical and bacterial infections. • Active against Trichomonas vaginalis, Entamoeba histolytica, H. pylori, Clostridium, C. difficile • Pharmacokinetics • Metronidazole is well-absorbed when taken orally. Metronidazole and Nitazoxanide • ADRs • Mitronidazole: anorexia, nausea, abdominal pain, dizziness, headache, metallic taste • Clinical use and dosing • Metronidazole is used against the protozoal infections T. vaginalis, G. lamblia, and E. histolytica. • Metronidazole is used for anaerobic bacterial infections, bacterial vaginosis, and is one of the drugs in H. pylori treatment. • Rational drug selection • Metronidazole is on $4 retail lists. • Avoid metronidazole in first trimester of pregnancy. • Monitoring • Resolution of symptoms • Signs of leukopenia • Patient education • Administration • Metallic taste with metronidazole • Avoid alcohol if taking metronidazole or tinidazole due to severe reaction. • Concurrent treatment of partner if sexually transmitted infection • flushing of the skin, accelerated heart rate, shortness of breath, nausea, vomiting, throbbing headache, visual disturbance, mental confusion, postural syncope, and circulatory collapse.

Monobactams (Prototype: Aztreonam)

Monobactams (Prototype: Aztreonam) ◦ Action: Interferes with CELL WALL synthesis but does not have typical beta lactam structure (so less cross-sensitivity) ◦ Use: Aerobic gm - bacteria resistant to other drugs (similar spectrum to aminoglycosides but not as toxic to kidneys, hearing) ◦ Contraindications: Hypersensitivity ◦ Caution: Renal impairment (dosage adjustment); History of seizure disorder ◦ Administration: ◦ Usually given IV ◦ May be given with aminoglycosides to work synergistically (but this also increases risk of nephrotoxicity) ◦ Adverse effects: ◦ Hypersensitivity, rash ◦ GI - nausea, vomiting, diarrhea, anorexia, abdominal pain ◦ Thrombophlebitis ◦ May cause elevated liver enzymes ◦ Fungal or bacterial superinfection including clostridium difficile ◦ Monitor renal function ◦ Monitor hepatic function

NSAIDS: Use

NSAIDS: Use • Uses: • Treat mild to moderate pain, including dysmenorrhea • Reduce inflammation: osteoarthritis, rheumatoid arthritis, gout, etc. • Use in Children: Used in children > 6 months of age • Use in Older Adults: Safe in lower doses or short term; if used long-term, monitor for GI blood loss, renal dysfunction, edema, hypertension; if used in high doses, use an agent to protect against GI bleeding (e.g. a proton pump inhibitor) • Use in Renal Impairment: May decrease renal blood flow; higher risk in person over 50, taking thiazide diuretics, hypertension, diabetes, heart failure or pre-existing renal impairment • BLACK BOX WARNING: Contraindicated for treatment of perioperative pain after CABG • Ibuprofen may be given IV - patient should be well hydrated NSAIDS: Adverse Effects • Hypersensitivity and anaphylaxis - increased risk in persons with asthma, allergies, nasal polyps • GI: dry mouth, heartburn, nausea, epigastric pain, constipation, GI ulceration, GI blood loss • GU: nephrotoxicity (monitor BUN/Creat and edema) • Respiratory: bronchospasm, dyspnea • Patient teaching: • Take with food • Drink 2-3 quarts of fluid daily to maintain hydration • Report signs of bruising, bleeding, dark tarry stools, stomach upset, swelling or weight gain Other First Generation NSAIDS • Meloxicam • Piroxicam • Diclofenac • Etodolac • Sulindac • Ketorolac (injectable) - comparable to morphine for moderate to severe pain; use is limited to 5 days due to increased risk of GI bleeding, ulceration and perforation • Indomethacin • Other Non-NSAID Topicals used for pain: Lidocaine patch* or cream - Postherpetic neuralgia, arthritis, local pain • Capsaicin patch* or cream; - found naturally in cayenne pepper; selective for C fiber nociceptors; relieves some arthritis pain

Non-acetylated salicylates (MOA)

