Freaking NAPLEX

DOC for sinusitis

Augmentin

BMP

Basic Metabolic Panel. Labs for electrolytes, glucose, acid/base, and renal function

Diagnostic tests for arrhythmias

ECG

Caspofungin

Echinocandin Brand: Cancidas

Micafungin

Echinocandin. Requires light protection during administration Brand: Mycamine

Candida glabrata or candida krusei treatment

Echinocandins

Diagnostic tests for onychomycosis (nail fungal infection)

20% KOH smear

How many g are in an oz

28.4

Blood osmolarity and pH

285 mOsm/L. pH is regulated by exchange of hydrogen and bicarbonate ions

Preprandial blood glucose goal

80 - 130 mg/dL

Goal LDL level

< 100 (fasting 9-12 hours before)

Long-acting reversible contraceptives

IUDs Copper-T IUD: Paragard. Can be used for emergency contraception and/or regular birth control Nexplanon: releases etonogestrel x3y

SVP (Small Volume Parenteral)

IV containers (bags) or prefilled syringes that are usually 50 or 100 mL of NS or D5W in water

Diarrhea treatment in cancer patients

IV/po fluid hydration *Antimotility agents*: loperamide: max 24 mg/d for chemo induced DA (16 mg/d otherwise) Diphenoxylate + atropine)

Metoprolol

IV:po 1:2.5 *Types*: tartrate: brand is Lopressor. Take with or immediately after food Succinate: XR. Brand is Toprol XL. Can be cut in half. Beta-1 selective blocker *Use*: chronic heart failure, HTN, angina *AE*: increased triglycerides *Monitor*: heart rate, bp, s/sx of HF

Toxoplasmosis treatment

Sulfadiazine + pyrimethamine. Leucovorin usually given to prevent myelosuppression from pyrimethamine

Types of blood pressure

Normal: SBP < 120 and DBP < 80 Elevated HTN Stage I: SBP 130-139 or DBP 80-89 HTN Stage 2: SBP ≥140 or DBP ≥90

Infertility

Not being able to get pregnant after 1y Treatments: clomiphene, gonadotropins. They can increase the risk of multiple births

Esomeprazole

PPI Brands: Nexium, Nexium 24HR-OTC, Nexium IV Forms: available IV, capsules can be opened Dose: take at least 60 min before breakfast DDI: decreases effectiveness of clopidogrel

Lansoprazole

PPI Brands: Prevacid, Prevacid SoluTab (PKU patients should not use), Prevacid 24HR-OTC Forms: capsules can be opened Dose: take before breakfast

Omeprazole

PPI Brands: Prilosec, Prilosec OTC Forms: capsules can be opened Dose: before a meal DDI: decreases effectiveness of clopidogrel

Rabeprazole

PPI Forms: capsules can be opened

What causes hypomagnesemia

PPIs and diuretics

What drugs cause Vitamin B12 to decrease

PPIs and metformin

Thimerosal

Preservative used in compounding. Contains mercury. Known to be in vaccines and falsely believed to be the cause of autism in children. Most childhood vaccines no longer contain thimerosal in it

Respiratory syncytial virus (in children)

Prophylaxis: palivizumab Treatment: supportive care. Inhaled ribavirin (Virazole) can be considered Can cause: bronchiolitis

Evolocumab

Proprotein convertase subtilisin kexin type 9 inhibitor. Treats hyperlipidemia. Reduces risk of MI, stroke, and coronary revascularization

Medications that can cause agranulocytosis

Propylthiouracil, methimazole, procainamide, clozapine, carbamazepine, Bactrim, and isoniazid

Cohort study

Prospectively compares a group of treated vs non-treated patients

Nitrogen intake calculation

g of protein intake / 6.25

How to calculate mol

g/MW

Flavoring agents used in compounding

glycerin, dextrose, lactose, mannitol, sorbitol, phenylalanine, stevia, xylitol

Temsirolimus

mTOR inhibitor Use: cancer Administration: use non-PVC bag and tubing AE: dyslipidemia, hyperglycemia, myelosuppression, interstitial lung disease

Stimulant OD

Supportive care (BZDs)

Sodium lauryl sulfate

Surfactant used to neutralize the static charge and keep the powder from floating away

Diagnostic tests for CF

Sweat test

Spearman's rank-order correlation

Tests correlation with ordinal and ranked data

Mitomycin

Use: cancer

Erenumab-aooe

Use: monoclonal antibody used for migraine prophylactic

Laminar Airflow Workbench

Used to compound non-hazardous CSPs. Has laminar airflow which is airflow that moves at the same speed, in the same direction, in parallel lines

Diagnostic tests for candida vaginitis

White, thicker vaginal discharge and pruritus

How should a compounding room be cleaned?

With 70% isopropyl alcohol cleaning from the cleanest to the dirtiest areas

Ethosuximide

AED Brand: Zarontin MOA: T-type Ca channel blocker Use: absence seizures Warnings: serious skin rash (SJS/TEN), blood dyscrasias

Theophylline therapeutic range

5 - 15 mcg/mL

Valproic acid therapeutic range

50 - 100 mcg/mL

Palonosetron

5HT3 receptor antagonist Brand: Alaxi Use: delayed CINV

Terbinafine

Antifungal. Comes in topical forms (Rx and OTC) Brand: Lamisil MOA: inhibits squalene epoxidase Use: ringworm (highly effective) and onychomycosis AE: hepatotoxicity, HA, and increased LFTs

Cirrhosis

Advanced fibrosis. All patients should be considered for liver transplant Most common causes: hepatitis C and alcohol Symptoms: jaundice, spider angiomata (veins that look like web protruding from skin)

Cyclophosphamide

Alkylating agent Use: cancer, lupus AE: N/V BBW: hemorrhagic cystitis with higher doses. Sometimes given with mesna to reduce risk by inactivating metabolite (acrolein) in bladder. Ensure adequate hydration

Balsalazide

Aminosalicylate Giazo brand approved in males only AE: staining of the teeth/tongue

Cost-Minimization Analysis

Comparing costs of two interventions that have the same outcome

WBC lab value

Increases due to systemic steroids. Decreases due to clozapine and carbamazepine

BBW purpose

Indicate when a drug can cause increased death in all patients

Alpha

Maximum possible error margin. Commonly set at 5%. Directly related to type I error (risk of type I error is <5%)

Diagnostic tests for bronchospastic diseases

FEV1, FVC, FEV1/FVC

Bicalutamide

First generation antiandrogen Brand: Casodex Use: prostate cancer

Hyperthyroidism treatment in pregnancy

If drugs are necessary, propylthiouracil if in 1st trimester, methimazole for remainder of pregnancy. Both drugs are at high risk for liver damage

Isosorbide mononitrate

Nitrate used for CHF Brand: Monoket AE: hypotension, HA, dizziness, lightheadedness, flushing, tachyphylaxis (solve with 10-12h nitrate-free period), and syncope CI: PDE5 inhibitor and riociguat

Akynzeo

Netupitant + palonosetron. Substance P/NK1-RA Use: CINV DDI: dexamethasone dose should be decreased

Receiving Hazardous Drugs

Never unpacked in sterile or positive pressure areas. Should be delivered in impervious plastic. Spill kit must be available in receiving area

NRT

Nicotine Replacement Therapy Warnings: avoid in immediate post-MI period with arrhythmias, angina, and pregnancy OD: supportive care and can give atropine (nicotinic receptor antagonist) if bradycardia is present

Direct thrombin inhibitors (IV or SC)

No antidote Drugs: argatroban, bivalirudin (Angiomax; used in patients at risk for HIT), and desirudin

Tocilizumab

Non-TNF biologic DMARD Brand: Actemra Use: RA DDI: other biologic DMARDs, live vaccines BBW: serious infections (screen for TB)

Abatacept

Non-TNF biologic DMARD Brand: Orencia Use: RA

Anakinra

Non-TNF biologic DMARD Use: RA AE: malignancies and serious infections

Travel vaccines

Inactivated: HepA (Havrix, VAQTA), HepB (Engerix-B, Recombivax HB), HepA/B (Twinrix), Japanese encephalitis (Ixiaro), meningococcus (Menveo, Menactra), polio (IPOL), typhoid-IM (Typhim Vi) Live: cholera-po (Vaxchora), typhoid-po (Vivotif), yellow fever-SC (YF-VAX)

Quality Assurance plan

Includes SOPs (Standard Operating Procedures; itemized steps on how to perform routine and expected tasks) and periodic testing of finished compounded preparations (which can be done in-house or outsourced to other testing facilities)

Amylase and lipase increase

Increase means pancreatitis. This can be caused by didanosine, GLP-1 agonists, valproic acid, and hypertriglyceridemia

Potassium lab value

Can be increased due to: ACE inhibitors, ARBs, aldosterone receptor antagonists, aliskiren, cyclosporine, tacrolimus, drospirenone, and canagliflozin Can be decreased due to: beta-2 agonists, diuretics, and insulin

Parenteral iron

Use: iron deficient anemia in patients who have CKD on hemodialysis, CKD receiving ESAs (Erythropoiesis Stimulating Agents), or unable to tolerate po iron BBW: anaphylactic reactions

Potassium-sparing diuretics

Use: most commonly for heart failure CI: hyperkalemia (>5.5), anuria, and renal impairment BBW: hyperkalemia (>5.5) Monitoring: check K before starting and frequently after

Mavyret

Used for HCV

Alpha-2 agonists

When activated in the brain, there is a decrease in overall sympathetic output *Eye drops*: MOA: increase aqueous outflow, reducing aqueous humor production Use: glaucoma

Ibuprofen

Non-selective NSAID *Brands*: Motrin, Advil *Dose*: adult: OTC 200 - 400 mg Pediatrics: 5 - 10 mg/kg/dose q6-8h *DDI*: if using ASA for cardioprotection and ibuprofen for pain, take ASA 1h before or 8h after ibuprofen

Doxazosin

Non-selective alpha blocker *Brands*: Cardura Cardura XL: can leave a ghost tablet *Use*: BPH *Dose*: titrate slowly. Qhs to minimize orthostasis/dizziness AE *AE*: more than other alpha blockers (along with terazosin)

Glycerin

Osmotic laxative

Lactulose

Osmotic laxative

AHFS

Provides comprehensive monographs that link to supporting evidence and references

PubMed

Provides journal articles available via NLM

NRTIs for HIV

Renal dose adjustment required except with abacavir. Take without regard to meals except didanosine (without food) MOA: DNA chain termination and stops further viral DNA synthesis DDI: no CYP450 DDIs BBW: (zidovudine, stavudine, didanosine > others) lactic acidosis and severe hepatomegaly with steatosis

What causes hyperphosphatemia

Renal failure

Corrected calcium level equation

Reported Ca + ( [4 - albumin] x 0.8)

Alprostadil

Refrigerate MOA: prostaglandin E1. Vasodilator Administration: injected into the penis or a pellet is inserted through the urethra AE: penile pain, priapism

How are ALT and AST released

Released due to injured hepatocytes

Probenecid

Requires adequate renal function to be effective MOA: inhibits reabsorption of UA Use: second line for chronic urate lowering treatment for gout after XOIs. Can also be used to increase beta lactam levels CI: G6PD deficiency

Isotretinoin

Retinoid Use: acne Monitor: cholesterol and pregnancy tests (should have 2 negative pregnancy tests before starting; cannot get pregnant for 1m before, during, and 1m after treatment) DDI: St. John's Wort, steroids, tetracyclines, vitamin A supplements

Ipratropium bromide

SAMA Brand: Atrovent HFA Use: COPD Dose: (MDI) 2 inhalation qid How to use: do not have to shake. Keep your eyes closed while inhaling so medication doesn't go in. Breathe slowly and deeply. Clean qw

Prostate cancer

Screening (if patient chooses to be tested): PSA (Prostate Specific Antigen) +/- DRE (Digital Rectal Exam)

Enzalutamide

Second generation antiandrogen Brand: Xtandi Use: prostate cancer

Why is bilirubin collected

To detect liver damage and bile duct blockage

Rosiglitazone

TZD Brand: Avandia Use: diabetes BBW: increased risk of MI

Docetaxel

Taxane Use: cancer AE: severe fluid retention

Gemcitabine

Pyrimidine analog antimetabolite Use: cancer

DOC for HNPEK

Beta-lactam/beta-lactamase inhibitor

Methylcellulose

Bulk-forming laxative Brand: Citrucel

Olopatadine

IN antihistamine Brand: Patanase

Calcium polycarbophil

Bulk-forming laxative Brand: FiberCon

Diagnostic tests for A-Fib/Flutter

CHADS2 or CHA2DS2-VASc Score

Diagnostic tests for breast cancer

Mammogram, ultrasound, MRI

Peginterferon beta-1a

Brand: Plegridy Use: MS Dose: q2w

Nabumetone

COX-2 selective NSAID

Nicardipine

DHP CCB IV Brand: Cardene IV

Blepharitis

Eyelid inflammation Treat: warm, moist washcloth

Beclamethasone

ICS. Does not need to be shaken Brand: Qvar Use: asthma

Primaxin generic

Imipenem/cilastatin

CRP lab

Indicates inflammation

Diagnostic tests for ovulation

Luteinizing Hormone

Teriflunomide

Oral immunomodulator Use: MS CI: pregnancy

Nelfinavir

PI used for HIV. Use with ritonavir not recommended AE: DA

Clearance for extravascular administration equation

(F x dose) / AUC

Natural products that increase risk of bleeding

"5 Gs:" Ginger, Garlic, Ginkgo, Ginseng, Glucosamine Fish oils, willow bark

ClimaraPro

"Pro" indicates it has progestin in it as well (Climara is just estradiol patch) Use: menopause in patients with a uterus

Drugs that should never be refrigerated

(*D*ear *S*weet *P*harmacist *M*arry *M*e *F*orever *E*ternally) Dexmedetomidine (unless diluted), SMZ-TMP, Phenytoin, Metronidazole, Moxifloxacin, Furosemide (crystallizes), Enoxaparin

Drugs that should be protected from light during administration

(*D*eliver *E*very *N*eeded *M*ed with a light *P*rotective cover) Doxycycline, Epoprostenol, Nitroprusside, Micafungin, Phytonadione

Calculation for E

(58.5 x i) / (MW x 1.8) i = based on number of particles 1 = 1 2 = 1.8 3 = 2.6 4 = 3.4 5 = 4.2

How to calculate mEq

(mg x valence) / MW Valence = number of positive or negative ions of a given compound (NaCl = 1, CaCl2 = 2)

Common resistant pathogens

*K*ill *E*ach *A*nd *E*very *S*trong *P*athogen Klebsiella pneumoniae (ESBL, CRE), E. Coli (ESBL, CRE), Acinetobacter baumannii, Enterococcus faecalis/faecium (VRE), Staph aureus (MRSA), Pseudomonas

Drugs that cause vision change or damage

*(* I *CORV*ed *5 VD*s then the *LEA CH* gave me *5 VD*s via *IV. AF)* *Color discrimination*: PDE5 inhibitor: greenish tinge around objects Voriconazole: color vision changes Digoxin: with toxicity- yellow/green *Optic neuropathy*: linezolid, ethambutol, amiodarone (plus corneal deposits) *Retinal changes/retinopathy*: chloroquine, hydroxychloroquine *Vision loss/abnormal vision*: PDE5 inhibitors: vision loss in one or both eyes (can be permanent) Voriconazole: abnormal vision, photophobia Digoxin: with toxicity. Blurriness, halos Isotretinoin: decreased night vision which can be permanent, dry eyes/irritation Vigabatrin: permanent vision loss (high risk) *Floppy iris syndrome* (causes difficulty in cataract surgery): alpha blockers (doxazosin)

Which drugs should be mixed with saline, not dextrose

*(ACID PE)* Ampicillin, Caspofungin, Infliximab, Daptomycin, Phenytoin, Ertapenem

Drugs with boxed warnings for liver damage

*(ANN* turned her *liver PINK* after joining *MTV)* APAP (high doses acute or chronic), isoniazid, ketoconazole, MTX, nefazodone, nevirapine, NRTIs, propylthiouracil, tipranavir, valproic acid

Interferon beta-1a

*Brands*: Avonex: IM qw Rebif: SC 3x/w *Use*: MS

Bacterial meningitis (in children)

*Symptoms*: nuchal rigidity *Diagnosis*: lumbar puncture *Empiric treatment*: ampicillin + cefotaxime/gentamicin Ceftriaxone: usually used in adults, avoid in neonates because it displaces bilirubin causing kernicterus. Ceftriaxone and calcium-containing solutions can precipitate causing embolus/death

Sensitivity

100% sensitivity = test will be positive in 100% of patients with the condition

Phenytoin therapeutic range

10 - 20 mcg/mL (same for fosphenytoin) Free phenytoin: 1 -2.5 mcg/mL

Specificity

100% specificity = test will be negative in 100% of patients without the condition

Lithium therapeutic range

0.6 - 1.2 mEq/L

GERD/heartburn treatment in pregnancy

1. Lifestyle 2. Calcium carbonates (Tums)

RBC average life span

120 days

Procainamide therapeutic range

4 - 10 mcg/mL

Yellow Fever Vaccine CI

Allergy to eggs

Certolizumab pegol

Anti-TNF biologic DMARD Brand: Cimzia Use: RA, CD Dose: SC qow

Hydroxyzine

Antihistamine Brand: Vistaril Use: general urticaria and anxiety (should not be used long term) AE: sedation and dry mouth

Tenoretic

Atenolol (beta-blocker) + chlorthalidone (diuretic)

Antiarrhythmics

Before starting, all patients should have an electrolyte and toxicology screening. Treats heart failure and decreases heart rate

Sugammadex

Brand: Bridion Use: OD of rocuronium, vecuronium

Cost-Benefit Analysis

Comparing costs (in monetary units [dollars]) of two interventions, regardless of their outcomes

Entacapone

COMT inhibitor Brand: Comtan MOA: increases duration of action of levodopa by inhibiting catechol-O-methyltransferase Use: adjunct to Sinemet for Parkinson's Disease Dose: 200 mg with each dose of levodopa AE: somnolence (sudden daytime sleep attacks), orthostasis, hallucinations, dyskinesias

Meloxican

COX-2 selective NSAID Brand: Mobic

Cytomegalovirus

Can cause retinitis, colitis, or esophagitis *Treatment*: ganciclovir: DOC. It is not bacteriostatic so prepare in sterile water. Refrigerate suspension form. BBW for myelosuppression Valganciclovir: DOC. Prodrug of ganciclovir. Refrigerate suspension form. BBW for myelosuppression Foscarnet: should be reserved for refractory cases. BBW for renal impairment Cidofovir: should be reserved for refractory cases

Benzoyl peroxide

Can stain clothing Benzamycin: bp and erythromycin. Mixed with 70% alcohol and shaken before dispensed. Stored in refrigerator Duac: bp / clindamycin. Store in fridge before dispensing, okay in room temperature for 2m BenzaClin: bp / clindamycin. Stored at room temperature

Nabilone

Cannabinoid Brand: Cesamet Use: breakthrough CINV

Macrolides

Caution in patients with CVD, with hypo-kalemia/magnesemia, taking other QT-prolonging drugs (azoles, antipsychotics, methadone, macrolides) *MOA*: binds to 50S ribosomal subunit *Covers*: atypicals and haemophilus *Uses*: CAP and beta-lactam alternative to strep throat *Drug-specifics*: azithromycin: ZPak (500 mg x1d, 250 mg x4d) and Tri-Pak (500 mg qd x3d). Commonly used for COPD exacerbation, chlamydia, gonorrhea (with other meds), whooping cough, prophylaxis for MAC (Mycobacterium Avium Complex). DOC for Travelers' Diarrhea Clarithromycin and erythromycin: CI with lovastatin and simvastatin. CYP3A4 inhibitors (caution when taking with warfarin) Clarithromycin: increased mortality in patients with CAD. Commonly used for H. Pylori Erythromycin: causes the most GI upset due to increased gastric motility *AE*: QT prolongation, hepatotoxicity, and GI upset

Common reconstituted drug that should not be refrigerated after opening

Cefdinir, doxycycline, Bactrim, clindamycin, and Cipro

DOC for CRE

Ceftazidime/avibactam, colistimethate, and polymyxin B

Enteric-coating ingredients used in compounding

Cellulose acetate phthalate and shellac

CDER

Center for Drug Evaluation and Research. Manages NDA approval process for prescription drugs

CKD

Chronic Kidney Disease. Degree of kidney function is measured by GFR (< 60), CrCl, and amount of albumin in urine (≥30) *Drugs that require dose adjustment in patients with CKD*: aminoglycosides (inc dosing), beta-lactams, fluconazole, quinolones (except moxi), vancomycin, LMWHs, rivaroxaban, H2RAs, metoclopramide, bisphosphonates, lithium *Drugs that are CI in patients with CKD*: CrCl <60: nitrofurantoin CrCl <50: tenofovir df, voriconazole IV CrCl <30: tenofovir a, NSAIDs, dabigatran, rivaroxaban GFR <30: SGLT-2 inhibitors, metformin *Treatment*: first line is ACEI or ARB (causes hyperkalemia if taken together). Works by inhibiting RAAS, causing efferent arteriolar dilation; reduces pressure in the glomerulus, decreases albuminuria, and provides CV protection. SCr can increase by up to 30% when first starting (normal). Monitor SCr and K 1 - 2 w after starting. Counsel patients to avoid potassium supplements and salt substitutes *Monitoring*: requires monitoring of PTH, PO4, Ca, and Vitamin D *Secondary illnesses*: Vitamin D deficiency, secondary hyperparathyroidism, anemia, hyperkalemia, metabolic acidosis Hyperphosphatemia: treatment options are sevelamer products, Auryxia, lanthanum

Otitis externa treatment

Ciprodex (Cipro and dexamethasone) ear drops

Dofetilide

Class III antiarrhythmic Brand: Tikosyn BBW: must be initiated in a setting with continuous ECG monitoring and with the ability to assess CrCl for a minimum of 3 days

UTI

Classified as complicated and uncomplicated. Positive urinalysis occurs when there is pyuria and bacteriuria *Symptoms*: cystitis: urgency, frequency, nocturia, dysuria, suprapubic heaviness, hematuria Pyelonephritis (upper UTI): flank pain Fungal infection (vaginal candida albicans): itchy *Treatment*: never use moxifloxacin Acute uncomplicated cystitis: nitrofurantoin 100 mg po bid wc x5d +/- phenazopyridine (to relieve dysuria; 2d max; take with 8 oz of water or wc; can cause red-orange coloring of the urine and other body fluids) Acute uncomplicated pyelonephritis: if local quinolone resistance ≤10 use Cipro or levofloxacin. If local quinolone resistance > 10% use ceftriaxone, Bactrim, or a beta-lactam Complicated UTI: If ESBL producing bacteria present use a carbapenem

Resources for investigational drugs

Clinicaltrials.gov

CYP450 pharmacogenomic test

Clopidogrel (Plavix): CYP2C19star2 or star3 decreased activity- patients should not use Codeine: CYP2D6. Ultra-rapid metabolizers should not use due to toxicity risk Warfarin (Coumadin): start with a lower dose if patient has CYP2C9star2, CYP2C9star3, or VKORC1

Andexxa

Coagulation factor Xa recombinant. Used for apixaban or rivaroxaban OD

Drugs to avoid in pediatrics

Codeine: CI <18 yo after tonsillectomy/adenoidectomy and <12 yo Codeine or hydrocodone cough/cold medications: not indicated for <18 yo Promethazine: CI <2 yo Quinolones: AE on cartilage, bone, and muscle Tetracyclines: not recommended for <8 yo. Stains teeth, weakens bone & cartilage. Not CI for tick-borne Rickettsial diseases. Doxycycline is most effective Tramadol: CI <12 yo Ceftriaxone: CI 1-28d old OTC teething medication with benzocaine: not recommended <2 yo OTC cough and cold: not recommended <6 yo

Ointments

Contain the least water out of all topical products Types: oleaginous (oily/greasy) bases, absorption bases, water-in-oil (w/o) emulsion bases, oil-in-water (o/w) emulsion bases, and water-soluble bases How prepared: powder form is triturated well, using a levigating agent. Powder is mixed into ointment base, using geometric dilution. Certain ointments will require heat to mix components together well. This should be done by melting ingredients with highest melting point, then add the others, according to their decreasing melting points

C-PEC

Containment Primary Engineering Control. Sterile hood used for Hazardous Drugs and must be kept on at all times (must be sanitized prior to re-initiation if turned off for whatever reason). Sterile and non-sterile C-PECs are placed at least 1 meter apart. Should have a plastic-backed preparation mat on work surface and tools (mortar, pestle, etc) dedicated only for HD-use. Emergency hand/eye washing sink must be nearby. ISO 5

C-SEC

Containment Secondary Engineering Control. Place where C-PEC is located. Must be negative pressure. Requires at least 12 ACPH. ISO 7

Lactated Ringer's solution

Contains calcium

Amethyst

Continuous contraceptive so no period occurs

Calcium

Critically important for children, pregnancy, and during the years of menopause *Types*: calcium citrate: better absorption when gastric pH is increased. 21% elemental calcium, can take with or without food. Calcitrate is a brand name Calcium carbonate: 40% elemental calcium, absorption is acid-dependent, must take with meals. Most calcium formulations are carbonate. Smaller tablet size than citrate. Caltrate is a brand name Calcium acetate: not used for calcium replacement. Brand is PhosLo. Used to decrease phosphate levels *Dose*: women 19-50: 1000 mg/d Women >50: 1200 mg/d *Administration*: saturable, so doses above 500-600 mg of elemental calcium should be divided *AE*: constipation

Vitamin D

Critically important for children, pregnancy, and during the years of menopause. Required for calcium absorption Vitamin D deficiency: vitamin D < 30. Can cause rickets in children and osteomalacia in adults. Treated with high doses of vitamin D2 (ergocalciferol) or vitamin D (cholecalciferol) x8-12w Dose: 800 - 2000 U/d. Infants and children who are exclusively breastfed need 400 U/d

Treatment to reduce dryness of eye

Cyclosporine emulsion eye drops (Restasis) or artificial tears

Cyclosporine emulsion

Cyclosporine eye drops Brand: Restasis Use: Sjorgen's syndrome AE: burning, infection

Orange Book

FDA. List of approved drugs that can be interchanged with generics based on therapeutic equivalence using an AB rating

Clevidipine

DHP CCB Brand: Cleviprex Form: lipid emulsion (provides 2 kCal/mL) and is a milky-white color. Must use strict aseptic technique and should be used within 12h of vial puncture AE: hypertriglyceridemia and infections CI: allergy to soybeans, soy products, or eggs

Amlodipine

DHP CCB. Considered the safest CCB in patients with heart failure with reduced ejection fraction Brand: Norvasc AE: peripheral edema and gingival hyperplasia

Minoxidil

DIrect vasodilator Use: HTN and OTC topical for hair growth (Rogaine) AE: fluid retention, tachycardia, and hair growth BBW: potent antihypertensive

Clomiphene

DOC for infertility in pts with irregular or absent menstrual cycles MOA: SERM (Selective Estrogen Receptor Modulator). Estrogen agonist in some tissues and estrogen antagonists in others. Increases LH/FSH to cause ovulation Forms: SC, IM AE: hot flashes, clotting risk

Aspergillus treatment

DOC: voriconazole Liposomal amphotericin B, isavuconazonium

Sitagliptin

DPP-4 inhibitor Brand: Januvia Use: diabetes

Hypothyroidism

Deficiency in T4 and elevation in TSH *Cause*: most commonly Hashimoto's disease (autoimmune condition in which a patient's antibodies attack thyroid gland) *Symptoms*: cold intolerance/sensitivity, dry skin, fatigue, muscle cramps, voice changes, constipation, weight gain, goiter, myalgias, weakness, depression, bradycardia, coarseness or loss of hair, menorrhagia, memory/mental impairment *Treatment*: levothyroxine DOC. Patients reported feeling better with combinations including liothyronine (T3. Cytomel and Triostat. Shorter half life) or dessicated thyroid (T3 and T4. Armour Thyroid and NP Thyroid). Decrease dose in pts with CV disease Pregnant: levothyroxine, will need a 30-50% increase in dose *DDI*: decrease levothyroxine absorption: aluminum, calcium, cholestyramine, iron, Mg, multivitamins, sevelamer, sucralfate. Separate by 4h Decrease effectiveness of levothyroxine: beta blockers *Monitoring*: TSH q4-6w (too high of a dose can cause Afib and fractures in the elderly) *Can cause*: myxedema coma (life-threatening emergency, treat with IV levothyroxine)

Scurvy

Deficiency in vitamin C

Succinylcholine

Depolarizing NMBA Brand: Quelicin Use: usually reserved for intubation

Sodium oxybate

Derived from GABA. C2. Considered a "date rape" drug Brand: Xyrem Use: narcolepsy with cataplexy REMS

Case report

Describes an adverse event or unique reaction that appears in a single patient

Case series

Describes an adverse event or unique reaction that appears in multiple patients

Hyperkalemia

Diabetic patients have a higher risk because the insulin deficiency reduces the ability to shift potassium into the cells *Most common cause*: kidney failure *Symptoms*: muscle weakness, bradycardia, and fatal arrhythmias *Drugs that raise potassium levels*: *(AAAABCD T)* ACEIs, aldosterone receptor antagonists, aliskiren, ARBs, canagliflozin, drospirenone-containing COCs, Bactrim, transplant drugs (cyclosporine, tacrolimus, everolimus) *Treatment*: discontinue potassium sources. If severe, one may need to stabilize myocardial cells, rapidly shift potassium intracellularly, or induce elimination from the body Drugs: Sodium Polystyrene Sulfonate (SPS; Kayexalate): binds to many oral drugs Patiromer (Veltassa): not for emergency use. Binds to many oral drugs, separate by at least 3 hours. AE are hypomagnesemia and constipation Sodium zirconium cyclosilicate (Lokelma): can bind other drugs, separate by at least 2 hours. Not for emergency use Calcium gluconate: used when ECG changes are already present, does not lower potassium. Should be used immediately

DMARD

Disease-Modifying AntiRheumatic Drug MOA: slows the disease process and helps prevent further joint damage Use: RA

What does a C-peptide lab indicate

Distinguishes type 1 from type 2 diabetes

Why would uric acid increase

Diuretics, niacin, high doses of aspirin, pyrazinamide, cyclosporine, tacrolimus, select pancreatic enzyme products, select chemotherapies

Centrally-acting alpha-2 agonists

Do not discontinue abruptly, can cause rebound hypertension, must taper Drugs: clonidine, guanfacine, methyldopa AE: dry mouth, somnolence, fatigue, dizziness, constipation, bradycardia, hypotension

Hydrocarbons (petroleum products) OD

Do not induce vomiting, keep patient NPO due to aspiration risks

Nicotine nasal spray

Do not sniff, swallow, or inhale through the nose. Wait 5 min after use before driving AE: nasal irritation

GLP-1 agonists

Do not store with needle attached. Keep refrigerated until you are ready to use it. Big decrease in A1c vs other diabetes treatments MOA: increases insulin secretion and decreases glucagon secretion Use: type 2 diabetes Form: SC (some available in combination with long-acting insulin) Drugs: end in "-tide" AE: pacnreatitis, N/V, weight loss, DA, HA (symptoms decrease over time) CI: not recommended in patients with severe GI disease, including gastroparesis

Tigecycline

Do not use for bloodstream infections. Reconstituted solution should be yellow-orange, discard if not Covers: MRSA, VRE, gram -, anaerobes, and atypical. No activity against the "3 Ps," pseudomonas, proteus, providencia BBW: increased risk of death

Counseling points on how to correctly take blood pressure

Do: go to restroom & completely empty bladder, sit in a chair and relax for at least 5 min, use correct cuff size, support arm at heart level, wait 1-2 min in between measurements Don't: talk, sit or lie down on an examination table, drink caffeine, exercise, or smoke 30 minutes before, use a finger or wrist monitor Ambulatory BP monitoring devices: wear during daily activities. Obtains readings q15-60 min Home BP monitoring devices" record average of 2-3 readings every morning and/or night before eating or taking any medications

Traditional compounding

Done for patients with specific needs. Exempt from FDA's drug approval process and from CGMPs (Current Good Manufacturing Practices)

Namzaric

Donepezil/memantine combo. Can be switched from donepezil once stable on 10 mg. Do not crush or chew, can be sprinkled on applesauce Use: Alzheimer's Disease

Pramipexole

Dopamine agonist Brands: Mirapex, Mirapex ER Use: Parkinson's Disease (ER), Restless Leg Syndrome (IR; taken 1-3h before bedtime)

Ropinirole

Dopamine agonist Brands: Requip, Requip XL Use: Parkinson's Disease (XR), Restless Leg Syndrome (IR; taken 1-3 h before bedtime)

Droperidol

Dopamine receptor antagonist BBW: QT prolongation and serious arrhythmias

Dopamine receptor antagonists

Drugs: prochlorperazine, promethazine, metoclopramide MOA: blocks dopamine receptors, including chemoreceptor trigger zone Use: breakthrough CINV AE: sedation, acute extrapyramidal symptoms, acute dystonic reactions (treat with anticholinergics [benztropine, diphenhydramine]), decreased seizure threshold

Hemostatic agents

Drugs: usually contain "throm" in the name (Recothrom, Thrombin-JMI) MOA: inhibit fibrinolysis or enhance coagulation Forms: topical (used surgically), tablet, solution, injection

DPI

Dry Powder Inhaler. Delivers a dose of fine powdered medication, no propellant. Do not shake Brand name identifiers: Diskus, Ellipta, Pressair, Handihaler, Neohaler, RespiClick, Flexhaler Administration: quick and forceful inhalation, no need to press anything, spacers cannot be used

Diagnostic tests for CHF

ECHO

Diagnostic tests for seizures/epilepsy

EEG

Diagnostic tests for lyme disease

ELISA (Enzyme-Linked ImmunoSorbent Assay)

Trazodone

ER brand: Oleptro Use: depression, insomnia (dosed qhs) AE: sedation, priapism, QT prolongation BBW: increased risk of suicidal thinking and behavior in children, adolescents, and young adults

Ambrisentan

ERA Use: PAH

Bosentan

ERA Use: PAH DDI: bosentan can decrease effectiveness of hormonal contraceptives BBW: hepatotoxicity

Epoetin alfa

ESA *Brands*: Epogen and Procrit *Use*: normocytic anemia *Dose*: CKD: 3x/w. Initiate when Hgb < 10. Decrease or interrupt dose when Hgb approaches or exceeds 11 Cancer: initiate when Hgb <10

Darbepoetin

ESA Use: normocytic anemia Dose: IV or SC qw (long half life)

Lipoglycopeptides

End with "-vancin." Has concentration-dependent killing *MOA*: inhibit bacterial cell wall synthesis by binding to the D-alanyl-D-alanine portion of cell wall *Drug-specifics*: telavancin: approved for SSTI (complicated skin and soft-tissue infections). BBW for teratogenicity and nephrotoxicity. Can falsely increase aPTT, PT, INR. Can cause red man syndrome Oritavancin (Orbactiv) and dalbavancin: single dose regimen. CI with IV UFH 120 h after oritavancin. Can falsely increase PT, INR, aPTT. AE of red man syndrome

ERAs

Endothelin Receptor Antagonists Use: PAH AE: hepatotoxicity, decreased Hgb/Hct, fluid retention, HA CI: pregnancy BBW: teratogenic (patients must have a negative pregnancy test before starting and qm while on therapy)

BEE (Basal Energy Expenditure)

Energy expenditure in the resting state (in kcal/d). Calculation will be on exam but it can be estimated by about 20 kcal/weight of pt in kg

Geometric dilution

Ensuring dry ingredients are evenly distributed throughout powder or paste mixture. A small amount of drug powder is mixed into an equal amount of other ingredients. Drug and other ingredients are added back and forth until all ingredients are mixed in

Natural products that can cause cardiotoxicity

Ephedra, bitter orange

EGFR inhibitors

Epidermal Growth Factor Receptor inhibitors *Pharmacogenomics*: EGFR gene: positive expression means better response rates KRAS mutation: must be wild type *MOA*: inhibits growth factor from binding to surface of tumor cell and promotes cell growth. Targets EGFR (Epidermal Growth Factor Receptor) *Use*: colon cancer *AE*: acneiform rash and dry skin *Toxicity*: acneiform rash (EGFR -> epidermis -> skin toxicity). This indicates that the patient will have a better response. Avoid sunlight, use sunscreen. Antibiotics and topical steroids may help

Anaphylaxis treatment

Epinephrine injection +/- diphenhydramine +/- steroids +/- IV fluids. Patient at risk should carry around EpiPen and emergency kit (diphenhydramine tablets 25 mg x 2)

Dispensing Hazardous Drugs

Equipment must be decontaminated after every use. Tablets and capsules cannot be put into automated counting or packaging machines

Diagnostic tests for GERD

Esophageal pH monitoring

Climara Pro

Estradiol / levonorgestrel Dose: qw

Gloved fingertip test

Evaluate gloving and garbing technique. Fingertip samples are taken 3 consecutive times using TSA (Trypticase Soy Agar) plates to test for CFUs, there must be 0 on both hands. Done annually for personnel who compound low- and medium-risk CSPs

Glass mortar

Every pharmacy must have at least one. Used to mix liquids or compounds that are oily and can stain

Cocrane library

Evidence-based information to guide clinical decision making. Contains systematic reviews

Narcolepsy

Excessive daytime sleepiness with cataplexy Treatment: stimulants, sodium oxybate

Kaolin

Excipient used as an adsorbent powder to keep powder dry

Magnesium carbonate

Excipient used as an adsorbent powder to keep powder dry

Magnesium oxide

Excipient used as an adsorbent powder to keep powder dry

Eye and ear formulation

Eye drops can be used in the ear but not vice versa. 1 drop = 0.05 mL. Suspensions should be shook well. For gels, shake once *Eye*: wait 5-10 min in between drops Ointments: can cause blurry vision Drops: should go in space between eyes and lower eyelid, eye should be closed, place a finger in between eye and top of your nose for one full minute *Ear*: administration: pull ear up & back for adults and down & back for children < 3 yo. Keep the ear facing up for 5 min

Absolute bioavailability equation

F (%) = 100 x (AUC extravascular / AUC intravenous) x (dose intravenous / dose extravascular)

Where should side effects, adverse events, and allergies be reported?

FDA's MedWatch program (FAERS [Fda Adverse Event Reporting System])

Resources for drug substitution

FDA's Orange Book and FDA's Purple Book

FPG

Fasting Plasma Glucose. Fasting for 8+ hours before ≥ 126 mg/dL: diabetes 100 - 125 mg/dL: pre-diabetes

Diagnostic tests for prediabetes

Fasting plasma glucose, oral glucose tolerance test, and A1C

What causes G6PD deficiency

Fava beans, chloroquine, dapsone, methylene blue, nitrofurantoin, primaquine, probenecid, quinidine, quinine, rasburicase, and sulfonamides

Alteplase

Fibrinolytic. Must keep bp < 180/105. Aka tPA *Brand*: Activase and Cathflo Activase *MOA*: restores blood flow. tPA (tissue Plasminogen Activator) *Use*: STEMI Ischemic stroke: only fibrinolytic agent used for acute ischemic stroke. Only use if clot is confirmed *Dose*: STEMI: > 67 kg, 100 mg IV Acute ischemic stroke: give within 3h of symptom onset. Max of 90 mg *AE*: major bleeding *CI*: when used for stroke: bp > 185/110 (in this case, lower bp so that alteplase can be used) and intracranial hemorrhage

Oxymetazoline

IN decongestant Brand: Afrin AE: rhinitis medicamentosa (rebound congestion if used longer than 3d)

Haloperidol

First generation antipsychotic (high potency- higher risk of EPS effects), butyrophenone Brand: Haldol Use: delirium in ICU, antipsychotic (qm) Form: long acting injection available AE: IV has high risk of CV events. EPS effects most likely in young males

Diagnostic tests for bacterial vaginosis

Fishy odor and pH > 4.5

DOC for bacteroides fragilis

Flagyl, beta-lactam/beta-lactamase inhibitor, cefotetan, cefoxitin, carbapenems

Malathion lotion

Flammable Brand: Ovide Use: lice AE: can irritate skin

Which insulins require a needle to be provided with it

FlexPen (Novolog), KwikPen (Humalog, Humulin, Basaglar), FlexTouch (Levemir, Fiasp, Tresiba), SoloStar (Lantus, Admelog, Toujeo), GLP-1 agonists (Byetta, Victoza, Adlyxin), pramlintide (SymlinPen) Needles range from 28G-32G

Ascites

Fluid accumulation within the peritoneal space. Patients should restrict dietary sodium intake. All patients should be considered for transplant. If infected, it can cause SBP (Spontaneous Bacterial Peritonitis) Treatment: spironolactone monotherapy or furosemide + spironolactone (40 mg:100 mg ratio to maintain potassium balance)

Symbyax

Fluoxetine + olanzapine Dose: qhs Use: depression CI: pimozide, thioridazine, other drugs that cause QT prolongation

Pemetrexed

Folate antimetabolite Use: cancer

Xiidra

Form: eye drops Use: Sjorgen's syndrome AE: unusual taste

Pancreatic enzyme products

Formulated to dissolve in more basic pH of duodenum *Use*: helps pts with CF digest food, maintain weight, and improve nutrient absorption *Forms*: not interchangeable. All are capsules except Viokase (tablet) DR capsules with EC microspheres or microtablets: can be opened and sprinkled on soft, acidic foods like applesauce, pureed bananas, pears (avoid high pH foods-dairy) *Dose*: high fat meals require higher doses. Use 50% of mealtime dose with snacks. Dose is adjusted until the stools are normalized *Administration*: do not chew or crush capsules. Swallow immediately and follow with water to avoid mucosal irritation and stomatitis. Take before or with all meals and snacks. Protect from moisture, dispense in original container (except Zenpep and some Creon strengths). Do not refrigerate *AE*: stomach pain, bloating, gas, nausea

Onychomycosis

Fungal infection of the nail Diagnosis: KOH (potassium hydroxide) smear Treatments: itraconazole or terbinafine. Pulse therapy (intermittent) can be used to reduce costs and possible toxicity, but may not be effective

Ezetimibe

Further decrease in CV events when added to a statin MOA: inhibits absorption of cholesterol at the small intestine AE: myalgia

Enfuvirtide

Fusion inhibitor used for HIV. Sc Brand: Fuzeon MOA: blocks fusion of HIV virus with CD4+ cells AE: local injection site reactions in 98% of patients

Tbo-filgrastim

G-CSF Brand: Granix Dose: qd AE: bone pain

Filgrastim

G-CSF Brands: Neupogen, Zarxio Dose: qd AE: bone pain

Exenatide

GLP-1 agonist *Brands*: IR: Byetta XR: Bydureon *Use*: diabetes *Dose*: IR: bid within 60 min before meals (never inject after a meal). Pen needle not provided. Each pen comes with enough to inject bid x30d XR: qw. Once mixed, it must be injected immediately *CI*: CrCl < 30 *BBW* (XR): risk of thyroid C-cell carcinoma

Liraglutide

GLP-1 agonist *Brands*: Victoza: approved to reduce risk of CV events in pts with type 2 diabetes and ASCVD. Pen needle not provided Saxenda: increases satiety. Used for weight loss *Dose*: qd *AE*: pancreatitis, hypoglycemia, nausea *BBW*: risk of thyroid C-cell carcinoma

Semaglutide

GLP-1 agonist Brand: Ozempic Use: diabetes Dose: qw BBW: risk of thyroid C-cell carcinoma

Dulaglutide

GLP-1 agonist Brand: Trulicity Use: diabetes Dose: qw BBW: risk of thyroid C-cell carcinoma

Sargramostim

GM-CSF AE: fever, bone pain, arthralgias, myalgias, rash

ARBs

Generics: end in "-sartan" MOA: block angiotensin II preventing vasoconstriction and decreasing aldosterone AE: angioedema, hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis, cough (cough and angioedema less likely with ARBs than ACEIs) DDI: alkiserin if patient has diabetes. Can decrease lithium renal clearance, increasing toxicity

Gentak

Gentamicin eye ointment for bacterial infection

Beta-blocker OD

Give glucagon

Memantine

Given alone (in severe cases) or with donepezil (moderate - severe) Brand: Namenda MOA: blocks NMDA Use: Alzheimer's Disease Forms: tablet, ER capsule (do not crush or chew; can be sprinkled on applesauce), oral solution

Utibron Neohaler

Glycopyrrolate/indacaterol Use: COPD How to use: remove capsule from blister pack, put it in chamber, press both buttons fully one time. The capsule in the chamber should be empty of all powder

Leuprolide

GnRH agonist Brand: Lupron Depot Use: prostate cancer

Goserelin

GnRH agonist Brand: Zoladex Use: prostate cancer

Estimated Average Glucose

Goal is < 154 mg/dL. eAG of 126 mg/dL indicates an A1c of 6%

Non-HDL

Goal: < 130 Non-HDL = TC - HDL

Resources for pharmacology

Goodman and Gilman's

Equation used to solve for the pH of a solution

Henderson-Hasselbalch Weak acid (pKa): pH = pKa + log (salt/acid) Weak base (pKb): pH = (pKw - pKb) + log (base/salt). pKw is always 14. Or pKa + log (base/salt)

Protamine

Heparin and LMWH antidote *Dose*: IV UFH reversal: 1 mg will reverse 100 units of heparin. Reverse the amount of heparin given in the last 2 - 2.5h. Max dose of 50 mg LMWH reversal: 1 mg protamine for 1 mg enoxaparin

Sickle cell disease

Group of inherited RBC disorders resulting from a genetic mutation in the genes that encode hemoglobin. RBCs contain abnormal hemoglobin or HgbS causing RBC to be rigid with a concave "sickle" shape, these cells burst (hemolyze) after 10-20d causing anemia. Most commonly affects African American population *Symptoms*: start 2-3m after birth because the fetus has HgbF (fetal hemoglobin) which blocks the sickling of cells *Complications*: vascular occlusion which can lead to sickle cell crises Vaso Occlusive crisis (VOC): aka acute pain crisis Acute chest syndrome: pain in chest and evidence of pulmonary infection Pulmonary HTN Infections: particularly with strep, h. influenzae, and neisseria meningitidis. Infection causes functional asplenia (absent spleen function) *Treatment*: nonpharm: blood transfusions (with goal Hgb being no higher than 10; iron overload is a risk, chelation therapy is used to remove excess iron- deferasirox or deferiprone) and bone marrow transplant Pharm: immunizations (flu, pneumococcal, meningococcal series plus routine boosters) & antibiotics (reduce risk of infection; worried about sepsis and meningitis. Prophylactic penicillin given po reduces risk of death; infants should be on bid until 5 yo), analgesics, hydroxyurea or L-glutamine (prevent or reduce frequency of complications), and chelation therapy

Linaclotide

Guanylate cyclase C agonist Brand: Linzess

Famotidine

H2RA Brands: Pepcid, Pepcid AC Forms: tablet, chewable tablet, suspension, injection Dose: decrease dose if CrCl < 50

Ranitidine

H2RA Brands: Zantac, Ranitidine Acid Reducer Forms: tablet, capsule, suspension, syrup, injection Dose: decrease dose if CrCl < 50

Nizatidine

H2RA Dose: decrease dose if CrCl < 50

Diagnostic tests for HIV

HIV antibody & antigen immunoassay and HIV-1/-2 antibody

Adenosine

Half life less than 10 seconds Use: paroxysmal supraventricular tachyarrhythmias

Resources for drug interactions

Hansten and Horn's

Daptomycin

Has concentration-dependent killing. Can falsely increase PT and INR. Compatible with NS. Do not refrigerate po suspension Brands: Cubicin, Cubicin RF Covers: MRSA and VRE. Do not use to treat PNA AE: myopathy, rhabdomyolysis, and increased CPK Monitor: CPK qw

Ingredients in a lozenge

Has the active drug in a base of sucrose or syrup for hard lozenges, PEG for soft lozenges, and glycerin or gelatin for chewable lozenges

Torsion balances

Have a sensitivity requirement of 6 mg Minimum weighable quantity = SR (6 mg) / acceptable error rate (usually 0.05 or 5%) = 120 mg

Naranjo scale

Helps determine the likelihood that a drug caused an adverse reaction

Warfarin

Has narrow therapeutic range. Racemic mixture of R- and S-enantiomers with S-enantiomer being more prevalent. Vitamin K levels in diet should be consistent throughout treatment. Common foods high in Vitamin K are brocoli, brussel sprouts, cabbage, spinach, tea. Stop 5d before major surgery (bridging to LMWH or UFH is recommended in patients with mechanical heart valve, Afib, or VTE at high risk for thromboembolism; d/c LMWH 24h before surgery) *Brands*: Coumadin and Jantoven *MOA*: Vitamin K antagonist, slightly inhibits Vitamin K epoxide reductase (VKORCI) enzyme complex, depleting activation of clotting factors II, VII, IX, & X, and proteins C & S *Dose*: healthy patients: 10 mg qd x2d, then adjust per INR ≤ 5 mg: elderly, malnourished, taking drugs which can increase warfarin levels, liver disease, heart failure, or having a high risk of bleeding DVT/PE: start warfarin on same day as parenteral anticoagulant and continue both for a minimum of 5d and until INR ≥2 for at least 24h *AE*: tissue necrosis/gangrene, HIT, bleeding (increased risk in patients who have CYP2C9star2 or star3 alleles and/or polymorphism of VKORC1 gene), teratogenic, purple toe syndrome (d/c if occurs) *DDI*: *(PRiMe BaF)* rifampin, fluconazole, metronidazole, Bactrim, PTU Decrease warfarin dose: amiodarone Increased bleeding risk without affecting INR: NSAIDs, antiplatelet agents, other anticoagulants, SSRIs, SNRIs, St. John's Wort (drugs that affect enzymes will affect INR), fibrates Drugs that increase clotting risk: estrogen, SERMs Herbal: garlic, ginger, ginkgo, ginseng, glucosamine, dong quai, vitamin E, high doses of fish oils, willow bark, wintergreen oil *CI*: pregnancy (except with mechanical heart valves) *Monitoring*: goal INR is 2-3 for most indications, 2.5-3.5 for high-risk indications (e.g. mechanical mitral valve or 2 mechanical heart valves). Can be done q12w for patients with stable INRs Follow up: if INR comes back out of range (within 0.5) but patient's readings have been adequate in the past, recheck in 1-2w *Tablet colors*: (Please Let Greg Brown Bring Peaches To Your Wedding) Pink (1 mg) Lavender (2 mg) Green (2.5 mg) Brown/tan (3 mg) Blue (4 mg) Peach (5 mg) Teal (6 mg) Yellow (7.5 mg) White (10 mg) *Warfarin reversal*: INR < 4.5 with no bleeding: reduce or skip warfarin dose. Monitor INR INR 4.5-10 without bleeding: hold 1-2 doses of warfarin INR> 10 without bleeding: po Vitamin K Major bleeding: slow IV injection of Vitamin K and Kcentra

Cold sores

Herpes simplex labialis Prevention: lysine Treatment: docosanol (Abreva) or acyclovir topical cream/ointment (Zovirax)

Haemophilus influenzae type b (Hib)-containing vaccines

Hiberix Given to adults with asplenia

Cough suppressants

High doses it acts as an NMDA-receptor blocker, leading to euphoria and hallucinations

Impetigo

Honey-colored crusts on the skin *Treatment*: mupirocin Numerous lesions: (systemic antibiotics that cover MSSA) cephalexin

NuvaRing

Hormonal contraceptive Administration: kept in place for 3w and taken out x1w. If kept in place >4w, confirm no pregnancy and insert a new ring, use backup. If first inserted on days 2-5 of cycle, backup for 7d

Conjugated equine estrogens

Hormone therapy *Brand*: Premarin *Use*: menopause *Forms*: topical: cream Systemic: tablet and injection

17-beta-estradiol

Hormone therapy *Use*: menopause *Forms*: topical: Estrace (cream), Estring (vaginal ring), Vagifem (vaginal tablet) Systemic: Estrace (micronized po tablet)

Drugs that should never be shaken or agitated

Hormones and other proteins

Relative Risk Reduction

How much risk is reduced in treatment group, compared to the control group. (RRR of 43% in metoprolol group means they were 43% less likely to have HF progression) = (% risk in control group - % risk in treatment group) / % risk in control group *or* 1-RR

HER2 inhibitors

Human Epidermal Growth Factor Receptor 2 inhibitors MOA: inhibits growth factor from binding to surface of tumor cell and promotes cell growth. Targets HER2 (Human Epidermal growth factor Receptor 2) Use: breast cancer Toxicity: cardiotoxicity, embryo-fetal toxicity Monitor: LVEF (using ECG or MUGA scan)