Non-acetylated salicylates (may have fewer GI effects than aspirin) • Choline magnesium trisalicylate (Trilisate) - weak COX-1 and COX-2 inhibitor • Salsalate - antipyretic, analgesic, anti-inflammatory Patient Education: Salicylates - Notify provider of any trouble breathing, bleeding, bruising, ringing in ears or decreased hearing - Notify providers prior to surgery or dental procedures and follow advice re: suspending therapy - Do not take herbals, supplements or other medications without checking with provider/pharmacist for interactions - Keep out of reach of children - Do not take during pregnancy Other: Acetaminophen (APAP; Tylenol) • Action: reduces fever by acting on hypothalamus; reduces pain by unknown mechanism; no major anti-inflammatory activity • Use: fever, mild to moderate pain • Use in children: drug of choice for pain or fever; risk of overdose due to mixtures in many OTC products and liquid medications of different concentrations • Use in older adults: Usually safe unless liver damage or alcohol abuse; consider maximum dose of not more than 3 gms/day in divided doses • Contraindications: hypersensitivity • Mild fever should not be treated - it is the body's response to infection • May alternate acetaminophen and ibuprofen q 4 hours x 3 days if needed for fever in young children • If 3 or more drinks per day - avoid acetaminophen Avoid Use with seizure medications (phenytoin, carbamazepine), large quantities of alcohol, cigarette smoking - increases risk for hepatotoxicity, even at usual doses Acetaminophen (APAP; Tylenol) - ADVERSE EFFECTS: - Hepatoxicity - Renal failure - Hypersensitivity - rash, fever - MAXIMUM DAILY DOSE: 3- 4 gms/day - May give with food to reduce GI upset - TOXICITY: - Early: nausea, vomiting, diaphoresis - Later: elevated AST/ALT, bilirubin, PT, jaundice - Overdose: - Antidote: Acetylcysteine (Mucomyst) - WARNING! - Acetaminophen is in MANY combination products - OTC and Rx (e.g. oxycodone + acetaminophen - "Percocet"); - if patient takes APA around the clock and also take a combination product, they will be overdosing

Other Medications IBS-C

Other Medications IBS-C • Lubiprostone (Amitiza)- chloride channel activator • Used for severe constipation including IBS-C and opioid-induced constipation • Adverse effects: nausea, severe diarrhea, acute-onset dyspnea, syncope, hypotension • Linaclotide (Linzess) • Contraindicated: children < 6 years of age (BB Warning - may result in death due to dehydration) • Give on empty stomach at least 30 minutes before meals • Adverse effects: diarrhea, abdominal discomort

Others

Others • Misoprostol - prostaglandin • BBB: DO NOT GIVE in women with childbearing potential - may cause spontaneous abortion, birth defects, premature birth • SE: diarrhea, N, V, HA, uterine cramps • Sucralfate • Protective barrier (does not neutralize acid) • Do not give with antacid (requires acid to activate) • Do not give within ½ - 2 hours of other medicines (decreases absorption) • SE: constipation • Misoprostol - naturally occurring prostaglandin; inhibits gastric acid secretion; increases mucus and bicarb secretion; inhibits gastric damage from acid, NSAIDS, ASA

Penicillins Prototypes: Penicillin G & Ampicillin

Penicillins Prototypes: Penicillin G & Ampicillin ◦ Action: Interferes with CELL WALL synthesis by binding to certain proteins called PBPs (penicillin-binding proteins) ◦ Use: mostly for gram + infections (some differences based on the penicillin) ◦ Ampicillin - a bit broader spectrum than penicillin G; covers some gram-negative bacilli, H. flu ◦ Extended spectrum penicillins - cover more gram - and resistant organisms; used for more critically ill patients ◦ Contraindications: Hypersensitivity to PCN or cephalosporins or carbapenems (cross-sensitivity) ◦ Caution: Renal impairment • Infants & Older adults • Increased risk of toxicity due to kidney and liver function • Increased sensitivity to GI & neuro effects • More susceptible to superinfections (secondary infections - occur AFTER a prior infection is treated; usually caused by organisms resistant to the earlier antibiotic) • Children • Accurate weights - dose based on age and weight • Caution re: use of "teaspoons" to measure dose Ampicillin ◦ Administration: ◦ PO: Most PCNS - give on an empty stomach, with full glass H2O to enhance absorption (amoxicillin or augmentin may be given with food) ◦ Suspension: Shake to resuspend & use measuring spoon or calibrated device to measure dose ◦ IV: Dilute [See IV drug reference]; do NOT mix in same syringe or IV tubing as aminoglycosides [flush IV first] ◦ IM: BLACK BOX WARNING - DO NOT GIVE PCN G by IV route - cardiac arrest and death ◦ Increasing resistance - staph, strep ◦ CAUTION - renal impairment ◦ Amoxicillin -needs to be taken for 7-10 days. The adverse effects most frequently seen with this antibiotic are nausea, diarrhea, rash, and superinfections. NEED DOSING SYRINGE; Store liquid in refrigerator; shake before use; diarrhea is common; lots of fluid intake; patches in mouth - superinfection; mild rash may occur Penicillins (category) ◦ Adverse Effects: ◦ Hypersensitivity - rash, anaphylaxis ◦ GI: Nausea, vomiting, diarrhea, gastritis, abdominal pain ◦ Renal: Nephropathy, interstial nephritis (uncommon) ◦ Electrolytes: Ticarcillin - hypernatremia ◦ CNS: (High dose PCN G) - lethargy, twitching, seizures, coma; ◦ Nursing Implications: ◦ Monitor: rash, hives, itching, severe diarrhea, fever, sore throat, black tongue, unusual bleeding [teach patient to report to provider if these occur] ◦ Monitor: BUN/Creat ◦ Patient teaching: ◦ Do not take if true allergic reaction prior (rash or difficulty breathing or swelling) ◦ Take full course of treatment to prevent secondary infection with resistant bacteria ◦ Take exact dose at times prescribed -lat even intervals (e.g. around the clock) - effectiveness depends upon adequate drug levels ◦ Shake liquids well before administering to mix suspensions ◦ Discard liquid after 1 week (room temp) or 2 weeks (refrigerated) Anti-staphylococcal Penicillins Prototype: Nafcillin • Others: dicloxacillin, oxacillin, (older: methicillin) • Penicillinase-resistant • Uses: Used to treat methicillin-susceptible staph aureus

Phenothiazines ("-azine") - Prototype: Promethazine (Phenergan)

Phenothiazines ("-azine") - Prototype: Promethazine (Phenergan) - Others: - Prochlorperazine (Compazine) - Chlorpromazine (Thorazine) - - first generation ("typical") antipsychotic drugs - depress the central nervous system (CNS) - In larger doses, chlorpromazine is used for schizophrenia or psychosis but in smaller doses, used as anti-emetics - Not all phenothiazines are effective for nausea - Chlorpromazine - used for intractable hiccups Phenothiazines - Action: Block dopamine (D2) receptors in midbrain - Use: Prevention and treatment of nausea & vomiting (due to surgery, anesthesia, migraines, chemotherapy or motion sickness - (Chlorpromazine is also used for intractable hiccups and in higher doses, as an antipsychotic) - Contraindicated: Children < 2 years old (fatal respiratory depression) - Contraindicated: Children with hepatic disease, sleep apnea, Reye's syndrome or family hx of sudden infant death syndrome (SIDS) - Also have some anti-muscarinic (M1; anticholinergic) and anti-histaminic (H1) effects Promethazine - Cautions • Glaucoma - may precipitate acute angle glaucoma due to anticholinergic effects • Benign prostatic hypertrophy (BPH) - may precipitate urinary retention due to anticholinergic effects • Renal impairment - may need dosage reduction • Older adults - may have increased adverse effects due to anticholinergic side effects • Beer's Criteria: Potentially inappropriate medication for older adults • Caution: EEG abnormalities (inc. risk seizures) Adverse Effects: Phenothiazines - Anti cholinergic effects, drowsiness, dizziness, photosensitivity, rash - Black Box Warning: Do not give subcutaneously (tissue damage) - IV extravasation - severe tissue injury, burning, pain [stop the IV] - Black Box Warning: Older adults with dementia - increased risk of death when treated with some antipsychotics - Rare but serious: Extrapyramidal symptoms (EPS) - acute dystonia, akathisia, parkinsonism, tardive dyskinesia o Acute dystonias have been reported after one dose of prochlorperazine - Serious effects: bone marrow suppression, respiratory depression - Blurred vision, dry mouth, constipation, urinary retention, drowsiness & confusion - Photosensitivity - Extrapyramidal reactions include acute dystonia, akathisia, parkinsonism, and tardive dyskinesia. These reactions have lasted months to years, especially in elderly patients with brain damage. Nursing Implications - Administration: No subcutaneous; careful monitoring if IV - Prevent interactions: CNS depressants, alcohol, herbals (kava kava, St. John's Wort, valerian), anticholinergics, do not give with MAO inhibitors - Monitor -Therapeutic effect: Prevention or resolution of N&V - Monitor - Adverse effects: Anticholinergic, EPS - Educate for self-care: o Caution with driving/heavy machinery; avoid alcohol with this medicine o Best to take medication prior to onset of N & V (e.g. 30-60 min before treatment or travel) o Take oral form with food to reduce GI upset o Use sunblock