Hypercalcemia of malignancy

Hypercalcemia due to cancer *Treatments*: hydration: fluids, mannitol, hypertonic saline, loop diuretics. Treats intravascular volume depletion IV bisphosphonates (zoledronic acid): prevent skeletal related events Denosumab: prevent skeletal related events Calcitonin: brand is Miacalcin

What causes basophils to increase

Hypersensitivity reactions

Shock

Hypoperfusion usually in the setting of hypotension *Types*: hypovolemic: first-line (if not caused by hemorrhage) is fluid resuscitation with crystalloids. Vasopressors not effective unless intravascular volume is adequate Distributive Sepsis/septic: life-threatening organ dysfunction caused by a dysregulated host response to infection. Treat with broad-spectrum antibiotics and IV fluid resuscitation with IV crystalloids. NE is vasopressor of choice Cardiogenic: ADHF (Acute Decompensated Heart Failure- worsening weight gain, functionality, SOB, fatigue) + hypotension and hypoperfusion. Stop beta-blockers. Treat hypoperfusion with dobutamine or milrinone due to the vasodilatory and inotropic properties (if bp is adequate). If bp is not adequate, inotrope + vasopressor *General treatment*: fill the tank: optimize preload with IV crystalloid bolus (prn) Squeeze the pipes: peripheral vasoconstrictor (alpha-1 agonist) to increase SVR (Systemic Vascular Resistance) Kick the pump: beta-1 agonist to increase myocardial contractility and CO

Fluticasone

ICS *Brands*: Flovent HFA: shake well for 5 sec before each spray. Breathe in slowly and deeply. Hold your breath for up to 10 sec Flovent Diskus Arnuity Ellipta: do not block air vent. Rinse mouth with water and spit out after *Use*: asthma

Ciclesonide

ICS. Does not need to be shaken Use: asthma

Fluticasone/salmeterol

ICS/LABA *Brands*: Advair Diskus: COPD and asthma. Breathe out before inhaling, making sure mouthpiece is facing away. Breathe in quickly and deeply. Do not breathe in through nose. Rinse mouth with water and spit out Advair HFA: asthma AirDuo RespiClick: asthma. Opening and closing the cap without inhaling will waste a dose. Hold breath for at least 10 seconds after inhaling. Rinse mouth with water and spit

Breo Ellipta

ICS/LABA. DPI Generic: fluticasone/vilanterol Use: COPD and asthma How to use: do not block air vent. Rinse mouth with water and spit out after

Resources for infectious diseases

IDSA and Sanford Guide

Alpha-glucosidase inhibitors

If hypoglycemia occurs while on this drug (due to another drug [this class does not cause hypoglycemia]), it cannot be treated with sucrose; glucose tablets or gel need to be used Use: diabetes (not commonly used) Dose: taken with first bite of each meal AE: flatulence, DA, abdominal pain

P-value

If less than 5% (0.05), the null hypothesis is rejected and the result is statistically significant

Lamotrigine

If patient has alopecia, supplement with selenium and zinc Brands: Lamictal, Lamictal Starter Kit (orange: standard starting dose, use if no interacting meds; blue: lower starting dose, use if taking valproic acid; green: higher starting dose, use if taking an enzyme inducer and not taking valproic acid), Lamictal ODT, Lamictal XR Use: bipolar depression and maintenance (safest for pregnant patients); seizure management Dose (epilepsy): start weeks 1 and 2 at 25 mg qd. Slow titration required due to risk of severe rash Forms: ODT, chewable tablets, tablet DDI: valproic acid increases lamotrigine levels BBW: increased levels can cause serious rash, including SJS/TEN (more common in children)

Toxo prophylaxis for HIV patients

If their CD4 < 100 DOC: Bactrim qd Can give dapsone + pyrimethamine + leucovorin

Bands

Immature neutrophils that fight infections. When it's released from bone marrow it's called a "let shift"

Parenteral nutrition

Indicated when patient has not been able to absorb adequate nutrition via GI tract >5d. Should be entered via central line *Formulations*: 2-in-1: dextrose and amino acid (along with other things) 3-in-1: dextrose, amino acid, and lipids (along with other things) *To calculate amount of fluid needed for a patient/d*: 1500 mL + (20 mL)(weight in kg - 20) *Lipids*: 1.2 micron filters are commonly used for lipids. PN requires a filter due to the risk of precipitate *Electrolytes*: calcium and phosphate should be added carefully (with phosphate being added first) because they can bind together and precipitate which can be fatal (gluconate has lower risk than chloride). Iron is not usually given

Standard Deviation

Indicates how spread out the data is and how dispersed away the data is from the mean. A large SD indicates that a small number of data is close to the mean

Infective endocarditis

Infection of heart valves *Causes*: staph, strep, and enterococci Diagnosis: echocardiogram to visualize positive blood cultures *Therapy*: + gentamicin for synergy when infection is more difficult to eradicated (e.g. pt has prosthetic valve, MDRs), peak levels should be 3-4 and trough levels should be <1 *Dental prophylaxis* (to prevent bacteria going from mouth into the bloodstream and to the heart during dental procedures): amoxicillin 2 g po 30-60 min before procedure Penicillin allergy: clindamycin 600 mg, azithromycin 500 mg, or clarithromycin 500 mg

Isoflurane

Inhaled anesthetic AE: malignant hyperthermia

HIV INSTI-based regimen

Initial HIV therapy. Consists of an INSTI + 2 NRTIs ("NRTI backbone") *Drugs*: Biktarvy: bictegravir/emtricitabine/tenofovir alafenamide Triumeq: dolutegravir/abacavir/lamivudine Tivicay + Truvada: dolutegravir + emtricitabine/tenofovir disoproxil fumarate Tivicay + Descovy: dolutegravir + emtricitabine/tenofovir alafenamide Stribild: elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate Genvoya: elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide Isentress + Truvada: raltegravir + emtricitabine/tenofovir disoproxil fumarate Isentress + Descovy: raltegravir + emtricitabine/tenofovir alafenamide *Drug-specifics*: abacavir: requires testing for HLA-B*5701 allele, cannot use if positive Tenofovir disoproxil fumarate: caution in patients with renal insufficiency Stribild: do not start if CrCl <70 Triumeq: do not start if CrCl <50 Genvoya, Biktarvy: do not start if CrCl <30 Lamivudine and emtricitabine are interchangeable

Zoledronic acid

Injectable bisphosphonate *Brands*: Zometa: used for hypercalcemia of malignancy Reclast: injection used for osteoporosis. Dosed qy

Chemotherapy pins

Inserted into ports on diluent bags to avoid multiple punctures into the medication port of the bag when new bags of diluent are hung

Diabetes treatment in pregnancy

Insulin

Deferoxamine

Iron OD treatment injection

Dermatophytes nail bed fungal infection treatment

Itraconazole, terbinafine, or fluconazole

Formoterol

LABA Brand: Perforomist Use: COPD

Arformoterol

LABA. Contains R-isomer of formoterol Use: COPD

Sodium phosphates

Laxative *Brands*: Fleet Enema OsmoPrep: CI if patient has acute phosphate nephropathy, gastric bypass, or stapling surgery. BBW for nephropathy *Use*: constipation, bowel prep *Warnings* (for bowel prep): risky in patients with renal disease, cardiac disease, if taking loop diuretics (due to additional fluid loss), and NSAIDs

MTX OD treatment

Leucovorin (folinic acid), levoleucovorin (Fusilev)

Hypothyroidism treatment in pregnancy

Levothyroxine (30-50% dose increase)

Resources for ODs, poisoning, and toxicology

Lexi-Tox, Micromedex (previously called POISINDEX), and TOXNET

Thyroid storm

Life-threatening Symptoms: fever (> 103°F), tachycardia, tachypnea, dehydration, profuse sweating, agitation, delirium, psychosis, coma Treatment: PTU preferred + SSKI or Lugol's Solution + propranolol + dexamethasone + aggressive cooling

Topical retinoids

Limit sun exposure. Apply qhs 20 minutes after washing face

Drugs that can lower blood glucose

Linezolid, lorcaserin (Belviq), pentamidine, beta blockers, and quinolones

Emulsion

Liquid dispersed in a liquid. Heterogeneous *How to prepare*: Continental Gum Method (Dry Gum Method): 4 parts oil, 2 parts water, 1 part emulsifier (usually acacia). Levigate the gum (emulsifier) with oil, then add water all at once English Gum Method (Wet Gum Method): 4 parts oil, 2 parts water, 1 part emulsifier. Triturate the gum and water to form a mucilage, then add the oil slowly

Zylet

Loteprednol eye drops Use: eye inflammation

Diagnostic tests for microcytic anemia

Low Hgb, Hct, RBC, and MCV

Diagnostic tests for macrocytic anemia

Low Hgb, Hct, and RBC. High MCV

LMWH

Low Molecular Weight Heparin. Preferred anticoagulation in pregnancy MOA: bind to antithrombin, increasing its activity, which inactivates thrombin (factor IIa), factor Xa (moreso this one), and other proteases involved in blood clotting. Inhibits Xa more specifically than UFH Use: anticoagulant and VTE treatment (preferred in patients with cancer) DDIs: NSAIDs, SSRIs, and SNRIs

Metformin

Lowers A1c by 1-2% (big decrease in A1c vs other diabetes treatments). Cheap Brands: Glucophage, Glucophage XR, Fortamet, Glumetza MOA: improves insulin sensitivity in the muscle and decreases glucose production by the liver Dose: take wc. ER forms can leave a ghost tablet (empty shell) in stool Warning: not recommended to initiate with eGFR 30-45 AE: vitamin B12 deficiency, N/V/D, flatulence, abdominal cramping CI: eGFR < 30 and metabolic acidosis BBW: lactic acidosis (risk increased with hypoxic states, renal impairment, alcohol, and intravascular iodinated contrast media [d/c metformin at time of, or before imaging procedure and can be restarted 48h after]) Monitoring: renal function

LH

Luteinizing Hormone. Used to detect ovulation

Rasagiline

MAO-B inhibitor Use: Parkinson's

Anthracyclines

MOA: *not* cell cycle specific Use: cancer AE: vesicant (except liposomal formulations; use dexrazoxane [Totect] or dimethyl sulfoxide to treat), cardiotoxicity (related to total cumulative dose over the lifetime)

Flibanserin

MOA: 5-HT1A agonist and 5-HT2A antagonist Use: sexual dysfunction in premenopausal women AE: fainting, hypotension BBW: CI with alcohol (REMS), CYP3A4 inhibitors

Nimodipine

MOA: DHP CCB that is more selective for cerebral arteries due to its lipophilicity Use: prevention of vasospasm in patients with SAH Administration: if pt cannot take capsule form, contents can be drawn into a parenteral syringe and transferred to an oral syringe labeled, For Oral Use Only" or "Not for IV Use" AE: HoTN BBW: administered IV can cause death and serious life-threatening reactions

Alpha blockers

May take 4-6w to assess whether beneficial Use: BPH (first line; does not shrink the prostate and does not change PSA levels) AE: (more likely with first few doses) intraoperative floppy iris syndrome (if cataract surgery is required, alpha blocker treatment should be delayed), orthostatic HoTn/syncope, dizziness, fatigue, HA, abnormal ejaculation DDI: PDE5 inhibitor- hypotensive effects

MCV lab value

Mean Corpuscular Volume. Increases due to B12 or folate deficiency. Decreases due to iron deficiency

TEE (Total Energy Expenditure)

Measure of basal energy expenditure plus excess metabolic demands (BEE x activity factor x stress factor)

BUN

Measures amount of nitrogen in blood that comes from urea (waste product of protein metabolism). Increases due to renal impairment and dehydration

Cost-Effectiveness Analysis

Measures costs and also outcomes in original units (change in BP, events avoided, etc). Most commonly used pharmacoeconomic methodology Disadvantage: inability to directly compare different types of outcomes

MDIs

Metered Dose Inhalers. Delivers a dose of aerosolized liquid medication. Shake well (except with Qvar, Qvar RediHaler, Alvesco, and Respimat products) Brand name identifiers: HFA (propellant), Respimat, or no suffix (e.g. Qvar) Administration: slow and deep inhalation at the same time of pressing the canister, spacer can be used for patients who cannot do both at the same time Clean: qw under warm running water

Glucovance

Metformin/glyburide

Janumet

Metformin/sitagliptin

Temperature and cervical mucus methods

Methods used to keep track of body temperature and cervical mucus content to avoid pregnancy by abstaining form intercouse during more fertile periods. Basal body temperature predicts ovulation, temperature methods work best when done in conjunction with tracking changes in cervical mucus

Insects and disease

Mosquitoes transmit the most infections including Japanese encephalitis, yellow fever, dengue (no vaccine available; symptom is severe bleeding), malaria, and Zika virus. Using mosquito repellents with DEET on skin and permethrin on clothing, gear, and bed nets recommended Vectors: insects that transmit disease Reservoir: any place in which the disease lives and can multiply

Pernicious anemia

Most common cause of vitamin B12 deficiency which occurs due to a lack of intrinsic factor Diagnosis: Schilling test Treatment: lifelong parenteral Vitamin B12 replacement

Neuroleptic Malignant Syndrome

Most commonly occurs due to first generation antipsychotics due to D2 blockade. Rare but highly lethal Symptoms: hyperthermia, muscle rigidity Treatment: taper off antipsychotic quickly. Dantrolene can be used for muscle relaxation

Passive diffusion

Movement of drugs from an area of high concentration to an area of lower concentration

Etravirine

NNRTI used for HIV. Take after meals. Do not initiate in women with CD4+ counts > 250 or men > 400 AE: increased LFTs BBW: hepatotoxicity and serious skin reactions (SJS/TEN)

Adefovir

NRTI used for HBV. Caution in patients with renal impairment or those at risk of renal toxicity

Epivir-HBV

NRTI used for HBV. Do not use if patient also has HIV

Entecavir

NRTI used for HBV. Take on an empty stomach

What drugs increase lactic acid

NRTIs and metformin

Vimovo

Naproxen + esomeprazole. Used to reduce the risk of NSAID-induced ulcers

Clindamycin

No dose adjustment needed for renal impairment. A D-test (induction test) should be performed on S. aureus that is susceptible to clindamycin but not resistant to erythromycin; a flattened area between the disks (positive D-test) indicated inducible clindamycin resistance and clindamycin should not be used Covers: aerobic and anaerobic gram + MOA: binds to 50S subunit BBW: C. Diff

Buspirone

No potential for abuse, tolerance, or physical dependence MOA: affinity for 5-HT1A and 5-HT2 receptors Use: anxiety Warning: do not use with MAOI

Discrete data

Nominal: categorical Ordinal: ranked in logical order (pain scale) and does not increase by the same amount (pain scale score of 4 does not mean 2x as much pain as a score of 2)

Verapamil

Non-DHP CCB Brands: Calan and Verelan AE: more likely to cause constipation than diltiazem

NSR

Normal Sinus Rhythm

Thyroid gland

Only organ that can absorb iodine *Produces*: triiodothyronine: T3. More potent, shorter half life Thyroxine: T4. Less potent, longer half life. Free T4 (active form) is monitored

Holter Monitor

Portable ECG device

Non-TNF biologic DMARD

Patients on these drugs are encouraged to register in a Pregnancy Exposure Registry so pregnancy outcomes can be monitored. Needles are included Warning: worsening or new heart failure

Chlorpromazine drug class

Phenothiazine (strong DA blocker)

Resources for drug identification

Pillbox

HLA-B pharmacogenomic test

Positive indicates risk of hypersensitivity, avoid drug *Drugs*: abacavir (Ziagen; and abacavir-containing products) Allopurinol (Zyloprim): SJS Carbamazepine (Tegretol), oxcarbazepine (Trileptal), phenytoin (Dilantin), fosphenytoin (Cerebyx): SJS/TEN. Should especially be tested in Asian patients

KRAS mutation pharmacogenomic test

Positive predicts poor response to cetuximab, avoid drug Cetuximab (Erbitux), panitumumab (Vectibix)

Treprostinil

Prostacyclin analog Use: PAH

Diagnostic tests for lice

Pruritus and nits (eggs) on scalp

RPR

Rapid Plasma Reagin (test for syphilis)

Gene

Sequence of nucleotides that code for a single protein

Hypophosphatemia

Severe and usually symptomatic when phosphate < 1 Treatment: IV phosphorous

TEN (Toxic Epidermal Necrolysis)

Severe skin reaction. Treat by stopping the offending agent and symptomatic treatment. Do not use systemic steroids

Fibrinolytics

Should be given within 120 minutes of hospital arrival (door-to-needle time) or within 3h of symptom onset MOA: converts entrapped plasminogen to plasmin Use: STEMI AE: bleeding (including ICH) and hypotension Monitoring: Hgb, Hct, and signs/symptoms of bleeding

Flatulence treatment in pregnancy

Simethicone

OTC for intestinal gas <1 yo

Simethicone drops

Fosfomycin

Single dose antibiotic Covers: E. Coli (including ESBLs) and E. faecalis (including VRE)

Methylphenidate

Stimulant *IR*: Brands: Ritalin, Methylin Dose: start at 5 mg bid *ER & IR*: Concerta: OROS tablet system. Decreases abuse potential. Start at 18-36 mg qam *XR*: QuilliChew ER, Quillivant XR (oral suspension), Cotempla XR-ODT *Transdermal patch*: Daytrana. Apply 2h before desired effect, remove after 9h. Alternate hips daily. Wash hands immediately after applying *Uses*: ADHD, narcolepsy

Dexmethylphenidate

Stimulant Active isomer of methylphenidate

Glimepiride

Sulfonylurea Brand: Amaryl Use: diabetes

Glipizide

Sulfonylurea Brands: Glucotrol, Glucotrol XL (OROS formulation, can leave a ghost tablet), and Glipizide XL Use: diabetes Dose: (IR) taken 30 min before a meal

Glyburide

Sulfonylurea. Renally cleared, not preferred in patients with renal insufficiency Brand: Glynase (micronized glyburide) Use: diabetes

Systematic review article

Summary of the clinical literature that focuses on a specific topic or question

Mumps symptoms

Swollen, tender salivary glands

Cortisone

Systemic steroid. Prodrug of cortisol

Diagnostic tests for pinworm

Tape test (looks for eggs on skin) and test for helminths (worms) in blood

Paclitaxel

Taxane Use: cancer

Paclitaxel albumin-bound

Taxane Use: cancer

Pearson's correlation coefficient

Test used for continuous data to indicate strength and relation between two variables

Bubble-point test

Test used on needles to test how much pressure is needed to force liquid to "bubble" out of the filter to test filter integrity

Striant

Testosterone buccal tablets Use: hypogonadism AE: buccal irritation

Confidence Interval

The CI range indicates that you are 95% confident, one of the data numbers will land in the range. Same significance as p-value and is directly correlated with alpha (if alpha is 0.05, CI is 95%). Narrow CI range indicates higher precision CI for "difference" data: if the value includes 0, the result is not statistically significant (12-23 is statistically significant) CI for "ratio" data (relative risk, odds ratio, hazard ratio): if the value includes 1, the result is not statistically significant (-0.2-0.5 is statistically significant)

TJC

The Joint Commission. Independent, not-for-profit organization that accredits and certifies healthcare organizations and programs in the US (hospitals, healthcare networks, long-term care facilities, home care organizations office-based surgery centers, and independent laboratories)

Study power

The probability that a test will reject the null hypothesis correctly (avoiding a type II error)

TPMT

ThioPurine MethylTransferase. Those with deficiencies in this may require lower doses with azathioprine and mercaptopurine

Irinotecan

Topoisomerase I inhibitor Use: cancer *AE* mucositis Acute cholinergic symptoms: treat with atropine *BBW*: DA: prevent or treat with atropine for acute DA. Use loperamide for delayed DA. DA usually accompanied with symptoms of cholinergic excess (cramping, rhinitis, lacrimation, salivation)

Scabies

Treatment: permethrin or ivermectin

Mohr pipette

Unlike a volumetric pipette, it can measure small volumes more accurately

Diagnostic tests for H. pylori

Urea breath test

Folic acid

All women of childbearing age should obtain 400 mcg/d. During pregnancy, they should receive 600 mcg/d. Only 400 and 800 mcg strengths are available OTC

Resources for compounding and pharmaceutics

Allen's, ASHP, Handbook of Pharmaceutical Excipients, Merck Index, Remington, Trissel's, USP 795, USP 797, USP 800, USP-NF

Drugs associated with severe skin reactions

Allopurinol, lamotrigine, penicillins, phenytoin, piroxicam, sulfamethoxazole

Tamsulosin

Alpha-1a blocker Brand: Flomax Use: BPH Dose: 0.4 mg qd

Silodisin

Alpha-1a blocker Use: BPH AE: retrograde ejaculation

Alfuzosin

Alpha-1a blocker Use: BPH CI: patients at risk for QT prolongation

Droxidopa

Alpha/beta agonist Use: neurogenic orthostatic hypotension in Parkinson's Disease AE: syncope, falls, HA

Drugs that cause constipation

Aluminum antacids, anticholinergic drugs, non-DHP CCBs, clonidine, colesevelam, iron, opioids, sucralfate

What causes SCr to increase

Aminoglycosides, amphotericin B, cisplatin, colistimethate, cyclosporine, loop diuretics, polymyxin, NSAIDs, radiocontrast dye, tacrolimus, and vancomycin

Main drugs that cause kidney disease

Aminoglycosides, amphotericin B, cisplatin, cyclosporine, loop diuretics, NSAIDs, polymyxins, radiographic contrast dyes, tacrolimus, and vancomycin

Mesalamine

Aminosalicylate Forms: oral and rectal (more effective for distal disease/proctitis in UC). May produce a ghost tablet Warnings: hypersensitivity reactions

Amino acid (in PN) brands

Aminosyn, FreAmine, Travasol, TrophAmine, Clinisol

Drugs associated with photosensitivity

Amiodarone, diuretics (thiazide and loop), MTX, oral & topical retinoids, quinolones, St. John's wort, sulfa, tacrolimus, tetracyclines, voriconazole

Half-life

Amount of time it takes for a drug's concentration to decrease by 50%. 5 half-lives reaches steady state, drug is almost completely eliminated = 0.693 / ke

Drugs that can increase blood pressure

Amphetamines/ADHD drugs, cocaine, decongestants, erythropoiesis-stimulating agents, NSAIDs, and systemic steroids

IV antibiotics compatible with saline only

Ampicillin, ampicillin/sulbactam, and ertapenem

Pramlinitide

Amylin analog MOA: slows gastric emptying, suppressing glucagon Use: diabetes Dose: prior to each major meal AE: hypoglycemia (reduce mealtime insulin by 50%), N/V, anorexia, HA, weight loss CI: gastroparesis BBW: severe hypoglycemia

Enteral nutrition

An NG tube is usually used. Give drugs 1 hour before or 2 hours after feeding (especially with warfarin, tetracycline, Cipro, and phenytoin) Formulas: Ensure, Osmolite, Jevity, Glucerna, Novasource Vs PN: lower cost, using the gut which prevents atrophy, and decreases risk of complications

Sentinel event

An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof

Vaccinations during pregnancy

Annual influenza and Tdap

Tums

Antacid Calcium carbonate

Mylanta Supreme

Antacid Calcium carbonate + Mg

Drugs that can cause diarrhea

Antacids containing magnesium, antibiotics, antineoplastics, colchicine, laxatives, metoclopramide, misoprostol, quinidine

Daunorubicin

Anthracycline Use: cancer AE: HF syndrome

Mitoxantrone

Anthracycline. Blue IV fluid Use: cancer AE: blue urine

Doxorubicin

Anthracycline. Potent vesicant Dose: max lifetime cumulative dose of 450-550 mg/m^2 due to cardiotoxicity AE: extravasation (can give Totect [dexrazoxane] to treat), HF syndrome (with liposomal doxorubicin), red urine, N/V BBW: cardiotoxicity (can use dexrazoxane [Zinecard] to prevent, usually considered when cumulative dose > 300; monitor LVEF before and after each treatment using ECG or MUGA scan), vesicant, myelosuppression

AEDs

Anti-Epileptic Drugs Pregnant patients: should take daily folate supplements. Levels of AEDs decline during pregnancy Dose: do not stop suddenly. Can slowly taper off after 2-4y of being seizure free AE: CNS depression, increased fracture risk (supplement AEDs with calcium and vitamin D), suicide risk DDI: decreased efficacy of oral contraceptives

Infliximab

Anti-TNF biologic DMARD. Requires a filter and is stable in NS only Brand: Remicade Use: RA, IBD, severe psoriasis Form: IV AE: infusion reactions, delayed hypersensitivity reaction CI: pregnancy

Golimumab

Anti-TNF biologic DMARD. Requires a filter. Store in refrigerator (can last 14d at room temperature) Brand: Simponi Aria Use: UC Dose: SC qm into abdomen, thigh, or upper arm

Etanercept

Anti-TNF biologic DMARD. Store in refrigerator Brand: Enbrel Use: RA, severe psoriasis Forms: syringe, auto-injector, vials Dose: SC qw into abdomen, thigh, or upper arm

Adalimumab

Anti-TNF biologic DMARD. Store in refrigerator (can last 14d at room temperature) Brand: Humira Use: RA, IBD Dose: SC qow into abdomen or thigh

Main drugs that can cause QT prolongation

Antiarrhythmics (Class I [especially Ia] and Class III), antibiotics (quinolones and macrolides), azole antifungals (not isavuconazole [Cresemba]), antidepressants (tricyclics, SSRIs, SNRIs, mirtazapine, and trazodone. Sertraline is safest option), antiemetic agents (5HT3 receptor antagonists, droperidol, and phenothiazines), most antipsychotics (chlorpromazine, clozapine, haloperidol, olanzapine, paliperidone, quetiapine, risperidone, thioridazine, ziprasidone), fingolimod, methadone, and donepezil

Chloramphenicol

Antibiotic that can cause gray syndrome

Fidaxomicin

Antibiotic used for C. diff infections, ineffective otherwise

Trimethoprim

Antibiotic. Do not refrigerate po suspension Brand: Septra

Rifaximin

Antibiotic. Not effective for systemic infections

Oxybutynin

Anticholinergic *Use*: overactive bladder *Forms* IR XR: Ditropan XL. OROS formulation (ghost shell) Patch: Oxytrol (Rx; biw), Oxytrol for Women (OTC). Causes less xerostomia Gel: Gelnique. Causes less xerostomia *AE*: (more than other anticholinergics) dizziness, drowsiness

Benztropine

Anticholinergic Brand: Cogentin Use: Parkinson's Disease AE: xerostomia, constipation, urinary retention, blurred vision, somnolence, confusion

Tolterodine

Anticholinergic Brand: Detrol Use: urinary incontinence AE: dry mouth (does not penetrate CNS much so otherwise, well tolerated)

Trospium

Anticholinergic Use: overactive bladder Administration: take on an empty stomach

Drugs that can increase IOP

Anticholinergics Cough cold motion sickness meds Chronic steroids (especially eye drops) Topiramate

Drugs that can cause psychotic symptoms

Anticholinergics, cannabis, dextromethorphan, dopamine or dopamine agonists (Requip, Mirapex, Sinemet), interferons, stimulants, systemic steroids, bath salts, cocaine, acid, meth, PCP

Betrixaban

Anticoagulant Brand: Bevyxxa MOA: inhibit factor Xa directly

Rivaroxaban

Anticoagulant, factor Xa inhibitor *Brand*: Eliquis *MOA*: inhibit factor Xa directly *Dose*: If there is a missed dose and taking 15 mg bid, take 2 15 mg tablets as soon as remembered. If 10, 15, or 20 mg qd, take immediately on the same day, otherwise skip. qpm wc DVT/PE treatment: 15 mg po bid x3w, then 20 mg po qd. CrCl <30, don't use *DDI*: drugs that are combined P-gp and strong CYP3A4 inducers/inhibitors

Apixaban

Anticoagulant, factor Xa inhibitor *Brand*: Eliquis *MOA*: inhibit factor Xa directly *Dose*: nonvalvular Afib: 5 mg bid. If pt has 2/3 (≥ 80 yo, ≤ 60 kg, SCr ≥ 1.5) 2.5 mg bid DVT/PE treatment: 10mg po bid x1w, then 5 mg po bid *DDI*: strong inducers of CYP3A4 and P-gp

Edoxaban

Anticoagulant, factor Xa inhibitor *Brand*: Savaysa *MOA*: inhibit factor Xa directly *Dose*: nonvalvular Afib (stroke prophylaxis): CrCl > 95, don't use DVT/PE treatment: start after 5-10d of parenteral anticoagulation

Fondaparinux

Anticoagulant, factor Xa inhibitor (indirect) MOA: bind to antithrombin, increasing its activity, which inactivates thrombin and other proteases involved in blood clotting Brand: Arixtra Form: injectable synthetic pentasaccharide Use: off label for HIT AE: bleeding CI: CrCl < 30 BBW: neuraxial anesthesia (spinal, epidural) increases risk of hematomas and subsequent paralysis

Flumazenil

Antidote for BZDs

Andexanet alfa

Antidote for apixaban and rivaroxaban Brand: Andexxa

DigiFab

Antidote for digoxin

CroFab

Antidote for rattlesnake bite

Fomepizole

Antidote for toxic alcohols (ethylene glycol antifreeze], methanol)

Butenafine

Antifungal Brand: Lotrimin Ultra Use: ringworm (highly effective)

Ringworm treatment

Antifungal cream. Reduce moisture to infected area Administration: apply 1-2 inches beyond the rash. Use for x≥2-4w even if it appears healed

Griseofulvin

Antifungal. Take with a fatty meal to increase absorption and with food/milk to avoid GI upset MOA: binds to keratin precursor cells Uses: dermatomycosis and tinea infections of skin, hair, & nails AE: photosensitivity and increased LFTs CI: pregnancy DDI: can increase metabolism of hormonal contraceptives

Diphenhydramine

Antihistamine *Brand*: Benadryl *Use*: allergy, sleep, motion sickness *Dose*: allergy: 25-50 mg po q4-6h Motion sickness: take 30-60 min before needed *CI*: < 6 yo. Avoid use in patients with BPH, glaucoma *AE*: peripheral anticholinergic side effects (urinary retention)

Cyclizine

Antihistamine Use: motion sickness Dose: 30-60 min before needed

Dimenhydrinate

Antihistamine Use: motion sickness Dose: 30-60 min before needed

Meclizine

Antihistamine Use: motion sickness, vertigo Dose: 30-60 min before needed Warnings: CNS depression, can increase intraocular pressure (glaucoma) AE: sedation, dry mouth, dry/blurry vision

Levocetirizine

Antihistamine. Fast onset but high sedation Brand: Xyzal

Loratadine

Antihistamine. Safe in pregnancy

Cetirizine

Antihistamine. Safe in pregnancy. Fast onset but high sedation

Fexofenadine

Antihistamine. Take with water not with juice

Dipyridamole

Antiplatelet drug used to prevent recurrent stroke MOA: inhibits adenosine

Mycophenolate

Antiproliferative agent. Take on empty stomach *Brands*: not interchangeable CellCept: mycophenolate mofetil. IV is stable in D5W only Myfortic: mycophenolic acid. EC to decrease DA *Use*: maintenance immunosuppression for transplant, lupus *Missed dose*: take if it is less than 4h after when it was supposed to be taken, skip otherwise *AE*: DA, GI upset *DDI*: decreases levels of hormonal contraception *BBW*: increased risk of infection, increased development of lymphoma & skin malignancies, increased risk of congenital malformations & spontaneous abortions

Quetiapine

Antipsychotic Brands: Seroquel, Seroquel XR (take qpm without food or with a light meal) Use: delirium in ICU, depression, psychosis, schizophrenia AE: high risk for metabolic side effects, lowest risk of the SGAs for EPS (recommended in patients with Parkinson's who require an antipsychotic). Somnolence, orthostasis, weight gain, increased lipids, increased glucose BBW: increased risk of suicidal thinking and behavior in children, adolescents, and young adults

Baclofen

Antispasmodic Brand: Lioresal Use: adjuvant for pain management AE: sedation, dizziness, confusion

Carisoprodol

Antispasmodic Brand: Soma Use: adjuvant for pain management AE: poor CYP2C19 metabolizers will have increased concentrations

Cyclobenzaprine

Antispasmodic Brands: Fexmid and Amrix ER Use: adjuvant for pain management AE: xerostomia, risk of serotonin syndrome (serotonergic)

Methocarbamol

Antispasmodic Brands: Robaxin, Robaxin-750 Use: adjuvant for pain management

Dicyclomine

Antispasmodic Use: diarrhea Warnings: caution in ≥65 yo and patients with mild-moderate UC (can cause toxic megacolon or paralytic ileus) AE: dizziness, dry mouth, nausea, blurred vision

Tizanidine

Antispasmodic, centrally acting alpha-2 agonist Brand: Zanaflex Use: adjuvant for pain management AE: HoTN, xerostomia, weakness

Common antibiotic drugs that do not require renal dose adjustment

Antistaphylococcal penicillins (dicloxacillin, nafcillin), ceftriaxone, clindamycin, doxycycline, macrolides, Flagyl, moxifloxacin, linezolid

Medication errors

Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Most common cause is due to design of medical system itself. Most common error is dispensing an incorrect drug or dose *Organizations*: improving medication safety: TJC (The Joint Commission) and ISMP (Institute for Safe Medication Practices; can report errors and close calls at ismp.org) Report hospital errors: P&T (Pharmacy and Therapeutics) committee and Medication Safety Committee

Preconception health

Any woman planning to conceive should take folic acid (folate) to help prevent neural tube defects. Keep vaccinations current. Avoid toxic chemicals, including drugs on Hazardous Drug List developed by NIOSH

Anastrazole

Aromatase inhibitor Brand: Arimidex Use: breast cancer

Exemestane

Aromatase inhibitor Brand: Aromasin Use: breast cancer

Letrozole

Aromatase inhibitor Brand: Femara Use: breast cancer

Xerostomia treatment in cancer patients

Artificial saliva substitutes, pilocarpine

ECHO Model

Assesses outcomes associated with disease and treatment. Economic Clinical and Humanistic Outcomes

Antibiotics that interfere with G6PD deficiency

Associated with hemolytic anemia. *(G6PD - G: Chloroquine, 6- 6 drugs, P- Probenecid, Primaquine, D- Dapsone & other easy drugs- sulfa and nitrofurantoin)* Chloroquine, dapsone, nitrofurantoin, primaquine, probenecid, sulfamethoxazole

Selecting correct BUD (Beyond Use Date)

Assuming product is non-sterile and packaged in tight, light-resistant containers (refrigeration for water-containing oral formulations): Nonaqueous formulations: expiration date of any active ingredient or 6 months, whichever is earlier Water-containing oral formulations: 14 days Water-containing topical: 30 days BUDs may be extended if stability data is obtained that determines the drug is stable for longer CSP (Compounded Sterile Product): based on risk of contamination and storage temperature

Where should compounded products be manufactures?

At an FDA-registered facility. If it is from a non-FDA-registered facility, the manufacturer must obtain a CoA (Certificate of Analysis)

Drugs that can cause DILE

(Drug-Induced Lupus Erythematosus) (*Hydr*o *Queen*!* My Ter*riffic *Pt Is A Meth[2] Pro*!*)* Methimazole, Procainamide, PTU, Methyldopa, Minocycline, Quinidine, Isoniazid, Anti-TNF agents, Terbinafine, Hydralazine

Cryptococcus neoformans treatment

(Fungus) Induction in serious infections: amphotericin B + flucytosine (5-FC) Consolidation: fluconazole (prolonged)

Drugs that can lower the seizure threshold

*(BC TV)* Clozapine, bupropion, tramadol, varenicline Higher risk if at a high dose and/or patient has renal impairment: *(Me LitT, PCQ antibiotics)* carbapenems (especially imipenem), lithium, meperidine, penicillin, quinolones, theophylline

Which drugs should be mixed with dextrose, not saline

*(BOAS)* Bactrim, Oxaliplatin, Amphotericin B, Synercid

IV antibiotics compatible with dextrose only

*(DAB)* Dalfopristin/quinupristin, Amphotericin B, Bactrim

Biggest CYP inhibitors

*(G PACMAN)* Grapefruit, PIs, -Azole antifungals, Cyclosporine, cimetidine, cobicistat, Macrolides, Amiodarone, and Non-DHP CCBs (diltiazem, verapamil) Ritonavir and cobicistat used often for this purpose to increase levels of HIV drugs

Drugs that can cause hypothyroidism

*(I TALC)* Interferons, tyrosine kinase inhibitors, amiodarone, lithium, carbamazepine

Resources for international drug information

*(IM U)* Index nominum, Martindale, USP Dictionary of United States Adopted Names (USAN) and International Drug Names

What are the main drugs that have leaching/adsorption/absorption issues with PVC containers?

*(LATTIN E)* Lorazepam, Amiodarone, Tacrolimus, Taxanes, Insulin, Nitroglycerin, Etoposide. These drugs can be placed in polyolefin, polypropylene, or glass containers

Secondary prevention after ACS

*(NAP AS BA)* *ASA*: 81 mg qd unless CI *P2Y12 inhibitor*: treated with medical therapy: ticagrelor or clopidogrel x≥1y PCI treated patients: clopidogrel, prasugrel, or ticagrelor x≥1y (> 1y considered if patients are tolerating DAPT and are not at high risk of bleeding) *Nitroglycerin*: indefinitely (SL tabs or spray prn) *Beta blocker*: x3y. Continue indefinitely if HF or if needed for management of HTN *ACEI*: indefinitely if EF < 40%, HTN, CKD, or diabetes. Consider for all patients with no CI *Aldosterone antagonist*: indefinitely if EF <40% + either symptomatic HF or DM receiving target doses of an ACEI and beta blocker CI: SCr > 2.5 in men, SCr > 2 in women, or K > 5 *Statin*: ≤75 yo: high intensity > 75: moderate intensity

CHF Classifications

*ACC/AHA*: A: at risk B: structural evidence but asymptomatic C: structural evidence + some symptoms usually with exertion D: advanced structural damage + symptomatic at rest *NYHA*: I: asymptomatic II: symptomatic with higher levels of exertion III: symptomatic doing normal activities IV: unable to carry any activity without feeling symptoms. Restrict fluid intake

SSRIs

*AE*: sexual side effects, somnolence, insomnia, nausea, dry mouth, diaphoresis (dose-related), weakness, tremor, dizziness, HA (but may help for migraines if taken continuously) *DDI*: MAOI: hypertensive crisis, allow a 2w (5w for fluoxetine) washout between MAOIs and SSRIs Anticoagulants, antiplatelets, NSAIDs: increase bleeding risk *CI*: MAOIs, linezolid *Warnings*: QT prolongation, SIADH, hyponatremia, bleeding *BBW*: increased risk of suicidal thinking and behavior in children, adolescents, and young adults

OTC for mild pain and fever <1 yo

*APAP*: infant drops and children's suspension are the same concentration Dose: 10 - 15 mg/kg/dose q4-6h *Ibuprofen*: avoid <6m old due to risk of nephrotoxicity Dose: 5 - 10 mg/kg/dose q6-8h *ASA*: can cause Reye's syndrome when used in pts recovering from a viral syndrome. Not recommended in anyone < 16 yo

Perioperative antibiotic prophylaxis

*Based on procedure*: cardiac/vascular: cefazolin Colon: cefotetan, cefoxitin, ampicillin/sulbactam, ertapenem, or Flagyl + ceftriaxone *Prophylaxis*: Infuse 30-60 min before surgery (120 min if using vanco or a quinolone) DOC is cefazolin Colorectal surgery: cefotetan or cefoxitin *Intraoperative*: give additional dose(s) if >3-4h or major blood loss *Postoperative*: discontinue no longer than 24h after surgery

Lithium

*Brand*: Lithobid *MOA*: influences reuptake of serotonin and/or NE. 100% renally cleared *Use*: bipolar mania, depression, and maintenance *Dose*: 5 mL solution = 8 mEq = 300 mg lithium *Administration*: drink 8 -12 glasses of water every day while on lithium. Do not change amount of salt you consume *Therapeutic range*: 0.6 - 1.2 (trough) >1.5: tremor, vomiting, ataxia >2.5: CNS depression, arrhythmia, coma, seizure *AE*: avoid AE: titrate slowly, switch to qhs, try taking at the end of a meal, drink adequate fluids GI upset, cognitive effects, cogwheel rigidity, tremor, weight gain, polyuria/polydipsia, hypothyroidism, sedation Worsened nausea, DA, feel shaky/confused: contact healthcare provider *CI*: avoid in pregnancy *DDI*: increased lithium levels with: decreased salt intake, ACEI, ARBs, NSAIDs Decreased lithium levels with: increased salt intake Increased risk of serotonin syndrome: SSRIs, SNRIs, triptans, linezolid, other serotonergic agents *Monitoring*: lithium levels, renal function, thyroid function

Finasteride

*Brand*: brands are not interchangeable Propecia: alopecia Proscar: BPH *MOA*: 5-alpha reductase type 2 inhibitor *Form*: tablet *Use*: alopecia and BPH *Dose*: alopecia: 1 mg qd x≥3m *CI*: pregnancy (pregnant patients shouldn't touch drug at all)

Nicotine polacrilex gum/lozenge

*Brand*: gum: Nicorette Lozenge: Nicorette, Nicorette Mini *Dose*: minimum dosing of 9 pieces/d for the first 6w. q1-2h 1st cigarette > 30 minutes after waking up: 2 mg 1st cigarette ≤ 30 minutes after waking up: 4 mg 4 mg strength has been shown to delay weight gain Gum: chew until there is no more taste DDI: acidic beverages interfere with absorption, wait 15 min after eating or drinking

Acetaminophen

*Brands*: Tylenol Ofirmev: injection FeverAll + hydrocodone: Norco, Vicodin, Lortab + oxycodone: Endocet, Percocet + codeine: Tylenol #2, 3, 4 + tramadol + butalbital/caffeine: Fioricet *MOA*: antipyretic (reduces pain and fever). PG synthesis inhibition *Dose*: adults: max < 4000 mg/d Pediatrics: 10 - 15 mg/kg q4-6h *AE*: severe skin rash *BBW*: hepatotoxicity (associated with doses > 4g/d or use of multiple APAP containing products) *OD Phases*: 1. 1-24h. Commonly asymptomatic or just N/V 2. 24-48h. Elevated INR, AST/ALT 3. 48-96h. Fulminant hepatic failure, renal failure, and/or death 4. >96h patient recovers or receives a liver transplant *Antidote*: NAC (N-AcetylCysteine, Cetylev are the tablets for oral solution [dose is 140 mg/kg x1, followed by 70 mg/kg q4h x17 doses. Repeat if emesis occurs within first hour of dose], Acetadote IV is the IV [150 mg/kg IV over 60 min, then 50 mg/kg IV over 4h, then 100 mg/kg IV over 16h]). Work by restoring glutathione, GSH converts NAPQI to mercapturic acid. Rumack-Matthew nomogram uses serum APAP level and time since ingestion to determine whether hepatotoxicity is likely

Bupropion

*Brands*: Zyban, Forfivo XL: used for smoking cessation Wellbutrin SR, Wellbutrin XL: used for depression Aplenzin *MOA*: blocks reuptake of dopamine and/or NE *Dose*: separate doses of bupropion by at least 8h. Tapering off not required to d/c Smoking: max 300 mg/d. Start at least 1w before quit date Depression: max 450 mg/d due to seizure risk. XL should be started at 150 mg qd *AE*: serious neuropsychiatric events, dry mouth, insomnia, tremors/seizures (dose-related), weight loss, sexual dysfunction is rare *CI*: seizure disorder, history of anorexia/bulimia, MAOI use within the past 14d, linezolid, IV methylene blue, abrupt d/c of ethanol or sedatives *DDI*: other forms of bupropion, decreases tamoxifen's effectiveness *BBW*: risk of suicidal thinking and behavior worsened in children, adolescents, and young adults taking antidepressants

Cyclosporine

*Brands*: not interchangeable, modified drugs have greater bioavailability than non-modified drugs Modified: Neoral, Gengraf Non-modified: Sandimmune *Use*: maintenance immunosuppression for transplant, severe UC, severe psoriasis *Dose* (UC): IM or SC qw *Oral solution*: do not administer from plastic or styrofoam cup. Hepatically metabolized. Can be mixed with orange or apple juice *AE*: HTN, nephropathy (using with tacrolimus will increase this risk by a lot), hyperkalemia, hypomagnesemia, hirsutism, gingival hyperplasia, edema, hyperglycemia, neurotoxicity, QT prolongation, increased UA *DDI*: numerous (CYP3A4 and P-gp substrate- inducers of either will decrease cyclosporine concentration, inhibitors will increase). Avoid grapefruit and St John's wort *BBW*: renal impairment, increased risk of lymphoma & other malignancies (including skin cancer), increased risk of infection *Monitor*: trough levels, serum electrolytes, renal function, bp, blood glucose, lipid profile

COCs and CHCs

*COC*: Combination Oral Contraceptive. Most contain ethinyl estradiol and a progestin. PPI (Patient Package Insert) must always be dispensed with these *Starting a COC*: can be started at any time. If started within 5d after start of period, no backup method needed Start today: requires backup for 7d Sunday start: start Sunday after onset of menstruation. Requires backup for 7d *CHC*: Combined Hormonal Contraceptive. Not po *Types*: monophasic: same dose of estrogen and progestin throughout pill pack. Junel Fe 1/20, Microgestin Fe 1/20, Sprintec, Loestrin 24 Fe, Lo Loestrin Fe Biphasic, triphasic, quadriphasic: mimic estrogen and progesterone levels during a menstrual cycle Extended cycle: 84d of active pills. Bleeding occurs q3m. Seasonique, Jolessa, Quartlette Lo: indicates ≤ 35 mcg estrogen Fe: indicates an iron supplement is included 24: 24 active + 4 placebo *MOA*: inhibit production of FSH and LH, preventing ovulation *Uses*: pregnancy prevention, dysmenorrhea, PMS, acne, anemia, menses regulation in PCOS (PolyCystic Ovary Syndrome) (DOC), endometriosis (DOC) *AE*: will often improve after 3m of use Too much estrogen: nausea, breast tenderness, bloating, weight gain, HTN, thrombosis Not enough estrogen: spotting (if it occurs early-mid cycle, consider switching to something with more estrogen; recommended to wait 3m cycles first) Too much progestin: hyperkalemia Not enough progestin: late-cycle spotting (consider a higher progestin dose) *CI*: estrogen products: history of DVT/PE, stroke, CAD, cancer (breast, ovarian, or liver), migraines with aura Progestin products: kidney, liver, or adrenal gland disease *DDI*: injection has no DDIs Decrease efficacy of contraceptive: rifampin (backup method needed for 6w after d/c rifampin), rifapentine, rifabutin, barbiturates, carbamazepine, oxcarbazepine, perampanel, phenytoin, primidone, topiramate, lamotrigine, St. John's wort, smoking tobacco Liver toxicity: Technivie and Viekira Pak *BBW*: estrogen products: CI in women > 35 yo who smoke *Missed dose COC*: 1 late pill: take ASAP (even if on same day as next dose). No backup required 2 missed pills: take most recent missed pill ASAP, omit hormone-free week, start next pack of pills right after. Backup required for 7d

Glycopyrrolate

*COPD*: LAMA Brands: Seebri Neohaler, Bevespi Aerosphere How to use: remove capsule from blister pack, put it in chamber, press both buttons fully one time. The capsule in the chamber should be empty of all powder *Anticholinergic*: reduce pt's secretions while on NMBA

Live vaccines

*COZY IV RM* Cholera, Oral typhoid, Zoster, Yellow fever, Intranasal influenza, Varicella, Rotavirus, MMR With other vaccines: multiple live vaccines can be given on the same day, if not, separate by 4 weeks (same for TB test) MMR with antibody-containing products (blood transfusions): vaccine first, wait 2 weeks, then antibody containing product. Or antibody containing product, 3 months, then vaccine AE: can occur 3 - 21 days after vaccine given. Cold-like symptoms for intranasal influenza due to the vaccine possibly replicating in the upper airway CI: pregnancy and immunosuppression (includes patients using systemic steroids ≥2w; HIV patients with CD4 < 200)

Macronutrients

*Carbohydrates*: glucose is primary energy source. Carbs from food give 4 kcal/g. In PN, dextrose monohydrate is used and provides 3.4 kcal/g *Fat*: from food: 9 kcal/g ILE: 10% provides 1.1 kcal/mL, 20% provides 2 kcal/mL, 30% provides 3 kcal/mL *Protein*: 4 kcal/g

Type 1 diabetes

*Cause*: autoimmune destruction of beta cells in the pancreas, causing insulin to not be able to produce. Fat breakdown produces ketones which can cause diabetic ketoacidosis *Treatment*: insulin: pump or multiple daily injections (3-4/d between basal and bolus). Rapid- and long-acting insulins are preferred over short- and intermediate-. Start at TDD of 0.6 U/kg/d Carbohydrate counting: recommended. Prandial (mealtime) insulin is dose adjusted based on number of carbs eaten. 1 carbohydrate serving = 15 g [small piece of fruit, slice of bread, 1/3 cup rice/pasta, or 1/2 cup oatmeal *Initiating insulin*: start a basal-bolus regimen with Lantus and Humalog 1. Calculate TDD 2. Divide TDD into 50% basal, 50% bolus 3. Divide bolus insulin among 3 meals

Hemorrhagic stroke

*Cause*: bleeding in the brain *Diagnosis*: CT scan *Types*: ICH: IntraCranial Hemorrhage. If on an anticoagulant, d/c. If there is clinical evidence of a seizure, treat but do not use prophylactic anticonvulsant medication. Treated with mannitol SAH: acute SubArachnoid Hemorrhage. Main symptom is severe HA. Cerebral artery vasospasm can occur 3-21d after bleed, nimodipine is used to prevent vasospasm Subdural hematoma

Epilepsy

*Cause*: decrease in GABA or increase in glutamate (if one increases, the other decreases and vice versa) *Seizure classifications*: tonic-clonic: uncontrolled jerking movements. Rigid or tense muscles Absence: momentary loss of awareness. Generalized seizure with non-motor symptoms Focal: start on one side of the brain Focal aware: focal with no loss of consciousness. Used to be known as simple partial seizure Focal seizure with impaired awareness: focal with loss of consciousness. Used to be known as a complex partial seizure Generalized: start on both sides. Loss of consciousness Status epilepticus: seizure lasting longer than 5 minutes *Diagnosis*: EEG *Chronic seizure management*: Non-drug: marijuana. Keto diet can be used in patients with refractory seizures; 4:1 ratio of fats to combined protein + carbs; ketosis (elevated ketone) can lead to seizure Drugs: AEDs

Type 2 diabetes

*Cause*: insulin resistance and insulin deficiency *Treatment*: 1. lifestyle modifications + metformin 2. Long-standing, uncontrolled diabetes + established ASCVD: empagliflozin or liraglutide recommended No ASCVD: sulfonylurea, TZD, DDP-4 inhibitor, SGLT2 inhibitor, GLP-1 agonist, or basal insulin 3. Not at target A1c after 3m, consider adding a 3rd agent. Combinations not recommended are metformin + DPP-4 inhibitor + GLP-1 agonist and metformin + basal insulin + sulfonylurea *Initiation and adjusting insulin*: basal insulin often initiated when a pt fails to reach goal. Started at 0.1 - 0.2 U/kg/d or 10 U/d. Dose is titrated once or twice a week until pt is at fasting blood glucose goal

Cystic Fibrosis

*Cause*: mutation in the gene for the protein CFTR (Cystic Fibrosis Transmembrane conductance Regulator; most common mutation is homozygous F508del mutation), causing an abnormal transplant of chloride, bicarbonate, and sodium, leading to thick viscous secretions. The thick mucus affects the lungs, pancreas, liver, and intestines, which causes difficulty breathing, lung infections, and digestive complications *Symptoms*: salty tasting skin, poor growth, poor weight gain, steatorrhea (fatty stools), malnutrition *Diagnosis*: "sweat test." Usually diagnosed by 2 yo *Intermittent infections*: early stages of disease: most commonly due to staph aureus and h. influenzae Adolescents/adults: pseudomonas (treat with 2 IV drugs to provide potential synergy and prevent resistance. Aminoglycosides recommended. Doses tend to be larger than normal) Chronic: inhaled antibiotics for chronic pseudomonas (28d on therapy, 28d off). Azithromycin not recommended *Treatment order*: order is very important. All inhaled (vitamin supplementation also essential, many will end up requiring insulin) 1. Bronchodilator (albuterol): opens the airways 2. Hypertonic saline (HyperSal): mobilize mucus to improve airway clearance 3. Dornase alfa (Pulmozyme): thins mucus to promote airway clearance 4. Chest physiotherapy: mobilize mucus to improve airway clearance 5. Antibiotics: control airway infection

Parkinson Disease

*Cause*: neurons in substantia nigra die (produce dopamine which allows coordinated function and movement by releasing dopamine) Drugs (worsen): phenothiazines (e.g. prochlorperazine), butyrophenones (haloperidol, droperidol), 2nd-generation antipsychotics (e.g. risperidone at higher doses, paliperidone), metoclopramide *Symptoms*: TRAP: major symptoms. Tremor, Rigidity, Akinesia/bradykinesia, Postural instability Initial: tremors on one-side Additional: micrographia, shuffling walk, muffled speech, drooling, dysphagia, dpression, anxiety, constipation, incontinence *Treatment*: goal is to reduce "off" periods (periods where drug isn't working and disease worsens) and limit dyskinesias Primary: replace dopamine. Give a precursor to dopamine that becomes dopamine in the brain (levodopa). Give dopamine agonist. Sinemet sometimes works better as initial treatment in elderly. Centrally-acting anticholinergic can be used for younger pts *Can cause*: depression: SSRIs, TCAs (preferably secondary amines) Psychosis: quetiapine preferred due to low risk of movement disorders, but it can cause metabolic complications. Clozapine has a high risk of agranulocytosis and seizures

Variceal bleeding cause and treatment

*Cause*: portal HTN due to complications of liver disease and cirrhosis *Physical*: band ligation: putting a band around the vessel Sclerotherapy: injecting a solution in to the vessel to make it collapse and close *Medications that vasoconstrict the splanchnic GI circulation can stop or minimize the bleeding*: octreotide: selective for splanchnic vessels Vasopressin: non-selective *Non-selective beta-blockers*: should be added after resolution for secondary prevention. Nadolol or propranolol. Reduce portal pressure. Titrated to target 55-60 BPM HR

H. pylori

*Cause*: spiral shaped gram negative bacteria *Symptoms*: eating lessens the pain *Diagnosis*: UBT (Urea Breath Test; PPIs, bismuth, and antibiotics should be d/c 2w prior to tests) *Treatments*: used to be triple therapy but due to the failing rates, it's now quadruple therapy with using triple only if clarithromycin resistance rates are low. x10-14d. Do not make drug substitutions First line: bismuth quadruple therapy. Bismuth subsalicylate 300 mg qid + Flagyl 250 - 500 mg qid + tetracycline 500 mg qid + PPI bid (or esomeprazole 40 mg qd). Pylera (bismuth subsalicylate + Flagyl + tetracycline) qid + PPI bid can be used. Do not use Flagyl with alcohol use or tetracycline in children/pregnant women Second line: amoxicillin 1g bid + clarithromycin 500 mg bid + Flagyl 250 - 500 mg qid + PPI bid (or esomeprazole 40 mg qd) Third line: amoxicillin 1g bid + clarithromycin 500 mg bid + PPI bid (or esomeprazole 40 mg qd). Prevpac (amoxicillin + clarithromycin + lansoprazole) can be used. PCN allergy, replace amoxicillin with Flagyl

Croup (in children)

*Cause*: viral infection, causing inflammation of the upper airway *Symptoms*: inspiratory stridor (high pitched breathing sound), barking cough, and hoarseness *Treatment*: systemic steroids: usually dexamethasone Nebulized racemic epinephrine: given with systemic steroids for moderate-severe symptoms and trouble breathing. L-isomer in this mixture is the active component

Peptic ulcer disease

*Causes*: H. pylori: spiral-shaped, gram negative NSAIDs Stress: critically ill or mechanically-ventilated *Symptoms*: dyspepsia (gastric pain extending to middle or upper stomach), heartburn, belching, bloating Duodenal ulcers: will cause pain 2-3h after eating. Eating lessens the pain Gastric ulcers: eating worsens the pain *Diagnosis*: endoscopy *Treatments*: based on cause

Sexual dysfunction

*Causes*: HTN, atherosclerosis, conditions that can cause neuropathies (diabetes), depression, stress, spinal cord injury, stroke Drugs: antidepressants (especially SSRIs and SNRIs; not bupropion), antihypertensives, alcohol, antipsychotics (first-generation [chlorpromazine], prolactin-raising second generation [risperidone, paliperidone]), BPH medications (finasteride, dutasteride, and silodosin) *Treatments*: natural products: yohimbe, L-arginine, and panax ginseng Drugs: PDE-5 inhibitors (sildenafil, vardenafil, tadalafil, avanafil) are first-line

Bronchitis

*Causes*: acute: viral Severe: bacterial *Treatment*: antibiotic only if there is increase in sputum purulence &/or volume, increased dyspnea, or if mechanical ventilation is required DOC: Augmentin

Travelers' Diarrhea

*Causes*: bacteria: E. Coli (~90%), campylobacter jejuni, shigella, salmonella Virus: rotavirus Protozoa: giardia, entamoeba histolytica *Prevention*: food: "boil it, cook it, peel it, or forget it." Avoid food that's been sitting at a buffet. Use bottled water or boil for ~1 minute, avoid ice Prophylaxis: BSS (Bismuth SubSalicylate) (Pepto-Bismol) 525 - 1050 mg po qid wc and qhs. Antibiotic prophylaxis is not routinely recommended but rifaximin would be preferred drug *Symptoms*: dysentery *Treatment*: hydration with increased fluid and salt intake is essential Elderly patient with severe diarrhea or any traveler with prolonged watery diarrhea/vomiting: oral rehydration solution Loperamide: everything you already know. max is 16 mg/d by Rx or 8 mg/d OTC. Should only be used up to 2d BSS Antibiotics: moderate-to-severe >24h. Macrolides, quinolones, or rifaximin preferred Severe TD and dysentery: azithromycin

Skin cancers

*Characteristics*: look for ABCDE in a suspicious spot that is changing over time or a spot that looks different than others on the skin: Asymmetry, Border (irregular), Color (not uniform throughout), Diameter (larger than 6 mm), Evolving Basal cell and squamous cell: common, unlikely to metastasize, easy to treat with topical treatment or surgery Melanoma: cancer forms in melanocytes. Most deadly

Vancomycin

*Covers*: MRSA (DOC): consider alternative drug when MRSA MIC ≥ 2 C. diff: DOC for first C. diff infection *MOA*: inhibits bacterial cell wall synthesis by binding to D-alanyl-D-alanine *Dosing*: systemic infections (IV): 15 - 20 mg/kg q8-12h based on ABW CrCl 20-49: qd C. diff (po): 125 - 500 mg qid x10d *Monitoring*: renal function and trough *AE*: ototoxicity, nephrotoxicity, infusion reaction/red man syndrome

Bactrim

*Covers*: gram -: shigella, salmonella, stenotrophomonas, (not underlined in book: haemophilus, proteus, E. Coli, klebsiella, enterobacter) Opportunistic pathogens: pneumocystis, toxoplasmosis(, nocardia) Does not cover pseudomonas, enterococci, atypicals, and anaerobes *MOA*: inhibits folic acid pathway *Uses*: CA-MRSA skin infections, UTI, PCP (Pneumocystis PNA) *Dose*: based on TMP component (SS has 80 mg, DS has 160 mg) Uncomplicated UTI: 1 DS po bid x3d *AE*: skin reactions, photosensitivity, hyperkalemia, hemolytic anemia (identified by positive Coombs test), and crystalluria *CI*: sulfa allergy and G6PD deficiency *DDI*: warfarin—Bactrim increases INR

CCBs

*DHP*: generics: end in "-pine" MOA: inhibit Ca from entering vascular smooth muscle, causing peripheral arterial vasodilation. Decreases SVR (afterload), decreasing oxygen demand and increases supply Uses: HTN, chronic stable angina, arrhythmias, and Prinzmetal's angina AE: reflex tachycardia, HA, flushing, hypotension, and peripheral edema *Non-DHP*: verapamil and diltiazem. Available as an injection MOA: work same way as DHPs but are more selective for myocardium. Causes a negative inotropic and chronotropic effect. Decreases heart rate. Slows rate in ventricular tachyarrhythmias Use: control HR usually in A-fib AE: edema, constipation (more with verapamil), HA, dizziness, HoTN, arrhythmias, heart failure, and gingival hyperplasia CI: HFrEF (Heart Failure with reduced Ejection Factor) patients DDIs: (substrates of P-gp and moderate inhibitors of CYP3A4) (lower simvastatin/lovastatin dose if using). Amiodarone, digoxin, and beta blockers decrease hr *DDIs*: (major substrates of CYP450 3A4) watch out with beta blockers, digoxin, and clonidine. Grapefruit juice

Hyperglycemia crises

*DKA*: most common in patients with type 1 diabetes. Occurs due to insulin non-compliance. Ketones are present Presentation: BG > 250, ketones (fruity breath), and anion gap (arterial pH < 7.35, anion gap > 12) *Hyperosmolar Hyperglycemic State*: most often occurs in patients with type 2 diabetes. Serum ketones are negligible or not present Presentation: BG > 600, extreme dehydration, pH > 7.3 *Treatment*: fluids: start with NS. When BG reaches 250, change to D5W1/2NS Regular insulin infusion: 0.15 U/kg bolus, then start a continuous infusion at a rate of 0.1 U/kg/h Prevent hypokalemia: monitor K and keep serum level between 4 and 5 Treat acidosis (only if pH < 7): give sodium bicarbonate

Phenylephrine

*Decongestant*: lasts for a shorter time and has more side effects than oxymetazoline *Vasopressor*: MOA: alpha-1 agonist Effects: vasoconstriction, increased bp AE: bradycardia

Medroxyprogesterone

*Depo-Provera*: Aka DMPA. Contraception that is injected q3m. Women on this should be taking calcium, vitamin D supplementation, and folic acid Dose: IM or SC q3m AE: can decrease amount of mineral stored in bones *Provera*: systemic hormone therapy Use: menopause Form: po

Depression

*Diagnosis*: Ham-D or HRS Assessment Scale. DSM-5 criteria requires presence of at least 5 of the following: *(M SIG E CAPS)* Mood Sleep: increased/decreased Interest/pleasure: diminished Guilt or feelings of worthlessness Energy: decreased Concentration: decreased Appetite: decreased/increased Psychomotor agitation or retardation Suicidal ideation *Treatments*: All have BBW for increase in suicidal thoughts or actions in children, teenagers, and young adults, MedGuides are required. Takes 6-8w to work psychologically but physical symptoms (low energy) may improve by 1-2w Rule out bipolar to avoid inducing mania or causing rapid-cycling (cycling rapidly between bipolar depression and mania) BZDs should not be used alone Natural products: St. John's wort, SAMe MAOIs: phenelzine, tranylcypromine, isocarboxazid. Restricted to patients unresponsive to other treatments due to serotonin syndrome Pregnancy: SSRIs DOC except paroxetine due to cardiac events. However, warning out due to risk of PPNH (Persistent Pulmonary HTN of Newborn). Brisdelle is CI Breastfeeding: SSRIs or tricyclics except doxepin Discontinuing: should be tapered over several weeks (except fluoxetine which self-tapers due to long half life) Not responding to initial treatment after 6-8w: increase dose, add drug with different MOA, add buspirone or atypical antipsychotic (Abilify, Symbyax [olanzapine + fluoxetine], quetiapine XR), or add lithium

Vaginal fungal infections

*Diagnosis*: pH > 4.5 indicates presence of Candida or trichomoniasis. OTC test kits are available to test vaginal pH (Vagisil Screening Kit) *Prevention*: lactobacillus or yogurt with active cultures is thought to reduce occurrence *Treatment*: x1, 3, or 7 days Pregnant: x7-10d

Insomnia

*Diagnosis*: symptoms occur at least 3x/w x3m *Treatment*: natural products: (not recommended for chronic use) melatonin, valerian OTC: diphenhydramine (not recommended for long term use), doxylamine

GERD

*Diagnosis*: ≥2x/w. Other options are endoscopy or esophageal pH monitoring *Treatment*: 1. lifestyle/OTC (weight loss). Further treatment needed if no relief after 2w or if alarming symptoms are present (e.g. trouble swallowing) 2. PPI x8w 3. If symptoms return, not manageable by OTC. Start PPI at lowest effective dose for maintenance treatment or H2RA prescription

Cephalosporins

*Do not choose on exam if patient has PCN allergy unless it's to treat pediatric with acute otitis media* Not active against enterococcus AE: seizures (with accumulation), GI upset, DA, and rash *1st generation*: covers gram + cocci, some gram - rods, and PEK (Proteus, E. Coli, and Klebsiella). Generation of choice to treat MSSA Cephalexin: usually used for MSSA or strep throat. Refrigerate po suspension Cefazolin: inpatient. Commonly used for surgical prophylaxis *2nd generation*: covers HNPEK (Haemophilus, Neisseria, Proteus, E. Coli, Klebsiella) Cefotetan and cefoxitin: also covers gram - anaerobes (B. fragilis). Cefotetan contains a side chain that can increase the risk of bleeding and cause a disulfiram-like reaction with alcohol ingestion. Commonly used for surgical prophylaxis (colorectal procedures) Cefuroxime: Ceftin. Refrigerate po suspension. Commonly used for acute otitis media, CAP (Community-Acquired PNA), sinus infection. Outpatient po *3rd generation*: group 1: ceftriaxone (CI with neonates that have hyperbilirubinemia [causes biliary sludging] and neonates ≤ 28d receiving calcium-containing products; does not require renal dose adjustment; only cephalosporin that comes as a once daily IV dose), cefixime (available as chewable), cefdinir (Omnicef; commonly used for CAP or sinus infection; outpatient po; do not refrigerate po suspension) and cefotaxime. Covers more resistant strep and more resistant HNPEK. Ceftriaxone and cefotaxime mostly used for CAP, meningitis, spontaneous bacterial peritonitis, and pyelonephritis Group 2: ceftazidime: covers pseudomonas Beta-lactamase inhibitor combinations: ceftazidime/avibactam (covers some CRE), ceftolozane/tazobactam. Added activity against MDR pseudomonas and other MDR gram - rods *4th generation*: cefepime only. Covers pseudomonas *5th generation*: ceftaroline only. Only beta-lactam that covers MRSA

H2RAs

*Dose*: use lower dose in patients with renal impairment *Warnings*: confusion (higher risk if elderly, severely ill, or have renal impairment) *CI*: avoid use in elderly patients with delirium, dementia, or cognitive impairment due to AE CNS effects *DDI*: decreased absorption of other drugs: rilpivirine, atazanavir, ledipasvir, velpatasvir/sofosbuvir, itraconazole, ketoconazole, posaconazole oral suspension, cefditoren, cefpodoxime, cefuroxime, iron products, mesalamine, erlotinib Others: INSTIs, bisphosphonates, isoniazid, mycophenolate, quinolones, sotalol, steroids (especially budesonide), tetracyclines (less with doxy and mino), thyroid products Completely avoid: delavirdine, dasatinib, pazopanib, risedronate DR (Atelvia)

Overweight patients

*Drugs that affect weight*: increase: antipsychotics, diabetes medications, valproic acid, lithium, mirtazapine, steroids Decrease: ADHD drugs, GLP-1 agonists, pramlintide, SGLT2 inhibitors, topiramate *Categorized*: Overweight: BMI 25 - 29.9 kg/m^2 Obese: ≥ 30 kg/m^2 *At risk for*: coronary heart disease, HTN, stroke, type 2 diabetes

Alzheimer's disease

*Drugs that worsen it*: antihistamines, antiemetics, antipsychotics, barbiturates, BZDs, central anticholinergics (e.g. benztropine), peripheral anticholinergics (including incontinence and IBS drugs), skeletal & muscle relaxants, other CNS depressants *Screening*: MMSE (Mini-Mental State Exam; score <24 indicates memory disorder) *Treatments*: if nausea is present, give medication in the evening. If insomnia is present, take in the morning Natural: Vitamin E, ginkgo biloba (increases bleeding risk) Acetylcholinesterase inhibitors: used alone or with memantine. Slows clinical progression

Overactive bladder

*Forms of urinary incontinence*: urge: associated with neuropathy Stress: urine leaks out during any form of exertion Overflow: occurs without need to urination, usually due to BPH *Patho*: outer muscular layer is the detrusor muscle, which is innervated mainly by parasympathetic nervous system (ACh acting on muscarinic receptors) OAB: inappropriate stimulation causing involuntary contractions. M3 receptor is responsible for bladder contractions *Nonpharm treatment*: behavioral therapies including Kegel exercises *Pharm treatment*: anticholinergic drugs and beta-3 receptor agonists (causes less xerostomia than anticholinergic)

A-fib

*Goal*: symptomatic patients: <80 BPM Asymptomatic: <110 BPM *Treatments*: rate control: medications that control ventricular rate (beta-blockers or non-DHP CCBs, sometimes digoxin) Rhythm control: goal is to restore and maintain NSR (Ia, Ic, or III antiarrhythmic or electrical cardioversion). Avoid rhythm control if A-fib is permanent Stroke prophylaxis: it is safer to have this as a priority vs trying to remain NSR. Anticoagulation (not clopidogrel alone) x4w or ASA indefinitely

Sodium disorders

*Hyponatremia*: Na < 135 Treatment: hypovolemic hyponatremia via NaCl. Hypervolemic hyponatremia via diuresis with fluid restriction. AVP (Arginine VasoPressin) receptor antagonists (conivaptan, tolvaptan) can be used to treat SIADH and hypervolemic hyponatremia. Correcting Na more rapidly than 12 mEq/L over 24h can cause ODS (Osmotic Demyelination Syndrome) or central pontine myelinolysis, which can cause paralysis, seizures, and death *Hypernatremia*: Na > 145. Associated with a water deficit and hypertonicity

Tobramycin

*Inhalation solution* Brands: TOBI, Bethkis, Kitabis Pak Use: targets pseudomonas aeruginosa in CF pts Dose: take at least 6h apart Administration: do not mix with any other drug in the nebulizer. Refrigeration recommended, safe at room temperature for 28d AE: ototoxicity, tinnitus, voice alteration, mouth & throat pain *Inhalation powder*: Brand: TOBI Podhaler Use: targets pseudomonas aeruginosa in CF pts Dose: take at least 6h and as close to 12h apart Administration: store at room temperature in a dry place. Do not swallow capsules. Not used with nebulizer, just podhaler

pH

*Kidneys*: help maintain a neutral pH by controlling bicarbonate which acts as a base *Lungs*: help maintain a neutral pH by indirectly controlling carbon dioxide which acts as an acid *Proton relationship*: the more acidic (lower pH), the more protons there are (acidic solution donates protons). The more basic (higher pH), the lower the protons (basic solution binds protons) *pKa*: pH = pKa: this is the point at which half the compound is not protonated and half is pH > pKa: more of the acid is ionized pH < pKa: more of the acid is unionized

Complications of ART therapy

*Lactic acidosis and severe hepatomegaly with steatosis*: most common with NRTIs *IRIS* (Immune Reconstitution Inflammatory Syndrome): paradoxical worsening of a preexisting ophthalmic condition. Continue ART therapy *Lipodystrophy*: lipoatrophy: most common with NRTIs, specifically with stavudine Lipohypertrophy: fat accumulation in the upper back and neck. Most common with PIs *Diarrhea*: most common with PIs

CHF treatment

*Lifestyle*: monitor & document body weight daily (notify provider when weight increases) and maintain sodium reduction (<1500 mg/d) in stages A and B CHF *OTC*: hawthorn, fish oil, and CoQ10 *Pharmacological*: all patients: ACEI or ARB (block neurohormonal activation of RAAS, resulting in vasodilation and improved EF), angiotensin receptor and neprilysin inhibitor (Entresto decreases risk of CV death and hospitalization for HF), beta blocker (blocks activation of SNS by blocking epi and NE), aldosterone receptor antagonist (provide added diuresis) Decreased mortality in select patients: hydralazine and nitrates (BiDil) decreases mortality in black patients Improve other aspects of HF (does not decrease mortality): loop diuretics, digoxin, and ivabradine (Corlanor) Shown to decrease mortality: ACEI, beta blockers, and aldosterone antagonists

Common anesthetics used in the ICU

*Local*: lidocaine: lidocaine/epinephrine combo used for local procedures, epinephrine keeps lidocaine localized *Inhaled*: desflurane (Suprane), sevoflurane *Injectable*: bupivacaine: epidurals. Fatal if administered IV Ropivacaine

Triptans

*MOA*: 5-HT1 receptor agonist causing vasoconstriction of cranial blood vessels *Use*: first line for treatment of acute migraines *Dose*: take at the first sign of a migraine *Forms*: tablet Useful in nausea: ODT, nasal spray, injection Work quicker: nasal spray, injection Avoid in patients with PKU: ODT *AE*: HTN, paresthesia, triptan sensations, nausea, chest heaviness *CI*: CV disease, uncontrolled HTN, ischemic heart disease, use within 24h of another triptan

Oxazolidines

*MOA*: Bind to 50S subunit *Coverage*: same as vancomycin but also VRE *DDI*: tyramine-containing foods (because they are reversible MAOIs) and serotonergic drugs *Linezolid*: no renal doses needed. IV:po ratio is 1:1. Do not shake suspension AE: duration-related myelosuppression (thrombocytopenia), optic neuropathy, serotonin syndrome CI: do not use within 2w of MAOI

P2Y12 inhibitors

*MOA*: binds ADP P2Y12 receptor on the platelet surface which prevents ADP-mediated activation of GPIIb/IIIa receptor complex *Thienopyridines*: clopidogrel and prasugrel. Irreversibly bind. Commonly used with ASA after ACS *DDI*: increase bleeding risk: NSAIDs, warfarin, SSRIs, SNRIs Omeprazole, esomeprazole, and other CYP2C19 inhibitors

First generation antipsychotics

*MOA*: block dopamine *Uses*: psychosis, schizophrenia *AE*: QT prolongation, dyskinesias Dystonias: higher risk with young males. Muscles contract uncontrollably. Diphenhydramine or benztropine can be used for prophylaxis or treatment Akathisia: makes it hard to sit still. Can be treated with anticholinergics (diphenhydramine, benztropine), BZDs, or propranolol Parkinsonism: treat with anticholinergics or propranolol TD: Tardive Dyskinesias. Repetitive jerking movements. Higher risk with elderly females. Must stop the drug and replace with an SGA with low EPS risk (quetiapine, clozapine). Can be irreversible Low potency FGAs: lower risk of EPS, higher degree of sedation, and high risk for CV events (orthostatic hypotension, tachycardia) High potency FGAs: lower sedation, higher risk of EPS *BBW*: increased risk of mortality in elderly patients with dementia-related psychosis. Increased risk of stroke in patients with dementia

NSAIDs

*MOA*: block synthesis of COX enzymes (non-selective blocks both, COX-2 selective decreases GI risk but increases risk of MI/stroke) *Administration*: requires a MedGuide due to risks- GI: bleeding and ulceration CV: MI and stroke CABG (Coronary Artery Bypass Graft) surgery: CI. Antiplatelet therapy (commonly ASA) recommended *AE*: HTN Premature closure of ductus arteriosus: before birth, this connects pulmonary artery to aorta, allowing oxygenated blood to flow to the baby, bypassing immature lungs. It closes on its own after birth, if not, IV NSAIDs (indomethacin, ibuprofen) can be used within 14d of birth to help it close Nausea: take wc to avoid Renal dysfunction: will worsen it if patient has liver toxicity *CI*: renal failure (avoid or use cautiously), uncontrolled HTN (avoid), third trimester of pregnancy

PDE5 inhibitors

*MOA*: blocks PDE5 from degrading cGMP, causing smooth muscle relaxation and pulmonary vasculature relaxation & vasodilation *Use*: PAH and sexual dysfunction (does not increase libido) *Dose*: decrease starting dose by 1/2 if ≥ 65 yo, using an alpha-blocker, using a CYP3A4 inhibitor, severe renal or liver disease *AE*: hearing loss, vision loss (may be due to NAION), priapism (seek medical help if > 4h), HoTN, HA, impaired color discrimination, chest pain (seek medical help immediately), flushing, dizziness, dyspepsia, back pain, dysphagia *CI*: nitrates or riociguat *DDIs*: alpha blockers: use with caution. Patient must be stable on alpha-1 blocker before starting PDE5 inhibitor Antihypertensive drugs: use caution Moderate and strong CYP3A4 inhibitors: use lower starting dose

BZDs

*MOA*: enhances GABA, an inhibitory neurotransmitter *Use*: acute anxiety: no more than 1-2w, tapered off slowly Sleep: non-BZDs preferred Seizures: by injection or Diastat AcuDial (diazepam rectal gel) for immediate control Alcohol withdrawal syndrome *Warning*: do not d/c, taper slowly if used for more than 10d. Crosses placenta during pregnancy *AE*: somnolence, ataxia, dizziness, unsteadiness Older adults: confusion, dizziness, falls *DDI*: olanzapine (should not be given together IM due to orthostasis risk) *BBW*: use with opioids can result in sedation, respiratory depression, and death

Tetracyclines

*MOA*: inhibit bacterial protein synthesis by binding to 30S ribosomal subunit *Drug specifics*: doxycycline: treats Lyme disease, Rocky Mountain Spotted Fever (tick-borne illnesses), CAP, COPD exacerbations, sinusitis, VRE UTI, monotherapy for chlamydia, combo therapy for gonorrhea Minocycline: AE of DILE (Drug-Induced Lupus Erythematosus) IV:po for both ^ is 1:1 Tetracycline: used in H. pylori treatment *AE*: photosensitivity *DDI*: antacids, cations, sucralfate, bismuth subsalicylate, and bile acid resins can chelate and inhibit tetracycline absorption *CI*: <8 yo, pregnant, and breastfeeding

Calcitonin

*MOA*: inhibits osteoclastic bone resorption *Use*: osteoporosis (only if other options are not suitable) *Forms*: nasal spray: "priming the pump," before the first dose, spray at least 5 times until a full spray is produced Injection *Dose*: nasal spray: one nostril qd (alternate nostrils every day) *AE*: hypocalcemia, increased risk of malignancy, hypersensitivity reactions to salmon-derived product

PPIs

*MOA*: irreversibly binds to gastric H+/K+-ATPase pump, blocking gastric secretion *Warnings*: C-diff associated diarrhea (chronic use can cause chronic change in gastric pH leading to infections including PNA), osteoporosis-related fractures, hypomagnesemia *CI*: ≥x8w in elderly patients *DDI*: (inhibit CYP2C19) decreased absorption of other drugs: rilpivirine, atazanavir, ledipasvir, velpatasvir/sofosbuvir, itraconazole, ketoconazole, posaconazole oral suspension, cefditoren, cefpodoxime, cefuroxime, iron products, mesalamine, erlotinib Others: INSTIs, bisphosphonates, isoniazid, mycophenolate, quinolones, sotalol, steroids (especially budesonide), tetracyclines (less with doxy and mino), thyroid products Completely avoid: delavirdine, dasatinib, pazopanib, risedronate DR (Atelvia)

Opioids

*MOA*: mu receptor agonists *AE*: increased risk of hypoxemia with COPD and sleep apnea Constipation: all AE lessen over time except for constipation. Opioids reduce GI tract peristalsis, making it difficult to poop. Prophylaxis for constipation required if dosed around the clock. Stimulant laxatives (senna) are first line +/- stool softener (helpful if stool is hard). Bisacodyl (stimulant laxative) comes as tablet for prophylaxis or suppository for treatment. If laxatives are not sufficient, specific medications that counteract effects of opioid receptor in gut (PAMORAs) can be used or lubiprostone *DDI*: BZDs, alcohol *BBW*: addiction, abuse, and misuse can lead to OD and death. Respiratory depression which can be fatal. Use with BZD or other CNS depressants, including alcohol can increase risk of death. Accidental ingestion/exposure of even one dose in children can be fatal. Crushing, dissolving, or chewing of long acting products can cause delivery of potentially fatal dose. Life-threatening neonatal opioid withdrawal with prolonged use during pregnancy *REMS* for all

Organophosphates (including industrial insecticides) OD

*MOA*: too much blocks acetylcholinesterase which increases ACh levels *Treat*: atropine Pralidoxime: relieves paralysis by reactivating cholinesterase

Dyslipidemia non-Rx treatments

*Natural products*: red yeast rice: contains naturally occuring HMG-CoA reductase inhibitors OTC fish oils: lower TG *Nonpharmacological*: diet: vegetables, fruits, whole grains, high-fiber. Limit saturated fats, trans fats, and cholesterol Physical activity: aerobic activity 3-4x/w

Common Cold treatments

*Natural products*: zinc, Vitamin C (decreases duration by 1-1.5 days), possibly echinacea, elderberry *Children*: < 2 yo: OTC not recommended. Avoid promethazine < 6 yo: AAP (American Academy of Pediatrics) says OTC not recommended ≤ 12 yo: avoid codeine ASA: avoid due to Reye's syndrome APAP infant's or children's: 10-15 mg/kg/dose Ibuprofen infants' drops: 5-10 mg/kg/dose

Newborn health

*Newborn*: APGAR (Appearance Pulse Grimace Activity Respiration) score: should be taken at 1 min and again at 5 min from birth. Measures performance in hr, respiratory effort, color, muscle tone, and reflex irritability. Healthy infant will score between 7 and 10, lower score requires more medical care Medications at birth: vitamin K. Light therapy if jaundice is present *Preterm*: low Apgar scores usually due to immature lung and heart development Patent Ductus Arteriosus: NSAIDs (IV indomethacin) can help PDA to close RDS: Respiratory Distress Syndrome. Caused by deficiency of surfactant production in lungs. Most babies born <35w gestation should receive surfactant to prevent. Drugs are recognizable by having "surf" or "actant" in the name

Diabetes adjunct therapies

*Nonpharm treatment*: quit smoking, reduce weekly calorie intake by 3500 kCal (will result in a 1lb weight loss), waist circumference should be <35 in for females and < 40 in for males. Eat healthy carbs. Omega-3 fatty acids recommended. Get up and move q30min, at least 150 min of moderate-intensity exercise per week *Antiplatelet treatment*: ASA for primary prevention for most men and women ≥ 50 yo who have at least one additional ASCVD risk factor. Secondary prevention in any patient with ASCVD *Statin therapy*: clinical ASCVD: high intensity No ASCVD: moderate intensity ASCVD and LDL ≥ 70: add ezetimibe or PCSK9 inhibitor *Bp therapy*: goal of < 140/90. Recommended that one or more antihypertensive be taken qhs ACEI or ARB: patients who have normal bp and albuminuria (≥ 30 mg/d or Urine Albumin-to-Creatinine Ratio [UACR] ≥ 30) *Vaccines*: annual influenza, both pneumococcal, and hepB

Anticoagulation for Atrial Fibrillation/Flutter

*Nonvalvular Afib*: Afib/Aflutter without heart valve involvement *Treatment*: patients with a mechanical heart valve: warfarin Anticoagulation in patients undergoing cardioversion: Afib>48h, anticoagulation for at least 3 w prior to and 4 w after cardioversion. Afib < 48h, continue full anticoagulatin for at least 4w

Weight loss treatment

*OTC*: usually contain bitter orange, caffeine (can be packaged under guarana, green tea powder) *Prescription*: not appropriate for patients with small amounts of weight to lose. Indicated when BMI ≥ 27 kg/m^2 with at least one weight-related condition. Only used in addition to dietary plan and increased physical activity Drugs: Qsymia, Belviq, Contrave, Saxenda (liraglutide), orlistat. Can be continued long-term. Should be d/c if doesn't produce at least 5% weight loss in 12w CI: pregnancy *Bariatric surgrery*: indicated when BMI ≥ 40 kg/m^2 or when BMI ≥ 35 with an obesity-related condition Nutrient deficiencies: calcium citrate supplementation preferred as it has non-acid-dependent absorption. Anemia can result from vitamin B12 and iron deficiency. Iron and calcium supplements should be taken 2h prior or 4h after antacids. May require life-long vitamin A, D, E, and K Medication: may need to be crushed and put in liquid or used in transdermal form for up to 2m post surgery. Ursodiol may be needed due to possible gallstones

Candida albicans treatment

*Oropharyngeal infection (thrush)*: mild: topical antifungals (clotrimazole, nystatin) HIV+ or moderate-severe: fluconazole po *Esophageal infection*: fluconazole or echinocandin

Multiple sclerosis

*Patho*: patient's immune system attacks myelin sheath *Symptoms*: fatigue, numbness, blurred vision, deterioration of cognitive function, muscle spasms, pain, incontinence, gait instability *Diagnosis*: MRI *Treatments*: interferon beta formulations, glatiramer acetate, pegylated interferon beta *Goal of therapy*: prevent disease progression, what is lost in neuronal function cannot be regained *Symptom control*: incontinence: anticholinergics Constipation: laxatives Muscle spasms: muscle relaxants Muscle pain: analgesics Tremor: propranolol

BPH

*Patho*: testosterone is metabolized to DHT (DiHydroTestostserone) by 5 alpha-reductase, DHT is responsible for normal cell growth. BPH occurs from overgrowth of cells *Drug causes*: anticholinergics, antihistamines, caffeine, decongestants, diuretics, SNRIs, TCAs, phenothiazines, testosterone products *Symptoms*: can be similar to prostate cancer, so should be checked. LUTS (Lower Urinary Tract Symptoms), frequent urination, hesitancy, intermittency, straining, weak stream, urinary urgency, leaking, nocturia Severe: acute renal failure *Diagnosis*: DRE (Digital Rectal Exam), PSA (Prostate Specific Antigen) *Treatments*: based on pt-reported severity. ALpha-blockers are first-line Natural products: saw palmetto. Lycopene is used for prostate cancer prevention Drug: alpha blockers +/- 5 alpha-reductase inhibitors. Tadalafil +/- finasteride also an option (good option for patients with BPH and ED)

Allergic rhinitis

*Prevention*: IgE-mediated skin prick test *Cause*: allergies (pollens, molds, dust mites, animal dander) *Symptoms*: rhinorrhea. Symptoms can be intermittent (has specific triggers) or chronic (last for months) *Nonpharm treatments*: nasal wetting agents or nasal irrigation with warm water (isotonic or hypertonic; water must be boiled or distilled). It rinses out allergens and mucus. Neti pot is an example *Pharm treatments*: mild: po antihistamines Moderate to severe: IN steroids Other: decongestants, IN cromolyn, Singulair, SL immunotherapy (first dose must be given in doctor's office, patient must be monitored for signs of allergic reaction [BBW] and Epipen should be on hand)

Acute otitis media

*Prevention*: PCV13 and influenza vaccine *Symptoms*: bulging tympanic membrane, otorrhea, otalgia, and tugging or rubbing of the ears *Treatment*: observation without antibiotics for 48-72h: non-severe cases- otalgia < 48h + <102.2°F or 6-23m old-symptoms are only in one ear Pain: systemic drugs preferred DOC: amoxicillin 80 - 90 mg/kg/d or Augmentin 90 mg/kg/d Others: ceftriaxone-injection only, used in children who cannot swallow or who have N/V

Pneumococcal vaccines indications and intervals

*Prevnar 13*: all patients <5 yo receive 4-dose series. Should only be given to patients once in their lifetime *Pneumovax 23*: *never* indicated for <2 yo *All patients ≥ 65 yo*: 1 dose of Prevnar 13 (if never received) + Pneumovax 23 1y later (separating by 5y from any other Pneumovax 23 vaccine) *Immunocompromised* (sickle cell disease, asplenia, HIV, chronic renal failure, malignancy, transplant, immunosuppressive drugs): 6-64 yo: 1 dose of Prevnar 13 (if haven't gotten before) + 2 doses of Pneumovax 23. Separate 13 from 23 by 8w. Separate 23s by 5y ≥65 yo: 3rd dose of Pneumovax 23 separated by at least 5y *Immunocompetent* (with DM, CV disease, lung disease, liver disease, alcohol abuse, or smokers): 2-64 yo: 1 dose of Pneumovax 23

CINV

*Risk factors*: female, < 50 yo, dehydration, history of motion sickness, history of N/V *Types*: acute: onset within 24h after chemo. Treat with 5HT3 receptor antagonists Delayed: onset 1 - 7d after chemo. Treat with NK1-RA (NeuroKinin 1- Receptor Antagonist), corticosteroids, palonosetron Anticipatory: onset before chemo. Treat with BZDs *Treatment*: administer 30 min prior to chemo and provide at home antiemetics. NK1-RA (NeuroKinin 1- Receptor Antagonist), 5HT3 antagonists, dexamethasone, metoclopramide, prochlorperazine, IV/po fluid hydration High emetic risk: Either NK1-RA + 5HT3-RA + dexamethasone, netupitant/palonosetron (Akynzeo) + dexamethasone, or olanzapine + palonosetron + dexamethasone Breakthrough N/V: 5HT3-RAs, dopamine receptor antagonists, cannabinoids (second line)

Diabetes

*Risk factors*: first degree relative with DM, HTN, BMI ≥25, race, low HDL *Symptoms*: polyuria, polyphagia and polydipsia. DKA is commonly the initial presentation *Diagnosis*: normal test results should be repeated at least q3y. Classic symptoms of hyperglycemia or hyperglycemic crisis + random plasma glucose ≥ 200 OR FPG ≥ 126 OR 2h plasma glucose ≥ 200 after a 75 g OGTT OR A1c ≥ 6.5% *Goals*: A1c: <7%. Should be measured quarterly in patients who are not at goal, at least 2x/y if patient is at goal. It measures average blood glucose over past 2-3m (6% = eAG of 126) Preprandial plasma glucose: 80-130 Peak postprandial plasma glucose: < 180 *Monitoring*: diabetic kidney disease: urine test performed annually to measure urine albumin excretion Neuropathy: annually for diabetic peripheral neuropathy using 10 g monofilament and at least one additional test. First line is duloxetine or pregabalin Foot care: comprehensive foot exam qy. Patients should inspect their own feet qd. Avoid walking barefoot Retinopathy: Dilated, comprehensive eye exam q2y. Higher risk in pregnant women

Stress ulcers in ICU

*Risk factors*: mechanical ventilation, coagulopathy *Prevention*: H2RA PPI: associated with increased risk of GI infections (C. diff), fractures, and nosocomial PNA

Stroke

*Risk factors*: most common risk factor is HTN *S&S*: *(FAST)* Face: ask person to smile, does one side of the face droop? Arms: ask the person to raise both arms Speech Time: call 911 immediately, even if symptoms go away *Immediate treatment*: first need a diagnosis of the kind of stroke *Secondary prevention*: ASA, clopidogrel, or Aggrenox

Compounding Hazardous Drugs

*Sterile*: a head cover, hair cover, two shoe covers, gown, and two pairs of gloves must be worn Compounding in a vial: use "negative pressure technique," smallest syringe should be used as long as it's not more than 75% full when filled with the solution. After diluent is drawn up and one is transferring to the vial, it should be pulled back once in the vial first to get some air and then some diluent is release, back and forth Closed System Transfer Devices (CTSDs): keeps HDs contained within the device and blocks entry of environmental contaminants. Recommended with all HDs, required when administering antineoplastics. They have built-in pressure equalization *Non-sterile*: performed in either CVE (Containment Ventilated Enclosure) or in a class I BSC (Biological Safety Cabinet)

Rheumatoid arthritis

*Symptoms*: bilateral, symmetrical. Pain is worse after rest, "morning stiffness." Joint swelling, pain, stiffness, bone deformity *Diagnosis*: anti-citrullinated peptide antibody and RF (Rheumatoid Factor) *Treatment*: all symptomatic patients should be on a DMARD (MTX DOC) MTX not enough: combination of DMARDs or a tumor necrosis factor inhibitor biologic or a non-TNF biologic +/- MTX. Never use two biologic DMARDs together Flares: steroids at its lowest dose for shortest duration possible

Hepatic encephalopathy

*Symptoms*: musty odor of the breath, changes in thinking, confusion, forgetfulness, and asterixis *Patho*: accumulation of gut-derived nitrogenous substances in the blood such as ammonia *Treatment*: reduce blood ammonia levels Nonabsorbable disaccharides: Lactulose is DOC for both acute and chronic prevention therapy. MOA is it works by converting ammonia produced by intestinal bacteria to ammonium. AE are flatulence, diarrhea, dyspepsia, abdominal discomfort Antibiotics: lactulose is followed by an antibiotic (rifaximin is DOC). Antibiotic is used because it inhibits production of urease-producing bacteria. Neomycin can be used BBW for neurotoxicity, AE GI upset. Flagyl can be used, shouldn't be used long term due to peripheral neuropathies Nonpharm management: reduce animal protein intake

Parkinson's disease S&S

*TRAP*: T: Tremor R: Rigidity A: Akinesia/bradykinesia (lack of movement or slow movement) P: Postural instability (poor balance- falls) *Advanced disease*: psychosis

Digoxin

*Therapeutic range*: CHF: 0.5-0.9 Afib: 0.8-2 *Brands*: Digitex, Digox, and Lanoxin *MOA*: inhibits Na/K ATPase pump, resulting in a positive inotropic effect (increased cardiac output and force). Also has a negative chronotropic effect (decreases heart rate) *Use*: CHF: improves symptoms, exercise tolerance, hospitalizations, and QOL. Does not improve survival Afib: usually given in combination with beta blockers or CCBs *Dose*: typically 0.125-0.25 mg po qd Smaller, older females: decrease dose CrCl < 50: decrease dose or frequency Po to IV: decrease dose by 20 - 25% *Toxicity*: initial: N/V, loss of appetite, and bradycardia. Higher risk in patients with hypokalemia (will allow digoxin to work more at site, causing toxicity), hypomagnesemia, and hypercalcemia Severe: blurred/double vision and greenish-yellow halos vision *DDI*: (CYP3A4 substrate) Decrease hr: amiodarone, non-DHP CCBs, beta blockers Increases digoxin levels: amiodarone *Monitor*: electrolytes and renal function

Rickettsial disease and related infections

*Transmitted by*: ticks, fleas, and lice *Lyme Disease*: symptoms: bullseye rash, achy joints, fever Diagnosis: ELISA test Treatment: doxycycline *Rocky Mountain Spotted Fever*: treatment: doxycycline *Ringworm*: symptoms: raised rings on skin, can be itchy Treatments: clotrimazole or another topical antifungal

Eczema

*Treatment*: moisturizers: decrease severity. Aquaphor, Eucerin Topical steroids: occasional po course if needed Antihistamines: itching Calcineurin inhibitors: if topical steroids with hydration is not adequate

Anxiety

*Treatments*: natural products: St. John's wort, Valerian First line: SSRIs and SNRIs. Does not provide immediate relief, takes at least 4w Second-line: buspirone (does not provide immediate relief, takes 2-4w), TCAs

Adverse drug reaction types

*Type A*: predictable. Dose-dependent, related to known pharmacological actions of drug. More common than type B *Type B*: generally not dose-dependent, unrelated to pharmacologic actions of drug. Due to Drug allergy: immune-mediated response. Type I (immediate. IgE-mediated. Urticaria, angioedema, bronchospasm, anaphylaxis, death), Type II (hemolytic anemia, thrombocytopenia), Type III (immune-complex reactions), Type IV (delayed hypersensitivity. Can occur from 48 h to several weeks after exposure. PPD skin test for TB shows Type IV reaction) Pseudoallergic reaction Idiosyncratic reaction

Bipolar disorder

*Types*: Bipolar I: severe mania (abnormally elevated or irritable mood x≥1w). May be psychotic/delusional Bipolar II: hypomania. Does not affect social/work functioning. Does not cause psychosis. Depressive phases *Treatment*: lithium, valproic acid, carbamazepine: can treat this and depression without inducing either state. Lamotrigine also an option but not preferred due to titration requirement Antipsychotics: if patient has psychosis. Use cautiously (especially with FGAs) because bipolar patients are at increased risk of EPS Acute: valproic acid or lithium + antipsychotic for patients in manic state. Lithium or lamotrigine for bipolar depression

ACS

*Types*: NSTE-ACS: non-ST segment Elevation Acute Coronary Syndromes. Consists of unstable angina and NSTEMI STEMI: ST segment Elevation Myocardial Infarction. Blocked arteries need to be opened as quickly as possible *Symptoms*: chest pain (pressure and squeezing) ≥ 10 min, severe dyspnea, and diaphoresis. Pain can radiate to arms, back, neck, jaw, or epigastric area *Diagnosis*: 12-lead ECG at site of first medical contact (ambulance in some cases). Troponins (TnI and TnT) are cardiac enzymes that can help in determination (would be positive in NSTEMI and STEMI) *Treatment*: Avoid NSAIDs and nifedipine IR in acute settings (naproxen can be considered) (MONA [immediately] -GAP [give next]-BA [give within 24h] : Morphine, Oxygen, Nitrates, ASA 325 mg, GPIIb/IIIa antagonists, Anticoagulants, P2Y12 inhibitors, Beta blockers [indefinite], ACEI (can use ARB if ACEI is CI); +/- PCI for NSTE-ACS, + PCI [preferred] or fibrinolytic for STEMI) Nitroglycerin is used q5min for up to 3 doses for acute pain. Antianginal, antiplatelet, anticoagulant, and high-intensity statin should be initiated Morphine: decreases myocardial O2 demand, provides pain relief Nitrates: decreases myocardial O2 demand by decreasing preload GPIIb/IIIa antagonists: abciximab (ReoPro), eptifibatide (Integrilin), tirofiban. AE are bleeding, thrombocytopenia, and hypotension Anticoagulants: LMWHs, UFH, bivalirudin P2Y12 inhibitors: clopidogrel, prasugrel, ticagrelor Other: PPIs should be prescribed in any patient with a history of GI bleeding if also on warfarin + P2Y12 inhibitor + ASA

IBD

*Types*: UC and Crohn's disease *Symptoms*: bloody diarrhea *Diagnosis*: colonoscopy with tissue biopsy *Treatments*: lifestyle: smaller, more frequent meals that are low in fat and dairy. Drink plenty of water Drugs: antidiarrheals or antispasmodics. Vitamin supplements to prevent deficiencies related to malabsorption. Probiotics can reduce abdominal pain Induction: (acute exacerbations) short courses of oral or IV steroids

Transplant

*Types*: allograft: transplant from one individual to another Isograft: transplanted organ from a genetically identical donor (twin) Autograft: transplant in the same pt *Prevention of graft rejection*: crossmatching is done for HLA (Human Leukocyte Antigen) and ABO blood group *Induction immunosuppression*: to prevent acute rejection which is due to either T-cell (cellular) or B-cell (humoral or antibody), type is distinguished via biopsy. Basiliximab Higher risk of rejection: antithymocyte globulin Acute rejection occurs: high-dose steroids High dose of maintenance drugs can also be used *Maintenance immunosuppression*: CNI (Calcineurin Inhibitor; tacrolimus DOC) + antiproliferative agent (mycophenolate DOC) +/- steroids. mTOR inhibitors and belatacept also options *Infection risk reduction*: tell pt to monitor for symptoms (fever ≥ 100.5°F, chills, sore throat, ear/sinus pain, cough, more sputum or change in color of sputum, pain with passing urine, mouth sores, wound that does not heal) *Complications*: metabolic syndrome Cancer: skin cancer common, wear sunscreen *Vaccines*: cannot receive live vaccines after transplant. Inactivated vaccines can be given post-transplant in 3-6m. Required vaccines are given pre-transplant Influenza Pneumococcal: ≥ 19 yo. PCV13 first, PPSV23 8w later Varicella: also vaccinate patient's close contacts. If a vaccinated household contact develops a rash, avoid contact with pt and contact physician

Pain

*Types*: nociceptive: sensory nerves identify tissue damage Neuropathic: damage or malfunctioning of nervous system (e.g. fibromyalgia, diabetic neuropathy)

Sjogren's syndrome

*Types*: primary Secondary: associated with another autoimmune disease *Symptoms*: dry eyes and mouth *Treatments*: dry eyes: OTC artificial teardrops. Not working, can try cyclosporine eye drops or Xiidra Dry mouth: sugar-free chewing gum (with xylitol)/lozenges + rinses with antimicrobial mouthwash. If not working, can try muscarinic agonists (pilocarpine or cevimeline; CI in patients with uncontrolled asthma and closed-angle glaucoma) *Can cause*: dental caries, corneal ulceration, chronic oral infections

HTN

*Types*: primary: unknown cause Secondary: caused usually by renal disease (increased activity of sympathetic nervous system and renin-angiotensin-aldosterone system) *Nonpharmacological treatments*: lifestyle: weight loss, DASH diet, sodium intake <1500 mg qd Natural: fish oil, CoQ10, L-arginine, and garlic *Pharmacological treatment*: when to start: Stage 2 HTN if SBP ≥140 or DBP ≥90. Stage 1 HTN + clinical CVD or + 10-year ASCVD risk ≥10%. Check bp qm and titrate med as needed Initial drug selection: non-black (thiazide, CCB, ACEI, or ARB), black (thiazide or CCB), CKD (ACEI or ARB), DM with albuminuria (ACEI or ARB). Start two drugs when baseline BP > 150/90 Pregnant patients: only receive treatment if SBP ≥160 or DBP ≥105. Okay drugs include labetalol, nifedipine XR, and methyldopa *Goal*: <130/80

Tricyclic antidepressants

*Types*: secondary amines: selective for NE Tertiary amines: can be slightly more effective but have worse anticholinergic AE *AE*: cardiac: QT prolongation with overdose (can cause fatal arrhythmias), orthostasis Anticholinergic: dry mouth, blurred vision, urinary retention, constipation *CI*: MAOIs *BBW*: increased risk of suicidal thinking and behavior in children, adolescents, and young adults

Arrhythmias

*Types*: silent: asymptomatic A-fib: most common type. Irregular and rapid response. Increases risk of blood clot PVC: Premature Ventricular Contractions. Referred to as a skipped heartbeat. Can be related to stress or too much caffeine VT: Ventricular Tachycardia. Series of PVCs in a row causing a heart rate of greater than 100. Untreated it can degenerate into ventricular fibrillation which is a medical emergency *Causes*: MI, electrolyte imbalances (K, Mg, Na, and Ca), elevated sympathetic states (hyperthyroidism, infection), and drugs *Symptoms*: dizziness, SOB, fatigue *Diagnosis*: ECG. Holter monitor is an ambulatory ECG that can detect intermittent arrhythmias

SNRIs

*Use*: depression *AE*: due to increased NE: increased hr, dilated pupils, dry mouth, excessive sweating, constipation HTN, sexual side effects Hyponatremia *DDIs*: anticoagulants, antiplatelets, NSAIDs: increased bleeding risk *CI*: MAOIs *BBW*: increased risk of suicidal thoughts and behavior in children, adolescents, and young adults

Testosterone

*Use*: hypogonadism (deficiency in testosterone. Drug causes include methadone, chemotherapy, cimetidine, spironolactone) *Forms*: IM, SC: painful Topical gels: apply at the same time qam. Wash hands after each use to avoid transferring testosterone to women/children Solutions Patch: qpm. Do not use same site for at least 7d *AE*: CV risks, increased clotting risk, increased hematocrit, noncancerous prostate growth, baldness, acne, gynecomastia, increased appetite, edema, hepatotoxicity, reduced sperm count *CI*: severe BPH *BBW*: early virilization

Hormone therapy

*Use*: menopause Indications: healthy symptomatic women who are within 10y of menopause, ≤ 60 yo, and have no CI Extending treatment beyond 60 yo may be acceptable (e.g. osteoporosis) if lowest possible dose is used and woman is advised of safety risk *Estrogen*: most effective treatment for vasomotor symptoms Women with uterus: should not take estrogen alone. Estrogen + a form of progesterone. This is because the "unopposed estrogen" increases risk of endometrial cancer Forms: transdermal, topical (bypass first pass metabolism; preferred for pts who only have vaginal symptoms), and tablet AE: increased risk for heart attacks, strokes, blood clots, breast cancer, and dementia CI: breast cancer, uterine bleeding, VTE, pregnancy BBW: VTE, stroke, dementia, breast cancer *Progestin*: can be given as part of a combo pill (with estrogen) or separate tablet (most commonly MPA [medroxyprogesterone]) AE: mood disturbances, spotting Micronized progestins: (e.g. Prometrium) safer than synthetic progestins *Systemic*: apply patch to lower abdomen, below waistline AE: increased risk of breast cacner BBW: endometrial cancer, dementia, increased risk of VTE & stroke, breast cancer

Varicella-containing vaccines

*Varivax*: live. SC. Should receive 2 doses. Store in freezer. reconstitute immediately after removing from freezer. Antivirals should be stopped 24 hours before vaccine Use: chickenpox CI: gelatin or neomycin allergy *Zostavax*: live. SC. Store in freezer. Reconstitute immediately after removing from freezer. Antivirals should be stopped 24 hours before vaccine Use: shingles CI: gelatin or neomycin allergy *Shingrix*: recombinant (not live). IM. Store in refrigerator. Preferred over Zostavax. 2 doses given at 0 and 2-6 month for those >50 yo. Patient should still receive it even if they have history of infection (chickenpox) Use: shingles

Conversion between anticoagulants

*Warfarin to* (d/c warfarin and start when): *(READ)* rivaroxaban: INR < 3 Edoxaban: INR ≤ 2.5 Apixaban: INR < 2 Dabigatran: INR ≤ 2 *Oral factor Xa inhibitors to warfarin*: stop Xa inhibitor, start warfarin and parenteral anticoagulant at next scheduled dose of factor Xa inhibitor *Dabigatran to warfarin*: start warfarin 1-3d before stopping dabigatran

Isavuconazonium

-Azole antifungal. Requires a filter during administration. Only azole that doesn't cause QT prolongation Covers: molds including aspergillus and zygomycetes Brand: Cresemba

How many mmol are in a mEq?