Proton Pump Inhibitors (PPIs)

Proton Pump Inhibitors (PPIs) ± Action: Binds to gastric H+-K+-ATPase (proton) pump to prevent release of HCl from parietal cells into stomach ± Use: Treatment of PUD, GERD with erosive esophagitis, ZES (may lead to faster healing) ± Blocks the last step in acid production -inhibits both daytime and nighttime symptoms whether stimulated by meals or not ± Faster healing - ~ 2 weeks for PUD (longer for esophagitis) - most potent inhibitors of gastric acid secretion Prototype: Omeprazole (Prilosec) ± Others in class "prazole": ° Dexlansoprazole (Dexilant) ° Lansoprazole (Prevacid) ° Pantoprazole (Protonix) ° Rabeprazole (Aciphex) CAUTION • Contraindications: hypersensitivity • Older adults: • Long-term PPI use associated with increased risk hip fractures • Increased risk of achlorhydria • Pregnancy: • Omeprazole - Category C • Others in class - Category B • Small risk of acute interstitial nephritis (kidney disease) • Category B • Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women. • Category C • Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Adverse Effects & Drug Interactions: PPIs ± Side effects infrequent ° CNS: headache ° GI: Nausea, diarrhea ° Long-term use: hip fracture ± Interactions: ° Different medications have different interactions - consult drug handbook ° Omeprazole has most interactions ± Lansoprazole - drowsiness, dizziness Nursing Implications ± Administration: ° Give omeprazole BEFORE food intake ° Swallow tablets/capsules whole without crushing or chewing (drugs are delayed-release, long-acting) ± Patient education: Read package instructions ° If taking Prevacid granules, these may be sprinkled on food but should not be chewed ° Liquid preparations are available ° If using Pepcid AC orally disintegrating tablet, allow to dissolve on tongue; do not take with liquid ° Lansoprazole ODT - aspartame (contraindicated in phenylketonuria (PKU) )

Prototype: diphenoxylate with atropine (Lomotil) - Schedule V Controlled substance (Weak opioid)

Prototype: diphenoxylate with atropine (Lomotil) - Schedule V Controlled substance (Weak opioid) • Action: slows peristalsis by acting on smooth muscle • Uses: moderate to severe diarrhea Caution • Atropine toxicity or overdose • Do not use in children < 2 years • Caution age 2-13 • Atropine: anticholinergic • Contraindication:; diarrhea due to toxins, microorganisms (E. coli, salmonella, shigella), antibiotic-associated colitis • Caution: severe Hepatorenal disease • Caution: elevated liver enzymes (AST, ALT) Adverse Effects • CNS: dizziness, headache • GI: nausea, vomiting • Other: flushing, dry skin, dry mouth, tachycardia, urinary retention • Rare but serious: hypotension, respiratory depression • Education: • Do not exceed maximum daily dose (Two 5 mg tablets, 3-4 times per day up to 20 mg max) • Caution with driving until effects are known Other Drugs • Loperamide (Imodium a-D) - synthetic derivative of meperidine • BB Warning: may cause qT prolongation and Torsades de Pointes or cardiac arrest if taken in higher than recommended doses • Octreotide (Sandostatin) - synthetic somatostatin (anterior pituitary hormone) • Decreases GI secretion & motility • Used for diarrhea associated with carcinoid syndrome, HIV/AIDS

SGLT2 Inhibitors

SGLT2 Inhibitors - GLUCORETIC MEDS - Decreases glucose reabsorption in kidneys - INVOKANA (canagliflozin) - FARXIGA (dapagliflozin) - JARDIANCE (empagliflozin) - STEGLATRO (ertugliflozin) - Side effects: Hypotension, UTI's, genital yeast infections, dehydration, ketoacidosis - **Must have good renal function - **Must stay well-hydrated - Monitor: BP and renal function - Benefits: no hypo or weight gain - Usually some weight loss and lower BP - CV protection - Lowers A1c 0.7%-1.2%

Salicylates Prototype: Acetylsalicylic Acid (ASA, Aspirin)