1 for monovalent ions (Na+, K+). 0.5 for divalent ions (Ca++)

Interpreting arterial blood gases

1. *Acidosis or alkalosis?* Based on pH 2. *Look at other values and see which match with pH*: respiratory: decreased CO2 (alkalosis). Increased CO2 (acidosis) Metabolic: increased HCO3 (alkalosis). Decreased HCO3 (acidosis) Example: low pH = acidosis. If patient had high CO2 and normal HCO3, this matches with respiratory acidosis 3. If both HCO3 and CO2 are abnormal, they usually go in different directions from pH due to compensation so just go with the one that matches pH

Diarrhea treatment

1. Fluid and electrolyte replacement with ORS (Oral Rehydration Solutions [e.g. Pedialyte]) or Gatorade .2. For non-infectious diarrhea use bismuth subsalicylate (Pepto-Bismol) or loperamide

Motion sickness treatment in pregnancy

1. Lifestyle 2. Pyridoxine (vitamin B6) +/- doxylamine Ginger is possibly effective

Constipation treatment in pregnancy

1. Lifestyle: adequate fluid intake, brown rice/bread, physical activity 2. Fiber (psyllium, calcium polycarbophil)

EpiPen use

1. Remove from carrying case and pull off blue safety release. Hold it facing down 2. Inject orange part into outer thigh at 90° angle 3. Hold needle firmly in place for 3 sec 4. Remove needle and massage area for 10 sec It is normal to see liquid remaining in the device after. A second dose in the opposite leg can be given if needed

Hyperphosphatemia treatment

1. Restrict dietary phosphate (rarely works long term). Further progression, use phosphate binders 2. Once controlled, treat elevations in PTH with vitamin D

Combined procainamide + NAPA therapeutic range

10 - 30 mcg/mL

Diagnostic tests for peripheral neuropathy

10-g monofilament test

Absolute Risk Reduction

12% indicates that 12 out of every 100 patients will benefit from treatment = % risk in control group - % risk in treatment group

How many g of carbs is equal to an average serving?

15

Goal vancomycin trough

15 - 20 mcg/mL for most serious infections, 10 - 15 mcg/mL otherwise

NAPA therapeutic range

15 - 25 mcg/mL

How many oz are in a pint

16

Cough, cold, allergy treatment in pregnancy

1st generation antihistamines: chlorpheniramine DOC Nasal steroid needed for chronic allergies: budesonide and beclomethasone are safest ("b" for babies) Avoid liquid formulations that contain alcohol

Goal INR for patients on warfarin

2 - 3

HIV treatment for pregnant women who are ART-naive

2 NRTIs + either a boosted-PI or INSTI

Insulins and other DM injectables room temperature BUD

3d: Afrezza (opened) 10d: Afrezza (unopened), Humulin 70/30 pen 14d: Humulin N pen, Novolog 70/30 pen, Trulicity 28d: Humalog, Humulin R U-500 pen, Novolog 70/30 vial, Novolog pen & vial, Bydureon, Lantus (including Basaglar) 30d: Victoza, Byetta 31d: Humulin R U-100, Humulin N vial, Humulin 70/30 vial 40d: Humulin R U-500 vial 42d: Novolin, Levemir, Toujeo 56d: Ozempic, Tresiba

Carbamazepine therapeutic range

4-12 mcg/mL

How many g are in a lb

454

Dolasetron

5HT3 receptor antagonist Brand: Anzemet Use: CINV (po, IV not recommended for CINV due to QT prolongation)

Granisetron

5HT3 receptor antagonist Brand: Sancuso Use: CINV

Ondansetron

5HT3 receptor antagonist Brands: Zofran, Zuplenz film Use: acute and breakthrough CINV Administration: for ODT, with dry hands, peel back foil of blister instead of trying to push it through

How many mg are in a grain

65

Platelets' average life span

7-10 days

How many oz are in a cup

8

RBC life span

90-120d

Postprandial blood glucose goal

< 180 mg/dL

Goal TC level

< 200 mg/dL (fasting 9-12 hours before)

Vitamin D deficiency

<30. Occurs when kidney is unable to hydroxylate vitamin D to its final active form, 1,25-dihydroxy vitamin D Treatment: Vitamin D analogs (Calcitriol - active form of Vitamin D3) for patients with CKD or ESRD to increase calcium absorption and inhibit PTH secretion

When to seek urgent care for a child based on temperature

<3m old: 100.4 F (rectal) 3-6m: 101 F (rectal) >6m: 103 F (rectal)

Specific Gravity

= g/mL. If >1, it's heavier than water, <1, lighter than water

Inert filler

A diluent used during compounding that can be used to provide a minimum weighable quantity if using a torsion balance (usually lactose, can be starches, calcium salts, mannitol, sorbitol cellulose)

Vesicant

A drug that can cause severe tissue damage. Examples are vasopressors, anthracyclines (antidotes are dexrazoxane [Totect] or dimethyl sulfoxide), and vinca alkaloids (antidote is hyaluronidase)

Conical graduate

A graduated cylinder that is wider at the mouth for mixing purposes

Michaelis-Menten kinetics

A kinetic pattern that is somewhat a mix of zero and first order elimination. Doubling a dose of a drug can more than double serum concentration. Phenytoin, theophylline, and voriconazole exhibit Michaelis-Menten kinetic

Eutectic mixture

A mixture that will melt at a lower temperature than the individual components of the mixture

Prostaglandin analogs

A preservative in these (BAK [BenzAlKonium chloride]) can stain contact lenses Use: glaucoma Dose: 1 drop qhs AE: darkening of the iris & eyelashes, increase in eyelash length & number, blurred vision, stinging

Spatulas in compounding

A steel (metal) one should be used if making a mixture that contains metallic ions, rubber should be used instead

Cardioversion

A way to try to return the heart to NSR. If patient is not already on therapeutic anticoagulation, it should be started at least 3w before cardioversion and continue for at least 4w

Red Book, Pediatrics

AAP. Summaries of pediatric infectious diseases, antimicrobial treatment, and vaccinations

Quinapril

ACEI Brand: Accupril

Ramipril

ACEI Brand: Altace

Benazepril

ACEI Brand: Lotensin

Enalaprilat

ACEI Brand: Vasotec IV

Brentuximab

ADC (Antibody-Drug Conjugates)- antibody binds to cell, enabling drug to enter tumor cell MOA: binds to antigens expressed on specific hematopoietic cells (targets CD30) and causes cell death Use: Hodgkin's Lymphoma Toxicity: suppression of specific hematopoietic cells leading to bone marrow suppression which causes an increased risk for reactivation of viral infections

Inotuzumab

ADC (Antibody-Drug Conjugates)- antibody binds to cell, enabling drug to enter tumor cell MOA: binds to antigens expressed on specific hematopoietic cells and causes cell death Use: non-Hodgkin's Lymphoma, Hodgkin's Lymphoma, multiple myeloma Toxicity: suppression of specific hematopoietic cells leading to bone marrow suppression which causes an increased risk for reactivation of viral infections

Drugs and medical conditions that can cause or worsen depression

ADHD medications: methylphenidate, atomoxetine Analgesics: indomethacin, methadone Antiretrovirals: efavirenz (in Atripla), rilpivirine (in Complera, Odefsey) Cardiovascular: beta-blockers (especially propranolol), clonidine, methyldopa, procainamide, reserpine Hormones: hormonal contraceptives, anabolic steroids Other: antidepressants, systemic steroids, cyclosporine, isotretinoin, interferons, varenicline, ethanol Medical conditions: stroke, Parkinson's, dementia, MS, hypothyroidism, low vitamin D levels, metabolic conditions (e.g. hypercalcemia), malignancy, overactive bladder, infectious diseases

Salicylate NSAIDs

AE: dyspepsia, heartburn (PPIs may be used to protect the gut, consider risk of chronic PPI use [decreased bone density, increased infection risk]), bleeding, tinnitus (salicylate OD) CI: children & teenagers with any viral infection (Reye's syndrome)

Lamustine

AE: pulmonary fibrosis

Topiramate

AED *Brand*: Topamax *Use*: migraine prophylaxis, seizures (used in children) *AE*: fetal harm, metabolic acidosis, nephrolithiasis, increased ammonia, open angle glaucoma, weight loss, somnolence, cognitive impairment, hypocalcemia Children: oligohidrosis/hyperthermia *Monitoring*: bicarbonate, intraocular pressure *DDI*: can decrease oral contraceptives

Zonisamide

AED *Brand*: Zonegran *Use*: seizures in children *AE*: weight loss, metabolic acidosis, nephrolithiasis Children: oligohidrosis/hyperthermia *CI*: sulfa allergy

Levetiracetam

AED *Brands*: Keppra, Keppra XR Spritam: dissolves with one sip of a liquid *Dose*: IV:po 1:1 *Forms*: ODT, oral solution, tablet *Warnings*: psychiatric reactions, somnolence, fatigue *DDI* (no DDIs with oral contraceptives)

Gabapentin

AED *Brands*: Neurontin Horizant: for PHN and restless leg syndrome Use: adjuvant for pain management and chronic seizure management *AE*: somnolence, ataxia, peripheral edema, weight gain, mild euphoria

Felbamate

AED BBW: hepatic failure, aplastic anemia

Vigabatrin

AED BBW: permanent vision loss

Valproic acid

AED Brand: Depakene, Depakote, Depacon, Depakote ER, Depakote Sprinkle MOA: increases GABA Use: migraine prophylactic, bipolar mania, epilepsy AE: *(TAP WHAT)* thrombocytopenia, alopecia, pancreatitis, weight gain, hepatotoxicity, ammonia increase (treat with carnitine in symptomatic adults), teratogenic (fetal valproate syndrome, long term cognitive effects for fetus) DDI: (enzyme inhibitor) will increase lamotrigine levels BBW: fetal harm (highest risk of AEDs; decreased IQ in child, neural tube defects), hepatic failure, pancreatitis Monitoring: drug blood levels (therapeutic range 50 - 100), LFTs (baseline and frequently in first 6m), platelets

Phenobarbital

AED Brand: Luminal AE: teratogenic, sedation, dependence/tolerance, hangover effect Warnings: habit forming, respiratory depression, fetal harm DDI: (enzyme inducer) oral contraceptives Monitoring: drug blood levels (therapeutic range 20-40 in adults)

Pregabalin

AED Brand: Lyrica Use: fibromyalgia, PHN, adjuvant for pain management, neuropathic pain, anxiety AE: somnolence, mild euphoria, weight gain, peripheral edema

Oxcarbazepine

AED Brand: Trileptal DDI: (enzyme inducer) AE: rash, sleepiness, ataxia, visual disturbances Warnings: hyponatremia, osteoporosis Monitoring: test for HLA-B*1502 before starting, Na for first 3m

Carbamazepine

AED Brands: Tegretol, Tegretol XR MOA: Na channel blocker Use: trigeminal neuralgia, adjuvant for pain management, chronic seizure management, and bipolar mania (as Equetro brand) AE: rash Warnings: hyponatremia (SIADH), fetal carbamazepine syndrome DDI: (enzyme inducer, Pgp inducer, autoinducer- decreases levels of itself as well) oral contraceptives CI: myelosuppression Monitoring: drug blood levels (therapeutic level 4-12), CBC, platelets, Na BBW: serious skin reactions (Asian patients should be tested for HLA-B*1502 allele), aplastic anemia, agranulocytosis

Eslicarbazepine

AED. Active metabolite of oxcarbazepine AE: hyponatremia, rash

Phenytoin

AED. Exhibits Michaelis-Menten kinetics *Brands*: Dilantin, Dilantin Infatabs *MOA*: Na channel blocker *Dose*: adjusted phenytoin concentration (used when albumin is low and CrCl ≥ 10) = total phenytoin measured / ([0.2 x albumin] + 0.1). IV:po 1:1 *Administration*: IV: requires a filter. Dilute in NS, stable for 4h, do not refrigerate G-tube: enteral feedings decrease phenytoin absorption. Hold feedings 1-2 h before and after administration *AE*: dose-related: nystagmus, ataxia, diplopia Chronic: gingival hyperplasia, hair growth, hepatotoxicity *Warning*: extravasation which can lead to Purple Glove Syndrome (more likely than fosphenytoin). Avoid in patients who have a positive HLA-B*1502. Fetal harm *DDI*: (enzyme inducer; high protein binding- can displace other drugs that are highly protein bound) oral contraceptive *Monitoring*: drug blood levels (therapeutic range 10-20). Small increase in dose can lead to a large increase in drug concentration. LFTs IV: continuous cardiac and respiratory monitoring *BBW*: IV should not exceed 50 mg/min. If given faster, cardiac arrhythmias may occur

Primidone

AED. Prodrug of phenobarbital AE: teratogenic, sedation, dependence/tolerance DDI: (enzyme inducer)

Fosphenytoin

AED. Prodrug of phenytoin *MOA*: Na channel blocker *Dose*: IV:po 1:1 *Forms*: comes as IM *AE*: dose-related: nystagmus, ataxia, diplopia Chronic: gingival hyperplasia, hair growth, hepatotoxicity *Warning*: extravasation which can lead to Purple Glove Syndrome (less likely than phenytoin). Avoid in patients who have a positive HLA-B*1502. Fetal harm *DDI*: (enzyme inducer; high protein binding- can displace other drugs that are highly protein bound) oral contraceptive *Therapeutic range*: 10-20 *Monitoring*: LFTs IV: continuous cardiac and respiratory monitoring *BBW*: IV should not exceed 150 mg PE/min. If given faster, cardiac arrhythmias may occur

ANC calculation

ANC = WBC x ((%segs [or % polys] + %bands) / 100)

ANOVA

ANalysis Of VAriance. Used when using continuous data with 3 or more samples

Pain treatment in pregnancy

APAP. Possible link between APAP during pregnancy and ADHD/autism in child

Candesartan

ARB Brand: Atacand

Irbesartan

ARB Brand: Avapro

Olmesartan

ARB Brand: Benicar AE: sprue-like enteropathy

Losartan

ARB Brand: Cozaar

Aggrenox

ASA + dipyridamole. Antiplatelet used to prevent recurrent stroke in noncardioembolic ischemic stroke or TIA patients AE: HoTN and HA

Yosprala

ASA + omeprazole Use: secondary prevention of CV events in patients at risk for ASA induced ulcers

Drugs that can worsen GERD

ASA/NSAIDs, bisphosphonates, dabigatran, estrogen products, fish oil products, iron supplements, nicotine replacement therapies, steroids, tetracyclines

Resources for drug shortages

ASHP and FDA

Resources for IV drug compatibility and stability

ASHP's Handbook on Injectable Drugs, King Guide, and Trissel's

Resources for ADRs

ASHP, FDAble, MedWatch (via FAERS), and VAERS

Tolvaptan

AVP antagonist Brand: Samsca Use: hyponatremia Dose: limited to ≤ 30d due to hepatotoxicity AE: hepatotoxicity, thirst, nausea, xerostomia, polyuria BBW: should be initiated and re-initiated in a hospital. ODS Monitor: rate of Na increase

Drugs in which pharmacogenomic testing is highly recommended

Abacavir & combo products, azathioprine, carbamazepine, cetuximab, panitumumab, trastuzumab, ado-trastuzumab, lapatinib, and pertuzumab

Oral iron

Absorption is decreased with food (take on an empty stomach), high gastric pH (avoid H2RAs and PPIs, separate from other antacids), and SR or EC forms upon initial use *Use*: iron deficiency anemia *AE*: constipation (dose-related; recommended to take with docusate) and dark & tarry stools *DDI*: decrease iron absorption: H2RAs and PPIs Iron decreases absorption of following, separate: quinolones, tetracyclines, bisphosphonates, levothyroxine Increases iron absorption: vitamin C, acidic foods *BBW*: accidental OD can be fatal in children, take to emergency department or call poison control immediately, even if asymptomatic

Itraconazole

Absorption is pH-dependent (advise to take with a non-diet cola) Use: onychomycosis Administration: take oral solution on an empty stomach AE: (if used with other drugs with this AE) QT prolongation, ventricular tachyarrhythmias (torsades de pointes) CI: history of heart failure (if using to treat onychomycosis)

Rivastigmine

Acetylcholinesterase inhibitor *Brand*: Exelon *Use*: Alzheimer's Disease *Forms*: capsule Patch: less GI side effects. Apply at the same time qd to upper back, upper arm, or chest. Rotate sites. Does not need to be removed before an MRI *Dose*: start patch with 4.6 mg/24h

Donepezil

Acetylcholinesterase inhibitor Brand: Aricept Use: Alzheimer's Disease Forms: tablet and ODT (less GI side effects) Dose: at bedtime (to prevent nausea)

Teratogenic drugs

Acne: isotretinoin and topical retinoids (including tazarotene) Antibiotics: quinolones, tetracyclines Anticoagulants: warfarin Dyslipidemia, HF, HTN: statins, RAAS inhibitors (ACEI, ARBs, aliskiren, sacubitril/valsartan) Hormones: most, including estradiol, progesterone (including megestrol [Megace]), raloxifene, Duavee, testosterone, contraceptives Migraine: dihydroergotamine, ergotamine Other: hydroxyurea, lithium, MTX, misoprostol, paroxetine, ribavirin, thalidomide, topiramate, weight loss drugs, valproic acid

Choosing birth control based on patient

Acne: lower androgenic activity (Ortho-Cyclen) or no andronergic activity (Yaz, Yasmin) Breastfeeding: POP or nonhormonal method Migraine with aura: POP Fluid retention/bloating: product containing drospirenone (mild K-sparing diuretic that helps reduce water retention. CI with liver or renal disease) Heavy menstrual bleeding: Natzia (COC) or Mirena (levonorgestrel-releasing IUD) approved. COCs wtih 4 placebos vs 7 will minimize bleeding risk HTN: POP Mood changes or disorder: monophasic CHC (extended cycle or continuous drospirenone preferred) Nausea: take qpm wc. Consider decreasing estrogen dose or switching to a POP or NuvaRing Overweight: do not use Depo-Provera Postpartum: do not use CHCs for 3w (6w if pt has additional risk factors for VTE). POPs Premenstrual dysphoric disorder: Yaz or antidepressant (sertraline, not escitalopram) Spotting: commonly occurs when initiating extended cycles or continuous regimens, resolves within 3-6m. Wait 3 cycles before switching when initiating any product, if no resolution, decrease estrogen dose. Still no resolution, increase progestin dose

Airborne precautions are used for what diseases

Active TB, measles, or varicella virus (chickenpox)

Penicillins

Active against gram + cocci *Natural penicillins*: penicillin G benzathine: not for IV use (can cause death). DOC for syphilis (2.4 million U IM x1) Pen VK: outpatient oral. First-line treatment for strep throat and mild nonpurulent skin infections *Aminopenicillins*: forms: amoxicillin and Augmentin come in chewable forms. Ampicillin and Unasyn come in injectable and can be diluted in NS only Amoxicillin: brand is Moxatag. First-line treatment for acute otitis media (80-90 mg/kg/d). DOC for infective endocarditis prophylaxis before dental procedures (2 g po x 1, 30 - 60 min before procedure), used in H. pylori treatment Augmentin: first line treatment for acute otitis media (90 mg/kg/d) and sinus infection. Use lowest dose of clavulanate to avoid diarrhea (Augmentin ES-600 has lowest ratio of clavulanate than other suspensions). If treating acute otitis media and patient failed on amoxicillin, Augmentin is good to try next Covers: strep, enterococci, gram + anaerobes, and HNPEK (gram - bacteria: Haemophilus, Neisseria, Proteus, E. Coli, and Klebsiella) Combined with beta-lactamase inhibitors: added activity against MSSA, more resistant strains of gram - bacteria (HNPEK), and gram - anaerobes AE: seizures (with accumulation of drug), GI upset, DA, rash CI: amoxicillin XR or 875 mg—CrCl < 30 *Extended-spectrum penicillins + beta-lactamase inhibitor*: Zosyn. Prolonged or extended infusions should be infused over 4 hours Covers: same as aminopenicillin/beta-lactamase inhibitor plus extended coverage of other gram - bacteria (CAPES [Citrobacter, Acinetobacter, Providencia, Enterobacter, Serratia] and pseudomonas [only penicillin active against pseudomonas]) *Antistaphylococcal penicillins*: cover strep and MSSA. Nafcillin, oxacillin, dicloxacillin Nafcillin: vesicant- administration through a central line is preferred. If extravasation occurs, use cold packs and hyaluronidase injections

Carbapenems

Active against gram +, gram - (including ESBL-producing bacteria), and anaerobes. No coverage of atypical pathogens, MRSA, VRE, C. Diff, or stenotrophomonas. IV only Common uses: polymicrobial infections (e.g. moderate - severe diabetic foot infection), empiric therapy when resistant organisms are expected, resistant pseudomonas or acinetobacter infections AE: seizures (higher risk with higher doses, renal failure, or use with imipenem/cilastatin) CI: PCN allergy Ertapenem: Invanz. Only carbapenem with no coverage against pseudomonas, acinetobacter, or enterococcus *(ErtAPenem doesn't cover E A P)*. Must be diluted in NS

Posaconazole

Active against molds including aspergillus and zygomycetes. Suspension form has lower bioavailability than the tablet form. Take qd wc

ADHF

Acute Decompensated Heart Failure. When combined with HoTN and hypoperfusion, it becomes cardiogenic shock *Treatment*: some patients require invasive heart monitoring via a Swan-Ganz catheter, which can measure pulmonary capillary wedge pressure Volume overload: loop diuretics and possible IV vasodilators

AKI

Acute Kidney Injury. Common cause is dehydration which presents as BUN:SCr ratio > 20:1

HBV and HCV

Acute illness that can lead to chronic infection, cirrhosis of the liver, liver cancer, liver failure, and death *HCV*: 6 different genotypes *Transmission*: contact with infectious blood or other body fluids *First line treatment*: HBV: PEG-INF or NRTI (tenofovir or entecavir) HCV: DAA combination, if that fails try DAA combination + riboflavin or DAA combination + riboflavin + PEG-INF *Vaccines*: HBV: 3-dose vaccine series takes 6m to complete (if a traveler is unable to finish the series before travel, do as much as possible before leaving, continue series upon return). Children routine should be started within 24h after birth. Recommended in healthcare workers, patients with chronic liver disease (including HCV), HIV, diabetes HCV: no vaccine available

Hepatitis A

Acute illness. Vaccine available Transmission: fecal oral route through improper hand washing or via contaminated food/water First line treatment: supportive care

Addison's Disease

Adrenal gland is not making enough cortisol. Addisonian Crisis can occur if exogenous steroids are stopped suddenly, can be fatal Treat: fludrocortisone

Cushing's Syndrome

Adrenal gland producing too much cortisol or when exogenous steroids are taken in high doses

AQI

Air Quality Index. Rates local air as good to hazardous

Ulipristal acetate

Aka "abortion pill" or RU-486. Low potency and used to delay ovulation & prevent implantation in the uterus. Requires a prescription. Can use up to 5d after sex

Gonadotropin-Releasing Hormone (GnRH) agonists

Aka Luteinizing Hormone Releasing Hormone (LHRH) agonists Use: prostate cancer AE: symptoms of "tumor flare" (antiandrogens are given for several weeks with initiation of GnRH agonist to prevent), osteoporosis risk, hot flashes, impotence, gynecomastia, peripheral edema, bone pain, injection site pain, QT prolongation, dyslipidemia, hyperglycemia

Primary peritonitis

Aka SBP (Spontaneous Bacterial Peritonitis). Infection of peritoneal space that often occurs in patients with liver disease Treatment: DOC is ceftriaxone x5-7d. Others include Bactrim and/or Cipro

Cyancobalamin

Aka Vitamin B12 or cobalamin Use: macrocytic anemia Forms: nasal solution (Nascobal, one nostril qw), tablets, IM, deep SC

Normocytic anemia

Aka anemia of CKD *Cause*: deficiency in erythropoietin (EPO) *Treatments*: iron therapy and ESAs (Erythropoiesis Stimulating Agents) Hemodialysis patients: IV iron DOC

Anticholinergics

Aka antimuscarinics. Beers Criteris recommend avoiding in patients ≥ 65 yo *MOA*: block ACh *Use*: overactive bladder (e.g. oxybutynin), allergies or insomnia (e.g. diphenhydramine), dystonic reactions (e.g. benztropine) *AE*: xerostomia (lower rate with XR form; avoid mouthwashes with alcohol. Use ice chips, sugar-free candy, or sugar-free gum to help), agitation, confusion, drowsiness, dizziness, blurred vision, use caution in tasks that require mental alertness), constipation Centrally-acting: acute cognitive impairment *CI*: closed-angle glaucoma

Nocturnal enuresis (in children)

Aka bed-wetting *Nonpharm treatment*: positive reinforcement, normal daytime voiding pattern, normal hydration pattern Not working: alarm therapy +/- pharm treatment *Pharm treatment*: desmopressin

Progestin-only pills (POPs)

Aka mini-pills. Safe in women who have migraines with aura MOA: suppress ovulation Use: pregnancy prevention (mainly used in women who are lactating because estrogen decreases milk production) Administration: can be started at any time Missed dose (> 3h): backup required x48h Examples: Nora-BE, Camila, Heather, Errin

Epstein-Barr Virus

Aka mono or mononucleosis. Transmitted through bodily fluids

Ischemic stroke

Aka non-cardioembolic stroke *Common risk factors*: HTN and Afib *Cause*: thrombus *Acute management*: alteplase (DOC) or ASA 162 - 325 mg po within 24-48h within stroke onset *Secondary prevention*: HTN: treat with ACEI or thiazide-type diuretic with a goal of <130/90 Afib: anticoagulation if Afib is due to cardioembolic stroke Lifestyle modifications: sodium restriction, bp reduction, diet, and maintenance of BMI 18.5 - 24.9 & waist circumference <35 in for women, <40 in for men Antiplatelet: for noncardioembolic ischemic stroke or TIA. Reduces risk of recurrent stroke. Options include ASA, ASA + dipyridamole XR, or clopidogrel (used when patients have ASA allergy). ASA + clopidogrel can be used within 24h of minor ischemic stroke but not long term due to risk of hemorrhage

Hand-Foot Syndrome

Aka palmar-plantar erythrodysesthesia *Treatments*: cooling: temporary relief of pain Emollients: moisturizing for hands and feet Steroids and pain meds: alleviate pain and inflammation

Lice

Aka pediculus humanus capitis *Treatments*: DOC: RID (pyrethrin/piperonyl butoxide), NIX, or permethrin Other: malathion lotion 0.5%, Lindane (no longer recommended due to neurotoxicity) After each treatment, check the hair and use a nit comb to remove nits and lice q2-3d

Conjunctivitis

Aka pink eye *Cause*: virus, bacteria, or allergen *Treatment*: viral: most commonly adenovirus. No topical treatment Bacteria: caused by staph, more serious ones include neisseria gonorrhoeae or Chlamydia. Treat with moxifloxacin (Vigamox), neomycin/polymyxin B/dexamethasone (Maxitrol), ofloxacin (Ocuflox), trimethoprim/polymyxin B (Polytrim), azithromycin (Azasite. store in refrigerator, stable for 14d at room temperature) Allergen: treat with antihistamine (azelastine, olopatadine [Patanol, Pataday])

Hyperthyroidism

Aka thyrotoxicosis. FT4 is high and TSH is low *Causes*: Grave's disease (autoimmune disorder) Drugs: *(I AIR)* iodine, amiodarone, interferons, exposure to radiographic contrast media *Symptoms*: *(SHE* [Dania] *GiMMe BoTH) (112, 231, 312)* Skin (heat intolerance or increase sweating) Hair (thinning) Eyes (diplopia, exophthalmos) GI (weight loss or gain, DA/frequently pooping) Mind (nervousness/anxiety, irritability/agitation, insomnia) Menstrual (light or absent periods) Body (muscle weakness, fatigue, tremor) Thyroid (goiter) Heart (palpitations, tachycardia) *Treatment*: anti-thyroid meds, destroying part of the gland via radioactive iodine or surgery. Takes 1-3m of treatment at high doses to control symptoms, once symptoms are controlled, the dose should be reduced to prevent hypothyroidism Thionamides, iodides Symptom control: beta blockers for palpitations, tremors, tachycardia

Drugs that can worsen insomnia

Alcohol, bupropion, caffeine, decongestants, diuretics, fluoxetine, steroids, stimulants, vernicicline

Hand hygiene

Alcohol-based hand rubs are more effective in healthcare setting than soap. Antimicrobial hand soaps that contain chlorhexidine (Hibiclens) may be preferred in some situations. Handwashing is more effective than alcohol-based rubs when dealing with C. diff or when caring for patients with food allergies

Disintegrants used in compounding

Alginic acid, polacrilin potassium (Amberlite), various cellulose products, starches, Nu-Tab

Bendamustine

Alkylating agent Use: cancer

Melphalan

Alkylating agent Use: cancer

Busulfan

Alkylating agent Use: cancer AE: pulmonary fibrosis

Carmustine

Alkylating agent Use: cancer AE: pulmonary fibrosis

Stable angina

All patients should have annual influenza and pneumococcal vaccine *Diagnosis*: stress test which is done by exercising on a treadmill. IV regadenoson (Lexiscan) is used to help people do the test who otherwise can't (adenosine [Adenoscan], dobutamine, or dipyridamole can also be used) *Treatment*: (ABCDE: Antiplatelet and antianginal, Blood pressure and beta blockers, Cholesterol [statins] and cigarette cessation, Diet and diabetes, Exercise and education) Maintaining a BMI of 18.5-24.9 is important Antiplatelet: ASA is DOC. Clopidogrel (Plavix) is used in patients who can't take ASA (sometimes used with ASA) Antianginal: looking for meds that decrease myocardial oxygen demand or increase myocardial oxygen supply. Beta blockers are first line. CCBs (avoid short-acting DHPs [nifedipine IR], DHPs preferred when using with beta blocker) or long acting nitrates as second line. SL nitroglycerin recommended for immediate relief in all patients Dual-therapy: effective in patients who just had a bare metal stent (use for at least 1m), a drug-eluting stent (6m), or post-CABG (1y). Should be clopidogrel + ASA 81 mg

Single tablet regimens for HIV

All should be kept in original container *PI-based*: Symtuza: darunavir 800 mg + cobicistat 150 + emtricitabine 200 + tenofovir alafenamide 10. Take with food *NNRTI-based*: Atripla: efavirenz 600 + emtricitabine 200 + tenofovir disoproxil fumarate 300. Take without food Symfi: efavirenz 600 + lamivudine 300 + tenofovir disoproxil fumarate 300. Take without food Symfi Lo: efavirenz 400 + lamivudine 300 + tenofovir disoproxil fumarate 300. Take without food Complera: rilpivirine 25 + emtricitabine 200 + tenofovir disoproxil fumarate 300. Take with food Odefsey: rilpivirine 25 + emtricitabine 200 + tenofovir alafenamide 25. Take with food *INSTI-based*: Stribild: elvitegravir 150 + cobicistat 150 + emtricitabine 200 + tenofovir disoproxil fumarate 300. Take with food Genvoya: elegravir 150 + cobicistat 150 + emtricitabine 200 + tenofovir alafenamide 10. Take with food Bitarvy: bictegravir 50 + emtricitabine 200 + tenofovir alafenamide 25 Triumeq: dolutegravir 50 + abacavir 600 + lamivudine 300 Juluca: dolutegravir 50 + rilpivirine 25. Not used for initial treatment. Take with food *NRTI*: Epzicom (lamivudine + abacavir) and Truvada

Smoking tobacco

All smokers aged 19-6 should have their pneumococcal vaccines and annual flu shot DDI: tobacco induces CYP450 enzymes, primarily CYP450 1A2. Smokers who quit can experience supratherapeutic levels. Oral contraceptives (women ≥ 35 yo) Treatments: behavioral counseling over drugs are recommended for pregnant women, adolescents, and "light" smokers. NRT (Nicotine Replacement Therapy), bupropion, and varenicline

CAD

Atherosclerosis within the inner walls of coronary arteries. Causes reduced blood flow to the heart Risk factor: men >45, women >55

HIV meds to be dispensed only in original container

Atripla, Biktarvy, Cimduo, Complera, Descovy, Genvoya, Juluca, Odefsey, Stribild, Symfi (and Symfi Lo), Symtuza, Triumeq, darunavir, dolutegravir (10 mg tabs only), etravirine, indinavir, nelfinavir, raltegravir, ritonavir (tablets), rilpivirine, tenofovir disoproxil fumarate

Insulin degludec

Available in 200 U/mL pen Brand: Tresiba

Echinocandins

Available only as injections. Qd. Do not require renal dose adjustment MOA: inhibit synthesis of beta (1,3)-D-glucan (an essential part of the fungal cell wall) Covers: most candida species and aspergillus AE: histamine-mediated symptoms (rash, pruritus, facial swelling)

A1c

Average glucose over the past three months. Goal is <7% per ADA, ≤ 6.5% per AACE

Prostacyclin analogs and receptor agonists

Avoid interruptions in therapy/large, sudden reductions in dose MOA: inhibitor of platelet aggregation Use: PAH AE: rebound pulmonary hypertension, sepsis & bloodstream infections (with chronic IV infusions), flushing, jaw pain, infusion-site pain (IV, SC) DDI: NSAIDs

DOC for atypical organisms

Azithromycin, doxycycline, and quinolones

Imatinib

BCR-ABL inhibitor (tyrosine kinase inhibitor) Brand: Gleevec Pharmacogenomic: must be Philadelphia chromosome (BCR-ABL) positive to use Use: CML Dose: wc AE: fluid retention

Diagnostic tests for abnormal weight

BMI and waist circumference

Hypertensive crisis

BP ≥ 180/120 *Types*: emergency: acute target organ damage (e.g. encephalopathy, stroke, AKI, acute coronary syndrome). Treat with IV and decrease bp by no more than 25% within the first hour (HTN drugs that come in IV form are *[C2E2 N4 PHML]* chlorthalidone, clevidipine, esmolol, enalaprilat, nicardipine, nitroglycerin, nitroprusside, Non-DHPs, propranolol, hydralazine, metoprolol tartrate, labetalol) Urgency: no evidence of acute target organ damage. Treat with short acting oral medication (clonidine, hydralazine, labetalol)

Diagnostic tests for dehydration

BUN:SCr ratio > 20:1

Clonazepam

BZD Brand: Klonopin Use: anxiety AE: teratogenic

Diazepam

BZD Brand: Valium Use: anxiety Forms: tablet, injection, oral solution, rectal gel

Alprazolam

BZD Brand: Xanax, Xanax XR Use: anxiety CI: strong CYP3A4 inhibitors

Oxazepam

BZD. Safest of the BZDs to use in elderly and those with liver impairment (since they are metabolized to inactive glucuronides)

Temazepam

BZD. Safest of the BZDs to use in elderly and those with liver impairment (since they are metabolized to inactive glucuronides) Brand: Restoril Use: sleep (*not anxiety*)

Sunscreen

Babies <6m should be kept out of the sun. Labeling is no longer allowed to say "waterproof" or "sweatproof," instead "water resistant" but only for 40-80 min Administration: apply liberally at least q2h and reapply after swimming SPF: if a person normally burns in 10 minutes, an SPF of 5 would protect them for (5 x 10) 50 minutes

DOC for CA-MRSA SSTIs (skin and soft tissue infections)

Bactrim, doxycycline, and minocycline

Lotrel

Benazepril (ACEI) + amlodipine (CCB)

Dobutamine

Beta-1 agonist, inotrope. Turns pink when solution is oxidized MOA: increases contractility Effects: increases cardiac output, increases hr

Bisoprolol

Beta-1 selective blocker Brand: Zebeta Use: chronic heart failure AE: increased triglycerides Monitor: heart rate, bp, s/sx of HF

Atenolol

Beta-1 selective blocker with ISA

Nebivolol

Beta-1 selective blocker with nitric oxide-dependent vasodilation Brand: Bystolic

Esmolol

Beta-1 selective blocker. Available as an injection Brand: Brevibloc

Mirabegron

Beta-3 agonist Brand: Myrbetriq MOA: relaxes detrusor muscle Use: overactive bladder (when pt is not tolerating anticholinergic) AE: HTN, less dry mouth than other agents for this condition

Timolol eye drops

Beta-blocker eye drop. Comes in 0.25 and 0.5%. Careful in patients with asthma, COPD, chronic bronchitis, emphysema, or advanced cardiac disease *Brands*: Timoptic, Timoptic-XE, Istalol *Use*: glaucoma *Dose*: 1 drop qd or bid Gel: qd. Turn upside down and shake before use

Drugs that can raise blood glucose

Beta-blockers, diuretics (thiazide, loop), immunosuppressants, niacin, PIs, quinolones, 2nd generation (atypical) antipsychotics, statins, and systemic steroids

Drugs that can cause hemolytic anemia

Beta-lactamase inhibitors (clavulanate, sulbactam, tazobactam), cephalosporins (especially ceftriaxone and cefotetan), isoniazid, levodopa, methyldopa, penicillins (especially piperacillin), platinum-based chemo, quinidine, quinine, ribavarin, rifampin High risk in patients with G6PD deficiency: chloroquine, dapsone, methylene blue, nitrofurantoin, primaquine, probenecid, rasburicase, sulfonamides

Taclonex

Betamethasone / Calcipotriene Use: psoriasis

TZDs

Big decrease in A1c vs other diabetes treatments. Cheap MOA: PPAR(gamma) agonist that causes an increase in peripheral insulin sensitivity Drugs: end in "-glitazone" Use: diabetes AE: hepatic failure, edema/peripheral edema (including macular edema), risk of fractures, weight gain, trouble breathing CI: NYHA class III/IV heart failure Monitoring: LFTs and s/sx of HF

Cholestyramine

Bile acid sequestrant that treats hyperlipidemia Brand: Questran DDI: take all other drugs 1-4h before or 4-6h after cholestyramine

Colestipol

Bile acid sequestrant that treats hyperlipidemia DDI: take all other drugs 1-4h before or 4-6h after colestipol

Colesevelam

Bile acid sequestrant that treats hyperlipidemia. Also approved for glycemic control and type 2 DM. Take wc and liquid. Can be used in pregnancy Brand: Welchol CI: bowel obstruction

Cyclessa

Birth control

Ziac

Bisoprolol (beta-blocker) + HCTZ (diuretic)

Ibandronate

Bisphosphonate *Brand*: Boniva *Use*: osteoporosis *Dose*: po: qm (stay upright for at least 60 min) Injection: q3m *AE*: hypocalcemia *CI*: not recommended if CrCl < 30

Risedronate

Bisphosphonate Atelvia: DR version. Requires acidic gut for absorption. H2RAs and PPIs should be avoided completely. Take after breakfast with 4 oz (1/2 cup) plain water Use: osteoporosis Dose (prevention and treatment in postmenopausal women): qd, qw, or qm CI: not recommended if CrCl < 30

Alendronate

Bisphosphonate Brand: Fosamax Use: osteoporosis Dose (treatment): qd or qw CI: not recommended if CrCl < 35

Natural products that can cause liver toxicity

Black cohosh (used for menopausal symptoms), kava (used for stress)

TTP (Thrombotic Thrombocytopenic Purpura)

Blood disorder in which clots form throughout the body Symptoms: small red and purple pinpoint spots on skin. Bruising Drugs associated with TTP: clopidogrel and ticlopidine

Hypoglycemia

Blood glucose < 70 *Symptoms*: sweating, hunger, confusion Severe: seizures, coma, death *Treatment*: goal glucose of 140-180 Sliding scale: strongly discouraged alone "Rule of 15": take 15-20 g of glucose, recheck glucose in 15 min Glucagon: used if pt is unconscious or not conscious enough to treat themselves. Given SC, IV, or IM

Dysentery

Blood in stool, which is often accompanied by systemic symptoms

Diagnostic tests for hypertensive emergency

Blood pressure ≥ 180/120 with acute target organ damage

Diagnostic tests for hypertensive urgency

Blood pressure ≥ 180/120 with no acute target organ damage

BSA

Body Surface Area = square root ( (height [cm] x weight [kg]) / 3600 )

Drugs and conditions that increase LDL and TG

Both: PIs, atypical antipsychotics, steroids, diuretics, and transplant drugs LDL: fibric acids, SGLT2 inhibitors, and TZDs TG: IV lipid emulsions, propofol, and alcohol Conditions: obesity, poor diet, hypothyroidism, nephrotic syndrome, and biliary obstruction

Etomidate

Brand: Amidate Use: agitation/sedation in ICU Monitor: adrenal insufficiency

Lubiprostone

Brand: Amitiza MOA: activate chloride channels Use: OIC (Opioid Induced Constipation), CIC (Chronic Idiopathic Constipation), IBS-c Dose: 24 mcg bid

Belimumab

Brand: Benlysta Use: lupus AE: infections DDI: biologic DMARDs, live vaccines

Blinatumomab

Brand: Blincyto Use: non-Hodgkin's Lymphoma, Hodgkin's Lymphoma, multiple myeloma

Neostigmine methylsulfate

Brand: Bloxiverz Use: OD of rocuronium, vecuronium, or pancuronium

Botulinum toxin type A

Brand: Botox Use: migraine prophylactic for chronic migraines only

Sucralfate

Brand: Carafate MOA: forms a physical barrier Dose: before meals AE: constipation

Varenicline

Brand: Chantix MOA: partial nicotinic receptor agonist Use: smoking cessation Dose: does not need to be tapered off to d/c. Start 1w before quit date. Take after eating with a full glass of water AE: serious neuropsychiatric events (used to be a BBW, not anymore), nausea, insomnia, HA DDI: other drugs that help quit smoking

Colchicine

Brand: Colcrys Use: acute gout attack Dose: start within 36h of onset of symptoms. Wait 12h after treatment dose to continue prophylaxis dose (if on). Treatment dose is 2 0.6 mg tablets followed by 0.6 mg in 1h (do not exceed 1.8 mg in 1h). Dose to be repeated no earlier than 3d AE: increased myopathy risk, DA, nausea, myelosuppression, neuropathy DDI: strong CYP3A4 inhibitor and strong P-gp inhibitor can cause fatal toxicities (renal)

Glatiramer acetate

Brand: Copaxone MOA: immune modulator, activates T-lymphocyte suppressor cells Use: MS (preferred agent during pregnancy) Dose: qd or 3x/w AE: injection site reactions, diaphoresis, dyspnea

Ivabradine

Brand: Corlanor MOA: reduces heart rate Use: CHF (reduction in hospitalization) in patients who are in sinus rhythm and have a resting heart rate ≥70. Target heart rate 50-60 AE: bradycardia, HTN, Afib, and luminous phenomena (phosphenes)

Hydroxocobalamin

Brand: Cyanokit Use: cyanide OD (can be from nitroprusside in high doses/long duration/renal impairment)

Raloxifene

Brand: Evista MOA: SERM (Selective Estrogen Receptor Modulator) that decreases bone resorption Use: osteoporosis (treatment or prevention), breast cancer prophylaxis (but causes vasomotor symptoms) AE: hot flashes, peripheral edema, arthralgia, leg cramps, blood clots (d/c at least 72h prior to and during prolonged immobilization [surgery, prolonged rest]) CI: VTE, pregnancy BBW: increased risk of VTE, increased risk of death due to stroke

Deferasirox

Brand: Exjade Use: iron OD treatment po (usually in patients with sickle cell disease)

Loperamide

Brand: Imodium A-D Use: diarrhea Dose: 4 mg po at first stool, then 2 mg after each diarrhea. Max 16 mg/d when prescribed, 8 mg/d OTC. Self treatment should not last >48h CI: children < 2 yo, dysentery, C. diff, bacterial enterocolitis

Metreleptin

Brand: Myalept Use: leptin deficiency with congenital or acquired generalized lipodystrophy

Tapentadol

Brand: Nucynta MOA: mu-opioid receptor agonist and NE reuptake inhibitor AE: increased seizure risk and increased risk of serotonin syndrome BBW: addiction, abuse, and misuse can lead to OD and death. Respiratory depression which can be fatal. Use with BZD or other CNS depressants, including alcohol can increase risk of death. Accidental ingestion/exposure of even one dose in children can be fatal. Crushing, dissolving, or chewing of long acting products can cause delivery of potentially fatal dose. Life-threatening neonatal opioid withdrawal with prolonged use during pregnancy. Do not consume alcohol, can cause potentially fatal OD

Bismuth subsalicylate

Brand: Pepto-Bismol Use: diarrhea Warnings: caution in patients on ASA therapy or anticoagulants. Children and teens recovering from the flu, chickenpox, or other viral infections should not use this drug due to risk of Reye's syndrome AE: black tongue/stool CI: salicylate allergy, use with other salicylates, ulcer, coagulopathy, black/bloody stool

Dexmedetomidine

Brand: Precedex MOA: alpha-2 agonist Use: sedative for use in intubated and non-intubated patients. Patients are arousable and alert upon stimulation with this agent Administration: duration of infusion should not exceed 24h AE: Ho/HTN, bradycardia

Dornase alfa

Brand: Pulmozyme Use: CF airway clearance Administration: do not mix with any other drug in the nebulizer. Store ampules in the refrigerator. Protect from light

Rituximab

Brand: Rituxan Administration: premedicate with a steroid, APAP, and diphenhydramine *RA*: Non-TNF biologic DMARD MOA: depletes CD20 B cells Use: RA (with MTX) DDI: other biologic DMARDs, live vaccines BBW: infusion-related reactions, HepB (screen high risk groups for HepB and HepC) reactivation, severe skin reactions *Cancer*: pharmacogenomics: must be CD20 positive MOA: binds to antigens expressed on specific hematopoietic cells and causes cell death Uses: non-Hodgkin's lymphoma, Hodgkin's lymphoma, multiple myeloma Toxicity: suppression of specific hematopoietic cells leading to bone marrow suppression which causes an increased risk for reactivation of viral infections (especially HepB)

Pilocarpine

Brand: Salagen Use: oral mucositis due to chemo, Sjogren's Syndrome

Cinacalcet

Brand: Sensipar MOA: calcimimetic that reduces PTH to treat vitamin D deficiency AE: hypercalcemia

Zaleplon

Brand: Sonata Use: sleep

Palivizumab

Brand: Synagis Use: prevention of serious lower respiratory tract diseases causes by RSV (Respiratory Syncytial Virus) for premature infants (born <29w gestation), premature infants (born <32w gestation) with CLD (Chronic Lung Disease) who are <1 yo, <1 yo with certain heart conditions, and children <24m with select medical conditions Dose: recommended during RSV season (late fall, early winter, early spring). IM (anterolateral thigh muscle for neonates and infants) qm. Infants should not receive more than 5 monthly doses

Tolnaftate

Brand: Tinactin

Scopolamine

Brand: Transderm Scop Use: motion sickness, N/V from surgery Administration: placed behind the ear and lasts 3d. Press firmly for 30 seconds when applying. Apply at least 4h before event. Alternate ears Warnings: remove before MRI, can cause pain if any medication gets in the eye AE: dry mouth, CNS effects (drowsiness, dizziness, confusion), stinging of the eyes, pupil dilation, increased intraocular pressure CI: hypersensitivity to belladonna alkaloids, angle closure glaucoma

Voriconazole

Brand: VFEND Use: DOC for aspergillus. Penetrates the CNS so can treat fungal meningitis. Also covers C. glabrata and C. krusei. Exhibits Michaelis-Menten kinetics Dosing: if CrCl <50, po is preferred (IV formulation-SBECD [SulfoButyl Ether beta-CycloDextrin] can accumulate and worsen renal failure) AE: visual changes (optic neuritis), liver damage, increased LFTs, increased SCr, CNS toxicity (hallucinations), and phototoxicity DDI: (enzyme substrate)

Omalizumab

Brand: Xolair MOA: monoclonal antibody that inhibits IgE binding Use: allergic asthma Administer: SC, must be done in a healthcare setting under medical supervision BBW: anaphylaxis

Antithymocyte globulin

Brands: ATGAM and Thymoglobulin MOA: reverses rejection by binding to antigens on T-lymphocytes and interfering with their function Use: induction immunosuppression of transplant AE: infusion-related reactions (premedicate to lessen)

Dihydroergotamine

Brands: D.H.E 45, Migranal MOA: nonselective agonist of serotonin receptors Use: migraines in patients who are CI to triptans or did not benefit from triptans Forms: IM, nasal spray (prime before use), SC AE: CV effects CI: uncontrolled HTN, pregnancy, ischemic heart disease BBW: potent CYP3A4 inhibitors can cause life-threatening peripheral ischemia

Gonadotropins

Brands: Menopur, Follistim, Gonal-F, Urofollitropin, Pregnyl, Novarel, Ovidrel MOA: trigger ovulation by acting similar to endogenous LH, FSH, or hCG (leading to increased ovulation [release of egg/s]) Use: infertility Forms: SC, IM

Mirtazapine

Brands: Remeron, Remeron SolTab Use: depression, insomnia, low appetite AE: sedation, increased appetite, weight gain, QT prolongation BBW: increased risk of suicidal thinking and behavior in children, adolescents, and young adults

Silver sulfadiazine

Brands: Silvadene and SSD Use: skin burns to reduce infection risk and promote healing

Tramadol

Brands: Ultram and Ultracet (+ APAP) MOA: mu-opioid receptor agonist, NE reuptake inhibitor, inhibits reuptake of serotonin AE: increased seizure risk, increased risk of serotonin syndrome when used with inhibitors of CYP2D6 or 3A4 DDI: use with CYP2D6 inhibitors can have variable effects (tramadol requires conversion to active metabolite by 2D6) CI: <12 yo and <18 yo for tonsillectomy or adenoidectomy BBW: addiction, abuse, and misuse can lead to OD and death. Respiratory depression which can be fatal. Use with BZD or other CNS depressants, including alcohol can increase risk of death. Accidental ingestion/exposure of even one dose in children can be fatal. Crushing, dissolving, or chewing of long acting products can cause delivery of potentially fatal dose. Life-threatening neonatal opioid withdrawal with prolonged use during pregnancy

Capsaicin

Brands: Zostrix and Zostrix HP Use: topical adjuvant for pain Forms: 0.025% and 0.075%

Iron recommendations for 4-6m old

Breastfed babies need 1 mg/kg/d until able to consume iron rich food

Resources for pregnancy and lactation

Briggs', CDC, Hale's, and LactMed

Drugs that can discolor skin and secretions

Brown: levodopa, entacapone, methyldopa Brown/yellow: nitrofurantoin Orange/yellow: sulfasalazine Yellow-green: propofol Red-orange: phenazopyridine and rifampin Red: anthracyclines Blue: mitoxantrone and methylene blue Blue-gray: amiodarone

Gout

Buildup of uric acid in joints, mainly metatarsophalangeal joint (big toe) *Risk factors*: organ meats, high-fructose corn syrup, red meats, and alcohol consumption *Treatment*: goal: UA < 6 Acute: NSAID, systemic steroid, or colchicine, intra-articular steroid injection (can be helpful if gout is only in 1 or 2 joints) Chronic: XOIs (Xanthine Oxidase Inhibitors- allopurinol, febuxostat. DOC). Can initially cause acute gout flare so take with colchicine or NSAID. Add on lesinurad (Zurampic) or probenecid if XOI not working or replace XOI with pegloticase (Krystexxa)