Salicylates Prototype: Acetylsalicylic Acid (ASA, Aspirin) - Pregnancy Category D Action: ◦ Blocks transmission of pain impulses in nerve fibers, central and peripheral ◦ Block pain receptors on cells from chemical substances ◦ Prevent hypothalamus from reacting to pyrogens, lower body temperature ◦ Block prostaglandins from increasing pain and edema ◦ Low-dose aspirin (75 - 81 mg) is used for: prevention of MI/CVA/TIA - Crosses placenta, enters breast milk - Low birth weight, stillbirth, intracranial bleeding have been reported in infants who took aspirin late in pregnancy; Aspirin: Uses and Contraindications • Use: • Analgesic: Relief of mild to moderate pain (325-650 mg q 4h) • Antipyretic: ADULTS ONLY • Anti-inflammatory: decrease inflammation in OA, RA, spinal conditions (higher doses) • Antiplatelet: CVA, TIA, MI (75-81 mg q day) • Specific Populations: • Children and adolescents: DO NOT USE because of risk of Reye's syndrome with viral infection • Renal impairment: High doses of aspirin are nephrotoxic; persons with reduced renal blood flow should not take prostaglandin inhibitors - further jeopardizes renal function • Contraindications: Hypersensitivity, allergy to tartrazine (cross-sensitivity) • BLACK BOX WARNING: children or adolescents should not use to treat chickenpox of flu-like symptoms • Children with chicken pox or flu with fever given aspirin may develop Reye's Syndrome • Reye's syndrome: encephalopathy, hepatic damage, fatty liver • CAUTION: renal impairment • ASA is an NSAID and has may similar properties but it is also an antiplatelet agent and has some unique properties Aspirin - Drug Interactions Increased effects: ◦ Alcohol, gingko - increase effects of aspirin ◦ Anticoagulants -increased risk of bleeding ◦ Steroids - increase risk of GI irritation and ulcers Decreased effects: ◦ NSAIDs - compete for COX-1 inhibition and negate cardiac benefit of low-dose aspirin Interferes with other agents: ◦ ACE inhibitors, Beta Blockers, Diuretics, Anti-hypertensives Aspirin: Adverse Effects ◦ GI: nausea, heartburn, epigastric distress, gastric ulcer ◦ Heme:: bruising, bleeding ◦ SEE ALSO: NSAIDS ◦ TOXICITY: ◦ Metabolic acidosis, reparatory alkalosis, hyperpnea, tachypnea, pulmonary edema, confusion, seizures, coma, CV collapse, renal failure, respiratory failure ◦ Salicylism (acute or chronic use): tinnitus, difficulty hearing, dizziness Overdose Treatment: ◦ Mild: lowering dose or stopping the drug; ◦ More severe: Gastric lavage, activated charcoal (decrease absorption from GI tract), IV sodium bicarbonate to increase excretion, possibly hemodialysis Nursing Implications ◦ To improve absorption and decrease GI irritation, the nurse would teach the patient to take the medicine: with a full glass of H2O or after food ◦ To prevent drug interactions, the nurse would teach the patient about: medications/herbs that interact such as anticoagulants, NSAIDs, alcohol or ginkgo ◦ To evaluate therapeutic effects, the nurse would assess: pain relief, fever reduction, reduced inflammation or prevention of MI/TIA/CVA ◦ To assess for adverse effects, the nurse would assess: GI: N,V,D,; Heme: bruising, petechiae, hypersensitivity (bronchospasm, dyspnea) ◦ To recognize toxicity, the nurse would be alert for: (salicylism - tinnitus, difficulty hearing, dizziness)

Saline cathartics

Saline cathartics • Magnesium citrate, milk of magnesia, polyethylene glycol (PEG) • Action: increased osmotic pressure • Use: bowel prep prior to procedures; short-term treatment of constipation • Contraindications/cautions: • prolonged use - fluid and electrolyte imbalance (less with PEG) • renal impairment - caution with sodium, phosphate, magnesium or potassium ingredients • CHF - caution with sodium preparations • MiraLAX - OTC polyethylene glycol solution - should not be used for > 2 weeks Other • Lactulose - reduces ammonia in hepatic encephalopathy • Sorbitol - often given with kayexalate to treat hyperkalemia or to remove toxins from body