Psyllium

Bulk-forming laxative Brand: Metamucil

Suboxone

Buprenorphine/naloxone MOA: buprenorphine suppresses withdrawal symptoms, naloxone prevents misuse Use: alternative to methadone for opioid dependence

Lacosamide

C5 Brand: Vimpat Use: epilepsy Warnings: prolongs PR interval and increases risk of arrhythmias

CBC with differential

CBC with the types of neutrophils analyzed

Maraviroc

CCR5 antagonist used for HIV. Before starting, patients must undergo tropism test (drug will only work in pts with CCR5-tropic disease; pts must be negative for CXCR4- or dual/mixed-tropic disease) MOA: inhibits binding to the CCR5 co-receptor, preventing HIV from entering cell BBW: hepatotoxicity

What labs are used to assess HIV and monitor treatment

CD4, T lymphocyte count, and HIV RNA Concentration (Viral Load)

Ibalizumab-uiyk

CD4-directed post-attachment HIV-1 inhibitor used for HIV. IV form only

Resources for travel medicine

CDC (Yellow Book and Travelers' Health)

Resources for immunizations

CDC Advisory Committee on Immunization Practices (ACIP), MMWR (Morbidity and Mortality Weekly Report), CDC Pink Book, and Immunization Action Coalition

Pink Book

CDC. Information on epidemiology and vaccine preventable diseases

Yellow Book

CDC. Information on the health risks of international travel, required vaccines, and prophylaxis medications

Resources for "regulatory" and business development

CDER (Center for Drug Evaluation and Research) and Pink Sheet

Tezacaftor

CFTR modulator MOA: increases amount of CFTR Use: CF for homozygous F508del mutation Administration: take with high fat containing food

Lumacaftor

CFTR modulator MOA: increases amount of CFTR Use: CF for homozygous F508del mutation only Administration: take with high fat containing food

Ivacaftor

CFTR modulator. Not approve for homozygous F508del mutation MOA: increases time CFTR channels remain open Use: CF Administration: take with high fat containing food

CHADS2-VASc score

CHF, HTN, Age ≥75 yo (2), DM, Stroke or TIA hx (2), Vascular disease, Age 65-74, Sex female 0: no anticoagulation 1: no anticoagulation, po anticoagulation, or ASA ≥2: warfarin, dabigatran, rivaroxaban, or apixaban

COPD vs asthma

COPD: age of onset usually > 40 yo, smoking history usually > 10y, sputum production, allergies are not common, symptoms are persistent, disease process is progressive, exacerbations are common, first line treatment is bronchodilators Asthma: age of onset usually < 40 yo, smoking history not common, infrequent sputum production, allergies are common, symptoms are variable, disease process is stable, exacerbations are common, first line treatment is corticosteroids

Diclofenac

COX-2 selective NSAID *Brand*: Voltaren Flector: patch. Only for topical pain *Dose*: Flector: bid Gel: no more than 32g/d *AE*: GI risk (misoprostol is used to replace gut-protective PG to decrease risk) *BBW*: avoid in women of childbearing potential

Celecoxib

COX-2 selective NSAID (most selective of NSAIDs) CI: sulfonamide allergy

NSAID induced ulcers

COX-2 selective NSAIDs decrease GI risk but increase CV risk (meloxicam, nabumetone, diclofenac, and etodolac) Cause: inhibition of prostaglandin synthesis (by inhibiting COX-1) Treatment: PPI x8w

Diagnostic tests for CVA

CT and MRI

Diagnostic tests for lung cancer

CT chest

Lung cancer screening

CT scan of chest if patient has 30-pack year smoking history

Ipilimumab

CTLA-4 inhibitor Brand: Yervoy MOA: targets immune system. Interferes with the body's ability to "down-regulate" the immune system which results in increased immune recognition of tumor antigens Use: non-small cell lung cancer and melanoma Toxicity: immune system becomes overactive which can can cause life-threatening immune-mediated reactions (colitis, hepatotoxicity, thyroid dysfunction, myocarditis)

Causes of a gap acidosis

CUTE DIMPLES Cyanide, Uremia, Toluene, Ethanol, Diabetic ketoacidosis, Isoniazid, Methanol, Propylene glycol, Lactic acidosis, Ethylene glycol, Salicylates. Considered high if >12

Tacrolimus

Calcineurin inhibitor *Protopic*: topical for eczema CI: <2 yo *Prograf*: maintenance immunosuppression for transplant Forms: po and IV (must be administered in a non-PVC container) Dose: q12h on an empty stomach AE: HTN, nephrotoxicity (using with cyclosporine will increase this risk by a lot), hyperglycemia, neurotoxicity, hyperkalemia, hyperlipidemia, QT prolongation, increased UA, photosensitivity DDI: numerous (CYP3A4 and P-gp substrate- inducers of either will decrease tacrolimus concentration, inhibitors will increase). Avoid grapefruit juice and St. John's wort BBW: increased susceptibility to infection, possible development of lymphoma Monitor: trough levels, serum electrolytes, renal function, LFTs, bp, blood glucose, and lipid profile

Maalox Advanced Maximum Strength

Calcium carbonate + simethicone Warning: can accumulate in patients with renal disease

Lanthanum

Calcium free, aluminum free phosphate binder Brand: Fosrenol MOA: prevents dietary phosphate from being absorbed Form: chewable tablet Dose: given a daily dose which should be divided and chewed with meals

Hydrocortisone

Can be given intrathecally but must be preservative-free *Topical*: amount is estimated via "finger-tip" unit. Low potency OTC availability: 0.5 and 1% Potency: ointment > cream > lotion > solution > gel > spray *Systemic steroid*: Brand: Solu-Cortef

How suppositories are compounded

Can use an oil-soluble base (cocoa butter [theobroma oil] or hydrogenated vegetable oils) or a water-soluble base (PEG [Polybase] or gelatin). The drug will displace part of the base; to calculate the amount of base displaced, find density factor (Weight of med per suppository) / (weight of suppository blank - weight of medicated suppository + weight of medication per suppository). If a lubricant is used, it must be the opposite of the suppository base (oil-soluble/water-soluble) *Methods*: hand molding Fusion molding: base is gently heated, ingredients are added, and mixture is poured into room temperature molds to harden Compression molding

Dronabinol

Cannabinoid Brand: Marinol Use: breakthrough CINV Administration: refrigerate

Ceftriaxone DDI

Cannot be mixed with calcium-containing solutions

What causes hyponatremia

Carbamazepine, oxcarbazepine, SSRIs, diuretics

DOC for acinetobacter

Carbapenems (Excet ertapenem)

DOC for ESBLs

Carbapenems, ceftolozane/tazobactam, ceftazidime/avibactam

Diagnostic tests for ischemic heart disease

Cardiac stress test

Pharyngitis

Cause: S. pyogenes Treatment: penicillin and amoxicillin

Acne

Cause: androgen (boys > girls) and presence of P. acnes & sebum present in oil (sebaceous) glands *Treatments*: Mild: first line is benzoyl peroxide, topical retinoid, or topical combination therapy. Second line includes adding a topical retinoid or BPO, switch to another retinoid, or topical dapsone Moderate: topical combination therapy or oral antibiotic + benzoyl peroxide + topical retinoid +/- topical antibiotic. Second line includes other combination therapy, change oral antibiotic, add combined oral contraceptives or spironolactone (females), or oral isotretinoin Severe: first line is topical combination therapy + oral antibiotic or oral isotretinoin. Second line includes change oral antibiotic, add combined oral contraceptive or spironolactone (females), or oral isotretinoin Combination therapy: benzoyl peroxide + topical antibiotic, benzoyl peroxide + retinoid, or benzoyl peroxide + retinoid + topical antibiotic

Iron deficiency anemia

Cause: one cause is increased iron requirements from the body (pregnancy, lactation) Symptoms: glossitis, koilonychias, or pica Diagnosis: low Hgb, microcytosis (MCV < 80), decreased RBC production (low reticulocyte count), low serum iron, low ferritin, low TSAT Treatment: 100-200 mg elemental iron/d Po drug options (% of elemental iron in each): *(G*od *S*aid *D*ont *F*orget to be *PC*) ferrous gluconate (12), ferrous sulfate (20), ferrous sulfate, dried (30), ferrous fumurate (33), carbonyl iron (100), polysaccharide iron complex (100) Goals: increase serum Hgb by 1 q2-3w, continue treatment x3-6m after anemia has resolved

Cholera

Caused by Vibrio cholerae. Most common symptom is "rice-water stools." Vaxchora is a po live-attenuated vaccine recommended for those traveling to a region with active cholera transmission

Typhoid fever

Caused by salmonella typhi. Spread through food or water contaminated by feces of someone with acute infection or a chronic asymptomatic infection

Direct Coombs Test

Causes excessive destruction of RBCs Comes back positive due to penicillins, cephalosporins, isoniazid, levodopa, methyldopa, nitrofurantoin, quinidine, quinine, rifampin, and sulfonamides in the blood

Alopecia

Causes: commonly with chemo, less commonly with heparin, valproic acid, and spironolactone. Zinc and vitamin D deficiency

Herpes Virus

Caution in patients with renal impairment, the elderly and those receiving nephrotoxic agents *Types*: HSV-1: associated with oropharyngeal disease HSV-2: associated with genital disease VZV: Varicella Zoster Virus is associated with chickenpox. Stays dormant in body once one is infected and can later present as shingles (cluster of fluid-filled blisters) *Treatments*: acyclovir (Zovirax): comes as a cream for cold sores. Dose is based on IBW, even in obese patients. IV form can cause viral encephalitis Valacyclovir: prodrug of acyclovir Famciclovir: prodrug of penciclovir Shingles: x1w. Antiviral therapy should be started within 72h of rash. Treat pain with topical agents (Lidoderm patch), neuropathic pain agents (antiepileptic drugs, antidepressants), and NSAIDs or opioids. Treated with acyclovir, valacyclovir, or famciclovir

Guanfacine ER

Central alpha-2a agonist non-stimulant Brand: Intuniv Dose: start 1 mg qd and increase 1 mg qw

Clonidine

Centrally acting alpha-2 agonist. Patch should be applied qw and removed before MRI. Do not stop suddenly Brand: Catapres, Kapvay (ADHD), Catapres-TTS (patch) Dose: (ADHD) start 0.1 mg qhs, increase by 0.1 mg qw Use: can be added to opioid in epidural pain infusion pumps for patients with cancer pain, ADHD (ER)

Methyldopa

Centrally-acting alpha 2 agonist. DOC in pregnancy. Available as an injection AE: risk for hemolytic anemia, DILE (Drug-Induced Lupus Erythematosus) CI: MAOI

Mild cellulitis treatment

Cephalexin

Thiotepa

Chemo Form: can be given intrathecally but must be preservative-free

Cytarabine

Chemo Form: can be given intrathecally but must be preservative-free AE: HF syndrome

Diagnostic tests for pneumonia

Chest X-ray

Thiazide and thiazide-type diuretics

Chlorothiazide is only one available as injectionf. Weaker than loop diuretics MOA: inhibit Na-Cl pump in the distal convoluted tubules causing increased excretion of sodium, chloride, water, & potassium and increased calcium resorption (long term use can have a positive effect on bones) AE: hypokalemia, hypomagnesemia, hyponatremia, hypercalcemia, hyperuricemia, elevated lipids, hyperglycemia CI: hypersensitivity to sulfonamide-like drugs and CrCl < 30 (not effective at this CrCl) DDI: avoid NSAIDs. Can decrease lithium renal clearance, increasing risk of lithium toxicity Monitoring: electrolytes and renal function

Migraine

Chronic headache that causes significant pain for hours or days *Causes*: serotonin *Triggers*: bright or flickering light, stress, too little sleep, alcohol, changes in hormone levels *Symptoms*: N/V, sensitivity to light & sound, some are accompanied with sensory warning symptoms or signs (auras) *Diagnosis*: at least 5 attacks fitting the following criteria- headaches last 4-72h, unilateral location, pulsating, and one of the following (N/V, photophobia, phonophobia) *Treatments*: Menstrual-Associated Migraine: treat with oral contraceptives or estradiol patch. If associated with aura, patient is at higher risk for stroke, do not use estrogen containing contraceptive Natural products: caffeine, butterbur, CoQ10, feverfew, Mg, peppermint, riboflavin Acute: Limit use to 2-3x/w. APAP, Advil, Excedrin (ASA, APAP, caffeine), Aleve, serotonin receptor agonists (triptans). Opioids, butalbital-containing products, tramadol, and tapentadol are not recommended Prophylactic: given if using acute treatment ≥ 2 d/w or ≥ 3x/m. Or given if it significantly impairs QOL. Beta blockers, topiramate, valproic acid, amitriptyline, venlafaxine

Dronedarone

Class III antiarrhythmic Brand: Multaq MOA: blocks K channels primarily. Also, blocks alpha & beta adrenergic receptors and Ca & Na channels AE: hepatic failure, pulmonary disease (including pulmonary fibrosis), QT prolongation DDI: avoid use with strong inhibitors and inducers of CYP3A4 and drugs that prolong QT interval BBW: increased risk of death, stroke, and HF in pts with decompensated HF or permanent Afib

Sotalol

Class III antiarrhythmic and non-selective beta blocker Brand: Betapace MOA: blocks K channels and is a beta blocker Dose: CrCl < 60 then decrease frequency

Amiodarone

Class III antiarrhythmic. Has a half life of 40-60d. Contains iodine *Brands*: Pacerone and Nexterone *MOA*: blocks K channels primarily. Also, blocks alpha & beta adrenergic receptors and Ca & Na channels *Use*: antiarrhythmic (DOC in patients with HF) and HF *Administration*: must be administered in a non-PVC (PolyVinyl Chloride) container such as polyolefin or glass. Premixed Nexterone comes in GALAXY containers (non-PVC and non-DEHP). Use a 0.22 micron filter. Incompatible with heparin (flush with saline) *AE*: hyper- & hypothyroidism (amiodarone partially inhibits conversion of T4 to T3), optic neuropathy, photosensitivity (slate-blue skin discoloration), HoTN, bradycardia, corneal microdeposits, dizziness, ataxia, N/V, constipation, tremor. Slow infusion rate or d/c if HoTN or bradycardia occurs *DDI*: increases level of these drugs: inhibitor of CYP2C9, 2D6, 3A4, and P-gp Digoxin: can decrease hr, decrease digoxin level by 50% Warfarin: decrease warfarin dose by 30-50% Simvastatin: do not exceed 20 mg/d Lovastatin: do not exceed 40 mg/d Beta-blockers: can decrease hr Sofosbuvir: can decrease hr Grapefruit *BBW*: pulmonary toxicity and hepatotoxicity *Monitoring*: ECG, bp, hr, electrolytes, pulmonary function, LFTs, and thyroid

Ibutilide

Class III antiarrhythmic. Hypokalemia and hypomagnesemia should be controlled prior to therapy and throughout treatment. IV only

Disopyramide

Class Ia antiarrhythmic AE: anticholinergic effects

Quinidine

Class Ia antiarrhythmic. Take with food AE: DILE, hemolysis risk (higher risk in patients with G6PD deficiency), can cause positive Coombs test, DA, stomach cramping, cinchonism, tinnitus, hearing loss, blurred vision, HA, delirium

Procainamide

Class Ia antiarrhythmic. The active metabolite (NAPA [N-Acetyl ProcainAmide]) is renally cleared BBW: agranulocytosis and ANA (AntiNuclear Antibody) which can result in DILE

Propafenone

Class Ic antiarrhythmic AE: metallic taste in mouth CI: HF and MI

Flecainide

Class Ic antiarrhythmic. Shown to *increase* mortality rates (no longer on the market) CI: HF and MI

Diagnostic tests for diabetes

Classic symptoms of diabetes (polydipsia, polyuria, polyphagia)

Vaughan Williams classification

Classification for antiarrhythmic drugs based on their dominant electrophysical effect (*D*ouble *Q*uarter *P*ounder, *L*ettuce, *M*ayo, *F*ries *P*lease *B*ecause *D*ieting *D*uring *S*tress *I*s *A*lways *V*ery *D*ifficult) *I*: has negative inotrope potential. Worsen heart failure MOA: Na channel blocker Ia: disopyramide, quinidine, procainamide Ib: lidocaine, mexiletine Ic: flecainide, propafenone *II*: beta blockers. Slows the heart rate *III*: MOA: K-channel blocker Drugs: dronedarone, dofetilide, sotalol, ibutilide, amiodarone *IV*: verapamil, diltiazem. Should not be used in cases of HFrEF

Treatment to reduce inflammation of the eye

Cold compress + either NSAID eye drop: if mild. Ketorolac (Acular) Steroid drop: if severe. Prednisolone (Pred Forte, Omnipred, Pred Mild)

Extravasation treatment

Cold compresses. If due to vinca alkaloid or etoposide, use warm compresses

Glidants used in compounding

Colloidal silica and magnesium stearate

Diagnostic tests for colon cancer

Colonoscopy and sigmoidoscopy

CMEA

Combat Methamphetamine Epidemic Act. Applies to any product containing pseudoephedrine, phenylpropanolamine, and epehedrine. Allowed to purchase 3.6 g/d and 9 g/30d

Meta-analysis

Combines results from multiple studies to develop a conclusion that has better statistical significance than can be gathered from one of the individual studies alone

Levonorgestrel

Comes as one 1.5 mg tablet. Highly effective within first 72h. OTC with no age restrictions. If a pregnant woman takes it, everything will be fine MOA: delays ovulation and thickens cervical mucus Use: emergency contraceptive AE: nausea (can take an anti-emetic 1h before use), vomiting (if pt vomits within 2h of dose, consider retaking a dose)

Nystatin

Comes as suspension (swish in mouth and retain for as long as possible [several minutes] before swallowing), tablet, and topical forms Dose: 4000 U/d (suspension) AE: well-tolerated, mild GI effects

Clotrimazole forms

Comes as troches, lozenges, and topical/vaginal forms (Mycelex) Brand: Lotrimin

Mild to moderate purulent abscess

Commonly caused by CA-MRSA Treatment: Bactrim or doxycycline

Preservatives used in compounding

Commonly have a "benz-" or "cetyl-" in the name. Chlorhexidine, EDTA, sodium benzoate, benzoic acid, benzalkonium chloride, thimerosal

CAP

Community Acquired PNA. "Walking pneumonia" is when symptoms are mild *Causes*: S. pneumoniae, H. influenzae, M. pneumoniae *Diagnosis*: chest X-ray is gold standard- infiltrates, opacities, or consolidations indicate PNA *Treatments*: healthy otherwise: DOC macrolide. Doxycycline Risk for drug resistant S. pneumoniae, antibiotic use within previous 3m, comorbidities, or immunocompromised: IV. DOC beta-lactam (ceftriaxone or cefotaxime preferred) + macrolide (azithromycin preferred) / doxycycline. Respiratory quinolone monotherapy Risk for pseudomonas: Zosyn / cefepime / meropenem + levofloxacin / aminoglycoside Concern for MRSA: + vanco / linezolid

Cost-Utility Analysis

Compares QOL using QALYs (Quality-Adjusted Life Years) and DALYs (Disability-Adjusted Life Years)

Moderate compouding

Compounding that requires calculations or procedures to determine quantity of an ingredient one must use

Complex compounding

Compounding that requires special training, environment/facilities, or procedures

CPOE

Computerized Prescriber Order Entry. Allows for electronic prescribing. Combination with CDS (Clinical Decision Support) tools benefit a lot because it can notify the prescriber if something is inappropriate

Dose Optimization

Concentration-dependent killing: aminoglycosides. Dosed less frequently at higher doses Time-dependent killing: beta-lactams. Dosed more frequently to maximize time above MIC

MERP (Medication Errors Reporting Program)

Confidential national voluntary reporting program that provides expert analysis of the system causes of medication errors and disseminates recommendations for prevention

Phase II metabolism uses mostly what kind of reactions

Conjugation reactions

MedGuide

Considered part of the drug labeling. Required with every fill

VTE

Consists of DVT and PE. CI for patients with VTE history to be on estrogen-containing medications and selective estrogen receptor modulators *Risk factors*: surgery, major trauma, immobility, cancer, previous VTE, pregnancy, estrogen-containing meds, selective estrogen receptor modulators, erythropoiesis-stimulating agents, obesity, antithrombin deficiency, Factor V Leiden, antiphospholipid syndrome, protein C/S deficiency, acute mental illness *Symptoms*: (ACHES) Abdominal pain that is severe, Chest pain, HA, Eye problems, Swelling or sudden leg pain *Prophylaxis*: never ASA or anticoagulants. IPC (Intermittent Pneumatic Compression) devices or GCS (Graduated Compression Stockings) recommended in patients at high bleeding risk Long distance travelers: frequent ambulation, calf muscle exercises, and GCS *Diagnosis*: pain in lower leg and unilateral lower extremity swelling. With ultrasound *Treatment*: x3m. Use CHADS2VASC score to choose therapy Pregnant: LMWH > UFH. Warfarin CI. Po factor Xa inhibitors and direct thrombin inhibitors are not adequately studied Cancer patients: LMWH DOC

Zero order elimination

Constant amount of drug (mg) is removed per unit of time. Half life does not always remain the same

First order elimination

Constant percent of drug is removed per unit of time. Linear relationship between dose and serum level

IV immunoglobulin

Contains immunoglobulin (IgG). It is extracted from blood donors Brands: Carimune NF, Flebogamma DIF, Gammagard, Gamunex-C, Octagam, Privigen MOA: antibodies recognize antigens on foreign targets (bacteria) Use: immunodeficiency conditions, MS, myasthenia gravis, Guillain-Barre Dose: use IBW. Use slower infusion rate in renal and CV disease AE: impaired response to vaccinations, HA, nausea, DA, injection site reaction, infusion reaction (facial flushing, chest tightness, fever, chills, HoTN; slow/stop infusion if occurs) BBW: acute renal dysfunction (more likely with products stabilized with sucrose), thrombosis

Lotion

Contains the most water out of all topical products

Poison ivy, oak, sumac

Contains toxin uroshiol *Treatment*: aluminum acetate: astringent Topical or po steroids: po for severe raash

CNS

Controls functions of the rest of the body through the two main systems in the peripheral nervous system: *Somatic nervous system*: controls muscle movement by sending neurons to release ACh to act on nicotinic receptors *Autonomic nervous system*: parasympathetic nervous system: rest and digest Sympathetic nervous system: fight or flight. Causes increased bp, hr, and glucose production. Releases Epi and NE to act on alpha-1, beta-1, and beta-2

Calcium lab value

Corrected calcium should be calculated if albumin is low. Can be increased due to vitamin D and thiazide diuretics. Can be decreased due to long term heparin, loop diuretics, bisphosphonates, and cinacalcet

Dextromethorphan

Cough suppressant AE: serotonin syndrome CI: should not be used within 14d of MAOI use

Flagyl and Flagyl-related drugs

Covers: anaerobes and protozoal infections. IV:po ratio is 1:1 *Common uses*: bacterial vaginosis and trichomoniasis. Used in combo regimens for intra-abdominal infections *Flagyl and tinidazole*: AE: metallic taste, Flagyl can increase INR CI: 1st trimester pregnancy and use of alcohol or propylene-glycol containing products during treatment or within 3d of treatment discontinuation (disulfiram-like reaction [abdominal cramping, N/V, HA, flushing]) *Secnidazole*: single dose AE: vulvovaginal candidiasis

Permethrin

Cream *Brand*: Elimite: treats scabies Nix: treats lice

Ivermectin

Cream *Brands*: Stromectol: po Sklice: topical

Imiquimod

Cream used for genital warts *Brands*: Aldara: also approved for superficial basal cell carcinoma and actinic keratosis Zyclara

CPK lab

Creatine Phosphokinase. Used to assess muscle inflammation or more serious muscle damage. Increases due to daptomycin, statins, tenofovir, raltegravir, and dolutegravir

Diagnostic tests for myopathy

Creatinine PhosphoKinase

Sinemet

D/c drug if pt has a positive Coombs test due to hemolysis risk *Other brands*: Sinemet CR: can be cut in half Rytary: take whole or sprinkle on applesauce Parcopa: ODT *MOA*: Levodopa: prodrug of dopamine, most effective agent. COMT (Catechol-O-MethylTransferase) inhibitors increase effect of levodopa by blocking its metabolism Carbidopa: prevents peripheral metabolism of levodopa by inhibiting dopa decarboxylase enzyme (70-100 mg/d required to work) *Use*: Parkinsons Disease *Dose*: titrate cautiously *AE*: nausea, dizziness, orthostasis, dyskinesias, brown/black/dark urine, unusual sexual urges, priapism Long-term: fluctuations in response and dyskinesias *DDIs*: CI with non-selective MAOI

Simeprevir

DAA NS3/4A PI used in HCV. Monotherapy not effective

Harvoni

DAA. Ledipasvir/sofosbuvir

Daclatasvir

DAA. NS5A replication complex inhibitor used in HCV. Should be taken in combination with sofosbuvir, monotherapy not effective

Sofosbuvir

DAA. NS5B polymerase inhibitor used in HCV. not effective when taken alone and should be dispensed in original container Brand: Sovaldi DDI: amiodarone-asymptomatic bradycardia. Antacids, H2RAs, and PPIs-decrease

Zepatier

DAA. Treats HCV AE: risk of increased LFTs DDI: CYP3A4 inducers

Technivie

DAA. Treats HCV DDI: *(CELS)* strong inducers of CYP3A4, ethinyl estradiol, lovastatin, and simvastatin

Dasabuvir

DAA. Treats HCV. NS5B polymerase inhibitor DDI: strong inducers or inhibitors of CYP2C8

Viekira Pak

DAA. Used to treat HCV. 2 paritaprevir/ritonavir/ombitasvir tablets every morning and 1 dasabuvir tablet. Viekira XR is 3 tablets once daily with a meal AE: hepatic decompensation and hepatic failure in patients with cirrhosis and risk of increased LFTs (female patients taking ethinyl estradiol products are at an even more increased risk) DDI: CYP3A4 inducers, CYP2C8 inhibitors, ethinyl estradiol (increased risk of hepatotoxicity), lovastatin, simvastatin

Diagnostic tests for osteoporosis

DEXA, T-score ≤ -2.5, osteopenia T-score of -1 to -2.4

Nifedipine

DHP CCB *Forms*: IR: do not use for chronic HTN or acute BP reduction. Brand is Procardia ER: brands are Adalat CC and Procardia XL. DOC in pregnancy IV: brand is Cardene IV *AE*: peripheral edema and gingival hyperplasia

Bisphosphonates

DOC for treatment or prevention of osteoporosis MOA: inhibit osteoclast activity and bone resorption Use: osteoporosis Forms: qw, qm po if adherence is difficult. Quarterly/yearly parenteral options if there are GI effects Administration: take first thing in the morning, before eating or drinking anything. Stay upright for 30 min after taking. Drink 6-8 oz plain water Treatment duration: x3-5y AE: esophagitis, musculoskeletal symptoms, hypocalcemia, ONJ (dental work should be done prior to treatment), atypical femur fractures, esophageal ulcers, erosions, dyspepsia, N/V, dysphagia, heartburn CI: inability to stand or sit upright for at least 30 min, hypocalcemia, severe renal impairment DDI: separate calcium, antacids, iron, and Mg supplements by at least 2h *Injectable bisphosphonates*: preferred if esophagitis is present due to risk of esophageal cancer AE: renal impairment CI: hypocalcemia

Linagliptin

DPP-4 inhibitor Brand: Tradjenta Dose: no renal dosing needed Use: diabetes

Diagnostic tests for psychiatric diseases

DSM-5

Resources for psychiatry

DSM-5

Idarucizumab

Dabigatran (direct thrombin inhibitors) antidote Brand: Praxbind

Glaucoma

Damage to optic nerve and loss of visual field (measured by visual field test). IOP (IntraOcular Pressure) is when it is above the normal range, goal of treatment is to reduce IOP *Types*: open-angle: most common Closed-angle: sharp, sudden increase in IOP due to a blockage. Medical emergency requiring surgery *Treatment*: PG (ProstaGlandin) analogs: most effective. Qd Beta-blockers: preferable if increased pressure is in one eye only. All are nonselective except betaxolol. AE are burning and stinging Cholinergics: increase aqueous outflow. AE include pupil constriction Carbonic anhydrase inhibitors: reduce aqueous humor production. Careful in patients with sulfonamide allergy Alpha-2 agonists: increase aqueous outflow and reduce aqueous humor production Rho Kinase inhibitors: increase aqueous outflow

Continuous data

Data with value that continuously increases (or decreases) by the same amount (e.g. 120 HR BPM is 2x as much as 60 HR BPM) Interval data: no meaningful zero (zero does not equal none, e.g. 0°C does not mean no temperature) Ratio data: zero means none

Ear wax blockage treatment

Debrox (carbamide peroxide) or triethanolamine

Anemia

Decrease in hemoglobin and hematocrit *Causes*: nutritional deficiencies (iron, folate, Vitamin B12), CKD, malignancy *Symptoms*: all: weakness, fatigue, SOB, exercise intolerance, HA, dizziness, anorexia, and/or pallor *Diagnosis*: reticulocyte counts can measure RBC production which is usually impaired in anemia Mhyicrocytic anemia: can be looked into more with iron labs. Low Hgb, low MCV (<80), low ferritin, high TIBC Macrocytic anemia: can be looked into more with Vitamin B12 and folate levels. Low Hgb, high MCV (>100) Normocytic anemia: low Hgb, normal MCV (80-100)

Diagnostic tests for hyperthyroidism

Decreased Thyroid Stimulating Hormone and increased Free T4

Sulfonylureas

Decreases A1c by 2% (big decrease in A1c vs other diabetes treatments). Cheap. Older, first generation sulfonylureas should not be used MOA: secretagogue (stimulates insulin secretion to decrease postprandial glucose) Drugs: start with "g-" and end in "-ide" Dose: wc qam (except glipizide IR [30 min before a meal]), hold doses if pt is NPO AE: hypoglycemia (hunger, confusion, sweating, seizures), weight gain, nausea CI: sulfa allergy

Crohn's disease

Deep, transmural inflammation that can affect any part of the GI tract with a non-continuous pattern *Symptoms*: chronic diarrhea *Treatments*: mild and limited to ileum and proximal colon: po budesonide ≤3m, then d/c treatment or change to thiopurine or MTX Moderate-severe: anti-TNF agents (adalimumab [Humira], infliximab [Remicade], certolizumab [Cimzia]), thiopurine (azathioprine, mercaptopurine), MTX, IL receptor antagonist (ustekinumab [Stelara]) Refractory to above treatments and/or steroid dependent: integrin receptor antagonists (vedolizumab, natalizumab)

Human chorionic gonadotropin

Detected in the urine during pregnancy. Best to test first thing in the morning. Important in pregnancy and ovulation

Direct Coombs test

Detects antibodies that are stuck to the surface of RBCs

ISO air quality

Determined by number of particles per volume of air of a specified particle size. The lower the count, the cleaner the air PEC (Primary Engineering Control): must be at least ISO 5 Buffer area: ISO 7; 30 ACPH Ante area: ISO 8 if opening into positive pressure buffer area, ISO 7 if opening into negative pressure buffer area; 30 ACPH

FRAX tool

Determines risk of osteoporotic fracture in next 10y

Who develops and approves REMS programs?

Developed by manufacturer, approved by FDA

Dextrose

Dextrose-containing products are used when water is needed intracellularly because it contains "free water"

DEHP

DiEthylHexyl Phthalate. Used as a plasticizer in plastic bags to make them more flexible. It can leach from the bag and cause solutions to be toxic

Resources for therapeutics and disease management

DiPiro's, Handbook of Nonprescription Drugs, Koda-Kimble's, The Merck Manual, and UpToDate

Most common causes of renal disease

Diabetes and HTN

Prediabetes

Diagnosis: FPG (Fasting Plasma Glucose) 100-125 or 2h plasma glucose of 140-199 after a 75 g OGTT (Oral Glucose Tolerance Test) or A1c 5.7-6.4% Treatment: metformin (especially helpful in patients with a BMI ≥ 35, < 60 yo, and women with history of gestational diabetes) Monitoring: annual monitoring for development of diabetes

Macrocytic anemia

Diagnosis: low Hgb and high MCV Cause: Vitamin B12 and/or folate deficiency. Crohn's disease, celiac disease, long term use (>2y) of metformin, H2RAs, or PPIs Treatment: Vitamin B12 injection is first line

Arthrotec

Diclofenac + misoprostol. Used to reduce the risk of NSAID-induced ulcers

Diagnostic tests for prostate cancer

Digital Rectal Exam and Prostate Specific Antigen

Main ingredients in a tablet

Diluents, binders, disintegrants, and lubricants

Lomotil

Diphenoxylate + atropine. C5 Use: diarrhea Dose: max 20 mg/d CI: < 6 yo cannot use tablets (not recommended in < 13 yo)

DAAs

Direct Acting Antivirals. Should all be taken with food except Zepatier (elbasvir/grazoprevir - doesn't matter) *Use*: HCV. 2-3 Direct Acting Antivirals with different mechanisms for 12w; ritonavir is sometimes used to boost levels of PIs used with it, not directly active against HCV *Drugs by mechanism*: NS3/4A protease inhibitors (-previrs), NS5A replication complex inhibitors (-asvirs), NS5B polymerase inhibitors (-buvirs) *AE*: risk of reactivating HBV (test for HBV first) *DDIs*: strong inducers of CYP3A4 (carbamazepine, oxcarbazepine, phenobarbital, phenytoin, rifampin, rifabutin, and St John's Wort) Harvoni, Epclusa, Vosevi-acid suppressive therapy (decreases concentrations of ledipasvir and velpatasvir)

Aliskiren

Direct renin inhibitor for HTN AE: angioedema, hyperkalemia, renal impairment, bilateral renal artery stenosis CI: ACEI or ARB in patients with diabetes BBW: teratogenic

Dabigatran

Direct thrombin (factor IIa) inhibitor *Brand*: Pradaxa *Dose*: missed dose, take as soon as remembered unless within 6h of next dose DVT/PE treatment and reduction in the risk of recurrence of DVT/PE: 150 mg po bid, start after 5-10d of parenteral anticoagulation. Requires renal dose adjustment *Administration*: dispense in original container and discard 4m after opening. Swallow capsules whole with full glass of water. Do not administer by NG tube *Use*: anticoagulant and VTE (preferred [along with po Xa inhibitors] vs warfarin in patients without cancer for the first 3m) *AE*: dyspepsia, gastritis-like symptoms, bleeding (mostly GI) *CI*: mechanical prosthetic heart valve *BBW*: patients receiving neuraxial anesthesia (epidural, spinal) are at increased risk of hematomas and subsequent paralysis *Monitoring*: no efficacy monitoring required

Hydralazine

Direct vasodilator. Available as an injection Bidil: hydralazine + isosorbide nitrate. CI with PDE5 inhibitors MOA: arterial vasodilation, decreasing afterload Use: HTN and CHF AE: DILE (Drug-Induced Lupus Erythematosus), HA, hypotension, reflex tachycardia, and palpitations

Antibiotics that interfere with positive Coombs test

Discontinue drug- indicates drug-related hemolysis. Beta-lactamase inhibitors, cephalosporins, isoniazid, nitrofurantoin, penicillins, quinine, rifampin, and sulfamethoxazole

Garbing instructions

Done in the ante area. Eye/face protection must be worn when there is a risk for HD spills or splashes when working outside of a C-PEC 1. Shoe covers, head and facial hair covers, face masks (required for sterile compounding; N95 respirator mask is adequate for airborne particles. Elastomeric half-mask with a multi-gas cartridge and P100-filter should be used for unpacking HDs which are not wrapped in plastic. A full-face piece, chemical cartridge-type respirator or powered air-purifying respirator should be worn for cleaning up large HD spills, sanitizing the undertray of a C-PEC, or when there is a known or suspected airborne exposure to powder or vapors) 2. Wash hands with soap and water 3. Gown (must be disposable, impermeable [polyethylene-coated polypropylene or other laminate material], closed in back, long-sleeved, closed cuffs, and changed q 2-3 h or immediately after a spill/splash) 4. Enter buffer area 5. Use alcohol-based surgical hand scrub (povidone-iodine can be used if first isn't possible) 6. Put on sterile, powder-free gloves (must meet ASTM [American Safety for Testing and Materials] standard D6978 and be changed q 30 min. When wearing two pairs, one must go under the cuff of the gown, the outer pair must go over) 7. Sanitize gloves routinely with 70% isopropyl alcohol

Apomorphine

Dopamine agonist Use: Parkinson's disease Form: injection Dose: written in mL not mg AE: severe N/V (trimethobenzamide can be used for emesis prevention, given 3d prior), HoTN CI: 5HT3 antagonists due to severe HoTN and loss of consciousness

Rotigotine

Dopamine agonist. Remove before MRI Brand: Neupro Use: Parkinson's Disease, Restless Leg Syndrome Form: patch Dose: qd, do not use the same site for at least 14d AE: application site (skin) reactions CI: avoid if pt has sulfite allergy

Metoclopramide

Dopamine antagonist Brand: Reglan MOA: causes accelerated gastric emptying and increases LES tone Use: GERD if patients also have gastroparesis Dose: before meals and qhs. Decrease dose by half in patients with CrCl < 40 due to CNS AE (if no other comorbidities) Warnings: EPS (including acute dystonia), parkinsonian-like symptoms AE: drowsiness DDI: avoid using with Parkinson drugs or antipsychotics BBW: tardive dyskinesia

Prochlorperazine

Dopamine receptor antagonist Brand: Compazine Use: breakthrough CINV

Promethazine

Dopamine receptor antagonist Brand: Phenergan Use: breakthrough CINV, motion sickness CI: should not be used in children BBW: do not give if < 2 yo. Do not give via intra-arterial or SC. IV route can cause serious tissue injury if extravasation occurs

Metocloprmide

Dopamine receptor antagonist Brand: Reglan Use: breakthrough CINV BBW: tardive dyskinesia that can be irreversible

Clearance for intravascular administration equation

Dose / AUC

Stimulant laxatives

Dose: can be taken qhs AE: cramping

Bulk-forming laxatives

Dose: take 2h before/after other drugs AE: gas, bloating

IV antibiotics that require light protection

Doxycycline and micafungin

First pass metabolism

Drug is extensively metabolized by the liver before reaching systemic circulation

Drug induced liver injury

Drug is usually stopped when LFTs are >3x normal limit

Red Book, Pharmacy

Drug pricing information

Hazardous Drugs basics

Drugs that can be carcinogenic (or genotoxic [damaging DNA, causing cancer]), teratogenic, have reproductive toxicities, or cause organ toxicity at low doses as determined by NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings. How to deal with them is in USP 800 (which adds to USP 795 and 797 which should still be followed). *Categories*: antineoplastics: chemotherapy drugs Non-antineoplastics: hormones and transplant drugs Drugs with reproductive risk

Diagnostic tests for autoimmune disorders

ESR (Erythrocyte Sedimentation Rate), CRP (C-Reactive Protein), RF (Rheumatoid Factor), ANA (Anti-Nuclear Antibody)

Beta-1 agonists

Effects: increased cardiac output, increased hr

Cardioembolic stroke cause

Embolus forms in the heart and travels to the brain

Docusate

Emollient laxative (stool softener) Brand: Colace MOA: soften fecal mass and make defecation easier Use: constipation, preferred when straining should be avoided (use when stool is hard and/or dry)

Febrile neutropenia

Empiric antibiotics must be started as soon as a fever occurs Cause: gram negative bacteria (including pseudomonas) pose greatest risk for causing sepsis

Green Book

FDA. Information on approved animal drug products

Purple Book

FDA. List of biological drug products, including biosimilars

Loxapine

FIrst generation antipsychotic *Adasuve*: brand for inhalation powder AE: dysgeusia, sedation BBW: bronchospasm (REMS)

Diagnostic tests for asthma

FVC, FEV1, and skin test to test for allergies

Tenecteplase

Fibrinolytic used for STEMI Brand: TNKase

Antiandrogens

First generation (bicalutamide) only used in combo with GnRH agonists MOA: competitively inhibits testosterone binding to prostate cancer cells Use: prostate cancer Drugs: -lutamide AE: hepatotoxicity

Thioridazine

First generation antipsychotic AE: higher risk for QT prolongation vs other FGAs

Lixisenatide

GLP-1 agonist. Starter pack comes with two different colored pens, you must start with the green pen Brand: Adlyxin Use: diabetes Dose: qd within 60 minutes of meals. Pen needle not provided

Abciximab

GPIIb/IIIa antagonist. Treats ACS. Injection that must be filtered

HPV vaccine

Gardasil. Prevents ~95% of cervical cancer. Recommended in patients 11-12 yo (can be given as young as 9 and as old as 21 for most males & 26 for females) *Regimens*: Started < 15 yo: 2 doses Started ≥15 yo: 3 doses

Gelling (thickening) agents (stabilizers) used in compounding

Gelatin, bentonite, agar, various gums (guar, xantham, acacia), tragacanth, Carbomer, cellulose, starches

Infection treatment in pregnancy

Generally considered safe: penicillins, cephalosporins, erythromycin, azithromycin Vaginal fungal infections: topical antifungals UTI: must also treat bacteriuria, even if asymptomatic Toxoplasmosis: women can be tested prior to pregnancy with an IgG test. If unsure of status, avoid unpasteurized dairy products and cat feces Do not use: quinolones, tetracyclines

Duavee

Generic: conjugated equine estrogen/bazedoxifene MOA: helps vasomotor symptoms but increases the risk of breat cancer Use: osteoporosis (prevention only in postmenopausal women with a uterus) AE: increased risk of breast and ovarian cancer CI: breast cancer, uterine bleeding, VTE, pregnancy BBW: endometrial cancer (due to unopposed estrogen use), increased risk of VTE and stroke

Combivent Respimat

Generic: ipratropium/albuterol Dose: (MDI) 1 inhalation qid How to use: Turn clear base in direction of arrows. Open cap until snaps fully open. Press the button and breathe in, hold for at least 10 sec. Clean with damp cloth or tissue qw

Tyrosine Kinase Inhibitors (TKIs)

Generic: many end in "-nib" Pharmacogenomic: testing must be done to identify patients likely to respond Use: cancer Forms: po AE: mucositis, QT prolongation, DA, HTN, acneiform rash (shows that it's working) Monitor: ECG

Stiolto Respimat

Generic: tiotropium/olodaterol Use: COPD How to use: Turn clear base in direction of arrows. Open cap until snaps fully open. Press the button and breathe in, hold for at least 10 sec. Clean with damp cloth or tissue qw

Anoro Ellipta

Generic: umeclidinium/vilanterol Use: COPD How to use: do not block air vent. Rinse mouth with water and spit out after

ACEIs

Generics: end in "-pril" MOA: blocks conversion of angiotensin I to angiotensin II, resulting in decreased vasoconstriction, decreased aldosterone secretion, and blocked degradation of bradykinin Use: HTN, HF (should be taken by all patients. Usually combined with an aldosterone receptor antagonist) AE: angioedema (more commonly with black patients), hyperkalemia, hypotension, renal impairment, bilateral renal artery stenosis, cough CI: history of angioedema and use within 36h of a neprilysin inhibitor (sacubitril/valsartan) DDI: aliskiren if patient has diabetes. Can decrease lithium renal clearance, increasing toxicity BBW: teratogenic, discontinue as soon as pregnancy is detected Monitoring: BP, potassium, s/sx of HF, and renal function

Cimetidine

H2RA. Avoid entirely due to DDIs and AE AE: gynecomastia, impotence DDI: (inhibitor of CYP450)

What increases prolactin

Haloperidol, risperidone, and paliperidone

Aminoglycosides

Has concentration-dependent activity and post-antibiotic effect (still killing bacteria after serum level drops below MIC) *Cover*: gram - (including pseudomonas) *Dosing*: by weight, if underweight use ABW, overweight use DBW, average use IBW or ABW Traditional: uses lower doses more frequently. Trough should be taken right before 4th dose and peak 30 minutes after end of 4th dose Extended interval: uses higher doses (to attain higher peaks) less frequently. Less accumulation of drug than with traditional. This strategy has been shown to decrease cost and nephrotoxicity. Random level should be drawn and check nonogram to see if any adjustments need to be made (if it plots on a line, round up) Tobramycin & gentamicin extended interval: 7 mg/kg *Drug-specifics*: gentamicin: can be used with a beta-lactam or vanco for synergy when treating gram + infections. Trough should be <2 for gram - infections Streptomycin: can be used with a beta-lactam or vanco for synergy when treating gram + infections Tobramycin: trough should be < 2 *AE*: nephrotoxicity, ototoxicity, and neuromuscular blockers *DDI*: avoid use with other neurotoxic/nephrotoxic drugs (amphotericin B, cisplatin, polymyxins, cyclosporins, loop diuretics, NSAIDs, radiocontrast dye, tacrolimus, and vanco)

Quinolones

Has concentration-dependent killing. Should be avoided to treat MRSA (except delafloxacin) due to resistance. Avoid systemic quinolones in children. Caution in patients with CVD, with hypo-kalemia/magnesemia, taking other QT-prolonging drugs (azoles, antipsychotics, methadone, macrolides) *MOA*: inhibit DNA topoisomerase IV and DNA gyrase *Drug-specifics*: respiratory quinolones: gemifloxacin, levofloxacin, and moxifloxacin. Referred to as such due to enhanced coverage against pneumoniae. Levo- and moxi- have a 1:1 IV:po ratio Antipseudomonal quinolones: Cipro and levofloxacin. Enhanced coverage against pseudomonas. Used for pseudomonas, UTI, intra-abdominal infections, and traveler's diarrhea without dysentery Moxifloxacin: Avelox. Enhanced anaerobic activity. Only quinolone that cannot be used for UTI. Highest risk of QT prolongation. No renal dosing required Delafloxacin: active against MRSA Levofloxacin: do not refrigerate po suspension *AE*: QT prolongation, hypo/hyperglycemia, psychiatric disturbances, photosensitivity *BBW*: tendon inflammation and/or rupture, peripheral neuropathy, seizures (use caution in patients with CNS disorders or taking drugs that cause seizures) *DDI*: antacids and other cations (Mg, Ca, etc): can chelate and inhibit quinolone absorption. Separate drugs by 2h Lanthanum carbonate, sevelamer, warfarin

High-alert drugs

Heightened risk of causing significant patient harm when used in error Insulin (do not place in ADCs [Automated Dispensing Cabinets], have them be checked by a RPh), anticoagulants, injectable KCl (remove all KCl vials from floor stock, use premixed containers, allow for automatic substitution of oral KCl, label all fluids containing K with a "Potassium Added" sticker), hypertonic saline, opioids, epidural/intrathecal medications Ways to avoid harm: using premixed products, limiting concentrations available at the institution, stocking high-alert products only in the pharmacy

Tranexamic acid

Hemostatic agent *Brands*: Cyklokapron Lysteda: po, used for menorrhagia

Recombinant factor VIIa

Hemostatic agent Brand: NovoSeven RT

What causes platelets to decrease

Heparin, LMWHs, fondaparinux, and valproic acid

hCG

Human Chorionic Gonadotropin. Used to detect pregnancy

Diagnostic tests for pregnancy

Human chorionic gonadotropin

OTC for nasal congestion <1 yo

Humidifier (reduces congestion, gentle suction with saline drops or spray. OTC cough and cold meds should not be used in children < 2 yo

Pain in ICU

Hydromorphone (Dilaudid), fentanyl, morphine

Symbicort

ICS/LABA. Do not put in water Generic: budesonide/formoterol Use: asthma and COPD How to use inhaler: shake well for 5 sec before each spray. Breathe in slowly and deeply. Hold your breath for up to 10 sec

Dulera

ICS/LABA. Do not put into water Generic: mometasone/formoterol Use: asthma How to use inhaler: shake well for 5 sec before each spray. Breathe in slowly and deeply. Hold your breath for up to 10 sec

Reslizumab

IL-5 receptor antagonist Form: IV Use: severe asthma with an eosinophilic phenotype BBW: anaphylaxis

Benralizumab

IL-5 receptor antagonist Form: SC q4w x3, then q8w Use: severe asthma with an eosinophilic phenotype

Mepolizumab

IL-5 receptor antagonist monoclonal antibody Brand: Nuluca Form: SC Use: severe asthma with an eosinophilic phenotype

Cromolyn

IN allergy medication Brand: Nasalcrom MOA: mast cell stabilizer Dose: regularly, not prn

Mometasone

IN steroid. Rx only Use: allergic rhinitis

Budesonide

IN steroid/ICS (only ICS available as nebulized solution). Preferred steroid in infants. Po undergoes extensive first pass metabolism (less systemic exposure than other steroids) *Brands*: Rhinocort Allergy OTC Pulmicort Flexhaler: asthma. Breathe in deeply and forcefully. Rinse mouth with water and spit out Pulmicort Respules: asthma. Only use with jet nebulizer. Any remaining ampules should be used within 2w Entocort: for CD only Uceris: for UC only. Rectal foam *Use*: allergic rhinitis (DOC in pregnancy), asthma, IBD *Dose* (po): if used longer than 2w, must taper off *Administration* (po): do not crush, chew, or break *AE* (po): short term: GI upset Long term: adrenal suppression, immunosuppression, HTN, osteoporosis (assess bone density, optimize Ca & vitamin D intake, consider bisphosphonates) *DDIs* (po): inhibitors of CYP3A4 (includes grapefruit)

Raltegravir

INSTI used for HIV *Brands*: Isentress Isentress HD: 1200 mg qd *AE*: increased CPK (higher risk vs other INSTIs), myopathy, and rhabdomyolysis

Bictegravir

INSTI used for HIV Brand: Biktarvy CI: do not start if CrCl < 30

Dolutegravir

INSTI used for HIV Brand: Tivicay AE: insomnia, HA, increased SCr (without affecting GFR)

Elvitegravir

INSTI used for HIV, take with food *Brands*: Stribild: do not start if CrCl < 70, d/c if CrCl < 50 Genvoya: do not start if CrCl < 30 *AE*: proteinuria, HA, and insomnia *Dose*: 1 po qd wc

Levothyroxine

IV:po 0.75:1. Contains T4, which will lower TSH *Brands*: Synthroid, Levoxyl, Unithroid (use Orange Book to check therapeutic equivalence between brand and generic) *Use*: hypothyroidism *Dose*: take with water at least 60 min before breakfast or qhs at least 3h after last meal. Full replacement dose = 1.6 mcg/kg/d based on IBW Known CAD: 12.5-25 mcg/d Pregnant: increase dose *Tablet colors*: (Orangutans Will Vomit On You Right Before They Become Large, Proud Giants) Orange 25 mcg, White (no dye) 50 mcg, Violet 75 mcg, Olive 88 mcg, Yellow 100 mcg, Rose 112 mcg, Brown 125 mcg, Turquoise 137 mcg, Blue 150 mcg, Lilac 175 mcg, Pink 200 mcg, Green 300 mcg *DDIs*: separate from phosphate binders and Ca because absorption can be affected

Therapeutic Interchange Protocol

IV:po protocol for easy to convert drugs (1:1 usually)

Pharmacogenomics

Identifies, measures, and compares the costs and consequences of pharmaceutical products and services

Diabetes in pregnancy

If blood glucose is high, baby can be large (macrosomia), will be at risk for hypoglycemia at birth, and high risk for type 2 diabetes Treatment: lifestyle modifications. If not adequate, then insulin. Metformin or glyburide can be considered. ASA to reduce risk of preeclampsia Goal: FBG ≤ 95

Cancer

If patient is cancer free for 5y, it is unlikely their cancer will recur. Vaccinations should be avoided during chemo but can be given ≥2w before chemo Warning signs: *(HoBo LIMBS)* Hoarseness or nagging cough, Bowel or bladder changes, Lump thickening, Indigestion/difficulty swallowing, Mole or wart obvious change, Bleeding or discharge that's unusual, Sore that does not heal

MAC (Mycobacterium Avium Complex) prophylaxis for HIV patients

If their CD4 < 50 DOC: azithromycin qw Clarithromycin + ethambutol Discontinue when CD4 > 100 for ≥3m on ART

PCP prophylaxis for HIV patients

If their CD4 count is < 200 DOC: Bactrim qd Can give dapsone or dapsone + pyrimethamine + leucovorin Pentamidine IV Discontinue when CD4 ≥200 for ≥3m on ART

HIT

IgG drug reaction leading to further platelet activation. Can lead to a prothrombotic state Diagnosis: >50% platelet drop from baseline Treatment: stop all forms of heparin. If on warfarin, d/c and Vitamin K should be administered. Replace anticoagulant with argatroban. Do not start warfarin therapy until platelets > 150,000. If urgent cardiac surgery or PCI is required, use bivalirudin as an anticoagulant