Second Generation: Celecoxib

Second Generation: Celecoxib • Selective COX-2 inhibitor • Selectively block prostaglandins associated with pain, inflammation • Do not block protective effects on gastric mucosa, renal function, platelet aggregation • Uses: juvenile arthritis, rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, familial adenomatous polyposis • Use in children: Used in children over age 2 with juvenile arthritis • Use in renal impairment: Not indicated in significant renal impairment Use in hepatic impairment: reduced dose CONTRAINDICATED: allergy to NSAIDs, aspirin or sulfonamides Etoricoxib and parecoxib available in UK, some other countries Celecoxib: Adverse Effects • BLACK BOX WARNING: Increased risk for MI, CVA • Rash, pruritis, dry mouth • Anaphylactic reactions • Administration with aspirin or anticoagulants - increased risk of bleeding

Serotonin 5HT-3 Antagonists ("-setron") - Prototype: Ondansetron (Zofran)

Serotonin 5HT-3 Antagonists ("-setron") - Prototype: Ondansetron (Zofran) - Others: - Granisetron (Sancuso) - Dolasetron (Anzemet) - Palonosetron (Aloxi) 5 HT3 Antagonists - Action: Block 5-HT3 serotonin receptors preventing activation by emetogenic substances - Uses: prevent or treat moderate to severe nausea and vomiting associated with chemotherapy, radiation therapy and postoperative symptoms - Often give with a corticosteroid prior to cancer chemotherapy with emetogenic drugs - Contraindications: Hypersensitivity - Cautions: o Hepatic impairment - monitor more closely for adverse effects (due to longer half-life) o Home care - risk for diarrhea and fluid/electrolyte imbalance - Adverse Effects: o General: fatigue o CNS: headache, dizziness o GI: diarrhea, constipation, transient elevation of liver enzymes (e.g. ALT/AST) o Cardiac: Prolonged QT interval (especially if higher dose I.V. or if patient has hx of arrythmia or is on other medications that prolong QT interval) Nursing Implications - Prevent interactions: o Inducers of CYP3A4 system (phenytoin, carbamazepine, rifampin, others) and St. John's Wort may increase metabolism/lower serum concentration of ondansetron - Administer: Do not remove from blister pack until ready to administer - Monitor: Therapeutic & Adverse Effects; Monitor LFTs - Educate: o Orally-disintegrating tablets (ODTs) contain phenylalanine (do not use with PKU) o Let ODT dissolve on tongue o Caution with driving until effects are known o Report any palpitations, dyspnea, dizziness

Stimulant Cathartics

Stimulant Cathartics • Prototype: Bisacodyl (Dulcolax) • Action: irritates GI mucosa & draws water in bowel lumen • Use: Bowel prep before colonoscopy, surgery, procedures; neurogenic bowel • Contraindicated: children < 6 yrs of age; undiagnosed abdominal pain, obstruction • Side effects: abdominal cramping, diarrhea, nausea, weakness • Administration: take on empty stomach or at bedtime • Patient education: • do not take for > 1 week - risk of serum electrolyte & acid-base imbalance • Other: glycerin suppository - osmotic effect; acts within 30 minutes

Substance P/Neurokinin 1 Antagonists

Substance P/Neurokinin 1 Antagonists - Action: Blocks substance P at the NK1 receptors in the brain - Uses: Used in combination with 5HT-3 receptor antagonists _ corticosteroids for acute and delayed nausea and vomiting related to chemotherapy - Prototype: Aprepitant (Emend) - Note: IV fosaprepitant, a pro-drug should NOT be used due to potential for arrythmias - Contraindications: Hypersensitivity; patients on certain drugs (ranolazine, pimozide, cisapride) - Cautions: Severe hepatic dysfunction - increase monitoring - Adverse Effects: o General: fatigue, weakness o CNS: dizziness, headache o Cardiac: arrythmia o Other: hiccups Concept Review - CYP450 enzyme inhibitors - reduce the enzymes and therefore reduce the metabolism of other meds - thereby INCREASING their levels - CYP450 enzyme inducers - increase the enzymes and therefore increase the metabolism of other meds - thereby DECREASING their levels Substance P/NK-1 Antagonists - Prevent interactions: o Reduced doses of steroids needed o Back-up method of contraception due to decreased effectiveness of oral contraceptives o Close monitoring of INR due to decreased effectiveness of warfarin o CYP3A4 inhibitors may increase the effects of aprepitant (e.g. macrolide antibiotics, protease inhibitors, azole antifungal antibiotics, many others) o CYP3A4 inducers may decrease the effects of aprepitant (e.g. carbamazepine, phenytoin, rifampin, phenobarbital) - Administer: take aprepitant orally with full glass of water, one hour prior to chemotherapy (or daily in the a.m. for 2 days after chemo) - Monitor: Therapeutic & Adverse Effects and assess heart rhythm - Educate: use alternate contraception for 1 month after therapy Miscellaneous Agents • Corticosteroids - e.g. dexamethasone, methylprednisolone • Anti-inflammatory • Used prior to chemotherapy in combination with 5-HT3 antagonists to prevent N&V • Benzodiazepines - e.g. lorazepam (anti-anxiety) • Prevent anticipatory nausea & vomiting • Relaxation