Angina

Imbalance between myocardial oxygen demand (workload) and supply (blood flow) *Types*: stable: aka SIHD (Stable Ischemic Heart Disease). Predictable chest pain often brought on by exertion and relieved within minutes by rest or with nitroglycerin Prinzmetal's angina: caused by vasospasm. Can occur at rest. Avoid using beta-blockers, CCBs DOC

Lenalidomide

Immunomodulator Brand: Revlimid Use: cancer REMS: teratogenic

Thalidomide

Immunomodulator Brand: Thalomid Use: cancer Dose: wc REMS: teratogenic

Pomalidomide

Immunomodulator Use: cancer REMS: teratogenic

Alcoholic liver disease

Includes fatty liver, alcoholic hepatitis, and chronic hepatitis. Chronic alcohol ingestion over a long period of time causes "steatosis" or fatty liver Treatment: alcohol cessation, BZDs for alcohol withdrawal in inpatients, naltrexone, acamprosate, and disulfiram (last 3 are to prevent relapses). Support group

Constipation treatment

Increase fiber intake (dietary and as supplements [psyllium]) +/- osmotic agent (PEG), or stool softener (docusate) Needs to go quickly: bisacodyl or glycerin suppository On chronic opioids: stimulant On iron or stool is very hard: docusate Children: glycerin suppository if needs to go quickly

Diagnostic tests for alcoholic liver disease

Increased AST which is higher than an increased ALT; increased GGT

Diagnostic tests for renal disease

Increased BUN/SCr

Diagnostic tests for glaucoma

Increased IntraOcular Pressure

Diagnostic tests for hypothyroidism

Increased TSH and decreased Free T4

Diagnostic tests for gout

Increased Uric Acid levels

Diagnostic tests for hepatic encephalopathy

Increased ammonia levels in the blood

Diagnostic tests for pancreatitis

Increased amylase and lipase

Portal hypertension

Increased blood pressure in the portal vein. Can cause development and bleeding of esophageal varices

Diagnostic tests for dyslipidemia

Increased total cholesterol, non-HDL, LDL, and triglycerides

Hemoglobin lab value

Increases due to ESAs (Erythropoiesis-Stimulating Agents). Decreases due to anemias

RBC lab value

Increases due to ESAs (Erythropoiesis-Stimulating Agents). Decreases due to chemotherapy that targets the bone marrow, deficiency anemia (B12-deficient, folate-deficient, etc), hemolytic anemia, and sickle cell anemia

What causes PT / INR to increase

Increases due to liver disease. Increases falsely due to daptomycin

Lymphocyte lab value

Increases due to: viral infections or lymphoma Decreases due to: bone marrow suppression, HIV, or systemic steroids

Asthma

Inflammation and bronchoconstriction, resulting in expiratory airflow limitation. This can be reversed with medication, shown as FEV1 increasing by more than 12% from patient's baseline *Risk factors*: tobacco, not getting the flu shot, not getting pneumococcal, and having unknown allergens (sensitivity testing) *Severity based on rescue inhaler use*: <2d/w: intermittent >2d/w but not qd or >1x/d: persistent mild Qd: persistent moderate Several times/d: persistent severe *Treatments*: if using more than one inhaler, wait 60 sec between each one (using bronchodilators before steroids) Vaccinations: (<65) flu, Pneumovax23 now, Pneumovax23 again after 65. Prevnar13 not indicated in asthma Rescue inhalers: SABAs (all patients must have one), systemic steroids (for exacerbations for severe asthma), and SAMAs Maintenance: ICS (Inhaled CorticoSteroids. First line for all patients with persistent asthma), LABAs (used in combo with ICS [should never be used alone], preferred add on with ICS), LTRAs (Leukotriene Receptor Agonists, mostly used in children), theophylline (monitor serum drug concentrations), LAMAs, and monoclonal antibodies (omalizumab for severe allergic asthma) Spacers: make it easier to inhale MDIs, prevents thrush, and should be cleaned qw *Each follow up*: perform medication counseling: appropriate inhaler technique including priming and cleaning Assess asthma severity: step up (if SABA is being used >2x/w), maintain, or step down. Steps in order are 1. SABA prn +/- low-dose ICS, 2. Low-dose ICS, 3. Low-dose ICS+LABA OR medium-dose ICS, 4. Medium-dose ICS + LABA, 5. High-dose ICS + LABA, 6. High-dose ICS + LABA + po steroid

C. diff

Inflammation of colon can lead to pseudomembranous colitis Diagnostic tests: C. diff stool culture, Toxin A and B Symptoms: abdominal cramps, profuse diarrhea (can be bloody), and fever Treatment: vancomycin (oral) or fidaxomicin, equally effective

NRTIs for hepatitis

Inhibit HBV replication. Monotherapy approved for HBV. Prior to treatment, all patients should be tested for HIV. Decrease dose or frequency if CrCl <50 BBW: lactic acidosis and severe hepatomegaly with steatosis

Mipomersen

Inication: homozygous familial hypercholesterolemia CI: acute liver disease BBW: hepatotoxicity (REMS)

Lomitapide

Inication: homozygous familial hypercholesterolemia CI: acute liver disease and pregnancy BBW: hepatotoxicity (REMS)

Amphotericin B

Injection Covers: broad spectrum including zygomycetes AE: infusion related (fever, chills, HA, malaise, rigors), hypokalemia, hypomagnesemia, nephrotoxicity *Amphotericin B deoxycholate* requires pre-medication: APAP or NSAID. Diphenhydramine and/or hydrocortisone BBW: conventional amphotericin B should not exceed 1.5 mg/kg/d, can cause cardiopulmonary arrest *Liposomal amphotericin B*: has less infusion reactions and nephrotoxicity. Dosed higher than amphotericin B deoxycholate Brand: AmBisome

Milrinone

Inotrope MOA: PDE3 inhibitor, significant vasodilation Form: IV

Peripheral venous catheter

Inserted into smaller veins than venous catheters and are usually entered in the cephalic vein Possible side effects include phlebitis (venous irritation), thrombosis, and interstitial fluid extravasation

Vedolizumab

Integrin receptor antagonist Brand: Entyvio Use: CD and UC Dose: d/c if no benefit by 14w

Natalizumab

Integrin receptor antagonist Brand: Tysabri MOA: monoclonal antibody that binds to integrins Use: MS, Crohn's Disease Form: injection Dose (CD): q4w. D/c if no response in 12w BBW: PML (Progressive Multifocal Leukoencephalopathy) REMS

Ustekinumab

Interleukin receptor antagonist Brand: Stelara Form: SC Use: psoriasis, CD AE: serious infections (screen for TB), DA

NPH insulin

Intermediate-acting insulin. Cloudy. Available without a prescription. Can mix with rapid or short acting insulins, draw up rapid- or short- acting first (clear before cloudy) Converting to different insulins: 1:1 unless from NPH bid to glargine qd (1:0.8) Brands: Humulin N, Humulin N KwikPen (stable for 14d at room temperature), Novolin N, Novolin N ReliOn

Antibiotic resistance

Intrinsic: bacteria has a natural resistant to a certain organism Selection pressure: bacteria becomes resistant to a certain organism after a while Enzyme inactivation: enzymes are produced by bacteria that break down the antibiotic. Beta-lactamases, extended-spectrum beta-lactamases (treated with carbapenems or cephalosporin/beta-lactamase inhibitors), and carbapenem-resistant enterobacteriaceae (multidrug-resistant; treated with a polymyxin)

Mucormycosis

Invasive disease due to zygomycetes which is a class of fungi which includes Mucor species and Rhizopus species

Schizophrenia

Involves dopamine (increased) and glutamine *Symptoms*: positive: hallucinations (seeing or hearing something that is not there), delusions (believing an obvious false belief like someone is trying to kill them), disorganized thinking/behavior Negative: lack of emotion (apathy), social withdrawal, loss of motivation (avolition), lack of speech (alogia) *Treatment forms*: forms: long-acting injections ODT: so patients don't "cheek" the medication Acute IM injections: "Haldol cocktail" includes haloperidol, lorazepam, and diphenhydramine

Primary drugs pediatrics accidentally OD on

Iron and APAP

Desferal

Iron antidote

Flucytosine

Is converted into fluorouracil in the body Use: + amphotericin B to treat invasive cryptococcal (meningitis) AE: myelosuppression

IV solutions physiochemical properties

Isotonic and neutral pH. Non-PVC bags should be used for medications that have leaching or sorption issues

Proper way to clean a compounding hood

It should first be cleaned with a germicidal detergent, then disinfected with 70% IPA 1. Ceiling from back to front 2. Back from top to bottom 3. Side walls starting from the back, going from up to down, moving towards the front. Clean IV bar and hooks 4. Bottom surface from back to front in a side to side motion

Orkambi

Ivacaftor/lumacaftor Use: CF in patients homozygous for F508del mutation

Hypokalemia

K < 3.5. Commonly occurs in hospitalized patients. A drop of 1 mEq/L in K below 3.5 represents a total body deficit of 100 - 400 mEq *Drug causes*: amphotericin, insulin *Treatment*: treat underlying cause IV K: should be done through a peripheral line with a max infusion rate ≤ 10 mEq/h and max concentration of 10 mEq/100 mL. Can be fatal if administered undiluted or through IV push Resistant: check Mg levels, they are necessary for K uptake

Parathyroid hormone analogs

Keep refrigerated Generics: end in "-paratide" MOA: increases bone formation Use: osteoporosis when there is a high risk of fracture Dose: x≤2y Administration: inject medication in abdomen and in a place where you can sit or lie down right away AE: hypercalcemia, arthralgias, leg cramps, pain, nausea, orthostasis/dizziness (especially after first few doses) BBW: osteosarcoma

Nizoral

Ketoconazole shampoo used for dandruff

Potassium chloride brands

Klor-Con Klor-Con M: can be dissolved in 4 oz of water Micro-K: capsules can be opened and contents sprinkled

Indacaterol

LABA Brand: Arcapta Neohaler Use: COPD Dose: 1 capsule via Neohaler device qd How to use: remove capsule from blister pack, put it in chamber, press both buttons fully one time (will pierce capsule). Breathe in fully and rapidly. The capsule in the chamber should be empty of all powder

Salmeterol

LABA Brand: Serevent Diskus Use: asthma (maintenance therapy only in combo with ICS), COPD, and EIB (if patient needs longer control than a SABA) BBW: increased risk of asthma-related deaths, should only be used in patients who are currently receiving an ICS but are not adequately controlled

Olodaterol

LABA Brand: Striverdi Respimat Use: COPD How to use: Turn clear base in direction of arrows. Open cap until snaps fully open. Press the button and breathe in, hold for at least 10 sec. Clean with damp cloth or tissue qw

Tiotropium

LAMA *Brands*: Spiriva HandiHaler: COPD. Remove capsule from blister pack and put it in chamber. Press green button once until it is flat. Turn head away from the inhaler and breathe out fully. Have inhaler in horizontal position, breathe deeply and fully, you will hear the capsule rattle. You must inhale twice from each capsule Spiriva Respimat: COPD and asthma *MOA*: inhibits cholinergic receptors, leading to bronchodilation *Dose*: DPI: 1 capsule (2 puffs) via HandiHaler device qd MDI: 2 inhalations qd

Umeclidinium bromide

LAMA Brand: Incruse Ellipta Use: COPD How to use: do not block air vent. Rinse mouth with water and spit out after

Aclidinium

LAMA Brand: Tudorza Pressair Use: COPD How to use: dose is ready for inhalation when window changes from red to green. Breathe in until you hear a click. Check window to make sure it's red

Friedewald equation

LDL = TC - HDL - (TG/5) Formula not used when TG > 400, TG can be falsely elevated resulting in a falsely low LDL

Enoxaparin

LMWH *Brand*: Lovenox *Dose*: VTE prophylaxis: 30 mg SC q12h or 40 mg SC qd. CrCl < 30 give 30 mg SC qd Unstable Angina/NSTEMI/VTE (outpatient) treatment: 1 mg/kg SC q12h. CrCl <30 give 1 mg/kg SC qd. Use ABW VTE inpatient treatment: 1.5 mg/kg SC qd or 1 mg/kg SC q12h. CrCl <30 give 1 mg/kg SC qd. Use ABW STEMI treatment: < 75 yo or CrCl < 30 give 30 mg IV bolus plus 1 mg/kg SC dose. ≥ 75 yo no bolus Syringes available (mg): 30, 40, 60, 80, 100, 120, 150 *Administration*: do not expel air bubble from syringe. Clean site with alcohol swab. Inject on right or left side of abdomen SC not IM, at least 2 in from the belly button. Do not rub site of injection *AE*: bleeding, anemia, increased LFTs, thrombocytopenia, hyperkalemia *CI*: history of HIT or active major bleed *BBW*: patients receiving neuraxial anesthesia (epidural, spinal) are at risk of hematomas and subsequent prophylaxis *Monitoring*: platelets, Hgb, Hct, SCr, anti-Xa (recommended for pregnancy; obtain peak 4 h prior to SC dose)

VTE/mechanical valves treatment in pregnancy

LMWH. Can be combined with pneumatic compression device in select patients CI: warafarin Not recommended: oral factor Xa inhibitors

Montelukast

LTRA *Brand*: Singulair *MOA*: inhibits leukotriene D4 *Forms*: tablet Chewable tablet Packet Granules: can be administered directly in the mouth, dissolved in breast milk, formula, applesauce, carrots, rice, or ice cream (do not mix with anything else and use within 15 minutes) *Use*: asthma *Dose*: qpm 6-14 yo: 5 mg 1-5 yo: 4 mg

Zileuton

LTRA MOA: inhibits leukotriene formation Use: asthma

Zafirlukast

LTRA. Dispense in original container Use: asthma

HTN treatment in pregnancy

Labetalol, methyldopa, nifedipine CI: ACEI, ARBs, aliskiren, Entresto

Colloids

Large molecules that primarily remain in the intravascular space and increase oncotic pressure Vs crystalloids: more costly, more AE Examples: albumin 5%, 25% (Albuminar, Albutein, AlbuRx)

Menopause

Last menstrual period was >12m ago *Cause*: decrease in estrogen and progesterone, resulting in vasomotor symptoms (hot flashes, night sweats; experienced more during perimenopause [transition to menopause]) *Symptoms*: hot flashes, night sweats, vaginal dryness, burning, and painful intercourse *Treatments* vasomotor symptoms: systemic hormone therapy with estrogen causing a decrease in LH and more stable temperature control All symptoms: hormone therapy *Other treatments*: natural products (vasomotor symptoms): black cohosh, red clover, soy, flaxseed, dong quai, St. John's wort, evening primrose oil SSRIs/SNRIs: paroxetine, desvenlafaxine Ospemifene: not indicated for mild symptoms

COPD

Limitation of airflow is not fully reversible *Risk factors*: AAT (Alpha-1 AntiTrypsin) deficient patients *Cause*: tobacco *Symptoms*: dyspnea, chronic cough, sputum production. Symptom scoring systems include mMRC dyspnea scale and CAT (COPD Assessment Test) *Diagnosis*: spirometry. Post-bronchodilator FEV1/FVC < 0.7 confirms COPD *Can lead to*: emphysema and bronchitis *Nonpharm treatment*: smoking cessation: slows progression Vaccinations: reduce risk of hospitalization and death. Annual influenza and pneumococcal *Pharm treatment*: bronchodilators: first line. SABA and/or SAMA prn. LABA and/or LAMA if regular use is required. Combining two bronchodilators is more effective in reducing exacerbatons than monotherapy or + ICS ICS: not recommended. Can be added to LABA or LABA/LAMA treatment in moderate-severe COPD Theophylline: not recommended unless long-acting bronchodilator not an option By group: A, give a bronchodilator. B, LAMA or LABA. C, LAMA. D, LAMA + LABA Antibiotic: for an exacerbation if there is increased sputum purulence, sputum volume, dyspnea, or if mechanical ventilation is required

Auscultation

Listening to the heart through a stethoscope

Compounding log

Log book of all products made at the pharmacy which includes reference for the master formula (a number or page in the MFR), the components with their source, lot numbers, expiration dates (if there is a product without an expiration date, it cannot be used more than 3 years after receiving it), control or prescription number, BUD, a duplicate prescription label, and a description of final preparation

Insulin glargine

Long-acting insulin. Do not mix with other insulins Brands: Lantus (stable for 28d at room temperature), Lantus SoloStar, Toujeo SoloStar (only comes as 300 U/mL), Basaglar KwikPen

Insulin detemir

Long-acting insulin. Do not mix with other insulins Brands: Levemir, Levemir FlexTouch

Furosemide

Loop diuretic. Store injection form at room temperature. IV:po 1:2

Myelosuppression in cancer patients

Lowest point WBCs and platelets reach (nadir) in about 7-14d after chemo and generally recover 3-4w post treatment *Neutropenia*: types: neutropenia (< 1000 cells), severe neutropenia (< 500 cells) Treatment: CSFs (Colony Stimulating Factors) *Febrile neutropenia*: empiric antibiotics must be started as soon as a fever occurs Cause: gram negative bacteria (including pseudomonas) pose greatest risk for causing sepsis *Anemia*: treatment: recovers on its own usually. ESAs (erythropoietin [Epogen, Procrit] or darbepoetin [Aranesp]) can shorten survival and increase tumor progression so not recommended in patients receiving chemo with curative intent. Initiate ESAs only when Hgb < 10. Use lowest dose needed to avoid RBC transfusions

Isocarboxazid

MAOI Brand: Marplan Use: depression

Phenlzine

MAOI Brand: Nardil Use: depression

Tranylcypromine

MAOI Brand: Parnate Use: depression

Basiliximab

MOA: IL-2 (InterLeukin-2) receptor antagonist. Monoclonal antibody that inhibits IL-2 recceptor on T-lymphocytes preventing rejection Use: induction immunosuppression for transplant

Loop diuretics

MOA: Inhibit Na-K pump in ascending limb of loop of Henle. This causes a decrease in Ca reabsorption back into the blood, causing calcium depletion. Increases excretion of Na, K, Cl, Mg, Ca, and water Warning: sulfa allergy (possible cross-reaction; does not apply to ethacrynic acid) AE: hypokalemia, hyponatremia, hypomagnesemia, decreased Cl, decreased Ca, increased bicarbonate/metabolic alkalosis, hyperuricemia, hyperglycemia, hypertriglyceridemia, increased total cholesterol, orthostatic hypotension, photosensitivity, ototoxicity (more likely with ethacrynic acid [Edecrin]). Long term use can decrease bone density Monitoring: renal function, fluid status (I and Os, weight), bp, electrolytes, audiology testing with high doses of rapid IV administration, s/sx of HF Equivalent dosing: furosemide 40 mg= bumetanide 1 mg = torsemide (Demadex) 20 mg = ethacrynic acid 50 mg DDIs: avoid NSAIDs

Activated charcoal

MOA: absorbs drug in GI to prevent it from being absorbed Use: emergency treatment of OD from specific drugs. Should be used within 1h of ingestion Dose: 1 g/kg CI: airway is unprotected

Aldosterone receptor antagonists

MOA: act in the distal convoluted tubule and collecting ducts AE: hyperkalemia, increased SCr, dizziness CI: hyperkalemia, anuria, CrCl ≤ 30, Addison's disease (or other conditions that increase K) Monitoring: bp, electrolytes (K before starting and frequently thereafter), renal function, fluid status (I and Os, weight), s/sx of HF

Decongestants

MOA: alpha adrenergic agonists that work by vasoconstriction CI: do not use within 14d of MAOI

Belatacept

MOA: binds to CD80 and CD86 to block T-cell costimulation and production of inflammatory mediators Use: maintenance immunosuppression for transplant Warning: treat latent TB infection prior to use BBW: increased risk of PTLD (Post-Transplant Lymphoproliferative Disorder)- use in EBV seropositive pts only

Daratumumab

MOA: binds to antigens expressed on specific hematopoietic cells and causes cell death Use: non-Hodgkin's Lymphoma, Hodgkin's Lymphoma, multiple myeloma Toxicity: suppression of specific hematopoietic cells leading to bone marrow suppression which causes an increased risk for reactivation of viral infections

Potassium iodide

MOA: blocks accumulation of radioactive iodine, preventing thyroid cancer Use: after exposure to radiation

MAO-B inhibitors

MOA: blocks breakdown of dopamine Use: Parkinson's Disease AE: serotonin syndrome, HTN CI: MAOI (including linezolid), opioids, SNRIs DDI: food high in tyramine

Amantadine

MOA: blocks dopamine reuptake Use: Parkinson's Disease, influenza A AE: somnolence, psychosis, dizziness, orthostatic HoTN

SAMAs and LAMAs

MOA: bronchodilation Use: COPD AE: xerostomia Monitoring: smoking status, COPD questionnaires, and annual spirometry

-azole antifungals

MOA: decrease ergosterol synthesis AE: increase LFTs and QT prolongation (except isavuconazonium)

5 alpha-reductase inhibitors

MOA: decrease prostate size, decreases PSA levels, improve symptoms, decrease risk of urinary retention, decrease need for surgery. Inhibits 5-alpha reductase enzyme, blocking conversion of testosterone to DHT (DiHydroTestosterone) Use: BPH (only in men who have an enlarged prostate) Dose: should be given for several months or longer AE: impotence, decreased libido, ejaculation disturbances, breast enlargement & tenderness CI: women of child-bearing potential, pregnancy (pregnant women should not handle either)

Xanthine oxidase inhibitors (XOI)

MOA: decreases uric acid production Use: chronic urate lowering treatment for gout Dose: titrated up until UA < 6 DDI: will increase the concentration of mercaptopurine (active metabolite of azathioprine)

Osmotic laxatives

MOA: draw fluid into the bowel lumen, which distends the colon and increases peristalsis AE: electrolyte imbalance

SGLT-2 inhibitors

MOA: inhibit SGLT-2 receptors (located on proximal renal tubules), reducing reabsorption of glucose, increasing urinary glucose excretion Drugs: end in "-gliflozin" Use: diabetes Dose: qam AE: ketoacidosis (N/V, stomach pains), genital mycotic infections, urosepsis, pyelonephritis, HoTN, AKI, volume depletion, weight loss, increased urination, increased thirst, dehydration CI: eGFR < 30 DDI: diuretics, RAAS inhibitors, and NSAIDs (these three will increase risk of HoTN and AKI) BBW: increased risk of leg and foot amputations Monitor: renal function

Topoisomerase II inhibitors

MOA: inhibit function at G2 phase Use: cancer

Topoisomerase I inhibitors

MOA: inhibit function at S phase Use: cancer

Pyrimidine analog antimetabolites

MOA: inhibit function at S phase Use: cancer Drugs: capecitabine, gemcitabine, 5-FU

Taxanes

MOA: inhibit function during M phase Use: cancer Administration: use non-PVC bag and tubing (except paclitaxel albumin-bound) AE: peripheral sensory neuropathy, fatal anaphylaxis BBW: severe infusion-related hypersensitivity reactions (except paclitaxel albumin-bound)

Uricosurics

MOA: inhibit reabsorption of uric acid Use: chronic urate lowering therapy for gout

Thionamides

MOA: inhibit synthesis of thyroid Use: hyperthyroidism AE: GI upset, DILE, hepatitis, agranulocytosis (rare) BBW: for pregnant women, PTU preferred in 1st trimester, methimazole often recommended for 2nd and 3rd trimesters Monitoring: q4-6w

VEGF inhibitors

MOA: inhibits growth or blood vessels by targeting VEGF (Vascular Endothelial Growth Factor) or VEGF receptor Use: colon and non-small cell lung cancer Toxicity: proteinuria (inhibition of blood vessel growth, leading to HTN, leading to this), hemorrhage or thrombosis, impaired wound healing (due to decreased blood flow) DDI: do not administer 28d before or after surgery because it can impair wound healing BBW: severe/fatal bleeding, GI perforation

Mannitol

MOA: osmotic diuresis. Reduces ICP (IntraCranial Pressure) by withdrawing water from the brain Use: ICH Forms: IV. Sometimes it may need to be heated up first to dissolve crystals CI: renal disease

DPP-4 inhibitors

MOA: prevent DPP-4 from breaking down incretin hormones, increasing insulin release and decreasing glucagon secretion Drugs: end in "-gliptin" AE: acute pancreatitis, arthralgia, risk of heart failure (more with saxagliptin and alogliptin)

Clopidogrel

MOA: prodrug that irreversibly inhibits P2Y12 ADP-mediated platelet activation and aggregation Use: angina and antiplatelet used to prevent recurrent stroke in noncardioembolic ischemic stroke or TIA patients AE: increased bleeding risk DDI: avoid omeprazole and esomeprazole CI: serious bleeding and TTP. Should be d/c 5d before surgery BBW: CYP2C19 poor metabolizers (clopidogrel will not be converted to active metabolizer effectively enough)

Hydroxyurea

MOA: simulates production of HgbF Use: sickle cell disease patients who have had ≥ 3 moderate - severe pain crises in 1y, severe psoriasis Administration: contraception is required. Hazardous agent, so gloves should be worn and hands washed before and after handling. Should also be on folic acid. Capsules should not be opened. Wear sun protection Warnings: embryo-fetal toxicity, pancreatitis, avoid vaccinations BBW: myelosuppression Monitoring: CBC with differential, ANC (<2000 is toxic)

Desmopressin

MOA: synthetic analogue of ADH, decreasing urine production Use: nocturnal enuresis Form: po tablet, nasal spray (Noctiva), injection Dose: qhs CI: hyponatremia, pts with increased risk of fluid retention BBW: hyponatremia Monitoring: Na

Atezolizumab

MOA: targets immune system. Interferes with the body's ability to "down-regulate" the immune system which results in increased immune recognition of tumor antigens Use: non-small cell lung cancer and melanoma Toxicity: immune system becomes overactive which can can cause life-threatening immune-mediated reactions (colitis, hepatotoxicity, thyroid dysfunction, myocarditis)

Iodides

MOA: temporarily inhibits secretion of thyroid hormones Use: hyperthyroidism

Aminosalicylates

MOA: topical anti-inflammatory effect in GI tract Use: UC

Diagnostic tests for MS

MRI (Magnetic Resonance Imaging)

Contact precautions are used for what diseases

MRSA, VRE, C. diff

Erythropoiesis-Stimulating Agents (ESAs)

Maintain Hgb levels and reduce need for blood transfusions. Ineffective if iron stores in patient are low *Use*: anemia of CKD (normocytic anemia). IV iron route recommended for patients on hemodialysis *Administration*: store in refrigerator. Do not shake. Rotate injection sites *AE*: HTN *BBW*: increased risk of death, MI, stroke, VTE, thrombosis, and tumor progression. Use lowest effective dose needed CKD: increased risk of death when Hgb > 11 Cancer: not indicated if anticipated outcome is cure *Monitoring*: Hgb, Hct, TSAT (Transferrin SATuration), serum ferritin, bp, Total Iron-Binding Capacity

Asthma treatment in pregnancy

Maintenance: inhaled budesonide Rescue: inhaled albuterol

Goal HDL level

Males > 40 Females > 50

Peak flow meter

Measures patient's PEFR (Peak Expiratory Flow Rate). Patient's best PEFR can be measured using spirometry, takes into account patient's height, gender, and age. Use qam upon awakening and before use of any asthma medications. Blow out as hard and fast as possible x3, record the highest number. Clean qw *Zones*: green: 80-100% personal best. Indicates "all clear" Yellow: 50-80% personal best. Indicates "caution." An action plan should be established Red: <50% personal best. Indicates "medical alert," may need to go to the emergency department

Resources for medication safety

MedWatch, NIOSH, and ISMP

MTM

Medication Therapy Management. A Personal Medical Record (PMR) is prepared and a Medication-related Action Plan (MAP) is developed. Then interventions, referrals, documentation, and plans for follow-up are done. Targets patients with multiple chronic conditions who are taking multiple drugs and are likely to incur annual costs for covered drugs that exceed a predetermined level

Nateglinide

Meglitinide Use: diabetes Dose: take 1-30 min before meals

Repaglinide

Meglitinide Use: diabetes Dose: take 15-20 min before meals. If a dose is missed, skip it

Coal tar

Messy Use: psoriasis, dandruff, dermatitis

Methylene blue

Mild MAOI

Allergic reactions treatment

Mild: diphenhydramine or hydroxyzine Severe: epinephrine (each pharmacy should have 3 adult Epipens)

Diagnostic tests for cognitive impairment

Mini-Mental State Exam

Solodyn generic

Minocycline

Integrin receptor antagonists

Monoclonal antibodies Use: induction and maintenance of remission in patients with IBD who have responded inadequately to other meds or are steroid dependent

Cetuximab

Monoclonal antibody, EGFR inhibitor Brand: Erbitux Use: colon cancer

Panitumumab

Monoclonal antibody, EGFR inhibitor Brand: Vectibix Use: colon cancer

Pertuzumab

Monoclonal antibody, HER2 inhibitor Use: breast cancer

Trastuzumab

Monoclonal antibody, HER2 inhibitor. Not interchangeable with ado-trastuzumab emtansine Brand: Herceptin Use: breast cancer

Ado-trastuzumab emtansine

Monoclonal antibody, HER2 inhibitor. Not interchangeable with trastuzumab Brand: Kadcyla Use: breast cancer

Bevacizumab

Monoclonal antibody, VEGF (Vascular Endothelial Growth Factor) inhibitor Brand: Avastin Use: colon and non-small cell lung cancer

Ramucirumab

Monoclonal antibody, VEGF (Vascular Endothelial Growth Factor) inhibitor Brand: Cyramza Use: colon and non-small cell lung cancer

LABA

Monotherapy for COPD only, increased risk of asthma related deaths when used as monotherapy for asthma AE: nervousness, tremor, tachycardia, palpitations, hyperglycemia, hypokalemia

Solifenacin

More M3-selective anticholinergic causing fewer CNS side effects Brand: Vesicare Use: overactive bladder

Fesoterodine

More M3-selective anticholinergic causing fewer CNS side effects Use: overactive bladder

Darifenacin

More M3-selective anticholinergic causing fewer CNS side effects Use: overactive bladder CI: gastroparesis

Insulin

Most come as 100 U/mL in 10 mL vials. Most pens come as 3 mL, needles must be dispensed with pens. Converting between insulins is usually a 1:1 conversion of TDD. Converting from bid NPH to qd glargine, use 80% of TDD. Big decrease in A1c vs other diabetes treatments *Types*: basal: long- or intermediate-acting. Mostly affects fasting blood glucose Bolus: rapid- or short-acting. Mainly used for prandial (mealtime) and correction for acute elevations *MOA*: signals the liver to convert glucose into glycogen, required for glucose uptake by muscle cells, and regulates fat storage in adipose tissue, converting excess glucose to fat *Pumps*: only rapid acting insulin or regular insulin can be used. It provides a continuous infusion throughout the day and boluses as needed. Not appropriate for newly diagnosed pts. 0.1 U/kg/h *Administration*: do not shake. If it is a pen, invert it 4-5 times. Prior to each injection, prime needle by turning knob to 2 units *AE*: hypoglycemia, hypokalemia (shifts K from extracellular to intracellular space), weight gain, and lipodystrophy *CI*: acute hypoglycemia *DDI*: meglitinides and sulfonylureas *Rule of 500*: 500 / TDD = g of carbs covered by 1 unit of rapid-acting insulin *Rule of 450*: 450 / TDD = g of carbs covered by 1 unit of regular insulin *Correction Dose*: amount of insulin needed to return blood glucose to a normal range. Dose is added to insulin patient normally takes Insulin correction factor- 1800 rule: for rapid-acting insulins. 1800 / TDD = correction factor for 1 unit Insulin correction factor- 1500 rule: for regular insulin. 1500 / TDD = correction factor for 1 unit Correction dose: (blood glucose now - target blood glucose) / correction factor

Gaussian Distribution

Most common form of distribution data forms. Curve is normal and symmetrical with the mean, median, and mode being the same. 68% of the values fall within 1 standard deviation and 95% of the values fall within 2 standard deviations

Osteoporosis

Most common in postmenopausal women *Risk factors*: pt characteristics: old, white, asian, women, family history, low body weight Medical diseases/conditions: anorexia, diabetes, GI diseases, hyperthyroidism, hypogonadism (men), menopause, RA/other autoimmune diseases Lifestyle: smoking, ≥ 3 drinks/d, low Ca intake, low vitamin D intake, physical inactivity Meds: anticonvulsants, aromatase inhibitors, depo-medroxyprogesterone, GnRH agonists, lithium, PPIs (decreases amount of calcium, can continue if taking calcium citrate as well), steroids, thyroid hormones *Diagnosis*: DEXA (or DXA) measures BMD (Bone Mineral Density) of the spine and hip and calculates a T-score (compares pt's measured BMD to average peak BMD of healthy, young, white, adult of same sex. ≥ -1 correlates with stronger bones. -1 - -2.4 is osteopenia, ≤ -2.5 is osteoporosis) and Z-score. All women ≥ 65 yo and men ≥ 70 yo should have BMD measured *Treatments*: Ca and vitamin D intake in addition to any therapy required, meds will not work well without supplementation. Exercise will improve bone and muscle strength Prevention: bisphosphonates and estrogen-based therapies (raloxifene and Duavee) Treatment: bisphosphonates High-risk: raloxifene, Duavee, teriparatide, denosumab, calcitonin

Systemic lupus erythematosus

Most common in women of African-American and Asian descent Symptoms: fatigue, depression, anorexia, weight loss, muscle pain, malar rash, photosensitivity, joint pain & stiffness Diagnosis: antinuclear antibodies, positive anti-ssDNA (anti-single stranded DNA), and postivie anti-dsDNA (anti-double stranded DNA) Nonpharm treatment: sunscreen Pharm treatment: (may take up to 6m to see benefit) hydroxychloroquine, cyclophosphamide, azathioprine, mycophenolate mofetil, cyclosporine, belimumab Can cause: arthritis, cutaneous, renal (lupus nephritis develops in over 50% of pts), hematologic, and neurologic manifestations

ADHD

Most common neurodevelopmental disorder in children. Certain food colorings and preservatives can worsen hyperactive behavior *Diagnosis*: symptoms must be present before age 12, symptoms must have been present in 2 different settings (work, school) Inattention: ≥6 symptoms for ≤16 yo, ≥5 symptoms for ≥17 yo. Symptoms must have been present for at least 6m Hyperactivity & impulsivity: ≥6 symptoms for ≤16 yo. Symptoms must have been present for at least 6m *Treatment*: 1. cognitive behavioral therapy 2. DOC for drug therapy are stimulants Young children and others who cannot swallow: long acting suspension (Quillivant XR, Dyanavel XR, Adzenys XR), chewable tablet (QuilliChew ER, Vyvanse), long-acting capsule with contents sprinkled on a small amount of applesauce (Focalin XR, Ritalin LA, Aptensio XR, Adderall XR), Vyvanse capsules (contains a powder which can be mixed in water, orange juice, or yogurt), long-acting ODT (Cotempla XR-ODT, Adzenys XR-ODT), patch (Daytrana; qam 2h before school). When putting on food, do not chew beads or warm food 3. Non-stimulants- when stimulants have failed or when worried about abuse

Molded tablets

Most common type of tablet. Made by adding alcohol and/or water to powder to moisten it. The pasty consistency can be molded into tablets and then it is allowed to dry

Albumin

Most commonly used colloid. Useful in patients with significant edema (e.g. cirrhosis) *ACR (Albumin to Creatinine Ratio)*: measures the degree of albuminuria. All patients with albuminuria should start on ACEI or ARB <30: minimal 30-300: moderate >300: severe

Central lines

Mostly used for long term antibiotics and drugs with a pH or osmolality that is not close to blood pH or osmolality Either placed into the superior vena cava or (PICC [Peripherally Inserted Central Catheter]) a smaller vein until the tip ends in the superior vena cava

Eluxadoline

Mu-opioid receptor agonist. C4 Brand: Viberzi Use: diarrhea CI: patients without a gallbladder

Ulcerative Colitis

Mucosal inflammation confined to rectum and colon with superficial ulcerations with a continuous pattern *Types*: distal disease: inflammation is confined to descending colon and rectum. Treated with topical treatment Proctitis: inflammation confined to rectum *Treatments*: aminosalicylates for maintenance therapy Mild: mesalamine (5-ASA) rectal and/or oral Moderate-severe: *(CAT JaK)* anti-TNF agents (adalimumab [Humira], infliximab [Remicade], golimumab [Simponi]), thiopurine (azathioprine, mercaptopurine), cyclosporine, janus kinase inhibitor (tofacitinib [Xeljanz]) Refractory to above treatments and/or steroid dependent: integrin receptor antagonists (vedolizumab)

Sanitizing equipment used for HDs

Must be done at least once daily. Wetted wipes (vs using a spray bottle directly on surface) should be used Deactivation and decontamination: Bleach alone or peroxide alone can do both jobs. Use sodium thiosulfate, sterile alcohol, or a germicidal detergent after using bleach to neutralize it and prevent corrosion Cleaning Disinfection: required

Sterility testing

Must be done for certain high-risk level CSPs and CSPs intended for use beyond recommended BUD. Testing should use either TSB (Tryptic Soy Broth) or FTM (Fluid Thioglycollate Medium) and include bacterial endotoxin

Genital herpes treatment

Must be initiated within 1d of lesion onset *Episode*: Acyclovir: least expensive. Dosed 3 or 5x/d Valacyclovir: prodrug of acyclovir that results in higher concentrations than with acyclovir, resulting in less frequent dosing, bid Famciclovir: tid *Chronic suppression*: acyclovir bid, valacyclovir qd, or famciclovir bid

Nicotine patch

Must be removed during an MRI. Rotate patch sites *Brand*: NicoDerm CQ *Dose*: > 10 cigarettes/d: start with 21 mg patch (weeks 1-6), 14 mg patch (weeks 7-8), then 7 mg patch (weeks 9-10) ≤ 10 cigarettes/d: start with 14 mg patch (weeks 1-6), then 7 mg patch (weks 7-8) *AE*: vivid dreams (remove patch prior to bedtime if troublesome but making sure the patch has been on for at least 16h first)

MMR

Must be stored in the refrigerator or freezer MMRV: MMR-varicella. Stored in the freezer. Diluents stored at room temperature or in the refrigerator

Storage of Hazardous Drugs

Must be stored on shelves with raised front lips. Must be stored separately from non-HDs in an externally ventilated, negative-pressure room with 12 or more ACPH. All containers must be labeled, tagged, or marked with identity of contents

Bacteriuria

Must be treated in pregnant women Treatment: amoxicillin, Augmentin, or oral cephalosporin. Avoid quinolones

Complera

NNRTI for HIV. Avoid if CrCl < 50

Atripla

NNRTI for HIV. Take without food. Avoid if CrCl < 50. Keep in original container

Efavirenz

NNRTI used for HIV. CYP450 inducer > inhibitor. Take without food *Brand*: Sustiva *Dose*: 600 mg qd *AE*: CNS effects: impaired concentration, abnormal dreams, confusion, and dizziness. Decreased risk if taken qhs without food. Usually resolves in 2-4w Serious psychiatric symptoms: depression and suicidality Convulsions, QT prolongation, and rash *DDIs*: methadone (efavirenz can decrease methadone levels, monitor for methadone withdrawal in pts) and hormonal contraception (levels can be decreased by efavirenz)

Rilpivirine

NNRTI used for HIV. CYP450 substrate. Take with food (requires acidic environment for absorption). Higher rates of failure if viral load > 100,000 copies/mL Brand: Edurant AE: QT prolongation, suicidality, mood changes, and insomnia CI: strong CYP3A4 inducers (PPIs)

Nevirapine

NNRTI used for HIV. Do not initiate in women with CD4+ counts > 250 or men > 400 Dose: requires lower dose for first 2w (lead-in period) to decrease risk of rash and hepatotoxicity AE: most likely of all the NNRTIs to cause rash and hepatotoxicity. Increased LFTs, hypersensitivity reactions BBW: hepatotoxicity and serious skin reactions (SJS/TEN) DDIs: methadone (nevirapine can decrease methadone levels, monitor for methadone withdrawal in pts) and hormonal contraception (levels can be decreased by nevirapine)

Epivir-HIV

NRTI used for HIV. Avoid combining with emtricitabine because they are both cytosine analogs Generic: lamivudine AE: N/V/D, HA BBW: use of Epivir-HBV can result in HIV resistance due to lower dose of lamivudine. Severe acute exacerbation of HBV

Emtricitabine

NRTI used for HIV. Avoid combining with lamivudine because they are both cytosine analogs Dose for capsule form: 200 mg po qd AE: N/V/D, rash, dizziness, HA, insomnia, hyperpigmentation BBW: severe acute exacerbation of HBV

Zidovudine

NRTI used for HIV. IV form should be given during labor in pregnant women with HIV. Avoid combing with stavudine because they are both thymidine analogs AE: myopathy, macrocytic anemia, and increased LFTs BBW: hematologic toxicities (anemia) and myopathy Monitoring: MCV, if it is not elevated, there may be an adherence issue

Abacavir

NRTI used for HIV. Only NRTI that doesn't require renal dose adjustment. Warning card summarizing symptoms of hypersensitivity required with this drug AE: hypersensitivity reaction (never rechallenge) and increased risk of MI CI: HLA-B*5701 positive test due to hypersensitivity reactions

Didanosine

NRTI used for HIV. Oral solution is stable for 30d in refrigerator. Take without food AE: N/V/D, peripheral neuropathy (can be irreversible), increased amylase, and pruritus/rash BBW: pancreatitis (can be fatal)

Stavudine

NRTI used for HIV. Oral solution is stable for 30d in the refrigerator, shake before use. Avoid combining with zidovudine because they are both thymidine analogs AE: N/V/D, peripheral neuropathy (can be irreversible), increased LFTs, hyperbilirubinemia, pancreatitis, and lipoatrophy

Tenofovirs

NRTIs used for HBV and HIV. Dispense in only original container *AE*: (less with alafenamide) nephrotoxicity, Fanconi syndrome, osteomalacia, and decreased bone mineral density *BBW*: severe acute exacerbation of HBV (if used for HIV) *Tenofovir disoproxil fumarate*: brand: Viread Dose: 300 mg qd Powder form: use only dosing scoop provided to measure powder. Mix with soft foods, not with a liquid. Give entire dose immediately after mixing *Tenofovir alafenamide* brand: Vemlidy. Used for HBV only AE: nausea

Piroxicam

NSAID. Only used if pain relief not possible with other agents AE: SJS/TEN, GI toxicity

Anion gap calculation

Na - Cl - HCO3

NPSG

National Patient Safety Goals. Set annually by TJC NPSG 01.01.01: use at least 2 patient identifiers when providing care NPSG 02.03.01: report critical results of tests and diagnostic procedures on a timely basis NPSG 03.04.01: label all meds, med containers, and other solutions on and off the sterile field in perioperative and other procedural settings NPSG 03.05.01: reduce likelihood of harm associated with anticoagulant therapy. Use standardized dosing protocols (starting dose ranges, alternate dosing strategies, and communication with dietary department to address drug-food interactions, get baseline INR), use programmable pumps for heparin, and provide education to patients NPSG 03.06.01: maintain and communicate accurate patient med information (medication reconciliation, conducting discharge counseling) PSG 07.01.01: comply with the CDC hand hygiene PSG 07.03-06.01 prevent healthcare associated infections with multidrug-resistant organisms (MRSA, C. diff, VRE, MDR gram - bacteria). Catheter-associated urinary tract infections are addressed in 07.06.01

Resources for natural products/alternative medicine

Natural Medicines

Ginseng

Natural product Use: ED

Yohimbe

Natural product Use: ED

L-arginine

Natural product Use: ED, HTN

Tea tree oil

Natural product Use: acne

Kava

Natural product Use: anxiety AE: hepatotoxicity

Valerian

Natural product Use: anxiety and sleep

SAMe

Natural product Use: anxiety, depression, osteoarthritis

Passionflower

Natural product Use: anxiety, sleep

L-lysine

Natural product Use: cold sores

Echinacea

Natural product Use: colds and flu

Vitamin C

Natural product Use: colds and flu

Zinc

Natural product Use: colds and flu

Vitamin E

Natural product Use: dementia/memory AE: increased CV risk. In almost all cases, the risk outweighs the benefit and Vitamin E supplementation should not be taken

Ginkgo

Natural product Use: dementia/memory AE: increases bleeding risk

5-HTP

Natural product Use: depression

Alpha lipoic acid

Natural product Use: diabetes

Chromium

Natural product Use: diabetes

Cinnamon

Natural product Use: diabetes

Plant sterols/stanols

Natural product Use: dyslipidemia

Red yeast rice

Natural product Use: dyslipidemia

Garlic

Natural product Use: dyslipidemia, HTN

Fiber

Natural product Use: dyslipidemia, IBD

Magnesium

Natural product Use: dyspepsia, migraine/headache

Bitter orange

Natural product Use: energy/weight loss

Guarana

Natural product Use: energy/weight loss, migraine/headache

Hawthorn

Natural product Use: heart failure

Coenzyme Q10

Natural product Use: heart failure, heart growth, HTN, migraine/headache

Milk thistle

Natural product Use: liver disease

Black cohosh

Natural product Use: menopause

Butterbur

Natural product Use: migraine/headache

Feverfew

Natural product Use: migraine/headache

Riboflavin

Natural product Use: migraine/headache

Ginger

Natural product Use: motion sickness

Peppermint

Natural product Use: motion sickness

Chondrotin

Natural product Use: osteoarthritis

Glucosamine

Natural product Use: osteoarthritis

Soy

Natural product Use: osteoporosis

Pygeum

Natural product Use: prostate health

Saw palmetto

Natural product Use: prostate health

Lemon balm

Natural product Use: sleep

Elderberry

Natural product Use: viral infections/common cold

HER2 pharmacogenomic test

Negative indicates to avoid HER2 inhibitors because they will not be effective Trastuzumab (Herceptin), ado-trastuzumab emtansine (Kadcyla), pertuzumab (Perjeta)

Resources for pediatrics

Neofox, Lexicomp, Red Book, and Harriet Lane

Zolpidem

Non-BZD *Brands*: Ambien, Ambien CR SL: Edluar (used to go to sleep), Intermezzo (used to stay asleep) Po spray: Zolpimist *Use*: falling and staying asleep

Eszopiclone

Non-BZD Brand: Lunesta Use: falling and staying asleep

Diltiazem

Non-DHP CCB Brands: Cardizem, Cartia, and Tiazac

Sarilumab

Non-TNF biologic DMARD Use: RA DDI: other biologic DMARDs, live vaccines BBW: serious infections (screen for TB)

Sevelamer

Non-calcium, non-aluminum based phosphate binder. Not systemically absorbed. Lowers total cholesterol and LDL by 15 - 30% Brands: Renagel and Renvela AE: N/V/D

Pancuronium

Non-depolarizing NMBA. Long-acting agent

Cisatracurium

Non-depolarizing NMBA. Metabolized by Hofmann elimination (independent of renal and hepatic function) Brand: Nimbex

Ketorolac

Non-selective NSAID *Brand*: Toradol, Acular *Nasal spray dose*: < 65 yo + ≥ 50 kg: spray in each nostril ≥ 65 yo or < 50 kg: spray in one nostril *AE*: acute renal failure, liver failure *BBW*: max combined duration of any form is 5d

Naproxen

Non-selective NSAID *Brands*: Aleve + esomeprazole: Vimovo *Dose*: bid *CI*: avoid use in renal disease and CVD risk

Indomethacin

Non-selective NSAID Brand: Indocin Use: acute gout attack AE: high risk for CNS and GI AE CI: avoid use in renal disease (does not require renal dose adjustment) and CVD risk

Terazosin

Non-selective alpha blocker Brand: Hytrin Use: BPH Dose: titrate slowly. Qhs to minimize orthostasis/dizziness AE AE: more than other alpha blockers (along with doxazosin)

Labetalol

Non-selective beta blocker and alpha-1 blocker. DOC in pregnancy. Available as an injection

Carvedilol

Non-selective beta blocker and alpha-1 blocker. Take with food Brands: Coreg, Coreg CR (Coreg CR TDD is 1.6x Coreg TDD dose- 3.125 mg Coreg bid = 10 mg Coreg CR qd) Use: chronic heart failure

Propranolol

Non-selective beta blocker. Lipophilic. Available as an injection Brands: Inderal LA, Inderal XL, InnoPran XL Use: anxiety, migraine prophylaxis, HTN AE: CNS side effects

Atomoxetine

Non-stimulant. Approved for use in adults and children ≥6 yo. Do not open capsule Brand: Strattera MOA: selective NE reuptake inhibitor Use: ADHD Warning: hepatotoxicity AE: HA, insomnia, somnolence, HTN, tachycardia, dry mouth, nausea, abdominal pain, decreased appetite CI: MAOI use within the past 14d BBW: risk of suicidal ideation

Central alpha-2a agonists

Non-stimulant. Can be used alone or with a stimulant MOA: stimulates alpha receptors in the brain Use: ADHD Warnings: dose-dependent CV events, sedation, drowsiness, do not d/c abruptly (can cause rebound HTN)

Motion sickness treatment

Nonpharm: ginger Pharm: antihistamines, anticholinergics, scopolamine (Transderm Scop; q72h prn)

Potassium

Normal potassium is 3.5 - 5.5, becomes concerning when >5. Most abundant intracellular cation. Renal potassium excretion is increased by aldosterone and diuretics (loop > thiazides). If an increase in potassium occurs due to a large meal, insulin will be released which will cause potassium to shift into the cells

Beta-blockers

Not recommended first line for HTN unless patient has comorbid condition (post-MI, stable ischemic heart disease, HF). DOC for antianginal treatment in SIHD and for Afib with no CI. Some have ISA (Intrinsic Sympathomimetic Activity) which means they partially stimulate beta-receptors while blocking effects of catecholamines (NE, epi), these are not recommended in post-MI patients *Generics*: end in "-olol" *MOA*: decreases heart rate, contractility, and left ventricular wall tension. Antagonizes effect of catecholamines (especially NE) *Use*: HTN, recommended in all HF patients (carvedilol and metoprolol succinate ER for HF, never an ISA. Only stop if hypotension or hypoperfusion occurs) *Dose*: SIHD: titrate to resting HR of 55-60 BPM, avoid abrupt withdrawal *DDIs*: diltiazem, verapamil, digoxin, clonidine *Beta-1 selective*: (AMEBBA: Atenolol, Metoprolol, Esmolol, Bisoprolol, Betaxolol, Acebutolol) AE: hyper/hypoglycemia (caution in patients with diabetes, they may not feel symptoms), careful in COPD/asthma patients, bradycardia, hypotension, fatigue, dizziness, depression BBW: do not d/c abruptly

Direct factor Xa inhibitors

Not recommended with prosthetic heart valves Use: anticoagulant and VTE treatment (preferred [along with dabigatran] vs warfarin in patients without cancer for the first 3m) AE: bleeding CI: active pathological bleeding BBW: patients receiving neuraxial anesthesia (epidural, spinal) are at risk for hematomas and subsequent paralysis Monitoring: no monitoring of efficacy required

Cockcroft-Gault equation

Not suitable for very young children or patients with unstable renal function CrCl = ( (140 - age) / 72 x SCr ) x weight (kg; IBW if normal, actual body weight if < IBW, AdjBW if >IBW & BMI ≥25, IBW if > IBW & BMI < 25) x 0.85 (if female)

Quinupristin/dalfopristin

Not well tolerated. Dilute in D5W only. Administer via central line Covers: most gram +, including MRSA and VRE but not E. faecalis MOA: binds to 50S ribosomal subunit

Type II Error

Null hypothesis was accepted in error

Type I Error

Null hypothesis was rejected in error

Number Needed to Treat

Number of patients who need to be treated for a certain period of time in order for one patient to benefit = 1 / ARR, rounded up

Number Needed to Harm

Number of patients who need to be treated for a certain period of time in order for one patient to experience harm = 1 - NNT, rounded down

Drugs that can cause or worsen heart failure

Occurs by increase of blood pressure or via negative inotropic effect, causing fluid retention/edema (It's the *D*rug *I*nformation *NATION*): DPP-4 inhibitors, Immunosuppressants, Non-DHP CCBs, Antiarrhythmics, TZDs, Itraconazole, Oncology agents, NSAIDs

Pinworm

Occurs mostly in children Symptoms: anal itching Diagnosis: "tape" test used to identify eggs by sticking a piece of tape around the anus in the morning (it can take up to 3 mornings to identify it) Treatment: pyrantel pamoate

CHF basics (not treatments)

Occurs when the heart is not able to supply sufficient oxygen-rich blood because of impaired ability to fill or eject ventricle *Causes*: usually due to MI or long-standing HTN *Patho*: during low cardiac output, blood volume is increased or force of speed of contractions are increased Main pathways: neurohormones that normally balance these systems (e.g. natriuretic peptides) are insufficient RAAS (Renin Angiotensin Aldosterone System. AngII causes vasoconstriction. Aldosterone causes sodium and water retention), SNS (Sympathetic Nervous System), and vasopressin (increases heart rate, contractility [positive inotropy], and vasoconstriction) *Diagnosis*: symptoms associated with fluid overload (SOB, edema), ECHO, and EF (<40% indicates systolic dysfunction or HFrEF [Heart Failure with reduced Ejection Fraction]) Labs: increased BNP, increased NT-proBNP Left-sided S&S: orthopnea, PND, bibasilar rales, S3 gallop, and hypoperfusion General S&S: dyspnea, cough, fatigue Right-sided S&S: peripheral edema, ascites, JVD, HJF, and hepatomegaly

Odds Ratio

Odds of an outcome occurring with an exposure, compared to the odds of the outcome occurring without the exposure = AD / BC

Cortisporin

Ointment consisting of bacitracin, neomycin, polymyxin B, and hydrocortisone Use: skin burns

Choosing the correct topical formulation

Ointment: best for thick, dry skin Cream: less potent Lotion, gel, foam: hairy skin

Burn

Ointments (80% oil/20% water) preferred to use for skin protection over a minor burn to hold in moisture and reduce scarring risk Treatments: silver sulfadiazine, mupirocin, Cortisporin, mebendazole, albendazole

Fluconazole

Only -aozle that requires renal dose adjustment, also only one that's not hepatically cleared. Covers C. albicans. C. glabrata and C. krusei can be resistant Use: vaginal candidiasis (non-pregnant patients; 150 mg po x1) and fungal meningitis (fluconazole penetrates CNS) AE: increased LFTs and QT prolongation

Ketoconazole

Only use oral tablets if other effective antifungal therapy is unavailable or not tolerated. Absorption is pH-dependent (advise to take with non-diet cola) AE: increased LFTs and QT prolongation BBW: hepatotoxicity

Hospital-acquired and ventilator-associated PNA

Onset >48h after admission (HAP), >48h after mechanical ventilation (VAP) Risk factor: IV antibiotic use within 90d

What kinds of drugs must be prepared in a sterile manner?

Ophthalmics, inhalations, and IV medications. Must be made in a buffer area and ante area with at least 30 ACPH (Air Changes Per Hour)

Hydromorphone

Opioid *Brand*: Dilaudid *Dose*: po: 2 - 4 mg q4-6h prn IV: 0.2 - 1 mg q2-3h prn Dosing conversion: IV/IM 1.5 mg = po 7.5 mg = 10 mg IM/IV morphine *BBW*: risk of medication error with high potency injection (use in opioid-tolerant patients only)

Oxycodone

Opioid *Brands*: CR: Oxycontin + APAP: Endocet, Percocet *BBW*: initiation of CYP3A4 inhibitors

Morphine

Opioid *Brands*: ER: MS Contin, Kadian (BBW: do not consume alcohol, can cause potentially fatal OD) Injection: Duramorph *Dosing conversion*: IV/IM 10 mg = po 30 mg = 1.5 mg IV/IM hydromorphone *Morphine-type allergy*: if allergic to one, may cross-react with others. Codeine, hydrocodone, oxycodone, morphine, hydromorphone, oxymorphone, buprenorphine, heroin (usually has cod or morph in the name) *morphine sulfate does not contain sulfa* *AE*: active metabolite can accumulate in patients with renal impairment (still okay to use in patients with renal impairment)

Hydrocodone

Opioid *Brands*: Hysingla ER: qd + APAP: Norco, Lorcet, Lortab, Vicodin + chlorpheniramine: Tussionex Pennkinetic ER Zohydro: ER. BBW, do not consume alcohol, can cause potentially fatal OD *BBW*: initiation of CYP3A4 inhibitors

Codeine

Opioid *Class*: CII CIII: tablet/capsule combo products CV: oral-solution combo products *Brand*: + APAP: Tylenol #2, 3, 4 *AE*: constipation *CI*: <12 yo, <18 yo following tonsillectomy/adenoidectomy surgery *BBW*: can lead to death in ultra-rapid metabolizers of codeine due to CYP450 2D6 polymorphism, including in children following tonsillectomy and/or adenoidectomy

Embeda

Opioid BBW: do not consume alcohol, can cause potentially fatal OD

Oxymorphone

Opioid Brand: Opana Administration: take on an empty stomach

Fentanyl

Opioid. Not used in opioid naive patients, a patient using morphine 60 mg/d or equivalent for at least 7d can be converted to fentanyl patch. *Brands*: Duragesic, Sublimaze Actiq: oral transmucosal lozenge ("lollipop," on a stick) *Dose*: 1 patch q72h *Forms*: comes in many SL forms *Administration*: dispose in toilet

Meperidine

Opioid. Short duration of action. Metabolite (normeperidine) is renally cleared and can cause seizures Brand: Demerol AE: renal impairment, CNS toxicity/seizures (risk for elderly), serotonin syndrome (serotonergic)

Methadone

Opioid. Variable half life *Brands*: Dolophine Methadose: liquid. Dispense with measuring cup or syringe *Dose*: hard to dose safely due to variable half-life *AE*: can decrease testosterone, serotonin syndrome *BBW*: QT prolongation

Fingolimod

Oral immunomodulator Use: MS AE: bradycardia (pt must be monitored for at least 6h after first dose, ECG required at baseline), macular edema CI: history of CVD or stroke Monitoring: eye exams, LFTs, CBC

Dimethyl fumarate

Oral immunomodulator Use: MS Administration: do not crush, chew, or sprinkle capsule contents onto food

Drug forms that can contain phenylalanine (avoid in PKU)

Orally disintegrating/SL forms, chewable forms, granules

Folic acid lab value

Ordered for further workup of macrocytic anemia. Decreases due to *(PP P/F Me Bac)* phenytoin/fosphenytoin, phenobarbital, primidone, methotrexate, and Bactrim

PEG

Osmotic laxative *Brands*: constipation: MiraLax Bowel prep: Colyte, GaviLyte-C, GaviLyte-G, Gavilyte-N, GoLytely, MoviPrep, NuLytely, TriLyte, Plenvu *Use*: constipation, bowel prep *Warnings* (for bowel prep): risky in patients with renal disease, cardiac disease, if taking loop diuretics (due to additional fluid loss), and NSAIDs

Magnesium hydroxide

Osmotic laxative Brand: Milk of Magnesia Warning: caution in patients with renal impairment

Low Vitamin D levels increase risk of what

Osteoporosis and osteomalacia

Disposal of PPE

Outer chemotherapy gloves, outer shoe cover, trace antineoplastic waste (empty vials), and gown should be discarded in yellow waste bin located inside C-PEC or in a sealable bag if not in C-PEC. Bulk antineoplastic waste (unused/partially empty IV bags, syringes, etc) go in black container

Ticagrelor

P2Y12 inhibitor *Brand*: Brilinta *Dose*: Maintenance: 90 mg po bid x1y, 60 mg bid Prior to PCI: 180 mg po x1 *AE*: bleeding and dyspnea *BBW*: maintenance dose of ASA > 100 mg should be avoided

Cangrelor

P2Y12 inhibitor given as infusion (only IV P2Y12 inhibitor) Transitioning to po P2Y12 inhibitors: give prasugrel: 60 mg or clopidogrel 600 mg immediately after stopping cangrelor

Prasugrel

P2Y12 inhibitor. Dispense in original container Brand: Effient Dose (pre-PCI): 60 mg po x1 AE: TTP and bleeding CI: history of TIA or stroke

Methylnaltrexone

PAMORA (Peripherally-Acting Mu Opioid Receptor Antagonist) Brand: Relistor Use: opioid induced constipation when patient has failed laxatives

Naloxegol

PAMORA (Peripherally-Acting Mu Opioid Receptor Antagonist) Use: opioid induced constipation

Alvimopan

PAMORA (Peripherally-Acting Mu-Opioid Receptor Antagonist) on receptors in the GI tract Brand: Entereg Dose: max of 15 total doses CI: patients who have taken therapeutic doses of opioids for >7 consecutive days, not safe in patients on chronic opioids BBW: MI REMS

Alirocumab

PCSK9 inhibitor Brand: Praluent MOA: inhibits LDL receptor degradation, allowing LDL to bind to hepatocytes

Pembrolizumab

PD-1 (Programmed Death receptor-1) inhibitor Brand: Keytruda MOA: targets immune system. Interferes with the body's ability to "down-regulate" the immune system which results in increased immune recognition of tumor antigens Use: non-small cell lung cancer and melanoma Toxicity: immune system becomes overactive which can can cause life-threatening immune-mediated reactions (colitis, hepatotoxicity, thyroid dysfunction, myocarditis)

Nivolumab

PD-1 (Programmed Death receptor-1) inhibitor Brand: Opdivo MOA: targets immune system. Interferes with the body's ability to "down-regulate" the immune system which results in increased immune recognition of tumor antigens Use: non-small cell lung cancer and melanoma Toxicity: immune system becomes overactive which can can cause life-threatening immune-mediated reactions (colitis, hepatotoxicity, thyroid dysfunction, myocarditis)

Roflumilast

PDE4 inhibitor Brand: Daliresp MOA: reduces lung inflammation AE: DA, weight loss CI: moderate to severe liver impairment

Sildenafil

PDE5 inhibitor *Brands*: Revatio: used for PAH Viagra: used for ED *Starting dose* (ED): 50 mg 1 hour before sexual activity (decrease by 1/2 in select pts [PDE5 inhibitors index card])

Tadalafil

PDE5 inhibitor *Use*: PAH: Adcirca ED: Cialis BPH: Cialis 5 mg *Dose* (ED): daily dosing: 2.5 - 5 mg qd On-demand dosing: 5 - 20 mg qd Starting dose: 10 mg 30 min before sexual activity (decrease by 1/2 in select pts [PDE5 inhibitors index card]) *AE*: back pain (more prominent with this one vs other PDE5 inhibitors) *CI*: nitrates, riociguat

Avanafil

PDE5 inhibitor Brand: Stendra Use: ED Starting dose: 100 mg 15 - 30 min before sexual activity (decrease by 1/2 in select pts [PDE5 inhibitors index card])

Vardenafil

PDE5 inhibitor Use: ED Starting dose: 10 mg 1 hour before sexual activity (decrease by 1/2 in select pts [PDE5 inhibitors index card])

Pancrelipase

PEP (Pancreatic Enzyme Product). Harvested from porcine pancreatic glands which contains a combination of lipase, amylase, and protease *Brands*: Creon Viokase: only PEP tablet. Non-EC, must be given with a PPI Zenpep *Use*: obstructed pancreatic flow (seen in CF pts as well) *Dose*: based on individual pt's lipase component. Adjusted q3-4d until stools are normalized Max: 10,000 units/kg/d *AE*: colonic strictures, mucosal irritation, abdominal pain, flatulence, nausea

Saquinavir

PI used for HIV, must be given with ritonavir AE: ECG changes (high risk vs other PIs when used with ritonavir), nausea

Tipranavir

PI used for HIV, must be given with ritonavir. Use caution in patients with sulfa allergy AE: hepatotoxicity (highest risk of all PIs), N/V/D BBW: hepatitis, hepatic decompensation, and intracranial hemorrhage

Lopinavir

PI used for HIV, taken with ritonavir Oral solution: take with food. Refrigerate. Contains 42% alcohol Dose: treatment naive patients can do qd or bid, other patients are bid AE: insulin resistance/hyperglycemia and ECG changes both have high risk vs other PIs. N/V/D, hyperlipidemia (especially TG)

Fosamprenavir

PI used for HIV. Adults should take oral suspension without food. Use caution in patients with sulfa allergy AE: rash

Darunavir

PI used for HIV. Caution in patients with a sulfa allergy. Must be given with a pharmacokinetic booster Brand: Prezista Dose: treatment naive patients get qd, others bid. Swallow tablets whole. Take with food AE: drug-induced hepatitis, serious skin reactions (SJS/TEN), N/V/D, HA, increased LFTs

Atazanavir

PI used for HIV. Take with food and a lot of water Brand: Reyataz AE: ECG changes (PR interval prolongation; high risk vs other PIs when used with ritonavir), severe skin reactions, indirect hyperbilirubinemia (jaundice or scleral icterus [reversible]), hepatotoxicity, nephrolithiasis, cholelithiasis, HA, depression, myalgia, asymptomatic jaundice DDIs: caution with acid-suppressive agents, they can reduce absorption of atazanavir

Indinavir

PI used for HIV. When taking with ritonavir, take with food and 48 oz of water AE: insulin resistance/hyperglycemia (high risk vs other PIs), nephrolithiasis/urolithiasis, N/V/D, HA

Ritonavir

PK Booster (and PI) used in combination with PIs to increase levels. Has antiretroviral activity. Inhibits P-gp. Take with food. Solution form contains 43% alcohol Brand: Norvir AE: N/V/D CI: alfuzosin, amiodarone, carbamazepine, dronedarone, lovastatin, phenobarbital, phenytoin, rifampin, simvastatin, St. John's wort DDI: methadone (ritonavir may decrease levels via CYP induction, monitor for methadone withdrawal) BBW: many DDIs

Cobicistat

PK booster used in combination with PIs to increase levels. Take with food. CYP inhibitor CI: alfuzosin, amiodarone, carbamazepine, dronedarone, lovastatin, phenobarbital, phenytoin, rifampin, simvastatin, St. John's wort

Other names for neutrophils

PMNs (PolyMorphoNuclear cells), polys, segs (segmented neutrophils)

Dexlansoprazole

PPI Brand: Dexilant Forms: capsules can be opened Dose: without regard to meals

Pantoprazole

PPI Brand: Protonix Forms: available IV

Diagnostic tests for pain

Pain scales

Diagnostic tests for gastric ulcer

Pain with food in stomach, no pain relief with antacids

Diagnostic tests for duodenal ulcer

Pain without food in stomach, pain relief with food/antacids

Diagnostic tests for cervical cancer

Pap smear and HPV test

Cervical cancer screening

Pap smear q3y. Pap smear + HPV test

Emergency Contraceptives

Paragard: copper IUD. Most effective form Morning after pill: levonorgestrel (Plan B One-Step), ulipristal acetate (Ella). Can be used within 5d (diminishing efficacy with time)

What causes eosinophils to increase

Parasitic infection

Abaloparatide

Parathyroid hormone analog Brand: Tymlos Use: osteoporosis (high risk patients only) Administration: pen should be discarded after 30d AE: hypercalcemia

Teriparatide

Parathyroid hormone analog. Requires protection from light Brand: Forteo Use: osteoporosis (high risk patients only) x≤2y Form: injection into abdomen or thigh Administration: pen should be discarded after 28d AE: hypercalcemia

Iron sucrose

Parenteral iron used for iron deficient anemia in select patients Brand: Venofer

Iron dextran

Parenteral iron used for iron deficient anemia in select patients. Patients should be given a test dose prior to first therapeutic dose due to high risk of anaphylaxis

Triferic

Paretneral iron Use: iron deficient anemia in patients receiving dialysis Administration: should be added to bicarbonate concentrate of hemodialysate

Ferumoxytol

Paretneral iron used for iron deficient anemia in select patients Brand: Feraheme

Buprenorphine

Partial mu-opioid agonist at low doses and antagonist at higher doses *Brands*: Butrans: patch form. Change qw. Dispose by folding sticky sides together and flush Belbuca: buccal film + naloxone: Suboxone, Zubsolv *Use*: opioid dependence, prescribers need a DATA 2000 waiver, DEA will issue them a new identification number starting with "X"

Raynaud's Phenomenon

Patho: triggered by exposure to cold and/or stress, leading to vasospasm in extremities (mainly fingers and/or toes) causing them to turn white and then blue Drugs that cause or worsen Raynaud's: beta blockers, bleomycin, cisplatin, sympathomimetics (due to vasoconstriction; amphetamines, pseudophedrine, illicit drugs) Prevention: nifedipine

PCA

Patient Controlled Analgesia. Friends and family members are not allowed (TJC requirement) to administer PCA doses

Code Blue

Patient requires emergency medical care, usually cardiac or respiratory arrest

Yellow fever

Patients should not have ASA or NSAIDs due to increased risk of bleeding *Cause*: mosquito bites *Vaccine*: YF-VAX. SC. Needs to be reconstituted with provided diluent. Patient provided International Certificate of Vaccination or Prophylaxis ("yellow card") after vaccination and is only valid if vaccination was received 10d before arrival. 1 dose is good for life CI: severe (life-threatening) allergy to eggs or gelatin

Neuromuscular blocking agents

Patients should receive adequate sedation and analgesia prior to NMBA and must be mechanically ventilated. All should be labeled with "WARNING, PARALYZING AGENT". Special care must be taken to protect these pt's skin, lubicrate their eyes, and suction their airway *Types*: depolarizing: succinylcholine is the only one Non-depolarizing: AE are flushing, bradycardia, HoTN, tachyphylaxis *MOA*: paralysis of skeletal muscle *Use*: facilitate mechanical ventilation, manage increased intracranial pressure, treat muscle spasms *DDI*: aminoglycosides can potentiate NMBA's effect

Gentamicin therapeutic range

Peak: 5-10 mcg/mL Trough: <2 mcg/mL

Tobramycin therapeutic range

Peak: 5-10 mcg/mL Trough: <2 mcg/mL

Harriet Lane Handbook

Pediatric dosing resource

Pegfilgrastim

Pegylated G-CSF Brand: Neulasta Dose: dosed less frequently due to it being longer-acting AE: bone pain

Pegaspargase

Pegylated form of asparaginase Use: cancer Dose: less frequent dosing and less allergic reactions than non-pegylated form AE: hypersensitivity reactions, prolonged prothrombin time (PT/INR)

Pegasys

Pegylated interferon alfa-2a Use: HCV

DOC for VRE

Pen G, ampicillin, linezolid, daptomycin Cystitis: nitrofurantoin, fosfomycin, doxycycline

Common drugs that require refrigeration after reconstitution

Pen VK, ampicillin, and Augmentin

Beta-lactam antibiotics

Penicillins, cephalosporins, and carbapenems MOA: inhibit wall synthesis AE: lower seizure threshold

Vitamin B12 deficiency symptoms

Peripheral neuropathies and serious neurological dysfunction which can become irreversible

Pink Sheet

Pharma Intelligence. News reports on regulatory, legislative, legal, and business developmets

Cardiac Action Potential

Phase 0: rapid ventricular depolarization Phase 1: early rapid repolarization Phase 2: plateau response Phase 3: rapid ventricular repolarization Phase 4: atrial depolarization

Biggest CYP inducers

Phenytoin, smoking, phenobarbital, oxcarbazepine, rifampin, carbamazepine, St. John's Wort Effects of inducers may take up to 2-4 weeks to go away after stopping medication

Ferric citrate

Phosphate binder. A form of iron that is systemically absorbed Brand: Auryxia

Statin equivalent dosing

Pitavastatin 2 mg Rosuvastatin 5 mg Atorvastatin 10 mg Simvastatin 20 mg Lovastatin 40 mg Pravastatin 40 mg Fluvastatin 80 mg (Lescol) (Pharmacists Rock AT Saving Lives and PReventing FLU)

Psoriasis

Plaque psoriasis is most common form (raised, red patches covered with silvery white buildup *Nonpharm treatment*: UV light exposure: causes activated T cells int he skin to die UVB phototherapy: can improve mild to moderate psoriasis *Pharm treatment*: topical steroids, vitamin D analogues, anthralin, retinoids, salicylic acid, coal tar, moisturizers. Topical calcineurin inhibitors can be tried if traditional options fail

Thrombocytopenia treatment in cancer

Platelet transfusion

Oxaliplatin

Platinum AE: cold-mediated sensory neuropathy (avoid cold temperatures and cold drinks)

Cisplatin

Platinum Dose: should not exceed 100 mg/m^2 per cycle due to nephrotoxicity (unless confirmed with prescriber). Can be given with amifostine (Ethyol) to decrease risk. Hydration with hypertonic solutions increases urine output to flush the kidneys (mannitol, hypertonic saline) AE: *MAJOR N/V*, nephrotoxicity (cisplatin has the highest incidence of both previous AE than other platinums. Can be given with amifostine [Ethyol] as a chemoprotectant), ototoxicity

Carboplatin

Platinum Use: cancer Dose: Calvert Formula (total dose [mg] = Target AUC x [GFR + 25])

Apremilast

Po PDE4 inhibitor Use: psoriasis AE: weight loss and DA

Acitretin

Po retinoid Use: severe cases of psoriasis

POC testing

Point of Care testing. Testing for patient specific lab values (A1c, INR, etc)

OTC for constipation <1 yo

Polyethylene glycol 3350: MiraLax. For intermittent constipation Dietary: prunes Pediatric-size glycerin suppositories: quick relief

Diagnostic tests for COPD

Post-bronchodilator FEV1/FVC < 0.7

DailyMed website

Posts current package inserts

Potassium lab

Potassium level should be checked if renal function changes, any changes in diuretic, ACEI, ARB, or ARA (Aldosterone Receptor Antagonist) dose. Magnesium levels should be checked and corrected prior to potassium levels

Eplerenone

Potassium-sparing diuretic Brand: Inspra MOA: selective aldosterone receptor antagonist AE: does not have endocrine side effects unlike spironolactone

Spironolactone

Potassium-sparing diuretic MOA: non-selective aldosterone receptor antagonist and also blocks androgen AE: gynecomastia, breast tenderness, and impotence

Vinca alkaloids

Potent vesicants (hyaluronidase used to treat) MOA: inhibit function during M phase of cell cycle Use: cancer AE: peripheral sensory neuropathy, autonomic neuropathy (constipation) BBW: for IV administration only (intrathecal is fatal)

PrEP

Pre-Exposure Prophylaxis for patients at risk for HIV who don't have HIV. Must have follow-up visits q3m. Must be tested for HIV, HBV, and STIs before initiating Dose: Truvada (emtricitabine/tenofovir DF) 1 tablet po qd

Ovulation predictor kits

Predict best time for intercourse. The mid-cycle LH surge results in release of oocyte (egg) and it lives int he fallopian tube for 24h. Most kits are positive when LH is present. Couple should have intercourse when LH surge is detected and for the following 2d

Anticoagulants

Prevent blood clot formation, they do not break down clots *Use*: ACS, prevention of cardioembolic stroke, and prevention/treatment of VTE (DVT and PE) *AE*: bleeding Cal 911: black stools, coughing/throwing up what looks like coffee grounds, unusual bruising, frequent nose bleeds, unusual bleeding gums

Genital warts

Prevention: Gardasil vaccine (also reduces risk of cervical and other cancers) Cause: HPV (Human PapillomaVirus) Treat: imiquimod cream

Hemorrhoids

Prevention: fiber to reduce straining Symptoms: bright red rectal bleeding Treatments: Preparation H (PE; vasoconstrictor, shrinking the hemorrhoid, reducing burning and itching), hydrocortisone (Anusol-HC, Preparation H Hydrocortisone), witch hazel (Tucks pads)

Anemia of CKD

Primarily due to a lack of erythropoietin (EPO; stimulates production of RBCs) *Treatment are ESAs*: erythropoiesis stimulating agents. Should only be used when hemoglobin < 10. Hold or discontinue if hemoglobin > 11 due to risk of thromboembolic disease. Only effective if adequate iron is available Examples: epoetin alfa (Procrit and Epogen) and darbepoetin alfa (longer-lasting formulation; Aranesp) AE: HTN

Polymyxins

Primarily used for MDR gram - *Coly-Mycin M*: prodrug that is converted to colistin. Be careful when dosing (can be represented as units, mg, etc) AE: dose-dependent nephrotoxicity and neurotoxicity *Polymyxin B sulfate*: BBW: nephrotoxicity and neurotoxicity (can result in respiratory paralysis from neuromuscular blockade)

Aztreonam

Primarily used when patient has beta-lactam allergy Covers: many gram - (including pseudomonas). No gram + or anaerobic activity *Cayston*: inhalation solution Use: targets pseudomonas aeruginosa in CF pts Dose: should be taken at least 4h apart Administration: do not mix with any other drugs in the nebulizer. Refrigeration recommended, can be kept at room temperature for up to 28d AE: allergic reactions (may be severe), bronchospasm, fever, wheezing, cough, chest discomfort

Acetazolamide

Primary prophylactic for altitude sickness. Should be started the day before (preferred) or day of ascent MOA: carbonic anhydrase inhibitor AE: polyuria, phototoxicity CI: sulfa allergy

FMEA (Failure Mode and Effects Analysis)

Proactive method used to reduce frequency and consequences of errors that have happened

Drospirenone

Progestin MOA: potassium-sparing diuretic, decreases bloating AE: clotting (higher risk than others), hyperkalemia

Epoprostenol

Prostacyclin analog Brand: Flolan (requires use of ice packs for stability), Veletri Use: PAH Administration: protect from light. Continuous infusion AE: flushing, jaw pain

Misoprostol

Prostaglandin E1 analog AE: diarrhea, abdominal pain BBW: abortifacient

Travoprost

Prostaglandin analog Brand: Travatan Z Use: glaucoma

Latanoprostene bunod

Prostaglandin analog. Keep in the refrigerator Use: glaucoma

Zioptan

Prostaglandin analog. Keep in the refrigerator Use: glaucoma

Latanoprost

Prostaglandin analog. Keep in the refrigerator. After opened, it can be kept at room temperature Brand: Xalatan Use: glaucoma Dose: qpm

Bimatoprost

Prostaglandin analog. Wait 15 min before reinserting contact lenses *Brands*: Lumigan Latisse: increases eyelash growth *Use*: glaucoma and hypotrichosis *Administration*: hypotrichosis: qpm to skin base of upper eyelashes *DDI*: PG analogs used for glaucoma (may increase IOP)

Pre-mixed insulins

Protamine and NPH insulins are cloudy. Humulin 70/30, Humulin 70/30 KwikPen, and Novolin 70/30 are available without a prescription. Named as the percentage of each component with long acting first

Bortezomib

Proteasome inhibitor Use: cancer AE: herpes reactivation (can be given with an antiviral [acyclovir, valacyclovir]), peripheral neuropathy

Carfilzomib

Proteasome inhibitor Use: cancer AE: peripheral neuropathy

P-glycoprotein efflux pump

Protect against foreign substances Drugs that inhibit pump: anti-infectives (clarithromycin, itraconazole), cardiovascular drugs, HIV drugs, HCV drugs (-asvir, -previr), cyclosporine, flibanserin, ticagrelor

ACIP (Advisory Committee on Immunization Practices)

Provides recommendations for vaccine administration. CDC approves recommendations and publishes them in CDC's Morbidity and Mortality Weekly Report (MMWR) and The Pink Book. CDC provides Vaccine Information Statements (VIS) for each vaccine and law requires each VIS be handed to the patient before vaccination

Antacids

Provides relief within minutes but only lasts for 30-60 min. Calcium containing products preferred in pregnancy. Aluminum containing products can cause constipation *Dose*: 4-6x/d *Warnings*: aluminum and Mg containing products can accumulate and cause renal dysfunction *DDI*: rilpivirine, atazanavir, ledipasvir, velpatasvir/sofosbuvir, itraconazole, ketoconazole, posaconazole oral suspension, cefditoren, cefpodoxime, cefuroxime, iron products, mesalamine, erlotinib, INSTIs, bisphosphonates, isoniazid, mycophenolate, quinolones, sotalol, steroids (especially budesonide), tetracyclines (less with doxy and mino), thyroid products, delavirdine, dasatinib, pazopanib, risedronate DR (Atelvia)

Antibiogram

Provides susceptibility patterns for certain bacteria at a hospital over a period of time

Nicotine inhaler

Puff in short, frequent breaths. Each cartridge provides about 20 min of continuous puffing. Clean mouthpiece with soap and water qw AE: mouth and throat irritation DDI: acidic beverages interfere with absorption, wait 15 min after eating or drinking

PAH

Pulmonary Arterial Hypertension *Causes*: cocaine and SSRI use during pregnancy *Diagnosis*: right heart catheterization may be needed to confirm PAH diagnosis and determine responsiveness to acute vasoreactivity PAP: ≥25 *Nonpharm treatment*: sodium-restricted diet: <2.4 g/d to manage volume status Immunizations: routine influenza and pneumococcal *Pharm treatment*: warfarin: the biochemical changes PAH causes can lead to a pro-thrombic state. Anticoagulation with a goal of 1.5-2.5 can be considered Loop diuretics: supportive treatment. Volume overload Digoxin: supportive treatment. Improves cardiac output or controls heart rate CCB: for patients who are considered responders after right heart catheterization (mPAP falls by at least 10 to a value less than 40). Usually long-acting nifedipine, diltiazem, or amlodipine; never verapamil Prostacyclin analogs & receptor agonists, PDE5, or ERAs or sGC (soluble Guanylate Cyclase) stimulator: non-responders to right heart catheterization or responders who failed CCB. Riociguat Pregnancy: PDE5 or prostacyclin analog

PPD

Purified Protein Derivative or Mantoux test. TB test

Fluorouracil

Pyrimidine analog antimetabolite. Aka 5-FU. Usually given with leucovorin or levoleucovorin (Fusilev) to increase efficacy Use: cancer AE: mucositis, DA (usually occurs several days after), HF syndrome, increased risk of toxicity if DPD deficient Antidote: uridine triacetate (Vistogard) to be used within 96h

Capecitabine

Pyrimidine analog antimetabolite. Oral prodrug of 5-FU Brand: Xeloda Use: cancer Dose: wc AE: mucositis, DA (usually occurs days after), HF syndrome, increased risk of toxicity if DPD deficient Antidote: uridine triacetate (Vistogard) to be used within 96h

Delirium in ICU

Quetiapine

Meglitinides

Quicker onset than sulfonylureas MOA: secretagogue (stimulates insulin secretion to decrease postprandial glucose) Drugs: end in "-glinide" Dose: if skipping a meal, skip dose AE: hypoglycemia (hunger, confusion, sweating, seizures) and weight gain

Denosumab

RANKL inhibitor Brands: Prolia (osteoporosis for high risk patients) and Xgeva (hypercalcemia of malignancy) MOA: monoclonal antibody that binds to RANKL, preventing interaction between RANKL and RANK, preventing osteoclast formation Dose: SC q6m in medical office AE: hypocalcemia, ONJ, femur fractures, HTN, fatigue, edema, dyspnea, HA, N/V, DA, decreased phosphorus levels CI: hypocalcemia, pregnancy

HIV MOA, diagnosis, and initial evaluation & monitoring

RNA retrovirus that attacks the immune system, mainly the CD4+ T-helper cells, causing a progressive decrease in CD4+ T cell count. Once CD4 < 200, patient becomes at increased risk of infections *Diagnosis*: during an acute infection, anti-HIV antibodies (HIV Ab) are undetectable (will present in 4-8w after contraction of disease), but HIV RNA and HIV p24 antigen will be present (using HIV Ab and antigen immunoassay test). If initial testing is positive, perform confirmatory testing with an HIV-1/HIV-2 antibody differentiation immunoassay test OTC (HIV Ab screening test): Should be used ≥3m after exposure. Home Access Express HIV Test System (blood test) and OraQuick In-Home HIV test (oral swab that offers results in 20-40 min) *Initial evaluation and monitoring*: CD4 count: treatment goal of 800-1200 HIV viral load: indicator of response to ART. Treatment goal is to have undetectable viral load HepB and HepC testing should be performed at baseline

Stimulants

Raise DA and NE levels Dose: qam, titrated up q7d. Does not need to be tapered off if not abused Use: ADHD (first line drug treatment) AE: nausea, insomnia, HA, irritability, blurry vision, dry mouth, priapism Warning: exacerbation of mixed/mania episodes can occur in patients with pre-existing bipolar disorder, increase risk of seizures, loss of appetite (can cause decrease in growth in children) CI: MAOI within 14d (serious CV events) Monitoring: consider ECG prior to treatment (not needed during), monitor bp & hr, height & weight (children) OD: BZD

Menstrual cycle

Ranges from 23-35d (average 28d). Start of menses (bleeding) indicates that the next cycle has begun and is counted as day 1 *Phases*: follicular: surge in estrogen causes LH (Luteinizing Hormone) and FSH to increase Ovulatory: LH surge triggers ovulation (also causes corpus luteum development in ovary) Luteal

Diagnostic tests for syphillis

Rapid Plasma Reagin Test

Insulin lispro

Rapid-acting insulin Brands: Humalog and Humalog KwikPen (comes in 200 units/mL and 100 U/mL)

Insulin aspart

Rapid-acting insulin Brands: Novolog and Novolog FlexPen (stable for 28d at room temperature)

Afrezza

Rapid-acting insulin. Replace inhaler q15d. Once opened, stable at room temperature for 3d Form: oral inhalation powder CI: asthma, COPD, not recommended in pts who smoke or who have recently stopped smoking BBW: acute bronchospasm (asthma, COPD) Monitoring: FEV1

Dantrolene

Rarely used muscle relaxant Brand: Dantrium Use: malignant hyperthermia, adjuvant for pain management

Noyes-Whitney equation

Rate of dissolution. Increase rate of dissolution by either increasing the tablet surface area or decreasing the size

Clearance equation

Rate of elimination / concentration

Master Formulation Record (MFR)

Recipe that provides the ingredients and instructions on how to prepare a compounded product

Alemtuzumab

Recombinant humanized monoclonal antibody Brand: Lemtrada Use: MS Part of REMS

Ocrelizumab

Recombinant humanized monoclonal antibody Brand: Ocrevus Use: MS

Recothrom

Recombinant thrombin, hemostatic agent. Not associated with disease transmission and is less immunogenic than previous formulations

Pegloticase

Recombinant uricase Brand: Krystexxa MOA: converts uric acid to allantoin Use: chronic gout for severe refractory disease Form: IV AE: risk of anaphylaxis DDI: allopurinol, febuxostat BBW: anaphylactic reactions- premedicate with antihistamines and steroids

Lactation

Recommended to breastfeed baby for first 6m, not recommended in women with HIV. Babies receiving breast milk partially or exclusively should receive 400 IU of vitamin D qd. Also should receive 1 mg/kg iron qd during months 4 - 6 *Drugs to avoid*: codeine and tramadol: risk of excessive sleepiness, breathing difficulty, and/or death (especially in CYP450 2D6 ultra-rapid metabolizers *(SO FELLA)* Opioids, amphetamines, ergotamines, lamotrigine, lithium, statins, Flagyl

Simple compounding

Reconstituting a commercial product by adding water or alcohol as directed by manufacturer

Resources for drug pricing

Red Book

Rifampin

Red IV fluid

Comminution

Reduce particle size by grinding, crushing, milling, or vibrating *Main methods*: trituration: mixing product thoroughly to make it homogenous. Usually grinding tables in a mortar and pestle until a fine powder is achieved or shaking a liquid emulsion Levigation and spatulation: levigation involves triturating the powder with a mortar and pestle by incorporating a small amount of liquid (levigating agent or wetting agent) to help with grinding process. Spatulation is the same method but using an ointment slab and spatula instead of mortar and pestle Pulverization by intervention: used for crystalline powders that will not crush easily. Crystals are dissolved with an intervening solvent

Systemic steroids

Reduce risk of AE by using alternate day dosing, give a high dose initially then taper down (dose packs), and use a steroid with low systemic absorption *Least potent to most potent*: Cute Hot Pharmacists and Physicians Marry Together & Deliver Babies. Cortisone, Hydrocortisone, Prednisone, Prednisolone, Methylprednisolone, Triamcinolone, Dexamethasone, Betamethasone Equivalent dosing (retrospectively): 25, 20, 5, 5, 4, 4, 0.75, 0.6 *AE*: short-term side effects can lead to increase in blood glucose (diabetes), increase in bp (HTN), increase in intraocular pressure (glaucoma), and emotional instability/euphoria/mood swings (psychiatric conditions). Adrenal suppression Other: buffalo hump, osteoporosis, impaired wound healing *Immunosuppressed*: pt becomes immunosuppressed if using ≥ 2 mg/kg/d or ≥ 20 mg/d x >2w. They cannot receive live vaccines. Due to HPA axis suppression, the steroid will need to be tapered slowly to allow the adrenal gland to resume normal cortisol production. Immunosuppression can lead to re-activation of TB, HepB, & HepC, viral infections which can be prevented by a live vaccine prior to start of therapy, lymphomas & certain skin cancers, and infections *Monitoring*: bp, weight, appetite, mood, growth (children), bone mineral density, blood glucose, electrolytes, IOP (if >6w), infection

RCA (Root Cause Analysis)

Retrospective investigation of an event that has already occured. Involves reviewing sequence of events that led to the error. Viewed as a repetitive process and is important as a Continuous Quality Improvement (CQI) tool

Case control study

Retrospective study that compares a patient with a disease to those without the disease

Tinea capitis

Ringworm of the scalp

Chemical exposure to eye treatment

Rinse eye gently with water from tap or hose (not a shower) for 15 min

Relative Risk

Risk in exposed group / risk in control group. Means the exposed person is that much less likely of getting the adverse reaction

RotaTeq

Rotavirus vaccine. Given at ages 2, 4, and 6 months Form: po

Wedgwood mortar

Rough surface and is preferred for grinding dry crystals and hard powders

Cardiac conduction pathway

SA node, AV node, bundle of His, right and left bundle branches, Purkinje fibers

Levalbuterol

SABA. Contains R-isomer of albuterol Brand: Xopenex Use: asthma

Albuterol

SABA. Inhaler should last 12m if patient has good asthma control. All have 200 inhalations/canister. Can also lower potassium levels *Brands*: ProAir HFA, ProAir RespiClick (BBW for patients who have severe hypersensitivity to milk proteins), Ventolin HFA (available as 200 inhalations/canister and 60 inhalations/canister), Proventil HFA *Use*: asthma *Dose*: DPI/MDI: 1-2 inhalations q4-6h prn Po: not recommended *Inhaler how to use*: Ventolin HFA, ProAir HFA: shake well for 5 sec before each spray. Breathe in slowly and deeply. Hold your breath for up to 10 sec. Let air dry, clean qw ProAir Respiclick: opening and closing the cap without inhaling, will waste a dose. Hold breath for at least 10 seconds after inhaling. Rinse mouth with water and spit. Do not shake

Racepinephrine

SABA. Should never be used since it is non-selective

Fulvestrant

SERM Brand: Faslodex Use: breast cancer

Tamoxifen

SERM Brand: Soltamox Use: breast cancer in men, adjuvant hormonal therapy for females with breast cancer who are HER positive Dose (adjuvant hormonal therapy): x5y, if still premenopausal give for another 5y AE: endometrial cancer, blood clot, cataracts DDI: recommend venlafaxine over fluoxetine for hot flashes

Canagliflozin

SGLT-2 Inhibitor Brand: Invokana Use: diabetes AE: hyperkalemia

Empagliflozin

SGLT-2 inhibitor Brand: Jardiance Use: approved to reduce risk of CV mortality in pts with type 2 diabetes and ASCVD

Duloxetine

SNRI Brand: Cymbalta Use: peripheral neuropathy, depression, fibromyalgia, anxiety DDI: will decrease effectiveness of tamoxifen

Desvenlafaxine

SNRI Brand: Pristiq Use: depression Form: OROS

Venlafaxine

SNRI Brands: Effexor, Effexor XR Dose: max 375 mg/d for IR (HTN likely when > 150 mg/d) Use: depression and anxiety AE: QT prolongation

Savella

SNRI Use: fibromyalgia pain

Citalopram

SSRI Brand: Celexa Dose: recommended max of 40 mg/d, 20 mg/d if ≥ 60yo due to QT prolongation

Escitalopram

SSRI Brand: Lexapro AE: QT prolongation (more so than other SSRIs, along with citalopram)

Sertraline

SSRI Brand: Zoloft DDI: will decrease effectiveness of tamoxifen

Vilazodone

SSRI and 5-HT1A partial agonist Use: depression Administration: wc AE: decreased libido (not as bad as SSRIs) CI: MAOI BBW: increased risk of suicidal thinking and behavior in children, adolescents, and young adults

Vortioxetine

SSRI, 5-HT receptor antagonist, and 5-HT1A agonist Brand: Trintellix Use: depression AE: nausea

Fluoxetine

SSRI. CYP2D6 and 2C19 inhibitor *Brands*: Prozac Sarafem: premenstrual dysphoric disorder *AE*: can be activating (energizing) *DDI*: will decrease tamoxifen effectiveness

Paroxetine

SSRI. CYP2D6 inhibitor *Brands*: Brisdelle: non-hormonal FDA approved treatment for moderate-severe vasomotor symptoms associated with menopause Paxil, Paxil CR: depression, anxiety Pexeva *DDI*: tamoxifen (paroxetine is a strong CYP450 inhibitor, decreasing tamoxifen's effectiveness), warfarin (increase risk in bleeding)

Entresto

Sacubitril + valsartan MOA: angiotensin receptor and neprilysin inhibitor. Neprilysin degrades several beneficial vasodilatory peptides, counteracting effect of RAAS activation and produces vasodilation Use: CHF (in place of ACEI or ARB) AE: angioedema, renal impairment, hyperkalemia, hypotension, cough CI: ACEI or ARB (must have 36h wash-out period for either) BBW: teratogenic Monitoring: bp, K, renal function, s/sx of HF

Lorazepam

Safest of the BZDs to use in elderly and those with liver impairment (since they are metabolized to inactive glucuronides) Brand: Ativan Use: agitation/sedation in ICU, anxiety, sleep Forms: injection (formulated in PEG, PEG toxicity can occur- acute renal failure and metabolic acidosis)

Magnesium salicylate

Salicylate NSAID Brand: Doans

Methyl salicylate

Salicylate NSAID. OTC topical found in Bengay

Aspirin

Salicylate NSAID. Should be given to all SIHD patients indefinitely (unless CI). Chewable ASA is preferred in ACS, if only EC is available, 325 mg should be chewed *Brands*: Bayer, Durlaza EC: Bufferin, Ecotrin +omeprazole: Yosplera. Indicated for patients who are at risk for gastric ulcers *MOA*: binds irreversibly to COX-1 and COX-2, resulting in decreased prostaglandin and thromboxane A2 *Use*: angina and antiplatelet used to prevent recurrent stroke in noncardioembolic ischemic stroke or TIA patients *Dose*: cardioprotection: 81 - 162 mg qd *AE*: bleeding, dyspepsia, heartburn, nausea, increased UA *DDI*: if using ASA for cardioprotection and ibuprofen for pain, take ASA 1h before or 8h after ibuprofen *CI*: salicylate allergy, children & teenagers (Reye's Syndrome)

Pulmonary fibrosis

Scarred and damaged lung tissue Causes: certain drugs Symptom: dyspnea

Aripiprazole

Second generation antipsychotic *Brands*: Abilify Abilify Maintena: IM qm for psychosis/ schizophrenia Aristada: IM q4-8w for psychosis/ schizophrenia Abilify Discmelt: comes in a blister pack- open with dry hands and do not push through pack, it may crumble. Patient does not need water if not needed *Use*: depression, psychosis, schizophrenia *AE*: low risk for metabolic side effects. Akathisia, anxiety, insomnia *BBW*: increased risk of suicidal thinking and behavior in children, adolescents, and young adults

Paliperidone

Second generation antipsychotic *Brands*: Invega: part of tablet can pass into stool, normal Invega Sustenna: IM injection qm Invega Trinza: IM, q3m. Start only after receiving Invega Sustenna x4m *AE*: moderate risk for metabolic side effects, high risk for increased prolactin levels. EPS (at higher doses especially) *CI*: avoid if patient has history of TD

Olanzapine

Second generation antipsychotic *Brands*: Zyprexa Zydis ODT Relprevv: injectable suspension. Lasts 2-4w. BBW for sedation and delirium (must be given in a healthcare facility and patient must be monitored for 3h post-injection) *AE*: high risk for metabolic side effects. Somnolence, weight gain, increased lipids, increased glucose *DDI*: BZDs (should not be given together IM due to orthostasis risk)

Asenapine

Second generation antipsychotic Brand: Saphris Form: SL tablet Administration: no food or drink 10 min after AE: low risk for metabolic side effects. Tongue numbness

Ziprasidone

Second generation antipsychotic Brands: Geodon, Geodon IM (acute injection) Administration: wc AE: higher risk for QT prolongation than other SGAs, low risk for metabolic side effects CI: QT prolongation

Risperidone

Second generation antipsychotic Brands: Risperdal and Risperdal Consta (IM q2w) Administration: can be put into a feeding tube or mixed with water, coffee, OJ, or low fat milk AE: higher risk for CV events than other SGAs, moderate risk for metabolic side effects, high risk for increased prolactin levels. EPS (especially at higher doses), weight gain, increased lipids, increased glucose, infection CI: avoid if patient has history of TD

Clozapine

Second generation antipsychotic. A trial run should only be considered for patients who have had no or poor response to two trials of other antipsychotic medications (one being an SGA) Brand: Clozaril, FazaClo (ODT) AE: high risk for metabolic side effects, highest risk for hematological side effects of the SGAs, highest risk for seizures of the SGAs (dose-dependent). Weight gain, increased lipids, increased glucose, sialorrhea BBW: agranulocytosis/neutropenia, myocarditis, cardiomyopathy, seizures. REMS Monitoring: to start treatment, ANC must be ≥ 1500. Stop therapy if < 1000

Lurasidone

Second generation antipsychotic. Generally safe in pregnancy Brand: Latuda Use: psychosis, schizophrenia, bipolar depression AE: low risk for metabolic side effects CI: avoid if patient has history of TD

Agitation in ICU

Sedation sometimes necessary to maintain synchronized breathing with ventilator (to prevent "bucking" the ventilator). Daily interruptions of sedative drugs ("sedation vacations") are used to assess readiness to wean off *Treatment*: BZD: good for pts with seizures or alcohol/BZD withdrawal Non-BZDs: preferred for sedation. Shown to have improved ICU outcomes. Dexmedetomidine

Status epilepticus

Seizure lasting longer than 5 minutes *Treatment*: 0-5 minutes: stabilization phase. Start EEG, check if BG is low, treat with D25-D50. Check AED levels, electrolytes, and oxygen 5-20 minutes: initial treatment phase. If seizure continues, give IV BZD. Give IM midazolam or rectal diazepam if IV BZD not available 20-40 minutes: if seizure continues, give IV fosphenytoin, valproic acid, levetiracetam. Give phenobarbital if none are available Diastat Acudial: given to patients who are at risk for long-lasting seizures. Each has 2 rectal syringes prefilled with diazepam rectal gel. Come in 2.5, 10, and 20 mg. Syringes must be dialed to the right dose and locked before dispensing. Once locked, green band should say READY and the syringe cannot be unlocked

Selegiline

Selective MAO-B inhibitor *Use*: Parkinson's Disease Emsam patch: depression. Change qd *Dose*: do not take at bedtime (it is energizing)

Safinamide

Selective MAO-B inhibitor Brand: Xadago Use: Parkinson's Disease CI: severe hepatic impairment

STIs

Sexual partners should be treated concurrently to prevent reinfection *Diagnosis*: syphilis: RPR aka VDRL *Symptoms*: chlamydia: asymptomatic or genital discharge Gonorrhea: asymptomatic or genital discharge Syphilis: painless, smooth genital sores HPV: asymptomatic or genital warts Bacterial vaginosis: females only. Vaginal discharge (clear, white, or gray) that has a fishy odor and pH > 4.5. Little or no pain Trichomoniasis: yellow/green frothy discharge, soreness, pain with intercourse *Treatment*: syphilis (<1y duration): Bicillin L-A 2.4 million U IM x1. Can use doxycycline. Pregnant patients allergic to PCN should be desensitized and treated with Bicillin L-A Syphilis (>1y duration): Bicillin L-A 2.4 million U IM qw x3w Gonorrhea: ceftriaxone 250 mg IM x1 + azithromycin (preferred)/doxycycline Chlamydia: azithromycin 1 g po x1 Bacterial vaginosis: Flagyl po, Flagyl 0.75% gel, or clindamycin po. Females with this should not douche Trichomoniasis: Flagyl 2 g po x1 (including during pregnancy) Gonorrhea and chlamydia infection: ceftriaxone 250 mg IM + azithromycin 1 g/doxycycline 100 mg bid x7d

Manufacturing capsules

Shells are made of either gelatin (animal product) or hypromellose (vegetable product). Glycerol and sorbitol are used as plasticizers to make capsules less brittle and more flexible. It is prepared by either hand filling method or manual capsule-filling machine

SABAs

Short Acting Beta-2 Agonists. MDIs should be shaken well before use. Most contain 200 inhalations/canister MOA: relaxation of bronchial smooth muscle, leading to bronchodilation Use: asthma (all patients who have asthma should be on this, prn) and EIB (Exercise Induced Bronchospasm. DOC. Use 5-15 min prior to exercise, lasts 2-3h) AE: nervousness, tremor, tachycardia, palpitations, cough, hyperglycemia, hypokalemia

Concentrated regular insulin

Short-acting insulin. 5x as concentrated as regular insulin, recommended when pts require > 200 U/d. Do not mix with other insulins Brands: Humulin R U-500 and Humulin R U-500 KwikPen Warnings: a U-500 insulin vial must be prescribed with a U-500 insulin syringe to avoid dose error

Regular insulin

Short-acting insulin. Insulin of choice for IV solutions, including TPN. Available without a prescription Brands: Humulin R, Novolin R, Novolin R ReliOn

Midazolam

Shortest acting BZD IV Brand: Versed (brand is d/c but brand name still used in practice) AE: active metabolite can accumulate in pts with renal impairment CI: potent CYP3A4 inhibitors

Poliovirus vaccine

Single lifetime booster dose recommended at least 4w prior to travel. Inactivated

Diagnostic tests for allergic reactions

Skin prick and IgE antibodies in the blood

Porcelain mortar

Smooth surface and is preferred for blending powders and pulverizing gummy consistencies

Metabolic acidosis treatments

Sodium bicarbonate (Neut): monitor sodium Sodium citrate/citric acid solution (Bicitra): monitor sodium

Suprep Bowel Kit

Sodium sulfate, potassium sulfate, and Mg sulfate Use: whole bowel irrigation

Suspension

Solid dispersed in a liquid. Heterogeneous

Solution

Solute dissolved in a solvent. Homogeneous

Vasopressors

Solutions should not be used if they are discolored or contain a precipitate MOA: stimulate multiple receptors, including alpha-1 and beta-1 leading to vasoconstriction, increased SVR (Systemic Vascular Resistance), increased hr & bp Form: central IV line AE: arrhythmias, tachycardia, necrosis BBW: vesicant when administered IV, treat extravasation with phentolamine (alpha-1 blocker) Monitoring: continuous bp

Error of Commission

Something was done incorrectly

Error of Omission

Something was left out that is needed for safety

Obligate intracellular parasites

Sometimes used to refer to viruses because they are dependent on host cell's metabolic processes for survival

Allele

Specific form of a gene. Most commonly occurring allele is the wild-type

Malaria

Spread through Anopheles mosquito. Caused by P. vivax or P. falciparum (most deadly species). No vaccine available *Prophylaxis*: started 1-2 d prior to travel: Malarone (Atovaquone/proguanil), doxycycline, primaquine (not used in patients with G6PD-deficiency). Daily regimens, avoid in pregnancy, causes nausea Started 1-2w prior to travel: chloroquine (stop 4 w after travel and AE is visual changes) and mefloquine (CI are underlying psychiatric conditions, seizures, or arrhythmias). Taken weekly

Zika virus

Spread through mosquitoes, possibly through sexual contact and blood transfusions. Causes infants to be born with microcephaly

Meningitis

Spread via respiratory secretions. High risk patients are travelers going to meningitis belt in Sub-Saharan Africa and those with HIV or asplenia/sickle cell disease *Causes*: strep pneumoniae (will look like dark purple diplococci on gram stain), neisseria meningitidis, and haemophilus influenzae. Listeria monocytogenes prevalent in neonates, > 50 yo, immunocompromised *Diagnosis*: lumbar puncture *Symptoms (require urgent treatment)*: fever, severe HA, nausea, nuchal rigidity, altered mental status *Treatment*: dexamethasone prior to or with first antibiotic <1m old: ampicillin (never ceftriaxone) + gentamicin. OR ampicillin + cefotaxime 2-50 yo: vanco + ceftriaxone / cefotaxime >50 yo: ampicillin PCN allergy: quinolone + vanco *Vaccine*: required by Saudi Arabia during Hajj (serotype B not required) Menveo: both of the vials (powder and liquid) contain the vaccine Menactra Bexsero: meningococcal serotype B. Recommended for patients with asplenia/sickle cell disease, lab workers exposed to N. meningitidis, and during an outbreak