Sulfonamides

Sulfonamides • Bacteriostatic against wide range of gram(+) and gram(−) microbes • Increasing resistance, decreasing efficacy • Susceptibility should be documented by culture and sensitivity testing • Some can be used in the treatment of systemic infections • Others exert only local effects. Sulfonamides • Sulfadiazine • Sulfasalazine (Azulfidine) • Sulfisoxazole • Trimethoprim-sulfamethoxazole (Bactrim) • Mafenide (Sulfamylon) • Silver sulfadiazine (Silvadene) Sulfonamides • First drugs available for systemic treatment of bacterial infection • More effective and less toxic drugs are now available • Inhibit the synthesis of folic acid (folate) • Mammalian cells do not manufacture their own folate (not affected as bacteria are affected) • Primary use now: Urinary tract infection (UTI) • Other uses: Nocardiosis, Chlamydia trachomatis, conjugation therapy for toxoplasmosis/malaria, ulcerative colitis • Silver sulfadiazine • Used to suppress bacterial colonization in patients with second- and third-degree burns • Local application of mafenide frequently is painful • Application of silver sulfadiazine usually is pain free • Systemic absorption • Mafenide: Acidosis

Tetracyclines

Tetracyclines • Older, broad-spectrum bacteriostats (does not directly kill the bacteria but impairs it's normal function) • Rarely used for systemic infections • Due to microbial resistance • Development of more effective/less toxic medications • Urinary antiseptics • Used only in UTIs • Tetracycline (Achromycin, others) • Demeclocycline (Declomycin) • Doxycycline (Vibramycin) • Minocycline (Minocin) Tetracyclines • Effective against wide range of gram(+) and gram(−) microbes • Not usually the drug of choice, but depends on the condition • Widely distributed into most body tissues and fluids • Older medications are excreted mainly in urine • Doxycycline eliminated in urine and feces • Minocycline eliminated mainly by liver • Pharmacodynamics • Tetracycline and doxycycline • Bind reversibly to the 30S subunit of the bacterial ribosome; Inhibit protein synthesis • Pharmacokinetics • Food decreases absorption. • Calcium supplements, milk products, iron supplements, magnesium-containing laxatives, and most antacids "chelation" • Precautions and contraindications • Do not prescribe to pregnant women, lactating women, or children less than age 8 years. • Drug interactions: many • Permanent staining of discoloration of teeth • Chelation= inactivation • Summary of major precautions • Tetracycline is eliminated primarily in urine; they accumulate in patients with kidney disease • Tetracyclines can cause discoloration of deciduous and permanent teeth • Diarrhea may indicate a potentially life-threatening • High-dose IV therapy has been associated with severe liver damage Tetracyclines • Clinical use and dosing • Doxycycline is considered first-line therapy for C. trachomatis, Ureaplasma urealyticum, Lyme. • Doxycycline and Minocycline are used to treat P. acnes. • Some H. pylori regimens include tetracycline. • Rational drug selection • Doxycycline and minocycline can be taken with food but are optimally absorbed on an empty stomach. • Patient education • Administration, ADRs, avoid during pregnancy, sun sensitivity

Therapies for Influenza

Therapies for Influenza ¡ Oseltamivir - neuraminidase inhibitor, a viral enzyme needed for virus to infect other cells ¡ Most effective when given within 2 days of onset of symptoms of influenza A or influenza B ¡ For prevention during an outbreak ¡ Adverse effects: ¡ GI: nausea, vomiting, diarrhea, abdominal pain ¡ ENT: conjunctivitis, epistaxis ¡ Heme: thrombocytopenia ¡ Antiviral treatment is recommended as early as possible for any patient with confirmed or suspected influenza who: ¡ is hospitalized;* has severe, complicated, or progressive illness;* or is at higher risk for influenza complications. ¡ CDC: Antiviral treatment also can be considered for any previously healthy, symptomatic outpatient not at high risk for influenza complications, who is diagnosed with confirmed or suspected influenza, on the basis of clinical judgment, if treatment can be initiated within 48 hours of illness onset.