Drug use in pregnancy

Standards set by ACOG (American College of Obstetricians and Gynecologists) Embryo is most susceptible to birth defects during the first trimester *Necessary drugs*: folate (Vitamin B9): deficiency can cause neural tube defects. Obtain via dietary supplements, fortified foods, and regular diet. Non-pregnant women should get 400 mcg/d, pregnant women 600 mcg/d Calcium: 1000 mg/d. If mother does not get enough, the embryo will build his/her skeleton by depleting the mother's Vitamin D: 600 IU/d *Pregnancy categories for drugs*: Old way: A (no risk), B (animal studies did not show a fetal risk), C (animal studies have shown harm to the fetus and there are no controlled studies in human, or humans/animals unavailable. Give only if benefit outweighs risk), D (positive evidence of fetal risk but benefits may outweigh the risk), X (CI) New way: has pregnancy sections in package insert. Section 8.1 Pregnancy (risk of adverse developmental outcomes; encouraged to participate in registries), 8.2 Lactation (whether the drug/metabolites go into human milk), 8.3 Females & Males of Reproductive Potential (effects on fertility and requirements for pregnancy testing & oral contraception

Armodafinil

Stimulant Brand: Nuvigil Use: narcolepsy AE: severe life-threatening rash

Modafinil

Stimulant Brand: Provigil Use: narcolepsy AE: severe life-threatening rash

Dextroamphetamine / amphetamine

Stimulant Brands: Adderall IR, Adderall XR, Mydayis Use: ADHD, narcolepsy CI: dextroamphetamine IR not recommended in children 5 years of age or younger

Bisacodyl

Stimulant laxative Brand: Dulcolax

Senna

Stimulant laxative Brand: Ex-Lax, Senokot

Constipation treatment in cancer patients

Stimulant laxatives, PEG

Lisdexamfetamine

Stimulant. Low abuse potential. Prodrug composed of l-lysine, if injected or snorted, the head rush is muted *Brand*: Vyvanse *Forms*: capsule: can be opened and mixed in water Chewable tablet

TSH

Stimulates production of T4 (elevations of T4 cause negative feedback and decreases TSH) Increases or decreases due to amiodarone or interferons. Increases due to tyrosine kinase inhibitors, lithium, or carbamazepine

Colon cancer screening

Stool-based tests: fecal occult blood test, stool DNA test Visual exams of colon and rectum: colonoscopy q10y, sigmoidoscopy q5y, CT colonography

DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) treatment

Stop offending agent. Symptoms may still continue to worsen for a period of time, this is normal

St. John's wort

Strong CYP3A4 inducer and p-gp Use: depression, anxiety, sleep AE: photosensitivity, serotonin syndrome, lower the seizure threshold

Aprepitant

Substance P/NK1 RA Brand: Emend Use: CINV DDI: dexamethasone dose should be decreased

Fosaprepitant

Substance P/NK1 RA Brand: Emend Use: CINV Form: injection DDI: dexamethasone dose should be decreased

Mucositis treatment in cancer patients

Symptomatic

Anticholinergics OD

Symptoms: flushing, dry skin, mydriasis, blurry vision Treatment: supportive care. Rarely physostigmine

Uric acid

Synovial joint fluid can also be used to identify uric acid crystals Produced: metabolism of purine (present in many foods and make up one of the base pairs of DNA) Normal level: 2 - 6.5 in females and 3.5 - 7.2 in males Drugs that can increase it: ASA (high doses), diuretics (loop and thiazides), niacin, pyrazinamide, select pancreatic enzyme products, calcineurin inhibitors (tacrolimus and cyclosporine), select chemo (with tumor lysis syndrome) Hyperuricemia: buildup can be asymptomatic or can cause painful gout attacks. Asymptomatic is not treated with drugs, goal is to prevent future attacks by lowering level to < 6

Cannabinoids

Synthetic analogs of delta-9-tetrahydrocannabinol (THC) Drugs: dronabinol, nabilone Use: second line agents for breakthrough CINV AE: increased appetite, sedation, dysphoria, euphoria

Estradiol

Systemic hormone therapy *Brands* (patch): Alora, Climara, Vivelle-Dot *Use*: menopause *Administration*: Alora and Vivelle-Dot: 2x/w Climara: qw

Micronized progesterone

Systemic hormone therapy Brand: Prometrium Use: menopause CI: peanut or soy allegy

Conjugated equine estrogens/MPA

Systemic hormone therapy Brands: Prempro and Premphase Use: menopause Form: po

Folliculitis/furuncles/carbuncles treatment

Systemic signs: cephalexin Not responding to initial treatment, treat CA-MRSA: Bactrim or doxycycline

Dexamethasone

Systemic steroid Brands: DexPak 6, 10, or 13 day; Decadron Use: CINV AE: (short term) fluid retnetion, insomnia

Methylprednisolone

Systemic steroid Brands: Medrol, Medrol Therapy Pack, Solu-medrol, Depo-Medrol Use: acute gout attack Form: intra-articular for gout if 1-2 large joints involved

Prednisolone

Systemic steroid Brands: Millipred, Orapred ODT, Prelone Use: acute gout attack Dose: can choose taper or non-taper regimen

Fludrocortisone

Systemic steroid MOA: mineralocorticoid activity, which is used to maintain balance of water and electrolytes Use: Addison's disease (FDA approved) and orthostatic hypotension (off-label)

Prednisone

Systemic steroid. Prodrug of prednisolone *Brands*: Prednisone Intensol, Deltasone *Use*: maintenance immunosuppression in transplant, acute gout attack, IBD *Dose*: if used >2w, must taper off Gout: can choose a taper or non-taper regimen *AE*: short-term: fluid retention, stomach upset, emotional instability (euphoria, mood swings, irritability), insomnia, increased appetite, weight gain, acute rise in blood glucose and blood pressure with high dose Long-term: adrenal suppression/Cushing's syndrome, impaired wound healing, HTN, diabetes, acne, osteoporosis, impaired growth in children *Monitor*: for long term, assess bone density (optimize Ca and vitamin D intake, consider bisphosphonates)

Nortriptyline

TCA, secondary amine Brand: Pamelor Use: depression

Amitriptyline

TCA, tertiary amine Brand: Elavil Use: adjuvant for neuropathic pain management, depression Dose: qhs

Doxepin

TCA, tertiary amine Use: depression. Silenor brand is used for insomnia

Cosopt, Cosopt PF

TImolol (beta blocker) + dorzolamide (carbonic anhydrase inhibitor) eye drops Use: glaucoma Dose: 1 drop bid

Pioglitazone

TZD Brand: Actos Use: diabetes AE: increased risk of urinary bladder tumors CI: active bladder cancer

Dyslipidemia basic treatment guidelines

Taken from American College of Cardiology & the American Heart Association and NLA (National Lipid Association). Statins are always recommended unless not tolerated *Nonpharm*: exercise 3-4x/w lasting 40 min, saturated fat should be 5-6% of diet *Treatment based on ASCVD risk*: risk of pt getting a CV event in the next 10y. Uses patient's TC, HDL, SBP, antihypertensive treatments, DM, and smoking status. Start statin therapy if ASCVD risk ≥ 7.5% and pt is 40-75 yo. Redo score every 4-6 y *Treatment prevention is by intensity*: clinical ASCVD: ≤ 75 yo give high-intensity, > 75 yo moderate intensity LDL elevation of ≥190: high DM + 40-75 yo + LDL 70-189: ASCVD ≥ 7.5%, high. < 7.5%, moderate 40-75 yo + LDL 70-189: ASCVD ≥7.5%, moderate - high. < 7.5%, consider risk-benefit of drug *Intensities*: High: rosuvastatin 20-40 mg qd, atorvastatin 40-80 mg qd Low: simvastatin 10, pravastatin 10-20, lovastatin 20, fluvastatin 20-40, pitavastatin 1

Cabazitaxel

Taxane Use: cancer

AndroGel

Testosterone gel. Flammable until dry *Use*: hypogonadism *Administration*: 1%: apply to shoulder, upper arms, or abdomen 1.62%: apply to shoulder or upper arms

Fortesta

Testosterone gel. Has reduced accidental exposure risk than other testosterone products, along with Natesto Use: hypogonadism Administration: apply to thighs

Testosterone cypionate

Testosterone injection Use: hypogonadism

Natesto

Testosterone nasal gel. Has reduced accidental exposure risk than other testosterone products, along with Fortesta Use: hypogonadism AE: nasal irritation

Androderm

Testosterone patch. Remove before an MRI Use: hypogonadism Dose: qpm Administration: apply to upper arms, back, abdomen, or thighs AE: skin irritation (treat with OTC hydrocortisone)

Enterohepatic recycling

The process of drugs going into the gut with some being absorbed by the small intestine and others going into the portal vein, where it travels into the liver. This increases the duration of action of drugs

Adjuvant

Therapy given after primary therapy

Neoadjuvant

Therapy given before primary therapy

Sieve

They are sifters that are used in compounding after a drug has been turned into a powder to ensure a uniform particle size. A sieve brush or plastic spatula is then used to force particles through a mesh to get a fine powder. Sieve number is based on number of holes per inch in the mesh

Propylthiouracil

Thionamide. Preferred during thyroid storm Brand: PTU MOA: inhibits synthesis of thyroid and peripheral conversion of T4 to T3 Use: hyperthyroidism DDI: decreases anticoagulation effect of warfarin BBW: severe liver injury and acute liver failure

Azathioprine

Thiopurine, antiproliferative agent Pharmacogenomic: low TPMT (ThioPurine MethylTransferase) activity increases risk of severe myelosuppression Brand: Imuran Use: maintenance immunosuppression for transplant, induction & maintenance of IBD remission, lupus Warning: genetic deficiency of thiopurine methyltransferase are at increased risk for myelosuppression, hematologic toxicities (leukopenia, thrombocytopenia, anemia) DDI: allopurinol BBW: increased risk of malignancy

Diphtheria-containing vaccines

Those with an upper-case D (e.g. DTaP) are pediatric formulations DTaP: < 7 yo Td: wound prophylaxis for deep or dirty wounds. Revaccinate if it's been more than 5 y Tdap: each pregnancy. Recommended in patients who will have close contact with infants < 1 yo

Babinski sign

Toes flex up when sole of foot is stimulated. Usually done in babies to make sure reflexes work

Pimecrolimus

Topical calcineurin inhibitor Brand: Elidel Use: eczema Administration: wash hands after use. Use smallest amount possible. Limit sun exposure AE: lymphomas and skin malignancies CI: < 2 yo

Adapalene

Topical retinoid Brand: Differin

Tretinoin

Topical retinoid Brands: Atralin, Renova, Retin-A, Retin-A Micro, Avita (last two are slower-release and have less skin irritation) *Cancer*: aka All-trans Retinoic Acid BBW: RA-APL differentiation syndrome

Mometasone furoate

Topical steroid *Brands*: Elocon Ointment 0.1%: high potency Elocon Cream 0.1%: medium potency

Fluocinonide

Topical steroid *Brands*: Lidex Ointment 0.05%: high potency Lidex-E Cream 0.05%: high-medium potency

Halobetasol

Topical steroid with very very high potency

Betamethasone dipropionate

Topical steroid. High potency Brand: Diprolene Cream AF 0.05%

Triamcinolone acetonide

Topical steroid. Medium potency Brand: Kenalog Cream/Spray 0.1%, Nasacort AQ spray

Clobetasol propionate

Topical steroid. Very high potency *Brands*: Clobex 0.05%: forms are lotion, spray, shampoo Olux foam 0.05%

What causes low bicarbonate

Topiramate

Etoposide

Topoisomerase II inhibitor *IV*: preparation: ≤ 0.4 mg/mL to avoid precipitation. Use non-PVC IV bag and tubing due to leaching AE: infusion rate-related HoTN *Capsules*: refrigerate Brand: VePesid

Corrected phenytoin level equation

Total phenytoin measured / ( [0.2 x albumin] + 0.1)

Hydroxychloroquine

Traditional DMARD Brand: Plaquenil Use: RA, SLE (systemic lupus) AE: irreversible retinopathy Monitoring: eye exam

Tofacitinib

Traditional DMARD MOA: inhibits JAK (JAnus Kinase) enzyme Use: RA, UC DDI: biologic DMARD, potent immunosuppressant

Baricitinib

Traditional DMARD MOA: inhibits JAK enzymes Use: RA DDI: biologic DMARD, potent immunosuppressant

Leflunomide

Traditional DMARD MOA: inhibits pyrimidine synthesis Use: RA CI: pregnancy BBW: teratogenic (must have negative pregnancy test prior and use 2 forms of birth control. Wait 2y after d/c to get pregnant or use accelerated drug elimination procedure [cholestyramine and activated charcoal]) and hepatotoxicity

Sulfasalazine

Traditional DMARD, aminosalicylate Use: RA, UC (used not as commonly due to AE) AE: yellow-orange coloration of skin/urine CI: sulfa or salicylate allergy

Methotrexate

Traditional DMARD/ Folate antimetabolite *Brands*: Otrexup, Rasuvo (SC), Trexall, Xatmep *MOA*: irreversibly binds and inhibits dihydrofolate reductase, inhibiting folate (leucovorin [or levoleucovorin (Fusilev) at 1/2 dose] "rescue" must be given with high doses of MTX) *Use*: RA, cancer, IBD, severe psoriasis *Forms*: po, sc, IM, can be given intrathecally but must be preservative-free *Dose*: RA: 7.5-20 mg qw (never qd because it can lead to liver damage) IBD: SC or IM qw *AE*: folate can be given to decrease hematological, GI, and hepatic side effects. Mucositis, inflamed gums *DDI*: alcohol, NSAIDs, salicylates *BBW*: hepatotoxicity, myelosuppression (leucovorin, levoleucovorin [Fusilev], or glucarpidase [Voraxaze] given after MTX in patients with acute renal failure/high MTX concentration to decrease myelosuppression and use as an antidote for mucositis), mucositis/stomatitis, pregnancy, nephrotoxicity (hydration and IV sodium bicarbonate must be given to alkalinize the urine and decrease risk) *Monitoring*: CBC, LFTs, CXR, HepB, HepC

Xulane

Transdermal contraceptive patch. Higher AUC than pills. Less effective in women > 198 lbs. High estrogen Administration: placed on butt, stomach, upper arm, or upper torso. Start on either day 1 of menses or Sunday Dose: x3w, off 4th week BBW: loss of bone mineral density

Measles

Transmission is airborne Symptoms: Koplik (small white) spots on the inside of the cheeks, maculopapular rash

Conduction

Transmit electric charges

TB

Transmitted via aerosolized droplets. Hospitalized patients with active TB are isolated in a single negative pressure room *Symptoms*: latent: asymptomatic Active: cough/hemoptysis and fever/night sweats *Diagnosis*: latent: TST (false positive can occur in patients who received BCG vaccine) Active: must be confirmed with sputum culture, M. tuberculosis is an acid-fast bacilli & slow growing organism and can be detected using an AFB stain *Treatment*: latent: isoniazid for 9m, preferred for HIV patients, pregnant women, and children. Rifampin for 4m. Isoniazid + rifapentine x12w Active: two phases—intensive and continuation. Intensive involves "RIPE" rifampin (AE are increased LFTs, orange-red discoloration of body secretions, positive Coombs test, flu-like syndrome. 3A4 inducer- decrease concentration of many other drugs or rifabutin can be used instead due to DDIs. DDIs include protease inhibitors [dec concentration], warfarin [decrease in INR], and contraceptives [dec efficacy]), isoniazid (BBW for hepatitis. AE are peripheral neuropathy [give with pyridoxine 25 mg po qd], increased LFTs, DILE, hemolytic anemia [positive Coombs test]), pyrazinamide (AE are increased LFTs and hyperuricemia/gout. Increase dosing interval with renal impairment), and ethambutol (AE are optic neuritis [dose-related], increased LFTs, confusion, and hallucinations. Increase dosing interval with renal impairment) x2m. Continuation can be scaled back to two drugs depending on drug susceptibility x4m

NNRTIs

Treat HIV by binding to reverse transcriptase. No renal dose adjustment needed in most. Most are CYP450 inducers AE: hepatotoxicity, rash (SJS/TEN), erythema, facial edema, skin necrosis, blisters, and tongue swelling

Alcohol OD

Treat with Vitamin B1 (thiamine) to prevent Wernicke's encephalopathy

Diaper rash

Treat with petrolatum ointment +/- zinc oxide (desiccant)

Salicylates OD

Treat: sodium bicarbonate is an alkalinizing agent. This will decrease drug reabsorption and increase excretion

Interferon-alfa

Treats HBV and HCV. The pegylated form (PEG-INF-alfa) has a longer half life and is prescribed less frequently than the non-pegylated forms. SC AE: flu-like symptoms (after injection-can pretreat with APAP and antihistamine), weakness, depression, diarrhea, thinning hair, GI upset, loss of appetite, increase LFTs (5-10x during treatment), myelosuppression BBW: can exacerbate neuropsychiatric, autoimmune, ischemic, or infectious disorders

Fibrates

Treats hyperlipidemia *MOA*: decreases TG (which can increase LDL), decreases LDL, increases HDL *Drugs*: fenofibrate: brands are Antara, Tricor, Trilipix, Fenoglide, and Lipofen (last 2 taken wc) Gemfibrozil: brand is Lopid. DDI with ezetimibe and statins *MOA*: PPAR-alpha activators, upregulating apoA-I and apoC-II. ApoC-II increases lipoprotein lipase activity leading to increased catabolism of VLDL particles, decreasing TG significantly *AE*: myopathy and dyspepsia *CI*: severe liver disease and gallbladder disease *DDIs*: may increase effects of sulfonylureas and warfarin

Fish oil

Treats hyperlipidemia, HTN, and ADHD. Increases LDL (especially with Lovaza, not seen with Vascepa) Indication: adjunct to diet when TG ≥ 500 Drugs: omega-3 acid ethyl esters (Lovaza) and icosapent ethyl (Vascepa) AE: eructation, dyspepsia, prolonged bleeding time, and taste perversions DDI: monitor INR in patients taking warfarin

Niacin

Treats hyperlipidemia. Aka nicotinic acid or Vitamin B3. Increases HDL by 15-35%. Take with food *Forms*: IR and XR are not interchangeable IR: increased flushing and itching CR and SR: increased hepatotoxicity XR: Niaspan. Take qhs after low-fat snack. Decreased flushing and hepatotoxicity *MOA*: decreases rate of hepatic synthesis of VLDL (decreases TG) and LDL *AE*: rhabdomyolysis, hepatotoxicity, flushing (reduce by taking with ASA 325 mg 30-60 min before dose wc, avoiding spicy foods), pruritus (itching), N/V/D, hyperglycemia, and hyperuricemia (or gout) *DDIs*: take 4-6h after bile acid sequestrants *CI*: peptic ulcer disease *Monitoring*: LFTs

Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors

Treats hyperlipidemia. Decreases LDL by about 60% Indication: heterozygous familial hypercholesterolemia or ASCVD MOA: increases number of LDL receptors available to clear LDL AE: injection site reaction

Bile acid sequestrants

Treats hyperlipidemia. Drink a lot of water and eat fiber with these medications. Patients may need to take multivitamin with this medication AE: constipation, abdominal pain, cramping, bloating, gas, and increased triglycerides DDI: can decrease absorption of fat soluble vitamins, separate dose

Statins

Treats hyperlipidemia. Shown to decrease ASCVD risk. Can take at anytime of the day (lovastatin [wc], fluvastatin, and simvastatin preferred qpm, Altoprev [lovastatin XR] preferred qhs) *MOA*: HMG-CoA reductase inhibitor, this is the rate-limiting step in cholesterol synthesis *AE*: liver damage: drug should be stopped if AST or ALT >3x upper normal limit Muscle damage: usually occurs within 6w of starting. Symmetrical on both sides of the body. Includes myalgia, myopathy, myositis, rhabdomyolysis (increases CPK). Increased risk in advanced age and patients taking CYP3A4 inhibitors or niacin. Prevent by avoiding simvastatin 80 mg/d and gemfibrozil + statin. Manage by holding statin, check CPK, and investigate other possible causes; after 2-4w rechallenge with same statin or same but decrease dose (most will tolerate rechallenge). If myalgia continues, d/c and use a low dose of a different statin when symptoms resolve, gradually increase dose Arthralgia *CI*: active liver disease, pregnancy, breastfeeding, grapefruit (except pravastatin) *DDIs*: colchicine Simvastatin: allowed max 10 mg/d with verapamil, diltiazem, or dronedarone. Allowed max 20 mg/d with amiodarone, amlodipine, lomitapide, or ranolazine Lovastatin: max 20-40 mg/d with danazol, diltiazem, dronedarone, verapamil, amlodipine, amiodarone, ticagrelor All except rosuvastatin 5: avoid cyclosporine *Monitoring*: LFTs at baseline and lipid panel at baseline and 4-12w after initiation

Phosphate binders

Treats hyperphosphatemia. If a dose is missed, skip *MOA*: blocks absorption of dietary PO4 *Types*: aluminum-based: potent, rarely used due to risk of aluminum accumulation which can cause nervous system and bone toxicity. AE is "dialysis dementia" Calcium-based: first line. AE is hypercalcemia (usually due to concomitant use of Vitamin D) Aluminum-free, calcium-free: may need to reduce IV iron. AE of N/V/D and constipation with chewable tablet *DDI*: should separate from levothyroxine and antibiotics that chelate (quinolones, tetracyclines)

Pralidoxime

Treats neostigmine OD

Etelcalcetide

Treats secondary hyperparathyroidism AE: hypercalcemia, muscle spasms, and paresthesia

Frovatriptan

Triptan. Long-acting but slower onset

Naratriptan

Triptan. Long-acting but slower onset

Sumatriptan

Triptan. Short half life but fast onset *Brands*: Imitrex: po. Nasal spray contains only one dose, do not prime Imitrex STATdose: SC upper outer arm Zembrace SymTouch: can use up to qid, separated by at least 1h. Injection Treximet: + naproxen. Dispense in original container. Approved for use in children and adolescents ≥ 12 yo Onzetra Xsail: nasal powder *Forms*: tablet, SC (autoinjector and prefilled syringe. Preferred site is lateral thigh or upper arm), nasal spray, nasal powder *CI*: MAOI

Zolmitriptan

Triptan. Shot half life but fast onset *Brands*: Zomig: nasal spray, contains only one dose, do not prime Zomig ZMT: ODT *Forms*: tablet ODT Nasal spray: approved for use in children and adolescents ≥ 12 yo *CI*: MAOI

Rizatriptan

Triptan. Shot half life but fast onset *Use*: approved for children and adolescents 6 - 17 yo *Forms*: tablet ODT: Maxalt MLT *CI*: MAOI

Eletriptan

Triptan. Shot half life but fast onset Brand: Relpax

Almotriptan

Triptan. Shot half life but fast onset Use: approved for use in children and adolescents ≥ 12 yo

Which labs are taken to diagnose MI

Troponin T, Troponin I, B-type Natriuretic Peptide (BNP), and N-Terminal-ProBNP. High values and heart failure symptoms indicate an MI

Diagnostic tests for TB

Tuberculin Skin Test

Rasburicase use

Tumor lysis syndrome

Anti-TNF biologic DMARD

Tumor necrosis factor alpha inhibitors. Each drug has its own pregnancy registry, due to unknown risks to fetus. Needles are included with device. Usually add on therapy to MTX when treating RA, but can initially be used alone if initial presentation is severe AE: demyelinating disease, hepB reactivation, HF, hepatotoxicity, lupus-like syndrome DDI: other biologic DMARDs, live vaccines BBW: serious infections, screen for latent TB (must be treated first if positive), malignancies Monitoring: TB test, signs of infection

Colony stimulating factors (CSFs)

Types: GM-CSF, G-CSF (filgrastim), pegylated G-CSF (pegfilgrastim) Use: reduction in mortality from infections when given prophylactically in cancer patients at high risk for febrile neutropenia Administration: store in refrigerator, protect form light. Administer first dose no sooner than 24h after chemo AE: report any signs of enlarged spleen (pain in left upper abdomen)

Lapatinib

Tyrosine kinase inhibitor Pharmacogenomics: must have HER2 overexpression in order to use the drug to treat breast cancer

Neratinib

Tyrosine kinase inhibitor Pharmacogenomics: must have HER2 overexpression in order to use the drug to treat breast cancer

ALK inhibitors

Tyrosine kinase inhibitors Pharmacogenomics: must be ALK mutation positive Use: cancer

BRAF inhibitors

Tyrosine kinase inhibitors Pharmacogenomics: must be BRAF V600E or V600K mutation positive Use: melanoma Warning: new malignancies

Diagnostic tests for DVT

US

Common nosocomial infections

UTIs (from indwelling catheters; remove catheter asap), bloodstream infections (from IV lines [central lines have highest risk] and catheters), C. diff, pneumonia (mostly due to ventilator)

UFH

Unfractionated Heparin. Has cross-sensitivity with HIT antibodies (chance of HIT occurring). Has unpredictable anticoagulant response *MOA*: bind to antithrombin, increasing its activity, which inactivates thrombin (Factor IIa), Factor Xa, and other proteases involved in blood clotting. Prevents the conversion of fibrinogen to fibrin *Dose*: VTE prophylaxis: 5000 U SQ q8-12h VTE treatment: 80 U/kg IV bolus followed by 18 U/kg/h infusion ACS/STEMI treatment: 60 U/kg IV bolus; 12 U/kg/h infusion. Use ABW *Administration*: continuous IV infusion due to very short half life *AE*: bleeding, thrombocytopenia, HIT, hyperkalemia, and osteoporosis with long term use *CI*: uncontrolled active bleed. *DDI*: SSRIs, SNRIs, NSAIDs *Monitor*: aPTT q6h until therapeutic range of 1.5-2x control (pt's baseline), platelets, Hgb, Hct

Restless Leg Syndrome

Urge to move the lower legs, especially at night Treatment: dopamine agonists

Lesinurad

Uricosuric. Used with XOI if XOI didn't work alone Use: chronic urate lowering treatment for gout AE: increased SCr

Nitrofurantoin

Use caution in patients with G6PD deficiency MOA: bacterial cell wall inhibitor Uses: uncomplicated UTI (DOC) Dose: 100 mg po bid x5d (Macro*bid*), Macrodantin qid AE: hemolytic anemia (detected with positive Coombs test), GI upset, and brown urine (harmless) CI: CrCl < 60

Condoms

Use condom with nonoxynol-9 spermicide for best efficacy (spermicide is least effective contraceptive method)

Theophylline

Use is limited due to low effectiveness and DDIs. Caffeine is an active metabolite. Convert aminophylline to theophylline by multiplying by 0.8 (vice versa, divide by 0.8 [*ATM*: Aminophylline Theophylline Multiply]). Exhibits Michaelis-Menten kinetics *MOA*: blocks phosphodiesterase, increasing cAMP, resulting in bronchodilation *Use*: asthma *Dose*: by IBW, loading dose by ABW *AE* (toxicity): persistent vomiting, arrhythmias, seizures *Therapeutic range*: 5-15 mcg/mL (peak). Always use IBW for aminophylline and theophylline calculations, except for loading dose (ABW) *DDIs*: increase theophylline levels: Cipro, zafirlukast, and zileuton Decrease theophylline levels: carbamazepine, fosphenytoin, phenobarbital, phenytoin, primidone, rifampin, ritonavir, high-protein diet, charbroiled meats, smoking

Conjugate vaccines

Use polysaccharide molecules from outside layer of encapsulated bacteria and join molecules to carrier proteins, which increases immune response in infants

Propofol

Use strict aseptic technique due to potential for bacterial growth. Discard vial and tubing within 12h of use. Oil-in-water emulsion provides 1.1 kCal/mL Brand: Diprivan Use: agitation/sedation in ICU AE: HoTN, apnea, hypertriglyceridemia, green urine/hair/nails, PRIS CI: egg or soy allergy Monitoring: triglycerides

Acetylcholinesterase inhibitors

Use: Alzheimer's Disease MOA: slows progression of disease, does not show clinical improvement AE: bradycardia, insomnia, nausea DDI: anticholinergic drugs can reduce efficacy

Guanylate cyclase C agonists

Use: CIC (Chronic Idiopathic Constipation), IBS-c AE: diarrhea

Interferon beta products

Use: MS Administration: if refrigerated, let stand at room temperature prior to injection, do not expel small air bubble due to loss of dose AE: psychiatric disorders, injection site necrosis, increased LFTs, thyroid dysfunction, flu-like symptoms

Interferon beta-1b

Use: MS Dose: qod

Dopamine agonists

Use: Parkinson's Disease AE: orthostasis, somnolence

Isoniazid

Use: TB AE: Vitamin B6 deficiency (peripheral neuropathy), agranulocytosis, hemolysis, DILE, gap acidosis BBW: liver damage DDI: acid-suppressive agents

Deutetrabenazine

Use: Tardive Dyskinesia CI: hepatic impairment Warning: somnolence

Valbenazine

Use: Tardive Dyskinesia (FDA approved) Warning: somnolence

PCSK9 inhibitors

Use: adjunct to diabetes when patient has clinical ASCVD with LDL ≥ 70 Form: SC

Ketamine

Use: agitation/sedation in ICU AE: emergence reactions (vivid dreams, hallucinations, delirium)

Lidocaine

Use: antiarrhythmic for refractory VT/cardiac arrest (as class Ib; ventricular arrhythmias only), 2% topical solution for oral mucositis due to chemo *Lidoderm*: use: topical adjuvant for PHN (shingles) pain Form: 5% patches Dose: apply to affected area up to 12h/d. Do not apply more than 3 patches at one time. Patches can be cut into smaller pieces

Leukotriene Receptor Antagonists (LTRAs)

Use: asthma AE: neuropsychiatric events

ICS

Use: asthma (maintenance therapy) AE: dysphonia, oral candidiasis (prevent by rinsing mouth and throat with warm water and spit out after each use or use a spacer device), cough

5HT3 receptor antagonists

Use: breakthrough CINV AE: migraine-like HAs, constipation DDI: apomorphine, other serotonergic agents (can cause serotonin syndrome, caution)

Ifosfamide

Use: cancer AE: N/V BBW: hemorrhagic cystitis. Mesna (Mesnex) is always given with ifosfamide to reduce risk by inactivating metabolite (acrolein). Ensure adequate hydration- hypertonic solutions to increase urine output, including mannitol and hypertonic saline

Monoclonal antibodies

Use: cancer AE: infusion-related reactions (premedication usually required)

Arsenic trioxide

Use: cancer BBW: RA-APL differentiation syndrome, QT prolongation Monitor: ECG

Immunomodulators

Use: cancer BBW: teratogenic

Bleomycin

Use: cancer Dose: max lifetime cumulative dose of 400 units due to pulmonary toxicity AE: (no myelosuppression) hypersensitivity reaction BBW: pulmonary fibrosis

Asparaginase

Use: cancer Dose: more frequent dosing and more allergic reactions than pegylated form (pegaspargase) AE: (no myelosuppression), hypersensitivity reactions, prolonged prothrombin time (PT/INR)

Alkylating agents

Use: cancer MOA: not cell cycle specific

Platinums

Use: cancer MOA: not cell cycle specific AE: toxicity that is similar to symptoms of heavy metal poisoning (neuropathy) BBW: anaphylactic-like reactions (risk increases with repeated exposure), renal toxicity, ototoxicity

Lysine

Use: cold sores prevention and treatment

Nefazodone

Use: depression AE: QT prolongation BBW: increased risk of suicidal thinking and behavior in children, adolescents, and young adults, hepatotoxicity (rarely used due to this)

MAOIs

Use: depression DDIs: drugs that increase concentrations of epinephrine, NE, serotonin, or dopamine can cause hypertensive crisis (2w wash out period required for SSRIs [5w for fluoxetine], SNRIs, TCAs, bupropion), serotonin syndrome, or psychosis. Tyramine-rich foods (aged cheese, pickled herring, yeast extract, air-dried meats, sauerkraut, soy sauce. Foods that have been aged [some wine/beer], fermented, pickled, or smoked) Warnings: drug-drug and -food interactions can be fatal BBW: increased risk of suicidal thinking and behavior in children, adolescents, and young adults

Bile acid binding resins

Use: diabetes (not commonly used) AE: constipation

Aromatase inhibitors

Use: hormonal therapy for breast cancer in postmenopausal women only Dose: wc AE: thromboembolic risk, higher risk of osteoporosis, higher risk of CVD, edema, bone pain, menopausal symptoms, hot flashes, arthralgia/myalgia, lethargy/fatigue, N/V, rash, hepatotoxicity, HTN, dyslipidemia DDI: tamoxifen, estrogen-containing products

Selective Estrogen Receptor Modulators (SERMs)

Use: infertility, osteoporosis, breast cancer AE: thromboembolic risk, menopausal symptoms, hot flashes, flushing, edema, weight gain, HTN, mood changes, amenorrhea, vaginal bleeding/discharge

Non-BZDs

Use: insomnia Warnings: increase risk of CNS depression AE: somnolence, dizziness, ataxia, parasomnias

Ferrous sulfate

Use: iron deficiency anemia Dose: 325 mg (65 mg elemental iron) po qd - tid

Naloxone

Use: opioid overdose Forms: SC (Evzio) and nasal spray (Narcan) AE: acute withdrawal (pain)

Mucosal Barrier Gel Spray

Use: oral mucositis due to chemo

Estrogen agonists/antagonists

Use: osteoporosis AE: increased risk of VTE and stroke

Mebendazole

Use: pinworm AE: HA, nausea, and hepatotoxicity

Albendazole

Use: pinworm and other systemic infections (when used with antiepileptic and high-dose steroids, take with high-fat meal) AE: HA, nausea, hepatotoxicity

Gonadotropin releasing hormone antagonist

Use: prostate cancer AE: osteoporosis risk, hypersensitivity reactions

PLO gel (Pluronic Lecithin Organogel)

Used as a gel base in compounding for transdermal drug administration. Delivery vehicle and surfactant because it reduces surface tension between compounds by permitting compounds to distribute into the "like" phase (hydrophobic compound into organic [lipophilic] phase), and hydrophilic compound into water-based phase

SCA (Segregated Compounding Area)

Used as a makeshift compounding room when one is unavailable. Has unclassified air and BUD of 12 hours; 12 ACPH

Simethicone in compounding

Used as anti-foaming agent

Petroleum jelly (petrolatum) in compounding

Used as emollient

Protease Inhibitors

Used for HIV. Mostly CYP450 inhibitors. No renal dose adjustments needed. Given with a pharmacokinetic booster (ritonavir or cobicistat) to increase levels of PI. Should all be taken with food to avoid GI upset (except fosamprenavir suspension) Generics: all end in -navir AE: hepatotoxicity, hyperlipidemia, lipohypertrophy (less risk with atazanavir and darunavir), insulin resistance/hyperglycemia, increased CVD risk (less risk with atazanavir and darunavir), GI upset, ECG changes, and rash (SJS/TEN) DDIs: obvious CYP ones (rifampin, St. John's wort, statins [PIs can increase statin levels- less risk with rosuvastatin and atorvastatin]) *(WHAT DARE P)* dronedarone, apixaban, edoxaban, rivaroxaban, ticagrelor, alfuzosin, warfarin (can decrease INR due to CYP2C9 induction), hormonal contraceptives, PDE5 inhibitors (PIs can increase PDE5 levels)

Ranolazine

Used for SIHD (not for acute pain). Has little to no clinical effects on HR or bp MOA: inhibits Na current and decreases intracellular Ca AE: QT prolongation DDI: strong CYP3A4 inhibitors or inducers

Nitrates

Used for SIHD. Call 911 if no relief occurs after first dose of SL tablet, SL powder, or TL spray. Long acting nitrates only used when beta-blockers are CI or as add on therapy MOA: causes vasodilation of veins more than arteries (decreasing preload) Use: anginal pain and CHF AE: flushing and HA DDI: sildenafil, tadalafil, vardenafil, avanafil, riociguat

Gram stains

Used for morphology (to categorize by shape) Gram-positive: thick cell wall. Purple or bluish from crystal violet stain Gram-negative: thin cell wall. Pink or reddish from safranin counterstain Atypical: do not stain well

Lactated Ringers

Used for volume resuscitation in shock states

Normal saline

Used for volume resuscitation in shock states

Hazard ratio

Used instead of risk in survival analysis. Rate at which an unfavorable event occurs within a short period of time

Hydroxyethyl starch

Used secondary to NS, D5W, etc. due to its boxed warning to avoid in critically ill pts due to mortality

Child-Pugh classification

Used to assess severity of liver disease

Chi-squared test

Used to determine statistical significance between treatment groups when dealing with discrete data Discrete data is nominal/ordinal (not continuous)

GFR

Used to dose certain drugs (e.g. metformin and SGLT-2 inhibitors)

Media-fill test

Used to evaluate one's aseptic technique (the one Muhammad Elsweesy had to do for Frank when he got hired). Done at least annually for personnel who compound low- and medium-risk level

Surfactant

Used to help two ingredients that resist each other to move closer together by reducing the surface tension. Amphiphilic surfactants are both hydrophilic and hydrophobic *HLB (Hydrophilic-Lipophilic Balance) number*: describes how hydrophilic or lipophilic a surfactant is and used to choose the right surfactant. Scale from 0-20, <10: lipid-soluble (used for w/o emulsions), >10: water-soluble (o/w) *Types*: wetting/levigating agent: used to reduce surface tension between a solid particle and a liquid. Mineral oil and glycerin mostly used Emulsifier: reduces the surface tension between oil and water *Examples*: detergent, PEG, PLO gel

Antifactor Xa activity lab value

Used to monitor LMWH and a peak value should be obtained 4 hours after SC LMWH dose. Increases due to heparin and LMWH

aPTT

Used to monitor unfractionated heparin

Thiamine

Used to prevent and treat Wernicke-Korsakoff syndrome (brain damage due to a lack of vitamin B1; causes mental confusion, ataxia , tremor and vision changes). Many alcoholics lack thiamine

PCI

Used to treat ACS. Preferred over a fibrinolytic for STEMI if it can be performed within 90 minutes (optimal door-to-balloon time) or 120 minutes of first medical contact. Involves inflating a small balloon inside a coronary artery to widen it and improve blood flow. A stent is usually also placed to keep artery open. Should be treated with one dose of a P2Y12 inhibitor before PCI

Ribavirin

Used to treat HCV, never as a monotherapy. Aerosolized ribavirin available for RSV (Respiratory Syncytial Virus). Male patients should avoid getting a female pregnant during therapy and 6 months after completion BBW: teratogenic and hemolytic anemia

INSTIs

Used to treat HIV. No renal dose adjustment needed Generic: all end in "-tegravir" AE: increased CPK, HA, insomnia, muscle pain/tenderness, weakness DDIs: polyvalent cations (INSTI should be taken 2 hours before or 6 hours after cation)

Neuraminidase inhibitors

Used to treat influenza. Decreases duration of symptoms by about 1 day and reduce complications from influenza. Should be administered within 48 hours of illness onset *MOA*: inhibits the enzyme that enables release of new viral particles from infected cells, thus reducing the amount of virus in the body *Oseltamivir*: forms: capsules and suspension Dose: >12 yo treatment, give 75 mg bid x5d. >12 yo prophylaxis give 75 mg qd x10d AE: neuropsychiatric events *Zanamivir*: inhalation AE: bronchospasm CI: asthma/COPD or other breathing issues

Filters used for IV

Used when drugs have a risk of particulates or other things getting trapped in solution. 0.22 micron filters most often used, 1.2 microns for lipids. If using compounding IV medications packaged in glass ampules, filter needles or filter straws are needed. Some drugs do not need filters due to the size of the drug particle. Drugs that typically need filters are *(GAL PLAT)* Golimumab, Amiodarone, Lorazepam, Phenytoin (last two are only required during continuous infusion), Lipids, Amphotericin B (5 micron filter), Taxanes except docetaxel

T-Tests

Used when endpoint has continuous data and data is normally distributed (one sample) Student/Independent/Unpaired T-Test: used when the study has two independent samples (treatment and control) Dependent/Paired T-Test: used when there is one sample group with before and after measures

Second generation antipsychotics

Uses: psychosis, schizophrenia AE: metabolic (weight gain, lipid abnormalities, hyperglycemia), hormonal issues (due to increasing prolactin levels), QT prolongation, increased risk of CV events Monitor: overweight/obesity, dyslipidemia, hyperglycemia, HTN, personal or family history of risk

Cyanide toxicity

Usually from nitroprusside Treatment: hydroxocobalamin or sodium thiosulfate + sodium nitrite

Vaccine storage

Vaccines in fridge/freezer should not be placed in the shelves on the doors. A calibrated thermometer or a digital data logger should be connected to a buffered temperature probe. Temperature logs should be kept for at least 3y

Exforge

Valsartan (ARB) + amlodipine (CCB)

DOC for nosocomial MRSA

Vancomycin, linezolid, daptomycin

DOC for severe SSTIs requiring IV treatment

Vancomycin, linezolid, daptomycin

Alpha-1 agonists effects

Vasoconstriction and increased bp

Nitroglycerin

Vasodilator *MOA*: reduces preload Low dose: venous vasodilator High dose: arterial vasodilator *Forms*: SL tablet: Nitrostat. 0.3, 0.4, and 0.6 mg. Should be kept in original amber glass bottle. Place under the tongue. Store at room temperature TL spray: NitroMist, Nitrolingual Pump Spray. 0.4 mg/spray. Do not shake. Spray onto or under the tongue, do not inhale SL powder: GoNitro. 0.4 mg/packet IR/ER tablet: isosorbide mononitrate (Monoket). ER requires 10-12h nitrate-free period to decrease tolerance Ointment: bid (6h apart). Measure dose with applicator supplied. Can stain clothing Patch: put on in the morning, wear for 12-14h, and rotate sites. Chest is preferred site IV: requires non-PVC container (e.g. glass, polyolefin) *Use*: SIHD, active MI, or uncontrolled HTN (effectiveness limited after 24 - 48h due to tachyphylaxis) *AE*: hypotension, HA, tachyphylaxis, flushing, syncope, tachycardia *CI*: PDE5 inhibitors, riociguat (both can cause decrease in bp), SBP < 90

Nesiritide

Vasodilator Brand: Natrecor MOA: recombinant B-type natriuretic peptide, increases cGMP

Nitroprusside

Vasodilator. Turns blue if it has completely dissociated to cyanide (requires light protection). Antidote is Cyanokit MOA: mixed (equal) arterial and venous vasodilator. Metabolism results in formation of thiocyanate and cyanide (both can cause toxicity, give hydroxocobalamin to reduce risk of thiocyanate toxicity and sodium thiosulfate for cyanide toxicity) AE: increases intracranial pressure, HA, tachycardia, thiocyanate/cyanide toxicity (risk increased in renal and hepatic impairment) CI: active MI (nitroprusside can cause "coronary steal," cause blood to be diverted away from diseased coronary arteries) BBW: produces cyanide, excessive HoTN, and not for direct injection (must be further diluted, D5W preferred)

Epinephrine

Vasopressor *Brands*: Adrenalin and EpiPen *MOA*: alpha-1, beta-1, and beta-2 agonist. Bronchodilation *Form*: IV push: 0.1 mg/mL (1:10,000). Use 1:1000 epinephrine when making IV push IM injection: 1 mg/mL (1:1,000) AE: hyperglycemia

Norepinephrine

Vasopressor Brand: Levophed MOA: alpha-1 agonist > beta-1 agonist

Vasopressin

Vasopressor. Aka arginine vasopressin and antidiuretic hormone

Dopamine

Vasopressor. Natural precursor of NE. MAO-B inhibitors prevent breakdown of dopamine *Use*: symptomatic bradycardia *Dose*: Low (renal): 1 - 4 mcg/kg/min (dopamine-1 agonist) Medium: 5 - 10 mcg/kg/min (beta-1 agonist) High: 10 - 20 mcg/kg/min (alpha-1 agonist)

Mupirocin

Very good staph and strep coverage *Brand*: Bactroban *Forms*: nasal ointment: eliminates MRSA colonization Cream/ointment: antibiotic for burns

Vincristine

Vinca alkaloid Dose: single dose max of 2 mg/w due to neuropathy. Intrathecal form is fatal (causes paralysis and death), it should never be dispensed in a syringe (prepare in a small IV bag [piggyback]) AE: (no myelosuppression) constipation, has most CNS toxicities of vinca alkaloids

Vinblastine

Vinca alkaloid Use: cancer AE: associated with more bone marrow suppression than other vinca alkaloids

Vinorelbine

Vinca alkaloid Use: cancer AE: associated with more bone marrow suppression than other vinca alkaloids

Influenza

Virus has two subtypes, hemagglutinin and neuraminidase. Primarily spreads through respiratory droplet transmission. Vaccine can be given at 6 months *Vaccine specific considerations*: 6m - 8 yo: give 2 doses, 4 weeks apart Egg allergy: can receive vaccine still, should be supervised by a healthcare provider who can treat severe allergic reactions. Flublok is an egg-free vaccine approved ≥18 yo. Do not give FluMist Pregnant: do not give FluMist ≥ 65 yo: Fluzone High-Dose (Fluzone is normal dose) or Fluad FluMist: approved for patients 2-49 yo. Given in both nostrils

Retinoids

Vitamin A derivative. Takes 4-12 w to work and acne may worsen initially MOA: reduce adherence of keratinocytes in the oil gland Use: acne Administration: qpm or every other night with pea sized amount AE: teratogenic

Ergocalciferol

Vitamin D2. Primary dietary source of Vitamin D

Cholecalciferol

Vitamin D3. Synthesized in the skin after exposure to UV light

Phytonadione

Vitamin K. Warfarin OD treatment

Poly-Vi-Sol

Vitamin drops with both Vitamin D and iron

Typhoid vaccines

Vivotif is a live oral vaccine. Store in the refrigerator. Should be complete at least 1w prior to possible exposure. Take on an empty stomach with cold or lukewarm water Typhim Vi: IM. Should be given ≥2w before possible exposure

Stroke volume

Volume of blood ejected

Vd

Volume of distribution. How large an area in the patient's body the drug has distributed into = amount of drug in body / concentration of drug in plasma

Cariprazine brand

Vraylar

Crystalloids

Vs. colloids: less costly, fewer AE Examples: 5% dextrose (D5W), 0.9% NaCl (normal saline, NS)

Which drugs are affected by albumin

Warfarin Phenytoin, valproic acid, and calcium require correction for low albumin levels

Kcentra

Warfarin and factor Xa reversal. Contains factors II, VII, X, protein C, protein S. Administer with Vitamin K Generic: four factor prothrombin complex concentrate

NovoSeven RT

Warfarin reversal Generic: factor VIIa recombinant

Three Factor Prothrombin Complex Concentrates

Warfarin reversal containing factors II, IX, and X

Vitamin K

Warfarin reversal. Aka phytonadione Brand: Mephyton Forms: po (for patients without significant major bleeding; 2.5-5 mg) and IV (when patient is experiencing major bleeding; infuse slowly to avoid anaphylaxis). Sc not recommended due to variable absorption, IM not recommended due to risk of hematoma AE: anaphylaxis BBW: hypersensitivity reactions

Creatinine

Waste product of muscle metabolism. Increases when kidney function declines

Equation to find percent ionization of a drug

Weak acid: % ionization = 100 / (1 + 10^[pKa-pH]) Weak base: % ionization = 100 / (1 + 10^[pH-pKa])

Cachexia

Weakness and wasting away of the body due to a chronic illness

BMI equation and classifications

Weight (kg) / height (m) squared Underweight: < 18.5 Normal: 18.5-24.9 Overweight: 25-29.9 Obese: ≥30

Contrave

Weight loss drug *Made up of*: naltrexone: decreases food cravings Bupropion: decreases appetite *AE*: suicide risk, lowers seizure threshold *Warning*: use caution with other psychiatric conditions *DDI*: opioids (naltrexone blocks opioid receptors) *CI*: uncontrolled HTN, chronic opioid use, seizure disorder, use of other bupropion-containing products, pregnancy

Phentermine

Weight loss drug Brand: Adipex-P MOA: sympathomimetic (stimulant) Administration: used short term for up to 12w AE: tachycardia, agitation, HTN CI: CV disease (uncontrolled HTN), hyperthyroidism, glaucoma, pregnancy, history of drug abuse Monitoring: hr, bp

Belviq

Weight loss drug Generic: lorcaserin MOA: increases satiety AE: serotonin syndrome, hypoglycemia CI: pregnancy

Orlistat

Weight loss drug. Alli is OTC Brand: Xenical MOA: decreases absorption of dietary fats by ~30% Administration: must be used with a low-fat diet plan (max 30% kCal from fat) to help with weight loss and lessen GI AE. Must take with multivitamin with vitamins A, D, E, K, and beta carotene qhs or separated by ≥ 2h AE: flatus with discharge, fatty stool CI: pregnancy

Qsymia

Weight loss drug. Taper off slowly when d/c in patients with seizure history *Made up of*: phentermine: MOA is sympathomimetic (stimulant) Topiramate *AE*: tachycardia *REMS*: teratogenic *Monitor*: heart rate

Hypomagnesemia

When serum Mg is < 1 with life-threatening symptoms (seizures, arrhythmias), IV Mg sulfate recommended

Phase I metabolism

Where CYP enzymes act. Mostly involves oxidation reactions

Aldosterone

Works on distal convoluted tubule and collecting duct to increase Na & water reabsorption and decrease K+ reabsorption

Allopurinol

XOI. Use with colchicine or NSAID for the first 3-6m due to high rate of gout attacks when starting Brand: Zyloprim, Aloprim Use: urea lowering therapy for gout Dose: titrated up slowly. Requires renal dose adjustment AE: rash, acute gout attacks, nausea BBW: severe hypersensitivity reaction, patients should be screened before use for the HLA-Bstar5801 allele. Hepatotoxicity

Febuxostat

XOI. Use with colchicine or NSAID for the first 3-6m due to high rate of gout attacks when starting Use: urea lowering therapy for gout Dose: titrate up AE: increased LFTs BBW: hepatotoxicity, increased thromboembolic events, serious skin reactions

Breast cancer screening

Yearly mammograms, then q2y or qy

Diagnostic tests for trichomoniasis

Yellow, green frothy vaginal discharge

DOC for pseudomonas

Zosyn, cefepime, ceftazidime, ceftazidime/avibactam, ceftolozane/tazobactam, carbapenems (except ertapenem), Cipro, levofloxacin, aztreonam, aminoglycosides, colistimethate, polymyxin B

Drugs that can cause anxiety

albuterol (if used frequently), antipsychotics, bupropion, caffeine, decongestants, levothyroxine, steroids, stimulants, theophylline

Elimination rate constant

k(e) = Cl / Vd k(e) = 0.693 / t1/2

Sirolimus

mTOR kinase inhibitor. CYP3A4 substrate MOA: inhibits T-lymphocyte activation and proliferation Use: maintenance immunosuppression for transplant Forms: tablet and oral solution (not bioequivalent) AE: impaired wound healing, hyperlipidemia, irreversible pneumonitis/bronchitis/cough (d/c therapy if this develops), hyperglycemia Monitor: trough levels

Everolimus

mTOR kinase inhibitor. Do not use within 30d of transplant. CYP3A4 substrate Brand: Afinitor, Zortress MOA: inhibits T-lymphocyte activation and proliferation Use: maintenance immunosuppression for transplant (Zortress brand), cancer AE: peripheral edema, HTN, worsening lipid parameters, rash, stomatitis, interstitial lung disease

nPEP

nonoccupational Post-Exposure Prophylaxis. Should be given within 72h since exposure INSTI based regimen preferred: Truvada + raltegravir or dolutegravir

PEP

occupational Post-Exposure Prophylaxis. Treatment should be started within 72h of exposure. Raltegravir (Isentress) + emtricitabine/tenofovir (Truvada) x4w

Riociguat

sGC stimulator MOA: sensitizes sGC, stimulating endogenous nitric oxide, increasing cGMP, leading to relaxation AE: HoTN, HA CI: pregnancy, PDE5 inhibitors, nitrates (will lead to excessively low bp) BBW: teratogenic (patients must have a negative pregnancy test before starting and qm while on therapy)