Trimethoprim/ Sulfamethoxazole

Trimethoprim/ Sulfamethoxazole • Trimethoprim/sulfamethoxazole (TMP/SMZ) combination: Inhibits sequential steps in bacterial folic acid synthesis, making it much more powerful than TMP or SMZ alone • Plasma drug levels • Therapeutic uses • UTI, otitis media, bronchitis, shigellosis, pneumonia caused by Pneumocystis jiroveci, Pneumocystis pneumonia, and GI infection Trimethoprim/Sulfamethoxazole • Adverse effects • Gastrointestinal • Nausea and vomiting • Rash • Hyperkalemia • Hypersensitivity reactions (Stevens-Johnson syndrome) • Blood dyscrasias • Kernicterus • Renal damage: Crystalluria Sulfonamides & Trimethoprim • Clinical use and dosing • Most commonly used with UTI infections • MRSA is susceptible in some areas • Rational drug selection • Low-cost alternative in children less than 2 months and PCN allergies • Monitoring • Control and status if treating UTI • Long-term use check CBC • Chest x-ray for patients that develop a cough when on nitrofurantoin • Patient education: finish course, ADRs, resistance Sulfonamide Indications for Use • UTI caused by E. coli, Proteus, Klebsiella organisms • In combination to treat chronic bronchitis • Ulcerative colitis, other uncommon infections • Topically • Prevention of burn wound infections • Ocular and other soft tissue infections

Zidovudine (AZT)

Zidovudine (AZT) ¡ Action: prevents reverse transcriptase from making DNA chains ¡ Uses: Used with 2+ other agents to treat HIV or prevent transmission from mother to fetus ¡ Adverse effects: ¡ General: Headache, malaise ¡ GI: nausea, vomiting, anorexia ¡ Heme: BLACK BOX WARNING: granulocytopenia, aplastic anemia, pancytopenia, hemolytic anemia, lymphadenopathy ¡ BLACK BOX WARNING: lactic acidosis, severe hepatomegaly ¡ Contraindications: hypersensitivity, lactic acidosis Other NRTIs are used for pre-exposure prophylaxis (PreP); Other Medications ¡ Numerous medication-specific side effects, interactions and nursing implications - look up each medication individually ¡ Common Adverse Effects HIV Meds Zidovudine (AZT) - Nursing implications ¡ Administration - must taken at scheduled times to prevent variation in peak/trough levels ¡ Prevent interactions - several drugs increase serum levels, risk for toxicity (antiseizure meds, chemotherapy meds, others) ¡ Monitor for therapeutic effects - CD4+ cell count, viral load ¡ Monitor for adverse effects - CNS depression, GI symptoms, myalgia, hepatomegaly, anemia, neutropenia (CBC at baseline and q2weeks) ¡ Patient education ¡ Notify provider of signs of lactic acidosis (musculoskeletal pain, nausea, vomiting, weakness ) ¡ Do not miss doses ¡ Do not take OTC, herbals, supplements, drugs of abuse with this medicine ¡ A normal range for CD4 cells is about 500-1,500. When the CD4 count drops below 200, a person is diagnosed with AIDS. ¡ Usually, the CD4 cell count increases when the HIV virus is controlled with effective HIV treatment. ¡ High viral loads are linked to faster disease progression. Reducing the viral load to "undetectable" levels slows or stops disease progression and prevents HIV transmission to sex partners. HIV will rebound to detectable if the HIV medicines are stopped.

• Psyllium (Metamucil) - bulk forming

• Psyllium (Metamucil) - bulk forming • absorbs water, adds bulk, stimulates peristalsis • May also lower cholesterol • Contraindicated: undiagnosed abdominal pain, obstruction, impaction, trouble swallowing, allergy • Avoid: persons confined to bed or immobile; dehydration; fluid restriction • Don't take within 1-2 hours of other medications • Take with 6-8 0z liquid • Psyllium may be used to add bulk in diarrhea